A clinical symptom or circumstance indicating that the use of a particular intervention would be appropriate.
(2) the same observer gets di?erent results on successive occasions – intraobserver error; (3) di?erent observers produce di?erent results.... validity
This technique is used when normal methods of attempted CONCEPTION or ARTIFICIAL INSEMINATION with healthy SEMEN have failed. In the UK, assisted-conception procedures are governed by the Human Fertilisation & Embryology Act 1990, which set up the Human Fertilisation & Embryology Authority (HFEA).
Human Fertilisation & Embryology Act 1990 UK legislation was prompted by the report on in vitro fertilisation produced by a government-appointed committee chaired by Baroness Warnock. This followed the birth, in 1978, of the ?rst ‘test-tube’ baby.
This Act allows regulation monitoring of all treatment centres to ensure that they carry out treatment and research responsibly. It covers any fertilisation that uses donated eggs or sperm (called gametes) – for example, donor insemination or embryos (see EMBRYO) grown outside the human body (known as licensed treatment). The Act also covers research on human embryos with especial emphasis on foolproof labelling and immaculate data collection.
Human Fertilisation & EmbryologyAuthority (HFEA) Set up by the UK government following the Warnock report, the Authority’s 221 members inspect and license centres carrying out fertilisation treatments using donated eggs and sperm. It publishes a code of practice advising centres on how to conduct their activities and maintains a register of information on donors, patients and all treatments. It also reviews routinely progress and research in fertility treatment and the attempted development of human CLONING. Cloning to produce viable embryos (reproductive cloning) is forbidden, but limited licensing of the technique is allowed in specialist centres to enable them to produce cells for medical treatment (therapeutic cloning).
In vitro fertilisation (IVF) In this technique, the female partner receives drugs to enhance OVULATION. Just before the eggs are released from the ovary (see OVARIES), several ripe eggs are collected under ULTRASOUND guidance or through a LAPAROSCOPE. The eggs are incubated with the prepared sperm. About 40 hours later, once the eggs are fertilised, two eggs (three in special circumstances) are transferred into the mother’s UTERUS via the cervix (neck of the womb). Pregnancy should then proceed normally. About one in ?ve IVF pregnancies results in the birth of a child. The success rate is lower in women over 40.
Indications In women with severely damaged FALLOPIAN TUBES, IVF o?ers the only chance of pregnancy. The method is also used in couples with unexplained infertility or with male-factor infertility (where sperms are abnormal or their count low). Women who have had an early or surgically induced MENOPAUSE can become pregnant using donor eggs. A quarter of these pregnancies are multiple – that is, produce twins or more. Twins and triplets are more likely to be premature. The main danger of ovarian stimulation for IVF is hyperstimulation which can cause ovarian cysts. (See OVARIES, DISEASES OF.)... assisted conception
Circumcision in women is a damaging procedure, involving the removal of all or parts of the CLITORIS, LABIA majora and labia minora, sometimes combined with narowing of the entrance to the VAGINA. Total removal of the external female genitalia, including the clitoris, is called INFIBULATION. The result may be psychological and sexual problems and complications in childbirth, with no known bene?t to the woman’s health, though cultural pressures have resulted in its continuation in some Muslim and African countries, despite widespread condemnation of the practice and campaigns to stop it. It has been estimated that more than 80 million women in 30 countries have been circumcised.... circumcision
Insulin-dependent and non-insulindependent diabetes have a varied pathological pattern and are caused by the interaction of several genetic and environmental factors.
Insulin-dependent diabetes mellitus (IDDM) (juvenile-onset diabetes, type 1 diabetes) describes subjects with a severe de?ciency or absence of insulin production. Insulin therapy is essential to prevent KETOSIS – a disturbance of the body’s acid/base balance and an accumulation of ketones in the tissues. The onset is most commonly during childhood, but can occur at any age. Symptoms are acute and weight loss is common.
Non-insulin-dependent diabetes mellitus (NIDDM) (maturity-onset diabetes, type 2 diabetes) may be further sub-divided into obese and non-obese groups. This type usually occurs after the age of 40 years with an insidious onset. Subjects are often overweight and weight loss is uncommon. Ketosis rarely develops. Insulin production is reduced but not absent.
A new hormone has been identi?ed linking obesity to type 2 diabetes. Called resistin – because of its resistance to insulin – it was ?rst found in mice but has since been identi?ed in humans. Researchers in the United States believe that the hormone may, in part, explain how obesity predisposes people to diabetes. Their hypothesis is that a protein in the body’s fat cells triggers insulin resistance around the body. Other research suggests that type 2 diabetes may now be occurring in obese children; this could indicate that children should be eating a more-balanced diet and taking more exercise.
Diabetes associated with other conditions (a) Due to pancreatic disease – for example, chronic pancreatitis (see PANCREAS, DISORDERS OF); (b) secondary to drugs – for example, GLUCOCORTICOIDS (see PANCREAS, DISORDERS OF); (c) excess hormone production
– for example, growth hormone (ACROMEGALY); (d) insulin receptor abnormalities; (e) genetic syndromes (see GENETIC DISORDERS).
Gestational diabetes Diabetes occurring in pregnancy and resolving afterwards.
Aetiology Insulin-dependent diabetes occurs as a result of autoimmune destruction of beta cells within the PANCREAS. Genetic in?uences are important and individuals with certain HLA tissue types (HLA DR3 and HLA DR4) are more at risk; however, the risks associated with the HLA genes are small. If one parent has IDDM, the risk of a child developing IDDM by the age of 25 years is 1·5–2·5 per cent, and the risk of a sibling of an IDDM subject developing diabetes is about 3 per cent.
Non-insulin-dependent diabetes has no HLA association, but the genetic in?uences are much stronger. The risks of developing diabetes vary with di?erent races. Obesity, decreased exercise and ageing increase the risks of disease development. The risk of a sibling of a NIDDM subject developing NIDDM up to the age of 80 years is 30–40 per cent.
Diet Many NIDDM diabetics may be treated with diet alone. For those subjects who are overweight, weight loss is important, although often unsuccessful. A diet high in complex carbohydrate, high in ?bre, low in fat and aiming towards ideal body weight is prescribed. Subjects taking insulin need to eat at regular intervals in relation to their insulin regime and missing meals may result in hypoglycaemia, a lowering of the amount of glucose in the blood, which if untreated can be fatal (see below).
Oral hypoglycaemics are used in the treatment of non-insulin-dependent diabetes in addition to diet, when diet alone fails to control blood-sugar levels. (a) SULPHONYLUREAS act mainly by increasing the production of insulin;
(b) BIGUANIDES, of which only metformin is available, may be used alone or in addition to sulphonylureas. Metformin’s main actions are to lower the production of glucose by the liver and improve its uptake in the peripheral tissues.
Complications The risks of complications increase with duration of disease.
Diabetic hypoglycaemia occurs when amounts of glucose in the blood become low. This may occur in subjects taking sulphonylureas or insulin. Symptoms usually develop when the glucose concentration falls below 2·5 mmol/l. They may, however, occur at higher concentrations in subjects with persistent hyperglycaemia – an excess of glucose – and at lower levels in subjects with persistent hypo-glycaemia. Symptoms include confusion, hunger and sweating, with coma developing if blood-sugar concentrations remain low. Re?ned sugar followed by complex carbohydrate will return the glucose concentration to normal. If the subject is unable to swallow, glucagon may be given intramuscularly or glucose intravenously, followed by oral carbohydrate, once the subject is able to swallow.
Although it has been shown that careful control of the patient’s metabolism prevents late complications in the small blood vessels, the risk of hypoglycaemia is increased and patients need to be well motivated to keep to their dietary and treatment regime. This regime is also very expensive. All risk factors for the patient’s cardiovascular system – not simply controlling hyperglycaemia – may need to be reduced if late complications to the cardiovascular system are to be avoided.
Diabetes is one of the world’s most serious health problems. Recent projections suggest that the disorder will affect nearly 240 million individuals worldwide by 2010 – double its prevalence in 1994. The incidence of insulin-dependent diabetes is rising in young children; they will be liable to develop late complications.
Although there are complications associated with diabetes, many subjects live normal lives and survive to an old age. People with diabetes or their relatives can obtain advice from Diabetes UK (www.diabetes.org.uk).
Increased risks are present of (a) heart disease, (b) peripheral vascular disease, and (c) cerebrovascular disease.
Diabetic eye disease (a) retinopathy, (b) cataract. Regular examination of the fundus enables any abnormalities developing to be detected and treatment given when appropriate to preserve eyesight.
Nephropathy Subjects with diabetes may develop kidney damage which can result in renal failure.
Neuropathy (a) Symmetrical sensory polyneuropathy; damage to the sensory nerves that commonly presents with tingling, numbness of pain in the feet or hands. (b) Asymmetrical motor diabetic neuropathy, presenting as progressive weakness and wasting of the proximal muscles of legs. (c) Mononeuropathy; individual motor or sensory nerves may be affected. (d) Autonomic neuropathy, which affects the autonomic nervous system, has many presentations including IMPOTENCE, diarrhoea or constipation and postural HYPOTENSION.
Skin lesions There are several skin disorders associated with diabetes, including: (a) necrobiosis lipoidica diabeticorum, characterised by one or more yellow atrophic lesions on the legs;
(b) ulcers, which most commonly occur on the feet due to peripheral vascular disease, neuropathy and infection. Foot care is very important.
Diabetic ketoacidosis occurs when there is insu?cient insulin present to prevent KETONE production. This may occur before the diagnosis of IDDM or when insu?cient insulin is being given. The presence of large amounts of ketones in the urine indicates excess ketone production and treatment should be sought immediately. Coma and death may result if the condition is left untreated.
Symptoms Thirst, POLYURIA, GLYCOSURIA, weight loss despite eating, and recurrent infections (e.g. BALANITIS and infections of the VULVA) are the main symptoms.
However, subjects with non-insulindependent diabetes may have the disease for several years without symptoms, and diagnosis is often made incidentally or when presenting with a complication of the disease.
Treatment of diabetes aims to prevent symptoms, restore carbohydrate metabolism to as near normal as possible, and to minimise complications. Concentration of glucose, fructosamine and glycated haemoglobin in the blood are used to give an indication of blood-glucose control.
Insulin-dependent diabetes requires insulin for treatment. Non-insulin-dependent diabetes may be treated with diet, oral HYPOGLYCAEMIC AGENTS or insulin.
Insulin All insulin is injected – mainly by syringe but sometimes by insulin pump – because it is inactivated by gastrointestinal enzymes. There are three main types of insulin preparation: (a) short action (approximately six hours), with rapid onset; (b) intermediate action (approximately 12 hours); (c) long action, with slow onset and lasting for up to 36 hours. Human, porcine and bovine preparations are available. Much of the insulin now used is prepared by genetic engineering techniques from micro-organisms. There are many regimens of insulin treatment involving di?erent combinations of insulin; regimens vary depending on the requirements of the patients, most of whom administer the insulin themselves. Carbohydrate intake, energy expenditure and the presence of infection are important determinants of insulin requirements on a day-to-day basis.
A new treatment for diabetes, pioneered in Canada and entering its preliminary clinical trials in the UK, is the transplantation of islet cells of Langerhans from a healthy person into a patient with the disorder. If the transplantation is successful, the transplanted cells start producing insulin, thus reducing or eliminating the requirement for regular insulin injections. If successful the trials would be a signi?cant advance in the treatment of diabetes.
Scientists in Israel have developed a drug, Dia Pep 277, which stops the body’s immune system from destroying pancratic ? cells as happens in insulin-dependent diabetes. The drug, given by injection, o?ers the possibility of preventing type 1 diabetes in healthy people at genetic risk of developing the disorder, and of checking its progression in affected individuals whose ? cells are already perishing. Trials of the drug are in progress.... diabetes mellitus
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
Computed tomography can distinguish soft tissues from cysts or fat, but in general soft-tissue masses have similar appearances, so that distinguishing an in?ammatory mass from a malignant process may be impossible. The technique is particularly useful in patients with suspected malignancy; it can also de?ne the extent of the cancer by detecting enlarged lymph nodes, indicating lymphatic spread. The main indications for computed tomography of the body are: mediastinal masses, suspected pulmonary metastases, adrenal disease, pancreatic masses, retroperitoneal lymph nodes, intra-abdominal abscesses, orbital tumours and the staging of cancer as a guide to e?ective treatment.... computed tomography
The Department of Health has drawn up a list of suitable eye-banks to which people can apply to bequeath their eyes, and an o?cial form is now available for the bequest of eyes. (See also DONORS; TRANSPLANTATION.)... corneal graft
The two most common causes of death in the UK are diseases of the circulatory system (including strokes and heart disease) and cancer.
Overall annual death rates among women in the UK at the start of the 21st century were
7.98 per 1,000 population, and among men,
5.58 per 1,000. Comparable ?gures at the start of the 20th century were 16.3 for women and
18.4 for men. The death rates in 1900 among infants up to the age of four were 47.9 per 1,000 females and 57 per 1,000 males. By 2003 these numbers had fallen to 5.0 and 5.8 respectively. All these ?gures give a crude indication of how the health of Britain’s population has improved in the past century.
Death rates and ?gures on the causes of deaths are essential statistics in the study of EPIDEMIOLOGY which, along with information on the incidence of illnesses and injuries, provides a temporal and geographical map of changing health patterns in communities. Such information is valuable in planning preventive health measures (see PUBLIC HEALTH) and in identifying the natural history of diseases – knowledge that often contributes to the development of preventive measures and treatments for those diseases.... death, causes of
Causes They may be the result of intense emotion or suggestion, sensory deprivation (for example, overwork or lack of sleep), disorders of sense organs, or disorders of the central nervous system. Although hallucinations may occur in perfectly sane people, they are more commonly an indication of a MENTAL ILLNESS. They may be deliberately induced by the use of HALLUCINOGENS.... hallucinations
Pregnancy lasts about 280 days and is calculated from the ?rst day of the last menstrual period – see MENSTRUATION. Pregnancy-testing kits rely on the presence of the hormone beta HUMAN CHORIONIC GONADOTROPHIN (b HCG) which is excreted in the woman’s urine as early as 30 days from the last menstrual period. The estimated date of delivery can be accurately estimated from the size of the developing fetus measured by ULTRASOUND (see also below) between seven and 24 weeks. ‘Term’ refers to the time that the baby is due; this can range from 38 weeks to 41 completed weeks.
Physical changes occur in early pregnancy – periods stop and the abdomen enlarges. The breasts swell, with the veins becoming prominent and the nipples darkening. About two in three women will have nausea with a few experiencing such severe vomiting as to require hospital admission for rehydration.
Antenatal care The aim of antenatal care is to ensure a safe outcome for both mother and child; it is provided by midwives (see MIDWIFE) and doctors. Formal antenatal care began in Edinburgh in the 1930s with the recognition that all aspects of pregnancy – normal and abnormal – warranted surveillance. Cooperation between general practitioners, midwives and obstetricians is now established, with pregnancies that are likely to progress normally being cared for in the community and only those needing special intervention being cared for in a hospital setting.
The initial visit (or booking) in the ?rst half of pregnancy will record the history of past events and the results of tests, with the aim of categorising the patients into normal or not. Screening tests including blood checks and ultrasound scans are a routine part of antenatal care. The ?rst ultrasound scan is done at about 11 weeks to date the pregnancy, with a further one done at 20 weeks – the anomaly scan – to assess the baby’s structure. Some obstetric units will check the growth of the baby with one further scan later in the pregnancy or, in the case of twin pregnancies (see below), many scans throughout. The routine blood tests include checks for ANAEMIA, DIABETES MELLITUS, sickle-cell disease and THALASSAEMIA, as well as for the blood group. Evidence of past infections is also looked for; tests for RUBELLA (German measles) and SYPHILIS are routine, whereas tests for human immunode?ciency virus (see AIDS/ HIV below) and HEPATITIS are being o?ered as optional, although there is compelling evidence that knowledge of the mother’s infection status is bene?cial to the baby.
Traditional antenatal care consists of regular appointments, initially every four weeks until 34 weeks, then fortnightly or weekly. At each visit the mother’s weight, urine and blood pressure are checked, and assessment of fetal growth and position is done by palpating the uterus. Around two-thirds of pregnancies and labours are normal: in the remainder, doctors and midwives need to increase the frequency of surveillance so as to prevent or deal with maternal and fetal problems.
