Quinine is commonly prescribed in low doses to help prevent leg cramps at night; adverse effects are rare.
Quinine is generally used in the form of one of its salts, such as the sulphate of quinine, or dihydrochloride of quinine. All are sparingly soluble in water, much more so when taken along with an acid.
Action Quinine is a powerful antiseptic (see ANTISEPTICS). Its best-known action is in checking the recurrence of attacks of MALARIA, as it destroys malarial parasites in the blood. In fevers it acts as an antipyretic (see ANTIPYRETICS).
Among its side-effects are ringing in the ears, temporary impairment of vision, and sometimes disturbance of kidney function leading to renal failure.
Uses The most important use of quinine is its original one in malaria, attacks of which it quickly cuts short or prevents altogether. It has been largely replaced by more e?ective and less toxic antimalarial drugs; however, development of malarial parasites resistant to newer drugs has revived the use of quinine. For intravenous injection, when this is necessary in cases of malaria, a soluble form of quinine, the dihydrochloride, is used. Quinine can also be given in combination with other antimalarial drugs on medical advice. The drug is sometimes used in the treatment of cramps.
During a bite by the female mosquito, one or more sporozoites – a stage in the life-cycle of the parasite – are injected into the human circulation; these are taken up by the hepatocytes (liver cells). Following division, merozoites (minute particles resulting from the division) are liberated into the bloodstream where they invade red blood cells. These in turn divide, releasing further merozoites. As merozoites are periodically liberated into the bloodstream, they cause the characteristic fevers, rigors, etc.
Malaria occurs in many tropical and subtropical countries; P. falciparum is, however, con?ned very largely to Africa, Asia and South America. Malaria is present in increasingly large areas; in addition, the parasites are developing resistance to various preventative and treatment drugs. The disease constitutes a signi?cant problem for travellers, who must obtain sound advice on chemoprophylaxis before embarking on tropical trips – especially to a rural area where intense transmission can occur. Transmission has also been recorded at airports, and following blood transfusion.
The World Health Organisation (WHO) has listed malaria as one of Europe’s top ten infectious diseases. In 1992, 20,000 cases were reported: this had risen to more than 200,000 by the late 1990s. The resurgence of malaria has been worldwide, in part the result of the development of resistant strains of the disease, and in part because many countries have failed (or been unable) to implement environmental measures to eliminate mosquitoes. Nearly 40 years ago the WHO forecast that by 1980 only four million people would be affected worldwide; now, at the beginning of the 21st century, around 500 million people a year are contracting malaria with about 3,000 people a day dying from the infection – as many as 70 per cent of them children under the age of ?ve, according to WHO ?gures. The apparently steady advance of global warming means that countries with temperate climates may well warm up su?ciently to enable malaria to become established as an ENDEMIC disease. In any case, the great increase in international air travel has exposed many more people to the risk of malaria, and infected individuals may not exhibit symptoms until they are back home. Doctors seeing a recent traveller with unexplained pyrexia and illness should consider the possibility of malarial infection.
Diagnosis is by demonstration of trophozoites – a stage in the parasite’s life-cycle that takes place in red blood cells – in thick/thin blood-?lms of peripheral blood. Serological tests are of value in deciding whether an individual has had a past infection, but are of no value in acute disease.
P. vivax and P. ovale infections cause less severe disease than P. falciparum (see below), although overall there are many clinical similarities; acute complications are unusual, but chronic ANAEMIA is often present. Primaquine is necessary to eliminate the exoerythrocytic cycle in the hepatocyte (liver cell).
P. falciparum Complications of P. falciparum infection include cerebral involvement (see BRAIN – Cerebrum), due to adhesion of immature trophozoites on to the cerebral vascular endothelium; these lead to a high death rate when inadequately treated. Renal involvement (frequently resulting from HAEMOGLOBINURIA), PULMONARY OEDEMA, HYPOTENSION, HYPOGLYCAEMIA, and complications in pregnancy are also important. In complicated disease, HAEMODIALYSIS and exchange TRANSFUSION have been used. No adequate controlled trial using the latter regimen has been carried out, however, and possible bene?ts must be weighed against numerous potential side-effects – for instance, the introduction of a wide range of infections, overload of the circulatory system with infused ?uids, and other complications.
P. malariae usually produces a chronic infection, and chronic renal disease (nephrotic syndrome) is an occasional sequel, especially in tropical Africa.
Gross SPLENOMEGALY (hyper-reactive malarious splenomegaly, or tropical splenomegaly syndrome) can complicate all four human Plasmodium spp. infections. The syndrome responds to long-term malarial chemoprophylaxis. BURKITT’S LYMPHOMA is found in geographical areas where malaria infection is endemic; the EPSTEIN BARR VIRUS is aetiologically involved.
Prophylaxis Malaria specialists in the United Kingdom have produced guidance for residents travelling to endemic areas for short stays. Drug choice takes account of:
risk of exposure to malaria;
extent of drug resistance;
e?cacy of recommended drugs and their side-effects;
criteria relevant to the individual (e.g. age, pregnancy, kidney or liver impairment). Personal protection against being bitten by
mosquitoes is essential. Permethrinimpregnated nets are an e?ective barrier, while skin barrier protection and vaporised insecticides are helpful. Lotions, sprays or roll-on applicators all containing diethyltoluamide (DEET) are safe and work when put on the skin. Their e?ect, however, lasts only for a few hours. Long sleeves and trousers should be worn after dark.
