vb. to cut out tissue, an organ, or a tumour from the body. —excision n.
(2) A cone biopsy is a surgical technique in which a conical or cylindrical section of the lower part of the neck of the womb is excised.... cone
Rarely, an enlarged gland may be the result of cancer in the thyroid.
Treatment A symptomless goitre may gradually disappear or be so small as not to merit treatment. If the goitre is large or is causing the patient di?culty in swallowing or breathing, it may need surgical removal by partial or total thyroidectomy. If the patient is de?cient in iodine, ?sh and iodised salt should be included in the diet.
Hyperthyroidism is a common disorder affecting 2–5 per cent of all females at some time in their lives. The most common cause – around 75 per cent of cases – is thyrotoxicosis (see below). An ADENOMA (or multiple adenomas) or nodules in the thyroid also cause hyperthyroidism. There are several other rare causes, including in?ammation caused by a virus, autoimune reactions and cancer. The symptoms of hyperthyroidism affect many of the body’s systems as a consequence of the much-increased metabolic rate.
Thyrotoxicosis is a syndrome consisting of di?use goitre (enlarged thyroid gland), over-activity of the gland and EXOPHTHALMOS (protruding eyes). Patients lose weight and develop an increased appetite, heat intolerance and sweating. They are anxious, irritable, hyperactive, suffer from TACHYCARDIA, breathlessness and muscle weakness and are sometimes depressed. The hyperthyroidism is due to the production of ANTIBODIES to the TSH receptor (see THYROTROPHIN-STIMULATING HORMONE (TSH)) which stimulate the receptor with resultant production of excess thyroid hormones. The goitre is due to antibodies that stimulate the growth of the thyroid gland. The exoph-
thalmos is due to another immunoglobulin called the ophthalmopathic immunoglobulin, which is an antibody to a retro-orbital antigen on the surface of the retro-orbital EYE muscles. This provokes in?ammation in the retro-orbital tissues which is associated with the accumulation of water and mucopolysaccharide which ?lls the orbit and causes the eye to protrude forwards.
Although thyrotoxicosis may affect any age-group, the peak incidence is in the third decade. Females are affected ten times as often as males; the prevalence in females is one in 500. As with many other autoimmune diseases, there is an increased prevalence of autoimmune thyroid disease in the relatives of patients with thyrotoxicosis. Some of these patients may have hypothyroidism (see below) and others, thyrotoxicosis. Patients with thyrotoxicosis may present with a goitre or with the eye signs or, most commonly, with the symptoms of excess thyroid hormone production. Thyroid hormone controls the metabolic rate of the body so that the symptoms of hyperthyroidism are those of excess metabolism.
The diagnosis of thyrotoxicosis is con?rmed by the measurement of the circulating levels of the two thyroid hormones, thyroxine and TRIIODOTHYRONINE.
Treatment There are several e?ective treatments for thyrotoxicosis. ANTITHYROID DRUGS These drugs inhibit the iodination of tyrosine and hence the formation of the thyroid hormones. The most commonly used drugs are carbimazole and propylthiouricil: these will control the excess production of thyroid hormones in virtually all cases. Once the patient’s thyroid is functioning normally, the dose can be reduced to a maintenance level and is usually continued for two years. The disadvantage of antithyroid drugs is that after two years’ treatment nearly half the patients will relapse and will then require more de?nitive therapy. PARTIAL THYROIDECTOMY Removal of three-quarters of the thyroid gland is e?ective treatment of thyrotoxicosis. It is the treatment of choice in those patients with large goitres. The patient must however be treated with medication so that they are euthyroid (have a normally functioning thyroid) before surgery is undertaken, or thyroid crisis and cardiac arrhythmias may complicate the operation. RADIOACTIVE IODINE THERAPY This has been in use for many years, and is an e?ective means of controlling hyperthyroidism. One of the disadvantages of radioactive iodine is that the incidence of hypothyroidism is much greater than with other forms of treatment. However, the management of hypothyroidism is simple and requires thyroxine tablets and regular monitoring for hypothyroidism. There is no evidence of any increased incidence of cancer of the thyroid or LEUKAEMIA following radio-iodine therapy. It has been the pattern in Britain to reserve radio-iodine treatment to those over the age of 35, or those whose prognosis is unlikely to be more than 30 years as a result of cardiac or respiratory disease. Radioactive iodine treatment should not be given to a seriously thyrotoxic patient. BETA-ADRENOCEPTOR-BLOCKING DRUGS Usually PROPRANOLOL HYDROCHLORIDE: useful for symptomatic treatment during the ?rst 4–8 weeks until the longer-term drugs have reduced thyroid activity.
