Hin: Gular, Umar
Ben: Jagya dumurMal, Tam,Kan: AthiTel: Udambaramu, PaidiGular fig, Cluster fig or Country fig, which is considered sacred, has golden coloured exudate and black bark. It is distributed all over India. Its roots are useful in treating dysentery. The bark is useful as a wash for wounds, highly efficacious in threatened abortions and recommended in uropathy. Powdered leaves mixed with honey are given in vitiated condition of pitta. A decoction of the leaves is a good wash for wounds and ulcers. Tender fruits (figs) are used in vitiated conditions of pitta, diarrhoea, dyspepsia and haemorrhages. The latex is administered in haemorrhoids and diarrhoea (Warrier et al, 1995). The ripe fruits are sweet, cooling and are used in haemoptysis, thirst and vomiting (Nadkarni, 1954; Aiyer et al, 1957; Moos, 1976). Nalpamaradi coconut oil, Candanasava, Valiya Arimedastaila, Dinesavalyadi Kuzhambu, Abhrabhasma, Valiya candanaditaila, etc. are some important preparations using the drug (Sivarajan et al, 1994).It is a moderate to large-sized spreading laticiferous, deciduous tree without many prominent aerial roots. Leaves are dark green and ovate or elliptic. Fruit receptacles are 2-5cm in diameter, sub- globose or pyriform arranged in large clusters on short leafless branches arising from main trunk or large branches. Figs are smooth or rarely covered with minute soft hairs. When ripe, they are orange, dull reddish or dark crimson. They have a pleasant smell resembling that of cedar apples. The bark is rusty brown with a fairly smooth and soft surface, the thickness varying from 0.5-2cm according to the age of the trunk or bark. Surface is with minute separating flakes of white tissue. Texture is homogeneously leathery (Warrier et al, 1995).Stem-bark gives gluanol acetate, -sitosterol, leucocyanidin-3-O- -D-glucopyrancoside, leucopelargonidin-3-O- -D-glucopyranoside, leucopelargonidin -3-O- -L-rhamnopyranoside, lupeol, ceryl behenate, lupeol acetate and -amyrin acetate. Stem- bark is hypoglycaemic and anti-protozoal. Gall is CVS active. Bark is tonic and used in rinder pest diseases of cattle. Root is antidysenteric and antidiabetic. Leaf is antibilious. Latex is antidiarrhoeal and used in piles. Bark and syconium is astringent and used in menorrhagia (Husain et al, 1992).2. Ficus microcarpa Linn. f. syn. F. retusa auct. Non. Linn.San: Plaksah; Hin,Ben: Kamarup;Mal: Ithi, Ithiyal;Tam: Kallicci, Icci;
Kan: Itti;
Tel: PlaksaPlaksah is the Ficus species with few branches and many adventitious roots growing downward. It is widely distributed throughout India and in Sri Lanka, S. China, Ryuku Isles and Britain. Plakasah is one of the five ingredients of the group panchvalkala i.e, five barks, the decoction of which is extensively used to clear ulcers and a douche in leucorrhoea in children. This decoction is administered externally and internally with satisfactory results. Plaksah is acclaimed as cooling, astringent, and curative of raktapitta doshas, ulcers, skin diseases, burning sensation, inflammation and oedema. It is found to have good healing property and is used in preparation of oils and ointments for external application in the treatment of ulcers (Aiyer and Kolammal, 1957). The stem-bark is used to prepare Usirasava, Gandhataila, Nalpamaradi taila, Valiya marmagulika, etc. (Sivarajan et al, 1994). The bark and leaves are used in wounds, ulcers, bruises, flatulent colic, hepatopathy, diarrhoea, dysentery, diabetes, hyperdipsia, burning sensation, haemaorrhages, erysipelas, dropsy, ulcerative stomatitis, haemoptysis, psychopathy, leucorrhoea and coporrhagia (Warrier et al,1995) F. microcarpa is a large glabrous evergreen tree with few aerial roots. Leaves are short- petioled, 5-10cm long, 2-6cm wide and apex shortly and bluntly apiculate or slightly emarginate. Main lateral nerves are not very prominent and stipules are lanceolate. Fruit receptacles are sessile and globose occurring in axillary pairs. It is yellowish when ripe without any characteristic smell. Bark is dark grey or brown with a smooth surface except for the lenticels. Outer bark is corky and crustaceous thin and firmly adherent to inner tissue. Inner bark is light and flesh coloured with firbrous texture (Warrier et al, 1995). It is also equated with many other species of the genus. viz. F. Singh and Chunekar, 1972; Kapoor and Mitra, 1979; Sharma, 1983).The bark contains tannin, wax and saponin. Bark is antibilious. Powdered leaves and bark is found very good in rheumatic headache. The bark and leaves are astringent, refrigerant, acrid and stomachic.3. Ficus benghalensis Linn.Eng: Banyan tree; San: Nyagrodhah, Vatah;Hin: Bat, Bargad;Ben: Bar, Bot; Mar: Vada; Mal: Peral, Vatavriksham;Tam: Alamaram, Peral;Kan: Ala;Tel: Peddamarri;Guj: VadBanyan tree is a laticiferous tree with reddish fruits, which is wound round by aerial adventitious roots that look like many legs. It is found in the Sub-Himalayan tract and Peninsular India. It is also grawn throughout India. It is widely used in treatment of skin diseases with pitta and rakta predominance. Stem-bark, root -bark, aerial roots, leaves, vegetative buds and milky exudate are used in medicine. It improves complexion, cures erysepelas, burning sensation and vaginal disorders, while an infusion of the bark cures dysentery, diarrhoea, leucorrhoea, menorrhagia, nervous disorders and reduces blood sugar in diabetes. A decoction of the vegetative buds in milk is beneficial in haemorrhages. A paste of the leaves is applied externally to abcesses and wounds to promote suppuration, while that of young aerial roots cure pimples. Young twigs when used as a tooth brush strengthen gum and teeth (Nadkarni, 1954; Aiyer and Kolammal, 1957; Mooss,1976). The drug forms an important constituent of formulations like Nalpamaradi Coconut oil, Saribadyasava, Kumkumadi taila, Khadi ra gulika, Valiyacandanadi taila, Candanasava, etc. (Sivarajan et al, 1994). The aerial roots are useful in obstinate vomiting and leucorrhoea and are used in osteomalacia of the limbs. The buds are useful in diarrhoea and dysentery. The latex is useful in neuralgia, rheumatism, lumbago, bruises, nasitis, ulorrhagia, ulitis, odontopathy, haemorrhoids, gonorrhoea, inflammations, cracks of the sole and skin diseases (Warrier et al, 1995).It is a very large tree up to 30m in height with widely spreading branches bearing many aerial roots functioning as prop roots. Bark is greenish white. Leaves are simple, alternate, arranged often in clusters at the ends of branches. They are stipulate, 10-20cm long and 5-12.5cm broad, broadly elliptic to ovate, entire, coriaceous, strongly 3-7 ribbed from the base. The fruit receptacles are axillary, sessile, seen in pairs globose, brick red when ripe and enclosing male, female and gall flowers. Fruits are small, crustaceous, achenes, enclosed in the common fleshy receptacles. The young bark is somewhat smooth with longitudinal and transverse row of lenticels. In older bark, the lenticels are numerous and closely spaced; outer bark easily flakes off. The fresh cut surface is pink or flesh coloured and exudes plenty of latex. The inner most part of the bark adjoining the wood is nearly white and fibrous (Warrier et al, 1995).The bark yields flavanoid compounds A, B and C; A and C are identified as different forms of a leucoanthocyanidin and compound B a leucoanthocyanin. All the 3 were effective as hypoglycaemic agents. Leaves give friedelin, -sitosterol, flavonoids- quercetin-3-galactoside and rutin. Heart wood give tiglic acid ester of taraxasterol. Bark is hypoglycemic, tonic, astringent, antidiarrhoeal and antidiabetic. Latex is antirheumatic. Seed is tonic. Leaf is diaphoretic. Root fibre is antigonorrhoeic. Aerial root is used in debility and anaemic dysentery (Husain et al, 1992)..4. Ficus religiosa Linn.Eng:Peepal tree, Sacred fig; San:Pippalah, Asvatthah; Hin:Pippal, Pipli, Pipar; Mal:ArayalBen: Asvatha;Tam: Arasu, Asvattam;Kan: Aswatha;Tel: Ravi; Mar: Ashvata, PimpalaPeepal tree or Sacred fig is a large deciduous tree with few or no aerial roots. It is common throughout India, often planted in the vicinity of the temples. An aqueous extract of the bark has an antibacterial activity against Staphylococcus aureus and Escherichia coli. It is used in the treatment of gonorrhoea, diarrhoea, dysentery, haemorrhoids and gastrohelcosis. A paste of the powdered bark is a good absorbent for inflammatory swellings. It is also good for burns. Leaves and tender shoots have purgative properties and are also recommended for wounds and skin diseases. Fruits are laxative and digestive. The dried fruit pulverized and taken in water cures asthma. Seeds are refrigerant and laxative. The latex is good for neuralgia, inflammations and haemorrhages (Warrier et al, 1995). Decoction of the bark if taken in honey subdues vatarakta (Nadkarni, 1954; Aiyer and Kolammal, 1957; Mooss, 1976; Kurup et al, 1979). The important preparations using the drug are Nalpamaradi taila, Saribadyasava, Candanasava, Karnasulantaka, Valiyamarma gulika etc (Sivarajan et al, 1994). branches bearing long petioled, ovate, cordate shiny leaves. Leaves are bright green, the apex produced into a linear-lanceolate tail about half as long as the main portion of the blade. The receptacles occurring in pairs and are axillary, depressed globose, smooth and purplish when ripe. The bark is grey or ash coloured with thin or membranous flakes and is often covered with crustose lichen patches. The outer bark is not of uniform thickness, the middle bark in sections appear as brownish or light reddish brown. The inner part consists of layers of light yellowish or orange brown granular tissue (Warrier et al, 1995).Bark gives -sitosterol and its glucoside. Bark is hypoglycaemic. Stem bark is antiprotozoal, anthelmintic and antiviral. Bark is astringent, antigonorrheic, febrifuge, aphrodisiac and antidysenteric. Syconium, leaf and young shoot is purgative (Husain et al, 1992).Agrotechnology: Ficus species can be cultivated in rocky areas, unused lands, or other wastelands of the farmyard. The plant is vegetatively propagated by stem cuttings. A few species are also seed propagated. Stem cuttings of pencil thickness taken from the branches are to be kept for rooting. Rooted cuttings are to be transplanted to prepared pits. No regular manuring is required. Irrigation is not a must as a plant is hardy. The plant is not attacked by any serious pests or diseases. Bark can be collected after 15 years. Ficus species generally has an economic life span of more than hundred years. Hence bark can be regularly collected from the tree. Root, bark, leaves, fruits and latex form the economic parts (Prasad et al,1995).... ficusBen: Kesutthe, Kesraj;
Mal: Kannunni, Kayyonni, Kayyunnni;Tam: Kayyantakara, Kaikeri;Kan: Kadiggagaraga;Tel: Guntagalijeran; Arab: Kadim-el-bintImportance: Eclipta is one of the ten auspicious herbs that constitute the group dasapuspam which is considered to destroy the causative factors of all unhealthy and unpleasant features and bestow good health and prosperity. The members of this group cure wounds and ulcers as well as fever caused by the derangement of the tridosas - vata, pitta and kapha. It is used in hepatitis, spleen enlargements, chronic skin diseases, tetanus and elephantiasis. The leaf promotes hair growth and use as an antidote in scorpion sting. The root is used as an emetic, in scalding of urine, conjuctivitis and as an antiseptic to ulcers and wound in cattle. It is used to prevent abortion and miscarriage and also in cases of uterine pains after the delivery. The juice of the plant with honey is given to infants for expulsion of worms. For the relief in piles, fumigation with Eclipta is considered beneficial. A decoction of the leaves is used in uterine haemorrhage. The paste prepared by mincing fresh plants has got an antiinflammatory effect and may be applied on insect bites, stings, swellings and other skin diseases. In Ayurveda, it is mainly used in hair oil, while in Unani system, the juice is used in “Hab Miskeen Nawaz” along with aconite, triphala, Croton tiglium, Piper nigium, Piper longum, Zingiber officinale and minerals like mercury, sulphur, arsenic, borax, etc. for various types of pains in the body. It is also a constituent of “Roghan Amla Khas” for applying on the hair and of “Majun Murrawah-ul-arwah”.Distribution: This plant is widely distributed in the warm humid tropics with plenty of rainfall. It grows commonly in moist places as a weed all over plains of India.Botany: Eclipta prostrata (Linn) Linn. syn. E. alba Hassk. is an annual, erect or postrate herb, often rooting at nodes. Leaves are sessile, 2.5-7.5cm long with white appressed hairs. Floral heads are 6-8 mm in diameter, solitary and white. Fruit is an achene, compressed and narrowly winged. Sometimes, Wedelia calendulacea, which resembles Eclipta prostrata is used for the same purpose.Properties and activity: The leaves contain stigmasterol, -terthienylmethanol, wedelolactone, dismethylwedelolactone and dismethylwedelolactone-7-glucoside. The roots give hentriacontanol and heptacosanol. The roots contain polyacetylene substituted thiophenes. The aerial part is reported to contain a phytosterol, -amyrin in the n-hexane extract and luteolin-7-glucoside, -glucoside of phytosterol, a glucoside of a triterpenic acid and wedelolactone in polar solvent extract. The polypeptides isolated from the plant yield cystine, glutamic acid, phenyl alanine, tyrosine and methionine on hydrolysis. Nicotine and nicotinic acid are reported to occur in this plant.The plant is anticatarrhal, febrifuge, antidontalgic, absorbent, antihepatic, CVS active, nematicidal, ovicidal and spasmolytic in activity. The alcoholic extract of entire plant has been reported to have antiviral activity against Ranikhet disease virus. Aqueous extract of the plant showed subjective improvement of vision in the case of refractive errors. The herbal drug Trefoli, containing extracts of the plant in combination with others, when administered to the patients of viral hepatitis, produced excellent results.... ecliptaNutritional Profile Energy value (calories per serving): Low Protein: Low Fat: Low Saturated fat: Low Cholesterol: None Carbohydrates: High Fiber: High Sodium: Low (fresh or dried fruit) High (dried fruit treated with sodium sulfur compounds) Major vitamin contribution: Vitamin C Major mineral contribution: Potassium
About the Nutrients in This Food Apples are a high-fiber fruit with insoluble cellulose and lignin in the peel and soluble pectins in the flesh. Their most important vitamin is vitamin C. One fresh apple, 2.5 inches in diameter, has 2.4 g dietary fiber and 4.6 mg vitamin C (6 percent of the R DA for a woman, 5 percent of the R DA for a man). The sour taste of all immature apples (and some varieties, even when ripe) comes from malic acid. As an apple ripens, the amount of malic acid declines and the apple becomes sweeter. Apple seeds contain amygdalin, a naturally occurring cyanide/sugar compound that degrades into hydrogen cyanide. While accidentally swal- lowing an apple seed once in a while is not a serious hazard for an adult, cases of human poisoning after eating apple seeds have been reported, and swallowing only a few seeds may be lethal for a child.