Drug prophylaxis should be started at least a week before travelling into countries where malaria is endemic (two or three weeks in the case of me?oquine). Drug treatment should be continued for at least four weeks after leaving endemic areas. Even if all recommended antimalarial programmes are followed, it is possible that malaria may occur any time up to three months afterwards. Medical advice should be sought if any illness develops. Chloroquine can be used as a prophylactic drug where the risk of resistant falciparum malaria is low; otherwise, me?oquine or proguanil hydrochloride should be used. Travellers to malaria-infested areas should seek expert advice on appropriate prophylactic treatment well before departing.
Treatment Various chemoprophylactic regimes are widely used. Those commmonly prescribed include: chloroquine + paludrine, me?oquine, and Maloprim (trimethoprim + dapsone); Fansidar (trimethoprim + sulphamethoxazole) has been shown to have signi?cant side-effects, especially when used in conjunction with chloroquine, and is now rarely used. No chemotherapeutic regimen is totally e?ective, so other preventive measures are again being used. These include people avoiding mosquito bites, covering exposed areas of the body between dusk and dawn, and using mosquito repellents.
Chemotherapy was for many years dominated by the synthetic agent chloroquine. However, with the widespread emergence of chloroquine-resistance, quinine is again being widely used. It is given intravenously in severe infections; the oral route is used subsequently and in minor cases. Other agents currently in use include me?oquine, halofantrine, doxycycline, and the artemesinin alkaloids (‘qinghaosu’).
Researchers are working on vaccines against malaria.... malaria
The complication is frequently fatal, being associated with HAEMOGLOBINURIA, JAUNDICE, fever, vomiting and severe ANAEMIA. In an extreme case the patient’s urine appears black. Tender enlarged liver and spleen are usually present. The disease is triggered by quinine usage at subtherapeutic dosage in the presence of P. falciparum infection, especially in the non-immune individual. Now that quinine is rarely used for prevention of this infection (it is reserved for treatment), blackwater fever has become very unusual. Treatment is as for severe complicated P. falciparum infection with renal impairment; dialysis and blood transfusion are usually indicated. When inadequately treated, the mortality rate may be over 40 per cent but, with satisfactory intensive therapy, this should be reduced substantially.... blackwater fever
Habitat: The alpine Himalayas of Sikkim, Nepal, the adjoining parts of southern Tibet, between altitudes of 3,000 m and 4,800 m. Ayurvedic: Prativishaa, Shyaamkan- daa, Patis. Folk: Bikhamaa.
Action: Root—antiemetic, antidiar- rhoeal, antirheumatic, antiperiodic.
The root contains diterpenoid alkaloids and a nitrogenous non-alkaloid compound, benzamide. Alkaloids include vakognavine, palmatisine, vaka- tisine, vakatisinine and vakatidine.The root is intensely bitter, like quinine, is used with Piper longum for diarrhoea and vomiting; used externally as an application for rheumatism.... aconitum violaceumNeutral principals are crystalline substances with actions similar to those of alkaloids but having a neutral reaction. The name of a neutral principal ends in ‘in’, e.g. digitalin, aloin.
The following are the more important alkaloids, with their source plants:
Aconite, from Monkshood.
Atropine, from Belladonna (juice of Deadly
Nightshade).
Cocaine, from Coca leaves.
Hyoscine, from Henbane.
Morphine, Codeine, from Opium (juice of
Poppy). Thebaine, Nicotine, from Tobacco. Physostigmine, from Calabar beans. Pilocarpine, from Jaborandi leaves. Quinidine, from Cinchona or Peruvian bark. Strychnine, from Nux Vomica seeds.... alkaloids
Habitat: Throughout India, up to an altitude of 1,500 m.
English: Coffee Senna, Foetid Cassia, Negro Coffee.Ayurvedic: Kaasamarda, Kaasaari.Unani: Kasondi.Siddha/Tamil: Paeyaavarai, Thagarai.Folk: Kasondi (bigger var.).Action: Purgative, diuretic, febrifugal, expectorant, stomachic. Leaves—used internally and externally in scabies, ringworm and other skin diseases. A hot decoction is given as an antiperiodic. Seeds— used for cough, whooping cough and convulsions. Roasted seeds (roasting destroys the purgative property) are mixed with coffee for strength.
The pods contain sennosides and anthraquinones; seeds polysacchari- des, galactomannan; leaves dianthron- ic hetroside; pericarp apigenin; roots emodol; plant xanthone—cassiolin; seeds phytosterolin; flowers physcion and its glucosides, emodin and beta- sitosterol.The volatile oil obtained from the leaves, roots and seeds showed antibacterial and antifungal activity.The seeds, when fed to animals, resulted in weight loss and also were found to be toxic to experimental animals. Leaves are preferred to quinine as a tonic, seeds are considered as a hae- mateinic toxic and root is used as a hepatic tonic.Dosage: Seed—3-6 g powder; leaf—10-20 ml juice; root bark— 50-100 ml decoction. (CCRAS.)... cassia occidentalisExamination of the ear includes inspection of the external ear. An auriscope is used to examine the external ear canal and the ear drum. If a more detailed inspection is required, a microscope may be used to improve illumination and magni?cation.
