Medical ethics are embedded in cultural values which evolve. Acceptance of abortion within well-de?ned legal parameters in some jurisdictions is an example of how society in?uences the way in which perceptions about ethical obligations change. Because they are often linked to the moral views predominating in society, medical ethics cannot be seen as embodying uniform standards independent of cultural context. Some countries which permit capital punishment or female genital mutilation (FGM – see CIRCUMCISION), for example, expect doctors to carry out such procedures. Some doctors would argue that their ethical obligation to minimise pain and suffering obliges them to comply, whereas others would deem their ethical obligations to be the complete opposite. The medical community attempts to address such variations by establish-ing globally applicable ethical principles through debate within bodies such as the World Medical Association (WMA) or World Psychiatric Association (WPA). Norm-setting bodies increasingly re?ect accepted concepts of human rights and patient rights within professional ethical codes.
Practical changes within society may affect the perceived balance of power within the doctor-patient relationship, and therefore have an impact on ethics. In developed societies, for example, patients are increasingly well informed about treatment options: media such as the Internet provide them with access to specialised knowledge. Social measures such as a well-established complaints system, procedures for legal redress, and guarantees of rights such as those set out in the NHS’s Patient’s Charter appear to reduce the perceived imbalance in the relationship. Law as well as ethics emphasises the importance of informed patient consent and the often legally binding nature of informed patient refusal of treatment. Ethics re?ect the changing relationship by emphasising skills such as e?ective communication and generation of mutual trust within a doctor-patient partnership.
A widely known modern code is the WMA’s International Code of Medical Ethics which seeks to provide a modern restatement of the Hippocratic principles.
Traditionally, ethical codes have sought to establish absolutist positions. The WMA code, for example, imposes an apparently absolute duty of con?dentiality which extends beyond the patient’s death. Increasingly, however, ethics are perceived as a tool for making morally appropriate decisions in a sphere where there is rarely one ‘right’ answer. Many factors – such as current emphasis on autonomy and the individual values of patients; awareness of social and cultural diversity; and the phenomenal advance of new technology which has blurred some moral distinctions about what constitutes a ‘person’ – have contributed to the perception that ethical dilemmas have to be resolved on a case-by-case basis.
An approach adopted by American ethicists has been moral analysis of cases using four fundamental principles: autonomy, bene?cence, non-male?cence and justice. The ‘four principles’ provide a useful framework within which ethical dilemmas can be teased out, but they are criticised for their apparent simplicity in the face of complex problems and for the fact that the moral imperatives implicit in each principle often con?ict with some or all of the other three. As with any other approach to problem-solving, the ‘four principles’ require interpretation. Enduring ethical precepts such as the obligation to bene?t patients and avoid harm (bene?cence and non-male?cence) may be differently interpreted in cases where prolongation of life is contrary to a patient’s wishes or where sentience has been irrevocably lost. In such cases, treatment may be seen as constituting a ‘harm’ rather than a ‘bene?t’.
The importance accorded to ethics in daily practice has undergone considerable development in the latter half of the 20th century. From being seen mainly as a set of values passed on from experienced practitioners to their students at the bedside, medical ethics have increasingly become the domain of lawyers, academic philosophers and professional ethicists, although the role of experienced practitioners is still considered central. In the UK, law and medical ethics increasingly interact. Judges resolve cases on the basis of established medical ethical guidance, and new ethical guidance draws in turn on common-law judgements in individual cases. The rapid increase in specialised journals, conferences and postgraduate courses focused on ethics is testimony to the ever-increasing emphasis accorded to this area of study. Multidisciplinary practice has stimulated the growth of the new discipline of ‘health-care ethics’ which seeks to provide uniformity across long-established professional boundaries. The trend is to set common standards for a range of health professionals and others who may have a duty of care, such as hospital chaplains and ancillary workers. Since a primary function of ethics is to ?nd reasonable answers in situations where di?erent interests or priorities con?ict, managers and health-care purchasers are increasingly seen as potential partners in the e?ort to establish a common approach. Widely accepted ethical values are increasingly applied to the previously unacknowledged dilemmas of rationing scarce resources.
In modern debate about ethics, two important trends can be identi?ed. As a result of the increasingly high pro?le accorded to applied ethics, there is a trend for professions not previously subject to widely agreed standards of behaviour to adopt codes of ethical practice. Business ethics or the ethics of management are comparatively new. At the same time, there is some debate about whether professionals, such as doctors, traditionally subject to special ethical duties, should be seen as simply doing a job for payment like any other worker. As some doctors perceive their power and prestige eroded by health-care managers deciding on how and when to ration care and pressure for patients to exercise autonomy about treatment decisions, it is sometimes argued that realistic limits must be set on medical obligations. A logical implication of patient choice and rejection of medical paternalism would appear to be a concomitant reduction in the freedom of doctors to carry out their own ethical obligations. The concept of conscientious objection, incorporated to some extent in law (e.g. in relation to abortion) ensures that doctors are not obliged to act contrary to their own personal or professional values.... ethics
Causes The direct cause is various BACTERIA. Sometimes the presence of foreign bodies, such as bullets or splinters, may produce an abscess, but these foreign bodies may remain buried in the tissues without causing any trouble provided that they are not contaminated by bacteria or other micro-organisms.
The micro-organisms most frequently found are staphylococci (see STAPHYLOCOCCUS), and, next to these, streptococci (see STREPTOCOCCUS) – though the latter cause more virulent abscesses. Other abscess-forming organisms are Pseudomonas pyocyanea and Escherichia coli, which live always in the bowels and under certain conditions wander into the surrounding tissues, producing abscesses.
The presence of micro-organisms is not suf?cient in itself to produce suppuration (see IMMUNITY; INFECTION); streptococci can often be found on the skin and in the skin glands of perfectly healthy individuals. Whether they will produce abscesses or not depends upon the virulence of the organism and the individual’s natural resistance.
When bacteria have gained access – for example, to a wound – they rapidly multiply, produce toxins, and cause local dilatation of the blood vessels, slowing of the bloodstream, and exudation of blood corpuscles and ?uid. The LEUCOCYTES, or white corpuscles of the blood, collect around the invaded area and destroy the bacteria either by consuming them (see PHAGOCYTOSIS) or by forming a toxin that kills them. If the body’s local defence mechanisms fail to do this, the abscess will spread and may in severe cases cause generalised infection or SEPTICAEMIA.
Symptoms The classic symptoms of in?ammation are redness, warmth, swelling, pain and fever. The neighbouring lymph nodes may be swollen and tender in an attempt to stop the bacteria spreading to other parts of the body. Infection also causes an increase in the number of leucocytes in the blood (see LEUCOCYTOSIS). Immediately the abscess is opened, or bursts, the pain disappears, the temperature falls rapidly to normal, and healing proceeds. If, however, the abscess discharges into an internal cavity such as the bowel or bladder, it may heal slowly or become chronic, resulting in the patient’s ill-health.
Treatment Most local infections of the skin respond to ANTIBIOTICS. If pus forms, the abscess should be surgically opened and drained.
Abscesses can occur in any tissue in the body, but the principles of treatment are broadly the same: use of an antibiotic and, where appropriate, surgery.... abscess
(2) Summary of scienti?c paper.... abstract
Habitat: Indigenous to the northern parts of southern Europe, Central and East-Central Europe; cultivated in the United States. A related sp., Asarum himalaicum, synonym A. canadense, is reported from the eastern Himalayas.
English: Asarbacca, Hazelwort, Wild Nard.Unani: Asaaroon, Subul-e-Barri, Naardeen-Barri.Folk: Tagar Ganthodaa.Action: Brain and nervine tonic, diuretic, deobstructant and anti- inflammatory; used in bronchial spasm and in preparations of cephalic snuffs.
The volatile oil (0.7-4%) consists of asarone up to 50%, asaraldehyde 2-3%, methyleugenol 15-20%, with bornyl acetate, terpenes and sesquiterpenes. Asarone and its beta-isomer is found to be carcinogenic in animals. The rhizome, in addition, contains caffeic acid derivatives and flavonoids.A related sp., Asarum canadense L., indigenous to North America and China, contains a volatile oil (3.5-Family: Asclepiadaceae.Habitat: Naturalized in many parts of India as an ornamental.
English: Curassavian Swallow- Wort, West Indian Ipecacuanha, Blood-Flower.Ayurvedic: Kaakanaasikaa (substitute).Folk: Kaakatundi (Kashmir).Action: Spasmogenic, cardiotonic, cytotoxic, antihaemorrhagic, styptic, antibacterial. Various plant parts, as also plant latex, are used against warts and cancer. Root—used as an astringent in piles. Leaves—juice, antidysenteric, also used against haemorrhages. Flowers—juice, styptic. Alcoholic extract of the plant—cardiotonic.
An alcoholic extract of the Indian plant has been reported to contain a number of cardenolides, including calactin, calotropin, calotropagenin, coroglaucigenin, uzarigenin, asclepin, its glucosides and uzarin. Asclepin, the chief active principle, is spasmogenic and a cardiac tonic, having longer duration of action than digoxin (96 h in cat, as opposed to the 72 h of digoxin). Calotropin exhibits cytotoxic activity.Pleurisy root of the U.S. is equated with Asclepias tuberosa. It is used for cold, flu and bronchitis in Western herbal medicine.Toxic principles of the herb include galitoxin and similar resins, and glu- cofrugoside (cardenolide). Toxicity is reduced by drying.... asclepias curassavicaHabitat: Throughout the hotter parts of India. Common in West Bengal and South India. Often grown as hedge plant.
English: Fever Nut, Bonduc Nut, Nikkar Nut.Ayurvedic: Puutikaranja, Lataa- karanja, Kantaki Karanja, Karanjin, Kuberaakshi (seed).Unani: Karanjwaa.Siddha/Tamil: Kazharchikkaai.Action: Seed—antiperiodic, antirheumatic. Roasted and used as an antidiabetic preparation. Leaf, bark and seed—febrifuge. Leaf and bark—emmenagogue, anthelmintic. Root—diuretic, anticalculous.
The seeds contain an alkaloid cae- salpinine; bitter principles such as bon- ducin; saponins; fixed oil.The seed powder, dissolved in water, showed hypoglycaemic activity in alloxanized hyperglycaemic rabbits. Aqueous extract of the seeds produced similar effects in rats. The powder forms a household remedy for treatment of diabetes in Nicobar Islands. In Kangra, Himachal Pradesh, roots are used in intermittent fevers and diabetes.In homoeopathy, the plant is considered an excellent remedy for chronic fever.(Three plant species—Pongamia pinnata Pierre, Holoptelea integrifo- lia (Roxb.) Planch. and Caesalpinia bonduc (L.) Roxb. are being used as varieties of Karanja (because flowers impart colour to water). P. pinnata is a tree and is equated with Karanja, Naktamaala and Udakirya; H. integri- folia, also a tree, with Chirabilva, Puti- ka (bad smell) and Prakiryaa; and C. bonduc, a shrub, with Kantaki Karanja or Lataa Karanja.)Dosage: Seed kernel—1-3 g powder. (CCRAS.)... caesalpinia bonducHabitat: Rajasthan, Punjab and Sindh; southward to Karnataka and Tamil Nadu.
English: Caper Berry.Ayurvedic: Karira, Krakar, Apatra, Granthila, Marubhoo-ruuha, Niguudhapatra, Karila.Unani: Kabar, Kabar-ul-Hind, Kabar-e-Hindi; Tenti.Siddha/Tamil: Chhengan.Folk: Tenti.Action: Anti-inflammatory (used for enlarged cervical glands, sciatica, rheumatoid arthritis; externally on swellings, skin eruptions, ringworm). Fruits and seeds—used for urinary purulent discharges and dysentery. Flowers and seeds— antimicrobial. The fruit is used as a pickle.
The root bark contains spermidine alkaloids, used for inflammations, asthma and gout.Activity of the seed volatiles against vibro cholerae has been recorded.Aqueous extract of the plant exhibits anthelmintic activity; seeds contain antibacterial principles—glucocapparin; isothiocynate aglycone of glucocap- parin.The blanched fruits, when fed to rats at 10% dietary fibre level, showed a significant hypocholesterolaemic effect, which is attributed to its hemicel- lose content.Pickled fruits are use for destroying intestinal worms.Dosage: Leaf, root—50-125 mg (CCRAS.)Folk: Hains, Kanthaar.Action: Antiseptic, antipyretic. Used for eczema and scabies.
Leaves contain taraxasterol, alpha- and beta-amyrin and beta-sitosterol, erythrodiol and betulin.Dosage: Root—5-10 g powder. (CCRAS.)... capparis aphyllaHin: 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).... cucurbitsHabitat: Native to Sudan and Arabia. Now cultivated mainly in Tirunelveli and Ramnathpuram districts and to a lesser extent in Madurai, Salem and Tiruchirapalli districts of Tamil Nadu. Also grown on a small scale in Cuddapah district of Andhra Pradesh and certain parts of Karnataka.
English: Indian Senna, Tinnevelly Senna.Ayurvedic: Svarna-pattri, Maarkandikaa, Maarkandi.Unani: Sannaa, Sanaa-makki, Senaai, Sonaamukhi, Sanaa-Hindi.Siddha/Tamil: Nilaavaarai.Folk: Sanaai.Action: Purgative (free from astringent action of rhubark type herbs, but causes gripe), used in compounds for treating biliousness, distention of stomach, vomiting and hiccups. Also used as a febrifuge, in splenic enlargements, jaundice, amoebic dysentery. Contraindicated in inflammatory colon diseases.
Key application: Leaf and dried fruit—in occasional constipation. (German Commission E.) As a stimulant laxative. (The British Herbal Pharmacopoeia.) 1,8- dihydoxy-anthracene derivatives have a laxative effect. This effect is due to the sennosides, specifically, due to their active metabolite in the colon, rheinanthrone. The effect is primarily caused by the influence on the motility of the colon by inhibiting stationary and stimulating propulsive contractions. (German Commission E, ESCOP, WHO.) Seena has been included in I.P. as a purgative.Most of the Senna sp. contain rhein, aloe-emodin, kaempferol, isormam- netin, both free and as glucosides, together with mycricyl alcohol. The purgative principles are largely attributed to anthraquinone derivatives and their glucosides.Senna is an Arabian name. The drug was brought into use by Arabian physicians for removing capillary congestion (pods were preferred to leaves).The active purgative principle of senna was discovered in 1866.Cassia acutifolia Delile is also equated with Maarkandikaa, Svarna-pattri, Sanaai.Dosage: Leaves—500 mg to 2 g (API Vol. I.)... cassia angustifoliaHabitat: Sub-Himalayan tract up to 2,000 m and South Indian hills.
English: Staff tree, Intellect tree.Ayurvedic: Jyotishmati, Paaraavat- padi. Kangunikaa, Kanguni, Vegaa, Maalkaanguni, Svarnalatikaa, Kaakaandaki, Katuveekaa.Unani: Maalkangani.Siddha/Tamil: Vaaluluvai.Action: Seeds—nervine and brain tonic, diaphoretic, febrifugal, emetic. Seed-oil—used for treating mental depression, hysteria and for improving memory; also used for scabies, eczema, wounds, rheumatic pains, paralysis. A decoction of seeds is given in gout, rheumatism, paralysis and for treating leprosy and other skin diseases. Leaves— antidysenteric, emmenagogue. Root—a paste of root-bark is applied to swollen veins and pneumonic affections.
Key application: As a tranquilizer (Indian Herbal Pharmacopoeia) and brain tonic (The Ayurvedic Pharmacopoeia of India). The Ayurvedic Pharmacopoeia of India indicated the use of ripe seed in leucoderma and vitiligo.The seeds are reported to contain the alkaloids, celastrine and paniculatine, which are the active principles of the drug.In experimental animals, the drug showed lowering of leptazol toxicity, motor activity and amphetamine toxi- city, and raising the capacity for learning process. It showed significant CNS depressant effect and a clear synergism with pentobarbital. The seed extract showed hypolipidaemic effect and prevented atherogenesis in rabbits.The seed oil showed tranquillizing effect and hastened the process of learning in experimental animals. It produced fall in blood pressure in anaesthetized dog, depressed the heart of frog, and was found to be toxic to rats.In addition to the seed, 70% alcoholic extract of the plant showed sedative, anti-inflammatory and antipyretic, anti-ulcerogenic effect in experimental animals.Methanolic extract of flowers showed both analgesic and anti- inflammatory activities experimentally.Dosage: Ripe seed, devoid of capsule wall—1-2 g; oil—5-15 drops. (API Vol. II.)... celastrus paniculatusPsychiatrists like to categorise mental illnesses because mental signs and symptoms do occur together in clusters or syndromes, each tending to respond to certain treatments. The idea that illnesses can be diagnosed simply by recognising their symptom patterns may not seem very scienti?c in these days of high technology. For most common mental illnesses, however, this is the only method of diagnosis; whatever is going wrong in the brain is usually too poorly understood and too subtle to show up in laboratory tests or computed tomography scans of the brain. And symptom-based definitions of mental illnesses are, generally, a lot more meaningful than the vague lay term ‘nervous breakdown’, which is used to cover an attack of anything from AGORAPHOBIA to total inability to function.
