Pallor Health Dictionary

A reduced number or volume of red blood cells, which results in lowered haemoglobin levels as seen in a number of tropical diseases, e.g. malaria, hookworm disease. It may present with a number of symptoms and signs including fatigue and pallor, especially of the conjunctival and mucous membranes. There are many possible causes.... anaemia

Mental arousal that the individual may ?nd enjoyable or unpleasant. The three components are subjective, physiological and behavioural. The instinctive fear and ?ee response in animals comprises physiological reaction – raised heart rate, pallor and sweating – to an unpleasant event or stimulus. The loving relationship between mother and child is another wellrecognised emotional event. If this emotional bond is absent or inadequate, the child may suffer emotional deprivation, which can be the trigger for behavioural problems ranging from attention-craving to aggression. Emotional problems are common in human society, covering a wide spectrum of psychological disturbances. Upbringing, relationships or psychiatric illnesses such as anxiety and DEPRESSION may all contribute to the development of emotional problems (see MENTAL ILLNESS).... emotion

An ENZYME that performs an essential function in the metabolism of CARBOHYDRATE. A de?ciency in this enzyme – acronym G6PD – results in the breakdown of ERYTHROCYTES (HAEMOLYSIS), usually in the presence of oxidants (see OXIDANT) such as infections or drugs. The de?ciency disorder is a hereditary condition in which the enzyme is absent. The condition, characterised by pallor, rigors and pain in the loin, is divided into African, European (including FAVISM) and Oriental types. Sufferers should avoid substances that trigger haemolysis. Acute episodes are best treated symptomatically.... glucose-6-phosphate dehydrogenase

A condition resulting from environmental temperatures which are too high for compensation by the body’s thermo-regulatory mechanism(s). It is characterised by hyperpyrexia, nausea, headache, thirst, confusion, and dry skin. If untreated, COMA and death ensue. The occurrence of heat stroke is sporadic: whereas a single individual may be affected (occasionally with fatal consequences), his or her colleagues may remain unaffected. Predisposing factors include unsatisfactory living or working conditions, inadequate acclimatisation to tropical conditions, unsuitable clothing, underlying poor health, and possibly dietetic or alcoholic indiscretions. The condition can be a major problem during pilgrimages – for example, the Muslim Hadj. Four clinical syndromes are recognised:

Heat collapse is characterised by fatigue, giddiness, and temporary loss of consciousness. It is accompanied by HYPOTENSION and BRADYCARDIA; there may also be vomiting and muscular cramps. Urinary volume is diminished. Recovery is usual.

Heat exhaustion is characterised by increasing weakness, dizziness and insomnia. In the majority of sufferers, sweating is defective; there are few, if any, signs of dehydration. Pulse rate is normal, and urinary output good. Body temperature is usually 37·8–38·3 °C.

Heat cramps (usually in the legs, arms or back, and occasionally involving the abdominal muscles) are associated with hard physical work at a high temperature. Sweating, pallor, headache, giddiness and intense anxiety are present. Body temperature is only mildly raised.

Heat hyperpyrexia is heralded by energy loss and irritability; this is followed by mental confusion and diminution of sweating. The individual rapidly becomes restless, then comatose; body temperature rises to 41–42 °C or even higher. The condition is fatal unless expertly treated as a matter of urgency.

Treatment With the ?rst two syndromes, the affected individual must be removed immediately to a cool place, and isotonic saline administered – intravenously in a severe case. The fourth syndrome is a medical emergency. The patient should be placed in the shade, stripped, and drenched with water; fanning should be instigated. He or she should be wrapped in a sheet soaked in cool water and fanning continued. When rectal temperature has fallen to 39 °C, the patient is wrapped in a dry blanket. Immediately after consciousness returns, normal saline should be given orally; this usually provokes sweating. The risk of circulatory collapse exists. Convalescence may be protracted and the patient should be repatriated to a cool climate. Prophylactically, personnel intended for work in a tropical climate must be very carefully selected. Adequate acclimatisation is also essential; severe physical exertion must be avoided for several weeks, and light clothes should be worn. The diet should be light but nourishing, and ?uid intake adequate. Those performing hard physical work at a very high ambient temperature should receive sodium chloride supplements. Attention to ventilation and air-conditioning is essential; fans are also of value.... heat stroke

Diseases affecting the kidneys can be broadly classi?ed into congenital and genetic disorders; autoimmune disorders; malfunctions caused by impaired blood supply; infections; metabolic disorders; and tumours of the kidney. Outside factors may cause functional disturbances – for example, obstruction in the urinary tract preventing normal urinary ?ow may result in hydronephrosis (see below), and the CRUSH SYNDROME, which releases proteins into the blood as a result of seriously damaged muscles (rhabdomyolosis), can result in impaired kidney function. Another outside factor, medicinal drugs, can also be hazardous to the kidney. Large quantities of ANALGESICS taken over a long time damage the kidneys and acute tubular NECROSIS can result from certain antibiotics.

K

Diagram of glomerulus (Malpighian corpuscle).

Fortunately the body has two kidneys and, as most people can survive on one, there is a good ‘functional reserve’ of kidney tissue.

Symptoms Many patients with kidney disorders do not have any symptoms, even when the condition is quite advanced. However,

others experience loin pain associated with obstruction (renal colic) or due to infection; fevers; swelling (oedema), usually of the legs but occasionally including the face and arms; blood in the urine (haematuria); and excess quantities of urine (polyuria), including at night (nocturia), due to failure of normal mechanisms in the kidney for concentrating urine. Patients with chronic renal failure often have very di?use symptoms including nausea and vomiting, tiredness due to ANAEMIA, shortness of breath, skin irritation, pins and needles (paraesthesia) due to damage of the peripheral nerves (peripheral neuropathy), and eventually (rarely seen nowadays) clouding of consciousness and death.

Signs of kidney disease include loin tenderness, enlarged kidneys, signs of ?uid retention, high blood pressure and, in patients with end-stage renal failure, pallor, pigmentation and a variety of neurological signs including absent re?exes, reduced sensation, and a coarse ?apping tremor (asterixis) due to severe disturbance of the body’s normal metabolism.

Renal failure Serious kidney disease may lead to impairment or failure of the kidney’s ability to ?lter waste products from the blood and excrete them in the urine – a process that controls the body’s water and salt balance and helps to maintain a stable blood pressure. Failure of this process causes URAEMIA – an increase in urea and other metabolic waste products – as well as other metabolic upsets in the blood and tissues, all of which produce varying symptoms. Failure can be sudden or develop more slowly (chronic). In the former, function usually returns to normal once the underlying cause has been treated. Chronic failure, however, usually irreparably reduces or stops normal function.

Acute failure commonly results from physiological shock following a bad injury or major illness. Serious bleeding or burns can reduce blood volume and pressure to the point where blood-supply to the kidney is greatly reduced. Acute myocardial infarction (see HEART, DISEASES OF) or pancreatitis (see PANCREAS, DISORDERS OF) may produce a similar result. A mismatched blood transfusion can produce acute failure. Obstruction to the urine-?ow by a stone (calculus) in the urinary tract, a bladder tumour or an enlarged prostate can also cause acute renal failure, as can glomerulonephritis (see below) and the haemolytic-uraemia syndrome.

HYPERTENSION, DIABETES MELLITUS, polycystic kidney disease (see below) or AMYLOIDOSIS are among conditions that cause chronic renal failure. Others include stone, tumour, prostatic enlargement and overuse of analgesic drugs. Chronic failure may eventually lead to end-stage renal failure, a life-threatening situation that will need DIALYSIS or a renal transplant (see TRANSPLANTATION).