Tuning-fork or Rinne tests are performed to identify the presence of DEAFNESS. The examiner tests whether the vibrating fork is audible at the meatus, and then the foot of the fork is placed on the mastoid bone of the ear to discover at which of the two sites the patient can hear the vibrations for the longest time. This can help to di?erentiate between conductive and nerve deafness.
Hearing tests are carried out to determine the level of hearing. An audiometer is used to deliver a series of short tones of varying frequency to the ear, either through a pair of headphones or via a sound transducer applied directly to the skull. The intensity of the sound is gradually reduced until it is no longer heard and this represents the threshold of hearing, at that frequency, through air and bone respectively. It may be necessary to play a masking noise into the opposite ear to prevent that ear from hearing the tones, enabling each ear to be tested independently.
General symptoms The following are some of the chief symptoms of ear disease: DEAFNESS (see DEAFNESS). EARACHE is most commonly due to acute in?ammation of the middle ear. Perceived pain in this region may be referred from other areas, such as the earache commonly experienced after tonsillectomy (removal of the TONSILS) or that caused by carious teeth (see TEETH, DISORDERS OF). The treatment will depend on the underlying cause. TINNITUS or ringing in the ear often accompanies deafness, but is sometimes the only symptom of ear disease. Even normal people sometimes experience tinnitus, particularly if put in soundproofed surroundings. It may be described as hissing, buzzing, the sound of the sea, or of bells. The intensity of the tinnitis usually ?uctuates, sometimes disappearing altogether. It may occur in almost any form of ear disease, but is particularly troublesome in nerve deafness due to ageing and in noise-induced deafness. The symptom seems to originate in the brain’s subcortical regions, high in the central nervous system. It may be a symptom of general diseases such as ANAEMIA, high blood pressure and arterial disease, in which cases it is often synchronous with the pulse, and may also be caused by drugs such as QUININE, salicylates (SALICYLIC ACID and its salts, for example, ASPIRIN) and certain ANTIBIOTICS. Treatment of any underlying ear disorder or systemic disease, including DEPRESSION, may reduce or even cure the tinnitis, but unfortunately in many cases the noises persist. Management involves psychological techniques and initially an explanation of the mechanism and reassurance that tinnitus does not signify brain disease, or an impending STROKE, may help the person. Tinnitus maskers – which look like hearing aids – have long been used with a suitably pitched sound helping to ‘mask’ the condition.
Diseases of the external ear
WAX (cerumen) is produced by specialised glands in the outer part of the ear canal only. Impacted wax within the ear canal can cause deafness, tinnitis and sometimes disturbance of balance. Wax can sometimes be softened with olive oil, 5-per-cent bicarbonate of soda or commercially prepared drops, and it will gradually liquefy and ‘remove itself’. If this is ineffective, syringing by a doctor or nurse will usually remove the wax but sometimes it is necessary for a specialist (otologist) to remove it manually with instruments. Syringing should not be done if perforation of the tympanic membrane (eardrum) is suspected. FOREIGN BODIES such as peas, beads or buttons may be found in the external ear canal, especially in children who have usually introduced them themselves. Live insects may also be trapped in the external canal causing intense irritation and noise, and in such cases spirit drops are ?rst instilled into the ear to kill the insect. Except in foreign bodies of vegetable origin, where swelling and pain may occur, syringing may be used to remove some foreign bodies, but often removal by a specialist using suitable instrumentation and an operating microscope is required. In children, a general anaesthetic may be needed. ACUTE OTITIS EXTERNA may be a di?use in?ammation or a boil (furuncle) occurring in the outer ear canal. The pinna is usually tender on movement (unlike acute otitis media – see below) and a discharge may be present. Initially treatment should be local, using magnesium sulphate paste or glycerine and 10-per-cent ichthaminol. Topical antibiotic drops can be used and sometimes antibiotics by mouth are necessary, especially if infection is acute. Clotrimazole drops are a useful antifungal treatment. Analgesics and locally applied warmth should relieve the pain.
CHRONIC OTITIS EXTERNA producing pain and discharge, can be caused by eczema, seborrhoeic DERMATITIS or PSORIASIS. Hair lotions and cosmetic preparations may trigger local allergic reactions in the external ear, and the chronic disorder may be the result of swimming or use of dirty towels. Careful cleaning of the ear by an ENT (Ear, Nose & Throat) surgeon and topical antibiotic or antifungal agents – along with removal of any precipitating cause – are the usual treatments. TUMOURS of the ear can arise in the skin of the auricle, often as a result of exposure to sunlight, and can be benign or malignant. Within the ear canal itself, the commonest tumours are benign outgrowths from the surrounding bone, said to occur in swimmers as a result of repeated exposure to cold water. Polyps may result from chronic infection of the ear canal and drum, particularly in the presence of a perforation. These polyps are soft and may be large enough to ?ll the ear canal, but may shrink considerably after treatment of the associated infection.
Diseases of the middle ear
OTITIS MEDIA or infection of the middle ear, usually occurs as a result of infection spreading up the Eustachian tubes from the nose, throat or sinuses. It may follow a cold, tonsillitis or sinusitis, and may also be caused by swimming and diving where water and infected secretions are forced up the Eustachian tube into the middle ear. Primarily it is a disease of children, with as many as 1.5 million cases occurring in Britain every year. Pain may be intense and throbbing or sharp in character. The condition is accompanied by deafness, fever and often TINNITUS.