Common complications of pregnancy
Some of the more common complications of pregnancy are listed below.
As well as early detection of medical complications, antenatal visits aim to be supportive and include emotional and educational care. Women with uncomplicated pregnancies are increasingly being managed by midwives and general practitioners in the community and only coming to the hospital doctors should they develop a problem. A small number will opt for a home delivery, but facilities for providing such a service are not always available in the UK.
Women requiring more intensive surveillance have their management targeted to the speci?c problems encountered. Cardiologists will see mothers-to-be with heart conditions, and those at risk of diabetes are cared for in designated clinics with specialist sta?. Those women needing more frequent surveillance than standard antenatal care can be looked after in maternity day centres. These typically include women with mildly raised blood pressure or those with small babies. Fetal medicine units have specialists who are highly skilled in ultrasound scanning and specialise in the diagnosis and management of abnormal babies still in the uterus. ECTOPIC PREGNANCY Chronic abdominal discomfort early in pregnancy may be caused by unruptured ectopic pregnancy, when, rarely, the fertilised OVUM starts developing in the Fallopian tube (see FALLOPIAN TUBES) instead of the uterus. The patient needs hospital treatment and LAPAROSCOPY. A ruptured ectopic pregnancy causes acute abdominal symptoms and collapse, and the woman will require urgent abdominal surgery. URINARY TRACT INFECTIONS These affect around 2 per cent of pregnant women and are detected by a laboratory test of a mid-stream specimen of urine. In pregnancy, symptoms of these infections do not necessarily resemble those experienced by non-pregnant women. As they can cause uterine irritability and possible premature labour (see below), it is important to ?nd and treat them appropriately. ANAEMIA is more prevalent in patients who are vegetarian or on a poor diet. Iron supplements are usually given to women who have low concentrations of HAEMOGLOBIN in their blood (less than 10.5 g/dl) or who are at risk of becoming low in iron, from bleeding, twin pregnancies and those with placenta previa (see below). ANTEPARTUM HAEMORRHAGE Early in pregnancy, vaginal bleedings may be due to a spontaneous or an incomplete therapeutic ABORTION. Bleeding from the genital tract between 24 completed weeks of pregnancy and the start of labour is called antepartum haemorrhage. The most common site is where the PLACENTA is attached to the wall of the uterus. If the placenta separates before delivery, bleeding occurs in the exposed ‘bed’. When the placenta is positioned in the upper part of the uterus it is called an abruption. PLACENTA PRAEVIA is sited in the lower part and blocks or partly blocks the cervix (neck of the womb); it can be identi?ed at about the 34th week. Ten per cent of episodes of antepartum bleeding are caused by placenta previa, and it may be associated with bleeding at delivery. This potentially serious complication is diagnosed by ultrasound scanning and may require a caesarean section (see below) at delivery. INCREASED BLOOD PRESSURE, associated with protein in the urine and swelling of the limbs, is part of a condition known as PRE-ECLAMPSIA. This occurs in the second half of pregnancy in about 1 in 10 women expecting their ?rst baby, and is mostly very mild and of no consequence to the pregnancy. However, some women can develop extremely high blood pressures which can adversely affect the fetus and cause epileptic-type seizures and bleeding disorders in the mother. This serious condition is called ECLAMPSIA. For this reason a pregnant woman with raised blood pressure or PROTEIN in her urine is carefully evaluated with blood tests, often in the maternity day assessment unit. The condition can be stopped by delivery of the baby, and this will be done if the mother’s or the fetus’s life is in danger. If the condition is milder, and the baby not mature enough for a safe delivery, then drugs can be used to control the blood pressure. MISCARRIAGE Also called spontaneous abortion, miscarriage is the loss of the fetus. There are several types:
threatened miscarriage is one in which some vaginal bleeding occurs, the uterus is enlarged, but the cervix remains closed and pregnancy usually proceeds.
inevitable miscarriage usually occurs before the 16th week and is typi?ed by extensive blood loss through an opened cervix and cramp-like abdominal pain; some products of conception are lost but the developing placental area (decidua) is retained and an operation may be necessary to clear the womb.
missed miscarriages, in which the embryo dies and is absorbed, but the decidua (placental area of uterine wall) remains and may cause abdominal discomfort and discharge of old blood.
THERAPEUTIC ABORTION is performed on more than 170,000 women annually in England and Wales. Sometimes the woman may not have arranged the procedure through the usual health-care channels, so that a doctor may see a patient with vaginal bleeding, abdominal discomfort or pain, and open cervix – symptoms which suggest that the decidua and a blood clot have been retained; these retained products will need to be removed by curettage.
Septic abortions are now much less common in Britain than before the Abortion Act (1967) permitted abortion in speci?ed circumstances. The cause is the passage of infective organisms from the vagina into the uterus, with Escherichia coli and Streptococcus faecalis the most common pathogenic agents. The woman has abdominal pain, heavy bleeding, usually fever and sometimes she is in shock. The cause is usually an incomplete abortion or one induced in unsterile circumstances. Antibiotics and curettage are the treatment. INTRAUTERINE GROWTH RETARDATION describes a slowing of the baby’s growth. This can be diagnosed by ultrasound scanning, although there is a considerable margin of error in estimates of fetal weight. Trends in growth are favoured over one-o? scan results alone. GESTATIONAL DIABETES is a condition that is more common in women who are overweight or have a family member with diabetes. If high concentrations of blood sugar are found, e?orts are made to correct it as the babies can become very fat (macrosomia), making delivery more di?cult. A low-sugar diet is usually enough to control the blood concentration of sugars; however some women need small doses of INSULIN to achieve control. FETAL ABNORMALITIES can be detected before birth using ultrasound. Some of these defects are obvious, such as the absence of kidneys, a condition incompatible with life outside the womb. These women can be o?ered a termination of their pregnancy. However, more commonly, the pattern of problems can only hint at an abnormality and closer examination is needed, particularly in the diagnosis of chromosomal deformities such as DOWN’S (DOWN) SYNDROME (trisomy 21 or presence of three 21 chromosomes instead of two).
Chromosomal abnormalities can be de?nitively diagnosed only by cell sampling such as amniocentesis (obtaining amniotic ?uid – see AMNION – from around the baby) done at 15 weeks onwards, and chorionic villus sampling (sampling a small part of the placenta) – another technique which can be done from 12 weeks onwards. Both have a small risk of miscarriage associated with them; consequently, they are con?ned to women at higher risk of having an abnormal fetus.
Biochemical markers present in the pregnant woman’s blood at di?erent stages of pregnancy may have undergone changes in those carrying an abnormal fetus. The ?rst such marker to be routinely used was a high concentration of alpha-fetol protein in babies with SPINA BIFIDA (defects in the covering of the spinal cord). Fuller research has identi?ed a range of diagnostic markers which are useful, and, in conjunction with other factors such as age, ethnic group and ultrasound ?ndings, can provide a predictive guide to the obstetrician – in consultation with the woman – as to whether or not to proceed to an invasive test. These tests include pregnancy-associated plasma protein assessed from a blood sample taken at 12 weeks and four blood tests at 15–22 weeks – alphafetol protein, beta human chorionic gonadotrophin, unconjugated oestriol and inhibin A. Ultrasound itself can reveal physical ?ndings in the fetus, which can be more common in certain abnormalities. Swelling in the neck region of an embryo in early pregnancy (increased nuchal thickness) has good predictive value on its own, although its accuracy is improved in combination with the biochemical markers. The e?ectiveness of prenatal diagnosis is rapidly evolving, the aim being to make the diagnosis as early in the pregnancy as possible to help the parents make more informed choices. MULTIPLE PREGNANCIES In the UK, one in 95 deliveries is of twins, while the prevalence of triplets is one in 10,000 and quadruplets around one in 500,000. Racial variations occur, with African women having a prevalence rate of one in 30 deliveries for twins and Japanese women a much lower rate than the UK ?gure. Multiple pregnancies occur more often in older women, and in the UK the prevalence of fertility treatments, many of these being given to older women, has raised the incidence. There is now an o?cial limit of three eggs being transferred to a woman undergoing ASSISTED CONCEPTION (gamete intrafallopian transfer, or GIFT).
Multiple pregnancies are now usually diagnosed as a result of routine ultrasound scans between 16 and 20 weeks of pregnancy. The increased size of the uterus results in the mother having more or worse pregnancy-related conditions such as nausea, abdominal discomfort, backache and varicose veins. Some congenital abnormalities in the fetus occur more frequently in twins: NEURAL TUBE defects, abnormalities of the heart and the incidence of TURNER’S SYNDROME and KLINEFELTER’S SYNDROME are examples. Such abnormalities may be detected by ultrasound scans or amniocentesis. High maternal blood pressure and anaemia are commoner in women with multiple pregnancies (see above).
The growth rates of multiple fetuses vary, but the di?erence between them and single fetuses are not that great until the later stages of pregnancy. Preterm labour is commoner in multiple pregnancies: the median length of pregnancy is 40 weeks for singletons, 37 for twins and 33 for triplets. Low birth-weights are usually the result of early delivery rather than abnormalities in growth rates. Women with multiple pregnancies require more frequent and vigilant antenatal assessments, with their carers being alert to the signs of preterm labour occurring. CEPHALOPELVIC DISPROPORTION Disparity between the size of the fetus and the mother’s pelvis is not common in the UK but is a signi?cant problem in the developing world. Disparity is classi?ed as absolute, when there is no possibility of delivery, and relative, when the baby is large but delivery (usually after a dif?cult labour) is possible. Causes of absolute disparity include: a large baby – heavier than 5 kg at birth; fetal HYDROCEPHALUS; and an abnormal maternal pelvis. The latter may be congenital, the result of trauma or a contraction in pelvic size because of OSTEOMALACIA early in life. Disproportion should be suspected if in late pregnancy the fetal head has not ‘engaged’ in the pelvis. Sometimes a closely supervised ‘trial of labour’ may result in a successful, if prolonged, delivery. Otherwise a caesarean section (see below) is necessary. UNUSUAL POSITIONS AND PRESENTATIONS OF THE BABY In most pregnant women the baby ?ts into the maternal pelvis head-?rst in what is called the occipito-anterior position, with the baby’s face pointing towards the back of the pelvis. Sometimes, however, the head may face the other way, or enter the pelvis transversely – or, rarely, the baby’s neck is ?exed backwards with the brow or face presenting to the neck of the womb. Some malpositions will correct naturally; others can be manipulated abdominally during pregnancy to a better position. If, however, the mother starts labour with the baby’s head badly positioned or with the buttocks instead of the head presenting (breech position), the labour will usually be longer and more di?cult and may require intervention using special obstetric forceps to assist in extracting the baby. If progress is poor and the fetus distressed, caesarean section may be necessary. HIV INFECTION Pregnant women who are HIV positive (see HIV; AIDS/HIV) should be taking antiviral drugs in the ?nal four to ?ve months of pregnancy, so as to reduce the risk of infecting the baby in utero and during birth by around 50 per cent. Additional antiviral treatment is given before delivery; the infection risk to the baby can be further reduced – by about 40 per cent – if delivery is by caesarean section. The mother may prefer to have the baby normally, in which case great care should be taken not to damage the baby’s skin during delivery. The infection risk to the baby is even further reduced if it is not breast fed. If all preventive precautions are taken, the overall risk of the infant becoming infected is cut to under 5 per cent.
Premature birth This is a birth that takes place before the end of the normal period of gestation, usually before 37 weeks. In practice, however, it is de?ned as a birth that takes place when the baby weighs less than 2·5 kilograms (5••• pounds). Between 5 and 10 per cent of babies are born prematurely, and in around 40 per cent of premature births the cause is unknown. Pre-eclampsia is the most common known cause; others include hypertension, chronic kidney disease, heart disease and diabetes mellitus. Multiple pregnancy is another cause. In the vast majority of cases the aim of management is to prolong the pregnancy and so improve the outlook for the unborn child. This consists essentially of rest in bed and sedation, but there are now several drugs, such as RITODRINE, that may be used to suppress the activity of the uterus and so help to delay premature labour. Prematurity was once a prime cause of infant mortality but modern medical care has greatly improved survival rates in developing countries.
Labour Also known by the traditional terms parturition, childbirth or delivery, this is the process by which the baby and subsequently the placenta are expelled from the mother’s body. The onset of labour is often preceded by a ‘show’ – the loss of the mucus and blood plug from the cervix, or neck of the womb; this passes down the vagina to the exterior. The time before the beginning of labour is called the ‘latent phase’ and characteristically lasts 24 hours or more in a ?rst pregnancy. Labour itself is de?ned by regular, painful contractions which cause dilation of the neck of the womb and descent of the fetal head. ‘Breaking of the waters’ is the loss of amniotic ?uid vaginally and can occur any time in the delivery process.
Labour itself is divided into three stages: the ?rst is from the onset of labour to full (10 cm) dilation of the neck of the womb. This stage varies in length, ideally taking no more than one hour per centimetre of dilation. Progress is monitored by regular vaginal examinations, usually every four hours. Fetal well-being is observed by intermittent or continuous monitoring of the fetal heart rate in relation to the timing and frequency of the contractions. The print-out is called a cardiotocograph. Abnormalities of the fetal heart rate may suggest fetal distress and may warrant intervention. In women having their ?rst baby (primigravidae), the common cause of a slow labour is uncoordinated contractions which can be overcome by giving either of the drugs PROSTAGLANDIN or OXYTOCIN, which provoke contractions of the uterine muscle, by an intravenous drip. Labours which progress slowly or not at all may be due to abnormal positioning of the fetus or too large a fetus, when prostaglandin or oxytocin is used much more cautiously.
The second stage of labour is from full cervical dilation to the delivery of the baby. At this stage the mother often experiences an irresistible urge to push the baby out, and a combination of strong coordinated uterine contractions and maternal e?ort gradually moves the baby down the birth canal. This stage usually lasts under an hour but can take longer. Delay, exhaustion of the mother or distress of the fetus may necessitate intervention by the midwife or doctor. This may mean enlarging the vaginal opening with an EPISIOTOMY (cutting of the perineal outlet – see below) or assisting the delivery with specially designed obstetric forceps or a vacuum extractor (ventouse). If the cervix is not completely dilated or open and the head not descended, then an emergency caesarean section may need to be done to deliver the baby. This procedure involves delivering the baby and placenta through an incision in the mother’s abdomen. It is sometimes necessary to deliver by planned or elective caesarean section: for example, if the placenta is low in the uterus – called placenta praevia – making a vaginal delivery dangerous.
The third stage occurs when the placenta (or afterbirth) is delivered, which is usually about 10–20 minutes after the baby. An injection of ergometrine and oxytocin is often given to women to prevent bleeding.
Pain relief in labour varies according to the mother’s needs. For uncomplicated labours, massage, reassurance by a birth attendant, and a warm bath and mobilisation may be enough for some women. However, some labours are painful, particularly if the woman is tired or anxious or is having her ?rst baby. In these cases other forms of analgesia are available, ranging from inhalation of NITROUS OXIDE GAS, injection of PETHIDINE HYDROCHLORIDE or similar narcotic, and regional local anaesthetic (see ANAESTHESIA).
Once a woman has delivered, care continues to ensure her and the baby’s safety. The midwives are involved in checking that the uterus returns to its normal size and that there is no infection or heavy bleeding, as well as caring for stitches if needed. The normal blood loss after birth is called lochia and generally is light, lasting up to six weeks. Midwives o?er support with breast feeding and care of the infant and will visit the parents at home routinely for up to two weeks.
Some complications of labour All operative deliveries in the UK are now done in hospitals, and are performed if a spontaneous birth is expected to pose a bigger risk to the mother or her child than a specialist-assisted one. Operative deliveries include caesarean section, forceps-assisted deliveries and those in which vacuum extraction (ventouse) is used. CAESAREAN SECTION Absolute indications for this procedure, which is used to deliver over 15 per cent of babies in Britain, are cephalopelvic disproportion and extensive placenta praevia, both discussed above. Otherwise the decision to undertake caesarean section depends on the clinical judgement of the specialist and the views of the mother. The rise in the proportion of this type of intervention (from 5 per cent in the 1930s to its present level of over 23 per cent
P
of the 600,000 or so annual deliveries in England) has been put down to defensive medicine
– namely, the doctor’s fear of litigation (initiated often because the parents believe that the baby’s health has suffered because the mother had an avoidably di?cult ‘natural’ labour). In Britain, over 60 per cent of women who have had a caesarean section try a vaginal delivery in a succeeding pregnancy, with about two-thirds of these being successful. Indications for the operation include:
absolute and relative cephalopelvic disproportion.
placenta previa.
fetal distress.
prolapsed umbilical cord – this endangers the viability of the fetus because the vital supply of oxygen and nutrients is interrupted.
malpresentation of the fetus such as breech or transverse lie in the womb.
unsatisfactory previous pregnancies or deliveries.
a request from the mother.