Familial renal disorders include autosomal dominant inherited polycystic kidney disease and sex-linked familial nephropathy. Polycystic kidney disease is an important cause of renal failure in the UK. Patients, usually aged 30–50, present with HAEMATURIA, loin or abdominal discomfort or, rarely, urinary-tract infection, hypertension and enlarged kidneys. Diagnosis is based on ultrasound examination of the abdomen. Complications include renal failure, hepatic cysts and, rarely, SUBARACHNOID HAEMORRHAGE. No speci?c treatment is available. Familial nephropathy occurs more often in boys than in girls and commonly presents as Alport’s syndrome (familial nephritis with nerve DEAFNESS) with PROTEINURIA, haematuria, progressing to renal failure and deafness. The cause of the disease lies in an absence of a speci?c ANTIGEN in a part of the glomerulus. The treatment is conservative, with most patients eventually requiring dialysis or transplantation.

Acute glomerulonephritis is an immune-complex disorder due to entrapment within glomerular capillaries of ANTIGEN (usually derived from B haemolytic streptococci – see STREPTOCOCCUS) antibody complexes initiating an acute in?ammatory response (see IMMUNITY). The disease affects children and young adults, and classically presents with a sore throat followed two weeks later by a fall in urine output (oliguria), haematuria, hypertension and mildly abnormal renal function. The disease is self-limiting with 90 per cent of patients spontaneously recovering. Treatment consists of control of blood pressure, reduced ?uid and salt intake, and occasional DIURETICS and ANTIBIOTICS.

Chronic glomerulonephritis is also due to immunological renal problems and is also classi?ed by taking a renal biopsy. It may be subdivided into various histological varieties as determined by renal biospy. Proteinuria of various degrees is present in all these conditions but the clinical presentations vary, as do their treatments. Some resolve spontaneously; others are treated with steroids or even the cytotoxic drug CYCLOPHOSPHAMIDE or the immunosuppressant cyclosporin. Prognoses are generally satisfactory but some patients may require renal dialysis or kidney transplantation – an operation with a good success rate.

Hydronephrosis A chronic disease in which the kidney becomes greatly distended with ?uid. It is caused by obstruction to the ?ow of urine at the pelvi-ureteric junction (see KIDNEYS – Structure). If the ureter is obstructed, the ureter proximal to the obstruction will dilate and pressure will be transmitted back to the kidney to cause hydronephrosis. Obstruction may occur at the bladder neck or in the urethra itself. Enlargement of the prostate is a common cause of bladder-neck obstruction; this would give rise to hypertrophy of the bladder muscle and both dilatation of the ureter and hydronephrosis. If the obstruction is not relieved, progressive destruction of renal tissue will occur. As a result of the stagnation of the urine, infection is probable and CYSTITIS and PYELONEPHRITIS may occur.

Impaired blood supply may be the outcome of diabetes mellitus and physiological shock, which lowers the blood pressure, also affecting the blood supply. The result can be acute tubular necrosis. POLYARTERITIS NODOSA and SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) may damage the large blood vessels in the kidney. Treatment is of the underlying condition.

Infection of the kidney is called pyelonephritis, a key predisposing factor being obstruction of urine ?ow through the urinary tract. This causes stagnation and provides a fertile ground for bacterial growth. Acute pyelonephritis is more common in women, especially during pregnancy when bladder infection (CYSTITIS) spreads up the ureters to the kidney. Symptoms are fever, malaise and backache. Antibiotics and high ?uid intake are the most e?ective treatment. Chronic pyelonephritis may start in childhood as a result of congenital deformities that permit urine to ?ow up from the bladder to the kidney (re?ux). Persistent re?ux leads to recurrent infections causing permanent damage to the kidney. Specialist investigations are usually required as possible complications include hypertension and kidney failure.

Tumours of the kidney are fortunately rare. Non-malignant ones commonly do not cause symptoms, and even malignant tumours (renal cell carcinoma) may be asymptomatic for many years. As soon as symptoms appear – haematuria, back pain, nausea, malaise, sometimes secondary growths in the lungs, bones or liver, and weight loss – urgent treatment including surgery, radiotherapy and chemotherapy is necessary. This cancer occurs mostly in adults over 40 and has a hereditary element. The prognosis is not good unless diagnosed early. In young children a rare cancer called nephroblastoma (Wilm’s tumour) can occur; treatment is with surgery, radiotherapy and chemotherapy. It may grow to a substantial size before being diagnosed.

Cystinuria is an inherited metabolic defect in the renal tubular reabsorption of cystine, ornithine, lysine and arginine. Cystine precipitates in an alkaline urine to form cystine stones. Triple phosphate stones are associated with infection and may develop into a very large branching calculi (staghorn calculi). Stones present as renal or ureteric pain, or as an infection. Treatment has undergone considerable change with the introduction of MINIMALLY INVASIVE SURGERY (MIS) and the destruction of stone by sound waves (LITHOTRIPSY).... kidneys, diseases of

Also known as Buerger’s disease, this is an in?ammatory disease involving the blood vessels and nerves of the limbs, particularly the lower limbs. TOBACCO is an important cause. Pain is the outstanding symptom, accompanied by pallor of the affected part; intermittent CLAUDICATION caused by a reduction in blood supply is common. Sooner or later ulceration and GANGRENE tend to develop in the feet or hands when AMPUTATION of the affected part may be necessary. There is no speci?c treatment, but, if seen in the early stages, considerable relief may be given to the patient. Regular walking exercise is helpful and affected individuals should not smoke.... thromboangiitis obliterans

A condition that some people experience during road, sea, or air travel. Symptoms range from uneasiness and headache to distress, excessive sweating and salivation, pallor, nausea, and vomiting.

Motion sickness is caused by the effect of repetitive movement on the organ of balance in the inner ear. Factors such as anxiety, a fume-laden atmosphere, or the sight of food may make the condition worse. So, too, can focusing on nearby objects; sufferers should look at a point on the horizon.

Motion sickness may be prevented or controlled by antiemetic drugs or by acupressure bands worn on the wrist.... motion sickness

n. subnormal activity of the pituitary gland, causing *dwarfism in childhood and a syndrome of impaired sexual function, pallor, and premature ageing in adult life (see Simmonds disease).... hypopituitarism

The daily requirement of iron for an adult is 12 mg, and 15–20 mg for an adult woman during pregnancy. This is well covered by an ordinary diet, so that by itself it is not a common cause. But if there is a steady loss of blood, as a result of heavy menstrual loss or ‘bleeding piles’, the intake of iron in the diet may not be su?cient to maintain adequate formation of haemoglobin.

Symptoms These depend upon whether the anaemia is sudden in onset, as in severe haemorrhage, or gradual. In all cases, however, the striking sign is pallor, the depth of which depends upon the severity of the anaemia. The colour of the skin may be misleading, except in cases due to severe haemorrhage, as the skin of many Caucasian people is normally pale. The best guide is the colour of the internal lining of the eyelid. When the onset of the anaemia is sudden, the patient complains of weakness and giddiness, and loses consciousness if he or she tries to stand or sit up. The breathing is rapid and distressed, the pulse is rapid and the blood pressure is low. In chronic cases the tongue is often sore (GLOSSITIS), and the nails of the ?ngers may be brittle and concave instead of convex (koilonychia). In some cases, particularly in women, the Plummer-Vinson syndrome is present: this consists of di?culty in swallowing and may be accompanied by huskiness; in these cases glossitis is also present. There may be slight enlargement of the SPLEEN, and there is usually some diminution in gastric acidity.

CHANGES IN THE BLOOD The characteristic change is a diminution in both the haemoglobin and the red cell content of the blood. There is a relatively greater fall in the haemoglobin than in the red cell count. If the blood is examined under a microscope, the red cells are seen to be paler and smaller than normal. These small red cells are known as microcytes.