In infants, crying may be the only sign that something is wrong – though this is usually accompanied by some localising manifestation such as rubbing or pulling at the ear. Examination of the ear usually reveals redness, and sometimes bulging, of the ear drum. In the early stages there is no discharge, but in the later stages there may be a discharge from perforation of the ear drum as a result of the pressure created in the middle ear by the accumulated pus. This is usually accompanied by an immediate reduction in pain.
Treatment consists of the immediate administration of an antibiotic, usually one of the penicillins (e.g. amoxicillin). In the majority of cases no further treatment is required, but if this does not quickly bring relief then it may be necessary to perform a myringotomy, or incision of the ear drum, to drain pus from the middle ear. When otitis media is treated immediately with su?cient dosage of the appropriate antibiotic, the chances of any permanent damage to the ear or to hearing are reduced to a negligible degree, as is the risk of any complications such as mastoiditis (discussed later in this section). CHRONIC OTITIS MEDIA WITH EFFUSION or glue ear, is the most common in?ammatory condition of the middle ear in children, to the extent that one in four children in the UK entering school has had an episode of ‘glue ear’. It is characterised by a persistent sticky ?uid in the middle ear (hence the name); this causes a conductive-type deafness. It may be associated with enlarged adenoids (see NOSE, DISORDERS OF) which impair the function of the Eustachian tube. If the hearing impairment is persistent and causes problems, drainage of the ?uid, along with antibiotic treatment, may be needed – possibly in conjunction with removal of the adenoids. The insertion of grommets (ventilation tubes) was for a time standard treatment, but while hearing is often restored, there may be no long-term gain and even a risk of damage to the tympanic membrane, so the operation is less popular than it was a decade or so ago. MASTOIDITIS is a serious complication of in?ammation of the middle ear, the incidence of which has been dramatically reduced by the introduction of antibiotics. In?ammation in this cavity usually arises by direct spread of acute or chronic in?ammation from the middle ear. The signs of this condition include swelling and tenderness of the skin behind the ear, redness and swelling inside the ear, pain in the side of the head, high fever, and a discharge from the ear. The management of this condition in the ?rst instance is with antibiotics, usually given intravenously; however, if the condition fails to improve, surgical treatment is necessary. This involves draining any pus from the middle ear and mastoid, and removing diseased lining and bone from the mastoid.
Diseases of the inner ear
MENIÈRE’S DISEASE is a common idiopathic disorder of ENDOLYMPH control in the semicircular canals (see EAR), characterised by the triad of episodic VERTIGO with deafness and tinnitus. The cause is unknown and usually one ear only is affected at ?rst, but eventually the opposite ear is affected in approximately 50 per cent of cases. The onset of dizziness is often sudden and lasts for up to 24 hours. The hearing loss is temporary in the early stages, but with each attack there may be a progressive nerve deafness. Nausea and vomiting often occur. Treatment during the attacks includes rest and drugs to control sickness. Vasodilator drugs such as betahistine hydrochloride may be helpful. Surgical treatment is sometimes required if crippling attacks of dizziness persist despite these measures. OTOSCLEROSIS A disorder of the middle ear that results in progressive deafness. Often running in families, otosclerosis affects about one person in 200; it customarily occurs early in adult life. An overgrowth of bone ?xes the stapes (the innermost bone of the middle ear) and stops sound vibrations from being transmitted to the inner ear. The result is conductive deafness. The disorder usually affects both ears. Those affected tend to talk quietly and deafness increases over a 10–15 year period. Tinnitus often occurs, and occasionally vertigo.
Abnormal hearing tests point to the diagnosis; the deafness may be partially overcome with a hearing aid but surgery is eventually needed. This involves replacing the stapes bone with a synthetic substitute (stapedectomy). (See also OTIC BAROTRAUMA.)... ear, diseases of
Habitat: Muddy shores and tidal creeks of India.
English: Compound Cymed Mangrove.Folk: Kirrari (Sindh, Maharashtra). Chauri (Maharashtra). Goran (Bengal, Sundarbans).Siddha/Tamil: Pandikutti, Pavrikutti, Pavrikutti, Kandal, Chira.Action: Plant—astringent. Stem bark—hypoglycaemic. Bark— haemostatic. A decoction is used to stop haemorrhage and is applied to malignant ulcers; also given after child birth.
Shoots—used as a substitute for quinine.The leaves (dry basis) gave 15.45% tannin, 19.99% non-tannin; twig bark 25.89%, tannin, 9.8% non-tannin; bole bark 41.42% tannin, 10.58% non-tannin.Presence of sitosterol, cholesterol, campesterol, stigmasterol, 28-isofu- costerol and a hydrocarbon, squalene, is reported in the leaves.... ceriops candolleanaHabitat: Cultivated in West Bengal and Tamil Nadu.
English: Crown or Loxa Bark.Ayurvedic: Quinine.Unani: Al-keenaa, Kanakanaa.Action: Antimalarial, febrifuge, astringent, orexigenic, sapasmolytic. Also prescribed in amoebic dysentery, jaundice, atonic dyspepsia, night cramps. Sometimes causes gastric and intestinal irritation.