There is still a lot to learn about the workings of the brain, but psychiatry has developed plenty of practical knowledge about the probable causes of mental illness, ways of relieving symptoms, and ways of aiding recovery. Most experts now believe that mental illnesses generally arise from di?erent combinations of inherited risk and psychological STRESS, sometimes with additional environmental exposure – for example, viruses, drugs or ALCOHOL.
The range of common mental illnesses includes anxiety states, PHOBIA, DEPRESSION, alcohol and drug problems, the EATING DISORDERS anorexia and bulimia nervosa, MANIC DEPRESSION, SCHIZOPHRENIA, DEMENTIA, and a group of problems related to coping with life that psychiatrists call personality disorders.
Of these mental illnesses, dementia is the best understood. It is an irreversible and fatal form of mental deterioration (starting with forgetfulness and eventually leading to severe failure of all the brain’s functions), caused by rapid death of brain cells and consequent brain shrinkage. Schizophrenia is another serious mental illness which disrupts thought-processes, speech, emotions and perception (how the brain handles signals from the ?ve senses). Manic depression, in which prolonged ‘highs’ of extremely elevated mood and overexcitement alternate with abject misery, has similar effects on the mental processes. In both schizophrenia and manic depression the sufferer loses touch with reality, develops unshakeable but completely unrealistic ideas (delusions), and hallucinates (vividly experiences sensations that are not real, e.g. hears voices when there is nobody there). This triad of symptoms is called psychosis and it is what lay people, through fear and lack of understanding, sometimes call lunacy, madness or insanity.
The other mental illnesses mentioned above are sometimes called neuroses. But the term has become derogatory in ordinary lay language; indeed, many people assume that neuroses are mild disorders that only affect weak people who cannot ‘pull themselves together’, while psychoses are always severe. In reality, psychoses can be brief and reversible and neuroses can cause lifelong disability.
However de?ned and categorised, mental illness is a big public-health problem. In the UK, up to one in ?ve women and around one in seven men have had mental illness. About half a million people in Britain suffer from schizophrenia: it is three times commoner than cancer. And at any one time, up to a tenth of the adult population is ill with depression.
Treatment settings Most people with mental-health problems get the help they need from their own family doctor(s), without ever seeing a psychiatrist. General practictitioners in Britain treat nine out of ten recognised mental-health problems and see around 12 million adults with mental illness each year. Even for the one in ten of these patients referred to psychiatrists, general practitioners usually handle those problems that continue or recur.
Psychiatrists, psychiatric nurses, social workers, psychologists, counsellors and therapists often see patients at local doctors’ surgeries and will do home visits if necessary. Community mental-health centres – like general-practice health centres but catering solely for mental-health problems – o?er another short-cut to psychiatric help. The more traditional, and still more common, route to a psychiatrist for many people, however, is from the general practititioner to a hospital outpatient department.
Specialist psychiatric help In many ways, a visit to a psychiatrist is much like any trip to a hospital doctor – and, indeed, psychiatric clinics are often based in the outpatient departments of general hospitals. First appointments with psychiatrists can last an hour or more because the psychiatrist – and sometimes other members of the team such as nurses, doctors in training, and social workers – need to ask lots of questions and record the whole consultation in a set of con?dential case notes.
Psychiatric assessment usually includes an interview and an examination, and is sometimes backed up by a range of tests. The interview begins with the patient’s history – the personal story that explains how and, to some extent, why help is needed now. Mental-health problems almost invariably develop from a mixture of causes – emotional, social, physical and familial – and it helps psychiatrists to know what the people they see are normally like and what kind of lives they have led. These questions may seem unnecessarily intrusive, but they allow psychiatrists to understand patients’ problems and decide on the best way to help them.
The next stage in assessment is the mental-state examination. This is how psychiatrists examine minds, or at least their current state. Mental-state examination entails asking more questions and using careful observation to assess feelings, thoughts and mental symptoms, as well as the way the mind is working (for example, in terms of memory and concentration). During ?rst consultations psychiatrists usually make diagnoses and explain them. The boundary between a life problem that will clear up spontaneously and a mental illness that needs treatment is sometimes quite blurred; one consultation may be enough to put the problem in perspective and help to solve it.
Further assessment in the clinic may be needed, or some additional tests. Simple blood tests can be done in outpatient clinics but other investigations will mean referral to another department, usually on another day.
Further assessment and tests
PSYCHOLOGICAL TESTS Psychologists work in or alongside the psychiatric team, helping in both assessment and treatment. The range of psychological tests studies memory, intelligence, personality, perception and capability for abstract thinking. PHYSICAL TESTS Blood tests and brain scans may be useful to rule out a physical illness causing psychological symptoms. SOCIAL ASSESSMENT Many patients have social diffculties that can be teased out and helped by a psychiatric social worker. ‘Approved social workers’ have special training in the use of the Mental Health Act, the law that authorises compulsory admissions to psychiatric hospitals and compulsory psychiatric treatments. These social workers also know about all the mental-health services o?ered by local councils and voluntary organisations, and can refer clients to them. The role of some social workers has been widened greatly in recent years by the expansion of community care. OCCUPATIONAL THERAPY ASSESSMENT Mental-health problems causing practical disabilities – for instance, inability to work, cook or look after oneself – can be assessed and helped by occupational therapists.
Treatment The aims of psychiatric treatment are to help sufferers shake o?, or at least cope with, symptoms and to gain or regain an acceptable quality of life. A range of psychological and physical treatments is available.
COUNSELLING This is a widely used ‘talking cure’, particularly in general practice. Counsellors listen to their clients, help them to explore feelings, and help them to ?nd personal and practical solutions to their problems. Counsellors do not probe into clients’ pasts or analyse them. PSYCHOTHERAPY This is the best known ‘talking cure’. The term psychotherapy is a generalisation covering many di?erent concepts. They all started, however, with Sigmund Freud (see FREUDIAN THEORY), the father of modern psychotherapy. Freud was a doctor who discovered that, as well as the conscious thoughts that guide our feelings and actions, there are powerful psychological forces of which we are not usually aware. Applying his theories to his patients’ freely expressed thoughts, Freud was able to cure many illnesses, some of which had been presumed completely physical. This was the beginning of individual analytical psychotherapy, or PSYCHOANALYSIS. Although Freud’s principles underpin all subsequent theories about the psyche, many di?erent schools of thought have emerged and in?uenced psychotherapists (see ADLER; JUNGIAN ANALYSIS; PSYCHOTHERAPY). BEHAVIOUR THERAPY This springs from theories of human behaviour, many of which are based on studies of animals. The therapists, mostly psychologists, help people to look at problematic patterns of behaviour and thought, and to change them. Cognitive therapy is very e?ective, particularly in depression and eating disorders. PHYSICAL TREATMENTS The most widely used physical treatments in psychiatry are drugs. Tranquillising and anxiety-reducing BENZODIAZEPINES like diazepam, well known by its trade name of Valium, were prescribed widely in the 1960s and 70s because they seemed an e?ective and safe substitute for barbiturates. Benzodiazepines are, however, addictive and are now recommended only for short-term relief of anxiety that is severe, disabling, or unacceptably distressing. They are also used for short-term treatment of patients drying out from alcohol.
ANTIDEPRESSANT DRUGS like amitriptyline and ?uoxetine are given to lift depressed mood and to relieve the physical symptoms that sometimes occur in depression, such as insomnia and poor appetite. The side-effects of antidepressants are mostly relatively mild, when recommended doses are not exceeded – although one group, the monoamine oxidase inhibitors, can lead to sudden and dangerous high blood pressure if taken with certain foods.
Manic depression virtually always has to be treated with mood-stabilising drugs. Lithium carbonate is used in acute mania to lower mood and stop psychotic symptoms; it can also be used in severe depression. However lithium’s main use is to prevent relapse in manic depression. Long-term unwanted effects may include kidney and thyroid problems, and short-term problems in the nervous system and kidney may occur if the blood concentration of lithium is too high – therefore it must be monitored by regular blood tests. Carbamazepine, a treatment for EPILEPSY, has also been found to stabilise mood, and also necessitates blood tests.
Antipsychotic drugs, also called neuroleptics, and major tranquillisers are the only e?ective treatments for relieving serious mental illnesses with hallucinations and delusions. They are used mainly in schizophrenia and include the short-acting drugs chlorpromazine and clozapine as well as the long-lasting injections given once every few weeks like ?uphenazine decanoate. In the long term, however, some of the older antipsychotic drugs can cause a brain problem called TARDIVE DYSKINESIA that affects control of movement and is not always reversible. And the antipsychotic drugs’ short-term side-effects such as shaking and sti?ness sometimes have to be counteracted by other drugs called anticholinergic drugs such as procyclidine and benzhexol. Newer antipsychotic drugs such as clozapine do not cause tardive dyskinesia, but clozapine cannot be given as a long-lasting injection and its concentration in the body has to be monitored by regular blood tests to avoid toxicity. OTHER PHYSICAL TREATMENTS The other two physical treatments used in psychiatry are particularly controversial: electroconvulsive therapy (ECT) and psychosurgery. In ECT, which can be life-saving for patients who have severe life-threatening depression, a small electric current is passed through the brain to induce a ?t or seizure. Before the treatment the patient is anaesthetised and given a muscle-relaxing injection that reduces the magnitude of the ?t to a slight twitching or shaking. Scientists do not really understand how ECT works, but it does, for carefully selected patients. Psychosurgery – operating on the brain to alleviate psychiatric illness or di?cult personality traits – is extremely uncommon these days. Stereo-tactic surgery, in which small cuts are made in speci?c brain ?bres under X-ray guidance, has super-seded the more generalised lobotomies of old. The Mental Health Act 1983 ensures that psychosurgery is performed only when the patient has given fully informed consent and a second medical opinion has agreed that it is necessary. For all other psychiatric treatments (except another rare treatment, hormone implantation for reducing the sex drive of sex o?enders), either consent or a second opinion is needed – not both. TREATMENT IN HOSPITAL Psychiatric wards do not look like medical or surgical wards and sta? may not wear uniforms. Patients do not need to be in their beds during the day, so the beds are in separate dormitories. The main part of most wards is a living space with a day room, an activity and television room, quiet rooms, a dining room, and a kitchen. Ward life usually has a certain routine. The day often starts with a community meeting at which patients and nurses discuss issues that affect the whole ward. Patients may go to the occupational therapy department during the day, but there may also be some therapy groups on the ward, such as relaxation training. Patients’ symptoms and problems are assessed continuously during a stay in hospital. When patients seem well enough they are allowed home for trial periods; then discharge can be arranged. Patients are usually followed up in the outpatient clinic at least once.
TREATING PATIENTS WITH ACUTE PSYCHIATRIC ILLNESS Psychiatric emergencies – patients with acute psychiatric illness – may develop from psychological, physical, or practical crises. Any of these crises may need quick professional intervention. Relatives and friends often have to get this urgent help because the sufferer is not ?t enough to do it or, if psychotic, does not recognise the need. First, they should ring the person’s general practitioner. If the general practitioner is not available and help is needed very urgently, relatives or friends should phone the local social-services department and ask for the duty social worker (on 24-hour call). In a dire emergency, the police will know what to do.
Any disturbed adult who threatens his or her own or others’ health and safety and refuses psychiatric help may be moved and detained by law. The Mental Health Act of 1983 authorises emergency assessment and treatment of any person with apparent psychiatric problems that ful?l these criteria.
Although admission to hospital may be the best solution, there are other ways that psychiatric services can respond to emergencies. In some districts there are ‘crisis intervention’ teams of psychiatrists, nurses, and social workers who can visit patients urgently at home (at a GP’s request) and, sometimes, avert unnecessary admission. And research has shown that home treatment for a range of acute psychiatric problems can be e?ective.
LONG-TERM TREATMENT AND COMMUNITY CARE Long-term treatment is often provided by GPs with support and guidance from psychiatric teams. That is ?ne for people whose problems allow them to look after themselves, and for those with plenty of support from family and friends. But some people need much more intensive long-term treatment and many need help with running their daily lives.
Since the 1950s, successive governments have closed the old psychiatric hospitals and have tried to provide as much care as possible outside hospital – in ‘the community’. Community care is e?ective as long as everyone who needs inpatient care, or residential care, can have it. But demand exceeds supply. Research has shown that some homeless people have long-term mental illnesses and have somehow lost touch with psychiatric services. Many more have developed more general long-term health problems, particularly related to alcohol, without ever getting help.
The NHS and Community Care Act 1990, in force since 1993, established a new breed of professionals called care managers to assess people whose long-term illnesses and disabilities make them unable to cope completely independently with life. Care managers are given budgets by local councils to assess people’s needs and to arrange for them tailor-made packages of care, including services like home helps and day centres. But co-ordination between health and social services has sometimes failed – and resources are limited – and the government decided in 1997 to tighten up arrangements and pool community-care budgets.
Since 1992 psychiatrists have had to ensure that people with severe mental illnesses have full programmes of care set up before discharge from hospital, to be overseen by named key workers. And since 1996 psychiatrists have used a new power called Supervised Discharge to ensure that the most vulnerable patients cannot lose touch with mental-health services. There is not, however, any law that allows compulsory treatment in the community.
There is ample evidence that community care can work and that it need not cost more than hospital care. Critics argue, however, that even one tragedy resulting from inadequate care, perhaps a suicide or even a homicide, should reverse the march to community care. And, according to the National Schizophrenia Fellowship, many of the 10–15 homicides a year carried out by people with severe mental illnesses result from inadequate community care.
Further information can be obtained from the Mental Health Act Commission, and from MIND, the National Association for Mental Health. MIND also acts as a campaigning and advice organisation on all aspects of mental health.... mental illness
Occupational health includes both mental and physical health. It is about compliance with health-and-safety-at-work legislation (and common law duties) and about best practice in providing work environments that reduce risks to health and safety to lowest practicable levels. It includes workers’ ?tness to work, as well as the management of the work environment to accommodate people with disabilities, and procedures to facilitate the return to work of those absent with long-term illness. Occupational health incorporates several professional groups, including occupational physicians, occupational health nurses, occupational hygienists, ergonomists, disability managers, workplace counsellors, health-and-safety practitioners, and workplace physiotherapists.
In the UK, two key statutes provide a framework for occupational health: the Health and Safety at Work, etc. Act 1974 (HSW Act); and the Disability Discrimination Act 1995 (DDA). The HSW Act states that employers have a duty to protect the health, safety and welfare of their employees and to conduct their business in a way that does not expose others to risks to their health and safety. Employees and self-employed people also have duties under the Act. Modern health-and-safety legislation focuses on assessing and controlling risk rather than prescribing speci?c actions in di?erent industrial settings. Various regulations made under the HSW Act, such as the Control of Substances Hazardous to Health Regulations, the Manual Handling Operations Regulations and the Noise at Work Regulations, set out duties with regard to di?erent risks, but apply to all employers and follow the general principles of risk assessment and control. Risks should be controlled principally by removing or reducing the hazard at source (for example, by substituting chemicals with safer alternatives, replacing noisy machinery, or automating tasks to avoid heavy lifting). Personal protective equipment, such as gloves and ear defenders, should be seen as a last line of defence after other control measures have been put in place.
The employment provisions of the DDA require employers to avoid discriminatory practice towards disabled people and to make reasonable adjustments to working arrangements where a disabled person is placed at a substantial disadvantage to a non-disabled person. Although the DDA does not require employers to provide access to rehabilitation services – even for those injured or made ill at work – occupational-health practitioners may become involved in programmes to help people get back to work after injury or long-term illness, and many businesses see the retention of valuable sta? as an attractive alternative to medical retirement or dismissal on health grounds.
Although a major part of occupational-health practice is concerned with statutory compliance, the workplace is also an important venue for health promotion. Many working people rarely see their general practitioner and, even when they do, there is little time to discuss wider health issues. Occupational-health advisers can ?ll in this gap by providing, for example, workplace initiatives on stopping smoking, cardiovascular health, diet and self-examination for breast and testicular cancers. Such initiatives are encouraged because of the perceived bene?ts to sta?, to the employing organisation and to the wider public-health agenda. Occupational psychologists recognise the need for the working population to achieve a ‘work-life balance’ and the promotion of this is an increasing part of occupational health strategies.
The law requires employers to consult with their sta? on health-and-safety matters. However, there is also a growing understanding that successful occupational-health management involves workers directly in the identi?cation of risks and in developing solutions in the workplace. Trade unions play an active role in promoting occupational health through local and national campaigns and by training and advising elected workplace safety representatives.