Treatment consists primarily of giving suf?cient iron by mouth to restore, and then maintain, a normal blood picture. The main iron preparation now used is ferrous sulphate, 200 mg, thrice daily after meals. When the blood picture has become normal, the dosage is gradually reduced. A preparation of iron is available which can be given intravenously, but this is only used in cases which do not respond to iron given by mouth, or in cases in which it is essential to obtain a quick response.

If, of course, there is haemorrhage, this must be arrested, and if the loss of blood has been severe it may be necessary to give a blood transfusion (see TRANSFUSION – Transfusion of blood). Care must be taken to ensure that the patient is having an adequate diet. If there is any underlying metabolic, oncological, toxic or infective condition, this, of course, must be adequately treated after appropriate investigations.

Megaloblastic hyperchromic anaemia There are various forms of anaemia of this type, such as those due to nutritional de?ciencies, but the most important is that known as pernicious anaemia.

PERNICIOUS ANAEMIA An autoimmune disease in which sensitised lymphocytes (see LYMPHOCYTE) destroy the PARIETAL cells of the stomach. These cells normally produce INTRINSIC FACTOR, the carrier protein for vitamin B12 (see APPENDIX 5: VITAMINS) that permits its absorption in the terminal part of the ILEUM. Lack of the factor prevents vitamin B12 absorption and this causes macrocytic (or megaloblastic) anaemia. The disorder can affect men and women, usually those over the age of 40; onset is insidious so it may be well advanced before medical advice is sought. The skin and MUCOSA become pale, the tongue is smooth and atrophic and is accompanied by CHEILOSIS. Peripheral NEUROPATHY is often present, resulting in PARAESTHESIA and numbness and sometimes ATAXIA. A rare complication is subacute combined degeneration of the SPINAL CORD.

In 1926 two Americans, G R Minot and W P Murphy, discovered that pernicious anaemia, a previously fatal condition, responded to treatment with liver which provides the absent intrinsic factor. Normal development requires a substance known as extrinsic factor, and this depends on the presence of intrinsic factor for its absorption from the gut. The disease is characterised in the blood by abnormally large red cells (macrocytes) which vary in shape and size, while the number of white cells (LEUCOCYTES) diminishes. A key diagnostic ?nd is the presence of cells in the BONE MARROW.

Treatment consists of injections of vitamin B12 in the form of hydroxocobalamin which must be continued for life.

Aplastic anaemia is a disease in which the red blood corpuscles are very greatly reduced, and in which no attempt appears to be made in the bone marrow towards their regeneration. It is more accurately called hypoplastic anaemia as the degree of impairment of bone-marrow function is rarely complete. The cause in many cases is not known, but in rather less than half the cases the condition is due to some toxic substance, such as benzol or certain drugs, or ionising radiations. The patient becomes very pale, with a tendency to haemorrhages under the skin and mucous membranes, and the temperature may at times be raised. The red blood corpuscles diminish steadily in numbers. Treatment consists primarily of regular blood transfusions. Although the disease is often fatal, the outlook has improved in recent years: around 25 per cent of patients recover when adequately treated, and others survive for several years. In severe cases promising results are being reported from the use of bone-marrow transplantation.

Haemolytic anaemia results from the excessive destruction, or HAEMOLYSIS, of the red blood cells. This may be the result of undue fragility of the red blood cells, when the condition is known as congenital haemolytic anaemia, or of acholuric JAUNDICE.

Sickle-cell anaemia A form of anaemia characteristically found in people of African descent, so-called because of the sickle shape of the red blood cells. It is caused by the presence of the abnormal HAEMOGLOBIN, haemoglobin S, due to AMINO ACID substitutions in their polypeptide chains, re?ecting a genetic mutation. Deoxygenation of haemoglobin S leads to sickling, which increases the blood viscosity and tends to obstruct ?ow, thereby increasing the sickling of other cells. THROMBOSIS and areas of tissue INFARCTION may follow, causing severe pain, swelling and tenderness. The resulting sickle cells are more fragile than normal red blood cells, and have a shorter life span, hence the anaemia. Advice is obtainable from the Sickle Cell Society.... inadequate intake of iron

n. a red blood cell (*erythrocyte) that is wafer-thin, generally large in diameter, and displays a thin rim of haemoglobin at the periphery with a large area of central pallor. Leptocytes are seen in certain types of anaemia.... leptocyte

a life-threatening syndrome seen after starting *antipsychotic medication. It is characterized by confusion, muscle rigidity, fever, pallor and sweating, urinary incontinence, and a high level of *creatine kinase. Its symptoms can appear similar to *catatonia. Treatment in a high-dependency unit with high-dose benzodiazepines and immediate cessation of antipsychotic drugs is usually indicated.... neuroleptic malignant syndrome

Lead and lead compounds are used in a variety of products including petrol additives (in the UK, lead-free petrol is now mandatory), piping (lead water pipes were once a common source of poisoning), weights, professional paints, dyes, ceramics, ammunition, homeopathic remedies, and ethnic cosmetic preparations. Lead compounds are toxic by ingestion, by inhalation and, rarely, by skin exposures. Metallic lead, if ingested, is absorbed if it remains in the gut. The absorption is greater in children, who may ingest lead from the paint on old cots

– although lead-containing paints are no longer used for items that children may be in contact with.

Acute poisonings are rare. Clinical features include metallic taste, abdominal pain, vomiting, diarrhoea, ANOREXIA, fatigue, muscle weakness and SHOCK. Neurological effects may include headache, drowsiness, CONVULSIONS and COMA. Inhalation results in severe respiratory-tract irritation and systemic symptoms as above.

Chronic poisonings cause gastrointestinal disturbances and constipation. Other effects are ANAEMIA, weakness, pallor, anorexia, insomnia, renal HYPERTENSION and mental fatigue. There may be a bluish ‘lead line’ on the gums, although this is rarely seen. Neuromuscular dysfunction may result in motor weakness and paralysis of the extensor muscles of the wrist and ankles. ENCEPHALOPATHY and nephropathy are severe effects. Chronic low-level exposures in children are linked with reduced intelligence and behavioural and learning disorders.

Treatment Management of patients who have been poisoned is supportive, with removal from source, gastric decontamination if required, and X-RAYS to monitor the passage of metallic lead through the gut if ingested. It is essential to ensure adequate hydration and renal function. Concentrations of lead in the blood should be monitored; where these are found to be toxic, chelation therapy should be started. Several CHELATING AGENTS are now available, such as DMSA (Meso-2,3dimercaptosuccinic acid), sodium calcium edetate (see EDTA) and PENICILLAMINE. (See also POISONS.)... lead poisoning

Leukaemia is an umbrella term for several malignant disorders of white blood cells in which they proliferate in a disorganised manner. The disease is also characterised by enlargement of the SPLEEN, changes in the BONE MARROW, and by enlargement of the LYMPH glands all over the body. The condition may be either acute or chronic.

According to the type of cells that predominate, leukaemia may be classi?ed as acute or chronic lymphoblastic leukaemia or myeloid leukaemia. Acute lymphoblastic leukaemia (ALL) is mostly a disease of childhood and is rare after the age of 25. Acute myeloid leukaemia is most common in children and young adults, but may occur at any age. Chronic lymphatic leukaemia occurs at any age between 35 and 80, most commonly in the 60s, and is twice as common in men as in women. Chronic myeloid leukaemia is rare before the age of 25, and most common between the ages of 30 and 65; men and women are equally affected. Around 2,500 patients with acute leukaemia are diagnosed in the United Kingdom, with a similar number annually diagnosed with chronic leukaemia.