Caesarean sections are usually performed using regional block anaesthesia induced by a spinal or epidural injection. This results in loss of feeling in the lower part of the body; the mother is conscious and the baby not exposed to potential risks from volatile anaesthetic gases inhaled by the mother during general anaesthesia. Post-operative complications are higher with general anaesthesia, but maternal anxiety and the likelihood that the operation might be complicated and di?cult are indications for using it. A general anaesthetic may also be required for an acute obstetric emergency. At operation the mother’s lower abdomen is opened and then her uterus opened slowly with a transverse incision and the baby carefully extracted. A transverse incision is used in preference to the traditional vertical one as it enables the woman to have a vaginal delivery in any future pregnancy with a much smaller risk of uterine rupture. Women are usually allowed to get up within 24 hours and are discharged after four or ?ve days. FORCEPS AND VENTOUSE DELIVERIES Obstetric forceps are made in several forms, but all are basically a pair of curved blades shaped so that they can obtain a purchase on the baby’s head, thus enabling the operator to apply traction and (usually) speed up delivery. (Sometimes they are used to slow down progress of the head.) A ventouse or vacuum extractor comprises an egg-cup-shaped metal or plastic head, ranging from 40 to 60 mm in diameter with a hollow tube attached through which air is extracted by a foot-operated vacuum pump. The instrument is placed on the descending head, creating a negative pressure on the skin of the scalp and enabling the operator to pull the head down. In mainland Europe, vacuum extraction is generally preferred to forceps for assisting natural deliveries, being used in around 5 per cent of all deliveries. Forceps have a greater risk of causing damage to the baby’s scalp and brain than vacuum extraction, although properly used, both types should not cause any serious damage to the baby.
Episiotomy Normal and assisted deliveries put the tissues of the genital tract under strain. The PERINEUM is less elastic than the vagina and, if it seems to be splitting as the baby’s head
moves down the birth canal, it may be necessary to cut the perineal tissue – a procedure called an episiotomy – to limit damage. This is a simple operation done under local anaesthetic. It should be done only if there is a speci?c indication; these include:
to hasten the second stage of labour if the fetus is distressed.
to facilitate the use of forceps or vacuum extractor.
to enlarge a perineum that is restricted because of unyielding tissue, perhaps because of a scar from a previous labour. Midwives as well as obstetricians are trained
to undertake and repair (with sutures) episiotomies.
(For organisations which o?er advice and information on various aspects of childbirth, including eclampsia, breast feeding and multiple births, see APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELF-HELP.)... pregnancy and labour
Major diet-related health problems in prosperous communities tend to be the result of dietary excesses, whereas in underdeveloped, poor communities, problems associated with dietary de?ciencies predominate. Excessive intakes of dietary energy, saturated fats, sugar, salt and alcohol, together with an inadequate intake of dietary ?bre, have been linked to the high prevalence of OBESITY, cardiovascular disease, dental caries, HYPERTENSION, gall-stones (see GALL-BLADDER, DISEASES OF), non-insulindependent DIABETES MELLITUS and certain cancers (e.g. of the breast, endometrium, intestine and stomach) seen in developed nations. Health-promotion strategies in these countries generally advocate a reduction in the intake of fat, particularly saturated fat, and salt, the avoidance of excessive intakes of alcohol and simple sugars, an increased consumption of starch and ?bre and the avoidance of obesity by taking appropriate physical exercise. A maximum level of dietary cholesterol is sometimes speci?ed.
Undernutrition, including protein-energy malnutrition and speci?c vitamin and mineral de?ciencies, is an important cause of poor health in underdeveloped countries. Priorities here centre on ensuring that the diet provides enough nutrients to maintain health.
In healthy people, dietary requirements depend on age, sex and level of physical activity. Pregnancy and lactation further alter requirements. The presence of infections, fever, burns, fractures and surgery all increase dietary energy and protein requirements and can precipitate undernutrition in previously well-nourished people.
In addition to disease prevention, diet has a role in the treatment of certain clinical disorders, for example, obesity, diabetes mellitus, HYPERLIPIDAEMIA, inborn errors of metabolism, food intolerances and hepatic and renal diseases. Therapeutic diets increase or restrict the amount and/or change the type of fat, carbohydrate, protein, ?bre, vitamins, minerals and/or water in the diet according to clinical indications. Additionally, the consistency of the food eaten may need to be altered. A commercially available or ‘homemade’ liquid diet can be used to provide all or some of a patient’s nutritional needs if necessary. Although the enteral (by mouth) route is the preferred route for feeding and can be used for most patients, parenteral or intravenous feeding is occasionally required in a minority of patients whose gastrointestinal tract is unavailable or unreliable over a period of time.
A wide variety of weight-reducing diets are well publicised. People should adopt them with caution and, if in doubt, seek expert advice.... diet
Because of its possible toxic effects – including kidney damage – lithium must only be administered under medical supervision and with monitoring of the blood levels, as the gap between therapeutic and toxic concentrations is narrow. Due to the risk of its damaging the unborn child, it should not be prescribed, unless absolutely necessary, during pregnancy – particularly not in the ?rst three months. Mothers should not take it while breast feeding, as it is excreted in the milk in high concentrations. The drug should not be taken with DIURETICS.... lithium carbonate
A researcher has suggested a link between the vaccine and AUTISM, but massive studies of children with and without this condition in several countries have failed to ?nd any evidence to back the claim. Nonetheless, the publicity war has been largely lost by the UK health departments so that vaccine rates have dropped to a worryingly low level.
(See IMMUNISATION.)... mmr vaccine
Structure Each tooth is composed of enamel, dentine, cement, pulp and periodontal membrane. ENAMEL is the almost translucent material which covers the crown of a tooth. It is the most highly calci?ed material in the body, 96–97 per cent being composed of calci?ed salts. It is arranged from millions of long, six-sided prisms set on end on the dentine (see below), and is thickest over the biting surface of the tooth. With increasing age or the ingestion of abrasive foods the teeth may be worn away on the surface, so that the dentine becomes visible. The outer sides of some teeth may be worn away by bad tooth-brushing technique. DENTINE is a dense yellowish-white material from which the bulk and the basic shape of a tooth are formed. It is like ivory and is harder than bone but softer than enamel. The crown of the tooth is covered by the hard protective enamel and the root is covered by a bone-like substance called cement. Decay can erode dentine faster than enamel (see TEETH, DISORDERS OF – Caries of the teeth). CEMENT or cementum is a thin bone-like material which covers the roots of teeth and helps hold them in the bone. Fibres of the periodontal membrane (see below) are embedded in the cement and the bone. When the gums recede, part of the cement may be exposed and the cells die. Once this has happened, the periodontal membrane can no longer be attached to the tooth and, if su?cient cement is destroyed, the tooth-support will be so weakened that the tooth will become loose. PULP This is the inner core of the tooth and is
composed of a highly vascular, delicate ?brous tissue with many ?ne nerve-?bres. The pulp is very sensitive to temperature variation and to touch. If the pulp becomes exposed it will become infected and usually cannot overcome this. Root-canal treatment or extraction of the tooth may be necessary. PERIODONTAL MEMBRANE This is a layer of ?brous tissue arranged in groups of ?bres which surround and support the root of a tooth in a bone socket. The ?bres are interspersed with blood vessels and nerves. Loss of the membrane leads to loss of the tooth. The membrane can release and re-attach the ?bres to allow the tooth to move when it erupts, or (to correct dental deformities) is being moved by orthodontic springs.
Arrangement and form Teeth are present in most mammals and nearly all have two sets: a temporary or milk set, followed by a permanent or adult set. In some animals, like the toothed whale, all the teeth are similar; but in humans there are four di?erent shapes: incisors, canines (eye-teeth), premolars (bicuspids), and molars. The incisors are chisel-shaped and the canine is pointed. Premolars have two cusps on the crown (one medial to the other) and molars have at least four cusps. They are arranged together in an arch in each jaw and the
cusps of opposing teeth interdigitate. Some herbivores have no upper anterior teeth but use a pad of gum instead. As each arch is symmetrical, the teeth in an upper and lower quadrant can be used to identify the animal. In humans, the quadrants are the same: in other words, in the child there are two incisors, one canine and two molars (total teeth 20); in the adult there are two incisors, one canine, two premolars and three molars (total 32). This mixture of tooth-form suggests that humans are omnivorous. Anatomically the crown of the tooth has mesial and distal surfaces which touch the tooth next to it. The mesial surface is the one nearer to the centre line and the distal is the further away. The biting surface is called the incisal edge for the anterior teeth and the occlusal surface for the posteriors.
Development The ?rst stage in the formation of the teeth is the appearance of a down-growth of EPITHELIUM into the underlying mesoderm. This is the dental lamina, and from it ten smaller swellings in each jaw appear. These become bell-shaped and enclose a part of the mesoderm, the cells of which become specialised and are called the dental papillae. The epithelial cells produce enamel and the dental papilla forms the dentine, cement and pulp. At a ?xed time the teeth start to erupt and a root is formed. Before the deciduous teeth erupt, the permanent teeth form, medial to them. In due course the deciduous roots resorb and the permanent teeth are then able to push the crowns out and erupt themselves. If this process is disturbed, the permanent teeth may be displaced and appear in an abnormal position or be impacted.
Eruption of teeth is in a de?nite order and at a ?xed time, although there may be a few months’ leeway in either direction which is of no signi?cance. Excessive delay is found in some congenital disorders such as CRETINISM. It may also be associated with local abnormalities of the jaws such as cysts, malformed teeth and supernumerary teeth.
The usual order of eruption of deciduous teeth is:
Middle incisors 6–8 months Lateral incisors 8–10 months First molars 12–16 months Canines (eye-teeth) 16–20 months Second molars 20–30 months
The usual order of eruption of permanent teeth is:
First molars 6–7 years Middle incisors 6–8 years Lateral incisors 7–9 years Canines 9–12 years First and second premolars 10–12 years Second molars 11–13 years Third molars (wisdom teeth) 17–21 years
The permanent teeth of the upper (top) and lower (bottom) jaws.
Teeth, Disorders of
Teething, or the process of eruption of the teeth in infants, may be accompanied by irritability, salivation and loss of sleep. The child will tend to rub or touch the painful area. Relief may be obtained in the child by allowing it to chew on a hard object such as a toy or rusk. Mild ANALGESICS may be given if the child is restless and wakens in the night. A serious pitfall is to assume that an infant’s symptoms of ill-health are due to teething, as the cause may be more serious. Fever and ?ts (see SEIZURE) are not due to teething.
Toothache is the pain felt when there is in?ammation of the pulp or periodontal membrane of a tooth (see TEETH – Structure). It can vary in intensity and may be recurring. The commonest cause is caries (see below) when the cavity is close to the pulp. Once the pulp has become infected, this is likely to spread from the apex of the tooth into the bone to form an abscess (gumboil – see below). A lesser but more long-lasting pain is felt when the dentine is unprotected. This can occur when the enamel is lost due to decay or trauma or because the gums have receded. This pain is often associated with temperature-change or sweet foods. Expert dental advice should be sought early, before the decay is extensive. If a large cavity is accessible, temporary relief may be obtained by inserting a small piece of cotton wool soaked, for example, in oil of cloves.
Alveolar abscess, dental abscess or gumboil This is an ABSCESS caused by an infected tooth. It may be present as a large swelling or cause trismus (inability to open the mouth). Treatment is drainage of the PUS, extraction of the tooth and/or ANTIBIOTICS.
Caries of the teeth or dental decay is very common in the more a?uent countries and is most common in children and young adults. Increasing awareness of the causes has resulted in a considerable improvement in dental health, particularly in recent years; this has coincided with a rise in general health. Now more than half of ?ve-year-old children are caries-free and of the others, 10 per cent have half of the remaining carious cavities. Since the start of the National Health Service, the emphasis has been on preventive dentistry, and now edentulous patients are mainly found among the elderly who had their teeth removed before 1948.
The cause of caries is probably acid produced by oral bacteria from dietary carbohydrates, particularly re?ned sugar, and this dissolves part of the enamel; the dentine is eroded more quickly as it is softer (see TEETH – Structure). The exposed smooth surfaces are usually protected as they are easily cleaned during normal eating and by brushing. Irregular and overcrowded teeth are more at risk from decay as they are di?cult to clean. Primitive people who chew coarse foods rarely get caries. Fluoride in the drinking water at about one part per million is associated with a reduction in the caries rate.
Prolonged severe disease in infancy is associated with poor calci?cation of the teeth, making them more vulnerable to decay. As the teeth are formed and partly calci?ed by the time of birth, the diet and health of the mother are also important to the teeth of the child. Pregnant mothers and children should have a good balanced diet with su?cient calcium and vitamin
D. A ?brous diet will also aid cleansing of the teeth and stimulate the circulation in the teeth and jaws. The caries rate can be reduced by regular brushing with a ?uoride toothpaste two or three times per day and certainly before going to sleep. The provision of sweet or sugary juices in an infant’s bottle should be avoided.
Irregularity of the permanent teeth may be due to an abnormality in the growth of the jaws or to the early or late loss of the deciduous set (see TEETH – Development). Most frequently it is due to an imbalance in the size of the teeth and the length of the jaws. Some improvement may take place with age, but many will require the help of an orthodontist (specialist dentist) who can correct many malocclusions by removing a few teeth to allow the others to be moved into a good position by means of springs and elastics on various appliances which are worn in the mouth.
Loosening of the teeth may be due to an accident or in?ammation of the GUM. Teeth loosened by trauma may be replaced and splinted in the socket, even if knocked right out. If the loosening is due to periodontal disease, the prognosis is less favourable.
Discoloration of the teeth may be intrinsic or extrinsic: in other words, the stain may be in the calci?ed structure or stuck on to it. Intrinsic staining may be due to JAUNDICE or the antibiotic tetracycline. Extrinsic stain may be due to tea, co?ee, tobacco, pan (a mixture of chuna and betel nuts wrapped in a leaf), iron-containing medicines or excess ?uoride.
Gingivitis or in?ammation of the gum may occur as an acute or chronic condition. In the acute form it is often part of a general infection of the mouth, and principally occurs in children or young adults – resolving after 10–14 days. The chronic form occurs later in life and tends to be progressive. Various microorganisms may be found on the lesions, including anaerobes. Antiseptic mouthwashes may help, and once the painful stage is past, the gums should be thoroughly cleaned and any calculus removed. In severe conditions an antibiotic may be required.
Periodontal disease is the spread of gingivitis (see above) to involve the periodontal membrane of the tooth; in its ?orid form it used to be called pyorrhoea. In this, the membrane becomes damaged by the in?ammatory process and a space or pocket is formed into which a probe can be easily passed. As the pocket becomes more extensive, the tooth loosens. The loss of the periodontal membrane also leads to the loss of supporting bone. Chronic in?ammation soon occurs and is di?cult to eradicate. Pain is not a feature of the disease but there is often an unpleasant odour (halitosis). The gums bleed easily and there may be DYSPEPSIA. Treatment is largely aimed at stabilising the condition rather than curing it.
Dental abscess is an infection that arises in or around a tooth and spreads to involve the bone. It may occur many years after a blow has killed the pulp of the tooth, or more quickly after caries has reached the pulp. At ?rst the pain may be mild and intermittent but eventually it will become severe and a swelling will develop in the gum over the apex of the tooth. A radiograph of the tooth will show a round clear area at the apex of the tooth. Treatment may be by painting the gum with a mild counter-irritant such as a tincture of aconite and iodine in the early stages, but later root-canal therapy or apicectomy may be required. If a swelling is present, it may need to be drained or the o?ending teeth extracted and antibiotics given.