The Most Nutritious Way to Serve This Food Fresh and unpared, to take advantage of the fiber in the peel and preserve the vitamin C, which is destroyed by the heat of cooking.
Diets That May Restrict or Exclude This Food Antiflatulence diet (raw apples) Low-fiber diet
Buying This Food Look for: Apples that are firm and brightly colored: shiny red Macintosh, Rome, and red Delicious; clear green Granny Smith; golden yellow Delicious. Avoid: Bruised apples. When an apple is damaged the injured cells release polyphenoloxi- dase, an enzyme that hastens the oxidation of phenols in the apple, producing brownish pigments that darken the fruit. It’s easy to check loose apples; if you buy them packed in a plastic bag, turn the bag upside down and examine the fruit.
Storing This Food Store apples in the refrigerator. Cool storage keeps them from losing the natural moisture that makes them crisp. It also keeps them from turning brown inside, near the core, a phe- nomenon that occurs when apples are stored at warm temperatures. Apples can be stored in a cool, dark cabinet with plenty of circulating air. Check the apples from time to time. They store well, but the longer the storage, the greater the natural loss of moisture and the more likely the chance that even the crispest apple will begin to taste mealy.
Preparing This Food Don’t peel or slice an apple until you are ready to use it. When you cut into the apple, you tear its cells, releasing polyphenoloxidase, an enzyme that darkens the fruit. Acid inactivates polyphenoloxidase, so you can slow the browning (but not stop it completely) by dipping raw sliced and/or peeled apples into a solution of lemon juice and water or vinegar and water or by mixing them with citrus fruits in a fruit salad. Polyphenoloxidase also works more slowly in the cold, but storing peeled apples in the refrigerator is much less effective than immersing them in an acid bath.
What Happens When You Cook This Food When you cook an unpeeled apple, insoluble cellulose and lignin will hold the peel intact through all normal cooking. The flesh of the apple, though, will fall apart as the pectin in its cell walls dissolves and the water inside its cells swells, rupturing the cell walls and turning the apples into applesauce. Commercial bakers keep the apples in their apple pies firm by treating them with calcium; home bakers have to rely on careful timing. To prevent baked apples from melting into mush, core the apple and fill the center with sugar or raisins to absorb the moisture released as the apple cooks. Cutting away a circle of peel at the top will allow the fruit to swell without splitting the skin. Red apple skins are colored with red anthocyanin pigments. When an apple is cooked, the anthocyanins combine with sugars to form irreversible brownish compounds.
How Other Kinds of Processing Affect This Food Juice. Apple juice comes in two versions: “cloudy” (unfiltered) and “clear” (filtered). Cloudy apple juice is made simply by chopping or shredding apples and then pressing out and straining the juice. Clear apple juice is cloudy juice filtered to remove solid particles and then treated with enzymes to eliminate starches and the soluble fiber pectin. Since 2000, follow- ing several deaths attributed to unpasteurized apple juice contaminated with E. coli O157: H7, the FDA has required that all juices sold in the United States be pasteurized to inactivate harmful organisms such as bacteria and mold. Note: “Hard cider” is a mildly alcoholic bever- age created when natural enzyme action converts the sugars in apple juice to alcohol; “non- alcohol cider” is another name for plain apple juice. Drying. To keep apple slices from turning brown as they dry, apples may be treated with sulfur compounds that may cause serious allergic reactions in people allergic to sulfites.
Medical Uses and/or Benefits As an antidiarrheal. The pectin in apple is a natural antidiarrheal that helps solidif y stool. Shaved raw apple is sometimes used as a folk remedy for diarrhea, and purified pectin is an ingredient in many over-the-counter antidiarrheals. Lower cholesterol levels. Soluble fiber (pectin) may interfere with the absorption of dietary fats, including cholesterol. The exact mechanism by which this occurs is still unknown, but one theory is that the pectins in the apple may form a gel in your stomach that sops up fats and cholesterol, carrying them out of your body as waste. Potential anticarcinogenic effects. A report in the April 2008 issue of the journal Nutrition from a team of researchers at the Universit y of Kaiserslautern, in Germany, suggests that several natural chemicals in apples, including but yrate (produced naturally when the pectin in apples and apple juice is metabolized) reduce the risk of cancer of the colon by nourishing and protecting the mucosa (lining) of the colon.
Adverse Effects Associated with This Food Intestinal gas. For some children, drinking excess amounts of apple juice produces intestinal discomfort (gas or diarrhea) when bacteria living naturally in the stomach ferment the sugars in the juice. To reduce this problem, the American Academy of Pediatrics recommends that children ages one to six consume no more than four to six ounces of fruit juice a day; for children ages seven to 18, the recommended serving is eight to 12 ounces a day. Cyanide poisoning. See About the nutrients in this food. Sulfite allergies (dried apples). See How other kinds of processing affect this food.
Food/Drug Interactions Digoxin (Lanoxicaps, Lanoxin). Pectins may bind to the heart medication digoxin, so eating apples at the same time you take the drug may reduce the drug’s effectiveness.... apples
Composition The cellular components are red cells or corpuscles (ERYTHROCYTES), white cells (LEUCOCYTES and lymphocytes – see LYMPHOCYTE), and platelets.
The red cells are biconcave discs with a diameter of 7.5µm. They contain haemoglobin
– an iron-containing porphyrin compound, which takes up oxygen in the lungs and releases it to the tissue.
The white cells are of various types, named according to their appearance. They can leave the circulation to wander through the tissues. They are involved in combating infection, wound healing, and rejection of foreign bodies. Pus consists of the bodies of dead white cells.
Platelets are the smallest cellular components and play an important role in blood clotting (see COAGULATION).
Erythrocytes are produced by the bone marrow in adults and have a life span of about 120 days. White cells are produced by the bone
marrow and lymphoid tissue. Plasma consists of water, ELECTROLYTES and plasma proteins; it comprises 48–58 per cent of blood volume. Plasma proteins are produced mainly by the liver and by certain types of white cells. Blood volume and electrolyte composition are closely regulated by complex mechanisms involving the KIDNEYS, ADRENAL GLANDS and HYPOTHALAMUS.... blood
Hin: Akasgaddah;
Mal: Kadamba, KollankovaTam: Akashagarudan, Gollankovai;Tel: Murudonda, NagadondaCorallocarpus is a prostrate or climbing herb distributed in Punjab, Sind, Gujarat, Deccan, Karnataka and Sri Lanka. It is monoecious with large root which is turnip-shaped and slender stem which is grooved, zigzag and glabrous. Tendrils are simple, slender and glabrous. Leaves are sub-orbicular in outline, light green above and pale beneath, deeply cordate at the base, angled or more or less deeply 3-5 lobed. Petiole is long and glabrous. Male flowers are small and arranged at the tip of a straight stiff glabrous peduncle. Calyx is slightly hairy, long and rounded at the base. Corolla is long and greenish yellow. Female flowers are usually solitary with short, stout and glabrous peduncles. Fruit is stalked, long, ellipsoid or ovoid. Seeds are pyriform, turgid, brown and with a whitish corded margin. It is prescribed in later stages of dysentery and old veneral complaints. For external use in chronic rheumatism, it is made into a liniment with cumin seed, onion and castor oil. It is used in case of snakebite where it is administered internally and applied to the bitten part. The root is given in syphilitic rheumatism and later stages of dysentery. The plant is bitter, sweet, alexipharmic and emetic. The root is said to possess alterative and laxative properties (Kirtikar and Basu, 1988). Root contains a bitter principle like Breyonin (Chopra et al, 1980).Agrotechnology: Cucurbits can be successfully grown during January-March and September- December. For the rainfed crop, sowing can also be started after the receipt of the first few showers.Pits of 60cm diameter and 30-45cm depth are to be taken at the desired spacing. Well rotten FYM or vegetable mixture is to be mixed with topsoil in the pit and seeds are to be sown at 4-5/pit. Unhealthy plants are to be removed after 2 weeks and retained 2-3 plants/pit. FYM is to be applied at 20-25t/ha as basal dose along with half dose of N (35kg/ha) and full dose of P (25kg) and K (25kg). The remaining dose of N (35kg) can be applied in 2 equal split doses at fortnightly intervals. During the initial stages of growth, irrigation is to be given at an interval of 3-4 days and at alternate days during flowering and fruiting periods. For trailing cucumber, pumpkin and melon, dried twigs are to be spread on the ground. Bitter gourd, bottle gourd, snake gourd and ash gourd are to be trailed on Pandals. Weeding and raking of the soil are to be conducted at the time of fertilizer application. Earthing up may be done during rainy season. The most dreaded pest of cucurbits is fruit flies which can be controlled by using fruit traps, covering the fruits with polythene, cloth or paper bags, removal and destruction of affected fruits and lastly spraying with Carbaryl or Malathion 0. 2% suspension containing sugar or jaggery at 10g/l at fortnightly intervals after fruit set initiation. During rainy season, downy mildew and mosaic diseases are severe in cucurbits. The former can be checked by spraying Mancozeb 0.2%. The spread of mosaic can be checked by controlling the vectors using Dimethoate or Phosphamidon 0.05% and destruction of affected plants and collateral hosts. Harvesting to be done at least 10 days after insecticide or fungicide application (KAU,1996).... cucurbitsCause Asthma runs in families, so that parents with asthma have a strong risk of having children with asthma, or with other atopic (see ATOPY) illnesses such as HAY FEVER or eczema (see DERMATITIS). There is therefore a great deal of interest in the genetic basis of the condition. Several GENES seem to be associated with the condition of atopy, in which subjects have a predisposition to form ANTIBODIES of the IgE class against allergens (see ALLERGEN) they encounter – especially inhaled allergens.
The allergic response in the lining of the airway leads to an in?ammatory reaction. Many cells are involved in this in?ammatory process, including lymphocytes, eosinophils, neutrophils and mast cells. The cells are attracted and controlled by a complex system of in?ammatory mediators. The in?amed airway-wall produced in this process is then sensitive to further allergic stimuli or to non-speci?c challenges such as dust, smoke or drying from the increased respiration during exercise. Recognition of this in?ammation has concentrated attention on anti-in?ammatory aspects of treatment.
Continued in?ammation with poor control of asthma can result in permanent damage to the airway-wall such that reversibility is reduced and airway-narrowing becomes permanent. Appropriate anti-in?ammatory therapy may help to prevent this damage.
Many allergens can be important triggers of asthma. House-dust mite, grass pollen and animal dander are the commonest problems. Occupational factors such as grain dusts, hard-metals fumes and chemicals in the plastic and paint industry are important in some adults. Viral infections are another common trigger, especially in young children.
The prevalence of asthma appears to be on the increase in most countries. Several factors have been linked to this increase; most important may be the vulnerability of the immature immune system (see IMMUNITY) in infants. High exposure to allergens such as house-dust mite early in life may prime the immune system, while reduced exposure to common viral infections may delay the maturation of the immune system. In addition, maternal smoking in pregnancy and infancy increases the risk.
Clinical course The major symptoms of asthma are breathlessness and cough. Occasionally cough may be the only symptom, especially in children, where night-time cough may be mistaken for recurrent infection and treated inappropriately with antibiotics.
The onset of asthma is usually in childhood, but it may begin at any age. In childhood, boys are affected more often than girls but by adulthood the sex incidence is equal. Children who have mild asthma are more likely to grow out of the condition as they go through their teenaged years, although symptoms may recur later.