Cause Both types of acute leukaemia seem to arise from a MUTATION in a single white cell. The genetically changed cell then goes through an uncontrolled succession of divisions resulting in many millions of abnormal white cells in the blood, bone marrow and other tissues. Possible causes are virus infection, chemical exposure, radiation and genetic background. The cause of chronic lymphocytic leukaemia is not known; the chronic myeloid version may have a genetic background.

Symptoms In acute cases the patient is pale due to anaemia, may have a purpuric rash due to lack of platelets, and may have enlarged lymphatic glands and spleen. The temperature is raised, and the condition may be mistaken for an acute infection (or may ?rst become apparent because the patient develops a severe infection due to a lack of normal white blood cells).

In the chronic type of the disease the onset is gradual, and the ?rst symptoms which occasion discomfort are either swelling of the abdomen and shortness of breath, due to painless enlargement of the spleen; or the enlargement of glands in the neck, armpits and elsewhere; or the pallor, palpitation, and other symptoms of anaemia which often accompany leukaemia. Occasional bleeding from the nose, stomach, gums or bowels may occur, and may be severe. Generally, there is a slight fever.

When the blood is examined microscopically, not only is there an enormous increase in the number of white cells, which may be multiplied 30- or 60-fold, but various immature forms are also found. In the lymphatic form of the disease, most white cells resemble lymphocytes, which, in healthy blood, are present only in small numbers. In the myeloid form, myelocytes, or large immature cells from the bone marrow, which are never present in healthy blood, appear in large numbers, and there may also be large numbers of immature, nucleated erythrocytes.

Treatment This varies according to the type of leukaemia and to the particular condition of the patient. Excellent results are being obtained in the control of ALL using blood transfusions, CHEMOTHERAPY, RADIOTHERAPY and bone-marrow TRANSPLANTATION. In the case of acute leukaemia, the drugs now being used include MERCAPTOPURINE, METHOTREXATE and CYCLOPHOSPHAMIDE. Blood transfusion and CORTICOSTEROIDS play an important part in controlling the condition during the period before a response to chemotherapy can be expected. Chemotherapy has almost completely replaced radiotherapy in the treatment of chronic leukaemia. For the myeloid form, BUSULFAN is the most widely used drug, replaced by hydroxyurea, mercaptopurine, or one of the nitrogen mustard (see NITROGEN MUSTARDS) derivatives in the later stages of the disease. For the lymphatic form, the drugs used are CHLORAMBUCIL, CYCLOPHOSPHAMIDE, and the nitrogen mustard derivatives.

Prognosis Although there is still no guaranteed cure, the outlook in both acute and chronic leukaemia has greatly improved – particularly for the acute form of the disease. Between 70 and 80 per cent of children with acute lymphoblastic leukaemia may be cured; between 20 and 50 per cent of those with acute myeloid leukaemia now have much-improved survival rates. Prognosis of patients with chronic lymphocytic leukaemia is often good, depending on early diagnosis.... leukaemia

degeneration of the optic nerve. It may be secondary to disease within the eye or it may follow damage to the nerve itself resulting from injury or inflammation. It is visible as pallor of the optic nerve as viewed inside the eye with an ophthalmoscope.... optic atrophy

The mucous membrane of the mouth can indicate the health of the individual and internal organs. For example, pallor or pigmentation may indicate ANAEMIA, JAUNDICE or ADDISON’S DISEASE.

Thrush is characterised by the presence of white patches on the mucous membrane which bleeds if the patch is gently removed. It is caused by the growth of a parasitic mould known as Candida albicans. Antifungal agents usually suppress the growth of candida. Candidal in?ltration of the mucosa is often found in cancerous lesions.

Leukoplakia literally means a white patch. In the mouth it is often due to an area of thickened cells from the horny layer of the epithelium. It appears as a white patch of varying density and is often grooved by dense ?ssures. There are many causes, most of them of minor importance. It may be associated with smoking, SYPHILIS, chronic SEPSIS or trauma from a sharp tooth. Cancer must be excluded.

Stomatitis (in?ammation of the mouth) arises from the same causes as in?ammation elsewhere, but among the main causes are the cutting of teeth in children, sharp or broken teeth, excess alcohol, tobacco smoking and general ill-health. The mucous membrane becomes red, swollen and tender and ulcers may appear. Treatment consists mainly of preventing secondary infection supervening before the stomatitis has resolved. Antiseptic mouthwashes are usually su?cient.

Gingivitis (see TEETH, DISEASES OF) is in?ammation of the gum where it touches the tooth. It is caused by poor oral hygiene and is often associated with the production of calculus or tartar on the teeth. If it is neglected it will proceed to periodontal disease.

Ulcers of the mouth These are usually small and arise from a variety of causes. Aphthous ulcers are the most common; they last about ten days and usually heal without scarring. They may be associated with STRESS or DYSPEPSIA. There is no ideal treatment.

Herpetic ulcers (see HERPES SIMPLEX) are similar but usually there are many ulcers and the patient appears feverish and unwell. This condition is more common in children.

Calculus (a) Salivary: a calculus (stone) may develop in one of the major salivary-gland ducts. This may result in a blockage which will cause the gland to swell and be painful. It usually swells before a meal and then slowly subsides. The stone may be passed but often has to be removed in a minor operation. If the gland behind the calculus becomes infected, then an ABSCESS forms and, if this persists, the removal of the gland may be indicated. (b) Dental, also called TARTAR: this is a calci?ed material which adheres to the teeth; it often starts as the soft debris found on teeth which have not been well cleaned and is called plaque. If not removed, it will gradually destroy the periodontal membrane and result in the loss of the tooth. (See TEETH, DISORDERS OF.)

Ranula This is a cyst-like swelling found in the ?oor of the mouth. It is often caused by mild trauma to the salivary glands with the result that saliva collects in the cyst instead of discharging into the mouth. Surgery may be required.

Mumps is an acute infective disorder of the major salivary glands. It causes painful enlargement of the glands which lasts for about two weeks. (See also main entry for MUMPS.)

Tumours may occur in all parts of the mouth, and may be BENIGN or MALIGNANT. Benign tumours are common and may follow mild trauma or be an exaggerated response to irritation. Polyps are found in the cheeks and on the tongue and become a nuisance as they may be bitten frequently. They are easily excised.

A MUCOCOELE is found mainly in the lower lip.

An exostosis or bone outgrowth is often found in the mid line of the palate and on the inside of the mandible (bone of the lower jaw). This only requires removal if it becomes unduly large or pointed and easily ulcerated.

Malignant tumours within the mouth are often large before they are noticed, whereas those on the lips are usually seen early and are more easily treated. The cancer may arise from any of the tissues found in the mouth including epithelium, bone, salivary tissue and tooth-forming tissue remnants. Oral cancers represent about 5 per cent of all reported malignancies, and in England and Wales around 3,300 people are diagnosed annually as having cancer of the mouth and PHARYNX.

Cancer of the mouth is less common below the age of 40 years and is more common in men. It is often associated with chronic irritation from a broken tooth or ill-?tting denture. It is also more common in those who smoke and those who chew betel leaves. Leukoplakia (see above) may be a precursor of cancer. Spread of the cancer is by way of the lymph nodes in the neck. Early treatment by surgery, radiotherapy or chemotherapy will often be e?ective, except for the posterior of the tongue where the prognosis is very poor. Although surgery may be extensive and potentially mutilating, recent advances in repairing defects and grafting tissues from elsewhere have made treatment more acceptable to the patient.... mouth, diseases of

Paracetamol is one of the safest drugs when taken in the correct dosage, but overdose may occur inadvertently or deliberately. Initially there may be no symptoms or there may be nausea, vomiting, abdominal pain and pallor. Then, 16–24 hours after ingestion, liver damage becomes evident and by 72–120 hours the patient may have JAUNDICE, COAGULATION abnormalities, hepatic failure (see LIVER, DISEASES OF), renal failure (see KIDNEYS, DISEASES OF), ENCEPHALOPATHY and COMA. Treatment involves the administration of antidotes such as METHIONINE (within 8 hours) orally or intravenous ACETYLCYSTEINE.