Injuries to teeth are common. The more minor injuries include crazing and the loss of small chips of enamel, and the major ones include a broken root and avulsion of the entire tooth. A specialist dental opinion should be sought as soon as possible. A tooth that has been knocked out can be re-implanted if it is clean and replaced within a few hours. It will then require splinting in place for 4–6 weeks.
Prevention of dental disease As with other disorders, prevention is better than cure. Children should be taught at an early age to keep their teeth and gums clean and to avoid re?ned sugars between meals. It is better to ?nish a meal with a drink of water rather than a sweetened drink. Fluoride in some of its forms is useful in the reduction of dental caries; in some parts of the UK natural water contains ?uoride, and in some areas where ?uoride content is low, arti?cial ?uoridation of the water supply is carried out. Overcrowding of the teeth, obvious maldevelopment of the jaw and persistent thumbsucking into the teens are all indications for seeking the advice of an orthodontist. Generally, adults have less trouble with decay but more with periodontal disease and, as its onset is insidious, regular dental inspections are desirable.... teeth
It is a recurrent and paroxysmal disorder starting suddenly and ceasing spontaneously due to occasional sudden excessive rapid and local discharge of the nerve cells in the grey matter (cortex) of the BRAIN. Epilepsy always arises in this way from the brain, but its origin is often of microscopic size. It is diagnosed by the clinical symptoms based on the observations of witnesses. Its cause can sometimes be established by laboratory tests, and brain scanning. Fits can be the ?rst sign of a tumour, or follow a stroke, brain injury or infection, but in the large majority no underlying cause is found – so-called idiopathic epilepsy.
A single epileptic ?t is not epilepsy. Of those people who have a single seizure, a signi?cant minority (20 per cent) have no further attacks.
Major (generalised) seizures have a sudden, often unprovoked onset; the patient emits a cry, then falls to the ground, rigid, blue, and then twitching or jerking both sides of the body: the tonic-clonic convulsion. Drowsiness and confusion may last for some hours after recovering consciousness. Some experience a momentary warning (AURA): a smell, or sensation in the head or abdomen, vision, or déjà vu.
Partial seizures: focal motor (Jacksonian) begin with twitching of the angle of the mouth, the thumb, or the big toe. If the seizure discharge then spreads, the twitching or jerking spreads gradually through the limbs. Consciousness is preserved unless the seizure spreads to produce a secondary generalised ?t. In some attacks the eyes and head may turn, the arm may rise, and the body may turn, while some patients feel tingling in the limbs.
Complex partial seizures (temporal lobe epilepsy) The patient usually appears blank, vacant and may be unable to talk, or may mumble or chatter – though later they often have no memory of this period. They may be able to carry out complex tasks, taking o? gloves or clothes, and may smack their lips or rub repeatedly on one limb (automatisms). A sense of strangeness supervenes: unreality, or a feeling of having experienced it all before (déja vu). There may be a sense of panic. Strange unpleasant smells and tastes are olfactory and gustatory hallucinations. The visual hallucinations evoke complex scenes. An initial rising sense of warmth or discomfort in the stomach, or ‘speeding-up’ of thoughts are common psychomotor symptoms. All these strange symptoms are brief, disappearing within a few seconds or up to 3–4 minutes.
Minor seizures (petit mal) Attacks start in childhood. They last a few seconds. The child ceases what he or she is doing, stares, looks a little pale, and may ?utter the eyelids. The head may drop forwards. Attacks are commonly provoked by overbreathing. The child and parents may be unaware of the attacks
– ‘just daydreaming’. Major ?ts develop in one-third of subjects. By contrast with other types of epilepsy, the ELECTROENCEPHALOGRAM (EEG) is diagnostic.
Precautions Children with epilepsy should take normal school exercises and games, and can swim under supervision. Adults must avoid working at heights, with exposed dangerous machinery, and driving vehicles on public roads. Current legislation allows driving after two years of complete freedom from attacks during waking hours; those who for more than three years have had a history of attacks only while asleep may also drive.
Treatment identi?es, and avoids where possible, any factors (such as shortage of sleep or excessive ?uids) which aggravate or trigger attacks. If ?ts are very infrequent, treatment may not be recommended. However, frequent ?ts may be embarassing, may cause injury or may cause long-term brain damage so treatment is advisable. Anti-epileptic drugs are usually necessary for several years under medical supervision. Carbamazepine and sodium valproate are the most frequently prescribed. The dose is governed by the degree of control of ?ts and sometimes drug levels can be monitored by blood tests to check on dosage. Strict adherence to the drug schedule gives a reasonable chance of total suppression of ?ts, especially in younger patients whose ?ts have started recently. The table summarises anticonvulsant drugs in use. Interactions can occur between anti-epileptics and, if drug treatment is changed, the patient needs careful monitoring. In particular, abrupt withdrawal of a drug should be avoided as this may precipitate severe rebound seizures.
Indications First-choice drugs: Ethosuximide PM, JME Phenobarbitone M, P Phenytoin M, P, CP Carbamazepine M, P, CP Valproate M, PM, JME Second-line drugs: Primidone M, P, CP Clobazam M, CP Vigabatrin M, P, CP Lamotrigine M, P, CP Gabapentin M, P, CP Topirimate P
M = major generalised tonic-clonic; P = partial or focal; CP = complex partial (temporal lobe); PM = petit mal; JME = juvenile myoclonic epilepsy.
Anticonvulsant drugs
As all anticonvulsant drugs have an e?ect on the brain, it is not surprising that there may be side-effects, especially inolving alertness or behaviour. In each case careful assessment is necessary for doctor and patient to agree on the best compromise between stopping ?ts and avoiding ill-effects of medication.
Patients who have an epileptic seizure should not be restrained or have a gag or anything else placed in their mouths; nor should they be moved unless in danger of further injury. Any tight clothing around the neck should be loosened and, when the seizure has passed, the person should be placed in the recovery position to facilitate a return to consciousness (see APPENDIX 1: BASIC FIRST AID).
Patients with epilepsy and their relatives can obtain further advice and information from the British Epilepsy Association or Epilepsy Action Scotland.... epilepsy
A number of co-factors are necessary for AIDS to develop: diet, environment, immoral lifestyle, drugs, etc also dispose to the disease which, when eliminated, suggest that AIDS needs not be fatal. However, there is no known cure. Smoking hastens onset. Causes include needle-sharing and sexual contacts. Also known as the ‘Gay Plague’ it can be transmitted from one member of the family to another non-sexual contact.
The virus kills off cells in the brain by inflammation, thus disposing to dementia.
Symptoms. Onset: brief fever with swollen glands. “Feeling mildly unwell”. This may pass off without incident until recurrence with persistent diarrhoea, night sweats, tender swollen lymph nodes, cough and shortness of breath. There follows weight loss, oral candida. Diagnosis is confirmed by appearance of ugly skin lesions known as Kaposi’s sarcoma – a malignant disease. First indication is the appearance of dark purple spots on the body followed by fungoid growths on mouth and throat.
While some cases of STDs have been effectively treated with phytotherapy, there is evidence to suggest it may be beneficial for a number of reasons. Whatever the treatment, frequent blood counts to monitor T-4 cells (an important part of the immune system) are necessary. While a phytotherapeutic regime may not cure, it is possible for patients to report feeling better emotionally and physically and to avoid some accompanying infections (candida etc).
Treatment. Without a blood test many HIV positives may remain ignorant of their condition for many years. STD clinics offer free testing and confidential counselling.
Modern phytotherapeutic treatment:–
1. Anti-virals. See entry.
2. Enhance immune function.
3. Nutrition: diet, food supplements.
4. Psychological counselling.
To strengthen body defences: Garlic, Echinacea, Lapacho, Sage, Chlorella, Reisha Mushroom, Shiitake Mushroom. Of primary importance is Liquorice: 2-4 grams daily.
Upper respiratory infection: Pleurisy root, Elecampane.
Liver breakdown: Blue Flag root, Milk Thistle, Goldenseal.
Diarrhoea: Bayberry, Mountain Grape, American Cranesbill, Slippery Elm, lactobacillus acidophilus.
Prostatitis: Saw Palmetto, Goldenrod, Echinacea.
Skin lesions: External:– Comfrey, Calendula or Aloe Vera cream.
To help prevent dementia: a common destructive symptom of the disease: agents rich in minerals – Alfalfa, Irish Moss, Ginkgo, St John’s Wort, Calcium supplements.
Nervous collapse: Gotu Kola, Siberian Ginseng, Oats, Damiana.
Ear Inflammation: Echinacea. External – Mullein ear drops.
With candida: Lapacho tea. Garlic inhibits candida.
Anal fissure: Comfrey cream or Aloe Vera gel (external).
Practitioner: Formula. Liquid extract Echinacea 30ml (viral infection) . . . Liquid extract Poke root 10ml (lymphatic system) . . . Liquid extract Blue Flag root 10ml (liver stimulant) . . . Tincture Goldenseal 2ml (inflamed mucous membranes) . . . Liquid extract Guaiacum 1ml (blood enricher) . . . Decoction of Sarsaparilla to 100ml. Sig: 5ml (3i) aq cal pc.
Gargle for sore throat: 5-10 drops Liquid extract or Tincture Echinacea to glass water, as freely as desired.
Abdominal Castor oil packs: claimed to enhance immune system.
Chinese medicine: Huang Qi (astragalus root).
Urethral and vaginal irrigation: 2 drops Tea Tree oil in strong decoction Marshmallow root: 2oz to 2 pints water. Inject warm.
Diet. Vitamin C-rich foods, Lecithin, Egg Yolk, Slippery Elm gruel, Red Beet root, Artichokes. Garlic is particularly indicated as an anti-infective.
Nutrition. Vitamin A is known to increase resistance by strengthening the cell membrane; preferably taken as beta carotene 300,000iu daily as massive doses of Vitamin A can be toxic. Amino acid – Glutathione: Garlic’s L-cysteine relates.
Vitamin C. “The virus is inactivated by this vitamin. Saturating cells infected with the HIV virus with the vitamin results in 99 per cent inactivation of the virus. The vitamin is an anti-viral and immune system modulator without unwanted side-effects. The ascorbate, when added to HIV cells, substantially reduced the virus’s activity without harming the cells at specific concentrations. Patients taking large doses report marked improvement in their condition. Minimum daily oral dose: 10 grams.” (Linus Pauling Institute, Science and Medicine, Palo Alto, California, USA)
Periwinkle. An anti-AIDS compound has been detected in the Madagascan Periwinkle (Catharanthus roseus), at the Chelsea Physic Garden.
Mulberry. The black Mulberry appears to inhibit the AIDS virus.
Hyssop. An AIDS patient improved to a point where ulcers were healed, blood infection eliminated, and Kaposi’s sarcoma started to clear when her mother gave her a traditional Jamaican tea made from Hyssop, Blessed Thistle and Senna. From test-tube research doctors found that Hyssopus officinalis could be effective in treatment of HIV/AIDS. (Medical Journal Antiviral Research, 1990, 14, 323-37) Circumcision. Studies have shown that uncircumcised African men were more than five to eight times more likely to contract AIDS than were circumcised men; life of the virus being short-lived in a dry environment. (Epidemiologist Thomas Quinn, in Science Magazine)
Study. A group of 13 HIV and AIDS patients received 200mg capsules daily of a combination of Chelidonium (Greater Celandine) 175mg; Sanguinaria (Blood root) 5mg; and Slippery Elm (Ulmus fulva) 20mg. More than half the patients enjoyed increased energy and improved immune function with reduction in both size and tenderness of lymph nodes. (D’Adamo P. ‘Chelidonium and Sanguinaria alkaloids as anti-HIV therapy. Journal of Naturopathic Medicine (USA) 3.31-34 1992)
Bastyr College of Naturopathy, Seattle, MA, USA. During 1991 the College carried out a study which claimed that a combination of natural therapies including nutrition, supplements, herbal medicine, hydrotherapy and counselling had successfully inhibited HIV and other viral activity in all patients in controlled trials lasting a year.
Patients chosen for the trial were HIV positive, not on anti-viral drugs and showing symptoms of a compromised immune system, but without frank AIDS (generally taken to be indicated by Karposi’s sarcoma and/or PCP-pneumocystitis carinii pneumonia).
Symptoms included: Lymphadenopathy in at least two sites, oral thrush, chronic diarrhoea, chronic sinusitis, leukoplakia, herpes, night sweats and fatigue.
Assessment was subjective and objective (including T-cell ratio tests). The patients did better than comparable groups in published trials using AZT.
Treatment was naturopathic and herbal. Patients receiving homoeopathy and acupuncture did not do as well as those receiving herbs.
Best results with herbs were: Liquorice (1g powder thrice daily); St John’s Wort (Yerba prima tablets, 3, on two days a week only). Patients reported a great increase in the sense of well-being on St John’s Wort. An equivalent dose of fresh plant tincture would be 10ml. The tincture should be of a good red colour. The College did not use Echinacea, which would stimulate the central immune system and which would therefore be contra-indicated.
Supplements given daily. Calcium ascorbate 3g+ (to bowel tolerance). Beta-carotene 300,000iu. Thymus gland extract tablets 6. Zinc 60mg (with some Copper). B-vitamins and EFAs.
To control specific symptoms: most useful herbs were: Tea Tree oil for fungal infections; Goldenseal and Gentian as bitters. Ephedra and Eyebright for sinusitis. Carob drinks for non-specific enteritis. Vitamin B12 and topical Liquorice for shingles.
Counselling and regular massage were used to maintain a positive spirit. Studies show all long term HIV positive survivors have a positive attitude and constantly work at empowering themselves.
Results showed significant improvements in symptoms suffered by HIV patients despite a slow deterioration in blood status. Methods used in the study had dramatically reduced mortality and morbidity. A conclusion was reached that AIDS may not be curable but it could be manageable. (Reported by Christopher Hedley MNIMH, London NW1 8JD, in Greenfiles Herbal Journal) ... aids
Nebulisers should carry a warning against misuse. Failure to respond should not be a signal to increase dosage, but an indication that asthma or the complaint is deteriorating. ... nebuliser
Viral infections by any of hepatitis A, B, C, D, or E viruses and also CYTOMEGALOVIRUS (CMV), EPSTEIN BARR VIRUS, and HERPES SIMPLEX.
Autoimmune disorders such as autoimmune chronic hepatitis, toxins, alcohol and certain drugs – ISONIAZID, RIFAMPICIN, HALOTHANE and CHLORPROMAZINE.
WILSON’S DISEASE.
Acute viral hepatitis causes damage throughout the liver and in severe infections may destroy whole lobules (see below).
Chronic hepatitis is typi?ed by an invasion of the portal tract by white blood cells (mild hepatitis). If these mononuclear in?ammatory cells invade the body (parenchyma) of the liver tissue, ?brosis and then chronic disease or cirrhosis can develop. Cirrhosis may develop at any age and commonly results in prolonged ill health. It is an important cause of premature death, with excessive alcohol consumption commonly the triggering factor. Sometimes, cirrhosis may be asymptomatic, but common symptoms are weakness, tiredness, poor appetite, weight loss, nausea, vomiting, abdominal discomfort and production of abnormal amounts of wind. Initially, the liver may enlarge, but later it becomes hard and shrunken, though rarely causing pain. Skin pigmentation may occur along with jaundice, the result of failure to excrete the liver product BILIRUBIN. Routine liver-function tests on blood are used to help diagnose the disease and to monitor its progress. Spider telangiectasia (caused by damage to blood vessels – see TELANGIECTASIS) usually develop, and these are a signi?cant pointer to liver disease. ENDOCRINE changes occur, especially in men, who lose their typical hair distribution and suffer from atrophy of their testicles. Bruising and nosebleeds occur increasingly as the cirrhosis worsens, and portal hypertension (high pressure of venous blood circulation through the liver) develops due to abnormal vascular resistance. ASCITES and HEPATIC ENCEPHALOPATHY are indications of advanced cirrhosis.
Treatment of cirrhosis is to tackle the underlying cause, to maintain the patient’s nutrition (advising him or her to avoid alcohol), and to treat any complications. The disorder can also be treated by liver transplantation; indeed, 75 per cent of liver transplants are done for cirrhosis. The overall prognosis of cirrhosis, however, is not good, especially as many patients attend for medical care late in the course of the disease. Overall, only 25 per cent of patients live for ?ve years after diagnosis, though patients who have a liver transplant and survive for a year (80 per cent do) have a good prognosis.