Key application: In peptic discomforts such as bloating and fullness, loss of appetite. (German Commission E.)The bark contains alkaloids quinine (2.35-4.42%); quinidine (1.44-2.56%); cinchonine (0.10-0.66%); cinchoni- dine (0.49-0.89%) and other alkaloids, quinamine, javanine (0.14-0.63%).The leaves contain quercetin, kaem- pferol and avicularin.Quinine is antimalarial; quinidine is antiarrhythmic and cardiac tonic, also used in psychic treatments.The bark shows potent inhibitory activity against polymorphonuclear leucocytes; the activity is attributed to the alkaloids of the bark. Cinchona may potentiate coumarin derivatives. In large doses, it is sedative to CNS and cardiac plexus.Quinine is toxic at over 3 g, quini- dine at 1 g.Related Cinchona sp.: C. calisaya Wedd. (Nilgiris and Sikkim); C. calisaya Wedd. var. ledgeriana How. (West Bengal, Khasi Hills and Tamil Nadu); and C. succirubra Pav. ex Klotz. (Nilgiris and Annamalis in Tamil Nadu, Sikkim and West Bengal).The bark of all the species contain quinine, quinidine, cinchonine and cinchonidine and exhibit antimalarial activity. The alcoholic extract of C. ledgeriana Moens ex Trimen bark exhibits antibacterial activity against Gram-positive bacteria comparable to sodium penicillin. The extract, however, exhibits lesser activity than di- hydrostreptomycin sulphate against Gram-negative bacteria.... cinchona officinalisHabitat: Throughout India in tidal forests, wild all over coastal areas; planted in gardens in Tamil Nadu.
English: Smooth Volkameria.Ayurvedic: Putigandhaa, Kundali, Vanajai.Siddha/Tamil: Peenaari, Sangan- kuppi.Folk: Lanjai.Action: Leaf—febrifuge, alterative. Used as a substitute for Swertia chirayita and quinine in remittent and intermittent fevers. The leaf juice is taken orally to relieve muscular pains and stiffness of legs (in tetanus).
The leaves and stem contain a number of triterpenes, neolignans, diter- penoids, sterols and flavones.The roots are prescribed in venereal diseases. The methanolic extract of the roots contains verbascoside which exhibits analgesic and antimicrobial properties.... clerodendrum inermeCramp Painful spasm of a muscle usually caused by excessive and prolonged contraction of the muscle ?bres. Cramps are common, especially among sportsmen and women, normally lasting a short time. The condition usually occurs during or immediately following exercise as a result of a build-up of LACTIC ACID and other chemical by-products in the muscles
– caused by the muscular e?orts. Cramps may occur more frequently, especially at night, in people with poor circulation, when the blood is unable to remove the lactic acid from the muscles quickly enough.
Repetitive movements such as writing (writer’s cramp) or operating a keyboard can cause cramp. Resting muscles may suffer cramp if a person sits or lies in an awkward position which limits local blood supply to them. Profuse sweating as a result of fever or hot weather can also cause cramp in resting muscle, because the victim has lost sodium salts in the sweat; this disturbs the biochemical balance in muscle tissue.
Treatment is to massage and stretch the affected muscle – for example, cramp in the calf muscle may be relieved by pulling the toes on the affected leg towards the knee. Persistent night cramps sometimes respond to treatment with a drug containing CALCIUM or QUININE. If cramp persists for an hour or more, the person should seek medical advice, as there may be a serious cause such as a blood clot impeding the blood supply to the area affected.
Dystrophy See myopathy below.
In?ammation (myositis) of various types may occur. As the result of injury, an ABSCESS may develop, although wounds affecting muscle generally heal well. A growth due to SYPHILIS, known as a gumma, sometimes forms a hard, almost painless swelling in a muscle. Rheumatism is a vague term traditionally used to de?ne intermittent and often migratory discomfort, sti?ness or pain in muscles and joints with no obvious cause. The most common form of myositis is the result of immunological damage as a result of autoimmune disease. Because it affects many muscles it is called POLYMYOSITIS.
Myasthenia (see MYASTHENIA GRAVIS) is muscle weakness due to a defect of neuromuscular conduction.
Myopathy is a term applied to an acquired or developmental defect in certain muscles. It is not a neurological disease, and should be distinguished from neuropathic conditions (see NEUROPATHY) such as MOTOR NEURONE DISEASE (MND), which tend to affect the distal limb muscles. The main subdivisions are genetically determined, congenital, metabolic, drug-induced, and myopathy (often in?ammatory) secondary to a distant carcinoma. Progressive muscular dystrophy is characterised by symmetrical wasting and weakness, the muscle ?bres being largely replaced by fatty and ?brous tissue, with no sensory loss. Inheritance may take several forms, thus affecting the sex and age of victims.
The commonest type is DUCHENNE MUSCULAR DYSTROPHY, which is inherited as a sex-linked disorder. It nearly always occurs in boys.