An overdose of paracetamol is a common choice of those attempting to commit suicide. Since the government restricted the number of paracetamol tablets an individual may purchase over the counter, the incidence of people taking the drug in overdose with the intention of taking their lives has fallen sharply.... paracetamol poisoning

A state of acute circulatory failure in which the heart’s output of blood is inadequate to provide normal PERFUSION of the major organs. It is accompanied by a fall in arterial blood pressure and is characterised by systemic arterial hypotension (arterial blood pressure less than 80 mm of mercury), sweating and signs of VASOCONSTRICTION (for example, pallor, CYANOSIS, a cold clammy skin and a low-volume pulse). These signs may be associated with clinical evidence of poor tissue perfusion, for example to the brain and kidneys, leading to mental apathy, confusion or restlessness and OLIGURIA.

Shock may result from loss of blood or plasma volume. This may occur as a result of haemorrhage or severe diarrhoea and vomiting. It may also result from peripheral pooling of blood due to such causes as TOXAEMIA or ANAPHYLAXIS. The toxaemia is commonly the result of a SEPTICAEMIA in which leakage through capillaries reduces circulating blood volume. Another form is called cardogenic shock, and is due to failure of the heart as a pump. It is most commonly seen as a result of myocardial infarction (see under HEART, DISEASES OF).

If failure of adequate blood ?ow to vital organs is prolonged, the effects can be disastrous. The ischaemic intestine permits the transfer of toxic bacterial products and proteins across its wall into the blood; renal ISCHAEMIA prevents the maintenance of a normal electrolyte and acid-base balance.

Treatment If the shock is a result of haemorrhage or diarrhoea or vomiting, replacement of blood, lost ?uid and electrolytes is of prime importance. If it is due to septicaemia, treatment of the infection is of paramount importance, and in addition, intravenous ?uids and vasopressor drugs will be required. Cardiogenic shock is treated by attention to the underlying cause. Full intensive care is likely to be required, and arti?cial ventilation and DIALYSIS may both be needed.... shock

Another word for fainting – a loss of consciousness due to a fall in BLOOD PRESSURE. This may result because the cardiac output has become reduced, or because the peripheral resistance provided by the arterioles has decreased. The simple faint or vaso-vagal attack is a result of a failure to maintain an adequate venous return of blood to the heart. This is likely to occur after prolonged periods of standing, particularly if one is standing still or if the climatic conditions are hot. It can also result from an unpleasant or painful experience. Pallor, sweating and a slow pulse are characteristic. Recovery is immediate when the venous return is restored by lying ?at.

Syncope can also result when the venous return to the heart is impaired as a result of a rise in intrathoracic pressure. This may happen after prolonged vigorous coughing – the so-called COUGH SYNCOPE – or when elderly men with prostatic hypertrophy strain to empty their bladder. This is known as micturition syncope. Syncope is particularly likely to occur when the arterial blood pressure is unusually low. This may result from overtreatment of HYPERTENSION with drugs or it may be the result of diseases, such as ADDISON’S DISEASE, which are associated with low blood pressures. It is important that syncope be distinguished from EPILEPSY.... syncope

A general term for a number of conditions arising from an abnormal breakdown of fats with rapid consumption of carbohydrates. Diabetic, oxybutyric acids and other allied bodies appear in the urine. Diagnosis may be confirmed by a smell of acetone on the breath.

Causes. Diet too rich in fats, inability to digest fats. May be associated with diabetes, starvation wasting diseases and liverish attacks; when followed by coma, situation is serious.

Symptoms. Physical weakness, pallor, lethargy, acid stools, constant yawning, constipation, diarrhoea – in severe cases, jaundice. A liver tonic would be an ingredient of a prescription (Barberry, Balmony, Dandelion, Mulberry, Wahoo).

A reduced alkalinity of the blood allows acidosis to take over. Symptoms of diabetic coma when due to salt deficiency profoundly affects the chemistry of the blood.

Alternatives. Teas: Agrimony, Balm (lemon), Bogbean, Boldo, Centuary, Chamomile, Cleavers, Dandelion, Fumitory, Hyssop, Meadowsweet, Motherwort, Wormwood.

Tea. Formula: equal parts, Balm, Chamomile and Dandelion. 1 heaped teaspoon to each cup boiling water, infuse 10 minutes; dose – 1 cup thrice daily.

Tablets/capsules. Seaweed and Sarsaparilla, Blue Flag, Goldenseal, Wild Yam, Yellow Dock.

Potter’s Acidosis tablets: Anise oil, Caraway oil, Cinnamon, Meadowsweet, Rhubarb, Medicinal Charcoal.

Formula. Equal parts: Dandelion, Blue Flag, Meadowsweet. Mix. Dose: Powders: 500mg; Liquid extracts: 30-60 drops; Tinctures: 1-2 teaspoons thrice daily.

Goldenseal tincture: 1-2ml thrice daily.

Diet. Vigorous cutback in food-fats, especially dairy products. Readily assimilable form of carbohydrate (honey), replenishing stores in the liver without working that organ too hard. Restore body chemistry. Kelp instead of salt. Powdered skimmed milk, yoghurt, plantmilk made from Soya bean. Pectin foods: raw apples help solidify the stool. Bananas, carrots, carob flour products. Vitamin B complex, B6, Folic ac., Niacin, Pantothenic acid. See: CAROB BEAN. ... acidosis

Failure of the bone marrow to produce red cells because of infection, also neutropenia and depletion of platelets in the blood through chronic disease (TB etc) elsewhere in the body, or through chemicals in food and medicine. Other causes include food preservatives, X-ray radiation, fluoride in water supply and environmental pollution. The condition is serious.

Possibility of mercurial poisoning. A 59-year-old man employed filling thermometers with mercury developed aplastic anaemia and died. His urine contained 1.01mg mercury per litre. (D.R. Ryrie. Brit. Medical Journal, i/1970, 499. A similar report D.R. Wilson, ibid., ii/1966, 1534)

Symptoms. Headache, dizziness, pallor of skin, loss of weight and appetite, sore or burning tongue, jaundice, bruising, nose-bleeds. A low state of the immune system exposes the subject to infection. Treatment. Hospital supervision. Necessary to identify the causative toxic agent and eliminate it. Condition fails to respond to usual preparations of iron taken by mouth. No specific exists but supportive adaptogen herbs sustain and raise haemoglobin levels, marginally increasing red cells.

To facilitate elimination of toxic chemicals:– Teas: Alfalfa, Red Clover, German Chamomile, Ground Ivy, Milk Thistle, Gotu Kola, Nettles, Fennel.

Tea. Formula. Equal parts: Dandelion, Nettles, Alfalfa. 1 heaped teaspoon in each cup boiling water, infuse 10-15 minutes. One cup freely.

Decoction: Gentian – 1 teaspoon in cup cold water. Steep overnight; drink on rising.

Tinctures. To stimulate bone marrow. Formula: equal parts, Echinacea, Prickly Ash bark, Horsetail. Dose: 1-2 teaspoons thrice daily, taken in water or cup of one of the above teas.

Tincture Cinnamon BP (1949). Dose: 2-4ml (30-60 drops).

