The 640 MEG Shareware Studio 1/The 640 Meg Shareware Studio CD-ROM Volume I (Data Express)(1992).ISO/person/healbeta.exe/HEALTHNT.DAT

Text File | 1992-05-01 | 1MB | 29,561 lines

HealthNet Reference Introduction

   The HealthNet Reference Library represents the premiere
source of health and medical information for the intelligent computer
user.  It is written in concise language, but comprehensive enough to
answer most questions you may have about any of the topics covered.

   The library is quite large, and is thus organized to be
menu-driven.  Once you are familiar with the menu structure,
virtually any article should be accessible within seconds.  A few
seconds of advance planning can be well worthwhile.  Before accessing
the library, consider the following points:

1.  Is your chosen topic a disease or a symptom?  Although many
subjects may be covered in both areas, you will probably do well to
start in the appropriate area.  A symptom is something which you note
about your body or health which may be due to many different
diseases.  For example, fever, pains, and swelling are symptoms,
whereas hepatitis, migraines, and heart failure are diseases.  If you
are not sure, just dive in where you think best, and often the
article will guide you to other appropriate sections for additional
information.  You will be learning about your health all the way.

2.  If you enjoy "browsing" in HealthNet, one enjoyable way is to
begin anywhere, and follow a "trail" of topics in a logical fashion.
If you start at "headaches" this might take you to "migraines," then
to "ergotamine" under the drug section, etc.  In this way you can
learn quite a bit about a single area in a short time.

3.  Of necessity, some articles are grouped in small numbers under
one menu choice, especially in the disorders section.  It may pay to
scan the entire section if your topic does not happen to be the first
article in the menu choice.  It should only take seconds, and your
chosen topic may be readily found in this way.

Enjoy your tour through the Reference Library, and remember that if
you have a health problem you should rely only on your personal
medical doctor for all of your care and personal advice.

** DISEASE REFERENCE LIBRARY **
          INTRODUCTION

   HealthNet proudly presents its Diseases Reference Library. This
section contains countless articles on various diseases, organized by
organ system and, in some cases, by type of disease.  This
introduction should help you find the article you want in the
briefest time.

   For most diseases, the quickest way to find the appropriate
article is to select the organ system involved from the previous menu
(key "M" at the end of this introduction). The most common diseases
of interest are included in the organ system menu to which you will
be sent, and it should be a simple matter to choose which articles
you want.  There are two major exceptions to this rule: cancers and
infections of all organ systems included are generally discussed in
the Cancer or Infection Sections. Thus kidney cancer is not in the
Urinary section, but rather in the Cancer section, under kidney,
bladder, etc.

  If you cannot find the article you want directly from a menu
choice, simply access the Index to Diseases from the previous menu.
This represents an alphabetical list of hundred and hundreds of
entries, along with their respective menu and choice number.  Please
note that this index is only for diseases, and countless other
entries on symptoms, surgeries, medications, etc. are found in other
sections of HealthNet.

   We could not, of course, include every possible disease. Some
important diseases of rarity are not included, and some common
diseases which are generally well understood or of little interest
are omitted.  If you would like to see a particular disease included,
please let us know through the Ask HealthNet feedback option. If
enough interest is apparent, we will be sure to include it in future
updates.  HealthNet aims to serve you, and your input can help us
grow as the premiere on- line Health Database for the sophisticated
enduser.

   This information is for educational and entertainment purposes
only.  Any personal medical problems should be dealt with by one's
personal physician only, and in no event should the user rely on this
or any other media sources for the diagnosis, treatment or other
management of any disease or condition.

   We hope you enjoy the material contained in HealthNet.



       ANXIETY DISORDERS

   Like many emotions, anxiety is generally considered an adaptive
feeling experienced by all humans, and generally leads to some action
to relieve the feeling.  It is by definition unpleasant, and familiar
to all. Although one can usually identify a source for most anxiety,
it may be perfectly normal to occasionally experience what is known
as "free floating" anxiety, for which no cause is clear.  Thus
anxiety is a normal phenomenon. Defining when such a concept becomes
a symptom or a disease in the medical or psychiatric sense is not
always easy.

   Anxiety may be caused by physical diseases, and in fact this is
sometimes the first or only clue to the disease. Examples include
hyperthyroidism, adrenal tumors, insulin reactions in diabetics, and
mitral prolapse.  An alert physician should consider these
possibilities based on other diagnostic findings or unusual aspects
to the patient's history.  This dicussion will focus on anxiety which
is not due to any underlying medical problem.

   When the intensity of anxiety becomes disabling to the patient in
terms of his/her lifestyle or interpersonal relations on a regular,
prolonged or very severe basis, and when the patient perceives this
as being disruptive to his or her quality of life, medical or
psychiatric aid may be sought.  The absence of a clear source to the
anxiety is often an accompaniment to this action, though other
situations may involve an unsatisfactory adaptation to a source of
anxiety which cannot or will not be avoided by the patient.

    SYMPTOMS

   The psychiatric model divides anxiety syndromes into groups based
upon the predominant symptom complex.  Thus, there are phobic
disorders in which an unnatural fear of something is present, such as
fear of heights, crowds (agoraphobia) or other phenomenon.  On the
other hand there are "anxiety states" in which the main problem is
the free floating anxiety mentioned above, often to the point of a
sense of overwhelming panic and a sense of impending doom. These may
be accompanied by a wide range of physical symptoms including:
lightheadedness, pounding heart, sweating, chest pain, breathing
symptoms, etc. Most people will recognize some of these symptoms
normally during very stressful moments.

   Other manifestations of anxiety disorders include the obsessive
and compulsive tendencies of some individuals taken to the extreme in
which lifestyle becomes impaired, or abnormally severe or prolonged
reactions to traumatic incidents in which the reaction fails to
subside within an appropriate period of time. Flashbacks and
nightmares or extreme jitteriness for years after the event may be
seen, and have been well described in Vietnam veterans.  Certainly
many patients do not fit clearly into one of the above categories,
and the counseling individual must exercise flexibility and insight
in such cases.  The actual classification is less important in many
cases than are a sensitive, intelligent, and an open-minded approach
to treatment.

CAUSES

   No single theory accounts for all cases of anxiety.  Some
currently accepted alternative theories are the psychoanalytic view,
which holds that certain suppressed unconscious sexual or aggressive
needs lead to anxiety when social attitudes force them to be denied,
or that certain key childhood events or trauma interfere with the
successful maturation toward independence from the mother figure,
which in turn leads to the emotional discomfort level being higher
than normal.  Such theoretical approaches may be more interesting
than useful for some patients.

   Behavioral theorists hold that the human "organism" has evolved in
such a way as to respond predictably to stress with a "fight or
flight" reaction in a biological sense. This leads to an outpouring
of certain hormones which increase heart rate and other reflexes, and
may change chemical balances within the brain as well.  In modern
society the stresses are often not paired with the need or ability to
generate the appropriate physical responses, which are repressed.
Depending on the personality and past experiences of the individual
patient, the anxiety disorder may manifest itself in various ways.

   Finally, the metabolic theorists hold that all anxiety is related
to inherent imbalances in the chemistry of certain parts of the
involuntary nervous system, of unknown cause in most cases.  They
contend that the feelings of anxiety are secondary to the unconscious
perception of these internal derangements, with the final syndrome
strongly colored by the individual's background, etc. Supporting at
least a role for this component in the cause of anxiety are data
showing changes in brain chemicals from drugs known to relieve
anxiety.

    TREATMENT

   Not all anxiety which brings a patient to the counselor requires
treatment beyond reassurance that what one is experiencing is within
the ranges of "normal."  When the anxiety is of proportions which
warrant intervention, several modalities are available.

Psychotherapy

   As appealing as the concept may be to some from an intellectual
perspective, and as sacrilegious as it may be to say so, there is
virtually no scientifically acceptable evidence to support
psychotherapy as the primary treatment for anxiety.  It is recognized
that such research is extremely difficult to do for a variety of
reasons, and that many patients give anecdotes of great benefit from
psychotherapy;  thus, the possibility that it is helpful cannot be
ruled out. Nonetheless, a healthy skepticism must be maintained in
view of the costs of involved psychotherapeutic programs.

   Behavioral approaches have been more successful than the above.
These include programs which "teach" the patient new ways of
responding to old stimuli, and various methods have been devised.
Phobias in particular have been successfully treated with these
techniques, which include gradual exposures to the feared experience,
"flooding" the patient with feared experiences under controlled
settings, etc. A careful and experienced therapist is essential.  The
more generalized anxiety states have not fared quite as well;
biofeedback, relaxation responses and similar techniques have some
utility here, but primarily in milder cases.  It seems fair to
conclude that more information is needed before a judgment can be
made on such approaches for more severely afflicted patients.

DRUGS

   Drugs may be used to blunt the physical aspects of anxiety
directly such as propranolol for palpitations, stage fright, or other
involuntary responses, or to alleviate the anxiety sensation itself,
as with Valium and its related compounds. Tricyclic drugs such as
imipramine are also useful in some settings.  Data on the long-term
use of these agents is less readily available.

   Any decision to use drugs for anxiety must weigh the risks and
benefits; with long-term use the risks increase accordingly, and many
patients with anxiety disorders will have the tendency for years.
Thus, a conservative approach is advocated by some. On the other
hand, they work. The patient and physician must arrive at a joint
decision in their use, based on need, safety, risks of psychologic
dependence developing, and the availability of behavioral treatments.
 One commonly accepted approach is to use the drugs intermittently
and for short periods only when the symptoms are overwhelming and
interfering with important activities; in the intervals between such
episodes, the patient attempts to make emotional and interpersonal
adjustments, and applies various behavioral techniques.

   One potential problem with the benzodiazepines such as Valium and
Librium is that they have the potential to worsen depression which
can often accompany anxiety.  Newer drugs such as alprazolam do not
have this effect, and may be better choice for some patients with a
depressive component.  Finally, the panic attacks which some patients
experience with their anxiety states seem to respond to propranolol
and its related drugs or to imipramine better than to Valium-like
drugs in many cases.

    SUMMARY

   Anxiety states may be approached as a combined medical and
psychological phenomenon. Treatment may range from simple reassurance
to extensive behavioral programs of a comprehensive nature.  Current
evidence does not favor a psychotherapeutic approach alone for most
patients.  Drug have proven benefit and risks, and play an important
role in treatment if the patients are well selected, well informed,
and are given appropriate drugs in appropriate doses for appropriate
intervals.



           DEPRESSION

   It is convenient to divide depressions into minor and major
categories, which correspond roughly to the diagnostic categories
used in standard psychologic and psychiatric nomenclature.  Minor
depressions are far more common than the major type.

MINOR DEPRESSIONS

   Everyone knows what depression feels like, and the distinction
between a normal mood of depression and that which becomes a
"disease" is one of great subtlety.  To a large extent it depends
upon what the patient perceives as extraordinary, and to what extent
it is interfering with daily activities and life satisfaction.  Women
present with this diagnosis far more often than men, for reasons
which are not clear; some feel that women are more able to express
the helplessness of depression more readily than men due to
sociocultural expectations.

   People who seek aid for minor depression are prone to recurrences
throughout their lives, with onset often in early adulthood.  It is
felt to stem from a part of the person's character which is
essentially an unsuitable reaction to stress; clearly almost any
emotional or physical stress can precipitate a recurrence.  Thus
depression is an intimate part of the personality of the patient,
ready to emerge should the appropriate circumstances elicit this
reaction.

    SYMPTOMS

   In addition to the obvious depressed mood, the intensity of the
depression may assume suicidal proportions.  An exceedingly common
finding is the presence of multiple apparent physical complaints
which can rarely be found to have a physical basis. The patient may
show little receptiveness to suggestions that his or her symptoms may
have a psychophysiologic basis. Family strife and alcohol abuse are
also occasional findings. Sleep problems, loss of interest in sex,
and lack of energy are not uncommon.

    TREATMENT

   A concerned and attentive counselor is essential to treatment for
many reasons.  One must determine how much a given episode is due to
outside factors which can be altered or responded to in a different
way by the patient.  Often, the patient is so apathetic or distracted
by his/her mood that little productive thought into the
practicalities of the situation is given.  An outside listener who is
properly trained can point the patient in the right direction.  The
very act of concerned listening can improve the patient's sense of
self-esteem.  The skill of the counselor can add inestimably to the
patient's recovery.

   Medications can be useful for intermittent treatment of sleep
disturbances or panic attacks, if a sense of anxiety accompanies the
depression; some anti-anxiety drugs can actually worsen depression,
and this must be considered.  Specific antidepressants which are
discussed elsewhere can be dramatically effective for the occasional
patient, and must be used carefully and with realistic expectations.

   Prognosis is difficult to evaluate.  In almost all cases, episodes
of depressions are self limited, but of fairly long duration, lasting
6 months to 2 years ("that was a bad year for me").  With treatment,
this period can usually be shortened considerably.  Stresses of
almost any sort can bring about recurrences at almost any time,
although as the patient enters the fifth decade and beyond, the
recurrences seem to dwindle for some.

MAJOR DEPRESSION

   Distinct from minor depressive illness, major depressions are
probably based on some as of yet poorly defined biochemical imbalance
in the brain.  It may come on at any age, striking women twice as
often as men, and affecting up to a tenth of the population at some
time in their life.  A major life stress may or may not have occurred
prior to the onset.

    SYMPTOMS

   In the full blown picture, the patient suffers from deep feelings
of sadness, guilt, uselessness and futility. Concentration may be
impaired, and memory may appear to suffer. A sense of losing one's
mind is not uncommon.  Tearfulness may be nearly uncontrollable at
times.  Profound apathy and fatigue occur.  Appetite disturbance may
be so severe that dehydration, severe weight loss, and eventual death
may occur.  Suicide is a constant risk, and sleep may be thoroughly
disturbed.  In some cases delusions may occur.

    DIAGNOSIS

   The above picture is not hard to recognize, but there are many
medical diseases which can cause a similar picture, including thyroid
imbalance, adrenal gland insufficiency, occult cancer especially of
the pancreas, and numerous others.  In addition, many patients only
develop certain aspects of the overall picture, and may not even
relate the depressed mood, but rather may have some overwhelming
physical symptom, fear of cancer or other problem.  In the elderly,
the patient may appear to simply be demented--confused and withdrawn,
and the tragedy of this assumption is that they may spend the rest of
their lives in a nursing home instead of receiving effective
treatment.

   On rare occasions the diagnosis is confusing even after due
consideration of the above and adequate medical evaluation.  In these
cases certain tests of cortisol balance may be used to strengthen
one's suspicions. Routine use of this test adds little, however.

    TREATMENT

   Intensive hospital support may be necessary to provide the
medical, nutritional, and supportive care these patients require.
Intravenous fluids, tube feedings, and hygiene may require full time
medical and nursing care.  Suicide precautions are often needed.

   The initial treatment usually consists of the administration of
antidepressant drugs.  These include one of the tricyclics such as
amitryptilline, imipramine, and doxepin, or the less commonly used
monoamine oxidase inhibitor drugs. Occasionally stimulants are used
where these fail, such as amphetamines or Ritalin.  Skill and caution
must be exercised especially in the elderly, since side effects of
these drugs are not rare.

   About 65% of patients respond to the medication with a complete
remission, although many others derive some lesser benefit.  Where no
response is seen over several weeks, or where there is medical danger
in waiting the several weeks necessary for the drugs to take effect,
and also in cases where hallucinations and delusions are prominent,
the therapy of choice may be electroconvulsive therapy.

   Electroconvulsive therapy (ECT) is an emotionally charged issue
largely because of the archaic abuses which took place early in its
history.  In addition, adverse publicity exaggerated these factors.
The way it is practiced today by legitimate psychiatrists is
painless, low risk, selective, and at times miraculously effective.
A series of 5 or more treatments is given over a week or two, and the
response is assessed.  Although not all patients respond well, many
do where all other methods have failed; they can then return to a
meaningful existence. Maintenance anti-depressant therapy is commonly
used to avoid relapse.  In such cases it may be considered inhumane
to withhold this therapy.

   Major depression is not a disease that responds well to
psychotherapy, although the patient's response to the event after
recovery, and the changes brought about in his or her life as a
result of the disease often do benefit or even require a close
psychotherapeutic relationship for months into recovery.  In this way
relapses can be detected early, and prevented from becoming full
blown.

   Prognosis has not been well defined statistically, but clearly
many patients are prone to relapse months to decades later.
Frequently the relapse is less of a problem since diagnosis and
treatment are initiated earlier.



           ALCOHOLISM

   Depending on one's definition of alcoholism (and this is no small
issue), alcoholism may be said to affect up to 10% of all adult
males, and perhaps half as many females.  Alcoholism may be virtually
life-long, starting in adolescence and continuing thereafter, or it
may begin in adulthood in association with depression or other life
stresses.  In the latter event, it is often an intermittent disease,
with periods of control and remission.

   For the purposes of this discussion, alcoholism may be defined as
drinking any alcoholic beverage to the point of recurrent,
persistent, or extreme physical or psychological impairment. This is
necessarily a broad definition, and factors relative to the society
or peer group must be considered.  Almost any definition may be
criticized on some basis, but the following may help in recognition
of an alcoholic individual.  If several are present, the diagnosis
should be considered:

Physical manifestations of alcohol withdrawal--tremor,
hallucinations, seizures, delirium.

Medical complications of alcohol abuse, such as gastritis, liver
disease, pancreatitis, muscle or nerve degeneration.

Blackouts or memory lapse during drinking episodes or thereafter.

More than one binge of 48 hours which has interfered with other
social obligations.

Inability to stop drinking despite efforts to do so.

Use of alcohol before breakfast, or use of nonbeverage forms of
alcohol, such as mouthwash, etc.

Legal troubles from drinking, or fighting or work-related discipline
problems with alcohol.

Self-perception of a drinking problem, or such a perception by the
patient's family and friends.

   A few grim statistics remind one of the importance of this
affliction to the national welfare: 20,000 deaths annually from
disease, plus 25,000 excess traffic deaths, 15,000 homicides or
suicides, and an annual cost estimated at $31 billion!

    CAUSES AND DIAGNOSIS

   Little is known of the root cause of alcoholism, but certain facts
give us some clues.  The son of an alcoholic father is four times as
likely to become alcoholic than one with a nonalcoholic father, even
if the child is adopted and raised in a nonalcoholic family.  Jews
and Italians consistently have lower incidences of alcoholism than do
Irish and American Indians, in many cutural settings, and no
difference in alcohol metabolism has been identified to explain this.
 Thus a genetic element may play a role in some settings, along with
complex familial, cultural, and psychologic factors.

   Initially, drinking in excess may be to relieve some physical or
mental distress, but soon becomes self-perpetuating.  The ability to
distinguish social drinking from drinking as a social crutch becomes
blurred. Eventually the symptoms mentioned above start to take over.
One analyst has described the alcoholic's reaction to alcohol as
progressing through stages of "jocose, morose, bellicose, lachrymose,
[and] comatose" (Harper). Experienced doctors and counselors develop
an almost intuitive ability to suspect alcoholism from a wide array
of physical, personality, and social findings.  This intuition is not
always without bias and distaste, and efforts must be made to
approach the disease in an enlightened and nonjudgmental manner.

    TREATMENT

   The complexities of treatment are far beyond the scope of a brief
discussion, and indeed libraries could be filled with such volumes.
The initial phase often involves acute alcohol withdrawal, with
delirium tremens which causes severe hallucinations of a terrifying
nature, fever, convulsions, dehydration, and a 15% mortality rate
even in the hospital. Intravenous fluids, sedatives, nutritional
supplements, and various other supportive measures are required.
Once the patient is medically stable, the important rehabilitative
phase begins.

  The initial phase of most programs, whether they are live- in
residential programs or outpatient programs, is to help the patient
accept the diagnosis.  Resistance is common, and often the most
difficult step to take, with many patients quitting the program at
the beginning.  The psychiatrist or oter physician who specializes in
alcoholism treatment is usually best consulted. Groups such as
Alcoholics Anonymous are also excellent resources.

  Compliance with medical advice is notoriously poor, and gentle
persistence may be necessary. The entire family or other group of
significant personal contacts in the patient's life should be
involved with the patient's consent.  Honesty and firm but
nonthreatening persistence are two important qualities for the
counselor to have.

   The main principles of the next step of treatment involve
replacing the alcohol with supportive group interactions, rebuilding
of self-worth, firm but forgiving peer pressure not to drink,
avoidance of situations of loneliness through accessibility to caring
others at all times, and involvement in helping others at a more
acute stage of alcohol withdrawal than the patient himself.  If one
agrees that for many alcoholics the drinking has replaced people in
his or her life, then treatment hinges on replacing the alcohol with
people once again.

   Whether reformed alcoholics can safely return to controlled social
drinking, or should remain forever abstinent is a controversial
point; most groups today feel that the risks outweigh the benefits
(whatever one considers a benefit of drinking), and permanent
abstinence seems the safest course.

    PROGNOSIS

   Even patients who enter and complete a comprehensive alcohol
treatment program with total abstinence achieved at its conclusion
have a relapse rate of around 75%.  Given the fact that many
alcoholics never seek aid, and many who do never enter a formal
program, the prognosis of this disease is very poor. Prevention thus
becomes an important goal, although there are few data on such
programs as high school level education, preventive counseling of
high risk children, etc.  The use of drugs such as Antabuse has
achieved renewed popularity recently; once taken under supervision
this drug interacts with any alcohol ingested that day to cause a
severe reaction with headache, nausea, and other unpleasant symptoms.
 It is unclear whether this achieves any better long-term success.

   The poor prognosis of alcoholism should not dissuade efforts to
direct patients toward treatment.  The reason for this is that the
successful patient is a true "save" from a life of tragedy, and that
even patients who relapse from time to time may achieve long periods
of sobriety sufficient to maintain their jobs, families, and health.
Just as one would not withhold treatment for a cancer which is likely
to recur despite treatment, the approach to the alcoholic should
receive similar patience, persistence, and understanding.



         SCHIZOPHRENIA

   Far from being the mythological "split personality" described by
misguided writers, schizophrenia is a complex psychiatric disease
found the world over, accounting for one half of more of all hospital
beds dedicated to psychiatric illness.  It is a disease of unknown
cause, generally affecting young adults, males and females.  It is a
common disease, said to affect some three percent of the population
at sometime in their lives.

   Most authorities believe there is a genetic component to the
disease, since comparative studies of identical and nonidentical
twins and risk factors in relatives of schizophrenics show a definite
correlation, even when corrected for family environment.

  This genetic element leaves many factors unexplained, however, and
there are many more questions than answers about the cause and risks
for this disease.  Only recently have scientists begun to unravel
some tantalizing clues suggesting that chemical abnormalities in the
brain involving the substance dopamine and related compounds may be
at the root of the symptoms.

    SYMPTOMS and DIAGNOSIS

   Usually noted in late adolescence or early adulthood, the first
symptoms often include a gradual withdrawal from social interaction
into what seems to be a private internal world. Suspiciousness,
apathy over appearance and social tact, and sometimes a bizarre
facade are described.   Eventually the withdrawal results in academic
or job related failures, and the consequential descent within
society's hierarchy.   Vague but undiagnosed physical symptoms may be
perceived.

   Eventually the patient will experience an acute psychotic episode
which may take almost any form.  Hallucinations, delusions about the
meaning of his or her surroundings, or a total withdrawal from
reality to within a mute, unresponsive, private world are common.
Bizarre or rigid postures may be assumed for hours at a time. Before
the days of successful treatment, these acute episodes could last for
many months.  The various categories of the disease depend largely on
the character of the acute psychotic interludes--paranoid (fearful,
threatening), and catatonic (com like in appearance) are two such
examples.

   Once the acute episode has subsided the patient returns to their
previous baseline, or often to a level of function slightly below
that of their previous level, thus beginning a gradual deterioration.
 Even in the chronic phase, the thought content of many
schizophrenics may be loosely associated, and psychotic thinking may
intermingle with normal thoughts.  Actual intellectual functioning
such as orientation to place and time, ability to perform
calculations or other scholastic tasks, etc. may be quite normal if
the patient can attend to it long enough. In some cases the
deterioration is sufficiently severe that lifelong institutional care
may be necessary.

   Additional hallmarks of the diagnosis include chronicity of
symptoms of six months or more, persistent talking to one's self,
hoarding of food or garbage, magical sorts of thoughts such as
telepathy or auditory signals of an eerie nature.  In the end the
diagnosis is made by a careful evaluation of the patient's mental
status over time, and the exclusion of such factors as medical
illness and drug use and abuse which can sometimes mimic some of the
above symptoms.

   Psychosis can be a part of other psychiatric diseases including
major depressions, mania, and isolated psychotic episodes.  Only an
experienced physician or other mental health worker should be relied
upon to make the final diagnosis of schizophrenia.

    TREATMENT and DIAGNOSIS

   Recent decades have seen nothing short of miraculous advances in
the drug treatment of schizophrenia, though much room remains for
further progress.  Whereas previous efforts at psychotherapy of the
disease produced volumes of theories as to the analytic and symbolic
causes of the disease, little benefit accrued to patients who would
regularly spend most of their lives in overcrowded "insane asylums"
more for the "protection" of the public than for their own benefit.

   Starting with thorazine and continuing with scores of other drugs,
including haloperidol, piperazine, thioridazine, fluphenazine and
others, acute psychotic episodes could now be controlled within days
instead of months, with less blatant symptoms of delusions and
hallucinations resolving over weeks. Improvement may continue to
occur for six or eight weeks, and the benefit could be maintained for
as long as the patient continued the medication.  Without maintenance
therapy, 60-70% of patients relapse within a year.  Even if mild
psychotic symptoms are not fully controlled on the drugs, the
intensity is reduced for most patients.  Occasionally patients will
"break through the medication" with acute episodes, but these will
usually respond to higher doses.

   Anti-psychotic drugs are not without serious side effects for some
patients, including blood pressure fluctuations, liver sensitivity,
and muscle spasms. One of the more troublesome syndromes is the
Parkinson's Disease-like state, which leads to tremor, slowness of
movements, rigid, stooped posture, and absence of facial expression
changes. Characteristically, the patient may turn the entire trunk
instead of just the head when addressed and fail to swing the arms
while walking.  The overall appearance may lead to a "spaced out"
appearance to the inexperienced layman; many criticisms have been
leveled against the apparent dehumanizing effects of these drugs.  To
such criticisms one must respond with understanding, but few who have
ever worked closely with an acute schizophrenic patient would forego
the drugs given the choice.

   As helpful as the drugs discussed above may be in controlling and
preventing acute symptoms and reducing the need for
institutionalization, the patients usually continue to decline in
their social skills, and some eventually require full time
supervision.  Skilled psychiatric, medical, and supportive care
combined with the social support system of a concerned community
offer the best chance for the schizophrenic patient to lead a
meaningful existence with the least possible disruption to themself
and to their world.



     PERSONALITY DISORDERS

   It may seem presumptuous to classify someone's personality as
"disordered" on some arbitrary basis, and indeed any such
categorization can be considered judgmental.  What is ideal to one
may be obnoxious to another, and it is not the purpose of this
discussion, nor of mental health professionals to deal with this
aspect of human variation.  Rather, it is recognized that there are
individuals who despite being productive, successful, and accepted
members of society have certain attributes to their personality which
either make them unhappy with themselves most of the time, interfere
with interpersonal relationships to a profound and consistent extent,
or otherwise obstruct the attainment of important or desired life
goals which would otherwise be reasonable to expect.  To this extent,
such people define their own personality as being maladaptive in some
regard by seeking professional help.

   Rather than approach the topic in a formal and clinical fashion,
this article will provide a descriptive overview of such traits.
Virtually every person has elements of these symptoms intermittently,
or mild awareness of some of these traits most of the time.  Only
when the individual perceives the problems as overwhelming does the
professional enter the picture.

   Freud might have called some of these syndromes "neuroses"
although this term has vague and inappropriately negative
connotations to some.

    Representative Types

OBSESSIVE-COMPULSIVE

   Such an individual may be driven to such a high degree of
orderliness, perfectionism, and conscientiousness that expectations
are unattainably high, or energy to meet the needs is so great that
other activities and emotions suffer. The appearance of these people
may be meticulous, and their surroundings will match.  Blind loyalty
and a high dependence on the praise of superiors is common.  He or
she may surround themself with regulations and rules to an extreme
degree. Others see them as logical and reliable, but formal,
inhibited, inflexible, and stubborn.

   Routines become an important part of such an individual's life,
even if they are inconvenient or downright inappropriate. Fiscal
"tightness" is the rule. Inability to relegate responsibility to
others is noted, and an increasing coldness is described by family
members.

   Analysts hypothesize that such traits stem from exaggerated
parental insistence on discipline and behavior in early childhood,
such as early toilet training and suppression of emotional
expression.  Normal aggression and defiance are not allowed, and thus
suppressed.

HYSTERIA

   Despite the somewhat sexist overtones of the above term, there is
no more suitable description of this personality style.  It is
acknowledged that this is a more common maladjustment in women. There
occurs a preoccupation with physical appearance, even in situations
where it is inappropriate.  The need to draw attention to himself or
herself is great.  The extremes of emotion may be manifest within
minutes, such that one may see exaggerated cheerfulness and
friendliness quickly replaced with hostility or aloofness. Tears and
laughter come readily, such that an observer may question the
genuineness of the emotions being displayed.

   There may be a history of failed relationships as premature
plunges into unwarranted intimacy give way to the realities of a
sharing and compromising relationship which the patient is unable to
sustain.  A stylish, even attractive appearance is common, with
either a "macho" or "seductive" look being common.

   Personality theorists have indicated that such a style stems from
a need to be dependent, with associated feelings of inner inadequacy
and lack of confidence.  The tendency is thus to trust or become
intimate too readily, with the stage set for disappointment.  The
patient's reaction is then typically immature or dramatic, and
reminiscent of a child. Dramatic and sometimes even ludicrous
"hysterical" symptoms with no basis in physical disease are sometimes
seen in such patients.

   It has been stated that between the ages of 3 and 6 years these
patients may have had difficulty in reconciling the ambivalence of
their affection for the parent of the opposite sex, with the love and
guilt never coming to terms.  It is not clear to what extent such
theories are valid.

PARANOIA

   This use of the term is not to be confused with paranoid
schizophrenia.  People with paranoid personality disturbance are
those who are overly defensive about every comment or suggestion,
suspicious of others' motives without cause, and unexpressive of
emotion to an extreme degree.  Heightened cynicism, hostility in
general, and "grumpiness" are common. Self-sufficiency and
independence may assume unusual importance, as may secretiveness.
Small arguments with others become crusades to these people. Their
perceived sense of self-importance often outpaces the little respect
which they receive from others. Humor, kindness, warmth and
vulnerability are character traits which are absent.

   Analysts tell us that such traits may come from families where
parental anger is dominant, conspicuous, and comes to be expected
even when unjustified.  The cycle may easily be seen to perpetuate
itself generation after generation.

BORDERLINE PERSONALITIES

   This disorder has only recently become widely understood, and is,
indeed, a clinical diagnosis.  It refers to people whose
personalities intermittently approach loss of reality awareness
almost to the point of a truly psychotic patient, often mixed with
any number of other traits of personality disorder, such as phobias
(see the section on anxiety), hysteria, etc.  At baseline the
patients are frequently perceived as highly immature, unhappy, and
have short tempers.  They display poor judgment in life decisions, in
a manner which may seem almost intentional or self- destructive.
They tend to see the world's population as good or bad with little in
between.  In some cases only during extreme stress and on careful
evaluation do the near-psychotic proportions of their thinking
process become recognized.

   Some theorists have said that this personality comes from
difficulties in the separation process from the mother at around 18
to 24 months of age. Any type of separation as an adult thus leaves
such patients feeling highly vulnerable and threatened.

    TREATMENT and PROGNOSIS

   It is probably in this area of psychiatry where analytic therapy
and strictly personality-based approaches have been the least
challenged. The subtleties of the intricate interaction which goes on
are beyond the scope of a written discussion.  In summary, the
therapist will attempt to know the patient sufficiently well through
listening, probing, testing, and eliciting reactions that eventually
some insights into the precipitating events in early life will be
made.  The patient may then be guided to understand these events in a
new way and can begin to reconstruct those elements of the
personality which are of concern.

   Such therapy is not usually available, affordable, or agreeable to
many patients, and understanding by those around him or her becomes
important. Many people simply make their way, however unhappily,
through life and only come to professional attention through some
crisis.  Any professional who deals with large numbers of people in a
helping role will encounter many variations of maladaptive
personalities. Peers, colleagues and family members can also benefit
from recognizing some of the traits as being reflective of such
problems as those described above, thereby enabling a more sensitive,
patient but firm, and adaptive attitude toward the affected
individual.



    MANIC DEPRESSIVE DISEASE

   Mania is in many ways the opposite of major depression discussed
elsewhere.  It represents a persistent (days to months) profound
elevation in mood far beyond that which is considered usual, with
parallel increases in energy level, wakefulness, sense of power and
influence, decisiveness, and euphoria which cloud judgment beyond
hope.  So intense may the feeling be that it "exceeds" pleasantness,
and becomes distinctly unpleasant for the patient.   When severe, it
may be accompanied by hallucinations and distorted thinking, and may
resemble symptoms of schizophrenia.

   During episodes of mania patients may go on binges of spending
large sums of money, travel long distances, become promiscuous, or
simply become a public nuisance and end up in trouble with the
police. Hypomania is a term which refers to a lesser degree of the
same symptoms.  What strikes many observers is that in many patients
mania is a cyclical disease. By this is meant that it occurs in clear
episodes of apparently spontaneous onset with remissions in between.
Then, in the remission phase, the patient may swing into a state
indistinguishable from a major depression which is described
elsewhere.  The resulting devastation on the life of the patient from
these wide swings may be severe.  When both disease manifestations
are present, the term manic depressive illness is noted. Either
component may occur alone, of course.

   The currently accepted theory of the mechanism of this disorder
revolves around the fact that the chemical norepinephrine is present
in excess in mania and is deficient in major depressions in brain
tissue.  Why this occurs is not known, but the biochemical component
seems to be crucial, and psychoanalytic theories of cause are out of
favor.

    TREATMENT and PROGNOSIS

   The acute manic phase can be life-threatening either through
dangerous loss of judgment and inhibition or through inattention to
nutrition and personal care.  Hospitalization, seclusion from
stimulating phenomena, and often sedation are necessary; the
unwilling patient may occasionally require involuntary
hospitalization in there is danger to life.

   As major tranquilizers have revolutionized the treatment of
schizophrenia, so has the drug lithium carbonate altered our approach
to mania and manic depressive disease.  Perhaps by altering the
transmission of certain brain chemicals, the drug seems to bring
about an equilibrium in the patient's behavior. The drug requires
very careful medical supervision and can have side effects involving
the thyroid, kidneys, fluid and chemical balance, and neurological
symptoms.

   Without treatment, manic depressive episodes may regularly take a
year or more to resolve.  Treatment shortens this to days or weeks.
During remissions, lithium reduces or prevents relapses of both mania
and depression in patients with both components.  Follow-up must be
very close, and treatment may have to be life-long.  Under proper
supervision the patient can return to a productive and meaningful
life, with reduced concern over the potential recurrence of the manic
spells.

   Patients and their families should be alert to the early signs of
an impending depression or manic spell, since even on treatment many
patients retain the tendencies described above, albeit in reduced
form.  With early attention, some episodes can be aborted or
supervised with additional medications, electroconvulsive therapy as
discussed under depression, or other means.  Once a truly tragic and
disabling disease, mania and manic depressive disease can currently
be controlled in most cases sufficiently for the patients to remain
productive, content, and largely unscathed by their disease for most
of their days. Unfortunately, a minority of patients fail to respond,
and long-term intermittent or chronic hospitalization may be
necessary.



      ALZHEIMER'S DISEASE

   Alzheimer's Disease has received tremendous attention in recent
years as the number one cause of chronic dementia in America.
Furthermore, it affects the elderly in most but not all cases, and
this is a rapidly expanding percentage of our population.

   Dementia refers to a global loss of what is termed cognitive
function--memory, attention span, orientation to time, place, and
self-identity, as well as judgment, ability to think in abstract
terms, and other basic mental skills which are essential to normal
human behavioral interaction.  Either as a direct manifestation of
the disease state, or else in reaction to awareness by the patient
over what is going on, depression, fatigue, moodiness and agitation
may be seen.  As the symptoms progress, patients lose the ability to
attend to even the most basic needs for self care, and urinary or
stool incontinence, absence of personal hygiene, and dangerous
self-neglect are seen. From a human standpoint, the personality of
the patient seems to wither on the vine, with enormous stress,
distress, and worry resulting to loved ones, and utilization of
immense societal resources for nursing, institutional, or other care.

   The course of the disease is highly variable.  Some notice only a
frustrating but not disabling memory deficit which remains reasonably
stable for life.  Others note a rapid progression leading to total
dependence in months.  It is common to see a sudden deterioration
after life changes; for example, moving in with family from a
previous home or apartment setting sometimes seems to be the "cause"
of a brisk deterioration.  In fact it is often the case that the
patient had been slowly becoming demented and was relying
increasingly on familiar cues to compensate for this--after the move,
these familiar surroundings are gone, and an apparent sudden
worsening occurs.

    DIAGNOSIS

   There is no specific test to confirm the diagnosis of Alzheimer's
Disease, although autopsy findings are virtually diagnostic in
retrospect, based on characteristic microscopic brain changes.
Rather, diagnosis rests upon identifying the important symptoms, and
most importantly ruling out other reversible causes of the same
symptoms.

   Important diseases to rule out include primary depression (not
rare in the elderly), chronic syphilis which has involved the brain,
hypothyroidism, vitamin B12 deficiency, alcohol or other drug effects
(since older patients are more sensitive to many drugs), recurrent
small strokes, and brain fluid accumulation (hydrocephalus). Several
other rare diseases are also often considered.  These various
diseases can often be ruled out with careful exam, detailed history,
blood tests, and sometimes a CAT scan of the brain.  About 10% of
patients evaluated for dementia will show some reversible component
after such an evaluation.

    Cause

   The cause of Alzheimer's Disease is not known.  Various toxic
chemicals, imbalance in brain chemicals such as acetylcholine, and
viruses have all been considered, but not proven.

    Treatment

   There is no cure for Alzheimer's Disease, since no cause has yet
been identified. Attempts at replacing acetylcholine-like chemicals
such as with lecithin have no proven benefit.  Recent trials of a
drug called physostigmine have shown some early promise, but there
have been problems wit the drug, and its use cannot be advised.

   Attention has been drawn to a drug called ergoloid mesylates
(Hydergine) by recent authors. This drug has been on the market for
years, and was assumed to be relatively useless for dementia; however
it appears that this judgment may have been too harsh. Until further
research can clarify its true role, some physicians may consider a
trial of the drug for Alzheimer's Disease in selected patients, and
there seems to be a possibility of limited benefit for some, with
acceptable side effects in most cases.

    Prognosis

   Most of the damage caused by the disease is behavioral and
psychosocial for both patient and family.  However, the problems
associated with the dementia do decrease life expectancy by several
years. Furthermore, severe dementia often makes aggressive treatment
of other diseases less desirable from a philosophical and ethical
perspective, and some patients are allowed to die a dignified death
from otherwise treatable diseases like pneumonia, in respect for the
family's wishes given the existing quality of the patient's life.

   It is extremely important to emphasize the importance of utilizing
the support services of geriatric and other institutions.  Home care,
family counseling, day care centers, medical support and social
services rendered in a comprehensive manner can enormously ease the
burden of the disease for all affected. The personal physician should
be asked about the availability and desirability of such resources.

   In summary, Alzheimer's Disease is a profound problem which taxes
the coping ability of all patients, their families and friends,
health care providers, and social support services. Research is
active, and medical and social treatment plans can offer significant
benefits;  yet we still have a long way to go.

    Other Causes of Dementia

  Although not sufficiently common for separate discussion (or
discussed elsewhere in HealthNet), certain other diseases warrant
emphasis as causes of apparent dementia, since their treatment and/or
prognosis may be quite different from that of Alzheimer's Disease.

   Depression in the elderly can often be mistaken for dementia. This
may be highly treatable with psychotherapy, medications or
electroconvulsive ("shock") therapy, and untreated may lead to
suicide or great emotional disruption for patient and loved ones.
 A skilled physician or team may be necessary to sort this out, and
even then it is sometimes unclear. Occasionally, a trial of therapy
is the best course of action.

   Vitamin B12 deficiency usually manifests as a low blood count
(pernicious anemia). Occasionally the deficiency can affect the brain
without causing anemia.  In these cases, dementia may be the only
symptom.  A blood test can rule this out.

   Hypothyroidism can first be recognized by diminished intellectual
functioning, and is readily corrected with replacement doses of
thyroid hormone.  Again, a blood test can reveal the diagnosis.

   Normal pressure hydrocephalus is a fancy term for accumulation of
excess fluid in the brain, of uncertain cause.  Dementia is common
and is sometimes accompanied by  disturbance in gait and loss of
urinary control.  Evaluation can be difficult, but some cases are
suspected on the CAT scan.  In questionable cases, that test should
be considered, if not the more definitive nuclear medicine study of
the spinal fluid.  If detected early, some cases can be arrested or
even reversed with a neurosurgical shunting procedure.

   Other rarer diseases can cause dementia, but if the above are
considered, almost all cases of reversible disease will be eliminated
from the diagnostic list.



            STROKE

   The rather ominous term "stroke" actually refers to a broad
spectrum of diseases, the common result of which is the abrupt onset
of neurologic symptoms; these may range from mild weakness of an arm
or leg to loss of speech, paralysis, coma, and death. To understand
the diseases, a brief discussion of their mechanisms is necessary.

   The brain is supplied with blood through a complex arrangement of
arteries starting in the neck, and branching, turning, and dividing
until microscopic capillaries feed the far reaches of the brain.
Since different parts of the brain are responsible for each of the
various functions of the nervous system, the symptoms occurring from
disturbances to the circulation depend profoundly upon the location
of the abnormality.

   Some functions receive input from both sides of the brain.
However, most movement is controlled by only one side--the opposite
of the body part in question.  For example, the right arm is
controlled by the left brain.  Speech is usually controlled by only
the left brain, although in a small percentage (more likely in left-
handed individuals), the speech center is on the right.  The bottom
or brainstem area controls such primitive functions as consciousness,
breathing, balance, muscle tone, and heart beat.  Thus it can be seen
that almost any area of the body's movement or behavior can be
affected by circulatory impairment to the brain.

     TYPES OF STROKE

   There are three basic ways in which the circulation to the brain
can be disturbed by a stroke.

1. Thrombotic-- this refers to a narrowing of an artery by
cholesterol, clot and other material, usually as a result of years of
accumulation.  Finally, the narrowing reaches a critical degree, and
a stroke occurs. The commonest risk factors leading to this are
smoking and high blood pressure.  Oral contraceptives are a rare
contributing factor as well.

2. Hemorrhagic-- referring to a sudden bleeding episode within the
brain.  This may occur from the spontaneous rupture of a congenital
pouch or aneurysm in a brain artery, or from high blood pressure.
Uncommon causes are oral contraceptives, blood clotting
abnormalities, and congenital growths comprised of veins and arteries
which rupture.

3. Embolic-- occurring when a small piece of clot of cholesterol
plaque breaks off from an artery, say, in the neck, and lodges deeper
in the brain.

   Although there are numerous other causes of stroke such as
inflammation of the arteries, severe migraine syndromes, and heart
rhythm disturbances, they are much less common and will not be
discussed specifically in the following section.

    SYMPTOMS

   As may be deduced from the above, the symptoms of a stroke depend
upon which arteries are affected.  However, certain syndromes are
most common.  In general, all strokes are of abrupt onset;  most
abrupt of all are hemorrahge and embolic strokes, which are often
instantaneous.  Thrombotic strokes typically evolve over hours in a
step-wise manner.

   Transient Ischemic Attacks

   "TIA's" refer to episodes of sudden onset of neurologic symptoms
which reverse themselves spontaneously after minutes to hours, and
leave no residual abnormalities.  Typical symptoms include loss of
vision in one eye, weakness of an arm or leg, sudden speech or
balance problems, or sudden loss of muscle tone. By definition, the
symptoms last less than 24 hours; longer episodes (which still clear
completely) have recently been dubbed "reversible ischemic neurologic
deficits" or RIND's.

   About a third of TIA victims will eventually develop a true
stroke, with some permanent damage.

        Stroke Syndromes

  Only a few common syndromes will be described, as the actual number
of findings is virtually limitless.  Most patients do not fit clearly
into a discrete syndrome, however, and individual factors are
strikingly variable.

   One common group of findings includes weakness of an arm, leg or
both (but usually unequally) on the side opposite of the side of the
brain involved.  If it is the left brain, speech may be affected.
"Aphasia" or speech impairment may be either receptive, expressive,
or both. This refers to whether the impairment affects ability to put
thoughts into words, to understand spoken words, or both.  In any
event, the thought process seems to be spared, making the frustration
that much more intense.

   If the area of the brain affecting vision, or the nerve to the eye
itself is affected, partial or even total blindness may occur.
Sometimes only one part of the visual field is affected.

   The bottom part of the brain when struck may give rise to sudden
vertigo or dizziness, nausea, vomiting, and balance problems.  Muscle
tone may be suddenly lost, with collapse in the absence of
alterations in awareness, a so-called "drop attack."

   Multiple tiny strokes, each of which may barely be noticed can
give a cumulative effect characterized by clumsiness, weakness, and
emotional sensitivity.

   When vast areas of both sides of the brain are affected, or when
swelling of a large stroke affects both sides by way of pressure
within the skull, somnolence, and coma may result. Seizures, fever,
blood pressure and heart rate changes are other general effects of
strokes.

    DIAGNOSIS

   Diagnosis revolves first around consideration of stroke as a cause
of symptoms, and then around which type of stroke is occurring.
Prior to the CAT scan, much guesswork was needed, and many patients
were incorrectly categorized.

   A careful history and neurologic exam constitute the mainstays of
diagnosis.  Prior high blood pressure and smoking history are markers
for thrombotic stroke.  Young age raises suspicion for ruptured
aneurysms as a cause of hemorrhagic stroke.  Trauma predisposes to
bleeding, as well.  The abruptness of onset of symptoms, as well as
their anatomic clues, further guide diagnostic efforts.

   Many patients today will undergo a CAT scan of the brain. This can
help rule out tumors, hemorrhage, and injury, as well as sometimes
locate the stroke itself.  Occasionally, a spinal tap is done to look
for bleeding or infection in the spinal fluid which communicates with
the brain.   Where a ruptured aneurysm or other circulatory
abnormality is concerned, a cerebral arteriogram is done; this is the
insertion of a small tube through the arteries in the neck and
subsequent injection of x-ray dye into the arteries themselves.

   Additional tests include blood tests to look for clotting
abnormalities and other medical complications, special circulation
tests of the arteries of the eyes and neck, and other tests in
individual cases.

   In general, the diagnosis is clear, and can be confirmed with
essentially non-invasive testing.

    TREATMENT

   This is a comprehensive topic which will only be summarized here.

   The minority of strokes involve a problem which will require
surgery; this includes certain arterial malformations or aneurysms,
hemorrhage into the cerebellum, and other miscellaneous problems such
as the unexpected tumor or brain abscess.

   Thrombotic strokes may initially require intensive hospital
support including intravenous hydration, blood pressure control, and
respiratory and othe life support measures.  If the stroke is
progressing at the time the patient is under medical care,
anticoagulants (blood thinners) are sometimes considered.  Once the
stroke has stabilized, the benefit of blood thinners is less clear,
and the risks are always significant.

   In hemorrhagic strokes, rest, blood pressure control, and the
occasional use of blood clot promoting agents (the opposite of
anticoagulants) are considered.  Any potential surgery is delayed
until after a period of stability, if possible.

   Rehabilitation becomes the top priority once the patient is
stable.  Progressive ambulation, physical therapy of the weakened
muscle groups, speech therapy of patients with aphasia, and
nutritional support are all crucial.  Occupational therapy can help
impaired patients learn new ways of adapting to their daily needs.
Bed sores and incontinence of urine can plague the bedridden patient,
and require skilled nursing support. Psychologic burdens can be
enormous, and depression can develop. The family and patient may
benefit from counseling.  It may require enormous spiritual and
physical effort, but many patients with significant disabilities can
resume a surprisingly meaningful life after a stroke.

    Prognosis

   Too many variables exist to allow for meaningful survival
statistics from stroke. Certainly massive strokes take the life of a
vast majority of their victims, but most lesser strokes are not fatal
in the absence of other serious diseases. Unfortunately, a stroke is
often a marker for widespread arteriosclerosis, or plugging of the
arteries, and recurrent stroke or heart attack are not rare in this
population group.

   Considerable controversy exists over whether certain operations
can prevent strokes in patients who are at high risk--namely patients
who have had TIA's, or patients with findings on physical exam that
suggest impaired circulation in the neck arteries.  Termed carotid
endarterectomy, the procedure involves cleaning out the plaques from
the inside of the involved artery.  The operation itself involves
some small risk of stroke as a complication.  The only consensus is
toward surgery for otherwise healthy patients with a typical plaque
in an area consistent with the symptoms of the TIA, when the plaque
has a characteristic ulcerated appearance on arteriography.

   Whether it is justified to do expensive, uncomfortable, and not
entirely safe evaluations on all patients at risk in order to find
the small minority who would benefit from the operation is not clear.
 Future research may provide further insight; for now only a few
major centers are following this approach.  It becomes an individual
choice of doctor and patient, based on local circumstances and
resources.

    Prevention

   High blood pressure control and smoking cessation dramatically
reduce the incidence of stroke.  Avoidance of oral contraceptives in
women over 35 years of age is also advised.  Diabetes is a major
risk, and excellent control may be protective, though this is not
proven.  All other preventive measures pale in importance compared to
the above, for most types of stroke.

   One additional area of interest is the use of low doses of aspirin
(1 tablet daily or less) and similar drugs in the treatment of TIA's.
 One well- known study showed that women so treated had fewer TIA's
than untreated women; for men the benefit was unclear.  No definite
survival impact was seen in either group.  Many physicians recommend
this relatively safe form of treatment, although the scientific
evidence is still somewhat unclear.

    SUMMARY
   It may be seen that strokes comprise a somewhat diverse group of
diseases, many of which are avoidable with risk factor control.  Once
a stroke has occurred, and stabilization has been achieved,
rehabilitation is the appropriate emphasis.



   PARKINSON'S DISEASE AND TREMORS

   Parkinson's Disease is a disease of that part of the brain
controlling aspects of movement pertaining to maintenance of muscle
tone balance, coordination of opposing muscle groups, and the smooth
transition from the resting state to movement. These seemingly
unrelated aspects of muscle control are what enable a normal person
to move in a fluid and gradual manner, without unnecessary jerking
motions as complex groups of muscles go into action.  In addition, it
allows us to use certain muscle groups while allowing others to stay
relaxed.  The part of the brain in question is called the basal
ganglia.

   In Parkinson's Disease, the basal ganglia begin to degenerate
progressively for unknown reasons.  The functional defect seems to
include a deficiency of the chemical called dopamine in this area,
and other chemical disturbances are suspected as well.  It has been
postulated that this damage may result from some unknown toxic
element or as the result of a previous viral infection. Familial
factors do not seem to play a major role.  It is not a contagious
disease, and generally affects older people.

   Any or all of the findings of Parkinsonism may be caused by
specific drugs (especially the major tranquilizers such as Thorazine
and Haldol), and following encephalitis or other forms of brain
injury.  The discussion below refers to the standard syndrome of
essentially unknown cause.

   Symptoms

   Although symptoms may occur in the fourth and fifth decade in as
many as 15% of cases, they usually come on in the late middle years
or in old age, in a gradual manner.  One side of the body may be
affected initially, but both sides generally become involved as time
goes on.  The patient may develop difficulty in initiating walking or
other movement, and such movements may be very slow and deliberate.
Resting muscle tone may increase, such that a rigid appearance
develops.  This interferes with such spontaneous phenomena as facial
expression, and a so-called "mask-like" face is common.  The arms may
fail to swing naturally during walking.  A shuffling gait with a
tendency to turn the whole body instead of just the head may occur.

   The characteristic tremor (not present in all patients) is the
most obvious symptom, but often is less disabling than the above
problems.  It is usually in the resting state and involves the hands
in a 4 or 5 per second "pill rolling" motion of the thumb and index
finger. The head, lips, and other parts may be involved.
Interestingly, the tremor may briefly abate during other purposeful
motions.

   Dementia, seborrhea of the skin, and difficulty with wide blood
pressure fluctuations are present in some patients, and the endstage
disease may involve all of the above symptoms, leaving the patient a
total invalid.

   Treatment

   The drug levodopa (l-dopa) has revolutionized the treatment of
Parkinson's Disease, although not without a price in terms of side
effects.  Often given with a second ingredient called carbidopa which
reduces some of the side-effects, the combination drug is called
Sinemet.  The drug is administered in very careful dosages which may
require frequent adjustments.  It must be given anywhere from hourly
to three times daily, depending on the individual's response.
Digestive upset and hemorrhage, cardiac rhythm disturbances,
confusion, depression, and even psychosis and delirium are among its
adverse effects in some patients, and often are dose-related.  Some
patients develop, ironically, bizarre facial or other movement
disorders which may be quite grotesque.

   Despite the potential for side-effects, l-dopa can provide
dramatic benefit for some patients who had been virtually crippled by
their disease, and under careful management the drug can usually be
successfully controlled and quite tolerable. The affects may
unexplainably disappear at periods in a sort of "on- off" phenomenon;
truly it is a poorly understood drug. Nonetheless, the suffering from
severe parkinsonism warrants its use in many patients.

   Alternative drugs which are of less benefit and less toxicity are
sometimes useful in milder cases.  These include bromocriptine,
trihexyphenidyl, amantadine, and others.  They can be used alone,
with l-dopa, or as a diagnostic trial when the diagnosis is in
question, but rarely provide significant long- term benefit.

   Prognosis

   Parkinson's Disease is progressive, although the rate of
progression is variable from patient to patient.  Even with optimal
treatment, disability may still occur within 5 to 10 years, though
current therapies may help significantly.  Life expectancy is reduced
by this disease, although the more optimistic recent estimates place
it within six months of normal life expectancy.  Exact figures are
difficult to specify, but clearly the quality of life for these
patients has been markedly improved with modern treatments.

   An excellent source of further information on Parkinson's Disease
is the United Parkinson Foundation, 360 West Superior Street,
Chicago, Illinois [phone].

   ESSENTIAL TREMOR

   Quite a common condition, essential tremor is a poorly understood
disorder of movement which causes the early onset (often in
childhood) of a rhythmic shaking of the hands and head, sometimes
involving the vocal cords.  It is usually most prominent during
purposeful activity or maintenance of a nonresting position. Often,
it is relieved temporarily by alcohol.  If it is familial, the term
familial tremor is used.

   Diagnosis is generally by history and careful examination. A
skilled physician can usually exclude, at least tentatively,
Parkinson's Disease by the absence of other signs of that disease.
Tumors of the brain, especially the cerebellum, must also be ruled
out sometimes with a CAT scan.  Any tremor warrants careful medical
evaluation prior to assuming it is "essential."

   It has been found that the drugs such as propranolol and primidone
are quite effective in the treatment of this symptom, when it impairs
the patient's quality of life. Alcohol is effective but when
evaluated as a drug for regular long-term use, it is regrettably
toxic.

   Essential tremor tends to progress only very slowly, and seems to
plateau in many patients.  With adequate drug management, most
patients can manage quite nicely, unless their work involves frequent
precise hand or voice control. In that event, more intensive drug
drug therapy or even a career re-evaluation may be necessary.  Life
expectancy is apparently completely normal. 1/89



       MULTIPLE SCLEROSIS

   Multiple sclerosis is a disease of unknown cause which affects the
nerves of the brain and spinal column.  The cell of all parts of the
nervous system are surrounded by a substance call myelin. Acting
somewhat like insulation on an electric wire, the myelin protects the
nerve fibers and enables efficient transmission of impulses along the
nerve.  In multiple sclerosis, the myelin is missing in patches
(plaques) scattered anywhere in the central nervous system.

   Typically the disease affects residents living in temperate
climates.  In fact, in such areas the incidence is 10 times higher
than in tropical zones. It seems that it is where one spends the
first 15 years of life which determines the geographic risk.  In
northern climates, about 1 person per 10,000 has the disease.  Social
affluence, urban lifestyle, and family history of the disease are
also statistical risk factors.

    Theories of Cause

   The epidemiology of the disease suggests a viral cause, though
this has not been proven. Certain sophisticated laboratory tests have
also suggested this possibility.

   Another possible causative factor may be immune disorders in which
the body somehow recognizes the myelin as being "foreign" and
proceeds to attack it much as if it were some invading organism.  It
is possible for viruses to initiate this sequence of events, so that
both mechanisms may be at play.

    SYMPTOMS

   The hallmark of multiple sclerosis is the occurrence of symptoms
reflecting abnormalities in separate and distinct areas of the
nervous system, and which come and go over a period of time.  For
this reason, the diagnosis is often delayed.

   Certain symptoms are most common in this disease, although almost
any neurologic symptom can occur.  Optic neuritis involves the nerve
of vision, and causes blurring, blind spots, and decreased vision.
Double vision can occur if the centers controlling eye movement are
affected.

   Weakness, clumsiness, and awkwardness are common in either the
arms or legs.  The face muscles may also be affected. Bladder
involvement can cause incontinence of urine, or inability to urinate.
 Rarely, seizures may occur.

   In the vast majority of cases, the disease begins in early
adulthood.  Onset after age 40 is unusual.  Usually the symptoms
progressive over a series of days, and remit after several weeks.
 Unfortunately, the remissions are not always complete, and a
cumulative residual disability can occur. Some patients are fortunate
to have only a few isolated episodes with no permanent impairment.

    DIAGNOSIS

   The characteristic history and appropriate neurologic
abnormalities on exam are the primary diagnostic clues.  No single
test is totally confirmatory, and since most of the symptoms can also
be the result of tumors and infections of the brain and spine, as
well as other less common diseases, most patients undergo CAT scans
of the brain, blood tests, and a spinal tap for fluid analysis.
Sophisticated brain wave analysis following stimulation of the ears
or eyes with various lights and sound (evoked response studies) can
also show characteristic abnormalities, even when symptoms are
absent.

    TREATMENT

   Currently available treatment of multiple sclerosis is inadequate.
 The mainstay of treatment for acute attacks is cortisone and its
related drugs (prednisone, ACTH, methylprednisolone).  Although these
are accepted as standard therapy, there is no solid evidence that
they favorably affect the course.  The unpredictable nature of the
disease make such data very difficult to obtain.

   Experimental treatments which have shown some promise, but which
are not of proven benefit, include plasmapheresis (removal of the
protein containing fraction of the patient's own blood), high
pressure oxygen administration, and interferon.

   Sometimes the weakness of multiple sclerosis is accompanied by
spasticity-- heightened muscle tone causing spasms and loss of
function. When this is present, drugs such as diazepam (Valium),
baclofen, and dantrolene are used.  Other drugs may be useful
depending on the specific symptoms and complications.

   In a disease such as this, support services such as physical
therapy, occupational therapy, social service workers and mental
health counselors can be of great assistance, especially in severe
cases. Medical care is often coordinated by a neurologist or a
primary care doctor working with a neurologist.

    Prognosis

   Marked individual variability makes the use of prognostic
statistics a bit risky; however, at least 70% of patients remain
employed five years after onset, according to some authors.  The
figure drops to 50% after 10 years, and 35% after 20 years. Actual
life expectancy is affected somewhat but in general long term
survival of 35 years or more is expected.



    HEADACHE SYNDROMES

    NOTE:  The symptom of headache is treated in the "Symptom"
portion of HealthNet Reference Library.  Further information may be
found there. This section deals with some of the common diseases
which manifest as headache, with emphasis on diagnosis and treatment.

    MIGRAINE

   Some authorities have stated that up to one quarter of the
population experience a migraine headache at some time in their life.
 It is a disease which usually starts in childhood or young
adulthood, and peaks in the third and fourth decades, only to subside
in many patients as they enter their fifties. Most but not all
patients have a history of migraine in other family members.

   Although the cause of migraine headaches is not known, the
mechanism of pain and other symptoms seems to be related to
exaggerated fluctuations in the size of the blood vessels to the
brain and its surrounding structures.  These contractions and
relaxations of the muscles in the blood vessels may be due to
abnormal concentrations of certain chemicals such as histamine,
serotonin, and prostaglandins.  In the classical episode, a period of
narrowing causes decreased blood flow, followed by the dilating phase
in which the onrushing blood stretches the pain sensitive lining
tissues.

    SYMPTOMS

   The stereotypic syndrome begins with a warning phase in which the
patient has an "aura" of impending problems.  There may be flashing
lights in one eye, blurring, blind spots, or distortions of vision.
Tingling of the arms or face may occur. After about thirty to sixty
minutes, the headache begins: usually on one side but sometimes
becoming generalized, it is pounding, worse with movement or bending
over, and can be excruciating.  Nausea and vomiting may follow, with
marked sensitivity to bright lights and loud noises.  The sufferer
may want to withdraw to a dark quiet room, yet the headache seems to
follow him everywhere.  Usually within 4 to 6 hours, it finally
subsides.

   The above description concerns a classic migraine; many or even
most patients have variations on this theme.  The more common "common
migraine" may lack the warning symptoms, and the headache may be far
longer lasting, although similar in nature. Irritability and
depression may occur hours or days before the onset.  Still other
patients may have combinations or alternating episodes of headaches
with exceptions to the above descriptions or other unusual symptoms
including periods of paralysis, dizziness, or even loss of
consciousness.

   Precipitating factors are multiple--commonly mentioned examples
include stress, sleep recovery after a period of deprivation ("Sunday
morning headache"), fasting, alcohol in general and red wine in
particular, menstruation, and caffeine excess or withdrawal. Birth
control pills may cause or worsen migraines, and may be a risk factor
for strokes.  More women than men suffer with migraines, but not to
an extreme degree.

    DIAGNOSIS

   Although the history is often virtually diagnostic, the careful
physician will be alert to clues suggesting the presence of an
alternative or additional diagnosis including tumors, hemorrhage,
infection, or other disorders.  If there is any doubt, further tests
of the blood, x-rays, and other neurologic evaluations may be
necessary.

    TREATMENT

   Once the diagnosis is firm, obvious precipitating factors removed,
and the patient reassured about the nature of the disorder,
appropriate counseling is given to deal with any stress or other
psychological elements at play. Medications may then play a major
role in management.

   Ergotamine and related drugs such as Cafergot, Ergomar, and Midrin
contain blood vessel constricting agents.  They are generally given
by mouth, but some may be given by rectal suppository if vomiting is
present.  When given early, especially in the warning stage, they may
successfully abort the headache within seconds to minutes.  Repeated
bouts of headaches may be prevented with weeks to months of
prophylactic doses of similar drugs.  Side effects include severe
blood vessel obstruction, angina, and other symptoms, but are
uncommon at the usual doses. These are potent drugs and should be
taken under close supervision and only in the prescribed doses.

   Sometimes the ergot class of drugs are not successful.  In the
acute case, pain relievers including narcotics may occasionally be
needed.  Other drugs including methysergide and cyproheptadine are
occasionally used.  Propranolol and amitryptilline are two of the
most commonly used preventive drugs, and are useful when headaches
are occurring with sufficient frequency to interfere with productive
daily activities, or when excessive doses of ergots are required.  A
promising new development is the discovery that a class of drugs
called "calcium channel blockers" can dramatically treat even the
most resistant cases at times, and possibly may have a preventive
role as well. Nifedipine is such a drug. Still experimental for this
disease (although in wide use for certain heart conditions), calcium
channel blockers may have a vital role in migraine therapy of the
near future.

    CLUSTER HEADACHES

   Somewhat similar to common migraines, cluster headaches differ in
their tendency to occur over several weeks or months in rapid
sequence--daily or several times weekly, then disappearing for months
at a time, i.e. clusters of headaches.  Typically, they strike young
adult males, often awakening the sufferer at night, confined to one
side of the face or head, and often accompanied by tearing or nasal
discharge. The pain may be the most severe ever experience, and
victims have been said to commit suicide to escape the pain.
Thankfully they are usually self-limited and disappear after an hour
or so.

   Therapy has traditionally been similar to that of migraine,
although a preventive emphasis is often more prominent.  Calcium
blockers, as discussed above, may revolutionize therapy as their role
becomes better established. Lithium, prednisone, and indomethacin
have also been useful at times.

    TENSION HEADACHES

   Probably the commonest of headaches, tension headaches are caused
by the involuntary sustained contraction of the muscles surrounding
the skull and face.  Prolonged mental concentration, stress, and a
variety of individual factors may bring on the pain.  Young people
are affected most often, though the headaches may persist for life.
Almost no one escapes at least an occasional tension headache.

   Common pain patterns are those involving the back of the head and
upper neck, the forehead (like a hat that is too tight), and around
the eyes. The pain is a steady ache, lasting hours to days.  Other
than fatigue and mild depression, other symptoms are usually absent.
It is not uncommon to have a tension headach not during periods of
stress, but rather after the stress is relieved.  Rarely do tension
headaches awaken a patient.

   Treatment involves the use of hot or cold applications, relaxation
or meditation techniques, and simple pain relievers such as aspirin,
acetaminophen, or ibuprofen. These drugs are far more effective taken
early in the course of the headache, as opposed to waiting until the
pain is severe.   Anecdotally, regular exercise of aerobic intensity
often reduces the incidence of tension headaches. The prognosis is
benign, but interference with normal activities can be significant.
In that event, medical attention may be necessary, and judicious use
of anti-anxiety agents, formal counseling, and other measures may be
necessary.

   Diagnosis rests upon ruling out other causes of headache, which
can usually be done without the use of extensive testing. At least
initially, a physician diagnosis should be made for this common
entity, although recurrences may be quite familiar to the patient,
and rarely require medical attention.

    MIXED HEADACHE SYNDROME

   Until fairly recently, the usual headache sufferer was classified
as either having migraine or tension headache. Treatment would be
given for one or the other, and the results would be observed.
Although most did quite well, there remained a sizable number of
patients who would continue to suffer despite treatment.  Many would
get partial relief only.

   It is now recognized that many patients actually have elements of
both tension and migraine or "vascular" headaches, or so-called
"mixed headache syndrome."  As might be assumed, treatment involves
delicately balancing the treatment to allow for both components, with
variations depending on the nature of the headache, the patients
ability to differentiate the two, all the while avoiding the tendency
toward overmedication. Diagnosis rests on a very carefully obtained
history and examination by a caring physician, who may then use
selected additional tests when indicated.  The main point is that a
clearcut categorization into the previously discussed types of
headaches is not always accurate, necessary or beneficial to the
patient.

    TEMPORAL ARTERITIS

   This disease is discussed under the Arthritis section of
HealthNet, but is mentioned here only to state that any headache
which comes on for the first time in a person over 50 years of age
should be considered as possible temporal arteritis until ruled out
by a simple blood test.  The risk of missing this diagnosis is sudden
onset of blindness.  It is an inflammation of blood vessels
(vasculitis) and can be treated with medications once diagnosed.



      EPILEPSY (SEIZURES)

   The term epilepsy refers to recurrent seizures or "convulsions."
Rarely do we experience such dramatic symptoms as with certain types
of seizures, and throughout history, a broad body of superstition,
misunderstanding, and unfounded fear have arisen around the
diagnosis.  Even today, sufferers are faced with many obstacles to
their daily activities which are related more to these misconceptions
than to their usually well- controlled disease.

   Seizures are episodes of spontaneous discharge of groups of nerve
cells in the brain. This may arise for unknown reasons, or may result
from some physical or chemical injury to the brain. They area
affected determines the type of seizure which occurs, but often the
seizure will spread beyond the area of injury to produce a
generalized seizure.

    SYMPTOMS

  Seizures can conveniently be divided into several categories,
depending largely upon the type of symptoms they cause. Tonic-Clonic,
or Grand Mal-- refers to the most widely recognized type, where
muscle groups rapidly contract and release in a jerking motion,
eventually involving many or all major groups, impairing
consciousness, and leading to coma during and following the seizure.
Vocalizations, urinary incontinence, irregular breathing and tongue
biting may occur.  Usually the seizure lasts but a few seconds or
minutes.

Absence Spells--refers to brief periods of loss of awareness,
sometimes with exaggerated blinking movements. Occasionally loss of
muscle tone may produce falling, although the patient appears to be
alert and conscious.

Partial Seizures--refer to seizures which are limited in effect to a
single region of the brain.  This may result in muscle contraction
seizures limited to one part of the body, e.g. the arm, or in
sometimes bizarre symptoms such as perception of unusual odors,
strange repetitive movements such as lip-smacking, or even unusual
behavior patterns of an inappropriate nature. The fictional crime
committed as a result of a complex seizure is just that--fiction; the
behavioral manifestations are almost always far too simplistic to
result in such a complex behavioral act.  Awareness and consciousness
during partial seizures may be either normal or impaired.

Petit Mal--refers to childhood seizures manifesting as brief periods
of unawareness, while an appearance of full consciousness persists;
the patient may not be aware of their occurrence, and they may be
very frequent during the day, resulting in school and developmental
problems until recognized and treated.

    CAUSES

  When the onset of recurrent seizures is in childhood and not
associated with some obvious facto, most cases are "idiopathic"--of
unknown cause. A slight family tendency is noted, but this is
inconsistent.

   High fevers can cause seizures especially in children. These are
usually isolated events, and very few such victims who are otherwise
medically normal develop recurrences (fewer than 3%). Whether
treatment with anti- seizure medications is warranted is
controversial, and depends on a variety of medical and philosophical
factors.

   Many diverse brain injuries can result in seizure disorders by
injuring the nerves of the brain, rendering them unstable. These
include infections (encephalitis, meningitis), alcohol, stroke,
trauma, tumors, and others.

    DIAGNOSIS

   The history, physical exam and brain wave test
(electroencephalogram or EEG) are the mainstays of diagnosis. A
judgment is important in many cases, since the EEG is not a totally
sensitive test, and some people without seizures may have an abnormal
EEG.

   If the onset of seizures is in adulthood, a CAT scan x-ray of the
brain may be considered, since the likelihood of finding some
anatomic abnormality such as tumors or areas of stroke is much
greater than in childhood. Ordinarily the above tests are adequate
for diagnosis, assuming other general screening blood tests are
normal.  Any detected abnormalities may require more extensive
evaluation.

    TREATMENT

   Isolated seizures of obvious cause may require no specific
treatment.  Most cases of recurrent seizures or idiopathic seizures
will require treatment with medications to reduce the risk of
recurrences.  The drugs used, their doses, side-effects, and efficacy
are highly complex, and should be under the management of an
experienced physician.

   Often, a single drug is used first, and pushed upward in dose
until seizures are controlled or side effects are noted.  At hat
point a second drug may be added.  In the past, phenytoin (Dilantin
and others) was often used first, with phenobarbital a close runner
up, especially for children.  Recently, drugs such as carbamazepine
and  valproic acid are receiving wider use. Ethosuximide is commonly
used in petit mal seizures.

   Modern thinking has tended toward gradual weaning of medications
after two or more years of successful seizure control; this highly
individualized judgment depends upon many factors including age at
onset, cause, EEG findings, and other factors.  When well- chosen,
fewer than 30% of patients with childhood onset disease relapsed at
all after the drugs were discontinued. Others may require life-long
therapy.

   Status epilepticus is a term used when seizures occur in rapid
succession, with incomplete recovery in between the seizures. This is
uncommon, and sometimes results when a patient abruptly discontinues
anti-seizure medications.  It is a life-threatening emergency, and
requires intravenous drugs, respiratory support and other measures
aailable only at medical facilities.

   First aid for any seizure consists of common sense measures to
prevent injury to the patient, and observance for total cessation of
respirations for greater than 30 seconds or so (which might require
resuscitation).  Most cases are self-limited, and all cases require
summoning of trained medical assistance as soon as possible.

   State and other agencies have specific requirements for drivers
licenses and other positions involving public safety. With growing
public education, many of these regulations are appropriate to the
disease.  However, some are archaic and deserve revision based on our
ability to control this once frightening and untamed malady.

   Modern care offers excellent hope for the diagnosis, treatment,
and understanding of epilepsy for almost all patients. If the public
perception of the disease were as enlightened as the medical
approach, most patients would have little to worry about other than
taking their medications as prescribed.



     PERIPHERAL NERVE DISEASE
        Tic Douloureux
        Bell's Palsey
        Carpal Tunnel Syndrome
        Guillain-Barre Syndrome

   The term "peripheral nerve" refers to those nerves which are
located outside of the brain and spinal cord, those being termed the
central nervous system. Peripheral nerves refer to those supplying
the face, arms, legs, and internal organs.  Of course, all nerves are
strongly controlled by the central nervous system in the end.

   Many diseases affect the peripheral nerves as a secondary
manifestation of the primary problem.  The most common example might
be diabetes, where the damage to microscopic blood vessels injures
the nerve tissue supplied by the vessel.  Cancer, vitamin
deficiencies, drugs and toxins are other such examples. The nerves
may be affected singly or in many different combinations. This
discussion will discuss those conditions which are considered
primarily as nerve disorders;  the reader is referred to the specific
disease, drug, or symptom for further information about other
diseases in question.

BELL'S PALSY

   Bell's Palsy is the sudden onset of paralysis of one side of the
face, due to loss of function of the facial nerve's upper division.
Its cause is unknown.  Usually the paralysis comes on very rapidly
over minutes or hours, and there is little or no pain or discomfort
other than that related to the paralysis itself.  The patient notices
that the eyelid, cheek, and facial muscles droop and fail to respond
to normal facial movements such as smiling. Taste and tearing of the
eye on the affected side are sometimes impaired.

   Fortunately, the disease usually resolves spontaneously over a
period of weeks, with most patients having no residual problems.
Treatment is not proven to be beneficial, although prednisone and
similar drugs are often given early in the course in the hopes of
improving the symptoms.  A small minority of cases resolve
incompletely, leaving varying degrees of permanent facial weakness.
Diagnosis is usually clear from the history and exam, although care
must be taken by the physician to rule out stroke and other more
serious problems.

TIC DOULOUREUX  (TRIGEMINAL NEURALGIA)

   One or two of every 10,000 people will develop this disorder,
which is characterized by the abrupt onset of sudden lightning-like
bursts of excruciating pain in the face on one side only.
Classically, the pain is sharp and fleeting, occurring in clusters
over several hours, and sometimes flaring up in a seasonal pattern.
Most patients notice that certain areas of the face serve as trigger
points which when touched cause the pain to recur.  The pain can be
so severe as to lead to great depression, disability, and even
thoughts of suicide.

   The cause of the disorder is unknown; occasionally tumos, multiple
sclerosis, and other diseases can cause symptoms identical to
trigeminal neuralgia, but most cases are of uncertain origin.  The
diagnosis is by history, and exclusion of other possibilities by
careful examination and follow-up. Treatment is with medications
which are those used for seizure disorders, such as carbamazepine,
phenytoin, and others.  This is usually effective, but resistant
cases may require surgical or radio- frequency destruction of the
nerve root to relieve pain.

CARPAL TUNNEL SYNDROME

   The carpal tunnel is an anatomic area at the palm side of the
wrist which is bounded on all sides by either bone or rigid
ligaments.  Through this "tunnel" passes, among other important
structures, the median nerve.  This nerve serves the thumb, index and
middle fingers of the hand in both sensory as well s muscle
functions. Because the tunnel is rigid, any swelling or compression
in the area readily press on the nerve and cause symptoms.

   Repeated use of the hand and wrist as in typing, sports and other
activities is a common cause of such swelling. Diseases which cause
generalized swelling or the accumulation of excess amounts of tissue
can also affect the carpal tunnel, including hypothyroidism, cancer,
and even pregnancy. Typical symptoms are pain and tingling in the
first three fingers, sometimes worse at night, and loss of ability to
detect subtle stimuli of the skin in these areas.  The muscles of the
thumb may weaken and shrink.

   Diagnosis is made by careful history and exam, and is usually
confirmed by a nerve conduction test (a variety of electromyogram).
Resting the wrist is best if possible, sometimes with the aid of a
splinting device.  When this is impossible or ineffective, surgery
can relieve the pressure and is generally quite successful.

GUILLAIN-BARRE SYNDROME

   First coming to general public awareness after the swine flu
immunization episode, Guillain-Barre Syndrome is a disease affecting
many peripheral nerves at once.  It is rare, and often follows
several weeks after a seemingly trivial viral infection such as a
cold, stomach virus, mono, or other illness.  The resulting syndrome
appears to be an autoimmune attack on the nerves, in which the body
sends its own white cells and other defenses against the nerves;
perhaps this is in response to a virus which mimics the nerve tissue
coincidentally.

   Usually, the patient develops sudden weakness in the legs which
spreads upwards over a matter of days to involve the arms, stomach,
back, trunk, and sometimes the muscles of breathing and swallowing.
Except for the occasional occurrence of a tingling sensation there
are usually no painful or other types of symptoms.  The danger occurs
when respiration or swallowing are involved.

   As a rule, the picture is sufficiently clear to make the diagnosis
obvious.  Rare diseases such as botulism should be considered in some
contexts. Confirmation of the diagnosis is important, and usually
involves a spinal tap, where the findings are characteristic.  The
course is usually one of progression for a week or two, with gradual
improvement thereafter.  Weeks or months may be necessary for total
recovery, and some patients are left with some permanent weakness.

   Treatment with whatever support measures are needed usually
results in a good prognosis for survival. However, the use of a
ventilator and a tracheostomy, feeding tubes, and intensive nursing
care may make the ordeal quite difficult for the patient and his/her
family.  Appropriate management should result in good recovery for
the vast majority of patients.



    MISCELLANEOUS NEUROLOGIC DISORDERS
          Myasthenia Gravis
          Narcolepsy
          Head Trauma

Myasthenia Gravis

   This rare disease affects the transmission of impulses from the
nerve endings to the muscle tissue through the occurrence of abnormal
antibodies in the blood.  The result is rapid tiring of the muscles
upon repetitive use.  Depending upon the severity this may range from
simple drooping of the eyelids to severe or even fatal episodes of
weakness.

   A special test is needed for diagnosis, in which a drug is given
to stimulate the nerve transmission, and muscle strength is measured
before and after.  Some patients with this disease have a poorly
understood complication of a tumor of the thymus (a vestigial gland
located in the chest).  In others, removal of even a normal thymus
gland results in improvement of the symptoms. Other treatment
consists of medications which increase the concentration of
neurotransmitter chemicals at the muscle-nerve junction. Great care
must be exercised in their use, since overdosing can cause weakness
just like the underlying disease, and crises can occur either way.

Narcolepsy

   Narcolepsy describes a disease of the sleep center of brain which
results in sudden and overwhelming episodes of sleepiness occurring
during usual waking hours.  The attacks may last from seconds to many
minutes, and usually are not resistable by the patient. Other aspects
of the syndrome in many patients include periods of sudden loss of
muscle tone, called cataplexy, in which the patient may suddenly fall
or slump for seconds or minutes, while still fully conscious. These
spells are often brought on by emotional stimuli such as laughing,
surprise, or anger.  A third syndrome suffered by some is called
"hypnagogic hallucinations" in which the period of transition between
sleep and wakefulness is marked by exaggerated, nightmare-like
hallucinations. Finally, some patients have sleep paralysis, in which
inability to move the body is experienced for excessive periods of
time while awakening or falling asleep.

   A minority of patients experience all of the above symptoms, but
over two thirds have both narcolepsy and cataplexy.  Socially the
symptoms can be disastrous, as well as dangerous in the context of
driving and other hazardous activities.  The cause is generally
unknown, with men and women equally affected.  Some cases follow
brain infections or injury.  Diagnosis is largely based on the
history and exclusion of other disorders with careful exam and
selected test.  Definitive diagnosis requires a sophisticated sleep
monitoring laboratory; these are becoming more widely available in
most regions.

   Narcolepsy can be treated with medications.  Standard therapy
includes stimulants such as methylphenidate and amphetamines for
sleep attacks, and tricyclic drugs such as Vivactyl for the weakness
spells.  Other drugs which have been reported to help some patients
(but not of proven general value) are codeine, cimetidine, and
propranolol. Management requires careful drug adjustment and
balancing of the hazards of treatment against the benefits.
Neurologists generally have the widest experience with this disease.

HEAD TRAUMA

   Injuries to the head are the cause of serious problems for over
500,000 people annually in America.  Motor vehicle accidents,
including motorcycles, and on-the-job accidents account for large
numbers of these.  Brain injury is only one aspect of this trauma,
with airway difficulties accounting for many of the deaths as well.

   Direct bruising of the brain can instantly disrupt the complex
functioning of its nerve cells, causing swelling, coma, and
eventually death if the vital centers of breathing and cardiovascular
control are affected.  Hemorrhage within the skull and brain can
likewise create excessive pressures. Some types of hemorrhage can
allow for temporary regaining of consciousness after initial injury,
only to return with deepening and fatal coma hours or even days
later.  Yet other types of hemorrhage may occur slowly such that
weeks go by before serious signs are noted.

   Any brain injury resulting in unconsciousness without obvious
signs of internal bleeding or other discrete damage to the brain or
skull is loosely termed a concussion; this is a vague term and is
more useful in conversation than in medical care.  Lack of
unconsciousness does not guarantee absence of serious problems, nor
does a "concussion" always signify serious complications.

   Any serious head injury warrants medical attention. Where there is
doubt, it is best to seek care.  The physician may caution the
patient or his/her family to be especially alert for signs of
increasing brain pressure: repeated or projectile vomiting, abnormal
levels of alertness, localizing weakness, asymmetry of the size of
the pupils of the eyes, etc.  These may warrant further tests even
when such tests were judged unnecessary at the initial evaluation.

   Prognosis is not meaningful in general terms since each injury is
unique.  Serious complications are less likely if mental status is
only briefly disturbed or not at all, if the patient is young, and if
a neurologic exam is normal after the injury. Prevention is
crucial--protective head gear, seat belts, and avoidance of clearly
dangerous sports such as boxing are obvious measures, yet rarely are
these seemingly sensible precautions heeded by the potential victims
of severe head injury.

   For survivors of serious head injury (coma), prolonged survival in
a "vegetative state" or true coma (absence of the awake state) may
occur. Where coma persists beyond several weeks, chances of
meaningful recovery become vanishingly small, despite the occasional
exception we have all read about in the newspapers. The ethical and
moral questions of providing indefinite and astoundingly expensive
care for such patients are among the most difficult facing society
today.



   Skin Disease--Introduction

   The skin is widely known as the largest organ of the body, but we
rarely consider its incredible burden as our first defense against a
biologically very hostile world.  The attacks it suffers daily come
from bacteria, viruses, heat and cold, physical injury, ultraviolet
radiation, constant moisture and scorching dryness, and other fronts.
 As if that were not enough to ask, the skin must regulate our body
temperature, detect potential harm before injury can occur, provide
input to the brain regarding the physical nature of the environment,
and even allow us to become sexually aroused so that the species can
go on. Humans that we are, we even expect it to make us look good, as
well!

   In view of the above it seems miraculous that skin diseases are
not more frequent and serious than they are.  None the less, they do
occur, and are familiar to many because of their conspicuous nature.
This section of HealthNet explores some of the commonest entities.

   Many diseases affect the skin through rashes, circulatory
impairment, and other means. They are discussed in the appropriate
sections elsewhere. Only diseases primarily affecting the skin are
included here.  For instance, measles is discussed under
"Infections."

   If you do not find what you are looking for, drop us a note
through "Ask HealthNet."  If enough interest is apparent, we will
consider it for future updates.  We hope you find this section
educational and helpful.



              ACNE

   Though common and virtually never life-threatening, acne is a
potentially disfiguring skin disease which often strikes those in an
emotionally and developmentally vulnerable stage of
life--adolescence.  It affects the glands in the skin which secrete
the natural lubrication (sebum) for the hair follicles and
surrounding skin, which are located in greatest concentrations on the
face, back, shoulders, and chest.

   Acne lesions are of several types.  Blackheads (comedones) are
glands plugged with excessive material which discolors on exposure to
air. Whiteheads are small collections of pus within glands, and
nodules or papules are the red, inflamed areas of more extensive
infection.

             Causes

   Contrary to popular opinion, factors such as chocolate, sugar,
soaps, and other environmental factors probably have little to do
with the onset or course of acne.  The strongest single factor seems
to be family history, though the actual fundamental cause is unknown.
 Stimulation of the sebaceous glands seems to occur with the
production of androgens (the masculinizing hormone found in both
sexes) at puberty.  Acne victims seem to produce normal amounts of
androgen, but their skin is unusually sensitive to it.

   The excessive and possibly abnormal sebum secreted tends to plug
the glands, irritate them and leave them open to infection with
otherwise normal skin bacteria.  This in turn causes further
infection and inflammation.

           Treatment

   Various approaches to treatment are available, each of which may
take a month or more to start to be effective.  The most direct
method is topical preparations.  They are generally somewhat abrasive
and irritating, and are not useful for the more inflammatory types.
Examples include sulfa or other antibiotic lotions which cut down the
bacterial component, benzoyl peroxide which also seems to irritate
the surface layer, causing it to shed along with some excess sebum,
and vitamin A acid (Retin-A) which may have a direct effect on the
surface sebum.  The latter seems to work well for blackheads, but may
increase the risk of ultraviolet light-induced skin cancers.

   Resistant or severe cases often require the use of oral agents.
Antibiotics, especially tetracycline, seem to prevent inflammatory
changes even in low doses, and are sometimes continued for years.
See the drug section for side effects and further details.
Minocycline and erythromycin are also used. Oral contraceptives seem
to help acne in some women, though whether its use for this alone is
justified is judgmental.

   The latest agent of benefit is isotretinoin--a vitamin A
derivative.  A 4 to 5 month course is usually given, and seems to
markedly decrease the production of sebum after 2 weeks.  Even the
most severe case have responded quite dramatically, and the benefit
has persisted for months or years after the drug is discontinued.
The eyes, liver, nose, joints and other organs may be involved with
side- effects, and usually only the severe inflammatory varieties are
appropriate for this drug. Nonetheless, it can offer dramatic
benefits for patients who previously had little hope. Long-term
safety is not known.

   Other measures sometimes used are the injection of individual
severe lesions with cortisone- like drugs, extraction of blackheads
before they become inflamed, and cosmetic surgery or "skin sanding"
procedures for scars.

   X-ray therapy is to be avoided due to its serious long- term side
effects, including thyroid cancer.

   Most patients have a marked decrease in acne after their
mid-twenties, although persistence and even worsening well into the
thirties is not rare.  For almost all patients, a careful combination
of topical and oral agents can control the disorder with excellent
safety, tolerable side-effects, and good results.


          Acne Rosacea

   Despite the superficial resemblance of the skin lesions to those
of common acne ("acne vulgaris"), acne rosacea is different in
several ways--it affects middle aged adults predominantly, and is
accompanied by flushing and spider-like blood vessel enlargement
beneath the skin. Usually the areas involved are confined to the
face.  The cause is not known, although an unusual sensitivity of the
blood vessels to dilating stimuli such as caffeine and certain drugs
is sometimes noted.  In some men in particular, prolonged disease
leads to a thickening of the skin of the nose (rhinophyma).

   Non-prescription measures consist of avoidance of such factors as
excessive cold or wind burn, sun, and caffeine and other heated
beverages.  Some patients note that spicy foods and alcohol may
worsen the symptoms.

   All of the standard medications which have demonstrated benefit
require prescriptions.  These include creams (e.g. erythromycin,
isotretinoin, clindamycin, sulfur), and oral antibiotics such as
tetracycline.  The mechanism of action is poorly understood, but each
of these can bring marked improvement in selected patients.

   It is important that many of the over-the-counter drugs touted for
the other type of acne, such as benzoyl peroxide or salicylic acid,
can actually worsen acne rosacea, and should be avoided. If effective
treatment is needed after the above avoidance measures are taken,
appropriate medical consultation for the above medications should be
highly effective.



    SEBORRHEA

    Description

   Seborrhea consists of a fine scaley rash with oily skin, in
well-defined areas of the face (mid-forehead, sides of the nose,
eyebrows and lids), scalp, chest and back.  Redness and weeping of
the skin are occasionally seen.  The cause is unknown.  As opposed to
simple dandruff, which is the normal flaking of the skin of the
scalp, seborrhea results in copious scaling of larger amounts of
skin, and is often the underlying cause of so- called severe
dandruff.

    Treatment

   Topical preparations containing sulfa, salicylic acid, or steroids
are highly effective.  Because of possible permanent scarring,
steroid usage on the face should be carefully monitored by physician.
 Control of this disease usually presents little problem.  More
severe cases, where the scales become thick and confluent sometimes
require the use of gels which disintegrate the crusts, and intensive
use of tar-based lotions.  Oral medications are not indicated, as a
rule.

            DANDRUFF

   Dandruff is not truly a disease.  The scalp area contains a very
high number of sebaceous glands;  their function is to produce sebum
which protects, lubricates, and moisturizes the skin and hair
follicles.  In such metabolically active skin regions, there is rapid
turnover of the surface cells of the skin.

   On the spectrum of normal skin turnover and subsequent scaling of
the shed scales and cells, there is wide variability.  Once this
becomes cosmetically significant (obviously a subjective matter), the
term dandruff is used.

   Almost every adult has some scaling.  Treatment is generally a
question of choice.  If, however, there is redness, weeping, severe
itching, or crust formation, seborrhea is likely.  This is discussed
elsewhere.

    Treatment

   Simple measures such as regular simple shampooing will remove most
of the excess scales;  excessive washing, or the use of harsh
detergent soaps can cause irritation and worsen the scaling.  How
often to wash the hair varies with the degree of "oiliness" or sebum
production.  A common range tolerated by most people is two to five
times weekly.

   Of the non-medicinal shampoos, despite claims of a rather
grandiose nature, there is probably little to support one brand over
another. Research is difficult in this area, but it seems that
considerations such as price, fragrance, and convenience are as good
as any other criteria in making a choice.

   For those who wish to reduce the degree of dandruff, and who are
already washing their hair regularly and avoiding irritating factors
(including dyes and permanent wave treatments), shampoos containing
either selenium sulfide or zinc pyrithione seem to be effective (and
expensive).  Both are available over the counter.

   Cases not improved by the above are probably crossing into the
seborrhea classification and will require more potent lotions
including steroid agents, by physician prescription.  Often, however,
a willingness to accept small degrees of dandruff under the above
regimen can save considerable amounts of money, inconvenience, and
time, since this is really a normal, physiologic process.



    PSORIASIS

   This is a skin disease of unknown cause affecting up to 3% of the
population.  It is characterized by plaques of red, scaley, easily
bleeding skin, often over the knees, elbows, trunk, and back.  The
nails may develop pitting, and some cases are associated with severe
arthritis much like rheumatoid arthritis. Some patients have a
tendency to develop impressive degrees of psoriasis at the sites of
scrapes and scratches, as well.

   The disease has wide variability from one patient to another, and
when severe may threaten survival by exposing wide areas of skin to
infection. Fortunately, the latter is rare.

             Cause
   The cause of psoriasis is not known, although genetic factors are
considered important; some environmental factors such as injury,
stress, climate (cold), and other illnesses are also important in
some patients. Conversely, about a third of patients have spontaneous
remissions of their disease.

