TEXT BOOK OF

CLINICAL
PHARMACOGNOSY
(For Pharmacists, Physicians, Clinicians, Paramedics, Health care providers,
Biopharmaceutical, Homoeopaths and Eastern Medicine Doctors, Students of
Medical, Pharm. D., and Alternative Medicine Practitioners)

Editors
Dr. MANSOOR AHMAD
M.Sc., DHMS, D. Sc. (ETH- Zurich, Swiss), D. Sc. (University of Karachi)
Meritorious Professor,
Department of Pharmacognosy, Faculty of Pharmacy,
University of Karachi, Karachi
Dr. MEHJABEEN
B. Pharm. Pharm. D., DHMS, M. Phil., Ph.D.
Department of Pharmacology, Faculty of Pharmacy,
Federal Urdu University of Arts, Science & Technology, Karachi
Dr. NOOR JAHAN
B. Pharm., Pharm. D., DHMS, M. Phil., Ph.D.
Department of Pharmacology,
Dow College of Pharmacy,
Dow University of Health Sciences, Karachi
DR. FARAH SAEED
B. Pharm., Pharm. D., DHMS, M. Phil., Ph.D.
Department of Pharmacognosy,
Dow College of Pharmacy,
Dow University of Health Sciences, Karachi

Department of Pharmacognosy
Faculty of Pharmacy, University of Karachi,
Karachi-75270, Pakistan
2016

i
TEXT BOOK OF
CLINICAL PHARMACOGNOSY
Published by University of Karachi.
Editors: Prof. Dr. Mansoor Ahmad, Dr. Mehjabeen & Dr. Noor Jahan, Dr. Farah Saeed
Printed at BCC& T Press, University of Karachi, Karachi-75270, Pakistan
ISBN:……………………

Copy right@2016
All right reserved. No reproduction, copy or transmission of this publication may be made
without written permission.

No part of this publication may be reproduced, copied saved or transmitted with or without
permission in accordance with the provision of the copy rights issued by the copy rights issued
by the copy right licensing agency.

Any unauthorized publication may be liable to criminal prosecution and civil claim of damage.

This book is published for academic purpose only

Book Available on: http://www.pjpps.com/HTML/Books.html

BCC&T PRESS, UNIVERSITY OF KARACHI, January 2016

ii
 Dedicated
To
Great Muslim Scientists

iii
iv
 PREFACE
Clinical Pharmacognosy is the field of pharmacy which deals with the clinical aspects of drugs of natural
origin (herbs, animals and minerals) and their relationships to disease/diseased persons/patients. There is
little authentic/research based medical information available for education, pharmacists, researchers,
medical doctors and indeed there is a need of comprehensive knowledge in the form of a book i.e.
Clinical Pharmacognosy. It is a major field of medical science and need to be included in medical and
health care education.
This book designed to provide information to Pharmacist/Hakims/Ayurveds/Physicians/ Homoeopath
doctors/herbalists and Herbal Pharma Industries etc. It is the first book of its kind ever written on this
aspect, where information on Pharmacognosy subject, contribution of Muslim scientists in the field of
medical science, clinical examination methods and usage of latest technologies and health related
problems. The main objective of this book is to define different problems of body systems. It covers
patient clinical examination and gives information about the symptoms and proper diagnosis. No doubt
that command in patient examination is necessary at every initial step whenever a health care provider
deals with the patient.
There is a great contribution of Muslim scientists in the field of medicine. People must be aware of their
contribution and the techniques they developed in that era summarized in this book with the scientist’s
names as well as their contribution and the area of their practice.
This book gives a comprehensive knowledge about different body systems, which include the central
nervous system, respiratory, cardiovascular, gastrointestinal tract, excretory systems and all aspects
related to the symptoms, diagnosis, diagnostic tests, pathology and treatment protocol. It gives initial
information that how different signs and symptoms can be utilized for proper diagnosis. In case of pain
management it is important to relate all aspects of the site, type, severity with relief of pain. There are
certain folkloric treatments and diagnostic methods which are used by specific communities in some part
of the world as their ancestors had been doing.
The information in this book has been taken from different sources including scientific journals, books,
diagnostic tests, protocol manuals and internet sources (medical and scientific sources) that give a clear
understanding about the body systems. The book covers gastrointestinal, respiratory, cardiovascular,
haematological and gynaecological aspects too. The diseases of these systems such as emesis, diarrhea,
ulcer, constipation, asthma, respiratory troubles, hepatitis, cholecystitin nephropathy, blood disorders as
well as male and female reproductive disorders are well explained. For the treatment of diseases herbal
formulae are also given to understand the healing power of natural drugs; the relative understanding about
these systems with clinical aspects are the need of present time.
This book is easy and comprehensive that can be used for educational purpose of Health care
professionals.
The editors are thankful to the University of Karachi and Prof. Dr. Muhammad Qaiser, Vice Chancellor,
University of Karachi, for publishing this book.
The editors will appreciate any suggestion and advice for the improvement of this book.

Prof. Dr. Mansoor Ahmad 2016

v
vi
 CONTENTS

Chapters Page
No.
1. Clinical Pharmacognosy…………………………………………… 03
2. Historical Development……………………………………………. 39
3. Practice in Clinical Pharmacognosy……………………………….. 69
i. Case Taking……………………………………………………… 69
ii. Examination of Patient…………………………………………… 73
4. Diseases and Health Problems
i) Pain in the head and face……………………………………… 83
ii) Mouth Sores and Swellings…………………………………… 87
iii) Swelling in the Neck …………………………………………. 89
iv) Breast Lumps and Nipple Discharges………………………… 92
v) Cough, Dyspnoea and Chest Pain……………………………… 95
vi) Dysphagia……………………………………………………. 100
vii) Dyspepsia……………………………………………………. 103
viii) Vomiting…………………………………………………….. 105
ix) Haematemesis and Melaena………………………………… 109
x) Jaundice…………………………………………………….. 111
xi) Abdominal swellings………………………………………... 114
xii) Abdominal Pains……………………………………………. 117
xiii) Diarrhea……………………………………………………. 121
xiv) Rectal bleeding……………………………………………… 125
xv) Constipation…………………………………………………... 128
xvi) Anal pains and discharge………………………………………. 130
xvii) Inguino-scrotal swellings……………………………………… 133
xviii) Frequencies and retention of urine………………………………… 136
xix) Haematuria……………………………………………………. 140
xx) Back Pain……………………………………………………… 143
xxi) Limb injuries…………………………………………………... 146

vii
 xxii) Limb pains……………………………………………………... 150
xxiii) Swellings and ulcers………………………………………….. 157
xxiv) Wounds and burns…………………………………………….. 161
xxv) Major injuries…………………………………………………. 167
5. Neurological (CNS) Examination…………………………………… 175
6. Brain Tumor Examination…………………………………………… 209
7. Epilepsy…………………………………………………………….. 217
8. Respiration Chest Examination……………………………………… 231
9. Sinus………………………………………………………………… 239
10. Heart (ECG, Doppler Ultrasound)…………………………………… 257
11. Gastrointestinal System and Examination……………………………. 315
12. Hepatitis……………………………………………………………… 329
13. Epidemiology diagnosis and treatment of Hepatitis…………………. 349
14. Hepatocellular Carcinoma ……………………………………………. 359
15. Diabetes……………………………………………………………… 371
16. Questions from common men on Diabetes………………………….. 403
17. Review on Diabetes…………………………………………………… 411
18. Gall Stones…………………………………………………………….. 425
19. Obstetric……………………………………………………………… 437
20. Gynecology………………………………………………………….. 447
21. Fibroids………………………………………………………………. 455
22. Osteoporosis………………………………………………………….. 459
23. Male Reproductive System……………………………………………. 467
24. Women Health Related Problems……………………………………… 477
25. Some Herb and herbal formulations…………………………………… 487
26. Nutrition………………………………………………………………. 499
27. Laboratory Investigations………………………………………………. 513
28. Glossary……………………………………………………………….. 525
29. Subject Index………………………………………………………….. 589

viii
Chapter 1

1
2
Clinical Pharmacognosy
What do we know about Pharmacognosy?
Basic Principles
History of Pharmacognosy
Clinical Pharmacognosy
Branches of Clinical Pharmacognosy
WHAT DO WE KNOW ABOUT
PHARMACOGNOSY?
When pain injury or disease struck, the early
man had little choice but to turn to plants.
Developed empirically, by trial and error,
many herbal treatments were nevertheless
remarkably effective. Then medicine became
more theoretical. The belief arose that the
harsher the treatment the better. Herbal
medicines fell out of favor, branded as
ignorant superstition. Change came only when
formal medicine opened its doors and let the
light of modern science shine in. Mow, the
new medical science is reaffirming much of the
old herbal lore and extending the horizons of
botanical medicine.
In this scientific age, it is easy to mistake
pseudoscience for the real thing. Misconceptions
or myths arise, which then pass as scientific
truths. One such myth concerns medicines. It
says, "Synthetic is best." If a medicine does not
contain purified chemicals, expensively made
in gleaming laboratories by highly trained
scientists in starched and sanitized white
coats, then so the myth goes on to say that, it
cannot possibly be a medicine that works.
Like all myths, this one grows out of a certain
body of human experience and is true up to a
point. Gone are the days when nobody could
ever be sure exactly what substances a medical
potion contained, or precisely which of the
substances, in what strength or combination,
might actually help anybody feel any better.
Modern science provides precise techniques of
analysis, separation, and measurement.
Scientists now test the effects and side effects
of a medicine before it is released for wide
public use. These modern procedures have
made the medicines we buy safer, but
unfortunately there is still room for tragic
3
errors, such as the one in the late 1950's
involving thalidomide, a sedative that caused
serious birth defects in the babies of pregnant
mothers for whom it was prescribed.
Medicines That Work
The myth also ignores the simple truth that
many botanical remedies worked, consistently
and effectively, and in some cases as well as or
better than the products of today's laboratories.
Finally, there is the fact that many of the drugs
and medicines we buy at the pharmacy
• often in fancy packages, at fancy prices,
contain the same active ingredients as
healing plants used by pre-scientific
cultures. In other words, people in
"primitive" societies were using basically
the same medicines for the same maladies
that bring us to our physicians and
pharmacists today. Examples abound. To
mention just two:
• Tea brewed from the stems of a low shrub
the Chinese call Mahuang will relieve
asthma, colds, and coughs. The stems are
a natural source of ephedrine, the active
ingredient of many medicines, including
decongestants that "unclog" breathing
passages.
• The leaves of a plant that grow along roads
and in fields contain a substance that is
highly effective in treating congestive heart
failure. The plant is common foxglove
(Digitalis purpurea), the source of a
chemical substance that aids the functioning
of heart muscle.
Through the centuries, sick people have been
helped over and over again by remedies that did
not arise out of the formal doctrines and
procedures of the medical profession. The use of
plants to treat sickness is probably as old as
mankind; formal medicine and medical
degrees are, of course, much more recent. Yet if
medicine is broadly defined as the attempt to
treat and cure human illness, then the human
beings who first grew and collected plants they
thought useful, herbalists, and the first people
to try to heal by the use of herbs, also called
herbalists or herb doctors, must surely rank as
pioneers of modern medicine.
This is not to say that "good, old-fashioned
herbal remedies" are better or safer than the
laboratory-made chemical prescriptions that
are in favor today, nor that herbalists are
somehow superior to today's physicians. Nor is
it meant to suggest that readers start dosing
themselves with "natural" medicines, to do so
would invite not only the risk of accidental
poisoning but the dangers arising from self-
diagnosis.
The fact remains that plants do produce a
variety of chemical substances that act upon
animal tissues. One remarkable example is a
pretty pink flower that blooms on the island of
Madagascar off the coast of Africa. Extracts
from this flower can stop the progress of
Hodgkin's disease and childhood leukemia.
The flower, a periwinkle, contains two sub-
stances known as vincristine and vinblastine
that physicians prescribe to fight certain types of
cancer. But there is no need to travel to
Madagascar to find medically useful botanical
specimens. More than a few familiar plants
including a number of the herbs that are basic
items in spice racks are commonly used in
pharmacy today.
Learning from medicine's fast
Through most of human existence, plants
(together with animal substances and mystical
rites) were virtually all that was available to
healers and those who hoped to be healed. This is
still largely true outside the developed world.
Not until the present century did advances in
pharmacology, chemistry, and technology make
possible the synthesis of many of the
compounds currently used in medicine. Even
so, roughly 30 percent of modern
pharmaceuticals are derived from some parts
of higher plants. (The figure approaches 50 per-
cent when pharmaceuticals made from microbial
organisms are included.) In most cases, today's
use of the modern pharmaceutical product is
similar to the traditional use of the plant from
4
which it is derived.
Furthermore, scientists are finding that the
purified active ingredients of some new
pharmaceuticals may cause undesirable side
effects that die old, unpurified, botanical
medicines did not cause. Could it be, ask these
scientists, that some plants may have built-in
safety factors, long ignored, that could mini-
mize some of the side effects of dieir active
ingredients? In the hope of answering such
questions, many researchers are looking back at
the ways of herbal doctors and medicine men
and women of bygone eras, as well as
scrutinizing the practices of contemporary folk
healers. Such investigations keep pointing to
the hypothesis that herbalists have been using
the same plant remedies for countless genera-
tions for the simple reason that those remedies
happen to work.
Earliest Treatments
In most past societies (and some present ones),
sickness was viewed as a punishment from the
gods. Early medicine men treated the sick with
prayers and rituals that included what may
have been considered magic potion. Most of
these medicinal preparations were concocted
from local herbs. Though it may be true that
the herbs were selected first because of their
color, odor, shape, or rarity, what followed
could hardly have been a process guided by whim
alone. Rather, the application of any one herb or
mixture of herbs to a specific disorder must
have been the result of much trial-and-error
experimentation over many generations. How
else to explain the fact that, oceans apart from
one another, different civilizations learned to use
closely related medicinal plants in almost
identical ways?
Archeological discoveries at a 60,000 year old
Neanderthal burial ground in Iraq point to the
use of several plants that still figure in folk
medicine and among them are marshmallow,
yarrow, and groundsel. Mexican Indians of thou-
sands of years ago used peyote cactus. Possibly
then, as now, peyote was valued for its halluci-
nogenic properties, and equally possibly for its
active medicinal substances, which are still
used to heal bruises and wounds, and are now
known to have antibiotic properties.
The Sumerian’s inhabited an area around the
Tigris and Euphrates rivers (now in Iraq)
about 4000 BC. From their cuneiform writings
on clay tablets we know that their medicines
included opium, licorice, thyme, mustard, and
the chemical element sulfur. The Babylonians
who followed apparently expanded the
Sumerians' stock of medicinal substances,
adding senna leaves, saffron, coriander,
cinnamon, and garlic, among other herbs, to
their formulary. From such herbs and from
plant resins such as galbanum and storax they
made medicinal decoctions (extracts), wines,
poultices, salves, and liniments.
Ancient Egyptian Medicines
Out of the next great civilization, the Egyptian
Imhotep, a skilled physician, who later
became the Egyptian god of Healing, Ancient
Egypt also gave the world one of its first
medical texts, the Ebers Papyrus, named for the
German Egyptologist Georg Ebers. He bought it,
in 1873, from an Arab who claimed to have
found it in the necropolis outside Thebes. The
papyrus is believed to have been written in the
16th century B.C. It contains some 800 recipes
and refers to over 700 drugs, including aloe,
wormwood, peppermint, henbane, myrrh, hemp
dogbane, castor oil, and mandragora. With such
ingredients, the Egyptians prepared decoctions,
wines and infusions, as well as pills, salves
and poultices.
The Ebers Papyrus mentions a recipe that
suggests the Egyptians had a treatment for
diabetes. It also advises putting mud or moldy
bread over sores to keep them from becoming
infected. Not until millennia later was it dis-
covered that mud and molds often contain
certain microorganisms, bacteria and
filamentous fungi that produce one class of
antibiotic wonder drugs.
Chinese, Hebrew, Sanskrit Writings
Ancient Egypt was not alone in recording the
healing power of plants. At least 2,000 years ago
5
(according to the rather hazy system that is
traditionally used to date events of ancient
China), die earliest known Chinese
pharmacopoeia, the Pen Tsao, appeared.
Attributed to the legendary emperor Shen
Nung, this work described the use of
chaulmoogra oil from trees of the Hydnocarpus
genus to treat leprosy. The Pen Tsao, like
pharmacopeias that followed it, attempts to
give an authoritative, up-to-date survey of the
age's medicinal preparations. Among its many
other plant listings are hemp dogbane and
opium poppy, as well as rhubarb and aconite.
These ancient Chinese first recorded the use of
the desert shrub called Chinese ephedra, or
mahuang, to improve circulation, reduce
fevers, help urinary function, suppress
coughing, and relieve lung or bronchial
disorders. Its active ingredient was nearly lost
to modern medical science until its rediscovery
earlier in this century. We now know it as
ephedrine, the key ingredient in modern
pharmaceuticals used to relieve breathing
difficulties and other symptoms of asthma, hay
fever, and the common cold.
The Jews of the Old Testament period are
remembered for their high standards of public
health and hygiene. Yet among these people of
the rugged terrain at the eastern end of the
Mediterranean, the use of plants for medicinal
purposes was an accepted custom. The Book of
Ecclesiasticus (or Sirach) in a sense authorizes
and encourages this practice: “The Lord created
medicines from the earth, and a sensible man
will not despise them”. Dozens of plants from
juniper to mandrake, from cotton to mustard,
yield substances dial were used medicinally in
Old Testament times.
In India, many generations of medical tradition
were formalized in the Aywveda, a collection of
Hindu medical lore that was probably first put
into writing about the time of Christ. The
doctrine itself goes back to me much earlier
Rig Veda and its hymns dedicated to the
medicine-god-narcotic Soma, since identified
as the narcotic and hallucinogenic mushroom
Amanita muscaria. The Vedas written down
originally in Sanskrit, made many references to
healing plants, including the snakeroot, Rauvolfia
serpentina, used in India to treat snake-bite,
epilepsy, mental disorders, and other
illnesses. R. serpentina is the source of
reserpine, a tranquilizer and hypotensive
agent used widely in modern pharmacy. The
Charaka Samkita, a comprehensive Indian
herbal, cites more than 500 plant remedies.
BASIC PRINCIPLES
The essential features of pharmacognosy
have important application on a wide range
of drugs. Its basic priciples includes the
safety, effectiveness, or usefulness of an
intervention including research on
therapeutics side, diagnostic procedures and
preventive measures of herbal medicines.
The basic requires both theoretical and
practical experiences. The crude form of a
drug contains many active constituents and
separation of them without special technical
or procedures is not so easy. Therefore, in
traditional system of medicine it is clearly
accepted and proven that some single
remedies are more effective than any
pharmaceutical medicine. The efficacy and
potency of these drugs might be increases by
several folds if used in a proper dose regimen
or the disease treated with adjuent therapy.
The patient needs a proper cure from diseases
or illnesses no matter what is the remedy,
beside these some guidelines are important
and necessary for clinical evaluation. The
International Human Right Agency allows
the physicians/surgens/therapists and
researchers to treat the patients with basic
ethical responsibilities such as:
- Secure the human rights in term of safety
- Correct diagnosis
- Verify the authenticity of drug
administration especially in children and
psychological problems/cases
- Must get correct satisfactory out come of
treatment
6
- Clear investigation of disease in the light of
present and past history
- Security of patient history and treatment
files
- Must take second opinion in case of
complications
- In human beings, for investigation and
treatment, different radiations - X-ray,
gamma rays and beta rays, radiopaque
contrast agents and radioactive materials
are used. The relative risks and benefits of
research proposal utilizing radioactive
materials or X-rays should be evaluated.
Radiation limits for the use of such
materials and X-rays should be in
accordance with the limits set forth by the
regulatory authority (BARC) for such
materials.
- Healthcare economics/financial status and
protection
- Clinical and laboratory tests
- Any other treatment that may be given
- Instruction to patient, relative and
concerned staff
- Medical care after discharge and surgery
- Compensation in case of loss or damage or
death
HISTORY OF
PHARMACOGNOSY
Early humans recognized their dependence
on nature in both health and illness. Led by
instinct, taste, and experience, primitive men
and women treated illness by using plants,
animal parts, and minerals that were not part
of their usual diet. Physical evidence of use
of herbal remedies goes back some 60,000
years to a burial site of a Neanderthal man
uncovered in 1960 (Solecki, 1975). In a cave
in northern Iraq, scientists found what
appeared to be ordinary human bones. An
analysis of the soil around the bones revealed
extraordinary quantities of plant pollen that
could not have been introduced accidentally
at the burial site. Someone in the small cave
community had consciously gathered eight
species of plants to surround the dead man.
Seven of these are medicinal plants still used
throughout the herbal world (Bensky and
Gamble, 1993). All cultures have long folk
medicine histories that include the use of
plants. Even in ancient cultures, people
methodically and scientifically collected
information on herbs and developed well-
defined herbal pharmacopoeias. Indeed, well
into the 20th century much of the
pharmacopoeia of scientific medicine was
derived from the herbal lore of native
peoples. Many drugs, including strychnine,
aspirin, vincristine, taxol, curare, and ergot,
are of herbal origin. About one-quarter of the
prescription drugs dispensed by community
pharmacies in the United States contain at
least one active ingredient derived from plant
material (Farnsworth and Morris, 1976).
Middle East medicine: The invention of
writing was a focus around which herbal
knowledge could accumulate and grow. The
first written records detailing the use of herbs
in the treatment of illness are the
Mesopotamian clay tablet writings and the
Egyptian papyrus. About 2000 B.C., King
Assurbanipal of Sumeria ordered the
compilation of the first known materia
medica--an ancient form of today's United
States Pharmacopoeia--containing 250 herbal
drugs (including garlic, still a favorite of
herbal doctors). The Ebers Papyrus, the most
important of the preserved Egyptian
manuscripts, was written around 1500 B.C.
and includes much earlier information. It
contains 876 prescriptions made up of more
than 500 different substances, including
many herbs (Ackerknecht, 1973).
Greece and Rome: One of the earliest materia
medica was the Rhizotomikon, written by
Diocles of Caryotos, a pupil of Aristotle.
Unfortunately, the book is now lost. Other
Greek and Roman compilations followed, but
none was as important or influential as that
written by Dioscorides in the 1st century
A.D., better known by its Latin name De
Materia Medica. This text contains 950
7
curative substances, of which 600 are plant
products and the rest are of animal or mineral
origin (Ackerknecht, 1973). Each entry
includes a drawing, a description of the plant,
an account of its medicinal qualities and
method of preparation, and warnings about
undesirable effects.
Muslim world: The Arabs preserved and built
on the body of knowledge of the Greco-
Roman period as they learned of new
remedies from remote places. They even
introduced to the West the Chinese technique
of chemically preparing minerals. The
principal storehouse of the Muslim materia
medica is the text of Jami of Ibn Baiar (died
1248 A.D.), which lists more than 2,000
substances; including many plant products
(Ackerknecht, 1973). Eventually this entire
body of knowledge was reintroduced to
Europe by Christian doctors traveling with
the Crusaders. Indeed, during the middle
Ages, trade in herbs became a vast
international commerce.
East India: India, located between China and
the West, underwent a similar process in the
development of its medicine. The healing
that took place before India's Ayurvedic
medical corpus was similar to that of ancient
Egypt or China (i.e. sickness was viewed as a
punishment from the gods for a particular
sin). Ayurvedic medicine emerged during the
rise of the philosophies of the Upanishads,
Buddhism, and other schools of thought in
India. Herbs played an important role in
Ayurvedic medicine. The principal
Ayurvedic book on internal medicine, the
Characka Samhita, describes 582 herbs
(Majno, 1975). The main book on surgery,
the Sushruta Samhita, lists some 600 herbal
remedies. Most experts agree that these
books are at least 2,000 years old.
China and Japan: The earliest written
evidence of the medicinal use of herbs in
China consists of a corpus of 11 medical
works recovered from a burial site in Hunan
province. The burial itself is dated 168 B.C.,
and the texts (written on silk) appear to have
been composed before the end of the 3rd
century B.C. Some of the texts discuss
exercise, diet, and channel therapy (in the
form of moxibustion--see the "Alternative
Systems of Medical Practice" chapter). The
largest, clearest, and most important of these
manuscripts, called by its discoverers
Prescriptions for Fifty-Two Ailments, is
predominantly a pharmacological work.
More than 250 medicinal substances are
named. Most are substances derived from
herbs and wood; grains, legumes, fruits,
vegetables, and animal parts are also
mentioned. Underlying this entire text is the
view that disease is the manifestation of evil
spirits, ghosts, and demons that must be
repelled by incantation, rituals, and spells in
addition to herbal remedies.
By the Later Han Dynasty (25-220 A.D.),
medicine had changed dramatically in China.
People grew more confident of their ability to
observe and understand the natural world and
believed that health and disease were subject
to the principles of natural order. However,
herbs still played an important part in
successive systems of medicine. The Classic
of the Materia Medica, compiled no earlier
than the 1st century A.D. by unknown
authors, was the first Chinese book to focus
on the description of individual herbs. It
includes 252 botanical substances, 45
mineral substances, and 67 animal-derived
substances. For each herb there is a
description of its medicinal effect, usually in
terms of symptoms. Reference is made to the
proper method of preparation, and toxicities
are noted (Bensky and Gamble, 1993).
Since the writing of the Classic of the
Materia Medica almost 2,000 years ago, the
traditional Chinese materia medica has been
steadily increasing in number. This increase
has resulted from the integration into the
official tradition of substances from China's
folk medicine as well as from other parts of
the world. Many substances now used in
8
traditional Chinese medicine originate in
places such as Southeast Asia, India, the
Middle East, and the America. The most
recent compilation of Chinese materia
medica was published in 1977. The
Encyclopedia of Traditional Chinese
Medicine Substances (Zhong yao da ci dian),
the culmination of a 25-year research project
conducted by the Jiangsu College of New
Medicine, contains 5,767 entries and is the
most definitive compilation of China's herbal
tradition to date (Bensky and Gamble, 1993).
Traditional Chinese medicine was brought to
Japan via Korea, and Chinese-influenced
Korean medicine was adapted by the
Japanese during the reign of Emperor Ingyo
(411-453 A.D.). Medical envoys continued to
arrive from Korea throughout the next
century, and by the time of the Empress
Suiko (592-628 A.D.), Japanese envoys were
being sent directly to China to study
medicine. Toward the end of the Muromachi
period (1333-1573 A.D.) the Japanese began
to develop their own form of traditional
oriental medicine, called kampo medicine.
As traditional Chinese medicine was
modified and integrated into kampo
medicine, herbal medicine was markedly
simplified.
Herbal Medicine in the United States
In North America, early explorers traded
knowledge with the Native American
Indians. The tribes taught them which herbs
to use to sharpen their senses for hunting, to
build endurance, and to bait their traps. In
1716, French explorer Lafitau found a
species of ginseng, Panax quinquefolius L.,
growing in Iroquois territory in the New
World. This American ginseng soon became
an important item in world herb commerce
(Duke, 1989). The Jesuits dug up the
plentiful American ginseng, sold it to the
Chinese, and used the money to build schools
and churches. Even today, American ginseng
is a sizable crude U.S. export.
As medicine evolved in the United States,
plants continued as a mainstay of country
medicine. Approaches to plant healing
passed from physician to physician, family to
family. Even in America's recent past, most
families used home herbal remedies to
control small medical emergencies and to
keep minor ailments from turning into
chronic problems. During this period there
was a partnership between home folk
medicine and the family doctor (Buchman,
1980). Physicians often used plant and herbal
preparations to treat common ills. Until the
1940s, textbooks of pharmacognosy--books
that characterize plants as proven-by-use
prescription medicines--contained hundreds
of medically useful comments on barks,
roots, berries, leaves, resins, twigs, and
flowers.
As 20th-century technology advanced and
created a growing admiration for technology
and technologists, simple plant-and-water
remedies were gradually discarded. Today,
many Americans have lost touch with their
herbal heritage. Few Americans realize that
many over-the-counter (OTC) and
prescription drugs have their origins in
medicinal herbs. Cough drops that contain
menthol, mint, horehound, or lemon are
herbal preparations; chamomile and mint teas
taken for digestion or a nervous stomach are
time-honored herbal remedies; and many
simple but effective OTC ache-and pain-
relieving preparations on every druggist's and
grocer's shelf contain oils of camphor,
menthol, or eucalyptus. Millions of
Americans greet the morning with their
favorite herbal stimulant--coffee.
Despite the importance of plant discoveries
in the evolution of medicine, some regulatory
bodies such as the U.S. Food and Drug
Administration (FDA)--the main U.S.
regulatory agency for food and drugs--
consider herbal remedies to be worthless or
potentially dangerous (Snider, 1991). Indeed,
today in the United States, herbal products
9
can be marketed only as food supplements. If
a manufacturer or distributor makes specific
health claims about a herbal product (i.e.,
indicates on the label the ailment or ailments
for which the product might be used) without
FDA approval, the product can be pulled
from store shelves.
Despite FDA's skepticism about herbal
remedies, a growing number of Americans
are again becoming interested in herbal
preparations. This surge in interest is fueled
by factors that include the following:
* Traditional European and North American
herbs are sold in most U.S. health food
stores. The same is true for Chinese and, to
a lesser extent, Japanese herbal medicinals.
Ayurvedic herbals are available in most
large U.S. cities, as are culinary and
medicinal herb shops called botanicas that
sell herbs from Central and South America
and Mexico. The reemergence of Native
American Indian cultural influences has
increased interest in Native American
Indian herbal medicines.
* Pharmaceutical drugs are seen increasingly
as overprescribed, expensive, even
dangerous. Herbal remedies are seen as less
expensive and less toxic.
* Exposure to exotic foreign foods prepared
with non-European culinary herbs has led
many Euroethnic Americans to examine
and often consider using medicinal herbs
that were brought to the United States
along with ethnic culinary herbs.
* People increasingly are willing to "self-
doctor" their medical needs by
investigating and using herbs and herbal
preparations. Many Americans, especially
those with chronic illnesses such as
arthritis, diabetes, cancer, and AIDS--are
turning to herbs as adjuncts to other
treatments.
The next section discusses the regulatory
status of herbal medicine in various countries
around the world, particularly in Europe and
Asia, as well as in less developed countries.
It is followed by an overview of promising
European and Asian herbal medicine
research and recommendations for making
herbal medicine a more viable health care
alternative in this country.
Regulatory Status of Herbal Medicine
Worldwide
The World Health Organization (WHO)
estimates that 4 billion people--80 percent of
the world population--use herbal medicine
for some aspect of primary health care
(Farnsworth et al., 1985). Herbal medicine is
a major component in all indigenous peoples'
traditional medicine and is a common
element in Ayurvedic, homeopathic,
naturopathic, traditional oriental, and Native
American Indian medicine.
The sophistication of herbal remedies used
around the world varies with the
technological advancement of countries that
produce and use them. These remedies range
from medicinal teas and crude tablets used in
traditional medicine to concentrated,
standardized extracts produced in modern
pharmaceutical facilities and used in modern
medical systems under a physician's
supervision.
Europe
Drug approval considerations for
phytomedicines (medicines from plants) in
Europe are the same as those for new drugs
in the United States, where drugs are
documented for safety, effectiveness, and
quality. But two features of European drug
regulation make that market more hospitable
to natural remedies. First, in Europe it costs
less and takes less time to approve medicines
as safe and effective. This is especially true
of substances that have a long history of use
and can be approved under the "doctrine of
reasonable certainty." According to this
principle, once a remedy is shown to be safe,
regulatory officials use a standard of
evidence to decide with reasonable certainty
that the drug will be effective. This
procedure dramatically reduces the cost of
10
approving drugs without compromising
safety. Second, Europeans have no inherent
prejudice against molecularly complex plant
substances; rather, they regard them as single
substances.
The European Economic Community (EEC),
recognizing the need to standardize approval
of herbal medicines, developed a series of
guidelines, The Quality of Herbal Remedies
(EEC Directive, undated). These guidelines
outline standards for quality, quantity, and
production of herbal remedies and provide
labeling requirements that member countries
must meet. The EEC guidelines are based on
the principles of the WHO's Guidelines for
the Assessment of Herbal Medicines (1991).
According to these guidelines, a substance's
historical use is a valid way to document
safety and efficacy in the absence of
scientific evidence to the contrary. (App. C
contains the complete WHO guidelines.) The
guidelines suggest the following as a basis
for determining product safety:
A guiding principle should be that if the
product has been traditionally used without
demonstrated harm, no specific restrictive
regulatory action should be undertaken
unless new evidence demands a revised risk-
benefit assessment. . . . Prolonged and
apparently uneventful use of a substance
usually offers testimony of its safety.
With regard to efficacy, the guidelines state
the following:
For treatment of minor disorders and for
nonspecific indications, some relaxation is
justified in the requirements for proof of
efficacy, taking into account the extent of
traditional use; the same considerations may
apply to prophylactic use (WHO, 1991).
The WHO guidelines give further advice for
basing approval on existing monographs:
If a pharmacopoeia monograph exists it
should be sufficient to make reference to this
monograph. If no such monograph is
available, a monograph must be supplied and
should be set out in the same way as in an
official pharmacopoeia.
To further the standardization effort and to
increase European scientific support, the
phytotherapy societies of Belgium, France,
Germany, Switzerland, and the United
Kingdom founded the European Societies'
Cooperative of Phytotherapy (ESCOP).
ESCOP's approach to eliminating problems
of differing quality and therapeutic use
within EEC is to build on the German
scientific monograph system (below) to
create "European" monographs.
In Europe, herbal remedies fall into three
categories. The most rigorously controlled
are prescription drugs, which include
injectable forms of phytomedicines and those
used to treat life-threatening diseases. The
second category is OTC phytomedicines,
similar to American OTC drugs. The third
category is traditional herbal remedies,
products that typically have not undergone
extensive clinical testing but are judged safe
on the basis of generations of use without
serious incident.
The following brief overviews of
phytomedicine's regulatory status in France,
Germany, and England are representative of
the regulatory status of herbal medicine in
Europe.
France, where traditional medicines can be
sold with labeling based on traditional use,
requires licensing by the French Licensing
Committee and approval by the French
Pharmacopoeia Committee. These products
are distinguished from approved
pharmaceutical drugs by labels stating
"Traditionally used for…..". Consumers
understand this to mean that indications are
based on historical evidence and have not
necessarily been confirmed by modern
scientific experimentation (Artiges, 1991).
Germany considers whole herbal products as
a single active ingredient; this makes it
simpler to define and approve the product.
The German Federal Health Office regulates
11
such products as ginkgo and milk thistle
extracts by using a monograph system that
results in products whose potency and
manufacturing processes are standardized.
The monographs are compiled from scientific
literature on a particular herb in a single
report and are produced under the auspices of
the Ministry of Health Committee for Herbal
Remedies (Kommission E). Approval of such
remedies requires more scientific
documentation than traditional remedies, but
less than new pharmaceutical drug approvals
(Keller, 1991).
In Germany there is a further distinction
between "prescription-only drugs" and
"normal prescription drugs." The former are
available only by prescription. The latter are
covered by national health insurance if
prescribed by a physician, but they can be
purchased over the counter without a
prescription if consumers want to pay the
cost themselves (Keller, 1991). OTC
phytomedicines--used for self-diagnosed,
self-limiting conditions such as the common
cold, or for simple symptomatic relief of
chronic conditions--are not covered by the
national health insurance plan.
England generally follows the rule of prior
use, which says that hundreds of years of use
with apparent positive effects and no
evidence of detrimental side effects are
enough evidence--in lieu of other scientific
data--that the product is safe. To promote the
safe use of herbal remedies, the Ministry of
Agriculture, Fisheries, and Food and the
Department of Health jointly established a
database of adverse effects of
nonconventional medicines at the National
Poisons Unit.
Asia
In more developed Asian countries such as
Japan, China, and India, "patent" herbal
remedies are composed of dried and
powdered whole herbs or herb extracts in
liquid or tablet form. Liquid herb extracts are
used directly in the form of medicinal syrups,
tinctures, cordials, and wines.
In China, traditional herbal remedies are still
the backbone of medicine. Use varies with
region, but most herbs are available
throughout China. Until 1984 there was
virtually no regulation of pharmaceuticals or
herbal preparations. In 1984, the People's
Republic implemented the Drug
Administration Law, which said that
traditional herbal preparations were generally
considered "old drugs" and, except for new
uses, were exempt from testing for efficacy
or side effects. The Chinese Ministry of
Public Health would oversee the
administration of new herbal products
(Gilhooley, 1989).
Traditional Japanese medicine, called kampo,
is similar to and historically derived from
Chinese medicine but includes traditional
medicines from Japanese folklore. Kampo
declined when Western medicine was
introduced between 1868 and 1912, but by
1928 it had begun to revive. Today 42.7
percent of Japan's Western-trained medical
practitioners prescribe kampo medicines
(Tsumura, 1991), and Japanese national
health insurance pays for these medicines. In
1988, the Japanese herbal medicine industry
established regulations to manufacture and
control the quality of extract products in
kampo medicine. Those regulations comply
with the Japanese government's Regulations
for Manufacturing Control and Quality
Control of Drugs.
Developing Countries
Herbal medicines are the staple of medical
treatment in many developing countries.
Herbal preparations are used for virtually all
minor ailments. Visits to Western-trained
doctors or prescription pharmacists are
reserved for life-threatening or hard-to-treat
disorders.
Individual herbal medicines in developing
regions vary considerably; healers in each
region have learned over centuries which
12
local herbs have medicinal worth. Although
trade brings a few important herbs from other
regions, these healers rely mainly on
indigenous herbs. Some have extensive
herbal materia medica. A few regions, such
as Southeast Asia, import large amounts of
Chinese herbal preparations. But the method
and form of herb use are common to
developing regions.
In the developing world, herbs used for
medicinal purposes are "crude drugs". These
are unprocessed herbs--plants or plant parts,
dried and used in whole or cut form. Herbs
are prepared as teas (sometimes as pills or
capsules) for internal use and as salves and
poultices for external use. Most developing
countries have minimal regulation and
oversight.
Research Base
The professional literature of Europe and
Asia abounds with efficacy and safety studies
of many herbal medicines. It is beyond this
report's resources to investigate the validity
of this vast literature. The following is an
overview of some of the more promising
research on herbal remedies around the
world.
Europe
European phytomedicines, researched in
leading European universities and hospitals,
are among the world's best studied
medicines. In some cases they have been in
clinical use under medical supervision for
more than 10 years, with tens of millions of
documented cases. This form of botanical
medicine most closely resembles American
medicine. European phytomedicines are
produced under strict quality control in
sophisticated pharmaceutical factories,
packaged and labeled like American
medicines, and used in tablets or capsules.
Examples of well-studied European
phytomedicines include Silybum marianum
(milk thistle), Ginkgo biloba (ginkgo),
Vaccinium myrtillus (Bilberry extract), and
Ilex guayusa (guayusa). Their efficacy is well
documented. Herbs of American origin, such
as Echinacea sp. (purple coneflower) and
Serenoa repens (saw palmetto) are better
studied and marketed in Europe than in the
United States. Below is an overview of
recent research on these phytomedicines and
American herbs.
Milk thistle (Silybum marianum): Milk
thistle has been used as a liver remedy for
2,000 years. In 1970s studies, seed extracts
protected against liver damage and helped
regenerate liver cells damaged by toxins
(alcohol) and by diseases such as hepatitis
(Bode et al., 1977) and cirrhosis (Ferenci et
al., 1989). More recently, a 6-month
treatment of milk thistle significantly
improved liver function in 36 patients with
alcohol-induced liver disease (Feher et al.,
1990). Animal studies show that it may
protect against radiation damage caused by
x-rays (Flemming, 1971), and it gave
"complete protection" to rats against brain
damage caused by the potent nerve toxin
triethyltin sulfate (Varkonyi et al., 1971).
European hospital emergency rooms use
intravenous milk thistle extract to counteract
cases of liver poisoning from toxins such as
those in the Amanita phalloides mushroom.
Bilberry extract (Vaccinium myrtillus):
Bilberry extract is believed to help prevent or
treat fragile capillaries. Capillary fragility
can cause fluid or blood to leak into the
tissues, causing hemorrhage, stroke, heart
attack, or blindness. Less serious effects
include a tendency to bruise easily, varicose
veins, poor night vision, coldness, numbing,
and leg cramping. Bilberry extract may
protect capillaries and other small blood
vessels by increasing the flexibility of red
blood cell membranes. This action allows
capillaries to stretch, increasing blood flow,
and red blood cells can deform into a shape
that eases their way through narrow
capillaries.
European clinical trials have shown the
effectiveness of Bilberry extract for venous
13
insufficiency of the lower limbs in 18 to 75
years old subjects (Corsi, 1987; Guerrini,
1987). It has been used to treat varicose veins
in the legs, where it significantly improved
symptoms of varicose syndrome such as
cramps, heaviness, calf and ankle swelling,
and numbness (Gatta, 1982). These trials
revealed no significant side effects, even at
50 percent over the normal dose. In two
clinical trials, a standardized Bilberry extract
was given to 115 women with venous
insufficiency and hemorrhoids following
pregnancy. Both studies documented
improvements of symptoms, including pain,
burning, and pruritus, all of which
disappeared in most cases (Baisi, 1987;
Teglio et al., 1987).
Ginkgo (Ginkgo biloba) extract: Though
this oriental herb has a different traditional
use in Asia, Ginkgo biloba is one of Europe's
most lucrative phytomedicines (Duke, 1988).
In Europe, ginkgo is used mainly against
symptoms of aging. It is believed to stimulate
circulation and oxygen flow to the brain,
which can improve problem solving and
memory. It was shown to increase the brain's
tolerance for oxygen deficiency and to
increase blood flow in patients with
cerebrovascular disease (Haas, 1981). No
other known circulatory stimulant, natural or
synthetic, has selectively increased blood
flow to disease-damaged brain areas. In a
French study, "the results confirmed the
efficacy of [ginkgo extract] in cerebral
disorders due to aging" (Taillandier et al.,
1988). In another experiment, those given
ginkgo showed consistent and significant
improvement over the control group on all
tests, including mobility, orientation,
communication, mental alertness, recent
memory, and other factors (Weitbrecht and
Jansen, 1985). A "digit copying test" and a
computerized classification test confirmed
the improved cognitive function related to
use of this herb (Rai et al., 1991).
Ginkgo extracts also stimulate circulation in
the limbs, reducing coldness, numbness, and
cramping. In elderly people, ginkgo
improved pain-free walking distance by 30
percent to 100 percent (Foster, 1990). It also
lowered high cholesterol levels in 86 percent
of cases tested and prevented oxygen
deprivation of the heart (Schaffler and Reeh,
1985). The extract seems to affect neurons
directly, as shown by a recent French study
(Yabe et al., 1992). Another French study
proved protection against cell damage, this
time by ultraviolet light (Dumont et al.,
1992).
A German study documented benefits of
long-term ginkgo use in reducing
cardiovascular risks, including those
associated with coronary heart disease,
hypertension, hypercholesterolemia, and
diabetes mellitus (Witte et al., 1992). By
maintaining blood flow to the retina, ginkgo
extracts inhibited deteriorating vision in the
elderly. An adequate amount of extract may
reverse damage from lengthy oxygen
deprivation of the retina. The assessment by
doctors and patients of the patients' general
condition showed a significant improvement
after therapy. These results show that visual
field damage from chronic lack of blood flow
is reversible (Raabe et al., 1991).
Guayusa (Ilex guayusa): In animal studies, a
concentrated aqueous herbal preparation
from guayusa leaves significantly reduced
uncontrolled appetite, excessive thirst, and
weight loss associated with diabetes
(Swanston-Flatt et al., 1989). Although
guayusa's active principles are not
established, guayusa contains guanidine, a
known hypoglycemic (blood sugar-lowering)
substance (Duke, 1992b).
Purple coneflower (Echinacea): The subject
of more than 350 scientific studies, most
conducted in Europe, Echinacea seems to
stimulate the immune system nonspecifically
rather than against specific organisms. In
laboratory tests, Echinacea increased the
14
number of immune system cells and
developing cells in bone marrow and
lymphatic tissue, and it seemed to speed their
development into immunocompetent cells
(cells that can react to pathogens). It speeds
their release into circulation, so more are
present in blood and lymph, and increases
their phagocytosis rate--the rate at which
they can digest foreign bodies. Echinacea
also inhibits the enzyme hyaluronidase,
which bacteria use to enter tissues and cause
infection. This inhibition helps wounds to
heal by stimulating new tissue formation.
Echinacea exhibits interferonlike antiviral
activity documented through extensive
experiments in Germany. For example, in a
double-blind, placebo-controlled study of
180 volunteers, Echinacea's therapeutic
effectiveness for treating flu-like symptoms
was "good to very good" (Braunig et al.,
1992). Another study showed that orally
administered Echinacea extracts significantly
enhanced phagocytosis in mice (Bauer et al.,
1988). Water-soluble Echinacea components
strongly activated macrophages (Stimpel et
al., 1984), enhanced immune system cell
motility, and increased these cells' ability to
kill bacteria. Other immune system cells
were stimulated to secrete the disease-
fighting tumor necrosis factor and
interleukins 1 and 6 (Roesler et al., 1991).
Another study showed that Echinacea
polysaccharides increased the number of
immunocompetent cells in the spleen and
bone marrow and the migration of those cells
into the circulatory system. The authors said
these effects resulted in excellent protection
of mice against consequences of lethal
listeria and candida infections (Coeugniet
and Elek, 1987).
Saw palmetto (Serenoa repens): These
berries have been used to treat benign
prostatic hypertrophy (BPH). The
standardized extract was clinically evaluated
as effective, has no observed side effects, and
costs 30 percent less than the main
prescription drug marketed in the United
States for BPH (Champpault et al., 1984).
Another effective herbal drug for treating
BPH is made from Prunus africanum and is
widely prescribed in France. It is interesting
to note that the U.S. government is funding a
multicenter study on BPH treatment to find
the most cost-effective criteria for surgical
versus medical treatment. However, because
the study includes neither saw palmetto nor
Prunus africanum, it may not reflect the
"state of the art" in clinical medicine
worldwide.
China
Since the early 19th century, attempts have
been made to understand the actions and
properties of traditional Chinese medicine
through scientific research. Nearly all of this
work has been conducted during the past 60
years, primarily in laboratories in China,
Korea, Japan, Russia, and Germany. It was
also during this time that most of the drugs
used in modern biomedicine were developed.
It is therefore not surprising that most of the
biomedical research into the effects and uses
of traditional Chinese medicinal substances
has attempted to isolate their active
ingredients and to understand their effects on
body tissues.
Several institutions and laboratories at the
forefront of medicinal plant research in
China are working to identify and study the
active ingredients in traditional Chinese
herbal remedies. Researchers at the Institute
of Materia Medica in Beijing study the use of
herbal remedies to prevent and treat the
common cold, bronchitis, cancer, and
cardiovascular disease and to prevent
conception. The institute has isolated
compounds such as bergenin from Ardisia
japonica, traditionally used to treat chronic
bronchitis, and monocrotaline from
Crotalaria sessiliflora, used in folk medicine
to treat skin cancer. Most of China's 5,000
medicinal plant species are represented in the
institute's herbarium. Other Chinese research
15
organizations with major programs on
medicinal herbs are the Institute of Chinese
Medicine, Beijing; the Institute of Materia
Medica, Shanghai; the Institute of Organic
Chemistry, Shanghai; the Municipal Hospital
of Chinese Traditional Medicine, Beijing; the
College of Pharmacy, Nanking; and the
Department of Organic Chemistry and
Biochemistry, Beijing University (Duke and
Ayensu, 1985).
Many herbs in China have been extensively
studied by using methods acceptable from a
Western perspective. For example, a 1992
article in the Journal of Ethnopharmacology
reported that during the preceding 10 years
more than 300 original papers on Panax
ginseng had been published in Chinese and
English (Liu and Xiao, 1992). Ginseng is one
of the world's most thoroughly researched
herbs. Following is an overview of recent
research on ginseng and other herbs in China.
Unless otherwise indicated, the data on
specific herbs are taken from Chinese Herbal
Medicine: Materia Medica, revised edition,
compiled and translated by Dan Bensky and
Andrew Gamble (1993).
Ginseng root (Panax ginseng): The Chinese
first used oriental ginseng, Panax ginseng
(ren shen) more than 3,000 years ago as a
tonic, a restorative, and a specific treatment
for several ailments. By the 10th century,
oriental ginseng had traveled the Silk Road to
the Arabic countries (Kao, 1992), and during
the next 4 centuries it spread to Europe,
where the French, among others, used it to
treat asthma and stomach troubles (Vogel,
1970).
In modern times, ginseng has been
extensively studied in China, Japan, and
Korea and, to a lesser degree, in the United
States. In its various forms, ginseng or its
compounds have various physiological
effects. These include antistress capabilities
(Cheng et al., 1986; Yuan et al., 1988),
antihypoxia effects (Cheng et al., 1988; Han
et al., 1979; Qu et al., 1988), alteration of
circadian rhythms by modifying
neurotransmitters (Lu et al., 1988; Zhang and
Chen, 1987), cardiac performance effects
(Chen et al., 1982), protection against
myocardial infarction in animals (Chen,
1983; Fang et al., 1986), histamine response
effects (Zhang et al., 1988), inhibition of
platelet aggregation (Shen et al., 1987; Yang
et al., 1988), alteration of circadian variation
of plasma corticosterone (Li et al., 1988),
modulation of immune functions (Qian et al.,
1987; Wang et al., 1980), and delay of the
effects of aging (Tong and Chao, 1980;
Zhang, 1989).
Fresh ginger rhizome (Zingiber officinale):
In one study, preparations of sheng jiang,
Zingiber officinale, and brown sugar were
used to treat 50 patients with acute bacillary
dysentery. A cure rate of 70 percent was
achieved in 7 days. Abdominal pain and
tenesmus (an urgent but ineffectual attempt
to urinate or defecate) disappeared in 5 days,
stool frequency returned to normal in 5 days,
and stool cultures were negative within 4
days, with no side effects.
In another study, 6 to 10 thin pieces of sheng
jiang placed over the testes were used to treat
acute orchitis (inflammation of the testicles).
The ginger was changed daily or every other
day. All participants felt a hot-to-numbing
sensation in the scrotum, while a few
reported local erythema and edema. Among
24 patients in the study, average cure time
was 3 days. In a control group of four
patients, average healing time was 8.5 days.
This technique is not recommended for
patients with scrotum lesions.
Chinese foxglove root (Rehmannia
glutinosa): A preparation of this herb
Rehmannia glutinosa (sheng di huang) and
Radix glycyrrhiza uralensis (gan cao) was
used to treat 50 cases of hepatitis in various
stages. Within 10 days, 41 cases showed
improved symptoms, reduced liver and
spleen size, and improved liver function
tests. Experiments from the 1930s seemed to
16
show that sheng di huang, given to rats via
gastric lavage or injection, lowered serum
glucose levels. Later studies of this problem
showed variable results. Work in Japan
showed that the herb is useful in treating
experimental hyperglycemia in rats. In other
studies, decoctions of sheng di huang have
been used to treat rheumatoid arthritis in
adults and children. In one uncontrolled
study, 12 subjects all showed reduced joint
pain and swelling, increased function,
improved nodules and rash, and lowered
temperature. The followup of the treatment
over 3 to 6 months showed only one relapse
case that was treated successfully with the
same preparation.
Baical skullcap root (Scutellaria
baicalensis): Scutellaria baicalensis, was
shown to inhibit the skin reaction of guinea
pigs to passive allergic and histamine tests. It
has been shown to be effective in treating
guinea pigs with allergic asthma. S.
baicalensis also prevented pulmonary
hemorrhage in mice subjected to very low
pressure. S. baicalensis has an inhibitory
effect against many kinds of bacteria in vitro,
including Staphylococcus aureus,
Corynebacterium diphtheriae, Pseudomonas
aeruginosa, Streptococcus pneumoniae, and
Neisseria meningitidis. In one report, one
strain of bacteria (S. aureus) that was
resistant to penicillin remained sensitive to
this herb. According to one study, 100
patients with bacillary dysentery received a
prescription composed mainly of S.
baicalensis. Mean recovery times were 2.5
days until symptoms disappeared, 3.3 days
until normal stool examination, and 4.3 days
until negative stool cultures.
Coptis rhizome or yellow links (Coptis
chinensis): Coptis chinensis, and one of its
active ingredients, berberine, have broad
effects in vitro against many microbes. It
strongly inhibits many bacteria that cause
dysentery; it is more effective than sulfa
drugs but less effective than streptomycin or
chloramphenicol. Decoctions of h C.
chinensis have been effective against some
bacteria that developed resistance to
streptomycin and other antibiotics. The herb's
antimicrobial ingredient is generally
considered to be berberine. Experiments on
chicken embryos show that C. chinensis has
an inhibitory effect against flu viruses and
the Newcastle virus.
C. chinensis preparations have a strong
inhibitory effect in vitro against many
pathogenic fungi. Capsules of powdered C.
chinensis were given to patients with typhoid
fever, with good results. In one report, two
cases that were resistant to antimicrobials
responded to this herb. In another study, 30
cases of pulmonary tuberculosis were treated
with C. chinensis for 3 months; all improved.
A 10-percent solution of C. chinensis also
was used to treat 44 cases of scarlet fever. It
was as effective as penicillin or a
combination of penicillin and a sulfa drug. C.
chinensis also has been successfully used to
treat diphtheria; in one study, the fever
subsided in 1 to 3 days. C. chinensis
ointments or solutions promoted healing and
reduced infections in first-and second-degree
burns. It also has positive effects on blood
pressure, smooth muscle, lipid metabolism,
and the central nervous system; is effective
as an anti-inflammatory; and has been used
successfully in gynecology, ophthalmology,
and dermatology patients.
Woad leaf (Isatis tinctoria): Isatis tinctoria,
kills some kinds of bacteria, including some
strains resistant to sulfa drugs. It was
reported effective in hundreds of cases of
encephalitis B, with cure rates of 93 percent
to 98 percent. In most cases the fever
subsided in 1 to 4 days, and symptoms
disappeared 3 to 5 days later. I. tinctoria has
been effective by itself in mild and moderate
cases; other herbs, acupuncture and western
drugs should be added in severe cases.
In a study of 100 subjects, only 10 percent of
the group given I. tinctoria decoction twice
17
daily had upper respiratory infections during
the study period versus 24 percent of the
control group. When a mixture of decoctions
of I. tinctoria and Herba taraxaci mongolici
cum radice was given to 150 children with
measles, signs and symptoms disappeared in
4 to 5 days. In 68 of 100 cases, I. tinctoria
was used successfully to treat infectious
hepatitis.
Wild chrysanthemum flower
(Chrysanthemum indicum), Chrysanthemum
indicum, has been used to treat hypertension,
either alone as an infusion or with Elos
lonicerae japonicae and Herba taraxaci
mongolicicum radice in a decoction. C.
indicum Ye ju hua preparations have an
inhibitory effect in vitro against some
bacteria and viruses. Preparations given
orally or as injections lowered blood
pressure. Preparations made from the whole
plant had more toxicity and less efficacy than
those made from the flower alone.
One study was performed with 1,000 subjects
to see whether C. indicum would prevent
colds. The subjects were compared with their
own histories and against a matched set of
261 controls. A C. indicum decoction was
taken once a month by people with histories
of infrequent colds, twice a month by those
with three to five colds a year, and weekly by
those with frequent colds. Comparison with
their own histories showed a 13.2-percent
reduction in frequency, but a greater
frequency in comparison with the controls.
At the same time, another clinical series of
119 cases of chronic bronchitis was
observed. Using the same preparation, this
group experienced a 38 percent reduction in
acute attacks in comparison with their
seasonally adjusted rate for the previous year.
Bletilla rhizome (Bletilla striata): Bletilla
striata, in powdered form or in a powder
made from starch and a decoction of B.
striata helped control bleeding in seven of
eight cases of surgical wounds to dogs' livers.
Pure starch was much less effective. Similar
results have been achieved with sponges
soaked in a sterile water-extraction solution
of the herb. In anesthetized dogs with 1-mm-
diameter stomach perforations, washing the
perforations with 9 g of powdered B. striata
through a tube closed the perforations in 15
minutes. Eight hours after the procedure the
abdomens were opened, and no trace of
gastric contents was found. When the dogs'
stomachs were full or the perforations were
larger, powdered bai ji had no effect.
In another study, powdered bai ji was used to
treat 69 cases of bleeding ulcers, and in all
cases the bleeding stopped within 6.5 days.
In another series of 29 perforated ulcer cases,
the powdered herb was successful in 23
cases, 1 required surgery, and the other 4
died (1 went into hemorrhagic shock while
under treatment, and the other 3 were in
precarious condition on admission).
In other studies, powdered bai ji was given to
60 chronic tuberculosis patients who had not
responded to normal therapy. After taking the
herb for 3 months, 42 were clinically cured,
13 significantly improved, and 2 showed no
change. A sterile ointment made from
decocted B. striata and petroleum jelly was
used in a local application to treat 48 cases of
burns and trauma (less than 11 percent of
total body area). Dressings were changed
every 5 to 7 days, and all patients recovered
within 1 to 3 weeks.
Salvia or cinnabar root (Salvia
miltiorrhiza): Dan shen, Salvia miltiorrhiza,
caused coronary arteries to dilate in guinea
pig and rabbit heart specimens. In one study
of 323 patients given a dan shen preparation
for 1 to 9 months, there was marked
improvement in 20.3 percent of clinical cases
and general improvement in 62 percent of
cases. Results were best when patients had
coronary artery disease and no history of
myocardial infarction. In a clinical series of
more than 300 patients with angina pectoris,
a combination of dan shen and Lignum
dalbergiae odoriferae (jiang xiang) has given
18
intramuscularly or intravenously improved
symptoms in 82 percent and
electrocardiograms in 50 percent of cases.
Corydalis rhizome (Corydalis yanhusuo):
Yan hu suo, Corydalis yanhusuo, is widely
used to treat pain. Powdered yan hu suo is a
very strong analgesic, about 1 percent the
strength of opium. In one clinical study of 44
patients with painful or difficult
menstruation, 50 mg of the yan hu suo active
ingredient, dihydrocorydaline, given 3 times
a day brought significant relief in 14 cases
and reduced pain in another 18 cases. Side
effects included reductions in menstrual
flow, headaches, and fatigue.
Root of Szechuan aconite (Aconitum
carmichaeli): Aconitum carmichaeli toxicity
has always been a major concern. It is
usually prepared with salt to reduce its
toxicity. Anesthetized dogs or cats given
aconite preparations showed a sharp drop in
blood pressure. In another experiment,
aconite caused blood vessels to dilate in
lower extremities and coronary vessels. In
normal dosage for humans, aconite slightly
lowers blood pressure, while a large overdose
can cause rapid heartbeat or ventricular
fibrillation. This herb seems to have some
cardiotonic function and a regulatory effect
on heart rhythm. Administered with herbs
such as Cortex Cinnamomi cassia, Panax
ginseng, Rhizoma Zingiberis officinalis and
Radix Glycyrrhiza uralensis, aconite raised
blood pressure in animals with acute
hemorrhage. In one study, patients with
congestive heart failure were treated by
intramuscular injections of a aconite
preparation. In all cases, including one of
cardiogenic shock, the result was increased
cardiac output as well as decreased breathing
difficulty, liver swelling, and general edema.
few cases showed temporary side effects of
flushing and slight tremors.
Licorice root (Glycyrrhiza uralensis): Gan
cao, Glycyrrhiza uralensis, preparations have
been used with common antituberculosis
drugs in many large clinical studies among
patients who did not respond to standard
treatment. In most cases, symptoms
improved or disappeared and x rays
improved markedly. In many clinical studies
using gan cao for ulcers with groups of 50 to
200 subjects, effectiveness was around 90
percent. It was especially useful to treat the
pain, which disappeared or improved within
1 to 3 weeks. The more recent the onset of
disease, the better the results: In almost all
cases the powdered herb was most effective.
In rats with experimentally induced
atherosclerosis, gan cao lowered cholesterol
levels and stopped progression of lesions. In
several experiments, the herb reduced the
toxicity of some substances, including
cocaine, and moderately reduced the toxicity
of others, including caffeine and nicotine.
When decocted with fu zi, it sharply reduced
fu zi's toxicity.
Dryopteris root, or shield fern (Dryopteris
crassirhizoma): Dryopteris crassirhizoma is
called dong bei guan zhong because it is
found in northeastern (dong bei) China. In
recent times this herb has been prescribed as
a preventive measure during influenza
epidemics. Guan zhong preparations strongly
inhibit the flu virus in vitro. In one clinical
trial, 306 people took twice-weekly doses of
guan zhong and 340 served as controls. In the
treatment group, 12 percent became ill versus
33 percent of the controls. Local versions of
guan zhong from Guangdong, Hunan, and
Jiangxi provinces have mildly inhibitory
effects in vitro against many pathogenic
bacteria. Guan zhong also is effective against
pig roundworms in vitro, and it expels
tapeworms and liver flukes in cattle.
In other studies, decoctions and alcohol
extracts of dong bei guan zhong strongly
stimulated the uterus of guinea pigs and
rabbits. It increased the frequency and
strength of contractions. Intramuscular
injections of dong bei guan zhong
preparations were used with more than 91-
19
percent success to treat postpartum,
postmiscarriage, and postsurgical bleeding.
Garlic bulb (Allium sativum): Da suan,
Allium sativum, preparations have a strong
inhibitory effect in vitro against amoebae. In
one study, concentrated da suan decoctions
were used to treat 100 cases of amebic
dysentery. The cure rate was 88 percent, and
the average hospital stay was 7 days. In this
clinical study, purple-skinned bulbs were
more effective than white-skinned bulbs.
Patients were discharged on a regimen that
included purple-skinned da suan in the daily
diet.
When used with Chinese leek seeds, da suan
juice and decoctions have a strong inhibitory
effect in vitro against many pathogenic
bacteria. Da suan can be effective against
bacteria that resist penicillin, streptomycin,
and chloramphenicol. In one clinical study,
130 patients with bacillary dysentery were
given da suan enemas. Of the followup
colonoscopies, 126 showed that pathological
changes were resolved within 6.3 days. In
other studies with hundreds of patients, da
suan's effectiveness against bacillary
dysentery was more than 95 percent. Again,
purple-skinned garlic seemed more effective
than white-skinned and fresh bulbs were
more effective than old ones. In one clinical
study, 17 cases of encephalitis B were treated
with an intravenous drip of da suan
preparations and supportive care. Except for
one fatality, all other cases recovered.
India
Ayurveda, the oldest existing medical
system, is recognized by WHO and is widely
practiced. The word comes from two Sanskrit
roots: ayus means life or span; Veda means
knowledge or science. India recently
increased research on traditional Ayurvedic
herbal medicines after observations that they
are effective for conditions to which they
have traditionally been applied. For example,
the ancient Sanskrit text on Ayurveda, the
Sushruta Samhita, noted that Commiphora
mukul was useful in treating obesity and
conditions equivalent to hyperlipidemia, or
increased concentrations of cholesterol in the
body. The plant has been used by Ayurveda
practitioners for at least 200 years and may
have been in use since the writing of the
Sushruta Samhita more than 2,000 years ago.
In a recent study, the crude gum from
Commiphora mukul significantly lowered
serum cholesterol in rabbits with high
cholesterol levels. The plant substance also
protected rabbits from cholesterol-induced
atherosclerosis (hardening of the arteries).
This finding led to pharmacological and
toxicological studies that showed this herbal
remedy to be effective in humans, with no
adverse side effects. Approval was obtained
from the national regulatory authority in
India for further clinical trials (Verma and
Bordia, 1988). The drug is marketed in India
and other countries for treatment of
hyperlipidemia (Chaudhury, 1992).
The following other Ayurvedic herbs have
recently been studied in India under modern
scientific conditions:
Eclipta alba: In Ayurvedic medicine, Eclipta
alba is said to be the best drug for treating
liver cirrhosis and infectious hepatitis. E.
alba and Wedelia calendulacea are widely
used in India for jaundice and other liver and
gall bladder ailments. One recent study
showed that a liquid extract from fresh
Eclipta leaves was effective in vivo in
preventing acute carbon tetrachloride-
induced liver damage in guinea pigs.
Clinically, the powdered drug is effective
against jaundice in children (Wagner et al.,
1986).
Common teak tree (Tectona grandis):
Trunk wood and bark of the common teak
tree are described in Ayurvedic medicine as a
cure for chronic dyspepsia (indigestion)
associated with burning pain. Teak bark
forms an ingredient of several Ayurvedic
preparations used to treat peptic ulcer.
Pandey et al. (1982) experimentally screened
20
teak bark and its effect on gastric secretory
function and ulcers in albino rats and guinea
pigs. The solution reduced gastric ulcers in
restrained albino rats and significantly
inhibited gastric and duodenal ulcers in
guinea pigs.
Indian gooseberry (Emblica officinalis):
Jacob et al. (1988) studied the effect of total
serum cholesterol by using Amla, Emblica
officinalis to supplement the diets of normal
and hypercholesterolemic men aged 35-55.
The supplement was given for 28 days in raw
form. Normal and hypercholesterolemic
subjects showed decreased cholesterol levels.
Two weeks after the supplement was
withdrawn, total serum cholesterol levels of
the hypercholesterolemic subjects rose to
almost initial levels.
Picrorhiza kurroa: P. kurroa rhizomes
(Kutki) are main ingredients of a bitter tonic
used in fever and dyspepsia (indigestion).
This drug occupies a prestigious position in
Ayurveda. It often substitutes for Gentiana
kurroo, the Indian gentian. Powdered
rhizomes also are used as a remedy for
asthma, bronchitis, and liver diseases. Other
researchers have reported that a P. kurroa-
derived mixture called kutkin exhibits
hepatoprotective activity; that P. kurroa acts
as a bile enhancer; that it has antiasthmatic
effects in patients with chronic asthma; and
that it has immunomodulating activity in
cell-mediated and humoral immunity.
Another study (Bedi et al., 1989) shows that
P. kurroa works to boost the immune system
as a supplement to other treatments in
patients with vitiligo, a skin disease that
causes discolored spots.
Articulin-F: This herbomineral formula
contains roots of Withania somnifera, stem of
Boswellia serrata, rhizomes of Curcuma
longa, and a zinc complex. Kulkarni et al.
(1991) performed a randomized, double-
blind, placebo-controlled crossover study of
articulin-F to treat osteoarthritis, a common
progressive rheumatic disease characterized
by degeneration and eventual loss of articular
cartilage. Articulin-F treatment produced a
significant drop in pain severity and
disability score, whereas radiological
assessment showed no significant changes.
Abortifacient plants: Nath et al. (1992)
organized a survey program in Lucknow and
Farrukhabad, two towns in Uttar Pradesh,
India, from March to July 1987. During the
survey, they recorded the common folk
medicine used by women and consulted
Ayurvedic and Unani drug encyclopedias for
the antireproductive potential of the
following medicinal plants: leaves of
Adhatoda vasica, leaves of Moringa oleifera,
seeds of Butea monosperma, seeds of
Trachyspermum ammai, flowers of Hibiscus
sinensis, seeds of Abrus precatorius, seeds of
Apium petroselinium, buds of Bambusa
arundensis, leaves of Aloe barbadensis,
seeds of Anethum sowa, seeds of Lepidium
sativum, seeds of Raphanus sativus, seeds of
Mucuna pruriens, seeds of Sida cordifolia,
seeds of Blepharis edulis, flowers of Acacia
arabica, and seeds of Mesua ferrea. Plant
materials were collected, authenticated,
chopped into small pieces, air dried in shade,
and then ground to a 60-mesh powder.
During the survey, female rats were given
aqueous or 90-percent ethanol extracts of the
plants orally for 10 days after insemination
by males, with special attention to effects on
fetal development. Leaf extracts of Moringa
oleifera and Adhatoda vasica were 100-
percent abortive at doses equivalent to 175
mg/kg of starting dry material.
Neem (Azadiractica indica) and turmeric
(Curcuma longa): In the Ayurveda and
Sidha systems of medicine, neem and
turmeric are used to heal chronic ulcers and
scabies. Charles and Charles (1991) used
neem and turmeric as a paste to treat scabies
in 814 people. Ninety-seven percent of cases
were cured within 3 to 15 days. The
researchers found this to be a cheap, easily
available, effective, acceptable mode of
21
treatment for villagers in developing
countries, with no adverse reactions.
Trikatu Trikatu is an Ayurvedic preparation
containing black pepper (Piper nigrum), long
pepper (P. longum), and ginger (Zingiber
officinale). It is prescribed routinely for
several diseases as part of a multidrug
prescription. These herbs, along with
piperine (alkaloid of peppers), have
biological effects in mammals, including
enhancement of other medicaments. Of 370
compounds listed in the Handbook of
Domestic Medicines and Common
Ayurvedic Remedies (Handbook, 1979), 210
contain trikatu or its ingredients. Trikatu is a
major decoction used to restore the
imbalance of kapha, vata, and pitta, the
body's three humors (see the "Alternative
Systems of Medical Practice" chapter). Piper
species are used internally to treat fevers,
gastric and abdominal disorders, and urinary
difficulties. Externally they are used to treat
rheumatism, neuralgia, and boils. P. longum
and P. nigrum are folklore remedies for
asthma, bronchitis, dysentery, pyrexia, and
insomnia (Akamasu, 1970; Chopra and
Chopra, 1959; Perry, 1980; Youngken,
1950). In Chinese folklore, P. nigrum is
mentioned as a treatment for epilepsy (Pei,
1983). The efficacy of P. longum fruits in
reducing asthma in adults (Upadhyaya et al.,
1982) and children has been reported
(Dahanukar et al., 1984). P. nigrum
promoted digestive juice secretion (Shukla,
1984) and increased appetite (Sumathikutty
et al., 1979). P. longum was reported useful
in patients with gastric disorders
accompanied by clinical symptoms of
achlorhydria (Kishore et al., 1990).
Native American Indian Herbal Medicine In
1977 and 1978, Croom (Kirkland et al.,
1992) spent 2 years documenting plant
remedies among the Lumbee Indians, the
largest group of Native American Indians
east of the Mississippi River. Following are
some often-used medicinal plant remedies of
the Lumbee:
Rabbit tobacco (Gnaphalium
obtusifolium): These annual herbs reach a
height of 1 to 3 feet and have erected stems
with brown, shriveled leaves persisting into
winter and stems covered with feltlike hairs
in summer. The leaves are 1 to 3 inches long,
and alternate. The flowers, minute in whitish
heads, appear in late summer to fall. Fields
pastures and disturbed areas are the sites of
this common native plant of the eastern
United States. It is used to treat colds, flu,
neuritis, asthma, coughs, and pneumonia.
This is one of the most popular plants used
by the Lumbee. The decoction is drunk hot,
like most medicinal teas, and is said to cause
profuse sweating.
Poke (Phytolacca americana): Also a
common native plant of the eastern United
States, poke is a robust, perennial herb that
reaches a height of 9 feet. It has a large white
root; a green, red, or purple stem; alternate
leaves up to 1 foot long; and white flowers in
a drooping raceme. The fruit is a dark purple
to black berry, round, soft, and juicy. Poke is
found in waste areas, road sides, disturbed
habitats, fields, and pastures. It is used to
treat asthma, spring tonic, boils (risings),
sores, intestinal worms in people or chickens,
cramps, and stomach ulcers. Poke is said to
inhibit gram-positive and gram-negative
bacteria and is listed as a parasiticide in the
British Herbal Pharmacopoeia.
Pine (Pinus echinata, P. palustris, P.
virginiana). Pines are resinous evergreen
trees with needlelike foliage leaves in
bundles of two to five. The male and female
reproductive structures are in separate cones
on the same tree; the female cone matures to
a large woody cone with winged seeds;
pollen sheds in the spring. Pine is used to
treat colds, flu, pneumonia, fever, heartburn,
arthritis, neuritis, and kidney problems.
Oak (Quercus laevis, Q. phellos). These
deciduous trees have alternate, unlobed, or
22
variously lobed leaves and minute flowers;
the fruit is an acorn. Oak is used to treat
kidney problems (including Bright's disease),
bladder problems, virus, menstrual bleeding,
diarrhea, sores, sprains, and swellings. It is
also used as a booster for other remedies.
Sassafras (Sassafras albidum): These
deciduous, aromatic, small trees or shrubs
have green twigs and--when mature--thick,
furrowed bark. The leaves are 2.5 to 5 inches
long; alternate; and either unlobed lobed on
one side, or three-lobed. Flowers are small
and yellow in clusters at the end of twigs.
The fruit is a dark blue, fleshy drupe on a
bright red stalk and cup. This common native
plant of fencerows, woodland borders, and
old fields of the eastern United States is used
to treat measles, chicken pox, colds, flu, and
fever. It is also used as a "shotgun heart
remedy," a blood purifier, and a spring tonic.
According to the Handbook of Northeastern
Indian Medicinal Plants Native American
Indians used about 25 percent of the flora of
Maryland for medicinal purposes (Duke,
1986). A few examples of medicinal plant
species in Maryland are as follows:
Sweetflag or calamus (Acorus sp.): The root
has been used to treat flatulence, colds,
coughs, heart disease, bowel problems, colic,
cholera, suppressed menses, dropsy, gravel,
headache, sore throat, spasms, swellings, and
yellowish urine. Some tribes considered the
root a panacea; others thought it had mystic
powers.
Bloodroot (Sanguinaria sp.): This very
poisonous plant is emetic, laxative, and
emmenagogue. It has been used to treat
chronic bronchitis, diphtheria, sore throat,
uterine and other cancers, tetterworm,
deafness, and dyspepsia; it has also been
used as a pain reliever and sedative. In
Appalachia it is carried as a charm to ward
off evil spirits.
Yellowdock (Rumex crispus): contains
anthraquinones of value in the treatment of
ringworm and some types of psoriasis.
Rumicin from the roots reportedly destroys
skin parasites. The anthraquinones are
proven laxatives.
Coneflower (Dracopis sp., Echinacea sp.,
Ratibida sp., Rudbeckia sp.): Echinacea
(purple coneflower) reportedly increases
resistance to infection, bad coughs,
dyspepsia, venereal disease, insect bites,
fever, and blood poisoning.
Witch hazel (Hamamelis virginiana;
H. vernalis; H. japonica; H. mollis): A
proven astringent and hemostat (to stop
bleeding).
Lobelia (Lobelia cardinalis): Cardinal
flower was used to indurate ulcers and to
treat stomachache, syphilis, and worms. The
leaf tea was used for cold, croup, epistaxis
(nosebleed), fever, headache, rheumatism,
and syphilis. Lobelia inflata (Indian tobacco)
yields lobeline sulfate, used in antitobacco
therapy. It is used as an antiasthmatic, an
expectorant, and a stimulant for bronchitis; it
also is used to treat aches, asthma, boils,
croup, colic, sore throat, stiff neck, and
tuberculosis of the lungs. Some smoked the
herb to break a tobacco habit.
Mayapple (Podophyllum peltatum): Early
Native American Indians used the roots as a
strong purgative, liver cleanser, emetic, and
worm expellant. A resin made from the plant
has been used to treat venereal warts and
exhibits antitumor activity; it also is used for
snakebite and as an insecticide for potato
bugs.
Wild cherry (Prunus virginiana): The bark
has been used to treat sores and wounds,
diarrhea, cold and cough, tuberculosis,
hemoptysis, scrofula, sore throat, stomach
cramps, and piles. Native American Indians
treated snow blindness by leaning over a
kettle of boiling bark "tea." Some smoked the
bark for headache and head cold.
White willow (Salix alba): The bark is
astringent, expectorant, hemostatic, and
tonic. It is used to treat calluses, cancers,
corns, tumors, and warts. Salicylic acid (used
23
to make aspirin) is found in white willow.
Leaves and bark of different willows are used
in a tea to break a fever. Some Native
American Indians burned willow stems and
used the ashes to treat sore eyes.
Barriers to Herbal Medicine Research in
the United States
The regulatory lockout of natural remedies
has crippled natural products research in U.S.
universities and hospitals. There is no
dedicated level of support by the Federal
Government for herbal medicine research.
Herbalists may apply under existing
guidelines for approval of new
pharmaceutical drugs, but this burden is
unrealistic because the total cost of bringing
a new pharmaceutical drug to market in the
United States is an estimated $140 million to
$500 million (Wall Street Journal, 1993),
because botanicals are not patentable,
although they can be patented for use. An
herbal medicine manufacturer could never
recover this expenditure. Therefore, herbal
remedies are not viable candidates for the
existing drug approval process:
pharmaceutical companies will not risk a loss
of this magnitude, and herb companies lack
the financial resources even to consider
seeking approval.
Another major barrier is that the academic
infrastructure necessary for proper study of
ethnomedical systems has seriously eroded in
recent decades and must be reinvigorated to
accommodate the newly recognized need for
preserving traditional medical systems and
biological diversity. Pharmacognosy and
other academic studies of medicinal plants
have declined alarmingly in the United
States. North American scientists, once at the
forefront of this research, lag behind their
European and Japanese colleagues, reducing
the likelihood that they will discover useful
new medicines from plants. This problem is
exacerbated by the fact that much of the
discipline of botany has moved away from
field studies and into molecular and
laboratory approaches. Today only a handful
of active full-time ethnobotanists are trained
to catalog information on the medicinal
properties of plants.
In contrast to the United States, many
European and Asian countries have taken a
more holistic approach to researching the
efficacy of herbal remedies. In Germany,
France, and Japan, the past 20 years have
seen a rapid increase in research into and use
of standardized, semipurified (still containing
multiple individual chemicals) herbal
extracts called phytomedicines. In Europe
and Japan, phytomedicines treat conditions
ranging from serious, life-threatening
diseases such as heart disease and cancer to
simple symptomatic relief of colds, aches and
pains, and other conditions treated by OTC
drugs in the United States. Phytomedicines
include preventive medicines, an often-
neglected area of medicine in the United
States. The FDA has approved many plant-
derived "heroic" cures, but never a plant-
derived preventive medicine.
Research Needs and Opportunities
Much modern-day medicine is directly or
indirectly derived from plant sources, so it
would be foolish to conclude that plants offer
no further potential for the treatment or cure
of major diseases. Worldwide, the botanical
pharmacopoeia contains tens of thousands of
plants used for medicinal purposes.
Hundreds, perhaps thousands, of definitive
texts, monographs, and tomes on herbal
remedies exist. But most of this information
is outside current databases and remains
unavailable to physicians, researchers, and
consumers.
Globally, herbal remedies have been
researched under rigorous controls and have
been approved by the governments of
technologically advanced nations. The
scientific validation is good to excellent, and
the history of clinical use is even stronger.
Many phytomedicines have been used by
thousands of physicians in their practices and
24
are consumed under medical supervision by
tens of millions of people.
A great deal of literature exists on the use of
phytomedicines in Europe and within native
medical systems in China, Japan, India, and
North America. Much of this literature can
be found in a unique database developed and
maintained by the University of Illinois at
Chicago, College of Pharmacy. The database,
NAPRALERT (Natural Products Alert),
holds references for more than 100,000
scientific articles and books on natural
products (plant, microbial, and animal
extracts). NAPRALERT includes
considerable data on the chemistry and
pharmacology (including human studies) of
secondary metabolites of known structure,
derived from natural sources. About 80
percent of the references are from post-1975
literature, the rest from pre-1975 literature
(see the "Research Databases" chapter for
more information on NAPRALERT).
In 1981 the U.S. Department of Agriculture
(USDA), in conjunction with the National
Cancer Institute, concluded a 25-year study
of plants with possible anticancer properties.
One result is published in the Handbook of
Medicinal Herbs (Duke and Ayensu, 1985).
This work lists 365 folk medicinal species
and identifies more than 1,000
pharmacologically active phytochemicals.
Toxicity estimates are given for many of
these biologically active compounds. More
recently, Dr. James Duke of USDA
published databases on biologically active
compounds of more than 1,000 species of
plants with potential medicinal uses (Duke,
1992a, 1992b). Duke proposed to FDA a
computer-calculated toxicity index to parallel
the Ames Human Exposure Rodent Potency
(HERP) index for carcinogenicity. He calls
his index the Better Understanding of
Relative Potency (BURP) index.
Much of the literature on traditional Chinese
and other Asian countries' herbal medicine is
only now beginning to be translated into
English. While much of this information is in
the form of folklore, there is a growing body
of data from scientifically valid literature on
herbal medicine research in China as well as
India and Japan. In 1986, the book Chinese
Herbal Medicine: Materia Medica was
published by Dan Bensky and Andrew
Gamble, both of whom are fluent in Chinese
dialects and studied herbal medicine in Asia.
Revised in 1993 (Bensky and Gamble, 1993),
it presents an indepth study of 470 herbs used
in traditional Chinese medicine. Each entry
details the traditional properties, actions and
indications, principal combinations, dosage,
and contraindications of the herbs, as well as
summaries of abstracts regarding
pharmacological and clinical research
conducted in Asia. The revised edition also
provides a brief description of the appearance
of each herb.
Although very little laboratory or clinical
research has been performed on Native
American Indian herbal remedies, extensive
listings of herbs and their uses have been
compiled by ethnobotanists for several tribes.
One source, American Indian Medicine
(Vogel, 1970), cites references in the
professional ethnobotanical literature on
herbal medicines for the following tribes:
Alabama-Koasati, Arakara, Algonquian,
Arapaho, Aztec, Catawba, Cheyenne,
Chickasaw, Choctaw, Comanche, Congaree,
Creek, Dakota, Delaware, Hoh, Hopi,
Houma, Huron, Illinois-Miami, Iroquois,
Kwakiutl, Lake St. John Montagnais, Mayan,
Menomini, Mescalero Apache, Malecite,
Meswaki, Michigan, Mohawk, Mohegan,
Natchez, Navajo, Nebraska, Oglala Sioux,
Ojibwa, Omaka, Pawnee, Penobscot, Ponca,
Potawatomi, Quileute, Rappahannock, San
Carlos Apache, Seminole, Sioux, White
Mountain Apache, Ute, Winnebago, Yuma,
and Zuni. Moerman's database (Moerman,
1982) lists more than 2,000 species of Native
American Indian medicinal plants, and Duke
(1986) lists more than 700 eastern ones.
25
These sources--the NAPRALERT database,
USDA laboratory research, the Bensky and
Gamble book, and the Native American
Indian herbal medicinal books--are the
foundation on which the U.S. Government,
particularly the National Institutes of Health
(NIH), can begin substantial research into
herbal medicines.
Much unwritten knowledge resides in the
hands of healers in many societies where oral
transmission of information is the rule.
Unfortunately, in many regions this
information is endangered because there are
no young apprentices to whom elderly
healers can pass on their unwritten wisdom;
the knowledge that has been refined over
thousands of years of experimentation with
herbal medicine is being lost. A major
research opportunity in this area would be to
catalog information on herbal medicines
from thousands of traditional healers in
cultures where these skills are normally
transmitted through an apprentice system.
Some organizations have recently increased
their efforts to catalog endangered herbal
knowledge from traditional medical systems
in Latin America, such as those practiced in
the rain forests of Belize (Arvigo and Balick,
1993) and Peru (Duke and Martinez, in
press).
Basic Research Priorities
Basic research into characterizing these plant
products and compounds in terms of
standardized content and potential toxicity is
needed to allow safe and replicable research
to document clinical efficacy. Basic science
research should be conducted to evaluate
research on the biochemical effects of
traditional herbal prescriptions from Western,
Ayurvedic, oriental, and other traditions (see
the "Alternative Systems of Medical
Practice" chapter).
Clinical Research Priorities
Research in phytomedicines in the United
States could follow on the results of existing
high-quality European and Asian research on
plant medicines and should focus on
replicating results of key studies or
addressing weaknesses in those studies.
Reviews of foreign literature and translations
of non-English literature would be helpful.
Current widespread use of herbal
medications as "food supplements" in the
United States provides a ready base of users,
producers, and practitioners for clinical
research in traditional and modern
applications of botanical medicine.
Key Research Issues
Before a comprehensive research agenda is
developed, several key issues must be
addressed, including the following: the
impending loss of knowledge about
traditional healing in many societies; the
impending loss of large numbers of plant
species of potential medicinal value;
impediments to the use of herbal remedies
outside the cultures in which they originated;
and determination of the conditions under
which herbal medicines are most appropriate,
safe, and effective. Additionally, several
regulatory issues hamper research into herbal
medicines.
Loss of Knowledge
The knowledge of traditional healers in
remote Amazonian or Central American
regions may have the potential to make a
significant contribution to Western society.
But few, if any, practitioners of these lesser
known medical systems practice outside their
native range, and those who still practice
within these regions are elderly and often
have not found younger disciples.
Loss of Plant Species of Potential
Medicinal Value
This loss of knowledge from traditional
healers comes at a time when native floras in
many areas, especially tropical regions, are
being destroyed at an alarming pace. In the
United States alone, an estimated 10 percent
of all species of flowering plants will be
extinct by the year 2000, including an
26
estimated 16 species of medicinally useful
plants (Farnsworth et al., 1985).
One hopeful sign is that the U.S. Government
recently formed a cooperative biodiversity
group including representatives from NIH,
the National Institute of Mental Health, the
National Science Foundation (NSF), and the
U.S. Agency for International Development.
This group intends to fund research to locate
and catalog medicinally active substances
that can be analyzed and used for new
pharmaceutical drug development, while
working to preserve biological diversity in
developing countries.
Use in Practice
Basic to the use of medicinal herbs in many
societies is the practice of using whole,
unrefined plant material. The material may
be leaves, buds, flowers, bark, or roots,
separately or in combination. In some cases
an herbal remedy is a complex mixture of
many plants. There is an age-old belief that
whole-plant medicines have fewer dangerous
side effects and provide a more balanced
physiological action than plant-derived
pharmaceutical drugs whose single
ingredient has been isolated, concentrated,
and packaged as a pill or liquid.
Herbs and herbal preparations generally are
self-administered. Often they are purchased
through native herbalists who prescribe one
or more herbs or preparations on the basis of
medical and health approaches that often
include concepts of attaining balance in the
client's body, psychology, and spirit (see the
"Community-Based Medical Practices"
section of the "Alternative Systems of
Medical Practice" chapter). Consequently, it
is often difficult to assess the relative value
of herbal remedies versus prescription drugs
on a one-to-one basis.
Indeed, herbal remedies of all types,
including those from China, are composed of
a multitude of ingredients whose interactions
with the body are exceedingly complex. A
high level of sophistication of research
methodology is necessary to describe the
interaction between the human body and
substances as complex as those contained in
many herbal remedies. Only recently has
such a rigorous methodology begun to be
developed. For example, the Chinese herb
Herba Hedyotidis diffusae (bai hua she she
cao) has been shown clinically effective in
the prevention and treatment of a variety of
infectious diseases. However, it has not been
demonstrated to have a significant inhibitory
effect in vitro against any major pathogen.
Only as techniques became available to test
the immunological system did it become
apparent that at least part of the herb's effect
was due to its enhancement of the body's
immune response (Bensky and Gamble,
1993).
Another complicating factor in researching
traditional Chinese herbal medicine is the
fact that Chinese medicine characteristically
tries to treat the whole body to alleviate
disease stemming from one body organ.
Therefore, it rarely relies on a single herb to
treat an illness. Instead, formulas usually
contain 4 to 12 different herbs (Duke and
Ayensu, 1985).
Beyond the problem of trying to test herbal
preparations that may contain many active
ingredients is the question of whether the
research eventually will lead to the isolation
of single active ingredients that can be
packaged and sold separately. Intense debate
surrounds the issue of how to conduct
clinical trials of herbal medicines according
to Western pharmaceutical clinical standards.
Critics say there is an inherent problem with
the single-active-ingredient approach
preferred by pharmaceutical companies that
are actively involved in herbal medicine
research. The problem, they say, is that
isolating a single compound may not be the
most appropriate approach in situations
where a plant's activity decreases on further
fractionation (separation of active ingredients
by using solvents) or where the plant
27
contains two or three active ingredients that
must be taken together to produce the full
effect (Chaudhury, 1992). Beckstrom-
Sternberg and Duke (1994) have documented
several cases where synergy has been lost by
using the single-ingredient approach to
developing drugs from plants.
A good example of this single-active-
ingredient versus whole-plant debate is
illustrated by intense interest among
pharmaceutical companies in the compound
called genistein. Genistein is part of a class
of compounds called flavonoids that occur
naturally in plants such as kudzu, licorice,
and red clover. Soybeans contain high
concentrations of genistein, and lima beans
reportedly are even higher in genistein than
soybeans (Duke, 1993). There is increasing
evidence that genistein may inhibit the
growth of cancers of the stomach
(Yanagihara et al., 1993), pancreas (Ura et
al., 1993), liver (Mousavi and Adlercreutz,
1993), and prostate (Peterson and Barnes,
1993). Genistein is believed to inhibit the
growth of cancers because of its
antiangiogenetic properties (i.e., it prevents
the growth of new blood vessels--a process
known as angiogenesis--to tumors).
Genistein is being intensely studied as a
possible preventive or treatment for breast
cancer, which kills an estimated 44,000
women in the United States each year (Duke,
1993). Studies indicate a correlation between
a high intake of foods containing genistein
(soy products) and a low incidence of
hormone-dependent cancers such as breast
cancer (Hirayama, 1986) and prostate cancer
(Baker, 1992). The growth of certain cancers,
especially breast cancers, has been shown to
depend on the female sex hormone estrogen.
Genistein exhibits estrogenlike activity in
plants and is often called a phytoestrogen. In
humans it binds to estrogen receptors (Baker,
1992). It has been suggested that these
phytoestrogens may compete with
endogenous estrogen on the cellular level,
further reducing the cellular proliferation and
the potentially carcinogenic effects of
estrogen (Tang and Adams, 1981). Thus, it
may prevent the growth of estrogen-
dependent cancer by competing for estrogen
sites on the tumor cells.
If genistein is developed as an isolated
pharmaceutical drug, it may have some
action against cancer, but the purified
compound may not be as potent as genistein
in its natural state, and trials may give
misleading results. The reason is that all
plant species containing genistein also
contain other flavonoid compounds, which
may have synergistic effects when ingested
with genistein. Formononetin--a precursor of
equol, which also occurs with genistein--is
said to be more active estrogenically than
genistein (Spanu et al., 1993). Although
genistein clearly inhibits angiogenesis,
several other compounds are
pseudoestrogens. With this in mind, the
question arises: Is a mixture of genistein,
formononetin, and other flavonoids, as
occurs in many plants, more estrogenic (and
antiangiogenic) than an equivalent quantity
of any one of these components? If so, the
herbal or dietary approach may make more
sense than a genistein "silver bullet"
approach.
Safety, Efficacy, and Appropriateness
Opinions about the safety, efficacy, and
appropriateness of medicinal herbs vary
widely among medical and health
professionals in countries where herbal
remedies are used. Some countries'
professionals accept historical, empirical
evidence as the only necessary criterion for
herbal medicine's efficacy. Others would ban
all herbal remedies as dangerous or of
questionable value.
The problem is further complicated by the
fact that many "patent medicines" available
in world trade often are sold as herbal
medicinal preparations when they include
nonherbal substances. These nonherbal
28
additives often include toxic metals
(cinnabar, i.e., mercury) (Kang-Yum and
Oransky, 1992), poisonous substances
(powdered scorpion), or refined prescription
drugs (Catlin et al., 1993). Usually labeled
"Chinese herbal medicine", many of these
products are manufactured in Thailand,
Taiwan, or Hong Kong and exported to the
United States, where they are sold in retail
outlets. The California Department of Health
Services, in conjunction with the Oriental
Herbal Association, recently published a list
of 20 popular Asian patent medicines that
contain toxic ingredients.
Regulatory Issues
The increased use of plant medicines has
potential for improving public health and
lowering health care costs. Phytomedicines,
if combined with the preventive model of
medical practice, could be among the most
cost-effective, practical ways to shift the
focus of modern health care from disease
treatment to prevention. But drug regulatory
policy prevents the United States from taking
advantage of these phytomedicines for two
reasons. The first is the exorbitant expense
involved in investigating each chemical
compound in a given plant extract before it
can be tested for clinical usefulness. Hence
there is an urgent need to rework current
research guidelines to allow the whole plant
material or combination mixture (an herbal
remedy containing more than one plant) to be
evaluated instead of requiring separate
evaluations of each chemical component of
the therapeutic ingredients.
The second reason is that regulatory
requirements for proof of safety and efficacy
constitute an economic disincentive for
private industry to conduct additional
scientific studies. Relaxing regulatory
requirements for efficacy for herbal products
might make it economically feasible for more
private companies to pursue research into
issues of safety and quality control. Even
with such regulatory change, some public
funding of research is needed to confirm the
remedies' validity. Public funds are needed
because private industry has no incentive to
develop an herbal product that might displace
a patented drug from an approved treatment
regime.
Recommendations
The Panel on Herbal Medicine recommends
the following:
- OAM (Office of Alternative Medicine)
should hold a research organizational
conference to facilitate planning in herbal
medicine research. The conference would
help to identify state-of-the-art questions
in ethnomedical research, existing
databases, and research personnel needed
to support basic and clinical research
needs in this area.
- Federal funding agencies such as NSF
and NIH must begin to support the
training of ethnobotanists--specifically in
the field of ethnomedicine--and to offer
funding opportunities to foster the rebirth
of this field at U.S. universities and
research institutions. This is a critical
priority because much traditional
knowledge in herbal remedies is in
danger of disappearing, as are the plant
species used in these systems of
medicine.
- The bias against plant medicines must be
eliminated by restructuring the
requirements for proof of efficacy and
concentrating on safety, and by removing
the need for extensive analyses of
chemically complex natural product
medicines (thus eliminating the
"monosubstance bias"). Several
international regulatory models exist to
guide the United States in this direction.
For example, the German "Kommission
E" (expert committee for herbal
remedies) monographs give a good
example of how the United States might
simplify the approval of natural products
without sacrificing safety or quality
29
standards. (The "doctrine of reasonable
certainty" that influences the approval of
drugs under this system was previously
mentioned.)
Adopting a more realistic standard of
evidence for established plant medicines
would eliminate much of the expense
required for approval of new and
unknown chemical drugs. Doing so
would be similar to having standardized
the crude drug senna leaf, used in the
United States as an OTC laxative and
documented for safety, effectiveness, and
quality.
Another option might be to require
pharmaceutical companies that are testing
a plant-derived, single ingredient
pharmaceutical on a specific condition to
demonstrate that it is more effective than
the natural product. For example, before
a patent could be issued to a
pharmaceutical company for an isolated
compound such as genistein, the
company would first have to prove that
the isolated compound is more effective
than genistein consumed in context (as a
food). But some market incentive, such
as exclusive prescriptive marketing
rights, might be needed to allow the
pharmaceutical company to recoup its
research costs.
- Legislative action may be required to
restate FDA's mandate with respect to
herbal products and traditional
medications. The current regulatory
mandate puts FDA in a difficult position.
It is expected to "protect the public" but
has no expertise or resources to evaluate
the global herbal medicine inventory. If a
crisis such as the contaminated
tryptophan affair (see the "Diet and
Nutrition" chapter) were to occur with a
popular herbal product, FDA might
attempt to prohibit the sale of medicinal
herbs altogether. Instead of expecting
FDA to be an omnipotent protector,
 Congress should legislate a more
educational, informational role.
With respect to herbs used in popular
health care, a proactive FDA role in
establishing quality and safety standards
would benefit the public and industry. A
certification system for herbal content
and potency of marketed products could
be set up by FDA with USDA and the
herbal industry. Such a system could
draw on the existing global database and
other countries' regulatory experiences.
Participation in a voluntary product
certification system would be a marketing
advantage for ethical producers, allowing
them, for example, to make a statement
such as "This product meets U.S.
government purity and potency
standards." New statutory authority also
would be necessary to establish a
category that would allow traditional
usages to be listed on labels according to
criteria similar to WHO guidelines.
Finally, if herbal remedy producers were
given the option to apply for specific
health condition label indications based
on new FDA phytomedicine standards,
the United States would have the same
three-tiered regulatory system adopted by
other developed countries. Such a
voluntary system would let consumers
make intelligent personal choices about
the use of medicinal herb products while
mandating safety standards consistent
with existing OTC practices for
potentially toxic drugs such as aspirin
and ibuprofen.
- OAM should review the TRAMIL
approach, in which distinguished
Caribbean botanists, chemists,
ethnologists, and physicians review
promising herbs and label them as
reasonably safe and effective for people
who cannot afford the prescription
alternatives.
30
CLINICAL PHARMACOGNOSY
Clinical pharmacognosy is a part of
allopathic syatem of medicine (but as such it
can be utilized in other systems of
medicines), therefore, the methods of
investigations, diagnosis and treatments will
remain the same. The physiology of the
human body depends upon homeostasis and
the function of vital organs. For the
functional study the body can be divided in
to three portions/parts i.e. First half: refers to
all the organs and parts from the base of the
sternum upwards; Second half: includes the
organs and parts in the middle region from
the navel to the base of the sternum; Third
half: refers to all the organs and parts from
the navel downwards.
The clinical pharmacognosy researches
(especially drug development) also requires
the same procedure as is in allopathic system
i.e. clininical trial phase I, II, III & IV.
BRANCHES OF CLINICAL PHARMA-
COGNOSY
The following are the branches of
pharmacognosy which now become
independent fields of specialization due to
intensive researches and in depth knowledge
of genetic engineering, development of
sofesticated reliable instruments and
advancement of internet facilities.
Pharmacology: An applied science and a
branch of pharmacognosy deals with the
action of drugs on human body.
Toxicology: A branch of pharmacognosy
where the toxic effects of drugs are
monitored on humam body.
Pathology and Physiology
(Pathophysiology): A branch of
pharmacognosy where the pathological and
physiological changes are monitored in
parts/organs/whole humam body after the
introduction of drugs. Same observations are
also monitopred in medicinal plants upon the
introduction of microbes, insects, heavy
metals, pesticides and genetic changes at
molecular level.
Histology and Pathology (Histopathology):
A branch of pharmacognosy where the
histological and pathological changes are
recorded in parts/organs/whole humam body
after the introduction of drugs. Same
observations are also observed in medicinal
plants upon the introduction of microbes,
insects, heavy metals, pesticides and genetic
changes at molecular level.
Cytology: A branch of pharmacognosy where
the drug actions are observed in
parts/organs/whole humam body after the
introduction of drugs, microbes, insects,
heavy metals, pesticides and genetic changes
at molecular level. Same observations are
also monitored in medicinal plants upon the
introduction of microbes, insects, heavy
metals, pesticides and genetic changes at
molecular level.
Morphology: A branch of
science/pharmacognosy where the
morphological features of different
parts/organs/whole humam body are
recorded after the introduction of drugs,
microbes, insects, heavy metals, pesticides
and genetic changes at molecular level. In
case of medicinal plants morphological
features are used in identification of
plants/plants parts and taxanomical
classification of plants.
Molecular Genetics: It is a branch of science/
pharmacognosy where the studies are carried
out on higher molecular genetic information
for therapeutic utilization of medicinals
plants, microbes and human cell/tissue/stem
cells etc.
Biopharmaceutics: It is also a branch of
pharmacognosy which deals with the
manufacturing of drugs of natural origin.
Biomedical Sciences: It is a branch of
pharmacognosy which deals with the drugs
of natural origin.
Forensic medicine: It is a branch of science
which deals with the toxic effects drugs of
natural origin and help in differentiating the
suicidal and murdering cases.
31
References
Ackerknecht, E.H. 1973. Therapeutics: from the
Primitives to the Twentieth Century. Hafner
Press, New York.
Akamasu, E. 1970. Modern Oriental Drugs.
Yishiyakusha, Tokyo.
Artiges, A. 1991. What are the legal requirements for
the use of phytopharmaceutical drugs in France?
J. Ethnopharmacol. 32:231-234.
Arvigo, R., and M. Balick. 1993. Rainforest
Remedies: 100 Healing Herbs of Belize. Lotus
Press, Twin Lakes, Wis.
Baisi, F. 1987. Report on Clinical Trial of Bilberry
Anthocyanocides in the Treatment of Venous
Insufficiency in Pregnancy and of Postpartum
Hemorrhoids. Presidio Ospedaliero di Livorno,
Italy.
Baker, M.E. 1992. Evolution of regulation of steroid-
mediated intercellular communication in
vertebrates: insights from flavonoids, signals that
mediate plant-rhizobia symbiosis. J. Steroid
Biochem. Mol. Biol. 41(3-8):301-308.
Bauer, V., K. Jurcie, J. Puhlmann, and H. Wagner.
1988. Immunologische in-vivo und in-vitro
untersuchungen mit echinacea-extrakten
(Immunologic in vivo and in vitro studies on
echinacea extracts). Arzneimittelforschung
38(2):276-281.
Beckstrom-Sternberg, S.M., and J.A. Duke. 1994.
Potential for synergistic action of phytochemicals
in spices. In G. Charalambous, ed. Spices, Herbs,
and Edible Fungi. Elsevier Sciences B.V., New
York.
Bedi, K.L., U. Zutshi, C.L. Chopra, and V. Amla.
1989. Picrorhiza kurroa, an Ayurvedic herb, may
potentiate photochemotherapy in vitiligo. J.
Ethnopharmacol. 27:347-352.
Bensky, D. and A. Gamble. 1993. Chinese Herbal
Medicine: Materia Medica (revised edition).
Eastland Press Inc., Seattle.
Bode, J.C., U. Schmidt, and H.K. Durr. 1977.
Silymarin for the treatment of acute viral
hepatitis? Med. Klin. 72:513-518.
Braunig, B., M. Dorn, Limburg, E. Knick, and
Bausendorf. 1992. Echinacea purpureae radix for
strengthening the immune response in flu-like
infections. Zeitschrift fhr Phytotherapie 13:7-13.
Buchman, D.D. 1980. Herbal Medicine. Gramercy
Publishing Company, New York.
Catlin, D.H., M. Sekera, and D.C. Adelman. 1993.
Erythroderma associated with the ingestion of an
herbal product. West. J. Med. 159:491-493.
Champpault, G., J.D. Patel, and A.M. Bonnard. 1984.
A double-blind trial of an extract of the plant
Serenoo repens in benign prostatic hyperplasia.
Br. J. Clin. Pharmacol. 18(3):461-462.
Charles, V., and S.X. Charles. 1991. The use and
efficacy of Adadirachta indica ADR (neem) and
Curcuma longa (turmeric) in scabies. Tropical
and Geographical Medicine (November):178-181.
Chaudhury, R.R. 1992. Herbal Medicine for Human
Health. World Health Organization (SEARO, No.
20).
Chen, X. 1983. Protective and FFA metabolic effect of
ginsenosides on myocardial ischemia. Journal of
Medical Cell and Cardiology 25:121-123.
Chen, X., Q.Y. Zhu, L.Y. Li, and X.L. Tang. 1982.
Effect of ginsenosides on cardiac performance
and hemodynamics of dogs. Acta Pharmacologica
Sinica 3:235-239.
Cheng, X.J., Y.L. Liu, G.F. Lin, and X.T. Luo. 1986.
Comparison of action of Panax ginsenosides and
Panax quinquonosides on anti-warm stress in
mice. Journal of Shenyang College of Pharmacy
3(3):170-172.
Cheng, X.J., X.R. Shi, and B. Lin. 1988. Effects of
ginseng root saponins on brain Ach and serum
corticosterone in normobaric hypoxia stressed
mice. Presented at the 5th Southeast Asian and
Western Pacific Regional Meeting of
Pharmacologists, Chinese Pharmacological
Association, Beijing.
Chopra, R.N., and I.C. Chopra. 1959. A review of
work on Indian medicinal plants. Indian Council
of Medical Research Special Report Series No. 1,
pp. 99, 107.
Coeugniet, E.G., and E. Elek. 1987.
Immunomodulation with Viscum album and
Echinacea purpurea extracts. Onkologie 10(3
Suppl.):27-33.
Corsi, S. 1987. Report on Trial of Bilberry
Anthocyanosides (Tegens-inverni della beffa) in
the Medical Treatment of Venous Insufficiency of
the Lower Limbs. Casa di Cura S. Chiara,
Florence, Italy.
Dahanukar, S.A., S.M. Karandikar, and M. Desai.
1984. Efficacy of Piper longum in childhood
asthma. Indian Drugs 21:384-388.
Duke, J.A. 1986. Handbook of Northeastern Indian
Medicinal Plants. Quarterman Press, Lincoln,
Mass.
Duke, J.A. 1988. Handbook of Nuts. CRC Press, Inc.,
Boca Raton, Fla.
Duke, J.A. 1989. Ginseng: A Concise Handbook.
Reference Publications Inc., Algonac, Mich.
Duke, J.A. 1992a. Handbook of Phytochemical
Constituents of GRAS Herbs and Other Economic
Plants. CRC Press, Inc., Boca Raton, Fla.
Duke, J.A. 1992b. Handbook of Biologically Active
Phytochemicals and Their Activities. CRC Press,
Inc., Boca Raton, Fla.
32
Duke, J. 1993. Lupinus perennis: hypotensive
wildflower under hypertensive wires. Coltsfoot
14(6):4-5.
Duke, J.A., and E.S. Ayensu. 1985. Handbook of
Medicinal Herbs. CRC Press, Inc., Boca Raton,
Fla.
Duke, J.A., and R.V. Martinez. In press. Amazonian
ethnobotanical dictionary. In Handbook of
Ethnobotanicals (Peru). CRC Press, Inc., Boca
Raton, Fla.
Dumont, E., E. Petit, T. Tarrade, and A. Nouvelot.
1992. UV-C irradiation-induced peroxidative
degradation of microsomal fatty acids and
proteins: protection by an extract of Ginkgo
biloba (EGb 761). Free Radic. Biol. Med.
13(3):197-203.
EEC Directive 75/318/EEC as amended.
Fang, X., N. Shen, and B. Lin. 1986. Beneficial
changes in prostacyclin and thromboxane A2 by
ginsenosides in myocardial infarction and
reperfusion of dogs. Acta Pharmacologica Sinica
7:226-230.
Farnsworth, N.R., O. Akerele, A.S. Bingel, D.D.
Soejarta, and Z. Eno. 1985. Medicinal plants in
therapy. Bull. World Health Organ. 63(6):965-
981.
Farnsworth, N.R., and R.W. Morris. 1976. Higher
plants: the sleeping giant of drug development.
Am. J. Pharm. March/April:46.
Feher, H., et al. 1990. Hepaprotective activity of
silymarin therapy in patients with chronic
alcoholic liver disease. Orv. Hetil. 130:51.
Ferenci, P., B. Dragosics, H. Dittrick, et al. 1989.
Randomized controlled trial of silymarin
treatment in patients with cirrhosis of the liver. J.
Hepatol. 9(1):105-113.
Flemming, K. 1971. Therapeutic effect of silymarin
on x-irradiated mice. Arzneimittelforschung
21(9):1373-1375.
Foster, S. 1990. Ginkgo. American Botanical Council,
Austin, Tex.
Gatta, L. 1982. Controlled Clinical Trial Among
Patients Designed to Assess the Therapeutic
Efficacy and Safety of Tegens 160. Ospedale
Filippo del Ponte, Varese, Italy.
Gilhooley, M. 1989. Pharmaceutical drug regulation in
China. Food Drug Cosmetic Law Journal 44:21-
39.
Guerrini, M. 1987. Report on Clinical Trial of
Bilberry Anthocyanosides in the Treatment of
Venous Insufficiency of the Lower Limbs. Istituto
di Patologia Speciale Medica e Metodologia
Clinica, Universit de Siena, Italy.
Haas, H. 1981. Brain disorders and vasoactive
substances of plant origin. Planta Med.
(Suppl.):257-265.
Han, B.H., M.H. Park, L.K. Woo, W.S. Woo, and
Y.N. Han. 1979. Studies on antioxidant
components of Korean ginseng. Korean
Biochemistry Journal 12(1):33.
Handbook of Domestic Medicine and Common
Ayurvedic Remedies. 1979. Central Council for
Research in Indian Medicine and Homeopathy,
New Delhi, pp. 91-112.
Hirayama, T. 1986. Nutrition and cancer--a large scale
cohort study. Prog. Clin. Biol. Res. 206:299-311.
Jacob, A., M. Pandey, S. Kapoor, and R. Saroja. 1988.
Effect of the Indian gooseberry (amla) on serum
cholesterol levels in men aged 35-55 years. Eur. J.
Clin. Nutr. 42:939-944.
Kang-Yum, E., and S.H. Oransky. 1992. Chinese
patent medicine as a source of mercury poisoning.
Vet. Hum. Toxicol. 34(3):235-238.
Kao, F.F. 1992. The impact of Chinese medicine on
America. Am. J. Chin. Med. 20(1):1-16.
Keller, K. 1991. Legal requirements for the use of
phytopharmaceutical drugs in the Federal
Republic of Germany. J. Ethnopharmacol.
32:225-229.
Kirkland, J., H.F. Mathews, C.W. Sullivan III, and K.
Baldwin, eds. 1992. Herbal and Magic Medicine:
Traditional Healing Today. Duke University
Press, Durham, N.C., and London.
Kishore, P., P.N. Pandey, S.N. Pandey, and S. Dash.
1990. Preliminary trials of certain Ayurvedic drug
formulation of Amalpitta. Sachitra Ayurved
33:40-45.
Kulkarni, R.R., P.S. Patki, V.P. Jog, S.G. Gandage,
and B. Patwardhan. 1991. Treatment of
osteoarthritis with a herbomineral formulation: a
double-blind, placebo-controlled, cross-over
study. J. Ethnopharmacol. 33:91-95.
Li, J.C., Y.P. Li, and L.S. Xue. 1988. Influence of
ginseng saponins on the circadian rhythm in brain
monoamine neurotransmitters. Presented at the
5th Southeast Asian and Western Pacific Regional
Meeting of Pharmacologists, Chinese
Pharmacological Association, Beijing.
Liu, C., and P. Xiao. 1992. Recent advances on
ginseng research in China. J. Ethnopharmacol.
36:27-38.
Lu, G., X.J. Cheng, and W.X. Yuan. 1988. Effect of
ginseng root saponins on serum corticosterene
and neurotransmitters of hypobaric hypoxic mice.
IRCS Med. Sc. Libr. Compend. 5(6):259.
Majno, G.M. 1975. Healing Hand: Man and Wound in
the Ancient World. Harvard University Press,
Cambridge, Mass.
Moerman, D.C. 1982. Geraniums for the Iroquois. A
Field Guide to American Indian Medicinal Plants.
Reference Publications, Algonac, Mich., 242 pp.
33
Mousavi, Y., and H. Adlercreutz. 1993. Genistein is
an effective stimulator of sex hormone-binding
globulin production in hepatocarcinoma human
liver cancer cells and suppresses proliferation of
these cells in culture. Steroids 58:301-304.
Nath, D., N. Sethi, R.K. Singh, and A.K. Jain. 1992.
Commonly used Indian abortifacient plants with
special reference to their teratologic effects in
rats. J. Ethnopharmacol. 36:147-154.
Pandey, B.L., R.K. Goel, N.K.R. Pathak, M. Biswas,
and P.K. Das. 1982. Effect of Tectona grandis
linn. (common teak tree) on experimental ulcers
and gastric secretion. Indian J. Med. Res.
76(Suppl.):89-94.
Pei, Y.Q. 1983. A review of pharmacology and
clinical use of piperine and its derivatives.
Epilepsia 24:177-181.
Perry, L.M. 1980. Medicinal Plants of East and
Southeast Asia: Attributed Properties and Uses.
MIT Press, Cambridge, Mass.
Peterson, G., and S. Barnes. 1993. Genistein and
biochanin A inhibit the growth of human prostate
cancer cells but not epidermal growth factor
receptor tyrosine autophosphorylation. Prostate
22:335-345.
Qian, B.C., X.X. Zhang, B. Li, C.Y. Xu, and X.Y.
Deng. 1987. Effects of ginseng polysaccharides
on tumor and immunological function in tumor-
bearing mice. Acta Pharmacologica Sinica 8:6-14.
Qu, J.B., Y.N. Cao, and X.Y. Ma. 1988. Effects of
ginseng leaves and root saponins on animals in
acute hypoxia due to negative air pressure.
Presented at the 5th Southeast Asian and Western
Pacific Regional Meeting of Pharmacologists,
Chinese Pharmacological Association, Beijing.
Raabe, A., M. Raabe, and P. Ihm. 1991. Therapeutic
follow-up using automatic perimetry in chronic
cerebroretinal ischemia in elderly patients:
prospective double-blind study with graduated
dose Ginkgo biloba treatment (EGb 761). Klin.
Monatsbl. Augenheilkd. 199(6):432-438.
Rai, G.S., C. Shovlin, and K.A. Wesnes. 1991. A
double-blind, placebo-controlled study of Ginkgo
biloba extract in elderly outpatients with mild to
moderate memory impairment. Curr. Med. Res.
Opin. 12(6):350-355.
Roesler, J., A. Emmendorffer, C. Stienmuller, B.
Luettig, H. Wagner, and M.L. Lohmann-Matthes.
1991. Application of purified polysaccharides
from cell cultures of the plant Echinacea purpurea
to test subjects mediates activation of the
phagocyte system. Int. J. Immunopharmacol.
13(7):931-941.
Schaffler, K., and P. Reeh. 1985. Long-term drug
administration effects of Ginkgo biloba on the
performance of healthy subjects exposed to
 hypoxia. In Effects of Ginkgo Biloba Extracts on
Organic Cerebral Impairment. Eurotext Ltd.,
London.
Shen, J.J., Y.Y. Jin, Y.S. Wu, and X. Zhou. 1987.
Effects of ginseng saponins on 14C-arachidonic
acid metabolism in rabbit platelets. Acta
Pharmaceutica Sinica 22:166-169.
Shukla, A.K. 1984. Endocrine Response of Certain
Species on Albino Rats (doctoral thesis). Banaras
Hindu University, Varanasi, India.
Snider, S. 1991. Beware the unknown brew: herbal
teas and toxicity. FDA Consumer (May):31-33.
Solecki, R.S. 1975. Shanidar IV, a Neanderthal flower
burial of northern Iraq. Science 190:880.
Spanu, F., A. Tava, L. Pacetti, and E. Piano. 1993.
Variability of oestrogenic isoflavone content in a
collection of subterranean clover from Sicily.
Journal of Genetics and Breeding 47:27-34.
Stimpel, M., A. Proksch, H. Wagner, and M.L.
Lohmann-Matthes. 1984. Macrophage activation
and induction of macrophage cytotoxicity by
purified polysaccharide fractions from the plant
Echinacea purpurea. Infect. Immun. 46(3):845-
849.
Sumathikutty, M.A., K. Rajaraman, B. Sankarikutty,
and A.G. Mathew. 1979. Chemical composition
of pepper grades and products. Journal of Food
Science and Technology 16:249-254.
Swanston-Flatt, S.K., C. Day, P.R. Flott, et al. 1989.
Glycemic effects of traditional European plant
treatments for diabetes: studies in normal and
streptozotocin diabetic mice. Diabetes Res.
10(2):69-73.
Taillandier, J. 1988. Ginkgo biloba extract in the
treatment of cerebral disorders due to aging. In
E.W. Funfgeld, ed. Rokan (Ginkgo Biloba):
Recent Results in Pharmacology and Clinic.
Springer-Verlag, Berlin.
Tang, B.Y., and N.R. Adams. 1981. Oestrogen
receptors and metabolic activity in the genital
tract after ovariectomy of ewes with permanent
infertility caused by exposure to phytoestrogens.
J. Endocrinol. 89(3):365-370.
Teglio, L. 1987. Quad. Clin. Ostet. Ginecol. 42:221.
Tong, L.S., and C.Y. Chao. 1980. Effects of
ginsengoside Rg1 of Panax ginseng on mitosis in
human blood lymphocytes in vitro. Am. J. Chem.
Med. 8(3):254.
Tsumura, A. 1991. Kampo, How the Japanese
Updated Traditional Herbal Medicine. Japan
Publications, Inc., Tokyo and New York.
Upadhyaya, S.D., C.M. Kansal, and N.N. Pandey.
1982. Clinical evaluation of Piper longum on
patients of bronchial asthma--a preliminary study.
Nagarjuna 25:256-258.
34
Ura, H., T. Obara, K. Okamura, and M. Namiki. 1993.
Growth inhibition of pancreatic cancer cells by
flavonoids. Gan To Kagaku Ryoho 20(13):2083-
2085.
Varkonyi, T. 1971. Brain edema in the rat induced by
triethyltin sulfate. 10 Effect of silymarin on the
electron-microscopy picture.
Arzneimittelforschung 21(1):148-149.
Verma, S.K., and A. Bordia. 1988. Effect of
Commiphora mucul (gum guggul) in patients with
hyperlipidemia with special reference to HDL
cholesterol. Indian J. Med. Res. 87:356-360.
Vogel, V.L. 1970. American Indian Medicine.
University of Oklahoma Press, Norman, Okla.
Wagner, H., B. Geyer, Y. Kiso, H. Hikino, and G.S.
Rao. 1986. Coumestans as the main active
principles of the liver drugs Eclipta alba and
Wedelia calendulacea. Planta Med.:370-377.
Wall Street Journal. 1993. Vital statistics: disputed
cost of creating a drug. November 9.
Wang, B.X., J.C. Cui, and A.J. Lui. 1980. The effect
of polysaccharides of root of Panax ginseng on
the immune function. Acta Pharmaceutica Sinica
17:312-320.
Weitbrecht, W.V., and W. Jansen. 1985. Doubleblind
and comparative (Ginkgo biloba versus placebo)
therapeutic study in geriatric patients with
primary degenerative dementia--a preliminary
evaluation. In A. Agnoli et al., eds. Effects of
Ginkgo Biloba Extract on Organic Cerebral
Impairment. John Libbey Eurotext Ltd., London.
Witte, S., I. Anadere, and E. Walitza. 1992.
Improvement of hemorheology with Ginkgo
biloba extract: decreasing a cardiovascular risk
factor. Fortschr. Med. 110(13):247-250.
World Health Organization. 1991. Guidelines for the
Assessment of Herbal Medicines. Programme on
Traditional Medicines, Geneva.
Yabe, T., M. Chat, E. Malherbe, and P.P. Vidal. 1992.
Effects of Ginkgo biloba extract (EGb 761) on the
guinea pig vestibular system. Pharmacol.
Biochem. Behav. 42(4):595-604.
Yanagihara, K., A. Ito, T. Toge, and M. Numoto.
1993. Antiproliferative effects of isoflavones on
human cancer cell lines established from the
gastrointestinal tract. Cancer Res. 53(23):5815-
5821.
Yang, Y., Z. Chen, G. Luo, and Y. Zhang. 1988. The
mechanism of inhibitory effects of panaxadiol
saponin on rabbit platelet aggregation. Presented
at the 5th Southeast Asian and Western Pacific
Regional Meeting of Pharmacologists, Chinese
Pharmacological Association, Beijing.
Youngken, H.W. 1950. A Textbook of
Pharmacognosy. McGraw-Hill, New York.
Yuan, W.X., X.J. Wu, and F.X. Yang. 1988. Effects of
ginseng root saponins on brain monoamine and
serum corticosterone in heat stressed mice.
Presented at the 5th Southeast Asian and Western
Pacific Regional Meeting of Pharmacologists,
Chinese Pharmacological Association, Beijing.
Zhang, F.L., and X. Chen. 1987. Effects of
ginsenosides on sympathetic neurotransmitter
release in pithed rats. Acta Pharmacologica Sinica
8:217-220.
Zhang, F.L., A.G. Meehan, and M.J. Rand. 1988.
Effects of ginsenosides on noradrenergic
transmission, histamine response and calcium
influx in rabbit ear isolated artery. Presented at
the 5th Southeast Asian and Western Pacific
Regional Meeting of Pharmacologists, Chinese
Pharmacological Association, Beijing.
Zhang, J.T. 1989. Progress of research on three kinds
of anti-aging drugs. Information of the Chinese
Pharmacological Society 6(3-4):4.

Note: Most of the Matters are drived from Internet

and Research Papers

35
Chapter 2

37
38
Historical Development
The Great Scholars and contributors of
Clinical Pharmacognosy
The history of medicine is as old as man
himself. In the construction of the pillars of
the medical sciences, mankind evolved
innumerable dogmas and views ranging from
superstition to philosophy in removing
suffering and pain. Hippocrates was the first
to separate medicine from philosophy. His
doctrines modified by Aristotle and Galen
enjoyed acceptance from all corner and
became tool of medication during the
different stages of development of medical
science. However, modern physicians appear
to be the direct descendents of Avicenna (Ibn
Sina) who introduced the element of
observation and analysis in addition to
prevention and treatment of disease by logic
and philosophy.
Hippocrates is called the father of medicine
Theophrastus (c. 371-c. 287 B.C.)
History's first scientific botanist was the
Greek philosopher Theophrastus. Extending to
plants a classification scheme developed by his
teacher Aristotle, Theophrastus wrote Inquiry
into Plants and Growth of Plants. These
works—covering some 550 plants from Eu-
rope to India—were the first to classify plants
by form and structure, and prefigure the
39
Linnaean system used today (see page 66).
Theophrastus was a first-rate observer as well:
his description of germinating seeds, for
example, was long unsurpassed. Yet he also
transmitted fantasies that were to haunt
natural science down to modem times, such as
the idea that plants were put on earth solely
for man's use, a notion implicit in the doctrine
of signatures. As to his reason for mixing
figment with fact, Theophrastus wrote:
"Fabulous tales are not made up without
reason."
Mithridates (died 63 B.C.)
A special place in the story of medicinal plants
belongs to Mithridates VI, king of Pontus.
Because he is said to have made himself invul-
nerable to poisoning by taking progressively
larger doses of poison, his name lives on in the
term mitkridaasni, "acquired tolerance of a
poison." Facing capture by Roman enemies,
he reputedly tried in vain to poison himself and
had to get a slave to stab him to death. Ac-
counts written after his death portray Mithri-
dates as a diligent biological investigator who
knew 22 languages and studied medicine as
well. An antidote called the mi thridate bore his
name in medieval pharmacology. Mithridates'
physician Crateuas was famous in antiquity for
his lifelike botanical paintings, now thought
to have been the basis for illustrations in
Dioscorides' De Materia Medica.
Dioscorides (first centuryA.D.)
The most influential pharmaceutical writer of
antiquity was the Greek physician Dioscor-
ides, born near Tarsus (in modem Turkey)
probably shortly after the time of Christ.
Little is known about Dioscorides' personal
life, other than that he may have served as a
doctor with the Roman army. His
pharmaceutical guide, De Materia Medica,
deals with more than 600 plants, 35 animal
products, and 90 minerals used in medicine.
Illustrated manuscripts of this work circulated
over the next 1,600 years throughout the West
and the Middle East. One of its earliest print
editions was published by the great
Renaissance botanist-naturalist Pietro Mattioli
in Venice in 1544. The Mattioli edition is
regarded as a cornerstone of modern botany. A
great many of the scientific and everyday
plant names we use today can be traced back
to Dioscorides.
Dioscorides instructs an Arabian doctor
Pliny (A.D. 23/24-79)
"To live is to be awake" was the credo of the
Roman administrator and natural historian
Pliny. His Natural History in 37 books was a
major source for herbalists and botanists from
medieval times through the I7th century.
Books 12 through 19 of the Natural History
deals with botany, and Books 20 through 27
with plant pharmacology. Pliny and die Greek
doctor Dioscorides, his contemporary, have
been cited by writers on medicinal plants down
to the present century. Generations of authors
passed along Pliny's words without attributing
them to him—so that a number of his state-
ments of fact and fancy have entered the
folklore of plants. Pliny died in a way befitting a
true naturalist: he went to investigate an
eruption of Vesuvius, and on a beach near
Pompeii succumbed to the sulfurous fumes. A
vivid account of this final scene exists in a letter
40
written by Pliny's nephew, who is called Pliny
the Younger to distinguish him from his uncle,
who is sometimes known as Pliny the Elder.
Galen (c. A.D. 130-200)
The most famous physician of his day and a
prolific medical writer, Galen found his intel-
lectual inspiration in Greek thought: the medi-
cine of Hippocrates, the science of Aristotle,
the philosophy of Plato. Born in Pergamum
(now Bergama, Turkey), Galen determined
when he was 16 years old to bring precision
to the study of medicine. He studied and
traveled for the next 12 years, spending
probably several years at Alexandria, the chief
medical center of the age. After returning to
Pergamum and serving as a physician to the
gladiators there, Galen went to Rome, about
161. He soon numbered influential Romans
among his admiring patients and thus began
his long association with Rome's rich and
powerful. Although he taught the now
antiquated concept of medicine as adjusting the
body's basic humors, Galen also believed in
testing medicines empirically, a very modern
stance. Not until the 16th and 17th centuries
did challenges arise to his medical authority.
The terms "galenicals" and "galenic products"
today refer to medicinal substances extracted
from plants by methods associated with Galen.
From this medical text, Arabs learned how to hunt snakes
for use in making medicine

Al-Biruni
ABU RAIHAN AL-BIRUNI
(973--1048 A.D.)
Abū Rayḥḥān Muḥḥammad ibn Aḥḥmad al-
Bīrūnī (September 15, 973 in Kath,
Khwarezm died December 13, 1048 in
Ghazni) was a Persian Muslim polymath of
the 11th century, whose experiments and
discoveries were as significant and diverse as
those of Leonardo da Vinci or Galileo, five
hundred years before the Renaissance; al-
Biruni was well-known in the Muslim world,
but unlike some of his other Muslim
contemporaries (such as Abulcasis, Alhacen,
and Avicenna), al-Biruni's name was little
known in the Western world.
He was a scientist and physicist, an
anthropologist, an astronomer and astrologer,
an encyclopedist and historian, a geographer,
a geodesist and geologist, a mathematician, a
pharmacist, a philosopher and theologian, a
scholar and teacher, and a traveller, who
contributed greatly to all of these fields. He
was also the first Muslim scholar to study
India and the Brahminical tradition and has
been described as the father of Indology, the
father of geodesy, and "the first
anthropologist". Along with Geber and Ibn al-
Haytham, al-Biruni was also one of the
earliest leading exponents of the experimental
method, and the first to conduct elaborate
experiments related to astronomical
phenomena. George Sarton, the father of the
history of science, described al-Biruni as:
41
"One of the very greatest scientists of Islam,
and, all considered, one of the greatest of all
times".A. I. Sabra desribed al-Biruni as:
"One of the great scientific minds in all
history". The Al-Biruni crater, on the Moon,
is named after al-Biruni.
Abu Raihan Mohammad Ibn Ahmad al-Biruni
was one of the well-known figures associated
with the court of King Mahmood Ghaznawi,
who was one of the famous Muslim kings of
the 11th century A.D. Al-Biruni was a
versatile scholar and scientist who had equal
facility in physics, metaphysics, mathematics,
geography and history. Born in the city of
Kheva near "Ural" in 973 A.D., he was a
contemporary of the well-known physician
Ibn Sina. At an early age, the fame of his
scholarship went around and when Sultan
Mahmood Ghaznawi conquered his
homeland, he took al-Biruni along with him
in his journeys to India several times and thus
he had the opportunity to travel all over India
during a period of 20 years. He learnt Hindu
philosophy, mathematics, geography and
religion from three Pandits to whom he taught
Greek and Arabic science and philosophy. He
died in 1048 A.D. at the age of 75, after
having spent 40 years in thus gathering
knowledge and making his own original
contributions to it.
He recorded observations of his travels
through India in his well-known book Kitab
al-Hind which gives a graphic account of the
historical and social conditions of the sub-
continent. At the end of this book he makes a
mention of having translated two Sanskrit
books into Arabic, one called Sakaya, which
deals with the creation of things and their
types, and the second, Patanjal dealing with
what happens after the spirit leaves the body.
His descriptions of India were so complete
that even the Aein-i-Akbari written by Abu-al-
Fadal during the reign of Akbar, 600 years
later, owes a great deal to al-Biruni's book. He
observed that the Indus valley must be
considered as an ancient sea basin filled up with
alluvials.

On his return from India, al-Biruni wrote his
famous book Qanun-i Masoodi (al-Qanun al-
Masudi, fi al-Hai'a wa al-Nujum), which he
dedicated to Sultan Masood. The book
discusses several theorems of astronomy,
trigonometry, solar, lunar, and planetary
motions and relative topics. In another well-
known book al-Athar al-Baqia, he has
attempted a connected account of ancient
history of nations and the related geographical
knowledge. In this book, he has discussed the
rotation of the earth and has given correct
values of latitudes and longitudes of various
places. He has also made considerable
contribution to several aspects of physical and
economic geography in this book.
His other scientific contributions include the
accurate determination of the densities of 18
different stones. He also wrote the Kitab-al-
Saidana, which is an extensive materia
medica that combines the then existing Arabic
knowledge on the subject with the Indian
medicine. His book the Kitab-al-Jamahir
deals with the properties of various precious
stones. He was also an astrologer and is
reputed to have astonished people by the
accuracy of his predictions. He gave a clear
account of Hindu numerals, elaborating the
principle of position. Summation of a
geometric progression appropos of the chess
game led to the number:
1616° - 1 = 18,446,744,073,709,551,619
He developed a method for trisection of angle
and other problems which cannot be solved
with a ruler and a compass alone. Al-Biruni
42
discussed, centuries before the rest of the
world, the question whether the earth rotates
around its axis or not. He was the first to
undertake experiments related to astronomical
phenomena. His scientific method, taken
together with that of other Muslim scientists,
such as Ibn al-Haitham, laid down the early
foundation of modern science. He ascertained
that as compared with the speed of sound the
speed of light is immense. He explained the
working of natural springs and artesian wells
by the hydrostatic principle of communicating
vessels. His investigations included
description of various monstrosities, including
that known as "Siamese" twins. He observed
that flowers have 3,4,5,6, or 18 petals, but
never 7 or 9.
He wrote a number of books and treatises.
Apart from Kitab-al- Hind (History and
Geography of India), al-Qanun al-Masudi
(Astro- nomy, Trigonometry), al-Athar al-
Baqia (Ancient History and Geography),
Kitab al-Saidana (Materia Medica) and Kitab
al-Jawahir (Precious Stones) as mentioned
above, his book al-Tafhim-li-Awail Sina'at al-
Tanjim gives a summary of mathematics and
astronomy.
He has been considered as one of the very
greatest scientists of Islam, and, all
considered, one of the greatest of all times.
His critical spirit, love of truth, and scientific
approach were combined with a sense of
toleration. His enthusiasm for knowledge may
be judged from his claim that the phrase Allah
is Omniscient does not justify ignorance.
AVICENNA (980-1037 A.D.)
(Abu Ali Hussain ibn Abdullah ibn Hasan
ibn Ali ibn Sina)
When he was barely out of his teens, the
Persian philosopher-statesman Avicenna (Abu
Ali Sina) earned a reputation as a healer by curing
a ruler of a critical illness. Thereafter he was in
demand as a physician and adviser to princes. For
the rest of his life, he worked by day as a
minister of state and wrote by night on an
encyclopedic range of subjects: medicine, natural
history, physics, chemistry, astronomy,
mathematics, music, economics, political science,
and theology. His poetry is quoted in the Arab
world to this day. The most important of his 131
authenticated works is the voluminous Canon of
Medicine, based on the Greek writings of
Hippocrates, Aristotle, Dioscorides, Galen, and
others. To their work Avicenna added his own
theoretical and empirical observations. Book 2 of
the Canon contains Avicen-na's pharmacology of
herbs. He also discussed various remedies such as
chicory, oxymel, and balsam. Latin translations of
the Canon existed within a century after
Avicenna's death, and it was die basic medical
text at all medieval universities both Christian
and Moslem. The scientific revolution of the
West was cruel to Avicenna. Leonardo da Vinci
(1452-1519) rejected his anatomy; the Swiss
physician Paracelsus (1493-1541) burned a
copy of the Canon while teaching medicine in
Switzerland; and William Harvey (1578-1657),
the English physician who discovered the
The most famous of this generation of
circulation of the blood, demolished Avicenna's
physicians, both in the skill of Medicine and
theories on this .important subject.
in writing medical works, were abul-ala, Zuhr
ABU MARWAN ABD AL MALIK IBN
b.Abi Marwan Abd al-Malik b.Muhammad
ZUHR (AVENZOAR) (1091 A.D)
b.Marwan b.Zuhr, Known by his kunya Abul-
Abu Marwan Abd al-Malik b. Abil-ala Zuhr
Ala, and especially his son Abd al-Malik
b. Abi Marwan Abd. al-Malik b. Muhammad
b.Zuhr the author of the kitab al-Taysir.
b. Marwan ibn Zuhr was born in Seville in
Abul-Ala studied medicine and stood out in
484 A.H. /1091 A.D. or 487 A.H. /1094
its practice. Ibn Abi Usaybia 3, says that he
according to Ibn al-Abbar', in a family of
was renowned by his dexterity and knowledge
physicians originating from Arabia as was a
and his excellent cures which indicated his
member of the family of Banu Zhur, that
efficacy in the skill of medicine and its
arrived to al-Andalus, and set up their
secrets, and he made prodigies in the
residence firstly in Jativa, then in Denia,
treatment of patients.
under the protection of their kings, from
Afterwards he went to Cordova where he
Mujahid, King of Denia, till the al-Mohad
studied literature and Hadith (Prophetic
Emirs, to whom they served as physicians.
tradition), and studied also the works of
Banu Zhur travelled all over North Africa,
Avicenna, inasmuch as wrote for his son Abd
and occupied there prominent posts. Ibn
al-Malik ibn Zuhr a book entitled "Maqala
Khallikan mentions several members of this
fi1-radd ala Abi Ali ibn Sina fi mawadic min
family as culama, (Scholars); ru'asa (Chiefs)
kitabi-hi fi1-adwiya al-mufrada ".
and hukama' (wise men).
Abul-Ala' worked firstly as a royal physician
for king al-Muctamid b.Abbad in Seville, and
afterwards in Agmat, the place of exile of al-
Muctamid, in order to treat his wife al-

43
Rumaykiyya. Later he went back to al-
Andalus, and worked at the service of Yusuf
ibn Tashufin, who gave him the title of wazir
(vizier, minister) and so he is known in the
West under the name of al-Guazir Abulelizor,
which is the phonetic corruption of al-wazir
Abul-Ala, ibn Zuhr. He died in Cordova in
1131 A.D. and was buried in the Victory Gate
(Bab al-Fath) in Seville.
His son Abd al-Malik ibn Zuhr, became the
most important physician of his family and is
considered as one of the best Andalusian
physicians.
Averroes, in the fifth book, chapter thirty-one,
of his Kitab al-Kulliyyat, described him as the
greatest physician after Galen.
Abd al-Malik learned the skill of Medicine
from his father, and studied in the best
schools of literature, fiqh Jurisprudence) and
religion of his time. He worked as a physician
at the service of the al-Moravidthen the al-
Mohad Emirs.
During his life, he was exposed to the
political changes, and he was in prison under
the government of the al-Moravides.
Afterwards, with the victory of the almohads,
he served them as physician in their court, and
wrote for Abu Muhammad Abd al-Mumin ibn
Ali a "Kitab al-Agdhiya wal-adwiya"5.
Abou Marwan Abd al-Malik ibn Abil-Ala ibn
Zuhr died in 557 A.H. /1131 A.D. and was
buried outside of the Victory Gate, next to his
father's grave.
THE MEDICAL CONCEPT OF
AVENZOAR
The medical and philosophical concept of
Avenzoar, as it happens with other Arab
physicians, comes from the Galen's theories,
based on the theory of the four elements: fire,
earth, air and water and their proper
characteristics, i.e. heat, coldness, dryness and
humidity. And according to this quaternary
system, the human body is composed from
four humors: Black bile, yellow bile, phlegm
and blood and the state of health and the
44
different diseases depend on the
proportionality of these four humors.
SPIRIT OF OBSERVATION OF AVENZOAR
Ibn Abi Usaybia mentions several stories that
reveal the spirit of observation and
examination at Avenzoar:
"The Caliph Abd al-Mumin needed to have a
laxative drug, and he detested to drink the
purgative drugs. Avenzoar acted by subtle
means, he went to a grapevine of his garden,
and irrigated it with water containing the
purgative drugs, macerated or boiled. When
the grapevine took the strength of the laxative
drugs, and the grapes appear with these
strengths, he ordered the Caliph to be on diet,
and then brought him a grape and indicated
him of eating it. The Caliph had a good
opinion of Avenzoar. When he ate it, in his
presence, he said to him: "Oh, Commander of
the faithful, it is sufficient for you to have
eaten ten grapes and you will go ten times to
evacuate the bowels". The Caliph asked him
the reason of this; he informed him of it. Then
it happened as he said. Abd al-Mumin became
calm and was healed, and so Avenzoar's
reputation and rank increased".
There is another episode that indicates the
spirit of observation of Avenzoar:
Abd al-Malik ibn Zuhr was going to the
palace of prince of Faithful in Seville, and on
his way, at Abul-Khayr bath, near Ibn
Mu'amil's house, found an ill man who had a
great tumor, his belly was swollen and his
complexion became pale. This patient was
always complaining of his state to the
physician, and asking him to take care of his
case. A day, when he asked him the same
thing, Abu Marwan ibn Zuhr stopped, looked
at him and found near his head an old jug
from which he has been drinking water.
Avenzoar told him: 'Break this jug, because it
is the cause of your disease'. The man replied
to him: 'No, by God, Sir, because I have not
another jug save this one'. The physician
ordered one of his servants to break the jug.
He broke it, and a big frog appeared from it.
Avenzoar said: 'You are saved from your
disease. Look at what you have been
drinking'. The man recovered his health".
WORKS OF AVENZOAR
Abu Marwan ibn Abi al-Ala ibn Zuhr wrote
the following books:
-Kitab al-Taysir fil-mudawa wal-tadbir.
-Kitab al-Iqtisad fi islah al-anfus wal-ajsad.
-Kitab al-Aghdiya wal-adwiya, that he wrote
for Abu Muhammad Abd al-Mur'nin ibn Ali.
-Kitab al-Sina
-Kitab al-Jamic fil-Ashriba wal-Maajin.
-Kitab Mukhtasar hilat al-bur' li-Jalinus.
-Risala fi tafdil al-asal alal-sukkar.
-Kitab al-Tadhkira fil-dawa' al-mushil
and two books: Maqala fi ilal al-kula and
Risala fil-baras.
KlTAB AL-TAYSIR
Its complete title is Kitab al-Taysir fil-
mudawa wal-tadbir, and it is organized in the
traditional order, i.e. mentioning the diseases
of the organs from head to feet.
We do not know exactly the date of its
composition. Ibn al-Abbar says that he wrote
it after he composed the Kitab al-Iqtisad and
Colin says that it was, then, written between
1121 and 1162 A.D.
We know that this book was written at the
request of the cadi Abul-Walid ibn Rushd
(Averroes), since this one says at the end of
his Kitab al-Kulliyat:
"Who thinks that this part of this book is
incomplete, and wanted to examine after that
the Kananish (notebooks), the best of these is
the book entitled al-Taysir which has been
written in our time by Abu Marwan Ibn Zuhr.
I asked it from him and I have copied it
(...)".8
The Kitab al-Taysir is one of the most
important Arabic works on medicine, and it
has had a great influence in Medicine of the
following ages, and it was found always in the
libraries of the Christian physicians.
There are several manuscript copies of this
book: one in the Bibliotheque Nationale de
Paris, MS or N° 2960, ff. 50r-189r. This copy
was finished in Barcelona in 651 A.H./1165
45
A.D. There is another copy of the Bodleian
Library of Oxford, MS Huntington N° 355, ff.
1-180v, but we do not know the place and
date of the copy. The third manuscript copy is
in the Biblioteca Medicea-Laurenziana of
Florence (Italy), n° 215, ff. 1 r-11 Ov. And,
finally there was another manuscript copy,
lost at present, in al-Maktabe al-Abdaliya in
Tunis, n° 2867/7. There are also many ancient
translations into Hebrew and Latin.
TREATISE ON LIVER AND ITS
DISEASES
Liver is one of the main organs, and Aristotle
sees in it the origin of natural heat, the heat of
heart. Physicians think that the heart in itself
is a principal organ, which has great influence
and effects. For that reason Hippocrates says:
"If we live a good life it is because of the
health of our liver. The liver is a source of the
natural force with which digestion,
maturation, attraction and repulsion are
accomplished. Liver spread these forces and
especially the transmissive force to all body,
and with these forces the organs digest the
food and transform it, after its attraction and
retention. All these forces are in liver and
come from it. When its mutative force is
weakened, diseases occur in the body,
according to this weakness, like dropsy. Its
cure consists of returning the state of liver to
its normal proportion or equilibrium. The
weakness of liver occurs because it is an
instrumental organ, origins obstruction and
tumor, since tumor is a disease of the
instrumental organs, and it is also a disease of
the organs of similar parts. The cure of this
consists of opening obstruction, if it is caused
for it, and making to disappear the tumor, if it
is the cause. If another sickness occurs in
liver, like in duration because of drinking cold
water, against what is convenient or
debilitation of strength because of an excess
in eating food with vinegar, what is caused by
drinking very cold water is not only cured
with something which can warm the liver but
adding altogether a strengthening force and a
moderate astringency and flavour. Chamomile
and rose are drugs useful for this.
Know that the kinds of dropsy are composed
like fevers. If the physician makes a good
inspection and proceeds with care in the
treatment of each kind of them, it will not be
difficult for him, the treatment of which is
composed of them always with the help of
God.
COMPOUND DRUG FOR THAT
One ounce each of lac deprived of wood,
flowers of chamomile and rose, Chinese
cinnamon, mastic clove, and lavender; half an
ounce of toasted linseed, agrimony, and scaly
spleenwort. The drugs are separately pounded
and sieved with a veil. Then, all of them are
pounded, sieved and kneaded with well-made
syrup of common eryngo. About five dirhams
of all this are taken every morning. Then the
liver is anointed with fever-few
chrysanthemum oil and lentisk grain oil, in
similar parts. Food must be fermented bread
with pigeons, small birds or young partridges
in white or green tafaya, God willing.
And if the weakness is caused by an excess in
eating sour food or vinegar, you must treat it
with the following prescription: half a pound
of dry raisins deprived of their seeds, licorice
wood; a quarter of a pound of common
eryngo, and agrimony; one ounce of mastic;
what is necessary of these drugs is separately
crushed and it is macerated for one night in a
quarter of boiled water; then, in the morning,
it is put on a low fire until a half of the water
is consumed; then, it is sieved, and about ten
pounds of sugar and five pounds of honey are
added to it; and it is cooked until becomes a
thick syrup. The dose of it, every morning, is
two ounces, with six ounces of lukewarm
drinking water, and five dirhams of electuary
of cushari roses. The liver is anointed
externally with lentisk grains oil, and
chamomile oil, in equal parts.
Tumor occurs in the liver substance, and what
suppurates from it, I do not hope absolutely
could be recovery, because it is a source of
46
strengths, and because of its disease the
strengths are disturbed and death overtakes
him.
Obstruction occurs in it, and the treatment for
liver obstruction consists of opening it with
water in which agrimonies, Venus' hair, scaly
spleen wart or similar drugs are cooked. The
juice of fennel has a good effect for this.
It happens in the cover of the liver that it is
swollen as it occurs in the other organs. The
patient feels an insufferable pain which he
fancies to be located in his liver. The
sensibility of this cover is great because all
the nerves coming to it are subdivided into
many branches, and its sensibility is very
great. The wicked Ali ibn Yusuf often
suffered of this pain. I treated him with oil
extracted from egg yolk and duck fat, and he
was cured in that same day. After this pain he
suffered from jaundice.
SPLEEN
The spleen is an organ that attracts the
melancholic residues, nourishing it with those
of them that are thinnest. Several diseases
affect it, as it happens in other organs. It is not
one of the main organs, and no strength
comes from it to the body, but it received the
thick residues of the body, as kidneys receive
the thin ones, and then it becomes very much
swollen and hard.
Its treatment consists of the same drugs that I
have mentioned for liver. Know that spleen
can tolerate stronger drugs than the ones
tolerated by the liver, and remember always
that when you give any drug to drink which is
useful for spleen, you must mix something
sour with it, because this organ is only
nourished with drugs containing some acidity,
and it attracts them to it, by taking them, and
accelerating the arrival of the useful sour
drugs.
We know that when spleen hardens itself, and
cannot receive the sediments of blood, these
ones remain spread within the body, and the
state of the liver becomes worse and after this
in duration it follows weakness of liver, and
also dropsy of one or more than one of its
kinds.
COMPOUND DRUG FOR SPLEEN'S
INDURATION
One ounce each of chamomile, bast of
tamarisk's root, agrimony, lavender, mountain
germander, Venus' hair, common ceterach,
and wild ginger; half an ounce of dyer's
madder, five dirhams each of common larch
root, bast of fennel's root, six dirhams of
mastic, one dirham of saffron, half the amount
of licorice of all the before mentioned drugs.
All that is necessary to crush is separately
crushed, and macerated for one night in
twenty-four pounds of very hot water. In the
morning, it is macerated with the fingers; its
broth is sieved, and put on a low fire, together
with eight pounds of honey bereft of froth and
two pounds of sugar. When it is about to grow
thicker, two pounds of very sour grape
vinegar are added to all the other drugs. When
thick syrup is formed, it is kept into a glass or
glazed earthenware vessel.
Every morning, are taken from one ounce and
half an ounce to two ounces, with three equal
parts of drinking water and two dirhams of
honey-suckle electuary. If weakness appears
in liver, the honey- -suckle electuary is
substituted for three dirhams of electuary of
cushari rose. Food must be the lightest
possible meat. Chicks and young turtle-dove
meat is enough. Occasionally, hen meat is not
bad, until total cure occurs. Put also the
following plaster over the spleen.
PLASTER FOR INDURATION OF
SPLEEN
One part each of tamarisk root, chamomile,
narcissus and jasmine flowers. Add to this
half the amount of all rest of barley flour and
darnel flour. It is kneaded with water and
vinegar in equal amounts. Apply this plaster
over the spleen, and bind it with fresh vine
leaves. It is convenient for the patient to have,
before his meal, caper in vinegar with some
salt, as caper so prepared is one of the useful
drugs for spleen, especially if they are eaten
47
on an empty stomach. Apply the plaster to
him in this way, at night, and order him to
annoint himself, by day, with lily oil, and rose
oil, in equal amounts, and apply them together
twice every day, and the plaster at night.
Often it happens that the strength of the body
repels it, because the spleen does not accept
this sediment, and it remains spread within
the body. Physicians say that sometimes it is
repelled, and very black blood goes out along
the anus, and consequently the hypertrophy
decreases. I saw this with my own eyes. Dr,
sometimes, this sediment is pushed to the
skin, which becomes black and blue; then the
swelling of the spleen decreases. I saw this
with my own eyes. I also saw many times
jaundice that occurs when the bilious
sediment is repelled, without feeling its issue
along the anus, because of its thinness and it
is carried by the laxity of belly or diarrhoea.
And if it is pushed towards the skin, this is
generally a dangerous thing; so hurry to the
physician.
JAUNDICE is originated by a bilious humor
which is suddenly impelled towards the skin
and this one takes the colour of the peel of the
cedrat, and likewise the white of the eyes
becomes yellow. When you see this, observe
if acute fever has occurred before the ejection
of this humor, or if fever has decreased, or if
it continues, or if he ejected it without fever,
or if there was fever after its ejection. If fever
continues, and the ejection was after the
apparition of fever, observe if this happens
after the seventh day, or in the seventh day. If
it is in the seventh day, approximately, hope
for a good end, because it has been ejected
after its maturity. If it is ejected immediately
after the beginning of the fever, suspect that a
hot tumor is in the liver or in its cover. In fact,
when this happens in the liver, everything
coming into it is transformed into this humor,
and it does not go out onto the skin by means
of crisis, but, spreading itself through the
whole body. If you know that the liver or its
cover have a tumor and are swollen, do not
give the patient anything hot to eat, not sweet,
or containing oil or fat, because if you do it,
you will kill the patient. Give him
immediately juice of watermelon, or
crumbled bread in juice of watermelon
without containing oil or spices, except dry
coriander, and give him pulp. of watermelon
or crumbled bread soup to eat, and the pulp is
not bad, if it is cooked in water with a bit of
salt. Then it is cooled in snow or in a well as
it is useful for this.
TREATISE ON THE HERNIAE WHICH
OCCUR IN HYPOCHONDRIUM
Hernia occurs in hyponchondrium either
because of a contusion with a stick or a stone,
on a full belly, or because of a great jump,
especially when the belly is full. At times, it
occurs because of an excess of violent cough,
or because of raising a heavy load, or the like.
When this happens in hypochondrium even if
the man is young, it does not stop increasing
until it becomes very big, and some bowels
come out, remaining hidden only by the skin
of the belly. Rumbling noises and pain occur
in the belly and the state of health of the
patient becomes worse, because of the hernia
of hypochondrium, especially if the patient is
fatigue or tired by walking or riding and
galloping a horse, or by hard works. When the
hernia happens, it increases continually,
because the man must move with sudden
movements. As for he who can be calm and
quiet, when he reduced his movements, lies
continually on his back, avoids crying, and
tries not to cough or sneeze, then you must
return the bowels to their place and bind his
belly over an astringent and not too thick
plaster, and if he remains so, it will be useful
for him.
The substance of the hypochondrium is
humid, and for that reason it cicatrisation is
difficult, because it moves a lot with the
movements of the body. I saw a man, who
was my friend, who suffered from hernia, and
for this reason remained disabled for some
time. I was then a young man. The man
48
suffered from intense pains, and no doubt this
was caused by eating a lot of apples or
grapes. Acute pains overtook him, and the
spread all over the body, and he could not
move but with great difficulty. I was treating
his pains, and denied him all food, except a
little fermented bread and small birds in white
tafaya, well-cooked until their meat was on
the point of being overdone. The man
remained lying on his back for a long time,
about two months, praying only by means of
gesticulations. Afterwards, pains disappeared
when their cause disappeared, and he
recovered completely from the hernia which
he suffered and whose treatment was difficult
form, because of this behaviour during that
time. When he remained quiet and kept calm,
he recovered, according to the symptoms. In
fact, lying on his back, his bowels returned to
their place, and the place remained calm. His
food was light, and his stomach was empty.
He healed due to all these things, not because
any one tried to treat.
TREATISE ON BELLY WOUNDS
Wounds can occur in the belly because of a
piece of iron, or a sharp stick, that pierce
through both the skin of the belly and the
hypochondrium, and the cauls come out.
When this happens, someone dexterous
enough must return it to its place. If it is
affected by earth, dirt or sawdust, it is
necessary to, wash it with tepid water and to
return it to its place with care. If a part of it is
rent and becomes black, the solution is to cut
off the part of it which is rent and corrupted
and to return it to the belly and seam it with a
silk thread. A skilful and responsible person
must make it, as this is only learned by
practice, not by science. Over the suture
something is put that helps the cicaterization.
At the same time, it is, necessary because of
the wound, to moderate food, as much as
possible, in order to reduce the flux of
humors. If the flux of blood is not excessive, a
little blood-letting in the medial arm vein is
not bad to him. This is a general means in all
kind of wounds for reducing the flux of
humors. It is possible that some portion of the
bowels comes out. If bowels come out
uninjured, without a great or a small injury,
except their issue to the outside, you must
hurry to return the bowels to their place with
care in order to avoid inflammation. And if
the bowels cannot be returned the same way
they came out, because the bowels are
swollen due to slowness of action, then you
must pour tepid water in the surface of the
fissure, so that it may be pleasant for the man,
pouring it softly on the inflamed part until the
swell disappears. After this has disappeared,
you must reduce it softly. The rent of the skin
and the peritoneum are seamed with a silk
thread, with great care. Make the patient stay
calm, not raise his voice, not move, and not
stuff him self with food or drink. Nourish him
with something in little quantity but very
nutritive, like cock testicles in tafaya; two of
them will be enough. Try the utmost to
remove matter from the place of the wound. It
is convenient to anoint around the wound with
much flavored rose oil, and the patient must
have anything to eat until the rent cicatrizes,
God willing. If bowels are affected by a
wound with this piece of iron, and if it is in
the small intestine, as it happens in most
cases, I think that there is not any means to
cure it. If rent occurs in the large intestine, the
patient may live, because the rent is only in
one of the tunics of the intestine, and the
patient may be saved. If both tunics are rent,
and especially if their rent is important,
recovery is very difficult. However, at times,
the patient can survive in this state.
Physicians are of this opinion, having
observed it in men and animals. I saw a man
who evacuated the bowels through the wound
he suffered, and he remained so for a long
time, moving himself very much to get food.
His life was long, but rather bad.
Here I finish with these organs, and I shall
begin to treat on stomach, God willing.
49
TREATISE ON STOMACH DISEASES
Stomach is affected by consumption and
weakness, so that its volume becomes thinner,
like a rag, and it does not digest any food. I
mentioned this disease, and presented it,
because of people's neglect of it, and of what
is against it. Beware of known drugs for
strengthening the stomach which are
astringent, desiccative and heating. The
symptoms of this disease are that the patient
cannot vomit what is in his stomach, the
saliva does not flow from his mouth, his
appetite is very weak and his digestion is far
weaker, he evacuates dregs not digested or
crushed, dregs are not very stinking, the
colour of food is lost, the patient does not
belch, and if he belches, does it scarcely, and
he often hiccups. Desiccative food, cold or
warm, damages him; his pulse is feeble, hard
and invariable, with a tendency to become
weaker. When you see these symptoms, you
can be sure that this disease is certainly
consumption and emaciation of the stomach
substance. If you observe, in spite of all this,
that the stomach looks, from outside, like a
hollow when the patient is lying on his back,
there is practically no doubt the patient suffers
from this disease. However, if you have a
sharp touch and you put your hand on the
stomach, pressing it hard, with the patient not
feeling any pain, and you perceive a pulsation
under your hand, be sure that your caution is
justified, and that the stomach suffers
consumption, because this movement comes
from the artery inside backbone. It is evident
that you would not have perceived, were it not
because of the stomach consumption. You
must then anoint the stomach with sweet
almond oil, together with some lentisk seed
oil, and put two dirhams of lentisk seed oil for
each ounce of sweet almond oil. Mix one
tenth of tepid water with the whole of it.
Shake it well, and anoint the stomach with it.
Feed the patient with young hens in tafaya
with almond oil and seasoned with a sarira of
mastic. Put a rough rag anointed with pitch,
previously softened with some almond oil, on
the stomach. Put it on the stomach for a
limited time, because if you leave it more than
it is convenient, you will injure the patient.
You must put the pitch on the stomach for
half an hour, more or less. Then remove the
rag together with its pitch from the stomach,
and anoint it with almond oil in which you
have put rose oil, mixing both of them well.
See that the roses are recent, of that same
year. Give him goat's milk to drink at the
same time when it is milked, before it is
affected by air, in a moderate quantity, from
two to three ounces. Feed him with hen meat
or cock testicles. Cock testicles are better than
the meat. Feed him with this food several
times on equal terms, and see that it is easily
digestible. Keep him away from all dry foods
either hot or cold. The hot ones are more
strengthening because the heat, even when it
is humid, dissolves a lot and accidentally
dries. If it moistens by its proper nature, water
evidently moistens by its natural humidity and
also it dissolves a part of the organ substance
because of the heat it has acquired. Things
dissolving the substance of the organ are to be
avoided in this disease. Endeavour, the,
procure humidity and that the patient makes a
good digestion, in as much as any food is
assimilated, except after it has been digested.
Remember also that the stomach is a main
organ, due to the relation between its pit and
the brain, because of the many nerves existing
between both of them. Preserve, then, his
strength, and there must be something softly
astringent and flavoured in your drug. And if
there is some bitterness in it, like bitterness of
roses, that is one of the most useful thing.
Chicken and hen meat and cock testicles
ought to be very well-cooked. Bread ought to
be fermented and proportionated, only with a
bit of salt; and the flour it is made of ought to
be from good wheat and to be grounded after
having been moistened. Before kneading the
dough it is put in a mortar and pounded for
some time until it becomes like powder. It is
50
kneaded as well as possible with tepid water.
Oil used in his food ought to be sweet almond
oil or sesame oil, and you must know that
almond oil is preferable and that the oil of
sesame in excess damages organs, because it
is not astringent. If there is any bad property
in it, halitosis results, but halitosis is only
produced when diseases and bad symptoms
are present. But, I do not see any objection to
using this drug two or three times until
halitosis disappears. Olive oil, if washed in
water three times, is used in diseases like this
one. Barley water well-made is also good, if it
is had in a small quantity.
I think that anything remains to be mentioned
on this disease, except one thing. The patient
himself prefers astringent and bitter drugs or
foods. Moderate astringency and bitterness
are useful for this organ, because it is the
stomach.
Keep in mind, then, all these aspects in your
treatment. Also, this disease and this organ
require avoiding sour drugs. However, for
making medicinal powers arrive at the
stomach layers, you must put, at times
something a bit sour. Pears, if broiled, are
good, because of its moisture, and have the
property of making thirst disappear, and
strengthening the stomach, due to its
astringency and flavour, that make medicinal
powers circulate and arrive at the organ with
drugs containing some sourness.
AVERROES (1126-1198)
(ABUL WALID MUHAMMED IBN
AHMED IBN RUSHD)
The medical school of the western Caliphate
was both medically and philosophically
antagonistic to Ibn Sina (1037) Avicenna,
who is usually regarded as the chief
representative of Islamic Medicine. The
Arabic physician that emanated from the
Cordova center of Islam showed a
modification, owing to its intimate contact
with the Christian West, and the medical and
philosophical literature issued by the
Christians and Jews of Moslem Spain is based
more on the practical realities and attach less
importance to dialectic vanities.
The eminent Arabic writers of the western
Caliphate are small in number as compared to
those of the Eastern, but their influence on the
Latin West was far-reaching. The most of the
Western Moslem physicians who reached any
degree of eminence date long after Razes and
Avicenna: the four most eminent of these
were Albucasis, Avenzear, Averoes and
Maimonides, all of whom exercised a great
influence over the Scholastics of the Latin
West.
Muslim Spain has produced some of the
brightest intellectual luminaries of the Middle
Ages. One of them was Ibn Rushd known in
the West as Averroes, who is universally
aknoweldge as the great philosopher of Islam
and one of the greatest of all times. George IBN RUSHD (1126-1198)
Sarton in his introduction of history of science Ibn Rushd under Islamic protection centered
said that “Averroes was great because of the on the masterworks of Plato and Aristotle as
tremendous stir he made in the minds of men preserved by an evolving series of lengthy
for centuries. A history of Averroism would and often innovative commentators, ideas that
include up to the end of the sixteenth-century, by now had been banned for centuries and
a period of four centuries which would virtually forgotten in the adjoining Holy
perhaps deserve as much as any other to call Roman Empire.
the Middle Ages, for it was the real transition
between ancient and modern methods”.
Abul Waleed Muhammed Ibn Ahmed Ibn
Muhammed Ibn Rushd
He was born in Cordova, the metropolis of
Moslem Spain in 520 A.H. (1126 C.E.). Both
his father and grand father were prominent
judges. His family was well known for
scholarship and it gave him fitting
environment to excel in learning. He studied
religious law, medicine, mathematics, and
philosophy and (according to Leo Africanus)
he was a friend of Avenzoar, the great
Moslem clinician. He studied medicine,
philosophy and law from Abu J'afar Harun
and from Ibn Baja (1138) and he learned
'Fiqh' (Islamic jurisprudence) from Hafiz Abu
Muhammed Ibn Rizq.

51
Like his father and his grandfather, he too
became a judge, first in Seville and then
Cordova, though his main love was
philosophy. Supposedly, one night over
dinner, he entered into a discussion with
Almohad prince Abu Ya'qub Yusuf over the
origin of the world and the nature of the mind.
Averroes' ruminations on Aristotle's account
of existence and the nature of the soul
impressed the ruler that he commissioned
Averroes to write an entire set of
commentaries. A few years later the prince
appointed Averroes as his personal physician;
under his auspices, Averroes spent the rest of
his life writing commentaries on virtually all
of Aristotle's works, producing detailed and
original reconstructive commentaries on
Aristotle's Metaphysics, Physics, Posterior
Analytics, De Caelo, and De Anima, as well
as Plato's Republic.
Ibn Rushd was a genius of encyclopedic
scope. He spent a great part of his fruitful life
as a judge and as a physician. Yet he was
known in the West for being the grand
commentator on the philosophy of Aristotle,
whose influence penetrated the minds of even
the most conservative of Christian
Ecclesiastes in the Middle Ages, including
men like St. Thomas Aquinas. People went to
him for consultation in medicine just as they
did for consultation in legal matters and
jurisprudence.
At the age of twenty-seven, Ibn Rushd was
invited to the Movahid Court at Marrakesh (in
Morocco) to help in establishing Islamic
educational institutions. Upon the ascendancy
of Yousuf, he was introduced to him by
another great Muslim philosopher Ibn Tufail
to help in translating, abridging and
commenting on some works of Aristotle (in
1169 C.E.).
Ibn Rushd was appointed a judge (Qaadi) in
Seville at the age of forty-four. That year he
translated and abridged Aristotle's book "de
Anima" (Animals). This book was translated
into Latin by Mitchell the Scott. Two years
52
later he was transferred to Cordova, his
birthplace where he spent ten years as judge
in that town. During those ten years Ibn
Rushd wrote commentaries on the works of
Aristotle including the Metaphysics. He was
later called back to Marrakesh to work as a
physician for the Caliph there, before his
return to Cordova as Chief Judge.
Ibn Rushd was well versed in the matters of
the faith and law, which qualified him for the
post of Qaadi (judge), but he was also keenly
interested in philosophy and logic. So he tried
to reconcile philosophy and religion in many
of his works. Besides this area of study, he
was deeply interested in medicine as well, as
was his predecessor Ibn Sina (Avicenna).
According to the French philosopher Renan
Paris 1866), Ibn Rushd wrote seventy-eight
books on various subjects.
A careful examination of his works reveals
that Averroes was a deeply religious man. As
an example, we find in his writing, "Anyone
who studies anatomy will increase his faith in
the omnipotence and oneness of God the
Almighty."
In his medical and philosophical works we
see the depth of his faith and knowledge of
the Qur'an and Prophetic traditions, which he
often quotes in support of his views in
different matters.
Ibn Rushd said that true happiness for man
can surely be achieved through mental and
psychological health, and people cannot enjoy
psychological health unless they follow ways
that lead to happiness in the hereafter, and
unless they believe in God and His oneness.
Ibn Rushd commented that Islam aims at true
knowledge, which is knowledge of God and
of His creation. This true knowledge also
includes knowing the various means that lead
to worldly satisfaction and avoidance of
misery in the Hereafter. This type of practical
knowledge covers two branches: (1)
Jurisprudence which deals with the material
or tangible aspect of human life and (2) the
spiritual sciences which deal with matters like
patience, gratitude to God, and morals. He
compared spiritual laws to medicine in their
effect on human beings physically on one
hand, and morally and spiritually on the other.
He pointed out that spiritual health is termed
'Taqwa' (righteousness and God-fearing) in
the Qur'an.
Ibn Rushd made remarkable contributions in
philosophy, logic, medicine, music and
jurisprudence. Ibn Rushd's writings spread
more than 20,000 pages, the most famous of
which deal with philosophy, medicine and
jurisprudence. He wrote 20 books on
medicine.
In Philosophy:
His most important work Tuhafut al-Tuhafut
was written in response to al-Ghazali's work.
Ibn Rushd was criticized by many Muslim
scholars for this book, which, nevertheless,
had a profound influence on European
thought, at least until the beginning of modern
philosophy and experimental science. His
53
views on fate were that man is in neither full
control of his destiny nor it is fully
predetermined for him.
He wrote three commentaries on the works of
Aristotle, as these were known then through
Arabic translations. The shortest Jami may be
considered as a summary of the subject. The
intermediate was Talkhis and the longest was
the Tafsir. These three commentaries would
seem to correspond to different stages in the
education of pupils; the short one was meant
for the beginners, then thintermediate for the
students familiar with the subject, and finally
the longest one for advanced studies. The
longest commentary was, in fact, an original
contribution as it was largely based on his
analysis including interpretation of Qur'anic
concepts.
Ibn Rushd wrote many books on the question
of theology, where he tried to use his
knowledge of philosophy and logic. It is not
surprising then that his works greatly
influenced European religious scholarship,
though Averroes is innocent of many views of
Western so-called Averroism.
Professor Bammate in his booklet "Muslim
Contribution to Civilization" quotes Renan:
St. Thomas Aquinas was "the first disciple of
the Grand Commentator (i.e., Averroes).
Albert Alagnus owes everything to Avicenna;
St. Thomas owes practically everything to
Averroes." Professor Bammate continues:
"The Reverend Father Asin Palacios, who has
carried out intensive studies of the theological
Averroism of St. Thomas and, in no way
classifies Averroes with Latin Averroists,
takes several texts of the Cordovan
philosopher and compares them with the
Angelic Doctor of (St.Thomas). The
similarity in their thought is confirmed by the
use of expressions similar to that of Ibn
Rushd. It leaves no room for any doubt about
the decisive influence that the Muslim
Philosopher (Averroes) had on the greatest of
all Catholic theologians.
In Medicine:
 The philosophical, religious, and legal works
of Ibn Rushd have been studied more
thoroughly than his medical books, since he
was primarily a theologian-philosopher and
scholar of the Koranic sciences.
Among his teachers in medicine was Ali Abu
Ja'lfar ibn Harun al-Tarrajjani (from
Tarragona) and Abu Marwan ibn Jurrayul (or
Hazbul, according to al-Safadi).
Ibn Rushd's major work in medicine, al-
Kulliyyat (Generalities), was written between
1153 and 1169.
Its subject matter leans heavily on Galen, and
occasionally Hippocrates' name is mentioned.
It is subdivided into seven books: Tashrih al-
a'lda' (Anatomy of Qrgans), al-Sihha
(Health), al-Marad (Sickness), al-Alamat
(Symptoms), al-Adwiya wa 'l-aghdhiya
(Drugs and Foods), Hifz al-sihha (Hygiene),
and Shifa al-amrad (Therapy)
Ibn Rushd requested his close friend Ibn Zuhr
to write a book on al-Umur al-juz'iyya
(particularities, i.e., the treatment of head-to-
toe diseases), which he did, and called his
book al-Taisir fi 'l-muddawat wa 'l-tadbir (An
Aid to Therapy and Regimen).
Ibn Rushd's al-Kulliyyat and Ibn Zuhr's al-
Taisir were meant to constitute a
comprehensive medical textbook (hence
certain printed Latin editions present these
two books together), possibly to serve instead
of Ibn Sina's al-Qanun, which was not well
received in Andalusia by Abu '1-,Ala' Zuhr
ibn Abd al-Malik ibn Marwan ibn Zuhr (Ibn
Zuhr's grandfather).
Two Hebrew vesions of al-Kulliyyat are
known, one by an unidentified translator,
another by Solomon ben Abraham ben David.
The Latin translation, Colliget, was made in
Padua in 125 5 by a Jew, Bonacosa, and the
first edition was printed in Venice in 1482,
followed by many other editions.
Ibn Rushd wrote an abstract on Galen's
works, parts of which are preserved in Arabic
manuscripts.
54
He showed interest in Ibn Sina's Urjuza fi 'I-
tibb (Poem on Medicine, Canticum de
medicina . . . ), on which he wrote a
commentary, Sharh Urjuzat Ibn Sina.
It was translated into Hebrew prose by Moses
ben Tibbon in 1260; a translation into Hebrew
verse was completed at Beziers (France) in
1261 by Solomon ben Ayyub ben Joseph of
Granada.
Further, a Latin translation of the same work
was made by Armengaud, son of Blaise, in
1280 or 1284, and a printed edition was
published at Venice in 1484.
Another revised Latin translation was made
by Andrea Alpago, who translated Ibn
Rushd's Maqala fi '1-Tiryaq (Treatise on
Theriac, “Tractatus de theiaca”).
Ibn Rushd's unsuccessful attempts to defend
philosophers against theologians paved the
way for a decline in Arabic medicine.
The great image of the Hakim (physician-
philosopher), which culminated in the persons
of al-Razi and Ibn Sina, has been superseded
by that of faqih musharik fi 'l-ulum (a jurist
who participates in sciences), among whom
were physician-jurists and theologian-
physicians.
Because Ibn Rushd'frame as a physician was
eclipsed by his frame as a philosopher, his
book Kitab al-Kulyat fi al-Tibb stands no
comparison to 'Continents' of Rhazes and
'Canon' of Avicenna.
Averroes wrote a commentary on Avicenna's
poem Canticum de Medicina (translated into
Latin by Armengaud) and also mentioned the
Philosophia Orientalis of the latter.
His commentary of the Canticum was
published at Vinice in 1484 under the title
Incipit translatio Canticor. Avi cum
commento Averrhoys facta ab Arabico in
Latinum a mag Armegando blassi de
Montepesulaano.
The German physician Max Meyerhof
remarked that: "In Spain, the philosophical
bias predominated among medical men. The
prototypes of this combination are the two
Muslims, Ibn Zuhr (Avenzoar) and Ibn Rushd
(Averroes)”.
In Astronomy:
He wrote a treatise on the motion of the
sphere, Kitab fi-Harakat al-Falak.
According to Draper, Ibn Rushd is credited
with the discovery of sunspots. He also
summarized Almagest and divided it into two
parts: description of the spheres, and
movement of the spheres. This summary of
the Almagest was translated from Arabic into
Hebrew by Jacob Anatoli in 1231.
His book on jurisprudence 'Bidayat al-
Mujtahid wa-Nihayat-al-Muqtasid' has been
held by Ibn Jafar Zahabi as possibly the best
book on the Maliki School of Fiqh.
General:
Ibn Rushd's writings were translated into
various languages, including Latin, English,
German and Hebrew.
Most of his commentaries on philosophy are
preserved in the Hebrew translations, or in
Latin translations from the Hebrew, and a few
in the original Arabic.
His commentary on zoology is entirely lost.
Ibn Rushd also wrote commentaries on Plato's
Republic, Galen's treatise on fevers, al-
Farabi's logic, and many others. Eighty-seven
of his books are still extant.
Ibn Rushd has been held as one of the greatest
thinkers and scientists of the twelfth century.
55
According to the Western writers, Ibn Rushd
influenced Western thought from the twelfth
to the sixteenth centuries.
His commentaries were used as standard texts
in preference to the treatises of Aristotle in
the fourteenth and fifteenth centuries.
His books were included in the syllabi of
Paris and other Western universities till the
advent of modern experimental sciences. Ibn
Rusd was studied in the University of Mexico
until 1831.
The intellectual movement initiated by Ibn
Rushd continued to be a living factor in
European thought until the beginning of
modern experimental science.
Ibn Nafis
IBN AL-NAFIS (1213 A.D)
Ala-al-Din Abu al-Hasan Ali Ibn Abi al-
Hazm al-Qarshi al-Dimashqi (known as Ibn
Al-Nafis) was born in 1213 A.D. in
Damascus. He was educated at the Medical
College Hospital (Bimaristan Al-Noori)
founded by Noor al-Din Al-Zanki. Apart from
medicine, Ibn al-Nafis learned jurisprudence,
literature and theology. He thus became a
renowned expert on the Shafi'i School of
Jurisprudence as well as a reputed physician.
In 1236 Ibn Nafis moved to Egypt and
worked in Al-Nassri Hospital then in Al-
Mansouri Hospital where he became chief of
physicians and the Sultan’s personal
physician. When he died in 1288 A.D. he
donated his house, library and clinic to the
Mansuriya Hospital.
The most voluminous of his books is Al-
Shamil fi al-Tibb, which was designed to be
an encyclopedia comprising 300 volumes, but
was not completed as a result of his death.
The manuscript is available in Damascus. His
book on ophthalmology is largely an original
contribution and is also extant. His book that
became most famous, however, was Mujaz al-
Qanun (The Summary of Law) and a number
of commentaries that were written on this
same topic. His commentaries include one on
Hippocrates' book, and several volumes on
Ibn Sina's Qanun, which are still extant.
Likewise he wrote a commentary on Hunayn
Ibn Ishaq's book. Another famous book
embodying his original contribution was on
the effects of diet on health entitled Kitab al-
Mukhtar fi al-Aghdhiya.
His major original contribution of great
significance was his discovery of the
pulmonary circulation, which was re-
discovered by modern science after a lapse of
three centuries. He was the first to correctly
describe the constitution of the lungs and gave
a description of the bronchi and the
interaction between the human body's vessels
for air and blood. He also elaborated on the
function of the coronary arteries as suppliers
of blood to the cardiac musculature.
Arab Discovery of the Pulmonary
Circulation
It was commonly believed that the Discovery
of Pulmonary Circulation that is, the
movement of blood from the right to the left
ventricles of the heart via the lungs had its
inception in Europe in the sixteenth century
by Servetus, Vesalius, Colombo, and finally
Harvey. However later it was found that 300
years before Servetus,Vesalius or Harvey
(who was credited for correct explanation of
pulmonary circulation) were born, an eminent
physician of the thirteenth century: Ibn Al-
Nafis explained correctly the Pulmonary
Circulation (Encarta encyclopedia, keyword
56
= ibn nafis) .This fact has been now
recognized by many of the historians but
some black sheep's still try to argue the fact.
In 1924 an Egyptian physician, Dr. Muhyo
Al-Deen Altawi, discovered a script titled,
"Commentary on the Anatomy of Canon of
Avicenna" in the Prussian state library in
Berlin while studying the history of Arab
Medicine at the medical faculty of Albert
Ludwig’s University in Germany. This script
is considered one of the best scientific books
in which Ibn Al-Nafis cover in detail the
topics of anatomy, pathology and physiology.
This discovery revealed an important
scientific fact, which up to then had been
ignored: the first description of the pulmonary
circulation.
The theory that was accepted prior to Ibn Al-
Nafis was placed by Galen in the second
century, who had theorized that the blood
reaching the right side of the heart went
through invisible pores in the cardiac septum
to the left side of the heart where it mixed
with air to create spirit and was then
consequently distributed to the body.
According to Galen's views, the venous
system was quite separate from the arterial
system, except when they came in contact
through the unseen pores.
However, Ibn Al-Nafis, based on his
knowledge in anatomy and scientific thinking
stated that, "...The blood from the right
chamber of the heart must arrive at the left
chamber but there is no direct pathway
between them. The thick septum of the heart
is not perforated and does not have visible
pores as some people thought or invisible
pores as Galen thought. The blood from the
right chamber must flow through the vena
arteriosa (pulmonary artery) to the lungs,
spread through its substances, be mingled
there with air, pass through the arteria venosa
(pulmonary vein) to reach the left chamber of
the heart and there form the vital spirit...”
Elsewhere in his book he said, "The heart has
only two ventricles ...and between these two
there is absolutely no opening. Also
dissection gives this lie to what they said, as
the septum between these two cavities is
much thicker than elsewhere. The benefit of
this blood (that is in the right cavity) is to go
up to the lungs, mix with what is in the lungs
of air, then pass through the arteria venosa to
the left cavity of the two cavities of the
heart...”.
In describing the anatomy of the lungs, Ibn
Nafis stated, "The lungs are composed of
parts, one of which is the bronchi, the second
the branches of the arteria venosa and the
third the branches of the vena arteriosa, all of
them connected by loose porous flesh". He
then added, "... The need of the lungs for the
vena arteriosa is to transport to it the blood
that has been thinned and warmed in the
heart, so that what seeps through the pores of
the branches of this vessel into the alveoli of
the lungs may mix with what there is of air
therein and combine with it, the resultant
composite becoming fit to be spirit when this
mixing takes place in the left cavity of the
heart. The mixture is carried to the left cavity
by the arteria venosa".
Another important contribution of Ibn Nafis
that is rarely mentioned is his postulation that
the nutrition of the heart is extracted from the
small vessels passing through its wall, when
he said "... Again his (Avicenna's) statement
that the blood that is in the right side is to
nourish the heart is not true at all, for the
nourishment to the heart is from the blood
that goes through the vessels that permeate
the body of the heart...". Ibn Al-Nafis was
thus the first to put forward the concept of the
coronary circulation.
Europe’s Late Awakening
These important observations were not known
in Europe until 300 years later when Andrea
Alpago of Belluno translated some of Ibn Al-
Nafis’ writings into Latin in 1547. Later,
Michael Servetus described the pulmonary
circulation in his theological book,
"Christianismi Restitutio", in 1553 and wrote,
57
"...air mixed with blood is sent from the lungs
to the heart through the arterial vein;
therefore, the mixture is made in the lungs.
The bright color is given to the sanguine spirit
by the lungs, not by the heart". It is worth
mentioning that the Church accused Servetus
of heresy for opposing the teachings of Galen,
and was consequently -with his book -burnt at
the stake. Andreas Vesalius described the
pulmonary circulation in his book "De
Fabrica", in a manner similar to Ibn Nafis'
description. An interesting observation is that
in the first edition of the book (1543),
Vesalius agreed with Galen that the blood "...
soaks plentifully through the septum from the
right ventricle into the left...” Then in the
second edition (1555) he omitted the above
statement and wrote instead..."I still do not
see how even the smallest quantity of blood
can be transfused through the substance of the
septum from the right ventricle to the left...".
Another similar description was given by
Realdus Colombo in 1559 in his book "De re
Anatomica".
Then it was William Harvey who, in 1628,
demonstrated by direct anatomic observation
in laboratory animals the movement of blood
from the right ventricle to the lung and then
observed the blood returning to the left side of
the heart via the pulmonary vein and again he
stated that he could not find any pores in the
interventricular septum. He wrote in his
monograph, "Exercitatio anatomica de motu
cordis et sanguinis in animalibus": "I began
to think there was a sort of motion as in a
circle. I afterwards found true, that the blood
is pushed by the beat of the left ventricle and
distributed through the arteries to the whole
body and back through the veins to the vena
cava and then returned to the right auricle,
just as it is sent to the lungs through the
pulmonary artery from the right ventricle and
returned from the lungs through the
pulmonary vein to the left ventricle, as
previously described." However, he did not
understand the physiology of the pulmonary
circulation (dissipation of carbon dioxide and
replacement with oxygen), which was fully
elucidated by Lavoisier in the 18th century.
Views of Some Modern Historians
It may be useful to mention the views of a
few modern historians who reviewed the
works of Ibn Nafis; Max Meyerholf, a
distinguished scholar of Arabic historical
medicine, stated: “... We have seen that Ibn
Nafis, three centuries before Colombo, had
already noticed visible passages between the
two types of pulmonary vessels".
In the William Osler Medal Essay on the
discovery of the pulmonary circulation,
Edward Coppola said,"...The theory of
pulmonary circulation propounded by Ibn
Nafis in the 13th century was not forgotten
and that centuries after his death it may have
influenced the direction of the anatomical
investigations of Colombo and Valverde, who
finally announced it to the Western world as a
physiological fact susceptible to experimental
proof, "Ibn al-Nafis is best known for his
writings on physiology and medicine. His
book Sharh Tashrīh al-Qānūn described
pulmonary circulation centuries before noted
English physician William Harvey described
the circulation of blood in 1628" (Encarta
Encyclopedia 2003).
Ibn al-Baitar
IBN AL-BAITAR (End of the l2th century)
58
Abu Muhammad Abdallah Ibn Ahmad Ibn al-
Baitar Dhiya al-Din al-Malaqi was one of the
greatest scientists of Muslim Spain and was
the greatest botanist and pharmacist of the
Middle Ages. He was born in the Spanish city
of Malaqa (Malaga) towards the end of the
l2th century. He learned botany from Abu al-
Abbas al-Nabati, a learned botanist, with
whom he started collecting plants in and
around Spain.
In 1219 he left Spain on a plant-collecting
expedition and traveled along the northern
coast of Africa as far as Asia Minor.
The exact modes of his travel (whether by
land or sea) are not known, but the major
stations he visited include Bugia, Qastantunia
(Constantinople), Tunis, Tripoli, Barqa and
Adalia. After 1224 he entered the service of
al-Kamil, the Egyptian Governor, and was
appointed chief herbalist. In 1227 al-Kamil
extended his domination to Damascus, and
Ibn al-Baitar accompanied him there which
provided him an opportunity to collect plants
in Syria. His researches on plants extended
over a vast area including Arabia and
Palestine, which he either visited or managed
to collect plants from stations located there.
He died in Damascus in 1248.
Ibn Baitar’s major contribution, Kitab al-Jami
fi al-Adwiya al-Mu frada, is one of the
greatest botanical compilations dealing with
medicinal plants in Arabic. It enjoyed a high
status among botanists up to the l6th century
and is a systematic work that embodies earlier
works, with due criticism, and adds a great
part of original contribution. The
encyclopedia comprises some 1,400 different
items, largely medicinal plants and
vegetables, of which about 200 plants were
not known earlier. The book refers to the
work of some 150 authors mostly Arabic, and
it also quotes about 20 early Greek scientists.
It was translated into Latin and published in
1758.
His second monumental treatise Kitab al-
Mughni fi al-Adwiya al-Mu frada is an
encyclopedia of medicine. The drugs are doctrine left an enduring imprint on herbal
listed in accordance with their therapeutical medicine
value. Thus, its 20 different chapters deal with
the plants bearing significance to diseases of
head, ear, eye, etc. On surgical issues he has
frequently quoted the famous Muslim
surgeon, Abul Qasim Zahravi. Besides
Arabic, Baitar, has given Greek and Latin
names of the plants, thus facilitating transfer
of knowledge.
Ibn Baitar’s contributions are characterized by
observation, analysis and classification and
have exerted a profound influence on Eastern
as well as Western botany and medicine.
Though the Jami was translated and published
late in the western languages as mentioned
above, yet many scientists had earlier studied
various parts of the book and made several
references to it.
Paracelsus (1493-1541)
The prime mover of a new direction in medi-
cine was named at birth Theophrastus Bom-
bastus voo Hohenheim, but later took the
name Philippus Aureolus Paracelsus. The
Paracelsus brought chemistry to medicine.
Swiss-born physician, who was also an able
chemist, realized that die virtues of medicinal Hildegard of Bingen (1098-1179 A.D.)
plants came from dieir chemical makeup. He A medieval pioneer in natural science was the
pioneered in the extraction of plant essences mystic Hildegard of Bingen, abbess of the
and the use of tinctures, a revolutionary ad- Rupertsberg convent in the Rhineland. A Ben-
edictine nun from age 15, Hildegard was
vance over the pharmacology of his day, which
taught the ancient doctrine of the humors,
settled for less meticulous ways of producing
according to which the "cardinal juice" called
drugs. Paracelsus was educated in botany,
phlegm, caused most illness. She added her
mineralogy, natural philosophy, and dies oc-
own broad knowledge of folk medicine, her
cult, and he traveled widely, ministering to
interest in nature, and her highly developed
the poor wherever he went. He was fired from
powers of intuition. (Visions commanded her:
his position at die University of Basel for
"Write what you see and hear.") Her writings on
disrespect for the establishment. His
the natural world include much on healing herbs.
published pharmacological research and his
She is often called St. Hildegard although she
unfinished herbal, On the Virtues of Plants,
was never formally canonized.
Roots, and Seeds, reveal his extensive work
Pietro Mattioli (1501-77)
with botanical medicine both in the laboratory
A typical Renaissance man, the Italian physi-
and in his practice. The doctrine of signatures
cian-naturalist Fietro Mattioli published a
in plants—that in the appearance of plants can
number of works in poetry and prose on a wide
be found a divine sign of their curative
range of subjects, including botany and phar-
powers— appears often in his works and in die
macology. After studying as a youth in Padua
writings of his influential followers. The
and Rome, he began a lifetime career as a

59
practicing physician, first to the cardinal of
Trent and then, later in his life, to the court of
the Holy Roman emperor in Prague. All during
these years, he devoted a great deal of time to
the study of plants and "Materia Medica", or
medicinal substances. The publication that
made Mattioli famous was his Italian edition of
Dioscorides' De Materia Medica. Its purpose
was to give Italian physicians and pharmacists
systematically organized information that
would enable them to identify the medicinal
plants discussed in the ancient Greek doctor's
herbal, then a still highly trusted source. The
book was a best-seller from its first printing, in
1544. A decade later, Mattioli issued an ex-
panded edition in Latin. It included die plant
names and their synonyms in various lan-
guages, a much expanded commentary, and
many illustrations. Conceived as a practical
reference tool, the book was so successful that
it went into an uninterrupted series of reprints
over the next 200 years. Mattioli continued to
publish books on related subjects, including a
lengthy work on identifying and collecting
medicinal plants.
Nicholas Culpeper (1616-54)
"He is arrived at the battlement of an absolute
atheist, and by two years' drunken labor hath
gallimaufred the apothecaries' book into non-
sense, mixing every receipt [recipe] therein
with……rebellion or atheism, besides the
danger of poisoning men's bodies." Thus did
the English medical establishment, in the roy-
alist periodical Mercurius Pragmaticus, greet
the publication of A Physical Directory, or a '
Translation of the London Dispensatory, by
Nicholas Culpeper. His mistake was to have
translated the Latin pharmacopeia into every-
day language, thus threatening the near mo-
nopoly on medical knowledge that the College
of Physicians enjoyed. A clergyman's son,
Culpeper attended Cambridge University and
was well versed in Greek, Latin, and both
classical and contemporary medical authors.
About 1640 he set up as an apoihecary-astrolo-
ger-healer in Spitalfields, near London. He
60
fought against the royalists in the English Civil
War, suffering a chest wound that may have
hastened his early death from consumption.
Besides A Physical Directory, Culpeper pub-
lished The English Physician, which included
"369 medicines made of English herbs." He
wrote many other works, all of which sold well
and angered the medical establishment.
Samuel Hahnemann founded homeopathic medicine
Samuel Hahnemann (1755-1843 A.D.)
A towering figure in herbal tradition is that of
the German chemist-physician Samuel Hahne
mann, founder of the system of alternative
medicine known as homeopathy. As a young
man he retired from conventional medical
practice in disgust at the excessive proce-
dures—bleedings, debilitating purges, and
dangerous drugs—that were then routinely
prescribed. During the 1790's, Hahnemann
made the discovery that Peruvian bark (also
called cinchona, the source of quinine) was
effective in treating malaria, and from this
discovery deduced the basic principle of home-
opadiy: "Like cures like." What this meant, in
practice, was that a minuscule dose of a drug
capable of producing in a healthy person a
response similar to a disease's primary symp
tom may produce a reaction that will overcome
the disease in a sick person's body. This and
related tenets set forth in Hahnemann's Orga-
non of Medicine (1810) form the conceptual
basis of homeopathy. An empirical basis was
then provided by Hahnemann's monumental
Maieria Medico Para,' comprising detailed
summaries of "provings" (proofs of effective
ness) for many, mainly plant, substances.
Hahnemann's denunciations of the medical
establishment and pharmaceutical industry,
his use of plant tinctures, and his counsels of
moderation in diet and the ingestion of coffee,
tea, alcohol, and tobacco presage views heard
in the late 20th century.
cope with the pressures of modern life.
Although his criteria for classifying plants
have undergone revision, binomial nomencla-
ture—his system of two-part names, genus
and species—has continued to serve science
well. His preoccupation with taxonomy, some
say, set back other aspects of botanical study,
such as plant physiology. Linnaeus' fame was
assured as much by his devoted students, who
traveled the world collecting plants in his
behalf, as by his written works such as Systema
Naturae and Philosophia Botanica.