Powders. Combine: Gentian 1; Yellow Dock 1; Echinacea 2; Cinnamon quarter; Cayenne quarter. Dose: 500mg (two 00 capsules or one-third teaspoon), before meals.

Liquid Extracts: Combine Echinacea 2; Black Cohosh half; Damiana 1; Ginger quarter. Dose: 1 teaspoon in cup Red Clover tea, before meals.

Diet. Dandelion coffee, high fibre, low fat, low salt, molasses, lamb’s liver. Foods containing Vitamin B12.

Supplements daily. Vitamin B12. Folic acid 400mcg, Vitamin C, Floradix. ... anaemia: aplastic

A form of anaemia growing into an acute social problem, affecting people of African, Asian, and Mediterranean origin. Thalassaemias are caused by defects of a gene that produces the globin part of haemoglobin. Such defects in the DNA can now be detected in the womb before birth. The name derives from sickle-shaped cells instead of circular red blood cells. Few sufferers survive beyond their 40th year.

Symptoms. Unhealthy pallor, listlessness, sore tongue, dizziness, vague aches and pains, rapid pulse and breathing, tinnitus, palpitation. The skull may be disproportionately large, resistance to infection feeble, chances of survival poor. This form of anaemia is linked with defective colour vision. Impaired liver function. Stunted growth, great pain. Sufferers have a higher risk of infection.

Malaria. Sufferers are less likely to die of malaria because their red cells do not support the growth of malaria parasites very well.

Carriers: Carriers of the sickle-cell gene can now be identified by a simple blood test.

Treatment. No specifics exist but supportive herbal treatment has been known to increase output of red cells and raise haemoglobin levels:– Red Clover flowers, Yellow Dock, Echinacea, Burdock, Wild Indigo, Gentian, Nettles, Birch leaves, Sage, Walnut leaves, Centaury, Gota Kola (Indian Pennywort). Alternatives:– Tea. Mix equal parts: Iceland Moss, Nettles, Red Clover flowers. 2 teaspoons to each cup boiling water; infuse 15 minutes; 1 cup morning and evening.

Decoction. Mix equal parts; Echinacea, Walnut leaves, Balm of Gilead buds; 1 teaspoon to each cup water gently simmered for 20 minutes. Half-1 cup, cold, 3 times daily, before meals.

Tablets/capsules. Sarsaparilla. Ginseng. Iceland Moss. Red Clover. Echinacea. Gentian.

Powders. Formula: Echinacea 1; Fringe Tree half; Ginseng half; White Poplar bark 1. Dose: 500mg (two 00 capsules or one-third teaspoon) thrice daily before meals.

Liquid extracts. Formula. Echinacea 2; Dandelion 1; Oat Husk (avena sativa) 1. Mix. Dose, 1-2 teaspoons before meals, in water or one of the above teas or decoctions.

Tinctures. Same combination. Dose: 2-3 teaspoons.

Dong quai. See entry.

Pollen. Claimed to be of value.

Diet. Dandelion coffee. Molasses. Desiccated liver. Calf liver, fresh. Green leafy vegetables contain chlorophyll, iron and folic acid. Cider vinegar. Dried beans, apricots and shellfish. Dandelion leaves in salads. Milk, eggs, meats, Soya. Carrot juice to increase red cells.

Supplements. Daily. Vitamin B12. Vitamin C, 1g; Folic acid 400mcg, Floradix. Of particular value: Vitamin E 400iu. Zinc.

Note: Those at risk should submit themselves for screening. The disease cannot be cured but can be controlled largely by orthodox measures and sometimes by natural medicine. ... anaemia: sickle cell

A state of extreme prostration and weakness due to shock, haemorrhage, overwork, surgery, or severe infective fever such as typhoid, etc.

Symptoms: cold sweat, sunken eyes, weak heart beat, reduced temperature, pallor, mental vacuity, icy coldness, low blood pressure.

Treatment. When patient is able to swallow. Recovery in quiet darkened room with electric blanket for extra warmth if cold. Herbal stimulants indicated. Life Drops, Composition powder or essence. Brandy. Tincture Capsicum (Cayenne): Few drops in cup of tea with honey.

Tincture Camphor: 1 drop (on honey) every 15 minutes.

If patient is unable to swallow: rub gums with brandy or Tincture Camphor.

Supportive: Apply hot wet towels to anus; patient in squatting position. Sponge-down with Cider Vinegar (1) to hot water (20). ... collapse

Loss of brain function with unconsciousness. Cause: head injury or violent spinal jarring as when falling on the base of the spine.

Symptoms. Sudden drawing-up of knees, nausea, vomiting, pallor, shallow breathing, prostration, weak heart beat, irritability, amnesia.

Treatment. Bed rest. Protection of eyes against light. Admission to hospital in case of deep brain damage. Quietness. Tranquillisers, sedatives and alcohol aggravate symptoms. If patient can swallow, alternatives as follows:–

Teas. St John’s Wort (concussion of the spine). Skullcap (to ease headache). Ginkgo (cerebral damage). Powders. Formula. Combine, St John’s Wort 3; Skullcap 2; Oats 2; Trace of Cayenne. Dose: 750mg (three 00 capsules or half a teaspoon) two-hourly.

Tinctures. Formula as above, but with few drops Tincture Capsicum in place of Cayenne powder: 1-2 teaspoons in water hourly.

Tincture Arnica. (European practise) 2-5 drops in hot water usually sufficient to hasten recovery.

Topical. Distilled Extract Witch Hazel saturated pad over eyes and to wipe forehead.

Supplements. Vitamin B-complex. B6, C. ... concussion

Cardiac or vasomotor syncope. A temporary arrest of flow of blood through the brain leading to loss of consciousness. (a) Due to slowing of the heart beat by temporary emotional experience, pain, low blood pressure, blood loss, fluid loss, drug effects. (b) Heart-shock, heart-block or sudden distress.

In the elderly fainting can be associated with adverse drug reactions.

Symptoms. Dilated pupils, pallor, sweating, yawning.

Treatment. Towards recovery: cup of Chamomile tea. Life Drops in tea. Elevation of legs to restore circulation.

Topical. Whiff of Camphor or oil of Rosemary to the nose. Smelling salts. Sponge-down with Cider Vinegar (1) and water (20). Wipe face with Witch Hazel, distilled extract.

General. Remove tight clothing about the neck. Dash water in face. Recovery in ‘heart-cases’ should be followed by investigation in a cardiac care unit. ... fainting

Hyperkinesis. Physically over-active. “Like a human jet engine at top velocity.” Excessive motor-nerve activity.

Causes: considerable evidence implicates side-effects of sugar, caffeine, mercurials and other mineral salts that find their way into the body in food additives, dental fillings, etc. Other related factors: exposure to television radiation, fluorescent lighting, environmental toxins, stress, genetic. Studies show a lack of zinc to be a factor.

Symptoms. Always thirsty yet urine is highly concentrated, revealing a deficiency of essential fatty acids (for which Evening Primrose is indicated). Impulsive disposition, nasal congestion, pallor, dark circles under eyes. Insomnia. Difficulty concentrating, clumsiness, low tolerance to failure.

Alternatives. Since an individual’s chemistry is unique, it may be necessary to experiment with one or two agents before concentrating on ones more effective.

To normalise motor activity: Passion flower, St John’s Wort, Xia ku cao (Chinese).

Tea. Formula. Equal parts: Passion flower, Skullcap, Valerian. Mix. 1-2 teaspoons to each cup water brought to boil and simmered one minute. Infuse 15 minutes. Dose: half-1 cup thrice daily.