Autoimmune hepatitis is a type that most commonly occurs in women between 20 and 40 years of age. The cause is unknown and it has been suggested that the disease has several immunological subtypes. Symptoms are similar to other viral hepatitis infections, with painful joints and AMENORRHOEA as additional symptoms. Jaundice and signs of chronic liver disease usually occur. Treatment with CORTICOSTEROIDS is life-saving in autoimmune hepatitis, and maintenance treatment may be needed for two years or more. Remissions and exacerbations are typical, and most patients eventually develop cirrhosis, with 50 per cent of victims dying of liver failure if not treated. This ?gure falls to 10 per cent in treated patients.
Viral hepatitis The ?ve hepatic viruses (A to E) all cause acute primary liver disease, though each belongs to a separate group of viruses.
•Hepatitis A virus (HAV) is an ENTEROVIRUS
which is very infectious, spreading by faecal contamination from patients suffering from (or incubating) the infection; victims excrete viruses into the faeces for around ?ve weeks during incubation and development of the disease. Overcrowding and poor sanitation help to spread hepatitis A, which fortunately usually causes only mild disease.
Hepatitis B (HBV) is caused by a hepadna virus, and humans are the only reservoir of infection, with blood the main agent for transferring it. Transfusions of infected blood or blood products, and injections using contaminated needles (common among habitual drug abusers), are common modes of transfer. Tattooing and ACUPUNCTURE may spread hepatitis B unless high standards of sterilisation are maintained. Sexual intercourse, particularly between male homosexuals, is a signi?cant infection route.
Hepatitis C (HCV) is a ?avivirus whose source of infection is usually via blood contacts. E?ective screening of blood donors and heat treatment of blood factors should prevent the spread of this infection, which becomes chronic in about 75 per cent of those infected, lasting for life. Although most carriers do not suffer an acute illness, they must practise life-long preventive measures.
Hepatitis D (HDV) cannot survive independently, needing HBV to replicate, so its sources and methods of spread are similar to the B virus. HDV can infect people at the same time as HBV, but it is capable of superinfecting those who are already chronic carriers of the B virus. Acute and chronic infection of HDV can occur, depending on individual circumstances, and parenteral drug abuse spreads the infection. The disease occurs worldwide, being endemic in Africa, South America and the Mediterranean littoral.
Hepatitis E virus (HEV) is excreted in the stools, spreading via the faeco-oral route. It causes large epidemics of water-borne hepatitis and ?ourishes wherever there is poor sanitation. It resembles acute HAV infection and the patient usually recovers. HEV does not cause chronic infection. The clinical characteristics of the ?ve hepatic
viruses are broadly similar. The initial symptoms last for up to two weeks (comprising temperature, headache and malaise), and JAUNDICE then develops, with anorexia, nausea, vomiting and diarrhoea common manifestations. Upper abdominal pain and a tender enlarged liver margin, accompanied by enlarged cervical lymph glands, are usual.
As well as blood tests to assess liver function, there are speci?c virological tests to identify the ?ve infective agents, and these are important contributions to diagnosis. However, there is no speci?c treatment of any of these infections. The more seriously ill patients may require hospital care, mainly to enable doctors to spot at an early stage those developing acute liver failure. If vomiting is a problem, intravenous ?uid and glucose can be given. Therapeutic drugs – especially sedatives and hypnotics – should be avoided, and alcohol must not be taken during the acute phase. Interferon is the only licensed drug for the treatment of chronic hepatitis B, but this is used with care.
Otherwise-?t patients under 40 with acute viral hepatitis have a mortality rate of around
0.5 per cent; for those over 60, this ?gure is around 3 per cent. Up to 95 per cent of adults with acute HBV infection recover fully but the rest may develop life-long chronic hepatitis, particularly those who are immunode?cient (see IMMUNODEFICIENCY).
Infection is best prevented by good living conditions. HVA and HVB can be prevented by active immunisation with vaccines. There is no vaccine available for viruses C, D and E, although HDV is e?ectively prevented by immunisation against HBV. At-risk groups who should be vaccinated against HBV include:
Parenteral drug abusers.
Close contacts of infected individuals such as regular sexual partners and infants of infected mothers.
Men who have sex with men.
Patients undergoing regular haemodialysis.
Selected health professionals, including laboratory sta? dealing with blood samples and products.... hepatitis
Sulphonylureas The main group of hypoglycaemic agents, these act on the beta cells to stimulate insulin release; consequently they are e?ective only when there is some residual pancreatic beta-cell activity (see INSULIN). They also act on peripheral tissues to increase sensitivity, although this is less important. All sulphonylureas may lead to HYPOGLYCAEMIA four hours or more after food, but this is relatively uncommon, and usually an indication of overdose.
There are several di?erent sulphonylureas; apart from some di?erences in their duration or action (and hence in their suitability for individual patients) there is little di?erence in their e?ectiveness. Only chlorpropamide has appreciably more side-effects – mainly because of its prolonged duration of action and consequent risk of hypoglycaemia. There is also the common and unpleasant chlorpropamide/ alcohol-?ush phenomenon when the patient takes alcohol. Selection of an individual sulphonylurea depends on the patient’s age and renal function, and often just on personal preference. Elderly patients are particularly prone to the risks of hypoglycaemia when long-acting drugs are used. In these patients chlorpropamide, and preferably glibenclamide, should be avoided and replaced by others such as gliclazide or tolbutamide.
These drugs may cause weight gain and are indicated only if poor control persists despite adequate attempts at dieting. They should not be used during breast feeding, and caution is necessary in the elderly and in those with renal or hepatic insu?ciency. They should also be avoided in porphyria (see PORPHYRIAS). During surgery and intercurrent illness (such as myocardial infarction, COMA, infection and trauma), insulin therapy should be temporarily substituted. Insulin is generally used during pregnancy and should be used in the presence of ketoacidosis.
Side-effects Chie?y gastrointestinal disturbances and headache; these are generally mild and infrequent. After drinking alcohol, chlorpropamide may cause facial ?ushing. It also may enhance the action of antidiuretic hormone (see VASOPRESSIN), very rarely causing HYPONATRAEMIA.
Sensitivity reactions are very rare, usually occurring in the ?rst six to eight weeks of therapy. They include transient rashes which rarely progress to erythema multiforme (see under ERYTHEMA) and exfoliate DERMATITIS, fever and jaundice; chlorpropamide may also occasionally result in photosensitivity. Rare blood disorders include THROMBOCYTOPENIA, AGRANULOCYTOSIS and aplastic ANAEMIA.
Biguanides Metformin, the only available member of this group, acts by reducing GLUCONEOGENESIS and by increasing peripheral utilisation of glucose. It can act only if there is some residual insulin activity, hence it is only of value in the treatment of non-insulin dependent (type 2) diabetics. It may be used alone or with a sulphonylurea, and is indicated when strict dieting and sulphonylurea treatment have failed to control the diabetes. It is particularly valuable in overweight patients, in whom it may be used ?rst. Metformin has several advantages: hypoglycaemia is not usually a problem; weight gain is uncommon; and plasma insulin levels are lowered. Gastrointestinal side-effects are initially common and persistent in some patients, especially when high doses are being taken. Lactic acidosis is a rarely seen hazard occurring in patients with renal impairment, in whom metformin should not be used.
Other antidiabetics Acarbose is an inhibitor of intestinal alpha glucosidases (enzymes that process GLUCOSIDES), delaying the digestion of starch and sucrose, and hence the increase in blood glucose concentrations after a meal containing carbohydrate. It has been introduced for the treatment of type 2 patients inadequately controlled by diet or diet with oral hypoglycaemics.
Guar gum, if taken in adequate doses, acts by delaying carbohydrate absorption, and therefore reducing the postprandial blood glucose levels. It is also used to relieve symptoms of the DUMPING SYNDROME.... hypoglycaemic agents
An anal fistula may be an indication of Crohn’s disease, colitis, or cancer of the colon or rectum (see colon, cancer of; rectum, cancer of). In most cases, it results from an abscess that develops for unknown reasons in the anal wall. The abscess discharges pus into the anus and out on to the surrounding skin.
An anal fistula is treated surgically by opening the abnormal channel and removing the lining. The wound is then left to heal naturally.... anal fistula
Child guidance professionals include psychiatrists, psychologists, and psychiatric social workers. For young children, play therapy may be used for diagnosis. Older children may be offered counselling, psychotherapy, or group therapy. Family therapy may be used in cases where there are difficulties between the child and 1 or both parents.... child guidance
Oxygen is essential for life. It is absorbed via the lungs (see RESPIRATION) and is transported by HAEMOGLOBIN within the ERYTHROCYTES to the tissues. Within the individual cell it is involved in the production of adenosine triphosphate (ATP), a compound that stores chemical energy for muscle cells, by the oxidative metabolism of fats and carbohydrates. HYPOXIA causes anaerobic metabolism with a resulting build-up in LACTIC ACID, the result of muscle cell activity. If severe enough, the lack of ATP causes a breakdown in cellular function and the death of the individual.
When hypoxia occurs, it may be corrected by giving supplemental oxygen. This is usually given via a face mask or nasal prongs or, in severe cases, during ARTIFICIAL VENTILATION OF THE LUNGS. Some indications for oxygen therapy are high altitude, ventilatory failure, heart failure, ANAEMIA, PULMONARY HYPERTENSION, CARBON MONOXIDE (CO) poisoning, anaesthesia and post-operative recovery. In some conditions – e.g. severe infections with anaerobic bacteria and CO poisoning – hyperbaric oxygen therapy has been used.... oxygen
Heart murmurs are regarded as an indication of possible abnormality in the blood flow. Apart from “innocent” murmurs, the most common cause of extra blood turbulence is a disorder of the heart valves. Murmurs can also be caused by some types of congenital heart disease (see heart disease, congenital) or by rarer conditions such as a myxoma in a heart chamber.... murmur
Bleeding from the nose (see nosebleed) is usually caused by injury or a foreign body in the nose.
A discharge of cerebrospinal fluid from the nose may follow a fracture at the base of the skull.... nasal discharge
For more prolonged arti?cial ventilation it is usual to use a specially designed machine or ventilator to perform the task. The ventilators used in operating theatres when patients are anaesthetised and paralysed are relatively simple devices.They often consist of bellows which ?ll with fresh gas and which are then mechanically emptied (by means of a weight, piston, or compressed gas) via a circuit or tubes attached to an endotracheal tube into the patient’s lungs. Adjustments can be made to the volume of fresh gas given with each breath and to the length of inspiration and expiration. Expiration is usually passive back to the atmosphere of the room via a scavenging system to avoid pollution.
In intensive-care units, where patients are not usually paralysed, the ventilators are more complex. They have electronic controls which allow the user to programme a variety of pressure waveforms for inspiration and expiration. There are also programmes that allow the patient to breathe between ventilated breaths or to trigger ventilated breaths, or inhibit ventilation when the patient is breathing.
Indications for arti?cial ventilation are when patients are unable to achieve adequate respiratory function even if they can still breathe on their own. This may be due to injury or disease of the central nervous, cardiovascular, or respiratory systems, or to drug overdose. Arti?cial ventilation is performed to allow time for healing and recovery. Sometimes the patient is able to breathe but it is considered advisable to control ventilation – for example, in severe head injury. Some operations require the patient to be paralysed for better or safer surgical access and this may require ventilation. With lung operations or very unwell patients, ventilation is also indicated.
Arti?cial ventilation usually bypasses the physiological mechanisms for humidi?cation of inspired air, so care must be taken to humidify inspired gases. It is important to monitor the e?cacy of ventilation – for example, by using blood gas measurement, pulse oximetry, and tidal carbon dioxide, and airways pressures.
Arti?cial ventilation is not without its hazards. The use of positive pressure raises the mean intrathoracic pressure. This can decrease venous return to the heart and cause a fall in CARDIAC OUTPUT and blood pressure. Positive-pressure ventilation may also cause PNEUMOTHORAX, but this is rare. While patients are ventilated, they are unable to breathe and so accidental disconnection from the ventilator may cause HYPOXIA and death.
Negative-pressure ventilation is seldom used nowadays. The chest or whole body, apart from the head, is placed inside an airtight box. A vacuum lowers the pressure within the box, causing the chest to expand. Air is drawn into the lungs through the mouth and nose. At the end of inspiration the vacuum is stopped, the pressure in the box returns to atmospheric, and the patient exhales passively. This is the principle of the ‘iron lung’ which saved many lives during the polio epidemics of the 1950s. These machines are cumbersome and make access to the patient di?cult. In addition, complex manipulation of ventilation is impossible.
Jet ventilation is a relatively modern form of ventilation which utilises very small tidal volumes (see LUNGS) from a high-pressure source at high frequencies (20–200/min). First developed by physiologists to produce low stable intrathoracic pressures whilst studying CAROTID BODY re?exes, it is sometimes now used in intensive-therapy units for patients who do not achieve adequate gas exchange with conventional ventilation. Its advantages are lower intrathoracic pressures (and therefore less risk of pneumothorax and impaired venous return) and better gas mixing within the lungs.... intermittent positive pressure (ipp)
Several diseases and conditions are treated under separate headings. (See APPENDICITIS; CHOLERA; COLITIS; CONSTIPATION; CROHN’S DISEASE; DIARRHOEA; DYSENTERY; ENTERIC FEVER; HAEMORRHOIDS; HERNIA; INFLAMMATORY BOWEL DISEASE (IBD); ILEITIS; INTUSSUSCEPTION; IRRITABLE BOWEL SYNDROME (IBS); PERITONITIS; RECTUM, DISEASES OF; ULCERATIVE COLITIS.)
In?ammation of the outer surface is called peritonitis, a serious disease. That of the inner surface is known generally as enteritis, in?ammation of special parts receiving the names of colitis, appendicitis, irritable bowel syndrome (IBS) and in?ammatory bowel disease (IBD). Enteritis may form the chief symptom of certain infective diseases: for example in typhoid fever (see ENTERIC FEVER), cholera and dysentery. It may be acute, although not connected with any de?nite organism, when, if severe, it is a very serious condition, particularly in young children. Or it may be chronic, especially as the result of dysentery, and then constitutes a less serious if very troublesome complaint.
Perforation of the bowel may take place as the result either of injury or of disease. Stabs and other wounds which penetrate the abdomen may damage the bowel, and severe blows or crushes may tear it without any external wound. Ulceration, as in typhoid fever, or, more rarely, in TUBERCULOSIS, may cause an opening in the bowel-wall also. Again, when the bowel is greatly distended above an obstruction, faecal material may accumulate and produce ulcers, which rupture with the ordinary movements of the bowels. Whatever the cause, the symptoms are much the same.
Symptoms The contents of the bowel pass out through the perforation into the peritoneal cavity, and set up a general peritonitis. In consequence, the abdomen is painful, and after a few hours becomes extremely tender to the touch. The abdomen swells, particularly in its upper part, owing to gas having passed also into the cavity. Fever and vomiting develop and the person passes into a state of circulatory collapse or SHOCK. Such a condition may be fatal if not properly treated.
Treatment All food should be withheld and the patient given intravenous ?uids to resuscitate them and then to maintain their hydration and electrolyte balance. An operation is urgently necessary, the abdomen being opened in the middle line, the perforated portion of bowel found, the perforation stitched up, and appropriate antibiotics given.
Obstruction means a stoppage to the passage down the intestine of partially digested food. Obstruction may be acute, when it comes on suddenly with intense symptoms; or it may be chronic, when the obstructing cause gradually increases and the bowel becomes slowly more narrow until it closes altogether; or subacute, when obstruction comes and goes until it ends in an acute attack. In chronic cases the symptoms are milder in degree and more prolonged.
Causes Obstruction may be due to causes outside the bowel altogether, for example, the pressure of tumours in neighbouring organs, the twisting around the bowel of bands produced by former peritonitis, or even the twisting of a coil of intestine around itself so as to cause a kink in its wall. Chronic causes of the obstruction may exist in the wall of the bowel itself: for example, a tumour, or the contracting scar of an old ulcer. The condition of INTUSSUSCEPTION, where part of the bowel passes inside of the part beneath it, in the same way as one turns the ?nger of a glove outside in, causes obstruction and other symptoms. Bowel within a hernia may become obstructed when the hernia strangulates. Finally some body, such as a concretion, or the stone of some large fruit, or even a mass of hardened faeces, may become jammed within the bowel and stop up its passage.