   In normal skin, the time necessary for an epidermal cell to go
from creation to shedding or scaling is about 28 days; psoriatic
cells complete the process in 3 or 4 days.  Thus there can be
enormous buildup, inadequate maturation, and finally plaque formation
from the cells so affected.     Treatment

   Treatment is complex, but relies on a carefully balanced program
of controlled ultraviolet light exposure (sometimes after ingestion
of sensitizing chemicals called psoralens), lotions containing tar
derivatives, and steroid creams.  Oral steroids and even cytotoxic
drugs similar to those used in cancer therapy may be needed for
severe cases.

   Most cases are mild to moderate and need only topical treatment.
In severe cases, balancing the disease against potentially dangerous
treatments presents a challenge.

   A typical, graded treatment program might consist of the
following:
 1.  Sun exposure as much as practical.
 2.  Addition ofsteroid creams and lotions in a gradually more potent
regimen.
 3. Addition of tar-based applications or other topical preparations.
 4.  Special ultra-violet light exposure programs, used sometimes
after the ingestion of psoralen drugs, which sensitize the skin.
 5.  Use of prednisone or other steroids, and finally the use of
drugs such as methotrexate which are actual cell poisons, as are used
in cancer treatment.

   Obviously, an experienced dermatologist is important in the
supervision of such regimes. Most cases are quite manageable with
relatively safe topical regimens.



   ECZEMA (ATOPIC DERMATITIS)

   Eczema is the final result of a complex series of internal
reactions to exposure to allergens and irritants in susceptible
individuals.  It often accompanies other allergic diseases such as
hay fever and asthma, but may also occur alone.

   The rash is a very itchy, peeling, thickened, sometimes weepy
area, typically noted in the creases of joints and about the trunk.
The rash may fluctuate both seasonally and over the course of the
day. Scratching may lead to bleeding and infection.
 Blood tests reveal increased levels of cells and chemicals
associated with allergic reactions in general.

   A variation of eczema occurs on the palms of the hands, and
sometimes on the soles of the feet.  This type may be quite
frustrating, since the common exposure to moisture, irritants, and
injury of these locations leads to self-perpetuation of the disease.
Furthermore the thickness of the skin in these regions makes topical
therapy more difficult.

   Infants and children are often affected, though the disease often
diminishes in intensity into adulthood.  The rashes of poison ivy and
other poisonous plants are similar to eczema, but of course are short
lived and limited to the areas of contact.

   "Contact Dermatitis" refers to the eczema-like rash occurrin from
touching a substance to which the patient is allergic. Common items
include industrial solvents, dyes, nickel and other metals, leather
tanning chemicals, and some soaps.

   Some patients find that factors such as psychological stress,
mechanical irritation, and heat worsen the rash. Dietary factors are
occasionally important especially in children (milk being the most
common).

    Treatment

   Once avoidance of the above factors is carried out, treatment is
aimed at reducing dryness, itching and inflammation.  Topical agents
include wet dressings and steroid or cortisone creams. These must be
controlled closely as they can be absorbed into the blood through the
abnormal skin, resulting in internal side effects.  For the hands,
the creams can be made to penetrate more deeply by using occlusive
gloves over the area after the lotions are applied.

   Moistening creams can be soothing, and use of protective gloves or
other garments is helpful in some settings.

   Oral anti-itching drugs such as hydroxyzine, diphenhydramine, and
other antihistamines may be quite helpful.  Severe or resistant cases
may require short (virtually never prolonged) courses of prednisone
or other cortisone-like drugs. Secondary infection may be treated
with the appropriate antibiotic.  Rather bizarre treatments,
including oatmeal baths, are said by some to be useful, though not
proven.

   The eczema sufferer can take comfort in the fact that modern
steroid creams and other topical agents can almost always control, if
not cure, the disease with little risk of serious side-effects.



   FUNGAL SKIN RASHES

   Fungal infections of the skin are very common in all age groups.
They are caused by microscopic fungal organisms which normally live
on the skin surface without causing symptoms. Under appropriate
conditions of moisture, warmth, irritation, or minor skin injury,
they start to grow more rapidly and invasively, causing the diseases
discussed below.

   Certain underlying conditions other than the above may cause
fungal infections to occur. These should be considered when the
infection is highly recurrent, severe, or resistant to treatment.
They include diabetes, Cushing's Syndrome (excess cortisone
production), and immune diseases including leukemia.

   The commonest diseases fall into one of three groups:
Candidiasis--yeast infection, Dermatophytosis--tinea or ringworm, and
Tinea Versicolor-- a separate group of fungal organisms.

Descriptions

     Candidiasis
   Candida, or yeast, typically grows in the moist, warm areas of the
body, often near mucosal areas such as the mouth or genitalia.
Redness, itching, and occurrence of whitish plaques are
characteristic.  The commonest sites are the groin, armpits, beneath
the breasts, and skinfolds of obese individuals.  Vaginal and oral
forms also occur (monilial vaginitis and thrush).  The finger nail
may be involved, causing redness, ridging, and swelling (paronychia).

    Tinea

   Tinea causes an itchy, red, scaley patch which spreads outward
     as it grows.  Hairs in the area may fall out or break. Sometimes
     the skin may crack and become secondarily infected with
bacteria.
     Spreading is by brushes, clothes, and other personal contact.
   The common terms used for tinea are as follows:
   Ringworm--tinea capitis-- involving the scalp or neck.
   Tinea barbae--involving the beard area.
   Tinea corporis--involving the non-hairy parts of the body, such as
     the arms, shoulders, or face.
   Tinea cruris--jock itch-- involving the groin.
   Tinea pedis--athletes foot. Peeling is especially common in
     this location.

Tinea Versicolor

   This infection usually occurs on and around the trunk, and often
is quite inapparent. Symptoms, if any, consist of mild itching or
scaling areas of irregular shape.  The only reason most cases come to
light is because the involved areas fail to tan naturally, thus
presenting as light patches in otherwise tanned regions.

    DIAGNOSIS

   Diagnosis of each of the above forms of fungal skin infection is
made by the typical appearance, and confirmed by microscopic
examination of scrapings of the involved area.  Usually, this is all
that is necessary.

   Cultures can be taken, but are very slow to grow in some cases,
and not often necessary.

    TREATMENT

   Over the past several years, several new agents have been
discovered which are active against all of the above fungi, and
topical application is almost always curative.  These include
miconazole, clotrimazole, and others.  In addition, some older, less
expensive agents are in use-- nystatin for candida, tolnaftate for
athlete's foot, and selenium for tinea versicolor.

   Sometimes, steroids are added to the cream to reduce itching and
inflammation.  Oral and vaginal preparations are available for the
appropriate forms of infection.

   Very deep or resistant infections may require oral agents which
penetrate the blood stream, and attack the fungus from within.  These
must be given for weeks to years, as the fungi respond very slowly.
The oldest is called griseofulvin, and the most recent is known as
ketoconazole.  Each has potentially serious side effects, and should
be reserved for cases where the risks are clearly worth taking.



    Skin Infections

   Considering how the massive surface of skin surrounding our bodies
is constantly exposed to injury, bacteria, and various other foreign
substances, it is rather incredible that we are not more frequently
afflicted with infections of this organ. A number of factors account
for this, including the keratin layer on the surface, the chemicals
in sebum and perspiration, and the internal defenses present in the
bloodstream.  Nonetheless, skin infections do occur, and vary from
trivial to life- threatening.

   The common types of infection are discussed below, and have at
least one element in common; since the bacteria normally present on
intact skin are the commonest causes of infection, they are the usual
culprits no matter which type of condition is present. Usually, this
means either staphylococcus or streptococcus--"staph" or "strep."

   The final entities discussed are lice and scabies; strictly
speaking these are infestations, rather than infections, as the
causative organisms are of a "higher" biologic order.

    Types of Infection

Impetigo

   Impetigo is infection of the skin with strep, or occasionally
staph, in which the face is most commonly involved.  Typically it
involves children and is highly contagious.  The characteristic
appearance is one of multiple tiny pus-filled blisters which break
readily, leading to a more spread-out, widespread involvement.
Eventually, it crusts over and heals without treatment in a week or
two.

   The main reason for aggressive treatment is that these forms of
strep often set off a chain of events in the immune system which may
lead to acute glomerulonephritis, a severe and rapidly progressive
form of kidney failure.  The relationship is similar to that between
strep throat and rheumatic fever.

   Staph impetigo can occur in a form which produces large blisters,
rarely leading to massive loss of outer layers of skin.

     Treatment

   Although the protective effect of treatment on the occurrence of
kidney complications is not proven, most authorities advise treating
impetigo with antibiotics, such as penicillin and erythromycin, or
their derivatives. Injections are the most effective method, but oral
therapy is also effective.  This also reduces the contagiousness and
progression of the infection.

   Topical soaps and disinfectants are of questionable value, except
for hygiene purposes. Furuncles and Carbuncles

   Commonly known as "boils," these infections are localized
abscesses starting in the hair follicles.  They emerge as tender, red
lumps in the skin, pus-filled, and often coming to a "head" with
subsequent drainage.  When deeper furuncles form and coalesce, the
term carbuncle is used.  This may drain at several openings in the
same region.  The shoulders, face, scalp, buttocks, and armpits are
common sites.

   Treatment

   Isolated lesions may be treated by the application of hot
compresses several times daily.  Manipulation, squeezing, or attempts
at opening the furuncle should be avoided, as this may cause spread
of the infection.

   Large carbuncles may require physician drainage, or the use of
appropriate antibiotics.  In addition, lesions near the nose and
middle of the face require antibiotics due to their proximity to
vital structures of the brain.  Fever, enlarged lymph nodes and
severe pain may also require antibiotic therapy.

   A few patients are plagued with frequent recurrences of furuncles
and carbuncles. Treatment may require long-term antibiotic use,
disinfectant soaps, and ultra-meticulous hygiene. Even then, the
recurrences may persist; experimental therapy with "bacterial
interference" may be worthwhile.  In this method, a different strain
is actually injected into the skin in the hopes that it will compete
with and supplant the original bacteria.

Cellulitis

   When a wound gets "infected," the body's defenses usually
successfully contain and eradicate the causative bacteria.  On other
occasions, due to a very large number of organisms or other factors,
the infection spreads rapidly, involving surrounding skin, lymph
channels and nodes, and ultimately the blood stream ("blood
poisoning").

   Symptoms start with redness around the wound, which spreads
sometimes at an alarming rate. Fever, heat, pain and pus may be
noted.  Red streaks may appear, generally spreading toward the trunk.
 Lymph nodes may enlarge, forming painful lumps in areas such as the
groin, neck, or other areas.

   Treatment

   If local heat applications do not contain minimal redness
surrounding a wound, elevation, rest and protection of the affected
area should be augmented.  If the symptoms progress despite this,
physician evaluation for possible antibiotics should be considered.

   Other indications for antibiotics may include red streaks, lymph
node enlargement, fever, or involvement of certain critical areas
such as the face, palms of the hands, or genitalia. Tetanus boosters
may also be indicated if not done in the past 5 years.

   Summary

   Bacterial skin infections are rarely life-threatening, but can
lead to considerable discomfort, cosmetic difficulty, and serious
complications.  Trivial and localized lesions only rarely require
physician attention, but severe lesions and impetigo should probably
be evaluated by your doctor.

    LICE
  Though rarely the cause of serious illness, lice have caused more
than their share of distress to parents, children and other exposed
patients. Slightly different types of louse infest different parts of
the body (head, body, groin) but the clinical syndrome is similar.

   Once present, the female lays her eggs on the hair follicle and
'glues' them there with an irritating secretion.  The newbo crop
matures in about 9 days, and joins the adults in regular feedings of
blood through the skin.  Common articles of contact spread the bug
from one infected person to another.

   The louse and its body products cause itching, at times intense.
Small whitish nits may be seen on hair follicles.  Once diagnosed,
treatment consists of disinfection of clothing, linens, and other
items of contact, and the application of products containing lindane
or other chemicals in the form of a shampoo, powder or other
appropriate vehicle.  Kwell is an example of such a drug.  At times,
careful cooperation with school and public health officials is
necessary to fend off epidemics of lice; otherwise, a ping-pong game
of recurrences results.

   One final note--there is no correlation between socio- economic
status or personal hygiene and the occurrence of lice; the outdated
concept of the infestation only happening in underprivileged or
underscrubbed victims is simply unfounded.

SCABIES

  This disease has many of the characteristics described under the
section on lice.  The mite is spread by direct skin contact, and
commonly affects the palm side of the wrists, the are between the
fingers, elbows, waist, and genitals.

  Intense itching, notably worse at night, is the main symptom,
occasionally with a rash felt to be an allergy to products of the
mite.  Careful observation sometimes reveals the presence of small
burrows as thin as thread just beneath the affected skin.

  Treatment consists of topical application of lindane and similar
products; the simplest course consists of one application washed off
the next day.  Sometimes, treatment of family and other contacts is
necessary.  The role of linens, towels, etc. is

unclear, but it seems wise to cleanse them after treatment.
   Occasionally the symptoms will persist for several days after
treatment, due to a residual irritation from the remaining mites and
the associated byproducts.  This does not require retreatment.
Symptoms resolving, then recurring, or lasting more than a week may
mean unsuccessful treatment or re-infection.

   As with lice, scabies knows no socio-economic boundaries, and may
occur in persons of impeccable personal hygiene.



    Keratoses

   There are two very different types of keratoses, seborrheic and
actinic.

Seborrheic keratoses

   These benign skin tumors are common in the elderly, often on the
face, trunk, and shoulders. They have a typical, "pasted-on"
appearance, with a dark, irregular, reticulated surface. Because of
their superficial resemblance to skin cancers, they should initially
be assessed by a doctor.  However, their main complication is
cosmetic.

   Seborrheic keratoses can be readily removed surgically under local
anesthesia in the office. Liquid nitrogen freezing can also be used.
In general, no scar is left.

Actinic keratoses

   These common lesions are caused by sun exposure, and thus are
found primarily on the scalp, face, hands, and arms. They are
increasingly common with advancing age, and can proceed to skin
cancer (usually the low grade type) in up to 13% of cases.

   They appear as pink, flat or slightly elevated areas with a
scaley, abrasive surface texture.  Experienced dermatologists can
diagnose them with confidence by appearance. Sun avoidance and the
use of sun screens are important preventive measures.

    Treatment

   Isolated keratoses may be easily frozen or "burned" off, as well
as by surgical excision. Multiple keratoses are sometimes best
treated with an solution of fluorouracil, an anti-cancer agent.  This
causes considerable irritation, and must be used carefully.

   Treatment is generally very successful, but continued observation
should be maintained for recurrences if skin cancer is to be
prevented.

    Sebaceous Cysts

   When a gland in the skin becomes plugged at its opening, either
spontaneously or after infection, the gland may swell with its own
contents, forming a firm, round nodule just beneath the skin.  If it
is opened surgically or spontaneously in the early phase, it may
discharge a whitish, cheesey material, and disappear, although
recurrences are common.

   Many unidentified lumps under the skin are such cysts, especially
on the shoulders, face, scalp and trunk.  No treatment is necessary
if the diagnosis is secure; unfortunately, such accuracy is often not
possible.  Thus any lump, especially if of recent onset, or if
progressing, may be considered for simple surgical removal under
local anesthesia. Cosmetic considerations are the other reason for
removal.

   This is one area where the old adage taught to surgical students
may be true: "If in doubt, take it out."

    Corns and Calluses

   Though very common, corns and calluses are not a normal
phenomenon.  They represent thickened areas of skin in response to
repeated or persistent pressure, rubbing, and injury; it is not
surprising, therefore, that the feet are the most common site. The
boney prominences provide the ideal conditions for their formation,
and ill-fitting shoes or foot deformities are major causes.

   Calluses are usually flatter areas of thickening, often serving a
protective function, as on the hands of a laborer or guitarist, for
example.  Corns are more discrete, often raised and painful.  As
neither is important unless it interferes with function due to pain
or pressure, treatment may be directed at relief of symptoms.

    Treatment

   Simple periodic reduction in the size of the area may provide
adequate relief.  A good home remedy is to soak the corn, and while
it is still wet to rub it firmly with a "pumice stone" or other
abrasive foot care product.  The skin should scrape away readily, and
if pain or bleeding is noted, the treatment should stop.  This may be
repeated daily until symptoms are gone, and then done periodically as
necessary.

   The physician will often augment the above by careful slicing of
the superficial layers with a blade.  Acid chemicals achieve the same
goal, applied regularly.  For severe or stubborn lesions, removal may
be carried out; recurrence is inevitable if the causative factors are
not corrected.

    Prevention

   Corrective shoes, even to the point of fitted prescription
varieties may be important, if not elegant.  Corrective toe or foot
surgery may be useful, especially if arthritic complications seem to
be present.  Most corns and calluses will resolve if these factors
are corrected.

   One caution is to avoid confusing these with warts, the treatment
of which may be different;  occurrence in a non- pressure bearing
area, a dark center, and intermittent occurrence are clues.  If there
is any doubt, a doctor visit is in order.

    Warts

   Warts are tumors--overgrowths of skin cells, generally caused by
infection with a common virus.  Of course, they are benign and cause
symptoms primarily by creating pressure points, or cosmetic
difficulties.
   Warts can take a wide variety of appearances: tiny flesh colored
lumps, sometimes with a dark core, thin and frond-like often on the
neck and face, flat and soft, or hard and pebble- like on the soles
of the feet. In warm moist areas such as the genitalia, they may grow
exuberantly, causing large accumulations achieving impressive sizes.

    Natural History

   Spread by person-to-person contact, or by self-inoculation,
development depends on the individual's immune response to the virus.
 This is poorly understood; though people with known immune
deficiencies are more susceptible, most sufferers are immunologically
normal.

   About 1/4 will resolve spontaneously in 6 months, 1/2 by a year,
and 2/3 by 2 years. Other new warts may arise in the meantime, and
people between 15 and 20 years of age are most vulnerable.  Toads do
not get warts.

    Treatments

   Despite the abundant folklore surrounding warts, treatment efforts
should be restrained, since serious morbidity is rare, recurrences
common, and complications likely if treatment is more vigorous than
justified.  Location largely guides treatment. Each of the following
are about 80% effective.

 Salicylic/lactic acid paste: this potion may be applied at home
daily, with regular scraping away of the destroyed layers. Several
weeks may be necessary, but effectiveness is comparable to other
methods.

 Liquid nitrogen:  applied by the doctor, the chemical freezes the
wart, which then forms a scab, and hopefully resolves; repeat
applications are sometimes needed.

 Podophyllin: a topical cell poison, this is used most often for
venereal warts.  It is irritating, but effective.

 Surgery: obviously effective, this may be the best treatment for
many larger or symptomatic warts.  Scar formation may be a problem.

   Plantar warts warrant special mention.  Since any scar may cause
as much pressure or pain as the original wart, and be permanent as
opposed to temporary, often no treatment at all is warranted.
Keeping the wart flat as for corns or calluses may be sufficient.
When treatment is necessary, acid paste may be tried. Surgery and
other methods should be done only by experienced physicians.

MISCELLANEOUS
   Vitiligo (Pigment loss)
   Pityriasis Rosea
   Hair Loss
   Diaper Rash
   Dry Skin

    Vitiligo

   A common cause of loss of pigment is vitiligo.  This is an
autoimmune disease where, for unknown reasons, the body attacks its
own pigment cells (melanocytes).  It tends to occur in adulthood, is
familial, and progressive.  The damage is purely cosmetic, though
there is a statistical association with other autoimmune diseases
such as thyroid problems, pernicious anemia, and diabetes.

    Diagnosis

   The appearance of irregular areas of loss of coloring in the skin
is characteristic; dark skinned individuals have the most obvious
lesions, but anyone can be affected.  Sun exposure accentuates the
contrast with normally tanned surrounding skin. Friction points are
involved early, but any skin surface may be involved; if hair is
located in the area, it too loses pigment.

   The most important diagnostic test is to do a simple scraping to
rule out tinea versicolor, a fungus which can also cause skin
lightening.

    Treatment

   Treatments range from cosmetic cover-up creams to drugs called
psoralens which sensitize skin to tanning, in th hopes of "over
tanning" the areas involved; severe burning can result, and the skin
may be more susceptible to skin cancer after treatment.  It may be
best in most cases to stick to the cosmetic choices.

   Where more skin is involved than half the surface area, the
uninvolved skin may be bleached with special chemicals to reduce the
apparent contrast with the vitiligo.

   Dermatologists are the primary resource for treatment.

    Pityriasis Rosea

   A common disorder of skin possibly due to a virus, this condition
typically begins as a large slightly raised red area, with a somewhat
fine, wrinkled appearance, several centimeters in diameter, often on
the trunk. One or two weeks later, numerous other areas appear,
somewhat smaller and aligning themselves in a peculiar orientation
along the skin lines of the trunk, wider across than up and down.

   The rash is somewhat itchy, but rarely causes severe symptoms.
 It subsides spontaneously without scarring after 6 to 8 weeks.
Treatment should be simple, and aimed at control of severe itching
with antihistamines and similar agents.  If there is any possibility
of syphilis exposure a blood test should be done, as the rash of
secondary syphilis may be identical.

    Alopecia Areata

   Alopecia areata is characterized by otherwise unexplained patches
of total hair loss, without any other signs of rash, inflammation, or
infection.  The patches are irregular and often involve the scalp,
although any hair-bearing area may be affected.

   Children and young adults are the commonest sufferers, and up to
20% of victims have another family member who has had the disease.
Regrowth of hair is unpredictable, and may occur for up to 5 years
following the onset.  A particularly severe form may involve all of
the hair on the body, including eyebrows, lashes, and body hair
(alopecia universalis).

    Causes

   The best recent theory is that this disease is an autoimmune
disease, in which the body's immune system, for reasons unknown,
suddenly recognizes the hair follicles as a foreign substance, and
subsequently attacks and destroys those structures.  As mentioned,
the strong familial component has been recognized, but little else is
known about the underlying mechanisms of causation.

    Diagnosis
   Diagnosis is by the typical appearance.  The most important test
is to rule out ringworm of the scalp, which can also cause hair loss,
since that disease is easily treated.

    Treatment

   One third of patients have total regrowth spontaneously, one third
have partial regrowth, and one third have none.  Thus the
effectiveness of a treatment must be carefully distinguished from
spontaneous improvement.

   Injection of cortisone directly into the plaques can be used for
small areas, with about 60% effectiveness, often lasting only months.
 Oral steroids may be useful, but the risks almost always outweigh
the benefits.

   An exciting new treatment still in the experimental phase, but
soon to be released, is the use of topical minoxidil. This drug was
originally developed for high blood pressure, but was found to cause
hair growth as a side effect. Topically, it helped a very high
percentage of alopecia sufferers.  Its effects were not permanent,
but the toxicity seemed acceptable in preliminary studies.  This
possibility should be inquired about of the dermatologist, if other
treatments have not been effective.

    Diaper Rash

   The combination of constant moisture exposure, irritation from the
chemicals present in urine and stool, and the friction of a snug
diaper give rise to the red, raw, and even blistering rash familiar
to so many parents.

   When areas outside the diaper region appear, it is important to
rule out yeast infections, eczema, psoriasis, and other problems, but
usually the diagnosis can be readily made on examination.

   Fever, pus, and digestive symptoms are NOT caused by simple diaper
rash, and should prompt evaluation for other problems.

   Although certain non- irritating ointments such as zinc oxide, "A
& D," and others may be helpful, the primary effort should be at
prevention, since the rash will resolve rapidly once the causative
factors are removed.

   Useful measures include air exposure (risks being all to familiar
to many mothers and fathers caught in the line of fire), frequent and
prompt changing of wet diapers, and avoidance or reduction in the use
of occlusive rubber pants over the diaper.

   Fortunately, most babies have few problems after 6 months of age,
and ultimately toilet training triumphs.

    Dry Skin

   Water is an important component of skin, and it is well designed
to retain its natural moisture through the protective outer layer,
oil secretion, and replenishment from the blood stream.  However,
under some conditions in some people, these mechanisms can be
overcome-- artificially heated and dried winter air, winds, rubbing,
harsh soaps and chemicals are some examples of such conditions.

   The primary symptoms of dry skin are whitish scaling and cracking,
and itching.  Onset in early winter is common in northern climates.
The lower legs and hands are often involved, and the dryness may
occur in round patches or more diffusely. The elderly are more
susceptible due to a lower baseline moisture content in the first
place.

   Occasionally an underactive thyroid can cause dry skin. This
should be considered, particularly if other symptoms are also
present.

       Treatment
       Preventive:  keeping heating temperature settings as low as
possible, humidifying the winter air indoors, avoiding undue exposure
to wind and cold, wearing gloves when necessary, avoidance of water
immersion such as dishwashing without gloves, bathing at only
moderate intervals, no more often then every 2 days.

Therapeutic:  The application of water-attracting oils and lotions
can be very useful, especially when done immediately after soaking
and before evaporative drying has occurred. Petrolatum, lanolin and
urea are examples of such substances. Used regularly such treatments
can resolve or prevent most cases.



             ASTHMA

   Asthma is a very common disease, affecting about one person in
forty, two thirds of whom first develop symptoms in early childhood.
It is characterized by the reversible narrowing of the airways of the
lung (bronchi) due to spasm of the muscles in the bronchial walls and
to the plugging of the airways with thick plugs of sputum.  Many
patients have elevated levels of certain types of white cells in the
blood, eosinophils, which are characteristic of allergic diseases.

   Often asthma is divided into two categories, allergic and
nonallergic.  In fact, many if not most patients have elements of
each type.  The common denominator is that all asthmatics have
airways which are overly sensitive to various irritants, going into
spasm with even "normal" levels of stimulation.  The stimuli to which
a given patient is most sensitive form a convenient way of
categorizing asthma as discussed below.

    SYMPTOMS

   The airway spasm and mucus plugging which occur in asthma can give
rise to a variety of symptoms.  The commonest is wheezing (whistling
or squeaking sounds with respiration) with shortness of breath.
Cough is also common from irritation of the sputum as well as
stretching of the cough receptor nerves in the lungs. Typically the
onset is sudden, but may become chronic without treatment.  As the
symptoms progress, they go from a mild nuisance to severe
breathlessness, fatigue, and even respiratory failure.  Some 5000
people die yearly in the U.S. from asthma, often because of failure
to seek medical care on time.  The common characteristic asthma types
are discussed in the following sections.

   A typical spectrum of asthma symptoms is as follows: minimal
shortness on heavy exertion, mild wheezing or shortness of breath on
lesser degrees of exertion, and finally at rest, mild cough worsening
at night and with cold air or exercise, wheezing and mild shortness
of breath at rest, and finally severe suffocating cough and
breathlessness at rest.  In the later stages, every ounce of energy
the patient has is spent in ejecting each breath, and the slightest
increase in fatigue or sedation can bring about sudden respiratory
failure and death.

Allergic Asthma

   In this form of asthma, the patient inherits a tendency to develop
sensitivities to various substances in the air, such as pollens,
molds, house dust and others.  Upon exposure, the patient's immune
system over- reacts, producing copious amounts of an antibody group
called immunoglobulin E, and other complex substances.  These
substances trigger a series of reactions which culminate in the
production of internal chemicals with bronchospastic properties. The
asthma reaction ensues.

   It is not uncommon for allergic asthma patients to have other
allergic diseases as well, including hay fever and eczema of the
skin.  Blood tests show high levels of antibodies, eosinophils (see
above), and other allergy-related substances

Exercise Asthma

   Some asthmatics note that the primary cause of their attacks is
exertion, where heavy breathing is stimulated.  Recent experiments
show that it is rapid loss of heat from the respiratory tree which
serves as the irritant, and cold air alone is often a causative
factor. Similarly, hyperventilation either from stress or other
circumstances often yields the same result. Drug-induced Asthma

   Aspirin and its relatives, the "nonsteroidal" drugs like
ibuprofen, indomethacin, naproxen and many others can set off severe
attacks in some patients.  It is felt that this is due in part to the
ability of these agents to interfere with the body chemicals called
prostaglandins.  Prostaglandins have an important controlling effect
on the lungs in asthmatics.  Yellow food dye (number 2) causes asthma
in some.  The coincidental presence of nasal polyps in an asthmatic
patient is a clue to aspirin and yellow dye sensitivity.

Occupational Asthma

   Certain materials common in some work settings have a tendency to
cause asthma in susceptible individuals. Sometimes this is a chronic
asthma picture, but often the patient can make the association
through the timing of symptoms-- better on weekends, etc.  Common
offending agents include animal dander, plastic or vinyl fumes as are
used in wraps for meat, grain products, and others. These reactions
seem to be nonallergic; they cause asthma through a direct affect on
the airways, rather than by producing antibody reactions.

   Additional precipitating factors may worsen symptoms in
susceptible asthmatics, including viral colds, laughing or prolonged
talking, emotional stress, passive cigarette smoke inhalation, and
drugs such as the beta blockers like propranolol (Inderal), and its
relatives.

    DIAGNOSIS

   The history is often nearly diagnostic in most patients,
particularly when there is a clear association with seasons, pets,
chemicals or other factors.  If the patient is symptomatic at the
time the physician is consulted, the characteristic lung findings,
blood tests, other data can confirm the diagnosis.

   The "gold standard" for the diagnosis is pulmonary function
testing.  In this test the patient performs various breathing
maneuvers into a special machine which measures air flow.  If
obstruction is noted, an inhaled bronchial relaxing drug is given and
the test repeated.  A typical obstructive test which reverses
completely is virtually diagnostic of asthma. Unfortunately some
asthmatics have a normal baseline pulmonary function test (especially
where cough is the only symptom).  In these cases, a mild bronchial
spasm producing drug may be inhaled, and the exaggerated patient
response in flow measurements gives the diagnosis.

   A few diseases can masquerade as asthma including blockage of the
upper airways by tumor, scars, or thyroid enlargement; congestive
heart failure, and pneumonia to name a few.  The alert physician will
rule these out, particularly if routine treatment does not bring
about the desired results.

    TREATMENT

   Treatment is guided by the degree of symptoms, and the type of
asthma the patient has. Counseling about the disease is of major
importance, as is elimination of every possible environmental factor
which is even possibly associated with asthma, to the extent this is
practical.

   Immunotherapy, allergy shots, is of controversial value in asthma.
 Though clearly beneficial to some patients with hay fever, there is
little scientific proof of its value in patients with asthma, the one
exception apparently being cat dander sensitivity.  This is an
exceptionally difficult area to research, and it is possible that
some patients do benefit. Nonetheless, given the cost, inconvenience,
and questionable efficacy for most patients, many authorities urge
restraint in this modality.  This is not to say that allergists are
not well equipped to handle asthma, which many do, using each of the
various treatment regimens available.  Desensitization shots
apparently should be restricted to a minority of patients. Drugs can
be dramatically effective in asthma.  There is a trend in recent
years to rely on inhaled agents, which offer increased benefit with
little or no absorption into the blood, thus causing minimal side
effects when compared to oral or intravenous therapy.  Though
somewhat awkward to take at the beginning, the benefits are apparent.

   Some common inhalers include albuterol and metaproterenol (direct
bronchial dilators), cromolyn (blocks allergy-related chemicals from
being released in the lung), and beclomethasone (a cortisone -like
drug which reduces inflammation and allergic manifestations).  The
experimental inhaler ipratropium seems especially helpful in
stress-related flare-ups.

   Oral drugs include theophylline, which dilates bronchial passages.
 Side effects are not rare, and careful dose adjustment is necessary.
 It is most useful in lower doses in combination with an inhaled
bronchodilator such as albuterol.  Many brands are available, some of
which can be used on a twice daily basis. Terbutaline is a different
type of oral bronchodilator, limited in usefulness by the occurrence
of tremor of the hands even at the usual doses.

   Cortisone and prednisone are steroid drugs which are very
effective in asthma.  Used in occasional short courses of two weeks
or less, they are generally safe and can control almost all asthma
flares which do not respond to the drugs mentioned above. In longer
course, as in maintenance therapy, their side-effects can be very
serious; included are decreased resistance to infection, dependence
of the body on the drug, stomach problems, osteoporosis, cataracts,
and others.  Many of these side-effects can be avoided by giving the
drugs on alternate days only, although some asthmatics do not respond
to such a program.  The inhaled drug beclomethasone has helped many
asthmatics reduce or eliminate the long-term use of prednisone.

   The severely ill patient may be given powerful intravenous forms
of the above drugs, as well as respiratory support until the attack
subsides.  The earlier treatment is begun, the more likely that
serious results can be avoided.

   Given the complex nature of treatment, the physician and patient
have a responsibility for careful follow-up, development of a
treatment program tailored to the patient's needs, and rigorous
compliance with the prescribed plan.  No specific "cook book"
approach is right for everyone, but with modern tools, almost all
asthmatics can lead normal lives with minimal inconvenience and side
effects from treatment. Unusual symptoms, resistance to the customary
treatment, or persistence of symptoms beyond the usual time frearly;
the commonest cause of serious complications from is delay in
treatment. Once a disease which often ruined the quality of life for
many of its sufferers, asthma has now become highly treatable in a
manner which is both effective and safe when used by a skilled
physician with a compliant and responsible patient.



EMPHYSEMA and CHRONIC BRONCHITIS


   Together, the two diseases emphysema and chronic bronchitis are
termed "chronic obstructive pulmonary disease" (COPD) and this term
tells much about the nature of the disorders.  The vast majority of
occurrences are the direct and unequivocal result of cigarette
smoking.  A sad result of the increasing incidence of smoking among
women is that COPD is rising rapidly in that segment of the
population, quickly catching up to that of males, who still comprise
the majority of patients. Unlike asthma, the respiratory damage of
COPD is irreversible, yet ironically quite preventable.

   Cigarette smoke contains hundreds of chemicals which can damage
lung tissue.  The net result after many years is that the lung loses
its natural tendency to deflate or spring shut.  The bronchial tubes
become swollen and inflamed, and their diameter may decrease
markedly.  Excessive amounts of sputum are characteristic of
bronchitis, and this may further impair air movement.  In emphysema,
the air sacs (alveoli) are destroyed and replaced by scar tissue.
Finally, the lungs become like large floppy balloons, with a major
effort necessary to squeeze out each breath.  In some cases, eventhat
air that is breathed in and out fails to transmit its life giving
oxygen normally, since it comes into contact with scar tissue or
sputum instead of healthy lung tissue.  An additional result in
severe cases is that the carbon dioxide produced in the body by
everyday metabolism can no longer be exhaled adequately, and
accumulates in the blood.


   Some individuals are more sensitive to nicotine and to cigarette
smoke than are others. In addition, an occasional nonsmoker may
develop the syndrome, either through congenital chemical imbalances,
occupational exposures, or unknown factors. In general, the patient
must have accumulated a long and heavy smoking history before noting
symptoms; the disease may have been present for years but the lungs'
reserve capacity will have compensated until over 50% of the airways
are involved.

    SYMPTOMS

   The first symptom of emphysema is usually shortness of breath on
exertion.  Chronic bronchitis usually has a longstanding cough as its
first warning.  Most patients have a mixture of the two. As the
disease progresses, shortness of breath increases such that in the
end, even speaking more than a few words at a time is too much.
Cough may become incapacitating; in chronic bronchitis cups of yellow
or green sputum may be coughed up daily.  Low blood oxygen is not
always present, and in fact is unusual in emphysema, as compared to
bronchitis.  When low oxygen levels are present, the lips and digits
may appear blue or dusky, and cardiac or cerebral symptoms may
appear.

   As the terminal stages are approached the patient begins to lose
weight as eating becomes difficult, and energy is spent breathing
through the damaged lungs.  The slightest respiratory burden such as
a mild cold, or the use of even mild sedatives is enough to cause
respiratory failure, and periods on a mechanical ventilator become
necessary if the patient survives. Eventually, the patient succumbs
to the disease, as even intensive care cannot replace a totally
damaged respiratory tree.

   The heart is burdened in many cases by trying to maintain
circulation through a scarred and narrowed pulmonary circulation;
heart failure commonly results.  Pneumonia finds a fertile home in
the lung of COPD patients, who can ill afford additional lung
problems. Still others get lung cancer from their smoking habits.

   Discontinuation of smoking slows down but does not stop the
progression, and continuation always speeds up the disease.
Amazingly, many patients keep smoking even as they are recovering
from a bout on the ventilator!

    DIAGNOSIS

   The complaints mentioned above in a heavy smoker are highly
suggestive of the disease.  Examination of the lungs reveals
characteristic sounds.  A peculiar rounding of the finger nails
occurs in some patients.  Chest x-rays sometimes but not always
reveal hyperinflation or scarring of the lungs.  The most sensitive
and reliable test is pulmonary function breathing measurement
(spirometry) where the rate of airflow is measured. Unlike asthma,
the reduced flow is not reversed to near normal after bronchodilator
drugs are given. Blood samples are measured for oxygen and carbon
dioxide content from an arterial sample taken usually at the wrist.

   Rarely is the diagnosis in question in the above evaluation,
although occasionally congestive heart failure, sarcoidosis,
tuberculosis and other lung diseases can be present. Care must be
taken by the physician to rule these out.

    TREATMENT

   No treatment can arrest or reverse COPD, although a variety of
aggravating factors can be treated.  In some patients, overgrowth of
bacteria in the bronchi cause flare-ups, and antibiotics such as
tetracycline, amoxicillin, and TMP-sulfa can help.  Still others have
an asthma-like reaction as part of their disease, and treament as
outlined for asthma provides benefit.  A fraction of patients respond
to cortisone or prednisone, and although long term use can have
serious side effects, this drug can also be helpful.

   Training of the patient in pulmonary exercises and other
techniques can enhance adaptation to the handicap.  A small minority
of patients will benefit from chronic oxygen use, although most do
not, and this is an expensive modality. Prompt treatment of any
worsenings is important.  The importance of pneumonia and influenza
immunizations are clear.  Emotional counseling is important for
others. Obviously, avoidance of smoking is advised.  It is very
important for severely ill patients to avoid sedating drugs, as these
may precipitate respiratory failure.

   Experimental treatments such as x-ray therapy and surgery have
found little acceptance, as their benefit has been disappointing. It
seems that once the diagnosis is made, the best course is to stop
smoking, find a skilled and caring physician, call her/him as soon as
any flare-ups begin, and follow a comprehensive program of judicious
medications, training, and careful lifestyle adjustment.  Despite the
fact that 50,000 people die yearly in the U.S. of COPD, and many
thousands more become severely disabled, the incidence of smoking and
illness continue to rise; this is a national health problem of major
proportions.



    BRONCHITIS

   The term bronchitis refers to an inflammation or infection of the
bronchi as opposed to either the lung tissue itself (pneumonia), or
the upper respiratory tract, as in the common cold.  Chronic
bronchitis is considered as an obstructive lung disease, and is
discussed in the section on emphysema. This discussion, then, refers
to acute bronchitis.

   In otherwise healthy people, the common cold is caused by any of
several viruses, and is confined to the upper respiratory tree.
These viruses rarely affect the bronchi, except that mucus from the
nose can drip downward causing an occasional cough with minimal
sputum production.  Once in a while the irritation from such a virus
can allow the bacteria normally present in the respiratory tree to
overgrow in great abundance, and often many strains of bacteria are
involved at the same time.  The bronchi can then become the sight of
such overgrowth, and respond with an outpouring of mucus, pus, and
fluid.  This state is what is called acute bronchitis. Recently, a
group of germs called mycoplasma has also been identified as a cause
of bronchitis; the vocal cords and windpipe or trachea are also
involved with mycoplasma in many cases.

    SYMPTOMS

   Typically the patient develops what appears to be a routine cold
with runny nose and perhaps a sore throat.  Instead of running its
course in a few days, however, a cough develops which starts out
"dry" but quickly becomes productive of varying amounts of sputum.
If the sputum is not copious and is clear or white in color, this is
probably due to the cold virus itself. When the amount increases and
the sputum becomes green, yellow, or gray, bronchitis may be present.
Occasionally the irritation may rupture a small blood vessel, causing
scanty amounts of blood to appear in the material coughed up.
Coughing may be severe and interfere with sleep or work.

   Bronchitis does not generally cause fever, although the viral
illness accompanying it may cause one.  A brassy sound to the cough
and tenderness over the "Adam's apple" may suggest mycoplasma as the
causative organism.  Chest pain may accompany the cough, but is
otherwise not common.

    DIAGNOSIS

   The history is often suggestive of the diagnosis, but it is
imperative that pneumonia, asthma, and other diseases be ruled out.
A careful examination of the chest is sometimes adequate for this
purpose, but if the exam is equivocal, fever is present, or blood is
noted in the sputum, a chest x-ray may be necessary. On occasion,
further tests may be required to evaluate persistence of the
symptoms.  It is generally agreed that any cough which persists
beyond a week or two, which produces blood, or which is accompanied
by a persistent fever warrants medical attention.

    TREATMENT

   Bronchitis is treated with antibiotics to reduce the overgrowth of
bacteria.  On the other hand, treating a viral cold alone with
antibiotics is neither helpful, necessary, or safe. Thus it is
important for the physician to elicit solid evidence of bronchitis in
the history before prescribing. Commonly used agents include
tetracycline, ampicillin or amoxicillin, Bactrim (Septra), and
erythromycin.

  In cases which have an element of bronchial spasm as is found in
asthma, a mild bronchodilator drug is added.  Decongestants such as
pseudoephedrine are sometimes added to relieve the accompanying nasal
congestion. The cough in bronchitis serves an important protective
and cleansing function, and thus should only be suppressed if it is
interfering severely with sleep or work. Useful agents in this regard
include dextromethorphan, codeine, and diphenhydramine.  Guafenisin
is a widely prescribed "expectorant" said to liquify thick
secretions.  Its usefulness is not proven.

    PROGNOSIS

   With or without treatment most cases will resolve spontaneously.
Untreated the course may be prolonged, especially in smokers.
Pneumonia may occur if the infection spreads downward into the lung.
In the absence of complications, serious outcomes are unusual in
healthy people. In the case of heavy smokers, asthmatics, or others
with underlying lung diseases, heart disease, or other serious
debility, acute bronchitis can lead to respiratory failure and even
death.  Early medical attention is the safest way to deal with this
disease.



    SHOCK LUNG

   The syndrome of shock lung is one that has been well defined and
recognized only within the last decade, largely as a result of the
Vietnam War injuries which led to so many cases. Also called Adult
Respiratory Distress Syndrome (ARDS), non- cardiac pulmonary edema,
and several other terms, the basic process is generally a secondary
result of some other serious disease process or injury to the body.

   The predisposing factors which can lead to shock lung include
periods of very low blood pressure from blood loss or other disease,
infections, blood clots, heart attacks, large fractures, stroke, head
injury, and many other disorders.  Only a small percentage of
patients with these disorders develops shock lung, but the widespread
incidence of these factors leads to a large total number of cases.

   Shock lung occurs when the membranes which separate the delicate
lung sacs or alveoli from the blood stream become injured in such a
way that the plasma or watery part of the blood is allowed to leak
into the lungs.  Referred to as pulmonary edema, this is similar to
that found in congestive heart failure. The major difference is that
in shock lung, the heart is not at fault, and the high pressures
which push fluid into the lungs in heart failure are not present. In
fact, many patients with shock lung may be dehydrated. As the lungs
fill with fluid, they become very stiff and difficult to inflate, and
less lung tissue is available for contact with the oxygen in the air.

    SYMPTOMS

   Usually the patient first notices shortness of breath, either with
minimal activity, or even at rest.  A dry cough is not rare. Within a
short time-- often just a few hours--the symptoms progress so that
suffocation may occur rapidly if treatment is not instituted.  No
other symptoms are attributable directly to shock lung, although the
underlying disease or complications may cloud the picture.

    DIAGNOSIS

   The physician will obtain a chest x-ray, which may be normal in
the very early stages, but almost always progresses into a florid
picture of fluid throughout both lungs.  This is usually identical to
the x-ray of certain types of pneumonia, heart failure, and other
diseases, and thus is not totally diagnostic. Blood samples may be
analyzed for oxygen and carbon dioxide to assess severity.  In many
cases the patient rapidly becomes seriously ill, and the importance
of ruling out treatable infectious or cardiac diagnoses leads to
invasive tests.

   Lung biopsy is one such test which can be done either with a small
operation under anesthesia, or through and instrument passed through
the nostril (bronchoscopy).  If cardiac failure is a possibility, a
catheter may be passed into the veins and directed to the lung region
where pressure readings may be made to help guide treatment
(Swan-Ganz catheter).  When other diagnoses are excluded and the
setting is appropriate, shock lung is diagnosed.

    TREATMENT

   Treatment is basically that of intensive support. Respirators are
often necessary, and a breathing tube is placed in the trachea for
this purpose. If a patient is alert and the disease is not extreme,
occasionally oxygen can be administered through a tight- fitting face
mask or nasal "prongs" under close observation. Oxygen may be needed
in high concentrations just to keep the body adequately supplied.
When this is still insufficient, the oxygen mixture may be pumped
into the lungs under slight pressure (PEEP or positive end-expiratory
pressure). Intravenous fluids are carefully regulated. Ironically,
oxygen in high concentrations for too long is one of the many causes
of ARDS. No specific drugs including steroids have been shown to
benefit the outcome of shock lung.

    PROGNOSIS

   This serious disease kills around one half of its over 150,000
victims in the U.S. each year.  Untreated it is universally fatal, or
nearly so. If a patient receives intensive support and survives the
critical weeks of illness, there is usually no significant residual
lung impairment, according to recent studies.  It seems that the keys
to survival relate to the general health of the patient before the
illness, and to the availability of aggressive and continuous
supportive medical intensive care.



            PLEURISY

   The pleura are the thin double layered membranes which surround
the lung on each side of the chest.  In effect, the lungs sit within
the pleura as if within a bag.  In health, the pleura function as the
walls of a balloon, pulling the lungs open as the diaphragms are
lowered, and allowing them to collapse as the chest wall relaxes.
The inner layer of the pleura adhere closely to the lung, whereas the
outer layer adheres to the inside of the rib cage; normally there is
nothing but a thin layer of lubricating fluid separating the two
layers, and they function as one membrane.

   Pleurisy is a general term referring to inflammation or infection
of the pleura.  The causes are outlined below.  One of the commonest
reactions of the pleura to this irritation is the production of large
amounts of pleural fluid between the two layers.  Since pleurisy is
actually a reaction to any of many diseases, the term should be
considered a symptom instead.

    Symptoms

   Pleural pain is characteristically very severe, somewhat sharp in
quality, and clearly worsened by breathing, as the inflamed layers
are rubbed against one another.  It may be so painful to take an
adequate deep breath that the underlying lung develops collapsed
areas.  Depending on the cause, there may be fever or accompanying
other symptoms.

    Common Causes

Pneumonia--Pneumonia of almost any type can extend to the borders of
the lung, causing pleurisy.  The chest x-ray will show the pneumonia,
and any fluid that may be present. Fever, chills and other pneumonia
symptoms may provide clues to diagnosis.

Pulmonary embolus--Blood clots in the lung frequently cause pleurisy.
 The best clues are the predisposing circumstances, such as prolonged
bed rest, phlebitis in the legs, etc.

Devil's Grip--Pleurodynia--This common entity is caused by a virus,
usually the coxsackie virus, which can cause a simple cold as well.
It sometimes occurs in epidemics, and is not associated with fluid or
other serious diseases.  In fact, some believe that it is actually an
infection of the muscles between the ribs rather than the pleura, but
the end result is symptomatically identical to pleurisy.

Tuberculosis--Either as a side effect of tuberculosis of the lung, or
as a direct infection of the pleura, tuberculosis is a common cause
of pleurisy.  It can be very painful, and resolve spontaneously;
unfortunately, the TB germ will usually re- emerge to cause serious
infection later, if the original episode goes untreated.

Cancer--Lung cancer, cancer of the pleura themselves (often from
asbestos exposure), or cancer of other organs which spread to the
pleura are common causes of pleurisy, and commonly produce copious
fluid.

Heart Failure--Though not a true pleural disease, fluid in the lung
from heart failure sometimes is its first manifestation, and may
require careful evaluation.

Miscellaneous--scores of less common infections can cause pleurisy,
including fungi. Leukemia and other blood cancers are another less
common cause. Liver and pancreas disorders can involve the pleura due
to their close anatomic proximity. Rheumatoid arthritis can involve
the pleura through autoimmune mechanisms.

    DIAGNOSIS

   When the symptoms of pleurisy are present, exam may reveal either
the presence of fluid, the scratching sound through the stethoscope
as the inflamed pleural layers rub together, or no abnormalities at
all.  A chest x-ray will confirm the fluid if more than a few hundred
milliliters are present.  If no fluid is seen the diagnosis can be
elusive, and careful observation, blood tests, skin testing for
tuberculosis may be done.

   When fluid is present, it is usual to remove a small sample under
local anesthesia by placing a needle between the ribs of the back.
This will often differentiate whether the fluid is from heart failure
versus another cause, and will be useful in identifying the causative
germ if pneumonia is present. Frequently, however, a small piece of
pleural tissue, or biopsy, must be taken through the needle.  Even
this is not always diagnostic, and when the potential diagnoses are
important to patient treatment and/or prognosis, a larger biopsy may
be done under anesthesia.

    TREATMENT

   It is not possible to generalize the treatment of a syndrome with
so many diverse causes.  In general, the underlying disease can be
treated, with resolution of the pleurisy.  In cases of untreatable
cancer or other situations where specific treatment is unavailable,
repeated fluid drainage (thoracentesis) can be done.  In some cases,
an intentionally irritating solution can be instilled between the
pleural layers, causing scar formation which fuses the layers
together, preventing the accumulation of additional fluid.

    SUMMARY
   Pleurisy is a final common path for many diseases, and diagnostic
efforts should be as aggressive as necessary to get a diagnosis.
Symptoms always warrant medical evaluation, and several fairly
innocent diseases can cause severe symptoms, including muscular
strain, viruses and rib injuries.



           ASBESTOSIS

   Asbestos is a compound derived from silica which has found
widespread industrial use because of its unique properties as an
insulator and fire retardant.  It also resists wear from abrasion,
and thus became one of the most ubiquitous materials in manufacturing
use. Common sites of asbestos include pipe linings, insulations,
automobile brakes, ship building, fireproofing, and numerous other
applications. From a health perspective, it was learned more recently
that the compound is capable of causing serious disease if it is
inhaled into the lungs.

   There are some peculiar aspects to asbestosis, or lung disease due
to asbestosis inhalation.  First of all, even a relatively small
exposure, say two months in an occupation using asbestos, can result
in the occurrence of the disease some twenty or thirty years later,
even if there was no apparent exposure in the interim.  In some
cases, the disease has been identified in the families of exposed
workers, apparently from exposure to the soiled work clothes worn
home after work.  Yet others with massive exposure for many years
escape seemingly unharmed from their exposure.

   There are essentially three forms of asbestos-related disease.

 The first is a form of progressive scarring of the walls of the air
sacs or alveoli, leading to stiffening of the lungs, poor transfer of
oxygen back and forth, and increased effort of breathing. The second
is the formation of characteristic plaques of thickened scars on the
pleura (the sacs surrounding the lungs. These may sometimes produce
fluid and lead to discomfort and stiffening of the chest-lung
breathing apparatus, or may be totally asymptomatic.  Finally, there
is the dread form of cancer called mesothelioma. Usually arising in
the pleura, this can also occur in the lining of the abdomen or
elsewhere.  In addition, the commoner cancers of the lung, bladder,
and ovary may occur with dramatically increased frequency in patients
who smoke in addition to having asbestos exposure.

    SYMPTOMS

   Most patients develop symptoms many years after first exposure,
although some are detected only on routine chest x-ray done for
unrelated symptoms.  The earliest symptoms are usually shortness of
breath on exertion, or a cough.  If pleural involvement is paramount,
pain or discomfort with breathing may be noted early.  As the disease
progresses, the breathlessness increases such that even at rest the
patient spends virtually all effort on each breath.  In end- stage
cases, heart failure may occur, pneumonia sets in and death may
follow.  In most cases, there are long periods of relative stability,
especially if smoking and continued exposure are avoided.  Like
emphysema, the disease predisposes to marked flare-ups from seemingly
trivial insults such as common colds.

   In the benign pleural form of the disease, the course is often
quite innocent, with few if any symptoms.  Occasional episodes of
pain and tightness may accompany the occurrence of pleurisy and fluid
accumulation, and this may be self-limited. When a malignant pleural
or other tumor occurs, the course is one of rapid decline, spread to
other organs, and death is almost inevitable within months.

   There is a very unpredictable course in most forms of asbestosis,
and the patient who first discovers its presence in the form of some
scar formation either in the lung or pleura, and who is otherwise
well, is probably not in jeopardy of rapid deterioration.
Nonetheless, the risk of worsening is everpresent, and careful
monitoring is important.

    DIAGNOSIS

   The history of asbestos exposure can sometimes be elusive, since
the patient may not be aware of its use if the job was performed
years ago before heightened public awareness.  When no exposure is
known, the physician may be clued in by the occurrence of certain
x-ray changes, especially in the pleura as discussed above.  Often
the x- ray is consistent with but not diagnostic of asbestosis, and
biopsies of lung and/or pleura may be necessary.  If scars seem to be
stable, some may choose to simply observe, and the diagnosis will
remain uncertain until the occurrence of some more diagnostic
complication.

   Pulmonary function tests which measure air flow and lung volumes
are used to follow the course of the lung-scarring form of the
disease, in addition to x-rays.  Blood tests and analysis of sputum
samples are also used in some cases.  The radiologic appearance of
pleural cancer is highly typical, and usually reveals this
complication;  it is common to confirm this with biopsy, due to the
implications of the diagnosis.

    TREATMENT

   There is no  treatment for asbestosis in any of its forms;
however, treatment of its complications, support of respiratory
function in severe disease, and prevention of worsening factors can
be highly beneficial.  The malignant form has no known beneficial
treatment, and therapy is usually geared toward symptom relief and
quality of life.

   Patients are prone to bronchitis and pneumonia as their lungs
weaken, and any worsenings should be evaluated for this, since
antibiotics can be helpful.  If the chronic disease causes a
component of bronchial spasm, as in asthma, bronchial drugs can be
useful. Immunization against pneumococcal pneumonia and influenza are
indicated.  In the end stages, intermittent use of mechanical
ventilators to help patients through potentially reversible flare-ups
are used. At some point, the ethical question of when to withhold
such therapy arises, as the quality of the patient's life at that
point may not warrant heroic measures in the philosophy of some
families and patients.

    PREVENTION

   The importance of prevention is emphasized by the relative lack of
effective therapy.  Most industrial use of asbestos has been replaced
by other processes today, but exposures continue, especially from
pre-existing sources.  Emotional discussions can arise when buildings
such as schools and hospitals are involved, not to mention older
homes.  Once identified, asbestos is generally only a hazard when the
fibers are aerosolized by handling, cutting, etc.  Thus the best
solution is sometimes to simply leave it in place, or even to seal it
off where it is; this effectively removes the hazard.

   Where circumstances necessitate removal or asbestos is known to be
contaminating the air, specialized firms have been formed for
managing its removal. Workers use special garments, face masks, and
other equipment, and occupants are evacuated during the work.  The
federal government has established technical guideline to protect
workers in these settings. Before decisions are made, before alarmed
emotional reactions are caused, and before unnecessary risks are
taken in asbestos-related issues, it is imperative to obtain
consultation from government or private experts.  The local agencies
to contact should be available under environmental branches of
county, state, or federal government offices.



    SARCOIDOSIS

   Although sarcoidosis can involve virtually any organ of the body,
it is most commonly identified in the lung, and is thus generally
considered to fall within the realm of pulmonary diseases.  It is a
unique disease, characterized by the formation of granulomas. These
are a type of scar with highly typical microscopic
appearance--rounded, well- defined, and composed of characteristic
types of cells. Granulomas are caused by many diseases other than
sarcoidosis, including tuberculosis, Hodgkin's Disease, rheumatoid
arthritis and lupus to name but a few.

   In sarcoidosis, the granulomas tend to replace the normal tissue
of the organs in question, have a characteristic distribution, and
are unassociated with evidence of the other diseases in question. The
cause of the disease is unknown, although it is widely believed based
on experimental evidence to be due to an immune reaction to some
foreign substance in a genetically predisposed patient.  Found the
world over, sarcoidosis in the U.S. is found in Blacks with an
incidence 10 times that in non- Blacks. It affects around 1 person in
10,000 annually.

    SYMPTOMS

   Most cases involve either the lungs or the lymph node tissue
within the chest cavity, and thus the commonest symptoms of the
disease are respiratory, namely shortness of breath on exertion with
or without a cough.  It is not rare to diagnose the disease almost by
accident when the findings are noted on an incidental x-ray, so that
many patients may have no symptoms at all.  Other common sites of
involvement include the skin and eye.  When the rash is noted, a
small biopsy of the involved skin will show the granulomas.  Ocular
involvement may present as a red eye, or with vision problems.  A
more dramatic variety manifests itself as sudden fever, swelling of
the salivary glands, eye involvement, and paralysis of the facial
nerve; however frightening this may be, this form (Heerfordt's
Syndrome) carries a favorable prognosis. In addition, rare forms of
sarcoidosis can involve almost any organ including the heart and
brain, so that the symptom list is virtually endless.  The final
common denominator is the presence of granulomas in the involved
organs.

    DIAGNOSIS

   As can be presumed from the above, the diagnosis can either be
very obvious, as in the case of a classical chest x-ray in a young
Black patient, or nearly impossible as in isolated pituitary gland
involvement is a white patient with no other manifestation.  In the
"fluke" cases, diagnosis is almost always the result of a surgical
biopsy and comes as a surprise to all. Rarely, and for uncertain
reasons, sarcoidosis elevates the level of calcium in the blood, and
this may be the first clue to diagnosis.

   When the combination of findings and epidemiologic factors suggest
the possibility of sarcoidosis, two approaches must be taken: first,
to rule out other diagnoses which are treatable and curable, and
second to obtain positive evidence of sarcoidosis. The former is
usually done by culturing various fluids and tissues for
tuberculosis, and carefully studying all samples microscopically.
Careful blood analysis for clues to the presence of signs of
rheumatoid arthritis and other diseases is crucial.  History taking
should be meticulous, as this can often provide the only clue to
possible alternative diagnoses (e.g. beryllium exposure can cause the
same findings).

   Once other diseases seem unlikely, diagnosis involves obtaining
tissue evidence of granulomas from two different organs ideally.
Common sites are the conjunctiva (outer lining of the eye), skin,
lungs (through bronchoscoy which is fairly simple for the patient
compared to open biopsy of the lung), or liver. However, almost any
apparently involved organ may provide the sample. In addition, the
blood should be checked for a recently identified chemical called ACE
(angiotensin converting enzyme). This chemical is almost always
elevated in active sarcoidosis, and is usually normal in other
diseases one commonly needs to rule out.  Not totally accurate, the
ACE level markedly aids in diagnosis.  Other tests useful in
diagnosis and monitoring of the diseases include special lung scans,
skin testing, and immunologic blood tests.

   Complicated as it may sound, the typical diagnosis often involves
simply seeing a characteristic chest x-ray, confirming elevated ACE
levels, and getting a biopsy of skin or lung.  If no other diseases
are suspected, that may be all that is necessary and can all be done
as an outpatient within a few days.

    TREATMENT

   Not all patients with sarcoidosis require treatment, since
symptoms may not be present and involvement of vital organs may be
absent.  Anywhere from 20% to over 65% of cases may go into remission
spontaneously, and most cases "burn out" over a period of years, at
any rate.  Indications for treatment are somewhat controversial, but
most authorities would agree that involvement of the eye, heart, and
brain require therapy.  In addition, involvement of any other vital
organ such as lung, kidney, liver or endocrine organs which is
significant and progressing may require treatment.  Finally, the
patient who is not in jeopardy of dying but who has persistent fever,
weight loss or other symptoms impairing quality of life should also
be considered for treatment.  Expert opinion is required to
individualize this decision.

   The reason for such difficult in treatment decisions is that the
only accepted therapy is the use of prednisone or other
cortisone-like drugs for long periods of time.  It is not known if
treatment improves the ultimate outcome of the disease, but it does
seem to control the symptoms and certain other manifestations of
active sarcoidosis, and may prevent complications.  It is known that
long-term use of these drugs entails serious and potentially
life-threatening side effects, as discussed elsewhere in HealthNet,
and very careful monitoring and preventive measures are indicated.
One to two years of therapy are usual.

    PROGNOSIS

   Spontaneous remission occurs in the majority of patients with
sarcoidosis, and this is especially true in milder cases, and with
Heerfordt's Syndrome (see above).  Even more severe cases generally
have a favorable outcome, although various degrees of residual damage
to the lungs or other organs may occur.  Deaths from sarcoid are very
unusual. Statistics as to survival are thus not generally available
or useful.  It may be stated that once the disease is present careful
management will result in satisfactory symptom control for most
patients, and the disease will run its course with little or no
residual damage for the majority of patients.



  LUNG COLLAPSE (PNEUMOTHORAX)

   To understand the reasons for and the results of a collapsed lung,
it is necessary to understand the basic mechanisms of the physiology
of ventilation.  The lung may be conceived as an elastic sac, which
tends to collapse or shrink under its own elastic properties when
allowed to do so--a balloon, in effect. Sealed in an airtight
container something like a piston cylinder, only the mouth of the
sack is open to the air. The sack only expands when the bottom of the
piston begins to drop down.  Since the only opening of the sack is at
the top of the cylinder, the expanding balloon draws in air as it is
stretched open by the opening of the piston.  Since the piston never
rises all the way back to the top of the cylinder, the sack is always
held open to a certain extent. In this admittedly contrived analogy,
the sack is the lung, the cylinder is the chest wall, and the piston
is the diaphragm.

   Imagine now that the sack is opened to some extent by the piston
and one of two events occurs: either a hole is suddenly punched
through the wall of the cylinder, or a hole made in the stretched
wall of the sack.  In either event, the result is the collapse of the
sack to its fully shrunken form. No matter how vigorously the piston
pumps, the hole will not permit total filling of the sack.  This,
then is the case of the collapsed lung, seen from a simplistic
perspective.

   In the case of the actual lung, the story is vastly more
complicated, but the principles are the same. Of course the collapsed
lung fails to participate fully in ventilation, and this is where the
dangers can occur.

    Causes

   The most obvious cause of pneumothorax ("air in chest" or
collapsed lung) is a penetrating injury to the chest wall, often a
knife or bullet wound, or from a motor vehicle accident.  Other
causes of chest wall leaking include surgery or other medical
piercing of the area, the shifting of a sharp edge of a fractured
rib, or even tumors or infections penetrating through the skin.

   Leaks in the lung or pleura which line the lung can occur
spontaneously.  This is often due to the rupture of a congenital
bubble on the lung which is weaker than normal lung.  A rare disease
called eosinophilic granuloma can also affect the lung surface.
Intrathoracic procedures such as bronchoscopy and surgery can injure
the lung, as can injuries and rib fractures. Mechanical ventilation
used to treat respiratory failure or during anesthesia is another
potential cause of lung leak, if pressures used to inflate the lung
are higher than the membranes can bear.

    SYMPTOMS

   Sudden onset of chest pain, difficulty breathing, rapid heart
rate, and great distress are characteristic of collapsed lung. In the
patient who has compromised heart or lungs to begin with, this can be
a fatal event.  In any event, emergency medical attention is
warranted.

   Several courses may be seen depending on the type of pneumothorax
which has occurred. If the hole was small and was sealed over quickly
by the body's defenses such as coagulation in the area, "flopping
back" of the displaced tissue, etc., the symptoms may rapidly
stabilize, and the air which did enter the pleural space (the
"cylinder") will be gradually reabsorbed by the body over several
days or weeks.  If the hole does not seal off, or if large amounts of
air have entered the leak, the body is unable to compensate, and the
symptoms put sufficient strain on the cardiopulmonary system that
survival will be threatened if treatment is not given promptly.
Finally, if the injury is such that the hole admits air when the
diaphragm is lowered, but fails to let the excess air back out the
hole as exhalation occurs, like a one way valve, the syndrome called
tension pneumothorax exists. As the chest cavity continuously fills
with more and more air, death occurs within minutes, and the heart is
compressed into uselessness.  This condition requires urgent
treatment, sometimes at the site of injury.

DIAGNOSIS

   In the presence of a consistent injury, appropriate circumstances,
and consistent symptoms the diagnosis is obvious to the physician,
and a chest-x-ray is confirmatory. When the pneumothorax occurs
spontaneously, care must be taken to listen to the lungs. In sizable
leaks, the breath sounds are reduced or absent, and the bottom of the
trachea or wind pipe may be shifted away from midline.  The nature of
the injury or the patients general condition dictate the type of
pneumothorax present, and x-rays are confirmatory.

    TREATMENT

  The occasional self-sealing leak which is small in extent may
require no treatment other than careful observation.  In most other
cases, the problem can be corrected by a combination of surgical
repair of the wound, if there is one, and insertion of a small tube
between the ribs into the chest cavity.  This tube is attached to an
apparatus which allows air to escape with each elevation of the
diaphragm, but does not permit re-entry of air during inspiration.
Within a few days, the leak will have generally sealed, and the tube
is removed.



       ALTITUDE SICKNESS

   Altitude Sickness is a syndrome occurring in some people within
hours to a day after exposure to previously unaccustomed high
altitudes. There is wide variability in the heights individual will
tolerate, but illness is most often seen at altitudes of 700 feet or
more.  The rapidity of ascent, baseline physical condition, and
activity level at the new altitude all play a role.

   The cause of Altitude Sickness is poorly understood, but most
authorities believe it relates to the body's reflex reactions to the
sudden drop in the oxygen pressure in the atmospheric air. In
acclimated persons living at these altitudes, the syndrome is not
seen, unless they spend weeks away at lower altitudes before
returning.  High altitude dwellers routinely have elevated levels of
oxygen carrying hemoglobin and other chemicals in the blood, possibly
explaining in part their relative resistance.

    SYMPTOMS

   A broad spectrum of symptoms ranges from mild headache and
weakness to varying degrees of shortness of breath, with nausea,
vomiting, abdominal pain, irritability and difficulty sleeping. Rapid
heart rate may be noted, and in extreme cases, the lungs may fill
with fluid in what may be a serious or even fatal complication.
Within one or two days the symptoms subside as a rule, unless they
are severe or the patient is otherwise ill.

    TREATMENT

   Mild symptoms require nothing more than rest and time. More severe
cases may respond to the administration of oxygen and mild diuretic
medications. Resistant or severe cases require hospitalization and/or
lowering of the patient to lesser altitudes.

   Acetazolamide is a drug which is said to prevent most cases of
altitude sickness, and in fact most evidence supports its
effectiveness.  Unfortunately, it has profound effects on body
metabolism, and should only be used in critical situations under
close medical supervision. The best preventive measure is to allow
time for acclimatization to new altitudes, optimize physical
condition before hand and to minimize physical activity during the
first 48 hours of altitude exposure.



  Heart Disease--Introduction

   The heart--long the most dramatic of the body's organs, both
scientists and poets have always paid it just a little more
attention, held it in a little more awe, and sometimes feared it just
a bit more than the other organs.  Little wonder.  It is in
continuous motion, requires no attention from us for its daily
duties, and provides a seemingly endless driving force of which all
are aware.

   Yet when it stops or malfunctions, the results are often dramatic.
 Even the heart has its vulnerabilities-- tobacco, fats, age, lack of
activity for which it was designed, and sometimes just bad luck can
all cause problems. This section of HealthNet explores the commonest
of these ailments, and their care.

   Some diseases affecting the heart are not discussed here, as they
are primarily disease of other organ systems.  For example
hyperthyroidism often causes a racing heart and pounding in the
chest, as do hyperventilation and other other entities.  These are
discussed elsewhere.  Heart symptoms which are of multiple causes are
also discussed in the symptoms section.

   If you cannot find what you want, feel free to use the "Ask
HealthNet" section for more information.  We hope you enjoy and
benefit from your readings in this section.



    CORONARY ARTERY DISEASE--HEART ATTACKS AND ANGINA

    Overview

   Coronary artery disease refers to those syndromes caused by
blockage to the flow of blood in those arteries supplying the heart
muscle itself, i.e., the coronary arteries.  Like any other organ,
the heart requires a steady flow of oxygen and nutrients to provide
energy for movement, and to maintain the delicate balance of
chemicals which allow for the careful electrical rhythm control of
the heart beat.  Unlike some other organs, the heart can survive only
a matter of minutes without these nutrients, and the rest of the body
can survive only minutes without the heart--thus the critical nature
of these syndromes.

   Causes of blockage range from congenital tissue strands within or
over the arteries to spasms of the muscular coat of the arteries
themselves.  By far the most common cause, however, is the deposition
of plaques of cholesterol, platelets and other substances within the
arterial walls.  Sometimes the buildup is very gradual, but in other
cases the buildup is suddenly increased as a chunk of matter breaks
off and suddenly blocks the already narrowed opening.

    Risk Factors

   Certain factors seem to favor the buildup of these plaques.  A
strong family history of heart attacks is a definite risk factor,
reflecting some metabolic derangement in either cholesterol handling
or some other factor.  Being male, for reasons probably related to
the protective effects of some female hormones, is also a relative
risk.  Cigarette smoking and high blood pressure Rare definite risks,
both reversible in most cases.  Risk also increases with age.
Elevated blood cholesterol levels (both total and low density types)
are risks, whereas the high density cholesterol level is a risk only
if it is reduced; the latter adds very little to predictive value
over the total cholesterol level.  Possible, but less well- defined
factors include certain intense and hostile or time- pressured
personality types (so- called type A), inactive lifestyle, and high
cholesterol diets.

   The Mechanism of Symptoms

   As plaques begin to clog the coronary arteries, several things may
occur.  In some, no symptoms are noted until a fatal heart attack or
sudden death occur as the first (and last) event.  In others, no
symptoms are noted at rest, but with exercise or other stress, a dull
aching pain is noted in the chest, neck, jaw, upper abdomen, arm, or
back.  Typically, this subsides with rest.
 Called "angina," this crushing type of pain represents the area of
the heart which is trying to function with inadequate supply from its
coronary artery, much as an overutilized muscle in the leg might hurt
under similar circumstances.

   If the stress is relieved, the previous level of circulation to
that area of heart is again adequate, and recovery takes place with
no permanent loss of muscle in the heart.  However, if the stress
continues, or if the blockage is so critical that even at rest the
blockage is too great, the patient experiences further
symptoms--progressive pain, profuse sweating, shortness of breath,
palpitations, and finally collapse.  A severe sense of dread or
impending doom is, understandably, reported by many patients.  As the
jeoporadized area of heart muscle finally dies, a heart attack or
myocardial infarction is said to occur.

   Effects of a Heart Attack

  The outcome of a heart attack depends on the location and size of
the area of heart involved. Even a "small" one, if located in a
critical area of the heart, or if it sets off an unstable rhythm (see
cardiac arrhythmia section) can be fatal.  Large heart attacks kill
so much muscle that the pumping action is inadequate, resulting in
severe low blood pressure and circulation to the body (shock) or
congestive heart failure. Many heart attacks are intermediate, and
various degrees of complications are noted.  In these cases total or
nearly total recovery is very common.

   In the pre-hospital minutes of a heart attack, there is a nearly
50% incidence of cardiac arrest due to ventricular fibrillation or
total stoppage of the heart (see arrhythmias). This is where
cardiopulmonary resuscitation, or CPR, saves lives. This technique is
discussed further elsewhere in HealthNet.

    Prevention

   The primary risk factors have been discussed, and prevention is a
matter of eliminating these when possible.  Of confirmed value are
smoking cessation, blood pressure control, and treatment of some
severe metabolic problems such as diabetes and marked cholesterol
elevation.  Please refer to the appropriate sections for further
information.

    Diagnosis

   Two thirds of patients with heart attacks have warning symptoms of
chest pain, marked fatigue, or other problems in the month before the
event. Sometimes the symptoms are typical as described, but often
they are atypical or subtle.  If there is doubt, a physician
evaluation is critical.  If unexplained chest, neck, abdominal, back,
jaw, or arm pain occur, the safest course is immediate medical
attention. Fleeting sharp pains, lasting only seconds, are much less
often related to the heart.

   The medical evaluation includes a thorough history and physical
exam.  In addition, an electrocardiogram (EKG) is often done,
although even if normal both angina and heart attack in the early
stages cannot be ruled out.  Blood tests may reveal chemical changes
of a heart attack, but sometimes only intense observation in the
cardiac unit with repeated blood tests and EKG's is adequate.

   Once an acute heart attack or unstable angina are ruled out, the
question is often whether a chest pain is from heart problems or some
less serious disorder.  Useful tests include exercise tests, where
the EKG, blood pressure and other factors are monitored during
treadmill or bicycle exercise.  Used alone, the sensitivity and
accuracy of this is limited, since a sizeable percent of normal
people may have some abnormality on standard exercise testing, and
many people with definite coronary disease have a normal study.  The
test may be improved by adding an injection of a slightly radioactive
substance the course of which is traced through the heart.  This is
called a Thallium stress test, or a radionuclide angiography,
depending on technique. Though not perfect, these improved tests are
very helpful in many cases.

   If there remains significant doubt about the cause of the pain,
and if making this diagnosis would significantly alter medical
management, the ultimate test is called coronary angiography, or
cardiac catheterization.  Most patients never require this, but
controversy rages over when to do it.  This involves passing a small
tube into the coronary arteries, injecting an x-ray dye, and
visualizing the arteries on film. The test is discussed further
elsewhere in HealthNet.  It is most useful when coronary bypass
surgery is being considered, as noted below.

    Treatment

   Treatment of symptoms is divided into medical and surgical types.
The choices are complicated, and depend largely on individual
factors, as well as regional resources and preferences.  General
comments on the major options are included in this section, although
exceptions are common.

   MEDICAL THERAPY--Each of these drugs is discussed in greater
detail in the drug section of HealthNet, and the reader is referred
to the appropriate section for more detail.

   Medications are increasingly effective for symptom control, as
well as prevention of complications.  The oldest and most common
agents are the nitrates, derivatives of nitroglycerine.  They include
nitroglycerine, isosorbide, and similar agents.  Newer forms include
long acting oral agents, plus skin patches which release a small
amount through the skin into the bloodstream over a full day.  They
act by reducing the burden of blood returning to the heart from the
veins and also by dilating the coronary arteries themselves.
Nitrates are highly effective for relief and prevention of angina,
and sometimes for limiting the size of a heart attack.  Used both for
treatment of symptoms as well as prevention of anticipated symptoms,
nitrates are considered by many to be the mainstay of medical therapy
for angina.

   The second group of drugs are called "beta blockers" for their
ability to block the activity of the beta receptors of the nervous
system.  These receptors cause actions such as blood pressure
elevation, rapid heart rate, and forceful heart contractions.  When
these actions are reduced, the heart needs less blood, and thus
angina and even the extent of a heart attack may be reduced. Because
the electrical irritability of damaged areas of heart is reduced,
these drugs can reduce the incidence of sudden death due to
ventricular fibrillation in some patients at risk.

   The newest group of drugs for coronary disease is called the
calcium channel blockers. Calcium channels refer to the areas of the
membranes of heart and other cells where calcium flows in and out,
reacting with other chemicals to modulate the force and rate of
contractions. In the heart, they can reduce the force and rate of
contractions and electrical excitability, thereby having a calming
effect on the heart. Although their final place in heart disease
remains to be seen, they promise to play an increasingly important
role.

SURGERY

   Coronary bypass surgery has become commonplace.  The procedure
consists of transplanting veins from the leg (or vessels from
elsewhere in the chest) to the blocked area, bypassing or "jumping
over" the obstructions.  As many as four or five vessels may be
bypassed, thus restoring flow to the area previously blocked off.
During the operation, the heart is temporarily replaced by the
"heart-lung" machine.  Mortality in better centers is less than one
percent.

   There is major controversy surrounding the benefits and selection
of patients for surgery.  A few facts are accepted: 1. Patients with
severe blockage of the main trunk of the coronary arteries live
longer if operated upon--"left main disease." 2. Patients with severe
pain unresponsive to intense medical therapy, or intolerant of it,
often feel better after surgery; whether they live longer is unclear.
3.  Patients with hearts that are not pumping well, i.e. with a
degree of congestive heart failure, have a higher mortality from
surgery than others.

   Beyond that, there is more emotion than fact. It is clear that
unless surgery is contemplated or the diagnosis is in question, most
patients do not require catheterization or surgery. Furthermore,
surgery as a life-prolonging measure is questionable for most
patients, and no study has been done comparing surgery with medical
management using the newer drugs.  Until these points are clarified,
the choice is a difficult one best left to individualized
considerations.

   One newer means of therapy is termed angioplasty.  This involves
passing a catheter through an artery to the point of blockage in the
coronary, then inflating a tiny balloon at the tip of the artery.
This squeezes and flattens the blocked area, thereby opening a larger
passage for the blood, and imporving the blockage.  Not all types or
locations of blockage are amenable to this treatment, and it is not
without its risks.  Furthermore, some blockages recur after
treatment. Currently angioplasty is available in selected major
medical centers only, but when appropriately applied, it can avoid
the need for surgery in selected patients.

    The Good News

  One final optimistic note-- since the late 60's, the incidence and
mortality of coronary disease has been steadily declining, and rather
markedly at that.  The reasons are not clear, but may be related to
changes in diet, blood pressure control, and activity levels.  As
this trend continues, and newer treatments are perfected, this once
dread disease may well be conquered by modern medicine, if not
completely, at least to a large extent.



    THROMBOSIS (BLOOD CLOTS)

   Blood clots can occur as either a protective reaction of the body
to wounds and blood loss, or else as an abnormal reaction within the
veins and arteries, causing various disease states. Although the term
thrombosis refers to any variety of clotting, it will be used here to
imply the latter abnormal state of affairs.

   When blood clots inside of a vein or artery, several reactions
occur--there is partial or complete obstruction to the flow of blood
within the vessel, and inflammation occurs at the site, much like at
the site of an infection.  These two effects account for the symptoms
of this disease.

   Phlebitis

   The veins of the lower leg are the usual sites of abnormal clots,
and the reaction is commonly referred to as phlebitis, inflammation
of a vein.  Several factors are may be responsible--injury to the
inside of the vein may disrupt the delicate lining layer of tissue,
thereby triggering the clotting mechanism. Alternatively, years of
blood pooling in the legs from the effects of gravity, pregnancy,
constraining garments, etc. may stretch the veins, injuring the
lining and pulling apart the valves which usually make the veins a
'one way street' back to the heart.  In any event, once a clot starts
to form the process is self-perpetuating.

   The classic setting for this disease is thus the bedridden or
inactive patient, especially after surgery to the legs or abdomen,
worsened by the presence of obesity, smoking, both of which are
harmful to the normal functioning of the veins.

   Acute symptoms may include pain in the calf, redness, swelling,
fever, and warmth of the leg.  It may be painful to bend the foot
upward.  On a more chronic basis, swelling becomes prominent, and
skin rashes, peeling, darkening and eventual blistering with
infection can occur.  In the end stages, so much tissue may be
involved that amputation is necessary.

   A large number of even extensive clots may be totally
asymptomatic, and first manifest as pulmonary embolus, which is
discussed later in this section.

  Clots can occur elsewhere occasionally, usually in the veins of the
lower abdomen or pelvis; this happens almost exclusively after some
surgery, infection, or injury to this area.

    Diagnosis

   Although the exam may be very suggestive of the diagnosis, most
authorities agree that it is unwise to rely on this alone.
Confirmatory tests are of two types: invasive and noninvasive. The
invasive test, a venogram or phlebogram, is an x-ray done after the
injection of a liquid contrast chemical into the vein, usually in the
foot. Noninvasive tests are called Doppler studies (listening for
subtle sound abnormalities over the veins with a sensitive
instrument), and impedance plethysmography, in which the response to
various changes in pressures of a large cuff placed around the leg
are measured.

   In straightforward cases, the noninvasive tests are safe,
adequately reliable, and sensitive.  Only a minority will require a
venogram, which is still the "gold standard" for diagnosis.

   Sometimes a clot will occur in the very superficial veins near the
skin, so-called varicose veins.  In these cases, careful exam may be
all that is necessary.

    Treatment

   If a clot is documented in the major or deep veins, treatment is
usually the administration of anticoagulants, or blood thinners.  The
rationale is to prevent the extension and production of additional
clots, thus allowing the body to slowly reabsorb the existing clot
through natural mechanisms. Because the danger of pulmonary embolus
is immediate (see below), this is often done by the intravenous use
of heparin, a potent drug which cannot be taken orally.  Shortly
thereafter, the oral drug warfarin (Coumadin) is begun, taking 4 to 5
days to have its full effect.  Once established, treatment is usually
continued on an outpatient for 3 months.

   These drugs have major side- effects, mainly the occurrence of
abnormal internal bleeding. Careful monitoring, avoidance of
interacting drugs, and avoidance of trauma are all imperative, but
even so up to 20% of patients may suffer some ill- effects. Recent
studies suggest that lower than previously accepted doses may be
equally effective yet safer; confirmation of these findings may
change current practice in the near future.  Still, the risk of
serious complications from the disease is felt to warrant treatment.

   In severe cases, a drug called streptokinase has been recently
introduced.  This actually dissolves the clot, and gives a head start
on recovery. Its use requires careful monitoring, entails additional
side effects, and is presently limited to massive clots.

   Finally, in patients who cannot use anticoagulants, or who have
serious clots despite using them, a filtering device can be inserted
in the vena cava, the main vein of the body. This does not prevent
clots, but if they break off, it prevents them from reaching the
lungs (see below).

    Prevention

   Use of low doses of blood thinners, either by pill or injection,
has recently been widely advocated in patients at high risk, such as
obese patients undergoing surgery. Since the doses are low, the risks
are low and the benefits are impressive.  This should be considered
by any patient in this setting.  Even small doses of aspirin have
such an effect, and may have a role in selected instances.  Further
research is needed and expected in this area.

  Patients should avoid prolonged sitting, standing, and lying down.
Elastic support hose may be helpful for some. Early ambulation after
surgery is optimal, when possible. Smoking is a risk.

    Pulmonary Embolus

   The most serious and frightening complication of clots in the
legs, namely those of the deep veins extending up to or above the
knee area, is that the clot will break off, travel up the vein into
the lung, and block the circulation there.  This can and often does
lead to sudden death with little or no warning, and is the reason
that treatment of thrombosis is so urgent.

   When death is not instantaneous, symptoms include chest pain,
anxiety, breathlessness, cough, and shock.  Mortality may be over 50%
untreated, but is reduced to 15% or less with treatment.  As with
thrombosis of the veins, anticoagulation is the mainstay of therapy,
with streptokinase playing an increasing but still limited role.
These topics are discussed above.

  Diagnosis is made by a combination of special nuclear scans of the
lungs and x-rays involving catheterization of the right side of the
heart.  The prevention, cause, and risks are those of
thrombophlebitis, as noted.



    HIGH BLOOD PRESSURE
   As one of the major risk factors for heart attacks, heartfailure,
stroke and kidney failure in America, hypertension, commonly known as
high blood pressure, is a familiar diagnosis to most people.
Although the term hypertension misleads some into assuming that
emotional tension is the major cause of the disease, this is not so.
   Estimates of the prevalence of this disease range up to the
millions; perhaps 10% of the general population is at risk.  Defining
the disease is, in fact, one of the major areas of controversy, as
discussed below.  A brief review of the concepts of blood pressure is
necessary to an understanding of hypertension.
   Each time the heart beats, the blood is forced from the left
ventricle of the heart into the aorta, then to the other arteries of
the circulation. These arteries are flexible, and stretch a bit,
returning to their previous state very quickly.  The stiffe rthe
arteries, or the greater they resist the force of the contractions of
the heart, the higher the pressure necessary to assure that the blood
flows adequately through them  .Unfortunately, at very high pressure
levels, the very force of the blood pressure can overstretch and
damage the delicate linings of the arteries, particularly the smaller
arteries.
   Once damaged, the arteries are far more prone to accumulate
plaques of cholesterol and other substances, and ultimately become
clogged up.  This is simply stated what leads to heart attack
(coronary arteries), stroke (cerebral and carotid arteries) and many
other complications.  Furthermore, weak areas in the arteries can
balloon out, thinning in the process.  This leads to hemorrhages or
areas of internal bleeding, as well as aneurysms or bulging "blown
out" areas of arteries.  Over time, some arteries become thickened
with muscle growth, thereby becoming stiffer and leading to even more
high blood pressure.
   As one might expect, the pressure in the arteries is higher during
a heart contraction than between beats. The higher pressure during a
contraction is called the systolic, and the lower pressure between
heart beats is the is the diastolic. Both are considered important in
the above process, and elevation of either one may be worrisome.
   When the blood pressure cuff is applied, the doctor inflates it
higher than the anticipated systolic reading, and then listens over
an artery below the cuff.  Of course nothing is heard until the cuff
is released enough to let a trickle of blood squirt noisily through
the artery beneath  the stethoscope; the first sound is heard and the
pressure is noted, this being the systolic reading. As the cuff is
deflated further, the artery returns to its previous wide open state.
 At some point, the blood no longer has to "squirt" through the small
opening in the compressed artery, but can again flow smoothly and
silently through the normal arterial opening. When this happens, the
noises of blood flow are no longer distinctly heard.  This is the
point where the diastolic reading is obtained.  Usually, the numbers
are reported as 120/80 or "120 over 80," or whatever the appropriate
numbers happen to be in terms of millimeters of pressure of mercury
(this being the metal within the blood pressure cuff apparatus-the
sphygmomanometer). WHAT IS CONSIDERED A NORMAL BLOOD PRESSURE?
   The range of normal varies with age, and generally in an otherwise
healthy person, the lower the pressure, the lower the risk for the
diseases mentioned. On the other hand, lowering the pressure
partially but not into the normal range still provides considerable
benefit for those patients whose pressure is difficult to normalize.
Readings under 140/90 are generally considered acceptable, though
even this level may justify treatment in a young person with multiple
other risk factors for heart disease and stroke.  Alternately,
readings of 180/105 or higher are abnormal, yet may not warrant
treatment in an elderly patient at risk for side effects of drugs,
and whose life may not be significantly lengthened by treatment.
Thus, the question is not what is normal, but rather, RWhen do the
benefits of treatment outweigh its risks and cost?S
    Having reviewed the above, some general guidelines for a thirty
year old man with no other risk factors or diseases might be to treat
when the pressures (either one) exceed 140/90 on three occasions.  If
there is only intermittent elevation, with normal readings in
between, many physicians would only observe carefully, since there is
increased probability of sustained elevations with time.

   The above factors apply to the garden variety or "essential"
hypertension. In a small percentage of patients with high blood
pressure, it is caused by some other secondary disease, such as
hyperthyroidism, kidney disease, or hormone imbalances leading to
excessive filling of the blood vessels with fluid, or as a
side-effect of some medications. Common examples of such medications
are cortisone, prednisone, indomethacin, common deconsgestants and
some antacids high in sodium. It is important for the physician to
rule out these secondary cause before embarking on treatment; this
can usually be done with office blood tests, and sometimes x-rays.
   Proper treatment is a complex and highly individualized affair,
and the following comments are merely general examples of one
potential approach. Further discussion of the drugs involvedmay be
found in the "Drugs" section.
   A useful first step when pressures are not severe is simple salt
restriction in the diet.  How salt effects blood pressure is not
entirely clear, but in some people it seems to cause fluid retention
and hypertension. Relief of reversible life stresses, obesity, and
unnecessary medications are advised, but often impractical or of
minimal benefit. Relaxation and meditation regimens are mildly useful
for a few dedicated patients.  Once these are tried, and the
resulting pressures are still judged to warrant treatment,
medications are usually warranted.
   First line drugs are often of the diuretic class.  These agents
(e.g. chlorothiazide, hydrochlorothiazide, Dyazide, and others) act
to rid the body of excess fluid and salt during the first couple of
weeks of treatment, and to gently relax the arteries on a long-term
basis.  They can be taken once daily, and for many patients are all
that is needed.  A high potassium diet (orange juice, bananas,
tomatoes) and low salt intake enhance the efficacy and safety of
these drugs.
   If additional drugs are needed, or if diuretics are not felt to be
the proper first drug for a given patient, drugs are given that act
directly on the arteries by relaxing them, reduce the force of the
heartbeat, or tone down the blood pressure regulating areas of the
brain.  Propranolol, clonidine, prazosin, methyldopa, reserpine, and
atenolol are examples (see Drugs section).
  One of the newest classed of drugs are called ACE inhibitors.
These act by blocking the action or formation of a hormone called
angiotensin converting enzyme or ACE, whose action is to increase the
body's fluid retaining capacity. Captopril and enalapril are two such
drugs.  They appear to be quite well-tolerated, though a few people
get allergic reactions, kidney damage, or white blood cell reductions
from the drugs.  Widespread use of these agents can be expected once
their longterm safety is well established.
    Another recently introduced type of drug for hypertension is the
calcium channel blocker class.  These drugs, such as nifedipine and
diltiazem, dilate arteries, thereby reducing the pressure within.
Though more widely used in Europe than the U.S., they are becoming
more popular here as well.
   Finally, some especially resistant cases require the combination
of three or more drugs, and the potential for adverse effects becomes
greater. Ample skill on the physician's part is called for, yet even
then some side-effects may occur.  It is here that a less than
optimal degree of control may have to be accepted by all parties.
   A stubborn problem is getting people to take there medications
regularly for the rest of their life, especially when they have no
apparent symptoms-- until they get a stroke or other complication, at
which point it is often too late. An educated patient, understanding
physician, and an understanding of the disease and its consequences
are the best incentives for good medication compliance.
  In summary, hypertension entails a complicated set of events
including: 1) Defining the need for treatment 2)  Identifyingthe
patient with the disease 3)  Ruling out secondary causes 4 )Modifying
risk factors and lifestyle factors 5)  Choosing and adjusting the
treatment to suit the patient 6)  Continuing treatment indefinitely
in most cases, and 7)  Monitoringtreatment, blood pressures, and the
scientific research which is continuously changing our understanding
of this important entity.
   Choose a doctor you can trust if youhave hypertension--you will be
seeing her or him for a long time if you want to lengthen your life
expectancy, reduce your chance of stroke and heart attack, and follow
a safe and effective treatment program.



   CONGESTIVE HEART FAILURE

   In the strictest medical terms, this entity is a very complex
group of findings and events caused by a large number of diseases of
the heart.  In the interests of clarity, this discussion will focus
primarily on the routine and common aspects of congestive heart
failure; details of the specific types may be obtained through the
inquiry areas of HealthNet. Heart failure is NOT the same as a heart
attack, which is discussed elsewhere.

   In essence, heart failure refers to states where the heart muscle
is unable to pump sufficient amounts of blood through the body to
meet its needs.  In thinking of the heart's pumping action it is
convenient to consider the right and left sides separately, each
having an upper and lower chamber, the atrium and the ventricle.

   Failure of the left ventricle, for causes discussed later, results
in inadequate circulation to the aorta and thus to the rest of the
body. The primary resulting symptoms are marked fatigue, weakness,
confusion, and ultimately stroke, cardiac arrest or severe drops in
blood pressure leading to death.  The symptoms of right heart
failure, on the other hand are related to backing up or "damming" of
the blood returning to the heart from the veins of the body, as the
right ventricle fails to clear out the returning blood as quickly as
it accumulates.  This results in accumulation of fluid in the legs,
or even in the entire body, referred to as edema.