The degree of airway-narrowing, and its change with time and treatment, can be monitored by measuring the peak expiratory ?ow with a simple monitor at home – a peak-?ow meter. The typical pattern shows the peak ?ow to be lowest in the early morning and this ‘morning dipping’ is often associated with disturbance of sleep.
Acute exacerbations of asthma may be provoked by infections or allergic stimuli. If they do not respond quickly and fully to medication, expert help should be sought urgently since oxygen and higher doses of drugs will be necessary to control the attack. In a severe attack the breathing rate and the pulse rate rise and the chest sounds wheezy. The peak-?ow rate of air into the lungs falls. Patients may be unable to talk in full sentences without catching their breath, and the reduced oxygen in the blood in very severe attacks may produce the blue colour of CYANOSIS in the lips and tongue. Such acute attacks can be very frightening for the patient and family.
Some cases of chronic asthma are included in the internationally agreed description CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) – a chronic, slowly progressive disorder characterised by obstruction of the air?ow persisting over several months.
Treatment The ?rst important consideration in the treatment of asthma is avoidance of precipitating factors. When this is a speci?c animal or occupational exposure, this may be possible; it is however more di?cult for house-dust mite or pollens. Exercise-induced asthma should be treated adequately rather than avoiding exercise.
Desensitisation injections using small quantities of speci?c allergens are used widely in some countries, but rarely in the UK as they are considered to have limited value since most asthma is precipitated by many stimuli and controlled adequately with simple treatment.
There are two groups of main drugs for the treatment of asthma. The ?rst are the bronchodilators which relax the smooth muscle in the wall of the airways, increase their diameter and relieve breathlessness. The most useful agents are the beta adrenergic agonists (see ADRENERGIC RECEPTORS) such as salbutamol and terbutaline. They are best given by inhalation into the airways since this reduces the general side-effects from oral use. These drugs are usually given to reverse airway-narrowing or to prevent its onset on exercise. However, longer-acting inhaled beta agonists such as salmeterol and formoterol or the theophyllines given in tablet form can be used regularly as prevention. The beta agonists can cause TREMOR and PALPITATION in some patients.
The second group of drugs are the antiin?ammatory agents that act to reduce in?ammation of the airway. The main agents in this group are the CORTICOSTEROIDS. They must be taken regularly, even when symptoms are absent. Given by inhalation they have few side-effects. In acute attacks, short courses of oral steroids are used; in very severe disease regular oral steroids may be needed. Other drugs have a role in suppressing in?ammation: sodium cromoglycate has been available for some years and is generally less e?ective than inhaled steroids. Newer agents directed at speci?c steps in the in?ammatory pathway, such as leukotriene receptor-antagonists, are alternative agents.
Treatment guidelines have been produced by various national and international bodies, such as the British Thoracic Society. Most have set out treatment in steps according to severity, with objectives for asthma control based on symptoms and peak ?ow. Patients should have a management plan that sets out their regular treatment and their appropriate response to changes in their condition.
Advice and support for research into asthma is provided by the National Asthma Campaign.
See www.brit-thoracic.org.uk
Prognosis Asthma is diagnosed in 15–20 per cent of all pre-school children in the developed world. Yet by the age of 15 it is estimated that fewer than 5 per cent still have symptoms. A study in 2003 reported on a follow-up of persons born in 1972–3 who developed asthma and still had problems at the age of nine. By the time these persons were aged 26, 27 per cent were still having problems; around half of that number had never been free from the illness and the other half had apparently lost it for a few years but it had returned.... asthma
They work by blocking the stimulation of beta adrenergic receptors by the neurotransmitters adrenaline and noradrenaline, which are produced at the nerve endings of that part of the SYMPATHETIC NERVOUS SYSTEM – the autonomous (involuntary) network
– which facilitates the body’s reaction to anxiety, stress and exercise – the ‘fear and ?ight’ response.
Beta1 blockers reduce the frequency and force of the heartbeat; beta2 blockers prevent vasodilation (increase in the diameter of blood vessels), thus in?uencing the patient’s blood pressure. Beta1 blockers also affect blood pressure, but the mechanism of their action is unclear. They can reduce to normal an abnormally fast heart rate so the power of the heart can be concomitantly controlled: this reduces the oxygen requirements of the heart with an advantageous knock-on e?ect on the respiratory system. These are valuable therapeutic effects in patients with ANGINA or who have had a myocardial infarction (heart attack – see HEART, DISEASES OF), or who suffer from HYPERTENSION. Beta2 blockers reduce tremors in muscles elsewhere in the body which are a feature of anxiety or the result of thyrotoxicosis (an overactive thyroid gland – see under THYROID GLAND, DISEASES OF). Noncardioselective blockers also reduce the abnormal pressure caused by the increase in the ?uid in the eyeball that characterises GLAUCOMA.
Many beta-blocking drugs are now available; minor therapeutic di?erences between them may in?uence the choice of a drug for a particular patient. Among the common drugs are:
| Primarily cardioselective | Non-cardioselective |
| Acebutolol | Labetalol |
| Atenolol | Nadolol |
| Betaxolol | Oxprenolol |
| Celiprolol | Propanolol |
| Metoprolol | Timolol |
These powerful drugs have various side-effects and should be prescribed and monitored with care. In particular, people who suffer from asthma, bronchitis or other respiratory problems may develop breathing diffculties. Long-term treatment with beta blockers should not be suddenly stopped, as this may precipitate a severe recurrence of the patient’s symptoms – including, possibly, a sharp rise in blood pressure. Gradual withdrawal of medication should mitigate untoward effects.... beta-adrenoceptor-blocking drugs
Habitat: Native to South Europe, grown as an ornamental.
English: Wall-flower, Gilli Flower.Unani: Tudri (Surkh, Safed, Zard)Action: Flowers—cardioactive, tonic, antispasmodic, purgative, emmenagogue, deobstruent (used in liver diseases and sexual debility). Seeds— stomachic, diuretic, expectorant (in bronchitis and asthma); also goitrogenic. Juice of leaves and seeds—antibacterial.
Flowers contain flavonoids (querce- tin and rhamnetin derivatives); seeds contain high levels of cardiac aglycones (30 cardiac glycosides have been isolated); oil contains cherinine, a glucoside of the digitalis group.In Unani medicine, the drug is used as a tonic to the male reproductive system, but recent findings do not validate its therapeutic use. The flavonoid, kaempferol, isolated from the young plant, inhibits spermatogenesis and alters leydig cell number and diameter, affecting the fertility.... cheiranthus cheiri(2) A drug which usually acts by relaxing smooth muscle to increase the diameter of blood vessels, the bronchial tree, or other organs.
(3) An instrument used to increase the diameter of an ori?ce or organ, either to treat a stricture or to allow surgical access.... dilator
The outer coat consists of the sclera and the cornea; their junction is called the limbus. SCLERA This is white, opaque, and constitutes the posterior ?ve-sixths of the outer coat. It is made of dense ?brous tissue. The sclera is visible anteriorly, between the eyelids, as the ‘white of the eye’. Posteriorly and anteriorly it is covered by Tenons capsule, which in turn is covered by transparent conjunctiva. There is a hole in the sclera through which nerve ?bres from the retina leave the eye in the optic nerve. Other smaller nerve ?bres and blood vessels also pass through the sclera at di?erent points. CORNEA This constitutes the transparent, colourless anterior one-sixth of the eye. It is transparent in order to allow light into the eye and is more steeply curved than the sclera. Viewed from in front, the cornea is roughly circular. Most of the focusing power of the eye is provided by the cornea (the lens acts as the ‘?ne adjustment’). It has an outer epithelium, a central stroma and an inner endothelium. The cornea is supplied with very ?ne nerve ?bres which make it exquisitely sensitive to pain. The central cornea has no blood supply – it relies mainly on aqueous humour for nutrition. Blood vessels and large nerve ?bres in the cornea would prevent light from entering the eye. LIMBUS is the junction between cornea and sclera. It contains the trabecular meshwork, a sieve-like structure through which aqueous humour leaves the eye.
The middle coat (uveal tract) consists of the choroid, ciliary body and iris. CHOROID A highly vascular sheet of tissue lining the posterior two-thirds of the sclera. The network of vessels provides the blood supply for the outer half of the retina. The blood supply of the choroid is derived from numerous ciliary vessels which pierce the sclera in front and behind. CILIARY BODY A ring of tissue extending 6 mm back from the anterior limitation of the sclera. The various muscles of the ciliary body by their contractions and relaxations are responsible for changing the shape of the lens during ACCOMMODATION. The ciliary body is lined by cells that secrete aqueous humour. Posteriorly, the ciliary body is continuous with the choroid; anteriorly it is continuous with the iris. IRIS A ?attened muscular diaphragm that is attached at its periphery to the ciliary body, and has a round central opening – the pupil. By contraction and relaxation of the muscles of the iris, the pupil can be dilated or constricted (dilated in the dark or when aroused; constricted in bright light and for close work). The iris forms a partial division between the anterior chamber and the posterior chamber of the eye. It lies in front of the lens and forms the back wall of the anterior chamber. The iris is visible from in front, through the transparent cornea, as the ‘coloured part of the eye’. The amount and distribution of iris pigment determine the colour of the iris. The pupil is merely a hole in the centre of the iris and appears black.
The inner layer The retina is a multilayered tissue (ten layers in all) which extends from the edges of the optic nerve to line the inner surface of the choroid up to the junction of ciliary body and choroid. Here the true retina ends at the ora serrata. The retina contains light-sensitive cells of two types: (i) cones – cells that operate at high and medium levels of illumination; they subserve ?ne discrimination of vision and colour vision; (ii) rods – cells that function best at low light intensity and subserve black-and-white vision.
The retina contains about 6 million cones and about 100 million rods. Information from them is conveyed by the nerve ?bres which are in the inner part of the retina, and leave the eye in the optic nerve. There are no photoreceptors at the optic disc (the point where the optic nerve leaves the eye) and therefore there is no light perception from this small area. The optic disc thus produces a physiological blind spot in the visual ?eld.
The retina can be subdivided into several areas: PERIPHERAL RETINA contains mainly rods and a few scattered cones. Visual acuity from this area is fairly coarse. MACULA LUTEA So-called because histologically it looks like a yellow spot. It occupies an area 4·5 mm in diameter lateral to the optic disc. This area of specialised retina can produce a high level of visual acuity. Cones are abundant here but there are few rods. FOVEA CENTRALIS A small central depression at the centre of the macula. Here the cones are tightly packed; rods are absent. It is responsible for the highest levels of visual acuity.
The chambers of the eye There are three: the anterior and posterior chambers, and the vitreous cavity. ANTERIOR CHAMBER Limited in front by the inner surface of the cornea, behind by the iris and pupil. It contains a transparent clear watery ?uid, the aqueous humour. This is constantly being produced by cells of the ciliary body and constantly drained away through the trabecular meshwork. The trabecular meshwork lies in the angle between the iris and inner surface of the cornea. POSTERIOR CHAMBER A narrow space between the iris and pupil in front and the lens behind. It too contains aqueous humour in transit from the ciliary epithelium to the anterior chamber, via the pupil. VITREOUS CAVITY The largest cavity of the eye. In front it is bounded by the lens and behind by the retina. It contains vitreous humour.
Lens Transparent, elastic and biconvex in cross-section, it lies behind the iris and in front of the vitreous cavity. Viewed from the front it is roughly circular and about 10 mm in diameter. The diameter and thickness of the lens vary with its accommodative state. The lens consists of: CAPSULE A thin transparent membrane surrounding the cortex and nucleus. CORTEX This comprises newly made lens ?bres that are relatively soft. It separates the capsule on the outside from the nucleus at the centre of the lens. NUCLEUS The dense central area of old lens ?bres that have become compacted by new lens ?bres laid down over them. ZONULE Numerous radially arranged ?bres attached between the ciliary body and the lens around its circumference. Tension in these zonular ?bres can be adjusted by the muscles of the ciliary body, thus changing the shape of the lens and altering its power of accommodation. VITREOUS HUMOUR A transparent jelly-like structure made up of a network of collagen ?bres suspended in a viscid ?uid. Its shape conforms to that of the vitreous cavity within which it is contained: that is, it is spherical except for a shallow concave depression on its anterior surface. The lens lies in this depression.
Eyelids These are multilayered curtains of tissue whose functions include spreading of the tear ?lm over the front of the eye to prevent desiccation; protection from injury or external irritation; and to some extent the control of light entering the eye. Each eye has an upper and lower lid which form an elliptical opening (the palpebral ?ssure) when the eyes are open. The lids meet at the medial canthus and lateral canthus respectively. The inner medial canthus is ?xed; the lateral canthus more mobile. An epicanthus is a fold of skin which covers the medial canthus in oriental races.
Each lid consists of several layers. From front to back they are: very thin skin; a sheet of muscle (orbicularis oculi, whose ?bres are concentric around the palpebral ?ssure and which produce closure of the eyelids); the orbital septum (modi?ed near the lid margin to form the tarsal plates); and ?nally, lining the back surface of the lid, the conjunctiva (known here as tarsal conjunctiva). At the free margin of each lid are the eyelashes, the openings of tear glands which lie within the lid, and the lacrimal punctum. Toward the medial edge of each lid is an elevation known as the papilla: the lacrimal punctum opens into this papilla. The punctum forms the open end of the cannaliculus, part of the tear-drainage mechanism.