Occupational medicine The branch of medicine that deals with the control, prevention, diagnosis, treatment and management of ill-health and injuries caused or made worse by work, and with ensuring that workers are ?t for the work they do.
Occupational medicine includes: statutory surveillance of workers’ exposure to hazardous agents; advice to employers and employees on eliminating or reducing risks to health and safety at work; diagnosis and treatment/management of occupational illness; advice on adapting the working environment to suit the worker, particularly those with disabilities or long-term health problems; and advice on the return to work and, if necessary, rehabilitation of workers absent through illness. Occupational physicians may play a wider role in monitoring the health of workplace populations and in advising employers on controlling health hazards where ill-health trends are observed. They may also conduct epidemiological research (see EPIDEMIOLOGY) on workplace diseases.
Because of the occupational physician’s dual role as adviser to both employer and employee, he or she is required to be particularly diligent with regards to the individual worker’s medical CONFIDENTIALITY. Occupational physicians need to recognise in any given situation the context they are working in, and to make sure that all parties are aware of this.
Occupational medicine is a medical discipline and thus is only part of the broader ?eld of occupational health. Although there are some speci?c clinical duties associated with occupational medicine, such as diagnosis of occupational disease and medical screening, occupational physicians are frequently part of a multidisciplinary team that might include, for example, occupational-health nurses, healthand-safety advisers, ergonomists, counsellors and hygienists. Occupational physicians are medical practitioners with a post-registration quali?cation in occupational medicine. They will have completed a period of supervised in-post training. In the UK, the Faculty of Occupational Medicine of the Royal College of Physicians has three categories of membership, depending on quali?cations and experience: associateship (AFOM); membership (MFOM); and fellowship (FFOM).
Occupational diseases Occupational diseases are illnesses that are caused or made worse by work. In their widest sense, they include physical and mental ill-health conditions.
In diagnosing an occupational disease, the clinician will need to examine not just the signs and symptoms of ill-health, but also the occupational history of the patient. This is important not only in discovering the cause, or causes, of the disease (work may be one of a number of factors), but also in making recommendations on how the work should be modi?ed to prevent a recurrence – or, if necessary, in deciding whether or not the worker is able to return to that type of work. The occupational history will help in deciding whether or not other workers are also at risk of developing the condition. It will include information on:
the nature of the work.
how the tasks are performed in practice.
the likelihood of exposure to hazardous agents (physical, chemical, biological and psychosocial).
what control measures are in place and the extent to which these are adhered to.
previous occupational and non-occupational exposures.
whether or not others have reported similar symptoms in relation to the work. Some conditions – certain skin conditions,
for example – may show a close relationship to work, with symptoms appearing directly only after exposure to particular agents or possibly disappearing at weekends or with time away from work. Others, however, may be chronic and can have serious long-term implications for a person’s future health and employment.
Statistical information on the prevalence of occupational disease in the UK comes from a variety of sources, including o?cial ?gures from the Industrial Injuries Scheme (see below) and statutory reporting of occupational disease (also below). Neither of these o?cial schemes provides a representative picture, because the former is restricted to certain prescribed conditions and occupations, and the latter suffers from gross under-reporting. More useful are data from the various schemes that make up the Occupational Diseases Intelligence Network (ODIN) and from the Labour Force Survey (LFS). ODIN data is generated by the systematic reporting of work-related conditions by clinicians and includes several schemes. Under one scheme, more than 80 per cent of all reported diseases by occupational-health physicians fall into just six of the 42 clinical disease categories: upper-limb disorders; anxiety, depression and stress disorders; contact DERMATITIS; lower-back problems; hearing loss (see DEAFNESS); and ASTHMA. Information from the LFS yields a similar pattern in terms of disease frequency. Its most recent survey found that over 2 million people believed that, in the previous 12 months, they had suffered from an illness caused or made worse by work and that
19.5 million working days were lost as a result. The ten most frequently reported disease categories were:
stress and mental ill-health (see MENTAL ILLNESS): 515,000 cases.
back injuries: 508,000.
upper-limb and neck disorders: 375,000.
lower respiratory disease: 202,000.
deafness, TINNITUS or other ear conditions: 170,000.
lower-limb musculoskeletal conditions: 100,000.
skin disease: 66,000.
headache or ‘eyestrain’: 50,000.
traumatic injury (includes wounds and fractures from violent attacks at work): 34,000.
vibration white ?nger (hand-arm vibration syndrome): 36,000. A person who develops a chronic occu
pational disease may be able to sue his or her employer for damages if it can be shown that the employer was negligent in failing to take reasonable care of its employees, or had failed to provide a system of work that would have prevented harmful exposure to a known health hazard. There have been numerous successful claims (either awarded in court, or settled out of court) for damages for back and other musculoskeletal injuries, hand-arm vibration syndrome, noise-induced deafness, asthma, dermatitis, MESOTHELIOMA and ASBESTOSIS. Employers’ liability (workers’ compensation) insurers are predicting that the biggest future rise in damages claims will be for stress-related illness. In a recent study, funded by the Health and Safety Executive, about 20 per cent of all workers – more than 5 million people in the UK – claimed to be ‘very’ or ‘extremely’ stressed at work – a statistic that is likely to have a major impact on the long-term health of the working population.
While victims of occupational disease have the right to sue their employers for damages, many countries also operate a system of no-fault compensation for the victims of prescribed occupational diseases. In the UK, more than 60 diseases are prescribed under the Industrial Injuries Scheme and a person will automatically be entitled to state compensation for disability connected to one of these conditions, provided that he or she works in one of the occupations for which they are prescribed. The following short list gives an indication of the types of diseases and occupations prescribed under the scheme:
CARPAL TUNNEL SYNDROME connected to the use of hand-held vibrating tools.
hearing loss from (amongst others) use of pneumatic percussive tools and chainsaws, working in the vicinity of textile manufacturing or woodworking machines, and work in ships’ engine rooms.
LEPTOSPIROSIS – infection with Leptospira (various listed occupations).
viral HEPATITIS from contact with human blood, blood products or other sources of viral hepatitis.
LEAD POISONING, from any occupation causing exposure to fumes, dust and vapour from lead or lead products.
asthma caused by exposure to, among other listed substances, isocyanates, curing agents, solder ?ux fumes and insects reared for research.
mesothelioma from exposure to asbestos.
In the UK, employers and the self-employed have a duty to report all occupational injuries (if the employee is o? work for three days or more as a result), diseases or dangerous incidents to the relevant enforcing authority (the Health and Safety Executive or local-authority environmental-health department) under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR). Despite this statutory duty, comparatively few diseases are reported so that ?gures generated from RIDDOR reports do not give a useful indication of the scale of occupational diseases in the UK. The statutory reporting of injuries is much better, presumably because of the clear and acute relationship between a workplace accident and the resultant injury. More than 160,000 injuries are reported under RIDDOR every year compared with just 2,500 or so occupational diseases, a gross underestimate of the true ?gure.
There are no precise ?gures for the number of people who die prematurely because of work-related ill-health, and it would be impossible to gauge the exact contribution that work has on, for example, cardiovascular disease and cancers where the causes are multifactorial. The toll would, however, dwarf the number of deaths caused by accidents at work. Around 250 people are killed by accidents at work in the UK each year – mesothelioma, from exposure to asbestos at work, alone kills more than 1,300 people annually.
The following is a sample list of occupational diseases, with brief descriptions of their aetiologies.
Inhaled materials
PNEUMOCONIOSIS covers a group of diseases which cause ?brotic lung disease following the inhalation of dust. Around 250–300 new cases receive bene?t each year – mostly due to coal dust with or without silica contamination. SILICOSIS is the more severe disease. The contraction in the size of the coal-mining industry as well as improved dust suppression in the mines have diminished the importance of this disease, whereas asbestos-related diseases now exceed 1,000 per year. Asbestos ?bres cause a restrictive lung disease but also are responsible for certain malignant conditions such as pleural and peritoneal mesothelioma and lung cancer. The lung-cancer risk is exacerbated by cigarette-smoking.
Even though the use of asbestos is virtually banned in the UK, many workers remain at risk of exposure because of the vast quantities present in buildings (much of which is not listed in building plans). Carpenters, electricians, plumbers, builders and demolition workers are all liable to exposure from work that disturbs existing asbestos. OCCUPATIONAL ASTHMA is of increasing importance – not only because of the recognition of new allergic agents (see ALLERGY), but also in the number of reported cases. The following eight substances are most frequently linked to occupational asthma (key occupations in brackets): isocyanates (spray painters, electrical processors); ?our and grain (bakers and farmers); wood dust (wood workers); glutaraldehyde (nurses, darkroom technicians); solder/colophony (welders, electronic assembly workers); laboratory animals (technicians, scientists); resins and glues (metal and electrical workers, construction, chemical processors); and latex (nurses, auxiliaries, laboratory technicians).
The disease develops after a short, symptomless period of exposure; symptoms are temporally related to work exposures and relieved by absences from work. Removal of the worker from exposure does not necessarily lead to complete cessation of symptoms. For many agents, there is no relationship with a previous history of ATOPY. Occupational asthma accounts for about 10 per cent of all asthma cases. DERMATITIS The risk of dermatitis caused by an allergic or irritant reaction to substances used or handled at work is present in a wide variety of jobs. About three-quarters of cases are irritant contact dermatitis due to such agents as acids, alkalis and solvents. Allergic contact dermatitis is a more speci?c response by susceptible individuals to a range of allergens (see ALLERGEN). The main occupational contact allergens include chromates, nickel, epoxy resins, rubber additives, germicidal agents, dyes, topical anaesthetics and antibiotics as well as certain plants and woods. Latex gloves are a particular cause of occupational dermatitis among health-care and laboratory sta? and have resulted in many workers being forced to leave their profession through ill-health. (See also SKIN, DISEASES OF.)
Musculoskeletal disorders Musculoskeletal injuries are by far the most common conditions related to work (see LFS ?gures, above) and the biggest cause of disability. Although not all work-related, musculoskeletal disorders account for 36.5 per cent of all disabilities among working-age people (compared with less than 4 per cent for sight and hearing impairment). Back pain (all causes – see BACKACHE) has been estimated to cause more than 50 million days lost every year in sickness absence and costs the UK economy up to £5 billion annually as a result of incapacity or disability. Back pain is a particular problem in the health-care sector because of the risk of injury from lifting and moving patients. While the emphasis should be on preventing injuries from occurring, it is now well established that the best way to manage most lower-back injuries is to encourage the patient to continue as normally as possible and to remain at work, or to return as soon as possible even if the patient has some residual back pain. Those who remain o? work on long-term sick leave are far less likely ever to return to work.
Aside from back injuries, there are a whole range of conditions affecting the upper limbs, neck and lower limbs. Some have clear aetiologies and clinical signs, while others are less well de?ned and have multiple causation. Some conditions, such as carpal tunnel syndrome, are prescribed diseases in certain occupations; however, they are not always caused by work (pregnant and older women are more likely to report carpal tunnel syndrome irrespective of work) and clinicians need to be careful when assigning work as the cause without ?rst considering the evidence. Other conditions may be revealed or made worse by work – such as OSTEOARTHRITIS in the hand. Much attention has focused on injuries caused by repeated movement, excessive force, and awkward postures and these include tenosynovitis (in?ammation of a tendon) and epicondylitis. The greatest controversy surrounds upper-limb disorders that do not present obvious tissue or nerve damage but nevertheless give signi?cant pain and discomfort to the individual. These are sometimes referred to as ‘repetitive strain injury’ or ‘di?use RSI’. The diagnosis of such conditions is controversial, making it di?cult for sufferers to pursue claims for compensation through the courts. Psychosocial factors, such as high demands of the job, lack of control and poor social support at work, have been implicated in the development of many upper-limb disorders, and in prevention and management it is important to deal with the psychological as well as the physical risk factors. Occupations known to be at particular risk of work-related upper-limb disorders include poultry processors, packers, electronic assembly workers, data processors, supermarket check-out operators and telephonists. These jobs often contain a number of the relevant exposures of dynamic load, static load, a full or excessive range of movements and awkward postures. (See UPPER LIMB DISORDERS.)
Physical agents A number of physical agents cause occupational ill-health of which the most important is occupational deafness. Workplace noise exposures in excess of 85 decibels for a working day are likely to cause damage to hearing which is initially restricted to the vital frequencies associated with speech – around 3–4 kHz. Protection from such noise is imperative as hearing aids do nothing to ameliorate the neural damage once it has occurred.
Hand-arm vibration syndrome is a disorder of the vascular and/or neural endings in the hands leading to episodic blanching (‘white ?nger’) and numbness which is exacerbated by low temperature. The condition, which is caused by vibrating tools such as chain saws and pneumatic hammers, is akin to RAYNAUD’S DISEASE and can be disabling.
Decompression sickness is caused by a rapid change in ambient pressure and is a disease associated with deep-sea divers, tunnel workers and high-?ying aviators. Apart from the direct effects of pressure change such as ruptured tympanic membrane or sinus pain, the more serious damage is indirectly due to nitrogen bubbles appearing in the blood and blocking small vessels. Central and peripheral nervous-system damage and bone necrosis are the most dangerous sequelae.
Radiation Non-ionising radiation from lasers or microwaves can cause severe localised heating leading to tissue damage of which cataracts (see under EYE, DISORDERS OF) are a particular variety. Ionising radiation from radioactive sources can cause similar acute tissue damage to the eyes as well as cell damage to rapidly dividing cells in the gut and bone marrow. Longer-term effects include genetic damage and various malignant disorders of which LEUKAEMIA and aplastic ANAEMIA are notable. Particular radioactive isotopes may destroy or induce malignant change in target organs, for example, 131I (thyroid), 90Sr (bone). Outdoor workers may also be at risk of sunburn and skin cancers. OTHER OCCUPATIONAL CANCERS Occupation is directly responsible for about 5 per cent of all cancers and contributes to a further 5 per cent. Apart from the cancers caused by asbestos and ionising radiation, a number of other occupational exposures can cause human cancer. The International Agency for Research on Cancer regularly reviews the evidence for carcinogenicity of compounds and industrial processes, and its published list of carcinogens is widely accepted as the current state of knowledge. More than 50 agents and processes are listed as class 1 carcinogens. Important occupational carcinogens include asbestos (mesothelioma, lung cancer); polynuclear aromatic hydrocarbons such as mineral oils, soots, tars (skin and lung cancer); the aromatic amines in dyestu?s (bladder cancer); certain hexavalent chromates, arsenic and nickel re?ning (lung cancer); wood and leather dust (nasal sinus cancer); benzene (leukaemia); and vinyl chloride monomer (angiosarcoma of the liver). It has been estimated that elimination of all known occupational carcinogens, if possible, would lead to an annual saving of 5,000 premature deaths in Britain.
Infections Two broad categories of job carry an occupational risk. These are workers in contact with animals (farmers, veterinary surgeons and slaughtermen) and those in contact with human sources of infection (health-care sta? and sewage workers).
Occupational infections include various zoonoses (pathogens transmissible from animals to humans), such as ANTHRAX, Borrelia burgdorferi (LYME DISEASE), bovine TUBERCULOSIS, BRUCELLOSIS, Chlamydia psittaci, leptospirosis, ORF virus, Q fever, RINGWORM and Streptococcus suis. Human pathogens that may be transmissible at work include tuberculosis, and blood-borne pathogens such as viral hepatitis (B and C) and HIV (see AIDS/HIV). Health-care workers at risk of exposure to infected blood and body ?uids should be immunised against hapatitis B.
Poisoning The incidence of occupational poisonings has diminished with the substitution of noxious chemicals with safer alternatives, and with the advent of improved containment. However, poisonings owing to accidents at work are still reported, sometimes with fatal consequences. Workers involved in the application of pesticides are particularly at risk if safe procedures are not followed or if equipment is faulty. Exposure to organophosphate pesticides, for example, can lead to breathing diffculties, vomiting, diarrhoea and abdominal cramps, and to other neurological effects including confusion and dizziness. Severe poisonings can lead to death. Exposure can be through ingestion, inhalation and dermal (skin) contact.
Stress and mental health Stress is an adverse reaction to excessive pressures or demands and, in occupational-health terms, is di?erent from the motivational impact often associated with challenging work (some refer to this as ‘positive stress’). Stress at work is often linked to increasing demands on workers, although coping can often prevent the development of stress. The causes of occupational stress are multivariate and encompass job characteristics (e.g. long or unsocial working hours, high work demands, imbalance between e?ort and reward, poorly managed organisational change, lack of control over work, poor social support at work, fear of redundancy and bullying), as well as individual factors (such as personality type, personal circumstances, coping strategies, and availability of psychosocial support outside work). Stress may in?uence behaviours such as smoking, alcohol consumption, sleep and diet, which may in turn affect people’s health. Stress may also have direct effects on the immune system (see IMMUNITY) and lead to a decline in health. Stress may also alter the course and response to treatment of conditions such as cardiovascular disease. As well as these general effects of stress, speci?c types of disorder may be observed.