   When both sides of the heart fail together (a very common
occurrence), there is often a condition called pulmonary edema. This
is a filling of the lungs with fluid which was not adequately removed
from the lungs by the left ventricle, and which was already present
in excessive amounts as a result of edema from right sided failure.
If it occurs rapidly, pulmonary edema can result from "pure" left
sided failure alone.  The symptoms in either case are profound
shortness of breath, cough, and debility.

   A few presentations are highly typical of heart failure. These
include sudden nighttime episodes of suffocating breathlessness,
which awaken the patient;  the effects of gravity pooling increased
amounts of fluid in the chest of the marginally compensated heart are
responsible.  This is called paroxysmal nocturnal dyspnea. Orthopnea
is also common, referring to any breathlessness worse when lying
down.

   The typical patient presents with any combination of the symptoms
mentioned above, accompanied by characteristic changes in the sound
of the heart through the stethoscope. Confirmatory tests include
ultrasound images of the ventricles beating, special x- rays, and
sometimes catheterization of the heart.

   What can cause heart failure? Most common is the longstanding
burden imposed by years of high blood pressure.  Eventually the heart
muscle just tires out. Sometimes, the heart muscle is so damaged by a
heart attack or attacks, that the surviving areas are just inadequate
to prevent failure.  Yet another cause is damage to one of the heart
valves from rheumatic fever, congenital defects, or infection causing
obstruction to the flow of blood, or lack of backwash of blood during
contractions. Viral infections can occasionally damage the heart so
severely that permanent heart failure results.  The list is
enormously long, but the resulting syndromes are similar.

   The physician approaches the disease by first looking for
reversible underlying causes-- valves that can be surgically
replaced, infections to be treated, etc.  If no such factors are
identified, three approaches are taken medically. The first is to
give diuretics, or water pills.  By forcing the kidneys to excrete
extra water (and by restricting salt intake), the load on the
circulation can be reduced as there is less fluid to be pushed around
the circulation.  Edema is also reduced.  Secondly, some drugs such
as digoxin actually increase the force of the pumping action of the
heart.  In recent months, the role of digitalis has been questioned,
as many patients do not benefit greatly, and side effects are common.
 Finally, one can give drugs which dilate and relax the blood
vessels.  This reduces the resistance against which the heart must
pump, and also reduces the amount of blood being squeezed back to the
heart by the venous system.  Examples of such drugs are prazosin,
captopril and certain forms of nitroglycerine.  Combinations of drugs
are common, and close supervision by an experienced internist,
cardiologist or other qualified doctor is crucial.  In severe
situations, these and other drugs must be given by vein, with
intensive care observation.

   Prevention is largely limited to measures to treat high blood
pressure and prevent coronary disease.  Once present, the usual type
of heart failure can often be controlled with medications for long
periods, though extreme variability is commonplace. Early detection
and treatment of setbacks is important, and the patient must promptly
report any marked weight gain, new breathing symptoms, swelling, or
fatigue promptly.  Ultimately, pulmonary edema or blood pressure
collapse is the cause of death in those succumbing to the disease.



    CARDIAC ARRHYTHMIAS

   The normal heartbeat results from an orderly sequence of
electrical stimulation passing from the upper to the lower chambers
through a well defined circuit.  It begins in the sinus node (the
natural 'pacemaker') and spreads from there.  Under influence from
the nervous system, the rate varies with stress, exertion, and many
other factors.  A slow leakage of chemicals through the cell membrane
sets up the next beat at the correct moment.

   Normally, the resting heart beat is between 60 and 100 per minute,
though frequently these limits are briefly exceeded in normal people.
 Under exertion or stress, maximum rates of 140 to 200 depending on
age and conditioning are seen, and rates as low as 40 at rest may
occur in athletes.  Minor fluctuations normally occur with the
breathing cycle.

   When the normal rhythm is no longer functional, the term
arrhythmia is used.  The common arrhythmias are discussed below;
first it is important to understand the possible symptoms which they
cause. A more detailed discussion of the symptoms may be found in the
"Symptoms" section of HealthNet.

   Palpitations--skipped, pounding, or otherwise noticeable heart
beats of brief duration.  Often of no significance, and brought on by
fright, caffeine, nicotine, etc., they can also signal serious
arrhythmias.

  Blood Pressure Drop (hypotension)--when the normal rhythm is lost,
the heart sometimes has insufficient time to fill with blood between
beats, at least when rates are very rapid.  This results in low heart
output and low blood pressure.

  Cardiac Arrest--when the rhythm is so chaotic that no effective
contractions occur, or when there is no electrical activity at all,
cardiac arrest occurs.  Within seconds to minutes, the brain, lungs,
and the heart itself lose their blood supply and death occurs unless
cardiac resuscitation are carried out.  If very brief, fainting or
transient lightheadedness may be the only symptom.

   The common arrhythmias are discussed below.  The usual causes are
idiopathic (unknown), ischemic (poor circulation to the electrically
important cells due to clogged arteries), and drug-induced or related
to other chemical imbalances in the blood.

   Atrial Fibrillation and Atrial Flutter--these arrhythmias result
from very rapid stimulation of the upper chambers, too fast for the
important lower chambers or ventricles to keep up with. Thus only
random or occasional beats get through in a random and irregular
pattern.  The pulse is irregular, with some weak and some strong
beats. Untreated, the rate can be rapid--up to 200 or more per
minute.  Symptoms depend on the rate (see above).  Treatment is
either mild electric shocks to restore normal rhythm, or medications
such as digitalis, verapamil, quinidine and others to slow the rate
down to safe levels.

   Ventricular Tachycardia-- beats originating in the lower chambers,
often but not always very rapid.  When the rate is slow, symptoms may
be mild; when rapid the severe symptoms and death may occur.
Especially worrisome is that this may lead to ventricular
fibrillation. Treatment is with electric shock and intravenous
lidocaine or procaineamide.  Procaineamide, propranolol, quinidine,
and phenytoin are sometimes used preventively long-term

   Ventricular Fibrillation-- this is the classic cause of cardiac
arrest and is fatal unless treated within seconds to minutes with
electric shocks, intravenous drugs and resuscitation.  It is
commonest shortly after heart attacks.  No effective heart
contractions can occur when this occurs.

   Premature Atrial Beats-- occasional extra beats of the upper
chambers, often quite benign and requiring no treatment, other than
avoidance of caffeine and other stimulants.

  Premature Ventricular Contractions-- arising in the lower chambers,
these may be benign and of no significance, especially if no other
heart problems are present.  On the other hand, in the presence of
coronary disease or other heart disorders, these may sometimes be a
warning of the more serious arrhythmias noted above.

  Paroxysmal Supraventricular Tachycardia (PSVT, or PAT)--some
otherwise normal young and occasionally older patients experience
"runaway" rapid heart beats similar to the normal rhythm
electrically, but very rapid, often to 180 to 200 beats per minute.
In a healthy heart this is usually well-tolerated, if frightening.  A
variety of maneuvers, each of which elicits a primitive "diving"
reflex, may terminate the spell, via stimulation of nerve impulses
which slow the heart.  These include bearing down while holding the
breath for several seconds, immersing the face in ice water and
applying pressure to certain areas of the neck. These are advisable
only after the diagnosis has been confirmed by a doctor, and found
safe to do. They can sometimes be quite effective.  When necessary,
and this is often not the case, drugs such as digoxin, verapamil, and
propranolol can prevent or reduce recurrences.

   All arrhythmias must be evaluated by a physician, and treatment
based on careful EKG, exam, and lab evaluation.  The area is complex,
and changing rapidly.  Not a disease for self-care or diagnosis,
cardiac arrhythmias should be thoroughly assessed by an internist,
cardiologist or other qualified physician.



 DISEASES OF THE HEART VALVES

      Mitral Prolapse

   Although widely recognized only within the last ten years, the
syndrome of mitral prolapse is now felt to be one of the commonest of
the heart valve abnormalities, affecting over ten percent of females
and a lesser but not negligible number of males as well.  In perhaps
half of these patients, there are absolutely no symptoms.
   The basic abnormality consists of a congenital or acquired
enlargement and alteration in the shape of one of the three leaflets
comprising the mitral valve of the heart. This valve separates the
left atrium (upper chamber) from the left ventricle (lower chamber).
As the ventricle contracts to send the blood into the aorta, the
leaflets normally shut, thereby preventing backflow into the atrium;
it is this shutting that is largely responsible for the first of the
two heart sounds.  If one of the leaflets does not quite "fit," the
closing is somewhat imperfect. Some blood from the ventricle can then
leak back into the atrium with each contraction. In addition, the
ill-fitting leaflet may flop back into the atrium like a parachute in
a breeze, and create a characteristic clicking sound through the
stethoscope.

   As a rule these events are of little significance, and cause no
symptoms.  In some cases, however, the disturbance in the normal
pattern cause palpitations (heightened awareness of heartbeats by the
patient), extra or irregular beats, and occasionally various unusual
chest pains, dizziness, and even fainting.  In the very rarest of
cases, the rhythm disturbance can be severe and even result in sudden
death; it is worth emphasizing that the later is extremely unusual
and most cases are mild and easily treated.

   One other important aspect of the syndrome is that the blood
currents are altered within the heart.  This can result in conditions
where germs that normally enter the blood stream and are rapidly
cleared by the body's defenses can find small areas to lodge within
the heart- -areas where the abnormal currents create "eddies" of
blood which do not clear the bacteria away in a normal fashion.  Such
conditions can result in serious heart infections after bacterial
contamination of the blood. Such contamination occurs regularly in
all people after such things as dental cleanings, gynecologic or
urologic surgery, childbirth, and other procedures.  It is thus
recommended that people with mitral prolapse take a few doses of
antibiotics prior to and immediately after such maneuvers; this is
felt to reduce the likelihood of heart infection.

   Diagnosis

   An astute physician can make the diagnosis simply by listening to
the heart in many cases--the classical "click- murmur" sounds are
unique.  In other cases, the findings are either very subtle
intermittent, or atypical.  Sometimes listening while the patient
arises from a crouching position, or squeezes the hands tightly
enhances or brings out the sounds.  Many patients have a typical
appearance--thin chest wall, long arms, or sunken breastbone, all of
which may heighten suspicion of the diagnosis. When there is doubt,
an echocardiogram (see "Tests and Procedures" section of HealthNet)
can often make the diagnosis.

   The cause of mitral prolapse is unknown.  Some cases are related
to other syndromes such as Marfan's Disease, but most probably
represent some inherited abnormality of tissue structure, or some
hypersensitivity of heart tissue to nervous system chemicals. There
is a frequent familial tendency, but isolated cases are common.

   Treatment and Prognosis

   Treatment is often not necessary, once counseling and reassurance
are offered.  The symptoms are usually more worrisome than truly
serious, and most patients accept this easily.  The important
exception is to take antibiotics prophylactically, as discussed
above.

   If any of the symptoms is so severe as to be disabling, or in the
rare case where the physician detects a worrisome rhythm disturbance,
medications of the "beta blocker" category are very effective and
well- tolerated.  Examples include metoprolol, nadolol, atenolol, and
others.

   It appears that survival and quality of life are rarely impaired
by this disease. Although case reports of sudden death at a higher
than usual frequency have been noted, most authorities consider this
to be rare.  The vast majority of patients can expect little or no
change in their lifestyle or longevity, except for the inconvenience
of antibiotics as described above.

    Rheumatic Heart Disease

   Rheumatic heart disease is generally understood to mean those
diseases effecting the heart valves which arise after a known or
suspected case of rheumatic fever, or those of unknown cause but
which are very typical of rheumatic type disease, and those
presumably of that cause.

   Rheumatic fever will not be discussed here in detail, but
generally is a syndrome of fever, joint inflammation, and neurologic
complications.  Its commonest cause is a preceding infection with
certain strains of strep bacteria, such as in strep throat.  Although
the acute syndrome may subside in weeks, it seems to initiate a
series of immune reactions in the body which attack the heart valves
along with the germs--a sort of "innocent bystander" phenomenon.  The
result is rheumatic valvular disease. Treatment of strep infections
in the early stage can prevent the vast majority of such cases, and
it is for this reason that culturing of sore throats is so important.
Fortunately the incidence of rheumatic fever seems to be declining
for unknown reasons.

    Types of Valve Disease

MITRAL STENOSIS

   This is the most common single valve disorder to follow rheumatic
fever, and about 65% of cases occur in females.  The valves become
thickened and stiff, and ultimately calcium deposits form on the
valve leaflets.  Since the function of the mitral valve is to direct
and control blood flow from the left atrium to the left ventricle,
eventually, this flow becomes markedly restricted.

   Ten or more years may elapse between the original case of
rheumatic fever and the development of symptoms from mitral stenosis,
although a physician may suspect the disease much earlier from its
characteristic, if sometimes subtle, murmur. Thus, young adults are
the typical patients.

   Symptoms

   Over a period of 4 to 8 years, the patient notes shortness of
breath as the heart is unable to drain the lungs adequately through
the narrowed mitral opening.  First noted only after exercise, this
later becomes evident even at rest. As pressure builds in the lungs,
blood vessels burst, and coughing of blood may occur. Finally all the
symptoms of congestive heart failure (see discussion elsewhere in
HealthNet) may ensue.

   During the process, the left atrium enlarges markedly, visible on
x-ray, and noted on exam.  Rhythm disturbances, notably atrial
fibrillation, occur.  Finally, shock may ensue, leading to death if
untreated.

      Diagnosis
   A combination of history, typical or worrisome murmur, signs of
heart enlargement and irregular rhythm are usually the first clues,
and echocardiography confirms the diagnosis.  Cardiac catheterization
is often done prior to treatment to better quantify the situation.

    Treatment

   In the early stages, avoidance of heavy exertion, and the use of
salt restriction are important; the latter avoids fluid accumulations
which may further strain the struggling heart. Diuretics such as
hydrochlorothiazide, furosemide, and others are added as needed.
Heart rhythm stabilizing drugs are useful in some cases, including
quinidine, propranolol, and others.  In some cases, blood clots form
on the rough and thickened valve, and break off, lodging in the
arteries of the body; anticoagulants such as warfarin are useful in
these cases.

   Surgical treatment of the diseased valve is indicated when the
symptoms become dangerous or severely impair the daily life of the
patient.  This may involve simple stretching of the narrowed orifice,
or total replacement of the valve with an artificial device.  In
major centers, such surgery has a mortality of under 2%.  Current
thinking suggests that the survival long-term is better if
replacement is done before the occurrence of severe symptoms. This is
a highly specialized area where the surgeon, cardiologist, and
patient must consider many variables.  Over two thirds of patients
operated upon are alive 10 years later, and the mean age is in the
50's at the time of surgery.  Thus there is a reasonably good
expectation for such patients who previously had almost no chance for
survival.

MITRAL REGURGITATION
   As opposed to mitral stenosis, regurgitation is more common in
males, and is often noted more rapidly after the rheumatic fever
episode.  In this disorder, the valve opening is unable to be closed
fully by the leaflets of the valve, and when the ventricle (lower
chamber) contracts, the blood flows right back into the atrium from
where it came, instead of into the aorta, where it belongs.  This is
a partial phenomenon, and symptoms are related to its severity.  The
ventricle must work overtime to compensate, and often hypertrophies
or enlarges to impressive proportions in the process.

    Symptoms

   Fatigue is often the earliest symptom, but later shortness of
breath occur.  Fluid accumulation, sometimes noted as ankle swelling
or edema may occur.  Arrhythmias such as atrial fibrillation (see
elsewhere in HealthNet) are sometimes noted. Finally, heart failure,
shock and death may occur.  It is noteable that many cases progress
very slowly and never require intensive treatment.  Survivals which
are normal or near normal are commonplace.

    Diagnosis

  First suspected by its murmur on exam, mitral regurgitation is
evaluated much like mitral stenosis, as described above.

    Treatment

   No treatment is necessary in many cases.  The careful addition of
appropriate drugs such as digoxin may be useful to control rhythm
irregularities. Although restraint is indicated, in some cases the
extent of symptoms warrants surgical valve replacement as discussed
above. This is best done when symptoms are severe, but not so severe
that the heart muscle is permanently damaged, as assessed by the
cardiologist.

AORTIC STENOSIS
   Only about one half of cases of aortic stenosis are related to
rheumatic heart disease, the remainder being due largely to a
congenital abnormality.  In this syndrome, the opening through which
the blood passes from the left ventricle to the aorta (and thereby to
the rest of the body) becomes markedly narrowed.  The ventricle
squeezes increasingly harder, but eventually can no longer meet the
challenge.

    Symptoms
  For many years the heart may compensate for the abnormality by
contracting more rapidly and vigorously.  After such a latent period,
symptoms may progress very rapidly, at which time surgical treatment
may sometimes be too late.  The primary symptoms are: a) angina, due
to inadequate blood flow through the coronary arteries arising from
the first part of the aorta (see elsewhere in HealthNet), b)
fainting, due to either blood pressure drop after exertion or
position change or to rhythm irregularities, and c) heart failure, as
described elsewhere, with shortness of breath, shock, and ultimate
death.

    Diagnosis
   Exam findings are combined with the history, echocardiogram,
electrocardiogram, x-ray, and finally cardiac catheterization in some
cases to confirm the diagnosis, similar to mitral disease as noted
above.

    Treatment
   Although medications such as diuretics or digoxin may be useful to
control some of the symptoms, this disease is best treated with
surgery.  The difficulty is to determine when to operate.

   Since many years may elapse before symptoms develop, immediate
surgery for some cases may be unwarranted.  On the other hand,
waiting too long may increase the surgical risk, since the heart is
less able to withstand the stress of the surgery.  Given all the
survival statistics, catheterization data, and development
progression of symptoms, most authorities advise relatively early
surgery in children and young adults, and a bit more patience in
adults when possible.  Five year survivals after surgery range from
60 to 95%, depending on the severity at the time of surgery. Without
surgery survival is poor once symptoms develop.

AORTIC REGURGITATION

   Aortic regurgitation occurs when the valve is damaged in such a
way that the opening cannot be closed completely by the valve
leaflets, thus allowing blood to wash back into the left ventricle
from where it came instead of the aorta where it should be going.  To
the extent that this is occurring, symptoms may be mild or severe.
Rheumatic fever causes most cases, but other diseases may be
causative as well (syphilis, ankylosing spondylitis).

    Symptoms

   Often ten or more years elapse after the acute rheumatic fever
episode, after which a period of compensation and relatively stable
symptoms occurs.  Then, shortness of breath, and later angina occur
similar to aortic stenosis, except for a more progressive and less
precipitous course. These are discussed elsewhere in HealthNet, under
heart failure and angina.  A period of ten or more years is common
between onset of symptoms and death, even if untreated.

    Treatment

   The same medications used for the other forms of valve disease
discussed above may also be used for patients with aortic
regurgitation, including digoxin, diuretics, rhythm stabilizing drugs
and nitroglycerine for angina. These can often defer the need for
surgery.

  Once symptoms of heart failure ensue, surgical valve replacement is
considered. Without this treatment, average survival is a matter of a
few years; with surgery prolonged survival is common.  As with other
valvular disease, it is important not to wait too long for the
operation, since irreversible damage to the heart musxle can
dramatically increase the dangers of surgery.

    General Comments

   All damaged heart valves are susceptible to infection with germs
that enter the blood stream; this occurs in all people normally, but
is generally not dangerous.  In cases of valve disease, it is
possible for the heart to become infected in a serious or even
life-threatening way.  A detailed discussion may be found under
"Endocarditis" in this section.  For this discussion, it is important
to recognize that special precautions are necessary to prevent this,
in the form of prophylactic antibiotics prior to dental and other
surgicial procedures, which routinely shower the blood with germs.

    Endocarditis

   Endocarditis refers to an infection of the inner layers of the
heart itself, usually predominantly around the heart valves.

   Normally, the smooth surface of the valves allows blood flow to
proceed swiftly, with little chance for any germs which happen to be
in the blood to lodge there.  If this smooth surface is disrupted by
disease or an artificial valve, the germs can occasionally lodge in
the rough areas, multiply, and cause infection.

   Every individual experiences the entry of germs into the blood
daily, during activities such as vigorous tooth brushing, minor
injuries, etc.  Certain other circumstances such as dental cleanings,
surgery in a non-sterile area such as the colon, urinary ract, or
genital areas also regularly admit bacteria into the blood.  In
normal individuals, the body's immune system quickly dispatches these
germs from the system.  As noted above, valvular disease presents
special problems.

   Other people at high risk for endocarditis include intravenous
drug abusers, mitral prolapse patients in some cases, and patients
with congenital heart disease. Immunosuppressed patients on
chemotherapy, transplant drugs, or with immune diseases may get
endocarditis with germs not usually associated with the infection.
Yet, in up to a third of patients, no underlying previous heart
disease is found.

    Symptoms

   In most cases where a preceding procedure is noted (which is the
exception rather than the rule), symptoms begin after a few weeks.
Fever, fatigue, weakness are common. Over time, the body starts to
react to the presence of chronic infection with many antibodies, some
of which can incidentally damage important organs such as the
kidneys.  The infection may throw off clumps of bacteria which lodge
in the brain, spinal cord, skin, lungs, or elsewhere, causing remote
infections.

   On occasion the infection can be fulminant, with sudden onset of
shaking chills, high fever, rapid destruction of the involved valve,
and shock and death.

    Diagnosis

   The diagnosis can be elusive due to the nonspecific nature of the
early symptoms.  Clues include knowledge of previous heart disease,
and subtle physical findings in the skin, back of the eye, and heart
(particularly a new or changing heart murmur).  A fever which lasts
more than a week or two without any other explanation is suspicious.

   Once suspected, cultures of at least two or three blood samples
usually are positive for the responsible germ. Confirmatory tests may
include echocardiography, further blood tests, and rarely,
catheterization.

    Treatment

   Antibiotics are the mainstay of treatment; due to the nature of
the infection, very high doses of potent agents must be given
intravenously for many weeks.  The exact choice is highly dependent
on the characteristics of the bacteria involved, and even more so
when the germ is more "esoteric," such as fungi, tuberculosis, and
others.  Very sophisticated laboratory evaluation and consultation
with an infectious disease consultant are commonplace.

   In many cases, the patient may be discharged with an intravenous
tubing apparatus inconspicuously in place in the collarbone area,
avoiding prolonged hospitalization.

   Prognosis is of course dependent on the previous health of the
patient.  Other factors are the particular germ involved, age, and
promptness of treatment.  Survival may range from 50% to 95%.
 There may be residual damage to the valve, even after cure.  The
severest cases may require surgery to remove the infected valve,
though this is a last-ditch measure in most cases.

    Prevention

   If a patient is known to have one of the many heart valve
conditions predisposing to the occurrence of endocarditis, they
should receive antibiotics shortly before and for a brief period
after procedures which could cause bacteria to enter the blood. The
conditions include any of the rheumatic heart diseases, congenital
valve diseases, mitral prolapse, artificial valves, and numerous
others.  The procedures include dental cleaning, oral or periodontal
surgery, child birth, urinary or gynecologic procedures, colon
procedures including barium x-rays and procto exams, and ear, nose,
or throat procedures, among others.

   Although the exact regimens recommended change frequently and vary
for many procedures, a typical dental prophylaxis may include
penicillin -- 2 grams orally one hour before and 1 gram 6 hours after
the procedure.  Patients should obviously consult their doctor each
time.  Though these recommendations are still of unproven benefit and
are certainly not totally successful, the potential benefits are
almost unanimously felt to outweigh there small risk.



  Congenital Heart Disease

   Babies are born with heart problems in about one out of every
hundred births.  Some die in infancy, whereas others may live with
varying degrees of symptoms;  by school age almost all congenital
heart problems have been discovered either by the pediatrician or by
the presence of symptoms.  This discussion will deal priarily with
those congenital heart problems most often encountered in older
children and adults; the infant problems represent a highly
specialized area usually dealt with in large pediatric referral
centers.  More may be learned about these in the HouseCalls section
of HealthNet, as desired.

    Murmurs

   A few words about heart murmurs are important to understand the
evaluation of congenital heart problems. Specific diseases causing
murmurs are discussed elsewhere, but certain general points pertain
to most.

   A murmur is an extra noise heard by the examiner through the
stethoscope.  It is generally a "whooshing" sound occurring after the
first or second heart beat.  Judging by the timing, quality,
intensity, and variability of a murmur, together with other aspects
of a patient's evaluation, an experienced doctor can usually
distinguish between those representing some sort of heart disease,
and those which are "innocent" or "functional."

   Functional or innocent murmurs are those which are present in a
minority of patients with no heart abnormalities; they are probably
caused by variations in the shape of the heart, or by exaggerated
blood flow through some areas of the heart which are otherwise
normal.  Obviously they carry no clinical significance and require no
therapy.  Most often noted in children, they are also common during
pregnancy, anxiety, and in people with thin chest walls. The murmurs
themselves may be intermittent and variable.

   In a minority of cases it is difficult to distinguish between
functional murmurs and those of certain heart diseases.
Echocardiography, using painless sound wave imaging, can usually
clarify the cause quickly.  Thus if you are told you have an innocent
murmur, it is no more alarming than being told you are
left-handed--it is not usual, but not a problem.

COMMON DISORDERS

    Atrial Septal Defect

   This relatively common condition is caused by an opening between
the two upper chambers of the heart, allowing some of the oxygenated
blood from the left heart to leak back into the right atrium.  When
severe, this can so overburden the heart and lungs that respiratory
failure occurs, referred to as "pulmonary hypertension."  Congestive
heart failure is the other major complication.

   Although the murmur can sound "functional," (see above) almost all
patients have an abnormal EKG and/or chest x-ray.

   Surgical correction is indicated when studies reveal significant
left to right blood leakage.  It is now a very effective and safe
procedure; in the advanced stages, mortality is considerably higher.

  Ventricular Septal Defect

   Though common in infants, this problem is far less often seen in
adults.  It represents a hole between the right and left lower
chambers of the heart, and does not require any treatment in most
adult cases, since it is usually very small, or grows closed
spontaneously.  The one possible exception is surgery to prevent
infection of the defect, which is controversial.  At the very least,
these patients require antibiotics before undergoing certain surgical
and dental procedures where germs may enter the blood stream, so that
the risk of infection is minimized

    Bicuspid Aortic Valve

   A common abnormality (about 2% of the population) is where the
normal three cusps of the aortic valve, between the left ventricle
and the aorta, are fused into two cusps.  It occurs almost
exclusively in males.  In the vast majority, this causes no
abnormality in function, and no symptoms.

   The primary importance is that such an arrangement can cause a
somewhat atypical murmur on examination, requiring further evaluation
to rule out more serious conditions.

   In a minority of patients with bicuspid aortic valves, adverse
complications may arise: the valve may become progressively thickened
and scarred resulting in conditions similar to rheumatic valvular
disease (see elsewhere in HealthNet), or it may become infected (see
"Endocarditis").

   In summary, congenital defects which escape treatment in the early
years of life are uncommon but important to recognize. Their
differentiation from so-called innocent or functional heart murmurs
requires a careful but not necessarily extensive evaluation by a
physician.



ARTERIAL DISEASE
   Arteriosclerosis (Hardening of the arteries)
   Aneurysms
   Raynaud's Disease (spasm)

    Arteriosclerosis

  Although the term arteriosclerosis has taken on broader meanings in
lay usage, its use in a medical sense maintains a stricter
definition. The full term is arteriosclerosis obliterans.  In
essence, this refers to the formation of plaques of cholesterol,
platelets, fibrin, and other substances within the arteries, leading
ultimately to progressive degrees of blockage of the involved part of
the body.

   The cause of these plaques is very complex, and much remains to be
learned.  Given hereditary susceptibility (heralded by a strong
family history of similar disease), factors seeming to accelerate the
process include diabetes, smoking, high cholesterol levels, and high
blood pressure.  Their occurrence in the arteries supplying the heart
is discussed under "coronary disease."

    Symptoms

   Anatomy determines symptoms; the most common site is the arteries
of the legs, either high in their course in the pelvis, or further
down in the calf.  Once blockage becomes severe, exertion of the
muscles supplied by the artery causes pain due to insufficient blood;
called intermittent claudication, this is an aching pain in the calf
or elsewhere, relieved by rest, worsened by resuming activity.  If
pain is present even at rest, the circulation is in great jeopardy,
with loss of limb possible.

   In the advanced stages, the limb becomes cold, pale, discolored,
and forms skin sores from gangrene to the area involved.  Infection
may set in, and ultimately the leg must be amputated to save the life
of the patient.

   It is unusual for other areas to be involved without the legs
being involved.  On the other hand, those with leg artery disease
have a high incidence of coronary disease, strokes, and kidney artery
blockage, reflecting the underlying processes.

    Diagnosis

   In addition to the above symptoms, the physician may notice absent
pulses, poor skin filling from capillaries which are compressed, and
other typical signs.  So-called noninvasive ultrasound tests may
further confirm the diagnosis, but arteriography is the most reliable
test.  Through a needle inserted in the larger arteries of the
affected area, a dye is injected and traced with x-rays.

    Treatment

   If symptoms in the legs are not impairing daily lifestyle,
progressive exercise and conservative observation is all that may be
needed.  Risk factors should be corrected when possible, of course.

   As symptoms progress, surgery may be considered.  Bypass grafts
made of synthetic material is inserted in place of the blocked
segments; alternatively, the area involved may be "reamed out"
surgically. Unfortunately, if the blockage is in many smaller vessels
instead of one or a few large vessels, this approach cannot be used.
If a single severe blockage is present, a procedure called "balloon
dilatation" may be used--a tube is inserted into the artery under
x-ray guidance, and at the area of obstruction a tiny balloon is
inflated, compressing the clot and relieving the obstruction.  This
is a much less traumatic event for the patient, when appropriate.

    Prognosis

   It is rare for peripheral artery disease to be fatal, and many
patients reach a stable or even improving stage, with time. The one
exception is the diabetic, whose disease often progresses rapidly.
Unfortunately, many patients succumb to coronary disease-- heart
attacks--another manifestation of the underlying process of
arteriosclerosis.

    Aortic Aneurysm

   An aneurysm is an area of an artery where the wall has weakened,
and thus dilates like the inner tube of a tire poking through the
sidewall.  In most cases, high blood pressure is the major cause, and
the aorta is the most frequent site. Injuries to the aorta may also
cause a weakened area and aneurysm, as can such diseases as syphilis
and various inflammatory blood vessel diseases.

   In the case of the aorta, most aneurysms occur in that section
which passes through the abdomen.  Older men are the primary victims,
and the disease is most often detected on physical exam as a mass
which pulsates with each heartbeat. Confirmation is usually through
an ultrasound study using painless sound waves.

   The aneurysm may also occur in the chest portion of the aorta, in
which case it may interfere with the outflow of blood from the heart.
 Fatal complications are not rare.

    Symptoms

   As the aneurysm enlarges it may cause pain by pressing on
surrounding structures, or it may remain asymptomatic.  At some
point, the wall may become so thin that it ruptures, resulting in
massive bleeding and death.  Occasionally, the aneurysm may interfere
with the normal blood flow such that symptoms of circulatory failure
are noted--calf pain with exercise, abdominal pain after eating, etc.

   It is not common for abdominal aneurysms under five centimeters
across to rupture, but they may enlarge over time, and require
treatment. Therefore careful observation is necessary.

   In the chest, pressure around the heart may cause congestive heart
failure or even sudden death.

    Dissection

   One of the serious complications of aneurysms is dissection. This
refers to the blood finding its way between the various layers of the
aortic wall, and spreading down the aorta, blocking side branches and
enlarging along the way. Depending on where and how extensive the
dissection is, this may be fatal or very serious, and is virtually
always a medical emergency. Symptoms range from sudden onset of
suffocating breathing symptoms, searing abdominal pain, back pain, or
sudden collapse.  The exam reveals loss of pulses, heart murmurs, and
abnormal x- ray studies.

    Treatment

   Asymptomatic abdominal aortic aneurysms may be treated by an
operation in which the abnormal area is removed and replaced with an
artificial artery.  In healthy patients with experienced surgeons,
this carries a mortality of 2-5%. Emergency treatment carries a
mortality of 25-50%, so early surgery is desirable. Most authorities
advise waiting until the aneurysm is larger than five centimeters, or
is causing symptoms.

   Thoracic (chest) aneurysms are more complex and difficult to
repair surgically; treatment is largely an individualized decision
dependent on age, health, cause, and preference.

   Dissections are generally treated medically to begin with, then
surgically for definitive repair.  Medical treatment consists of
drugs which lower the blood pressure and the force of the heart's
contractions, and is carried out with sophisticated monitoring in the
intensive care unit.

    Prevention

   The most important, and one of the only, means of prevention is
control of high blood pressure early in its course. Cigarette smoking
is contributory in some cases. Finally, detection of aneurysms early
through regular checkups can allow repair at an early stage, thereby
lowering mortality from this disease.

    Raynaud's Phenomenon

   Raynaud's phenomenon is a disease of the arteries of the fingers,
in which upon exposure to cold or, less commonly, strong emotional
stimuli, sudden spasm of the vessels occur.  The result is temporary
partial loss of the circulation, characterized by three stages:

   1) White--blanching of the skin color as the amount of blood in
the fingers decreases.

   2) Blue--as the blood remaining in the fingers loses its last bit
of oxygen to the tissues, turning blue from the color of the
deoxygenated hemoglobin.

   3) Red--during recovery as with rewarming; the circulation
temporarily is increased above normal to compensate for the recent
shortage of blood and its nutrients.

   Often occurring in young adults, particularly women, the disease
is called Raynaud's Disease (as opposed to "phenomenon") when there
is no other causative factor found. It is of unknown cause, and is
closely related to imbalances in the nerve-secreted chemicals which
regulate the tone of the arteries.  Injuries, immunologic diseases,
certain drug overdoses, and other factors can also cause the
occurrence of the same symptoms.  In these cases, the term
"phenomenon" is used.

   In the vast majority of cases, the symptoms are readily reversed
with warming, and no permanent damage is done. Though it can be quite
uncomfortable, it is rarely dangerous.  However, some patients have a
more severe form in which the acute and/or cumulative effects can
result in scarring, and even ultimate loss of finger tips.

    Diagnosis

   The history and physical findings are characteristic. The primary
task is to rule out associated diseases, either by selective testing
or by careful observation over time. Scleroderma is one such disease,
which is discussed elsewhere in HealthNet.

    Treatment

   If the conditions of cold can be avoided with protective clothing
or other measures, no treatment is required.  Where this is either
not feasible or not effective, or in cases which fail to reverse
rapidly after rewarming, certain drugs may be quite useful.

   Prazosin and hydralazine are two vasodilator (vessel dilating)
drugs which are used mostly in high blood pressure treatment but are
also useful for Raynaud's Disease.  More recently, the calcium
blocking drugs such as nifedipine, verapamil, and diltiazem are being
studied for this problem, and hold promise. In general, treatment can
be confined to either the appropriate seasons, or the period prior to
unavoidable environmental exposure.  Severe cases may require
continuous treatment.

    Prognosis

   The disease is usually stable or even improves for many years, and
fewer than one half of one percent of patients ever require surgical
amputation of the tip of the finger; for most, then, it is an
inconvenience only.



ntroduction--Digestive Diseases

   The digestive organs comprise a complicated and varied group,
whose functions are highly specialized, yet intricately connected in
a physiologic sense.  The most obvious function of converting
ingested nutrients into a usable form, delivering them to the blood
stream, and filtering out impurities is well known; yet the other
aspects of these organs include hormone secretion, responses to
stress, and regulation of delicate metabolic balances.

   Diseases of these organs are likewise diverse.  Some are linked to
a civilized lifestyle, its diet and stresses.  Others are probably
due to familial factors, and many are of unknown cause.  As you
explore the sections in this category, bear in mind the burden this
system must face, and realize how amazing it is that it performs so
well most of the time.

   Symptoms of these organs which are of a generalized or vague
nature may be found in the symptoms section of HealthNet; since many
diseases manifest with similar symptoms in this area, you will see
them repeated under various organ systems. This serves to underline
the diagnostic dilemma faced by the physician when evaluating
patients with digestive diseases.

   If you cannot find what you are looking for, check related organ
systems.  If you still wish more information, you are welcomed to
access the Housecalls section.  We welcome your feedback, and hope
you find this enlightening and educational.



          Appendicitis

      The appendix is the remnant of a primitive extension of the
digestive system, and occurs as a small, worm-like pouch arising from
the first part of the colon, just after it begins to attach to the
small intestine.  It has no important function in human digestion.

   When the opening of the appendix becomes obstructed with a
particle of undigestible food, a small calcium-containing stone, or
other matter, the chemicals and bacteria within it begin to interact,
and swelling and pressure build up.  The pressure eventually
compresses the draining veins, and the process accelerates.  The
stretched walls are then invaded by the bacteria, pus is produced
from the white cells rushed to the areaby the body, and ultimately
the appendix may burst.  If this happens, contamination of the
usually sterile abdominal cavity and its surrounding sac, the
peritoneum, occur.  This so-called "acute abdomen" may rapidly be
fatal, as blood poisoning and shock develop.

   Most victims are between the ages of 5 and 35.  Males and females
are both affected.  No definite causative factors are known; although
grape seeds, popcorn and other similar particles are sometimes found
to in the appendiceal opening, there is no good evidence linking
these statistically with the disease.

    Symptoms

   Classically, but by no means consistently, there is a relatively
abrupt onset of pain in the upper abdomen or navel area, which later
radiates to the right lower abdomen.  Nausea or vomiting often will
follow. Low grade fever is noted in many patients, rising markedly if
perforation occurs.  As the disease and symptoms progress in
frequency, perforation becomes a concern, and urgency of treatment is
obvious.

   The physician may also look for elevated white blood cell counts,
abdominal tenderness, rigidity, and characteristic sounds (or lack of
sounds) in the abdomen.  In the classical case, the diagnosis is
rarely missed.

   Unfortunately, many cases are not typical.  The pain may not occur
in the right lower abdomen, or may occur there as well as other areas
such as the upper abdomen or back. Differential considerations may
include diseases of the colon, gall bladder, ovary, pancreas, small
intestine, kidney, or other organs.  It is generally recognized that
even the most wise, conscientious, and concerned physician will
occasionally miss or misdiagnose appendicitis.  In fact, most
surgeons would agree that the occasional removal of a normal appendix
in sincere efforts to remove the diseased ones at an appropriate time
is an unfortunate but acceptable price to pay for careful medical
practice.  The price of NOT removing a truly infected appendix is far
greater.

    Treatment

  Appendectomy--the removal of the appendix-- is the treatment of
choice unless there is some strong medical reason to the contrary.
It is interesting that in other countries, treatment is often more
conservative, with antibiotics, intravenous fluids, and other
measures.  This leaves the potential for recurrences, and is only
recommended for rare exceptions in current American practice.

   If perforation has not yet occurred, some 15% of patients may
develop some postoperative complication, but these are generally
easily managed.  On the other hand, if perforation has occurred, up
to 50 or 60% of patients have complications. Mortality of
appropriately treated appendicitis today is extremely low, and
usually occurs in elderly or debilitated patients.  The main goal of
the patient is to seek care early.

   It is important to realize that many doctors will take an
observational approach early in the disease; this is wise under some
circumstance to avoid unnecessary surgery, since many apparent cases
will turn out to be some other self-limited disease such as
infection, ovarian pain, etc.  Careful judgment is called for, and
intimate communication between doctor and patient (sometimes
entailing hospitalization) is crucial.

   Preventive appendectomy is not generally necessary (General
Eisenhower is said to have done this before going to the front),
unless an unrelated surgery is necessary and the appendix is removed
incidental to this.  No long-term complications of uncomplicated
appendectomy are recognized.

         Diverticulitis

   Although once felt to be similar to left-sided "appendicitis," in
fact diverticulitis is probably quite distinct in its nature and
cause.  A diverticulum is generally an acquired outpouching of the
colon, although there are occasional congenital varieties, and some
can occur elsewhere in the digestive tract.  The predisposing
abnormality is diverticulosis, the occurrence of the puches with no
apparent disease.  This condition is found in over half of all people
over age 60, although very few (1%) of these develop diverticulitis.

   It is generally believed that the far reaches of the colon near
the rectum (the sigmoid colon) are exposed repeatedly to the very
high pressures of contraction in some individuals. Since the stool in
the area must be propelled forward for final removal through a bowel
movement, when the fecal matter is hard or compacted, the
contractions become increasingly forceful. Ultimately, like the inner
tube of an old tire, the weaker areas of the colon wall bulge as
described, sometimes forming hundreds of diverticula.

   The factors responsible are believed by many to be dietary. High
fiber foods generally retain water as they; move through the colon,
leaving the stool soft and easy to expel. With no fiber the bolus is
hard and inflexible.  Poor fluid intake may play the same role.
Chronic laxatives may cause forceful contractions as well.

   Diverticulitis is caused when factors weaken the wall of the
diverticulum so much that the wall microscopically perforates into
the surrounding abdominal cavity.  From there on, a process similar
to appendicitis may occur.

    Symptoms

   Pain in the left lower abdominal area, often with fever, is
typical.  The patient is usually older than 50 years. A tender mass
in the abdomen may be felt by the physician, sometimes representing
an abscess near the site of perforation.  Sometimes, the diverticulum
may wear its way into the bladder, causing urinary symptoms.

   Differential considerations include those discussed under
appendicitis, but in addition one must consider cancer of the colon,
and other diseases common to the older population seen with this
disease.  Certain blood test results, judicious plain and barium
x-rays, and careful judgment are most important.

    Treatment

   Unlike appendicitis, diverticulitis only occasionally requires
surgical treatment. Generally, the digestive system is placed at
total rest with elimination of oral intake, stomach suction and
replacement of fluids by vein.  Antibiotics are given to counter the
abdominal infection.

   If there is no improvement in 24 to 48 hours (there usually is),
or if things worsen despite treatment, surgery may be necessary, with
removal of large portions of the colon sometimes necessary..
Recurrences may also warrant surgery.  It is essential that a
coexistent tumor be ruled out at some point, usually with x-rays and
a proctosigmoidoscopy.

   Almost all deaths occur in older patients, under conditions of
emergency surgery.  Thus, when possible, many surgeons prefer to wait
until the patient has stabilized before operating, when this is
possible.



          Pancreatitis

   The pancreas is a glandular organ which sits deep in the abdomen,
lying behind the stomach.  In health, its functions fall into two
major categories: digestive, and endocrine.  The latter consists
primarily of secreting insulin, glucagon and other hormones important
to the blood sugar balance.  This is further discussed under
diabetes.  The digestive functions concern the production of enzymes
such as amylase important to the chemical digestion of fats and other
nutrients.

   When the pancreas becomes inflamed, its own enzymes are released
into the blood, as well as within the organ itself; though the highly
active enzymes are usually contained in protected ductal areas, in
the inflamed pancreas they may actually start to attack the organ
itself.

    Symptoms

   Almost all victims of acute pancreatitis suffer very severe mid-
and upper abdominal pain, frequently radiating straight through to
the back.  Vomiting is common, and often early signs of shock are
seen.  Large amounts of fluid may pour into the abdominal cavity
which, when combined with the vomiting and poor intake, leave the
circulation with inadequate volumes to maintain a normal blood
pressure.  Ultimately, shock and death may occur. The intensely
tender abdomen may mimic that seen in many other conditions, and
requires careful differentiation from surgically treatable diseases;
surgery in the presence of pancreatitis is very dangerous.

    Diagnosis

   In the face of the symptoms mentioned above, the physician may ask
for additional history based on the causative factors listed below.
Laboratory tests often show characteristic abnormalities, including
elevated levels of amylase and white blood cells. Analyses of blood,
urine, and the exam findings, with a consistent history are usually
adequate for diagnosis. Determining whether the patient has simple
pancreatitis or has an associated disease often requires further
studies specific to the disease being sought.

    Causes

   The vast majority of patients with recurrent pancreatitis, as well
as many of those with even an isolated episode, are serious alcohol
abusers.  Alcohol has a direct toxic effect on the pancreas, among
other organs. In one study, the average intake of pure alcohol
equivalent was over five ounces daily, with many consuming much
higher amounts.  As these patients are often plagued with other
complications of alcoholism, the outcome may be very serious.

   In the non-alcohol-abusing population with pancreatitis, the
commonest cause is the presence of a large gall stone blocking the
duct draining the pancreas of its enzyme juices. These then back up
into the pancreas, causing the same symptoms discussed above. Tumors
of the liver, pancreas, or gallbladder may cause similar blockage.

   Occasionally an ulcer on the rear wall of the stomach may
penetrate through the wall and allow stomach acid to enter the
neighboring pancreas, setting off the inflammatory process mentioned
above.  Yet another cause is the presence of very high levels of
triglycerides (a form of blood fat) due to familial abnormalities;
the exact connection between the two diseases is not entirely
understood, but the association is quite striking.

   Finally, many drugs can cause pancreatitis as a side effect. It is
unusual for any given drug to do this, but because so many do, drugs
must be considered an important cause.  These include thiazide
diuretics, estrogens, tetracycline, and certain cancer drugs.

    Treatment

   Given the sequence of events mentioned above, it is not surprising
that treatment is aimed at replacing large amounts of body fluid by
vein.  The pancreas and digestive system in general should be "shut
down" to minimize enzyme production through the use of a stomach tube
and/or regular antacids to neutralize acid production. Large doses of
injected narcotic pain relievers may be necessary. After days or
weeks, things have usually calmed down enough to resume a normal
diet, and full recovery is common.

   Complicating diseases may be treated either urgently (gall stone
or tumor) or later (alcoholism).

    Complications

   In a minority of patients, infection may set in from bacteria in
the intestinal tract, requiring massive antibiotic treatment, which
is not always successful.  Still others develop severe bleeding from
the raw and inflamed pancreas, or develop a highly aggressive
pus-forming pancreatic involvement.  With these complications, up to
90% of patients may die.

    Long Term Effects

   In recurrent or prolonged pancreatitis the cumulative damage to
the pancreatic tissue can result in loss of pancreatic function.
Malabsorption of fats and some vitamins may occur, and be serious or
even fatal.  Oral pancreatic supplements can be helpful.  See the
discussion on malabsorption for further details.

   If the damage includes the insulin producing cells, diabetes may
result.

    Prognosis

   If the acute disease is not complicated as noted above, the
mortality is about one in twenty;  broader prognosis depends on the
underlying situation.  Alcoholics generally do poorly with
recurrences, complications, and decreased survival.  Tumors in this
area are generally very serious, and have a poor prognosis. Gall
stones offer a totally curable situation, with removal of the stone
and gallbladder being a routine procedure.

   In summary, pancreatitis is a very painful and serious disease,
sometimes presenting major diagnostic problems.  It can be a very
serious disease, and is commonly associated with alcohol abuse, gall
stones, and certain drugs.  The final prognosis in most cases is
dependent on the cause.

    Gall Bladder Disease

   The overwhelming majority of gallbladder problems are related to
the formation of "stones." An understanding of the basics of
gallbladder function is essential to discussion of these diseases.

   The gallbladder sits just off the tube leading from the bile ducts
of the liver to the small intestine (duodenum, more specifically).
Its function is not essential, and perhaps was more useful to us in
primitive times when digestive needs were different.  In essence, the
gallbladder traps the bile from the liver, storing and concentrating
it in anticipation of a food load.  During meals, the gallbladder
contracts, releasing the contents into the duct and the digestive
system. This may function as a "boost" to the usual digestive
enzymes. Certain foods, notably fats, provide more of a stimulation
to the gallbladder than others.

   When the bile from the liver has a very high saturation of
cholesterol due to some metabolic abnormality, the action of certain
estrogen hormones or some other reason, or unknown factors, the
saturation is further increased as the bile gets concentrated in the
gallbladder.  When the solution can no longer hold the dissolved
cholesterol, it begins to crystallize, much the way rock candy does
in sugar water.  The result is a cholesterol gallstone, the most
common kind.  Although bile and its other products can sometimes form
stones as well, this is usually only in the presence of some excess
in the amount of bile presented to the gallbladder, or some abnormal
concentration of one of its ingredients (for example, excess
bilirubin released by dying blood cells in certain types of anemia).

   Once formed, gallstones can take a widely variable pattern. They
may be big, small, or even remain as a "sludge-like" substance in the
gallbladder. They may remain unnoticed for life, or cause disease as
discussed below.  The term cholelithiasis refers to the presence of
stones in the gallbladder; cholecystitis refers to inflammation of
infection of the gallbladder, related 95% of the time to
cholelithiasis.

    Symptoms

   Contemporary opinion based on recent data suggests that most
patients without symptoms (who have gallstones diagnosed incidental
to some other test, for example) will not develop problems.  Some
exceptions are noted, including diabetics. Whether such patients
should be advised to undergo preventive removal of the gallbladder is
not known, but opinion may be shifting away from the routine
performance of such surgery.

   When symptoms do occur, they range from intermittent right upper
abdominal pain after meals, especially fatty foods, lasting up to an
hour, to acute excruciating pain, unremitting, with fever, vomiting,
and severe prostration.  The former probably represents reversible
temporary blockage of the gallbladder's opening by a stone, whereas
the latter ("acute cholecystitis") represents a stone impacted in the
opening.  As with all syndromes, many variations and atypical
presentations are seen.

   Additional symptoms may include pale stools due to loss of pigment
from the bile, and dark urine, since this blocked pigment is
reabsorbed by the blood and secreted in the urine. Jaundice is
yellowing of the skin which may occur from this same pigment in the
blood becoming visible in the skin or the whites of the eyes.

    Who Gets Them

   Women get stones three times more frequently than men, possibly
because of a contributory role of estrogens; the childbearing years
are therefore the highest risk period. Obesity increases estrogen
levels, and is also a risk for gallstones.  Certain American Indian
and Inuit groups are afflicted in as many as 70% of the females.

    Diagnosis

   The symptoms of gallstones may be caused by other disease
including hepatitis, pancreatitis, tumors and more. Thus,
confirmatory tests are necessary.  They may include blood tests for
specific chemicals from the liver and pancreas.  Ultrasound tests of
the area will detect 90% or more of the stones; this involves aiming
a microphone-like device against the skin near the involved area.
Nuclear studies using intravenous agents which are slightly
radioactive are becoming increasingly useful. The older gallbladder
x-ray taken after the ingestion of an oral "dye" is still useful the
patient is not acutely ill, and time is not of the essence.

    Treatment

   Acute gallbladder attacks are treated with intravenous fluids and
pain relievers, and sometimes with antibiotics if an infectious
component is suspected because of fever or high white cell count.
Once the episode has subsided, removal of the gallbladder is
indicated in almost all cases, since recurrences are common.  Acute
cases which do not respond to conservative treatment may require
emergency surgery, the risk of which may be considerably higher than
that done electively.

   In the chronic case, surgery is curative and quite safe if done
electively.  Unfortunately, some patients with stones have had
suspicious pain for years; with gallbladder removal the pain may
persist, suggesting that it was due to some other problem, such as
irritable bowel syndrome, all along.

   The occurrence of asymptomatic gallstones was mentioned above.
 Probably only one in five will develop symptoms over a 15 year
period, and very few if any will develop serious complications. These
factors must be born in mind in decisions over whether to operate.

MEDICAL TREATMENT

   Recent years have seen the development of a drug called
chenodeoxycholic acid, which was said to dissolve up to three
quarters of gallstones when given to appropriate patients orally.
 Unfortunately, despite great initial interest, the drug was noted to
raise cholesterol levels, and follow-up studies of higher quality
revealed that in fact only 14% of patients had total dissolution of
their stones, even after 2 years, and stones tended to recur after
the pills were stopped.  Quite a few patients developed diarrhea from
the medication.

   Thus, except for a few special cases such as an elderly person
with high risks for elective surgery, the medication is rarely
indicated.  The routine elective removal of the gallbladder is a
curative treatment, and for most patients with symptomatic gallstones
remains the treatment of choice.



Esophagitis, Peptic Ulcers, Gastritis

          Esophagitis
          (Heartburn)

   The apparent function of the esophagus seems simple:  convey the
food from the mouth to the stomach.  Yet there are other aspects to
consider.  For example, the stomach contents are highly acid at
times; whereas the stomach lining is protective against this acid,
this is not the case with the esophagus. Thus, there must be some way
to let the food pass while stopping the acid from splashing back into
the esophagus.

   In health, this is accomplished with a ring of muscle surrounding
the junction of the two organs, commonly known as the lower
sphincter. As food passes, it "relaxes" to admit the food to the
stomach. Once this has occurred, it promptly shuts again.
Unfortunately, in some cases the sphincter is incompetent.  This may
be related to totally unknown factors, but certain factors are known
to contribute to this.  The commonest are nicotine, caffeine,
alcohol, aspirin, and stress, among others.  If the mechanical
factors of overeating, tight clothing, and assuming the lying -down
position are added, it is clear why acid will be able to enter the
esophagus in certain individuals.

   Conditions related to this phenomenon include simple heartburn and
esophagitis.  They represent different places on a spectrum of acid
irritation of the lining of the esophagus.

    Symptoms

   A burning sensation anywhere from the middle of the abdomen
extending upward under the breastbone, all the way to the throat is
typical; all or any part of the above areas may be involved.
Sometimes the pain may extend to the back, left arm, or jaw.
Differentiation from the pain of heart disease can be impossible in
some cases.

  Occasionally, there may be regurgitation of sour liquid in the back
of the throat.

   Typically certain factors bring on the pain--large meals, the
factors discussed above, and emotional stress.  If exertion plays a
role it is usually inconsistent.  In simple heartburn, the symptoms
are infrequent, moderate, and readily relieved by simple antacids, or
even by food or water.  This is not necessarily a disease state.
When symptoms become severe, frequent, or are associated with
interference in daily activities, or when regular antacids are
required for relief, further investigation may be indicated. True
esophagitis occurs when the lining of the esophagus becomes red and
inflamed.

    Diagnosis

   The symptoms noted above are highly suggestive of the diagnosis,
but do not necessarily distinguish esophagitis from ulcers,
gastritis, and heart disease, or several other diagnoses.
 How much diagnostic evaluation is necessary is judgmental; the
patient's age, life habits, risk factors for other diseases, and
other factors must be considered.  For example, a young patient with
classical symptoms, no cardiac risk factors, and a normal history and
physical may only require a diagnostic trial of treatment. Others may
require further tests.

    Upper gastrointestinal x- rays (upper g.i.) will rule out most
ulcers, and is commonly done.  Only through endoscopy (a viewing
instrument passed down the throat) can the actual red, irritated
lining of the esophagus be seen.  Fortunately, this is often not
necessary once other diseases are ruled out. To this extent,
esophagitis is a diagnosis of exclusion.

    Treatment

   Avoidance of precipitating factors is of paramount importance,
particularly nicotine, caffeine, and drugs. Patients should stop all
food intake at least three hours prior to retiring.

   The first line of therapy is the use of antacids.  Large doses are
taken after meals, at bedtime, and for pain in between.  This should
be followed on a regular basis, even without symptoms, for four to
six weeks so that the esophagus can heal.  Elevating the head of the
bed six inches is helpful in avoiding nighttime "splashback" of acid.

   When this regimen is inadequate, additional medications such as
cimetidine or ranitidine may be useful. Drugs which cause
constriction of the sphincter are occasionally used, including
bethanechol.  The most refractory of cases may require surgical
procedures which act to prevent sphincter incompetence, but need for
this is uncommon.

    Complications

   After long exposure to acid reflux, the esophagus may form a scar
which narrows its diameter, forming a stricture which blocks the
passage of food.  Swallowing difficulty may ensue, and dilating
procedures become necessary.  Severe esophagitis may cause bleeding
from the surface of the mucous lining, which can at times be life-
threatening.

   A very common disease, esophagitis can usually be quickly
diagnosed, promptly and safely treated, and largely prevented or
reduced by a combination of the above actions.  Because of its
similarity to other diseases which can be more serious, the diagnosis
requires a physician evaluation.

    Peptic Ulcers

   Part of the normal digestive function of the stomach is to secrete
hydrochloric acid and an enzyme called pepsin, both of which are
essential to the preliminary digestive process. The stomach lining
itself is really no different from many foods, and would be subject
to self-digestion, were it not for a coating of mucus which protects
the wall from the actions of these chemicals.

   A number of factors regulate how much acid the stomach puts
out--the presence or even the sight of food, histamine, anger, and
certain hormones are examples. Caffeine and nicotine are additional
factors.  Aspirin and other drugs can reduce the protective mucus
barrier mentioned above.  Alcohol, though possibly predisposing to
gastritis, probably does not cause ulcers in most people (it may
retard healing of an existing ulcer).

   When any combination of factors overwhelms the protective factors,
the acids and pepsin eat away at the stomach lining, causing a crater
-like sore which can be very painful, and become very swollen and
tender.  If it penetrates through a nearby artery, profuse bleeding
may occur; if it penetrates the wall entirely, the entire contents of
the abdominal cavity may become involved with infection, acid burning
and "peritonitis"-- inflammation of the lining tissue of the
abdominal cavity. Penetration into the pancreas causes pancreatitis,
discussed elsewhere.  These can be very serious or even fatal, and
any of the complications can occur with none of the typical warning
symptoms noted below

   Most ulcers occur in the duodenum, where the stomach enters the
small intestine; this is where the acid seems to affect the mucosa
most intensively.  Ulcers higher in the stomach itself are less
common, and require more careful evaluation for underlying related
disease, including stomach cancer which can ulcerate.

   Gastritis is a similar disease in which the same types of factors
cause symptoms almost identical to ulcers, including the potential
for bleeding. However, no actual ulcer is seen on exam, but rather
the lining appears red friable, and inflamed.  It may be considered a
pre-ulcer state in some ways.

   The prevalence of ulcers has decreased in recent decades, from a
high of about 10% of the population being affected at some time in
their life in the 1940's.  It is most common in the middle years,
though children are not immune.  Males are affected twice as often as
females, and there is a definite, if inconsistent, familial tendency.

    Symptoms

   The classical symptom complex of an ulcer consists of a burning,
intense pain in the mid - upper abdomen, awakening the patient in the
early morning, often with a sensation of abnormal hunger 1 or 2 hours
after meals.  Lasting about half an hour, the pain is relieved by
most foods, but coffee and juices may worsen it.  It may occur
several times daily. Without complications, some variation of this
complex is usually present; with complications, additional symptoms
may occur (see below).

    Diagnosis

   The history is the most important clue to the diagnosis. There may
be tenderness on examination of the abdomen, but other findings are
unusual.  Lab findings are generally normal.

   If the symptoms are suggestive, the physician may order an upper
gastrointestinal x-ray (upper g.i.).  This is a stomach x-ray taken
after ingestion of barium.  In up to 80% of cases, the ulcer will be
visible.  Alternatively, a diagnostic/therapeutic trial of therapy as
discussed below may be the only necessary step.  The x-ray becomes
more important if there is a history of ulcers in the past.

   In cases where the symptoms fail to improve, recur, or where x-ray
healing does not occur, a test called endoscopy may be helpful.  A
viewing instrument is passed down the esophagus, and the stomach
visualized directly.  Virtually painless biopsies may be obtained at
the same time.  Since ulcers in certain parts of the stomach are more
likely to be related to stomach cancer, these ulcers also warrant
endoscopy.  The decision of whether to perform endoscopy depends on a
variety of factors, but its routine use is not considered necessary
in many cases.  X-rays are used more routinely, but physician
discretion is the most important element, taking into account all of
the factors pertinent to a given patient.

   Of great importance is ruling out stomach cancer and other serious
diseases which can mimic ulcers.  For this reason, whatever series of
tests is chosen, follow-up becomes crucial.

    Treatment

    DIET

   Years ago, patients with ulcers were routinely placed on
milk-cream diets which were quite restrictive.  Modern research has
shown that such diets are not only useless, but may be harmful, since
they stimulate acid output an hour after being taken.  The only
dietary advice given to most sufferers today is to avoid caffeine and
any other foods which worsen symptoms, eat frequently when possible,
and possibly to increase dietary fiber intake.

MEDICATIONS

   Antacids remain the mainstay of therapy, despite recently
introduced newer medications. By their ability to neutralize the acid
produced by the stomach, they allow the ulcer to heal spontaneously.
Since most acid is produced within an hour of eating or after
retiring at night, a typical regiment consists of doses one hour
after meals, at bedtime, and whenever pain occurs.
 Typical antacids include Mylanta, Maalox, Tums, Gaviscon, and
Titralac.  Those containing magnesium may produce diarrhea, and
others may cause other side effects; however, they are generally very
safe and effective, causing ulcer healing in most patients within a
month.

   Recent years have seen the introduction of Tagamet, Zantac, and
other so-called histamine blockers.  Though originally felt to be
revolutionary in their ability to decrease acid production and
promote ulcer healing, it is now known that they are usually no more
effective than antacids, have many more side effects, and are quite
expensive.  They have been overused for vague abdominal symptoms, and
generally should be reserved for refractory or recurrent cases, and
for special situations of great rarity. Nonetheless, Tagamet
(cimetidine) has become one of, if not the, most widely prescribed
drugs in America.

   An additional type of drug, anticholinergics, work by decreasing
acid output.  They are occasionally useful, but have not been
employed routinely because of unpleasant side- effects. Finally, a
relatively new drug called sucralfate which acts by coating and
protecting the ulcerated area, has received some attention.  It seems
to be as effective as cimetidine, has almost no side effects, and is
probably very valuable as an adjunct to antacids. Ironically, this
agent has received less widespread use than it merits, in the opinion
of some.

   With appropriate use of the above medications, almost all ulcers
can be easily and safely managed.  Patient compliance is critical, as
are the reduction or elimination of precipitating factors, and
careful follow-up.

    Complications
    BLEEDING

   If an ulcer involves an artery, sudden and severe bleeding may
occur, often without preceding pain.  This may be noticed as black
tarry stools due to digested blood products, vomiting of blood, or
sudden collapse, lightheadedness, or fainting. If it is more gradual,
anemia may be the first symptom. Sometimes, pallor or fatigue may be
the tipoff.  Aggressive treatment which may include transfusions as
well as some of the measures mentioned before are indicated.  All of
the above require physician evaluation without delay.

OBSTRUCTION

   If the area around the ulcer gets very swollen, it can block the
passage of food through the duodenum.  This manifests as vomiting
after eating, sometimes with cramping pain, and subsequent
dehydration. Treatment requires passage of a tube to relieve the
pressure, and intensive anti-ulcer treatment as outlined.

PERFORATION

   If an ulcer penetrates all the way through the wall of the stomach
or duodenum, it can cause an acute inflammation and contamination of
the abdominal cavity (peritonitis), a true surgical emergency.  If
untreated, shock and death may occur, though occasionally the opening
seals itself off.  If the penetration is through the rear wall into
the pancreas, pancreatitis will occur, causing another type of very
painful emergency (see article).

SURGERY

   In the most resistant or recurrent cases, or in those in which the
possibility of cancer cannot be ruled out by less drastic means,
surgery is necessary.  This can range from total removal of the
stomach to selective removal or severing of the nerves which
stimulate acid secretion in the stomach. Fortunately, few cases
require surgery with the modern regimens used today.

    Summary

  Contemporary management of peptic ulcers results in excellent cure
rates, diagnostic accuracy, and prognosis for the vast majority of
patients.  A combination of prudent medical management and excellent
patient compliance are the prerequisites for such results.



           Hepatitis

   There are many different types of hepatitis, each with its own
cause, prognosis, and other features.  This discussion will first
address the topic in general, and later sections will deal with the
specifics of some of the more common individual types of hepatitis.

   Hepatitis means inflammation of the liver.  The functions of the
liver are exceedingly complex, and include metabolism of body
chemicals and drugs, the production of blood clotting chemicals, and
the recycling of certain highly pigmented products of the blood,
namely bilirubin.  When the function of the liver is impaired, any or
all of these aspects may come into play, and the symptoms will vary
accordingly.

    Symptoms

   Certain symptoms may occur in most types of hepatitis, including
fever, loss of appetite, nausea, and fatigue. A dull pain in the
right upper abdomen is not rare.  A peculiar loss of taste for
cigarettes in smokers is sometimes the first symptom of hepatitis.

   Jaundice is perhaps the most dramatic symptom, and refers to a
brownish yellow discoloration of the skin, eyes, and oral tissues.
It is due to accumulation in the skin of the chemical bilirubin,
which is normally metabolized by the liver.  Depending on the type of
hepatitis this may be accompanied by darkening of the color of the
urine, as the kidney excretes the excess blood pigment, or by a pale
color to the stool, as pigment normally excreted by the liver into
the intestine is blocked in this passage.  The same chemical in the
skin may cause marked

   Bleeding may occur in hepatitis, often in the gastrointestinal
tract.  This is often due to inadequate levels of blood clotting
chemicals normally manufactured in the liver.  It often heralds
rather severe hepatitis.  In other instances, it is due to rupture of
veins which, like varicose veins, are "backed up" behind the swollen
liver.

   Ultimately, if large amounts of poisonous substances normally
produced by the body in its daily metabolism are not cleared by the
liver, coma, convulsions, and death may occur.  This is seen in the
rare severest cases.

    Specific Types

    Hepatitis A


   This is a common form of hepatitis, caused by a virus, and often
called infectious hepatitis.  After a period of fatigue, nausea,
vomiting and darkened urine, the patient notes fever, vague abdominal
pain, and muscle aches.

   Before too long, jaundice appears, with the patient often
beginning to feel better as she looks more and more yellow.  In most
cases, the illness resolves within a few weeks of onset of jaundice
without specific treatment.  Diagnosis is made by technical blood
test results in the context of a consistent clinical history and
exam.

   Patients are contagious from 3 weeks before to 3 weeks after
jaundice appears.  The virus is present in all digestive excretions,
and spread is generally by food or utensils contaminated by the
patient. Epidemics happen regularly. Immunity occurs after the
disease.  The incubation period is from two to seven weeks, typically
three to five weeks. Almost all cases resolve on their own, and long
term side effects are very rare.

   In certain cases of known exposure, injections of gamma globulin
can protect the exposed individual from obvious disease with high
success rates.

Hepatitis B

   Also known as serum hepatitis, this is very similar to hepatitis A
in its initial symptoms.  Differences include a longer incubation
period (two to five months), a 10% rate of progression to chronic
forms of liver disease with sometimes serious complications, and a
higher incidence of non- digestive symptoms, including joint pain,
rashes and others.

  Infection of the Hepatitis B virus is by contact with blood, serum,
saliva, or semen of the patient.  It is common in homosexual men.
Infection confers immunity in most but not all patients.  Standard
gamma globulin does not protect against Hepatitis B very effectively,
although a special form can be used in selected patients.

   There is a recent vaccine available for this disease, which has
proven very safe and effective.  It is given in three injections, and
is recommended for populations at high risk who do not have blood
test evidence for previous infection.  This includes certain medical
occupations, gay men, dentists, certain institutionalized people, and
others.  There is no evidence that the vaccine spreads "AIDS."

Post-Transfusion Hepatitis

   Also called "non-A, non-B hepatitis," this variety occurs in up to
10% of patients who have received one or many blood transfusions, and
is probably caused by a different group of viruses which as of yet
are poorly defined scientifically. It also accounts for a sizable
number of spontaneously occurring cases, and may be increasing in
frequency.

   From the patient's standpoint, the disease is much like hepatitis
B, including the occurrence of some of the complications noted below.
Regular gamma globulin is somewhat protective in cases of disease
exposure, though not as much so as in hepatitis A.

Miscellaneous Types                   -

   Other viruses, including that of mononucleosis, can produce
hepatitis, as can certain drugs.

  The reactions are often idiosyncratic, that is unpredictable, and
usually rare.

  Examples of drugs which are involved include isoniazid
(anti-tuberculous), methyldopa (anti-hypertension), oral
contraceptives, and major tranquilizers.  Alcohol in excess also
causes a form of hepatitis.

   A state very much like hepatitis can be caused by liver
involvement in other diseases. These include Hodgkin's Disease,
lupus, sarcoidosis, and others. Prognosis

   In viral hepatitis, almost all cases resolve without problems;
this is true of hepatitis A in over 95% of cases, and in type B in
85% of cases.   In the remainder, several other courses may follow.

   1.  Fulminant Hepatitis--in this event the disease seems to be
very aggressive, relentless, and frought with complications.
Treatment seems almost useless, and many patients die of
complications within days to weeks.

   2.  Persistent Hepatitis-- where the disease lingers for months to
years, in a mild to moderate form, sometimes with intermittent
worsenings which are usually milder than the

original bout.  Most cases eventually resolve spontaneously.
   3.  Chronic Active Hepatitis- -rare after type A, this represents
a serious complication in which the disease smolders along, gradually
damaging more and more liver tissue such that after months to years,
cirrhosis and liver failure set in. Recent years have seen excellent
responses to certain drug regimens, and this once hopeless
complication now carries a much more favorable prognosis than
previously.

    Treatment

   Except where hepatitis is related to some other disease as noted
above, there is no specific cure or therapy which has been proven
useful in acute viral hepatitis.  Prophylaxis has an important role,
as discussed, especially in close contacts and high risk populations.
 Usually the treatment is aimed at symptom relief, nutritional
support, and therapy of complications.

   Various measures may include replacement of vitamins usually
manufactured by the liver (especially vitamin K), anti- itching drugs
where this is a problem, rest, and medication for nausea, pain, or
fever. Often it is best to avoid medications, since they can
interfere with the monitoring of the course of the disease. Careful
physician follow-up to watch for complications or unusual features
suggestive of an alternate diagnosis is essential.

    Summary

   Hepatitis comprises a varied group of diseases of the liver, and
the outcome is generally favorable; factors of greatest significance
include the previous health of the patient, type of hepatitis
involved, and careful observation for and treatment of possible
complications.  Effective preventive measures are available for some
forms of the disease, and should be instituted whenever appropriate.

    Cirrhosis

   Despite the rather remarkable ability of the liver to regenerate
and heal itself after injury or disease, severe or protracted injury
can result in permanent damage to large numbers of liver cells, with
eventual loss of function and replacement of normal tissue with scar
tissue.

   When sufficient permanent damage has occurred to cause disease,
cirrhosis is said to occur.  In essence, this means a liver so filled
with scar tissue that it can no longer meet the needs of the body.

   Many causes of cirrhosis are recognized.  Probably the most common
is the toxic effect of alcohol on the liver, when consumed in large
amounts over months or longer.  The common accompanying factors of
poor nutrition and recurrent bouts of alcoholic hepatitis also
contribute.  Additional causative factors are previous episodes of
hepatitis (especially type B), certain other types of chronic
hepatitis, hemochromatosis (a disease of iron storage), chronic
blockage of the bile ducts due to diseases of the biliary tract, and
an infection called schistosomiasis, which is uncommon in the U.S.,
but common in other parts of the world. There are other rarer causes,
and finally a category of unknow causes termed "cryptogenic."

    Diagnosis

   When the diagnosis is suspected by a consistent history, exam, and
blood tests, the only definitive test for diagnosis is a liver
biopsy. This is done under local anesthesia.  No other test can make
the diagnosis, although strong suspicion can exist.

    Symptoms

   Due to the varied functions of the liver, symptoms due to its
malfunction are equally diverse.  Decreased levels of proteins,
clotting factors, and abnormal liver chemicals are common.  There may
be abnormal bleeding due to poor blood clotting, and this may be
severe.  Enlargement of the veins leading through the liver may cause
"varices" in the esophagus.  These are swollen veins much like
varicose veins; when sufficiently enlarged they can rupture causing
massive bleeding through the mouth. Jaundice may occur as with
hepatitis.

   The blocked veins and certain chemical abnormalities may lead to
massive accumulations of fluid in the abdominal cavity and elsewhere;
known as ascites, the abdominal fluid can reach staggering amounts,
sometimes appearing as large as a full- term pregnancy.

   When toxic chemicals normally removed by the liver reach
sufficiently high levels, they begin to affect the brain. Tremor,
confusion, weakness, delirium, and finally coma may occur. Marked and
dangerous imbalances in blood levels of potassium, sodium and other
chemicals may occur.

    Treatment

   Treatment is highly dependent on the cause; thus great efforts are
justified to diagnose Wilson's Disease, chronic active hepatitis,
hemochromatosis, and other reversible entities. Unfortunately, the
majority of cases are not curable, and treatment is geared toward
complications.

   Of course, alcohol is to be avoided, as are many other drugs and
substances which are normally affected by the liver. Vitamin K may be
given to promote clotting of blood, as this is often inadequate in
cirrhotic patients.  Antacids and anti-ulcer medications are given to
soothe the stomach in an effort to prevent ulcers and gastritis.
Salt restriction and reduced amounts of dietary protein may be
necessary to avoid overburdening the weakened liver.  Fluid may be
drained from the abdominal cavity if excessive, both for diagnostic
tests, and for symptom relief. When neurologic symptoms are seen,
substance are given to remove toxic burdens from the digestive tract.

   Bleeding esophageal varices may be treated with transfusions or
surgery; this is usually a desperate measure, as the condition has a
grave prognosis and the patients are often able to tolerate surgery
only poorly.

   All in all, treatment is often frustrating and only incompletely
successful in the patient with severe cirrhosis.

   Some patients have few symptoms, and a low grade stable form of
cirrhosis.  If the underlying cause is removed or no longer active,
no treatment may be required other than dietary discretion.

    Summary

   As this is a disease which is uncurable, emphasis is properly
placed on prevention.  Alcohol treatment and moderation, immunization
against hepatitis B, evaluation for the rare but treatable causes,
and meticulous management of the complications of established
cirrhosis are the keys to coping with the disease.



     Anal and Rectal Disease

   Though diseases in this section of the anatomy are the "butt" of
many a bad joke (such as that one), they can cause considerable
suffering, anxiety, missed work and other distress to their
sufferers.  The surest way to generate interest in and respect for
such diseases is to acquire one.

HEMORRHOIDS

   Hemorrhoids (or "piles") refer to veins in the anal area which
become enlarged or dilated, often filling with clots of blood, and
occasionally rupturing.  Their cause is not precisely known, but it
would appear that any prolonged pressure to the area may predispose
one to their development.  This may include constipation with
repeated bearing down with bowel movements, prolonged sitting,
pregnancy, and similar situations.  Sometimes they develop without
apparent cause.

SYMPTOMS

   When the veins are located toward the outside of the anal opening,
the overlying skin is very sensitive.  Severe pain and a bulging
worm-like mass may be noted, either present all the time, or
intermittently protruding from the canal with bowel movements.

 If it ruptures, bleeding may occur, typically as blood staining on
the tissue or stool.  In very severe cases, bleeding may be marked or
prolonged, leading to iron deficiency.

DIAGNOSIS

   The appearance of hemorrhoids is typical to an experienced doctor.
 Some hemorrhoids occur somewhat deeper in the rectum, and manifest
as bleeding only; in this event a proctosigmoidoscopy may be
needed--a viewing tube passed into the rectum.  Bleeding from the
rectum should not be attributed to hemorrhoids without excluding
other diseases, since polyps, cancers, colitis, and other diseases
may be the cause.  Of course, the presence of hemorrhoids does not
exclude the presence of these diseases.

TREATMENT

   Initially upon diagnosis, most cases can be managed with simple
measures designed to reduce pressure in the area, and to speed
healing of the existing hemorrhoids.  These include a high fiber
diet, stool softeners, soaking in hot water (a "sitz bath"), and
avoidance of sitting.  If the patient must sit, a donut shaped
cushion can be comforting.  Rectal suppositories containing cortisone
or local anesthetics are soothing to some.

   A variety of surgical maneuvers can be useful in resistant or
recurrent cases. These include total removal of the hemorrhoids, or
the less drastic measures of injecting agents to form an obliterating
scar in the hemorrhoidal vein, tying off the vein with a rubber
band-like device to allow it to shrink and "die," and freezing the
tissue with liquid nitrogen.

SUMMARY

   Most cases of hemorrhoids can be approached with a simple regimen
as outlined above. Recurrences are common, but avoidance of the
conditions described should minimize these. At least initially, all
cases should be diagnosed by a physician, so that other more serious
diseases may be ruled out.

ANAL FISSURE

   A fissure is a fine crack in the skin which is caused in most
cases by physical injury to vulnerable skin.  Many people are
familiar with fissures occurring with dry skin of the hands, or of
the toes in athlete's foot.  When the skin around the anal opening is
involved, the repeated irritating effect of bowel movements, sitting,
and continued moist conditions can cause a very uncomfortable
condition.

   Many anal fissures have no obvious cause, and once present, may
ulcerate and become quite large.  Pain is the commonest symptom and
may be severe. Bleeding is occasionally seen. Severe cases may
involve the deeper muscle tissue, leading to permanent scarring and
narrowing of the anal opening.

   Almost all cases resolve spontaneously, with measures identical to
those listed under the nonsurgical treatment of hemorrhoids.  Only
the most unusual cases require surgical excision.

PROCTALGIA--ANAL PAIN

   When pain in the anus occurs without obvious relationship to an
identified disease, the term proctalgia is used.  This presumes that
a complete proctoscopic exam is done and normal.

   A few diseases can be difficult to diagnose, and escape detection;
 these include injuries to the coccyx or tailbone, spinal cord
diseases, and anal gonorrhea.  Anal sexual activity or other
mechanical injury should be investigated.

   If no source is noted, the pain may be sharp and fleeting
(proctalgia fugax), or cramping, and lasting up to an hour.  No cause
has been found, and a variety of simple treatments have been only
inconsistently effective.  These include hot soaks, nitroglycerine,
and pressure against the painful area.  Often the pain stops on its
own, lasting intermittently for months at a time.

   Pain of a more persistent nature, especially if clearly related to
bowel movements may be due to stenosis or narrowing of the anal canal
of a spontaneous or injury-related cause.  Careful stretching of the
opening under anesthesia by a surgeon may be curative.

ANAL/RECTAL ABSCESS

   Any injury within the anal area is a portal through which millions
of bacteria present in the stool may enter.  The surrounding anatomy
is such that a large, painful and dangerous abscess may form very
quickly.

   Symptoms consist of the abrupt onset of severe, throbbing pain
around and within the anus, with a tender mass noted either by the
patient or on rectal exam.  Fever is not rare.  Small amounts of pus
may leak out from the opening. Sometimes, fistulae form; these are
small tracts which meander along the deeper tissues, eventually
exiting through the skin away from the original abscess.

   Treatment is surgical drainage of the abscess, and removal of the
surrounding tissues.  Many surgeons believe that conservative therapy
with sitz baths, antibiotics, etc. leads to too many longterm
complications, and fails to definitively solve the problem.

ANAL ITCHING

   Itchy skin diseases such as seborrhea, psoriasis, and allergies
can affect the skin near the anus, and are discussed elsewhere.  In
addition, certain infections such as pinworm, spread of a vaginal or
skin yeast or fungus infection, or scabies can cause itching.
Hemorrhoids may present with itching as the only initial symptom.

   A small remaining few have anal itching of unknown cause.
Treatment consists of topical anti-inflammatory or anti- itching
ointments such as cortisone or local anesthetics, and avoidance of
such possible offenders as scented or colored soaps, toilet tissue,
hygiene sprays, and other chemicals. A careful and sometimes repeated
exam is needed to rule out other causes.





Intestinal Diseases
     Irritable Colon
     Ulcerative Colitis
     Crohn's Disease

    IRRITABLE BOWEL SYNDROME (Spastic Colon, Irritable Colon)

   Irritable Bowel Syndrome is an extremely common disorder of the
digestive system, which can affect not only the bowel or intestine,
as the name would imply, but actually may affect any area of the
digestive tract. It is considered a "functional" disease, meaning it
is one which cannot be seen on x-rays, or even under the microscope,
but rather causes temporary disturbances in the functioning of the
affected organ(s), without disturbing their anatomy.

   The digestive tract is designed to propel the food along from
mouth to intestines in an orderly fashion, with a series of many
contractions occurring consecutively.  Since the normal contractions
are well organized under the control of the involuntary nervous
system, the process, known as peristalsis, proceeds continuously
without any conscious effort on our parts. In the colon (large
intestine), the contractions are particularly prominent, since the
material which reaches this level is generally much more solid than
at other higher levels of the system.

   In Irritable Bowel Syndrome, the contractions become disordered,
or out of "synch." When this occurs, forceful contractions may trap
food, stool, or air and fluid between two such contractions, an
stretch the intestinal wall to the point of pain.  Waves of
contractions cause cramps of pain.  Furthermore, the progression of
the material may slow down, causing constipation despite vigorous but
ineffective peristalsis.  If the contractions occur too rapidly, the
food may be pushed out too early, while still in liquid form, as
diarrhea.  If the disorder affects the higher parts of the tract,
such as the stomach or esophagus, nausea, vomiting, or difficulty in
swallowing may occur.

Symptoms

   As expected from the above, there is wide variation in the course
of symptoms.  The typical presentation might consist of intermittent
cramping pain in the lower abdomen, traveling from one area to
another over time.  It is often worsened with eating, which
stimulates peristalsis in general. Emotional stress can play a
closely associated role, which varies considerably.  There may be
alternating periods of diarrhea and constipation.  Some patients
notice certain foods, such as milk, spices, caffeine, and others
which affect the symptoms.  There may be occasional periods of nausea
and vomiting.

   It is rare for the symptoms to awaken the patient, and younger
people are generally affected.  Rectal bleeding is not caused by
Irritable Bowel Syndrome.  There is some controversy over whether all
patients are to be considered as having some important emotional or
personality component to their illness; it seems reasonable to
conclude that although some patients do indeed have such disorders
which may benefit from counseling or other intervention, many others
simply have a predisposition for manifesting otherwise normal stress
symptoms in the digestive tract.  Individual consideration seems to
be very important, and an open mind is essential for doctor and
patient alike.

   The disease tends to last for years intermittently.  Many patients
become less symptomatic as they approach the fourth decade.  Although
symptoms may persist for life, it is unusual to have symptoms begin
after middle age.

     DIAGNOSIS

   The symptoms of Irritable Bowel Syndrome may be caused by a vast
number of other digestive diseases ranging from ulcers to cancer.
Often a difficult decision must be made regarding how much testing is
appropriate. Previously, this was considered a disease of exclusion,
with a standard series of tests required make the diagnosis,
including upper and lower gastrointestinal x-rays,
proctosigmoidoscopy, and others. More recently, it has been proposed
that the diagnosis can be strongly suggested by the appropriate exam,
history, and selected tests guided by the patient's age, symptoms,
and other factors.  A careful, caring, and cooperative
physician-patient relationship is the single most important factor in
successful diagnosis and treatment.

   An increasingly important mimic of Irritable Bowel Syndrome is an
infection called giardiasis; this should at least be considered in
most patients.

TREATMENT

   A comprehensive approach is ideal.  Reassurance as to the causes
and relatively benign prognosis of the disease often serves to reduce
the distress, if not the symptoms, of Irritable Bowel Syndrome.
Dietary and social habits should be evaluated to reduce factors which
seem to cause symptoms to flare.  If there are obvious stresses or
emotional factors, these should be addressed as needed.  Aerobic
conditioning can be useful to reduce physical manifestations of
stress, even that which is considered an acceptable part of modern
life.

   Dietary fiber, such as found in whole grains, nuts, bran, many
fruits and vegetables, and in commercial products, has been
recommended for years. Scientific evidence of its benefit is lacking,
but it is a good general health habit to encourage, at least on a
trial basis.

   When these measures leave the patient still impaired by symptoms
to the point of interference with daily activities, medications can
be a useful temporary adjunct.  Bowel relaxing drugs such as
propantheline, Donnatol, Robinul and others are taken for cramps and
diarrhea.  Anti-anxiety agents have a minor role for some patients.
Antacids have no basis as a rational treatment, unless esophagitis or
other acid-related disease is present as well.  Surgery is not
indicated.

SUMMARY

   Irritable Bowel Syndrome is a common and complicated disease which
exemplifies the important common ground between the physical,
psychological, and unknown in medicine.  For this reason, a close and
holistic relationship between doctor and patient is important.  The
disease will cause no death or permanent damage to the patient, but
can generate much discomfort, fear, and lost productivity.  Adequate
management and patient motivation can minimize this in most cases.

    ULCERATIVE COLITIS

   Ulcerative colitis is a disease of the lining of the colon, or
large intestine.  It affects around one out of each one thousand
people in the United States.  Although not strictly familial, it does
tend to cluster in some families, and is more common in certain
racial groups, especially Jews.

   In this disease, the mucosa, or lining tissue of the colon,
becomes inflamed, red, swollen, and sensitive.  In about half of all
patients, the process may be limited to the colon's last segment, the
rectum, whereas in the remainder the upper reaches may be involved.
The cause of this disease is simply not known. It was felt for years
that it was due to some sort of infection, but no proof was found.
Recent theories have centered around an autoimmune basis where the
body attacks its own tissues.  Perhaps a combination of the two
factors in a genetically susceptible population is necessary.  At any
rate, no good basis is available to support any definite cause at
this time.

    SYMPTOMS

   The spectrum of symptoms at onset range from minimal diarrhea and
crampy abdominal pain to a fulminant disease with fever, severe pain,
bloody diarrhea, severe dehydration, and even death. In about half of
all patients, the milder onset is noted, with the remainder varying
among the range of more prominent symptoms. Most patients then go on
to develop a chronic series of flare-ups, feeling quite well in
between, although a few seem to have continuous symptoms.

   Rectal bleeding, diarrhea, abdominal pain and fatigue are common.
Severe bleeding, fever, marked dehydration, and debility are not rare
in most patients at some point in the course of the disease.
Profound illness and total shutdown or even rupture of the colon are
unusual but dreaded complications in a minority of patients.

   Complications of this disease include irritation of the liver
similar to hepatitis or gallstones, anemia due to blood loss, and
even symptoms far from the colon such as arthritis, blood clotting
disturbances, rashes, and eye inflammation. These non-intestinal
symptoms lend support to the autoimmune theory of causation, since
such a mechanism could affect several apparently unrelated organs.

DIAGNOSIS

   Diagnosis begins with recognition of the characteristic symptoms.
Though there is considerable overlap with irritable bowel syndrome
and other diseases, the presence of blood in the stool or the other
findings mentioned above often leads to proctosigmoidoscopy and
barium x-ray studies of the colon.  The findings on either of these
tests are characteristic of multiple ulcerated inflamed areas of
colon.  The lining bleeds readily. Certain diseases can closely mimic
even these findings, and sometimes a biopsy is necessary.  Infections
with amoebae, gonorrhea, and other germs must be excluded, as must
Crohn's Disease and several other entities.  In general, a
gastroenterologist, internist, or other specialist familiar with the
disease is involved in the diagnosis.

TREATMENT

   There is no cure for ulcerative colitis; treatment is aimed at
relief of symptoms, support of nutrition and hydration during
flare-ups, maintenance of remissions, and reduction in the intensity
of flare-ups.  This is accomplished by careful avoidance of any foods
noted to be irritating (often dairy products), management of
emotional stress, and general health awareness.

   Medications may play an important role.  Bowel relaxing drugs may
be carefully used if colon shutdown ("toxic megacolon") is not a
concern. Sulfasalazine (Azulfidine) is an antibiotic which seems to
help some patients both during attacks and during maintenance of
remissions.  Prednisone and related cortisone-like drugs are reserved
for severe attacks, but can be life saving when needed. Their
long-term use is avoided when possible due to potential side-effects.
 Cromolyn and azothioprine are drugs used experimentally and seem to
have helped some patients.

CANCER AND ULCERATIVE COLITIS

   It was recognized some years back that a higher percentage of
ulcerative colitis patients developed colon cancer after many years
of disease than did the general population; in fact after 10 or more
years, patients with disease involving the entire colon developed
cancer at a rate of more than 1% yearly, cumulative to a risk of
around 40% after 25 years of disease. Accordingly, very careful
repeated evaluations with colonoscopy are necessary for monitoring,
and some situations may even call for preventive removal of the
colon--a drastic but possibly life-saving measure.

   Surgery is not widely used except as above, even though it "cures"
the disease by removing the target organ.  Since this type of surgery
involves a permanent colostomy or drainage opening for many patients,
it is considered a last ditch treatment in serious or complicated
attacks.  The philosophy of many specialists is evolving rapidly in
this area, and careful consultation with the medical and surgical
consultant in conjunction with the patient's desires is crucial to a
successful outcome.

   A complicated disease, ulcerative colitis runs a highly variable
course from patient to patient, making generalization difficult.
Treatments available today are far from ideal, but can keep most
patients comfortable and functional most of the time.  Newer methods
of diagnosis and management may improve the outcome of most patients
in coming years, and close and careful physician follow-up is highly
important to all patients with this diagnosis.

        Crohn's Disease

   Like ulcerative colitis, Crohn's Disease affects young people
primarily, and is a disease which causes inflammation of the colon.
In this disease, however, the small intestine is also commonly
affected, and the farthest reaches of the colon, rectum, and anal
regions are less common targets.

   Crohn's disease is of unknown cause, and seems to be less common
than ulcerative colitis. Current theories revolve around a
combination of an autoimmune reaction of the body directed toward the
intestinal tissue, perhaps triggered by one or more infectious or
environmental factors.  Around 30 out of 100,000 Americans have the
disease, which is more frequent in Jews for unknown reasons. Some
inconsistent familial tendencies have been identified, but the
genetic component is poorly understood.

   Under the microscope, the inflammation of Crohn's Disease is
distinct, and resembles the body's reaction to certain types of
infection such as tuberculosis, although no such germs are
associated.  If the colon is the main area affected, which happens
occasionally if not often, the microscopic picture can be the only
way to separate it from ulcerative colitis in some cases.

    SYMPTOMS

   Typically, a teenager or young adult experiences a period of weeks
or months of "the blahs," with fatigue, weight loss, and depression.
Then ther occur a progressive combination of abdominal cramping and
diarrhea, usually in the lower right abdomen.  A low grade fever may
be present, and eventually, medical attention is sought.

   The disease may also cause fistulae; these are small tunnels or
tracts within the intestine, and may result in communicating
infections or abscesses between areas of intestine, or even between
intestine and bladder, skin, or other organs. Extra-intestinal
symptoms of the disease include joint pains, rashes, eye
inflammation, and kidney and gall bladder stones.

   The disease may come on at any age, not rarely in the 40's and
50's.  Delay in diagnosis is not rare, since so many diseases can
cause similar symptoms.

    DIAGNOSIS

   When the history suggests the diagnosis, this is usually confirmed
with upper and lower digestive x-rays, and occasionally with a biopsy
of tissue when necessary; this can sometimes be done through a
special viewing tube swallowed by the patient as an outpatient
procedure (endoscopy) or through the proctoscope if the colon is
involved.  Evaluation of the extent and complications usually
includes special blood tests.

   If enough of the last part of the small intestine is inflamed, it
becomes unable to absorb certain nutrients, especially vitamin B 12,
fats, and dairy sugar.  This can lead to anemia, malnutrition, and
calcium deficiency.

   Special care must be taken to rule out alternative diagnoses
including intestinal lymph node cancers like Hodgkin's Disease,
appendicitis in the acute cases, tuberculosis of the intestine, and
other rare diseases.