Powders, liquid extracts, tinctures. Formula: Valerian 1; Hops (Lupulin) 1; Wild Lettuce 2. Dose: Powders, 500mg (two 00 capsules or one-third teaspoon). Liquid Extracts, 30-60 drops. Tinctures, 1-2 teaspoons, thrice daily.

Evening Primrose oil capsules. One 500mg capsule morning and evening.

Diet. Wholefoods, raw-food days, reformed dietary pattern.

Aromatherapy. Oil of Lavender.

Supplementation. Daily: Vitamin B-complex; Vitamin C 500mg; Vitamin B6 50mg; Vitamin E 500iu; Niacin; Magnesium, Zinc. ... hyperactivity

Reaction to any insect bite is due to either venom released or allergic response. Symptoms: redness, pain, itching, swelling. Remove sting where possible.

Alternatives. External.

Tinctures: Arnica, Acid tincture of Lobelia, Echinacea, Marigold, Myrrh, St John’s Wort.

Fresh plants. Crush and apply: Comfrey, Garlic, Houseleek, Marigold, Onion, Plantain. St John’s Wort: specific – horsefly.

Witch Hazel Lotion.

Cider Vinegar: wasp bites.

Bee and ant bites: in absence of any of the above: bicarbonate of soda.

Aromatherapy. Any one oil – Eucalyptus, Clove, Lavender.

For shock: with faintness and pallor: few grains Cayenne pepper in honey or cup of tea. Supplements. Vitamin A and B-complex. ... insect bites

Bone marrow tumour. Neoplastic, with presence of high globulin levels in the blood. Bone marrow becomes impregnated with plasma cells. Lesions appear in pelvis and dorsal spine, skull and rib cage.

Symptoms: weight loss, back pain, anaemia, impaired kidney function. Usual symptoms of anaemia: weakness, fatigue, pallor, drowsiness, indigestion.

Differential diagnosis. Important. Early X-ray confirms. Patient may be treated for back pain long before true condition is revealed.

Special investigations: for anaemia, plasma cells in the bone marrow. Check ESR (erythrocyte sedimentation rate), kidney function and for excess calcium in the blood.

Treatment. Chemotherapy; radiotherapy. Anti-tumour agents with a tendency to reduce side-effects: Echinacea, Poke root. Comfrey: potential benefit outweighs possible risk. Thuja.

Tea. Combine, equal parts, Red Clover, Gotu Kola, Clivers, Plantain. 1 heaped teaspoon to each cup boiling water; infuse 15 minutes. 1 cup 3 or more times daily.

Decoction. Combine: Echinacea 2; Comfrey root 1; Poke root half. 1 heaped teaspoon to each cup water simmered gently 20 minutes. Half-1 cup 3 or more times daily.

Tablets/capsules: Echinacea, Comfrey, Poke root. Liquid Extracts: Echinacea 2; Comfrey 1; Poke root half; few drops Tincture Capsicum. Dose: 1 teaspoon, thrice daily.

Tinctures: Echinacea 2; Yellow Dock 1; Horsetail 1; Tincture Capsicum quarter. Dose: 2 teaspoons, thrice daily.

Powders: Echinacea 2; Comfrey 1; Yellow Dock 1; pinch Cayenne. Dose: 500mg (two 00 capsules or one-third teaspoon), thrice daily.

Dr William Boericke. Poke root often assuages pain in bone cancers and tumours. Supplements. Vitamins B12, C, D, E, Selenium.

At the discretion of the physician, any of the above alternatives may be used secondary to hospital treatment.

Treatment by a general medical practitioner or hospital specialist. ... myeloma

An unpleasant emotional state ranging from mild unease to intense fear. Various physical symptoms are associated with anxiety; the most common include palpitations, chest pains, a feeling of tightness in the chest, and a tendency to overbreathe (see hyperventilation). Muscle tension leads to headaches and back pains. Gastrointestinal symptoms include dry mouth, bloating, diarrhoea, nausea, and difficulty in swallowing. Other symptoms include sweating, blushing, pallor, lightheadedness, and a frequent need to urinate or defaecate. Anxiety is a normal response to stressful situations and prepares the mind and body to respond effectively. However, anxiety that occurs without reason may be a symptom of an anxiety disorder or another psychological disorder such as depression.

People suffering from anxiety may be helped by counselling or psychotherapy.

If there is an underlying disorder such as depression, treatment with antianxiety drugs can help.

Antianxiety drugs are used for short-term control of symptoms but are avoided for long-term treatment because they are addictive.... anxiety

Loss of blood from the circulatory system caused by damage to the blood vessels or by a bleeding disorder. Bleeding may be visible (external) or concealed (internal). Rapid loss of more than 10 per cent of the blood volume can cause symptoms of shock, with fainting, pallor, and sweating.

The speed with which blood flows from a cut depends on the type of blood vessel damaged: blood usually oozes from a capillary, flows from a vein, and spurts from an artery. If an injury does not break open the skin, blood collects around the damaged blood vessels close under the skin to form a bruise.

Any lost blood that mixes with other body fluids such as sputum (phlegm) or urine will be noticed quite readily; bleeding in the digestive tract may make vomit or faeces appear darker than usual.

Internal bleeding may not be discovered until severe anaemia develops.... bleeding

A condition in which a person’s water content is at a dangerously low level. Water accounts for about 60 per cent of a man’s weight and 50 per cent of a woman’s. The total water (and mineral salts and other substances dissolved in the body’s fluids) content must be kept within fairly narrow limits for healthy functioning of cells and tissues.

Dehydration occurs due to inadequate intake of fluids or excessive fluid loss. The latter may occur with severe or prolonged vomiting or diarrhoea or with uncontrolled diabetes mellitus, diabetes insipidus, and some types of kidney failure. Children are especially susceptible to dehydration by diarrhoea.

Severe dehydration causes extreme thirst, dry lips and tongue, an increase in heart rate and breathing rate, dizziness, confusion, lethargy, and eventual coma. The skin looks dry and loses its elasticity. Any urine passed is small in quantity and dark-coloured. If there is also salt depletion, there may also be headaches, cramps, and pallor.

Bottled mineral water can help maintain the intake of salts. For vomiting and diarrhoea, rehydration therapy is needed; salt and glucose rehydration mixtures are available from chemists.

In severe cases of dehydration, fluids are given intravenously.

The water/salt balance is carefully monitored by blood tests and adjusted if necessary.... dehydration

A pregnancy that develops outside the uterus, most commonly in the fallopian tube, but sometimes in the ovary or in the abdominal cavity or cervix. As the pregnancy develops, it may damage surrounding tissue, causing serious bleeding, which is potentially life-threatening and requires emergency treatment.

Ectopic pregnancy is more common in women who have had previous pelvic infections (see pelvic inflammatory disease) and with some types of IUD and progestogen-only oral contraceptives.

Most ectopic pregnancies are discovered in the first 2 months, often before the woman realizes she is pregnant. Symptoms usually include severe painin the lower abdomen and vaginal bleeding. Internal bleeding may cause symptoms of shock, such as pallor, sweating, and faintness.

Diagnosis is made by a transvaginal ultrasound examination and can be confirmed by ectopic laparoscopy. If the diagnosis is made early, medical treatment using the drug methotrexate may be considered. In most cases, surgery, usually minimally invasive surgery, to remove the pregnancy is carried out. If blood loss is severe, blood transfusions are needed. An affected fallopian tube is removed if it cannot be repaired.... ectopic pregnancy

A vitamin that is essential for the production of red blood cells by the bone marrow. Folic acid is contained in a variety of foods, particularly liver and raw vegetables; adequate amounts are usually included in a normal diet.