A genus named for Linnaeus: botany and

herbal medicine were never the same after his
work

Linnaeus was the father of modern taxonomy.

Carolus Linnaeus (1707-78 A.D.)
No less an ambition than to name and to
categorize everything in the "three kingdoms"
of nature—plants, animals, and minerals—
inspired young Carolus Linnaeus (or Carl von
Linne"). Aiming so high, [his great Swedish
scientist fell short, but he put his stamp on ail
future botanical study. Linnaeus' preeminence
in the intellectually rigorous field of botanical
taxonomy—plant classification— has tended to
obscure his joyful enthusiasm for roaming the
Scandinavian countryside on collecting
expeditions. Nor is it generally remembered dial
Linnaeus received his doctorate in medicine in
Holland and lectured at the University of
Uppsala (Sweden) on such subjects as how to "Doctrine of signatures": hairlike plants made hair
grow; eyed flowers gave sharp vision

61
The Great Plant Trade often administered in doses that would have
Early settlers in North America quickly dis- horrified Paracelsus. To give them then-due,
covered that many plants that had always been these Paracelsans were quite willing to
familiar to them and were recommended in administer a plant drug, provided its action
their herbals could not be found in their new was powerful enough. They were fondest of
home. As a result, a business developed in the narcotics and purgatives such as opium, bella-
importation of seeds and plants from Europe. donna, aconite, scammony, jalap, henbane,
Many of these eventually escaped cultivation to hemlock, and other poisonous plants because of
become naturalized in the New World. their high level of "activity," as it was called.
This plant migration was not one-sided, for
botanists were eager to expand their knowl-
edge. As new plants were discovered in the
colonies, samples were dispatched to the Old
World. In 1577 a London merchant named
John Frampton published Joyful Naves out of
the Neiue Founde Worlds, an English version
of a book by the Spanish physician Nicolas Mon-
ardes. The "joyful news" was of the vast array of
medicinal plants that explorers and colonists had
found in America.
Schism: Academics versus Healers
The period from the dawn of the Renaissance to
modern times was one of heated disputes in
medicine. The establishment of university
medical schools and of a system of formal
medical education, coupled with the increasingly
accurate understanding of human physiology, was
changing the practice of medicine from an art into
a science and a profession. But long before this
metamorphosis was complete, an ugly schism
opened between the new, academically trained
physicians and the traditional healers. With
hindsight, today's scholars see right and wrong
on both sides of this conflict, which lasted into
the 20th century.
Moderates versus Extremists
Meanwhile, a heated battle was raging within the
profession of academic medicine. On one side
were the Galenics, who adhered to the practice
of botanic medicine as set forth by Galen in
ancient times. On the other side were Theory of "humors" reigned for millennia
Paracelsans, who appear to have come to a Alternative Systems
somewhat selective understanding of Paracelsus So traumatic were these approved cures, so
dicta. These latter-day Paracelsans felt that agonizing for the patient, that eventually an
medicinal plants were generally inferior to the array of alternative systems of medicine began to
stronger medicine of nonbotanic chemicals, spring up both within the medical profession

62
and without. One of the most influential of these
was homeopathy. Rooted in Paracelsus' theory
that like cures like. The homeopathic system of
medicine was developed in Europe by a German
physician named Samuel Hahnemann in the early
19th century and spread later to the United States.
Homeopathy grew out of Hahnemann's
observation that cinchona (Peruvian bark, the
source of quinine) made people sweat
profusely, just as patients did when they had
malaria. He experimented by dosing himself
with cinchona and eventually built up his own
collection of drugs, each of which he and his
pupils "proved," or tested on them in precisely
the same manner that he had tested cinchona.
A few of the drugs were from animals and
minerals, but the majority was from plants.
In using any drug, Hahnemann was ever
mindful of Paracelsus' caveat against overdosing
his patients. Hahnemann frequendy diluted his
doses to the point that there was little of the
active drug left. The science of immunology has
long since confirmed the basis of Hahnemann's
philosophy—that triggering the body's defense
mechanisms is a key to curing illness. Such
modern medical practices as vaccination and
desensitization therapy for allergies reflect the
validity of some homeopathic principles. As for
Not only did 16th-century doctors bleed their patients, they also relied on astrological signs.
63
the principle of the effectiveness of the minimal
dose, consider radiation therapy for cancer, a
treatment where minimal dosage is absolutely
necessary to protect the life of the patient.
Another alternative system of medicine was
eclecticism, established in New York by Dr.
Wooster Beach. It eventually spread through-out
the United States. In practicing eclecticism, Dr.
Beach attempted to combine what was good in
the old medicine with what was good in the
new. His treatments relied heavily on plant
drugs.
Islamic Medicine
Islamic Medicine in its true context, can thus
be defined as a body of knowledge of
Medicine that was inherited by the Muslims
in the early phase of Islamic History (40-247
AH/661 -861 AD) from mostly Greek
sources, but to which became added medical
knowledge from, Persia, Syria, India and
Byzantine. This knowledge was not only to
become translated into Arabic, the literary and
scientific lingua franca of the time, but was to
be expounded, assimilated, exhaustively
added to and subsequently codified, and
‘islamicized’.
 Linnaeus' capacity for work awed friends. In this painting, he catnaps after collecting
REFERENCES
A.Z. Iskandar, "Ibn al-Nafis", DSB, volume 9,
pp. 600-604.
Al-Dabbagh SA. Ibn Al-Nafis and the pulmonary
circulation. Lancet. 1978;1:1148.
Ayman O. Soubani, MD; Faroque A. Khan, MB .
The Discovery of the Pulmonary Circulation.
A.S.M. 1995; 15:185-186
CF. E -Levi-Provencal. "in Encyclopedie de
/'Islam", Nouvelle Edition, I. pp. 401-402
s.v.
CF. Ibn Abi Usaybla, "Uyun al-anba fi-tabaqat
al-attibba". Sources d'informations sur les
classes de medecine. Xllle Chapitre.
Medecine de l'Occident Musulman. Public,
traduit et annote par Henri Jahier et Abdel-
kader Noureddine. (Aiger, 1958) Vol.l,
pp.88-89 ; 94-97
CF. Ibn Abu Rushd, "Kitab al-Kulliyat MS. OF
Sacromonte (Granada)", f.230; Ibn Abi
Usaybia, Uyun al-anba p.131.
CF. Ibn Al-Abbar, "Kitab al-takmila li-kitab al-
sila". Ed. F. Codera, Complementum Libri
64
Assilah, 2 vols. (Mad- rid 1887- 1889) I,
pp.76-77
CF. Ibn Khallikan, "Wafayat al-acyan", ed. F.
Wustendeld. (Gottingen, 1835- 1843).
Coppola ED. The discovery of the pulmonary
circulation: A new approach. Bull Hist Med
1957;31:44-77.
Emilie Savage-Smith, "Ibn al-Nafis's Perfected
Book on Ophthalmology and His Treatment
of Trachoma and Its Sequelae," Journal for
the History of Arabic Science, vol. 4 (1980)
pp. 147-206.
Gordon EJ. William Harvey and the circulation of
the blood. South Med J. 1991;84:1439-44.
Haddad TE, Khairallah AA. A forgotten chapter
in the circulation of the blood. Ann Surg
1936;104:1-8.
Ibn al-Nafis, 'Ali ibn Abi al-Hazm, 1210 or 11-
1288 Ibn an Nafis et la decouverte de la
circulation pulmonaire. Damas : Institut
Francais de Damas, 1955. (41 QP101.I2)
Keys TE, Wakim KG. Contributions of the Arabs
to medicine. Proceedings of the staff meet.
Mayo Clinic 1953;28:423-37.
Les promoteurs de l'esprit scientifique dans la
civilisation islamique par Halima El Ghrari
Max Meyerhof and Joseph Schacht, The
Theologus Autodidactus of Ibn al-Nafis,
Oxford: Clarendon Press, 1968;
Mettler CC. History of Medicine. Philadelphia,
PA, USA. The Blakiston Co, 1947:40-59 and
113-128.
65
Meyerhof M. Ibn Al-Nafis and his theory of the
lesser circulation. Isis 1935; 23:100-20.
Meyerhof, Max, 1874-1945 Etudes de
pharmacologie Arabe tirées de manuscripts
inédits. Le Caire : Imprimerie de l'Institut
Francais d'Archeologie Orientale, 1940. (41
RS64.M4)
Nicholas Heer, "Thalathat mujalladat min Kitab
al-Shamil li-Ibn al-Nafis," Revue de I'Institut
des Manuscrits Arabes, 1960, pp. 203-210;
Note: Most of the Matters are drived from Internet and
Research Papers
Chapter 3

67
68
Practice in Clinical Pharmacognosy
CASE TAKING
For correct diagnosis, 3 things are needed.
Perfect history
Good and complete examination of patient
Laboratory investigations
History of Patient
1. Name this is asked for identification.
2. Age for correct drug dosage
3. Sex for clear identification
4. Religion Chances of carcinoma of penis
are for less among Muslims
and Jews, as both practice
circumcision in early
childhood.
5. Profession. Detail is given in personal
history.
6. Address. Certain diseases are endemic
in certain areas, so address
must always be asked in detail.
7. Present complaint(s). The complaints,
which have brought the patient to the
doctor, come under this heading. These are
arranged in chronological order, i.e.
complaint of longest duration at the top and
that of shortest duration in the last. Each
complaint should be written in one line. It
should be brief and it is better if adjectives
have also been mentioned with each
complaint. For examples instead of writing
fever for five days, if it is written, fever
with rigors for five days, it will give an idea
about the diagnosis.
History of present illness: This should be
written in three paragraphs.
69
1st paragraph
In this paragraph details of each complaint are
asked in chronological order. Now as the
patients lacks technical knowledge so he is
unable to express himself adequately. It is
therefore the duty of examiner to put such
questions as will bring out a fuller description
of individual symptom. While writing the
history two things should be kept in mind:
1. Never put a leading question:
2. Do not use technical terminology.
Always write down the history in the
patient’s language.
The following general points should be noted
while describing the symptom.
a) Duration of symptom
Duration of symptom should be
ascertained by asking the patient. “Were
you alright before such period of time”?
b) Mode of onset
The patient should be asked, did the
symptom come on suddenly or gradually”.
c) Continuity of symptom
This should be recorded whether the
symptom has been present continuously
since its onset: or there have been
intervals of freedom. The length of these
intervals is also noted down.
Now if the illness consists of series of attacks
the mode of onset, course, duration, mode of
decline, and after effects of each should be
asked.
d) Factor, which modify the symptom.
An inquiry should be made about the
factors aggravating or relieving the
 symptom. For example, pain in the chest
aggravated by exertion and relieved on
rest is suggestive of ischaemic heart
disease. The pain in or around the
epigastrium, relieved by the intake of
milk, is suggestive of peptic ulcer, and on
the other hand if is aggravated by intake
of milk, it indicates Cholecystitis.
e) Associated phenomena
Ask the patients if he has noticed any
other symptom associated with the main
symptom. For example patient who has
attacks of pain in right upper abdomen
followed by yellowness of eyes, is
suggestive of involvement of liver or
biliary tract. Pain in the loin followed by
haemmaturia indicates renal disease.
f) Development of symptom
It is an important part of history to ask
about the development of symptom
whether this is becoming worse or is of
same nature as it was in the start.
Aggravation of symptom indicates an
advancement of disease, which results in
the damage of the organ affected. For
example if to start with the patient had
breathlessness on moderate exertion,
which has now aggravated to such an
extent that he has breathlessness even on
rest, it clearly indicates that more damage
of lung tissue has taken place and, there is
possibility of involvement of the heart
secondarily. The yellowness of eyes
which is becoming more and more intense
indicates the aggravation of liver damage
or biliary obstruction.
2nd paragraph
In this paragraph of history, question relevant
to the symptom are asked in detail as to have
a clear idea about the possible diseases
coming in to the doctor’s mind while going
through the first paragraph. These relevant
questions are asked so as to bring about
certain points missed by the patient about his
disease. In this way some diseases will be
ruled out and it would be easy for the
70
clinician to reach a probable diagnosis. For
example patient has presenting complaint of
polyuria.
Following relevant interrogation will help to
reach a probable diagnosis that is
a) delayed healing of wound
b) repeated skin infection
c) weight loss
d) Deterioration of vision
e) Pruritis valve (in case of female)
Above details will lead to a conclusion that
patient is probably suffering from diabetes
mellitus. In this way other disease causing
polyuria can be ruled out.
3rd paragraph (treatment history)
This paragraph comprises of details about the
previous treatments. This also helps the
doctor to reach a probable diagnosis.
For example if a patient who is suffering from
fever, had a course of chloroquine in the past
with out any beneficial effect, it means he is
(most probably) not suffering from malaria.
8. History of drug hypersensitivity
(particularly about penicillin) should be
asked for.
9. Past histories
This should not be confused with the
earlier symptoms of the present condition
but this includes attacks of a similar
nature when a long interval has elapsed.
The following points should be kept in while
taking history of past illness.
i) Any history of relevant disease in the
past, i.e. in pyloric stenosis, enquires
about the history of peptic ulcer.
Diseases of child-hood such as
rheumatic fever, whooping cough,
mumps measles, and primary
pulmonary tuberculosis should also be
enquired.
ii) Any history of trauma, accident,
surgery, visit abroad, intake of
‘kushtas’ or any other poison should
be asked.
 iii) History of any previous admission in eaten up in hurry. All these investigations
the hospital indicates the seriousness give important information about
of the disease. digestive disorder.
10. Personal History (c) Intake of Tobacco, Alcohols or any other
In this connection one should enquire about addictive substance. Smoking is important
the following in relation to the following diseases:
a) Occupation of the patient (i) Bronchial carcinoma:
b) Hours and regularity of meals (ii) Vascular disorders
c) In take of tobacco, alcohol or any (Burger’s disease).
other addictive substances (iii) Ischaemic heart disease.
d) Sleep Alcoholic hobbits are relevant in the
e) Sexual history (married/unmarried) following cases:
a) Occupation of the patient (i) Liver cirrhosis
Enquiry should be made about his past as well (ii) Neuropathies
as present occupation (occupational history). (iii) Pancreatitis
It is important to note the condition of his (iv) Psychoneurosis
work, because certain diseases like Persons addicted to opium have severe
tuberculosis, anthrax, asthma, skin diseases type of constipation.
are related to certain occupations, i.e. (d) Sleep. One should enquire about the
(i) Anthrax, in persons who deal with quality of sleep whether it is restful and
skins of animals; refreshing or not. Are there dreams and
(ii) Asthma, in persons who work in nightmares? Patient should be asked about
factories where earthen pots are the intake of hypnotics. Sleep
manufactured. Asthma percentage is disturbances are common in anxiety state
fairly high among cooks and and psychosis.
weavers. (e) Sexual history.
(iii) Skin diseases are common among Patient is married or unmarried is of great
the laborers who are exposed to importance in psychoneurosis. History of
radiations, chemicals and other contact should be asked to rule out
irritant materials. venereal diseases. In case of females
(iv) Silicosis of the lungs is common menstrual history should always be asked.
among the persons working in the 11. Family history
mining industry. Ask about the number of his family
(v) “Farmer’s lung” may result from members, both males and females, and
exposure to the dust of mouldy day. about their health. In case of suspected
This is seen in persons living in rural disease of heditary or familial type, e. g.
areas. haemophelia, mental retardation and
(vi) Carcinoma of the bladder occurs in myopathies, a detailed family history is
persons working in the industries required. Other diseases like diabetes,
connected with rubber, chemicals hypertension, epilepsy, certain renal and
and cables where the individual is cardiovascular diseases, rheumatic fever,
exposed to aromatic amines. have also familial background.
(b) Hours and regularity of the meals. The Tuberculosis is very common in our
amount of food, variety of food and way country, so any history of tuberculosis in
of eating, i. e. whether properly cooked or the family should always be required.
not, it is chewed adequately or is simply 12. Social History

71
 A detailed history about the social
surroundings of the patient must be taken.
His behavior towards his friends, relatives
and other persons with whom he comes in
contact should be asked as this has an
important part in diagnosis of certain
psychological disorders.
FURTHER READING
Drew Provan, Charles R J Singer, Trevor Baglin, and
Inderjeet Dokal. Oxford Handbook of Clinical
Haematology. Third Edition. 19 February 2009,
UK.
James Thomas and Tanya Monaghan. Oxford
Handbook of Clinical Examination and Practical
Skills. 31 May 2007, UK.
Kerry J. Breen, Stephen M., Colin J. H. Thomson,
Vernon D. Plueckhahn. Good Medical Practice:
72
Professionalism, Ethics and Law. March 2010.
Cambridge University Press, UK.
Laura Mitchell and David A. Mitchell. Oxford
Handbook of Clinical Dentistry. Fifth Edition. 30
July 2009,UK
Punit Ramrakha and Jonathan Hill. Oxford Handbook
of Cardiology. Second Edition, 23 February 2012.
UK
Punit Ramrakha, Kevin Moore, and Amir Sam. Oxford
Handbook of Acute Medicine. Third Edition, 29
April 2010, UK.
Tim Raine, Katherine McGinn, James Dawson,
Stephan Sanders and Simon Eccles. Oxford
Handbook for the Foundation Programme. Third
Edition, 11 August 2011, UK.
Note: Most of the Matters are derived from Internet,
Research Papers and Clinical Methods by
Dr. Muhammad Ali
EXAMINATION OF PATIENT
(xix) Blood pressure
Before going to the patient for his (xx) Temperature
examination a student must have (xxi) Respiration
Stethoscope (i) GENERAL APPEARANCE OF THE
Patellar hammer PATIENT
Torch Just look at the patient and note his
Measuring tape appearance, whether he looks ill, unwell, or
If possible a B.P. apparatus healthy. Also note down his facial expression.
(Details are given in chapter exam of CNS)
(ii) AGE
Age of the patient is important because
malignancy, vascular disorders, i.e.
atherosclerosis, thrombosis occur in old
patients, while Wilm’s tumor is present in
children.

Examination of the patient comprises of two

types:
1. General physical examination
2. Systemic examination
1. GENERAL PHYSICAL
EXAMINATION
(N. B. the patient should be approached
from right side)
(i) General appearance of the patient.
(ii) Age
(iii) Sex
(iv) Facies
(v) Nutrition (iii) SEX
(vi) Build Females never suffer from haemophilia.
(vii) Posture and attitude Raynauds’s disease is mainly present among
(viii) Pallor females (5:1)
(ix) Cyanosis Ankylosing spondylitis has preponderance
(x) Jaundice among the males (10:1).
(xi) Oedema Bronchogenic carcinoma is more in females
(xii) Clubbingkoilonychia (8:1)
(xiii) Splinter hemorrhage Gout is 95% in males.
(xiv) Lymph nodes (iv) FACIES
(xv) Any specific deformity Certain appearance of face is characteristics
(xvi) Condition of skin of certain diseases.
(xvii) Thyroid (i) moon like face …Cushing’s
(xviii) Pulse Syndrome

73
 (ii) Mask like face Parkinsonism children may eat limited quantities of refined
(iii) Idiopathic face Mental sweets if these are included among the
retardation allowed carbohydrate grams for that day.
(iv) Hippocratic face Eyes are sunken See the general health of the patient and note
but bright, face is drawn and whether the patient is diabetic or not. Is it the
anxious (peritionitis). case of diarrhea, vomiting, dysentery,
(v) Apathetic face Severe constipation, distention of gases or a general
depression weakness etc? Ask for history or food taken
(vi) Face in facial never palsy by him.
(described in exam of CNS) i) Check sugar (if positive then control
(vii) Acromegalic face: This is broad sugar)
and large face present in ii) Examine food particles in vomit (if
hyperpituitarism. unwanted material are seen then
(viii) Pale face Anaemia lavage the stomach)
(ix) Reddish face Polycythemia, iii) Examine food toxicity (if positive
Mitral stenosis, Atropine then treat symptomatically)
poisoning, Heat stroke, High grade iv) Perform general laboratory tests
fever, Disseminated lupus including electrolyte balance (if
erythematosus (DLF), carbon worst results found then bring on
monoxide poisoning, familial, ventilation)
alcoholics. v) Perform sonography (if symptoms
(x) Dusky face Uraemia are mixed and unclear then
(xi) Yellow face Jaundice, ultrasound is recommended)
carotinaemia.
(xii) Bluish face Cyanosis (vi) BUILD
See the general health of the patient and note See the build of patient whether it is
whether the patient is too stout, well according to his age or is abnormal. If patient
nourished or emaciated. Emaciation occurs in has retarded growth he may be suffering
the following disease. from:
i) Malignant growth (i) Hypothyroidism (Cretinism)
ii) Pulmonary tuberculosis (ii) Hypopituitarism
iii) Thyrotoxicasis (iii) Achondroplasia
iv) Diabetes mellitus (iv) Hurler’s Syndrome (Gorgylism)
Extraordinary presence of fat may be due to: (v) Familial
(i) Cushing’s syndrome If patient is unusual tall and broad he may be
(ii) Familial suffering from Hyperpituitarism (gigantism).
(v) NUTRITION (vii) POSTURE AND ATTITUDE
Ask for the diet because nutrition also plays a Look for the posture adopted by the patient in
key role in providing energy and regulating the bed:
blood glucose levels. The most common - Patient lying the bed on his back, still
current approach to diet is based on and quiet with shallow breathing, may
carbohydrate counting in which patients are to be suffering from peritonitis
consume a prescribed number of grams of - Patient with heart failure and
carbohydrates at each meal and scheduled congestion of lungs does not lie
snack. Dietary management of diabetes has horizontal in the bed but he sits more
become more liberal in recent years, and

74
 or less in upright position with the
help of backrest.
- Patient of chronic obstructive airways
disease usually sits up in the bed and
bends forward.
- Patient suffering from high-grade
fever passively slips downward from
his pillow and lies listless, flaccid and
silent.
- Patient suffering from renal colic rolls
about on the bed, burries his head in
the pillow and tries one position after
another in search of a position free
from pain.
- Patients suffering from rheumatic
fever will have a peculiar aspect of
helplessness, the limbs lying
motionless, the joint being swollen,
still and painful.
- Patient suffering from meningitis has
typical posture. His neck is bent
forward so that his head seems to bore
in to the pillow.
(viii) PALLOR
- Decreased amount of hemoglobin is
called anemia.
- Clinically anemias are examined from
the nails, conjunctiva of lower eyelids,
under surface of tongue, mucous
membrane of cheek and hard palate,
and from palmer creases.
- From nails. Examine the nails of the
patient and compare them with your
own nails. In anemia the nails become
pale.
- From lower eyelid. Ask the patient to
look upward and pull his lower eyelid
down. See the interior of the lid.
Normally this is pink but in anemia,
the pinkish color fades away and
becomes pale.
- From oral cavity. Now ask the patient
to open his mouth and examine the
color of tongue and mucous
membrane of the cheeks and hard
palate. These will look pale.
75
- Also examine the palm creases of
hands. Paleness indicates anemia.
(ix) CYANOSIS
When the amount of reduced hemoglobin
reaches up to 5gm% or more cyanosis
appears. In this the nails, lips, tongue, tip of
nose, mucous membrane of mouth give bluish
tinge. Cyanosis may be central or peripheral
according to the cause.
Peripheral cyanosis: Appears due to the
vasoconstriction and due to the other
conditions, which lead to the stasis of blood in
the blood vessels.
Causes:
(i) Exposure to cold.
(ii) Venous congestion due to the local
pressure i.e. ligature and deep
venous thrombosis.
(iii) Excessive vasomotor stimulation
(Raynaud’s disease).
Central cyanosis: It appears when there is
mixing of venous blood with arterial blood or
there is impaired diffusion of oxygen due to
pulmonary disease.
1. Causes in heart are:
(i) Fallot’s tetralogy. This includes:
a. High ventricular septal defect
b. Over riding of aorta
c. Pulmonary stenosis
d. Hypertrophy of right ventricle.
(ii) Diseases, which causes cyanosis at
latter stage.
(a) Lutembacher’s disease. This
includes:
(1) Arterial septal defect
(2) Mitral stenosis
(b) Ventricular septal defect
(c) Atrial septal defect
(d) Patent ductus arteriosus
2. Causes in lungs:
(i) Consolidation (pneumonia)
(ii) Cor pulmonale
(iii)Chronic obstructive airways
disease i.e. asthma
3. Other causes:
 (i) At high altitude where there is low Edema is demonstrated on the dependent
partial pressure of the alveolar parts of body i.e. sacrum and lower part of
oxygen. legs.
(ii) Obstruction in respiratory tract. N.B Edema due to obstruction of lypmphatics
(iii) Right heart failure: This leads to and hypothyroidism
increased venous pressure is non pitting.
producing venous stagnation and
Causes:
cyanosis.
4. Causes in the blood: (i) Congestive cardiac failure (edema is on
(i) Methaemoglobinaemia dependent parts);
(ii) Sulph-haemoglobinaemia (ii) Renal edema—Nephrotic syndrome,
(usually first appears on the face below the
Central cyanosis Peripheral cyanosis eyes especially when patient rises in the
____________________________________________ morning);
__ (iii) Hypoproteinemia
(1) Caused by disease of (1) Caused by cold (iv) Cor pulmonale
lungs and heart.
(2) Cyanosed parts are (2) Cyanosed parts are cold.
(v) Local venous congestion due to venous
Warm. obstruction
(3) Not effected by (3) Disappears on making (vi) Beriberi
the (vii) Angioneurotic edema (allergic)
heating. patient warm. (viii) Lymphatic edema (non-pitting)
(4) Warm hands (4) Cold hands.
____________________________________________
(ix) Filariasis (non-pitting)
___ (x) Milroy's disease (non-pitting)
(x) JAUNDICE (xii) CLUBBING
When serum bilirubin level rises up to 2.5 mg In this condition the soft tissues at the, base of
% jaundice appears clinically. the nails are thickened and the angle between
Method of Examination: Retract upper lid the base of the nail and adjacent skin of the
upward with the help of your thumb. Now ask finger is obliterated. There are 3 stages.
the patient to look downward (towards his 1st Stage:
feet) with out tilting his head. See the colour Place the finger of the patient horizontally at
of sclera which will be yellow in ease of the level of your eyes and note the
jaundice. obliteration of angle between the nail bed and
Along with it examine the under surface of finger by placing a piece of paper over it
tongue, the mucous membrane of the mouth. vertically straight. This is stage one.
Remove the shirt of patient and examine the 2nd Stage:
skin for yellow colouration. Fluctuation at the base of nail can be
(NB: Colour of sclera, mucous membrane of demonstrated at this stage, by placing the two
mouth should be examined in Sunlight and index fingers on either side of the base of nail
never in artificial light.) and dressing one of them with the help of
(xi) EDEMA respective thumb. The feeling of a life by the
It is an excess of fluid present in the other finger indicates "fluctuation".
interstitial tissues. 3rd Stage :
Clinically this can be demonstrated by In this, terminal segments of the fingers
pressing swollen part with thumb for 15-20 become so bulbous that fingers have "Drum
seconds. stick appearance".
A pit will be formed at that site. The pit must Causes: These are as followings.
stay for about half minute.

76
(a) Acquired. Causes in the (iii) Supra clavicular;
(i) Lungs. (iv) Axillary;
(a) Bronchogenic carcinoma; (v) Inguinal.
(b) Bronchiectasis; Differential Diagnosis of Lymphadenopathy.
(c) Lung abscess; (i) In syphilis the lymph nodes are shotty,
(d) Fibrosing alveolitis. painless and discrete.
(e) Empyema. (ii) In tuberculosis they are matted
(ii) Heart. together and there may be formation
(a) Cyanotic diseases of the heart of sinus over them.
(Fallot's tetrrology): (iii) In case of secondary growth they are
(b) Sub-acute bacterial endocarditis hard, irregular and fixed, to the
(SBE). surroundings.
(iv) In case of Hodgkin's disease and other
(iii) Alimentary tract. reticulosis the glands are enlarged,
(a) Crohn's disease; discrete, rubbery and elastic.
(b) Ulcerative colitis; (v) Lymph nodes supplying area of
(c) Mal-absorption syndrome inflammation are enlarged and tender,
(iv) Liver: Biliary cirrhosis i.e. lymph nodes at the angles of
(b) Familial. The clubbing may be mandible in case of Tonsillitis
familial. becomes enlarged and tender. Skin
(c) Idiopatbic. There may be no over them also becomes hot.
causes. (vi) In case of leukemia the glands are
(xiii) KOILONYCHIA greatly enlarged on both sides of the
The nails become soft, brittle and spoon body. Spleen is also enlarged.
shaped. (vii) Supra clavicular lymph gland of left
Causes: side (Virchow's gland) is enlarged in
(i) Iron deficiency anemia ; carcinoma of stomach.
(ii) Plummer-Vinson's Syndrome; (xvi) THYROID
(iii) Excessive use of detergents and Inspect the neck for local or general
soap; enlargement of the thyroid gland. Ask the
(iv) Familial; patient to swallow, the thyroid will move
(v) Idiopathic. upward.
(xiv) SPLINTER HAEMORRHAGE Examination of Thyroid: Stand behind the
These are small reddish, dark brown, vertical patient and put your fingers of both hands in
lines in the nails. These are present in the front of the neck and palpate the gland. If
following conditions: gland is enlarged note its size, shape, surface,
(i) Sub-acute bacterial endocarditis. any tenderness, consistency, movements of
(ii) Haemorrhagic disorder. skin over the swelling and any pulsation.
(iii) Infestation of Trichurus trichura. N.B. A systolic bruit can be heard with
(iv) Sickle cell anemia. stethoscope over a toxic goiter.
(v) Atrial myxoma. Van Graef's Sign: This sign is present in case
(vi) Occupational (i.e. carpenters). of thyrotoxicosis.
(xv) LYMPH NODES Method: The patient should look straight at
Palpate various groups of lymph nodes, i.e. your index finger which is kept in horizontal
position at a distance of 1—2 feet from the
(i) Posterior cervical;
patient eyes. Hold the head of the patient in
(ii) Sub mandibular;

77
your hand. Now move your finger downwards
gradually, and ask the patient to move his
eyes with the finger without tilting his head
down. In positive case the whitening of sclera
can be seen above the cornea.
(xvii) PULSE
It is described in detail in the Chapter
"Examination of CVS".
(xviii) BLOOD PRESSURE
It is described in detail in the Chapter
"Examination of CVS".
(xix) TEMPERATURE
Thermometer is put under the tongue of the
patient after giving it 2-3 jerks so as to bring
its mercury column below 96°F. This should
be kept there for one to three minutes and
then taken out and read. Normal temperature
ranges between 98-99 °F (average 98.4 °F).
If the thermometer is put in axilla or groin
then add one to its reading, this will give body
temperature.
N.B. When the thermometer is in the mouth,
patient must breathe from his nose.
(xx) FEVER
Types:
(i) Continuous: When the fever does not
fluctuate more than a degree and a half
(Fahrenheit) during the twenty-four
hours and at no time touches the normal,
this is called continuous fever.
(ii) Remittent:. When the daily fluctuation
exceeds, two degrees, it is called as
remittent fever (fever does not touch the
normal).
(iii) Intermittent: When the fever is only
present for several hours during the day,
i.e. fever touches the normal during 24
hours, this is known as intermittent
fever.
(iv) Quotidian: When the paroxysm of the
intermittent fever occurs daily.
(v) Tertian. When the paroxysm of the
fever occurs on the alternate day.
(vi) Quartan: When there is interval of 2
days between consecutive attacks.
78
(vii) Pel Ebstein fever: Seen in case of
Hodgkin's disease. In this case fever
rises to 102—103°F for several days
(usually for 7 to 10 days) and then there
is remission for 7—10 days and so on.
(xxi) RESPIRAITON
This is described in the Chapter "Examination
of Respiratory System".
(xxii) ANY SPECIFIC DEFORMITY
Note any specific deformity i.e.
(i) Kyphosis. When vertebral column has
convexity posteriorly.
(ii) Scoliosis. When vertebral column is
deformed laterally.
(iii) Lordosis. When vertebral column has
convexity anteriorly.
(iv) Cubitus varus or valgus;
(v) Genu valgum or varus;
(vi) Coxa vara or valga;
(vii) Talipese equino varus;
(viii) Hallux valgus;
(xxiii) CONDITION OF SKIN
Patient is examined for the presence of skin
lesions, which occur as a part of systemic
disease or the disease of skin itself.
Followings are the descriptive terms.
(i) Macules: This is simply an alteration in
the colour of the skin They may be of
white, red, blue or yellow colour.
Example is leucoderma.
(ii) Papules: It is few milimeter in diameter
hemi spherical elevation of epidermis.
This may be due to infilammatary
infilteratior of the dermis or growth of
new cells, i.e. nevus.
(iii) Vesicles-Bullae: This is formed due to
the accumulation of serous fluid with in
the epidermis. For example after burns.
(iv) Pastules: When there it accumulation of
pus in the epidermis, it is called pastule.
Example vaccination pastule.
(v) Nodule: Involvement of whole
thickness of the skin by inflammatory
infiltrate or some new growth of cells is
 called as nodule. This is harder than
papule.
(vi) Weal Formation: When edema
formation in the dermis is due to allergy
and is associated with severe itching, it
is called as weal formation. Its colour,
size, and shape rapidly changes-
Example is urticaria. .
(vii) Tissue defect: This is of following
types.
(a) Maceration: It is the softening of the
outer epidermal layers by some
secretions.
(b) Erosion: Intra-epidermal tissue defect is
called as erosion.
(c) Ulcer. Defect of skin, as deep as dermis,
is called as ulcer.
(viii) Deposition on the skin:
(a) Scale formation (squama). This is
excessive accumulation of horny layers
Erosion
of epidermis. Example is Psoriasis.
(b) Crust or scab formation. When scales are
combined with exudates it is called as
curst or scab.
Followings are important skin lesions which
appear as a part of systemic disease.
(a) Heberdens nodes: These are small
nodules present at the terminal
phalangeal joints in case of osteo-
arthrosis.
(b) Erythema marginatum: These are pale
centered ringlets with pink margins
present over the trunk and flexor
surfaces of joints. These are present in the extensor surface of the elbow and on
case of rheumatic fever. shins. They may be present on the
(c) Erythema nodosum: These are painless dorsum of hands or feet. They are
conical rounded nodules, present just present in case of rheumatic fever.
under the skin. They vary in size from a
pin-bead to about 2 cm, in diameter. (d) Haemorrhagic spots:
They are present on (i) Petechial and purpura spots. These are
small pin points haemophilia. Spots in
the skin. These do not blanch when
compressed with glass slide (D/D
telangiectasia).
(ii) Ecchfmoses 1. These are haemorrhagic
spots with are larger than petechiae.

79
(e) Spider naevi: these are spider shaped
small redish marks formed by the
dilatation of the central arteriole from
which numerous small vessels radiate.
They are found on the chest (above the
nipples), face, fore arm, and some times
on the dorsum of the hands. These are
present in case of liver cirrhosis.
(f) Erythema ab-igne: These are snake like
red lines present on the surface of the
shins. These are produced due to the
prolonged exposure to fire.
(Myxoedema).
(g) Janeway's lesions: These are small
reddish brown spots over the palms.
These are present in case of S.B.E.
(h) Cambel de Morgan spots: These are tiny
red spots present over the body. They
are normally present in certain persons.
(i) Pigmentation of skin is seen in cases of
Addison's disease, arsenic poisoning,
malignancy, and cachexia.
Colour of skin:
(a) Pale—anemia:
(b) Yellow—jaundice:
(c) Blue—cyanosis.
2. SYSTEMIC EXAMINATION
This means examination of various systems.
These are as following:
(i) Respiratory system;
(ii) Cardio-vascular system;
(iii) Alimentary system;
(iv) Nervous system
80
FURTHER READING
Drew Provan, Charles R J Singer, Trevor Baglin, and
Inderjeet Dokal. Oxford Handbook of Clinical
Haematology. Third Edition. 19 February 2009, UK.
Huw Llewelyn, Hock Aun Ang et al. Oxford
Handbook of Clinical Diagnosis Second Edition, 26
February 2009, UK.
James Thomas and Tanya Monaghan. Oxford
Handbook of Clinical Examination and Practical
Skills. 31 May 2007, UK.
Kerry J. Breen, Stephen M., Colin J. H. Thomson,
Vernon D. Plueckhahn. Good Medical Practice:
Professionalism, Ethics and Law. March 2010.
Cambridge University Press, UK.
Laura Mitchell and David A. Mitchell. Oxford
Handbook of Clinical Dentistry. Fifth Edition. 30
July 2009,UK
Punit Ramrakha and Jonathan Hill. Oxford Handbook
of Cardiology. Second Edition, 23 February 2012.
UK
Punit Ramrakha, Kevin Moore, and Amir Sam. Oxford
Handbook of Acute Medicine. Third Edition, 29
April 2010, UK.
Tim Raine, Katherine McGinn, James Dawson,
Stephan Sanders and Simon Eccles. Oxford
Handbook for the Foundation Programme. Third
Edition, 11 August 2011, UK.
Note: Most of the Matters are derived from Internet,
Research Papers and Clinical Methods by Dr.
Muhammad Ali
Chapter-4

81
Most of the contents of chapter 4 are derived from the
chapters written by:
Mr J. Keith Henderson, Head of Neurosurgical Unit, St Vincent’s Hospital, Melbourne.
Mr Brian Fleming, Head and Neck Surgeon, Royal Melbourne Hospital.
Professor T.S. Reeve, University of Sydney, Department of Surgery, Royal North Shore
Hospital, Sydney.
Professor Richard C. Bennett, Uiversity of Melbourne Department of Surgery, St Vincent’s
Hospital, Melbourne.
Miss Antoinette White, Cardiothoracic Surgeon, St Vincent’s Hospital, Melbourne.
Associate Professor John Ham, University of New South Wales, Department of Surgery, Prince
of Wales Hospital, Sydney.
Professor Gabriel A. Kune, University of Melbourne, Department of Surgery, Repatriation
General Hospital, Melbourne.
Professor Gordon Clunie, University of Melbourne, Department of Surgery, Royal Melbourne
Hospital.
Professor Bruce N. Gray, University of Western Australia, Department of Surgery, Royal Perth
Hospital.
Dr David Failes, Colorectal Surgeon, Westmead Hospital, Sydney.
Mr Desmond C. Hoffman, Head of Colorectal Unit, Royal Adelaide Hospital. Mr Daniel
Lenaghan, Urological Surgeon, St Vincent’s Hospital, Melbourne.
Mr Kevin King, Head of Orthopedic unit, Royal Melbourne Hospital.
Associate Professor John P. Masterton, Monash University, Department of Surgery, Alfred
Hospital, Melbourne.

Note: This book is written solely for academic and awareness purpose only

82
PAIN IN THE HEAD AND FACE
PAIN IN THE HEAD (HEADACHE)
Headache is the most common human
complaint. There are many different types of
headaches. Although not all headaches are the
same, they all share at least one thing in
common i.e. they cause pain. But many
headaches also cause other unwanted
symptoms, including nausea and vomiting.
Headaches accompany many diseases. Few
headaches are serious but some serious
diseases present with headache.
Migraines and other types of headache such
as tension headache and sinus headache are
painful. Migraine symptoms include a
pounding headache, nausea, vomiting and
light sensitivity.
Headache remedies include various types of
pain relievers. Migraine treatments may also
include anti-nausea drugs and medications to
prevent or stop headaches.
With no diminution of consciousness
Non-organic (no demonstrable central
nervous abnormality)
Anxious or depressed people often suffer
tension headache like a band compressing the
head, associated with spasm of head and neck
muscles.
Obscure post-traumatic headache, associated
with vertigo and depression, may last months
after head injury.
The main therapy for both is reassurance.
Inflammatory
In headaches due to inflammations- sinusitis,
otitis, dental infection, temporal arteritis-
there is tenderness over the inflamed area.
83
Bacterial inflammations require antibiotics.
Temporal arteritis is part of a giant cell
arteritis affecting cranial arteries. After
confirming diagnosis by biopsy, treat it with
large doses of steroids to avoid blindness due
to ophthalmic ischemia.
Vascular
Among the most common severe recurrent
headaches are those due to transient dilation
of extra-cranial arteries. Premonitory flashes
and tingling are frequent in migraine,
accompanied by vomiting. In histamine or
cluster headaches, due to hypersensitivity,
paroxysms of pain are accompanied by facial
vasodilatation causing weeping and a running
nose. Treat with vasoconstrictor drugs such as
Ergotamine and Methylsergide.
Hypertensive
Hypertension with severe headache suggests a
diagnosis of phaeochromocytoma, a
chromaffin cell tumor secreting
catecholamines. Patient’s complaint of
palpitation, perspiration and tremor identify
the tumour by MRI (magnetic resonance
imaging) or CT (computerized tomographic)
scan and remove the adrenal gland.
Milder headaches occur in those in the more
severe groups of primary hypertension, in
whom eye changes have developed (fundal
haemorrhages and exudates).
With diminution of consciousness and
normal intracranial pressure (ICP)
Sudden severe headache and vomiting may
precede stroke due to cerebral haemorrhage.
Coma may be instant or may come later after
brain swelling-when MRI or CT scan may be
required to exclude an intra-cranial tumour.
With diminution of consciousness and
raised ICP
Papilloedema and pupil (oculomotor)
paralysis with at first constricted and then
dilated pupils are found together with
increasing headache and vomiting, where ICP
is raised. Systolic blood pressure rises and
pulse rate falls.
Traumatic
If there is a history of recent trauma, acute
extra-dural or sub-dural haematoma should be
suspected. Identify by MRI or CT scan and
evacuate via burrhole or, if clot is too firm,
via cranial osteoplastic flap.
Chronic subdural haematoma may present
with headache, often accompanied by
confusion and hemi-paresis, weeks, months or
years after even a trivial head injury.
Inflammatory
Meningitis may follow upper respiratory tract
infection (URTI) or compound, particularly
basal, skull fracture. There is severe
headache, meningismus and fever.
Inflammation may extend to the brain
(encephalitis). Neisseria meningitidis is the
usual organism in non-traumatic meningitis.
The disease is primarily a septicaemia
metastasizing to the meninges. Do a blood
culture; give penicillin first and other
antibiotics according to bacterial sensitivity
tests. At lumbar puncture cerebrospinal fluid
(CSF) pressure is raised, fluid is cloudy with
high polymorphonuclear count, increased
protein, diminished glucose and many micro-
organisms usually identifiable (except
viruses) on routine staining and/or culture.
Mortality rate is still 10%.
Headache with fever but no meningismus
may be due to cerebral abscess, which causes
focal paresis and fits. This is identified by
MRI or CT scan and requires eventual
aspiration by stereotactic needle or burrhole
and antibiotic instillation as well as
immediate systemic antibiotics. 50% follow
mastoiditis; mortality rate is 50%. A large
abscess behaves like and mimics cerebral
tumor.
Vascular
Sudden severe headache, without fever but
with meningismus and coma, is often due to a
subarachnoid haemorrhage from a ruptured
congenital intracranial ‘berry’ aneurysm in
84
the arterial circle of Willis on the under-
surface of the cerebral hemispheres. Lumbar
puncture confirms the diagnosis. Removal of
a small amount of CSF may help to reduce
ICP. Removal of too much too quickly may
allow herniation of part of the cerebrum
through the tentorial notch (coning); pressure
on the brain stem vital nerve centers may
cause coma and sudden death. Two-thirds of
patients survive the original bleed. The
aneurysm neck is clipped via osteoplastic flap
craniotomy.
Neoplastic
If there is no fever, headache (often worse in
the morning) may be due to intracranial
tumour. Meningiomas are all benign. Gliomas
are all malignant and non-metastasizing. They
are lethal not because of spread, but because
of incomplete removal, with local recurrence,
focal destruction of nervous tissue and
increased ICP. Surgery is curative for
meningioma and for accessible benign
tumours, such as acoustic (eighth nerve)
neuroma. Surgery for malignant neoplasms is
usually palliative, but long-term survival may
follow removal of a solitary metastasis.
PAIN IN THE FACE
Face pain may be dull and throbbing or an
intense, stabbing discomfort in one or both
sides of the face or forehead.
Considerations
Pain that starts in the face may be caused by a
nerve disorder, an injury, or an infection in a
structure of the face. Face pain may also
begin elsewhere in the body.
Causes
• Abscessed tooth (continuous
throbbing pain on one side of the
lower face aggravated by eating or
touching)
• Cluster headache
• Herpes zoster (shingles) or herpes
simplex (cold sores) infection
• Injury to the face
• Migraine
 • Myofascial pain syndrome
• Sinusitis or sinus infection (dull pain
and tenderness around the eyes and
cheekbones that worsens when
bending forward)
• Tic douloureux
• Temporomandibular joint dysfunction
syndrome
Ask the following questions:
• What part of your face is in pain?
• Is the pain on both sides?
• If the pain is only on one side, which
side is it on?
• Is the pain over a sinus (forehead,
cheekbones)?
• Did the pain begin suddenly?
• Is face pain occurring repeatedly (is it
recurrent)?
• How long have the episodes of face
pain lasted (for how many months)?
• How long does each episode of pain
last (how many seconds)?
• Is the pain worse when speaking,
chewing, or swallowing?
• Does the pain develop when touching
a specific part of the face (trigger
point)?
• Did face pain occur before the start of
a brain or nervous system problem
(weakness, speech loss)?
• What other symptoms do you have?
Diagnostic tests that may be performed
include:
• Dental x-rays (if a tooth problem is
suspected)
• ECG (if heart problems are suspected)
• Tonometry (if glaucoma is suspected)
• X-rays of the sinuses
Neurological tests will be performed if nerve
damage is suspected.
85
Inflammation
Most acute facial pain is due to inflammation,
for instance acute parotitis (in dehydrated or
hypovolaemic patients); maxillary antrum
infection (fluid filled antrum on X-ray
requiring pre-nasal or sublabial drainage of
antrum); dental infection (usually requiring
antibiotics and later removal of the tooth
causing an alveolar abscess or dental root
abscess).
Neuralgia
The most striking facial pain is trigeminal
neuralgia, due to pressure on the trigeminal
nerve by tortuous dilated local small vessels.
This causes sudden severe shooting pain,
along the distribution of one branch of the
trigeminal nerve (usually the maxillary branch
supplying the face). Pain is triggered off by
touching tongue, teeth or face. There is no
sensory loss at the site of the pain such a
finding means there is a neoplasm involving
either the nerve or its brain stem origin.
Surgery (division of the appropriate sensory
root proximal to the trigeminal ganglion) has
been disappointing. The root or ganglion may
be destroyed by radio frequency probes under
X-ray control. Carbamazepine (tegretol)
usually relieves symptoms.
Arthralgia
Pain in the region of the temporomandibular
joint is likely to be due to infection about a
partially erupted wisdom tooth in adolescents;
to pain dysfunction syndrome (a doubtful
entity) in young adults; to jaw muscle
ischemia in the elderly, associated with giant
cell arteritis. Temporomandibular arthralgia
and arthritis are rare.

FURTHER READING
Digre KB. Headaches and other head pain. In:
Goldman L, Ausiello D, eds. Cecil Medicine. 24th
ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap
405.
Joseph Kandel, David Sudderth, David B. Sudderth.
The headache cure: how to uncover what's really
causing your pain and find lasting relief. 3 Reviews,
McGraw-Hill, 22-Sep-2005.
Lawrence Robbins MD and Susan Land. Headache
Help. Houghton Mifflin, 2000.
Lawrence Robbins MD. Management of Headache and
Headache Medications. Second Edition, Springer
Verlag, 2000.
Silberstein SD, Young WB. Headache and facial pain.
In: Goetz CG, ed. Textbook of Clinical Neurology.
3rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:
chap 53.

Note: Most of the Matters are drived from Internet and

Research Papers

86
MOUTH SORES AND SWELLINGS
The most common medical conditions
indicate by the symptoms mouth sores and
swelling including Allergic reaction,
Angioedema, and Coxsackie virus infection.
There are 19 conditions associated with
mouth ulcer and swelling.
Allergic reaction: Allergic reaction causes
sneezing, running nose and hives and can
leads to anaphylaxis, a whole body reaction.
Mouth ulcers
Painful
Shallow painful ulcers on the tongue are
usually dyspeptic but may occur in Crohn’s
disease. Sunburn ulcers on the lips are
painful, soft and often bleed when crusts are
displaced.
Painless
Chronic traumatic (dental) ulcers on the
tongue are painless and soft, as are ulcers in
irregular white patches of leukoplakia on the
lip, tongue or in the mouth. A hard painless
ulcer on the lip, tongue or in the mouth is
likely to be a squamous cell carcinoma. After
biopsy, excision is required. Nodes persisting
more than six weeks after the primary
excision wound has healed should be
removed, but it is reasonable to excise an
enlarged node and perform frozen section
before proceeding with block dissection. If
the mandible is involved (in carcinoma of the
mouth or tongue) part or all of it should be
excised and block dissection carried out at the
same time. Otherwise, prophylactic dissection
of impalpable nodes is unnecessary.
87
Mouth swellings
Soft
Soft transparent swellings are ranulae if in the
floor of the mouth (‘plunging’ ranulae may
present in the submandibular region), buccal
mucous cysts if in the cheek. They may be
excised or merely unroofed. A blue
compressible swelling is a cavernous
haemangioma (excise if it bleeds) and a white
opaque swelling is a dermoid cyst, often more
obvious in the submental triangle. Dermoid
cysts are removed because of supposed risk of
malignancy.
Hard
A hard smooth swelling at the foramen
caecum on the dorsum of the tongue may be a
ligual thyroid, perhaps the only thyroid tissue.
A hard smooth swelling on the alveolus is a
fibrous epulis (fibrous gingival hypertrophy)
and harmless. A similar swelling on the hard
palate is probably a mixed salivary tumour
and should be removed. A hard irregular
swelling in the buccal mucosa is probably a
squamous cell carcinoma.
Do Biopsy of every hard lesion on the lips or
in the mouth so as not to miss a cancer.
Swelling of the jaw
Upper
Painless static swellings of the upper jaw are
usually fibrous or bony dysplasias. Growing
swellings may be malignant maxillary
tumours (adenocarcinoma, adenoid cystic
carcinoma, squamous cell carcinoma,
transitional cell carcinoma) and are best
treated by a combination of radiation and
surgery after biopsy.
Infection of the maxillary antrum causes
painful swelling of the upper jaw and may
require antrostomy after confirmation by plain
X-ray which shows a fluid level in the
antrum. A periapical tooth abscess in the
upper jaw may cause a similar swelling,
diagnosed by dental X-ray. Treat it with
antibiotics and remove the tooth later.
FURTHER READING
Harmenberg J, Oberg B, Spruance S. Prevention of
ulcerative lesions by episodic treatment of recurrent
herpes labialis: A literature review. Acta
DermVenereol. 2010 Mar; 90(2):122-30.
Leco JC, Gomes VB, Porter S. Ulcerative lesions of the
mouth: an update for the general medical
practitioner. Clinics (Sao Paulo). 2007 Dec; 62
(6):769-80.
Silverman S Jr. Mucosal lesions in older adults. J Am
Dent Assoc. 2007 Sep;138 Suppl:41S-46S.
Volpato LE, Silva TC, Oliveira TM, et al. Radiation
therapy and chemotherapy-induced oral mucositis.
Braz J Otorhinolaryngol. 2007 Jul-Aug;73(4)

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Research Papers

Lower
Painless swelling of the mandible may be due
to paget’s disease with or with out osteogenic
sarcoma. Usually other bones will be affected
and the diagnosis will be obvious. X-ray, may
be a ‘giant cell tumour’, treated by curettage
and packing with bone chips; or an
ameloblastoma, locally destructive basal cell
tumour treated by local excision. If
unilocular, the swelling may be a chondroma
or chondrosarcoma.

Either
Painful alveolar swelling may be due to a
developmental cyst or odontome if there is an
unerupted tooth at the spot. Loose teeth over
an alveolar swelling suggest a diagnosis of
periosteal fibroma or fibrosarcoma, a large
bluish swelling, ulcerating late.

88
SWELLING IN THE NECK
What do you mean by swelling in the neck?
Swelling in the Neck is an accumulation of
fluid in the neck tissues or inflammation in
the neck. Neck inflammation can arise either
from an infection, injury, disorder(s) in body
functions or a recent medical treatment.
Unusual skin conditions may cause small
areas of the neck to appear swollen. Swelling
of the lymph nodes/glands in the neck is a
common symptom of many different types of
viral and bacterial infections. Rarely, neck
swelling can be a result of cancer.
ANTERIOR SWELLINGS
Cystic
Below cricoid
Most below the cricoid are thyroid cysts. A
thyroglossal cyst will move up, not merely on
swallowing, but also on protruding the
tongue.
Above cricoid
A cyst above the hyoid is a submental
dermoid. Rarely, an enlarged subhyoid bursa
may become a cystic swelling below the
hyoid.
Because of the supposed risk of carcinoma,
excision of dermoid cysts and thyroglossal
cysts (including the thyroglossal tract) is
advised.
Solid
Diffuse goiter
A part from rare lymph nodes most anterior
solid swellings are thyroid. The whole thyroid
is enlarged and confirmed in primary
thyrotoxicosis (plus exophthalmos, muscle-
particularly quadriceps femoris-weakness,
89
hyperreflexia), usually treated by carbimazole
and radioiodine. 7 to 9 millicuries of
radioiodine in one dose will usually avoid the
necessity of a further dose. Cure may take up
to six months and patients are usually treated
with carbimazole in the mean time. More than
10% of patients will require surgery (subtotal
thyroid ectomy), generally patients with
exophthalmic thyrotoxicosis (Graves’disease)
aged 20 to 40 years, especially if medical
control has been difficult or if they have been
allergic to anti-thyroid drugs.
The whole gland is hard and lobulated in
autoimmune thyroiditis (Hashimoto’s disease)
but the patient is usually menopausal, slightly
hypothyroid, IgG and IgM titres are high and
technetium scan may be hot. Treat with
Thyroxine.
Nodular goiter
Solitary
50% of solitary nodules are multinodular
goiters, the rest are cyst, benign tumors
(follicular adenomas) or malignant tumors
(10%). Slow growing papillary carcinomas
occur in the 2nd and 3rd decades and spread
slowly to lymph nodes (20%). Follicular, like
papillary, carcinomas have a good prognosis
while confined to the thyroid (intra-thyroidal),
if not angio-invasive. Both are more likely to
have extended through the capsule (extra-
thyroidal) in older people-50% of such
patients die of the disease compared with 3%
of intra-thyroid carcinoma arise from thyroid
‘C’ cells. 90% secrete calcitonin, they are
multicentric and spread to nodes. Those in
younger people (with neuromas of face,
mouth and bowel) are more malignant than
familial tumors in older people with or with
out phaeochromocytoma (secreting serotonin)
or parathyroid adenoma. Lymphoma may
follow autoimmune thyroiditis if thyroxine
replacement has been inadequate. Unlike
carcinoma, thyroid enlargement is rapid and
painless. It is treated by limited surgery and
radiation. Anaplastic carcinoma presents in
the 50s as a hard lump in a normal gland,
soon with evidence of invasion (recurrent
laryngeal nerve palsy and hoarseness, local
pain, dysphagia) and is treated by total
thyroidectomy if possible.
Fine needle aspiration cytology (FNAC) is
useful in the case of solitary nodule and
identifies a cyst, Hashimoto’s disease,
papillary carcinoma or follicular tumour. If
the lesion is papillary, perform total
thyroidectomy because the lesions are likely
to be multifocal and bilateral, especially if
more than 1.5 cm in diameter; remove
enlarged nodes. If it is follicular, perform
hemithyroid-ectomy and frozen section
completing total thyroidectomy if it is found
to be malignant. FNAC does not exclude a
diagnosis of carcinoma, which may depend
upon histological evidence of capsular
invasion, so it is safer to remove all nodules
found to be solid on ultrasound.
At risk after total rather than after subtotal
thyroidectomy are the recurrent laryngeal
nerve (RLN) and the parathyroids. Severe
90
dyspnoea after bilateral RLN division may
require tracheostomy. Unilateral division
causes dysphonia. Hypoparathyroidism,
usually temporary due to ischaemia, is
recognized by tetany developing 48 hours
after operation and treated with calcium and
parathormone. After total thyroidectomy,
allow the patient to become hypothyroid,
detect residual thyroid by further scan and
ablate with radioiodine. Metastases may then
function and may be treated with radioiodine.
In all cases of papillary carcinoma, 0.3 mg of
thyroxine should be given daily to supree
TSH (thyroid stimulating hormone), since this
cancer is often TSH-dependent.
Multinodular
In multinodular goiter (confirmed by
ultrasound or nuclear scan) surgery (subtotal
thyroidectomy removing most of each lobe
and the isthmus) is indicated only for pressure
effects, possibility of carcinoma, retrosternal
extension or (secondary) thyrotoxicosis.
Painful goiter
Haemorrhage in to a thyroid nodule may
cause sudden pain lasting a few days and
requiring no treatment. Subacute thyroiditis
(de quervain’s disease), probably of viral
origin, causes pain in part or all of the gland
accompanied by tenderness and settles down
(without treatment) in days or weeks. Thyroid
carcinoma may cause persistent local pain.
Lateral swellings
Cystic
Brachial cysts, in the upper anterior cervical
triangle, occur in middle age and should be
excised because of the risk of cancer.
Laryngoceles, hernias of laryngeal mucosa
through the thyrohyoid membrane, are found
in wind instrument players and are left alone.
Pharyngeal pouch, a diverticulum between
thyropharyngeus and cricopharyngeus, is a
rare cause of dysphagia in men and should be
excised if large to avoid aspiration of
contents. Cystic hygroma, perhaps due to
congenital obstruction of lymphatic channels,
is found in infants, rarely persists in to adult Mixed salivary tumours (pleomorphic
life and is left alone unless large. adenomas) are hard, smooth grow slowly,
Solid occur at any age and are treated by superficial
Carotid body tumour at the carotid bifurcation to the main trunk and branches of the facial
(C4) is usually benign, but intimately nerve deep tumours may require division of
associated with the internal carotid artery wall the styloid process for access and may present
(between adventitia and media), so that with dysphagia.
removal may require vascular reconstruction- Adenolymphomas are benign, partly cystic,
resection of carotid bifurcation using an often bilateral, tumours of old people.
internal arterial bypass. Angiogram confirms Adenocarcinoma may be fixed to mandible or
the diagnosis of these very vascular tumours skin and may cause facial palsy. More
and assesses adequacy of cerebral collateral malignant varieties are adenoid cystic
circulation. Neurofibromas occur on vagal (cylindroma), mucoepidermoid and
nervebranches or trunks and, like carotid body anaplastic.
tumours, can be moved from side to side Chronic enlargement of salivary glands may
rather than up and down. Excision is advised occur in alcoholics, in Sjögren’s syndrome, in
but may cause Horner’s syndrome (ptosis, sarcoidosis and in lymphomas.
meiosis, anhidrosis). Further Reading
Most solid swellings at the side of the neck M.K.Kearse, PT, PT-CLT, E. McMahon, PhD,
are lymph nodes, either secondary carcinoma and A. Ehrlich, MA. Lymph Notes Lymphedema
or lymphoma. All patients should have the Cargiver's Guide. 2009, pages 16, 79, 99, 135, 146
larynx and pharynx examined, enlarged nodes & 310.
should be sought elsewhere, together with
Itzhak Brook. My Voice: A Physician’s personal
liver or spleen enlargement, lung lesions
experience with throat cancer. Booksurge
(chest X-ray), leukaemia (blood examination); Publishing, Self-Publication, Charleston SC.
finally, biopsy is performed. 2010. p. 282
Salivary swellings
Painful Note: Most of the Matters are drived from Internet and
Mumps parotitis is often bilateral, usually in Research Papers
children, with or with out orchitis or
pancreatitis. Acute suppurative parotitis
occurs in old, dehydrated or shocked patients
and may require multiple incisions parallel
with branches of the facial nerve. Recurrent
parotitis occurs with congenital siallectasis or
parotid duct obstruction due to stenosis or
(rare) calculus. Painful submandibular duct
calculus (made of radio-opaque calcium
carbonate and bitartrate) can be removed
through the mouth. Incise the duct orifice
over a probe, or the duct itself over the
calculus. If in the gland, the gland must be
removed via a submandibular incision,
avoiding the marginal mandibular branch of
the facial nerve.
Painless

91
BREAST LUMPS AND NIPPLE DISCHARGES
What is Nipple discharge?
Nipple discharge is regarded a sign of
breast cancer. Type of discharge and
cytology are unreliable for diagnosis. Most
malignant cases have a detectable breast
mass. The aim of this study was to assess
the association between nipple discharge
and breast cancer.
Breast disorders may be noncancerous
(benign) or cancerous (malignant). Most are
noncancerous and not life threatening. Often,
they do not require treatment. In contrast,
breast cancer can mean loss of a breast or of
life. Thus, for many women, breast cancer is
their worst fear. However, potential problems
can be detected early when women regularly
examine their breasts themselves, are
examined regularly by their doctor, and have
mammograms as recommended. Early
detection of breast cancer is essential to
successful treatment.
Cancer specimen-not attached to deep fascia, with no
Breast carcinoma is the most common or mobile discrete axillary nodes, distant
malignancy in women (1 in 15). Those with a metastasis’s exclude by liver and bone
first-degree relative who had breast cancer is nuclear scan and chest X-ray), definitive local
the most common malignancy in women (1 in treatment is carried out. Local excision
15). Those with a first-degree relative who (lumpectomy, with a margin of 2 cm) and
had breast cancer, who ha borne children late radiotherapy to the rest of the breast are as
or not at all, or have had multiple (usually) good as mastectomy, which is now reserved
apocrine cysts, are at a higher risk, but most for large, locally recurrent, or incompletely
breast cancers occur in ‘low risk’ patients. excised cancers. Cancers near the nipple,
Screening high risk groups by low dose multi focal on mammogram, or showing
mammography identifies a few early extensive intraduct carcinoma or plasma cell
impalpable cancers by showing punctuate infiltration histological, also require
microcalcification the radiologist inserts a mastectomy. Axillary clearance through a
fine wire in to the lesion and the surgeon cuts separate wound stages the lesion and reduces
down on it. axillary local recurrence rate from 20% to
A hard ill-defined lump, different from 30%. 70% with negative nodes live five years
adjacent tissue, or red smooth hard in duration or more.
of nipple or areola (paget’s disease or
intraepithelial carcinoma) requires biopsy.
Fine needle aspiration or True-cut biopsy is
useful if positive; prognosis is better, with a
20% improvement in survival.
If the carcinoma is early (clinically less than 5
cm in size –often half as big in the excised

92
Ductal in situ carcinoma (DICS) becomes
invasive in 0% of cases so is treated by
lumpectomy, with out radiotherapy or axillary
clearance. Lobular carcinoma in situ (LCIS) is
treated in the same way, no longer by
prophylactic mastectomy, although often
multicentric and bilateral, since invasive
carcinoma is much less common.
Where nodes are involved, adjuvant
chemotherapy improves the disease-free five
year survival by one fifth, from 35% to more
than 40%. In postmenopausal women, or
where estrogen receptors were positive,
Tamoxifen is appropriate and has none of the
side effects in young women, whose demands
for hormone replacement therapy (HRT)
complicate management. Functional but
reversible ‘oophorectomy’ may be produced
by syntheticluteinizing hormone-releasing
factors, for instance Goserelin.
Locally advanced the late cancers (large,
fixed or with matted nodes) are treated by
radiotherapy first. Where there are distant
metastases, chemotherapy is the first
treatment, or Tamoxifen if appropriate,
although its effect is too slow for rapidly
progressive lesions.
Residual primary carcinoma persisting after
such treatments is excised of metastases are
under control.
After mastectomy, recommended a prosthesis
(some surgeon insert one at the same time ) or
later latissimus dorsi flap may be better,
perhaps with revascularization of the flap by
attachment to the internal mammary vessels.
Benign breast lesions
The most common benign lumps (and the
most common lumps in the breast are
aberrations of the normal development and
93
involution (ANDI), either cystic (aspiration
yields coloured fluid) or solid (lumps or cord-
like thickenings not palpable with the hand
flat).
Use of terms such as ‘mammary dysplasia’ or
‘fibrocystic diseases’
In mammary duct ectasi, a varient, a whole
quadrant may be indurate and tender. There
may be toothpaste-like nipple discharges.
The most common breast lesion in young
women is a fibroadenoma, or ‘breast mouse’,
hard, smooth and very mobile. FNAC will
confirm this benign diagnosis. Although half
will disappear, many patients prefer surgical
removal.
The end result of a large bruise may be fat
necrosis, by then a hard, irregular swelling
attached to the skin. It may closely resemble
cancer, as may a chronic, non specific or
tuberculous abscess.
Gynaecomastia (enlargement of the male
breast) is common in young men and
harmless but may be painful. Rarely, it is due
to raised serum female hormone concentration
in testicular interstitial cell tumours (usually
palpable) or leydig cell tumours (some times
identifiable only by ultrasound).
Gynaecomastia is also found in liver failure,
because estrogens are not destroyed by the
hepatic cells.
Painful lumps
The swelling and cysts of ANDI are often
painful, particularly just before menstrual
periods.
Breast abscesses, during lactation, may
sometimes be treated by antibiotics and
repeated aspiration but often need incision
and drainage incision may be required.
Mastitis carcinomatosa, a florid form of
breast cancer found in young women, often
during lactation, is reed and hot but not
invariably painful or tender. There is no fever.
Early breast cancer is rarely painful. In late
cases, pain is due to invasion of muscle or
bone, or ulceration with secondary infection.
Nipple discharges
ANDI is the most common cause of nipple
discharges, usually coloured and expressible
from several lacteal duct orifices in both
nipples. By contrast, blood-stained or clear
serous discharges, usually from a duct
papilloma, appears from one orifice only and
is treated by removing that duct and adjacent
breast tissue via a perioareolar incision
(microdochectomy).

FURTHER READING
T Richards, A Hunt, S Courtney, and H Umeh Nipple
Discharge: A Sign of Breast Cancer? Ann R Coll
Surg Engl. 2007 March; 89(2): 124–126.
Brennan M, Houssami N, French J. Management of
benign breast conditions. Part 3: Other breast
problems. Aust Fam Physician. 2005;34(5):353-5.
Talley NJ, O'Connor S. Clinical Examination: A
systematic guide to physical diagnosis. 4th Edition.
Eastgardens, NSW: MacLennan & Petty; 2001.
Lanitis S, Rice AJ, Vaughan A, et al. Diagnosis and
management of male breast cancer. World J Surg.
2008;32(11):2471-76.
Jatoi I, Kaufmann M (eds). Management of Breast
Diseases. 1st Edition. New York, NY: Springer-
Verlag Berlin, Heidelberg; 2010.
Burkitt HG, Quick CRG, Reed JB. Essential Surgery:
Problems, diagnosis and management. 4th Edition.
Philadelphia, PA: Elsevier Saunders. 2007.

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Research Papers

94
COUGH, DYSPNOEA AND CHEST PAIN
Cough
Definition: A cough (Latin: Tussis), is a
sudden and often repetitively occurring reflex
which helps to clear the large breathing
passages from secretions, irritants, foreign
particles and microbes. The cough
reflex consists of three phases: an inhalation,
a forced exhalation against a closed glottis,
and a violent release of air from the lungs
following opening of the glottis, usually
accompanied by a distinctive
sound. Coughing can happen voluntarily as
well as involuntarily.
Frequent coughing usually indicates the
presence of a disease.
Many viruses and bacteria benefit
evolutionarily by causing the host to cough,
which helps to spread the disease to new
hosts. Most of the time, irregular coughing is
caused by a respiratory tract infection but can
be triggered by choking, smoking, air
pollution, asthma, gastro -esophageal reflux
disease, post-nasal drip, chronic bronchitis,
lung tumors, heart failure and medications
such as ACE inhibitors.
Coughs may be: a) acute coughs usually begin
suddenly and are often due to a cold, flu, or
sinus infection. They usually go away after 3
weeks b) sub-acute coughs last 3 to 8 weeks
c) chronic coughs last longer than 3weeks.
Acute
Sputum
In tracheo-bronchitis, the most common
cause, the patient coughs yellow sputum and
has substernal pain. In pulmonary oedema, he
painlessly coughs large amounts of clear
frothy sputum and is dyspnoeic.
Blood
Haemoptysis (coughing up blood) suggests
pulmonary embolism in the post-operative
patient. Nuclear venous pool scan will show a
non-perfused segment. If this segment shows
normal ventilation on ventilation scan (V/Q
mismatch), pulmonary embolism is probable.
95
If surgery or thrombolytic treatment is
contemplated, perform pulmonary
arteriography, anticoagulant with intravenous
heparin, later with Warfarin for six weeks.
In lobar pneumonia, the sputum contains
altered blood (rusty), fever is high, a lobe is
consolidated clinically and on chest X-ray.
Treat with intravenous Penicillin.
Dry
Persistent cough with little sputum,
commonly containing blood, suggests
carcinoma of bronchus. If MRI or CT scan
shows no nodes are involved, perform
pneumonectomy and remove nodes and
involved chest wall. Partial pneumonectomy
is often possible, with partial bronchectomy
and bronchial anastomosis. This is the therapy
for squamous cell carcinoma arising in large
bronchi, large cell anaplastic carcinoma. The
treatment for small (oat) cell carcinomas and
lymphomas are combined chemotherapy.
Surgery is indicated only if there is doubt
about the histological nature of the tumour.
Chronic or recurrent
Sputum
Chronic cough and sputum in patients who
are other wise swell may be due to
bronchiectasis, that is, chronic suppuration in
a lung segment, which may require segmental
resection. In chronic obstructive airways
disease (COAD) patient are usually ill,
dyspnoeic and cyanosed.
Haemoptysis
Pulmonary tuberculosis patients have a
chronic cough with recurrent haemoptysis.
They are usually ill and dyspnoeic.
Haemoptysis in well patients may be due to
bronchial adenoma, although with such
lesions (most are carcinoids or hamartomas
and identified by bronchoscopy) bleeding is
sporadic and severe rather than frequent and
slight. Carcinoids block a segment and cause
bronchiectasis, requiring lung resection.
Hamartomas are half as common, usually
chondromatous, show up as ‘coin’ lesion on
X-ray, some times with punctate calcification.
They are usually just under the surface in the
lower lobe and easily removed.
Dyspnoea
Definition:
Dyspnoea (Latin: Dyspnoea; Greek:
Dýspnoia), shortness of breath (SOB), or air
hunger, is the subjective symptom of breath-
lessness or difficulty with breathing.Dyspnoea
is a sign of serious disease of the airway,
lungs, or heart (e.g. asthma, pneumonia,
cardiac ischemia, interstitial lung disease,
congestive heart failure, chronic obstructive,
pulmonary disease or psychogenic causes.
Acute
Painless
Sudden painless dyspnoea following
coughing ma be caused by spontaneous
pneumothorax due to rupture of an
emphysematous bulla. Decompression via the
second intercostals space interiorly will be
urgently required if tension pneumothorax (air
keeps escaping from the lung but will not go
96
back) develops. Sudden shortness of breath
during a meal may be due to food bolus
aspiration- the patient should be struck hard
on the back to dislodge the bolus. Dyspnoea
waking one at night is due to pulmonary
oedema in congestive cardiac failure.
Painlessly increasing dyspnoea over hours or
days is likely to be due to mediastinal
tumours (including retrosternal goiter) if there
is venous engorgement and to chronic
obstructive airways disease if there is none.
Painful
Sudden dyspnoea with pleuritic pain (hurts to
take a deep breath) is characteristic of
pulmonary embolism. If pain is sternal,
radiates to neck or arm and is perhaps
associated with arrhythmia, suspect
myocardial infarct. If onset of acute dyspnoea
is slower and associated with pleuristy, if pain
is retrosternal, suspect pericarditis, pericardial
effusion muffles the heart beat and neck veins
are engorged.
Chronic
Wheezing
If the patient is not very short of breath but
wheezing because of bronchospasm, the cause
is likely to be carcinoma of the bronchus or
COAD if wheezing is inspiratory and
bronchial asthma if it is expiratory. Of
course, asthma, carcinoma of the bronchus
and COAD may all cause acute severe
painless dyspnoea.
Non-wheezing
Chronic dyspnoea is most often due to
pulmonary infiltration (sarcoidosis,
secondary carcinoma, tuberculosis and
lymphoma).
If chronic non wheezing dyspnoea is
associated with peripheral oedema it is due to
congestive cardiac failure if the juglar venous
pressure is raised and to anaemia if it is not-
but hypervolaemia may cause congestive
failure in anaemic patients.
Pain in the chest
Definition: Chest pain may be a symptom of
a number of serious conditions and is
generally considered a medical emergency. • Functional dyspepsia
Even though it may be determined that
the pain is non-cardiac in origin, this is often Chest wall
a diagnosis of exclusion made after ruling out • Costochondritis or Tietze's syndrome -
more serious causes of the pain. a benign and harmless form of
Causes of chest pain range from non-serious osteochondritis often mistaken for
to serious to life threatening. Diagnosis heart disease
reports show more than 440 causes on it. • Spinal nerve problem
Cardiovascular • Fibromyalgia
• Acute coronary syndrome • Chest wall problems
• Unstable Angina Pectoris - requiring • Radiculopathy
emergency medical treatment but not • Precordial catch syndrome - another
primary intervention as in a myocardial benign and harmless form of a sharp,
infarction. localised chest pain often mistaken for
• Myocardial infarction ("heart attack") heart disease
• Aortic dissection • Breast conditions
• Pericarditis and cardiac tamponade • Herpes zoster commonly known as
• Arrhythmia - atrial fibrillation and a shingles
number of other arrhythmias can cause • Tuberculosis
chest pain. • Osteoarthritis
• Stable angina pectoris - this can be treated • Bornholm disease
medically and although it warrants Psychological
investigation, it is not an emergency in its • Panic attack
strictest sense • Anxiety
• Myocarditis • Clinical depression
• Mitral valve prolapse syndrome • Somatization disorder
• Aortic aneurysm • Hypochondria
Respiratory Others
• Pulmonary embolism • Hyperventilation syndrome often
• Pneumonia presents with chest pain and a tingling
• Hemothorax sensation of the fingertips and around
• Pneumothorax and Tension the mouth
pneumothorax • Da costa's syndrome
• Pleurisy - an inflammation which can • Carbon monoxide poisoning
cause painful respiration • Sarcoidosis
• Tuberculosis • Lead poisoning
• Tracheitis • High abdominal pain may also mimic
• Lung malignancy chest pain
Gastrointestinal • Prolapsed intervertebral disc
• Gastroesophageal reflux • Thoracic outlet syndrome
disease (GERD) and other causes Sudden (seconds or minutes)
of heartburn Pleuritic
• Hiatus hernia If severe chest pain is associated with
• Achalasia, nutcracker esophagus and breathing and is in the chest, shoulder or
other neuromuscular disorders of abdomen, it is pleuritic and probably due to
the esophagus pulmonary embolism.

97
Cardiac
If the pain is precordial (retrosternal pain with
or with out radiation to neck, arms or
abdomen) it is probably due to myocardial
infarction.
Mediastinal
If pain is mediastinal (retrosternal pain
radiating to the back and perhaps chiefly in the
back), it may be due to dissecting aortic
aneurysm if there are no upper limb pulses or
to ruptured oesophagus if pulses are normal -
this follows vomiting after a large meal.
Dissecting aneurysms will also cause
haematuria and soon anuria and require urgent
surgical division of intima to halt dissection.
Ruptured oesophagus (fluid level in media-
stinum, pleural effusion containing
gastrointestinal content) requires immediate
repair and intubation. In late cases (several
hours post-rupture) temporary stapled
exclusion of the perforated section, with
cervical oesophagostomy and feeding
gastrostomy, is needed.
Gradual (hours or days)
In pneumonia, there is gradual onset of
pleuritic pain and in pericarditis, of precordial
pain. In a patient with a known aortic arch
aneurysm, gradual development of mediastinal
pain signals rupture and requires urgent
operation,
Chronic or recurrent
Pleuritic pain of this kind is found in plural
malignancy, whether primary pleural
mesothetioma in asbestosis or secondary
carcinoma. Angina pectoris is recurrent with
exertion. Most mediastinal tumours are
painless but may cause chronic mediastinal
pain as they grow larger. Aortic arch
aneurysms and retrosternal goitre are the most
common tumours in the superior mediastinum.
Malignant nodes (usually from bronchial
carcinoma, with irregular expanded
mediastinum on chest X-ray) and
bronchogenic cysts are the most common
tumours in the middle mediastinum. In the
latter, X-ray outline is smooth and ultrasound
98
identifies the cyst, which is easily removed..
The most common swellings in the posterior
mediastinum are nerve tumours, solid on
ultrasound, either ganglioneuroma forming a
'dumbbell' tumour on an intercostal nerve root
or neurofibromas on intercostal nerves - both
usually easy to remove - or enteric cysts
(partial reduplications of the oesophagus and
usually next to it).
Coronary artery disease
Prognosis in angina depends upon age, extent
of coronary artery disease, number of vessels
involved and ventricular function. Coronary
artery grafts may restore the coronary
circulation but will not affect the other factors.
Investigation of patients for whom operation is
proposed requires cardiac catheterization and
cardiac angiography.
The place of coronary angioplasty (dilatation
of atheromatous coronary arteries with
triluminal balloon catheters) is controversial.
The main indication is angina with one or
more accessible coronary. One-third of
patients suffer re-stenosis within one year. The
procedure is 'blind' and may be improved by
better angioscopy.
Multiple coronary artery grafts can now be
performed in special centers with a 2%
mortality rate, relieving angina in 85% of
cases. Half of these grafts remain patent at ten
years.. The ideal candidate has severe angina
with a heart of normal size, no previous
infarct) localized disease in one or more
vessels and normal ventricular function.
Internal mammary artery-coronary artery
grafting, if it works, will last longer (ten years
or more), therefore, is more suitable for
younger patients with disease of one or two
vessels.
FURTHER READING
Aidan O'Brien & Tim Liesching. Dyspnea, chest pain, and
cough: The lurking culprit. Kindle Edition,
Postgraduate Medicine. 200; 2112(1): 1-7
Debabrata Mukherjee; Carl Sferry; Jacob Joseph; Paul
Lange; Atul Mehta Dyspnea, Cough, and Chest Pain
in a 35-Year-Old Pregnant Woman. Chest. 1995;
107(5): 1460-1462.
Val E. Ginzburg, Chest pain, dyspnea, and cough. Can
Fam Physician. 2006 September 10; 52(9): 1060.

Note: Most of the Matters are drived from Internet and

Research Papers

99
DYSPHAGIA
Dysphagia (difficulty in swallowing)
Dysphagia is the medical term for the
symptom of difficulty in
swallowing. Although classified under
"symptoms and signs" in ICD-10, the term is
sometimes used as a condition in its own
right. Sufferers are sometimes unaware of
their dysphagia.
It is derived from the Greek dys meaning bad
or disordered, and phago meaning "eat". It
may be a sensation that suggests difficulty in
the passage of solids or liquids from
the mouth to the stomach, a lack of
pharyngeal sensation, or various other
inadequacies of the swallowing mechanism.
Dysphagia is distinguished from other
symptoms including odynophagia, which is
defined as painful swallowing and globus,
which is the sensation of a lump in the throat. Chronic
A psychogenic dysphagia is known Obstructive
as phagophobia. Individuals who suffer from Usually painless, it may be static and then due
dysphagia are often ordered onto thickened to a benign lesion, or progressive (difficult to
fluids. The thicker consistency makes it less swallow solids, later liquids and saliva), then
likely that an individual with dysphagia usually malignant. Chronic obstruction may
will aspirate while they are drinking. be congenital (dysphagia lusoria-aortic arch
Individuals with difficulty swallowing may split about the oesophagus; congenital genital
find liquids cause coughing, spluttering or atresia with tracheo-oesophageal fistula);
even choking and thickening drinks enables ‘traumatic’ (extrinsic compression usually
them to swallow safely. A range of due to malignant nodes); inflammatory
commercial thickening agents are available to (benign stricture, usually due to gastro-
purchase for the dietary management of oesophageal reflux); degenerative
dysphagia. (pharyngeal diverticulum or pouch;
oesophageal web, usually associated with
Acute plummer-Vinson syndrome); neoplastic
Always painful, may be due to swallowing a (carcinoma of the oesophagus).
foreign body (bone, coin) or corrosive, Non-obstructive
damage to the oesophagus during Non-obstructive or functional causes of
oesophagoscopy; acute inflammations dysphagia include achalasia, motor disorder
(tonsillitis, quinsy, retro-pharyngeal abscess, with failure of relaxation of distal
thrush, reflux oesophagitis, alcoholic oesophageal spasm (cork-screw oesophagus),
oesophagitis); spontaneous perforation of the a motility disorder where normal peristalsis is
oesophagus (fever, tachycardia, pleural replaced by non-propulsive spasms; bulbar
effusion, surgical emphysema). palsy with regurgitation not merely through

100
the mouth but through the nose;
cricopharyngeal disco-ordination; hysteria;
other causes (scleroderma, multiple sclerosis,
myasthenia gravis).
Common causes in women
Achalasia
Occurring in middle age, there is slowly
increasing dysphagia for fluid. Chest X-ray
shows a fluid level in the mediastinum.
Pneumatic dilation of the lower oesophageal
sphincter is successful in 80% of cases.
Heller’s operation, dividing the muscle of the
cardia and lower oesophagus, is used in those
who fail to respond to dilatation and is
successful in 85% of cases, with reflux in
15% and some strictures. Some cardio-
oesophageal carcinomas infiltrate the
myenteric plexus and cause an ‘achalasia
syndrome’.
Gastro-oesophageal reflux with stricture
Dysphagia in middle age follows symptoms
of reflux over many years. Repeated dilation
and use of H2-reflux over many years,
repeated dilation and use of H2 receptor
antagonists, or acid pump inhibitors like
Omeprazole, may be sufficient. Anti-reflux
surgery, for instance mobilization of the
gastric fundus and plicating it in inkwell
fashion about the lower oesophagus (Nissen’s
operation), is required for intractable cases.
Reflux sometime causes columnar epithelial
metaplasia in the oesophagus with ulceration
(Barrett’s ulcer), in which adenocarcinoma
may develop.
Plummer-vinson syndrome, with later
carcinoma of the upper oesophagus, presents
in women in late middle age as iron
deficiency anaemia, achlorhydria and web
formation in hypopharynx. It is treated by
dilation, diet and vitamins and iron. Only in
these women does one find carcinoma in the
uppermost oesophagus, the best treatment for
which is resection.
Common causes in men
Carcinoma of the oesophagus: Men over 60
years present with progressive dysphagia, loss
101
of weight and some times poorly localized
pain. Barium swallow shows the extent of the
carcinoma but endoscopy and biopsy are
necessary for diagnosis. MRI or CT scan
excludes metastatic mediastinal nodes and the
carcinoma is resected if possible. Large
resecetions are necessary because of extensive
intramural spread. Long side to side stapling
of upper oesophagus to stomach has
eliminated stomal stenosis. X-ray therapy
palliates middle-third cancers. Celestin or
Atkinson tube allows swallowing to go on for
a while when the growth is irremovable.
Endoscopic laser or diathermy will do the
same. 30% of those who survive resection for
squamous cell carcinoma live five years, 3%
after adenocarcinoma resection.
Malignant mediastinal nodes
These are most often due to carcinoma of the
bronchus but may be due to lymphoma. There
is extrinsic pressure on barium swallow and
widening of the mediastinum on chest X-ray.
Pharyngeal diverticulum
Men over 70 years present with cough, foul
breath and postural regurgitation. Dysphagia
is a late symptom, coming on when the pouch
is large. A soft swelling on the left side of the
neck gurgles and can be emptied on pressure.
Dilation is effective unless the pouch is large
when it must be excised, taking care to keep a
tube in the oesophagus during the operation to
protect it from accidental division. It is
essential, at the same time, to divide the
cricopharyngeus, inappropriate contraction of
which caused the diverticulum.
FURTHER READING
Joseph Murray. Manual of Dysphagia Assessment in
Adults. Cengage Learning, 1999.
Michael E. Groher, Michael A. Crary. Dysphagia:
Clinical Management in Adults and Children. Mosby
Elsevier, 28-Oct-2009.
Michael E. Groher. Dysphagia: Diagnosis and
Management. Amazon Best Sellers.Jan 15, 1997.
Nancy B. Swigert. The sources for Dysphagia. 3rd
Edition. LinguiSystems. 2007.
Note: Most of the Matters are drived from Internet and
Research Papers
102
DYSPEPSIA
Dyspepsia: It means discomfort related to
eating.
Definition: Dyspepsia (Greek: indigestion)
also known as upset stomach or indigestion,
is a condition of impaired digestion. It is a
medical condition characterized by chronic or
recurrent pain in the upper abdomen, upper
abdominal fullness and feeling full earlier
than expected when eating. It can be
accompanied by bloating, belching, nausea or
heart burn. Dyspepsia is a common problem
and is frequently caused by gastro-esophageal
reflux disease (GERD) or gastritis. In a small
minority it may be the first symptom of peptic
ulcer disease (an ulcer of the stomach
or duodenum) and occasionally cancer.
Hence, unexplained newly onset dyspepsia in
people over 55 or the presence of other
alarming symptoms may require further
investigations.
With weight loss
Painful
Epigastric pain relieved by antacids,
aggravated by any food, is usually due to
chronic gastric ulcer. Gastroscopy is
necessary to diagnose the ulcer and four
quadrant biopsy must be carried out to
exclude carcinoma. 50% of benign ulcers are
controlled by H2-receptor antagonists. If
persistent, or where carcinoma cannot be
102
excluded, Billroth I two-thirds gastrectomy is
required, joining the stomach remnant to the
first part of the duodenum. Severe
complications (perforation, bleeding) usually
require emergency Billroth I gastrectomy.
In alcoholics dyspepsia associated with
chronic gastritis or chronic pancreatitis may
not be relieved by antacids.
Painless (discomfort, fullness, flatulence)
Carcinoma of the stomach may be painless
and present with anorexia, weight loss,
anaemia, dysphagia or vomiting due to
malignant pyloric stenosis (pyloric antrum is
the most common site of gastric
cancer).Partial gastrectomy (total where the
carcinoma extends to within 5 cm of the
cardiac) is the only useful treatment and cures
early cases (confined to the gastric wall)."
These comprise only 10% of those with
symptoms. 'Early gastric cancers' (mucosal
and sub-mucosal) are picked up by endoscopy
surveillance programs, but the effort is not
worth the cost, except in societies where
gastric cancer is most common (e.g. Japan).
Gastric lymphoma is the most common non-
Hodgkin's extranodal lymphoma, often
beginning in mucosa-associated-lymphoid-
tissue ('MALT'). Subtotal gastrectomy is
recommended with adjuvant therapy
(chemotherapy or radiotherapy) if resection
margins were not clear.
Adenocarcinoma of the pancreas may grow
large before causing symptoms due to liver
metastases, exocrine or endocrine lack,
migrating thrombophlebitis, malignant
cachexia and myopathy. Carcinoma of the
head of the pancreas presents earlier with
painless progressive obstructive jaundice.
Carcinoma may also cause gastric or
duodenal obstruction or upper gastrointestinal
bleeding. Carcinoma of the body and tail of
the pancreas may present with back pain
alone. Diagnosis is by MRI or CT scan, which
shows a discrete mass of abnormal density,
distinguishing it from chronic pancreatitis.
Resection of the body and- tail of the
pancreas is easier than resection of the head
(where the pylori c antrum, duodenum and
upper jejunum must be removed also-but
presentation is late and liver metastases are
usual.
No weight loss
Equivocal relation to meals
Discomfort and pain (often retrostemal) in
those with gastro-oesophageal reflux, with or
without oesophagitis, are often postural,
brought on by lying flat or bending forwards
and are associated with flatulence and acid
regurgitation. Found in 10% of normal
people, worst in overweight women, reflux is
permitted by relaxation of the intrinsic lower
esophageal sphincter (LOS) but may be
aggravated by sliding hiatus hernia. In that
state the cardiac moves up into the chest, with
loss of the hiatus 'pinch-cock' mechanism,
also of the oesophagogastric angle (of His)
and there is no intra-abdominal oesophagus to
be collapsed by intra-abdominal pressure. The
usual mechanism leading to reflux, however,
is transient LOS relaxation (TLOSR). These
unexplained episodes of TLOSR are the basis
of reflux and peptic oesophagitis and may
constitute a neural disorder.
In patients with severe oesophagitis due to
reflux, surgical correction has proved
disappointing, presumably because the main
problem is not weakness of the LOS, but
transient relaxation. The Nissen
fundoplication operation (which may be
performed laparo-scopically) mobilizes the
fundus and wraps it around the cardiac
making an inkwell anti-reflux valve, but
interferes with vomiting; it may cause-
dysphagia and reflux recurs in 10-20% of
patients.
Pain in gallstone disease may follow rich or
fatty meals and often occurs in overweight
patients who also have refluxed (see above).
However the severe colic across the upper
abdomen and back associated with cystic duct
obstruction is unlikely to be mistaken for
103
anything else. Such biliary colic may also be
due to a stone in the common bile duct, in
which case jaundice appears some hours later.
Abdominal ultrasound identifies gallstones, a
normal serum amylase excludes pancreatitis
(often associated with gallstones), absence of
abdominal rigidity excludes perforated
duodenal ulcer. Recommend cholecystectomy
because of danger of subsequent
complications (including carcinoma in 1% of
cases). Attempted dissolution of stones with
chenodeoxycholic acid fails in 50% of cases,
may cause liver damage and is followed by
recurrence in 50%. Extracorporeal shock-
wave lithotripsy (ESWL) may be used for
large stones retained in the common bile duct
where ERCP-sphincterotomy is likely to be
inadequate and where the patient is unfit for
choledocholithotomy. Only 10% of
gallbladder gallstones are treatable by ESWL,
which has been superseded by percutaneous
laparoscopic cholcystec- tomy.
Fever and local rigidity distinguish acute
cholecystitis from colic. If in doubt, inject an
isotope excreted in the bile (hydro-imido-
acetic acid, HIDA). It will not enter the
gallbladder because of cystic duct obstruction,
invariable in acute cholecystitis. Acute
cholecystitis usually responds to Ampicillin,
allowing safe cholecystectomy in a day or so.
If cholecystitis grows worse, emergency
operation will be required. If cholecystectomy
looks too dangerous, cholecyst-ostomy will
be sufficient, removing the stones and
bringing a tube through the gallbladder
fundus and the abdominal wall. If resolution
is slow on antibiotics or ii there is associated
pancreatitis, it is better to perform elective
cholecystectomy three months later.
Indications for operative cholangiography
during elective cholecystectomy are: present
or previous jaundice; previous pancreatitis;
raised serum bilirubin or alkaline
phosphatase; small stones and large cystic
duct; palpable bile duct stone. Routine
operative cholangiography may be preferred,
especially during laparoscopic
cholecystectomy, as this will reveal any
variation in the anatomy of the bile ducts.
Stones in the bile duct may be removed by
open or laparoscopic choledochotomy or by
subsequent ERCP sphincter-otomy. Leave in
a temporary T-tube after choledocho-
lithotomy, remove it a week or more after
operation when T-tube cholangiogram has
shown no stones left.
Primary bile duct stones, without gallbladder
stones, frequently occur in East Asia and
South East Asia and may require
choledochojejunostomy. -Before meals
Epigastric pain before meals relieved by food,
often seasonal, usually in young males, is due
to chronic duodenal ulcer. Identify by
gastroscopy (barium meal misses 30% of
ulcers).
Treatment with H2-receptor antagonists:
Bismuth subcitrate Metronidazole and
Doxycycline for associated Heliobacter pylori
(present in 95% of patients)-heals the ulcer in
80% of cases. Prolonged maintenance
medical treatment is safe.
Emergency surgery is usually required for
perforation. The perforation is closed with an
omental patch. Routine definitive operation is
not justified because one-third of the patients
have no further symptoms after simple
closure and because most of these patients
have never had medical treatment. Those who
treat perforation conservatively (with
nasogastric suction and intravenous fluid)
must be confident of the diagnosis and are
obliged to operate at once if the pulse rate
rises or the pain persists.
10% of those admitted with severe bleeding
require emergency operation. Bilateral truncal
(total abdominal) vagotomy and pyloroplasty
is most useful when one has to under-run a.
severely bleeding posterior wall duodenal
ulcer and has a recurrence rate of 5 %.
In those patients (10-20%) in whom medical
treatment has failed to prevent recurrence a
definitive operation is necessary. Proximal
gastric (highly selective) vagotomy, in which
vagal branches to all but the distal pyloric
antrum are divided, is the safest operation
with the best functional results (no discomfort
or faintness - 'dumping' - after meals, no
diarrhoea) but has a recurrence rate of 10%.
Posterior truncal vagotomy and anterior
seromotomy (dividing anterior branches of
greater anterior gastric nerve of Latarjet to
cardia and lesser curve) is quicker than and as
good as proximal gastric vagotomy and may
be performed laparoscopically. Antrectomy
and bilateral truncal vagotomy provides the
lowest recurrence rate (1 %) but is Jiot quite
as safe as the other two operations. Use it if
medical treatment (H2-receptor antagonists)
fails to reduce acid secretion enough even to
relieve symptoms.
FURTHER READING
Emad M. El-Omar, Richard M. Peek. Dyspepsia.
Mosby, Jan 2004
Kenneth L. Koch, Michael Lancaster-Smith.
Dyspepsia. Health Press, Jan 2003.
David A. Johnson, Philip O. Katz, Donald O. Castell.
Dyspepsia. American College of Physicians--
American Society of Internal Medicine, 2001.
Ronnie Fass. GERD/Dyspepsia.Elsevier Health
Sciences, 2004.
Marko Duvnjak. Dyspepsia in Clinical Practice. `
Springer, Jan 2011.
P. Moayyedi. Dyspepsia:The Clinical Consequences Gut
2001;49:314
1.
Note: Most of the Matters are drived from Internet and
Research Papers
104
VOMITING
Vomiting
Definition: Vomiting (medically called
emesis) is the forceful expulsion of the
contents of one's stomach through
the mouth and sometimes the nose. Vomiting
can be caused by a wide variety of conditions;
it may present as a specific response to
ailments like gastritis or poisoning, or as a
non-specific sequela of disorders ranging
from brain tumors and elevated intracranial
pressure to overexposure to ionizing
radiation. The feeling that one is about to
vomit is called nausea, which often precedes
but does not always lead to, vomiting. Anti-
emetics are sometimes necessary to suppress
nausea and vomiting. In severe cases, where
dehydration develops, intravenous fluid may
be required.
Vomiting is different from regurgitation,
although the two terms are often used
interchangeably. Regurgitation is the return of
undigested food back up the esophagus to
the mouth, without the force and displeasure
associated with vomiting. The causes of
vomiting and regurgitation are generally
different.
WITH DIARRHOEA
Vomiting coming on first or at the same time
as diarrhoea is due to food poisoning or
gastroenteritis/If diarrhoea is first or
predominant, suspect dysentery or
inflammatory bowel disease.
WITHOUT DIARRHOEA
No bile in vomits
105
This means gastric obstruction.
If there is a long history of dyspepsia and
large amounts are vomited every few days,
the patient has benign pyloric stenosis due to
chronic duodenal ulcer. If there is much pain,
stenosis may be partly inflammatory and may
settle down with nasogastric aspiration,
intravenous fluids and intravenous H2-
receptor antagonists. If painless (the usual
case) bilateral truncal vagotomy and
gastroenterostohly will be required in most,
though w some it is possible to dilate the
pylorus via an antrotomy and perform
proximal gastric vagotomy.
•
A short history suggests carcinoma of the
pyloric antrum. The irregular antral filling
defect and stomach of moderate size shown
on barium meal X-ray contrast with the huge
stomach and sharp stricture found
in duodenal ulcer stenosis. After gastroscopy
and biopsy, gastrectomy is performed or, if
the lesion is irremovable, gastroenterostomy.
Bile in vomits
Paralytic
Painless vomiting of small intestinal contents
occurs in so-called 'paralytic' ileus. This may
follow spinal injury, retroperitoneal
haematoma or major abdominal operations. It
may be 'spastic' rather than 'paralytic*
because it sometimes responds to anti-
adrenergic drugs. It is usually sufficient to
commence nasogastric suction with
intravenous fluid replacement. Remove the
tube when aspirate falls off and flatus is
passed.
Central
Painless vomiting may be central, due to
damage to the vomiting centre in the brain
stem by uraemia, cerebral compression or
drugs, including alcohol. Nausea and
vomiting in the morning are common in the
first trimester of pregnancy.
Acute abdominal
Vomiting is common at the outset of
appendicitis, cholecystitis, pancreatitis and in
patients with biliary or ureteric colic.
Persistent bile vomiting with severe
abdominal pain is due to peritoneal irritation
(peritonitis, ruptured abdominal aortic
aneurysm, intestinal ischaemia) or intestinal
obstruction. Vomiting is early in high small
bowel obstruction and late in low small bowel
and large bowel obstruction.
In young or middle aged adults small bowel
obstruction is more common (adhesions,
strangulated hernia Crohn's disease) while
large bowel obstruction is more common in
older people (carcinoma of colon, volvirfus,
sigmoid diverticular disease).
COMMON CAUSES OF INTESTINAL
OBSTRUCTION IN ADULTS
Small bowel obstruction
Adhesions
Obstruction occurs months or years after an
abdominal operation, comes on abruptly with
colic, constipation and distension, in that
order. Constant pain, worse colic, local
tenderness and tachycardia suggest associated
strangulation (obstruction of blood supply)
and may precede evidence of intestinal
obstruction. Bowel sounds are increased, the
abdomen is distended and resonant and there
is a succussion splash. X-ray shows distended
gas filled loop? of bowel in the centre of the
abdomen with fluid levels on the erect film.
The stomach is emptied via a nasogastric
tube, fluids are replaced intravenously and
operation is carried out to divide adhesions. If
the viability of the bowel is doubtful in cases
of strangulation resects.
Strangulated hernia
Femoral hernia is uncommon (5% of hernias)
but comprises 50% of strangulated hernias.
Strangulated hernias account for less than
50% and adhesions for more than 50% of all
small bowel obstructions. A strangulated
hernia is tense, irreducible and has no cough
impulse. Do not attempt taxis, operate at
once:
106
open the sac first, divide the narrow orifice
and then the narrow neck of the sac, deliver
the bowel, resects non-viable bowel, remove
the sac and repair the orifice.
Crohn's disease
There is usually a long history of anaemia,
loss of weight and diarrhoea (the cardinal
symptom of incomplete small bowel
obstruction). Examination may reveal anal
lesions, scars of previous operations or a
tender abdominal mass. The cause of
obstruction may be a single narrow segment,
an abscess with extramural pressure or matted
loops of small bowel with multiple small
fistulae. Resection of the obstructing segment
is usually required but in some short lesions
stricture-plasty is feasible, making a
longitudinal anti-mesenteric incision and
closing it transversely.
Large bowel obstruction
Carcinoma of colon
Obstruction is most often due to a short non-
palpable carcinomatous stricture of the colon,
usually in the sigmoid, but may be due to
intussusception of a cancer. Usually there is
slow onset of complete obstruction beginning
with constipation followed by distension.
Colic and vomiting
X-ray shows wide peripheral fluid levels on
the erect film and supine film shows gas-
distended colon down to the site of the
obstruction. Rectal examination,
sigmoidoscopy and limited barium enema will
confirm the site of the lesion. If obstruction is
incomplete (still passing flatus) it might be
possible to empty the bowel and perform
elective surgery. If there is absolute
constipation (no flatus) the standard treatment
is right transverse colostomy, followed by
resection, later by closure of the colostomy. If
the patient is fit, immediate resection may be
performed. After immediate resection of the
left colon the prox-imal end is usually brought
out as a temporary colostomy and the distal
end brought out as a mucous fistula or closed.
Some surgeons perform immediate
anastomosis after on-table bowel wash-out via
a catheter inserted into the ileum. After
immediate resection of the right colon,
immediate anastomosis is safe if the small
bowel is not grossly distended.
Volvulus
Most common in the sigmoid, it presents with
sudden abdominal distension, pain and a huge
sigmoid loop on the right on X-ray of the
abdomen. Obstruction is relieved by passage
of flatus tube via sigmoidoscope and elective
sigmoid colectomy is carried out later. Local
tenderness, passage of blood per rectum or
failure of relief by passage of flatus tube
suggest ischaemia, requiring immediate
laparotomy and Hart-mann resection (closing
the distal end and bringing the proximal end
out as a terminal colostomy).
In caecal volvulus, the distended caecum lies
transversely in the mid-abdomen. Abdominal
X-ray shows the dilated caecum ('head') on
the left and the dilated ascending colon
('body') on the right, a typical 'foetal' sign.
The volvulus is untwisted at operation and the
entire right colon fixed behind a long flap of
right paracolic peritoneum.
Sigmoid divertirylar disease
Obstruction (rarely complete) may be due to
muscular hypertrophy of the lower sigmoid or
to stricture following previous abscess.
Complete obstruction requires transverse
colostomy and later resection, or Hartmann
resection with colorectal anastomosis months
later.
Less common causes of intestinal
obstruction in adults
Mesenteric ischaemia
This may be occlusive due to embolus or
atheromatous obstruction, or non-occlusive. If
there is rectal bleeding or shock in a patient
with intestinal obstruction (vomiting, pain,
distension) perform technetium-labelled red
cell scan which will show an avascular
intestinal area and probably mesenteric artery
obstruction. Embolectomy may be possible,
otherwise resection. Survival requires a
107
minimum of 20 cm of jejunum beyond the
flexure. If no occlusion is shown on scan,
selective superior mesenteric angiography,
showing a 'winter-tree' picture with poor
filling of all branches but no obstruction,
confirms a diagnosis of non-occlusive
ischaemia, in which heparinization should be
tried first.
Gallstone ileus
In an elderly patient with intermittent bowel
obstruction and increasing distension the
diagnosis will be made by seeing gas in the
biliary tree on X-ray. The stone should be
removed at laparotomy. If the stone is faceted,
look for another stone higher up in the small
bowel.
Lymphoma
Ileocaecal lymphoma commonly presents as a
mass in the right iliac fossa with small bowel
obstruction and may require right
hemicolectomy followed by chemotherapy.
Primary small bowel tumours
Leiomyoma and submucous lipoma may
cause ileal intussusception. Adenocarcinoma
is rare, leiomyo-sarcoma is a little less so.
Carcinoid tumours of the terminal ileum may
present with obstruction or with the
carcinoidsyndrome due to liver metastases
producing serotonin which causes diarrhoea,
hypertension and flushing, relieved by
Somatostdtin.
Benign colon lesions
Stricture in ulcerative colitis is less common
than in Crohn's colitis. Either may ciuse
obstruction. Adenomas may intussuscept.
Ischaemic colitis is sometimes fcl^vved by
stricture.
Intraluminal causes of obstruction
Cellulose or lignin in vegetable or cereal
(phytobezoar) may obstruct the stomach.
Food bolus obstruction of the terminal ileum
occasionally follows abolition or bypass of
the pylorus.
Colonic pseudo-obstruction
Large bowel 'obstruction', even caecal
perforation, may be due to retroperitoneal
malignancy (Ogilvie's syndrome) or Tintinalli, Judith E. Emergency Medicine:A
haematoma, spinal injury or multiple organ Comprehensive Study Guide (Emergency Medicine
(Tintinalli)). New York: McGraw-Hill
failure. Colonoscopic decompression, Companies.2010
Cisapride (a cholinergic drug) or epidural Helena Britt; Fahridin, S. Presentations of nausea and
analgesia (causing sympathetic blockade) vomiting. Aust Fam Physician , 2007; 36 (9): 673–
may save life. 784

FURTHER READING Note: Most of the Matters are drived from Internet and
Research Papers
Nicolette Heaton-Harris. Living with Emetophobia:
Coping with Extreme Fear of Vomiting. Jessica
Kingsley Publisher, London, UK. April 2007.

108
HAEMATEMESIS AND MELAENA
Haematemesis and Melaena
Definition: Hematemesis or haematemesis is
the vomiting of blood. The source is generally
the upper gastrointestinal tract.
Patients can easily confuse
with hemoptysis (coughing up blood),
although the latter is more common.
Haematemesis with or without melaena
Haematemesis is vomiting of fresh blood or
altered blood ('coffee grounds'). Melaena is
passage of black stools (altered blood).
Following a bout of vomiting
Vomiting may cause cardio-oesophageal
mucosal laceration {Mallory-Weiss
syndrome). After endo-scopic diagnosis, the
tear may be under-run via a high gastrotomy.
it De novo
In alcoholics
Varices: If the patient has cirrhosis, bleeding
may be due to oesophageal varices (10% of
severe upper gastrointestinal bleeds). One-
third of those admitted with varices die during
the first admission, one-third during the next
admission for bleeding and the remainder
during the third admission. The Sengstaken-
Blakemore bag, passed orally and blown up in
the fundus of the stomach and lower
oesophagus, demonstrates that bleeding is due
to varices by stopping it, but cannot be
sustained for more than six hours for fear of
causing oesophageal necrosis. The tube
should have a third lumen open above the
oesophageal balloon to prevent pharyngeal
aspiration. It is important to maintain pressure
in the oesophageal and gastric balloons to
avoid the tube being pulled up and causing
asphyxiation. Intravenous Pitressin constricts
gut arterioles, reducing gastrointestinal blood
flow and portal venous return. It may stop
variceal haemorrhage, bleeding from
extensive gastritis, or from superficial
erosions. Endoscopic injection of varices with
sclero-sants often stops bleeding. Surgical
interruption of vessels in the lower
oesophagus may be performed with an end-
to-end circular stapler introduced via a
gastrotomy. Mortality after emergency porta-
caval or mesenterico-caval shunt is 50%.
Gastritis: Early in alcoholism, a drinking
bout may be followed by acute erosive
gastritis with one or more superficial erosions
in the stomach and/or duodenum. In non-
alcoholics, such erosions might be due to
Aspirin or other non-steroidal anti-
inflammatory drugs. These erosions account
for 20% of severe haemorrhages. Most settle
with H2-receptor antagonists or Pitressin. 5%
109
require emergency surgery. Those who
require emergency operation are often ill with
multiple erosions and mortality rate is high
(5% or more) in non-alcoholics
Reflux: A history of reflux-type dyspepsia
(flatulence, substen.al heartburn, acid postural
regurgitation) suggests that reflux
oesophagitis has caused frank bleeding (less
than 5% of severe haemorrhages). It more
commonly causes anaemia. If suspected in
patients requiring emergency operation, pre-
operative endoscopy must be carried out.
Neoplasm: Atypical dyspepsia may raise the
question of gastric neoplasm (carcinoma,
polyps, leiomyosarcoma, lymphoma). They
cause only 2% of severe haemorrhages. All
are treated by gastrectomy (if possible).
Gastric ulcer: A history of pain after meals
and weight loss is typical of chronic gastric
ulcer which accounts for 20% of severe upper
gastrointestinal haemorrhages. 20% of these
will require emergency gastrectomy, with a
mortality rate of 10% because the patients are
usually older and less fit. 20% will require
later elective gastrectomy because of repeated
bleeding, suspicion of carcinoma or failure of
medical treatment.
Incidence of complications of chronic peptic
ulcers has not diminished since the advent of
H2-receptor-ant-agonists. Given
intravenously, these drugs will, however, stop
acid secretion and allow ulcers to heal. Thus,
there is a place for non-surgical methods of
stopping bleeding from ulcers. If the bleeding
is from a large vessel, there is no alternative
to surgery. If not, it may be possible to stop
bleeding using gastroscopic laser or
diathermy or local injection of Pitressin or
other vasoconstrictor drugs, while treating the
ulcer medically.
Melaena alone
Definition:
In medicine, melena or melæna refers to the
black, "tarry" feces that are associated with
gastrointestinal hemorrhage. The black color
110
is caused by oxidation of the iron in
hemoglobin during its passage through the
ileum and colon.
Black stool
Chronic duodenal ulcer accounts for 40% of
severe upper gastrointestinal haemorrhages.
There may be haematemesis as well.
Treatment is by intravenous Cimetidine or
Ranitidine. Most stop bleeding after
admission. 10% require emergency operation
(gastro-duodenotomy) to find the bleeding
ulcer, under-run it with catgut sutures; closure
of wound at right angles to long axis as
Heineke-Mikulicz pyloroplasty; bilateral
truncal vagotomy). Mortality rate is 5%. 20%
will require elective operation either in this
admission or later because of repeated
haemorrhages, other complications
(perforation, stenosis) or failure of medical
treatment.
Red-black stool
In catastrophic upper gastrointestinal
bleeding, red or reddish blood may be passed
per rectum. Such patients are shocked. Red or
reddish-black bleeding in the absence of
shock is probably colonic (diverticular disease
or angiodysplasia if severe, neoplasm if not).
FURTHER READING
"Vomiting blood". Medical Encyclopedia. University
of Maryland Medical Center. 2011.
Armstrong, G. E. (George E.), b. 1854.
Hematemesis; Stomach; Duodenum; Hématémèse; E
stoma; Duodénum S.l. s.n. University of Alberta
Libraries,
Canada
Walker HK, Hall WD, Hurst JW, editors. Clinical
Methods: The History, Physical, and Laboratory
Examinations. 3rd edition. Butterworths;
Boston:1990.
Allan R, Dykes P. A study of the factors influencing
mortality rates from gastrointestinal
haemorrhage. QJ Med.1976;45:533–50.
Note: Most of the Matters are drived from Internet and
Research Papers
JAUNDICE
Jaundice
Definition: Jaundice (icterus; derived from
Greek word: icteric) is a yellowish
pigmentation of the skin,
the conjunctival membranes over the sclera
(whites of the eyes) and other mucous
membranes caused
Choluric
by hyperbilirubinemia (increased levels of
If there is bile in the urine, jaundice is
bilirubin in the blood). This
probably due to hepatitis if liver enlargement
hyperbilirubinemia subsequently causes
is smooth {infective hepatitis, if onset is slow
increased levels of bilirubin in
preceded by nausea and anorexia over several
the extracellular fluid. Concentration of
days; toxic hepatitis if onset is rapid). If liver
bilirubin in blood plasma is normally below
enlargement is irregular, the cause is cirrhosis
1.2 mg/dL (<25µmol/L). A concentration
if the patient is alcoholic or has a history of
higher than 2.5 mg/dL (>50µmol/L) leads to
hepatitis, especially if the liver is rather small;
jaundice. The term jaundice comes from the
there may be splenomegaly: Primary (?
French word jaune, meaning yellow.
autoimmune) biliary cirrhosis, due to gradual
Jaundice is often seen in liver disease such as
atrophy of the small bile ducts in the liver,
hepatitis or liver cancer. It may also
presents in the 40s and is the most common
indicate leptosirosis or obstruction of
indication for liver transplant; when the serum
the biliary tract, for example
bilirubin rises above 100, life expectancy is
by gallstones or pancreatic cancer, or less
less than two years. A large irregular liver is
commonly be congenital in origin
probably malignant. In a person with known
(e.g., biliary atresia).
cirrhosis it might be a hepatoma (identified by
Yellow discoloration of the skin, especially
MRI or CT scan). If the patient does not have
on the palms and the soles, but not of the
cirrhosis the most likely cause of a large
sclera and mucous membranes (i.e. oral
irregular liver is secondary carcinoma,
cavity) is due to carotenemia, a harmless
usually from gastrointestinal cancer; if no
condition important to differentiate from
gastrointestinal symptoms, lymphoma.
jaundice.
OBSTRUCTIVE
NON-OBSTRUCTIVE
In this type of jaundice there is no bile in the
In this type of jaundice there is bile in the
faeces.
faeces.
With colic (biliary)
Acholuric
Biliary colic is a bout of severe pain across
If there is no bile in the urine (acholuric), the
the upper abdomen and back, making the
jaundice is haemolytic. If episodes of jaundice
patient restless. If the patient has had a
date from birth, the patient has congenital
previous biliary operation, the cause is
haemolytic anaemia (sphero-cytosis or sickle
probably residual stone left in the bile duct
cell anaemia or thalassaemia). If onset was in
system. Endoscopic retrograde cholangio-
adult life, he has acquired haemolytic
pancreatography (ERCP) will identify the
anaemia, probably autoimmune.
stone, which may be removed by endoscopic
sphincterotomy. Bilary fistula as well as
jaundice means there was damage to the bile
duct. ERCP will show the stricture. It may be

111
necessary to perform percutaneous
transhepatic cholangiography (PTC) to show
the upper end and length of a long, narrow
stricture. Choledocho-jejunostomy is usually
required but some short strictures may be
excised with immediate re-anastomosis over a
long-term T-tube, the long limb of which is
brought out below the anastomosis.
If there has been no operation, the likely
cause (and the most common cause of
obstructive jaundice in adults) is gallstone.
Colicky pain, fever (due to cholangitis) and
jaundice are intermittent (Charcot's triad).
Ultrasound (first investigation in patients with
obstructive jaundice) shows gallstones in the
gallbladder and dilated extrahepatic ducts but
may not show the stone causing the jaundice
because of lack of fluid about it. After
treatment with intravenous antibiotics
(Ampicillin), elective cholecystectomy and
choledocholithotomy are performed. If
cholangitis has caused septicaemia
unresponsive to antibiotics, or if obstruction is
persistent and complete, ERCP should be
carried out to allow the duct to drain and
perhaps permit removal of the obstructing
stone, after endo-scopic sphincterotomy.
Cholongitic liver abscesses are usually
multiple and small and the organisms are
Gram negative, E. coli or Kicbsiella.
(systemic bacteraemia may also cause
multiple abscesses, usually due to
streptococci or staphylococci.) Large solitary
liver abscesses may be drained
percutaneously under CT control.
A stone impacted at the lower end of the
common bile duct may not be removable by
ERCP sphincterotomy; or by stone forceps or
Fogarty balloon catheter at choledochotomy.
Then perform duodenotomy and
ampulloplasty - operative sphincterotomy
with suture of cut edges of bile duct and
duodenum. Use flexible fibreoptic
choledochoscope or on-table T-tube
cholangiogram to make sure no stones are left
behind.
112
Ultrasound will also show hydatid cyst(s) of
the liver. Complicated hydatids communicate
with the bile passages. Pieces of cyst,
laminated membrane or daughter cysts may
obstruct the main duct, a rare cause of
jaundice. Obstructing material must be
removed at choledochotomy, the cyst of
origin must be removed and its adventitial
cavity drained.
No colic
Painful
Jaundice with acute severe right upper
abdominal pain is probably due to acute
cholecystitis, to acute pancreatitis if there is
acute severe upper abdominal and back pain.
Chronic pancreatitis occasionally causes
obstructive jaundice, which may be painless,
although there is often a history of recurrent
epigastric and back pain and alcoholism.
Painless
Patients presenting with painless obstructive
jaundice may have a history of anorexia and
loss of weight suggesting primary gastric
cancer or change of bowel habit and bleeding
suggesting primary bowel cancer. Either may
cause jaundice by producing malignant nodes
in the porta hepatis. Haemoccult test is
usually positive, as it may be in patients with
carcinoma of the bile duct or of the ampulla.
Both of the latter will be diagnosed by ERCP
and may often be successfully treated by
pancreatico-duodenectomy, since lymph node
and other metastases are likely to be late.
In carcinoma of the head of the pancreas
blood is absent from the faeces until late.
Jaundice is painless at first but later there may
be severe pain radiating to the back because
of extrapancreatic extension. Jaundice is
progressive and the gallbladder is palpable.
MRI or CT scan confirms the diagnosis.
Gastro-jejunostomy and cholecyst-
jejunostomy are usually performed. In young
people with small tumors pancreatico-duo-
denectomy may be worthwhile.
Ultrasound shows dilated extrahepatic ducts
in patients with carcinoma of the head of the
pancreas, bile duct or ampulla, or with
malignant nodes in the porta. In intra-hepatic
cholestasis, not merely is the gallbladder
impalpable, but extra-hepatic ducts are not
dilated on ultrasound.

FURTHER READING
C. A. Goresky, Murray M. Fisher, Jaundice. Canadian
Hepatic Foundation, Plenum Press, 1975
Neonatal Jaundice. NICE Clinical Guidelines, No. 98;
National Collaborating Centre for Women's and
Children's Health (UK). London: May 2010.
Silbernagl S, Despopoulos A. Color atlas of
physiology. 6 Edition. Thieme. 2009. p. 252.
Collier J, Longore M, Turmezei T, Mafi AR. Neonatal
jaundice. Oxford Handbook of Clinical Specialties.
Oxford University Press. 2010.
Pashankar, D; Schreiber, RA). "Jaundice in older
children and adolescents". Pediatrics in Review.
2001; 22 (7): 219–226.
Medicine: Prep Manual for Undergraduates, 3rd
Edition. Mathew K.G. 2010. pp. 296-297

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113
ABDOMINAL SWELLINGS
Abdominal swellings
Definition: A swollen abdomen is bigger
belly area than usual. Abdominal swelling, or
distention, is more often caused by overeating
than by a serious illness. This problem can be
caused by:
• Air swallowing (a nervous habit)
• Buildup of fluid in the abdomen (this
can be a sign of a serious medical
problem)
• Gas in the intestines from eating foods
that are high in fiber (such as fruits
and vegetables)
• Irritable bowel syndrome
• Lactose intolerance
• Ovarian cyst
• Partial bowel blockage
• Pregnancy
• Premenstrual syndrome (PMS)
• Uterine fibroids
• Weight gain
PAINFUL SWELLINGS
Strangulated hernias are considered in chapter
"Inguino-scrotalswelling", acute
inflammatory swellings (acute cholecystitis,
acute appendicitis with mass, acute
diverticulilis) and intraperitoneal abscesses
(appendix abscess, pancreatic abscess or
pseudocyst) are considered in chapter "Acute
abdominal pain".
114
Abdominal malignancies are painless unless
rapidly growing (e.g. liver metastases, kidney
carcinoma) or unless invading somatic
structures (e.g. carcinoma of caecum,
carcinoma of pancreas).
Bleeding into an organ e.g. hamartoma of
kidney, traumatic haematoma of spleen or
from an organ e.g. ruptured spleen with
perispleenic haematoma, ruptured abdominal
aortic aneurysm will produce a painful tender
swelling.
PAINLESS SWELLINGS
The organ can usually be identified by the site
of the swelling (gallbladder swellings are in
the right upper abdomen, aortic masses are
midline); shape (the spleen preserves its
notch, kidneys are reniform); depth
(retroperitoneal masses are usually resonant);
mobility (contact with the diaphragm causes
movement on inspiration, downwards and
inwards for liver, gallbladder and spleen,
downwards and outwards for kidneys).
The pathological nature of the swelling may
often be diagnosed by its size (a huge
stomach means benign, not malignant, pyloric
stenosis; a large mass in the sigmoid is likely
to be diverticulitis rather than carcinoma);
number (bilateral kidney swellings are
probably polycystic; splenomegaly with
hepatomegaly suggests cirrhosis rather than
carcinoma); shape (cysts are round);
sensitivity (neoplasms and chronically
distended viscera are usually non-tender);
surface (all benign tumors are smooth, all
malignant tumors are hard but may or may
not be irregular); fixation (chronic
inflammatory lesions are more likely to be
fixed than carcinomas); surroundings (look
for a carcinoma of the testis where there are
large para-aortic nodes).
COMMON PAINLESS “SURGICAL”
ABDOMINAL SWELLINGS
Liver
The most common cause of a hard enlarged
liver is metastatic carcinoma. Where MRI or
CT scan shows a solitary metastasis (5% of
all), resection is followed by a 25% five-year
survival.
In women taking the contraceptive pill a large
solitary neoplasm may be primary adenoma.
A hard painful nodule appearing in a cirrhotic
liver, especially in haemochromatosis, may be
a hepatocellular carcinoma (hepatoma). The
lesion is 100 times more common in hepatitis
B carriers. It kills 150 000 Chinese yearly and
is the world's most common malignancy. (The
fibrolamellar variety has no association with
cirrhosis, occurs in young adults and may be
successfully resected). Introhepatic
cholangiocarcinoma presents as a tumor with
jaundice. (Extrahepatic cholangio-carcinoma
is an adenocarcinoma of the bile duct,
sometimes found in patients with chronic
ulcerative colitis and best treated by resection,
with up to 30% five-year survival). Resection
of primary tumors in otherwise normal livers
is worthwhile.
Hydatid cyst of the liver appears as a hard
swelling on the anterior border of the right
lobe. A sharp tap may produce a “hydatid
thrill”. Ultrasound confirms their usually
solitary nature. Diagnosis is confirmed by
serum antibody tests. The adventitia should
then be incised, the contents of the adventitial
cavity aspirated and the cyst or cysts
removed. In patients with obstructive jaundice
hydatid material must be removed by
choledochotomy.
Gallbladder
A painless smooth gallbladder swelling is a
mucocele due to cystic duct obstruction by
stone without inflammation. A hard irregular
swelling may be a carcinoma. 90% of such
patients have gallstones and only half of them
have had symptoms before presenting with
their cancer.
Stomach
The only stomach cancer which can be felt is
carcinoma of the pyloric antrum, the most
common site; A palpable carcinoma may still
be resectable, but not if fixed.
115
In benign pyloric stenosis due to chronic
duodenal ulcer, no swelling can be felt at the
pylorus but the huge stomach is a cystic
swelling in the left side of the abdomen with a
succussion splash. With malignant
obstruction, the history is too short to produce
so large a swelling.
Pancreas
A pseudocyst is a fixed round swelling above
the umbilicus, sometimes tender, following an
attack of acute pancreatitis or blunt abdominal
trauma. Some will subside after percutaneous
aspiration under MRI or CT scan control.
Cysts which are growing larger and causing
pain or obstruction require cysto-gastrostomy
or cysto-duodenostomy, preferably when the
cyst is six weeks old, when it has a thick wall
which takes sutures well.
Most pancreatic tumors are impalpable.
Epigastric swelling in the case of carcinoma
of the pancreas is probably due to liver
metastases.
Small bowel and mesentery
Mesenteric cysts are developmental, may
grow large before causing bowel obstruction
and can be moved at right-angles to the
attachment of the mesentery.
Small bowel tumors are rare. Leiomyoma and
leiomyosarcoma are most common and may
be partly cystic that should be excised if
possible.
Colon
Benign tumors are often too soft to feel. Most
colon carcinomas are too small to feel except
carcinoma of the caecum which may grow
large before causing other symptoms. A hard
mass in the right iliac fossa may be a
lymphoma.
The most common chronic inflammatory
swellings of the bowel are Crohn's disesae on
the right and sigmoid diverticulitis on the left.
Neither may be tender.
Aorta
Aortic aneurysm is a midline cystic swelling,
above the umbilicus, with expansile pulsation
and asystolic bruit, showing calcification on
X-ray and confirmed by ultrasound. An
aneurysm more than 6cm in diameter is in
danger of rupture, usually posteriorly,
producing back pain. Elective replacement
with a knitted synthetic graft is recommended
for all with symptoms and in otherwise fit
asymptomatic patients for any aneurysm more
than 4cm in diameter. Mortality rate for
elective operation is 5% and for emergency
operation in cases of rupture, 50%.
Any irregular fixed mass above the umbilicus
may be due to para-aortic lymphadenopathy,
either primary lymphoma, or metastatic
cancer, especially in semin-oma of the testis.
Uterus and ovaries
The only ovarian lesions palpable in the
abdomen are ovarian cysts and cystadenomas.
Bilateral cysts are likely to be serous and
perhaps cystadenocarcinomas. A solid
component on ultrasound suggests
malignancy. Most hard swellings of the uterus
are fibromyomata. (Fibroids) often calcified
on X-ray. Bleeding or recent increase in size
raises the possibility of malignancy, requiring
hysterectomy.
Carcinoma of the body of the uterus is less
common than carcinoma of the cervix, occurs
in older women and has a poorer prognosis
after hysterectomy.
Remember pregnancy is the most common
cause of non-tender enlargement of the uterus.
Bladder
The most common cystic swelling of the
lower abdomen is a distended bladder. If non-
tender, this indicates chronic retention. Pelvic
tumors may obstruct the bladder and cause
retention but are more likely to obstruct the
ureters and cause hydronephrosis.
Most hard solid bladder neoplasms are at the
base and are non-palpable but may cause
116
retention. Tumors of the dome of the bladder
are usually papillary and soft.
Kidneys
A large ballottable non-tender unilateral
swelling is probably due to hydronephrosis,
confirmed by ultrasound. Most often due to
idiopathic pelviureteric obstruction, it may
require pyeloplasty (making a long
anastomosis between dilated pelvis and
ureter), especially if bilateral.
Ultrasound distinguishes a large smooth renal
carcinoma from hydronephrosis, polycystic
kidneys (bilateral) and solitary renal cyst. It
requires nephrectomy after diagnosis has been
confirmed by MRI or CT scan, which also
shows venous invasion and node metastases.
FURTHER READING
Choi YK, Johlin FC Jr, Summers RW, et al. Fructose
intolerance: an under-recognized problem. Am J
Gastroenterol 2003; 98:1348.
Larry Szarka, MD, Mayo Graduate School of
Medicine, Rochester, MN and Michael Levitt,
MD,. Belching, Bloating and Flatulence. American
College of Gastroenterology. 2013.
Ohge H, Furne JK, Springfield J, et al. Effectiveness of
devices purported to reduce flatus odor. Am J
Gastroenterol 2005; 100:397
Suarez FL, Furne JK, Springfield J, Levitt MD.
Bismuth subsalicylate markedly decreases hydrogen
sulfide release in the human colon. Gastroenterology
1998; 114:923.
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Research Papers
ABDOMINAL PAINS
Abdominal Pains
Definition: Abdominal pain (or stomach
ache) is pain that feel anywhere between
chest and groin. This is often referred to as
the stomach region or belly. It is a common
symptom associated with transient disorders
or serious disease. Diagnosing the cause of
abdominal pain can be difficult, because
many diseases can cause this symptom. Most
frequently the cause is benign and/or self-
limiting, but more serious causes may require
urgent intervention.
Acute abdominal pains
Colic pain
Intermittent pain makes the patient restless.
The pulse rate is unchanged.
COLIC IN ABDOMEN AND BACK
Unilateral
This is renal or ureteric colic usually due to a
stone in the ureter. Each pain lasts up to 20
minutes, begins in the loin and radiates to the
groin and is associated with microscopic
haematuria. Most stones are radio-opaque
(calcium oxalate) and small. Liberal fluids
and exercise will encourage most small stones
to pass. Large or impacted stones, particularly
with pelvic dilatation on IVP or impairment
of excretion, require removal. Stones at the
lower end of the ureter may be removed
cytoscopically using a basket.
Large stones in the renal pelvis, ureter or
bladder are now treated by shock wave
lithotripsy, but stone fragments may have to
be removed endoscopically.
117
Bilateral
Biliary colic may be due to a stone in the
common bile duct when it is followed within
12 hours by jaundice or more usually to a
stone in the cystic duct, when it is followed
by painless enlargement of the gall-bladder
(mucocele) or acute cholecystitis (see below).
Ultrasound confirms the diagnosis and
cholecystectomy is recommended - with
operative cholangiogram if the patient had
been jaundiced.
COLIC CONFINED TO THE ABDOMEN
Low colic
All intestinal colic is central or symmetrical.
Supra-pubic or lower abdominal colic
suggests an obstructing colon lesion if the
patient is constipated and distended. If he has
lost weight or has bled, the most likely cause
is carcinoma of the left colon. If the patient
has gained weight, diverticular disease may
be the cause. Colon colic is relieved by
passage of flatus or faeces. Sigmoidoscopy
and immediate gastrografin enema should
identify the lesion after plain X-ray has shown
distended colon with or without small bowel
distension. If the obstruction is low grade, the
bowel may be prepared with oral balanced
electrolyte solution and elective resection
performed. Complete obstruction requires
emergency operation.
Middle abdominal colic
Colic associated with small bowel obstruction
may be higher in the abdomen. The patient
soon vomits. Abdominal distension is central
(large bowel distension is peripheral). Most
small bowel obstruction is “acute” (complete)
and there is a succession splash. Abdominal
x-ray shows large central loops of small
bowel distended with gas and liquid,
producing fluid levels in the erect film.
Emergency laparotomy is required.
Crohn 's ileitis usually causes chronic small
bowel obstruction with colic and diarrhoea
but obstruction may be acute.
 uninflamed. These unnecessary operations
should be avoided by clinical observation of
doubtful cases and, in young women, by
laparoscopy.
Gradual onset of pain in the left iliac fossa is
usually due to acute diverticular disease (no
fever or leucocytosis) or acute diverticulitis
with or without pericolic or mesocolic
perforation (fever, leucocytosis). Immediate
INFLAMMATORY PAIN
technetium scan shows a “hot” area in the left
Pain which persists and grows worst is
iliac fossa, a specific test which rules out
aggravated by movement and relieved by rest.
acute inflammatory diverticulitis if negative
Tenderness is much more pronounced than in
(a “hot” area, however, may be due to
patients with colic.
carcinoma or pelvic inflammatory disease).
Slow onset
Operation is rarely required. Treat the patient
Upper abdominal
with Metronidawie, Cephalothin and
This may be due to an exacerbation of peptic
Gentamicin intravenously.
ulcer, but tenderness is then uncommon. The
Suprapubic pain on both sides in women is
commonest cause is acute cholecystitis with
usually due to acute salpingitis. The white
pronounced right upper abdominal tenderness
cell count is high and there may be a profuse
and muscle guarding preventing palpation of
vaginal discharge. Give appropriate
the distended gallbladder. A HIDA nuclear
antibiotics - Tetracyclines for Chlamydia.
scan (hydro-imido-acetic acid is excreted by
Gradual onset of unilateral lower abdominal
the liver but will not enter an inflamed
pain in women may be due to ectopic
gallbladder because there is always cystic
pregnancy. Whenever ectopic pregnancy is
duct obstruction) confirms the diagnosis when
suspected, perform urine, and serum P-HCG
one is not certain that gallstones seen on
(P-human choriongonadotrophin), ultrasound
ultrasound are the cause of the pain and fever.
(not always diagnostic) and laparoscopy.
Give intravenous antibiotics and perform
Sudden onset upper abdominal
early cholecyst-ectomy (within a few days) if
Sudden severe upper abdominal pain
symptoms settle, or emergency
becoming generalized is usually due to a
cholecystectomy if pain, fever and tenderness
perforated peptic ulcer, an anterior wall
increase, suggesting imminent perforation.
chronic duodenal ulcer in 90% of cases.
Lower abdominal
There is board-like abdominal rigidity and gas
Gradual onset of pain in the right iliac fossa,
under the diaphragm in 70% of chest x-rays.
particularly if it began in the middle, is
Immediate surgical closure of the perforation
usually due to acute appendicitis. Mesenteric
is required, usually with an omental patch. If
adenitis (? viral) in children causes similar
there is associated severe bleeding (rare), the
pain but no anorexia, nausea or vomiting. The
bleeding vessel must be under-run and a
appendix is small, so fever and tachycardia
vagotomy and drainage operation carried out.
are slight unless the appendix has perforated.
Definitive surgery is rarely justified because
In all cases there is right iliac fossa tenderness
30% of patients have no further symptoms
even where the tip of the appendix is high
after closure of the perforation and most have
(retrocaecal appendicitis) or low (pelvic
never had medical treatment.
appendicitis). Perform immediate
Perforated gastric ulcer is usually treated by
appendicectomy. In 10-30% of
Billroth-I gastrectomy, removing the distal
appendicectomies, the appendix is

118
two-thirds of the stomach, including the
perforated ulcer and joining the remnant to
the first part of the duodenum.
Sudden onset of severe upper abdominal
constant pain radiating to the back 's probably
due to acute pancreatitis, confirmed by
finding a serum amylase more than 1000
IU/1. Ultrasound may show gallstones or
pancreatic pseudocyst or abscess. In
alcoholics, there may be pancreatic
calcification on abdominal x-ray. Severe pain
must be relieved, for instance by epidural
analgesia, to prevent pulmonary collapse and
infection and perhaps adult respiratory
distress syndrome (ARDS). Epidural
Bupivacaine (Marcain) may improve
splanchnic blood flow and reduce pancreatic
ischaemia. Antibiotics are not helpful. Blood
volume must be maintained with blood,
electrolyte solution and colloid (albumin).
Abscesses may require drainage, sloughing of
the pancreas may require its piecemeal
removal and pseudocysts may have to be
drained into the stomach or duodenum (cysto-
gastrostomy or cysto-duodenostomy). Pro-
longed peritoneal irrigation via multiple tubes
helps desperate cases. The most feared
complication is intraperitoneal secondary
haemorrhage which is usually untreatable.
Lower abdominal
119
Sudden severe lower abdominal pain without
previous symptoms may be due to perforated
diverticular disease rather than to
appendicitis, in which the onset is less
sudden. Pain and tenderness may be worse on
the right or left or may be generalized. There
is often a lot of gas under the diaphragm.
Immediate Hartmann resection is the safest
procedure.
Sudden severe lower abdominal pain in
women, particularly if it radiates from the
sacral region, may be due to a twisted ovarian
cyst. It may be possible to feel such a cyst
abdominally or on pelvic examination, but, in
any case, it will be quickly identified by
ultrasound Oophorectomy, often with partial
salping-ectomy is required
SUDDEN SEVERE ABDOMINAL PAIN
AND SHOCK
This syndrome is often due to intraperitoneal
bleeding or strangulation, most often of the
intestine.
A young woman who has missed a menstrual
period and suddenly complains of lower
abdominal pain becoming generalized and felt
in the shoulder probably has a ruptured
ectopic pregnancy. On pelvic examination the
cervix feels soft. If the cervix is firm, such
severe bleeding may rarely be due to
ovulation (“Mittelschmerz”). At any rate,
operation is required to stop bleeding.
In ruptured aortic aneurysm, pain is usually
felt in the back at first but rapidly becomes
generalized. X-ray of the abdomen shows the
calcified aorta and the presence of the
aneurysm is confirmed by ultrasound. There
may be no time for these investigations.
Avoid further bleeding by minimal pre-
operative transfusion. Emergency aortic
aneurysm replacement with a graft is
necessary but carries a 50% mortality rate.
Intestinal ischaemia, particularly due to
mesenteric vascular occlusion, may cause
severe generalized pain and shock, as may
internal strangulation about a band. But pain
may be less severe than expected. Never-
theless, there will be tachycardia up to
160/mm, leucocytosis (up to 30000 white
cells/µl) perhaps passage of dark red blood
per rectum and possibly a vague tender mass
of ischaemic gut. In such cases there may be
no vomiting, constipation or distension - it
takes time for these features to develop and
there is no time to waste. Recent myocardial
infarct or atrial fibrillation raises the question
of embolus - embol-ectomy is sometimes
possible. If the patient is fit for it, immediate
selective superior mesenteric angiography
may show a major vessel obstruction. In
“non-occlusive” ischaemia all mesenteric
vessels will be small giving a “winter-tree”
appearance - in such cases treatment is
confined to heparinization. It may be possible
to relieve a major vessel obstruction but, if
not, resection of large amounts of gangrenous
small bowel might be necessary, when the
prognosis is poor.
Septic or bacteraemic shock may accompany
bowel gangrene, perforation or anastomotic
leakage. Toxins from anaerobic Gram-
negative or Gram-positive organisms open up
peripheral vascular shunts and cause severe
hypotension. Gram-negative septic shock now
causes more deaths than haemorrhage. Gram-
120
negative endotoxin targets macrophages,
releasing cytokines which in turn release
prostaglandins, nitric oxide, endothelin and
thromboxane causing widespread blood
damage (disseminated intravascular
coagulation, DIC) and widespread tissue
damage, ultimately resulting in multiple organ
failure.
INTRA-ABDOMINAL ABSCESSES
Abscesses may develop anywhere in the
abdomino-pelvic cavity after pancreatitis or
intraperitoneal perforations or anastomotic
leaks. They are best identified by CT scan and
more than 50% can be satisfactorily drained
percutaneously under CT control.
FURTHER READING
Boyle, J. T.; Hamel-Lambert, J. Biopsychosocial issues
in functional abdominal pain. Pediatr
Ann. 2001;30 (1): 32–40.
Richard F. LeBlond (in English). Diagnostics. US:
McGraw-Hill Companies, Inc. 2007.
Steven A. Edmundowicz. 20 Common Problems in
Gastro-enterology. McGraw-Hill. 2002.
Tytgat GN. Hyoscine butylbromide: a review of its use
in the treatment of abdominal cramping and
pain". Drugs. 2007; 67 (9): 1343–57.
Note: Most of the Matters are drived from Internet and
Research Papers
DIARRHOEA
Diarrhoea
Definition: Diarrhoea or diarrhea (Greek’s
word means “flowing through”) is the
condition of having three or more loose or
liquid bowel movements per day. It is a
common cause of death in developing
countries and the second most common cause “gipoma”).
of infant deaths worldwide. The loss
of fluids through diarrhea can cause Acute diarrhoea
dehydration and electrolyte disturbances such Acute infantile gastroenteritis is best treated
as potassium deficiency or other salt with oral rehydration solution (ORS), using
imbalances. the WHO solution (90mmol/l sodium, 20
Diarrhoea means frequent passing of liquid potassium, 80 chloride, 10 citrate and 2%
stools. In diarrhoea due to disease of the glucose). Remember that this treatment will
upper gastro-intestinal tract, the stools are not stop the diarrhoea. Children who vomit
large, watery or fatty, pale yellow or green in more than four times per hour, are too tired to
colour in colonic disease. Stools, though drink or have very high stool volumes
frequent, may be small, vary from liquid to requires intravenous fluid. In Australia most
semi-solid, may contain blood or exudates infantile diarrhoea is caused by rotavirus with
and are brown Diarrhoea may be due to: much lower stool electrolyte losses than in
More rapid transit (e.g. short bowel syndrome, cholera, so that the Australian solution
pyloric resection or bypass, irritable bowel contains only 60 mmol/l of sodium. The
syndrome, carcinoid tumours of small bowel viruses destroy enterocytes which are
or pancreas - serotonin is a smooth muscle replaced by undifferentiated cells, resistant to
stimulant). the virus but incapable of digestion or
Mural disease (e.g. gastroenteritis, absorption.
diverticular disease, inflammatory bowel
disease, bowel neoplasms):
Malabsorption of carbohydrate (e.g. lactose
deficiency, coeliac disease) causes osmotic
diarrhoea; or of fat (e.g. pancreatic
insufficiency) causes secretory diarrhoea.
Mucosal secretagogues (e.g. cholera exotoxin,
unabsorbed bile acids causing colonic hyper-
secretion after excessive terminal ileal resec-
tion, polypeptide-secreting pancreatic islet
cell tumors - vasoactive intestinal peptides by
“vipoma” and gastric inhibitory peptides by

Many bacteria cause mild brief episodes of

enteritis, usually not requiring antibiotics.
Severe Shigella dysentery should be treated
with Ampicillin or Norfloxacin. Salmonella

121
dysentery in old or immuno-suppressed
people requires Chloramphenicol. This is also
the treatment of typhoid and paratyphoid
fever. Cholera is treated with Tetracycline.
Give Erythromycin to abolish the carrier state
in those with Campylobacter (Helicobacter)
jejuni enteritis who handle food.
Giardia lamblia protozoal infestation causes
prolonged diarrhoea, should be identified in
the faeces and responds to Metronidawle. In
amoebic dysentery, deep ulcers are seen at
sigmoidoscopy. Motile Entamoeba histolytica
organisms are seen in fresh faeces. This
disease is usually quickly cured by
Metronidawie, but perforation may be fatal
and chronic cases may imitate carcinoma by
producing a filling defect (amoeboma) on
barium enema x-ray. Amoebic liver abscesses
respond to Metronidazole and rarely require
drainage.
Ischaemic colitis causes sharp abdominal pain
in an elderly patient with bleeding and
passage of mucus or diarrhoea. Submucosal
oedema causes “thumb-printing” on barium
enema. Most episodes resolve but may be
followed by stricture.
Pseudomembranous colitis is due to
Clostridium difficile and causes profuse
diarrhoea due to necrosis of the superficial
mucosa which becomes a white adherent
membrane. It is cured by Metronidazole.
122
Chronic diarrhoea
Those causes of chronic diarrhoea most likely
to require surgery are:
Ulcerative colitis
Ulcerative colitis is a non-microbial
inflammation, usually confined to mucosa and
submucosa, but in acute severe colitis (5% of
colitis patients) inflammation is transmural
with dilatation of the transverse and sigmoid
colon (“toxic megacolon”) and even perfora-
tion. 5% (only those with total colitis)
develop carcinomas, often multiple and
atypical. Ulcerative colitis begins in the
rectum and is continuous proximally.
Crohn's disease
Crohn's disease is a chronic necrotizing
granulomatous transmural inflammation
producing deep fissures, fistulae, abscesses
and strictures. It is discontinuous, with “skip
areas” of disease and intervening normal gut.
Half the patients have ileocolic disease, one-
quarter have disease confined to the small
bowel and one-quarter have disease only in
the colon. Anal lesions (multiple soft fissures,
fistulae and abscesses) are found in half the
patients and may precede intestinal disease.
Common and contrasting features in both
ulcerative colitis and Crohn's disease the
lumen is narrowed and ulcerated. Specific x-
ray features of Crohn's disease include
“cobblestoning” (oedematous mucosa
between fissures) and deep fissuring with
barium outside the lumen, fistula formation.
Extracolic manifestations (cholongitis and
cirrhosis, iridocyclitis, pyoderma
gangrenosum, arthralgia, rheumatoid-type
arthritis affecting larger joints - sero-
negative) are found in both. Acute severe
episodes are more common in ulcerative
colitis - half of those with total disease
present with acute severe colitis.
Sulphasalazine (Salawpyrin) reduces the
number of exacerbations, for which steroids
are required.
Ulcerative colitis is cured by total
proctocolectomy, whereas recurrence rate
after resection for Crohn's disease is more
than 50%. Emergency surgery is required for
toxic megacolon, severe bleeding and acute
intestinal obstruction.
Elective surgery is required in ulcerative
colitis for intractable symptoms, severe
extracolic manifestations, carcinoma, or
suspicion of carcinoma (dysplasia on biopsy
in longstanding - more than eight years - total
disease). Elective surgery is required in
Crohn's disease for fistulae (usually
enteroenteric, sometimes ileosigmoid),
stricture with obstruction or chronic abscess
with recurrent septicaemia. Sometimes it is
possible to perform “stricture-plasty” because
the antimesenteric border of the strictured
ileum may not be diseased, making a
longitudinal incision, closed transversely.
In young people requiring bowel resection for
ulcerative colitis it is often possible to
preserve the anal canal and join it to an ileal
reservoir making a “new rectum”. 30% suffer
recurrent “pouchitis”, cured by
Metronidazole.
Diverticular disease
Diarrhoea (often alternating with
constipation) is a common symptom of left-
sided diverticular disease with muscle spasm
and thickening and narrow-necked sigmoid
diverticula. Exacerbation of muscle spasm
can cause acute diverticular disease with pain
and tenderness in the left iliac fossa but no
fever or leucocytosis. Localized or mesocolic
perforation may cause acute diverticulitis -
pain, fever, leucocytosis - localized and
responding to antibiotics. Free perforation of
a diverticulum causes general peritonitis and
requires emergency Hartmann resection -
sigmoid colectomy without anastomosis,
closing the rectal stump and bringing the
123
proximal sigmoid end out in the left iliac
fossa as a temporary terminal colostomy.
A localized pericolic abscess may point into
the vagina producing a colovaginal fistula or,
more often, into the bladder, causing a
cohvesicalfistula, with the striking symptom
of pneumaturia - bubbles of air in the urine.
Cystoscopy identifies the fistula (on the
postero-superior bladder wall) in more than
half and barium enema in less than half the
cases. Perform sigmoid colectomy and close
the hole in the bladder. If the abscess is still
there, do a Hartmann resection. As a result of
one or repeated episodes of localized
perforation, a stricture may develop, longer
than seen in sigmoid carcinoma, but
colonoscopy may be required to be sure of the
diagnosis. Such cases may present with
chronic or acute bowel obstruction.
Common symptoms of chronic bowel
obstruction, whether the cause is carcinoma,
Crohn's colitis or diverticular stricture, are
alternating constipation and diarrhoea.
AIDS DIARRHOEA
In immunosuppressed AIDS patients (CD4
lymphocyte level less than 350),
cytomegalovirus (CMV) causes an ulcerating
colitis with bloody diarrhoea and toxic
megacolon, often requiring emergency
colectomy with permanent ileostomy
FURTHER READING
Ranjit N. Ratnaike. Diarrhoea and Constipation in
geriatric practice. Cambridge University Press, UK.
1999.
The Management and prevention of diarrhoea:
practical guidelines. World Health Organization –
1993.
Michael A. Kamm. Constipation. Wrightson
Biomedical Publication. 1994
Michael A. Kamm. Gastrointestinal Transit: Patho-
physiology and Pharmacology. Taylor & Francis
Group, 1991.
Rome II: Douglas A. Drossman. The Functional
Gastrointestinal Disorders : Diagnosis,
Pathophysiology, and Treatment : a Multinational
Consensus. Degnon Associates, 2000.
William E. Whitehead, Marvin Meier Schuster.
Gastro-intestinal disorders: behavioral and
physiological basis for treatment. Academic Press.
1985

Note: Most of the Matters are drived from Internet and

Research Papers

124
RECTAL BLEEDING
Rectal bleeding
Definition: Rectal bleeding can refer to any
blood that passes from anus, although rectal
bleeding is usually assumed to refer to
bleeding from lower colon or rectum. Rectum
makes up the last few inches of large
intestine.
Rectal bleeding may show up as blood in
stool, on the toilet paper or in the toilet bowl.
Blood that results from rectal bleeding can
range in color from bright red to dark maroon
to a dark, tarry color.
Rectal bleeding may occur for many reasons,
including constipation and hemorrhoids.
Even if there is an anal lesion, proximal
bleeding must be excluded in all cases by
sigmoidoscopy and by colonoscopy if there
are any bowel symptoms (or no anal cause).
It is usually small non-prolapsing
haemorrhoids which bleed. If a high fiber diet
does not stop it, rubber band ligation or
sclerosant injection will stop it. Large
prolapsing or thrombosed haemorrhoids
require haemorrhoidectomy.
Bright bleeding may be the first or only
symptom of polyps (tubular or villous
adenomas). They are removed via
sigmoidoscope if in the rectum. Those who
had rectal polyps require colonoscopy to
exclude others in the colon. Most cancers
begin as polyps, which take several years to
become malignant, so colonoscopy is
repeated at intervals of one year or more.
Painful defaecation with bleeding is most
often due to an anal fissure, a vertical midline
posterior or anterior mucosal tear extending
125
from the anal valves to the anal margin.
Fissures may heal on a high fibre diet.
Adequate rectal filling provokes the rectoanal
reflex, allowing internal sphincter relaxation.
If the fissure persists, the lower half of the
internal anal sphincter on one side is divided
(lateral subcutaneous internal
sphincterotomy). Anal stretch is an
alternative, but causes more (usually brief and
partial) incontinence.
Painful passage of mucus mixed with blood is
usually due to non-specific proctitis. In the
lower-third of the rectum, a particular kind
(solitary rectal ulcer syndrome) shows
nodules or ulcers with characteristic
disruption of the muscularis mucosae on
biopsy and may be cured by operation for
(occult) rectal prolapse.
Associated change of bowel habit
(constipation, diarrhoea) suggests a diagnosis
of carcinoma of the rectum or left colon.
Bleeding from right colon cancer is often
occult, presenting as anaemia. A few small
mobile rectal cancers less than 2 cm in
diameter are curable by local excision or by
other local methods (radiation, laser). Most
require resection that is the removal of a
segment of bowel. A bowel resection is
required often after polypectomy for
malignant polyp if the carcinoma extended
through the muscularis mucosae.
Extensive bowel resection for cancer or
extensive lymphadenectomy does not
improve the prognosis. Bowel cancer does not
spread much longitudinally but it is the
custom to perform right hemicolectomy for
carcinoma of the right colon, transverse
colectomy or extended right hemicolectomy
for carcinoma of the transverse colon and left
hemicolectomy for carcinoma of the
descending or proximal sigmoid colon,
because anastomosis between mobile parts of
the gut is easier and perhaps safer because of
the complete serous coat.
Carcinomas of the distal sigmoid, upper
rectum (12 to 16cm from the anus) and mid-
rectum (8 to 12 cm from the anus) are
removed by anterior resection via a lower
abdominal incision, joining proximal sigmoid
to mid or lower rectum by hand suture or
using a circular stapler. A few small
carcinomas in the lower rectum (4 to 8cm
from the anus) are treatable by resection with
colo-anal anastomosis carried out per anum,
in all cases “covered” by a proximal
colostomy.
A resection margin of 3 cm is adequate for
rectal cancer. Local “recurrence” occurs in
15% of cases and is usually outside the
rectum. It may be avoided by careful removal
of the mesorectum. Pre-operative
radiotherapy, given where rectal ultrasound
probe has shown spread through the wall, also
reduces local recurrence as does abdomino-
iliac lymphadenectomy but neither measure
improves long-term prognosis. Besides,
irradiation may damage bladder and small
bowel and radical dissection, dividing the S2
and S3 parasympathetics in the pelvic nerves,
may cause impotence in males.
126
Low rectal cancers, less than 6 cm from the
anal margin, require an abdomino-perineal
resection, removing rectum and anal canal
and constructing a permanent left iliac
(sigmoid) terminal colostomy. An alternative
in the elderly and unfit is Hartmann resection,
simply closing the anorectal stump after
abdominal resection.
After bowel resection for adenocarcinoma,
patients are followed up at shorter and then
longer intervals by clinical examination and
carcino-embryonic antigen (CEA) estimation
to identify metastases or local recurrences.
The latter are more common after rectal than
colon cancer operations. 5% of local
recurrences and metastases are curable by
further surgery (e.g. partial hepatectomy), or
palliated by cryosurgery. Patients are also
followed up by colonoscopy every year or so
to identify new (metachronous) tumors. 90%
of patients whose carcinomas did not extent
through the bowel wall (Dukes' stage A)
survive five years or more; 70% where the
cancer has extended through the bowel wall
(stage B); 35% where nodes are involved
(stage C); 5% of those who had liver
metastases; none of those with peritoneal or
pulmonary metastases.
Bleeding from a hard irregular anal swelling
may be due to anal carcinoma, either
squamous or basaloid. Primary treatment with
combined chemotherapy and radiotherapy
may be sufficient but, if the carcinoma
persists, local excision will be necessary or
abdomino-perineal resection.
Diarrhoea with bleeding in young people is
usually due to inflammatory bowel disease.
Bleeding is commoner in ulcerative colitis
than in Crohn's disease. Familial multiple
polyposis, familial adenomatous polyposis) is
an uncommon cause of bloody diarrhoea in
the second decade, FAP is due to inactivation
of a tumor suppressor gene on the long arm of
chromosome 5. It is instantly recognizable by
the large number of polyps in the rectum.
Proctocolectomy prevents otherwise certain
bowel cancer, but upper gastrointestinal Marvin L. Corman. Colon And Rectal Surgery.
tumors may appear later, e.g. peri-ampullary Lippincott Williams & Wilkins. 2005.
David E. Beck. Handbook of Colorectal Surgery. CRC
carcinoma in 12% of patients. Press, May 2003.
Sudden abdominal pain and bleeding in older
people may be due to occlusion of an inferior Note: Most of the Matters are drived from Internet and
mesenteric artery branch, causing ischaemic Research Papers
colitis. “Thumb-printing” filling defects on
barium enema at the spleenic flexure or in the
sigmoid colon are due to submucosal oedema.
Most patients quickly recover, but some
develop a stricture.
SEVERE COLORECTAL BLEEDING
Severe bleeding is rarely due to
haemorrhoids, polyps or cancer. It is most
often due to total diverticular disease (many
wide-necked diverticula) or to angio-
dysplasia (5mm collections of dilated mucosal
capillaries and thick-walled submucosal
veins). Patients are elderly and have no other
bowel symptoms. Those with angiodysplasia
may have aortic stenosis.
The site is identified by technetium-labelled
red cell scan. The patient is transfused.
Bleeding usually stops, and allowing
definitive diagnosis of the cause (not merely
the site) by endoscopy.
Massive, persistent or recurrent severe
bleeding will require emergency partial
colectomy where the site has been identified
by scan and total colectomy and ileorectal
anastomosis if the site is uncertain.

FURTHER READING
Anthony J. DiMarino, Stanley B. Benjami.
Gastrointestinal Disease: An Endoscopic Approach.
SLACK Incorporated. 2002.
Roger Jones. Oxford Textbook of Primary Medical
Care: Clinical management. Volume 2. Oxford
University Press. 2005.
Joe Tjandra, Gordon J. A. Clunie, Andrew H. Kaye,
Julian Smith. Textbook of Surgery. Blackwell
Publishing. 2006.

127
CONSTIPATION
Constipation preliminary colostomy and join the colon to
Definition: Constipation is infrequent anal canal by a “pull through” method.
defaecation and is also known
as costiveness or dyschezia. Usually refers
to bowel movements that are infrequent or
hard to pass. Constipation is a common cause
of painful defecation. Severe constipation
includes obstipation (failure to pass stools or
gas) and fecal impaction, which can progress
to bowel obstruction and become life-
threatening.
Constipation is a symptom with many causes.
These causes are of two types: obstructed
defecation and colonic slow transit (or hypo-
mobility). About 50% of patients evaluated
for constipation at tertiary referral hospitals
have obstructed defecation. This type of
constipation has mechanical and functional
causes. Causes of colonic slow transit
constipation include diet, hormonal Rectum dilated
disorders such as hypo-thyroidism, side If constipation dates from infancy but the
effects of medications, and rarely heavy rectum itself is dilated, the diagnosis is
metal toxicity. Because constipation is a probably acquired megacolon but lower
symptom, not a disease, effective treatment of segment Hirschsprung's disease must be
constipation may require first determining the excluded. Patients also have pseudo-diarrhoea
cause. Treatments include changes in dietary and may present with sigmoid volvulus. The
habits, laxatives, enemas, biofeedback, and in atonia in this idiopathic acquired megacolon
particular situations surgery may be required. may extend to involve the small bowel. Most
respond to high bulk diet, bulk agents, bowel
LONG HISTORY stimulants and repeated enemas but some
From infancy require total colectomy and ileo-rectal
Rectum “normal” anastomosis, not always successful because of
Constipation from infancy may be due to possible small bowel atonia (see above).
Hirsch-sprung's disease if the rectum is From childhood or adulthood
normal or narrow, there is abdominal Slow transit
distension and abdominal x-ray shows a If the rectum and colon are dilated the
distended colon full of faeces down to the diagnosis is probably idiopathic acquired
rectum. Diagnosis is confirmed by full megacolon (see above). If neither is dilated,
thickness biopsy which shows absence of the patient is suffering from chronic
ganglion cells or by demonstration of an constipation. The colon is often long
absent rectoanal reflex by anal manometry -if (aolichocolon), perhaps absorbing more water
a rectal balloon is inflated, the anal sphincters from the faeces and making stools harder.
do not relax. Resect the narrow segment after Diagnosis is confirmed with ingested radio-

128
opaque markers, with x-rays daily for three
days. If the markers fail to move, the patient
has colonic constipation. The bowel is not
atonic and will usually respond to bulk
agents. Colectomy is a last resort.
Slow evacuation
In “rectal constipation” transit time is normal
as far as the rectum, which fails to empty.
This is sometimes called “outlet syndrome” or
“puborectalis syndrome” or “levator ani
syndrome” or “anismus” and may be due to
failure of pelvic floor relaxation during
defaecation or to paradoxical pubo-rectalis
contraction. Suppositories and disposable
enemas may be effective but persistent
puborectalis contraction may require its
dilatation or even partial division.
RECENT HISTORY
No loss of weight or bleeding
Diverticular disease is likely to be the cause,
confirmed by barium enema x-ray, showing
diverticula in the sigmoid colon with necks
narrowed by muscle thickening and/or
peridiverticular scarring following previous
occult perforation. There is often diarrhoea as
well -alternating constipation and diarrhoea
are well known symptoms of incomplete
colon obstruction. Diverticular disease usually
responds to a high fiber diet. More severe
obstructive symptoms with colic may be due
to stricture following previous pericolic or
mesocolic abscess or merely to sigmoid
129
muscle “contracture”. Such cases sometimes
require sigmoid resection.
Weight loss
With overt or occult bleeding, the likely cause
of such constipation is carcinoma of the left
colon. Diagnosis is by barium enema showing
an “apple core” narrowing of the colon or by
colonoscopy, especially required to
distinguish carcinoma from associated severe
diverticular disease with spasm. Elective
partial colectomy or anterior resection is
performed, depending on the site.
Constipation with weight loss and without
bleeding may be due to extrinsic malignancy
such as lymphoma, or carcinoma of the ovary,
compressing or invading the gut. Extrinsic
compression may be obvious on barium
enema and colonoscopy but in any case
laparotomy will be required and perhaps
palliative bowel resection or proximal
colostomy.
FURTHER READING
Ranjit N. Ratnaike. Diarrhoea and Constipation in
geriatric practice. Cambridge University Press, UK.
1999.
The Management and prevention of diarrhoea:
practical guidelines. World Health Organization –
1993.
Michael A. Kamm. Constipation. Wrightson
Biomedical Publication. 1994
Michael A. Kamm. Gastrointestinal Transit: Patho-
physiology and Pharmacology. Taylor & Francis
Group, 1991.
Rome II: Douglas A. Drossman. The Functional
Gastrointestinal Disorders : Diagnosis,
Pathophysiology, and Treatment : a Multinational
Consensus. Degnon Associates, 2000.
William E. Whitehead, Marvin Meier Schuster.
Gastro-intestinal disorders: behavioral and
physiological basis for treatment. Academic Press.
1985
Note: Most of the Matters are drived from Internet and
Research Papers
ANAL PAINS AND DISCHARGE
Anal pains and discharge
Definition: Pain in anus due to inflammation
in anus. Rectal discharge (anal discharge, anal
drainage or anal leakage) is a medical
symptom that can be defined as intermittent
or continuous expression of liquid from the
anus (per rectum). This topic is closely related
to types of fecal incontinence (e.g. fecal
leakage) but the term rectal discharge does
not necessarily imply degrees of incontinence.
Types of fecal incontinence that produce a
liquid leakage could be thought of as a type of
rectal discharge.
PAIN WITHOUT SWELLING
Acute severe anal pain without swelling is
usually due to an acute anal fissure, most
often in the posterior midline and so tender
that rectal examination is impossible. Such
fissures are tears of the anal mucosa due to
forceful defaecation, either with constipation
or diarrhoea. They may heal with a high
residue diet or may require anal dilatation or
sphincterotomy.
Chronic anal fissures are less painful. If there
are multiple fissures, suspect Crohn's disease.
130
PAINFUL SWELLING
Perianal abscess presents as a hot red tender
swelling next to the anal margin and should
be incised and drained. Ischiorectal abscess
presents as a larger more diffuse tender dusky
red swelling in the buttock. Again, it should
be incised and drained.
In these cases there may already be an anal
fistula (see below) but such a fistula is usually
treated later. Fistula is also a sequel of
abscess. Most abscesses begin as infected anal
inter-muscular glands, between the sphincters.
Sometimes the inter-muscular abscess
presents with severe rectal pain before it has
tracked down to the anal margin as a perianal
abscess or through the external sphincter as an
ischiorectal abscess and can be felt on rectal
examination as a tender posterior midline
swelling (deep post-anal abscess). This
abscess may be incised into the anal canal,
incising mucosa and internal sphincter.
Perianal haematoma is .a blue tender
swelling at the anal margin, coming on after
straining at defaecation or some other effort
involving a Valsalva manoeuvre, causing
rupture or thrombosis of an external
haemorrhoidal vein. It may be incised and
evacuated under local anesthesia if pain is
severe.
Strangulated internal haemorrhoids cause a
circumferential swelling but if only one
haemorrhoid is strangulated, proctoscopy will
distinguish it from perianal haematoma. Half
are cured with rest and ice packs but most
surgeons recommend haemorrhoid-ectomy.
DISCHARGE (INVOLUNTARY ESCAPE
OF FLUID FROM OR NEAR ANUS)
Continent
The most common cause in younger people is
an anal fistula, a track leading from the anal
canal at about the level of the anal valves to
the perianal skin, usually a sequel of an
abscess (see above). The most common fistula
(intersphincteric) runs from the anal canal
through the internal sphincter, between the
internal and the external sphincters, to the
perianal skin near the anal margin. Such a
track running through external sphincter to
the buttock is a trans-sphincteric fistula.
These two comprise more than 75% of
fistulae and are treated by incision over a
probe passed along the track.
Uncommon fistulae include suprasphincteric,
running above the sphincters into the anal
canal; extra-sphincteric, running from the
buttock through levator ani into the rectum.
Partial healing of an anal fissure with
“bridging” may produce a short subcutaneous
anal fistula.
Recurrent abscesses and discharge in the
sacral region may be due to midline pilonidal
sinus. Suppuration may cause secondary
sinuses on the buttock. Lay abscesses open
and pack with antiseptic gauze. Primary
closure is often effective after elective
excision of the pilonidal sinus track(s). Make
the incision convex to one side (Bascom) so
as to avoid a midline scar. Pilonidal sinuses
are also found in digital clefts, at the
umbilicus and in the inguino-scrotal region.
Discharge is common in sexually transmitted
disease including anal warts (viral
condylomata acuminata), gonococcal ulcers
(yellow purulent discharge), Chlamydia
(small vesicles ulcerating and healing quickly,
treated with Tetracycline) and genital herpes
(several vesicles join to produce round painful
131
ulcers with red margins, no treatment).
Suspect acquired immunodeficiency syndrome
(AIDS) due to human immunodeficiency virus
(HIV) in all cases of sexually transmitted
disease (STD).
Non-specific proctitis, Crohn's perianal
disease (multiple soft fissures and fistulae)
and solitary rectal ulcer syndrome may cause
anal discharge with or without blood.
Squamous cell carcinomas of the anal margin
and basaloid carcinomas of the anal canal
cause discharge with or without pain or
bleeding.
Incontinent
Minor anal incontinence associated with
internal sphincter weakness - the anus is
partly open or easily opened by gentle finger
pressure on the perianal skin - causes mucous
discharge, usually in older people. More
severe rectal incontinence with faecal soiling
and “accidents” in which a whole stool is
passed without the patient being aware of it, is
usually due to levator ani and particularly
puborectalis weakness, again most common
in older people. Such incontinence might
respond to low residue diet with external
sphincter “squeeze” and levator ani “lift”
exercises, or to electrical stimulation.
Operations for incontinence in older people,
for instance pleating the external sphincter
and levator ani behind the anal canal and
anorectal ring to produce a shelf, are
disappointing (Parks). If incontinence is
associated with overt or occult complete
rectal prolapse (another cause of mucous
discharge), continence may be restored by
repairing the prolapse, usually by fixing the
reduced rectum against the sacral hollow with
a synthetic sling, completely encircling the
bowel (Ripstein) or deficient in front (Wells)
to avoid rectal constriction.
Traumatic incontinence, due to lacerations or
birth injuries, is successfully treated by
dissecting out and joining the cut ends of the
anal sphincters.
FURTHER READING
Kahan S, et al. Rectal pain. In: Kahan S, et al. In a
Page Signs and Symptoms. 2nd Edition. Philadelphia,
Pa.: Wolters Kluwer Health Lippincott Williams &
Wilkins; 2009:282.
Ellis H. Anorectal pain. In: Kinirons M, et al. French's
Index of Differential Diagnosis. 14th Edition. New
York, N.Y.: Oxford University Press; 2005:375.
Marcello PW. Diseases of the anorectum. In: Feldman
M, et al. Sleisenger & Fordtran's Gastrointestinal
and Liver Disease: Pathophysiology, Diagnosis,
Management. 9th Edition. Philadelphia, Pa.: Saunders
Elsevier; 2010.
Tadataka Yamada ; David H. Alpers. et al. Textbook of
gastroenterology. 5thEdition. Chichester, West
Sussex: Blackwell Publication. 2009.
Bruce G. Wolff et al. The ASCRS textbook of colon and
rectal surgery. New York: Springer. 2007.