Exposure to extremely traumatic incidents at work – such as dealing with a major accident involving multiple loss of life and serious injury
(e.g. paramedics at the scene of an explosion or rail crash) – may result in a chronic condition known as post-traumatic stress disorder (PTSD). PTSD is an abnormal psychological reaction to a traumatic event and is characterised by extreme psychological discomfort, such as anxiety or panic when reminded of the causative event; sufferers may be plagued with uncontrollable memories and can feel as if they are going through the trauma again. PTSD is a clinically de?ned condition in terms of its symptoms and causes and should not be used to include normal short-term reactions to trauma.... occupational health, medicine and diseases
Dose: One dissolved on the tongue daily. (Burroughs Wellcome during World War I) ... forced march tablet
Habitat: In marshy places throughout India up to 200 m.
English: Asiatic Pennywort, Indian Pennywort.Ayurvedic: Manduukaparni, Manduukaparnikaa, Maanduuki, Saraswati, Brahma-manduuki.Siddha/Tamil: Vallaarai.Action: Adaptogen, central nervous system relaxant, peripheral vasodilator, sedative, antibiotic, detoxifier, blood-purifier, laxative, diuretic, emmenagogue. Used as a brain tonic for improving memory and for overcoming mental confusion, stress, fatigue, also used for obstinate skin diseases and leprosy.
Key application: Extracts orally to treat stress-induced stomach and duodenal ulcers; topically to accelerate healing, particularly in cases of chronic postsurgical and post trauma wounds; also to treat second and third degree burns. Patients suffering from venous insufficiency were treated with a titrated extract of the drug. (WHO.)Used in Indian medicine as a brain tonic and sedative. (Indian Herbal Pharmacopoeia.)Major constituents of the plant are: triterpenoid saponins—brahmoside, asiaticoside, thankuniside; alkaloids (hydrocotyline); bitter principles (vel- larin).Brahmoside, present in the plant, is reported to exhibit tranquilizing and anabolic activity. Raw leaves are eaten or plant decoction is drunk to treat hypertension.Asiaticoside, extracted from leaves, gave encouraging results in leprosy. It dissolves the waxy covering of Bacillus leprae. Centelloside has also been found useful in leprosy. Asiaticoside reduced the number tubercular lesions in the liver, lungs, nerve ganglia and spleen in experimental animals. Another derivative of asiaticoside, oxyasi- aticoside, inhibits growth of Tubercle bacillus at a concentration of 0.15 ml/ml Asiaticosides are also hyperglycaemic.The asiatic acid acts against resistant bacteria, particularly Mycobacterium tuberculosis and M. leprae as well as Gram-positive cocci.Asiaticosides elevate blood glucose, triglycerides and cholesterol levels. They seem to decrease blood urea nitrogen and acid phosphatase levels. (Pharmacological findings. Natural Medicines Comprehensive Database, 2007.)Boiled leaves are eaten for urinary tract infections, and unfiltered juice for scrofula and syphilis.Extract of the fresh plant significantly inhibits gastric ulceration by cold restraint stress in rats.In research, using rats, the herb exhibited protective effect against alcohol-induced and aspirin-induced ulcers. (JExp Biol, 2001, Feb, 39(2), 13742.)Dosage: Whole plant—3-6 g (API Vol. IV.)... centella asiaticaSynonym: Vitis quadrangula Wall.
Family: Vitaceae.Habitat: Throughout the warmer parts of India, also cultivated in gardens.
English: Square Stalked Vine, Adamant Creeper.Ayurvedic: Asthisamhaara, Asthisamhrita. Asthi-samyojaka, Vajravalli, Chaturdhaaraa.Unani: Hadjod.Siddha/Tamil: Perandai.Action: The anabolic and steroidal principles of the aerial part showed a marked influence in the rate of fracture-healing. The drug exerts influence both on the organic and mineral phase of fracture-healing. Stem—alterative in scurvy (the plant is rich in vitamin C) and irregular menstruation.
The plant contains phytogenic steroid, ketosteroids, sitosterol, alpha- amyrin, alpha-ampyrone and tetra- cyclic triterpenoids. Phytogenic ste- riods showed bone healing properties. Coloside-A possesses smooth muscle relaxant effect. The total alcoholic extract of the plant neutralizes the anti- anabolic effect of the cortisone in healing of fractures. The aqueous extract of... cissus quadrangulaClinical psychologists are involved in health care in the following ways: (1) Assessment of thoughts, emotions and behaviour using standardised methods. (2) Treatment based on theoretical models and scienti?c evidence about behaviour change. Behaviour change is considered when it contributes to physical, psychological or social functioning. (3) Consultation with other health-care professionals about problems concerning emotions, thinking and behaviour. (4) Research on a wide variety of topics including the relationship between stress, psychological functioning and disease; the aetiology of problem behaviours; methods and theories of behaviour change. (5) Teaching other professionals about normal and dysfunctional behaviour, emotions and functioning.
Clinical psychologists may specialise in work in particular branches of patient care, including surgery, psychiatry, geriatrics, paediatrics, mental handicap, obstetrics and gynaecology, cardiology, neurology, general practice and physical rehabilitation. Whilst the focus of their work is frequently the patient, at times it may encompass the behaviour of the health-care professionals.... clinical psychology
artificial joints and heart valves, plaster casts, and kidney dialysis machines.... biomechanical engineering
Habitat: British and European hedge plant, met with in the temperate Himalayas of Kashmir and Himachal Pradesh at an altitude of 1,800-3,000 m. (The plant does not thrive in the plains of India.)
English: English Hawthorn.Folk: Ring, Ringo, Pingyat, Phindak, Ban Sanjli (Punjab hills).Action: Coronary vasodilator (strengthens heart muscle without increasing the beat in coronary arteries), antispasmodic, antihypertensive, sedative to nervous system, diuretic.
Key application: In cases of cardiac insufficiency Stage II as defined by NYHA (New York Heart Association). An improvement of subjective findings as well as an increase in cardiac work tolerance, a decrease in pressure/heart rate product, an increase in the ejection fraction and a rise in the anaerobic threshold have been established in human pharmacological studies. (German Commission E, WHO.)The active principles include oligo- meric procyanidins and flavonoids.The drug is official in Homoeopathic Pharmacopoeia of India.Contraindicated in low blood pressure, chest pain, bleeding disorders. The herb may interfere with therapeutic effect of cardiac drugs. (Sharon M. Herr.) Preparations based on hydroal- coholic extracts of Crataegus monogy- na or C. laevigata are used as Hawthorn in the Western herbal.... crataegeus oxyacanthaHabitat: Cultivated all over India, particularly in West Bengal, Tamil Nadu and Maharashtra.
English: Turmeric.Ayurvedic: Haridraa, Priyaka, Haridruma, Kshanda, Gauri, Kaanchani, Krimighna, Varavarni- ni, Yoshitapriyaa, Hattavilaasini, Naktaahvaa, Sharvari.Unani: Zard Chob.Action: Anti-inflammatory, cholagogue, hepatoprotective, blood-purifier, antioxidant, detoxi- fier and regenerator of liver tissue, antiasthmatic, anti-tumour, anticu- taneous, antiprotozoal, stomachic, carminative. Reduces high plasma cholesterol. Antiplatelet activity offers protection to heart and vessels. Also protects against DNA damage in lymphocytes.
Key application: In dyspeptic conditions. (German Commission E, ESCOP, WHO.) As antiinflammatory, stomachic. (Indian Herbal Pharmacopoeia.)The rhizomes gave curcuminoids, the mixture known as curcumin, consisting of atleast four phenolic diaryl- heptanoids, including curcumin and monodesmethoxycurcumin; volatile oil (3-5%), containing about 60% of turmerones which are sesquiterpene ketones, and bitter principles, sugars, starch, resin.Curcumin related phenolics possess antioxidant, anti-inflammatory, gastroprotective and hepatoprotective activities. The antioxidant activity of curcumin is comparable to standard antioxidants—vitamin C and E, BHA and BHT.The volatile oil, also curcumin, exhibited anti-inflammatory activity in a variety of experimental models (the effects were comparable to those of cortisone and phenylbutazone). Used orally, curcumin prevents the release of inflammatory mediators. It depletes nerve endings of substance P, the neu- rotransmitter of pain receptors.Curcumin's cholesterol-lowering actions include interfering with intestinal cholesterol uptake, increasing the conversion of cholesterol into bile acids and increasing the excretion of bile acids via its choleretic effects.Curcuminoids prevent the increases in liver enzymes, SGOT and SGPT; this validates the use of turmeric as a he- patoprotective drug in liver disorders. Curlone, obtained from the dried rhizome, is used against hepatitis.Turmeric and curcumin increase the mucin content of the stomach and exert gastroprotective effects against stress, alcohol, drug-induced ulcer formation. (Curcumin at doses of 100 mg/kg weight exhibited ulcerogenic activity in rats.)The ethanolic extract of the rhizome exhibited blood sugar lowering activity in alloxan-induced diabetic rats.Piperine (a constituent of black and long pepper) enhances absorption and bioavailability of curcumin.Dosage: Cured rhizome—1-3 g powder. (API Vol. I.)... curcuma longaHabitat: A parasitic climber, occuring in Europe, Asia, South Africa.
English: Lesser Doddar, Hellweed, Devil's Guts.Ayurvedic: Aakaashvalli, Amarvalli, Amarvela.Unani: Aftimoon.Folk: Sitammapogunalu (Telugu).Action: Hepatic, laxative, carminative.
The parasitic plant accumulates alkaloids from the host plant. It contains flavonoids, including kaempferol and quercetin, hydroxycinnamic acid derivatives. Cuscutalin (1%) and cus- cutin (0.02%) are main active principles of the plant. Seeds contain amar- velin, resins, oil (3%) and reducing sugars.Used in urinary, spleen and liver disorders.... cuscuta epithymumHabitat: The Western Himalayas and Kashmir at 1,000-3,000 m.
English: Mezereon.Folk: Kutilal, Kanthan (Punjab).Action: Active principles are attracting scientific interest. The orthoesters are co-carcinogenic and mezerein antileukaemic in experimental studies. Bark— used as an ointment for inducing discharge from indolent ulcers. Bark, root and root bark—used mainly for obstinate cutaneous diseases, especially for eczema with severe itching and copious exudation (weeping eczema).
As the plant is poisonous, it is used in homoeopathic dilutions internally and topically.The bark gave diterpenes including mezerein, daphnetoxin (0.02%). Mezerein is anti-inflammatory and anticar- cinogenic. Daphnetoxin is poisonous. Seeds contain daphnane ester (0.1%) and daphnetoxin (0.02%).EtOH extract showed significant activity against P-388 lymphocytic leukemia and L-1210 leukemia in mice, due to mezerein.... daphne oleoidesHabitat: Native to China; now grown in Himachal Pradesh, Kumaon, the Nilgiris and West Bengal for edible fruits.
English: Japanese Persimmon.Ayurvedic: Tinduka (var.).Action: Hypotensive, hepatopro- tective, antidote to poisons and bacterial toxins. Calyx and peduncle of fruit—used in the treatment of cough and dyspnoea. Roasted seeds—used as a substitute for coffee.
The fruit, in addition to sugars, glucose, fructose, ascorbic acid, citric acid, contains (% of fresh weight) 0.20-1.41 tannins, 0.21-10.07 total pectins, 0.67 pentosans and 0.16-0.25 polyphenols. The fruit also contains 2.4 mg/100 g carotenoids; carotene expressed as vitamin A 2200-2600 IU. The carote- noids identified in the pulp include cryptoxanthine, zeaxanthin, antherax- anthin, lycopene and beta-carotene. (Many carotenoids originally present in the fruit decompose during ripening.The fruit pulp is an antidote to bacterial toxins and is used in the preparation of a vaccine for pertussis.Condensed tannins from the fruits effectively inhibited 2-nitrofluorene mutagen.The immature leaves contain a ster- oidal saponin, lignin and phenolic compounds. Eugenol and dihydroac- tinidiolide are reported from fresh leaves.The leaves are reported to exhibit hepatoprotective activity. Leaves also contain hypotensive principles. Astra- galin and isoquercitrin have been isolated from leaves.... diospyros kakiHabitat: Throughout India, up to 2,000 m on the hills.
English: Trailing Eclipta Plant.Ayurvedic: Bhringaraaja, Bhringa, Bhringaja, Bhrngaaraka, Bhrngaara, Maarkava, Kesharaaja, Keshranjana.Siddha/Tamil: Karisalaankanni.Folk: Bhangaraa.Action: Deobstruent, antihepato- toxic, anticatarrhal, febrifuge. Used in hepatitis, spleen enlargements, chronic skin diseases. Leaf—promotes hair growth. Its extract in oil is applied to scalp before bed time in insomnia. The herb is also used as an ingredient in shampoos.
Key application: As hepatoprotec- tive. (Indian Herbal Pharmacopoeia; The Ayurvedic Pharmacopoeia of India.)The herb should be dried at room temperature under shade. Its active principles are lost due to aerial oxidation during sun drying or drying under reduced pressure below 40°C. The herb contains wedelolactone and demethyl- wedelolactone, which showed a dose- dependenteffectagainstCCl4, d-galac- tosamine- or phalloidin-induced cyto- toxicity in primary cultured rat hep- atocytes, and exhibited potent anti- hepatotoxic property. The whole plant shows effect on liver cell regeneration. Immunoactive property has been observed against surface antigen of hepatitis B-virus. The plant is also reported to be effective in the treatment of peptic ulcer, inflammatory diseases, including rheumatoid arthritis, diseases of the gallbladder and skin infections.Aqueous extract of leaves exhibits myocardial depressant and hypoten- sive activity (unrelated to cholinergic and histaminergic effects).The roots are very rich in thio- phene acetylenes. Thiophene derivatives show activity against nematodes.Dosage: Whole plant—3-6 ml fresh juice; 13-36 g for decoction. (API Vol. II.)... eclipta albaHabitat: Throughout India.
English: Embelia.Ayurvedic: Vidanga, Krmighna, Krmihara, Krmiripu, Chitratandula, Jantughna, Jantunaashana, Vella, Amogha.Unani: Baobarang, Barang Kaabuli.Siddha/Tamil: Vaayuvidangam.Action: Ascaricidal, anthelmintic, carminative, diuretic, astringent, anti-inflammatory, antibacterial, febrifuge. Used in diseases of chest and skin. Active principles are found to be oestrogenic and weakly progestogenic. Root—bechic, antidiarrhoeal. Seed—spermicidal, oxytocic, diuretic. The plant is also used for its blood purifying properties. It is an ingredient in cough syrups, preparations for anaemia, genitourinary tract infections, diarrhoea and diseases of the liver.
Embelin, isolated from the berries, shows significant anti-implantation and post-coital antifertility activity. (Successful trials have been carried out at the National Institute of Immunology, New Delhi on human beings.) It is found to be a potential male antifer- tility agent. Spermatogenesis has been impaired and sperm count reduced to the level of infertility. The antisper- matogenic changes are found to be reversible without any toxic effects.Aqueous and EtOH extract of the fruit—anthelmintic against earthworms. Fruit powder (200 mg/kg), taken with curd on empty stomach, expelled tapeworm within 6-24 h. The treatment was also found effective in giardiasis. EtOH (50%) of the plant was found slightly active against E.coli. Di-salts of embelin—an- thelmintic. Amino salts exhibited less side effects than embelin. The effect of di-isobutyl amino derivatives lasted up to 10 h, also showed anti-inflammatory, hypotensive and antipyretic activities.Berries gave quinones—embelin, ra- panone, homoembelin, homorapnone and vilangin.Dosage: Fruit—5-10 g powder. (API Vol. I.)... embelia ribesHabitat: Throughout warmer parts of India.
Ayurvedic: Mayura-shikhaa, Gojihvaa. (Actinopteris dichotoma Bedd. and Celosia cristata Linn. are also used as Mayura-shikhaa. Anchusa strigosa Lebill., and other Boraginaecae sp. are used as Gojihvaa.)Siddha/Tamil: Yaanaichhuvadi.Folk: Mayurjuti, Maaraajuti.Action: Plant—astringent, cardiac tonic, diuretic, mucilaginous, emmolient (used in dysuria, diarrhoea, dysentery. Leaves—
Family: Zingiberaceae.Habitat: Cultivated either as pure plantation crop, or as subsidiary to coffee and arecanut in hilly forests regions of Western Ghats in Karnataka and Kerala, and in parts of Madurai, the Nilgiris and Tirunelveli in Tamil Nadu.