Symptoms There are four chief symptoms: pain, vomiting, constipation and swelling of the abdomen.
Treatment As a rule the surgeon opens the abdomen, ?nds the obstruction and relieves it or if possible removes it altogether. It may be necessary to form a COLOSTOMY or ILEOSTOMY as a temporary or permanent measure in severe cases.
Tumours are rare in the small intestine and usually benign. They are relatively common in the large intestine and are usually cancerous. The most common site is the rectum. Cancer of the intestine is a disease of older people; it is the second most common cancer (after breast cancer) in women in the United Kingdom, and the third most common (after lung and prostate) in men. Around 25,000 cases of cancer of the large intestine occur in the UK annually, about 65 per cent of which are in the colon. A history of altered bowel habit, in the form of increasing constipation or diarrhoea, or an alternation of these, or of bleeding from the anus, in a middle-aged person is an indication for taking medical advice. If the condition is cancer, then the sooner it is investigated and treated, the better the result.... intestine, diseases of
One of the major problems of the menopause which does not give rise to symptoms until many years later is osteoporosis (see BONE, DISORDERS OF). After the menopause, 1 per cent of the bone is lost per annum to the end of life. This is a factor in the frequency of fractures of the femur in elderly women as a result of osetoporosis, but it can be prevented by hormone replacement therapy (see below).
Hormone replacement therapy (HRT) This term has become synonymous with the scienti?cally correct term ‘OESTROGENS replacement therapy’ to signify the treatment of menopausal symptoms and signs with oestrogens, now usually combined with PROGESTOGEN. Oestrogen and combined treatment relieve the short-term symptoms such as hot ?ushes, sweats and vaginal dryness. Atrophic vaginitis and vulvitis (shrinking of the tissues of VULVA and VAGINA due to fall in natural oestrogen levels) also usually respond to treatment with oestrogens.
Cyclical therapy is necessary to avoid abnormal bleeding in women who have reached the menopause. If oestrogens are given alone, there is an increased risk of endometrial hyperplasia (overgrowth of the ENDOMETRIUM) which may lead to endometrial cancer, so these are restricted to women who have had a hysterectomy and are no longer at risk. Other women can be given oestrogen-progestogen combinations.
There is good evidence that oestrogen alone or in combination can prevent the bone-loss associated with the menopause by reducing the demineralisation of bone which normally occurs after the menopause; and, if it is started early and continued for years, it may prevent the development of osteoporosis. Oestrogen is far more e?ective than calcium supplements and has been shown greatly to reduce fractures affecting the spine, wrists and legs after the age of 50.
However, HRT is no longer licensed for ?rst-line treatment to prevent osteoporosis, as increased risk of stroke, breast cancer and coronary heart disease cannot justify treatment for long periods – unless the woman has severe menopausal symptoms. HRT is recommended for short-term use only in menopausal women whose lives are inconvenienced by vasomotor instability (severe ?ushes, etc.) or vaginal atrophy, although the latter may respond to local oestrogen treatment – creams or pessaries. In terms of oestrogenic activity, natural oestrogen such as oestradiol, oestrone and oestriol are more appropriate for HRT than synthetic oestrogens like ethinyloestradiol, mestranol and diethylstilboestrol.
Many experts believe that controversy surrounding the risks and bene?ts of HRT have been settled by a large randomised trial (the Women’s Health Initiative), published in 2003, which showed that combined treatment increases the risk of breast tumours, stroke and coronary heart disease (in the ?rst year). Oestrogen alone (given to women who have had a hysterectomy) also increases the risk of stroke. Five years of combined treatment may double the risk of breast cancer, and the heart-disease risk is nearly doubled during the ?rst year of use. This is in spite of the bene?cial effects of HRT on blood lipids. However, there are others who consider that di?erent dose combinations of di?erent hormones may one day prove bene?cial, so research continues.
HRT can also provoke minor adverse effects such as breast tenderness, ?uid retention, leg cramps and nausea. The risk of abnormal blood clotting means that HRT is not normally recommended for women who smoke heavily or have had THROMBOSIS, severe HYPERTENSION, stroke or liver disease. HRT has, however, brought symptomatic bene?ts to many menopausal women, who can then justify taking the other increased risks – only fully understood since the large trial results were published.
As the evidence stands at present, careful consideration of each woman’s medical history and the severity of her menopausal symptoms is necessary in deciding what combination of drugs should be given and for how long. In general, the indications should be severe menopausal symptoms that can be controlled by the lowest dose for the shortest time. Using HRT to alleviate mild symptoms, or to prevent future bone loss, is probably of insu?cient bene?t to counter the other risks described above.... menopause
Resistance may also mean the extent of the body’s IMMUNITY – an indication of its ability to withstand disease. Another meaning relates to the development of resistance in a bacterium (see BACTERIA) to the effects on it of ANTIBIOTICS.
In PSYCHOANALYSIS, resistance refers to the blocking-o? from a person’s consciousness of repressed emotions and memories. A psychoanalyst helps the patient to break this resistance and bring the repressed material out into the open. (See also REPRESSED MEMORY THERAPY.)... resistance
Habitat: Native to Southern Europe and parts of Asia; also found in Kashmir.
English: Alizari, European Madder.Action: Root—used for menstrual and urinary disorders and liver diseases.
The root contains anthraquinone and their glycosides, including alizarin, purpurin, purpuroxanthin, pseudopurpurin, rubiadin, ruberythric acid and lucidin primeveroside. There are indications that lucidin is carcinogenic. All parts of the plant contained an iri- doid, asperuloside.... rubia tinctorumIdiopathic stammering begins at some time between the onset of speech and puberty, mostly between 2–5 years of age. Acquired stammering at a later age due to brain damage is rare. The prevalence of stammering (the percentage of the population actually stammering at any point in time) is approximately 0·9 per cent. Three times as many boys as girls stammer. About 70 per cent of stammering children recover with little or no therapy. Stammerers have not been shown to demonstrate di?erences in personality from non-stammerers; there are, however, indications that at least some stammerers show minimal di?erences from ?uent speakers in cerebral processing of verbal material.
There is a genetic predisposition towards stammering. The risk of stammering among ?rst-degree relatives of stammerers is more than three times the population risk. In 77 per cent of identical twins, either both stammer or both are ?uent. Only 33 per cent of non-identical twins agree in this way. As there are identical twins who di?er for stammering, environmental factors must be important for some stammerers. There are relatively large numbers of stammerers in highly competitive societies, where status and prestige are important and high standards of speech competence are valued.
Di?erent treatments have been demonstrated to produce considerable bene?t, their basic outline being similar. A long period of time is spent in training stammerers to speak in a di?erent way (?uency-shaping techniques). This may include slowing down the rate of speech, gentle onset of utterance, continuous ?ow with correct juncturing, etc. When the targets have been achieved within the clinic, a series of planned speech assignments outside the clinic is undertaken. In these assignments, and initially in everyday situations, the ?uency-enchancing techniques have to be used conscientiously. Gradually speech is shaped towards normality requiring less and less e?ort. Therapy may also include some work on attitude change (i.e. helping the client to see him or herself as a ?uent speaker) and possibly general communicative skills training.
For information about organisations concerned with stammering, see Appendix 2.... stammering
Acute tonsillitis The infection is never entirely con?ned to the tonsils; there is always some involvement of the surrounding throat or pharynx. The converse is true that in many cases of ‘sore throat’, the tonsils are involved in the generalised in?ammation of the throat.
Causes Most commonly caused by the ?haemolytic STREPTOCOCCUS, its incidence is highest in the winter months. In the developing world it may be the presenting feature of DIPHTHERIA, a disease now virtually non-existant in the West since the introduction of IMMUNISATION.
Symptoms The onset is usually fairly sudden with pain on swallowing, fever and malaise. On examination, the tonsils are engorged and covered with a whitish discharge (PUS). This may occur at scattered areas over the tonsillar crypts (follicular tonsillitis), or it may be more extensive. The glands under the jaw are enlarged and tender, and there may be pain in the ear on the affected side: although usually referred pain, this may indicate spread of the infection up the Eustachian tube to the ear, particularly in children. Occasionally an ABSCESS, or quinsy, develops around the affected tonsil. Due to a collection of pus, it usually comes on four to ?ve days after the onset of the disease, and requires specialist surgical treatment.
Treatment Most cases need no treatment. Therefore, it is advisable to take a throat swab to assess the nature of any bacterial treatment before starting treatment. Penicillin or erythromycin are the drugs of choice where betahaemolytic streptococci are isolated, together with paracetamol or aspirin, and plenty of ?uids. Removal of tonsils is indicated: when the tonsils and adenoids are permanently so enlarged as to interfere with breathing (in such cases the adenoids are removed as well as the tonsils); when the individual is subject to recurrent attacks of acute tonsillitis which are causing signi?cant debility, absence from school or work on a regular basis (more than four times a year); when there is evidence of a tumour of the tonsil. Recurrent sore throat is not an indication for removing tonsils.... tonsillitis
In cases of prolongation of the ?rst stage of labour, the ventouse may be used to accelerate dilatation of the cervix – provided that the cervix is already su?ciently dilated to allow application of the cup. The ventouse cannot be applied to the breech or face; in urgent cases of fetal distress the operation takes too long, and forceps delivery is preferred. There is some doubt about its safety when used on premature babies; many obstetricians feel that forceps delivery reduces the risk of intracranial haemorrhage. The vacuum extractor, while resulting in a slower delivery than when forceps are used, has a lower risk of damage to the mother’s birth canal. (See PREGNANCY AND LABOUR – Some complications of labour.)... vacuum extractor
Minor variations from the mean do not warrant investigation, but if the height of an individual falls below the third centile (3 per cent of normal children have a height that falls below the third centile) or above the 97th centile, investigation is required. Changes in the rate of growth are also important, and skeletal proportions may provide useful information. There are many children who are normal but who are small in relation to their parents; the problem is merely growth delay. These children take longer to reach maturity and there is also a proportional delay in their skeletal maturation – so that the actual height must always be assessed in relation to maturity. The change in skeletal proportions is one manifestation of maturity, but other features include the maturing of facial features with the growth of nose and jaw, and dental development. Maturity of bone can readily be measured by the radiological bone age.
Failure to gain weight is of more signi?cance. Whilst this may be due to some underlying disease, the most common cause is a diet containing inadequate calories (see CALORIE). Over the last six decades or so there has been quite a striking increase in the heights and weights of European children, with manufacturers of children’s clothing, shoes and furniture having to increase the size of their products. Growth is now completed at 20–21 years, compared with 25 at the turn of the century. It has been suggested that this increase, and earlier maturation, have been due to a combination of genetic mixing as a result of population movements, with the whole range of improvement in environmental hygiene – and not merely to better nutrition.
In the case of adults, views have changed in recent years concerning ‘ideal’ weight. Life-insurance statistics have shown that maximal life expectancy is obtained if the average weight at 25–30 years is maintained throughout the rest of life. These insurance statistics also suggest that it is of advantage to be slightly over the average weight before the age of 30 years; to be of average weight after the age of 40; and to be underweight from ages 30–40. In the past it has been usual, in assessing the signi?cance of an adult’s weight, to allow a 10 per cent range on either side of normal for variations in body-build. A closer correlation has been found between thoracic and abdominal measurements and weight.... weight and height
Treatment. See entries for specific disorders. Teas, powders, tinctures, liquid extracts, or essential oils – see entry of appropriate remedy.
The following are brief indications for action in the absence of a qualified practitioner. Flatulence (gas in the intestine or colon), (Peppermint). Upper right pain due to duodenal ulcer, (Goldenseal). Inflamed pancreas (Dandelion). Gall bladder, (Black root). Liver disorders (Fringe Tree bark). Lower left – diverticulitis, colitis, (Fenugreek seeds). Female organs, (Agnus Castus). Kidney disorders, (Buchu). Bladder, (Parsley Piert). Hiatus hernia (Papaya, Goldenseal). Peptic ulcer, (Irish Moss). Bilious attack (Wild Yam). Gastro-enteritis, (Meadowsweet). Constipation (Senna). Acute appendicitis, pain central, before settling in low right abdomen (Lobelia). Vomiting of blood, (American Cranesbill). Enlargement of abdominal glands is often associated with tonsillitis or glandular disease elsewhere which responds well to Poke root. As a blanket treatment for abdominal pains in general, old-time physicians used Turkey Rhubarb (with, or without Cardamom seed) to prevent griping.
Diet: No food until inflammation disperses. Slippery Elm drinks. ... abdominal pain
Contains aucubin and agnuside (iridoid glycosides), flavonoids, castin (bitter), fatty and ethereal oils. Action: acts on the anterior pituitary gland, reducing FSH (follicle-stimulating-hormone) and increasing LSH (luteum-stimulating-hormone). Stimulates production of progesterone but reducing that of oestrogen. “Has a corpus luteum hormone effect” (Dr Weiss 1974 322. New herbal Practitioner, March 1977). Alternative to hormone replacement therapy (HRT).
Uses: Symptoms caused by excess FSH and low progesterone output. used as substitution therapy for primary and secondary corpus luteum deficiency. Pre-menstrual symptoms, especially nervous tension, irritability, mood-swings, depression, anxiety, crying, forgetfulness, insomnia. Amenorrhoea (by regulating sex hormones). Pain in breasts. To promote breast milk in nursing mothers; assist bust development. Acne vulgaris (to restore sex hormone balance). Water-retention (pre-menstrual) caused by oestrogen excess or progesterone deficiency. “Regular bleeding between periods decreased following temporary increase” (Dr W. Amann, Bundesanzeiger, No 90, 15/5/1985). Premature old age from sexual excess and masturbation. Agnus lowers sexual vitality; reduces nervous excitability. By opposing excess oestrogen it lessens the risk, however small, of endometrial carcinoma. For symptoms of the menopause and of withdrawal on giving-up The Pill.
Preparations: Extracts made from crushed roots.
Tablets: 300mg; 2 tablets after meals thrice daily.
Liquid Extract: 1:1 in 25% alcohol. Dose: 2-4ml.
Caution: Not taken in the presence of progesterone drugs.
Contra-indications and interaction with other drugs: None known.
Tincture: 10-20 drops daily morning dose during second half of menstrual cycle. ... agnus castus
Action: Smooth muscle relaxant, carminative, diuretic, antifungal, antibacterial, diaphoretic, expectorant, gentle digestive tonic, antispasmodic.
Uses: Cold conditions where increase in body heat is required. To create distaste for alcohol. Friend of the aged as a circulatory stimulant and to sustain heart, stomach and bowel. Loss of appetite, chronic dyspepsia, aerophagy.
Preparations: Thrice daily.
Decoction. Half an ounce bruised root to 1 pint water; simmer 5 minutes. Dose: Half-1 cup, thrice daily. Liquid Extract BHP (1983) 1:1 in 25 per cent alcohol. Dose: 0.5 to 2ml.
Tincture, BHP (1983) 1:5 in 50 per cent alcohol.
Dose: 0.5 to 2ml.
Powder: 250mg capsules: 2 capsules before meals. (Arkocaps)
Contra-indications: pregnancy, diabetes.
Cancer inhibitor. The coumarin of Angelica has an inhibitory effect on cancer. (Planta Medica 1987, 53(6), pp 526-9)
Note: Used in the production of Chartreuse and Benedictine. ... angelica
Some essential oils are natural antibiotics. Others: Blue Flag root, Buchu, Chaparral, Butterbur, Echinacea, Feverfew, Garlic, Goldenseal, Holy Thistle, Horse Radish (Vogel), Juniper berries, Myrrh, Nasturtium, Poke root, Red Clover, Watercress (Vogel), Wild Indigo, Wild Thyme.
Vitamin C is a powerful antibiotic (1-2g daily).
ANTI-INFLAMMATORIES. A group of agents known to reduce inflammation. Action is not to suppress but to enable tissue to return to normal on the strength of its own resources. Some members of the group are helpful for chronic conditions such as polyarthritis and rheumatism caused by a sub-acute inflammation going on quietly over a long time. Others work by blocking prostaglandin synthesis. General. Chamomile (German, Roman), Cowslip root, Fennel, Feverfew, Heartsease, Mistletoe, Turmeric, Yellow Dock.