Orbit The bony cavity within which the eye is held. The orbits lie one on either side of the nose, on the front of the skull. They a?ord considerable protection for the eye. Each is roughly pyramidal in shape, with the apex pointing backwards and the base forming the open anterior part of the orbit. The bone of the anterior orbital margin is thickened to protect the eye from injury. There are various openings into the posterior part of the orbit – namely the optic canal, which allows the optic nerve to leave the orbit en route for the brain, and the superior orbital and inferior orbital ?ssures, which allow passage of nerves and blood vessels to and from the orbit. The most important structures holding the eye within the orbit are the extra-ocular muscles, a suspensory ligament of connective tissue that forms a hammock on which the eye rests and which is slung between the medial and lateral walls of the orbit. Finally, the orbital septum, a sheet of connective tissue extending from the anterior margin of the orbit into the lids, helps keep the eye in place. A pad of fat ?lls in the orbit behind the eye and acts as a cushion for the eye.
Conjunctiva A transparent mucous membrane that extends from the limbus over the anterior sclera or ‘white of the eye’. This is the bulbar conjunctiva. The conjunctiva does not cover the cornea. Conjunctiva passes from the eye on to the inner surface of the eyelid at the fornices and is continuous with the tarsal conjunctiva. The semilunar fold is the vertical crescent of conjunctiva at the medial aspect of the palpebral ?ssure. The caruncle is a piece of modi?ed skin just within the inner canthus.
Eye muscles The extra-ocular muscles. There are six in all, the four rectus muscles (superior, inferior, medial and lateral rectus muscles) and two oblique muscles (superior and inferior oblique muscles). The muscles are attached at various points between the bony orbit and the eyeball. By their combined action they move the eye in horizontal and vertical gaze. They also produce torsional movement of the eye (i.e. clockwise or anticlockwise movements when viewed from the front).
Lacrimal apparatus There are two components: a tear-production system, namely the lacrimal gland and accessory lacrimal glands; and a drainage system.
Tears keep the front of the eye moist; they also contain nutrients and various components to protect the eye from infection. Crying results from excess tear production. The drainage system cannot cope with the excess and therefore tears over?ow on to the face. Newborn babies do not produce tears for the ?rst three months of life. LACRIMAL GLAND Located below a small depression in the bony roof of the orbit. Numerous tear ducts open from it into predominantly the upper lid. Accessory lacrimal glands are found in the conjunctiva and within the eyelids: the former open directly on to the surface of the conjunctiva; the latter on to the eyelid margin. LACRIMAL DRAINAGE SYSTEM This consists of: PUNCTUM An elevated opening toward the medial aspect of each lid. Each punctum opens into a canaliculus. CANALICULUS A ?ne tube-like structure run-ning within the lid, parallel to the lid margin. The canaliculi from upper and lower lid join to form a common canaliculus which opens into the lacrimal sac. LACRIMAL SAC A small sac on the side of the nose which opens into the nasolacrimal duct. During blinking, the sac sucks tears into itself from the canaliculus. Tears then drain by gravity down the nasolacrimal duct. NASOLACRIMAL DUCT A tubular structure which runs down through the wall of the nose and opens into the nasal cavity.
Visual pathway Light stimulates the rods and cones of the retina. Electrochemical messages are then passed to nerve ?bres in the retina and then via the optic nerve to the optic chiasm. Here information from the temporal (outer) half of each retina continues to the same side of the brain. Information from the nasal (inner) half of each retina crosses to the other side within the optic chiasm. The rearranged nerve ?bres then pass through the optic tract to the lateral geniculate body, then the optic radiation to reach the visual cortex in the occipital lobe of the brain.... eye
Nutritional Profile Energy value (calories per serving): Low Protein: Low Fat: Low Saturated fat: Low Cholesterol: None Carbohydrates: High Fiber: Moderate Sodium: Low Major vitamin contribution: Vitamin A, vitamin C Major mineral contribution: Potassium
About the Nutrients in This Food Grapefruit and ugli fruit (a cross between the grapefruit and the tangerine) have moderate amounts of dietary fiber and, like all citrus fruits, are most prized for their vitamin C. Pink or red grapefruits have moderate amounts of vitamin A. One-half medium (four-inch diameter) pink grapefruit has 1.4 g dietary fiber, 1,187 IU vitamin A (51 percent of the R DA for a woman, 40 percent of the R DA for a man), and 44 mg vitamin C (59 percent of the R DA for a woman, 49 percent of the R DA for a man). One half medium (3.75-inch diameter) white grapefruit has 1.3 g dietary fiber, 39 IU vitamin A (2 percent of the R DA for a woman, 1 percent of the R DA for a man), and 39 mg vitamin C (52 percent of the R DA for a woman, 43 percent of the R DA for a man). Pink and red grapefruits also contain lycopene, a red carotenoid (plant pigment), a strong antioxidant that appears to lower the risk of cancer of the prostate. The richest source of lycopene is cooked tom atoes.
The Most Nutritious Way to Serve This Food Fresh fruit or fresh-squeezed juice.
Buying This Food Look for: Firm fruit that is heavy for its size, which means that it will be juicy. The skin should be thin, smooth, and fine-grained. Most grapefruit have yellow skin that, depending on the variety, may be tinged with red or green. In fact, a slight greenish tint may mean that the grapefruit is high in sugar. Ugli fruit, which looks like misshapen, splotched grapefruit, is yellow with green patches and bumpy skin. Avoid: Grapefruit or ugli fruit with puff y skin or those that feel light for their size; the flesh inside is probably dry and juiceless.
Storing This Food Store grapefruit either at room temperature (for a few days) or in the refrigerator. Refrigerate grapefruit juice in a tightly closed glass bottle with very little air space at the top. As you use up the juice, transfer it to a smaller bottle, again with very little air space at the top. The aim is to prevent the juice from coming into contact with oxygen, which destroys vitamin C. (Most plastic juice bottles are oxygen-permeable.) Properly stored and protected from oxygen, fresh grapefruit juice can hold its vitamin C for several weeks.
Preparing This Food Grapefruit are most flavorful at room temperature, which liberates the aromatic molecules that give them their characteristic scent and taste. Before cutting into the grapefruit, rinse it under cool running water to flush debris off the peel. To section grapefruit, cut a slice from the top, then cut off the peel in strips—starting at the top and going down—or peel it in a spiral fashion. You can remove the bitter white membrane, but some of the vitamin C will go with it. Finally, slice the sections apart. Or you can simply cut the grapefruit in half and scoop out the sections with a curved, serrated grapefruit knife.
What Happens When You Cook This Food Broiling a half grapefruit or poaching grapefruit sections reduces the fruit’s supply of vitamin C, which is heat-sensitive.
How Other Kinds of Processing Affect This Food Commercially prepared juices. How well a commercially prepared juice retains its vitamin C depends on how it is prepared, stored, and packaged. Commercial flash-freezing preserves as much as 95 percent of the vitamin C in fresh grapefruit juices. Canned juice stored in the refrigerator may lose only 2 percent of its vitamin C in three months. Prepared, pasteurized “fresh” juices lose vitamin C because they are sold in plastic bottles or waxed-paper cartons that let oxygen in. Commercially prepared juices are pasteurized to stop the natural enzyme action that would otherwise turn sugars to alcohols. Pasteurization also protects juices from potentially harmful bacterial and mold contamination. Following several deaths attributed to unpas- teurized apple juices containing E. coli O157:H7, the FDA ruled that all fruit and vegetable juices must carry a warning label telling you whether the juice has been pasteurized. Around the year 2000, all juices must be processed to remove or inactivate harmful bacteria.
Medical Uses and/or Benefits Antiscorbutic. All citrus fruits are superb sources of vitamin C, the vitamin that prevents or cures scurvy, the vitamin C-deficiency disease. Increased absorption of supplemental or dietary iron. If you eat foods rich in vitamin C along with iron supplements or foods rich in iron, the vitamin C will enhance your body’s ability to absorb the iron. Wound healing. Your body needs vitamin C in order to convert the amino acid proline into hydroxyproline, an essential ingredient in collagen, the protein needed to form skin, ten- dons, and bones. As a result people with scurvy do not heal quickly, a condition that can be remedied with vitamin C, which cures the scurvy and speeds healing. Whether taking extra vitamin C speeds healing in healthy people remains to be proved. Possible inhibition of virus that causes chronic hepatitis C infection. In Januar y 2008, research- ers at Massachusetts General Hospital Center for Engineering in Medicine (Boston) published a report in the medical journal Hepatology detailing the effect of naringenin, a compound in grapefruit, on the behavior of hepatitis viruses in liver cells. In laborator y studies, naringenin appeared to inhibit the ability of the virus to multiply and/or pass out from the liver cells. To date, there are no studies detailing the effect of naringenin in human beings with hepatitis C.
Adverse Effects Associated with This Food Contact dermatitis. The essential oils in the peel of citrus fruits may cause skin irritation in sensitive people.
Food/Drug Interactions Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen and others. Taking aspirin or NSAIDs with acidic foods such as grapefruit may intensif y the drug’s ability to irritate your stomach and cause gastric bleeding. Antihistamines, anticoagulants, benzodiazepines (tranquilizers or sleep medications), calcium channel blockers (blood pressure medication), cyclosporine (immunosuppressant drug used in organ transplants), theophylline (asthma drug). Drinking grapefruit juice with a wide variety of drugs ranging from antihistamines to blood pressure medication appears to reduce the amount of the drug your body metabolizes and eliminates. The “grapefruit effect” was first identified among people taking the antihypertensive drugs felodipine (Plendil) and nifedip- ine (Adalat, Procardia). It is not yet known for certain exactly what the active substance in the juice is. One possibility, however, is bergamottin, a naturally occurring chemical in grapefruit juice known to inactivate cytochrome P450 3A4, a digestive enzyme needed to convert many drugs to water-soluble substances you can flush out of your body. Without an effective supply of cytochrome P450 3A4, the amount of a drug circulating in your body may rise to dangerous levels. Reported side effects include lower blood pressure, increased heart rate, headache, flushing, and lightheadedness. Some Drugs Known to Interact with Grapefruit Juice* Drug Class Generic (Brand name) Antianxiety drug Diazepam ( Valium) Antiarrhythmics Amiodarone (Cordarone) Blood-pressure drugs Felodipine (Plendil), nicardipine (Cardene), nimodipine (Nimotop), nisoldipine (Sular), verapamil ( Verelan) Cholesterol-lowering drugs Atorvastatin (Lipitor), lovastatin (Mevacor), simvastatin (Zocor), simvastatin/ezetimibe ( Vytorin) Immune Suppressants Cyclosporine (Neoral), tacrolimus (Prograf ) Impotence Drug Sildenafil ( Viagra) Pain Medication Methadone (Dolophine, Methadose) * This list may grow as new research appears.... grapefruit
Habitat: Among hedges and bushes.
Features ? Quadrangular stem, rough, weak but very lengthy, creeping up the hedges by little prickly hooks. Many side branches, always in pairs. Leaves small, lanceolate, in rings of six to nine round stem, with backward, bristly hairs at margins. Flowers white, very small, petals arranged like Maltese Cross ; few together on stalk rising from leaf ring. Fruit nearly globular, one-eighth inch diameter, also covered with hooked bristles. Saline taste.Part used ? Herb.Action: Diuretic, tonic, alterative.
Obstructions of urinary organs. Hot or cold infusion of 1 ounce to 1 pint in wineglass doses frequently. Clivers is similar in action to Gravelroot, the former causing a more copious watery flow, the latter a larger proportion of solid matter. The two herbs are frequently used together.... cliversGall-stones affect 22 per cent of women and 11 per cent of men. The incidence increases with age, but only about 30 per cent of those with gall-stones undergo treatment as the majority of cases are asymptomatic. There are three types of stone: cholesterol, pigment and mixed, depending upon their composition; stones are usually mixed and may contain calcium deposits. The cause of most cases is not clear but sometimes gall-stones will form around a ‘foreign body’ within the bile ducts or gall-bladder, such as suture material. BILIARY COLIC Muscle ?bres in the biliary system contract around a stone in the cystic duct or common bile duct in an attempt to expel it. This causes pain in the right upper quarter of the abdomen, with nausea and occasionally vomiting. JAUNDICE Gall-stones small enough to enter the common bile duct may block the ?ow of bile and cause jaundice. ACUTE CHOLECYSTITIS Blockage of the cystic duct may lead to this. The gall-bladder wall becomes in?amed, resulting in pain in the right upper quarter of the abdomen, fever, and an increase in the white-blood-cell count. There is characteristically tenderness over the tip of the right ninth rib on deep inhalation (Murphy’s sign). Infection of the gall-bladder may accompany the acute in?ammation and occasionally an EMPYEMA of the gall-bladder may result. CHRONIC CHOLECYSTITIS A more insidious form of gall-bladder in?ammation, producing non-speci?c symptoms of abdominal pain, nausea and ?atulence which may be worse after a fatty meal.
Diagnosis Stones are usually diagnosed on the basis of the patient’s reported symptoms, although asymptomatic gall-stones are often an incidental ?nding when investigating another complaint. Con?rmatory investigations include abdominal RADIOGRAPHY – although many gall-stones are not calci?ed and thus do not show up on these images; ULTRASOUND scanning; oral CHOLECYSTOGRAPHY – which entails a patient’s swallowing a substance opaque to X-rays which is concentrated in the gall-bladder; and endoscopic retrograde cholangiopancreatography (ERCP) – a technique in which an ENDOSCOPE is passed into the duodenum and a contrast medium injected into the biliary duct.