    TREATMENT

   The approach to treatment of this disease includes a careful
combination of medical and surgical modalities.  General measures
include careful nutritional measures such as a high protein and ample
calorie diet.  Activity and rest should be carefully combined, and
undue fatigue will contribute to the symptoms of the disease.  Foods
such as dairy products and concentrated fats are often poorly
tolerated, and should be taken in moderation.

   Sulfasalazine (Azulfidine and others) is a useful agent for the
treatment of mild flares and prevention of future attacks. It is
metabolized in the intestine to chemicals which have both
anti-inflammatory and anti-microbial actions, but its exact mechanism
of action in not known.

   In more severe worsenings, corticosteroids (cortisone-like drugs)
are often used, despite their well-recognized side effects.  It is
questionable whether these drugs alter the long-term outcome of the
disease but the do seem to control symptoms of acute attacks,
especially when organs outside the intestine are involved, such as
eye, skin, and joints.  When possible, their use should be kept as
brief as possible.  When even corticosteroids are not useful in the
seriously ill patient, immunosuppressive drugs, such as those used in
the treatment of some cancers, may be cautiously added.  These are
serious agents with potentially fatal side effects, and only should
be used in expert hands with careful monitoring.

   The role of surgery in this disease is important. Unfortunately,
recurrences in regions adjacent to the surgery, or even distant
areas, is very common.  If too much surgery is done, the patient may
be left with insufficient intestine to absorb nutrients (see
malabsorption).  Nonethless, selective surgery can reduce symptoms,
and in the more serious complications of obstruction or internal
fistulae, it may be the only alternative.

    PROGNOSIS

   The course is highly variable, and generalizations are of little
use.  There is some increased mortality in patients compared to those
without the disease, but this is often in the few patients with
fulminant, unremitting disease. For most patients, the disease
presents a recurrent source of illness, the need for long-term
medication, and a significant burden.  Optimal care, patient
cooperation, and attitude adjustment can keep these intrusions to a
minimum during the frequent remissions.





         Malabsorption

   Malabsorption refers to the inadequate transporting of nutrients
from the digestive system into the circulation where they can be
processed by the body.  By convention, it often also refers to
conditions where the digestive process fails to transform the
ingested food into a form in which even normal absorptive mechanisms
can function.  This latter disorder is more properly called
maldigestion, but will be included in the discussion as well.

   Digestive absorption depends on a complex interaction;  the
digestive organs must secrete enzymes to break down the food, propel
the partially digested food along the digestive tract, attach carrier
chemicals to certain food chemicals to promote absorption, reject
unabsorbable and some toxic chemicals, and finally expel the
remaining products of the process.  When various stages of the
process fail, certain nutrients remain in the intestine instead of
being absorbed.

    SYMPTOMS

   The symptoms depend to some extent on the group of substances
which are not being absorbed.  If fats remain in the intestines, they
result in copious diarrhea, a common symptom.  Iron and vitamin B12
malabsorption lead to anemia, nerve problems, and many other
symptoms.  Calcium and protein malabsorption lead to weakness, bone
disease, and decreased immunity.  Weight loss is almost universal at
some point in the syndrome.  Eventually, infection sets in,
compensatory fluid retention may occur, and the patient may succumb
to any of a myriad of complications.

    CAUSES

  As may be guessed from the above discussion, almost any disease
affecting the digestive organs can lead to malabsorption.  Some of
the commoner syndromes are discussed below:

Pancreatitis--the pancreatic enzymes are necessary for digestion of
fats.  When the pancreas malfunctions, fat malabsorption may occur.

Digestive Surgery--although there is a margin of safety, removal of
too much intestine or stomach can lead to malabsorption.  The stomach
is responsible for processing of vitamin B12, the small intestine for
iron, calcium, fats, and other nutrients, etc.

Bacterial Overgrowth--when the bacteria normally present in the colon
and very last part of the small intestine grow too rapidly, they tend
to absorb or breakdown certain chemicals necessary for nutrition.
This occurs in conditions of inadequate intestinal motility as occurs
in diabetes and other diseases.

Inflammation--Crohn's Disease, cancers of the intestinal or stomach
lining, certain tropical diseases, and similar processes can
interfere with absorption.

Miscellaneous--radiation treatments, allergy to gluten (a grain
component)--this is known as sprue--and any disease blocking bile
flow from the liver can cause malabsorption.

    LACTASE DEFICIENCY

   One very common and mild form of selective malabsorption is called
lactase deficiency.  This is an enzyme necessary for the absorption
of the sugar lactose, found in milk and dairy products.  In
Mediterranean, Black, Jewish and certain other cultural groups, up to
90% of adults (but not children) have at least a mild lack of the
enzyme.

   The symptoms are cramps, diarrhea, bloating, and gas excess
following too much milk or cheese.  Most patients have a "threshhold"
which they tolerate.  Often they just stop drinking milk after a
certain age without even realizing why.

   Treatment consists of avoidance.  If the intolerance prevents
intake of adequate calcium, supplements are necessary. Alternatively,
one may prepare milk in advance with a product called "Lact-aid"
which pre-digests the lactose, allowing adequate digestion. Certain
products such as buttermilk and yogurt have less lactose, and are
often tolerated when milk is not.

   Insufficiency of the adrenal glands (Addison's Disease) can mimic
malabsorption, and should be considered in some cases.

    DIAGNOSIS

   Once the symptoms are sufficient to make the diagnosis suspect, a
series of intestinal x-rays, blood tests, stool analyses, and
sometimes small intestinal biopsy under local anesthesia will confirm
the diagnosis in most cases. Usually the causative disease is obvious
if it is not intestinal in location.

    TREATMENT

   Of course, treatment depends upon the causative disease. Some
specific supportive measures include vitamin and mineral supplements,
sometimes by injection (vitamins K and B12), pancreatic enzyme
replacement with meals by mouth, avoidance of gluten in "sprue,"
antibiotics in infections, and even intravenous total nutrition in
very debilitated patients.

    SUMMARY

   Malabsorption is actually a complex syndrome caused by a variety
of diseases, most of which are discussed elsewhere. Recognition is
the crucial first step, since thorough evaluation in most cases leads
to the diagnosis of a highly treatable disease which in some cases
would otherwise be serious or even fatal.





         Kidney Stones

   Three percent of all Americans will suffer from a kidney stone at
some time in their life, and half of these people will suffer
recurrences over the following ten or more years.  It is thus a
disease which touches a significant portion of our population.
Fortunately it rarely causes permanent loss of kidney function if
properly treated, and is almost never fatal in the absence of
complications.

   There are several types of stones from a chemical standpoint,
although the vast majority contain calcium in some form. Exceptions
to this are stones composed of uric acid, which is the same chemical
that causes gout.  These and other calcium-free stones account for
fewer than 10% of all stones, and thus will not be addressed in
detail here; if such a stone is diagnosed, special treatment
considerations come into play.

   It is common for normal urine to contain predictable amounts of
calcium, magnesium, uric acid, and other chemical byproducts or
excesses from the body's daily metabolism. Normally these substances
are in solution and pass into the bladder.  Under certain conditions
of high saturation, and in a complex chemical environment that is not
yet completely understood, the chemicals may crystallize like rock
candy, and form a stone- like particle in the kidney. Once such a
particle has formed, it serves as a stimulus to the continued
formation of additional crystallization.  If the stone remains in the
wide open spaces of the kidney, no symptoms may occur, although there
will often be microscopic signs of blood in the urine. Once a piece
of the stone breaks off and enters the ureter leading to the bladder,
prompt spasms occur, leading to the unforgettable symptoms described
below.

   Several abnormalities can predispose to the formation of kidney
stones.  Some individuals absorb an excessive amount of calcium form
the intestines, and this overwhelms the ability of the kidney to
dissolve all the calcium.  Others absorb normal amounts, but the
kidney allows too much to leak into the urine from the blood.  Still
others produce a urine which is too acid in content, and this allows
crystallization to occur too easily. Finally, some patients who form
stones have no identifiable abnormality to explain the tendency
(perhaps 20% of the total group).  There are other diseases which
cause the calcium to rise markedly in the blood, such as
hyperparathyroidism and certain types of cancer.  Kidney stones may
then occur as a secondary phenomenon serving as the first clue to the
underlying disease. Rarely, patients are found who have been
digesting huge amounts of calcium or vitamin D in a misguided effort
to supplement their nutrition, and have kidney stones as a result of
this.

    SYMPTOMS

   The pain of a kidney stone comes on suddenly.  Classically, there
is severe, even excruciating pain in the flank on the side of the
stone, coming in waves, radiating around to the lower abdomen and
into the groin, scrotum or vagina, and occasionally into the upper
thigh area.  The intensity is as severe as most people ever
experience.  There may or may not be blood in the urine.  The patient
may have nausea and vomiting, and many break into a profuse sweat.
After anywhere from minutes to days or even longer, most stones pass
into the bladder, and the pain is gone.  The small, usually brown or
black stone may be identified in the urine, and should be kept for
analysis. If fever is present it may be from infection which has
formed behind the stone in the stagnant urine.

    DIAGNOSIS

   The symptoms are almost diagnostic when described as above, but
many cases are unusual in one way or another. Low back sprain,
intestinal viruses, pleurisy, and many other disorders can cause
similar pains, and some patients with stones have highly unusual
pains, or no pain at all. Bloody urine is sometimes the only finding.

   Once suspected, several measures are usually carried out.
Urinalysis is important, as is straining the urine through a special
filter or even a nylon stocking may trap the stone as it passes.
Most patients will undergo a kidney x-ray using a special dye, called
an IVP.  This will show the stone's location.

 It is also important to rule out a complete blockage from the
kidney, since this may call for more aggressive treatment. Ultrasound
tests can detect total blockage (hydronephrosis) quickly when IVP is
unavailable or medically unwise (as in dye allergy and other
conditions). Rarely, the stone will have passed undetected and the
urine cleared before evaluation, and the diagnosis remains
presumptive.

    COMPLICATIONS

   The worrisome complications usually consist of total blockage of
the ureter or infection behind the stone.  In total blockage, the
kidney continues to produce urine, and pressures can reach levels
which jeopardize the kidney. In infections, spread can be very rapid
since the flushing action of the urine flow is lost; blood poisoning,
shock and death may occur in the severest cases, and permanent kidney
damage is not rare. Fortunately, the vast majority of cases are
uncomplicated.

    TREATMENT

   The standard case of uncomplicated kidney stones requires two
things: pain relief and hydration, while waiting for the stone to
pass on its own. If both of these can be accomplished by mouth, the
patient may be observed closely and be treated at home.  If one of
these two goals is not feasible, hospitalization for pain relief and
intravenous hydration are necessary.  Often one can safely wait weeks
for a stone to pass, but if total blockage, recurrent pain,
infection, or other complications are noted, surgery may be
necessary.  Depending on the location of the stone and the urgency of
the situation, the stone may be relieved by snaring it using an
instrument inserted under anesthesia through the urethra into the
bladder and ureter, or an open operation may be needed.

   A new procedure called lithotrypsy uses high energy "shock" waves
to disintegrate stones without surgery.  By focusing the waves on the
stone, this may be accomplished without surgery or damage to other
tissues.  It requires general anesthesia and is not yet widely
available; when surgery is considered necessary it seems worthwhile
to inquire about the availability and applicability of this new
procedure.

Prevention

    Part of the preventive effort relies upon the category of stone
one is preventing.  For this reason, many authorities advise that a
24 hour urine collection obtained under routine activity and diet be
obtained.  From this data, one can recommend specific therapy.

   General measures include avoiding dehydration especially after
exercise, but even during routine days, by the ingestion of copious
amounts of fluid. Ideally, the patient should be drinking enough to
cause routine awakening at night to urinate, though this may be
unrealistic to expect for many patients. Unless intake has been
excessive, calcium restriction in the diet is not generally found to
be useful, except for certain severe over-absorbers of the element.
In many cases no further therapy may be necessary, although
recurrences are common years later. An occasional repeat x-ray will
identify those who are developing recurrent or increasing stone, and
therapy may be reconsidered in that case.

   If the stones are progressive, recurrent, or if a marked metabolic
disturbance is identified, numerous drugs have been shown to reduce
the tendency to form recurrent stones.  These include allopurinol,
hydrochlorothiazide, orthophosphates and others.  The choice depends
on the results of the urinary analysis and other factors, and is
usually a life- long commitment.





         KIDNEY FAILURE

   The term kidney failure is very broad, and refers to the loss of
those functions which are necessary for normal existence.  As a rule
there is ample reserve capacity present in the kidneys such that even
removal of one entire kidney and part of the other will cause no
demonstrable abnormality in metabolism, except in specially designed
tests.  Thus for imbalances to occur, there is usually some disorder
affecting both kidneys at the same time.

  A condensed description of the function of the kidneys is that they
are responsible for the regulation of certain chemicals in the body
fluids;  by selectively secreting or keeping varying amount of these
substances in the urine, a very delicate and complex balance is
maintained.  The substances in question include water, sodium,
potassium, acid byproducts of metabolism, drugs, calcium, magnesium,
uric acid, and hundreds of others. The blood carries the ingested and
metabolically produced substances to the kidneys, which then filters
them and "chooses" how much of each should remain or be secreted into
the urine. Hormones, concentration gradients, blood flow, and other
factors all play a role in this elegant scheme.

   Kidney failure may be either acute or chronic.  It is a general
rule that chronic renal (kidney) failure is irreversible in most
cases, whereas acute failure may be sometimes reversible, and other
times lead to chronic kidney failure.

CAUSES OF ACUTE KIDNEY FAILURE

Loss of blood supply to the kidneys through bleeding, drop in the
blood pressure from shock of any cause, congestive heart failure, or
other factors.

Toxins including carbon tetrachloride, certain mushrooms, illicit
drugs, anti- freeze, medications, allergic reactions.

Sudden breakdown in muscle tissue as after marathon running or
injury, releasing a chemical myoglobin which can damage kidneys.

   This list is not comprehensive, but attests to the wide variety of
potential damaging factors which are commonly seen.

CAUSES OF CHRONIC KIDNEY FAILURE High Blood Pressure

Chronic kidney infection.

Diabetes, where the small blood vessels of the kidney are damaged.

Lupus and other immune diseases where the kidneys are involved.


Certain drugs and toxins.

Glomerulonephritis (see nephritis section).

   The list is not comprehensive, and many cases of chronic renal
failure are never found to have a clear cause.  It seems that in the
end stage, the various causes yield the same basic abnormalities, and
the final approach is quite similar.

SYMPTOMS AND MECHANISMS

   The first symptoms of kidney failure are due to accumulation in
the blood of excess amounts of certain chemicals, often urea.
Fatigue, nausea or vomiting, weight loss, muscle cramps are common.
Irregular heart rhythms may result from imbalances in potassium and
other chemicals.  The formation of red blood cells and the function
of platelets are dependent on certain kidney functions, and anemia
and abnormal blood clotting are sometimes seen.  Virtually any
symptom and organ system can be affected, given the widespread duties
of the kidneys.  Once the abnormalities become profound, death may
occur from excessive fluid retention, chemical imbalance which the
heart cannot tolerate, or coma due to the toxic effects of
accumulated metabolic byproducts on the brain.

    DIAGNOSIS

   Due to the diffuse nature of the symptoms of kidney failure, the
precise diagnosis depends upon the laboratory data, which is done
when symptoms persist in the appropriate setting.  A typical
combination of common laboratory abnormalities would include an
abnormal urinalysis, elevated blood potassium, decreased calcium, low
blood count, and elevation of two chemicals called creatinine and
urea nitrogen.  The last two are considered to be the most closely
related to actual kidney function.  Precise estimates are further
obtained by analyzing 24 hour urine specimens.

    TREATMENT

   The therapy of specific underlying diseases is beyond the scope of
this discussion, but clearly the reversible elements must be actively
sought and addressed.  Therapy specific to the kidney failure are
divided into dialysis and other forms of treatment.

    NON-DIALYSIS TREATMENT

   Dietary restriction of such things as protein, salt, total fluid,
and potassium.  A very precise and highly regulated regimen must be
worked out for each patient individually, and rigid adherence may
improve symptoms and delay or even prevent the need for further
measures.  Many drugs are excreted through the kidneys, and all
medications should be carefully assessed as dosage adjustments are
often necessary. Vitamin D can sometimes be useful to reduce the bone
weakening which sometimes accompanies kidney failure. High blood
pressure either as a pre-disposing disease or secondary to the kidney
failure (through excessive fluid retention or hormone imbalances)
should be carefully treated. Specific drugs for nausea or itching can
be quite helpful. Diuretics used selectively can help to increase
fluid excretion when this is a problem.

    DIALYSIS

   Dialysis refers to the artificial filtering of blood in the hopes
of replacing the filtering functions of the kidneys.  It is an
expensive and complex undertaking, requiring total patient
commitment, family involvement, and an intense patient-physician
relationship. Patients must be carefully chosen both from those
standpoints, as well as from a medical perspective; those with
underlying diseases which carry a poor prognosis may not benefit from
dialysis, since the underlying disease may prove fatal at any rate.

   There are two major forms of dialysis in common use at this time,
hemodialysis and peritoneal dialysis. Hemodialysis--this procedure
requires that a small artificial shunt be surgically inserted between
an artery and a vein through a small operation. Then, several times a
week, the patient's blood is pumped from the shunt through an
artificial kidney machine which uses certain filtering techniques to
bring the vital chemicals back into balance.  This may take many
hours, and obviously presents a major burden on the patient and
family.  For this reason there has been increasing emphasis on
providing this service in clinics and even at home, when the patient,
family, and supporting medical resources can all be arranged.

   The patient on dialysis is not free of disease or complications,
and these include infection, neurologic, and cardiac problems.
Psychologic reactions to the sort of existence this requires can be
major.  Very close medical follow-up remains necessary. The mortality
of patients on chronic hemodialysis range from 2 to 10% yearly; it
must be recalled that these are patients who would likely have died
imminently of their kidney failure without treatment.

PERITONEAL DIALYSIS

   The lining of the abdominal cavity has been found to have many of
the filtering properties for blood that are performed in the normal
kidneys.  If fluid containing carefully calculated amounts of
chemicals is present on one side of the lining, the blood which
circulates in and around the lining (peritoneum) will equilibrate its
chemical balance with that of the fluid. This process is called
peritoneal dialysis.

   After the surgical insertion of a special tube through the
abdominal wall, dialysis fluid is instilled into the abdomen and
allowed to remain there for several hours.  It is then drained out
and replaced with fresh fluid.  By choosing the type of fluid, the
blood chemicals can be regulated in this manner. While the fluid is
waiting to equilibrate the patient is free to go about normal
activities.  Exchanges are made 4 or 5 times daily in many cases.

   Not all patients can do well with peritoneal dialysis, and
complications such as intra- abdominal infections are common. It does
provide freedom from the "machine" of hemodialysis, is largely
manageable by the patient with careful medical supervision, and is
quite suitable for many patients.

KIDNEY TRANSPLANT SURGERY

   It is clear that dialysis is not an easy treatment even at best.
For this reason, many patients on dialysis are considered for receipt
of transplanted kidneys from either a live donor, or a recently
deceased donor whose kidneys have been carefully preserved.

   Aside from the surgical problems involved, the transplanted
kidneys may fail for reasons of rejection by the body.  In the case
of identical twin donors, up to 90% of transplants succeed after
three years.  With other related donors, up to 3/4 are functioning at
three years, and in cadaver transplants, about 60% remain.
Successful transplantation requires the institution of anti-rejection
drugs, and complicated follow-up programs. Immunosuppressive drugs
such as prednisone, azothioprine and others leave the patient
vulnerable to infections of many varieties. The newer drug
cyclosporine has improved this picture, and active research may bring
even further progress in this important area.  Many patients have to
revert to dialysis after a transplant fails, but still others undergo
second or even third transplants.

    SUMMARY

   Kidney failure is a major national health problem against which
major progress has been made in the past 10 years.  The financial,
medical, psychological, and societal problems associated with it are
profound, and patients are generally under virtually constant medical
supervision. The most promising areas of future progress seem to be
in the areas of prevention of transplant rejection and newer programs
of maintenance dialysis.





DISEASES OF THE TESTICLE AND RELATED STRUCTURES


   This discussion deals with disorders of the scrotal contents, i.e.
the testicles, spermatic structures and related anatomic areas.
Cancers and other tumors, infections including epididymitis, and
hormonal imbalances are dealt with in other specific sections such as
those on cancer, infections, and endocrinology.

ANY MASS, LUMP, OR OTHER CHANGE IN THE SCROTUM OR TESTICLE AREA
SHOULD BE IMMEDIATELY EVALUATED BY A PHYSICIAN, SINCE CANCERS OF THIS
AREA ARE NOT RARE.  UNTIL PROVEN OTHERWISE, ANY SUCH ABNORMALITY
SHOULD BE CONSIDERED POTENTIALLY SERIOUS UNTIL A PHYSICIAN RULES THIS
OUT.

    VARICOCOELE

   A varicocoele is the equivalent of a varicose vein in the vessels
surrounding and draining the testicle and related structures within
the scrotum.  Generally it is of unknown cause, although rarely the
vein becomes dilated because it is being blocked by an unsuspected
tumor;  the vast majority are not of this nature. Interestingly over
97% of cases occur on the left side, due to the anatomy of the veins
in the area.

   Most cases are first noted in patients who become aware of a
bulging fullness or a mass near the testicle.  It has been
unglamourously described as resembling a "bag of worms" in
consistency.  There is usually little or no discomfort associated
unless the size of the veins becomes so large as to put mechanical
pressure on the surrounding structures.  The disorder routinely
decreases the sperm production on the involved side, and even on the
other side as well; it is thus an occasional cause of male
infertility.  Most cases can be diagnosed on examination.

   When treatment is judged necessary, a fairly simple surgical
procedure is curative.

    TORSION OF THE TESTICLE

   One of the more painful conditions known to man, testicular
torsion occurs when the supporting structures of the testicle are
formed in such a way as to allow the testis to twist into a position
which strangulates off the supplying blood vessels; when swelling
takes place from this, the twisting may become irreversible and a
torsion is said to have occurred.  There may be no obvious
precipitating factor, or the patient may recall some unusual movement
or strain. Young men are affected far more often than those over 40.

   Symptoms consist of sudden onset of severe and progressive pain in
the testicle, which because of its visceral nature may be accompanied
by nausea and vomiting.  Left untreated, this can result in gangrene
of the testicle.  Diagnosis is suggested by the history, but care
must be taken not to confuse this with conditions such as infections
or tumors which have suddenly hemorrhaged. An experienced examiner,
usually a urologist, can often feel the reversed position of the
detailed anatomy of the testis, and make a rapid diagnosis.  As a
relative urologic emergency, surgery is important before too much
time has elapsed and the testis is sacrificed due to lack of blood
supply.

   HYDROCOELE & SPERMATOCOELE

   A hydrocoele is a fluid-fille mass within the scrotum which is
generally painless and very slow growing.  It seems to occur from a
mild congenital abnormality which leaves certain structures within
the scrotum open to the accumulation of fluid, instead of being
closed off from the surrounding structures. Spermatocoeles are also
cyst-lik masses which arise from the sperm carrying tubules of the
testicle and adjoining epididymis, and are filled with sperm
containing fluids.

   Diagnosis revolves on the characteristic feel of the cysts, and
their exact anatomic location, i.e. outside of the testicle itself.
In addition, these cysts are somewhat translucent to a bright light
source, and this can sometimes be helpful in diagnosis.

   These cysts are generally progressive if only slowly, and should
be surgically repaired at a convenient time by a urologist or a
general surgeon.  Any sudden change in the mass would require more
urgent evaluation, as would any diagnostic uncertainty.

   Cancers and tumors of this area are discussed in the cancer
section of HealthNet.  Another disorder which can sometimes present
as a mass near the testicle is an inguinal hernia, which can be read
about in the "Common Surgical Problems" section.

    ORCHITIS

   Orchitis refers to infection of the testicle with micro organisms.
 It is not common, but cases can be most confusing. The commonest
cause is the mumps virus; usually it only occurs in men who get mumps
as adults or teenagers, and is less common in children.  Painful
swelling of the testis is the main symptom, and the end result may be
scarring, shrinkage and loss of sperm production on the involved
side.

   Diagnosis usually is made from the presence of typical mumps
symptoms elsewhere, such as swelling of the salivary glands.  If
there is even the slightest question about the origin of such
swelling, urologic consultation is warranted.

    DISORDERS OF THE PENIS

     HYPOSPADIUS

   This is a common congenital condition in which the urethral
opening normally at the tip of the penis is instead located along the
shaft of the penis on its bottom aspect.  Depending on its exact
position, this may present absolutely no problem for the patient, or
else sexual functioning and urination may be interfered with.  When
such problems are present, repair can be accomplished through
surgical procedures.

    PHIMOSIS

   The foreskin of the uncircumcised male forms a sort of band around
the shaft of the penis.  If injury, local infection, or swelling from
almost any cause occurs and progresses, the band can act like a
tourniquet.  When this happens, the return of blood from the end
portions of the penis are cut off, and further swelling can occur.
This condition is known as phimosis.

  Diagnosis is obvious from examination.  Treatment should be prompt,
and consists of somewhat forceful withdrawing of the foreskin  when
possible, even if anesthesia is necessary. More often, the foreskin
must be cut and removed to prevent recurrences, in effect a
circumcision.  Preventive measures include proper hygiene of the
foreskin and underlying penis, and early attention when the patient
first finds that retracting the foreskin is not easily done.

    Peyronie's Disease

   This rather unusual disease is the formation of a contracture or
shortening of one of the major tendons attaching the shaft of the
penis to the supporting pelvic area.  In the normal state, the
patient may be unaware of this.  During erection of the penis, the
patient may note pain as the tendon is stretched beyond its usual
length, and the penis may point to the side of the contracture.
Embarrassing though it may be, this can cause considerable
dysfunction of a sexual nature, and often warrants treatment.  The
cause is unknown.

   Treatment is basically surgical if reassurance of its benign
nature is not sufficient to relieve the patients symptoms.  Some
authorities advise the use of high doses of PABA (para-amino benzoic
acid) which is said to reduce scar formation, but scientific evidence
of its effectiveness is poor.





DISEASES OF THE TESTICLE AND RELATED STRUCTURES


   This discussion deals with disorders of the scrotal contents, i.e.
the testicles, spermatic structures and related anatomic areas.
Cancers and other tumors, infections including epididymitis, and
hormonal imbalances are dealt with in other specific sections such as
those on cancer, infections, and endocrinology.

ANY MASS, LUMP, OR OTHER CHANGE IN THE SCROTUM OR TESTICLE AREA
SHOULD BE IMMEDIATELY EVALUATED BY A PHYSICIAN, SINCE CANCERS OF THIS
AREA ARE NOT RARE.  UNTIL PROVEN OTHERWISE, ANY SUCH ABNORMALITY
SHOULD BE CONSIDERED POTENTIALLY SERIOUS UNTIL A PHYSICIAN RULES THIS
OUT.

    VARICOCOELE

   A varicocoele is the equivalent of a varicose vein in the vessels
surrounding and draining the testicle and related structures within
the scrotum.  Generally it is of unknown cause, although rarely the
vein becomes dilated because it is being blocked by an unsuspected
tumor;  the vast majority are not of this nature. Interestingly over
97% of cases occur on the left side, due to the anatomy of the veins
in the area.

   Most cases are first noted in patients who become aware of a
bulging fullness or a mass near the testicle.  It has been
unglamourously described as resembling a "bag of worms" in
consistency.  There is usually little or no discomfort associated
unless the size of the veins becomes so large as to put mechanical
pressure on the surrounding structures.  The disorder routinely
decreases the sperm production on the involved side, and even on the
other side as well; it is thus an occasional cause of male
infertility.  Most cases can be diagnosed on examination.

   When treatment is judged necessary, a fairly simple surgical
procedure is curative.

    TORSION OF THE TESTICLE

   One of the more painful conditions known to man, testicular
torsion occurs when the supporting structures of the testicle are
formed in such a way as to allow the testis to twist into a position
which strangulates off the supplying blood vessels; when swelling
takes place from this, the twisting may become irreversible and a
torsion is said to have occurred.  There may be no obvious
precipitating factor, or the patient may recall some unusual movement
or strain. Young men are affected far more often than those over 40.

   Symptoms consist of sudden onset of severe and progressive pain in
the testicle, which because of its visceral nature may be accompanied
by nausea and vomiting.  Left untreated, this can result in gangrene
of the testicle.  Diagnosis is suggested by the history, but care
must be taken not to confuse this with conditions such as infections
or tumors which have suddenly hemorrhaged. An experienced examiner,
usually a urologist, can often feel the reversed position of the
detailed anatomy of the testis, and make a rapid diagnosis.  As a
relative urologic emergency, surgery is important before too much
time has elapsed and the testis is sacrificed due to lack of blood
supply.

   HYDROCOELE & SPERMATOCOELE

   A hydrocoele is a fluid-fille mass within the scrotum which is
generally painless and very slow growing.  It seems to occur from a
mild congenital abnormality which leaves certain structures within
the scrotum open to the accumulation of fluid, instead of being
closed off from the surrounding structures. Spermatocoeles are also
cyst-lik masses which arise from the sperm carrying tubules of the
testicle and adjoining epididymis, and are filled with sperm
containing fluids.

   Diagnosis revolves on the characteristic feel of the cysts, and
their exact anatomic location, i.e. outside of the testicle itself.
In addition, these cysts are somewhat translucent to a bright light
source, and this can sometimes be helpful in diagnosis.

   These cysts are generally progressive if only slowly, and should
be surgically repaired at a convenient time by a urologist or a
general surgeon.  Any sudden change in the mass would require more
urgent evaluation, as would any diagnostic uncertainty.

   Cancers and tumors of this area are discussed in the cancer
section of HealthNet.  Another disorder which can sometimes present
as a mass near the testicle is an inguinal hernia, which can be read
about in the "Common Surgical Problems" section.

    ORCHITIS

   Orchitis refers to infection of the testicle with micro organisms.
 It is not common, but cases can be most confusing. The commonest
cause is the mumps virus; usually it only occurs in men who get mumps
as adults or teenagers, and is less common in children.  Painful
swelling of the testis is the main symptom, and the end result may be
scarring, shrinkage and loss of sperm production on the involved
side.

   Diagnosis usually is made from the presence of typical mumps
symptoms elsewhere, such as swelling of the salivary glands.  If
there is even the slightest question about the origin of such
swelling, urologic consultation is warranted.

    DISORDERS OF THE PENIS

     HYPOSPADIUS

   This is a common congenital condition in which the urethral
opening normally at the tip of the penis is instead located along the
shaft of the penis on its bottom aspect.  Depending on its exact
position, this may present absolutely no problem for the patient, or
else sexual functioning and urination may be interfered with.  When
such problems are present, repair can be accomplished through
surgical procedures.

    PHIMOSIS

   The foreskin of the uncircumcised male forms a sort of band around
the shaft of the penis.  If injury, local infection, or swelling from
almost any cause occurs and progresses, the band can act like a
tourniquet.  When this happens, the return of blood from the end
portions of the penis are cut off, and further swelling can occur.
This condition is known as phimosis.

  Diagnosis is obvious from examination.  Treatment should be prompt,
and consists of somewhat forceful withdrawing of the foreskin  when
possible, even if anesthesia is necessary. More often, the foreskin
must be cut and removed to prevent recurrences, in effect a
circumcision.  Preventive measures include proper hygiene of the
foreskin and underlying penis, and early attention when the patient
first finds that retracting the foreskin is not easily done.

    Peyronie's Disease

   This rather unusual disease is the formation of a contracture or
shortening of one of the major tendons attaching the shaft of the
penis to the supporting pelvic area.  In the normal state, the
patient may be unaware of this.  During erection of the penis, the
patient may note pain as the tendon is stretched beyond its usual
length, and the penis may point to the side of the contracture.
Embarrassing though it may be, this can cause considerable
dysfunction of a sexual nature, and often warrants treatment.  The
cause is unknown.

   Treatment is basically surgical if reassurance of its benign
nature is not sufficient to relieve the patients symptoms.  Some
authorities advise the use of high doses of PABA (para-amino benzoic
acid) which is said to reduce scar formation, but scientific evidence
of its effectiveness is poor.





    PROSTATE AND BLADDER

    PROSTATIC HYPERTROPHY

   Prostate diseases generally fall into three categories:
infectious, malignant, and hypertrophy.  The first two categories are
dealt with under the sections on common infections and common
cancers. This discussion will focus on the common entity medically
known as benign prostatic hypertrophy, or BPH.

   The prostate gland is present in all men from birth, and assumes
importance when fertility is achieved.  Its function is to produce
the fluid which accompanies the sperm during ejaculation.  Located
deep within the pelvis, it sits on top of the urethra, which is the
tube connection the penis to the bladder.  As it achieves adult size,
the prostate wraps itself around the urethra, into which its
secretions empty. Because of this unusual anatomic locations two
health-related events become important: first, the prostate gland is
only able to be examined by feeling it through the rectum, and
second, any enlargement or swelling of the gland is prone to block
off flow of urine from the bladder to the penis.

    CAUSE AND MECHANISM

   Congestion and overgrowth of the prostate gland is virtually
universal in men over the age of 60.  Why this happens is not well
understood, but theories revolve around hormonal responses of the
glands cells as androgen and other hormone levels vary with age.
Fortunately, the growth does not cause problems for many older men,
although the many who are not so lucky take little consolation in
that fact.

   As the swelling progresses, the flow through the urethra
decreases, and the bladder grows thicker and stronger to compensate
for the increased resistance it has to overcome. Eventually, the
bladder is no longer able to overcome such forces completely, and
emptying becomes incomplete; urine is thus allowed to "stagnate" in
the bladder.  If the obstruction is allowed to become severe, the
pressures can back up all the way to the kidneys and permanent kidney
damage can occur.

   When the bladder is unable to empty itself of all its contents,
the occasional bacteria present in the urinary tract are able to
multiply, and urinary infection occurs as a common companion to BPH.
This in turn can worsen the swelling already present in the prostate.

    SYMPTOMS

   The earliest symptoms are usually hesitancy in initiating
urination, weakening of the urinary stream, incomplete emptying with
urination (sometimes giving rise to a need to urinate in two
"stages"). Dribbling of urine may occur. If infection sets in,
burning, blood, and fever may occur.  In the severest case, the
patient finds himself totally unable to urinate, sometimes with
massive enlargement of the bladder.

    DIAGNOSIS

   The symptoms mentioned above are highly suggestive of BPH,
although cancers and bladder problems are other possible causes. The
physician will assess the size and hardness of the gland with a
rectal exam, and the urine should usually be analyzed for signs of
infection, which could be one reversible element.  Often blood tests
will be obtained to check for kidney function.  If there is any
question as to diagnosis, an IVP or kidney dye xray is helpful. Some
urologists add additional tests to determine how much the bladder is
being affected.

    TREATMENT

   If the symptoms are not markedly impairing the patient's
lifestyle, and if recurrent, serious, or resistant infections or
kidney damage are not present conservative therapy may be adequate
for long periods of time.  This consists of treatment of any
infection, occasional massaging of the gland through a rectal exam to
relieve excessive congestion, and frequent ejaculations on the
patient's part for the same purpose.  Any drugs which reduce bladder
tone can precipitate sudden urinary retention, and should be avoided
if possible. These include antidepressants and certain tranquilizers
and antihistamines.

   Often many patients will eventually find the symptoms too
distressing to tolerate, or one of the complications mentioned above
will occur. In that event, surgery may be performed.  This may
involve simply shaving away the excess tissue through an instrument
passed into the urethra (in which regrowth is always a possibility),
or a more radical total prostate excision. In patients who cannot
tolerate any surgery, and chronic catheter may be necessary.
Vigilance for cancer of the prostate must continue after the shaving
procedure (termed TURP for transurethral resection of the prostate),
and careful follow-up of kidney function and possible infection is
needed indefinitely.

    BLADDER DISORDERS

   (As with the prostate, malignant and infectious disorders are
discussed in other sections of HealthNet).

   The urinary bladder is prone to manifestations of diseases of
other urinary organs such as stone formation, infection, and blockage
by the prostate. However, a few common conditions affect the bladder
primarily, along with its adjacent structure, the urethra.

    URETHRAL STENOSIS

   The urethra (the tube leading from the bladder to the penis or
urinary opening in women) in both men and women is prone to injury
from recurrent infections and trauma during sexual activity or other
activities. Previous medical procedures including catheterization is
another possible source of injury. If the body responds to the injury
by forming a scar within the urethra itself, the scar may block the
flow of urine from the bladder.

  Narrowing or stenosis may not cause any symptoms at all, but if the
flow is sufficient to prevent complete emptying of the bladder,
recurrent infections may result in the "stagnant" urine.
 Diagnosis is by a procedure called cystoscopy, in which the
physician looks into the anesthetized urethra through a viewing
instrument.  Recurrent infections are probably the commonest reason
to suspect the diagnosis.  Treatment can be rendered at the same time
as cystoscopy by dilating the urethra or cutting away any scars.
This may have to be done periodically as the narrowing recurs.

    NEUROGENIC BLADDER

   This condition occurs when the nerves which control emptying and
retention of urine by the bladder are functioning improperly.

 Since the proper control of urine is a complex system with both
voluntary control, involuntary elements, and learned behavior, the
cause of adult onset of incontinence of urine must be evaluated very
carefully before the cause is assumed to be neurogenic (nerve-
related).

   Any condition which damages nerve tissue can cause this condition.
 The commonest include diabetes, multiple sclerosis, syphilis, and
some forms of stroke and spinal disease.  Patients may have both
difficulty initiating urination, and when the bladder fills to the
brim, may also suffer from what is called overflow incontinence.

   Certain treatments are helpful in selected patients, including
bethanechol which stimulates bladder emptying, and propantheline and
related drugs which inhibit bladder emptying in those whose bladders
go into involuntary contractions.  Other patients, especially those
with spinal cord injury, can initiate urination by stroking or
stimulating the lower abdomen, thighs, or other skin regions; this
seems to set off a special reflex arc which initiates bladder action.
 When these measures fail, a chronic urinary catheter may be
necessary, or a permanent surgical procedure may be done to divert
the urinary flow to an abdominal opening to which a removable
appliance can be attached.
   Loss of bladder control is a serious social handicap for many
patients, but with proper medical management, a positive attitude by
the patient, and proper emotional support the problem can usually be
dealt with in an acceptable way.





 MISCELLANEOUS UROLOGIC DISEASE-Kidney Cysts, Protein in the Urine

    POLYCYSTIC KIDNEYS

   Primarily an inherited disease (although spontaneous cases are
seen), polycystic kidney disease is characterized by the presence of
numerous fluid filled cysts scattered throughout the kidneys. Their
cause is unknown.  Most patients develop progressive involvement, and
symptoms may first occur as blood in the urine, or protein noted on a
routine urinalysis. Blood pressure may rise due to interference with
normal kidney regulatory functions regarding body fluid volume.
Stones and infections are common, and the kidneys may enlarge to the
point of being quite noticeable in the mid-back.  About a third of
the patients may also have cysts in the liver which are commonly not
a serious threat to health.  One in ten may have aneurysms (small
outpouchings) in the arteries of the brain which can occasionally
rupture, causing a so-called subarachnoid hemorrhage, a form of
stroke.

   Diagnosis is usually instigated by one of the above symptoms or
findings.  A routine kidney x-ray reveals the problem.

   There is no specific treatment for this disorder, and most
patients go on to develop chronic kidney failure by late middle life.
 Special measure should be taken to control high blood pressure and
infections which can both accelerate kidney failure.

  BENIGN PROTEIN IN THE URINE

   Protein in the urine is often an early sign of almost any of the
kidney diseases discussed in this section.  However, some cases of
protein in the urine are not associated with serious problems.  In
these cases the challenge is to find these cases without subjecting
them to unnecessary testing, all the while identifying those with
more serious kidney disease which require further evaluation.

ORTHOSTATIC PROTEINURIA--This entity refers to a small group of
people whose kidneys allow a small amount of protein into the urine
only after certain upright positions (probably by compressing the
kidneys).  No increased incidence of kidney problems over that of the
general population is present in these people.

   Diagnosis is made by obtaining a 24 hour urine collection,
separating out those portions collected after sleep (when the patient
has not been upright) from that after upright position periods.  The
various amounts are calculated, and if general evaluation of the
results of this test and the routine blood tests are normal, the
diagnosis is confirmed.

   Fever, exercise, and even emotional stress can cause temporary
excessive amounts of protein to appear in the urine, but these do not
progress on repeat evaluation, and resolve when the underlying
circumstances are gone. Finally, there is a small group of patients
who simply excrete abnormal amounts of protein (modestly increased)
without demonstrable kidney disease, even after exhaustive
evaluation.  Although a few go one to develop obvious kidney disease
later, some remain perfectly normal indefinitely.





     Introduction to Cancer

   Cancer is a frightening term to most people, and few have escaped
being touched by one of the cancerous diseases in either their
families, friends, or themselves.  One of the reasons for
apprehension from this disease is that many people have little
knowledge of what cancer really means.  In this section, general
principles will be addressed, and aspects of prevention and cause
will be discussed.  It is recommended that you read this introduction
before proceeding to the remaining choices, which deal with some of
the commoner cancers encountered in medicine.

    GENERAL PRINCIPLES

   Cancer is a term referring to the loss of control over cell
reproduction within a given organ.  Normal cells will reproduce until
certain genetically determined limits are reached--limits of size,
boundaries from adjacent tissues and organs, or other biologic
"fences."  Just as each organ of the body has its own specialized
cell types and functions, cancer can have almost any cell type as its
origin, depending on the organ and location of the cells which lose
control.  In cancer, the growth boundaries fail to work.  Although
some cancer cells attack by reproducing faster than normal, others
just live longer, and just accumulate in number.  Still others do
both--they reproduce like mad, and hang around longer.

   As the cancer cells accumulate, they stimulate growth of blood
vessels as well, which assures them of a supply of nutrients.
Eventually, the growth outstrips the ability of the ability of the
body to supply it with blood, and tumor cell death, growth cessation,
or stability may occur; alternatively, the tumor may demand so much
of the bod's resources that healthy tissues begin to suffer.  Weight
loss, loss of muscle mass, weakness and other symptoms may result in
part from this phenomenon.

   Cancer cells' failure to follow the rules of growth result in two
very dangerous tendencies: invasiveness and metastasis. Invasiveness
refers to the tendency of some cancers to grow right into surrounding
areas, rather than thus push them aside as a benign growth might do.
Thus they invade the very structure of an organ and may literally
fill that organ with tumor cells rendering it functionless.  Of
course the very bulk of a tumor may cause blockage of an organ
without invading it, and when the two events occur together the
results may be horrible.

   Metastasis is a term which refers to the "ability" of small
numbers of cancer cells to break away from the primary tumor, travel
in the veins, and lodge in a distant organ.  There, they may start to
reproduce again. Common sites of metastatic spread include the lung,
liver, and bone marrow; these organs are rich in their vein supply.
Thus "liver cancer" or "lung cancer" when used by the layman may
refer to either primary cancer in that organ, or to cancer which has
spread from a cancer starting, say, in the intestine or the breast.
In medical usage, the cancer is always to by its primary site. Thus
one might say a patient has breast cancer metastatic to the lung.

    Doctors can often distinguish primary from metastatic cancer
because certain cell types are foreign to the organ in question. In
the case of cells in the liver which have the appearance
microscopically of skin cancer cells, one can confidently assume that
the liver involvement is metastatic. Unfortunately, there is much
overlap, and diagnostic confusion may persist even after a biopsy (or
surgical sample) of tissue is obtained.

    CAUSES

   The factors which lead that one cell to transform into a
malignancy are probably highly diverse, with the final common
denominator being damage to the genetic material inside the cell.
 Of course once it starts to reproduce, the offspring may share the
malignant characteristics, and no further spontaneous damage is
necessary.

   Among the factors which have been suspected or proven to cause at
least some types of cancer are viruses, environmental toxins,
cigarettes, alcohol, and irradiation including sunlight. It is
usually necessary for exposures to be quite large, small amounts of
carcinogens (cancer causing substances) are virtually everywhere but
cause little harm.  The future of cancer research must identify the
products and exposures present in dangerous amounts without inciting
panic each time a new correlation is made.

    PRINCIPLES OF TREATMENT

   The goal of an ideal cancer treatment is to kill every last cancer
cell while leaving healthy cells unharmed.  While it is rarely
possible to achieve the ideal, most therapies use the above strategy
in a numbers game.

   Surgery can quickly remove millions of cells in a tumor in one
fell swoop, and can occasionally be curative if a cancer has neither
metastasized nor invaded a vital adjacent organ which cannot be
removed. Unfortunately, this is only the case in some cancers; this
is one reason why early detection is so important, and allows more
tumors to be approached surgically for attempted cure. In other cases
surgery may be beneficial in relieving blockage, pain, deformity, and
in improving prognosis.

   Drugs (chemotherapy) works by poisoning all living cells to some
extent.  The goal is to find drugs which work more effectively on
cancer cells, usually because of their rapid growth rate, than on
normal cells.  If all the cancer cells can be killed before too many
normal cells die, a cure may be achieved.  More often, chemotherapy
achieves temporary improvements only.  One of the reasons for the
common side effects of some chemotherapy drugs can be readily
understood- -the body's rapidly dividing healthy cells take a
beating. These include blood cells, hair follicles, and stomach
lining cells, and decreased immunity to infection, hair loss, and
vomiting are not unusual during some regimens.

   Radiation therapy kills cells by causing damage to the vital
chemicals present within the cell itself; it disrupts their molecular
structure more rapidly in cells which are actively reproducing.
Unlike drugs, radiation can be focused on one area of the body, and
spare others, although some "scatter" within other organs is
unavoidable.

   Often the above strategies are combined; most clinical cancer
research revolves around determining just which program works best
against each particular types of cancer.  If no treatment is
effective, it is equally important to protect the patient from the
dangers and emotional distress of undergoing unnecessary treatments.
In desperation some patients may turn to various untested or
ineffective fad treatments. Aside from the financial and ethical
costs, this deprives a terminally ill p atient of the time and
emotional resources necessary to come to terms with a death with
dignity and acceptance, and can cause enormous family stress.  Only
in a well-designed and carefully monitored experimental setting
should untried modalities be used in cancer therapy.

   Preventive measures are assuming an enormous importance, which is
likely to grow rapidly. These are discussed with the specific cancers
to which they apply.   As you read each of the articles in this
section, be aware that every day brings new data in this area, and
even a computer assisted forum cannot hope to be totally current in
every disease.  Local cancer specialists and societies are the best
source of information on the diseases, and what can be done about
them.





    CANCERS OF THE BLOOD

    Note:  The reader is encouraged to read the introductory section
on cancer in general prior to reading this specific disease article.
Certain terms and principles are used which may otherwise be unclear
to some.

   The commonest blood cancers include those of the white cells (the
leukemias), the lymph cells (discussed under the "Lymphatics" section
elsewhere) and the antibody-producing plasma cells, or myeloma.

LEUKEMIA

   Although most leukemia is of unknown cause, there is increasing
evidence that some cases are related to exposure to radiation,
benzene, and certain rarely used drugs.  Viruses are suspected but
not proven to play a role in some others. Acute Leukemia (myelocytic)

   These rank among the most dreaded of cancers due to their
aggressive course and resistance to almost all treatment currently
available.  All blood cell lines become affected since the white
cells involved tend to crowd out the other cells in the bone marrow,
where all blood cells are formed.

    Symptoms

   Weakness, bleeding, and fever are the commonest initial symptoms,
and accompanying infections of almost any organ are common.  The
cancerous blood cells may lodge and grow in almost any site, and the
spleen, liver, lymph nodes and other organs may often be enlarged
with leukemia cells.  Bleeding and bruising may occur from deficient
platelets.


    DIAGNOSIS
   Since the symptoms may be quite nonspecific, one often first
suspects the disease based on incidental blood tests or the detection
of organ enlargement as mentioned above.  The blood count may give
the first suspicion of the diagnosis, but some nonmalignant diseases
can cause false positive blood findings. Thus a bone marrow biopsy is
the definitive diagnostic test; microscopically the marrow is highly
diagnostic.

    TREATMENT and PROGNOSIS

   The treatment of this disease is drastic.  For those choosing to
proceed, huge doses of powerful drugs are given which predictably
wipe out almost all of the patient's own white blood cells, and often
other cells as well.  Repeated severe infections are the result, and
are sometimes fatal.  Multiple transfusions are used, and side-
effects are marked.

   Currently, about three quarters of treated patients go into a
remission lasting several months to about two years; only rarely do
remissions last longer.  Untreated cases are usually fatal within a
few weeks to months.

   Bone marrow can occasionally be transplanted from a compatible
donor, after the recipient's marrow has been intentionally destroyed
with radiation or drugs.  Half of such patients may die of
complications, but the survivors have included some long-term
survivors.  This is the best hope for a meaningful good prognosis in
patients under forty if a suitable donor can be found.  Only a
relatively few medical centers perform the procedure, and serve as
regional referral centers.

ACUTE LEUKEMIA (lymphocytic)

   One type of acute leukemia affects primarily the lymphocytes of
the blood, and is termed acute lymphocytic leukemia.  This type
occurs primarily in children, and carries a far different prognosis
from that of the myelocytic type.  This disease often shows up as a
fever or protracted infection, with bruising, an enlarged spleen, and
a characteristic blood count.  Bone marrow testing confirms the
diagnosis.

   Intensive combination therapies with drugs such as prednisone,
vincristine, and asparaginase, plus irradiation can bring about a
high percentage of remissions (over 80%), many of whom remain in
remission over 2-5 years.  In children, follow-up retreatment
preventively has yielded even better results, although the regimen is
long and arduous. There are even hushed whispers of possible cures in
some centers, although what period of time this really means is open
to debate.  Bone marrow transplantation is reserved for patients who
have relapsed several times, and even then is of dubious overall
benefit.

CHRONIC LEUKEMIA

Chronic Myelogenous Leukemia

   This is uncommon and usually strikes adults.  The commonest
symptoms are nonspecific and include bruising, fatigue, abdominal
fullness from an enlarged spleen, and unexplained sweating.  The
blood count is virtually always abnormal, as is biopsy of the bone
marrow.  A characteristic chromosome abnormality called the
Philadelphia chromosome is noted in the cells of such patients.

   Eventually all patients reach a stage where the disease merges
into an accelerated phase similar to acute myelocytic leukemia
discussed above. Treatment is aimed at suppressing the rapid cell
turnover during the chronic phase, thereby reducing symptoms and
complications.

   Treatment usually includes the drug busulfan, which is given as a
pill.  The dosage is gradually adjusted to achieve a suitable white
blood count.  If the white count is so high on presentation that
acute complications of stupor, visual artery blockage or other severe
symptoms are present, a procedure called leukapheresis may provide
temporary benefit. This process removes only the white cells from the
patient's blood, returning the other components to the circulation.

   Prognosis is guarded; the median survival is around 3 to 4 years,
although prolonged survival of 10 or more years is not rare.
Although treatment probably does little to prolong these figures, it
clearly improves the quality of life of most

patients. Chronic Lymphocytic Leukemia

   A disease of middle aged and older adults, CLL, as it is commonly
called, is often diagnosed incidentally at the time of a physical
exam.  It is the least aggressive of the leukemias from a prognostic
perspective.  Most patients do have some symptoms at the time of
diagnosis, including fatigue, weight loss, abdominal pain, or
enlarged lymph nodes.  The physician may find enlarged nodes
unidentified by the patient, and skin rashes are sometimes noted.

   Diagnosis consists of a blood count which is usually abnormal in
the red and white cell areas, and platelets are sometimes abnormal as
well.  Often this is adequate for diagnosis.  Where there is doubt,
an enlarged lymph node or bone marrow biopsy will confirm the
disease.  Often the blood will contain abnormal antibodies produced
by some of the cells.

   Treatment is not always necessary for this type of leukemia if
symptoms and blood abnormalities are within acceptable limits. The
reason for this is that treatment only provides benefit for symptoms
and complications, and not for overall survival. Chemotherapy is the
main modality, with chlorambucil and cyclophosphamide being the two
most commonly used agents.  If red blood cells are involved,
prednisone is often added. Radiation therapy is sometimes useful for
local accumulations of leukemic cells which are causing problems.  In
cases where platelet deficiency is severe and unresponsive to drugs,
removal of the spleen is sometimes helpful, as this is the site of
abnormal platelet destruction on this disease.

   Survival may be prolonged in many patients, and since many of the
affected patients are elderly it is not uncommon for patients with
CLL to die of other causes.  When death occurs from the disease it is
usually from tumor involvement of a vital organ or overwhelming
infection.

   In few areas of medicine does the state of the art change as often
as in leukemia treatment, even on a local or regional basis.  Only an
active hematologist can provide up to the minute information on these
frightening but far from hopeless cancers.





        BREAST CANCER

    Note:  The reader is encouraged to read the introductory section
on cancer in general prior to reading this specific disease article.
Certain terms and principles are used which may otherwise be unclear
to some.

   Over one out of twenty women in the United States will develop
breast cancer, and this makes it the commonest cancer in women. It is
one of the commonest fatal diseases of women, yet it has been
estimated that over one half of all cases are curable.  Men can also
develop this disease, but with only a hundredth of the frequency of
that in women.

   Spontaneous occurrences of breast cancer are very common, but
certain factors are associated with an increased risk.  These include
a mother or sister with the disease, absence of pregnancy in the
past, first pregnancy after age thirty, and either early onset of
menstruation or late onset of menopause.  Almost all patients
discover their cancer themselves, and around one half of these have
already spread (metastasized) at that time. Thus efforts have been
aimed at screening for the purpose of detecting tumors at an earlier
stage, when cure rates are highest. Screening implies that no obvious
abnormalities are present--it refers to the apparently healthy woman.

    SCREENING

   Mammography is one aspect of screening; this is actually a
specialized form of x-ray which in recent years is accomplished with
doses of irradiation which are quite low.  Research has shown that in
women over age 50, periodic mammography combined with breast exam by
a physician can decrease mortality from breast cancer.  Current
recommendations are for a baseline mammogram between ages 35 to 40,
every two years or so thereafter.  Some physicians think this is
excessive, others feel it is insufficient.  Only one's personal
physician can make this judgment on an individual basis.

   Breast exam by each adult woman every month at a consisent time of
the menstrual cycle improves the prognosis of cancers that are
detected.  A physician exam periodically will add to this benefit.
Many masses which are detected turn out to be benign cysts or other
noncancerous problems, but only through biopsy or other techniques
can this be determined.

    DIAGNOSIS
   Once a lump or abnormal mammogram is detected, some sort of biopsy
is necessary to make the diagnosis.  Some cystic lumps can be drained
through a simple needle and syringe, but this decision requires
careful judgment and follow-up. Consensus of opinion currently is to
do an initial biopsy of the lump under local or general anesthesia,
with definitive therapy decided upon after the final biopsy results
are analyzed.  Definitive therapy depends upon the stage of the
disease, as discussed below.

    TREATMENT and PROGNOSIS

   Breast cancers are staged in the following manner:

   Stage I--tumor less than 2 centimeters, no spread to lymph nodes
or elsewhere.
   Stage II--tumor less than 5 centimeters, with spread to the nearby
nodes but not to distant organs.
   Stage III--various stages of primary tumors of all sizes, with
spread to nearby nodes and easily felt nodes in the armpit and lower
neck.
   Stage IV--any tumor which has spread to a distant organ. There are
various subdivisions of this simplified schema which are beyond the
scope of this discussion.

   Treatment for stages I and II include surgical removal of the
involved breast for most patients with more selective surgeries being
done than in the past.  The radical mastectomy in which large blocks
of surrounding muscle and lymphatic tissue are removed is rarely
required.  A modified procedure in which the breast and some lymph
nodes are removed is now quite popular and seem to be effective.

   Another option is that of high energy radiation, after the lump is
removed.  Although the more extensive surgery is avoided, some skin
damage is inevitable.  Survival is apparently equivalent when proper
techniques are followed. Ongoing research should clarify the place of
radiation which is still somewhat controversial.

   Stage III cancer may be treated with a combination of radiation
and surgery, with chemotherapy often added depending on the
subclassification.  Prognosis seems to be improving as the most
effective combinations of treatment are identified.  Local practice
and expertise are crucial to treatment selection in these stages.

   Stage IV breast cancer requires surgery for removal of a bulky or
invasive primary tumor, sometimes with radiation to reduce local
recurrence of the tumor.  Chemotherapy is the treatment of distant
spread of the tumor.

   Chemotherapy is taking on new dimensions in breast cancer. Even
very early tumors (stages I and II) are often treated with 6 to 12
months of preventive chemotherapy, since recent studies have shown
that prognosis can be improved in premenopausal women so treated. The
theory is that many patients have microscopic distant spread even at
that stage, and therapy can cure these in the early stages.  This is
termed adjuvant therapy.

   Chemotherapy for advanced disease consists of various combinations
of drugs whose aim is to bring about a temporary improvement or
relief of symptoms.  Commonly used agents include doxorubicin,
prednisone, cyclophosphamide, and methotrexate. Breast cancer cells
also may be sensitive to the effects of various female hormones to
some extent, and removal of the ovaries or adrenal glands (the source
of estrogens), the use of anti- estrogen drugs, and similar measures
have a place in come cases.

PROGNOSIS

   Within very broad guidelines, and with wide individual variations,
the prognosis for survival ten years after diagnosis is 70-80% for
stage I, 50% for stage II, 25-30% for stage III, and negligible for
stage IV.  These data are obviously based on older treatment
modalities and lesser screening intensity, and considerably improved
odds are faced by a woman diagnosed today, it would appear.

   Cosmetic reconstructive surgery is an alternative for women after
breast surgery, as is the constantly improving choice of prosthetic
garments. The psychologic toll of this disease can be alleviated by
caring health personnel, formal counseling, and patient to patient
contact through local cancer groups.

SUMMARY

   Screening techniques, public awareness, newer surgical, radiologic
and drug techniques, as well as changing attitudes toward breast
cancer are beginning to make important inroads into the progress
against this disease, both in terms of survival, quality of life, and
even cure.  It remains a major public health problem, and active
research will continue to be a high priority.





           LYMPHOMAS

    Note:  The reader is encouraged to read the introductory section
on cancer in general prior to reading this specific disease article.
Certain terms and principles are used which may otherwise be unclear
to some.

   The lymphatic system consists of drainage vessels which pervade
every organ of the body, like the circulation.  In addition, it
contains collections of cells in locations such as the lymph nodes,
spleen and tonsils, as well as internal lymph organs in the chest,
abdomen and elsewhere.  Cancer may arise in any of these areas.  The
commonest form of lymph node cancer is termed Hodgkin's Disease,
which constitutes about 40% of all lymph cancers; the so-called
non-Hodgkin's lymphomas comprise the rest.

Hodgkin's Disease

   Almost 8000 cases of this disease occur yearly in the U.S., with a
slight male predominance.  The treatment of this disease has been one
of the most promising areas in cancer medicine. Despite many theories
as to the cause of Hodgkin's Disease, such as infections with viruses
or other organisms, it still must be considered of unknown cause.

    SYMPTOMS

   Common initial symptoms consist of enlargement of lymph nodes in
the neck, armpit, or elsewhere.  This is usually painless, and
noticed quite incidentally.  Of course many benign diseases can also
cause temporary enlargement of nodes, but if the enlargement lasts
more than two weeks or so, suspicion must increase.  In some cases
this is accompanied by weight loss, fever, sweating, and itching.

    DIAGNOSIS

   When readily accessible, lymph nodes can be easily biopsied under
local anesthesia, and often confirm the diagnosis. A chest x-ray will
often show enlargement of internal lymph nodes of which the patient
may have been unaware.  A typical cell called a Reed-Sternberg cell
is virtually diagnostic of Hodgkin's under the microscope; one cause
of similar changes is a rare reaction to the drug phenytoin or
Dilantin.  Other than anemia and other nonspecific blood test
findings, other tests are more useful for establishing the stage of
the disease than for diagnosis. Defects in the immune system
predispose patients to unusual viral and parasitic infections.

   Staging and classification of the various types of Hodgkin's
Disease have importance in determining treatment and prognosis. Stage
I involves a single lymph node region only. Stage II involves more
than one lymph node region but both on the same side of the
diaphragms, or one node area and one site of spread outside the lymph
system. Stage III is when node regions on both sides of the diaphragm
are involved, with or without a single non-lymph organ involved.
Stage IV involves diffuse spread to non-lymphatic organs.  In
addition different categories are assigned on the type of microscopic
appearance of the cells.

    TREATMENT and PROGNOSIS

   Stage I and II disease usually is treated primarily with radiation
therapy either alone or combined with chemotherapy. Megavoltage
radiation available at referral centers is the technique of choice.
The decisions of how much to give, what organs to include and so
forth are crucial and individually determined. Side effects include
suppression of the bone marrow, inflammation of the lung and thyroid
failure.

   Most stage III and IV disease is treated with chemotherapy which
may include drugs such as vincristine, prednisone, procarbazine,
doxorubicin, and methotrexate in various combinations given in
intermittent doses over many months.  Many variations and other drugs
are used in various centers, and patterns are changing almost weekly.

   The exciting aspect of all this is that even patients with
advanced stages of the disease stand a realistic chance of being
cured of the disease.  For example, many regimens routinely bring
about complete remissions in 70 or 80% of patients; the median
duration of survival after such programs is now over 2 years and many
patients are thriving ten or more years after treatment, which must
be considered probable cures. Although staging does affect the
prognosis within these figures, there is sufficient overlap that no
patient should be considered uncurable until all efforts have been
exhausted.  Major referral centers and hematologists or oncologists
(cancer specialists) are the consultants of choice.

    OTHER LYMPHOMAS

   Whereas Hodgkin's Disease affects most patients in their 20's to
40's, other lymphomas strike a slightly older population on the
average. Enlarged lymph nodes, fever, weight loss, sweating and
fatigue are common initial symptoms.  Lymphomas may also affect the
nodes of the intestines more commonly, and sometimes an intestinal
blockage may occur.  In about 1/8 of patients, the lymph cells may
pour into the blood giving a picture indistinguishable from chronic
lymphocytic leukemia, discussed elsewhere.

   Diagnosis is usually by surgical biopsy of an enlarged node. Like
Hodgkin's Disease, lymphomas can be staged in a complicated and
technical manner, and this is important for management and prognosis.
Tests often required for staging include bone marrow sampling, cat
scans, and lymph system x- rays, as well as special nuclear scanning
tests.  Only occasionally is major surgery done for staging, as was
the practice in the past.

    TREATMENT and PROGNOSIS

   This complex area involves a combination of surgery, radiation
therapy, and chemotherapy used in various combinations or alone. It
is beyond the scope of this article to detail these, but in general
radiation alone is used for localized disease, surgery is primarily
used for diagnosis and removal of symptomatic masses, and
chemotherapy for advanced disease; the latter constitutes some 3/4 of
all patients. Commonly used drugs include prednisone, chlorambucil,
procarbazine, cyclophosphamide, bleomycin and doxorubicin.

   Prognosis is complex, and depends as much on individual factors as
it does on stage; some general survival figures show 5 year rates
ranging from 50 to 75% for stage I, with 2 to 3 year median survival
times for advanced disease treated with combination chemotherapy.  As
with many such diseases, the prognosis for patients diagnosed
recently may be better, and apparent cures are seen with increasing
frequency.





    COLON AND RECTAL CANCER

    Note:  The reader is encouraged to read the introductory section
on cancer in general prior to reading this specific disease article.
Certain terms and principles are used which may otherwise be unclear
to some.

   Cancers of the colon and rectum are the commonest cancers of
humankind.  Several factors contribute to their high mortality--their
internal location makes early detection difficult, and social values
and personal factors make public awareness and screening efforts
somewhat difficult.  Yet current methods of screening would cut the
mortality of these diseases considerably if only the medical and lay
community would institute them regularly.

   The colon and rectum are exposed to a wide variety of metabolic
and environmental toxins ingested and excreted daily. Furthermore,
the bacteria within the intestinal tract produce additional chemicals
of their own.  It is likely that some of this myriad of substances is
cancer-causing in susceptible individual.  A low fiber diet allows
these chemical to come into contact with the inner wall of the colon
and rectum for longer periods of time than a high fiber diet, and
fiber may chemically neutralize some of these substances.  Thus this
dietary factor has been theorized to play a role in some populations
as well. The specific cause of this cancer must nonetheless be
considered unknown.

   Some 60,000 deaths occur annually in the  U.S. from this cancer, a
high percentage of which could be avoided with appropriate screening
and follow-up programs

    SYMPTOMS

   By the time a colon or rectal cancer causes symptoms it is
frequently advanced beyond hope for a cure, although this is not
always the case.  Frequent symptoms include altered bowel habits or
bloody stools, abdominal pain or fullness, a lump in the abdomen,
weight loss and fatigue.  Sometimes bleeding causes anemia which can
in turn lead to lightheadedness, pale skin, and other symptoms.

Screening

   A major goal is to detect the disease in the very earliest stages,
or even in the pre- malignant phase.  This refers to the detection of
certain types of benign colon polyps which might later degenerate
into cancer.  Screening measures include testing several stool
samples for microscopic amounts of blood using a special card test.
This is advised periodically after age 40.  A rectal exam by the
physician also becomes important at that age in both sexes.  After
age fifty, proctosigmoidoscopy ("procto") becomes equally important,
this being examination of the lower colon through a viewing
instrument; recently smaller flexible instruments have made this a
much less uncomfortable and a more sensitive exam than it was just a
few years ago.  Barium enema colon x-ray is another exam used for
diagnosis, but not generally in a screening setting.

   Certain patients are at higher risk for colon cancer, including
those with a familial form of colon polyps, ulcerative colitis, and a
very strong family history of this type of cancer.
 Even more vigorous screening is called for in this setting. Although
the screening recommendations are applicable to general populations,
variations on them are common and the advice of the patient's
personal physician should be sought.

    DIAGNOSIS

   Once one or more of the tests above shows an abnormality,
additional tests may include biopsy of any polyps or tumors. This may
be done through a colonoscope (a longer version of the procto
instrument) in some cases.  If the tumor is large or if blockage
appears imminent, an operation may be necessary. Depending on the
location and extent of the tumor, the colon may be repaired to its
normal state.  In other cases a temporary or permanent drainage
opening in the abdomen may be necessary (a colostomy).

   Blood tests, x-rays, and scans may reveal evidence of tumor spread
at the time of diagnosis, and at least preliminary evaluation should
be done to evaluate the extent of spread.

    TREATMENT
   Surgery as mentioned above is the primary means of treatment. In
the case of polyps or very early cancers, this may be curative, and
even in other cases is often beneficial since blockage of the colon
is inevitable in other cases at some point.
 Cancers low in the rectum may be approachable and occasionally even
curable by special radiation techniques. This may not be available or
advisable in many cases, but is worth considering for some.

   Chemotherapy has been disappointing both as a curative and even as
a palliative measure to reduce symptoms.  Some patients derive
temporary reduction in the tumor and metastases, but this usually
does not last long enough to be meaningful for most.  At present the
role of chemotherapy in colon and rectal cancer must be considered
limited.

    PROGNOSIS
   Five year survival data for colon cancer vary from around 70% for
early cancers confined to the lining of the intestine to less than
10% when the tumor has already spread to the nearby lymph nodes.  If
distant spread has already occurred at the time of diagnosis,
long-term survival should not be anticipated.

    SUMMARY
   It is worth emphasizing that the means to improve the detection of
and survival for this disease is already available in the form of
screening tests as discussed. The minor inconvenience, cost, and
discomfort of the measures described, and the social reluctance to
address issues pertaining to the rectum are killing many people each
year. Every effort should be made to overcome these factors given the
dismal and worsening statistics for cancer of the colon and rectum.





        PROSTATE CANCER

    Note:  The reader is encouraged to read the introductory section
on cancer in general prior to reading this specific disease article.
Certain terms and principles are used which may otherwise be unclear
to some.

   Some 24,000 men die yearly from cancer of the prostate in the
U.S., making this the second commonest cause of death from cancer in
males.  In addition, thousands of cases are present at autopsy in men
dying of other causes.  Because of the hidden location of the
prostate gland (which is discussed further under diseases of the
prostate in another section), early detection becomes a problem.

   Most cases are detected by the performance of a rectal examination
by the physician. This should be a routine part of a complete
physical in men over 40, and is also done frequently when urinary
symptoms arise in a male, including hesitancy before starting the
stream, frequency, buning, dribbling, or blood in the urine.  In
other cases, the first clue is the presence of metastases in distant
organs such as the bones or lungs.

    TREATMENT

   When possible, surgery should be done for most cases to remove the
primary tumor, and possibly to cure the disease if it is confined
within the capsule of the prostate.  Cancer which has spread beyond
the capsule into the surrounding areas may be additionally treated
with radiation for temporary symptom relief and to slow the progress
of the disease.

   Prostate cancer which has spread to distant organs is treated with
hormone therapy when possible.  This is based on the fact that most
cancers depend for their growth to some extent on the actions of male
hormones.  If the influence of these hormones can be neutralized, the
rate of cancer progression can be reduced. To accomplish this goal,
female hormones can be given by mouth, or the testes can be
surgically removed.  The emotional effects of these measures,
including the feminization that can occur, must be carefully weighed
against the temporary benefit that will be derived from the
treatment.  Clearly it should be reserved for patients with advanced
disease and severe symptoms.

    PROGNOSIS
   Cure can be achieved in about one half to 60% of early localized
cancers of the prostate, and even locally spreading disease can be
cured in a slightly lesser percentage by combining surgery with other
measures.  Cancer spread beyond this degree is generally not
considered curable.  Many such patients do respond very well to other
measures, and can lead a high quality life for many months or years.
The combined services of a urologist, radiation therapist, and
internal medicine or cancer specialist are usually required to
coordinate medical management.





           LUNG CANCER

   Note:  The reader is encouraged to read the introductory section
on cancer in general prior to reading this specific disease article.
Certain terms and principles are used which may otherwise be unclear
to some.

   Few cancers in man are more dangerous, aggressive, or cause more
suffering than lung cancer. Few cancers in man are more preventable
than lung cancer. The obvious paradox underlies one of the great
frustrations of preventive medicine--identifying the necessary
measures to prevent a disease is not adequate.  One must first learn
how to overcome human nature. The issue in question is, of course,
cigarette smoking which is felt to cause some 90% of all cases of
lung cancer.

   Lung cancer is the leading cause of cancer death in American men,
and is fast catching up in women.  Although air pollution and
industrial exposures account for some of these cancers, the
dramatically increasing frequency is felt by most authorities to
correlate with the increased use of cigarettes.  The scientific
evidence is overwhelming in this area both in research models and in
epidemiologic studies.  Many authorities express horror at the
continued and expensive efforts of special interest groups to counter
this fact, rather than pouring the same resources into combating the
disease.

    SYMPTOMS and DIAGNOSIS

   Most lung cancers are detected because of symptoms of weight loss,
cough, blood in the sputum, shortness of breath, or pain in the chest
or at the sight of spread of the cancer. Attempts at screening to
detect the disease at an earlier stage by using periodic chest x-rays
or sputum tests have failed to show any survival benefit--the patient
simply learns that he or she has the disease several months sooner.
At the time of diagnosis 80% of lung cancers are too advanced to
allow even an attempt at surgical removal for cure.

   Either analysis of sputum or biopsy of the cancer is necessary for
definite diagnosis.  In some cases the biopsy can be done under local
anesthesia by a bronchoscopy, where an instrument is passed through
the anesthetized nostrils, or a needle is passed through the skin.
Other cases require an open operation under general anesthesia.

   Lung cancers have widespread and sometimes bizarre effects on the
rest of the rest of the body, sometimes producing hormones which
mimic the body's normal hormones, but cause exaggerated
actions--elevated calcium levels, low sodium, confusion and other
syndromes. Metastases to the brain, bone, liver, adrenals or
elsewhere are routinely detected.  It is not rare for some distant
symptom or metastatic area to be the first clue to a cancer which on
further evaluation turns out to have started in the lung.

    TREATMENT and PROGNOSIS

   About 5% of lung cancers can be cured by surgical removal. The
remainder may require surgery for diagnosis or symptom relief but
should not be approached for possible cure. Radiation therapy is
widely used to shrink down noncurable tumors and to eradicate
metastases which may be causing symptoms.

   Until recently, chemotherapy had little role in lung cancer. More
recent combinations have begun to show some benefit for the type of
cancer called "oat cell" cancer, with median survivals being
increased from a few months to ten or eleven months;  this hardly
calls for celebration, but does hold out some hope that the future
may hold better results. Chemotherapy in other forms of lung cancer
are of little benefit overall.

   Well over 90% of patients with lung cancer are dead within 5
years, and most die within one year.

PREVENTION

   All measures pale in comparison to avoidance of cigarette smoking.
 Asbestos exposure, certain other toxins and air pollution, alcohol,
and radiation exposure play a limited role for some subgroups. The
savings in lives, suffering, and money if smoking were eliminated as
a risk factor are incalculable.

   The warning symptoms of lung cancer include a cough that persists
beyond 2 weeks, coughing up of blood, unexplained chest pain, and
weight loss in a smoker.





     CANCER OF THE PANCREAS

    Note:  The reader is encouraged to read the introductory section
on cancer in general prior to reading this specific disease article.
Certain terms and principles are used which may otherwise be unclear
to some.

   Pancreatic cancer is on the rise, with a tripling of its incidence
over the past 40 years.  The normal functions of the pancreas are
outlined in the section on pancreatitis, but in summary it provides
various enzymes necessary for digestion of fats, and also is the site
of insulin production.  The location of the pancreas is deep in the
abdomen, behind the stomach; this is such that even large cancers can
form before being detected. In part this accounts for the grim
prognosis.

   This cancer affects three to four males for each female, and
usually strikes in the middle or older years. It is the fourth or
fifth most common cancer. The cause of pancreatic cancer is not
known.  Several years ago, some research suggested a connection with
excessive coffee intake.  This research was subsequently brought into
question, and is not currently accepted by most authorities.
Cigarette smoking and chronic diabetes may be risk factors for some
cases.

    SYMPTOMS

   Loss of appetite, weight loss and nausea are common presenting
complaints.  It has long been observed that severe depression can
also be associated with pancreatic cancer, and may be the only
symptom at first.  A dull constant upper abdominal or mid-back pain
is common.  If the tumor is near the liver and gall bladder, blockage
of bile drainage may occur, and is a common cause of yellow jaundice,
often with no pain at all.  Other patients develop diabetes from the
destruction of the insulin producing cells.

    DIAGNOSIS

   Once the above symptoms raise the possibility of the diagnosis,
confirmation is not always easy.  In some cases, a simple stomach
x-ray may show the bulging mass as it pushes into the stomach, but
this is far from a universal finding. Ultrasound tests will show the
tumor in over 80% of cases.  CAT scan x-rays of the pancreas will
usually show a tumor, but sometimes simple swelling of an inflamed
pancreas without tumor will appear misleadingly as a cancer.

   More invasive techniques include needle biopsies of the pancreas,
and passing of a tube from the intestine (swallowed by the patient)
into the ducts of the pancreas, and taking x-rays after injecting
dye.  Ancillary tests of the blood and digestive function can enhance
one's diagnostic confidence, but do not of themselves confirm the
diagnosis.

    TREATMENT and PROGNOSIS

   Surgery is almost never curative, but when a tumor is apparently
well-localized may offer the only chance for cure, however remote.
It is a radical procedure, and has its own risks and side effects.
Surgery can also provide temporary relief of liver or intestinal
blockage, and improvement in the pain if a mechanical cause is
present.

   Various types of radiation therapy have been investigated, and
some temporary improvements have been noted.  Unfortunately,
uninvolved organs must necessarily receive high doses as well, and
side effects may be severe, involving the stomach and spinal cord
among other organs.  Thus the role of radiation is currently quite
limited.

   Chemotherapy can provide temporary improvement in about 20% of
treated patients, and may prolong survival slightly at the expense of
side-effects.

   As may be deduced from the above, the prognosis of this disease is
grim with or without treatment.  Within one year of the diagnosis,
90% of patients are dead.  The five year cure rate is probably around
5%. Little hope for improvement in these figures can be expected
until research shows more about the causes and means of early
detection for this most dismal cancer.





       GYNECOLOGIC CANCER
    Note:  The reader is encouraged to read the introductory section
on cancer in general prior to reading this specific disease article.
Certain terms and principles are used which may otherwise be unclear
to some.

   This discussion will focus on cancers of the ovary, cervix, and
uterus.  The vaginal structures and fallopian tubes can also be the
site of cancer (as can virtually any organ) but this is much less
common than the above.

    OVARIAN CANCER
   The fourth most common cancer in women, ovarian cancer affects
over 18,000 new patients yearly in the U.S.  It has been estimated
that one third of these cases are potentially curable. Its cause is
unknown, as are most of its risk factors. Hormones probably play some
role, since oral contraceptives and number of pregnancies have a
clear if not absolute protective effect for this cancer.

    SYMPTOMS
   Most patients do not develop symptoms until the disease is far
advanced, although in retrospect one often can recall vague abdominal
symptoms dating back several months.  The fortunate patient who has
her disease diagnosed early (fewer than 35% of all cases) usually has
an ovarian enlargement detected on routine pelvic exam; it is
important to recognize that even an optimal exam will fail to detect
even advanced tumors, depending on location. Many ovarian tumors
produce large amounts of fluid which can accumulate in the abdomen
and will eventually cause swelling, bloating, and even shortness of
breath as the fluid begins to impinge on the diaphragms.

   The symptoms of advanced disease, namely weight loss, massive
amounts of abdominal fluid, metastatic cancer in other organs, and
shortness of breath are the initial symptoms in all to many cases.

    DIAGNOSIS

   Most cases are diagnosed after surgery is performed for one of the
above symptoms. Tests which help to confirm the presence of a tumor
before surgery, or to determine the likelihood of a tumor being a
cancer versus a benign cyst include ultrasound studies, CAT scan
x-rays of the pelvic area, and analysis of fluid sampled through a
needle passed either through the deep vaginal area or the abdomen.
On occasion, the first clue comes on the usual Pap smear, as tumor
cells work their way to the cervix.

    TREATMENT and PROGNOSIS

   Combined therapeutic methods are commonly used for ovarian cancer.
 The first step is usually surgical removal of all traces of obvious
tumor, and biopsy of the other organs including the diaphragms and
lymph nodes if any suspicion exists of possible spread.  Even in
obvious advanced disease, surgery is often done to reduce the amount
of cancer present.

   Radiation therapy may be useful for the treatment of residual
disease, and can be very effective in shrinking large tumor masses
which are causing symptoms.  It is generally not as important as
surgery and chemotherapy for most patients, however.

   Chemotherapy of ovarian cancer is most commonly used in advanced
disease, but is being investigated for possible preventive use
following surgery for localized tumors.  In advanced cases, the drugs
commonly used in combination include cyclophosphamide, doxorubicin,
and platinum containing agents.

   Survival is clearly dependent on how advanced the cancer is at the
time of diagnosis.  In the early cases which are confined to the
ovaries, over 70% of patients can expect a 5 year survival, and
presumed cure. Moderate cases in which the cancer has extended within
the pelvic area but not elsewhere are cured (5 year survival) in
around 30% of cases, and advanced metastatic cases are rarely cured.

   This complex area is rapidly changing, and patients diagnosed
today may face a better prognosis than indicated by those figures
cited above. Whether a five year period represents a true cure is not
known, but hopefully we will be seeing more and more cases in this
category, and fewer in the advanced stages.  The skillful use of the
treatments discussed often requires the comprehensive management of a
team of specialists available primarily at major medical centers.
Indeed the specialty of gynecologic oncology has emerged as a new
addition to the list in medicine's war against cancer.

  UTERINE (ENDOMETRIAL) CANCER

   Cancer of the lining of the uterus, as opposed to that of the
cervix discussed below) is the commonest of the gynecologic cancers.
Hormonal influences play an important role in its cause, and it is
known that risk factors for its development include diabetes,
obesity, infertility of either voluntary or involuntary type, and
late onset of menopause.  These data, as well as the evidence from
certain research projects suggest that estrogen exposure is a major
factor in the cause of endometrial cancer.  Of interest is that
progesterone which in some ways neutralizes the effects of estrogen,
can reduce the excess risk of endometrial cancer in certain cases.

    DIAGNOSIS

   Early diagnosis and its better prognosis depend upon a pelvic exam
at regular intervals, with this being determined to some extent on
the risk factor profile.  Part of a routine Pap smear includes
sampling the area which leads to the uterine lining (the endocervical
canal).  Over half of uterine cancers may be detected in this way.  A
deeper biopsy of the uterus may be done through a vaginal approach
where suspicion is higher, and the traditional dilatation and
curettage (D & C) is the definitive method of diagnosis. Additional
staging tests done after the diagnosis is made have been kept to a
minimum recently, since many such tests have been shown not to affect
outcome.

    TREATMENT and PROGNOSIS

   Surgery is the primary treatment method, and allows careful
assessment of the extent of the disease.  Often no other treatment is
required.  The place of radiation therapy is somewhat controversial.
Wide experience has been acquired in its use, and it can be clearly
curative in some cases. Whether it can replace surgery is less clear.
 At least it provides an alternative method of treatment when surgery
is not felt to be wise.  Radiation is perhaps most useful as an
additional treatment after surgery, when it can act to reduce any
microscopic residual tumor clusters left behind.

   Given the hormonal nature of this cancer, it is not surprising
that progestins can sometimes reduce the progress of widespread
uterine cancer. Their role is only temporary, however, and not all
patients respond at all.  Chemotherapy with doxorubicin and other
anti- cancer drugs has been quite disappointing, and their role is
limited at this time.

   Endometrial cancer which is confined to the inner surface of the
uterus can achieve five year survival rates over 90%. Cancers which
have extended only to the cervix (vaginal extension of the uterus)
have survivals of 57% to 89%, depending on how extensively the cervix
is involved.  Extension beyond the uterus and pelvis makes cure
unrealistic, although symptomatic and palliative measure may be very
effective if temporary.

    SUMMARY

   It is generally agreed that attention to regular pelvic
examinations including after menopause, avoidance of obesity, and the
careful use of progestins in post-menopausal women on estrogens can
have a marked impact on death rates from this disease.  Once
diagnosed, effective treatments are available, with cure being
realistic for some, and reasonable palliation available for the
remainder of patients.

      CANCER OF THE CERVIX

   Our understanding of this cancer has changed markedly with each
passing decade.  Referring to cancers arising in the lining cell of
the cervix, cervical cancer seems to be related to factors of sexual
behavior and exposure in a complex but intimate way.  It has been
recognized that celibate women rarely get this disease, and its
incidence is much lower in women whose sexual exposure has been
limited to men who have been circumcised.  On the other hand, women
with multiple sexual partners, particularly during their teens, are
at high risk. Certain viruses including those of the herpes and
papilloma group are increasingly suspected of playing a role in the
cause o this disease.  Thus, some combination of genetic
susceptibility, and sexual exposures to viruses, sperm, or other
factors may all be involved.

    SYMPTOMS

   Once symptoms occur, cervical cancer is often advanced.  This is
why the Pap smear (see below) assumes such importance. Symptoms
include vaginal bleeding between periods, pain with intercourse, and
a vaginal discharge.

    DIAGNOSIS

   Cervical cancer is the primary disease which can be detected in
the very early stages when in fact it can be considered more
accurately pre- cancerous.  This is thanks to the development of the
Pap smear, which has surely saved countless lives.  During a pelvic
exam, the physician takes a small, usually painless scraping of the
outside of the cervix, and this is sent for microscopic analysis.
Although established cancers can be diagnosed this way, more commonly
certain changes in the cells can be identified which are known to
preceded the development of cancer, or else cancer confined to the
very earliest stages (carcinoma-in- situ) may be identified.  AT this
point, cure is routine.

   When suspicious findings or Pap smears are seen, a the nest
approach is often colposcopy, where the physician views the cervix
through a magnifying lens.  In this way, abnormal areas invisible to
the naked eye may be seen, guiding any further biopsies, or
treatment.  A more extensive biopsy under anesthesia may include a
circular cuff or the cervix (cone biopsy) or even a hysterectomy in
extensive cases.

    TREATMENT and PROGNOSIS

   Pre-invasive cancer such as those detected with the Pap smear can
be universally cured with surgical removal, freezing, burning, or
lasers.  Often these techniques can be done under local anesthesia.
When the area is more extensive, hysterectomy can achieve cure as
well.  More invasive cancers will require hysterectomy of a more
extensive nature, with removal of surrounding lymph nodes and other
sites of likely spread. The ovaries can usually be spared in
pre-menopausal women.

   Radiation is the usual treatment for more advanced cervical
cancers, and is used by some even in the early cancers as an
alternative to surgery.  A unique aspect of radiation therapy for
this disease is the implantation of radioactive substances within the
uterus and cervix, allowing higher doses to the tumor while largely
sparing surrounding healthy tissue. This is generally used along with
standard external radiation.

   Advanced and disseminated cervical cancer may improve temporarily
in some patients treated with drugs such as methotrexate, bleomycin,
platinum and others.

   Prognosis for pre-invasive cancers or pre-cancerous changes is
excellent, with routine cure being expected.  Careful follow- up for
recurrences is of course mandatory.  Those cancers which are invasive
only within the cervical tissue are still curable in over 90% of
cases. Cancers extending only to the immediately surrounding areas
are yield 5 year survivals of over 55%, and those which have grown
into the other pelvic organs drop to about 32% survival.   Cure is
not expected in cancers which have widely disseminated.

   Current recommendations call for Pap smears annually until two or
three in a row are normal, and then every 2 to three years
thereafter.  There is some controversy in this area, and the
individual's risk factors are important.  The best resource for
guidance is the physician who will be following the patient.





   INTRODUCTION TO SYMPTOMS

   Symptoms are subjective complaints about one's health.  The
articles in this section explain why they occur, what causes them and
how they are evaluated.  Most symptoms have many possible causes.
Because treatment depends on the specific diagnosis, only general
therapeutic measures are discussed.  Please consult Disorders and
Diseases section for additional information about therapy.





   DEPRESSION

   Depression is a disturbance in mood or affect characterized by
feelings of sadness, unhappiness, and in extreme cases, thoughts of
harming oneself.  It is by far the most common mood disorder,
affecting about ten to twenty percent of the population.

   A person who is depressed will seem sad and withdrawn.  They may
experience fatigue, listlessness, decreased sexual interest,
inability to concentrate, loss of appetite, hypochondriacal pains,
crying spells and insomnia.  Feelings of guilt, hopelessness and
worthlessness begin to dominate their thoughts. In extreme cases
suicide is comtemplated, or there may be a profound change in
personality, evidenced by disordered thinking, delusions (abnormal,
wrong thoughts) and/or hallucinations.

   Feeling depressed, however, is not always abnormal.  For instance,
the grieving process is a necessary and healthy way to resolve one's
feelings about the death or loss of a relative or friend.  And
depression can be expected to occur in reaction to life's setbacks,
such as a broken marriage or loss of a job.  The above are examples
of exogenous (from without) depression.

   What differentiates, then, an acceptable level of depression from
one that clearly is not?  The answer is not easy.  In general, any
depressive state that occurs without regard to or out of proportion
to external causes; is prolonged, severe or associated with an
inabiity to function in everyday life; includes suicidal thoughts; or
leads to a physical deterioration deserves medical evaluation.

   Major Causes

   There are a number of medical conditions that can cause
depression.  Among the more common of these are hormonal diseases of
the adrenal and thyroid glands, infections, nutritional deficiencies,
tumors of the brain and pancreas, multiple sclerosis, Parkinson's
disease, medications (tranquilizers, blood pressure) and alcohol-drug
abuse.

   Psychiatric causes of depression can be divided into two types:
unipolar and bipolar.  Unipolar disorders include depression as the
only type of mood disturbance.  Examples are anaclitic
depression--seen in neglected infants, grief reactions in response to
external events, involutional states--seen in the elderly who
experience physical and emotional losses, endogenous (from within)
depression, and psychoses.  Bipolar depression refers mainly to
manic-depressive illness (MDI), a specific disorder characterized by
psychotic depression usually in association with periods of mania.
It is believed to be genetic- biochemical in nature.

   Evaluation and Treatment

   It is imperative that medical causes be ruled out prior to
attributing depression to a psychiatric illness.  Physical complaints
such as weight loss should be investigated prior to psychiatric
consultation.  Psychiatric therapies include suicide prevention,
supportive psychotherapy, anti-depressant medications such as
amitriptyline (Elavil) and others, and in severe cases, electric
shock treatments.  Lithium is the drug of choice for MDI.





   ANXIETY

   Anxiety is an uncomfortable feeling of dread characterized by
nervousness, tension and apprehension.  Unlike fear which develops in
reaction to a real or imagined danger, it has no obvious cause of
which the person is aware.  Free-floating anxiety is is a term used
to describe this lack of focus on a specific target.  Panic is an
exaggerated state of anxiety resulting in a profound disturbance in
one's ability to function.

   There are many physical counterparts of anxiety which in the eyes
of an anxious person may supercede the emotional distress in
importance.  Among these signs are headache, dizzness, numbness,
tremors, sweating, fatigue, dry mouth, lack of energy, insomnia,
aching, shortness of breath, chest and abdominal pains, palpitations,
nausea, vomiting, changes in appetite, diarrhea and menstrual
difficulties.

   It is important to remember: anxiety is only a symptom that
something is wrong.  It can have many different causes, physical as
well as psychological.

   Major Causes

   Perhaps a third of the persons who are treated for anxiety have a
physical explanation.  The disorders most frequently implicated
include reactions to medications, alcohol and drug abuse or
withdrawal, caffeinism, hormonal diseases of the thyroid and adrenal
glands, and abnormal heart rhythms.

   The cause of anxiety in the majority of persons who do not have a
physical explanation is not well understood.  There are three major
theories that are used to explain the development of anxiety and
anxiety disorders: psychoanalytic, behavioral and metabolic.
Proponents of psychoanalytic theories hold that anxiety is a product
of either unresolved subconscious conflict or childhood trauma.
Behavioral theorists believe that anxiety is a normal response to
unpleasant life circumstances or punishment, and that anxiety
disorders result from a failure to recognize, escape from and/or
adapt to these noxious situations. Finally, metabolic theories center
around a chemical explanation--that there is a defect in certain
cerebral functions due to an imbalance in neurotransmitters, the
substances that control the flow of electrical impulses between nerve
cells in the brain.

   Anxiety Disorders

   The American Psychiatric Association has classified the following
as primary anxiety disorders:

Phobic Disorders -- including agoraphobia (fear of either being alone
or in public) with and without panic attacks, social phobias (fear of
public humiliation), and simple phobias (fear of certain objects or
animals).

Anxiety States -- including primary panic disorders, generalized
anxiety, and obsessive-compulsive disorder.

Post-traumatic Stress Disorders -- characterized by abnormal
psychological reactions to stressful events, e.g. war experiences.

Atypical Anxiety Disorder

   Free-floating anxiety is also a major symptom of depressive
states, hysterical reactions and some psychotic illnesses.

   Evaluation and Treatment

   Some amount of anxiety is unavoidable with the stress of modern
life; however, when it is severe enough to affect one's happiness or
ability to perform everyday activities, it deserves medical
evaluation.  One must be careful not to dismiss physical explanations
too quickly, in the same way that one should be prepared to accept a
psychological cause when medical conditions are excluded.