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132
INGUINO-SCROTAL SWELLINGS
Inguino-scrotal swellings
Definition: The abnormal protrusion of part of
an organ or tissue through the structures
normally containing it.
In this condition, a weak spot or other
abnormal opening in a body wall permits part
of the organ to bulge through.
PAINFUL TENDER SWELLINGS WITH
ABDOMINAL PAIN
If there is low abdominal pain as well, a
painful inguino-scrotal swelling is likely to be
a strangulated inguinal hernia if it is
impossible to get above it. The hernia is
irreducible and there is no cough impulse.
The sac should be surgically exposed by an
inguinal incision, opened, fluid contents
removed and bowel or other contents
inspected. Gangrenous bowel will require
resection. Incise the strangulating agent, often
the external ring. Next, incise the narrow part
of the sac maintaining the strangulation.
Withdraw normal bowel on each side of the
strangulated segment. If the bowel colour
returns to normal at once it is viable and is
returned to the abdomen. The hernia is
repaired in the usual way. If it is doubtfully
viable (look at the constriction rings at each
end and the anti-mesenteric border at the
apex), resects it.
A painful tender swelling confined to the
scrotum with associated lower abdominal pain
may be a torsion of the testis. Any attempted
133
rotation causes pain and the testicle is often
high in the scrotum. Immediate technetium
scan shows absent blood flow in that side of
the scrotum, distinguishing it from acute
epididymitis. Immediate surgical de-torsion is
required, orchidectomy if the testicle is
gangrenous. Otherwise perform a fixation
operation, either attaching the lower pole of
the testis to the lower pole of the scrotum or
performing a Jaboulay operation (joining the
cut edges of the tunica vaginalis behind the
testis). The anatomical abnormality (long,
narrow mesorchium) will probably be present
on the other side, which should also be
operated upon.
No abdominal pain
Where the testis alone is painful and tender,
without abdominal pain, the lesion is probably
mumps orchitis, which is always post-pubertal
and often bilateral. If it is the epididymis
which is swollen and tender and there is no
abdominal pain the diagnosis is probably
acute epididymitis. Most acute epididymitis is
due to E. coli and responds to Ampicillin.
Gonococcal epididymitis (note purulent
urethral discharge) is cured by Penicillin.
Chlamydial epididymitis may be recognized
by associated perianal chlamydia vesicles.
PAINLESS NON-TENDER SWELLINGS
INGUINO-SCROTAL
If the swelling is inguino-scrotal, it is an
indirect inguinal hernia. Operation is
recommended because of the danger of
strangulation. Irreducible hernias still have a
cough impulse, lost when they strangulate. At
operation, the inguinal hemial sac is removed
at the neck (hemiotomy). The posterior wall
may be repaired using local tissue, for
instance joining the conjoint muscle-tendon to
the inguinal ligament (hemiorrhaphy) or
perhaps with a relaxation incision in the
rectus sheath (Tanner slide). If the defect is
large, as it may be in a direct inguinal hernia,
foreign material is used to fill the gap
(hemioplasty), e.g. Mariex mesh (knitted
teflon). A danger in laparoscopic hernia repair
is intestinal obstruction due to adhesion to the
mesh, avoided by placing it extraperitoneally.
Scrotal Cystic swellings
A very transilluminable swelling, usually
above and separate from the testis, is a
spermatocele. Multi-loculated epididymal
cysts often occur bilaterally in old men.
Neither requires treatment.
If the swelling surrounds the testicle or is
mainly below it, it is a hydrocele. If tense and
large it is probably primary, may be aspirated,
with the danger of haematocele or pyocele, or
operated upon - for instance by Jaboulay's
operation (see above). Softer hydroceles may
be secondary and it is important to exclude
underlying inflammation or tumor by early
surgery.
Solid swellings normal testis or epididymis
palpable
Epididymal swelling If the swelling is in the
epididymis, it is probably chronic
epididymitis and will respond slowly (if
coliform) to Trimethoprim-
Sulphamethoxawle. In tuberculous
epididymitis suppuration may occur, the vas
may be “beaded” if the disease has spread
from the seminal vesicles and other genito-
urinary tuberculosis must be excluded.
Testicular swelling If it is the testis which is
abnormal, it is most probably a malignant
134
neoplasm. 60% are seminomas, occurring in
men aged 30 to 50 years. Seminoma presents
as a hard heavy swelling without testicular
sensation and is “cold”' on technetium scan. It
is treated by radical orchid-ectomy followed
by deep x-ray treatment to para-aortic nodes.
30% are teratomas, usually in men aged 20 to
40 years. 85 % are now curable by orchid-
ectomy and node dissection, with prior
chemotherapy (Vincristine, Bleomycin,
Cisplatinum) if the lung or node metastases
are present (identified by x-ray and MRI or
CT scan). Live tumor cells persist in
retroperitoneal nodes in 25 % of cases after
chemotherapy. 70% of teratomas do not
involve para-aortic nodes, so node dissection
may be reserved for residual tumor following
chemotherapy.
Adenomas are rare and other malignancies
(interstitial cell tumor, chorionepithelioma,
embryonal cell carcinoma) are treated like
teratomas. In general, testicular tumor patients
are given chemotherapy if there are raised
tumor markers (CEA, β-HCG, α-
foetoprotein) or if there is a positive MRI or
CT scan of chest or abdomen. Seminoma
responds to chemotherapy as well as does
teratoma. Chemotherapy does not make
subsequent node dissection more difficult.
Chemotherapy may transform nodes into non-
malignant differentiated teratoma.
No normal organ palpable
If there is no history of trauma the lesion is
probably a carcinoma. After trauma,
including repeated needling for hydrocele, the
lesion may be a clotted haematocele,
clinically indistinguishable from carcinoma.
Orchid-ectomy is indicated.
Bilateral hard testes without sensation are
found in tertiary syphilis-gummata.
FURTHER READING
A Basu, S Ranjith, S Jagdish, S C Sistla, and S
Jayanthi. A 62 year old man with an inguinoscrotal
swelling. Postgrad Med J. 2006; 82:969.
Kliegman: Nelson Textbook of Pediatrics: Evaluation
of Acute Inguinal-Scrotal Swelling. Saunders 2011.
Working Party of the Royal College of
Surgeons. Clinical guidelines on the management of
groin hernias in adults. RCS London 1993.
Kingsnorth A N. Modern hernia management. In: eds.
Taylor I Johnson C D Recent Advances in surgery 18.
Churchill Livingston 1995. 159 - 178.
Kingsnorth A N. Inguinal hernia repair. Current
Practice in Surgery 1993; 5: 202 - 206.

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135
FREQUENCIES AND RETENTION OF URINE
Frequencies and retention of urine
Definition: Urinary retention, also known
as ischuria, is a lack of ability to urinate. It is
a common complication of benign prostatic
hyperplasia (BPH), though it can also be
caused by nerve dysfunction, tethered spinal
cord syndrome, constipation, infection,
medications
including anticholinergics, antidepressents,
COX-2 inhibitors, amphetamines and opiates.
Diagnosis and treatment may require a
catheter or prostatic sent.
FREQUENCY
Non-infective (clear urine)
Polyuria
Polyuria is the passage of large amounts of
urine.
Central nervous
In diabetes insipidus, due to posterior
pituitary-hypothalamic disease, there is
diminished production of antidiuretic
hormone with passage of large amounts of
low specific gravity urine.
Osmotic
In diabetes mellitus, the increased amount of
glucose in the glomerular filtrate reduces
tubular reabsorption of water, again
producing low specific gravity urine.
136
Renal
In chronic glomerulonephritis, renal arterio-
sclerosis and early after acute renal tubular
necrosis, large amounts of urine of fixed
specific gravity are excreted.
Prostatomegaly
Frequency may be due to irritation (residual
urine due to middle lobe hypertrophy causes
urgent desire to pass small amounts of urine
frequently, even at night), infection (usually
with chronic retention) or hydronephrosis.
Patients with prostatomegaly usually
complain of poor stream and hesitancy as well
as frequency.
Infective (with dysuria and pyuria) Lower
urinary tract infection
Acute cystitis
Acute cystitis in young women is due to easy
ascent of perineal coliform organisms along
with short urethra. The cloudy smelly urine
contains pus and more than 20 leucocytes per
high power field and 100000 pathogens/ml on
culture. It may respond to free fluids and
alteration of the pH of the urine or it may
require sulphonamides.
Chronic interstitial cystitis in older women
This may be associated with severe pain on
micturition (strangury), rarely with
haematuria if there is ulceration (Hunner's
ulcer). Symptoms may be relieved by
dilatation of the contracted bladder.
Upper urinary tract infection Pyelonephritis
Pyelonephritis is most common in young
women, due to cystitis, and may cause abdo-
minal pain, but pain and tenderness are
mostly marked in the loin. It always requires
antibiotic treatment.
Chronic pyelonephritis may be due to
repeated acute attacks or to some underlying
cause (see below).
Tuberculosis of the kidney
Slow onset with frequency first and abacterial
(sterile) pyuria suggests primary tuberculous
or chronic pyelonephritis. Diagnosis is
confirmed by urine culture on egg medium,
tuberculosis elsewhere is excluded and anti-
tuberculous drugs given.
Infection due to underlying cause Congenital
Anatomical anomalies, such as medullary
sponge kidney, pelviureteric obstruction,
mega fleeter, reflux and vesical diverticulum,
predispose to infection.
Vesico-ureteric reflux, due to short intramural
ureteric course and hypomuscularity of the
intravesical ureter and trigone, is identified by
voiding cystogram. Patients are advised to
perform double micturition.
Traumatic
Accidental or operative injury, foreign body
and radiation can cause chronic urinary tract
inflammation and frequency.
Inflammatory
Upper urinary tract tuberculosis, lower
urinary tract chronic inflammations (e.g.
bacterial prostatitis), colovesical fistula (most
often due to diverticular disease, associated
with pneumaturia) and ileovesical fistula in
Crohn's disease all cause frequency.
Less common causes of colovesical fistula are
sigmoid cancer, Crohn's colitis and carcinoma
of the bladder.
Neoplastic
Carcinoma of the bladder, renal pelvis or of
adjacent organs (cervix, body of uterus, colon,
and ovary) may cause cystitis.
Degenerative
137
Arteriosclerotic kidneys may present with
polyuria as may prostatomegaly. Actual
infection is uncommon in such cases.
Metabolic
“Silent” (painless) urinary calculi may cause
recurrent infection. In patients with recurrent
calculi, suspect hyperparathyroidism (raised
serum calcium). Remove parathyroid
adenoma(s), perform subtotal removal of
parathyroids in hyperplasia, total with auto-
transplantation if familial (multiple endocrine
neoplasia -MEN-syndrome). Implant 20
tissue fragments and cryopreserve the rest.
RETENTION OF URINE
Acute
Retention is sudden and painful, with tender
distended bladder.
Benign prostatomegaly
Retention is precipitated by cold, voluntary
inhibition or surgery (haemorrhoidectomy,
hernia repair). On rectal examination the
prostate is rubbery, enlarged and retains its
median groove. Warmth and running water
may provoke micturition. If not,
catheterization is required, usually with an
F18 latex Foley catheter, lubricating the
anterior urethra by injection of gel. The
bladder is emptied and the catheter removed
in 24 hours. Recurrent retention needing re-
catheterization requires operation usually
transurethral prostatectomy (TURP). Better
control of bleeding is achieved by endoscopic
laser prostatectomy.
Urethral stricture
Posterior urethral stricture follows intrapelvic
rupture of the membranous urethra in pelvic
fractures. Bulbar strictures are due to
gonorrhoea. Anterior strictures are due to
instrumentation, particularly transurethral
resection, or to meatal stricture following
catheterization. If stricture is suspected, some
prefer to perform suprapubic puncture with a
fine catheter to avoid damaging the urethra
and causing false passages. Filiform bougies
can be used to find the proper passage with
minimal trauma. Such a bougie may be
passed under direct vision through a
urethroscope and may be accompanied by
internal urethrotomy under vision.
Urethral calculus
Pain during micturition with passage of blood
first then a small amount of urine, with
sudden arrest of micturition in mid-stream,
suggests a diagnosis of calculous obstruction.
The calculus can usually be dislodged by a
well-lubricated catheter with or without
dilatation of the anterior urethra by injection
of lubricant or saline. If, as often happens, the
calculus is arrested in the fossa navicularis,
meatotomy will be necessary.
If impacted more proximally, the calculus
may be removed by urethroscopy, sometimes
by pushing it back into the bladder and
removing it by lithotrity -breaking up the
calculus.
Chronic
Retention is painless with a distended non-
tender bladder and is usually due to the same
causes: It is often accompanied by overflow
incontinence, particularly at night.
Chronic retention follows spinal cord
transection. The bladder must be emptied
regularly to encourage automatic (spinal
reflex) micturition.
Extrinsic spinal tumors (lymphoma, multiple
myeloma, metastatic vertebral carcinoma,
meningioma, Schwannoma) commonly
compress nerve roots as well as the cord
producing root pain as well as paraparesis and
chronic retention. Intrinsic tumors
(ependymoma, glioma) and non-neoplastic
cord lesions such as multiple sclerosis and
transverse myelitis are usually painless but
may present with disorders of sensation and
urinary retention.
Retention of urine in women
Abdominal wound pain often causes retention
in men and women. The female with a sore
perineum following vaginal surgery, an
episiotomy or trauma due to childbirth is
often unable to void. Anxiety makes it worse.
138
The presence of a vaginal pack always
demands an indwelling catheter.
Urethral obstruction in the female is very rare.
Pelvic causes of retention in women are all
due to an impacted pelvic tumor which
interferes with the opening of the internal
urethral sphincter. Causes include
haematocolpos, retroverted gravid uterus,
uterine fibroids, ovarian tumor or rarely
pelvic haematocele due to a slowly leaking
ectopic pregnancy. The fetal head deeply
engaged in the pelvis during labour completes
the list. All but the alert clinician may be
distracted by urinary frequency which, in fact,
is due to chronic retention with overflow
incontinence.
FURTHER READING
Abramovici,I.,and M. Assael. 1981. Psychogenic
retention of urine. Psychiatria Clinica 14:196-
204.
American Psychiatric Association. The
Diagnostic and Statistical Manual of Mental
Disorders - Fourth Edition. Washington, D.C.
1994.
Anonymous. Urinary retention in women.
British Medical Journal, 1976:1554.
Ascher, L. M. Paradoxical intention in the
treatment of urinary retention. Behaviour
Research and Therapy. 1979;17:267-270.
Barnard, G., C. Flescher, and R. Stinbrook.
1966. The treatment of urinary retention by
aversive stimulus cessation and assertive
training. Behaviour Research and Therapy
4:231-236.
Bassi, P., F. Zattoni, F. Aragona, F., M. Dal
Bianco, A. Calabro, and W. Artibani.
Psychogenic urinary retention of urine in
women: Diagnostic and therapeutic problems.
Journal of Urology Paris, 1980; 94:159-162.
Bosio, M., S. Mazzucchelli and S. Sandri.
Psychogenic urinary retention in childhood: A
severe case treated by an integrated global
approach. Minerva Pediatrician, 1996;
48:117-120.
Caffaratti, J., S.Perez-Rodriguez, J.M. Garat
and L. Farre. Acute urinary retention of
psychogenic cause in a girl. Actas Urology
Espanola, 1993; 17:367-370.
Chapman, A. H. Psychogenic urinary retention
in women: Report of a case. Psychosomatic
Medicine, 1959; 21: 119-122.
Cooper, A. J. Conditioning therapy in hysterical
retention of urine. British Journal of
Psychiatry . 1965; 111: 575-577.
Davis, M, E.R. Eshelman, and M. McKay. The
Relaxation and Stress Reduction Workbook
(4th Edition). Oakland, CA: New Harbinger
Publications. 1995.

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139
HAEMATURIA
Haematuria
Definition: In medicine (hematuria
haematuria) is the occurrence of red blood
cells (erythrocytes) in the urine. It may be
idiopathic and/or benign, or it can be a sign
that there is a kidney stone or a tumor in
the urinary tract (kidneys, ureters, urinary
bladder, prostate, and urethra), ranging from
trivial to lethal. If white blood cells are found
in addition to red blood cells, then it is a
signal of urinary tract infection.
Occasionally "hemoglobinuria" is used
synonymously, although more precisely it
refers only to hemoglobin in the urine.
Any episode of haematuria, or blood in the
urine, must be fully investigated to exclude
tumor.
PAINFUL HAEMATURIA
Urinary calculus
Ureteric calculus is the most common cause
but haematuria is usually microscopic (more
than 100 red cells per high power field).
Calculi in the renal pelvis or in a bladder
diverticulum may be painless.
Jolting causes penile or perineal pain and
haematuria at the end of micturition in those
with vesical calculi. Treat by cytoscopic
lithotrity or ESWL, irrigating fragments out
of the bladder.
Urinary tract infection
Urinary tract infection may cause haematuria,
usually with loin pain in pyelonephritis and
suprapubic pain in acute cystitis.
Vascular accidents
Vascular accidents (renal infarcts due to
or thrombosis or embolism) are rare but cause
sudden severe loin pain with macroscopic
haematuria.
Neoplasms may cause pain in their later
stages.
PAINLESS HAEMATURIA
(NEOPLASMS)
Kidneys
Carcinoma
Clear cell adenocarcinomu invades the renal
vein and spreads to nodes, but rarely to
adjacent tissues. Two-thirds are in males.
Carcinomas present with haematuria,
sometimes with pain, mass, fever,
hypertension or polycythaemia. IVP may
show “spider-leg” deformity due to loss of the
calyces. Large carcinomas replacing the
kidney will show no picture on IVP - because
of venous obstruction - but will show up on
MRI or CT scan. Small lesions may be shown
only on angiogram. 50% survive five years
after radical nephrectomy with node
dissection, sometimes with pre-operativc deep
x-ray therapy and post-operative
chemotherapy. It is often worth removing an
apparently solitary secondary, for instance in
the lung.
Renal pelvis and ureter
Transitional cell tumors present with
haematuria and sometimes with clot colic.
IVP shows a crenellated filling defect (the
clot is smooth and often round). Radical
nephro-ureterectomy with bladder cuff cures
low grade tumors but lymph node spread is
common in high grade tumors.
Wilms' tumor
This carcinosarcoma begins in the foetus but
may not present for years. There is an
abdominal mass. Haematuria is late and
means renal pelvis invasion. Hypertension
means renal pedicle obstruction. Prompt
nephrectomy with Dactinomycin pre-
operatively and post-operatively, and post-
140
operative deep x-ray therapy produce a 50%
five-year survival.
Bladder
Some transitional cell tumors are caused by
aniline dyes, tobacco tars and chronic
irritation. They are all malignant, the higher
grades invading the bladder wall. Squamous
cell carcinoma is more invasive.
They present with haematuria. Frequency and
dysuria suggest ulceration. Pelvic and
perianal pain are due to local invasion. IVP
may show a papillary defect. 25% of solid
lesions are not found on IVP. Diagnosis is
confirmed by cystoscopy and biopsy.
Superficial lesions are successfully treated by
transurethral resection. Recurrence,
involvement of the whole bladder wall or
local invasion require partial or total
cystectomy with urinary diversion, usually
into a segment of terminal ileum, one end of
which is brought out as a stoma.
Rare adenocarcinoma may be due to
metaplasia or arise from the urachus.
Prostate
Prostatic adenocarcinoma is common in men
over 65 years, locally invasive (but rarely into
the rectum) and commonly produces
osteoblastic bony metostases which look like
Paget's disease on x-ray. It may present with
pain due to bony metastases. All urinary
symptoms, including haematuria, are late. On
rectal examination a hard nodule suggests
carcinoma Prostatic calculi are excluded by
plain x-ray. The median groove may be lost
and there may be lateral extension in late
cases. Prostate-specific antigen (PSA) may be
determined by radioimmunoassay and is
raised in half of those with benign prostatic
hypertrophy and in most of those with
prostatic carcinoma. It is the best marker for
monitoring progress and response. Diagnosis
is confirmed by transrectal or transpcrineal
needle biopsy. Early local disease may be
cured by radiotherapy if small, or by radical
protatectomy but most have metastases and
141
are created with oestrogens or bilateral
orchidectomy.
PROTOCOL FOR INVESTIGATION ON
HAEMATURIA
1. Test urine for sugar, albumin, blood,
specific gravity and nitrite.
2. Microscopic examination of the urine and
culture.
3. Blood urea and creatinine estimation.
4. Plain x-ray of the abdomen shows most
calculi and kidney size and shape.
5. Intravenous pyelogram (TVT), performed
unless blood urea is high, indicates rate of
excretion, obstruction, dilatation and
lesions in the pelvis, ureter and bladder.
Post-micturition films give a good idea of
the amount of residual urine in the
bladder. IVP shows up most kidney
cancers and confirms the presence of a
contralateral kidney.
6. Ultrasound distinguishes cysts from solid
swellings, shows up hydroneplyosis and
spread of tumor to the inferior vena cava.
7. CT scan and MRI show spread of tumors
into the adjacent tissues, inferior vena
cava and para-aortic nodes.
8. Cytoscopy identifies bladder tumors and
vesical fistulae and allows biopsy.
9. Ureteric catheterization and retrograde
pyelogram are used for suspected
carcinomas of the renal pelvis or ureter.
The pyelogram shows up the renal pelvis
when IVP is unsatisfactory or
contraindicated and may relieve
obstruction due to a stone.
10. Renal nuclear scan is used for estimating
renal clearance in chronic renal disease.
11. Selective renal angiogram is the only way
of identifying carcinomas smaller than 1
cm in diameter (by abnormal tumor
circulation).
12. Renal biopsy distinguishes different kinds
and stages of medical renal disease.
FURTHER READING
Hebert, LA.; Nadasdy, T.; Nadasdy, G.; Agarwal, G.;
Mauer, M.; Agarwal, AK.; Khabiri, H.; Nagaraja,
HN. et al. (Mar 2006). "Proposed pathogenesis of
idiopathic loin pain-hematuria syndrome.". Am J
Kidney Dis 47 (3): 419-27.
Koshy, CG.; Govil, S.; Shyamkumar, NK.; Devasia, A.
(Jan 2009). "Bladder varices--rare cause of painless
hematuria in idiopathic retroperitoneal
fibrosis.". Urology 73 (1): 58–9.
Graham, DM.; McMorris, MS.; Flynn, JT. (Nov 2002).
"Episodic gross hematuria in association with allergy
symptoms in a child.". Clin Nephrol58 (5): 389–92.
Russo, D.; Minutolo, R.; Iaccarino, V.; Andreucci, M.;
Capuano, A.; Savino, FA. (Sep 1998). "Gross
hematuria of uncommon origin: the nutcracker
syndrome.". Am J Kidney Dis 32 (3): E3.

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142
BACK PAIN
Back Pain
Definition: Back pain is pain felt
the back that usually originates from the
muscles, nerves, bones, joints or other
structures in the spine. Back pain may have a
sudden onset or can be a chronic pain; it can
be constant or intermittent, stay in one place
or radiate to other areas. It may be a dull ache,
or a sharp or piercing or burning sensation.
The pain may radiate into
the arms and hands as well as the legs or feet,
and may include symptoms other than pain.
These symptoms may include tingling,
weakness or numbness.
Back pain affects 75% of old age Pakistanis.
It comes in many forms, from lower back
pain, middle back pain, or upper back pain to
low back pain with sciatica. Common back
pain causes include nerve and muscular
problems, degenerative disc disease, and
arthritis.
The first step is to see if the pain is in the
back itself. Local signs usually mean a local
cause. If there are none, look elsewhere for
the source of referred pain.
NO SPINAL TENDERNESS OR
DEFORMITY
Episodic
Colicky pain may be due to gallstone colic if
infra-scapular or renal (ureteric) colic if in
the loin. In both cases, pains are usually felt in
the abdomen also.
Episodic non-colicky pain in the lower dorsal
region may be due to penetrating chronic
duodenal ulcer.
Persistent
Abdominal mass
Back pain with an upper abdominal pulsating
mass is probably due to abdominal aortic
aneurysm, identified by its calcified wall anc!
by ultrasound. If not pulsating, the mass may
be lymphoma in para-aortic nodes. MRI or
CT scan will confirm the diagnosis and may
show enlarged nodes elsewhere.
No abdominal mass
Persistent pain with no abdominal mass is
in often due to carcinoma of the body of the
pancreas, again identified by MR1 or CT
scan. If the pancrease is diffusely enlarged (or
not enlarged) on the scan the cause may be
chronic pancreatitis, particularly in alcoholics.
SPINAL TENDERNESS AND/OR
DEFORMITY
In adolescent kyphosis and congenital
kyphoscoliosis there may be obvious
deformity with no pain whatever.
Hyperparathyroidism, multiple myeloma and
vertebral haemangioma produce striking
radiological signs, but usually no pain.
Pain plus deformity
A local lower dorsal deformity ('kyphos') is
characteristic g-'spinal tuberculosis (usually in
patients aged one to five years), due to
collapse of two adjacent vertebrae and their
disc. Response to anti-tuberculous treatment
is shown by weight gain; fall in ESR and
recalcification on X-ray. Plaster cast immobil-
ization might be necessary at first and spinal
fusion later.
Local lumbosacral deformity is due to
spondylo-tisthesis, caused by spontaneous
'fracture' of the pedicles of the 5th lumbar
vertebra, allowing it to slide forwards on the
sacrum, producing a 'step' visible from
behind, together with extra skin folds above
the hips where the trunk has slipped into the
pelvis. It may be quite painless unless nerve
roots are so stretched as to cause bilateral
thigh or sciatic pain, when spinal fusion may
be required to arrest it.
Diffuse deformity (kyphosis, or forward
bending of the dorsal spine) may be due to
143
postural kyphosis in adolescence, in which
case it disappears on lying down. If it persists,
it may be due to congenital kyphoscoliosis in
patients aged five to 10 years. There is
progressive rotation as well as flexion
deformity. When the trunk is flexed, one
shoulder will be up and the other down. It
may be treated by a combination of
osteotomies and internal fixation if painful. In
those aged 15 to 20 years, persistent kyphosis
might be due to spinal osteochondritis
(Scheuermann's disease) caused by
disappearance of ossification centers on the
anterior aspects of the upper and lower
surfaces of dorsal vertebrae. No treatment is
required.
In young adults persistent painful kyphosis is
likely to be due to ankylosing spondylitis, a
variant of rheumatoid arthritis associated with
ankylosis not merely of the spine but also of
the costovertebral joints, with tell-tale
absence of rib movement on respiration. Hips
may be affected and fixed in flexion and
cervical spine flexion draws the head down on
the chest. Surgery may be required to replace
the hips and permit walking.
In elderly women, painful kyphosis may be
due to osteoporosis with or without crush
fracture. Bones are 'pale' on X-ray. Make sure
such patients are not calcium deficient with
osteomalacia (for instance, after gastrectomy).
Osteitis fibrosa cystica due to hyper-
parathyroidism occurs in younger people and
may be associated within renal calculi.
Multiple crush fractures with 'ghost vertebrae'
are seen in Gushing's syndrome due to
adrenocorticotrophic hormone (ACTH)
secreted by a pituitary tumour or to adrenal
cortical hyperplasia or neoplasm, On CT scan
adrenal cortical carcinomas are likely to be
partly cystic and partly calcified. Solid
tumours less than 5cm in diameter are
probably bemga and may be treated with
Andnoglutethamidf or Tmmtad/en. Adrenal
cortical cancers have a poor prognosis.
Pagei's disease of the spine is also found in
144
old age. Osteolysis and bone resorption allow
the soft bones to be bent by gravity and
muscle pull. In the later osteoblastic phase,
new bone is laid down with no distinction
between cortex and medulla and a 'cotton
wool' appearance on X-ray which may be
mimicked by secondary carcinoma of the
prostate. The brittle bones break easily but
join quickly because of the good blood supply
(extra arteriovenous communications). The
only osteogenic sarcomas occurring over the
age of 50 years are those found in Paget's
disease. They are often multiple and common
in the skull. Paget's disease may respond to
calcitonin.
No deformity
Spinal pain and tenderness without vertebral
deformity may be due to disc prolapse,
particularly if there is sciatic pain down the
back of the thigh and calf and if there are
objective neurological signs (foot drop when
L5 root is compressed by prolapsed disc
material, absent ankle jerk in SI compression)
(exaggerated lumbar lordosis and scoliosis
may be produced by sacrospinalis muscle
spasm in these cases, but will usually
disappear when the patient lies prone). Most
acute back pains (lumbago) are due to tearing
of muscle fibres and may be relieved by
manipulation. True disc prolapse with nerve
compression requires laminectomy with
removal of the prolapsed disc.
Chronic disc degenerative disease affecting
several discs is often found in older people
and may require spinal fusion to abolish
movement (and therefore pain). Secondary
carcinoma may cause chronic back pain
without deformity - or with deformity if the
affected vertebra collapses. Pain due to
localized bony meta-stases may be relieved
by radiotherapy.
FURTHER READING
A.T. Patel, A.A. Ogle. Diagnosis and Management of
Acute Low Back Pain. American Academy of
Family Physicians. March 12, 2007.
Curtis W. Slipman, Larry H. Chou et al. Interventional
spine : An algorithmic approach. Philadelphia, PA:
 Saunders Elsevier. 2008. pp. 13.
Savage RA, Whitehouse GH, Roberts N. The
relationship between the magnetic resonance
imaging appearance of the lumbar spine and low
back pain, age and occupation in males. Eur Spine J .
1997;6 (2): 106–14.
Burke,G.L. Backache: From Occiput to Coccyx,
Chapter 5: The Differential Diagnosis of a Nuclear
Lesion. Vancouver, BC: Macdonald Publishing.
.
2008.
French S, Cameron M, Walker B, Reggars J, Esterman
A. A Cochrane review of superficial heat or cold for
low back pain. Spine. 2006; 31 (9): 998–1006.
Note: Most of the Matters are drived from Internet and
Research Papers

145
LIMB INJURIES
Limb injuries
Definition: Limb injuries mean damage of
bones, joints, ligament, muscles, the major
blood vessels and nerves of limbs. Depending
on the severity, limb injuries may be life
threating, or cause considerable pain and long
term disability. Blood loss and shock may
result, particularly in cases of multiple
injuries.
Fracture usually causes deformity but may
cause nothing more than local tenderness over
a bone. Dislocations and internal joint injuries
usually cause more swelling. Severe bleeding
usually means major vessel damage. Shock in
closed limb injuries is due to bleeding, in this
case into the limb. Loss of power may be due
to bone or joint injury but loss of sensation or
tendon reflexes is due to nerve injury.
Fractures must be reduced, that is, bone ends
should be apposed in proper alignment. They
should be immobilized until union. Where
there is no pain or movement at the fracture
site, clinical union has occurred. When x-ray
shows bony trabeculae crossing the fracture
site, there is bony union. Loss of healing
callus (in compound fractures), too much
distraction, inadequate fixation, infection or
avascular necrosis (e.g. scaphoid and neck of
femur) cause non-union. Malunion
(shortening, angulation, rotation) and fracture
into a joint cause early osteo-arthritis.
146
Joints must be moved to avoid stiffness. The
problem with plaster casts is that the joints
above and below the fractures is immobilized.
Internal fixation (and external fixation using
fixateurs) aims to allow free joint movement
from the outset. In fact, some weight bearing
in lower limb fractures, compressing the bone
ends, encourages bony union, providing there
is already clinical union and that fixation is
adequate. It has been shown that fractures
rigidly held compressed, using strong internal
fixation with plates and screws, unite directly
without formation of external callus. This is
called “primary bone union”. If callus forms,
movement must have occurred.
Most long bone fractures in adults (except
fractures of the tibia, which are often
compound) are now treated by internal
fixation rather than by the traditional methods
described below. Internal fixation is also used
for fractures of the ankle in young patients
and for hip fractures in the elderly. External
fixation is used for compound fractures of the
tibia. Compression is achieved by “lag
screws”. The thread engages bone and is fixed
only in the fragment furthest away from the
screw head. The part of the screw shaft in the
near fragment slides along the screw track.
The head of the screw is wider than the shaft
and, as the screw is advanced into the furthest
fragment, the wide head pulls the near
fragment on to it. Compression of long bone
fractures by plates is achieved by putting each
screw into the part of the oval hole in the
plate furthest away from the fracture site. The
under-surface of the screw head is round and
as it is tightened, pulls the bone along the
plate towards the fracture site, compressing it.
COMMON BONE AND JOINT INJURIES
IN THE UPPER LIMB
Due to indirect force
It is usually a fall on the outstretched hand.
Fractured clavicle
The most common fracture is at the junction
of the outer and middle-thirds. The outer
fragment drops due to the weight of the limb.
Lift it up with a triangular sling or
doublesling, to be wore for three weeks.
Acromioclavicular subluxation
Rupture of the conoid part of the
coracoclavicular ligament allows the outer
end of the clavicle to ride up on the acromion.
No treatment is necessary.
Gleno-humeral (shoulder) dislocation
Dislocation is usually anteroinferior and
shoulder contour is lost. The circumflex
(axillan) nerve may be injured causing deltoid
paralysis. Reduce by overcoming
subscapularis tone, either by gradual external
rotation of the shoulder (Kocher) or by using
the foot in the axilla to push upwards and
outwards on the humeral head (Hippocrates).
Fractured neck of humerus
The lower fragment is abducted on the upper
and often impacted. Deformity may be
minimal. In that case merely wear a triangular
sling for a month.
Fractured humeral shaft
Deformity is convex backwards due to strong
flexors. A plaster cast from just below the
shoulder, including the flexed elbow and
forearm, maintains alignment after reduction.
A collar and cuff sling allows the weight of
the cast to prevent over-riding. Leave it on
until there is clinical union (six weeks).
Supracondylar fracture of the humerus
Common in children, the danger is damage to
the brachial artery by the forward flexed
lower fragment. Ischaemia after reduction
147
requires immediate operative exploration of
the artery. Reduce it by hyperflexion of the
elbow during traction. Immobilize in flexion
in a plaster cast from the shoulder to the wrist
for six weeks.
Monteggia fracture - dislocation of the elbow
Fracture of the upper-third of the ulna is
associated with dislocation of the head or the
radius out of the radio-humeral joint. Reduce
it by traction and immobilize in a cast from
above the elbow to below the wrist for six
weeks. In adults every Monteggia fracture is
now treated by internal fixation.
Colles fracture of lower end of radius
The lower fragment is dorsiflexed, supinated
and abducted on the upper fragment and
impacted in it. Increase the deformity to
disimpact it then reduce the fracture.
Immobilize with the wrist flexed in a cast
extending to the metacarpal heads below and
to below the elbow above. The main danger is
early recurrence of deformity in the padded
cast and further reduction may be required a
week or so later. Leave the cast on for a
month.
Smith's fracture of lower end of radius
Here the lower fragment is flexed and
impacted on the upper fragment. Disimpact
and reduce the fracture and immobilize as for
Colics' fracture, but with the wrist extended.
Bennett's fracture of the thumb
Fracture through the base of the thumb
metacarpal leaves the ulnar fragment attached
and articulated with the trapezium. The rest of
the first metacarpal is dislocated upwards. It
must be reduced and immobilized for a month
with a forearm cast extending on to the thumb
beyond the metacarpophalangeal joint.
Others
Avascular necrosis of the proximal fragment
may cause non-union of a fracture of the
carpal scaphoid followed by osteoarthritis of
the wrist.
Fracture of the head of the radius, if into the
joint, will cause osteoarthritis of the elbow
unless reduction is perfect.
Due to direct force
Fracture of mid-clavicle
The fracture is of little account. The main
danger is damage to the brachial plexus and
the subclavian-axillary vessels.
Fracture-dislocation of the shoulder
A direct blow fractures the neck of the
humerus and separates the fragment. This
allows abduction and external rotation of the
separate head and upper neck. It requires
operative reduction and internal fixation.
Compound comminuted (many fragments)
fracture of shaft of humerus
The main dangers are damage to the radial
nerve with wrist drop and loss of part of the
shaft, requiring bone graft later to avoid
shortening.
Compound comminuted fracture of elbow
Due to injury of the elbow outside a car
window usually requires arthrodesis (fusion)
of the joint in flexion.
Fracture of both bones of the forearm
The upper fragment of the radius is pronated
and the lower fragment supinated. Reduce by
pronating the lower fragment to restore
alignment. Recurrence of the deformity is
likely in a cast. Internal fixation is best.
COMMON LOWER LIMB INJURIES
DUE TO INDIRECT FORCE
Fractured neck of femur
An older person with osteoporosis loses
control of one foot which slides outwards on a
slippery surface. Weight is suddenly borne on
the abducted hip breaking the weak femoral
neck. The patient then falls - the fall does not
cause the fracture but follows it. The lower
fragment is shortened, adducted and
externally rotated. The bug-bear of internal
fixation with nail and plate after difficult
reduction is necrosis of the head of the femur.
Many surgeons prefer immediate joint
replacement with a metal head and neck joint
prosthesis, certainly in cases of intracapsular
fracture, which damages the blood vessels
running along the neck to the head.
148
Internal derangements of the knee joint (IDK)
Injuries to the collateral ligaments, menisci
and cruciate ligaments are due to twisting the
weight-bearing knee.
There are often several such injuries in one
knee, producing a painful effusion and
perhaps locking. Arthrography and
arthroscopy permit adequate assessment of
the injuries. Surgery (excision of torn
meniscus and repair of the ligaments) is often
required in young people to avoid inevitable
early onset of osteoarthritis. Closed surgery is
often possible using an arthroscope.
Sprained ankle
Stumbling with inversion of the foot tears the
lateral talonavicular and/or calcaneonavicular
ligament, with bruising below the lateral
malleolus. Use an elastic bandage and avoid
weight-bearing until pain subsides.
Pott's fracture-dislocation c the ankle
Abduction on the leg of the fixed foot during
a fall to that side fractures the lateral
malleolus (1st degree), perhaps ruptures the
deltoid, or medial ligament of the ankle with
or without fracture of the medial malleolus
(2nd degree) and fractures the posterior part
of the lower end of the tibia (posterior
malleolus) in 3rd degree injuries. 1st and 2nd
degree lesions are treated by brief
immobilization in a plaster cast. In 3rd degree
fractures the posterior tibial malleolus must
be maintained in reduction with a screw.
Due to direct force Dislocation of the hip
Posterior dislocation of the hip and internal
dislocation with acetabular fracture are now
most often due to road trauma, either due to
direct force or indirect force transmitted along
the femur of the sitting car occupant. The
latter may require traction after reduction. In
dislocation without fracture, weight-bearing
must be avoided for six weeks.
Fractured shaft of femur
Prolonged traction often causes malunion and
nonunion. Treat by internal fixation with
Kuntscher nail or its modifications.
Supracondylar fracture of femur
The lower fragment is flared by the attached
gastroc-tiemius. Reduction can be maintained
only by internal fixation with a T-plate or
some similar device.
Fractured tibia and fibula
These fractures are often compound because
of the subcutaneous site of the tibia which is
usually hit from in front. Union is slow. Plates
and screws may prolong healing. External
fixateurs placed at some distance from the
fracture site do not interfere with it. The
wound must be closed early in compound
fractures to allow bone healing. If there has
been much tissue loss, a free flap is used, with
microvascular anastomoses.
FURTHER READING
A. Lerner, Daniel Reis, Michael Soudry. Severe
Injuries to the Limbs: Staged Treatment. Springer-
Verlag Berlin Heidelberg, Jan-2007.
Hans-Ulrich Steinau. Major limb replantation and
postischemia syndrome: investigation of acute
ischemia-induced myopathy and reperfusion injury.
Springer-Verlag, 1988.
Robert W. H. Pho. Microsurgical technique in
orthopaedics. Butterworths, 1988.
Michael Bruce Wood. Atlas of reconstructive
microsurgery. Aspen Publishers, 1990.
Alan D. McGregor, Ian A. McGregor. Fundamental
Techniques of Plastic Surgery: And Their Surgical
Applications. Churchill Livingstone, 2000.

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Research Papers

149
LIMB PAINS
Limb pains
Definition: Pain in limb is a term used to
describe discomfort affecting any part of a
limb or extremity (such as an elbow or knee)
or the entire limb (arm or leg). The term is
general in nature and could be used to
describe pain that arises from various causes.
The pain may arise from the skin, nerves,
muscles, bones, joints, or even the brain (in
psychogenic or phantom pain). Arm pain may
arise from pathology in the neck (cervical
spine), whereas leg pain may originate in the
low back (lumbar spine). Typically, the term
"pain in the limb" would be used to describe a
person's symptoms until a definitive diagnosis
is made (such as broken arm, tendinitis,
peripheral neuropathy, etc.).
SHOULDER
Cervical spondylosis and brachial neuralgia
Osteophytes and capsular thickening in cases
of disc degenerative disease entrap lower
cervical nerve roots, causing pain on the outer
150
aspects of the shoulder, arm, forearm and in
the thumb and index finger (C5, 6, 7). Lateral
flexion of the neck to that side reproduces the
pain. Loss of power and sensation are
uncommon. There is painless full movement
of the shoulder. Exercises, a cervical collar,
or, rarely, cervical fusion may be required.
Rotator cuff lesions
Degenerative changes, including calcification,
occur in the small muscles holding the
humeral head on the glenoid fossa. There is
pain and tenderness over the rotator cuff
insertion on the greater tuberosity of the
humerus. Partial rupture causes a 'painful arc'
in the middle range of abduction. Complete
rupture causes inability to begin abduction,
often masked by the patient who quickly
flexes his trunk to that side to start it off. In
the worst cases the shoulder may be 'frozen'.
Stiffness lasts for months. The patient wears a
sling while pain is present and moves the joint
after the pain has gone. Avoid passive
exercises which may precipitate frozen
shoulder by causing peri-articular damage.
Missed traumatic lesions
Impacted abduction fracture of the upper end
of the humerus, fracture of the outer end of
the clavicle lateral to the coracoclavicular
ligament, acromioclavicular subluxation and
fractured greater tuberosity of the humerus
are easily missed because there is no defor-
mity. Even an unreduced humeral (shoulder)
dislocation may be missed in the elderly and
should then be left alone, encouraging active
exercises to regain as much movement as
possible.
Chronic arthritis Rheumatoid arthritis
The small joint or of the hands are most often
affected but also the knees, spine, hips and
shoulders. There is synovial thickening and
effusion. Dissolution of the capsule, adjacent
tendons and ligaments causes subluxation of
joints. X-rays show osteoporosis about the
joint with periarticular soft tissue thickening,
uniform arrowing of the joint space and
subluxation or bony ankylosis. Treat with
anti-inflammatory drugs.
Osteoarthritis
This may occur in the shoulder following
injury but is usually confined to weight-
bearing joints (see Lower Limbs).
Tuberculous arthritis
A destructive tuberculous lesion in the bony
epiphysis secondarily involves the joint. Pain,
stiffness and swelling without redness or heat
are typical but in tuberculous arthritis of the
shoulder in older people there may be few
signs ('caries sicca'). Rifampicin, Isonicotinic
acid and Streptomycin heal the infection (no
pain, normal ESR, X-ray re-calcification) but
the joint may require arthrodesis.
ELBOW
Tennis elbow
Rupture of a few fibers of the extensor
digitorum longus arising frorn the lateral
humeral epicondyle causes pain and
tenderness at that spot relieved by rest and
local hydrocortisons injection. It sometimes
requires division of the partly torn extensor
origin.
Osteochondritis dissecans with loose bodies
Patients present with pain and locking. The
separated fragments may be visible on X-ray
and should be removed to avoid osteoarthritis.
Chronic osteoarthritis
This is rare but may follow previous injury,
for instance Monteggia fracture (Chapter 21).
Olecranon bursitis
Unless gouty, this will respond to antibiotics.
Recurrent bursitis may require excision of the
bursa.
HAND AND FINGERS
Acute infections
Minor: After opening minor abscesses, apply
a dry dressing and use an infra-red lamp
several times a day to allow return to work in
two or three days.
Apical space infection: There is an abscess
under the distal end of the fingernail. Excise a
small wedge of overlying nail and skin.
151
Dorsal furuncle: Remove the centre “core”.
Paronychia: Infection under the paronychium
and eponychium may be superficial to the
nail, when it is merely necessary to lift the
eponychium up with a flat instrument to allow
pus to escape. If pressure on the nail causes
pain, pus is also beneath it and a flap of
eponychium must be raised to drain it.
Infected palmar blister: Unroof to drain the
blister but do not miss frequent 'collar-stud*
intradermal or subcutaneous abscess
communicating with the blister via a small
hole in its floor.
Web space infection: Incise the web but do
not cross the edge and beware of the digital
nerve proximally.
Major: Major infections require antibiotics,
admission to hospital and elevation of the
limb.
Pulp space infection: Use a tourniquet to
provide a bloodless field. Unroof the abscess
convening it into a shallow ulcer. If all the
pulp compartments are fused into one large
abscess cavity, now uncommon, anterolateral
incisions and drains may be necessary.
Tenosynovitis: This may follow pulp space
infection. Tenderness is localized along the
mid palmar aspect of the finger. Pain is
aggravated by passive extension but not by
flexion. Intravenous antibiotics may abort
infection. If not, open the sheath via one or
more incisions avoiding creases and the
digital neurovascular bundle just in front of
the anterior edge of the phalanx. Irrigate with
small doses of Penicillin via an indwelling
fine silastic catheter.
Thenar space infection: This follows a
penetrating wound of the radial aspect of the
palm, or index finger tenosynovitis. There is
gross swelling of the hand between the thumb
and middle finger. Incise the distal palm-
between the index and middle fingers.
•
Mid palmar space infection: Severe swelling
of the ulnar aspect of the palm causes a 'main
en griffe' (monkey hand). The abscess is deep
to the tough palmar aponeurosis, so there may
be more swelling on the dorsum. Make a
vertical incision in the distal palm between
the middle and ring fingers.
Ulnar bursitis and radial bursitis: Infection
of the long flexor tendon sheaths in the palm
from tenosynovitis of the little finger (ulnar
bursitis) or of the thumb (radial bursitis).
Drain by incision on the medial or lateral
palmar aspects of the wrist.
Brachial neuralgia: (Cervical spondylosis
and brachial neuralgia)
Carpal tunnel syndrome: This is the most
common nerve entrapment. Pressure on the
median nerve beneath the flexor retinaculum
is caused by swelling or enlargement of the
HIP
surrounding structures, for instance
Tuberculous arthritis: This is confined to
osteoarthritis with osteophytes, rheumatoid
children under the age of five years.
arthritis with synovitis, fluid retention during
Perthes' disease: Osteochondritis of the
pregnancy. Pain and para-esthesia in thumb
femoral head epiphysis with flattening of the
and index finger are worse at night. Divide
head occurs in young children and causes
the flexor retinaculum being careful of the
early osteoarthritis in young adults.
thenar branch hooking upwards over the
Slipped epiphysis: In adolescents, the
lower lateral edge of the retinaculum to
femoral head epiphysis 'slips' downwards,
supply the thenar muscles.
forwards, and medially on the neck. As in
Raynaud's syndrome: This may be
Perthes' disease, the Trendelenberg test (the
idiopathic or caused by scleroderma,
pelvis tilts upwards on that side when
vibration injury, ergotism or peripheral
standing on the affected limb) is positive.
emboli from brachial or subclavian
Traction may stop slipping.
aneurysm. Pain and pallor of index and
Rheumatoid arthritis: In young adults with
perhaps other digits are brought on by
ankylosing spondylitis the hips are often
exposure to cold and relieved by heat which
affected and bilateral hip replacement may be
causes temporary cyanosis. In true Raynaud's
necessary to permit walking.
disease, where there is local digital artery
Osteoarthritis: This is the most common
sensitivity to cold, symptoms may be relieved
chronic arthritis of the hip. Usually in older
by cervical sympath-ectomy, but are likely to
people, it may occur early after injury or other
recur because the cause is local.
abnormalities. The patient complains of stiff-
ness after rest and pain after use. Uneven
wear and tear of joint cartilage means painful
limitation of some movements but not others -
particularly abduction and flexion in the case
of the hip. X-rays show osteophytes,
eburnation of bone ends, uneven narrowing of
joint space and cystic spaces in the bone.
Exercises, weight reduction and a walking

152
stick will help, but severe pain and stiffness
may require joint replacement.
KNEE
Internal derangement of the knee (IDK):
Meniscus and ligament injuries present with
painful effusion or locking (see Limb
injuries).
Osteochondritis dissecans: Osteochondritis
dissecans of medial femoral condyle with
loose body and locking X-ray identifies the
lesion and the loose body must be removed.
Rheumatoid arthritis (see above): Hands are
usually affected as well.
Osteoarthritis (see above): Common in older
people, it may occur early after IDK or
fractures involving the joint.
Bursitis: Inflammation of pre-patellar,
infrapatellar and semimembranosus bursae
may cause painful swelling about the knee.
Baker's cyst (cystic protrusion of knee joint
synovium into the popliteal fossa in cases of
osteoarthritis) may be painful. This should be
distinguished from popliteal aneurysm which
is painless and identified by its pulsation.
LEG
Peripheral arterial disease
The most common pain is intermittent
claudication (cramps when walking relieved
by rest) due to reduced blood flow through
muscles and usually implying main vessel
obstruction. Rsst pain is an ache in the foot or
toes at night when the blood flow slows
down. Sometimes engorgement of the skin
with blood in cases where all arteriovenous
anastomoses are open causes a burning
erythromelalgic pain. Ischaemia of sensory
nerves in the limb may cause sharp pains
(neuralgia). This may be followed by trophic
ulceration due to prolonged pressure on
insensitive skin. The symptom of impending
gangrene of the distal parts of the limb is a
severe constant boring pre-gangrenous pain.
Pulses are weak or absent and special organs
in the limb atrophy (muscles waste, sk'n
becomes dry and hairless), Buerger's sign is
positive in late cases (the dependent foot is
153
reddish-blue and white on elevation because
all arteriovenous anastomoses remain
permanently open).
Minor atherosclerotic obstructions may be
dilated with a special intra-arterial balloon
catheter (percutaneous angioplasty).
Otherwise endarterectomy may be possible in
short stenoses. In longer obstructions, a
bypass graft is required. Below the inguinal
ligament a long saphenous vein is dissected
out, joined to the iliac or femoral artery above
and to the popliteal or anterior or posterior
tibial artery below (taking care to reverse the
graft in view of its valves).
Amputate through the metatarsophalangeal
joint in cases of gangrene confined to a toe. It
might be possible to save the rest of the limb
by bypass graft and/or lumbar
sympathectomy. Perform below-knee amputa-
tion if gangrene involves more than one toe,
all of the great toe, or extends to the foot. If
the knee is not stiff, below-knee prosthesis is
best. More extensive gangrene, particularly in
the bedridden, requires above-knee
amputation.
Acute ischaemia of the limb presents with
pain, pallor, pulselessness, paraesthesia,
paralysis and perishing cold. The most
common cause is an embolism, for instance
from the left atrium in a patient with atrial
fibrillation. The foot is white and numb. Give
5000 units of Heparin intravenously to
prevent extension of the clot. Emergency
embolectomy will restore pulses but if not an
arteriogram should be done at once to identify
distal thrombosis.
Less dramatic acute ischaemia is due to
thrombosis, recognized by arteriogram and
treated by introducing 5000 units per hour of
streptokinase through the arteriogram
cannula, advanced into the clot.
Less severe degrees of vascular obstruction
may be treated by giving up smoking and
taking exercise.
Varicose veins
Varicose veins may be quite painless even
though large. Where there are incompetent
perforating veins in the legs running from
posterior tibial vein to the surface through the
soleus muscle, pain is common, particularly
aching pain after long standing and cramps in
the leg at night. With severe incompetence of
lower leg perforating veins (lower leg venous
hypertension syndrome), there is
pigmentation, subcutaneous scarring and
narrowing of the leg, loss of skin structures
(hair, sweat glands) and atrophy of the skin.
These changes make the leg prone to
ulceration, particularly about the malleoli.
Where there is much exudation, ulcers should
be cleaned with warm normal Saline and
Calcium Alginate should be placed on the
wound and covered with a secondary
dressing. Exudates convert the Alginate into a
protective gel over the wound. Soon, dressing
changes may be reduced to once or twice a
week to avoid damaging new epithelium.
Ulcers may be cured by prolonged elevation
of the limb to relieve venous hypertension; by
elastic bandage or stocking compression
combined with exercise, forcing the blood
into the deep system; or by operative division
of incompetent perforating veins if
identifiable. Superficial varicose veins alone
may be cured by sapheno-femoral division (or
by sapheno-popliteal division in the case of
short saphenous varices) and multiple
excision of varicosities, with or without
stripping. Surgical cure of the lower limb
venous hypertension syndrome (see above) is
much more unpredictable.
Cellulitis of lower limb
Subcutaneous infection (usually
streptococcal) with fever and extending
redness and swelling may follow minor
trauma (lacerations, bites), varicose ulceration
(see above) or superficial thrombophlebitis
(see below). In severe cases, admit the patient
to hospital, elevate the limb and treat with
154
intravenous antibiotics (usually
Flucloxacillin).
Venous thrombosis
Superficial thrombosis (thrombophlebitis)
often occurs in superficial varices, producing
a painful tender cord in the leg at the site of
the vein. Antibiotics are required. Where the
thrombosis is spreading upwards, admit to
hospital and give intravenous antibiotics.
Sometimes sapheno-femoral division will be
necessary to avoid extension to the deep
system.
Deep vein thrombosis (DVT) of some degree
is common after operations and where injuries
or illnesses require long-term immobilization
of the leg. Intra-operative electrical
stimulation of calf muscles and post-operative
administration of 5000 units of subcutaneous
Calcium Heparin once or twice a day,
maintaining the prothrombin ratio
(international normalized ratio - INR) at 2.0
to 2.5, reduces the risk of post-operative DVT
but has not been shown to reduce the
incidence of post-operative pulmonary
embolism.
Such DVT may be quite asymptomatic or
there may be tenderness in the calf with pain
on extension of the foot (Romans' sign),
oedema, increased warmth of that limb and
prominent superficial veins. Venous pool
radioisotope scan identifies dangerous main
vein obstruction. Such patients must be anti-
coagulated with Heparin and maintained for
some weeks with Warfarin, to avoid
pulmonary embolism. A partial occlusion
device ('umbrella') may be introduced via
neck veins into the IVC below the renal veins
to stop embolism.
Nerve entrapment
The most common entrapment is of L4, L5, or
S1 by disc prolapse into the spinal canal
causing sciatica, with pain radiating from the
buttock down the back of the lower limb to
the sole of the foot (see Back pain).
Meralgia paraesthetica is due to thickening
of the fibrous tunnel beneath the outer end of
the inguinal ligament through which the
lateral femoral cutaneous nerve runs. Pain and
paraesthesia on the outer anterior thigh may
require freeing or division of the nerve.
In anterior compartment syndrome, due to
injury or ischaemia, ihere is compression of
the anterior tibial nerve, with pain and
paraesthesia in the foot.
FOOT
Painful heel
This may be-due to Achilles tendonitis,
calcaneal bursitis, haematoma of heel fat pad
or plantar fasciitis.
Painful hindfoot
Pes cavus (claw foot) may be idiopathic,
ischaemic, due to poliomyelitis or peroneal
muscle atrophy. Foot and toe flexors are short
and there is a high arch with hammer toes,
leading to pain and early osteoarthritis.
Osteotomies and arthrodeses may be required.
Painful forefoot
Talipes (club foot) is due to unequal
development of limb muscles and tendons
with plantar flexion or dorsi-flexion at the
ankle and adduction or abduction of the
forefoot. Best treated with reduction aril
splinting in early infancy, it may go on to
cause pain later with osteoarthritis (see pes
cavus). In hallux valgus, the big toe is
abducted or the first metatarsal is adducted
(primus metatarsus varus). The prominent
head of the first metatarsal may develop an
exostosis. Excise the exostosis and perform
arthroplasty of the first meta-tarsophalangeal
joint. The most commonly used arthroplasty
is Keller's, in which the proximal third of the
proximal phalanx of the great toe is excised.
Hallux rigidus (osteoarthritis of first
metatarso-phalangeal joint) is a common
sequel of hallux valgus. It shortens the step by
limiting dorsi-flexion of the great toe.
Painful toes
In 'juvenile' ingrowing great toenail, the nail
is normal and cuts into the excessive soft
pulp. Treatment is by wedge excision
(excision of the lateral edge of the nail, nail
155
bed and adjacent pulp); In 'adult' ingrowing
great toenail, the nail is hypercurved and
there is pain on pressure. Operation is best
avoided. Hammer toe, with hyperextension of
the metatarsophalangeal joint and terminal
interphalangeal joint and hyperflexion of the
proximal interphalangeal joint, may be due to
claw foot (see above) or muscle weakness (for
instance, following poliomyelitis or peroneal
nerve injury). Corns develop on the proximal
joint. It may be necessary to arthrodese the
toe joints in extension with or without
division of long extensor tendons.
Painful sole
Callus under the forefoot is due to excessive
weight-bearing on the metatarsal heads and
may be relieved by a metatarsal bar under the
shoe. In plantar papilloma, in contrast to
callus, the skin lines do not go through the
lesion and lateral pressure causes as much
pain as does direct pressure. Treatment is by
diathermy excision. Morton's metatarsalgia is
due to pressure on the digital nerve between
metatarsal heads producing a painful
neuroma, which may have to be excised.
'March' fracture of a metatarsal is due to
excessive walking and shows large amounts
of callus on X-ray, raising the question of
bone tumour.
FURTHER READING
Craig Murray. Amputation, Prosthesis Use, and
Phantom Limb. Springer 2010.
Rothgangel, A.; Braum, S.; Beurskens, A.; Seitz, R.;
Wade, D. The clinical aspects of mirror therapy in
rehabilitation: a systematic review of the
literature. International Journal of Rehabilitation
Research . 2011; 34 (March): 1–13.
Kooijman, Carolien M.; Dijkstra, Pieter U.; Geertzen,
Jan H. B.; Elzinga, Albert; van der Schans, Cees P.
(July 2000), "Phantom Pain and Phantom Sensations
in Upper Limb Amputees: An Epidemiological
Study. Pain. 2000; 87 (1): 33–41.
Halligan, Peter W. Phantom limbs: The body in mind.
Cognitive Neuropsychiatry . 2002; 7 (3): 251–268.
Bittar, Richard G.; Otero, Sofia; Carter, Helen; Aziz,
Tipu Z. Deep Brain Stimulation for Phantom Limb
Pain. J. Clinical Neuroscience 2005; 12 (4): 399–
404.
Note: Most of the Matters are drived from Internet and
Research Papers
SWELLINGS AND ULCERS
Swellings and ulcers
SWELLINGS
Definition: In medical parlance, swelling,
turgescence or tumefaction is a transient
abnormal enlargement of a body part or area
not caused by proliferation of cells. It is
caused by accumulation of fluid in tissues. It
can occur throughout the body (generalized),
or a specific part or organ can be affected
(localized).
Swelling is considered one of the five
character-istics of inflammation; along with
pain, heat, redness, and loss of function.
In a general sense, the suffix “-megaly” is
used to indicate a growth, as in hepatomegaly,
acro-megaly and sleenomegaly.
A body part may swell in response to injury,
infection, or disease. Swelling, especially of
the ankle, can occur if the body is not
circulating fluid well.
Generalized swelling, or massive edema (also
called anasarca), is a common sign in
severely ill people. Although slight edema
may be difficult to detect to the untrained eye,
especially in an overweight person, massive
edema is very obvious.
Skin
Benign
Dermatofibroma
156
This hard smooth nodule in the dermis is
covered by adherent epithelium. Vascular
lesions contain dark brown haemosiderin and
may ulcerate, mimicking melanoma.
Pedunculated fibroma or neurofibroma
Soft harmless sometime pigmented swellings
which project from the surface.
Solar keratosis
A rough raised firm swelling on a surface
exposed to sunlight. Ulceration means malig-
nant changes.
Seborrhoeic wart
Multiple harmless greasy grey-brown flat
swellings with overhanging edges, found in
older people.
Keratoacanthoma
A keratin plug grows quickly and may
ulcerate normal overlying skin. It may be
indistinguishable from squamous cell
carcinoma and should be excised.
Pigmented naevus
These lesions may be flat and black with
melanocytes only in the basal layer of the
epidermis (junctional naevus); raised and blue
with melanocytes only deep in the dermis
(dermal or blue naevus); or raised and black
or brown, with melanocytes in both places
(compound naevus). Any naevus containing
junctional tissue may become a malignant
melanoma. Those on the soles, palms and
genitalia are always junctional.
Malignant
Basal cell carcinoma (BCC): A smooth
pearly white swelling which later ulcerates
producing a deep round ulcer with rolled
edges (“rodent ulcer”). Variants include
cystic BCC; cylindroma (with acinus-like
structures), “leap-frog” type (where one spot
heals as the carcinoma spreads beyond it) and
pigmented BCC (like melanoma). Excise with
a small margin of 2 to 5 mm. Make sure the
lesion is removed in depth as recurrence is
due to leaving the deep part of the tumor.
BCCs are found on the “batwing” area of the
face (lower eyelid, mid-cheek, upper lip).
Squamous cell carcinoma (SCC): A hard
nodule (like a keratoacanthoma), often on the
lower lip or dorsum of the hand becomes an
ulcer with raised averted edges and spreads
slowly to lymph nodes (unlike BCC). Excise
then wait six weeks after the primary excision
wound is healed before removing enlarged
regional nodes (which may be inflammatory).
SCC should be suspected in long-standing
ulcers (varicose, bums) if there is bleeding
and the ulcer edge or floor is raised.
Bowen's disease is a rough nodular skin
plaque, an intraepidermal squamous cell
carcinoma.
Melanoma
This is a black or brown swelling (5% are
amelanotic) later ulcerating and bleeding.
30% arise in benign naevi. Male sex, some
sites (back, arms, neck, and scalp), spread to
nodes or subdermal penetration, means a
worse prognosis. But tumor thickness
(Breslow) is the best prognostic indicator.
Excise probable melanomata with a margin of
1 cm. No more need be done for melanomata
less than 0.76 mm thick. Excision with a 2 cm
margin is required for lesions 0.76 to 1.5 mm
thick, plus regional dissection if nodes are
palpable (and in all males). All those with
tumors 1.5 to 4mm thick need elective node
dissection (ELND), because you cannot detect
metastases in impalpable nodes, yet that is the
very group in which there is a survival
advantage of 40% with ELND. 70% of those
have more than 4 mm thick have distant meta-
stases, so node dissection is useless. The order
of increasing malignancy is lentigo maligna
(Hutcbinson's face freckle); superficial
spreading (the most common); acro-
lentiginous (palms and soles); nodular;
polypoid.
Dermatofibrosarcoma
A hard swelling in the dermis becomes larger
and soon ulcerates. It is locally malignant,
without blood or lymphatic spread and should
be widely excised.
Local recurrence of carcinoma
157
The most common variety is due to breast
cancer and is usually found in or near a
mastectomy scar. Excise for diagnosis.
Secondary carcinoma
As patients with gastro-intestinal and other
carcinomas survive longer with
chemotherapy, more late skin metastases
appear.
Subcutaneous
Benign
Epidermoid or sebaceous cysts
Many arise in hair follicles and these lesions
(with or without overlying “punctum”) are
called pilar cysts. Excise to avoid infection
and ulceration. Multiple such lesions are
found in Gardner's syndrome, associated with
familial (colonic) polyposis, adenomas,
osteomas and desmoids.
Lipoma
These swellings are most commonly found
about the shoulder girdle and neck. Painful
lipomata are usually multiple (Dercum's
disease), to be distinguished from nodular
panniculitis (Weber-Christian syndrome), in
which lumps are less well defined. Remove if
large by enucleation from within the
“capsule”.
Ganglia and bursae
These cystic swellings are found near joints.
Ganglia are most common on the radial dorsal
aspect of the wrist, bursae about the knee
joint-. Semimembranosus bursa is more
obvious with the knee flexed, osteoarthritic
posterior synovial protrusion (Baker's cyst) on
extension. Excise ganglia down to the joint
capsule or fibrous tendon sheath.
Malignant
Malignant lymph nodes
Lymphomatous nodes are firm or rubbery.
Secondary carcinomatous nodes are hard.
Chronic inflammatory nodes may be firm but
are rarely large.
Subcutaneous metastasis or recurrence
These are as common as skin metastases and
due to the same causes.
Desmoid tumour
These tumors in aponeuroses (most
commonly anterior rectus sheath) are locally
malignant and should be widely excised. They
belong to the family of lesions which include
retroperitoneal fibrosis and may be associated
with Gardner's syndrome (see above), when
they are often intraperitoneal and cause small
bowel obstruction.
Subfascial Benign
Lipoma: A subfascial lipoma on the chest wall
feels hard, like a rib tumor.
Fibroma: It is most common in the thigh
muscles. Only excision differentiates such a
lesion from a sarcoma.
Malignant
Fibrosarcoma: Most often presenting as a
large painless swelling in the thigh, this lesion
and its variants (neurofibrosarcoma,
synoviosarcomd) spread via the blood stream
and must be widely excised.
RhabdoTiyosarcoma: This rare malignant
tumor of striated muscle is clinically
indistinguishable from fibrosarcoma and must
be widely excised also.
Lesions attached to bone or periosteum
Benign
Exostoses and ecchondromata: These are
hard, sometimes pointed swellings attached to
bones near joints and pointing away from the
158
joint. They are often familial 10% become
chondiosarcomas.
Osteomas and chondromas: Osteomas on the
skull must be distinguished from sebaceous
cysts and bony metastases. Benign
chondromas are usually in the middle of a
long bone. Osteoid osteoma is a radiolucent
area in d long bone surrounded by sclerosis. It
should be removed if painful.
Giant cell tumor: These benign lesions
expand epiphyses in persons in their 20s,
producing a soap-bubble appearance on x-ray.
They are usually cured by deep x-ray therapy,
but recurrence is common. 10% become
sarcomas.
Malignant
Osteogenic sarcoma: Found in teenagers,
most are in a metaphysis above or below the
knee. They present with persistent pain. X-ray
shows bone destruction and formation. 10%
survive five years after amputation.
Ewing's tumour: The most malignant bone
tumor. It occurs in males before the age of 20
years, in the mid-shaft of a long bone. Deep
x-ray therapy provides local control but
metastasis is inevitable and amputation is to
be avoided.
Metastatic bone tumours: These are the most
common malignant tumors of bone. They may
present with painless pathological fractures or
with bone pain which is relieved by deep x-
ray therapy.
ULCERS (SORES)
Definition: An ulcer is a sore on the skin or a
mucous membrane, accompanied by the
disintegration of tissue. Ulcers can result in
complete loss of the epidermis and often
portions of the dermis and even subcutaneous
fat. Ulcers are most common on the skin of
the lower extremities and in the
gastrointestinal tract. An ulcer that appears on
the skin is often visible as an inflamed tissue
with an area of reddened skin. A skin ulcer is
often visible in the event of exposure to heat
or cold, irritation, or a problem with blood
circulation. They can also be caused due to a
lack of mobility, which causes prolonged is common, particularly in patients with
pressure on the tissues. This stress in the diabetic neuropathy.
blood circulation is transformed to a skin Malignant (see Swellings)
ulcer, commonly known as bedsores or Basal cell carcinoma (rodent ulcer)
decubitus ulcers. Ulcers often Squamous cell carcinoma
become infected, and pus forms. Malignant melanoma
Benign Venous stasis ulcer: These ulcers are Ulcerating metastases (There is often a hard
painful, shallow (but may reach periosteum lump under the ulcer, fixed to deeper tissues.)
due to loss of subcutaneous tissue), irregular
with a flat edge and a granulating floor,
sometimes with surrounding cellulitis. The
cause of venous, hypertension should be
removed by wearing a compression bandage
and walking, or by surgical division of
incompetent perforating veins. Skin grafting
may be required.
Chronic inflammatory ulcers
Chronic pyogenic ulcers are uncommon but
may produce much granulation and become
pyogenic granulomas. All other chronic
inflammatory ulcers (punched out chancre of
primary syphilis, beginning as a button-like
plaque; “snail track” ulcers of secondary
syphilis; ulcerating tertiary gummata on the
legs; soft ulcers in tuberculosis and Crohn's
disease rare. Low grade infection with
anaerobic organisms may cause undermining
ulcers, to be distinguished from tuberculosis.
Ischaemic ulcers: Such ulcers are found
furthest away from the blood supply (tips of
toes and point of heel) or at pressure points
(heels, head of first metatarsal, malleoli).
They are painful, punched-out, with little
granulation and no sign of healing. They
indicate advanced arterial disease requiring
bypass or amputation. Decubitus ulcers (bed
sores) are due to recumbency pressure in ill
people. Avoid by moving patients often and
by having them lie on a sheepskin or
waterbed.
Trophic ulcers: These ulcers are due to
deficient sensation and follow injury of which
the patient was unawared. Like ischaemic
ulcers these deep, punched-out lesions are
found over pressure points and may extend to
the bone and into joints. Secondary infection

159
FURTHER READING
Kumar, Vinay; Fausto, Nelso; Abbas, Abul. Robbins &
Cotran Pathologic Basis of Disease (7th ed.).
Saunders. 2004.
Habif TP. Eczema and hand dermatitis. In: Habif TP,
ed. Clinical Dermatology. 5th ed. St. Louis, Mo:
Mosby Elsevier; 2009.
Scully C, Shotts R; ABC of oral health. Mouth ulcers
and other causes of orofacial soreness and pain.
BMJ. 2000 Jul 15;321(7254):162-5.
Coventry J, Griffiths G, Scully C, et al; ABC of oral
health: periodontal disease. BMJ. 2000 Jul
1;321(7252):36-9.

Note: Most of the Matters are drived from Internet and

Research Papers

160
WOUNDS AND BURNS
Wounds and burns
WOUNDS
Definition: Wounds are breaches of the body
surface by sharp or blunt trauma or wound is
a type of injury in which skin is torn, cut, or
punctured (an open wound), or where blunt
force trauma causes a contusion (a closed
wound). In pathology, it specifically refers
to a sharp injury which damages the
dermis of the skin.
Types
Contamination
Wounds may be cleaned (surgical),
contaminated (non-surgical trauma, surgical
opening of viscus) or dirty (road and
military trauma, bathing of surgical wound
in faeces or pus).
161
Edge: Wounds may be incised, facerated
(torn irregular edges) or ischaemic
(associated compression or shearing).
Depth: Wounds may be simple (skin and
superficial tissues only), complicated
(division of deep structures such as nerves,
vessels, viscera) or part of a compound frac-
ture (with underlying broken bone).
Healing: May be:
First intention: Apposition of edges with
minimal granulation.
Second intention: Filling of the defect by
granulation tissue which becomes scar
tissue, gradually drawing the edges together.
Epithelium grows over the diminished area.
Third intention: By adhesion of granulating
surfaces.
Closure
Primary
When the wound is clean, incised and
simple, close at once.
Delayed primary When the wound is
contaminated, dress it for a few days and, if
it remains clean, close it.
Secondary
When the wound has become infected, clean
it with local antiseptics and administer
systemic antibiotics. Close it when clean.
Wounds may be closed by primary suture,
split skin graft, full thickness skin graft, skin
flaps or micro-vascular tissue transfer. Any
of these methods may be used in primary,
delayed primary or secondary closure.
Complications
Necrosis
Due to ischaemia of edges (tight sutures,
poor blood supply, too much tension,
infection)
Dehiscence
It takes place due to inadequate sutures,
tension on wound and necrosis of edges or
infection.
Infection
It is due to susceptibility as with ischaemia,
diabetes or immunosuppression (HIV,
transplant cases); contamination; favourable
local conditions - haematoma, dead tissue or
foreign bodies.
Haemorrhage
It may be primary - bleeding never stopped;
reactionary - bleeding begins within 48
hours as blood pressure rises; in secondary -
vessels are eroded in infected wounds 10
days after closure.
Factors interfering with wound healing
General
Impaired nutrition age, hypovitaminosis -
especially vitamin C – hypoproteinaemia,
Intercurrent illness (diabetes, vascular
disease, jaundice).
Local
Ischaemia Infection
Principles of management of traumatic
wounds
Assessment
Assess patient in general, other injuries,
local extent and depth.
Debridement
It is the removal of dead skin or doubtfully
viable tissue, particularly muscle; removal
of foreign bodies; incision of deep fascia.
Repair
Primary repair is of vessels, nerves and
tendons; reduction and immobilization of
fractures; primary repair of visceral injuries
with the exception of colon wounds, which
should be exteriorized.
Closure
Primary closure of clean wounds or larger
wounds where immediate cover is required
(compound fractures); delayed primary
closure for contaminated wounds; secondary
closure for successfully treated infected
wounds; no closure for persistently infected
wounds - allow to granulate and healed by
second intention.
BURNS
Definition: Burns are injuries to the body
surface by heat, chemicals, electric current
162
or irradiation. OR is a type of injury to flesh
or skin caused by heat, electricity,
chemicals, friction or radiation. Most burns
affect only the superficial skin (known as
superficial or first degree) or extend into the
deeper skin but do not involve the full
thickness of the skin (known as partial
thickness or second degree). Rarely all
layers of the skin or deeper tissues, such
as muscle or bone can be injured in which
case the burn is either full thickness (third
degree) or fourth degree.
Extent
The head is 9 % of the body area, each
upper limb 9 %, anterior trunk 18%,
posterior trunk 18%, each lower limb 18%
and the scrotum 1% (rule of nines). In
children, apply the rule of sixes. The head
and neck is 12% in a child under five years
and 18% in older children.
Depth
Penetration of skin structures (hair follicles,
sebaceous glands) is deepest on face and
scalp so that even deep burns here may be
partial thickness. Thin skin bums (eyelids,
dorsum of hand) are more likely to be full
thickness than thick skin bums (palms and
soles). Blistering usually means partial
thickness but prolonged blanching on finger
pressure means it is full thickness. A dry
insensitive area is probably full thickness.
Deep burns may damage major nerves and
cause major vessel thrombosis but rarely
require blood transfusion.
Chemicals will cause on-going tissue
damage unless washed off with water.
Domestic electric burns (110/240 volts)
cause a deep local burn. “Industrial” burns
(e.g. 3000 volts) conducted through the deep
tissues of a limb produce large amounts of
heat and extensive damage. Inhalation
damages the lungs by heat, by poisonous
gases (carbon monoxide, cyanide from
burning vinyl) and by smoke particles.
Suspect inhalation damage if the face is
burned and intubate early.
Management
Fluid
Fluid loss is greatest at first and falls off
over 36 hours. Oral fluid avoids water
intoxication but give fluid intravenously if
the burn is more than 15% of body surface
area (BSA), or more than 10% in children. A
burn of more than 30% BSA threatens life,
especially by hyponatraemia. There is not
much to choose between crystalloid and
colloid (most of which is lost into the
tissues). Colloid is given early, if at all.
Colloids include plasma or serum, stable
plasma-protein solution (SPPS),
concentrated human albumin and synthetic
blood volume expanders such as Dextron
(large molecule polysaccharides) or
Haemaccel (degraded gelatin polypeptides -
polygeline).
In the first four hours after the burn give
fluid at the rate of 0.5 ml per kg of body
weight per 1 % BSA burned, which comes
to about 1 liter in a 70 kg person with a 30%
BSA burn. Give the same amount in each of
five more unequal time periods: 4 to 8, 8 to
12, 12 to 18, 18 to 24 and 24 to 36 hours
after burning. Thus 2.5ml per kg of body
weight per 1 % BSA will have been given in
the first 24 hours - 5250ml in a 70kg person
with 30% BSA. These amounts are over and
above the normal daily loss of three liters of
fluid, which must also be replaced. The
Brooke Army Formula (2 ml per kg body
weight per percentage BSA, half in eight
163
hours, a quarter in the second eight hours
and quarter in the third 8 hours) gives less
fluid. The most common mistake is to
overestimate the area burned and overload
the circulation, especially in children and the
aged.
The patient must be re-assessed every two
hours. Fluid must be given at such a rate as
to maintain the urine output at more than 0.5
ml per kg body weight per hour (35 ml in a
70 kg person) and the haematocrit at less
than 35 to maintain blood flow through the
capillaries.
Burn
Silversulphadwdne cream is applied one or
more times per day. Full thickness bums are
best excised early and covered with split
skin at first. Early tangential excision
(especially where thin skin overlies moving
structures, like tendons) allows early
recognition of depth - bleeding dermal
papillae show the burn is partial thickness.
Later surgery may be required if split skin is
insufficiently elastic or scarring has fixed
joints. Use pedicle grafts or full thickness
grafts with micro-vascular anastomoses.
Amnion, homografts (e.g. from cadavers or
amputated 1'mbs) and heterografts (e.g. pig
skin) reduce bacterial growth on the burn
surface and may be used in extensive bums
as temporary 'dressings'.
Where the depth of the bum is in doubt (a
common situation) treat conservatively with
silver sulphodiazine cream or by an open
method for two weeks until demarcation is
clear. Then the eschar can be lifted off and
the surface grafted if necessary.
COLD INJURY
Exposure of extremities (fingers, toes, ears)
to extremely low temperatures quickly
closes skin arterioles and shunts and causes
skin necrosis {“frostbite”). Warming should
be rapid, the patient should be heparinized
and blood viscosity should be reduced by
infusion with Saline or low molecular
weight Dextran. Amputation may be
required.
LOSS OF BLOOD AND BODY FLUIDS
BLOOD
Loss of one unit of blood is a minor bleed
and is the amount given regularly by blood
donors.
Loss of two units (1 liter) is severe bleeding
and requires transfusion or replacement with
colloid or with crystalloid solution (e.g.
saline). Remember that crystalloids
equilibrate rapidly between the intra-
vascular and interstitial fluid spaces, so give
three times the amount of intravascular
deficit. If, for instance, crystalloids are used
in burn cases, larger volumes will be
required than if colloids are used.
Massive bleeding is loss of four to five units
(2 to 2.5 liters) - half the blood volume.
Repeated, continued severe or massive
bleeding is an indication for emergency
operation to tie off a bleeding vessel.
Large amounts of blood may be lost into
body cavities or limbs with no evidence of
external bleeding. Such blood loss must be
recognized and rapidly replaced. If
continuous transfusion is then required to
maintain blood pressure then urgent
operation is necessary to stop the on-going
bleeding.
Body fluids
In superficial burns large amounts of plasma
are lost early and large amounts of serum or
blood volume expander are required. In deep
burns much blood is lost at once in
coagulated vessels but blood transfusion is
rarely required.
Ions as well as water are lost from gastrn-
intesithal fistulae and in vomiting and
diarrhoea. Alkalosis results from loss of
hydrogen ion in gastric fistulae. Sodium ion
losses are large in high intestinal, biliary and
pancreatic fistulae. Potassium ion losses are
greater in low small intestinal fistulae.
Principles of fluid replacement in surgical
patients
164
Normal losses
Three liters of water are lost per day in
breathing, faeces and urine with 150 mmol
of sodium and 75 mmol of potassium.
Maintenance fluids may be given as three
liters of 4% dextrose in one-fifth normal
saline, adding 25 mmol of potassium
chloride to each liter.
Energy requirements are not supplied on this
regimen, which also does not allow for
minute daily losses of other elements such
as magnesium.
Abnormal losses
Larger amounts of fluid will be required
according to the amount lost. Electrolytes
lost may be replaced by appropriate
crystalloid solutions. Normal saline is suit-
able in pyloric stenosis vomiting because it
contains relatively more chloride than
sodium (150 mmol in each liter compared
with 90 mmol per liter in blood). Sodium
lactate compound (Hartinann's solution)
contains sodium lactate rather than sodium
chloride and is appropriate when more
sodium ions are lost, as in intestinal fistulae.
Calcium gluconate may be required in
diarrhoea and in pancreatitis where more
calcium ions are lost.
Successful replacement depends upon
normal renal function, accurate
intake/output monitoring including urine
output, state of peripheral circulation and
clinical evidence of dehydration.
Where losses are severe and/or sudden or
where the vascular bed is expanded as in
septicaemia and in congestive
cardiac/allure, more sophisticated methods
of monitoring are required, such as:-
Central venous pressure (CVP)
A catheter introduced via the subclavian
vein into the superior vena cava is connected
to a manometer and the pressure in it
estimated with reference to a “zero” point in
the mid-axillary line with the patient supine.
A rise in CVP above the normal range of 5
to 10 cm of water indicates over-filling of
the right heart either because of too rapid
infusion or inadequate left ventricular
function, or both. If CVP is low, peripheral
hypotension is likely to be due to inadequate
blood volume replacement.
Pulmonary artery wedge pressure (PAWP)
A balloon catheter introduced via a
peripheral vein is carried by blood flow into
the right ventricle. The catheter is then
moved into and “wedged” in the pulmonary
artery and the pressure in it (recorded by
transducer) reflects that in the left atrium. It
indicates more accurately the efficiency of
the left ventricle in propelling arterial blood
than does the CVP estimation, the latter
being separated from the left heart by the
pulmonary circulation. PAWP is raised in
cardiac failure, but reduced in septicaemia,
severe haemorrhage and pulmonary
embolism.
Nutrition
Enteral feeding is carried out via a fine
silastic tube introduced into the small bowel
via the nose, in patients who are semi-
conscious or too weak to eat. It may be
possible to manipulate such a tube under x-
ray control into normal small bowel even if
there is proximal obstruction or
fistula/polymeric (larger molecule) liquid
nutrients are isosmolar and may be used via
such tubes, avoiding the diarrhoea caused by
monomeric (hyperosmolar) nutrient fluids.
Such solutions should contain other ions
(e.g. zinc, magnesium) and vitamins as well
as sufficient calories, essential amino acids
and lipids.
A feeding jejunostomy line may be created
if such a tube cannot be used.
Parenteral nutrition is required if the gastro-
intestinal tract is unavailable. A long
catheter is introduced into the superior vena
cava via a peripheral vein. A central venous
line or Hickman's cannula is preferable for
prolonged total parenteral nutrition (TPN),
with less likelihood of thrombosis and
infection;
165
The main dangers of TPN are sepsis
(controlled by antibiotics or otherwise
requiring removal of catheter) and
thrombosis (uncommon because the solution
is diluted in the large vein).
Circulation
Patients severely ill for one reason or
another for instance with septic shock, major
injury, peritonitis or pancreatitis may need
drugs supporting the cardiovascular system
(inotropes). Low dose Dopamine (2 to 5 mg
per kg of body weight per minute) constricts
peripheral arterioles and dilates renal and
mesenteric arterioles, thus maintaining
perfusion of kidney and bowel without
lowering the systemic blood pressure. High
dose Dopamine (10 to 50 mg per kg of body
weight per minute) constricts peripheral
vessels, dilates coronary vessels and
increases cardiac contractility, rate and
conduction velocity. Noradrenalin
(Norepinephrine) is a cardiac muscle
stimulant and dilates cardiac vessels but may
cause severe peripheral vasoconstriction
with gangrene if not used with caution.
ORGAN REPLACEMENT
Organs which are diseased beyond recovery
while the rest of the body is relatively
healthy are now often replaced. Rejection of
replacement organs is avoided by
immunosuppression with Cyclosporin.
Immunosuppressed survivors ultimately
develop cancers, especially easily removable
cutaneous squamous cell carcinomas. The
most compatible organs are those from live
closely-related donors, for instance, a kidney
from a brother or sister (preferably a twin);
pan of a mother's liver for her child.
Unfortunately most transplant organs are at
present derived from brain-dead young
people injured in road crashes. It is noted
that this source of organs will diminish,
encouraging research into and production of
artificial biomechanical organs. Most of the
diseases requiring organ transplantation are
“medical” and detailed consideration of
indications for these operations is beyond
the scope of this book. Common indications
for cardiac transplantation are viral myocar-
ditis, severe congenital defects, cardiac
failure due to ischaemic heart disease in
younger patients; for renal transplantation,
severe glomerulonephritis and polycystic
kidneys; for liver transplantation, large
primary benign and malignant neoplasms,
non-alcoholic cirrhosis, and congenital
biliary atresia. There have now been
numerous successful heart-lung transplants
and a few successful small bowel transplants
have been reported in cases of short bowel
syndrome.

FURTHER READING
Avni T, Levcovich A, Ad-El DD, Leibovici L, Paul
M. Prophylactic antibiotics for burns patients:
systematic review and meta-analysis. BMJ. 2010;
340: c241.
Bailey and Love's Short Practice of Surgery. United
Kingdom: Hodder Arnold. 2008.
David Herndon. Total Burn Care, 3rd Edition,
Saunders, 2007.
Hubley P. Review: evidence on dressings for
superficial burns is of poor quality. Evid Based
Nurs. 2009; 12 (3): 78.
Sevitt S A review of the complications of burns, their
origin and importance for illness and death. J
Trauma 1979; 19 (5): 358–69.

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and Research Papers

166
MAJOR INJURIES

Major injuries
Definition: Any fracture other than finger,
thumb or toes. Any dislocation of shoulder,
hip, knee or spine. Any amputation. Loss of
the sight of an eye (whether temporary or
permanent). Chemical or hot metal burn to the
eye or any penetrating injury to the eye. Any
injury which results in electric shock and
electric burns leading to unconsciousness and
requires resuscitation or admittance to
hospital for 24 hours or more. Any other
injury leading to hypothermia, heat induced
illness or unconsciousness requiring
resuscitation or admittance to hospital for 24
hours or more. Loss of consciousness caused
by asphyxia or lack of oxygen or exposure to
a biological agent or harmful substance. Critical injury is where this damage leads to
Absorption of any substance by inhalation, failure of one or more of the vital systems
skin or ingestion causing loss of (nervous, cardiovascular, respiratory, urinary,
consciousness or acute illness requiring gastrointestinal).
medical treatment. Acute illness requiring Use of a Trauma Score (TS), based on the
medical treatment where there is reason to scale of coma, the systolic blood pressure and
believe the exposure was to biological agents, the respiratory rate, and an Injury Severity
its toxins or infected materials. Score (ISS), derived from rating of the
There is major injury when more than one severity of injury to six different body
area of the body (head and neck, chest, spine, regions, rapidly helps to identify seriously
abdomen and pelvis, limbs) is damaged by injured patients and improves their early
severe external trauma. management.

EARLY MANAGEMENT
FIRST AID
Stop arterial bleeding by direct pressure or
tourniquet. Stop venous bleeding by elevating
the part and by direct compression.
Start breathing by holding the lower jaw
forwards removing vomitus or other material
from the mouth and oropharyfix with the

167
fingers, then giving mouth to mouth
respiration.
Start the heart by external cardiac
compression. Move the patient as little as
possible at first in case of cervical or lumbar
spine injury. Movement might complete
transection of the spinal cord or cause sudden
death by pushing the odontoid process into
the brain stem.
Cover open wounds with a firm dressing,
particularly open chest wounds.
Splint limb fractures by binding the lower
limbs together or the upper limbs against die
chest wall, or use inflatable splints if
available.
Evacuation
Special cases should be treated in special
areas or in special hospitals (children, severe
burns, patients with extensive skin loss
requiring major plastic surgery).
Speedy evacuation by ambulance and by
helicopter with in route intravenous infusion,
intubation, carried out by specially trained
crews, has saved life and limb in warfare and
is applicable to civilian situations where
population is dense and major trauma is
frequent.
Hospital Emergency Departments should be
staffed by highly trained emergency specialist
surgeons and physicians or general hospitals
should have rostered trauma teams, consisting
of senior residents or registrars trained in
resuscitation techniques. These teams, com-
prising a surgeon, a physician (internist) and
anaesthetist, should be quickly available 24
hours a day.
EMERGENCY DEPARTMENT
Stop major external bleeding by clamping
bleeding vessels and restore circulation with
rapid infusion of Hypertonic saline, Dextran
or Polygeline while taking blood for cross-
matching. Invariably, large amounts of blood
must be given in the first eight hours. Major
injury patients may require, on the day of
injury, amounts of whole blood or blood
substitute equivalent to three times the total
168
blood volume (15 liters). Several lines may be
required to administer so much blood. Such
rapid replacement requires monitoring by
CVP and PAWP estimation as well as by
estimation of pulse, blood pressure and urine
output.
Clear the airways by aspiration. Perform
endo-tracheal intubation if the patient is
unconscious. Recognize tension
pneumothorax (dyspnoea, cyanosis,
tympanitic expanded hemithorax) and insert
second intercostal space catheter connected to
underwater seal. Cover an open chest wound
with a sterile dressing. Begin positive
pressure assisted respiration if there is a large
loose segment of chest wall with severe flail
chest institute epidural analgesia as soon as
possible in such cases.
If shock persists after control of external
bleeding, in spite of rapid infusion, suspect
internal bleeding. This may be recognized by
spreading dullness to percussion in the chest
associated with dyspnoea, in the abdomen by
widespread tenderness and increasing
distension. A mid-axillary line intercostals
catheter in the 9th space will identify
haemothorax. If blood is escaping at a more
rapid rate than fluid is being infused and if the
blood pressure continues to fall, speed up the
infusion rate and organize immediate
thoracotomy.
Severe persistent shock associated with a
wound near the heart is best dealt with by
median sternotomy, sewing up the wound(s)
in the heart and/or great vessels. Major intra-
abdominal bleeding is an indication for
immediate laparotomy, dealing with the
bleeding vessels or organs as required.
Meanwhile the conscious state is quickly
assessed. External evidence of head injury
(bruising, palpable fractures) and evidence of
rising ICP (high blood pressure, low pulse,
diminishing consciousness, pupil changes)
mean immediate MRI or CT scan is required
to identify treatable intracranial bleeding.
Quickly assess limb injuries. In the case of
simple fractures, nothing more than splinting
is necessary at this stage. Fractures should be
reduced and immobilized once circulation and
respiration are stable and other major injuries
have been cared for. Indications for early
surgery are compound fractures, particularly
with gross contamination or tissue loss or
evidence of major nerve or vessel injury
requiring primary repair. Early reduction and
immobilization of fractures stop continuing
blood loss into the limb.
Spinal injury may be minor but major injury
with paraplegia or quadriplegia requires
immediate transfer to a Spinal Unit.
DEFINITIVE MANAGEMENT
Head
Operation is worthwhile in cases of
intracranial compression only if there is a
local lesion, never where there are widespread
lacerations and cerebral oedema.
Avoid respiratory obstruction in face fractures
by reducing and fixing depressed fractures
and overcoming nasopharyngeal compression;
by bandaging and then wiring the jaws
together in cases of fractured mandible,
preventing the tongue from falling back.
Neck
Indications for surgical exploration of rounds
include severe bleeding, pulsatile haematoma,
abseil pulses or bruits, blood-stained sputum,
air bubbling through the wound, subcutaneous
emphysema with no pneomo-thorax, all high
velocity gunshot wounds or wide
mediastinum on x-ray in the absence of chest
injury. Only 50% require operation. The most
severe injuries are those involving vessels.
Chest
Early re-expansion of the lungs is the aim of
the treatment. A small haemothorax may be
left alone, but a large one should eventually
be removed to avoid organization of clot
preventing lung re-expansion.
Abdomen
Diagnostic peritoneal lavage (DPL) will
identify bleeding in doubtful cases. One liter
169
of warmed normal saline is introduced. 75%
of the infused volume is returned and
examined for blood cells, bile, bacteria and
food fiber. DPL is indicated in unconscious or
drunk patients or in those with spinal injuries.
Not all patients with bleeding due to blunt
injury require laparotomy. Many cases of
bleeding from spleen, liver or kidney will
settle down without surgery. In sharp or
penetrating injuries (less lethal than blunt
injuries) laparotomy is required if penetration
is proven by exploration of the entry wound.
If there is bleeding from a liver wound,
compress the free edge of the lesser omentum
(Pringle's manoeuvre). If bleeding stops, it is
from hepatic arteries or portal veins. Find the
bleeding vessels and ligate them. If bleeding
does not stop, it is from the hepatic veins.
Exposure will require abdomino-thoracic
incision. An internal bypass may have to be
inserted in the inferior vena cava above the
renal veins, extending up to the left atrium.
Immediate right hepatectomy might be
necessary to stop torrential bleeding from
large short hepatic veins. Always leave a
drain down to lacerated liver in case of bile
leakage.
If laparotomy is necessary for bleeding from
the spleen, try to preserve it by suturing its
capsule, to avoid loss of immunity to
pneumococcal infection. If laceration is gross,
divide the anterior pedicle (gastrosplenic
omentum); and posterior pedicle (splenic
vessels), avoiding the tail of the pancreas and
the splenic flexure of the colon and remove
the spleen.
Perform cholecystectomy for gallbladder
injuries and suture stomach and duodenal
wounds (not forgetting the difficulty of
recognition of retroperitoneal rupture of the
second part of the. duodenum). Suture small
bowel wounds, remembering lacerations of
the mesentery may embarrass the circulation
to the bowel beyond the area of laceration.
Exteriorize crushed or lacerated colon with or
without immediate resection, bringing out
both ends. Lacerations of intraperitoneal
rectum may be closed but require proximal
colostomy if there is much contamination.
Lacerations of infraperitoneal rectum always
require a divided proximal colostomy with
vigorous wash-out to prevent pelvic sepsis.
Always carry out intravenous pyelogram in
case of suspected kidney injury to show the
other kidney is normal. If the patient is
shocked, immediate MRI or CT scan best
identifies severe kidney injury. Operate if
there is severe persistent haematuria,
continuing shock in spite of transfusion or CT
evidence of major disruption. Most ruptured
kidneys needing operation require
nephrectomy, in some cases partial.
A damaged ureter should be sutured leaving
in an internal splint if there has been loss of
tissue. The area should be drained.
Pelvis
Blunt injury of the abdomen compressing a
full bladder causes intraperitoneal rupture
and is treated by laparotomy, suture and
indwelling catheter.
Suspect extra peritoneal rupture of the
bladder where there is pubic symphysis
separation pulling the two halves of the
Madder apart in the midline anteriorly. Repair
and drain the extravesical space. Leave a
catheter in for 10 days.
Suspect ruptured membranous urethra in
“push back” injuries of the anterior pelvic
ring (four pubic rami fractures) pushing the
prostate backwards off the urogenital
diaphragm. Immediate cystourethro-gram
distinguishes extraperifoneal rupture of the
bladder from ruptured membranous urethra.
Perform cystotomy, railroading sounds from
penis into bladder and then out again carrying
an indwelling catheter which, with tension,
will fix the prostate against the urogenital
diaphragm. Leave the catheter in for six
weeks. Subsequent strictures require
bouginage. In some cases primary repair is
possible, protected by suprapubic cystostomy.
Limbs
170
Spine
Remarkable recovery from quadriplegia due
to cervical spine injury may follow prompt
reduction of flexion-rotation injuries with
bilateral facet dislocation. Open reduction
may be required.
Hyperextension injuries, common in the older
patient with immobile spine, need no
treatment and may recover some sensation
and movement. Younger patients with such
injuries require skull traction but outlook is
poor.
Severe injuries of upper cervical spine are
fatal at once. Minor fractures of the odontoid
process seldom cause cord compression but
should be treated by posterior atlanto-axial
fusion to avoid instability.
Thoracic spine injuries require no special
treatment and the lumbar spine is well
protected by thick muscles. Fracture-
dislocation is most common at the
thoracolumbar junction, where the vertebrae
are smallest, flexion and extension are
maximal and torsion is possible. Injury of the
spinal cord will cause paraplegia. Operation
to reduce the fracture-dislocation and
“decompress” the spinal cord is rarely useful.
Carry put immediate MRI or CT scan. If the
cord is not transected and there is a large
haematoma in the spinal canal, immediate
exploration may be worthwhile. Otherwise
manage such patients as paraplegics and make
no attempt to reduce the fracture-dislocation.
In paraplegia, aim to avoid pressure sores by
frequent (two hourly) turning. Encourage
development of automatic bladder by
indwelling catheter and regular release,
avoiding over-distension. Develop automatic
defaecation by avoiding early over-distension
of the rectum with the help of regular enemas.
Avoid the sequels of recumbency - muscle
wasting, joint stiffness, urinary calculi,
pressure sores, obesity, osteoporosis and
fractures. Games, hobbies, work, education
and training for new jobs are important in
restoring self-confidence, self-respect and
self-support.
REHABILITATION
Exercises and activities of all kinds are
required in cases of fracture and joint injury
to regain full movement. With brain damage
and spinal cord injury, attempts must be made
to compensate for lost functions, making the
most of automatic processes.

FURTHER READING
David L. Streiner, Geoffrey R. Norman. Health
Measurement Scales: A Practical Guide to Their
Development and Use. Oxford University
Press, 2008
LoPachin R.M. and Lehning E.J. Mechanism of
calcium entry during axon injury and
degeneration. Toxicology and Applied
Pharmacology. 1997; 143 (2): 233—244.
Sanders M.J. and McKenna K. Mosby’s Paramedic
Textbook, 2nd revised Ed. Chapter 22, "Head and
Facial Trauma." Mosby. 2001.
Semyon Slobounov. Injuries in Athletics:Causes and
Consequences. Springer, Jan 2008.
Sundstrom, T.; Grände, P.-O.; Juul, N.; Kock-Jensen,
C.; Romner, B.; Wester, K Management of Severe
Traumatic Brain Injury: Evidence, Tricks, and
Pitfalls. Springer. 2012

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Research Papers

171
Chapter-5

173
174
NEUROLOGICAL (CNS) EXAMINATION
A neurological examination is the certain aspects of a patient's history will
assessment of sensory neuron and motor become more important depending upon the
responses, especially reflexes, to determine complaint issued). Important factors to be
whether the nervous system is impaired. This taken in the medical history include:
typically includes a physical examination and • Time of onset, duration and associated
a review of the patient's medical history, but symptoms (e.g., is the
not deeper investigation such as neuro- complaint chronic or acute)
imaging. It can be used both as a screening • Age, gender, and occupation of the patient
tool and as an investigative tool, the former of • Handedness (right- or left-handed)
which when examining the patient when there • Past medical history
is no expected neurological deficit and the • Drug history
latter of which when examining a patient • Family and social history
where you do expect to find abnormalities. If a Handedness is important in establishing the
problem is found either in an investigative or area of the brain important for language (as
screening process then further tests can be almost all right-handed people have a left
carried out to focus on a particular aspect of hemisphere, which is responsible for
the nervous system (such as lumbar language). As patients answer questions, it is
punctures and blood tests). important to gain an idea of the complaint
In general, a neurological examination is thoroughly and understand its time course.
focused on finding out whether there Understanding the patient's neurological state
are lesions in the central and peripheral at the time of questioning is important, and an
nervous systems or there is another diffuse idea of how competent the patient is with
process that is troubling the patient. Once the various tasks and his/her level of impairment
patient has been thoroughly tested, it is then in carrying out these tasks should be obtained.
the role of the physician to determine whether The interval of a complaint is important as it
these findings combine to form a recognizable can help aid the diagnosis. For
medical syndrome or neurological example, vascular disorders (such as strokes)
disorder such as Parkinson's disease or motor occur very frequently over minutes or hours,
neurone disease. Finally, it is the role of the whereas chronic disorders (such as
physician to find the cause for why such a Alzheimer's disease) occur over a matter of
problem has occurred, for example finding years.
whether the problem is due to inflammation or Carrying out a 'general' examination is just as
is congenital. important as the neurological exam, as it may
A patient's history is the most important part lead to clues to the cause of the complaint.
of a neurological examination and must be This is shown by cases
performed before any other procedures unless of cerebral metastases where the initial
impossible (i.e., if the patient is unconscious complaint was of a mass in the breast.
Specific tests in a neurological examination include the following:
Category Tests Example of write up
• The assessment of consciousness, often using
Mental the Glasgow Coma Scale (EMV) "A&O x 3, short
status • Mental status examination, often including and long-term
examination the abbreviated mental test score (AMTS) or mini memory intact"
mental state examination (MMSE)

175
 • Global assessment of higher functions
• Intracranial pressure is roughly estimated
by fundoscopy; this also enables assessment
for microvascular disease.
Cranial nerves (I-XII): sense of smell (I), visual fields
and acuity (II), eye movements (III, IV, VI) and pupils
(III, sympathetic and parasympathetic), sensory function
Cranial of face (V), strength of facial (VII) and shoulder girdle
"CNII-XII grossly
nerve muscles (XI), hearing (VII, VIII), taste (VII, IX, X),
intact"
examination pharyngeal movement and reflex (IX, X), tongue
movements (XII). These are tested by their individual
purposes (e.g. the visual acuity can be tested by a Snellen
chart).
• Muscle strength, often graded on the MRC scale 0 to
5 (i.e., 0 = Complete Paralysis to 5 = Normal Power).
• grades 4−, 4 and 4+ maybe used to indicate
movement against slight, moderate and strong
resistance respectively.
• Muscle tone and signs of rigidity.
• Examination of posture
• Decerebrate
• Decorticate
• Hemiparetic
• Resting tremors
• Abnormal movements "strength 5/5
Motor
• Seizure throughout, tone
system
• Fasciculations WNL"
• Tone
• Spasticity
• Pronator drift
• Rigidity
• Cogwheeling (abnormal tone suggestive
of Parkinson's disease)
• Gegenhalten – is resistance to passive
change, where the strength of antagonist
muscles increases with increasing
examiner force. More common in
dementia.
Reflexes: masseter, biceps and triceps tendon, knee
tendon, ankle jerk and plantar (i.e. Babinski sign).
Deep Globally, brisk reflexes suggest an abnormality of
"2+ symmetric, down
tendon the UMN or pyramidal tract, while decreased reflexes
going plantar reflex"
reflexes suggest abnormality in the anterior
horn, LMN, nerve or motor end plate. A reflex
hammer is used for this testing.

176
 Sensory system testing involves provoking sensations of
fine touch, pain and temperature. Fine touch can be
evaluated with a monofilament test, touching
various dermatomeswith a nylon monofilament to detect
any subjective absence of touch perception.
• Sensory
• Light touch
• Pain
• Temperature
"intact to sharp and
Sensation • Vibration
dull throughout"
• Position sense
• Graphesthesia
• Stereognosis, and
• Two-point discrimination (for discriminative
sense)
• Extinction
• Romberg test – 2 out of the following 3 must be
intact to maintain balance: i. vision ii.
vestibulocochlear system iii. epicritic sensation
• Cerebellar testing
• Dysmetria
• Finger-to-nose test
• Ankle-over-tibia test
• Dysdiadochokinesis
"intact finger-to-
Cerebellum • Rapid pronation-supination
nose, gait WNL"
• Ataxia
• Assessment of gait
• Nystagmus
• Intention tremor
• Staccato speech
Interpretation]
The results of the examination are taken (CNS), or both. Considering if the
together to anatomically identify the lesion. finding (or findings) can be explained
This may be diffuse (e.g., neuromuscular by a single lesion or whether it
diseases, encephalopathy) or highly specific requires a multifocal process.
(e.g., abnormal sensation in • Establishing the lesion's location. If the
onedermatome due to compression of a process involves the CNS, clarifying
specific spinal nerve by a tumor deposit). if it is cortical, subcortical, or
General principles multifocal. If subcortical, clarifying
• Looking for side to side symmetry: whether it is white matter, basal
one side of the body serves as a ganglia, brainstem, or spinal cord. If
control for the other. Determining if the process involves the PNS then
there is focal asymmetry. determining whether it localizes to the
• Determining whether the process nerve root, plexus, peripheral nerve,
involves the peripheral nervous neuromuscular junction, muscle or
system (PNS), central nervous system whether it is multifocal.

177
A differential diagnosis may then be
constructed that takes into account the
patient's background (e.g., previous cancer,
autoimmune diathesis) and present findings to
include the most likely causes. Examinations
are aimed at ruling out the most clinically
significant causes (even if relatively rare, e.g.,
brain tumor in a patient with subtle word-
finding abnormalities but no
increased intracranial pressure) and
ruling in the most likely causes.
The goals of the neurological examination
are several:
1. For patients presenting with symptoms
suggestive of a neurological problem,
the examination should:
a. Determine, on the basis of an
organized and thorough
examination, whether in fact
neurological dysfunction exists.
b. Identify which component(s) of
the neurological system are
affected (e.g. motor, sensory,
cranial nerves, or possibly
several systems
simultaneously).
c. If possible, determine the
precise location of the problem
(e.g. peripheral v central
nervous system; region and
side of the brain affected etc.).
d. On the basis of these findings,
generate a list of possible
etiologies. Unlikely diagnoses
can be excluded and
appropriate testing (e.g. brain
and spinal cord imaging) then
applied in an orderly and
logical fashion.
2. Screening for the presence of discrete
abnormalities in patients at risk for the
development of neurological disorders.
This is appropriate for individuals who
have no particular subjective
symptoms suggestive of a neurological
problem, yet have systemic illnesses
178
that might put them at risk for subtle
dysfunction. Diabetic patients, for
example (particularly those with long
standing poor control), may develop
peripheral nerve dysfunction. This may
only be detected through careful
sensory testing (see below under
Sensory Testing), which would have
important clinical implications.
3. Cursory screening/documentation of
baseline function for those who are
otherwise healthy. In patients with
neither signs nor risk factors for
neurological disease, it's unlikely that
the detailed exam would uncover
occult problems. Simply observing the
patient during the course of the usual
H&P (i.e. watching them walk, get up
and down from the exam table, etc.)
may well suffice. Many examiners
incorporate some aspects of the neuro
exam into their standard evaluations.
Cranial Nerve testing, for example, can
be easily blended into the Head and
Neck evaluation. Deciding what other
aspects to routinely include is based on
judgment and experience.
The major areas of the exam, covering the
most testable components of the neurological
system, include:
1. Mental status testing
2. Cranial Nerves
3. Muscle strength, tone and bulk
4. Reflexes
5. Coordination
6. Sensory Function
7. Gait
Real and imagined problems with the
neurological examination:
The neurological examination is one of the
least popular and (perhaps) most poorly
performed aspects of the complete physical. I
suspect that this situation exists for several
reasons:
1. This exam is perceived as being time
and labor intensive.
 2. Students and house staff never develop
an adequate level of confidence in
their ability to perform the exam, nor
in the accuracy of their findings. This,
in turn, probably translates into poor
performance later in their careers.
3. Exam findings are often quite
subjective.Thus, particularly when the
examiner does not have confidence in
their abilities (see above),
interpretation of the results can be
problematic.
4. Understanding/Interpretation of some
neurological findings requires an in
depth understanding of neuroanatomy
and pathophysiology. As many
clinicians do not see a large number of
patients with neurological disorders,
they likely maintain a limited working
understanding of this information.
5. There is an over reliance on the utility
of neuro-imaging (e.g. CT, MRI).
These studies provide an evaluation of
anatomy but not function. Thus, while
extremely helpful, they must be
interpreted within the context of exam
findings. Careful examination may
make imaging unnecessary. Also,
exam findings can make a strong case
for the presence of a pathologic
process, even if it is not seen on a
particular radiological study (i.e. there
are limits to what can be seen on even
the most high tech imaging).
The above are not meant to lower expectations
with regards to how well a physician should
be expected to learn and perform the
neurological examination. Rather, I mention
these points to highlight some of the real and
imagined obstacles to clinical performance.
Like all other aspects of the physical exam,
there is a wealth of information that can be
obtained from the neurological examination,
provided that it is done carefully and
accurately.This is, of course, predicated on
179
learning how to do it correctly. A few
practical considerations/suggestions:
1. In general, the neurological
examination is not applied in its
entirety to asymptomatic, otherwise
healthy people as the yield (i.e.
likelihood of identifying occult
disease) would be quite low. It is,
however, a good idea to practice the
exam early in your careers, even when
working with normal patients.This will
improve the facility with which you
perform the exam, provide you with a
better sense of the range of normal,
increase the accuracy of the results
generated, and give you confidence in
the meaning of findings identified
when evaluating other patients.
2. It is sometimes appropriate to perform
only certain parts of the neurological
examination (e.g. just cranial nerves;
or only motor testing)These situations
will become apparent with experience.
3. The testing described below is still
rather basic. There are many additional
aspects of the exam that should be
applied in specific settings. They are
beyond the scope of this text, but can
be found in other references.
4. Take advantage of those opportunities
when a more experienced clinician
examines one of your patients. When
possible, watch them perform their
exam. Then go back alone and verify
the findings.
Like any other aspect of the exam, the
neurological assessment has limits. Testing of
one system is often predicated on the normal
function of other organ systems. If, for
example, a patient is visually impaired, they
may not be able to perform finger to nose
testing, a part of the assessment of cerebellar
function (see below). Or, a patient's severe
degenerative hip disease will prevent them
from walking, making that aspect of the exam
impossible to assess. The interpretation of
"findings" must therefore take these things 20/400 means that the patient's vision 20
into account. Only in this way can you feet from an object is equivalent to that of a
generate an accurate picture. Doing this, of normal person viewing the same object from
course, takes practice and experience. 400 feet. In other words, the larger the
Cranial Nerve (CN) Testing denominator, the worse the vision.
Many practitioners incorporate cranial nerve
testing with their complete examination of the
head and neck (see the Head and Neck section
of this web site for details). A detailed
description of the CN assessment is provided
below. As each half of the body has its own
cranial nerve, both right and left sides must be
checked independently.
Cranial Nerve 1 (Olfactory): Formal
assessment of ability to smell is generally
omitted, unless there is a specific complaint. If
it is to be tested:
1. 1. Check to make sure that the patient
is able to inhale and exhale through the Snellen chart for measuring visual acuity
open nostril. c. There are hand held cards that look like
2. Have the patient close their eyes. Snellen Charts but are positioned 14 inches
3. Present a small test tube filled with from the patient. These are used simply for
something that has a distinct, common convenience. Testing and interpretation are
odor (e.g. ground coffee) to the open as described for the Snellen.
nostrils. The patient should be able to
correctly identify the odor at
approximately 10 cm.
Cranial Nerve 2 (Optic): This nerve carries
visual impulses from the eye to the optical
cortex of the brain by means of the optic
tracts. Testing involves 3 phases (also covered
in the section of this site dedicated to the Eye Hand held visual acuity card
Exam): d. If neither chart is available and the patient
1.Acuity: has visual complaints, some attempt
a. Each eye is tested separately. If the patient should be made to objectively measure
uses glasses to view distant objects, they visual acuity. This is a critically important
should be permitted to wear them (referred reference point, particularly when trying to
to as best corrected vision). communicate the magnitude of a visual
b.A Snellen Chart is the standard, wall disturbance to a consulting physician. Can
mounted device used for this assessment. the patient read news print? The headline
Patients are asked to read the letters or of a newspaper? Distinguish fingers or
numbers on successively lower lines (each hand movement in front of their face?
with smaller images) until you identify the Detect light?Failure at each level
last line which can be read with 100% correlates with a more severe problem.
accuracy. Each line has a fraction written 2. Visual Field Testing: Specific areas of the
next to it. 20/20 indicates normal vision. retina receive input from precise areas of

180
 the visual field. This information is carried
to the brain along well defined anatomic
pathways. Holes in vision (referred to as
visual field cuts) are caused by a
disruption along any point in the path from
the eyeball to the visual cortex of the
brain. Visual fields can be crudely
assessed as follows:
a. The examiner should be nose to nose with
the patient, separated by approximately 8
to 12 inches.
b. Each eye is checked separately. The
examiner closes one eye and the patient
closes the one opposite. The open eyes
should then be staring directly at one
another.
c. The examiner should move their hand out
towards the periphery of his/her visual
field on the side where the eyes are open.
The finger should be equidistant from both
persons.
d. The examiner should then move the
wiggling finger in towards them, along an
imaginary line drawn between the two
persons.The patient and examiner should
detect the finger at more or less the same
time.
e. The finger is then moved out to the
diagonal corners of the field and moved
inwards from each of these directions.
Testing is then done starting at a point in
front of the closed eyes. The wiggling
finger is moved towards the open eyes.
f. The other eye is then tested.
Meaningful interpretation is predicated upon
the examiner having normal fields, as they are
using themselves for comparison.
If the examiner cannot seem to move their
finger to a point that is outside the patient's
field don't worry, as it simply means that their
fields are normal.
Interpretation: This test is rather crude, and it
is quite possible to have small visual field
defects that would not be apparent on this type
of testing. Prior to interpreting abnormal
findings, the examiner must understand the
181
normal pathways by which visual impulses
travel from the eye to the brain.
3. Pupils: The pupil has afferent (sensory)
nerves that travel with CN2. These nerves
carry the impulse generated by the light
back towards the brain. They function in
concert with efferent (motor) nerves that
travel with CN 3 and cause pupillary
constriction. Seen under CN 3 for specifics
of testing.
Cranial nerves 3, 4 and 6 & extra ocular
movements:
Normally, the eyes move in concert (ie when
left eye moves left, right eye moves in same
direction to a similar degree). The brain takes
the input from each eye and puts it together to
form a single image. This coordinated
movement depends on 6 extra ocular muscles
that insert around the eye balls and allow them
to move in all directions. Each muscle is
innervated by one of 3 Cranial Nerves (CNs):
CNs 3, 4 and 6. Movements are described as:
elevation (pupil directed upwards), depression
(pupil directed downwards), adbduction (pupil
directed laterally), adduction (pupil directed
medially), extorsion (top of eye rotating away
from the nose), and intorsion (top of eye
rotating towards the nose).
The 3 CNs responsible for eye movement and
the muscles that they control are as follows:
CN 4 (Trochlear): Controls the Superior
Oblique muscle.
CN 6 (Abducens): Controls the Lateral Rectus
muscle.
CN 3 (Oculomotor): Controls the remaining 4
muscles (inferior oblique, inferior rectus,
superior rectus, and medial rectus). CN3 also
raises the eyelid and mediates constriction of
the pupil (discussed below).
The mnemonic "S O 4, L R 6, All The Rest 3"
may help remind you which CN does what
(Superior Oblique CN 4, Lateral Rectus CN 6,
All The Rest of the muscles innervated by CN
3).
EOMs and their function: The medial and
lateral rectus muscles are described first, as
Practically speaking, cranial nerve testing is
their functions are very straight forward:
done such that the examiner can observe eye
Lateral rectus: Abduction (i.e. lateral
movements in all directions. The movements
movement along the horizontal plane)
should be smooth and coordinated. To assess,
Medial rectus: Adduction (i.e. Medial
proceed as follows:
movement along the horizontal plane). The
1. Stand in front of the patient.
remaining muscles each causes movement in
2. Ask them to follow your finger with their
more than one direction (e.g. some
eyes while keeping their head in one
combination of elevation/depression,
position
abduction/adduction, intorsion/extorsion).
3. Using your finger, trace an imaginary "H"
This is due to the fact that they insert on the
or rectangular shape in front of them,
eyeball at various angles, and in the case of
making sure that your finger moves far
the superior oblique, thru a pulley. Review of
enough out and up so that you're able to
the origin and insertion of each muscle sheds
see all appropriate eye movements (ie
light on its actions (see links @ the end of this
lateral and up, lateral down, medial down,
section). The net impact of any one EOM is
medial up).
the result of the position of the eye and the
4. At the end, bring your finger directly in
sum of forces from all other contributing
towards the patient's nose. This will cause
muscles.
the patient to look cross-eyed and the
Specific actions of the remaining EOMs are
pupils should constrict, a response referred
described below. The action which the muscle
to as accommodation.
primarily performs is listed first, followed by
secondary and then tertiary actions.
Inferior rectus: depression, extorsion and
adduction.
Superior rectus: elevation, intorsion and
adduction
Superior oblique: intorsion, depression and
abduction
Inferior oblique: extorsion, elevation and
abduction Testing Extraocular Movements
Pathology: Isolated lesions of a cranial nerve
or the muscle itself can adversely affect
extraocular movement. Patients will report
diplopia (double vision) when they look in a
direction that's affected. This is because the
brain can't put together the discordant images
in a way that forms a single picture. In

182
response, they will either assume a head tilt
that attempts to correct for the abnormal eye
positioning or close the abnormal eye. As an
example, the patient shown below has a left
cranial nerve 6 lesion, which means that his
Right eye ptosis from CN 3 Palsy. In
left lateral rectus no longer functions. When
addition, the right eye is directed laterally,
he looks right, his vision is normal. However,
which is due to unopposed effects of CNs 4
when he looks left, he experiences double
& 6. The dilated right pupil is explained
vision as the left eye can't move laterally. This
below.
is referred to as horizontal diplopia.
The response of pupils to light is controlled by
afferent (sensory) nerves that travel with CN 2
and efferent (motor) nerves that travel with
CN 3. These innervate the ciliary muscle,
which controls the size of the pupil. Testing is
performed as follows:
1. It helps if the room is a bit dim, as this will
cause the pupil to become more dilated.
2. Using any light source (flashlight, oto-
Left CN 6 Palsy
ophtahlmoscope, etc), shine the light into
Patient was asked to look left. Note that left
one eye. This will cause that pupil to
eye will not abduct.
constrict, referred to as the direct response.
It's worth mentioning that disorders of the
3. Remove the light and then re-expose it to
extra ocular muscles themselves (and not the
the same eye, though this time, observe the
CN which innervate them) can also lead to
other pupil. It should also constrict,
impaired eye movement. For example,
referred to as the consensual response.
pictured below is a patient who has suffered a
This occurs because afferent impulses
traumatic left orbital injury. The inferior
from one eye generate an efferent response
rectus muscle has become entrapped within
(i.e. signal to constrict) that is sent to both
the resulting fracture, preventing the left eye
pupils.
from being able to look downward. The
4. If the patient's pupils are small at baseline
scleral blood and peri-orbital echymosis are
or you are otherwise having difficulty
secondary to the trauma as well.
seeing the changes, take your free hand
and place it above the eyes so as to
provide some shade. This should cause the
pupils to dilate additionally, making the
change when they are exposed to light
As mentioned above, CN 3 also innervates the more dramatic. If you are still unable to
muscle which raises the upper eye lid (Levator appreciate a response, ask the patient to
Palpebrae Superioris muscle). This can be close their eye, generating maximum
assessed by simply looking at the patient. If darkness and thus dilatation. Then ask the
there is CN 3 dysfunction, the eyelid on that patient to open the eye and immediately
side will cover more of the iris compared with expose it to the light. This will (hopefully)
the other eye. This is referred to as ptosis. make the change from dilated to
constricted very apparent.
Interpretation:

183
1. Under normal conditions, both pupils will
appear symmetric. Direct and consensual
response should be equal for both.
2. Asymmetry of the pupils is referred to as
aniosocoria. Some people with anisocoria
have no underlying neuropathology. In
this setting, the asymmetry will have been
present for a long time without change and
the patient will have no other neurological
signs or symptoms. The direct and
consensual responses should be preserved.
3. A number of conditions can also affect the
size of the pupils.
Medications/intoxications which cause
generalized sympathetic activation will
result in dilatation of both pupils. Other
drugs(e.g. narcotics) cause symmetric
constrictionof the pupils. These findings
can provide important clues when dealing
with an agitated or comatose patient
suffering from medication overdose. Eye
drops known as mydriatic agents are used
to paralyze the muscles, resulting marked
dilatation of the pupils. They are used
during a detailed eye examination,
allowing a clear view of the retina.
Addiitonally, any process which causes
increased intracranial pressure can result
in a dilated pupil that does not respond to
light.
4. If the afferent nerve is not working,
neither pupil will respond when light is
shined in the affected eye. Light shined in
the normal eye, however, will cause the
affected pupil to constrict. That's because
the efferent (signal to constrict) response
in this case is generated by the afferent
impulse received by the normally
functioning eye. This is referred to as an
afferent pupil defect.
5. If the efferent nerve is not working, the
pupil will appear dilated at baseline and
will have neither direct nor consensual
pupillary responses.
184
Right CN 3 Palsy - Note that the right
pupil is dilated relative to the left, due to
loss of efferent input. The ptosis and
abnormal eye positioning are discussed
above.
CN 4 (Trochlear): Seen under CN 3.
CN 5 (Trigeminal): This nerve has both motor
and sensory components.
Assessment of CN 5 Sensory Function: The
sensory limb has 3 major branches, each
covering roughly 1/3 of the face. They are:
the Ophthlamic, Maxillary, and
Mandibular. Assessment is performed as
follows:
1. Use a sharp implement (e.g. broken
wooden handle of a cotton tipped
applicator).
2. Ask the patient to close their eyes so that
they receive no visual cues.
3. Touch the sharp tip of the stick to the right
and left side of the forehead, assessing the
Ophthalmic branch.
4. Touch the tip to the right and left side of
the cheek area, assessing the Maxillary
branch.
5. Touch the tip to the right and left side of
the jaw area, assessing the Mandibular
branch.
The patient should be able to clearly identify
when the sharp end touches their face. Of
course, make sure that you do not push too
hard as the face is normally quite
sensitive. The Ophthalmic branch of CN 5
also receives sensory input from the
 surface of the eye. To assess this
component:
1. Pull out a wisp of cotton.
2. While the patient is looking straight ahead,
gently brush the wisp against the lateral
aspect of the sclera (outer white area of the
eye ball).
3. This should cause the patient to blink.
Blinking also requires that CN 7 function
normally, as it controls eye lid closure.
Assessment of CN 5 Motor Function: The
motor limb of CN 5 innervates the Temporalis
and Masseter muscles, both important for
closing the jaw. Assessment is performed as
follows:
1. Place your hand on both Temporalis
muscles, located on the lateral aspects of
the forehead.
2. Ask the patient to tightly close their jaw,
causing the muscles beneath your fingers
to become taught.
3. Then place your hands on both Masseter
muscles, located just in from of the
Tempero-Mandibular joints (point where
lower jaw articulates with skull).
4. Ask the patient to tightly close their jaw,
which should again cause the muscles
beneath your fingers to become taught.
Then ask them to move their jaw from side
to side, another function of the Massester.
185
CN6 (Abducens): See under CN 3.
CN7 (Facial): This nerve innervates many of
the muscles of facial expression.
Assessment is performed as follows:
1. First look at the patient's face. It should
appear symmetric. That is:
a. There should be the same amount of
wrinkles apparent on either side of the
forehead... barring asymmetric Bo-Tox
injection!
b. The nasolabial folds (lines coming down
from either side of the nose towards the
corners of the mouth) should be equal
c. The corners of the mouth should be at the
same height
If there is any question as to whether an
apparent asymmetry if new or old, ask the
patient for a picture (often found on a
driver's license) for comparison.
2. Ask the patient to wrinkle their eyebrows
and then close their eyes tightly. CN 7
controls the muscles that close the eye lids
(as opposed to CN 3, which controls the
muscles which open the lid). You should
not be able to open the patient's eyelids
with the application of gentle upwards
pressure.
3. Ask the patient to smile. The corners of
the mouth should rise to the same height
and equal amounts of teeth should be
visible on either side.
4. Ask the patient to puff out their cheeks.
Both sides should puff equally and air
should not leak from the mouth.
Interpretation: CN 7 has a precise pattern of
inervation, which has important clinical
implications. The right and left upper motor
neurons (UMNs) each innervate both the right
and left lower motor neurons (LMNs) that
allow the forehead to move up and down.
However, the LMNs that control the muscles
of the lower face are only innervated by the
UMN from the opposite side of the face.
CN7 - Facial Nerve
Precise Pattern of Innervation

Right central CN7 dysfunction: Note

preserved abiltiy to wrinkle forehead. Left
Thus, in the setting of CN 7 dysfunction, the
corner of mouth, however, is slightly
pattern of weakness or paralysis observed will
lower than right. Left naso-labial fold is
differ depending on whether the UMN or
slightly less pronounced compared with
LMN is affected. Specifically:
right.
1. UMN dysfunction: This might occur with
2. LMN dysfunction: This occurs most
a central nervous system event, such as a
commonly in the setting of Bell's Palsy, an
stroke. In the setting of R UMN CN 7
idiopathic, acute CN 7 peripheral nerve
dysfunction, the patient would be able to
palsy. In the setting of R CN 7 peripheral
wrinkle their forehead on both sides of
(i.e. LMN) dysfunction, the patient would
their face, as the left CN 7 UMN cross
not be able to wrinkle their forehead, close
innervates the R CN 7 LMN that controls
their eye or raise the corner of their mouth
this movement. However, the patient
on the right side. Left sided function
would be unable to effectively close their
would be normal.
left eye or raise the left corner of their
mouth.

186

Left peripheral CN7 dysfunction: Note loss
of forehead wrinkle, ability to close eye,
ability to raise corner of mouth, and decreased
naso-labial fold prominence on left.
This clinical distinction is very important, as
central vs peripheral dysfunction carry
different prognostic and treatment
implications. Bell's Palsy (peripheral CN 7
dysfunction)tends to happen in patient's over
50 and often responds to treatment with
Acyclovir (an anti-viral agent) and Prednisone
(a corticosteroid). Over the course of weeks or
months there is usually improvement and
often complete resolution of symptoms.
Assessment of acute central (UMN) CN 7
dysfunction would require quite a different
approach (e.g. neuroimaging to determine
etiology).
CN 7 is also responsible for carrying taste
sensations from the anterior 2/3 of the tongue.
However as this is rarely of clinical import,
further discussion is not included.
CN8 (Acoustic): CN 8 carries sound impulses
from the cochlea to the brain. Prior to reaching
187
the cochlea, the sound must first traverse the
external canal and middle ear. Auditory acuity
can be assessed very crudely on physical exam
as follows:
1. Stand behind the patient and ask them
to close their eyes.
2. Whisper a few words from just behind
one ear. The patient should be able to
repeat these back accurately. Then
perform the same test for the other ear.
3. Alternatively, place your fingers
approximately 5 cm from one ear and
rub them together. The patient should
be able to hear the sound generated.
Repeat for the other ear.
These tests are rather crude. Precise
quantification, generally necessary whenever
there is a subjective decline in acuity, requires
special equipment and training.
The cause of subjective hearing loss can be
assessed with bedside testing. Hearing is
broken into 2 phases: conductive and
sensorineural. The conductive phase refers to
the passage of sound from the outside to the
level of CN 8. This includes the transmission
of sound through the external canal and
middle ear. Sensorineural refers to the
transmission of sound via CN 8 to the brain.
Identification of conductive (a much more
common problem in the general population)
defects is determined as follows:
Weber Test:
1. Grasp the 512 Hz tuning fork by the
stem and strike it against the bony
edge of your palm, generating a
continuous tone. Alternatively you can
get the fork to vibrate by "snapping"
the ends between your thumb and
index finger.
512 Hz Tuning Fork
 2. Hold the stem against the patient's
skull, along an imaginary line that is
equidistant from either ear.
3. The bones of the skull will carry the
sound equally to both the right and left
CN 8. Both CN 8s, in turn, will
transmit the impulse to the brain.
4. The patient should report whether the
sound was heard equally in both ears
or better on one side then the other
(referred to as lateralizing to a side).

Rinne Test
Interpretation:
1. The above testing is reserved for those
Weber Test
instances when a patient complains of a
Rinne Test:
deficit in hearing. Thus, on the basis of
1. Grasp the 512 Hz tuning fork by the stem
history, there should be a complaint of
and strike it against the bony edge of your
hearing decline in one or both ears.
palm, generating a continuous tone.
2. In the setting of a conductive hearing loss
2. Place the stem of the tuning fork on the
(e.g. wax in the external canal), the
mastoid bone, the bony prominence
Webber test will lateralize (i.e. sound will
located immediately behind the lower part
be heard better)in the ear that has the
of the ear.
subjective decline in hearing. This is
3. The vibrations travel via the bones of the
because when there is a problem with
skull to CN 8, allowing the patient to hear
conduction, competing sounds from the
the sound.
outside cannot reach CN 8 via the external
4. Ask the patient to inform you when they
canal. Thus, sound generated by the
can no longer appreciate the sound. When
vibrating tuning fork and traveling to CN 8
this occurs, move the tuning fork such that
by means of bony conduction is better
the tines are placed right next to (but not
heard as it has no outside "competition."
touching) the opening of the ear. At this
You can transiently create a conductive
point, the patient should be able to again
hearing loss by putting the tip of your
hear the sound. This is because air is a
index finger in the external canal of one
better conducting medium then bone.
ear. If you do this while performing the
Webber test, the sound will be heard on
that side.
3. In the setting of a sensorineural hearing
loss (e.g. a tumor of CN 8), the Webber
test will lateralize to the ear which does
not have the subjective decline in hearing.

188
 This is because CN 8 is the final pathway
through which sound is carried to the
brain. Thus, even though the bones of the
skull will successfully transmit the sound
to CN 8, it cannot then be carried to the
brain due to the underlying nerve
dysfunction.
4. In the setting of conductive hearing loss,
bone conduction (BC) will be better then
air conduction (AC) when assessed by the
Rinne Test. If there is a blockage in the
passageway (e.g. wax) that carries sound
from the outside to CN 8, then sound will
be better heard when it travels via the
bones of the skull. Thus, the patient will
note BC to be better then or equal to AC in
the ear with the subjective decline in
hearing.
5. In the setting of a sensorineural hearing
loss, air conduction will still be better then
bone conduction (i.e. the normal pattern
will be retained). This is because the
problem is at the level of CN 8. Thus,
regardless of the means (bone or air) by
which the impulse gets to CN 8, there will
still be a marked hearing decrement in the
affected ear. As AC is normally better then
BC, this will still be the case.
Summary:
Identifying conductive v sensorineural hearing
deficits requires historical information as well
as the results of Webber and Rinne testing. In
summary, this data is interpreted as follows:
1. First determine by history and crude acuity
testing which ear has the hearing problem.
2. Perform the Webber test. If there is a
conductive hearing deficit, the Webber
will lateralize to the affected ear. If there is
a sensorineural deficit, the Webber will
lateralize to the normal ear.
3. Perform the Rinne test. If there is a
conductive hearing deficit, BC will be
greater then or equal to AC in the affected
ear. If there is a sensorineural hearing
deficit, AC will be greater then BC in the
affected ear.
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CN9 (Glosopharyngeal) and CN 10
(Vagus): These nerves are responsible for
raising the soft palate of the mouth and the
gag reflex, a protective mechanism which
prevents food or liquid from traveling into the
lungs As both CNs contribute to these
functions, they are tested together.
Testing Elevation of the soft palate:
1. Ask the patient to open their mouth and
say, "ahhhh," causing the soft palate to rise
upward.
2. Look at the uvula, a midline structure
hanging down from the palate. If the
tongue obscures your view, take a tongue
depressor and gently push it down and out
of the way.
3. The Uvula should rise up straight and in
the midline.
Normal Oropharynx
Interpretation:
If CN 9 on the right is not functioning (e.g. in
the setting of a stroke), the uvula will be
pulled to the left. The opposite occurs in the
setting of left CN 9 dysfunction.
Left CN9 Dysfunction: Patient status post
stroke affecting left CN9. Uvula therefore
pulled over towards right.
Be aware that other processes can cause
deviation of the uvula.A peritonsilar abscess,
for example, will push the uvula towards the
opposite (i.e. normal) tonsil.
 2. Patient's suffering from sudden decreased
level of consciousness. In this setting, the
absence of a gag might indicate that the
patient is no longer able to reflexively
protect their airway from aspiration.
Strong consideration should be given to
intubating the patient, providing them with
a secure mechanical airway until their
general condition improves.
Left peritonsillar abscess: infection within CN 9 is also responsible for taste originating
left tonsil has pushed uvula towards the right. on the posterior 1/3 of the tongue. As this is
Testing the Gag Reflex: rarely a clinically important problem, further
1. Ask the patient to widely open their discussion is not included.
mouth. If you are unable to see the CN 10 also provides parasympathetic
posterior pharynx (i.e. the back of their innervation to the heart, though this cannot be
throat), gently push down with a tongue easily tested on physical examination.
depressor. CN11 (Spinal Accessory): CN 11 innervates
2. In some patients, the tongue depressor the muscles which permit shrugging of the
alone will elicit a gag. In most others, shoulders (Trapezius) and turning the head
additional stimulation is required. Take a laterally (Sternocleidomastoid).
cotton tipped applicator and gently brush it 1. Place your hands on top of either shoulder
against the posterior pharynx or uvula. and ask the patient to shrug while you
This should generate a gag in most provide resistance. Dysfunction will cause
patients. weakness/absence of movement on the
3. A small but measurable percent of the affected side.
normal population has either a minimal or
non-existent gag reflex. Presumably, they
make use of other mechanisms to prevent
aspiration.
Gag testing is rather noxious. Some people are
particularly sensitive to even minimal
stimulation. As such, I would suggest that you
only perform this test when there is reasonable
suspicion that pathology exists. This would
include two major clinical situations:
1. If you suspect that the patient has suffered
2. Place your open left hand against the
acute dysfunction, most commonly in the
patient's right cheek and ask them to turn
setting of a stroke. These patients may
into your hand while you provide
complain of/be noted to cough when they
resistance. Then repeat on the other side.
swallow. Or, they may suffer from
The right Sternocleidomasoid muscle (and
recurrent pneumonia. Both of these events
thus right CN 11) causes the head to turn
are signs of aspiration of food contents
to the left, and vice versa.
into the passageways of the lungs. These
patients may also have other cranial nerve
abnormalities as lesions affecting CN 9
and 10 often affect CNs 11 and 12, which
are anatomically nearby.

190
CN12 (Hypoglossal): CN 12 is responsible for
tongue movement. Each CN 12 innervates
one-half of the tongue.
Testing:
1. Ask the patient to stick their tongue
straight out of their mouth.
2. If there is any suggestion of deviation
to one side/weakness, direct them to
push the tip of their tongue into either
cheek while you provide counter
pressure from the outside.
Interpretation:
If the right CN 12 is dysfunctional, the tongue
will deviate to the right. This is because the
normally functioning left half will dominate as
it no longer has opposition from the right.
Similarly, the tongue would have limited or
absent ability to resist against pressure applied
from outside the left cheek.
191
Left CN 12 Dysfunction: Stroke has resulted
in L CN 12 Palsy.Tongue therefore deviates to
the left.
Sensory and Motor Examinations - A Brief
Review of Anatomy and Physiology:
Testing of motor and sensory function
requires a basic understanding of normal
anatomy and physiology. In brief:
1. Voluntary movement begins with an
impulse generated by cell bodies
located in the brain.
2. Signals travel from these cells down
their respective axons, forming the
Cortiospinal (a.k.a. Pyramidal) tract.
At the level of the brain stem, this
motor pathway crosses over to the
opposite side of the body and continue
downward on that side of the spinal
cord. The nerves which comprise this
motor pathway are collectively
referred to as Upper Motor Neurons
(UMNs). It's important to note that
there are other motor pathways that
carry impulses from the brain to the
periphery and help modulate
movement. A discussion of these tracts
can be found in other Neurology
reference texts.
3. At a specific point in the spinal cord
the axon synapses with a 2nd nerve,
referred to as a Lower Motor Neuron
(LMN). The precise location of the
synapse depends upon where the lower
motor neuron is destined to travel. If,
for example, the LMN terminates in
the hand, the synapse occurs in the
 cervical spine (i.e. neck area).
However, if it's headed for the foot, the
synapse occurs in the lumbar spine
(i.e. lower back).
4. The UMNs are part of the Central
Nervous System (CNS), which is
composed of neurons whose cell
bodies are located in the brain or spinal
cord. The LMNs are part of the
Peripheral Nervous System (PNS),
made up of motor and sensory neurons
with cell bodies located outside of the
brain and spinal cord. The axons of the
PNS travel to and from the periphery,
connecting the organs of action (e.g.
muscles, sensory receptors) with the
CNS.
5. Nerves which carry impulses away
from the CNS are referred to Efferents
(i.e. motor) while those that bring
signals back are called Afferents (i.e.
sensory).
6. Axons that exit and enter the spine at
any given level generally connect to
the same distal anatomic area. These
bundles of axons, referred to as spinal
nerve roots, contain both afferent and
efferent nerves. The roots exit/enter
the spinal cord through neruoforamina
in the spine, paired openings that allow
for their passage out of the bony
protection provided by the vertebral
column.
7. As the efferent neurons travels
peripherally, components from
different roots commingle and branch,
following a highly programmed
pattern. Ultimately, contributions from
several roots may combine to form a
named peripheral nerve, which then
follows a precise anatomic route on its
way to innervating a specific muscle.
The Radial Nerve, for example, travels
around the Humerus (bone of the
upper arm), contains contributions
from Cervical Nerve Roots 6, 7 and 8
192
and innervates muscles that extend the
wrist and supinate the forearm.
It may help to think of a nerve root as
an electrical cable composed of many
different colored wires, each wire
representing an axon. As the cable
moves away from the spinal cord,
wires split off and head to different
destinations. Prior to reaching their
targets, they combine with wires
originating from other cables. The
group of wires that ultimately ends at a
target muscle group may therefore
have contributions from several
different roots.
For more information about radial
nerve anatomy and function, see
below.
8. Afferents carry impulses in the
opposite direction of the motor nerves.
That is, they bring information from
the periphery to the spinal cord and
brain.
9. Sensory nerves begin in the periphery,
receiving input from specialized
receptor organs. The axons then move
proximally, joining in a precise fashion
with other axons to form the afferent
component of a named peripheral
nerve. The Radial Nerve, for example,
not only has a motor function
(described previously) but also carries
sensory information from discrete
parts of the hand and forearm.
10. As the sensory neurons approach the
spinal cord, they join specific spinal
nerve roots. Each root carries sensory
information from a discrete area of the
body. The area of skin innervated by a
particular nerve root is referred to as a
dermatome. Dermatome maps describe
the precise areas of the body
innervated by each nerve root. These
distributions are more or less the same
for all people, which is clinically
important. In the setting of nerve root
 dysfunction, the specific area supplied
by that root will be affected. This can
be mapped out during a careful exam
(see below), identifying which root(s)
is dysfunctional.
11. Sensory input travels up through the
spinal cord along specific paths, with
the precise route defined by the type of
sensation being transmitted. Nerves
carrying pain impulses, for example,
cross to the opposite side of the spinal
cord soon after entering, and travel up
to the brain on that side of the cord.
Vibratory sensations, on the other
hand, enter the cord and travel up the
same side, crossing over only when
they reach the brain stem (see
following sections for detailed
descriptions).
12. Ultimately, the sensory nerves
terminate in the brain, where the
impulses are integrated and perception
occurs.
Understanding the above neruo-anatomic
relationships and patterns of innervation has
important clinical implications when trying to
determine the precise site of neurological
dysfunction. Injury at the spinal nerve root
level, for example, will produce a
characteristic loss of sensory and motor
function. This will differ from that caused by a
problem at the level of the peripheral nerve.
An approach to localizing lesions on the basis
of motor and sensory findings is described in
the sections which follow. Realize that there is
a fair amount of inter-individual variation with
regards to the specifics of innervation. Also,
recognize that often only parts of nerves may
become dysfunctional, leading to partial motor
or sensory deficits. As such, the patterns of
loss are rarely as "pure" as might be suggested
by the precise descriptions of nerves and their
innervations.
Sensory Testing
Sensory testing of the face is discussed in the
section on Cranial Nerves. Testing of the
193
extremities focuses on the two main afferent
pathways: Spinothalamics and Dorsal
Columns.
1. Spinothalamics: These nerves detect
pain, temperature and crude touch.
They travel from the periphery, enter
the spinal cord and then cross to the
other side of the cord within one or
two vertebral levels of their entry point
They then continue up that side to the
brain, terminating in the cerebral
hemisphere on the opposite side of the
body from where they began.
2. Dorsal Columns: These nerves detect
position (a.k.a. proprioception),
vibratory sensation and light touch.
They travel from the periphery,
entering the spinal cord and then
moving up to the base of the brain on
the same side of the cord as where they
started. Upon reaching the brain stem
they cross to the opposite side,
terminating in the cerebral hemisphere
on the opposite side of the body from
where they began.
A screening evaluation of these pathways can
be performed as follows:
Spinothalamics
1. The patient's ability to perceive the
touch of a sharp object is used to
assess the pain pathway of the
Spinothalamics. To do this, break a Q-
tip or tongue depressor in half, such
that you create a sharp, pointy end.
Alternatively, you can use a disposable
needle or the sharp and blunt ends of a
safety pin. I would discourage the use
of the pointy, metal spikes that
accompany some reflex hammers. If,
for example, you used this and caused
bleeding, it's possible (if the tip were
not well cleaned) to transmit blood
borne infections from one patient to
another. Better to use a disposable
implement.
 2. Ask the patient to close their eyes so
that they are not able to get visual
clues.
3. Start at the top of the foot. Orient the
patient by informing them that you are
going to first touch them with the
sharp implement. Then do the same
with a non-sharp object (e.g. the soft
end of a q-tip). This clarifies for the
patient what you are defining as sharp
and dull.
4. Now, touch the lateral aspect of the
foot with either the sharp or dull tool,
asking them to report their response.
Move medially across the top of the
foot crossing multiple dermatomes,
noting the patient’s response to each
touch.
5. If they give accurate responses, do the
same on the other foot. The same test
can be repeated for the upper
extremities (i.e. on the hand), though
this would only be of utility if the
patient complained of
numbness/impaired sensation in that
area.
6. Spinothalamic tract function can also
be assessed by checking the patient’s
ability to detect differences in
temperature. Cold and warm can be
reproduced by running a tuning fork
under water of that temperature,
touching it against the affected limb,
and asking the patient to comment
(patient’s eyes should be closed).
Dorsal Columns
194
Proprioception: This refers to the body's
ability to know where it is in space. As such, it
contributes to balance. Similar to the
Spinothalamic tracts, disorders which affect
this system tend to first occur at the most
distal aspects of the body. Thus,
proprioception is checked first in the feet and
then, if abnormal, more proximally (e.g. the
hands).
Technique:
1. Ask the patient to close their eyes so
that they do not receive any visual
cues.
2. With one hand, grasp either side of
great toe at the interphalangeal (IP)
joint. Place your other hand on the
lateral and medial aspects of the great
toe distal to the IP.
3. Orient patient to up and down as
follows:
Flex the toe (pull it upwards) while
telling patient what you're doing.
Extend toe (pull it downwards) while
informing them of which direction
you're moving it.
Testing Proprioception
4. Alternately deflect the toe up or down
without telling the patient in which
direction you are moving it. They
should be able to correctly identify the
movement and direction.
5. Both great toes should be checked in
the same fashion. If normal, no further
testing need be done in the screening
exam.
6. If the patient is unable to correctly
identify the movement/direction, move
 more proximally (e.g. to the ankle
joint) and repeat (e.g. test whether they
can determine whether the foot is
moved up or down at the ankle).
Similar testing can be done on the fingers.
This is usually reserved for those settings
when patients have distal findings and/or
symptoms in the upper extremities.
Vibratory Sensation: Vibratory sensation
travels to the brain via the dorsal columns.
Thus, the findings generated from testing this
system should corroborate those of
proprioception (see above).
Technique:
1. Start at the toes with the patient seated.
You will need a 128 hz tuning fork.
128 Hz tuning fork
2. Ask the patient to close their eyes so
that they do not receive any visual
cues.
3. Grasp the tuning fork by the stem and
strike the forked ends against the heel
of your hand, causing it to vibrate.
4. Place the stem on top of the
interphalangeal joint of the great toe.
Put a few fingers of your other hand on
the bottom-side of this joint.
195
Testing vibratory sensation
5. Ask the patient if they can feel the
vibration. You should be able to feel
the same sensation with your fingers
on the bottom side of the joint.
6. The patient should be able to
determine when the vibration stops,
which will correlate with when you are
no longer able to feel it transmitted
through the joint. It sometimes takes a
while before the fork stops vibrating. If
you want to move things along, rub the
index finger of the hand holding the
fork along the tines, rapidly
dampening the vibration.
Repeat testing on the other foot.
Additional/Special Testing for Dorsal Column
Dysfunction
Testing Two Point Discrimination: Patients
should normally be able to distinguish
simultaneous touch with 2 objects which are
separated by at least 5mm. These stimuli are
carried via the Dorsal Columns. While not
checked routinely, it is useful test if a discrete
peripheral neruropathy is suspected (e.g.
injury to the radial nerve).
Technique:
1. Testing can be done with a paperclip,
opened such that the ends are 5mm
apart.
2. The patient should be able to correctly
identify whether you are touching
them with one or both ends
simultaneously, along the entire
distribution of the specific nerve which
is being assessed.
Special Testing for Early Diabetic
Neuropathy: A careful foot examination
should be performed on all patients with
symptoms suggestive of sensory neuropathy
or at particular risk for this disorder (e.g.
anyone with Diabetes). Loss of sensation in
this area can be particularly problematic as the
feet are a difficult area for the patient to
evaluate on their own. Small wounds can
become large and infected, unbeknownst to
the insensate patient. Sensory testing as
described above can detect this type of
problem. Disposable monofilaments (known
as the Semmes-Weinstein Aethesiometer) are
specially designed for a screening evaluation.
These small nylon fibers are designed such
that the normal patient should be able to feel
the ends when they are gently pressed against
the soles of their feet.
Monofiliment
Technique:
1. Have the patient close their eyes so
that they do not receive any visual
cues.
2. Touch the monofilament to 5-7 areas
on the bottom of the patient's foot.
Pick locations so that all of the major
areas of the sole are assessed. Avoid
calluses, which are relatively
insensate.
3. The patient should be able to detect the
filament when the tip is lightly applied
to the skin.
Monofiliment testing: Patients with normal
sensation should be able to detect the
monofiliment when it is lightly applied
(picture on left). If the force required to
provoke a sensory response is strong enough
196
to bend the monofiliment (picture on right),
then sensation is impaired.
Interpretation: If the examiner has to supply
enough pressure such that the filament bends
prior to the patient being able to detect it, they
likely suffer from sensory neuropathy. Testing
should be done in multiple spots to verify the
results. Patient's with distal sensory
neuropathy should carefully examine their feet
and wear good fitting shoes to assure that skin
breakdown and infections don't develop.
Efforts should also be made to closely control
their diabetes so that the neuropathy does not
progress.
Neuropathic Ulcer: Large ulcer has
developed in this patient with severe diabetic
neuropathy.
Interpreting Results of Sensory Testing
Patterns of Impairment for the Spinothalamic
Tracts:
1. Patients should be able to correctly
distinguish sharp sensation, indicating
normal function of the spinothalamic
pathway.
2. Mapping out regions of impaired
sensation: The examination described
above is a screening evaluation for
evidence of sensory loss. This is
perfectly adequate in most clinical
settings. Occasionally, the history or
screening examination will suggest a
discrete anatomic region that has
sensory impairment. When this occurs,
it is important to try and map out the
territory involved, using careful pin
testing to define the medial/lateral and
proximal/distal boundaries of the
affected region. You may even make
pen marks on the skin to clearly
 identify where the changes occur. As
most clinicians have not memorized
the distributions of all peripheral
nerves or spinal nerve roots, you can
simultaneously consult a reference
book to see if the mapped territory
matches a specific nerve distribution.
This type of mapping is somewhat
tedious and should only be done in
appropriate situations.
3. Diffuse Distal Sensory Loss: A
number of chronic systemic diseases
affect nerve function. The most
commonly occurring of these, at least
in Western countries, is Diabetes.
When control has been poor over
many years, the sensory nerves
become dysfunctional. This first
affects the most distal aspects of the
nerves and then moves proximally.
Thus, the feet are the first area to be
affected. As it is a systemic disease, it
occurs simultaneously in both limbs.
Exam reveals loss of ability to detect
the sharp stimulus across the entire
foot. Thus, the sensory loss does not
follow a dermatomal (i.e. spinal nerve
root) or peripheral nerve distribution.
As the examiner tests more
proximally, he/she will ultimately
reach a point where sensation is again
normal. The more advanced the
disease, the higher up the leg this will
occur. Hands can be affected, though
much less commonly then feet as the
nerves traveling to the legs are longer
and thus at much greater risk. This
pattern of loss is referred to as a
Stocking or Glove distribution
impairment, as the area involved
covers an entire distal region, much as
a sock or glove would cover a foot or
hand. Such deficits may be associated
with neuropathic pain, a continuous
burning sensation affecting the distal
extremity.
197
4. Peripheral Nerve Distribution: A
specific peripheral nerve can become
dysfunctional. This might, for
example, occur as the result of trauma
or infarction (another complication of
diabetes). In this setting, there will be a
pattern of sensory impairment that
follows the distribution of the nerve.
Radial nerve palsy, for example, can
occur if an intoxicated person falls
asleep in a position that puts pressure
on the nerve as it travels around the
Humerus (bone of the upper arm).
Intoxication induced loss of
consciousness then prevents the patient
from reflexively changing position, the
normal means by which we prevent
nerves from being exposed to constant
direct pressure. The resultant sensory
loss would involve the back of the
hand and forearm. Motor function
would also be affected (see under
motor exam). Pinning down the culprit
nerve requires knowledge of nerve
anatomy and innervation. On a
practical level, most clinicians don't
commit this to memory. Rather, they
gather a history suggestive of a
discrete nerve deficit, verify the
territory of loss on exam, and then
look it up in a reference book.
For more information about peripheral
nerve injuries, see the following link:
Peripheral nerves and their territories
of innervation
5. Nerve Root Impairment: A nerve root
(or roots) can be damaged as it leaves
the cord. This will result in a sensory
deficit along its specific distribution,
which can in turn be identified on
examination. The S1 nerve root, for
example, can be compressed by
herniated disc material in the lumbar
spine. This would cause sensory loss
along the lateral aspect of the lower leg
and the bottom of the foot. Only the
 leg on the affected side would have
this deficit. As mentioned under
peripheral nerve dysfunction, most
clinicians do not memorize the
dermatomes related to each nerve root.
Rather, they gather a history
suggestive of a discrete nerve deficit,
verify a dermatomal distribution of
loss on exam, and then look it up in a
reference book.
6. The Spinothalamics are also
responsible for temperature
discrimination. For practical reasons
(i.e. it's often hard to find test tubes,
fill them with the requisite temperature
water, etc) this is omitted in the
screening exam. The information from
sharp stimulus testing as described
above should suffice. Temperature
discrimination could be assessed as a
means of verifying any abnormality
detected on sharp/dull testing.
7. Testing of the sacral nerve roots,
serving the anus and rectum, is
important if patients complain of
incontinence, inability to
defecate/urinate, or there is otherwise
reason to suspect that these roots may
be compromised. In the setting of
Cauda Equina syndrome, for example,
multiple sacral and lumbar roots
become compressed bilaterally (e.g. by
posteriorly herniated disc material or a
tumor). When this occurs, the patient
is unable to urinate, as the lower motor
neurons carried in these sacral nerve
roots no longer function. Thus there is
no way to send an impulse to the
bladder instructing it to contract. Nor
will they be aware that there bladders
are full. There will also be loss of anal
spincter tone, which can be
appreciated on rectal exam. Ability to
detect pin pricks in the perineal area
(a.k.a. saddle distribution) is also
diminished.
198
Patterns of Impairment for Dorsal Column
Dysfunction:
Proprioception:
Patients should be able to correctly identify
the motion and direction of the toe. In the
setting of Dorsal Column dysfunction (a
common complication of diabetes, for
example), distal testing will be abnormal. This
is similar to the pattern of injury which affects
the Spinothalamic tracts described above.
Vibratory Sensation:
1. Patients should be able to detect the
initial vibration and accurately
determine when it has stopped.
2. As described under testing of
proprioception, dorsal column
dysfunction tends to first affect the
most distal aspects of the system.
When this occurs, the patient is either
unable to detect the vibration or they
perceive that the sensation
extinguishes too early (i.e. they stop
feeling it even though you can still
appreciate the sensation with your
fingers on the underside of the joint).
3. The findings on vibratory testing
should parallel those obtained when
assessing proprioception, as both
sensations travel via the same
pathway.
Motor Testing
The muscle is the unit of action that causes
movement. Normal motor function depends
on intact upper and lower motor neurons,
sensory pathways and input from a number of
other neurological systems. Disorders of
movement can be caused by problems at any
point within this interconnected system.
Muscle Bulk and Appearance:
This assessment is somewhat subjective and
quite dependent on the age, sex and the
activity/fitness level of the individual. A frail
elderly person, for example, will have less
muscle bulk then a 25 year old body builder.
With experience, you will get a sense of the
normal range for given age groups, factoring
in their particular activity levels and overall
states of health.
Things to look for:
1. Using your eyes and hands, carefully
examine the major muscle groups of
the upper and lower extremities. First
you need to fully expose the muscles
of both extremities (for comparison)
that you're examining. Palpation of the
muscles will give you a sense of
underlying mass. The largest and most
powerful groups are those of the
quadriceps and hamstrings of the upper
leg (i.e. front and back of the thighs).
2. Muscle groups should appear
symmetrically developed when
compared with their counterparts on
the other side of the body. They should
also be appropriately developed, after
making allowances for the patient's
age, sex, and activity level.
Muscle Asymmetry
While both legs have well developed
musculature, the left has greater bulk.
There should be no muscle movement
when the limb is at rest. Rare disorders
(e.g. Amyotrophic Lateral Sclerosis)
result in death of the lower motor
neuron and subsequent denervation of
the muscle. This causes twitching of
the fibers known as
fasciculations,which can be seen on
199
gross inspection of affected muscles.
ALS is accompanied by other findings
and symptoms, in particular,
relentlessly progressive weakness.
A number of more common (and
relatively benign) conditions can also
cause fasciulations, including: post
exercise, meds, stimulants, and
assorted metabolic processes.
3. Tremors are a specific type of
continuous, involuntary muscle
activity that results in limb movement.
Parkinson's Disease (PD), for example,
can cause a very characteristic resting
tremor of the hand (the head and other
body parts can also be affected) that
diminishes when the patient
voluntarily moves the affected limb.
Benign Essential Tremor, on the other
hand, persists throughout movement
and is not associated with any other
neurological findings, easily
distinguishing it from PD.
4. The major muscle groups to be
palpated include: biceps, triceps,
deltoids, quadriceps and hamstrings.
Palpation should not elicit pain.
Interestingly, myositis (a rare
condition characterized by idiopathic
muscle inflammation) causes the
patient to experience weakness but not
pain.
5. If there is asymmetry, note if it follows
a particular pattern. Remember that
some allowance must be made for
handedness (i.e. right v left hand
dominance). Does the asymmetry
follow a particular nerve distribution,
suggesting a peripheral motor neuron
injury? For example, muscles which
lose their LMN inervation become
very atrophic. Is the bulk in the upper
and lower extremities similar? Spinal
cord transection at the Thoracic level
will cause upper extremity muscle bulk
to be normal or even increased due to
 increased dependence on arms for
activity, mobility, etc. However, the
muscles of the lower extremity will
atrophy due to loss of innervation and
subsequent disuse. Is there another
process (suggested by history or other
aspects of the exam) that has resulted
in limited movement of a particular
limb? For example, a broken leg that
has recently been liberated from a cast
will appear markedly atrophic.
Diffuse Muscle Wasting: Note loss
muscle bulk in left hand due to
peripheral denervation.
In particular, compare left and right
thenar eminences.
Tone: When a muscle group is relaxed, the
examiner should be able to easily manipulate
the joint through its normal range of motion.
This movement should feel fluid. A number of
disease states may alter this sensation. For the
screening examination, it is reasonable to limit
this assessment to only the major joints,
including: wrist, elbow, shoulder, hips and
knees.
Technique:
1. Ask the patient to relax the joint that is
to be tested.
2. Carefully move the limb through its
normal range of motion, being careful
not to maneuver it in any way that is
uncomfortable or generates pain.
3. Be aware that many patients,
particularly the elderly, often have
other medical conditions that limit
joint movement. Degenerative joint
disease of the knee, for example, might
cause limited range of motion, though
tone should still be normal. If the
200
patient has recently injured the area or
are in pain, do not perform this aspect
of the exam.
Things to look for:
1. Normal muscle generates some
resistance to movement when a limb is
moved passively by an examiner. After
performing this exam on a number of
patients, you'll develop an appreciation
for the range of normal tone.
2. If the examiner moves the joint
(patient relaxed) and there is increased
resistance, this is referred to as
increased tone, which can be further
characterized as rigid or spastic.
a. Spasticity: Tone increases if
the examiner moves the joint
more quickly (i.e. the
hypertonicity is affected by the
rate of movement of the joint).
This is the typical finding with
an upper motor neuron lesion
(e.g. stroke or spinal cord
injury).
b. Rigidity: Tone remains
increased regardless of how
quickly the joint is moved. One
example of this is Parkinson�s
disease, where limb movement
generates a ratchet-like
sensation known as cog
wheeling.
3. Flaccidness is the complete absence of
tone. This occurs when the lower
motor neuron is cut off from the
muscles that it normally innervates.
Strength: As with muscle bulk (described
above), strength testing must take into account
the age, sex and fitness level of the patient.
For example, a frail, elderly, bed bound
patient may have muscle weakness due to
severe deconditioning and not to intrinsic
neurological disease. Interpretation must also
consider the expected strength of the muscle
group being tested. The quadriceps group, for
example, should be much more powerful then Nerve roots providing the greatest
the Biceps. contribution are printed in bold. More
There is a 0 to 5 rating scale for muscle extensive descriptions of individual muscles
strength: and their functions, along with their precise
0/5 No movement innervations can be found in a Neurology
Barest flicker of movement of reference text.
the muscle, though not enough 1. Intrinsic muscles of the hand (C 8, T
1/5 1): Ask the patient to spread their
to move the structure to which
it's attached. fingers apart against resistance
Voluntary movement which is (abduction). Then squeeze them
not sufficient to overcome the together, with your fingers placed in
force of gravity. For example, between each of their digits
2/5 (adduction). Test each hand separately.
the patient would be able to
slide their hand across a table The muscles which control adduction
but not lift it from the surface. and abduction of the fingers are called
Voluntary movement capable the Interossei, innervated by the Ulnar
of overcoming gravity, but not Nerve.
any applied resistance. For
3/5 example, the patient could raise
their hand off a table, but not if
any additional resistance were
applied.
Voluntary movement capable
4/5 of overcoming "some"
resistance
5/5 Normal strength
'+' and '-' can be added to allow for more
nuanced scoring of 4/5 strength (e.g., 4+ or 4-
but not 5-, 3+ or 3-, etc.) Thus, a patient who
can overcome "moderate but not full
resistance" might be graded 4+. This is quite
subjective, with a fair amount of variability
amongst clinicians. Ultimately, it's most
For more information about finger
important that you develop your own sense of
abductors and adductors, see the
what these gradations mean, allowing for
following links:
internal consistency and interpretability of
University of Washington, Anatomy of
serial measurements.
finger abductors and adductors
Specifics of Strength Testing - Major Muscle
2. Flexors of the fingers (C 7, 8, T1): Ask
Groups: In the screening examination, it is
the patient to make a fist, squeezing
reasonable to check only the major
their hand around two of your fingers.
muscles/muscle groups. More detailed testing
If the grip is normal, you will not be
can be performed in the setting of
able to pull your fingers out. Test each
discrete/unexplained weakness. The names of
hand separately. The Flexor Digitorum
the major muscles/muscle groups along with
Profundus controls finger flexion and
the spinal roots and peripheral nerves that
provide their innervation are provided below.

201
 is innervated by the Median (radial
1/2) and Ulnar (medial 1/2) Nerves.
5. Elbow Flexion (C 5, 6): The main
3. Wrist flexion (C 7, 8, T 1): Have the
patient try to flex their wrist as you
provide resistance. Test each hand
separately. The muscle groups which
control flexion are innervated by the
Median and Ulnar Nerves.
6. Elbow Extension (C 7, 8): The main
4. Wrist extension (C 6, 7, 8): Have the
patient try to extend their wrist as you
provide resistance. Test each hand
separately. The Extensor Radialis
muscles control extension and are
innervated by the Radial Nerve.
Clinical Correlate: Damage to the
radial nerve results in wrist drop (loss
of ability to extend the hand at the
wrist). This can occur via any one of a
number of mechanisms. For example,
the nerve can be compressed against
the humerus for a prolonged period of
time when an intoxicated person loses
consciousness with the inside aspect of
202
the upper arm resting against a solid
object (known as a "Saturday Night
Palsy").
flexor (and supinator) of the forearm is
the Brachialis Muscle (along with the
Biceps Muscle). Have the patient bend
their elbow to ninety degrees while
keeping their palm directed upwards.
Then direct them to flex their forearm
while you provide resistance. Test
each arm separately. These muscles
are innervated by the
Musculocutaneous Nerve.
extensor of the forearm is the triceps
muscle. Have the patient extend their
elbow against resistance while the arm
is held out (abducted at the shoulder)
from the body at ninety degrees. Test
each arm separately. The Triceps is
innervated by the Radial Nerve.
7. Shoulder Adduction (C 5 thru T1): The
main muscle of adduction is the
Pectoralis Major, though the
Latissiumus and others contribute as
well. Have the patient flex at the elbow
while the arm is held out from the
body at forty-five degrees. Then
provide resistance as they try to further 10. Hip Extension (L5, S1): With the
adduct at the shoulder. Test each patient lying prone, direct the patient
shoulder separately. to lift their leg off the table against
resistance. Test each leg separately.
The main hip extensor is the gluteus
maximus, innervated by inferior
gluteal nerve.

8. Shoulder Abduction (C 5, 6): The

deltoid muscle, innervated by the
axillary nerve, is the main muscle of
abduction. Have the patient flex at the
elbow while the arms is held out from
the body at forty-five degress. Then
provide resistance as they try to further
abduct at the shoulder. Test each
shoulder separately.
11. Hip Abduction (L 4, 5, S1): Place your
hands on the outside of either thigh
and direct the patient to separate their
legs against resistance. This movement
is mediated by a number of muscles.

12. Hip Adduction (L 2, 3, 4): Place your

9. Hip Flexion (L 2, 3, 4): With the
patient seated, place your hand on top
of one thigh and instruct the patient to
lift the leg up from the table. The main
hip flexor is the Iliopsoas muscle,
innervated by the femoral nerve.
hands on the inner aspects of the thighs
and repeat the maneuver. A number of
muscles are responsible for adduction.
They are innervated by the obturator
nerve.

203

13. Knee Extension (L 2, 3, 4): Have the
seated patient steadily press their lower
extremity into your hand against
resistance. Test each leg separately.
Extension is mediated by the
quadriceps muscle group, which is
innervated by the femoral nerve.
14. Knee flexion (L 5; S 1, 2): Have the
patient rest prone. Then have them pull
their heel up and off the table against
resistance. Each leg is tested
separately. Flexion is mediated by the
hamstring muscle group, via branches
of the sciatic nerve.
15. Ankle Dorsiflexion (L 4, 5): Direct the
patient to pull their toes upwards while
you provide resistance with your hand.
Each foot is tested separately. The
muscles which mediate dorsiflexion
are innervated by the deep peroneal
nerve. Clinical Correlate: The peroneal
204
nerve is susceptible to injury at the
point where it crosses the head of the
fibula (laterally, below the knee). If
injured, the patient develops "Foot
Drop," an inability to dorsiflex the
foot.
16. Ankle Plantar Flexion (S 1, S 2). Have
the patient "step on the gas" while
providing resistance with your hand.
Test each foot separately. The
gastrocnemius and soleus, the muscles
which mediate this movement, are
innervated by a branch of the sciatic
nerve. Plantar flexion and dorsiflexion
can also be assessed by asking the
patient to walk on their toes (plantar
flexion) and heels (dorsiflexion).
It is generally quite helpful to directly
compare right v left sided strength, as they
should more or less be equivalent (taking into
account the handedness of the patient). If there
is weakness, try to identify a pattern, which
might provide a clue as to the etiology of the
observed decrease in strength. In particular,
make note of differences between:
1. Right v Left
2. Proximal muscles v distal
3. Upper extremities v lower
 4. Or is the weakness generalized, the examination table, etc. Pronator drift is a
suggestive of a systemic neurological test for slight weakness of the upper
disorder or global deconditioning extremities. The patient should sit with both
Special Testing for subtle weakness: Subtle arms extended, palms directed upward. Subtle
weakness can be hard to detect. Pay attention weakness in either arm will cause slight
to how the patient walks, uses and holds their downward drift and pronation of that limb (i.e.
arms and hands as they enter the room, get up the arm will rotate slightly inward and down).
and down from a seated position, move onto
Common peripheral nerves, territories of innervation, and clinical correlates.
Contributing
Peripheral Sensory Motor
Spinal Nerve Clinical
Nerve Innervation Innervation
Roots
Back of thumb,
Wrist extension
index, middle, At risk for compression at
Radial and abduction
and 1/2 ring C6, 7, 8 humerus, known as
Nerve of thumb in
finger; back of "Saturday Night Palsy"
palmer plane
forearm
At risk for injury with
Abduction of
Palmar and elbow fracture. Can get
fingers
Ulnar dorsal aspects of transient symptoms when
(intrinsic C7, 8 and T1
Nerve pinky and 1/2 of inside of elbow is struck
muscles of
ring finger ("funny bone"
hand)
distribution)
Palmar aspect of
the thumb, Abduction of
index, middle thumb Compression at carpal
Median
and 1/2 ring perpendicular to C8, T1 tunnel causes carpal
Nerve
finger; palm palm (thenar tunnel syndrome
below these muscles).
fingers.
Lateral Can become compressed
Cutaneous Lateral aspect in obese patients, causing
L1, 2
Nerve of thigh numbness over its
Thigh distribution
Can be injured with
Dorsiflexion of proximal fibula fracture,
Lateral leg, top
Peroneal foot (tibialis L4, 5; S1 leading to foot drop
of foot
anterior muscle) (inability to dorsiflex
foot)
This table provides information about usual setting of peripheral nerve dysfunction, the
patterns of innervations. There is level of the lesion will determine the extent
occasionally interindividual variation. In the of the deficit. That is, proximal insults will

205
cause the entire nerve distribution to be Note: Most of the Matters are drived from Internet
affected while more distal lesions will only and Research Papers
impact function beyond the site of the
injury.

Carpal Tunnel Induced Atrophy: Chronic,

severe compression of the median nerve
within the carpal tunnel has led to atrophy of
the Thenar muscles (hand on ri
References
Fuller, Geraint (2004). Neurological
Examination Made Easy. Churchill
Livingstone. p. 1. ISBN 0-443-07420-8.
Medical Research Council (1976). "Medical
Research Council scale. Aids to
examination of the peripheral nervous
system. Memorandum no. 45.".
Murray ED, Price BH. "The Neurological
Examination." In: Comprehensive Clinical
Psychiatry, First Edition. Stern TA,
Rosenbaum JF, Fava M, Rauch S,
Biederman J. (eds.) Philadelphia:
Mosby/Elsevier. April 25, 2008. ISBN
0323047432. ISBN 978-0323047432
Nicholl DJ, Appleton JP (May 29, 2014).
"Clinical neurology: why this still matters
in the 21st century". J Neurol Neurosurg
Psychiatr. Online first. doi:10.1136/jnnp-
2013-306881. PMID 24879832.
Oommen, Kalarickal. "Neurological History
and Physical Examination".
Retrieved 2008-04-22.

206
Chapter-6

207
208
BRAIN TUMOR
A brain tumor is a mass or growth of
abnormal cells in brain or close to brain.
Primary brain tumors emerge from the various
cells that make up the brain and
central nervous system and are named for the
kind of cell in which they first form. The most
common types of adult brain tumors are
Nobody knows what are the causes of brain
tumors but researches shows some known risk
factors i.e. Children who receive radiation to
the head have a higher risk of developing a
brain tumor as well as adult people. Some
rare genetic conditions such as neurofibro-
matosis or Li-Fraumeni syndrome may cause
brain tumor. Age is also a risk factor, people
over the age of 65 are diagnosed with brain
209
gliomas and astrocytic tumors. These tumors
form from astrocytes and other types of glial
cells, which are cells that help keep nerves
healthy.
The second most common type of
adult brain tumors are meningeal tumors.
These form in the meninges, the thin layer of
tissue that covers the brain and spinal cord.
tumor at a rate four times higher than younger
people.
A primary brain tumor is one that originates in
the brain, and not all primary brain tumors are
cancerous; benign tumors are not aggressive
and normally do not spread to surrounding
tissues,although they can be serious and even
life threatening.
Brain cancer symptoms vary from
patient to patient, and most of
these symptoms are:
- Headaches
- Seizures
- Nausea and Vomiting
- Vision or hearing problems
- Problems with weakness
- Behavioral and cognitive problems
- Changes in speech or hearing
- Changes in vision
- Balance problems
- Problems with walking
- Numbness or tingling in the arms or legs
- Problems with memory
- Personality changes
- Inability to concentrate
- Weakness in one part of the body
Headaches: This was the most
common symptom, with 46% of the patients
reporting having headaches. There is not a
definite sign of brain cancers. But the brain
tumor headache has different pain which a
person has not feel before and is usually
accompanied by nausea/vomiting. It becomes
worse by bending over or straining when
going to the bathroom.
Seizures: This was the second most
common symptom reported, with 33% of the
patients reporting a seizure before the
diagnosis was made. Seizures can also be
caused by other things, such as epilepsy, high
fevers, stroke, trauma, and other disorders. In
a person who never had a seizure before, it
usually indicates something serious and must
get a brain CT scan or MRI.
A seizure is a sudden, involuntary change in
behavior, muscle control, consciousness,
and/or sensation. Symptoms of a seizure can
range from sudden, violent shaking and total
loss of consciousness to muscle twitching or
slight shaking of a limb. Staring into space,
altered vision, and difficulty in speaking are
some of the other behaviors that a person may
exhibit while having a seizure. Approximately
210
10% of the US population experiences a single
seizure in their lifetime.
Nausea and vomiting with headaches are
non-specific symptoms. It does not mean
people having nausea and vomiting do NOT
have a brain cancer. Twenty-two percent of
the people in a survey reported that they had
nausea and /or vomiting as a symptom.
Nausea and/or vomiting is more likely to point
towards a brain cancer if it is accompanied by
the other symptoms mentioned here.
Vision or hearing problems: Twenty-five
percent reported vision problems. The eye
specialist doctor is the first one to make the
diagnosis - because when they look in your
eyes, they can sometimes see signs of
increased intracranial pressure. This must
investigate the reasons.
Problems with weakness of the arms, legs or
face muscles and strange sensations in head or
hands are likely the brain tumor symptoms.
Twenty-five percent reported weakness of the
arms and/or legs. Sixteen percent reported
strange feelings in the head, and 9% reported
strange feelings in the hands. This may result
in an altered gait, dropping objects, falling, or
an asymmetric facial expression. These could
also be symptoms of a stroke. Sudden onset of
these symptoms is an emergency. If a person
notice a gradual change over a time period
then he must report it to doctor.
Behavioral and cognitive problems: Many
reported behavioral and cognitive changes,
such as: problems with recent memory,
inability to concentrate or finding the right
words, acting out; no patience or tolerance,
and loss of inhibitions, saying or doing things
that are not appropriate for the situation.
Keep in mind that brain cancers are relatively
rare compared to most other disorders. With
the malignant brain cancers, a delay of starting
treatment can make a major impact on the
outcome.
The National Cancer Institute estimates there
will be about 23,380 new cases of brain cancer
diagnosed in 2014.
Brain tumor diagnosis look for signs of a tumor or abnormal blood
To diagnose a brain tumor, the doctor starts by vessels.
asking questions about your symptoms and A biopsy very clearly determines whether
taking a personal and family health history. tumor is cancerous or not. A tissue sample is
Then he or she performs a physical exam, removed from the brain either during surgery
including a neurological exam. If there's to remove the tumor or with a needle inserted
reason to suspect a brain tumor, the doctor through a small hole drilled into the skull
may request one or more of the following before treatment is started.
tests: The most common primary brain tumors are:
Imaging studies such as a CT (CAT) scan • Gliomas (50.4%)
or MRI to see detailed images of the brain • Meningiomas (20.8%)
Angiogram or MRA, which involve the use of • Pituitary adenomas (15%)
dye and X-rays of blood vessels in the brain to • Nerve sheath tumors (8%)
These common tumors can also be organized according to tissue of origin as shown below:
Tissue of origin Children Adults
Astrocytes Pilocytic Astrocytoma (PCA) Glioblastoma Multiforme (GBM)
Oligodendrocytes Oligodendroglioma
Ependyma Ependymoma
Neurons Medulloblastoma
Meninges Meningioma
Specific types (Main article: WHO Treatment
classification of the tumors of the central When a brain tumor is diagnosed, a medical
nervous system): team will be formed to assess the treatment
Anaplastic astrocytoma, Astrocytoma, Central options presented by the leading surgeon to
neurocytoma, Choroid plexus carcinoma, the patient and his/her family. Given the
Choroid plexus papilloma, Choroid plexus location of primary solid neoplasms of the
tumor, Dysembryoplastic neuroepithelial brain in most cases a "do-nothing" option is
tumour, Ependymal tumor, Fibrillary usually not presented. Neurosurgeons take the
astrocytoma, Giant-cell glioblastoma, time to observe the evolution of the neoplasm
Glioblastoma multiforme, Gliomatosis before proposing a management plan to the
cerebri, Gliosarcoma, Hemangiopericytoma, patient and his/her relatives. These various
Medul-loblastoma, Medulloepithelioma, types of treatment are available depending on
Meningeal carcinomatosis, Neuroblastoma, neoplasm type and location and may be
Neurocytoma, Oligoastrocytoma, Oligodendro combined to give the best chances of survival:
glioma, Optic nerve sheath meningioma, • Surgery: complete or partial resection of
Pediatric ependymoma, Pilocytic astrocytoma, the tumor with the objective of removing
Pinealoblastoma, Pineocytoma, Pleomorphic as many tumor cells as possible.
anaplastic neuroblastoma, Pleomorphic • Radiotherapy: the most commonly used
xanthoastrocytoma, Primary central nervous treatment for brain tumors; the tumor is
system lymphoma, Sphenoid wing irradiated with beta, x rays or gamma rays.
meningioma, Subependymal giant cell • Chemotherapy: is a treatment option for
astrocytoma, Subependymoma, Trilateral cancer however it is seldom used to treat
retinoblastoma. brain tumors as the blood-brain barrier
prevents the drugs from reaching the
cancerous cells. Chemotherapy can be

211
 thought of as a poison that prevents the
growth and division of all cells in the
body including cancerous cells. This
causes the significant side effects
experienced by patients undergoing
chemotherapy.
• A variety of experimental therapies are
available through clinical trials.
Survival rates in primary brain tumors depend
on the type of tumor, age, functional status of
the patient, the extent of surgical tumor
removal and other factors specific to each
case.[20]
Surgery
The primary and most desired course of action
described in medical literature is surgical
removal (resection) via craniotomy.
Minimally invasive techniques are becoming
the dominant trend in neurosurgical
oncology. The prime remediating objective of
surgery is to remove as many tumor cells as
possible, with complete removal being the
best outcome and cytoreduction (debulking) of
the tumor otherwise. In some cases access to
the tumor is impossible and impedes or
prohibits surgery.
Many meningiomas, with the exception of
some tumors located at the skull base, can be
successfully removed surgically. Most
pituitary adenomas can be removed surgically,
often using a minimally invasive approach
through the nasal cavity and skull base (trans-
nasal, trans-sphenoidal approach). Large
pituitary adenomas require a craniotomy
(opening of the skull) for their removal.
Radiotherapy, including stereotactic
approachesis reserved for inoperable cases.
Several current research studies aim to
improve the surgical removal of brain tumors
by labeling tumor cells with 5-aminolevulinic
acid that causes them to fluoresce.
Postoperative radiotherapy and chemotherapy
are integral parts of the therapeutic standard
for malignant tumors. Radiotherapy may also
be administered in cases of "low-grade"
212
gliomas, when a significant tumor burden
reduction could not be achieved surgically.
Any person undergoing brain surgery may
suffer from epileptic seizures. These can take
the form of either absence seizures or tonic-
clonic seizures. Medication can lessen and
sometimes prevent these attacks.
Multiple metastatic tumors are generally
treated with radiotherapy and chemotherapy
rather than surgery and the prognosis in such
cases is determined by the primary tumor, and
is generally poor.
Radiation Therapy
The goal of radiation therapy is to kill tumor
cells while leaving normal brain tissue
unharmed. In standard external beam radiation
therapy, multiple treatments of standard-dose
"fractions" of radiation are applied to the
brain. This process is repeated for a total of 10
to 30 treatments, depending on the type of
tumor. This additional treatment provides
some patients with improved outcomes and
longer survival rates.
Radiosurgery is a treatment method that uses
computerized calculations to focus radiation at
the site of the tumor while minimizing the
radiation dose to the surrounding brain.
Radiosurgery may be an adjunct to other
treatments, or it may represent the primary
treatment technique for some tumors. Forms
used include stereotactic radiosurgery, such
as Gamma knife, Cyberknife or Novalis Txra-
diosurgery.
Radiotherapy may be used following, or in
some cases in place of, resection of the tumor.
Forms of radiotherapy used for brain cancer
include external beam radiation therapy, the
most common, and brachy therapy and proton
therapy, the last especially used for children.
Radiotherapy is the most common treatment
for secondary brain tumors. The amount of
radiotherapy depends on the size of the area of
the brain affected by cancer. Conventional
external beam "whole-brain radiotherapy
treatment" (WBRT) or "whole-brain
irradiation" may be suggested if there is a risk
that other secondary tumors will develop in
the future. Stereotactic radiotherapy is usually
recommended in cases involving fewer than
three small secondary brain tumors.
People who receive stereotactic radiosurgery
(SRS) and whole-brain radiation therapy
(WBRT) for the treatment of metastatic brain
tumors have more than twice the risk of
developing learning and memory problems
than those treated with SRS alone.
Chemotherapy
Patients undergoing chemotherapy are
administered drugs designed to kill tumor
cells. Although chemotherapy may improve
overall survival in patients with the most
malignant primary brain tumors, it does so in
only about 20 percent of patients.
Chemotherapy is often used in young children
instead of radiation, as radiation may have
negative effects on the developing brain. The
decision to prescribe this treatment is based on
a patient's overall health, type of tumor, and
extent of the cancer. The toxicity and many
side effects of the drugs, and the uncertain
outcome of chemotherapy in brain tumors puts
this treatment further down the line of
treatment options with surgery and radiation
therapy preferred.
UCLA Neuro-Oncology publishes real-time
survival data for patients with a diagnosis of
glioblastoma multiforme. They are the only
institution in the United States that displays
how brain tumor patients are performing on
current therapies. They also show a listing of
chemotherapy agents used to treat high-grade
glioma tumors.
Other treatment
A shunt may be used to relieve symptoms
caused by intracranial pressure, by reducing
the build-up of fluid (hydrocephalus) caused
by the blockage of the free flow
of cerebrospinal fluid.
References
Auer R, Bell JC (January 2012). Oncolytic
viruses: smart therapeutics for smart
213
cancers. Future Oncology8 (1): 1–
4. doi:10.2217/fon.11.134. PMID22149027.
Bloch, O (2015). Immunotherapy for
malignant gliomas. Cancer Treatment and
Research 163: 143–58.doi:10.1007/978-3-
319-12048-59. PMID25468230.
Bondy ML, Scheurer ME, Malmer B, et
al.(2008). Brain Tumor Epidemiology:
Consensus from the Brain Tumor
Epidemiology Consortium
(BTEC). Cancer 113 (7 Suppl): 1953–1968.
doi:10.1002/cncr.23741.
Central Brain Tumor Registry of the United
States, Primary Brain Tumors in the United
States, Statistical Report, 2005–2006.
Retrieved 23 July 2014.
Chamberlain MC, Kormanik PA (February
1998). Practical guidelines for the treatment
of malignant gliomas. West. J. Med. 168 (2):
114–20. PMC 1304839. PMID 9499745.
Chien-Kuo Tai, Noriyuki Kasahara (1 January
2008). Replication-competent retrovirus
vectors for cancer gene therapy
(PDF). Frontiers in Bioscience 13: 3083–
3095. doi:10.2741/2910. PMID 17981778.
Echevarría ME, Fangusaro J, Goldman S
(June 2008). Pediatric central nervous
system germ cell tumors: a
review". Oncologist 13 (6): 690–
9. doi:10.1634/ theoncologist.2008-0037
PMID 18586924.
Frei P, Poulsen AH, Johansen C, Olsen JH,
Steding-Jessen M, Schüz J (19 October
2011). Use of mobile phones and risk of
brain tumors: update of Danish cohort
study.BMJ 343: d6387.
doi:10.1136/bmj.d6387. PMC 3197791. PM
ID 22016439.
Garber K (1 March 2006). China Approves
World's First Oncolytic Virus Therapy For
Cancer Treatment. J Natl Cancer Inst 98 (5):
298–300. doi:10.1093/jnci/djj111.
PMID 16507823.
Greenlee RT, Murray T, Bolden S, Wingo PA
(2000). Cancer statistics, 2000. CA Cancer J
Clin 50 (1): 7–
 33. doi:10.3322/canjclin.50.1.7. PMID 1073
5013.
Herholz, Karl; Langen, Karl-Josef; Schiepers,
Christiaan; Mountz, James M. (2012).Brain
Tumors. Seminars in Nuclear
Medicine 42 (6): 356–70. doi: 10.1053/j.
semnuclmed.
2012.06.001. PMC 3925448.PMID 2302635
9.
IARC classifies radiofrequency
electromagnetic fields as possibly
carcinogenic to humans. World Health
Organization press release N° 208 (Press
release). International Agency for Research
on Cancer. 31 May 2011. Retrieved 2
June 2011.
Kleihues P, Ohgaki H, Eibl RH, Reichel MB,
Mariani L, Gehring M, Petersen I, Höll T,
von Deimling A, Wiestler OD, Schwab M
(1994). Type and frequency of p53
mutations in tumors of the nervous system
and its coverings. Molecular Neuro-
oncology and Its Impact on the Clinical
Management of Brain Tumors. Recent
results in cancer research 135. Springer.
pp. 25–31. ISBN 3540573518.
Krishnatreya, M; Kataki, AC; Sharma, JD;
Bhattacharyya, M; Nandy, P; Hazarika, M
(2014). Brief descriptive epidemiology of
primary malignant brain tumors from North-
East India. Asian Pacific Journal of Cancer
Prevention 15 (22): 9871–3. doi:10.7314/
apjcp. 2014. 15.22.9871. PMID 25520120.
Merrel RT (Dec 2012). "Brain tumors.". Dis
Mon. 58 (12): 678–89. doi:10.1016/
j.disamonth.2012.08.009.PMID 23149521.
Murphy AM, Rabkin SD (Apr 2013). Current
status of gene therapy for brain
214
tumors. Transl. Res. 161 (4): 339–
54. doi:10.1016/j.trsl. 2012.11.003.PMID
23246627.
Paul Brennan (4 August 2008). Introduction to
brain cancer. cliniclog.com. Retrieved 19
December 2011.
Tai CK, Wang WJ, Chen TC, Kasahara N
(November 2005). Single-shot, multicycle
suicide gene therapy by replication-
competent retrovirus vectors achieves long-
term survival benefit in experimental
glioma. Molecular Therapy 12 (5): 842–
851. doi: 10.1016/j.ymthe. 2005.03.017.
PMID 16257382.
Treating secondary brain tumours with
WBRT. Cancer Research UK. Retrieved 5
June 2012.
Ty AU, See SJ, Rao JP, Khoo JB, Wong MC
(January 2006). Oligodendroglial tumor
chemotherapy using decreased-dose-
intensity PCV: a Singapore experience.
Neurology 66 (2) :247–
9.doi:10.1212/01.wnl.0000194211.68164.a0
. PMID 16434664.
What are the key statistics about brain and
spinal cord tumors? American Cancer
Society. May 1, 2012.
World Cancer Report 2014. World Health
Organization. 2014. pp. Chapter 5.16. ISBN
928320-4298.
World Cancer Report 2014. World Health
Organization. 2014. pp. Chapter 1.3. ISBN
928320 4298.
Note: Most of the Matters are drived from Internet and
Research Papers
Chapter-7

215
216
EPILEPSY
Epilepsy is a diverse collection of disorder
and it is define as a chronic nervous disorder
characterized by brief recurrent convulsion,
seizure and loss of consciousness. Along
epilepsy some other terms are also come in
our mind these are seizures, convulsion and
fit. The difference between seizure,
convulsion and fits are as follows: A seizure
denotes any interruption of consciousness that
might be accompanied by change in behavior,
motor or sensory activity, Convulsion
specifically denotes motor involvement or it
is a violent involuntary spasmodic contraction
of the muscle. (Seizure and Convulsion are
interconvert able term), Fit is an un-
controllable attack which is either
characterized by loss of consciousness or any
disturbance in physical activity or mental
activity.
Epilepsy consists of complex set of symptom
including altered state of consciousness,
change in behavioral, perceptual and motor
function. These are exhibited due to activation
and inactivation of neuron responsible for the
abnormal degree of electrical discharge.
More than two million people in USA and
over 50 million people in the world suffer
217
from epilepsy. More than 300,000 people
with epilepsy are under the age of 14 and
more than 500,000 are over the age of 65. It is
estimated that 1.38 million people are
suffering from epilepsy in Pakistan, which
makes it one neurologist available for every
46200 sufferers of epilepsy. Prevalence of
epilepsy in general population is estimated to
be 9.99 in 1,000 populations. In rural areas of
Pakistan the burden of epilepsy is twice of
what is observed in urban areas (14.8/1000 vs
7.4/1000). Prevalence of epilepsy in
childhood varied from 15.5 to 23 per 1000
children. It is most prevalent in younger
population (less than 30 years of age).
Highest prevalence rates were noted between
the ages of 20-40. The prevalence between
the ages of 40-60 was the lowest. A slight
increase in prevalence was noted in the group
aged greater than 60 years.
There are different types of classification of
epilepsy such as it is classified as idiopathic
or symptomatic. Idiopathic epilepsy does not
have a signs of neurological disease or mental
deficiency where as symptomatic epilepsy
result from a known condition such as stroke,
head injury, poisoning, Lennox-Gastuat
Syndrome and cerebral palsy.
Before going to discuss about the diagnosis
and treatment it is important to know the
pathophysiology of the disease. Basically a then to the rest of the body. He hypothesized
nerve cell transmits signals to and from the that there were areas in the brain that control
brain in two ways, one is by altering the isolated and the adjacent areas, therefore a
concentration of salts (Na, K and Ca+2) with seizure began in one area and spread to the
in the cell and other is by releasing the rest of the cortex. His hypothesis was later
chemical called neurotransmitter such as substantiated by Fritsch and Hittig’s
GABA and Acetylcholine. The change in salt excitation experiment on motor cortex.
concentration conducts impulse from one end
of the nerve cell to the other. At the end, a
neurotransmitter is released which carries the
impulse to the next nerve cell.
Neurotransmitters are the chemical agents that
either slow down or stop cell-to-cell
communication (inhibitory neurotransmitters)
or it stimulates this process (excitatory
neurotransmitters). Normally nerve
transmission in the brain occurs in an orderly
way, which allows a smooth flow of electrical
activity. Improper concentration of salts with
in the cell and the over activity of either type
of neurotransmitter can disrupt this nerve cell
transmission and trigger seizure activity.
Certain areas of the brain are more likely then
other involved in seizure activity for example
the motor cortex which is responsible for
body movement and the temporal lobes,
including the hippocampus (which is involved
in memory). This area is more sensitive to
biochemical changes (for example decreased
oxygen level, metabolic imbalance, infection)
that provoke abnormal brain cell activity.