English: Lesser Cardamom.Ayurvedic: Elaa, Sukshmailaa, Kshudrailaa, Bhrngaparnikaa, Tutthaa, Draavidi, Prithvikaa, Triputaa, Truti, Upkunchikaa.Unani: Heel Khurd.Siddha/Tamil: Yelakkai, Ilam.Action: Carminative antiemetic, stomachic, orexigenic, anti-gripe, antiasthmatic, bechic, Oil— antispasmodic, antiseptic. Used for flatulence, loss of appetite, colic, bronchitis, asthma. Paste used as balm for headache, husk for rheumatism.
Key application: In dyspepsia; also as cholagogue. (German Commission E.)The seeds yield an essential oil (611% dry basis). The major constituents are, 1,8-cineole and alpha-terpinylace- tate, with limonene, alpha-terpineol, sabinene and linalool. The seeds contain palmitic and oleic as dominant fatty acids, besides linoleic and linolenic acids, along with alpha-tocopherol, desmosterol and campesterol.The extracts of cardamom cause a significant decrease in gastric secretion after 3 h of treatment. The effect of methanol extract is primarily observed as decreased pepsin output.Terpineol and acetylterpineol, the active principles of cardamom seeds, showed greater penetration enhancing capacities than Azone which was used as a comparative penetration enhancer for the diffusion of Pred- nisolone through mouse skin in vitro.Volatile components exhibit antimicrobial activity. The oil inhibits afla- toxin synthesis.The cardamom seed can trigger gallstone colic (spasmodic pain) and is not recommended for self-medication in patients with gallstone. (German Commission E, PDR, Natural Medicines Comprehensive Database, 2007.)Dosage: Seed of dried fruit—1-2 g powder. (API Vol I.)... elettaria cardamomumHabitat: Eastern Himalayas, hills of Bihar, Orissa and South India.
English: Garbee Bean, Mackay Bean, Elephant Creeper.Ayurvedic: Gil.Siddha/Tamil: Chillu, Vattavalli.Folk: Gil-gaachh.Action: Seed—carminative, anodyne, spasmolytic bechic, anti-inflammatory, anthelmintic, antiperiodic. Used in liver complaints, glandular swellings, debility, skin diseases. The seed, stems and bark are poisonous. A paste of the seeds is applied locally for inflammatory glandular swellings. The juice of wood and bark is used as an external application for ulcers. The leaves are reported to be free from the toxic saponins. After soaking in water and roasting toxic principles can be removed from the white kernels of the seeds.
The seeds gave saponins of entagenic acid; a triterpenoid glucoside entanin; beta-sitosterol, alpha-amyrin, querce- tin, gallic acid, cyamidin chloride, lu- peol and a saponin mixture which gave prosapogenin A. Entanin exhibits anti- tumour activity. It inhibits Walker 256 tumours in rats without deaths.Entadamide A (the sulphur-containing amide from the seed) is a 5-lipo-xygenase inhibitor and is found to be effective in the treatment of bronchial asthma. The bark is used for hair wash.Entagenic acid, a sapogenin of entada saponin IV, imparts antifungal activity to the bark.... entada scandensHealth has driven much of environmental policy since the work of Edwin Chadwick in the early 1840s. The ?rst British public-health act was introduced in 1848 to improve housing and sanitation with subsequent provision of puri?ed water, clean milk, food hygiene regulations, vaccinations and antibiotics. In the 21st century there are now many additional environmental factors that must be monitored, researched and controlled if risks to human health are to be well managed and the impact on human morbidity and mortality reduced.
Environmental impacts on health include:
noise
air pollution
water pollution
dust •odours
contaminated ground
loss of amenities
vermin
vibration
animal diseases
Environmental risk factors Many of the major determinants of health, disease and death are environmental risk factors. Some are natural hazards; others are generated by human activities. They may be directly harmful, as in the examples of exposure to toxic chemicals at work, pesticides, or air pollution from road transport, or to radon gas penetrating domestic properties. Environmental factors may also alter people’s susceptibility to disease: for example, the availability of su?cient food. In addition, they may operate by making unhealthy choices more likely, such as the availability and a?ord-ability of junk foods, alcohol, illegal drugs or tobacco.
Populations at risk Children are among the populations most sensitive to environmental health hazards. Their routine exposure to toxic chemicals in homes and communities can put their health at risk. Central to the ability to protect communities and families is the right of people to know about toxic substances. For many, the only source of environmental information is media reporting, which often leaves the public confused and frustrated. To bene?t from public access to information, increasingly via the Internet, people need basic environmental and health information, resources for interpreting, understanding and evaluating health risks, and familiarity with strategies for prevention or reduction of risk.
Risk assessment Environmental health experts rely on the principles of environmental toxicology and risk assessment to evaluate the environment and the potential effects on individual and community health. Key actions include:
identifying sources and routes of environmental exposure and recommending methods of reducing environmental health risks, such as exposure to heavy metals, solvents, pesticides, dioxins, etc.
assessing the risks of exposure-related health hazards.
alerting health professionals, the public, and the media to the levels of risk for particular potential hazards and the reasons for interventions.
ensuring that doctors and scientists explain the results of environmental monitoring studies – for example, the results of water ?uoridation in the UK to improve dental health.
National policies In the United Kingdom in 1996, an important step in linking environment and health was taken by a government-initiated joint consultation by the Departments of Health and Environment about adding ‘environment’ as a key area within the Health of the Nation strategy. The ?rst UK Minister of State for Public Health was appointed in 1997 with responsibilities for health promotion and public-health issues, both generally and within the NHS. These responsibilities include the implementation of the Health of the Nation strategy and its successor, Our Healthy Nation. The aim is to raise the priority given to human health throughout government departments, and to make health and environmental impact assessment a routine part of the making, implementing and assessing the impact of policies.
Global environmental risks The scope of many environmental threats to human health are international and cannot be regulated e?ectively on a local, regional or even national basis. One example is the Chernobyl nuclear reactor accident, which led to a major release of radiation, the effects of which were felt in many countries. Some international action has already been taken to tackle global environmental problems, but governments should routinely measure the overall impacts of development on people and their environments and link with industry to reduce damage to the environment. For instance, the effects of global warming and pollution on health should be assessed within an ecological framework if communities are to respond e?ectively to potential new global threats to the environment.... environment and health
Habitat: Grows abundantly throughout France, Spain, and large areas of Central
Europe.Part used ? Large quantities of Gentiana lutea root are imported into this country as it is preferred to the English variety (Gentiana campestris—see below) for no very apparent therapeutic reason. It is certain, however, that Gentian root, of whichever kind, is the most popular of all herbal tonics and stomachics—and deservedly so.Features ? Gentiana lutea root is cylindrical in form, half to one inch thick, and ringed in the upper portion, the lower being longitudinally wrinkled. It is flexible and tough, internally spongy and nearly white when fresh, an orange-brown tint and strong distinctive odour developing during drying. The taste is extremely bitter.A decoction of 1 ounce to 1 pint (reduced from 1 1/2 pints) of water, given in wineglass doses, will be found very helpful in dyspepsia and loss of tone, or general debility of the digestive organs. One of the effects of the medicine is to stimulate the nerve-endings of taste, thus increasing the flow of gastric juice. As a simple bitter it may be given in all cases when a tonic is needed.The English Gentian (also known locally as Baldmoney and Felwort) grows to six inches high and is branched above. Leaves opposite, ovate- lanceolate above and ovate-spatulate below, entire margins. Flowers are bluish-purple. The whole herb may be used for the same purposes as the foreign root, although here also the root contains the more active principles.... gentianHabitat: Central and Peninsular India.
English: Australian Cow Plant, Ipecacuanha (Indian).Ayurvedic: Meshashringi, Meshav- ishaanikaa, Meshavalli, Chhaagal- shrngi. Ajashringi (also equated with Dolichandrone falcata and Pergularia extensa).Unani: Gurmaar Buuti.Siddha/Tamil: Kannu Minnayam- kodi, Passaam, Shirukurinja.Action: Leaf—antidiabetic. Stimulates the heart and circulatory system, activates the uterus. Used in parageusia and furunculosis. Plant—diuretic, antibilious. Root— emetic, expectorant, astringent, stomachic.
Gymnemagenin, the main sapoge- nin in the leaves, yielded 3.9-4.6% of total gymnemic acids.Gymnemic acids are antisweet principles and exhibit inhibitory effect on levels of plasma glucose.The extract of dried leaves, given to diabetic rats at a dose of 20 mg/day per rat for 8 weeks, was found to bring about blood glucose homoeostasis by increasing serum insulin levels. Increased glycoprotein level and the resultant nephropathy, retinopathy and micro-and macro-angiopathy were also controlled.The leaf extract (25-100 mg/kg), when orally administered to experimentally induced hyperlipidaemic rats for 2 weeks, reduced the elevated serum triglyceride and total cholesterol in a dose-dependent manner. The efficacy and antiatherosclerotic potential of the extract (100 mg/kg) were comparable to that of a lipid lowering agent, clofibrate.In homoeopathy, a drug obtained from the leaves and roots is prescribed for both diabetes mellitus and insipidus Gymnemic acid is reported to inhibit melanin formation in vitro. It also inhibits dental plaque formation.Dosage: Root, leaf-3-5 g powder; 50-100 ml decoction. (CCRAS.)... gymnema sylvestreBleeding into or around the brain is a major concern following serious head injuries, or in newborn infants following a di?cult labour. Haemorrhage is classi?ed as arterial – the most serious type, in which the blood is bright red and appears in spurts (in severe cases the patient may bleed to death within a few minutes); venous – less serious (unless from torn varicose veins) and easily checked, in which the blood is dark and wells up gradually into the wound; and capillary, in which the blood slowly oozes out of the surface of the wound and soon stops spontaneously. Haemorrhage is also classi?ed as primary, reactionary, and secondary (see WOUNDS). Severe haemorrhage causes SHOCK and ANAEMIA, and blood TRANSFUSION is often required.
When a small artery is cut across, the bleeding stops in consequence of changes in the wall of the artery on the one hand, and in the constitution of the blood on the other. Every artery is surrounded by a ?brous sheath, and when cut, the vessel retracts some little distance within this sheath and a blood clot forms, blocking the open end (see COAGULATION). When a major blood vessel is torn, such spontaneous closure may be impossible and surgery is required to stop the bleeding.
Three main principles are applicable in the control of a severe external haemorrhage: (a) direct pressure on the bleeding point or points;
(b) elevation of the wounded part; (c) pressure on the main artery of supply to the part.
Control of internal haemorrhage is more dif?cult than that of external bleeding. First-aid measures should be taken while professional help is sought. The patient should be laid down with legs raised, and he or she should be reassured and kept warm. The mouth may be kept moist but no ?uids should be given. (See APPENDIX 1: BASIC FIRST AID.)... haemorrhage
Habitat: Throughout the moist parts of India, up to 2,000 m. Also grown in gardens of Assam and South India.
English: Ginger Lily.Ayurvedic: Shati (related species).Action: Anti-inflammatory, antirheumatic, febrifuge, tranquilizer.
The rhizomes gave furanoditerpene, hedychenone, an anti-inflammatory principle, also cytotoxic principles as labdane-type diterpenes.The essential oil from rhizome shows anthelmintic and mild tranquil- izing property. The essential oil contains alpha- and beta-pinene, limo- nene, carene, and its oxide, linalool and elemole in varying concentrations. The essential oil also gave borneol, methyl salicylate, eugenol and methy- lanthranilate.... hedychium coronariumHabitat: Dry forests throughout the country.
English: East Indian Screw tree.Ayurvedic: Aavartani, Aavartphalaa, Aavartaki.Unani: Marorphali.Siddha/Tamil: Valampiri.Action: Pods and bark—antidiar- rhoeal, astringent, antibilious. Bark and root—antigalactic, demulcent, expectorant (used in cough and asthma). Leaf—paste used against skin diseases. Pods—anthelmintic. Used in fever due to cold. Seeds— aqueous extract administered in colic and dysentery.
The plant contains a 4-quinolone alkaloid, malatyamine, an antidiarrhoeal principle.The seeds gave diosgenin. Root gave cytotoxic principles—cucurbitacin B and iso-cucurbitacin B. Leaves yielded as ester tetratriacontanyl—tetratri- acontanoate along with tetratriacon- tanoic acid, tetratriacontanol and sitos- terol.Dosage: Fruit, bark—3-6 g powder; 50-100 ml decoction. (CCRAS.)... helicteres isoraHabitat: Native to Europe and Asia. Conditions for its successful cultivation are reported to exist in Kashmir and parts of Himachal Pradesh.
English: Hops.Unani: Hashish-ut-Dinaar.Action: Flowers—sedative, hypnotic, nervine tonic, diuretic, spasmolytic on smooth muscle, analgesic, astringent. Used for nervous diseases, intestinal cramps, menopause, insomnia, neuralgia and nervous diarrhoea. Also as a tonic in stomach and liver affections. As a blood cleanser, the root is used like sarsaparilla.
Key application: In mood disturbances, such as restlessness and anxiety, sleep disturbances. (German Commission E. ESCOP.)The British Herbal Compendium and The British Herbal Pharmacopoeia reported herb's action as sedative, soporific, spasmolytic and aromatic bitter, and indicated its use for excitability, restlessness, disorders of sleep and lack of appetite.Hop cones consist of the whole dried female inflorescences of Humu- lus lupulus.Hop contains bitter principles— lupulin containing humulon, lupulon and valerianic acid; volatile oil (0.31.0%) including humulene; flavonoids including xanthohumole; polypheno- lic tannins, asparagin, oestrogenic substances.Bitter principles stimulate the digestive system. Valerianic acid is sedative. The resin components, lupulon and humulon are antiseptic against Grampositive bacteria. Asparagin is diuretic. Research suggested that the anti- spasmodic effect is stronger than the sedative, and hops also possess antihis- taminic and anti-oxytocic properties. (Cases of amenorrhoea and dysmen- orrhoea are treated with hops.)Hop extracts exert different effects on CNS in mice. They show hypother- mic, hypnotic, sedative, muscle relaxing and spontaneous locomotor activities, besides potentiating pentobarbital anaesthesia in mice.Humulone inhibited induced inflammation in mice.The dried strobila containing humu- lone and lupulone showed antidiabetic activity in experimental rats.Hop mash or extract is used in the preparation of toothpaste for inhibiting Gram-positive bacteria and in hair preparations for preventing dandruff formation. It is also used in skin- lightening creams.... humulus lupulusMETABOLIC DISORDERS such as URAEMIA and pancreatitis (see PANCREAS, DISORDERS OF)
Bowel infarction
Drug ingestion
Massive blood transfusion, transfusion reaction (see TRANSFUSION OF BLOOD), CARDIOPULMONARY BYPASS, disseminated intravascular coagulation
Treatment The principles of management are supportive, with treatment of the underlying condition if that is possible. Oxygenation is improved by increasing the concentration of oxygen breathed in by the patient, usually with mechanical ventilation of the lungs, often using continuous positive airways pressure (CPAP). Attempts are made to reduce the formation of pulmonary oedema by careful management of how much ?uid is given to the patient (?uid balance). Infection is treated if it arises, as are the possible complications of prolonged ventilation with low lung compliance (e.g. PNEUMOTHORAX). There is some evidence that giving surfactant through a nebuliser or aerosol may help to improve lung e?ectiveness and reduce oedema. Some experimental evidence supports the use of free-radical scavengers and ANTIOXIDANTS, but these are not commonly used. Other techniques include the inhalation of NITRIC OXIDE (NO) to moderate vascular tone, and prone positioning to improve breathing. In severe cases, extracorporeal gas exchange has been advocated as a supportive measure until the lungs have healed enough for adequate gas exchange. (See also RESPIRATORY DISTRESS SYNDROME; HYALINE MEMBRANE DISEASE; SARS.)... indirect insult
Habitat: Gardens of Kerala and West Bengal.
Action: Leaves, flowers—cytotoxic, antitumour.
The ethanolic, extract of leaves showed cytotoxic activity against Dal- ton's lymphoma, Ehrlich ascites carcinoma and Sarcoma 180 tumour cells in vitro. The flowers have been found to contain antitumour principles, active against experimentally induced tumour models.Jacaranda acutifolia auct. non-Humb. & Bonpl.Synonym: J. mimosifolia D. Don J. ovalifolia R. Br.Family: Bignoniaceae.Habitat: Cultivated in Indian gardens.
Folk: Nili-gulmohar.Action: Leaves' volatile oil—applied to buboes. Leaves and bark of the plant—used for syphilis and blennorrhagia. An infusion of the bark is employed as a lotion for ulcers.