Hypothyroidism A condition resulting from underactivity of the thyroid gland. One form, in which the skin and subcutaneous tissues thicken and result in a coarse appearance, is called myxoedema. The thyroid gland secretes two hormones – thyroxine and triiodothyronine – and these hormones are responsible for the metabolic activity of the body. Hypothyroidism may result from developmental abnormalities of the gland, or from a de?ciency of the enzymes necessary for the synthesis of the hormones. It may be a feature of endemic goitre and retarded development, but the most common cause of hypothyroidism is the autoimmune destruction of the thyroid known as chronic thyroiditis. It may also occur as a result of radio-iodine treatment of thyroid overactivity (see above) and is occasionally secondary to pituitary disease in which inadequate TSH production occurs. It is a common disorder, occurring in 14 per 1,000 females and one per 1,000 males. Most patients present between the age of 30 and 60 years.
Symptoms As thyroid hormones are responsible for the metabolic rate of the body, hypothyroidism usually presents with a general sluggishness: this affects both physical and mental activities. The intellectual functions become slow, the speech deliberate and the formation of ideas and the answers to questions take longer than in healthy people. Physical energy is reduced and patients frequently complain of lethargy and generalised muscle aches and pains. Patients become intolerant of the cold and the skin becomes dry and swollen. The LARYNX also becomes swollen and gives rise to a hoarseness of the voice. Most patients gain weight and develop constipation. The skin becomes dry and yellow due to the presence of increased carotene. Hair becomes thinned and brittle and even baldness may develop. Swelling of the soft tissues may give rise to a CARPAL TUNNEL SYNDROME and middle-ear deafness. The diagnosis is con?rmed by measuring the levels of thyroid hormones in the blood, which are low, and of the pituitary TSH which is raised in primary hypothyroidism.
Treatment consists of the administration of thyroxine. Although tri-iodothyronine is the metabolically active hormone, thyroxine is converted to tri-iodothyronine by the tissues of the body. Treatment should be started cautiously and slowly increased to 0·2 mg daily – the equivalent of the maximum output of the thyroid gland. If too large a dose is given initially, palpitations and tachycardia are likely to result; in the elderly, heart failure may be precipitated.
Congenital hypothyroidism Babies may be born hypothyroid as a result of having little or no functioning thyroid-gland tissue. In the developed world the condition is diagnosed by screening, all newborn babies having a blood test to analyse TSH levels. Those found positive have a repeat test and, if the diagnosis is con?rmed, start on thyroid replacement therapy within a few weeks of birth. As a result most of the ill-effects of cretinism can be avoided and the children lead normal lives.
Thyroiditis In?ammation of the thyroid gland. The acute form is usually caused by a bacterial infection elsewhere in the body: treatment with antibiotics is needed. Occasionally a virus may be the infectious agent. Hashimoto’s thyroiditis is an autoimmune disorder causing hypothyroidism (reduced activity of the gland). Subacute thyroiditis is in?ammation of unknown cause in which the gland becomes painful and the patient suffers fever, weight loss and malaise. It sometimes lasts for several months but is usually self-limiting.
Thyrotoxic adenoma A variety of thyrotoxicosis (see hyperthyroidism above) in which one of the nodules of a multinodular goitre becomes autonomous and secretes excess thyroid hormone. The symptoms that result are similar to those of thyrotoxicosis, but there are minor di?erences.
Treatment The ?rst line of treatment is to render the patient euthyroid by treatment with antithyroid drugs. Then the nodule should be removed surgically or destroyed using radioactive iodine.
Thyrotoxicosis A disorder of the thyroid gland in which excessive amounts of thyroid hormones are secreted into the bloodstream. Resultant symptoms are tachycardia, tremor, anxiety, sweating, increased appetite, weight loss and dislike of heat. (See hyperthyroidism above.)... goitre
Varieties Haemorrhoids are classi?ed into ?rst-, second- and third-degree, depending on how far they prolapse through the anal canal. First-degree ones do not protrude; second-degree piles protrude during defaecation; third-degree ones are trapped outside the anal margin, although they can be pushed back. Most haemorrhoids can be described as internal, since they are covered with glandular mucosa, but some large, long-term ones develop a covering of skin. Piles are usually found at the three, seven and eleven o’clock sites when viewed with the patient on his or her back.