The paraoxysmal depolarizing shift (PDS)

In 1800’s it was noted by Jackson that
epileptic seizures begin in isolated part of the
body such as thumb and from there spread to
the neighboring region perhaps the arm and
remain the best cellular marker to generate
epileptic event. This PDS is corresponding to
the interictal spike of the EEG. This PDS
actually represent a sustained movement of
the neuronal resting potential, 10-15 times
more than normal resting potential. During
PDS positive charge is initially carried in
through Na+ channels but Ca+2 channel open
with in a few minutes, this Ca+2 which is
enter in the cell during PDS is rapidly bound

218
to calcium binding protein and sequestered in
mitochondria. This prevent the intracellular
free Ca+2 concentration from becoming
excessive and triggering a cascade of
cytotoxic events.
Below this toxic thresh hold Ca+2 entry
produces a proportional degree of potassium
channel opening which serves to terminate the
PDS and induce a prolonged after
hyperpolarization. Failure of this Ca+2
dependent potassium current appears to be
crucial to the transition from interictal spike
(between seizures to seizure). The failure of
Ca+2 dependent potassium seizures is the
subject of current work.
The cause or etiology of epilepsy has been
studied intentionally but still remain some
what unclear for example whole tissue sample
of epileptic patient showed a trend to higher
GABA concentration, however the affinity of
GABA for binding site was found to be
decreased in this study, so we can say that the
concentration of GABA in tissue is increase
due to the decrease GABA affinity to its
binding sites.
Several neuropeptide especially the opoid like
peptide, ACTH and some hypothalamic
releasing factors have been found to alter
neuronal excitability so it is proposed that
these peptides may play a role in the
pathogenesis of the epilepsies.
At non toxic doses, several exogenously
administered peptides had anticonvulsant
properties while others were proconvulsant.
Proconvulsant include TRH and corticotropin
hormone. Anticonvulsant includes oxytocin,
ACTH and vasopressin, most potent β-
edorphin. One possible role for the
endogenous opiod peptides may be to limit
the spread of seizure susceptibility.
Loss of GABA inhibition and hyper-
excitability of the hippocampus
Many neuro-chemical analyses suggest that
inhibitory neurotransmitters concentration
especially GABA are decrease in brain of the
patient with partial (focal) epilepsy. Other
219
neurotransmitters involve may be
acetylcholine glutamate, aspartate and taurine.
Presence of hypokalemia and tendency to
wards alkalosis
One study found that a factor common to the
entire subject was the presence of
hypokalemia and a tendency to ward
alkalosis. In the presence of alkaline urine, the
diffusion of ammonia from the renal tubular
cell in to the urine is diminished/decrease so
in turn brain has high concentration of
ammonia because it can cross BBB.
Detoxification of ammonia in the brain
involves the formation of less toxic
glutamine. This formation of glutamine acid
which is the precursor of GABA and we
know that GABA is the major mediator of
central inhibition. This may lead to epileptic
attack.
So whether epilepsy is a result of decrease
inhibitory central process or increase
excitatory central process, there are different
experimental data in which the experimentally
induce epilepsy is preserved up to some
extent by inhibitory neurotransmitters, so
there are three hypothesis according to that a)
increase excitatory mechanism without
change in inhibitory neurotransmitters, b)
inhibition of chloride mediated conduction so
not produces IPSP, c) more than one
inhibitory neurotransmitters involve.
Experimental work has demonstrated that
prolong seizure cause hippocampus sclerosis
through excessive activation of excitatory
glutamate receptors, which result in excito-
toxicity. Removal of sclerotic hippocampus
leads to dramatic improvement or even a cure
of the epileptic condition so it suggested that
the sclerotic hippocampus some how cause
the epilepsy. However, we can also see that or
in other way some individual have had
hypoxic injury that may cause hippocampul
sclerosis which than cause epilepsy.
Repeated and intense seizure causes a loss of
GABA (gamma amino butyric acid) of
mediation of inhibition of dentate granule cell
(in-vitro). Thus the recent hypothesis was that
the death of GABAergic inhibitory
interneuron resulted in (attenuation) decrease
of inhibition, which is lead to hyper
excitability of the remaining neurons of
hippocampus.
A detail immunohistochemical studies of
sclerotic hippocampus which is isolated from
experimental model and also from human
have provided new potential mechanism of
hyperexcitability in which it is demonstrated
by “Sloviter” that GABA neuron were more
resistant to seizure induce neuronal death than
other hippocampul neurons. Further study
from human tissue also confirms this theory.
In fact other type of cell in these specimens
was readily destroyed, these are mossy cell.
These mossy cells are located in the
hippocampus has dentate hilus, so actually
mossy cell are present in that part. These
mossy cells were found to be extremely
sensitive to seizure induced neuronal death.
Mossy cell are the most common type of
neuron in the hilus of dentate gyrus of
hippocampus. They receive synaptic inputs
from hippocampus and from cortex.
Functionally mossy cells are more activating
by low threshold stimulation and thought to
be and thought to be excitatory. These mossy
cells are damage following intense synaptic
activation. It is probably through excitotoxic
mechanism of activation of N-methyl-D-
aspartate (NMDA) subtype of glutamate
receptor which results in excessive
intracellular Ca+2.
These finding results a hypothesis called
“Dormant Basket cell hypothesis”. In this
seizure cause the death of excitatory neuron in
the hilus (probably mossy cell) which remove
the excitatory projection from GABAergic
220
basket cell so the inhibitory neuron are not
activated by mosy cell because basket cell lie
dormant (or we say that death of ecitatory
neuron lead to inhibition of inhibitory neuron)
once this is a vicious cycle is started in which
partial loss of this inhibition combine with
excitatory synaptic input lead to excessive
firing of granule cell. More the death of
mossy cell causes further loss of GABAergic
inhibition and so on, result in epileptic
condition.
The relation ship between GABA and seizure
is further supported by the fact that many of
the antiepileptic medication act on GABA
receptor, for example new antiepileptic drug
Tiagabine inhibit GABA uptake this sort of
clinical observation suggest that GABA does
play a role in epilepsy.
Types
The international classification of epileptic
seizure identified seizure types on the basis of
site of origin in brain. The two main
categories include:
1. Partial seizure
2. Generalized seizure
There is several sub type of each; the most
common are described here.
Partial Seizure
The site of origin is a localized area in one
hemisphere of the brain. The two most
common type of partial seizure are:
1. Simple partial seizure
2. Complex partial Seizure
Simple partial seizure produces symptom
associated with the abnormal activity in brain.
It produces motor signs, Sensory symptom
and psychic symptom. It alters the state of
consciousness but there is no impairment of
consciousness.
Impairment of consciousness is the
characteristic of complex partial seizure
which result the inability to carry simple
command and lack of awareness of one’s
surrounding event. Automatism (it is a more
or less coordinated involuntary motor
activity) may occur and a simple partial
seizure may cause complex seizure.
Generalized seizure
Grand mal (Tonic Clonic)
It is characterized by extreme neuronal
discharge in all area of the brain like in
cortex, cerebrum, thalamus and brain stem.
There is loss of consciousness during the
seizure. The tonic phase consists of increase
muscle tone (rigidity) followed by clonic
phase which involve jerking of extremities.
Autonomic symptom may also be present.
Often the person bites or swallows the tongue
and usually has difficulty in breathing and
some time develops cyanosis (bluish of skin).
It also causes urination and defecation due to
signal to the viscera. It last up to few second
to as long as 3 or 4 minutes and is
characterized by post seizure depression of
the entire nervous system.
The person remain in the stupor (condition of
unresponsiveness from which patient arouse
by repeated stimulation) from one to many
minutes after the attack is over and often
remain severely fatigue or even a sleep for
many hour.
During these seizure high voltages
synchronous discharge occurs over the entire
cortex. In human Grand mal attacks can be
initiated by administrating neuronal
stimulation such as drug Metrazol or they can
be cause by insulin hypoglycemic shock or by
alternating the electrical current in the brain.
Electrical recording from the Thalamus also
show the high voltage activity as recorded
from cerebral cortex therefore Grand mal
attack may also initiated by the activating of
lower part of the brain. The major factor that
stop the attack after a few minute is
phenomena of neuronal fatigue, secondly by
221
inhibitory neuron that also have been
activated by the attack.
Petit mal (Absence) seizure
This type occurs mostly in children usually
beginning between the age of 5-12 years and
often stop spontaneously the teen. The loss of
consciousness is so brief that the child usually
does not even change the position or 3-30
second. Mostly it last up to 10 second or less.
There is no postictal phase but the person
usually lacks the awareness of what occurs
during the seizure. During this seizure person
has several twitch like contraction of the
muscle usually in the head region specially
blinking of eye. This is followed by return to
consciousness and resumes the previous
activity. The patient may have one such attack
in many months or in rare cases have rapid
series of attack in late child hood and then
disappear entirely by the age of 30.
Occasionally petit mal attack initiates grand
mal attack. The brain wave pattern of a petit
mal attack is typical by a spike and dom
pattern. The spike (sharp high action
potential) portion is almost identical to that
occur in grand mal attack but the dom portion
is entirely different. This pattern of spike and
dom recorded over most or all of the area of
cerebral cortex.
Myoclonic seizure
These seizures are so brief that may go
unnoticed. They involve sudden muscle
contraction that occur much more rapidly than
clonic activity and often it occur at all ages
and area associated with epileptic syndrome
such as West syndrome and Lennox Gastaut
Syndrome.
West syndrome
West syndrome is also called infantile spasm
and it is a rare disorder of early child hood
and infancy it is characterized by epilepsy,
hydrocephalus congenital anomalies and
mental retardation.
Lennox-Gastaut syndrome
It usually develops between the age of 1 and 8
year old and is characterized by atonic,
absence and myoclonic seizure. Many of 3. Stroke that result in lack of blood
these children have developmental and flow or hemorrhage
behavioral problem. Adult several medical 4. Metabolic disturbance
conditions may precipitate epilepsy like i) electrolyte imbalance that is
withdrawal from alcohol, drug abuse and alteration of level of Na, ca+2,
stroke eclampsia. magnesium
OTHER EPILEPSIES ii) Hypoglycemia or hyperglycemia
Focal epilepsy iii) Renal failure with uremia
It can involve almost any part of brain. It is iv) Hepatic failure which elevate toxin
result from localize lesion, scar, tumor or v) Hypoxia low oxygen in brain
damage area in the brain or also occur due to vi) Over dosage of some drug also
congenital defect in local circuit. These lesion precipitate seizure or abrupt with
cause rapid discharge, so synchronous wave drawl of drug
spread in the adjacent area, this spreading of 5. Substance that may induce seizure
wave may from few mm/min. to several include
cm/sec. So these excited wave cause progress
muscle contraction. It can also initiate grand i) TCA like lithium, Elavil
mal attack. ii) Antipsychotic drug;
Psychomotor seizure chlorpromazine haloperidol,
It may cause clozapine,
1) Short period of amnesia iii) Aminophylline bronchodilator
2) An attack of abnormal range iv) High dose of penicillin
3) Sudden anxiety discomfort or pain v) Chronic illicit drug use also cause
4) Movement of incoherent speech seizure like cocaine, heroin,
mumbling amphetamine and Pencyclidine
5) A motor attack to some one to rub the vi) Alcohol withdrawl
face vii) Poisoning from CO, lead and other
6) Some time person cannot remember heavy metal.
his activity during this attack on the 6. Infection like meningitis,
other had some time he will have been encephalitis, HIV
conscious of every thing that he had 7. Tumors; Malignant (cancerous)
been doing but unable to control it. benign brain tumors
This attack involves limbic system 8. Degenerative Disorder
such as such as hippocampus, i) Alzheimer’s disease
amygdala and temporal cortex. ii) Creutzfeld-jakob disease
Causes and risk factor iii) Neurofibromatosis
Many abnormalities of the nervous system iv) Phenylketonuria “(PKU)
can result in seizure activity. Seizure can also v) Tuberous sclerosis
occur in the normal nervous system when its vi) Sturge-weber syndrome
metabolic balance is disturbed. The causes vii) Tay-sachs disease (it is disease of
(etiology) of epilepsy may be idiopathic or CNS affliction which bring death
related to a particular disease state. About before age of 5, it involve neuronal
35% of all cases of epilepsy have no definite degeneration of CNS because of
cause. excessive store of lipid)
1. Genetic factor viii) Cerbral Palsy (Group of moptor
2. Head injury disorder resulting in muscular

222
 unco-ordinational and loss of
muscle control); epilepsy is often a
symptom of cerebral palsy which
result from lack of oxygen,
infection
ix) Febrile seizure; Trauma during
birth occur in small children and
cause by high fever
9. Triggers; they do not cause seizure
but provoke the onset of seizure in
a patient whose epilepsy is under
control. These are alcohol
consumption, hormonal changes,
sleep deprivation, flutter,
flickering or flashing light, sudden
blaze and stress can trigger a
seizure in susceptible person
Diagnosis
Patient should be diagnosed completely or
thoroughly after first seizure and take
complete patient history. In diagnosis a
detailed description of seizure is important to
distinguish seizure type. Significant
information include following.
Event that occur during seizure
Nature of the onset of seizure
Presence of trigger
Whether seizure occur during wakefulness or
sleep
Whether awareness return immediately or
have prolong period of confusion
Thorough physical and neurological
examination also performed
Laboratory studies of blood and urine helps to
identify liver and kidney dysfunction which is
important to augment adverse effect of
antiepileptic drug and identify the underlying
cause
Differential diagnosis
It is important to identify the treatment of
disease that may produce seizure such as head
trauma, infection and drug intoxication.
Condition that produce symptom similar to
those symptom occur in seizure are
223
a) Breath holding spell characterized by
cyanosis, loss of consciousness, loss of
muscles tone
b) Meniere’s disease characterized by
vertigo, visual disturbance, speech
impairment, alter consciousness
c) Migraine characterized by aura, loss of
consciousness, nausea, photophobia,
muscle weakness
d) Movement disorder characterized by
tics, chorea, tremor
e) Syncope characterized by sudden loss of
muscle tone and posture, loss of
consciousness, vertigo, nausea, muscle
spasm
Electro-encephalogram (EEG)
Electroencephalogram is a diagnostic test
used to investigate seizure disorder. It
identifies abnormal activity of brain and
provides information about seizure and at
which part of brain seizure occur.
Some findings of the EEG are specific to
particular disorder and subtype of epilepsy
like delta wave pattern found in epilepsy and
beta wave pattern found in psychotic disorder.
The EEG measures electrical activity by
placing small electrode on the scalp of both
side of head if result is normal than test is
repeat after patient is subjected to seizure
trigger. Continuous 24-72 hour EEG and
video monitoring may be performed at home
to obtain record of seizure.
NEUROIMAGING
MRI magnetic resonance imaging or CAT
scan computerized axial tomography are also
perform when a lesion or other structural
cause these.
Treatment
Treatment with a single drug is the goal or
target. Seizure treatment is complicated in
patients by using more than one drug because
of drug interaction and increase side effects.
Compliance is essential to control seizure and
must maintain the therapeutic level of drug on
body and should not withdraw abruptly.
Treatment is through different way like by,
Medication
Surgery
A new technique is by vagus nerve stimulator
By ketogenic diet
Usually surgery is not recommended and only
use when there is tumor condition or any
other serious cause.
Vagus nerve stimulator is implant near collar
bone and attach to the vagus nerve, which
connect the lower part of brain to heart lung
and gastrointestinal tract. It delivers small
electrical energy at regular interval. In some
patient seizure frequency is reduce or in
patient who has medication may reduce the
dose.
Ketogenic diet is used in children ho do not
respond to standard therapy. In this high fat
and low carbohydrate diet is given which
provide energy for skeletal muscle, heart,
kidney and brain. It is done under careful
supervision and must monitor the growth of
children. For this often vitamin supplements
are given. Children may develop weight gain,
increase cholesterol and constipation.
Medication can be divided in to first
generation anticonvulsant (older medication)
and second generation anticonvulsant (more
recent development).
First generation antiepileptic drugs
Phenytoin: Its use is declined and not
considered as first line of treatment but it is
effective in tonic clonic partial seizures. Half
life is 12 to 36 hours or average 24 hours. It
works through suppressing the electrical
activity in brain nerve cell. It is administer
orally and IV. New form of drug is
fosphenytoin can also give intramuscularly.
Therapeutic concentration is between 10 to 20
mg/L. drug level is monitor by LFT and CBC.
It is highly bound to plasma proteins. It
interacts with sulphonamide and
phenylbutazone. It has a number of side
effects like impaired cognition, sedation,
cerebeller disorders, peripheral neuropathy,
weakness, rashes, gum hyperplasia, coursing
224
of facial features which are acromegaloid,
hirsutism, folate dependent megaloblastic
anemia and osteomalasia.
Carbamazepine: It is a considered drug of
choice for tonic clonic seizure, partial seizure
and trigeminal neuralgia. It is also use for
prophylaxis of manic depressive illness and
pituitary dependent diabetes insipidus.
Its mechanism is not well known; it may be
like phenytoin or may inhibit uptake and
release of norepinephrine. Recommended
therapeutic level is 8-12 mg/L. it has
interaction with number of drugs. It increase
metabolism of theophylline, warfarin, adrenal
and contraceptive steroids and it has complex
drug interaction with other anticonvulsant
agents also. Half life is 35 hours because it is
a potent inducer of hepatic enzymes. Its
adverse effects include dose dependent
neurotoxicity, blurring f vision, diplopia,
dizziness, skin rash osteomalasia, folate
deficiency and hypernatrimea.
Barbiturate: Phenobarbitone and primidone is
no longer a drug of choice but use in all form
of epilepsy as a second choice. it is potent
inducer of cytochrome P-450 system.
Therapeutic level is 15-40mg/L. its side effect
is sedation and folate induce megaloblastic
anemia.
Sodium valproate: It is considered as a drug
of choice for all common seizure disorders.
Mechanism of action is through GABA.
Therapeutic level is 50-100 mg/L. adverse
effects are nausea, elevated liver enzyme, rare
hepatic and pancreatic disorders,
coagulatopathy or inhibition of platelet
aggregation, increase appetite and weight small number of patients; if it occur patient
gain, change in hair growth, hair loss or should notify the physician immediately.
alopecia. Gabapentin: It is adjunct, structurally related
Benzodiazepine: Mostly these are sedative. to the GABA but not interact with GABA
Adverse effect is sedation, hypotension. receptor in brain.
Lamotrigine: It is also used as adjunct
Newer antiepileptic agent treatment for partial seizure. Most
Drug Mechanism Comments considerable adverse effect is potentially life
Vigabatrin Analogue of It has threatening skin rash.
GABA similar Tiagabine: It is uses for adult. It also effects
Cause CNS through GABA mechanism.
irreversible effects Levetiracetam: It is also used in adult.
inhibition of like other Oxcarbazepine:It is indicated as monotherapy
GABA Weight for adult and children. Common side effects
transaminase gain are dizziness, sleepiness and nausea.
Use in Zonisamide: It is derivative of sulphonamide.
combinati Ethosuximide: It works through suppressing
on brain cell activity. it is use to treat petitmal
Lomotrigine Act by blocking Has less seizure. therapeutic level is 40-100 µg/ml.
voltage CNS potrntial side effects are related to GI like
dependent effect nausea, vomiting, abdominal cramps, diarrhea
sodium channel Skin rash and weight loss; Hematological adverse
Secondly impair Use as effects include bone marrow suppression;
the release of alone or Genitourinary adverse effects include vaginal
excitatory combinati bleeding integumentry hirsutism and
neurotransmitter on hematuria; neurologic adverse effects include
GABA GABA Use in headach, dizziness, aggression, fatigue and in
pentin analogue combinati coordination.
Mechanism is on only Primidone: It is barbiturate and is use in tonic
unknown clonic seizure and partial seizure. Its side
Topiramate Block voltage Adjunct to effects include dizziness, vertigo, impotence,
dependent partial blurring vision, nausea, vomiting and weight
sodium channel seizure loss.
Secondly Drug of Choice in Treatment of Specific
enhance GABA Seizure Type
and inhibit Seizure disorder Agent
glutamate Primary generalized Valproate
Second generation anticonvulsant tonic clonic Carbamazepine
Topiramate: It is effective for both child and Phenytoin
adult. It may act by increasing GABA. It is Partial seizure Valproate
effective for both partial and generalized Carbamazepine
seizure along with other drugs. It can cause Phenytoin
aggressiveness of children which is Absence petitmal Valproate
potentially very serious side effect. Acute Ethosuximide
glaucoma and visual abnormality occur in a Atypical, Absence, Valproate
Myoclonic, Atonic

225
Prognosis
When a patient has been seizure for several
years, it may possible to discontinue the
medication depending upon the patient age
and type of epilepsy; this is done only by
supervision of physician. So if person is free
from fits then consider withdrawal of therapy
but;
- Should reduce gradually over several
months;
- Expect 20% relapse in first year;
- 20% relapse over next 5 years;
- Subsequent relapse is rare.
If epilepsy was severe and patient have
multiple drug therapy then it is better that
therapy should reduce gradually over several
months.
Status epilepsy
It is generalized tonic clonic fit lasting more
than 30 minute or repeated fit without
recovery of normal alertness or behaviour. It
requires prompt treatment and management.
Driving and Epilepsy
A person having epilepsy can never drive car.
if have epilepsy then drive only if fit free for
one year.
Pregnancy and Teratogenicity
Seizure in pregnancy constitutes a major risk
to mother and fetus so pay special attention in
therapeutic level of drug because of change of
protein binding and change of hepatic drug
metabolism. carbamazepine is a drug of
choice in women have child bearing potential.
Anticonvulsants have teratogenic effect
(increase incidence of birth defect like cause
cleft lip, cardiac defect, neural tube defect.
First aid
A person having seizure require following
first aid:
1. Prevent injury.
2. Maintain an open airway.
3. Should recognize the emergency
condition to know for immediate help.
226
4. Help the person to lie down as soon s
possible.
5. If person have other problem like diabetic
or pregnant woman call ambulance.
6. Turn person to one side and put soft
object under their head.
7. Do not put anything in to person mouth
because in tonic clonic seizure jaw are
locked and forcing can cause damage.
8. Remove harmful object from area.
9. Loose ties and collar.
10. Do not restrain person in anyway because
it may cause bone breakage or aggressive
behavior.
11. Remain with person until they are
completely aware about them.
12. If seizure is longer then 5 minutes
immediately call ambulance.
Genetic Epilepsy
Epilepsy can also occur due to mutation in
gene and it was first identify by Shoffner.
This mutation in gene causes a disease known
as MERRF syndrome that is myoclonic and
Ragged Red fibers. It is associated with defect
in mitochondrial oxidative phosphorylation.
This mitochondrial abnormality in the neuron
will have negative effect on aerobic
respiration and lead to neuronal
dysfunctioning and myoclonic seizure.
Recently the mutant gene for epilepsy has
been successfully identified. Further inquiry
on genetic epilepsy has suggested that there
are two classes of genes. They may me
glutamate receptor and potassium channel
gene both are involve in regulation of
neuronal excitability.
Zinc and Epilepsy
Zinc and epilepsy have puzzling relationship.
in experiment on rat it is suggested that zinc
induce seizure so it may play a major role in
generation of epileptic activity because this
zinc decreases the GABA activity while in
some experiment it is found that it act as
inhibitory neurotransmitter so decreases
seizure.
Some researchers noted that in mice and rat
after seizure the level of zinc is increase but
some not show that so these variations could
be due to variation in other factor. But zinc
has important role in pathophysiology of
epilepsy although it has too many
contradictions.
Role of Pharmacist:
It is the role of Pharmacist to educate the
patient, the public and his colleagues about
epilepsy and its rational therapeutic
management. He should also expand his own
knowledge of the disorder and should know
the new advancement in the therapy so more
epileptic seizure could improve and control
with fewer complications.
Adjunctive measures include, adequate
nutrition, rest and emotional support is also
important.
REFERENCES
Brodie, MJ; Elder, AT, Kwan, P (2009 Nov).
Epilepsy in later life. Lancet
neurology 8 (11): 1019–30.
Cascino GD (1994). "Epilepsy: contemporary
perspectives on evaluation and
treatment". Mayo Clinic Proc 69: 1199–
1211.
Chang BS, Lowenstein DH
(2003). "Epilepsy". N. Engl. J.
Med. 349(13): 1257–66. .
Duncan, JS; Sander, JW, Sisodiya, SM,
Walker, MC (2006 Apr 1). Adult
epilepsy. Lancet 367 (9516): 1087–100.
Frucht MM, Quigg M, Schwaner C,
Fountain NB. (2000). Distribution of
227
seizure precipitants among epilepsy
syndromes. Epilepsia 41 (12): 1534–1539.
Engel J Jr (1996). Surgery for
seizures. NEJM 334 (10): 647–652.
Epilepsy: Fact Sheets. World Health
Organization. October 2012.
Fisher R, van Emde Boas W, Blume W, Elger
C, Genton P, Lee P, Engel J.
(2005). Epileptic seizures and epilepsy:
definitions proposed by the International
League Against Epilepsy (ILAE) and the
International Bureau for Epilepsy
(IBE). Epilepsia 46 (4): 470–2.
Herzog AG, Harden CL, Liporace J, Pennell
P, Schomer DL, Sperling M et al. (2004).
"Frequency of catamenial seizure
exacerbation in women with localization-
related epilepsy". Annals Neurology 56 (3):
431–34.
Holmes, Thomas R. Browne, Gregory L.
(2008). Handbook of epilepsy(4th ed.).
Philadelphia: Lippincott Williams &
Wilkins.
Oby, Emily; Janigro, Damir (2006). "The
Blood–Brain Barrier and
Epilepsy" (PDF). Epilepsia 47 (11): 1761–
1774
Patient Fact Sheet: Epilepsy". American
Academy of Neurology. Retrieved January
5, 2012.
Wyllie's treatment of epilepsy : principles and
practice. (5th ed.). Philadelphia: Wolters
Kluwer/Lippincott Williams & Wilkins.
2010.
Note: Most of the Matters are drived from Internet and
Research Papers
Chapter-8

229
230
RESPIRATION CHEST EXAMINATION
Introduction sternocleidomastoid, upper trapezius,
Pulmonary examination, Physicalpectoralis major, and others.
Examination, provides important information The position of a patient indicates severity of
to the physician. Physical observation helps inrespiration and is an important clues to a
determining the level of distress, use of diagnosis. A patient with asthma or chronic
accessory muscles, respiratory position, chest obstructive pulmonary disease (COPD)
structure, respiratory pattern, and other cluesexacerbation may be seen sitting and leaning
outside of the chest. forward with shoulders arched forward to
Initial observations assist the accessory muscles of respiration.
The patient’s level of distress should be It is also important to note whether the trachea
immediately assessed if necessary in case of is midline or deviated. Tracheal deviation may
severe distress where patient experiencing occur ipsilateral to an abnormality (such as in
impending respiratory failure immediate collapse or mucous plugging) or contralateral
intubation is required. The increased work of to an abnormality (such as in pleural
breathing should be noted on initial effusion or pneumothorax). Table 1 shows
assessment. These muscles include the possible tracheal findings in several common
disorders.
Table 1. Pulmonary Examination Findings of Common Disorders (Open Table in a new window)
Disorder
Pleural Mucous Plug
Examination Consolidation Emphysema Pneumothorax
Effusion (With Collapse)
finding
Tracheal
Contralateral None None Contralateral Ipsilateral
deviation
Fremitus Decreased Increased Decreased Decreased Decreased
Hyper- Hyper-
Percussion Dull Dull Dull
resonant resonant
Pectoriloquy Decreased Increased Decreased Decreased Decreased
Breath sounds Decreased Decreased Crackles Decreased Decreased

There are both congenital and acquired
variations of chest wall structure. Congenital
variations include pectus excavatum, in
which the sternum is depressed relative to
the ribs, or, conversely, pectus carinatum,
which is characterized by anterior protrusion
of the sternum. Kyphoscoliosis, which may
be congenital or acquired, is a spinal
deformity characterized by lateral curvature
and forward flexion of the spine, which can
result in restrictive lung disease.
Longstanding obstructive disease can lead to
what is commonly known as “barrel” chest,
in which the ribs lose their typical 45°
downward angle, leading to an increase of
the anteroposterior diameter of the chest.
Chest Form
Examination of the shape of the chest is
used to assess the structure of the ribs and
spine.
- Normal Chest
Elliptical Form (normal form): a) Asthenic
type b) Sthenic type
- Abnormal form of chest
a) a) Barrel shape b) Pigeon Shape c)
Ricketic d) Funnel Shape

231
Breathing Patterns
Differential breathing patterns gives clues to
different diseases of respiratory system. The
breathing pattern comprises of rate, rhythm,
and volume of a patient’s breathing. The
normal breathing rate is 10-14 breaths per
minute, with an approximate 1:3 ratio of
inspiration to expiration.
Three principal abnormal patterns of
breathing are as under:
- Cheyne-Stokes respiration is characterized
by periods of apnea that are interspersed
between cycles of progressively increasing
then decreasing respiratory rates, which
often indicates uremia or congestive heart
failure (CHF).
- Kussmaul breathing is a rapid, large-
volume breathing caused by acidotic
stimulation of the respiratory center; it can
indicate metabolic acidosis.
- Biot breathing is an irregular breathing
pattern alternating between tachypnea,
bradypnea, and apnea, a possible indicator
of impending respiratory failure.
Extrathoracic observations
Observations outside of the chest add
information to the initial assessment.
Peripheral cyanosis or clubbing indicates
impaired oxygen delivery. Patients with a
severe obstructive defect may breathe with
pursed lips, as this can partially ameliorate
the obstruction.
Practical approach in respiratory examination
This is essentially an examination of the
patient’s lungs; however, it is a complex
examination which also includes
examination of other parts of the body
including the hands, face and neck.
The respiratory examination aims to pick up
on any respiratory (breathing) pathology that
may be causing a patient’s symptoms e.g.
shortness of breath, cough, wheeze etc.
Common conditions include chest
infections, asthma and chronic obstructive
pulmonary disease (COPD). This
examination is performed on every patient
232
that is admitted to hospital and regularly in
clinics and general practice.
Like most major examination stations this
follows the usual procedure of inspect,
palpate, percuss, auscultate (look, feel, tap,
listen). It is an essential skill to examine
respiration.
Steps in examination
1. Begin by washing your hands, introduce
yourself and clarify the patient’s identity.
Explain what you would like to do and
gain the patient’s consent.
Wash your hands
2. The patient should be sitting up and
exposed from the waist up. Make a
general observation of the patient. Check
whether they are comfortable at rest, do
they look tachypnoeic, are they using
accessory muscles, are there any obvious
abnormalities of the chest. Also check for
any clues around the bed such as inhalers,
oxygen masks, or cigarettes.
Observe the patient from the end of the bed
3. Move to the hands. Hot, pink peripheries
may be a sign of carbon dioxide
retention. Look for any signs of clubbing
or nicotine staining. Ask the patient to
extend their arms and cock their wrists to
90 degrees. Observe the hands in this
 position for 30 seconds; a coarse flap may
also be a sign of carbon dioxide retention.
Inspect the patient's hands
Look for CO2 flap
4. At the wrist you should take the patient’s
pulse. A bounding pulse may indicate
carbon dioxide retention. After you have
taken the pulse it is advisable to keep
your hands in the same position and
subtly count the patient’s respiration rate.
This helps to keep it as natural as
possible.
Take the radial pulse
5. Move up to the face. Ask the patient to
stick out their tongue and note its colour
checking for anaemia or central cyanosis.
Remember to ask them to raise their
tongue up and check underneath.
233
Inspect the mouth and tongue
6. Look for any use of accessory muscles
such as the sternocleidomastoid muscle.
Also palpate for the left supraclavicular
node (Virchow’s Node). This drains the
thoracic duct so an enlarged node
(Troisier’s Sign) may suggest metastatic
cancer e.g. lung or abdominal.
Palpate for the left supraclavicular node
7. The examination now moves onto the
chest. Take time to observe the chest
looking for any abnormalities such as
changes in rib cage shape, or scars.
Remember these may be in the axillae or
on the back.
8. Now palpate the chest. Firstly feel
between the heads of the two clavicles for
the trachea. If it is deviated, it may
suggest a tumour or pneumothorax.
Palpate the trachea
9. Feel for chest expansion. Place your
hands firmly on the chest wall with your
 thumbs meeting in the midline. Ask the
patient to take a deep breath in and note
the distance your thumbs move apart.
Normally this should be at least 5
centimetres. You should measure this at
the top and bottom of the lungs as well as
on the back.

Check for tactile vocal fremitus

12. Finally, auscultate. Do this in all
areas of both lungs and on front and back
comparing the sides to each other. Listen
for any reduced breathe sounds, or added
sounds such as crackles, wheeze, pleural
rub or rhonchi.
Assess chest expansion
10. Perform percussion on both sides,
comparing similar areas on both sides.
You should start by tapping on
the clavicle which gives an indication of
the resonance in the apex. Then percuss
normally for the entire lung fields. Hyper-
resonance may suggest a collapsed lung
where as hypo-resonance or dullness Auscultate left lung
suggests consolidation such as in
infection, effusion or a tumour. Be sure to
perform this on the back as well.

Auscultate right lung

Percuss the lung fields
11. Check for tactile vocal fremitus.
Place the medial edge of your hand on the
chest and ask the patient to say “99”. Do
this with your hand in the upper, middle
and lower areas of both lungs. This again
gives a suggestion of the constitution of
the tissue deep to your hand.
13. Whilst using the stethoscope, ask the
patient to again say “99” whilst listening
in all areas – this is a more reliable test
than the one described earlier.
14. Finish by examining the lymph
nodes in the head and neck. Start under
the chin with the submental nodes, move
along to the submandibular then to the
back of the head at the occipital nodes.
Next palpate the pre- and post- auricular
nodes. Move down the cervical chain and
onto the supraclavicular nodes.

234
 Palpate the submental lymph nodes
Palpate the submandibular lymph nodes
Palpate the occipital lymph nodes
Palpate the pre-auricular lymph nodes
Palpate the post-auricular lymph nodes
235
Palpate the cervical lymph nodes
Thank your patient and allow them to dress.
Wash your hands and report your findings to
your examiner.
References
Colin D. Selby (25 October 2002). Respiratory : an
illustrated colour text. Elsevier Health Sciences.
pp. 14–. ISBN 978-0-443-05949-0. Retrieved 7
March 2011.
Forgacs P. Functional significance of clinical signs in
diffuse airway obstruction. Brit J Dis
Chest. 1971;65:170.[PubMed]
Kilburn KH. et al. Anterior–posterior chest diameter
in emphysema. Arch Int
Med. 1969;123:379. [PubMed]
Leblanc P. et al. Breath sounds and distribution of
pulmonary ventilation. Amer Rev Resp
Dis. 1970;102:10.[PubMed]
Lehrer S. Understanding lung sounds. Philadelphia:
W.B. Saunders, 1984.
Nath AR, Capel LH. Inspiratory crackles—early and
late. Thorax. 1974;29:223.
Palaniappan R, Sundaraj K, Ahamed NU, Arjunan A,
Sundaraj S. Computer-based Respiratory Sound
Analysis: A Systematic Review. IETE Tech Rev
2013;30:248-56
Pierce JA, Ebert RB. The barrel deformity of the
chest, the senile lung and obstructive pulmonary
emphysema.Amer J Med. 1958;25:13. [PubMed]
Rales, rhonchi and Laennec, recorded by A. John
Robertson, after an evening with Robert Coope.
Lancet 1957; 2:417.
Note: Most of the Matters are drived from Internet
and Research Papers
Chapter-9

237
238
SINUS The frontal sinuses are located in the area
near the eyebrows; the maxillary sinuses are
INTRODUCTION
located inside the cheekbones; the ethmoid
If a person feeling stuffy or congested,
sinuses are between the eyes; and the
waking up with a headache, and noticing
sphenoid sinuses sit behind the ethmoid
swelling around eyes, that means he may have
sinuses.
sinusitis. Sinusitis can be inconvenient or
Most of the cases of sinusitis involve more
even painful at times, but it's usually not
than one sinus; maxillary sinus is most
severe.
commonly involved, followed in frequency
If a cold or allergy attack has not gone away?
by the ethmoid, frontal and sphenoid sinuses.
Then there is a good chance of sinusitis.
Each sinus is lined with a respiratory
Experts estimate that 37 million people are
epithelium that produces mucus. This mucus
afflicted with sinusitis each year, making it
is transported out by ciliary’s action through
one of the most common health conditions in
the sinus ostium in to nasal cavity.
America and other countries. That number
Normally mucus does not accumulate in the
may be significantly higher, since the
sinuses, which remain sterile despite their
symptoms of bacterial sinusitis often mimic
adjacency to the bacterium-filled nasal
those of colds or allergies, and many sufferers
passages.
never see a doctor for proper diagnosis and
When the sinus ostia are obstructed, or when
treatment with an antibiotic.
ciliary’s clearance is impaired or absent, the
Infection of upper respiratory tract infection
secretion can be retained, producing the
(URI) has a tremendous impact on public
typical signs and symptoms of sinusitis.
health.
The retained secretion may become infected
They are among the most common reasons
with a variety of pathogens, including viruses,
for visits to primary care providers, the
bacteria and fungi.
illnesses are typically mild.
Sinusitis affects a tremendous portion of the
The high incidence and transmission rates
population, accounts for millions of visits to
place them among the leading causes of time
primary care physicians each year. It is the
lost from work or school.
fifth leading diagnosis for which antibiotics
are prescribed.
Classification
Duration of illness
1. Acute
2. Chronic
By etiology
1. Infectious
i. Viral
ii. Bacterial
iii. Fungal
Sinusitis refers to an inflammatory condition
2. Noninfectious
involving the four paired structures
Acute sinusitis
surrounding the nasal cavities.
Sinusitis of less than four weeks duration and
Maxillary sinus
constitute the vast majority of cases.
Ethmoid sinus
Differentiating of viral, bacterial and fungal
Frontal
sinusitis is difficult; therefore it is perhaps
Sphenoid

239
unsurprising that antibiotics are prescribed
frequently for this condition.
Acute sinusitis can be viral, bacterial or
fungal.
Viral rhinosinusitis is far more common than
bacterial sinusitis. The most commonly
isolated viruses both alone and with bacteria
have been rhinovirus, parainfluenza virus and
influenza virus.
Bacterial causes of sinusitis have been better
described. Among community acquired cases,
S. pneumoniae and non-typable Haemophilus
influenza are the most common pathogens
accounting for 50 to 60% of cases. Other
streptococcal species and staphylococcus
aureus causes a small percentage of cases.
Nosocomial cases are commonly associated
with bacteria found in the hospital
environment includind S. aureus,
Pseudomonas aeruginosa, Serratia
marcescens, Klebsiella pneumoniae and
enterobacter species.
Fungi are also established causes of sinusitis,
although most acute cases are in immuno-
compromised patients and represent invasive,
life-threatening infections usually occur in
diabetic patient with ketoacidosis but also
develop in transplant recipients, patient with
hematologic malignancies and patient
receiving chronic glucocorticoid or
deferoxamine therapy.
The best known example is rhinocerebral
mucormycosis caused by the fungi of the
orderMucorales, which includes species of
Rhizopus, Rhizomucor, Mucor, Absidia and
Cunninghamella.
Chronic sinusitis
Chronic sinusitis is characterized by
symptoms of sinus inflammation lasting more
than12 weeks. This is more commonly
associated with either bacteria or fungi and
clinical cure in most of the cases is very
difficult.
Many patients have undergone treatment with
repeated courses of antibacterial agents and
multiple sinus surgeries increasing their risk
240
of colonization with antibiotic-resistant
pathogens and of surgical complications.
In chronic bacterial sinusitis, infection is
thought to be due to the impairment of
mucociliary clearance from repeated
infections rather than to persistent bacterial
infection. However, the pathogenesis of this
condition is poorly understood. Although
certain conditions (for example Cystic
fibrosis) can predispose patients to chronic
bacterial sinusitis, most patient with this
infection do not have obvious underlying
conditions that result in the obstruction of
sinus drainage, the impairment of ciliary’s
action or immune dysfunction.
Patient experience constant nasal congestion
and sinus pressure, with intermittent periods
of greater severity, that may persist for a
years.
CT scan can be helpful in defining the extent
of disease and the response to therapy. The
management team should include an
otolaryngologist to conduct endoscopic
examinations and obtain tissue samples for
histologic examination and culture.
In chronic fungal sinusitis is a disease of
immunocompetent hosts and is usually non
invasive, although slowly progressive
invasive disease is sometime seen.
Noninvasive disease, which is typically,
associated with hyaline molds such as
Aspergillus species and dematiaceous molds
such as Curvularia or Bipolaris species, can
present as a number of different scenarios.
Only nonspecific mucosal changes may be
seen on sinus CT. Endoscopic surgery is
usually curative in these patients with long
standing, often unilateral symptoms and
opacification of a single sinus on imaging
studies as a result of a mycetoma (fungus
ball) with in the sinus. Treatment for this
condition is surgical, although systemic
therapy may be warranted in the rare case
where bony erosion occurs.
Allergic fungal sinusitis is a third form of
disease and is seen in patients with a history
of nasal polyposis and asthma, who often
have had multiple sinus surgeries. Patient
with this condition produces thick,
eosinophilic mucous with the consistency of
peanut butter that contains sparse fungal
hyphae on histologic examination.
Signs and symptoms of sinusitis
Some of the signs that a person may have
bacterial sinusitis are: a stuffy or runny nose
with a daytime cough that lasts for 10 to 14
days without improvement mucous discharge
from the nose (this can occur with both viral
and bacterial sinusitis but continuous thick
discharge is more likely to be from bacterial
sinusitis) persistent dull pain or swelling
around the eyes tenderness or pain in or
around the cheekbones a feeling of pressure in
your head a headache when you wake up in
the morning or when bending over bad breath,
even after brushing your teeth pain in the
upper teeth a fever greater than 102 degrees
Fahrenheit (39 degrees Celsius)
Some people also have dry coughs and find it
hard to sleep. Others have upset stomachs or
feel nausea. Although many of these
symptoms are similar to those you can get
from viral sinusitis or allergic rhinitis
(inflammation of the nose and sinuses due to
allergy), it's a good idea to see your doctor
just in case. Viral sinusitis and allergic rhinitis
are more common, but bacterial sinusitis often
needs to be treated with antibiotics, and you
can only get these with a doctor's prescription.
Most people with sinusitis, however, have
pain or tenderness in several locations, and
their symptoms usually do not clearly indicate
which sinuses are inflamed.
Other symptoms of sinusitis can include:
Fever
Weakness
Tiredness
A cough that may be more severe at night
Runny nose (rhinitis) or nasal congestion
In addition, the drainage of mucus from the
sphenoid or other sinuses down the back of
your throat (postnasal drip) can cause you to
241
have a sore throat. Mucus drainage also can
irritate the membranes lining your larynx
(upper windpipe). Not everyone with these
symptoms, however, has sinusitis. On rare
occasions, acute sinusitis can result in brain
infection and other serious complications.
What are the Sinuses effects?
No one is completely sure why the people
have sinuses, but some researchers think they
keep the head from being too heavy. Sinuses
are pockets of air, and air doesn't weigh very
much. If those pockets were solid bone, the
head would weigh more.
Sinuses also give the depth or tone to voice.
In stuffy sinuses the voice sounds become
quite funny (harshy) especially when there is
a cold.
How do sinuses become bad/problem?
When a cold virus damages the delicate cilia
therefore that mucous does not swept away
and causes the mucous lining of the nose to
become swollen, which narrows and blocks
the small opening from the sinuses into the
nose lead to the production of more mucous,
which is often thicker and stickier, making it
harder to flow out of the sinuses. When the
tiny openings that drain the sinuses get
blocked, mucus becomes trapped in the
sinuses. Like water in a stagnant pond, it
makes a good home for bacteria, viruses, or
fungi to grow.
If a cold remain for more than 10 to 14 days
(sometimes there is a low-grade fever), this
means it might be a sinusitis or an infection of
the sinuses. Sinusitis is a pretty common
infection; in fact, close to 37 million people in
the United States have sinusitis each year and
similar figures are also found in other parts of
the world.
Causes
Some causes of acute sinusitis
Most cases of acute sinusitis start with a
common cold, which is caused by a virus.
These viral colds do not cause symptoms of
sinusitis, but they do inflame the sinuses. Both
the cold and the sinus inflammation usually
go away without treatment in 2 weeks. The
inflammation, however, might explain why
having a cold increases your likelihood of
developing acute sinusitis. For example, your
nose reacts to an invasion by viruses that
cause infections such as the common cold or
flu by producing mucous and sending white
blood cells to the lining of the nose, which
congest and swell the nasal passages.
When this swelling involves the adjacent
mucous membranes of your sinuses, air and
mucus are trapped behind the narrowed
openings of the sinuses. When your sinus
openings become too narrow, mucus cannot
drain properly. This increase in mucus sets up
prime conditions for bacteria to multiply.
Most healthy people harbor bacteria, such as
Streptococcus pneumoniae and Haemophilus
influenzae, in their upper respiratory tracts
with no problems until the body's defenses are
weakened or drainage from the sinuses is
blocked by a cold or other viral infection.
Thus, bacteria that may have been living
harmlessly in the nose or throat can multiply
and invade sinuses, causing an acute sinus
infection.
Sometimes, fungal infections can cause acute
sinusitis. Although fungi are abundant in the
environment, they usually are harmless to
healthy people, indicating that the human
body has a natural resistance to them. Fungi,
such as Aspergillus, can cause serious illness
in people whose immune systems are not
functioning properly. Some people with
fungal sinusitis have an allergic-type reaction
to the fungi.
Chronic inflammation of the nasal passages
also can lead to sinusitis. If someone has
allergic rhinitis or hay fever, he can develop
episodes of acute sinusitis. Vasomotor
rhinitis, caused by humidity, cold air, alcohol,
perfumes, and other environmental
conditions, also may be complicated by sinus
infections.
Acute sinusitis is much more common in
some people than in the general population.
242
For example, sinusitis occurs more often in
people who have reduced immune function
(such as those with primary immune
deficiency diseases or HIV infection) and
with abnormality of mucous secretion or
mucous movement (such as those with cystic
fibrosis).
Causes of Chronic Sinusitis
It can be difficult to determine the cause of
chronic sinusitis. Some investigators think it
is an infectious disease but others are not
certain. It is an inflammatory disease that
often occurs in patients with asthma. If you
have asthma, an allergic disease, you may
have chronic sinusitis with exacerbations. If
you are allergic to airborne allergens, such as
dust, mold, and pollen, which trigger allergic
rhinitis, you may develop chronic sinusitis.
An immune response to antigens in fungi may
be responsible for at least some cases of
chronic sinusitis. In addition, people who are
allergic to fungi can develop a condition
called “allergic fungal sinusitis”. If someone
has chronic sinusitis a damp weather,
especially in northern temperate climates, or
pollutants in the air and in buildings also can
affect him.
If someone has an immune deficiency disease
or an abnormality in the way mucous moves
through and from the respiratory system (e.g.,
primary immune deficiency, HIV infection,
and cystic fibrosis) he might develop chronic
sinusitis with frequent flare-ups of acute
sinusitis due to infections. In otherwise
normal individuals, sinusitis may or may not
be infectious. In addition, if a person has
severe asthma, nasal polyps (small growths in
the nose), or a severe asthma attacks caused
by aspirin and aspirin-like medicines such as
ibuprofen, he has more chances of chronic
sinusitis.
Diagnosis
It may be extremely difficult to diagnose a
sinus infection early in the course of the
disease. After taking a careful history, which
is extremely valuable in helping diagnose
sinusitis, and doing a physical exam, the sprays or drops. Inhaling steam or using
diagnosis is typically made by looking inside saline nasal sprays or drops can help relieve
the nose with a flexible rubber or rigid steel sinus discomfort.
tube called an endoscope. Antibiotic and sinusitis: An antibiotic is a
soluble substance derived from a mold or
bacterium that inhibits the growth of other
microorganisms.
The first antibiotic was Penicillin, discovered
by Alexander Fleming in 1929, but it was not
until World War II that the effectiveness of
antibiotics was acknowledged, and large-scale
fermentation processes were developed for
their production.
Acute sinusitis is one of many medical
disorders that can be caused by a bacterial
Depending on what is found at the time of the infection. However, it is important to
endoscopy, an x-ray (CT scan) of your remember that colds, allergies, and
sinuses may need to be done. Previously, x- environmental irritants, which are more
rays of the sinuses were done. Now CT scans common than bacterial sinusitis, can also
are ordinarily done because a much greater cause sinus problems. Antibiotics are
amount of information can be gleaned from effective only against sinus problems caused
the CT scan, and at a very slight increase in by a bacterial infection.
the cost. If there is a need of surgery, a CT SYMPTO SINUSITI ALLERG
COLD
scan will ordinarily be done prior to surgery. M S Y
The CT scan is often performed in a special Facial Yes Sometimes Sometime
way (called coronal views) so that certain Pressure/ s
portions of the sinuses are better seen. Pain
Endoscopy and CT scans are now done very Duration of Over 10-14 Varies Under 10
commonly for sinus infections. Many doctors Illness days days
and all sinusitis specialists can look inside Nasal Thick, Clear, thin, Thick,
your nose with the endoscope. It is not painful Discharge yellow-green watery whitish or
but might be a little uncomfortable. But nose thin
is sprayed first with a local anesthetic which Fever Sometimes No Sometime
reduces the un-comfortability. s
The symptoms of sinusitis sometimes mimic Headache Sometimes Sometimes Sometime
those of colds and allergies, in this case s
consult a doctor. If a person suspects sinusitis, Pain in Upper Sometimes No No
review these signs and symptoms if suffers Teeth
from three or more, then see the doctor. Bad Breath Sometimes No No
TREATMENT OF SINUSITIS Coughing Sometimes Sometimes Yes
Bacterial sinusitis: Therapy for bacterial Nasal Yes Sometimes Yes
sinusitis should include an appropriate Congestion
antibiotic. In addition to an antibiotic, an oral Sneezing No Sometimes Yes
or nasal spray or drop decongestant may be
The following symptoms may indicate the
recommended to relieve congestion, although
presence of a bacterial infection in the
avoid prolonged use of nonprescription nasal
sinuses:

243
 - Pain in your cheeks or upper back teeth
- A lot of bright yellow or green drainage
from your nose for more than 10 days
- No relief from decongestants, and/or
- Symptoms that gets worse instead of
better after your cold is gone.
Most patients with a clinical diagnosis of
acute sinusitis caused by a bacterial infection
improve without antibiotic treatment. The
specialist will initially offer appropriate doses
of analgesics (pain-relievers), antipyretics
(fever reducers), and decongestants. However
if symptoms persist, a treatment consisting of
antibiotics may be recommended.
Antibiotic Treatment
Antibiotics are labeled as narrow-spectrum
drugs when they work against only a few
types of bacteria. On the other hand, broad-
spectrum antibiotics are more effective by
attacking a wide range of bacteria, but are
more likely to promote antibiotic resistance.
For that reason, ear, nose, and throat specialist
will most likely prescribe narrow-spectrum
antibiotics, which often cost less. The
consultant may recommend broad-spectrum
antibiotics for infections that do not respond
to treatment with narrow-spectrum drugs.
Acute sinusitis
In most cases, antibiotics are prescribed for
patients with specific findings of persistent
purulent nasal discharge and facial pain or
tenderness who are not improving after seven
days or those with severe symptoms of
rhinosinusitis, regardless of duration. On the
basis of clinical trials, amoxicillin/
doxycycline/ trimethoprim-sulfamethoxazole
is preferred antibiotics.
Chronic sinusitis
Even with a long regimen of antibiotics,
chronic sinusitis symptoms can be difficult to
treat. In general, however, treating chronic
sinusitis, such as with antibiotics and
decongestants, is similar to treating acute
sinusitis. When antibiotic treatment fails,
allergy testing, desensitization, and/or surgery
may be recommended as the most effective
244
means for treating chronic sinusitis. Research
studies suggest that the vast majority of
people who undergo surgery have fewer
symptoms and better quality of life.
Pediatric sinusitis
Antibiotics that are unlikely to be effective in
children who do not improve with amoxicillin
include trimethoprim-sulfamethoxazole
(Bactrim) and erythromycin-sulfisoxazole
(Pediazole), because many bacteria are
resistant to these antibiotics. For children who
do not respond to two courses of traditional
antibiotics, the dose and length of antibiotic
treatment is often expanded, or treatment with
intravenous cefotaxime or ceftriaxone and/or
a referral to an ENT specialist is
recommended.
Frequency:
In the US and otherparts of the world: An
estimated more than 30 million patients in the
United States only have sinus disease. Upper
respiratory infections (URIs) are one of the
most common presentations in the ED. A
viral infection associated with the common
cold is the most frequent etiology of acute
sinusitis. Only a small percentage (as low as
2%) of viral sinusitis cases are complicated by
bacterial sinusitis. The challenge is to
differentiate a simple URI and allergic rhinitis
from sinusitis. Medical treatment is
expensive, with an estimated $5 billion spent
annually; another $60 billion is spent on
surgical treatment each year.
Mortality/Morbidity: Sinusitis is rarely life
threatening, but the close proximity of the
paranasal sinuses to the central nervous
system, the multiple fascial plains of the neck,
and the associated venous and lymphatic
channels can lead to serious complications.
Age: An estimated 5-10% of URIs in children
is related to sinusitis, while up to 10% of
URIs in adults is related to sinusitis. Sinusitis
is rare in children younger than 1 year
because the sinuses are poorly developed
before that age.
Antibiotic Resistance: Antibiotic resistance
means that some infection-causing bacteria
are immune to the effects of certain
antibiotics prescribed by the doctor.
Antibiotic resistance is making even common
infections, such as sinusitis, challenging to
treat. But to overcome this problem if the
medication is taken just as the doctor
instructs, even if the symptoms are gone
before the medicine runs out.
Chronic sinusitis
In chronic sinusitis intensive antibiotic
therapy may be prescribed and surgery is
sometimes necessary to remove physical
obstructions that may contribute to sinusitis.
After diagnosing sinusitis and identifying the
possible cause, the treatments will reduce the
inflammation and relieve the symptoms.
Acute sinusitis
In acute sinusitis recommend
• Decongestants to reduce congestion
• Antibiotics to control a bacterial
infection, if present
• Pain relievers to reduce any pain
The use of OTC (over-the-counter) or
prescription decongestant nose drops and
sprays for longer periods leads to congestion
and swelling of nasal passages, it is a
common observation.
If bacteria cause the sinusitis, use of
antibiotics along with a nasal or oral
decongestant usually helps in controlling it.
An antibiotic fights the bacteria most
commonly associated with sinusitis.
Many cases of acute sinusitis end without
antibiotics. If there is an allergic disease along
with sinusitis, however, the correct use of
medicine relieves the allergy symptoms. If
there is asthma then the chances to get
sinusitis are more and the worsening of
asthma are 100 percent. In this condition may
prescribe a steroid nasal spray, along with
other treatments, to reduce sinus congestion,
swelling, and inflammation.
245
Physicians and chronic sinusitis
Doctors often find it difficult to treat chronic
sinusitis successfully, realizing that symptoms
persist even after taking antibiotics for a long
period. As discussed below, many doctors
treat with steroids such as steroid nasal
sprays. Many doctors do treat chronic
sinusitis as though it is an infection, by using
antibiotics and decongestants. Other doctors
use both antibiotics and steroid nasal sprays.
Further research is needed to determine what
is the best treatment?
Some people with severe asthma are said to
have dramatic improvement of their
symptoms when their chronic sinusitis is
treated with antibiotics.
Doctors commonly prescribe steroid nasal
sprays to reduce inflammation in chronic
sinusitis. Although doctors occasionally
prescribe these sprays to treat people with
chronic sinusitis over a long period, doctors
do not fully understand the long-term safety
of these medications, especially in children.
Therefore, doctors will consider whether the
benefits outweigh any risks of using steroid
nasal sprays.
In severe chronic sinusitis, usually oral
steroids, such as prednisone is prescribed
because oral steroids are powerful medicines
but are having significant side effects.
Therefore, that should be taken only when
other medicines do not work.
Although home remedies cannot cure sinus
infection, they might give some comfort:
• Inhaling steam from a vaporizer or a
hot cup of water can soothe inflamed
sinus cavities.
• Saline nasal spray can give some
relief.
• Gentle heat applied over the inflamed
area give comfort.
When medical treatment fails, surgery may be
the only alternative for treating chronic
sinusitis. Research studies suggest that the
vast majority of people who undergo surgery
have fewer symptoms and better quality of
life.
In children, problems often are eliminated by
removal of adenoids obstructing nasal-sinus
passages.
Adults who have had allergic and infectious
conditions over the years sometimes develop
nasal polyps that interfere with proper
drainage. Removal of these polyps and/or
repair of a deviated septum to ensure an open
airway often provides considerable relief from
sinus symptoms.
The most common surgery done today is
functional endoscopic sinus surgery, in which
the natural openings from the sinuses are
enlarged to allow drainage. This type of
surgery is less invasive than conventional
sinus surgery, and serious complications are
rare.
Complications of sinusitis
When sinusitis is managed properly,
complications rarely occur. However, because
of the close proximity of such structures as
the intracranial cavity and the orbit, in certain
circumstances these infections may spread
and cause life-threatening sequelae. These
complications may occur after either acute or
chronic infections but do so more commonly
after the former. The following list includes
many of the potential complications of
sinusitis, but is by no means exhaustive:
Intracranial complications: The frontal,
ethmoid and sphenoid sinuses are separated
from the intracranial cavity by a layer of
246
bone. If the infection passes through this bone
it may infect the tissue and fluid that lines the
brain, causing “meningitis”. In even more
severe cases the infection may spread to the
brain itself causing an “abscess”, or collection
of pus. These problems are life threatening
and require prompt and aggressive treatment.
Orbital complications: When the frontal,
maxillary, ethmoid and sphenoid sinuses
occupy the place immediately above, below,
between and behind the eyes, respectively.
Infections of any of the sinuses may spread to
the orbit, causing a wide spectrum of
complications from mild inflammation of the
eyelid to abscesses with possible blindness.
Vascular complications: The carotid artery
and cavernous sinus are two large vascular
structures that border the sphenoid sinus.
Infections that involve either of these
structures may lead to aneurysms or infected
blood clots in the intracranial cavity, both of
which are potentially fatal.
Asthma: A number of patients suffer from
both asthma and chronic sinusitis and, for
these individuals flare-ups of the sinusitis can
lead to asthma attacks. Many studies have
shown that resolving the sinus condition will
result in dramatic improvement of the asthma.
Loss of smell and taste: Sinusitis may
diminish the senses of smell and taste, since
the two are interconnected. This may be either
temporary or permanent, depending on the
nature of the injury. In most cases, the cause
is poor airflow to the olfactory nerve (which
detects odors) and by improving the nasal
airway the senses of smell and taste improve.
This is particularly true in patients who suffer
from nasal polyps. However, in some cases
chronic sinusitis may permanently injure
these nerve endings.
Osteomyelitis: Some recent studies suggest
that bone becomes actively involved during a
chronic sinus infection, making the infection
more difficult to treat. This may even cause
the destruction of bone that leads to the
intracranial and intraorbital complications
discussed above.
Many patients are reluctant to undergo
endoscopic sinus surgery for sinusitis but
surgery may be imperative, as when one of
these complications develops or to prevent
one from occurring in the face of a chronic
infection. While these complications are
fortunately rare, their outcomes may be severe
and tragic.
Headache and sinus disease
Headache is a common complaint that is
often associated with sinusitis. However, the
true cause for a headache may be difficult to
determine because headaches have many
causes. The United States Center for Disease
Control reports that sinusitis affects over 30
million people and is the most common
chronic disease in this country. Thus, many
sinus sufferers will also suffer headaches.
While headaches and sinusitis are common
problems sometimes headaches occur with
sinusitis and sometimes they do not.
The Nasal sinus problem
Typically, a nasal and/or sinus problem will
have congestion and stuffiness, often with
nasal drainage. If an infection is present there
will be discolored, thick drainage in the front
of the nose and down the back of the throat. If
a headache is present, it is usually a pressure
sensation varying in intensity from almost
non-existent to somewhat severe.
247
Generally, a sinus headache will be located
over the sinuses, (forehead, corners of the
eye, and cheek areas). On occasion, the pain
will be felt behind the eyes, in the back of the
neck, or may extend into the upper teeth.
Head movement usually worsens this
headache.
The true cause for headache may be difficult
to determine... sometimes headaches occur
with sinusitis and sometimes not.
Non-sinus headaches
Non-sinus headaches may give these same
symptoms thus making it difficult to
determine if the headache is truly from a sinus
problem. For example, tension headaches will
occur in the forehead and neck; migraine
headaches often occur in and around the eyes.
It is unusual for a person with a sinus or nasal
problem to only have a headache. A sinus
headache is nearly always accompanied by
nasal stuffiness, congestion, obstruction, or
drainage. When headache is the only
symptom, it is rarely sinus related.
Sinus headaches
Main cause of nasal and sinus headaches is
the nasal turbinates - nasal structures that
swell and contract throughout the day giving
the feeling of nasal congestion and
occasionally pressure. Worsened by irritants
such as perfume, cigarette smoke or allergens,
the internal swelling causes facial pressure.
When the turbinates swell, not only is the
breathing passage blocked, but also normal
sinus draining passages are blocked creating a
“back-up” situation.
Drainage remains “trapped”" in the sinus
cavity causes the pain and pressure over the
sinuses. It may also cause an infection.
Oral decongestants (i.e. pseudoephedrine) or a
nasal spray (i.e. neosynephrine,
oxymetazoline) usually give relief. However,
these sprays should not be used for more than
a few days since they can cause even more
congestion when their effect wears off.
Caution is needed when using decongestant
pills, especially is a person has a history of
heart disease or high blood pressure. These
adrenaline-like medications can cause a rapid
heart rate or increased blood pressure.
If OTC medical management for nasal
congestion is not effective then go for a
steroid nasal spray.
If medical management fails or cannot be
tolerated, surgery to reduce the turbinates is
extremely successful.
Another cause for a sinus headache is the
common cold, which may seem to be a sinus
infection. If over-the-counter cold remedies
fail and the symptoms continue beyond
several days or if there are other debilitating
medical problems, a physician should be
called.
Sinus Surgery
When you have frequent sinusitis, or the
infection lasts three months or more, it could
be chronic sinusitis. Symptoms of chronic
sinusitis may be less severe than those of
acute; however, untreated chronic sinusitis
can cause damage to the sinuses and
cheekbones that sometimes requires
surgery to repair.
Surgery should be considered only if medical
treatment fails or if there is a nasal
obstruction that cannot be corrected with
medications. The type of surgery is chosen to
best suit the patient and the disease. Surgery
can be performed under the upper lip, behind
the eyebrow, next to the nose or scalp, or
inside the nose itself.
Functional endoscopic sinus surgery (FESS)
is recommended for certain types of sinus
248
disease. With the endoscope, the surgeon can
look directly into the nose, while at the same
time, removing diseased tissue and polyps and
clearing the narrow channels between the
sinuses. The decision whether to use local or
general anesthesia will be made between the
patient and the doctor, depending on the
individual circumstances.
Before surgery, the realistic expectations can
be made for the results, recovery, and
postoperative care. Good results require not
only good surgical techniques, but a
cooperative effort between the patient and
physician throughout the healing process. It is
equally important for patients to follow pre-
and postoperative instructions.
Complications of nasal and sinus surgery
Surgery on the nasal septum, turbinates, and
sinuses is recommended only after it has been
determined that medical management has
been unsuccessful. While these procedures
are generally very successful, patients must be
aware of certain risks before electing to
proceed. These risks include, but are not
necessarily limited to, the following:
Postoperative bleeding: Aspirin, ibuprofen
and certain non-prescription supplements
(vitamin E, garlic, etc.) can increase the
propensity to bleed therefore patients should
consult with their physicians before using
these agents before or after surgery. Intranasal
packing is utilized by many sinus surgeons to
help avoid this complication but occasionally
postoperative bleeding is encountered despite
all precautions.
Anesthesia complications: Adverse reactions
to local or general anesthesia may occur,
including cardiac and pulmonary
complications. Fortunately, these risks are
quite rare in this era of modern anesthesia.
Intracranial complications: The base of the
skull forms the roof of the ethmoid and
sphenoid sinuses. If this layer is violated, a
leak of cerebrospinal fluid (the fluid that
bathes the brain and spinal cord) may occur
(Figure 3). This can usually be repaired at the
time of the initial surgery, although in rare
cases further complications such as meningitis
may ensue.
Intraorbital complications: The orbit is
situated immediately adjacent to several of
the paranasal sinuses but is separated by a
layer of bone. Because of this close
proximity, in rare cases bleeding may occur
into the orbit requiring repair at the time of
the initial surgery. Visual loss and blindness
have been reported but are extremely rare.
Smell: The sense of smell usually improves,
although it may occasionally worsen,
depending on the extent of infection, allergy
or polyps.
Voice changes: One of the functions of the
sinuses is to affect resonance, so vocal
professionals should be aware of potential
changes in their voice after sinus surgery.
Infection: The most common reason to
undergo sinus surgery is a chronic infection
that does not resolve with medications. The
patient with sinusitis is therefore at risk of
developing certain other infections in this area
(abscesses, meningitis, etc.) regardless of
whether they manage the sinusitis with or
without surgery.
Nasal obstruction: Much of the nasal septum
is made of cartilage, which has "memory" -
the propensity to move back to its original
position. Despite certain measures performed
249
by the surgeon at the time of septoplasty this
may still occur and require a secondary
procedure. Small scar bands may also occur
in the nose and require removal by the
surgeon at postoperative visits.
Numbness: A transient numbness of the front
upper teeth, lip or nose may occur after
surgery but is usually self-limiting.
While surgery may entail these complications,
it is also crucial to remember that the failure
to intervene surgically may also place the
patient at risk for certain complications. When
left untreated, the infection may rarely spread
to adjacent structures such as the eye or brain
and lead to abscesses in these areas,
meningitis, visual loss, or even death.
Fortunately, the rare patient suffers from
complications of the infection or sinus
surgery.
PREVENTION
Although a person cannot prevent all sinus
disorders for example colds or bacterial
infections but at least he can do certain things
to reduce the number and severity of the
attacks and possibly prevent acute sinusitis
from becoming chronic.
• You may get some relief from your
symptoms with a humidifier,
particularly if room air in your home
is heated by a dry forced-air system.
• Air conditioners help to provide an
even temperature.
• Electrostatic filters attached to heating
and air conditioning equipment are
helpful in removing allergens from the
air.
If you are prone to getting sinus disorders,
especially if you have allergies, you should
avoid cigarette smoke and other air pollutants.
If your allergies inflame your nasal passages,
you are more likely to have a strong reaction
to all irritants.
If someone sinus inflammation is related to
dust, molds, pollen, or food or any of the
hundreds of allergens that can trigger an
upper respiratory reaction. A care must be
taken in this regard and take advise from the
doctors to determine the allergy and its
causes. This will help in reducing or limiting
the allergy symptoms.
Drinking alcohol also causes nasal and sinus
membranes to swell.
If you are prone to sinusitis, it may be
uncomfortable for you to swim in pools
treated with chlorine, since it irritates the
lining of the nose and sinuses.
Divers often get sinus congestion and
infection when water is forced into the sinuses
from the nasal passages.
Air travel poses create problems if there is
acute or chronic sinusitis. As air pressure in a
plane is reduced, pressure can build up in the
head blocking the sinuses or eustachian tubes
in ears. Therefore, there is a discomfort in
sinus or middle ear during the plane's ascent
or descent. Using decongestant nose drops or
inhalers before a flight is recommended.
To avoid developing sinusitis during a cold or
allergy attack, keep sinuses clear by:
• Using an oral decongestant or a short
course of nasal spray decongestant
• Gently blowing your nose, blocking
one nostril while blowing through the
other
• Drinking plenty of fluids to keep nasal
discharge thin
• Avoiding air travel. If flying is
essential use a nasal spray
decongestant before take-off to
prevent blockage of the sinuses
allowing mucus to drain
• If there an allergy sensitivity, try to
avoid contact with things that trigger
attacks. If it is not possible then use
OTC or prescription antihistamines
and/or a prescription nasal spray to
control allergy attacks
Allergy testing, followed by appropriate
allergy treatments, may increase tolerance of
allergy-causing substances.
250
NASAL ENDOSCOPY
The Nasal Telescope
The nasal telescope is an optical instrument
for examining the nose. This examination is
known as diagnostic nasal endoscopy. The
telescope is so slender (only 2.7-4.0 mm in
diameter), it may be passed easily through the
nostril to examine the nasal passages and the
sinuses. In some nasal telescopes, the view is
straight ahead from the tip of the instrument;
in other telescopes, the view is at an angle
from the tip of the telescope. These “angled”
telescopes can be used to see around corners.
The standard nasal examination is quite
limited; however, nasal endoscopy provides a
detailed examination of both the nasal cavity
and sinuses. Also, nasal telescopes are also
used during surgical procedures.
Nasal Endoscopy Room
Nasal endoscopy is commonly performed in
the office of otorhinolaryngologists (ENT
doctors). The ENT doctor can look directly
through the telescope. Alternatively, a
medical video camera can be attached to the
telescope, and then the images are viewed on
a special video monitor as shown here. The
examination may be recorded on a VCR, or a
digital image archive (like a digital camera)
may be used. If a patient wishes, he or she
may view the images from his or her own
examination.
 surgeons use a medical video camera that
sends a TV picture to a video monitor. The
reference frame is used for computer-aided
surgery (described below). It is important to
remember that endoscopic sinus surgery is a
challenging and demanding surgical
procedure.
Nasal Endoscopy
Patients tolerate nasal endoscopy very well.
Many ENT doctors will apply a topical nasal
decongestant and numbing medicine to the
lining of the nose by a nasal spray prior to
endoscopy. Often the examination can be
completed without any special medicines at
all.
Nasal Instruments
These instruments are designed to be used in
the nose and sinuses during nasal endoscopy.
They may be used both in the operating room
and in the office.

Computer-Aided Sinus Surgery

Frontal Sinus Instruments
These instruments are also designed to be
used during nasal endoscopy both in the
operating room and in the office. Note that the
instruments are curved. Because the
instruments are bent, it is possible to reach
around corners. These instruments are used
with the “angled” telescopes.
Recently, computer-aided surgery (CAS)
systems have been introduced into sinus
surgery. This technology allows a surgeon to
directly localize specific points seen during
endoscopy with the CT scans that have been
obtained prior to surgery. CAS provides
important anatomic information--as a result,
CAS probably decreases the risks of surgery
and may improve the results of surgery.

Nasal Endoscopy in the Operating Room Endoscopic View of the Middle Turbinate
Since the early 1980's, endoscopic sinus This is a normal middle turbinate in the
surgery has become a common method for the patient's right nasal cavity. Note that the right
treatment of surgical treatment of sinus side is marked on the image.
infections that do not improve with antibiotic
treatment. Some surgeons prefer to look
directly through the telescope, while other

251

The middle turbinate is a normal structure of
the sidewall of the nose. During the routine
nasal examination, a physician cannot really
see the middle turbinate reliably, but an ENT
doctor can use nasal endoscopy for an
inspection of this structure. This is important,
since a small amount of swelling in this area
can cause sinus infections.
Endoscopic View of Acute Sinusitis
Nasal endoscopy can be used to make the
diagnosis of acute sinusitis. In this example,
pus is seen draining under the middle
turbinate. This infected nasal mucous falls
posteriorly and produces symptoms of
“postnasal drip”. Endoscopy can tell which
sinuses are involved, and it can confirm the
diagnosis of sinusitis. Also, endoscopy can be
used to guide cultures of the infected mucous.
These cultures provide important information
so that the ENT doctor can choose an
appropriate antibiotic.
Endoscopic view of maxillary sinus mucous
recirculation
This patient reported persistent sinus
infections despite previous surgery. In this
picture, pus is seen draining from the natural
ostium (drainage opening) of the maxillary
sinus. This mucus is then falling back into the
maxillary sinus through an antrostomy
(surgical opening) that had been made during
surgery. This occurrence is known as
252
maxillary sinus mucous recirculation. It
happens since the maxillary sinus tries to push
mucous to the natural opening, even if a
surgeon has created an opening in another
location. Revision endoscopic sinus surgery
can be performed to fix this problem.
Endoscopic view of nasal polyps
This picture shows nasal polyps. Note the
orientation of the picture. Polyps are seen
filling the middle meatus. The uncinate
process is an important landmark. This
uncinate process looks unusual, since as they
grew, the polyps have pushed it forward.
Sinusitis and children
Acute sinusitis: It may cause different
symptoms in different age groups. In adults
and older children, for example, symptoms
include: a stuffy nose; a discharge from the
nose that is yellow, green, bad-smelling or
tinged with blood; redness inside the nose;
swelling or dull pain around the eyes;
tenderness in the area of the cheeks or around
the eyes; cheek pain that may be mistaken for
a toothache; a feeling of “pressure” in the
head; a morning headache; a headache that
gets worse when the child bends forward; and
bad breath. Sometimes there may also be a
dry cough or a low-grade fever, and the child
may have trouble sleeping. Stomach upset
with vomiting of mucus may be present.
Younger children may have any of the
symptoms listed above, but sometimes their
complaints are less specific. They may appear
to have a “common cold” (stuffy nose, runny
nose, and low fever) that continues for 10
days or more, or their “cold” may make them
look sicker than usual, with a high fever and a
discolored discharge from the nose. In a child
with allergies, sinusitis may appear as a stuffy
or runny nose that doesn't improve with the
usual doses of allergy medication.
Children with subacute sinusitis or chronic
sinusitis have symptoms that last for more
than one month. They may have any of the
following symptoms: an abnormally-colored
nasal discharge; stuffy nose; redness inside
the nose; cough (especially at night); snoring;
and trouble sleeping. They are less likely to
have fever than children with acute sinusitis.
Word about Children
Child's sinuses are not fully developed until
age 20. However, children can still suffer
from sinus infection. Although small, the
maxillary (behind the cheek) and ethmoid
(between the eyes) sinuses are present at
birth. Sinusitis is difficult to diagnose in
children because respiratory infections are
more frequent, and symptoms can be subtle.
Unlike a cold or allergy, bacterial sinusitis
requires a physician's diagnosis and treatment
with an antibiotic to prevent future
complications.
The following symptoms may indicate a sinus
infection in a child:
A “cold” lasting more than 10 to 14 days,
sometimes with low-grade fever thick yellow-
green nasal drainage post-nasal drip,
sometimes leading to or exhibited as sore
throat, cough, bad breath, nausea and/or
vomiting headache, usually not before age 6
irritability or fatigue swelling around the eyes
If despite appropriate medical therapy these
symptoms persist, care should be taken to
seek an underlying cause. The role of allergy
253
and frequent upper respiratory infections
should be considered.
RESEARCH
At least two-thirds of sinusitis cases caused
by bacteria are due to two organisms that can
also cause otitis media (middle ear infection)
in children as well as pneumonia and acute
exacerbations of chronic bronchitis. NIAID is
supporting multiple studies to better
understand the basis for infectivity of these
organisms as well as identifying potential
candidates for future vaccines strategies that
could eliminate these diseases.
A project supported by NIAID is developing
an advanced “sinuscope” that will permit
improved airway evaluation during a medical
examination especially when surgical
intervention is contemplated.
Scientific studies have shown a close
relationship between having asthma and
sinusitis. At least 75 percent of people with
asthma also get sinusitis. Some studies state
that up to 80 percent of adults with chronic
sinusitis also had allergic rhinitis. NIAID
conducts and supports research on allergic
diseases as well as bacteria and fungus that
can cause sinusitis. This research is focused
on developing better treatments and ways to
prevent these diseases.
Scientists supported by NIAID and other
institutions are investigating whether chronic
sinusitis has genetic causes. They have found
that certain alterations in the gene that causes
cystic fibrosis may also increase the
likelihood of developing chronic sinusitis.
This research will give scientists new insights
into the cause of the disease in some people
and points to new strategies for diagnosis and
treatment.
Another NIAID-supported research study has
recently demonstrated that blood cells from
patients with chronic sinusitis make chemicals
that produce inflammation when exposed to
fungal antigens, suggesting that fungi may
play a role in many cases of chronic sinusitis.
Further research, including clinical trials of
antifungal drugs, will help determine whether,
and for whom, this new treatment strategy
holds promise.

REFERANCES
Anon JB (April 2010). "Upper respiratory
infections". Am. J. Med. 123 (4 Suppl): S16–25.
Brook I (February 2009). Sinusitis. Periodontology
2000 49: 126–39.
Brook I, Foote PA, Hausfeld JN (August
2008). "Increase in the frequency of recovery of
meticillin-resistant Staphylococcus aureus in acute
and chronic maxillary sinusitis". J. Med.
Microbiol. 57 (Pt 8): 1015–7.
Brook I, Frazier EH (June 2005). "Bacteriology of
chronic maxillary sinusitis associated with nasal
polyposis". J. Med. Microbiol. 54 (Pt 6): 595–7.
Christine Radojicic. "Sinusitis". Disease Management
Project.Cleveland Clinic. Retrieved November 26,
2012.
Gelfand, Jonathan L. "Help for Sinus Pain and
Pressure". WebMD.com. Retrieved 2 October 2011.
Gwaltney JM, Hendley JO, Phillips CD, Bass CR,
Mygind N, Winther B (February 2000). "Nose
blowing propels nasal fluid into the paranasal
sinuses". Clin. Infect. Dis. 30 (2): 387–91.
Leung, R.S.; Katial, R. (2008). "The Diagnosis and
Management of Acute and Chronic
Sinusitis". Primary Care: Clinics in Office
Practice 35 (1): 11–24.
Pearlman, AN; Conley, DB (June 2008). "Review of
current guidelines related to the diagnosis and
treatment of rhinosinusitis.". Curr Opin Otolaryngol
Head Neck Surg 16 (3): 226–30.

Note: Most of the Matters are drived from Internet and

Research Papers

254
Chapter-10

255
256
HEART
Heart is made up of many parts working
together to pump blood. In a healthy heart, all
the parts work well so that your heart pumps
blood normally. Then all parts of the body
that depend on the heart to deliver blood also
stay healthy.
Heart disease can disrupt a heart’s normal
electrical system and pumping functions.
Diseases and conditions of the heart’s muscle
make it difficult for heart to pump blood
normally. Damaged or diseased blood vessels
make the heart work harder than normal.
Problems with the heart’s electrical system,
called arrhythmias, can make it difficult for
the heart to pump blood efficiently.
Heart Exterior
The illustration shows the front surface of the heart,
including the coronary arteries and major blood
vessels.
Anatomy of the heart
Heart is located under the ribcage in the
center of the chest between the right and left
lung. It’s shaped like an upside-down pear. Its
muscular walls beat, or contract, pumping
blood continuously to all parts of the body.
The size of the heart can vary depending on
age, size, or the condition of heart. A normal,
healthy, adult heart most often is the size of
an average clenched adult fist. Some diseases
of the heart can cause it to become larger.
The Exterior of the heart
Below is a picture of the outside of a normal,
healthy, human heart.
257
The heart is the muscle in the lower half of
the picture. The heart has four chambers. The
right and left atria (AY-tree-uh) are shown in
purple. The right and left ventricles (VEN-
trih-kuls) are shown in red.
Connected to the heart are some of the main
blood vessels/arteries and veins that make up
blood circulatory system.
The ventricle on the right side of your heart
pumps blood from the heart to your lungs.
When a person breathe air in, oxygen passes
from lungs through blood vessels where it’s
added to blood. Carbon dioxide, a waste
product, is passed from blood through blood
vessels to the lungs and is removed from the
body when breathe air out.
The atrium on the left side of the heart
receives oxygen-rich blood from the lungs.
The pumping action of left ventricle sends
this oxygen-rich blood through the aorta (a
main artery) to the rest of the body.
The Right side of the heart
The superior and inferior vena cavae are in
blue to the left of the muscle as look at the
picture. These veins are the largest veins in
the body. They carry used (oxygen-poor)
blood to the right atrium of the heart. “Used”
blood has had its oxygen removed and used
by the body’s organs and tissues. The superior
vena cava carries used blood from the upper
parts of the body, including head, chest, arms,
and neck. The inferior vena cava carries used
blood from the lower parts of the body.
The used blood from the vena cavae flows
into the heart’s right atrium and then on to the
right ventricle. From the right ventricle, the
used blood is pumped through the pulmonary
(PULL-mun-ary) arteries (in blue in the
center of picture) to the lungs. Here, through
many small, thin blood vessels called
capillaries, blood picks up oxygen needed by
all the areas of the body.
The oxygen-rich blood passes from lungs
back to the heart through the pulmonary veins
(in red to the left of the right atrium in the
picture).
The Left side of the heart
Oxygen-rich blood from lungs passes through
the pulmonary veins (in red to the right of the
left atrium in the picture). It enters the left
atrium and is pumped into the left ventricle.
From the left ventricle, blood is pumped to
the rest of the body through the aorta.
Heart Interior
Like all of the organs, heart needs blood rich
with oxygen. This oxygen is supplied through
the coronary arteries as it’s pumped out of
heart’s left ventricle. The coronary arteries are
located on heart’s surface at the beginning of
the aorta. The coronary arteries (shown in red
in the drawing) carry oxygen-rich blood to all
parts of the heart.
The Interior of the heart
Below is a picture of the inside of a normal,
healthy, human heart.
The illustration shows a cross-section of a
healthy heart and its inside structures. The
blue arrow shows the direction in which low-
oxygen blood flows from the body to the
lungs. The red arrow shows the direction in
which oxygen-rich blood flows from the
lungs to the rest of the body.
The Septum
The right and left sides of the heart are
divided by an internal wall of tissue called the
septum. The area of the septum that divides
258
the two upper chambers (atria) of the heart is
called the atrial or interatrial septum. The area
of the septum that divides the two lower
chambers (ventricles) of the heart is called the
ventricular or interventricular septum.
Heart chambers
The picture shows the inside of heart and how
it’s divided into four chambers. The two
upper chambers of heart are called atria. The
atria receive and collect blood. The two lower
chambers of heart are called ventricles. The
ventricles pump blood out of the heart into the
circulatory system to other parts of the body.
Heart valves
The picture shows heart’s four valves. Shown
counterclockwise in the picture, the valves
include the aortic (ay-OR-tik) valve, the
tricuspid (tri-CUSS-pid) valve, the pulmonary
valve, and the mitral (MI-trul) valve.
Blood flow
The arrows in the drawing show the direction
that blood flows through the heart. The light
blue arrows show that blood enters the right
atrium of the heart from the superior and
inferior vena cavae. From the right atrium,
blood is pumped into the right ventricle. From
the right ventricle, blood is pumped to lungs
through the pulmonary arteries.
The light red arrows show the oxygen-rich
blood coming in from lungs through the
pulmonary veins into the heart’s left atrium.
From the left atrium, the blood is pumped into
the left ventricle, where it’s pumped to the
rest of the body through the aorta.
For the heart to function properly, the blood
flows in only one direction. The heart’s
valves make this possible. Both of heart’s
ventricles has an “in” (inlet) valve from the
atria and an “out” (outlet) valve leading to the
arteries. Healthy valves open and close in
very exact coordination with the pumping
action of the heart’s atria and ventricles. Each
valve has a set of flaps called leaflets or
cusps, which seal or open the valves. This
allows pumped blood to pass through the
chambers and into the arteries without
backing up or flowing backward.
Heartbeat
Almost everyone has heard the real or
recorded sound of a heartbeat. When heart
beats, it makes a “lub-DUB” sound. Between
the time “lub” and “DUB,” blood is pumped
through the heart and circulatory system.
A heartbeat may seem like a simple event
repeated over and over. A heartbeat actually
is a complicated series of very precise and
coordinated events that take place inside and
around the heart. Each side of heart uses an
inlet valve to help move blood between the
atrium and ventricle. The tricuspid valve does
this between the right atrium and ventricle.
The mitral valve does this between the left
atrium and ventricle. The “lub” is the sound
of the mitral and tricuspid valves closing.
Each of the heart’s ventricles has an outlet
valve. The right ventricle uses the pulmonary
valve to help move blood into the pulmonary
arteries. The left ventricle uses the aortic
valve to do the same for the aorta. The "DUB"
is the sound of the aortic and tricuspid valves
closing.
Each heartbeat has two basic parts: diastole
(di-AS-toe-lee, or relaxation) and atrial and
ventricular systole (SIS-toe-lee, or
contraction). During diastole, the atria and
ventricles of your heart relax and begin to fill
with blood. At the end of diastole, your
heart’s atria contract (an event called atrial
systole) and pump blood into the ventricles.
The atria then begin to relax. Next, the heart’s
ventricles contract (an event called ventricular
systole) and pump blood out of the heart.
Pumping Action
The heart uses the four valves to ensure the
blood flows only in one direction. Healthy
valves opens and closes in coordination with
the pumping action of the heart’s atria and
ventricles. Each valve has a set of flaps called
leaflets or cusps. These seal or open the
valves. This allows pumped blood to pass
through the chambers and into the blood
259
vessels without backing up or flowing
backward.
Blood without oxygen from the two vena
cavae fill the heart’s right atrium. The atrium
contracts (atrial systole). The tricuspid valve
located between the right atrium and ventricle
opens for a short time and then shuts. This
allows blood to enter into the right ventricle
without flowing back into the right atrium.
When the heart’s right ventricle fills with
blood, it contracts (ventricular systole). The
pulmonary valve located between right
ventricle and pulmonary artery opens and
closes quickly. This allows blood to enter into
your pulmonary artery without flowing back
into the right ventricle. This is important
because the right ventricle begins to refill
with more blood through the tricuspid valve.
Blood travels through the pulmonary arteries
to the lungs to pick up oxygen.
Oxygen-rich blood returns from the lungs to
the heart’s left atrium through the pulmonary
veins. As the heart’s left atrium fills with
blood, it contracts. This event also is called
atrial systole. The mitral valve located
between the left atrium and left ventricle
opens and closes quickly. This allows blood
to pass from the left atrium into the left
ventricle without flowing back into the left
atrium.
As the left ventricle fills with blood, it
contracts. This event also is called ventricular
systole. The aortic valve located between the
left ventricle and aorta opens and closes
quickly. This allows blood to flow into the
aorta. The aorta is the main artery that carries
blood from the heart to the rest of the body.
The aortic valve closes quickly to prevent
blood from flowing back into the left
ventricle, which is already filling up with new
blood.
Heart’s Electrical System
The heart’s electrical system controls all the
events that occur when the heart pumps
blood. The electrical system also is called the
cardiac conduction system. The heart test
called EKG/ECG (electrocardiogram), it is a
graphical picture of the electrical activity of moves to the His bundle located in the walls
heart. of the heart’s ventricles.
The heart’s electrical system is made up of From the His bundle, the signal fibers divide
three main parts: into left and right bundle branches through the
- The sinoatrial (SA) node located in the Purkinje fibers that connect directly to the
right atrium of your heart cells in the walls of the heart’s left and right
- The atrioventricular (AV) node located on ventricles, as the signal spreads across the
the interatrial septum close to the tricuspid cells of the heart’s ventricle walls, both
valve ventricles contract, but not at exactly the same
- The His-Purkinje system located along the moment. The left ventricle contracts an
walls of the heart’s ventricles instant before the right ventricle. This pushes
A heartbeat is a complicated series of events blood through the pulmonary valve (for the
that take place in the heart. A heartbeat is a right ventricle) to lungs and through the aortic
single cycle in which the heart’s chambers valve (for the left ventricle) to the rest of the
relax and contract to pump blood. This cycle body.
includes the opening and closing of the two As the signal passes, the walls of the
inlets and outlet valves of the right and left ventricles relax and await the next signal.
ventricles of the heart. This process continues over and over as the
Each heartbeat has two basic parts: diastole, atria refill with blood and other electrical
and atrial and ventricular systole. During signals come from the SA node.
diastole, the atria and ventricles of your heart Heart and Blood Vessel Diseases
relax and begin to fill with blood. At the end • Aneurysm
of diastole, heart’s atria contract (atrial • Angina
systole), pumping blood into the ventricles,
• Arrhythmia
and then begin to relax. The heart’s ventricles
then contract (ventricular systole) pumping • Atherosclerosis
blood out of the heart. • Atrial Fibrillation
Each beat of heart is set in motion by an • Cardiogenic Shock
electrical signal from within the heart muscle. • Cardiomyopathy
In a normal, healthy heart, each beat begins
• Congenital Heart Defects
with a signal from the SA node. This is why
the SA node is sometimes called heart’s • Coronary Artery Disease
natural pacemaker. Pulse, or heart rate, is the • Heart Attack
number of signals the SA node produces per • Heart Failure
minute. • Heart Murmur
The signal is generated as the two vena cavae
• High Blood Cholesterol
fill heart’s right atrium with blood from other
parts of the body. The signal spreads across • High Blood Pressure
the cells of heart’s right and left atria. This • Holes in the Heart
signal causes the atria to contract. This action • How the Heart Works
pushes blood through the open valves from • Hypotension
the atria into both ventricles. • Long QT Syndrome
The signal arrives at the AV node near the • Marfan Syndrome
ventricles, where it slows for an instant to
allow your heart’s right and left ventricles to • Metabolic Syndrome
fill with blood. The signal is released and • Mitral Valve Prolapse

260
 • Overweight and Obesity
• Patent Ductus Arteriosus
• Peripheral Arterial Disease
• Raynaud's Disease
• Sudden Cardiac Arrest
• Tetralogy of Fallot
• Varicose Veins
• Vasculitis
Tests and Procedures
• Angioplasty
• Cardiac Catheterization
• Cardiac CT
• Cardiac MRI
• Carotid Ultrasound
• Catheter Ablation
• Coronary Angiography
Aneurysm
• Coronary Artery Bypass Grafting An aneurysm (AN-u-rism) is an abnormal bulge
• Coronary Calcium Scan or “ballooning” in the wall of an artery. Arteries
• Echocardiography are blood vessels that carry oxygen-rich blood
• Electrocardiogram from the heart to other parts of the body. An
aneurysm that grows and becomes large enough
• Heart Transplant can burst, causing dangerous, often fatal, bleeding
• Implantable Cardioverter Defibrillator inside the body.
• Nuclear Heart Scan Most aneurysms occur in the aorta. The aorta is
the main artery that carries blood from the heart to
• Pacemaker
the rest of the body. The aorta comes out from the
• Stents left ventricle (VEN-trih-kul) of the heart and
• Stress Testin travels through the chest and abdomen. An
aneurysm that occurs in the aorta in the chest is
called a thoracic (tho-RAS-ik) aortic aneurysm.
An aneurysm that occurs in the aorta in the
abdomen is called an abdominal aortic aneurysm.
Aneurysms also can occur in arteries in the brain,
heart, intestine, neck, spleen, back of the knees
and thighs, and in other parts of the body. If an
aneurysm in the brain bursts, it causes a stroke.
About 15,000 Americans die each year from
ruptured aortic aneurysms. Ruptured aortic
aneurysm is the 10th leading cause of death in
men over age 50 in the United States.
Many cases of ruptured aneurysm can be
prevented with early diagnosis and medical
treatment. Because aneurysms can develop and
become large before causing any symptoms, it is
important to look for them in people who are at
the highest risk. Experts recommend that men

261
who are 65 to 75 years old and have ever smoked
(at least 100 cigarettes in their lifetime) should be
checked for abdominal aortic aneurysms.
When found in time, aneurysms can usually be
treated successfully with medicines or surgery. If
an aortic aneurysm is found, the doctor may
prescribe medicine to reduce the heart rate and
blood pressure. This can reduce the risk of
rupture.
Large aortic aneurysms if found in time can often
be repaired with surgery to replace the diseased
portion of the aorta. The outlook is usually
excellent.
Angina
Angina (an-JI-nuh or AN-juh-nuh) is chest pain or
discomfort that occurs when heart muscle does
not get enough blood. Angina may feel like
pressure or a squeezing pain in chest. The pain
may also occur in shoulders, arms, neck, jaw, or
back. It may also feel like indigestion.
Angina is a symptom of coronary artery disease
(CAD), the most common type of heart disease.
CAD occurs when plaque builds up in the
coronary arteries. This buildup of plaque is called
atherosclerosis. As plaque builds up, the coronary
arteries become narrow and stiff. Blood flow to
the heart is reduced. This decreases the oxygen
supply to the heart muscle.
Types of Angina
The three types of angina are stable, unstable, and
variant (Prinzmetal's). It is very important to know
the differences among the types.
Stable angina: Stable angina is the most common
type. It occurs when the heart is working harder
than usual.
There is a regular pattern to stable angina. After
several episodes, it is easy to recognize the pattern
and can predict when it will occur.
The pain usually goes away in a few minutes after
rest or takes angina medicine.
Stable angina is not a heart attack but makes it
more likely that you will have a heart attack in the
future.
Unstable angina: Unstable angina is a very
dangerous condition that requires emergency
treatment. It is a sign that a heart attack could
occur soon. Unlike stable angina, it does not
follow a pattern. It can occur without physical
exertion and is not relieved by rest or medicine.
Variant angina: Variant angina is rare. It usually
occurs at rest. The pain can be severe and usually
262
occurs between midnight and early morning. It is
relieved by medicine.
Not all chest pain or discomfort is angina. Chest
pain or discomfort can be caused by a heart attack,
lung problems (such as an infection or a blood
clot), heartburn, or a panic attack. However, all
chest pain should be checked by a doctor.
Other Names for Angina
Angina pectoris
Stable or common angina
Unstable angina
Variant angina
Prinzmetal's angina
Coronary artery spasms
Acute coronary syndrome
Arrhythmia
An arrhythmia (ah-RITH-me-ah) is a problem
with the speed or rhythm of the heartbeat. During
an arrhythmia, the heart can beat too fast, too
slow, or with an irregular rhythm. A heartbeat that
is too fast is called tachycardia. A heartbeat that is
too slow is called bradycardia.
Most arrhythmias are harmless, but some can be
serious or even life threatening. When the heart
rate is too slow, too fast, or irregular, the heart
may not be able to pump enough blood to the
body. Lack of blood flow can damage the brain,
heart, and other organs.
Heart’s Electrical System
The heart has an internal electrical system that
controls the speed and rhythm of the heartbeat.
With each heartbeat, an electrical signal spreads
from the top of the heart to the bottom. As it
travels, the electrical signal causes the heart to
contract and pump blood. The process repeats
with each new heartbeat.
Each electrical signal begins in a group of cells
called the sinus node, or sinoatrial (SA) node. The
SA node is located in the right atrium (AY-tree-
um), which is the upper right chamber of the
heart. In a healthy adult heart at rest, the SA node
fires off an electrical signal to begin a new
heartbeat 60 to 100 times a minute.
From the SA node, the electrical signal travels
through special pathways to the right and left
atria. This causes the atria to contract and pump
blood into the heart’s two lower chambers, the
ventricles (VEN-trih-kuls). The electrical signal
then moves down to a group of cells called the
atrioventricular (AV) node, located between the
atria and the ventricles. Here, the signal slows
down just a little, allowing the ventricles time to
finish filling with blood. The electrical signal then
leaves the AV node and travels along a pathway
called the bundle of His. This pathway divides
into a right bundle branch and a left bundle
branch. The signal goes down these branches to
the ventricles, causing them to contract and pump
blood out to the lungs and the rest of the body.
The ventricles then relax, and the heartbeat
process starts all over again in the SA node.
A problem with any part of this process can cause
an arrhythmia. For example, in atrial fibrillation, a
common type of arrhythmia, electrical signals
travel through the atria in a fast and disorganized
way. This causes the atria to quiver instead of
contract.
Overview
There are many different types of arrhythmia.
Most arrhythmias are harmless but some are not.
The outlook for a person with an arrhythmia
depends on the type and severity of the
arrhythmia. Even serious arrhythmias can often be
successfully treated. Most people with
arrhythmias are able to live normal, healthy lives.
How the Heart Works?
The heart is a muscle about the size of your fist.
The heart works like a pump and beats about
100,000 times a day.
A healthy adult heart generally beats 60 to 100
times a minute, but it can beat faster or slower at
times. For example, physical activity, strong
emotion, certain medicines, fever, or infection can
make the heart beat faster. A person’s heart rate
generally slows down during sleep. Some very fit
athletes always have heart rates below 60 beats a
minute because their hearts work so well.
The heart has two sides, separated by an inner
wall called the septum. The right side of the heart
pumps blood to the lungs to pick up oxygen.
Then, oxygen-rich blood returns from the lungs to
the left side of the heart, and the left side pumps it
to the body.
The heart has four chambers and four valves and
is connected to various blood vessels. Veins are
the blood vessels that carry blood from the body
to the heart. Arteries are the vessels that carry
blood away from the heart to the body.
263
Illustration of a Healthy Heart Cross-Section
Heart Chambers
The heart has four chambers or “rooms”—two on
the left side of the heart and two on the right.
The atria are the two upper chambers that collect
blood as it comes into the heart.
The ventricles are the two lower chambers that
pump blood out of the heart to the lungs or other
parts of the body.
Heart Valves
Four valves control the flow of blood from the
atria to the ventricles and from the ventricles into
the two large arteries connected to the heart.
The tricuspid (tri-CUSS-pid) valve is in the right
side of the heart, between the right atrium and the
right ventricle.
The pulmonary (PULL-mun-ary) valve is in the
right side of the heart, between the right ventricle
and the entrance to the pulmonary artery that
carries blood to the lungs.
The mitral (MI-tral) valve is in the left side of the
heart, between the left atrium and the left
ventricle.
The aortic (ay-OR-tik) valve is in the left side of
the heart, between the left ventricle and the
entrance to the aorta, the artery that carries blood
to the body.
Valves are like doors that open and close. They
open to allow blood to flow through to the next
chamber or to one of the arteries, and then they
shut to keep blood from flowing backward.
When the heart’s valves open and close, they
make a “lub-DUB” sound can be heard by using a
stethoscope.
The first sound—the “lub”—is made by the mitral
and tricuspid valves closing at the beginning of
systole (SIS-toe-lee). Systole is when the
ventricles contract, or squeeze, and pump blood
out of the heart.
The second sound—the “DUB”—is made by the
aortic and pulmonary valves closing at beginning
of diastole (di-AS-toe-lee). Diastole is when the
ventricles relax and fill with blood pumped into
them by the atria.
Arteries
The arteries are major blood vessels connected to
your heart.
The pulmonary artery carries blood pumped from
the right side of the heart to the lungs to pick up a
fresh supply of oxygen.
The aorta is the main artery that carries oxygen-
rich blood pumped from the left side of the heart
out to the body.
The illustration shows a normal artery with normal
The coronary arteries are the other important
arteries attached to the heart. They carry oxygen- blood flow (Figure A) and an artery containing
rich blood from the aorta to the heart muscle, plaque buildup (Figure B).
which must have its own blood supply to function.
Veins Atherosclerosis is a slow, progressive disease
The veins are also major blood vessels connected that may start in childhood. It can affect the
to your heart. arteries of the brain, heart, kidneys, and the
The pulmonary veins carry oxygen-rich blood arms and legs. As plaque builds up, it can
from the lungs to the left side of the heart so it can cause serious diseases and complications.
be pumped out to the body.
These include:
The vena cava is a large vein that carries oxygen-
Coronary artery disease
poor blood from the body back to the heart.
Angina
Atherosclerosis
Heart attack
Atherosclerosis is the hardening and narrowing of
the arteries. It is caused by the slow buildup of Sudden death
plaque on the inside of walls of the arteries. Cerebrovascular disease
Arteries are blood vessels that carry oxygen-rich Stroke
blood from the heart to other parts of the body. Transient ischemic attack (TIA) or "mini strokes"
Plaque is made up of fat, cholesterol, calcium, and Peripheral arterial disease
other substances found in the blood. As it grows, Diseases caused by atherosclerosis are the
the buildup of plaque narrows the inside of the leading cause of illness and death in the
artery and, in time, may restrict blood flow. There United States.
are two types of plaque: Hard and stable; Soft and Other Names for Atherosclerosis
unstable Hardening of the arteries
Hard plaque causes artery walls to thicken and Arteriosclerosis
harden. Soft plaque is more likely to break apart Atrial Fibrillation
from the walls and enter the bloodstream. This
Atrial fibrillation (A-tre-al fi-bri-LA-shun), or
can cause a blood clot that can partially or totally
block the flow of blood in the artery. When this
AF, is the most common arrhythmia (ah-
happens, the organ supplied by the blocked artery RITH-me-ah). An arrhythmia is a problem
starves for blood and oxygen. The organ's cells with the speed or rhythm of the heartbeat. A
may either die or suffer severe damage.

264
disorder in the heart’s electrical system causes
AF and other types of arrhythmia.
AF occurs when rapid, disorganized electrical
signals in the heart’s two upper chambers,
called the atria (AY-tree-uh), cause them to
contract very fast and irregularly (this is
called fibrillation). As a result, blood pools in
the atria and isn’t pumped completely into the
heart’s two lower chambers, called the
ventricles (VEN-trih-kuls). When this
happens, the heart’s upper and lower
chambers don’t work together as they should.
Often, people who have AF may not even feel
symptoms. However, even when not noticed,
AF can lead to an increased risk of stroke. In
many patients, particularly when the rhythm
is extremely rapid, AF can cause chest pain,
heart attack, or heart failure. AF may occur
rarely or every now and then, or it may
become a persistent or permanent heart
rhythm lasting for years.
People who have AF can live normal, active
lives. For some people, treatment can cure AF
and return their heartbeat to a normal rhythm.
For people who have permanent AF,
treatment can successfully control symptoms
and prevent complications. Treatment consists
primarily of different kinds of medicines or
nonsurgical procedures.
Cardiogenic Shock
Cardiogenic (kar-dee-oh-JE-nik) shock is a
state in which a weakened heart is not able to
pump enough blood to meet the body's needs.
It is a medical emergency and is fatal if not
treated right away. The most common cause
of cardiogenic shock is damage to the heart
muscle from a severe heart attack.
Not everyone who has a heart attack develops
cardiogenic shock. In fact, less than 10
percent of people who have a heart attack
develop it. But when cardiogenic shock does
occur, it is very dangerous. For people who
die from a heart attack in a hospital,
cardiogenic shock is the most common cause.
265
Shock
The medical term "shock" refers to a state in
which not enough blood and oxygen reach
important organs in the body, such as the
brain and kidneys. In a state of shock, a
person's blood pressure is very low.
Shock can have a number of different causes.
Cardiogenic shock is only one cause of shock.
Other causes of shock include:
Hypovolemic (hy-poe-voe-LEE-mik) shock:
This is shock due to not enough blood in the
body. The most common cause is severe
bleeding.
Vasodilatory (VAZ-oh-DILE-ah-tor-ee)
shock: In this type of shock, the blood vessels
relax too much and cause very low blood
pressure. When the blood vessels are too
relaxed, there is not enough pressure to push
the blood through them. Without enough
pressure, blood does not reach the organs. A
bacterial infection in the bloodstream, a
severe allergic reaction, or damage to the
nervous system (brain and nerves) may cause
vasodilatory shock.
When a person is in shock (from any cause),
not enough blood or oxygen is reaching the
body's organs. If shock lasts more than
several minutes, the lack of oxygen to the
organs starts to damage them. If shock is not
treated quickly, the organ damage can become
permanent, and the person can die.
Some of the signs and symptoms of shock
include:
Confusion or lack of alertness
Loss of consciousness
A sudden, rapid heartbeat
Sweating
Pale skin
Weak pulse
Rapid breathing
Decreased or no urine output
Cool hands and feet
Prompt treatment in shock can help prevent or
limit lasting damage to the brain and other
organs and can prevent death.
Outlook
In the past, almost no one survived
cardiogenic shock. Now around 50 percent of
people who go into cardiogenic shock
survive. The reason more people are able to
survive cardiogenic shock is because of
treatments (medicines and devices) that
restore blood flow to the heart and help the
heart pump better. In some cases, devices that
take over the pumping function of the heart
are used. Implanting these devices requires
major surgery.
Cardiomyopathy
Cardiomyopathy (KAR-de-o-mi-OP-a-the)
refers to diseases of the heart muscle. These
diseases have a variety of causes, symptoms,
and treatments. In cardiomyopathy, the heart
muscle becomes enlarged or abnormally thick
or rigid. In rare cases, the muscle tissue in the
heart is replaced with scar tissue.
As cardiomyopathy progresses, the heart
becomes weaker and less able to pump blood
through the body. This can lead to heart
failure, arrhythmias (ah-RITH-me-ahs;
abnormal heart rhythms), fluid buildup in the
lungs or legs, and, more rarely, endocarditis (a
bacterial infection of the lining of the heart).
The weakening of the heart also can lead to
other severe complications.
The four main types of cardiomyopathy are:
Dilated cardiomyopathy
Hypertrophic (hi-per-TROF-ik)
cardiomyopathy
Restrictive cardiomyopathy
Arrhythmogenic (a-rith-mo-JEN-ik) right
ventricular dysplasia (ARVD)
Cardiomyopathy can have a specific cause,
such as damage to the heart from a heart
attack, high blood pressure, or a viral infection.
Some types of cardiomyopathy are caused by
a gene mutation and run in families. In many
cases, the cause is unknown.
Cardiomyopathy can affect people of all ages,
from babies to older adults. However, certain
age groups are more likely to have certain
types of cardiomyopathy. Treatment may
266
involve medicines, surgery, nonsurgical
procedures, and lifestyle changes.
Outlook
Some people live long, healthy lives in spite
of having cardiomyopathy. Some people do
not even realize that they have the disease
because they have no symptoms. In other
people, the disease develops rapidly,
symptoms are severe, and serious
complications develop. Current treatments
can reduce symptoms and complications of
cardiomyopathy.
Types of Cardiomyopathy
Dilated Cardiomyopathy
Dilated cardiomyopathy is the most common
form of cardiomyopathy. It generally occurs
in adults aged 20 to 60 years. Men are more
likely than women to develop dilated
cardiomyopathy.
Dilated cardiomyopathy affects the heart's
ventricles (VEN-trih-kuls) and atria. The
ventricles are the two lower chambers of the
heart, and the atria are the two upper
chambers. Dilated cardiomyopathy usually
starts in the left ventricle, where the heart
muscle begins to dilate or stretch and become
thinner. This leads to enlargement of the
inside of the ventricle. The problem often
spreads to the right ventricle and then to the
atria as the disease gets worse.
When the chambers dilate, the heart can not
pump blood very well. The heart tries to cope
by dilating the chambers even more. Over
time, the heart becomes weaker and heart
failure can occur. Symptoms of heart failure
include feeling tired, swelling of the legs and
feet, and shortness of breath. Dilated
cardiomyopathy also can lead to heart valve
problems, arrhythmias, and blood clots in the
heart. Having advanced dilated
cardiomyopathy is a common reason for
needing a heart transplant.
Up to one-half of all cases of dilated
cardiomyopathy may be hereditary (passed
down in the genes from parent to child).
These cases are called familial dilated
cardiomyopathy. Dilated cardiomyopathy also
can be a complication of many conditions,
including coronary artery disease and high blood
pressure. It also can be caused by viral
infections, excessive use of alcohol, and
exposure to certain drugs (including cocaine,
amphetamines, and some drugs used in cancer
treatments). In some cases, no cause can be
found.
Hypertrophic Cardiomyopathy
Hypertrophic cardiomyopathy occurs when
the heart muscle thickens abnormally. The
thickening generally happens in the left
ventricle, the heart's main pumping chamber.
This type of cardiomyopathy can affect
people of any age.
Hypertrophic cardiomyopathy can be
obstructive or nonobstructive. In the
obstructive type, the septum (the wall that
divides the left and right sides of the heart)
thickens and bulges into the left ventricle.
This bulge blocks the flow of blood out of the
ventricle. The ventricle must work much
harder to pump blood past the blockage and
out to the body. Symptoms can include chest
pain, dizziness, shortness of breath, or
fainting.
Obstructive hypertrophic cardiomyopathy
also can affect the heart's mitral (MI-trul)
valve, causing blood to leak backward
through the valve.
In nonobstructive hypertrophic cardiomyo-
pathy, the thickened heart muscle does not
block the flow of blood out of the ventricle.
The entire ventricle may become thicker
(symmetric ventricular hypotrophy) or it may
happen only at the bottom of the heart (apical
hypertrophy). The right ventricle also may be
affected.
In both kinds of hypertrophic
cardiomyopathy, the thickened muscle makes
the inside of the left ventricle smaller so that
it holds less blood. The walls of the ventricles
also may become stiff. As a result, they are
less able to relax and fill with blood. This
causes increased pressure in the ventricles and
267
the blood vessels of the lungs. Changes also
occur to the cells in the damaged heart
muscle. This may interfere with the heart's
electrical signals, leading to arrhythmias.
Some people with hypertrophic
cardiomyopathy have no symptoms, and the
condition does not affect their lives. Others
have severe symptoms or develop
complications such as serious arrhythmias. A
few people with the condition have sudden
cardiac arrest because of dangerous
arrhythmias.
Hypertrophic cardiomyopathy can be
inherited because of a gene mutation or
develop over time because of high blood
pressure or aging. Often, the cause is
unknown.
Restrictive Cardiomyopathy
Restrictive cardiomyopathy tends to mostly
affect older adults. In this cardiomyopathy,
the ventricles become stiff and rigid due to
replacement of the normal heart muscle with
abnormal tissue, such as scar tissue. As a
result, the ventricles cannot relax normally
and expand to fill with blood, which causes
the atria to become enlarged. Eventually,
blood flow in the heart is reduced, and
complications such as heart failure or
arrhythmias occur.
Restrictive cardiomyopathy can occur for no
known reason, or it can develop because the
person has another disease. Some of the
diseases that can cause restrictive
cardiomyopathy include hemochromatosis,
sarcoidosis, amyloidosis, and connective tissue
disorders. Restrictive cardiomyopathy also
can occur as a result of radiation treatments,
infections, or scarring after surgery.
Arrhythmogenic Right Ventricular
Dysplasia
Arrhythmogenic right ventricular dysplasia
(ARVD) is a rare type of cardiomyopathy.
ARVD develops when the muscle tissue in
the right ventricle dies and is replaced with
scar tissue. This process causes problems in
the heart's electrical signaling, resulting in
arrhythmias. Symptoms include a feeling of
strong or irregular heartbeats (palpitations)
and fainting after exercise.
ARVD usually develops in teens or young
adults and is often the cause of sudden cardiac
death in young athletes. ARVD is thought to
be an inherited disease.
Other Names for Cardiomyopathy
Dilated cardiomyopathy
Familial dilated cardiomyopathy
Congestive cardiomyopathy
Idiopathic dilated cardiomyopathy
Hypertrophic cardiomyopathy
Hypertrophic obstructive cardiomyopathy
Asymmetric septal hypertrophy
Idiopathic hypertrophic subaortic stenosis
Familial hypertrophic cardiomyopathy
Arrhythmogenic right ventricular dysplasia
Right ventricular dysplasia
Right ventricular cardiomyopathy
Restrictive cardiomyopathy
Arrhythmogenic ventricular cardiomyopathy
Congenital Heart Defects
Congenital (kon-JEN-i-tal) heart defects are
problems with the heart’s structure that are
present at birth. These defects can involve the
interior walls of the heart, valves inside the
heart, or the arteries and veins that carry
blood to the heart or out to the body.
Congenital heart defects change the normal
flow of blood through the heart.
There are many different types of congenital
heart defects. They range from simple defects
with no symptoms to complex defects with
severe, life-threatening symptoms.
Congenital heart defects are the most
common type of birth defect, affecting 8 of
every 1,000 newborns. Each year, more than
35,000 babies in the United States are born
with congenital heart defects. Most of these
defects are simple conditions that are easily
fixed or need no treatment.
A small number of babies are born with
complex congenital heart defects that need
special medical attention soon after birth.
Over the past few decades, the diagnosis and
268
treatment of these complex defects has greatly
improved.
As a result, almost all children with complex
heart defects grow to adulthood and can live
active, productive lives because their heart
defects have been effectively treated.
Most people with complex heart defects
continue to need special heart care throughout
their lives. They may need to pay special
attention to certain issues that their condition
could affect, such as health insurance,
employment, pregnancy and contraception,
and preventing infection during routine health
procedures. Today in the United States, about
1 million adults are living with congenital
heart defects.
Coronary Artery Disease
Coronary artery disease (CAD) occurs when
the arteries that supply blood to the heart
muscle (the coronary arteries) become
hardened and narrowed. The arteries harden
and narrow due to buildup of a material called
plaque (plak) on their inner walls. The
buildup of plaque is known as atherosclerosis
(ATH-er-o-skler-O-sis). As the plaque
increases in size, the insides of the coronary
arteries get narrower and less blood can flow
through them. Eventually, blood flow to the
heart muscle is reduced, and, because blood
carries much-needed oxygen, the heart muscle
is not able to receive the amount of oxygen it
needs. Reduced or cutoff blood flow and
oxygen supply to the heart muscle can result
in:
Angina (AN-ji-na or an-JI-na): Angina is
chest pain or discomfort that occurs when the
heart does not get enough blood.
Heart attack: A heart attack happens when a
blood clot develops at the site of plaque in a
coronary artery and suddenly cuts off most or
all blood supply to that part of the heart
muscle. Cells in the heart muscle begin to die
if they do not receive enough oxygen-rich
blood. This can cause permanent damage to
the heart muscle.
Over time, CAD can weaken the heart muscle
and contribute to:
Heart failure: In heart failure, the heart can’t
pump blood effectively to the rest of the body.
Heart failure does not mean that the heart has
stopped or is about to stop. Instead, it means
that the heart is failing to pump blood the way
that it should.
Arrhythmias (a-RITH-me-as): Arrhythmias
are changes in the normal beating rhythm of
the heart. Some can be quite serious.
CAD is the most common type of heart
disease. It is the leading cause of death in the
world in both men and women.
Other Names for Coronary Artery Disease
CAD
Coronary heart disease (CHD)
Heart disease
Ischemic (is-KE-mik) heart disease
Heart Attack
A heart attack occurs when blood flow to a
section of heart muscle becomes blocked. If
the flow of blood isn’t restored quickly, the
Heart With Muscle Damage and a Blocked Artery
Figure A is an overview of a heart and coronary artery
showing damage (dead heart muscle) caused by a heart
attack. Figure B is a cross-section of the coronary artery with
plaque buildup and a blood clot.
269
section of heart muscle becomes damaged
from lack of oxygen and begins to die.
Heart attack is a leading killer of both men
and women in whole world. But fortunately,
today there are excellent treatments for heart
attack that can save lives and prevent
disabilities. Treatment is most effective when
started within 1 hour of the beginning of
symptoms.
Overview
Heart attacks occur most often as a result of a
condition called coronary artery disease (CAD).
In CAD, a fatty material called plaque (plak)
builds up over many years on the inside walls
of the coronary arteries (the arteries that
supply blood and oxygen to heart).
Eventually, an area of plaque can rupture,
causing a blood clot to form on the surface of
the plaque. If the clot becomes large enough,
it can mostly or completely block the flow of
oxygen-rich blood to the part of the heart
muscle fed by the artery.
During a heart attack, if the blockage in the
coronary artery isn’t treated quickly, the heart
muscle will begin to die and be replaced by
scar tissue. This heart damage may not be
obvious, or it may cause severe or long-
lasting problems.
Severe problems linked to heart attack can include
heart failure and life-threatening arrhythmias
(irregular heartbeats). Heart failure is a condition
in which the heart can’t pump enough blood
throughout the body. Ventricular fibrillation is a
serious arrhythmia that can cause death if not
treated quickly.
Acting fast at the first sign of heart attack
symptoms can save life and limits damage to
the heart. Treatment is most effective when
started within 1 hour of the beginning of
symptoms.
The most common heart attack signs and
symptoms are:
- Chest discomfort or pain, uncomfortable
pressure, squeezing, fullness, or pain in the
center of the chest that can be mild or strong
(This discomfort or pain lasts more than a
few minutes or goes away and comes back).
- Upper body discomfort in one or both arms,
the back, neck, jaw, or stomach
- Shortness of breath may occur with or
before chest discomfort.
- Other signs include nausea (feeling sick to
your stomach), vomiting, lightheadedness or
fainting, or breaking out in a cold sweat.
(If the symptoms stop completely in less than
5 minutes, still patient need medical aid. Give
a nitroglycerin pill if it has already prescribed.
Place an aspirin under the tongue. Aspirin
reduces blood clotting and can help keep a
heart attack from getting worse.)
Outlook
Each year, about 1.1 million people in the
United States have heart attacks, and almost
half of them die. CAD, which often results in
a heart attack, is the leading killer of both
men and women in the United States.
Many more people could recover from heart
attacks if they got help faster. Of the people
who die from heart attacks, about half die
within an hour of the first symptoms and
before they reach the hospital.
Other Names for a Heart Attack
Myocardial infarction or MI
Acute myocardial infarction or AMI
Acute coronary syndrome
Coronary thrombosis
Coronary occlusion
Heart failure is a condition in which the heart
can not pump enough blood throughout the
body. Heart failure does not mean that the
heart has stopped or is about to stop working.
It means that the heart is not able to pump
blood the way that it should. The heart can
not fill with enough blood or pump with
enough force, or both.
Heart failure develops over time as the
pumping action of the heart grows weaker. It
can affect the left side, the right side, or both
sides of the heart. Most cases involve the left
side where the heart can’t pump enough
oxygen-rich blood to the rest of the body.
With right-sided failure, the heart can’t
270
effectively pump blood to the lungs where the
blood picks up oxygen.
The weakening of the heart’s pumping ability
causes:
- Blood and fluid to "back up" into the lungs
- The buildup of fluid in the feet, ankles, and
legs
- Tiredness and shortness of breath
Heart failure is a serious condition. About 5
million people in the United States have heart
failure, and the number is growing. Each year,
another 550,000 people are diagnosed for the
first time. It contributes to or causes about
300,000 deaths each year.
Heart Murmur
A heart murmur is an extra or unusual sound
heard during your heartbeat. Murmurs range
from very faint to very loud and sometimes
sound like a whooshing or swishing noise.
Normal heartbeat sounds, "Lub-DUPP" or
"Lub-DUB", are the valves closing as blood
moves through the heart. A heart murmur is
not a disease; it is a sound that the doctor
hears with a stethoscope. It may be normal, or
it could be a sign that something may be
wrong. Most heart murmurs are harmless.
Some are signs of heart problems, especially
if other signs or symptoms of a heart problem
are present.
Types of Murmurs
Innocent (harmless) murmurs
A person with an innocent murmur has a
normal heart and usually has no other signs or
symptoms of a heart problem. Innocent
murmurs are common in healthy children.
Abnormal murmurs
A person with an abnormal murmur usually
has other signs or symptoms of a heart
problem. Most abnormal murmurs in children
are due to congenital heart defects—heart
defects present at birth. In adults, abnormal
murmurs are most often due to heart valve
problems caused by infection, disease, or
aging
CHOLESTEROL
To understand high blood cholesterol (ko-
LES-ter-ol), it is important to know more
about cholesterol.
Cholesterol is a waxy, fat-like substance that
is found in all cells of the body. The body
needs some cholesterol to work the right way.
The body makes all the cholesterol it needs.
Cholesterol is also found in some of the
foods.
The body uses cholesterol to make hormones,
vitamin D, and substances that help in
digestion of foods.
Blood is watery, and cholesterol is fatty. Just
like oil and water, the two do not mix. To
travel in the bloodstream, cholesterol is
carried in small packages called lipoproteins
(lip-o-PRO-teens). The small packages are
made of fat (lipid) on the inside and proteins
on the outside. Two kinds of lipoproteins
carry cholesterol throughout the body. It is
important to have healthy levels of both:
Low-density lipoprotein (LDL) cholesterol is
sometimes called bad cholesterol.
High LDL cholesterol leads to a buildup of
cholesterol in arteries. The higher the LDL
The illustration shows a normal artery with normal blood
flow (Figure A) and an artery containing plaque buildup
(Figure B).
271
evel in the blood, there is greater chance of
getting heart disease.
High-density lipoprotein (HDL) cholesterol is
sometimes called good cholesterol.
HDL carries cholesterol from other parts of
the body back to liver. The liver removes the
cholesterol from the body. If there is higher
HDL cholesterol level, the lower chances of
getting heart disease.
High Blood Cholesterol
Too much cholesterol in the blood, or high
blood cholesterol, can be serious. People with
high blood cholesterol have a greater chance
of getting heart disease. High blood
cholesterol on its own does not cause any
symptoms therefore blood test is necessary to
detect because many people are unaware that
their cholesterol level is too high.
Cholesterol can build up on the walls of the
arteries (blood vessels that carry blood from
the heart to other parts of the body). This
buildup of cholesterol is called plaque (plak).
Over time, plaque can cause narrowing of the
arteries. This is called atherosclerosis (ath-er-
o-skler-O-sis), or hardening of the arteries.
Special arteries, called coronary arteries,
bring blood to the heart. Narrowing of
coronary arteries due to plaque can stop or
slow down the flow of blood to the heart.
When the arteries narrow, the amount of
oxygen-rich blood is decreased. This is called
coronary artery disease (CAD). Large plaque
areas can lead to chest pain called angina (an-
JI-nuh or AN-juh-nuh). Angina happens when
the heart does not receive enough oxygen-rich
blood. Angina is a common symptom of
CAD.
Some plaques have a thin covering and burst
(rupture), releasing fat and cholesterol into the
bloodstream. The release of fat and
cholesterol may cause your blood to clot. A
clot can block the flow of blood. This
blockage can cause angina or a heart attack.
Lowering your cholesterol level decreases
your chance for having a plaque burst and
cause a heart attack. Lowering cholesterol
may also slow down, reduce, or even stop
plaque from building up.
Plaque and resulting health problems can also
occur in arteries elsewhere in the body.
Other Names for High Blood Cholesterol
Hypercholesterolemia (HI-per-ko-LES-ter-ol-
E-me-a)
Hyperlipidemia (HI-per-lip-i-DE-me-a)
High Blood Pressure
High blood pressure is a blood pressure
reading of 140/90 mmHg or higher. Both
numbers are important.
Nearly 1 in 3 American adults has high blood
pressure. Once high blood pressure develops,
it usually lasts a lifetime. The good news is
that it can be treated and controlled.
High blood pressure is called the silent killer
because it usually has no symptoms. Some
people may not find out they have it until they
have trouble with their heart, brain, or
kidneys. When high blood pressure is not
found and treated, it can cause:
- The heart to get larger, which may lead to
heart failure.
- Small bulges (aneurysms (AN-u-risms)) to
form in blood vessels. Common locations
are the main artery from the heart (aorta);
arteries in the brain, legs, and intestines; and
the artery leading to the spleen.
- Blood vessels in the kidney to narrow,
which may cause kidney failure.
- Arteries throughout the body to "harden"
faster, especially those in the heart, brain,
kidneys, and legs. This can cause a heart
attack, stroke, kidney failure, or amputation
of part of the leg.
- Blood vessels in the eyes to burst or bleed
which may cause vision changes and can
result in blindness.
Blood Pressure
Blood is carried from the heart to all parts of
your body in vessels called arteries. Blood
pressure is the force of the blood pushing
against the walls of the arteries. Each time the
heart beats (about 60–70 times a minute at
rest) it pumps out blood into the arteries. Your
272
blood pressure is at its highest when the heart
beats, pumping the blood. This is called
systolic (sis-TOL-ik) pressure. When the
heart is at rest, between beats, your blood
pressure falls. This is the diastolic (di-a-
STOL-ik) pressure.
Blood pressure is always given as these two
numbers, the systolic and diastolic pressures.
Both are important. Usually they are written
one above or before the other, such as 120/80
mmHg (measured in millimeters of mercury,
a unit for measuring pressure). When the two
measurements are written down, the systolic
pressure is the first or top number, and the
diastolic pressure is the second or bottom
number (for example, 120/80). If your blood
pressure is 120/80, it is also called "120 over
80."
Blood pressure changes during the day. It is
lowest as sleep and rises when get up. It also
can rise when a person is excited, nervous, or
active.
Still, for most of waking hours, blood
pressure stays pretty much the same when
some body is sitting or standing still. The
level should be lower than 120/80 mmHg.
When the level stays high, 140/90 mmHg or
higher, the person has high blood pressure.
With high blood pressure, the heart works
harder, the arteries take a beating, and the
chances of a stroke, heart attack, and kidney
problems are greater.
Normal Blood Pressure
A blood pressure reading below 120/80
mmHg is considered normal. In general,
lower is better. However, very low blood
pressure can sometimes be a cause for
concern and should be checked out by a
doctor.
Doctors classify blood pressures under 140/90
mmHg as either normal or pre-hypertension.
Normal blood pressure is lower than 120/80
mmHg. Pre-hypertension is blood pressure
between 120 and 139 for the top number, or
between 80 and 89 for the bottom number.
For example, blood pressure readings of
138/82, 128/89, or 130/86 are all in the pre- Other
hypertension range. If the blood pressure is in Essential hypertension
the pre-hypertension range, it is more likely Primary hypertension
that the person will end up with high blood Idiopathic hypertension
pressure unless take action to prevent it. Holes in the Heart
What Is High Blood Pressure? A blood A hole in the heart is a type of simple
congenital (kon-JEN-i-tal) heart defect (a
Categories for Blood Pressure Levels in problem with the heart's structure that is
Adults (in mmHg, millimeters of present at birth). Congenital heart defects
mercury)a change the normal flow of blood through the
Systolic (top Diastolic (bottom heart.
Category
number) number) Heart has two sides, separated by an inner
Normal Less than 120 Less than 80 wall called the septum. With each heartbeat,
Pre- the right side of the heart receives oxygen-
120–139 80–89
hypertension poor blood from the body and pumps it to the
High blood lungs. The left side of the heart receives
pressure oxygen-rich blood from the lungs and pumps
Stage 1 140–159 90–99 it to the body. The septum prevents mixing of
Stage 2 160 or higher 100 or higher blood between the two sides of the heart.
a
Some babies are born with a hole in the upper
For adults 18 and older who are not on medicine for high
blood pressure; are not having a short-term serious illness;
or lower septum. A hole in the septum
and do not have other conditions, such as diabetes and between the heart's upper two chambers (the
kidney disease. atria, pronounced AY-tree-uh) is called an
Note: When systolic and diastolic blood pressures fall into atrial septal defect (ASD). A hole in the
different categories, the higher category should be used to septum between the heart's lower two
classify blood pressure level. For example, 160/80 mmHg
would be stage 2 high blood pressure. chambers (the ventricles, pronounced VEN-
pressure of 140/90 mmHg or higher is trih-kuls) is called a ventricular septal defect
considered high blood pressure. Both (VSD).
numbers are important. If one or both A hole in the septum can allow blood to pass
numbers are usually high, that means high from the left side of the heart to the right side.
blood pressure. This means that oxygen-rich blood can mix
There are two levels of high blood pressure: with oxygen-poor blood, causing the oxygen-
stage 1 and stage 2 (see the chart below). rich blood to be pumped to the lungs a second
There is an exception to the above definition time.
of high blood pressure. A blood pressure of Over the past few decades, the diagnosis and
130/80 mmHg or higher is considered high treatment of ASDs and VSDs have greatly
blood pressure in people with diabetes and improved. As a result, a child with a simple
chronic kidney disease. heart defect can grow to adulthood and live a
Other Names for High Blood Pressure normal, active, and productive life because
General his or her heart defect closes on its own or has
HBP been repaired.
Hypertension Hypotension
HTN Hypotension is abnormally low blood
Caused by another Condition pressure. Normal blood pressure is a reading
Secondary hypertension of less than 120/80 mmHg (mmHg =
millimeters of mercury, a unit for measuring

273
pressure). Hypotension is blood pressure that
is lower than 90/60 mmHg.
Some people have low blood pressure all the
time. They have no signs or symptoms and
their low readings are normal for them. In
other people, blood pressure drops below
normal because of some event or medical
condition. Hypotension is a medical concern
only if it causes signs and/or symptoms such
as dizziness, fainting, or, in extreme cases,
shock.
Blood Pressure
Blood is carried from the heart to all parts of
your body in vessels called arteries. Blood
pressure is the force of the blood pushing
against the walls of the arteries. Each time the
heart beats (about 60–70 times a minute in
adults at rest), it pumps blood out into the
arteries. Blood pressure is at its highest when
the heart beats, pumping the blood. This is
called systolic (sis-TOL-ik) pressure. When
the heart is at rest, between beats, blood
pressure falls. This is the diastolic (di-a-
STOL-ik) pressure.
Blood pressure is always given as these two
numbers, the systolic and diastolic pressures.
Both are important. Usually they are written
one above or before the other, such as 120/80
mmHg. When the two measurements are
written down, the systolic pressure is the first
or top number, and the diastolic pressure is
the second or bottom number (for example,
120/80). If the blood pressure is 120/80, it is
also called “120 over 80.”
Blood pressure changes during the day. It
lowers as you sleep and rises when you wake
up. It also can rise when a person is excited,
nervous, or active.
The body is very sensitive to changes in blood
pressure. Special cells in the arteries, called
baroreceptors (BAR-o-re-SEP-ters), can sense
if blood pressure begins to rise or drop. When
the baroreceptors sense a rise or drop in blood
pressure, they cause certain responses to
occur throughout the body in an attempt to
bring the blood pressure back to normal.
274
For example, if we stand up quickly, the baro-
receptors will sense a drop in blood pressure.
It quickly takes action to make sure that blood
continues to flow to the brain, kidneys, and
other important organs. The baro-receptors
cause the heart to beat faster and harder. They
also cause the small arteries (arterioles) and
veins (the vessels that carry blood back to the
heart) to narrow.
Most forms of hypotension happen when the
body can not bring blood pressure back to
normal or can not do it fast enough.
Outlook
In a healthy person, hypotension without
signs or symptoms is usually not a problem
and requires no treatment. Doctors will want
to identify and treat any underlying condition
that is causing the hypotension, if one can be
found. Hypotension can be dangerous if a
person falls because of dizziness or fainting.
Shock, a severe form of hypotension, is a life-
threatening condition that is often fatal if not
treated immediately. Shock can be
successfully treated if the cause can be found
and the right treatment provided in time.
Types of Hypotension
There are several types of hypotension. One
type, chronic asymptomatic hypotension,
happens in people who always have low
blood pressure. They have no symptoms and
need no treatment. Their low blood pressure
is normal for them.
Other types of hypotension happen only
sometimes, when blood pressure suddenly
drops too low. The symptoms and effects on
the body can be mild or severe. The three
main types of this kind of hypotension are
orthostatic hypotension, neurally mediated
hypotension (NMH), and severe hypotension
associated with shock.
Orthostatic Hypotension
Orthostatic hypotension is low blood pressure
that occurs upon standing up from a sitting or
lying down position. It can cause a person to
feel dizzy, lightheaded or even to faint. It
occurs when the body is not able to adjust
blood pressure and blood flow fast enough for
the change in position. Usually orthostatic
hypotension lasts for only a few seconds or
minutes after a person stands up. Sometimes a
person will need to sit or lie down for a short
time while the blood pressure returns to
normal.
Orthostatic hypotension can occur in all age
groups, but it is more common in older adults,
especially those who are frail or in poor
health. Orthostatic hypotension can be a
symptom of other medical conditions, and
treatment generally focuses on treating the
underlying condition(s). Some people can
have orthostatic hypotension but also have
high blood pressure when lying down.
A form of orthostatic hypotension called
postprandial hypotension is a sudden drop in
blood pressure after a meal. Postprandial
hypotension most commonly affects older
adults. It also is more likely to affect those
with high blood pressure or diseases such as
Parkinson disease.
Neurally Mediated Hypotension
In this form of hypotension, blood pressure
drops after a person has been standing for a
long time. A person may feel dizzy, faint, or
sick to the stomach as a result. NMH also can
happen when a person faces an unpleasant,
upsetting, or frightening situation. NMH
affects children and young adults more often
than other age groups. Children often outgrow
this form of hypotension.
Severe Hypotension Associated With Shock
Many times people will say a person has
“gone into shock” as a result of an
emotionally upsetting experience. But to
doctors, the word “shock” has a different
meaning. Shock is a life-threatening condition
in which blood pressure drops so low that the
brain, kidneys, and other vital organs can not
get enough blood to work properly. It is
different from the other forms of hypotension
because blood pressure drops much lower,
and it is life threatening if not treated
immediately. There are many causes of shock,
275
including major loss of blood, certain severe
types of infection, severe burns, severe
allergic reactions, and poisoning.
Other Names for Hypotension
Low blood pressure
Orthostatic hypotension
Postprandial hypotension
Postural hypotension
Neurally mediated hypotension
Neurogenic orthostatic hypotension
Shock
Long QT Syndrome
Long QT syndrome (LQTS) is a disorder of
the heart's electrical activity that may cause to
develop a sudden, uncontrollable, and
dangerous heart rhythm (called an
arrhythmia) in response to exercise or stress.
Such abnormal heart rhythms also can
develop for no known reason in people who
have LQTS. Not everyone who has LQTS
develops a dangerous heart rhythm, but if one
does occur, it may be fatal.
The term "long QT" refers to an abnormality
seen on an EKG (electrocardiogram). An
EKG is a test that detects and records the
electrical activity of the heart. The QT
interval, recorded on the EKG, corresponds to
the time during which the lower chambers of
the heart (the ventricles) are triggered to
contract and then build the potential to
contract again.
The timing of the electrical activity of the
heartbeat is complex and carefully controlled
by the body. Normally the QT interval of the
heartbeat lasts about a third of each heartbeat
cycle on the EKG. But in people with LQTS,
the QT interval usually lasts longer than
normal, which can upset the careful timing of
the heartbeat and trigger a dangerous,
irregular rhythm.
Overview
On the surface of each muscle cell in the heart
are tiny pores called ion channels. Ion
channels open and close to let electrically
charged sodium, calcium, and potassium
atoms (ions) flow into and out of the cell.
This generates the electrical activity of the
heart.
This activity causes each heart cell to
contract. Normally, the electrical activity
spreads from one heart cell to the next in an
orderly and coordinated way to allow the
heart to pump blood. During each normal
heartbeat, the muscle cells in the upper
chambers of the heart, the atria (AY-tree-uh),
contract. The contraction pumps blood from
the atria to the ventricles. Then the muscle
cells in the ventricles contract, pumping blood
from the ventricles to the lungs and the rest of
the body. This coordinated contraction of the
atria and ventricles represents one normal
heartbeat.
In people who have LQTS, problems with the
ion channels in the heart cells may disrupt the
timing of the electrical activity in the
ventricles. The ion channels may not work
properly, or there may be too few of them. In
this situation, the heart may suddenly develop
a fast and abnormal heart rhythm that can be
life threatening.
Many cases of LQTS are inherited, which
means you are born with the condition and
have it your whole life. There are seven
known types of inherited LQTS. The most
common ones are called LQTS 1, LQTS 2,
and LQTS 3.
Emotional stress or physical exercise
(especially swimming) that makes the heart
beat faster tends to trigger irregular heart
rhythms if you have LQTS 1. In LQTS 2,
irregular rhythms may be triggered by
surprise or other extreme emotions. In LQTS
3, a low heart rate during sleep may be the
trigger for an irregular heart rhythm.
Acquired, or non-inherited, LQTS may be
brought on by certain medicines and other
medical conditions.
Outlook
More than half the people who have an
untreated, inherited form of LQTS die within
10 years. But for many people with LQTS,
lifestyle changes and medical treatments can
276
help prevent dangerous complications and
lengthen life expectancy. Some of these
changes include:
Avoiding strenuous physical activity or
startling noises
Adding more potassium to your diet
Taking heart medicines called beta blockers,
which are very effective at preventing sudden
cardiac arrest
Having an implantable device, such as a
pacemaker or implantable cardioverter
defibrillator, that helps control abnormal
heart rhythms
Other Names for Long QT Syndrome
Jervell and Lange-Nielsen syndrome
Romano-Ward syndrome
Marfan syndrome
Marfan syndrome is a disorder of connective
tissue. Connective tissue holds all the parts of
the body together and helps control growth.
Connective tissue gets some of its strength
from a protein called fibrillin 1. Fibrillin 1
also plays an important role in controlling the
growth and development of the body. In
Marfan syndrome, the body produces fibrillin
1 that does not work properly. As a result, the
connective tissue is not as strong as it should
be, and the growth and development of the
body are affected.
Effects of Marfan syndrome on the Body
The Heart and Blood Vessels
Most people who have Marfan syndrome
have problems with their heart and blood
vessels because of weak connective tissue.
Valves in the heart may not close properly
and may let blood leak backward. The aorta––
the large artery that carries blood away from
the heart out to the body––may stretch and
enlarge, and it can burst. The aorta also can
develop a tear in its inner wall. This tear can
expand and block blood flow through the
aorta. This is called aortic dissection.
The Bones, Cartilage, and Ligaments
People with Marfan syndrome tend to have
tall and slender bodies with arms and legs
disproportionately long compared to the
trunk. They also usually have long fingers and
toes. The ligaments and joints are typically
loose. Because of rib overgrowth, the chest
may protrude or be indented. Abnormal
curving of the spine, called scoliosis (sko-le-
O-sis), lordosis (lor-DO-sis), or kyphosis (ki-
FO-sis), can occur.
The Eyes
The most common vision problem in people
with Marfan syndrome is nearsightedness
(myopia). Nearsightedness is sharp vision for
things that are close and blurred vision for
things that are farther away. Dislocation of
the lens of the eye is a hallmark of Marfan
syndrome that occurs in very few other
conditions. Cataracts, or glaucoma at an early
age, or detached retinas, also occur in people
with Marfan syndrome.
The Lungs
In Marfan syndrome, the air sacs in the lungs
may be unusually large. In addition, the chest
may be abnormally shaped. For these reasons,
people with Marfan syndrome may have
breathing problems, such as collapsed lungs
(spontaneous pneumothorax) and early
emphysema.
The Skin
Stretch marks, not due to weight gain or loss,
commonly occur on the skin of people with
Marfan syndrome.
Outlook
Marfan syndrome is a lifelong disorder with
no known cure. As recently as the 1970s,
most people with Marfan syndrome did not
survive beyond age 40–50. Some infants and
children died from complications due to the
condition. In most cases, death was due to
heart and blood vessel problems.
Today, because of early diagnosis and better
medical and surgical treatments, people with
Marfan syndrome can live longer and
healthier lives, with fewer and less severe
complications. However, aging with Marfan
syndrome poses new concerns as this chronic
and progressive disorder advances. In
addition, those who are not diagnosed or
277
treated are still at risk of an early sudden
death due to blood vessel problems.
Metabolic syndrome
Metabolic syndrome is the name for a group
of risk factors linked to overweight and
obesity that increase the chance for heart
disease and other health problems such as
diabetes and stroke. The term “metabolic”
refers to the biochemical processes involved
in the body’s normal functioning. Risk factors
are behaviors or conditions that increase the
chance of getting a disease.
The five conditions listed below are metabolic
risk factors for heart disease. A person can
develop any one of these risk factors by itself,
but they tend to occur together. Metabolic
syndrome is diagnosed when a person has at
least three of these heart disease risk factors:
A large waistline: This is also called
abdominal obesity or “having an apple
shape.” Excess fat in the abdominal area is a
greater risk factor for heart disease than
excess fat in other parts of the body, such as
on the hips.
A higher than normal triglyceride level in the
blood: Triglycerides are a type of fat found in
the blood.
A lower than normal level of HDL cholesterol
(high-density lipoprotein cholesterol) in the
blood (or you’re on medicine to treat low
HDL): HDL is considered “good” cholesterol
because it lowers the chances of heart disease.
Low levels of HDL increase the chances of
heart disease.
Higher than normal blood pressure: Blood
pressure is recorded as two numbers, usually
written one on top of or before the other, such
as 120/80. The top or first number, called the
systolic blood pressure, measures the pressure
in the bloodstream when your heart beats. The
bottom or second number, called the diastolic
blood pressure, measures the pressure in your
bloodstream between heartbeats when the
heart is relaxed.
Higher than normal fasting blood sugar:
Mildly high blood sugar can be an early
warning sign of diabetes.
The more of these risk factors present the
greater chances of developing heart disease,
diabetes, or a stroke. In general, a person with
metabolic syndrome is twice as likely to
develop heart disease and five times as likely
to develop diabetes as someone without
metabolic syndrome.
Other risk factors aside from those of the
metabolic syndrome also increase the risk for
heart disease. A high level of LDL cholesterol
(low-density lipoprotein cholesterol;
considered “bad” cholesterol) and smoking,
for example, are key risk factors for heart
disease, but they are not components of
metabolic syndrome. Even a single risk factor
raises the risk for heart disease, and every risk
factor should be lowered to reduce the risk.
The chance of developing metabolic
syndrome is closely linked to being
overweight or obese and to a lack of physical
activity. Another cause is insulin resistance.
Insulin resistance is a condition in which the
body can not use its insulin properly. Insulin
is a hormone the body uses to help change
blood sugar into energy. Insulin resistance can
lead to high blood sugar levels and is closely
linked with being overweight or obese.
Genetics (ethnicity and family history) and
older age are other important underlying
causes of metabolic syndrome.
Outlook
About 47 million adults in the United States
(almost 25 percent) have metabolic syndrome,
and the numbers continue to grow. The
increasing number of people with this
condition is connected to the rise in obesity
rates among adults. In the future, metabolic
syndrome may overtake smoking as the
leading risk factor for heart disease.
It is possible to prevent or delay metabolic
syndrome, mainly with lifestyle changes. A
healthy lifestyle is a lifelong commitment.
Successfully controlling metabolic syndrome
278
takes a long-term effort and teamwork with
the health care providers.
Other Names for Metabolic Syndrome
Syndrome X
Insulin resistance syndrome
Dysmetabolic syndrome
Hypertriglyceridemic waist
Obesity syndrome
Mitral Valve Prolapse
Mitral (MI-tral) valve prolapse (MVP) is a
condition in which one of the valves of the
heart, the mitral valve, does not work
properly. The flaps of the valve are “floppy”
and do not close tightly. Much of the time,
MVP does not cause any problems. Rarely,
blood can leak the wrong way through the
floppy valve, which may cause shortness of
breath, palpitations, chest pain, and other
symptoms.
Normal Mitral Valve
The mitral valve controls the flow of blood
between the two chambers on the left side of
the heart. The two chambers are the left
atrium (AY-tree-um) and the left ventricle
(VEN-trih-kul). The mitral valve allows blood
to flow from the left atrium to the left
ventricle, but not back the other way. (The
heart also has a right atrium and ventricle,
separated by the tricuspid (tri-CUSS-pid)
valve.)
At the beginning of a heartbeat, the atria
contract and push blood through to the
ventricles. The flaps of the mitral and
tricuspid valves swing open to let the blood
through. Then, the ventricles contract to pump
the blood out of the heart. When the ventricles
contract, the flaps of the mitral and tricuspid
valves swing shut and form a tight seal that
prevents blood from flowing back into the
atria.
Mitral Valve Prolapse
In MVP, when the left ventricle contracts, one
or both flaps of the mitral valve flop or bulge
back (prolapse) into the left atrium. This can
prevent the valve from forming a tight seal,
and allow blood to flow backward from the
ventricle into the atrium. The backward flow
of blood is called regurgitation (re-GUR-ji-
TA-shun), and it can lead to symptoms and
complications.
Regurgitation does not occur in all cases of
MVP. In fact, the majority of people with
MVP does not have regurgitation and never
have any symptoms or complications. In these
people, even though the valve flaps prolapse,
the valve is still able to form a tight seal.
When regurgitation does occur, it can cause
complications and troublesome symptoms
Figure A shows the normal mitral valve separating
the left atrium from the left ventricle. Figure B
shows the heart with mitral valve prolapse. Figure C
shows the detail of mitral valve prolapse. Figure D
shows a mitral valve that allows blood to flow
backward into the left atrium.
279
such as shortness of breath, a racing or
irregular heartbeat, or chest pain.
Regurgitation can get worse over time and
lead to changes in the heart’s size and higher
pressures in the left atrium and lungs.
Regurgitation increases the risk for heart
valve infections.
Medicines can treat MVP symptoms that
cause people to worry or have discomfort.
Medicines are also used to prevent
complications. Sometimes a person will need
surgery to repair or replace the mitral valve.
MVP was once thought to affect as much as 5
to 15 percent of the population. It is now
believed that many people who were
diagnosed with MVP in the past did not
actually have an abnormal mitral valve. They
may have had a slight bulging of the valve
flaps due to other conditions such as
dehydration or a small heart. However, their
valve was normal and there was little or no
regurgitation through the valve. Now, more
precise rules for diagnosing MVP with a test
called an echocardiogram make it easier to
identify true MVP and to detect troublesome
regurgitation. Based on these new rules, it is
now believed that less than 3 percent of the
population actually has true MVP, and an
even smaller percentage has serious
complications from it.
Outlook
In most people with MVP, the condition
causes no symptoms or medical problems,
and no treatment is needed. These people are
able to lead normal, active lives, and they
may not even know they have the condition.
However, people with mild MVP are often
prescribed antibiotics before dental work or
certain types of surgery to prevent a heart
valve infection called infective endocarditis
(EN-do-kar-DI-tis). This infection is caused
by bacteria that can enter the bloodstream at
the time of dental work or some kinds of
surgery. These bacteria can stick to and infect
the heart valves in people with MVP.
Only a very small number of people with
MVP have troublesome symptoms or
regurgitation through the valve. They may
need medicine to relieve their symptoms. A
very few people with MVP may need heart
valve surgery.
Overweight and Obesity
The terms “overweight” and “obesity” refer to
a person’s overall body weight and where the
extra weight comes from. Overweight is
having extra body weight from muscle, bone,
fat, and/or water. Obesity is having a high
amount of extra body fat. The most useful
measure of overweight and obesity is the
body mass index (BMI). BMI is based on
height and weight and is used for adults,
children, and teens.
Millions of Americans and people worldwide
are overweight or obese. Being overweight or
obese puts the person at risk for many
diseases and conditions. The more body fat
that the more risk to develop heart disease,
high blood pressure, type 2 diabetes,
gallstones, breathing problems, and certain
cancers.
A person’s weight is a result of many factors.
These factors include environment, family
history and genetics, metabolism, behavior or
habits, and other factors.
Certain things, like family history, can not be
changed. However, other things—like a
person’s lifestyle habits—can be changed. To
prevent or treat overweight and obesity if:
Follow a healthful diet, while keeping your
calorie needs in mind. Physically active, limit
the time when spend being physically
inactive. Weight loss medicines and surgery
also are options for some people who need to
lose weight if lifestyle changes do not work.
Outlook
Reaching and staying at a healthy weight is a
long-term challenge for people who are
overweight or obese. But it also can be a
chance to lower the risk of other serious
health problems. With the right treatment and
280
motivation, it is possible to lose weight and
lower long-term disease risk.
Patent Ductus Arteriosus
Patent ductus arteriosus (PDA) is a heart
problem that occurs soon after birth in some
babies. In PDA, there is an abnormal
circulation of blood between two of the major
arteries near the heart. Before birth, the two
major arteries—the aorta and the pulmonary
artery—are normally connected by a blood
vessel called the ductus arteriosus, which is
an essential part of the fetal circulation. After
birth, the vessel is supposed to close within a
few days as part of the normal changes
occurring in the baby's circulation. In some
babies, however, the ductus arteriosus
remains open (patent). This opening allows
blood to flow directly from the aorta into the
pulmonary artery, which can put a strain on
the heart and increase the blood pressure in
the lung arteries.
Figure A shows the normal anatomy and blood flow
of the interior of the heart. Figure B shows a heart
with a patent ductus arteriosus. The defect connects
the aorta with the pulmonary artery, allowing
oxygen-rich blood from the aorta to mix with
oxygen-poor blood in the pulmonary artery.
A PDA is a type of congenital heart defect. A
congenital heart defect is any type of heart
problem that is present at birth.
If baby has a PDA, but has an otherwise
normal heart, the PDA may shrink and go
away completely, or it may need to be treated
to close it. But, if baby is born with certain
types of heart defects that decrease blood flow
from the heart to the lungs or the body,
medicine may be given to keep the ductus
arteriosus open to maintain blood flow and
oxygen levels until corrective surgery for the
heart defect(s) can be performed.
About 3,000 infants are diagnosed with PDA
each year in the United States. It is more
common in premature infants (babies born too
early) but does occur in full-term infants.
Premature babies with PDA are more
vulnerable to its effects. PDA is twice as
common in girls as in boys.
Peripheral Arterial Disease
Peripheral arterial disease (PAD) occurs when
a fatty material called plaque (plak) builds up
on the inside walls of the arteries that carry
The illustration shows the location of leg arteries that
can be affected by peripheral arterial disease. Figure
A shows a normal artery with normal blood flow (the
inset image shows a cross-section of the normal
artery). Figure B shows an artery with plaque
buildup, which is partially blocking blood flow (the
inset image shows the degree to which the artery is
blocked).
blood from the heart to the head, internal
organs, and limbs. PAD is also known as
atherosclerotic peripheral arterial disease.
281
The buildup of plaque on the artery walls is
called atherosclerosis (ath-er-o-skler-O-sis),
or hardening of the arteries. Atherosclerosis
causes the arteries to narrow or become
blocked, which can reduce or block blood
flow. PAD most commonly affects blood flow
to the legs.
Blocked blood flow can cause pain and
numbness. It also can increase a person's
chance of getting an infection, and it can
make it difficult for the person's body to fight
the infection. If severe enough, blocked blood
flow can cause tissue death (gangrene). PAD
is the leading cause of leg amputation.
mportant General Information
Atherosclerosis can affect arteries anywhere
in the body, including the arteries that carry
blood to the heart and brain. When
atherosclerosis affects the arteries of the heart,
it is called coronary artery disease (CAD).
CAD can cause a heart attack. If
atherosclerosis is in the limbs, it also is likely
to be in the coronary arteries.
When atherosclerosis affects the major
arteries supplying the brain, it is called carotid
artery disease. Carotid artery disease can
cause a stroke.
PAD (atherosclerosis in the arteries that
supply blood to the limbs, especially the legs)
is a common, yet serious disease. Men are
more likely to have symptoms of PAD, but
both men and women can develop the disease.
PAD can impair physical health and diminish
the ability to walk.
In the advanced stages of PAD, blood flow to
one or both legs can be completely or mostly
blocked. This is known as chronic critical
limb ischemia (CLI). A very severe blockage
in the legs and feet means that the legs do not
receive the oxygen or nutrition needed for
cellular or skin growth and repair. CLI may
lead to painful leg or foot sores, and it could
eventually lead to gangrene. If this condition
is left untreated, the foot or leg may need to
be amputated.
Outlook common and tends to be less severe than
A person with PAD has a six to seven time secondary Raynaud's.
greater risk of CAD, heart attack, stroke, or When a person has primary or secondary
transient ischemic attack ("mini stroke") than Raynaud's, cold temperatures or stressful
the rest of the population. If a person has emotions can trigger attacks. During these
heart disease, he or she has a 1 in 3 chance of attacks, there is a brief lack of blood flow to
having blocked arteries in the legs. Early the affected body part(s), and the skin can
diagnosis and treatment of PAD, including temporarily become white then bluish. As
screening high-risk individuals, are important blood flow returns to the area, the skin turns
to prevent disability and save lives. PAD red. The affected areas can throb or feel numb
treatment may stop the disease from and tingly. With severe Raynaud's, prolonged
progressing and reduce the risk of heart or repeated episodes can cause sores or tissue
attack, heart disease, and stroke. death (gangrene).
Although PAD is serious, it is treatable. The
buildup of plaque in the arteries can often be
stopped or reversed with dietary changes,
exercise, and efforts to lower high cholesterol
levels and high blood pressure. In some
patients, blood flow in the vessels may be
improved by medicines or surgery.
Other Names for Peripheral Arterial
Disease
Atherosclerotic peripheral arterial disease
Peripheral vascular disease (PVD)
Vascular disease
Hardening of the arteries
Claudication
Poor circulation Figure A shows the normal digital arteries with
Leg cramps from poor circulation normal blood flow to the fingers. The inset images
show cross-sections of a normal artery. Figure B
Raynaud's Disease shows white discoloration of the fingertips caused by
Raynaud's disease and Raynaud's blocked blood flow. Figure C shows narrowed digital
phenomenon are rare disorders that affect arteries, causing blocked blood flow and purple
blood vessels. These disorders are marked by discoloration of the fingertips. The inset images
brief episodes of vasospasm (narrowing of the show cross-sections of a narrowed artery blocking
the flow of blood.
blood vessels). Vasospasm causes decreased
blood flow to the fingers and toes, and rarely
It is normal for the body to keep its vital inner
to the nose, ears, nipples, and lips. The fingers
organs warm by limiting blood flow to the
are the most commonly affected area, but the
arms, legs, fingers, and toes. The body
toes also are affected in 40 percent of people
naturally does this in response to a long
with Raynaud's.
period of cold. This response can cause
When this disorder occurs without any known
frostbite. In people with Raynaud's, the
cause, it is called Raynaud's disease, or
response to cold is quicker and stronger. The
primary Raynaud's. When the condition
response can be triggered by mild or short-
occurs along with a likely cause, it is known
lived changes in temperature, such as:
as Raynaud's phenomenon, or secondary
Taking something out of the freezer
Raynaud's. Primary Raynaud's is more

282
Temperatures that dip below 60 degrees
Fahrenheit
In people with Raynaud's, blood flow is more
strongly reduced in response to cold
temperatures than in people without the
disorder. When Raynaud's is severe (which is
uncommon) exposure to cold for as little as
20 minutes can cause major tissue damage.
The blood vessels of people with Raynaud's
also physically overreact to stressful
emotions. It is normal during times of
psychological stress for the body to release
hormones that narrow its blood vessels. But
for people with Raynaud's, this squeezing of
blood vessels is stronger. This results in less
blood reaching fingers, toes, and sometimes
other extremities.
Outlook
For most people, primary Raynaud's is more
of a bother than a serious illness and it can
usually be managed with minor lifestyle
changes. Secondary Raynaud's can be more
difficult to manage, but several treatments
may help prevent or relieve symptoms.
Among the most important treatments for
secondary Raynaud's is treating of the
underlying condition.
Sudden Cardiac Arrest
Sudden cardiac arrest (SCA), also known as
sudden cardiac death, is when the heart
suddenly and unexpectedly stops beating.
When this occurs, blood stops flowing to the
brain and other vital organs. SCA usually
causes death if not treated in minutes.
The heart has an internal electrical system that
controls the rhythm of the heartbeat. Problems
with the electrical system can cause abnormal
heart rhythms, called arrhythmias (ah-RITH-
me-ahs). There are many types of arrhythmia.
During an arrhythmia, the heart can beat too
fast, too slow, or it can stop beating. SCA
occurs when the heart develops an arrhythmia
that causes it to stop beating.
SCA is not the same thing as a heart attack. A
heart attack is a problem with blocked blood
flow to a part of the heart muscle. In a heart
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attack, the heart usually does not suddenly
stop beating. SCA, however, may happen
during recovery from a heart attack.
People with heart disease have a higher
chance of having SCA. But most SCAs
happen in people who appear healthy and
have no known heart disease or other risk
factors for SCA.
Outlook
Ninety-five percent of people who have SCA
die from it, most within minutes. Rapid
treatment of SCA with a device that sends an
electrical shock to the heart (called a
defibrillator) can be lifesaving. Automated
external defibrillators (AEDs), which are
often found in public places like airports and
office buildings, can be used to save the lives
of people having SCAs.
Other Names for Sudden Cardiac Arrest
The term "sudden cardiac death" is
sometimes used to describe the sudden loss of
heart function, even if the person is
resuscitated and survives. This is the term that
doctors most often use when gathering
information on the number of people who
have suffered sudden cardiac arrest.
Tetralogy of Fallot
Tetralogy of Fallot is a congenital (kon-JEN-
i-tal) heart defect (a problem with the heart’s
structure that’s present at birth). Congenital
heart defects change the normal flow of blood
through the heart. This rare and complex heart
defect occurs in about 5 out every 10,000
babies. It affects boys and girls equally.
Tetralogy of Fallot involves four defects:
A large ventricular (ven-TRICK-u-lar) septal
defect (VSD)
Pulmonary (PULL-mon-ary) stenosis (steh-
NO-sis)
Right ventricular hypertrophy (hy-PER-trow-
fee)
An overriding aorta
Ventricular Septal Defect
The heart has a wall that separates the
chambers on its left side from those on its
right side. This wall is called a septum. The
septum prevents blood from mixing between
the two sides of the heart.
A VSD is a hole in the part of the septum that
separates the ventricles—the lower chambers
of the heart. The hole allows oxygen-rich
blood to flow from the left ventricle into the
right ventricle instead of flowing into the
aorta, the main artery leading out to the body.
Pulmonary Stenosis
This is a narrowing of the pulmonary valve
and the passageway through which blood
flows from the right ventricle to the
pulmonary arteries. Normally, oxygen-poor
blood from the right ventricle flows through
the pulmonary valve into the pulmonary
arteries and out to the lungs to pick up
oxygen. In pulmonary stenosis, the heart has
Overview
Together, these four defects mean that not
enough blood is able to reach the lungs to get
oxygen, and oxygen-poor blood flows out to
the body.
Normal Heart and Heart With Tetralogy of Fallot
Figure A shows the normal structure and blood flow in
the interior of the heart. Figure B shows a heart with
the four defects of tetralogy of Fallot.
Babies and children with tetralogy of Fallot
have episodes of cyanosis (si-a-NO-sis),
which is a bluish tint to the skin, lips, and
fingernails. Cyanosis occurs because the
oxygen level in the blood is below normal.
Tetralogy of Fallot must be repaired with
open-heart surgery, either soon after birth or
later in infancy. The timing of the surgery
284
to work harder than normal to pump blood,
and not enough blood can get to the lungs.
Right Ventricular Hypertrophy
This is when the right ventricle thickens
because the heart has to pump harder than it
should to move blood through the narrowed
pulmonary valve.
Overriding Aorta
This is a defect in the location of the aorta. In
a healthy heart, the aorta is attached to the left
ventricle, allowing only oxygen-rich blood to
go to the body. In tetralogy of Fallot, the aorta
is between the left and right ventricles,
directly over the VSD. As a result,
oxygen-poor blood from the right ventricle
can flow directly into the aorta instead of into
the pulmonary artery to the lungs.
depends on how severely the pulmonary valve
is narrowed.
Outlook
Over the past few decades, the diagnosis and
treatment of tetralogy of Fallot has greatly
improved. As a result, the majority of children
with this heart defect grow to adulthood.
However, they need lifelong medical care
from a specialist to make sure they stay as
healthy as possible.
Varicose Veins
Varicose veins are swollen and twisted veins
that are visible just under the surface of the
skin. They appear most commonly in the legs,
but also can develop in other parts of the
body.
Veins are blood vessels that carry blood from
the tissues of the body to the heart. In the
heart, blood is pumped to the lungs to pick up
oxygen. The oxygen-rich blood is then
pumped out to the body through the arteries.
From the arteries, blood flows through tiny
blood vessels called capillaries, where it gives
up its oxygen to the body’s tissues. The blood
then returns back to the heart through the
veins to pick up more oxygen.
Veins have one-way valves that help to keep
the blood flowing toward the heart. When the
valves don’t work well, blood backs up and
pools in the veins. This causes them to swell
and become varicose veins.
Varicose veins usually don’t cause medical
problems. On occasion, they require treatment
for pain, skin problems, blood clots, or other
complications. People may choose to have
cosmetic treatment to improve the appearance
of varicose veins.
Related Vein Problems
A number of other types of vein problems are
related to varicose veins.
Spider Veins
Spider veins are a smaller version of varicose
veins. They occur in the capillaries, which are
the smallest blood vessels in the body. Spider
veins are commonly found on the legs and
face, and they usually resemble a spider web
or tree branch in shape. They can be red or
blue. Spider veins are usually not a medical
concern.
Telangiectasias
Telangiectasias (tel-AN-juh-ek-TA-ze-uhs)
are small clusters of blood vessels that look
similar to spider veins. They are red in color
and are commonly found on the upper body,
including the face. They can develop during
pregnancy and in people who have certain
genetic disorders, viral infections, and other
medical conditions (such as liver disease).
Newly developed telangiectasias are often a
reason to see a doctor.
Venous Lakes
Venous lakes are another type of varicose
veins in which blood collects in the veins of
the face and neck.
Reticular Veins
Reticular veins are flat blue veins commonly
seen behind the knees.
Hemorrhoids
Hemorrhoids are varicose veins in blood
vessels in and around the anus.
Varicoceles
Varicoceles (VAR-i-ko-seals) are varicose
veins in the scrotum (the skin over the
testicles). Varicoceles may be linked to male
infertility and should be checked by a doctor.
285
Outlook
People with varicose veins often require only
simple self-care measures, such as performing
certain leg exercises, wearing compression
stockings, and avoiding long periods of sitting
or standing. For those who are concerned
about the appearance of varicose veins,
several cosmetic treatments are available.
Although uncommon, in some cases,
complications such as pain, skin ulcers, and
blood clots can develop. A variety of medical
and surgical procedures are used to treat
varicose veins in these more complicated
cases.
Vasculitis
Vasculitis is an inflammation of the blood
vessels in the body. In vasculitis, the body’s
immune system mistakenly attacks the body’s
own blood vessels, causing them to become
inflamed. Inflammation can damage the blood
vessels and lead to a number of serious
complications.
Vasculitis can affect any of the body’s blood
vessels. These include arteries, veins, and
capillaries. Arteries are vessels that carry
blood from the heart to the body’s organs,
veins are the vessels that carry blood back to
the heart, and capillaries are the tiny blood
vessels that connect the small arteries and
veins.
When a blood vessel becomes inflamed, it
can:
Narrow, making it more difficult for blood to
get through
Close off completely so that blood can’t get
through at all (occlusion)
In rare cases, stretch and weaken so much
that it bulges (aneurysm) and may possibly
burst (aneurysm rupture)