Specific. Bistort (bowel). Comfrey (bones). Devil’s Claw (muscles). St John’s Wort (nerve tissue). Lignum vitae (rheumatic joints). Poke root (lymph vessels). Eyebright (conjunctivitis: topical as an eye lotion). Horsechestnut (anus). Bogbean (liver and gall bladder).
Steroid-like action. Ginseng, Black Cohosh, Black Haw, Liquorice, Wild Yam.
Aspirin-like action. Birch, Black Willow bark, Meadowsweet, White Poplar bark, White Willow bark, Wintergreen.
Some types of inflammation may be reduced by herbs that stimulate the eliminatory organs – lungs, bowel, skin and kidneys. A timely enema may reduce a high temperature with inflammation, to expel toxins and unload an over-loaded bowel; (Dandelion root, Parsley root, Sarsaparilla).
ANTI-INFLAMMATION FORMULA. (Biostrath). Drops containing cultures combined with extracts derived from medicinal plants possessing known therapeutic properties: Arnica, Bryony, Balm, Chamomile, Horseradish, Marigold, Hypericum, Echinacea.
Indications: colic, inflammation of the alimentary tract. ... anti-infectives
Action: external use only.
Uses: Bruises and contusions where skin is unbroken. Severe bruising after surgical operation. Neuralgia, sprains, rheumatic joints, aches and pains after excessive use as in sports and gardening.
Combination, in general use: 1 part Tincture Arnica to 10 parts Witch Hazel water as a lotion. Contra- indications: broken or lacerated skin.
Preparations: Compress: handful flowerheads to 1 pint boiling water. Saturate handtowel or suitable material in mixture and apply.
Tincture. 1 handful (50g) flowerheads to 1 pint 70 per cent alcohol (say Vodka) in wide-necked bottle. Seal tight. Shake daily for 7 days. Filter. Use as a lotion or compress: 1 part tincture to 20 parts water. Weleda Lotion. First aid remedy to prevent bruise developing.
Nelson’s Arnica cream.
Ointment. Good for applying Arnica to parts of the body where tincture or lotion is unsuitable. 2oz flowers and 1oz leaves (shredded or powdered) in 16oz lard. Moisten with half its weight of distilled water. Heat together with the lard for 3-4 hours and strain. For wounds and varicose ulcers.
Wet Dressing. 2 tablespoons flowers to 2 litres boiling water. For muscular pain, stiffness and sprains. Tincture. Alternative dosage: a weak tincture can be used with good effect, acceptable internally: 5 drops tincture to 100ml water – 1 teaspoon hourly or two-hourly according to severity of the case.
Widely used in Homoeopathic Medicine.
First used by Swiss mountaineers who chewed the leaves to help prevent sore and aching limbs.
Note: Although no longer used internally in the UK, 5-10 drop doses of the tincture are still favoured by some European and American physicians for anginal pain and other acute heart conditions; (Hawthorn for chronic).
Pharmacy only sale. ... arnica
The immune system is the body’s internal defence armoury which protects from sickness and disease. White blood cells are influenced by the thymus gland and bone marrow to become “T” lymphocytes or “B” lymphocytes which absorb and destroy bacteria. There are times when these powerful defence components inflame and attack healthy tissue, giving rise to auto immune disease which may manifest as one of the numerous anaemic, rheumatic or nervous disorders, even cancer.
A watchful eye should be kept on any sub-acute, non-specific inflammation going on quietly over a long period – a certain indication of immune-inadequacy. It would appear that some unknown body intelligence operates behind the performance of the immune system; emotional and physic stresses such as divorce or job dissatisfaction can lead to a run-down of body defences. Some psychiatrists believe it to be a self-produced phenomenon due to an unresolved sense of guilt or a dislike of self. When this happens, bacterial, virus or fungus infections may invade and spread with little effective opposition. People who are happy at their home and work usually enjoy a robust immune system.
An overactive immune system may develop arthritis with painful joint inflammation, especially with a background of a fat-rich diet. A link between silicone implants and auto-immune disease is suspected.
“There is increasing evidence,” writes Dr D. Addy, Consulting Pediatrician, “that fevers may enhance the defence mechanism against infection.” (See: FEVER) “There is also increasing evidence of a weakening of the immune system through suppression of fevers by modern drugs. In this way, aspirin and other powerful anti-inflammatories may be responsible for feeble immune response.”
White cell stimulators: Liquorice, Ginseng (Siberian), Goldenseal, Echinacea. These increase ability of white blood cells to attack bacteria and invading cells. Chinese medicine: Ginseng (men), Chinese Angelica (women).
Treatment. To strengthen body defences. Garlic, Borage, Comfrey, Agrimony, Balm, Chamomile (German), Echinacea, Horsetail, Liquorice, Lapacho, Sage, Wild Yam, Wild Indigo, Poke root, Thuja. Shiitake Mushroom. Reishi Mushroom, Chlorella..
Tea. Combine, equal parts, St John’s Wort, Borage, Chamomile (German). 1 heaped teaspoon to each cup boiling water; infuse 15 minutes. 1 cup thrice daily.
Powders. Combine, Echinacea 4; Comfrey root 2; Wild Yam 1. 500mg (two 00 capsules, or one-third teaspoon) thrice daily.
Tinctures. Combine, Echinacea 4; Poke root 1; Thuja 1. 1-2 teaspoons in water thrice daily.
Tincture: Tincture Myrrh BPC 1973: 5-10 drops in water, morning and evening.
Decoctions. Horse-radish. Fenugreek seeds.
Bio-strath. Yeast-based herbal tonic. Exerts a positive influence on the immune system by rapid and marked increase in white blood cells.
Diet. Foods rich in essential fatty acids: nuts, seeds, beans, pulses, Evening Primrose oil, Cod Liver oil flavoured with mint or lemon. High protein: eggs, fish. (Low protein – acute stage). Foods rich in selenium. Yoghurt, cider vinegar, pineapple juice. Sugar has an immune suppressing effect.
Supplements. To rebuild immune system. Vitamins A, B5, B6, C, D, E. Zinc is required to produce histamine which is a vasodilator. Combination: zinc, selenium and GLA. Iron. Calcium.
Aromatherapy. Lavender oil: massage or baths.
Note: An alleged link exists between silicone implants and auto-immune disease. A new study reveals evidence that women with silicone breast implants who breast-feed their children put them at risk of developing systemic sclerosis. (JAMA Jan 19 1994) ... auto immune disease
Action. Liver stimulant, cholagogue, antiseptic, alterative. Tonic to spleen and pancreas, antemetic, digestive tonic. Hypotensive. Mild sedative and anticonvulsant. Uterine stimulant. Anti-haemorrhagic, Febrifuge, Anti-inflammatory, Anti-diarrhoeal, Amoebicidal, Bactericidal.
Uses: Sluggish liver, jaundice, biliousness, gastritis, gallstones, itching anus, ulcerated mouth, malaria, sandfly fever, toxaemia from drugs and environmental chemicals. Shingles, bladder disorders, leucorrhoea, renal colic. Old gouty constitutions react favourably. Cholera (animals). Leukopaenia due to chemotherapy.
Combinations. With Yarrow for malaria. With Gelsemium for pain in the coccyx (tailbone). With Fringe Tree bark for skin disorders.
Contra-indications: pregnancy, diarrhoea.
Preparations: Thrice daily.
Decoction: 1 teaspoon to each cup cold water left to steep overnight. Half-1 cup. Liquid Extract: BHP (1983) 1:1 in 25 per cent alcohol. Dose (1-3ml).
Tincture: BHP (1983) 1:10 in 60 per cent alcohol. Dose (2-4ml).
Powdered bark, dose, 1-2g. ... barberry bark
Action. Antispasmodic, antasthmatic, anti-sweat, sedative, lactifuge.
For use by qualified practitioner only.
Uses: Spasmodic asthma; colic of intestines, gall bladder or kidney; spasm of bladder and ureters. Whooping cough, excessive perspiration (night sweats, etc), spermatorrhoea, bed-wetting (dose afternoon and at bedtime), dribbling of saliva in Parkinsonism. The common cold, hay fever, acidity – to inhibit secretion of stomach acid.
Contra-indications. Glaucoma, rapid heart, pregnancy, enlarged prostate. Side-effects – dry mouth, dilated pupils, mental disorientation. Used for a millennia in China as an anaesthetic (Kiangsu – 1719)
Widely used in homoeopathic medicine.
Preparations: Unless otherwise prescribed – up to thrice daily. Dried herb, 50mg in infusion. Tincture, BHC (vol 1). 1:10, 70 per cent ethanol, 0.5ml.
Initial dose recommended per week by British Herbal Compendium, Vol 1; dried leaf, 200mg (max 1g); tincture, 2ml (max 10ml).
A weaker solution may sometimes be used with good effect: 5 drops tincture to 100ml water – 1 teaspoon hourly. (Dr Finlay Ellingwood)
Pharmacy only sale ... belladonna
Action: stimulating expectorant, diuretic, hepatic, anti-rheumatic, anti-fungal, alterative. Contains saponin glycoside Dulcamarin.
Uses: Chronic bronchitis. Chronic eczema with itching. Gout. Mild analgesic for rheumatism. Warts, tumours, (external).
Preparations: Thrice daily.
Decoction: half-2g twigs to each cup water simmer 10 minutes. Dose: half a cup.
Liquid extract: 2-4ml in water.
French traditional: wives boiled handful of twigs or root-bark in lard for ulcers, warts and ringworm. Contra-indication: pregnancy and lactation. ... bittersweet
Action: cardio-active, diuretic, laxative, oxytocic, peripheral vasoconstrictor. Increases power of the heart, slows it down, increases urine. “Works on the conductive mechanism of the heart. Atrial and ventricular fibrillation disappear.” (Rudolf F. Weiss MD)
Uses: ‘Heart’ dropsy. To reduce frequency of the heartbeat. Tendency to extrasystoles. Tachycardia. Liver conditions. Whole plant.
Reported use for tumour. (J.L. Hartwell, Lloydia, 33, 97, 1970) Combination, traditional: with Agrimony and Dandelion root for dropsy. Contra-indications: High blood pressure, pregnancy, lactation.
Preparations: Thrice daily.
Decoction: 1oz (30g) to each 1 pint (500ml) water, simmer gently 10 minutes. Dose: half-1 cup. Liquid extract. 10-30 drops.
Tincture BHP (1983) 1:5 in 45 per cent alcohol; Dose: 0.5-2ml.
Kasbah Remedy (Potter’s). Broom, an important constituent of.
Spartoil drops (Klein).
BROWN SPOTS on the skin. Liver spots. Chloasma, melasma. Melanin is a dark pigment found in the skin and hair. When it is unnaturally concentrated into yellow-brown patches during pregnancy or from taking contraceptive pills it is known as chloasma. The darkness of such patches is enhanced by sunlight. Liver spots are common in the aged.
Topical. Cider vinegar. Castor oil (E. Cayce) Houseleek (traditional). Distilled extract of Witch Hazel. The juice or gel of Aloe Vera has reduced or removed spots after several months twice-daily applications. ... broom
Action: diaphoretic, expectorant, powerful hydragogue, emetic, cathartic, anti-tumour, anti-rheumatic. Externally: as a rubefacient. Internal use, practitioner only.
Uses: Rheumatism worse from movement, rheumatic fever, acute arthritis. Heart disorder following rheumatic fever. For absorption of serous fluid as in pleurisy. Congested bronchi and lungs. Synovitis, malaria and zymotic diseases.
Combinations: With Black Cohosh for muscular pain. Also for tenderness of the spinal vertebre (an important indication). With Poke root for inflammation of the breast or testicles.
Preparations: Owing to difficulty of the layman to dispense accurately dosage of powder or decoction, use is best confined to liquid extract or tincture; small doses frequently repeated; large doses avoided. Liquid Extract: 10 drops in 4oz water; dose 1 teaspoon every half hour.
Tincture: dose; 2 teaspoons every half hour (acute) cases; thrice daily (chronic).
External. Tincture used as a lotion.
Note: Not used in pregnancy, lactation or in presence of piles. ... bryony, white
In the absence of sterile dressings and modern hospital amenities, powdered vegetable charcoal has an ancient reputation as an astringent dressing. It absorbs bacterial toxins and is useful for chronic bowel discharge. Powdered charcoal dressings were used during World War I. Rubbed in lard, was used for purulent foul discharging wounds to neutralise smell and promote healing.
Other indications: relaxed veins, stomach tense and full of wind, constant belching. For weak and cachetic individuals where vital powers are weak.
Available in biscuits, tablets and capsules for its purifying properties and as an aid to digestion. Tablets containing a high sodium content should be avoided. ... charcoal, vegetable
Cholesterol is necessary for maintenance of brain and glandular system, the production of bile salts and certain hormones.
Excesses plug arteries with a gluey consistency. Fats may start furring up arteries from childhood, yet it may take many years for symptoms to develop. The more meat and dairy products eaten the more cholesterol is produced. 90 per cent cases of gall stones are composed of cholesterol. A link between coronary heart disease and high cholesterol levels is strong and consistent. Anger and hostility raise cholesterol level.
The first indication of narrowing of the arteries may be an attack of angina, severe chest pain occurring on exertion due to an inadequate supply of blood and oxygen to the heart muscle. No one should exceed a fat and cholesterol count of 40 per day. For those of moderate risk level, a count of below 30 is advised.
Dr Paul Durrington, consultant physician, Manchester Royal Infirmary and researcher in lipids, believes that ‘reducing the amount of saturated fats in the diet and reducing weight are the most effective ways of lowering cholesterol levels’.
Treatment: same as for HYPERLIPIDAEMIA.
Diet. See: DIET – CHOLESTEROL. ... cholesterol
Symptoms: low grade fever, malaise, sore throat, massive swelling of cervical lymph glands, thick white exudate from tonsils, false membrane forms from soft palate to larynx with brassy cough and difficult breathing leading to cyanosis and coma. Toxaemia, prostration, thin rapid pulse. Throat swabs taken for laboratory examination. See: NOTIFIABLE DISEASES.
Treatment. Bedrest. Encourage sweating.
Recommendations are for those parts of the world where medical help is not readily available and may save lives. Alternatives:–
1. Combine: Tincture Echinacea 3; Tincture Goldenseal 2; Tincture Myrrh 1. Dose: 30-60 drops in water, two-hourly.
2. Combine equal parts: Tincture Lobelia; Tincture Echinacea. Dose: 30-60 drops in water, two-hourly.
3. Combine Tincture Poke root 2; Tincture Echinacea 3. Dose: 30-60 drops in water, two hourly.
4. G.L.B. Rounseville, MD, Ill., USA. I have treated diphtheria since 1883. I have treated diphtheria until I am sure the number of cases treated run into four digits. I have never given a hypodermic of antitoxin on my own initiative, nor have I ever lost a case early enough to inhibit conditions. I have depended upon Echinacea not only prophylactic but also as an antiseptic . . . In the line of medication the remedies are: Aconite, Belladonna, Poke root and Cactus grand, according to indications. But remember, if you are to have success, Echinacea must be given internally, externally and eternally! Do not fear any case of diphtheria with properly selected remedies as the symptoms occur. Echinacea will also be your stimulant, diaphoretic, diuretic, sialogogue, cathartic and antipyretic. (Ellingwood’s Physiomedicalist, Vol 13, No 6, June, 1919, 202)
5. Alexander M. Stern MD, Palatka, Florida, USA. Combine: tinctures Echinacea 1oz, Belladonna 10 drops, Aconite 10 drops. Water to 4oz. 1 teaspoon 2-hourly.
6. F.H. Williams, MD, Bristol, Conn., USA. I took a case which had been given up to die with tracheal diphtheritic croup. I gave him old-fashioned Lobelia (2) seed and Capsicum (1) internally and externally and secured expulsion of a perfect cast of the trachea without a tracheotomy.
7. Gargle, and frequent drink. To loosen false membrane. Raw lemon juice 1, water 2. Pineapple juice. Teas: Red Sage, fresh Poke root. Cold packs – saturated with Echinacea (Tincture, Liquid Extract or decoction) to throat.
Note: Capsicum and Lobelia open up the surface blood flow of the body thus releasing congestion on the inner mucous membranes.
Diet. Complete lemon-juice and herb tea fast with no solid foods as long as crisis lasts.
To be treated by a general medical practitioner or hospital specialist. ... diphtheria
A strong tea is prepared from one of a number of agents according to indications.