Symptoms There are three chief types of myopathy. The commonest, known as pseudohypertrophic muscular dystrophy, affects particularly the upper part of the lower limbs of children. The muscles of the buttocks, thighs and calves seem excessively well developed, but nevertheless the child is clumsy, weak on his legs, and has di?culty in picking himself up when he falls. In another form of the disease, which begins a little later, as a rule at about the age of 14, the muscles of the upper arm are ?rst affected, and those of the spine and lower limbs become weak later on. In a third type, which begins at about this age, the muscles of the face, along with certain of the shoulder and upper arm muscles, show the ?rst signs of wasting. All the forms have this in common: that the affected muscles grow weaker until their power to contract is quite lost. In the ?rst form, the patients seldom reach the age of 20, falling victims to some disease which, to ordinary people, would not be serious. In the other forms the wasting, after progressing to a certain extent, often remains stationary for the rest of life. Myopathy may also be acquired when it is the result of disease such as thyrotoxicosis (see under THYROID GLAND, DISEASES OF), osteomalacia (see under BONE, DISORDERS OF) and CUSHING’S DISEASE, and the myopathy resolves when the primary disease is treated.
Treatment Some myopathies may be the result of in?ammation or arise from an endocrine or metabolic abnormality. Treatment of these is the treatment of the cause, with supportive physiotherapy and any necessary physical aids while the patient is recovering. Treatment for the hereditary myopathies is supportive since, at present, there is no cure – although developments in gene research raise the possibility of future treatment. Physiotherapy, physical aids, counselling and support groups may all be helpful in caring for these patients.
The education and management of these children raise many diffculties. Much help in dealing with these problems can be obtained from Muscular Dystrophy Campaign.
Myositis ossi?cans, or deposition of bone in muscles, may be congenital or acquired. The congenital form, which is rare, ?rst manifests itself as painful swellings in the muscles. These gradually harden and extend until the child is encased in a rigid sheet. There is no e?ective treatment and the outcome is fatal.
The acquired form is a result of a direct blow on muscle, most commonly on the front of the thigh. The condition should be suspected whenever there is severe pain and swelling following a direct blow over muscle. The diagnosis is con?rmed by hardening of the swelling. Treatment consists of short-wave DIATHERMY with gentle active movements. Recovery is usually complete.
Pain, quite apart from any in?ammation or injury, may be experienced on exertion. This type of pain, known as MYALGIA, tends to occur in un?t individuals and is relieved by rest and physiotherapy.
Parasites sometimes lodge in the muscles, the most common being Trichinella spiralis, producing the disease known as TRICHINOSIS (trichiniasis).
Rupture of a muscle may occur, without any external wound, as the result of a spasmodic e?ort. It may tear the muscle right across – as sometimes happens to the feeble plantaris muscle in running and leaping – or part of the muscle may be driven through its ?brous envelope, forming a HERNIA of the muscle. The severe pain experienced in many cases of LUMBAGO is due to tearing of one of the muscles in the back. These conditions are usually relieved by rest and massage. Partial muscle tears, such as occur in sport, require more energetic treatment: in the early stages this consists of the application of an ice or cold-water pack, ?rm compression, elevation of the affected limb, rest for a day or so and then gradual mobilisation (see SPORTS MEDICINE).
Tumours occur occasionally, the most common being ?broid, fatty, and sarcomatous growths.
Wasting of muscles sometimes occurs as a symptom of disease in other organs: for example, damage to the nervous system, as in poliomyelitis or in the disease known as progressive muscular atrophy. (See PARALYSIS.)... muscles, disorders of
Action: febrifuge, anti-periodic. Used by Australian aborigines for all kinds of fevers. Contains indole alkaloids.
Other uses: high blood pressure, mild analgesic, intermittent fevers.
Preparations: Thrice daily.
Tea: 1oz to 1 pint water simmered gently 5 minutes: one wineglassful. Liquid Extract: 5-30 drops. Powdered bark: 1-3g. Tincture. 15-60 drops. ... alstonia bark
Habitat: The temperate Himalayas from Nepal to Bhutan and Khasi Hills.
Folk: BasakAction: Febrifuge, antipyretic, antiparasitic (used for malarial fever). Dried roots, known as Chang Shan, dried leafy tops, known as Shu Chi, in Chinese medicine, are used for malarial fever. Dried roots (Chang Shan) contain the alkaloid dichroine A and B, dichrin A and B.
The active principle febrifugine compared to quinine was estimated to be 16 to 64 times more efficacious against Plasmodium gallinaceum in chicks, about 100 times against Plasmodium lophurae in ducks also against Plasmodium relictum in canaries. The aqueous extract of the plant inhibited the infecting rate of the parasite Plasmodium berghei up to 10 days and increased the mean survival time to twice that of untreated control at 2.5 g/kg dose.Clinical trials with febrifugine indicated that the drug given in four oral doses totalling 2-5 mg/day reduces the parasite count.... dichroa febrifugaHabitat: Native to tropical America; naturalized and occurs throughout India. Also grown as hedge plant.
English: Lantana, Wild Sage, Surinam Tea Plant.Ayurvedic: Chaturaangi, Vanachch- hedi.Siddha/Tamil: Unnichedi.Folk: Ghaaneri (Maharashtra).Action: Plant—antirheumatic, antimalarial; used in tetanus and ataxy of abdominal viscera. Pounded leaves are applied to cuts, ulcers and swellings; a decoction of leaves and fruits is used as a lotion for wounds.