The leaves contain jacaranone, ver- bascoside and phenylacetic-beta-glu- coside along with a glucose ester, jaca- ranose. Flavonoid scutellarein and its 7-glucuronide, and hydroquinones were also isolated. Fruits contain beta- sitosterol, ursolic acid and hentriacon- tane; stem bark gave lupenone and beta-sitosterol.The flowers contain an anthocyanin. In Pakistan, the flowers are sold as a substitute for the Unani herb Gul-e- Gaozabaan.The lyophylized aqueous extract of the stem showed a high and broad antimicrobial activity against human urinary tract bacteria, especially Pseudomonas sp.The fatty acid, jacarandic acid, isolated from the seed oil, was found to be a strong inhibitor of prostaglandin biosynthesis in sheep.J. rhombifolia G. F. W. May., syn. J. filicifolia D. Don is grown in Indian gardens. Extracts of the plant show insecticidal properties.Several species of Jacaranda are used for syphilis in Brazil and other parts of South America under the names carobin, carabinha etc. A crystalline substance, carobin, besides resins, acids and caroba balsam, has been isolated from them.... ixora javanicaHabitat: Native to Europe. Imported into India.
English: Bitter Lettuce, Wild Lettuce.Unani: Kaahuu Sahrai (var.), Kaahuu Barri (var.).Action: Mild sedative, hypnotic, (once used as a substitute for opium), anodyne, expectorant.
Key application: As sedative. (The British Herbal Pharmacopoeia.)Used in insomnia, nervous excitability, anxiety, restlessness, hyperactivity in children, nymphomania, smoker's cough, irritable cough and bronchitis.Aerial parts contain sesquiterpene glycosides.The leaves and dried juice contain lacticin, lactucopicrin (sesquiterpene lactones); flavonoids (mainly based on quercetin); coumarins (cichoriin and aesculin); N-methyl-beta-phenethy- lamine; triterpenes include taraxas- terol and beta-amyrin. The sesquiterpene lactones have a sedative effect.The Wild Lettuce also contains hyos- cyamine, while the dried sap is devoid of it. Morphine content has been found in low concentrations, too low to have pharmacological effect. (Natural Medicines Comprehensive Database, 2007.)The oil of seeds is used for arteriosclerosis.Synonym: L. vulgaris Ser. L. leucanth Rusby. Cucurbita siceraria Mol.Family: Cucurbitaceae.Habitat: Throughout India.
English: Bitter Bottle-Gourd.Ayurvedic: Katu-tumbi, Tumbini, Ikshavaaku. Tiktaalaavu, Pindapha- laa.Unani: Kaddu-e-talkh (bitter var.).Siddha/Tamil: Suraikai.Action: Pulp—purgative, emetic. Leaf—used in jaundice.
Cucurbita lagenaria Linn. is equated with Lauki or Sweet Bottle-Guard, used all over India as a vegetable.Cucurbita siceraria Mol. is equated with Titalauki or the Bitter Bottle- Gourd. Bitter fruits yield 0.013% of a solid foam containing cucurbitacin B,D,G and H, mainly cucurbitacin B. These bitter principles are present in the fruit as aglycones. Leaves contain cucurbitacin B, and roots cucurbitacins B, D and traces of E. The fruit juice contains beta-glycosidase (elaterase).Plants which yield non-bitter fruits contain no bitter principles or elat- erase; their roots are not bitter.... lactuca virosaBURSITIS, TENDINITIS and non-speci?c back pain (see BACKACHE).
Osteoarthritis (OA) rarely starts before 40, but by the age of 80 affects 80 per cent of the population. There are structural and functional changes in the articular cartilage, as well as changes in the collagenous matrix of tendons and ligaments. OA is not purely ‘wear and tear’; various sub-groups have a genetic component. Early OA may be precipitated by localised alteration in anatomy, such as a fracture or infection of a joint. Reactive new bone growth typically occurs, causing sclerosis (hardening) beneath the joint, and osteophytes – outgrowths of bone – are characteristic at the margins of the joint. The most common sites are the ?rst metatarsal (great toe), spinal facet joints, the knee, the base of the thumb and the terminal ?nger joints (Heberden’s nodes).
OA has a slow but variable course, with periods of pain and low-grade in?ammation. Acute in?ammation, common in the knee, may result from release of pyrophosphate crystals, causing pseudo-gout.
Urate gout results from crystallisation of URIC ACID in joints, against a background of hyperuricaemia. This high concentration of uric acid in the blood may result from genetic and environmental factors, such as excess dietary purines, alcohol or diuretic drugs.
In?ammatory arthritis is less common than OA, but potentially much more serious. Several types exist, including: SPONDYLARTHRITIS This affects younger men, chie?y involving spinal and leg joints. This may lead to in?ammation and eventual ossi?cation of the enthesis – that is, where the ligaments and tendons are inserted into the bone around joints. This may be associated with disorders in other parts of the body: skin in?ammation (PSORIASIS), bowel and genito-urinary in?ammation, sometimes resulting in infection of the organs (such as dysentery). The syndromes most clearly delineated are ankylosing spondylitis (see SPINE AND SPINAL CORD, DISEASES AND INJURIES OF), psoriatic or colitic spondylitis, and REITER’S SYNDROME. The diagnosis is made clinically and radiologically; no association has been found with autoantibodies (see AUTOANTIBODY). A particularly clear gene locus, HLA B27, has been identi?ed in ankylosing spondylitis. Psoriasis can be associated with a characteristic peripheral arthritis.
Systemic autoimmune rheumatic diseases (see AUTOIMMUNE DISORDERS). RHEUMATOID ARTHRITIS (RA) – see also main entry. The most common of these diseases. Acute in?ammation causes lymphoid synovitis, leading to erosion of the cartilage, associated joints and soft tissues. Fibrosis follows, causing deformity. Autoantibodies are common, particularly Rheumatoid Factor. A common complication of RA is Sjögren’s syndrome, when in?ammation of the mucosal glands may result in a dry mouth and eyes. SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) and various overlap syndromes occur, such as systemic sclerosis and dermatomyositis. Autoantibodies against nuclear proteins such as DNA lead to deposits of immune complexes and VASCULITIS in various tissues, such as kidney, brain, skin and lungs. This may lead to various symptoms, and sometimes even to organ failure.
Infective arthritis includes: SEPTIC ARTHRITIS An uncommon but potentially fatal disease if not diagnosed and treated early with approriate antibiotics. Common causes are TUBERCLE bacilli and staphylococci (see STAPHYLOCOCCUS). Particularly at risk are the elderly and the immunologically vulnerable, such as those under treatment for cancer, or on CORTICOSTEROIDS or IMMUNOSUPPRESSANT drugs. RHEUMATIC FEVER Now rare in western countries. Resulting from an immunological reaction to a streptococcal infection, it is characterised by migratory arthritis, rash and cardiac involvement.
Other infections which may be associated with arthritis include rubella (German measles), parvovirus and LYME DISEASE.
Treatment Septic arthritis is the only type that can be cured using antibiotics, while the principles of treatment for the others are similar: to reduce risk factors (such as hyperuricaemia); to suppress in?ammation; to improve function with physiotherapy; and, in the event of joint failure, to perform surgical arthroplasty. NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) include aspirin, paracetamol and many recently developed ones, such as the proprionic acid derivatives IBUPROFEN and naproxen, along with other drugs that have similar properties such as PIROXICAM. They all carry a risk of toxicity, such as renal dysfunction, or gastrointestinal irritation with haemorrhage. Stronger suppression of in?ammation requires corticosteroids and CYTOTOXIC drugs such as azathioprine or cyclophosphamide. Recent research promises more speci?c and less toxic anti-in?ammatory drugs, such as the monoclonal antibodies like in?iximab. An important treatment for some osteoarthritic joints is surgical replacement of the joints.... joints, diseases of
Habitat: Native to tropical America; naturalized and occurs throughout India. Also grown as hedge plant.
English: Lantana, Wild Sage, Surinam Tea Plant.Ayurvedic: Chaturaangi, Vanachch- hedi.Siddha/Tamil: Unnichedi.Folk: Ghaaneri (Maharashtra).Action: Plant—antirheumatic, antimalarial; used in tetanus and ataxy of abdominal viscera. Pounded leaves are applied to cuts, ulcers and swellings; a decoction of leaves and fruits is used as a lotion for wounds.
The plant is considered poisonous. The leaves contain toxic principles, lantadenes A and B, which cause acute photosensitization, jaundice, kidney and liver lesions. A steroid, lanca- marone, is cardioactive and fish poison.The bark of stems and roots contain a quinine-like alkaloid, lantanine. The extract of the shoot showed antibacterial activity against E. coli and Micrococcus pyogenes var. aureus. Flowers contain anthocyanin.... lantana camaraHabitat: Throughout the warmer parts of India.
Ayurvedic: Granthiparni, Kaaka- puchha.Folk: Gathivan, Deepamaal (Maharashtra).Action: Leaves—spasmolytic. Ash of flower head—applied to burns and scalds, in ringworm and other skin diseases.
The Ayurvedic Pharmacopoeia ofIn- dia recommends the root in cough, bronchitis and dyspnoea.The root contains n-octacosanol, n-octacosanoic acid, quercetin, 4,6,7- trimethoxy-5-methylchromene-2-one, campesterol and beta-sitosterol-beta- D-glucopyranoside.The plant contains 4,6,7-trimethoxy- 5-methyl-chromene-2-one.The leaves contain neptaefolin, nep- taefuran, neptaefuranol, neptaefolinol, leonitin, neptaefolinin and (-)-55, 6- octadecadienoic acid.The seed oil contains oleic, linoleic, palmitic and stearic acids. The fattyFamily: Labiatae; Lamiaceae.Habitat: Native to Europe; also distributed in Himalayas from Kashmir to Kumaon.
English: Common Motherwort, Lion's Tail.Unani: Baranjaasif. (Also equated with Artemesia vulgaris Linn; and Achillea millifolium Linn.)Action: Stomachic, laxative, antispasmodic, diaphoretic, em- menagogue (used in absent or painful menstruation, premenstrual tension, menopausal flushes). Hypnotic, sedative. Used as a cardiac tonic. (Studies in China have shown that Motherwort extracts show antiplatelet aggregation actions and decrease the levels of blood lipids.)
Key application: In nervous cardiac disorders and as adjuvant for thyroid hyperfunction. (German Commission E.) As antispasmodic. (The British Herbal Pharmacopoeia.) The British Herbal Compendium indicated its use for patients who have neuropathic cardiac disorders and cardiac complaints of nervous origin.The plant contains diterpene bitter principles, iridoid monoterpenes, flavonoids including rutin and querci- trin, leonurin, betaine, caffeic acid derivatives, tannins and traces of a volatile oil.The herb is a slow acting adjuvant in functional and neurogenic heart diseases. Its sedative and spasmolytic properties combine well with Valeriana officinalis or other cardioactive substances.The herb contains several components with sedative effects—alpha- pinene, benzaldehyde, caryophyllene, limonene and oleanolic acid. (Sharon M. Herr.)Habitat: Western Europe. Seeds are imported into India from Persia.
English: Pepper-Grass.Unani: Bazr-ul-khumkhum, Todari (white var.).Action: Seeds—blood purifier; prescribed in bronchitis.
The fatty acid of the oil are: oleic 12.9, linoleic 47.87, linolenic 5.43, erucic 31.97, stearic 0.54 and palmitic 1.22%.The seed mucilage on hydrolysis gave galactose, arabinose, rhamnose and galacturonic acid.Flowering tops and seeds contain a bitter principle, lepidin.The plant yield a sulphur-containing volatile oil.... leonurus cardiacaHabitat: Native to Europe and West Asia; now cultivated in Himachal Pradesh., Kashmir, Kulu, Kumaon, Assam and in the Nilgiris.
English: Cultivated Apple.Ayurvedic: Sinchitikaa.Folk: Seb, Sev.Action: Bark—anthelmintic, refrigerant, hypnotic, given in intermittent, remittent and bilious fevers. Leaves—inhibit the growth of a number of Gram-positive and Gram-negative bacteria.
The fruit contains malic (90-95% of the total acids), citric, lactic and succinic acids; (unripe fruit contains quinic acid, citric acid, succinic acid, lactic acid); caffeic acid derivatives, pectins, minerals and vitamins.Edible portion of fresh apple contains thiamine 0.12, riboflavin 0.03, niacin 0.2 and ascorbic acid 2 mg/100 g. The ascorbic acid content varies widely and values up to 40 mg/100 g. Sugars constitute about 80% of the total carbohydrates of ripe fruits—fructose (60), glucose (25) and sucrose (15%). The pectin content of the edible portion varies from 0.14 to 0.96% (as calcium pectate). The uronic acid content of apple pectin varies from 0.5 to 15%.The astringent principles of apple include tannins, tannin derivatives and colouring materials (flavones). The browning of apple slices on exposure to air is due to enzymic oxidation of tannin compounds.Fresh juice contains 0.20-0.80 malic acid, 11.6 total sugars and 0.02100.080% tannin.The seeds contain cyanogenic gly- coside, amygdalin (0.62-1.38%, HCN equivalent, 0.037-00.087%).... malus pumilaHabitat: A common plant in the United States and Canada, the root is imported into this country in large quantities for medicinal purposes.
Features ? The rhizome (as the part used should more strictly be termed) is reddish- brown in colour, fairly smooth, and has knotty joints at distances of about two inches. The fracture shows whitish and mealy.American Mandrake is an entirely different plant from White Bryony or English Mandrake, dealt with elsewhere. Preparations of the rhizome of the American Mandrake are found in practice to be much more effective than those of the resin. This is one of the many confirmations of one of the basic postulates of herbal medicine—the nearer we can get to natural conditions the better the results. Therapeutic principles are never the same when taken from their proper environment.Podophyllum is a very valuable hepatic, and a thorough but slow-acting purgative. Correctly compounded with other herbs it is wonderfully effective in congested conditions of the liver, and has a salutary influence on other parts of the system, the glands in particular being helped to normal functioning. Although apparently unrecognised in Coffin's day, the modern natural healer highly appreciates the virtues of this medicine and has many uses for it.As American Mandrake is so powerful in certain of its actions, and needs such skillful combination with other herbs, it should not be used by the public without the advice of one experienced in prescribing it toindividual needs.... mandrake, americanHabitat: Eastern Himalayas, lower hills of Assam, hills of South India up to 1,000 m., cultivated in various parts of India.
English: Champak, Golden Champa.Ayurvedic: Champaka, Svarna Champaka, Hemapushpa, Chaam- peya.Siddha/Tamil: Sampagi.Action: Flowers—bitter, carminative, antispasmodic, demulcent, antiemetic, diuretic (used for dy- suria), antipyretic. Fruits—used for dyspepsia and renal diseases. Bark—stimulant, diuretic and febrifuge. Dried root and root bark—purgative and emmena- gogue. Externally—flower oil is used as an application in cepha- lalgia, gout and rheumatism; fruits and seeds for healing cracks in feet.
The ethanolic extract of the stem bark showed hypoglycaemic activity in rats. The benzene extract of the anthers showed 67% post-coital antiimplantation activity in rats (1000 mg/ kg per day).Stem bark and roots yielded an alkaloid liriodenine. Root bark yielded sesquiterpene lactones (including parthenolide and micheliolide). Leaves gave a polyisoprenoid, beta-sitosterol and liriodenine. Mono-and sesquiter- penes occur in essential oils isolated from the flowers, leaf and fruit ring.The bark and root cortex of the Chinese plant gave magnosprengerine (0.41%) and salicifoline (0.39%). These active principles showed lasting muscle relaxant and hypotensive activity.The bark of Michelia montana Blume (Eastern Himalayas and hills of Assam) is used as a bitter tonic in fevers. It bears white and fragrant flowers. The leaf and stem yield an essential oil, 0.95 and 0.36% on fresh basis, respectively. The flowers contains 75% safrole and the latter 76% sarisan.Michelia nilgarica Zenk. (Western Ghats, above 1,700 m) is known as Kattu-sambagam in Tamil Nadu, the yellow-flowered var. of Champaa. The bark and leaves are considered febrifuge. The bark contains a volatile oil, acrid resins, tannin and a bitter principle. The flowers yield a volatile oil similar to the bark oil. Aerial parts exhibit diuretic and spasmolytic activity.Dosage: Dried buds and flowers— 1-3 g powder. (API, Vol. IV.) Bark— 50-100 m decoction. (CCRAS.)... michelia champacaA range of research investigations has developed within medical education. These apply to course monitoring, audit, development and validation, assessment methodologies and the application of educationally appropriate principles at undergraduate and postgraduate levels. Research is undertaken by medical educationalists whose backgrounds include teaching, social sciences and medicine and related health-care specialties, and who will hold a medical or general educational diploma, degree or other appropriate postgraduate quali?cation.