Figure A shows a normal artery with normal blood
flow (the inset image shows a cross-section of the
normal artery). Figure B shows an artery narrowed due
to inflammation in the arterial wall, causing decreased
blood flow (the inset image shows a cross-section of
the inflamed artery). Figure C shows a totally occluded
(blocked) artery due to inflammation and scarring in
the arterial wall (the inset image shows a cross-section
of the block artery). Figure D shows an artery
containing an aneurysm.
The disruption in blood flow from
inflammation can damage the body’s organs.
Specific signs and symptoms depend on
which organ has been damaged and the extent
of the damage. Typical signs and symptoms
of inflammation (fever, swelling, and a
286
general sense of feeling ill) are common
among people with vasculitis.
Outlook
The outlook for people who have vasculitis
varies depending on both the type and
severity of the vasculitis. The course of a case
of vasculitis can be hard to predict. Treatment
is often very effective if vasculitis is
diagnosed and treated early. Vasculitis may
disappear or go into a period of remission. In
some cases, it may be a chronic problem,
requiring ongoing treatment, or it may come
back (“flare”) after a period of remission. In
more severe cases, treatment may not help,
and vasculitis can lead to disability or even
death.
Much is still unknown about vasculitis. There
are many different types of vasculitis, but
overall it is a fairly rare condition in the
general population. Additional research is
needed to learn more about the various types
of vasculitis and their causes, treatments, and
remission patterns.
Types of Vasculitis
There are many different disorders that are
classified as types of vasculitis. Although all
of these disorders include inflammation of the
blood vessels, most differ from each other in
terms of what populations of people and
which organs they affect.
Behcet’s Disease
Behcet’s disease can affect any part of the
body because it can occur in vessels of any
size or type. Commonly affected organs
include the eyes, the mouth, and the genitals.
Patients with this type of vasculitis are often
younger than those with other types, many
times in their twenties and thirties. The HLA-
B51 gene allele is often associated with
Behcet’s disease, but not everyone with the
gene will develop the disease. Behcet’s is
more common in individuals of
Mediterranean, Middle Eastern, or Far
Eastern descent, but is usually not found in
Blacks.
Buerger’s Disease
Buerger’s disease typically affects blood flow
to the hands and feet. Buerger’s disease is
also known as thromboangiitis obliterans and
is more likely to occur in smokers than
nonsmokers.
Central Nervous System Vasculitis
Central nervous system vasculitis affects the
brain and sometimes the spinal cord.
Churg-Strauss Syndrome
Churg-Strauss syndrome can affect many
different organs, but it most commonly affects
the lungs, skin, kidneys, and heart. Many
people who are diagnosed with Churg-Strauss
syndrome also have asthma. They may have
had preexisting, newly diagnosed, or recently
worsened asthma when diagnosed with
Churg-Strauss syndrome.
Cryoglobulinemia
Common signs and symptoms of
cryoglobulinemia (KRI-o-GLOB-u-luh-NE-
me-uh) are a rash on the lower limbs, arthritis,
and nerve damage. Type 1 cryoglobulinemia
is often associated with lymphoma, while
Type 2 cryoglobulinemia is often associated
with hepatitis C infection.
Giant Cell Arteritis
Common symptoms of giant cell arteritis
include headache, fever, blurred vision, and
pain in the jaw, shoulders, or hips. It is the
most common form of vasculitis that occurs
in adults older than 50 years. It is more likely
to occur in people of Scandinavian origin, but
can occur in people of any race.
Henoch-Schonlein Purpura
Henoch-Schonlein purpura most commonly
affects the skin, kidneys, joints, and stomach.
It is the most common form of vasculitis
found in children, but can occur at any age.
When seen in children, it often follows an
upper respiratory infection. It is not usually a
chronic disease, and full recovery is common.
Microscopic Polyangiitis
Microscopic polyangiitis (POL-e-an-je-i-tis)
most commonly affects the kidneys, skin, and
nerves, but it can affect any organ in the body.
287
Polyarteritis Nodosa
Polyarteritis nodosa (POL-e-ar-ter-i-tis no-
DO-suh) most commonly affects the kidneys,
skin, and nerves, but it can affect any organ in
the body. It is most common in people in their
thirties and forties. Men are twice as likely as
women to get polyarteritis nodosa. In some
cases, it is associated with chronic hepatitis B
infection or a very specific type of leukemia
known as hairy cell leukemia.
Polymyalgia Rheumatica
Polymyalgia rheumatica (POL-e-mi-AL-je-a
ROO-ma-ti-kuh) most commonly affects the
large joints in the body, such as the shoulders
and hips. It often occurs along with giant cell
arteritis.
Rheumatoid Vasculitis
Rheumatoid vasculitis can affect many
different organs, including the eyes, skin,
hands, and feet. It commonly occurs in
patients who have severe rheumatoid arthritis.
Takayasu’s Arteritis
Takayasu (Tock-e-AH-sue) arteritis (ar-ter-I-
tis) affects the aorta (the largest blood vessel
in the body) and its branches, which carry
blood away from the heart. It typically occurs
in Asian women younger than 40.
Wegener’s Granulomatosis
Wegener’s granulomatosis (GRAN-u-lo-ma-
TO-sis) can occur anywhere in the body. It
most commonly affects the upper respiratory
tract (nose, sinuses, and throat), lungs, and
kidneys. It is most common in people who are
middle-aged and older.
Other Names for Vasculitis
Angiitis
Arteritis
TESTS AND PROCEDURES
Coronary Angioplasty
Coronary angioplasty (AN-jee-oh-plas-tee) is
a medical procedure in which a balloon is
used to open a blockage in a coronary (heart)
artery narrowed by atherosclerosis (ATH-er-
o-skler-O-sis). This procedure improves blood
flow to the heart.
Atherosclerosis is a condition in which a
material called plaque (plak) builds up on the
inner walls of the arteries. This can happen in
any artery, including the coronary arteries,
which carry oxygen-rich blood to your heart.
When atherosclerosis affects the coronary
arteries, the condition is called coronary
artery disease (CAD).
Angioplasty is a common medical procedure.
It may be used to:
Improve symptoms of CAD, such as angina
and shortness of breath.
Reduce damage to the heart muscle from a
heart attack. A heart attack occurs when
blood flow through a coronary artery is
completely blocked. Angioplasty is used
during a heart attack to open the blockage
and restore blood flow through the artery.
Reduce the risk of death in some patients.
Angioplasty is done on more than 1 million
people a year in the United States. Serious
complications do not occur often, but can
happen no matter how careful the doctor is, or
how well he or she does the procedure.
Research on angioplasty is ongoing to make it
safer and more effective, to prevent treated
arteries from closing again, and to make the
procedure an option for more people.
Other Names for Coronary Angioplasty
Percutaneous coronary intervention (PCI)
Percutaneous intervention
Percutaneous transluminal angioplasty
Percutaneous transluminal coronary
angioplasty (PTCA)
Balloon angioplasty
Coronary artery angioplasty
Who Needs Coronary Angioplasty?
Coronary angioplasty is used to restore blood
flow to the heart when the coronary arteries
have become narrowed or blocked due to
coronary artery disease (CAD).
When medicines and lifestyle changes, such
as following a healthy diet, quitting smoking,
and getting more physical activity, does not
improve CAD symptoms. There remain some
options i.e. angioplasty and coronary artery
288
bypass grafting (CABG), a type of open-heart
surgery.
Angioplasty is often used when there is less
severe narrowing or blockage in your arteries,
and when the blockage can be reached during
the procedure.
CABG might be chosen if there is severe
heart disease, multiple arteries that are
blocked, or diabetes or heart failure.
Compared with CABG, some advantages of
angioplasty are that it:
- It has fewer risks than CABG.
- It is not surgery therefore it does not require
a large cut.
- It is done with medicines that numb you and
help you relax. Unlike CABG, you would not
be put to sleep for a short time.
- It has a shorter recovery time.
Angioplasty also is used as an emergency
procedure during a heart attack. As plaque
builds up in the coronary arteries, it can burst,
causing a blood clot to form on its surface. If
the clot becomes large enough, it can mostly
or completely block blood flow to part of the
heart muscle.
Quickly opening a blockage lessens the
damage to the heart during a heart attack and
restores blood flow to the heart muscle.
Angioplasty can quickly open the artery and
is the best approach during a heart attack.
A disadvantage of angioplasty when
compared with CABG is that the artery may
narrow again over time. The chance of this
happening is lower when stents are used,
especially medicine-coated stents. However,
these stents are not without risk. In some
cases, blood clots can form in the medicine-
coated stents and cause a heart attack.
Procedure of Coronary Angioplasty
Before coronary angioplasty is done, it is
necessary to locate the coronary arteries
which are blocked and how much severity is
there.
To find out it an angiogram and x-ray picture
of arteries is required. During an angiogram, a
small tube called a catheter with a balloon at
the end is put into a large blood vessel in the
groin (upper thigh) or arm. The catheter is
then threaded to the coronary arteries. A small
amount of dye is injected into the coronary
arteries and an x-ray picture is taken.
This picture will show any blockages, how
many, and where they are located. Once the
doctor has this information, the angioplasty
can proceed. The doctor will blow up (inflate)
the balloon in the blockage and push the
plaque outward against the artery wall. This
opens the artery more and improves blood
flow.
Coronary Balloon Angioplasty
The illustration shows a cross-section of a coronary
artery with plaque buildup. The coronary artery is
located on the surface of the heart. Figure A shows the
deflated balloon catheter inserted into the narrowed
coronary artery. In figure B, the balloon is inflated,
compressing the plaque and restoring the size of the
artery. Figure C shows the widened artery.
289
A small mesh tube called a stent is usually
placed in the newly widened part of the
artery. The stent holds up the artery and
lowers the risk of the artery re-narrowing.
Stents are made of metal mesh and look like
small springs.
Some stents, called drug-eluting stents, are
coated with medicines that are slowly and
continuously released into the artery. These
medicines help prevent the artery from
becoming blocked again from scar tissue that
grows around the stent.
Stent Placement
The illustration shows the placement of a stent in a
coronary artery with plaque buildup. Figure A shows
the deflated balloon catheter and closed stent inserted
into the narrowed coronary artery. The inset image on
figure A shows a cross-section of the artery with the
inserted balloon catheter and closed stent. In figure B,
the balloon is inflated, expanding the stent and
compressing the plaque to restore the size of the artery.
Figure C shows the stent-widened artery. The inset
image on figure C shows a cross-section of the
compressed plaque and stent-widened artery.
In some cases, plaque is removed during
angioplasty. In a procedure called
atherectomy (ath-er-EK-toe-me), a catheter
with a rotating shaver on its tip is inserted into
the artery to cut away plaque. Lasers also are
used to dissolve or break up the plaque. These
procedures are now rarely done because
angioplasty gives better results for most
patients.
Cardiac Catheterization
Cardiac catheterization (KATH-e-ter-i-ZA-
shun) is a medical procedure used to diagnose
and treat certain heart conditions. A long,
thin, flexible tube called a catheter is put into
a blood vessel in arm, groin (upper thigh), or
neck and threaded to heart. Through the
catheter, doctors can perform diagnostic tests
and treatments on the heart.
Sometimes a special dye is put into the
catheter to make the insides of the heart and
blood vessels show up on x-rays. The dye can
show whether a material called plaque (plak)
has narrowed or blocked any of coronary
arteries.
Plaque is made up of fat, cholesterol, calcium,
and other substances found in blood. The
buildup of plaque narrows the inside of the
arteries and, in time, may restrict blood flow
to your heart. When this happens, it’s called
coronary artery disease (CAD).
Blockages in the arteries also can be seen
using ultrasound during cardiac
catheterization. Ultrasound uses sound waves
to create detailed pictures of the heart’s blood
vessels.
Doctors may take samples of blood and heart
muscle during cardiac catheterization, as well
as do minor heart surgery.
Cardiologists usually perform cardiac
catheterization in a hospital. Patient can see
the procedure, and it causes little to no pain,
although he may feel some soreness in the
blood vessel where the doctor put the
catheter. Cardiac catheterization rarely causes
serious complications.
290
Needs of Cardiac Catheterization
Cardiac catheterization is used to diagnose
and/or treat various heart conditions. Doctors
may recommend this procedure for a number
of different reasons. The most common
reason is to evaluate chest pain. Chest pain
can be a symptom of coronary artery disease
(CAD), and cardiac catheterization can show
whether plaque is narrowing or blocking your
heart’s arteries.
CAD can be treated during cardiac
catheterization with a procedure called
angioplasty (AN-jee-oh-plas-tee). During
angioplasty, a tiny balloon is put through the
catheter and into the blocked artery. When the
balloon is inflated, it compresses the plaque
that has built up inside the artery. This creates
a wider pathway for blood to flow to the
heart. Sometimes a stent is placed in the
artery during angioplasty. A stent is a small
mesh tube that’s used to treat narrowed or
weakened arteries in the body.
Most people who have heart attacks have
partially or completely blocked coronary
arteries. Thus, cardiac catheterization may be
done on an emergency basis while patient
having a heart attack. When used with
angioplasty, the procedure allows the doctor
to open up blocked arteries and prevent more
damage to the heart.
Patient may have cardiac catheterization to
help the doctor figure out the best treatment
for CAD if he:
- Recently recovered from a heart attack, but
are having chest pain
- Had a heart attack that caused major damage
to the heart
- Had an EKG (electrocardiogram), stress test,
or other test with results that suggested heart
disease
A patient also may need cardiac
catheterization if the doctor suspects he has a
heart defect or has heart surgery. The
procedure shows the overall shape of your
heart and the four large spaces (heart
chambers) inside it. This inside view of the
heart will show certain heart defects and help
the doctor to plan heart surgery.
Sometimes the doctor may do a cardiac
catheterization to see how well the valves at
the openings and exits of the heart chambers
are working. Valves control the flow of blood
in the heart.
To evaluate the valves, your doctor will
measure blood flow and oxygen levels in
different parts of r heart. Cardiac
catheterization also can check how well an
artificial heart valve is working or how well
heart is pumping blood.
If the doctor thinks patient has a heart
infection or tumor, he or she may take
samples of heart muscle through the catheter.
With the help of cardiac catheterization,
doctors can even do minor heart surgery, such
as repair certain heart defects.
Expectation during Cardiac
Catheterization
During a cardiac catheterization, patient is
kept on back and awake. That way he can
follow the doctor’s instructions during the
procedure. Patient is given medicine to help
him relax, which may make him sleepy.
The doctor will numb the area on the arm,
groin (upper thigh), or neck where the small
plastic tube (catheter) will enter your blood
vessel. A needle is used to make a small hole
in the blood vessel. Through this hole the
doctor will put a tapered tube called a sheath.
Next, the doctor will put a thin, flexible wire
through the sheath and into the blood vessel.
This guide wire is then threaded through the
blood vessel to the heart. The wire helps the
doctor position the catheter correctly. The
doctor then puts a catheter through the sheath
and slides it over the guide wire and into the
coronary arteries.
Special x-ray movies are taken of the guide
wire and the catheter as they’re moved into
the heart. The movies help the doctor see
where to position the tip of the catheter. When
the catheter reaches the right spot, the doctor
then uses it to conduct tests or treatments. For
291
example, the doctor may perform angioplasty
and stenting.
During the procedure, the doctor may put a
special dye in the catheter. This dye will flow
through the bloodstream to the heart. Once
the dye reaches the heart, it will make the
inside of the heart’s arteries show up on an x
ray called an angiogram. The test is called
coronary angiography.
Coronary angiography can show how well
blood is being pumped out of the heart’s main
pumping chambers, which are called
ventricles (VEN-trih-kuls). An x-ray taken
when the dye is in the heart’s ventricles is
called a ventriculogram. (The procedure is
called ventriculography.) When the catheter is
inside the heart, the doctor may use it to take
blood samples from different parts of the
heart or to do minor heart surgery.
To get a more detailed view of a blocked
coronary artery, the doctor may do
intracoronary ultrasound. For this, the doctor
will thread a tiny ultrasound device through
the catheter and into the artery. This device
gives off ultrasound waves that bounce off the
artery wall (and its blockage) to make an
image of the inside of the artery.
If the angiogram or intracoronary ultrasound
shows blockages or other possible problems
in the heart’s arteries, the doctor may use
angioplasty to open up the blocked arteries.
After the doctor does all of the needed tests or
treatments, he or she will pull back the
catheter and take it out along with the sheath.
The opening left in the blood vessel will then
be closed up and bandaged. A small weight
may be put on top of the bandage for a few
hours to apply more pressure. This will help
prevent major bleeding from the site.
Cardiac CT
Cardiac computed tomography (to-MOG-rah-
fee), or cardiac CT, is a painless test that uses
an x-ray machine to take clear, detailed
pictures of the heart. It is a common test for
showing problems of the heart. During a
cardiac CT scan, the x-ray machine will move
around the body in a circle and take a picture
of each part of the heart.
Because an x-ray machine is used, cardiac CT
scans involve radiation. However, the amount
of radiation used is small. This test gives out a
radiation dose similar to the amount of
radiation a body naturally exposed to over 3
years. There is a very small chance that
cardiac CT will cause cancer.
Each picture that the machine takes shows a
small slice of the heart. A computer will put
the pictures together to make a large picture
of the whole heart. Sometimes an iodine-
based dye is injected into one of the veins
during the scan to help highlight blood vessels
and arteries on the x-ray images.
Overview
Cardiac CT is a common test for finding and
evaluating:
Problems in the heart: Iodine-based dye used
with a cardiac CT scan can show pictures of
the coronary arteries. The coronary arteries
are blood vessels on the surface of the heart.
If these blood vessels are narrowed or
blocked, the patient may have chest pain or a
heart attack. The CT scan also can find
problems with heart function and heart valves.
Problems with the aorta: The aorta is the
main artery that carries oxygen-rich blood
from the heart to the body. Cardiac CT can
detect two serious problems in the aorta:
Aneurysms, which are diseased areas of a
weak blood vessel wall that bulge out.
Aneurysms can be life threatening because
they can burst.
Dissections can occur when the layers of the
aortic artery wall peel away from each other.
This condition can cause pain and also may
be life threatening.
Blood clots in the lungs. A cardiac CT scan
also may be used to find a pulmonary
embolism, a serious but treatable condition. A
pulmonary embolism is a sudden blockage in
a lung artery, usually due to a blood clot that
traveled to the lung from the leg.
292
Pericardial disease: This is a disease that
occurs in the pericardium, a sac around heart.
Because the heart is in motion, a fast type of
CT scanner, called multi-detector computed
tomography (MDCT), is used to show high-
quality pictures of the heart.
Another type of CT scanner, called electron-
beam computed tomography (EBCT), is used
to detect calcium in the coronary arteries.
Calcium in the coronary arteries may be an
early sign of coronary artery disease (CAD).
CAD occurs when the coronary arteries (the
arteries that supply blood and oxygen to the
heart muscle) harden and narrow due to the
buildup of a material called plaque (plak) on
their inner walls. CAD is the leading cause of
death for both men and women in the United
States.
Researchers also are studying new ways to
use cardiac CT.
Other Names for Cardiac CT
CAT scan
Coronary CT angiography (an-je-OG-ra-fee)
Coronary artery scan
CT angiography (CTA)
Cardiac MRI
Magnetic resonance imaging (MRI) is a safe,
noninvasive test that creates detailed images
of the organs and tissues. “Noninvasive”
means that no surgery is done and no
instruments are inserted into the body.
MRI uses radio waves and magnets to create
images of the organs and tissues. Unlike
computed tomography (to-MOG-ra-fee) scans
(also called CT scans) or conventional x-rays,
MRI imaging does not use ionizing radiation
or carry any risk of causing cancer.
Cardiac MRI uses a computer to create
images of your heart as it is beating,
producing both still and moving pictures of
the heart and major blood vessels. Doctors
use cardiac MRI to get images of the beating
heart and to look at the structure and function
of the heart. These images can help them
decide how best to treat patients with heart
problems.
Cardiac MRI is a common test for diagnosing
and evaluating a number of diseases and
conditions, including:
Coronary artery disease
Damage caused by a heart attack
Heart failure
Heart valve problems
Congenital heart defects
Pericardial disease (a disease that affects the
tissues around the heart)
Cardiac tumors
Cardiac MRI images can help explain results
from other tests, such as x-ray and CT scans.
Cardiac MRI is sometimes used to avoid the
need for other tests that use radiation (such as
x-rays), invasive procedures, and dyes
containing iodine (these dyes may be harmful
to people who have kidney problems).
Sometimes during cardiac MRI, a special dye
is injected into a vein to help highlight the
heart or blood vessels on the images. Unlike
the case with x-rays, the special dyes used for
MRI do not contain iodine, so they do not
present a risk to people who are allergic to
iodine or have kidney problems.
Other Names for Cardiac MRI
Heart MRI
Cardiovascular MRI
Cardiac nuclear magnetic resonance (NMR)
Carotid Ultrasound
Carotid (ka-ROT-id) ultrasound is a painless
and harmless test that uses high-frequency
sound waves to create images of the insides of
the two large arteries in neck. These arteries,
called carotid arteries, supply brain with
blood. One carotid artery present on each side
of the neck.
Carotid ultrasound shows whether a material
called plaque (plak) has narrowed the carotid
arteries. Plaque is made up of fat, cholesterol,
calcium, and other substances found in the
blood. It builds up on the insides of the
arteries as age.
Too much plaque in a carotid artery can cause
a stroke. The plaque can slow down or block
the flow of blood through the artery, allowing
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a blood clot to form. A piece of the blood clot
can break off and get stuck in the artery,
blocking blood flow to the brain. This is what
causes a stroke.
A standard carotid ultrasound shows the
structure of the carotid artery. The carotid
ultrasound test may include a Doppler
ultrasound. Doppler ultrasound is a special
ultrasound that shows the movement of blood
through your blood vessels. The doctor often
will need results from both types of
ultrasound to fully assess if there is a problem
with blood flow through carotid arteries.
Other Names for Carotid Ultrasound
Doppler ultrasound
Carotid duplex ultrasound
Catheter Ablation
Catheter ablation (ab-LA-shun) is a medical
procedure used to treat some arrhythmias (ah-
RITH-me-ahs). An arrhythmia is a problem
with the speed or rhythm of the heartbeat.
During catheter ablation, a long, thin, flexible
tube is put into a blood vessel in arm, groin
(upper thigh), or neck. This tube is called an
ablation catheter. It’s then guided to your
heart through the blood vessel. A special
machine sends energy through the catheter to
the heart. This energy finds and destroys
small areas of heart tissue where abnormal
heartbeats may cause an arrhythmia to start.
Overview
The heart’s electrical system controls the
speed and rhythm of the heartbeat. With each
heartbeat, an electrical signal spreads from the
top of the heart to the bottom. As it travels,
the electrical signal causes the heart to
contract and pump blood.
The process repeats with each new heartbeat.
A problem with any part of this process can
cause an arrhythmia.
Catheter ablation is one of several treatments
for arrhythmia. The doctor may recommend it
if:
- The medicines do not control arrhythmia.
- Can not tolerate the medicines the doctor
has prescribed for arrhythmia.
- Certain types of arrhythmia, such as Wolff-
Parkinson-White syndrome.
Though few, catheter ablation has risks.
These include bleeding, infection, and pain
where the catheter is inserted. More serious
problems include blood clots and puncture of
the heart. The doctor will explain the risks
topatient.
Cardiologists (doctors who specialize in
treating people with heart problems)
sometimes perform ablation through open-
heart surgery. But this method is not as
common as catheter ablation, which does not
require surgery to open the chest cavity.
Outlook
Catheter ablation alone does not always
restore a normal heart rate and rhythm. Other
treatments may need to be used as well. Also,
some people who have the procedure may
need to have it done again. This can happen
when the first procedure does not fully correct
the problem.
Other Names for Catheter Ablation
Ablation
Cardiac ablation
Cardiac catheter ablation
Radiofrequency ablation
Catheter cryoblation
Coronary Angiography
Coronary angiography (an-jee-OG-ra-fee) is a
test that uses dye and special x-rays to show
the inside of coronary arteries. The coronary
arteries supply blood and oxygen to the heart.
A material called plaque (plak) can build up
on the inside walls of the coronary arteries
and cause them to narrow. When this
happens, it’s called coronary artery disease
(CAD). CAD can prevent enough blood from
flowing to your heart and can lead to angina
(an-JI-nuh or AN-juh-nuh) (chest discomfort
or pain) and heart attack. Coronary
angiography shows if you have CAD.
Most of the time, the coronary arteries can not
be seen on an x-ray. During coronary
angiography, a special dye is injected into the
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bloodstream to make the coronary arteries
show up on an x-ray.
To deliver the dye to the coronary arteries, a
procedure called cardiac catheterization
(KATH-e-ter-i-ZA-shun) is used. A long,
thin, flexible tube called a catheter is put into
a blood vessel in your arm, groin (upper
thigh), or neck. The tube is then threaded into
the coronary arteries, and the dye is injected
into the bloodstream. Special x-rays are taken
while the dye is flowing through the coronary
arteries. Cardiac catheterization rarely causes
serious complications
Coronary Artery Bypass Grafting
Coronary artery bypass grafting (CABG) is a
type of surgery called revascularization (re-
VAS-kyu-lar-i-ZA-shun), used to improve
blood flow to the heart in people with severe
coronary artery disease (CAD).
CAD occurs when the arteries that supply
blood to the heart muscle (the coronary
arteries) become blocked due to the buildup
of a material called plaque (plak) on the
inside of the blood vessels. If the blockage is
severe, chest pain also called angina,
shortness of breath, and, in some cases, heart
attack can occur.
CABG is one treatment for CAD. During
CABG, a healthy artery or vein from another
part of the body is connected, or grafted, to
the blocked coronary artery. The grafted
artery or vein bypasses (that is, it goes
around) the blocked portion of the coronary
artery. This new passage routes oxygen-rich
blood around the blockage to the heart
muscle. As many as four major blocked
coronary arteries can be bypassed during one
surgery.
Overview
CABG is the most common type of open-
heart surgery in the United States, with more
than 500,000 surgeries performed each year.
Doctors called cardiothoracic (KAR-de-o-tho-
RAS-ik) surgeons perform this surgery.
CABG is not used for everyone with CAD.
Many people with CAD can be treated by
other means, such as lifestyle changes,
medicines, and another revascularization
procedure called angioplasty.
CABG may be an option if you have severe
blockages in the large coronary arteries that
supply a major part of the heart muscle with
blood—especially if the heart’s pumping
action has already been weakened.
CABG may also be an option if a patient has
blockages in the heart that can not be treated
with angioplasty. In these situations, CABG is
considered more effective than other types of
treatment.
The goals of CABG surgery are:
- Improve quality of life and decrease angina
and other symptoms of CAD
- Resume a more active lifestyle
- Improve the pumping action of the heart if it
has been damaged by a heart attack
- Lower the chances of a heart attack (in some
patients, such as those with diabetes)
- Improve your chance of survival
Repeat surgery may be needed if grafted
arteries or veins become blocked, or if new
blockages develop in arteries that were not
blocked before. Taking medicines as
prescribed and making lifestyle changes that
the doctor recommends can lower the chance
of a graft becoming blocked.
In people who are candidates for the surgery,
the results are usually excellent, with 85
percent of people having significantly reduced
symptoms, less risk for future heart attacks,
and a decreased chance of dying within 10
years following the surgery.
Types of Coronary Artery Bypass Grafting
Traditional Coronary Artery Bypass Grafting
This is the most common type of coronary
artery bypass grafting (CABG). It is used
when at least one major artery needs to be
bypassed. During the surgery, the chest bone
is opened to access the heart. Medicines are
given to stop the heart, and a heart-lung
machine is used to keep blood and oxygen
moving throughout the body during surgery.
This allows the surgeon to operate on a still
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heart. After surgery, the heart is restarted
using mild electric shocks.
Off-Pump Coronary Artery Bypass
Grafting
This type of CABG is similar to traditional
CABG in that the chest bone is opened to
access the heart. However, the heart is not
stopped, and a heart-lung machine is not used.
Off-pump CABG is sometimes called beating
heart bypass grafting. This type of surgery
may reduce complications that can occur
when a heart-lung machine is used, and it may
speed up recovery time after surgery.
Minimally Invasive Direct Coronary
Artery Bypass Grafting
This surgery is similar to off-pump, but
instead of a large incision to open the chest
bone, several small incisions are made on the
left side of the chest between the ribs. This
type of surgery is used mainly for bypassing
the vessels in front of the heart. It’s a fairly
new procedure, which is performed less often
than the other types. This type of surgery is
not for everybody, especially if more than one
or two coronary arteries need to be bypassed.
Other Names for Coronary Artery Bypass
Grafting
Bypass surgery
Coronary artery bypass surgery
Heart bypass surgery
Coronary Calcium Scan
A coronary calcium scan is a test that can help
show whether the patient has coronary artery
disease (CAD) or not. In CAD, a fatty
material called plaque (plak) narrows the
coronary arteries and limits blood flow to the
heart. CAD is the most common type of heart
disease in both men and women. It can lead to
angina, heart attack, heart failure, and
arrhythmia.
Coronary calcium scanning looks for specks
of calcium (called calcifications) in the walls
of the coronary arteries. Calcifications are an
early sign of heart disease. The test can show,
before other signs and symptoms occur,
whether the patient is at increased risk for a
heart attack or other heart problems.
A coronary calcium scan is most useful for
people who are at moderate risk for a heart
attack. Doctor can calculate 10-years risk
using the Risk Assessment Tool from the
National Cholesterol Education Program.
People at moderate risk have a 10 to 20
percent chance of having a heart attack within
the next 10 years. The coronary calcium scan
helps doctors decide who within this group
needs treatment.
Two machines can show calcium in the
coronary arteries—electron beam computed
tomography (EBCT) and multi-detector
computed tomography (MDCT). Both use an
x-ray machine to make detailed pictures of the
heart. Doctors study the pictures to see
whether the patient is at risk for heart
problems in the next 2 to 10 years.
A coronary calcium scan is simple and easy
for the patient, who lies quietly in the scanner
machine for about 10 minutes. Pictures of the
heart are taken that show whether the
coronary arteries have calcifications.
Coronary Calcium Scan
Figure A shows the position of the heart in the body
and the location and angle of the coronary calcium scan
image. Figure B is the coronary calcium scan image
showing calcification in a coronary artery.
Other Names for Coronary Calcium Scans
Calcium scan test
Cardiac CT for calcium scoring
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Sometimes people refer to a coronary calcium
scan by the name of the machine used to take
pictures of the heart:
Electron-beam computed tomography (EBCT)
or electron-beam tomography (EBT)
Multidetector computed tomography (MDCT)
Echocardiography
Echocardiography (EK-o-kar-de-OG-ra-fee)
is a painless test that uses sound waves to
create images of the heart. It provides the
doctor with information about the size and
shape of the heart and how well heart’s
chambers and valves are working.
The test also can identify areas of heart
muscle that are not contracting normally due
to poor blood flow or injury from previous
heart attack(s). In addition, a type of
echocardiography called Doppler ultrasound
shows how well blood flows through the
chambers and valves of the heart.
Echocardiography can detect possible blood
clots inside the heart, fluid buildup in the sac
around the heart (pericardium), and problems
with the aorta (the main artery that carries
oxygen-rich blood out of the heart).
Needs Echocardiography
Doctor may recommend echocardiography if
some body is suffering from signs and
symptoms of heart problems. For example,
symptoms such as shortness of breath and
swelling in the legs can be due to weakness of
the heart (heart failure), which can be seen on
an echocardiogram.
Doctors also use echocardiography to provide
information on:
The size of your heart: An enlarged heart can
be the result of high blood pressure, leaky
heart valves, or heart failure.
Heart muscles that are weak and aren’t
moving (pumping) properly: Weakened areas
of heart muscle can be due to damage from a
heart attack. Or weakening could mean that
the area isn’t getting enough blood supply,
which can be due to coronary artery disease.
Problems with your heart’s valves:
Echocardiography can show whether any of
the valves of your heart don’t open normally
or don’t form a complete seal when closed.
Abnormalities in the structure of your heart:
Echocardiography can detect a variety of
heart abnormalities, such as a hole in the
septum (the wall that separates the two
chambers on the left side of the heart from the
two chambers on the right side) and other
congenital heart defects (structural problems
present at birth).
The aorta: Echocardiography is commonly
used to assess and detect problems with the
aorta such as aneurysm (abnormal bulge or
“ballooning” in the wall of an artery).
Blood clots or tumors: If a patient has had a
stroke, echocardiography might be done to
check for blood clots or tumors that may have
caused it.
Doctors also use echocardiography to see how
well the heart responds to certain heart
treatments, such as treatment for heart failure.
Types of Echocardiography
There are several different types of
echocardiography—all use sound waves to
create images your heart. This is the same
technology that allows doctors to see an
unborn baby inside a pregnant mother. Unlike
x rays and some other tests, echocardiography
does not involve radiation.
Transthoracic Echocardiography
Transthoracic (tranz-thor-AS-ik)
echocardiography is the most common type of
echocardiogram test. It’s painless and
noninvasive. “Noninvasive” means that no
surgery is done and no instruments are
inserted into your body.
This type of echocardiography involves
placing a device called a transducer on your
chest that sends special sound waves, called
ultrasound, through your chest wall to your
heart. Ultrasound waves can not be heard by
the human ear. As the ultrasound waves
bounce off the structures of the heart, a
computer in the echocardiography machine
converts them into pictures on a screen.
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Stress Echocardiography
This is an echocardiography test that’s done
as part of a cardiac stress test. During a
cardiac stress test, the patient exercise or take
medicine (given by the doctor) to make the
heart pump harder and beat faster. Some heart
problems, such as coronary artery disease, are
easier to diagnose when the heart is beating
fast and pumping hard.
Transesophageal Echocardiography
With standard transthoracic
echocardiography, it can be difficult to see the
aorta and certain other parts of the heart. If
the doctor needs a better look at these areas,
he or she may recommend transesophageal
(tranz-ih-sof-uh-JEE-ul) echocardiography.
In this test, the transducer is attached to the
end of a flexible tube that’s guided down
throat and into esophagus (the tube leading
from mouth to stomach) to get a more
detailed image of the heart.
Fetal Echocardiography
This type of echocardiography is used to look
at an unborn baby’s heart. A doctor may
recommend this test to check the baby for
heart problems. Fetal echocardiography is
commonly performed during pregnancy at
about 18 to 22 weeks.
Other Names for Echocardiography
Ultrasound of the heart
Echo
Surface echo
Electrocardiogram
An electrocardiogram, also called an EKG or
ECG, is a simple test that detects and records
the electrical activity of the heart. It is used to
detect and locate the source of heart
problems.
Electrical signals in the heart trigger
heartbeats. These signals start at the top of the
heart in an area called the right atrium. The
electrical signals travel from the top of the
heart to the bottom. They cause the heart
muscle to contract as they travel through the
heart. As the heart contracts, it pumps blood
out to the rest of the body.
An EKG shows how fast the heart is beating.
It shows the heart’s rhythm (steady or
irregular) and where in the body the heartbeat
is being recorded. It also records the strength
and timing of the electrical signals as they
pass through each part of the heart.
An EKG is sometimes called a 12-lead EKG
(or 12-lead ECG) because the electrical
activity of the heart is most often recorded
from 12 different places on the body at the
same time.
EKG Reveals
Many heart problems change the electrical
signature of the heart in distinct ways. EKG
recordings of this electrical activity can help
reveal a number of heart problems, including:
Heart attack
Lack of blood flow to the heart muscle
A heart that is beating irregularly, or too fast
or too slow
A heart that does not pump forcefully enough
EKG recordings can help doctors diagnose a
heart attack that is happening now or has
happened in the past. This is especially true if
doctors can compare a current EKG recording
to an older one. EKG recordings can also
reveal:
Heart muscle that is too thick or parts of the
heart that is too big
Birth defects in the heart
Disease in the heart valves between the
different heart chambers
An EKG also reveals whether the heartbeat
starts at the top right part of the heart like it
should. It shows how long it takes for the
electrical signals to travel through the heart.
Heart Transplant
A heart transplant is an operation in which the
diseased heart in a person is replaced with a
healthy heart from a deceased donor. Ninety
percent of heart transplants are performed on
patients with end-stage heart failure.
Heart failure is a condition in which the heart
is damaged or weakened and can not pump
enough blood to meet the body's needs. "End-
stage" means the condition has become so
298
severe that all treatments, other than heart
transplant, have failed.
Overview
Heart transplants are done as a life-saving
measure for end-stage heart failure when
medical treatment and less drastic surgery
have failed. Because donor hearts are in short
supply, patients who need a heart transplant
go through a careful selection process. They
need to be sick enough to need a new heart,
yet healthy enough to receive it.
Survival rates for people receiving a heart
transplant have improved over the past
5 to 10 years—especially in the first year after
the transplant. About 88 percent of patients
survive the first year after transplant surgery,
and 72 percent survive for
5 years. The 10-year survival rate is close to
50 percent, and 16 percent of heart transplant
patients survive 20 years.
After the surgery, most heart transplant
recipients (about 90 percent) can come close
to resuming their normal daily activities.
However, fewer than 40 percent return to
work for many different reasons.
The Heart Transplant Process
The heart transplant process starts when
doctors refer patients with end-stage heart
failure to a heart transplant center for
evaluation. Patients found to be eligible for a
heart transplant are placed on a waiting list
for a donor heart.
Heart transplant surgery is done in a hospital
when a suitable donor heart is found. After
the transplant, patients are started on a
lifelong health care plan involving multiple
medicines and frequent medical monitoring.
Implantable Cardioverter Defibrillator
An implantable cardioverter defibrillator
(ICD) is a small device that is placed in the
chest or abdomen. This device uses electrical
pulses or shocks to help control life-
threatening, irregular heartbeats, especially
those that could lead the heart to suddenly
stop beating (sudden cardiac arrest). If the
heart stops beating, blood stops flowing to the
brain and other vital organs. This usually
causes death if it's not treated in minutes.
The Heart's Electrical System
Heart has its own internal electrical system
that controls the speed and rhythm of
heartbeat. With each heartbeat, an electrical
signal spreads from the top of the heart to the
bottom. As it travels, the electrical signal
causes the heart to contract and pump blood.
Electrical signals normally begin in a group of
cells called the sinus node. As these signals
spread from the top to the bottom of the heart,
they coordinate the timing of heart cell
activity. First, the two upper chambers of the
heart, called atria (AY-tree-uh), contract. This
contraction squeezes blood into the lower
chambers of the heart, which are called
ventricles (VEN-trih-kuls). The ventricles
then contract and send blood to the rest of the
body. The combined contraction of the atria
and ventricles is a heartbeat.
A problem with any part of the electrical
system process can cause irregular heartbeats
called arrhythmias (ah-RITH-me-ahs). During
an arrhythmia, the heart can beat too fast, too
slow, or with an irregular rhythm. Faulty
electrical signaling in the heart causes
arrhythmias.
ICDs use electrical pulses or shocks to treat
life-threatening arrhythmias that occur in the
ventricles (lower chambers of the heart).
When these ventricular arrhythmias occur, the
heart can not effectively pump blood, and a
person will pass out within seconds and die
within minutes if not treated. To prevent
death, the condition must be treated right
away with an electric shock to the heart. This
treatment is called defibrillation.
An ICD has wires with electrodes on the ends
that connect to the chambers of your heart.
The ICD will continually monitor your heart
rhythm. When the device detects that patient
is having an irregular rhythm in the ventricles,
the ICD will use low-energy electrical pulses
to restore a normal rhythm. If this does not
restore normal heart rhythm, or if ventricles
299
start to quiver rather than contract strongly,
the ICD will switch to high-energy electrical
pulses for defibrillation.
Doctors also treat irregular heartbeats with
another device called a pacemaker. An ICD is
similar to a pacemaker, but there are some
differences. Pacemakers can only give off
low-energy electrical pulses. They are often
used to treat less dangerous heart rhythms,
such as those that occur in the upper
chambers of your heart. Most new ICDs can
act as both pacemakers and ICDs.
Comparison of an Implantable Cardioverter
Defibrillator and a Pacemaker
The illustration compares an implantable cardioverter
defibrillator and a pacemaker. Figure A shows the
location and general size of an implantable cardiac
defibrillator in the upper chest. The wires with
electrodes on the ends are inserted into the heart
through a vein in the upper chest. Figure B shows the
location and general size of a double-electrode
pacemaker in the upper chest. The wires with
electrodes on the ends are inserted into the heart
through a vein in the upper chest.
Patient may need an implantable cardioverter
defibrillator (ICD) if he is at risk for certain
life-threatening ventricular arrhythmias, such
as ventricles that beat too fast or that quiver.
For example, he may be considered at high
risk for a ventricular arrhythmia if he:
- Has had a ventricular arrhythmia before
- Has had a heart attack that has damaged the
electrical system in your ventricles
An ICD is often recommended for people
who have survived sudden cardiac arrest.
The doctor may recommend an ICD if he or
she sees signs of a ventricular arrhythmia (or
heart damage that would make one likely) on
the following tests.
Electrocardiogram
This simple and painless test detects and
records the electrical activity of the heart. An
EKG (electrocardiogram) shows how fast the
heart is beating and the heart's rhythm (steady
or irregular). It also records the strength and
timing of electrical signals as they pass
through each part of the heart.
Holter Monitor
A Holter monitor, also called an ambulatory
EKG, records the electrical signals of heart
for a full 24- or 48-hour period. The patient
wears small patches called electrodes on chest
that are connected by wires to a small,
portable recorder. The recorder can be clipped
to a belt, kept in a pocket, or hung around the
neck.
During the 24 or 48 hours, the do his/her
usual daily activities and keep a notebook,
writing down any symptoms he/she has and
the time they occur. Then return both the
recorder and the notebook to the doctor to
read the results. The doctor can see how the
heart was beating at the time he/she had
symptoms.
The purpose of a Holter monitor is to record
heart signals during typical daily activities
and while sleeping, and to find heart problems
that may occur for only a few minutes out of
the day. Also, the Holter monitor can pick up
irregular heartbeats that do not cause
symptoms, but are important to treat.
Echocardiogram
This test uses sound waves to create a moving
picture of heart. An echocardiogram provides
information about the size and shape of heart
and how well heart chambers and valves are
working. The test also can identify areas of
poor blood flow to the heart, areas of heart
muscle that are not contracting normally, and
injury to the heart muscle caused by poor
blood flow.
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Electrophysiology Study
For an electrophysiology study, the doctor
threads a catheter (a small, flexible tube) from
a blood vessel in the arm or leg up to heart.
Through the catheter, the doctor gives certain
medicines and electrically stimulates heart to
see how the heart's electrical system responds.
The electrical stimulation helps to find where
the heart's electrical system is damaged.
Stress Test
Some heart problems are easier to diagnose
when heart is working harder and beating
faster than when it is at rest. During stress
testing, patient exercise (or are given
medicine if he/she is unable to exercise) to
make heart work harder and beat faster while
heart tests, such as an EKG or
echocardiogram, are performed.
Implantable Cardioverter Defibrillator
Work
An implantable cardioverter defibrillator
(ICD) has wires with electrodes on the ends
that connect to one or more of heart's
chambers. These wires monitor heart rhythm.
They also deliver high- or low-energy
electrical pulses to the heart when it beats
abnormally.
Single-chamber ICDs have wires that connect
to one or both of the ventricles. These ICDs
correct faulty electrical signaling within the
ventricles. Dual-chamber ICDs have wires
that connect to both an upper heart chamber
(atrium) and a ventricle. These ICDs correct
faulty electrical signaling between the two
chambers.
The wires on an ICD connect to a small metal
box implanted in the chest or abdomen that
contains a battery, pulse generator, and
computer. The computer triggers the ICD's
pulse generator to send electrical pulses when
it detects irregular rhythms. Wires carry these
pulses to the heart.
The ICD also can record the heart's electrical
activity and heart rhythms. The recordings
can help the doctor fine-tune the
programming of ICD so it works better to
correct irregular heartbeats.
Whether patient receive a single-chamber or
dual-chamber ICD is based on heart's
pumping abilities, structural defects, and the
type of irregular heartbeats the patient had.
Whichever type of ICD receive, it will be
programmed to respond to the type of
irregular heart rhythm the patient most likely
to have.
Nuclear Heart Scan
A nuclear heart scan is a type of medical test
that allows the doctor to get important
information about the health of the heart.
During a nuclear heart scan, a safe,
radioactive material called a tracer is injected
through a vein into the bloodstream. The
tracer then travels to the heart. The tracer
releases energy, which special cameras
outside of the body detect. The cameras use
the energy to create pictures of different parts
of the heart.
Nuclear heart scans are used for three main
purposes:
- To provide information about the flow of
blood throughout the heart muscle. If the scan
shows that one part of the heart muscle is not
receiving blood, it is a sign of a possible
narrowing or blockage in the coronary
arteries. Decreased blood flow through the
coronary arteries may mean coronary artery
disease (CAD). CAD can lead to angina, heart
attack, and other heart problems. When a
nuclear heart scan is performed for this
purpose, it is called myocardial perfusion
scanning.
- To look for damaged heart muscle. Damage
may be due to a previous heart attack, injury,
infection, or medicine. When a nuclear heart
scan is performed for this purpose, it is called
myocardial viability testing.
- To see how well heart pumps blood out to
the body. When a nuclear heart scan is
performed for this purpose, it’s called
ventricular function scanning.
301
Usually, two sets of pictures are taken during
a nuclear heart scan. The first set is taken
when the heart is beating fast due to
exercising. This is called a cardiac stress test.
If can not exercise, the heart rate can be
increased using medicines such as adenosine,
dipyridamole, or dobutamine.
The second set of pictures is taken later, when
the heart is at rest and beating at a normal
rate.
Types of Nuclear Heart Scanning
There are two main types of nuclear heart
scanning:
Single positron emission computed
tomography (SPECT)
Cardiac positron emission tomography (PET)
SPECT is the most well-established and
widely used type, while PET is newer. There
are specific reasons for using each, which are
discussed in the following paragraphs.
Single Positron Emission Computed
Tomography
Cardiac SPECT is the most commonly used
nuclear scanning test for diagnosing coronary
artery disease (CAD). Combining SPECT
with a cardiac stress test can show problems
with blood flow to the heart that can be
detected only when the heart is working hard
and beating fast.
SPECT also is used to look for areas of
damaged or dead heart muscle tissue, which
may be due to a previous heart attack or other
cause of injury.
SPECT also can show how well the heart’s
left ventricle pumps blood to the body. Weak
pumping ability may be the result of heart
attack, heart failure, and other causes.
The most commonly used tracers in SPECT
are called thallium-201, technetium-99m
sestamibi (Cardiolite®), and technetium-99m
tetrofosmin (Myoview™).
Positron Emission Tomography
PET uses different kinds of tracers than
SPECT. PET can provide more detailed
pictures of the heart. However, PET is newer
and has some technical limits that make it less
available than SPECT. Research into
advances in both SPECT and PET is ongoing.
Right now, there is no clear cut advantage of
using one over the other in all situations.
PET can be used for the same purposes as
SPECT—to diagnose CAD, check for
damaged or dead heart muscle, and evaluate
the heart's pumping strength.
PET takes a clearer picture through thick
layers of tissue (such as abdominal or breast
tissue). PET also is better than SPECT at
showing whether CAD is affecting more than
one of heart's blood vessels. A PET scan also
may be used if a SPECT scan was not able to
produce good enough pictures.
Other Names for Nuclear Heart Scans
Names used for nuclear heart scans:
Nuclear stress test
SPECT scan
PET scan
Pacemaker
A pacemaker is a small device that is placed
under the skin of chest or abdomen to help
control abnormal heart rhythms. This device
uses electrical pulses to prompt the heart to
beat at a normal rate.
Pacemakers are used to treat heart rhythms
that are too slow, fast, or irregular. These
abnormal heart rhythms are called
arrhythmias (ah-RITH-me-ahs). Pacemakers
can relieve some symptoms related to
arrhythmias, such as fatigue (tiredness) and
fainting. A pacemaker can help a person who
has an abnormal heart rhythm resume a more
active lifestyle.
Overview
Faulty electrical signaling in the heart causes
arrhythmias. A pacemaker uses low-energy
electrical pulses to correct faulty electrical
signaling. Pacemakers can:
- Speed up a slow heartbeat
- Help end an abnormal and fast rhythm (only
in implantable cardioverter defibrillator/
pacemaker combination devices)
- Make sure the ventricles contract normally
if the atria are quivering instead of beating
302
in a normal rhythm (a condition called
atrial fibrillation)
- Coordinate the electrical signaling between
the upper and lower chambers of the heart
- Coordinate the electrical signaling between
the ventricles (cardiac resynchronization
therapy used in heart failure)
Pacemakers also can monitor and record the
heart's electrical activity and the rhythm of
heartbeat. Newer pacemakers can monitor
blood temperature, breathing rate, and other
factors and adjust heart rate to changes in
activity.
Pacemakers can be temporary or permanent.
Temporary pacemakers are used to treat
temporary heartbeat problems, such as a slow
heartbeat due to heart attack, heart surgery, or
an overdose of medicine. Temporary
pacemakers are used in emergencies until a
permanent pacemaker can be implanted or
until the temporary condition goes away. A
person with a temporary pacemaker will stay
in the hospital as long as the pacemaker is in
place.
In this article, "pacemakers" refers to
permanent devices, unless stated otherwise.
Doctors also treat arrhythmias with another
device called an implantable cardioverter
defibrillator (ICD). An ICD is like a
pacemaker in some ways, but it can use
higher energy electrical pulses to treat certain
dangerous types of arrhythmia.
Stent
A stent is a small mesh tube that is used to
treat narrowed or weakened arteries in the
body.
In angioplasty a patient may have a stent
placed in an artery as part of a procedure
called angioplasty (AN-jee-oh-plas-tee).
Angioplasty can restore blood flow through
narrowed or blocked arteries. Stents help
prevent arteries from becoming narrowed or
blocked again in the months or years after
treatment with angioplasty. A stent placed in
a weakened artery to improve blood flow and
to help prevent the artery from bursting.
Stents are usually made of metal mesh, but
sometimes they are made of fabric. Fabric
stents, also called stent grafts, are used in
larger arteries. Some stents are coated with
medicines that are slowly and continuously
released into the artery. These medicines help
prevent the artery from becoming blocked
again.
Stents use
Stents for Arteries in the Heart
With age and some health conditions, the
inside openings of the coronary arteries tend
to narrow due to deposits of a fatty substance
called plaque (plak). High cholesterol,
diabetes, and smoking can cause the arteries
to narrow. This narrowing of the coronary
arteries can cause angina (chest pain) or lead
to heart attack.
During angioplasty, doctors use an expanding
balloon inside the artery to compress the
plaque and widen the passageway. The result
is improved blood flow to the heart and a
decreased chance of heart attack.
Unless an artery is too small, doctors usually
place a stent in the treated portion of the
artery during angioplasty. The stent supports
the inner artery wall and reduces the chance
of the artery closing up again. A stent also can
keep an artery open that was torn or injured
during angioplasty.
When stents are placed in coronary arteries,
there is a 1 in 5 chance that the arteries will
close in the first 6 months after angioplasty.
When stents are not used, the risk of the
arteries closing can be twice as high.
Stents for the Carotid Arteries in the Neck
Both the right and left sides of neck have
blood vessels called carotid (ka-ROT-id)
arteries. These arteries carry blood from the
heart to the brain. Carotid arteries can become
narrowed by plaque. These plaque deposits
limit blood flow to the brain and increase risk
for stroke. The chance of developing plaque
in carotid arteries increases with age, and may
increase with smoking.
303
A new procedure uses stents to help keep the
carotid arteries fully open after they are
widened with angioplasty. Not all hospitals
offer this procedure. How effective it is long
term is still not known. The National Institute
of Neurological Disorders and Stroke
supports clinical studies to explore the risks
and benefits of angioplasty and stenting of
carotid arteries.
Stents for other Arteries
The arteries in the kidneys also can become
narrowed. This reduces blood flow to the
kidneys, which can affect their ability to
control blood pressure. This can cause severe
high blood pressure.
The arteries in the arms and legs also can
narrow with plaque over time. This narrowing
can cause pain and cramping in the affected
limbs. If the narrowing is severe, it can
completely cut off the blood flow to a limb,
which could require surgical treatment.
To relieve these problems, doctors may
perform angioplasty on the narrowed kidney,
arm, or leg arteries. This procedure often is
followed by placing a stent in the treated
artery. The stent helps keep the artery fully
open.
Stents for the Aorta in the Abdomen or
Chest
The major artery coming out of the heart and
supplying blood to the body is called the
aorta. The aorta travels through the chest and
then down into the abdomen. Over time, some
areas of the walls of the aorta can become
weak. These weakened areas can cause a
bulge in the artery called an aneurysm.
An aorta with an aneurysm can burst, leading
to potentially deadly internal bleeding. When
aneurysms occur, they are usually in the part
of the aorta in the abdomen. To help avoid a
burst, doctors place a fabric stent in the
weakened area of the abdominal aorta. The
stent creates a stronger inner lining for the
artery.
Aneurysms also can develop in the part of the
aorta in the chest. These aneurysms also can
be treated with stents. But this new use of
stents is not offered by all hospitals, and how
effective it is long term is still not known.
Stents to close off Aortic Tears
Another problem that can develop in the aorta
is a tear in the inside wall. Blood can be
forced into this tear, causing it to widen and
eventually block blood flow through the
artery or burst. When this occurs, it is usually
in the part of the aorta that is in the chest.
Fabric stents are being developed and used
experimentally to prevent aortic dissection by
stopping blood from flowing into the tear.
Tears in the aorta reduce blood flow to the
tissues the aorta serves. A fabric stent placed
within the torn area of the artery can help
restore normal blood flow and reduce the risk
of a burst aorta. Stents to treat aortic tears are
still being researched. Only a few hospitals
offer this procedure.
Stress Testing
Stress testing provides the doctor with
information about how heart works during
physical stress. Some heart problems are
easier to diagnose when heart is working hard
and beating fast. During a stress test, exercise
(walk or run on a treadmill or pedal a bicycle)
or are given a medicine to make the heart
work harder while heart tests are performed.
During these tests, heart is monitored using
images or through dime-sized electrodes
attached to chest, arms, or legs. The patient
may be asked to breathe into a special tube
during the test. This will allow the doctor to
see how well are breathing.
The patient may have arthritis or another
medical problem that prevents from
exercising during a stress test. If so, the
doctor can give medicine that makes heart
work harder, as it would exercise. This is
called a pharmacological stress test.
Overview
Doctors usually use stress testing to help
diagnose coronary artery disease (CAD) or to
see how serious this disease is in those who
are known to have it. It is sometimes used to
304
assess other problems such as heart valve
abnormalities or heart failure.
CAD occurs when the arteries that supply
blood to the heart muscle (the coronary
arteries) become hardened and narrowed with
a material called plaque (plak). Plaque is
made up of fat, cholesterol, calcium, and
other substances found in the blood. Plaque
builds up on the insides of the arteries,
narrowing them and restricting blood flow to
heart.
A patient may not have any signs or
symptoms of CAD when heart is at rest. But
when the heart has to work harder during
exercise, it needs more blood and oxygen, and
narrowed arteries are not able to supply
enough blood for the heart to work well.
Thus, the signs and symptoms may occur only
during exercise.
A stress test can detect the following
indications that the heart may not be getting
enough blood during exercise.
- Abnormal changes in the heart rate or blood
pressure
- Symptoms such as shortness of breath or
chest pain
- Abnormal changes in heart rhythm or the
electrical activity of the heart
During the stress test, if a patient can not
exercise for as long as what is considered
normal for someone your age, it may be a
sign that not enough blood is flowing to the
heart. But other factors besides CAD can
prevent from exercising long enough (for
example, lung diseases, anemia, or poor
general fitness).
Stress Testing Using Imaging
Some stress tests take pictures of the heart
when is in exercise and when at rest. These
imaging stress tests can show how well blood
is flowing in the different parts of the heart
and/or how well heart squeezes out blood
when it beats
One type of imaging stress test involves
echocardiography, which is a test that uses
sound waves to create a moving picture of the
heart. An echocardiogram stress test can show
how well heart’s chambers and valves are
working when heart is under stress. The test
can identify areas of poor blood flow to heart,
dead heart muscle tissue, and areas of the
heart muscle wall that are not contracting
normally. These areas may have been
damaged during a heart attack or may be
getting too little blood.
Other imaging stress tests use a radioactive
dye to create images of the blood flow to your
heart. The dye is injected into your
bloodstream before pictures are taken of the
heart. The pictures show how much of the dye
has reached various parts of your heart during
exercise and at rest.
Tests that use a radioactive dye include a
thallium or sestamibi stress test and a positron
emission tomography (PET) stress test. The
amount of radiation in the dye is safe and not
a danger to patient or those around the patient.
However, if a patient is pregnant, she should
not have this test because of risks it might
pose to the unborn child.
Some doctors may use magnetic resonance
imaging (MRI) to take pictures of the heart
when it is working hard. This test does not
use a radioactive dye or sound waves. Instead,
it uses radio waves and magnetic fields to
create images that show blood flow in the
heart and whether all parts of the heart wall
are contracting strongly.
Imaging stress tests tend to be more accurate
at detecting CAD than standard (non-
imaging) stress tests. An imaging stress test
may be done first if a patient:
- Can not exercise for enough time to get your
heart working its hardest. (Medical problems,
such as arthritis or leg arteries clogged by
plaque, may prevent from exercising enough.)
- Have abnormal heartbeats or other problems
that will cause a standard exercise stress test
to be inaccurate.
- Standard stress tests are less accurate in
women than in men. If the patient is a woman
and live far from a testing facility, the doctor
305
may want to skip a standard stress test and get
an imaging stress test instead.
Other Names for Stress Testing
Exercise test
Treadmill test
Exercise echocardiogram or exercise stress
echo
Thallium stress test
Sestamibi stress test
Stress EKG
Myocardial perfusion imaging
Pharmacological stress test
MRI stress test
PET stress test
Nuclear stress test
REFERENCES
Chaturvedi N, Coady E, Mayet J, Wright AR, Shore
AC, Byrd S, McG Thom SA, Kooner JS, Schalkwijk
CG, Hughes AD. Indian Asian men have less
peripheral arterial disease than European men for
equivalent levels of coronary disease.
Atherosclerosis. 2007 Jul;193(1):204-12.
Duprez DA. Pharmacological interventions for
peripheral artery disease. Expert Opin
Pharmacother. 2007 Jul; 8(10):1465-77. (Review)
Farmer JA. Diabetic dyslipidemia and atherosclerosis:
evidence from clinical trials. Curr Atheroscler Rep.
2007 Aug; 9(2):162-8.
Gonzalez-Juanatey C, Llorca J, Amigo-Diaz E,
Dierssen T, Martin J, Gonzalez-Gay MA. High
prevalence of sub-clinical atherosclerosis in psoriatic
arthritis patients without clinically evident
cardiovascular disease or classic atherosclerosis risk
factors. Arthritis Rheum. 2007 Aug 15; 57(6):1074-
80.
Goto Y. (1990). Etiology and prevention of ischemic
heart diseases. Asian Med J.:33(5); 265-274
Hirulog. Angioplasty Study Investigators, N Engl J
Med; 333:764 – 9
Leone A. Smoking, haemostatic factors and
cardiovascular risk. Curr Pharm Des. 2007;
13(16):1661-7. (Review)
Noel M, Jobin J, Poirier P, Dagenais GR, Bogaty P.
Different thresholds of myocardial ischemia in ramp
and standard bruce protocol exercise tests in patients
with positive exercise stress tests and
angiographically demonstrated coronary arterial
narrowing. Am J Cardiol. 2007 Apr 1; 99(7):921-4.
O'Brien E, Petrie J, Littler WA, de Swiet M, Padfield
PD, Dillon MJ. Blood pressure measurement:
recommendations of the British Hypertension
 Society. 3rd ed. London: BMJ Publishing Group,
1997
Staessen J, Fagard R, Amery A. The relationship
between body weight and blood pressure. J Hum
Hypertens 1988;2:207-17.
Yeon SB, Sabir A, Clouse M, Martinezclark PO, Peters
DC, Hauser TH, Gibson CM, Nezafat R, Maintz D,
Manning WJ, Botnar RM. Delayed-enhancement
cardiovascular magnetic resonance coronary artery
wall imaging: comparison with multislice computed
tomography and quantitative coronary angiography.
J Am Coll Cardiol. 2007 Jul 31; 50(5):441-7. Epub
2007 Jul 13.
York KM, Hassan M, Li Q, Li H, Fillingim RB, Sheps
DS. Coronary artery disease and depression: patients
with more depressive symptoms have lower
cardiovascular reactivity during laboratory-induced
mental stress. Psychosom Med. 2007 Jul-Aug;
69(6):521-8.

Note: Most of the Matters are drived from Internet and

Research Papers

306
DOPPLER ULTRASOUND USE IN HEART AND OTHER ORGANS
Doppler ultrasound: A form of ultrasound that
can detect and measure blood flow. Doppler
ultrasound depends on the Doppler effect a
change in the frequency of a wave resulting here
from the motion of a reflector, the red blood cell.
There are several kinds of Doppler ultrasound:
• Color Doppler: This technique estimates the
average velocity of flow within a vessel by
color coding the information. The direction
of blood flow is assigned the color red or
blue, indicating flow toward or away from
the ultrasound transducer.
• Pulsed Doppler: This method allows a
sampling volume or "gate" to be positioned A Doppler ultrasound may help diagnose many
in a vessel visualized on the gray-scale conditions, including:
image, and displays a graph of the full range
of blood velocities within the gate versus
time. The amplitude of the signal is
approximately proportional to the number of
red blood cells and is indicated, not in color,
but simply as a shade of gray.
• Power Doppler: This device depicts the
amplitude, or power, of Doppler signals
rather than the frequency shift. This allows
detection of a larger range of Doppler shifts
and thus better visualization of small vessels,
but at the expense of directional and velocity
information.
• Blood clots
Color Doppler depicts blood flow in a region • Poorly functioning valves in your leg veins,
and is used as a guide for the placement of the which can cause blood or other fluids to pool
pulsed Doppler gate for more detailed analysis at in your legs (venous insufficiency)
a particular site. • Heart valve defects and congenital heart
Doppler ultrasound has many applications disease
including, for example, the detection and • A blocked artery (arterial occlusion)
measurement of decreased or obstructed blood • Decreased blood circulation into your legs
flow to the legs. Color Doppler ultrasound is (peripheral artery disease)
done first to evaluate vessels rapidly for • Bulging arteries (aneurysms)
abnormalities and to guide placement of the • Narrowing of an artery, such as in your neck
pulsed Doppler to gain sample volume for (carotid artery stenosis)
detailed analysis of velocities. A Doppler ultrasound can estimate how fast
A Doppler ultrasound is a noninvasive test that blood flows by measuring the rate of change in
can be used to estimate the blood flow through its pitch (frequency). During a Doppler
blood vessels by bouncing high-frequency sound ultrasound, a technician trained in ultrasound
waves (ultrasound) off circulating red blood imaging (sonographer) presses a small hand-held
cells. A regular ultrasound uses sound waves to device (transducer), about the size of a bar of
produce images, but can't show blood flow. soap, against your skin over the area of your
body being examined, moving from one area to
another as necessary.

307
This test may be done as an alternative to more
invasive procedures, such as arteriography and
venography, which involve injecting dye into the
blood vessels
essels so that they show up clearly on X
X-
ray images.
A Doppler ultrasound test may also help the
doctor check for injuries to your arteries or to
monitor certain treatments to your veins and
arteries.
Sonography is a useful way of evaluating the
body's circulatory system. Vascular ultrasound is
performed to:
• help monitor the blood flow to organs and
tissues throughout the body.
• locate and identify blockages (stenosis) and
abnormalities like plaque or emboli and help
plan for their effective treatment.
• detect
tect blood clots (deep venous thrombosis
(DVT) in the major veins of the legs or arms.
• determine whether a patient is a good
candidate for a procedure such
as angioplasty.
• evaluate the success of procedures
that graft or bypass blood vessels.
• determine if there is an enlarged artery
(aneurysm).
• determine the source and severity of varicose
veins.
In children, ultrasound is used to:
• aid in the placement of a needle or catheter
into a vein or artery to help avoid
complications such as bleeding, nerve injury
or pseudo-aneurysm
aneurysm (abnormal outpouching
of an artery with the risk of rupture).
308
• evaluate a connection between an artery and a
vein which can be seen in congenital vascular
malformations (arteriovenous malformations
or fistula) and in dialysis fistula.
If a line is placed in an artery or vein of the legs
or arms, there is a much higher chance of
developing a clot around it due to the smaller
vessel size (especially in infants and young
children). In some instances, a clot can form in
the arm or in the left leg with the latter
extending into the major vein of the abdomen.
Plaque formation is not frequently seen in
children but there can be compression at the
inlet of the chest.
Doppler ultrasound images can help the
physician to see and evaluate:
• blockages to blood flow (such as clots)
• narrowing of vessels
• tumors and congenital vascular
malformations
• less than normal or absent blood flow to
various organs
• greater than normal blood flow to different
areas which is sometimes seen in infections
• Ultrasound scanners consist of a console
containing a computer and electronics, a video
display screen and a transducer that is used to
do the scanning. The transducer is a small
hand-held
held device that resembles a
microphone, attached to the scanner by a cord.
Some exams ams may use different transducers
(with different capabilities) during a single
exam. The transducer sends out inaudible,
high—frequency
frequency sound waves into the body
and then listens for the returning echoes from
the tissues in the body. The principles are
similar
milar to sonar used by boats and submarines.
• The ultrasound image is immediately visible
on a video display screen that looks like a
computer or television monitor. The image is
created based on the amplitude (loudness),
frequency (pitch) and time it takes for the
ultrasound signal to return from the area
within the patient that is being examined to the
transducer (the device used to examine the
patient), as well as the type of body structure
and composition of body tissue through which
the sound travels. A small amount of gel is put
on the skin to allow the sound waves to best
travel from the transducer to the examined
area within the body and then back again.
• Ultrasound imaging is based on the same
principles involved in the sonar used by bats,
ships and fishermen. When a sound wave
strikes an object, it bounces back, or echoes.
By measuring these echo waves, it is possible
to determine how far away the object is as
well as the object's size, shape and consistency
(whether the object is solid or filled with
fluid).
309
• In medicine, ultrasound is used to detect
changes in appearance, size or contour of
organs, tissues, and vessels or detect abnormal
masses, such as tumors.
• In an ultrasound examination, a
transducer both sends the sound waves and
receives the echoing waves. When the
transducer is pressed against the skin, it directs
small pulses of inaudible, high-frequency
sound waves into the body. As the sound
waves bounce off internal organs, fluids and
tissues, the sensitive microphone in the
transducer records tiny changes in the sound's
pitch and direction. These signature waves are
instantly measured and displayed by a
computer, which in turn creates a real-time
picture on the monitor. One or more frames of
the moving pictures are typically captured as
still images. Small loops of the moving real-
time images may also be saved.
• Doppler ultrasound, a special application of
ultrasound, measures the direction and speed
of blood cells as they move through vessels.
The movement of blood cells causes a change
in pitch of the reflected sound waves (called
the Doppler Effect). A computer collects and
processes the sounds and creates graphs or
color pictures that represent the flow of blood
through the blood vessels.
• For most ultrasound exams, you will be
positioned lying face-up on an examination
table that can be tilted or moved. Patients may
be turned to either side or on occasion placed
in a face down position to improve the quality
of the images.
• A clear water-based gel is applied to the area
of the body being studied to help the
 transducer make secure contact with the body
and eliminate air pockets between the
transducer and the skin that can block the
sound waves from passing into your body. The
sonographer (ultrasound technologist) or
radiologist then places the transducer on the
skin in various locations, sweeping over the
area of interest or angling the sound beam
from a different location to better see an area
of concern.
• Doppler sonography is performed using the
same transducer.
• When the examination is complete, you may
be asked to dress and wait while the
ultrasound images are reviewed.
• This ultrasound examination is usually
completed within 30 to 45 minutes.
Occasionally, complex examinations may take
longer.
Carotid Doppler Test
Purpose
A carotid Doppler test is used to detect
narrowing of the arteries in the neck (the carotid
arteries) that supply blood to the brain. During
this test, these arteries are visualized using high-
310
frequency sound waves (ultrasound) for
evidence of plaque (blockages). Analysis of the
blood flow through the arteries by Doppler
ultrasound permits accurate measurement of the
degree of narrowing of the blood vessel.
Ultrasound is not harmful in any way.
Description
1. The patient is asked to lie flat on an
examination table, with his or her head on a
pillow, slightly turned away from the side
being examined.
2. A water-soluble gel is applied to the
transducer (the part of the ultrasound machine
that produces and receives sound waves). The
transducer is placed on either side of the neck
to examine the anatomy and flow in the
arteries.
3. The patient will feel only a slight pressure as
the transducer is moved around the neck.
4. The patient may hear sounds during the test.
This is due to the flow of blood that is
amplified by the ultrasound machine; this
occurs normally during the test.
5. The entire examination takes approximately
30 to 40 minutes. Digital recordings are taken
by the sonographer.
6. The completed study is reviewed by a
cardiologist and a report is sent to the
patient’s doctor.
Special Instructions
The patient should bring along a list of current
medications. Fasting (not eating) before the test
is not required.
Doppler Ultrasound Usage in Other Organs

311
 P. S. a. L. L. Abigail Swillens, "Two-Dimensional
Blood Velocity Estimation With Ultrasound:
Speckle Tracking Versus Crossed-Beam Vector
Doppler Based on Flow Simulations in a Carotid
Bifurcation Model," IEEE Transactions on
Ultrasonics, Ferroelectrics, and Frequency Control,
pp. 327-338, 2010.
R. S. C. Cobbold, Foundations of Biomedical
Ultrasound, Oxford University Press, 2007.
X. Chen, M. J. Zohdy, S. Y. Emelianov and M.
O'Donnell, "Lateral Speckle Tracking Using
Synthetic Lateral Phase," IEEE Transactions on
Ultrasonics, Ferroelectrcs and Frequency Control,
References vol. 51, no. 5, pp. 540-550, 2004.
Abdul Latif Mohamed, Jun Yong, Jamil Masiyati,
Lee Lim, Sze Chec Tee. The Prevalence of X. Lai and H. Torp, "Interpolation Methods for Time-
Diastolic Dysfunction In Patients With Delay Estimation Using Cross-Correlation Method
Hypertension Referred For Echocardiographic for Blood Velocity Measurement," IEEE
Assessment of Left Ventricular Function.Malaysian Transactions on Ultrasonics, Ferroelectrcs and
Journal of Medical Sciences, Vol. 11, No. 1, Frequency Control, vol. 46, no. 2, pp. 277-290,
January 2004, pp. 66-74 1999.
G. Reutern, M. Goertler, N. Bornstein, M. Sette, D.
Evans, A. Hetzel, M. Kaps, F. Perren, A. Note: Most of the Matters are drived from Internet
Razumovky, T. Shiogai, E. Titianova, P. Traubner, and Research Papers
N. Venketasubramanian, L. Wong and M. Yasaka,
"Grading Carotid Stenosis Using Ultrasonic
Methods," Stroke, Journal of the American Heart
Association, vol. 43, pp. 916-921, 2012.
J. A. Jensen, Estimation of Blood Velocities Using
Ultrasound, A Signal Processing Approach, New
York: Cambridge University Press, 1996.
J. Luo and E. E. Konofagou, "A Fast Motion and
Strain Estimation," in Ultrasound Symposium,
2010.
J. Udesen, F. Gran, K. Hansen, J. Jensen, C.
Thomsen and M. Nielsen, "High Frame Rate Blood
Vector Velocity Imaging Using Plane Waves:
Simulations and Preliminary Experiments," IEEE
Transactions on Ultrasonics, Ferroelectrics and
Frequency Control, vol. 55, no. 8, pp. 1729-1743,
2008.
M. Richards, O. Kripfgans, J. Rubin, A. Hall and J.
Fowlkes, "Mean Volume Flow Estimation in
Pulsatile Flow Conditions," Ultrasound in Med. &
Biol., vol. 35, pp. 1880-1891, 2009.
Ommen, S. R.; Nishimura, R. A.; Appleton, C. P.;
Miller, F. A.; Oh, J. K.; Redfield, M. M.; Tajik, A.
J. (10 October 2000). "Clinical Utility of Doppler
Echocardiography and Tissue Doppler Imaging in
the Estimation of Left Ventricular Filling
Pressures : A Comparative Simultaneous Doppler-
Catheterization Study". Circulation. Circulation.
pp. 1788–1794. doi:10.1161/01.CIR.102.15.1788.
Retrieved 12 July 2012.

312
Chapter-11

313
314
GASTROINTESTINAL SYSTEM PHYSICAL EXAMINATION
Pain and discomfort

SOCRATES
• Character: colicky (in waves) vs. not.
• Alleviating, exacerbating factors: meals,
any certain foods, vomiting, exercise,
antacids, stress, defecation, flatus.

Pain:
• Colicky (GI or ureter obstruction).
Small bowel: 3min. cycle. Large: 10min.
cycle. _______
• Localized, relieved by staying still
(peritonitis). Y/N
• Burning, relieved by food or antacid
(heartburn). Y/N
• Steady pain, relieved by sitting up,
leaning forward (pancreatic). Y/N
• Severe pain for hours, prior attacks
(biliary). Y/N
• Constant pain overlying severe pain
radiating to groin (renal). Y/N

Dysphagia

Location of food sticking.
_____________

Intermittent vs. worsens during meal
vs. eases during meal.
_______________________

Cannot initiate swallow vs. choking
on swallow. Y/N

Painful vs. painless. Y/N

Painful on swallowing:
"odynophagia" (inflammatory processes).
Y/N

Solids worse vs. liquids worse. Y/N

Changes since onset.
________________

Nausea, vomiting and reflux
 Family history

Timing of vomit: _____________

Morning (pregnant, raised ICP,
ethanol). Y/N

1hr post-meal (gastric outlet
obstruction, gastroparesis). Y/N

Vomit contents: Blood, Bile, Old food
(pyloric stenosis) vs. new food.
 Y/N
315

Colour: Yellow-green (bile, from
obstruction), Coffee grounds (altered
blood), Hematemesis. Y/N
_________________________

Projectile (pyloric stenosis, raised ICP).
Y/N

GERD, acid regurgitation: Relieved by
raising head of bed. Y/N

Stools

Frequency: constipated vs.
diarrheic.______________

normal frequency? Y/N

Amount. ______________

Blood: melena [black stool],
hematochezia [bright red stool].
___________

Pale, fatty, buoyant stool (steatorrhea 2°
to fat malabsorption). __________

Odour. ________________

Mucous: mixed with stool or not. Y/N

Consistency: hard vs. soft, watery. Y/N

Painfulness of defecation. Y/N

Needing to strain a lot on defecation. Y/N
Other systemic

Wasting, weight loss vs. gain. Y/N

Anemia, jaundice, bronze diabetes Y/N

Lethargy (liver). Y/N

Abdominal swelling.
 Y/N
Past medical, surgical history

Current complaint in the past. Y/N v

Post-op from a recent operation
(anesthetic s/e, damaged GI). Y/N

IBD. Y/N

Ulcers.
 Y/N

Past surgeries, treatments. Y/N



Current complaint in family member
(acute: food poisoning).
 Y/N

Heritable bowel. Y/N
Social history

Smoking: ever smoked, how many per
day, for how long, type [cigarette, pipe,
chew] (ulcers). Y/N

Alcohol (cirrhosis, gastritis). Y/N

Occupation (hepatitis), others at
workplace with similar.
 Y/N

Stress level (ulcers). Y/N

Toxin exposure (liver dz). Y/N

Travel, sex, IV, tattoo use (hepatitis).
________________, Y/N
Drug history

Laxatives. Y/N

Indigestion medications.
 Y/N

NSAIDs (GI bleed).
 Y/N

Liver-damaging drugs.
 Y/N

Steroids. Y/N

Allergies.
 Y/N

Allergic reactions to drugs.
 Y/N
Systems

Dark urine (jaundice). Y/N

RHF signs (nutmeg liver).
 Y/N
Examination - Gastrointestinal System
Environment

NG tube. Y/N

Feeding tube. Y/N

Cans of special food. Y/N
General appearance

Colors:
• Anemic (iron malabsorption,
hemorrhage, CA). Y/N
• Jaundiced (liver disease). Y/N
• Hyperpigmented (hemochromatosis).
Y/N
• Skin Colors. _________________

Hydration and nutrition.
__________________

Weight loss vs. gain, wasting. Y/N

Shocked. Y/N

Postural hypotension.
_______________________
Nails

CLUBBING (UC or Crohn's, Biliary
cirrhosis, GI malabsorption). Y/N

Koilonychia (iron deficiency 2° to GI
bleeding). Y/N

Leuconychia (hypoalbuminism 2° to
cirrhosis). Y/N

Muehrke's lines (hypoalbuminism 2° to
cirrhosis). Y/N
316

Blue lunulae (Wilson's). Y/N

Nicotine stains (some GI CA's). Y/N

Nails. Y/N
Hands

Asterixis (PSE 2° to alcoholism): Y/N
• Pt. stretches out hands in policeman's
stop position, fingers spread out.
______________
• Coarse flapping tremor, "liver flap", is
seen. Y/N

Pallor of palmar creases (anemia 2° to
blood loss, malabsorption). _________

Palmar erythema (cirrhosis). Y/N

Dupuytren's contracture [fibrosis,
contracture of palm's fascia, usu
contracting ring finger] (alcoholism,
manual labor). Y/N

Palmar xanthomata [yellow deposists on
palm of hand] (Type III hyperlipidemia).
Y/N

Tendon xanthomata [yellow deposits on
dorsum of hand, arm] (Type II
hyperlipidemia).
Arms

Scratch marks (itch from jaundice). Y/N

Spider naevi (alcoholism). Y/N

Bruising (clotting factors 2° to liver
damage). Y/N

Tuboeruptive xanthomata [yellow
deposists on elbows, knees] (Type III
hyperlipidemia). Y/N
Eyes

Cornea rings (Wilson's). Y/N

Sclera: jaundice. Y/N

Iritis: IBD. Y/N

Xanthelasma [yellow plaque periobital
deposits] (elevated cholesterol). Y/N
Mouth

Temporalis muscle wasting. Y/N

Lips:
• Telangiectasia (Osler-Weber-Rendu)
Y/N
• Brown freckles (Peutz-Jeghers). Y/N

Breath:
• Fetor hepaticus (alcoholism). Y/N
• Ethanol. Y/N

Mouth:
• Ulcers (Crohn's, coeliac disease). Y/N
• White candida patches (spread down
throat). Y/N
• Cracks at mouth edges (iron deficiency
anemia). Y/N

Teeth:
• Cavities (acid 2° to vomiting). Y/N
• Nicotine stains. Y/N

Gums:
• Hypertrophy. Y/N
• Bleeding. Y/N
• Gingivitis. Y/N

Tongue:
• Leucoplakia
(smoke, spirits, sepsis, syphilis, sore
teeth). Y/N
• Atrophic glossitis [withered tongue]
(deficiencies, Plummer-Vinson). Y/N
• Macroglossia (B12 deficiency). Y/N
Neck, chest, back

Cervical nodes:
• Supraclavicular nodes for Virchow's
node (lung CA, GI malignancy). Y/N
• Nodes. Y/N

Gynecomastia (chronic liver disease).
Y/N

Hair loss (chronic liver disease). Y/N

Back: neuro-fibromas. Y/N
Abdomen: Examination

317
 • Caput medusae (portal HTN). Y/N
• Costal margin (normal).

Dilated vein flow direction. Test by
occluding with fingers:
• Flows superior (IVC block). Y/N
• Flows inferior (SVC block). Y/N
• Navel radiation (portal HTN). Y/N

Umbilicus:
• Sister Joseph nodule (metastatic tumor).
Y/N
• Cullen's "black eye" (acute pancreatitis,
extensive hemoperitoneum). Y/N

Groin: brown freckles (Peutz-Jeghers).
Y/N

Squat to pt's stomach level, and watch for
asymmetrical movement during breathing
(mass, large liver). Y/N
Palpate general abdominal

Warm hands. Y/N

Ask pt if any part tender: examine that
last. Y/N

Abdominal muscles relaxed, pt bends
Pt is supine, abdomen visible from nipples knees if necessary. Y/N
to pubic symphysis. Y/N
Light palpation. Y/N

Abdominal Scar. Y/N
Deep palpation. Y/N

Stoma from surgery, trauma. Y/N
Note rigidity, rebound tenderness,

PEG (dysphagia, usu. 2º to neurological involuntary guarding (peritonitis). Y/N
damage, like stroke). Y/N
Record mass characteristics. Y/N

Distension
Distinguish abdominal wall mass from
(fat, fetus, feces, flatus, fluid, full-sized intrabdominal mass:
tumors). Y/N • Pt folds arms and sits halfway up. Y/N

Local swellings (enlarged organs, hernia). • Wall mass if size is same, tenderness
Y/N same or greater. Y/N

Pulsations (AAA). Y/N Palpate liver

Peristalsis visible (thin person, intestinal
Find edge:
obstruction). Y/N • Dr's R hand held still at base of RLQ,

Skin: parallel to costal margin. Y/N
• Herpes zoster (abdominal pain). Y/N • Ask pt. to breathe slowly. Y/N
• Grey-Turner's sign [discolored skin] • During each inspiration, see if liver
(acute pancreatitis). Y/N edge strikes radial edge of index finger.

Striae: Y/N
• Regular striae (ascities, pregnancy, • During each expiration, Dr's hand
weight loss). Y/N moves superiorly 2cm. Y/N
• Purple, wide striae (Cushings). Y/N
Palpate liver surface, edge:

Dilated veins location: • Hard vs. soft. Y/N
• Anterior leg (IVC block). Y/N • Regular vs. irregular. Y/N

318
 • Tender vs. not. Y/N
• Pulsatile (tricuspid incompetence) vs.
not. Y/N

Find top border by percussing down R
midclavicular line [normal: 5th rib in
midclavicular line]. Y/N

Calculate span [normal span: 12.5cm].
Y/N
Palpate gallbladder

Dr's fingers placed perpendicular to R
costal margin near midline, then moved
medial to lateral to palpate. Y/N

Do Murphy's sign: cessation of
inspiration upon palpation.
• Murphy's point: costal margin in mid
clavicular line. Y/N
• Courvoisier's
law: Stones= stays small since scarred.
Y/N
Palpate spleen

Bimanual technique:
• Dr's L hand posterolaterally, below pt's
L ribs, compressing on rib cage. Y/N
• Dr's R hand below pt's umbilicus,
parallel to L costal margin. Y/N
• Advance R hand superiorly to L costal
margin. Y/N
• 1.5x-2x enlarged spleen is palpable.
Y/N
• If miss spleen, roll pt. towards Dr. (so pt
lies on pt's R side) and repeat palpation.
Y/N

Alternatively: palpate like liver edge with
just R hand, starting from RLQ
diagonally over to LUQ. Y/N

Alternatively: combine the two methods:
start to palpate from RLQ like liver edge
with just R hand, but then as get closer,
reach with L hand around to pt's L
ribcage and pull, while continuing
advancing with R hand. ___________

Assess spleen characteristics [these also
help differentiate from kidney]:
• Size ___________
• Shape, notch vs. no notch.
_____________
319
• Percussion dullness vs. not.
__________________
• Moves on respiration vs.
not._________________

Can get above it vs. not. Y/N
Palpate kidneys

Dr's L heel of hand slipped under pt's R
loin, L fingers under R back.

R hand held over RUQ.

Dr flexes L MCPs in renal angle. Y/N

Dr R hand feels strike as kidneys float
anteriorly. Y/N

Repeat for other side. Y/N
Auscultate stomach

Perform on empty stomach. Y/N

Stethoscope on epigastrium. Y/N

Then shake both iliac crests.

While shaking, listen to splash from
retained fluid. Y/N

Audible splash called "succussion splash"
(ulcer or gastric CA). Y/N
Palpate pancreas

Palpate for a round, fixed, swelling above
umbilicus that doesn't move with
inspiration (pseudocyst, acute
pancreatitis, CA in thin pt).
________________
Palpate aorta

Palpate in midline, superior to umbilicus.
Y/N

Dr's 2 fingers on outer margins of aorta,
watch if if fingers diverge (AAA).
__________

Normally felt in thin pt. Y/N
Palpate bowel

Sigmoid usu. palpable in severe
constipation. Y/N

Whether indents (feces) or doesn't indent
(masses). Y/N

Sometimes can feel CA, megarectum.
Y/N
Palpate bladder

Ask pt when last urinated, and whether
was complete emptying.. Y/N

Usually palpable if full, usually not
palpable if empty. Y/N

Look for palpable, empty bladder Abdomen: auscultation
(swelling). Y/N
Below umbilicus to assess bowel sounds
Palpate testes for:

Atrophy (liver disease). Y/N • Rushing sound called "borborygmi"
Abdomen: percussion (diarrhea). Y/N

Liver border for loss of of dullness • No sound for 3 minutes (ileus,
(necrosis, perforated bowel). Y/N paralysis). Y/N

Spleen for splenomegaly. Y/N • "Tinkling" sound (obstructed bowel).

Kidneys. __________________ Y/N

Bladder for enlarged bladder, pelvic
Above umbilicus for:
mass. Y/N • AAA bruit. Y/N

Percuss masses. Y/N • Venus hum [blood flowing in caput

Abdomen percussion: ascites. Y/N medusae] (portal HTN). Y/N

Shifting dullness:
R and L above umbilicus for renal artery
• The Dr's percussing finger placed stenosis. Y/N
vertically, so Dr's finger pointing toward
Over liver for:
pt's legs. _____ • Friction rub [grating during breathing]
• Starting at midline, percuss laterally to (peritonitis, Fitz-Hugh-Curtis, others).
dullness on L flank, and mark site of Y/N
dullness with non-permanent marker. • Bruit (CA, alcoholic hepatitis). Y/N
_______________
Over spleen for splenic rub (splenic
• Roll pt towards Dr., so pt now laying on infarct). Y/N
R side._________ Groin, hernias, rectal
• Pt stays lying on R side for 30min, then
Palpate lymph nodes: Inguinal Nodes.
repercuss while still lying on R side. Y/N Y/N
• Ascites present if the dullness has
Hernia Examination (given below). Y/N
moved medially (ie the point of dullness
Rectal Examination (given below). Y/N
is now resonant). Legs
_________________________
Edema. Y/N
• Optionally: percuss laterally on both R
Bruising. Y/N
and L flanks, and mark both before
Tuboeruptive xanthomata [yellow
rolling pt, so can assess them both deposists on elbows, knees] (Type III
moving. __________________ hyperlipidemia). Y/N

Dipping:
Chronic liver disease. Y/N
• Flex MCP joint fast to displace fluid
Toenails and foot showing same
and palpate a mass. Y/N symptoms as Fingernails and Hands.

Fluid thrill: Y/N
• Dr. puts hands on each of pt's flanks. Per Rectal
Y/N Setting up
• If obese, pt places pt's lateral edge of
Describe procedure to pt.
hand, vertically on midline at umbicus.
Pt. in Sim position: on table, lying on L
Y/N side, knees up towards chest, facing away
• Dr. flicks hand on right flank, by from Dr.
quickly flexing MCPs. Y/N
Gloves on.
• Ascites if Dr feels resulting thrill on left External inspection
flank. Y/N
Piles. Y/N

320

Skin tags (normal, Crohn's, hemorhoids).
Swellings. Y/N
Y/N
Swellings: bilateral (direct) or unilateral

Rectal prolapse. Y/N (indirect). Y/N

Anal fissure. Y/N
Swellings: only appear on standing? Y/N

Fistula. Y/N
Swelling location: above or below

Anal warts. Y/N inguinal ligament. Y/N

Carcinoma. Y/N
Hernia surgical scars. Y/N

Signs of incontinence, diarrhea. Y/N
External genitalia, including undescended
External inspection: straining testicle (DDx). Y/N

Ask patient to strain. _______________
Ask pt. to reduce hernia themselves. Y/N

Rectal prolapse upon straining. Y/N
Pt. coughs to highlight hernia. Y/N

Hemorrhoid prolapse. Y/N Palpate

Incontinence. Y/N
Ask pt. about tenderness first.

Ask if straining is painful. Y/N ______________
Internal palpation
Inguinal Canal Reference for landmarks.

Lubricate index finger. Y/N

Insert finger slowly, assessing external
Inguinal hernia goes in inguinal canal.
sphincter tone as enter.
Palpate mass, scrotal ones can be done up

Male: palpate prostate [anterior of scrotum with little finger. Y/N
rectum]: Y/N
Optionally can cough here while little
• Hard nodule (prostate cancer). Y/N finger up scrotum to feel an impulse on
• Tender (prostatitis). Y/N end of finger (indirect) vs. superior part

Female: palpate cervix [anterior of of finger. Y/N
rectum]:
See whether can reduce it back up
• Mass in pouch of Douglas. Y/N through the inguinal ring to reduce it.

Rotate finger, palpating along left, Y/N
posterior, right walls. Y/N Palpate: cough impulse

Withdraw finger.
Reduce. Y/N

Wipe lubricant off pt.
Hold two fingers on internal ring.

Ask if was significant pain during
Pt. coughs while holding fingers on ring.
examination. Y/N Y/N
Stool examination
See if hernia can extrude around

Inspect withdrawn fingertip for: elsewhere (direct) or stays reduced
• Blood, melena. Y/N (indirect). Y/N
• Stool color._______________ Direct vs. indirect summary
• Pus. Y/N
Bilateral (direct) vs. unilateral (indirect).
• Mucous. Y/N _________________

If indicated, do a fecal occult blood
Strangulation concern (indirect) vs. rarely
test: blue result means blood. Y/N strangulate (direct). Usually obstruction
Hernia Examination precedes strangulation (except Richter's).
Inguinal hernia ________________
Examination
Through inguinal ring (indirect) vs.

Is pt. male (predisposing factor). Y/N around inguinal ring (direct). _______

Pt's lifting muscles, ascities (predisposing
factors). Y/N

Pt. stands, exposed area visible. Y/N

321

Femoral hernia
Examine

Is pt female? [predisposing factor]. Y/N

Pt. stands, exposed area visible. Y/N

Swellings. Y/N

Swellings: only appear on standing? Y/N

Reddening. Y/N

Hernia surgical scars. Y/N

External genitalia. Y/N

Ask pt. to reduce hernia themselves. Y/N

Pt. coughs to highlight hernia, though
may not appear in femorals. Y/N

Whether hernia goes through
Hasselbach's triangle. Y/N
Palpate

Ask pt. about tenderness first.
_______________

Femoral 'neck' is usually palpated inferior
and lateral to pubic tubercle. Y/N

Femorals more likely to be irreducible
than inguinals. Y/N

Can have pt. cough while palpating,
reducing. Y/N

Don't confuse with firm lymph node,
femoral vein.
Examination
• Abdominal examination gives a general
account and is orientated to examination
322
of the acute abdomen or abdominal
masses.
• Specific areas with problems are
covered in the separate articles Left
Upper Quadrant Pain, Right Upper
Quadrant Pain, Right Iliac Fossa
Pain, Left Iliac Fossa Pain and Loin
Pain.
• Children pose specific difficulties
As always, examination begins by looking
at the patient.
Examination
A general inspection precedes inspection of
the abdomen.
• Establish what the patient's nutrition is
like. Note whether the patient is thin and
wasted, bloated and oedematous or
obese.
• Note whether the skin looks pale or
yellow. In black people, a slightly
yellow colour of the palms is equivalent
to pallor.
• Features of scleroderma may account for
dysphagia.
• Look for liver palms and a hepatic flap
as described in the separate Abdominal
Examination article.
• Look for abnormalities of the nails such
as clubbing or koilonychia.
• Check the sclerae for jaundice.
• Note the angles of the mouth. Angular
cheilitis may suggest iron deficiency. In
pernicious anaemia around 50% of
patients have a smooth tongue with loss
of papillae but this can also be due to
friction in those with a plastic palate
with upper dentures.
• Note whether the mouth looks healthy.
• Note whether dentition is good.
• Note whether there is halitosis.
• Oral candida may be associated with
oesophageal candidiasis, especially if
immunity is suppressed.
Only now is it time to turn to the abdomen
and, as always, first look.
• Abdominal distension may be apparent.
 • Abdominal masses may be apparent on
inspection.
• High pressure in the abdomen may
cause protrusion of the umbilicus.
Cirrhosis or portal hypertension may
produce prominent blood vessels on the
abdomen.
Now it is time for palpation and, again,
reference is made to examination of the
abdomen, which also includes palpating for
splenomegaly and detection of ascites.
Hepatomegaly can be difficult to detect and it
is often useful to percuss the liver edge. The
liver is dull to percussion while bowel is
resonant.
• Check for herniae. Femoral hernia is
uncommon but very liable to
strangulate.
• In secondary care the dictum is that no
abdominal examination is complete
without rectal examination. In primary
care this is less vigorously applied,
especially if the findings are unlikely to
affect management.
• Few GPs have the skills or resources for
sigmoidoscopy but proctoscopy and
digital rectal examination should be
within the capacity of everyone.
• Such examination may reveal rectal
prolapse or an obvious cause of rectal
bleeding, although haemorrhoids are so
common that they do not exclude other
causes of bleeding.
• Carcinoma of the rectum may well be
palpable.
• If an elderly person has diarrhoea, it is a
distinct possibility that it is really
spurious diarrhoea caused by faecal
impaction with overflow. Therefore,
before starting medication that may
aggravate constipation, it is imperative
to perform a rectal examination. The old
adage is 'Put your finger in it before you
put your foot in it.'
Differential diagnosis
This includes two important aspects:
323
Be aware of the warning signs that may
indicate malignancy:
• Malignancy should be considered with
significant, unintentional weight loss,
progressive dysphagia, chronic blood
loss, persistent vomiting and change of
bowel habit in excess of six weeks'
duration, especially over the age of 40.
• Dyspepsia presenting for the first time at
age over 55 or irritable bowel
syndromepresenting for the first time at
age over 40 is also a warning feature.
Be aware of the many diseases not of the
gastrointestinal tract and which need to be
considered:
• In females think of gynaecological
conditions, although they rarely cause
pain outside the pelvis.
• Note the full differential diagnosis of
pain in the chest. Both chest
pain and epigastric pain can be cardiac
in origin and many a patient with
'indigestion' has died of heart disease.
• Abdominal pain can be from the urinary
tract or a dissecting abdominal aortic
aneurysm.
• Thyrotoxicosis can cause weight loss.
• Congestive heart failure can cause
engorgement of the liver.
• Metabolic disease such as porphyria can
cause abdominal pain.
• Depression or psychotic illness can
cause hypochondriacal or bizarre
symptoms. Recognition of depression is
not always easy but remember that
depression can result from somatic
illness and is not necessarily the
cause. Screening for depression in
primary care may be employed if there
is suspicion.
Children
Children, especially when small, represent an
entirely different problem from adults.
• An important feature for children and
babies is failure to thrive. Centile
 charts plotting weight and height with examination on an older child, as it may be as
time are extremely useful. traumatic as sexual abuse.
• Children vomit very easily and are often Ultrasound and Endoscopy of abdomen
remarkably unperturbed by it. Parents
will recall how a child has vomited
during a meal and, before they have
finished clearing it up, the child is
eagerly finishing the meal.
• Vomiting with a high temperature,
unrelated to the gastrointestinal tract, is
common.
• The frequency of defecation in milk-fed
babies is extremely variable as there is
little residue, especially if they are
Upper abdominal scan is a detailed
breast-fed.
• If children are asked where it hurts, they examination of the liver, gallbladder, bile
usually point to the umbilicus, even if ducts, pancreas, spleen and kidneys.
the primary lesion is tonsillitis or otitis
media.
• Acute surgical problems in children can
be very difficult to diagnose.

Examination of children also presents special

difficulties.
If rectal examination is required for a baby,
use the little finger, as it is smallest. Think
carefully before performing a rectal

324
 Manterola C, Astudillo P, Losada H, Pineda
V, Sanhueza A, Vial M (2007). Manterola,
Carlos, ed. "Analgesia in patients with
acute abdominal pain". Cochrane database
of systematic reviews (Online) (3):
CD005660.doi:10.1002/14651858.CD0056
60.pub2. PMID 17636812.
MD, Lynn B. Bates' Guide to Physical
Examination and History-Taking, 11th
Edition. Lippincott Williams & Wilkins,
11/2012.
PCSG: Primary Care Society for
Gastroenterology
Ranji SR, Goldman LE, Simel DL, Shojania
KG (2006). "Do opiates affect the clinical
evaluation of patients with acute abdominal
pain?". JAMA 296 (14): 1764–
74. doi:10.1001/jama.296.14.1764. PMID 1
7032990.

Note: Most of the Matters are drived from Internet

and Research Papers

Gastritis can also be caused by other irritants

like coffee and cigarettes, as well as some
common medications like Advil and Aspirin.
In some cases, it can also be caused by
bacterial infection
References
Amarenco G; [Bristol Stool Chart:
Prospective and monocentric study of
"stools introspection" in healthy subjects].
Prog Urol. 2014 Sep;24(11):708-13. doi:
10.1016/j.purol.2014.06.008. Epub 2014
Aug 22.
Bristol Stool Chart; MedGatdget.com
British Society of Gastroenterology

325
Chapter-12

327
328
HEPATITIS
Viral hepatitis has emerged as a major public
health problem throughout the world affecting
several hundreds of millions of people. Viral
hepatitis is a cause of considerable morbidity
and mortality in the human population, both
from acute infection and chronic sequelae
which include, in the case of hepatitis B, C
and D, chronic active hepatitis and cirrhosis.
Hepatocellular carcinoma which is one of the
ten most common cancers worldwide is
closely associated with hepatitis B, and at
least in some regions of the world with
hepatitis C virus.
Hepatitis A virus
Hepatitis A virus (HAV), classified as
hepatovirus, is a small, unenveloped
symmetrical RNA virus which shares many of
the characteristics of the picornavirus family,
and is the cause of infectious or epidemic
hepatitis transmitted by the fecal-oral route.
Hepatitis B virus
Hepatitis B virus (HBV) is a member of the
hepadnavirus group, double-stranded DNA
viruses which replicates unusually by reverse
329
transcription. Hepatitis B virus is endemic in
the human population and hyperendemic in
many parts of the world. A number of variants
of this virus have been described. Natural
hepadnavirus infections also occur in other
mammals including woodchucks, beechy
ground squirrels and ducks.
Hepatitis C virus
Hepatitis C virus (HCV), is an enveloped
single-stranded RNA virus which appears to
be distantly related (possibly in its evolution)
to flaviviruses, although hepatitis C is not
transmitted by arthropod vectors. Several
genotypes have been identified. Infection with
this more recently identified virus is common
in many countries. Hepatitis C virus is
associated with chronic liver disease and also
with primary liver cancer in some countries.
Hepatitis D virus
Hepatitis D virus (HDV) is an unusual,
single-stranded, circular RNA virus with a
number of similarities to certain plant viral
satellites and viroids. This virus requires
hepadna virus helper functions for
propagation in hepatocytes, and is an
important cause of acute and severe chronic
liver damage in many regions of the world.
Hepatitis E virus
Hepatitis E virus (HEV), the cause of
enterically-transmitted non-A, non-B
hepatitis, is another non-enveloped, single-
stranded RNA virus, which shares many
biophysical and biochemical features with
caliciviruses. The most similar genome to
HEV is found in a plant virus, beet necrotic
yellow vein virus, and there are similarities in
the functional domains to rubella virus. Final
taxonomic classification is yet to be agreed
upon.
Hepatitis E virus is an important cause of
large epidemics of acute hepatitis in the
subcontinent of India, Central and Southeast
Asia, the Middle East, parts of Africa and
elsewhere. This virus is responsible for high
mortality (15-20%), during pregnancy
particularly during the third trimester.
The GB hepatitis viruses
The GB hepatitis viruses (GBV-A, GBV-B and
GBV-C): The GB hepatitis viruses were
cloned recently and preliminary genomic
characterization shows that they are related to
other positive-stranded RNA viruses with
local regions of sequence identity with
various flaviviruses. Phylogenetic analysis of
genomic sequences showed that these viruses
are not genotypes of the hepatitis C virus.
Hepatitis A
330
Hepatitis A is a liver infection caused by the
hepatitis A virus (HAV). Hepatitis A usually
causes temporary liver inflammation, and
most people recover without any long-term
liver problems.
Other viruses, most commonly hepatitis B and
hepatitis C, also cause hepatitis. Hepatitis A is
the most common type of viral hepatitis.
Causes
Hepatitis A is caused by a virus (hepatitis A
virus, or HAV) that multiplies in liver cells
and is shed in stool.
How HAV is spread?
Hepatitis A virus is found in the stool (feces)
of a person who has hepatitis A. The virus is
spread most commonly when people put food
or objects contaminated with stool containing
HAV into their mouths.
Large numbers of people get the virus after
drinking contaminated water because, in
many parts of the world, drinking water is
contaminated with raw sewage. The virus also
may be spread by eating uncooked food (such
as raw shellfish) and unpeeled fruits and
vegetables washed in contaminated water.
Hepatitis A outbreaks caused by contaminated
drinking water are rare in the United States
because water supplies are treated to destroy
the virus and other harmful organisms.
HAV is spread mainly among people who
have close contact with someone who has the
virus. HAV occurs usually if someone:
Eat food prepared by someone who does not
wash his or her hands well after using the
bathroom or changing a diaper.
Don't wash hands after changing a diaper.
Eat raw or undercooked shellfish that was
harvested from waters contaminated with raw
sewage.
Is a man and have sex with other men?
Outbreaks of hepatitis A among children in
day care facilities occur because children,
especially those who wear diapers, may get
stool on their hands and then touch objects
that other children put into their mouths.
Caregivers in day care centers can spread the
virus if they do not wash their hands
thoroughly after changing a child's diaper.
It is very rare for hepatitis A virus to be
spread by infected blood or blood products. It
is not known to be spread through saliva or
urine.
Some people fear that hepatitis A infection is
related to or increases the risk of contracting
acquired immunodeficiency syndrome
(AIDS). This is not true. The hepatitis A virus
is not related to the human immunodeficiency
virus (HIV), which causes AIDS, nor does it
increase your risk of HIV infection. A person
can be infected with both hepatitis A and
HIV, but the two infections have nothing to
do with each other.
Symptoms
Symptoms usually appear 15 to 50 days (2 to
7 weeks) after you have been exposed to the
hepatitis A virus (HAV). The average time is
30 days. Symptoms usually are mild and may
not be noticed in children younger than 6
years of age. In older children and adults,
early symptoms are often similar to those of a
stomach virus. Possible symptoms include:
Extreme tiredness (fatigue)
Fever
Sore muscles
Headache
Pain on the right side of the abdomen, under
the rib cage (where the liver is located)
Nausea
Loss of appetite and weight loss
Yellowing of the skin and the white part of
the eyes (jaundice), sometimes accompanied
by dark urine and clay-colored (whitish)
stools. Jaundice is less common in children
and younger adults.
331
Approximately 14% of people infected with
HAV may develop a rash after the incubation
period but before symptoms appear. In rare
cases-usually in recurrent HAV or cholestatic
hepatitis-swollen blood vessels may cause
red, raised skin lesions in the legs and
buttocks.
In general, by the time symptoms appear, the
amount of virus being shed in your stools is
declining. You still may spread the virus, but
you are less likely to do so after symptoms
appear.
Symptoms of hepatitis A usually last less than
2 months.
What Happens?
Once it enters your body, the hepatitis A virus
(HAV) incubates for 2 to 7 weeks (average
incubation period is about 4 weeks).
Your stools (feces) and body fluids contain
the highest levels of the virus 2 weeks before
symptoms (if there are any) start. This is the
time when you are most contagious.
However, you still may pass the virus to
another person until all of your symptoms
have gone away.
From 5 to 10 days after you become infected
with HAV, your body usually starts to make
HAV antibodies.
Between 3 and 6 months after you become
infected with the virus, antibodies develop
that will give you lifelong protection
(immunity) against HAV infection. The
antibodies can always be detected in your
blood, indicating that you were once infected
with the hepatitis A virus.
Symptoms of hepatitis A usually last less than
2 months. More than 99% of people who have
hepatitis A recover fully. Within 1 to 2
months after your symptoms go away, your
liver will be completely healed.
Possible complications of hepatitis A include
the following:
About 15% of people with HAV have a
temporary return (relapse) of symptoms or
prolonged symptoms that last 6 to 9 months
before the infection clears up.
A rare condition called cholestatic hepatitis
may develop and is associated with severe
itching. In some people, the illness lasts
weeks or months.
Problems with other organs, including sudden
gallbladder inflammation (acute cholecystitis)
and inflammation of the pancreas
(pancreatitis), may occur, but these
complications are uncommon.
A very small number of people, most often
older adults or those with long-term (chronic)
liver disease, rapidly develop severe liver
failure when they become infected with HAV.
This condition is called fulminant hepatitis.
Up to 70% of people with fulminant hepatitis
A recover without major treatment; however,
some people may require a liver transplant to
avoid liver failure and death.
Hepatitis A during pregnancy
Hepatitis A does not increase the risk of
stillbirth, miscarriage, or birth defects.
Preventive treatment with immune globulin,
which contains hepatitis A antibodies, is safe
for pregnant women who have been exposed
to the virus.
Exams and Tests
If some one has been exposed to hepatitis A,
he requires blood tests to study liver function
and to determine whether liver is damaged or
inflamed. Blood tests to study liver function
include:
332
Bilirubin: When bilirubin builds up in the
blood, it may indicate hepatitis.
Albumin: Lower than normal levels may
indicate hepatitis or other liver problems.
Prothrombin time: a blood test that
measures how long it takes blood to clot. An
abnormal prothrombin time can be caused by
liver disease or injury.
Blood tests that may be done to determine
whether the liver is damaged or inflamed
include:
Alanine aminotransferase (ALT): When the
liver is damaged or diseased, ALT is released
into the bloodstream, causing levels of the
enzyme to rise.
Aspartate aminotransferase (AST): When
body tissues or organs such as the heart or
liver are damaged, AST is released into the
bloodstream. The amount of AST in the blood
is directly related to the extent of the tissue
damage.
Alkaline phosphatase (ALP): Large
amounts of ALP in the bloodstream may
indicate liver damage.
Lactic dehydrogenase (LDH): Many
diseases can cause elevations in LDH levels.
Other tests are usually needed to confirm a
diagnosis of hepatitis A.
If tests show your liver is inflamed, you will
have an antibody (anti-HAV) test on a sample
of your blood. The presence of HAV
antibodies means that HAV infection is the
most likely cause of your hepatitis.
If the results of the anti-HAV test show that
HAV is not multiplying in your body, your
doctor may do other hepatitis blood tests to
find out whether hepatitis B virus, hepatitis C
virus, or Epstein-Barr virus (which causes
infectious mononucleosis, or “mono”) is
causing your hepatitis.
Early Detection
If you are concerned that you have been
exposed to the virus and you have not been
previously infected or vaccinated, contact
your health professional. If you get a shot of
immune globulin (IG) within 2 weeks of
being exposed to HAV, you probably will not
develop symptoms of HAV infection.
Routine vaccination of hospital workers, food
handlers, and child care center workers and
attendees is not recommended because their
risk of infection generally is no greater than
that of the wider community. If outbreaks of
HAV infection do occur in those settings,
people who were exposed to the virus should
receive a shot of immune globulin (IG).
Treatment Overview
Hepatitis A goes away on its own in almost
all cases. No medications are used to treat the
illness. Home treatment will usually help
relieve your symptoms and help you prevent
the spread of hepatitis A virus (HAV).
Prevention
The hepatitis A vaccine is the most effective
means of preventing hepatitis A virus (HAV)
infection. The vaccine provides 94% to 100%
protection if you receive both of the shots in
the vaccination series.
Vaccination is important for people at
increased risk of exposure to the virus or of
complications from HAV infection. The
hepatitis A vaccine is recommended for:
Anyone 2 years of age or older who is
planning to travel to a foreign country where
sanitary conditions are poor and hepatitis A is
common.
Children 2 years of age or older who live in
states with high rates of hepatitis A infection:
States that recommend these vaccinations
include Alaska, Arizona, California, Idaho,
Nevada, New Mexico, Oklahoma, Oregon,
South Dakota, Utah and Washington. For
more information, contact your local health
department.
People who use illegal drugs
Men who have sex with men
People who work with monkeys that are infected with
the virus and those who work with the virus in a
research setting
People who have long-term (chronic) liver disease
People who are awaiting or have had a liver transplant
People with hemophilia or related blood-clotting
disorders
333
A combination vaccine (Twinrix) has been
approved to prevent infection with both
hepatitis A and hepatitis B viruses for people
18 and older.
Important features for the prevention of
hepatitis A
If you have been infected with HAV, there are
steps you can take to avoid infecting the
people you are in close contact with.
Inform those you live with or have sex with
that you have hepatitis A. They should ask
their doctor whether they need a shot of
immune globulin. If given within 2 weeks of
possible exposure to the virus, immune
globulin (IG) is effective in preventing
hepatitis A or reducing its symptoms. For
more information, see the Medications section
of this topic.
Wash your hands with soap and hot water
immediately after using the toilet or changing
a diaper and before preparing food.
Avoid any anal contact with a sex partner
while you are infected.
Hepatitis B
Hepatitis B is a liver disease caused by
infection with the hepatitis B virus (HBV).
Hepatitis B is one of the most easily spread
(contagious) forms of viral hepatitis, which
includes hepatitis A, B, C, D, and E.
However, hepatitis has many other causes,
including some medications, long-term
alcohol use, and exposure to certain industrial
chemicals.
Hepatitis B is a liver disease caused by
infection with the hepatitis B virus (HBV).
Hepatitis B is one of the most easily spread
(contagious) forms of viral hepatitis, which
includes hepatitis A, B, C, D, and E.
However, hepatitis has many other causes,
including some medications, long-term
alcohol use, and exposure to certain industrial
chemicals.
How does HBV spread?
HBV is spread when blood, semen, or vaginal
fluids (including menstrual blood) from an
infected person enter another person's body,
usually in one of the following ways:
Sexual contact: The hepatitis B virus can
enter the body through a break in the lining of
the rectum, vagina, urethra, or mouth. Sexual
contact is the most important risk factor for
the spread of HBV in North America.
Sharing needles: People who share needles
and other equipment (such as cotton, spoons,
and water) used for injecting illegal drugs
may inject HBV-infected blood into their
veins.
Work-related exposure: People who handle
blood or instruments used to draw blood may
become infected with the virus. Health care
workers are at risk of becoming infected with
the virus if they are accidentally stuck with a
used needle or other sharp instrument infected
334
with an infected person's blood, or if blood
splashes onto an exposed surface, such as the
eyes, mouth, or a cut in the skin.
Childbirth: A newborn baby can get the virus
from his or her mother during delivery when
the baby comes in contact with the mother's
body fluids in the birth canal (perinatal
transmission). However, breast-feeding does
not transmit the virus from a woman with
HBV to her child.
Body piercing and tattoos: HBV can be
spread when needles used for body piercing
or tattooing is not properly cleaned
(sterilized) and HBV-infected blood enters a
person's skin.
Toiletries: Grooming items such as razors and
toothbrushes can spread HBV if they carry
blood from a person who is infected with the
virus.
In the past, blood transfusions were a
common means of spreading HBV. Today, all
donated blood in the United States is screened
for the virus, so it is extremely unlikely that
you could become infected with the virus
from a blood transfusion.
Exam and test
Along liver test
Hepatitis blood tests include:
Hepatitis B antigens and antibodies, which
help determine whether you are or were once
infected with HBV, whether you have been
immunized, whether you have long-term
(chronic) HBV infection, and whether you
can pass the virus to others (contagious).
Hepatitis B viral DNA (HBV DNA), which
detects genetic material (DNA) from the
hepatitis B virus: HBV DNA indicates that
the virus is multiplying in the body (active)
and that it is contagious.
Tests that determine whether the hepatitis A,
hepatitis C, or Epstein-Barr (which causes
infectious mononucleosis, or "mono") viruses
are causing the hepatitis if the results of tests
show that HBV is not multiplying in the body
that means the cause of liver inflammation is
not a viral.
The tests that determine whether a person is
infected with hepatitis A along with hepatitis
B:
The person must see his health professional
regularly if he has chronic HBV infection.
If he has been diagnosed with chronic HBV
infection, the health professional may
recommend for vaccination of hepatitis A if
he has not been vaccinated or is not immune
to this disease. The person also will need to
visit the health professional regularly. He will
do blood tests to monitor the liver function
and the activity of the hepatitis B virus (HBV)
in the body. Some of the tests can tell the
doctor whether HBV is actively multiplying
in the liver, which increases the risk for
chronic hepatitis. Chronic hepatitis can lead to
liver disease such as cirrhosis or liver cancer
(hepatocellular carcinoma).
Treatment
For people with acute hepatitis B infection
(HBV), treatment with medication is not
recommended. Antiviral medication may be
used for chronic HBV infection if the virus is
multiplying or liver damage exists or may
develop.
Prevention
A person can protect himself from hepatitis B
virus (HBV) infection by avoiding contact
with the body fluids of someone whose health
and sexual history are not known.
To prevent infection:
Use a condom during intercourse
Don't share needles
Wear latex or plastic gloves if you have to
touch blood
Don't share toothbrushes or razors
Important features of Hepatitis B
335
The hepatitis B vaccine is the most effective
way to prevent infection with HBV. The
vaccine is up to 95% effective against HBV
infection. Three vaccination shots are
necessary at different times. The vaccine
provides protection against HBV infection for
at least 15 years.
Vaccination is recommended for:
All newborn babies
Anyone 18 years old or younger who has not
previously received the vaccine
People who inject illegal drugs
People who have had more than one sex partner
in the past 6 months or who have a history of
sexually transmitted diseases
Men who have sex with men
Household contacts and sex partners of people
who have hepatitis B
People who have blood-clotting disorders such as
hemophilia and have received clotting factors
from human donors
People who have a severe kidney disease that
requires them to have their blood filtered through
a machine (hemodialysis)
Health care workers and public safety workers
who are likely to be exposed to blood
Staff and residents of prisons or institutions for
the developmentally disabled
People who will spend more than 6 months in
parts of the world where hepatitis B is common or
where a large number of people have chronic
HBV infection.
Histology of liver of chronic hepatitis (inflammation)
Hepatitis C
Hepatitis C is a liver disease caused by
infection with the hepatitis C virus. The virus
causes liver inflammation, which interferes
with proper liver function. Hepatitis C can
eventually lead to severe, permanent liver
damage and cirrhosis and may be complicated
by liver cancer. Because the initial symptoms
are mild, hepatitis C often goes unnoticed
until years later when liver damage is
discovered.
There are six major strains or genotypes of
hepatitis C. Genotype 1 is the most common
type in the United States. Types 1, 2 and 3 are
found worldwide; type 4 is found throughout
Africa, 5 is common in South Africa, and 6 is
common in Asia.
Causes
Hepatitis C is caused by the hepatitis C virus
(HCV), which multiplies in liver cells.
How does it spread?
336
Histology of liver of chronic hepatitis (necrosis)
The incubation period is the time it takes for
the first symptoms to appear after the hepatitis
C virus has entered the body—usually about 2
weeks to 6 months.
Anyone who tests positive for the HCV
antibody is presumed to be contagious and
should take precautions (such as using a
condom during sex if you have more than one
partner, not sharing needles, and keeping cuts,
scrapes, or blisters covered) to avoid
spreading the infection.
The virus spreads through infected blood.
Sharing needles and other equipment (such as
cotton, spoons, and water) used to inject drugs
is the most common way HCV is spread.
The virus also can be spread by sexual
contact, but the risk is low, especially for
long-term monogamous couples. The risk
increases if you have many sex partners or if
one partner is infected. Having a sexually
transmitted disease (STD) or being infected
with HIV may increase the risk of HCV
infection.
 the possibility of becoming infected from a
blood transfusion is vanishing and now rare.
Organ transplant (such as a kidney, liver, or
pancreas) from a donor infected with HCV
also used to be a source of infection. Now,
however, all donor organs are screened for
HCV infection, so the risk of becoming
infected with HCV in this manner is very low.
In 10% of people who become infected with
HCV, the cause of infection is never known.
Symptoms
Hepatitis C is considered an acute illness
when first infected with the hepatitis virus.
During this stage symptoms may not be
Histology of liver of chronic hepatitis (fibrosis)
present or may mild, temporary, vague
Although the risk is low, pregnant women
symptoms such as fatigue and sore muscles
infected with the hepatitis C virus can pass it
appear. These symptoms usually resolve
to their babies—the risk is higher if the
within a few days or weeks. Many of those
woman also is infected with HIV. HCV does
with acute hepatitis C go on to develop
not spread from a mother to her baby through
chronic hepatitis C; up to 70% of those people
breast milk; however, breast-feeding women
develop liver damage; and around 40% of
should make sure their nipples are not cracked
those people do not have any symptoms.
or bleeding.
Normal, daily household contact with a
family member who has hepatitis C is not a
common means of spreading the illness.

Rash in patients with chronic HCV (porphyria cutanea

tarda)
Acute hepatitis C
Young children with short-term (acute)
hepatitis C usually have no symptoms. Some
of the following mild symptoms may develop
Purpuric rash and swelling on lower limb of a patient
of chronic HCV (cryoglobulinemia). in older children and adults:
In the past, it was possible to spread hepatitis Constant tiredness (fatigue)
Sore muscles
C through blood transfusions. Since 1992, all
Headache
donated blood has been screened for HCV, so

337
Widespread abdominal discomfort or discomfort
that is concentrated in the upper right quadrant of
the abdomen
Nausea
Dark urine or light (clay-colored) stools
Loss of appetite or weight loss
Aversion to some foods, particularly those that
are fatty or fried or high in protein
A less-common symptom of acute hepatitis C is
yellowing of the skin and the whites of the eyes
(jaundice).
Chronic hepatitis C Enlargement (ascites) of abdominal viscera due to
Chronic hepatitis C occurs when the infection chronic liver disease.
with or without noticeable inflammation of Other body systems affected by hepatitis C
the liver, lasts longer than 6 months. Most In addition to causing liver damage, hepatitis
people, especially young children, have no C may play a role in the development of:
symptoms once they develop chronic A disorder that makes the skin sensitive to
sunlight (porphyria cutanea tarda)
infection. If symptoms develop, they can
A skin disease that causes itchy, inflamed bumps
include: or papules (lichen planus)
Constant tiredness (fatigue) Inflammation of the salivary glands (sialadenitis)
A general sense of not feeling well (malaise) Abnormal amounts of a certain blood protein that
Mild abdominal discomfort can damage or block blood vessels
Itchy skin (pruritus) (cryoglobulinemia)
People who have been infected with the hepatitis Kidney disease (membranoproliferative
C virus for many years may develop the following glomerulonephritis)
symptoms of severe liver scarring (cirrhosis): An increase in the number of rheumatoid factors
Redness on the palms of the hands (palmar which are antibodies that indicate an infection is
erythema) caused by the expansion of small blood present in the body.
vessels (capillaries) A disorder that causes itchy, dry eyes
Clusters of blood vessels just below the skin that (keratoconjunctivitis sicca).
look like tiny red spiders (spider angiomas) and Thinning of the clear covering (cornea) of the eye
usually appear on the chest and shoulders (Mooren's ulcer)
Fluid buildup in the abdomen (ascites)
Swelling of the legs and feet (peripheral edema)
and, rarely, the arms
Breakdown (wasting) of muscles
Many other symptoms related to long-term
cirrhosis may develop. For more information, see
the topic Cirrhosis.
There are other conditions with similar symptoms
(such as hepatitis A or B, Epstein-Barr virus, or
cytomegalovirus) that may need to be ruled out
before a diagnosis of hepatitis C is confirmed. Lichen planus in the buccal cavity in a patient with
HCV
Exams and Tests
A thorough medical history and physical
examination give important information about
symptoms and the likelihood the exposure to
the virus that causes hepatitis C.

338
Hepatitis C is diagnosed with a hepatitis C
virus test, which is a blood test that detects
antibodies or genetic material (RNA) of the
virus that causes hepatitis.
If the hepatitis C antibody test is negative, do
other blood tests to find out what might be
causing liver inflammation.
Histology of mild chronic hepatitis due to HCV
If the hepatitis C antibody test is positive, a
liver biopsy and possibly diagnostic imaging
tests may be used to confirm the extent of any
liver damage. This information, along with
the type of virus (genotype) guides the
treatment plan. Genotypes 2 and 3 respond
better to treatment than genotype 1. If there
are little or no liver damage (fibrosis) and
have normal or only slightly elevated liver
enzyme levels that need no treatment. If you
have moderate but not extensive fibrosis, you
may have a good chance of responding to
treatment.
Histology of severe chronic hepatitis due to HCV
Treatment
Initial treatment of hepatitis C will depend on
whether the infection is in an early (acute)
stage or whether it has progressed (chronic).
339
Treatment of short-term (acute) hepatitis:
Acute hepatitis C may not be treated because
symptoms are usually mild or absent, and
hepatitis C is therefore often not diagnosed.
By the time HCV is detected in most people,
it has already progressed to long-term
(chronic) infection. However, when acute
hepatitis C is identified and treated with
medications (such as interferon), the
development of progressive, chronic infection
may be prevented. In one study, 98% of
people with acute infection who were treated
for 6 months with interferon alone had no
HCV in their blood and had normal liver
enzymes 6 months after treatment. Some
people-such as those who share needles or
health care workers stuck by a needle-may be
aware of their risk of acute infection and seek
early treatment.
Treatment of chronic hepatitis: Chronic
hepatitis C may be treated with a combination
of medicaments including herbal medicines.
Treatment if the condition gets worse
When hepatitis C progresses, it can cause
severe liver damage or end-stage liver failure;
In this case, a liver transplant may be the only
way to prevent death. However, if the person
is using alcohol, sharing needles to inject
drugs, or has severe depression or other
serious psychological disorders, liver
transplant may not be an option.
Prevention
No vaccine is available to prevent infection
with the virus that causes hepatitis C. A risk
of becoming infected can be reduced by:
Not sharing needles to inject drugs: Avoid
sharing of needles or other equipment (such
as cotton, spoons, and water) with others in
case of injecting drugs.
Practicing safer sex: Reduce number of sex
partners if these are more than one. Unless
they are in a long-term relationship in which
neither partner has sex with anyone else,
always use latex condoms correctly during
sex.

Classic sore on the muscles of patient with HCV
If some one works in a health care setting,
follow institution's standard precautions for
wearing protective gloves and clothing and
for disposing of needles and other
contaminated sharp objects.
Making sure the practitioner sterilizes the
instruments and supplies if there is a tattoo,
body pierced, or have acupuncture.
Donating blood as recommended before non-
emergency or elective surgery if a blood
transfusion may be needed even though the
risk of getting HCV infection from a blood
transfusion is very low.
If there is hepatitis C, take precautions
against spreading it by:
Not sharing needles or other equipment such as
cotton, spoons, and water if you continue to share
needles to inject drugs.
People in long-term, monogamous relationships
should discuss with their partners the risk of
getting HCV. People who have multiple sex
partners should always wear condoms.
Keeping any cuts, scrapes, or blisters covered to
prevent others from coming in contact with the
blood and other body fluids.
Avoiding donation of blood, sperm, or body
tissues
Washing your hands—and any object that has
come in contact with your blood—thoroughly with
water and soap
340
Refraining from sharing your toothbrush, razor,
diabetes supplies, or anything else, that might
have your blood on it.
Nursing mothers who have been infected with the
hepatitis C virus may continue to breast-feed their
babies. However, mothers should practice good
breast care to avoid cracked nipples, which might
pose a risk of spreading the virus to the baby. For
more information, see the topic Breast-Feeding.
There is risk of developing cirrhosis increases
if there are other liver diseases (such as
hepatitis B or diabetic liver disease). The
doctor may recommend either be tested for or
receive vaccinations for hepatitis A and B
viruses.
Important features
If you have been diagnosed with the chronic
liver disease hepatitis C, it is important that
you do everything you can to keep severe
liver damage from developing. Lifestyle
changes such as not using alcohol, not sharing
needles for drug use, and avoiding herbal
supplements which have not been
recommended by your doctor may help slow
the progression of chronic hepatitis C.
Although there is no vaccine for hepatitis C,
your doctor may still advise you to have
vaccines to prevent infection with the
hepatitis A and hepatitis B viruses and protect
you from further liver inflammation.
The U.S. National Institutes of Health has
made recommendations on who should
receive antiviral treatment for hepatitis C. For
example, treatment is recommended for
people who are 18 and older who have
detectable levels of HCV in the blood, or who
have significant liver damage confirmed with
a liver biopsy. For people who do not meet
these criteria, the decision to try antiviral
therapy is more complicated.
Antiviral therapy is expensive, and the
medications often cause unpleasant side
effects, including flu like symptoms such as
constant fatigue, nausea, headaches, and
severe depression.
Researchers are working to develop other
treatments, including gene therapy and
medications that regulate the immune system infection with HDV is unknown, but their
(interleukin-10). proper use may reduce transmission);
Hepatitis D By sharing drugs, needles, or "works" when
Hepatitis D is a disease caused by a small "shooting" drugs;
circular RNA virus Through needle sticks or sharps exposures on
Signs & symptoms the job; or
Jaundice From an infected mother to her baby during
Fatigue birth
Abdominal pain Risk groups
Loss of appetite Injection drug users
Nausea, vomiting Men who have sex with men
Joint pain Hemodialysis patients
Dark (tea colored) urine Sex contacts of infected persons
HDV can be acquired either as a co-infection Health care and public safety workers
(occurs simultaneously) with hepatitis B virus Infants born to infected mothers (very rare)
(HBV) or as a super-infection in persons with Treatment & medical management
existing chronic HBV infection. Acute HDV infection
HBV-HDV co-infection may have more Supportive care
severe acute disease and a higher risk (2%- Chronic HDV infection
20%) of developing acute liver failure Interferon-alfa
compared with those infected with HBV Liver transplant
alone HBV-HDV super infection chronic Prevention
HBV carriers who acquire HDV super Hepatitis B vaccination
infection usually develop chronic HDV HBV-HDV co-infection
infection progression to cirrhosis is believed Pre- or post-exposure prophylaxis (hepatitis
to be more common with HBV/HDV chronic B immune globulin or vaccine) to prevent
infections HBV infection
HBV-HDV super infection
Education to reduce risk behaviors among
persons with chronic HBV infection
Vaccine recommendations
Hepatitis B vaccine should be given to
prevent HBV/HDV co-infection
HEPATITIS E

How does it spread?

HDV occurs when blood from an infected
person enters the body of a person who is not
immune
HDV is spread through having sex with an
infected person without using a condom (the HEV was not recognized as a distinct human
efficacy of latex condoms in preventing disease until 1980. Hepatitis E is caused by

341
infection with the hepatitis E virus, a non-
enveloped, positive-sense, single-stranded
RNA virus.
Although man is considered the natural host
for HEV, antibodies to HEV or closely related
viruses have been detected in primates and
several other animal species.
How does it spread?
HEV is transmitted via the fecal-oral route.
Hepatitis E is a waterborne disease, and
contaminated water or food supplies have
been implicated in major outbreaks.
Consumption of fecal contaminated drinking
water has given rise to epidemics, and the
ingestion of raw or uncooked shellfish has
been the source of sporadic cases in endemic
areas. There is a possibility of zoonotic spread
of the virus, since several non-human
primates, pigs, cows, sheep, goats and rodents
are susceptible to infection. The risk factors
for HEV infection are related poor sanitation
in large areas of the world, and HEV shedding
in faeces.
Person-to-person transmission is uncommon.
There is no evidence for sexual transmission
or for transmission by transfusion.
The highest rates of infection occur in regions
where low standards of sanitation promote the
transmission of the virus. Epidemics of
hepatitis E have been reported in Central and
South-East Asia, North and West Africa, and
in Mexico, especially where fecal
contamination of drinking water is common.
However, sporadic cases of hepatitis E have
also been reported elsewhere and serological
surveys suggest a global distribution of strains
of hepatitis E of low pathogenicity.
The disease
The incubation period following exposure to
HEV ranges from 3 to 8 weeks, with a mean
of 40 days. The period of communicability is
unknown. There are no chronic infections
reported.
Hepatitis E virus causes acute sporadic and
epidemic viral hepatitis. Symptomatic HEV
infection is most common in young adults
342
aged 15-40 years. Although HEV infection is
frequent in children, it is mostly
asymptomatic or causes a very mild illness
without jaundice (anicteric) that goes
undiagnosed.
Sign and symptoms
Typical signs and symptoms of hepatitis
include jaundice (yellow discoloration of the
skin and sclera of the eyes, dark urine and
pale stools), anorexia (loss of appetite), an
enlarged, tender liver (hepatomegaly),
abdominal pain and tenderness, nausea and
vomiting, and fever, although the disease may
range in severity from sub-clinical to
fulminant.
Exam and test
Since cases of hepatitis E are not clinically
distinguishable from other types of acute viral
hepatitis, diagnosis is made by blood tests
which detect elevated antibody levels of
specific antibodies to hepatitis E in the body
or by reverse transcriptase polymerase chain
reaction (RT-PCR). Unfortunately, such tests
are not widely available.
Hepatitis E should be suspected in outbreaks
of waterborne hepatitis occurring in
developing countries, especially if the disease
is more severe in pregnant women, or if
hepatitis A has been excluded. If laboratory
tests are not available, epidemiologic
evidence can help in establishing a diagnosis.
Treatment
Hepatitis E is a viral disease, and as such,
antibiotics are of no value in the treatment of
the infection. There is no hyper-immune E
globulin available for pre- or post-exposure
prophylaxis. HEV infections are usually self-
limited, and hospitalization is generally not
required. No available therapy is capable of
altering the course of acute infection.
As no specific therapy is capable of altering
the course of acute hepatitis E infection,
prevention is the most effective approach
against the disease. Hospitalization is required
for fulminant hepatitis and should be
considered for infected pregnant women.
Surveillance and control procedures should
include:
Provision of safe drinking water and proper
disposal of sanitary waste
Monitoring disease incidence
Determination of source of infection and
mode of transmission by epidemiologic
investigation
Detection of outbreaks
Spread containment
Vaccines
At present, no commercially available
vaccines exist for the prevention of hepatitis
E. However, several studies for the
development of an effective vaccine against
hepatitis E are in progress.
Prevention
As almost all HEV infections are spread by
the fecal-oral route, good personal hygiene,
high quality standards for public water
supplies and proper disposal of sanitary waste
have resulted in a low prevalence of HEV
infections in many well developed societies.
For travelers to highly endemic areas, the
usual elementary food hygiene precautions
are recommended. These include avoiding
drinking water and/or ice of unknown purity
and eating uncooked shellfish, uncooked
fruits or vegetables that are not peeled or
prepared by the traveler.
Important features:
Determination of the mode of transmission
Identification of the population exposed to
increased risk of infection
Elimination of a common source of infection
Improvement of sanitary and hygienic
practices to eliminate fecal contamination of
food and water
HEPATITIS G
343
Hepatitis G Virus is an RNA virus
(ribonucleic acid) similar to, but distinct from,
the hepatitis C virus.
Hepatitis G virus is a newly identified virus.
It was found after people who had a blood
transfusion developed ‘post transfusion
hepatitis’ which could not be identified as any
known virus.
Infection with the hepatitis G virus can lead to
persistent infection in 15 – 30% of adults. The
long term outcomes of the infection are not
yet known. People with hepatitis A, B, or C
can be co- or super- infected with hepatitis
G.
Causes
Hepatitis G Virus (HGV): Also known as GB
virus-C (GBV-C)
HGV and GB virus-C were discovered about
the same time, and are thought to be different
strains of the same virus (referred to below as
HGV/GBV-C).
HGV/GBV-C was first described in 1995-96
HGV/GBV-C is a single stranded RNA virus
belonging to the Flaviviridae family
Clinical Characteristics
Carrier rate of between 2 and 5% in the
general population
Causes persistent infection for up to 9 years in
15-30% of adults
HGV/GBV-C is often found in co-infections
with other viruses, such as hepatitis C virus
(HCV), hepatitis B virus (HBV), and Human
Immunodeficiency Virus (HIV)
There is little proof that Hepatitis G (Hep G)
causes serious liver disease at any age. It is
possible that HGV/GBV-C may not be a true
'hepatitis' virus.
Signs and Symptoms
Almost no cases have symptoms like the other
Hepatitis viruses.
How does it spread?
Transmitted by infected blood or blood
products
HGV/GBV-C can be transmitted by sharing
personal items contaminated with the virus
and other similar behaviours (parenterally),
from mother-to-newborn child at birth
(vertical), or various sexual activities.
Treatment
There is currently no recommended treatment
for Hepatitis G.
Prevention
If you are regularly exposed to blood or blood
products from others, try to protect yourself
with gloves to reduce the risk of the spread of
viruses.
If you use injection drugs, ensure you use
clean, sterile needles. Sharing needles,
syringes or other drug-use equipment with
others can put you at risk of infection.
Home Treatment
Although no specific medical treatment is
given for hepatitis A, home treatment can
help relieve symptoms and prevent the spread
of the virus.
Reduce activity level to match body energy
level. Do not stay in bed; it may slow
recovery and slow down the activities when
become tired.
Don't go to work or school unless workload
can be decreased to match energy level.
Avoid strenuous exercise
When start to feel better, go back to regular
activities gradually. To meet your regular
pace too soon, then it is possible to get sick
again.
Eat right
Even though food may not appeal, but it is
important to get adequate nutrition. Try eating
small, frequent meals instead of three large
meals. For most people, nausea and loss of
appetite don't set in until later in the day. Try
eating more in the morning and less in the
day.
Try to maintain a balanced diet while eating
foods that appeal.
Avoid dehydration: It is very important to
keep the body well hydrated when hepatitis A
is there, especially if vomiting is the reason.
Contact health professional immediately or
the nearest emergency room if vomited more
than two times in one day.
344
Drink plenty of water; fruit juices and broth
are other good choices because they provide
additional calories
Many of the sports drinks available in grocery
stores can help replace essential electrolytes
that are lost through vomiting
Avoid alcohol and drugs: Hepatitis impairs
liver's ability to break down certain medicines
and alcohol. If drugs (legal or illegal) or
alcohol is taken when hepatitis is there the
effects may become more powerful and last
longer. In addition, alcohol and some
medications can make liver damage worse.
Do not take any new medications or stop
taking existing prescription medications
without the doctor's approval.
Try to control itching: People with hepatitis
sometimes develop itchy skin. Use
nonprescription medications, such as
Benadryl or Chlor-Trimeton, to control the
itching. Be sure to follow the instructions for
use that are provided with the product, and
stop using the product if there is any side
effect.
A REPORT FROM DAILY TIMES
One out of every 10 Pakistanis suffers from
either Hepatitis B or C. Almost 15 million
patients infected with the disease have waited
for several years for a campaign against the
deadly disease.
Unsafe drinking water, unscreened blood
transfusions and used syringes have made
Hepatitis one of Pakistan’s greatest health
concerns.
Health professionals and the government are
making conflicting statistics on Hepatitis B
prevalence in the country. According to these
statements, the rate may vary from 4.8 to 5.8
percent.
The Extended Program of Immunization
(EPI) launched an anti-hepatitis campaign in
the country and set out to immunize 80
percent of all children. This, however, did not
improve conditions significantly.
The program has been facing problems in the
rural areas of the country where parents are
not cooperative on the immunization of
children under the age of one.
Although millions of Pakistanis are infected
with the deadly Hepatitis virus, no concerned
public department or agency has accurate
statistical information. The 5.8 percent
prevalence rate suggests that there may be
around 8 million patients in the country.
The virus has five types, A, B, C, D and E.
Hepatitis A and E are caused by oral
infection, contaminated water and unhygienic
food. Hepatitis B, C and D are caused by un-
sterilised syringes, sexual intercourse, blood
transfusion, and from mother to infant.
Hepatitis B and C are global health problems.
There are 350 million Hepatitis B carriers
worldwide. Medical experts associate the fast
increase in Hepatitis B cases to ignorance and
a lack of appropriate preventive measures.
The efforts against Hepatitis in Pakistan are
being supported by the Global Alliance for
Vaccines and Immunization (GAVI), which is
financially supported by the Bill and Melinda
Gates Foundation. Pakistan is expected to
receive 81.093 million medicinal doses from
GAVI to immunize more than 21 million
children by the end of the year 2005.
It is claimed that the hepatitis B virus is 100
times more concentrated in the blood than the
HIV, virus making it much easier to be
transmitted through bodily fluids such as
blood, semen, saliva and vaginal secretions.
Hepatitis C is often called the “silent
epidemic”. The virus can live in the body for
decades, often with no symptoms,
continuously damaging the liver. The long-
term consequences of hepatitis C include liver
diseases such as liver cancer, and may even
cause death. There is also neither a cure nor a
vaccine for hepatitis C.
The federal government is set to launch the
first ever “National Program for Prevention
and Control of Hepatitis in Pakistan” today
(Monday). An official of the National
Institute of Health estimates that the five-year
program will cost Rs 2.59 billion.
345
The major goals of the program include
ensuring safe drinking water, safe blood
transfusions, the safe disposal of injection and
invasive devices, capacity building,
vaccination of high risk groups, and the free
treatment of over 5,000 patients annually.
REFERENCES
Alberti A, et al. (2003). Prevalence of liver disease in a
population of asymptomatic persons with hepatitis C
virus infection. Annals of Internal Medicine, 137:
961–964.
American Academy of Pediatrics (2000). Hepatitis C.
In LK Pickering, ed., 2000 Red Book: Report of the
Committee on Infectious Diseases, 25th ed., pp. 302–
306. Elk Grove, IL: American Academy of
Pediatrics.
American Academy of Pediatrics (2003). Hepatitis A.
In LK Pickering, ed., Red Book: 2003 Report of the
Committee on Infectious Diseases, 26th ed., pp. 309–
318. Elk Grove Village, IL: American Academy of
Pediatrics.
Bell BP, et al. (2004). Hepatitis A virus. In RD Feigin
et al., eds., Textbook of Pediatric Infectious
Diseases, 5th ed., vol. 2, pp. 2069–2086.
Philadelphia: Saunders.
Berenguer M, Wright TL (2002). Hepatitis C virus
section of Viral hepatitis. In M Feldman et al., eds.,
Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 7th ed., vol. 2, pp. 1303–1323.
Philadelphia: W.B. Saunders.
Berenguer M, Wright TL (2002). Viral Hepatitis. In M
Feldman et al., eds., Sleisenger and Fordtran's
Gastrointestinal and Liver Disease, 7th ed., vol. 2,
pp. 1278–1303. Philadelphia: W.B. Saunders.
Bloodborne Pathogens Section, Blood Safety
Surveillance and Health Care Acquired Infections
Division, Health Canada, 2003
Boucher EJ, et al. (2003). High rate of long-term
virological response after a 1-year course of
interferon plus ribavirin in chronic hepatitis C
relapsers: Results of a 191-patient randomized trial.
Liver International, 23(4): 255–261.
Bressler BL, et al. (2003). High body mass index is an
independent risk factor for nonresponse to antiviral
treatment in chronic hepatitis C. Hepatology, 38(3):
639–644.
Centers for Disease Control and Prevention (1999).
Prevention of hepatitis A through active or passive
immunization: Recommendations of the Advisory
Committee on Immunization Practices (ACIP).
MMWR, 48(RR-12): 1–37.
Centers for Disease Control and Prevention (2002).
Sexually transmitted diseases treatment guidelines.
MMWR, 51(RR-6): 64–66.
Centers for Disease Control and Prevention (2003).
Hepatitis Surveillance Report No. 58, pp. 1–24.
Atlanta, GA: U.S. Department of Health and Human
Services, Centers for Disease Control and
Prevention.
Centers for Disease Control and Prevention (2004).
Hepatitis A Fact Sheet.
Chin J (2000). Viral hepatitis B. In Control of
Communicable Diseases Manual, 17th ed., pp. 243–
251. Washington, DC: American Public Health
Association.
Committee on Infectious Diseases, American Academy
of Pediatrics (2000). Hepatitis B. In LK Pickering et
al., eds., 2000 Red Book: Report of the Committee
on Infectious Diseases, 25th ed., pp. 289–302. Elk
Grove, IL: American Academy of Pediatrics.
Committee on Infectious Diseases, American Academy
of Pediatrics (1998). Hepatitis C virus infection.
Pediatrics, 101(3): 481–485.
Cuthbert JA (2001). Hepatitis A: Old and new. Clinical
Microbiology Reviews, 14(1): 38–58.
Dieperink E, et al. (2000). Neuropsychiatric symptoms
associated with hepatitis C and interferon alpha: A
review. American Journal of Psychiatry, 157(6):
867–876.
Hattori Y, et al. (2003). Loss of hepatitis C virus RNA
after parturition in female patients with chronic HCV
infection. Journal of Medical Virology, 71: 205–211.
Hepatitis C Resource Centers (2003). Treatment
Recommendations for Patients With Chronic
Hepatitis C: June 2003 Version 4.0, pp. 1–38.
Washington, DC: Department of Veterans Affairs.
Jaeckel E, et al. (2001). Treatment of acute hepatitis C
with interferon alfa-2b. New England Journal of
Medicine, 345(20): 1452–1457.
Koff RS (2001). Nonresponse to interferon in chronic
hepatitis C: Re-treatment redux. JAMA, 285(2): 212–
214.
346
Leder K, et al. (2001). Travel vaccines and elderly
persons: Review of vaccines available in the United
States. Clinical Infectious Diseases, 33(9): 1553–
1566.
Lindsay KL, Hoofnagle JH (2000). Chronic hepatitis
C. In L Goldman, JC Bennett, eds., Cecil Textbook
of Medicine, 21st ed., vol. 1, pp. 794–795.
Philadelphia: W.B. Saunders.
Lok ASF, McMahon BJ (2001). Chronic hepatitis B.
AASLD Practice Guidelines. Hepatology, 34(6):
1225–1241.
Management of hepatitis C: 2002. Consensus
Development Conference statement, National
Institutes of Health Consensus Development
Conference (2002 June 10–12). NIH Consensus
Program.
Manns MP, et al. (2001). Peginterferon alfa-2b plus
ribavirin compared with interferon alfa-2b plus
ribavirin for initial treatment of chronic hepatitis C:
A randomised trial. Lancet, 358: 958–965.
National Institutes of Health (2000). Hepatitis C:
Treatment alternatives. National Center for
Complementary and Alternative Medicine.
Peginterferon alfa-2A (Pegasys) for chronic hepatitis C
(March 2003). Medical Letter on Drugs and
Therapeutics. Available online:
http://www.medletter.com.
Szabo G, et al. (2000). Management of recurrent
hepatitis C after liver transplantation: A concise
review. American Journal of Gastroenterology,
95(9): 2164–2170.
U.S. Centers for Disease Control and Prevention
(2003). Viral Hepatitis B Fact Sheet.
World Health Organization (2003). Vaccines,
immunizations, and biologicals: Hepatitis B.
Note: Most of the Matters are drived from Internet and
Research Papers
Chapter-13

347
348
EPIDEMIOLOGY, DIAGNOSIS AND TREATMENT OF
HEPATITIS
Acute and chronic liver diseases are an
assortment of disorders brought to the
clinician’s attention by abnormal liver
function tests or specific signs and symptoms.
The differential diagnosis includes disorders
that have primary or secondary liver
involvement. This paper will be limited to the
epidemiology, clinical manifestations,
diagnosis, treatment, and prevention of the
different viral liver diseases: A, B, C, D, E
and G.
The word hepatitis connotes an infection or
inflammation of the hepatocytes, as evidenced
by abnormal liver function tests (LFTs). This,
however, is a nonspecific term since the
laboratories combine hepatic enzyme tests
(aspartate aminotransferase [AST], alanine
aminotransferase [ALT]) and synthetic tests
(albumin, bilirubin, and prothrombin time
[PT]) into LFTs. These tests can be elevated
in a healthy individual. The differential
diagnoses of hepatitis should include, at a
minimum: virus infection; drugs or alcohol
abuse; hemochromatosis; thyroid, muscle, and
autoimmune disorders; celiac disease; alpha-1
antitrypsin deficiency; Wilson’s disease;
masses; and fatty liver. This article will be
limited to the current appraisal of the
epidemiology, clinical manifestations,
diagnosis, and treatment of the different viral
hepatic disorders: hepatitis A, B, C, D, E, and
G.
HEPATITIS A
Epidemiology
Hepatitis A virus (HAV) was first recognized
in 1947, but it has been around for centuries.
The two distinct forms of the virus were only
identified in 1973, consisting of a RNA virus
with four genotypes. It occurs worldwide but
is highly prevalent in the developing countries
and Greenland; however, the global incidence
is decreasing because of improved sanitary
349
and living conditions. In the United States, the
incidence of hepatitis A has declined
dramatically with the institution of the
hepatitis A vaccine. HAV is spread mainly by
the fecal oral route in low-socioeconomic
areas, but person-to-person spread has
occurred in daycare centers, as have
community epidemics from contaminated
foods (Mexican green onions).4 Sexual
intercourse, blood, and intravenous drugs are
minor routes of transmission of this virus as
opposed to the other viral hepatitis disorders.
Clinical Manifestations HAV infection is
usually an acute, self-limiting disease with no
sequelae or chronic disease state. Its
manifestations vary according to the age of
the patient at presentation. Children usually
have a silent or subclinical course as opposed
to adults, who present with a wide range of
symptoms, from an influenza-like illness to
fulminant hepatic failure.
Diagnosis
The diagnosis of HAV infection is made by
the presence of antibodies against HAV in
conjunction with the clinical picture. The
incubation period is 30 days, with a range of
15 to 50 days. Hepatitis A virus (HAV)
immunoglobulin M (IgM) is the gold standard
for making the diagnosis; however HAV IgG
appears early and remains positive for
decades.
Treatment
Since HAV is usually a self-limiting disease,
treatment is generally supportive. Eighty-five
percent of patients recover by three months,
and nearly 100% will recover by six months.
Death can occur in elderly patients or in those
concomitantly infected with hepatitis C virus
(HCV).
Prevention
Since HAV is predominately spread by the
fecal-oral route, the mainstay of prevention is
thorough hand washing, heating foods
properly, and avoiding water and raw foods in
endemic areas. Household bleach
(1:100dilution) will adequately inactivate the
virus. Passive immunity with intramuscular
serum immune globulin, given within two
weeks of exposure, will also provide
protection against this virus.
Vaccinations
The current epidemic of hepatitis A could be
avoided though a worldwide viral campaign.
The vaccines are safe, efficacious, and
relatively inexpensive. The live, attenuated
vaccine is no longer in use because of the
superiority of the inactivated vaccines.
Therefore, the inactivated vaccines are the
only Food and Drug Administration (FDA)-
approved vaccines that are used in the United
States. The inactivated vaccine provides
almost a 100% seroconversion rate and a
higher antibody response than even serum
immune globulin.
Acute viral hepatitis (AVH) is a systemic
infection affecting the liver predominantly. It
is caused by six distinct types of viruses A, B,
C, D, E and G. Acute viral hepatitis is defined
as those cases which have acute self limited
disease and a serum aspartate
aminotransferase elevation of atleast five fold
or clinical jaundice or both. Fulminant
hepatic failure is considered when the patient
after having a typical acute hepatitis, develops
hepatic encephalopathy within four weeks. It
is characterized by mental changes
progressing from confusion to stupor and
coma as a result of severe impairment of
hepatic function, without any history of pre-
existing liver disease.
Viral hepatitis in pregnancy has been a
subject of continuing interest and controversy.
Reports from Europe and United States have
shown the course of viral hepatitis during
pregnancy to be in no way different from non
pregnant women. However, studies carried
out in India, Iran, Africa and Middle East has
found the incidence of fulminant hepatitis to
350
be higher in pregnancy. Malnutrition
superimposed on the normal demands of
pregnancy and inversion of T and B
lymphocytes in early pregnancy have been
postulated to be the contributing factors.
HEV infection alone is responsible for 47.4%
of the cases of viral hepatitis in pregnant
females in the third trimester. This is
corroborative with the fact that HEV infection
accounts for 50-70% of all patients with
sporadic viral hepatitis in India. In pregnant
females in third trimester with viral hepatitis,
the prevalence of HEV infection is
reoportedly between 40-57%. HAV infection
was less common (0% vs 5.2%) and HBV
infection more common (34.6% vs 7.2%) in
central India. HCV infection was not seen in
any case as was also observed by other
groups. This is explained by the low
prevalence of high risk factors for HCV
transmission in the study group. Seventy five
percent of the FHF cases were HEV positive.
Thus, HEV was the most common
hepatotrophic virus associated with FHF.
Among the HEV positive pregnant females,
the mortality rate was 39.1%. The mortality
rate is in the range of 30-45% and may be as
high as 70%. Majority of the cases die
undelivered. Two of the five (40%) HAV
positive patients expired out of which one had
co-infection with HEV. One pregnant female
who died had co-infection with HBV and
HEV. Five of the 46 (10.8%) patients in non
A-E group expired. Thus, HEV was
associated with a high mortality rate among
pregnant women.
HEPATITIS B
Epidemiology
Hepatitis B virus (HBV) is a global problem,
with .350 million carriers worldwide and
>1.25 million in the United States. An
estimated 100,000 acute infections occur
every year in the United States. The mortality
is substantial; each year 5000 patients in the
United States and >1 million worldwide die.
In high-prevalence areas, the predominant
mode of transmission is perinatal, while in
low-prevalence areas it is by sexual
transmission and intravenous drug use. Blood
transfusions are another source of spread of
HBV, which remains the number one
transmitted blood-borne virus in the
healthcare environment.6 Individuals with
HBV are at risk of developing chronic
infection, cirrhosis, hepatic decompensation,
and hepatocellular carcinoma. After the acute
infection, 3%–5% of adults and up to 95% of
children fail to produce a sufficient immune
response to clear the infection, thus going on
to chronic hepatitis B.
Clinical Manifestations
The clinical manifestations encompass a wide
spectrum in the acute as well as the chronic
state. The virus has an incubation period of
two to six weeks. Up to 70% of the acute
cases present as a subclinical anicteric state,
and the remainder present with jaundice,
nausea and vomiting, fevers, right upper
quadrant pain, and hepatomegaly or fulminant
hepatic failure. Some of these can also present
with extra hepatic manifestations. If the LFTs
are still elevated after six months, then the
individual is considered to have a chronic
HBV infection, but most patients with chronic
hepatitis B are asymptomatic.
Diagnostic Markers
The diagnosis of HBV is based on the clinical
presentation (complete history and physical);
serologic, virologic, and biochemical
markers; and occasionally histologic markers.
Hepatitis B surface antigen (HBsAg) is the
first serologic marker to appear after
infection. Hepatitis B ‘‘e’’ antigen (HBeAg)
indicates active viral replication, which makes
a patient highly contagious. Hepatitis B core
antibody (HBcAb) appears next and implies
an acute or chronic state or early recovery
period. Hepatitis B surface antibody (HBsAb)
is the last to appear and implies recovery,
immunity, or the post-vaccine state. Hepatitis
B virus (HBV) DNA is a virologic marker
351
that measures the level of viral replication. In
the past, this was measured by nonamplified
hybridization assays, which have been
replaced by the current target amplification
assays, such as polymerase chain reaction
(PCR). Hepatitis B virus (HBV) has eight
genotypes (A–H) based on DNA sequencing
and geographic distribution. However,
genotype testing is not used in clinical
practice because its relevance remains
uncertain and controversial. Elevated LFTs
are an indication of necroinflammation and
represent the biochemical markers. An
elevated PT, in conjunction with a low
albumin, usually indicates a poor prognosis or
chronicity. Histologic examination by liver
biopsy is the most specific and accurate
indicator of liver disease. Most individuals do
not need a biopsy for diagnosis or prognosis.
However, some individual with normal LFTs,
and elevated HBV DNA levels have
substantial fibrosis on biopsy.
Treatment of HBV
The goals of HBV treatment are to 1) prevent
cirrhosis and its complications; 2) prevent
hepatocellular carcinoma; 3) obtain
undetectable HBV DNA levels; 4) normalize
LFTs; 5) eradicate HBeAg; and 6) improve
histology. The dilemma is that the above aims
are difficult to achieve because no standard
treatment algorithms, guidelines, or treatment
endpoints exist and because, patients usually
present with conflicting data. Treatment
should be considered for individuals who are
HBsAg-positive or DNA-positive by PCR.
The care of the patient with normal ALT adds
a further dilemma to the treatment options.
With or without treatment, circulating HBsAg
can disappear but HBV DNA can be found by
PCR in the liver of many individuals.
Regardless of the treatment, many experts
believe that chronic HBV infection can be
controlled but not cured. Agents used to treat
HBV include interferon, lamivudine, adefovir,
entecavir, and telbivudine.11 Tenofovir is
approved to treat HIV and HBV coinfection
only. The Asian-Pacific guidelines also
include thymosin alpha, which is not an FDA-
approved drug. Interferon was the first drug
used to treat HBV in most countries and has
antiviral, antiproliferative, and
immunomodulatory effects; in addition, it can
achieve a durable response after a finite
course of treatment (24–52 weeks). In
general, elevated LFTs and low HBV DNA
are the best predictors of treatment
response.12 Interferon therapy, however, is
costly, must be given by injection, and has
many side effects.
The nucleoside/nucleotide analogues are more
potent than interferon in suppressing the HBV
DNA levels and can lead to undetectable
levels by PCR; however, interferon has
immunmoduatory effects and is the only drug
associated with HBVsAg conversion.
Interferon usually causes a flare in the ALT
level because of immunemediated lyses of the
hepatocytes. This response, coupled with a
later normalization of LFTs and a decrease in
inflammation, heralds a good prognosis.
Polyethylene glycol (PEG) is attached to the
interferon molecule to decrease its rate of
absorption and renal and cellular clearance,
which increases its half-life. This
characteristic has propelled PEG-interferon as
the drug of choice over standard interferon.14
PEG interferon is safe in compensated but not
decompensated cirrhosis. Lamivudine, a
nucleoside analog, was originally used to treat
HIV disease. For HBV, it is well tolerated, is
given orally (100 mg/day), is relatively
inexpensive ($7/day), has minimal side
effects, and can be used in decompensated
cirrhosis; however, it is associated with a high
rate of drug resistance. Adefovir, a nucleotide
analog of adenosine, can be used in
HBeAgpositive or HBeAg-negative patients
and with compensated or decompensated
cirrhosis. Its route of administration is oral
(10 mg/day) at a cost of $15–$20/day. It has a
low rate of drug resistance, but its duration of
therapy is greater than one year, and the dose
352
needs to be adjusted in renal insuffiency.
Adefovir can be added to lamivudine in case
of lamivudine resistance; therefore, most
physicians prefer adefovir. Entecavir is a
nucleoside analog that is given orally at
0.51mg/day that suppresses HBV DNA levels
to a greater extent than lamivudine and
adefovir. It is associated with a low rate of
drug resistance, and the duration of therapy is
greater than one year. Entecavir has few side
effects, but like lamivudine, it has a black box
warning as a potential cause of lactic acidosis,
hepatomegaly, and steatosis. Tenofovir is a
nucleotide analog similar to adefovir, but it is
more potent. It is effective against HIV and
HBV and should only be used in coinfection
with both diseases. Telbivudine is a
nucleoside analogue that was recently
approved by the FDA. It is administered
orally (600 mg/day) and might suppress HBV
DNA levels to a greater extent than the
previous medications.
HBV Prevention
There are more than 350 million carriers
worldwide with HBV and almost one million
deaths per year. The greatest hope to prevent
this disease is through primary prevention:
safe sexual practices, intravenous drug
avoidance, and vaccination to increase herd
immunity. The HBV vaccine is safe, is
relatively inexpensive, has a high
seroconversion rate, and is given in three
doses intramuscularly.
HEPATITIS C
The hepatitis C virus (HCV) is a small
enveloped RNA virus belonging to the family
flaviviridae and genus hepacivirus. The HCV
RNA genome is 9,600 nucleotides in length
and encodes a single polyprotein that is post-
translationally cleaved into 10 polypeptides
including t3 structural (C, E1, and E2) and
multiple nonstructural proteins ([NS] NS2 to
NS5). The NS proteins include enzymes
necessary for protein processing (proteases)
and viral replication (RNA polymerase). The
virus replicates at a high rate in the liver and
has marked sequence heterogeneity. There are
6 genotypes and more than 90 subtypes of
HCV, the most common in the United States
being 1a and 1b (approximately 75%), 2a and
2b (approximately 15%), and 3 African Americans.17 Most acutely infected
(approximately 7%). Acute hepatitis C is
marked by appearance of HCV RNA in serum
within 1 to 2 weeks of exposure followed by
serum alanine aminotransferase (ALT)
elevations, and then symptoms and jaundice.
Antibody to HCV (anti-HCV) tends to arise
late. In acute resolving hepatitis, HCV RNA
is cleared and serum ALT levels fall to
normal. However, 55% to 85% of patients do
not clear virus, but develop chronic hepatitis
C. Chronic hepatitis C is often asymptomatic,
but is usually associated with persistent or
fluctuating elevations in ALT levels. The
chronic sequelae of hepatitis C include
progressive hepatic fibrosis, cirrhosis, and
hepatocellular carcinoma. Extra-hepatic
manifestations include sicca syndrome,
cryoglobulinemia, glomerulonephritis, and
porphyria cutanea tarda. Knowledge of the
course and outcome of hepatitis C is
important in developing approaches to
management and therapy.
Epidemiology
Hepatitis C infection affects >170 million
people worldwide and >4 million Americans,
but most are asymptomatic and unaware of
their disease.16 Most patients acquired HCV
by injection drug use or through pre-1990
blood transfusions. In the 1980s, 230,000 new
cases were diagnosed each year in the United
States, but now only 36,000 cases are
diagnosed year because of decreased injection
drug use and increased awareness. The risk of
transmission between monogamous partners
is low but rises with multiple sexual partners.
Rare forms of percutaneous transmissions are
tattoos, body piercing, and intranasal cocaine
use. HCV is a small RNA virus with six
genotypes and was first identified in 1989.
Genotype 1 accounts for 70%– 75% of all
HCV infections in the United States. It is the
353
most common blood-borne infection in the
United States, and the highest prevalence is in
persons aged 30–49 years old. In this age
group, the highest prevalence occurs in
patients area symptomatic or has a sub-
clinical infection without jaundice. Chronic
HCV infection develops in 60%–80% of
infected persons, probably secondary to rapid
mutations that cause a failure in T-cell
immune recognition. Hepatitis C virus (HCV)
is the number one cause of chronic liver
disease, cirrhosis, and liver transplantation in
the United States.
Diagnostic Tests
Hepatitis C virus (HCV) DNA in the serum or
liver is the first sign of infection. The virus
becomes positive in tests days to weeks after
exposure. This test detects, quantifies, and
characterizes the viral particle components.
This test is further broken down into a
qualitative and a quantitative test. The
qualitative test is more sensitive, 98%–99%
specific, and is done by either PCR or by
transcription-mediated amplification (TMA).
The quantitative test can detect 50 copies of
the virus and is done by either PCR, TMA, or
branched chain DNA (bDNA). The indirect
tests (HCV and genotyping) detect antibodies.
The third generation enzyme assay detects
HCV proteins. It becomes positive eight
weeks after exposure and detects 99% of
immunocompetent individuals. The
recombinant immunoblot assay now has
limited utility thanks to this third generation
test. HCV genotyping detects type-specific
antibodies and predicts treatment response.
Table 1. Factors associated with SVR
Viral Adherence
- Genotype (2 or 3) - More than 80% of
intended
- Lower HCV RNA level - treatment for more than
80%
- Early virologic response - of intended duration
Disease-related Host factors
- Absence of advanced - Lower body weight
fibrosis
- Lack of steatosis - Younger age
- Higher ribavirin dose - Women
- non African -American
Liver function tests (LFTs) start to rise 6–12
weeks after exposure, with a range of 20–26
weeks. However, ALT level correlates poorly
with disease activity and many individuals
have normal levels despite having chronic
HCV. The National Institutes of Health (NIH)
Consensus Development Conference in 1997
endorsed pretreatment liver biopsy as the gold
standard for assessing inflammation (grade)
and extent of fibrosis (stage) in anticipation of
instituting antiviral therapy.18 It is also used
to determine the urgency of treatment and
prognosis, and it can rule out other diseases,
such as fatty liver, alcoholic liver disease, and
hemochromatosis.
A liver biopsy is not necessarily needed with
genotypes 2 and 3, since these are associated
with an excellent prognosis. In untreated
patients, a repeat liver biopsy — the only
reliable means of assessing the progression of
fibrosis — is recommended every three to
five years. Several histologic classifications
are used to standardize results and
comparisons when assessing results in
different clinical trials. The three common
scoring systems are Knodell, Metavir, and
Ishak systems. The Knodell score, also known
as the histologic activity index, and the
Metavir score have four scores, from normal
to cirrhosis. The Metavir score was designed
to address some of the shortcomings of the
Knodell system; in addition, it was designed
specifically to stage hepatitis C. The Ishak
system goes from normal (zero) to cirrhosis
(six).
Factors Affecting Prognosis
The factors that affect the progression of
fibrosis with a detrimental effect are external
or host related. External factors are alcohol
consumption, drug use, and cigarette
smoking. The hostrelated factors are
advanced age at infection, being African
American, male sex, immunosuppression or
354
co-infection (HIV, HBV, HAV), and
comorbidities (hemochromatosis, obesity).
Therapy for Hepatitis C
The 2002 NIH consensus conference
recommended that all patients with hepatitis
C should be considered potential candidates
for therapy. Once a patient is treated, the
optimal endpoint of therapy is sustained
virologic response (SVR). The factors
associated with a SVR are: genotype, absence
of fibrosis, etc (Table 1). Hepatitis C virus
(HCV) RNA testing is done before therapy,
12 weeks into therapy, and 24 weeks after the
end of therapy, and its absence is a surrogate
marker for resolution of liver injury, reduction
in fibrosis, and a low likelihood of recurrent
HCV infection. The guidelines for therapy
can be broken down into three areas: those in
whom therapy is widely accepted, those
whose therapy should be individualized, and
those in whom therapy is contraindicated.
Indications for therapy are age >18 years,
abnormal LFTs, HCV RNA level elevation,
and acceptable hematologic and biochemical
values (hemoglobin >13 g/dL, lack of
significant thrombocytopenia, creatinine <1.5
mg/gL, and liver biopsy without significant
fibrosis). Therapy needs to be individualized
in those with normal LFTS, continuous
alcohol or drug use, prior treatment failures
with the older regimens, age <18 years,
minimal liver involvement, de-compensated
cirrhosis, and HIV co-infection. Absolute
contraindications to therapy are pregnancy,
major uncontrolled psychiatric disorders,
autoimmune disorders, hemoglobinopathies,
transplant recipients, severe co-morbid
conditions (coronary artery disease,
cerebrovascular accident, end-stage renal
disease, and chronic obstructive pulmonary
disease) and hypersensitivity to the
components of therapy. The use of PEG
rather than standard interferon with ribavirin
increases SVR to 54%–56% with genotype 1
and 82% with genotype 2 or 3. Two different
formulations of PEG-interferon are available:
interferon alfa-2a is dosed at 180 ug
subcutaneously every week, and interferon
alfa-2b is dosed at 1.5ug/kg subcutaneously
every week. Either drug plus oral ribavirin
800– 1200 mg (weight-based dosing) once a
day is given for 48 weeks with genotype 1.
The NIH consensus conference recommended
that with genotypes 2 or 3, PEG-interferon
plus ribavirin 800 mg be used for 24 weeks.
Regardless of the regimen, therapy should be
discontinued if HCV RNA has not decreased
by >2 logs at 12 weeks.
Treatment is associated with many side
effects (Table 2), and <20% of patients
experience severe side effects that result in
discontinuation of their therapy. Before
starting therapy, patients should be
thoroughly educated about the side effects
and self-management techniques to help them
get through their therapy. Many of the side
effects can be easily managed with proper
dose reductions, growth factors, epoetin for
anemia, increased fluids and exercise,
acetaminophen, dosing the medications at
night, diphenhydramine, serotonin reuptake
inhibitors for depression, and thyroid
medications. Milk thistle has been advocated
by some to be beneficial in the treatment of
HCV. It lowers LFTs but does not affect the
virus itself. Viramidine, a ribavirin prodrug,
produces less hemolysis, lasts longer in the
liver, is less concentrated in peripheral blood,
and has fewer overall side effects but is not
FDA approved. The protease inhibitor VX-
950 has shown promise in early clinical trials.
Table 2. Side effects of therapy
Interferon Ribavirin
Common Influenza-like symptoms Cough, shortness of
breath
Irritability Insomnia
Diarrhea, GI intolerance Rash, pruritis
Alopecia Elevated uric acid
Leukopenia, thrombocytopenia
More serious Retinopathy Hemolytic anemia
Thyroid dysfunction Teratogenicity
Neuropsychiatric Autoimmune diseases
Hepatocellular Carcinoma
Patients with hepatitis B, hemochromatosis,
environmental toxins and cirrhosis due to any
355
cause are at increased risk for developing
hepatocellular carcinoma (HCC). Hepatitis C
in many parts of the world is the number one
cause though. Screening for HCC should
include: upper endoscopy in those with
cirrhosis, ultrasound and serum alfa
fetoprotein every six months.
Vaccines
Individuals with chronic liver disease should
receive vaccines for hepatitis A and B,
pneumococcus, and influenza.
HEPATITIS D
Hepatitis D virus, also known as delta virus,
is a defective RNA virus that can replicate on
its own, but it requires concurrent HBV for
assembly and secretion; as a result, patients
with HDV are always dually infected with
HBV. There are three genotypes; all are
spread percutaneously, through injection drug
use, and through unprotected intercourse. The
virus is endemic in the Mediterranean region
and Asia. Hepatitis D virus (HDV) presents as
either a co-infection like an acute hepatitis B
infection with its manifestations or as a super
infection a severe, acute infection in a
previously stable chronic hepatitis B patient.
Diagnosis
Since HDV is dependent on HBV, HBsAg is
a requirement for the diagnosis of HDV
infection. In addition, antibodies to HDV
(IgM and IgG) are required for the diagnosis.
Serum assays for HDAg are short-lived and
are not clinically available in the United
States. HDV RNA can be detected by
molecular hybridization or by PCR.
Treatment
The primary aim and endpoint of treatment
are undetectable HDV RNA levels,
normalization of LFTs, and a decrease of
inflammation on liver biopsy. A secondary
aim is suppression of HBV DNA levels and
seroconversion of HBsAg to HBsAb.
Interferon alfa is the only FDA-approved drug
against HDV. Ribavirin, lamivudine, and
other drugs are ineffective against HDV
infection.
Prevention
Hepatitis B affects >350 million people
worldwide. Thus, the only way to prevent
HDV is through primary education about its
risk factors or through vaccination against
HBV.
HEPATITIS E
Epidemiology
The hepatitis E virus (HEV) is an RNA virus
with four genotypes that was first described in
India in 1955. It is a self-limiting, enterically
transmitted disease like hepatitis A but is
more severe, easily transmitted, and
distributed worldwide. Its highest incidence is
in developing countries, and it is the second
most common cause of sporadic hepatitis in
northern Africa and the Middle East. It is
usually spread by fecally contaminated water,
but it can also be spread by blood and blood
products. There is a low incidence of person-
to-person transmission.
Manifestations
Hepatitis E virus (HEV) infection has an
incubation period of 15–60 days. It presents
like other acute hepatitis illnesses but with
prolonged cholestatis. There is a low rate of
fulminant hepatic failure, except in pregnant
women, who have a mortality of 15%–25%.
The acute state usually lasts for up to six
weeks, and for those that recover there is no
chronic state.
Diagnosis, Treatment, and Prevention
Hepatitis E virus (HEV) infection is
diagnosed by detecting HEV in the serum or
feces by PCR or by detecting IgM antibodies.
A March 1, 2007 NEJM article featured a new
recombinant HEV vaccine that showed
promise in a phase two trial from Nepal.
Heretofore, treatment is generally supportive
since there is no FDA approved vaccine.
Therefore, prevention entails avoiding
contaminated water and uncooked foods in
endemic areas.
356
HEPATITIS G
Epidemiology
The hepatitis G virus (HGV) is a blood-borne
virus that is spread by contaminated blood
and blood products. It has a worldwide
distribution and is especially common in
blood donors in the United States. Because
this virus may not produce disease in humans,
blood is not routinely screened for HGV.
Studies have found that in the United States,
10% 20% of HGV patients are also co-
infected with HCV. Mounting evidence has
also shown a protective role of HGV in HIV
patients.
HEPATITIS G VIRUS
Hepatitis G virus (HGV) infection is thought
to be a blood borne virus. However, little is
known about the epidemiology, transmission,
replication site, and disease inducing capacity
of this virus. Association of HGV with
fulminant hepatitis (FH) and acute viral
hepatitis (AVH) is still controversial and its
clinical significance is to be clearly
understood. HGV infection has been reported
in the patients with AVH, chronic hepatitis,
fulminant hepatitis, haemodialysis,
intravenous drug abuser and blood donors
around the world.
HGV is a positive sense single stranded RNA
genome, approximately 9.4 Kilo base and
belongs to Flaviviridae family. Though HGV
genome is related to hepatitis C virus (HCV),
it is too divergent to be classified as the
genotype of HCV2. It is well established that
HCV exhibits significant genetic
heterogeneity not only between different
patients but also in the same individual and
the same is expected in HGV3. Sequence
variation in HGV ranges from 0.5 to 20.7 per
cent at the nucleotide level, and from 0 to
16.5 per cent at the amino acid level4. HGV
has considerable degree of genetic
heterogeneity, the NS3 region of HGV
hassequence divergence of 10-20 per cent.
The viral hepatic disorders are divided into
the acute disorders (hepatitis A, E, G) and
those with acute and chronic states (hepatitis
B, C, D). They are spread by the fecal-oral
route, perinatally, percutaneously, through
blood or blood products, or by unprotected
intercourse. Treatment is mostly supportive,
although several medications are available,
depending on the individual disorder.
Prevention is through proper sanitary
conditions, vaccination, and education on risk
factors.
FURTHER READING
AGA guidelines: evaluation of LFTs.
Gastroenterology. 2002;123:1364.
Alter MJ, Kruszon-Moran D, Nainan OV, et al. The
prevalence of hepatitis C virus infection in the
United States, 1988 through 1994. N Engl J Med.
1999;341:556–562.
Armstrong GL, Wasley A, Simard EP. The prevalence
of hepatitis C virus infection in the United States,
1999 through 2002. Ann Intern Med.
2006;144(10):705–714.
Bonino F, Heermann KH, Rizzetto M, et al. Hepatitis
delta virus: protein composition of delta antigen and
its hepatitis B virus-derived envelope. J Virol.
1986;58:945.
Davis GL, Wong JB, McHutchinson JG, Manns MP.
Early virologic response to treatment with
peginterferon alfa-2b plus ribavirin in patients with
chronic hepatitis C. Hepatology. 2003;38:645.
Feinstone SM, Kapikian AZ, Purceli RH. Hepatitis A:
detection by immune electron microscopy of a virus
like antigen associated with acute illness. Science.
1973;182:1026.
Fong TL, DiBisceglie AM, Gerber MA, et al.
Persistence of hepatitis B virus DNA in the liver
after loss of HbsAg in chronic hepatitis B.
Hepatology. 1993;18:1313–1318.
Fried MW, Schiffman ML, Reddy K, et al. Pegylated
(40 kDa) interferon alfa-2a (PEGASYS) in
combination with ribavirin: efficacy and safety
results from a phase II, randomized, activity-
controlled, multicenter study. Gastroenterology.
2001;120:A–55 (abstract).
Gerberding JL. The infected health care provider. N
Engl J Med. 1996;334:594.
Keeffe E, Dieterich D, Han S, et al. A treatment
algorithm for the management of chronic hepatitis B
virus infection in the United States. Clin
Gastroenterol Hepatol. 2004;2:87–106.
Komori M, Yuki N, Nagaoka T, et al. Longterm
clinical impact of occult hepatitis B virus infection in
chronic hepatitis B patients. J Hepatology.
2001;35:798–804.
357
Lai CL, Chien RN, Leung NW, et al. A one year trial
of lamivudine for chronic hepatitis B. N Engl J Med.
1998;339:61–68.
Lee W. Hepatitis B virus infection. N Engl J Med.
1997;337:1733–1745.
Manns MP, McHutchison JG, Gordon SC, et al.
Peginterferon alfa-2b plus ribavirin compared with
interferon alfa-2b plus ribavirin for initial treatment
of chronic hepatitis C: a randomized trial. Lancet.
2001;358: 958–965.
Marcellin P, Lau GKK, Bonino F, et al. Peginterferon
alfa-2a alone, lamivudine alone, and the 2 in
combination in patients with HBe antigen-negative
chronic hepatitis B. N Engl J Med. 2004;351:1206–
1217.
NIH Consensus Development Conference Panel
Statement: management of hepatitis C. Hepatology.
1997;26:2S–10S.
Perrillo R, Gish R, Peters M, et al. Chronic hepatitis B:
a critical appraisal of current approaches to therapy.
Clin Gastroenterol Hepatol. 2006;4:233–248.
Pratt DS, Kaplan MM. Evaluation of abnormal liver-
enzyme results in asymptomatic patients. N Engl J
Med. 2000;342:1266.
Schiff ER. Treatment algorithm for hepatitis B and C.
Gut. 1993;34(Suppl 2):S148–S149.
Seef LB, Hoofnagle JH. NIH Consensus Development
Conference: management of hepatitis C. Hepatology,
2002;(Suppl 1):S1.
Tillmann HL, Heiken H, Knapik-Botai A, et al.
Infection with GB virus C and reduced mortality
among HIV-infected patients. N Engl J Med. 2001;
345(10):715–724.
Wheeler C, Vogt TM, Armstrong GL, et al. An
outbreak of hepatitis A associated with green onions.
N Engl J Med. 2005;353: 890–897.
Wong DKH, Cheung AM, O’Rourke K, et al. Effect of
alpha-interferon treatment in patients with hepatitis B
antigen-positive chronic hepatitis B: a meta-analysis.
Ann Intern Med. 1993;119:312–323.
Xiang J, Wunschmann S, Diekema DJ, et al. Effect of
coinfection with GB virus C on survival among
patients with HIV infection. N Engl J Med.
2001;345(10):707–714.
Yim HJ, Lok A. Natural history of chronic hepatitis B
virus infection: what we knew in 1981 and what we
know in 2005. Hepatology. 2006;43(2 Suppl
1):S173–S181.
Note: Most of the Matters are drived from Internet and
Research Papers
Chapter-14

359
360
HEPATOCELLULAR CARCINOMA (HCC)
Hepatocellular carcinoma (HCC) is a
primary malignancy of the liver.
Hepatocellular carcinoma is now the third
leading cause of cancer deaths worldwide,
with over 500,000 people affected. The
incidence of hepatocellular carcinoma is
highest in Asia and Africa, where the endemic
high prevalence of hepatitis B and hepatitis C
strongly predisposes to the development of
chronic liver disease and subsequent
development of hepatocellular carcinoma.
The presentation of hepatocellular carcinoma
has evolved significantly over the past few
decades. While, in the past, hepatocellular
carcinoma generally presented at an advanced
stage with right upper quadrant pain, weight
loss, and signs of decompensated liver disease,
hepatocellular carcinoma is now increasingly
recognized at a much earlier stage as a
consequence of the routine screening of
patients with known cirrhosis, using cross-
sectional imaging studies and serum alpha-
fetoprotein measurements.
Resection may benefit certain patients, albeit
mostly transiently. Many patients are not
candidates given the advanced stage of their
cancer at diagnosis or their degree of liver
disease and, ideally, could be cured by liver
transplantation. Globally, only a fraction of all
patients have access to transplantation, and,
even in the developed world, organ shortage
remains a major limiting factor. In these
361
patients, local ablative therapies, including
radiofrequency ablation, chemo-embolization,
and potentially novel chemotherapeutic agents,
may extend life and provide palliation.
Primary liver cancer, also known as
hepatocellular carcinoma, is a cancer that
begins in the liver. Each year in the United
States, approximately 15,000 men and 6,000
women are diagnosed with primary liver
cancer.
The liver is also the most common site to
which cancer has spread (metastasized) from
other parts for the body, most commonly the
colon, lungs, or breast. When this happens, it
is NOT liver cancer. Instead, the cancer is
named for the organ it originated from (the
primary site). For example, colon cancer that
spreads to the liver is called metastatic colon
cancer. It is not liver cancer. In the U.S.,
metastatic cancer in the liver is far more
common than primary liver cancer. Cirrhosis is
a serious disease that develops when liver cells
are damaged and replaced with scar tissue.
Many exposures cause cirrhosis, including
HBV or HCV infection, heavy alcohol use, too
much iron stored in the liver, certain drugs,
and certain parasites.
Obesity and diabetes studies have shown that
obesity and diabetes may be important risk
factors for liver cancer.
Table 1: Incidence and mortality of five most common •Yellow skin and eyes, pale stools, and dark
cancers worldwide, 2000*.
urine from jaundice
_____________________________________________
Site Incidence (%) Mortality • Fever
_____________________________________________ These symptoms may be caused by liver
cancer or by other health problems. With any
Lung 1238.9 (12.3) 1103.1 (17.7)
Breast 1050.3 (10.0) 373.0 (6.0) of these symptoms, a doctor should be
Colon/rectum 944.7 (9.4) 492.4 (7.9) consulted so that problems can be diagnosed
Stomach 876.3 (8.7) 646.6 (10.4) and treated as early as possible.
Liver† 564.3 (5.6) 548.6 (8.8)
All sites 10055.6 (100) 6208.7 (100) Table 3: Risk factors for HCC worldwide, by geographical
area, 2000.
*Numbers of cases and deaths (1000s). †Including HCC and
cholangiocarcinoma (<10%), Modified from reference 1, Age-adjusted Incidence (men/women)

Geographical area
Europe
Western- 5-8/1.6
Southern 9.8/3.4
Northern 2 .6/1.3
North America
Northern 4-.1/1.6
Southern 4-.8/3.6
Asia and Africa
East Asia 35.4/12.6
Southeast Asia 18.3/5.7
Middle Africa 24.2/12.9
Developed 8.7/2.8
Countries
Table 2: Risk Factor of Hepatocellular carcinoma worldwide. Developing 17.4/6.7
__________________________________________________ countries
Risk Factor World 14.9/5.5
________________________________________________________ Diagnosis
Hepatitis C Hepatitis B* Alcohol Other
________________________________________________________ The following tests are used to diagnose liver
Europe 60-70% 10-15% 20% 10% cancer:
North America 50-60% 20% 20% 10%
Asia and Africa† 20%_________ 70%____ ___10% <10%‡___ • Physical examination: If doctor feels to
*Estimates from HbsAg carriers. Occult hepatitis B virus infection
might involve additional patients. †Except Japan, lor which hepatitis C
check abdomen includes liver, spleen, and
virus 70%. Hepatitis B virus 10-20%, alcohol 10%, other =10% other nearby organs for any lumps or
‡Aflatoxin is main co-factor enhancing oncogeneticrisk of patients
with hepatitis B virus infection.
changes in their shape or size. The doctor
Symptoms may also check for ascites, an abnormal
Early liver cancer often doesn't cause buildup of fluid in the abdomen. Also, skin
symptoms. When the cancer grows larger, one and eyes may be checked for signs of
or more of these common symptoms may jaundice.
occur: • Blood tests: Many blood tests may be used
to check for liver problems. One blood test
• Pain in the upper abdomen on the right
detects alpha-fetoprotein (AFP). High AFP
side
levels could be a sign of liver cancer. Other
• A lump or a feeling of heaviness in the
blood tests can show how well the liver is
upper abdomen
working.
• Swollen abdomen (bloating)
• CT scan: An x-ray machine linked to a
• Loss of appetite and feelings of fullness
computer takes a series of detailed pictures
• Weight loss
of your liver and other organs and blood
• Weakness or feeling very tired
vessels in your abdomen. The patient may
• Nausea and vomiting
receive an injection of contrast material so

362
 that your liver shows up clearly in the
pictures. On the CT scan, your doctor may
see tumors in the liver or elsewhere in the
abdomen.
• MRI: A large machine with a strong magnet
linked to a computer is used to make
detailed pictures of areas inside your body.
Sometimes contrast material makes
abnormal areas show up more clearly on the
picture.
Open MRI machine
• Ultrasound test: The ultrasound device uses
sound waves that can't be heard by humans.
The sound waves produce a pattern of
echoes as they bounce off internal organs.
The echoes create a picture (sonogram) of
your liver and other organs in the abdomen.
Tumors may produce echoes that are
different from the echoes made by healthy
tissues.
• Biopsy: A biopsy is usually not needed to
diagnose liver cancer, but in some cases, the
doctor may remove a sample of tissue. A
pathologist uses a microscope to look for
cancer cells in the tissue. Tissue can be
obtained through several methods:
o A needle through the skin: The doctor
inserts a thin needle into the liver to remove
a small amount of tissue. CT or ultrasound
may be used to guide the needle. The most
common risk of a needle biopsy is bleeding,
especially because liver cancer is a tumor
that has many blood vessels (vascular).
Rarely, new small areas of tumor can be
seeded from the tumor into the liver along
the needle track.
363
o Laparoscopic Surgical Procedure: The
surgeon makes a few small incisions in your
abdomen. A thin, lighted tube (laparoscope)
is inserted through the incision. The
laparoscope has a tool to remove tissue
from the liver.
o Open Surgical Procedure: The surgeon can
remove tissue from the liver through a large
incision
Staging
If liver cancer is diagnosed, the doctor needs to
learn the extent (stage) of the disease to help
determine the optimal treatment. Staging is an
attempt to find out whether the cancer has
spread, and if so, to what parts of the body.
When liver cancer spreads, the cancer cells
may be found in the lungs. Cancer cells also
may be found in the bones and in lymph nodes
near the liver.
When cancer spreads from its original place to
another part of the body, the new tumor has
the same kind of abnormal cells and the same
name as the primary tumor. For example, if
liver cancer spreads to the bones, the cancer
cells in the bones are actually liver cancer
cells. The disease is metastatic liver cancer,
not bone cancer. It's treated as liver cancer, not
bone cancer. Doctors sometimes call the new
tumor "distant" or metastatic disease.
To learn whether the liver cancer has spread,
one or more of the following tests may be
used:
• CT scan (CAT scan) of the Chest: A CT
scan often can show whether liver cancer
has spread to the lungs. A CT scan
procedure that makes a series of detailed
pictures of areas inside the body, such as the
chest, taken from different angles. The
pictures are made by a computer linked to
an x-ray machine. A dye may be injected
into a vein or swallowed to help the organs
or tissues show up more clearly. This
procedure is also called computed
tomography, computerized tomography, or
computerized axial tomography.