   The place to start is with a complete examination, including blood
tests, X-rays, etc. as indicated.  Consultation with a psychiatrist
or therapist may become necessary.  Treatment regimens for anxiety
disorders independent of physical illness may involve psychotherapy,
behavioral therapy, relaxation training, hypnosis, family counseling
and tranquilizers such as benzodiazepines (Valium) and other
medications.  Panic disorders may respond to phenelzine or
imipramine.  Learning how to avoid stress, getting enough rest and
eating right are also important.

   One final note:  Although tranquilizing medications help many
individuals, they have a high potential for abuse and side effects.
A pill is not always the best or easiest answer to this complicated
problem.





   INSOMNIA

   Despite the traditional belief that eight hours comprise a good
night's sleep, healthy individuals vary widely in the quantity of
sleep they need.  While the average is about seven to eight hours,
others need as few as three or as many as ten hours of sleep each
night to feel refreshed.  Because there is no standard daily sleep
requirement, insomnia or sleeplessness is considered to be of medical
importance only when it compromises a persons's ability to function
in everyday life.  One of the three most common disorders that
primary care physicians are asked to evaluate, it affects about one
out of every three adults.

   Major Causes

Situational/Psychological -- Emotional disturbances are the most
common reasons for an inability to sleep.  The stresses of modern
life, financial insecurity, job worries, family discord, health
concerns, excitement, etc. all may contribute to insomnia.  In
addition, sleeplessness is a cardinal symptom of depression and
anxiety disorders.  Classically, depressed persons have insomnia and
fitful sleep, yet they awaken early in the morning.  Also, an
inability to sleep may be a result of major psychoses such as
schizophrenia and manic-depressive illness.

Altered Sleep-Wake Cycle -- Most of us have a stable pattern of
activities that relate to the solar day.  If we work days, we sleep
nights and vice versa.  When this cycle is disrupted, insomnia can
occur.  Disturbances in the sleep-wake cycle may be seen in frequent
travelers to distant time zones and in employees who rotate
day-night/night-day work schedules.

Medical Illness -- A number of health problems produce symptoms that
can disturb sleep.  Ulcer pain, asthma attacks, croup and itching
tend to be more frequent at night.  Congestive heart failure,
heartburn and sinus congestion may be aggravated when a horizontal
postion is assumed.  In addition, intestinal and urinary disorders
which require frequent trips to the commode, and any condition that
causes severe pain, can disrupt the sleep pattern.

Drugs -- Among the prescribed, non-prescription and illicit drugs
that can cause insomnia are stimulants such as caffeine, diet pills
and speed; tranquilizers; hormones; cancer chemotherapy; blood
pressure medications; alcohol; and thyroid medicines. Sudden
withdrawal of depressants (downers), alcohol, sleeping pills,
narcotics, psychiatric medication and most recreational drugs can
produce abstinence syndromes manifested, at least in part, by
sleeplessness.

Sleep Disorders -- Three primary sleep disorders are implicated.
Myoclonic syndrome refers to an involuntary nocturnal jerking of the
leg muscles.  The restless leg syndrome is manifested by an
ill-defined nighttime discomfort in the legs that is relieved by
walking.  Finally, sleep apnea includes a variety of conditions
characterized by repetitive episodes of sleep-induced cessation of
breathing.  In severe cases, heart disease and sudden death can
occur.

Hospitalization -- Persons who are admitted to the hospital often
have multiple reasons for insomnia: illness, medication, anxiety,
noise level, environmental stress, etc.

Aging -- Sleep requirements diminish only slightly with advancing
age, but the elderly may sleep less soundly.  Daytime inactivity and
napping may contribute to insomnia in this population.

   Evaluation

   The initial step is a detailed medical history and examination.
Attention is paid to psychosocial problems and stress-related health
complaints.  Usually the diagnosis is readily apparent, but blood
tests may be required.  Referral to a psychiatrist, sleep center or
specialist in sleep disorders may be appropriate for difficult cases
which do not respond to treatment.

   Treatment

   The therapy must be tailored to the diagnosis, e.g. medication
change, pain control, improvement in life situation.  General
measures include stopping caffeine and alcohol, regular exercise,
relaxing before bedtime, avoidance of daytime naps and developing a
sleeping routine.  Use of the bedroom should be reserved only for
sleeping.  Specific measures include relaxation training and sleeping
pills.  The benzodiazepine class of hypnotic medications (Dalmane,
Restoril, Halcion) is commonly prescribed.  In general, sleeping
pills are addicting, have side effects and are ineffective after
long-term use.  And withdrawal syndromes may actually aggravate
insomnia.  These medications should be used with discretion and close
medical supervision.






   HALLUCINATIONS

   A hallucination is an imagined sensory phenomenon.  Sounds,
sights, smells, tastes or tactile (feel) sensations are perceived to
exist without basis in external reality.  Although psychiatric
diseases are often implicated, a variety of drugs, medications and
hormonal and neurologic disorders may be responsible.

   Hallucinations are not always abnormal or indicative of disease
states.  Dreaming, and hallucinations in the periods just before
falling asleep (hypnogognic) and waking up (hypnopompic), are common
examples.

   Major Causes

Psychiatric Disease -- Persons with schizophrenia and other psychoses
frequently suffer from hallucinatory disturbances. Auditory (hearing)
phenomena predominate.  Often, voices are perceived to originate from
within one's own body, or from other persons or objects.  The content
may be variable: highly emotional, pleasant, threatening,
guilt-producing or commanding.

Hallucinogenic Drugs -- Typified by LSD, mescaline and peyote, these
illegal substances produce primarily visual disturbances. The user
may experience flashes of light, bright colors and distortion of
shape, movement and hue.  Auditory hallucinations are less frequent.
Flashbacks may occur spontaneously months after stopping the drug.

Alcohol and Other Drugs -- Addiction to alcohol may be complicated by
acute and chronic auditory hallucinosis. Withdrawal from alcohol is
often characterized by visual and tactile (haptic) hallucinations.
The latter, often described as crawling sensations or bugs on the
skin, is known as formication.  Cocaine abusers may have similar
symptoms ("the bug").  Barbiturates and common tranquilizing
medications may precipitate hallucinations when their use is stopped
suddenly. And finally, intoxication with amphetamines (speed),
atropine (locoweed) or anti-psychotic medication is sometimes
responsible.

Seizure Disorders -- Persons with epilepsy of the temporal lobe of
the brain sometimes have discomforting disturbances of taste
(gustatory) and smell (olfactory) as part of a warning or aura prior
to a convulsion.  Other types of hallucinatory experiences are less
common.

Miscellaneous -- delirium from any cause, drug or medication
overdose, strokes, brain tumors, overactive thyroid disease, kidney
failure, blood chemistry imbalance.

   Evaluation and Treatment

   A complete medical history and examination is the place to start.
It is important to focus on prescribed and illicit drug use, alcohol
intake and previous psychiatric or neurologic disease.  Blood and
urine tests and drug screens may be elucidating.  If the history or
physical findings suggest seizures or another neurologic disorder, a
brain wave test (EEG) and brain X-rays (CAT scan) can be helpful.
Early psychiatric consultation is advisable for patients without a
physical cause. Therapy depends upon the underlying problem, e.g.
drug rehabilitation, psychiatric medication, seizure medicine, etc.






   POOR EYESIGHT AND BLINDNESS

   Normal vision requires that light rays be allowed to pass through
the cornea, the clear outer covering on the outside of the eye.  The
lens, located behind the pupil, focuses the rays through the
jelly-substance of the eyeball onto the light- sensitive retina at
the back of the eye.  The image formed on the retina then is
converted to electrical impulses which are transmitted along the
optic nerve to the visual centers in the brain.  The brain interprets
these messages from the eye as the picture we see.  Poor or absent
vision may result from a disturbance in any portion of this pathway.

   Major Causes

Near-sightedness (myopia) -- An inability to see in the distance
occurs when the light image is focused just in front of the retina.
In general, the eye is slightly larger than normal.

Far-sightedness (hyperopia) -- The inability to see up close occurs
when the light image is focused just beyond the retina.

Presbyopia (old eyes) -- In the mid-forties, most of us begin to have
difficulty focusing on near objects due to hardening of the substance
of the lens.  Reading glasses are corrective.

Cataracts -- Clouding of the lens occurs with aging and in
association with congenital disorders, diabetes, infection, injury
and medications.

Glaucoma -- An increase in the pressure inside the eye damages the
cornea, iris, lens, retina and optic nerve.

Macular Degeneration -- The macula is the important central, most
color-sensitive section of the retina.  It may degenerate
spontaneously leading to significant vision loss.

Retinal Detachment -- Loosening of the retina from the back lining of
the eye results in flashing light sensations followed by loss of
vision.  A hole in the retina is the usual cause.

Retinal Artery Occlusion -- Blockage of the tiny arteries of the
retina can result in sudden, painless loss of vision.

Retinal Vein Occlusion -- Blood clots in the veins of the retina
cause bleeding into the retina.

Eye Hemorrhages -- Bleeding into the jelly portion of the eye is more
common in persons with diabetes and atherosclerosis.

Strokes -- Damage to the visual centers and connections in the brain
may cause loss of sight in the absence of eye disease.

Miscellaneous -- eye injury, head injury, diabetes, retinitis
pigmentosa, damage or disease of the optic nerve, multiple sclerosis,
electric shock, medication toxicity, congenital disorders,
infections, migraines, retinopathy of prematurity or retrolental
fibroplasia.

   Evaluation

   Any change in one's ability to see requires prompt evaluation by
an ophthalmologist.  Vision testing and eye examination reveal the
cause in most instances.  For additional information please consult
the Eye Disorders and Disease section.





   DOUBLE VISION (Diplopia)

   Due to its position on either side of the nose, each eye views an
object from a different perspective.  As light from an object hits
each retina (the light-sensitive membrane at the back of the eye) in
corresponding but not identical locations, slightly different images
are created.  Although the brain receives two retinal images, it
interprets them as one and uses the difference in perspective to
allow for depth perception.  Diplopia, the medical term for double
vision, is classified as monocular (i.e. one eye) when two images are
seen only when the affected eye is open and the other eye closed.
Binocular (two eyes) diplopia refers to seeing double only when both
eyes are open.

   Major Causes

   Monocular diplopia occurs when two different images are displayed
on the same retina.  Possible explanations include dislocation of the
lens, the portion of the eye that focuses light onto the retina;
injury of the iris, the colored part of the eye; disorders of the
macula, the most sensitive part of the retina; congenital doubling of
the pupils; and certain types of cataracts.  This type of double
vision is very uncommon. Hysteria and malingering (feigning illness)
may be responsible.

   Binocular diplopia occurs when the brain misinterprets the slight
normal differences in the images received from each eye or when
images are formed on each retina in widely disparate locations.  An
example of the former is the double vision seen with intoxication
from alcohol.  The latter occurs when one or both eyes is pushed out
of position or when there is strabismus, a paralysis or weakness of
the eye muscles resulting in an eye turning in, out, up, or down
(e.g. crossed eyes, walleyed.) Among the disorders that have been
implicated are eye tumors, infections, blood clots, thyroid disease,
strokes, multiple sclerosis, injury, previous eye surgery, skull
fractures, diabetes and botulism.

   Evaluation and Treatment

   Consultation with an ophthalmologist is recommended.  See Eye
Disorders and Diseases for additional information.





   RED OR PINK EYE(S)

   After loss of sight, redness is the most common symptom for which
persons consult physicians about their eyes.  Redness may be
associated with eye pain, drainage, tearing, itching or changes in
vision.

   Major Causes

Conjunctivitis ("pink eye") -- Inflammation of the conjunctiva, the
clear membrane lining the outside of the white of the eye and the
undersurface of the lids, is the most frequent explanation for a red
eye.  Bacterial and viral infections may affect one or both eyes;
they are highly contagious.  Allergic conjunctivitis with tearing and
swelling of the eyelids is seen with "hay fever" and other
sensitivity reactions.

Foreign Bodies -- Dusts, solid objects, metal, wood chips, glass,
lashes, etc. may fly into the eye causing irritation, inflammation
and infection.

Subconjunctival Hemorrhage -- Bleeding beneath the conjunctiva may
result in a bright red spot.  Injury (e.g. eye rubbing), coughing,
straining, sneezing and high blood pressure may be responsible.

Abrasions and Ulcers -- Scrapes of the cornea (the clear protective
layer over the iris and pupil) or the conjunctiva can cause the
sensation that something is in the eye.  Tearing, redness and pain
ensue.  Ulcers or erosions on the surface of the eye are due to
chemical injuries (acids, Mace) or infections with viruses, bacteria
or fungi.

Pingecula -- These tissue growths develop adjacent to the iris on the
surface of the white of the eye.  With wind, dust or smoke, they
become irritated.

Episcleritis -- This term refers to inflammation of the white part of
the eye (sclera).  The eye is bright red and painful, but there is
usually no drainage or change in vision.  This disorder is often
associated with arthritis and intestinal diseases.

Glaucoma -- A sudden increase in the pressure of the fluid inside the
eye causes pain, an enlarged pupil and decreased vision. Headache,
nausea and vomiting may ensue.  This is a medical emergency!

   Evaluation

   Examination of the eye with complete vision and glaucoma tests is
indicated.  With conjunctivitis the redness will blanch under direct
pressure.  Drainage can be cultured for infecting organisms.
Fluorescent dye testing will disclose a corneal abrasion or ulcer.
Foreign objects are usually visible. Consultation with an
ophthalmologist may be necessary.

   Treatment

   Conjunctivitis responds to warm compresses and antibiotics
eyedrops.  Cool compresses are indicated for hemorrhages. Foreign
objects should be removed immediately.  Special eyedrops, medications
or surgery may be required for the other disorders. See Eye Disorders
and Diseases for additional information.







    SEEING SPOTS AND FLOATERS

   Seeing spots, webs, flashes or sparks in front of your eyes can be
frightening.  Although serious eye disorders may be responsible,
there is usually little cause for concern.  A careful eye examination
is indicated.

   Major Causes

   Floaters are dark spots, webs or threads which are visible against
a light background.  They continue to move across the line of sight
after the eye has come to rest.  Most often they are due to aging and
degeneration of the vitreous, the jelly part of the eye.
Near-sighted persons are predisposed.  Similar spots can be produced
by tears or detachment of the retina, the light- sensitive part of
the eye; uveitis, inflammation of the middle layer of the outer
lining of the eye; and by bleeding and infections inside the eye.
Sometimes mucous on the outside of the eye will come across the pupil
and partially blur one's vision.  This goes away with blinking.

   Dark spots that do not move across the field of vision may result
from injury, degeneration, tumors, disease or infection of the
retina.  Other causes include glaucoma and strokes.

   Bright sparks or flashes of light may be seen after blows on the
head, with migraine headaches and as warning signs of retinal
detachment.

   Evaluation

   Examination by an ophthalmologist is necessary to exclude serious
disease of the inside of the eye.  In the overwhelming majority of
cases, floaters do not represent a permanent threat to vision.  See
Eye Disorders and Diseases for additional information.







   EARACHE (Otalgia)

   The medical term for pain in the ear is "otalgia."  It is the most
frequent health complaint that family physicians and pediatricians
are asked to evaluate.  Most often ear pain is attributable to
infection, injury or pressure in the ear. Sometimes, however, pain
that is perceived to come from the ear may actually originate from
structures in the head, neck or chest.  This type of discomfort is
called referred ear pain.  It accounts for over half the cases of
earache in adults.

   Major Causes

Otitis Media -- Infection of the middle ear (behind the eardrum) is
the most common cause in young children.  Fever, hearing loss and
irritability may be associated.

Otitis Externa -- "Swimmer's ear" infections of the ear canal are
frequent in the summer months.  Ear drainage is common. Cellulitis, a
serious infection of the entire outer ear, may ensue.

Injury and Cold Exposure -- Blows to the ear may lacerate the skin,
cause fractures and bleeding, and injure the hearing mechanism and
eardrum.  The outer ear is particularly susceptible to frostbite.

Barotrauma -- Sudden changes in pressure, such as those induced by
scuba diving and air flight, may precipitate ear pain due to pressure
on the eardrum.  Persons with colds and sinus congestion are at
increased risk.

Herpes Zoster Oticus -- Herpes virus or "shingles" infections of the
outside of the ear are marked by painful external blisters and,
sometimes, vertigo and paralysis of the face.

Bell's Palsy -- Paralysis of the muscles on one side of the face may
be heralded by ear pain.

Mastoiditis -- Infection of the mastoid sinuses behind the ear may
follow inadequately treated middle ear infections.

Tumors -- Cancers of the ear, the ear canal and the adjacent bones of
the skull are relatively rare.

Referred Pain -- Tonsillitis, throat infections, gum and teeth
disorders, enlarged lymph glands in the neck, nerve irritation,
inflammation of the thyroid gland, arthritis of the jaw and neck, and
even heart attacks may transmit pain to the ear.

   Evaluation

   The examination of the head, ears, nose, throat, sinuses and neck
will almost always reveal the diagnosis.  The most important part of
the exam is the inspection of the eardrum and ear canal using an
otoscope (lighted instrument with magnification).  X- rays may be
necessary to detect sinus infections, tumors or arthritis.

   Treatment

   Please consult the Disorders and Diseases section for information
about the therapy of the underlying causes.  Besides antibiotics,
warm compresses and aspirin or acetaminophen (e.g. Tylenol) are
prescribed for most ear infections.  Swimming should be avoided.





   HEARING LOSS AND DEAFNESS

   Hearing loss affects about fifteen million Americans, most of them
at the extremes of age.  In children, untreated deafness can result
in slow learning, decreased communicative skills and delayed
psychosocial development; in adults, it can lead to loss of work,
frustration and social isolation.

   There are two types of hearing loss: conductive hearing loss (CHL)
and sensorineural (SNHL).  The former includes disorders of the
external ear, ear canal, eardrum and middle ear (part of the ear just
behind the eardrum).  The latter includes disorders that affect the
cochlea (the inner ear organ of hearing), the auditory nerve and the
parts of the brain responsible for interpreting sound.

   Major Causes

Conductive Hearing Loss -- Obtruction of the ear canal due to earwax,
deformity, foreign objects, infection or tumor may block the pathway
through which sound waves hit the eardrum.  Earwax is the most common
cause.  Holes in the eardrum diminish its ability to vibrate.
Infections, fluid accumulations and tumors of the middle ear may
decrease the transmission and amplification of sound after it hits
the eardrum.  Chronic infections may damage the eardrum itself and
the tiny bones responsible for conducting sound from the eardrum
through the middle ear to the cochlea. Otosclerosis, an inherited
disease of the bones in the middle ear, affects about one in ten
white Americans.

Sensorineural Hearing Loss -- Congenital (inborn) and inherited
disorders are frequently responsible.  Examples are chromosome
abnormalities, exposure to rubella (German measles) during pregnancy,
birth injury, cerebral palsy and cretinism.  Acquired infections such
as mumps, chickenpox, measles, herpes, meningitis and congenital
syphilis have also been implicated. Medications can damage the inner
ear hearing mechanism.  Aspirin, "mycin" antibiotics, diuretics
("water pills") and quinine are the major offenders.  Miscellaneous
causes of SNHL are noise exposure, tumors of the auditory nerve or
brain, Meniere's disease, aging, diabetes, strokes and head injuries.

   Evaluation

   A complete general and ear examination with formal hearing testing
(audiometry) is recommended.  Special ear and neurologic tests can
detect even minor abnormalities of the ear and the nerve connections
to the brain.  X-rays of the ear canals, the bones of the skull, and
the brain may be helpful.  An ear, nose and throat specialist
(otolaryngologist) may be consulted for difficult cases.





   RINGING IN THE EARS

      (Tinnitus)

   Introduction

   Ringing or buzzing in the ears is referred to by physicians as
"tinnitus."  It is most often noticeable at rest when ambient noise
is diminished; however, when severe, it can disturb normal hearing.
Tinnitus should not be confused either with normal sounds in the head
related to the movement of jaw, facial muscles and neck, or with
auditory hallucinations (hearing voices).  Ear disorders are usually
implicated.

   Major Causes

Earwax -- Blockage of the ear by wax may produce low-pitched tinnitus
and muffled hearing.  Swimming or showering may force the wax deeper
into the canal.

Otitis Externa -- "Swimmer's ear", an infection of the ear canal, is
frequent in hot weather.  Ear pain is a cardinal symptom.

Otitis Media -- Infection of the middle ear is one of the most
commmon childhood illnesses, but any age can be affected.

Perforated Eardrum -- i.e. hole in the eardrum.

Loud Noises -- High-pitched tinnitus and hearing loss can occur after
noise exposure, e.g. explosions, loud music.  Permanent hearing
deficits can develop after prolonged exposure.

Meniere's disease -- Hearing loss, tinnitus in one ear and vertigo
(spinning sensation) are characteristic of this disorder of the inner
ear.

Medications -- Aspirin, some of the "mycin" antibiotics, and other
drugs are notorious for producing this side effect.

Otosclerosis -- A disease of the small bones in the middle ear, it
affects about one percent of the population.  It is manifested by a
gradual onset of hearing loss and tinnitus.

Miscellaneous -- tumors, high and low blood pressure, anemia, loud
heart murmurs, abnormal blood vessels in the head, syphlilis of the
brain, arsenic poisoning, presbyacusis (aging of the hearing
mechanism), strokes, foreign objects lodged in the ear canal.

   Evaluation

   Physicians must rely on a careful health history and exam. Often,
inspection of the ear canal and eardrum will reveal the diagnosis.
An ear specialist may be consulted for hearing tests, X-rays and
sometimes, surgery.

   Treatment

   Earwax and most infections are easily treated.  Although tinnitus
has a natural tendency to diminish over time, it is frequently
resistant to therapy.  Withdrawal of the offending medication or
predisposing factor may result in improvement if permanent damage has
not already occurred.  Ear surgery may be indicated for otosclerosis,
tumors or Meniere's disease. Medications such as lidocaine,
carbamazapine, phenytoin, and primidone have shown some promise in
some patients.  Relaxation techniques, biofeedback, hearing aids and
electronic masking devices are sometimes helpful.  Research is
ongoing.








   NOSEBLEED (Epistaxis)

   We have all suffered the misfortune of having had an important
activity interrupted by profuse bleeding from the nose.  While
frightening and perhaps embarrassing, most nosebleeds remit easily
and are not indicative of a serious bleeding disorder. "Epistaxis" is
the medical term for a nosebleed.

   Major Causes

   Injury to blood vessels is, by far, the most common cause of
nosebleeds.  Nosepicking is a significant factor--especially in
children.  Fistfights, contact sports and work accidents are not
uncommonly implicated.  Nosebleeds occur more frequently in the
winter months when low humidity heat produces dry, scabbed nasal
membranes.  Noseblowing and sneezing may precipitate the
hemorrhaging.

   Persons taking aspirin or "blood-thinning" medications are at
increased risk.  Spontaneous bleeding may complicate the course of
colds, hay fever, and nose and sinus infections.  Persons with high
blood pressure, abnormal blood vessels in the nose or diseases of the
blood's clotting system (e.g. hemophilia) are also prone to
nosebleeds.  The latter group rarely develops epistaxis in the
absence of hemorrhage from other sites.

   Evaluation

   Finding the source of the bleeding is important.  When there is
active hemorrhage, blood must be suctioned out in order for the
doctor to complete the nasal examination.  The majority of nosebleeds
originate from a damaged web of veins in the front of the nose called
Kiesselbach's plexus.  With a bright light, a physician can view
these vessels directly and identify the bleeding site in most cases.
Localization of the exact bleeding site in the back of the nose is
more difficult because of the relative inaccessability of that area.

   Persons with recurrent, spontaneous nosebleeds not attributable to
a damaged blood vessel should be evaluated to exclude an underlying
blood clotting disorder.

   Treatment

   At the start of bleeding, the nose should be squeezed firmly
between the fingers.  The person is best kept in a sitting position
to prevent choking from drainage of large amounts of blood into the
back of the throat.  Ice can be applied directly to the nose.  To
control the bleeding, a physician may have to pack the nose with
adrenalin-impregnated gauze.  The packing may have to stay in place
for up to ten days.

   Once bleeding has stopped, broken vessels in the front of the nose
can be cauterized (burned chemically or electrically) to prevent a
recurrence.  Occasionally, surgery is necessary to tie a bleeding
artery or place a skin graft over weakened blood vessels.
Transfusions are employed when there has been significant blood loss.
 Preventive measures include home humidification, especially the
bedroom, and avoidance of nosepicking.





   RUNNY NOSE (Rhinorrhea)

   Runny nose is a common symptom of diseases of the nose and
sinuses.  The discharge may be thin and watery, thick like mucous or
yellow-green like pus.  Sneezing, congestion, postnasal drip and
cough may be associated.  Allergic and infectious disorders are often
responsible.  The medical term for a runny nose is "rhinorrhea."

   Major Causes

Common Cold -- Viral infections of the nose and upper respiratory
tract usually begin with a thin, clear discharge from the nose. Nasal
congestion and thicker mucous develop later.

Allergic Rhinitis ("Hay Fever") -- Runny nose, sneezing and itchy
eyes may occur seasonally or year-round.  Allergic disorders such as
asthma, eczema and hives may be associated.

Vasomotor Rhinitis -- Although this disease is similar to hay fever,
no allergic component can be identified.  The symptoms are often
brought on by smoke or temperature changes.

Sinusitis -- Infection or inflammation of the sinuses usually results
in a stuffy nose, face pain or headache, and fever.  When there is
drainage from the nose, it is thick and yellow-green in appearance.

Cerebrospinal Fluid (CSF) Rhinorrhea -- CSF, the thin watery fluid
that bathes the brain and spinal cord, can leak from the nose through
fractures in the skull and sinuses.  Head injury, previous surgery
and tumors are sometimes implicated. Meningitis, an infection of the
membranes lining the brain, may result.

Miscellaneous -- measles, congenital syphilis, diphtheria, nasal
polyps (benign growths), overuse of decongestants, foreign objects in
the nose , ozena--an inflammatory disease of unknown cause.

   Evaluation

   The diagnosis is often readily apparent after the health history
and examination of the head, ears, nose and throat. Examination of
the drainage under the microscope may reveal signs of an allergic
reaction or infection.  Sinus X-rays can be helpful.  When CSF
rhinorrhea is suspected, special X-rays and scans of the head, brain
and CSF are indicated.

   Treatment

   Therapy depends on the cause.  Decongestants help cold symptoms.
Antihistamines and decongestants are effective for allergic and
vasomotor rhinitis, but more potent medications are sometimes
necessary.  Aggravating factors should be avoided. Sinusitis is
treated with antibiotics.  CSF rhinorrhea may heal spontaneously or
require an operation.





   ABNORMAL SENSE OF SMELL

   Our sense of smell is important for protection from fire, smoke,
noxious gases and poisons, as well as for the enjoyment of life's
finer things.  While anosmia, the loss of the sense of smell, is not
often a major disability, it affects the sense of taste and can
change one's whole outlook towards eating and food preparation.
Hyposmia, the decreased ability to smell, and dysosmia, the
distortion of smell, can be extremely bothersome. Fortunately, these
disorders are usually short-lived.

   Major Causes

   As air is inspired, aromas are picked up by tiny branches of the
olfactory nerve located beneath the membranes of the nose. The
sensation is transmitted to the brain along nerve fibers which course
through tiny holes in the skull inside the top of the nose.  The
brain discriminates between odors.  Disorders of smell may result
from disruption of any portion of this pathway. Among the causes:

Infections -- The common cold decreases smell by causing swelling and
inflammation inside the nose.  Influenza and viral hepatitis are
other infectious causes.

Diseases Affecting the Nose -- e.g. hay fever, sinusitis, nasal
polyps (benign growths), obstruction to air flow from any cause.

Neurologic Disorders -- Head injuries can fracture the skull and
damage the olfactory nerve.  Brain tumors and degenerative diseases
like multiple sclerosis are rarely implicated.

Nutritional Deficiencies -- e.g. vitamins B12 and A, zinc

Congenital Disorders -- Inborn anosmia may be associated with a
deficiency of the male hormone, testoserone (Kallman's syndrome).

Medications -- aspirin, arthritis medicines, cancer chemotherapy,
antibiotics, many others.

Miscellaneous -- diabetes, aging, underactive thyroid gland,
cigarette smoking, air pollution, psychiatric illness, cystic
fibrosis, cirrhosis, kidney failure.

   Evaluation

   Nose, throat and neurological examinations are performed. The
ability to smell can be tested by asking the person to identify known
odors with their eyes closed.  If the cause is not readily
identifiable, referral to a neurologist or ear, nose and throat
specialist may be necessary.  Brain and skull X-rays and hormone
tests are employed.

   Treatment

   General measures include use of more seasoning, food flavor
additives, eating slowly and chewing better, and alternating foods
with each bite.  Specific therapy depends on the cause. For anosmia,
zinc and methacholine have been touted by some researchers, but proof
of their efficacy is lacking.





   ABNORMAL SENSE OF TASTE

   Taste sensation relies on normally functioning taste buds located
on the tongue, throat, lips and palate; an intact sense of smell; and
the ability of the brain to integrate this information into a variety
of perceptible flavors.  Diseases, injuries or medications that
affect any portion of this delicate system may alter the sense of
taste.  The distortion (dysgeusia), diminution (hypogeusia) or
complete absence of taste (ageusia) can significantly affect the
quality of human life as well as present a danger from the ingestion
of spoiled foods.

   Major Causes

Disorders of Smell -- Taste is greatly altered by the loss of smell,
e.g. colds, hay fever, sinusitis.  Please consult the article in this
section entitled "Abnormal Sense of Smell" for a more complete review
of these disorders.

Neurologic Disorders -- head injuries; Bell's palsy (paralysis of the
facial nerve, the nerve responsible for taste sensation on the front
two-thirds of the tongue); multiple sclerosis.

Nutritional Disorders -- zinc and niacin deficiencies.

Hormonal Diseases -- diabetes, adrenal gland disorders, underactive
thyroid.

Medications -- antibiotics, blood pressure medicines, narcotics,
aspirin, arthritis medicines, cancer chemotherapy.

Miscellaneous -- influenza, hepatitis, kidney failure, "voicebox"
surgery, ear surgery, congenital abnormalities of the face, cancer,
cirrhosis, radiation therapy, dental disease.

   Dysgeusia is  most often attributable to dental disease or sinus
infection and postnasal drip.

   Evaluation

   Bitter, sweet, sour and salty, the four primary taste sensations,
can be tested for directly with samples placed on the tongue.
Electrical measurement can quantitate the response to stimuli applied
to the tongue.  Ear, nose, throat and neurologic examinations are of
primary importance.  Consultations with a specialist may be
advisable.

   Treatment

   Foul tastes can be relieved by chewing gum, baking soda swishes
and mouthwashes.  Zinc supplements may be effective in some persons
with ageusia.  Cortisone medications, vitamins and allergy treatments
are recommended in special cases.  General measures include use of
more seasoning and food flavoring additives, eating slowly and
alternating foods between bites.





   MOUTH SORES

   Sores or ulcers in or around the mouth are a common source of of
embarrassment as well as discomfort.  The pain is especially
aggravated by eating crunchy, salty or acidic foods.  Although
benign, short-lived disorders are usually responsible, some serious
skin diseases, infections, tumors and nutritional deficiencies can
first reveal their presence in this manner.

   Major Causes

Aphthous Ulcers -- The common "canker sore" is manifested by a
shallow, pale ulcer in the mouth, under the tongue or near the lips.
The cause is unknown, but they may occur in association with
arthritis and diseases of immunity.  They resolve in about a week.

Herpes Labialis -- The "cold sore" or "fever blister" is, in reality,
a recurrent infection with a herpes virus.  A painful blister(s)
occurs on the lip.  It crusts over and goes away in about seven to
ten days.

Herpes Stomatitis -- The herpes virus may also infect the inside of
the mouth, throat, palate and tongue causing blisters, ulcers,
redness and swelling.  Like cold sores, this infection may be more
common in times of physical and emotional stress.

Vitamin Deficiencies -- Lack of vitamins A, B6, B12, C, D, thiamine,
riboflavin, niacin, folic acid and biotin, as well as a lack of iron
and zinc causes a number of different mouth and tongue sores.
Perhaps surprisingly, vitamin C deficiency affects only the gums.

Vincent's Stomatitis -- "Trench mouth" is a contagious bacterial
infection of the gums.  Painful, bleeding ulcers are associated with
fever.

Venereal Infections -- Syphilis and gonorrhea can be contracted
through oral-genital intercourse.

Injury -- i.e. damage to the sensitive membranes in the mouth from
dentures, foods, bones, burns, bad teeth or radiation therapy.

Medications -- Mouth inflammation is a side effect of many medicines
including gold, penicillin, penicillamine, local anesthetics,
aspirin, quinidine and phenytoin (Dilantin).

Tumors -- Cancers of the lip, tongue and mouth are much more common
in pipesmokers and users of smokeless tobacco.

Miscellaneous -- tuberculosis, yeast infections (thrush), leukemia,
Behcet's syndrome, diabetes, allergic reactions, pernicious anemia,
lupus, scarlet fever, neurologic diseases.

   Evaluation and Treatment

   In most cases the appearance of the sores, ulcers or areas of
inflammation will give the examiner a clue to the diagnosis. Biopsy,
cultures or blood tests may be indicated depending on what is
observed and how long it has been present.  A throat specialist or
dentist may have to be consulted.

   Therapy depends on the cause.  General measures are aspirin or
local anesthetic gels (e.g. lidocaine) for pain, bland easy-to- eat
foods and throat lozenges.





   SORE THROAT

   Sore throat is one of the most common afflictions known to man.
Typically, it is described as a raw or burning sensation in the back
of the throat (pharynx) that is aggravated by swallowing.  Children
are particularly susceptible.

   Major Causes

   Infection of the throat (pharyngitis) is usually responsible.
Tonsillitis may occur concomitantly.  Among the infectious causes
are:

Viruses -- Eighty to ninety percent of sore throats are caused by
viral upper respiratory infections, i.e. the common cold. Infectious
mononucleosis (Mono.) is a viral infection which classically presents
with a bad sore throat, swollen glands, fatigue and fever.  Young
adults are predisposed.  Other viral causes include measles,
chickenpox, herpes and whooping cough.

Bacteria -- By far the most common bacterial infection is the
streptococcus (strep.); however, it accounts for only ten to twenty
percent of throat infections.  Fever and swollen lymph glands are the
cardinal symptoms.  Children may have abdominal pain and vomiting.
Scarlet fever and rheumatic fever may be complications of a strep.
throat.  Although other bacteria are not often implicated, gonorrhea
may cause pharyngitis in persons who have had oral-genital
intercourse.  Rare since the development of effective immunization,
diphtheria presents with a malodorous membrane-like covering on the
throat.

Fungi -- These infections occur primarily in persons with decreased
immunity due to disease or medication.  Diabetics and persons taking
antibiotics or cortisone medications may develop yeast infections
(oral Candidiasis or thrush).

   Not all sore throats are caused by infections.  Inhaled irritants,
throat injury, chronic postnasal drip, mouth breathing, neuralgia and
inflammation of the thyroid gland must be considered when infection
is unlikely.  A sore throat may be a symptom of decreased numbers of
white blood cells--as seen in persons with leukemia.

   Evaluation

   Sneezing, cough, hoarseness, runny nose and sore throat are
characteristic of the common cold.  Classically, strep. pharyngitis
is marked by a red throat and enlarged tonsils covered with pus; yet,
because viral infections can produce a similar appearance, a throat
culture is necessary to make the diagnosis.  In general, even
physicians cannot tell a strept. throat from a viral infection by the
appearance of the throat.  A blood test is required to diagnose Mono.
 Most non-infectious causes are apparent from the history.

   Treatment

   When viral infections are responsible, no specific therapy is
available.  Throat lozenges, saltwater gargles, voice rest, liquids
and analgesics may provide some relief.  Antibiotics, such as
penicillin, are ineffective and may predispose to resistant bacterial
infections and adverse side effects.

   Penicillin is the treatment of choice for strep. throat in
nonallergic persons.  It can prevent the complications of abscess
formation and rheumatic fever.





   PALPITATION

   (Abnormal Heart Beat)

   Except with excitement or physical exertion, most of us are not
consciously aware of the muscular contractions of our heart. The
uncomfortable feeling of one's heart beating is referred to as
palpitation.  It may be described as a "pounding," "racing," or
"skipping," sensation.  Although sometimes heralding significant
heart disease, palpitation is often due to medications, diet or
psychological disorders.

   Major Causes

   Each heart beat is a coordinated contraction of the heart muscle.
The frequency, regularity and strength of the contractions are under
control of the heart's intrinsic electrical system--as modified by
disease and chemical, hormonal, and neurologic factors.  Palpitation
is a subjective sensation; the physical correlate is a change in the
rate, rhythm or contractility of the heart.

    Abnormal changes in the heart rate and rhythm are called
arrhythmias.  Along with temporary increases in the strength of
individual heart contractions, they are the major explanation for
palpitation when psychological causes are not responsible.  The
causes of palpitation are outlined:

Heart Disease -- Atherosclerosis, abnormal heart valves and primary
disorders of the heart muscle and intrinsic electrical system can
cause the heart to beat rapidly and irregularly. Palpitations,
sweating, lightheadedness, shortness of breath and low blood pressure
may result from these arrhythmias.

Fever, Anemia, Low Oxygen, Hypoglycemia and Dehydration -- These
disorders cause palpitation by increasing the heart rate and force of
contraction in an attempt to pump more blood.  When severe they may
provoke arrhythmias.

Thyroid Disease -- Increased blood levels of thyroid hormone due to
overactivity of the thyroid gland can stimulate the heart.

Medications -- Among the drugs implicated are adrenalin, heart
medicines, and aminophylline.

Alcohol, Tobacco, Caffeine and Amphetamines - These substance
increase the irritability of the heart muscle and electrical system.

Psychological Causes -- Anxiety, fear and stress are common
explanations for palpitation.

   Evaluation

   Recurrent palpitations require an evaluation to exclude a serious
arrhythmia or underlying disorder.  The history may implicate diet,
drugs or medications.  Examinaton of the heart is important.
Arrhythmias should be documented by electrocardiographic (EKG)
monitoring.  A twenty-four hour EKG taped recording (holter monitor)
is usually necessary to detect short-lived abnormal rhythms.  Blood
count, blood sugar and thyroid tests may be elucidating.  When
anxiety disorders are responsible, the EKG is normal at the time of
the symptoms.

   Treatment

   Therapy of the underlying problem is indicated.  There are
specific medicines for the prevention of arrhythmias. Reassurance
that there is nothing wrong is often effective when anxiety is a
major factor.  Propranolol (Inderal), a medication which slows the
heart beat and decreases its force of contraction, may help control
symptoms.





   SHORTNESS OF BREATH

   Shortness of breath (SOB, dyspnea) is defined as an abnormal
uncomfortable awareness of breathing.  It is best quantified by the
amount of physical activity it takes to bring it on (e.g. walking a
block).  Whether or not it is related to body position is also
important.  For example, orthopnea refers to SOB while lying supine.
It may indicate heart disease.  Healthy adults take about fourteen
600 ml. breaths each minute.  Persons who are severely SOB breathe
much more rapidly and deeply.

   Major Causes

   SOB may be caused by a wide number of disorders which affect the
lungs, chest wall, respiratory muscles, heart and nervous system.
Any obstruction to the normal flow of air from the mouth and nose to
the the tiny air sacs in the lungs can produce SOB. Back and ribcage
deformities, as well as paralysis or weakness of the respiratory
muscles, can upset the normal mechanics of inspiration and
expiration.  Diseases that damage the oxygen- absorbing membranes and
small blood vessels in the lungs also cause this symptom.  Heart and
blood disorders are commonly implicated.  Persons with kidney failure
or diabetic coma may experience SOB as they hyperventilate to rid
their bloodstream of excess acid.  Hyperventilation associated with
fear, pain or anxiety is a relatively benign disorder.  The common
disorders that cause of SOB are asthma, blood clot in the lungs,
bronchitis, heart failure, emphysema, collapsed lung, pneumonia,
work-related diseases such black lung and asbestosis, and anemia.

   Evaluation

   SOB is often a symptom of serious disease of the heart or lungs.
For this reason, it requires thorough evaluation by a physician.  A
history of smoking, cough, chest pain, fever, heart disease or chest
injury may point towards the diagnosis.  When the symptoms are severe
or new in onset, a complete examination with bloodwork, chest X-ray
and electrocardiogram (EKG) is usually indicated.  Specialized
breathing tests and measurement of the blood oxygen concentration may
be necessary.

   Treatment

   General measures such as rest, avoidance of tobacco and
supplemental oxygen administration are employed.  Mechanical
ventilation (respirator) is required for life-threatening situations.
 The use of antibiotics, heart and breathing medications or surgery
depends upon the specific cause.





   COUGH

   A cough is a forceful episodic expulsion of air from the windpipe
and bronchial tubes.  It functions to clear these airways of mucous
and foreign objects.  Coughing may be loose and productive of phlegm
(sputum), or it may be dry and irritative. A chronic cough can be
defined as one which persists for three to four weeks.  It is a major
manifestation of respiratory and cardiac disease.

   Major Causes

   Although coughing may be voluntary, reflex actions are responsible
for the cough due to disease.  The most common cause of a new cough
is the postnasal dripping of secretions into the back of the throat
which occurs in adults and children with the common cold.  Exposure
to airborn irritants, acute bronchitis (inflammation of the bronchial
tubes) and pneumonia are frequently implicated.  Croup is a type of
laryngitis/bronchitis that affects young children.  Chronic
bronchitis due to cigarette smoking is the most likely explanation
for a chronic cough in adults.  Postnasal drip due to hay fever or
sinus infection, asthma, lung cancer, tuberculosis, heart failure,
recurrent aspiration ("going down the wrong pipe") of mouth or
stomach contents and ear, nose, and throat infections and tumors are
some other possibilities.

   Evaluation

   Because it may be a sign of a serious illness, a cough should
never be ignored.  Important information can be gained from the
description of the cough.  A croupy cough has a brassy sound to it.
Coughs that produce thick green or yellow sputum imply bronchitis or
pneumonia.  Those which are worse at night may indicate heart
disease.  If associated with a history of allergy and wheezing,
asthma should be considered.  Cancer must be suspected in every
smoker with a new or changing cough, especially if there is a history
of bloody sputum or weight loss. Although a dry cough associated with
head congestion, fever, and sore throat, usually indicates a minor
viral infection, severe, persistent or worsening coughs require
medical attention.

   The physical examination is directed at the ears, nose, throat,
chest and heart.  The diagnosis may be apparent after the general
examination, but blood tests, sputum examination and a chest X-ray
are usually necessary.  Specialized breathing tests are used to
document asthma and other chronic lung diseases.

   Treatment

   Once the diagnosis is established, it may be possible to treat the
underlying cause: i.e. decongestants for postnasal drip, antibiotics
for bacterial infections, cessation of smoking for chronic
bronchitis, medication for asthma and heart disease, specialized
therapy for cancer.  General measures such as the avoidance of lung
irritants, rest and fluids are helpful.

   Productive coughs should not be suppressed as they perform a
useful function in clearing the airways of mucous.  When the cough is
dry, however, antitussives such as codeine and dextromethorphan
(Robitussin DM) are helpful.  Expectorants like guaifenesin may
loosen up thick mucous.





   COUGHING BLOOD (Hemoptysis)

   The coughing of blood or bloody mucous (sputum) is referred to as
hemoptysis.  It can vary from slight streaking of the mucous to
life-threatening hemorrrhage.  Because hemoptysis may be a warning
signal of serious lung or heart disease, its cause should always be
investigated.

   Major Causes

   Bronchitis -- Inflammation or infection of the bronchial tubes is
the most common cause of coughing up blood-tinged mucous. Cigarette
smoking is a risk factor.

   Lung Tumors -- The onset of hemoptysis in a cigarette smoker
always makes one think lung cancer.  Up to one out of five pesons who
cough up blood will turn out to have this malignant disease. Benign
bronchial tumors can also cause hemoptysis.

   Lung Infection -- Pneumonia and lung abscess produce bloody
sputum, depending on the type of bacteria and the location of the
infectious process.

   Pulmonary Embolism -- Blood clots in the lung classically present
with chest pain and shortness of breath.  Hemoptysis occurs in
approximately a third of the cases.

   Heart Disease -- Abnormalities of the heart valves can lead to
increased pressures in the veins in the lungs.  Cough, shortness of
breath and hemoptysis ensue.

   Lung Injury -- Contusions and foreign objects in the bronchial
tree or lung can traumatize blood vessels and lead to bleeding.

   Tuberculosis -- This lung infection was the leading cause of
hemoptysis prior to the development of effective antibiotics. Fever,
sweats and weight loss are associated.

   Bronchiectasis -- This disease is manifested by enlargement and
infection of the bronchial tubes.  Cystic fibrosis often leads to its
development in children.

   Abnormal Lung Vessels -- Inflammation or abnormalities in the
circulation in the lung occur with a variety of diseases.

   Bleeding Disorders -- Hemoptysis may be a sign of a bleeding
tendency due to defects in the blood's clotting system (e.g.
hemophilia, leukemia).

   Evaluation

   The chest X-ray and examination of the sputum for signs of
infection are essential.  Bronchoscopy, the examination of the
bronchial tree and lungs via a flexible scope placed through the
mouth and windpipe, can be used to inspect and biopsy the bleeding
source directly.  Arteriography, a dye X-ray test of the arteries and
veins in the lungs, is sometimes required. Exploratory surgery is a
last resort.

   Treatment

   When the bleeding is minimal, rest, cough suppressants and
treatment of the cause are sufficient.  Massive hemorrhaging requires
blood transfusions, bronchoscopy to locate the bleeding site,
placement of a tube in the trachea to facilitate breathing and
prevent blood from entering the remainder of the lung and sometimes
emergency surgery.





   CROUP OR BARKING COUGH

   Croup is a respiratory illness of young children between the ages
of three months and seven years.  It is manifested by a typical
brassy, barking cough due to at least partial blockage of the
windpipe.  When the child breathes in, there may be an audible
high-pitched sound referred to as inspiratory stridor. Fever,
hoarseness, laryngitis, sore throat and difficulty breathing may also
be associated.  In severe cases the windpipe closes off suddenly--a
life-threatening emergency! Croup is not one disease: a number of
different conditions, mostly infections, can produce a "croupy"
cough.

   Major Causes

Viral Croup -- The vast majority of cases occurring in children less
than three years of age are due to viral infections of the throat,
voicebox (laryngitis) and/or windpipe.  Like colds, viral croup is
more common in the winter.

Epiglottitis -- The epiglottis is the cartilage which covers the
windpipe (trachea) as you swallow to prevent food from going "down
the wrong pipe."   Epiglottitis, or inflammation of this cartilage,
is characteristic of croup caused by a bacterial infection.  The
rapid onset of croup, high fever, stridor and severe breathing
trouble in a three to seven year old child suggests the diagnosis.
This is a medical emergency!

Spasmodic Laryngitis -- Youngsters between the ages of one and three
years are affected by a recurrent sudden, nighttime croup associated
with anxiety, hoarseness and difficulty breathing. It remits during
the daytime.  Fever is absent.  Emotional factors, allergy and viral
infections may be responsible.

Foreign Body -- Young children often put small objects into their
mouths.  Blockage of the windpipe results in choking, coughing and
trouble breathing.

Retropharyngeal Abscess -- A pocket of pus (abscess) behind the
throat may block the airway.

Diphtheria -- This bacterial infection has been rare since the
development of an effective vaccine ("D" of the DPT).

Pertussis (Whooping Cough) -- As with diphtheria, this bacterial
infection can be prevented with a vaccine ("P" of DPT).

Miscellaneous -- asthma, allergic throat swelling, tetanus, botulism,
infectious mononucleosis, injury to the throat, tumors, and
congenital deformities of the throat, voicebox or windpipe.

   Evaluation

   The diagnosis of croup is evident after the initial examination.
Looking into the back of the throat can cause spasm and complete
obstruction of the windpipe.  It should be avoided if epiglottitis or
other severe forms of croup are suspected. Throat cultures, blood
tests, and an X-ray of the voicebox, windpipe and chest may be
necessary to determine the exact cause and severity.  Immediate
hospitalization is required for children with epiglottitis,
diphtheria, pertussis, abscess or any other forms of croup which
produce severe breathing difficulty.

   Treatment

   Please consult the Disorders and Diseases and Home Care and First
Aid sections for more information about therapy of the underlying
condition and practical tips about the care of children with croup.
Fluids and humidified air are helpful in mild cases due to viral
infections.





   POOR APPETITE (Anorexia)

   "Anorexia" is the medical term for loss of appetite or the lack of
desire to eat.  Often individuals with this symptom will comment that
"the food doesn't look good."  Loss of appetite should not be
confused with either the fear of eating or "filling up" easily.
Anorexia nervosa is a specific psychiatric illness characterized by
extreme weight loss and an altered attitude toward food and body
weight.  It will be discussed elsewhere.

   Major Causes

   Hunger and appetite are controlled by feeding and satiety centers
located in the hypothalamic section of the brain. Although disease,
exercise, hormones, diet and psychological factors are believed to
exert their influence on appetite through these centers, the
mechanism is unknown.

   Almost any major or minor physical or psychological disturbance
can affect the desire to eat.  Minor infections and emotional upset
probably account for the majority of cases of anorexia that last only
a few days.  Prolonged loss of appetite is a cardinal symptom of
cancer, intestinal disease, chronic infection, pain syndromes,
hormone deficiencies, heart, lung and kidney failure, and profound
psychiatric illness.

   Evaluation and Treatment

   Anorexia is such a nonspecific symptom that, alone, it gives
little clue to its cause.  When it is short-lived and associated with
an obvious explanation such as influenza, no specific testing is
required.  If it persists or is associated with weight loss and signs
of poor nutrition, a complete medical and laboratory evaluation must
be undertaken.

   Appetite will improve with therapy of the underlying disorder. In
general, appetite stimulants should be discouraged because they are
either ineffective or associated with serious effects.





   NAUSEA AND VOMITING

   Vomiting or emesis is the forceful elimination of gastrointestinal
contents through the mouth.  Nausea refers to the uncomfortable
feeling of the need to vomit.  These common symptoms occur with a
variety of physical and psychological illnesses.  When protracted,
vomiting can lead to weakness, dehydration and even tears of the
esophagus.

   Physiology

   The act of vomiting is influenced by two centers located in the
medulla at the base of the brain: the vomiting center and the
chemoreceptor trigger zone (CTZ).  The vomiting center receives
"vomiting messages" from the intestinal tract, the organ of balance,
the CTZ and the rest of the brain.  It controls the muscles and
nerves which initiate and carry out the vomiting reflex.  The CTZ
reacts to drugs, chemicals and toxins in the blood and provides the
stimulus for emesis to the vomiting center.

   Major Causes

   Nausea and vomiting have many causes:

Infections -- Viral illnesses such as "stomach flu" are associated
with fever and diarrhea.  Bacterial and parasitic intestinal
infections and kidney infections may also produce nausea and
vomiting.

Abdominal Emergencies -- e.g. appendicitis, gallbladder attacks,
bowel obstructions, gastrointestinal bleeding.

Medications -- e.g. narcotics, many antibiotics, arthritis medicines,
cancer chemotherapy.

Neurologic Disorders -- e.g. brain tumors, meningitis, head injuries,
strokes, migraine headaches.

Disorders of Balance -- The organ of balance is located in the inner
ear.  Nausea, vomiting, vertigo and dizziness are seen with inner ear
diseases.

Hormone Imbalances -- e.g. diabetes, adrenal disease.

Pregnancy -- Morning sickness occurs in the first three months.
Hyperemesis gravidarum is a disorder characterized by protracted
vomiting during gestation.

Heart Attack -- Gastrointestinal upset occurs with the chest
discomfort of an evolving heart attack.

Psychological -- Nausea and vomiting may occur with any emotional
excitement or upset.  Anorexia nervosa and bulimia (binge/purge) are
two psychiatric eating disorders in which self-induced vomiting plays
a role.

   Evaluation

   Careful examination of the nervous system and abdomen is
important.  The diagnosis is usually apparent from the history and
initial examination.  Blood tests and abdominal X-rays may be needed.
 Pregnancy should be considered in any young sexually active woman
when there is not another obvious cause.

   Treatment

   A clear liquid diet is recommended.  Protracted emesis requires
fluid transfusion and nutritional support.  Anti-emetic medications,
such as metoclopramide (Reglan) and prochlorperazine (Compazine), are
effective.  Please consult the sections on Disorders and Diseases,
and Home Care and First Aid, for additional information about the
underlying causes as well as practical advice about therapy.







   VOMITING BLOOD (Hematemesis)

   The vomiting of blood is referred to as hematemesis.  The color of
the blood may vary from red to brown or black depending on the degree
of its reaction with the stomach's acid and digestive juices.  Fresh
bleeding is typically bright red, while old blood clots may produce a
"coffee grounds" appearance.  If the rate of bleeding is rapid,
lightheadedness, sweating and thirst are associated.  In severe
cases, loss of consciousness and shock may ensue.  Hematemesis is a
frightening occurrence which requires immediate medical attention.

   Major Causes

   The source of bleeding can be anywhere in the upper
gastrointestinal tract from the mouth to the first part of the small
intestine.  Sites farther down the intestinal tract are rarely
responsible.  Ulcers, gastritis (stomach inflammation) and enlarged
esophageal veins called varices are the most common sources of
hemorrhage.   Inflammation and (Mallory-Weiss) tears of the
esophagus, tumors, abnormal blood vessels and defects in the blood
clotting system (e.g. hemophilia) are some other possibilities.

   Evaluation

   Clues to the diagnosis can be obtained from the medical history.
Abdominal pain occurring after meals and relieved by antacid
medication suggests ulcer disease.  The heavy use of alcohol and
aspirin products is associated with gastritis. Esophageal varices
should be suspected if a person has a history of jaundice, hepatitis,
liver disease or alcoholism.  Hemorrhage only after a prolonged bout
of vomiting suggests a tear of the esophagus.  Persons who vomit
blood are often very ill.

   The examination may disclose pallor, a fast heart rate and low
blood pressure.  Blood counts help to determine the amount of blood
lost.  Depending upon the severity of the bleeding, emergency
endoscopy (direct visualization of the esophagus, stomach and
duodenum through a fiberoptic scope) and/or "upper GI" X-rays are
required to make the diagnosis.  Massive hemorrhage may require
angiography, a dye X-ray test of the arteries, to localize the
bleeding site.

   Treatment

   Severe hemorrhage necessitates immediate treatment to maintain a
normal blood pressure and pulse while the diagnostic tests are being
completed.  Intravenous fluids and blood transfusions are
administered.  The specific therapy depends on the cause of the
bleeding.  Medications to decrease acidity are indicated for ulcers
and gastritis.  Emergency surgery may be required to stop the
bleeding.





   DIFFICULTY SWALLOWING

      (Dysphagia)

   The sensation of food or liquid sticking in the mouth, throat or
esophagus is referred to as "dysphagia."  It should be differentiated
from the fear of swallowing, the inability to initiate the act of
swallowing and from globus hystericus, the feeling of a "lump in the
throat."  The latter is a benign psychological disorder which we all
have experienced at one time or another.  Odynophagia is painful
swallowing; it frequently occurs with dysphagia.

   Physiology

   The normal process of swallowing starts under voluntary control as
food is pushed back into the throat by muscles of the mouth and
tongue.  Reflex actions in the throat cover the trachea (windpipe)
and propel food into the esophagus.  Peristalsis, a coordinated
series of esophageal muscular contractions and relaxations, helps the
food pass down into the stomach.  Any disorder which interferes with
the normal act of swallowing can produce symptoms.

   Mechanical Dysphagia

   Mechanical dysphagia is difficulty swallowing that results from a
physical narrowing of the inside diameter of the food passageway.
Throat and esophageal conditions that cause dysphagia by this
mechanism include benign and cancerous tumors, strictures due to
scarring from previous injury, infection or ulcers, and swelling due
to inflammation or infection.

   External compression of the esophagus by adjacent structures in
the neck and chest can also produce mechanical dysphagia. Examples of
disorders that can cause esophageal compression are spinal arthritis,
abscesses, thyroid goiters, tumors, enlarged heart and abnormal blood
vessels.  Finally, mechanical dysphagia can occur in the absence of
disease if a foreign object or large piece of food becomes lodged in
the food passageway.

   Motor Dysphagia

   Motor dysphagia is difficulty swallowing due to weakness, spasm or
paralysis of the swallowing muscles.  Many diseases of the brain,
nerves and muscles have been implicated, e.g. strokes, polio,
muscular dystrophy.  Achalasia is a specific disease of the
esophageal muscles.

   Evaluation and Treatment

   The history can provide a clue to the diagnosis in the majority of
patients.  Isolated solid food dysphagia is indicative of mild to
moderate mechanical obstruction.  As the degree of esophageal
narrowing increases, difficulty with liquids may occur as well.  The
vomited food will be undigested.

   Liquid and solid food dysphagia from the onset of symptoms points
toward a motor abnormality.  Concurrent symptoms may include
heartburn, chest pain, cough, weight loss, hoarseness or shortness of
breath.

   The physical examination may reveal signs of cancer or wasting
neurologic and muscular diseases.  Poor nutrition is evident in
longstanding cases.  X-rays of the chest, esophagus and stomach are
routinely performed.  Direct visualization of the inside of the
esophagus through a flexible scope inserted through the mouth is
often necessary.

   Therapy is dependent upon the cause of the dysphagia.  Surgery is
often needed and nutritional support is important.
 /ex





   HEARTBURN AND INDIGESTION

   Despite its name, heartburn is not a disorder of the heart, but a
common symptom of diseases of the esophagus.  It is characterized by
a burning sensation that starts at the bottom of the breastbone and
moves upward through the chest to the neck. Belching and a sour taste
in the mouth are often associated. Typically, heartburn is aggravated
by eating, bending over, lying down, alcoholic beverages, aspirin,
arthritis medicines and caffeine; it is relieved by antacids, e.g.
Maalox.  At times the discomfort of heartburn may resemble true heart
pain or angina pectoris.  Careful evaluation may be required to
differentiate the two.

   Indigestion is a nonspecific term used by non-medical persons to
describe a variety of discomforts associated with eating: heartburn,
abdominal pain, nausea, bloating, belching and flatulence.  Because
these complaints can have many different causes, they require
independent evaluation.  For more information, please refer to the
separate articles dealing with these subjects.

   Major Causes

   At the point where the lower esophagus passes through the
diaphragm to reach the stomach is a circular muscle or sphincter
which acts to prevent the reflux (backwards flow) of stomach acid and
digestive juices.  When this lower esophageal sphincter malfunctions,
refluxed stomach contents can cause esophageal irritation, ulcers,
bleeding, scarring and abnormal muscular contractions.  Heartburn is
a prominent symptom of esophageal reflux.

   A hiatal hernia is a protrusion of the upper portion of the
stomach through the diaphragm into the chest cavity.  Although it is
often associated with heartburn and malfunction of the sphincter,
many persons haave this abnormality without experiencing pain.
Conversely, many individuals who have heartburn do not have a hiatal
hernia.

   Other causes of esophageal reflux include medications that relax
the sphincter, tumors of the esophagus and stomach, previous
esophageal/stomach surgery and diseases that weaken the muscles of
the esophagus.

   Finally, heartburn does not necessarily imply reflux: esophageal
infection, muscle spasm and injury to due corrosive substances (e.g.
lye) can produce a similar chest discomfort.

   Evaluation

   Persons with new or recurrently severe heartburn require testing
to rule out serious diseases of the esophagus or stomach. An upper GI
(gastrointestinal) X-ray with special fluoroscopic studies (X-ray
movies) may disclose reflux, abnormal esophageal muscle contractions,
inflammation, ulcers and/or tumors. Endoscopy, the insertion of a
flexible scope through the mouth, allows for direct visualization of
the esophagus and stomach.  It is valuable when X-rays are normal and
can be employed to obtain tissue samples.  Assessment of the function
of the lower sphincter is possible by measuring pressures within the
esophagus.  Unfortunately, many people suffer from recurrent
heartburn without demonstrable abnormalities on the above tests.

   Treatment

   Once the diagnosis is confirmed, specific therapy may be available
for the underlying disorder.  Esophageal reflux can be diminished by
eating smaller meals, not eating before bedtime, raising the head of
the bed, maintenance of the proper body weight and avoidance of
alcohol, caffeine and aspirin.  Among the effective medications are
antacids, bethanecol, metoclopramide (Reglan), cimetidine (Tagamet)
and ranitidine (Zantac).  Surgery may be required for refractory
cases.  Hiatal hernias are repaired surgically only when the
individual is symptomatic and conservative measures have failed.





   JAUNDICE (Icterus)


   Jaundice refers to a discoloration of the skin and whites of the
eyes due to an accumulation of the yellow bile pigment, bilirubin.
Another name for it is icterus.  Itching, fatigue and changes in the
color of the stool may be associated.

   Normal Physiology

   A review of the body's normal production and elimination of
bilirubin will help you understand the disorders that cause jaundice.
 Bilirubin is a normal breakdown product of hemoglobin, the
oxygen-carrying protein in red blood cells.  Small amounts of it are
also derived from sources in the liver and bone marrow. Unconjugated,
it is carried by the bloodstream to the liver where a sugar molecule
is attached to its structure by enzymatic action.  Now, in a
water-soluble conjugated form, it is excreted into the bile and
stored in the gallbladder.  With meals, the gallbladder contracts and
forces bile to enter the intestinal tract.  Some conjugated bilirubin
is reabsorbed in the intestines and excreted in the urine, but most
is lost in the stool.

   Major Causes of Jaundice

   Any disorder that either increases the production or decreases the
excretion of bilirubin can cause jaundice.

Increased Bilirubin Production -- When there is an increase in the
number of red blood cells that are being destroyed (hemolyzed),
anemia results, and more hemoglobin is available for conversion to
bilirubin.  The bilirubin accumulates in the bloodstream as the liver
is overwhelmed with its tasks of conjugation and elimination.
Jaundice from hemolytic anemias may be associated with medications,
blood transfusions, hereditary disorders (e.g. sickle cell disease)
or immune diseases.

Decreased Liver Uptake -- Some medications, starvation and infection
can inhibit the ability of the liver to extract bilirubin from the
bloodstream.

Decreased Liver Conjugation -- Inability of the liver to produce a
water-soluble conjugated form of bilirubin will significantly
diminish the amount of this pigment than can enter the bile.
Inherited liver enzyme deficiencies, medications such as
chloramphenicol, cirrhosis, hepatitis, tumors and infection may
hamper the liver's enzyme activity.  Until their liver matures during
the first week of life, newborn infants are prone to this type of
jaundice.

Decreased Excretion by the Liver -- Inherited disorders, pregnancy,
hepatitis, medications (e.g. sex hormones) and infections are common
examples of disorders that cause jaundice by this mechanism.

Blockage of the Flow of Bile -- Gallbladder disease and tumors of the
pancreas and bile ducts are among the disorders which cause
obstruction of the normal flow of bile into the intestines.

   Evaluation

   When it comes on gradually, jaundice may not be apparent to the
person who has it.  Friends or family may notice it first as the
whites of the eye turn yellow before changes in skin color are
perceptible.  Light, clay-colored stools may occur from the lack of
bilirubin excretion into the intestine.  Dark urine can indicate
excess bilirubin excretion through the kidneys.

   Prompt medical evaluation is required to determine the cause of
jaundice.  Attention should be paid to present medications, liver and
blood diseases, cancer and infections.  Blood tests including livers
enzymes and measurement of serum bilirubin levels (normal = less than
1.4) are required.  Specialized liver, bile duct and gallbladder
scans and X-rays are usually necessary.

   Treatment

   Please consult Disorders and Diseases section for information
about the therapy of the underlying causes.  Alcohol and liver- toxic
medications must be avoided.





   DIARRHEA

   Diarrhea is defined as an increase in the frequency, volume or
liquid content of bowel movements.  The stool may appear soft,
watery, oily, bloody and/or foul-smelling.

   Major Causes

   Between ingested foods and liquids and digestive secretions,
approximately ten quarts of fluid enter the gastrointestinal tract
each day.  More than 90 percent of it is absorbed in the small
intestine; most of the remainder is absorbed in the colon (large
intestine).  Diarrhea can result from an increase in intestinal
secretions, or a decrease in absorption.

   When it is of short duration--less than one to two weeks-- viral,
bacterial, protozoan (e.g. amoeba), and parasitic infections are
usually responsible.  Intestinal infection ("stomach flu") is termed
gastroenteritis; it is associated with fever, nausea, vomiting,
abdominal cramping and muscle aches. Food and water sources can cause
epidemics.  Travelers are particularly at risk.  Other causes of
diarrhea of recent onset include inflammatory bowel diseases such as
colitis, diverticulitis (infection of an outpouching of the colon),
appendicitis, medications such as antibiotics and antacids, irritable
(spastic) colon and X-ray therapy.  Anxiety, excitement and
depression may trigger diarrhea in otherwise healthy individuals.

   Diarrhea that lasts for weeks or months is often complicated by
weight loss and signs of poor nutrition.  Among the many causes are
inflammatory bowel diseases, parasitic infections (e.g. worms),
cystic fibrosis, previous intestinal surgery, deficiency in digestive
enzymes produced by the pancreas, bowel and pancreatic tumors, milk
sugar (lactose) intolerance, diabetes mellitus, overactive thyroid,
food allergy and medications. Laxative abuse, as a weight loss
method, can cause persistent diarrhea.

   Evaluation

   Gastroenteritis is so common that most people recover at home
without a visit to their physician.  When diarrhea is profuse,
prolonged or associated with high fever, bloody stool or severe
abdominal pain, a physician's care should be sought.  The evaluation
will include a detailed health history with attention paid to
medications, diet, and recent travel.  Examination of the abdomen and
rectum are important.  The stool can be studied for evidence of
blood, mucous. bacterial infection, toxins or parasites.  Proctoscopy
(direct viewing of the rectum through a scope inserted into the anus)
and upper and lower gastrointestinal X-rays may be indicated.  Often
no diagnosis is confirmed, and the patient recovers.

   Treatment

   Rest, clear liquids and mild anti-diarrheal medications (e.g.
Pepto-Bismol, Lomotil, Immodium) are effective for most forms of
gastroenteritis.  Antibiotic therapy is rarely indicated, except for
parasites. Please consult the Disorders and Diseases, and Home Care
and First Aid sections for more information about the treatment of
specific underlying disorders.





   GAS, BELCHING AND FLATULENCE

   Common ills attributable to gas accumulation in the intestinal
tract are chest and abdominal discomfort, indigestion, belching,
bloating and flatulence.  Gas pains may even simulate heart attacks,
but unlike the real thing, the pain is relieved by belching.  Perhaps
the biggest concern for persons who suffer from gas is embarrassment
in social situations.  Serious medical conditions are not often
responsible.

   Major Causes

   There are three ways by which gas can enter the intestinal tract:
air swallowing, production from chemical reactions in the intestines,
and diffusion from the blood.

   Air swallowing accounts for about 60 % of intestinal gas, most of
it being nitrogen and oxygen.  It occurs with normal eating and
drinking, but nervous disorders and poor eating habits may be
responsible.

   Neutralization of stomach acid in the small intestine produces
significant quantities of carbon dioxide, hydrogen and methane gases
as byproducts of the fermentation of unabsorbable starches. These
starches are found in high concentrations in beans, cabbage, milk and
apples.  Bowel diseases that cause a decreased ability to digest or
absorb starches often cause bloating and flatulence by this
mechanism.  Gluten-enteropathy (celiac disease), an intestinal
disease induced by reaction to an ingested wheat protein, is a good
example.

   Diffusion of gases from the blood accounts for only small amounts
of intestinal gas.

   Evaluation

   In the vast majority of cases, complaints of excessive belching
and flatulence are not due to intestinal disease.  X- rays and
laboratory studies rarely turn up a remediable cause. Abdominal
discomfort and bloating after meals may require intestinal X-rays and
blood and stool tests to exclude a disorder of absorption.

   Treatment

   Reassurance that nothing serious is wrong may be all that is
necessary.  Avoidance of precipitating foods, low carbohydrate diets
and attempts to decrease air swallowing (eating slower) are
frequently effective.  Anti-spasmodic medications, simethicone or
activated charcoal are sometimes helpful.  Intestinal diseases
require specific therapy.





   DARK OR BLACK STOOL

       (Melena)

   The normal color of stool varies between several shades of brown,
depending on the ingestion of certain pigment-containing foods--there
is no cause for concern.  However, when dark, tarry or black stools
develop, bleeding into the intestinal tract is the most common
explanation.  Known as melena (rhymes with "Helena"), this condition
requires prompt medical consultation.

   Major Causes

   Blood in the intestinal tract turns the stool black as it mixes
with stomach acid and undergoes a chemical reaction.  About two to
four ounces of blood are required to cause a visible change in the
color of the stool.

   Because bleeding sites in the large intestine are too far down in
the intestinal tract to have the blood either mix with stomach acid
or have time enough to react chemically before passing out of the
body, melena is an indication of upper gastrointestinal bleeding.
(Bleeding from the large intestine produces bright red blood in the
stool.)  Any disorder that causes hemorrhage from the mouth to the
end of the small intestine may be responsible. Melena is frequently
associated with the vomiting of blood. After a major bleeding episode
in the stomach, it can persist for days.  Among the causes of melena
are bleeding from brisk nosebleeds, esophagitis and gastritis
(inflammation of the esophagus and stomach), peptic ulcer disease,
enlarged esophageal veins called varices, tumors and abnormal tangles
of blood vessels in the wall of the bowel.

   Importantly, not all dark stools are due to bleeding.  Iron pills,
activated charcoal and bismuth preparations (Pepto-Bismol) can also
produce slate grey or black stools!

   Evaluation

   Clues to the diagnosis can be obtained from the medical history.
Fatigue, weakness or lightheadedness point toward either a chronic
process or brisk bleeding.  Abdominal pain occurring after meals and
relieved by antacids suggests ulcer disease.  The heavy use of
alcohol or aspirin products is associated with gastritis.  Esophageal
varices are suspected in persons with a history of jaundice,
hepatitis, cirrhosis or alcoholism.  Review of the list of
medications may provide an immediate answer.

   The physical examination can reveal pallor, a rapid pulse, and if
a significant amount of blood has been lost, low blood pressure.  The
stool is tested for blood.  If positive, a work-up for the source of
bleeding is mandatory.  Among the initial diagnostic tests may be
blood counts, upper GI X-rays, or upper gastrointestinal endoscopy
(direct visualization of the esophagus, stomach and proximal small
intestine through a scope). If there is concern about rapid bleeding
from the stomach, and the patient is not vomiting blood, a (NG -
nasogastric) tube can be passed through the nose into the stomach to
test for blood.

   Treatment

   Intravenous fluids and blood transfusions may be necessary if
there has been significant blood loss.  Specific therapy for the
cessation of bleeding depends on the cause.





   BLOODY URINE (Hematuria)

   "Hematuria" is the medical term for blood in the urine. Depending
on the amount of bleeding, the color of the urine varies from normal
to dark red.  Microscopic hematuria refers to small numbers of red
blood cells in the urine which can be seen only with a microscope.
Because even a small amount of blood in the urine may be a sign of a
serious disorder, it should not be ignored.

   Major Causes

   Blood cells can gain access to the urinary tract at any point from
the kidneys to the urethra (the passageway that leads from the
bladder to the outside).  Bladder and kidney tumors, urinary and
prostate infections, kidney stones and urinary tract obstruction
account for the majority of the cases.  Other causes include
traumatic injury to the urinary tract, blood clots in the kidney or
its veins, nephritis, abnormal kidney blood vessels and toxic
medications and poisons.

   Hemorrhage due to "blood thinning" medicines or blood diseases
such as hemophilia and leukemia can produce hematuria in the absence
of urinary tract abnormalities.  Microscopic hematuria may be seen
after vigorous exercise or during febrile illnesses. In about five
percent of persons with hematuria no explanation can be found.

   Evaluation and Treatment

   Because certain dyes, pigments and medications can cause reddish
urine, it is important that hematuria be documented by microscopic
examination of a urine specimen.  If rectal and vaginal bleeding have
not contaminated the specimen, red blood cells in the urine can be
assumed to come from the urinary tract.

   The medical history often suggests the cause.  Frequent, painful
urination with fever and abdominal or back pain points toward an
infectious etiology.  Hematuria with the sudden onset of severe flank
and groin pain suggests a kidney stone.  Kidney tumors may be
manifested by abdominal pain, fever and weight loss.  Bleeding
disorders are usually associated with easy bruising or bleeding into
the intestinal tract.

   Unless an infection or bleeding disorder is obvious, kidney X-
rays (IVP) and cystoscopy (direct visualization of the bladder
through a scope placed through the urethra) are employed to find the
source of the bleeding.  Kidney biopsy and angiography (dye X-ray
study of the blood vessels in the kidney) are sometimes necessary.

   In most cases, treatment of the underlying cause is effective.
Profuse bleeding requires blood transfusion, fluid administration and
sometimes surgery.





   PAINFUL URINATION (Dysuria)

   Pain or difficulty with urination is referred to as dysuria. It
may be associated  with urinary frequency (the need to void at
shortened intervals) and/or an abnormal flow of urine.

   Major Causes

   Painful urination is often an indication of inflammation of the
bladder or urethra, the passageway from the bladder to the outside.
Among the common causes of dysuria are:

Urinary Tract Infection (UTI) -- Bacterial infections of the bladder
(cystitis) and urethra (urethritis) are the most common causes of
painful urination.  They are often associated with frequent,
sometimes bloody, urination.  The presence of fever, back pain and
gastrointestinal upset may indicate a serious kidney infection.

Venereal Diseases -- A frequent explanation in sexually active young
people is urethritis due to venereal infections.  Men experience
painful urination, a penile discharge and frequent urination several
days after sexual contact.  Women may have a vaginal discharge and
abdominal pain.  Gonorrhea, chlamydia and herpes infections
predominate.

Vaginitis -- In young women, infection of the vagina by yeast or
bacteria is common.  Vaginal discharge, burning and itching are the
usual symptoms.  Some venereal infections cause vaginitis (e.g.
trichomonas).

Prostatitis -- The gradual development of dysuria, frequency and
difficulty initiating the stream of urine is a typical presentation
for prostate infection.  Elderly men are especially susceptible.

Acute Urethral Syndrome -- Many persons who have symptoms
characteristic of a urinary tract infection, but do not have
sufficient evidence of infection when their urine is examined, are
said to have this disorder.  Antibiotics are sometimes curative.

Other causes include epididymitis, bladder and prostate tumors,
bladder spasms, kidney stones, scarring or stricture of the urethra
and urethral injury.  Occasionally, dysuria may occur if the urine is
bloody or extremely concentrated.

   Evaluation

   If a urinary tract infection is suspected, examination of the
urine may confirm the diagnosis.  Genital and rectal examinations are
required to diagnose venereal and non-venereal vaginal and prostate
infections.  Cultures of the urine and discharge material are
diagnostic.  Kidney and bladder X-rays and cystoscopy (direct
visualization of the bladder through a scope inserted through the
urethra) may be indicated.

   Treatment

   The therapy of dysuria depends on the cause.  Please consult the
Disorders and Diseases section for specific treatment regimens.  In
the absence of obstruction to the flow of urine, a high fluid intake
is encouraged.  Dysuria due to urinary tract infections may respond
to phenazopyridine (Pyridium), a urethral analgesic.





   FREQUENT URINATION

   Frequent urination (also called frequency) can be defined as the
need to void at intervals shorter than normal.  It may or may not be
associated with polyuria, the production of an increased volume of
urine (greater than three quarts/24hours).  Nocturia is having to get
up at night to urinate.

   MAJOR CAUSES

   A) Frequency Without Polyuria

   Disorders of the urinary bladder and the urethra, the passageway
which leads from the bladder to the outside, are the most common
causes of frequency without polyuria:

Urinary Tract Infection -- Inflammation of the bladder and urethra by
bacterial infections create an urge to void.

Venereal Diseases -- Urethral infection by gonorrhea, chlamydia or
herpes is a common cause in sexually active young people.

Prostate Enlargement or Infection -- This is the most likely
explanation for urinary frequency in elderly men.

Acute Urethral Syndrome -- Urethral infection may be the cause of the
urinary frequency seen in this common disorder of young women.  But
antibiotics are not always effective.

Pregnancy

Bladder Compression from Abdominal Tumors

Small Bladder Capacity

Diseases that affect the nerves that control the act of urination,
e.g. strokes, neuropathy

   B) Frequency With Polyuria

   Urinary frequency associated with polyuria is more often a result
of medications or hormonal and kidney diseases:

Diabetes Mellitus -- High concentrations of sugar in the urine cause
a concomitant loss of water.

Medications -- e.g. diuretics ("water pills") and medicines such as
lithium that decrease the ability of the kidneys to concentrate
urine.

Diabetes Insipidus -- Disorders of the pituitary gland which decrease
the production of the hormone vasopressin result in an inability of
the kidneys to concrentrate urine.

Kidney Diseases

Alcoholic Beverages

High Blood Calcium Levels

Excessive Water Drinking

   C) Nocturia

   Nocturia occurs when the volume of urine produced while sleeping
exceeds the bladder capacity.  Obviously, any disorder which causes
frequency or polyuria can cause nocturia.  Although nocturia is more
of a habit for some individuals, in the absence of daytime frequency,
getting up to urinate at night to urinate may be a sign of congestive
heart failure, cirrhosis or kidney disease.

   Evaluation and Treatment

   The history and physical exam together with examination and
culture of the urine will yield the diagnosis in the majority of
patients.  Blood tests, hormone measurements, kidney and bladder
X-rays (IVP) and cystoscopy (direct visualization of the bladder
through a scope inserted through the urethra) may be necessary.
Therapy depends on the underlying cause.  Please consult the
Disorders and Disease section for additional information.





   DECREASED URINATION

       (oliguria)

   The normal volume of urine produced in a twenty-four hour period
depends on a number of factors: the amount of fluid ingested, the
volume of perspiration and stool, kidney function, blood pressure,
blood flow to the kidneys, medications, hormones and disease states.
Adults average between one to three quarts of urine each day.
Oliguria refers to the daily production of less than about one-half
quart.  Because decreased urination may not be apparent until urine
volumes are actually measured, related health complaints may first
prompt the visit to the doctor.

   Major Causes

   A good way to think about the causes of decrease urination is to
divide them into three groups based upon whether the problem is
related to the decreased blood flow to the kidney, kidney disease or
blockage of the free flow of urine.

   Blood flow to the kidney requires an adequate volume of blood,
good blood pressure and patent arteries.  Therefore, any disorder
that diminishes the blood volume, lowers the blood pressure or blocks
or narrows the arteries to the kidneys can decrease urine production.
 Examples are dehydration, profuse bleeding, heart failure, shock,
arterial blood clots and medications that constrict the blood supply
to the kidneys.

   Kidney diseases are an obvious cause for diminished urine
prodction; however, normal urine volumes are often maintained until
very severe kidney damage has occurred.  Among the many causes of
kidney disease are medications, diabetes, high blood pressure, shock,
X-ray dye, toxins, recurrent infection and glomerulonephritis
(inflammation of the kidney due to an immune immune disorder).

   Blockage of the flow of urine from the kidneys or through the
bladder and urethra may occur with medications that cause urinary
tract spasms (especially after surgery), tumors and enlargement of
the prostate gland.

   Evaluation

   During the examination, emphasis is placed on the blood pressure,
degree of hydration (fluid balance), heart and lungs. Measurement of
fluid intake and urine output is the next step. Blood and urine tests
are required to check the kidneys' ability to filter the blood.
Kidney and urinary tract X-rays, scans or ultrasound may yield
further information.  Biopsy of the kidney is useful in the diagnosis
of kidney disease of unknown cause.

   Treatment

   Dehydration and bleeding mandate fluid and/or blood transfusions.
Low blood pressure is treated emergently, and offending medications
are withdrawn.  Dietary salt, protein and fluid are regulated with
most forms of kidney failure.  Surgery may relieve urinary tract
obstruction.  Overall, treatment of the underlying cause of oliguria
is most important.






   DIZZINESS

   Dizziness refers to a variety of disturbing sensations ranging
from a spinning, falling or tilting feeling to faintness and
lightheadedness.  The term giddiness includes all non-rotational
forms of dizziness, whereas vertigo is used to describe the
experience of feeling that either oneself or the environment is
spinning.  Unlike giddiness, vertigo is often associated with
sweating, nausea and vomiting.  Most episodes of dizziness are
short-lived and of little significance; however, they may indicate a
serious condition.  Fainting spells and loss of consciousness
("blacking out") are discussed in a separate article.

   Major Causes

Vertigo -- The organs for the sensation of movement and changes in
body position and balance are located in the inner ear. Information
from the ear is transmitted by the vestibular nerve to the brain
where it is integrated with stimuli from the eyes, joints and
muscles.  Vertigo may result from any disturbance that upsets the
normal functioning of the inner ear, vestibular nerve or portions of
the brain responsible for maintaining equilibrium. Psychological
factors are also important.

   The most common causes are inflammation, injury or infection of
the inner ear; tumors, infection or degeneration of the vestibular
nerve; antibiotic medications such as gentamicin; skull fractures;
strokes; seizures; and diseases of the nervous system.  Meniere's
disease is manifested by vertigo associated with ringing in the ears
and hearing loss.  Sudden motion, as in seasickness, can precipitate
vertigo in susceptible individuals.

Giddiness -- The most common causes are anxiety, fever, medications,
viral infections, hyperventilation, eye disorders, anemia, abnormal
heart beats, low blood pressure, strokes and low blood sugar or
oxygen.  Often, no explanation is discovered.

   Evaluation

   The most important factor here is deciding whether the dizziness
is characteristic of vertigo, giddiness or fainting. Many people have
difficulty describing and differentiating these symptoms.  A complete
examination is recommended with close attention paid to the blood
pressure, pulse, head, eyes, ears, heart and nervous system.

   The evaluation of vertigo may require hearing and balance testing,
special X-rays of the ear canals, sinuses and brain, and consultation
with a neurologist or specialist in diseases of the ears, nose and
throat.  Blood tests and electrocardiogram (EKG) may reveal the cause
of giddiness.

   Treatment

   Vertigo may respond to resting, closing the eyes and medications
such as meclizine (Antivert) and diphenhydrate (Dramamine).
Scopolamine skin patches are employed to prevent motion sickness.
With giddiness as well as vertigo, therapy of the underlying cause is
best.





FAINTNESS, LIGHTHEADEDNESS AND LOSS OF CONSCIOUSNESS

   Faintness and loss of consciousness represent different degrees of
severity of the same physiologic process.  Faintness is the feeling
that one is about to pass out.  It is characterized by
lightheadedness, nausea, sweating and pallor. Loss of consciousness
is the act of "blacking out."  It may follow a period of faintness or
may occur without warning. Syncope is the medical term for brief
periods of loss of consciousness.  Both faintness and syncope
required medical evaluation.

   Major Causes

Fainting -- Simple fainting spells are the most common type of
syncope.  A temporary fall in blood pressure and slowing of the pulse
occur as a result of nervousness, fear, pain or surprise.

Heart Disorders -- Abnormal heart rhythms, heart attacks and blockage
or leakage of the valves can decrease the blood flow to the brain.
The faintness or syncope may occur suddenly or be brought on by
exercise.

Orthostasis -- This term refers to a drop in blood pressure which
occurs only when the person assumes an upright position.  It is an
exaggeration of the feeling we all experience if we get up too
quickly.  Orthostasis may result from dehydration, profuse bleeding
or disorders or medications which affect the ability of the
circulatory and nervous system reflexes to increase blood pressure.
Diabetes, alcoholism, prolonged bedrest, neurologic diseases or blood
pressure medications are often implicated.

Brain Disorders -- Faintness or syncope may be caused by strokes,
narrowing of the arteries to the brain and seizures.

Miscellaneous -- coughing, urination, anemia, low blood oxygen,
hypoglycemia, hyperventilation, hysterical fainting, carotid sinus
syncope.  The latter refers to loss of consciousness which occurs
when pressure is placed on the major artery(s) in the neck.

   Evaluation

   The position of the person and the rate of onset of the faintness
or syncope are important.  A complete examination with attention to
the blood pressure, pulse, heart, circulation and neurologic exams is
mandatory.  Orthostasis can be documented by checking the blood
pressure standing up and lying down.  Blood tests, X-rays and
electrocardiogram are usually required. Syncope of unknown cause will
require hospitalization for special heart and neurological testing.
Heart monitoring, brain scans or X-rays, and brain wave tests may be
performed.  Despite thorough evaluation and extensive testing, many
patients with syncope remain undiagnosed.

   Treatment

   The therapy of faintness and loss of consciousness must be
individualized depending on the cause.  Simple fainting spells should
be treated by rest in the supine position with the legs elevated.





   SHAKINESS AND TREMORS

   A tremor is an oscillatory movement of a part of the body. The
head, mouth, tongue, hands, arms and feet are most commonly involved.
 When hand tremors are severe, the person may have difficulty
writing, holding objects and performing simple manual tasks.  There
are three main types of tremors: resting, action and intention.
Neurologic disorders and psychological factors are responsible.

   Major Causes

   Resting tremors occur only when the affected body part is not
being used; they disappear with voluntary movement.  Slowness of
walking and body movements and rigidity of muscles, may be
associated.  Parkinson's disease--a degenerative neurologic disease;
Parkinson's syndrome--a nonprogressive form of the disease; Wilson's
disease, an inherited disorder of brain degeneration and cirrhosis
associated with abnormal copper metabolism; strokes; and "old age"
are commonly implicated.  A Parkinsonian-type tremor and syndrome may
also be seen as a side effect of antipsychotic medications
(Thorazine, Haldol).

   Action tremors occur when the affected body part is held in a
particular position; they persist with movement.  Benign familial
tremor is an inherited disorder that manifests itself as an isolated
(no other symptoms) action tremor which is worse when the person is
anxious or self-conscious.  Other family members are affected.  Other
causes are alcohol and drug withdrawal--"the shakes", overactivity of
the thyroid gland, nervousness, delirious states and breathing
medications (terbutaline, albuterol, metaproterenol, aminophylline.)

   Intention tremors are brought on by the performance of detailed,
coordinated tasks.  For example, when the person is asked to touch
the end of his nose with his finger, the tremor will start just as
the nose is about to be reached.  This type of tremor is
characteristic of degenerative disorders of the cerebellum, a portion
of the brain important for muscular coordination and balance.
Unsteadiness while standing and walking is often associated.  Common
causes are chronic alcoholism, drug intoxications, nutritional
deficiencies, strokes, inherited diseases, cancer, infections and
head injuries.

   Evaluation and Treatment

   Review of medications and exacerbating factors will give important
clues to the diagnosis.  A detailed neurologic examination is most
important.  Blood tests, brain wave tests, brain X-rays and a spinal
tap may be required.   Consultation with a neurologist is often
necessary.

   Cessation of the responsible medication, alcohol or drug may cure
the tremor.  Thyroid disease is easily treated.  Benign familial
tremors respond to propranolol (Inderal).  Please consult the
Disorders and Diseases section for more information about
Parkinsonism.





   MUSCULAR WEAKNESS

   Voluntary muscle movement requires intact connections between the
brain, spinal cord, nerves and muscles.  Disorders affecting any part
of this complicated system can cause muscular weakness. The symptoms
may strike suddenly or may come on gradually over days, weeks or
months.  Their severity varies from outright paralysis to a minimal
deterioration in normal strength.

   Major Causes

Disuse -- Just as exercise increases muscle bulk and strength,
prolonged inactivity decreases muscle size (atrophy) and strength.
The best example is the muscle wasting and weakness seen after a cast
is removed.

Nerve Injury -- Direct injury to a nerve can occur with deep cuts,
surgery or forceful blows.  "Slipped discs" and spinal arthritis may
press on the spinal nerves.  Any muscle that loses its normal nervous
input, begins to degenerate.

Strokes -- Damage to brain tissue often causes muscular weakness on
one side of the body.  The exact muscles affected depend on the area
of the brain involved.

Muscular Dystrophies -- This usually fatal group of muscle disorders
is characterized by a gradual, progressive decline in strength
associated with severe muscle wasting.  Their cause is unknown, but
genetic factors are important.

Myasthenia Gravis -- Typically, this disease affects the face, eye,
throat and respiratory muscles.  It is believed to be caused by a
defect in the transmission of the electrical impulse from nerves to
muscles.  The weakness is episodic and improves with rest.  A similar
disorder (Eaton-Lambert syndrome) occurs in association with cancers.

Polymyositis -- Painless weakness of large muscles gradually
develops, often in association with skin rashes in this inflammatory
muscle disease.  Cancers and medications are sometimes implicated as
the cause.

Neurological Diseases -- Many unexplained disorders cause parts of
the brain, spinal cord and nerves to degenerate or malfunction.
Examples are multiple sclerosis, amyotrophic lateral sclerosis (Lou
Gehrig's disease) and cerebral palsy.

Miscellaneous -- thyroid disease, poor nutrition, alcoholism,
"cortisone" medication, spinal cord injury, botulism, polio.

   Evaluation and Treatment

   Many persons complain of weakness, but do not demonstrate it when
strength is formally tested.  In most cases nothing is wrong.
Involved neurologic testing, nerve studies, blood tests and sometimes
brain X-rays and muscle biopsies may be required to clarify the
diagnosis in persons with true weakness.  A neurologist is usually
consulted.  Therapy is directed at the underlying cause.





   NUMBNESS AND TINGLING

      (Paresthesias)

   Sensory nerves in the skin detect pain, pressure, temperature and
touch.  Disorders of these nerves or their connections in the spinal
cord and brain may result in abnormal sensations such as numbness,
tingling, "pins and needles," pain and burning.  The medical term for
abnormal skin sensations is "paresthesias." Diseases of nerves are
called neuropathies.

   Major Causes

Injury -- Partial or temporary damage to a nerve is a common cause of
paresthesias.  The primary examples are hitting your "funny bone"
(ulnar nerve) and having your foot "fall asleep" when you cross your
legs.

Pinched nerve -- Pressure on a nerve by vertebral discs or spinal
arthritis produces pain, tingling and numbess.

Entrapment Neuropathy -- Compression of a nerve as it passes through
a narrow tunnel of bone or tissue may result from arthritis,
long-term injury and inflammatory diseases.  Carpal tunnel syndrome
involves the wrist and hand.

Hyperventilation -- Rapid, deep breathing in times of stress or
excitement may cause paresthesias in the fingertips and around the
lips.  These sensations are short-lived.

Diabetes mellitus -- Damage to sensory nerves is one of the major
complications of high blood sugar and long-term diabetes.

Alcohol -- Heavy drinking not only harms the sensory nerves, but the
brain as well.

Migraines -- Paresthesias often occur just prior to or during a
migraine headache.

Toxicities -- A number of metals, chemicals and medications cause
neuropathy, including arsenic, mercury, lead, solvents, insecticides,
phenytoin (Dilantin), vincristine, vitamins.

Strokes -- Numbness, especially on one side of the body, may be a
symptom or a stroke or a prelude to a stroke.

Miscellaneous -- multiple sclerosis, brain tumors, infections, kidney
failure, vitamin deficiencies (B12), imbalance in blood calcium or
sodium, atherosclerosis, lupus, head and spinal cord injury.