Infections: Blue Flag root, Yellow Dock root, Echinacea, Marshmallow root, Sarsaparilla.
Leucorrhoea: Motherwort, Plantain, Bayberry, Black Cohosh.
Endometritis: Raspberry leaves.
Candida: injection of neat yoghurt or, half cup cider vinegar to 2 pints warm water.
Acute discomfort, itching, inflammation: equal parts Chamomile, Marshmallow, Ladies Mantle. 1oz to 2 pints boiling water; infuse, inject warm.
Alternative to herbs: use liquid extracts, 2-4 teaspoons to two pints water.
Thuja douche: Thuja, Liquid Extract half an ounce; Ginger Tincture 10 drops; Glycerine 1oz. Hot water to 1 pint. Candida, leucorrhoea, Polypi. ... douche
Some eliminatives have a biochemical action on cell wastes and toxins, breaking them down preparatory to voiding from the body. Others stimulate organs of elimination to speed them on their journey: liver, kidneys, skin, bowel. This group will therefore include diuretics, hepatics, lymphatics, expectorants, diaphoretics or laxatives according to indications of the case. ... eliminative
Constituents: Alkaloids – ephedrine, pseudoephedrine.
Action: brain, heart and circulatory stimulant, antasthmatic, bronchodilator, anti-allergic, vasodilator, hypertensive, diaphoretic. Dilates vessels of the heart causing a rise in blood pressure. Cough sedative. Febrifuge, antispasmodic. The essential oil has antibacterial and antiviral properties.
Uses: Practitioner’s first choice for asthma. Bronchitis, breathlessness, whooping cough. Used for such chest conditions for over a millennia in Chinese medicine.
Allergies: hay fever, irritative skin rashes. Low blood pressure. Hypothermia. Bed-wetting. Myasthenia gravis BHP (1983). Chinese Barefoot doctors inject the tea into nostrils for hay fever.
Usually given with expectorants: Liquorice, Lobelia, Senega, Sundew. “Combines well with Lobelia and Skunk Cabbage for bronchitis; and with Horsetail for frequency of urine.” (Fletcher Hyde) Contra-indications: hypertension, coronary thrombosis, thyrotoxicosis, glaucoma. Not given with anti- depressants (MAO inhibitors).
Preparations: Thrice daily. Average dose: 15-60mg.
Tea. Quarter to half a teaspoon herb to cup water simmered gently 5 minutes. Half a cup. Liquid extract. BHP (1983) 1:1 in 45 per cent alcohol. Dose: 15-45 drops (1-3ml). Tincture BHP (1983) 1 part to 4 parts 45 per cent alcohol. Dose: 6-8ml.
Ephedrine. Maximum dose: 30mg. Maximum daily dose 60mg.
Store in airtight container out of the light. Pharmacy only medicine. Practitioners only. ... ephedra
Action: bitter, diuretic, cholagogue, stimulating laxative.
Uses: Chronic spastic constipation. Torpid liver.
Preparations: Decoction: half-1 teaspoon to each cup water simmered 10 minutes: half-1 cup.
Liquid extract: 1-2 teaspoons in water once or twice daily.
Powder. Capsules (200mg). 2 capsules before meals.
Hoxsey Cancer Cure (1950s): Ingredient of.
Contra-indications. “Inflammatory colon diseases (e.g. ulcerative colitis, Crohn’s disease, ileus, appendicitis, abdominal pain of unknown origin.” (European monograph, ESCOP)
Side-effects. If used correctly side-effects will be minimal.
Not recommended during pregnancy, lactation or for children. ... frangula bark
Constituents: Xanthones, iridoids, alkaloids, phenolic acids, pectin, gum, no tannin.
Action: well-known traditional European bitter (all bitters are liver and pancreatic stimulants). Haemopoietic action speeds production of red blood cells. (Should not be given for overproduction of red blood cells as in polycythaemia.) Emmenagogue, sialagogue, antispasmodic, anti-inflammatory, anthelmintic. King of tonics. Digestant, increases gastric juices by 25 per cent, without altering pH. Appetite stimulant.
Uses: Alkalosis, feeble digestion in the elderly from gastric acid deficiency. Thin people anxious to put on weight. Jaundice – promotes flow of bile. Nausea, vomiting, travel sickness (with or without Ginger), bitter taste in mouth, diarrhoea with yellow stool, malaria (as a substitute for Quinine), post-influenzal or ME depression and lack of appetite, severe physical exhaustion (Ginseng). To antidote some types food- poisoning (salmonella, shigella, etc).
Preparations: Thrice daily. Average dose half-2g. Before meals.
Decoction: half-1 teaspoon to cup cold water; steep overnight. Dose: half a cup.
Tincture: 1 part powdered root to 5 parts Vodka; macerate 8 days. Dose: 1-2 teaspoons.
Tablets: formula. Skullcap 45mg; Hops 45mg; Asafoetida 30mg, and the aqueous extractive from 120mg Gentian and 90mg Valerian. Two tablets thrice daily for nervous exhaustion and stress disorders. Anorexia nervosa, specific combination: equal parts – Gentian and Valerian roots. One heaped teaspoon to each cup cold water; steep overnight. Dose – half a cup the following day, morning and evening. Contra-indications: pregnancy, hyperacidity. Gastric ulcer.
Note: An ingredient of anti-smoking preparations. Well-known in Chinese medicine. ... gentian
Constituents: gum, resin, starch, saponin glycosides, volatile oil.
Uses: Physical weakness, neurasthenia, recovery after surgery. Promotes physical and intellectual efficiency. A mood-raiser. Induces a feeling of well being and stability. Depression, sexual debility, sleeplessness. The sportsman’s remedy, improving running ability and endurance. Retards build-up of lactic acid which normally occurs during hard exercise and causes fatigue. Increases resistance to excess cold or heat exposure and to a working environment with a noisy background. Lessens side-effects of insulin in diabetes. To help the body adapt to a changed environment (jet lag). Enhances mental performance in students. Promotes biosynthesis of DNA and RNA.
Preparations: Miscellaneous products available. Single morning dose.
Decoction. Half-1 teaspoon to each cup water gently simmered 10 minutes, or added to a cup of domestic tea.
Powder. Half-1g daily.
Contra-indications: hyperactivity in children, pregnancy, high blood pressure, menopause. Not taken continuously but for periods from 1 week to 1 month. Should not be taken with coffee. ... ginseng - king plant
Action. Anti-stress, antiviral, adaptogen, aphrodisiac, vasodilator, hypoglycaemic, tonic, adrenal hormone stimulant, anti-toxic activity in chemotherapy. Beneficial for boosting the body’s natural defence system, to resist viruses, free-radical toxins and even radiation. Increases immune resistance.
Uses: Conditions related to stress. Improves capacity for mental and physical exertion, to revitalise a run- down constitution, shingles, myalgic encephalomyelitis (ME), atherosclerosis in heart and arterial conditions, increases cerebral circulation in the elderly, non-caffeine invigorator, depression from overwork, jet-lag, children – classroom stress, recovery from surgical operation, radiation injury, immune stimulant in cancer therapy. To increase fertility. Enables patient to tolerate higher doses of radiation. Counters nuclear reactor leakage. Inhibits HIV-1 replication in cells acutely or chronically infected. Preparations. Miscellaneous products available.
Tea. Quarter of a teaspoon powdered root to each cup boiling water. OR: dissolve 1-2 capsules in cup of boiling water, once daily.
Tablets/capsules. 150mg, one thrice daily.
General uses and contra-indications: see GINSENG (PANAX). ... ginseng - siberian
Symptoms: diarrhoea, abdominal swelling and pain, irritability, inability to gain weight, neuritis, ulcers on tongue and mouth, low blood pressure, debility, lactase-deficiency. Breast-feeding stops coeliac disease.
Alternatives. Tea. Mix, equal parts: Raspberry leaves, Agrimony, Lemon Balm. 2 teaspoons to each cup boiling water; infuse 15 minutes. 1 cup freely.
Tablets/capsules. Goldenseal, Slippery Elm. Calamus. Fenugreek seeds, Papaya. Wild Yam.
Powders, Liquid Extracts, Tinctures. Formula. Equal parts: Sarsaparilla, Wild Yam, Stone root. Dose. Powders: 500mg (two 00 capsules or one-third teaspoon). Liquid Extracts: 30-60 drops. Tinctures: 1-2 teaspoons. In water, banana mash or honey, thrice daily.
Papaya (papain) digests wheat gluten and assists recovery. Half-1g with meals.
Aloe Vera juice. Promotes improved bowel motility, increases stool specific gravity, and reduces indication of protein putrefaction, flatulence and bloating after meals. (J. Bland PhD. JAM June 1985, p.11)
Topical. Warm hip baths of Lemon Balm, Chamomile, etc. (Alfred Vogel)
Diet. Gluten-free. Rice. Unpasteurised yoghurt. Buttermilk. Sweet acidophilus milk. Raw carrot juice. Bananas mashed with a little Slippery Elm or dried milk powder, carob bean powder and Soya milk. Supplementation. Vitamins A, B-complex, B6, B12, Folic acid, C, D, E, K (Alfalfa tea). Calcium, Iron and Magnesium orotates. ... gluten-sensitive disease
Guar has an effect upon sugar metabolism, blood fat levels, body weight and blood pressure. (Dr J. Tuomilehto, University of Turku, Finland) A study at Hammersmith Hospital, London, showed Guar efficacious in reducing blood sugar levels. Its cholesterol-lowering action is of benefit in diabetics.
Guar induces weight loss in obese subjects; reduces risk of kidney stone. Granules of the gum may be taken with water or sprinkled direct on food – fluid being taken at the meal to ensure swelling of the granules.
By slowing the rate of sugar absorption, it reduces the post-prandial peak in blood sugar level, making possible a reduction of insulin. Contra-indications: obstruction of the intestines and diseases of the gullet.
Guarina or Guarem, sachets: 5g unit dose sprinkled over food. Adults: one sachet daily, increasing if necessary to a maximum of 3 sachets. A preparation Glucotard is taken as dry minitablets, washed down in portions with a glass of water.
Alternative: Powdered Guar gum – 15 grams daily.
Note: Effectiveness for weight loss unproven. Guar gum may cause throat obstruction in rare cases and should be prescribed by a medical practitioner only.
See: DIABETES. HYPERLIPIDAEMIA. CHOLESTEROL. ... guar gum
Constituents. Flavonoids, phenolic acids, tannins, amines.
Action. Positive heart restorative. Coronary vasodilator BHP (1983), antispasmodic, antihypertensive, adaptogen, diuretic, sedative to nervous system, cholesterol and mineral solvent. Action lacks the toxic effects of digitalis. Useful where digitalis is not tolerated.
Uses: To increase blood flow through the heart. Strengthens heart muscle without increasing the beat or raising blood pressure. Enhances exercise duration. Myocarditis with failing compensation. Improves circulation in coronary arteries. Arteriosclerosis, atheroma, thrombosis, rapid heart beat, paroxysmal tachycardia BHP (1983), fatty degeneration; angina, enlargement of the heart from over-work, over- exercise or mental tension, alcoholic heart, Buerger’s disease, intermittent claudication, risk of infarction, dizziness (long term), mild to moderate hypertension, insomnia. Used by sportsmen to sustain the heart under maximum effort.
Preparations: Thrice daily.
Tea. Leaves and flowers. 1-2 teaspoons to each cup boiling water; infuse 5-10 minutes. Dose: 1 cup. Traditional for insomnia or for the heart under stress.
Decoction. Fruits. 1-2 heaped teaspoons haws to each cup water; simmer gently 2 minutes. Dose: half-1 cup.
Tablets/capsules. Two 200-250mg.
Liquid extract. 8-15 drops in water.
Tincture. 1:5 in 45 per cent alcohol, dose: 15-30 drops (1-2ml).
Popular combinations:–
With Mistletoe and Valerian (equal parts) as a sedative for nervous heart.
With Lily of the Valley 1; Hawthorn berries 2; for cardiac oedema.
With Lime flowers, Mistletoe and Valerian (equal parts) for high blood pressure.
With Horseradish or Cayenne, as a safe circulatory stimulant.
Gradual onset of action. Low incidence of side-effects. No absolute contra-indications.
Note: Dr D. Greene, Ennis, County Clare, Eire, attained an international reputation for treatment of heart disease keeping the remedy a secret. Upon his death his daughter revealed it as a tincture of red-ripe Hawthorn berries. Pharmacy only ... hawthorn
Tablets/capsules. St John’s Wort.
Formula. Comfrey root 2; St John’s Wort 1; Echinacea 2; trace of Cayenne (Capsicum). Dose – Powders: 750mg (three 00 capsules or half a teaspoon). Liquid Extracts: 1-2 teaspoons. Tinctures: 1-3 teaspoons. Effect is enhanced when doses are taken in cup of Comfrey herb tea. Other agents to promote renewal of tissue. Slippery Elm bark, Fenugreek seeds, Wild Yam, Carragheen Moss.
Discomfort from a scar. Aloe Vera gel, Calendula, Comfrey or Chickweed cream or ointment. See: CASTOR OIL PACK.
Diet. High protein, oily fish or fish oils.
Supplements. Vitamin C: 3-6g daily. Calcium ascorbate, Zinc. Magnesium. Cod Liver oil for Vitamins A and D; 2 teaspoons daily.
Note: Where titanium alloy implants are used for this operation serum levels of the metal are likely to show up higher than normal. Raised serum titanium has been linked with lung cancer, osteoporosis, and platelet suppression. A New Zealand study has found deaths from cancer were significantly higher in patients having had a metal hip replacement. See: CHELATION.
Comfrey. Potential benefit far outweighs possible risk. ... hip replacement operation
Constituents: oestrogens, volatile oil, resin.
Action: sedative, sustaining nervine, hypnotic, mild analgesic, spasmolytic on smooth muscle, bitter, tonic, astringent, antimicrobial (externally), liver and gall bladder relaxant, anaphrodisiac, diuretic.
Uses: Nervous anxiety, hysteria, nervous diarrhoea, nervous stomach, Crohn’s disease, intestinal cramps, nervous bladder, insomnia, neuralgia, excessive sexual excitability. Loss of appetite, menopause, restless legs.
Chinese medicine – tuberculosis of the lungs.
“Of value in cancer.” (J.L. Hartwell, Lloydia, 33, 97, 1970)
Combination. Combines well with Passion flower and Valerian.
Preparations: Average dose: half-1 gram. Thrice daily.
Tea. 1 teaspoon to each cup boiling water; infuse 15 minutes. Dose: half cup.
Liquid Extract: 0.5-1ml.
Tincture BHC Vol 1. One part to 5 parts 60 per cent ethanol. Dose: 1-2ml.
Popular tablet/capsule: powdered Hops BHP (1983) 45mg; powdered Passiflora BHP (1983) 100mg; powdered Extract Valerian 5:1 20mg. For minor stresses and strains, irritability and nervous headaches. For over-activity of children over 12 years. (Gerard House)
Diet: young shoots cooked as Asparagus.
Hop pillow: for healthful sleep.
Fresh Hops require careful handling on drying to prevent loss of pollen. May cause an allergic dermatitis in those susceptible.
Contra-indication: depression.
Powder. 250mg. One 00 capsule or one-sixth teaspoon. ... hops
Action: expectorant, diaphoretic, antiprotozal BHP (1983), emetic (large doses). Acts upon the pneumogastric nerve. Antispasmodic. Stimulant to mucous membranes.
Uses: to liquefy bronchial phlegm and promote expectoration. Sore throat, whooping cough, stubborn cough. Amoebic dysentery. Expulsion of mucus from the chest. Alternative to a stomach pump to induce vomiting.
Combinations: with Lobelia for respiratory disorders. With Tincture Myrrh for bowel infection, orally or by enema.
Preparations: Average dose, rhizome and roots: 25-100mg. Thrice daily. Dose more accurately controlled by use of liquid extract or tincture rather than infusion or decoction.
Liquid extract BP 1973: dose 0.025 to 0.1ml. Emetic dose – 0.5 to 2ml.
Tincture BP (1973). Dose 0.25 to 1ml. Emetic dose 5 to 20ml.
Cough mixtures: an ingredient of. (Potter’s Balm of Gilead) etc. Contra-indications: shock, heart disease. ... ipecacuanha root
Health Encyclopedia