The plant is considered poisonous. The leaves contain toxic principles, lantadenes A and B, which cause acute photosensitization, jaundice, kidney and liver lesions. A steroid, lanca- marone, is cardioactive and fish poison.The bark of stems and roots contain a quinine-like alkaloid, lantanine. The extract of the shoot showed antibacterial activity against E. coli and Micrococcus pyogenes var. aureus. Flowers contain anthocyanin.... lantana camaraHabitat: Northwestern Himalaya at 1,200-3,000 m, also grown in avenues.
English: White Poplar.Folk: Safedaa, Jangali Fraas.Action: Bark—antirheumatic, anti-inflammatory, antibacterial, antipyretic, diuretic, febrifuge, stimulant, antiseptic. Used for arthritis, rheumatic affections, cystitis and other urinary diseases, stomach and liver disorders, anorexia and debility.
Key application: Unopened leaf- buds externally for haemorrhoids, frostbite and sunburn. (German Commission E.)The bark contains glycosides, salicin and populin, erisin and tannin (5-9%). Salicin, a bitter tonic and antiperiod- ic, is used like quinine in intermittent fever, also in rheumatism.... populus albaHabitat: North-western Himalaya at 900-3,700 m.
English: Black Lombardy Poplar.Action: Bark and balsam from leaf bud— used for cold. Bark— depurative. Leaf bud—antiseptic, anti- inflammatory.
The bud exudate contains dimethyl- caffeic acid, which was found active against herpes simplex virus type 1.A 50% ethanol extract of a mixture of flowers and buds showed 11% inhibition of enzymatic conversion of testosterone into 5 alpha-dihydrotesterone and 4-androstene-3,17-dione. The extract was partitioned between ethylac- etate and water and the resultant ethy- lacetate fraction contained the active compounds, pinobanksin, demethyl- quercetin and pinocembrin. It exhibited 15% inhibitory activity on the enzyme. Pinocembrin was the most potent, almost equal to estradiol, which was used as a control.The bark of all Populus species contains, phenolic glycosides, salicin and populin (salicinbenzoate). Tannins are also present (5-9%).Both salicin and populin cause elimination of uric acid. Salicin is antiperi- odic and is used like quinine in intermittent fever, also in coryza, rheumatism and neuralgia.... populus nigraCauses
KIDNEY DISEASE is the most important cause of proteinuria, and in some cases the discovery of proteinuria may be the ?rst evidence of such disease. This is why an examination of the urine for the presence of albumin constitutes an essential part of every medical examination. Almost any form of kidney disease will cause proteinuria, but the most frequent form to do this is glomerulonephritis (see under KIDNEYS, DISEASES OF). In the subacute (or nephrotic) stage of glomerulonephritis, the most marked proteinuria of all may be found. Proteinuria is also found in infections of the kidney (pyelitis) as well as in infections of the bladder (cystitis) and of the urethra (urethritis). PREGNANCY The development of proteinuria in pregnancy requires investigation, as it may be the ?rst sign of one of the most dangerous complications of pregnancy: toxaemia of pregnancy (PRE-ECLAMPSIA and ECLAMPSIA) and glomerulonephritis. Proteinuria may also result from the contamination of urine with vaginal secretions. (See also PREGNANCY AND LABOUR.) CARDIOVASCULAR DISORDERS are commonly accompanied by proteinuria, particularly when the right side of the heart is failing. In severe cases of failure, accompanied by OEDEMA, the proteinuria may be marked. (See also HEART, DISEASES OF.) FEVER often causes proteinuria, even though there is no actual kidney disease. The proteinuria disappears soon after the temperature becomes normal. (See also PYREXIA.) DRUGS AND POISONS These include arsenic, lead, mercury, gold, copaiba, salicylic acid and quinine. ANAEMIA A trace of albumin may be found in the urine in severe anaemia.
POSTURAL OR ORTHOSTATIC ALBUMINURIA
This type is important because, if its true cause is unrecognised, it may be taken as a sign of kidney disease. The signi?cance of postural proteinuria is unclear: it is more common among young people and is absent when the person is recumbent – hence the importance of testing a urine sample that is taken before rising in the morning.
Treatment The treatment is that of the underlying disease. (See KIDNEYS, DISEASES OF.)... proteinuria
The daily urine output varies, but averages around 1,500 ml in adults, less in children. The ?uid intake and ?uid output (urine and PERSPIRATION) are interdependent, so as to maintain a relatively constant ?uid balance. Urine output is increased in certain diseases, notably DIABETES MELLITUS; it is diminished (or even temporarily stopped) in acute glomerulonephritis (see under KIDNEYS, DISEASES OF), heart failure, and fevers generally. Failure of the kidneys to secrete any urine is known as anuria, while stoppage due to obstruction of the ureters (see URETER) by stones, or of the URETHRA by a stricture, despite normal urinary secretion, is known as urinary retention.
Normal urine is described as straw- to amber-coloured, but may be changed by various diseases or drugs. Chronic glomerulonephritis or poorly controlled diabetes may lead to a watery appearance, as may drinking large amounts of water. Consumption of beetroot or rhubarb may lead to an orange or red colour, while passage of blood in the urine (haematuria) results in a pink or bright red appearance, or a smoky tint if just small amounts are passed. A greenish urine is usually due to BILE, or may be produced by taking QUININE.