During pregnancy, folic acid is important for fetal growth and in the development of the nervous system and formation of blood cells. The incidence of neural tube defects is reduced if women take folic acid supplements for a month before conception and during the first 12 weeks of pregnancy.

Folic acid deficiency is a cause of megaloblastic anaemia, which produces symptoms such as headaches, fatigue, and pallor. Deficiency can occur during any serious illness or can be the result of a nutritionally poor diet.... folic acid

A type of leukaemia in which excessive numbers of immature white blood cells called blasts are produced in the bone marrow. If untreated, acute leukaemia can be fatal within a few weeks or months. The abnormal cells may be of 2 types: lymphoblasts (immature lymphocytes) in acute lymphoblastic leukaemia, and myeloblasts (immature forms of other types of white cell) in acute myeloblastic leukaemia.

Exposure to certain chemicals (such as benzene and some anticancer drugs) or high levels of radiation may be a cause in some cases. Inherited factors may also play a part; there is increased incidence in people with certain genetic disorders (such as Fanconi’s anaemia) and chromosomal abnormalities (such as Down’s syndrome). People with blood disorders such as chronic myeloid leukaemia (see leukaemia, chronic myeloid) and primary polycythaemia are at increased risk, as their bone marrow is already abnormal.

The symptoms and signs of acute leukaemia include bleeding gums, easy bruising, headache, bone pain, enlarged lymph nodes, and symptoms of anaemia, such as tiredness, pallor, and breathlessness on exertion. There may also be repeated chest or throat infections. The diagnosis is based on a bone marrow biopsy. Treatment includes transfusions of blood and platelets, the use of anticancer drugs, and possibly radiotherapy. A bone marrow transplant may also be required. The outlook depends on the type of leukaemia and the age of the patient. Chemotherapy has increased success rates and 6 in 10 children with the disease can now be cured, although treatment is less likely to be completely successful in adults.... leukaemia, acute

An inherited blood disease in which the red blood cells contain haemoglobin S, an abnormal type of haemoglobin. This crystallizes in the capillaries, making red cells sickle-shaped and fragile, and leading to haemolytic anaemia. The abnormal cells are unable to pass easily through tiny blood vessels. The blood supply to organs is blocked intermittently, causing sickle cell crises. The disease affects mainly black people.Symptoms usually appear after age 6 months, often beginning with painful swelling of the hands and feet. Chronic haemolytic anaemia causes fatigue, headaches, shortness of breath on exertion, pallor, and jaundice. Sickle cell crises start suddenly; they are sometimes brought on by an infection, cold weather, or dehydration, but may also occur for no apparent reason. The sufferer may experience pains (especially in the bones), blood in the urine (from kidney damage) or damage to the lungs or intestines. If the brain is affected, seizures, a stroke, or unconsciousness may result.

In some affected children, the spleen enlarges and traps red cells at a particularly high rate, causing a life-threatening form of anaemia. After adolescence, the spleen usually stops functioning, increasing the risk of infection in those affected.

Diagnosis is made from examination of a blood smear and electrophoresis.

Supportive treatment may include folic acid supplements, and penicillin and immunization to protect against infection.

Life-threatening crises are treated with intravenous infusions of fluids, antibiotics, oxygen therapy, and analgesic drugs.

If the crisis still does not respond, an exchange blood transfusion may be performed.

This may be done regularly for people who suffer frequent severe crises.... sickle cell anaemia

Involuntary forcible expulsion of stomach contents through the mouth. Vomiting may be preceded by nausea, pallor, sweating, excessive salivation, and slowed heart-rate. It occurs when the vomiting centre in the brainstem is activated by signals from 1 of 3 places in the body: the digestive tract; the balancing mechanism of the inner ear; or the brain, either due to thoughts and emotions or via the part of the brain that responds to poisons in the body. The vomiting centre sends messages to both the diaphragm, which presses down on the stomach, and the abdominal wall, which presses inwards, thereby expelling the stomach contents upwards through the oesophagus.

Vomiting may be due to overindulgence in food or alcohol, is a common side effect of many drugs, and may follow general anaesthesia. Vomiting is also common in gastrointestinal disorders such as peptic ulcer, acute appendicitis, gastroenteritis, and food poisoning. Less commonly, it is due to obstruction (see pyloric stenosis; intussusception) or a tumour of the digestive tract. It may also be due to inflammation (see hepatitis; pancreatitis; cholecystitis).

Other possible causes are pressure on the skull (see encephalitis; hydrocephalus; brain tumour; head injury; migraine), conditions affecting the ear’s balancing mechanism (see Ménière’s disease; labyrinthitis; motion sickness), and hormonal disorders (see Addison’s disease).

Vomiting may be a symptom of ketoacidosis in poorly controlled diabetes mellitus. It may also be a symptom of an emotional problem or be part of the disorders anorexia nervosa or bulimia.

Persistent vomiting requires medical investigation. Treatment depends on the cause. Antiemetics may be given. (See also vomiting blood; vomiting in pregnancy.)... vomiting

n. (in dentistry) a fixed replacement for missing teeth. The artificial tooth is attached to one or more natural teeth, usually by a crown. Bridges may also be fitted on dental *implants. The supporting teeth (or implants) are referred to as abutments, and the artificial teeth that fit over them are referred to as retainers. The replacements of missing teeth are known as pontics. Adhesive bridges are attached to one or more adjacent teeth by a metal plate that adheres to the enamel on the tooth surface prepared by the *acid-etch technique; these bridges require minimal tooth preparation compared with conventional types of bridges.

brief resolved unexplained episode (BRUE) a sudden, brief (less than 30 to 60 seconds), and resolved episode in an infant that includes one or more of the following: decreased or irregular breathing; change in muscle tone; pallor or cyanosis or altered responsiveness. The episode is frightening for the person caring for the infant. BRUE is a description rather than a diagnosis and the term is used only when there is no explanation for the event after a thorough history and examination.... bridge

a hereditary disorder – an X-linked condition (see sex-linked) – in which the absence of the enzyme glucose-6-phosphate dehydrogenase (G6PD), which functions in carbohydrate metabolism, results in the breakdown of the red blood cells (*haemolysis), usually after exposure to *oxidants, such as drugs, or infections. The breakdown causes acute attacks that are characterized by pallor, loin pain, and rigors. There are several varieties of G6PD deficiency, which is most common in people of African, Middle Eastern, and Mediterranean descent. Treatment involves identifying and avoiding agents that trigger the haemolysis and treating acute attacks symptomatically. See also favism.... glucose-6-phosphate dehydrogenase deficiency

n. the telescoping (invagination) of one part of the bowel into another: most common in young children under the age of four. As the contents of the intestine are pushed onwards by muscular contraction more and more intestine is dragged into the invaginating portion, resulting in obstruction. Symptoms include intermittent screaming and pallor, vomiting, and the passing of bloody mucus (‘redcurrant jelly’) with the stools; if the condition does not receive prompt surgical treatment, shock from gangrene of the bowel may result. A barium or Gastrografin enema may confirm the diagnosis and in many cases may relieve the intussusception.... intussusception

a condition of unknown cause in which the arteries of the fingers are unduly reactive and enter spasm (angiospasm or vasospasm) when the hands are cold. This produces attacks of pallor, numbness, and discomfort in the fingers. A similar condition (Raynaud’s phenomenon) may result from atherosclerosis, connective-tissue diseases, ingestion of ergot derivatives, or the frequent use of vibrating tools. Gangrene or ulceration of the fingertips may result from lack of blood to the affected part. Warm gloves and peripheral *vasodilators may relieve the condition. In unresponsive cases *sympathectomy is of value. [M. Raynaud (1834–81), French physician]... raynaud’s disease