Psychological -- Numbness may be a sign of hysterical illness.

   Evaluation and Treatment

   The first step is a careful and detailed neurological examination.
 The location on the skin of the abnormal sensations is indicative of
the nerve(s) involved.  Frequently, blood tests and electrical
measurements of the ability of the nerves to conduct impulses are
needed.  Depending on the findings, brain X- rays, spinal tap and
consultation with a neurologist may be required.  Therapy is directed
at the underlying cause.





   ABNORMAL VAGINAL BLEEDING

   Bleeding from the vagina is a normal part of menstruation.
However, when it is excessive or irregular with respect to monthly
periods, it may be a sign of serious disease.  The bleeding may
originate in the ovaries, tubes, uterus or vagina. It can be profuse,
slow, constant or intermittent.  Abdominal cramping and the passage
of clots may be associated.

   Major Causes

Ovarian -- Cysts or tumors of the ovary may bleed directly or produce
excessive female hormones.

Complications of Pregnancy -- Miscarriages, ruptured tubal
pregnancies and placental tumors or abnormalities must always be
considered if there is a possibility that the woman is preganant.

Uterine -- Tumors, polyps and fibroids are of particular importance
in the older population group.

Injury -- e.g. rape, foreign objects, surgery

Infection -- Infection of the vagina (vaginitis), cervix, uterus
(endometritis), tubes or ovaries may result in vaginal bleeding.
Venereal diseases are often responsible.

Bleeding Disorders -- Leukemia and defects in the blood clotting
system can produce heavy and irregular menstrual bleeding just as
they cause bleeding elsewhere.

Medicines -- The birth control pill not infrequently causes
breakthrough bleeding between periods--low estrogen pills especially.
 Steroids, aspirin products and "blood thinners" may increase
menstrual flow.

Hormonal Disorders -- Ovarian, thyroid, pituitary and adrenal
diseases upset the balance of female hormone production.

   Evaluation

   The first step is a complete health history and abdominal/pelvic
examination.  Review of the pattern of the recent menstrual periods
is very important.  Pregnancy should be ruled out.  Fever, abdominal
pain or vaginal discharge suggest infection.  Hormonal causes are
most often responsible in young women.  After menopause, the
likelihood of a tumor is increased.

   Diagnostic studies may include a Pap smear, venereal infection
cultures, ultrasound (sonar - sound wave pictures of the female
organs), hysterosalpingogram (uterine X-rays), laparoscopy (flexible
scope or tube inserted through the abdominal wall for direct viewing
of the ovaries, tubes and uterus), D and C, and female hormone tests.

   Treatment

   Please consult the section on Disorders and Diseases for
information about therapy of the underlying conditions. Prolonged
and/or heavy bleeding results in an anemia which responds to iron
supplementation.





   VAGINAL DISCHARGE

   Drainage or discharge from the vagina is common symptom of
diseases of the female organs.  Itching, burning and painful
urination may be associated.  Infections are usually responsible.

   Major Causes

   Vaginitis -- Inflammation of the vagina due to infection is the
most common cause in young women.  The discharge may be associated
with pain, burning, itching, bleeding or a foul odor. There are three
main types:

   I.  Candidiasis (Yeast) - Typically, yeast infections produce a
thick, white cottage cheese-like discharge, itching and skin
irritation.  Diabetics and persons taking antibiotics or steroid
medications are predisposed.

   II.  Trichomonas ("Trich.") - Infections with this protozoan are
usually contracted through sexual contact.  A thin yellow, foul-
smelling drainage is noted.

   III.  Gardnerella (Nonspecific) - A thin gray, foul-smelling
discharge is characteristic of this bacterial infection.

   Other Causes Include:

   Pelvic Inflammatory Disease (PID) -- Infection of the cervix,
uterus, tubes and/or ovaries from venereal diseases may result in
lower abdominal pain, fever and vaginal discharge or bleeding.
Gonorrhea and chlamydia infections are most common.

   Herpes Genitalis -- Although this viral infection usually causes
external blisters and painful urination, when it involves the cervix
(vaginal end of the uterus), a discharge can develop.

   Endometritis -- Infection of the inside of the uterus is
manifested by chills, fever, lower abdominal pain and discharge. The
principle causes are fibroid tumors, cancer, childbirth and
intrauterine devices (IUD).

   Fistula -- A direct communication from the rectum or bladder into
the vagina can cause a loss of stool or urine through the vaginal
opening.  These passageways develop after injury or surgery in the
area, infection, inflammation or radiation.

   Miscellaneous -- pinworms (children), foreign objects in the
vagina, pregnancy, venereal warts, cancer.

   Evaluation

   The medical history should focus in on the type of discharge and
its relation to sexual activity and menstruation.  A complete female
pelvic examination will almost always determine the diagnosis.  With
vaginitis, the vagina appears inflammed. Examination of the discharge
under a microscope can differentiate the three types.  Cultures,
blood tests, Pap smears and biopsies may be required to diagnose some
of the other causes.  An obstetrician-gynecologist may be consulted.

   Treatment

   The therapy is directed at the underlying disorder. Infections are
treated with specific antibiotics, sometimes in the form of vaginal
creams or tablets.  Venereal causes require treatment of sexual
partners and abstinence from sexual contact until the infection
clears.





   PAINFUL MENSTRUAL PERIODS

        (Dysmenorrhea)

   Painful menstruation or dysmenorrhea is a common gynecologic
problem.  Typically it is manifested by lower abdominal cramping
associated with nausea, vomiting and headache at the time of
menstruation.  About one in ten young women is affected, often severe
enough to limit normal activities or employment.

   Dysmenorrhea can be classified as primary or secondary.  The
former refers to painful menstruation for which no abnormality of the
female organs can be identified.  Psychological factors are believed
to play a role.  Secondary dysmenorrhea, on the other hand, occurs as
a result of disease of the uterus, tubes or ovaries.

   Major Causes

Primary Dysmenorrhea -- This disorder afflicts young women fairly
soon after they first begin to menstruate.  It is believed that the
painful contractions develop in response to the release of a natural
substance called prostaglandins from the muscular walls of the
uterus.  Nervous, emotionally upset, non-athletic girls are
predisposed.

Secondary Dysmenorrhea -- Painful periods associated with increased
bleeding after months or years of normal menstruation are
characteristic.  Common causes are pelvic infection, fibroid tumors,
cancer of the uterus, polyps and endometriosis. Endometriosis is a
disease in which painful uterine glandular tissue is found outside
the uterus on the tubes, ovaries and abdominal organs.

   Evaluation

   The health history and gynecologic examination provide information
concerning pelvic disease and emotional factors.  The following
studies may be indicated depending on the results of the examination
and the severity and character of the symptoms: ultrasound,
hysterosalpingography (uterus X-rays using dye), dilatation and
curettage (D & C) and diagnostic laparoscopy (direct visualization of
the abdominal and pelvic structures via a scope inserted through the
abdominal wall).

   Treatment

   Primary dysmenorrhea is often alleviated by prostaglandin-
inhibiting medications such as ibuprofen (e.g. Motrin, Advil, Nuprin)
and aspirin.  In severe cases birth control pills or other hormones
are used.  Exercise, good nutrition and avoidance of stress are
important.  The therapy of secondary dysmenorrhea is directed at the
specific cause.  Hormonal, antibiotic or surgical measures are
employed.





   ABSENT MENSTRUAL PERIODS

        (Amenorrhea)

   The absence of menstrual bleeding is referred to as amenorrhea.
Girls who reach the age of sixteen to seventeen years old and still
do not have their periods are said to have primary amenorrhea.  The
term "secondary amenorrhea" applies to the cessation of menstruation
for six to twelve consecutive months in women who have previously
experienced normal periods.

   Normal Menstruation

   In order for regular monthly bleeding to occur, there must be
normal hypothalamic-pituitary hormone secretion as well as
functioning ovaries, an intact uterus and a patent vaginal opening.
Regulating hormones in the hypothalamus at the base of the brain
stimulate the pituitary gland to synthesize and release the
gonadotropins, follicle-stimulating hormone (FSH) and luteinizing
hormone (LH).  The ovaries, under the influence of FSH and LH,
produce the female hormones estrogen and progesterone that cause the
glandular inner lining of the uterus to proliferate and shed itself
with each menstrual cycle.  This complicated process is under the
influence of a variety of anatomical, genetic, hormonal,
neuropsychiatric and nutritional factors.

   Physiologic Amenorrhea

   Amenorrhea is not always abnormal.  In association with childhood,
pregnancy, lactation or menopause, it is an expected physiologic
response.  Pregnancy is by far the most common cause of secondary
amenorrhea in reproductive age women.  In the absence of
complications, menstruation normally resumes within six weeks to six
months after childbirth.  Breastfeeding (lactation), however, delays
the onset of menses until it is discontinued.

   The average age at menarche (start of periods) in the U.S. is
twelve years.  The average age for natural menopause in American
women is 51 years, but the majority of women stop having their
periods sometime between the ages of 40 and 55.

   Causes of Amenorrhea

   Congenital or acquired defects in the anatomy, or the complete
absence of the ovaries, uterus or vagina are obvious causes of
amenorrhea.  These structural abnormalities include chemical,
radiation-induced or surgical castration, hysterectomy and diseases
resulting in destruction of the uterine glands.  Rare causes are
blockage of the flow of blood by fibrous adhesions inside the uterus
from previous surgery (Asherman's syndrome) or by an imperforate
hymen covering the vaginal opening.

   Genetic factors often involve an abnormality in the number or
structure of sex chromosomes.  In Turner's syndrome (XO - sex
chromosomes), the individual has poorly developed ovaries (gonadal
dysgenesis) in association with short stature, an unusually-shaped
chest and neck, and lack of secondary sexual characteristics.  The
testicular feminization syndrome refers to genetic males (XY - sex
chromosomes) whose tissues lack the ability to respond to the male
hormone testosterone.  Although these children have testes, they are
raised as girls because they never develop primary or secondary male
sexual characteristics, i.e. no penis, etc.  Lacking a uterus and
ovaries, they can never menstruate.  True hermaphroditism is a rare
condition in which the individual has both ovarian and testicular
tissues present in at least small amounts.

   Among the major hormonal disorders are pituitary, adrenal gland
and ovarian underactivity, pituitary tumors, ovarian cysts and
tumors, overactive and underactive thyroid disease, and amenorrhea in
association with galactorrhea (breast milk production) in women who
are not nursing infants.

   Severe physical or emotional stress or psychiatric disease can
lead to amenorrhea.  Anorexia nervosa is the classic example.
Pseudocyesis is an unusual condition in which the woman exhibits some
signs--e.g. weight gain, anmenorrhea--of an imaginary or delusional
pregnancy.

   Many drugs and medications have been implicated.  Perhaps the most
notorious are birth control pills, cancer chemotherapy drugs,
narcotics and anti-psychotic medications (Thorazine).  The inhibition
of the pituitary production of FSH and LH by oral contraceptives may
take six to twelve months to resolve after discontinuation of the
"pill."

   General factors include obesity, malnutrition, chronic illness of
any cause, diabetes, tuberculosis and vigorous physical exercise.  In
particular, long-distance runners with a low percentage of body fat
are predisposed.  Cessation of training typically leads to menstrual
regularity within a couple of months.

   Evaluation and Treatment

   In girls with primary amenorrhea, a genetic defect or congenital
structural abnormality of the uterus can be found in more than
one-third of the cases.  The gynecologic examination should disclose
obvious abnormalities of the vagina, uterus or tubes.  Attention is
also paid to breast and external genital development, body hair and
stature.  Measurement of blood FSH, LH and testosterone levels, and
chromosome studies may be indicated early on.

   After pregnancy is ruled out, the progesterone challenge test is
often the first test employed in the evaluation of patients with
secondary amenorrhea.  The administration and withdrawal of
progesterone results in vaginal bleeding in women who have sufficient
estrogenic stimulation of uterine tissues.  A positive test
(bleeding) implies intact, but not fully functional,
pituitary-ovarian pathways.  Depending on the results of this test,
subsequent studies can become quite complicated.  They might include
measurements of certain hormones, blood tests, skull and brain
X-rays, chromosome studies and laparoscopy.

   The treatment of amenorrhea is tailored to the specific cause.





   PAINFUL SEXUAL INTERCOURSE

        (dyspareunia)

   Given the importance of sexual fulfillment in the relationships
between lovers, painful vaginal intercourse, or dyspareunia, is often
a source of intense emotional conflict and loss of self confidence.
One of the major causes of sexual dysfunction in women, it can
completely disrupt a woman's life as well that of her partner.

   Dyspareunia is described as a burning, tearing, ripping or aching
sensation associated with penile penetration.  It may be localized to
a point anywhere from the vaginal opening to deep into the pelvis, or
it may be more generalized and brought on only by deep thrusting.
Although physical factors may be implicated, psychological causes are
usually responsible.

   Physical Causes

Infection -- Yeast, bacterial or protozoan infection of the vagina
(vaginitis), is manifested by itching, burning and pain. The
diagnosis is usually fairly obvious after a routine examination.
Pelvic infection (pelvic inflammatory disease) of the tubes and
ovaries typically is venereal in origin.  Deep pain, vaginal
discharge and fever may be associated.  Other infectious causes are
herpes, infected cysts and boils.

Atrophic Vaginitis -- Degeneration of the vaginal tissues due to a
decline in the ovarian production of estrogen hormones is a normal
part of the menopausal aging process (See Disorders and Diseases).
As the vagina gradually loses its natural secretions, it becomes dry,
itchy and painful.  Estrogen creams and lubricating gels are
effective therapy.

Local Vaginal Lesions -- Scars, cysts or tumors, or any condition
that narrows the diameter of the vagina can lead to pain with
intercourse.

Endometriosis -- This chronic condition is characterized by the
presenced of uterine glandular tissue (endometrium) found outside the
uterus in the tubes, ovaries or lower abdomen.  These endometrial
implants may enlarge, bleed and cause pain and scarring.  Dyspareunia
is a common complaint.  (See separate article in the Disorders and
Diseases section.)

Intact Hymen -- This thin tissue narrows the vaginal opening of most
girls and young women who have not yet begun to have intercourse.  At
the onset of sexual activity, it may cause pain and minor bleeding
with penetration, but the symptoms quickly resolve as the hymen is
torn and the vaginal opening is enlarged. In the rare case, the hymen
remains imperforate and rigid, causes discomfort and entirely
precludes penetration.  Forced dilatation or an operation may be
required.

Miscellaneous -- Tilted uterus, fibrous adhesions in the pelvis,
tumors of the ovaries and uterus, congestion of the veins around the
uterus.

   Vaginismus

   One of the most common causes of dyspareunia, vaginismus is an
unintentional spasm of the muscles of the thighs, pelvis and vagina,
such that penile penetration is made impossible.  It develops in
response to one of the above physical disorders, but more frequently,
psychological forces are responsible.  An irrational fear of genital
injury is one theory of causation. Women who have vaginismus tend to
be anxious and afraid of sexual encounters.

   Evaluation and Treatment

   A careful gyneclogic history and pelvic examination is often all
that is necessary.  Specific attention should be paid to the details
of the sexual act.  Ultrasound, laparoscopy and exploratory surgery
are needed in some cases to diagnose endometriosis or tumors.
Therapy is aimed at the primary cause.

   The treatment of vaginismus is a regimen of progressive vaginal
dilatation combined with special exercises, relaxation techniques and
counseling.  Using dilators of gradually increasing calibers over a
period of weeks, the woman conditions herself to accept a foreign
object into her vagina.  Satisfying penile intercourse is resumed in
the majority of cases.





   BREAST DISCHARGE OR DRAINAGE

         (Galactorrhea)

   The discharge of liquid material from the nipples of the breasts
may be normal or abnormal.  In women who have recently given birth,
the secretion of breast milk is a normal response to breastfeeding.
However, when it occurs in non-nursing women, a serious hormonal
imbalance may be responsible.  Galactorrhea is the term for the
unexpected release of milk from the breast. Other types of drainage
or discharge (not milk) may be indicative of  breast infection,
inflammation or tumor.

   Major Causes

   During pregnancy the glands of the breasts produce milk through
the combined actions of ovarian, placental, adrenal, pituitary and
thyroid hormones.  Prolactin, a milk-forming hormone secreted by the
pituitary gland, is one of the major influences.  With nipple
stimulation during breast feeding, oxytocin, another pituitary
hormone, is released into the bloodstream.  It increases the levels
of prolactin and allows for milk to be discharged from the nipples.
Galactorrhea may result from an increase in the production of
prolactin due to:

Pituitary Tumors -- Benign tumors of this gland located at the base
of the brain may produce prolactin in excessive amounts. Cessation of
menstrual periods is often associated.

Hypothyroidism -- Underactivity of the thyroid gland is not an
unusual cause.

Medications & Drugs -- e.g. reserpine, methyldopa, marijuana,
antidepressants, psychiatric medications, birth control pills,
anesthetics, narcotics.

Brain Disorders -- Because the hypothalamic section of the brain
normally has an inhibitory influence on the pituitary production of
prolactin, diseases or injury of the hypothalamus can result in
increases in prolactin.

Miscellaneous -- stress, sexual stimulation and tumors of the
placenta.

   Evaluation

   A bloody, thin, white, green or yellow discharge suggests a breast
tumor or infection.  Breast X-rays and perhaps a biopsy are
indicated.  If milk can be expressed from the nipples, the health
history, examination and initial blood tests may yield an obvious
cause such as medications or hypothyroidism.  Prolactin blood levels
are helpful.  If they are elevated, or if there have been changes in
the menstrual periods, a workup for a pituitary tumor is indicated.
Brain X-rays and a series of complicated hormone measurements may be
required.  In approximately 50 percent of persons with galactorrhea,
no cause is found.

   Treatment

   Breast binders can help to decrease nipple stimulation when no
obvious cause is identified.  Thyroid disease is easily treated.
Bromocryptine, a medication which decreases the production of
prolactin, may be effective when prolactin levels are high. Surgery
may be indicated for pituitary tumors.





   BREAST LUMPS

   Approximately one out of eleven American women will develop breast
cancer during their lifetime.  In 1986, there will be about 125,000
new cases and almost 40,000 deaths from this disease.  Although the
majority (80%) of breast lumps are not malignant, they are the most
common first sign of breast cancer. For this reason, lumps or nodules
in the breast should never be ignored.

   Major Causes

Breast Cancer -- Predisposing factors for breast cancer include
advanced age, previous breast disease, family history of the disease,
onset of menstruation at a young age, late menopause and late first
full-term pregnacny.   A breast lump is more suggestive of cancer if
it is solid, immobile, fixed to the skin or associated with dimpling
of the skin, breast discharge, nipple scaling, nipple inversion,
redness, swelling or enlarged lymph nodes under the armpit.

Fibrocystic Disease -- This is the most common benign breast disease.
 Fibrocystic breast changes are so common, in fact, that some experts
in this field believe that it just be a variation of normal, not a
true disease.  About twenty percent of women have symptoms; many more
are affected without knowing it.  Typically, breast pain and swelling
associated with lump(s) or nodule(s) are noted five to seven days
preceding menstrual periods.  The lumps are cystic (i.e. filled with
fluid).  They recede after menses, but may recur monthly.

Fibroadenoma -- These benign tumors usually present as solitary,
rubbery lumps in women under the age of twenty-five.

Intraductal Papilloma -- These are benign tumors of the ducts.  A
bloody nipple discharge and small lump are characteristic.

Mammary Duct Ectasia -- This disorder is caused by inflammation of
the tissue beneath the nipple due to perforation of a duct.  A thick
discharge, swelling of the nipple and burning pain result.

   Other causes include breast injury leading to fat necrosis
(degeneration), Mondor's Disease--phlebitis or blood clots in the
breast, and mastitis--breast infection which usually occurs during
breast feeding.

   Evaluation

   To detect breast cancer in its early stages, monthly self breast
examinations and regular physician checkups are recommended for all
women.  The American Cancer Society has advised routine screening
mammography (breast X-rays) for all women over the age of
thirty-five.

   When a lump is discovered, by any method, cancer must be ruled
out!  Mammography, ultrasound, thermography and other breast imaging
techniques may be of value, but all solid lumps mandate a biopsy.
Cystic lumps may be observed for a month or two.  If they do not go
away, fluid can be aspirated (withdrawn with a needle).  Indications
for biopsy of a cystic lump are bloody fluid or no fluid obtained
with aspiration, failure to resolve completely after aspiration and a
high suspicion of cancer.

   Treatment

   Please consult the Disorders and Diseases section for information
about breast cancer and other diseases.  Also, see "Breast Imaging"
and "Breast Biopsy" in the Surgeries, Tests and Procedures section.
Fibrocystic disease may respond to dietary changes (avoidance of
caffeine-type substances) or hormone therapy.  Benign tumors are
treated by excision.





   The medication section of HealthNet contains descriptions, doses,
side effects, drug interactions, and wholesale costs of most of the
medications commonly used in the United States.  They are listed
according to generic rather than brand name.  If you do not know the
generic name of the medication you are taking, ask your pharmacist or
doctor.  In order to find the medication you are looking for, choose
the category which best fits the purpose of the drug.  Once within
the category, all medications are listed alphabetically.

  The dose ranges are given for the average adult patient and do not
apply to children.  Costs provided are representative wholesale costs
as of June, 1984, and may be different in your part of the country.

   PLEASE BE ADVISED THAT THE INFORMATION INCLUDED MAY NOT BE
COMPLETE AND ANY QUESTIONS CONCERNING USAGE OF ANY MEDICATION SHOULD
BE DISCUSSED WITH YOUR PHYSICIAN.

   We hope you find the medication section of HealthNet enjoyable.





GENERIC NAME: Acyclovir
        ===============

BRAND NAME: Zovirax
        ===============

INDICATIONS: Acyclovir is indicated for the treatment of specific
viral infections including some herpes viruses.
        ===============

MECHANISM OF ACTION: this drug inhibits specific viruses' ability to
reproduce themselves thus limiting their ability to cause infection.
It does this b interfering with the replication of DNA (the genetic
building blocks).
        ===============

DOSE RANGE: Acyclovir can be applied to the skin or mucus membranes
as a five percent ointment or it can be given by vein at doses of 5
mg for every kg (2.2 lbs) of body weight.
        ================

SIDE EFFECTS: the side effects of the drug used topically include
mild pain in the area of application, rash, inflammation of the
vulva, and itching. Acyclovir given by vein can cause local venous
irritation, mild decrease in kidney function, rash and less
frequently, sweating, blood in the urine, low blood pressure,
headache, and nausea.  Acyclovir should be used with caution in
pregnant women and nursing mothers.
        ===============

DRUG INTERACTIONS: none reported.
        ===============

COST: the wholesale cost of this medication is $15.88 for a 15 gram
tube of the 5% topical ointment, and $558.90 for one vial of a
500mg/10cc solution.
        ***************
        ***************





GENERIC NAME: Amantidine Hydrochloride
        ===============

BRAND NAME: Symmetrel
        ===============

INDICATIONS: influenzae type "A" infections, and Parkinsons disease.
        ===============

MECHANISM OF ACTION: these are twofold. The first is that it is
effective in increasing the amount of a brain substance known as
dopamine.  People with Parkinson's Disease have a relative deficiency
of this. Secondly, it inhibits the ability of the influenzae "A"
virus to infect human cells.
        ===============

DOSE RANGE: for Parkinsons disease the dose range is 100mg to 400 mg
per day.  The recommended dose for the treatment of influenzae "A" is
is 200 mg per day.
        ===============

SIDE EFFECTS: depression, heart failure, low blood pressure,
psychosis, difficulty urinating, and less frequently, seizures, low
white blood cell counts, hallucinations, confusion, anxiety, loss of
appetite, nausea, and skin rash. Amantidine should be used with
extreme caution in pregnant females and nursing mothers.
        ===============

DRUG INTERACTIONS: none reported
        ===============

WHOLESALE COST: 100 mg tablets - $28.50 for 100 tablets.
        ***************
        ***************

GENERIC NAME: Amikacin
        ===============

BRAND NAME: Amikin
        ===============

INDICATIONS: this drug is indicated for the treatment of severe
bacterial infections especially when due to organisms normally found
in the intestines.
        ===============

MECHANISM OF ACTION: Amikacin works to kill bacteria by inhibiting
their ability to produce vital proteins.
        ===============

DOSE RANGE: 15mg/kg (2.2 lbs) body weight  given in divided doses
usually three times per day.  This should be decreased in patients
with kidney disease.
        ===============

SIDE EFFECTS: kidney damage, deafness, and severe muscle weakness.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with capreomycin, cephalotihn, colistimethate, ethacrynic
acid, ether, furosemide, methoxyflurane penicillins, polymyxin b, and
succinylcholine.
        ===============

WHOLESALE COST: 500 mg/2cc vial - $16.62
        ***************
        ***************





GENERIC NAME: Amoxicillin
        ===============

BRAND NAMES: Amoxicillin, Amoxil, Larotid, Polymox, Trymox, Wymox.
        ===============

INDICATION:  used in a wide variety of infections including
infections of the kidneys and bladder, lungs, middle ear, and the
intestines.
        ===============

MECHANISM OF ACTION: this drug works by binding to the bacterial cell
wall thus preventing the bacteria from dividing.  It also allows
substances to leak out of the wall which then cause the bacterial
cell to burst.
        ===============

DOSE RANGE: 250mg - 500mg, three times per day.
        ===============

SIDE EFFECTS: skin rashes, severe lowering of blood pressure, asthma
type reactions, lowered white and red blood cell counts, decreased
platelet counts, diarrhea, and kidney abnormalities.  These side
effects are very infrequent.
        ===============

DRUG INTERACTIONS: Amoxicillin may interact unfavorably when used in
conjunction with chloramphenicol, erythromycin, birth control pills,
and tetraycline.
        ===============

WHOLESALE COST: $50.00 for 500, 250 mg capsules.  $15.00 for 50, 500
mg capsules.
        ***************
        ***************

GENERIC NAME: Amphotericin B
        ===============

BRAND NAMES: Fungizone, Mysteclin-F
        ===============

INDICATIONS: Severe systemic fungal infections.
        ===============

MECHANISM OF ACTION: this drug inhibits fungi by binding to a
component of the cell wall causing detrimental substances to leak in.
        ===============

DOSE RANGE: by vein - .25 - 1.5 mg/kg of body weight. Treatment
usually lasts for months.
        ===============

SIDE EFFECTS: fever, chills headache, anorexia, weight loss, nausea,
vomiting, belly pain, muscle and joint pain, pain at the site of
injection, blood clots at the site of injection, low blood counts,
kidney failure,  and less commonly, heart disease and abonrmal heart
rhythms, thinning of the blood, blood in the stool, deafness,
dizziness, visual disturbances, allergic reactions, liver damage, and
numbness.
        ===============

DRUG INTERACTIONS: none found
        ===============

WHOLESALE COST: $13.00 for a 50 mg vial.
        ***************
        ***************





GENERIC NAME: Ampicillin
        ===============

BRAND NAMES: Amcil, Ampicillin, Omnipen, Pfizerpen, Polycillin.
        ===============

INDICATIONS: (see amoxicillin)
        ===============

MECHANISM OF ACTION: (see amoxicillin).  Ampicillin is not absorbed
from the intestines as well as amoxicillin.  It also causes more
stomach upset.
        ===============

DOSE RANGE: by mouth - 2-4 grams per day in divided doses usually 4
times per day.  It is used by vein at the dose range of 6-12 grams
per day given in divided doses four to six times per day.
        ===============

SIDE EFFECTS: (see amoxicillin)
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with allopurinol, aminoglycosides, chloramphenicol,
erythromycin, heparin, oral blood thinners, birth control pills, and
tetracycline.
        ===============

WHOLESALE COST: $30.00 for 500, 250 mg capsules.  $9.50 for 50, 500
mg capsules. $20.00 for 10 500 mg vials.
        ***************
        ***************

GENERIC NAME: Azlocillin
        ===============

BRAND NAME: Azlin
        ===============

DOSE RANGE: 200-300 mg per kg per day given in four to six doses.
        ===============

SIDE EFFECTS: severe allergic reactions, skin rash, itching,
wheezing, headache, seizures, belly pain, nausea and vomiting,
increased tendency to bleed, lowered blood counts, decreases in
kidney and liver function, pain at the site of injection. There have
been no harmful effect to unborn laboratory animals, however, no
information concerning use in pregnant human females is available.
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with aminoglycosides and probenicid.
        ===============

WHOLESALE COST: $150.00 for 10, 3 gram vials.
        ***************
        ***************





GENERIC NAME: Bacampicillin
        ===============

BRAND NAME: Spectrobid
        ===============

INDICATIONS: (see amoxicillin)
        ===============

MECHANISM OF ACTION:(see amoxicillin) Bacampicillin is a derivative
of ampicillin.  It inhibits bacteria in the same way, however, it is
better absorbed in the intestines. After it is absorbed into the
bloodstream the body converts it to ampicillin thus the similarity.
        ===============

DOSE RANGE: 400 mgs two to four times per day.
        ===============

SIDE EFFECTS: (see amoxicillin)
        ===============

DRUG INTERACTIONS: (see ampicillin)
        ===============

WHOLESALE COST: 100, 400 mg tablets cost $85.00
        ***************
        ***************

GENERIC NAME: Bacitracin
        ===============

BRAND NAME: Bacitracin
        ===============

INDICATION: used for the topical treatment of mild bacterial
infections.
        ===============

MECHANISM OF ACTION: causes bacteria to be unable to make or repair
their cell walls (outer coating).
        ===============

DOSE RANGE: this drug should be applied directly to the involved area
(skin or below the eye) as needed to cure infection (usually one to
six times per day).
        ===============

SIDE EFFECTS: irritation at the site of application.
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with aminoglycosides, cephalothin, certain muscle
relaxants, and phenothiazines.  These interactions are probably not
significant when bacitracin is used topically.
        ===============

WHOLESALE COST: $1.50 for one 15 gram tube at the concentration of
500 units/gram.
        ****************
        ****************





GENERIC NAME: Carbenicillin
        ===============

BRAND NAME: Geopen
        ===============

INDICATIONS: for the treatment of moderate to severe bacterial
infections including Pseudomonas (a very aggressive bug).
        ===============

MECHANISM OF ACTION: (see penicillin)
        ===============

DOSE RANGE: by mouth - one to two tablets every six hours.  If given
by vein the dose is 200 to 400 mg/kg body weight in divided doses.
        ===============

SIDE EFFECTS: (see penicillin) pain at the injection site, local
irritation of the vein used for injection.
        ===============

DRUG INTERACTIONS: the same as ampicillin with the exception of
allopurinol (see ampicillin).
        ===============

WHOLESALE COST: $30.48 for 10, 2 gram vials.
        ***************
        ***************

GENERIC NAME: Cefaclor
        ===============

BRAND NAME: Ceclor
        ===============

INDICATIONS: treatment of bacterial infections including ear, throat,
lung, kidneys and bladder, and skin.
        ===============

MECHANISM OF ACTION: (see penicillin)
        ===============

DOSE RANGE: One to four grams per day given in divided doses.
        ===============

SIDE EFFECTS: severe allergic reactions, diarrhea, nausea and
vomiting, skin rashes, abnormal white blood cells (eosinophilia),
itching, vaginal irritation, decreased liver and kidney function.
Caution should be used when giving this drug to pregnant and nursing
mothers as there is no scientific information available relating to
the side effects in these individuals and their children. PATIENTS
ALLERGIC TO PENICILLIN SHOULD USE THIS DRUG WITH EXTREME CAUTION.
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with alcohol, and drugs in the aminoglycoside class.
        ===============

WHOLESALE COST: $12.09 for 15, 250 mg capsules.
        ***************
        ***************

GENERIC NAME: Cefadroxil
        ===============

BRAND NAMES: Duricef, Ultracef
        ===============

INDICATIONS: for the treatment of bacterial infections including
urinary tract, skin, and throat.
        ===============

MECHANISM OF ACTION: (see penicillin)
        ===============

DOSE RANGE: one to two grams two times per day.
        ===============

SIDE EFFECTS: (see cefaclor)
        ===============

DRUG INTERACTIONS: (see cefaclor)
        ===============

WHOLESALE COST: $27.00 for 24 500 mg capsules
        ***************
        ***************





GENERIC NAME: Cefamandole
        ===============

BRAND NAME: Mandol
        ===============

INDICATIONS: for the treatment of serious bacterial infections and
for prevention of infections due to surgical procedures.
        ===============

MECHANISM OF ACTION: (see penicillin)
        ===============

DOSE RANGE: 500 TO 1000 mg every four to six hours.
        ===============

SIDE EFFECTS: nausea, vomiting, diarrhea, severe and mild allergic
reactions, decreased platelets, decreased white blood cells, anemia,
kidney and liver dysfunction, pain and blood clots in the area of
injection. This drug should be given with caution to pregnant or
nursing mothers. PATIENTS ALLERGIC TO PENICILLIN SHOULD ALSO USE THIS
DRUG WITH CAUTION.
        ===============

DRUG INTERACTIONS: (see cefaclor)
        ===============

WHOLESALE COST: $163.00 for 10, 1 gram vials.
        ***************
        ***************

GENERIC NAME: Cefazolin
        ===============

BRAND NAMES: Ancef, Kefzol
        ===============

INDICATION: for the treatment of bacterial infection
        ===============

MECHANISM OF ACTION: (see amoxicillin)
        ===============

DOSE RANGE: 500 mg to 1500 mg every six to twelve hours.
        ===============

SIDE EFFECTS: (see cephamandole)
        ===============

DRUG INTERACTIONS: (see cefaclor)
        ================

WHOLESALE COST: $70.00 for 10, one gram vials.
        ****************
        ****************

GENERIC NAME: Cefotaxime
        ================

BRAND NAME: Claforan
        ================

INDICATIONS: for the treatment of severe bacterial infections. It is
also used for the prevention of infection due to surgical procedures.
        ================

MECHANISM OF ACTION: (see amoxicillin)
        ================

DOSE RANGE: one gram every six to eight hours.
        ================

SIDE EFFECTS: (see cefamandole)
        ================

DRUG INTERACTIONS: (see ceclor)
        ================

WHOLESALE COST: $115.00 for 10, 1 gram vials.
        ****************
        ****************





GENERIC NAME: Cefoxitin
        ===============

BRAND NAME: Mefoxin
        ===============

INDICATION: for the treatment of severe bacterial infection, and the
prevention of bacterial infection due to surgical procedures.
        ===============

MECHANISM OF ACTION: (see amoxicillin)
        ===============

DOSE RANGE: one to two grams every six to eight hours.
        ================

SIDE EFFECTS: (see cefamandole)
        ================

DRUG INTERACTIONS: (see cefamandole)
        ================

WHOLESALE COST: $205.00 for 25 one gram vials.
        ****************
        ****************

GENERIC NAME: Cephalexin
        ================

BRAND NAME: Keflex
        ================

INDICATIONS: for the treatment of bacterial infections.
        ================

MECHANISM OF ACTION: (see amoxicillin)
        ================

DOSE RANGE: 250 mg to 1000 mg every six hours
        ================

SIDE EFFECTS: (see cefaclor)
        ================

DRUG INTERACTIONS: (see cefaclor)
        ================

WHOLESALE COST: $50.00 for 100, 200 mg capsules.
        ****************
        ****************

GENERIC NAME: Cephalothin
        ================

BRAND NAME: Keflin
        ================

INDICATION: for the treatment and prevention of bacterial infections.
        ================

MECHANISM OF ACTION: (see amoxicillin)
        ================

SIDE EFFECTS: (see cefaclor)
        ================

DOSE RANGE: 500 to 2000 mgs every four to six hours.
        ================

DRUG INTERACTIONS: (see cefaclor)
        ================

WHOLESALE COST: $63.00 for 10, two gram vials.
        ****************
        ****************



CompuServe

GENERIC NAME: Chloramphenicol
        ================

BRAND NAME: Chloromycetin
        ================

INDICATION: for the treatment of severe bacterial infections.
        ================

MECHANISM OF ACTION: this drug inhibits bacteria by interfering with
their ability to make vital proteins.
        ================

DOSE RANGE: 50 to 100 mg per kg per day in divided doses.
        ================

SIDE EFFECTS: depression of the bone marrow causing decreased red
blood cells, blurred vision fever, rashes, severe allergic reactions,
death when used in infants.  There are no studies documenting its
safety in pregnant or nursing mothers.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when used in
conjunction with acetaminophen, barbiturates, cyclophosphamide,
dilantin, iron supplements, blood thinners given by mouth,
penicillin-like drugs, sulfonylureas, and vitamin B-12
        ================

WHOLESALE COST: $58.00 for 100, 250 mg capsules. $62.00 for 10, one
gram vials.
        ****************
        ****************

GENERIC NAME: Cloxacillin
        ================

BRAND NAME: Tegopen
        ================

INDICATION: for the treatment of certain bacterial infections
including those caused by Staphylococcus.
        ================

MECHANISM OF ACTION: (see amoxicillin)
        ================

DOSE RANGE: 250 to 500 mg every six hours.
        ================

SIDE EFFECTS: (see amoxicillin)
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when used in
conjunction with chloramphenicol, erythromycin, birth control pills,
and tetracyclines.
        ================

WHOLESALE COST: $54.00 for 100, 250 mg capsules.
        ****************
        ****************

GENERIC NAME : Dicloxacillin
        ================

BRAND NAMES: Dicloxacillin, Dynapen, Pathocil.
        ================

INDICATION: for the treatment of certain bacterial infections
including those due to Staphylococcus.
        ================

MECHANISM OF ACTION: (see amoxicillin)
        ================

DOSE RANGE: one to two grams per day in divided doses.
        ================

SIDE EFFECTS: (see amoxicillin)
        ================

DRUG INTERACTIONS: (see cloxacillin)
        ================

WHOLESALE COST: $67.00 for 100, 200 mg capsules.
        ****************
        ****************





GENERIC NAME: Doxycycline
        ================

BRAND NAME: Vibramycin
        ================

INDICATION: for the treatment of certain bacterial infections
including gonorrhea.
        ================

MECHANISM OF ACTION: this drug inhibits the growth of bacteria by
preventing them from making life sustaining proteins.
        ================

DOSE RANGE: The usual dose for adults is 200 mg on the first day
taken as two 100 mg doses followed by 100 mg per day.
        ================

SIDE EFFECTS: decreased appetite, nausea, vomiting diarrhea,
irritation of the tongue, difficulty swallowing, irritation of the
genital area, skin rashes, decreased kidney function, increased fluid
pressure in the brain, severe allegic reactions, decreased white and
red blood cell count, decreased platelets, discoloration of the
thyroid gland, abnormal tooth and bone formation in children.  This
drug should not be used during pregnancy, or by nursing mothers.
        ================

DRUG INTERACTIONS:  this drug may interact unfavorably when given in
conjunction with aluminum salts, barbiturates, bicarbonate, bismuth
salts, bumetanide, carbamazepine, penicillin-like drugs,
theophylline-like drugs, thiazide diuretics, and zinc.
        ================

WHOLESALE COST: $67.41 for 50, 100 mg capsules
        ****************
        ****************

GENERIC NAME: Erythromycin
        ================

BRAND NAMES:  A/T/S, ERYC, Ery- tab, Ilotycin, Pediamycin, Pediazole,
Robimycin, Staticin, E-Mycin, Erythromyucin, E.E.S., EryPed,
Wyamycin, Erythrocin, Bristamycin, Pfizer-E, SK- Erythromycin.
        ================

INDICATION: for the treatment of certain bacterial infections
including Legionnaire's disease.
        ================

MECHANISM OF ACTION: erythromycin exerts its action by preventing
bacteria from making vital proteins.
        ================

DOSE RANGE: 250 to 1000 mg four times per day.
        ================

SIDE EFFECTS: allergic reactions, skin rashes, reduced liver
function, deafness, irritation of the vein when given by that route,
nausea, vomiting, belly pain. This drug has not been determined to be
safe for usage during pregnancy.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with carbamazepine, digoxin, blood thinners by mouth,
penicillin- like drugs, and theophyllines.
        ================

WHOLESALE COST: $15.45 for 100, 500 mg tablets.  $5.00 for one vial
of 500 mg injectable.
        ****************
        ****************





GENERIC NAME: Griseofulvin
        ================

BRAND NAMES: Fulvicin, Grifulvin, Grisactin.
        ================

INDICATIONS: This drug is indicated for the treatment of certain
types of moderate to severe fungal infections including ringworm and
athlete's foot.
        ================

MECHANISM OF ACTION: Griseofulvin inhibits the growth of certain
fungi by rendering them unable to genetically duplicate themselves.
        ================

DOSE RANGE: The usual adult dose is 500 to 1000 mgs per day.
        ================

SIDE EFFECTS: Skin rashes, numbness of the hands and feet, fungal
infection of the mouth (thrush), nausea, vomiting, belly pain,
diarrhea, headache, fatigue, inability to sleep, confusion, protein
in the urine, and decreased white blood cells. It should be noted
that although there are many potential side effects, they occur
rarely.  The safety of this drug for use in pregnant women has not
been determined.
        ================

DRUG INTERACTIONS: Griseofulvin may interact unfavorably with drugs
in the barbiturate class, and with blood thinners that are taken by
mouth.
        ================

COST: The wholsale cost of this medication is $42.70 for 100, 500 mg
tablets.
        ****************
        ****************

GENERIC NAME: Isoniazid
        ================

BRAND NAMES: INH, Isoniazid, Rifamate.
        ================

INDICATIONS:  Isoniazid is used for the treatment of tuberculosis and
tuberuclosis- like infections.
        ================

MECHANISM OF ACTION: This medication inhibits growth and kills the
tuberculosis organism by an unknown mechanism.
        ================

DOSE RANGE: usually 300 mgs/day but may increase to 600 mgs/day in
severe cases.
        ================

SIDE EFFECTS: these include rash, fever, inflammation of the liver
with or without yellow jaundice, arthritis symptoms, depressed
production of blood cells.  If pyridoxine, a B vitamin, is not given
simultaneously with isoniazid, nerve abnormalitites and anemia may
result.  This drug should be prescribed during pregnancy only in
grave situations as there is evidence that it causes birth defects in
laboratory animals.
        ================

DRUG INTERACTIONS: isoniazid may react unfavorably when given in
conjunction with aspirin, benzodiazepines (valium), most seizure
medications, Antabuse, blood thinners taken by mouth, Rifampin, and
Theophylline.
        ================

COST: 1000, 300 mg tablets have a wholesale cost of $12.70.
        ****************
        ****************





GENERIC NAME: Kanamycin
        ================

BRAND NAME: Kantrex
        ===============

INDICATIONS:  Kanamycin therapy is indicated for the treatment of
life threatening infections due to organisms usually found in the
bowel.
        ===============

MECHANISM OF ACTION:  this drug destroys bacteria by inhibiting their
ability to make life sustaining proteins.
        ===============

DOSE: The usual dose is 15 mg of drug per kg of body weight divided
into two equal doses.
        ===============

SIDE EFFECTS: these are kidney damage, deafness, pain at the site of
injection, rash, fever, and tingling sensations.
        ===============

DRUG INTERACTIONS: there may be unfavorable interactions if this drug
is used concomitantly with Bacitracin, Bumetanide, Capreomycin,
Cephalothin Colistimethate, Digoxin, Ethacrynic Acid, Ether
Methoxyflurane, or Blood Thinners by mouth.  This drug has not been
determined to be safe for usage during pregnancy.
        ===============

COST: $8.59 for one 2cc vial containing 500 mg.
        ***************
        ***************

GENERIC NAME: Ketoconazole
        ===============

BRAND NAME: Nizoral
        ===============

INDICATION: this drug is indicated for the systemic treatment of
certain forms of fungal infection such as candida, coccidiomycosis,
and histoplasmosis.
        ===============

MECHANISM OF ACTION: this drug works by interfering with the fungi's
ability to produce their cell membranes by inhibiting production of a
substance called ergosterol.
        ===============

DOSE RANGE: 200 - 400 mg per day.
        ===============

SIDE EFFECTS:  these are usually mild and include nausea, vomiting,
abdominal pain, itching, headache, dizziness, sleepiness, fever,
sensitivity to light, diarhhea, yellow jaundice and enlarged breasts
in males.  The safety for use in pregnant females has not been
determined.
        ===============

DRUG INTERACTIONS: ketoconazole may react unfavorably when given in
conjunction with Tagamet, Zantac, and antacids.
        ===============

COST:the wholesale cost is $1.10 for one 200 mg tablet.
        ***************
        ***************





GENERIC NAME: Lincomycin
        ================

BRAND NAME: Lincocin
        ================

INDICATION: for the treatment of certain bacterial infections.
        ================

MECHANISM OF ACTION: this drug inhibits the growth of bacteria by
inhibiting the organism's ability to produce vital proteins.
        ================

DOSE RANGE:  by mouth - 500 mg three times per day. If given by vein
for serious infections - one to eight grams every eight to twelve
hours.
        ================

SIDE EFFECTS: severe diarrhea, irritation of  the mouth and tongue,
nausea, vomiting, rectal itch, decreased white and red blood cells,
decreased platelets, allergic reactions, skin rashes, vaginal
irritation, decreased liver function, low blood pressure, heart
standstill, ringing in the ears, dizziness, pain at the site of
injection.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with aluminum salts, certain muscle relaxants, and
succinylcholine.
        ================

WHOLESALE COST: $52.00 for 100, 500 mg capsules. $3.50 for one 2 cc
vial containing 300mg per cc.
        ****************
        ****************

GENERIC NAME: Methenamine
        ================

BRAND NAMES: Hiprex, Urex, Mandelamine, Thiacide, Uroqid- Acid.
        ================

INDICATION: for the treatment and prevention of urinary tract
infection.
        ================

MECHANISM OF ACTION: this drug is inactive until it is excreted in
the urine.  In the urine it is changed into ammonia and formaldehyde
which are capable of killing bacteria.
        ================

DOSE RANGE: one gram after each meal and at bed time.
        ================

SIDE EFFECTS: skin rash, stomach upset.
        ================

DRUG INTERACTIONS: none reported
        ================

WHOLESALE COST: $20.57 for 56, one gram tablets.
        ****************
        ****************

GENERIC NAME: Methicillin
        ================

BRAND NAME: Staphcillin
        ================

INDICATION: for the treatment of certain bacterial infections
including those caused by the staphylococcal organism.
        ================

MECHANISM OF ACTION: (see amoxicillin)
        ================

DOSE RANGE: one to four grams every four to six hours.
        ================

SIDE EFFECTS: (see cloxacillin)
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with aminoglycosides, chloramphenicol, erythromycin,
blood thinners, birth control pills, and tetracyclines.
        ================

WHOLESALE COST: $3.94 for one, one gram vial.
        ****************
        ****************





GENERIC NAME: Metronidazole
        ================

BRAND NAME: Flagyl
        ================

INDICATION: for the treatment of certain bacterial and protozoan
infections including trichomonas and giardia.
        ================

MECHANISM OF ACTION: this drug probably interferes with the ability
of the organism to produce DNA ( the genetic building blocks ).
        ================

DOSE RANGE: this drug can be given as a one time dose of two grams or
250 - 500 mg three times per day for three to ten days.
        ================

SIDE EFFECTS: nausea, decreased appetite, "furry tongue", irritation
of the mouth and tongue, dizziness, difficulty with coordination,
numbness and tingling, rashes, flushing, itching, burning on
urination, seizures, lowered blood counts, weakness, difficulty
sleeping, allergic reactions, frequent urination, inability to hold
urine, darkened urine, and joint pains.  Metronidazole should not be
used in pregnant females or nursing mothers.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with barbiturates, antabuse, alcohol, and blood thinners
given by mouth.
        ================

WHOLESALE COST:$75.00 for 100, 250 mg tablets.
        ****************
        ****************

GENERIC NAME: Miconazole
        ================

BRAND NAME: Monistat
        ================

INDICATION:  for the treatment of yeast infections predominantly of
the skin and vagina.
        ================

MECHANISM OF ACTIONS: this drug inhibits yeast by binding to the cell
wall allowing potentially lethal substances to leak into the
organism.
        ================

DOSE RANGE: for skin infections apply to affected area twice a day.
Treat vaginal infections with one suppository inserted in the vagina
per day for seven days.
        ================

SIDE EFFECTS: local irritation and burning, skin rashes.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with blood thinners by mouth.
        ================

WHOLESALE COST: vaginal - $8.39 for 7 vaginal suppositories, skin -
$4.36 for one 15 gram tube.
        ****************
        ****************

GENERIC NAME: Moxalactam
        ================

BRAND NAME: Moxam
        ================

INDICATION: for the treatment and prevention of serious bacterial
infections.
        ================

MECHANISM OF ACTION: (see amoxicillin)
        ================

DOSE RANGE: two to six grams in divided doses given every eight
hours.
        ================

SIDE EFFECTS: (see cefaclor), also decreased ability to form blood
clots, mild liver abnormalties.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with alcohol.
        ================

WHOLESALE COST: $122.00 for 10, 1 gram/10cc vials.
        ****************
        ****************





GENERIC NAME: Nafcillin
        ================

BRAND NAMES: Nafcil, Unipen
        ================

INDICATION: for the treatment of certain  bacterial infections
including those caused by the staphylococcus.
        ================

MECHANISM OF ACTION: (see amoxicillin)
        ================

DOSE RANGE: Two to twelve grams per day in divided doses.
        ================

SIDE EFFECTS: (see cloxacillin)
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with aminoglycosides, chloramphenicol, erythromycin,
heparin, blood thinners by mouth, birth control pills, and
tetracyclines.
        ================

WHOLESALE COST: $6.53 for one, one gram vial.
        ****************
        ****************

GENERIC NAME: Nitrofurantoin
        ================

BRAND NAME: Furadantin, Nitrex, Nitrofurantoin, Macrodantin, and
Ivadantin.
        ================

INDICATION: for the treatment and prevention of urinary tract
infections.
        ================

MECHANISM OF ACTION: unknown.
        ===============

DOSE RANGE: 50 - 100 mg by mouth at bedtime.
        ================

SIDE EFFECTS: nausea, vomiting, diarrhea, allergic reactions
involving the skin, blood, liver, or lungs, headache, dizziness,
drowsiness, muscular aches, numbness and tingling.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with dilantin or magnesium.
        ================

WHOLESALE COST: $22.00 for 100, 50 mg capsules.
        ****************
        ****************





GENERIC NAME: Oxacillin
        ================

BRAND NAME: Oxacillin, Prostaphlin.
        ================

INDICATION: (see methicillin)
        ================

MECHANISM OF ACTION: (see amoxicillin)
        ===============

DOSE RANGE:  two to twelve grams per day in divided doses.
        ================

SIDE EFFECTS: (see cloxacillin)
        ================

DRUG INTERACTIONS: (see nafcillin)
        ================

WHOLESALE COST: $7.83 for one, one gram vial.
        ****************
        ****************

GENERIC NAME: Penicillin
        ================

BRAND NAMES: Penicillin, Pentids, Pfizerpen, SK- Penicillin,
Bicillin, Crysticillin, Wycillin, Omnipen, Principen, Unipen,
Veetids, Betapen.
        ================

INDICATION: for the treatment and prevention of bacterial infections.
        ================

MECHANISM OF ACTION: (see amoxicillin)
        ================

DOSE RANGE: by mouth, one to two grams per day in divided doses. When
given by vein or in the muscle the dose ranges from one to twenty
million units per day in divided doses.
        ================

SIDE EFFECTS: (see amoxicillin)
        ================

DRUG INTERACTIONS: (see methicillin)
        ================

WHOLESALE COST: $21.50 for 1000, 250 mg tablets, $33.75 for 1000
doses of 400,000 units.
        ****************
        ****************





GENERIC NAME: Rifampin
        ================

BRAND NAMES: Rifadin, Rifamate, Rimactane.
        ================

INDICATIONS: for the treatment of specific bacterial infections
including tuberculosis.
        ================

MECHANISM OF ACTION: this drug inhibits the genetic building blocks
of the organism, thus making it unable to tell itself what protein to
make (inhibits RNA production).
        ================

DOSE RANGE: 600 mg once daily
        ================

SIDE EFFECTS: skin rash, fever, nausea and vomiting, flu-like
syndrome, decreased platelet count, decreased liver function,
diarrhea, belly pain, fatigue, drowsiness, headache, dizziness, poor
coordination, confusion, numbness, allergic reactions, anemia,
lowered white blood cell count, and protein in the urine.
        ================

DRUG INTERACTIONS: rifampin may interact unfavorably when used in
conjunction with aspirin, barbiturates, valium-like drugs,
beta-blockers, clofibrate, corticosteroids, digitoxin, digoxin,
disopyramide, halothane, isoniazid, methadone, blood thinners by
mouth, birth control pills, progesterone, quinidine, sulfa drugs,
diabetes pills.
        ================

WHOLESALE COST: $96.00 for 100, 300 mg capsules.
        ****************
        ****************

GENERIC NAME: Sulfamethoxazole
        ================

BRAND NAMES: Azo-Gantanol, Bactrim, Gantanol, Septra.
        ================

INDICATION: for the treatment and prevention of bacterial infections
including of the urinary tract.
        ================

MECHANISM OF ACTION: this drug inhibits the organism's ability to
metabolize a specific vitamin known as folic acid.  Successful
metabolism of this vitamin is essential for the bacteria to survive.
This drug is often combined with trimethoprim, another folic acid
metabolism inhibitor (Bactrim and Septra).
        ================

DOSE RANGE:  The usual dose of Bactrim or Septra is one double or two
single strength pills two times per day.
        ================

SIDE EFFECTS: anemias, inhibition of the blood forming organs, mild,
moderate and severe allergic reactions, irritation of the tongue and
mouth, nausea, vomiting, belly pains, diarrhea, decreased liver
function, headache, depression, seizures, poor coordination,
hallucinations, dizziness, fever, chills, weakness.
        ================

DRUG INTERACTIONS: This drug may interact unfavorably when given in
conjunction with dilantin, barbiturates, cyclophosphamide, blood
thinners by mouth, and diabetes pills.
        ================

WHOLESALE COST: the combination of trimethoprim and sulfamethoxazole
is $97.00 for 250, double strength tablets.
        ****************
        ****************





GENERIC NAME: Tetracycline
        ================

BRAND NAMES: Achromycin, Mysteclin, Panmycin, Robitet, Sumycin,
Azotrex, Tetrex.
        ================

INDICATION: (see doxycycline)
        ================

DOSE RANGE: 250 to 500 mgs, two to four times per day.
        ================

SIDE EFFECTS: (see doxycycline)
        ================

DRUG INTERACTIONS: (see doxycycline)
        ================

WHOLESALE COST: $30.45 for 1000, 250 mg capsules.
        ****************
        ****************

GENERIC NAME: Ticarcillin
        ================

BRAND NAME: Ticar
        ================

INDICATION: for the treatment of serious bacterial infections.
        ================

MECHANISM OF ACTION: (see amoxicillin)
        ================

DOSE RANGE: 50 to 300 mg/kg per day in divided doses.
        ================

SIDE EFFECTS: (see carbenicillin)
        ================

DRUG INTERACTIONS: this medication may interact unfavorably when
given in conjunction with aminoglycosides, chloramphenicol,
erythromycin, heparin, blood thinners by mouth, birth control pills,
and tetracyclines.
        ================

WHOLESALE COST: $2.41 for one, one gram vial.
        ****************
        ****************





GENERIC NAME: Tobramycin
        ================

BRAND NAME: Nebcin
        ================

INDICATION: for treatment of serious bacterial infections.
        ================

MECHANISM OF ACTION: (see amikacin)
        ================

DOSE RANGE: one to two mg/kg per day given in divided doses.
        ================

SIDE EFFECTS: (see gentamicin)
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with bacitracin, bumetanide, capreomycin, cephalothin,
colistimethate, ethacrynic acid, ether, furosemide, methoxyflurane,
muscle relaxants, penicillins, polymyxin b, and succinylcholine.
        ================

WHOLESALE COST: $145.00 for 24, 80 mg vials.
        ****************
        ****************






GENERIC NAME: Codeine
        ================

BRAND NAMES: A.P.C., Acetaco, Amephen with codeine, Anatuss,
Ascriptin with Codeine, Bancap with Codeine, Bromanyl Expectorant,
Bromphen Expectorant, Buff-A Comp No. 3, Bufferin with Codeine,
Captial with Codeine, Codalan, Codegisc, Codiaml PH, Colrex, Conex
with Codeine, Co-Xan, Deproist Expectorant with Codeine, Empirin with
Codeine, Emprazil, Fiornal with Codeine, G2 and G3 tablets, Guiatuss
A-C, Iophen-C, Maxigesic, Naldecon-CX, Uncofed, Pediacof, Phenaphen
with Codeine, Phenergan with Codeine, Robitussin AC and DAC, Rogesic
#3, Ru-Tuss, Soma with Codeine, Stopayne, Tussar, Tyelenol with
Codeine.
        ================

INDICATION: for the treatment of moderate to severe pain.
        ================

MECHANISM OF ACTION: this medication exerts its pain relieving
properties by imitating naturally occurring pain relieving substances
(enkephalins) within the brain.
        ================

DOSE RANGE: 15 to 60 mg as often as every four hours.  This
medication is often given simultaneously with aspirin or
acetaminophen as they supposedly are more effective in tandem.
        ================

SIDE EFFECTS: light headedness, dizziness, sleepiness, nausea an
vomiting, euphoria, constipation, difficulty in urination. High doses
may decrease stimulus to breath and lower blood pressure. THIS
MEDICATION MAY BE HABIT FORMING.
        ================

DRUG INTERACTIONS: this medication may interact unfavorably when
given in conjunction with barbiturates, or cimetidine.
        ================

WHOLESALE COST: $22.70 for 100, 30 mg tablets.
        ****************
        ****************

GENERIC NAME: Flucinolide
        ================

BRAND NAMES: Derma-Smooth, Flucinolone, Fluonid, Neo- Synalar,
Synalar, Synemol, Lides, Topsyn.
        ================

INDICATION: for the treatment of certain inflammatory or irritating
skin rashes.
        ================

MECHANISM OF ACTION: this medication acts by preventing the body from
producing certain inflammatory or irritating substances
(prostaglandins and leukotrienes among others).  It also acts to
prevent numerous body processes by unknown mechanisms.
        ================

DOSE RANGE: .025% to .2% cream or ointment applied three to four
times daily to involved area.
        ================

SIDE EFFECTS: burning, itching, irritation, dryness, acne, decreased
skin color, thinning of the skin.
        ================

DRUG INTERACTIONS: none reported
        ================

WHOLESALE COST: $12.42 for one 60 gram tube of .025%
        ****************
        ****************





GENERIC NAME: Gold Sodium Thiomalate
        ================

BRAND NAME: Myochrysine
        ================

INDICATION: for the treatment of sever rheumatoid arthritis.
        ===============

DOSE RANGE: 10 to 50 mg injected into the muscle every one to two
weeks.
        ================

MECHANISM OF ACTION: unknown
        ================

SIDE EFFECTS: skin rash, itching, skin reaction to sunlight,
baldness, loss of fingernails, irritation of the mouth and tongue,
decreased function of the kidney, protein in the urine, decreased
blood counts, allergic reactions, nausea, vomiting, diarrhea,
abdominal cramps, irritation of the eyes, decrease liver function,
inflammation of the lungs, numbness.
       =================

DRUG INTERACTIONS: this drug may interact unfavorably when used in
conjunction with penicillamine.
        ================

WHOLESALE COST: $23.03 for 6, 50 mg vials for injection.
        ****************
        ****************

GENERIC NAME: Hydrocodone
        ================

BRAND NAMES: Adatuss DC, Bancaps HC, Citra Forte, Codiclear DH,
Codimal DH, Damason-P, Detussin Expectorane, Di-Gesic, Donatussin Dc,
Duradyne DHC, Entuss, Hycodan, Hycomine, Hycotuss, PV Tussin, RuTuss,
ST Forte, T-gesic, Tussend, Vicodin.
        ================

INDICATION: for the treatment of cough and moderate to severe pain.
        ================

MECHANISM OF ACTION: (see codeine)
        ================

DOSE RANGE: 5 mg every four to six hours.
        ================

SIDE EFFECTS: (see codeine) This drug should not be given to pregnant
women or nursing mothers.
        ================

DRUG INTERACTIONS: (see codeine)
        ================

WHOLESALE COST: $17.34 for 100 tablets, $17.16 for 480 ml of liquid.
        ****************
        **************** GENERIC NAME: Gold Sodium Thiomalate
        ================

BRAND NAME: Myochrysine
        ================

INDICATION: for the treatment of sever rheumatoid arthritis.
        ===============

DOSE RANGE: 10 to 50 mg injected into the muscle every one to two
weeks.
        ================

MECHANISM OF ACTION: unknown
        ================

SIDE EFFECTS: skin rash, itching, skin reaction to sunlight,
baldness, loss of fingernails, irritation of the mouth and tongue,
decreased function of the kidney, protein in the urine, decreased
blood counts, allergic reactions, nausea, vomiting, diarrhea,
abdominal cramps, irritation of the eyes, decrease liver function,
inflammation of the lungs, numbness.
       =================

DRUG INTERACTIONS: this drug may interact unfavorably when used in
conjunction with penicillamine.
        ================

WHOLESALE COST: $23.03 for 6, 50 mg vials for injection.
        ****************
        ****************

GENERIC NAME: Hydrocodone
        ================

BRAND NAMES: Adatuss DC, Bancaps HC, Citra Forte, Codiclear DH,
Codimal DH, Damason-P, Detussin Expectorane, Di-Gesic, Donatussin Dc,
Duradyne DHC, Entuss, Hycodan, Hycomine, Hycotuss, PV Tussin, RuTuss,
ST Forte, T-gesic, Tussend, Vicodin.
        ================

INDICATION: for the treatment of cough and moderate to severe pain.
        ================

MECHANISM OF ACTION: (see codeine)
        ================

DOSE RANGE: 5 mg every four to six hours.
        ================

SIDE EFFECTS: (see codeine) This drug should not be given to pregnant
women or nursing mothers.
        ================

DRUG INTERACTIONS: (see codeine)
        ================

WHOLESALE COST: $17.34 for 100 tablets, $17.16 for 480 ml of liquid.
        ****************
        ****************





GENERIC NAME: Hydrocortisone
        ================

BRAND NAMES: Aeroseb, Allersone, Alphaderm, Alposyl, Carmol Cort-
Dome, Cortenema, Corticaine, Corticream, Cortisporin, Cortril,
Dermacort, Dermasone, FEP Creme, Hill Cortac, Hytone, Loroxide,
Neo-Cot-Dome, Otocidin, Otomycet, Pedicort, ProCort, Poctocort,
Pyocidin, Syncort, Terra Cortril, Texaort, Vanoxide, Vioform,
VoSol,Bytone, AnusolHC, CaladrylHC, CarmolHC, ColyMycin, Cortifoam,
Epifoam, Komed, Mantadil, Ophthocort, Orabase, Pramosone, Wyanoids,
Barseb, HCV, Solu-Cortef.
        ================

INDICATIONS: for the treatment of inflammatory disorders including
various forms of arthritis, skin irritations, kidney disease, lung
disease, certain forms of brain and nerve disease, lowered blood
pressure due to serious bacterial infection, and replacement of
certain hormone deficiencies.
        ================

MECHANISM OF ACTION: this drug, considered in the class of drugs
known as glucocorticoids, or steroids, inhibits inflammation by
supressing the formation of inflammatory substances produced by the
body such as the prostaglandins and the leukotrienes.  It probably
has other therapeutic effects the mechanisms of which have yet to be
determined.
        ================

DOSE RANGE: 100 to 500 mg every 2 to 6 hours.
        ================

SIDE EFFECTS: the side effects of this medication may be quite
serious and thus it should always be used with extreme caution.  They
include: salt and water retention, lowered blood potassium, high
blood pressure, weakness, loss of muscle mass, thinning of bones,
ulcer, difficulty in healing, increased sweating, seizures,
dizziness, headache, menstrual irregularities, fattened face,
decreased growth in children, diabetes, acne, cataracts, and
glaucoma.  Use of this medication might put the user at risk for
severe infections.
        ================

DRUG INTERACTIONS: this medication may interact unfavorably when used
in conjunction with antacids, barbiturates, cholestyramine,
cyclophosphamide, ephedrine, dilantin, isoniazid, certain muscle
relaxants, blood thinners by mouth, birth control pills, rifampin,
aspirin, theophyllines, and troleandomycin.
        ===============

WHOLESALE COST: $2.75 for one 100 mg vial. $2.68 for one 30 gram tube
of 3% cream. $6.24 for 100, 10mg tablets, $4.12 for one 50 mg vial
for injection.
        ****************
        ****************

GENERIC NAME: Hydromorphone
        ================

BRAND NAME: Dilaudid
        ================

INDICATION: for the treatment of cough and moderate to severe pain.
        ================

MECHANISM OF ACTION: (see codeine)
        ================

DOSE RANGE: two to four mg every four to six hours.
        ================

SIDE EFFECTS: (see codeine)
        ================

DRUG INTERACTIONS: (see codeine)
        ================

WHOLESALE COST: $4.63 for 2 mg vial. $16.44 for 100 2 mg tablets
        ****************
        ****************





GENERIC NAME: Ibuprofen
        ================

BRAND NAMES: Motrin, Rufen, Nuprin, Advil.
        ================

INDICATION: for the treatment of mild to moderate pain, the treatment
of arthritis, and the treatment of pain due to menstrual cramping.
        ================

MECHANISM OF ACTION:  ibuprofen exhibits its therapeutic effect by
inhibiting the production of substances in the body known as
prostaglandins. Prostaglandins are a main cause for pain and
inflammation within the body.
        ================

DOSE RANGE: 200 to 800 mg three to four times per day.
        ================

SIDE EFFECTS: nausea, vomiting, belly pain, indigestion,
constipation, dizziness, headache, nervousness, skin rash, ringing in
the ears, decreased blood cell counts, decreased appetite, fluid
retention, severe allergic reactions, kidney failure, dry eyes and
mouth, stomach or duodenal ulcer, bleeding in the intestines, yellow
jaundice, decreased hearing, blurred vision, heart failure, fast
heart rate, enlarged breasts in males, low blood sugar, easy
bleeding, tingling of the arms and legs.  This medication should be
used in pregnant women and nursing mothers with extreme caution.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with digoxin, dilantin, blood thinners by mouth and
aspirin-like drugs.
        ================

WHOLESALE COST: $72.37 for 500, 300 mg tablets.
        ****************
        ****************

GENERIC NAME: Indomethacin
        ================

BRAND NAME: Indocin
        ================

INDICATION: (see ibuprofen)
        ================

MECHANISM OF ACTION: (see ibuprofen)
        ================

DOSE RANGE: 25 to 75 mg two to three times per day.
        ================

SIDE EFFECTS: (see ibuprofen)
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when used in
conjunction with aluminum sal diet pills, beta blockers, bumetanide,
captopril, furosemide, lithium, blood thinners by mouth, prazosin,
probenicid, aspirin, and water pills.
        ================

WHOLESALE COST: $19.74 for 100, 25 mg capsules.
        ****************
        ****************





GENERIC NAME: Meclofenamate
        ================

BRAND NAME: Meclomen
        ================

INDICATION: (see ibuprofen)
        ================

MECHANISM OF ACTION: (see ibuprofen)
        ================

DOSE RANGE: 200 to 400 mg per day given in three to four divided
doses.
        ================

SIDE EFFECTS: (see ibuprofen)
        ================

DRUG INTERACTIONS: (see ibuprofen)
        ================

WHOLESALE COST: $26.54 for 100, 100 mg capsules.
        ****************
        ****************

GENERIC NAME: Mefenamic Acid
        ================

BRAND NAME: Ponstel
        ================

INDICATION: for the treatment of mild to moderate pain including pain
due to menstruation.  This drug should not be continued for more than
one week.
        ================

MECHANISM OF ACTION: (see ibuprofen)
        ================

DOSE RANGE: 500 mg first time dose followed by 250 mg every six
hours.
        ================

SIDE EFFECTS: (see ibuprofen)
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with blood thinners by mouth.
        ================

WHOLESALE COST: $24.31 for 100 250 mg capsules.
        ****************
        ****************






GENERIC NAME: Morphine
        ================

BRAND NAME: Morphine
        ================

INDICATION: for the treatment of severe pain.
        ================

MECHANISM OF ACTION: (see codeine)
        ================

DOSE RANGE: 2 to 12 mgs every two to six hours.
        ================

SIDE EFFECTS: (see codeine)
        ================

DRUG INTERACTIONS: this narcotic may interact unfavorably when given
in conjunction with barbiturates or cimetidine.
        ****************
        ****************

GENERIC NAME: Nalbuphine Hydrochloride
        ================

BRAND NAME: Nubain
        ================

INDICATION: for the treatment of moderate to severe pain.
        ================

MECHANISM OF ACTION:  (see codeine)
        ================

DOSE RANGE: 10 mg every three to six hours.
        ================

SIDE EFFECTS: (see codeine)
        ================

DRUG INTERACTIONS: (see codeine)
        ================

WHOLESALE COST: $13.62 for one, 10 mg vial.
        ****************
        ****************

GENERIC NAME: Naproxen
        ================

BRAND NAME: Naprosyn, Anaprox
        ================

INDICATION: (see ibuprofen)
        ================

MECHANISM OF ACTION: (see ibuprofen)
        ================

DOSE RANGE: 250 to 375 mg two to three times per day.
        ================

SIDE EFFECTS: (see ibuprofen)
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with blood thinners by mouth, probenicid, and
aspirin-like drugs.
        ================

WHOLESALE COST: $40.98 for 100, 250 mg tablets.
        ****************
        ****************





GENERIC NAME: Oxycodone
        ================

BRAND NAME: Tylox, Percocet, Percodan.
        ================

INDICATION: for the treatment of moderate to severe pain.
        ================

MECHANISM OF ACTION: (see codeine)
        ================

DOSE RANGE:  this medication is usually given in conjunction with
aspirin or acetaminophen. The usual dose is 5 to 10 mg every four to
six hours.
        ================

SIDE EFFECTS: (see codeine)
        ================

DRUG INTERACTIONS: (see codeine)
        ================

WHOLESALE COST: $44.50 for 250 tablets.
        ****************
        ****************

GENERIC NAME: Phenacetin
        ================

BRAND NAMES: A.P.C., Emprazil, Propoxyphene Compound 65, Soma,
Soprodol Compound
        ================

INDICATION: for the treatment of mild to moderate musculoskeletal
pain.
        ================

MECHANISM OF ACTION: (see ibuprofen)
        ================

DOSE RANGE:  phenacetin is usually given in combination with other
pain relievers such as aspirin.  The average single dose of
phenacetin is 300 mg. The total dose should not exceed 2400 mg per
day.
        ================

SIDE EFFECTS: low blood sugar, kidney failure, lowered red blood cell
counts, decreased breathing, skin rash, fever, lowered blood white
cells.
        ================

DRUG INTERACTIONS: there may be a mildly unfavorable interaction when
used in conjunction with blood thinners by mouth.
        ================

WHOLESALE COST: not sold as an individual drug.
        ****************
        ****************





GENERIC NAME: Piroxicam
        ================

BRAND NAME: Feldene
        ================

INDICATION: for the treatment of mild to moderate pain including the
pain from arthritis.
        ================

MECHANISM OF ACTION: (see ibuprofen)
        ================

DOSE RANGE: 10 to 20 mg one time per day.
        ================

SIDE EFFECTS: (see ibuprofen)
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with lithium.
        ================

WHOLESALE COST: $77.00 for 100, 20 mg capsules.
        ****************
        ****************

GENERIC NAME: Prednisilone
        ================

BRAND NAMES: Delta-Cortef, Sterane, Metimyd, Predate, Hydeltrasol,
Metreton.
        ================

INDICATIONS: (see hydrocortisone
        ================

MECHANISM OF ACTION: (see hydrocortisone)
        ================

DOSE RANGE: five to one hundred mgs per day.
        ================

SIDE EFFECTS: (see hydrocortisone)
        ================

DRUG INTERACTIONS: (see hydrocortisone)
        ================

WHOLESALE COST: $5.12 for 100, 5 mg tablets.
        ****************
        ****************





GENERIC NAME: Prednisone
        ================

BRAND NAMES: Delatsone, Orasone, Prednisone.
        ================

INDICATIONS: (see hydrocortisone)
        ================

MECHANISM OF ACTION: (see hydrocortisone)
        ================

DOSE RANGE: five to one hundred mgs per day.
        ================

SIDE EFFECTS: (see hydrocortisone)
        ================

DRUG INTERACTIONS:  this drug may interact unfavorably when given in
conjunction with antacids, barbiturates, cholestyramine,
cyclophosphamide, ephedrine, dilantin, isoniazid, muscle relaxants,
blood thinners by mouth, birth control pills, rifampin, aspirin,
theophyllines, and troleandomycin.
        ================

WHOLESALE COST: $2.18 for 100, 5 mg tablets.
        ****************
        ****************

GENERIC NAME: Propoxyphene
        ================

BRAND NAME: Darvon, Propox, Wygesic.
        ================

INDICATIONS: for the treatment of mild to moderate pain.
        ================

MECHANISM OF ACTION: (see codeine)
        ================

DOSE RANGE: 32 to 65 mgs every four to six hours.
        ================

SIDE EFFECTS: (see codeine)
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with barbiturates, carbamazepine, charcoal, cimetidine,
dilantin, blood thinners by mouth, phenobarbital, and
antidepressants.
        ================

WHOLESALE COST: $6.45 for 100, 32 mg capsules
        ****************
        ****************





GENERIC NAME: sulindac
        ================

BRAND NAME: Clinoril
        ================

INDICATION: (see ibuprofen)
        ================

MECHANISM OF ACTION: (see ibuprofen)
        ================

DOSE RANGE: 100 to 200 mgs two times per day.
        ================

SIDE EFFECTS: (see ibuprofen) there is some evidence suggesting that
sulindac has less effect on kidney function than other drugs in its
class.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with blood thinners by mouth.
        ================

WHOLESALE COST: $36.68 for 100, 150 mg tablets.
        ****************
        ****************

GENERIC NAME: Tolmetin
        ================

BRAND NAME: Tolectin
        ================

INDICATIONS: (see ibuprofen)
        ================

MECHANISM OF ACTION: (see ibuprofen)
        ================

DOSE RANGE: 400 to 600 mgs three times per day.
        ================

SIDE EFFECTS: (see ibuprofen)
        ================

DRUG INTERACTIONS: none reported
        ================

WHOLESALE COST: $20.00 for 100, 200 mg tablets.
        ****************
        ****************





GENERIC NAME:  Aluminum Hydroxide.
        ================

BRAND NAMES: Camalox, Escot, Estomul-M, Gaviscon, Gelusil, Maalox,
Mygel, Tempo.
        ================

INDICATION: for the treatment of gastric and duodenal ulcer,
esophageal reflux, and other stomach pain due to excess stomach acid.
        ================

MECHANISM OF ACTION:  this drug is capable of neutralizing stomach
acid rendering it unable to damage the stomach lining or cause
irritation.
        ===============

DOSE RANGE: 15 to 30 cc's every two to six hours.
        ================

SIDE EFFECTS: constipation
        ================

DRUG INTERACTIONS:  this drug may interact unfavorbly when given in
conjunction with valium-like drugs, beta blockers, chloroquine,
cimetidine, steroids, diflusinal, digoxin, ethambutol, dilantin,
hydroxychloroquine, indomethacin, iron, isoniazid, ketoconazole,
levodopa, lincomycin, penicillamine, phenothiazines, primaquine,
sodium polystyrene, tetracyclines, valproic acid.
        ================

WHOLESALE COST: $2.28 for 12 oz.
        ****************
        ****************

GENERIC NAME: Belladonna
        ================

BRAND NAMES: Bellergal, Chardonna, Belladenal, Bellermine, Donnagel,
Donnatal, Kinesed, Trac Tabs, Wyanoids.
        ================

INDICATION: possibly effective in the treatment of the irritable
bowel syndrome.
        ================

MECHANISM OF ACTION: this medication decreases bowel activity.
        ================

DOSE RANGE: usually given in fixed combinations with other
medications and dose should be obtained from your pharmacist or
physician.
        ================

SIDE EFFECTS: dry mouth, difficulty in initiating urination, blurred
vision, increased heart beat, loss of taste, headache, anxiety,
drowsiness, weakness, difficulty sleeping, nausea and vomiting,
impotence, constipation, and severe allergic reactions.  This
medication should only be used in pregnant women and nursing mothers
with extreme caution.
        ================

DRUG INTERACTIONS: this medication may interact unfavorably when
given in conjunction with cimetidine, digoxin, haloperidol, levodopa,
phenothiazines, and certain water pills.
        ================

WHOLESALE COST: $4.60 for 100 capsules.
        ****************
        ****************





GENERIC NAME: Cimetidine
        ================

BRAND NAME: Tagamet
        ================

INDICATION:  for the treatment and prevention of gastric and duodenal
ulcers, esophageal reflux, and other abdominal pain due to increased
stomach acid.
        ================

MECHANISM OF ACTION: cimetidine inhibits the action of a substance
known as histamine. Histamine stimulates the production of stomach
acid. Thus, cimetidine prevents this stimulation and decreases
stomach acid.
        ================

DOSE RANGE:  300 mg one to four times per day.
================================

SIDE EFFECTS: mild diarrhea, dizziness, sleepiness, rash, headache,
joint and muscle pain, increased breast size in males, impotence,
decreased white blood cell counts, decreased platelets, decreased
kidney function, fever, and irritation of the pancreas.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with antacids, barbiturates, valium and similar drugs,
beta blockers, caffeine, carbamazepine, digoxin, alcohol, dilantin,
ketoconazole, lidocaine, metoclopramide, narcotics, blood thinners by
mouth, procainamide, tetracyuclines, theophyllines, antidepressants.
        ================

WHOLESALE COST: $30.45 for 100, 300 mg tablets.
        ****************
        ****************

GENERIC NAME: Diphenoxylate
        ================

BRAND NAMES: DI-Atro, Lomotil, Lonox.
        ================

INDICATION: Diarrhea
        ================

MECHANISM OF ACTION: this drug decreases the activity of the
intestines thus alleviating the symptoms of diarrhea.
        ================

DOSE RANGE: two tablets or two teaspoons four times per day.
        ================

SIDE EFFECTS: dry skin, dry mouth, flushing, increased body
temperature, fast heart rate, difficulty urinating, decreased
appetite, nausea, vomiting, itching, swelling of gums, headache,
restlessness, depression, decreased breathing, coma, numbness of the
arms and legs.
        ================

DRUG INTERACTIONS: none reported but may be similar to codeine.
        ================

WHOLESALE COST: $22.37 for 100 tablets.
        ****************
        ****************





GENERIC NAME: Docusate
        ================

BRAND NAMES: Bilax, Colace, DSS, Dilax, Ferro-Sequels, Filibon,
Geriplex, Liqui-Doss, Materna, Modane, Neolax, Peri-Colace,
Peritinic, Prenate, Sarolax,. Senokot, Trilax, X-Prep, and Zenate.
        ================

INDICATION: for the treatment of constipation.  This medication is
also indicated for any condition requiring softening of the stool.
        ================

MECHANISM OF ACTION: docusate increases the amount of fluid excreted
into the bowel thus softening the stool.
        ================

DOSE RANGE: 100 to 300 mg per day.
        ================

SIDE EFFECTS: bitter taste, throat irritation, and nausea.
        ================

DRUG INTERACTIONS: none reported
        ================

WHOLESALE COST: $25.11 for 250, 100 mg capsules.
        ****************
        ****************

GENERIC NAME: Magnesium Hydroxide
        ===============

BRAND NAMES: Aludrox, Camalox, Gelusil, Kudrox, Maalox, Milk of
Magnesia, Mygel, Mylanta, Simeco, Tempo.
       =================

INDICATION: (see aluminum hydroxide)
        ================

MECHANISM OF ACTION: (see aluminum hydroxide)
        ================

DOSE RANGE: (see aluminum hydroxide)
        ================

SIDE EFFECTS: diarrhea
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with amphetamines, benzodiazepines, chloroquine,
cimetidine, steroids, digoxin, ephedrine, dilantin, iron,
ketoconazole, levodopa, lithium, methotrexate, nitrofurans,
penicillamine, primaquine, pseudoephedrine, quinidine, aspirin,
tetracyclines, and valproic acid.
        ================

WHOLESALE COST: $2.55 for 355 cc's.
        ****************
        ****************





GENERIC NAME: Metoclopramide
        ================

BRAND NAME: Reglan
        ================

INDICATION: for the treatment of delayed emptying of the stomach, and
for the treatment of nausea.
        ================

MECHANISM OF ACTION: this drug stimulates activity of the stomach, it
also blocks the nausea center of the brain decreasing the desire to
vomit.
        ================

DOSE RANGE: 10 mg four times a day.
        ================

SIDE EFFECTS: restlessness, drowsiness, headache, dizziness, nausea,
increased heart rate, abnormal muscle contractions.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with cimetidine, digoxin, alcohol, and levodopa.
        ================

WHOLESALE COST:$19.50 for 100, 10 mg tablets. $40.80 for 25 10mg
vials for injection.
        ****************
        ****************






GENERIC NAME: Pancreatic Enzymes
        ================

BRAND NAMES: Arco-Lase, Cotazym, Donnazyme, Entozyme, Enzypan,
Kanulase, Ku-Zyme, Pancrease, Phazyme, Tolerase, Viokase, Zypan.
        ================

INDICATION: for replacement of necessary enzymes in patients with
poorly or non-funtioning pancreases.
        ================

MECHANISM OF ACTION: pancreatic enzyme supplementation increases the
ability to digest food, particularly carbohydrates and fats.
        ================

DOSE RANGE: 1 to 2 tablets or powdered doses every 2 to 6 hours.
        ================

SIDE EFFECTS: powdered form may cause irritation to the lining of the
nose.  Other effects include occasional diarrhea and abdominal
distress.
        ================

DRUG INTERACTIONS: none reported
        ================

WHOLESALE COST: $29.05 for 500 tablets.
        ****************
        ****************

GENERIC NAME: Paregoric
        ================

BRAND NAME: Parapectolin, Paregoric
        ================

INDICATION: diarrhea
        ================

MECHANISM OF ACTION: forms a protective coating on the intestinal
lining.  Also aids in adding bulk to stool.
        ================

DOSE RANGE: one to two tablespoons after each loose stool not to
exceed four doses in twelve hours.
        ================

SIDE EFFECTS:  (see codeine)
        ================

DRUG INTERACTIONS: (see codeine)
        ================

WHOLESALE COST: $3.20 for 480 cc's.
        ****************
        ****************





GENERIC NAME: Phenolpthalein
        ================

BRAND NAMES: Agoral, Evac-Q-Kit, Prulet, Sarolax, Trilax
        ================

INDICATION: Constipation
        ================

MECHANISM OF ACTION: this drug causes increasing excretion of water
and salts into the bowel by directly effecting the bowel lining.
        ================

DOSE RANGE: 60 mg as needed (usually once a day)
        ================

SIDE EFFECTS: lowered blood salts, dehydration, skin rash, allergic
reactions.
        ================

DRUG INTERACTIONS: none reported
        ================

WHOLESALE COST: $40.00 for 500 capsules.
        ****************
        ****************

GENERIC NAME: Prochlorperazine
        ================

BRAND NAME: Combid, Compazine, Prochlor-Iso.
        ================

INDICATION: Nausea
        ================

MECHANISM OF ACTION: inhibits the nausea center within the brain,
thus lessening the desire to vomit.
        ================

DOSE RANGE: 2.5 to 25 mg every six to eight hours.
        ================

SIDE EFFECTS: drowsiness, dizziness, inhibition of menstruation,
blurred vision, rashes, low blood pressure, yellow jaundice,
decreased red and white blood cell counts, abnormal muscle
contractions, skin rashes.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with aluminum, amphetamines, diet pills, bacitracin,
barbiturates, capreomycin, charcoal, clonidine, colistimethate,
diazoxide, estrogens, alcohol, guanethidine, dilantin, hydroxyzine,
lithium, methyldopa, orphenadrine, piperazine, polymyxin b,
succinylcholine, antidepressants, and vitamin c.
        ================

WHOLESALE COST: $14.00 for 50, 10 mg capsules.
        ****************
        ****************





GENERIC NAME: Ranitidine
        ================

BRAND NAME: Zantac
        ================

INDICATION: (see cimetidine)
        ================

MECHANISM OF ACTION: (see cimetidine)
        ================

DOSE RANGE: 150 mg two times per day.
        ================

SIDE EFFECTS: none reported, but may similar to cimetidine.
        ================

DRUG INTERACTIONS: none reported
        ================

WHOLESALE COST: $44.81 for 60 150 mg tablets.
        ****************
        ****************





GENERIC NAME: Aminoglutethamide
        ===============

BRAND NAME: Cytadren
        ===============

INDICATIONS: for the temporary suppression of hormones produced by
cancer of the adrenal glands.
        ===============

MECHANISM OF ACTION: this medication prevents cells of the adrenal
gland from producing various steroid hormones out of cholesterol.
        ===============

DOSE RANGE: 250 to 500 mg four times per day.
        ===============

SIDE EFFECTS: drowsiness, skin rash, nausea, decreased appetite,
decreased white blood cell count, low blood pressure, anemia,
headache, dizziness, liver damage, abnormal hair growth in females,
and fever.
        ================

DRUG INTERACTIONS: none reported
        ================

WHOLESALE COST: $42.84 for 100, 250 mg tablets.
        ****************
        ****************

GENERIC NAME: Busulfan
        ================

BRAND NAME: Myleran
        ================

INDICATIONS: for the treatment of specific kinds of leukemia (cancer
of the blood).
        ================

MECHANISM OF ACTION: this drug probably exerts its therapeutic effect
by interfering with the cancer cell's ability to reproduce its DNA (
genetic building blocks ).  This drug should not be used in pregnant
or nursing women.
        ================

DOSE RANGE: four to eight milligrams each day.
        ================

SIDE EFFECTS: suppression of the bone marrow causing low blood
counts, scarring of the lung, scarring of the heart, cataracts,
increased skin color, decreased function of the adrenal gland, skin
rash, hair loss, dryness of the skin, jaundice, and weakness.
        ================

DRUG INTERACTIONS: none reported
        ================

WHOLESALE COST: $3.41 for 25, 2 mg tablets.
        ****************
        ****************





GENERIC NAME: Bleomycin Sulfate
        ================

BRAND NAME: Blenoxane
        ================

INDICATIONS: for the treatment of squamous cell cancers of the head
and neck, skin, larynx, penis, cervix, vulva, and cancer of the lymph
glands and testicles.
        ================

MECHANISM OF ACTION: ( see carmustine)
        ================

DOSE RANGE: .25 TO .50 units per kg body weight, one to two times
weekly.
        ================

SIDE EFFECTS: scarring of the lungs, severe allergic reactions, skin
rash, itching, fever, chills, vomiting, decreased appetite, weight
loss, and pain at the site of the tumor.
        ================

DRUG INTERACTIONS: this drug may interact unfavorbly when given in
conjunction with dilantin or digoxin.
        ================

WHOLESALE COST: $76.78 for one, 15 unit vial for injection.
        ****************
        ****************

GENERIC NAME: Carmustine
        ================

BRAND NAME: BiCNU
        ================

INDICATION: for the treatment of tumors of the brain, lymph glands,
and specific blood cells (plasma cells).
        ================

MECHANISM OF ACTION: this drug works by inhibiting the cells ability
to duplicate and translate genetic information to the rest of the
cancer cell (inhibits DNA and RNA).
        ================

DOSE RANGE: 100 to 200 mg per square meter of body surface area,
every six weeks.
        ================

SIDE EFFECTS: suppression of the bone marrow causing lowered blood
and platelet counts, nausea and vomiting, liver damage, scarring of
the lung, kidney damage, and burning at the site of injection.  Safe
use of this drug in pregnant or nursing women has not been
established.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with dilantin or similar drugs.
        ================

WHOLESALE COST: $23.19 for one, 100 mg vial for injection.
        ****************
        ****************





GENERIC NAME: Chlorambucil
        ================

BRAND NAME: Leukeran ================================ INDICATION: for
the treatment of cancer of the blood and lymph glands.
        ================

MECHANISM OF ACTION: this medication interferes with the cancer
cell's ability to reproduce itself by adversely effecting the genetic
building blocks (DNA).
        ================

DOSE RANGE: .1 to .2 mg per kg of body weight per day.
        ================

SIDE EFFECTS: depression of the bone marrow's ability to produce
blood cells and platelets, stomach discomfort, fever, skin rash,
sterility in males, liver damage, seizures, protein in the urine,
decreased menstruation. Safe use in pregnancy has not been
established.
        ================

DRUG INTERACTIONS: none reported.
        ================

WHOLESALE COST: $6.34 for 50, 2 mg tablets.
        ****************
        ****************

GENERIC NAME: Cyclophosphamide
        ================

BRAND NAMES: Cytoxan, Neosar
        ================

INDICATIONS: for the treatment of cancers of the lymph glands, blood,
certain forms of skin cancer, neuroblastoma, cancer of the ovaries,
cancer of the breast, and retinoblastoma. This drug is also indicated
for various rheumatic diseases such as Systemic Lupus Erythematosis,
and Wegener's Granulomatosis.
        ================

MECHANISM OF ACTION: (see chlorambucil)
        ================

DOSE RANGE: one to five mg per kg body weight per day.
        ================

SIDE EFFECTS: predispostion to a second cancer, suppression of the
bone marrow's ability to make blood cells and platelets, decreased
appetite, nausea, vomiting, blood in the stool, jaundice, mouth
irritation, bloody inflammation of the urinary bladder, sterility in
males, hair loss, scarring of the lung. This drug should not be used
in pregnant or nursing women.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with allopurinol, chloramphenicol, chlorpromazine,
steroids, digoxin, methotrexate, blood thinners by mouth,
succinylcholine, sulfa drugs, certain water pills.
        ================

WHOLESALE COST: $68.80 for 100, 50 mg tablets. $54.33 for one, 100 mg
vial for injection.
        ****************
        ****************





GENERIC NAME: Cytarabine
        ================

BRAND NAME: Cytosar
        ================

INDICATION: for the treatment of leukemia
        ================

MECHANISM OF ACTION: this medication interferes with the cancer
cell's ability to produce its genentic building blocks (DNA) thus
preventing it from growing.
        ================

DOSE RANGE: 200 mg per square meter of body surface area. This is
given every day for five days then repeated every two weeks.
        ================

SIDE EFFECTS: decreased appetite, nausea, vomiting, diarrhea,
irritation of the mouth and anus, liver failure, fever, skin rash,
blood clots, bleeding, suppression of the bone marrow causing
decreased blood cells and platelets.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with digoxin.
        ================

WHOLESALE COST: $18.50 for one, 500 mg vial.
        ****************
        ****************





GENERIC NAME: Dacarbazine
        ================

BRAND NAME: DTIC-Dome
        ================

INDICATION: for the treatment of malignant melenoma (skin cancer) and
Hodgkin's disease (cancer of the lymph glands).
        ================

MECHANISM OF ACTION: unknown
        ================

DOSE RANGE: 2 to 4.5 mg per kg of body weight per day.  This should
be repeated at four week intervals for malignant melenoma. The
recommended treatment for Hodgkins disease is 150 mg for each square
meter of body surface area for five days.
        ================