Development and validation for all courses are an important part of continuing accreditation processes. The relatively conservative courses at both undergraduate and postgraduate levels, including diplomas and postgraduate quali?cations awarded by the specialist medical royal colleges (responsible for standards of specialist education) and universities, have undergone a range of reassessment and rede?nition driven by the changing needs of the individual practitioner in the last decade. The stimuli to change aspects of medical training have come from the government through the former Chief Medical O?cer, Sir Kenneth Calman, and the introduction of new approaches to specialist training (the Calman programme), from the GENERAL MEDICAL COUNCIL (GMC) and its document Tomorrow’s Doctors, as well as from the profession itself through the activities of the British Medical Association and the medical royal colleges. The evolving expectations of the public in their perception of the requirements of a doctor, and changes in education of other groups of health professionals, have also led to pressures for changes.
Consequently, many new departments and units devoted to medical education within university medical schools, royal colleges and elsewhere within higher education have been established. These developments have built upon practice developed elsewhere in the world, particularly in North America, Australia and some European countries. Undergraduate education has seen application of new educational methods, including Problem-Based Learning (PBL) in Liverpool, Glasgow and Manchester; clinical and communications skills teaching; early patient contact; and the extensive adoption of Internet (World Wide Web) support and Computer-Aided Learning (CAL). In postgraduate education – driven by European directives and practices, changes in specialist training and the needs of community medicine – new courses have developed around the membership and fellowship examinations for the royal colleges. Examples of these changes driven by medical education expertise include the STEP course for the Royal College of Surgeons of England, and distance-learning courses for diplomas in primary care and rheumatology, as well as examples of good practice as adopted by the Royal College of General Practitioners.
Continuing Professional Development (CPD) and Continuing Medical Education (CME) are also important aspects of medical education now being developed in the United Kingdom, and are evolving to meet the needs of individuals at all stages of their careers.
Bodies closely involved in medical educational developments and their review include the General Medical Council, SCOPME (the Standing Committee on Postgraduate Medical Education), all the medical royal colleges and medical schools, and the British Medical Association through its Board of Medical Education. The National Health Service (NHS) is also involved in education and is a key to facilitation of CPD/CME as the major employer of doctors within the United Kingdom.
Several learned societies embrace medical education at all levels. These include ASME (the Association for the Study of Medical Education), MADEN (the Medical and Dental Education Network) and AMEE (the Association for Medical Education in Europe). Specialist journals are devoted to research reports relating to medical educational developments
(e.g. Academic Medicine, Health Care Education, Medical Education). The more general medical journals (e.g. British Medical Journal, New England Journal of Medicine, The Lancet, Annals of the Royal College of Surgeons) also carry articles on educational matters. Finally, the World Wide Web (WWW) is a valuable source of information relating to courses and course development and other aspects of modern medical education.
The UK government, which controls the number of students entering medical training, has recently increased the quota to take account of increasing demands for trained sta? from the NHS. More than 5,700 students – 3,300 women and 2,400 men – are now entering UK medical schools annually with nearly 28,600 at medical school in any one year, and an attrition rate of about 8–10 per cent. This loss may in part be due to the changes in university-funding arrangements. Students now pay all or part of their tuition fees, and this can result in medical graduates owing several thousand pounds when they qualify at the end of their ?ve-year basic quali?cation course. Doctors wishing to specialise need to do up to ?ve years (sometimes more) of salaried ‘hands-on’ training in house or registrar (intern) posts.
Though it may be a commonly held belief that most students enter medicine for humanitarian reasons rather than for the ?nancial rewards of a successful medical career, in developed nations the prospect of status and rewards is probably one incentive. However, the cost to students of medical education along with the widespread publicity in Britain about an under-resourced, seriously overstretched health service, with sta? working long hours and dealing with a rising number of disgruntled patients, may be affecting recruitment, since the number of applicants for medical school has dropped in the past year or so. Although there is still competition for places, planners need to bear this falling trend in mind.
Another factor to be considered for the future is the nature of the medical curriculum. In Britain and western Europe, the age structure of a probably declining population will become top-heavy with senior citizens. In the ?nancial interests of the countries affected, and in the personal interests of an ageing population, it would seem sensible to raise the pro?le of preventive medicine – traditionally rather a Cinderella subject – in medical education, thus enabling people to live healthier as well as longer lives. While learning about treatments is essential, the increasing specialisation and subspecialisation of medicine in order to provide expensive, high-technology care to a population, many of whom are suffering from preventable illnesses originating in part from self-indulgent lifestyles, seems insupportable economically, unsatisfactory for patients awaiting treatment, and not necessarily professionally ful?lling for health-care sta?. To change the mix of medical education would be a di?cult long-term task but should be worthwhile for providers and recipients of medical care.... medical education
Habitat: Cultivated all over India for its fruits.
English: Bitter Gourd, Blsam Pear, Carilla.Ayurvedic: Kaaravellaka, Kaaravella, Kaathilla, Sushaavi.Unani: Karelaa.Siddha/Tamil: Paakal, Paharkai.Action: Seed/fruit—improves diabetic condition. Fruit—stomachic, laxative, antibilious, emetic, anthelmintic. Used in cough, respiratory diseases, intestinal worms, skin diseases, also for gout and rheumatism. Powdered fruit—applied to wounds and ulcers. Leaf— emetic, antibilious, purgative. Fruit, leaf and root—abortifacient. Leaf and seed—anthelmintic. Root— astringent; appled to haemorrhoids.
Immature fruits gave several nonbitter and bitter momordicosides. Fruits, seeds and tissue culture gave a polypeptide containing amino acids. Fruits also gave 5-hydroxytryptamine, charantin (a steroidal glucoside), dios- genin, cholesterol, lanosterol and beta- sitosterol. Bitter principles are cucur- bitacin glycosides.Hypoglycaemic effects of the fruit have been demonstrated by blood tests in both humans and animal studies.Researchers have warned that the fruit extract leads to a false negative test for sugar in the urine (due to its ability to maintain the indicator dye in the glucose oxidase strips and the alkaline copper salts in a reduced state).Chronic administration of the fruit extract (1.75 g/day for 60 days) to dogs led to testicular lesions with mass atrophy of the spermatogenic elements. The extract reduced the testicular content of RNA, protein and sialic acid as also the acid-phosphatase activity. (Medicinal Plants of India, Vol. 2,1987, Indian Council of Medical Research, New Delhi.)The fruits and seeds yielded a poly- peptide, p-insulin, which was considered similar to bovine insulin. (Fitoter- apia, 60,1989; Chem Abstr 112,1990.)The seed and fruit contain an inhibitor of HIV, MAP-30 (Momordi- ca anti-HIV-protein) which exhibited antiviral and antitumour activity in vitro. (Chem Abstr, 113, 1990; ibid, 117, 1992.) Another protein, MRK-29, found in the seed and fruit of a smaller var. of Bitter Gourd found in Thailand, was found to inhibit HIV reverse transcriptase and to increase tumour necrosis factor (TNF). (Planta Med, 67, 2001; Natural Medicines Comprehensive Database, 2007.)The seeds yield alpha-and beta- momorcharins (glycoproteins). When these glycoproteins were co-cultured with isolated hepatocytes, morphological changes in hepatocytes were observed, indicating hepatotoxicity. Another principle with antilipolytic and lipogenic activities, found along with the alpha-and beta-momorcharin in the seed extract, did not show toxic effect.Vicine is the hypoglycaemic constituent in the seed. Pure vicine has been found to possess 32.6% hypogly- caemic activity as against 22.2% shown by fresh juice, when tested on albino rats. The vicine is non-haemolytic.Dosage: Fresh fruit—10-15 ml juice (API, Vol. II); 10-20 ml juice (CCRAS.)... momordica charantiaAction: All parts of the tree are reported to be used as cardiac and circulatory stimulant. Pods—antipyretic, anthelmintic; fried pods are used by diabetics. Flowers—cholagogue, stimulant, diuretic. Root juice—cardiac tonic, antiepileptic. Used for nervous debility, asthma, enlarged liver and spleen, deep-seated inflammation and as diuretic in calculus affection. Decoction is used as a gargle in hoarseness and sore throat. Root and fruit—antiparalytic. Leaf—juice is used in hiccough (emetic in high doses); cooked leaves are given in influenza and catarrhal affections. Root-bark—antiviral, anti-inflammatory, analgesic. Bark—antifungal, antibacterial. Stem-bark and flower—hypo- glycaemic. Seeds—an infusion, anti-inflammatory, antispasmodic and diuretic; given in venereal diseases.
Along with other therapeutic applications, The Ayurvedic Pharmacopoeia of India indicated the use of the dried root bark in goitre, glycosuria and lipid disorders (also dried seeds), and leaf, seed, root bark and stem bark in internal abscess, piles and fistula-in-ano.The plant contains antibacterial principles, spirochin and pterygosper- min which are effective against both Gram-Positive and Gram-Negative bacteria.The leaves contain nitrile glycosides, niazirin and niazirinin and mustard oil glycosides. The mustard oil glycosides showed hypotensive, bradycardiac effects and spasmolytic activity, justifying the use of leaves for gastrointestinal motility disorders.The roots possess antibacterial, anti- choleric and antiviral properties due to the presence of pterygospermin, Spiro chin and benzylisothiocyanate. The root extract exhibited significant anti- inflammatory activity in carrageenan- induced paw-oedema in rats.The leaves exhibited hypoglycaemic activity, although the plasma insulin level did not alter much.The root and bark showed antifer- tility activity through biphasic action on the duration of the estrous cycle of female rats.Dosage: Leaf—10-20 ml. juice. (API, Vol. III); root bark—2-5 g powder; stem bark—2-5 g powder; seed—5-10 g powder (API, Vol. IV). Leaf, flower, fruit, seed, bark, root— 1-3 g powder; 50-100 ml decoction. (CCRAS.)... moringa pterygospermaThe symptoms depend upon the site of the infection. General symptoms such as fever, weight loss and night sweats are common. In the most common form of pulmonary tuberculosis, cough and blood-stained sputum (haemoptysis) are common symptoms.
The route of infection is most often by inhalation, although it can be by ingestion of products such as infected milk. The results of contact depend upon the extent of the exposure and the susceptibility of the individual. Around 30 per cent of those closely exposed to the organism will be infected, but most will contain the infection with no signi?cant clinical illness and only a minority will go on to develop clinical disease. Around 5 per cent of those infected will develop post-primary disease over the next two or three years. The rest are at risk of reactivation of the disease later, particularly if their resistance is reduced by associated disease, poor nutrition or immunosuppression. In developed countries around 5 per cent of those infected will reactivate their healed tuberculosis into a clinical problem.
Immunosuppressed patients such as those infected with HIV are at much greater risk of developing clinical tuberculosis on primary contact or from reactivation. This is a particular problem in many developing countries, where there is a high incidence of both HIV and tuberculosis.
Diagnosis This depends upon identi?cation of mycobacteria on direct staining of sputum or other secretions or tissue, and upon culture of the organism. Culture takes 4–6 weeks but is necessary for di?erentiation from other non-tuberculous mycobacteria and for drug-sensitivity testing. Newer techniques involving DNA ampli?cation by polymerase chain reaction (PCR) can detect small numbers of organisms and help with earlier diagnosis.
Treatment This can be preventative or curative. Important elements of prevention are adequate nutrition and social conditions, BCG vaccination (see IMMUNISATION), an adequate public-health programme for contact tracing, and chemoprophylaxis. Radiological screening with mass miniature radiography is no longer used.
Vaccination with an attenuated organism (BCG – Bacillus Calmette Guerin) is used in the United Kingdom and some other countries at 12–13 years, or earlier in high-risk groups. Some studies show 80 per cent protection against tuberculosis for ten years after vaccination.
Cases of open tuberculosis need to be identi?ed; their close contacts should be reviewed for evidence of disease. Adequate antibiotic chemotherapy removes the infective risk after around two weeks of treatment. Chemoprophylaxis – the use of antituberculous therapy in those without clinical disease – may be used in contacts who develop a strong reaction on tuberculin skin testing or those at high risk because of associated disease.
The major principles of antibiotic chemotherapy for tuberculosis are that a combination of drugs needs to be used, and that treatment needs to be continued for a prolonged period – usually six months. Use of single agents or interrupted courses leads to the development of drug resistance. Serious outbreaks of multiply resistant Mycobacterium tuberculosis have been seen mainly in AIDS units, where patients have greater susceptibility to the disease, but also in developing countries where maintenance of appropriate antibacterial therapy for six months or more can be di?cult.
Streptomycin was the ?rst useful agent identi?ed in 1944. The four drugs used most often now are RIFAMPICIN, ISONIAZID, PYRAZINAMIDE and ETHAMBUTOL. Three to four agents are used for the ?rst two months; then, when sensitivities are known and clinical response observed, two drugs, most often rifampicin and isoniazid, are continued for the rest of the course. Treatment is taken daily, although thrice-weekly, directly observed therapy is used when there is doubt about the patient’s compliance. All the antituberculous agents have a range of adverse effects that need to be monitored during treatment. Provided that the treatment is prescribed and taken appropriately, response to treatment is very good with cure of disease and very low relapse rates.... nature of the disease tuberculosis has
Habitat: Native to Mediterranean region; grown in Indian gardens.
English: Red Oleander, Rose Bay.Unani: Surkh Kaner.Action: See N. indicum. (The white- and red-flowered varieties are equated with Nerium oleander; both possess similar properties. The yellow-flowered variety is equated with Thevetia peruviana.)
Key application: Leaf—included among unapproved herbs by German Commission E. Positively inotropic and negatively chronotropic actions have been mentioned; the use of leaf for diseases and functional disorders of the heart, as well as for skin diseases has been indicated.The leaves and roots gave a number of active principles including gly- cosides, terpenoids, sterols and other compounds. Cardiac steroids, isolated from the leaf, include oleandrin, gen- tiobiosyl oleandrin, odoroside. The stem contained alanine arginine, as- partic acid, cysteine, glutamic acid, glycine, histidine, leucine, isoleucine, lysine, phenylalanine, proline, serine, threonine, tryptophan, tyrosine and valine. A polysaccharide (2.3%), containing galacturonic acid, rhamnose, arabinose and galactose has been isolated from leaves.Neutral fraction from leaves at low doses caused marked suppression of locomotor activity.Aqueous extract of leaves showed significant antibacterial activity against Pseudomonas aeruginosa. The leaves also showed insecticidal activity.... nerium oleanderHabitat: Native to Moluccas, cultivated in Indonesia, also in India.
English: Java Long Pepper.Ayurvedic: Gajapippali (spikes of Scindapsis officinalis, Araceae, are also known as Gajapippali), Chavya, Chavika.Siddha/Tamil: Chevuyam.Action: Similar to P. longum and P. nigrum. Fruits—stimulant, carminative; used in haemorrhoidal affections; as a tonic, after- childbirth. Roots—chewed or brewed in decoction for colic, dyspepsia and gastralgia.
Key application: In diseases of the spleen, chlorosis, diseases of the abdomen. colic, worm infestation. (The Ayurvedic Pharmacopoeia of India.)Java long pepper is similar in composition to black pepper; it contains less piperine and volatile oil (piperine 4.5 and volatile oil 1.5%).The stem is used as a substitute for Piper longum root. It contains the alkaloids piperine and piplartine. Beta- sitosterol, glycosides, glucose and fructose and mucilage have also been reported. Active principles show muscle relaxant property.... piper chabaHabitat: Throughout the tropical zones of India in the hilly regions.
English: Indian Kino tree, Malabar Kino tree.Ayurvedic: Asana, Bijaka, Priyaka, Pitashaala.Unani: Bijaysaar.Siddha/Tamil: Vengai.Action: Bark-kino—astringent, antihaemorrhagic, antidiarrhoeal. Flowers—febrifuge. Leaves—used externally for skin diseases.