CT scan machine
• PET scan (positron emission tomography
scan): A procedure to find malignant tumor
cells in the body. A small amount of
radioactive glucose (sugar) is injected into a
vein. The PET scanner rotates around the
body and makes a picture of where glucose
is being used in the body. Malignant tumor
cells show up brighter in the picture because
they are more active and take up more
glucose than normal cells do.
PET (positron emission tomography) scan. The patient lies on
a table that slides through the PET machine. The head rest
and white strap help the patient lie still. A small amount of
radioactive glucose (sugar) is injected into the patient's vein,
and a scanner makes a picture of where the glucose is being
used in the body. Cancer cells show up brighter in the picture
because they take up more glucose than normal cells do.
• Bo ne scan: The doctor injects a small
amount of a radioactive substance into your
blood vessel. It travels through the
bloodstream and collects in the bones. A
machine called a scanner detects and
measures the radiation. The scanner makes
pictures of the bones. The pictures may show
cancer that has spread to the bones.
364
Treatment
Treatment options for liver cancer are surgery
(including a liver transplant), ablation,
embolization, targeted therapy, radiation
therapy, and chemotherapy. A combination of
these treatments may be used.
The appropriate treatment depends on the
following:
• the number, size, and location of tumors in
your liver
• how well your liver is working and whether
the patient have cirrhosis
• whether the cancer has spread outside your
liver
• the patient's age and general health including
the ability to handle potential side effects
At this time, liver cancer can be cured only
when found at an early stage (before it has
spread) and removed surgically. For patients
who are not surgical candidates, other
treatments are available. Patients with liver
cancer may also consider enrolling in a clinical
trial. These are research studies testing new
treatments and are an important option for
patients with all stages of liver cancer.
Specialists who treat liver cancer include
transplant and hepatobiliary surgeons, surgical
oncologists, gastroenterologists, medical
oncologists, and radiation oncologists. The
healthcare team also includes an oncology
nurse and a registered dietitian.
Surgery
Liver Resection
Surgery is an option for patients with an early
stage of liver cancer. The surgeon may remove
the whole liver or only the part that has cancer.
If the whole liver is removed, it's replaced with
healthy liver tissue from a donor.

A liver resection is the removal of part of the
liver. Surgery to remove part of the liver is
also called a partial hepatectomy. A patient
with liver cancer may have part of the liver
removed if lab tests show that the liver is
working well and if there is no evidence that
the cancer has spread to nearby lymph nodes
or to other parts of the body.
The surgeon removes the tumor along with a
margin of normal liver tissue around the
tumor. The extent of the surgery depends on
the size, number, and location of the tumors. It
also depends on how well the liver is working.
As much as 80 percent of the liver may be
removed. The surgeon leaves behind normal
liver tissue. The remaining healthy tissue takes
over the work of the liver. Also, the liver can
re-grow the missing part. The new cells grow
over several weeks.
It takes time to heal after surgery, and the time
needed to recover is different for each patient.
The patient may have pain or discomfort for
the first few days. Medicine can help control
your pain. Before surgery, the patient should
365
discuss the plan for pain relief with your
doctor or nurse. After surgery, your doctor can
adjust the plan if the patient need more pain
control.
It's common of a patient to feel tired or weak
for a while. Also, the patient may have
diarrhea and a feeling of fullness in the
abdomen.
The health care team will watch the patient for
signs of bleeding, infection, liver failure, or
other problems.
Liver Transplant
A liver transplant is an option if the tumors are
small, the disease has not spread outside the
liver, and suitable donated liver tissue can be
found.
Donated liver tissue comes from a deceased
patient or a live donor. If the donor is living,
the tissue is part of a liver, rather than a whole
liver.
While the patients wait for donated liver tissue
to become available, the health care team
monitors your health and provides other
treatments.
When healthy liver tissue from a donor is
available, the transplant surgeon removes your
entire liver (total hepatectomy) and replaces it
with the donated tissue. After surgery, your
health care team will give the patient medicine
to help control your pain. The patient may
need to stay in the hospital for several weeks.
During that time, your health care team
monitors how well your body is accepting the
new liver tissue.
The patient will take medicine to prevent your
body's immune system from rejecting the new
liver. These drugs may cause puffiness in your
face, high blood pressure, or an increase in
body hair.
Other Procedures and Treatments generated by microwave energy. The
Ablation surgeon inserts a small laparoscopic port or
open incision to access the tumor. A CT
Methods of ablation destroy the cancer in the
scan or ultrasonic guidance is used to
liver. They are treatments to control liver
pinpoint the exact location of the tumor. A
cancer and extend life. They may be used for
thin antenna, which emits microwaves, is
patients waiting for a liver transplant. Or they
then inserted into the tumor. This produces
may be used for patients who can't have
intense heat which destroys cancer cells,
surgery or a liver transplant. Surgery to
often within 10 minutes. Microwave
remove the tumor may not be possible because
ablation is faster than RFA and thus reduces
of cirrhosis or other conditions that cause poor
the time patients must remain under general
liver function, the location of the tumor within
anesthesia. Surgeons can also ablate
the liver, or other health problems.
multiple liver tumors simultaneously and
Methods of ablation include the following: ablate larger tumors than with RFA.
• Radiofrequency ablation ( RFA) is the
destruction of tumors with heat from
radiofrequency waves. The doctor uses a
special probe that contains tiny electrodes to
kill the cancer cells with heat. Ultrasound,
CT, or MRI may be used to guide the probe
to the tumor. Usually, the doctor can insert
the probe directly through your skin, and
only local anesthesia is needed. Sometimes,
surgery under general anesthesia is needed.
The doctor inserts the probe through a small
incision in your abdomen (using a
laparoscope) or through a wider incision A new type of FDA-approved high efficiency microwave coagulation
that opens your abdomen. Some patients system has now been tested in Asia by doctors from the University of
Hong Kong Li Ka Shing Faculty of Medicine 2011.
have pain or a slight fever after this
• Cryosurgery: A treatment that uses an
procedure. Staying overnight in the hospital
is not usually needed. instrument to freeze and destroy abnormal
• Laser Ablation Technique
tissue, such as carcinoma in situ. This type
of treatment is also called cryotherapy. The
doctor may use ultrasound to guide the
instrument.

• Microwave ablation, used less frequently

than RFA, destroys liver tumors using heat

366

• Percutaneous Ethanol Injection: Ultrasound
is used to guide a thin needle into the liver
tumor. Alcohol (ethanol) is injected directly
into the tumor and kills cancer cells. The
procedure may be performed once or twice
a week. Usually local anesthesia is used, but
if the patient has many tumors in the liver,
general anesthesia may be needed. The
patient may have fever and pain after the
injection.
Embolization
For those who can't have surgery or a liver
transplant, embolization or chemoembolization
may be an option. The doctor inserts a tiny
catheter into an artery in your leg and moves
367
the catheter into the hepatic artery. For
embolization, the doctor injects tiny sponges
or other particles into the catheter. The
particles block the flow of blood through the
artery. Depending on the type of particles
used, the blockage may be temporary or
permanent.
Without blood flow from the hepatic artery,
the tumor dies. Although the hepatic artery is
blocked, healthy liver tissue continues to
receive blood from the hepatic portal vein.
For chemoembolization, the doctor injects an
anticancer drug (chemotherapy) into the artery
before injecting the tiny particles that block
blood flow. Without blood flow, the drug stays
in the liver longer.
The patient must be sedated for this procedure,
but general anesthesia is not usually needed.
The patient will probably stay in the hospital
for 2 to 3 days after the treatment.
Embolization often causes abdominal pain,
nausea, vomiting, and fever. Your doctor can
give the patient medicine to help lessen these
problems. Some patients may feel very tired
for several weeks after the treatment.
Targeted Therapy
Patients with liver cancer who cannot have
surgery or a liver transplant may receive a drug
called targeted therapy. Sorafenib (Nexavar)
tablets were the first targeted therapy approved
for liver cancer.

Targeted therapy slows the growth of liver
tumors. It also reduces their blood supply. The
drug is taken by mouth.
Side effects include nausea, vomiting, mouth
sores, and loss of appetite. Sometimes, a
patient may have chest pain, bleeding
problems, or blisters on the hands or feet. The
drug can also cause high blood pressure. The
health care team will check your blood
pressure often during the first 6 weeks of
treatment.
Radiation Therapy
Radiation therapy uses high-energy rays to kill
cancer cells. It may be an option for a few
patients who can't have surgery. Sometimes it's
used with other approaches. Radiation therapy
also may be used to help relieve pain from
liver cancer that has spread to the bones.
368
Doctors use two types of radiation therapy to
treat liver cancer:
External radiation therapy: The radiation
comes from a large machine. The machine
aims beams of radiation at the chest and
abdomen.
Internal radiation therapy: The radiation comes
from tiny radioactive spheres. A doctor uses a
catheter to inject the tiny spheres into your
hepatic artery. The spheres destroy the blood
supply to the liver tumor.
The side effects from radiation therapy include
nausea, vomiting, or diarrhea. Your health care
team can suggest ways to treat or control the
side effects.
Chemotherapy
Chemotherapy, the use of drugs to kill cancer
cells, is sometimes used to treat liver cancer.
Drugs are usually given by vein (intravenous).
The drugs enter the bloodstream and travel
throughout your body.
Chemotherapy may be given in an outpatient
part of the hospital, at the doctor's office, or at
home. Rarely, the patient may need to stay in
the hospital.
The side effects of chemotherapy depend
mainly on which drugs are given and how
much. Common side effects include nausea
and vomiting, loss of appetite, headache, fever
and chills, and weakness.
Some drugs lower the levels of healthy blood
cells and the patients are more likely to get
infections, bruise or bleed easily, and feel very
weak and tired. Your health care team will
check for low levels of blood cells. Some side
effects may be relieved with medicine.
Supportive Care
Liver cancer and its treatment can lead to other
health problems. The patient can have
supportive care before, during, and after cancer
treatment.
Supportive care is treatment to control pain
and other symptoms, to relieve the side effects
of therapy, and to help the patient cope with
the feelings that a diagnosis of cancer can
bring. The patient may receive supportive care
to prevent or control these problems and to
improve your comfort and quality of life
during treatment.
References
Abby, Siegel; Andrew X. Zhu (15 Oct 2009). "Metabolic Syndrome
and hepatocellular carcinoma". Cancer (ACS) 115 (24): 5651–
5661.
American Society of Clinical Oncology, 2005 Annual Meeting,
Abstracts on Hepatobiliary Cancer.
Bernstein, L.R.; van der Hoeven, J.J.; Boer, R.O.
(2011). "Hepatocellular carcinoma detection by gallium scan and
subsequent treatment with gallium maltolate: rationale and case
study". Anti-Cancer Agents in Medicinal Chemistry 11 (6): 585–
590.
Bruix, Jordi; Sherman, Morris; Practice Guidelines Committee
(November 2005). "Management of hepatocellular
carcinoma". Hepatology 42 (5): 1208–1236.
Chen, Min-Shan; Li, Jin-Qing; Zheng, Yun; Guo, Rong-Ping; Liang,
Hui-Hong; Zhang, Ya-Qi; Lin, Xiao-Jun; Lau, Wan Y (2006). "A
Prospective Randomized Trial Comparing Percutaneous Local
Ablative Therapy and Partial Hepatectomy for Small
Hepatocellular Carcinoma". Annals of Surgery 243 (3): 321–8.
Cheng, W; S. Govindarajan, A Redeker (February 1992).
"Hepatocellular carcinoma in a case of Wilson's disease". Liver
International 12 (1): 42–45.
Chua, M.-Z.; Bernstein, L.R.; Li, R.; So, S.K. (2006). "Gallium
maltolate is a promising chemotherapeutic agent for the treatment
of hepatocellular carcinoma". Anticancer Research 26 (3A): 1739–
1743.
Cillo, Umberto; Vitale, Alessandro; Bassanello, Marco; Boccagni,
Patrizia; Brolese, Alberto; Zanus, Giacomo; Burra, Patrizia;
Fagiuoli, Stefano; Farinati, Fabio; Rugge, Massimo; d'Amico,
Davide Francesco (February 2004). "Liver transplantation for the
treatment of moderately or well-differentiated hepatocellular
carcinoma".Ann. Surg. 239 (2): 150–9.
Colli, A; Fraquelli, M; Casazza, G; Massironi, S; Colucci, A; Conte,
D; Duca, P (March 2006). "Accuracy of ultrasonography, spiral CT,
magnetic resonance, and alpha-fetoprotein in diagnosing
hepatocellular carcinoma: a systematic review.". The American
journal of gastroenterology 101 (3): 513–23.
Donadon, Valter; Massimiliano Balbi, Michela Ghersetti, Silvia
Grazioli, Antonio Perciaccante, Giovanni Della Valentina, Rita
Gardenal, Maria Dal Mas, Pietro Casarin, Giorgio Zanette, Cesare
Miranda (28 May 2009). "Antidiabetic therapy and increased risk
of hepatocellular carcinoma in chronic liver disease". World
Journal of Gastroenterology 15 (20): 2506–11.
369
El-Serag, Hashem B.; Howard Hampel, Fariba Javadi (20 Feb
2006). "the association between diabetes and hepatocellular
carcinoma: a systematic review of epidemiological
evidence". Clinical Gastroenterology and Hepatology 4 (3): 369–
380.
Fan, Jia; Yang,Guang-Shun; Fu, Zhi-Ren; Peng, Zhi-Hai; Xia, Qiang;
Peng, Chen-Hong; Qian, Jian-Ming; Zhou, Jian; Xu, Yang; et al.
(2009). "Liver transplantation outcomes in 1,078 hepatocellular
carcinoma patients: a multi-center experience in Shanghai,
China". Journal of Cancer Research and Clinical
Oncology 135 (10): 1403–1412.
Fan, Jia; Yang,Guang-Shun; Fu, Zhi-Ren; Peng, Zhi-Hai; Xia, Qiang;
Peng, Chen-Hong; Qian, Jian-Ming; Zhou, Jian; Xu, Yang; et al.
(2009). "Liver transplantation outcomes in 1,078 hepatocellular
carcinoma patients: a multi-center experience in Shanghai,
China". Journal of Cancer Research and Clinical
Oncology 135 (10): 1403–1412.
Hassan, Manal M.; Steven A. Curley, Donghui Li, Ahmed Kaseb,
Marta Davila, Eddie K. Abdalla, Millind Javie, Dalia M. Moghazy,
Richard D. Lozano, Jean-Nicholas Vauthey (17 Feb 2010).
"Association of diabetes duration and diabetes treatment with the
risk of hepatocellular carcinoma". Cancer (ACS) 116 (8): 1938–
1946.
Hepatocellular carcinoma MedlinePlus, Medical Encyclopedia.
Hopfner, Michael; Alexander Huether, Andreas P. Sutter, Viola
Baradari, Detlef Schuppan, Hans Scherubl (14 May 2006).
"Blockade of IGF-1 receptor tyrosine kinase has antineoplastic
effects in hepatocellular carcinoma cells". Biochemical
Pharmacology 71 (10): 1435–1448.
Josep M. Llovet; Sergio Ricci; Vincenzo Mazzaferro; Philip Hilgard;
Edward Gane; Jean-Frédéric Blanc; Andre Cosme de Oliveira;
Armando Santoro; Jean-Luc Raoul; Alejandro Forner; Myron
Schwartz; Camillo Porta; Stefan Zeuzem; Luigi Bolondi; et
al. (2008). "Sorafenib in Advanced Hepatocellular Carcinoma". N
Engl J Med359 (4): 378–390.
Journal of Clinical Oncology, Special Issue on Molecular Oncology:
Receptor-Based Therapy, April 2005.
Kooby, DA; Egnatashvili, V; Srinivasan, S; Chamsuddin, A; Delman,
KA; Kauh, J; Staley CA, 3rd; Kim, HS (February 2010).
"Comparison of yttrium-90 radioembolization and transcatheter
arterial chemoembolization for the treatment of unresectable
hepatocellular carcinoma." Journal of vascular and interventional
radiology: JVIR21 (2): 224–30. .
Kumar V, Fausto N, Abbas A (editors) (2003). Robbins & Cotran
Pathologic Basis of Disease (7th ed.). Saunders. pp. 914–7.
Liu, Chi-leung, M.D., "Hepatic Resection for Hepatocellular
Carcinoma", The Hong Kong Medical Diary, Vol.10 No.12,
December 2005 Medical Bulletin.
Madoff, DC; Hicks, ME; Vauthey, JN; Charnsangavej, C; Morello
FA, Jr; Ahrar, K; Wallace, MJ; Gupta, S (September–October
2002). "Transhepatic portal vein embolization: anatomy,
indications, and technical considerations.". Radiographics : a
review publication of the Radiological Society of North America,
Inc 22 (5): 1063–76.
Obed, Aiman; Tsui, Tung-Yu; Schnitzbauer, Andreas A.; Obed,
Manal; Schlitt, Hans J.; Becker, Heinz; Lorf, Thomas
(2009). "Liver Transplantation for Hepatocellular Carcinoma: Need
for a New Patient Selection Strategy: Reply". Langenbeck's
Archives of Surgery 393 (2): 147–141.
Stickely, Felix; Claus Hellerbrand (21 July 2010). "Non-alcoholic
fatty liver disease as a risk factor for hepatocellular carcinoma:
mechanisms and implications". Gut 59 (10): 1303–1307.
Tanabe, KK; Curley, SA; Dodd, GD; Siperstein, AE; Goldberg, SN
(February 1, 2004). "Radiofrequency ablation: the experts weigh
in.". Cancer 100 (3): 641–50.
Tanaka, M.; Katayama, F.; Kato, H.; Tanaka, H.; Wang, J.; Qiao, Y.
L.; Inoue, M. (2011). "Hepatitis B and C virus infection and
hepatocellular carcinoma in China: A review of epidemiology and
control measures". Journal of epidemiology / Japan
Epidemiological Association 21 (6): 401–416.
Tateishi, R; Shiina, S; Teratani, T; Obi, S; Sato, S; Koike, Y;
Fujishima, T; Yoshida, H; Kawabe, T; Omata, M (15 March 2005).
"Percutaneous radiofrequency ablation for hepatocellular
carcinoma. An analysis of 1000 cases." Cancer 103 (6): 1201–9.
Vente MA, Wondergem M, van der Tweel I, et al (April 2009).
"Yttrium-90 microsphere radioembolization for the treatment of
liver malignancies: a structured meta-analysis". Eur Radiol 19 (4):
951–9.
Vitale, Alessandro; Gringeri, Enrico; Valmasoni, Michele; D'Amico,
Francesco; Carraro, Amedeo; Pauletto, Alberto; D'Amico,
Francesco Jr.; Polacco, Marina; D'Amico, Davide Francesco; Cillo,
Umberto (2007). "Longterm results of liver transplantation for
hepato-cellular carcinoma: an update of the University of Padova
experience". Transplantation Proceedings 39 (6): 1892–1894.
Wang, Xin W; S.Perwez Hussain, Teh-Ia Huo, Chuan-Ging Wu,
Marshonna Forgues, Lorne J Hofseth, Christian Brechot and Curtis
C Harris (2002). "Molecular pathogenesis of human hepatocellular
carcinoma".Toxicology. 181-182: 43–47.
Wilkinson, ML; B Portmann, R Williams (1983). "Wilson's disease
and hepatocellular carcinoma: possible protective role of
copper". Gut 24 (8): 767–771.
Yamamoto, Junji; Okada, Shuichi; Shimada, Kazuaki; Okusaka,
Takushi; Yamasaki, Susumu; Ueno, Hideki; Kosuge, Tomoo
(2001). "Treatment strategy for small hepatocellular carcinoma:
Comparison of long-term results after percutaneous ethanol
injection therapy and surgical resection". Hepatology 34 (4): 707–
713.
Further Reading
"Cancer". World Health Organization. February 2006. Retrieved
2007-05-24.
"Interventional Radiology Treatments for Liver Cancer". Society of
Interventional Radiology. Retrieved 4 February 2014.
"Long-term results of liver transplantation for hepatocellular
carcinoma: an update of the University of Padova experience".
September 23, 2013. Retrieved 6 February 2014.
"onsurgical therapies for localized hepatocellular carcinoma:
Transarterial embolization, radiotherapy, and radioembolization".
UptoDate. Retrieved 4 February 2014.
"Sorafenib in Advanced Hepatocellular Carcinoma". Retrieved May
12, 2010.
"WHO Disease and injury country estimates". World Health
Organization. 2009. Retrieved November 11, 2009.

Note: Most of the Matters are drived from Internet and

Research Papers

370
Chapter-15

371
372
DIABETES
Diabetes occur either because of lack of
insulin or because of the presence of factors
that oppose the action of insulin. The result of
insufficient action of insulin is an increase in
blood glucose concentration (hyperglycemia).
Many other abnormalities occurs notably an
increase in ketone bodies in the blood when
there is a severe lack of insulin.
Pancreas
DIAGNOSIS
The diagnosis of diabetes must always be
established by measuring blood glucose,
although glycosuria nearly always indicates
diabetes. Fasting blood glucose
concentrations greater than 6.7mmol/l and
random blood glucose concentrations greater
than 11.1mmol/l are clearly diagnostic of
diabetes; and fasting values less than 6mmol/l
373
or random postprandial levels less than
8mmol/l almost exclude diabetes.
Glycosuria usually occurs when blood
glucose values are greater than 10mmol/l but
this threshold varies considerably between
individuals and increases with age. Only if
blood glucose concentrations are borderline
and there is cause for doubt about the
presence of diabetes should a glucose
tolerance test be performed.
For reliable results a glucose tolerance test
should be performed in the morning after an
overnight fast with the patient sitting quietly
and not smoking; it is also important that he
should have had normal meals for the last
three days and should not have been dieting.
False results may also occur if the patient has
been ill recently or has had prolonged bed
rest. Blood glucose concentrations are
measured fasting and than every half an hour
(for two hours) after a drink of 75 g of
glucose in 250-230 ml water (in children 1.75
g/kg to a maximum of 75 g), preferably
flavored for example, with pure lemon juice.
Urine tests should be performed before the
glucose drink and at 1 and two hours.
Interpretation of blood glucose level
according to WHO criteria is shown.
Glucose tolerance test may also show:
Renal glycosuria, when there is glycosuria but
normal blood glucose values; this is a benign
condition, only rarely indicating unusual
forms of renal disease. It is worth issuing
these patients a ‘certificate’ to prevent them
from being subjected to repeated glucose
tolerance tests at every medical examination.
A steeple or lag curve, when fasting and 2-
hour concentrations are normal but those
between are high, causing glycosuria; this is
also a benign condition, which most
commonly occurs after gastrectomy but may
occur in healthy people.
TYPES OF DIABETES
Although all types of diabetes have
hyperglycemia in common, the causes vary,
as does treatment and long term out look.
Nearly all diabetics have ‘primary’ diabetes,
and most of the other syndromes and
associations shown in the table are rare.
Primary diabetes mellitus is of two types:
(a) Insulin dependent diabetes,
(b) Non-insulin dependent diabetes.
This division is important clinically in
assessing the need for treatment and in
understanding the causes of diabetes, which
are different in the two groups. Nevertheless,
although most patients can be clearly
distinguished as having one type of diabetes
or the other, some non insulin dependent
diabetes come to need insulin for good health,
if not survival, and this does to some extent
blur the edges of an apparently simple
classification.
Other terms
Gestational diabetes
The diabetes, which diagnosed during
pregnancy but remits afterward, is known as
Gestational diabetes.
Latent diabetes
In patients known to have been previously
diabetic but who are now normal.
Potential diabetes
In those at special risk of becoming diabetic
for various reasons i.e. strong family history,
bad obstetric history (unexplained fetal death)
or very large babies at birth.
Insulin dependent diabetes is due to damage
to and eventual loss of the B cells of the
pancreatic islets of langerhans with resulting
374
loss of insulin production. The agent that
damages the islets is not known; in rare cases
it may be a virus. The role of auto immunity
is probable important. Complement fixing
islet cell antibodies are almost always present
at the onset of diabetes. Immune suppression
with cyclosporin may to some extent preserve
islet function, but permanent remissions are
normally achieved, and since the treatment is
also hazardous it is unsuitable for routine use.
The incidence of Addison’s disease, thyroid
disease, and pernicious anemia are increased
in insulin-dependent diabetics, and appear to
occur especially in those with persisting islet
cell antibodies.
Insulin dependent diabetes is not inherited,
though individuals may inherit a
predisposition in that those with certain HLA
types show increased susceptibility to this
type of diabetes, and almost all are HLA DR3
or DR4. Only about half the pairs of identical
twins with insulin-dependent diabetes are
concordant for diabetes; among the rest one of
the pair is diabetic and the other is not.
Non-insulin-dependent diabetics secrete
insulin, and their serum insulin concentrations
may be diminished, normal or even increased.
The cause of the diabetes is unknown; several
factors are implicated and there is increasing
interest in neural mechanisms of metabolic
control, which may be at fault.
The best-known association is with obesity;
women who have had large babies or large
families are also more prone to develop this
type of diabetes later in life. In many of these
cases there is a strong genetic component,
unrelated to the HLA system and sometimes a
dominant pattern of inheritance: the diabetes
is always non-insulin-dependent, even among
the young and these patients seem to be lass
prone to long term complications (Mason-
type diabetes). Most of the diabetics in these
families show a chlorpropamide alcohol flush.
Identical twins are almost always concordant
for non-insulin-dependent diabetes, that is,
both members of the pair are diabetic.
____________________________________________
Insulin-dependent Non-insulin-
dependent
____________________________________________
Inflammatory reaction in islets No insulin
Islet B cells destroyed B cells function
Islet cell antibodies No islet
antibodies
HLA related Not HLA related
Not directly inherited Strong genetic
basis (some cases)
____________________________________________
A child of an insulin dependent mother or
father has an increased risk of developing the
same type of diabetes before he is 20, but the
risk is still small, probably about 1%. If both
have insulin-dependent diabetes the risk is
increased by an uncertain amount; though the
risk is probably not too serious, these rare
couples would be wise to seek genetic
counseling.
In Great Britain 1-2% of the populations have
diabetes, about half are known to have the
condition and the rest can be found by
population studies. Among school children
about 2 in thousand have diabetes.
Diabetes can occur at any age. Non-insulin-
dependent diabetes is most common after
middle age and occurs most often at50-70
years of age. The peak incidence of insulin
dependent diabetes is at 10-12 years.
Nevertheless, elderly patients can also be
insulin dependent and a few children are non-
insulin dependent.
Under 30 years of age there is a slight male
predominance of diabetes.
CLINICAL PRESENTATION: WHY IS
DIABETES SO OFTEN MISSED?
Thirsts, tiredness, pruritus, vulvae or balanitis,
polyurea and weight loss are the familiar
symptoms of diabetes. Why than is the
diagnosis so often missed? Of 15 new patients
with diabetes presenting in our diabetic ward
for the first time in ketoacidosis 14 had no
urine test after a test of 41 visits to their
doctors. Almost all these serious cases could
have been prevented.
Patients do not of course always describe their
symptoms in the earliest possible terms, or
else their complaints may occur only as an
indirect consequence of the more common
features. Many patients describe dry mouth
cell rather than thirst and I have seen cases
investigated for dysphagia when dehydration
was its cause. Frequency is often treated
blindly with antibiotics; it may cause enuresis
in the young and incontinence in the elderly
and the true diagnosis is often overlooked.
Complex urological investigations are
sometimes performed before the urine is
tested.
Some diabetics present chiefly with weight
loss, but even than the diagnosis is sometimes
missed, and I have seen two teenagers
referred for psychiatric management of
anorexia nervosa before admission in
ketoacidosis. Perhaps weakness, tiredness and
lethargy, which may be the dominant
symptoms, are most commonly
misinterpreted: ‘tonics’ and iron are
sometimes given as the symptoms worsen.
Deteriorating vision is not uncommon as a
presentation due either to a change of
refraction causing myopia or to the early
development of retinopathy. Foot ulceration
and sepsis in older patients brings them to
casualty departments And is nearly always
due to diabetes. Occasionally neuritis is the
presenting symptom, causing exquisite pain in
the feet, thighs or trunk.
Glycosuria itself is responsible not only for
the monilial overgrowth, which causes
pruritus valvae or balanitis; some older men
are first aware of diabetes when they notice
white spots on their trousers. In hot climates
drops of surgery urine attract an interested
population of ants, and at least one patient
now attending the clinic at King’s College
Hospital presented in this way before he came
to England.
Patterns of presentation: insulin-dependent
and non-insulin-dependent
Symptoms are similar in the two types of
375
 diabetes (insulin-dependent and non-insulin-
dependent), but they vary in their intensity.
The presentation is most typical and the
symptoms develop most rapidly in patients
with insulin-dependent-diabetes, they usually
develop over some weeks, but the duration
may be a few days to a few months. There is
usually considerable weight loss and
exhaustion. If the diagnosis is missed diabetic
ketoacidosis occurs (see below).
Insulin-dependent-diabetes may occur at any
age, even in the very old but is very common
in patients under thirty years of age.
Symptoms in patients with non-insulin-
dependent diabetes are similar but insidious in
their onset; sometimes these patients deny any
symptoms although they often admit to
feeling more energetic after treatment has
been started. These patients are usually
middle aged or elderly, but children do
occasionally develop non-insulin-dependent
diabetes.
Identifying patients in need of insulin
Patients in need of treatment with insulin
must be identified. This is done by judging
the patient’s clinical features: blood glucose
concentrations offer a relatively poor guide,
although most patients whose blood glucose
is greater than 25mmol/l are likely to need
insulin.
Features suggesting a need for insulin are: a
rapid development of symptoms; substantial
weight loss-patients are usually thin, vomiting
and have a dry tongue or more severe
dehydration; weakness; and ketoacidosis-
these patients are drowsy, dehydrated, over
breathing, and their breath smells of acetone
(though many people are unable to detect this
smell).
The following groups of patients are likely to
need insulin: children and most of those under
30 years of age; women who present during
pregnancy; diabetics whose tablet treatment
has failed; all patients who have undergone
pancreatectomy. If there is any doubt use
insulin. It can never be wrong to do so, and if
376
the decision was mistaken it can easily be
reversed.
Blood glucose and urine tests
The diagnosis of diabetes should no longer be
missed. Now patients attending their doctor,
weather their family doctor or at a hospital
outpatient clinic, should have a blood glucose
measurement or at the very least urine test,
especially if their symptoms are unexplained.
Only a few diabetic patients are wholly
without symptoms and their diabetes is
detected by screening at routine medical
examinations.
TREATMENT
Aims
Save life
Alleviate symptoms
Achieve good control
Minimize complications
The aims of treatment are, firstly to save life
and alleviate symptoms and secondly to
achieve the best possible control of diabetes
with blood glucose concentrations as
maintained as near normal as possible to
minimize long term complications. The first
aim is relatively easy to attain, and in some
elderly patients or those who lack motivation
or ability it is the only aim.
Control is achieved by lowering blood
glucose using diet alone, diet and oral
hypoglycemic agents, or diet and insulin.
Patients who need insulin immediately were
described in the previous chapter. All others
are normally started first on a diet alone and
tablets are added if that fails.
The ideal in non-insulin-dependent patients is
to aim for sugar free urine tests together with
a post-prandial blood glucose concentration
no greater then 9 mmol/ l, or a fasting level
less then 6.7 mmol/ l.
Other important aims in management include
control of weight and elimination of risk
factors, notably hypertension, smoking and
hazards to the feet.
Diet
Simple dietary guidelines
Never: take any form of sugar.
Do not take too much: fat or carbohydrate

No need to restrict: most meat, fish or vegetables.
Control your weight: there is no need to buy
proprietary diabetic foodstuffs.
Most forms of alcohol (other than sweet wines and
liqueurs) are suitable for diabetics, with the usual
restrictions for the overweight.
Diet is the cornerstone of the diabetic
treatment. Eliminating sugar (sucrose and
glucose) and imposing other restrictions (see
below) non-insulin-dependent diabetics.
Artificial sweeteners can be used. Good
dietary advice is essential to the proper care
of diabetics; ill considered advice can be very
damaging or else it is ignored. I recall one
patient who kept to the same sample menu for
many years before she reported it to be rather
boring. Diet needs to be tailored to the
patient’s age and weight, type of work, race
and creed.
Diet for non-insulin-dependent diabetics
A DIABETIC DIET
DO NOT EAT OR DRINK:
Sugar or glucose in any form or do not use sugar in
your cooking.
Jam, marmalade, honey, syrup or lemon curd.
Sweets or chocolates
Cakes and sweet biscuits
Tinned fruit
Lucozade, Ribena, Coca cola, Lemonade and other
Fizzy drinks
Apart from these fruits and drinks, you may eat and
drink anything else, just as you did before you were
diabetic.
You may use artificial sweeteners, such as saccharin,
sweetex, hermesetas, saxin, but NOT sucron and any
sugar free drinks including squashes and slim line
range.
377
Diets for non-insulin-dependent diabetics
should aim to eliminate all forms of sugar and
restrict the total energy intake. Many of the
patients are overweight, and their main goal is
to lose weight, although this aim is difficult to
achieve. it is important to try to ensure that
when patients reduce their carbohydrate
intake they do not replace it by an increase of
fatty foodstuffs, notably a high intake of
cheese. The present emphasis is on reducing
total calorie intake, with special emphasis on
fat reduction and a proportionately more
generous allowance of carbohydrate than in
previous years. It has been suggested that as
much as half the energy content of the dirt
may be derived from the carbohydrates, while
the fat intake is drastically reduced, although
these diets may in practice require rather
difficult and radical changes of the types of
food normally eaten. The use of
polyunsaturated fats is probably desirable,
although diabetes continues. High-fiber diets
are of value and may help to reduce blood
glucose concentrations if enough fiber is
taken. Bran, All bran, whole meat bread and
beans have relatively high fiber content and
are therefore recommended, but foodstuffs
with really high fiber content such as guar
gum are unpalatable. For some elderly
patients it is enough simply to eliminate all
forms of sugar from diet. Their blood glucose
concentrations therefore fall and symptoms
resolve. Optimal control may not be needed
or even desirable, and it is best to interfere as
little as possible with a patient’s usual way of
life. Dietary advice for these patients can be
presented on a post card.
Diets for insulin dependent patients
Some artificial sweeteners
____________________________________________
Aspartame based Hermesetas Gold
Sweetex Plus
Saccharin based Sweetex
Saxin
Hermesetas
____________________________________________
Sugar lite, Sucron and Sweetex powders contain sugar
and should not be used. Sorbitol, and fructose are
suitable for baking but high in calories.
The following will increase the fiber content of the
diet:
Bread Whole meal or stone ground-whole meal for
preference. If these are not available use highbran or
wheat meal or granary loaves
Biscuits and crisp breads Ryvita, Macvita and similar
varieties. Digestive oatcakes, coconut and bran
biscuits, Crackawheat etc.
Breakfast cereals Porridge, Weetabix, Weetaflakes, All
bran, Bran buds, Shredded weat, Oat crunchies,
mueslialpen and similar cereals
Wholemeal flour or 100% rye flour should be used
with white flour for making bread, scones, cakes,
biscuits, pudding etc.
Fresh fruits and vegetables should be included at least
twice daily. The skin and peel of fruit and vegetables,
apples, pears, plums, tomatoes and potatoes should be
eaten.
Dried fruits and nuts Use frequently.
Brown rice, whole meal pasta
Pulse vegetables Such as peas and all varieties of
beans.
Greater fitness is required in managing the
diets of insulin-dependent patients: if they eat
too much diabetic control deteriorates; if they
eat too little they become hypoglycemic. The
important principles are that the carbohydrate
intake be steady from day to day and that it
should be taken at fairly regular times each
day. If this discipline is not followed diabetic
control becomes difficult. Severe
carbohydrate restriction is not necessarily
required; indeed, if the diet is fairly generous
patients are less likely to resort to a high fat
intake, which may be harmful in the long
term.
Insulin treated diabetics must therefore be
able to calculate the carbohydrate content of
their food; they need no longer weigh the
foodstuffs. The actual requirement for
carbohydrate varies considerably: it is
unsatisfactory to prescribe less than 100 g
daily, and control may become more difficult
if more than 250 g daily is allowed. The
smaller amounts are more suitable for elderly,
sedentary diabetics while the larger amounts
are more appropriate for younger, very active
people. Although it has been observed that
378
not all carbohydrates containing foodstuffs
are equally absorbed and they therefore do not
have the same influence on the blood glucose
values, there is little factual information on
this problem and it is impossible to make
allowances, other than recommending that
sugar (sucrose) should be avoided except for
the treatment of hypoglycemia.
For social convenience it is customary to
advice that most of the carbohydrates should
be taken at the main meals-breakfast, lunch
and dinner-even though these are not
necessarily the times when according to blood
glucose profiles, most carbohydrate is needed;
for example less carbohydrate at breakfast
and more at mid morning and lunch often
improves the profile. Snacks should be taken
between meals that is, at elevens, during the
afternoon and at bedtime-to prevent
hypoglycemia; at least the morning and night
snacks are essential and should never be
missed.
For convenience 10 g of carbohydrate is
described as one portion’, so that a 170 g
carbohydrate diet is described to patients as
one of ‘17 portions.’ Patients need to know
the number of carbohydrate portions of
different foodstuffs.
Oral hypoglycaemics
There are two types of oral hypoglycaemic
drugs with entirely different modes of action:
sulfonylureas and biguanides. They can be
used singly or together. They have an
established place in treatment and are used by
30% of all diabetics. Unlike insulin they are
not essential for life and should be with drawn
whenever dietary treatment alone will suffice.
An oral hypoglycemic agent should be given
when diet has failed. Sulfonylureas are
generally preferred to biguanides because
they are more potent and have fewer side
effects. There should be no reluctance to use
sulfonylureas even in over weight patients
who remain symptomatic despite proper
dietary management. A biguanide may
occasionally be used as the first line of
treatment in grossly obese patients, chiefly
because it will help weight reduction to a
small extent. Otherwise a biguanide is
generally added to a sulfonyluria if this alone
has failed. There are unfortunately many
overweight diabetics who never achieve
adequate control and medical advice is
frustratingly of no avail. If a patient remains
unwell and continues to lose weight it is best
to switch to insulin without delay. Some
patients who just manage to maintain
adequate control with maximum doses of oral
hypoglycemics together with a minute diet are
extremely grateful when they are changed to
insulin and a more generous diet.
Oral hypoglycemics should not usually be
used during pregnancy. If a diet alone is
insufficient then insulin should be given.
Drug interactions are uncommon. Alcohol
may dangerously potentiate hypoglycemic
effect of oral hypoglycemics. Aspirin,
butazolidine, sulphonamides and monoamine
oxidase inhibitors may enhance the
hypoglycemic effect of sulphonylureas, but
the hazard is probably small and should not
prohibit the use of such drugs if they are
needed. Corticosteroids have powerful
hypoglycemic action, especially in larger
doses and may necessitate a change of
treatment to insulin. The indications for their
use are however same as in non-diabetics and
they should not be withheld just because the
patient is diabetic. Thiazide diuretics should
be avoided if possible. Oral contraceptives
have a weak hyperglycemic effect but rarely
disturb diabetic control.
Sulphonylureas
The hypoglycemic effect of early
sulphonamides was observed in the 1940s,
and in the next decade first tolbutamide
(1956) and then chlorpropamide (1957) were
introduced in clinical practice. They act
chiefly by stimulating insulin release from the
B cells of the pancreatic islets.
Nine sulphonylureas are available, together
with glymidine, which is a sulphapyrimidine.
379
They are remarkably safe and free from side
effects although rare toxic effects have been
reported, including rashes and jaundice.
Glymidine does not cross react with other
sulphonylureas, which can be useful if a rash
has occurred with one of the other
preparations. Only one sulphonylurea should
be used at a time since there is nothing to be
gained from any combination of these drugs
and there is no evidence that any one drug is
likely to be more successful than another.
Selecting a sulphonylurea is largely a matter
of personal choice. Chlorpropamide however
has an exceptionally long duration of action
(half life 36 hours) and may cause profound
hypoglycemia: both chlorpropamide and for
similar reasons glibenclamide should
therefore be avoided in the elderly who may
take too much or eat too little food, and in
renal failure since they are excreted almost
unchanged by the kidneys. Drugs, which are
chiefly, metabolized before excretion, such as
tolbutamide, gliclazide and gliquidone should
be chosen for patients with renal failure.
Many diabetics taking chlorpropamide
experience an unpleasant facial burning and
flushing very shortly after drinking even
small amounts of alcohol. This is sometimes
an inherited trait and it may be sufficiently
disagreeable to warrant changing to a
different sulphonylurea.
Biguanides
Biguanides act chiefly by reducing hepatic
glucose production, Metformin is therefore
the only biguanide which should be used
because phenformin has, albeit rarely, caused
fatal lactic acidosis in some patients. This side
effect has also been reported with Metformin
in patients with renal failure or any state of
shock: Metformin should therefore never be
used in these conditions or in the elderly or
those with serious liver disease.
Metformin has several unpleasant side effects,
which include nausea, diarrhoea and
vomiting, and may cause a disagreeable
metallic taste in the mouth. Some patients
suffer an insidious malaise and are grateful Types of insulin
when the drug is withdrawn. (Soluble, Isophane, Insulin zinc suspension)
Guar gum Human
Guar gum preparations if taken in adequate
quantity three times a day before meals can
reduce post prandial blood sugar
concentrations. Flatulence is common. There
are at present four available preprations-
Glucotard, Guarem, Guarina and Lejguar.
100 U/ml preparations of insulin available in the United Kingdom.
________________________________________________________________________________________________________
Neutral soluble insulin Isophane insulin Zinc suspensions Mixtures
________________________________________________________________________________________________________
Human
Human Velosulin† Human Insulatard† Human Monotard*† Human Initard*† (50/50
Velosulin/Insulatard)
Human Actrapid† Human Protaphane† Human lente*† Human Mixtard*†(30/70
Velosulin/Insulatard)
Human S‡ Human I‡ Human Ultratard† Human Actraphane*†(30/70
Actrapid/Isophane)
Humulin Zn‡ Humulin M1*‡ (10/90
neutral/Isophane)
Humulin M2*‡ (20/80
neutral/Isophane)
Humulin M3*‡ (30/70
neutral/Isophane)
Humulin M4*‡ (40/60
neutral/Isophane)
________________________________________________________________________________________________________
*insulin mixtures, †Human insulin prepared from enzymaticaily manipulated pork. ‡Biosynthetic human insulin.
Some other insulin such as Rapitard, Lentard, and Semitard are still available but no longer generally used.
Selection of insulin is a suitable initial dose for most patients.
The choice of insulin preparation is based on Many patients who present with acute
the duration of action. Although insulin can diabetes enter remission soon after diagnosis,
be broadly classified as having short, medium when a small dose of almost any insulin is
or long durations of action, their effect varies enough to maintain good control. The practice
considerably from one patient to another: thus of withdrawing insulin at this stage is not
soluble insulin, usually considered to be of encouraged because after a few months the
rather short duration, may have a more need for insulin is almost inevitable.
sustained effect in one patient than isophane, Maintenance regimens
generally described as medium acting insulin, Most insulin-dependent diabetics who want to
has in another patient. The duration of action achieve very good control will need twice
of insulin in an individual patient can daily injections, but multiple injections (three
therefore be discovered only by trial and or four times daily) are increasing in
error. popularity, may improve control and to some
Starting insulin extent increase flexibility (for example the
For relatively ill patients with acute-onset timing of the midday meal) and are often
diabetes, treatment should be started with needed in pregnancy. Multiple injections can
short acting soluble insulin two to four times be made easier by the use of the insulin in
a day. For those less severely ill treatment cartridge form administered by apparatus
should be started with medium acting insulin which maters the dose (such as Novo Pen, see
given once or twice daily; 8 units twice daily

380
page 12). Suitable insulin regimens are as
follows.
Twice daily
(1) Mixture of neutral soluble and medium-
acting insulin before breakfast and evening
meal, or (2) medium-acting insulin alone
Three times daily
(1) Mixtures of neutral soluble and medium
acting insulin before breakfast; neutral soluble
insulin alone before evening meal; medium
acting insulin alone before bed time; or (4)
neutral soluble insulin alone before each of
the three main meals.
Four times daily
(5) Neutral soluble insulin alone before each
of the three main meals and medium acting or
long acting (Human Ultratard Insulin) before
bedtime.
There is several suitable medium acting
insulin but those most often used are either
one of the isophane preparations or Human
Monotard insulin.
When changing from one insulin regimen to
another some trial and error by regular blood
glucose monitoring is always needed. In
converting a patient to the four times daily
regimen (5 above) the normal dose should be
divided by four and a slight adjustment made
to give more than one quarter before breakfast
and less than one quarter before bedtime.
For patients who lack either motivation or
ability to mix insulin in a syringe, because of
old age, poor intelligence, or blindness, fixed
mixtures of short and medium acting insulin
are available. In these patients a single daily
injection may suffice, and this has the added
advantage of preventing the nocturnal
hypoglycaemia, which is hazard especially for
elderly patients living alone.
Syringes and other devices
Insulin U 100 syringes (BS 1619) are marked
directly in units. Most patients should use the
0.5 ml syringe (which takes 50 U), but a 1 ml
syringe is available for the few who need 50-
100 U in each injection disposable syringes
are cheap and can be used repeatedly. The
best are those with fixed needles; after use the
cap should be replaced over the needle and
the syringe kept in the refrigerator. Plastic
syringes should not be stored in spirit. For
blind people a glass syringe is available with
a locking screw on the plunger which can be
set to deliver a specific dose. Needle size is
traditionally 25G but finer 27 G needles are
popular with many patients.
Several insulin ‘Pen’ devices deliver metered
doses of insulin from an insulin cartridge.
They are portable and simplify the procedure
of measuring the insulin. In some models the
dose is present on a dial; in others it is
administered by delivering the appropriate
number of clicks on the plunger. Each model
is designed for the use with specific insulin.
Neutral soluble insulin are now available in
cartridge form, and insulin mixtures will
shortly be available.
Some insulin Pens are:
Novo Pen
Insuject (UK licence pending)
Accupen
Injection sites
Insulin for routine treatment is given
subcutaneously by intermittent injections or
by continuous infusion. Insulin can be

381
injected subcutaneously almost anywhere if
there is enough flesh. The best site is the front
of thigh. The lower abdominal walls, buttocks
and upper arms may also be used. Women
who want to wear short sleeves should
normally avoid using the arms in case
unsightly marks should appear: some may
then prefer to combine injections to the bikini
area.
It is important to vary the injection sites from
day to day, using for example each thigh
alternately over as wide an area as possible.
Absorption of insulin varies from one site to
another, and if there are any difficulties with
‘control’ it is advisable to use one area
consistently for example the thigh.
Injection of insulin
Drawing up the insulin
(1) Clean top of insulin bottle with
industrial methylated spirit.
(2) Draw air in to syringe to the number
of marks of insulin required and inject
this in to the insulin bottle; then draw
the required dose of insulin in to the
syringe, and before withdrawing the
needle from the insulin bottle, expel
the air bubble if one has formed.
If clear and cloudy insulin are to be mixed,
inject the correct number of marks of air first
in to the cloudy insulin bottle; inject the air in
to the clear bottle; and with draw the insulin
in to the syringe; finally insert the needle in to
the cloudy bottle and withdraw the insulin.
Injection technique
(1) The skin need not be specially
cleaned; repeated application of spirit
hardens the skin.
(2) Stretching the skin at the injection site
is the best way to obtain a painless
injection; in thin people it may be
necessary to pinch the skin between
thumb and forefinger of the left hand.
(3) The needle should be inserted briskly
at almost 90º to the skin to almost its
whole length (needles are usually 3.8
inch to 5/8 inch long).
382
(4) Inject the insulin by depressing the
plunger. It is not necessary to pull
back the plunger beforehand.
(5) Withdraw the needle and press briefly
on the injection site with cotton wool.
(6) Replace the needle, cover and return
the whole syringe-needle in to its
container. Keep in the refrigerator.
Plastic syringes can be used until they
are blunt. Plastic syringes should not
be kept in any form of preservative.
Problems associated with insulin injection
Soon after starting insulin injections, small
red itchy marks about one inch across may
occur at the injection sites. These are
temporary and will disappear with in a few
weeks. On the very rare occasions when they
continue to be troublesome the addition of
hydrocortisone to the insulin bottle, so that
each injection contains about 1 mg
hydrocortisone may eliminate the problem.
Many patients develop some blurring of
vision soon after starting insulin, which
makes reading difficult. This is due to a
change of lens reflection and corrects it self
with in two to three weeks. Transient edema
of the feet is not uncommon during the first
few weeks of insulin treatment.
Fat atrophy used to be common in women
taking conventional insulin but is most
unusual in those using the newer purified
insulin. It fat atrophy has already occurred it
can be reversed by injecting purified insulin
around the edge of the hollow towards its
center and during several weeks the hollow
will fill out.
Fatty tumors occasionally occur. Their cause
is not known but they sometimes develop if
injections are repeatedly given over a very
limited area of skin. For this reason it is best
to vary the site from day to day. They are
rarely troublesome, but once present they tend
to persist.
Insulin allergy causing urticaria is very rare
indeed. If it occurs desensitization may be
needed. Abscesses at injection sites are also
remarkably rare.
All cardiovascular risk factors apply to people
with diabetes. Indeed they are even stronger
determinants in this group. This may be partly
explained by the fact that people with diabetes
have a higher prevalence of many
cardiovascular risk factors, notably
hypertension, obesity, lipid disorders and
insulin resistance. These risk factors are
interrelated and are more prominent in type 2
diabetes than in type1 diabetes.
CONTINUOUS SUBCUTANEOUS
INSULIN INFUSION
Education on CSII
(1) Talk with patient and spouse or partner.
(2) Demonstrate pump, alarms, batteries, basal
rate alterations, meal boosts, cannula insertion
and site changes.
(3) Re-educate about blood glucose and urinary
ketone monitoring at home and dosage
adjustments.
383
(4) Provide general and CSII related dietary
advice (possible weight gain but more
flexibility of meal times)
(5) Advice on CSII and exercise, bathing, sports
and sexual intercourse.
(6) Give instructions for hypoglycemia and
hyperglycemia, illness, ketonuria, infusion site
problems, pump breakdowns.
(7) Inform about 24 h on-call services.
(8) Supply insulin and syringes for emergencies.
Continuous subcutaneous insulin infusion
(CSII) is now available as a method of
treatment for patients whose life style requires
considerable flexibility especially with regard
to meal times, who are capable of the
technical manipulations and reliable blood
glucose monitoring which are needed and
have the necessary funds to buy and maintain
the equipment.
It is also one means by which ‘super’ control
can be achieved, although it is not necessarily
better than the multiple insulin regimens
described already. Indications for its use for
improving control for more conventional
methods have failed include pregnancy,
painful diabetic neuropathy, and in some
cases of unstable diabetes causing disabling
hypoglycemic episodes. Almost physiological
control can be achieved in most cases, but
there are notable exceptions, including some
very unstable (brittle) diabetics who are not
always improved by continuous subcutaneous
insulin infusion. Continuous intramuscular
insulin infusion is an experimental technique
that has been achieved some short-term
success in brittle diabetics; continuous
intravenous infusion has also been described
over long periods, but the potential hazards of
infection and thrombosis have restricted its
general application. The use of potential
delivery system is still experimental.
CSII is also an important research tool. Its
role in preventing or retarding diabetic
complications is under investigation at
present.
Technique
Delivery cannulae and implantation site A
fine gauge (25-27G) metal needle, with wings
attached to a connecting tube (for example, Reservoir insulin 2ml syringe Pre-filled
butterfly, Abbott Laboratories) is usually cartridge
(Graseby) Velosulin 570 U
used. This can be inserted by the patient, is Basal range 1-99 7.5-100
relatively non-kinking, and is easily secured (U/24 h) In 1 U step In steps
to the skin by the wings. Accidental with Bolus control Push-button Push-button
drawl almost never occurs. Tactile+audible 1 unit
The cannula is re-implanted every other day Feed back. 1 unit
Power Disposable Disposable
at a different site in the subcutaneous tissue of 5.4V battery 5.4V battery
the anterior abdominal wall; usually at the Battery life 10 weeks 28 days
same time as the pump insulin syringe is Alarms Full No
refilled, in those pumps receiving disposable blockage/empty
syringes. Reservoir
____________________________________________
Insulin
Patients are usually admitted to a metabolic
Neutral soluble insulin is used in the insulin
ward for about 2-3 days for education about
pumps. It is either drawn directly in to the
continuous infusion and stabilization on the
syringe to be used in the pump or is contained
infusion. Assuming that the patient is not
in the cartridge form (as in the Velosulin
being grossly under treated or over treated by
cartridge which contains 5.7 ml of 100 U/ml
conventional injection treatment, about 80-
Velosulin and is for use in the Nordisk-
100% of the total daily insulin dose will be
Wellcome Infuser system).
needed per day during infusion. On day one
Pumps
of the admission about half of the total dose is
Several suitable infusion pumps are available,
given at the basal rate (mean value for adult
and improved ones are being developed. They
diabetics 1 U/h) and the remaining half
infuse insulin at a basal rate and have
divided equally among the three main meals.
facilities for delivering a preprandial boost
In most patients no additional boosts are
either manually or electronically.
given for snacks. We find a delay of 30
The pump is usually worn in a pouch,
minutes between the mealtime insulin boost
attached to a belt around the waist or a
and the start of the meal suits most patients,
shoulder harness.
but the timing sometimes has to be tailored to
The following two pumps represent the most
the individual’s absorption pattern (range 15-
popular equipment use in the UK at the time
45 minutes).
of writing:
____________________________________________
Blood glucose is monitored throughout the
Graseby Nordisk period in hospital as a guide to adjusting
MS36 Infuser insulin rates. The fasting blood glucose is
____________________________________________ used particularly as a measure of basal
Address Graseby Medical NordiskUK infusion rate and the postprandial value
Colonial way Highview
House
(about 90 minutes after a meal) as a guide to
Watford Tattenham the magnitude of the mealtime boost. During
Crescent the rest of the stay in hospital blood glucose
Herts Epsom Downs control is optimized by fine tuning the basal
Epsom arte and the magnitude and timing of
Surrey
Size (mm) 120x58x25 100x60x20
preprandial boosts. There is no fixed ratio of
Weight (g) 170 189 basal to preprandial
189 insulin dose; but more
Appearance Smart White metal, insulin is often needed for breakfast than for
clinical Whitesize.
other meals of equal metal, clinical

384
The pump and the infusion cannula are
removed for bathing, the blood glucose
remaining fairly constant during the first hour
after disconnection. The pump may be kept in
place during moderately severe exercise,
without a change in infusion rate, but it
should be removed for sports in which it may
be damaged such as rugby, football or
swimming.
Outpatient management
Patients should be taught how to measure
capillary blood glucose concentrations with
reagent strips. This enables them to adjust the
rate of infusion at home when, for example
inter-current illness causes a temporary
increase in requirements. Home monitoring
also teaches the diabetic the size of the
mealtime boost appropriate for a given meal.
In our practice on continuous subcutaneous
insulin infusion also record each day their
blood glucose results, insulin dose (basal and
preprandial), and events such as
hypoglycemia, infection and pump
malfunction. A number of the medical term is
on call at all times to offer advice and help.
Patients are at special risk of developing
ketoacidosis because of the small
subcutaneous insulin reservoir at any one time
during CSII. The frequency of ketoacidosis
may be increased when centers start using
CSII but decreases to the same rate as that
during injection treatment, as patients and
doctors gain experience. It is wise for patients
to have reagent strips at home for urinary
ketone measurement, as an early warning of
loss of control.
Because continuous subcutaneous insulin
infusion uses new technology special skills
and precautions are needed. It should
probably be offered only by centers, which
have enough experience, equipment and staff
to provide the necessary education and
supervision of the patient and to take rapid
corrective action if the system breaks down or
other management problems occur.
385
ASSESMENT OF DIABETIC CONTROL:
ADJUSTMENT OF INSULIN DOSE
Blood glucose measurement
Blood glucose concentrations can now be
very simply measured the nurses at the
bedside or by patients at home. Most diabetics
especially those on insulin, find this technique
extremely valuable, but it is neither suitable
nor desirable foe every diabetic. Those who
do learn to measure their own blood glucose
should also be taught very carefully how to
interpret the results.
For many who decide to measure their own
blood glucose concentrations it is sufficient to
use blood glucose strips read by eye and
expensive meters are unnecessary. Others
obtain better results using a meter and gain
considerable reassurance from the readings. A
high degree of accuracy is not needed but if
the technique of performing the test is poor
results will be hopelessly inaccurate
whichever method is used.
Obtaining the blood
The blood can be obtained by pricking a
finger or, less easily an earlobe (using a
mirror). The best instrument to use is a
purpose made needle (for example, Monolet).
Several spring-loaded prickers are available
which simplify the task and ensure that an
adequate drop of blood is obtained: they
include the Autolet (Owen Mumford Ltd,
Woodstock, Oxfordshire), Monojectoe Lancet
Device (Sherwood Medical, Crawly, Sussex),
Autoslix (Hypoguard, Woodbride, Suffolk),
and Glucolet (Ames Division, Slough).
The test strip
The test strips are read by eye or by meter.
The following strips are available: BM-Test-
Glycemie 1-44; Ames Visidex II; Ames
Glucostix; Hypoguard GA Test strips. It is
very important to remember that a blood
glucose reading at the top of the scale of each
of the strip represents maximum values and
actual blood glucose levels could be much
higher.
Blood glucose meters
Several meters are now available; the
manufacturers’ instructions should be
followed very closely. A novel development
is the introduction of a memory chip in to the
glucochek meter (Medistron Ltd, Harsham,
West Sussex which retains the previous 400
blood glucose values; blood glucose profiles
are then printed using the Glucochek printer.
Other systems (for example, Hypocount MX,
Hypoguard, Woodbridge, Suffolk) have
smaller memory systems recording the
previous 10 blood glucose results.
Capillary blood samples
If patients cannot cope with self-measurement
of blood glucose but can manage to take
capillary blood they can take their samples to
hospitals in simple plastic tubes coated with
heparin and fluoride (Sarstedt tubes) and have
their home blood glucose profiles measured at
the diabetic clinic.
Purposes of home blood glucose
measurements
The purposes of monitoring blood glucose are
threefold: (a) as a spot check to detect
hypoglycemia; (b) as a spot check to detect
hyperglycemia; (c) to access the blood
glucose profile over 24 hours.
Detecting hypoglycemia
Detection of hypoglycemia is one of the most
important benefits of home measurement of
glucose values. Thus the blood glucose
concentration may be measured if the patient
386
is uncertain about suspected hypoglycemic
symptoms, or if relatives suspect
hypoglycemia when a child behaves
abnormally, becomes unconscious or
develops an epileptic convulsion. Home
measurements discover for him self the times
of day when he is most susceptible to this
hazard. In particular measurement at bedtime
in those prone to nocturnal hypoglycemia is
valuable; if the blood glucose is low (In
general less than 5 mmol/l) extra
carbohydrate may prevent hypoglycemia. The
same applies on other occasions when
hypoglycemia could be hazardous for
example before driving for a long distance.
Detecting hyperglycemia
The discovery of high blood glucose readings
in a symptom less diabetic is of limited value.
During illness however, when blood glucose
concentrations tend to be high and
accompanied by heavy glycosuria, raised
blood glucose values may be a valuable guide
to the need for extra insulin. If the level is
above about 15mmol/l an additional dose of
soluble insulin (approximately 8 units) would
usually be quite safe. Random blood glucose
readings may also help when particularly fine
control is needed for example during
pregnancy.
Blood glucose profiles
Assessment by insulin treated diabetics of the
daily fluctuations of their blood glucose
values results in a much greater understanding
by patients and doctors of both diabetic
control and the effects of different insulin
preparations. Home blood glucose
measurement is now an important educational
exercise for seriously motivated and well
organized diabetics. It is not suitable for all
diabetics, and those who lack the necessary
enthusiasm are better off using more
traditional methods of urine testing: their
blood glucose profiles may in any case be
chaotic and differ from day to day and may
thus be unhelpful in improving control.
Reproducible blood glucose profiles are
valuable in marking rational adjustments to
treatment. They can show not only the times
of the peaks and troughs of the blood glucose
but also the duration of action of given insulin
preparation in an individual patient. Indeed
the effects of individual insulins vary
considerably between patients to the extent
that soluble insulin may have a more
prolonged effect in one person than isophane
in another.
To obtain a blood glucose profile blood
samples are taken at the following times:
fasting, 2 hours after breakfast, before lunch,
2 hours after lunch, before the evening meal,
at bedtime and possibly during the night.
Advice on improving diabetic control must be
give individually but some general guidelines
are presented here. Changes in insulin dose at
any time should normally be kept with in 10-
20% of the existing daily dose: for example, a
change of 4-8 units may be made in a patient
taking a total daily dose of 40 units. At least
three to four days should normally pass before
a further change is made.
Adjustments after assessment of blood
glucose profiles
When consist daily fluctuations of blood
glucose have been shown treatment should be
modified, aiming chiefly to eliminate
hypoglycemic episodes and thereafter to
obtain better control by increasing the blood
glucose in the troughs and decreasing it at the
peaks.
To increase blood glucose in the troughs:
(a) Eat more carbohydrate at or before the
times when blood glucose values are
at their lowest; the exact amount of
extra carbohydrate can be determined
only by trial and error.
(b) Reduce the dose of insulin before the
trough.
To decrease blood glucose:
(a) Reduce by a little the amount of
carbohydrate taken at the meals that
387
precede the peaks by two or three
hours.
(b) Increase the dose of insulin before the
peak.
Soluble insulin should be altered to change
blood glucose concentration with in six hours.
Medium-acting insulin should be altered to
change blood glucose in 6-12 hours. The
duration of insulin action varies considerably,
however and these figures provide only a
rough guide.
Adjusting the insulin dose according to
urine test
For patients on mixed insulin (With soluble or
medium acting insulin each given twice
daily). If the urine test shows a large amount
of glucose:
- Before breakfast-increase the evening
medium acting insulin.
- Before lunch-increase the morning soluble
insulin.
- Before evening meal-increase the morning
medium acting insulin.
- Before bedtime-increase the evening
soluble insulin
- For patients on twice daily unmixed
insulin injections - If the urine test shows
a large amount of glucose:
- Before lunch or evening meal-increase the
morning dose.
- Before bedtime or breakfast-increase the
evening dose.
Haemoglobin A1 (glycated haemoglobin)
Persistent hyperglycemia modifies (glycates)
haemoglobin A
Measurement of this haemoglobin fraction is
a relatively new method of assessing diabetic
control and is unique in reflecting blood
glucose concentrations in a period of about
four weeks before the sample is taken. Unlike
blood glucose concentrations, glycated
haemoglobin concentrations do not fluctuate
from hour to hour, so they are useful in the
long term assessment of control and may
identify the patients whose control is not so
good but who prepare themselves for their
clinic attendance. When pregnancies are
planned haemoglobin A1 measurement may
prove helpful in establishing optimal control
before conception. It is frustrating to find that
even in those whose control is thought to be
satisfactory haemoglobin A1 values are often
raised; and sometimes normal haemoglobin
A1 is achieved only at the dangerous expense
of nocturnal hypoglycemia.
Haemoglobin A1 values vary according to
methods and laboratories, and no reference
standards are yet available. Using the popular
corning method, normal values are: <8%
(difficult to achieve); good control, <10%;
fair control, 10-12%; poor control, >12%.
Assessments of other glycated proteins by
fructosemine assay and by determination of
glycated albumin are under review but not at
present in routine use.
I thank Miss S George for her help with the photographs.
THE UNSTABLE INSULIN DEPENDENT
DIABETIC
Identify technical errors
Give best diabetic regimen
Search for other illness
Seek social or psychological problems
Blood glucose concentrations inevitably
oscillate considerably over 24 hours in most
insulin –treated diabetics. If these swings are
used as a definition of instability then many
diabetics might be classified as unstable.
Indeed, the ardent desire of some doctors to
‘stabilize’ diabetics sometimes leads patients
to undertake innumerable blood and urine
tests, to keep obsessional records, and to
make them selves thoroughly miserable. The
failure to succeed leads to recriminations,
388
admissions to hospital and absence from
work. This form of physician-induced
unstable diabetes is made worst by the
inappropriate use of home blood glucose
monitoring. It needs considerable patience to
unravel the effects of such advice, but a more
relaxed approach together with fewer tests
can have a remarkable effect.
Very unstable diabetes (sometimes described
as ‘brittle’) disrupts the lives of a small group
of insulin-treated diabetics with repeated
admission to hospital either from
hypoglycemia or ketoacidosis. Home life,
school and work are totally disrupted. I doubt
whether with very few exceptions, this is a
special type of diabetes: it most commonly
occurs in teenage girls, it is almost always
temporary and the problems appear to vanish
as life itself stabilizes with employment and
marriage.
Disruptive diabetes has several causes,
ranging from simple technical errors to gross
deceptions of great ingenuity. Management of
these patients therefore demands time and
patience: one must identify any technical
errors, recommend the best possible diabetic
treatment, search for inter-current illness; and
seek social or psychological problems which
might cause the patient to manipulate his or
her diabetes.
Identifying technical problems
Check
Injection technique
Visual acuity
Insulin strength and types
Urine and blood glucose testing technique
The technique of injecting insulin should be
checked, injection sites inspected and
equipment scrutinized. Sometimes, especially
in elderly patients, poor visual acuity makes
drawing up of insulin extremely inaccurate.
The insulin bottles themselves should also be
checked for the type and strength of insulin.
Techniques of urine and blood glucose testing
must be observed and checked with
laboratory results. Adequate understanding of
diet should be verified.
The dose and type of insulin should be
adjusted to the best possible regimen (ideal
insulin regimens have been described
elsewhere). Some unstable diabetics benefit
from continuous subcutaneous insulin
infusion, which may also alleviate unpleasant
hypoglycaemic episodes. Unfortunately some
patients remain unstable even when this
technique is used and continuous
intramuscular or intravenous infusion for long
periods, which offers the hope of further
improvements, is still at the experimental
stage.
If recurrent hypoglycemic episodes are the
chief problem then careful education is
needed to eliminate them; careful attention
needs to be given not only to the dose of
insulin but also to timing and measurement of
blood glucose. Sometimes excessive amounts
of insulin, especially soluble insulin may
cause severe hypoglycemia. Improvement
results from reducing the dose of insulin.
In a few women menstruation regularly
causes severe upset of diabetes; control
usually deteriorates in the premenstrual phase,
causing ketoacidosis at times, followed by a
decrease in insulin requirement and
sometimes-troublesome hypoglycemia. A
carefully planned campaign of insulin
adjustment usually overcomes this problem.
Perhaps above all, these patients need
encouragement and need restoration of self-
confidence together with the reassurance that
they are neither physically nor mentally
abnormal. The home telephone number of the
doctor or the nurse offers added security. If at
all possible unstable patients should not be
admitted to hospital. If all these measures fail,
however and life is still disrupted by the
diabetes, then admission is after all required.
Admission to hospital
The nursing staff takes over the admission of
insulin completely - both the procedure of
drawing up the insulin and giving injections.
If some measure of stability is then achieved
the patient equipment is returned for self-
389
injection: if chaos resumes it seems likely that
the patient is either incompetent or cheating.
If diabetes continues to cause disruptive even
when the nursing staff are giving insulin
injections some form of manipulation should
be suspected. Some patients use great
ingenuity: insulin may just be concealed in a
locker, but it has also been found inside
transistor radios, in the false bottoms of jewel
boxes, and taped outside hospital lavatory
windows.
Manipulation should be suspected in patients
whose lives are totally disrupted by their
diabetes. A careful history may reveal slips,
which give the vital clue. For instance one
teenager developed profound hypoglycemia
two days after apparently ‘stopping insulin’;
another, whose life was spent in and out of
hospital with hypoglycemia or ketoacidosis,
claimed to be perfectly stable in between,
presenting a whole volume of negative urine
tests. Even constant insulin infusion does not
solve the problem, especially when the patient
replaces the insulin in the syringe with water.
When there is strong evidence of
manipulation, I usually hint at the possibility
to the patient and her parents without
accusation. The technique is sometimes
successful and gratitude considerable.
Emotional, social or psychiatric causes
underlie disruptive diabetes and the desire to
manipulate the situation to cause widespread
havoc among families. Teenage defiance is a
common cause. Quiet support of families at
these difficult times helps to overcome what
is almost always a temporary phase. Careful
enquiry should establish weather or not there
is family strife. Psychiatric advice should not
be sought unless there is evidence of true
psychiatric disorder; otherwise, confrontation
with a psychiatrist may provoke even more
aggression. Nonetheless, a few patients
remain incapable of independent existence,
and whether they are children or adults some
form of institutional care has to be
considered.
Various disorders especially infections and
some endocrine disorders, may alter the
insulin requirements, although they rarely
cause the type of instability already described.
HYPOGLYCAEMIA
HYPOGLYCAEMIA (‘hypo’ ‘insulin reaction’)
This is when the blood sugar goes too low in diabetics taking
insulin.
Symptoms are sweating, shaking, tingling round the mouth,
hazy eyesight or seeing double, slow thinking, in children
naughtiness.
Causes are late meal, too little carbohydrate, extra exercise,
too much insulin.
Cure is to take carbohydrate preferably three dextrosol
tablets, glucose, sugar (2 large lumps), barley sugar,
Lucozade.
Symptoms will soon wear off.
If in doubt about an attack, take sugar.
Always carry some form of SUGAR with you.
Hypoglycaemia is the major hazard of insulin
treatment. Patients may experience the
symptoms of hypoglycaemia when the blood
concentration is less than 2.5mmol/l but
individual susceptibility varies considerably.
The risks are small in most diabetics but
because they exist at all diabetics on insulin
are barred from certain occupations such as
driving trains or buses. All diabetics on
insulin who are reasonably well controlled
will experience hypoglycaemia at some stage.
At its mildest it is no more than a slight
inconvenience but at its severest, when
unconsciousness can occur, it is both a hazard
and an embarrassment. Hypoglycaemia
occurs infrequently in patients on oral
hypoglycaemics.
All diabetics taking insulin must be carefully
taught about the causes, symptoms and
treatment of hypoglycaemia. Ideally new
diabetics should be made to experience
hypoglycaemia during their initial education.
Symptoms
Early warning Shaking, trembling Sweating Pins and
needles in lips and tongue Hunger Palpitations
Headache (occasionally) Neuroglycopenia: Mild
Double vision Difficulty in concentration Slurring of
speech More advanced Confusion Change of behavior
Truculence Naughtiness in children Unconsciousness
Restlessness with sweating Epileptic fits, especially in
children Hemiplegia, especially in the elderly (but rare)
Most diabetics experience the early warning
symptoms of hypoglycaemia and take sugar
before most severe symptoms develop with
increasing duration of diabetics and in older
patients there is a tendency of the early
warning symptoms not to occur, and patients
develop the more serious problems. Although
this lack of warning has been attributed to
autonomic neuropathy, I doubt whether this is
generally the case, although β-blocking drugs
occasionally have this effect. Friends and
relations are than more often aware of
hypoglycaemia than the patient himself,
observing him to be slow-witted with a vacant
expression and perspiring face and hands:
they should give him sugar immediately.
Diabetics who become unconscious from
hypoglycaemia should be taken to hospital
immediately. Brain death and damage do not
occur because the blood glucose
concentration tends to increase spontaneously
as the effect of insulin wears off. Many
diabetics especially children, need
reassurance that they will not die in their
sleep.
Nevertheless prolonged hypoglycaemia from
insulin overdose can be fatal, and suicides and
attempted murder with insulin have occurred.
Causes of hypoglycaemia
In every diabetic of insulin the blood glucose
concentration shows peaks and troughs,
which can be most clearly shown by home
measurement of blood glucose. Since the
lowest blood glucose concentrations, when
the symptoms of hypoglycemia are most
likely to appear, occur at different times in
each patient, it is a great advantage of
individual patients know when their own
troughs are likely to occur. The commonest
times are before lunch and during the night.
Apart from the natural troughs in blood
glucose concentrations, other events are likely
to provoke hypoglycaemic attacks are:
insufficient carbohydrate in meals; delayed
meals; physical activity; and errors of insulin
dosage. Really severe physical activity such

390
as swimming very long distances is a
powerful stimulus of hypoglycaemia, and as
much as 40-50g additional carbohydrates may
be needed to prevent it.
Hypoglycaemia is particularly likely to occur
shortly after stabilization of new diabetics, as
their insulin requirement decline
considerably; the insulin dose should
therefore always be reduced before they leave
hospital.
Hypoglycaemia is also troublesome when
insulin requirement insidiously decrease at the
onset of certain disorders, including
Addison’s disease, hypopituitarism, and
malabsorption syndromes.
Treatment
Dr Charles Fletcher’s account of
hypoglycaemia
My main problem has always been
hypoglycaemia. At first I was nearly always
aware of it by day and woke at night, because
of the adrenaline response. But, particularly in
the past 20 years, it gradually became more
difficult. I may now feel normal and do
ordinary tasks quite easily with blood sugar as
low as 2.5mmol/l (45mg/100 ml). Some times
diplopia, dysphasia, weariness and inability to
think may lead me to do a blood sugar. But I
often become too muddled to know what is
wrong, and I have had to think my wife, my
children and many generations of housemen,
registrars and secretaries for spotting these
low levels on many occasions. Before I
retired 50% glucose was always available
with syringe in a drawer in my desk. I became
quite used to a quiet registrar’s voice in
outpatients. (And elsewhere) syringe, ‘I think,
sir, a little extra venous glucose might help.’
Lucozade has been available. I always have it
available in the car, in the office and at home.
It is acceptably free from sugariness, it saves
me chewing and choking on dry glucose
tablets, and it is rapidly absorbed. My wife
finds it much easier to get me to drink this
then to take any other form of sugar when I
am severely hypoglycaemic and refuse to
391
acknowledge it. I have made it a rule, which I
now keep, even when semi-comatose, that if
my wife-or any one else-tells me to take sugar
I do so however sure I may be that I am not
hypoglycaemic. They have only been wrong
on rare occasions I am very sensitive to
exercise but for some reason I find it difficult
always to suck prophylactic sweets on
country walks or when digging or mowing in
the garden.
Prevention is most important. All diabetics
should carry on their person and in their cars
eithersugar lumps, sweets, or dextrosol
tablets (or sugar gel which may be squeezed
around the gums). They should take ample
carbohydrate at the times when their blood
glucose troughs occur and extra carbohydrate
before vigorous exercise such as swimming or
football.
If the early warning symptoms occur (table)
they should take 10-20 g sugar immediately.
If the response is poor more can be taken.
Unconscious patients should be given
intravenous glucose (20-50 ml of 50%
glucose) in hospital after blood has been taken
for confirmatory analysis later. At home they
can be given an injection of glucagons (1 mg
intravenously), which quickly raises the blood
glucose. It may be very helpful and a great
comfort to the relations of diabetics who are
liable to become unconscious from
hypoglycaemia to keep glucagon in a
convenient place.
Patients who remain unconscious after
prolonged hypoglycaemia are sometimes
given treatment for cerebral edema with
intravenous mannitol and dexamethasone.
They usually recover. It is very important to
be certain of the correct diagnosis of
unconsciousness.
Management of patients with recurrent
disabling hypoglycaemic episodes is
described in the chapter on the unstable
insulin-dependent diabetic.
Diagnosis
Blood glucose
Serum potassium and sodium
Acid-base status
Urea, creatinine
Plasma ketones (ketostix)
Blood count
Blood culture (when indicated)
The diagnosis of ketoacidosis is confirmed by
laboratory tests. Urine tests show heavy
glycosuria and ketonuria.
Blood glucose concentrations may range from
slightly increased to extreme hyperglycaemia.
The blood glucose concentration itself does
not usually indicate the severity of the illness.
Blood acid-base state-pH ranges from normal
to 6.9 the bicarbonate vale is depressed.
Plasma ketones are easily detectable with
ketostix. In patients with ketoacidosis the
results on plasma ketostix testing should be
++ or +++. The plasma ketostix test is useful
if acidosis is thought to be due to another
cause, such as lactic acidosis.
Electrolytes-The serum potassium
concentration is usually but not always rose.
This measurement is vital and lifesaving
treatment is needed to maintain potassium
values in the normal range. The sodium
concentration is normal or reduced and urea
and creatinine concentrations are often raised
through dehydration.
Blood count-If the blood count is performed
the white count is often spuriously raised to
15-20x109/l even in the absence of infection.
Treatment
____________________________________________
Normal saline:* 11 in first half-hour -1/2 h
11 over next hour ½-1 ½ h
11 over next hour 1 ½ -2 ½
h subcutaneous soluble insulin is then given
11 over next 2 hours 2 ½ -4 ½
h after the meal. Intravenous insulin should
11 over next 3 hours 4 ½ -7 ½
h
11 over next 4 hours 7 ½ -11 ½
h Intramuscular insulin-Soluble insulin 20
____________________________________________
Total: 61 11 ½ h
____________________________________________
* Change to dextrose 10% when blood glucose is less
than 10mmol/l.
392
(1) Insert a nasogastric tube (unless the
patient is fully conscious). Do not
allow any fluids by mouth; if patients
are thirsty they ay suck ice.
(2) Give intravenous fluids. The regimen
needs to be modified according to age,
weight and the presence of cardiac
disease. In seriously ill patients or
those with cardiac disease a catheter
for measuring central venous pressure
is useful. A suitable regimen for most
patients is shown. Saline 0.9% is used.
The fluid should be changed to
dextrose 10% once the blood glucose
concentration has fallen to less than
10mmol/l. The rate of infusion is
determined by individual need but at
this stage should probably be about 1
liter every 8 hours.
(3) Start intravenous or intramuscular
soluble insulin immediately.
Insulin treatment
Intravenous insulin-soluble insulin is
diluted in 0.9% saline in a syringe, at a
concentration of 1U/ml. It is given by
infusion pump (or pediatric drip set) at 6
U/h (o.1U/kg/h for children) until the
blood glucose concentration is less than
10 mmol/l. blood glucose should fall at a
rate of about 5mmol/l/h. then the dose
may be reduced to 3 U/h. higher infusion
rates are rarely needed; when they are
needed in insulin resistant cases, the rate
should be doubled or quadrupled etc. the
insulin infusion is continued until the
patient is well enough to eat. Preprandial
and intravenous insulin is discontinued
not be stopped before subcutaneous
insulin has been given.
units is given as a loading dose, then 6
units every hour until blood glucose is less
than 10 mmol/l, then continued at 2
hourly intervals. As with intravenous
insulin, higher doses are rarely needed.
Potassium and sodium bicarbonate
Potassium chloride administration
Serum value <3.5 3.5 - 4 4 -5
(mmol/l)
Administer 40 30 20
mmol/l mmol/l mmol/l
Potassium chloride administration should
usually start at about the 2nd hour,
preferably not before the serum potassium
concentration is known. It should be
withheld in exceptional cases of oligurea
or anurea, or if the serum potassium value
remains above 5mmol/l. after the 2nd hour,
or earlier if the initial serum potassium
value is normal or less than 4mmol/l,
20mmol/l of potassium chloride should be
added to each liter of saline. If the serum
potassium value falls below 3.5mmol/l,
40mmol should be used in each liter. The
exact amount should be determined by
serial serum potassium measurements-
every two hours at first, then every four-
serum potassium maintained between 4
and 5mmol/l. an electrocardiographic
monitor should be set up; there is,
however, no substitute for serial
potassium measurements.
Sodium bicarbonate is not normally
beneficial and is not given unless the
blood pH is less than 7.0 or the patient is
shocked. If it is needed, aliquots of
sodium bicarbonate (200 ml of 2.74 %
containing 65mmol) with added
potassium chloride (15mmol potassium
chloride) should be given over 30 to 60
minutes. This can be repeated if there is
no response with in one hour or if the
patient’s condition remains serious.
Treatment of the underlying condition-
underlying disease should be sought,
especially respiratory or urinary
infections, which may not be obvious at
the beginning. Blood culture, culture of a
mid-stream, specimen of urine and a chest
radiograph are performed. There is no
need to give antibiotics routinely. it is not
usually difficult to distinguish a genuine
surgical acute abdomen from the moderate
>5 pain and tenderness that are simply due to
ketoacidosis.
0
Aketotic, hyperosmolar states-
management is exactly the same as that
for ketoacidosis, except that 0.45% saline
is given (if the serum sodium value is
greater than 160mmol/l), and a lower rate
of insulin infusion (3U/h) is often
sufficient. In shocked and dehydrated
patients prophylactic low dose
subcutaneous heparin is considered.
Patients who develop this condition are
often elderly or West Indian, and they
often turn out to be non-insulin dependent.
Lactic acidosis- these patients are
profoundly ill and the cause of the
acidosis must be sought and rigorously
treated. They are often very insulin
resistant and need large amounts of
sodium bicarbonate. A plasma ketostix
value less than ++ excludes ketoacidosis
as a likely cause of metabolic acidosis.
Management of diabetes during surgery
The chief principle of diabetic management
through any crisis in which patients can not
eat or drink for any reason is to continue
insulin administration. The best method is to
give the insulin by continuous intravenous
infusion, either by infusion pump, directly
from the drip bag, or using a paediatric drip
set. Traditional ‘sliding scales’ are obsolete.
During surgery, management of the diabetic
will depend on whether he needs insulin or
not.
Insulin treated diabetics
Dextrose drip and variable-rate insulin infusion
(1) Give normal insulin on the night before the
operation.
(2) Early on the day of operation start an infusion
of dextrose 10%, add 10mmol KCl to each
liter and run at a constant rate appropriate to
the patient’s fluid requirements, usually 125
ml/h.
393
 (3) Make up a solution of soluble insulin 1 U/ml < 4mmol/l 8 U soluble
saline in a syringe and infuse intravenously by insulin/l
a line piggybacked to the intravenous drip 4-15mmol/l 16 U soluble
using a syringe pump. The infusion rate insulin/l
should normally be as shown in regimen 1, > 15mmol/l 32 U soluble
but is resistant cases use regimen 2 or 3. insulin/l
________________________________________ > 20mmol/l Review
Soluble insulin infusion rate _________________________________________
Bloodglucose Blood glucose is measured 2 hourly until stable,
_____________________________ then 6 hourly.
Regimen 1 Regimen 2 Urine tests should also be performed as a
Regimen 3 safeguard against erroneous ward blood glucose
_________________________________________ readings.
<4 mmol/l 0.5 U/h 1U/h After recovery
2U/h Once the patient starts to eat and the
4-15 mmol/l 2 U/h 4 U/h 8
U/h
intravenous drips have been removed, soluble
> 15 mmol/l 4 U/h 8U/h 16 insulin should always be given
U/h subcutaneously twice or thrice daily. It is best
> 20 mmol/l Review to start this regimen in the morning before
_________________________________________ breakfast. If blood glucose concentrations are
Blood glucose is measured preoperatively and then
2 hourly until stable, then 6 hourly.
high (more than about 17mmol/l) additional
Urine tests should also be performed as a doses should be given at noon or bedtime, or
safeguard against erroneous ward blood glucose both. The regimen may need to be adjusted
readings. every day. Don’t use a sliding scale.
Regimen 1 is satisfactory for most cases; very Non-insulin-dependent diabetics
severely ill patients, shocked patients and those on Omit usual treatment.
steroids or salbutamol infusions may need higher Use insulin treatment if diabetic control deteriorates.
dose infusions, such as regimens 2 or 3 or Maintain urine chart as well as blood glucose.
occasionally even more. Never stop the insulin
infusion since intravenous insulin lasts for only a
Management of diabetic treated with diet or
few minutes. oral hypoglycemic agents is more
straightforward, so long as the diabetes is well
For operations in which a patient is likely to controlled.
be maintained on a drip for more than 12 If the patient has well controlled diabetes
hours a regimen is needed, which can be (random blood glucose value<12mmol/l):
continued for an indefinite period. Again (1) Omit the tablet on the day of
there are two methods of administering the operation.
insulin: a variable rate infusion using a pump (2) Check the blood glucose concentration
or if this is not available, a glucose-insulin before and soon after operation; if the
infusion. blood glucose value is over 12 to
Glucose insulin infusion (when no pump is available) 15mmol/l start soluble insulin
(1) Give normal insulin on the night before subcutaneously.
operation. (3) If the diabetes is poorly controlled
(2) Begin an infusion of dextrose 10 % containing
10mmol KCl and soluble insulin 16 units per
(random blood glucose >15mmol/l)
liter. Run it at the rate appropriate to the the patient should be started on insulin
patient’s fluid requirements, usually 125 ml/h. before operation, using one of the
adjust insulin dose as follows: regimens described above.
_________________________________________
Blood glucose Soluble insulin
infusion
_________________________________________

394
DIABETIC COMPLICATIONS:
RETINOPATHY
Microangiopathy
Retinopathy
Nephropathy
Neuropathy
Macroangiopathy
Atheroma
Medial calcification
Patients with long standing diabetes may
develop complications affecting the eyes or
kidneys (micro-vascular complications),
nerves or major arteries.
The major arteries are affected by diabetes in
two ways. Coronary artery disease is
commoner in diabetics than in non-diabetics,
especially young women with diabetes of
long duration, in whom the prevalence of this
disorder approaches that of men; this
contrasts with the differential prevalence in
non-diabetics, it being much commoner in
men. The disease is otherwise no different
from that seen in non-diabetics. There is also
a very high prevalence of medial arterial
calcification (Monckeberg’s sclerosis) in long
standing diabetics, especially those with
neuropathy. Its functional importance is
uncertain.
Pattern of micro-vascular complications
The cause of the micro-vascular
complications is not understood, but the most
important influence is probably the quality of
diabetic control over many years. There may
also be a genetic influence, which can be
detected in identical twins. Fortunately not all
diabetics develop these complications, and
probably as many as a fifth are spared
altogether even after 40 or 50 years of
diabetes.
Curiously both retinopathy and neuropathy
may occur in isolation, but serious neuropathy
is always accompanied by retinopathy and
usually by neuropathy as well.
Retinopathy
After 30 years of diabetes over 80% of
patients will have retinopathy. In many cases
this is a mild background retinopathy which
changes little over the years. Rather
395
unpredictably, however, changes may develop
which threaten vision, generally from macular
disease or vitreous haemorrhage. Since,
treatment is now available which can prevent
blindness, it is essential to identify the lesions
which are amenable to treatment before vision
deteriorates.
Classification of retinopathy
Background retinopathy
Microaneurysms appear as tiny red dots and
represent small capillary aneurysms or bulges.
They are abnormally permeable but by
themselves not harmful.
Haemorrhages appear as small (dot) and large
(blot) red spots on the retina. They are
harmless unless they occur on the macula
itself, when they can severely impair vision.
‘Hard’ exudates- these are yellow-white
discrete patches, which often occur in rings
around leaking capillaries. They may coalesce
to form extensive sheets of exudates. They
cause blindness only when they occur in the
macula.
Maculopathy- if hard exudates advance on to
the macula vision gradually declines and
blindness eventually develops. Macular
edema also causes blindness: it may develop
quite rapidly. Its recognition is difficult, but
its presence is suggested by a gray
discoloration at the macula.
Preproliferative lesions
Ischemia of the retina probably predisposes to
the development of dangerous formation of
new vessels. An opthalmologist should be
consulted at this stage. The lesions are: (a)
multiple cotton wool spots, which are
indistinct and relatively large pale lesions,
representing areas of capillary closure; (b)
multiple large blot haemorrhages; (c) venous
beading, loops and reduplication; (d) arterial
sheathing; and (e) atrophic-looking retina.
Proliferative retinopathy
If there are peripheral new vessels the risk of
serious vitreous haemorrhage is small, but
new vessels on the disk are likely to develop.
New vessels on the disk commonly bleed,
causing preretinal haemorrhages and
blindness from vitreous haemorrhage.
Advance diabetic eye disease
The signs of advanced diabetic eye disease
are: vitreous haemorrhage; fibrous tissue,
which may shrink and cause retinal
detachment; and rubeosis iridis and
glaucoma-new vessels spread to the anterior
chamber and affect the iris (rubeosis iridis). If
the new vessel obstructs the out flow from the
anterior chamber a most painful form of
glaucoma occurs, sometimes requiring
enucleation.
Causes of blindness in diabetics
After 30 years of diabetes, about 7% of
patients are blind: there are in all about 8000
registered blind diabetics in England and
Wales, most being over 60 years old.
Vitreous haemorrhage from new vessels
occurs suddenly, painlessly and without
warning, and blindness rapidly develops.
Some clearing of the haemorrhage is likely
over the following weeks but recovery of
vision becomes progressively less likely after
repeated haemorrhage.
Maculopathy – exudates or oedema that
directly affects the macula causes blindness.
The onset is gradual over weeks or months,
during vision gradually deteriorates.
Glaucoma and retinal detachment are other
causes of blindness in diabetic retinopathy.
The lens- lens opacities or cataracts probably
develop more often in diabetics than in non-
diabetics. There is a very rare form of rapidly
developing cataract, which occurs in some
young patients.
Prevention of blindness
Retinopathy needs to be actively sought by
physicians because if it is detected early
enough blindness can be prevented by light
coagulation with xenon arc or argon laser.
The indications for photocoagulation are: (a)
the presence of new vessels on the disc.
Sometimes new vessels peripheral to the disk
are treated as well, especially if they become
pre-retinal, because they often herald the
396
development of vessels on the disc; (b) the
development of maculopathy either by
exudates or edema: this should be treated
when visual acuity begins to decline-that is, a
decrease of one or two lines on the Snellen
chart. Once visual acuity is less than 6/36 the
treatment is of no value.
Surgical treatment of blindness, including
vitrectomy, will not be discussed here.
Clinical examination of the eyes
Routine examination of the fundi should be
performed on all diabetics: the pupils should
be dilated and examined preferably in a
darkened room. Pupils should not be dilated if
there is any suspicion of glaucoma.
Tropicamide (Mydriacil) eye drops are
recommended because the pupils recover
from their action in two or three hours
without the need for reversal with pilocarpine
eye drops.
The fundi of all new diabetics should be
examined. Ideally visual acuity should be
tested and a retinal examination performed
each year. Examinations may be performed
less often in short-term symptom-less
diabetics without known retinopathy. Once
retinopathy is present examinations should be
performed every 6 to 12 months or more often
if indicated. If the dates and results of eye
examinations appear in a prominent place in
the records, it becomes a simple matter to
decide on the date of follow up examinations.
If the visual acuity is declining, exudates are
encroaching on the macula, cotton wool spots
(or other pre-proliferative changes) or early
new vessels are present, frequent eye
examinations are required and consultation
with an opthalmologist is essential.
It is simple to test visual acuity, and this
should become a routine practice in diabetic
clinics. Some clinics have arranged for annual
visual tests (and sometimes fundal
examinations as well) to be undertaken by
local ophthalmic opticians or opthalmic
medical practitioners willing to collaborate in
this form of assessment. This scheme is very
promising and could become an important
part of diabetic care. Refraction may be
performed by viewing the testing chart
through a ‘pin hole’ if patients have not
brought their glasses.
The blind diabetic
Once blind the patient should register with the
local authority because some amenities and a
little financial help are available.
Rehabilitation is available for suitable patients
at the Royal National Institute for the blind
center at Torquay, and some blind diabetics
are helped by guide dogs. Printing in Braille
is valuable but many diabetics cannot read it
because of the impairment of fine sensation in
their fingers. For insulin injections A present
syringe is available, but even more valuable is
one of the insulin ‘pens’ or the click count
syringe (Hypoguard Ltd, Ispwich, Suffolk), in
which each palpable click corresponds to a
single mark on the syringe. Urine tests can be
performed using Diastix together with a
Hypotest instrument, which gives an audible
signal corresponding to the amount of
glycosuria.
DIABETIC NEUROPATHY-1
Diabetic neuropathy
Diffuse polyneuropathy
Symmetrical sensory neuropathy
Autonomic neuropathy
Mononeuropathies
Femoral neuropathy
Radiculitis (nerve root involvement
Diabetic neuropathy is of two kinds: the
commonest is a diffuse neuropathy that
affects peripheral nerves chiefly of the legs
and autonomic nervous system; a much less
common form affects individual nerves or
nerve roots (mono-neuropathies) and has an
entirely different course. Pressure
neuropathies, including carpal tunnel
syndrome (median nerve) and foot nerve
(lateral popliteal nerve) are probably
commoner in diabetics than in other people.
Symmetrical sensory neuropathy
Diffuse neuropathy affects peripheral nerves
symmetrically, chiefly those of the feet and
397
legs. It is almost always sensory, though
motor involvement causing weakness and
wasting does occur rarely. Peripheral
neuropathy is common in longstanding
diabetics, but in older patients it may already
be present at the onset of the diabetes.
Neuropathy is usually symptom less and is
therefore a hazard to the unwary patient. In
more advanced neuropathies the patient is
aware of sensory loss: numbness (and in some
a sensation of coldness) may progressively
worsen until there is almost complete
anesthesia below the knee, but this is not
common. Reduced sensation in the feet may
result in unnoticed trauma from ill-fitted
shoes, nails or shoes, nails or stones, walking
barefoot, or burns from hot water bottles or
sitting close to a fire. Self-inflicted wounds
from crude attempts at chiropody are
dangerous because they often become
infected.
The diabetic foot
Neuropathic foot
Calluses, ulsers, sepsis, osteomyelitis, charcot joints,
edema, good pulses
Ischaemic foot
Painful, pink, cold, no pulses
Neuropathy or vascular disease, or a
combination of the two, is responsible for
serious foot problems in diabetics. The
neuropathic foot is a characteristic of diabetes
while the ischaemic foot is the same as the
occurring in the non-diabetics.
The neuropathic foot
Calluses are formed from repeated trauma and
lead to ulceration of the sole of the foot,
usually under the head of the first metatarsal
or at other protruberant pressure points. These
ulcers are painless and indolent, sometimes
persisting for years. The circulation is actually
increased in these patients, who are easily
palpable or even bounding foot pulses, and
edema is not uncommon, probably as a result.
The neuropathic ulcer may become infected,
which may lead to bony destruction from
osteomyelitis or to abscess formation.
Burns sometime occur. They either heal
spontaneously or become infected, with the
serious consequences or described above.
Gangrene of individual toes may occur after
sepsis or trauma despite the fact that the
major arteries supplying the blood to the foot
remain intact. Amputation of individual toes
in the neuropathic (but not ischaemic) foot
can be very successful and patients may
sometimes have a further trouble with their
feet.
Neuroarthropathy-Charcot’s joints- loss of
pain sensation together with possible
rarefaction of the bones of the neuropathic
foot may have serious consequences:
abnormal mechanical stresses usually
prevented by pain may occur, and the
susceptible bones are then damaged by
relatively minor trauma. Patients present with
a hot swollen foot, sometimes cahing and the
appearances are often mistaken for infection.
Injury may have occurred days or weeks
earlier or may not even have been noticed.
Sometimes charcot changes develop after
minor amputations which change the normal
weight-bearing stress. Radiographs at this
stage are normal, but bony damage appears
and develops rapidly during the following
weeks, leading to gross deformity of the foot.
The destructive process does not continue
indefinitely but stops after weeks or months.
Bony changes are most often seen at the
tarsometatarsal region of the foot, but they
occur also at the ankle or at the
metatarsophalangeal region. Changes at other
sites are rare.
The ischaemic foot
This looks quite different from the
neuropathic foot: it is painful, pink and cold
and the pulses are absent. Neuropathic lesions
occurring in an ischaemic limb are especially
indolent. Chemical sympathectomy is
sometimes performed for pain, usually
without much relief. When gangrene occurs it
398
may affect a single toe or be much more
extensive. Local amputation rarely succeeds.
Treatment of the infected neuropathic
diabetic foot
Foot problems must be managed jointly by
the diabetic physician and an interested
orthopaedic surgeon together with a
chiropodist and shoe fitter. Conservative
measures should be used when ever possible.
The most important is to relieve pressures
from the affected site.
(1) Rest with the foot raised is important,
though great care must be taken to prevent
excessive pressure on the heel since heel
ulcers become infected and then below-
knee amputation is often needed.
Orthopaedic supports to take pressure off
the heel are essential.
(2) Simple ulcers are best cleaned with
ordinary antiseptics such as Savlon or four
times daily irrigations with 2% Milton
solution. They are covered with a thin
plastic dressing soaked in Milton solution
(the surrounding skin must not be soaked).
When they have almost resolved they
should be covered with non adhesive
dressings. If the wound is deep Milton
irrigations are used. Systemic antibiotics
are essential, especially if infection is
spreading, if cellulites develop, or if there
is bony involvement. Staphylococci and
streptococci are the commonest infecting
organisms, so flucloxacillin and penicillin
are used together (or erythromycin in
cases of penicillin allergy). Metronidazole
is added when the lesion is deep and dirty.
(3) Surgery is needed only when there is
extensive sepsis with bony destruction,
abscess formation or gangrene. Local
surgery on the foot succeeds because the
circulation is intact; a ray amputation,
removing a toe and metatarsal together
with accumulated pus, is often successful.
Mid-tarsal amputation rarely succeeds.
(4) Specially made shoes are essential, since
friction from ill-fitting shoes rubbing on
pressure points can cause ulceration.
(5) A walking plaster sometimes allows
patients to retain mobility while relieving
pressure from the ulcer.
(6) Crutches may also be used to retain
mobility and eliminate pressure.
Care of the feet: preventing foot disease
To help prevent complications
Do
Wash daily with soap and water.
Dry well, especially between toes.
Change soaks, stockings daily.
See that your shoes are not too tight.
See a chiropodist.
Do not
Walk barefoot.
Sit too close to a fire or radiator. Put your feet
on hot water bottles.
Neglect even slight injuries-see your doctor.
Attempt your own chiropody-see your
chiropodist.
Many foot problems can be prevented, so all
diabetics should be aware of the problem. We
try to issue every patient with a postcard
containing the simplest instructions.
A good chiropodist must be available for the
diabetics. Ill-fitting shoes are the cause of
many problems. New shoes should always be
broken in by wearing them initially for only
short periods. If the foot is in any way
misshapen-for example from bunions,
hammer toes, charcot deformities, or as a
result of surgery-shoes must be specially
made to fit. It is great advantage if a shoe
fitter attends the chiropody clinic: it is
possible to make simple shoes fit on the spot
(Dru shoes for example) while awaiting
delivery of more elaborate fitted shoes made
in a workshop.
Neuropathy and the hands
Inability to read Braille
Carpal tunnel compression
Ulnar nerve compression
Diabetic neuropathy rarely causes symptoms
in the hands, and when it does the disease is
399
already advanced in the feet and legs.
Numbness and the clumsiness of the fingers
are thus very unusual and usually due to some
other neurological disorders. Impairment of
sensation is, however, often enough to
prevent blind diabetics from reading Braille.
Paraesthesiae and numbness in the fingers,
especially at night, are usually due to carpal
tunnel syndrome, which is also common in
non-diabetics. It is easily and effectively
relieved by a minor operation performed
under local anesthetic without admission to
hospital.
Interosseous muscle wasting, especially of the
first dorsal interosseous, is often seen. It is
usually due to ulnar nerve compression at the
elbow, and typical sensory defects in the
fourth and fifth fingers are detectable. It
causes little disability and there is no
satisfactory treatment. Patients are advised
not to lean on their elbows too much, thereby
avoiding further damage to the ulnar nerve.
Painful neuropathy
Pain is an uncommon but disabling symptom
of diabetic neuropathy. It occurs in the thigh
in patients with femoral neuropathy, in nerve
root distribution in radiculitis, and in both feet
in symmetrical peripheral neuropathy. The
pain causes exceptional distress because it is
protracted and unremitting lasting several
months or even two or three years. Contrast
burning sensations, paraesthesia, or shooting
pains occur, but the most characteristic
symptom is a cutaneous hypersensitivity
leading to acute discomfort on contact with
clothing and bed clothes. The pain leads to
insomnia, depression, and weight loss.
Patients are so distressed that they may seek
several opinions on their condition.
Treatment is difficult but above all the
promise that the symptoms always remit
eventually may sustain patients during the
wretched months of their illness. Diabetic
control should be optimal and insulin should
be given if necessary by continuous
subcutaneous infusion. Regular analgesics are
essential although drugs of addiction should
be avoided. Antidepressents and hypnotics
agents are also helpful. Help can be obtained
from a combination of a phenothiazine
(fluphenazine) and a tricyclic antidepressent.
Vitamins, phenytoin, carbamazepine and
antiplatelet drugs have been given with rather
inconsistent results. Electrical stimulation
using a cutaneous nerve stimulator at the sites
of pain may help, though it is probably more
useful in boosting morale and enabling the
patients and their relatives to take an active
part in treatment.
DIABETIC NEUROPATHY-II
Autonomic neuropathy
Clinical symptoms
Diarrhoea Postural hypotension
Gustatory sweating Persistent tachycardia
Impotence Gastroparesis
Neurogenic bladder Respiratory arrests
Diffuse damage to both sympathetic and
parasympathetic nerves, probably developing
in that order, is common in diabetics with
diffuse peripheral neuropathy. Fortunately the
disabling symptoms which result are not
common, and even when they do occur some
of them especially diarrhea, vomiting and
postural hypo tension are curiously
intermittent.
Gastrointestinal symptom
Diarrhoea: This is a catastrophic watery
diarrhea with severe nocturnal exacerbations
and faecal incontinence, preceded
momentarily by characteristic abdominal
rumblings.
NEUROPATHY
Proteinuria is the hallmark of diabetic
neuropathy and is often its only sign. More
than half of all diabetics develop proteinuria
after 30 years of diabetes. Renal failure is the
cause of death in about one-fifth to about one
quarter of diabetics diagnosed under 30 years
of age and nephropathy with renal impairment
contributes to morbidity in many others.
Nevertheless many diabetics are completely
spared and never develop glomerulosclerosis.
400
At the onset of diabetes and for many years
thereafter there is evidence of hyperfunction
of the kidneys of diabetics-their kidneys and
glomeruli are larger than usual, glomerular
filteration is greater than normal and exercise
induced albuminuria is greater than expected.
These early defects can be reversed by
meticulous diabetic control. It is likely that
they predispose to the subsequent
development of diabetic neuropathy.
Clinical course
The onset of nephropathy is insidious, and
until it becomes advanced patients are
unaware of any symptoms. It begins with very
small amounts of albuminuria
(microalbuminuria) detectable only by special
assays. As the disease developed positive
albustix tests are observed intermittently.
During subsequent years the proteinuria
becomes continuous and increases in amount,
although it is rarely very heavy, not usually
exceeding 5g/24hours. Renal function
remains normal for several years. When renal
function eventually declines it does so
progressively and without remission, although
the rate of decline is sometimes very slow,
taking some years before advanced renal
failure develops. The first symptoms occur
before the creatinine concentration reaches
500µmol/l and are due to fluid retention:
ankle edema develops first, followed by
breathlessness from pulmonary edema and
anaemia. Treatment is usually needed when
uraemic symptoms occur.
The rate of progression of disease is best
followed by measuring serum creatinine
concentrations: if the inverse of the creatinine
values is plotted against time a straight line
retention can be shown once the creatinine
concentration is greater than 200µmol/l, and
its slope indicates whether the disease is
advancing rapidly or slowly.
Patients with advanced diabetic nephropathy
are usually afflicted with other diabetic
complications. All have retinopathy, 80% of
them proliferative retinopathy, and about a
quarter are blind. Many have coronary artery
disease or peripheral vascular disease, and
medial vascular calcification is the rule.
Myocardial infarction is the common cause of
death before and after transplantation, and
amputations are all too common. Severe
neuropathy is sometimes present as well, with
both autonomic involvement and foot disease,
especially sepsis.
Diagnosis
Testing samples for the presence of protein
should be routine clinical practice. If
proteinuria develops it is important to
distinguish the onset of diabetic neuropathy
from other causes of renal disease, which may
need treatment, particularly severe urinary
infections or glomerulonephritis. If the renal
disease evolves in the typical way, and
particularly if retinopathy is already present
(as it usually is) then extensive investigation
is not necessary. Only if the clinical disorder
is atypical is further investigation including
renal biopsy, needed. In the most advanced
stages of diabetic renal disease retinopathy,
usually proliferative is always present and its
absence should make one suspect another
cause for the renal failure.
Treatment
In the early stages of diabetic nephropathy
strenuous efforts should be made to achieve
optimal control of diabetes.
401
REFERENCES
1. American Diabetes Association, Standards of
medical care in diabetes, Diabetes Care 28 (2005)
(Suppl 1), pp. S4–S36.
2. The Diabetes Control and Complications Trial
Research Group, The effect of intensive treatment
of diabetes on the development and progression of
long-term complications in insulin-dependent
diabetes mellitus, N Engl J Med 329 (1993), pp.
977–986.
3. I.M. Stratton, A.I. Adler and H.A. Neil et al.,
Association of glycaemia with macrovascular and
microvascular complications of type 2 diabetes
(UKPDS 35): Prospective observational study,
BMJ 321 (2000), pp. 405–412.
4. American College of Endocrinology consensus
statement on guidelines for glycemic control,
Endocr Pract 8 (2002) (Suppl 1), pp. 5–11.
5. The American Association of Clinical
Endocrinologists medical guidelines for the
management of diabetes mellitus: The AACE
system of intensive diabetes self-management—
2002 update, Endocr Pract 8 (2002) (Suppl 1), pp.
40–82.
6. M.N. Feinglos and M.A. Bethel, Oral agent
therapy in the treatment of type 2 diabetes,
Diabetes Care 22 (1999) (Suppl 3), pp. C61–C64.
A. Wright, A.C. Burden, R.B. Paisey et al. and
U.K. Prospective Diabetes Study Group,
Sulfonylurea inadequacy: Efficacy of addition of
insulin over 6 years in patients with type 2
diabetes in the U.K. Prospective Diabetes Study
(UKPDS 57), Diabetes Care 25 (2002), pp. 330–
336.
7. K.T. Khaw, N. Wareham and R. Luben et al.,
Glycated haemoglobin, diabetes, and mortality in
men in Norfolk cohort of European Prospective
Investigation of Cancer and nutrition (EPIC-
Norfolk), BMJ 322 (2001), pp. 15–18.
8. C.L. Rohlfing, H.M. Wiedmeyer and R.R. Little et
al., Defining the relationship between plasma
glucose and HbA(1c): Analysis of glucose profiles
and HbA1C in the Diabetes Control and
Complications Trial, Diabetes Care 25 (2002), pp.
275–278.
9. J.B. Saaddine, M.M. Engelgau and G.L. Beckles et
al., A diabetes report card for the United States:
Quality of care in the 1990s, Ann Intern Med 136
(2002), pp. 565–574.
Note: Most of the Matters are drived from Internet and
Research Papers
Chapter-16

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404
QUESTIONS FROM COMMON
MEN ON DIABETES
What is the difference between Diabetes
and Sugar?
Diabetes is an ailment in which there is too
much sugar in the system. Everybody has
some sugar in the blood because sugar is
needed for energy. Sugar comes from starchy
foods known as carbohydrates and these are
the commonest and cheapest food available.
Breads, potatoes, rice and spaghetti are all
carbohydrates, similarly jams, cakes, pastry,
biscuits, chocolates and sugar itself.
Whenever carbohydrate food is eaten, it is
digested in the bowel and converted to sugar.
This sugar is then absorbed in to blood stream
and becomes available for energy. The
process of digestion is slow one and so sugar
is only gradually absorbed in to the blood.
If a big meal or a box of chocolates is taken
then clearly a great deal of sugar is taken in to
the blood which is too much for the body’s
ordinary needs. The liver is the body’s great
storehouse and excess sugar is stored away
there, readily available when needed. If the
sugar is not used up, then it is gradually
converted into fat.
The amount of sugar present in the blood for
immediate needs is carefully regulated. After
a meal the sugar in the blood increases
slightly but the excess is stored so quickly and
efficiently in the liver that the blood is soon
normal again. This is really a wonderful
mechanism. Its efficiency all depends on a
hormone called insulin. The pancreas gland
produces insulin and its main job is to store
away all the excess sugar as soon as it appears
in the blood after a meal. If a lot of bread and
jam has been taken the pancreas gland
immediately pour out insulin which controls
the excess sugar.
What does happen in diabetes?
In diabetes the system does not work perfectly
for some reason there is not enough insulin to
cope and so excess sugar accumulates in the
blood. This excess sugar clogs the whole
405
energy system and the body makes strenuous
efforts to get rid of it by excreting it through
the kidneys. The excess sugar passed out in
the urine. Now-a-days, when food is plentiful
and sugar particularly so, excess sugar can
accumulate very rapidly in the blood if there
is not enough insulin. This means that when
diabetes occurs large quantities of urine have
to be passed to get rid of the unwanted sugar.
If you pass a great deal of urine you will soon
become very thirsty. You will have to replace
all the fluid that you are losing.
There are two main symptoms of diabetes-
passing a lot of urine and feeling thirsty all
the time. Other features soon follow because
the energy system (it is known as metabolism)
is working badly, there will be the feeling of
tiredness and unwell. Although quite a lot
meal has already be taken but the body will
not make good use of the food, and the weight
will go down. This makes two more
symptoms of diabetes: loss of energy and loss
of weight.
When diabetes occurs in a severe form it is
nearly always due to a complete lack of
insulin and this inevitably leads to thinness
and wasting units, it must properly be
diagnosed and treated. In some people,
however, particularly the middle aged or
elderly, diabetes is not due to a complete lack
of insulin but rather to a supply of insulin that
is inadequate to deal with an excessive intake
of food. In other words, diabetes is developed
because of eating too much and supplies of
insulin are just not able to cope. There is
enough insulin present if you eat less and if
you reduce your weight.
There are a at least two kinds of diabetes. The
more severe one, usually occurring in children
and young people, is due to a complete lack
of insulin. There is a milder form, usually
occurring in middle aged people, due to a
relative lack of insulin.
What are the causes of diabetes?
There is no known cause of it. Currently it
recognizes as genetic factor in some families
diabetes is recognized among the family
members such as where two or three
sisters/brothers all have diabetes whether any
body in the family has this ailment, only
about one in three knows of a diabetic
relative. Two thirds of those developing
diabetes know of no body in the family with
this complaint.
Can you inherit it?
Occasionally two people with diabetes marry
each other. If diabetes were inherited, you
would certainly expect all the children of such
a marriage to develop diabetes, but this does
not happen. In practice, even when both
parents have diabetes, less than a quarter of
their children will ever develop the ailment,
and even then mainly when they are middle
aged. If only one parent has diabetes the
chances of their children getting diabetes is
even less.
Now what does this mean? It means that
diabetes itself is not inherited. What inherited
is a tendency to diabetes. Some thing else is
needed to bring it out. This is comforting to
know because if you are young and you have
diabetes, you need not worry about getting
married for fear that your children will also
have diabetes. If your husband or wife has not
got the complaint, the chances of the children
getting diabetes are very remote. Even if you
both have diabetes there is very good chance
that none of your children will have the
disorder.
Can it be avoided?
If there is diabetes in the family it is a wise
precaution not to get overweight and to keep
to a healthy diet. It is unhealthy and unwise to
over eat under any circumstances but
particularly so if there is some body in the
family with diabetes and especially when
middle age approaches. As we get older the
production of insulin tends to be less plentiful
anyway and if there is a tendency to diabetes,
406
mild age spread is likely to bring on the
ailment.
Overeating does not explain the onset of
diabetes in children. Why should a little child
of 5, with no body in the family with diabetes,
suddenly become thirsty and have a lot of
sugar in the water? Why should the supply of
insulin suddenly cease in this way?
We do not know but many doctors suspect
that a virus may be responsible. Indeed we
know that occasionally diabetes develops
after mumps, and this is due to a virus. Many
virus infections can be detected even after the
illness is over: the virus leaves its
fingerprints.
Recently there have been some evidences that
children developing diabetes have had a
special virus infection called Coxsackie, and
research is now being under taken to see
whether this virus can cause diabetes. If so,
perhaps children can be protected against it.
How many kinds of diabetes are there?
Diabetes can come at any age. It can occur in
infants, though this is rare, or it can first
appear at the age of 90. In fact probably the
commonest time for diabetes is in the early
50s and when it comes on at this age it is
usually mild. We use the term mild to mean
that symptoms are not troublesome but this
does not mean the condition is harmless. If
too much sugar persists in the blood, it can
cause ill health over the years, so it must be
controlled by taking care with the diet and
some time medicines are necessary as well.
When diabetes occurs in children or young
people it is nearly always more severe. The
symptoms are more marked and indeed
control would not be possible with out
injections of insulin. Diabetes can be
controlled, therefore, in one of three ways: by
diet alone, by diet and medicine and by diet
and injections of insulin.
What is Mild diabetes?
Mild diabetes is often detected when routine
examination of the urine is performed for
insurance purposes or by the doctor when
visited for some other reason. Sugar in the
water does not always mean that there is
excess sugar in the blood. Some people show
sugar in the urine even when the sugar in the
blood is quite normal. This is an innocent
condition and is not diabetes.
In diabetes there is always excess sugar in the
blood and this is measured by taking blood
from a vein in the arm or from a blob of blood
taken from a finger.
The diagnosis may come as a complete
surprise because there may be no symptoms at
all, or only mild ones. There may be feeling
of thirst, passing more urine than usual and
generally feeling tired and lacking in the zest.
In women there may be troublesome. Genital
irritation may keep then awake at night. Most
people who develop diabetes at this age are
overweight, though not always so. There may
be some body else in the family who has
diabetes and this may give rise to suspicion
when symptoms occur. Some times the
diagnosis is associated with infections such as
boils on the skin or tonsillitis. These minor
infections may be made worse by too much
sugar in the blood it can gradually cause harm
in the years ahead. This means that if you
have diabetes, even though you may not feel
ill, it is always wise to make sure the diabetes
is properly controlled if you want to remain
healthy when you are really old.
The main treatment in this type of diabetes is
to eat less and to get the weight down. There
must be an absolute ban on sugar itself and on
things containing sugars such as sweetened
drinks, jams, cakes, biscuits and chocolates.
These must be cut out entirely. Remember
that many fizzy drinks, tinned fruits, baked
beans, sweet corn, various cereals and
condiments may contain sugar. A suitable diet
is discussed later but you can judge the
success of your diet on your bathroom scales.
If you remain overweight you are still eating
more than is good for you.
Is it necessary to have regular exercise?
Another important aspect of treatment is
407
exercise. One of the courses of our modern
life is that we tend to sit around too much and
never use our legs. We sit in an office chair
during the day. We travel home by bus or car
and sit and watch the television at night. Now
this is thoroughly bad. We must take some
exercise, even if it is nothing more exciting
than a regular walk. In younger people the
skipping rope is very good where there is no
opportunity for the usual sports. Walking and
swimming are always suitable, even for the
elderly. It is not wise to try to be too vigorous
too soon. It is better to increase gradually the
range of activity.
What is the role of smoking in diabetes?
Another hazard in diabetes is cigarette
smoking. This is a dangerous habit for
anybody, but particularly so in diabetes
because cigarettes dispose to coronary
thrombosis and so does diabetes. It is no good
cutting down on cigarettes; they must be cut
out. Coronary thrombosis is due to hardening
of the arteries of the heart. Unfortunately it
has become very common today and
particularly in those who are overweight, in
those who smoke cigarettes, and in those who
have too much sugar in the blood. Happily
these hazards can be avoided with sensible
care.
Are urine and blood tests necessary?
The urine should be tested for sugar as a
regular routine, even in mild diabetes, and this
is very easy to do. Bottles of special strips are
available. The strip is dipped in to the urine
and changes color if sugar is present. In the
early stages of diabetes, it is probably wise to
test the urine after every afternoon until it is
certain that all the sugar has disappeared. This
usually happens quite soon if the weight is
reduced and the diet kept to. Thereafter it is
probably enough to test the urine once a week
and it need only be tested more frequently if
the sugar returns.
Incidentally, it is a mistake to assume that if
the urine has no sugar then all is well. Once
mild diabetes has been proved, it will
gradually recur unless care is maintained to
keep to a restricted diet and keep the weight
down. As well as urine tests, it is wise to have
a regular blood check just to make sure that
every thing is all right. Indeed it is not
difficult to test your own blood sugar. Attend
your doctor or a hospital clinic at regular
intervals for a general check.
Once the weight has been reduced to a
satisfactory level and the urine and blood test
show no excess sugar, the diet can be
increased from the initial rigid restrictions.
Keep off sugar of course, but do not be afraid
of your carbohydrate intake so long as it is the
right carbohydrate high in fiber: whole meal
bread is better than white bread. Protein’s
foods can be eaten more or less as desired but
keep low on fats. Avoid constipation by
taking plenty of whole grains, vegetables,
salads and fresh fruit. All this is discussed
more fully later on.
Is it necessary to take medicine in diabetes?
Not all people who develop diabetes in
middle age get better just by eating less. In
some people, although they have really tried
to get their weight down and have made sure
to take some exercise, the urine continues to
show sugar because there is still too much
sugar in the blood. They really just have not
got enough insulin even to cope with a
restricted diet. In the old days, these patients
had to have insulin by injection but now a
day, tablets are available which help to bring
the blood sugar down to normal.
These tablets stimulate the pancreas to
produce more insulin and so bring down the
sugar in the blood. Of course, they are no use
at all in young people with diabetes; however,
the tablets can be very helpful. Their role is
limited: if the diet is wrong the tablets lose
their effect and it is no use and not safe to
increase the dose beyond a certain level.
The most commonly prescribed tablets are in
the group called sulphonylureas and there are
about eight different varieties. They are all
good and your doctor will prescribe the most
408
suitable one for you. They are best taken
before a meal, usually in the morning before
breakfast.
It should be stressed that although the tablet
will soon get rid of the sugar from the urine, it
is a great mistake to become too careless
about the diet. If you start to eat too much, the
tablets will lose their effect and you will be
worse off than ever. A careful watch must be
kept on your weight, and once again urine and
blood tests should be done at regular
intervals. Do not be lulled in to a false sense
of security merely because there is no
symptom and an occasional urine test shows
no sugar. We have to think of all the years
ahead and we know for sure that the more
care you take of the diabetes, the more likely
you are to be fit in the future.
When insulin is needed?
In severe diabetes the symptoms are more
acute and more obstructive. Thirst can
become very trouble some and several quarts
of liquid may have to be taken during the day
and during the night. In consequence, large
quantities of urine are passed and this often
disturbs sleep. There is a steady loss of weight
and a feeling of weariness and weakness.
Unless advice is sought and treatment started,
drowsiness or even coma with loss of
consciousness may follow after a time.
Fortunately most people seek the help of their
doctor long before this stage is reached. When
the doctor tests the urine he finds that sugar is
present and also acetone. Acetone is a
substance due to improper burning up of body
fats and this is a sign that the whole energy
system has become disturbed. Acetone does
not appear in the urine in mild diabetes.
In severe diabetes, the body makes its own
sugar from protein and fat: the sugar in the
blood increases even without food. In
diabetics taking insulin it is a serious error to
assume that if no food is taken insulin is not
needed. The very reverse is true. The three
principles for the successful treatment of
severe diabetes are the right diet, the correct
dose of insulin and keeping fit by physical
activity.
The diet for people needing insulin must be a
full and nutritious one. Nobody with diabetes
today need go hungry or thirsty. Their diet
must contain enough food to enable them to
lead a full and active life and to maintain their
weight at a proper level. It must contain the
correct proportions of carbohydrate, protein,
and fat and meals must be regularly spaced
throughout the day.
If you develop the type of diabetes needing
insulin, you must learn all about the food you
eat. Do not be frightened by the idea of a diet.
Get a sheet of a paper and write down what
you ate yesterday and at what times you had
yours meals. That was your diet yesterday.
Now that you have diabetes this diet may
need adjustment.
No sugar for a start. Sugar is a highly
concentrated and unnatural food and is best
left out entirely (except for hypoglycemia see
page 23). Carbohydrate is the cheapest and
most readily available food and is good for
you especially if it is high in fiber. It must be
divided out between the main meals, and in
practice this means a regular amount of bread
or potato at breakfast, lunch and supper. Fill
up on salads, vegetables and fresh fruit.
Protein is more expensive but an essential part
of the diet. On the whole it need not be
watched as carefully as carbohydrate. Meat,
fish, chicken, cheese, milk, and eggs are4
common protein foods and some protein
should be taken with each main meal. For
example, you may have had an egg and a slice
of toast yesterday for breakfast. This is well
balanced, since it contains both protein and
carbohydrate.
The third item of food is fat and we are in a
bit of a quandary about this. Fat is a
concentrated form of food and is an essential
part of our diet. It is mostly available in the
form of butter, cream and meat fat derived
from animals, may dispose to increasing the
cholesterol in the body.
409
Now if the cholesterol concentration is too
high, this can be associated with an increased
chance of developing coronary thrombosis.
This being so, most doctors advise reducing
the animal fat in the diet and replacing it with
certain vegetable oils which do not increase
the cholesterol. Of course it offers great
difficulty if we try to cut out animal fats
entirely and substitute vegetable oils but we
should avoid too much fried food and be
careful not to take too much butter, cream and
fat.
The other two groups that make up the
famous five of nutrition are vitamins and
minerals. They are an essential part of the diet
in maintaining good general health and for
growth and repair. So your diet must also
contain fresh vegetables, salads and fruit and
enough milk and cheese to provide calcium,
particularly in the young.
Life saving insulin
In severe diabetes the body seems incapable
of producing any insulin at all and if we were
not able to inject insulin, life itself would
soon be threatened. The injection replaces the
insulin that the body no longer produces.
Unfortunately insulin loses its effect when
taken by mouth because it is destroyed by the
digestive juices. It simply has to be injected
under the skin by syringe and needles.
Different types of insulin
Insulin is derived mainly from the pancreas
glands (the sweetbread) of pigs and cattle and
is then known as porcine or bovine insulin.
The structure of the insulin is slightly
different from natural human insulin. Human
insulin produced by artificial methods is also
available but whatever the type the effect is
same.
FURTHER READING
American Diabetes Association Complete Guide to
Diabetes: American Diabetes Association The
Ultimate Home Diabetes Reference. American
Diabetes Association, 01-Jan-2000
David K. McCulloch. Diabetes Answer Book: Practical
Answers to More Than 300 Top Questions.
Sourcebooks, Inc., Oct-2008
David M. Nathan, M. D., Linda Michele Delahanty.
Beating Diabetes (A Harvard Medical School Book):
Lower Your Blood Sugar, Lose Weight, and Stop
Diabetes and Its Complications in Their Tracks.
McGraw Hill Professional, Jul-2006
Michael Bryer-Ash.100 Questions & Answers About
Diabetes. Jones & Bartlett Learning, Oct-2010
Umesh Masharani. Diabetes Demystified: A Self-
Teaching Guide. McGraw Hill Professional, Nov-
2007

Note: Most of the Matters are drived from Internet and

Research Papers

410
Chapter-17

411
412
Common Diseases medications are variable and somewhat
unpredictable. Thus, persons with diabetes
DIABETES REVIEW
must also perform daily blood glucose tests
The disease results from autoimmune
that require pricking a finger with a lancet,
destruction of the islet cells in the pancreas
putting a small blood sample on a test strip
that produces insulin, resulting in a complete
and inserting the strip into a blood glucose
and permanent deficiency of that hormone.
meter that displays the test result after a few
Because insulin is required for cellular use of
seconds and, typically, stores the result for
glucose and healthy glucose metabolism is
later retrieval or computer download. Modern
essential for growth, activity, wound healing,
therapy usually requires that patients perform
fat deposition, and brain function, people with
blood glucose tests before each meal and at
type I diabetes can not survive without insulin
bedtime as well as at other times to evaluate
replacement therapy.
possible abnormally high or low blood
Type II diabetes mellitus (previously known
glucose levels. Nutrition also plays a key role
as non–insulin-dependent diabetes mellitus)
in regulating blood glucose levels. The most
is, until recently, uncommon in the pediatric
common current approach to diet is based on
age group. However, type II diabetes now
carbohydrate counting in which patients are to
accounts for 10% to 20% of new cases of
consume a prescribed number of grams of
diabetes in youths (American Diabetes
carbohydrates at each meal and scheduled
Association, 2000; Rosenbloom &
snack. Dietary management of diabetes has
Silverstein, 2003). This increased incidence is
become more liberal in recent years, and
widely felt to be because of the epidemic of
children may eat limited quantities of refined
obesity and sedentary lifestyle among youths
sweets if these are included among the
in Western societies. Rather than the insulin
allowed carbohydrate grams for that day.
deficiency that characterizes type I diabetes,
Exercise is also crucial to modern diabetes
in type II diabetes, a state of insulin resistance
management. Regular aerobic exercise is
develops such that the body’s ability to use
valuable because it may reduce insulin
available insulin is impaired. This results in
requirements, promote cardiovascular health,
symptoms similar to those of type I diabetes,
and facilitate weight control. Modern diabetes
albeit through a different physiological
therapy allows patients to live relatively
mechanism.
normal and productive lives, yet it offers only
Patients with type I diabetes are treated with
a rather crude approximation to normal
either multiple daily insulin injections or the
pancreatic function. Children and adolescents
use of an insulin pump, which infuses insulin
with diabetes therefore often experience
through an indwelling catheter at a constant
unwanted fluctuations in their blood sugar
basal rate, with bolus doses delivered just
levels, including episodes of abnormally high
prior to meals. Some youths with type II
blood glucose (hyperglycemia) and
diabetes may be managed with diet and
abnormally low blood glucose
exercise alone or with daily oral medications.
(hypoglycemia) that must be recognized and
Many cases of type II diabetes progress to a
corrected promptly. Causes of hyperglycemia
state of islet cell failure and insulin
may include under dosing, delaying or
deficiency, and these patients, therefore,
skipping insulin injections or oral
require insulin injections, and their treatment
medications, overeating, prolonged
regimens are virtually identical to those for
psychological stress, and infections.
children with type I diabetes. Although these
Hyperglycemia may produce no obvious
therapies restore the ability to use glucose, the
symptoms, but if prolonged, it can lead to a
effects of a given dosage of insulin or oral

413
dangerous state of diabetic ketoacidosis and
possibly diabetic coma, requiring
hospitalization. Most such hospitalizations are
preventable if adequate treatment adherence
could be maintained (Glasgow et al., 1991;
White Kolman, Wexler, Polin, & Winter,
1984). Hypoglycemia may result from giving
too much insulin, under-eating, or
extraordinary physical exertion. Symptoms of
hypoglycemia may include trembling, nausea,
sweating, dizziness, confusion, and memory
loss. Mild to moderate hypoglycemia can be
interrupted by ingestion of carbohydrates.
Severe hypoglycemia is treated urgently by
injection of glucagon, a hormone that
interferes with insulin action, raising the
blood glucose level. Youths with both forms
of diabetes are prone to becoming over-
weight. In the case of type II diabetes,
effective weight control may prevent or
reverse the need for insulin replacement
therapy, permitting some patients to be
managed on an appropriate combination of
oral medications, diet, and exercise. In
addition to these short-term complications of
diabetes, both forms of the disease raise the
long-term risks of heart disease, kidney
failure (nephropathy), blindness (retinopathy),
and nerve damage (neuropathy). Recent large-
scale studies of type I diabetes (Diabetes
Control and Complications Trial Research
Group, 1993, 1994) and type II diabetes
(United Kingdom Prospective Diabetes Study
Group, 1997) have proven that the risks of
these complications increase linearly with
patients’ average blood glucose levels during
the long term. Maintenance of near-normal
blood glucose levels can reduce the incidence
of these complications by as much as 75%.
Patients who consistently keep their blood
glucose levels within the normal range
probably face no greater risk of these health
problems than do members of the general
population. After these studies, clinical care
for youths with diabetes has evolved toward
much more aggressive attempts to maintain
414
blood glucose levels as close as possible to
the normal range (Tamborlane, Gatcomb,
Held, & Ahern, 1994). Changes that have
occurred during the past decade include
increased use of insulin pumps and of three or
more daily insulin injections; so-called basal-
bolus insulin regimens incorporating a
combination of very long acting insulin and
pre-meal bolus injections of very fast acting
insulin; training of patients and families in
adjusting their regimens to prevent or correct
unwanted blood glucose fluctuations; flexible
nutritional management using a carbohydrate
counting approach; more frequent blood
glucose testing; and a greater emphasis on the
family as the center of a multidisciplinary
team approach to diabetes management.
Referral Processes, Procedures, and
Problems
The greatest barriers to effective diabetic
control are behavioral (Anderson & Rubin,
1995; Weissberg-Benchell et al., 1995;
Wysocki, 1997; Wysocki, Buckloh, Lochrie,
& Antal, in press). Although most children
and adolescents with diabetes adapt to these
self-management responsibilities successfully,
many do not. As the management of diabetes
has become increasingly sophisticated and
technologically complex, the role of behavior
change specialists in the management of
diabetes has increased correspondingly.
Youths with diabetes and their families are
often referred by health care professionals for
behavior management services. Referral
problems can be divided into several
categories: problems with treatment
adherence and diabetic control, problems with
social and coping skills, and problems with
diabetes-related anxiety and stress
management. Behaviorally oriented clinicians
have many skills that can be brought to bear
in these situations. At Nemours Children’s
Clinic, a psychologist or postdoctoral fellow
typically sees newly diagnosed patients and
families for an initial consultation within a
few days after the diagnosis is made. This
occurs as a part of the overall family
educational process. Among the most
important objectives of this consultation is an
assessment of family barriers to adequate
treatment adherence. A number of
demographic and behavioral factors have
been identified consistently in the research
literature as important correlates of diabetes
treatment adherence. Demographic factors
that increase risk for non-adherence with
treatment include older age of the youth
(John-son, 1995; La Greca, Follansbee, &
Skyler, 1990), single-parent family
composition (Hanson, Henggeler, Rodrigue,
Burghen, &Murphy, 1988; Harris, Greco,
Wysocki, Elder, & White, 1999), and lower
socioeconomic status (Glasgow et al., 1991;
White et al., 1984).
Behavioral factors that may predict poor
treatment adherence are inordinate child
responsibility for treatment tasks (Allen,
Tennen, McGrade, Affleck, & Ratzan, 1983;
Anderson, Ho, Brackett,
Finkelstein, & Laffel, 1997; La Greca et al.,
1990; Weibe et al., 2005; Wysocki et al.,
1996), high levels of family conflict and poor
family communication and problem solving
skills (e.g. Anderson, Miller, Auslander, &
Santiago, 1981; Bobrow, AvRuskin, & Siller,
1985; Miller-Johnson et al., 1994; Wysocki,
1993), and deficient social skills and coping
methods (e.g., La Greca et al., 1995). If a
child or family is identified as being at high
risk of non-adherence with treatment, they are
scheduled for outpatient follow-up by the
psychologist, often coincident with medical
follow-up visits. Deficient social skills and
coping methods are also common reasons for
referral of youths for behavioral services.
Successful coping with diabetes and its
treatment is facilitated when youths succeed
in developing and maintaining a network of
supportive peer relationships that promote
rather than impede effective diabetes self-
management (La Greca et al., 1995) and when
they have developed a flexible repertoire of
415
diverse coping and problem-solving skills.
Anxiety about diabetes and its management
and the impact of psychological stress on
diabetic control are additional common
reasons for referral to a behavior change
specialist. Among the common clinical
presentations in this category are escape and
avoidance behaviors surrounding insulin
injections, hypoglycemia, school attendance,
and long-term complications of diabetes. As
is typical of many anxiety-related referral
problems, it is often the case that both
parental and child behaviors need to be
targeted for treatment. Psychological stress
can interfere with diabetic control indirectly
by impeding treatment adherence and directly
by inducing secretion of stress hormones that
block insulin action and increase blood
glucose levels. Consequently, behavior
change specialists may be called on to assist
in identifying and managing sources of such
stress.
Standardized Approaches to Assessment
There is a very extensive research literature
on adaptation to diabetes among children,
adolescents, and their parents (Johnson, 1995;
Lorenz & Wysocki, 1991; Wysocki et al., in
press). Many measures have been developed
and validated to enable a careful specification
of treatment targets and an analysis of factors
that may be controlling the problem behavior
(Bradley, 1994). Among these measures are
numerous self-report instruments and
questionnaires that can be valuable clinically
as part of a systematic screening process
designed to elucidate general treatment targets
that may then be specified more care-fully.
Some examples of self-report instruments and
other assessment methods that have been
validated empirically with the childhood
diabetes population are discussed below.
The assessment of diabetes treatment
adherence has presented substantial
challenges to behavioral researchers and
clinicians. Because the relevant self-
management behaviors occur in the patient’s
daily life, direct observation of these
behaviors is impractical. Consequently,
practical constraints force the use of tools that
provide estimates of treatment adherence that,
to varying degrees, may approximate the ideal
of continuous direct observation. A variety of
self-report and parental report questionnaires
and interviews have been developed and
validated, but correlations between these
measures and biochemical indices of diabetic
control tend to be marginal. Evidence
suggests that adherence rates are commonly
over reported by parents and by youths
(Wing, Epstein, Nowalk, Scott, & Koeske,
1985), emphasizing the importance of relying
on multiple informants when using self-report
measures of adherence. Among existing self-
report measures of diabetes treatment
adherence, those that have received
substantial research attention and empirical
support are Johnson’s 24-Hour Recall
Interview method (Johnson, Freund,
Silverstein, Hansen, &Malone, 1990;
Johnson, Kelly, Henretta, Cunningham,
Tomer, et al., 1992; Johnson, Silverstein,
Rosenbloom, Carter, & Cunningham, 1986),
the Self-Care Inventory (La Greca et al.,
1995), and the Diabetes Self-Management
Profile (Harris et al., 2000). A brief
description of each method and a comparison
and contrast of their characteristics appears
below.
The 24-Hour Recall Interview (Johnson,
1995; Johnson et al., 1986) method consists
of a series of three interviews, conducted by
telephone or in person, in which the
interviewer’s task is to guide the parent and
child in reconstructing the diabetes-relevant
events of the preceding 24-hour period.
Ideally, interviews are not announced or
scheduled in advance and the series of three
interviews covers 2 week-days and 1 weekend
day. Parents and older youths are interviewed
separately. The interview format yields raw
scores for 13 dimensions of diabetes self-care
behavior and scores for five-factor,
416
analytically derived subscales. Reliability and
validity of the method have been confirmed
amply, although the scoring procedures are
time-consuming and require some complex
computations. Unfortunately, the resulting
scores have generally been poorly correlated
with biochemical measures of diabetic
control.
The Self-care Inventory (La Greca et al.,
1995) is a self-report questionnaire on which
parents or youths with diabetes rate on a 5-
point Likert-type scale the patient’s
completion of each of 14 diabetes self-care
tasks during the prior 3 months. It is
convenient to administer and score and some
studies have shown it to be reliable, stable (La
Greca et al., 1995), and responsive to
behavioral intervention (Wysocki et al.,
1999). We have recently published data on a
structured interview for the assessment of
diabetes adherence, the Diabetes Self-
Management Profile, which yields reliable
adherence estimates and moderate
correlations with measures of diabetic control
(Harris et al., 2000). This instrument was
adapted from a similar tool developed
previously by Hanson, Henggeler, and
Burghen (1987). Respondents estimate the
frequency with which each of 25 self-
management behaviors has occurred during
the prior 3 months. The method yields a total
adherence score as well as scores for five
components of diabetes management:
exercise, diet, glucose testing, management of
hypoglycemia, and insulin administration.
Items are worded to enable adaptations for
children on insulin pump therapy and to
capture sophisticated diabetes treatment
adjustment skills. Data reported by Harris et
al. (2000) indicate that the instrument has
sound test-retest and inter-observer reliability
and total scores correlated moderately with
Hemoglobin A1C levels. The validity of data
obtained from this tool is enhanced with
several procedural nuances: using a trained
interviewer who is not a member of the
diabetes team, interviewing parents and
youths separately, conducting the interview
elsewhere than in the diabetes clinic setting,
introducing each section of the interview with
introductory comments that normalize non-
adherence, clearly specifying the time frame
over which self-management is being
assessed, and by refraining from judgmental
or emotional reactions to reports of non-
adherence. Separate versions of the interview
(Diabetes Research in Children Network
[DirecNet] Study Group, 2005) have now
been validated for patients on conventional
insulin regimens and on flexible regimens
(e.g., insulin pump therapy or basal-bolus
injection regimens). In addition to these self-
report measures of overall diabetes treatment
adherence, additional methods enable reliable
measurement of other selected dimensions of
diabetes self-management behaviors. For any
childhood chronic disease that has a
nutritional treatment component, there may be
an increased risk of feeding problems among
toddlers and preschoolers. Direct observation
systems such as the Mealtime Observation
Schedule (Stark, Powers, Jelalian, Rape, &
Miller, 1994) yield valid, treatment-relevant
data and are preferable to parental reports
about feeding interactions. A variety of
technological alternatives to self-report
measures exist for assessing adherence with
certain components of the diabetes regimen.
Most modern blood glucose meters record in
memory each blood glucose test by date, time,
and result. These data can then be
downloaded for various levels of analysis.
Several models of insulin pumps also record
in memory a timeline of the basal and pre-
meal bolus dosages, enabling assessment of
adherence with insulin administration among
patients treated via insulin pump. Physical
activity can now be recorded very reliably by
using any of several accelerometer devices,
which are capable of recording and storing in
memory the frequency, duration, and intensity
of movement in three planes during prolonged
417
intervals. Dietary composition and caloric
intake can be assessed by asking patients and
parents to record everything eaten during a 3-
day interval and then analyzing those data
with any of a variety of nutritional analysis
computer programs. This technique is heavily
dependent on the ability of parents or youths
to estimate accurately the portion sizes of
foods that were eaten. It is difficult to define
alternatives to self-report measures for
assessing diabetes-related affect. Cox, Irvine,
Gonder-Frederick, Nowacek, and Butterfield
(1987) developed and validated the
Hypoglycemia Fear Survey as a tool to assess
anxiety about hypoglycemia and behaviors
maintained by avoidance of these episodes,
such as maintaining slightly elevated blood
glucose levels to reduce the probability of
hypoglycemia. Green, Wysocki, and Reineck
(1990) confirmed the psychometric properties
of the Hypoglycemic Fear Survey with
children as young as 10 years of age. Kamps,
Roberts, and Varela (2005) have recently
reported a validation study of a similar
instrument, the Children’s Hypoglycemia
Inventory. Another common type of anxious
and avoidant behavior in youths with diabetes
relates to fears of insulin injections. Harkavy
et al. (1983) developed a reliable direct
observation system for the assessment of
injection-related escape and avoidance
behavior. There have been surprisingly few
studies of behavioral interventions for
reducing injection-related distress in children
with diabetes.
A variety of self-report measures have been
developed for identification of psychological
stressors that may interfere with treatment
adherence and diabetic control (e.g., Polonsky
et al., 1995). Their Problem Areas in Diabetes
scale is designed to catalog such stressors,
enabling the clinician to assist the patient in
identifying and exploring methods of stress
reduction and management. Several
investigators have validated direct
observation systems for the assessment of
diabetes-specific social skills. For example,
Gross, Magalnick, and Richardson (1985) and
Kaplan, Chadwick, and Schimmel (1985)
developed role-play scenarios in which
children with diabetes rehearsed effective
methods of resisting peer pressure to engage
in contra-therapeutic behaviors. Other
investigators have validated direct
observation methods of assessing family
communication about diabetes. Using such
methods, Bobrow, AvRuskin, & Siller (1985)
showed that adolescents’ diabetes treatment
adherence could be predicted from directly
observed parent-adolescent conflict. Wysocki
et al. (1999) adapted the Interaction Behavior
Code method of Prinz, Foster, Kent, and
O’Leary (1979). Families were instructed to
spend 10 minutes discussing and resolving
one diabetes-specific issue and then one
general issue that they had reported as sources
of family conflict. Raters coded six
dimensions of individual communication
behavior and four characteristics of group
interaction, with an average kappa coefficient
of 0.82 (range 0.78 to 0.84 across
dimensions).
Standardized Treatment Protocols
A variety of behaviorally oriented treatments
for diabetes-specific problems have been
evaluated empirically (Hampson et al., 2001;
Wysocki et al., in press), and a number of
these are described and evaluated below.
Among the interventions that have been
investigated most thoroughly and
systematically are those targeting treatment
adherence, diabetes-specific social skills and
coping skills, and family communication and
problem solving. Anxiety management and
stress management interventions have also
been evaluated empirically. In addition, an
extensive research literature on weight control
interventions in the pediatric age group may
also have direct relevance to this population
(Jelalian & Saelens, 1999). Let us consider
some examples of behavioral interventions
within each of these categories. Several
418
studies evaluated behavioral contracting and
behavior modification targeting diabetes
treatment adherence. In each of these studies,
parents and youths were assisted in
negotiating contingency management systems
in which various kinds of positive
reinforcement could be earned frequently by
fulfilling specified improvements in particular
diabetes self-management behaviors. Lowe
and Lutzker (1979), Epstein et al. (1981), and
Daneman et al. (1981) contributed early
studies demonstrating that behavior
modification improved adherence with
various aspects of the diabetes regimen.
Carney, Schechter, and Davis (1983) and
Schafer, Glasgow, and McCaul (1982)
reported that behavioral contracting improved
adherence with blood glucose testing and that
these changes were associated with improved
diabetic control in most patients. Wysocki,
Green, and Huxtable (1989) evaluated
behavioral contracting for adherence with
blood glucose monitoring and was the first
study to do so using blood glucose meters
with memory, which have since become
commonplace. Such meters automatically
record every completed blood glucose test by
date, time, and result, providing a convenient
method of assessing adherence with that
aspect of the diabetes regimen. A sample of
42 patients either remained in current medical
therapy for diabetes (Conventional Therapy; n
= 12), used a glucose meter with memory for
4 months without any new consequences
(Meter Alone; n = 15), or used a glucose
meter with memory for 4 months and earned
money contingent on meeting monthly testing
goals (Meter Plus Contract; n = 15).
Adherence exceeded 80% for the Meter Plus
Contract group for all 4 months of treatment,
whereas it varied between 50% and 60% for
the Meter Alone group. Despite the differing
adherence rates, both treatment groups
evidenced better diabetic control during the
study than did the Conventional Therapy
group This collection of studies shows that
behavioral interventions can improve diabetes
treatment adherence. The demonstration that
these treatment gains are accompanied by
corresponding improvements in diabetic
control has been less consistent. However,
there are many plausible reasons why the
relationship between treatment adherence and
diabetic control might be difficult to
demonstrate (see Johnson, 1995, for a
discussion).
Other studies have evaluated behavioral
interventions that have been delivered in
group settings, including multifamily groups
(Anderson et al., 1997; Citrin, La Greca, &
Skyler, 1985; Satin, La Greca, Zigo, &
Skyler, 1989; Smith, Dickerson, Saylor, &
Jones, 1989) and groups composed only of
youths with diabetes (Anderson, Wolf,
Burkhart, Cornell, & Bacon, 1989; Cigrang,
Schuster, Hanson, Burghen, Harris, &
Schinkel, 1991; Warren-Boulton, Anderson,
Schwartz, & Dreyer, 1981). These
interventions have typically targeted specific
coping skills or problem-solving skills that
may mediate effective management of
diabetes. For example, Delamater et al.
(1990) reported that a multifamily self-
management training program based on
behavioral parent training was effective in
promoting treatment adherence and diabetic
control among youths who were newly
diagnosed with type I diabetes. In the first few
months after diagnosis, children and parents
in the experimental treatment group attended
a behavioral parent-training program in which
families completed behavioral homework
assignments designed to enhance their
diabetes self-management and problem-
solving skills. Patients in the self-
management training condition remained in
better diabetic control than the standard care
comparison group throughout the first 2 years
after diagnosis.
Grey and colleagues (Grey et al., 1998; Grey,
Boland, Davidson, Yu, & Tamborlane, 1999;
Grey, Boland, Davidson, Li, & Tamborlane,
419
2000) have contributed a series of papers
documenting both the short-term and long-
term benefits of a group coping skills training
intervention for adolescents in terms of both
glycemic control and quality of life. Family-
directed interventions with youths with
diabetes have also received considerable
empirical support. Anderson and colleagues
developed an intervention that targeted
declining parental involvement with diabetes,
which has been related to decreases in
glycemic control (Anderson, Brackett, Ho, &
Laffel, 1999; Anderson et al., 1997). Their
four-session intervention delivered in a
diabetes clinic focused on improving parent-
teen sharing of diabetes responsibilities and
reducing family conflict that might affect this
teamwork. The experimental group showed
no significant declines in parental
involvement in diabetes management and less
family conflict com-paredto an attention
control group or standard care group. The
application of Robin and Foster’s (1989)
Behavioral Family Systems Therapy model to
adolescents with diabetes show that this
approach is effective in reducing both general
and diabetes-related family conflict (Wysocki
et al., 2000) and in improving directly
observed family communication and problem-
solving skills (Wysocki et al., 1999).
Furthermore, this treatment was rated as more
socially valid than was participation in a
multifamily diabetes educational support
group (Wysocki et al., 1997), and the
demonstrated treatment effects persisted for
up to 1 year (Wysocki, Harris, Greco, Bubb,
& White, 2001). Unfortunately, these
treatment gains did not result in improved
diabetic control. In a second trial of this
intervention incorporating components
designed to increase its impact on diabetes
outcomes, we have recently reported
(Wysocki et al., 2005) that it yielded
significant improvements in diabetic control,
treatment adherence, and family conflict for
those in very poor diabetic control at baseline.
One year post-treatment follow-up of that
sample will soon be completed. Ellis and
colleagues (2004) reported that a 6-month
trial of Multi-Systemic Therapy with
adolescents with diabetes was improved
adherence to blood glucose testing and
metabolic control compared to controls and
also decreased the number of inpatient
admissions 6 months post-intervention. Multi-
Systemic Therapy is an intensive home-based
treatment model that uses family systems and
socioecological theories of behavior; the
intervention targets several systems of the
child’s world, including individuals, family,
peers, school, and the medical team. Diabetes
management is firmly embedded in the
youth’s social context, and effective disease-
specific social and coping skills are crucial to
treatment adherence and diabetic control. A
number of studies have targeted disease-
specific social skills and coping skills in
youths with diabetes. Gross and his
colleagues (Gross, Heiman, Shapiro, &
Schultz, 1983; Gross, Johnson, Wildman, &
Mullett, 1981; Gross et al., 1985) published a
series of studies on a social skills training
intervention in which children learned
diabetes-specific assertiveness skills.
Children participated in role-playing and
rehearsal sessions in which they learned new
ways of responding to common peer
interactions that often influence adversely
children’s diabetes self-management
behaviors such as teasing, offers of
concentrated sweets, and so forth. The
intervention was consistently effective in
improving the targeted social skills but less
consistently improved diabetic control.
Kaplan et al. (1985) compared a similar social
skills training intervention to enhanced
diabetes education. Diabetic control of the
social skills training group was significantly
better than the comparison group 4 months
after intervention. Greco, Shroff-Pendley,
McDonnell, and Reeves (2001) reported
promising results for an intervention in which
420
peers of youths with diabetes were
systematically trained to acquire and exhibit
behaviors that were identified by the youths
with diabetes as supportive and helpful in
promoting effective diabetes self-care. Other
studies support the effectiveness of treatments
targeting anxiety reduction and stress
management for youths with diabetes. Fowler,
Budzynski, and Vandenbergh (1976) reported
that biofeedback-assisted relaxation training
lowered glucose levels in session, but these
effects did not generalize to the home
environment. Rose, Firestone, Heick, and
Faught (1983) showed that 6 months of
progressive relaxation training yielded
improved diabetic control in four of five girls
who were treated. Boardway, Delamater,
Tomakowsky, and Gutai (1993) evaluated a
comprehensive stress management
intervention, including training in
identification of idiosyncratic stressors in
daily life, self-monitoring of responses to
stress, and progressive relaxation exercises.
The authors concluded that their intervention
significantly reduced subjective stress without
affecting treatment adherence or diabetic
control. Similar demonstrations have been
reported by Mendez and Belendez (1997) and
Silverman, Hains, Davies, and Parton (2003).
One speculation from this line of research is
that stress management interventions may be
useful adjuncts to interventions that directly
target behaviors that may impede treatment
adherence and diabetic control but that these
methods when used alone may be unlikely to
affect those outcomes significantly.
Summary of Treatment Efficacy
There are quite a few studies that have
evaluated behaviorally oriented interventions
for diabetes treatment adherence (e.g., Carney
et al., 1983; Daneman et al., 1981; Lowe &
Lutzker, 1979; Schafer et al., 1982). Several
of these studies provide sound empirical
support for the use of behavioral approaches
to enhance adherence with selected aspects of
the diabetes regimen (e.g. Snyder, 1987;
Wysocki et al., 1989). However, translation
of behavior change into improved diabetic
control has been a less consistent finding
(Johnson, 1995).Only one study has directly
targeted improved blood glucose control
(Epstein et al., 1981). Some therapeutic
promise has been demonstrated for
interventions that target peer relationships
among youths with diabetes. Social skills
training (e.g., Greco et al., 2001; Gross et al.,
1985; Kaplan et al., 1985) and coping skills
training interventions (e.g., Citrin et al., 1985)
have been shown effective in several studies,
although the critical elements of these
strategies have not been identified. Family
interventions have also received considerable
empirical attention. Of these, behaviorally
oriented family therapy approaches have
demonstrated considerable promise (e.g.,
Ryden et al., 1994; Snyder, 1987; Wysocki et
al., 2000). The Behavioral Family Systems
Therapy approach is effective in improving
many dimensions of family function without
comparable effects on glycemic control
(Wysocki et al., 1997; 1999; 2000; 2001).
Ongoing evaluation of that model should
verify whether refinements to the intervention
achieve lasting improvements in diabetic
control and treatment adherence (Wysocki et
al., 2005).
There are only a few published studies of
behavioral interventions that target diabetes-
specific anxiety for treatment (Boardway et
al., 1993; Fowler et al., 1976; Mendez &
Belendez, 1997; Rose et al., 1983; Silverman
et al., 2003). However, it is parsimonious to
conclude that methods developed and
validated for the treatment of anxious
behaviors in other contexts would be equally
efficacious in addressing diabetes-related
symptoms. Additional research demonstrating
this would be valuable.
Practice Recommendations
The following are specific practice
recommendations derived from the empirical
research summarized above as well as from
421
extensive clinical experience with pediatric
diabetes patients and their families.
- Behavior change specialists are most
effective when they work closely with
the other members of the diabetes team
and acquire knowledge about diabetes
and its treatment. Ideally, families
should come to recognize the behavioral
specialist as a key member of the
diabetes team.
- Clinical practice of behavior
modification with pediatric diabetes
patients should be based in a thorough
appreciation of the extensive empirical
literature on child and family adaptation
to the disease. Training of diabetes
health care professionals in this area is
another important role.
- Consultation with patients and families
soon after the diagnosis of diabetes
about effective behavior management
may prevent problematic adjustment to
the disease and its treatment as well as
facilitate timely acquisition of
appropriate services later on. Periodic
delivery of educational workshops on
diabetes and behavior can have similar
effects.
Early detection of behavioral problems and
prompt referral for services is critical. Ideal
practices could include routine screening of
youths and families for evidence of clinically
significant behavioral problems or providing
diabetes health care professionals with
specific criteria for referring families for
behavioral services.
- Assessment of barriers to effective
diabetes management and metabolic
control should include a detailed and
systematic interview, selection, and
administration of appropriate
questionnaires and structured
interviews to further narrow the
specification of target behaviors,
concluding with a careful behavioral
definition of the selected target
 behaviors. To the extent possible,
automated measures of treatment
adherence should be used.
- Behavioral contracting and related
behaviorally oriented family
interventions have enjoyed the
strongest empirical support for the
treatment of non-adherence with the
diabetes regimen.
Behavior therapy techniques have proven
effective with anxiety-induced symptoms
similar to those seen in pediatric diabetes
patients. Behavioral specialists working with
this population should also be skilled in these
techniques.
Many youths with diabetes could benefit from
weight-control interventions. Methods such as
those described by Epstein, Valoski, Wing,
and McCurley (1994); Baranowski et al.
(2000); and Jeffery et al. (2000) should be
applicable to this population.
REFERENCES
Allen, D. A., Tennen, H., McGrade, B. J., Affleck, G.,
& Ratzan, S. (1983). Parent and child per-ceptions of
the management of juvenile diabetes. Journal of
Pediatric Psychology, 8, 29-41.
Alexandria, VA. American Diabetes Association.
(2000). American Diabetes Association complete
guide to dia-betes.
Anderson, B. J., Brackett, J., Ho, J., &Laffel, L. M.
(1999). Anoffice-based intervention to maintain
parent-adolescent teamwork in diabetes
management. Diabetes Care, 22, 713-721.
Anderson, B. J., Ho, J., Brackett, J., Finkelstein, D.,
&Laffel, L. (1997). Parental involvement in diabetes
management tasks: Relationships to blood glucose
monitoring adherence and meta-bolic control in
young adolescents with insulin-dependent diabetes
mellitus. Journal of Pedi-atrics, 130, 257-265.
Anderson, B. J., Miller, B., Auslander, W. F., &
Santiago, J. V. (1981). Family characteristics of
diabetic adolescents: Relationships to metabolic
control. Diabetes Care, 4, 586-594.
Anderson, B. J., & Rubin, R. (1995). Practical
psychology for diabetes clinicians. Alexandria, VA:
American Diabetes Association.
Anderson, B. J., Wolf, F. M., Burkhart, M. T., Cornell,
R. G., &Bacon, G. E. (1989). Effects of a peer group
intervention on metabolic control of adolescents with
IDDM: Randomized outpa-tient study. Diabetes
Care, 12, 184-188.
422
Baranowski, T., Mendlein, J., Resnicow, K., Frank, E.,
Cullen, K. W., & Baranowski, J. (2000). Physical
activity and nutrition in children and youth:
Anoverviewof obesity prevention. Pre-ventive
Medicine: An International Journal Devoted to
Practice and Theory, 31, S1-S10.
Boardway, R. H., Delamater, A. M., Tomakowsky, J.,
& Gutai, J. P. (1993). Stress management
training for adolescents with diabetes. Journal of
Pediatric Psychology, 18, 29-45.
Bobrow, E. S., AvRuskin, T. W., & Siller, J. (1985).
Mother-daughter interaction and adherence to
diabetes regimens. Diabetes Care, 8, 146-151.
Bradley, C. (1994). Handbook of psychology and
diabetes. Amsterdam: Harwood Academic.
Carney, R. M., Schechter, K., & Davis, T. (1983).
Improving adherence to blood glucose moni-toringin
insulin-dependent diabetic chidlren. Behavior
Therapy, 14, 247-254.
Cigrang, J. A., Shuster, M. L., Hanson, C. L., Burghen,
G. A., Harris, M. A., & Schinkel, A. M. (1991).
Psychosocial intervention for youths with IDDM: A
controlled study of the meta-bolicand psychological
effects of group therapy. Diabetes, 40(Suppl. 1),
536A.
Citrin, W. S., La Greca, A. M., & Skyler, J. S. (1985).
Group intervention in type I diabetes. In P. Ahmed
&N. Ahmed (Eds.), Coping with juvenile diabetes
(pp. 181-204). Springfield, IL:
Charles C Thomas.Cox, D. J., Irvine, A., Gonder-
Frederick, L. A., Nowacek, G., & Butterfield, J.
(1987). Fear of hypoglycemia: Quantification,
validation and utilization. Diabetes Care, 10, 617-
621.
Daneman, D., Epstein, L. H., Siminerio, L. A., Beck,
S., Farkas, G., Figueroa, J., et al. (1981). Effects of
enhanced conventional therapy on metabolic control
in children with insulin-dependent diabetes mellitus.
Diabetes Care, 5, 472-478.
Delamater, A. M., Bubb, J., Davis, S. G., Smith, J. A.,
Schmidt, L., &White, N. H. (1990). Ran-domized
prospective study of self-management training with
newly diagnosed diabetic chil-dren. Diabetes Care,
13, 492-498.
Diabetes Control and Complications Trial Research
Group. (1993). Diabetes control and com-plications
trial (DCCT): The effect of intensive treatment of
diabetes on the development and progression of long
term complications in insulin-dependent diabetes
mellitus. NewEngland Journal of Medicine, 329,
977-986.
Diabetes Control and Complications Trial Research
Group. (1994). Effect of intensive treatment on the
development and progression of long term
complications in adolescents with insulin-dependent
diabetes mellitus: Diabetes Control and
 Complications Trial. Journal of Pediat-rics, 125,
177-188.
Diabetes Research in Children Network (DirecNet)
Study Group. (2005). Diabetes Self Management
profile for flexible insulin regimens: Cross-sectional
and longitudinal analysis of psychometric properties
in a pediatric sample. Diabetes Care, 28(8), 2034-
2035.
Ellis, D. A., Naar-King, S., Frey, M., Templin, T.,
Rowland, M., & Greger, N. (2004). Use of multi-
systemic therapy to improve regimen adherence
among adolescents with type I diabe-tes in poor
metabolic control: A pilot investigation. Journal of
Clinical Psychology in Medi-calSettings, 11, 315-
324.
Epstein, L. H., Beck, S., Figueroa, J., Farkas, G.,
Kazdin, A. E., Daneman, D., et al. (1981). The
effects of targeting improvement in urine glucoe on
metabolic control in children with insulin-dependent
diabetes mellitus. Journal of Applied Behavior
Analysis, 14, 365-375.
Epstein, L. H., Valoski, A., Wing, R. R., &McCurley,
J. (1994). Ten-year outcomes of behavioral family-
based treatment for childhood obesity. Health
Psychology, 13, 373-383.
Fowler, J., Budzynski, T., &Vandenbergh, R. (1976).
Effects of an EMGbiofeedback relaxation program
on the control of diabetes: A case study. Biofeedback
and Self-Regulation, 1, 105-112.
Glasgow, A. M., Weissberg-Benchell, D. R., Tynan,
W. D., Epstein, S. F., Driscoll, C., Terek, J., et al.
(1991). Re-admissions of children with diabetes
mellitus to a children’s hospital. Pedi-atrics, 88, 98-
104.
Greco, P., Shroff Pendley, J., McDonell, K., & Reeves,
G. (2001). A peer group intervention for adolescents
with type I diabetes and their best friends. Journal of
Pediatric Psychology, 26, 485-490.
Green, L. B., Wysocki, T., & Reineck, B. M. (1990).
Fear of hypoglycemia in children and ado-lescents
with diabetes mellitus. Journal of Pediatric
Psychology, 15, 633-641.
Grey, M., Boland, E. A., Davidson, M., Yu, C.,
Sullivan-Bolyai, S., &Tamborlane, W. V. (1998).
Short-term effects of coping skills training as adjunct
to intensive therapy in adolescents.Diabetes Care,
21, 902-908.
Grey, M., Boland, E., Davidson, M., Yu, C., &
Tamborlane, W. V. (1999). Coping skills training
for youth with diabetes on intensive therapy. Applied
Nursing Research, 12, 3-12.
Grey, M., Boland, E., Davidson, M., Li, J., &
Tamborlane, W. V. (2000). Coping skills training
for youth on intensive therapy has long-lasting effects
on metabolic control and quality of life. Journal of
Pediatrics, 137, 107-113.
423
Gross, A. M., Heimann, L., Shapiro, R., &Schultz, R.
M. (1983). Children with diabetes: Social skills
training and HbA1C levels. Behavior Modification,
7, 151-163.
Gross, A. M., Johnson, W. G., Wildman, H., & Mullett,
H. (1981). Coping skills training with insulin-
dependent preadolescent diabetics. Child Behavior
Therapy, 3, 141-155.
Gross, A. M., Magalnick, L. J., &Richardson, P.
(1985). Self management training with families of
insulin-dependent diabetic children: Along term
controlled investigation. Child and Fam-ily Behavior
Therapy, 3, 141-153.
Hampson, S. E., Skinner, T. C., Hart, J., Storey, L.,
Gage, H., Foxcroft, D., et al. (2001). Effects of
educational and psychosocial interventions for
adolescents with diabetes mellitus: Asystematic
review. Health Technology Assessment, 5(10), 1-79.
Hanson, C. L., Henggeler, S. W., &Burghen, G. A.
(1987). Social competence and parental sup-port as
mediators of the link between stress and metabolic
control in adolescents with insulin-dependent
diabetes mellitus. Journal of Clinical and Consulting
Psychology, 55, 529-533.
Hanson, C. L., Henggeler, S. W., Rodrigue, J. R.,
Burghen, G. A., & Murphy, W. D. (1988). Father-
absent adolescents with insulin-dependent diabetes
mellitus: A population at special risk? Journal of
Applied Developmental Psychology, 9, 243-252.
Harkavy, J., Johnson, S. B., Silverstein, J., Spillar, R.,
McCallum, M., &Rosenbloom, A. (1983). Who
learns what at diabetes summer camp? Journal of
Pediatric Psychology, 8, 143-153.
Harris, M. A., Greco, P., Wysocki, T., Elder, C. L.,
&White, N. H. (1999). Adolescents with diabetes
from single parent, blended and intact families:
Health-related and family functioning. Families,
Systems and Health, 17, 181-196.
Harris, M. A., Wysocki, T., Sadler, M., Wilkinson, K.,
Harvey, L. M., Buckloh, L. M., et al. (2000).
Validation of a structured interview for the
assessment of diabetes self management. Diabetes
Care, 23, 1301-1304.
Jeffery, R., Epstein, L. H., Wilson, G. T., Drewnowski,
A., Stunkard, A. J., &Wing, R. R. (2000). Long term
maintenance of weight loss: Current status. Health
Psychology, 19(Suppl. 1), 5-16.
Jelalian, E., & Saelens, B. (1999). Empirically
supported treatments in pediatric psychology:
Pediatric obesity. Journal of Pediatric Psychology,
24, 223-248.
Johnson, S. B. (1995). Insulin-dependent diabetes
mellitus in childhood. In M. C. Roberts (Ed.),
Handbook of pediatric psychology (pp. 263-285).
New York: Guilford.
Johnson, S. B., Freund, A., Silverstein, J. H., Hansen,
C. A., &Malone, J. I. (1990). Adherence-health
status relationships in childhood diabetes. Health
Psychology, 9, 606-631.
Johnson, S. B., Kelly, M., Henretta, J., Cunningham,
W., Tomer, A., &Silverstein, J. H. (1992). A
longitudinal analysis of adherence and health status
in childhood diabetes. Journal of Pediat-ric
Psychology, 17, 537-553.
Johnson, S. B., Silverstein, J. H., Rosenbloom, A.,
Carter, R., & Cunningham, W. (1986). Assessing
daily management in childhood diabetes. Health
Psychology, 5, 545-564.
Kamps, J. L., Roberts, M. C., &Varela, R. E. (2005).
Development of a newfear of hypoglycemia scale:
Preliminary results. Journal of Pediatric Psychology,
30, 287-291.
Kaplan, R. M, Chadwick, M. W., & Schimmel, L. E.
(1985). Social learning intervention to improve
metabolic control in type I diabetes mellitus.
Diabetes Care, 8, 152-155.
La Greca, A. M., Auslander, W. F., Greco, P., Spetter,
D., Fisher, E.B., &Santiago, J. V. (1995). I get by
with a little help from my friends: Adolescent
support for diabetes care. Journal of Pediatric
Psychology, 20, 449-476.
La Greca, A. M., Follansbee, D. M., & Skyler, J. S.
(1990). Developmental and behavioral aspects of
diabetes management in youngsters. Children’s
Health Care, 19, 132-139.
Lorenz, R. A., &Wysocki, T. (1991). From research to
practice: The family and childhood diabetes.
Diabetes Spectrum, 4, 261-292.
Lowe, K., & Lutzker, J. R. (1979). Increasing
compliance to a medical regimen with a juvenile
diabetic. Behavior Therapy, 10, 57-64.
Mendez, F. J., & Belendez, M. (1997). Effects of a
behavioral intervention on treatment adherence and
stress management in adolescents with IDDM.
Diabetes Care, 20, 1370-1375.
Miller-Johnson, S., Emery, R. E., Marvin, R. S.,
Clarke, W., Lovinger, R., & Martin, M. (1994).
Parent-child relationships and the management of
insulin-dependent diabetes mellitus. Journal of
Consulting and Clinical Psychology, 62, 603-610.
Polonsky, W. H., Anderson, B. J., Lohrer, P. A.,
Welch, G., Jacobson, A. M., & Schwartz, C. (1995).
Assessment of diabetes-specific distress. Diabetes
Care, 18, 754-760.
Prinz, R., Foster, S. L., Kent, R. N., & O’Leary, K. D.
(1979). Multivariate assessment of conflict in
distressed and non-distressed parent-adolescent
dyads. Journal of Applied Behavior Analysis, 12,
691-700. Wysocki, T. (1993). Associations among
teen-parent relationships, metabolic control and
424
adjustment to diabetes in adolescents. Journal of
Pediatric Psychology, 18, 443-454.
Wysocki, T. (1997). The ten keys to helping your child
grow up with diabetes. Alexandria, VA: American
Diabetes Association.
Wysocki, T., Buckloh, L. M., Lochrie, A., & Antal, H.
(in press). The psychological context of pediatric
diabetes. Pediatric Clinics of North America.
Wysocki, T., Greco, P., Harris, M. A., Harvey, L. M.,
McDonell, K., Elder, C. L., et al. (1997). Social
validity of support group and behavior therapy
interventions for families of adoles-cents with
insulin-dependent diabetes mellitus. Journal of
Pediatric Psychology, 22, 635-650.
Wysocki, T., Green, L. B., &Huxtable, K. (1989).
Blood glucose monitoring by diabetic adolescents:
Compliance and metabolic control. Health
Psychology, 8, 267-284.
Wysocki, T., Harris, M., Buckloh, L. M., Locrhie, A.,
Mertlich, D., Wilkinson, K., et al. (2005). Effects of
behavioral family systems therapy on adolescents’
diabetes outcomes. Diabetes, 53(Suppl. 1), A19.
Wysocki, T., Harris, M. A., Greco, P., Bubb, J., Elder,
C. L., Harvey, L. M., et al. (2000). Random-ized,
controlled trial of behavior therapy for families of
dolescents with insulin-dependent diabetes mellitus.
Journal of Pediatric Psychology, 25, 23-33.
Wysocki, T., Harris, M. A., Greco, P., Bubb, J.,
&White, N. H. (2001). Behavior therapy for families
of adolescents with diabetes: Maintenance of
treatment effects. Diabetes Care, 24, 441-446.
Wysocki, T., Miller, K. M., Greco, P., Harris, M. A.,
Harvey, L. M., Elder-Danda, C. L., et al. (1999).
Behavior therapy for families of adolescents with
diabetes: Effects on directly observed family
interactions. Behavior Therapy, 30, 496-515.
Wysocki, T., Taylor, A., Hough, B. S., Linscheid, T.
R., Yeates, K. O., & Naglieri, J. A. (1996). Deviation
from developmentally appropriate self-care
autonomy: Association with diabetes outcomes.
Diabetes Care, 19, 119-125.
Tim Wysocki, Ph.D., A.B.P.P., is Director of the Center
for Pediatric PsychologyResearch at the Nemours
Children’s Clinic in Jacksonville Florida and
Chairperson of the Nemours Florida Institutional
Review Board.
Note: Most of the Matters are drived from Internet and
Research Papers
Chapter-18

425
426
GALLSTONES
Gallstones are hard particles that develop in
the gallbladder. The gallbladder is a small,
pear-shaped organ located in the upper right
abdomen, the area between the chest and
hips, below the liver.
Gallstone, also called as cholelith or stone.
It is a calculus (stone) formed inside the gall
bladder as a concretion of bile components.
Lithiasis (stone formation) in the gallbladder
is called cholelithiasis. Gallstones are
formed in the gallbladder but may
pass distally into other parts of the biliary
tract such as the cystic duct, common bile
duct, pancreatic duct or the ampulla of Vater.
Rarely, in cases of severe inflammation,
gallstones may erode through the gallbladder
into adherent bowel potentially causing an
obstruction termed gallstone ileus.
Presence of gallstones in the gallbladder may
lead to acute cholecystitis, an inflammatory Gallstones in x-ray
condition characterized by retention of bile
in the gallbladder and often secondary
infection by intestinal microorganisms,
predo-minantly Escherichia oli, Klebsiella,
Enterobacter, and Bacteroides species.
Presence of gallstones in other parts of the
biliary tract can cause obstruction of the bile
ducts, which can lead to serious conditions
such as ascending cholangitis or pancreatitis.
Either of these two conditions can be life-
threatening and are therefore considered to
be medical emergencies.
Gallstone is a common clinical finding in the
world populations. Ultrasound studies
indicate mean prevalence rates of 10–15% in More than 80% of gallstone carriers are
adult European, and of 3–5% in African and unaware of their gallbladder disease but
Asian populations. In USA, the prevalence about 1–2% per year of patients develop
rates range from 5% for non-Hispanic black complications and need surgery7. In USA,
men to 27% for Mexican-American women. gallstone disease has the most common
In American Indians, gallstone disease is inpatient diagnosis among gastrointestinal
epidemic and found in 73% of adult female and liver diseases and stands for $5.8 billion
Pima Indians, and in 30% of male and 64% direct costs, exceeded only by
of female in other American Indians. gastroesophageal reflux disease.

427
Importance of Bile formation
The formation of bile is essential for lipid
digestion and the removal of excess
cholesterol from the body either by direct
excretion or after conversion to bile acids.
Bile mainly consists of water (90%) and
three lipid species: cholesterol (4% of solutes
by weight), phospholipids (24%) and bile
salts (72%). For each of these compounds,
specific ATP-binding-cassette transport
proteins (ATP transporters) are expressed at
the canalicular membrane domain of
hepatocytes. ABCB4, in human also known
as multidrug resistant p-glycoprotein MDR3,
acts as a ‘flippase’ that translocates
phospholipids from the inner to the outer
leaflet of the membrane. Mutations in the
MDR3 gene were first described in
progressive familial intrahepatic cholestasis
(PFIC) type 3 and later found in a number of
hepatobiliary diseases, including cholesterol
gallstone disease and intrahepatic cholestasis
of pregnancy (ICP). ABCB11, also known as
the bile salt export pump BSEP, is the main
bile salt transporter. This transporter is
mutated in PFIC type 2 and in benign
recurrent intrahepatic cholestasis (BRIC)
type 2. Cholesterol is transported by ABCG5
and ABCG8 that form obligate heterodimers.
Mutations of these transport proteins cause
sitosterolemia.
Gene expression levels of ABCB4, ABCB11
and ABCG5/8 are regulated by at least two
nuclear receptors (NR) initially found to
regulate cholesterol and bile acid
metabolism. The farnesoid or bile acid
receptor FXR/BAR regulates transcription of
ABCB4 and ABCB11 while ABCG5 and
ABCG8 are under control of the oxysterol or
liver X receptors LXRα/β, perhaps mediated
by FXR.
Once secreted, hepatic bile is modified by
bicarbonate-and chloride-rich secretions of
cholangiocytes, accompanied with water
influx through aquaporin channels (recently
reviewed in Biol. Cell.). The chloride
428
channel in cholangiocytes is the cystic
fibrosis transmembrane conductance
regulator (ABCC7, CFTR) that is mutated in
cystic fibrosis.
Cholesterol uptake into the liver is mainly
mediated by the scavenger receptor B1 (SR-
B1) for HDL and to lesser extent by the
apolipoprotein (Apo) B/E receptor for LDL
that is controlled by sterol-regulatory-
element-binding protein (SREBP-1). LDL-
receptor-related protein (LRP) transfers
cholesterol from chylomicron remnants that
carry exogenous cholesterol from the
intestine. Recently, also in the intestine
transporters have been identified that are
able to transfer cholesterol, the ABC
transporter ABCA1 that is defective in
Tangier disease and the Niemann-Pick C1-
like protein 1 (NPC1L1). The role of the
intestine in cholesterol absorption and its
regulation has recently been reviewed by
Lammert and Wang.
Transport systems for bile acids at the
basolateral site of hepatocytes, i.e. the
sodium-dependent taurocholate transport
protein NTCP (SLS10A1), organic anion
transport proteins OATPs (SLC21A), and in
cholangiocytes, intestine and kidney, i.e.,
ASBT/ISBT, the ileal/apical sodium-
dependent bile salt transporter (SLC10A2),
MDR1 (ABCB1) and MRP2, 3 (ABCC2, 3),
have recently been reviewed by Trauner and
Boyer (2003).
Gallbladder hypomotility
As supersaturated bile often is found in
healthy individuals, it is assumed that
microcrystals formed are effectively flushed
from the gallbladder during postprandial
contractions. In cholesterol gallstone
patients, altered interdigestive gallbladder
emptying was observed, and patients with
incomplete gallbladder emptying were found
to have increased total lipid concentrations.
Impaired gallbladder motility is commonly
seen in several risk groups for cholesterol
gallstones, e.g. patients with diabetes
mellitus, total parenteral nutrition (TPN),
rapid weight loss (reviewed in Aliment
Pharmacol. Ther.). On the other hand, once
gallstones have formed, the risk for
developing symptomatic gallstones disease
seems to be higher for those patients who
have efficient gallbladder emptying (>70%
emptying after a test meal) compared to
those with sluggish motility (<55% emptying
after a test meal, as estimated by
ultrasonography).
Treatment of acromegalic patients with
octreotide, a long-acting somatostatin-
analogue, impairs the postprandial release of
duodenal cholecystokinin (CCK) that is the
principal stimulus for gallbladder
contraction. Thus, the risk for gallstones is
substantially increased in these patients that
might be further increased by higher levels
of DCA by impaired intestinal motility. For
the prevention of gallstone development by
gallbladder dysmotility, CCK injections have
been recommended in patients receiving
long-term TPN, and small fat containing
meals during weight reducing diets. Recent
study in mice showed that fibroblast growth
factor 15 (FGF-15; human homologue, FGF-
19), a hormone made by the distal small
intestine in response to bile acids
suppressing Cyp7a1 in the liver as a counter
player of CCK also controls gallbladder
filling. However, the importance of FGF-19
for gallbladder emptying and gallstone
development in humans remains to be
shown.
Causes of Gallstones
Imbalances in the substances that make up
bile cause gallstones. Gallstones may form if
bile contains too much cholesterol, too much
bilirubin, or not enough bile salts. Scientists
do not fully understand why these
imbalances occur. Gallstones also may form
if the gallbladder does not empty completely
or often enough.
The two types of gallstones are cholesterol
and pigment stones:
429
• Cholesterol stones, usually yellow-green in
color, consist primarily of hardened
cholesterol. In the United States, more than
80 percent of gallstones are cholesterol
stones.
• Pigment stones, dark in color, are made of
bilirubin.
Risk factor for gallstone formation
Certain people have a higher risk of
developing gallstones than others:
• Women are more likely to develop
gallstones than men. Extra estrogen can
increase cholesterol levels in bile and
decrease gallbladder contractions, which
may cause gallstones to form. Women may
have extra estrogen due to pregnancy,
hormone replacement therapy, or birth
control pills.
• People over age 40 are more likely to
develop gallstones than younger people.
• People with a family history of gallstones
have a higher risk.
• American Indians have genetic factors that
increase the amount of cholesterol in their
bile. In fact, American Indians have the
highest rate of gallstones in the United
States, almost 65 percent of women and 30
percent of men have gallstones.
• Mexican Americans are at higher risk of
developing gallstones.
Other factors that affect a person’s risk of
gallstones include
• Obesity. People who are obese, especially
women, have increased risk of developing
gallstones. Obesity increases the amount of
cholesterol in bile, which can cause stone
formation.
• Rapid weight loss. As the body breaks
down fat during prolonged fasting and
rapid weight loss, the liver secretes extra
cholesterol into bile. Rapid weight loss can
also prevent the gallbladder from emptying
properly. Low-calorie diets and bariatric
surgery, surgery that limits the amount of
food a person can eat or digest, lead to
 rapid weight loss and increased risk of
gallstones.
• Diet. Research suggests diets high in
calories and refined carbohydrates and low
in fiber increase the risk of gallstones.
Refined carbohydrates are grains processed
to remove bran and germ, which contain
nutrients and fiber. Examples of refined
carbohydrates include white bread and
white rice.
• Certain intestinal diseases. Diseases that
affect normal absorption of nutrients, such
as Crohn’s disease, are associated with
gallstones.
• Metabolic syndrome, diabetes, and
insulin resistance. These conditions
increase the risk of gallstones. Metabolic
syndrome also increases the risk of
gallstone complications. Metabolic
syndrome is a group of traits and medical
conditions linked to being overweight or
obese that puts people at risk for heart
disease and type 2 diabetes.
Pigment stones tend to develop in people
who have
• Cirrhosis, a condition in which the liver
slowly deteriorates and malfunctions due
to chronic, or long lasting, injury
• infections in the bile ducts
• severe hemolytic anemias, conditions in
which red blood cells are continuously
broken down, such as sickle cell anemia
Symptoms and Complications
• Many people with gallstones do not
have symptoms. Gallstones that do not
cause symptoms are called asymptomatic,
or silent, gallstones. Silent gallstones do not
interfere with the function of the
gallbladder, liver, or pancreas.
• If gallstones block the bile ducts,
pressure increases in the gallbladder,
causing a gallbladder attack. The pain
usually lasts from 1 to several
hours.1 Gallbladder attacks often follow
heavy meals, and they usually occur in the
evening or during the night.
430
• Gallbladder attacks usually stop
when gallstones move and no longer block
the bile ducts. However, if any of the bile
ducts remain blocked for more than a few
hours, complications can occur.
Complications include infl-ammation, or
swelling, of the gallbladder and severe
damage or infection of the gallbladder, bile
ducts, or liver.
• A gallstone that becomes lodged in
the common bile duct near the duodenum
and blocks the pancreatic duct can cause
gallstone pancreatitis, inflammation of the
pancreas.
• Left untreated, blockages of the bile
ducts or pancreatic duct can be fatal.
Diagnosis of gallstones
A health care provider will usually order an
ultrasound exam to diagnose gallstones.
Other imaging tests may also be used.
• Ultrasound exam: Ultrasound uses a
device, called a transducer that bounces
safe, painless sound waves off organs to
create an image of their structure. A
specially trained technician performs the
procedure in a health care provider’s office,
outpatient center, or hospital, and a
radiologist—a doctor who specializes in
medical imaging, interprets the images.
Anesthesia is not needed. If gallstones are
present, they will be visible in the image.
Ultrasound is the most accurate method to
detect gallstones.
Gallstones in ultrasound
• Computerized tomography (CT)
scan: A CT scan is an x ray that produces
pictures of the body. A CT scan may
include the injection of a special dye, called
contrast medium. CT scans use a
combination of x rays and computer
technology to create three-dimensional (3-
D) images. CT scans require the person to
lie on a table that slides into a tunnel-shaped
device where the x rays are taken. An x-ray
technician performs the procedure in an
outpatient center or hospital, and a
radiologist interprets the images. Anesthesia
is not needed. CT scans can show gallstones
or complications, such as infection and • Cholescintigraphy: Cholescintigrap
blockage of the gallbladder or bile ducts. hy, also called a hydroxyl iminodiacetic
However, CT scans can miss gallstones that acid scan, HIDA scan, or hepatobiliary
are present. scan, uses an unharmful radioactive material
to produce pictures of the biliary system. In
cholescintigraphy, the person lies on an
exam table and a health care provider
injects a small amount of unharmful
radioactive material into a vein in the
person’s arm. The health care provider may
also inject a substance that causes the
gallbladder to contract. A special camera
takes pictures of the radioactive material as
it moves through the biliary system. A
specially trained technician performs the
• Magnetic resonance imaging procedure in an outpatient center or
(MRI): MRI machines use radio waves and hospital, and a radiologist interprets the
magnets to produce detailed pictures of the images. Anesthesia is not needed.
body’s internal organs and soft tissues Cholescintigraphy is used to diagnose
without using x rays. A specially trained abnormal contractions of the gallbladder or
technician performs the procedure in an obstruction of the bile ducts.
outpatient center or hospital, and a
radiologist interprets the images. Anesthesia
is not needed, though people with a fear of
confined spaces may receive light sedation.
An MRI may include the injection of
contrast medium. With most MRI machines,
the person lies on a table that slides into a
tunnel-shaped device that may be open
ended or closed at one end; some newer
machines allow the person to lie in a more
open space. MRIs can show gallstones in
the ducts of the biliary system.