Treatment Biliary colic is treated with bed rest and injection of morphine-like analgesics. Once the pain has subsided, the patient may then be referred for further treatment as outlined below. Acute cholecystitis is treated by surgical removal of the gall-bladder. There are two techniques available for this procedure: ?rstly, conventional cholecystectomy, in which the abdomen is opened and the gall-bladder cut out; and, secondly, laparoscopic cholecystectomy, in which ?breoptic instruments called endoscopes (see FIBREOPTIC ENDOSCOPY) are introduced into the abdominal cavity via several small incisions (see MINIMALLY INVASIVE SURGERY (MIS)). Laparoscopic surgery has the advantage of reducing the patient’s recovery time. Gall-stones may be removed during ERCP; they can sometimes be dissolved using ultrasound waves (lithotripsy) or tablet therapy (dissolution chemotherapy). Pigment stones, calci?ed stones or stones larger than 15 mm in diameter are not suitable for this treatment, which is also less likely to succeed in the overweight patient. Drug treatment is prolonged but stones can disappear completely after two years. Stones may re-form on stopping therapy. The drugs used are derivatives of bile salts, particularly chenodeoxycholic acid; side-effects include diarrhoea and liver damage.... gall-bladder, diseases of
Habitat: This freely-branched, evergreen shrub may be seen growing on dry heaths and mountain slopes to a height of from two to five feet.
Features ? The leaves open in whorls of three, are glaucous and concave above, keeled underneath. The berries are blue-black, globular, and a quarter to half-inch in diameter. An acrid taste, and a characteristic odour resembling that of turpentine, are noticeable.Part used ? Every part of the shrub is medicinal, but the dried, ripe fruit or berries only are used in modern practice.Action: Diuretic, stimulant and carminative.
An infusion of 1 ounce of the berries to 1 pint of water may be taken freely in wineglassful doses.As a reliable tonic diuretic, the medicine is much appreciated in kidney and bladder disorders, whether acute or chronic. Although frequently successful when taken alone, it is more usually prescribed with other agents such as Parsley Piert, Uva Ursi, and Buchu. The berries are sometimes included with suitable alteratives in formula for rheumatic complaints.It is on account of the Juniper Berries used in its manufacture that gin is so frequently recommended when a diuretic is needed. However, one authority at least. Dr. Coffin, considers that "the better plan ... is to eschew the gin, and make a tea of the berries"! The same writer tells us that if Juniper boughs are burnt to ashes and the ashes put into water, "a medicine will be obtained that has cured the dropsy in an advanced stage."... juniperPregnancy lasts about 280 days and is calculated from the ?rst day of the last menstrual period – see MENSTRUATION. Pregnancy-testing kits rely on the presence of the hormone beta HUMAN CHORIONIC GONADOTROPHIN (b HCG) which is excreted in the woman’s urine as early as 30 days from the last menstrual period. The estimated date of delivery can be accurately estimated from the size of the developing fetus measured by ULTRASOUND (see also below) between seven and 24 weeks. ‘Term’ refers to the time that the baby is due; this can range from 38 weeks to 41 completed weeks.
Physical changes occur in early pregnancy – periods stop and the abdomen enlarges. The breasts swell, with the veins becoming prominent and the nipples darkening. About two in three women will have nausea with a few experiencing such severe vomiting as to require hospital admission for rehydration.
Antenatal care The aim of antenatal care is to ensure a safe outcome for both mother and child; it is provided by midwives (see MIDWIFE) and doctors. Formal antenatal care began in Edinburgh in the 1930s with the recognition that all aspects of pregnancy – normal and abnormal – warranted surveillance. Cooperation between general practitioners, midwives and obstetricians is now established, with pregnancies that are likely to progress normally being cared for in the community and only those needing special intervention being cared for in a hospital setting.
The initial visit (or booking) in the ?rst half of pregnancy will record the history of past events and the results of tests, with the aim of categorising the patients into normal or not. Screening tests including blood checks and ultrasound scans are a routine part of antenatal care. The ?rst ultrasound scan is done at about 11 weeks to date the pregnancy, with a further one done at 20 weeks – the anomaly scan – to assess the baby’s structure. Some obstetric units will check the growth of the baby with one further scan later in the pregnancy or, in the case of twin pregnancies (see below), many scans throughout. The routine blood tests include checks for ANAEMIA, DIABETES MELLITUS, sickle-cell disease and THALASSAEMIA, as well as for the blood group. Evidence of past infections is also looked for; tests for RUBELLA (German measles) and SYPHILIS are routine, whereas tests for human immunode?ciency virus (see AIDS/ HIV below) and HEPATITIS are being o?ered as optional, although there is compelling evidence that knowledge of the mother’s infection status is bene?cial to the baby.
Traditional antenatal care consists of regular appointments, initially every four weeks until 34 weeks, then fortnightly or weekly. At each visit the mother’s weight, urine and blood pressure are checked, and assessment of fetal growth and position is done by palpating the uterus. Around two-thirds of pregnancies and labours are normal: in the remainder, doctors and midwives need to increase the frequency of surveillance so as to prevent or deal with maternal and fetal problems.
Common complications of pregnancy
Some of the more common complications of pregnancy are listed below.
As well as early detection of medical complications, antenatal visits aim to be supportive and include emotional and educational care. Women with uncomplicated pregnancies are increasingly being managed by midwives and general practitioners in the community and only coming to the hospital doctors should they develop a problem. A small number will opt for a home delivery, but facilities for providing such a service are not always available in the UK.
Women requiring more intensive surveillance have their management targeted to the speci?c problems encountered. Cardiologists will see mothers-to-be with heart conditions, and those at risk of diabetes are cared for in designated clinics with specialist sta?. Those women needing more frequent surveillance than standard antenatal care can be looked after in maternity day centres. These typically include women with mildly raised blood pressure or those with small babies. Fetal medicine units have specialists who are highly skilled in ultrasound scanning and specialise in the diagnosis and management of abnormal babies still in the uterus. ECTOPIC PREGNANCY Chronic abdominal discomfort early in pregnancy may be caused by unruptured ectopic pregnancy, when, rarely, the fertilised OVUM starts developing in the Fallopian tube (see FALLOPIAN TUBES) instead of the uterus. The patient needs hospital treatment and LAPAROSCOPY. A ruptured ectopic pregnancy causes acute abdominal symptoms and collapse, and the woman will require urgent abdominal surgery. URINARY TRACT INFECTIONS These affect around 2 per cent of pregnant women and are detected by a laboratory test of a mid-stream specimen of urine. In pregnancy, symptoms of these infections do not necessarily resemble those experienced by non-pregnant women. As they can cause uterine irritability and possible premature labour (see below), it is important to ?nd and treat them appropriately. ANAEMIA is more prevalent in patients who are vegetarian or on a poor diet. Iron supplements are usually given to women who have low concentrations of HAEMOGLOBIN in their blood (less than 10.5 g/dl) or who are at risk of becoming low in iron, from bleeding, twin pregnancies and those with placenta previa (see below). ANTEPARTUM HAEMORRHAGE Early in pregnancy, vaginal bleedings may be due to a spontaneous or an incomplete therapeutic ABORTION. Bleeding from the genital tract between 24 completed weeks of pregnancy and the start of labour is called antepartum haemorrhage. The most common site is where the PLACENTA is attached to the wall of the uterus. If the placenta separates before delivery, bleeding occurs in the exposed ‘bed’. When the placenta is positioned in the upper part of the uterus it is called an abruption. PLACENTA PRAEVIA is sited in the lower part and blocks or partly blocks the cervix (neck of the womb); it can be identi?ed at about the 34th week. Ten per cent of episodes of antepartum bleeding are caused by placenta previa, and it may be associated with bleeding at delivery. This potentially serious complication is diagnosed by ultrasound scanning and may require a caesarean section (see below) at delivery. INCREASED BLOOD PRESSURE, associated with protein in the urine and swelling of the limbs, is part of a condition known as PRE-ECLAMPSIA. This occurs in the second half of pregnancy in about 1 in 10 women expecting their ?rst baby, and is mostly very mild and of no consequence to the pregnancy. However, some women can develop extremely high blood pressures which can adversely affect the fetus and cause epileptic-type seizures and bleeding disorders in the mother. This serious condition is called ECLAMPSIA. For this reason a pregnant woman with raised blood pressure or PROTEIN in her urine is carefully evaluated with blood tests, often in the maternity day assessment unit. The condition can be stopped by delivery of the baby, and this will be done if the mother’s or the fetus’s life is in danger. If the condition is milder, and the baby not mature enough for a safe delivery, then drugs can be used to control the blood pressure. MISCARRIAGE Also called spontaneous abortion, miscarriage is the loss of the fetus. There are several types:
threatened miscarriage is one in which some vaginal bleeding occurs, the uterus is enlarged, but the cervix remains closed and pregnancy usually proceeds.
inevitable miscarriage usually occurs before the 16th week and is typi?ed by extensive blood loss through an opened cervix and cramp-like abdominal pain; some products of conception are lost but the developing placental area (decidua) is retained and an operation may be necessary to clear the womb.
missed miscarriages, in which the embryo dies and is absorbed, but the decidua (placental area of uterine wall) remains and may cause abdominal discomfort and discharge of old blood.
THERAPEUTIC ABORTION is performed on more than 170,000 women annually in England and Wales. Sometimes the woman may not have arranged the procedure through the usual health-care channels, so that a doctor may see a patient with vaginal bleeding, abdominal discomfort or pain, and open cervix – symptoms which suggest that the decidua and a blood clot have been retained; these retained products will need to be removed by curettage.
Septic abortions are now much less common in Britain than before the Abortion Act (1967) permitted abortion in speci?ed circumstances. The cause is the passage of infective organisms from the vagina into the uterus, with Escherichia coli and Streptococcus faecalis the most common pathogenic agents. The woman has abdominal pain, heavy bleeding, usually fever and sometimes she is in shock. The cause is usually an incomplete abortion or one induced in unsterile circumstances. Antibiotics and curettage are the treatment. INTRAUTERINE GROWTH RETARDATION describes a slowing of the baby’s growth. This can be diagnosed by ultrasound scanning, although there is a considerable margin of error in estimates of fetal weight. Trends in growth are favoured over one-o? scan results alone. GESTATIONAL DIABETES is a condition that is more common in women who are overweight or have a family member with diabetes. If high concentrations of blood sugar are found, e?orts are made to correct it as the babies can become very fat (macrosomia), making delivery more di?cult. A low-sugar diet is usually enough to control the blood concentration of sugars; however some women need small doses of INSULIN to achieve control. FETAL ABNORMALITIES can be detected before birth using ultrasound. Some of these defects are obvious, such as the absence of kidneys, a condition incompatible with life outside the womb. These women can be o?ered a termination of their pregnancy. However, more commonly, the pattern of problems can only hint at an abnormality and closer examination is needed, particularly in the diagnosis of chromosomal deformities such as DOWN’S (DOWN) SYNDROME (trisomy 21 or presence of three 21 chromosomes instead of two).
Chromosomal abnormalities can be de?nitively diagnosed only by cell sampling such as amniocentesis (obtaining amniotic ?uid – see AMNION – from around the baby) done at 15 weeks onwards, and chorionic villus sampling (sampling a small part of the placenta) – another technique which can be done from 12 weeks onwards. Both have a small risk of miscarriage associated with them; consequently, they are con?ned to women at higher risk of having an abnormal fetus.
Biochemical markers present in the pregnant woman’s blood at di?erent stages of pregnancy may have undergone changes in those carrying an abnormal fetus. The ?rst such marker to be routinely used was a high concentration of alpha-fetol protein in babies with SPINA BIFIDA (defects in the covering of the spinal cord). Fuller research has identi?ed a range of diagnostic markers which are useful, and, in conjunction with other factors such as age, ethnic group and ultrasound ?ndings, can provide a predictive guide to the obstetrician – in consultation with the woman – as to whether or not to proceed to an invasive test. These tests include pregnancy-associated plasma protein assessed from a blood sample taken at 12 weeks and four blood tests at 15–22 weeks – alphafetol protein, beta human chorionic gonadotrophin, unconjugated oestriol and inhibin A. Ultrasound itself can reveal physical ?ndings in the fetus, which can be more common in certain abnormalities. Swelling in the neck region of an embryo in early pregnancy (increased nuchal thickness) has good predictive value on its own, although its accuracy is improved in combination with the biochemical markers. The e?ectiveness of prenatal diagnosis is rapidly evolving, the aim being to make the diagnosis as early in the pregnancy as possible to help the parents make more informed choices. MULTIPLE PREGNANCIES In the UK, one in 95 deliveries is of twins, while the prevalence of triplets is one in 10,000 and quadruplets around one in 500,000. Racial variations occur, with African women having a prevalence rate of one in 30 deliveries for twins and Japanese women a much lower rate than the UK ?gure. Multiple pregnancies occur more often in older women, and in the UK the prevalence of fertility treatments, many of these being given to older women, has raised the incidence. There is now an o?cial limit of three eggs being transferred to a woman undergoing ASSISTED CONCEPTION (gamete intrafallopian transfer, or GIFT).