Causes The veins in the anus tend to become distended because they have no valves; because they form the lowest part of the PORTAL SYSTEM and are apt to become over?lled when there is the least interference with the circulation through the portal vein; and partly because the muscular arrangements for keeping the rectum closed interfere with the circulation through the haemorrhoidal veins. An absence of ?bre from western diets is probably the most important cause. The result is that people often strain to defaecate hard stools, thus raising intra-abdominal pressure which slows the rate of venous return and engorges the network of veins in the anal mucosa. Pregnancy is an important contributory factor in women developing haemorrhoids. In some people, haemorrhoids are a symptom of disease higher up in the portal system, causing interference with the circulation. They are common in heart disease, liver complaints such as cirrhosis or congestion, and any disease affecting the bowels.
Symptoms Piles cause itching, pain and often bleeding, which may occur whenever the patient defaecates or only sometimes. The piles may prolapse permanently or intermittently. The patient may complain of aching discomfort which, with the pain, may be worsened.
Treatment Prevention is important; a high-?bre diet will help in this, and is also necessary after piles have developed. Patients should not spend a long time straining on the lavatory. Itching can be lessened if the PERINEUM is properly washed, dried and powdered. Prolapsed piles can be replaced with the ?nger. Local anaesthetic and steroid ointments can help to relieve symptoms when they are relatively mild, but do not remedy the underlying disorder. If conservative measures fail, then surgery may be required. Piles may be injected, stretched or excised according to the patient’s particular circumstances.
Where haemorrhoids are secondary to another disorder, such as cancer of the rectum or colon, the underlying condition must be treated – hence the importance of medical advice if piles persist.... haemorrhoids
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
Thrush is characterised by the presence of white patches on the mucous membrane which bleeds if the patch is gently removed. It is caused by the growth of a parasitic mould known as Candida albicans. Antifungal agents usually suppress the growth of candida. Candidal in?ltration of the mucosa is often found in cancerous lesions.
Leukoplakia literally means a white patch. In the mouth it is often due to an area of thickened cells from the horny layer of the epithelium. It appears as a white patch of varying density and is often grooved by dense ?ssures. There are many causes, most of them of minor importance. It may be associated with smoking, SYPHILIS, chronic SEPSIS or trauma from a sharp tooth. Cancer must be excluded.
Stomatitis (in?ammation of the mouth) arises from the same causes as in?ammation elsewhere, but among the main causes are the cutting of teeth in children, sharp or broken teeth, excess alcohol, tobacco smoking and general ill-health. The mucous membrane becomes red, swollen and tender and ulcers may appear. Treatment consists mainly of preventing secondary infection supervening before the stomatitis has resolved. Antiseptic mouthwashes are usually su?cient.
Gingivitis (see TEETH, DISEASES OF) is in?ammation of the gum where it touches the tooth. It is caused by poor oral hygiene and is often associated with the production of calculus or tartar on the teeth. If it is neglected it will proceed to periodontal disease.
Ulcers of the mouth These are usually small and arise from a variety of causes. Aphthous ulcers are the most common; they last about ten days and usually heal without scarring. They may be associated with STRESS or DYSPEPSIA. There is no ideal treatment.
Herpetic ulcers (see HERPES SIMPLEX) are similar but usually there are many ulcers and the patient appears feverish and unwell. This condition is more common in children.
Calculus (a) Salivary: a calculus (stone) may develop in one of the major salivary-gland ducts. This may result in a blockage which will cause the gland to swell and be painful. It usually swells before a meal and then slowly subsides. The stone may be passed but often has to be removed in a minor operation. If the gland behind the calculus becomes infected, then an ABSCESS forms and, if this persists, the removal of the gland may be indicated. (b) Dental, also called TARTAR: this is a calci?ed material which adheres to the teeth; it often starts as the soft debris found on teeth which have not been well cleaned and is called plaque. If not removed, it will gradually destroy the periodontal membrane and result in the loss of the tooth. (See TEETH, DISORDERS OF.)
Ranula This is a cyst-like swelling found in the ?oor of the mouth. It is often caused by mild trauma to the salivary glands with the result that saliva collects in the cyst instead of discharging into the mouth. Surgery may be required.