Cholescintigraphy, also called a hydroxyl

iminodiacetic acid scan (HIDA).

431
• Endoscopic retrograde
cholangiopancreato-graphy
(ERCP): ERCP uses an x ray to look into
the bile and pancreatic ducts. After lightly
sedating the person, the health care
provider inserts an endoscope,a small,
-flexible tube with a light and a camera on
the end, through the mouth into the
duodenum and bile ducts. The endoscope
is connected to a computer and video
monitor. The health care provider injects
contrast medium through the tube into the
bile ducts, which makes the ducts show up
on the monitor. The health care provider
performs the procedure in an outpatient
center or hospital. ERCP helps the health
care provider locate the affected bile duct
and the gallstone. The stone is captured in
a tiny basket attached to the endoscope and
removed. This test is more invasive than
other tests and is used selectively.
ERCP confirming Mirizzi syndrome
with the guidewire in the gallbladder
(GB). The stone is impacted in the
cystic duct, which is anterior and
parallel to the common hepatic duct.
ERCP image. Dilated common
bile duct containing multiple
filling defects compatible with
432
calculi. MRCP appearances are
comparable to the contrast
Health care providers also use blood tests to
look for signs of infection or in-flammation
of the bile ducts, gallbladder, pancreas, or
liver. A blood test involves drawing blood at
a health care provider’s office or commercial
facility and sending the sample to a lab for
analysis.
Gallstone symptoms may be similar to those
of other conditions, such as appendicitis,
ulcers, pancreatitis, and gastro-esophageal
reflux disease.
Sometimes, silent gallstones are found when
a person does not have any symptoms. For
example, a health care provider may notice
gallstones when performing ultrasound for a
different reason.
Gallstones treatment
If gallstones are not causing symptoms,
treatment is usually not needed. However, if
a person has a gallbladder attack or other
symptoms, a health care provider will
usually recommend treatment. A person may
be referred to a gastroenterologist, a doctor
who specializes in digestive diseases, for
treatment. If a person has had one
gallbladder attack, more episodes will likely
follow.
The usual treatment for gallstones is surgery
to remove the gallbladder. If a person cannot
undergo surgery, nonsurgical treatments may
be used to dissolve cholesterol gallstones. A
health care provider may use ERCP to
remove stones in people who cannot undergo
surgery or to remove stones from the
common bile duct in people who are about to
have gallbladder removal surgery.
Surgery
Surgery to remove the gallbladder, called
cholecystectomy, is one of the most common
operations performed on adults in the United
States.
The gallbladder is not an essential organ,
which means a person can live normally
without a gallbladder. Once the gallbladder
is removed, bile -flows out of the liver
through the hepatic and common bile ducts
and directly into the duodenum, instead of
being stored in the gallbladder.
Surgeons perform two types of
cholecystectomy:
• Laparoscopic cholecystectomy: In a
laparoscopic cholecystectomy, the surgeon
makes several tiny incisions in the
abdomen and inserts a laparoscope, a thin
tube with a tiny video camera attached.
The camera sends a magnified image from
inside the body to a video monitor, giving
the surgeon a close-up view of organs and
tissues. While watching the monitor, the
surgeon uses instruments to carefully
separate the gallbladder from the liver, bile
ducts, and other structures. Then the
surgeon removes the gallbladder through
one of the small incisions. Patients usually
receive general anesthesia.
Most cholecystectomies are performed with
laparoscopy. Many laparoscopic
cholecystecto- mies are performed on an
outpatient basis, meaning the person is able
to go home the same day. Normal physical
activity can usually be resumed in about a
week.
433
• Open cholecystectomy: An open chole-
cystectomy is performed when the
gallbladder is severely infl-amed, infected,
or scarred from other operations. In most
of these cases, open cholecystectomy is
planned from the start. However, a surgeon
may perform an open cholecystectomy
when problems occur during a
laparoscopic cholecystectomy. In these
cases, the surgeon must switch to open
cholecystectomy as a safety measure for
the patient.
To perform an open cholecystectomy, the
surgeon creates an incision about 4 to 6
inches long in the abdomen to remove the
gallbladder.4 Patients usually receive general
anesthesia. Recovery from open
cholecystectomy may require some people to
stay in the hospital for up to a week. Normal
physical activity can usually be resumed
after about a month.

A small number of people have softer and
more frequent stools after gallbladder
removal because bile fl-ows into the
duodenum more often. Changes in bowel
habits are usually temporary; however, they
should be discussed with a health care
provider.
Though complications from gallbladder
surgery are rare, the most common
complication is injury to the bile ducts. An
injured common bile duct can leak bile and
cause a painful and possibly dangerous
infection. One or more additional operations
may be needed to repair the bile ducts. Bile
duct injuries occur in less than 1 percent of
cholecystectomies.5
Nonsurgical Treatments for Cholesterol
Gallstones
Nonsurgical treatments are used only in
special situations, such as when a person
with cholesterol stones has a serious medical
condition that prevents surgery. Gallstones
often recur within 5 years after nonsurgical
treatment.6
Two types of nonsurgical treatments can be
used to dissolve cholesterol gallstones:
• Oral dissolution therapy: Ursodiol
(Actigall) and chenodiol (Chenix) are
medications that contain bile acids that can
dissolve gallstones. These medications are
most effective in dissolving small
cholesterol stones. Months or years of
treatment may be needed to dissolve all
stones.
434
• Shock wave lithotripsy: A machine called
a lithotripter is used to crush the gallstone.
The lithotripter generates shock waves that
pass through the person’s body to break the
gallstone into smaller pieces. This
procedure is used only rarely and may be
used along with ursodiol.
Pathophysiology
Cholesterol gallstones develop when bile
contains too much cholesterol and not
enough bile salts. Besides a high
concentration of cholesterol, two other
factors are important in causing gallstones.
The first is how often and how well the
gallbladder contracts; incomplete and
infrequent emptying of the gallbladder may
cause the bile to become over concentrated
and contribute to gallstone formation. This
can be caused by high resistance to the flow
of bile out of the gallbladder due to the
complicated internal geometry of the cystic
duct. The second factor is the presence of
proteins in the liver and bile that either
promote or inhibit cholesterol crystallization
into gallstones. In addition, increased levels
of the hormone estrogen, as a result
of pregnancy or hormone therapy, or the
use of combined (estrogen-containing) forms
of hormonal contraception, may increase
cholesterol levels in bile and also decrease
gallbladder movement, resulting in gallstone
formation.
Prevention
Cholesterol gallstone disease may be prevented
by life-style changes, in particular by reducing
total caloric intake, but controlled studies are
missing. Oral UDCA during weight-loss Portincasa P, Ciaula AD, Bonfrate L, Wang DQ.
prevented cholesterol gallstone formation in Therapy of gallstone disease: what it was, what it
man, in contrast to Aspirin that was previously is, what it will be. World J Gastrointestinal
found to be effective in the prairie dog. An Pharmacology and Therapeutics. 2012;3(2):7–20.
Portincasa, P.; Moschetta, A.; Petruzzelli, M.;
exciting new concept in the prevention of
Palasciano, G.; Di Ciaula, A.; Pezzolla, A. (2006).
gallstone formation is the stimulation of nuclear Gallstone disease: Symptoms and diagnosis of
receptors regulation cholesterol metabolism and gallbladder stones. Best Pract Res Clin
secretion, as shown by the efficient prevention Gastroenterol. 20 (6): 1017–29.
with synthetic FXR agonists in mice. Stinton LM, Shaffer EA. Epidemiology of gallbladder
References disease: cholelithiasis and cancer. Gut and
Acalovschi, Monica; Blendea, Dan; Feier, Cristina; Liver.2012;6(2):172–187.
Letia, Alfred I.; Raitu, Nadia; Dumitrascu, Dan L.; Trauner M, Boyer JL. Bile salt transporters: molecular
Veres, Adina (2003). "Risk factors for characterization, function, and regulation. Physiol
symptomatic gallstones in patients with liver Rev 2003; 83: 633–71.
cirrhosis: a case-control study". The American J Vivian McAlister, Eric Davenport, and Elizabeth
Gastroenterology 98 (8): 1856–1860. Renouf. Cholecystectomy Deferral in Patients with
Ahlberg J, Angelin B, Bjorkhem I, Einarsson K, Leijd Endoscopic Sphincterotomy. Cochrane Database
B. Hepatic cholesterol metabolism in normo- and of Systematic Reviews .4 (2007): CD006233.
hyperlipidemic patients with cholesterol
gallstones. J Lipid Res 1979; 20: 107–15.
Ahlberg J, Angelin B, Einarsson K, Hellstrom K, Note: Most of the Matters are drived from Internet and
Leijd B. Prevalence of gallbladder disease in Research Papers
hyperlipo-proteinemia. Dig Dis Sci 1979; 24: 459–
64.
Allen MJ, Borody TJ, Bugliosi TF, May GR, LaRusso
NF, Thistle JL. Rapid dissolution of gallstones by
methyl tert-butyl ether. Preliminary observations.
N Engl J Med 1985; 312: 217-20.
Broomfield PH, Chopra R, Sheinbaum RC et al.
Effects of ursodeoxycholic acid and aspirin on the
formation of lithogenic bile and gallstones during
loss of weight. N Engl J Med 1988; 319: 1567–72.
Channa, Naseem A.; Khand, Fateh D.; Khand, Tayab
U.; Leghari, Mhhammad H.; Memon, Allah N.
(2007)."Analysis of human gallstones by Fourier
Transform Infrared (FTIR)". Pakistan Journal of
Medical Sciences 23(4): 546–50.
Keus, Frederik; de Jong, Jeroen; Gooszen, H G;
Laarhoven, C JHM; Keus, Frederik (2006).
"Laparoscopic versus open cholecystectomy for
patients with symptomatic
cholecystolithiasis". Cochrane Database of
Systematic Reviews (4): CD006231.
Koppisetti, Sreedevi; Jenigiri, Bharat; Terron, M.
Pilar; Tengattini, Sandra; Tamura, Hiroshi; Flores,
Luis J.; Tan, Dun-Xian; Reiter, Russel J. (2008).
Reactive Oxygen Species and the Hypomotility of
the Gall Bladder as Targets for the Treatment of
Gallstones with Melatonin: A Review. Digestive
Diseases and Sciences 53 (10): 2592–603.
Ortega RM, Fernández-Azuela M, Encinas-Sotillos A,
Andrés P, López-Sobaler AM (1997). "Differences
in diet and food habits between patients with
gallstones and controls". Journal of the American
College of Nutrition16 (1): 88–95

435
Chapter-19

437
438
Obstetric
It is the branch of medicine that deals with additional tests, procedures or hospitalizations
the care of women during pregnancy, during the pregnancy.
childbirth, Her past OB history is significant for (all
and the recuperative period following delivery
pregnancies and their outcomes are
Etiquette
- Always introduce yourself; tell the patient who summarized here): xx/xx/xxx (date), M or F,
you are and say why you have come to see them. weight, type of delivery (vaginal, forceps,
- Sensitive to intensely private data. vacuum), any complications.
- Some women will wish another person (chaperon) Her Gyne history: menarche age, frequency
to be present if the doctor or students is male, even just to of menses, # of days of menses, any h/o inter-
take a history, and this wish should be respected. menstrual spotting.
Obstetric Case Format (Oral Examination)
STD is, abnormal pap smears? Last pap ____.
Case no./ID __________________________
Her past medical history is significant for
Photo _______________________________
__________________
Name of patient: _______________________
Her past surgical history _________________
w/o _________________________________
Her medications include _________________
Age: ________________________________
She has (no known) drug allergies _________
Religion: _____________________________
Her family history is significant for (any
Address: _____________________________
breast, colon, uterine, ovarian cancer)
Contact no. ___________________________
_____________________________________
Cell no. ______________________________
Her social history is significant for
Date of last menstruation: ________________
____________________________________
Expected Date of Delivery: __________________
Her review of systems is significant for
Social History
____________________________________
1) Marital status: Single ____, married _____,
On physical exam: she is alert, gravid, ('lying
partnership _____ , Divorced ______ ,
comfortably in a stretcher; writhing in pain
Medicolegal _____.
with contractions); list VS; (HEENT, CV, and
2) Occupation; __________________
lungs are examined, but only positive findings
3) Vices: alcohol ________ , smoking _________ ,
are mentioned; if these are all WNL, go
illicit drugs ___________
directly from vital signs to the abdominal
Complaint/purpose of presence in hospital:
exam); abdomen is soft, gravid and non-tender
Female who presents at (EGA) weeks with
(or otherwise); vaginal exam (or sterile
(main presenting symptom explained as
speculum exam) is significant for (dilatation,
pertinent positives as well as negatives;
effacement per ___________ (person
typically 'painful contractions or 'leakage of
performing), station); fetal heart rate is
fluid or 'decreased fetal movement or
___________ Extremities have no edema or
'bleeding or any combination of these) x
calf tenderness (or otherwise).
(duration of presenting symptom).
Labs at admission are significant for
History:
_____________ (typically CBC only).
Her ante-partum course has been significant
for (normal vs. abnormal prenatal labs, any

439
In summary, this is a (age) y/o (primip,
multip) who presents (preterm, at term) weeks
with (main presenting symptom); the plan is
_____________________________________
Her interval course ____________________
(explain in a brief but detailed manner her
labor course; use terms like 2 hours later
_____________ and '4 hours after that
_____________ rather than times; for births,
include Body weight and body mass index,
gender, Apgars and gasses if obtained) _____ .
Overview
- Taking a history and performing an obstetric
examination are quite different from their medical
and surgical equivalents.
- Not only will the type of questions change with
gestation but also will the purpose of the
examination
Clinical Examination
1) General Physical Examination
It is described in Case Taking and
Examination of Patient Chapters but here
important is edema, albumen-urea and high
blood pressure examination. If she is a case
of pre-eclampsia then should be treated
accordingly.
Diagnosis of pregnancy and calculation of
gestational age
• Diagnosis of pregnancy is best confirmed
using a urine-testing kit that determines
the presence of β-human chorionic
gonadotrophin (β-hCG).
• Many women will have confirmed their
own pregnancy by such means.
• Where the absence of menses is the only
current indicator of early pregnancy, it is
important to confirm pregnancy using a
testing kit.
• An early ultrasound scan should be
offered at 10-13 weeks, to determine
gestational age and detect multiple
pregnancies. This has added benefits of
ensuring consistency of gestational age
440
assessments and improving the
performance of mid-trimester serum
screening for Down's syndrome, and
reducing the need for induction of
labourat >41 weeks.
• Crown-rump length is the best surrogate
measure of gestational age.
• Pregnant women who present at or
beyond 14 weeks of gestation should be
offered an ultrasound scan to estimate
gestational age using head circumference
or biparietal diameter.If a health
professional is involved at this stage they
should check if the woman has been
taking folic acid and advise as
appropriate.
The first antenatal appointment
The first antenatal appointment take place
early in pregnancy (before 12 weeks) and that
it may need to be booked as a double
appointment due to the large amount of
information and assessments that are required.
The checklist given above covers those areas
that are considered important:
• Give mother information on her antenatal
care and an opportunity to ask any
questions/raise any concerns. Consider
topics such as: Diet
• All women should be informed at the
booking appointment about the
importance, for their own and their baby's
health, of maintaining adequate vitamin D
stores during pregnancy and whilst breast-
feeding.
• 10 micrograms of vitamin D per day
should be taken by women at risk. These
include:
• Women of South Asian, African,
Caribbean or Middle Eastern family
origin.
• Women who have limited exposure to
sunlight, such as women who are
predominantly housebound, or who
usually remain covered when outdoors.
• Women who eat a diet particularly low in
vitamin D, such as women who consume
 no oily fish, eggs, meat, vitamin D-
fortified margarine or breakfast cereal.
• Women with a pre-pregnancy body mass
index (BMI) above 30 kg/m2.
• Lifestyle:
• Advice on avoiding food-borne infections
such as Listeriosis/Salmonella.
• Benefits of gentle exercise and high-
impact sports that should be avoided.
• Safety of sexual intercourse.
• Alcohol, smoking and other recreational
drug use during pregnancy.
• Available pregnancy care services.
• Maternity and associated benefits.
• Working and finishing work when
pregnant.
• Availability, purpose and logistics of
screening tests in pregnancy.
• Identify women who may need special
care (see list below under 'Criteria for
more specialized care'; plan pattern of
care for pregnancy depending on
parity/previous complications of
pregnancy.
• Check blood group and rhesus (RhD)
status.
• Offer blood test to screen for:
• Anaemia.
• Red-cell alloantibodies.
• Hepatitis B.
• HIV.
• Rubella immunity status.
• Syphilis serology.
• Screening for sickle cell diseases
and thalassaemias should be offered to all
women as early as possible in pregnancy
(ideally by 10 weeks). The type of
screening depends upon the prevalence
and can be carried out in either primary or
secondary care.[2][3]
• Urine testing to screen for asymptomatic
bacteriuria.
• The 'combined test' (nuchal
translucency, β- human chorionic
gonadotrophin (β-hCG), pregnancy-
associated plasma protein-A) should be
441
offered to screen for Down's
syndrome between 11 weeks 0 days and
13 weeks 6 days. For women who book
later in pregnancy, the most clinically
effective and cost-effective serum
screening test (triple or quadruple test)
should be offered between 15 weeks 0
days and 20 weeks 0 days.
• Offer early ultrasound scan to assess
gestational age.
• Screening for gestational diabetes, using
risk factors, is recommended in a healthy
population. Women with any one of these
risk factors should be offered testing for
gestational diabetes at the booking
appointment:
• BMI above 30 kg/m2.
• Previous macrosomic baby weighing 4.5
kg or above.
• Previous gestational diabetes.
• Family history of diabetes (first-degree
relative with diabetes).
• Family origin with a high prevalence of
diabetes:
• South Asian (specifically women whose
country of family origin is India, Pakistan
or Bangladesh).
• Black Caribbean.
• Middle Eastern (specifically women
whose country of family origin is Saudi
Arabia, United Arab Emirates, Iraq,
Jordan, Syria, Oman, Qatar, Kuwait,
Lebanon or Egypt).
• Offer 20-week ultrasound screening for
fetal anomaly.
• Measure BMI.
• Check and record blood pressure (BP).
• Test urine for glycosuria/proteinuria.
2) Systemic Examination
Already described in previous chapters
3) Obstetrical Examination
This examination consist of following:
a) Examination of Breast
Examination of enlargement of breast

b) Per Abdominal Examination

442
443
 Pelvic organs (cervix, vagina, ovaries,
fallopian tubes, and uterus) are checked during
a pelvic examination.

Heterotopic pregnancy in a 32-year

old woman at 7 weeks' gestation
c) Per Vaginal Examination

444

An opened oviduct with an ectopic pregnancy
at about 7 weeks gestational age.
Transvaginal ultrasound. An ultrasound probe
connected to a computer is inserted into the
vagina and is gently moved to show different
organs.
Child Delivery
445
A
OB Case Example
MS is a 36 y/o G3P1011 female who presents
at 38 4/7 weeks with painful contractions for
four hours and leakage of fluid for two hours;
she has no bleeding and feels the baby
moving; her antepartum course has been
significant for prenatal labs with an elevated
glucose challenge test followed by a normal
glucose tolerance test and a brief
hospitalization at 22 weeks for dehydration
due to gastroenteritis; her past OB history is
significant for a full term normal spontaneous
vaginal delivery at term in 1998, and a
spontaneous abortion with a dilatation and
curettage at 8 weeks in 2000; her Gynae
history is significant for a triad of 31 x 4-5 x
14; she was diagnosed with HPV in 1994, and
has no fibroids or ovarian cysts; her past
medical history is significant for
hypothyroidism, and her medications include
Synthroid 88 mcg as well as prenatal vitamins;
she gets a rash from sulfa containing
medications, and a family history is significant
for a maternal grandfather with CHF and a
paternal aunt with post-menopausal breast
cancer; her social history is significant for a
15 pack-year history of cigarettes ending prior
to her first pregnancy; no alcohol or drugs; her
review of systems is significant for
generalized fatigue and constipation; on
physical exam, she is alert, gravid, and in
moderate discomfort with contractions; vital
signs are stable; there is a four over six
systolic ejection murmur loudest over the left
lower sternal border; her abdomen is soft,
gravid and nontender; vaginal exam is
significant for a cervix that is 4-5 cm, 80%
effaced and at minus three station; the fetal
heart rate has a baseline of 140is with
accelerations and occasional mild
decelerations; there are 60 second contractions
every four to six minutes; extremities have no
edema or calf tenderness to the mid-shin;; labs
at admission are significant for a hematocrit of
30.1%; in summary, this is a 36 y/o multipara
at term who presents in active labor; the plan
is to admit her, offer epidural, monitor
continuously and anticipate spontaneous
vaginal delivery; her interval course: She
received an epidural, and two hours later her
vaginal exam was 7 cm, 80% effaced and
minus two station; the heart remained
reassuring, and she was fully dilated three
hours later; she pushed effectively for 45
minutes, and had a normal spontaneous
vaginal delivery of a 3840 gram female,
Apgars 8 @ 1 minute and 9 @ 5 minutes over
a first degree laceration; the placenta delivered
spontaneously and intact, and the laceration
was repaired; mother and newborn were
brought to post-partum in stable condition.
References
American College of Obstetricians and Gynecologists.
Cervical Cytology Screening. ACOG Practice
Bulletin No. 109. Obstet Gynecol. 2009. 114:1409-
20.
Gallager HS, Leis HP Jr, Synderman RK, Urban JA,
eds. The breast. St. Louis: CV Mosby, 1978
Henderson JT, Harper CC, Gutin S, Saraiya M,
Chapman J, Sawaya GF. Routine bimanual pelvic
examinations: practices and beliefs of US
obstetrician-gynecologists. Am J Obstet Gynecol.
2013 Feb. 208(2):109.e1-7. [Medline].
Hoyo C, Yarnall KSH, Skinner CS, Moorman PG,
Sellers D, Reid L. Pain predicts nonadherence to Pap
smear screening among middle-aged African
American women. Prev Med. 2005. 41:439-45.
446
Larsen M, Oldeide CC, Malterud K. Not so bad after
all...women's experiences of pelvic
examinations. Fam Pract. 1997. 14:148-52.
Myers ER, Bastian LA, Havrilesky LJ, Kulasingam SL,
Terplan MS, Cline KE, et al. Management of Adnexal
Mass. Evidence Report/Technology Assessment
No.130 (Prepared by the Duke Evidence-based
Practice Center under Contract No. 290-02-0025.)
AHRQ Publication No. 06-E004. Rockville, MD:
Agency for Healthcare Research and Quality;
February 2006. [Full Text].
Pregnancy and breast cancer – Royal College of
Obstetricians and Gynaecologists Royal College of
Obstetricians and Gynaecologists (March 2011)
Green-top Guidelines No.12. Pregnancy and Breast
Cancer (This is a resource aimed at healthcare
professionals.)
Royal College of Obstetricians and Gynaecologists
(October 2014) for patients
Stormo AR, Hawkins NA, Cooper CP, Saraiya M. The
pelvic examination as a screening tool: practices of
US physicians. Arch Intern Med. 2011 Dec 12.
171(22):2053-4. [Medline].
Wright D, Fenwick J, Stephenson P, Monterosso L.
Speculum 'self-insertion': a pilot study. J Clin Nurs.
2005 Oct. 14(9):1098-111. [Medline].
www.Examen de las Mamas". Manual de Semiología
www.rcog.org.uk/en/patients/patient-
leaflets/pregnancy-and-breastcancer
www.rcog.org.uk/files/rcog-
corp/GTG12PregBreastCancer.pdf
www.Well Woman’s Exam". trive. Campus Health
Services
www.Well-Woman Visit". The American College of
Obstetricians & Gyne
Yanikkerem E, Ozdemir M, Bingol H, Tatar A,
Karadeniz G. Women's attitudes and expectations
regarding gynaecological examination. Midwifery.
2009 Oct. 25(5):500-8. [Medline]. [Full Text].
Note: Most of the Matters are drived from Internet and
Research Papers
Chapter-20

447
448
GYNECOLOGY
The word "gynaecology" comes from
the Greek γυνή gyne. "woman" and -logia"
study. Gynaecology or gynecology is the same
terms in medical language. It deals with the
health of the female reproductive systems
(vagina, uterus and ovaries) and the breasts.
Actually, it means "the science of women". On
other side, the Science of man is called
andrology, which deals with medical issues
specific to the male reproductive system.
Almost all modern gynecologists are
also obstetricians (see obstetrics and
gynecology). In many areas, the specialties of
gynecology and obstetrics overlap.
Case Taking
Pre-requisite
Case no./ID __________________________
Photo _______________________________
Name of patient: ______________________
w/o Age: ____________________________
Religion: ____________________________
Address: ____________________________
Contact no. __________________________
Cell no. _____________________________
Date of last menstruation: _______________
Expected Date of Delivery: ______________
Social History
1) Marital status: Single ____, married _____,
partnership_____, Divorced ______ ,
Medicolegal _____.
2) Occupation; __________________________
3) Vices: alcohol ________________________ ,
smoking _________ , illicit drugs ___________
Past History
History about pregnancy
1) Previous pregnancies ______ (Y/N)
2) Any miscarriage/abortion ______ (Y/N).
If yes then how many ________.
3) Abortion of how many weeks ________.
4) Where delivery take place, in hospital
_____ (Y/N), at home ________ (Y/N),.
5) Delivery was normal ________ (Y/N)
or C/S ________ (Y/N).
6) Last delivery period (date) ___________
Any chronic disease(s) in the past years:
7) TB ______ (Y/N)
449
8) HIV _______________________ (Y/N)
9) Syphilis ____________________ (Y/N)
10) Cardiovascular disease ________ (Y/N)
11) Kidney disease _______________ (Y/N)
12) Hepatitis A< B or C ___________ (Y/N)
13) Diabetes
14) Any pelvic infection __________ (Y/N)
15) Any operation for cyst _________ (Y/N)
Examination
In some countries, women must first see
a general practitioner (GP; also known as a
family practitioner (FP)) prior to seeing a
gynecologist. If their condition requires
training, knowledge, surgical procedure, or
equipment unavailable to the GP, the patient
is then referred to a gynecologist. In
the United States, however, law and
many health insurance plans allow
gynecologists to provide primary care in
addition to aspects of their own specialty.
With this option available, some women opt
to see a gynecological surgeon for non-
gynecological problems without another
physician's referral.
Advises information and intimations
As in all of medicine, the main tools of
diagnosis are clinical history and
examination. Gynecological examination is
quite intimate, more so than a routine
physical exam. It also requires unique
instrumentation such as the speculum. The
speculum consists of two hinged blades of
concave metal or plastic which are used to
retract the tissues of the vagina and permit
examination of the cervix, the lower part of
the uterus located within the upper portion of
the vagina. Gynecologists typically do a
bimanual examination (one hand on the
abdomen and one or two fingers in the
vagina) to palpate the cervix, uterus, ovaries
and bony pelvis. It is not uncommon to do
a recto-vaginal examination for complete
evaluation of the pelvis, particularly if any
suspicious masses are appreciated. Male
gynecologists may have a
female chaperone for their examination. An Some of the more common operations that
abdominal and/or vaginal ultrasound can be gynecologists perform include:
used to confirm any abnormalities 1. Dilation and curettage (removal of the
appreciated with the bimanual examination or uterine contents for various reasons,
when indicated by the patient's history. including completing a partial
Examples of conditions during pregnancy: miscarriage and diagnostic sampling
• Cancer and pre-cancerous diseases of the for dysfunctional uterine bleeding
reproductive organs including refractive to medical therapy)
ovaries, fallopian tubes, uterus, cervix, 2. Hysterectomy (removal of the uterus)
vagina, and vulva 3. Oophorectomy (removal of the
• Incontinence of urine ovaries)
• Amenorrhoea (absent menstrual periods) 4. Tubal ligation (a type of permanent
• Dysmenorrhoea (painful menstrual sterilization)
periods) 5. Hysteroscopy (inspection of the
• Infertility uterine cavity)
• Menorrhagia (heavy menstrual periods); 6. Diagnostic laparoscopy – used to
a common indication for hysterectomy diagnose and treat sources of pelvic
• Prolapse of pelvic organs and abdominal pain; perhaps most
• Infections of the vagina (vaginitis), famously used to provide a definitive
cervix and uterus diagnosis of endometriosis.
(including fungal, bacterial, viral, 7. Exploratory laparotomy – may be
and protozoal) used to investigate the level of
• Other vaginal diseases progression of benign or malignant
There is some crossover in these areas. For disease, or to assess and repair
example, a woman with urinary incontinence damage to the pelvic organs.
may be referred to a urologist. 8. Various surgical treatments
Gynaecologic oncology is a subspecialty of for urinary incontinence,
gynecology, dealing with gynecology- including cystoscopy and sub-
related cancer. urethral slings.
Therapy 9. Surgical treatment of pelvic
As with all surgical specialties, gynecologists organ prolapse, including correction
may employ medical or surgical therapies (or of cystocele and rectocele.
many times, both), depending on the exact 10. Appendectomy – often performed to
nature of the problem that they are treating. remove site of
Pre- and post-operative medical management painful endometriosis implantation
will often employ many standard drug and/or prophylactically (against
therapies, such as antibiotics, diuretics, anti- future acute appendicitis) at the time
hypertensives, and anti-emetics. Additionally of hysterectomy or Caesarean
gynecologists make frequent use of section. May also be performed as
specialized hormone-modulating therapies part of a staging operation for ovarian
(such as Clomifene citrate and hormonal cancer.
contraception) to treat disorders of the female 11. Cervical Excision Procedures
genital tract that are responsive (including cryosurgery): removal of
to pituitary and/or gonadal signals. the surface of the cervix containing
Surgery pre-cancerous cells which have been
previously identified on Pap.

450
Examination Table
Examination of Pelvis
The pelvic examination encompasses an
examination of the vulva, vagina, and
internal pelvic organs. Females typically
undergo their first pelvic examination for the
evaluation of gynecological complaints or at
age 21 years, whichever comes first. Pelvic
examinations were once performed for
cervical cytology or screening for
gonorrhea or chlamydia before age 21 years.
However, the availability of urine testing for
gonorrhea and chlamydia has reduced the
necessity of routine pelvic examination
before age 21 years.
451
The examination is a basic tool of physical
diagnosis and can be performed by either
physicians or trained allied health
professionals. Few studies have addressed
patient preference concerning pelvic
examinations alone, but about 45% of women
reported that they would prefer a female
doctor for their gynecologic care, 4.2%
reported that they would prefer a male
doctor, and the remaining women expressed
no preference. Many women anticipate that
the nurse assisting the physician will give
them additional information about the pelvic
examination.
Since the American College of Obstetricians
and Gynecologists (ACOG) guidelines
changed the frequency of cervical cancer
screening based on age and risk factors,
many experts have begun to doubt the need
for routine pelvic examination. An Agency
for Healthcare Research and Quality
(AHRQ), commissioned report found no
evidence that these examinations led to
earlier detection of ovarian cancer. In
addition, no evidence has shown the benefits
of a pelvic examination in the early diagnosis
of other conditions in asymptomatic women.
Speculum and bimanual examinations are
uncomfortable and disliked by many women
and take up valuable time during a well-
woman visit.

Annual pelvic examinations are often equated
with the Papanicolaou (Pap) test, but they are
separate tests. For women older than 21
years, the pelvic examination is typically
performed as part of the well-woman visit,
even when cervical screening is not
indicated.
Chaperones typically accompany the
provider performing the pelvic examination,
although, in usual practice, female providers
frequently do not have them present.
Fear of the pain associated with a pelvic
examination is a barrier to consistent
care,] and patients need reassurance. The
clinician should establish patient rapport.
Making the patient feel at ease, maintaining
eye contact, being aware of the patient’s
involuntary muscle contraction, selecting the
appropriate speculum, clearly explaining the
steps of the examination (and providing
advanced warning of each step as the
examination progresses), and explaining the
findings are helpful during a pelvic
examination.
References
Adekunle, Julius O.; Williams, Hettie V.
(2010-02-24). Color Struck: Essays on
Race and Ethnicity in Global Perspective.
University Press of America. pp. 397–
. ISBN 9780761850922. Retrieved 11
October2013.
American College of Obstetricians and
Gynecologists. Cervical Cytology
Screening. ACOG Practice Bulletin No.
109. Obstet Gynecol. 2009. 114:1409-20.
452
Daly, Mary (1990). Gyn/ecology: The
Metaethics of Radical Feminism. Beacon
Press. pp. 225–. ISBN 9780807014134.
Retrieved 11 October 2013.
Do patients talk differently to male and
female physicians?: A meta-analytic
review. 2002-12-02.
From Past to Present: The Changing
Demographics of Women in Medicine.
2008-02-01. Retrieved 2014-06-24.
Henderson JT, Harper CC, Gutin S, Saraiya
M, Chapman J, Sawaya GF. Routine
bimanual pelvic examinations: practices
and beliefs of US obstetrician-
gynecologists. Am J Obstet Gynecol. 2013
Feb. 208(2):109.e1-7.
Hoyo C, Yarnall KSH, Skinner CS,
Moorman PG, Sellers D, Reid L. Pain
predicts nonadherence to Pap smear
screening among middle-aged African
American women. Prev Med. 2005.
41:439-45.
Larsen M, Oldeide CC, Malterud K. Not so
bad after all...women's experiences of
pelvic examinations. Fam Pract. 1997.
14:148-52.
Laurinda S. Dixon. Perilous Chastity:
Women and Illness in Pre-Enlightenment
Art and Medicine, Cornell University Press
1995, pp.15f.
Male Gynaecologist in Turkey: Dying
profession?. 2014-05-22. Retrieved 2014-
06-25.
Myers ER, Bastian LA, Havrilesky LJ,
Kulasingam SL, Terplan MS, Cline KE, et
al. Management of Adnexal Mass. Evidence
Report/Technology Assessment No.130
(Prepared by the Duke Evidence-based
Practice Center under Contract No. 290-
02-0025.) AHRQ Publication No. 06-E004.
Rockville, MD: Agency for Healthcare
Research and Quality; February 2006. [
Nurse questions all female OB-GYN
practice". 2014-02-02. Retrieved 2014-07-
14.
Stormo AR, Hawkins NA, Cooper CP,
Saraiya M. The pelvic examination as a
screening tool: practices of US
physicians. Arch Intern Med. 2011 Dec 12.
171(22):2053-4. .
Wright D, Fenwick J, Stephenson P,
Monterosso L. Speculum 'self-insertion': a
pilot study. J Clin Nurs. 2005 Oct.
14(9):1098-111. .
Yanikkerem E, Ozdemir M, Bingol H, Tatar
A, Karadeniz G. Women's attitudes and
expectations regarding gynaecological
examination. Midwifery. 2009 Oct.
25(5):500-8.

Note: Most of the Matters are drived from Internet

and Research Papers

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Chapter-21

455
456
FIBROIDS
Fibroids are benign tumors of the uterus. They
can be found on the uterus, in its muscular
wall or within the uterine cavity. 2020-50% of
women can have fibroids, often very small,
although they can grow as large as a
grapefruit. There may be multiple fibroi
fibroids of
different sizes. Most women don’don’t have any
Pelvic circulation and energy can be increased
symptoms from fibroids, but if they get large
with kegal exercises and alternating sits baths.
they can cause pressure on the bladder or
Acupuncture and massage can also increase
rectum or if located in the uterine cavity may
circulation and energy. Emotional work
cause severe bleeding and pain. A pelvic exam
should focus on expressing creativity.
and ultrasound can diagnosis is fibroids and be
Herbal treatment for fibroids involves
used to monitor them over time. They usually
balancing hormones, increasing circulation
shrink with menopause indicating their growth
and elimination, reducing bleeding and
is influenced by hormones. If they are not
managing pain.
causing symptoms they can just be observed
over time. Conventional treatment includes
surgery, either hysterectomy
ysterectomy or just the
removal of the fibroid, progesterone treatment,
or medication to decrease pituitary hormones.
Again, we find hormonal imbalance, poor
circulation and poor elimination to be related
to the development of fibroids. I have treated a
number of women with fibroids-- all had relief
of symptoms with several months of
treatment, but none continued treatment for an
extended time to see if the fibroids would
shrink in size.

To correct hormonal imbalance:

imbalance Vitex-
helps to normalize hormonal production and
ovulation through its effects on the pituitary
gland.
Natural treatment includes a whole foods diet Dosage: Liquid extract- 1/2 teaspoon each
with the elimination of estrogen containing morning
meat and dairy products, plenty of Dry herb in capsules: 500 mg each morning.
morning
phytoestrogen foods including soy, flax, and Standardized extract-225
225 milligrams of an
other beans and grains, vitamin and mineral extract standardized for 0.5 percent agnusides
supplementation including plenty of Vitamin To improve elimination: Dandelion-a
Dandelion very
C, betacarotene, vitamin E,, B vitamins and good nutritive herb with high levels of
magnesium. vitamins and minerals. Dandelion
Dand improves
liver function, helping to metabolize
hormones.

457
Dosage: Liquid extract 1 teaspoon three times
a day
Dry herb in capsules: 1000 mg three times a
day
Other herbs: Milk Thistle, Burdock, Yellow
Dock, Artichoke, Goldenseal.
To improve circulation and decrease
bleeding: Witch hazel, a good astringent herb
to help with excessive uterine bleeding.
Liquid extract: 1/4-1/2 teaspoon three times a
day.
Dry herb in capsules: 250-500 mg three times
a day.
Caution: only use witch hazel intended for
internal use, witch hazel preparations intended
for topical application should not be taken
internally.
Other herbs: Geranium, Goldenseal
Relief of pain
Wild Yam: a good antispasmodic
Liquid extract- 1/2-1 teaspoon every 2-3 hours
as needed for pain
Dry herb in capsules- 500- 1000 mg every 2-3
hours as needed for pain
Other herbs: Cramp Bark, Black Haw,
California Poppy, kava kava, Jamaican
Dogwood.
FURTHER READING
Cesen-Cummings, K.; Houston, K.; Copland, J.;
Moorman, V.; Walker, C.; Davis, B. (2003). "Uterine
leiomyomas express myometrial contractile-
associated proteins involved in pregnancy-related
hormone signaling".Journal of the Society for
Gynecologic Investigation 10 (1): 11–20.
Garg, K.; Tickoo, S. K.; Soslow, R. A.; Reuter, V. E.
(2011). "Morphologic Features of Uterine
Leiomyomas Associated with Hereditary
Leiomyomatosis and Renal Cell Carcinoma
Syndrome". The American Journal of Surgical
Pathology 35 (8): 1235–1237.
Makinen, N.; Mehine, M.; Tolvanen, J.; Kaasinen, E.;
Li, Y.; Lehtonen, H. J.; Gentile, M.; Yan, J. et al.
(2011). "MED12, the Mediator Complex Subunit 12
Gene, is Mutated at High Frequency in Uterine
Leiomyomas". Science 334(6053): 252–5.
458
Maruo, T.; Ohara, N.; Wang, J.; Matsuo, H. (2004).
"Sex steroidal regulation of uterine leiomyoma
growth and apoptosis". Human reproduction
update 10 (3): 207–220.
Massart, F.; Becherini, L.; Marini, F.; Noci, I.;
Piciocchi, L.; Del Monte, F.; Masi, L.; Falchetti, A. et
al. (2003). "Analysis of estrogen receptor (ERalpha
and ERbeta) and progesterone receptor (PR)
polymorphisms in uterine leiomyomas". Medical
science monitor : international medical journal of
experimental and clinical research 9 (1): BR25–
BR30
Neiger, R.; Sonek, J.; Croom, C.; Ventolini, G. (2006).
"Pregnancy-related changes in the size of uterine
leiomyomas". The Journal of reproductive
medicine 51 (9): 671–674.
Okolo, S. (2008). "Incidence, aetiology and
epidemiology of uterine fibroids". Best practice &
research. Clinical obstetrics & gynaecology 22 (4):
571–588.
Rein, MS (2000). "Advances in uterine leiomyoma
research: the progesterone
hypothesis". Environmental health perspectives 108
Suppl 5: 791–3.
Strissel, P.; Swiatek, J.; Oppelt, P.; Renner, S.;
Beckmann, M.; Strick, R. (2007). "Transcriptional
analysis of steroid hormone receptors in smooth
muscle uterine leiomyoma tumors of postmenopausal
patients". The Journal of Steroid Biochemistry and
Molecular Biology 107 (1-2): 42–47.
Wallach EE, Vlahos NF (August 2004). "Uterine
myomas: an overview of development, clinical
features, and management". Obstet Gynecol 104 (2):
393–406. Fibroid Tumors. American Society of
Reproductive Medicine Patient Booklet:Uterine
Fibroids, 2003
Wei, T.; Geiser, A.; Qian, H.; Su, C.; Helvering, L.;
Kulkarini, N.; Shou, J.; N'cho, M. et al.
(2007). "DNA microarray data integration by
ortholog gene analysis reveals potential molecular
mechanisms of estrogen-dependent growth of human
uterine fibroids". BMC Women's Health 7: 5.
Yen-Ping Ho J, Man WC, Wen Y, Polan ML, Shih-Chu
Ho E, Chen B (June 2009). Transforming growth
interacting factor expression in leiomyoma compared
with myometrium. Fertil. Steril. 94 (3): 1078–83.
Note: Most of the Matters are drived from Internet and
Research Papers
Chapter-22

459
460
Osteoporosis
Osteoporosis is a disorder of the bones
characterized by a progressive loss of bone
tissue, with a resulting increase in the risk of
bone fractures. Normal bone is composed of a
framework made of protein (called collagen)
and calcium salts. Osteoporosis depletes both
the calcium salts and the protein in the bone.
The bone then becomes weaker and is more
prone to breakage (fracture), either by
cracking or collapsing (compression). Bone
fracture in osteoporosis can occur with only a
minor fall or injury that normally would not
cause a bone fracture.
Normal bone has two layers. The outer layer,
called the "cortical bone", is very dense and
compact. The inner layer, called the
"trabecular bone," is far less compact than the
cortical bone, and has a honeycomb structure.
The bones of the spine (vertebrae) are mainly
composed of trabecular bone, while bones of
the neck of the hip bone (femur) are mostly
made of cortical bone. Different types of
osteoporosis affect different proportion of
trabecular and cortical bone. In
postmenopause osteoporosis, the spine is
461
more commonly affected than the hip. In
contrast, in senile (due to aging) osteoporosis,
both cortical and trabecular bones are
affected. Osteoporosis leads to bone fractures.
Fractures of the spine cause loss of height due
to compression of the vertebrae (the building
blocks of the spine).
Over 20 million people have osteoporosis in
the United States, and approximately 1.3
million people each year will suffer a broken
bone as a result of osteoporosis. The
osteoporosis process can operate silently for
decades. The patients may not be aware of
their brittle osteoporotic bones until suffering
a fracture. In 1993, the United States incurred
an estimated loss of 10 billion dollars due to
loss of productivity and health care costs
related to osteoporosis.
Factors determine bone mass
Bone mass (or bone density) is the amount of
bone present in the skeletal structure. The
higher is the bone mass and density, the
stronger the bones. Bone mass is primarily
determined by genetic factors. Men have a
higher bone mass than women. Black
Americans have a higher bone mass than
white or Asian Americans. A vitamin D
receptor gene has been found in the human
chromosomes that regulates bone mass.
Adequate dietary intake of calcium and
physical exercise can increase bone mass.
Normally, bone mass is accumulated during
childhood and reaches a peak by age 25. Bone
mass is then maintained for ten years. After
age 35, both men and women will lose 0.3-
0.5% of their bone mass per year as part of
the normal aging process.
Estrogen is important in maintaining bone
mass, especially in the trabecular bone of the
spine. When estrogen levels drop after
menopause, bone loss accelerates. During the
first five to ten years after menopause, women
can suffer up to two to four percent loss of
trabecular bone mass per year! This can result
in the loss of up to 25-30% of their trabecular
bone mass during that time period. hormone causes too much calcium to be
Accelerated bone loss after menopause is a removed from the bone, which can lead to
major cause of osteoporosis in women. osteoporosis.
Vitamin D helps the body absorb calcium.
When vitamin D is lacking, the body cannot
Factors for osteoporosis absorb adequate amounts of calcium to
Many factors will increase the risk of prevent osteoporosis. Vitamin D deficiency
developing osteoporosis. These factors are can result from lack of intestinal absorption as
related to genetics, life style, hormones, and in celiac sprue and in primary biliary
certain medications. Genetic factors include cirrhosis. In celiac sprue, the damaged small
female gender, Caucasian or Asian race, thin bowel lining cannot absorb vitamin D. In
and small body frames, and a family history primary biliary cirrhosis, insufficient bile
of osteoporosis. from the liver prevents the absorption of
Life style risk factors include cigarette vitamin D.
smoking, excessive alcohol and caffeine Certain common medications can cause
consumption, lack of exercise, and a diet low osteoporosis. These include heparin (a blood
in calcium. thinner), anti-seizure medications phenytoin
Hormone related risk factors include (DILANTIN) and phenobarbital.
menopause, early surgical removal of both Corticosteroids (such as PREDNISONE) are
ovaries, a pituitary gland tumor in the brain, used for many conditions such as asthma,
hyperthyroidism (the presence of too much rheumatoid arthritis, and ulcerative colitis.
thyroid hormone), hyperparathyoidism (the When administered over long periods of time,
presence of too much parathyroid hormone), corticosteroids can cause osteoporosis.
and a lack of vitamin D.
Low estrogen levels caused by menopause or
surgical removal of both ovaries can lead to
osteoporosis in women. Similarly, low
testosterone levels in men can also cause
osteoporosis. Tumors of the pituitary gland in
the brain can cause a reduction in the
production of estrogen. They can also release
excessive amounts of a hormone, called
prolactin, which can cause osteoporosis.
Hyperthyroidism, a condition wherein too
much thyroid hormone is produced by the
thyroid gland (as in Grave's disease), can
cause osteoporosis. Osteoporosis can also
result from taking too much thyroid hormone
medication.
Hyperparathyroidism is a disease wherein
there is excessive parathyroid hormone
production by the parathyroid gland.
Normally, the parathyroid hormone maintains Symptoms of osteoporosis
blood calcium levels by, in part, removing Patients with osteoporosis generally have no
calcium from the bone. In untreated symptoms until bone fractures occur.
hyperparathyroidism, excessive parathyroid Fractures of the spinal vertebrae are usually a

462
result of the compression of bone (vertebral
compression fractures). Spine vertebral
fractures can occur without pain. However,
they can often cause a severe "band-like" pain
that radiates around from the spine to both
sides of the body. Over many years, the spinal
fractures cause a loss of height of the spine
resulting in the person becoming shorter. A
curvature of the spine can also occur, giving
the individual a hunched-back appearance.
This can lead to chronic backaches.
Fractures of the other bones in the body can
cause severe pain at the site of the fracture.
The trauma causing the fracture can be
relatively minor. When fracture occurs during
the "stress" of normal activity, it is called a
stress fracture. For example, some patients
with osteoporosis can develop stress fractures
of the feet while walking or stepping off a
curb.
Hip fractures usually occur as a result of a
fall. Since the bone can become so weakened
in osteoporosis, hip fractures can occur with
trivial accidents. Hip fractures in the elderly
can lead to other medical complications. The
weak, osteoporotic bone may be difficult to
heal after surgical repair of the fracture.
Pneumonia and blood clots in the leg veins
that can travel to the lungs (pulmonary
embolism) can complicate hip fracture
recovery due to prolonged bed rest.
Aggressive physical therapy after repair of the
hip fracture can decrease these complications.
Despite these measures, up to 30% of patients
will require long-term nursing home care
following a hip fracture.
Diagnosis of osteoporosis
A routine x-ray examination can reveal
osteoporotic bones, which appear much
thinner and lighter than normal bones.
Unfortunately, by the time x-rays can detect
osteoporosis, at least 30% of the bone mass
has already been lost.
Bone densitometry can be used to calculate
the bone density and can detect osteoporosis
earlier than routine x-rays. There are several
463
ways to perform bone densitometry.
Computerized tomography or CT scans are
useful in evaluating the spine. Single photon
absorptiometry (SPA) typically evaluates
bone mass in the forearm and is fairly precise
in gauging bone loss. The best technique
currently available in measuring bone mass is
dual energy x-ray absorptiometry (DEXA).
DEXA measures bone mass in the hip and the
spine. The test takes only 5-10 minutes to
perform, uses very little radiation (less than
one tenth the amount used on a standard chest
x-ray), and is quite precise. DEXA can also
be used repeatedly over a period of time to
follow changes in bone density.
Treatment of osteoporosis
The best treatment for osteoporosis is
prevention. Quitting smoking and curtailing
alcohol intake are helpful. Exercise against
gravity can reduce bone loss and can even
stimulate new bone formation. Additionally,
exercise increases the agility, strength, and
endurance; factors that can reduce accidents.
Exercise programs are individualized and
should be regular; at least several times
weekly. For patients with underlying
musculoskeletal disorders, combining
exercising with joint protection techniques is
important.
Calcium supplements are useful, especially in
women. Average women in the United States
receive less than 500 milligrams of calcium
per day in their diet. The recommended daily
allowance (RDA) of calcium intake is 800mg
per day. The National Institute of Health
Consensus Conference on Osteoporosis has
recommended a calcium intake for
postmenopausal women of 1000mg per day if
they are also taking estrogen and 1500mg per
day if they are not taking estrogen.
Estrogen replacement in postmenopausal
women is important in the prevention of
accelerated bone loss. Estrogen can even
reverse the bone loss that occurs after
menopause. Estrogen is available orally
(PREMARIN) or as a skin patch
(ESTRADERM). Women with certain
conditions, such as a history of breast cancer,
phlebitis, or stroke may not be candidates for
estrogen because of the potential for
worsening or inducing recurrences of these
conditions.
Calcitonin (CALCIMAR) is a drug that is
FDA approved for the treatment of
postmenopausal osteoporosis. Calcitonin is a
natural hormone that slows the rate of bone
loss. Calcitonin increases bone density and
can occasionally relieve bone pain. Common
side effects of calcitonin include nausea and
flushing. Calcitonin can be given by an
injection under the skin every other day.
Recently, a nasal spray form of calcitonin
(MIACALCIN) has become available. Nasal
sprays seem to have fewer side effects than
injectable calcitonin.
Etidronate (DIDRONEL) is a drug that
increases bone density and decreases the rate
of recurrence of fractures in patients with
osteoporosis. It currently is not FDA
approved for the treatment of osteoporosis,
but is approved for use in another bone
disorder called Paget's disease. Despite its
lack of FDA approval for use in osteoporosis,
it has been used extensively over the past few
years to treat osteoporosis.
Alendronate (FOSAMAX) is a new
medication that has recently been approved
by the FDA for the treatment of
postmenopausal osteoporosis. Alendronate
decreases the accelerated rate of bone loss
that occurs after menopause. It has been
shown to increase lumbar spine bone density
by 10% and hip bone density by 6%.
Alendronate is taken in the morning, on an
464
empty stomach thirty minutes before
breakfast, with a glass of water. Side effects
are usually mild, but can include upset
stomach. Alendronate is chemically referred
to as a biphosphonate drug. Other
biphosphonates are being studied for both
postmenopausal and cortisone-induced
osteoporosis. These include risedronate for
which preliminary studies are encouraging.
Vitamin D supplementation has been shown
to be of benefit in elderly patients,
particularly those in nursing homes. This is
probably due to the fact that many patients in
nursing homes are vitamin D deficient.
Medications that are undergoing testing for
osteoporosis include sodium flouride and
parathyroid hormone. Flouride appears to
decrease the incidence of fractures and
increase bone density. Parathyroid hormone
given daily in low dosages appears to
significantly increase bone density.
As the population of the United States
continues to age, the number of people with
osteoporosis and subsequent fractures will
increase exponentially. The pain, suffering,
and economic costs will be enormous. It is
vitally important for people to become aware
of osteoporosis and its prevention and
treatment to limit its impact. With continued
research, there will hopefully be even better
and more effective treatment options for
osteoporosis.
FURTHER READING
Berg KM, Kunins HV, Jackson JL et al. (2008).
Association between alcohol consumption and both
osteoporotic fracture and bone density. Am J
Med 121 (5): 406–18.
Brian K Alldredge; Koda-Kimble, Mary Anne; Young,
Lloyd Y.; Wayne A Kradjan; B. Joseph Guglielmo
(2009). Applied therapeutics: the clinical use of
drugs. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins. pp. 101–3.
Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ (2007).
Will my patient fall? JAMA 297 (1): 77–86.
Kim DH, Vaccaro AR (2006). Osteoporotic
compression fractures of the spine; current options
and considerations for treatment. The spine journal :
official journal of the North American Spine
Society 6 (5): 479–87.
Melton LJ (2003). "Epidemiology
worldwide". Endocrinol. Metab. Clin. North
Am. 32 (1): 1–13, v.
Nieves JW (1 May 2005). "Osteoporosis: the role of
micronutrients". Am J Clin Nutr 81 (5): 1232S–9S.
Ojo F, Al Snih S, Ray LA, Raji MA, Markides KS
(2007). History of fractures as predictor of
subsequent hip and nonhip fractures among older
Mexican Americans. Journal of the National
Medical Association 99 (4): 412–8.
Old, JL; Calvert, M (2004). Vertebral compression
fractures in the elderly. American Family
Physician 69 (1): 111–6.
Poole KE, Compston JE (December
2006). Osteoporosis and its
management. BMJ 333 (7581): 1251–6.
Raisz L (2005). "Pathogenesis of osteoporosis:
concepts, conflicts, and prospects". J Clin
Invest 115 (12): 3318–25..
Waugh, EJ; Lam, MA, Hawker, GA, McGowan, J,
Papaioannou, A, Cheung, AM, Hodsman, AB,
Leslie, WD, Siminoski, K, Jamal, SA,
Perimenopause BMD Guidelines Subcommittee of
Osteoporosis, Canada (2009 Jan). "Risk factors for
low bone mass in healthy 40-60 year old women: a
systematic review of the literature". Osteoporosis
international : a journal established as result of
cooperation between the European Foundation for
Osteoporosis and the National Osteoporosis
Foundation of the USA 20 (1): 1–21.
WHO (1994). Assessment of fracture risk and its
application to screening for postmenopausal
osteoporosis. Report of a WHO Study Group. World
Health Organization technical report series 843: 1–
129.
WHO Scientific Group on the Prevention and
Management of Osteoporosis (2000 : Geneva,
Switzerland) (2003). Prevention and management of
osteoporosis : report of a WHO scientific
group (PDF). Retrieved 2007-05-31.
Wong PK, Christie JJ, Wark JD (2007). The effects of
smoking on bone health. Clin. Sci. 113 (5): 233–41.

Note: Most of the Matters are drived from Internet and

Research Papers

465
Chapter-23

467
468
MALE REPRODUCTIVE SYSTEM
Diseases and Disorders of the Male
Reproductive System
A man's reproductive system has many
functions including ensuring the fertility and
providing sex hormones that support sexual
performance. Most of the problems that arise
in the system are treatable and several
disorders are having potentially serious
s.
Erectile (Penile) dysfunction
Erection problems may have a physical,
psychological, behavioural or iatrogenic basis.
Erectile dysfunction (ED) is defined as the
inability to have or maintain an erection hard
enough for satisfactory sexual intercourse. It
remains one of the most common untreated
conditions in many countries. A study by
Pinnock et al. showed ED to be strongly
correlated with age with erections inadequate
for intercourse affecting 3% of men aged 40-
49 years, increasing to 64% of men aged 70 -
79 years.
While in younger men ED may be more
commonly due to psychological causes (e.g.
performance anxiety), in many middle aged
and older men, the inability to achieve a hard
erection is the result of faulty arterial flow to
the corpora cavernosa of the penis, the
pathophysiology being lack of blood flow
rather than lack of male hormones.
469
consequences for example, erectile
dysfunction, premature ejaculation, loss of
libido, testicular cancer and prostate disease
may cause embarrassment to the patient and,
occasionally, the general practitioner.
Diseases of the male sex organs are not
identified as often as they should be for
several reason
Symptoms
The importance of ED being identified is that
in the majority of men, ED is not a disease in
itself, but rather an early symptom of cerebro-
cardio-vascular disease. Arterial narrowing
initially manifests itself in the small arteries
(such as the penile arteries) before narrowing
of larger arteries (such as the coronary and
cerebral arteries) declares itself in the form of
symptoms such as angina and transient
ischaemic attacks (TIAs). If men became more
open to discussing the sensitive issue of ED
with their GP, they would benefit from the
opportunity of having their occult
cardiovascular disease being diagnosed and
managed, thereby minimizing their risk of a
premature heart attack.
Ideally, GPs asking their male patients about
erectile function as a risk factor for
cardiovascular disease should become as
routine as inquiring about smoking history,
angina or breathlessness. Management of ED
involves investigating for other evidence of
cardiovascular disease or risk factors (e.g.
hypertension, diabetes, elevated blood lipids,
smoking) and introducing appropriate therapy.
There is evidence that lifestyle interventions
can benefit both general health and ED.
Infertility
There are two primary disorders that affect the
male reproductive external organs. These
include penis disorders and testicular
disorders. Disorders of the penis and testes
can affect a man's sexual functioning
and fertility.
The testicles make male hormones, including
testosterone, and produce sperm, the male
reproductive cells. Problems with the testes
can lead to serious illnesses, including
hormonal imbalances, sexual problems,
and infertility.
Male infertility may develop because of
genetic factors that cause low or absent sperm
production, a blockage in the duct system, a
hormonal imbalance that interferes with sperm
production, or certain medications. A
condition called varicocele, in which veins in
the scrotum that carry blood back to the heart
become enlarged, can also cause fertility
problems. These veins help cool warm blood
flowing into the scrotum, where sperm
production depends on a reduced temperature.
When blood flow in the veins is slow, the
scrotum heats up and interfere with sperm
production. Varicocele may often be treated
successfully with surgery or other procedures.
Premature ejaculation
Premature ejaculation (PE) is a common and
highly sensitive matter and most men avoid
broaching the problem with their GP. When
raised (either by the GP or the patient), a frank
and supportive approach goes a long way to
opening up conversation and working toward
a more satisfying sex life for both the patient
and their partner.
Assessment
Lifelong (primary) or acquired (secondary) PE
is typically diagnosed via a sexual, medical
470
and psychological history:
• Sexual history: onset and duration,
ejaculatory latency time, perceived control
over ejaculation, frequency of occurrence,
past sexual relationships and functioning
• Medical history: general history,
medications, past or current infections, past
traumas
• Psychological history: guilt, inhibitions or
misinformation about sex, negative sexual
experiences, anxiety, depression, and the
impact of PE on the patient and their
partner.
A brief physical examination of the vascular,
endocrine and neurologic systems may be
undertaken if the patient’s history suggests an
underlying medical condition, such as chronic
illness, genitourinary infection, Peyronie
disease, endocrinopathy or autonomic
neuropathy.
Libido
Libido relates to a person’s desire for sexual
activity and sex seeking behaviour. Levels of
libido vary from person-to-person and there is
considerable individual variation, with libido
changing across relationships as well in
different social and environmental
circumstances. Low libido becomes a problem
when it creates distress for the patient and/or
their partner and difficulty across the
relationship.
Unrealistic perceptions about male libido may
strongly influence a man’s feelings of shame
and embarrassment if they experience low sex
drive.
Assessment and management
Loss of libido is a not uncommon presenting
symptom in general practice and can be
affected by many factors including:
• fatigue – such as from long or irregular
working hours
• stressors – from any source, but potentially
related to work, finances, health or
relationships
• lack of psychological wellbeing – such as
depression, anxiety or low self esteem
• relationship problems – such as conflict,
poor intimacy or sexual incompatibility.
Infection
In men, the testes reside in the scrotum. A
system of ducts carries semen from the testes
to the penis, where it's released at ejaculation.
An infection may develop in any of these
areas, potentially causing inflammation and
pain in the testes or other structures. Infections
may be caused either by bacteria or a virus,
Testicular lumps
Although testicular cancer is rare – diagnosed
in about 750 Australian men annually – it is
the most common solid cancer in men aged
18–39 years. Risk factors include a family
history, a history of un-descended testis or
congenital inguinal hernia.9Embarrassment
delays many young men with testicular
swellings seeking medical opinion. While
most testicular swellings are the result of
benign conditions such as cysts or hydroceles,
an enlarged testicle can be an early sign of a
testicular tumor. Therefore an important
community message is that any man with a
swelling in the testis should consult a doctor
so as to exclude testicular cancer.
There is no evidence from randomized
controlled trials – and it is unlikely that such
trials could ever be designed – to prove that
regular testicular self examination reduces
471
for example prostatitis, a bacterial infection
that may start in the prostate gland
surrounding the urethra; in one of the testes,
the infection is called orchitis. The mumps
virus may be the cause of an infection in the
system and may result in long-lasting fertility
problems. Bacterial causes also include
sexually transmitted diseases such as
chlamydia or gonorrhea.
mortality. A recent Cancer Council Australia
position statement recommends that men
become aware of the health of their testicles,
and encourages men with testicular lumps to
present early for medical assessment. It does
not recommend encouraging testicular self
examination. It stands to reason that early
detection (before metastases have developed)
reduces the need for toxic therapies such as
major abdominal surgery and chemotherapy.
Prostate disease
Many men may find it embarrassing to talk
about lower urinary tract symptoms (LUTS)
such as nocturia, urge incontinence and
reduction of the urinary stream; symptoms
which could indicate benign prostatic
hypertrophy. Men may also be embarrassed to
undergo a digital rectal examination, which
forms part of the assessment for prostatic
concerns. This is despite an Australian study
showing that 7% of men aged 40 years and
more had moderate to severe LUTS, and that
57% of men were moderately or very
concerned about prostate cancer.
Benign Prostate Hypertrophy (BPH)
A disorder called benign prostatic hypertrophy
involves enlargement of the prostate gland and
generally affects older men, usually after the
age of 50. In BPH, a man might experience a
slow stream of urine, a feeling that his bladder
doesn't empty fully or a need to strain to
urinate. A non-cancerous condition whose
cause is not well understood, BPH can often
be relieved through medications or surgery
when its symptoms become severe.
Cancer Symptoms
Cancer can develop in any of the organs that
make up the male reproductive system, but
prostate cancer is the most common cancer
among men. Although the cause is still
unknown, research published in the September
2013 issue of the journal "Prostate" concluded
that changes in gene function related to aging
account at least partly for higher rates of
prostate cancer in older men. Symptoms
include difficulty urinating and low back pain
or pain with ejaculation, although symptoms
may be absent, especially in early stages.
Cancer may also develop in one of the testes,
where it develops most often in men aged 20
to 39 and can cause pain, swelling or lumps in
the scrotum or in the penis. Penile cancer,
though rare, can be caused by the human
papilloma virus, or HPV, the virus that also
causes most cervical cancers in women.
Disorders of Testicles
Some of the more common conditions that
affect the testicles include testicular
trauma, testicular torsion, testicular
cancer, epididymitis, and hypogonadism.
Testicular TraumaBecause the testicles are
located within the scrotum, which hangs
outside of the body, they do not have the
protection of muscles and bones. This
makes it easier for the testicles to be
struck, hit, kicked, or crushed, which
472
occurs most often during contact sports.
Males can protect their testicles by
wearing athletic cups during sports.
Trauma to the testicles can cause severe pain,
bruising, and/or swelling. In most cases, the
testes -- which are made of a spongy material -
- can absorb the shock of an injury without
serious damage. A rare type of testicular
trauma, called testicular rupture, occurs when
the testicle receives a direct blow or is
squeezed against the hard bones of the pelvis.
This injury can cause blood to leak into the
scrotum. In severe cases, surgery to repair the
rupture -- and thus save the testicle -- may be
necessary.
Testicular Torsion
Within the scrotum, the testicles are secured at
either end by a structure called the spermatic
cord. Sometimes, this cord gets twisted around
a testicle, cutting off the blood supply to the
testicle. Symptoms of testicular torsion
include sudden and severe pain, enlargement
of the affected testicle, tenderness, and
swelling.
This condition, which occurs most often in
men under the age of 25, can result from an
injury to the testicles or from strenuous
activity. It also can occur for no apparent
reason
Testicular Torsion Treatment
Testicular torsion requires immediate medical
attention. Treatment usually involves
correction of the problem through surgery.
Testicular function may be saved if the
condition is diagnosed and corrected
immediately. If the blood supply to the testicle
is cut off for a long period of time, the testicle
can become permanently damaged and may
need to be removed.
Testicular Cancer
Testicular cancer occurs when abnormal cells
in the testicles divide and grow uncontrolled.
In some cases, certain benign (non-cancerous)
tumors may progress and become cancer.
Testicular cancer can develop in one or both
testicles in men or young boys.
 Symptoms of Testicular Cancer
Symptoms of testicular cancer include a lump,
irregularity or enlargement in either testicle; a
pulling sensation or feeling of unusual
heaviness in the scrotum; a dull ache in the
groin or lower abdomen; and pain or
discomfort (which may come and go) in a
testicle or the scrotum.
Causes of Testicular Cancer
The exact causes of testicular cancer are not
known, but there are certain risk factors for
the disease. A risk factor is anything that
increases a person's chance of getting a
disease. The risk factors for cancer of the
testicles include:
• Age. Testicular cancer can occur at any age,
but most often occurs in men between the ages
of 15 and 40.
• Undescended testicle. This is a condition in
which the testicles do not descend from the
abdomen, where they are located during fetal
development, to the scrotum shortly before
birth. This condition is a major risk factor for
testicular cancer.
• Family history. A family history of testicular
cancer increases the risk.
• Race and ethnicity. The risk for testicular
cancer in white men is more than five times
that of black men and more than double that of
Asian-American men.
Treatments available for Testicular Cancer
Testicular cancer is a rare form of cancer, and
is highly treatable and usually curable.
Surgery is the most common treatment for
testicular cancer. Surgical treatment involves
removing one or both testicles through an
incision in the groin. In some cases, the doctor
also may remove some of the lymph nodes in
the abdomen. Radiation, which uses high-
energy rays to attack cancer,
and chemotherapy, which uses drugs to kill
cancer, are other treatment options.
Removing the one testicle should not lead to
problems with having sexor children. The
remaining testicle will continue making sperm
and the male hormone testosterone. To re-
473
establish a normal appearance, a man may be
able to have a testicular prosthesis surgically
implanted in the scrotum which looks and
feels like a normal testicle.
Causes of Epididymitis
Epididymitis often is caused by infection or
by sexually transmitted diseases,
including chlamydia and gonorrhea. In men
over 40 years of age, the most common cause
is due to bacteria in the urinary tract.
Symptoms of Epididymitis
Symptoms of epididymitis include scrotal pain
and swelling. Discharge from the
penis, painful urination, and painful
intercourse or ejaculation may also be present.
In severe cases, the infection can spread to the
adjacent testicle, causing fever and abs
cess (collection of pus).
Epididymitis Treatment
Treatment for epididymitis
includes antibiotics (drugs that kill the
bacteria causing the infection), bed rest, ice to
reduce swelling, the use of a scrotal supporter,
and anti-inflammatory medicines
(NSAIDS such as ibuprofen). Partners will
need to be treated if the epididymitis is due to
a sexually transmitted infection to prevent re-
infection.
If left untreated, epididymitis can produce scar
tissue, which can block the sperm from
leaving the testicle. This can cause problems
with fertility, especially if both testicles are
involved or if the man has recurring
infections.
Hypogonadism
One function of the testes is to secrete the
hormone testosterone. This hormone plays an
important role in the development and
maintenance of many male physical
characteristics. These include muscle mass
and strength, fat distribution, bone mass,
sperm production, and sex drive.
Hypogonadism in men is a condition that
occurs when the testicles (also called gonads)
do not produce enough testosterone. Primary
hypogonadism occurs when there is a problem
or abnormality in the testicles themselves.
Secondary hypogonadism occurs when there
is a problem with the pituitary gland in
the brain, which sends chemical messages to
the testicles to produce testosterone.
Hypogonadism can occur during fetal
development, at puberty, or in adult men.
Associated problems with Hypogonadism
When it occurs in adult men, hypogonadism
may cause the following problems:
• Erectile dysfunction (the inability to
achieve or maintain an erection)
• Infertility
• Decreased sex drive
• Decrease in beard and growth of body hair
• Decrease in size or firmness of the testicles
• Decrease in muscle mass and increase in
body fat
• Lose of bone mass (osteoporosis)
• Enlarged male breast tissue
• Mental and emotional symptoms similar to
those of menopause in women (hot flashes,
mood swings,
irritability, depression, fatigue)
Causes of Hypogonadism
There are various causes of hypogonadism,
including:
• Klinefelter's syndrome. This syndrome
involves the presence of abnormal sex
chromosomes. A male normally has one X
chromosome and one Y chromosome. The
Y chromosome contains the genetic
material with the codes that determine the
male gender, and related masculine
characteristics and development. Males
with Klinefelter's syndrome have an extra
X chromosome, which causes abnormal
development of the testicles.
• Undescended testicles. (see above)
• Hemochromatosis. This condition is
marked by too much iron in the blood, and
can cause the testicles or the pituitary gland
to malfunction.
• Testicular trauma. Damage to the testicles
can affect the production of testosterone.
474
• Cancer treatment. Chemotherapy or
radiation therapy, common treatments for
cancer, can interfere with testosterone and
sperm production by the testicles.
• Normal aging. Older men generally have
lower levels of testosterone, although the
decline of the hormone varies greatly
among men.
• Pituitary disorders. Problems affecting
the pituitary gland, (a small organ in the
middle of the brain) including a head
injury or tumor, can interfere with the
gland's ability to send hormonal signals to
the testicles to produce testosterone.
• Medications. Certain drugs can affect
testosterone production. These include
some commonly used psychiatric drugs.
Hypogonadism Treatment
Treatment for hypogonadism depends on the
cause. Male hormone replacement
(testosterone replacement therapy or TRT)
often is used to treat disorders of the testicles.
If the problem is related to the pituitary gland,
pituitary hormones may help increase
testosterone levels and sperm production.
References
Andrews CN, Piterman L. Sex and the older
man: GP perceptions and management. Aust
Fam Physician 2007;36:867–9. Search
PubMed
Cancer Council Australia. Position statement
– testicular cancer. February 2013.http://wiki.
cancer.org.au/prevention/Position_statement_
-_Testicular_cancer.
Corona G, Petrone L, Manucci E, et al. The
impotent couple: low desire. Int J Androl
2005;28(S2):46–52. Search PubMed
Hatzimouratidis K, Amar E, Eardley I, et al.
Guidelines on male sexual dysfunction:
erectile dysfunction and premature
ejaculation. Eur Urol 2010;57:804–14.
Search PubMed
Holden CA, McLachlan RI, Pitts M, et al.
Men in Australia Telephone Survey
(MATeS): a national survey of reproductive
health and concerns of middle-aged and older
 Australian men. Lancet 2005;366:218–24.
Search PubMed
Moul JW. Timely diagnosis of testicular
cancer. Urol Clin North Am 2007;34:109–17.
Search PubMed
Murtagh J. General practice. 5th edn. North
Ryde: McGraw-Hill Australia, 2011; p. 1089.
Search PubMed
Palmer NR, Stuckey BGA. Premature
ejaculation: a clinical update. Med J Aust
2008;188;662–6. Search PubMed
Pinnock CB, Stapleton AMF, Marshall VR.
Erectile dysfunction in the community: a
prevalence study. Med J Aust 1999;171:353–
7. Search PubMed
Porst H, Montorsi F, Rosen RC, Gaynor L,
Grupe S, Alexander J. The Premature
Ejaculation Prevalence and Attitudes (PEPA)
survey: prevalence, comorbidities, and
professional help seeking. Eur Urol
2007;51:816–24. Search PubMed

Note: Most of the Matters are drived from Internet

and Research Papers

475
Chapter-24

477
478
Women Health Related Problems
A woman may be a wife, a mother, a sister Women health and breast cancer
or a daughter. Whatever is her role, she is Prevention has always been the best way to
special because of the care she gives to the avoid certain problems and complications
people whose lives she touches. Because of and when it comes to breast cancer, it
the special role that women play in actually seems one of the best alternatives.
everyone's lives, therefore, Women's Health According to a survey of breast cancer
need special care at all age stages. This is survivors, women affected by breast cancer
especially important when a woman finds who have chosen to remove their healthy
herself in the hospital. breast along with the diseased one seem to
2004 has been a year to celebrate and honor have a quality of life equal to patients who
the work of the people who make the didn't have a preventive mastectomy.
Women’s Health Centre a unique and
supportive environment for Women. The
highly-skilled nurses provide exceptional
care using the latest technology and medical
advancements for the comfort of patients.
The Women’s Health Centre provides a
wide range of care to the Women including
General Breast and Oncology Breast clinics,
General Gynaecology and Oncology
Gynaecology clinics, Menopause clinics and
Urodynamics clinics. Assessment tools and
clinical indicators provide a means for
continual and ongoing review and
improvement of services and information.
There is a special link created with the
General practitioners of women who are
kept informed of services provided and
"A large majority of women were satisfied
ongoing treatment to their referred patients.
with their decisions to have the preventive
The Women’s Health Centre Nursing staff is
mastectomy in addition to their primary
a highly dedicated group who provide
breast cancer treatment", said Ann Geiger,
sensitive and caring support to the needs of
Ph.D., lead author, from Wake Forest
the clients as well as providing health
University School of Medicine and women
promotion services to the broader
who had the preventive mastectomy were
community and specific presentations to
equally content with their quality of life as
interest groups. They also provide patient
women who didn't”.
support throughout the year by way of
The study was conducted by six health care
involvement in fund raiser events.
systems that participate in the National
Cancer Institute-funded Cancer Research

479
Network, whose goal is to conduct research
that transforms cancer care and prevention.
Geiger was at Kaiser Permanente Southern
California, one of the six study sites, when
the research was conducted.
Women Health and Depression
As anyone who has experienced it knows,
depression is far more than simply feeling
sad. It is more like an overwhelming feeling
of despair and unworthiness that essentially
takes over body, mind, and spirit. More than
17 million Americans experience some type
of depression each year. Women are
disproportionately affected, suffering from
depression at roughly twice the rate of men.
A diagnosis of major depression is made
when a woman experienced at least five of
the following symptoms daily for 2 weeks:
• Feeling of sadness or periods of
crying
• Feelings of guilt, self-blame, or
worthlessness
480
• Changes in sleep patterns
(usually, waking up earlier than
intended, still tired)
• Changes in appetite and weight
(usually weight loss)
• Decreased interest in sex
• Decreased ability to enjoy things
once already enjoyed
• Decreased ability to concentrate
• Decreased energy
• Feelings of hopelessness and
helplessness
• Thoughts of death and even
suicide
People with major depression are usually not
able to function normally at work, at home,
or in personal relationships. But not all
depression is this severe. Some people suffer
from a milder, and more chronic form of
depression called dysthmia, which causes
these same signs and symptoms, but fewer
of them. People with mild depression may
appear to function normally, but actually are
struggling more than usual to maintain the
status quo.
According to a report, 80 to 90 percent of all
cases of depression can be treated
effectively. Since depression is caused by a
change in brain chemistry, modern treatment
makes use of specific medications that help
return this chemistry to normal. It
sometimes takes several months to find the
right medication and dosage for you, but
doctors today have an ever-increasing
assortment of drugs that can maximize
benefits and minimize side effects.
Treatment also involves counseling, or
psychotherapy, which helps patients
overcome the negative patterns that have
intruded on normal moods, thoughts, and
behaviors. Unfortunately, it is estimated that
only 3 in 10 depressed people get any form
of treatment. Without treatment, the
frequency and severity of symptoms tend to
increase over the years.
Depression after childbirth
Postpartum depression can be caused by
hormonal changes that can affect brain
chemicals after giving birth. About 10
percent of new mothers experience some
degree of postpartum depression. Treatment
can include medication and psychotherapy.
Symptoms include:
Sluggishness, fatigue, exhaustion
Feelings of hopelessness or depression
Disturbances with appetite or sleep
Confusion
Uncontrollable crying
Lack of interest in the baby
Fear of harming the baby or oneself
Mood swings
Postpartum psychosis is more severe and
less common, occurring in one to two of
every 1,000 new mothers. Of those, an
estimated 5 percent commit suicide, and 4
percent kill their babies. Risk factors include
a family history of psychosis, bipolar
disorder or schizophrenia. Postpartum
depression can evolve into psychosis after a
dramatic or traumatic event.
Symptoms, which usually arise within three
days of delivery, can include:
Hallucinations
Delusions, for example, about a need to kill
the baby, that the baby is possessed or a
denial of the birth
Delirium, mania and frantic energy
Extreme confusion, memory loss or
incoherence
481
Paranoia, irrational statements,
preoccupation with trivial things
Refusal to eat
A woman who is found to have postpartum
psychosis should be hospitalized until she is
in stable condition, according to the
National Mental Health Association.
Doctors may prescribe a mood stabilizer,
antipsychotic drug or antidepressant to treat
the psychosis.
Women's Screening Schedule
• Cervical Cancer: Pap smears at least
every 3 years if the person is sexually
active or over age 21.
• Sexually Transmitted Infections
(STIs): if patient is 25 or younger and
sexually active. Talk to doctor about risks
after 25
• Breast Cancer: mammograms every
year, starting at age 40
• Cholesterol: regular screening from age
45; if patient smoke, has diabetes, or a
family history of heart disease, starting at
age 201
• Colorectal cancer: starting at age 50.
The doctor can help in deciding which
test is right for Colorectal cancer. How
often need to be tested it depends on
which test is recommended.
• Blood pressure: at least every 2 years2
• Diabetes: if there is high blood pressure
or high cholesterol
• Depression: if person felt "down," sad, or
hopeless or have been without interest or
pleasure for 2 straight weeks.
• Given that some health conditions
disproportionately affect racial and ethnic
minority groups (i.e., hypertension among
African Americans), it might be useful to
consider screening certain groups more
frequently for some conditions.
- Cholesterol levels of 200-239 mg/dL is
borderline high and 240 mg/dL or more
is high. Be sure to pay attention to types
of cholesterol - aim for less than 160
mg/dL LDL ("bad" cholesterol) and
more than 40 mg/dL HDL ("good"
cholesterol).
- A healthy blood pressure level is below
120/80 mm Hg. High blood pressure is
defined as 140/90 mm Hg. A person
may be at risk for high blood pressure if
blood pressure is 120-139/80-89 mm
Hg.
• Osteoporosis: Bone Density tests starting
at age 65
Osteoporosis is the thinning of the solid
structure of bone, the protein matrix with its
482
deposited calcium, resulting in bone that is
weak and at risk for fracture or collapse. To
understand how osteoporosis occurs, needs
to understand bone metabolism. Bone is not
just sitting there in the body like an inert
piece of rock. Bone is living tissue, in which
there is a dynamic process of build up and
breakdown (resorption) constantly going
on. Build-up requires the building blocks,
calcium and protein. The female hormone
estrogen stimulates build up and discourages
breakdown thereby maintaining bone
strength. When estrogen drops for any
reason, extreme weight loss, removal of the
ovaries, or menopause, bone loss will occur.
Women of any age, but especially young
women, mothers and women around the
time of menopause, "perimenopause," need
to take steps to prevent osteoporosis.
How to Prevent Osteoporosis
There is really no reason why contemporary
young women should suffer the deformities
and fractures of osteoporosis when they
reach old age. Spine, hip and wrist fractures
are not the inevitable consequences of aging.
Proper diet, exercise and a number of new
medications can be used for both prevention
and treatment of primary osteoporosis.
"Primary" osteoporosis refers to those cases
where there are no other detectable causes,
i.e., medications (steroids, anticonvulsants),
endocrine conditions (hyperthyroidism or
hyperparathyroidism) or bone disease,
causing the bone loss.
In every woman, active bone formation
occurs up to the age of 30, when she
achieves peak bone mass. Thereafter, a
gradual loss of bone begins until
menopause, with an acceleration of bone
loss for a period of about five years.
Following that, there is again a gradual
steady decrease. A woman who achieves a
high peak bone density is much less likely to
fall below the bone density level at which
fracture risk becomes high.
Young women must adopt eating and
exercise habits that contribute to bone
formation. One half to one hour of weight
bearing exercise three to six days per week,
combined with adequate calcium intake,
1000-1500 mg/day, and vitamin D, 400-800
IU/day, are the most important building
blocks of bone.
Two trends in modern life are great hazards
to bone formation: phosphoric acid-
containing diet soda drinks and the
sedentary lifestyle. Diet sodas have a high
acid content that the body must neutralize
with alkaline substances, notably calcium
carbonate, which is leached from the bones.
Frequently, girls and young women have
made matters worse by trading in their milk
for diet sodas and have thus deprived
themselves of the single most important
source of calcium. All women need milk
products in their diets but it is especially
critical for women who drink diet sodas. An
8 oz. glass of milk, 8 oz. of yogurt, a 1.5 oz.
serving of cheese all provide 300 or more
milligrams of calcium, providing a big boost
to the daily requirement.
483
Whether the sedentary lifestyle happens in
front of a TV screen or a computer terminal,
it is still sedentary. But it is also true that too
much exercise can backfire and interrupt
bone mass build-up. Exercises that are
associated with extreme thinness -- distance
running, gymnastics and ballet dancing --
can lead to abnormally low estrogen levels
with cessation of menstrual periods. This
pseudo "post-menopausal state" can, by
itself, produce further bone loss. The eating
disorder, anorexia nervosa, contributes to
bone loss by the same mechanism.
Tests to Detect Osteoporosis Regular X-
rays and DEXA (DXA)
If there is an X-ray that reveals osteoporosis,
that means woman already had a 30-50%
decrease in bone mass from the normal
level. Plain X-rays are certainly not
appropriate for screening for osteoporosis,
since they reveal late-stage disease. The
current best test is the "DEXA," Dual
Energy X-ray Absorptiometry. This
technique is becoming widely available. The
standard test provides a density
measurement of the lower spine and the
thigh bone (femur).
These measurements are compared with a
standardized measurement of a healthy 35-
year-old woman, the T-score, and with the
average for same age group, the Z-score. A
score may be expressed as a percentage of
those numbers. The scores can also be
plotted on a graph (below) of bone mass
densities (BMD) at various ages. The reports
are impossible to read (even for doctors) but
with a little concentration it can be sort out.
On report, if there will be a little star on the
graph, indicating the bone density. One
report of hip and one of spine is required for
exact analysis.
NOTE: The dotted line in the graph is the fracture
threshold. Note how more and more women
fall below that line as they age. The light
green area is two standard deviations (a
measure of variation) above average and the
dark green area, which is the one that
concerns us, is two standard deviations below
the average. As you can see, as women age,
even average and above average BMDs can
fall below the fracture line.
In DEXA report, BMD will be noted on this
diagram by a star-like symbol. The bone
density will be compared with the average
women in two ways. The Z-score compares
with the average women in same age group.
The T-score compares with the average
young adult woman. Attention to the T-
score is very important.
Actually that is just the point. This graph
represents what is happening to women
now. Health care wants every women to
achieve a high peak bone mass in her 20s
and 30s and maintain it for the rest of her
life. Then women would not have all these
fractures and spinal deformities and
disabilities and deaths attributable to
osteoporosis.
484
The World Health Organization has
developed definitions for degrees of bone
loss. Normal is -1 standard deviation (SD)
and above. Osteopenia (low bone mass) is -
1.0 to -2.5 SD's. Osteoporosis is -2.5 SD's
and below. An individual with -2.5 SD or
below plus a history of weak bone related
fracture is considered to have severe
osteoporosis. The doctor can tell her where
she is just by looking at the graph on her
report.
DEXAs cost in the $100-300 range and may
or may not be covered by insurance.
Medicare is now covering bone density
tests, so it is likely that the other insurers
will follow. There are other tests for bone
density, a type of CT (CAT) scan and
ultrasound. If you have a screening test on
the wrist or on the heel and it comes back
low, my advice is to get a DEXA because,
of all the tests, the DEXA is most accurate.
If you need follow up tests, have them done
by the same technique (DEXA or CT) and
the same type of machine (DEXA by
Hologic or Lunar). Different tests and
different types of machines do not give
comparable results. The same principle is
true for the next type of test.
Bone Resorption Tests
Bone resorption tests, either in urine or
blood, can also be useful. They measure
how much breakdown of bone is occurring.
The level can vary, depending on the time of
day the test is taken. These tests are useful in
monitoring therapy. A test may show high
levels of breakdown that decrease after a
particular medication is taken. Because of
the variation in these tests, it is very
important to have the same type of test done
by the same laboratory, with the sample
taken at the same time of day, in order for
serial tests to be comparable.
When to Get Follow up Tests
Follow up tests are usually done to find out
if lifestyle/diet changes or medications are
stabilizing or improving bone density.
DEXA's and CT's really cannot be done any
more frequently than once a year because
significant changes do not register in a
shorter period of time. The bone resorption
tests can be done more frequently, say, after
three months of a therapy, to see if bone
breakdown markers are decreasing.
Who Should Get a Bone Density Test?
Anyone with signs or symptoms suggestive
of osteoporosis should be tested. Loss of
height (indicating spine fractures) or a hip
fracture would be examples. Perimenopausal
women with risk factors should be tested.
Now experts recommend that all women
over age 65 be tested.
Most perimenopausal women have no idea
what bone density is or that they are at risk
for osteoporosis. Specialist recommends a
bone density measurement at menopause,
particularly if certain risk factors are
present:
1. Family history of osteoporosis
2. Caucasian or Asian race
3. Sedentary lifestyle
4. Cigarette smoking
5. Moderate to heavy alcohol intake
6. Early menopause or hysterectomy
7. Poor diet: anorexia, lactose intolerant
These risk factors are additive. The more
patient has, the more likely that bone density
is low.
485
Other Causes of Osteoporosis
Sometimes, a specific medical condition or a
medication can be causing osteoporosis. If
patients are found to have low bone density,
they need to find out if other treatable
factors are contributing. Some endocrine
conditions, like hyperthyroidism or
hyperpara-thyroidism, can cause
osteoporosis. Severe malnutrition can cause
bone loss (called osteomalacia). Some long-
term medications, corticosteroids
(prednisone), anticonvulsants (taken for
seizure disorders), certain diuretics and too
much thyroid replacement hormone, can
produce osteoporosis. If a patient must take
these medications, there are other medicines
that can successfully counteract the bone
loss.
How to Treat Osteoporosis
The truth is that a combination of lifestyle
improvements and medication produce the
most successful treatment. Currently, there
are three key treatment regimens:
1. Exercise: weight bearing, weight lifting
and balance.
2. Nutrition: calcium, vitamin D and
protein.
3. Medications: ERT (estrogen replacement
therapy)/HRT (hormone replacement
therapy), Selective Estrogen Receptor
therapy), and calcium treatment.
First, the patient should correct the risk
factors that can be controlled. Decrease or
quit drinking alcohol/Cocacola/Pepsi etc.,
stop smoking, get moving and eat right.
Exercise
Bones respond to stress and weight-bearing
exercise, like walking or jogging, and
weight training strengthens bones. Balance
exercise, like Tai Chi, can also lessen the
risk of falls.
References
Dawson-Hughes B et al. A controlled
calcium and vitamin supplementation trial
in men and women age 65 and older. N
Engl J Med 1997; 337:670-676.
Delmas PD et al. Effects of raloxifene on
bone mineral density, serum cholesterol
concentrations, and uterine endometrium
in postmenopausal women. N Engl J Med
1997; 337: 1641-1647.
Fisher B et al. Tamoxifen for prevention of
breast cancer: report of the National
Surgical Adjuvant Breast and Bowel
Project P-1 Study. J Natl Cancer Inst.
1998; 90:1371-88.
Greenspan, SL. Clinical Crossroads. A 73
year old woman with osteoporosis. JAMA
1999; 281: 1531-1540.
Powles TJ et al. The effect of tamoxifen on
bone mineral density measured by dual-
energy X-ray absorptiometry in healthy
premenopausal and postmenopausal
women. J Clin Oncol 1996; 14:78-84.
Saag KG et al. Alendronate for the
prevention and treatment of
glucocorticoid-induced osteoporosis. N
Engl J Med 1998; 339:292-299.

Note: Most of the Matters are drived from Internet

and Research Papers

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Chapter-25

487
488
SOME HERBS AND HERBAL FORMULATIONS
WARNING: The editors do not advocate self-diagnosis or self-medication: they urge anyone with continuing
symptoms, however minor, to seek medical advice. The readers should be aware that any plant substance, whether
used as food or medicine, externally or internally, may cause an allergic reaction in some people.
HERBAL POWDER
FOR COUGH & COLD
Composition: Adhatoda vasica (leaves) 20%,
Ocimum sanctum (leaves) 10%, Piper longum
(fruits) 10%, Phyllanthus emblica (fruits)
25%, Zinziber officinale (roots) 10%,
Glycyrrhiza glabra (roots) 15%, Solanum
xanthocarpum (whole plant) 10%.
Dosage
About 3 gms powder should be given to the
patient twice daily (morning and at night
before going to bed) with lukewarm water or
mixed with honey.
FOR CYSTS
Composition: Azadirachta indica (bark) 20%,
Holarrhena antidysenterica (bark) 10%,
Terminalia bellirica (fruits) 10%, Withania
somnifera (roots) 20%, Tinospora cordifolia
(stems) 20%, Terminalia chebula (fruits) 20%
Dosage
About 3 to 4 gms (one teaspoonful) powder is
given to the patient, twice a day (morning and
evening) with water.
FOR FISTULA
Composition: Glycyrrhiza glabra (roots) 20%,
Tinospora cordifolia (stems) 15%,
Azadirachta indica (leaves) 15%, Terminalia
bellirica (fruits) 15%,
Withania somnifera (roots) 15%, Terminalia
chebula (fruits) 20%
Dosage
About 3 to 4 gms. powder should be given to
the patient, twice daily with water.
FOR SLEEPLESSNESS
Composition: Withania somnifera (roots)
20%, Centella asiatica (leaves) 30%,
Piper longum (roots) 20%, Glycyrrhiza glabra
(roots) 10%, Terminalia bellirica (fruits) 10%.
Dosage
About 3 gms powder is given to the patient, at
night before going to bed, with milk or water.
489
FOR ASTHMA, BRONCHITIS
Composition: Solanum xanthocarpum (whole
plant) 25%, Piper longum (fruits)
10%,Adhatoda vasica (leaves) 25%, Zinziber
officinale (roots) 10%, Curcuma zedoaria
(roots) 10%, Ocimum sanctum (leaves) 10%,
Phyllanthus emblica (fruits) 10%.
Dosage
About 4 gms (one teaspoonful) powder should
be given to the patient, twice a day (morning
and at bedtime) with water or honey.
FOR HYPER ACIDITY & PEPTIC ULCER
Composition: Tinospora cordifolia (stems)
20%, Glycyrrhiza glabra (roots) 40%,
Zinziber officinale ((roots) 5%, Terminalia
chebula (fruits) 10%, Phyllanthus emblica
(fruits) 10%, Achyranthes aspera (leaves) 5%,
Cyperus rotundus (roots) 10%.
Dosage
About 4 gms. powder should be given to the
patient, twice a day after meals with water.
FOR SKIN DISEASES & ALLERGY
Composition: Cyperus rotundus (roots) 10%,
Tinospora cordifolia (stems) 20%,
Azadirachta indica (bark) 20%, Terminalia
chebula (fruits) 10%,
Curcuma longa (roots) 10%, Terminalia
bellirica (fruits) 10%, Phyllanthus emblica
(fruits) 10%, Centella asiatica (leaves) 10%.
Dosage
About 3 gms. powder should be given to the
patient, twice a day before meals with water.
FOR INDIGESTION & LACK OF
APPETITE
Composition: Zinziber officinale (roots) 10%,
Piper longum (fruits) 10%, Phyllanthus
emblica (fruits) 30%, Terminalia chebula
(fruits) 15%, Tinospora cordifolia (stems)
15%, Cassia angustifolia (leaves) 10%,
Mentha piperata (leaves) 10%.
Dosage
About 4 gms. powder should be given to the
patient, two times a day after meals with
water.
FOR INTESTINAL WORMS
Composition: Holarrhena antidysenterica
(bark) 10%, Mentha piperata (leaves) 10%,
Tinospora cordifolia (stems) 20%, Butea
monosperma (seeds) 20%, Azadirachta indica
(leaves) 10%, Phyllanthus emblica (fruits)
20%, Tribulus terrestris (fruits) 10%.
Dosage
About 3 gms powder should be given to the
patient, twice daily (morning and at bedtime)
with water.
FOR ANEMIA & WICKEDNESS
Composition: Asparagus racemosus (roots)
20%, Withania somnifera (roots) 20%,
Phyllanthus emblica (fruits) 15%, Phyllanthus
niruri (leaves) 10%, Tephrosia purpurea
(leaves) 10%, Plumbago zeylanica (roots) 5%,
Glycyrrhiza glabra (roots) 15%, Piper longum
(fruits) 5%.
Dosage
About 4 gms powder should be given to the
patient, twice daily with water.
FOR GENERAL HEALTH TONIC
Composition: Withania somnifera (roots)
20%, Asparagus racemosus (roots) 10%,
Pueraria tuberosa (roots) 10%, Glycyrrhiza
glabra (roots) 10%, Tribulus terrestris (fruits)
10%, Phyllanthus emblica (fruits) 15%,
Terminalia arjuna (bark) 15%, Centella
asiatica (leaves) 10%.
Dosage
About 4 gms (one teaspoonful) powder is
given to the patient, twice daily (morning and
evening) with milk or water.
FOR DIARRHEA & DYSENTERY
Composition: Holarrhena antidysenterica
(bark) 25%, Aegle marmelos (fruits) 25%,
Zinziber officinale (roots) 10%, Terminalia
chebula (fruits) 10%, Cyperusus rotundus
(roots) 10%, Syzygium cumini (seeds) 10%,
Phyllanthus emblica (fruits) 10%.
Dosage
490
About 3 gms powder should be given to the
patient, two/three times a day, with curd or
water or honey.
FOR CHRONIC FEVER
Composition: Tinospora cordifolia (stems)
15%, Ocimum sanctum (leaves) 15%,
Adhatoda vasica (leaves) 15%, Azadirachta
indica (leaves) 15%, Holarrhena
antidysenterica (bark) 10%, Piper longum
(fruits) 10%, Zinziber officinale (roots) 10%,
Terminalia bellirica (fruits) 10%.
Dosage
About 4 gms powder should be given to the
patient, twice daily before meals with water or
honey.
FOR BRAIN TONIC
Composition: Centella asiatica (leaves) 25%,
Piper longum (fruits) 10%, Zinziber officinale
(roots) 10%, Withania somnifera (roots) 10%,
Achyranthes aspera (whole plant) 25%,
Glycyrrhiza glabra (roots) 10%, Terminalia
chebula (fruits) 10%.
Dosage
About 3 gms. powder is given to the patient,
twice daily with milk or water.
FOR GASTRITIS
Composition: Zinziber officinale (roots) 10%,
Piper longum (fruits) 10%, Mentha piperata
(leaves) 10%, Terminalia chebula (fruits)
15%, Phyllanthus emblica (fruits) 15%,
Terminalia bellirica (fruits) 15%, Plumbago
zeylanica (roots) 10%, Tinospora cordifolia
(stems) 15%.
Dosage
About 4 gms. (one teaspoonful) powder
should be given to the patient twice daily, half
an hour before meals with water.
FOR CHRONIC CONSTIPATION
Composition: Holarrhena antidysenterica
(bark) 10%, Plantago ovata (husk) 20%,
Terminalia bellirica (fruits) 10%, Phyllanthus
emblica (fruits) 15%, Terminalia chebula
(fruits) 15%, Cassia angustifolia (leaves)
20%, Glycyrrhiza glabra (roots) 10%.
Dosage
About 4 gms powder should be given to the
patient, at night before going to bed, with
water.
FOR STONES IN URINARY TRACT
Composition: Tribulus terrestris (fruits) 25%,
Zinziber officinale (roots) 10%, Solanum
xanthocarpum (whole plant) 10%, Crataeva
nurvala (bark) 25%, Tinospora cordifolia
(stems) 10%, Asparagus racemosus (roots)
10%, Tephrosia purpurea (leaves) 10%.
Dosage
About 4 gms powder is given to the patient,
twice daily with water.
FOR THROAT DISEASES
Composition: Glycyrrhiza glabra (roots) 30%,
Terminalia chebula (fruits) 10%, Solanum
xanthocarpum (whole plant) 20%, Piper
longum (fruits) 10%, Sida cordifolia (roots)
10%, Phyllanthus emblica (fruits) 10%,
Terminalia bellirica (fruits) 10%.
Dosage
About 4 gms powder should be given to the
patient twice daily, morning and at bedtime
with water or honey.
FOR DENTAL DISEASES
Composition: Azadirachta indica (leaves)
15%, Acacia arabia (bark) 15%, Acacia
catechu (bark) 15%, Achyranthes aspera
(leaves) 10%, Ficus benghalensis (bark) 15%,
Quercus infectoria (fruits) 15%, Symplocos
racemosa (bark) 15%.
Dosage
The powder is applied to the gums and teeth,
two/three times a day. Additionally a gargle of
the decoction (about 3 to 4 gms. powder
mixed in 100 to 150 mls. water) is
recommended. The decoction should be
retained in the mouth for some time.
FOR ACTIVATION OF BLOOD
CIRCULATION
Composition: Zinziber officinale (roots) 20%,
Piper longum (roots) 10%, Withania
somnifera (roots) 10%, Phyllanthus emblica
(fruits) 10%, Terminalia chebula (fruits) 10%,
Curcuma longa (roots) 10%,
491
Terminalia bellirica (fruits) 10%, Ocimum
sanctum (leaves) 10%, Tephrosia purpurea
(leaves) 10%.
Dosage
About 4 gms. powder should be given to the
patient, twice daily with water or honey.
FOR FRACTURES & DISLOCATION OF
BONES
Composition: Asparagus racemosus (roots)
15%, Withania somnifera (roots) 15%, Acacia
arabica (bark) 20%, Terminalia arjuna (bark)
20%, Terminalia chebula (fruits) 10%,
Phyllanthus emblica (fruits) 10%, Terminalia
bellirica (fruits) 10%.
Dosage
About 3 gms. powder should be given to the
patient, twice a day with water or honey.
FOR STRESS
Composition: Withania somnifera (roots) -
20%, Mangifera indica (bark) - 10%, Zingiber
officinale (roots) - 10%, Ocimum sanctum
(leaves) - 20%, Piper longum (roots) - 10%,
Centella asiatica (leaves) - 15%, Glycyrrhiza
glabra (roots) - 15%.
Dosage
About 3 gms powder to be given to the patient
twice/thrice a day with water or honey or fruit
juice.
ANXIETY REMEDIES
Several herbal remedies have been studied as
a treatment for anxiety, but more research is
needed to understand the risks and benefits.
Here's what we know — and don't know:
Kava: Kava appeared to be a promising
treatment for anxiety, but reports of serious
liver damage — even with short-term use —
caused several European countries to pull it
off the market. The Food and Drug
Administration has issued warnings but not
banned sales in the United States. Avoid using
kava until more rigorous safety studies are
done, especially if you have liver problems or
take medications that affect your liver.
Passionflower: A few small clinical trials
suggest that passionflower might help with
anxiety. In many commercial products,
passionflower is combined with other herbs,
making it difficult to distinguish the unique
qualities of each herb. Passionflower is
generally considered safe when taken as
directed, but some studies found it can cause
drowsiness, dizziness and confusion.
Valerian: In some studies, people who used
valerian reported less anxiety and stress. In
other studies, people reported no benefit.
Valerian is generally considered safe at
recommended doses, but since long-term
safety trials are lacking, don't take it for more
than a few weeks at a time. It can cause some
side effects such as headaches and drowsiness.
Chamomile: Limited data shows that short-
term use of chamomile is generally considered
safe and can be effective in reducing
symptoms of anxiety. Use of chamomile can
cause allergic reactions in some people who
are sensitive to the family of plants that
includes chamomile. Other members of this
family are ragweed, marigolds, daisies and
chrysanthemums.
Lavender: Some evidence suggests that oral
lavender or aromatherapy with lavender can
reduce anxiety; however, evidence is
preliminary and limited. Oral lavender can
cause constipation and headache. It also can
increase appetite and the sedative effect of
other medications and supplements and can
cause low blood pressure.
Lemon balm: Preliminary research shows
lemon balm can reduce some symptoms of
anxiety, such as nervousness and excitability.
Lemon balm is generally well-tolerated and
considered safe for short-term use, but can
cause nausea and abdominal pain.
HERBAL TEAS (DECOCTIONS)
Mint tea is the classic herbal tea. Mint is an
ingredient in many different commercial tea
492
blends and is much-loved for its refreshing
fragrance.
Caution
If you suffer from acid reflux, mint tea may
worsen your symptoms. Mint has
antispasmodic properties
Mint tea can be used to
- Reduce congestion in a cold or flu sufferer
- Reduce pain and bloating from gas
- Reduce cramping from diarrhea
- Act as a mild expectorant for a chest cold
or bronchitis
- Induce sweating, the body’s natural cooling
mechanism. This is a natural way to reduce
a fever
- Relieve nausea without vomiting
Cough, Cold, and Nausea Treatments
Ginger root is an ingredient in many natural
cough, cold, and nausea treatments. Instead of
giving your child gingerale when they are
suffering from an upset stomach (and all of
the HFCS and artificial flavors that come in it)
brew up a nice cup of ginger tea sweetened
with honey for a real dose of soothing ginger!
Caution
It’s not recommended to exceed 4 grams of
ginger per day – components in the herb can
cause irritation of the mouth, heartburn and
diarrhea if taken in excess.
Ginger tea can be used to
- Reduce nausea
- Prevent or treat motion sickness
- Warm the body of someone suffering from
chills
- Induce sweating to break a fever
- Soothe a sore throat
Chamomile tea should be steeped a little
longer than other herbal teas in order to get all
of the medicinal benefits. This soothing,
slightly apple-flavored tea has mild sedative
properties. The petals of the tiny flowers are
where the medicinal values lie.
Caution
Chamomile tea should be avoided by people
who take blood thinners. As well, those who
suffer from ragweed allergies may also have
 an allergic reaction to chamomile, as the two • act as a mild diuretic to reduce fluid
plants are related. retention
Chamomile tea can be used to: Echinacea Tea
- Relieve anxiety This lovely flowering plant is probably the
- Induce sleep pinnacle of herbal preventatives. Echinacea is
- Soothe mild nausea and indigestion not only anti-bacterial – but it stimulates the
- Relieve a cough from throat irritation body’s immune system to fight off bacterial
Cinnamon doesn’t just smell like a holiday in and viral attacks. The medicinal properties are
a cup, it is anti-bacterial, antiviral, and in the leaves and the purple flowers.
antifungal, making it an excellent all-around Echinacea tea can help to
remedy for whatever ails you. Cinnamon is a • enhance the immune system
wonderful source of immune-boosting • relieve pain
antioxidants. It’s a primary ingredient in • reduce inflammation
Chai. • provide antioxidant effects
Winter beverage: • shorten illness time for sufferers of the
• 1-1/2 tsp of cinnamon powder or a common cold
cinnamon stick Rosehips Tea
• 1 tea bag Rosehips make a tart, tangy pink-colored tea.
• honey to taste They are the seed-filled pod at the base of a
• Milk to taste rose blossom, giving you a practical reason to
Stir cinnamon powder well into boiling water have more rose bushes in your garden. It
and steep for 8 minutes. Add a tea bag and mixes well and enhan ces the flavor of any
steep for 2 more minutes. Stir in honey and berry or fruit-flavored tea.
warm milk. Rosehip tea can help to
Cinnamon tea can be used to • provide a nutritional supplement of Vitamin
• - Increase blood flow and improve C
circulation • improve adrenal function
• - Reduce nausea • boost the immune system
• - Ease stomach discomfort, bloating, gas • provide minerals such as calcium, iron,
and indigestion silicon, selenium, natural sodium,
- Warm the body of someone suffering from magnesium, manganese, potassium,
chills phosphorus and zinc
- Soothe a sore throat • increase energy
- Reduce cold symptoms • heal tissues and cells
Lemon grass is another herb that is loaded Blackberry leaf Tea
with healing properties. The spiky, easy-to- Dried blackberry leaves give a luscious fruity
grow plant has antibacterial, anti- flavor when steeped in boiling water. Not
inflammatory, anti-parasitic, and antifungal only are they the basis of many delicious teas,
properties, making it helpful in treating a they are loaded with a beneficial component
plethora of ailments. called tannins.
Lemongrass tea can help to Caution
• aid in digestion Excess consumption of blackberry leaves (or
• calm nervous disorders and anxiety anything containing tannins) can cause liver
• aid in the treatment of high blood pressure damage.
if a daily cup is enjoyed Blackberry leaf tea can help to
• dilate blood vessels and improve circulation • provide vitamin C

493
• treat diarrhea
• reduce pain and inflammation from sore
throats
• provide an antibacterial effect against H
pylori, the bacteria that causes stomach
ulcers
• provide immune-boosting antioxidants
• provide high levels of salicylic acid, which
gives them similar properties to aspirin, such
as pain relief and fever relief
• reduce inflammation of the gums
Cloves Tea
Cloves are a wonderful addition to herbal tea
just for the taste. Not only is the flavor
delicious, but cloves have been used for
centuries to treat a variety of ailments. The
multipurpose little seed packs a mighty punch
with its antiviral, antifungal, antimicrobial,
antioxidant, and anti-inflammatory properties.
Caution
In high amounts cloves can cause liver
damage, blood in the urine, diarrhea, nausea,
and dizziness.
Clove tea can help to
• provide pain relief – it is a powerful
analgesic
• break up mucous and work as an
expectorant
• provide a fragrant decongestant in a
steaming cup of tea
• treat strep throat or tonsillitis – it relieves
pain and provides a wash of antiviral and
antibacterial components
Lemon balm (Bee Balm)
Lemon balm, also known as Bee Balm, was
first recorded to have been used by the ancient
Greeks as an overall tonic for good health. It
is an ingredient in the old world Carmelite
water, a recipe created by Carmelite nuns in
the early 1600s to treat headaches. (The
traditional mixture also
contained coriander, lemon-peel, nutmeg, and
angelica root.)
Lemon balm tea can help to:
• fight off viruses – it was used historically
against shingles, mumps, and cold sores
494
• calm anxiety and nervousness
• aid in sleep
• aid the digestive system by reducing spasms
and quelling heartburn
• reduce nausea
Skin Conditions
Burns
1. Honey: This is especially good for severe
burns. It will stop infection, stimulate skin
regeneration and keep the burned area moist.
Honey is better for burns than nearly all
medical interventions, even for third-degree
burns.
2. Prickly pear cactus pads, filleted: Wear
gloves to hold the pads while using a sharp
knife to gently fillet the exterior skin off the
pads. You will be left with slimy, oval pads
of plant matter. Place the pads directly on
the burn and bandage the wound. For a
sunburn, rub the pads on the affected area.
Cuts and scrapes: Every one of us encounters
life’s sharp edges, often over and over again.
Here’s how I handle the aftereffects.
1. Wound powder: My homemade wound
powder stops the bleeding, dries out the
wound, inhibits infection and stimulates
healing. I generally use a bandage the first
day and then leave the wound open
afterward (unless it’s in a hard-to-protect
area or is gaping).
A good wound powder recipe contains any
berberine plant (such as barberry, goldenseal
or Oregon grape root); comfrey root or leaf;
juniper needles (the older the needles on the
tree or bush, the better — old needles
contain more tannins and will thus stop
bleeding faster than young needles will); and
maybe oregano, rosemary or thyme. The
berberine plant and juniper needles will
disinfect, and the juniper needles will also
stop the bleeding. Comfrey will stimulate
healing, and oregano, rosemary and thyme
are also antibacterials. I usually make the
following recipe and keep it in the freezer to
retain freshness:
 Measure out 1 ounce of the berberine plant
root or bark, a half-ounce of the comfrey
root, 1 ounce of the juniper needles, and a
quarter-ounce of the oregano, rosemary or
thyme leaves (optional). Combine the
ingredients, mix them in a blender or food
processor until well-ground, and then
powder the mixture until fine in a clean
coffee grinder. I often sieve it afterward to
get as flour-like a powder as possible.
Sprinkle it liberally on the wound.
2. Honey: Stop using the wound powder after
a few days and switch to honey. It’s
effective against all known drug-resistant
bacteria and really speeds healing. Just
cover the wound with honey, bandage, and
change the dressing daily.
3. Wound salve: Use a combination of
berberine plants, black walnut hulls,
comfrey root, oregano leaves, rosemary
leaves, Siberian elm bark (Ulmus pumila)
and dried thyme. Add a quarter-cup each of
the roughly ground herbs to a baking dish
and mix. Cover the blend with about a
quarter-inch olive oil, cover the dish, and
bake overnight in an oven on its lowest heat
setting. In the morning, let the mixture cool.
Press out and then reheat the oil. Stir in
finely chopped or grated beeswax — 2
ounces per cup of infused oil — and let
melt. To check hardness, put a drop of salve
on a plate and wait until the salve cools. It
should remain solid but melt after a second
of pressing on it with your finger.
Rashes. Rashes come in many forms, so
treatments will vary. Here are a few.
1.For hives: Apply a tincture of Echinacea
angustifolia root topically, using a cotton
ball to administer it to the affected areas.
Take a half-teaspoon of the tincture
internally each hour or so as well. (Pass
on E. purpurea — I’ve found it useless for
hives.)
2. For poison ivy: Jewelweed salve is best.
Good additives are calendula flowers,
chamomile flowers and Siberian elm bark,
495
all of which will soothe skin. Add any other
herbs you want, but use the aerial parts of a
jewelweed plant for half of the dried herbs
by weight. Then, follow the same process as
above for making the wound salve.
Stings and bites: Use Prickly pear for burns
or Echinacea.
Homemade Soap
Ingredients for Earth Spice Soap
1. 1 lb. unscented clear glycerine melt &
pour base
2. 1 1/2tsp. ground cinnamon, divided
3. 10 drops sweet orange essential oil
4. 5 drops lavender essential oil
5. 1 drop rosemary essential oil
6. 1 tsp. sunflower oil
Instructions:
Combine essential oils and 1/2 tsp. cinnamon
in glass mixing bottle, set aside. Cut melt &
pour soap into 1 inch cubes, place into top of
double boiler. Heat over low-medium heat
until begins to melt. Sprinkle cinnamon evenly
over soap, stirring gently, being careful to
avoid over stirring. Continue melting until
soap is completely melted, remove from heat
and immediately add sunflower oil, and
essential oil blend, stirring gently. Pour into
prepared molds. Let set for 5-6 hours or
overnight, gently remove soap from molds,
cut into slices if necessary, and store in a cool,
dry, dark place for at least 1 week, flipping
bars daily to prevent warping. Should make an
amber colored soap with a darker layer where
the cinnamon settles, like an amber sunset.
Lip Balm
Vitamin E Lip Balm
Ingredients:
1. 1/2 cup and 4 Tbsp. almond oil
2. 8 Tbsp. beeswax
3. 2 tsp. honey
4. 1 tsp. Vitamin E oil
5. 1 tsp. Cocoa Oil
Instructions:
Melt beeswax on low heat. Add honey and
stir. Stir in Vitamin E oil and cocoa butter.
Gently pour into containers and let cool. Add
essential oils too.
The Heart
This is one of the most important organs of the
body and any disease which affects it, is
always be very serious and fatal. There are
two types of diseases that is: Functional
disease: It is usually caused by the excessive
use of alcohol, smoking etc. the best treatment
is to stop the use of alcohol and smoking. One
of the best herb is White Bryony (Bryonia)
and should be taken regularly as an infusion.
Organic diseases
These diseases are pericarditis (the heart
action quicker than normal) and where there is
palpitation with tenderness around the heart
with difficulty in lying on the left side the best
remedies is Hawthorn. Endocarditis is an
inflammation of the lining membrane of the
heart. The best herb is Lily of the Valley.
Fatty degeneration
One of the finest herbals for this condition is
Nux vomica.
Myocarditis
It may be acute or chronic. It is an
inflammation of the heart muscles and in its
final stages results in fibroid degeneration. In
the treatment of this condition Lily of the
Valley, Marigold, Hartstongue, Cactus and
Tansy are having excellent action.
Heart Remedies
The following is a proven and tried herbal
formula which is suitable for all conditions
which affect the heart:
To prepare recipe take Marigold flowers,
Hartstongue, Tansy, Vervain, Valerian root,
100g each.
Place them in two pints of boiling water and
simmer to 1½ pint. Allow it to cool and then
strain, storing in a cool place. Take a glassful
of the decoction (every two to three hours). It
produces wonderful and lasting results for all
heart sufferers.
Disorders of the blood vessels and
circulatory system
496
A loss of elasticity in the walls of the blood
vessels will result in conditions such as blood
pressure, varicose veins, chilblains, and
hemorrhoids.
Treatment: blood pressure
A general mixture would be a combination of
the following:
Lime flowers, Yarrow, Uva-ursi, Elder
flowers, Skullcap dried herbs (100g each).
Place these in two pints of boiling water and
simmer down to 1 ½ pints. Allow to cool and
strain for use, keeping in a cool storage place.
Take a wine glassful of the mixture three or
four times daily according to severity of
conditions. Take of this mixture after meal is
preferable. Always make this decoction fresh
every two or three days. This is an ideal
treatment for high blood pressure.
In cases of low blood pressure use the
following dried herbs:
Nettles, Marshmallow, Kola, (100g each) and
Wood Betony (50g).
Prepare this decoction in exactly the same
way, adding the herbs to two pints of boiling
water and simmering down to 1 ½ pints before
cooling and straining ready for use.
Varicose veins in the legs
Bandages of extract of witch Hazel can be
worn during sleep at night. Do not bind them
too tightly. Just soak the bandage in the
extract and place over the area covering with a
dry bandage loosely fastened.
Place these dried prepared herbs, Bayberry
bark, Wood betony, Wood sage, Yellow dock,
Echinaceae, Boneset (100g each) in three
pints of boiling water and simmer until you
have two pints of mixture left. Allow this to
cool and then strain and bottle ready for use.
Take a wineglassful of this mixture every four
hours in cases of varicose veins in the testicles
(Vericosele).
Haemorrhoids (Piles)
Haemorrhoids are really varicose veins
occurring in the rectum or at the anus. During
the treatment it is important to avoid any
degree of constipation and any tendency to
liver congestion. In extreme cases local
application of ointment of Hazel or Nut Gall
can be used. The following mixture should be
taken for about a month when all traces of the
piles should have disappeared.
Dried herbs (100g each): Oak bark, Stone
root, Black root, Motherwort and Blood root.
Place these prepared dried herbs in two pints
of boiling water and allow to simmer gently
until 1 ½ pints remain. Allow the whole to
cool before straining ready for use. Bottle and
keep tightly corked in a cool place. Take a
wineglassful of the mixture three times daily
before meals.
Chilblains
In case of poor circulation (during winter) it is
advisable to take a course of rutin tablets
during the early autumn as a preventive
measure. They are made from extract of
buckwheat. The following mixture of prepared
dried herbs (100g each) made in to a
decoction is a wonderful treatment:
Lily of the valley, Motherwort and Skullcap.
Simmer these in two pints of boiling water
until approximately 1½ pints are left.
Cool and strain ready for use. The dose for
this mixture is a wineglassful every three
hours for about a week. The chilblains can be
banded with liquid extract of Witch Hazel.
The nerves
Lesions in the motor sensory nervous system
can lead to muscle cramps, spasms and even
paralysis and for these conditions species of
Primula, primrose and the cowslip are helpful.
Wood Betony enhances the action of
Primrose. Take 2 oz. of one or other variety of
primrose or cowslip and 1 oz. of wood betony
and simmer in two pints of water for one hour.
Cool and strain, after words taking a
wineglassful of the mixture every three to four
hours according to the severity of the
condition.
Neuritis
This can involve one or several nerves and can
be acute or chronic. There is inflammation of
the nerve sheaths or nerve fibers. Take the
497
following dried herbs (100g): Mistletoe,
Skullcap, Lupulin, Gentian, Valerian.
Simmer in three pints of water for 1 hour.
After cooling strain and take a wineglassful of
the mixture three times daily after meals.
Neuralgia
This is usually aggravated by debility, anemia
or other run down general conditions. It may
be due to irritation of the nerves such as in
tooth decay or it may be the result of neuritis.
For this condition the best herbal treatment is
to make a mixture of the following dried
herbs:
Skullcap (200g), Lupulin (200g), Asafetida
(100g), Gentian (100g), Valerian(50g).
Simmer in four pints of water until about three
pints are left. Cool and strain. Take a
wineglassful of the mixture every three hours.
Cirrhosis of the liver
The following mixture made from dried herbs
should be taken: Poplar Bark (200g), Golden
Seal (100g), Bitter Root (100g), Culvers Root
(100g), Capsicum (50g). Simmer these in
three pints of water until half is left. Cool,
strain and store in a cool place. The dose is a
wineglassful of the mixture three times daily
after meals.
Jaundice
Catarrh or inflammation of the bile ducts will
prevent the flow of bile from the liver and gall
bladder in to the intestine. The following
mixture should be prepared from dried herbs:
Dandelion Root (200g), Curcuma (100g),
Barberry Bark (100g), Agrimony (100g), and
Poplar Bark (100g).
Boil these dried herbs in 5 pints of water for
an hour. Cool and strain and add half a
teaspoonful of cayenne pepper. The dose is a
large wineglassful three or four times a day
according to the severity of symptoms.
Here is another good mixture for all liver
disorders especially when there is any fever
present. Take the following dried herbs (100g
each): Wild Cherry Bark, Rhubarb Root,
Prickly Ash Berries, Pleurisy Root, Culvers
Root.
Boil these in four pints of water in an hour.
Cool and strain. Take a wineglassful of the
mixture three times daily or four times if the
symptoms are acute.
Diseases of the urinary system
The urinary system comprises the kidneys,
ureters the bladder and urethra.
Take the following dried herbs (100g each):
Asparagus root, Parsely root, Celery root,
Fennel.
Pour a pint of boiling water over these herbs
in a clean teapot. Allow to stand until and then
take a wine glassful of the mixture with a few
drops of lemon juice before each meal for two
or three days consecutively.
Kidney disease
Stones or calculi are quite a common disease
of the kidneys and their presence may be
undetected until such time as they began to
pass towards the bladder.
One of the finest herbal mixtures for stones or
calculi is the following made from dried herbs
(100g each): Dropwort, Poplar Bark, Clivers,
Buchu Leaves and Tansy.
Boil these for 20 minutes and then allow to
cool before straining, after which, dissolve 2
oz. of gum Arabic in the liquor. Take a
wineglassful of this mixture three times daily
between meals with 10 drops of oil of cubebs
in each dose.
Bright’s Disease
This is a chronic inflammation of the kidneys
also known as nephritis. Pain in this condition
is usually felt at the back of the lions. One of
the bet herbal mixtures for this is to take the
following dried herbs (100g each): Golden
Seal, Buchu Leaves, Prickly Ash and Broom.
Boil for 20 minutes in 4 pints of water. Allow
to cool and strain. Take a tumblerful of the
mixture three or four times a day and make
fresh supplies of this every two or three days.
Suppression of urine
This is a serious condition in which the
kidneys fail to produce urine, usually as a
result of acute inflammation sometimes due to
fever, etc. prompt treatment is essential if it is
498
to be effective. Hot and cold compresses over
the kidney region are very helpful. To make a
cold compress wring out a large handkerchief
in cold water and place over the area. Place an
old warm woolen garment over this and
loosely hold in place. it should be kept on for
up to 2 hours, when a sensation of warmth is
experienced in the first 20 minutes. If this
does not happen commence with a hot flannel
compress for half an hour and then try the cold
compress again.
Here is a well-tried herbal mixture which
should produce good results swiftly. Take the
following dried herbs (100g each): Broom,
Dandelion Root, Tansy, Pellitory, Valerian
(50).
Simmer these in four pints of water until only
half the quantity is left. A wineglassful of this
mixture should be taken every two hours after
it has been cooled and strained.
References
Ayurvedic Herbal Mixtures;
www.biznet1.com/ayurveda, 5000 years old
ayurvedic medicines.
David Hoffman Holistic Herbal 4th Edition: A
Safe and Practical Guide to Making and Using
Herbal Remedies. Amazon.com Australia,
UK, 2003
Note: Most of the Matters are drived from Internet and
Research Papers
Chapter-26

499
500
NUTRITION
Nutrition: The process of the body using food
to sustain life; the study of food and diet.
Recently our food has been changed more in
the last forty years than in the last forty
thousand. Actually we are now in the midst of
a crisis in our food system that is challenging
our understanding of what is nutritious food.
Air, Sea and Surface transportation
abundantly supplies food around the world,
and the global supermarket chains ensure that
a wide variety of food is available year-round
to those with income and access.
Through factors such as artificially cheap
production costs and pervasive marketing and
advertising, fast food and other processed
foods high in fat, refined sugar and salt have
become staples of people's diets. This is
especially the case in low-income
communities, where access to healthy
alternatives is particularly limited. This
increasingly industrialized, unhealthy food
system is spreading throughout developing
countries as well. The health costs of this
system are becoming apparent in terms of
obesity, heart disease, diabetes and high
blood pressure in both adults and children.
Nutritious Food
Food and nutrition are not the same. Nutrition
comprises the process of providing the
nutrients needed for health, growth,
development and survival. Food is an essential
part of this process since it is the source of
these nutrients, but good caring practices and
good health care are also essential to the
nutrition process. Nutrition in the wider sense
comprises the substances, community and
environment that impact the body and
influence health. Nutrition incorporates food
systems and support of the biological systems
of the body. It includes agricultural inputs as
these affect plant and animal systems.
Nutrition impacts the building and repair of
tissues as they wear out and die the fuel for
energy and growth. The environment is
essential to nutrition since people cannot be
501
healthy in a sick environment. Poverty,
hunger, culture, food insecurity and nutrition
are interlinked and this means that income,
access, social determinants, education,
genetics, and social norms must also be
considered. From this whole complex of
factors, this topic will focus mainly on access
to nutritious food.
Food has a unique power to restore the health
of individuals and communities. Real food
means fresh growing without toxic chemicals
and processed without harmful additives. See
health from medical point of view as
stemming from quality food, low in
cholesterol and high in complex
carbohydrates. Food is medicine, and along
with exercise and a healthy body weight,
guards against "diseases of civilization" such
as cancer, heart disease and diabetes.
Nutritious food has many other benefits. It can
turn a simple meal into a feast, as people
reclaim the social dimension of food.
Nutritious food is an integral part of every
culture and can bring people together across
race, class, creed, and country. Growing and
eating nutritious food also has environmental
implications. Food that is grown close to its
place of consumption without synthetic
chemicals and unnecessary processing is not
only beneficial for our health, but for the
environment as well.
Access Nutritious Food
Nutritionists and dieticians are beginning to
document the links between human nutrition
and health, "sustainable diets" and sustainable
agriculture. A "food systems" approach to
building community food security is
emerging, with a focus on food availability,
affordability, accessibility, and quality. The
Local Food Movement is a response to the
exploding need for nutritious food, for whole
foods rather than processed foods, for food
grown sustainable, and for meat and dairy
products from farms that treat animals
humanely. Due to such demand, local food is
becoming available in soup kitchens and food
banks, in farmers' markets, restaurants,
supermarkets, schools, colleges, and even
hospitals.
Ways to access local food are described in the
Food Security Learning Center topics such as
Community Supported Agriculture,
Community Gardens, Farmers Markets, Farm
to Cafeteria, and Local and Regional Food
Systems.
It is a powerful and political decision of the
government to eat local and, where possible,
to eat organic. It opens doors to food which is
nutritious, ecological, fair in terms of trade,
and humane in the treatment of farm animals.
It shows the power of consumers to change
the dominant food system and build
alternatives that are just, democratic,
sustainable, and healthy.
Preventive Nutrition from medical point of
view
Preventive nutrition covers all aspects of
wellness, including genetic variation, diet and
nutritional awareness, physical fitness, stress
management, and gaining a sense of
responsibility for lifestyle choices and their
effects upon one's health.
Preventive nutrition is concerned with a high
level of personal well-being, disease
prevention, and recognition of recurring health
problems or symptoms of discomfort which
are often precursors to medical problems.
The Benefits
Many people find that small changes in life-
style can greatly increase their general sense
of well-being, contribute to higher levels of
energy and vitality, decrease mood swings,
and increase resistance to illness and infection.
Often, recurring health problems can be
alleviated or abetted through changes in diet,
exercise levels, stress management skills, and
nutritional supplementation.
In addition to these daily benefits, current
scientific research clearly documents the need
for dietary change to reduce the risk of
developing degenerative diseases including
502
heart disease, cancer, arthritis, obesity, and
diabetes. Fortunately, the recommendations
for those varied medical problems are similar.
First genetic variation plays a vital role in
addressing these problems, second eating a
large variety of fresh, natural foods with
emphasis on bio-available protein, compatible
carbohydrates, and healthy fats while reducing
harmful food additives, refined sugar, heavily
processed foods, and empty calories will also
address these problems.
Who can benefit?
People with any or most of the following
conditions:
Allergies/ food sensitivities
Heart disease risks
Candida
Celiac disease (gluten intolerance)
Cancer history
Blood sugar imbalance
Digestive distress
Fatigue/low energy
Blood pressure imbalances
Suppressed immunity/autoimmune disorders
Obesity
Underweight/mal-absorption
-Children with behavior/learning problems
-Children who are finicky eaters
-People with compulsive eating patterns
-Senior citizens trying to slow down the aging
process
-Pregnant/nursing women or women trying to
conceive
-Women with cystic breast disease, PMS,
vulvodynia, or chronic vaginal/bladder
infections
-Women struggling with menopausal issues
-Athletes
Weight Control
Many people think that reaching a weight goal
constitutes successful dieting. While losing
weight is a great achievement, the real
challenge and success comes from
maintaining that weight loss. By altering
eating habits based on individual’s needs.
Nutritional Supplementation
In addition to optimizing body functions,
nutritional supplements can provide dietary
support for disease prevention. Since each
individual differs biochemically and
genetically, a separate nutritional
supplementation program is necessary to meet
individual’s needs.
Genetics – the Future of Nutrition
As stated by the Centers for Disease Control
and Prevention, “virtually all human diseases
result from the interaction of genetic
susceptibility factors and modifiable
environmental factors, broadly defined to
include infections, chemical, physical,
nutritional, and behavioral factors” (CDC,
August, 2000).
Each of human being genotypes contains
genetic polymorphisms, a polite word for
“defects”. Whether health issues are
developed or not is dependent on phenotypes,
or how the genes are expressed. Under the
influence of environmental and dietary
triggers, genetic polymorphisms can make a
person more or less prone to developing
certain diseases or physiological imbalances.
Balance diet sheet
ACID-FORMING AND ALKALINE-
FORMING FOODS
It must be noted that a food is acid it is no
indication that it remains acid in the body. It
can turn alkaline due to body enzymes actions
and bile. Honey and raw sugars produce
alkaline ash, but because of a high concentrate
of sugar become acid-formers. Some fruits
should not be eaten with some other foods
because they are acid externally but showed
alkaline nature internally.
ALKALINE
FRUITS
Apples/cider, Apricots, Avocados, Bananas,
Berries (all), Cantaloupe, Carob (pod only),
Cherries, Citron, Currants, Dates, Figs,
Grapes, Grapefruit, Guavas, Kumquats,
Lemons (ripe), Limes, Loquats, Mangos,
Nectarines, Olives (ripe), Oranges, Papayas,
Passion fruit, Peaches, Pears, Persimmons,
503
Pineapple (fresh), Pomegranates, Melons (all),
Raisins, Sapotes, Tamarind, Tangerines and
Tomatoes (fully ripened).
ACID FRUITS
All preserves, all canned with sugar,
Cranberries, Dried-sulphured, glazed, Olives
(pickled), Plums and Prunes.
ALKALINE
VEGETABLES
Alfalfa sprouts, Artichokes, Asparagus,
Bamboo shoots, Beans (green, lima, wax, and
string), Beets, Broccoli, Cabbages, Carrots,
Celery, Cauliflower, Chard, Chicory, Coconut,
Corn, Cucumber, Dill, Dock, Dulse, Eggplant,
Endive, Escarole, Garlic, Horseradish,
Jerusalem artichokes, Kale, Leeks, Lettuce,
Mushrooms, Okra, Onions, Oyster plant,
Parsley, Parsnips, Peppers (bell), Potatoes
(skin is best part), Pumpkin, Radish, Romaine
lettuce, Rutabagas, Sauerkraut, Soybeans,
Spinach, Sprouts, Squash, Turnips,
Watercress, Yam and sweet potatoes.
ACID VEGETABLES
Asparagus tips (white only), Beans (dried),
Brussel sprouts, Garbanzos, Lentils and
Rhubarb.
ALKALINE DAIRY
Acidophilus milk, Buttermilk, Yogurt, Milk
(raw only -- human, cow or goat) and Whey
ACID DAIRY
Butter, Cheese (all), Cottage cheese, Cream,
Custards, Margarine and Milk (boiled,
cooked, malted, dried, canned)
ALKALINE, MISC.
Agar, Coffee substitute, Honey, Kelp (edible),
Tea (herbal and Chinese) and Egg yolks
ACID MISC.
Alcoholic drinks, Cocoa, Coffee, Indian teas,
Condiments (all), Dressings, Drugs, Eggs
(whites), Flavorings, Mayonnaise, Tapioca,
Tobacco and Vinegar.
ALKALINE NUTS
Almonds, Chestnuts (roasted) and Coconut
(fresh)
ACID NUTS
All except above, Coconut (dried)
ALKALINE FLESH FOOD
Beef juice, Blood and bone (only bone-meal is
alkaline)
ACID FLESH FOOD
All meats, Fowl, fish, shellfish, Jell-O, gelatin
ALKALINE GRAINS
Buckwheat and millet are thought to be either
neutral or alkaline
ACID GRAINS
All grains and grain products except
buckwheat and millet
Basic Nutrition Principles
Absorption and metabolism of proteins,
carbohydrates and lipids
Absorption and metabolism of vitamins and
minerals
Fluids, electrolytes and acid-base balance
Energy requirements and expenditures
Composition of a healthy diet
Food sources of nutrients
Clinical assessment of nutritional status
Food drug interactions
Supplements and nutraceuticals
Nutrition from a cultural perspective
Political & social issues pertaining to food
Contemporary food environment
Doctor-Patient communication: effecting
dietary change
Dietary patterns and practices
Nutrition throughout the life cycle
Nutrition and disease prevention
Nutrition and hypermetabolic states
Factors that affect taste/smell acuity resulting
in weight loss
Health effects of specific vitamin/mineral
deficiencies
General Principles of Clinical Medicine
Correlation of various types of ìlimitedî diets
with specific nutritional deficiencies
Health effects of specific vitamin/mineral
excesses
Obesity and chronic disease
Hypercholesterolemia and chronic disease
Hypertension and chronic disease
504
For a considerable amount of time, nutrition
has not played a prominent role in the life of
many martial artists, police, and military
personnel as a means of improving
performance. Top athletes are always looking
for an edge. Although the martial arts are
more of a way of life and a life style than a
sport per se, the needs of the martial artist are
the same as that of the elite athlete. Mental
aspects not withstanding (i.e. mental
awareness, strategy, cunning, etc.), the need
for speed, agility, strength, flexibility, and the
ability to recuperate from tough workouts (and
unforgiving sparing partners) is paramount to
the success of athletes and martial artists alike.
Police and military personnel can also have
unique requirements that require them to
perform at peak physical and or psychological
levels.
Over the past decade our knowledge of sports
nutrition has evolved into a science that has
swept the athletic world and has been partially
responsible for the ever increasing numbers of
athletes who are pushing the envelope of
human ability and performance. Although a
handful of the worlds top martial artists,
police, and elite military units have taken
advantage of the “cutting edge” nutrition
being used by top athletes, the majority of
these communities have not taken advantage
of the new science of sports nutrition. The
advantage of improving one’s performance
through nutrition and correct supplementation
is obvious for the athlete, but what about the
martial artist? Obviously technique, form, and
knowledge of one’s chosen martial art is
essential to the mastery of that art, but what if
the person, regardless of skill level, becomes a
little faster, stronger, and able to resist and
repair from injuries and training better? Will
they not be an improved version of their
former self? Of course they will! Proper
nutrition can make the martial artist, as it has
for so many of today’s top athletes, an
improved and potentially more accomplished
practitioner of their art, plain and simple. If a
policeman is able to stay alert, has more
endurance or strength, etc., will he/she not
have an added advantage to the job? Of
course, the benefits to the soldier are obvious.
To not take advantage of the science of
nutrition and supplementation, is to short
change the martial artists, police, and military
personnel.
Protein
Proteins are made up of amino acids which are
the structural units of the protein molecule.
There are approximately 20 amino acids.
Eight of them are considered “essential”
because the human body cannot make them on
its own - which is the definition of an essential
nutrient. Link a few amino acids together and
you get a peptide. Link a bunch of peptides
together and you get a protein. The shape of
the individual amino acids (and resulting
proteins) is unique and highly specific, so I
won’t go into great detail about it here. Suffice
it to say, proteins are an essential part of
virtually every function in our body from the
muscles, to certain hormones, to our immune
system(s) and a whole lot more. In particular,
the amino acids known as the “branched
chain” amino acids (leucine, isoleucine, and
valine) and the amino acid L-glutamine are of
particular interest to active people as they are
anti-catabolic (muscle sparing) and immune
enhancing, to name only a few functions and
benefits of these particular amino acids.
Though the RDA for protein is generally
sufficient for couch potatoes (with some
debate) the majority of athletes and/or highly
active people will benefit from higher intakes
of high quality proteins. Proteins with the
highest biological value (BV) are the proteins
that should constitute the majority of the
active person’s diet, as they are superior for
maintaining positive nitrogen balance,
reducing recuperation time from workouts,
improving immune function, etc. Whey
protein concentrate (WPC) and isolates (WPI)
have the highest BV of any protein, is almost
50% branched chain amino acids, and is high
505
in L-glutamine, which is why I recommend
several servings a day of WPC/WPI to all the
athletes/martial artists/police I work with.
There are several brands of WPC/WPI on the
market. Other high quality proteins such as
skinless chicken, fish, eggs, soy, and lean red
meats, have relatively high BV values and are
good proteins. Another point that is important
to know, the higher quality the protein, the
less the person has to eat and this allows the
person to keep total calories lower by sticking
to these high BV proteins.
For a person who is active in the martial arts,
has a busy job, and probably does some
weight lifting and/or aerobics, an intake of 0.7
– 0.8 grams of protein per pound of lean body
weight is what I have generally recommended.
For high level bodybuilders and competitive
distance athletes, the protein intake will be
higher, approximately 1g of protein per
lb/bodyweight being the most common. In
certain situations, amino acid supplementation
is useful, but most people will have no
problem getting what they need by eating
plenty of high quality protein foods. Low
grade, high fat, preservative loaded, protein
foods such as luncheon meats, hot dogs, etc.,
should be avoided for obvious reasons.
Carbohydrates
Carbohydrates are made primarily of carbon,
hydrogen, and oxygen atoms that cycle into a
ring. They can be “simple” or “complex”
depending on the number of rings that are
hooked together and the way the carbohydrate
effects blood sugar. Though the rings can be
slightly different in shape, their common
theme is the ring structure. Similar to amino
acids that make up proteins, when you link the
simple units (the sugars) together you get
carbohydrates with different properties. As
most people know, carbohydrates are a
primary source of energy for the body. The
best types of carbohydrates to eat are those
that are high in fiber, vitamins, and minerals.
Though foods such as pasta, breads, and white
rice are considered “complex” they are highly
processed foods, totally inadequate in fiber,
vitamins, and minerals and should not make
up a high percentage of a person carbohydrate
intake. Though these foods are often fortified
with certain vitamins, in my opinion this does
not truly replace what is lost during
processing, not to mention the many nutrients
that are not replaced. Americans are
notoriously low eaters of fiber, and heavily
processed foods mentioned above do nothing
to correct this deficit. High fiber carbohydrate
foods such as brown rice, beans, lentils,
oatmeal, sweet potatoes, and many others, are
the preferred carbohydrate foods for health,
performance, steady blood sugar levels, and
reduced body fat levels.
Though the high carbohydrate/low fat diet is
all the rage these days, it has not been in my
experience the optimal diet for the many
athletes, martial artists, and “normal” people I
have worked with (see fats below). Data
continues to support the fact that high
carbohydrates low fat diets are not optimal for
either health for weight loss. Eating too much
of anything, including carbohydrates, will
make one fat and cause a host of other ills I
don't have the space here to cover. There are
many researchers, books, and studies using
both animals and humans that seriously
question the high carbohydrate/low fat diet as
the optimal diet for health and performance.
Two grams per pound of lean bodyweight of
carbohydrates is more than sufficient to fuel
the energy needs of most athletes if other
aspects of their diet is adequate (i.e. correct
use and amounts of certain fats and proteins).
And, as mentioned previously, the source of
those carbohydrates is of paramount
importance.
Fats
Fats have just as many biochemical
differences in the human body as do
carbohydrates and proteins and thus have just
as many different effects on the body that
range from very good to very bad. It really
506
depends on the type and amount of fat(s) we
eat. Americans tend to get their dietary fats
from saturated fats, rancid fats, and highly
processed fats (which contain by products
such as trans fatty acids), thus giving fats a
bad name.
As mentioned earlier, an essential nutrient is
anything the human body cannot manufacture
on its own and must be obtained from the diet,
or the person will become sick and/or perish if
the nutritional deficit is not corrected. We
know there are a multitude of vitamins and
minerals, eight amino acids, and two types of
fats that are considered essential nutrients for
life itself to continue. The two fats that are
known to be essential to health are Linoleic
acid (LA) which is an Omega-6 fatty acid and
Alpha-linolenic acid (LNA) which is an
Omega-3 fatty acid. Both of these fats can be
found in various foods that have not been
heavily processed. These two fats are highly
sensitive and reactive to heat, light, and
oxygen and are totally ruined or lost during
the processing of our foods. The reason poly -
unsaturated vegetable oils that line the shelves
of most super markets can sit there for years
on end is because they have been heated,
deodorized, and generally processed to the
point that they are the nutritional equivalent of
white bread and table sugar. People are advice
to avoid those oils.
Because of all the fat bashing by the popular
media and health professionals who should
know better, most people have come away
thinking that all fat is bad and serves no other
purpose than to make our hips and stomach
wider while ruining our health. Nothing could
be further from the truth. The membrane that
surrounds every single cell in the body, the
sheath around nerves, various hormones,
prostaglandins, and countless other parts of
the body (especially the brain) depend on the
dietary intake of the right fats. The importance
of the essential fatty acids for health and
performance cannot be understated. It is true
that certain fats, such as, saturated fats, rancid
fats, and trans fatty acids (found in margarine,
Crisco, and other products), can cause
numerous health problems from heart disease
to cancer and insulin resistance, to name only
a few ills of a diet high in the wrong types of
fat. However, the essential fatty acids
(especially the Omega-3 fatty acids) are anti-
lipolytic (stop fat storage), anti-catabolic (stop
the breakdown of muscle tissue), increase
metabolic rate and beta oxidation (burn
calories/increase fat burning), improve insulin
sensitivity, reduce the chances of heart
diseases, and a whole lot more.
Though early research told us that we need a
bit more LA (the Omega-6 fatty acid) than
LNA (the Omega-3 fatty acid) in our diet, we
find in practice that a diet containing higher
amounts of Omega-3 fatty acids (LNA) gets
the best results in health, body fat levels, and
performance. The richest source of the
Omega-3 fatty acid LNA is Flax oil, which
also contains a small amount of the Omega-6
oil LA. Flax oil can be found in the
refrigerated section of any good health food
store and is derived from the careful
processing of flax seeds. As a nutritional
consultant to various athletes, I have used flax
oil with many of the country’s top
bodybuilders (a group of athletes notoriously
fearful of eating fat) to reduce their body fat
levels and improve their performance and
health. Two–three tablespoons a day over a
salad, taken straight, or in a protein drink does
the trick. Another major source of Omega-3
fatty acids can be found in deep water cold
fish such as sardines, mackerel, and salmon,
and I recommend that people eat two to three
servings of these fish per week. Good sources
of LA are unprocessed vegetable oils such as
safflower, sunflower, sesame, and many other
oils found in health food stores.
Fats to avoid are highly processed vegetable
oils and other processed vegetable products
(such as margarine), rancid fats, and to a
lesser degree, saturated fats. The key to health
and performance is a proper balance of
507
essential fatty acids (LNA and LA), mono
unsaturated oils (found in olive oil, avocados,
etc.), and small amounts of saturated fats
found in lean meats and other sources
combined with the right carbohydrates and
proteins.
Vitamins/Minerals
A good multi vitamin is an insurance plan to
make sure we get all the major vitamins and
minerals that for whatever reason we failed to
get from our food on any given day. There is
not a single cell in our entire body that does
not require the use, or interaction with, some
vitamin, mineral, or biological function that is
dependent on the above nutrients in adequate
amounts.
Antioxidants
“Anti-oxidants” and “free radicals” are the hot
buzz words these days on television news
shows, news paper articles, and magazine
features. Though scientists in the health and
nutritional fields have known about them for
decades, they have recently been getting a lot
of attention by mainstream media and more
open minded medical researchers. Anti-
oxidants are a special class of vitamins and
other non vitamin compounds that neutralize
free radicals before they can damage cells in
our body. What is a free radical? A free
radical is a highly reactive molecular fragment
that has a single unpaired electron. The
unpaired electron wants to “pair up” with
another electron. The free radical will steal
this electron from virtually anything it comes
in contact with, including our cells. This
reaction, if left unchecked, leads to a free
radical chain reaction and damage to various
parts of the cell depending on where it takes
place. An anti-oxidant can donate an electron
without itself becoming a free radical and thus
can break the chain of events leading to an
uncontrolled free radical chain reaction. Free
radical pathology is now believed to be linked
to diseases such as cancer, heart disease,
diabetes, and dozens of other afflictions.
Without going into a long biochemical
explanation, there are many things that cause
free radicals to be released, such as smoking,
exposure to various toxins found in air, food
and water, sickness, exercise, and stress in
general.
Anti-oxidants such as vitamin E and C and
other compounds such as selenium, N-acetyl
cysteine (NAC), and proanthocyanidins
(derived from grape seed extract), to mention
a few, will help recuperation from tough
workouts, improve immunity, possibly
prevent certain diseases, and improve the
health in so many different ways.
Sports Supplements
The topic of sports nutrition supplements,
such as: androstenedione and other “andros,”
Arginine, Colostrum, CLA, Creatine,
Ecdysterone, GH Supplements, Ginseng,
HMB, Myostatin Inhibitors and Tribulus, to
name just a few, is beyond the scope of this
article. Each supplement has its potential uses,
drawbacks, doses and other variables that need
to be examined on an individual basis.
The above list of foods and supplements is in
no way complete or the entire picture when it
comes to additional ways the martial artist,
police, and military personnel can improve his
or her health, strength, body fat levels, and
recuperative abilities. However, the
information presented here can make for a
foundation of health and performance that
could add a considerable edge for those who
seeks it.
(1)The way a carbohydrate effects blood
sugar after it is eaten is known as the
glycemic response. The glycemic index
(GI) is a list of foods and how they affect
blood sugar. Some foods we think of as
“complex” actually raise blood sugar
much faster than many foods we think of
as “simple.”
(2) The health problems related to fats is far
more complex than most people
appreciate. The pathology of disease(s)
caused by high fat intakes of the wrong
types of fat is a complex interaction
508
between certain fats, carbohydrates, a lack
of certain vitamins and other nutrients,
free radical/anti-oxidant mechanisms, and
other factors that are poorly understood.
(3) For more information on the many benefits
of the essential fatty acids and to find out
more information about fats and health in
general, read further books on nutrition.
(4) LNA and LA are in a 4:1 ratio in flax oil.
(5) Like fresh eggs, milk, meat, etc, all fresh
unprocessed oils will spoil if not
refrigerated constantly and eaten shortly
after opening the bottle.
(6) All highly unsaturated oils, including flax,
should never be used to cook with as this
will change the structure of theses oils
making them toxic and of little use for the
purpose they are intended for.
(7) The “fish oils” DHA and EPA can be
formed in the human body from LNA by
desaturase enzymes.
(8) It is important to note that free radical
reactions are a normal and essential part of
metabolism. It is the uncontrolled free
radical chain reactions that we are
concerned with.
The Importance of Good Nutrition
Good nutrition is very important for both
your general and eye health. Good
nutrition helps our body to grow, repair
wear and tear, protect against infection and
to function properly. An eye condition
called? xerophthalmia', which is a
common cause of childhood blindness in
developing countries, is a good example of
how nutrition and eye health go hand in
hand. This condition is caused by a lack of
vitamin A in a person's diet and could be
prevented by eating fresh vegetables, fat
(animal and plant) and protein such as
meat, eggs, cheese, fish, poultry, milk,
yogurt, dairy products, grains, etc.
A good diet, full of fresh fruits and vegetables,
may help protect against macular degeneration
in later life. Some studies have shown that a
good diet can help in preventing AMD and
age-related cataracts.
The importance of food and the role it plays in
our health is largely overlooked. Beyond
paying lip service to it, very few people
actually put into practice even what they know
is good for them. Nutrition is not even an
important part of the medical doctor’s training
– but it is believed one part of the subject is
related to "Social Medicine".
It is estimated that over 70-80% of our
diseases are related directly our indirectly to
our diet. It is in the area of food and diet that
we unknowingly commit the most frequent
and great transgressions to natural laws, that
adversely affect our health. Most of our
chronic health problems can be done away
with if only we were to make our diet more
natural.
The American Dietetic Association says that
"The role of nutrition and diet in promoting
health and reducing chronic disease for
conditions ranging from preventing low birth
weight to weight reduction, diabetes mellitus,
cardiovascular disease, and dietary
intervention in cancer prevention and control
has been well established".
Principles of Good Food
The hygienic perspective has been unchanged
for the past two hundred years. In fact,
hygienists have evolved a comprehensive
evaluation system which enables you to
objectively rate the quality of a food.
Fruits & Vegetables
Of all the various foods available for human
beings to eat, raw fruits and vegetables remain
the prime and best choice from every possible
perspective.
Water
Even though water is not a food, it is of
primary importance to us since over 70% of
our body is composed of water. We can leave
without food for even forty days, but without
water for few days we can die. Hygienic water
must be pure and full of its mineral contents.
Nuts and Sprouts
509
Nuts and sprouts are one of the finest sources
of proteins for human beings and in fact they
have none of toxins and other problems
associated with animal products.
Grains and lentils
Rice and/or wheat are the staple foods for over
90% of the world's population and a good
source of energy too.
Animal products
A significant part of the world's population
routinely eats animal products such as meat,
fish & eggs at least once a day. In fact it is
widely considered that this food is good for
heath, especially necessary for obtaining the
protein requirements. But how many people
know the true answers to these questions?
Milk and Milk Products
Strictly speaking, milk and milk products like
yoghurt, cheese, butter etc. come under the
category of animal products.
Cooked food v/s raw food
Almost all of us have been brought up on a
diet of predominantly cooked food. Fire has
been burning in the kitchens from time
immemorial. But what is the effect of
subjecting our foods to the effects of fire on
the foods and on our health? There is no
denying that it is very difficult to eliminate
cooked food from our diet. But we ought to
know the importance of raw foods in our diet
and try to increase the percentage of raw foods
consumed, gradually, to as much as is
practically possible.
Junk food
Luckily, the deleterious effects of "junk food"
or "fast food" are coming to light even in the
conventional health and nutrition
communities. It is no one's case that these are
the healthiest of foods. Unfortunately, after
being rejected as healthy food in the West,
these foods are making a backdoor entry into
developing countries like India, Pakistan,
Saudi Arab, Middle East etc. And what's
more, they are being lapped up, especially by
the younger generation for reasons other than
health and nutrition.
Micro-waved Food
Do you know that a Swiss Scientist, Dr.
Henreich Hertel, came to the conclusion after
scientific studies, ten years ago, that
consumption of micro-waved food created
changes in blood chemistry similar to those on
the onset of cancer? And that the electrical
industry filed a case against him in the Swiss
Courts and prevented him from making his
findings public for ten years? And that
recently he has won his appeal, the Swiss
government has been fined.
Irradiated Food
The nuclear lobby after the embargo on
nuclear weapons and also having failed in
many countries of providing a significant
quantity of power, safely, efficiently and cost
effectively, is now desperately searching for
reasons to justify its continued existence. It
has hit upon the idea of irradiating our food to
preserve it from decay.
510
Healthy Food
As a reaction to the assault on our foods by
unhealthy food, a huge number of "health food
stores" have mushroomed up all over the
world. And they are becoming more and more
popular.
Nutrition and Children
The American Heart Association, the National
Cholesterol Education Program (NCEP), and
the Food and Drug Administration advocate
"heart-healthy" diets for adults. The major
goal of such diets is to restrict the total intake
of fats, especially saturated fat and
cholesterol, which have the potential to raise
plasma levels of low density lipoprotein
(LDL) cholesterol, a major risk factor for
developing coronary artery disease. The AHA
Step I diet recommends (1) that calories
consumed as fat not exceed 30% of total
calories consumed per day, (2) that calories
consumed as saturated fat equal no more than
8% to 10% of total calories consumed per day,
and (3) that total cholesterol intake be less
than 300 mg/d. Although it is well established
that the Step I diet is safe and beneficial for
adults, some controversy surrounds the
benefits and safety of this type of diet for
children. For example, because the clinical
manifestations of atherosclerosis usually do
not develop until well into adulthood, it has
been argued that institution of the AHA Step I
diet in childhood is of little benefit and may
even be hazardous by inducing nutritional
deficiencies compromising growth and
development. The Nutrition Committee has
reviewed the evidence concerning the safety
and efficacy of the AHA Step I diet in
children. The Step I diet can be safely
recommended for the majority of children and
will ultimately result in a lower frequency of
coronary artery disease in the general
population.
Studies of the early stages of atherosclerosis in
children and young adults began in the 1950s
and have consistently shown the presence of
arterial deposits of fats and early plaques at
young ages. Recently the most systemic and
rigorous test of the hypothesis that
atherosclerosis begins in childhood and is
influenced by risk factors for adult coronary
artery disease was undertaken. The
Pathological Determinants of Atherosclerosis
in Youth (PDAY) study examined over 1500
persons aged 15 to 34 years, most of them died
from accidental or traumatic causes, for
evidence of arterial lesions and risk factors
such as smoking, hyperlipidemia, and
diabetes. The extent of fatty and fibrous
arterial lesions increased with age. The risk
factor most closely associated with arterial
lesions was the LDL serum cholesterol
concentration measured postmortem.
Smoking, adiposity, glycohemoglobin and
hypertension (as indicated by renal vascular
lesions) also were closely associated with
arterial lesions, particularly advanced plaques.
These early results provide compelling data
that starting a heart-healthy diet before
adulthood reduces the prevalence of obesity
and elevations in serum cholesterol levels and
blood pressure that commonly occur in adults,
thereby retarding the rate of progression of
atherosclerosis and delaying the onset of
clinical coronary artery disease.
The major safety issue that has been
considered is whether a heart-healthy diet will
support the special needs of childhood, growth
and development.
511
Because growth and development in early
childhood occur in the context of a milk-based
diet naturally high in saturated fat and
cholesterol, the AHA Step I diet is not
proposed for children less than 2 years old.
In children older than 2 years, the safety of a
diet with a total fat intake in the range of 30%
has been amply shown in both survey and
prospective studies. In the Third National
Health and Nutrition Examination Survey
(NHANES III), the decrease in the average
level of fat intake from the second survey in
children aged 3 to 19 years did not result in an
increased prevalence of poor growth or weight
gain. Another survey found no difference in
intake of specific micronutrients between
children whose fat intake was 28% to 30% of
total calories and children consuming higher-
fat diets. In a prospective study (Dietary
Intervention Study in Children [DISC])
involving more than 600 children aged 8 to 10
years with elevated LDL-cholesterol levels,
the subjects consumed one of two diets: a diet
designed to provide 28% of calories as fat,
10% as saturated fat, and 95 mg cholesterol
per day, and the subjects' "usual" diet
containing 33% to 34% of calories as fat, 13%
as saturated fat, and 112 mg cholesterol per
day, respectively. There were no differences
between the two groups in any variables tested
(height, weight, micronutrients, or
psychological well-being) except for a small
but significant reduction of LDL cholesterol in
the group consuming less dietary fat.
Another source of concern has been that the
dietary recommendations are population based
and that person who are overly zealous about
diet or those already eating a heart-healthy
diet may drastically reduce their intake of
foods with a fat content containing essential
fatty acids, vitamins, and other specific
nutrients. For this reason, the Nutrition
Committee does not recommend consumption
of diets with very low total fat intake and has
established a limit of no less than 15% total fat
intakes for adults. The American Academy of
Pediatrics recommends a total fat intake of no
less than 20% in children older than 2 years.
In the 15% to 20% range of fat intake, there
should be no deficiencies of fat-associated
nutritional factors, such as vitamins A, D, and
E and long-chain polyunsaturated essential
fatty acids.
Rigorous and ongoing research shows that
atherosclerosis begins in children and the
extent of early arterial involvement is strongly
associated with LDL-cholesterol levels. When
started in childhood, diets restricted in
components that elevate LDL cholesterol
(saturated fat and cholesterol) have the long-
term potential to decrease the frequency of
coronary artery disease and the extent of
clinical disease later in adulthood.
Recent surveys of childhood nutritional intake
have shown averages of 33% to 35% of total
food energy intake coming from fat, with 12%
to 13% of calories from saturated fat. Despite
improvements compared with intake patterns
of previous decades, both of these values are
higher than those of the AHA Step I diet (no
more than 30% and 10% of total calories,
respectively). However, the elevations are
relatively modest, so that often only minor
changes in food selection and dietary habits
are necessary to achieve the recommended
goals. After the age of 2, when the diet
becomes progressively more varied and
includes foods prepared both in and out of the
home, a gradual transition to a heart-healthy
diet can be accomplished by replacing foods
512
rich in fat with grains, fruits, lean meat, and
other foods low in fat and high in complex
carbohydrates and protein.
The Nutrition Committee strongly believes
that the AHA Step I Diet supports normal
growth and development in children older than
2 years so that limiting the amount of fat and
cholesterol consumed should be a family
concern, not just something parents do for
themselves.
REFERENCES
Daily dietary fat and total food energy intakes: Third
National Health and Nutrition Examination Survey,
Phase 1, 1988-96. MMWR Morb Mortal Wkly Rep..
1994;43:116-125.
DISC Collaborative Research Group. Efficacy and
safety of lowering dietary intake of fat and
cholesterol in children with elevated low-density
lipoprotein cholesterol: the Dietary Intervention
Study in Children (DISC). JAMA.. 1995;273:1429-
1435.
Kleinman RE, Finberg LF, Klish WJ, Lauer RM.
Dietary guidelines for children. J Nutr..
1996;126:1028S-1030S.
McGill HC Jr, McMahan CA, Malcom GT, Oalmann
MC, Strong JP. Relation of glycohemoglobin and
adiposity to atherosclerosis in youth: Pathobiological
Determinants of Atherosclerosis in Youth (PDAY)
Research Group. Arterioscler Thromb Vasc Biol..
1995;15:431-440.
McGill HC Jr, Strong JP, Tracy RE, McMahan CA,
Oalmann MC. Relation of a postmortem renal index
of hypertension to atherosclerosis in youth:
Pathobiological Determinants of Atherosclerosis in
Youth (PDAY) Research Group. Arterioscler
Thromb Vasc Biol.. 1995;15:2222-2228.
McPherson RS, Nichaman MZ, Kohl HW, Reed DB,
Labarthe DR. Intake and food sources of dietary fat
among school children in The Woodlands, Texas.
Pediatrics.. 1990;86:520-526.
PDAY Research Group. Relationship of atherosclerosis
in young men to serum lipoprotein cholesterol
concentrations and smoking. JAMA. 1990; 264:3018-
3024.
Note: Most of the Matters are drived from Internet and
Research Papers
Chapter-27

513
514
Laboratory Investigations
Clinical lab testing often provides few plainly the full name of the test desired in
simple answers to commonly asked the space marked "OTHER REQUESTS".
questions. healthcare provider. Directions
Lab Tests 1.Complete a separate requisition for each
Requests for laboratory tests must patient.
2.Please provide all information on the left
accompany with appropriate requisition
hand side of the requisition form.
form and a physician's written request. All 3.Fold completed request form and place in
verbal requests for additional test(s) needs a the outside pocket of the Specimen Bag. If
written order must be followed by written submitting more than one specimen per
confirmation within few days. patient, and specimens need to be stored
and transported at different temperatures,
Laboratory services:
use separate bags and Test Request forms
• Patient name, sex, birth date, includes ID
for each temperature type.
number, lab reference number.
4.Special requests for testing should be
• Collection date and time
noted on the requisition.
• Diagnosis Code
Forms format:
• Type of specimen submitted, indicate
• General
serial and timed collection
• Genetics Requisition
• Patient fasting conditions (if applicable)
• Hematopathology (morphology, flow
• Interval and total volume if a timed urine
cytometry, molecular, cytogenetics)
collection
• Merkel Cell Carcinoma Serology
• Source of specimen if for Microbiology or
• Microbiology
Virology test(s), or other comments in
• Molecular Diagnostics - Microbiology
"comments" box
• Prenatal Requisition
• Authorization for laboratory work, include
• Toxicology
the name of the ordering physician and
• Virology
hospital/clinic name in addition to the
Laboratory Methods
name and address of the facility to which
Medical laboratories use a variety of
the results will be sent.
methodologies including immunoassay (IA),
• Check test(s) requested. If the Department
enzyme-linked immunoassay (ELISA),
of Laboratory Medicine of a
western blot, fluorescence in situ
Hospital/Clinic offers a procedure that
hybridization (FISH), and polymerase chain
does not appear on the request form, print
reaction (PCR).

515
This operation-automated machine from
RADIM has many special features like: the
fully automated ELISA system, a high load
of 120 samples per run.
Fluorescence in situ hybridization (FISH)
determines the positions of particular genes.
It can be used to identify chromosomal
abnormalities.

Triple Quadrupole LC-MS/MS – Offers

analytical specificity superior to that of
immunoassays or conventional high
performance/pressure
chromatography.
liquid
A product of Thermo Scientific the
PikoReal has outstanding performance and
offers innovative features includes sample
preparation, nucleic acid extraction,
DNA/RNA analysis and PCR assays and
reagents. High temperature uniformity
block.

JUNYI JY-ZY5 Western Blotting

electrophoresis tank DNA nucleic acid
purification and preparation.

516
Laboratory Values
All values are for adults
Albumin 3.2 - 5 g/dl

Alkaline phosphatase
33 - 131 IU/L
(Adults: 25-60)

Adults > 61 yo: 51 - 153 IU/L

Ammonia 20 - 70 mcg/dl

Bilirubin, direct 0 - 0.3 mg/dl

Bilirubin, total 0.1 - 1.2 mg/dl

Blood Gases

Arterial Venous

pH 7.35 - 7.45 7.32 - 7.42

pCO2 35 - 45 38 - 52

pO2 70 - 100 28 - 48

HCO3 19 - 25 19 - 25

O2 Sat % 90 - 95 40 - 70

BUN 7 - 20 mg/dl

Complete blood count (CBC) Adults

Male Female

Hemoglobin (g/dl) 13.5 - 16.5 12.0 - 15.0

Hematocrit (%) 41 - 50 36 - 44

RBC's ( x 106 /ml) 4.5 - 5.5 4.0 - 4.9

517
RDW (RBC distribution width) < 14.5

MCV 80 - 100

MCH 26 - 34

MCHC % 31 - 37

Platelet count 100,000 to 450,000

Creatine kinase (CK) isoenzymes

CK-BB 0%

CK-MB (cardiac) 0 - 3.9%

CK-MM 96 - 100%

Creatine phosphokinase (CPK) 8 - 150 IU/L

Creatinine (mg/dl) 0.5 - 1.4

Electrolytes

Calcium 8.8 - 10.3 mg/dL

Calcium, ionized 2.24 - 2.46 meq/L

Chloride 95 - 107 mEq/L

Magnesium 1.6 - 2.4 mEq/L

Phosphate 2.5 - 4.5 mg/dL

Potassium 3.5 - 5.2 mEq/L

Sodium 135 - 147 mEq/L

Other

Ferritin (ng/ml) 13 - 300

518
Folate (ng/dl) 3.6 - 20

Glucose, fasting (mg/dl) 60 - 110

Glucose (2 hours postprandial)

Up to 140
(mg/dl)

<6% of total Hb
AACE Guidelines (2011)
Hemoglobin A1c, % (as a screening test)
5.4 - Normal
-------------------------
5.5-6.4 - High risk/pre-diabetes; requires screening by
Hemoglobin A1c glucose criteria
-------------------------
6.5 -Diabetes, confirmed by repeating the test on a
different day
=================
In general, therapy should target a A1C level of 6.5% or
less for most non-pregnant adults.

Iron (mcg/dl) 65 - 150

Lactic acid (meq/L) 0.7 - 2.1

LDH (lactic dehydrogenase) 56 - 194 IU/L

Lipoproteins and triglycerides

Cholesterol, total < 200 mg/dl

HDL cholesterol 35 mg/dL. Negative risk factor: 60 mg/dL

LDL cholesterol 65 - 180 mg/dl

Normal: < 150 mg/dL.

Borderline-high: 150 to 199 mg/dL
Triglycerides
High: 200 to 499 mg/dL
Very High: >499 mg/dL

519
Osmolality 289 - 308 mOsm/kg

SGOT (AST) < 35 IU/L (20-48)

SGPT (ALT) <35 IU/L

Male: 300 to 1000 ng/dL

Female: < 62 ng/dL

Testosterone - total(serum)
ALT:
Male:
14-15 yr: 33-585 ng/dL
16-17 yr: 185-886 ng/dL
18-39 yr: 400-1080 ng/dL
40-59 yr: 350-890 ng/dL
> 60 yr: 350-720 ng/dL

Tanner Stage IV: 165-854 ng/dL

Tanner Stage V: 194-783 ng/dL

Thyroid Function tests

Thyroid Function Testing

Thyroid Function Measurement Normal Range

Test

Total T4 (TT4) bound and free T4 4.5 -11.5 ug/dL

Free T4 (FT4) free T4 0.8 -2.8 ng/dL

Free T4 Index estimate of free T4 1.0 -4.3 U

(FT4I) FT4I = TT4 x RT3U

Total T3 (TT3) bound and free T3 75 -200 ng/dL

Resin T3 Uptake binding capacity of 25 -35%

(RT3U) TBG

TRH TRH 5 -25 mIu/mL

TSH TSH 0.5 - 4.70 µIU/mL

520
 American Association of Clinical
Endocrinologists guidelines changed
their normal range for TSH to
0.3 - 3.04 mIU/L.

Thyroglobulin Thyroglobulin 5-25 ng/mL

Radioactive Iodine Distribution of 5 hr – 5 to 15%

Uptake (RAIU) radiolabeled iodine in 24 hr – 15 to 35%
the thyroid

Notes:
Free T4 - much more useful then total T4 (e.g. interested in unbound or active form). Total
T4 not commonly measured. Greatly affected by TBG.
Free T4 index: indirect measure of free T4. Corrects for high/low values of TBG.
Total T3: not as useful as free T3, however, may be useful in locating problems with TBG,
or if looking for problems with peripheral conversion of T4 to T3.
Resin T3 Uptake: if low, then TBG binding capacity is high. Opposite if high.
TSH: best measure to determine thyroid function.
Thyroglobulin: nonspecific test that is elevated when the thyroid gland is inflamed or
enlarged.

Free T3 2.3-4.2 pg/ml

Total iron binding capacity

250 - 420 mcg/dl
(TIBC)

Transferrin > 200 mg/dl

Uric acid (male) 2.0 - 8.0 mg/dl

(female) 2.0 - 7.5 mg/dl

WBC + differential

WBC (cells/ml) 4,500 - 10,000

Segmented neutrophils 54 - 62%

Band forms 3 - 5% (above 8% indicates left shift)

521
Basophils 0 - 1 (0 - 0.75%)

Eosinophils 0 - 3 (1 - 3%)

lymphocytes 24 - 44 (25 - 33%)

Monocytes 3 - 6 (3 - 7%)

Absolute Neutrophil Count (ANC) - Oncology

Equations:
(1) Segs and bands reported as a percentage:
WBC * ((segs / 100) + (bands / 100))

(2) Segs and bands reported in total numbers:

WBC * (segs + bands)

Neutrophils (aka polymorphonuclear cells, PMNs, granulocytes, segmented neutrophils, or

segs) fight against infection and represent a subset of the white blood count. Neutropenia by
definition is an ANC below 1800/mm3 (some sources use a lower value).

Absolute neutrophil count (ANC) of 1000-1800:

Most patients will be given chemotherapy in this range.
Risk of infection is considered low.

Mild neutropenia - Absolute neutrophil count (ANC) of 500-1000:

Carries with it a moderate risk of infection.

Absolute neutrophil count (ANC) of less than 500:

Severe neutropenia - high risk of infection. Remember that a reduced WBC is known as
leukopenia.

The WBC consists of the following (differential):

Lymphocytes: 20-40%
Neutrophils: 50-60%
Basophils: 0.5-2%
Eosinophils: 1-4%
Monocytes: 2-9% (average: 4%).
ANC = Total WBC x (% "Segs" + % "Bands")
Equivalent to: WBC x ((Segs/100) + (Bands/100))

The ANC refers to the total number of neutrophil granulocytes present in the blood.

522
 Normal value: 1500 cells/mm3.
Mild neutropenia: 1000 - <1500/mm3.
Moderate neutropenia: 500 - <1000/mm3.
Severe neutropenia: < 500/mm3.

Reference:
Ayalew Tefferi, MD, ed. Primary Hematology. Totowa, NJ: Humana Press, 2001

Urinalysis • Urine Colour • Dipstick Overview table

• Urine Transparency • Analysis Chart
• Urine Odour • Laboratory Urine Analysis
• Dipstick Urinalysis • Urine Electrolytes and
Urinary Anion Gap

Laboratory
Electrolytes • HYPERkalaemia • HYPERphosphataemia
• HYPOkalaemia • HYPOphosphataemia
• HPERnatraemia • HYPERmagnesaemia
• HYPOnatraemia • HYPOmagnaesemia
• HYPERcalcaemia • HYPERchloraemia
• HYPOcalcaemia • HYPOchloraemia
Acid-Base • General Interpretation • Respiratory Acidosis
• Metabolic Acidosis • Respiratory Alkalosis
• Metabolic Alkalosis
Renal • Urea • Urea-Creatinine Ratio
Function • Creatinine • Urate (Uric Acid)
Liver • Liver Function Tests • Bilirubin
Function • Hyperammonaemia
Full Blood • Anaemia • Coagulation Studies
Picture
Fluid • Paracentesis (Ascitic • Arthrocentesis (Joint Tap)
Analysis Tap) • Cerebrospinal Fluid (CSF)
• Pleural Fluid Analysis
Pregnancy • BHCG, Rhesus D and
Progesterone
Endocrine • Thyroid Function Tests
(TFT)
Radiology
Chest X- • Chest X-Ray (CXR) • Normal CXR Anatomy
Ray
Abdominal • Abdominal X-Ray • Labeled AXR images
X-ray (AXR)
CT Head • CT Head interpretation • Labeled CT Head images

523
References:
Ayalew Tefferi, MD, ed. Primary Hematology.
Totowa, NJ: Humana Press, 2001

Stephen K. Bangert MA MB BChir MSc MBA

FRCPath; William J. Marshall MA MSc PhD
MBBS FRCP FRCPath FRCPEdin FIBiol;
Marshall, William Leonard (2008). Clinical
biochemistry: metabolic and clinical
aspects. Philadelphia: Churchill
Livingstone/Elsevier. ISBN 0-443-10186-8.
Abbassi-Ghanavati, M.; Greer, L. G.;
Cunningham, F. G. (2009). "Pregnancy and
Laboratory Studies".Obstetrics &
Gynecology 114 (6):
1326. doi:10.1097/AOG.0b013e3181c2bde8
.

Armbruster, David; Miller (August

2007). "The Joint Committee for
Traceability in Laboratory Medicine
(JCTLM): A Global Approach to Promote
the Standardization of Clinical Laboratory
Test Results". The Clinical Biochemist
Reviews 28 (3): 105–14.

Lee, Mary Ann (2009). Basic Skills in

Interpreting Laboratory Data. Amer Soc of
Health System. ISBN 1-58528-180-8

Note: Most of the Matters are drived from

Internet and Research Papers

524
GLOSSARY
Abdomen, that part of the human body which lies between the thorax and the pelvis,
containing the stomach, liver, spleen, pancreas, kidneys, bladder, and intestines.
Abducens, the sixth cranial nerve, which supplies the external rectus muscle of the eye.
Ablation, the act of removal of a bodily part by surgery.
Abort, to miscarry in giving birth.
Abortion, the act of spontaneous or induced expulsion of a fetus before it is at a viable
stage. See also miscarriage.
Abrade, to rub or wear through friction.
Abrasion. 1. the act of abrading. 2. an injury of the skin by abrading of the outer layer. 3,
any scraped area.
Abscess, a collection of purulent matter in the tissue of a body organ or part, with pain,
heat, and swelling.
Acantha, 1. the spine. 2. one of the acute processes of the vertebrae.
Acariasis, a skin disease caused by mites. See also scabies.
Accommodation, the adjustment of the eye lens whereby it is able to focus a clear image
onto the retina.
Accoucheuse, midwife.
Achalasia, failure of the sphincter or other muscular valves to relax normally and allow
the gastrointestinal contents to pass on.
Achilles heel, the point of weakness that is most vulnerable or susceptible.
Achondroplasia, defective development of cartilage causing dwarfism.
Achromatous, having no color; of a lighter color than is usual or normal.
Actinomycin, one of the yellow-red or red poly-peptide antibiotics separated from soil
bacteria.
Acuity, sharpness: acuteness; keen sense of perception.
Acupunture, an ancient Chinese technique of puncturing certain points in the body with
long thin needles to treat painful conditions and to produce local anesthesia.
Adactylia, absence of fingers or toes or both from birth.
Adam's apple, the prominence of the thyroid cartilage on the fore part of the throat,
predominantly in men.
Addict, one who is addicted to a practice or a habit, esp. to narcotics.
Addison's disease, a disease characterized by asthenia, digestive disturbances, and
usually a brownish coloration of the skin caused by disturbance of function of the
suprarenal glands.
Adduction, the action by which a part of the body is drawn toward the bodily axis.
Adductor, the muscle that draws toward the medial line of the body
Adenalgia, a glandular pain.
Adenectomy, the surgical removal of a gland.
Adenitis, inflammation of gland or lymph nodes.
Adenocarcinoma, a malignant tumor that appears in glandular epithelium,
Adenofibroma, a benign tumor of connective tissue frequently found in the uterus.
Adenoid, an enlarged mass of lymphoid tissue in the upper pharynx that hinders nasal
breathing.
Adenopathy, disease of glands.

525
Adenosarcoma, a malignant growth with characteristics of adenoma and sarcoma.
Adjuvant, a substance added to a prescription to aid the operation of the principal
ingredient or basis.
Adler's theory, an approach to psychology based on the hypothesis that behavior is
governed by an effort to compensate for inferiority or deficiency.
Adolescence, youth; the period of life between childhood and the full development of the
body, or from puberty to full maturity.
Adrenalin, a drug used as a heart stimulant, muscle relaxant, etc. (trademark).
Adrenaline, epinephrine, a hormone secreted by the medulla of the adrenal gland.
Adventitia, an external connective tissue that covers an organ.
Afflux, a flowing to, or that which flows to as a stream of blood or other fluid to any part
of the body.
Agglutination, the clumping together of bacteria or other cells because of the
introduction of an antibody.
Akinesia, complete or partial absence of muscle movement.
Albinism, lack of pigment; inability to produce pigment.
Albino, a person of abnormally pale, milky complexion, with light hair and pink eyes,
resulting from a deficiency in pigmentation.
Albumen, albumin, a member of a class of water-soluble proteins that are found in the
juices and tissues of animals, in the white or clear viscous part of eggs, and in vegetables,
and that contain sulfur, oxygen, hydrogen, carbon, and nitrogen.
Alcoholize, 1. to convert into alcohol. 2. to rectify (spirit) until it is wholly purified. 3. to
make drunk or put under the influence of alcohol
Alcoholophilla, pathological craving for alcohol
Alcoholuria, alcohol in the urine.
Alethia, inability to forget.
Aleukemia, deficiency of white blood cells
Alexia, a cerebral disorder marked by inability to read, or to read aloud.
Algesia, super sensitiveness or increased sensitivity to pain.
Alimentary canal, the canal from the mouth to the anus through which food passes;
digestive tract.
Alimentation, the act or power of affording nutriment; the state of being nourished
Alkalinity, 1. the state of being alkaline. 2. an excess of alkali.
Alkalinuria, presence of alkali in the urine.
Alkalosis, a condition wherein the concentration of alkali in the body is higher than
normal
Allele, in genetics, either a dominant or a recessive member of any pair of
alternative characters, as tallness and shortness, which are present as genes and
segregate at the time of sex cell production.
Allergen, any substance that induces allergy.
Allergy, excessive sensitivity producing a bodily reaction to certain substances, as
food, pollen, drugs, or heat or cold, which are harmless to most persons; common
allergies are hay fever, hives, and asthma.
Allopathy, method of treating disease by the use of agents producing effects different
from those of the disease treated; opposed to homeopathy, all-or-none, denoting either a
complete response to a stimulus by a nerve or muscle, or none at all.