Multiple pregnancies are now usually diagnosed as a result of routine ultrasound scans between 16 and 20 weeks of pregnancy. The increased size of the uterus results in the mother having more or worse pregnancy-related conditions such as nausea, abdominal discomfort, backache and varicose veins. Some congenital abnormalities in the fetus occur more frequently in twins: NEURAL TUBE defects, abnormalities of the heart and the incidence of TURNER’S SYNDROME and KLINEFELTER’S SYNDROME are examples. Such abnormalities may be detected by ultrasound scans or amniocentesis. High maternal blood pressure and anaemia are commoner in women with multiple pregnancies (see above).
The growth rates of multiple fetuses vary, but the di?erence between them and single fetuses are not that great until the later stages of pregnancy. Preterm labour is commoner in multiple pregnancies: the median length of pregnancy is 40 weeks for singletons, 37 for twins and 33 for triplets. Low birth-weights are usually the result of early delivery rather than abnormalities in growth rates. Women with multiple pregnancies require more frequent and vigilant antenatal assessments, with their carers being alert to the signs of preterm labour occurring. CEPHALOPELVIC DISPROPORTION Disparity between the size of the fetus and the mother’s pelvis is not common in the UK but is a signi?cant problem in the developing world. Disparity is classi?ed as absolute, when there is no possibility of delivery, and relative, when the baby is large but delivery (usually after a dif?cult labour) is possible. Causes of absolute disparity include: a large baby – heavier than 5 kg at birth; fetal HYDROCEPHALUS; and an abnormal maternal pelvis. The latter may be congenital, the result of trauma or a contraction in pelvic size because of OSTEOMALACIA early in life. Disproportion should be suspected if in late pregnancy the fetal head has not ‘engaged’ in the pelvis. Sometimes a closely supervised ‘trial of labour’ may result in a successful, if prolonged, delivery. Otherwise a caesarean section (see below) is necessary. UNUSUAL POSITIONS AND PRESENTATIONS OF THE BABY In most pregnant women the baby ?ts into the maternal pelvis head-?rst in what is called the occipito-anterior position, with the baby’s face pointing towards the back of the pelvis. Sometimes, however, the head may face the other way, or enter the pelvis transversely – or, rarely, the baby’s neck is ?exed backwards with the brow or face presenting to the neck of the womb. Some malpositions will correct naturally; others can be manipulated abdominally during pregnancy to a better position. If, however, the mother starts labour with the baby’s head badly positioned or with the buttocks instead of the head presenting (breech position), the labour will usually be longer and more di?cult and may require intervention using special obstetric forceps to assist in extracting the baby. If progress is poor and the fetus distressed, caesarean section may be necessary. HIV INFECTION Pregnant women who are HIV positive (see HIV; AIDS/HIV) should be taking antiviral drugs in the ?nal four to ?ve months of pregnancy, so as to reduce the risk of infecting the baby in utero and during birth by around 50 per cent. Additional antiviral treatment is given before delivery; the infection risk to the baby can be further reduced – by about 40 per cent – if delivery is by caesarean section. The mother may prefer to have the baby normally, in which case great care should be taken not to damage the baby’s skin during delivery. The infection risk to the baby is even further reduced if it is not breast fed. If all preventive precautions are taken, the overall risk of the infant becoming infected is cut to under 5 per cent.
Premature birth This is a birth that takes place before the end of the normal period of gestation, usually before 37 weeks. In practice, however, it is de?ned as a birth that takes place when the baby weighs less than 2·5 kilograms (5••• pounds). Between 5 and 10 per cent of babies are born prematurely, and in around 40 per cent of premature births the cause is unknown. Pre-eclampsia is the most common known cause; others include hypertension, chronic kidney disease, heart disease and diabetes mellitus. Multiple pregnancy is another cause. In the vast majority of cases the aim of management is to prolong the pregnancy and so improve the outlook for the unborn child. This consists essentially of rest in bed and sedation, but there are now several drugs, such as RITODRINE, that may be used to suppress the activity of the uterus and so help to delay premature labour. Prematurity was once a prime cause of infant mortality but modern medical care has greatly improved survival rates in developing countries.
Labour Also known by the traditional terms parturition, childbirth or delivery, this is the process by which the baby and subsequently the placenta are expelled from the mother’s body. The onset of labour is often preceded by a ‘show’ – the loss of the mucus and blood plug from the cervix, or neck of the womb; this passes down the vagina to the exterior. The time before the beginning of labour is called the ‘latent phase’ and characteristically lasts 24 hours or more in a ?rst pregnancy. Labour itself is de?ned by regular, painful contractions which cause dilation of the neck of the womb and descent of the fetal head. ‘Breaking of the waters’ is the loss of amniotic ?uid vaginally and can occur any time in the delivery process.
Labour itself is divided into three stages: the ?rst is from the onset of labour to full (10 cm) dilation of the neck of the womb. This stage varies in length, ideally taking no more than one hour per centimetre of dilation. Progress is monitored by regular vaginal examinations, usually every four hours. Fetal well-being is observed by intermittent or continuous monitoring of the fetal heart rate in relation to the timing and frequency of the contractions. The print-out is called a cardiotocograph. Abnormalities of the fetal heart rate may suggest fetal distress and may warrant intervention. In women having their ?rst baby (primigravidae), the common cause of a slow labour is uncoordinated contractions which can be overcome by giving either of the drugs PROSTAGLANDIN or OXYTOCIN, which provoke contractions of the uterine muscle, by an intravenous drip. Labours which progress slowly or not at all may be due to abnormal positioning of the fetus or too large a fetus, when prostaglandin or oxytocin is used much more cautiously.
The second stage of labour is from full cervical dilation to the delivery of the baby. At this stage the mother often experiences an irresistible urge to push the baby out, and a combination of strong coordinated uterine contractions and maternal e?ort gradually moves the baby down the birth canal. This stage usually lasts under an hour but can take longer. Delay, exhaustion of the mother or distress of the fetus may necessitate intervention by the midwife or doctor. This may mean enlarging the vaginal opening with an EPISIOTOMY (cutting of the perineal outlet – see below) or assisting the delivery with specially designed obstetric forceps or a vacuum extractor (ventouse). If the cervix is not completely dilated or open and the head not descended, then an emergency caesarean section may need to be done to deliver the baby. This procedure involves delivering the baby and placenta through an incision in the mother’s abdomen. It is sometimes necessary to deliver by planned or elective caesarean section: for example, if the placenta is low in the uterus – called placenta praevia – making a vaginal delivery dangerous.
The third stage occurs when the placenta (or afterbirth) is delivered, which is usually about 10–20 minutes after the baby. An injection of ergometrine and oxytocin is often given to women to prevent bleeding.
Pain relief in labour varies according to the mother’s needs. For uncomplicated labours, massage, reassurance by a birth attendant, and a warm bath and mobilisation may be enough for some women. However, some labours are painful, particularly if the woman is tired or anxious or is having her ?rst baby. In these cases other forms of analgesia are available, ranging from inhalation of NITROUS OXIDE GAS, injection of PETHIDINE HYDROCHLORIDE or similar narcotic, and regional local anaesthetic (see ANAESTHESIA).
Once a woman has delivered, care continues to ensure her and the baby’s safety. The midwives are involved in checking that the uterus returns to its normal size and that there is no infection or heavy bleeding, as well as caring for stitches if needed. The normal blood loss after birth is called lochia and generally is light, lasting up to six weeks. Midwives o?er support with breast feeding and care of the infant and will visit the parents at home routinely for up to two weeks.
Some complications of labour All operative deliveries in the UK are now done in hospitals, and are performed if a spontaneous birth is expected to pose a bigger risk to the mother or her child than a specialist-assisted one. Operative deliveries include caesarean section, forceps-assisted deliveries and those in which vacuum extraction (ventouse) is used. CAESAREAN SECTION Absolute indications for this procedure, which is used to deliver over 15 per cent of babies in Britain, are cephalopelvic disproportion and extensive placenta praevia, both discussed above. Otherwise the decision to undertake caesarean section depends on the clinical judgement of the specialist and the views of the mother. The rise in the proportion of this type of intervention (from 5 per cent in the 1930s to its present level of over 23 per cent
P
of the 600,000 or so annual deliveries in England) has been put down to defensive medicine
– namely, the doctor’s fear of litigation (initiated often because the parents believe that the baby’s health has suffered because the mother had an avoidably di?cult ‘natural’ labour). In Britain, over 60 per cent of women who have had a caesarean section try a vaginal delivery in a succeeding pregnancy, with about two-thirds of these being successful. Indications for the operation include:
absolute and relative cephalopelvic disproportion.
placenta previa.
fetal distress.
prolapsed umbilical cord – this endangers the viability of the fetus because the vital supply of oxygen and nutrients is interrupted.
malpresentation of the fetus such as breech or transverse lie in the womb.
unsatisfactory previous pregnancies or deliveries.
a request from the mother.
Caesarean sections are usually performed using regional block anaesthesia induced by a spinal or epidural injection. This results in loss of feeling in the lower part of the body; the mother is conscious and the baby not exposed to potential risks from volatile anaesthetic gases inhaled by the mother during general anaesthesia. Post-operative complications are higher with general anaesthesia, but maternal anxiety and the likelihood that the operation might be complicated and di?cult are indications for using it. A general anaesthetic may also be required for an acute obstetric emergency. At operation the mother’s lower abdomen is opened and then her uterus opened slowly with a transverse incision and the baby carefully extracted. A transverse incision is used in preference to the traditional vertical one as it enables the woman to have a vaginal delivery in any future pregnancy with a much smaller risk of uterine rupture. Women are usually allowed to get up within 24 hours and are discharged after four or ?ve days. FORCEPS AND VENTOUSE DELIVERIES Obstetric forceps are made in several forms, but all are basically a pair of curved blades shaped so that they can obtain a purchase on the baby’s head, thus enabling the operator to apply traction and (usually) speed up delivery. (Sometimes they are used to slow down progress of the head.) A ventouse or vacuum extractor comprises an egg-cup-shaped metal or plastic head, ranging from 40 to 60 mm in diameter with a hollow tube attached through which air is extracted by a foot-operated vacuum pump. The instrument is placed on the descending head, creating a negative pressure on the skin of the scalp and enabling the operator to pull the head down. In mainland Europe, vacuum extraction is generally preferred to forceps for assisting natural deliveries, being used in around 5 per cent of all deliveries. Forceps have a greater risk of causing damage to the baby’s scalp and brain than vacuum extraction, although properly used, both types should not cause any serious damage to the baby.
Episiotomy Normal and assisted deliveries put the tissues of the genital tract under strain. The PERINEUM is less elastic than the vagina and, if it seems to be splitting as the baby’s head
moves down the birth canal, it may be necessary to cut the perineal tissue – a procedure called an episiotomy – to limit damage. This is a simple operation done under local anaesthetic. It should be done only if there is a speci?c indication; these include:
to hasten the second stage of labour if the fetus is distressed.
to facilitate the use of forceps or vacuum extractor.
to enlarge a perineum that is restricted because of unyielding tissue, perhaps because of a scar from a previous labour. Midwives as well as obstetricians are trained
to undertake and repair (with sutures) episiotomies.
(For organisations which o?er advice and information on various aspects of childbirth, including eclampsia, breast feeding and multiple births, see APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELF-HELP.)... pregnancy and labour
before descending, behind it, through the chest cavity. It terminates in the abdomen by dividing into the 2 common iliac arteries of the legs.