SIDE EFFECTS: depressed bone marrow function causing lowered blood
and platelet counts, decreased appetite, vomiting, and fever.
        ================

DRUG INTERACTIONS: none reported
        ================

WHOLESALE COST: $79.66 for 12, 100 mg vials for injection
        ****************
        ****************

GENERIC NAME: Daunorubrocin
        ================

BRAND NAME: Cerubidine
        ================

INDICATIONS:  for the treatment of certain forms of leukemia
        ================

MECHANISM OF ACTION: this drug inhibits the cancer cell's ability to
produce DNA (the genetic building blocks) thus killing the tumor
cells.
        ================

DOSE RANGE: 60 mg per kg body weight per day on two to three
consecutive days.  This is given once every 3 to 4 weeks.
        ================

SIDE EFFECTS: scarring of the heart, suppression of the bone marrow
thus decreasing blood cells and platlets, loss of hair, nausea, and
vomiting.
        ================

DRUG INTERACTIONS: none reported
        ================

WHOLESALE COST: $248.66 for 10, 20 mg vials for injection.
        ****************
        ****************





GENERIC NAME: Doxorubicin Hydrochloride
        ================

BRAND NAME:  Adriamycin
        ================

INDICATION: for the treatment of cancers of the breast, blood, bone,
urinary bladder, lung, lymph glands, ovaries, and thyroid among
others.
        ================

MECHANISM OF ACTION: (see daunorubrocin)
        ================

DOSE RANGE: variable, not to exceed a total dose of 550 mg per square
meter of body surface area.
        ================

SIDE EFFECTS: (see daunorubrocin)
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with digoxin or barbiturates.
        ================

WHOLESALE COST: $18.19 for one, 10 mg vial for injection.
        ****************
        ****************

GENERIC NAME: Fluorouracil
        ================

BRAND NAMES: Adrucil, Efudex, Fluoroplex
        ================

INDICATION: for the treatment of cancers of the breast, colon,
pancreas, stomach, and rectum.
        ================

MECHANISM OF ACTION: (see daunorubrocin)
        ================

DOSE RANGE: 6 to 12 mg per kg body weight.
        ================

SIDE EFFECTS: irritation of the mouth and the esophagus, diarrhea,
decreased appetite, nausea, vomiting, suppression of the bone marrow
causing decreased blood cells and platelets, hair loss, skin rash,
sensitivity to light, increased tearing, and nose bleeds.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with thiazide type diuretics (water pills).
        ================

WHOLESALE COST:  $13.11 for 10, 500 mg ampuls for injection.
        ***************
        ****************





GENERIC NAME: Hydroxyurea
        ================

BRAND NAME: Hydrea
        ================

INDICATIONS: for the treatment of certain blood cancers, cancer of
the head and neck, and cancer of the ovary.
        ================

MECHANISM OF ACTION: unknown
        ================

DOSE RANGE: 20 to 80 mg per kg body weight per day.
        ================

SIDE EFFECTS: suppression of the bone marrow's ability to produce
blood cells and platelets, irritation of the mouth, nausea, vomiting,
diarrhea, constipation, skin rash, burning on urination, hair loss,
drowsiness, headache, seizures, and decreased kidney function.
        ================

DRUG INTERACTIONS: none reported
        ================

WHOLESALE COST: $42.76 for 100, 500 mg capsules.
        ****************
        ****************






GENERIC NAME: Melphalan
        ================

BRAND NAME: Alkeran
        ================

INDICATION: for the treatment of multiple myeloma, and certain
cancers of the ovary which cannot be surgically removed.
        ================

MECHANISM OF ACTION: this drug interferes with the cancer cell's
ability to reproduce itself by effecting the DNA (genetic building
blocks).
        ================

DOSE RANGE: 6 mg three times per day.
        ================

SIDE EFFECTS: bone marrow suppression causing decreased blood and
platelet counts, nausea, vomiting, skin rashes, and occasionally
scarring of the lung.
        ================

DRUG INTERACTIONS: none reported
        ================

WHOLESALE COST: $14.58 for 50, 2 mg tablets
        ****************
        ****************

GENERIC NAME: Methotrexate
        ================

BRAND NAME: Mexate
        ================

INDICATION: for the treatment of cancer of the amniotic sac, blood,
and the lymph glands. This drug is also indicated for the treatment
of severe psoriasis.
        ================

MECHANISM OF ACTION: inhibits the production of the cancer cell`s
genetic building blocks (DNA) by interfering with an important enzyme
known as folic acid reductase.
        ================

DOSE RANGE: 15 to 50 mg from once per week to every day.
        ================

SIDE EFFECTS: irritation of the mouth, lowered white blood cell
counts, nausea, abdominal distress, chills, fever, dizziness, skin
rash, itching, anemia, decreased platelet count, vomiting, kidney
failure, blood in the urine, sterility, headaches, and blurred
vision.
        ================

DRUG INTERACTIONS: methotrexate may interact unfavorably in
conjunction with acetazolamide, calcium carbonate, cyclophosphamide,
dilantin, magnesium, potassium, probenecid, aspirin, water pills, and
tromethamine.
        ================

WHOLESALE COST: $11.37 for one, 50 mg vial for injection.
        ****************
        ****************





GENERIC NAME: Tamoxifen
        ================

BRAND NAME: Nolvadex
        ================

INDICATION: for the treatment of breast cancer.
        ================

MECHANISM OF ACTION: tamoxifen blocks breast cancer cells from
utilizing estrogen which is sometimes necessary for tumor growth.
        ================

DOSE RANGE: 10 to 20 mg two times per day.
        ================

SIDE EFFECTS: hot flashes, nausea, vomiting, bone pain, increased
blood calcium, vaginal bleeding, vaginal discharge, swelling of the
ankles, dizziness, and headache.
        ================

DRUG INTERACTIONS: none reported
        ===============

WHOLESALE COST: $46.20 for 60, 10 mg tablets.
        ****************
        ****************

GENERIC NAME: Vinblastine
        ================

BRAND NAME: Velban
        ================

INDICATION: for the treatment of cancer of the lymph glands, breast,
testicles, and certain cancers of the skin.
        ================

MECHANISM OF ACTION: vinblastine kills cancer cells by interfering
with the normal production and breakdown of specific amino acids
(protein building blocks).
        ================

DOSE RANGE: 3.7 to 11.1 mg per square meter of body surface area to
be given once a week.
        ================

SIDE EFFECTS: decreased blood and platelet counts, nerve damage,
nausea, vomiting, constipation, irritation of the mouth, decreased
appetite, abdominal pain, bleeding from the rectum, headache, and
seizures.
        ================

DRUG INTERACTIONS: vinblastine may interact unfavorably when given in
conjunction with digoxin or dilantin.
        ================

WHOLESALE COST: $22.90 for one 10 mg vial for injection.
        ****************
        ****************

GENERIC NAME: Vincristine
        ================

BRAND NAME: Oncovin
        ================

INDICATION: for the treatment of cancers of the blood and lymph
glands among others.
        ================

MECHANISM OF ACTION: unknown
        ================

DOSE RANGE: 1.4 mg for each square meter of body surface area.
        ================

SIDE EFFECTS: hair loss, nerve damage, constipation, seizures, low
white blood cell count, and lowered blood sodium.
        ================

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with digoxin.
        ================

WHOLESALE COST: $44.38 for one two mg vial for injection.
        ****************
        ****************





GENERIC NAME: Acetazolamide
        ===============

BRAND NAMES: Acetazolamide, Diamox.
        ===============

MECHANISM OF ACTION: this drug inhibits the action of an enzyme known
as carbonic anhydrase. Inhibition of this enzyme causes the
inhibition of normal handling of various body salts and water within
the kidney and eye.
        ===============

INDICATION: for the treatment of certain types of glaucoma (increased
fluid pressure within the eye), excess fluid accumulation within the
body, and for making the urine less acid to avoid kidney damage from
the simultaneous use of other drugs especially some anti- cancer
medications.
        ===============

DOSE RANGE: 250 to 1000 mgs given singly or in divided doses.
        ===============

SIDE EFFECTS: tingling of the arms and legs, drowsiness, confusion,
loss of appetite, increased urination, and increased uric acid in the
blood.  These occur rarely with short term use.  Even less common are
the following side effects: transient blurred vision, hives, blood in
the stool, blood in the urine, sugar in the urine, liver failure,
paralysis, and seizures.
        ===============

DRUG INTERACTIONS: the following drugs may interact unfavorably when
given in conjunction with acetazolamide: amphetamines (speed),
ephedrine, lithium, methotrexate, primidone, pseudoephedrine,
quinidine, and aspirin-like drugs.
        ===============

WHOLESALE COST: $14.24 for 100, 250 mg tablets.
        ****************
        ****************

GENERIC NAME: Amiloride
        ===============

BRAND NAMES: Midamor, Moduretic.
        ===============

MECHANISM OF ACTION:  this drug prevents potassium, an essential
salt, from being lost through the kidney.  It may also cause a mild
loss of sodium through the kidney and by this action it has a mild
ability to lower blood pressure.
        ===============

INDICATION: for the prevention of low blood potassium when another
water pill or anti high blood pressure medication is being used.
        ===============

DOSE RANGE: 5 to 20 mgs depending upon the severity of the lowered
blood potassium.
        ===============

SIDE EFFECTS:  abnormally high blood potassium, headache, weakness,
nausea, diarrhea, gas pain, constipation, muscle cramps, joint pain,
dizziness, cough, and impotence are the most common.  Safety for
usage in pregnant women has not been established.
        ===============

DRUG INTERACTIONS:  Amiloride may interact unfavorably when used in
combination with digoxin, and potassium supplements.
        ===============

WHOLESALE COST: $14.84 for 100, mg tablets.
        ***************
        ***************





GENERIC NAME: Atenolol
        ===============

BRAND NAME: Tenormin
        ===============

INDICATIONS: for the treatment of high blood pressure, and angina
pectoris.  Drugs of this class are also occasionally used for the
treatment of migraine headaches, certain types of tremors or
shakiness, abnormal rhythms of the heart, and certain abnormalities
of the heart muscle and heart valves.
        ===============

MECHANISM OF ACTION:   Drugs such as Tenormin block the ability of
adrenalin, or catecholamines to exert their effects on certain
receptors of the body known as the beta receptors.  Thus, these
medications are known as the beta blockers.   Beta receptors are
located on the surfaces of many of the body's cells. Stimulation of
these receptors cause increased heart rate, increased force of heart
beat, increased diameter of the bronch (breathing tubes), and
feelings of "stage fright" or anxiety, among other things.   The
blocking of these receptors have the opposite effects.
        ===============

DOSE RANGE: 50 to 100 mg, one time per day.
        ===============

SIDE EFFECTS: skin rash, decreased white blood cells, decreased
platelets, fever, sore throat, difficulty breathing, mental
sluggishness, difficulty seeing, hallucinations, baldness, narrowing
of the arteries of the arms and legs causing blue cool extremities
(Raynaud's Phenomenon), slow heart beat, wheezing, and low blood
sugar.
        ===============

DRUG INTERACTIONS:  this drug may interact unfavorably when given in
conjunction with aluminum salts, calcium salts, clonidine, ergot
alkaloids, indomethacin, lidocaine, methyldopa, nondepolarizing
relaxants, phenformin, prazosin, procainamide, and theophyllines.
        ===============

WHOLESALE COST:  $33.55 for 100, 50 mg tablets.
        ***************
        ***************

GENERIC NAME: Atropine
        ===============

BRAND NAMES: Antrocol, Arco- Lase, Atropine, Butabell,m Colidrops,
Comhist, Di-Atro, Probocon, Prosed, Ru-Tuss, Trac Tabs, Uretron,
Urised, Urogesic.
        ===============

INDICATIONS: for the treatment of abnormally slow heart rates,
certain forms of abnormal motion of the intestines, asthma, nasal
congestion, and certain problems with urinary bladder emptying.
        ===============

MECHANISM OF ACTION:  Atropine blocks the action of acetylcholine on
certain receptors located throughout the body.  Blockage of these
receptors results in a decreased ability for acetyl choline to
increase heart rate, increase muscular activity of the intestines,
urinary bladder, breathing tubes (bronchi) and eyes, among others.
        ===============

DOSE RANGE: .3 to 1 mg, one to four times per day.
        ===============

SIDE EFFECTS: dry skin, dry mouth, difficulty urinating, abnormally
fast heart rate, increased body temperature, hallucinations, and
increased pressure of the fluid of the eyes.
        ===============

DRUG INTERACTIONS:  this drug may interact unfavorably when given in
conjuction with cimetidine, digoxin, haloperidol, levodopa,
phenothiazines, thiazide type water pills.
        ===============

WHOLESALE COST:  $40.56 for 100, .4 mg ampules.
        ===============







GENERIC NAME: Bretylium
        ===============

BRAND NAME: Bretylol
        ===============

INDICATION: for the treatment of certain types of abnormal and life
threatening heart rhythms.
        ===============

MECHANISM OF ACTION:  this drug decreases the potential of abnormal
heart rhythms to originate in the ventricle (larger chambers of the
heart) probably by decreases the ability of norepinephrine ( one of
the components of adrenalin) to excite the heart's electrical
activity.
        ===============

DOSE RANGE: five to ten mg per kg of body weight given as often as
every one hour.  If the original abnormal heart rhythm disappears, a
constant infusion of one to two mg per minute may be given.
        ===============

SIDE EFFECTS: low blood pressure, nausea and vomiting, dizziness,
fainting, chest pain, abnormal kidney function, hiccups, skin rash,
increased body temperature, confusion, fatigue, shortness of breath,
nasal stuffiness, and irritation of the eyes.  This drug has not been
proven to be safe for use during pregnancy.
        ===============

DRUG INTERACTIONS:  this drug may interact unfavorably when given in
conjunction with drugs like digoxin.
        ===============

WHOLESALE COST:  $16.66 for one 500 mg ampule.
        ***************
        ***************


GENERIC NAME: Captopril
        ===============

BRAND NAME: Capoten
        ===============

INDICATION: High blood pressure and congestive heart failure ( the
inability of the heart to pump blood causing back-up of fluid into
the lungs).
        ===============

MECHANISM OF ACTION: captopril works by blocking angiotensin
converting enzyme.  This prevents the formation of a substance known
as angiotensin II Angiotensin II narrows the blood vessels.  This
blood vessel narrowing can increase blood pressure, and increase the
force which the heart has to pump against.
        ===============

DOSE RANGE: 5 to 150 mg, three times per day.
        ===============

SIDE EFFECTS: protein in the urine, kidney failure, lowered white
blood cells, skin rash, fever, swelling of the face, swelling of the
larynx, low blood pressure, fast heart rate, chest pain, loss of
ability to taste, stomach and abdominal pain, dizziness, headache,
fatigue, dry mouth, and shortness of breath. This drug causes birth
defects in experimental animals and should be used in pregnant or
nursing women only if the benefit outweighs the risk.
        ===============

DRUG INTERACTIONS:  this drug may interact unfavorably when given in
conjunction with indomethacin, probenecid, and aspirin-like drugs.
        ===============

WHOLESALE COST:  $20.00 for 100, 25 mg tablets.
        ***************
        ***************






GENERIC NAME: Chlorothiazide
        ===============

BRAND NAMES: Aldoclor, Chlorothiazide, Diupres, and Diuril.
        ===============

INDICATIONS: for the treatment of high blood pressure, and for
increased body fluid.
        ===============

MECHANISM OF ACTION: this medication works by increasing salt and
water loss through the kidney.  It also exerts a direct effect on
blood vessels causing them to increase in diameter.
        ===============

DOSE RANGE: 500 to 1000 mg given once or twice per day.
        ===============

SIDE EFFECTS: decreased appetite, nausea and vomiting, diarrhea,
constipation, yellow jaundice, dizziness, tingling of the hands and
legs, headache, decreased white and red blood cells, decreased
platelets, irritation of the pancreas, low blood pressure, skin rash,
increased blood sugar, increased uric acid in the blood, weakness,
muscle cramping, blood in the urine, blurred vision, and lowered
blood potassium. This drug may effect the unborn fetus or a nursing
child and should be used in these situations only when the benefits
outweigh the risks.
        ===============

DRUG INTERACTIONS:  this drug may interact unfavorably when given in
conjunction with anticholinergic drugs, calcium salts,
cholestyramine, colestipol, cyclophosphamide diazoxime, digitalis,
flourouracil, indomethacin, lithium, methotrexate, muscle relaxants,
blood thinners by mouth, sulfa drugs, tetracyclines, and vitamin D.
        ===============

WHOLESALE COST:  $27.95 for 1000, 250 mg tablets.
        ***************
        ***************

GENERIC NAME: Chlorthalidone
        ===============

BRAND NAMES: Chlorthalidone, Combipres, Demi-Regroton, Hygroton, and
Regroton.
        ===============

INDICATIONS: for the treatment of high blood pressure and for the
treatment of increased body fluid.
        ===============

MECHANISM OF ACTION: (see chlorothiazide)
        ===============

DOSE RANGE: 25 to 100 mg, one time per day.
        ===============

SIDE EFFECTS: (see chlorothiazide)
        ===============

DRUG INTERACTIONS:  (see chlorothiazide)
        ===============

WHOLESALE COST:  $13.63 for 100, 25 mg tablets
        ***************
        ***************






GENERIC NAME: Clonidine
        ===============

BRAND NAME: Catapres, Combipres
        ===============

INDICATION: for the treatment of high blood pressure.
        ===============

MECHANISM OF ACTION: this drug increases the diameter of the blood
vessels directly.
        ===============

DOSE RANGE: .1 to .8 mg per day in divided doses.
        ===============

SIDE EFFECTS: drowsiness, dry mouth, constipation, dizziness,
headache, decreased appetite, nausea, vomiting, weight gain,
increased blood sugar, increased breast size in males, heart failure,
nightmares, inability to sleep, depression, skin rash, impotence, dry
eyes, and increased sensitivity to alcohol.  This drug is not
recommended for use in pregnant or nursing women.
        ===============

DRUG INTERACTIONS:  this drug may interact unfavorably when given in
conjuction with drugs in the beta-blocker class (like inderal),
levodopa, phenothiazines, and certain antidepressants.
        ===============

WHOLESALE COST:  $16.39 for 100, .1 mg tablets.
        ***************
        ***************

GENERIC NAME: Diazoxide
        ===============

BRAND NAME: Hyperstat, Proglycem
        ===============

INDICATION: for the treatment of severe high blood pressure.
        ===============

MECHANISM OF ACTION: this medication causes direct relaxation of the
muscle tissue in the walls of arteries causing an increase in
diameter of these &arteries.
        ===============

DOSE RANGE: one to three mg per kg of body weight administered as
often as every fifteen minutes until blood pressure decreases to a
safe level.
        ===============

SIDE EFFECTS: retention of salt and water, high blood sugar, severe
low blood pressure, decrease oxygen to the heart, fainting, seizures,
confusion, numbness, blindness, rash, lowered white blood cell
counts, fast heart beat, slow heart beat, headache, shortness of
breath, cough, nausea, vomiting, dry mouth, constipation and/or
diarrhea. Safety for use in pregnant women has not been established.
        ===============

DRUG INTERACTIONS:  this drug may interact unfavorably when given in
conjunction with dilantin, phenothiazines, sulfa drugs, and thiazide
type water pills.
        ===============

WHOLESALE COST:  $21.40 for one 300 mg vial.
        ***************
        ***************







GENERIC NAME: Digoxin.
        ===============

BRAND NAMES: Lanoxin, Lanoxicaps
        ===============

MECHANISM OF ACTION: Digoxin is a member of the drug class known as
the cardiac glycosides.  It is derived from the leaves of the plant
Digitalis lanatas. The drug works by causing the heart muscle to pump
more forcefully.  It also causes the electricity of the heart to
travel more slowly and may decrease rapid heart rates.
        ===============

INDICATIONS:  Digoxin is given to patients suffering from congestive
heart failure, a condition resulting in back up of fluid from the
heart to the lungs.  This back up is caused by a weakened heart
muscle's inability to adequately pump blood.  It is also useful in
patients who have certain types of abnormally rapid heart rates or
tachycardia.
        ===============

DOSE RANGE: The usual adult dose is .125 - .375 MG. per day.
        ===============

SIDE EFFECTS: These include dangerous abnormal heart rhythms,
dangerously slow heart rate, loss of appetite, nausea, vomiting,
diarrhea, blurred vision, headache, weakness, apathy, and psychosis.
Enlargement of the breasts in males may also be seen.
        ===============


DRUG INTERACTIONS: Cimetidine, Erythromycin, Nifedipine, Quinidine,
Quinine, Tetracycline, and Verapamil.
        ===============

WHOLESALE COST:  $5.25 for 1000, .25 mg tablets.
        ***************
        ***************

GENERIC NAME: Diltiazem
        ===============

BRAND NAME: Cardizem
        ===============

INDICATION: for the treatment of angina pectoris.  Drugs of this
class (the calcium channel blockers) may also be used for certain
heart muscle or valve abnormalities.  They may also be useful in the
treatment of high blood pressure and abnormal decrease in the
diameter of the arteries of the hands and feet (Raynauds).
        ===============

MECHANISM OF ACTION:  these drugs inhibit the influx of calcium from
the blood into the cells, particularly the muscle cells of the heart
and blood vessels.  This blockage of calcium influx may decrease the
force of the heart's contraction, and also increase the diameter of
blood vessels.
        ===============

DOSE RANGE: 30 to 60 mg usually four times per day.
        ===============

SIDE EFFECTS:  flushing, heart failure, low blood pressure, fainting,
drowsiness, dizziness, difficulty sleeping, confusion,
hallucinations, vomiting, diarrhea, constipation, indigestion, skin
rash, thirst, tingling sensations, and joint pain.  This drug is not
safe for use in pregnant women as it may cause fetal deaths in
laboratory animals.
        ===============

DRUG INTERACTIONS:  this drug may interact unfavorably when given in
conjunction with drugs in the beta-blocker class, like propranalol,
and digitalis preparations.
        ===============

WHOLESALE COST:  $20.00 for 100, 30 mg tablets.
        ***************
        ***************






GENERIC NAME: Disopyramide
        ===============

BRAND NAME: Norpace
        ===============

INDICATION: for the treatment of abnormal heart rhythms usually
originating from the ventricles (large chambers of the heart).
        ===============

MECHANISM OF ACTION: this drug decreases the potential of abnormal
rhythms of the heart by slowing down one phase of the heart's
electrical conduction.
        ===============

DOSE RANGE: 100 to 200 mg every six hours.
        ===============

SIDE EFFECTS: dry mouth, difficulty urinating, constipation, blurred
vision, nausea, dizziness, weakness, headache, impotence, low *lood
pressure, abnormal heart rhythms, fainting, chest pain, diarrhea,
skin rash, nervousness, and low blood potassium.
        ===============

DRUG INTERACTIONS:  this drug may interact unfavorably when given in
conjunction with dilantin, blood thinners by mouth, and rifampin.
        ===============

WHOLESALE COST:  $25.01 for 100, 100 mg capsules.
        ***************
        ***************

GENERIC NAME: Dobutamine
        ===============

BRAND NAME: Dobutrex
        ===============

INDICATION: for the treatment of severe low blood pressure.
        ===============

MECHANISM OF ACTION: this medication stimulates the heart's pumping
force.
        ===============

DOSE RANGE: 2.5 to 10 micrograms per kg body weight, per minute.
        ===============

SIDE EFFECTS: increased heart rate, abnormal heart rhythms, nausea,
headache, chest pain, and shortness of breath. This drug should be
used in pregnant females only when the benefits clearly outweigh the
risks.
        ===============

DRUG INTERACTIONS:  this drug may interact unfavorably when given in
conjunction with dilantin, and phenothiazines.
        ===============

WHOLESALE COST:  $19.50 for one 250 mg vial.
        ***************
        ***************





GENERIC NAME: Dopamine
        ===============

BRAND NAME: Intropin
        ===============

INDICATION: for the treatment of severe low blood pressure.
        ===============

MECHANISM OF ACTION: this medication increases the contractile force,
or pumping ability of the heart thus increasing its output and the
blood pressure.
        ===============

DOSE RANGE: two to fifty micrograms per kg body weight, per minute.
        ===============

SIDE EFFECTS: extra heart beats, nausea, vomiting, fast heart beat,
chest pain, shortness of breath, headache, low blood pressure, severe
decrease diameter of blood vessels, goose bumps, and decreases kidney
function.
        ===============

DRUG INTERACTIONS: this medication may interact unfavorably when
given in conjunction with guanethidine, dilantin, indomethacin,
lithium maprotiline, methyldopa, monoamine oxidase inhibitors,
oxytocin, phenothiazines, reserpine, and antidepressants.
        ===============

WHOLESALE COST: $6.60 for one, 40 mg vial for injection.
        ***************
        ***************





GENERIC NAME: Epinephrine
        ===============

BRAND NAMES:  Adrenalin, Sus- phrine, and Epipen.
        ===============

MECHANISM OF ACTION:  this medication causes stimulation of many of
the body's functions including heart rate, heart force of
contraction, diameter of blood vessels, and diameter of breathing
tubes (bronchi), among other things.
        ===============

INDICATIONS:  for the treatment of conditions which cause decreased
heart rate or heart stoppage, low blood pressure, severe decrease in
the diameter of the breathing tubes, and severe swelling due to
allergic reactions.
        ===============

DOSE RANGE:  .1 TO .5 cc's of a 1/1000 solution if given by injection
under the skin.  the dilution should mixed at a 1/10,000 ratio if
given by vein.
        ===============

SIDE EFFECTS: palpitations, difficulty breathing, dizziness,
weakness, shaking of the hands, headache, throbbing, anxiety, high
blood pressure, and severly abnormal heart rhythms.
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with beta blocking drugs like propranalol, guanethidine,
dilantin, indomethacin, lithium, maprotiline, methyldopa, oxytocic
drugs, phenothiazines, and certain antidepressants.
        ===============

WHOLESALE COST:  $30.00 for 100, 1 ml vials of 1/1000.
        ***************
        ***************

GENERIC NAME: Furosemide
        ===============

BRAND NAME: Furosemide, Lasix
        ===============

MECHANISM OF ACTION:  furosemide stimulates the kidney's ability to
get rid of salt and water.
        ===============

INDICATIONS:  for the removal of excess body water due to conditions
such as congestive heart failure where the heart fails to pump blood
adequately and there is a back-up of fluid into the lungs.
        ===============


DOSE RANGE:  10 to 1000 mgs depending on the severity of the fluid
overload and the ability of the kidneys to respond to the drug.
        ===============


SIDE EFFECTS: these are many and include nausea, vomiting, cramping
diarrhea, yellow jaundice,. irritation of the pancreas, dizziness,
headache, hearing loss, inhibition of the bone marrow to produce
white and red blood cells, skin rashes, high blood sugar, weakness,
and restlessness among others.
        ===============

ADVERSE REACTIONS:  this drug may interact unfavorably when given in
conjunction with aminoglycosides such as gentamicin, barbiturates,
beta blockers such as propranalol, chloral hydrate, digitalis,
dilantin, indomethacin, lithium, certain muscle relaxants,
probenecid, aspirin-like drugs, sulfa drugs, tetracyclines, and
theophyllines.
        ===============

WHOLESALE COST: $8.85 for 100, 20 mg tablets.
        ***************
        ***************





GENERIC NAME: Guanabenz
        ===============

BRAND NAME: Wytensin
        ===============

MECHANISM OF ACTION: this medication acts to lower blood pressure by
stimulating receptors in the brain that in turn decrease the amount
and sensitivity to certain substances within the body called
catechols which increase blood pressure,
        ===============

INDICATIONS: for the treatment of high blood pressure.
        ===============

DOSE RANGE: 8 to 32 mgs per day in divided doses.
         ============== SIDE EFFECTS: important side effects include
drowsiness, dry mouth, weakness, and headache.
        ===============

DRUG INTERACTIONS: none reported, however, it should be used with
caution in conjunction with other drugs that may cause sedation.
        ===============

WHOLESALE COST: $16.00 for 100 4 mg tablets.
        ***************
        ***************

GENERIC NAME: Hydralazine
        ===============

BRAND NAME: Apresoline
        ===============

MECHANISM OF ACTION: Hydralazine lowers blood pressure by directly
increasing the diameter of the arteries.
        ===============

INDICATION: for the treatment of high blood pressure and for the
treatment of certain patients with congestive heart failure
(ineffective pumping of the heart)
        ===============

DOSE RANGE:  10 to 75 mgs given four times per day.
        ===============

SIDE EFFECTS: headache, fast forceful heartbeat (palpitations),
decreased appetite, nausea, vomiting, diarrhea, chest pain, nasal
*congestin, tearing, swelling in the ankles, joint pains,
constipation, decreased ability for the bone marrow to make blood
cells, and low blood pressure.
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with beta blocking drugs such as propranalol.
        ===============

WHOLESALE COST: $5.98 for 100 10 mg tablets.
        ***************
        ***************





GENERIC NAME: Hydrochlorothiazide
        ===============

BRAND NAMES: Dyazide, Hydrodiuril.
        ===============

MECHANISM OF ACTION: this drug increases the ability of the kidney to
get rid of salt and water which serves to lower the blood pressure.
It probably also has a direct effect on blood vessels causing their
diameters to increase which would also cause a decrease in blood
pressure.
        ===============

INDICATION:  for the treatment of high blood pressure and for some
types of swelling in the ankles.
        ===============

DOSE RANGE:  25 to 100 mgs per day.
        ===============

SIDE EFFECTS: decreased appetite, nausea, vomiting, diarrhea,
constipation, yellow jaundice, irritation of the pancreas, dizziness,
headache, decreased ability of the bone marrow to make blood cells,
skin rashes, high blood sugar, sugar in the urine, and weakness.
        ===============


DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with anticholinergics, calcium, cholestyramine,
colestipol, cyclophosphamide, diazoxide, digitalis, fluorouracil,
indomethacin, lithium, methotrexate, blood thinners by mouth, sulfa
drugs, tetracyclines, and vitamin D.
        ===============

WHOLESALE COST: $40.99 for 1000, 25 mg tablets.
        ***************
        ***************

GENERIC NAME: Isoproterenol
        ===============

BRAND NAME: Isuprel.
        ===============

MECHANISM OF ACTION: Isuprel stimulates certain receptors in the body
known as the beta receptors.  These receptors are responsible for the
force and speed of the heart beat, and the diameter of the breathing
tubes (bronchi), among other things.
        ===============

INDICATIONS: for the treatment o severe decrease in the diameter of
the breathing tubes such as that seen in asthma, for certain
conditions of abnormal electrical conduction of the heart, and for
certain cases of extremely low blood pressure.
        ===============

DOSE RANGE: the doses are extremely variable based upon the
underlying condition, and the severity of the condition.
        ===============

SIDE EFFECTS: flushing of the face, sweating, mild shaking of the
hands, headache, and a very rapid and strong heart beat.
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with dilantin or phenothiazines.
        ===============

WHOLESALE COST: $29.72 for 25 one cc vials at a dilution of 1:5000.
        ***************
        ***************





GENERIC NAME: Isosorbide dinitrate
        ===============

BRAND NAMES: Dilitrate, Isordil, Sorate, Sorbide, Sorbitrate.
        ===============

MECHANISM OF ACTION: this medication causes increased diameter of the
veins by causing relaxation of the muscles within the venous walls.
This, in some manner causes decrease or elimination of chest pain due
to angina pectoris, although the actual mechanism is not understood
at this particular time.
        ===============

INDICATIONS:  for the treatment of anginal pectoris.  This drug may
also be useful in the treatment of congestive heart failure (the
backflow of fluid from the heart into the lungs due to ineffective
pumping of the heart), and spasm of the esophagus.
        ===============

DOSE RANGE:  this medication may be given under the tongue at a dose
range of 2.5 to 10 mgs every two to three hours, or it can be
swallowed at a dose range of 5 to 30 mgs four times per day.
        ===============

SIDE EFFECTS: flushing, headache, dizziness, weakness, nausea,
vomiting, sweating, skin rash, and paleness of the skin.
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with ergot alkaloid drugs (often given for migraine
headaches). This drug should be used with caution in pregnant or
nursing women.
        ===============

WHOLESALE COST:  $5.87 for 100, 5 mg tablets.
        ***************
        ***************

GENERIC NAME: Lidocaine
        ===============

BRAND NAMES: Xylocaine, Anestacon, Dalcaine.
        ===============

MECHANISM OF ACTION: this drug makes it less likely for an abnormal
irritation of the heart to trigger abnormal beating of the heart
(premature ventricular contractions).
        ===============

INDICATIONS:  for the treatment and prevention of certain forms of
abnormal heart rhythms.
        ===============

DOSE RANGE:  this drug is usually given as an initial or loading dose
of 50 to 100 mgs, followed by a constant infusion of 2 to 4 mgs per
minute.
        ===============

SIDE EFFECTS: light headedness, seizures, blurred vision,  low blood
pressure, slow heart rates, and allergic reactions.
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with beta- blockers, cimetidine, procainamide, and
succinylcholine.
         ==============

WHOLESALE COST: $163.12 for 50, 200 mg vials.
        ***************
        ***************





GENERIC NAME: Methyldopa
        ===============

BRAND NAMES: Aldoclor, Aldomet, Aldoril.
        ===============

MECHANISM OF ACTION:  Methyldopa lowers blood pressure by interfering
with the ability of norepinephrine, a substance known to increase
blood pressure, to exert its effects.
        ===============

INDICATION:  for the treatment of high blood pressure.
        ===============

DOSE RANGE:  250 to 500 mgs four times per day.
        ===============

SIDE EFFECTS: drowsiness, headache, weakness, depression, slow heart
rates, fluid retention, nausea, diarrhea, yellow jaundice, decreased
function of the liver, depression of the bone marrow's ability to
make blood cells, skin rash, nasal stuffiness, and enlarged breasts
in males. This drug should be used with caution in pregnant and
nursing women.
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with barbiturates, beta blockers, haloperidol, levodopa,
lithium, monoamine oxidase inhibitors, phenothiazines, sulfa drugs,
certain antidepressants, and drugs used to treat asthma and severely
lowered blood pressure.
        ===============

WHOLESALE COST: $13.07 for 100, 250 mg tablets.
        ***************
        ***************

GENERIC NAME: Metoprolol
        ===============

BRAND NAME: Lopressor
        ===============

MECHANISM OF ACTION: (see atenolol)
        ===============

INDICATIONS: (see atenolol)
        ===============

DOSE RANGE: 50 to 225 mgs two times per day.
        ===============

SIDE EFFECTS: (see atenolol)
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with aluminum salts, barbiturates, calcium,
chlorpromazine, cimetidine, clonidine, ergot alkaloids, furosemide,
hydralazine, indomethacin, lidocaine, methimazole, methyldopa,
certain muscle relaxants, birth control pills, phenformin, prazosin,
procainamide, propylthiouracil, rifampin, theophyllines, and thyroid
hormones.
        ===============

WHOLESALE COST: $15.59 for 100, 50 mg tablets.
        ***************
        ***************





GENERIC NAME: Nadolol
        ===============

BRAND NAME: Corgard
        ===============

MECHANISM OF ACTION:  (see atenolol)
        ===============

INDICATIONS: (see atenolol)
        ===============

DOSE RANGE: 40 to 160 mgs from one to four times per day.
        ===============

SIDE EFFECTS: (see atenolol)
        ===============

DRUG INTERACTIONS: (see phenformin)
        ===============

WHOLESALE COST:  $24.29 for 100, 40 mg tablets.
        ***************
        ***************

GENERIC NAME: nitroglycerin
        ===============

BRAND NAMES: Nitrostat, Nitrobid.
        ===============

MECHANISM OF ACTION:  (see isosorbide dinitrate)
        ===============

INDICATIONS: (see isosorbide dinitrate).
        ===============

DOSE RANGE: .15 to .6 mgs under the tongue as needed.
        ===============

SIDE EFFECTS: ( see isosorbide dinitrate ).
        ===============

DRUG INTERACTIONS: (see isosorbide dinitrate)
        ===============

WHOLESALE COST:  $3.33 for 100, .3 mg tablets.
        ***************
        ***************





GENERIC NAME:  Norepinephrine
        ===============

BRAND NAME: Levophed
        ===============

MECHANISM OF ACTION: This medication causes a decrease in the
diameter of the body's arteries thus causing significant increases in
the blood pressure.
        ===============

INDICATION: For the treatment of severely low blood pressure.
        ===============

DOSE RANGE: the average dose is 4 to 12 micrograms per minute given
through the vein. However, some persons require the dose to be
significantly higher in order to maintain a blood pressure that
decreases the chance of damage to the vital organs.
        ===============

SIDE EFFECTS: low pulse rate, headache, severe narrowing of arteries
which may cause damage to the tissues supplied by these arteries.
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with guanethedine, dilantin, indomethacin, lithium,
maprotiline, methyldopa, phenothiazines, and certain antidepressants.
        ===============

WHOLESALE COST: $26.09 for 10, 4 ml ampules.
        ***************
        ***************

GENERIC NAME: Phentolamine
        ===============

BRAND NAME:  Regitine
        ===============

MECHANISM OF ACTION:  this medication lowers blood pressure by
interfering with substances like adrenalin rendering them ineffective
in their ability to decrease the diameter of arteries.
        ===============

INDICATIONS:  for the treatment and diagnosis of specific types of
high blood pressure usually caused by an abnormally high production
of adrenalin by the body.
        ===============

DOSE RANGE: if given by mouth the usual dose is 50 mg four to six
times per day.  If given by vein or in the muscle the dose is usually
5 mgs one time only.
        ===============

SIDE EFFECTS:  severe prolonged low blood pressure, fast pulse rate,
weakness, dizziness, flushing of the face, nasal stuffiness, nausea,
vomiting, and diarrhea.  This drug should be used in pregnant or
nursing women with extreme caution.
        ===============

DRUG INTERACTIONS: none found by healthnet
        ===============

WHOLESALE COST: $8.75 for one 5 mg ampule.
        ***************
        ***************





GENERIC NAME: Prazosin
        ===============

BRAND NAME: Minipress, Minizide
        ===============

MECHANISM OF ACTION: this drug lowers blood pressure by decreasing
the diameter of the arteries directly.
        ===============

INDICATIONS:  (see hydralazine)
        ===============

DOSE RANGE: one to six mgs by mouth three times per day.
        ===============

SIDE EFFECTS: dizziness, headache, drowsiness, weakness,
palpitations, nausea, vomiting, swelling of the ankles, fast heart
rate, shortness of breath, skin rash, and blurred vision among
others.  This drug is not recommended for pregnant or nursing women
unless the benefits clearly outweigh the risks.
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with beta blockers (like propranalol) and indomethacin.
        ===============

WHOLESALE COST: $30.91 for 250, 1 mg capsules.
        ***************
        ***************

GENERIC NAME: Propranalol
        ===============

BRAND NAMES: Inderal, Inderide
        ===============

MECHANISM OF ACTION: (see atenolol)
        ===============

INDICATIONS: (see atenolol) may also be useful for certain types of
tremors, fast heart rates, extra heart beats, and migraine headaches.
        ===============

DOSE RANGE: 10 to 80 mgs two to four times per day.
        ===============

SIDE EFFECTS: (see atenolol)
        ===============

DRUG INTERACTIONS: (see metoprolol)
        ===============

WHOLESALE COST: $55.03 for 1000, 10 mg tablets.
        ***************
        ***************





GENERIC NAME: Quinidine
        ===============

BRAND NAMES: Duraquin, Quinaglute, Quinidex, Quinidine, and Quinora.
        ===============

MECHANISM OF ACTION:  Quinidine causes decreases in certain types of
abnormal heart rhythms including those originating in the ventricle
(largest heart chamber) by slowing the electrical conduction of the
heart.
        ===============

INDICATIONS: for the treatment and prevention of abnormal heart
rhythms.
        ===============

DOSE RANGE: 300 to 500 mgs, four times per day.
        ===============

SIDE EFFECTS: fainting, abnormally slow heart rhythms, worsening or
initiating new abnormal rhythms, low blood pressure, blurred vision,
diarrhea, abdominal upset, vomiting, fever, and decrease blood and
platelet counts.
        ===============

DRUG INTERACTIONS: the following drugs may interact unfavorably when
given in conjunction with quinidine - acetazolamide, amiodarone,
barbiturates, calcium, digoxin, dilantin, magnesium, methazolamide,
blood thinners given by mouth, potassium supplements, rifampin,
succinylcholine, and tromethamine.
        ===============

WHOLESALE COST: $30.88 for 500, 200 mg tablets.
        ***************
        ***************


GENERIC NAME: Sodium Nitroprusside.
        ===============

BRAND NAME: Nipride
        ===============

MECHANISM OF ACTION: lowers the blood pressure by directly increasing
the diameter of the blood vessels.  It also decreases the force that
the heart has to pump against in certain situations.
        ===============

INDICATIONS: for the treatment of severely high blood pressure and in
some instances congestive heart failure (the backing up of fluid into
the lungs because of ineffective pumping by the heart).
        ===============

DOSE RANGE: .5 to 10 micrograms per 2.2 lbs of body weight per
minute.  This drug is given by vein in a continuous manner.
        ===============

SIDE EFFECTS: nausea, vomiting sweating, headache, dizziness,
abdominal pain.
        ===============

DRUG INTERACTIONS:  none found by healthnet.
        ===============

WHOLESALE COST: $10.19 for one, 50 mg vial.
        ***************
        ***************





GENERIC NAME: Timolol
        ===============

BRAND NAME: Blocadren
        ===============

MECHANISM OF ACTION: (see atenolol)
        ===============

INDICATIONS: (see atenolol)
        ===============

DOSE RANGE: 10 to 30 mgs twice per day.
        ===============

SIDE EFFECTS: (see atenolol)
        ===============

DRUG INTERACTIONS: (see metoprolol)
        ===============

WHOLESALE COST: $19.50 for 100, 10 mg tablets.
        ***************
        ***************

GENERIC NAME: Verapamil
        ===============

BRAND NAMES: Isoptin, Calan.
        ===============

MECHANISM OF ACTION: (see diltiazem)
        ===============

INDICATIONS: for the treatment of abnormally fast heart rhythms and
for chest pain to due narrowing of the arteries to the heart.
        ===============

DOSE RANGE: by vein - 5 to 10 mgs over two minutes. If given by mouth
- 60 to 120 mgs every six to eight hours.
        ===============

SIDE EFFECTS: low blood pressure, abnormally slow heart rate,
dizziness, headache, tiredness, heart failure, constipation, and
nausea.
        ===============

DRUG INTERACTIONS: this drug may interact unfavorably when given in
conjunction with calcium, digoxin, beta blockers, and vitamin D.
        ===============

WHOLESALE COST: $113.00 for 10, 5 mg ampules.  $20.40 for 100, 80 mg
tablets.
        ***************
        ***************





   CATARACT OPERATIONS

   The lens is a clear, disc-shaped structure located in the center
of the eye behind the pupil.  It functions to focus light onto the
retina at the back of the eye.  A cataract is an opacity or clouding
of the lens.  Depending on the type, location, sevrity and presence
of other eye disease, it may cause significant visual impairment.

   The most common cause of cataract formation is normal aging; about
fifteen percent of Americans over the age of 50 have their vision
affected by this process.  Among the other causes are diabetes, eye
injury, radiation, toxic substances, low blood calcium,
cortisone-type medication and a variety of eye diseases. Hereditary
and congenital cataracts may affect newborns and children.

   There are no known medications which are effective in preventing
or treating this disorder.  Surgical extraction of the lens is the
definitive therapy.  About 600,000 cataract operations are performed
each year in this country.

   Indications for Surgery

   1) need to improve vision (will vary depending on the patient's
requirements).  2) foreign object embedded in the lens. 3) to prepare
the patient for other types of ophthalmic surgery. 4) to follow-up or
treat other eye diseases.  5) to allow for normal visual development
in young infants.

   Correction of Vision

   Cataract surgery results in aphakia, or the absence of a lens.
Therefore, the patient needs a device to focus light onto the retina.
 There are three alternatives: eyeglasses, contact lenses and
intraocular lens (IOL) implantation.

   "Coke bottle" glasses, the easiest option, are the least
effective; they magnify, distort and narrow the image.

   Contact lenses have only a slight magnifying effect and do not
limit the field of vision, but they can be difficult for an elderly
person to manipulate.

   The IOL is an artificial lens made of glass or other hard,
transparent materials.  It is implanted at the site of the original
lens at the time of surgery.  Almost normal vision is obtained.
Unfortunately, greater technical skill is required and the risk of
operative complications is increased.  The IOL, while reserved mainly
for older adults, is the most commonly employed method of correcting
aphakic vision.

   Overall, cataract operations improve vision 90 percent of the
time.  Failures are due to complications and concomitant eye disease.

   Operations

   There are two main techniques by which the lens can be removed:
intracapsular and extracapsular cataract extraction (ICCE & ECCE).
Typically, sedation and local anesthesia are employed, but general
anesthesia is required for children and adults who are unable to
cooperate.  The operation is performed either as an outpatient
procedure or as a part of a short, one to two day hospitalization.

   ICCE refers to extraction of the entire lens through a
cresent-shaped incision in the cornea (clear outer covering of the
eye) near the iris.  The eye surgeon uses an operating microscope to
remove the lens with a freezing probe, a forceps or a suction device.
 While ICCE is the standard technique, ECCE is gaining popularity.
It is safer for children and is required for patients who undergo
certain types of IOL implantation.  ECCE involves extraction of the
front and center portions of the lens while leaving behind the back
capsule, or outer covering. Phacoemulsification, a method which
employs a high frequency sound wave probe to shatter the lens, may be
used for ECCE.

   Postoperative Care

   There is a little sedation right after the surgery, but few
limitations in activity or diet.  The eye dressing is removed in 24
hours and replaced with glasses or a protective shield.  Eye drops
may be prescribed.  Complete healing takes six to eight weeks.
During this time glasses must be worn to protect the eye from
ultraviolet light, unless an IOL is in place.  There is a permanent
irregularity in the shape of the pupil.

   Complications

   Short-term problems include hemorrhage, injury to the iris and
cornea, tears in the back capsule during ECCE, loss of the jelly
substance in the eye (1-2%), wound leakage, eye infection (0.2%) and
acute glaucoma.  Among the long-term complications are chronic
glaucoma, detached retina (2.2%), swelling of the cornea (1%),
chronic swelling of a portion of the retina (2-4%) and astigmatism.
In addition, IOL implantation may be complicated by infection,
bleeding, dislodgement of the lens, glaucoma or damage to the cornea.
 Blindness is a risk common to all eye operations.





   FACELIFT (Rhytidoplasty)

   Despite the gradual increase in the average age of the population,
society continues to place great deal of importance on youthful
appearance.  The facelift, or rhytidoplasty, is one way of attempting
to reverse time's inexorable onslaught.  When performed by an
experienced plastic surgeon, it is safe and effective.  As with all
operations, however, complications and poor results may occur.

   Before embarking on cosmetic surgery, the patient and surgeon
should have similar expectations for the success of the procedure.
While it is reasonable to hope for an improved appearance, it is
unrealistic to believe that one's whole life will change or that one
can be made to look like somebody completely different.  The risk for
serious complications must be understood.

   While rhytidoplasties may improve acne scars and reduce
deformities due to nerve palsies, the vast majority are performed for
cosmetic reasons.  Predisposing factors for wrinkling include
age-related loss of skin elasticity and subcutaneous fat, family
history, cigarette smoking, sun exposure, emotional disturbances and
wide fluctuations in body weight.

   Procedure

   Prior to the operation, the hair is shaved on the temples and
behind the ears.  With the patient under general anesthesia--or more
often, local anesthesia with sedation--the surgeon makes incisions
just behind the hairline of the temples and extends them down in
front of the ears, around underneath the earlobes, then backwards
towards the scalp.  Next the facial tissues are dissected away from
their attachments to underlying structures. Large flaps of skin are
created which include parts of the forehead, cheek and neck on each
side.  These flaps, along with the superficial muscles, are pulled
upwards and backwards to tighten the tissues.  Excess skin is excised
and tiny stitches are placed along the incision lines.  Sometimes a
separate incision is made to tighten the neck and chin.  The entire
operation takes one to three hours.

   Recovery

   If done under local anesthesia, rhytidoplasty does not require
overnight hospitlization.  The patient should be aware, however, that
the facial bruising and swelling may take one to four weeks to
resolve.  Depression in the postoperative period is not unusual.

   Results

   The majority of patients are satisfied.  Some may require surgery
to revise the lift after the tissues have had time to settle in.
Because the aging process does not stop, re-operation at a later date
may be considered.

   Complications

   Reactions to the anesthesia, bleeding, infection, unsightly scars,
damage to nerves, blood clots, hair and skin loss, swelling,
numbness, bruising, pain.  Most adverse reactions are minor and
short-lived.  Major complications occur in about ten percent of the
cases.

   Cost: $2,000-$5,000





   EAR TUBES

   (Tympanostomy/Myringotomy)

   Young children are susceptible to developing collections of fluid
behind the eardrum due to infection, injury, allergy, bleeding,
tumors or hormonal diseases.  Blockage of the eustachian tube, the
drainage passageway connecting the ears to the back of the throat, is
an important factor.

   At first, the treatment is conservative: antibiotics,
antihistamines, decongestants, allergy therapy and/or eustachian tube
exercises may be employed over a six to eight week period. If
non-surgical therapy is unsucccessful, however, the insertion of
tubes through the eardrum (tympanostomy) to drain the fluid and
prevent it from reoccurring may be indicated.  Persistent middle ear
fluid can lead to scarring and hearing loss. Tympanostomy can be
combined with sinus surgery or tonsillectomy and adenoidectomy.

   Procedure

   For small children, the ear, nose and throat specialist may
recommend general anesthesia.  In cooperative older children the
operation can be done in the office under local anesthesia.

   Using a magnifying device or operating microscope and a long thin
knife, the surgeon makes a tiny incision in the eardrum called a
myringotomy.  The fluid is then drained and sent to the laboratory
for examination.  The tubes themselves resemble tiny donuts of
silicone, rubber, plastic or metal, about a 1/4 inch in diameter.
They are placed into the incision in the eardrum with the use of tiny
forceps.  There should be little pain or bleeding and no stitches.
Sometimes myringotomy is done without tube placement for the
evaluation and treatment of middle ear infections which do not
improve with antibiotics.

   Follow-up Care

   Water must be prevented from entering the ear. Cotton/vaseline
plugs are recommended for bathing, and swimming is prohibited without
specially made earplugs. The tubes stay in place for three to nine
months after which they are spontaneously extruded by the eardrum;
the hole usually seals itself.  About 25 percent of the patients will
require a second tube for recurrent middle ear disease.

   Complications

   Infection, postoperative drainage from the ear, permanent hole in
the eardrum and scarred eardrum are the most common hazards.





   TONSILLECTOMY & ADENOIDECTOMY

   The objective of this operation is to remove the tonsils and
adenoids, the lymph tissues in the back of the throat.

   Indications

   1) recurrent or persistent tonsillitis (controversial--see
alternatives)  2) tonsillar enlargement such that breathing is
obstructed.  3) Quinsy (abscess--pocket of pus) 4) certain types of
hearing loss and ear infections in children.  5) tumors of the
tonsils  6) carriers of diphtheria  7) history of rheumatic fever,
nephritis or congenital heart disease.  8) Adenoidectomy may be
performed without tonsillectomy if the tonsils are not affected.

   Not Indicated For:

   Recurrent colds, non-streptococcal sore throats, enlarged tonsils
which do not block the breathing passages, asthma, allergy, sinusitis
or cough.  This operation is rarely done on children less than two
years old.

   Operative Procedure

   Tonsillectomies are performed by ear, nose and throat surgeons.
The patient is admitted to the hospital the evening before the
surgery.  Nothing is given by mouth for six to eight hours prior to
the operation, and an injection is given to dry secretions in the
throat.  With the patient under general (gas) anesthesia and the
tongue held out of the way, the surgeon removes the tonsils using
sharp scissors or a snare.  Gauzes and a few dissolvable stitches
help to control bleeding.  The whole operation takes about one-half
hour.

   Postoperative Care

   The nurse observes the patient until recovery from anesthesia is
complete.  To prevent secretions and blood from entering the lungs,
the child is kept in the prone postion with his head to one side.
Pain medicine and ice on the neck will help to diminish the severity
of the thoat discomfort.  Ice chips and liquids are given at first
(Ice cream is soothing.); hot drinks and spicy foods should be
avoided for about a week.  If there are no complications, the patient
is discharged home on the day after the operation and advised against
strenuous activity for two to three days.  The sore throat lasts
about five days, and some earache is not unusual.

   Complications

   Bleeding is the most common complication, occurring in one to five
percent of the cases.  It may be delayed until as late as seven to
ten days afterward.  Anesthetic complications and lung, throat and
bloodstream infections may also occur.

   Results and Alternatives

   For the small minority of children who suffer greater than seven
strep. throats in one year, or three per year for three consecutive
years, tonsillectomy may decrease the number of subsequent strep.
throats by about one per year compared to children who don't have the
surgery.  Most children do not require tonsillectomy, and not having
the operation is an acceptable alternative in this situation.

   Cost:  Approximately $2,500.





   TRACHEOSTOMY

   Tracheostomy is incision of the trachea (windpipe) for the purpose
of opening the airway and/or inserting a breathing tube for
mechanical respiration.  It can be a lifesaving procedure.

   Indications for tracheostomy include blockage (obstruction) of the
upper airway, for example, due to allergic reactions, cancer, food
stuck in the throat or infections; inability to prevent mouth and
throat secretions from entering the lungs in persons who are
paralysed or unconscious; and lung failure necessitating prolonged
use of a respirator (ventilator).

   Ideally, tracheostomy is done electively in the operating room
under controlled conditions, although it may be done elsewhere in an
emergency.  When possible, endotracheal intubation, the insertion of
a breathing tube into the trachea via the mouth, should be performed
first.  In the short-term this is safer and may obviate the need for
tracheostomy.

   Emergency Tracheostomy

   With the person lying on his back with his neck extended, a small
horizontal incision is made in the middle of the neck.  The trachea
is opened just below the level of the Adam's apple; then a breathing
tube is inserted into the hole.  If necessary the tube can be
connected to a respirator.  Often emergency tracheostomy is done
outside the hospital where surgical instruments are unavailable.
Knives, keys, pens, needles, scissors and razor blades have been used
to open the airway in life-threatening situations.

   Elective Tracheostomy

   When an endotracheal tube is in place, the operation can be done
under general anesthesia; even so, local anesthesia is preferred in
most instances.  A horizontal incision is made in the middle of the
neck between the breast bone and Adam's apple. The surgeon divides a
part of the thyroid gland and enters the trachea either through or
between its cartilaginous rings to insert the tracheostomy tube.

   What tube is chosen depends on the indication for the operation as
well as the specific anatomy of the patients neck and airway.  Most
are short and curved and are about 1/2 inch in diameter.  They are
sewn in place and stabilized with tape around the neck.  Unless the
tube is a special kind, the patient is unable to speak.

   Postoperative Care

   The tracheostomy requires frequent vacuum suctioning of airway
secretions, administration of humidified air (oxygen if necessary)
and care to avoid infection.  Most surgeons recommend weekly tube
changes at first.  When the tube is ready to come out for good, it is
corked for 24 hours to test the patency of the upper airway.  This is
not possible in children, however, because the small diameter of the
trachea doesn't allow air to pass around the plugged tube.  In most
cases the trachea gradually seals itself after the tube is removed.

   Complications

   The complication rate is high (10-20 %), in large part because of
the seriousness of the patient's condition.  Children and infants
fair even poorer.  Among the complications are bleeding, infection,
hoarseness, air leakage under the skin, paralysis of the vocal cords
due to injury to the nerves to the voicebox, collapsed lung, crusting
of the airways and injury to arteries and the esophagus.  Tracheal
stenosis, a narrowing of the diameter of the trachea in reaction
either to pressure from the tube or to healing of the tracheostomy,
develops in as many as fifteen percent of patients who require
prolonged tracheostomy. Reconstructive surgery may be necessary.





   ELECTROCARDIOGRAM (EKG)

   The electrocardiogram is a means by which the innate electrical
activity of the heart can be observed and recorded. Its other names
are cardiogram, EKG and ECG.  When used in conjunction with the
patient's symptoms, examination and other laboratory tests, the EKG
can be an important diagnostic tool. During emergencies and in the
operating room and intensive care unit, electrocardiographic monitors
are used to chart a patient's heart beat on a 24 hour basis. (The
beeping machines that are so popular on TV.)

   Major Indications

   1) chest pain suggestive of heart disease.  2) heart attack. 3)
irregular heart beat--palpitations.  4) congestive heart failure.  5)
shortness of breath.  6) evaluation prior to surgery.  7)
fainting/blackout spells.  8) risk factors for heart disease, i.e.
high blood pressure, cholesterol, strong family history.  9) baseline
test for comparison when heart symptoms develop.  10) monitoring
during surgery.

   Procedure

   EKG's are performed in the office or at the bedside by nurses or
technicians.  With the patient lying on his back, metal electrodes or
leads are attached to the arms, legs and chest with suction cups or
straps.  A conducting gel is placed beneath each electrode to
facilitate the transfer of electric current from the skin.  The leads
connect to a machine that converts the impulses into squiggly lines
on a strip of paper.  Because muscular activity can obscure the heart
tracing, the person being tested is asked to lie quietly while the
machine is on.  EKG's are painless and take only about five minutes.

   Complications

   There may be temporary red marks (from pressure, not burns) where
the electrodes were positioned, and the gel has to be wiped off, but
no serious adverse effects are associated.  There is no danger from
electric shock because no current goes into the patient.

   What Can An EKG Tell?

   The cardiogram can detect abnormalities (arrhythmias) in the rate,
rhythm and regularity of the heartbeat. "Skipped" beats and extra
beats are observed.  The form and size of the waves produced by each
heartbeat help to determine whether the person is suffering from, or
had previously suffered, a heart attack or damage to the heart
muscle.  Among the many other disorders that may produce changes in
the EKG are anginal chest pains, long-term high blood pressure, heart
valve disease, diseases of the pericardium (membrane surrounding the
heart), injury to the heart muscle, blood clots in the lungs, stroke,
disturbances in body metabolism and medications.

   Limitations

   A normal electrocardiogram does not guarantee that a person has a
normal heart: many cardiac disorders do not affect the heart's
electrical activity.  Even heart attacks occasionally do not show up
on the tracing.  Furthermore, because a routine EKG is only a picture
of what is going on in the minute or so that the tracing is being
made, it may miss abnormalities that occur sporadically or are
brought on only by stress or exercise.  The latter disadvantages can
be overcome by the use of Holter monitoring, a 24 hour continuous
tape-recorded EKG, and exercise (treadmill) tolerance testing.  See
the separate article for more information about exercise testing.

   Cost:  approx. $25-$50





   EXERCISE TOLERANCE TESTING

       (Treadmill Test)

   Because many cardiac abnormalities become apparent only after a
physical stress is placed on the heart, the exercise tolerance test
(ETT) is a valuable diagnostic and prognostic aid in the evaluation
of heart disease.  The treadmill is the most commonly employed mode
of exercise although stationary bicycles, step-ups and arm exercises
are sometimes used.  Special protocols which involve the injection of
a radioactive isotope (thallium scintigraphy/ventriculography) prior
to exercise may enhance the diagnostic accuracy of an ETT by
providing a scan or picture of the areas of the heart that do not
receive enough oxygen.

   Major Indications

   1) undiagnosed chest pain possibly indicative of angina pectoris
(heart pain).  2) suspected heart disease--especially coronary artery
disease.  3) evaluation of the efficacy of cardiac surgery and heart
medications.  4) guide for prognosis and rehabilitation after heart
attack.  5) screening test for persons at risk for coronary disease.
6) evaluation of heart patients and older individuals prior to a
program of physical fitness.

   Major Contraindications

   Ongoing or impending heart attack, heart inflammation, heart
failure, extreme high blood pressure, heart arrhythmias, known severe
coronary disease, acute illness.  Certain pre-existing
electrocardiographic (EKG) abnormalities may make interpretation of
the exercise tracing impossible.

   Procedure

   In most cases the test is done in an office or special exercise
laboratory under the supervision of a physician.  After an initial
examination, a baseline EKG is obtained.  Then EKG electrodes are
attached to the chest and a blood pressure cuff placed on one arm.

   The patient steps onto the treadmill and begins to walk.  With
each three minute period, the incline and/or speed of the treadmill
increases in difficulty.  Depending on the protocol, the incline
varies from 0-26 degrees and the speed from 2-6 mph. The EKG is
observed continuously on an oscilloscope, and the blood pressure
reading and EKG tracing are recorded after each three minute period.
The subject is asked to report if he has chest pain, discomfort,
trouble breathing, etc.

   The treadmill is stopped when the patient is fatigued or has signs
or symptoms of heart disease, when the most difficult step has been
reached (usually 20-45 minutes), when the EKG shows something
serious, or when a predetermined heart rate (e.g. 90% of predicted
maximum for sex/age) or workload has been attained.

   There is a post-exercise observation period during which the EKG
and blood pressure continue to be monitored.

   Results

   Interpreting the data obtained from an ETT can be challenging.
Medications may affect the person's exercise capabilities as well as
the physiologic parameters.  Changes in the wave form of the EKG,
cardiac symptoms, alterations in blood pressure and maximum work
capacity attained are important.

   In healthy asymptomatic men with risk factors for coronary disease
(such as smoking, diabetes), positive findings on an ETT may warrant
further evaluation, although the specificity of test in this
population is not very high.  For men with undiagnosed chest pain,
ETT's are about 50-70 percent sensitive and 80-95 percent specific
for diagnosing coronary disease; the specificity is not as good for
women.  Radionuclide thallium scans may increase the diagnostic
ability when the routine ETT is equivocal.

   Patients who are able to exercise twelve minutes and/or achieve a
heart rate of 160 beats/minute have an excellent prognosis even if
there are changes on the EKG.

   Individuals who have positive findings on a limited ETT two to
three weeks after a heart attack have a much poorer prognosis with
regard to mortality and recurrent chest pains than persons with
negative tests.

   Often ETT results are used to advise a patient with known heart
disease just how much physical activity he can tolerate with safety.

   Complications

   The mortality rate is approximately 3.5 per 100,000 tests. Adverse
effects include prolonged chest pain, heart attack, abnormal heart
rhythm, blackouts and leg cramps.





   ECHOCARDIOGRAM

   Echocardiography is the process of using sonar or ultrasound to
create a picture (echocardiogram) of the heart.  Through a
microphone-shaped transducer on the skin, sound waves pass into the
chest towards the heart where they bounce off the interface between
tissues of different densities--for example, heart muscle and blood.
The sound wave echoes are picked up by the transducer and transmitted
by wires to an ultrasound machine that converts the electrical
impulses into an image.

   Major Indications

   1) suspected pericardial effusion (fluid around the heart). 2)
evaluation of the heart valves.  3) evaluation of heart failure.  4)
strokes in persons with heart disease.  5). congenital heart disease.
 6) heart tumors.

   Procedure

   No hospitalization, anesthesia or special preparation is required;
the test is done either right in the office or in a special echo
laboratory.  Although a technician may perform the procedure, a
cardiologist (specialist in heart diseases) is responsible for the
interpretation.

   The patient is asked to lie on his back while the transducer is
held on the skin over the middle of the chest.  A lubricating gel
helps assure clear transmission and reception of the sound waves.
The technician manipulates the transducer, pointing it in different
directions to obtain the desired pictures.  Overweight persons and
those with thick chests may be difficult to examine. The test is
entirely painless and takes less than a one-half hour.

   Information Obtained

   Depending on the type and quality of the echocardiogram, a skilled
cardiologist will be able to determine the size of the heart
chambers, the thickness and strength of the heart muscle, the
quantity of blood pumped with each beat, whether there is fluid in
the sac surrounding the heart and whether the valves are abnormal,
narrowed or leaking.  This information can be extremely helpful to
physicians trying to diagnose and treat many diseases of the heart.

   Adverse Effects

   There are no known adverse effects.





   HEART CATHETERIZATION

   (Coronary Angiography)

   The objective of heart catheterization is to thread a thin plastic
tube or catheter through the circulation into the heart for the
measurement of pressures and blood flow, and the performance of
certain procedures.  Coronary arteriography or angiography is a test
in which dye is squirted into the heart chambers and coronary
arteries, the vessels that supply the heart muscle with blood.
Simultaneous X-ray pictures are taken to detect heart muscle and
valve abnormalities as well as atherosclerotic blockages of the
dye-filled arteries.

   Major Indications

   1) suspected severe atherosclerotic disease of the coronary
arteries.  2) unexplained chest pain or heart failure.  3) disease of
the heart valves.  4) evaluation of patients being considered for
heart surgery.  5) follow-up evaluation of patients who have had
heart surgery.  6) congenital heart disease.  7) assessment of the
efficacy of certain heart medications.  8) performance of the
following procedures: thrombolysis (dissolution of blood clots in the
coronary arteries), coronary angioplasty (balloon dilatation of a
narrowed coronary artery) and heart biopsy.

   Procedure

   Heart catheterization is usually performed in the hospital by
cardiologists (heart specialists).  Although the patient is awake for
the catheterization, a sedating medication like Valium is given just
prior to the procedure.  The cardiologist may choose to insert the
catheter into the blood vessels on the inside of the elbow or in the
groin.  In order for each side of the heart to be tested, the artery
and vein must be entered separately.

   After a local anesthetic is injected, a small (one inch) incision
is made to locate the desired artery and vein. Alternatively, the
vessels can be entered by direct puncture through the skin.  The
catheter, a plastic tube less than a quarter of an inch in diameter,
is then inserted into the vessel and advanced toward the heart under
the guidance of fluoroscopic X-rays.  It is pushed, pulled and
twisted into the proper position for pressure measurements and
injection of the dye.  The patient feels very little discomfort,
except for perhaps, a feeling of warmth and nausea when the dye is
injected.  A "cath." takes about an hour.

   Afterwards, pressure is applied to the puncture sites to minimize
bleeding and the patient is observed overnight.

   Complications

   Heart attack (.07%), stroke (.07%), blood clot formation in the
artery and vein, injury to the heart and blood vessels, abnormal
heart rhythms, hazards from electrical equipment, bleeding and
infection are the major complications.  Death occurs in about one out
of 700 procedures.

   Alternatives

   Although catheterization is the best method of demonstrating the
anatomy of the coronary arteries prior to heart bypass surgery, there
is a great deal of controversy surrounding the selection of patients
to have it done.  The treating physician must take into account the
patient's history of heart disease, symptoms, electrocardiogram (EKG)
and treadmill test, as well as whether similar information could be
obtained from various heart scans.





CORONARY ARTERY BYPASS GRAFTING

    (CABG - Heart Bypass )

   The objective of CABG surgery is to increase the blood flow to the
heart muscle by bypassing blockages in the the arteries (coronary
arteries) that supply it with blood.

   Indications

   1) Relief of chronic, disabling angina pectoris (heart pain) that
does not respond to medication.  2) Prolongation of life in persons
with severe (greater than 50% narrowing) blockage of the left main
coronary artery.  3) Prolongation of life in selected patients with
severe (greater than 70% narrowing) blockage of all three major
coronary arteries (controversial).  4) CABG is still being studied in
patients with:  a) blockages in less than three of the major coronary
arteries.  b) recent heart attacks.  c) previous cardiac arrests
(after resuscitation).  d) moderately severe congestive heart
failure.  e) angina pectoris which is increasing in severity.  f)
certain abnormal heart rhythms.  g) no symptoms of heart disease.

   Contraindications

   1) Severe heart failure.  2) Heart attack within three months
(unless part of a study).  3) Blockages in the coronary arteries not
amenable to bypass.  The artery distal to the blockage must not be
free of atherosclerotic disease.  4) Poor general health-- unable to
withstand a major operation.

   Preoperative Evaluation

   In the days or weeks prior to the surgery, a thorough evaluation
of the patient's heart condition and general health is undertaken.
Electrocardiogram (EKG), treadmill test and, frequently, radionuclide
heart scans are ordered.  All patients must undergo a heart
catheterization with coronary arteriography (dye X-ray pictures of
the heart and coronary arteries).  The results of the "cath." help to
determine whether the CABG is indicated, as well as how the surgeon
will do the operation.

   Operation

   With the patient under general anesthesia, a team of
cardiovascular surgeons opens the chest by cutting through the breast
bone.  The ribs are spread apart to expose the heart.  An important
part of the operation is putting the patient on the heart-lung
machine.  This is done by putting tubes into the major artery (aorta)
and vein near the heart.  The blood then goes to the machine where it
receives oxygen and is pumped back through the body.

   With the heart stopped by a icy, cold potassium-containing
solution, the surgeon takes segments of veins which have been removed
from the leg(s) and sews their ends to the coronary arteries such
that the areas of blockage are bypassed. Alternatively or in
addition, the left internal mammary artery (IMA), a vessel which runs
beneath the left side of the breastbone, is diverted and sewn to a
patent section of coronary artery below the point of obstruction.
Consequently, blood flows around the blockage through the newly
attached veins or artery.

   The number of bypasses depends on the results of the preoperative
arteriogram; most patients require from one to five. Recently,
cardiovascular surgeons have begun grafting a single IMA to more than
one coronary artery as well as using both the left- and right-sided
internal mammary arteries.

   If all is well, the patient is taken off the heart-lung machine
and the heart is started again.  The breastbone is put back together
with wires.  The duration of the operation may be two to twelve
hours.

   Postoperative Care

   The first few days after the operation are spent in the intensive
care unit, and the average total length of the hospitalization is ten
to twenty-one days.  Heart medicines usually need to be adjusted.
Soon afterward a graduated program of exercise (walking) is advised.
There is some pain from the incisions and a little swelling in the
leg from which the vein was taken.

   Complications

   The overall mortality rate is about 0.5-3.5 percent.  Most of the
deaths occur in the very ill patients.  Among the other complications
are heart attack, heart failure, blood clots, bleeding, wound and
breastbone infection, pericarditis (inflammation of the membrane
around the heart), strokes and the usual risks of general anesthesia.

   Results

   About ten to fifteen percent of the grafted veins will become
occluded in the first year.  Thereafter, the rate of occlusion is
about 0.5-3.0 percent per year.  Long-term patency is better with
internal mammary artery than with vein grafts (95% vs. 70% after ten
years), and recent data suggest that so, perhaps, is patient survival
(83-94% vs. 71-88% depending on the number of blocked coronary
arteries).

   Angina pectoris is relieved in 80-90 percent of patients who have
this operation.  In patients with severe narrowing of the left main
coronary artery, survival can be prolonged compared to patients
treated with medication alone (90% vs. 67% alive at five years).  For
patients with mild to moderate angina pectoris--in the absence of
left main disease as above--treatment with medications is equally
effective in relieving pain and preserving life (about 90% alive at 5
years).





   PACEMAKERS

   The heart has an intrinsic system of electrical activity which
accounts for its orderly and regular contraction.  The rate and
rhythm of the heart beat are modified by heart diseases and
medications as well as psychological, neurological, chemical and
hormonal factors.

   When certain abnormal heart rhythms (arrhythmias) occur, the heart
may be unable to pump enough blood to maintain either a normal blood
pressure or an adequate supply of oxygen to body tissues.  Blackouts
and/or sudden death may result.

   If arrhythmias cannot be reversed and prevented by medication, a
pacemaker is often required.  The vast majority of arrhythmias that
necessitate pacemaker insertion are manifested by extremely slow
heart rates (less than 50 beats per minute).  Occasionally, pacers
are used to shock abnormally fast heart rates back into a normal
rhythm.

   Types of Pacermakers

   Pacemakers are comprised of a hockey puck-sized electrical impulse
generator connected to one (unipolar) or two (bipolar) wire leads
which are attached to the heart muscle.  Although there are many
power sources available--from nuclear to a variety of power
cells--lithium batteries are most commonly employed.

   Temporary pacers are utilized when the heart abnormality or
disorder is reversible or short-lived, e.g. heart attack, chemical
imbalance, or drug overdose.  They are also used to treat certain
fast heart rhythms, evaluate the effects of heart medications, and to
tide the patient over until arrangements can be made for placement of
a permanent pacemaker.  Permanent pacers are designed to work
indefinitely, limited only by the lifetime of their power source
(about eight years for lithium batteries).

   Fixed-rate pacers generate impulses without regard for the
intrinsic heart beat.  Once the pacer is turned on and the rate is
set, it fires continually at regular intervals.  Because it can be
dangerous for the pacer to fire at certain points during the heart
beat, fixed-rate pacers have been replaced, for the most part, by
demand pacers.  The demand feature refers to the ability of the pacer
to sense the heart's intrinsic beat and transmit an impulse only when
necessary.  Demand pacers, therefore, function intermittently
depending upon the heart's ability to beat on its own.

   Programmable pacers are adjustable for a variety of parameters.
While they are not truly programmable in the computer sense of the
word, changes in the rate, electrical output, sensitivity, mode, etc.
can be made without removing the device.  The two techniques of
effecting alterations in generator function are radio-frequency
signals and pulsating magnetic fields.  The former is preferrable and
can be adapted to receive information from the pacer as well as
transmit.

   The two methods of pacemaker placement are described below.
Endocardial leads are those attached to the inner lining of the
heart; epicardial leads are attached to the outside lining.

   Endocardial Lead Placement

   Also known as transvenous pacing, about 90 percent of all
pacemakers are placed by this method using either local or general
anesthesia.  First the wire lead(s) is inserted into a vein in the
neck, beneath the collarbone or near the shoulder. Then, using
fluoroscopic X-rays as a guide, the surgeon advances the lead(s) into
the chambers on the right side of the heart where it becomes lodged
in the muscular fibers.  Some leads have hooks, tines or screws to
facilitate attachment to the inner wall (endocardium) of the heart.
Which chamber (atrium or ventricle) is used to anchor the lead(s)
depends on the type of arrhythmia and the pacemaker used.  For
permanent pacing, the generator is connected and placed beneath a
pocket of skin on the chest or near the shoulder.  Temporary pacers
utilize an external generator at the bedside.

   Epicardial Lead Placement

   An operation under general anesthesia is required.  Either the
chest cavity is opened through a small incision beneath the left
breast or, more commonly, an incision is placed below the breastbone.
 The heart is visualized directly, and the lead(s) is screwed into
its outer wall (epicardium).  The generator may be placed inside the
chest cavity or under the skin in the upper abdomen of flank.
Although this method assures more accurate and secure lead placement,
it involves a bigger operation at greater risk to the patient.

   Postoperative Care

   The placement of the pacer leads can be checked with X-rays.
Still, the patient is kept in bed for the first few days to prevent
the leads from dislodging.  The heart rhythm and pacer function are
monitored by continuous electrocardiography (The pacer makes a
characteristic spike on the EKG tracing.)  The average length of
hospitalization is about one week for insertion of a permament pacing
device.  Most patients are followed-up by their cardiologists for
regular pacemaker checks.

   Complications

   Among the operative problems are the risks of anesthesia,
infection, bleeding, damage to blood vessels, perforation of the
heart, blood clots in the veins, life-threatening arrhythmias and
death.  Long-term complications include lead dislodgement and
erosion, pacer malfunction, migration of the generator, broken wires,
damage to heart valves and pacemaker stimulation of the diaphragm
muscle.

   Results

   About 80 percent of pacemaker patients are alive at two years, 65
percent at five years, and 40 percent at ten years.  These figures do
not differ remarkably from those for the general population matched
for age.





   THORACENTESIS (Chest Tap)

   The pleura is a thin membrane that covers the surfaces of the
lungs and the inside of the ribcage.  Normally these pleural surfaces
are in direct contact with each other.  There is no space between the
lungs and chest wall.  With certain diseases and chest injuries,
however, fluid collects between the two membranes at the bottom of
the lungs.  This condition is called a "pleural effusion" or "fluid
on the lungs."

   Thoracentesis is the insertion of a needle into the chest cavity
to withdraw pleural fluid and, sometimes, to perform a biopsy.
Examination of the fluid and tissue specimens can help diagnose a
variety of disorders.  If there is a great deal of pleural fluid or
blood preventing the lung from expanding completely, thoracentesis
can be used to relieve shortness of breath.

   Major Indications

   1) diagnosis of diseases which produce pleural fluid, e.g.
infection, cancer.  2) shortness of breath in a patient with a large
pleural effusion.  3) as an emergency procedure in a person with a
collapsed lung or rapid bleeding into the chest cavity. 4)
performance of a pleural biopsy (removal of small bit of pleura).

   Procedure

   This is a test that is done by physicians in many specialties
including internists, surgeons and family practitioners. Although
hospitalization is not required, many persons with pleural effusions
are ill enough to be in the hospital.  A chest X-ray is taken prior
to the test to locate the fluid collection.


   First the doctor checks the amount of fluid in the patient by
tapping on the chest with his fingers.  Then a local anesthetic is
injected, usually into the back of the lower chest just below the
upper level of the fluid.  While the patient is asked to breath out,
a needle is inserted into the chest between the ribs. The pain is not
severe.  Next, the fluid is withdrawn into a syringe or vacuum bottle
connected to the needle.  Unless the person is markedly short of
breath or the doctor is suspicious of cancer, only an ounce or two
will be removed.  The whole procedure takes about fifteen minutes.  A
chest X-ray is obtained afterwards.

   Complications

   Bleeding into the lung, collapsed lung and infection are the most
common problems.  Serious complications are rarely encountered.





   CHEST TUBE (Thoracostomy)

   The pleura is a smooth, thin, membrane that covers the surfaces of
the lungs and the inside of the ribcage.  Normally these pleural
surfaces are in direct contact with each other; there is no actual
space between the lungs and the chest wall. During chest surgery or
penetrating injuries, however, air can rush into the chest cavity,
collect in the space between the lung and chest wall, and collapse
the lung.  This is called a pneumothorax.  Furthermore, certain
disorders such as cancer, heart failure, chest injury or lung
infections, can cause fluid to accumulate between the pleural
membranes, a condition known as pleural effusion or "fluid on the
lung."

   A chest or thoracostomy tube is a long, clear, flexible tube about
one-half inch in diameter.  It is inserted into the chest cavity to
drain out fluid and air.

   Indications for Chest Tube

   1) collapsed lung from any cause including--injury, chest surgery,
spontaneous.  2) infection or pus in the chest cavity. 3) rapid
bleeding into the chest cavity--hemothorax.  (President Reagan had a
chest tube after he was shot.)  4) large pleural effusions which
cause breathing difficulty that cannot be relieved with medication,
e.g. with cancers that involve the lung.

   Procedure

   Except in extreme emergencies, a chest X-ray is taken beforehand
to evaluate the problem and confirm the need for a chest tube.  The
amount of chest fluid or degree of lung collapse can be quantified.
Then, with the patient under local anesthesia, an inch long
horizontal incision is made in the chest between the ribs either
under the arm or just below the collarbone.  The chest cavity is
entered with a blunt instrument and the tube is advanced into the
space adjacent to the lung. The end of the tube is hooked up to
vacuum suction such that air and fluid are seen to collect in a
bubbling plastic container (Pleurovac) hooked to the bedside.
Several stitches are needed to close the skin and hold the chest tube
in place.  An airtight seal is attained with the use of a tight
petrolatum dressing. The whole procedure takes five to ten minutes or
less.

   Follow-up Care

   A chest X-ray is obtained immediately afterward to assess the
results and check the placement of the tube.  The patient may
experience some sharp pains in the area of tube when he takes a deep
breath.  Most chest tubes only need to stay in for three of four
days--for collapsed lungs, until the hole in the pleura stops leaking
air.  The tube is removed simply by pulling it out. To prevent
recurrent effusions in certain cancer patients, medications can be
injected through the tube prior to its removal to help the pleural
membranes stick together.

   Complications

   Bleeding, reactions to the local anesthetic, infection in the
chest cavity, air escaping beneath the skin and injuries to the
heart, lung, diaphragm and major blood vessels have been reported.





   LUNG SURGERY

   The trachea (windpipe) divides into two major bronchi, the right
mainstem bronchus and the left mainstem bronchus.  The mainstem
bronchi open into each lung respectively then branch into smaller
bronchi that lead into the lobes of each lung.  The right lung has
three lobes (upper, middle and lower) and the left has two (upper and
lower).  The lobes are subdivided into two to five segments (total of
20), each with its own branch of a lobar bronchus.  Surgery to remove
lung tissue (resection) may involve removal of an entire lung, one or
more lobes, one or more segments or just a portion of a segment.

 Major Indications for Resection

   1) lung cancers amenable to surgery.  2) benign lung tumors. 3)
chronic lung infection unresponsive to medication.  4) profuse
bleeding.  5) injury.  6) bronchiectasis.  7) lung biopsy (tissue
sample) when other methods are not rewarding.

   Preoperative Evaluation

   Operations to remove a lung or a part of a lung are considered
major surgery.  Performed by a thoracic surgeon with the patient
under general anesthesia, they require the patient to be in stable
condition.  Severe heart disease is a contraindication, and advanced
age is a significant risk factor.

   Another important preoperative consideration is the assessment of
the patient's lung function--the ability to exchange oxygen and
carbon dioxide.  Special blood and breathing tests are performed to
determine whether the patient's lungs have enough working volume to
withstand the proposed resection.  For instance, it is not unusual
for a long-time smoker to develop cancer of the lung.  If the
person's residual lung function is markedly dimished due to
emphysema, he may be unable to tolerate the extensive surgery
necessary to effect a cure.

   Operations

   The choice of procedure depends upon the type and location of lung
abnormality as well as the condition of the patient. "Pneumonectomy"
is the term used for the excision of an entire lung.  Its major use
is in patients with cancers that involve either more than one lobe or
one of the mainstem bronchi. Lobectomy, the excision of a lobe, is
the usual procedure performed for most indications.  Segmental or
wedge (subsegmental) resections are reasonable alternatives for
patients with small lesions in the periphery of the lung or for those
too ill to tolerate more extensive surgery.

   In most cases the chest cavity is opened (thoracotomy) through an
incision in the back of the chest below the fifth or sixth rib.  The
ribs are spread apart and sometimes one is removed. For better
visualization, the thoracotomy incision is extended laterally.
Alternatively, the chest is entered in front below the third rib;
this technique allows for better lung ventilation during surgery.

   In about one out four thoracotomies for cancer, the resection will
not be performed after the initial exploration because the tumor will
be found to have spread more extensively than what could have been
predicted by preoperative testing.  When resection is possible, the
surgeon removes the lung tissue by severing the appropriate artery,
vein and bronchus and repairing them with stitches and staples.  The
surgeon may insert chest drainage tubes prior to closing the
incision, depending on the procedure.

   Postoperatively, narcotics are given for pain.  Oxygen may be
required.  Chest tubes remain in place for several days until the
chest cavity seals itself airtight and drainage has diminished.
Coughing and breathing exercises are encouraged.  The average length
of hospitalization is seven to ten days.

   Complications

   Risks of anesthesia, bleeding, infection, pneumonia, respiratory
failure, collapsed lung, heart problems and injury to the esophagus,
major blood vessels, ribs and nerves.  The 30 day overall mortality
is about ten percent for pneumonectomy and five percent for
lobectomy.  Cardiac arrest is the leading cause of death.





   INTRAVENOUS (IV) LINE

   The objective is to insert a metal needle or plastic catheter
(tube) into a vein in order to administer fluids or medication.

   Who Needs An IV?

   1) Persons who are severely dehydrated or cannot take liquids or
foods for a prolonged period.  2) Those who need, or might need in a
hurry, IV medications like heart medicines or antibiotics for severe
infections.  3) Patients who require blood transfusions.

   Intravenous Devices

   There are two major types of IV devices that can be placed into
veins near the skin.  The  butterfly is a small metal needle with two
plastic "wings" by which it can be held.  It is relatively easy to
insert, but is just as easily dislodged.  It cannot be used to give
fluids or blood at a fast rate.  The second type, the angiocath, is a
needle surrounded by a plastic catheter; only the catheter stays in
the vein.  It is sturdier and more durable than a butterfly and can
be used to give fluids very rapidly.  Unfortunately, it is more prone
to infection.

   Procedure

   Doctors, many nurses, paramedics and IV technicians are trained in
IV insertion.  Almost any vein near the surface of the skin can be
used, although usually a vein in the arm, forearm or hand is
selected.  In small babies with tiny, hard-to-find veins, a scalp
vein is a reasonable alternative.

   First, a tourniquet is applied around the extremity until the vein
can be felt or seen.  Then, the skin over the insertion site is
cleaned with alcohol or an antiseptic solution.  Using a sterile
technique, the inserter stretches the skin and pierces the vein until
blood flows backwards through the needle.  After the tourniquet is
released, the IV is hooked up to clear tubing that is connected to a
bag of fluid.  Finally, the puncture site is covered with antibiotic
ointment and the IV and tubing are taped in place.  A board may be
used to keep the arm straight.

   In the event that there is difficulty finding a suitable vein--not
an unusual occurrence in very old, young, overweight or chronically
ill patients--a cutdown may have to be performed. This procedure
involves making a small incision in the skin to find the vein and
inserting the IV device under direct vision. Another alternative is
the central venous catheter, an IV placed into one of the large veins
in the neck.  This line can be used to give large amounts of fluid at
very fast rates.  (See separate article.)

   Maintenance

   The medications, type of fluid and the rate of administration are
ordered by the doctor.  The nursing staff adjusts the rate of the IV
by varying the number of drops per minute going through the tubing.
An IVAC, an electonic device which produces an annoying beep when the
fluid is not flowing correctly, may be utilized.  To prevent
infection, all IV's must be changed every two to three days.

   Complications

   Aside from missing the vein when trying to insert the IV, the most
common complication is infiltration.  This is when the IV needle or
catheter becomes dislodged and fluid pours into the tissues adjacent
to the vein.  It is not serious.  Other complications include
bleeding, infection, giving the wrong amount of fluid and superficial
phlebitis.  The latter refers to blood clot formation in the vein
caused by irritation from the needle or from an IV medication or
fluid.  Unlike phlebitis in the deep veins, it is not dangerous.





  CENTRAL VENOUS CATHETERIZATION

  (CVP - Central Venous Pressure)

   Central venous catheterization is the insertion of a thin plastic
tube or catheter into a large vein in the neck for the administration
of intravenous (IV) fluids or medications. Because the vein entered
by the catheter is so large, fluids can be given at higher
concentrations and at faster rates than they can be adminstered
through small veins in the arm.  The catheter can also be used to
monitor the central venous pressure (CVP - pressure in the vein that
empties into the right side of the heart).  For this reason, it is
often referred to as a CVP catheter or line.

   Indications

   1) rapid transfusion of large quantities of fluid or blood
products.  2) intravenous feedings.  3) administration of certain
medications.  4) measurement of central venous pressure.  5) access
to the venous system during surgery.  6) access to the venous system
when no veins are available in the extremities.  7) As a technique
for inserting special catheters for dialysis and home intravenous
feedings.

   Procedure

   Placement of a CVP catheter is done in the hospital by physicians
in many different specialties.  There are three different locations
where the catheter can be inserted: below the collarbone
(subclavian), above the collarbone (supraclavicular) and next to the
windpipe (internal jugular).  Regardless of the site selected, the
insertion is similar.  It is done at the bedside under sterile
conditions.

   First, the patient is positioned on his back, and a local
anesthetic is injected into the skin.  Then the patient is asked to
exhale as a large needle is pushed through numbed skin and advanced
into the vein.  Next the plastic catheter is inserted through the
needle into the vein and the needle is removed. Finally, an
intravenous line and bag are connected, the catheter is sewn in
place, and a dressing is applied.  The patient experiences little
pain except for the initial anesthetic injection.

   A chest X-ray is ordered immediately afterward to check both for
complications and the exact location of the catheter.  (The tip
should be in the, superior vena cava, the large vein that emptie into
the heart.)

   Catheter Maintenance

   Some hospitals have special teams assigned to take care of the
catheter and its dressing.  With careful attention to sterile
technique and frequent dressing changes, these catheters can stay in
place for weeks.  Patients who feel well enough are not restricted to
bed.

   Complications

   CVP insertion is generally very safe, but there are some hazards.
Among these are collapsed lung (3%), bleeding, injury to the
arteries, veins and nerves in the neck, blood clots, air leakage into
the heart and lungs, fluid leakage into the lung and retained
catheter fragments.  Bloodstream infection is a complication of
prolonged use.  The overall complication rate is five to ten percent.





   BLOOD DONATION

   Blood donation is a valuable community service.  Each day
thousands of units of blood and blood products are required to care
for the nation's sick.  Despite the combined efforts of hospitals and
national organizations such as the American National Red Cross, there
are still not enough volunteer donors. While paid donors help fill
the need, blood from these individuals is thought to be more likely
to carry hepatitis and other diseases.  Volunteer recruitment is
emphasized.

   In addition to whole blood, there are two other types of donation:
autotransfusion and pheresis.  The former refers to donation of blood
for later use only by the donor.  Pheresis is whole blood donation
followed by replacement of the portions not used.  For example,
plasmapheresis is the net removal of just the liquid portion of blood
(plasma); the cells are returned to the donor.

   Who Can Give Blood?

   Persons in good health between the ages of 17 and 66 are potential
donors.  Older individuals should obtain consent from their
physician.  Blood cannot be given at less than eight week intervals
or more frequently than five times per year.  (It takes six weeks for
the donor's blood count to return to normal.)


   Among the other conditions that make a potential donor ineligible
are dental surgery within three days, malaria within three years,
tattoo or transfusion within six months, poor general health, severe
heart disease, trouble breathing, tuberculosis, kidney disease,
insulin-requiring diabetes, epilepsy, bleeding disorders, cancer,
AIDS, pregnancy, drug abuse, history of jaundice or hepatitis,
exposure to hepatitis, some recent vaccinations, certain medications,
weight less than 110 pounds, and recent exposure to mumps, measles,
or chickenpox.

   Procedure

   After the history and physical examination, a blood sample is
drawn for typing, blood count determination, syphilis serology and
AIDS and hepatitis testing.  Hemoglobin levels of less than 13.5 and
12.5 mg./dl. in men and women respectively are considered
unacceptably low.

   To give the blood, the donor is asked to lie on his back while the
technician scrubs his arm with an antiseptic solution and applies a
tourniquet.  Then a needle is inserted into a prominent vein near the
elbow and connected to a plastic collection bag through clear
flexible tubing.  The collection apparatus remains in place as blood
flows freely into the bag; a total of about 450 cc. (1 pint) of blood
is removed.  The procedure is painless apart from the initial needle
stick.

   Instructions

   After the blood has been taken and the needle removed, the donor
is asked to elevate his arm and apply pressure to the puncture site
for several minutes with a sterile gauze. Refreshments are offered as
the donor is observed for a fifteen to twenty minute period.  Smoking
and drinking are discouraged in the first few hours and strenuous
activity is prohibited for a day.  Increased fluid consumption and
regular meals are advised. The bandage needs to stay in place for
only a few hours.

   Complications

   Fainting with prompt recovery is the most common adverse reaction.
 Psychological factors are important.  Other rare complications
include hyperventilation, cramps, and rarely, seizures and
cardiopulmonary arrest.  AIDS NEVER has been a risk for blood donors!