Healthy urine has a faint aroma, but gives o? an unpleasant ammoniacal smell when it begins to decompose, as may occur in urinary infections. Many foods and additives give urine a distinctive odour; garlic is particularly characteristic. The density or speci?c gravity of urine varies normally from 1,015 to 1,025: a low value suggests chronic glomerulonephritis, while a high value may occur in uncontrolled diabetes or during fevers. Urine is normally acidic, which has an important antiseptic action; it may at times become alkaline, however, and in vegetarians, owing to the large dietary consumption of alkaline salts, it is permanently alkaline.
Chemical or microscopical examination of the urine is necessary to reveal abnormal drugs, poisons, or micro-organisms. There are six substances which must be easily detectable for diagnostic purposes: these are ALBUMINS, blood, GLUCOSE, bile, ACETONE, and PUS and tube-casts (casts from the lining of the tubules in the kidneys). Easily used strip tests are available for all of these, except the last.
Excess of urine It is important to distinguish urinary frequency from increase in the total amount of urine passed. Frequency may be due to reduced bladder capacity, such as may be caused by an enlarged PROSTATE GLAND, or due to any irritation or infection of the kidneys or bladder, such as CYSTITIS or the formation of a stone. Increased total urinary output, on the other hand, is often a diagnostic feature of diabetes mellitus. Involuntary passage of urine at night may result, leading to bed wetting, or NOCTURNAL ENURESIS in children. Diagnosis of either condition, therefore, means that the urine should be tested for glucose, albumin, gravel (fragments of urinary calculi), and pus, with appropriate treatment.... urine
Habitat: Distributed throughout India. Common in waste places and road side.
English: Ash coloured Fleabane, Purple Fleabane.Ayurvedic: Sahadevi, Uttamkanya- ka, Dandotpalaa.Siddha/Tamil: Naichotte Poonde.Action: Plant—febrifuge, diaphoretic (infusion of herb, combined with quinine, is used against malaria). Used as a specific herb for leucor- rhoea, dysuria, spasm of bladder, strangury and for haematological disorders, as a blood purifier and styptic. Also used in asthma. Seeds—anthelmintic, antiflatulent, antispasmodic; used in dysuria, leucoderma, psoriasis and other skin diseases. Roots—anthelmintic; decoction used for colic.
The Ayurvedic Pharmacopoeia ofIn- dia recommends the plant in inter mittent fever, filariasis, pityriasis versi- colour (tinea versicolor), blisters, boils, vaginal discharges and in cases of psy- choneurosis.Aerial parts gave luteolin-7-mono- beta-D-glucopyranoside. Whole plant gave triterpene compounds—beta- amyrin acetate, lupeol acetate, beta- amyrin and lupeol; sterols—beta-sito- sterol, stigmasterol and alpha-spinaste- rol; phenolic resin and potassium chloride.Dosage: Whole plant—10-20 ml juice; 5-10 g powder for external use. (API, Vol. III.)... vernonia cinereaAction: antiperiodic, diuretic, laxative.
Uses: Promotes excretion of uric acid. Intermittent fevers; one-time substitute for Quinine, (Bark). As a tea, the young leaves have a reputation for gout, rheumatism and sluggish kidney function. “To stimulate blood circulation of hands and feet” (Russian Science Academy).
Preparations: Tea: 1 heaped teaspoon, leaves, to each cup boiling water; infuse 15 minutes. Half a cup thrice daily.
Case: “A Mrs Louis, Connecticut, informed me that an Indian cured a cancer by internal and external use of the juice of White Ash that issued from the end of wood as it burned.” (Samuel Stearn, 1741-1809, in “American Herbal”.)
Poultice, for gouty and rheumatic limbs. Combines well with Devil’s Claw. ... ash
Constituents: quinoline alkaloids, (quinine is extracted from the bark) resin, tannins, glycosides.
Action: anti-protozoal, anti-cramp, anti-malarial, appetite stimulant, bitter, febrifuge, tonic.
Uses: Cinchona was named after the Countess of Cinchona, wife of the Viceroy of Peru who was cured of a malarial fever with the powdered bark. News of her recovery spread like wildfire through the high society circles of Europe which started a world demand for the bark.
Its temperature-reducing effect is felt by other fevers with shivering chill and violent shaking. Enlargement of the spleen due to abnormal destruction of blood cells. Iron-deficient anaemia. Atrial fibrillation of the heart. Alcoholism. Debility. For recovery from excessive diarrhoea, loss of blood and exhausting liver and gall bladder conditions. Persistent flatulence. Polymyalgia. Loss of appetite (with Hops).
Practitioner only use. The remedy is on the General Sales List, Schedule 2, Table A up to 50mg per dose (Rla); over 50mg per dose it is obtainable from a pharmacy only. Herbal practitioners are exempt up to 250mg per dose (750 daily).
Tincture (BPC 1949). Dose: 2 to 4ml.
Tonic Mineral Water. On open sale. A palatable way of taking quinine for malaria prevention. ... cinchona 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
Recurrent, sudden pain in a muscle that is not associated with hardness of the muscle may be caused by peripheral vascular disease. In this case, the condition should be investigated and treated by a doctor.... cramp
Many sufferers make use of a radio, television, cassette player, or headphones to block out the noise in their ears.
A tinnitus masker, a hearingaid type device that plays white noise (a random mixture of sounds at a wide range of frequencies), may be effective.... tinnitus
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