The aorta is thick-walled and has a large diameter in order to cope with the high pressure and large volume of blood passing through it. (See also arteries, disorders of; circulatory system.)... aorta
Ben: Amlaki
Guj: AmbalaMal,Tam: NelliKas: AonlaImportance: Indian gooseberry or emblic myrobalan is a medium sized tree the fruit of which is used in many Ayurvedic preparations from time immemorial. It is useful in haemorrhage, leucorrhaea, menorrhagia, diarrhoea and dysentery. In combination with iron, it is useful for anaemia, jaundice and dyspepsia. It goes in combination in the preparation of triphala, arishta, rasayan, churna and chyavanaprash. Sanjivani pills made with other ingredients is used in typhoid, snake-bite and cholera. The green fruits are made into pickles and preserves to stimulate appetite. Seed is used in asthma, bronchitis and biliousness. Tender shoots taken with butter milk cures indigestion and diarrhoea. Leaves are also useful in conjunctivitis, inflammation, dyspepsia and dysentery. The bark is useful in gonorrhoea, jaundice, diarrhoea and myalgia. The root bark is astringent and is useful in ulcerative stomatitis and gastrohelcosis. Liquor fermented from fruit is good for indigestion, anaemia, jaundice, heart complaints, cold to the nose and for promoting urination. The dried fruits have good effect on hair hygiene and used as ingredient in shampoo and hair oil. The fruit is a very rich source of Vitamin C (600mg/100g) and is used in preserves as a nutritive tonic in general weakness (Dey, 1980).Distribution: Indian gooseberry is found through out tropical and subtropical India, Sri Lanka and Malaca. It is abundant in deciduous forests of Madhya Pradesh and Darjeeling, Sikkim and Kashmir. It is also widely cultivated.Botany: Phyllanthus emblica Linn. syn. Emblica officinalis Gaertn. belongs to Euphorbiaceae family. It is a small to medium sized deciduous tree growing up to 18m in height with thin light grey, bark exfoliating in small thin irregular flakes. Leaves are simple, many subsessile, closely set along the branchlets, distichous light green having the appearance of pinnate leaves. Flowers are greenish yellow in axillary fascicles, unisexual; males numerous on short slender pedicels; females few, subsessile; ovary 3-celled. Fruits are globose, 1-5cm in diameter, fleshy, pale yellow with 6 obscure vertical furrows enclosing 6 trigonous seeds in 2-seeded 3 crustaceous cocci. Two forms Amla are generally distinguished, the wild ones with smaller fruits and the cultivated ones with larger fruits and the latter are called ‘Banarasi’(Warrier et al, 1995).Agrotechnology: Gooseberry is quite hardy and it prefers a warm dry climate. It needs good sunlight and rainfall. It can be grown in almost all types of soils, except very sandy type. A large fruited variety “Chambakad Large“ was located from the rain shadow region of the Western Ghats for cultivation in Kerala. Amla is usually propagated by seeds and rarely by root suckers and grafts. The seeds are enclosed in a hard seed coat which renders the germination difficult. The seeds can be extracted by keeping fully ripe fruits in the sun for 2-3 days till they split open releasing the seeds. Seeds are soaked in water for 3-4 hours and sown on previously prepared seed beds and irrigated. Excess irrigation and waterlogging are harmful. One month old seedlings can be transplanted to polythene bags and one year old seedlings can be planted in the main field with the onset of monsoon. Pits of size 50 cm3 are dug at 6-8m spacing and filled with a mixture of top soil and well rotten FYM and planting is done. Amla can also be planted as a windbreak around an orchard. Irrigation and weeding are required during the first year. Application of organic manure and mulching every year are highly beneficial. Chemical fertilisers are not usually applied. No serious pests or diseases are generally noted in this crop. Planted seedlings will commence bearing from the 10th year, while grafts after 3-4 years. The vegetative growth of the tree continues from April to July. Along with the new growth in the spring, flowering also commences. Fruits will mature by December-February. Fruit yield ranges from 30-50kg/tree/year when full grown (KAU,1993).Properties and activity: Amla fruit is a rich natural source of vitamin C. It also contains cytokinin like substances identified as zeatin, zeatin riboside and zeatin nucleotide. The seeds yield 16% fixed oil, brownish yellow in colour. The plant contains tannins like glucogallia, corilagin, chebulagic acid and 3,6-digalloyl glucose. Root yields ellagic acid, lupeol, quercetin and - sitosterol (Thakur et al, 1989).The fruit is diuretic, laxative, carminative, stomachic, astringent, antidiarrhoeal, antihaemorrhagic and antianaemic.... indian gooseberryThe lumps are removed surgically and the tissue examined to confirm diagnosis.... fibroadenoma
The zygote travels down 1 of the woman’s fallopian tubes, dividing as it does so. After about a week, the mass of cells (now called a blastocyst) implants into the lining of the uterus, and the next stage of embryological growth begins.
(See also embryo; fertilization.)... zygote
Habitat: United States of America.
Features ? Flower supposed to resemble a lady's shoe in form. Rhizome about quarter- inch diameter, many cupshaped scars on top surface; wavy, thickly-matted roots underneath. Fracture short and white.Part used ? Rhizome.Action: Antispasmodic, tonic, nervine.
Combined with other tonics in the relief of neuralgia, and to allay paingenerally. Of use in hysteria and other nervous disorders. Dose, 1 drachm of the powdered rhizome. Like other medicines of a similar nature, it is of little use unless the cause of the nervous excitement is traced and removed.The remarks of Rafinesque, then Professor of Medical Botany in the University of Transylvania, are interesting in view of the "orthodox" attitude towards remedies of the herbalists ? "I am enabled to introduce, for the first time, this beautiful genus into our materia medica ; all the species are equally remedial. They have long been known to the Indians, who called them moccasin flower, and were used by the empyrics of New England, particularly Samuel Thomson. Their properties, however, have been tested and confirmed by Dr. Hales, of Troy; Dr. Tully, of Albany, etc.. . . They produce beneficial effects in all nervous diseases and hysterical affections by allaying pain, quieting the nerves and promoting sleep. They are preferable to opium in many cases, having no baneful or narcotic effect."Professor Rafinesque, however, goes even further than would Thomson and his successors when he announces that "all the species are equally remedial."... ladies' slipperGranulocytes Also known as polymorphonuclear leucocytes (‘polys’), these normally constitute 70 per cent of the white blood cells. They are divided into three groups according to the staining reactions of these granules: neutrophils, which stain with neutral dyes and constitute 65–70 per cent of all the white blood cells; eosinophils, which stain with acid dyes (e.g. eosin) and constitute 3–4 per cent of the total white blood cells; and basophils, which stain with basic dyes (e.g. methylene blue) and constitute about 0·5 per cent of the total white blood cells.
Lymphocytes constitute 25–30 per cent of the white blood cells. They have a clear, non-granular cytoplasm and a relatively large nucleus which is only slightly indented. They are divided into two groups: small lymphocytes, which are slightly larger than erythrocytes (about 8 micrometres in diameter); and large lymphocytes, which are about 12 micrometres in diameter.
Monocytes Motile phagocytic cells that circulate in the blood and migrate into the tissues, where they develop into various forms of MACROPHAGE such as tissue macrophages and KUPFFER CELLS.
Site of origin The granulocytes are formed in the red BONE MARROW. The lymphocytes are formed predominantly in LYMPHOID TISSUE. There is some controversy as to the site of origin of monocytes: some say they arise from lymphocytes, whilst others contend that they are derived from histiocytes – i.e. the RETICULO-ENDOTHELIAL SYSTEM.
Function The leucocytes constitute one of the most important of the defence mechanisms against infection. This applies particularly to the neutrophil leucocytes (see LEUCOCYTOSIS). (See also ABSCESS; BLOOD – Composition; INFLAMMATION; PHAGOCYTOSIS; WOUNDS.)... leucocytes
Breast reconstructive surgery (MAMMOPLASTY) may be done at the same time as the mastectomy – the preferred option – or, if that is not feasible, at a later date. Where the whole breast has been excised, some form of arti?cial breast (prosthesis) will be provided. This may be an external prosthesis ?tted into a specially made brassiere, or an internal implant – perhaps a silicone bag, though there has been controversy over the safety of this device. Reconstructive techniques involving the transfer of skin and muscle from nearby areas are also being developed. Post-operatively, patients can obtain advice from Breast Cancer Care.... mastectomy
(2) An internationally agreed unit (see SI UNITS) for measuring the quantity of a substance at molecular level.... mole
The most common cause of this condition (hypoparathyroidism) is accidental injury to or removal of the glands during the operation of thyroidectomy for the treatment of Graves’ disease (see THYROID GLAND, DISEASES OF – Thyrotoxicosis). If there is over-production of the parathyroids, there will be an increase of calcium in the blood: this extra calcium is drawn from the bones, causing cysts to form with resulting bone fragility. This cystic disease of bone is known as OSTEITIS FIBROSA CYSTICA. Tumours of the parathyroid glands result in this overactivity of the parathyroid hormone, and the resulting increase in the amount of calcium in the blood leads to the formation of stones in the kidneys. The only available treatment is surgical removal of the tumour. Increased activity of the parathyroid glands, or hyperparathyroidism, may cause stones in the kidneys. (See KIDNEYS, DISEASES OF.)... parathyroid
Resistance may also mean the extent of the body’s IMMUNITY – an indication of its ability to withstand disease. Another meaning relates to the development of resistance in a bacterium (see BACTERIA) to the effects on it of ANTIBIOTICS.
In PSYCHOANALYSIS, resistance refers to the blocking-o? from a person’s consciousness of repressed emotions and memories. A psychoanalyst helps the patient to break this resistance and bring the repressed material out into the open. (See also REPRESSED MEMORY THERAPY.)... resistance
Habitat: Woods and shady places.
Features ? Stem nearly simple, reddish, furrowed, up to two feet high. Leaves radical, palmate, long-stalked, glossy green above, paler underneath, serrate, nearly three inches across. White, sessile flowers, blooming in June and July. Taste astringent, becoming acrid.Part used ? Herb.Action: Astringent, alterative.
With more powerful alteratives in blood impurities. As an astringent in diarrhea and leucorrhea. Wineglass doses of the ounce to pint (boiling water) infusion are taken. Claims have been made for this herb in the treatment of consumption, and Skelton has given publicity to alleged cures. These cases are not now considered to have been proved.SARSAPARILLA, JAMAICA. Smilax ornata. N.O. Liliaceae.Synonym: Smilax medica, Smilax officinalis.Habitat: Sarsaparilla is imported from the West Indies and Mexico. Features ? The root, which is the only part used medicinally, is of a rusty-
brown colour and cylindrical in shape. It is a quarter of an inch to half an inch in diameter, has many slender rootlets, is deeply furrowed longitudinally, and the transverse section shows a brown, hard bark with a porous central portion. The taste is rather acrid, and there is no smell.The "Brown" Jamaica Sarsaparilla comes from Costa Rica. The Honduras variety reaches us in long, thin bundles with a few rootlets attached, and further supplies are imported from Mexico.First introduced by the Spaniards in 1563 as a specific for syphilis, this claim has long been disproved, although the root undoubtedly possesses active alterative principles. It is consequently now held in high regard as a blood purifier, and is usually administered with other alteratives, notably Burdock.Compound decoctions of Sarsaparilla are very popular as a springtime medicine, and Coffin's prescription will be found in the Herbal Formulas section of this volume.... sanicleThe incidence of silicosis is steadily being reduced by various measures which diminish the risk of inhaling silica dust. These include adequate ventilation to draw o? the dust; the suppression of dust by the use of water; the wearing of respirators where the risk is particularly great and it is not possible to reduce the amount of dust – for example, in sand-blasting; and periodic medical examination of work-people exposed to risk. Fewer than 100 new cases a year are diagnosed now in the United Kingdom. (See also OCCUPATIONAL HEALTH, MEDICINE AND DISEASES.)... silicosis
Habitat: Rocky woods in high situations.
Features ? Stem from twelve to eighteen inches high, with alternate sessile leaves. White flowers in May and June, usually solitary, stalks axillary ; black berries. Rhizome cylindrical, about half an inch diameter, transverse ridges, slightly flattened above, circular stem scars at intervals. Fracture short, yellowish, waxy. Taste mucilaginous, sweet then acrid.Part used ? Rhizome.Action: Astringent, demulcent.
Lung complaints, when combined with other remedies. Also in leucorrhea. Powdered root used as poultice for inflammations.Infusion of 1 ounce to 1 pint boiling water—wineglass doses.... solomon's sealOnce ejaculated during intercourse the spermatozoon travels at a rate of 1·5–3 millimetres a minute and remains mobile for several days after insemination, but quickly loses its potency for fertilisation. As it takes only about 70 minutes to reach the ovarian end of the uterine tube, it is assumed that there must be factors other than its own mobility, such as contraction of the muscle of the womb and uterine tube, that speed it on its way.... spermatozoon
Habitat: U.s.a
Features ? Rhizome is about one inch in diameter, oblique, with concave stem scars. Root is a similar thickness at the base, wrinkled, light brown. Fracture short and whitish. Taste and odour aromatic.Part used ? Root, rhizome.Action: Alterative, diaphoretic.
The strong alterative properties are made considerable use of in rheumatic and general uric acid disorders, as well as various skin diseases. Decoction of 1/2 ounce to 1 1/2 pints (reduced to 1 pint) is taken in tablespoonful doses four times daily.... spikenardLouse typhus, in which the infecting rickettsia is transmitted by the louse, is of worldwide distribution. More human deaths have been attributed to the louse via typhus, louse-borne RELAPSING FEVER and trench fever, than to any other insect with the exception of the MALARIA mosquito. Louse typhus includes epidemic typhus, Brill’s disease – which is a recrudescent form of epidemic typhus – and TRENCH FEVER.
Epidemic typhus fever, also known as exanthematic typhus, classical typhus, and louse-borne typhus, is an acute infection of abrupt onset which, in the absence of treatment, persists for 14 days. It is of worldwide distribution, but is largely con?ned today to parts of Africa. The causative organism is the Rickettsia prowazeki, so-called after Ricketts and Prowazek, two brilliant investigators of typhus, both of whom died of the disease. It is transmitted by the human louse, Pediculus humanus. The rickettsiae can survive in the dried faeces of lice for 60 days, and these infected faeces are probably the main source of human infection.
Symptoms The incubation period is usually 10–14 days. The onset is preceded by headache, pain in the back and limbs and rigors. On the third day the temperature rises, the headache worsens, and the patient is drowsy or delirious. Subsequently a characteristic rash appears on the abdomen and inner aspect of the arms, to spread over the chest, back and trunk. Death may occur from SEPTICAEMIA, heart or kidney failure, or PNEUMONIA about the 14th day. In those who recover, the temperature falls by CRISIS at about this time. The death rate is variable, ranging from nearly 100 per cent in epidemics among debilitated refugees to about 10 per cent.
Murine typhus fever, also known as ?ea typhus, is worldwide in its distribution and is found wherever individuals are crowded together in insanitary, rat-infested areas (hence the old names of jail-fever and ship typhus). The causative organism, Rickettsia mooseri, which is closely related to R. prowazeki, is transmitted to humans by the rat-?ea, Xenopsyalla cheopis. The rat is the main reservoir of infection; once humans are infected, the human louse may act as a transmitter of the rickettsia from person to person. This explains how the disease may become epidemic under insanitary, crowded conditions. As a rule, however, the disease is only acquired when humans come into close contact with infected rats.