526
Allotopia, displacement or malposition of an organ.
Aloe, medicinal plant that yields a purgative drug.
Alopacia, loss of hair.
Alum, common or potash alum is used as an astringent and a styptic.
Aluminosis, inflammation of the lungs caused by inhaling aluminum dust, an
occupational disease of alum workers.
Alveolar, pertaining to the sockets of the teeth.
Alveolar abscess, an abscess at the root of a tooth.
Amatgam, an alloy of mercury with another metal or metals.
Amaranth, a purplish-red nitrogen dye used to color medicines, cosmetics, and food.
Amastia, absence of breast development.
Amaurosis, partial or complete loss of sight from loss of power in the optic nerve or
retina, without any visible defect in the eye except an immovable pupil.
Ambidextrous, having the faculty of using both hands with equal ease and facility.
Ambivalence, coexistence of contradictory feelings about a particular person, object, or
action.
Ambiversion, the state of being an ambivert.
Ambivert, a person possessing characteristics of both the introvert and the extrovert.
Ambiyopia, dullness or dimness of eyesight without any apparent defect in the organs.
Ambulate, to walk; travel; move about.
Amelioration, improvement; moderation of a patient's condition.
Amenorrhea, a morbid or unnatural suppression of menstruation.
Aminopyrine, a drug used as a fever preventive and pain reliever.
Amitosis, the direct method of cell division, characterized by simple cleavage of the
nucleus, without formation of chromosomes.
Amnesia, partial or complete loss of memory.
Amnion, the innermost membrane surrounding the fetus.
Amniotic fluid, the liquid or albuminous fluid contained in the amnion in which the
embryo floats and which protects the fetus from injury.
Amoebic dysentery, a form of dysentery characterized by ulceration of the intestinal
tract caused by the amoeba.
Amphetamine, a compound used as a drug to stimulate the central nervous system;
prolonged use may cause drug dependence.
Amputate, to cut off, as a limb or other member, by a surgical operation; to remove all or
part of by cutting.
Amputee, one who has had one or more limbs, or parts of limbs, amputated.
Amusia, music deafness; inability to produce or comprehend musical sounds.
Amyella, underdevelopment or congenital absence of spinal cord.
Amygdalin, a white glycosidic powder, obtained from bitter almonds, chiefly used
medically as an expectorant.
Amylase, any of the enzymes that convert starch into sugar, as in saliva.
Amyloid, 1. starchlike; resembling starch. 2. a protein complex of starch like
characteristics forming a hard substance in tissues during diseases.
Amylolysis, the conversion of starch into sugar, esp. by enzymes.
Amylopsin, an enzyme of the pancreatic juice, capable of converting starch into sugar.
Amyocardia, weakness of the heart muscle.

527
Amyosthenia, lack of muscle tone; muscular weakness.
Amyotonia, extreme flaccidity and smallness of the muscles, occurring mostly in early
childhood.
Amyotrophic lateral sclerosis, a chronic disease marked by muscular weakness and
atrophy resulting from degeneration of the nerve tracts that supply the muscles, causing
virtual paralysis.
Amyotrophy, painful muscle wasting, usually of the deltoid muscle.
Anabiosis, a return to life from a state resembling death.
Anabolism, constructive metabolism: opposed to catabolism.
Anadipsia, intense thirst.
Anakusis, complete deafness.
Anal, pertaining to or situated near the anus.
Analeptic, invigorating; giving strength after disease; awakening, especially from drug
stupor.
Analgesia, absence of sensibility to pain while retaining consciousness analgesic, 1.
pertaining to or causing analgesia 2. a remedy that relieves pain.
Anamnesis, the original case history of a psychiatric or medical patient. Anaphase, the
stage in mitosis in which the chromosome halves move away from each other toward
opposite ends of the cell.
Anaphia, lack of or diminished sense of touch
Anaphoresis, insufficient or defective activity of the sweat glands,
Anaphoretic, a substance that prevents sweating.
Anaphrodisia, diminished sexual desire or sexual impotence.
Anaphylaxis, increased susceptibility to the action of a foreign protein such as penicillin,
as the result of a first injection of the substance. A special form of severe shock can
follow a second injection.
Anasarca, dropsy, of considerable extent, in the subcutaneous connective tissue.
Anastigmat, a system of lenses in which anastigmatic defects are overcome.
Anastomosis, union of vessels such as arteries and veins.
Anatomist, one who is skilled in dissection or in the principles of anatomy. Anatomy, 1.
the structure or study of the body. 2. dissection or cutting apart of an organized body.
Ancon, the upper end of the ulna or elbow.
Ancylostomiasis, hookworm disease, caused by any of certain bloodsucking nematode
worms equipped with mouth hooks, which feed off the lining of the intestine of men and
animals. The disease is characterized by severe anemia.
Anencephaly, impaired development of the brain and spinal cord.
Anesthesia, 1. diminished or lost sense of feeling because of disease. 2. an artificially
produced state of insensitivity, esp. to pain.
Aneurysm, a localized dilation of an artery, caused by the pressure of the blood acting on
a part weakened by disease.
Angel's wing, abnormal prominence of the shoulder blades; also called winged scapulae.
Angina pectoris, a disease characterized by paroxysms of acute pain in the chest, with a
sense of suffocation, associated usually with morbid conditions of the heart or arteries
caused by ischemia of the heart muscle.
Angiocardiogram, an X ray of the heart and great blood vessels after the intravenous
injection of a solution that makes the shape of these organs visible.

528
Angioma, a tumor consisting chiefly of dilated or newly formed blood or lymph vessels.
Angioneurectomy, surgical removal of nerves and blood vessels.
Angioplasty, repair of blood vessels by plastic surgery.
Anguish, 1. extreme pain or distress of either body or mind. 2. any keen affection of the
emotions or feelings.
Anhydremia, lowering or lessening of the normal fluid content of the blood Anhydrous,
free of water.
Ankylosis, 1. stiffness and immovability of a joint, as a result of disease or surgery. 2.
morbid adhesion of the articular ends of contiguous bones.
Annular, having the form of a ring; pertaining to a ring.
Annular ligament, a ring shaped ligament
Anodyne, 1. any medicine that allays pain. 2. any thing that diminishes stress.
Anomalous, pertaining to an anomaly; irregular-peculiar; abnormal.
Anomaly, 1. deviation from the common rule. 2. a malformation. 3. some thing
abnormal.
Anonychia, absence of nails.
Anopheles, a mosquito which, when infected with the organisms causing malaria, may
transmit the disease to human beings by biting.
Anorexia, pathological loss of appetite.
Anorexia nervosa, loss of appetite accompanied by psychotic symptoms. Anosmia,
deficiency or loss of the sense of smell.
Anovulation, cessation of production or discharge of ova.
Anoxemia, a condition characterized by an abnormally low amount of oxygen in
arterial blood.
Anthrax, 1. a carbuncle. 2. a malignant ulcer. 3. a malignant infectious disease of certain
warm blooded animals, which may be transmitted to man.
Anthropophobia, a pathological fear of human companionship or of society in general.
Anthropology, the science of man and mankind, including the study of the physical and
mental constitution of man, his cultural development and social conditions, as exhibited
both in the present and in the past.
Antibiotic, any of a variety of substances produced by fungi or synthetically which, in
diluted solution, inhibit or destroy bacteria.
Antibody, any of various substances existing in the blood or developed in immunization
that counteract toxins or bacterial poisons in the system. Anticoagulant, any agent that
prevents coagulation, esp. of the blood.
Antidote, a medicine that neutralizes the effects of poison.
Antienzyme, 1. a substance that retards, inhibits, or prevents enzymatic action. 2. a
chemical substance (an antibody) produced by an organism to inhibit or counteract the
effect of a foreign enzyme.
Antifebrile, having the quality of abating fever.
Antigalactic, an agent that diminishes or prevents the secretion of milk.
Antimony, a metallic element used chiefly in alloys and in medicine
Antipathy, natural aversion.
Antipyretic, a remedy efficacious against fever.
Antisepsis, 1. the inhibition or destruction of microorganisms. 2. prevention of sepsis.

529
Antiseptic, 1. pertaining to or effecting antisepsis. 2. devoid of germs. 3. an agent that
inhibits the growth of microorganisms.
Antiserum, a serum containing antibodies for a specific antigen.
Antitoxin, a substance formed in the body, capable of counteracting a specific toxin or
infective agency.
Antitussive, substance capable of controlling or counteracting a cough.
Anuresis, inability to bring about the act of urination.
Anuria, 1. total suppression of urine. 2. failure to urinate because of lack of urine.
Anxiety, pain or uneasiness of mind in respect to some future or uncertain event.
Aortic stenosis, narrowing of the aorta resulting from lesions of the wall caused by scar
tissue or infection as rheumatic fever; hypertrophy of the heart is a usual result.
Aortitis, inflammation of the aorta.
Apareunia, inability to have sexual intercourse.
Apathetic, 1. affected with or proceeding from apathy. 2. devoid of feeling; insensible. 3.
displaying no emotion; indifferent.
Apathy, 1. want of feeling. 2. privation of passion, emotion or excitement. 3. in-
sensibility; indifference.
Aperient, 1. gently purgative. 2. a medicine that gently opens the bowels; a laxative.
Aperiodic, 1. not periodic, as a fever. 2. of irregular occurrence.
Aperitive, a stimulant for the appetite.
Aphagia, inability to swallow.
Aphakia, absence of the crystalline lens of the eye.
Aphasia, loss of the fluency of speech, or of connecting words and ideas.
Aphonia, loss of voice.
Aphonogelia, the inability to laugh out loud.
Aphrasia, a nervous disorder that causes inability to use connected phrases when
speaking.
Aphrodisia, sexual passion.
Aphrodisiac, 1. exciting sexual desire. 2. food or medicine exciting sexual desire.
Aplasia, congenital absence or defective development of a tissue or organ.
Apnea, temporary cessation of breathing.
Apocrine, pertaining to cells that lose part of their cytoplasm while functioning, esp.
gland cells, such as the cells of the mammary glands and of certain sweat glands.
Apodal, having no feet.
Apomorphine, a drug used as an emetic and expectorant.
Aponeurosis, a white, shining, and very resistant membrane, surrounding the voluntary
muscles and large arteries.
Apoplexy, abolition or sudden diminution of sensation and voluntary motion, resulting
from congestion or rupture of a blood vessel of the brain (stroke).
Appendectomy, surgical excision of the vermiform appendix.
Appendicitis, inflammation of the appendix.
Appendicular, relating to an appendage or limb.
Appestat, an area of the brain supposed to control appetite for food and satiety.
Arachnoid, weblike.
Arachnoid membrane, the semitransparent, thin center membrane that covers the brain
and spinal cord.

530
Arcuate, bent or curved in the form of a bow or an arc.
Arcus, an arc or arch.
Aribofiavinosis, a disease caused by a deficiency of riboflavin (vitamin B2, or G) in the
diet.
Arnica, a composite plant, also called mountain tobacco. A tincture of its dried flower
heads is used as an application to wounds and bruises.
Arsenic, an element of grayish-white substance with a metallic luster, forming poisonous
compounds used in medicine and industry.
Arterial, pertaining to an artery or to the oxygenated blood contained in the arteries.
Arterioplasty, an operation to repair or reconstruct an artery.
Arteriosclerosis, a disease in which thickening of the walls of arteries impedes
circulation of the blood.
Arteriospasm, spasm of an artery.
Arteriostenosis, temporary or permanent narrowing of the duct of an artery.
Arthralgia, pain, esp. neuralgic pain, in a joint.
Arthritis, any inflammation of the joints.
Arthrography, the inside of a joint shown by X rays. It is usually necessary to inject the
joint with a substance opaque to X rays.
Arthroplasty, 1. surgical repair of a joint. 2. the making of an artificial joint.
Arthrosclerosis, stiffening or hardening of a joint or joints, occurring esp. in the aged.
Articulation, 1. a joining or juncture, as of the bones. 2. the part between two joints. 3. a
joint. 4. distinct and clear speech.
Artifact, any unnatural change in structure or tissue.
Artificial insemination, mechanical injection of spermatozoa into the uterus.
Asteatosis, any disease in which there is a loss of activity of the sebaceous glands or
scantiness of their secretions.
Asthenopia, weakness of the eye muscles or visual power because of fatigue.
Asthma, a chronic, paroxysmal disorder of respiration, characterized by difficulty in
breathing.
Astigmatism, a detect of the eye or of a lens whereby rays of light from an external point
fail to converge to a focus, thus giving rise to imperfect vision or images.
Astraphobia, pathological fear of lightning and thunderstorms.
Astringent, 1. contracting; styptic. 2. an agent that contracts the organic tissues and
canals of the body, thereby checking or diminishing bleeding or excessive discharges. 3.
an astringent substance, as alum, catechu, etc.
Astrocyte, a star-shaped neurological cell.
Astrocytoma, a tumor formed by astrocytes.
Asystole, faulty contraction of the ventricles of the heart, preventing it from performing a
complete systole.
Atactilla, failure of the sense of touch.
Ataractic, a drug that decreases anxiety or tension; a tranquilizer
Atavism, the recurrence of any peculiarity or disease of an ancestor.
Ataxia, irregularity in the functions of the muscles.
Atelectasis, 1. partial collapse of the lung. 2. failure of the lung to expand completely,
esp. at birth.

531
Athetosis, a condition in which the hands and feet continually perform involuntary, slow,
irregular movements.
Athlete's foot, ringworm of the feet, a contagious disease caused by a fungus that grows
in wet or damp areas.
Athrombia, defective clotting of the blood.
Atlas, the first vertebra of the neck.
Atomizer, an apparatus for reducing a liquid to a spray for disinfecting, cooling,
perfuming, etc.
Atony, 1. a want of tone; flaccidity. 2. defect of muscular power; debility.
Atopy, an allergic disorder, as acquired or inherited hypersensitivity of the skin to a drug
or other agent.
Atrioventricular, relating or referring to both the ventricles and atria (auricles) of the
heart.
Atrophy, a wasting away of the body or of an organ or part, as from defective nutrition
or other causes; degeneration.
Atropine, a highly poisonous alkaloid obtained from the deadly nightshade, used esp. to
dilate the pupil of the eye and alleviate spasms.
Attenuate, to make thin; to make slender or fine; to reduce in density; to dilute; to
weaken; to lower; to reduce.
Auditory nerve, the nerve of hearing, going from the organs of hearing and the
semicircular canals to the brain; the eighth cranial nerve.
Aura, a feeling or sensation that precedes an attack of some kind, such as hysteria or
epilepsy.
Aural, relating to the ear.
Aureomycin, an antibiotic isolated from a fungus (trademark).
Auricle, 1. the external ear. 2. either of the two cavities in the heart, situated above
the two ventricles and resembling in shape the external ear.
Auscultation, a method of distinguishing the state of the internal parts of the body,
particularly of the chest, by observing the sounds arising there through the application of
the ear or the stethoscope.
Autism, the tendency to escape reality through day dreams or fantasy.
Autogenous, self-produced; generated within the body.
Autograft, a graft made by taking tissue from one part of the body and using it at another
part of the same body.
Autologous, grafted, transplanted, or relocated within the same body.
Autolysin, any agent or substance that produces autolysis.
Autoplasty, the repairing of lesions with tissue from another part of the same body.
Autopsy, dissection and inspection of a body after death to determine the cause of death;
a postmortem examination.
Autosome, any chromosome that is not a sex chromosome.
Beriberi, a form of multiple neuritis caused by a lack of vitamin B. characterized by loss
of muscular power, emaciation, and exhaustion.
Bifurcation, a forking or division into two branches.
Binocular, pertaining to or employing both eyes.
Biotype, a group of organisms or individuals having many of the same or similar genetic
traits and physiological characteristics.

532
Biovular, originating from two ova, such as fraternal twins.
Birthmark, a congenital mark on the body.
Birthrate, the ratio of the number of births in a given time and population to the total
population (usually expressed in terms of the number of births per one thousand of
population).
Birth trauma, severe emotional stress experienced by a child at birth, considered in
psychoanalytic theory a likely source of neurosis in later years.
Bisexual, 1. having the organs of both sexes in one individual. 2. of two sexes.
Blackhead, a comedo or skin blemish consisting of a blackish fatty secretion in a follicle.
Blackwater fever, an acute form of malaria occurring in tropical and semitropical
regions, characterized by febrile paroxysms and bloody urine.
Blastema, the mass of un-differentiated cells from which an organ or a body part
evolved during embryonic development.
Blastoma, a tumor originating in immature cells.
Blistomere, any of the cells into which the ovum segments after fertilization.
Blennuria, an excess of mucus in the urine.
Blister, a thin vesicle on the skin containing watery matter or serum, as from an injury; a
pustule.
Blood bank, an institution for storing and processing blood or blood plasma.
Blood corpuscle, 1. a cell circulating in the blood. 2. a red ceil or corpuscle; see also
erythrocyte. 3. a white cell or corpuscle; see also leukocyte.
Blood count, determination of the number and proportion of red and white cells in a
specific volume of blood.
Blood group, one of several classifications into which human blood can be divided,
based on the proportion of specific antigens.
Blood plasma, the clear, almost colorless fluid of the blood when separated from blood
corpuscles by centrifuging; used in blood transfusions.
Blood pressure, the pressure exerted by the blood against the inner walls of the blood
vessels, varying in different parts of the body, with exertion, excitement, strength of the
heart, age or health.
Bronchitis, an inflammation of the lining membrane of the bronchi or bronchia.
Bronchodilatation, dilation of a bronchus with a bronchodilator, a drug that dilates the
bronchus and the bronchial tubes.
Broncho pneumonia, inflammation of the bronchia and lungs: a form of pneumonia.
Bronchoscopy, examination of the interior of the bronchus with a bronchoscope.
Bubonic plague, an epidemic disease caused by infection from rodents and fleas and
characterized by the formation of buboes.
Bunion, a knob on the side of the ball of the great toe resulting from chronic
inflammation at the bursa.
Bursectomy, removal of a bursa by surgery.
Cachexia, a state of extreme wasting occurring in persons with chronic diseases, as
certain malignancies.
Cachou, a pill or pastille for sweetening the breath.
Cacidrosis, excessive, offensive sweating.
Cacoethes, 1. a strong compulsion; mania. 2. a bad habit, as of incessant talking.
Cadaver, a dead body, asp. of a human being used for dissection; a corpse.

533
Cadaverous, pertaining to a dead body; esp. having the appearance or color of a dead
human body.
Caduceus, the emblem of the medical profession
Caducity, tendency to fall; frailty; the infirmity of old age; senility.
Caesarean operation, the operation by which a fetus is taken from the uterus by cutting
through the walls of the abdomen and uterus.
Caffeine, a slightly bitter alkaloid used as a stimulant and diuretic and found in coffee,
tea. etc.; poisonous when taken in large doses.
Caisson disease, a painfully paralyzing, sometimes fatal sickness resulting from a too
rapid lowering of air pressure, as in the change from the compressed air of a caisson to
surface air pressure, which causes dissolved nitrogen to be released as bubbles in the
blood and tissues; the bends.
Calamine, a pink, water-insoluble powder consisting of zinc oxide and a small amount of
ferric oxide, used in lotions and ointments to treat skin disorders.
Calcareous, partaking of the nature of. having the qualities of or containing calcium
carbonate.
Calcic, of or pertaining to lime, containing calcium.
Calciferol, vitamin D2, a crystalline, fat-soluble compound, occurring naturally in milk
and fish-liver oils.
Calcification, the process of changing a substance through the deposition of lime.
Calcinations, the drying of a substance by roasting to make a powder.
Calcine, to reduce to a powder or to a friable state by the action of heat.
Calcinosia, a state characterized by abnormal deposits of lime salts in tissues.
Calclpenla, calcium deficiency in the body.
Calcium, the basic element of lime, an essential Ingredient of bones and teeth.
Calcium carbonate, a colorless crystal or gray powder used as an antacid.
Calculous, pertaining to, caused by, or affected with a calculus or calculi.
Calculus, a stone like mass sometimes formed in the gallbladder, kidneys, or other
organs or ducts of the body.
Calf, the fleshy back part of the human leg below the knee.
Calisthenics, the art or practice of exercising for health, strength, or grace
of movement.
Callosity, abnormal hardness and thickness of skin and other tissues.
callous, 1. tiard, assKin. 2, indurated, as portions of the skin exposed to friction.
Callus, 1. a hardened or thickened portion of the skin; a callosity. 2. a new growth of
osseous matter at the ends of a fractured bone, serving to unite them.
Caloric, of or pertaining to heat or calories.
Calvaria, the cranium; skull.
Calyx, a cuplike part, as one of the funnel-shaped structures that enclose the tips of the
renal pyramids.
Camphor, a whitish, translucent, volatile, and aromatic crystalline substance, obtained
chiefly from the camphor tree, used in medicine and as an irritant and stimulant.
Camphor ice, an ointment composed chiefly of camphor, white wax. spermaceti,
and castor oil, used for chapped or blemished skin.
Canal, any cylindrical or tubular cavity in the body through which solids and liquids
pass, a duct.

534
Canaliculus, a tubular or canal like passage or channel, as in a bone.
Cancellate, of spongy or porous structure.
Cancer, a malignant growth or tumor, esp. originating in the epithelium, and
characterized by abnormal cellular growth that spreads to other areas.
Canella, the cinnamon like bark of a West Indian tree, used as a condiment and in
medicine.
Canine, pertaining to the four pointed teeth situated one on each side of each jaw, next to
the incisors.
Canker, 1. a kind of cancerous, gangrenous, of ulcerous sore or disease. 2. an eating,
corroding, or other noxious agency producing ulceration, gangrene, rot, decay, and the
like.
Canker sore, an ulcerated sore of the lips or membranous lining of the mouth.
Cannabis, the tops and leaves of Indian hemp used as a narcotic or intoxicant.
Cannula, a small tube of metal or the like that draws off fluid from or injects medicine
into the body.
Cannular, hollow or tubular; as a cannulated needle, a surgeon's hollow needle,
cantharidism, a morbid state caused by the use of cantharis.
Cantharis, a substance obtained from dried and crushed blister beetles and used in
medicine, esp. externally for raising blisters and formerly as a stimulant.
Canthectomy, surgical excision of a canthus.
Canthus, the angle or corner on each side of the eye formed by the junction of the upper
and lower lids.
Capiat, an instrument for removing a foreign substance from the uterus or other body
cavities, capillarity, the state of being capillary.
Capitellum, 1. the round eminence at the lower end of the uterus. 2. any small, rounded
knob on a bone.
Capsicum, the pod of the pepper plant which, when dried and prepared, is used in
medicine as an irritant and a stimulant.
Carbohydrate, a member of several groups of compounds including simple sugars such
as glucose, double sugars such as sucrose, and polymers such as starch and cellulose; one
of the major sources of food.
Carbon 13, a rare carbon isotope used in cancer research and tracer studies.
Carbon dioxide, a heavy, colorless, odorless, noncombustible gas, present in the
atmosphere and formed during respiration.
Carbon monoxide, a colorless, odorless, very poisonous gas, which bums with a pale
blue flame and is formed when carbon bums with an insufficient supply of air.
Carbon monoxide poisoning, poisoning by inhalation of carbon monoxide. It causes
dizziness, headache, and convulsions and can lead to paralysis and death, Carbuncle, a
painful local inflammation of tissues, esp. of the back of the neck and trunk, charac-
terized by hardness and having a tendency to spread like a boil. Carcinectomy, the
surgical excision of a cancerous growth.
Carcinogenic, pertaining to the development of cancer.
Carcinoid, a benign tumor in the appendix or other intestinal tissue.
Carcinoma, a malignant epithelial tumor that spreads and often recurs after excision; a
cancer.
Carcinomatophobia, pathological fear of cancer.

535
Carcinomatosis, a state in which numerous carcinomas, disseminated from a primary
source, grow in the body at the same time.
Cardiectomy, surgical excision of the cardiac end of the stomach.
Cardiogram, the record of heart action made by a cardiograph.
Cardiograph, an instrument that traces and records the action of the heart.
Cardiotomy, surgical incision of the heart.
Cardiovalvulitis, inflammation of the valves of the heart.
Cardiovascular, having reference to or involving the heart and blood vessels, Carditis,
inflammation of the muscles of the heart.
Carminative, 1. Expelling wind from the body or relieving flatulence. 2. a
carminative medicine.
Carnophobia, pathological fear of eating meat.
Carotene, the orange or red hydrocarbon pigment found in some vegetables and animal
fats, capable of being converted into vitamin A
Carpophalangeal, pertaining to the carpus and the phalanges or the finger bones.
Carpus, 1. the part of the skeleton between the forearm and hand: the wrist. 2. the wrist
bones collectively.
Carrier, a person carrying bacteria that he can transmit to others although immune to
their effects himself.
Caron oil, an ointment composed of equal parts of lime water and olive oil, used as
treatment for burns and scalds.
Car sickness, nausea caused by motion, esp. when riding in a car.
Cartilage, 1. an elastic tissue composing most of the skeleton in embryos, then largely
being converted into bone. 2. the gristle or specialized connective tissue between bones.
Caseous, cheesy; as caseous degeneration, pertaining to a morbid process in which
tissues are converted into a thick, cheese like mass.
Cassia, a tropical plant that yields senna, used as a purgative.
Cast, 1. fibrous matter that takes the shape of the organ in which it is formed and is
ejected from The Body. 2. a mold made of plastic or plaster of paris, usually applied for
immobilization, as in fractures, dislocations, and other injuries.
Castor bean, the seed of the castor-oil plant.
Castor oil, a viscid oil obtained from the castor bean, used as a cathartic or lubricant.
Castrate, to remove the testicles or the ovaries.
Castration, removal of the sex glands in either male or female.
Cataleptic, a parson with catalepsy.
Cataract, a disease of the eye consisting of opacity of the crystalline lens or its capsule,
which impairs or destroys vision.
Catarrh, inflammation of a mucous membrane, esp. of the respiratory tract accompanied
by exaggerated secretions.
Catatonia, 1. a state of suspended animation with loss of voluntary motion; catalepsy. 2.
any of several schizophrenic syndromes in which the patient exhibits muscular rigidity
and periods of stupor alternating with periods of agitation Catatonic, pertaining to
Catatonia.
Catechu, a strong, astringent substance prepared from the wood of various tropical
Asiatic plants and used in medicine with prepared chalk to treat diarrhea,

536
Catgut, a substance made from the intestine of sheep and other animals for use as an
absorbable ligature.
Catharsis, 1. purgation 2. emotional release by recalling the memory of an event that
was the cause of a psychoneurosis.
Cathartic, pertaining to catharsis.
Cathator, a hollow tube inserted into the body to allow the withdrawal or injection of
fluids, usually inserted through the urethra into the bladder to draw off urine when natural
discharge is arrested.
Cauda equine, the terminal portion of the spinal cord that resembles a horse's tail.
Caudal anesthesia, insensibility to pain in the lower portion of the body, caused by
injection of an anesthetic drug into the caudal or sacral part of the spinal canal.
Cautery, 1. a burning or searing, as of diseased tissue, by a hot iron or by caustic
substances. 2. the instrument or chemical agent employed in cauterizing.
Cava, 1. any body cavity.
Cavernous, 1. containing caverns. 2. of or like a cavern. 3. full of or containing small
cavities or interstices; porous.
Cecectomy, surgical removal of part of, or incision of, the cecum,
Cecum, a sac or cavity with an opening only at one end. esp. the intestinal cecum, or
"blind gut" in humans, at the beginning of the large intestine.
Celiac disease, 1. a disease common to the tropics, characterized by anemia, sore tongue,
and gastrointestinal disturbance. 2. a dietary deficiency disease occurring in children.
Cellulose, the chief constituent of the cell walls of plants.
Cementum, the layer of bony tissue forming the outer surface of the root of the tooth
within the gum.
Cenogenesis, the introduction of new characters in the development of an individual,
absent from early phylogeny of the species.
Central nervous system, the part of the nervous system consisting of the brain and
spinal cord, with their nerves and end-organs, which control and coordinate the entire
voluntary nervous system.
Cephalad, toward the head opposed to caudad.
Cephalic, 1. of or pertaining to the head. 2. situated or directed toward the head.
Cephalic Index, the ratio of the greatest breadth of the skull to the greatest length from
front to back, multiplied by 100.
Cerate, a thick ointment composed of oils mixed with wax, resin, etc., and medicinal
ingredients.
Cerebellum, a large section of the brain, the coordinating center for voluntary
movements, equilibrium, and posture, composed of a central lobe and two lateral lobes,
and located posterior to and underlying the cerebrum.
Cerebral hemisphare, either of the two convoluted halves of the cerebrum.
Cerebral palsy, paralysis caused by brain damage prior to birth or during delivery, and
marked by a lack of muscular coordination, spasms, and difficulties in speech.
Cerebral thrombosis, a clot in a blood vessel of the brain.
Cerebrate, to have or exhibit brain action to think.
Cerebration, mental activity.
Cerebrospinal, of or pertaining to the brain and spinal cord, or to these coupled with the
spinal and cranial nerves.

537
Cerebrospinal fever, see cerebrospinal meningitis.
Cerebroapinal fluid, a serum like liquid in the lateral ventricles of the brain.
Cerebrospinal meningitis, an acute bacterial disease. involving inflammation of the
membranes covering the brain and spinal cord, and manifested by fever and sometimes
red spots on the skin.
Cerebrum, the main, anterior part of the brain, divided into halves, or cerebral
hemispheres, and considered the center of conscious and voluntary processes. Cervical,
1. belonging to the neck. 2. pertaining to the narrow lower part of the uterus,
Cheek, 1. either side of the face below the eye and above the tower jawbone.
2. something resembling the cheeks, as for instance any rounded prominence, as the
buttocks.
Cheilitis, inflammation of the lip.
Cheiloisis, a condition in which fissures and ulcers appear at the angles of the mouth,
caused by vitamin B deficiency.
Chemoreception, the physiological response of a sense organ to the reception of
chemical stimuli.
Chemotaxis, the movement of a cell or organism toward or away from a chemical
stimulus.
Chemotherapy, treatment of disease with chemicals.
Cherophobia, pathological fear of and aversion to pleasure.
Chiasma, a crossing as of two tendons or two nerves.
Chicken pox, an acute contagious, eruptive disease generally appearing in children.
Chigoe, an insect closely resembling the common flea, but of more minute size, which
burrows beneath the skin and becoming distended with eggs, produces a troublesome
ulcer.
Chilblain, 1. a blain or inflamed sore on the hands or feet. produced by cold 2. to afflict
with chilblains; to produce chilblains on.
Child bearing, the act of producing or bringing forth children: parturition.
Chiropractic, a system of therapeutics based upon the theory that disease is caused by
interference with nerve function, the method being to restore normal condition by ad-
justing body structures esp. the spinal column.
Chiropractor, one who practices chiropractic.
Chloasma, a skin discoloration caused by deposits of pigment and occurring in patches
or spots of yellowish-brown color.
Chloral, 1. a colorless mobile liquid first prepared from chlorine and alcohol. 2. awhile
crystalline substance "chloral hydrate" formed by combining liquid chloral with water,
and used as a hypnotic and an anesthetic.
Chloralose, a crystalline compound, made by combining chloral with dextrose: used in
medicine as a hypnotic.
Chloramphenicol, a synthetic antibiotic used to treat typhoid fever and other infections
caused by Salmonellae.
Chloroma, green cancer, a greenish tumor in certain bones, a condition mainly affecting
young people.
Chlorophyll, the green coloring matter of plants and leaves, used in the manufacture of
carbohydrates.

538
Chlorosis, loss of the normal green color in a plant, from lack of iron in the soil or other
causes, exclusive of lack of sunlight.
Chlortetracycline, an antibiotic, having a antimicrobial spectrum, and also used as an
animal feed supplement,
Choke, to stop the breath of, by stricture of or obstruction in the windpipe: strangle;
suffocate.
Cholangitis, inflammation of the bile ducts.
Cholecystectomy, surgical removal of the gallbladder.
Cholecystitis, inflammallon of the gallbladder.
Cholecystolithiasis, the presence of gallstones in the gallbladder.
Cholesystotomy, removal at gallstones by surgical incision of the gallbladder.
Choledochitis, inflammation of the bile duct.
Choleric, pertaining to bile.
Cholelithiasis, presence of bile stones in the gallbladder
Cholelithotomy, removal at gallstones by surgical incision of the gallbladder, Cholemia,
presence of bile or bile pigments in the blood, causing jaundice. Cholera, any of several
acute infectious diseases of humans and domestic animals, characterized by severe
intestinal disturbances.
Chondritis, inflammation of a cartilage.
Chondromalacia, softening of cartilage.
Chondropathy, any disease of cartilages.
Chorda, any nerve filament.
Chorea, St. Vitus's dance; convulsive motions of the limbs and strange and involuntary
gesticulations
Chorion, the vascular outer membrane enveloping a fetus, enclosing the amnion.
Chorioretinitis, inflammation of the choroid and the retina.
Choroid, l. the middle coat of the eye. 2. pertaining to the choroid. 3. resembling the
chorion and corium.
Choroiditis, inflammation of the choroid membrane of the eye.
Chromatid, one of a pair of chromosomal strands formed when a chromosome
duplicates during cell reproduction.
Chromatin, the constituent of a chromosome that is believed to carry the genes and that
stains deeply with basic dyes,
Chromatosis, abnormal skin pigmentation.
Chromoprotein, a protein compound, as hemoglobin, made up of a protein combined
with a pigment or a carotenoid.
Chromosome, one of the rod or thread shaped bodies containing chromatin that carry the
genes and are present, in a fixed number for each species, in all the cell nuclei of plants,
animals, and humans.
Chronic, long-lasting or recurring frequently over a long period of time; of a disease or
ailment of long duration or repeated occurrence, as differentiated from acute: as chronic
arthritis.
Chyle, the milk like fluid found in the intestinal lymph vessels, produced during
digestion of fats.
Chime, the small liquid mass into which food is converted by gastric secretion during
digestion.

539
Cilia, the hairs that grow from the margin of the eyelids; eyelashes.
Ciliary, 1. belonging to the eyelids or eyelashes, 2. pertaining to or performed by
bibratile cilia; as, ciliary motion.
Cinchona, any of the trees or shrubs constituting the genus cinchona and cultivated for
the bark, which yields quinine and other alkaloids.
Cinchonine, an alkaloid obtained from the bark of several species of cinchona, along
with quinine, and one of the medicinal active principles of this bark, used to reduce fever.
Cinchonism, a disturbed condition of the body characterized by dizziness, ringing of the
ears, temporary deafness, and headache, the result of overdoses of cinchona or quinine.
Cinnamon, the inner dark of a tree of the laurel family, used as a spice or in medicine as
a cordial or carminative.
Circadian rhythm, rhythmic changes that occur during a period of 24 hours. See
biological clock.
Cirsotome, instrument for cutting varicose veins.
Cirsotomy, multiple surgical incisions of veins as treatment of a varicosity.
Citric acid, the acid derived from lemons and similar fruits or obtained by the
fermentation of carbohydrates, used to flavor foods, beverages, and pharmaceuticals and
to condition water.
Clamp, a surgical device to grasp, compress, or support tissue or a vessel.
Clavicular, pertaining to the clavicle.
Clavus, a horny growth on the skin; a corn,
Cleft palate, a congenital malformation in which more or leas of the palate is lacking, so
as to leave a longitudinal gap in the upper jaw often an accompaniment of harelip.
Cleidotomy, a surgical operation in which a fetal clavicle is divided to make delivery
possible.
Clinic, a medical institution in which a group of physicians jointly examine and treat
patients.
Clinical, 1. pertaining to clinic. 2. based on examination or diagnosis in a clinic. 3.
dealing with the study of patients as opposed to laboratory experiment.
Clinician, a physician who studies diseases at the bedside or is skilled in clinical
methods.
Clitoris, a small erectile organ of the female, located at the anterior part of the vulva, and
homologous to the penis of the male.
Cloaca, a cavity at the posterior end of the embryo into which urinary, digestive, and
reproductive ducts open.
Clonic, convulsive, with alternate relaxation.
Clonic spasm, a spasm in which the muscles or muscular fibers rapidly contract and
relax alternately, as in epilepsy.
Clot, a coagulated mass of soft or fluid matter, as of blood or lymph.
Clotting, to coagulate, as soft or fluid matter, into a thick, inspissated mass. Blood
clotting insures the stoppage of blood flow.
Cocainism, 1. addiction to the habitual use of cocaine. 2. the general breakdown due to
excessive or habitual use of cocaine.
Cocainize, to treat with or affect by cocaine.

540
Coccidioidomycosis, a fever and pulmonary disease or sometimes a skin infection in the
form of lesions, occurring in man and some animals, and caused by inhaling the spores
of the fungus.
Coccyx, a small triangular bone forming the lower extremity of the spinal column,
consisting of four ankylosed rudimentary vertebrae.
Cochlea, a bony structure in the internal ear, so called from its resemblance to a snail
shall.
Coconscious, pertaining to mental process apart from but influencing the stream of
consciousness often characterized by unintended utterances or hallucinations.
Codeine, a white, crystalline, slightly bitter alkaloid, obtained from opium, used in
medicine as an analgesic, a sedative, and a hypnotic.
Cohabit, to dwell or live together as husband and wife: often applied to persons not
legally married, and suggesting sexual intercourse.
Cohabitation, the living together of a man and a woman.
colchicine, the compound colchicine tannate, used to alleviate the symptoms of gout.
Colchicum, a drug obtained from a genus of liliaceous plants, colchicum, used in the
treatment of gout.
Colectomy, complete or partial removal of the large intestine or colon.
Colic, 1. a painful spasm of the intestines, esp. of the colon.
Collagen, the protein that makes up the major portion of the white fiber in connective
tissues, particularly in the skin, bones, and tendons.
Collapse, a more or less sudden failure of the vital powers; a sudden and complete failure
of any kind; a breakdown.
Coloboma, a congenital defect of the eye or any portion of it usually a cleft or fissure of
the iris.
Colocynth, a purgative derived from the fruit of a Mediterranean plant of the gourd
family.
Colostrums, the first milk secreted in the breasts after childbirth, containing a large
amount of protein and immunizing factors for the newborn.
Coma, a state of prolonged unconsciousness, usually due to disease or injury, from which
it is difficult or impossible to rouse a person; stupor.
Comatose, 1. pertaining to coma. 2. drowsy. 3. lethargic.
Comedo, a hardened plug of sebum in a skin duct: a blackhead.
Commissure, 1. a joint, seam, or suture. 2. a connecting band of nerve tissue.
Communicable, capable of being communicated or imparted, as, a communicable
disease.
Conceive, 1. to become pregnant with. 2. to form a notion or idea in the mind.
Condom, a thin rubber sheath worn over the penis during sexual intercourse as a
contraceptive and to prevent venereal disease.
Condyle, a protuberance on the end of a bone serving to form an articulation with
another bone.
Confabulate, to engage in fantasy to replace memory loss.
Confabulation, a mental disorder in which the patient invents events, usually to replace
lost memory
Congenital, existing from birth; relating to characteristics dating from birth that are not
hereditary.

541
Congest, to cause an unnatural accumulation of blood in the vessels of an organ or part.
Congestion, an inflammation or excess of fluid in an organ or part.
Consciousness-expanding, causing the mental slate of perception or awareness to be
greatly intensified, as LSD is a consciousness-expanding drug
Constipation, the state of being constipated: a condition of !he bowels marked by
irregular or difficult evacuation.
Contagion, 1. a communication of disease by direct or indirect contact. 2. a disease so
communicable. 3. the medium by which a contagious disease is transmitted.
Contagious, causing or involving contagion.
Contraception, the deliberate prevention of conception or impregnation.
Contraindication, the evidence that a particular remedy or treatment of a condition is
Inadvisable or dangerous.
Contralateral, pertaining to the opposite side of the body.
Contuse, 1. to wound or injure by bruising. 2. to injure without breaking the flesh.
Contusion, 1. a severe bruise. 2. a hurt or an injury as to the flesh or some part of the
body without breaking of the skin, as by a blunt instrument or a fall.
Convalesce, to grow better after sickness; to recover health.
Convalescence, 1. the gradual recovery of health and strength after illness. 2. the state
of a person renewing his vigor after sickness or weakness.
Convalescent, 1. recovering health and strength after sickness or debility. 2, one who is
recovering his health after sickness.
Convulsion, 1. a violent and involuntary spasmodic contraction of the muscles. 2 an
affliction marked by such contractions.
Coprolalia, a morbid, obsessive compulsion to use obscene words.
Coprolite, a roundish, stony mass of petrified fecal matter.
Coprophagy, the eating of excrement.
Coprophilia, pathological attraction to faces.
corona, the upper portion or crown of a part, as of the head or a tooth.
Corpus luteum, the yellowish endocrine tissue formed in the ovary by rupture of a
graafian follicle after ovulation which, during pregnancy, secretes the hormone pro-
gesterone.
Costotomy, surgical removal of a rib or part of one.
Cough, 1, expulsion of air from the lungs marked by sudden loud noise 2. an illness
characterized by such a condition.
Counterirritant, an agent for producing irritation in one part of the body to counteract
irritation or relieve pain or inflammation elsewhere.
Cowpox, a disease that causes vesicles or blisters on the teats of a cow: the fluid or virus
contained therein is capable of immunizing man against smallpox.
Cramp, 1. an involuntary, spasmodic, painful contraction of a muscle or muscles, as
rrorn a slight strain or sudden chill. 2. a sudden, violent abdominal pain.
Creatine, a colorless, crystalline substance that can be isolated from various organs and
body fluids. Combined with phosphate to phosphocreatine, it is an energy-storing
substance found esp. in muscle juice and in blood.
Cretinism, a chronic disease, caused by absence or deficiency of the normal thyroid
secretion, characterized by physical deformity, stunted growth, idiocy, and in many cases,
goiter,

542
Cribriform plate, a bone in the skull perforated with many small openings through
which nerve filaments pass.
Crick, a painful muscle spasm, esp. on the neck or back.
Cripple, 1. one who has lost or never enjoyed the use of his limbs. 2. a partially disabled
or lame person.
Crotch, the part of the human body where the legs are joined.
Croup, an inflammation of the respiratory passages characterized by highly labored
breathing and a hoarse, rasping cough.
Crown, 1. the part of a tooth that appears beyond the gum. 2. to cover the top of a tooth
with a false crown.
Crowning, that stage in delivery when the baby's head appears at the opening of the birth
canal.
Crystalluria, the appearance of crystals in the urine.
Culex, a genus of malaria-carrying mosquitoes. culture, the cultivation of
microorganisms, as bacteria, for scientific study or medicinal use.
Cupule, a cup-shaped structure or part.
Curare, a blackish, resin like substance obtained from tropical plants, used by South
American Indiana as arrow poison. used in surgery for arresting the action of the
motor nerves.
Curettage, scraping with a curette.
Cuticle, 1. the epidermis. 2. nonliving skin that frames the nails of fingers and toes.
Cycloplegia, paralysis of the ciliary muscles of the eye.
Cyclothymia, a mild psychosis of the manic-depressive type in which the personality
alternates between depressed and elated states.
Cyst, 1. a bladder, sac, or vesicle. 2. closed bladder like sac containing fluid or semifluid
morbid matter
Cystic fibrosis, a hereditary disease appearing in childhood involving the pancreas and
lungs.
Cystitis, inflammation of the bladder.
Cystocele, a hernia or rupture formed by the protrusion of the urinary bladder into the
vagina
Cystolithectomy, surgical removal of a calculus from either the urinary bladder or
gallbladder.
Cystoscopy, examination of the bladder by means of a cystoscope.
Cystospasm, a spasmodic contraction or cramp of the urinary bladder.
Cytokinesis, cytoplasmic changes during fertilization and cell division,
Cytology, the scientific study of the structure, functions, and life cycle of cells.
Cytoplasm, the living substance of protoplasm of a cell exclusive of the nucleus.
Dactylology, 1. the art of communicating ideas or thoughts by the fingers. 2. the
language of the deaf and dumb.
Dartos, the muscular tissue beneath the skin of the scrotum, which is able to tighten up
the organ, as in cold weather.
Debility, a state of general bodily weakness; feebleness.
Debridement, the surgical removal of foreign matter or contaminated tissue from a
wound to prevent the spread of infection
Decalcification, the loss or removal of lime or calcium salts from bones.

543
Dacant, 1. to pour off gently, without disturbing sediment. 2. to pour from one vessel to
another.
Decapitate, to cut off the head. 2. to kill by beheading
decoct, to extract the strength or flavor from a medicinal preparation by boiling.
Decoction, 1. the act of decocting. 2. an extract obtained by decocting. 3. a liquid in
which a substance, "usually animal or vegetable, has been boiled, and which thus
contains the soluble constituents or principles of the substance.
Decrepitude, 1. the state of being decrepit. 2. weakened, as from the infirmities of old
age.
Decrudescence, decline in severity of a disease.
Decubtal, pertaining to decubitus.
Defecate, to void excrement from the bowels.
Deformity, defective, 1. marked by a subnormal condition, either mental or physical, 2.
one who is physically or mentally deficient.
Defeminization, loss of secondary feminine sexual characteristics, usually as a result of
hormonal defects.
Deferant, serving to convey away: as, a deferent duct.
Daferentitis, an inflammation of the vas deferens.
Defervescence, a lowering of fever.
Defibrillation, stopping of the normal rhythm of the heart.
Deglutition, the act of swallowing.
Deleterious, injurious; pernicious; harmful to health or well-being.
Delinquency, antisocial behavior
Delinquent, 1. failing in or neglectful of duty or obligation 2. guilty of a misdeed or
offense 3. being antisocial.
Deliquesce, to melt gradually and become liquid by attracting and absorbing moisture
from the air. as certain salts, acids, and alkalis.
Delirium, a more or less temporary disorder of the mental faculties, as in fevers and
intoxication, characterized by restlessness, excitement, delusions, and hallucinations
Deltoid, a large triangular muscle covering the joint of the shoulder and serving to raise
the arm laterally.
Delusion, an abnormal phenomenon in which a belief is held despite the presence of
evidence sufficient to destroy it.
Dementia, any condition of deteriorated mentality, esp. a decline in the appropriateness
of emotional responses and in intellectual powers.
Demoniac, 1. one Seemingly possessed by a demon or evil spirit. 2. a lunatic.
Demulcent, a medicine that lessens the effects of irritation, as mucilaginous substances
Demyelinated, pertaining to nerve fibers from which the myelin sheaths have been
removed.
Dengue, an infectious, eruptive, usually epidemic fever of warm climates, characterized
esp. by severe pains in the joints and muscles; breakbone fever.
Dentrifice, a powder, paste, or liquid used in cleaning teeth.
Desquamation, shedding or peeling of the skin.
Dextrose, 1. the sugar found in blood and in many plants. 2. corn sugar.
Dextrosuria, the presence of dextrose in the urine.

544
Diabetes, any one of various diseases, most of them characterized by abnormal urinary
conditions without qualification, the term diabetes refers to diabetes rnellitus.
Diabetes Insipidus, a disease characterized by chronic excretion of large amounts of
unconcentrated urine and extreme thirst, alleviated by a pituitary hormone extract.
Dialysis, the act or process of separating the crystalloid elements of a body from colloid
by diffusion through a membrane.
Diathesis, 1. predisposition to certain diseases rather than to others. 2. the tendency to a
particular mental development.
Dicrotic, pertaining to dicrotism.
Dicrotism, a condition in which there are two arterial beats for ore heartbeat.
Dicumarol, a substance found in clover and hay and also prepared synthetically, used to
prevent clotting of the blood (trademark).
Digestion, the process that food undergoes, primarily through the action of enzymes in
the alimentary canal, whereby it is prepared for absorption into and nourishment of the
body tissues.
Digitalin, 1. a white, crystalline powder, a glycoside of digitalis used in medicine. 2. any
of several mixtures of glycosides extracted from digitalis.
Digitalis, 1. any of several Eurasian herbs of the figwort family, esp. the common
foxglove. 2. The dried and powdered leaf of fox glove containing several important
glycosides and serving as a powerful heart stimulant and a diuretic.
Digitoxin, a bitter, odorless, white, highly poisonous powder, the most active glucoside
of digitalis, used as a heart stimulant.
Dioptric, 1. of or pertaining to dioptrics. 2. assisting vision by refracting light, as a lens.
Diphtheria, an epidemic inflammatory disease of the air passages, and esp. of the throat,
characterized by the formation of a false membrane; now controlled by vaccine in-
fections.
Diplegia, paralysis of two similar parts on either side of the body, as two legs or two
arms.
Diplophonia, the simultaneous production of two different voice tones from the larynx
caused by paralysis of one of the vocal cords.
Diplopia, double vision.
Disaccharide, a class of sugars yielding two monosaccharide molecules upon hydrolysis.
Disinfect, to cleanse of infection by destroying or inhibiting the activity of disease-
producing microorganisms.
Distemper, 1 one of several highly contagious diseases of animals, esp. one affecting
young dogs. 2. to derange the bodily function or mental state.
Dither, a state of great agitation, excitement, or confusion
Dieresis, an excessive flow of urine.
Diuretic, a medicine that increases the secretion of urine.
Diurnal, belonging to the period of daylight, as distinguished from night; happening
every day.
Diver's paresis, an occupational disease taking the form of paralysis, occurring in
caisson disease or bends.
Dizzy, 1. having a sensation of whirling with instability or proneness to fall; giddy. 2.
mentally confused or dazed.
Dizziness, the state of being dizzy.

545
DNA, deoxyribonucleic acid, a compound found in chromosomes consisting of a long
chain molecule comprising many repeated and varied combinations of four nucleotides,
one of which is the sugar deoxyribose; subdivisions of the molecule are believed to be the
genes.
Doraphobia, pathological aversion to touching skins or fur.
Dropsy, an abnormal collection of serous fluid in any cavity of the body or in cellular
tissue.
Drug, any medicinal substance for internal or external use given for the purpose of
treatment or prevention of disease or for diagnosis; also for relieving pain.
Druggist, a pharmacist; the operator or owner of a drugstore.
Dura mater, the tough, fibrous membrane forming the outermost of the three coverings
of the brain and spinal cord.
Dwarf, a human being much smaller than the ordinary stature or size.
Dwarfism, the state of being a dwarf.
Dysentery, an infectious disease characterized by inflammation and ulceration of the
lower portion of the bowels, with diarrhea that becomes mucous and hernorrhagic.
Dysgraphia, inability to write, usually caused by a disorder of the brain.
Dyskinesia, a number of diseases causing impairment of voluntary movements.
Dyslexia, a term for a variety of writing, reading, and learning disorders
Dysmenorrheal, excessively painful or difficult menstruation.
Dyaphasia, impairment of speech caused by a disease of the nervous system.
Dyspnea, labored of difficult breathing; shortness of breath, sometimes accompanied by
pain,
Echinosis, a change in the blood corpuscles by which they lose their smooth outline.
Eclampsia, a form of toxemia, marked by convulsions of recurrent nature, and occurring
during pregnancy or childbirth.
Ecmnesia, loss of memory of recent events, occurring in senility.
Ecological, pertaining to ecology.
Ecologist, a specialist in ecology.
Ectopic pregnancy, a pregnancy occurring in the abdomen or a fallopian tube instead
of in the womb.
Ectromelia, congenital absence of a limb or part of a limb.
Effusion, 1. the escape of any fluid from the vessel containing it into a cavity of the
body. 2. the escaping fluid itself.
Egersis, extreme alertness; abnormal wakefulness.
Egest, to discharge from the body; void: excrete.
Ejaculate, to eject semen.
Ejaculation, the sudden discharge of semen by the male reproductive organs.
Electrocardiogram, the record produced by an electrocardiograph.
Elinguation, surgical removal of the tongue from the oral cavity, elixir, an aromatic,
sweetened alcoholic liquid containing medicinal agents.
Emaciate, 1. to cause to lose flesh gradually. 2. to become lean from loss of appetite or
other cause.
Emaciation, the process of making or becoming lean.
Emaculation, the removal of spots from the skin

546
Embalm, to protect a dead body from decay by treatment with drugs and chemicals; to
preserve from decay.
Embolism, the blockage of a blood vessel by an embolus: broadly, an embolus.
Embryonic disk, 1. the blastodisc or blastoderm. 2. the homologous disk of cells of the
blastocyst from which the embryo develops.
Emollient, 1. softening; making supple; relaxing; soothing to the skin. 2. a medicine that
softens and relaxes inflamed tissues.
Emphysema, distension or puffiness caused by the presence of air in body tissues or
organs; esp. a disease of the lungs characterized by a thinning and loss of elasticity of the
lung tissues.
Empirical, pertaining to experiments or experience. 2. depending upon experience or
observation alone, without regard to science and theory.
Empyema, a collection of pus in certain cavities of the body. esp. in the chest cavity.
Enamel, the smooth, hard substance that covers the crown of a tooth, overlying the
dentine.
Enanthesis, a skin eruption or rash caused by specific internal diseases, such as typhoid
fever or syphilis.
Encephalagia, headache.
Encephalic, belonging or relating to the brain or to other structures within the cranial
cavity.
Encephalogram, an X-ray photograph of the brain.
Encephalography, the technique or act of taking X-ray photographs of the brain,
usually after replacing some of the cerebrospinal fluid with oxygen or another gas.
Encephalomeningitis, inflammation of the covering of the brain.
Endamoeba, parasitic amoebias that cause amoebic dysentery.
Endoneuritis, inflammation of the endoneurium.
Endoacope, an instrument designed to give a view of some internal part or hollow organ
of the body, such as the womb.
Endotoxin, the poison liberated at the death and disintegration of a microorganism, such
as the typhoid fever agent.
End plate, the ending of a motor nerve, usually embedded in muscle fiber.
Enema, 1. the injection of fluid into the rectum for cleansing, diagnosis, etc. 2. the liquid
injected.
Engorgement, 1. the act of engorging, or the state of being engorged. 2. congestion with
blood.
Engram, a lasting subconscious memory of a physical experience.
Enuresis, incontinence or involuntary discharge of urine.
Enzyme, a large class of protein substances produced by living cells, essential to life by
acting as catalysts in the metabolism of the organism.
Enzymology, the branch of science that deals with the nature and activity of enzymes.
Ependyma, the membrane lining the cerebral cavities and the central canal of the spinal
cord.
Epiboly, the surrounding of a group of cells by another more rapidly dividing group.
Epicardium, the inner serous layer of the pericardium, lying directly upon the heart.

547
Epidemic, 1. common to or affecting a whole people, or a great number in a community
at the same time, as a contagious disease; widely prevalent. 2. an occurrence of an
epidemic disease. 3. any outbreak that spreads or increases rapidly.
Epiglottis, a thin cartilaginous plate behind the tongue, which covers the glottis like a lid
during the act of swallowing and thus prevents food or drink from entering the larynx.
Epilate, to remove hair with the roots.
Epilepsv, a chronic disease characterized by brief convulsive seizures and loss of
consciousness.
Epileptic, 1. pertaining to or affected with, epilepsy. 2. one affected with epilepsy.
Epinephrine, an adrenal gland hormone that raises blood pressure, having among its
many medicinal uses those of heart stimulant and muscle relaxant in asthma.
Epineurium, the dense sheath of connective tissue that surrounds the trunk of a nerve.
Epiphora, excessive flow of tears caused by a disorder of the lacrimal glands.
Epistasis, the suppressive action one gene exercises over the effect of another not
alletomorphic ton.
Epistaxis, bleeding from the nose.
Epithelium, any tissue that covers an external or internal surface, or lines a cavity or the
like, which performs protective, secreting, or other functions, as the epidermis or the
lining of the blood vessels.
Epsom salt, hydrated magnesium sulfate, used in medicine as a cathartic.
Erectile, capable of being distended with blood and becoming rigid, as tissue.
Erection, a distended and rigid state of an organ or part that contains erectile tissue, esp.
of the penis or the clitoris.
Ereuthrophobia, pathological fear of blushing.
Ergonovine, a crystalline alkaloid made from ergot, used esp. to prevent hemorrhage
after childbirth or abortion.
Ergosterol, a sterol obtained from ergot or yeast, which is converted to vitamin D by
ultraviolet radiation, and is used to prevent or cure rickets.
Ergot, a drug derived from a fungus and used in medical practice and midwifery.
Ergotamine, an alkaloid extracted from ergot, used chiefly in treating migraine and in
stimulating labor contractions.
Ergotism, a disease resulting from the consumption of food prepared from rye and other
cereals affected with the ergot fungus.
Ergot poisoning, poisoning resulting from eating bread made with diseased grain or
from taking an overdose of the drug ergot.
Erogenous, inducing sexual desire, sexually excitable, as, the body's erogenous zones.
Eroticism, 1. a sexual quality. 2. use of sexually stimulating themes in art, literature, and
drama. 3. a condition of sexual excitement. 4. an unusually insistent sexual desire.
Erotomania, abnormally strong sexual desire.
Eructation, the act of belching wind from the stomach; a belch.
Eruption, 1. the breaking out of a rash. 2. a rash or exanthema.
Eruptive fever, any fever that produces a rash on the skin.
Erythema, abnormal redness of the skin caused by local congestion, as by inflammation.
Estrogen, a female hormone that induces estrus, causes sexual receptivity, and promotes
the development of secondary sex characteristics in the female.

548
Estrone, a female sex hormone used in treating estrogen deficiency and some
menopausal and postmenopausal symptoms.
Estrus, the point of highest sexual excitability in the female, during which conception is
possible.
Etiology, the study of causation in the fields of pathology, biology, philosophy, and
physics.
Eugenic, pertaining to or bringing about improvement in the type of offspring produced.
Euphoria, a feeling of well being not always justified by physical health: a mood of
elation.
Evacuate, to make empty, or expel the contents of, as, to evacuate the stomach by an
emetic.
Exacerbate, 1. to increase the violence, intensity, or bitterness or, as a disease or
unfriendly feeling. 2. to irritate, exasperate, or embitter.
Exophthalmos, protrusion of the eyeball from the eye socket, usually caused by
excessive activity of the thyroid gland.
Exotoxin, a soluble toxin formed within and secreted by a microorganism which itself is
not toxic
Expectorant, 1. having the quality of promoting discharges from the mucous membrane
of the lungs or trachea. 2. a drug that promotes such discharges.
Extirpate, to eradicate; to destroy totally; to exterminate.
Extravasation, 1. the act of extravasating, 2. the state of fluid being forced or let out of
the ducts of the body that contain its effusion.
Extremity, the end part of a limb, or the limb itself, esp. the human hand or foot.
Extrovert, one whose interest and attention is directed primarily toward what is outside
the self; one who relates to the external or objective: loosely, one who is outgoing, active,
expressive, and gregarious.
Extrude, to thrust out to expel.
Exude, to ooze: to seep out gradually, as sweat through the pores.
Exudation, 1. the set or process of exuding 2. an exuded substance.
Facet, a flat smooth surface of a bone.
Facioplasty, plastic surgery of the face.
Facioplegia, facial paralysis.
Factitious, contrived rather than spontaneous; artificial
Factitious fever, a fever produced artificially, usually by the use of a drug.
Fallopian tube, either of a pair of slender tubes that convey the ova from the
ovaries to the cavity of the uterus.
Fallotomy, a division of the fallopian tubes by surgery.
Fascicule, a fascicle, as of nerve fibers or muscle fibers.
Fatigue, 1. weariness from bodily labor or mental exertion, lassitude or exhaustion of
strength. 2. a temporary loss or diminution in a bodily organ because of continued stress.
Fauces, the passage that links the mouth and the pharynx, lying between the soft palate
and the base of the tongue.
Febrifacients, causing of producing fever.
Febrifuge, 1. serving to dispel or reduce fever. 2. a febrifuge medicine or agent. 3 a
cooling drink.
Femur, a bone in the leg extending from the hip to the knee.

549
Fenestra, a natural perforation, esp. one in the bone between the typanum and the inner
ear.
Fenestration, surgical formation of an opening in the bone between the middle and inner
ear.
Fennel, a herb of the parsley family bearing aromatic seeds used in cooking and
medicine.
Ferment, any of various agents or substances, as yeast, enzymes, or certain bacteria,
capable of producing chemical changes, as effervescence or decomposition, in other
substances.
Fermentation, the act or process of fermenting.
Fetation, the development of a fetus pregnancy.
Fetor, any strong offensive smell; stench.
Fetus, an unborn human from after the third month of pregnancy until birth.
Fibroid, 1. resembling or formed of fibrous tissue 2. a fibroid tumor.
Fibroma, a benign tumor or growth of fibrous matter.
Fibula, the outer and lesser bone of the lower leg.
Filarial, a type of threadworm.
Filariasis, any disease due to one of the filariae, eap. elephantiasis, which is caused by
filariae gaining entrance to the lymphatic ducts and causing inflammation, fibrosis, and
blockage of the lymph flow that results in swelling of the area.
Filiform, threadlike; filamentous,
Finger, any of the terminal members of the hand other than the thumb.
Fingernail, the hard protective growth at the end of back of the fingers of the hand.
Fissure, 1. any cleft or groove in an organ, as in the brain. 2. to cleave or make a fissure
3. crack or fracture.
Flabby, hanging loosely or limply, as flesh or muscles.
Flection, 1. the act of bending a limb of the body. 2. the bending of a limb by exercising
the flexor muscle 3. a curved or bowed part.
Follicle stimulating hormone, a pituitary hormone that stimulates production of graffian
follicles in the female and spermatozoa in the male.
Formaldehyde, a colorless, water-soluble, poisonous gas with a pungent odor, used,
usually in solution, in the manufacture of synthetic resins and other organic compounds
and as a preservative and disinfectant.
Formalin, an aqueous solution of formaldehyde.
Fracture, the breaking of a bone or cartilage and the resulting condition.
Frall, lacking physical strength and robust health
Frailty, the condition or quality of being frail.
Fraternal twin, one of a pair of twins each originating from separately fertilised ova,
consequently having different hereditary features and not necessarily being identical or of
the same sex.
Freckle, a brownish spot on the skin, particularly on the face, neck, or hands, often
caused by exposure to the sun, but sometimes of congenital origin and an inherited factor.
Frenzy, violent mental agitation resembling temporary madness. 2. wild excitement or
enthusiasm. 3. delirium.
Friable, easily crumbled or pulverized.

550
Fugue, a mental state in which the person shows rational behavior but has a complete
loss of memory for the behavior when he recovers from the fugue state. Fulguration,
destruction, esp. of tissue of an abnormal growth, by electricity.
Funiculus, a part of the body resembling a cord, as the umbilical cord, spermatic cord,
and small bundles of nerve fibers.
Furfuraceous, scurfy: scaly or flaky, as with dandruff.
Furuncle, a boll or inflammatory sore.
Fusiform, spindle-shaped: rounded and tapering from the middle toward each end.
Gag, 1. to hold open, as the jaws with an instrument in a surgical operation. 2. to cause to
vomit. 3. to choke or prevent passage through.
Gait, a characteristic manner of walk.
Galactacrasia, an abnormal composition of the breast milk.
Galactemia, a milky condition of the blood.
Galactic, 1. pertaining to milk. 2. increasing the flow of milk.
Galactophagous, feeding upon milk.
Gambler, an astringent extract obtained from the leaves and young shoots of a tropical
Asiatic vine and used in medicine.
Gametocyte, a gamete-producing cell.
Gamma globulin, a protein separated from blood and containing antibodies, used in
inoculation against measles, poliomyelitis, and infectious hepatitis.
Gamma ray, penetrating rays emitted by radioactive material and reducing the energy of
the cell nucleus, used in radiotherapy.
Gamogenesis, sexual reproduction.
Ganglia, pertaining to ganglion.
Gangliectomy, surgical excision of a ganglion.
Gargle, 1. a liquid preparation for washing the mouth and throat. 2. to wash or rinse the
mouth or throat with a liquid preparation kept in motion by air expelled from the lungs.
Gargoylism, a usually congenital condition characterized by mental deficiency and
dwarfism.
Gastric juice, an acidic digestive fluid containing enzymes and hydrochloric acid
secreted by glands in the mucous membrane of the stomach.
Gastric ulcer, an open sore on the mucous membrane of the stomach, usually caused by
excessively acidic gastric juice.
Gastrin, a hormone inducing secretion of gastric juices.
Gauze, a loosely woven cotton bandage applied to wounds.
Gavage, forced feeding by means of a flexible stomach tube and force pump.
Gelsemium, the rool of the yellow jasmine, or in a tincture from it, used as a drug.
Gene, the element or unit of a chromosome that carries and transfers an inherited
characteristic from parent to offspring and determines the development of some particular
character or trait in the offspring.
Gene mutation, a significant alteration in an organism resulting from a chemical
rearrangement within the molecules of a gene.
Geriatric, the area of medicine that deals with the diseases of old age and the problems
and care of aging persons.
Germ cell, 1. a cell capable of sexual reproduction. 2. sperm or egg cell.
Germ layer, any one of the three embryonic cell layers: ectoderm, endoderm, mesoderm.

551
Giddy, 1. having a sensation of whirling or reeling. 2. affected with vertigo; dizzy.
Gingivitis, inflammation of the gum tissues.
Glabella, the flat area of the face between the eyebrows.
Glabrous, 1. smooth. 2. having a surface devoid of hair or pubescence.
Glaucoma, a disease of the eye characterized by increased intraocular pressure and
progressive loss of vision.
Gleet, 1. a transparent mucous discharge from the urethra, an effect of gonorrhea 2. a
thin fluid running from a sore.
Glenoid, 1. shallow or slightly cupped, as the articular cavities of the scapula and the
temporal bone. 2. pertaining to such a cavity.
Gliadin, any simple vegetable protein or globulin found in gluten, the protein of wheat
and rye, used in the synthesis of spinal anesthetics and other drug preparations.
Globin, a protein formed in the decomposition of hemoglobin.
Globulin, any of several simple proteins that are insoluble in water, soluble in dilute
solutions of salt, and coagulated by heat, as, gamma globulin.
Glutel, the muscles that form the buttocks.
Gluten, the protein in flour and bread.
Goiter, a morbid enlargement of the thyroid gland, forming a protuberance on the side or
front part of the neck.
Gonorrhea, a contagious, inflammatory ailment of the male urethra or the female vagina,
caused by the gonococcus and accompanied by secretions of mucus and pus.
Gout, a disease caused by defective metabolism and characterized by inflamed joints,
esp. the big toe. and excessive uric acid in the bloodstream, affecting mainly males.
Graft, a portion of living skin, muscle, bone, nerve, or other tissue transplanted by
surgery from one body or part of a body to another.
Grand mal, a severe variety of epilepsy marked by convulsions, stupor, and
unconsciousness.
Granuloma, a mass or growth of granulation tissue occurring during the process of
infection.
Growing pains, dull indefinite pains in the limbs during childhood and adolescence,
commonly associated with the process of growing.
Gumma, a soft tumor that can appear anywhere on the body, characteristic of the tertiary
stage of syphillis.
Gynecology, the aspect of medical science that deals with the functions and diseases
peculiar to women, esp. of the organs of reproduction.
Halation, blurring of vision because of strong light shining directly in one's eyes.
Hallucination, an apparent perception, as by sign or hearing, for which there is no real
external cause, as distinguished from illusion.
Hallucinogen, a chemical substance or drug such as LSD or mescaline that causes
hallucinations.
Hallux, the big toe.
Hallux valgus, a displacement of the big toe toward the other toes.
Ham, 1. the part of the leg behind the knee. 2. the back of the thigh together with the
buttocks; the area of the thigh from the buttock to the back of the knee, in which region
the hamstring muscles are located.
Hamartophobia, pathological fear of making a mistake.

552
Harelip, 1. a congenital division or vertical fissure of the upper lip, often extending to the
palate. 2 the deformed lip itself.
Heart, the hollow muscular organ that circulates blood throughout the body by means of
rhythmic contractions and dilations.
Heart block, an impairment of the ventricular beat of the heart.
Heartburn, a burning sensation in the thorax and stomach, sometimes accompanied by a
slight eructation of acid-tasting fluid. Also called cardialgia.
Heart murmur, an abnormal heart sound, usually audible with the aid of a stethoscope,
and usually indicating a structural or functional defect.
Heartstroke, a state of collapse, usually accompanied by high fever, brought on by
exposure to heat, as of the sun or a furnace; also called sunstroke.
Hebetude, dullness; lethargy, stupidity.
Hebosteotomy, surgical enlargement of the pelvic diameter to aid childbirth.
Helminth, 1. a worm. 2. an intestinal worm, as the tapeworm or roundworm.
Hemarthroala, bleeding into a joint, usually as the result of an injury.
Hematocrit, 1. a centrifugal device for determining the percentage of red cells in a given
amount of whole blood. 2. the volume percentage of red blood cells in blood.
Hematoma, a swelling or mass of blood, usually clotted, in an organ or tissue, caused by
a ruptured blood vessel due to injury.
Hamatometra, hemorrhage within the cavity of the womb.
Hamaturia, blood in the urine.
Hemiplegia, paralysis of only one side of the body.
Hemisphere, either of the two convoluted parts, one on each side which constitute a
great part of the cerebrum.
Hemlock, a plant the extract of which, when drunk, causes drowsiness, nausea, paralysis,
and if not treated, death.
Hemocytometer, an instrument used to count blood corpuscles.
Hemoglobin, a red respiratory pigment occurring in the red corpuscles of the blood and
composed of iron-containing protein matter that carries oxygen from the lungs to the
tissues.
Hemophilia, an inherited defect of males, transmitted through the mother, which leads to
excessive bleeding due to deficiency of a coagulant factor in the blood.
Hemorrhage, 1. a rapid and heavy flow of blood from a ruptured blood vessel. 2. to
bleed heavily.
Hemorrhoid, a swelling formed by the dilatation of a blood vessel at the anus.
Henbane, a poisonous viscid Eurasian herb of the nightshade family, which contains
narcotic alkaloids and is in limited cultivation for sedative drugs.
Heroin, a morphine derivative, being white, odorless, and crystalline, and constituting a
dangerously addictive narcotic.
Herpes, any of certain inflammations of the skin or mucous membrane characterized by
clusters of blisters, which often spread.
Herpes simplex, a viral disease marked by clusters of blisters chiefly around the mouth
and on the lips.
Hatorologous, abnormal, consisting of tissue unlike the normal tissue of a part, as a
tumor.
Heterology, an abnormality, deviating from the common type, as a tumor.

553
Heterozygosis, the union of genetically unlike gametes that form a hetero-zygote.
Heterozygote, a person who has one or more unlike pairs of genes.
Hexachlorophene, a bactericidal agent used in soaps, cosmetics, and deodorants.
Hiccup, 1. a quick involuntary intake of breath suddenly checked by closure of the
glottis, producing a characteristic sound. 2. by an attack of such spasms.
Hilum, the point at which vessels, ducts, or nerves enter a bodily part or emerge from it.
Hindbrain, the posterior of the vertebrate brain including, primarily, the pons,
cerebellum, and medulla oblongata; rhombencephalon.
Hirsute, 1. hairy. 2. shaggy. 3. of or relating to hair. 4. covered with long, bristly hair.
Hirsutism, abnormal, excessive growth of hair or the presence of hair in unusual places,
esp. that which occurs on the face of some women.
Histaminases, an enzyme that deactivates a histamine .and therefore is used to treat
certain allergies.
Histamine, a chemical, amine that occurs naturally in the tissue of the body and is
released during allergic reactions, it dilates the capillaries, stimulates gastric secretion,
and causes uterine contractions. histamine can also be produced synthetically.
Hodgkin's disease, a progressive disease marked by chronic inflammation and enlarge-
ment of the lymph nodes and other organs.
Homicide, 1. the killing of one human being by another, including acts of manslaughter,
murder, accidental killing 2. a person who kills another.
Homogeneous, of the same kind or nature; essentially alike; uniform in structure;
belonging to the same type.
Homogenetic, 1. pertaining to homogenesis. 2. having a common origin. 3. derived from
the same structure, however modified.
Homology, 1. the state of being homologous. 2. sameness of relation. 3. correspondence,
or an" instance of correspondence. 4. homologous relation or correspondence.
Homosexuality, condition in which sexual desire is directed to a member of the same
sex.
Humerus, the long, cylindrical bone of the arm, extending from shoulder to elbow.
Hunchback, 1. a back deformed by a convex curvature of the spine. 2. one who has such
a back.
Huntington's chorea, an adult form of St. Vitus's dance, an inherited disease of the
central nervous system.
Hyaline, 1. any of various nitrogenous substances, esp. that which is the main component
of hydatid cysts. 2. something glassy or transparent.
Hyaline cartilage, the typical translucent form of cartilage, containing little fibrous
tissue.
Hybrid, the offspring of parents of different races or parents who differ in one or more
distinct characteristics.
Hydrocephalus, an accumulation of serous fluid within the cavity of the cranium, esp. in
infancy, causing enlargement of the head.
Hyperopia, a defect of the eyesight in which the focus falls behind the retina, with the
result that distant objects are seen more sharply than those nearby.
Hypertrophy, an abnormal growth of tissue caused by enlargement of each of the
cellular parts without an increase in the number of cells.
Hypervitaminosis, a condition caused by excessive amounts of vitamins.

554
Hypnosis, a condition or state, allied to normal sleep, that can be artificially induced and
is characterized by marked susceptibility to suggestion and considerable loss of will
power and sensation.
Hypnotic, 1. pertaining to hypnosis or hypnotism. 2. susceptible to hypnotism,
as a person. 3. inducing sleep 4. an agent or drug that produces sleep. 5. a sedative. 6. a
person under the influence of hypnotism. 7. one subject to hypnotic influence.
Hypnotism, 1. the induction of hypnosis. 2. the science dealing with the induction of
hypnosis.
Hypochondria, a morbid condition, characterized by depressed spirits and fancies of ill
health.
Hypodermic syringe, a device composed usually of a hollow glass barrel and a hollow
needle used to inject fluid into or under the skin.
Ichor, a watery, acrid discharge from an ulcerated wound.
Ichthyol, a dark-brown syrupy compound, used as an astringent, antiseptic, and
alterative, esp. for skin diseases, as to relieve pruritus (trademark).
Ichthyophobia, abnormal aversion to fish.
Ichthyosis, a hereditary skin disorder marked by a thick, scaly skin surface
Icteric, affected with or relating to jaundice.
Idiopathic, pertaining to idiopathy.
Idiopathy, 1. a disease of unknown or obscure cause. 2. a primary or spontaneous
disease.
Immunization, the condition of being immunized. 2. the act of immunizing.
Immunotharapy, the prevention or cure of disease through the use of antigens.
Impetigo, a contagious akin disease, esp. of children, which manifests itself in pustules
and eruptions.
Impetus, 1. anything that is an incentive to action. 2. stimulus.
Implant, 1. tissue grated in to the body. 2. a filled tube, as one containing radium, placed
in an organ or tissue for treatment
Impotence, lack of sexual power.
Impregnate, 1. to make pregnant. 2. to fertilize. 3. to fill or saturate with, or cause to
absorb, some substance.
Inborn, innate; inherent; implanted by nature; congenital.
Incoherent, disorganized or uncoordinated, without logical connection, disjointed or
rambling, as thought or language.
Incompatible, undesirable or dangerous when combined, as substances in medications.
2. unable to coexist in harmony.
Incomprehensible, 1. not to be grasped by the mind 2. not to be understood. 3.
unintelligible.
Incoordination, inability to coordinate voluntary muscular movements.
lncrustation, the forming of a crust over a healing wound.
Incubate, to maintain, as bacterial cultures or embryos, in a controlled environment most
suitable for development.
Incubation, 1. the act or process of incubating. 2. the period of development of a disease
between infection and the appearance of symptoms.
Infant, a child during the earliest period of its life.
Infarction, the formation and development of an infarct.

555
Infertile, not fruitful or productive; sterile; barren.
Inflammation, 1. the act of inflaming. 2. a redness and swelling of any part of the body,
attended by heat and pain.
Innervate, 1. to supply with nerves. 2. to communicate nervous energy to. 3. to stimulate
through nerves.
Innervation, 1. the communicating of nervous energy by means of nerves. 2. the
stimulation of some part or organ through its nerves. 3 the disposition of nerves In a body
or some part of it.
Inoculate, 1. to implant, a; virus or bacteria, within a human body to cause a mild disease
and thus confer immunity from that disease. 2. to introduce, microorganisms, into
surroundings suitable to their growth, esp. into living organisms. 3. to perform
inoculation.
Insanitary, 1. not hygienic. 2 unclean. 3. injurious to health.
Insufflation, the act of insufflating.
Insufflator, an apparatus used for insufflation.
Insulin, 1. a hormone secreted by the islets of langerhans in the pancreas, essential to the
regulation of carbohydrate metabolism. 2, a preparation of this hormone used in the treat-
ment of diabetes.
Insulinemia, presence of an abnormally large percentage of insulin in the blood.
Insulin shock, an abnormal condition, likely to cause collapse, which occurs when an
overdose of insulin causes a sudden reduction of sugar in the blood.
Ineuloma, a tumor of the islets of langerhans in the pancreas.
Introspection, the observation or examination of one's own mental states or processes
Intubate, to insert a tube into a hollow organ or orifice, as into the larynx to aid
breathing.
Intubation, the process of intubating.
In vitro, occurring outside a living organism and in an artificial environment, as tissues
cultivated in a test tube.
In vivo, occurring within a living organism.
Involuntary; operating or acting independently of will or conscious control.
Isotonic, 1. noting or pertaining to a solution containing just enough salt to prevent the
destruction of the red corpuscles when added to the blood. 2. noting or pertaining to a
contraction of a muscle when under a constant tension.
Isotope, any of two or more forms of the same element having the same atomic number
and nearly the same chemical properties but of different atomic weight.
Isotropic, 1. having the same properties in all directions, as elasticity or conduction. 2.
lacking well-defined axes.
Isthmus, a connecting part, organ, or passage joining structures or cavities larger than
itself, as the isthmus of the fauces.
Itch, 1. to have or feel a peculiar irritation of the skin that causes the desire to scratch the
part affected. 2, to cause such an irritation.
Jaundice, an abnormal physical condition caused by bile pigments in the blood,
characterized by yellowness of the skin and sclera of the eye, and by lassitude and loss of
appetite.
Jaw, one of the two bones or structures, upper and lower, that form the framework of
the mouth.

556
Jawbone, a bone of the jaw, esp. the lower jaw or mandible.
Jugular veins, the two large veins of the neck that return blood from the neck, face, and
brain to the heart.
Kaolin, a mineral clay that remains white after firing, used as a coating for pills and a
component of ointments, lotions, and poultices.
Keryolymph, the transparent substance that surrounds the nucleus of a cell.
Karyotype, the total characteristics of a cell's nucleus, esp. its size, form, and
chromosome number.
Keratitis, inflammation of the cornea.
Keratodermia, a thickening of the horny layer of the epidermis, esp. on the palms and
soles of the Feet.
Kernicterus, a form of jaundice occurring in infants. It is the most dangerous form of
childhood jaundice, as it can cause degeneration of parts of the brain.
Ketogenesis, the production within the body of ketone bodies, esp. in diabetes.
Ketone body, 1 . an acetone body. 2. any acetone, beta-hydoxybutyric acid, or
acetoacetic acid present in the blood or urine, esp. of the diabetic.
Knuckles, 1. joints of the fingers, esp. the joints at the roots of the fingers. 2. the rounded
prominences of such joints when the fingers are bent.
Kymograph, an instrument for graphically recording variations in motion or pressure,
esp. blood pressure.
Labia, the lips or lip like parts.
Labia majors, the two folds of hair-bearing tissue situated on each side of the opening of
the vagina.
Labor, the process of childbirth.
Labyrinth, the inner ear, including the bony end fluid-filled structures.
Labyrinthectomy, surgical excision of the labyrinth.
Labyrinthine, pertaining to or like a labyrinth; winding; intricate.
Labyrinthine vertigo, dizziness associated with disorders of the labyrinth.
Lacrimation, secretion and discharge of tears.
Laotagogue, a substance that stimulates the secretion of milk from the breasts.
Lactalbumin, a protein belonging to the albumin class, found in milk.
Lactate, to produce or secrete milk.
Lactation, 1. the production of milk. 2. the time period of milk production. 3. the act of
nursing or suckling young.
Lactic acid, a syrup like acid, present naturally in sour milk, produced commercially by
synthesis or bacterial fermentation of carbohydrates, and utilized in food processing,
medicine, and industry.
Lactiferous, producing or conveying milk or a milky liquid.
Lagophthalmos, inability to close the eyelids compilation.
Lallation, 1. a babbling form of speech. 2 the use of the letter "I" instead of "r."
Lallopathology, the branch of science concerned with speech defects and their treatment.
Lamina, a flat, thin plate, or sheet, as of bone, or a thin membrane.
Laminectomy, surgical excision of the posterior arch of a vertebra.
Lanolin, an oily or greasy substance obtained from unwashed wool, said to be beneficial
in skin ointments or lotions.
Laparotomy, surgical incision of the abdominal wall.

557
Laryngeal, pertaining to the larynx.
Laryngostomy, surgical operation to make a permanent opening through the throat into
the larynx.
Laryngotomy, surgical incision of the larynx.
Lassitude, a feeling of weariness or weakness; listlessness of body or mind.
Latent period, 1. the period in a disease between the moment of infection and
appearance of symptoms. 2. the time between stimulation and reaction.
Lavage, the process of cleansing, as by injection, esp. the washing out of the stomach.
Laxation, 1. a loosening or relaxation, or the state of being loosened or relaxed 2.
defecation.
Lecithin, a fatty substance consisting of fatty acids, choline, phosphoric acid, and
glycerol, found in the calls of plants and animals. and utilised in the drug, food, and
cosmetic industries.
Leprosy, an infectious, chronic disease caused by a microorganism and variously
characterized by ulcerations, tubercular nodules, loss of lingers and toes, and anesthesis
in certain nerve regions.
Lesion, an abnormal, localized change in the structure of an organ or tissue, resulting
from disease or injury.
Lethal, causing or able to cause death; deadly; mortal; fatal.
Lethargic, 1. affected with lethargy. 2. inclined to sleep; dull, sluggish. 3. pertaining to
lethargy.
Leukemia, a fatal disease of the blood, in which there is a pronounced increase in the
number of leukocytes; cancer of the blood.
Libido, 1. The sexual instinct. 2. the instincts and drives that activate human action.
Lichen, any of various eruptive skin diseases, resembling lichen in appearance.
Ligament, a band of strong fibrous tissue connecting bones at a joint, or serving to hold
in place and support body organs.
Lingual, of or pertaining to the tongue or a tongue-like part.
Liniment, a liquid preparation, usually oily, for rubbing on or applying to the skin, as for
sprains or bruises.
Locomotor, 1. one who or that which has locomotive power. 2. of or pertaining to
locomotion.
Lumbago, rheumatism or rheumatic pains affecting the lumbar region of the back.
Lumbar, 1. of or pertaining to the loin or loins. 2. a lumbar vertebra, artery, or the like.
Luteinizing hormone, a secretion of the pituitary gland that stimulates the activity of the
reproductive organs.
Luteoma, a tumor in the ovaries containing lulein cells.
Luxate, to put out of joint, as a limb; to dislocate
Luxation, a dislocation.
Lying-in, confinement during and following childbirth
Lymph, 1. a clear, coagulable bodily fluid composed of plasma and white corpuscles and
carried in the lymphatic system. 2. any of similar fluids emitted from inflamed areas.
Lymphadenitis, inflammation of lymph nodes or glands.
Lymphatic, pertaining to, containing, or conveying lymph,
Lymph cell, a cell found in lymph; lymphocyte.

558
Lymph gland, one of the numerous glandular masses of lymphatic tissue, scattered
through the lymph system, which produces lymphocytes.
Lymphoblast, an immature cell that becomes a lymphocyte.
Lymphocyte, a leukocyte, one of the white blood corpuscles that develops in the
lymphatic tissues.
Lymphoma, a tumor found in lymphoid tissue.
Maceration, the process of macerating.
Macrocardlus, abnormal enlargement of the heart.
Macrocsphalic, having an abnormally large head or cranial capacity
Mscrocyte, a red blood cell that is abnormally large.
Macula, a spot or stain, esp. a discolored spot on the skin.
Malaise, 1. a condition of unlocalized bodily uneasiness, debility, or discomfort, often a
preliminary symptom of disease. 2. an indefinite feeling of morbid discontent and ill-
being.
Malar, pertaining to the cheek or cheekbone.
Malaria, a febrile disease, usually intermittent or remittent, and characterized by attacks
of chills, fever, and sweating, caused by parasitic protozoans, transferred to the blood by
mosquitoes.
Malignancy, the quality or condition of being malignant, as, a tumor that is malignant.
Malpighian corpuscle, a small round body in the cortical substance of the kidney.
Maltose, a white crystalline sugar, formed by the action of diastase as in malt, on starch
and used primarily as a sweetener.
Mamma, the breast; the organ that secretes milk.
Mammogram, an X-ray photograph of the breast or mammary glands.
Mammography, study of the breast or mammary glands by X-ray photography to
diagnose cancer.
Mammotomy, surgery of a breast.
Mandible, the lower jawbone.
Mania, 1. intense excitement or enthusiasm. 2. excitement passion or desire. 3. a rage 4.
a form of insanity characterized by great excitement, with or without delusions, and by
violence in its acute stage.
Maniac, 1. a raving or wildly insane parson. 2. a lunatic. 3. raving with insanity. 4. mad.
Maternal, of, pertaining to, befitting, having the qualities of, or being a mother,
Maternity, the state or character of being a mother; motherhood.
Matter, to form or exude pus.
Maxilla, the upper jawbone.
Melanemia, presence of free dark pigment in the blood.
Melanin, any of various dark pigments in the hair, epidermis, or eyes, produced in excess
by certain diseases.
Melanoma, a tumor, usually malignant, composed of cells containing dark pigment.
Meningitis, inflammation of the membranes of the brain or spinal cord. esp.
inflammation of the pia mater and arachnoid.
Menopause, 1. the natural and permanent cessation of menstruation, normally between
the ages of 45 and 50. 2 woman's change of life
Menorhagia, 1. profuse or prolonged menstrual discharge. 2. hemorrhage from the
uterus.

559
Menstruation, 1. the uterine discharge of blood and mucus occurring on an average
every 28 days from puberty to menopause. 2. the act or time of menstruation.
Marital age, the age that corresponds to the level of a person's ability.
Mesenteron, the early stages in the development of the intestinal cavity of the embryo,
bounded by endoderm.
Mesentery, a fold or duplicate of peritoneum investing and attaching to the posterior wall
of the abdomen, a part or parts of the intestines, or other abdominal viscera.
Mesic, having a medium amount of moisture.
Mesmeric, of or pertaining to mesmerism,
Mesmerism, 1. the doctrine of the induction of a hypnotic state through an influence or
emanation transmitted from the operator to the subject. 2. the induction, influence, or
state concerned. 3. in general, hypnotism.
Mesmerize, to hypnotize; to subject to spellbinding influence
Metacarpus, the part of a hand, esp. its bony structure, included between the wrist or
carpus and the fingers or phalanges.
Metaplasia, the change of one kind of tissue into another kind.
Metastasis, the transfer, as through the blood or lymphatics, of disease or disease
producing cells from one part of the body to another, and the condition resulting from
such transfer.
Metrorrhagia, bleeding from the uterus, unconnected with the menses.
Microtome, an instrument tor cutting very fine sections of organic tissue for microscopic
study.
Midwife, a woman who assists a mother in childbirth.
Midwifery, the art or practice of a midwife.
Migraine, a recurring head ache marked by severe pain, usually limited to a single side
of the head and often with attendant nausea.
Miliaria, an inflammatory disease of the skin, located about the sweat glands, marked by
the formation of vesicles or papules resembling millet seeds.
Miscarriage, the premature expulsion of a nonviable fetus; abortion.
Molluscum, a skin disease characterized by tumor-like formation of nodules.
Monaural, of or pertaining to sound that is perceived through only one ear.
Mongolism, a congenital mental deficiency in a child characterized by
slanting eyes and broad skull, face, and hands. See also Downs syndrome.
Monomania, 1. a mental disorder in which the patient is obsessed by one idea, or is
irrational on one subject only 2. excessive enthusiasm for one idea, object, or project.
Morbidity, 1. a rnorbid state or quality. 2. the proportion of death, sickness, or disease in
a given locality.
Morgue, a place where the bodies of dead people, particularly accident victims, are kept
until identified or buried.
Moron, an adult with retarded intellectual development whose mentality corresponds to
that of a normal child from 8 to 12 years of age.
Morphine, a bitter crystalline alkaloid, the most important narcotic principle of opium,
used in medicine, usually in the form of a sulfate or other salt, to dull pain or induce
sleep.
Mortality, the state of being mortal.

560
Mucin, any of a group of nitrogenous substances found in mucous secretions, varying in
composition according to its source; the principal constituent of mucus.
Mucocutaneous, pertaining to an area where mucous membrane and skin come together,
as in the nose, mouth, vagina and anus.
Mucoprotein, any of various proteins containing polysaccharides, found in the body's
fluids and in connective tissues.
Mucosa, a mucous membrane.
Murmur, a sound emitted by the heart that is a sign of an abnormality.
Muscular dystrophy, a disease that results in progressive deterioration and atrophy of
muscle tissue.
Myalgia, 1. pain in the muscles. 2. muscular rheumatism.
Mydriatic, 1. pertaining to or producing mydriasis. 2. a mydriatic drug.
Myelencephalitis, inflammation of the brain and the spinal cord.
Myoma, a tumor composed of muscle tissue.
Myopia, a condition of the eye in which images are focused in front of the retina, obiects
being seen distinctly only when near to the eye, nearsightedness.
Narcolepsy, an illness characterized by the frequent, sudden, uncontrollable need for
deep, but brief sleep.
Nareoteptic, 1. of or pertaining to narcolepsy. 2. one who suffers from narcotepsy.
Narcosis, 1. the production of stupor or insensibility by a narcotic drug. 2. a state of
drowsiness or insensibility.
Narcotic, 1. a substance that relieves pain, induces sleep, and in large doses brings on
stupor, coma, and even death, as opium or morphine. 2. an addict. 3. something that
soothes of numbs. 4. having the properties of a narcotic. 5. relating to or induced by
narcotics.
Narcotize, 1. to bring under the influence of a narcotic. 2. to numb the awareness of.
Natal, of or pertaining to birth.
Nebulizer, 1. to reduce to fine spray; atomize. 2. to become unclear or nebulous.
Nebulizer, an instrument used for spraying in a fine mist.
Necrotize, to produce necrosis, as in an organ or tissue.
Neonatal, affecting or pertaining to a newborn infant.
Neoplasty, surgical restoration of tissue or parts.
Nephralgia, pain in the kidney region.
Nephrolithotomy, surgical incision for removal of a kidney stone.
Neuralgia, pain, usually sharp and paroxysmal, along the course of a nerve.
Neural tube, a hollow tubular formation of nerve tissue in the embryo made of joined
ectodermal folds on each side of the neural plate and developing at one end into the brain.
Neurasthenia, a condition, as from prolonged emotional tension or overwork,
characterized by excessive menial and physical fatigue and sometimes by obscure
physical complaints or phobias.
Neurology, the science of the nerves or the nervous system and their diseases or
disorders.
Neuropathy, any disease of the nervous system.
Nodular, characterized by or resembling nodules.
Nodule, a small knot or lump.

561
Nutritious, 1. containing or serving as nutriment 2. promoting growth, replacing worn
out tissues, and supplying energy; nourishing.
Nux vomica, the strychnine-containing seed of an Asiatic tree, used in medicine.
Nyctalgia, pain occurring mainly during the night.
Nyctalopia, night blindness.
Nystagmus, an involuntary oscillation of the eyeball, usually lateral but sometimes rotary
or vertical, occurring in certain diseases.
Obese, excessively corpulent; fat; overweight.
Obesity, the state of excessive corpulence; abnormal amount of fat on the body.
Obsessive, of or pertaining to obsession.
Obstetric, pertaining to obstetrics or to the case of a woman in pregnancy, labor, birth,
and the postnatal period.
Obturator, something that closes an opening, as a surgical plate for closing an
abdominal opening.
Occipital, of or pertaining to the occiput; of the posterior part of the head or skull.
Occlusion, the act of occluding, or the state of being occluded.
Occult blood, blood that occurs in such minute quantities that it can be recognized only
with a microscope.
Odontectomy, surgical excision of a tooth.
Odontoid, 1. resembling a tooth. 2. related to the odontoid process. 3. the odontoid
process.
Odontoma, a tumor arising from a tooth or dental tissue.
Ointment, any soft, unctuous substance, usually medicated, applied to the skin for
medicinal and cosmetic purposes; an unguent; a salve.
Oligocythemia, a deficiency in the number of red blood corpuscles.
Omphalocele, hernia of the umbilicus.
Omphalotomy, the severing of the umbilical cord at birth.
Oncogenesis, the formation and development of a tumor.
Oncology, the part of medical science that treats and studies tumors.
Onychectomy, surgical removal of the nail of a finger or toe.
Onychia, inflammation of the nailbed.
Onhidism, poisoning from a snakebite.
Ophthalmia, inflammation of the eyelid, the eye or its membranes.
Ophthalmology, the science that deals with the anatomy, functions, and diseases of the
eye.
Opium, the dried juice of the unripe fruit of the opium poppy, a poisonous, narcotic,
addictive alkaloid from which morphine and codeine are derived.
Opsonin, a constituent of blood serum that causes invading cells or bacteria to become
more susceptible to the destructive action of the phagocytes.
Optic nerves, one of a pair of cranial nerves of sight.
Organotherapy, the use of extracts from animal organs, such as kidneys or thyroid
glands, for therapeutic purposes.
Orgasm, the ultimate emotional and physical excitement of a sexual act.
Orthogenic, pertaining to or concerned with treatment of mentally retarded or seriously
maladjusted children.

562
Orthopedics, the branch of surgery dealing with the correction of skeletal deformities
and with the treatment of chronic diseases of bones and muscles, esp. of the joints and
spine.
Orthopnea, a condition in which breathing is uncomfortable in any but an erect sitting or
standing position.
Orthopsychiatric, of or pertaining to orthopaychiatry.
Oscillogram, the tracing or record made by an oscilloscope or oscillograph.
Oscillography, the process of recording alternating-current wave forms.
Osteoblast, a bone-forming cell.
Osteology, the branch of anatomy that deals with bones and their structure. Osteoma, a
tumor composed of bony tissue.
Osteomalacia, a condition marked by softening of the bones, caused by a lack of certain
vitamins and minerals.
Osteomyelitis, an inflammatory, suppurative disease of bones, resulting from an
infection.
Osteoplasty, the transplanting, rebuilding, or inserting of bone to correct a defect or loss.
Oataosclerosis, abnormal hardening of bone with increasing weight, Oateoseptum, the
bony part of the septum of the nose.
Oateotome, a surgical instrument for cutting or dividing bone.
Ovariktomy, surgical removal of one or both ovaries.
Ovulate, to produce or release an ovum from an ovary.
Ovum, 1. a tiny egg. 2. an ovum. esp. when small, immature, or unfertilized,
Oxytocic, 1. accelerating childbirth. 2. stimulating contraction of the muscle of the
uterus. 3. an oxytocic medicine.
Oxytocin, a hormone that promotes contraction of smooth muscle of the uterus and
release of breast milk.
Ozone, a form of oxygen, having three atoms to the molecule, with an odor suggesting
that of weak chlorine.
Pacemaker, 1. the area in the right atrium that controls the heartbeat. 2. a small
electronic device used to stimulate and control heart action in certain pathological condi-
tions.
Pachycephaly, an abnormal thickness of the walls of the skull.
Pachydermatous, having an abnormally thick skin.
Palatable, agreeable to the palate or taste; savory.
Palate, the roof of the mouth, which separates the nasal and the oral cavities and consists
of the anterior bony arch, the hard palate, and the soft palate, a muscular tissue at the
posterior part of the upper mouth.
Palmar, 1 pertaining to or situated in the palm of the hand. 2. similar to or of the
breadth of the hand.
Palpable, 1. perceptible to the touch. 2. capable of being felt. 3. tangible. 4. easily
perceived and detected; plain; obvious.
Palpate, to examine by the sense of touch, palpation, examination by touch or feeling, as
with the hand, to assist in diagnosing an illness.
Pilpebral, pertaining to or situated near the eyelid.
Palpitate, 1. to pulsate violently, applied particularly to an abnormally rapid and strong
beat of the heart, as from fright or disease. 2. to throb; to tremble; to quiver.

563
Palpitation, the act of palpitating.
Palsy, paralysis, esp. a progressive form of paralysis culminating late in life,
characterized by tremors of the limbs, muscular weakness and rigidity, and a peculiar
gait and attitude.
Pandemic, 1. of a disease, prevalent throughout an entire country or continent, or the
world. 2. general. 3. universal. 4. a pandemic disease.
Papilla, 1. a nipple, or one of certain small protuberances such as the papillae of the
tongue or of the skin of the fingertips. 2. a process at the root of a hair. 3. the optic disc.
Papillary, 1. resembling a papilla. 2. of or pertaining to the breast nipple.
Papilloma, a benign tumor of the skin or a mucous membrane, as a wart or corn,
consisting of a hypertrophied papilla or group of papillae.
Popular, resembling a papule.
Papule, a small, solid, somewhat pointed elevation at the skin, usually inflammatory but
not forming pus.
Pira-anesthesia, the loss of sensation of two corresponding sides of the body, as. loss of
sensation in both legs.
Paramedic, a person who supplements the work of professional medical personnel.
Paranoiac, a person affected by paranoia.
Paranoid, of, like, or characterized by paranoia.
Paranoid schizophrenia, a mental disorder similar to paranoia, but often accompanied
by hallucinations and behavioral deterioration.
Paraphasia, the misuse of spoken words; a form of asphasia.
Paraphobia, a mild form of any phobia.
Paraphonia, weakness, partial loss, or abnormal change of the voice.
Paraplegia, paralysis of both legs and the tower trunk.
Paraplegic, 1. one who is afflicted win paraplegia. 2. of or pertaining to paraplegia.
Parasympathetic nervous system, the section of the autonomic nervous system made up
of nerves arising in the sacral and cranial regions, which slows the heartbeat, contracts
the pupils, dilates blood vessels, and in general functions in contrast to the sympathetic
nervous system.
Parathyroid gland, any of four small glands, lying near or embedded in the thyroid
gland, which control the calcium content of the blood.
Parencephalitis, inflammation of the cerebellum.
Paresthesia, a spontaneous abnormal sensation, such as tingling, itching, burning, or
numbness.
Paresthetic, of or pertaining to paresthesia.
paretic, pertaining to or affected with paresis.
Parietal bone, either of the two bones forming the top and sides of the part of the skull
enclosing the brain.
Parkinsonism, 1. Parkinson's disease. 2. a group of nervous disorders including
Parkinson's Disease, that have similar symptoms.
Parkinson's disease, a progressive form of paralysis marked by toss of flexibility in the
muscles, tremor, and a jerky gait.
Parodontism, inflammation of the tissues around a tooth.
Paroxysm, 1. a sudden and violent access of passion or emotion. 2. any sudden
intensification of a disease or symptom, esp. one occurring with regularity, as chills.

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Paroxysmal, 1. of the nature of a paroxysm. 2. occurring in or pertaining to paroxysms.
Parturition, the act of bringing forth young: child-birth.
Pasteurize, to subject, as milk, wine, beer, fruit juices, or other liquids, to a temperature
ranging from 140 to 155°F for one-half hour, in order to kill the bacteria that cause
fermentation.
Pasteur treatment, a treatment tor preventing certain diseases, esp. hydrophobia, by a
series of inoculations with a virus of gradually increasing strength.
Pathetic, 1. causing or arousing pity or sorrow. 2. typified by arousing such emotions. 3.
affecting the feelings.
Pathology, 1. the science dealing with the nature of diseases, their causes, symptoms, and
effects. 2. the entire set of circumstances that constitute a diseased condition.
Pectoral girdle, the arch formed by the shoulder blade and collarbone.
Pectoralis, one of four muscles of the upper frontal part of the chest.
Pedal, pertaining to the foot.
Pedalgia, foot pain.
Pederasty, sexual relations between males through anal intercourse, esp. between a man
and a young boy.
Pediatrician, a physician specializing in pediatrics.
Pediatrics, the science that deals with the medical care and diseases of children.
Peduncle, 1. the stem that attaches a new growth, esp. some types of tumors that hang
free on a stalk. 2. a stalk like structure in the brain.
Pellagra, a disease affecting the skin, digestive system, and nervous system, caused by
niacin deficiency.
Pellicle, 1. a thin skin. 2. membrane.
Pelvimetry, the measurement of pelvic dimensions, either manually or with X rays. It
helps the gynecologist to determine whether it is possible to deliver the fetus through the
normal route.
Pelvis, the basin like cavity in the lower part of the trunk, formed by the innominate
bones, sacrum, and coccyx. 2. the bones forming this cavity. 3. the basin like cavity into
which the ureter expands at the hilum of the kidney.
Penis, the male sex organ teamed primarily by erectile tissue, also serving as the organ of
urination.
Peptic, 1. promoting or relating to digestion. 2. relating to pepsin. 3 a medicine that
promotes digestion.
Peptic ulcer, a term used to cover duodenal ulcer, gastric ulcer, and pyloric ulcer,
collectively.
Percutaneous, performed or effected through the skin, referring to a procedure in which
a medicated ointment is applied by rubbing into the skin or by injection.
Perfusion, passing of a fluid into an organ through the blood vessels.
Perineorrhaphy, the closing of a wound in the perineum by suture. The wound is usually
caused by laceration following labor.
Perinectomy, surgical incision of the perineum, usually done to facilitate childbirth.
Perineum, 1. the region between the anus and the genital organs 2. The region of the
body including the passage way for the rectum and genitourinary ducts.
Phagocyte, a leukocyte that destroys and absorbs harmful bacteria, foreign matter, and
inert cells in the bloodstream.

565
Phalanxx, any of the digital bones of the hand or foot.
Pharmaceutics, the science of preparing medicines.
Pharmacist, 1. one skilled in the practice of pharmacy. 2. a druggist.
Pharmacodynamics, the division of pharmacology that deals with the action of drugs
and their effect upon the body.
Pharmacognosy, that deals with sources, characteristics, and possible uses of medicinal
substances in their natural or unprepared state.
Pharmacyology, the science or knowledge of drugs, or the art of preparing medicine,
Pharmacopoeia, 1. a book of directions and requirements for the preparation of
medicines, generally published by an authority. 2. a collection or stock of drugs.
Pharmacy, 1. the art of preparing and compounding medicines, and of dispensing them
according to the prescriptions of medical practitioners. 2. the place where medicines are
compounded or dispensed. 3. a drugstore.
Phenacetin, a compound, of coaltar origin, used to relieve nervous headaches, neuralgia,
or fever
Phenobarbital, a crystalline barbiturate, usually in white powder form, used as a
hypnotic or sedative.
Phlebotomy, the act or practice of opening a vein for letting blood.
Phlegmm, the thick mucus secreted in the respiratory passages.
Phlyctena, a watery pustule or blister.
Phobia, a morbid, abnormal, persistent, exaggerated, and usually illogical fear or dread
Phonic, pertaining to voice.
Photodermatitis, skin disorders caused by excessive exposure to light, for instance,
sunburn,
Photophobia, an intolerance or dread of light.
Photopia, vision in bright lighting conditions.
Phrenalgia, 1. pain in the diaphragm. 2. pain, depression, or melancholia caused by a
mental process.
Phrenasthenia, 1. mental feebleness. 2. paralysis of the diaphragm.
Phrenic, 1 pertaining to the mind or activity of the mind. 2. pertaining to the diaphragm.
Phylaxia, the active defense of the body itself against infection.
Physiotherapy, the treatment of disease, bodily weaknesses, or defects by physical
remedies, such as massage and exercise.
Pia mater, the delicate, fibrous, highly vascular membrane forming the innermost of the
three coverings enveloping the brain and spinal cord.
Pilar, of pertaining to or covered with hair.
Piles, sea hemorrhoids.
Pill, a small, usually globular or rounded mass of medicinal substance, to be swallowed
whole.
Pimple, 1- a small elevation of the skin with an inflamed base, 2, see pustule.
Pinkeye, 1. contagious inflammation of the mucous membrane of the eyelids, affecting
humans and certain animals. 2. acute conjunctivitis.
Pinna, the auricle, or external ear
Pin worm, a small nematoid worm, infesting the intestine and rectum, esp. of children.
Pitting, a function or process that makes pita, such as the hollows left by smallpox.

566
Plague, 1. a widespread disease with a high mortality rate. 2. pestilence, specifically a
virulent, infectious, and febrile disease caused by the Bacillus Patteurella pestis,
primarily a rodent disease but transmitted to men by fleas and occurring in several forms:
Bubonic, pneumonic, and septicemic.
Planomania, an abnormal desire to wander and to have no social restraints.
Plantar, relating or belonging to the sole of the foot
Plantar wart, a usually very painful wart occurring on the sole of the foot
Plaque, a small, flat, rounded, abnormal formation or area, as on the skin.
Plasma, a nearly colorless fluid in which the corpuscles of the blood are suspended. 2. a
human blood product used for transfusions and prepared by removing all red cells, white
cells, and platelets from whole blood.
Plasmin, a proteolytic enzyme in the bloodstream causing fibrin breakdown and the
dissolving of clots.
Plastic surgery, surgery undertaken to restore or repair lost, malformed, or injured
bones, other tissues, or organs of the body.
Pleura, a thin membrane that covers the inside of the thorax and also invests the lungs,
pleural, of or pertaining to the pleura.
Pleurisy, an inflammation of pleura often accompanied by fever and respiratory
difficulties.
Pleuritic, of or pertaining to pleurisy.
Pleurapneumonia, an inflammation of the pleura and of the lungs,
Plexor, a small hammer with a soft rubber head or the like, used in percussion for
diagnostic purposes.
Plexus, 1. a network of vessels, nerves, or fibers. 2. any complicated structure forming a
network of interlacing parts.
Plica, 1. a fold or folding, as of skin. 2. a matted, filthy condition of the hair caused by
disease.
Plicate, 1. pleated. 2. folded like a fan.
Plumbism, poisoning by lead taken into the system.
Pnaumonia, 1. an inflammation of the lungs. 2. an acute infectious disease of the lungs,
either viral or bacteriological in origin.
Pock, 1. a pustule raised on the surface of the body in an eruptive disease, as smallpox. 2.
a pit or scar left on the skin by such a disease.
Pockmark, a mark or scar on the skin made by smallpox or other disease.
Podagra, gout, esp. in the foot or big toe.
Podophyllin, a resin obtained from the rhizome of the mayapple, used in medicine as a
purgative.
Podoencephalitis, inflammatory lesions of the gray matter of the brain,
Poliomyelitis, inflammation of the gray matter of the spinal cord. esp. an infectious form
causing motor paralysis followed by atrophy of the muscles and sometimes lasting
disability.
Polycythemia, a condition in which red blood cells are abnormally increased in number.
Polyvalent, pertaining to vaccine having several strains of antibodies.
Popliteal, of or pertaining to the ham, the part of the leg in the back of the knee.
Porphyrin, any of a group of metal-free pyrrole derivatives, formed in protoplasm by the
decomposition of hemoglobin and chlorophyll.

567
Portal, 1. noting or pertaining to the transverse fissure of the liver. 2. the portal vein.
Portal vain, a large vein carrying blood from the stomach, intestine, pancreas, and spleen
to the liver.
Posology, the branch of scientific study that deals with the dosage of medicines.
Post mortem, 1. subsequent to death, as an examination of the body. 2. a postmortem
examination.
Postnatal, subsequent to birth.
Postpartum, after childbirth.
Postprandial, happening after a meal, esp. dinner.
Pott's disease, caries of the vertebrae usually caused by a tubercular infection, often
resulting in marked curvature of the spine.
Poultice, 1. a soft dressing composed of meal, bread, or other mollifying substance, to be
applied to sore of inflamed parts of the body. 2. a cataplasm.
Precocious, 1. forward in development, esp. mental development, as a child or young
person. 2. prematurely developed, as the mind or faculties. 3. pertaining to or showing
premature development.
Premature, happening, arising, existing, or done before the proper time. Premaxilla, one
of a pair of bones in front of the upper jaw, situated between the maxillary bones.
Premenstrual, pertaining to the period just prior to menstruation.
Presbyopia, an imperfection of vision in which near objects are seen less distinctly than
those at a distance, common in old age.
Prescription, 1. a physician's direction, usually written, for the preparation and use of a
medicine or remedy. 2 the medicine prescribed. 3. the act of prescribing.
Prickly heat, a cutaneous eruption accompanied by a prickly and itching sensation,
resulting from an inflammation of the sweat glands.
Primary atypical pneumonia, a typically mild form of pneumonia, probably of viral
origin.
Primary lesion, an original lesion from which a second one develops.
Primary sore, 1. the initial sore of syphilis or chancre. 2. hard sore.
Probe, an instrument for examining the depth or other circumstances of a wound, ulcer,
or cavity.
Progesterone, 1. a female sex hormone produced in the ovaries that prepares the uterus
for reception and development of the fertilized ovum. 2. a form of this hormone obtained
from pregnant cows or by synthesis.
Prognosis, a forecast of the probable course of a disease and the probability of recovery.
Proliferation, growth and production by multiplication.
Prone, 1. lying with face downward. 2. the position of the hand with the palm turned
downward. 3. inclined, as to sickness, by disposition or natural tendency.
Propagate, 1. to breed. 2. to continue or multiply by sexual reproduction.
Prophylactic, 1. a medicine that protects or defends against disease. 2. a preventive
device, as a contraceptive.
Prophylaxis, preventive or protective treatment against disease
Proprioceptive, having the ability to receive stimuli originating within such body tissues
as muscles and tendons.
Proprioceptor, the peripheral end organ of nerves in organs that are responsive to
internal stimuli.

568
Prosthetics, the branch of surgery specializing in artificial replacements, as of limbs or
teeth.
Protoplasm, a complex substance, typically colorless and of viscid semi-fluid
consistency, regarded as the physical basis of life having the powers of spontaneous
motion and reproduction; the living matter of all vegetable and animal cells and tissues.
Provitamin, that which can become a vitamin when acted upon by certain substances in
the body, as carotene, which is changed by liver action Into vitamin A.
Proxymal, nearest the point of attachment or insertion, as the extremity of a bone or
limb, opposed to distal.
Prurient, 1. inclined or inclining to lascivious thoughts. 2. bringing about lasciviousness
or lust. 3. eagerly desirous.
Psoriasis, a chronic skin disease characterized by red scaly patches. Psychasthenia, an
emotional disorder manifested by morbid anxieties, fears, and phobias.
Psychedelic, 1. of pertaining to or causing extraordinary changes in consciousness, as the
intensification of sense perception and awareness, hallucination, and delusion. 2. of or
pertaining to any of a group of drugs that produce this effect, as LSD.
Psychosis, a major mental disorder characterized by a disintegration of personality.
Puberty, 1. the period in both male and female marked by the functional development of
the generative system. 2. the age at which persons become capable of reproduction.
Pulverize, 1. to reduce to fine powder, as by beating, grinding, or the like. 2. to crush or
demolish.
Pulverulent, 1. consisting of fine powder. 2. reducible to powder. 3 powdery. 4. dusty.
Pulvis, a powder.
Pump, an apparatus to drawing up fluids or gases by pressure or suction, as, a breast
pump to remove milk from the breast, a dental pump to remove saliva during dental
procedures, a stomach pump for removing the content of the stomach.
Purge, to evacuate the bowels by means of cathartic.
Purpura, a disease characterized by purple or livid spots on the skin or mucus
membrane, cause by the extravasation of blood.
Purulent, 1. consisting of pus or matter. 2. full of resembling pus. 3. d charging pus.
Pus, a yellowish-white more or less viscid substance produced by suppuration and found
in abscesses and healing sores, consisting of liquid plasma in which
leukocytes are suspended
Pustuleant, 1. causing the formation of pustules.2. a pustulant medicine or agent.
Putrefaction, 1. the act or process of putrefying. 2. the decomposition of animal and
vegetable substances, producing a malodorous compound. 3. that which is putrefied.
Pyelonephritis, an inflammation of the kidney and the pelvis of the kidney. Pyemia, 1. a
form of blood poisoning caused by pyogenic bacteria. 2. general septicemia
marked by the development of abscesses.
Pylorus, the outlet between the stomach and the duodenum through which food passes to
the intestines.
Pyorrhea, a bacterial infection of the gums in and about the sockets of the teeth, with
discharge of pus and loosening of the teeth.
Pyrogen, a toxin that causes fever.
Pyrogenic, producing fever.

569
Quinacrine, a bright yellow, crystalline compound used in treating malaria, Quinidine, a
clear crystalline alkaloid isomeric with quinine, used in its sulfate form in the regulation
of the heart rhythm and the treatment of malaria,
Quinine, 1. a bitter crystalline alkaloid, obtained from the bark of several species of
cinchona trees, and used, esp. in the form of a salt, as a remedy for malaria. 2. a salt of
this alkaloid, esp. the sulfate.
Quinoadine, a brownish-black, resinous substance consisting of a mixture of alkaloids,
obtained as a by-product in the manufacture of quinine and used as a cheap substitute for
it.
Quinsy, an inflammation of the tonsils, esp. a suppurating inflammation.
Q wave, the wave in an electrocardiogram that is associated with the contraction of the
ventricles of the heart.
Rabid, affected with rabies; pertaining to rabies, hydrophobia.
Rauwolfia, any shrub or tree of the genus rauwolfia, of the dogbane family, a source of
the drug reserpine.
Rave, to speak irrationally; to be wild, furious, or raging.
Reaction, 1. the specific effect in an organism or its systems of introduction of a foreign
element. 2. depression or exhaustion as a consequence of excessive excitement or stimu-
lation. 3. increase of activity succeeding depression. 4. abnormal behavior resulting from
a personal experience or situation.
Recurrent, 1. returning from time to time, as a fever. 2. turning back in its course, as a
nerve or blood vessel.
Regurgitate, to rush or surge back; to pour forth, as food.
Regurgitation, 1. the act of regurgitating. 2. the backward circulation of blood through a
faulty heart valve.
Rehabilitate, to restore to a healthy condition or useful capacity.
Rehabilitation, the process of restoring to a healthy condition or useful capacity a person
who was ill or handicapped.
Rahydrate, to replace water removed in dehydration.
Reimplantation, replacement of tissue or an organ in its original site, as an extracted tooth
in its original socket.
Reinfection, a second infection of the same type as one from which a person is suffering
or has recovered.
Remission, the act of remitting. 2. abatement. 3. a temporary subsidence of the force,
violence, or symptoms of a disease or of pain.
Remit, to relax; to abate; to allow to slacken.
Remittent, temporarily easing or abating; having remissions from time to time.
Reticulocyte, an immature red blood cell containing a network of granules or filaments.
Reticulocytosis, an abnormal increase in the number of reticulocytes.
Retroinfection, the infection of the mother by the fetus.
Retromammary, situated behind the mammary gland.
Retromandibular, situated behind the lower Jaw.
Revulsion, 1. a sudden and strong emotional reaction or change of feeling, uau-ally in the
direction of extreme displeasure. 2. a counterirritant.
Rheumatic, 1. pertaining to or characteristic of rheumatism. 2. affected with
Rheumatism, 3. one subject to or afflicted with rheumatism.

570
Rheumatic fever, a severe infectious disease, usually occurring in young adults or
children, characterized by painful swollen joints, fever, and often by Inflamed heart
lining and valves.
Rheumatism, a painful inflammation affecting muscles and joints, attended by swelling
and stiffness.
Rheumatoid arthritis, a progressive disease of the joints causing painful swelling and
shortening of fibrous tissues, frequently resulting in deformity.
Rh factor, any of several inherited antigens in red blood cells of most humans, who are
Rh positive, which under certain conditions such as blood transfusion and pregnancy, are
capable of destroying red corpuscles in persons whose blood is Rh negative, or deficient
in these substances: also called Rhesus factor, so named because it was first found in the
blood of rhesus monkeys.
Rhinitis, an inflammation of the nose or its mucous membrane.
Rhodopsin, a photosensitive red pigment in the rod like retinal cells of the eye that is
considered important for night vision, and that in light breaks down to protein compo-
nents allied to vitamin A.
Rickets, a disease of children in which there is usually some softening and distortion of
the bones due to faulty deposition of calcium or a vitamin D deficiency, or both.
Rickettsia, any of the microorganisms of the genus Riekettsia, parasitic in arthropods and
transmitted by them to man, causing such diseases as typhus.
Rigor, 1. rigidity. 2. a sudden coldness, accompanied by shivering, that precedes certain
levers. 3. rigidity of the body tissues or organs causing lack of response to stimuli.
Rigor mortis, the stiffening of the muscles of the body after death.
Rima, a silt, fissure, cleft, or crack.
Rimose, full of chinks, fissures, or cracks.
Ringworm, a disease caused by fungi, appearing in the form of rings or patches on
different parts of the body, esp. on the scalp.
Rocky Mountain spotted fever, an infectious disease caused by the microorganism
Rickettsia rickettsii, transmitted by the bite of certain wood ticks, and marked by pain in
muscles and joints, fever, prostration, skin eruptions, and chills.
Rosacea, a chronic skin disease occurring on the face, characterized by redness of the
skin tissue and pustules.
Rose fever, an allergy similar to hay fever, associated with rose pollen and usually
occurring in early summer.
Saccharin, a white crystalline substance, synthetically produced, which in dilute form is
300 to 500 times as sweet as cane sugar and is used primarily as a calorie-free sugar
substitute.
Saccharine, pertaining to, of the nature of, containing, or resembling sugar: sugary.
Sacrum, a bone resulting from the fusion of two or more vertebrae between the lumbar
and the coccygeal regions, forming the posterior wall of the pelvis.
Salutery, 1. promoting health. 2. producing a beneficial effect.
Sandfly, 1. a small biting fly of the family Psychodidae, inhabiting the seashore. 2, a
blood sucking fly of the genus Phlebotomus whose bite transmits certain diseases, as
sandfly fever.
Sane, mentally sound; not deranged; having reason and the other mental faculties.
Sangulcolous, living in the blood, as a parasite.

571
sanguineous, pertaining to or containing blood.
Saphenous nerves, the inner and the outer saphenous nerves, which follow the course of
the saphenous veins.
Sapremia, a form of blood poisoning, asp. that due to the absorption of the toxins
produced by certain microorganisms.
Sarcoid, a sarcoma like tumor.
Sarcoma, any of various malignant tumors originating in the connective
tissue.
Sartorius, a flat, narrow muscle, the longest in man, running from the ilium to the top of
the tibia and crossing the thigh obliquely in front, the chief muscle involved in rotating
the leg to the cross-legged position.
Scab, a crust formed over a sore in healing.
Scabby, l. covered or coated with scabs. 2- affected with scabies.
Scabies, an easily transmitted skin disease, the itch caused by the itch mite, affecting
cattle and sheep as well as man.
Scalp, 1. the integument of the upper part of the head, usually including the associated
subcutaneous structures. 2. a part of this integument with the accompanying hair.
Scaly, 1. covered with or abounding in scales or scale. 2. characterized by scales. 3.
consisting of scales or scale. 4. of the nature of scales.
Scapula, the shoulder blade.
scarify, to superficially pierce the skin.
Scarlet fever, a contagious streptococcal disease, usually of children, characterized by
fever, inflammation of the throat, and an extensive scarlet rash.
Schizont, a cell found in certain sporozoans that reproduces itself by repeated asexual
fission to form many small cells.
Schizophrenia, a psychosis characterized by emotional intellectual, and behavioral
disturbances, such as withdrawal from reality, delusions, and progressive deterioration
also called dementia praecox.
Schizophrenic, 1. one afflicted with schizophrenia. 2. pertaining to schizophrenia.
Sciatica, 1. pain and tenderness in a sciatic nerve and its branches. 2. sciatic neuritis. 3.
sciatic neuralgia
Scleraotic, 1. pertaining to the sclera, as the sclerotic coat of the eye. 2. hard, firm, as the
sclera. 3. affected with or pertaining to sclerosis.
Sclerous, hard; bony.
Scotopia, the adaptation of the eye to see in the dark.
Scrotacele, hernia in the scrotum.
Scrotam, the external pouch that contains the testicles.
Scurvy, a disease characterized in part by swollen and readily bleeding gums, livid skin
patches, and generalized exhaustion, affecting persona who are deprived of vitamin C.
Sebaceous, 1. pertaining to sebum. 2. pertaining to or containing fat. 3. made of or
secreting fatty matter. 4. fatty
Seizure, 1. a sudden attack; as of some disease. 2. a fit, as an epileptic fit, a heart attack,
or a stroke.
Self-abasement, degradation of oneself, esp. because of feelings of guilt. inferiority, or
shame.

572
Semen, the whitish, viscous substance that carries spermatozoa and is secreted by the
male reproductive organs.
Semilunar, resembling in form a half moon; crescent-shaped.
Senile, 1. pertaining to old age. 2. characterized by the weakness of old age. esp. a
decline in mental faculties.
Senna, any of various leguminous herbs, shrubs, or trees of the ganus Cassia, the dried
leaflets of which are used as a laxative medicine.
Septicemia, the presence in the bloodstream of infectious microorganisms or their toxins:
blood poisoning.
Septicemic, of or pertaining to septicemia.
Serology, the scientific study of the nature and actions of blood serum.
Serum, 1. a clear, pale-yellow liquid that separates from the clot in the coagulation of
blood. 2. a fluid obtained from the blood of an animal that has been rendered immune to
some disease by inoculation, used as an antitoxic or therapeutic agent.
Serum globulin, a plasma protein that may be separated by electrophoresis into three
blood tractions, alpha. beta, and gamma globulin, which have been shown to serve related
functions; the last named is responsible for the body's ability to resist certain infections.
Serum sickness, an allergic reaction that may occur after serum injections.
Shiver, to shake involuntarily or tremble, as with cold, fear, or excitement.
Shock, a sudden debilitating effect on the bodily functions caused by a violent
impression on the nervous system, as from a severe injury, a surgical operation, an
emotional disturbance, or the like. 2. the resulting condition of nervous depression or
prostration. 3. the effect produced on the body by the sudden passage through it of a
current of electricity.
Sialoncus, a tumor under the tongue, usually caused by the presence of an obstruction in
a salivary gland or duct.
Sigmoid, 1. shaped like the letter S. 2. of or pertaining to a flexure of the colon,
specifically its last curve before terminating in the rectum.
Silicon, a nonmetallic element having both crystalline and amorphous forms, occurring in
a combined state in rocks and minerals, and constituting more than one-fourth of the
earth's crust.
Sinuous, abounding in curves, bends, or turns: winding.
Sinus, 1. any of various cavities, recesses, or passages, as a hollow in a bone, or a
reservoir or channel for venous blood. 2. a cranial hollow, containing air, which connects
with the nasal cavities. 3. a dilated part in a canal or vessel. 4. a narrow. elongated
abscess with a small orifice. 5. a narrow passage leading to an abscess or the like.
Sterols or groups of sterols that occur widely in plants, esp. soybeans, and are used in
varying forms and combinations for the synthetic production of steroid hormones.
Smallpox, an acute virus disease, highly contagious, and marked by fever and pustular
eruptions that leave permanent scarring of the skin.
Solar plexus, a network of nerves situated at the upper part of the abdomen, behind the
stomach and in front of the aorta.
Somatic cell, any of the cells that compose the various organs, tissues, and other parts of
the body, except the reproductive cells, opposed to germ cell.

573
Somatology, 1. the science dealing with the body in all its physical aspects. 2. a branch
of anthropology in which the physical nature of evolving man is subjected to comparative
study and evaluation.
Somatotype, 1. physique. 2. body type. 3. one of the types of body build, ectomorph,
endomorph, or mesomorph, differentiated by the relative prominence of structures
developed from one of the three embryonic germ layers.
Somnifacient, producing or inducing sleep or sleepiness.
Somniferous, causing or inducing sleep, as a narcotic; soporific.
Somnolence, sleepiness; drowsiness.
Sopor. 3 deep, unnatural sleep; stupor.
Sore, 1. painful or tender, as a bruise, wound, or inflammation on the body or skin. 2.
stiff and tender, as from physical exercise. 3. suffering mental anguish and grief, as, sore
in mind and heart. 4. a place where the skin or flesh is bruised, cut, infected, or painful. 5.
any cause of sorrow, pain, misery, or vexation.
Sore throat, an inflammation of the pharynx, fauces, or tonsils, marked by pain, esp. in
swallowing.
Spanish fly, a blister beetle, esp. Lytta vesicatoria, used in medicine, after drying and
powdering, as a counter irritant or a diuretic.
Speculum, a surgical instrument for rendering a part accessible to observation, as by
enlarging an orifice.
Sperm, the reproductive seminal fluid of males.
Spew, to discharge the contents of the stomach through the mouth, to vomit.
Sphenoid, pertaining to the sphenoid bone.
Sphenoid bone, the wedge-shaped bone at the base of the skull
Splanchnic, of or pertaining to viscera or intestines.
Sphincterectomy, the surgical removal of a part of a splanchnic nerve.
Spondylaigia, a painful condition of a vertebra.
Spondylitis, a disorder of the spine or vertebrae that causes inflammation, rigidity, or
deformity.
Strain, 1. to impair, injure, or weaken by stretching or over exertion, as a muscle or
tendon. 2. to filter.
Stupor, a state of suspended or deadened sensibility; mental torpor or apathy.
Stypticc, 1. having the quality of stopping the bleeding of a wound. 2. astringent.
Styptic pencil, a pencil-shaped stick containing a styptic material, used to check
bleeding.
Sudatorium, a hot-air bath for inducing sweating.
Suicidal, 1. pertaining to, involving, or suggesting suicide. 2. tending or leading to
suicide.
Sulfur, a nonmetallic element existing in several forms, the common one being a yellow
crystalline solid that burns with a blue flame and a suffocating odor, and is used, among
others, in medicine.
Supination, 1, the position of the hand extended with the palm upward. 2. the rotating of
a limb or joint upward and away from the mid line of the body
Supine, lying on the back, or with the face or front upward.
Suppository, a mass of some prepared substance, usually in the form of a cone or
cylinder for introduction in to the rectum, vagina or urethra.

574
Sympathetic nervous system, the section of the autonomic nervous system originating
in the thoracic and lumbar regions, which stimulates the heartbeat, dilates the pupils,
contracts the blood vessels, and, in general, functions in opposition to the
parasympathetic nervous system.
Syringitis, an inflammation of the eustachian tube.
Systole, the regularly repeated contraction of the heart that forces the blood through the
circulatory system; opposed to diastole.
Tachycardia, excessively rapid heart action.
Tachypnea, abnormally rapid respiration.
Tactile, 1. pertaining to or possessing the sense of touch, 3. capable of being touched or
felt.
Tactile corpuscle, any of numerous minute oval bodies, esp. of the fingers and toes,
concerned with the sense of touch.
Taeniasis. a diseased condition caused by the presence of tapeworms.
Talalgia, pain in the heel or ankle.
taligrade, walking with the weight on the outer edge of the foot.
Talus, the anklebone or astragalus; the ankle.
Temporal, 1. of or pertaining to the temple or temples of the head. 2. noting or pertaining
to either of a pair of comlex bones that form part of the sides and base of the skull.
Temporal bone, one of the two compound bones situated on either side of the head.
Tenaculum, a small, sharp-pointed hook set in a handle, used for picking up and
maintaining a hold on parts, such as arteries, in operations and dissections.
Tenalgia, pain in a tendon.
Tender, acutely or painfully sensitive, as a tender bruise.
Tendinitis, an inflammation of a tendon.
Tendinous, of, relating to, or full of tendons; sinewy.
Tendon, a hard, tough cord or bundle of fibers by which a muscle is attached to a bone or
other part that it serves to move.
Tenesmus, an urge to void the bowels or bladder, accompanied by straining, but without
discharge.
Tennis elbow, a pain at the side of the elbow, usually caused by overexertion of the arm,
only rarely caused by playing tennis.
Tenodesis, the surgical fixation of a tendon to restore the lost function or to increase the
power of the motion of a joint.
Tenotomy, the surgical section of a tendon.
Tensile, pertaining to tension; capable of tension or being extended.
Tension, 1. mental or emotional strain, as in worry or excitement. 2. an intense or
uncomfortable feeling between people or groups of people.
Tensor, a muscle that stretches or tightens some part of the body.
Teratic, of or pertaining to a badly deformed fetus.
Teratology, the study of monstrosities or malformations in fetuses.
Taratoma, a tumor containing embryonic elements of all three primary germ layers.
Terato phobia, the pathlogical fear of giving birth to a malformed fetus.
Testicle, one of the two oval shaped reproductive glands in the male, enclosed in the
scrotum, which secrete the spermatozoa and several of the fluid elements of the semen.

575
Tetanus, 1. an infectious, often fatal disease, caused by a specific bacterium,
Cloatridium tetani, which gains entrance to the body through wounds, characterized by
more or less violent tonic spasms and rigidity of many or all of the voluntary muscles,
esp. those of the neck and lower jaw; 2. the condition of prolonged contraction that a
muscle assumes under rapidly repeated stimuli.
Tetany, a disorder or condition characterized by irregularly intermittent muscular spasms
and pain, esp. in the extremities, and usually occurring because of defective metabolism
of calcium salts.
Tetracyeline, a yellow crystalline powder, produced artificially by chemical synthesis or
naturally by certain soil bacilli of the genus Streptomyces, used as an antibiotic.
Tetrad, 1. a tetravalent or quadrivalent element, atom, or radical. 2. the arrangement of
four chromosomes, formed during meiosis by the splitting of paired
chromosomes.
Thalamencephalon, the segment of the brain behind the prosencephalon or forebrain,
containing the optic thalami and the pineal gland; the between brain.
Thalamus, a part of the diencephalon composed of gray matter that relays sensory
impulses to the cortex of the brain.
Thalassophobia, a pathological fear of the sea
Thecal, of or pertaining to a sheath.
Thecities, an inflammation of the sheath of a tendon.
Thellum, a nipple; a papilla.
Thenal, of or pertaining to the palm of the hand.
Thenar, the fleshy part of the palm of the hand at the base of the thumb.
Theophobia, a pathological fear of God.
Tharmoanesthesia, the loss of the ability to distinguish between heat and cold.
Thermocauterectomy, surgical excision by thermocautery.
Thermotaxis, 1. the property in a cell or organism of movement toward or away from a
heat source. 2. the regulation of the body temperature.
Thiouracil, an antithyroid agent, used in the treatment of thyrotoxicosis to reduce the
production of hormones by the thyroid gland.
Thirst, 1. the distressing sensation of dryness in the mouth and throat caused by want or
need of fluids. 2. the physical condition resulting from this want.
Thirsty, having thirst; craving drink.
Thoracentesis, the surgical puncture of the chest to remove fluid.
Thoracic duct, the largest lymphatic vessel in the body, lying along the vertebral column
and serving to convey lymph to the left subclavian vein, where it enters the circulatory
system.
Thoracostomy, the opening of the chest, usually for drainage.
Thoracotomy, an incision of the chest wall.
Thorax, 1. the cavity of the body formed by the spine, ribs, and breast bone, and
containing the lungs and heart. 2. the chest.
Threadworm, any of various nematode worms, esp. a pinworm, which inhabit the
intestines.
Threshold, the point at which a stimulus to the sensory organism is just intense enough
to be felt, as, the threshold of consciousness.

576
Thrill, 1. to affect with a keen emotion, as of delight or excitement 2. to vibrate. 3. to
produce a tingling sensation 4 to feel a shivering sensation through the body.
Throb, 1, to beat, as the heart or pulse, with more than usual force or rapidity. 2. to show,
exhibit, or feel emotion 3. to palpitate, quiver, or vibrate. 4. a beat or strong pulsation;
palpitation.
Throbbing, rhythmic beating movement.
Throe, 1 a violent spasm or pang. 2. a paroxysm. 3. a sharp attack of emotion.
4. the pains of childbirth.5. the agony of death 6. any violent convulsion or struggle.
Thrombin, 1. the enzyme that causes the coagulation of blood. 2. a preparation to control
capillary bleeding.
Thromboangittis, an inflammation of the lining of a blood vessel with formation or
existence of a blood clot.
Thrombocyte, any blood platelet.
Thromboembolism, an embolism that has become dislodged from the thrombus and is
blocking a blood vessel.
Thrombogenesis, the formation of a blood clot.
Thrombolysis, the breaking up of a thrombus.
Thrombolytic. pertaining to or causing thrombolysis.
Thrombophlebitis, an inflammation of any blood vessel accompanied by a thrombus.
Thrombosis, 1. a coagulation of the blood in a blood vessel or in the heart during life 2.
the formation or existence of a thrombus.
Thrombus, a fibrinous clot of blood that forms in and obstructs a blood vessel
Thrush, a disease, esp. in children, characterized by whitish spots and ulcers on the
membranes of the mouth, fauces, or the like caused by parasitic fungus.
Thylacitis, an inflammation of the sebaceous glands of the skin.
Thymectomy, the surgical excision of the thymus gland.
Thymic, of or related to the thymus gland.
Thyroadenitis, an inflammation of the thyroid gland.
Thyrochondrotomy, an incision of the thyroid cartilage,
Thyroptosis, a condition in which the thyroid gland is partially or completely displaced
into the thorax.
Thyrotomy, a surgical incision of the thyroid gland.
Thyrotoxicosis, a disorder caused by an overabundant secretion of the thyroid gland
resulting usually in an enlarged thyroid gland, bulging of the eyes, tremors, and rapid
heart beat; hyperthyroidisrn.
Thyroxine, 1. an active iodine compound of the thyroid gland that controls metabolism
and is used in treating hypothyroidism. 2. a similar compound prepared synthetically or
extracted from animals.
Tibia, the large bone of the lower leg; the shinbone.
Tic, a habitual spasmodic contraction of certain muscles, esp. of the face.
Tic doutoureux, severe facial neuralgia accompanied by convulsive twitchings of the
facial muscles.
Tick, any of various parasitic mites or acarids as those of the genus Ixodes, which bury
the head in the skin of the host and suck the blood, and often are carriers of disease.

577
Tick fever, any fever transmitted to man or animals by a mite or acarid of the families
Ixodidae and Argasidae as Rocky Mountain spotted fever afficting man, and Texas fever
occurring in some animals, esp. cattle.
Tilmua, involuntary picking at the bedclothes by seriously ill, delirious patients.
Tincture, an extract or solution of the active principle of some substance in a solvent,
Tinea, ringworm or any similar fungus infection of the skin.
Tinnitus, a ringing, buzzing, or other similar subjective or pathological sensation in the
ears.
Tired, exhausted, by exertion; fatigued weary.
Tissue, an aggregate of cells usually of similar structure that perform the same or related
functions, as, xylem or muscle tissue.
Titubation, disturbance of body equilibrium in standing or walking, resulting in an
uncertain gait and trembling, usually caused by diseases of the cerebellum.
Tobacco heart, a functional disorder of the heart, characterized by a rapid and often
irregular pulse, resulting from excessive use of tobacco.
Toddle, 1. to walk with short steps in a tottering way as a child or an old person 2. the act
of walking in this manner; an unsteady gait.
Tolerance, the capacity to endure or resist the action of a drug or poison.
Tolerate, to endure or resist the action of, as a drug or poison.
Tomentum, a blood vessel network found within the cortex of the brain and the cerebral
surface of the pia mater.
Tomography, an X-ray technique by which detailed images or a structure lying in a
specific layer of tissue may be obtained, with images of structures in other layers
eliminated or blurred.
Tonaphasia, the loss of the ability to remember a tune because of cerebral lesions.
Tone, that condition of a vital body in which the parts have tension, the organs function
normally, and the tissues are firm, sound, and resilient.
Tonic, a tonic agent or remedy; anything invigorating or bracing, physically, mentally, or
morally.
Tonicity. the normal elastic tension of living muscles, arteries, and other parts by which
the tone of the system is maintained.
Tonometer, any of various physiological instruments, as for measuring the tension of the
eyeball, or for determining blood pressure within the vessels.
Tonsil, one of two oblong masses of lymphoid tissue, situated on each side of the throat.
Tophus, a uratic or calcareous deposit formed in the fibrous tissue of the body, as around
or at a joint or on the roots of teeth, esp. in gout.
Torpid, having lost motion or the power of motion and feeling numb, dull, sluggish.
Torpidity, numbness, sluggishness.
Torticollis, an affliction in which the neck is twisted and the head inclined to one side,
caused by spasmodic muscular contraction also called wryneck.
Torus, a rounded ridge; a protuberant part.
Tourniquet, a bandage that is tightened by twisting with a stick, or a pad pressed down
with an elastic, to arrest hemorrhage.
Toxanemia, anemia caused by poison.
Toxemia, a form of blood poisoning, esp. one in which toxins produced by certain
microorganisms enter the blood.

578
Toxin, any of various usually unstable organic poisons produced in living or dead
organisms or their products, as venom. or ptomaine 2. any of the specific poisonous prod-
ucts generated by pathogenic microorganisms, and constituting the causative agents in
various diseases, as tetanus or diphtheria. Compare antitoxin.
Toxin-antitoxin, a mixture or combination of antitoxin and toxin for inducing, esp.
formerly, active immunity from various diseases.
Toxoid, a toxin whose toxic property has been eliminated, usually by a chemical agent,
but which retains its antigen to qualities that produce immunity on injection into the body
by initiating antibody production.
Toxoplasmosis, a disease, esp. of the nervous system, resulting from infestation of tissue
by toxoplasma gondii, a parasitic protozoan, occurring sporadically in certain animals
and occasionally in man.
Trabecula, 1. the tissue supporting an organ. 2. a structural part resembling a small beam
or crossbar.
Tracheostomy, an incision of the trachea for insertion of a tube to overcome an
obstruction.
Trachoma, a contagious inflammation of the conjunctiva of the eyelids, characterized by
the formation of granulations or small rounded growths.
Traction, the action of pulling on an organ or muscle to relieve or lessen pressure, or to
repair dislocation,
Tragus, a small cartilaginous eminence at the front entrance of the external ear.
Trait, a distinguishing or peculiar feature or quality; a characteristic.
Trance, an unconscious, cataleptic, or hypnotic condition.
Tranquilizer, that which tranquilizes or soothes; any of several drugs capable of
relieving tension.
Transect, to cut across, to divide by passing across; to dissect transversely.
Transference, the revival and transferral of emotions, esp. those related to forgotten
childhood experiences, toward a different person than that to whom they were initially
directed, usually a psychoanalyst.
Transfusion, the act of transfusing.
Transilluminate, to throw a strong light through, as an organ or part, as a means of
diagnosis.
Tranaillumination, examining a cavity or organ by throwing a strong light
through its walls.
Transmigration, the act of passing across or through, as the passage of white blood cells
through capillary membranes, or the passage of the egg cell from the ovary to the womb.
Transmutation, the act of transmuting, or state of being transmuted, change into another
substance, form, or nature.
Transmute, to change from one nature, form, or substance into another; to change into
another thing or body; to metamorphose; to transform.
Transpiration, 1. the act or process of transpiring. 2. exhalation of moisture through the
skin. See perspiration.
Transpire, to excrete, as waste matter, in the form of perspiration, through the pores of
the skin.

579
Transplant, 1. to transfer, as an organ or a portion of tissue, from one part of the body to
another or from one person to another. 2. to undergo transplanting, esp. in a manner
specified, 3. the act of transplanting. 4. something that has been transplanted.
Transverse colon, the part of the colon that extends across the abdominal cavity from
right to left, as distinguished from the ascending and descending parts.
Transversectomy, the surgical excision of a transverse process of a vertebra.
Trauma, 1. a wound; a bodily injury produced by violence or shock; the condition
produced by this. 2. a disordered or disturbed state, either mental or behavioral, which is
an effect of stress or injury, and which sometimes has lifelong effect a shock.
Travail, 1. the pain and labor involved in childbirth. 2. to suffer the pangs of childbirth.
Tremble, 1. any condition or disease characterized by continuing trembling or shaking.
2. to shake involuntarily.
Tremor, involuntary shaking of the body or limbs, as from fear, weakness, or fever; a fit
of trembling.
Trench fever, a recurrent rickettsial fever spread by body lice that occurred commonly
among the troops during world war.
Trench foot, a condition of the feet resembling frostbite, frequently terminating in
gangrene, and caused by exposure to wet and cold, as in trench warfare.
Trepidation, trembling of the limbs, as in paralytic affections.
Treponema, any spirochete of the genus treponema, parasitic on man and other
mammals, as the organism that causes syphilis.
Triceps, a muscle having three heads or points of origin, esp. one extending along the
humerus at the back of the upper arm.
Trichiasis, an inversion or in growth of an eyelid, causing irritation of the eyeball by the
eyelashes.
Trichinosis, a disease caused by the presence of the trichina worm, Trichinella spiralis,
in the intestines and muscular tissues.
Trichinous, 1. infected with trichinae. 2. pertaining to or of the nature of trichinosis.
Trichomonad, any flagellate protozoan, genus trichomonas, parasitic in many animals
and certain species in human beings.
Tricrotic, 1. having a three fold beat, as of the arterial pulse. 2. pertaining to such a
pulse.
Tricuspid, 1. having three cusps or points, as a tooth. 2. pertaining to the tricuspid valve.
3. a tricuspid tooth. 4. the tricuspid valve.
Tricuspid valve, a valve of three cusps or folds that prevents the back flow of blood
coursing from the right auricle into the right ventricle of the heart.
Trigone, a triangular space, esp. the one at the base of the bladder.
Trilabe, a three-pronged surgical forceps used to remove foreign substances, as stones,
from the bladder.
Trismus, a species of tetanus affecting the under jaw with spastic rigidity.
Triturable, capable of being pulverized.
Triturate, to reduce to fine particles or powder by rubbing, grinding, bruising, of the
like.
Trituration, any triturated substance, esp. a mixture of a medicinal substance with sugar
or milk, triturated to an impalpable powder.

580
Trocar, a perforating surgical instrument, specifically a sharp-tipped rod used to insert a
cannula for drawing off fluid from a body cavity.
Trochanter, a prominence or process on the upper part of the femur, to which a muscle
is attached.
Trochlea, a pulley like structure or arrangement of parts affording a smooth surface upon
which another part glides, as the surface of the inner condyle of the humerus with which
the ulna articulates.
Trophic, 1. of or pertaining to nutrition. 2. concerned in nutritive processes.
Trophoblast, a special layer of cells external to the ectoderm of the embryo and haying
to do with embryonic nutrition.
True rib, one of the seven upper ribs in man directly attached by cartilages to the
sternum.
Trunk, 1. the body of a human being considered apart from the head and limbs; the
torso. 2. the main body of an artery, nerve, or the like, as distinct from the branches.
Trypanosome, any of the minute flagellate protozoans constituting the genus
Trypanosoma, parasitic in the blood of man and other vertebrates, and often causing
serious diseases, as sleeping sickness, the infection being transmitted by the bite of a
tsetse fly.
Trypsin, the protein-splitting enzyme of the pancreatic juice, capable of converting
proteins into peptone, used in medicine and to peptonize milk.
Tryptophan, an essential amino acid in proteins, requisite in the nutrition of humans.
Tsutsugamushi disease, an infectious rickettsial disease usually occurring in the orient,
caused by the microorganism rickettsia tsutsugamushi,
or rickettsia orientalis and transmitted by mites.
Tubercle, 1. a small, firm, rounded nodule or swelling 2. the characteristic lesion of
tuberculosis.
Tubercle bacillus, a short, slender, rodlike, often slightly curved bacterium,
Mycobacterium tuberculosis, the cause of tuberculosis.
Tubercular, 1. of, pertaining to, or of the nature of a tubercle or tubercles; characterized
by tubercles. 2. pertaining to or characterized by small rounded nodules or tubercles. 3.
pertaining to tuberculosis; tuberculous. 4. a person afflicted with tuberculosis.
Tuberculin, a sterile liquid prepared from cultures of the tubercle bacillus, used in the
diagnosis and treatment of tuberculosis.
Tuberculosis,(TB), an infectious disease affecting any of various tissues of the body,
caused by the tubercle bacillus, and characterized by the production of tubercles. 2. this
disease when affecting the lungs.
Tularemia, tularamia, a disease of rabbits, squirrels, and other rodents, caused by a
bacterium, Pasteurella tularensis, transmitted to man by insects or by the handling of
infected animals, and causing prolonged intermittent fever and swelling of the lymph
nodes.
Tularemic, of or pertaining to tularemia.
Tumid, swollen, enlarged, or distended, as a body organ or part
Tumor, an abnormal or morbid swelling in any part of the body; a more or less
circumscribed morbid growth of new tissue, not due to inflammation, and differing in
structure from the part in which it grows.
Tunic, any revering or investing membrane or part, as of an organ.

581
Twitch, 1. to be suddenly contracted, as a muscle. 2. to move or make motion with a jerk.
3. a brief involuntary contraction of the muscles; a short quick pull; a jerk.
Tympanectomy, the surgical excision of the tympanic membrane.
Tympanic, of or pertaining to the tympanum.
Tympanic bone, a bone of the skull supporting the tympanic membrane and enclosing
part of the tympanum or middle ear.
Tympanic membrane, a membrane separating the tympanum or middle ear from the
passage of the external ear also called eardrum.
Tympanites, a distention of the abdomen from a collection of air or gas in the intestines
or the peritoneum
Typhoid, 1. an infectious, often fatal, febrile disease, characterized by intestinal
inflammation and ulceration, caused by a specific bacillus, Salmonella typhi, which is
usually introduced with food or drink. 2. of or pertaining to typhoid fever.
Typhus, an acute infectious disease characterized by great prostration, severe nervous
symptoms, and a peculiar eruption of reddish spots on the body, caused by the mi-
croorganism Rickettsia prowazeki, and transmitted by fleas and lice.
Ulalgia, pain in the gums.
Ulatrophia, recession of the gums.
Ulcer, a sore open either to the surface of the body or to a natural cavity, and
accompanied by the disintegration of tissue and usually the formation of pus.
Ulemorrhagia, bleeding from the gums.
Ulocarcinoma, a carcinoma of the gums: cancer of the gums.
Ultraviolet, 1. beyond the violet end in the visible spectrum, as of light rays with very
short wavelengths, contrasted with infrared. 2. producing or pertaining to these rays. 3.
ultraviolet radiation.
Umbilectomy, the surgical excision of the navel.
Umbilical, 1. pertaining to the navel or umbilicus. 2. formed or located in the middle,
like a navel. 3. central, esp. relating to the abdomen.
Umbilical cord, a cord like structure that passes from the navel of the fetus or embryo to
the mother's placenta, carrying nourishment to and wastes from the fetus.
Unciform, hooklike: having a curved or hooked shape.
Unconsciousness, the condition of being unconscious.
Underhung, 1. projecting beyond the upper jaw, as applied to the under or lower jaw. 2
having this projection of the jaw.
Underweight, 1. weight deficiency. 2. weight below average. 3. having a weight
deficiency.
Undinism. a mental state in which the libido is awakened by running water, urination or
the site of urine.
Ungual, pertaining to or resembling a fingernail or to a nail.
Unguent, any soft preparation or salve, either liquid or semi liquid applied to sores and
wounds; an ointment.
Unguiculate, having nails or claws, as distinguished from hoofs.
Urachus, an epithelioid cord surrounded by fibrous tissue connecting the urinary bladder
with the fetal allantois.
Uracil, a crystalline heterocyclic compound, obtained usually by hydrolysis of nucleic
acid and used in growth research.

582
Uremia, a toxic condition resulting from the retention in the blood of waste products that
should normally be eliminated in the urine.
Ureteralgia, pain in the ureter.
Ureterectasis, dilation of the ureter.
Ureterectomy, the surgical excision of the ureter.
Ureteritis, an inflammation of the ureter.
Urethra, a tube extending from the bladder that serves to convey and discharge urine and
that, in the male, discharges semen also.
Uric acid, a nitrous, soluble, crystalline acid, found in urine, used in its natural state for
agriculture, and extracted or synthesized for both agriculture and industry.
Urogenital, noting or pertaining to the urinary and genital organs.
Urolith, a urinary calculus.
Urologic, of or pertaining to urology.
Urologist, a specialist in examining and treating disorders of the urinary organs.
Uropyoureter, an infected ureter with an accumulation of urine and pus.
Uroschesis, retention of urine with the inability to pass it.
Urosepsis, septic poisoning caused by escape of urine into tissue other than the urinary
tract.
Urticant, inducing itching or stinging.
Urticaria, a disorder of the skin characterized by transient eruptions of itching wales,
caused by an allergy.
Uteralgia, pain in the uterus.
Uteroplasty, plastic surgery to repair the uterus.
Vaccinate, 1. to inoculate with cowpox vaccine to produce immunity to smallpox or
mitigate its attack, 2. to inoculate with microorganisms of any other disease. 3. to practice
or perform vaccination as a preventive action.
Vaccineation, 1. the act of vaccinating, 2. inoculation with vaccine.
Vagina, 1. the canal in females leading from the exterior genital orifice to the uterus. 2.
an organ or a part haying sheath like characteristics.
Vaginal, 1. of or pertaining to a sheath. 2. of or pertaining to the vagina.
Vaginalitis, an inflammation of the tunica of the testicles.
Vaginodynia, pain in the vagina.
Vaginoscopy, the visual examination of the vagina using a vaginoscope.
Vaginotomy, a surgical incision of the vagina.
Vagus, either of the tenth pair of cranial nerves extending down through the neck and
thorax to the upper part of the abdomen, providing sensory, motor, or secretory impulses
through its branches to the larynx, lungs, heart, stomach, and abdominal viscera.
Valerian, l. any of the perennial herbs constituting the genus valerians, as Valeriana
officinalis, the root of which yields a drug formerly used as a sedative and an agent to
check spasms. 2. the drug obtained from the root of the plant.
Valve, a structure within a hollow organ that opens to allow the passage of a fluid in one
direction or shuts to prevent its return, as the valves of the heart.
Valvotomy, the surgical incision of a valve.
Viricella, see chicken pox.
Variciform, resembling a varix.
Varicocele, a varicose enlargement of the spermatic cord veins of the scrotum.

583
Varicocelectomy, the surgical excision of a portion of the scrotum to remove a
varicocele.
Varicose, 1. abnormally dilated, as a vein. 2. pertaining to or affected with varicose
veins. 3. resembling or having the characteristics of a varix.
varicose veins, an enlarged, swollen, and knotted condition of the veins, usually observed
in the legs.
Variole, a shallow pit or depression like the mark left by a smallpox pustule.
Varioloid, 1. resembling smallpox. 2. pertaining to a mild form of smallpox. 3. a miki
form of smallpox, esp. as occurring in persons who have been vaccinated or who have
previously had smallpox.
Vasectomy, the surgical excision of the vas deferens or of a portion of it.
Vasodepression, the lowering of blood pressure by dilatation of blood vessels.
and vasodilatation.
Vasospasm, spasm of blood vessel.
Vellication, a twitching or spasm of muscular fibers.
Venereal, 1. of or pertaining to venery. 2. arising from or connected with sexual
intercourse with an infected person, as, venereal diseases. 3 adapted to the cure of such
diseases, as, a venereal remedy. 4. infected with or suffering from venereal disease.
Venereal disease, any disease contracted from an infected person by means of sexual
intercourse.
Vaneraology, the area of medical science concerned with the study and treatment of
venereal disease.
Veniplex, a network of veins.
Venipuncture, the puncturing of a vein, either for intravenous medication or feeding, or
for drawing a blood sample for analysis.
Venom, the poisonous fluid secreted by certain animals and introduced into the bodies of
other animals or man by biting, as in the cases of snakes, and stinging, as in the case of
scorpions, wasps, or bees.
Venomous, 1. having a venom producing gland or glands, as a venomous insect. 2.
capable of causing a poisonous bite or sting.
Venous hum, the hum heard when listening at a larger vein, esp. of the neck, with a
stethoscope.
Vent, 1. the external excretory opening, as the anus. 2. any outlet.
Venter, 1. the abdomen or belly 2. a belly like cavity or concavity, as of bones.
3. a bally like protuberance as of muscles.
Ventral, belonging or pertaining to the belly or the abdomen, or to the surface of the
body opposite to the dorsal or back side.
Vermicide, an agent or drug used to destroy intestinal worms, esp. parasitic worms.
Vermicular, 1. pertaining to worms. 2. resembling a worm, esp. in shape or movement.
3. having wormlike wavy tracks.
Vermifuge, a medicine of agent that expels parasitic intestinal worms.
Verruca, 1. any wart. 2. any wart like prominence or projection.
Vertex, the crown or top of the head.
Vertigo, a disordered condition in which a person feels that he or his immediate
environment is whining about; dizziness.
Vesica, a bladder, esp. the urinary bladder.

584
Vesicate, to raise vesicles or blisters on: to blister.
Vesication, the formation of blisters.
Vesiclee, 1. a small bladder like structure or cavity. 2. a small sac or cyst. 3. a
small bladder or bladder like air cavity. 4. a circumscribed elevation of the epidermis
containing serous fluid.
Vessel, a tube or duct, as an artery, vein, or the like, containing or conveying blood or
some other bodily fluid.
Vestibule, 1. any of various cavities or channels regarded as forming an approach or
entrance to another cavity or space, as the vestibule of the ear. 2. to provide with a
vestibule or vestibules.
Villi, minute, worm like vascular processes or certain membranes. (Plural of villus).
Vincent,s angina, an acute inflammation of the tonsils, the floor of the mouth, and esp.
the gums, characterized by ulceration, swelling, fever, and other fewer symptoms, often
resulting in deterioration of the gums and loss of teeth. Also called trench mouth.
Viosterol, a vitamin D preparation used in medicine, made of irradiated ergosterol dis-
solved in oil.
Viral, of, relating to, or as a result of a virus.
Virile, of. pertaining to, or characteristic of a man; masculine or manly.
Virilla, the male sex organs.
Virilism, a disorder in which male secondary sexual characteristics, as facial hair develop
in a female.
Virulent, 1. malignant; actively or highly poisonous or infectious. 2. having the ability to
produce disease, as a bacterium.
Viscera, 1. the soft interior organs contained in the cavities of the body, esp. those of the
abdomen and thorax including the lungs, heart, stomach, and thorax. 2. in popular usage,
the intestines or bowels.
Visceral, 1. of or pertaining to the viscera. 2. affecting or situated within the viscera. 3.
having the character of viscera,
Viscid, sticking or adhering, and of a glutinous consistency.
Vital, 1. of or pertaining to life, as vital functions or processes. 2. being the seat or source
of life, as, the vital parts or organs. 3. necessary to life.
Vitamin, one of several organic substances occurring in minute quantities in natural
foods and necessary for metabolism, the lack of which causes various diseases.
Vitamin A, a terpene, fat-soluble alcohol, obtained from egg yolk and certain other
animal products prescribed for night blindness and for protecting epithelial tissue.
Vitamin Bc, folic acid.
Vitamin B complex, an important group of vitamins including vitamin B1 vitamin B2
and others that are water-soluble.
Vitamin B1, thiamine.
Vitamin B2, riboflavin.
Vitamin B6, pyridoxine.
Vitamin B12, a water-soluble, crystalline vitamin, obtained from milk, eggs, liver, fish,
and meat, which treats pernicious and other anemias and is used as nutriment.
Vitamin C, ascorbic acid

585
Vitamin D, any of a group of fat-soluble vitamins often prescribed for treatment of
rickets, whose common sources are fish-liver oils, milk products, eggs and ultraviolet
irradiation of ergosterol.
Vitamin E, a vitamin found in wheat germ and other grains.
Vitamin G, riboflavin; vitamin B2.
VitaminH, biotin.
Vitamin K, a vitamin found in many green vegetables, necessary for normal blood
clotting.
Vitamin P, a vitamin found in paprika and citrus fruits, which helps to maintain capillary
and cell wall permeability.
Vitellin, a protein in the yolk of eggs
Vitiligo, a disease in which smooth white patches form on various parts of the body
because of the loss of natural pigment.
Vitreous, of or pertaining to the vitreous humor of the eye.
Vitreous chamber, the part of the cavity of the eyeball behind the lens.
Vitreous humor, the transparent gelatinous substance filling the body of the eyeball
behind the crystalline lens.
Voler, relating to the palm of the hand or the sole of the foot.
Voluntary, subject to or controlled by the will, as voluntary muscles.
Volvulus, a torsion or twisting of the intestine causing intestinal obstruction.
Vomer, a bone of the skull in most vertebrates, forming a large part of the nasal septum.
Vomit, 1. to eject the contents of the stomach through the mouth; to throw up. 2. the act
of vomiting. 3. the matter ejected in vomiting.
Vulnerability, susceptibility to injury, infection or illness.
Vulnerable, capable of being wounded; liable to injury; subject to being affected
injuriously or attacked.
Vulnus, an injury or a wound.
Vulva, the female external genital organs,
Vulvitis, an inflammation of the vulva.
Wad, a soft mass of fibrous material, as cotton, used for surgical dressing.
Waist, the part of the human body between the ribs and the hips.
Wale, a stripe or ridge produced on the skin, as by the stroke of a whip.
Walleyed, 1. having one or both eyes with blue or no color, as the result of a light
colored or white iris or of white opacity of the cornea. 2. having eyes in which an
abnormal amount of the white shows, because of divergent strabismus.
Wan, having a pale or sickly color; pallid; indicative of or showing fatigue emotional
distress, illness, or the like.
Wart, a small, dry, hard, nonrnalignant lesion of the skin.
Wassermann test, a test used for the detection of syphilis.
Waste, 1. to wear down or reduce in bodily substance, health, or strength. 2. to emaciate
or enfeeble. 3. excrement
Wasting, sapping the bodily strength, as a wasting disease.
Water blister, a blister containing a fluid that is clear, watery and devoid of blood or
pus.
Wen, a nonmalignant tumor, esp. of the scalp without inflammation and caused by
blockage of a sebaceous gland.

586
Wheat germ, the embryo or germ of a grain of wheat, used particularly as a vitamin
source
Whooping cough, an infectious disease of the respiratory mucous membrane, esp. of
children, characterized by a series of short, convulsive coughs followed by a deep
inspiration accompanied by a whooping sound.
Willpower, strength of mind; determination; resoluteness.
Windbum, discoloration or inflammation of the skin caused by excessive exposure to
wind.
Wisdom tooth, a large back molar, so named because it usually appears when a person is
nearing or has reached adulthood.
Witch hazel, an alcoholic solution of an extract obtained from the bark of a North
American shrub, used to treat bruises and sprains and as an astringent.
Wrist, the joint by which the hand is united to the arm, and by means of which the hand
moves on the forearm; the carpus.
Writer's cramp, a spasmodic muscle contraction affecting the fingers or hand of a
person who has been writing excessively.
Xanthemia, a yellow pigment in the blood.
Xanthine, a crystalline nitrogenous compound, closely related to uric acid, found in
urine, blood, and certain body tissues.
Xanthinuria, excretion of xanthine in large amounts with the urine.
Xanthochromia, a yellow discoloration of patches of the skin or of the spinal fluid.
Xanthocyanopia, a form of color blindness in which the person can distinguish between
yellow and blue but not between red and green.
Xanthoma, a skin condition marked by small, yellow, raised plates or nodules, esp. in
the eyelids.
Xenogenesis, the supposed production of offspring entirely unlike the parents.
Xenophobia, a pathological fear of unfamiliar persons.
Xeransis, a loss of moisture in the tissues: a gradual drying up.
Xerophthalmia, a dry, red soreness or itching of the eyes, caused by an insufficiency of
vitamin A.
Xerostoma, excessive dryness of the mouth due to insufficient secretion of the salivary
glands.
Yeast, a yellowish, somewhat viscid semifluid substance consisting of the aggregated
cells of certain minute fungi, used medicinally as a source of B-complex vitamins.
Yellow fever, an acute, dangerous, often fatal, infectious disease of warm climates,
transmitted by the bite of a mosquito of the genus Aedes characterized by jaundice,
vomiting, hemorrhages, and fever.
Zinc ointment, a preparation consisting of 20% zinc oxide in a base of white petroleum
and paraffin, used to treat skin disorders.
Zinc oxide, an amorphous white powder, primarily used in paint pigments and cosmetics,
and as an antiseptic or astringent in medicine.
Zoanthropy, a mental illness in which the patient has the delusion that he is an animal.
Zonesthesia, the feeling as if a cord constricted the waist; also called girdle pain.
Zoonosis, a disease communicable from animals to man
Zooplasty, the surgical transplantation to the human body of tissue from a lower animal.
Zygoma, the prominence of the cheekbone or the part that joins it to the cranium.

587
Zymase, an enzyme in yeast that causes the decomposition of sugar into alcohol and
carbon dioxide, and that may be obtained in the form of an extract.
Zymogen, any of various substances that, by internal change, give rise to an enzyme.
Zymolysis, 1. the fermentative action of enzymes. 2. the resulting fermentation.
Zymolytic, pertaining to zymolysis.
Zymosis, 1. fermentation, 2. a zymotic disease: the infective process by which certain
diseases were once believed to evolve.
Zymotic, pertaining to or relating to fermentation. 2. denoting an infectious disease.

588
Subject Index
A
Ancient Egyptian medicine 5
Asia 11
Aconitum carmicheli 18
Allium sativum 19
Articulin-F 20
Abotrifacient plants 21
Abrus precatorius 21
Aloe barbedensis 21
Apium petroselinium 21
Anethum sowa 21
Acacia arabica 21
Adhatoda vesica 21
Azadirachta indica 21
Acorus sp. 22
Abu Raihan Al. Biruni 41
Avicenna (Abu Ali Sina) 42
Abu. Marwan AbdAlmalik (Ibn Zuhur) 43
Avenzoar medical concept 44
Averroes 50
Abdul Wahid Mohammad Ibn Ahmad Ibn Rushd 51-53
Arab discovery of pulmonary circulation 56
Alternative system 52
Arthralgia 85-86
Achalasia 97, 100-101
Adenocarcinoma 101
Acholuric 111
Abdominal swelling 114-115
Abdominal pain 318, 323
Abdominal colic 117
Aids diarrhea 123
Angiodysplasia 110, 127
Annal pain and discharge 130
Anal fistula 130-131
Aids 131
Adenomas 89, 91, 107, 116, 125, 134, 157, 211-212
Abdominal mass 106, 140, 143, 318, 322-323
Acromioclavicular subluxation 147, 150
Arthritis 9, 16, 20, 22, 97, 122, 143-144, 146-155, 287,
304-305, 462, 502, 530, 539, 571
Aneurysm 261
Angina 18, 97-98, 260-264, 268, 271, 281, 287-288, 511-
512
Atherosclerosis 20, 73, 262, 264, 268, 271, 281, 287-288, 511-
512, 260

589
Atrial fibrillation 97, 120, 153, 260, 263-264, 302
Ablation 261, 364, 366, 525
B
Bilberry 12-13
Baical skull cap 16
Bletilla striata 17
Butea monosperma 21, 490
Bambusa arundensis 21
Blepharisedulis 21
Blood root 22, 497
Belly wounds 48
Blood pressure 17-18, 73, 78, 83, 162, 164, 167-168, 248, 260,
262, 265-267, 272-277, 280, 282, 296, 303, 368,
440-441, 481-482, 493, 496, 501-502, 511, 533,
548, 556, 584
Breast lumps 92
Bile in vomits 105
Benign colon lesion 107
Bascom 131
Benign prostatomegaly 137
Back pain 143
Bennett’s fracture of the thumb 147
Brachial neuralgia 150, 152
Bursitis 151-152, 155
Burns 17-18, 78, 161-163, 168, 275, 397-398, 494-495,
436, 574
Brain tumor 178, 209-213
Behcet’s disease 286
Buerger’s disease 287
Biliary cirrhosis 77, 111, 316, 462
Bone resorption 144, 484-485
C
Clinical Pharmacognosy 3, 30, 39, 69
Branches:
Pharmacology 30, 40, 43, 59
Toxicology 30
Pathophysiology 30
Histopathology 31
Morphology 31
Molecular genetics 31
Biopharmaceutics 31
Biomedical sciences 31
Forensic medicine 31
C
Chinese 5
Crude drug 12

590
Coptis rhizome 16
Coptis chinensis 17
Chrysanthemum indicum 17
Corydalis rhizome 18
Corydalis yanhusuo 18
Curcuma longa 20-21
Calamus 22
Cone flower 23
Carolus Linnaeus 61
Case taking 69
Cyanosis 73
Clubbing 73
Condition of skin 73
Cough 95-96, 100-101, 109, 133
Chest pain 95-97, 279
Coronary artery disease 98, 260-261, 281, 288-290, 294
Carcinoma of colon 106
Colonic pseudo-obstruction 107
Choleric 539
Colic 22-23, 75, 103, 106-107, 111-112, 117, 122-123,
140, 143, 147, 541
Clostridium difficile 122
Crohn’s disease 77, 87, 106, 122, 126, 130, 430
Colon cancer 125-126, 361
Colorectal bleeding 127
Constipation 125, 128-130, 136, 224, 319, 323, 408, 445, 490,
492, 496, 542
CT scan 134
Chemotherapy 93, 95, 102, 107, 126, 134, 364, 367-368, 471-
474, 522, 538
Cystitis 136-137, 140
Carcinosarcoma 140
Colles fracture of lower end of radius 147
Compound fracture 146, 149, 161-162, 169
Carpal tunnel syndrome 152, 205, 397, 399
Cellulitis 154, 159
Cold injuries 163, 194
CNS examination 175
Cranial nerve testing 178, 180, 182
Chest examination 231
Complication of sinusitis 246
Cardiogenic shock 18, 260, 265-266
Cardiomyopathy 260, 266-268
Coronary artery 18, 98, 260, 262, 267, 269, 271, 281, 288-292,
297, 401, 510-512
Cholesterol 271-271

591
Cryoglobulinemia 287, 338, 353
Churg-Strauss syndrome 287
Coronary angioplasty 98, 287-288
Catheterization 290-291
Cardiac CT 291-292
Cardiac MRI 292
Carotid ultrasound 293
Catheter ablation 294
Coronary artery bypass grafting (CABG) 295
Coronary calcium scan 295
Cardioverter defibrillator 298
Carotid Doppler test 310
Cholelithiasis 427
Computerized tomography scan 463
Child delivery 445
D
Digitalis purpurea 3
Dryopteris 19
Dracopis sp. 23
Dioscorides 39
Diffuse goiter 89
Dyspnoea 95-96
Dysphagia 100
Dyspepsia 103
Diarrhea 104-107, 117
Duodenal ulcer 143
Diverticular disease 106-110
Dyschezia 128
Diabetes insipidus 136
Deformity 73, 78, 231, 235, 398, 542, 544, 570, 574
Dislocation of hip 146-147
Dermatofibroma 156
Diffuse muscle wasting 200
Dysplasia 87, 93, 166, 267-268
Ductus-arteriosus 75, 261, 280-281
Doppler ultrasound 293
Colour Doppler 307
Pulsed Doppler 307
Power Doppler 307
Disorders of testicles 472
Testicular cancer 472
Testicular lump 471
Testicular torsion 472
E
Europe 10
Echinacea 13-14, 23, 493

592
Eclipta alba 20
Emblica officinalis 20
Examination of patients 69, 73, 440
Edema 16, 18, 73, 76
Ergotamine 83, 548
Epidermoid 157
Evacuation 168
Extra ocular movement 182
Epilepsy 217, 222
ECG 259
Extrathoracic examination 232
Echocardiography 296
EKG 259
Endoscopy 324
Examination of enlargement of breast 442
Embolization 361, 364, 367
Epididymitis 133, 472-473
F
Fistula 83
Fox glove 545
Facies 73
Fever 473, 490, 497
Fractured clavicle 147
Fractured neck of humerus 147
Fractured shaft of femur 148
Fractured tibia and fibula 149
Facial nerve 186
Fibroids 457
G
Ginkgo biloba 12-13
Guayusa 12, 14
Ginseng root 15
Ginger 16
Glycyrrhiza uralensis 16, 18
Garlic 19
Gentianakurroo 20
Gnaphaliumobtusifolium 22
Galen 39-40
Gout 73, 151, 541
Gastroesophagea reflux 97, 427
Gall stones 427
Gastric lymphoma 103
Gallstone ileus 107, 427
Gastritis 103, 490
Gastric ulcer 102, 110
Gastroenteritis 105, 121, 445

593
Gonorrhea 451, 552
Glanohumeral dislocation 147
Genetic epilepsy 226
Giant cell arteritis 287
Gastrointestinal system physical examination 315
GI malabsorption 316
Gynecology 449
Clinical examination 449
H
History of Pharmacognosy 6
Herbal medicine in USA 8
Hibiscus sinensis 21
Hamamalis virginiana 23
H. vernalis 23
H. mollis 23
Hernia 48
Hypochondrium 48
Hildegard of Bingen 59
Hypertensive 83
Haematemesis 109
HIV 131, 162, 222, 242, 250, 331, 336, 343
Hydrocele 134, 471
Hematuria 140
Hunner’s ulcer 136
Heart 257
Heart valves 258, 263
Hypovolemic 265
Heart murmur 270
Holes in the heart 273
hypotension 273
Hemorrhoid 285
Henoch-schonlein purpurea 287
Holter monitor 300
Hernia examination 321
Hepatitis 329
Hepatitis A 329-330
Hepatitis B 329
Hepatitis C 329
Hepatitis D 329
Hepatitis E 329
Hepatocellular carcinoma 115, 329
Hepatitis G 356
Hypogonadism 442, 472
Herbal formulations 489
I
Ilex guayusa 12, 14

594
Isatis tinctoria 17
Indian goose berry 20
Ibn Al-Baitar 58
Islamic medicine 63
Inflammatory 78, 83-84, 100
Intestinal obstruction 106-107
Ischiorectal abscess 130
Inguinoscrotal swelling 133
Inguinal hernia 133
Inflammatory ulcer 159
J
Jaundice 47, 73, 75, 161, 315, 331, 337, 341, 497
Swelling of the jaw 87
K
Kitab al taysir 43
Koilonychia 73
keratoacanthoma 157
Klinefelle’s syndrome 474
L
Lepidium sativum 21
Lobelia cardinalis 23
Ibn Al-Nafis 55
Lymph node 73, 77, 89, 158
Lymphoma 90-91, 102, 558
Limb injuries 146, 148
Limb pain 150
Lipoma 107, 157-158
Long QT syndrome 260, 275-276
Leuconychia 316
Liver transplant 111, 166
Liver reseaction 364
Radiation therapy 212, 368
Chemotherapy 368
Laparoscopy 433
Laboratory investigations 515
Laboratory values 517
Libido 469-470, 558
M
Mitral valve prolapse 97, 260, 278
Mahuang 3
Middle east medicine 7
Milk thistle 13
Moringa oleafera 21
Mucuna pruriens 21
Mesuaferrea 21
Mayapple 23, 567

595
Mithridates 39
Methyl sergide 83
Mouth sores 87, 368
Mouth ulcers 87
Mouth swellings 87
Mesenteric ischemia 107
Melaena 109
Midline pilonidal sinus 131
Monteggia fracture 147
Missed traumatic lesions 150
Melanoma 157
Major injuries 167
Motor testing 179, 198
Muscles asymmetry 199
Myoclonic seizure 221
Muehrke’s lines 216
Male reproductive system 449, 469
Erectile dysfunction 469
Infertility 470
Premature ejaculation 470
N
Nicholas Culpeper 60
Nutrition 73-74
Neoplastic 84
Neuralgia 150, 152
Nodular goiter 89
Nipple discharge 92
Neoplasm 110
Nerve entrapment 152, 154
Neurological examination 175
Neuroimaging 223
Nasal endoscopy 250
Nuclear heart scan 261, 301
O
Oak tree 22, 497
Obstipation 128
Orchid ectomy 134
Osteoarthritis 146
Organ replacement 165
Orthostatic hypotension 274
Obstetric 374, 439
Clinica l examination 440
Osteoporosis 461
P
Purple cone flower 13
Panax ginseng 15

596
Picrorhiza curroa 20
Piper nigrum 489
Poke 22
Phytolacca americana 22
Pinusachinata 22
p. palustris 22
P. virginiana 22
Podophyllum peltatum 23
Prunus virginiana 23
Pliny 40
Plaster for induration of spleen 47
Paracelsus 59
Pietromattioli 59
Physical examination 73
Posture and attitude 73
Pallor 73
Pulse 73
Pain in head and face 83
Phaeochromocytoma 83
Papilloedema 83
Pleuritic 96-97
Peptic ulcer 103
Pancreatitis 119-120
Polyps 125
Perianal hematoma 130
Perianal abscess 130
Prostatomegaly 136-137
Pyelonephritis 137
Polyurea 375
Prostatic adenocarcinoma 141
Pott’s fracture dislocation of the ankle 148
Perthes disease 152
Painful heel 155
Peduculated fibroma or neurofibroma 157
Peritonsillar abscess 190
Petitmal seizure 225
Peripheral arterial diseases 261
Polyarteritis 287
Polymyalgia 287
Pacemaker 299
Pulpate liver 318
Pulpate abdomen 318
Pulpate gall bladder 319
Pulpate spleen 319
Pulpate kidney 319
Pulpate pancreas 319

597
Pulpate aorta 319
Pulpate bladder 319
Pulpate testis 320
Prostate diseases 469, 471
Benign prostate 472
Q
Quercus laevis 22, 491
Q-phellos 22
Questions from common man on diabetes 405
R
Regulatory status of herbal medicine 10
Rehmannia glutinosa 16
Raphanus sativus 21
Rabbit tobacco 22
Rumex crispus 22
Ratibida sp. 23
Rudbeckis sp. 23
Regulatory issues 26, 28
Recommendations 29
Respiration 73, 97, 144, 231
Reflux 95, 101
Rectal bleeding 107, 125, 127
Rectal ulcer 130
Retention of urine 136-138
Rotator cuff lesions 150
Rheumatoid arthritis 16, 144, 150, 152
Raynaud’s syndrome 75, 152, 261, 282
Rehabilitation 171, 397
Rinne test 188
Radiation therapy 63, 212. 368
Respiratory examination 332
Reticular vein 285
S
Sanskrit 5, 19, 41
Silybum marianum 12-13
Saw palmetto 14
Serenoa repens 14
Scutellaria baicalensis 16
Salvia cinnabar 18
Salvia mittiorrhiza 18
Szechuan aconite 18
Shield fern 19
Sida cordifolia 21, 491
Sassafras 22
Sassafras albidum 22
Sweet flag 22

598
Sanguinaria sp. 22
Salix alba 23
Spleen 46
Stomach diseases 49
Samuel Hahnemann 60
Sex 73
Splinter hemorrhage 73, 77
Specific deformity 78
Systemic examination 80
Swelling in the neck 89
Salivary swellings 91
Sigmoid diverticular disease 106
Surgical abdominal swelling 114
Septic shock 120, 165
Supra sphincteric 131
Subcutaneous anal fistula 131
STD 131
Squamous cell carcinoma 13, 141, 157, 159
Scrotal cystic swelling 134
Syphilis gummata 134
Spinal tenderness 143
Supracondylar fracture of humerus 147
Smith’s fracture of lower end of radius 147
Sprained ankles 148
Slipped epiphysis 152
Solar keratosis 157
Sebaceous cyst 157
Spine injury 170
Sensory testing 193, 196
Surgery 211-212
Sinus 289
Sinusitis 240
Sinus surgery 247
Spider vein 285
Stent placement 289
T
Teak tree 20
Tectona grandis 20
Trachyspermum ammi 21
Trikatu 21
Theophrastus 39
Treatise on liver and its diseases 45
Thyroid 73, 77
Traumatic 84
Trans-sphincteric fistula 131
Tuberculosis of the kidney 137

599
Tuberculous arthritis 151
Tennis elbow 151
Tenosynuvitis 151
Trophic ulcer 159
Thoracic spine injuries 170
Tetralogy of fallot 261, 283
Talengiectosis 285
Takayasu’s arteritis 287
Tomography 291
Testicular lumps 471
Testicular cancer 472
U
Urethral discharge 133
Urethral calculus 138
Urinary tract infection (UTI) 140
Ulcer 157
Ultrasound and endoscopy of abdomen 324
V
Vaccinium myrtyllus 12
Vomiting 105
Varices 109
Vincristine 134
Venous thrombosis 154
Ventricular dysplasia 268
Valve prolapse 260, 292
Varicose 284
Venous lake 285
Vericoceles 285
Vasculitis 285
Vaccination 333
W
Waod leaf 17
Wild chrysanthemum 17
Withania somnifera 20
Witch hazel 23
Wild cherry 23
White willow 23
Warts 23
Wilm’s tumor 73
Wound 161
Weber test 187
Wegener’s granulomatosis 287
Women health related problems 478
Depression 480
Post partum psychosis 481
Wounds and burns 161

600
Y
Yellow links 16
Yellow dock 458, 496
Z
Zingiber officinalis 16, 18

601