Key application: Heartwood— in anaemia, worm infestation, skin diseases, urinary disorders, lipid disorders and obesity. Stem bark—in diabetes. (The Ayurvedic Pharmacopoeia of India.)The heartwood and roots contain isoflavonoids, terpenoids and tannins. Tannins include the hypoglycaemic principle (-)-epicatechin. Stilbenes, such as pterostilbene; flavonoids, including liquiritigenin, isoliquiritige- nin, 7-hydroxyflavanone, 7,4-dihy- droxyflavanone, 5-deoxykaempferol and pterosupin; a benzofuranone mar- supsin and propterol, p-hydroxy-ben- zaldehyde are active principles of therapeutic importance.The gum-kino from the bark provides a non-glucosidal tannin, Kino tannic acid (25-80%).The (-)-epi-catechin increases the cAMP content of the islets which is associated with the increased insulin release, conversion of proinsulin to insulin and cathepsin B activity.Oral administration of ethylacetate extract of the heartwood and its fla- vonoid constituents, marsupin, ptero- supin and liquiritigenin, for 14 consecutive days to rats exhibited a significant reduction of serum triglycerides, total cholesterol and LDL- and VLDL-cholesterol levels, but it did not exert any significant effect on HDL- cholesterol.The ethanolic and methanolic extracts of the heartwood exhibited significant in vitro antimicrobial activity against Gram-positive and Gramnegative bacteria and some strains of fungi.Kino is powerfully astringent. The therapeutic value of kino is due to Kino tannic acid.Dosage: Heartwood—50-100 g for decoction. (API, Vol. I); stem bark—32-50 g for decoction (API, Vol. III).... pterocarpus marsupiumEthics of research Although Britain has had legislation governing aspects of research on animals since the 19th century, there is no over-arching statute regulating research on humans and human material. Such activity is covered in law by the vaguely de?ned common-law concept of consent, and by piecemeal legislation such as the DATA PROTECTION ACT 1998 and the HUMAN FERTILISATION & EMBRYOLOGY ACT 1990. Nevertheless, extensive and very detailed ethical guidance on aspects of research has been published by a wide range of national and international organisations (see ETHICS COMMITTEES). Several basic principles feature in all statements about research ethics: these include the importance of ensuring that research is independently and rigorously scrutinised by appropriately constituted ethics committees; verifying that any risk to the research subject is reasonable in relation to the anticipated bene?t; and ensuring that all e?orts are made to minimise possible harm. The research subject’s willingness to tolerate some risk does not relieve researchers of the responsibility of making sure that all risks are kept to a minimum. Above all, a key feature of ethical research has involved seeking informed consent from research participants. This rule, initially applied to actual involvement by human subjects in research, has gradually been extended to include seeking informed consent from patients or from their relatives to the use of data and to the use of human organs and tissue in research, including after POST-MORTEM EXAMINATION. (See also EVIDENCE-BASED MEDICINE.)... research
Habitat: Sub-alpine Himalayas, from Kashmir to Sikkim at altitudes of 3,300-5,200 m.; also cultivated in Assam.
English: Indian Rhubarb, Himalayan Rhubarb.Ayurvedic: Amlaparni, Pitamuuli, Gandhini Revatikaa. Revandachini (roots).Unani: Revandchini.Siddha/Tamil: Revalchinikattai, Nattirevaichini.Action: Purgative, astringent, aperient. Used for constipation and atonic dyspepsia. Not advised for patients suffering from gout, rheumatism, epilepsy. (When given internally, the root imparts a deep tinge to the urine.)
The root gave emodin, emodin- 3-monomethyl ether, chrysophanol, aloe-emodin, rhein. These occur free and as quinone, anthrone or dianthrone glycosides. The astringent principle consists of gallic acid together with small amounts of tannin. The drug also contain cinnamic and rhe- inolic acids, volatile oil, starch and calcium oxalate. Two major glyco- sidic active principles, sennoside A and B, are present along with free an- thraquinones.At low doses, the tannin exerts astringent effect and relieves diarrhoea; at higher doses anthraquinones stimulate laxative effect and relieve constipation. (Natural Medicines Comprehensive Database, 2007.)There are three main types of rhubarbs—Chinese, Indian or Himalayan, and Rhapontic.The Chinese rhubarb consists of the rhizomes and roots of Rheum palma- tum and R. officinale.The Indian rhubarb consists of dried rhizomes of R. emodi and R. web- bianum; rhizomes and roots of R. moorcroftianum and R. spiciforme are also reported to be mixed with the drug. R. rhaponticum is the Rhapontic rhubarb.Rheum moorcroftianum Royle (the Himalayas at altitudes of 3,0005,200 m., chiefly in Garhwal and Ku- maon) possesses properties similar to those of R. emodi and the roots are mixed with the latter.Rheum spiciforme Royle (drier ranges of Kumaon and Sikkim at altitudes of 2,700-4,800 m.) also possesses purgative properties. The rhizomes and roots are mixed up with Himalayan rhubarb.Rheum webbianum Royle (the western and central Himalayas at altitudes of 3,000-5,000 m.) is the source of Himalayan rhubarb.Rheum palmatum is esteemed as the best type of (Chinese) rhubarb. Two new stilbene glycosides, 4'-O- methylpiceid and rhapontin, isolated from the roots, exhibited moderate alpha-glucosidase inhibitory activity. Anthraquinone glucoside, pul- matin, isolated from the roots, along with its congeners, chrysophanein and physcionin, showed cytotoxic activity against several types of carcinoma cells. Polysaccharides, isolated from the roots and rhizomes, contained lyx- ose, glucose, galactose, xylose, rham- nose, mannose and ribose.Dosage: Root—0.2-1.0 g powder. (CCRAS.)... rheum emodiHabitat: 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.... sanicleHabitat: Indigenous to the United States, the plant is also found in England on the banks of streams and in wet ditches.
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 Formulae section of this volume.... scullcap– an early graded return to activity gives the best long-term results, but doing too much too soon runs the risk of exacerbating the original injury.
Chronic (overuse) injuries affecting the bones (see BONE), tendons (see TENDON) or BURSAE of the JOINTS are common in many sports. Examples include chronic INFLAMMATION of the common extensor tendon where it
attaches to the later EPICONDYLE of the humerus – common in throwers and racquet sportspeople – and stress fractures of the TIBIA or METATARSAL BONES of the foot in runners. After an initial period of rest, management often involves coaching that enables the athlete to perform the repetitive movement in a less injury-susceptible manner.
Exercise physiology is the science of measuring athletic performance and physical ?tness for exercise. This knowledge is applied to devising and supervising training regimens based on scienti?c principles. Physical ?tness depends upon the rate at which the body can deliver oxygen to the muscles, known as the VO2max, which is technically di?cult to measure. The PULSE rate during and after a bout of exercise serves as a good proxy of this measurement.
Regulation of sport Sports medicine’s role is to minimise hazards for participants by, for example, framing rule-changes which forbid collapsing the scrum, which has reduced the risk of neck injury in rugby; and in the detection of the use of drugs taken to enhance athletic performance. Such attempts to gain an edge in competition undermine the sporting ideal and are banned by leading sports regulatory bodies. The Olympic Movement Anti-Doping Code lists prohibited substances and methods that could be used to enhance performance. These include some prohibited in certain circumstances as well as those completely banned. The latter include:
stimulants such as AMPHETAMINES, bromantan, ca?eine, carphedon, COCAINE, EPHEDRINE and certain beta-2 agonists.
NARCOTICS such as DIAMORPHINE (heroin), MORPHINE, METHADONE HYDROCHLORIDE and PETHIDINE HYDROCHLORIDE.
ANABOLIC STEROIDS such as methandione, NANDROLONE, stanazol, TESTOSTERONE, clenbuterol, androstenedone and certain beta-2 agonists.
peptide HORMONES, mimetics and analogues such as GROWTH HORMONE, CORTICOTROPHIN, CHORIONIC GONADOTROPHIC HORMONE, pituitary and synthetic GONADOTROPHINS, ERYTHROPOIETIN and INSULIN. (The list produced above is not comprehen
sive: full details are available from the governing bodies of relevant sports.) Among banned methods are blood doping (pre-competition administration of an athlete’s own previously provided and stored blood), administration of arti?cial oxygen carriers or plasma expanders. Also forbidden is any pharmacological, chemical or physical manipulation to affect the results of authorised testing.
Drug use can be detected by analysis of the URINE, but testing only at the time of competition is unlikely to detect drug use designed to enhance early-season training; hence random testing of competitive athletes is also used.
The increasing professionalism and competitiveness (among amateurs and juveniles as well as professionals) in sports sometimes results in pressures on participants to get ?t quickly after injury or illness. This can lead to
players returning to their activity before they are properly ?t – sometimes by using physical or pharmaceutical aids. This practice can adversely affect their long-term physical capabilities and perhaps their general health.... sports medicine
Habitat: Temperate Himalayas from Kashmir to Bhutan and in Khasi Hills.
English: Chiretta.Ayurvedic: Kiraata, Kairaata, Kiraataka, Kandatikta, Kiraatatikta, Kiraatatiktaka, Katutikta, Trin- nimba, Bhuunimba, Aranyatikta, Raamasenaka. Bhuunimba (also equated with Andrographis paniculata).Unani: Chiraitaa.Siddha: Nilavembu.Action: Blood purifier and bitter tonic (The Ayurvedic Pharmacopoeia of India); used in skin diseases. Other properties: antiinflammatory (experimentally, the benzene extract was comparable with phenylbutazone and betamethasone in induced arthritis); hypoglycaemic (xanthone, swerchirin, lowers blood sugar), astringent, stomachic (in dyspepsia and diarrhoea); antimalarial (before the discovery of Peruvian bark), anthelmintic; antiasthmatic, bechic; and as a liver tonic (several active principles are hepatoprotective).
The herb contains oxygenated xan- thone derivatives, including decus- satin, mangiferin, swerchirin, swer- tianin, isobellidifolin; iridoids including chiratin, alkaloids including gen- tianine, gentiocrucine, enicoflavine and glycosyl flavones.Antitubercular activity has been claimed in xanthones. (Natural Medicines Comprehensive Database, 2007.)Green chiretta is equated with Andrographis paniculata Nees, Acantha- ceae.Dosage: Whole plant—1-3 g powder; 20-30 g for decoction. (API, Vol. I.)... swertia chirayitaHabitat: Tropical India and the Andamans.
Ayurvedic: Guduuchi, Gudu- uchikaa, Guluuchi, Amrita, Am- ritaa, Amritalataa, Amritavalli, Chinnaruuhaa, Chinnodbhavaa, Madhuparni, Vatsaadani, Tantrikaa, Kundalini. Guduuchi sattva (starch).Unani: Gilo, Gulanchaa. Sat-e-Gilo (starch).Siddha: Seenil, Amrida-valli.Folk: Giloya.Action: Herb—antipyretic, an- tiperiodic, anti-inflammatory, antirheumatic, spasmolytic, hypo- glycaemic, hepatoprotective. Water extract increases urine output. Stem juice—prescribed in high fever; decoction in rheumatic and bilious fevers. Aqueous extract of the plant—fabrifuge. Starch—antacid, antidiarrhoeal and antidysenteric.
The Ayurvedic Pharmacopoeia of India, along with other therapeutic applications, recommends the dried stems in jaundice, anaemia, polyuria and skin diseases.The stem contains alkaloidal constituents, including berberine; bitter principles, including columbin, chas- manthin, palmarin and tinosporon, tinosporic acid and tinosporol.The drug is reported to possess one- fifth of the analgesic effect of sodium salicylate. Its aqueous extract has a high phagocytic index.Alcoholic extract of the stem shows activity against E. coli. Active principles were found to inhibit in vitro the growth of Mycobacterium tuberculosis.Oral administration of alcoholic extract of the root resulted in a significant reduction in blood and urine glucose and in lipids in serum and tissues of alloxan diabetic rats. (Phytother Res. 2003 17 (4), 410-3.)A significant reduction in levels of SGOT, SGPT, ALP and bilirubin were observed following T. cordifolia treatment during CCl4 intoxication in mature rats. (J. Toxicol Sci. 2002, 27 (3), 139-46.) The plant extract showed in vitro inactivating activity in Hepatitis- B surface antigen. (Indian Drugs, 1993, 30, 549.)A new hypoglycaemic agent was isolated from the plant; it was found to be 1,2-substituted pyrrolidine.The starch from roots and stem, used in chronic diarrhoea and dysentery, contains a polysaccharide having 1-4 glucan with occasional branching points.Dosage: Stem—3-6 g powder; 2030 g for decoction. (API, Vol. I.)... tinospora cordifoliaLouse 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
Habitat: Native to North Africa; commonly grown in North Western India.
English: Broad bean, Windsor bean.Unani: Baaqlaa.Action: Fresh beans—cooked alone or with meat, are prescribed in Unani medicine for cough, also for resolving inflammations. Externally, the bean and flowers are used as a poultice for inflammations, warts and burns.
A number of harmful principles are reported in the broad beans. A large amount of Dopa, mainly in free state and partly in the form of its beta- glucoside; and gluco alkaloids, vicine and convicine, have been isolated.Ingestion of fresh, uncooked or partially cooked beans is not recommended.The seeds gave positive test for hydrocyanic acid and also contain arsenic.The fresh beans exhibit an oestro- genic activity. Phytoalexins of the immature seeds exhibit antifungal activity.Malic, citric and glyceric acids are the principal organic acids present in the pods (also present in the hulls). The glyceric acid on subcutaneous injection produced a marked diuresis in rabbit. (A decoction of the leaves and stems of the field bean, Faba vulgaris Moench, is used as a diuretic.)An aqueous extract of the root nodules exhibited vasoconstricting activity on rabbits.... vicia fabaHabitat: This shrub, like the Alders and the Hazel, grows in bunches as high as eight or ten feet, and is found on high lands and the stony banks of streams.
Features ? The branches are flexuous and knotty, the bark smooth and grey with brown spots. The leaves are four to five inches long and about two inches broad, obovate; feather-veined, irregularly notched at the edges, smooth above and downy underneath. Yellow flowers appear in autumn, when the leaves are falling. Taste is astringent, and smell slight and agreeable.Part used ? Bark and leaves.Action: Astringent and tonic.
A decoction of the bark, which is more astringent than the leaves, checks external and internal hemorrhages, and this astringency, when in combination with the more specific principles of Pilewort, makes one of the most effective pile medicines known. The compound can be obtained in the form of both ointment and suppositories for external application. For varicose veins an extract of the fresh leaves and young twigs of Witch Hazel is applied on a lint bandage kept constantly moist.Both decoctions of the bark and infusions of the leaves are made in the proportion of 1 ounce to 1 pint boiling water (after simmering for ten minutes in the case of the bark decoction) and taken in wineglassful doses.... witch hazelHabitat: Native to Southeast Asia; now cultivated mainly in Kerala, Andhra Pradesh, Uttar Pradesh, West Bengal, Maharashtra.
English: Ginger.Ayurvedic: Fresh rhizome— Aardraka, Aadrikaa, Shrngibera, shrngavera, Katubhadra. Dried rhi- zome—Shunthi, Naagara, Naagaraa, Naagaraka, Aushadha, Mahaushad- ha, Vishvaa, Vishvabheshaja, Vishvaaushadha.Unani: Fresh rhizome—Zanjabeel- e-Ratab, Al-Zanjabeel. Dried rhizome—zanjabeel, Zanjabeel-e- yaabis.Siddha: Fresh rhizome—Inji, Allam, Lokottai. Dried rhizome— chukku, Sunthi.Action: Rhizome—antiemetic, antiflatulent, hypocholesterolaemic, anti-inflammatory, antispasmodic, expectorant, circulatory stimulant, diaphoretic, increases bioavailabil- ity of prescription drugs. Used for irritable bowel and diarrhoea, colds and influenza. Showed encouraging results in migraine and cluster headache (J Ethnophar- macol, 1990, 29, 267-273; Aust J Med Herbalism, 1995, 7/3, 6978; Natural Medicines Comprehensive Database, 2007.) The Ayurvedic Pharmacopoeia of India recommends dried rhizomes in dyspepsia, loss of appetite, tympanitis, anaemia, rheumatism, cough and dyspnoea; fresh rhizomes in constipation, colic, oedema and throat infections.
Key application: For dyspepsia and prevention of motion sickness (German Commission E); vomiting of pregnancy, anorexia, bronchitis and rheumatic complaints (The British Herbal Compendium); as a post-operative antiemetic. (ESCOP).The rhizome contains an essential oil containing monoterpenes, mainly geranial and neral; and sesquiterpenes, mainly beta-sesquiphellandrene, beta- bisabolene, ar-curcumene and alpha- zingiberene; pungent principles, consisting of gingerols, shogaols and related phenolic ketone derivatives. Other constituents include diarylheptenones, diterpenes, gingesulphonic acid and monoacyldigalactosyl glycerols.Gingerol and shogaol have been shown to suppress gastric contractions. Both fresh and dried rhizomes suppress gastric secretion and reduce vomiting. Gingerol and shogaol have gained importance due to their sedative, anti-inflammatory, antipyretic, analgesic, hypotensive and hepatopro- tective activities.Cardiotonic effects of ginger has been attributed to 6-and 8-shagaols and gingerols. (Antithrombotic effects remain unconfirmed.) Antimigraine effect is due to ginger's ability to decrease platelet aggregation. It also acts as a potent inhibitor of prostaglandins which enhance release of substance P from trigeminal fibers. (PDR, 2004.)Indian ginger is considered only second to Jamaican in quality.There are three main types of Indian ginger—Cochin ginger (light brown or yellowish grey; Calicut ginger from Malabar (orange or reddish brown, resembling African ginger) and Kolkata ginger (greyish brown to greyish blue).... zingiber officinaleCandida utilis is a highly active wild yeast able to synthesise its own vitamins. More than 90 selected plant species from 14 countries are used in Biostrath preparations. The Company has pioneered an important advance in the preparation of herbal medicines. Results have in some instances led to completely new discoveries. ... biostrath a. g.
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