Symptoms These are similar to those of louse-borne typhus, but the disease is usually milder, and the mortality rate is very low (about 1·5 per cent).
Tick typhus, in which the infecting rickettsia is transmitted by ticks, occurs in various parts of the world. The three best-known conditions in this group are ROCKY MOUNTAIN SPOTTED FEVER, ?èvre boutonneuse and tick-bite fever.
Mite typhus, in which the infecting rickettsia is transmitted by mites, includes scrub typhus, or tsutsugamushi disease, and rickettsialpox.
Rickettsialpox is a mild disease caused by Rickettsia akari, which is transmitted to humans from infected mice by the common mouse mite, Allodermanyssus sanguineus. It occurs in the United States, West and South Africa and the former Soviet Union.
Treatment The general principles of treatment are the same in all forms of typhus. PROPHYLAXIS consists of either avoidance or destruction of the vector. In the case of louse typhus and ?ea typhus, the outlook has been revolutionised by the introduction of e?cient insecticides such as DICHLORODIPHENYL TRICHLOROETHANE (DDT) and GAMMEXANE.
The value of the former was well shown by its use after World War II: this resulted in almost complete freedom from the epidemics of typhus which ravaged Eastern Europe after World War I, being responsible for 30 million cases with a mortality of 10 per cent. Now only 10,000–20,000 cases occur a year, with around a few hundred deaths. E?cient rat control is another measure which reduces the risk of typhus very considerably. In areas such as Malaysia, where the mites are infected from a wide variety of rodents scattered over large areas, the wearing of protective clothing is the most practical method of prophylaxis. CURATIVE TREATMENT was revolutionised by the introduction of CHLORAMPHENICOL and the TETRACYCLINES. These antibiotics altered the prognosis in typhus fever very considerably.... typhus fever
In its course from the base of the skull to the lumbar region, the cord gives o? 31 nerves on each side, each of which arises by an anterior and a posterior root that join before the nerve emerges from the spinal canal. The openings for the nerves formed by notches on the ring of each vertebra have been mentioned under the entry for spinal column. To reach these openings, the upper nerves pass almost directly outwards, whilst lower down their obliquity increases, until below the point where the cord ends there is a sheaf of nerves, known as the cauda equina, running downwards to leave the spinal canal at their appropriate openings.
The cord is a cylinder, about the thickness of the little ?nger. It has two slightly enlarged portions, one in the lower part of the neck, the other at the last dorsal vertebra; and from these thickenings arise the nerves that pass to the upper and lower limbs. The upper four cervical nerves unite to produce the cervical plexus. From this the muscles and skin of the neck are mainly supplied, and the phrenic nerve, which runs down through the lower part of the neck and the chest to innervate the diaphragm, is given o?. The brachial plexus is formed by the union of the lower four cervical and ?rst dorsal nerves. In addition to nerves to some of the muscles in the shoulder region, and others to the skin about the shoulder and inner side of the arm, the plexus gives o? large nerves that proceed down the arm.
The thoracic or dorsal nerves, with the exception of the ?rst, do not form a plexus, but each runs around the chest along the lower margin of the rib to which it corresponds, whilst the lower six extend on to the abdomen.
The lumbar plexus is formed by the upper four lumbar nerves, and its branches are distributed to the lower part of the abdomen, and front and inner side of the thigh.
The sacral plexus is formed by parts of the fourth and ?fth lumbar nerves, and the upper three and part of the fourth sacral nerves. Much of the plexus is collected into the sciatic nerves, the largest in the body, which go to the legs.
The sympathetic system is joined by a pair of small branches given o? from each spinal nerve, close to the spine. This system consists of two parts, ?rst, a pair of cords running down on the side and front of the spine, and containing on each side three ganglia in the neck, and beneath this a ganglion opposite each vertebra. From these two ganglionated cords numerous branches are given o?, and these unite to form the second part – namely, plexuses connected with various internal organs, and provided with numerous large and irregularly placed ganglia. The chief of these plexuses are the cardiac plexus, the solar or epigastric plexus, the diaphragmatic, suprarenal, renal, spermatic, or ovarian, aortic, hypogastric and pelvic plexuses.
The spinal cord, like the brain, is surrounded by three membranes: the dura mater, arachnoid mater, and pia mater, from without inwards. The arrangement of the dura and arachnoid is much looser in the case of the cord than their application to the brain. The dura especially forms a wide tube which is separated from the cord by ?uid and from the vertebral canal by blood vessels and fat, this arrangement protecting the cord from pressure in any ordinary movements of the spine.
In section the spinal cord consists partly of grey, but mainly of white, matter. It di?ers from the upper parts of the brain in that the white matter (largely) in the cord is arranged on the surface, surrounding a mass of grey matter (largely neurons – see NEURON(E)), while in the brain the grey matter is super?cial. The arrangement of grey matter, as seen in a section across the cord, resembles the letter H. Each half of the cord possesses an anterior and a posterior horn, the masses of the two sides being joined by a wide posterior grey commissure. In the middle of this commissure lies the central canal of the cord, a small tube which is the continuation of the ventricles in the brain. The horns of grey matter reach almost to the surface of the cord, and from their ends arise the roots of the nerves that leave the cord. The white matter is divided almost completely into two halves by a posterior septum and anterior ?ssure and is further split into anterior, lateral and posterior columns.
Functions The cord is, in part, a receiver and originator of nerve impulses, and in part a conductor of such impulses along ?bres which pass through it to and from the brain. The cord contains centres able to receive sensory impressions and initiate motor instructions. These control blood-vessel diameters, eye-pupil size, sweating and breathing. The brain exerts an overall controlling in?uence and, before any incoming sensation can affect consciousness, it is usually ‘?ltered’ through the brain.
Many of these centres act autonomously. Other cells of the cord are capable of originating movements in response to impulses brought direct to them through sensory nerves, such activity being known as REFLEX ACTION. (For a fuller description of the activities of the spinal cord, see NEURON(E) – Re?ex action.)
The posterior column of the cord consists of the fasciculus gracilis and the fasciculus cuneatus, both conveying sensory impressions upwards. The lateral column contains the ventral and the dorsal spino-cerebellar tracts passing to the cerebellum, the crossed pyramidal tract of motor ?bres carrying outgoing impulses downwards together with the rubro-spinal, the spino-thalamic, the spino-tectal, and the postero-lateral tracts. And, ?nally, the anterior column contains the direct pyramidal tract of motor ?bres and an anterior mixed zone. The pyramidal tracts have the best-known course. Starting from cells near the central sulcus on the brain, the motor nerve-?bres run down through the internal capsule, pons, and medulla, in the lower part of which many of those coming from the right side of the brain cross to the left side of the spinal cord, and vice versa. Thence the ?bres run down in the crossed pyramidal tract to end beside nerve-cells in the anterior horn of the cord. From these nerve-cells other ?bres pass outwards to form the nerves that go direct to the muscles. Thus the motor nerve path from brain to muscle is divided into two sections of neurons, of which the upper exerts a controlling in?uence upon the lower, while the lower is concerned in maintaining the muscle in a state of health and good nutrition, and in directly calling it into action. (See also NERVE; NERVOUS SYSTEM.)... spinal cord
Ultrasound is replacing ISOTOPE scanning in many situations, and also RADIOGRAPHY. Ultrasound of the liver can separate medical from surgical JAUNDICE in approximately 97 per cent of patients; it is very accurate in detecting and de?ning cystic lesions of the liver, but is less accurate with solid lesions – and yet will detect 85 per cent of secondary deposits (this is less than COMPUTED TOMOGRAPHY [CT] scanning). It is very accurate in detecting gall-stones (see GALL-BLADDER, DISEASES OF) and more accurate than the oral cholecystogram. It is useful as a screening test for pancreatic disease and can di?erentiate carcinoma of the pancreas from chronic pancreatitis with 85 per cent accuracy.
Ultrasound is the ?rst investigation indicated in patients presenting with renal failure, as it can quickly determine the size and shape of the kidney and whether there is any obstruction to the URETER. It is very sensitive to the presence of dilatation of the renal tract and will detect space-occupying lesions, di?erentiating cysts and tumours. It can detect also obstruction of the ureter due to renal stones by showing dilatations of the collecting system and the presence of the calculus. Adrenal (see ADRENAL GLANDS) tumours can be demonstrated by ultrasound, although it is less accurate than CT scanning.
The procedure is now the ?rst test for suspected aortic ANEURYSM and it can also show the presence of clot and delineate the true and false lumen. It is good at demonstrating subphrenic and subhepatic abscesses (see ABSCESS) and will show most intra-abdominal abscesses; CT scanning is however better for the retroperitoneal region. It has a major application in thyroid nodules as it can di?erentiate cystic from solid lesions and show the multiple lesions characteristic of the nodular GOITRE (see also THYROID GLAND, DISEASES OF). It cannot differentiate between a follicular adenoma and a carcinoma, as both these tumours are solid; nor can it demonstrate normal parathyroid glands. However, it can identify adenomas provided that they are more than 6 mm in diameter. Finally, ultrasound can di?erentiate masses in the SCROTUM into testicular and appendicular, and it can demonstrate impalpable testicular tumours. This is important as 15 per cent of testicular tumours metastasise whilst they are still impalpable.
Ultrasonic waves are one of the constituents in the shock treatment of certain types of gallstones and CALCULI in the urinary tract (see LITHOTRIPSY). They are also being used in the treatment of MENIÈRE’S DISEASE and of bruises and strains. In this ?eld of physiotherapy, ultrasonic therapy is proving of particular value in the treatment of acute injuries of soft tissue. If in such cases it is used immediately after the injury, or as soon as possible thereafter, prompt recovery is facilitated. For this reason it is being widely used in the treatment of sports injuries (see also SPORTS MEDICINE). The sound waves stimulate the healing process in damaged tissue.
Doppler ultrasound is a technique which shows the presence of vascular disease in the carotid and peripheral vessels, as it can detect the reduced blood ?ow through narrowed vessels.
Ultrasound in obstetrics Ultrasound has particular applications in obstetrics. A fetus can be seen with ultrasound from the seventh week of pregnancy, and the fetal heart can be demonstrated at this stage. Multiple pregnancy can also be diagnosed at this time by the demonstration of more than one gestation sac containing a viable fetus. A routine obstetric scan is usually performed between the 16th and 18th week of pregnancy when the fetus is easily demonstrated and most photogenic. The fetus can be measured to assess the gestational age, and the anatomy can also be checked. Intra-uterine growth retardation is much more reliably diagnosed by ultrasound than by clinical assessment. The site of the placenta can also be recorded and multiple pregnancies will be diagnosed at this stage. Fetal movements and even the heartbeat can be seen. A second scan is often done between the 32nd and 34th weeks to assess the position, size and growth rate of the baby. The resolution of equipment now available enables pre-natal diagnosis of a wide range of structural abnormalities to be diagnosed. SPINA BIFIDA, HYDROCEPHALUS and ANENCEPHALY are probably the most important, but other anomalies such as multicystic kidney, achondroplasia and certain congenital cardiac anomalies can also be identi?ed. Fetal gender can be determined from 20 weeks of gestation. Ultrasound is also useful as guidance for AMNIOCENTESIS.
In gynaecology, POLYCYSTIC OVARY SYNDROME can readily be detected as well as FIBROID and ovarian cysts. Ultrasound can monitor follicular growth when patients are being treated with infertility drugs. It is also useful in detecting ECTOPIC PREGNANCY. (See also PREGNANCY AND LABOUR.)... ultrasound
The onset of the 1st stage of labour is marked by regular contractions which become progressively more painful, and occur at shorter intervals. The cervix becomes thinned and softened and then begins to dilate with each contraction. During this time, there may be a “show’’, the mucous plug that blocks the cervical canal during pregnancy is expelled as a bloody discharge. “Breaking of the waters’’, the rupture of the amniotic sac, may occur as a slow trickle of fluid or a sudden gush. The cervix is fully dilated when the opening has widened to about 10 cm in diameter. This may take 12 hours or more for a first baby, but only a few hours for subsequent babies.
In the 2nd stage of labour, the woman feels the urge to push with each strong contraction. As the baby’s head descends into the vagina, it rotates to face the mother’s back. The perineum is stretched thin at this stage, and an episiotomy may be performed to prevent it from tearing. Once the baby’s head is delivered, the rest of the body follows with the next contractions. After delivery, the umbilical cord is clamped and cut.
In the 3rd stage of labour, the delivery of the placenta takes place.
The various forms of pain relief available during normal labour and delivery include opioid analgesic drugs, epidural anaesthesia, and pudendal block.... childbirth
A lymph node consists of a thin, fibrous outer capsule and an inner mass of lymphoid tissue. Penetrating the capsule are several small lymphatic vessels (whichcarry lymph into the node). Each node contains sinuses (spaces), in which the lymph is filtered. The flow of the lymph slows as it moves through narrow channels in the sinuses; this reduction in flow allows macrophages (white blood cells that engulf and destroy foreign and dead material) time to filter microorganisms from the lymph. Germinal centres in the lymph node release white blood cells called lymphocytes, which also help to fight infection. A single, larger vessel carries lymph out of the node.... lymph node
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