Mumps is an acute infective disorder of the major salivary glands. It causes painful enlargement of the glands which lasts for about two weeks. (See also main entry for MUMPS.)
Tumours may occur in all parts of the mouth, and may be BENIGN or MALIGNANT. Benign tumours are common and may follow mild trauma or be an exaggerated response to irritation. Polyps are found in the cheeks and on the tongue and become a nuisance as they may be bitten frequently. They are easily excised.
A MUCOCOELE is found mainly in the lower lip.
An exostosis or bone outgrowth is often found in the mid line of the palate and on the inside of the mandible (bone of the lower jaw). This only requires removal if it becomes unduly large or pointed and easily ulcerated.
Malignant tumours within the mouth are often large before they are noticed, whereas those on the lips are usually seen early and are more easily treated. The cancer may arise from any of the tissues found in the mouth including epithelium, bone, salivary tissue and tooth-forming tissue remnants. Oral cancers represent about 5 per cent of all reported malignancies, and in England and Wales around 3,300 people are diagnosed annually as having cancer of the mouth and PHARYNX.
Cancer of the mouth is less common below the age of 40 years and is more common in men. It is often associated with chronic irritation from a broken tooth or ill-?tting denture. It is also more common in those who smoke and those who chew betel leaves. Leukoplakia (see above) may be a precursor of cancer. Spread of the cancer is by way of the lymph nodes in the neck. Early treatment by surgery, radiotherapy or chemotherapy will often be e?ective, except for the posterior of the tongue where the prognosis is very poor. Although surgery may be extensive and potentially mutilating, recent advances in repairing defects and grafting tissues from elsewhere have made treatment more acceptable to the patient.... mouth, diseases of
(a) The practitioner must supply remedies from premises (apart from a shop) in private practice ‘so as to exclude the public’. He is not permitted to exceed the maximum permitted dose for certain remedies, or to prescribe POM medicines.
(b) The practitioner must exercise his judgement in the presence of the patient, in person, before prescribing treatment for that person alone.
(c) For internal treatment, remedies are subject to a maximum dose restriction. All labels on internal medicines must show clearly the date, correct dosage or daily dosage, and other instructions for use. Medicines should not be within the reach of children.
(d) He may not supply any remedies appearing in Schedule 1. Neither shall he supply any on Schedule 2 (which may not be supplied on demand by retail).
He may supply all remedies included in the General Sales List (Order 2129).
(e) He must observe requirements of Schedule III as regards remedies for internal and external use.
(f) He must notify the Enforcement Authority that he intends to supply from a fixed address (not a shop) remedies listed in Schedule III.
(g) Proper clinical records should be kept, together with records of remedies he uses under Schedule III. The latter shall be available for inspection at any time by the Enforcement Authority.
The practitioner usually makes his own tinctures from ethanol for which registration with the Customs and Excise office is required. Duty is paid, but which may later be reclaimed. Accurate records of its consumption must be kept for official inspection.
Under the Medicines Act 1968 it is unlawful to manufacture or assemble (dispense) medicinal products without an appropriate licence or exemption. The Act provides that any person committing such an offence shall be liable to prosecution.
Herbal treatments differ from person to person. A prescription will be ‘tailored’ according to the clinical needs of the individual, taking into account race as well as age. Physical examination may be necessary to obtain an accurate diagnosis. The herbalist (phytotherapist) will be concerned not only in relieving symptoms but with treating the whole person.
If a person is receiving treatment from a member of the medical profession and who is also taking herbal medicine, he/she should discuss the matter with the doctor, he being responsible for the clinical management of the case.
The practitioner can provide incapacity certificates for illness continuing in excess of four days for those who are employed. It is usual for Form CCAM 1 5/87 to be used as issued on the authority of the Council for Complementary and Alternative medicine.
General practitioners operating under the UK National Health Service may use any alternative or complementary therapy they choose to treat their patients, cost refunded by the NHS. They may either administer herbal or other treatment themselves or, if not trained in medical herbalism can call upon the services of a qualified herbalist. The herbal practitioner must accept that the GP remains in charge of the patient’s clinical management.
See: MEDICINES ACT 1968, LABELLING OF HERBAL PRODUCTS, LICENSING OF HERBAL REMEDIES – EXEMPTIONS FROM. ... herbal practitioner
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