    BLOOD TRANSFUSIONS

   Blood is comprised of liquid plasma containing clotting factors,
other proteins and three types of cells.  The red blood cells (RBC)
contain hemoglobin, the oxygen-carrying protein that gives blood its
red color; the white blood cells (WBC) act to fight infection and
produce antibodies; and the platelets--along with the clotting
system--help to stop bleeding.

   When bleeding occurs or the cells are low in number, transfusion
may be required.  Among the types of transfusions are whole blood,
packed RBC's, platelets, WBC's and fresh frozen plasma.  Because of
allergic/toxic reactions and the risk of transmitting diseases such
as hepatitis, AIDS, malaria, syphilis, and babesiosis, transfusion
should be undertaken only when absolutely necessary.

   Whole Blood

   A unit contains 450 cc. (about a pint) of blood cells and plasma.
It is given primarily to persons who are rapidly hemorrhaging and
need both cells and clotting factors.  To minimize the risks of a
reaction, only typed cross-matched blood is used, except in extreme
emergencies when type O-negative is transfused.

   Despite careful testing, not all mismatches can be identified:
major transfusion reactions still occur on occasion.  They are
manifested by head, back and chest pain, weak pulse, shortness of
breath, kidney failure, jaundice and sometimes, shock and death.
Other side effects include fever, hives, asthma, infection, high
blood potassium, citrate intoxication (It is used to keep the blood
from coagulating.), phlebitis (blood clots in the vein) and fluid
overload.

   Packed Red Blood Cells

   A unit contains twice the concentration of RBC's as whole blood.
Therefore, more cells can be given in less volume. Packed RBC's are
the blood product of choice for patients with severe anemia.  One
unit raises the hematocrit (nl-45%) about two to four percent.  The
adverse effects are similar to those seen with whole blood, but there
is less risk of fluid overload. Persons who receive multiple
transfusions over many years may accumulate too much iron in their
system (hemosiderosis).

   Platelets

   Platelet transfusions are given to patients who are at risk for
bleeding due to temporarily low platelet counts, e.g. patients with
leukemia or other blood diseases and persons receiving cancer
chemotherapy.  Fever, chills and allergic reactions are not unusual.

   White Blood Cells

   Unable to fight life-threatening infections, persons with by
extremely low WBC counts may receive transfusions of WBC's to tide
them over until their blood counts return to normal.  Among the
candidates are patients with leukemia and recipients of bone marrow
transplants.  Adverse reactions are common.

   Fresh Frozen Plasma

   Plasma transfusions containing clotting factors are given to
patients at risk for bleeding: e.g. persons who have received massive
transfusions of packed RBC's without plasma, individuals with severe
liver disease, and persons who overdose on "blood- thinning"
medications.  Hemophiliacs can receive just factor VIII, the clotting
factor they lack.

   Autotransfusion

   Persons who are planning elective surgery, for example cosmetic
surgery, can assure a supply of perfectly-matched blood for their
operation by donating blood to themselves.  The blood is donated
weeks ahead of the surgery and stored in the blood bank until it is
needed.





   VARICOSE VEIN SURGERY

   A varicose vein is a vein that is swollen, enlarged and tortuous.
The superficial veins in the legs (near the surface of the skin) are
often affected.  Varicosities develop after phlebitis (blood clots)
or obstruction of the veins deep inside the leg, and in repsonse to
certain heart valve and arterial abnormalities.  However, in most
cases they arise spontaneously due to inadequate function of the
small valves and/or walls of the superficial veins.  Predisposing
factors include family history, female gender, obesity and pregnancy.

   Although there may be no symptoms, aching, cramps, swelling and in
severe cases, blood clots and bleeding may occur.  The symptoms are
aggravated by standing, leg crossing and constricting hosiery.  Skin
ulcers may be a consequence of long- term swelling, infection or
injury.  Fortunately the majority of patients with varicose veins
have no symptoms; their major concerns are cosmetic.

   Treatment

   There are no effective medications.  Avoidance of aggravating
factors, leg elevation and support stockings are recommended.
Sometimes the doctor will prescribe elastic hose (TEDS) or
special-fitting compression stockings (Jobst).  Definitive therapy
requires interruption of the blood flow through the enlarged veins.
In patients with normally functioning, non- obstructed deep veins,
this is accomplished by sclerotherapy and/or vein stripping surgery.
Other procedures are employed if there is obstruction in the deep
venous system.

   Sclerotherapy

   With this outpatient method, an irritating liquid is injected into
the veins to cause scarring (sclerosing) and, eventually,
obliteration.  Anesthesia is not necessary, and there are no
incisions.  About ten injections are made on the first occasion.

   Afterwards the legs are wrapped firmly with elastic bandages to
keep the veins from reopening.  Walking is encouraged after the first
48 hours.  The leg wrapping stays on continuously for three weeks, at
which time the legs are examined and wrapped again.  At six weeks the
bandages are replaced with elastic stockings.

   About 40 percent of patients with varicose veins are candidates
for this therapy; those who have enlarged veins which cannot be
compressed by the bandages will not respond.

   Complications include allergy to the irritating liquid,
misplacement of the injection, tenderness at the injection sites,
blood clots, bleeding, skin discoloration, difficulty with the
bandages and recurrence.

   Vein Stripping

   About 60 percent of patients require surgical removal of the
varicosities with a vein stripper, a long wire with interchangeable
heads of different sizes.  With the patient under general or spinal
anesthesia, the surgeon inserts the stripper into a varicosity
through a small incision at the ankle and threads it upward to the
point where the vein enters the deep venous system behind the knee
and/or in the groin.  When the stripper reaches the end of the vein,
the small head is exchanged for a large one and the stripper is
withdrawn along the path of the vein.  As a result, the varicosity is
gradually pulled out, or stripped, along its length.  The surgeon may
also have to tie the superficial veins closed at the groin and knee.

   The bandages stay on for a couple days until the patients go home.
 Elastic stockings are advised for walking for the first two weeks.
Complications include risks of anesthesia, bleeding, infection, blood
clots and recurrence.

   Results

   Despite appropriate indications, there is a significant rate of
recurrence.  With sclerotherapy good-excellent results are obtained
in over 90 percent of patients during the first year, but the figure
drops to ten percent at ten years.  For stripping the results are
approximately 95 and 65 percent respectively. Often sclerotherpy and
vein stripping are used together.





   EXPLORATORY ABDOMINAL SURGERY

   (Laparotomy)

   The operation to explore the abdominal cavity and its major organs
through a surgical incision in the abdominal wall is called a
laparotomy.

   Major Indications

   1) unexplained abdominal pain.  2) fever of undetermined origin.
3) suspected cancer.  4) staging of certain cancers of the lymphatic
system (Hodgkin's disease).  5) life-threatening abdominal
emergencies, e.g. rapid bleeding.

   In the absence of an emergency, exploratory laparotomy should be
reserved for those patients in whom available non-surgical means of
diagnosis have been exhausted.

   Procedure

   The surgeon prepares to undertake several different operations,
depending on what is or is not discovered, for example--removal of a
tumor, appendectomy, nothing but look. Obviously, informed consent is
an important consideration.

   With the patient under general anesthesia, the entire abdominal
cavity is examined through a vertical midline incision. The surgical
team can view and/or feel the liver, spleen, gall bladder, stomach,
intestines, pancreas, kidneys, urinary bladder, uterus, ovaries,
blood vessels and lymph nodes.  Biopsies (tissue specimens) can be
taken from many of these organs.  The entire operation may take only
an hour if the surgeon just looks or takes biopsies.

   Postoperative Care

   Afterwards the patient will have incisional pain that requires
injections of painkillers.  A general diet can be resumed in a couple
of days.  The stitches come out in about a week.  Although the entire
hospitalization may take only five days, there is a great deal of
variation depending on the findings and the type of operation.
Strenuous activity is prohibited for six weeks.

   Complications

   Infection, bleeding, injury to arteries, veins and nerves, wound
falling apart, reactions to anesthesia, heart problems.  As with any
major operation, there is a small risk of death.

   Perspective

   As mentioned above, unless there is an emergency, exploratory
surgery is usually the last step in a diagnostic evaluation. Studies
such as blood tests, abdominal and intestinal X-rays, CAT scans,
liver/spleen scans, ultrasound, scoping procedures and angiography
(dye X-rays of the blood vessels) can be performed prior to the
operation.  In most cases one or more of these tests will confirm or
at least point to the diagnosis.  If laparotomy does not document a
physical cause for the symptoms, the patient must be willing to
consider a psychological explanation.





   PEPTIC ULCER SURGERY

   Non-cancerous peptic ulcers affect ten to fifteen percent of the
population.  The duodenum, the first part of the small intestine, and
the stomach are involved about eighty and twenty percent of the time,
respectively.  Although avoidance of factors that increase ulcer
formation and stomach acidity (tobacco, alcohol, aspirin) and
treatment with medication (antacids, cimetidine) are often curative,
recurrence is not unusual.

   Indications for surgery include failure to heal with medication,
life-threatening hemorrhage, perforation and obstruction due to
scarring.  Besides dealing directly with these complications, ulcer
operations are aimed at decreasing stomach acidity.  This is done by
severing the acid-stimulating nerves to the stomach and/or by removal
of the stomach.  Some of the more common operations are discussed
below.

   Gastrectomy

   Total gastrectomy is the removal of the entire stomach. Rarely
done for benign peptic ulcers, its most common indication is cancer
of the stomach.  Subtotal gastrectomy refers to resection of the
distal 2/3 to 3/4 of the stomach and sewing the upper remnant to
either the duodenum or the jejunum, a more distal segment of small
intestine.  Antrectomy is the removal of just the antrum, the distal
forty percent of the stomach that contains gastrin-producing cells.
(Gastrin is a potent acid- stimulating hormone.)  The latter two
operations often are combined with vagotomy (see below).

   Vagotomy

   The vagus nerves course from the brain through the chest to the
abdomen where they stimulate the stomach to make acid and propel food
into the duodenum.  Cutting these nerves (vagotomy) decreases stomach
acid.  But because vagotomy also decreases the ability of the stomach
to empty into the intestine, it usually is combined with
pyloroplasty--a procedure in which the pyloris, the channel between
the stomach and duodenum, is incised and sewn back together in such a
way to facilitate emptying.  Highly selective or proximal vagotomy
refers to severing just the vagus nerve fibers which supply the
acid-producing portion of the stomach, leaving the remaining fibers
intact for normal stomach emptying.

   Postoperative Care

   Ulcer operations are considered major surgery and, as such,
require general anesthesia.  As with any abdominal operation, the
intestinal tract doesn't move normally for the first few days after
the operation.  And the problem is compounded somewhat by the
narcotic injections required for incisional pain. Consequently, a
nasogastric tube (stomach drainage tube passing through the nose) is
required until the bowels begin to work again.  Typically, foods and
liquids are withheld for three to four days, after which the diet is
slowly advanced.  Intravenous fluids are given until a regular diet
is tolerated.  The average length of hospitalization is about seven
to ten days.  Full activities are resumed in six weeks.

   Applications and Results

   1) Stomach Ulcers -- Subtotal gastrectomy is the standard
operation; vagotomy is added if a duodenal ulcer is also present.
Good results are obtained in about 95 percent of the cases, and the
reoperation rate (for ulcer recurrence) is only about three percent.
Highly selective vagotomy without pyloroplasty has a slightly lower
success rate, but less complications.

   2) Duodenal Ulcers -- Subtotal gastrectomy and vagotomy and
antrectomy show recurrence rates of two to three percent and five
percent, respectively.  Vagotomy and pyloroplasty has been abandoned,
for the most part, in favor of highly selective vagotomy.  The latter
operation is considered by some surgeons to be the procedure of
choice for intractable duodenal ulcer without obstruction.
Recurrence rates of ten to fifteen percent have been reported.

   Major Complications

   Immediate complications are bleeding, abdominal infection, wounds
falling apart, effects of general anesthesia and bowel obstruction.
The mortality varies from zero to three percent depending on the
operation.  Long-term complications of gastrectomy include dumping
syndrome, i.e. pain, sweating, nausea, vomiting and diarrhea after
meals (5%); iron, vitamin B-12 or calcium deficiencies (30%);
diarrhea (10%); weight loss; bile gastritis (stomach inflammation);
and ulceration of the bowel (1-5%) at the site where it is sewn
together.





   GALLBLADDER REMOVAL

    (Cholecystectomy)

   Cholecystectomy, the operation to remove the gallbladder, is one
of the most common procedures performed by general surgeons. It is
still considered the mainstay of treatment for gallstones and
inflammation of the gallbladder.

   Major Indications

   1) inflammation or infection of the gallbladder (cholecystitis) or
its ducts.  2) cancer of the gallbladder.  3) injury to the
gallbladder.  4) large gallstones (greater than three cm. in
diameter).  5) gallstones in patients who have no symptoms, i.e. they
feel well (controversial).  Emergency surgery may be required for
indications 1) and 3).

   Preoperative Evaluation

   Patients with diseases of the gallbladder and bile system usually
undergo a number of diagnostic tests prior to surgery. Among them are
gallbladder X-rays, gallbladder scans, gallbladder ultrasound (sonar)
and upper GI X-rays.

   Procedure

   When it is possible to schedule the surgery ahead of time, the
patient is asked to be admitted to the hospital the day before the
operation.  Nothing is allowed by mouth after the evening meal.  An
injection is given, and an intravenous line is started just prior to
the operation.

   With the patient under general anesthesia, the surgeon removes the
gallbladder through a slanting incision beneath the right ribcage.
During the operation, a dye X-ray of the bile ducts helps the surgeon
determine if any stones remain.  In about one out of four cases, it
will be necessary to open (to look for stones) the common bile duct,
the large duct which empties bile into the first part of the small
intestine.  The whole operation takes several hours.

   Postoperative Care

   When the patient awakens from anesthesia, there will be a stomach
drainage tube passing out through his nose.  A bile drainage tube (T
tube) may be poking through the skin on the right side of their
abdomen.  Narcotic injections are required to relieve the expected
incisional pain.  No foods or liquids are allowed initially, but
after a couple days the bowels begin to work again and a regular diet
is gradually resumed.  The usual length of hospitalization is five to
seven days.

   Complications

   The mortality of gallbladder surgery in young persons is about
0.05 percent; with advancing age it can range as high as 6.0 percent.
 Complications occur in six to twenty percent of the cases.  These
include bleeding, abdominal infection, wound infection, retained
stone, injury to the bile ducts, leakage of bile and the usual risks
of major surgery and general anesthesia. About five percent of
patients do not have relief of their symptoms.

   Alternatives

   For many people who have small gallstones, but no symptoms,
watchful waiting is reasonable.  Only about ten to twenty percent of
these individuals will develop gallbladder pain or complications over
the ensuing twenty years.  Pills that dissolve gallstones can be used
in about fifteen percent of patients, but they are partially or
completely effective only about 40 percent of the time.

   Cost: approximately $4500





   LIVER BIOPSY

   A liver biopsy is the removal of a small sample of liver tissue
for special microscopic examination.  When studies such as blood
tests, liver scans, CAT scans, X-rays and ultrasound (sonar) fail to
yield adequate information, it can be a valuable test.  Liver biopsy
helps establish the patient's diagnosis in about four out of five
cases.

   Other than major abdominal surgery under general anesthesia, there
are two ways by which the liver specimen can be obtained: needle
biopsy through the skin and directed biopsy using laparoscopy.  With
the latter method, the sample is removed under direct visualization
of the liver through a long flexible fiberoptic tube (laparoscope)
inserted into the abdominal cavity.

   This discussion will deal only with needle biopsies through the
skin; laparoscopy is reviewed in detail in a separate article.

   Major Indications

   1) liver enlargement.  2) unexplained hepatitis.  3) suspected
cancer.  4) inherited liver diseases.  5) jaundice.

   Contraindications

   1) bleeding disorder.  2) uncooperative patient.  3) infection in
right lower lung or in the abdomen near the liver. (The needle could
carry bacteria into the liver.) 4) abdominal fluid collections.  5)
certain types of jaundice.

   Procedure

   Because a period of observation is required after the test, needle
biopsies are done in the hospital.  With the patient lying on his
back, a local anesthetic is injected into the skin at the site of
entry--usually in between two ribs of the right lower chest.  Then
the patient is instructed to exhale and hold his breath while the
biopsy needle is inserted through a small incision in the skin and
thrust rapidly into and out of the liver.  Because the liver is
located in the upper abdomen, directly underneath the right
diaphragm, the course of the biopsy needle actually passes through
the chest cavity.  But the needle passes through so quickly--staying
in the liver for only a second--that the pain is not severe.

   The biopsy technique may differ slightly depending on the anatomy
of the liver and type of needle used.  In patients with liver
enlargement, an entry site below the ribcage may be chosen. Sometimes
a specific area of the liver is sampled by using ultrasound or CAT
scan X-rays to guide the biopsy.

   At the end of the procedure a bandage is applied, and the patient
is asked to lie on his right side.  There is a 24-48 hour observation
period.

   Complications

   During the first day, about 25 percent of patients will experience
pain in the liver or right shoulder.  It is usually short-lived.
Serious complications occur in about 0.3 percent of cases.  Among
them are reactions to the anesthetic, bleeding into the abdominal or
chest cavities (0.2 percent), collapsed right lung, leakage of bile,
shock, infection, injury to abdominal organs and blood vessels, and
broken needles.  The overall mortality is estimated to be 0-0.3
percent.





   SPLENECTOMY

   (Removal of the Spleen)

   The spleen is a lymph organ located in the abdominal cavity
beneath the left ribcage.  A valuable part of the immune system, it
produces antibodies and filters the bloodstream of bacteria and
damaged and aged blood cells.

   When the spleen is absent or poorly functioning, there is an
increased susceptibility to life-threatening bloodstream infection by
certain bacteria.  This risk of infection is exaggerated in the first
two years after splenectomy and in infancy and childhood, before full
immunity has had time to develop.  As a result, splenectomy, the
surgical removal of the spleen, is an operation that should be
performed only when absolutely necessary.

   Major Indications

   1) ruptured spleen.  2) hypersplenism, a condition characterized
by low blood counts due to pooling of blood cells in an enlarged
spleen.  3) certain blood diseases.  4) some cancers of the lymph
glands, e.g. Hodgkin's disease.  5) splenic abscess (collection of
pus).

   Preoperative Vaccination

   When splenectomy is an elective operation in persons with
functioning immune systems, vaccination against several types of
bacterial infection is recommended at least two weeks prior to the
operation.  Because many disorders that necessitate splenectomy may
also diminish the protective response to vaccines, preoperative
immunization is of uncertain value in some patients.

   With the patient under general anesthesia, an incision is made in
the upper abdomen; the one most commonly used slants beneath the left
ribcage.  The spleen is removed by severing its ligamentous
attachments and tying its artery and vein.  About 10- 30 percent of
patients have a small second or accessory spleen that also needs to
be taken out.  Ruptured and large spleens can present technical
problems.  The surgeon has to be careful not to injure the stomach
and pancreas.  Bleeding may be profuse, requiring transfusions.

   Postoperative Care

   Nothing is given by mouth until the bowels begin to work a few
days after surgery.  And activity is limited so as not to strain the
incision.  As with most surgery, pain shots are required initially.
The total hospitalization lasts about four to seven days.

   Complications

   Immediately after splenectomy, the platelet count (cells in the
blood which act to stop bleeding) may rise temporarily, creating a
risk of blood clots.  There is also a characteristic change in the
microscopic appearance of certain blood cells. This is permanent and
easily detectable on future blood tests. Bleeding, infection of the
wound and abdomen, pneumonia, collapsed lung and injury to the
stomach and pancreas are the most common short-term complications.





   APPENDECTOMY

   (Removal of the appendix)

   About one out of every fifteen persons develops appendicitis
sometime in his lifetime.  Appendectomy remains the treatment of
choice.

   Indications

   1) appendicitis.  2) tumors, very rarely.  Sometimes, with the
patient's permission, the appendix is taken out incidentally during
another operation, e.g. hysterectomy.

   Procedure

   Appendicitis is a serious disease that requires prompt treatment
to prevent the appendix from bursting.  Appendectomies, therefore,
are almost always done as emergency operations.

   With the patient under general anesthesia and receiving
antibiotics, the surgeon makes a three to five inch long, vertical,
horizontal or slanting incision through the skin in the right lower
portion of the abdomen.  The muscles are split open and the abdominal
cavity entered and explored.  The appendix is tied off with stitches,
then cut, leaving only a stump connected to the first portion of the
large intestine (cecum).  If all is well, the wounds can then be
closed, the whole operation taking less than an hour.

   If the appendix has perforated or burst prior to the operation, an
abscess (collection of pus) may have developed.  It is drained of
pus, if possible, such that the remainder of the abdomen is not
contaminated with the infection.  A rubber drainage tube(s) may be
left place.  Occasionally, in an adult the infection is so severe
that only drainage is accomplished; the wound is left open.  In these
instances the appendix is left in place and is removed at a later
date after a course of antibiotic therapy.

   Recovery

   In the uncomplicated case, the patient begins to take liquids and
have bowel movements in a day or two.  Medication is prescribed for
pain along the incision.  The average length of hospitalization is
about four days.

   Complications

   Because appendicitis can be difficult to differentiate from
several other causes of right lower abdominal pain, and because risks
are minimized by operating early in the course of the infection,
approximately twenty percent of appendices removed at surgery are, in
fact, normal and not inflammed.  This rate of "misdiagnosis" is
expected and comes about despite the best medical and surgical care.
Even with this aggressive approach, a similar percentage of patients
are found to have burst appendices at the time of surgery.

   The risk of complications is directly related to whether the
appendix is intact or perforated (5-10% vs. 30%).  The overall
mortality is less than one percent, with most deaths occurring in
patients over 50 years old.  Infection of the wound is the most
common complication.  It occurs in about ten percent of the cases.
Other complications include abscess formation, bleeding, wound
falling apart, blood clots, bloodstream infection (sepsis) and bowel
obstruction.





   COLON OPERATIONS

   (Large Intestine)

   Anatomy & General Information

   The colon or large intestine is a five foot length of bowel that
begins in the right lower part of the abdominal cavity where the
ileum, the last section of the small intestine empties into it at the
cecum, near the attachment of the appendix.  The ascending colon
courses upward from the appendix and cecum toward the upper abdomen
where it enters transverse colon.  The descending colon receives
fecal material form the transverse colon under the left ribcage near
the spleen and courses down to the sigmoid colon, rectum and anus.

   Operations on the colon or large intestine are among the most
common surgeries performed.  Cancer, bowel obstruction,
diverticulitis, benign growths (polyps), colitis, injury, perforation
and bleeding are some of the major indications.

   Colectomy refers to removal of all or a part of the colon.
Colostomy is a procedure in which the colon is sewn to a hole in the
wall of the abdomen such that stool passes into a plastic bag taped
to the skin.  The opening is called the stoma.  An ileostomy is
similar to a colostomy, except that the ileum is used to create the
stoma.

   Colectomy

   Removal of the colon is a major operation performed under general
anesthesia.  Antibiotics are given and blood transfusions are
required.  Just how much colon is removed depends on the indication
for the operation and the location of the disease process.  For
example, hemorrhage from a localized site may be treated with
resection of just a small segment of bowel; whereas, cancers or
diseases that involve large parts of the colon may require removal of
half (right or left hemicolectomy) or all of the colon (total
colectomy).  The remaining intestine is sewn or stapled together.
When a disease process involves the lower sigmoid colon or rectum, a
transverse colostomy (transverse colon forms the stoma) is often
necessary because either the rectum must be removed or the
reconnection of the ends of the bowel is technically difficult.  A
total colectomy may leave the patient with an ileostomy.

   Colostomy and Ileostomy

   There are two major types of colostomies: temporary and permanent.
 Temporary colostomies are used either to divert the fecal stream
away from the diseased segment of bowel or to decompress a bowel
obstruction.  When the disease process resolves (six weeks), the
colostomy is taken down and the colon is reconnected.  Bowel
perforations and infections are examples of disorders which often
necessitate temporary colostomy.

   Permanent colostomies serve the functions of an anus when
reconnection is not possible; for example, in patients with cancer of
the rectum.  Postoperatively, the patient must learn to care for the
stoma and manage the colostomy bag.  The average length of
hospitalization is ten to fourteen days.

   As mentioned above an ileostomy is created when the entire colon
is removed.  (Certain types of colitis may necessitate this
operation.)  However, a recently developed technique, mucosal
proctectomy with ileoanal anastomosis, may offer an alternative. With
this operation the ileal end of the small intestine is sewn directly
to the anus avoiding the necessity of the stoma and external drainage
bag.

   Major Complications

   Risks of anesthesia, infection, bleeding, bowel obstruction and
perforation, leakage of stool, failure of the stoma to heal, wound
falling apart, injury to the urinary tract, hernias within the
abdomen, spread of cancer and chronic diarrhea.





   HERNIA OPERATIONS

   A hernia is defined as the bulging of the contents of a body
cavity through the boundaries that contain them.  It results from an
acquired or inborn weakness of the supporting tissues and muscles.
In common usage, the term hernia refers to a protrusion of the
intestines through the wall of the abdomen.

   Ruptures in the groin--inguinal and femoral hernias--are most
common.  Among the other types are ventral (in the middle of the
abdomen), umbilical (around the navel) and incisional (at the site of
an old surgical scar) hernias.

   A hiatal hernia occurs when the stomach slides or pokes into the
chest cavity through the diaphragm.  For more information, consult
the article on heartburn in the "Symptoms" section.

   The signs and symptoms a person with a hernia experiences are
aching and bulging in the affected area.  The protrusion is
exaggerated by coughing, laughing and straining.  In men a groin
hernia may cause swelling in the scrotum.

   The major complications of hernias are incarceration, bowel
obstruction and strangulation.  Incarceration occurs when the loop of
herniated intestine gets stuck and cannot be pushed back into the
abdomen.  As a result, life-threatening intestinal obstruction and
interference with the blood supply (strangulation) may develop.  To
prevent these serious problems, surgical repair is recommended for
all patients who are well enough to tolerate the operation.  A truss
is employed only for those in whom surgery is contraindicated.

   Operation for Hernia

   For groin hernias, the surgery is performed in the hospital by a
general surgeon with the patient sedated and under local anesthesia.
Overweight persons and those with recurrent or complicated hernias
will require general anesthesia.

   There are many types of operations for hernias in the groin. Which
one the surgeon chooses depends on the age of the patient and the
type and size of the rupture.  In general, some tissue is removed and
the hole in the abdominal wall is closed and reinforced through a
three to four inch long incision. Occasionally, artificial mesh will
be used to patch the defect. Both sides can be repaired at the same
time if necessary.

   Postoperative Care

   For groin hernias, the average length of hospitalization is four
to five days; it is one to two days for children.  Some incisional
pain and swelling of the scrotum are to be expected, and temporary
difficulty with urination is not unusual.  There is a six week
recuperative period during which strenuous activity is prohibited.

   Complications

   The major complications are risks of anesthesia, bleeding,
infection, wound falling apart, and injury to the bowel, nerves,
blood vessels and vas deferens.  Rarely the blood supply to a testis
may be compromised.  The overall mortality is about 1 in 400, with
most of the deaths occuring in ill, older patients. Emergency surgery
for bowel obstruction due to incarceration is fraught with
complications.

   Results

   Despite good surgical technique, about one to ten percent of groin
hernias recur.





   HEMORRHOIDECTOMY

   Hemorrhoids are swollen blood vessels in the lower rectum. About
50 percent of the population over age 50 are affected. Predisposing
factors are straining at stool, chronic liver disease, pregnancy,
diarrhea and family history.  While hemorrhoids often are not
bothersome, they may enlarge, ache, itch, bleed, become inflamed,
form blood clots (thrombose) or prolapse (fall out) through the anus.
 Stool softeners, high fiber diets and suppositories may alleviate
mild symptoms, but surgical therapy usually is necessary to deal with
complications.

   Rubber Band Ligation

   Only internal (originating well inside the anus) hemorrhoids
should be removed by this outpatient technique.  After an anoscope
(tube for viewing the lower rectum) is inserted into the rectum, the
hemorrhoids are grasped with a clamp and banded at their base.  No
anesthesia is required.  Over the next five to ten days the
hemorrhoids fall off spontaneously.

   There may be a little aching and fullness which can be relieved by
mild analgesics and hot baths.  And bleeding may occur as the vessels
slough off.  Although several bandings at monthly intervals may be
required, the patients are cured about 90 percent of the time.
Bleeding and pain occur in less than five percent and activity is not
restricted.

   Sclerotherapy

   A painless injection of irritating liquid is given into the
membranes of the rectum to cause scarring (sclerosis) and
obliteration of the hemorrhoids.  As with the rubber technique, only
internal hemorrhoids can be treated by this method.  Results are
better for bleeding than they are for prolapse.

   Closed Hemorrhoidectomy

   The traditional method of hemorrhoid surgery, this operation is
indicated when the symptoms are severe or associated with other
rectal diseases that require surgery.  It is performed in the
hospital with the patient under local or general anesthesia. The
hemorrhoidal tissues are excised and repaired with stitches. The
average hospital stay is one to four days; healing takes four weeks.
Complications include bleeding (4%), urinary retention (10%),
infection, incontinence, wound falling apart, scarring and a hole or
fistula in the rectum.

   Cryotherapy

   This technique involves the destruction of hemorrhoid tissue by
freezing, e.g. liquid nitrogen.  A local anesthetic is used. Pain
medication may be required afterward, and until the hemorrhoidal
tissues degenerate, there is a foul-smelling rectal discharge.
Activity is limited for a couple of weeks. Cryotherapy is a
reasonable alternative for patients with internal or external
hemorrhoids who cannot tolerate traditional hemorrhoidectomy.

   Thrombosed Hemorrhoids

   When blood clots form in hemorrhoidal vessels, the patient notices
a tender blue lump adjacent to the anus.  In the absence of gangrene
or infection, excision under local anesthesia is indicated only if
the external hemorrhoids are involved and the clot is of recent
onset.  Otherwise, rest and hot baths are prescribed.  After the
initial improvement, definitive surgery can be scheduled.





   KIDNEY TRANSPLANTATION

   About 55-60,000 Americans receive long-term kidney dialysis at a
cost of over three billion dollars.  Despite advances in the
management of chronic kidney failure with dialysis (artificial kidney
machine, or peritoneal), only about 60 percent of the nondiabetic and
35 percent of the diabetic patients are able to achieve levels of
activity beyond that required for self care. Over 80 percent of
dialysis patients have their regular treatments at a hospital, and
multiple medications and restrictive diets are the rule.  The annual
mortality rate is about five to ten percent.

   The past two decades have brought great advances in kidney
transplantation; the operation is now performed routinely at many
hospitals.  About 5,000 are done each year in the U.S.

   While successful transplantation offers many advantages over
dialysis in regard to overall hospitalization time and the correction
of kidney function, hormonal imbalances and blood and nutritional
abnormalities, there are often serious complications. Besides the
usual risks of anesthesia and technical failure of any major
operation in a chronically ill patient, there are special concerns
for rejection of the donor kidney.  Although blood and tissue typing
are employed to match the donor and recipient, these methods do not
always predict the recipient's immune response to the new kidney.

   To prevent rejection, all transplant patients receive potent
medications to suppress their immune system.  Unfortunately, the
drugs also weaken the recipient's resistance to infection and cancer.
 Life-threatening complications may result.

   Candidates for Transplant

   The ten to twenty percent of dialysis patients who are fully
active and employed rarely desire, or are advised to seek, a
transplant.  For the remaining 80 percent, the decision is
individualized depending on the preferences, age, lifestyle and
co-existing medical conditions of the potential recipient as well as
the availability of donor kidneys and the local success and
complication rates of the operation.

   Contraindications to transplantation include reversible kidney
failure, ongoing infection, cancer and severe heart, lung, liver,
intestinal, neurologic or psychiatric disorders.  Age over 50-55
years, urinary tract abnormalities and diabetes are relative
contraindications.  Only 35-50 percent of new kidney failure patients
are potential candidates for transplantation.

   Kidney Donors

   In the U.S. about a third of the transplants are received from
living-related family members with compatible blood and tissue types.
 The donor must volunteer, be in good health, and have no kidney or
urinary tract abnormalities.  Aside from the risks of the operation
to remove the kidney, there are not believed to be any deleterious
effects; however, most donors have not been observed for more than
ten to fifteen years.  Recipients of kidneys from living related
donors have the best results in terms of mortality and incidence of
rejection.

   Unfortunately, most (70 percent) transplant candidates do not have
relatives who meet the donor requirements.  These individuals are
placed on a waiting list to receive a cadaver kidney.  Because
recipients of cadaver kidneys are not chosen first come-first serve,
but according to which one best matches the cadaver's tissue and
blood type, many dialysis patients wait months to years for the right
kidney.

   Acceptable kidneys must come from deceased individuals less than
55 years of age who have no evidence of kidney disease, infection,
high blood pressure, atherosclerosis or cancer.  The kidneys must be
harvested from the cadaver and cooled to four degrees C. within 30
minutes of death.  And with current cold preservation techniques, the
kidneys must be transplanted within 48-72 hours.  Although finding
matched cadaver organs has been facilitated by a national computer
network and by increased public awareness of the need for organ
donation, donors are still in demand.

   Preparation for Surgery

   The recipient undergoes a thorough general medical evaluation to
assure that they are in the best possible shape to tolerate the
transplant.  Medical treatment and/or surgery for other disorders may
be advisable.  For unknown reasons, multiple blood transfusions prior
to transplantation significantly decrease the incidence of rejection
of the new kidney.  Patients who are to receive kidneys from living
relatives may be transfused with donor-specific blood.

   Operation

   The surgery is scheduled electively when the kidney transplant is
from a living related donor, emergently when it is from a cadaver.
With the patient under general anesthesia, the transplant surgeon
places the donor kidney near one of the recipient's diseased kidneys
above the hip bone.  The artery and vein of the donor kidney are
grafted (sewn with stitches) to a major branch of the aorta called
the iliac artery.  In most cases the ureter, the tube which leads
from the kidney to the bladder, is sewn to the recipient's bladder to
allow for a free-flow of urine.

   Although the diseased kidneys may be removed if they are
chronically infected, large, responsible for severe high blood
pressure or associated with certain urinary tract abnormalities, they
are usually left in place.

   Postoperative Care

   Immunosuppressive medications are started prior to the operation
on the day of surgery to decrease the likelihood of rejection of the
grafted kidney.  Typically, prednisone, a steroid cortisone-like
medicine, is prescribed in combination with azathioprine (Imuran) or
cyclosporin A.  The latter drug is relatively new; studies show that
it prevents rejection better with less risk of infection.

   The average length of hospitalization is two to three weeks. If
all goes well, the doses of the medications are gradually decreased,
but are continued indefinitely.  Episodes of rejection, evidenced by
deteriorating kidney function among other problems, may complicate
the course at any time after the operation, but they are more common
during the first three months.  They are treated with increased doses
of immunosuppressive medication, or in refractory cases, by removal
of the transplant.

   Complications

   Among the operative complications are narrowing, damage to or
clots in the artery and vein to the grafted kidney; injury to the
ureter and bladder; bleeding; blockage of the flow of urine; risks of
anesthesia; collection of lymph fluid around the kidney; and death.
One or more of these occurs 15-25 percent of the time.

   The major postoperative complications are life-threatening viral,
bacterial, fungal and parasitic infections; kidney rejection;
recurrence of the original kidney disease in the grafted kidney;
kidney rupture; high blood cholesterol and calcium; blood clots; high
blood pressure; peptic ulcers; and heart and liver disease.
Additional side effects of the medications are liver, kidney and bone
disease; a tendency to develop cancer; cataracts; diabetes; weight
gain; and acne. Infection and heart disease are the leading causes of
death in transplant patients.

   Results

   The one year survival rate of transplant patients is 90-99 percent
for those receiving kidneys from living related donors and 85-90
percent recipients of cadaver kidneys.  The latter rate is comparable
to the survival of patients maintained on dialysis. A year after
transplant about 90 percent of the living donor kidneys and 60
percent of the cadaver transplants are still functioning.  The
figures are approximately 65 percent and 40 percent at five years.
The majority of transplant recipients are able to work.





   PROSTATE SURGERY (TURP)

   The prostate is a gland located at the outlet of the urinary
bladder just in front of the rectum at the base of the penis.  It
surrounds the proximal portion of the urethra, the passageway leading
from the bladder to the outside through the tip of the penis, and
contributes enzymatic juices to the ejaculate.

   The two major indications for prostate surgery (prostatectomy) are
benign prostatic hypertrophy (BPH) and cancer.  BPH is a noncancerous
enlargement of the gland that occurs in 50 percent of males over the
age of 50; with advancing age, just about all men develop this
problem.  The primary problem is obstruction to the normal flow of
urine through the urethra.  This is characterized by urinary
dribbling, frequency, infection, pain and, sometimes, incontinence
(inability to hold the urine) or total obstruction.  Cancer of the
prostate gland affects ten to fifteen percent of men over age 50 and
as many as 60 percent by the eighth decade.

   Transurethral resection of the prostate (TURP) is the most common
method of prostatectomy for urethral obstruction due to either BPH or
cancer.  Although it may be curative for small nodular cancers,
radical prostatectomy operations through incisions in the lower
abdomen or groin are preferred for most early stage malignancies.

   Procedure for TURP

   The operation is performed by a urologist with the patient lying
on his back, legs spread apart.  After the administration of spinal
anesthesia, the surgeon inserts the resectoscope--a long, rigid
fiberoptic tube with its own light source--through the urethral
opening at the end of the penis.  If the urethra is too narrow or if
there is a stricture, the scope may have to be inserted through a
small incision (perineal urethrotomy) made into the urethra at the
base of the penis.

   The surgeon removes slices of prostatic tissue by burning it
electrically (electrocautery) with a wire loop positioned at the end
of the resectoscope.  Even though bleeding may be profuse, continuous
fluid irrigation of the bladder through tubes connected to the scope
allows direct visualization of important structures.  The patient may
experience nausea and restlessness from absorption of the irrigation
fluid, but there is little pain unless the fluid escapes through the
outer capsule of the prostate.  The whole operation takes one to two
hours.

   Postoperative Care

   There is discomfort around the urethra, but no severe pain unless
there has been a complication.  The patient has a desire to urinate.
A rubber bladder catheter is in place for three to four days until
the urine clears of blood; sometimes bladder irrigation through the
catheter is required.  Frequently antibiotics are prescribed.
Hospital discharge occurs one day after the catheter is removed if
the act of urination is normal.

   Complications

   Partly because of the age of the patients undergoing this
operation, the overall complication rate is relatively high at
fifteen to twenty percent.  The incidence of adverse effects is
higher in patients who are older or in poor general health. Among the
problems which may occur are excessive bleeding (6%), urinary
infection (6%), urethral strictures (6%), incontinence (1-4%),
impotence (4-6%), heart trouble, blood clots in the veins and
chemical imbalance due to absorption of the irrigation fluid.  The
overall mortality is approximately one percent.





  VASECTOMY - MALE STERILIZATION

   The purpose of a vasectomy is to interrupt the flow of sperm from
the testes to the penis by cutting the connecting tubes called the
vas deferens.  By this means, it is hoped to prevent fertilization.

   Major Indications

   1) male sterilization.  2) prevention of postoperative or
recurrent epididymitis (inflammation of the small sac at the end of
the testicle).

   Preoperative Counseling

   Vasectomy is considered a permanent form of sterilization, and men
or couples who choose this method of contraception should approach
the operation in that light.  The decision to operate should not be
made hastily or during a time of emotional stress. Failure rates,
complications and alternatives (see below) must be understood.

   Operation

   Urologists (urinary tract surgeons) and some family physicians
perform this operation right in their offices.  It is done under
local anesthesia and takes only about 45-60 minutes.

   First, a one-half inch long incision is made in the skin of the
scrotum, just over the vas.  Next the vas is brought into view and
either clamped, cauterized (electrically burned) or cut and tied.
Frequently, a section of it is removed or excised. Finally, the skin
is sewn with dissolvable stitches.  Obviously, both sides must be
done; separate incisions are usually required. Pain during the
procedure is minimal.

   Postoperative Care

   There will be a little swelling and pain for a couple of days, and
strenuous activity is limited during this period.  Ice packs and an
athletic supporter are suggested.  Bruising over the operative sites
is not unusual for the first two weeks. Ejaculation should be limited
to a couple times a week for two weeks.  Most importantly, because
the sperm count does not drop to zero immediately, alternative means
of contraception must be practiced until the semen has been shown to
be free of sperm on two separate occasions.  Sperm counts are
routinely checked six and twelve weeks after surgery.  In general, at
least twelve to fifteen ejaculations are required before sterility
occurs.

   Sexual Function

   Because the male hormones are not affected, there is no physical
reason why vasectomy should adversely affect sexual desire or
fulfillment.  In fact, minimizing the risk of pregnancy, allows most
couples to enjoy sex more freely.  The volume of the ejaculate
decreases by only ten percent.

   Results

   About one in 400 procedures fails to work; the severed ends grow
back together and allow for fertilization.

   Reversibilty?

   Operations to reverse vasectomies are successful in achieving
pregnancy just over half the time.  An alternative to surgical
reversal is sperm banking.  If sperm is frozen prior to vasectomy,
its ability to fertilize is diminished only by about ten percent.

   Complications

   Bleeding (5%), infection, swelling and wound falling apart. In
about twenty percent of patients, a small granuloma (lump of
inflammation) will grow near the incision.  Antibodies to sperm may
develop, but their significance is uncertain.  Although vasectomized
monkeys have been shown to develop severe atherosclerosis when fed a
diet extremely high in cholesterol diet, a similar relationship
between sterilization and atherosclerosis and heart disease has not
been shown in humans. In fact, most studies find no long-term side
effects.

   Alternatives

   Female sterilization ("tubes tied"), the pill, condom, diaphragm,
IUD, sponge, etc.





   CIRCUMCISION

   Circumcision is the surgical removal of the foreskin of the penis.
 Despite the lack of a medical indication for this operation in
healthy newborn males with normal penile and foreskin anatomy, it is
often requested and performed for personal or cultural reasons.
Although it has been observed that circumcised men rarely develop
cancer of the penis, and that their sexual partners may be less
likely to develop cancer of the cervix, a cause-and-effect
relationship has not been established.

   The most common medical indication for circumcision at any age is
phimosis, a narrowing of the foreskin over the end of the penis such
that it cannot be pulled back.  Infection, swelling, scarring and in
extreme cases, obstruction to urination may result.  When there is
severe pain or infection, a tension- releasing incision may be done
as an emergency, with circumcision reserved for a later date.

   Procedure

   Adults -- A urologist (specialist in surgery of the urinary tract)
performs this operation right in the office.  After the penis is
washed with an antiseptic, the foreskin is injected with a numbing
local anesthetic.  The excess skin is removed by a circumferential
incision at the corona, the ring-like prominence at the base of the
glans.  Bleeding is controlled by electrocautery (electrical
burning), and dissolvable stitches are placed around the corona.
Despite how it sounds, the surgery is not very painful and only takes
about fifteen minutes. Occasionally, short-term hospitalization and
general anesthesia may be required.

   Newborns -- Circumcision may be done within 24-48 hours of birth.
Local or regional (an injection at the base of the penis that numbs
the entire organ) anesthesia may be used.  The surgery is facilitated
by employing a Yellin clamp, a metal, ringed instrument that fits
over penis around the corona.  No stitches are necessary.

   Complications

   Bleeding, infection and loss of skin occur rarely.

   Postoperative Care

   Sexual activity should be avoided until healing is complete--
about seven to ten days.





   AMNIOCENTESIS

   Amniocentesis is the removal of fluid from the amniotic sac ("bag
of waters") via a long needle inserted through the abdomen and wall
of the pregnant uterus.  The fluid sample can be studied for chemical
and genetic abnormalities as well as for fetal maturity, well-being
and gender.  Early in pregnancy this information may help the parents
make an informed decision about abortion.  Prior to birth it can help
the physicians plan for possible complications of the delivery and
the care of the newborn baby.

   Indications During the Second Trimester of Pregnancy

      (14th to 18th Weeks)

   1) pregnant women over age 35.  2) previous birth of a
chromosomally abnormal child.  3) known chromosomal abnormality in
either parent.  4) family history of chromosomal disorders. 5)
history of multiple miscarriages.  6) previous birth of a child with
multiple inborn malformations.  7) women with male relatives with
certain blood or muscle diseases, e.g. hemophilia, muscular
dystrophy.  8) women at risk for bearing a child with other inherited
diseases such as sickle-cell anemia and Tay-Sachs disease.  9) women
at risk for bearing a child with a spinal disorder, e.g. spina
bifida.

   Indications After 30 Weeks of Pregnancy (3rd trimester)

   1) determination of fetal well-being in cases of fetal distress or
late onset of labor.  2) suspicion of fetal disease due to a blood
group mismatch between mother and fetus (hemolytic disease of
newborn).  3) assessment of fetal maturity if early delivery is
contemplated.

   Important Note

   Many fetal abnormalities and diseases are not detectable by this
test.  A normal result does not guarantee a normal child.

   Procedure

   Many obstetricians are qualified to perform amniocentesis. The
test is done in the office or at a hospital with or without local
anesthesia.  An overnight stay is not necessary.  First, ultrasound
(sonar) of the uterus and fetus is done to locate the fetus, amniotic
sac and placenta.  Then a long, thin needle is introduced through the
abdomen into the amniotic sac with the guidance of the ultrasound
pictures.  There is very little discomfort.  Finally, a small bit of
fluid is withdrawn through a syringe, and the needle is removed.
Afterwards the woman is observed for 10-30 minutes and advised to
take it easy for 24 hours.  She should watch for bleeding, fever,
fluid leakage and pain.

   Complications

   A large study at the National Institutes of Health has shown no
statistical increase in the rate of miscarriage, stillbirths, fetal
deaths, birth defects or abnormal development during the first year
of life.  Vaginal bleeding and leakage of amniotic fluid occur in
less than two percent of women.  Rare complications have included
fetal and maternal bleeding, miscarriage (1%), premature labor,
uterine infection, fetal injury, ruptured membranes and blood group
mismatch sensitization in Rh negative fetuses of Rh positive mothers.





   CESAREAN SECTION

   Cesarean section is the delivery of an infant through incisions in
the abdominal wall and uterus.  It is a major operation that is
performed when vaginal delivery is unsafe for mother or child.  As
techniques such as fetal monitoring, ultrasound and amniocentesis
have developed for recognizing the maternal and fetal complications
of pregnancy and delivery, the incidence of C-sections has climbed.
Another major factor has been the increase in the percentage of women
who are delivering for the first time--a group that is much more
likely to have an indication for this operation.  About ten to twenty
percent of all deliveries in the U.S. now occur by C-section.

   Major Indications

   1) early delivery required for maternal or fetal disease, e.g.
diabetes or blood group mismatch, when vaginal delivery is not
possible.  2) the infant is too large, or the birth canal too small,
for safe passage.  3) the fetus is in distress.  4) failure of labor
to progress despite medication.  5) uterine bleeding from an abnormal
or malpositioned placenta.  6) uterine infection.  7) previous
C-section.

   The last indications deserves further discussion.  Because a scar
in the uterine muscle from a previous operation weakens the uterus
and predisposes it to rupture from the force of contractions during
labor, once a woman has had a C-section, she may require one for her
subsequent pregnancies.  However, for women in whom the initial
indication for C-section is no longer present, and the scar on the
uterus is in a favorable location, the risk of uterine rupture is
minimal and vaginal delivery can usually be accomplished safely.

   Procedures

   C-sections may be done as elective or emergency operations. With
the woman under general or spinal anesthesia, the obstetrician makes
a vertical incision on the abdomen from just below the navel to above
the pubic bone.  Occasionally a horizontal, lower abdominal incision
is used.  The uterus is then opened and the child delivered.  From
incision to delivery takes about five to fifteen minutes.  Next the
uterus is explored and the placenta removed by hand.  Medication is
given to shrink down the uterus and diminish bleeding.  While the
newborn is being cared for, the obstetrician repairs the uterine and
abdominal wounds.

   Postoperative Care

   Pain shots are required initially.  Breastfeeding can be started
the next day.  Ambulation is encouraged and a general diet is resumed
within 48 hours as the bowels begin to work.  If there are no
complications, the woman is ready to go home in four to seven days.
Full wound healing takes about six weeks.

   Complications

   Maternal mortality is approximately 1-2 per 1,000 operations.
Among the nonfatal complications are urinary, uterine and wound
infections, fever, bleeding, inability to urinate and defecate,
adverse reactions to the anesthetic, blood clots, bowel and bladder
injuries, retained placenta and rupture of the uterus during ensuing
pregancies.  Fetal complications are two to three times more common
than with vaginal deliveries, but the difference is due, in large
part, to fetal problems that prompted the operation in the first
place.





   IUD INSERTION

   (Intrauterine device)

   IUD's are small plastic or metal objects which may contain copper
(Copper-7, Copper-T) or the hormone progesterone (Progestasert).
When inserted into the uterus, they are an effective means of
contraception.  The mechanism by which they work is not known for
certain: either fertilization is prevented or uterine implantation of
the already-fertilized egg is made more difficult.

   Advantages

   97-99 percent effective, does not require insertion prior to each
sexual encounter, no medication to remember, cheap.

   Disadvantages

   Complications (see below), expulsion from the uterus (can come
out), may be morally reprehensible to women who object to possibly
aborting a fertilized egg.

   Possible Contraindications

   Pregnancy, current or previous pelvic infection, uterine cancer,
fibroids, vaginal bleeding, abnormal uterine shape, narrowing of the
cervical opening, previous tubal pregnancy, heart valve disease.

   Insertion

   IUD's can be inserted right in the office by gynecologists, family
physicians and some internists.  The best time is during the woman's
menstrual period, although they can be placed after abortion or
childbirth.

   A general health and gynecological examination is performed, and
the size, shape and location of the uterus is determined. The depth
of the inside of the uterus is then measured with a plastic rod
inserted through the cervix (the vaginal opening of the uterus).  A
local anesthetic or tranquilizer may be administered.   The IUD is
then advanced through the widened cervical opening to the
pre-determined depth.  There is usually a sharp cramping pain as this
is done.  The whole process takes about ten minutes.

   What to Expect

   Pelvic cramping and vaginal bleeding may persist for several days,
and during the first few months, there may be heavier, more painful
menstrual periods and bleeding between cycles.  These symptoms
usually resolve.  The IUD has a string on its end which can be felt
by placing the fingers in the vagina.  In the beginning it should be
checked weekly, after periods and any time there is a question about
whether the IUD is in place.  To be safe, it is best to use an
additional form of contraception for the first several months.

   Follow-up Care

   Yearly checkups are advisable.  Most IUD manufacturers recommend
that their products be changed every two to three years.  A "lost" or
displaced IUD should be located by X-ray or ultrasound as soon as
possible.

   Complications

   Perforation of the uterus occurs in about one out of 2,000
insertions.  Soon after placement, up to about five percent of women
will require removal of the IUD for severe or persistent pain; this
is more common in women who have never had children. During the first
year, the IUD is expelled in approximately ten percent of women, and
another ten to twenty percent request removal for pain, bleeding or
pelvic infection.

   The incidence of pelvic infection and tubal pregnancy is
significantly increased with the IUD, and when pregnancy does occur,
the risk of uterine infection is high.  In these cases the IUD should
be removed right away.

   The Dalkon Shield--a single-string, crab-shaped IUD popular in the
early 1970's--has been found to have an unacceptably high risk of
infectious complications in women who become pregnant while using it.
 Both the FDA and A. H. Robbins Company, the manufacturer, recommend
that all women who still have this device in place have it removed
immediately.

   Note: In early 1986 G.D. Searle & Co., manufacturer of the
copper-T and copper-7 IUD's, withdrew its products from the U.S.
market.  The reason cited was the high cost of defending
"unwarranted" lawsuits regarding medical complications from its
IUD's.  The only remaining IUD available in the U.S. is Alza
Corporation's Progestasert.  It must be replaced annually.

   Alternatives

   The pill, diaphragm, condoms, contraceptive sponge, male and
female sterilization.





   TUBAL LIGATION ("Tube Tying")

   The objective of tubal ligation is to prevent fertilization by
interrupting the passageways (fallopian tubes) that connect the
ovaries to the uterus.  The only indication is permanent female
sterilization

   Operations

   Two major types of operations are employed.

   Laparoscopy (see separate article) is a technique whereby a
flexible fiberoptic tube or scope is inserted through a small
incision in the wall of the abdomen for direct visualization of the
tubes and performance of the procedure.  Either general or local
anesthesia can be used, and overnight hospitalization is not
required.  Using the laparoscope, the gynecologist may choose to
block the tubes by electrically burning them (cautery) or by applying
an occluding band, clip or spring.  The discomfort is not severe and
activities are not limited afterwards.

   The second method of tubal ligation is by laparotomy, or open
abdominal incision.  With the patient under general anesthesia, the
gynecologist makes a small incision in the middle of the abdomen and
removes a small segment of each tube, tying the ends closed.
Frequently, this method is employed soon after childbirth when the
uterus is still somewhat enlarged. Hospitalization is usually
required, although a so-called minilaparotomy may be done under local
anesthesia without overnight observation.

   Complications

   Bleeding, infection, bowel and bladder injuries, and burns from
the electrocautery occur infrequently--less than one percent.
Cardiac complications from the anesthesia may develop in those with
heart disease.  There are no physical reasons why sexual function
should be adversely affected.  The unfertilized eggs are absorbed
into the tissues of the blocked tubes.  They cause no harm.

   Results

   Although tubal ligation is considered to be permanent, and should
only be done with that expectation, it has a recognized failure rate
of from one to six unexpected pregnancies per 1,000 operations.
Sometimes the tubes grow back together, even though the surgical
technique is flawless.  When pregnancies do occur, the majority are
of the tubal (ectopic) variety.

   Can Tubals be Reversed?

   After the operation, less than one percent of women change their
mind about having more children.  Perhaps as few as twenty percent of
these patients have enough length of tube left to attempt a reversal
operation.  The success rates for these procedures are not known for
certain, but may approach twenty percent or more.  To reiterate, the
initial operation should be considered permanent.

   Alternatives

   Careful preoperative counseling and informed consent are a
necessity.  Other methods of contraception include vasectomy, the
pill, IUD, diaphragm, condom and the contraceptive sponge.





   ABORTION

   Abortion is the termination of pregnancy before the fetus is
mature enough to survive on its own, i.e. not viable.  There are two
types: spontaneous (miscarriage) and induced (elective). This article
will deal only with the latter.

   Abortion has been legal in all 50 states since 1973 when the U.S.
Supreme Court ruled that state laws prohibiting first and second
trimester (up to 24 weeks) abortions were unconstitutional.  Up until
that decision abortion could be performed, in most states, only if a
pregnant woman's life was in danger.  At present the decision
regarding abortion during the first six months of pregnancy is left
up to the woman and her physician, although the states may regulate
the procedure. Abortions beyond 24 weeks are proscribed unless
dictated by maternal health.

   Major Indications

   1) personal/socioeconomic.  2) poor maternal health, e.g. severe
high blood pressure, diabetes, kidney disease, heart disease, cancer.
 3) maternal psychiatric illness.  4) severe fetal abnormalities.

   First Trimester Procedures

   About 80-90 percent of abortions are done during the first twelve
weeks.  They are safer and easier to perform than later abortions and
can often be done without overnight hospitalization.

   1) Endometrial Extraction ("menstrual regulation," "mini-
abortion") -- Women who are less than eight weeks from their last
menstrual period are candidates for this method.  With a speculum in
place, a flexible straw-like tube is inserted into the uterus through
the cervical opening and the products of conception are removed by
vacuum suction.  Afterward the patient is observed for 30 minutes to
be sure that there is no bleeding.

   2) Dilatation and Suction Curettage -- This is the most common
technique employed.  To allow for the passage of surgical instruments
into the uterus, the cervical opening must first be dilated or
enlarged.  A safe and easy method utilizes thin rods made from
seaweed or other absorbent material (laminaria). Placed into the
cervix the day before the operation, they swell with fluid and gently
dilate the opening.  Alternatively, rigid probes of gradually
increasing diameter can be inserted under local anesthesia at the
beginning of the operation.

   After dilatation by either method, a vacuum suction device is
passed into the uterus and rotated in different directions to
withdraw the fetal tissues.  Finally a sharp metal scraping
instrument called a curette is used to check that all the uterine
contents have been removed.  The patient is allowed to go home after
a three hour observation period.  Sexual intercourse is prohibited
for a month.

   3) Dilatation and Sharp Curettage (D & C) -- In this procedure
only the sharp curette is utilized after dilatation.  Because of the
high incidence of adverse effects, suction curettage is preferred.

   Second Trimester Procedures

        (12 to 24 weeks)

   1) Stimulation of Uterine Contractions -- The most common method
of mid-trimester abortion after sixteen weeks is the induction of
preterm labor by injection of a substance into the aminiotic sac.  A
needle is inserted through the wall of the abdomen into the uterus.
After a small amount of fluid is removed, saline (salt water), urea
or natural substances called prostaglandins are injected.  Some
prostaglandins can be administered by injection into a muscle or by
suppository.

   Labor begins and the fetus and membranes are "delivered" some 8-36
hours later.  Prostaglandins produce nausea, vomiting and diarrhea,
and there are labor pains.  Overnight hospitalization is usually
necessary for labor induction techniques.  The success rate is 85-95
percent.

   2) Dilatation and Evacuation -- This technique is most often used
between twelve and sixteen weeks of gestation.  The fetal tissues are
removed after dilatation of the cervix by a combination of forceps,
suction and sharp curettage.  Most women can be treated as
outpatients under local anesthesia.

   3) Hysterectomy -- Complete removal of the uterus with the patient
under of general anesthesia is a major operation. Indications include
uterine abnormalities and failure of other abortion techniques.
Occasionally, hysterotomy, the incision of the uterus without
removing it, is a reasonable alternative.

   Complications

   Risks of anesthesia, bleeding, injury to the cervix and uterus,
infection, incomplete abortion (retained fetus or membranes),
perforation of the uterus, blood clots and death.

   The complication rate is three to four times higher in the second
trimester than the first.  The overall mortality is about 1/100,000,
but may be higher than 30/100,000 for abortions during late second
trimester.





   DILATATION AND CURETTAGE

           (D&C)

   The purpose of a D&C is to scrape the inside of the uterus and
remove its lining.  The operation may be done for either diagnostic
or therapeutic purposes.

   Major Indications

   1) irregular or abnormal uterine bleeding in an adult.  2)
incomplete miscarriage (to be sure that the uterus is totally empty
of fetal and placental contents).  3) as a method of abortion  4)
suspicion of uterine cancer.

   Operation

   A D&C is performed by a gynecologist, either as an outpatient
procedure or as part of a two day hospitalization.  For diagnostic
purposes, it yields the most information when done just prior to the
woman's menstrual period.

   With the patient under general or local anesthesia, the uterus is
approached through the vagina so that there are no scars or abdominal
incisions.  Dilatation refers to the insertion of metal rods of
gradually increasing diameter through canal of the cervix at the
vaginal end of the uterus.  This is done to increase the size of the
opening to the uterus for the passage of surgical instruments.  The
curette is a sharp metal tool which is employed to scrape out the
inside lining of the uterus; sometimes a vaccuum suction device is
used (suction curettage).  The removed tissue is sent to the
laboratory for microscopic examination. The operation takes about
fifteen minutes.

   Postoperative Care

   Vaginal bleeding--similar to that seen with a menstrual period--
requires that the woman wear a vaginal pad for three to four days.
Pain medication may be prescribed.  Normal activity can be resumed
right away, but the patient is asked to refrain from vaginal
intercourse for two weeks.

   Complications

   In addition to the risks of anesthesia, the major complications
are bleeding, infection, laceration of the cervix, cervical stenosis
(narrowing or scarring of the uterine opening) and perforation of the
uterus.  The latter occurs in about one out of 300 D&C's.





    HYSTERECTOMY

    (Removal of the Uterus)

   The objective is to surgically remove the uterus.  The tubes and
ovaries are often taken out at the same time, especially if the woman
is over 35 years old.  This operation may be performed either through
an incision in the abdomen or through the vagina.

   Major Indications

   1) abnormal uterine bleeding in women past childbearing age. 2)
fibroid tumors.  3) certain cancers of the uterus and ovary. 4)
complication of pelvic infections.  5) endometriosis.  6) uterine
prolapse (falling out into the vagina).  Sterilization alone is not
an indication for hysterectomy!

   Operations

   Hospitalization and general anesthesia are required.  While an
abdominal hysterectomy allows the gynecologist more room to work,
women who undergo the vaginal operation recover more quickly, leave
the hospital sooner and do not have a visible scar. Unfortunately,
the abdominal approach is required for most indications, although
vaginal hysterectomy is done safely in patients with uterine
prolapse, small fibroids or small, bleeding uteri.  For either
procedure, the patient is not allowed to eat prior to the operation
and an intravenous line and bladder tube (catheter) are inserted.
Abdominal hysterectomies take about 1.5-4 hours; the vaginal
operations last 1-1.5 hours.  Blood transfusions may be required.

   Postoperative Care

   The bladder catheter is left in for 24 hours and pain shots are
necessary for the first few days.   Patients who have undergone the
abdominal operation are unable to eat for several days until their
bowels begin to work again.  Their average length of hospitalization
is four to six days.  After a vaginal hysterectomy, packing is left
in the vagina for the first day. Vaginal patients, however, can eat
right away and are usually able to go home in four days.  For both
groups of patients, iron pills--and maybe hormone pills if the
ovaries were removed--are prescribed.  Sexual intercourse is
prohibited for six weeks. Full activity can be resumed six  weeks
after abdominal and two to six weeks after vaginal operations.

   Complications

   There is approximately one death per 500 abdominal operations, the
majority in patients who are very ill.  Elective operations go
smoothly, with an overall incidence of complications varying from
about 3 to 30 percent.  Minor complications such as urinary
infections, fever, and wound infection predominate.  Among the major
complications are bleeding, life-threatening infection, wound falling
apart, injury to the urinary tract, shock, pneumonia, blood clots and
bowel obstruction.

   For vaginal hysterectomies, there is approximately one death per
1,000 operations; the overall complication rate is approximately
25-30 percent.  In addition to the problems listed above, the
intestines or bladder may drop through into the vagina from weakening
of the tissues, and rarely, there may be injury to the nerves to the
legs.

   Libido should not be affected with either operation.





   SPINAL TAP (Lumbar Puncture)

   The objective of a spinal tap or lumbar puncture is to insert a
needle into the spinal canal to withdraw fluid or give medication.

   Major Indications

   1) suspected meningitis or other infections of the brain and
spinal cord.  2) undiagnosed diseases of nervous system.  3) the
evaluation of certain cancers.  4) unexplained fever, headache or
change in personality.  5) delivery of medication or spinal
anesthesia.  6) as part of a myelogram (a dye X-ray of the spinal
cord).

   Contraindications

   1) increased pressure inside the brain.  2) persons with
uncontolled bleeding disorders.

   Preparation

   Spinal taps are done routinely by physicians in the following
specialties: family practice, internal medicine, pediatrics,
neurology, neurosurgery and anesthesiology.  They do not require
hospitalization or fancy equipment.

   Prior to the test, the doctor will look into the back of the
patient's eyes with an ophthalmoscope to examine the main nerve to
the eye.  If the pressure inside the brain is too high to perform the
test, the optic nerve may show signs of swelling.

   Procedure

   First, the patient is asked to lie on his side, curled into a ball
with head bent forward and thighs towards the chest. Sometimes a
sitting position is used.  Infants and adults who are unable to
cooperate with the test are held in place or mildly sedated.

   The point of entry is selected in the lower lumbar spine, below
the level at which the spinal cord ends.  The skin is washed with an
antiseptic solution and numbed with a local anesthetic.  Next, a
long, skinny spinal needle is poked through the skin and advanced
between the vertebrae into the sac of fluid which bathes the brain
and spinal cord.  Only about a teaspoon of fluid is removed in most
instances.  Finally, the needle is withdrawn and the fluid is sent to
the laboratory for examination.

   Unless it is difficult to hit the right place on the first
attempt, the whole procedure takes only about ten to twenty minutes.
The pain of the needle stick should not be severe. Afterwards, the
patient is advised to remain in a horizontal position for about eight
hours to decrease the chances of spinal tap headache.

   Complications

   There is a great deal of unfounded fear surrounding this test. A
headache will bother about one-third of the patients for a few days
afterwards.  Paralysis is extremely rare, however.  When it does
occur, it is usually due to compression of the spinal cord by a blood
clot formed at the site of entry; it is almost always reversible.
Other unusual complications include strokes if the pressure in the
brain is too high, paralysis of the eye muscles and meningitis
induced by the needle entering the spinal canal.



CompuServe

   MYELOGRAM

   The spinal cord and its nerve roots do not show up on routine
X-rays of the back or spine.  Therefore, a special X-ray procedure
called myelography may be required to evaluate persons with spinal
cord disorders.  In this test a spinal tap is done and dye is
injected into the sac of fluid that surrounds the spinal cord.
Because the dye is not penetrated by X-ray beams, the outline of the
spinal cord and nerves shows in detail when X- rays are taken.

   Major Indications

   1) suspected spinal disc disease.  2) spinal cord tumors.  3)
spinal cord malformations.  4) certain cases of sudden unexplained
paralysis.  5) evaluation of back pain prior to spinal surgery.

   Contraindications

   1) increased risk of bleeding.  2) high pressure in the brain and
spinal fluid.

   Procedure

   Generally, the test is done in the hospital by radiologists, often
those who specialize in X-rays of the nervous system.  A sedative may
be given beforehand.  Solid foods are prohibited. Using a local
anesthetic, the radiologist performs a spinal tap (See separate
article for this procedure.) either in the lower lumbar spine, or
less frequently, in the neck (cisternal puncture).

   There are two major types of dye that can be injected: water-
soluble, e.g. metrizamide, and oil-based, e.g. Pantapaque.
Metrizamide may yield more information about the nerve roots, but it
is irritating to the spinal membranes.  And because it starts to be
absorbed in about 30 minutes, the X-rays must be taken promptly.
Pantopaque is less irritating and is much more slowly absorbed.  If
not removed at the end of the test, it will remain in the spinal cord
for years.

   Regardless of the dye selected, the injection is about the same.
X-ray pictures are taken while the patient in asked to asssume
various positions on a table.  The whole procedure takes about an
hour.  Most patients are discharged home the next day.

   Complications

   Side effects are a little more common with metrizamide
myelography.  Headaches occur in almost 60 percent, nausea and
vomiting in 40 percent and increased leg or back pain in about 25
percent.  Other problems are fever (10%), bleeding, infection,
allergy and seizures.  Fortunately, serious complications are
unusual.

   With Pantopaque injections, headache, nausea and vomiting occur in
about a one-third and increased leg pain in fifteen percent.
Iodine-related allergy may be a little more common, but convulsions
are rare.

   To minimize the risk of adverse effects from either dye, patients
are advised to consume extra liquids, and unlike after a regular
spinal tap, to avoid lying down.

   Alternatives

   The CAT scan (computerized cross-sectional X-ray) is a valuable
diagnostic tool that has decreased the need for myelography in
certain patients.  Myelograms, however, are required for confirmation
and documentation of anatomy prior to spinal surgery.





   LOW BACK DISC SURGERY

   (discectomy, laminectomy)

   The spine consists of a column of small bones called vertebrae.
Between each vetebra is a shock-absorbing disc made of cartilage.
The disc is comprised of a soft gelatinous center surrounded by a
tough fibrous cartilage.  With disc degeneration or injury, the soft
center may poke through defects or tears in the outer cartilage and
compress spinal nerves.  This process is referred to as disc
herniation or "slipped disc."

   Although any level of the spine may be involved, the lumbar or low
back area is most often affected.  Lumbar disc herniation frequently
produces compression of the sciatic nerve, the major nerve to the
leg.  Patients with sciatic nerve irritation (sciatica) experience
low back pain which moves down the leg on the affected side.
Numbness, tingling and muscular weakness may be associated.

   Therapeutic Considerations

   Conservative treatment with bedrest, heat, traction, physical
therapy and/or muscle relaxants is indicated for patients with first
attacks, infrequent attacks or only mild disability. Although back
operations are mandatory only for those persons with major neurologic
deficits or severe pain, they may also be beneficial for patients who
fail to respond to conservative measures.  In selected patients,
chemonucleolysis, a procedure in which an enzyme injection is used to
dissolve the damaged disc, may obviate the need for surgery.

   Preoperative Evaluation

   Patients who are candidates for an operation must undergo testing
to confirm the diagnosis of disc herniation.  Among the studies are
electromyography (EMG--measurement of the electrical activity of the
nerves and muscles) and CAT scan (computerized cross-sectional X-rays
of the spine and spinal cord).  A myelogram (dye X-ray of the spinal
cord) is required to detail the anatomy for the surgeon.

   Operations

   Spinal surgery is performed by orthopedic or neurological
surgeons.  General anesthesia and a seven to ten day hospitalization
are required.

   Through a longitudinal incision over the lower spine, the surgeon
spreads apart the muscles to expose the vertebrae.  Part of the bone
may have to be excised (laminectomy) to get at the disc.
Cartilaginous fragments are removed from the spinal canal, and
portions of the disc are scraped away (discectomy).  The nerve roots
are freed from bony and cartilaginous impingement. In some cases,
further spinal stability is provided by fusing the vertebrae together
with bone transferred from the hip.  The indications for spinal
fusion are somewhat controversial.

   Postoperative Care/Results

   Narcotics are prescribed for pain, and initially there may be
trouble with urination.  The patient is up and out of bed in a day or
two.  Employment is prohibited for one month, strenuous work for
three.  Back-strengthening exercises are recommended. Young patients
with lumbar disc herniation have good-excellent results from the
surgery about 85-95 percent of the time. Unfortunately, about five
percent have no relief of pain despite accurate diagnosis and good
operative technique.  Results of second surgeries are not as
promising.

   Complications

   Risks of anesthesia, bleeding, infection, nerve and spinal cord
injury, paralysis, inflammation of the spinal membranes, blood clots
and retained disc fragments.  Persons who have undergone laminectomy
and discectomy are more prone to develop disc disease at other spinal
levels.





   ARTHROSCOPY

   Arthroscopy is the insertion of an instrument called an
arthroscope into a joint for direct observation of its internal
structures and the performance of surgical procedures.  While some
wrist, shoulder an ankle disorders have been diagnosed and treated
with this technique, knee injuries remain its primary application.
This article will discuss diagnostic and therapeutic knee
arthroscopy.

   Diagnostic Indications

   1) unexplained knee pain or locking.  2) early evaluation of
athletic injuries (torn cartilage/ligaments).  3) confirmation of a
preoperative diagnosis.  4) evaluation of the results of surgery or
other therapy.

   Therapeutic Applications

   1) excision of torn cartilages (meniscectomy).  2) removal of
loose bone or cartilage chips.  3) excision of the joint membrane
(synovectomy).  4) biopsy of joint tissue.  5) kneecap surgery for
chondromalacia.

   The Arthroscope

   The instrument is a six to nine inch long straight tube with a
fiberoptic light source and tube attachments for fluid irrigation and
drainage.  Arthroscopes come in different diameters ranging up to
about one-quarter inch in size.  The viewing angle may vary from
straight to 90 degrees.

   Procedure

   Arthroscopy can be done as an outpatient procedure with the
patient under local, spinal or general anesthesia.  First a
tourniquet is placed around the thigh to decrease the blood flow to
the operative site.  Then the orthopedic surgeon inserts a large
needle into the joint near the kneecap and begins to irrigate the
inside of the joint with large volumes of sterile saline (salt
water).  The irrigation distends the joint, clears the field of view
and allows the surgeon to manipulate the scope.

   The arthroscope is inserted through an incision towards the front
of the knee, either on the inside or outside, and is maneuvered
within the joint under direct visualization.  The knee is flexed and
moved into different positions to facilitate the examination of the
tissues, cartilages, ligaments and bones.  If an arthroscopic
surgical procedure is to be performed, specially designed scissors,
forceps, knives and shavers are available.  A separate incision may
be utilized.  The whole operation takes 15- 30 minutes and the
incision(s) requires only a stitch or two.  A compression bandage is
applied.

   Results

   Athletes may derive the most benefit from arthroscopic surgery.
In the diagnosis of knee injuries, arthroscopy is about 85-95 percent
accurate.  When combined with arthrography (dye X- rays of the inside
of the joint) the accuracy is 98 percent. This compares favorably
with the less than 70 percent accuracy obtained by the medical
history and physical examination alone.

   In the treatment of uncomplicated tears of the medial meniscus
cartilage, over 95 percent of patients report improvement and are
able to return to normal athletic activities.  On the average,
crutches are used for less than a week, and work and competitive
sports can be resumed at two and four weeks respectively.

   Complications

   Risks of infection, bleeding, infection, instrument breakage and
joint injury.





   BRONCHOSCOPY (Flexible)

   Bronchoscopy is the insertion of a flexible tube or scope into the
windpipe (trachea) for direct observation, and sometimes biopsy, of
the airways and lungs.  Objects stuck in the windpipe can be removed.

   Major Indications

   1) evaluation of an abnormal shadow on a chest X-ray, or "spot" on
the lung.  2) coughing up of blood.  3) unexplained cough or
wheezing.  4) suspected lung cancer.  5) collapsed lung. 6) lung
biopsy.  7) removal of a foreign object in the windpipe, e.g. a
chicken bone.  8) as an aid to inserting a breathing tube into the
lung.

   Major Contraindications

   1) heart attack or anginal chest pains.  2) severe asthma.  3) low
blood oxygen.  4) bleeding disorder.  5) poor patient cooperation.

   Flexible Bronchoscope

   The typical bronchoscope is a long, flexible fiberoptic tube about
one-quarter inch in diameter.  It has its own source of light and can
be made to bend in any direction by manipulation of the controls at
its near end.  The scope also has a separate channel within it for
vacuum suction (to remove mucous) and to insert the biopsy forceps (a
long wire with pinchers on the end).

   Procedure

   In general, the test is performed either by a specialist in
diseases of the lung (pulmonary) or by a chest (thoracic) surgeon.
It is usually done at the hospital, but the patient does not have to
be admitted.  Prior to the procedure the patient is given an
intravenous injection of a tranquilizing medicine (e.g. Valium) which
may prevent him from remembering the details of the test.  Also the
back of the throat is sprayed with a numbing local anesthetic to
prevent gagging.  General anesthesia is not required, but oxygen is
administered and the electrocardiogram is monitored.

   The bronchoscopist inserts the scope through either the nose or
mouth causing a slight pulling sensation.  There may be some
coughing.  As the scope is pushed down through the windpipe, the
larynx (voicebox) and vocal cords can be examined.  The proximal
portions of the bronchial tubes are then viewed in a systematic
fashion looking for tumors, inflammation, narrowing or other
abnormalities.  If a biopsy is required, it is not painful.  The
scope is removed simply by pulling it out gently.  The whole
procedure takes only five to twenty minutes.  Afterward the patient
feels groggy from the tranquilizer, but is otherwise fine.

   Complications

   In experienced hands, bronchoscopy is a safe test; however, the
complications that do occur can be serious.  They include reactions
to the anesthetic, bleeding from the nose or biopsy site, collapsed
lung, wheezing, shortness of breath, fever, pneumonia, injury to the
larynx and abnormal heart rhythms. The overall incidence of major
complications is 0.08 percent for bronchoscopy alone, 2.0 percent if
a lung biopsy is performed. The mortality is about 0.01 percent, i.e.
1/10,000.

   Alternatives

   Unfortunately, not all lung diseases are amenable to bronchoscopic
biopsy.  When necessary, the chest can be opened in the operating
room, but this requires major surgery.  A needle biospy through the
wall of the chest may be possible when the questionable area is near
the surface of the lung.





UPPER GASTROINTESTINAL ENDOSCOPY

   Other Names -- upper GI endoscopy, gastroscopy, esophagoscopy

   The objective of upper GI endoscopy is to insert a flexible tube
or scope through the mouth for direct visualization of the esophagus,
stomach and duodenum.  Biopsies (tissue specimens) can be taken,
foreign objects removed (e.g. chicken bones), small growths excised
and medications injected.  Upper endoscopy is also used to perform
dilatation (forced widening) of the esophagus, electrocoagulation
(cautery or burning to stop bleeding), minor surgery and ERCP, a
special dye X-ray of the bile and pancreatic duct systems.

   Major Indications

   1) upper gastrointestinal bleeding (vomiting blood).  2)
unexplained persistent upper abdominal or chest pain.  3) suspicion
of cancer of the esophagus or stomach.  4) difficulty swallowing.  5)
foreign object stuck in the esophagus or stomach. 6) ERCP  7)
esophageal dilatation  8) injection of scarring medications into
enlarged esophageal veins (sclerotherapy).

   The Instrument

   The endoscope or gastroscope is a long, flexible fiberoptic tube
about one-half inch in diameter.  It has its own light source and can
be made to bend in any direction by manipulation of the controls at
its near end.  There is a separate channel right in the scope for
vaccuum suction and for the insertion of biopsy forceps (a long wire
with pinchers on the end).

   Procedure

   Endoscopy is performed by specialists in intestinal diseases
(gastroenterologists) and by some general surgeons.  It does not
require hospitalization or general anesthesia.  The patient is asked
not to eat or drink anything after midnight the day before.

   First, an intravenous injection of a sedative (Valium) is
administered, and the back of the throat is numbed with a local
anesthetic spray.  With the patient on his side the physician inserts
the scope through the mouth and gradually advances it into the
stomach and duodenum as the person swallows.  There will be some
slight discomfort and fullness, but gagging is inhibited by the
anesthetic.

   When the examination is complete, the patient feels drowsy and may
not remember much of what went on.  If there are no additional
procedures other than taking a biopsy, the whole test takes less than
an hour.

   Complications

   In experienced hands this procedure is very safe.  The overall
complication rate is 0.13 percent(1.3/1000); the mortality is 0.004
percent (1/25,000).  The major complications include perforation or
rupture of the esophagus or stomach (0.1%), abnormal heart rhythms or
heart attack, bleeding and pneumonia. Minor complications are
bloating and swelling of the salivary glands.

   Alternatives

   Upper GI X-rays are not as sensitive for detecting ulcers, but may
be a reasonable first step if there is no emergency. Endoscopy is
clearly better for finding a source of bleeding. Frequently, these
two tests are used together.  Endoscopy may be indicated to
investigate an X-ray abnormality.

   Cost: approximately $300-$700





   LAPAROSCOPY

   The objective is to insert a tube or scope through the abdominal
wall for direct visualization of the abdominal structures and the
performance of simple surgical procedures.

   Major Indications

   1) as a diagnostic method in women with unexplained uterine,
ovarian or tubal abnormalities, pelvic pain, infertility or anemia.
2) suspected tubal pregnancy or pelvic tumor  3) lost intrauterine
device (IUD).  4) evaluation of the liver.  5) unexplained fever.  6)
Performance of the following operations: biospy of the liver and
ovaries, female sterilization ("tube tying") and a variety of minor
gynecologic procedures.

   The Instrument

   The laparoscope is a staight metal tube about a foot long and
one-half inch in diameter.  It has its own light source and a
separate channel for vaccum suction, the insufflation of gas and the
insertion of long, wire-like instruments for cutting, burning
(electrocautery) and biopsying.

   Operation

   Gynecologists, many surgeons and some gastroenterologists
(intestinal specialists) do this operation.  Overnight
hospitalization is not required.  General, spinal or local anesthesia
may be used, although most laparoscopists favor putting the patient
to sleep.

   First a one-half inch long incision is made near the navel. Then a
large needle is inserted through the incision for the insufflation of
two to three liters of gas (carbon dioxide or nitrous oxide) into the
abdominal cavity.  The abdominal distention produced by the gas
allows the surgeon to see and manipulate the scope and instruments.
Next, the needle is withdrawn and the laparoscope is inserted in its
place.  It can be redirected to view and operate on the abdominal
organs.  For gynecological patients, the uterus, tubes and ovaries
can be maneuvered into postion by an instrument clamped to the end of
the uterus (cervix) in the vagina.  A second incision just above the
pubic hairline is utilized for the insertion of surgical instruments.
 At the end of the operation, the scope is removed and the gas is
allowed to escape.  The operation takes 30-60 minutes.

   Postoperative Care

   The patient can expect some pain near the navel and perhaps some
shoulder discomfort.  Physical activity, including sex, is not
limited.  Work can be resumed in two days.  The residual abdominal
gas will be absorbed.  The stitches are out in a week.

   Complications

   Only about two ot six patients per 1000 have a complication:
infection, bleeding, burns from electrocautery, puncture of the
urinary bladder and rarely cardiac arrest.

   Alternatives

   Exploratory surgery allows for a more thorough examination of the
abdominal cavity and gives the surgeon more room to work. But it is
more complicated and requires prolonged hospitalization.  The choice
of procedure depends on the patient and the specific indications.





   COLONOSCOPY

   The objective of colonoscopy is to view the entire length of the
inside of the colon (large intestine) with a flexible tube or scope
inserted through the anus.  Biopsies (tissue specimens) can be taken
and minor electrocautery (electrical burning) operations can be
performed.

   Major Indications

   1) unexplained blood in the stool.  2) suspected colon cancer. 3)
abnormal finding on a lower GI X-ray (barium enema).  4) polypectomy
(removal of a polyp or small growth).  5) follow-up examinations for
patients with certain intestinal diseases, e.g. ulcerative colitis.

   The Instrument

   The colonoscope is a tube, six feet long, one-half inch wide, and
made of flexible fiberoptic glass.  It has its own light source and
can be made to bend in any direction by manipulation of controls at
its near end.  There is a separate channel within the tube for vacuum
suction, insufflation of air and insertion of long, wire-like
surgical instruments.

   Preparation

   So that the inside of the bowel is not obscured by stool, the
patient is asked to go on a liquid diet and take laxatives for two to
three days prior to the test.  An enema(s) is administered just
beforehand.

   Procedure

   Colonoscopy is performed by gastroenterologists (intestinal
specialists) or surgeons who are trained in the procedure.  It does
not require hospitalization or general anesthesia, but an injection
of a tranquilizing medication (Valium) is given just before starting.

   With the patient on his side on a table, the doctor inserts the
lubricated scope into the anus and advances it through the colon by
pushing and twisting.  The colon is insufflated with air or gas to
facilitate passage of the scope.  The patient may feel some abdominal
pressure, cramping or urge to have a bowel movement.  If biopsies are
required of suspicious looking areas, a long wire with pinchers on
the end can be inserted through the scope.  For removal of a polyp
under direct visualization, a wire snare is looped around the base of
the growth.  The electric current is then turned on, melting the
tissues.  Several "burnings" may be required for large growths.
Colonoscopy takes 30-60 minutes.

   Complications

   For colonoscopies without polypectomy, the most common
complication is perforation (put a hole in) of the colon.  It occurs
in about one out of 500 patients.  Other complications include
bleeding, abscess formation, lacerations of the rectum, gas
accumulation in the small intestine and rarely, explosion of bowel
gas with electrocautery.  When polypectomies are performed, the
incidence of bleeding is about two percent, and perforation occurs in
approximately one out of 350 cases.

   Alternatives

   The lower GI X-ray is a complimentary procedure.  It misses some
things that colonoscopy doesn't and vice versa.  Major abdominal
surgery can sometimes be avoided by using colonoscopy for biopsy and
polypectomy.





   PROCTOSIGMOIDOSCOPY

   Other Names -- procto, proctoscopy, sigmoidoscopy

   The objective is direct inspection of the rectum and lower
intestine (sigmoid colon) through a scope inserted via the anus.

   Major Indications

   Proctos are used to evaluate bleeding from the rectum, diarrhea
and inflammatory bowel diseases such as ulcerative colitis and
Crohn's disease.  In persons over 40 years old, and in those with
special risks, it is employed as a screening test for cancer of the
colon.

   Special Instruments

   1) Rigid proctoscope: a three-quarter inch diameter, eight- nine
inch long, plastic tube or 2) Flexible proctosigmoidoscope: a
one-half inch diameter, snake-like fiberoptic instrument about 15-25
inches in length.

   Procedure

   The person to be examined is prepared ("prepped") at home for this
office procedure with one to two days of a liquid diet, laxatives and
perhaps an enema.  (Too much stool can obscure the view.)  During the
procedure, the patient is positioned bottom up, head down on a
special table; the test can also be performed with the person on his
left side.  In either case, no anesthesia is required, but the exam
is easier to complete and better tolerated if the patient can relax,
bear down like on a commode and breathe slowly and deeply.  Prior to
inserting the scope, the doctor will check the anus with a gloved,
lubricated finger.  Stool is tested for blood.

   The scope is gently inserted through the anus and slowly
advanced--the distance depending on the length of the instrument.
With a strong light source, the scope can highlight the wall of the
rectum and colon revealing tumors, inflammation, infection or other
abnormalities.  Biopsy specimens of suspicious areas can be taken
with special instruments.  The whole procedure lasts ten to twenty
minutes.

   Complications

   Mild abdominal pressure and cramping occur during the procto, and
there may be a slight amount of bleeding if a biopsy is taken, but
serious side effects are very rare.  Perforation injury to the wall
of the intestine is the most serious.  It happens in less than one
out of 5,000 examinations.

   Alternatives

   Lower GI barium X-rays do not show the rectum and lower colon in
much detail.  The stool blood test and procto. compliment each other
in the detection of cancers; they are both necessary for screening
purposes.  Colonoscopy (See separate article.) is a similar procedure
using a much longer scope to investigate the entire colon.

   Cost: $45-$75 is not unusual.





   UPPER GASTROINTESTINAL X-RAY

          (Upper GI)

   Because routine X-rays do not show the esophagus, stomach or small
intestine in detail, a special test called an "upper gastrointestinal
(GI) X-ray" or "barium swallow" is required to study the anatomy of
these organs.  Barium sulfate, a substance which is not penetrated by
X-ray beams, is administered by mouth. As it coats the intestinal
tract, X-ray pictures are taken to outline the structures.

   Major Indications

   1) abdominal pain.  2) difficulty swallowing.  3) intestinal
bleeding.  4) vomiting blood.  5) weight loss.  6) diarrhea.  7)
follow-up of ulcer disease.  8) vomiting.

   Preparation

   So that the stomach is not obscured by food, the patient is asked
not to eat or drink anything for at least six hours before the test
(nothing after midnight the day before.)

   Procedures

   The patient is asked to swallow an effervescent agent (produces
gas) and water to distend the stomach.  Then chalky, liquid barium is
ingested.  As it passes down into the stomach, X-ray "movies"
(fluoroscopy) are taken of the esophagus.  Next, more barium is given
(about eight oz. total) to fill the stomach and first part of the
small intestine (duodenum).  X-rays are taken as the patient is moved
into various positions to distribute the barium.  The abdomen may be
compressed to get the right pictures. If a small intestine X-ray
(small bowel follow through) is ordered, X-rays are obtained as the
barium passes further down the intestinal tract.  It could take
several hours, so a medication is sometimes given to speed things up.

   Complications

   This test is very safe and there is little discomfort. Pregnant
women should avoid it, however, because of the X-ray exposure.  Among
the rare complications are having the barium "go down the wrong pipe"
into the lung, escape of barium into the chest or abdomen via a hole
or perforation in the intestinal tract and barium impaction.  Elderly
and dehydrated persons are prone to barium constipation after the
procedure.  A laxative can prevent this bothersome occurrence.

   Alternatives

   Upper gastrointestinal endoscopy, the insertion of a flexible
scope into the stomach through the mouth for direct viewing of the
stomach, etc. is preferred by some digestive specialists. Although it
may be a more sensitive test for some disorders, it can be more
dangerous and expensive.  Often endoscopy and upper GI X-rays are
used in combination.





   LOWER GASTROINTESTINAL X-RAY

     (Lower GI, Barium Enema)

   Because routine X-rays of the abdomen do not show the large
intestine in much detail, a special X-ray called a barium enema or
lower GI is required when the doctor needs to have more information
about the anatomy of the colon.  With this test, an enema of barium
sulfate, a substance that is not penetrated by X- ray beams, outlines
of the colon as X-ray pictures are taken. The X-rays are interpreted
by radiologists, but many gastrointestinal specialists and surgeons
are also proficient at reading them.

   Major Indications

   1) unexplained intestinal bleeding, abdominal pain, diarrhea,
constipation or weight loss.  2) suspicion of cancer of the colon.
3) follow-up or screening test for patients with certain intestinal
diseases.  4) evaluation prior to and after colon surgery.

   Preparation

   So that the inside of the intestine is not obscured by stool, the
patient is asked to go on a liquid or low residue diet and take
laxatives for two to three days prior to the test.  At least one
cleansing enema is given before starting.

   Procedure

   With the patient positioned on the X-ray table, and the
radiologist in attendance, an enema tube is inserted into the rectum
and the preparation of liquid barium is allowed to flow into the
colon by gravity from a bag positioned above the level of the
abdomen.  Some abdominal cramping, fullness or urgency to have a
bowel movement may be experienced.

   During this time fluoroscopic (motion picture) X-rays are taken as
the radiologist presses gently on the abdomen while the patient is
asked to breath deeply and move into various positions.  Also, a
series of permanent X-ray pictures are taken from different angles so
that most of the large bowel is visualized.  In an air-contrast
study--this shows the intestinal lining in even more detail--air is
insufflated into the colon along with a thicker preparation of
barium.

   The whole procedure takes about a half hour.  To prevent the
barium from solidifying in the intestine after the test, a laxative
may be prescribed.

   Complications

   This test is very safe.  Very rare complications include
perforation of the colon, injuries to the rectum, changes in the
heart rhythm, bloodstream infection and allergy to the barium.
Dehydration from the dietary preparation, post-X-ray impaction of the
barium or constipation may develop in the elderly or debilitated.

   Alternatives

   Because the barium enema X-ray does not clearly show the rectum
and lower colon, proctoscopic (sigmoid) examination is also
recommended.  Colonoscopy, the direct visualization of the entire
colon via a long scope inserted through the anus, can pick up some
abnormalities that the X-rays miss.  The two tests are complementary.





        KIDNEY X-RAY

(IVP - Intravenous Pyelogram)

   Because routine X-rays do not show the urinary tract in much
detail, a special X-ray called an IVP or intravenous pyelogram is
performed when the doctor needs to know more about the kidneys,
ureters or bladder.  After an iodine-containing dye is injected into
the bloodstream, it is filtered out and concentrated by the kidneys,
then drained into the bladder through the ureters. Because the dye is
not penetrated by X-ray beams, the outline of the urinary tract
appears when X-rays are taken.  Tumors, stones, blockages, cysts and
the exact location of the various organs can be identified.

   Major Indications

   1) blood in the urine.  2) suspected kidney stone.  3) cancer of
the kidney, ureters or bladder.  4) evaluation of flank and abdominal
pain.  5) severe or recurrent urinary infection.  6) unexplained or
severe high blood pressure.  7) suspected urinary tract blockage.  8)
suspected congenital urinary tract abnormalities.  9) location of the
urinary tract structures prior to certain pelvic operations.  10)
follow-up of known urinary disorders.

   Possible Contraindications

   1) kidney failure -- The urinary tract won't show up if the
kidneys are unable to filter the dye.  Also kidney failure may be
made worse by reactions to the dye (see below).  2) pregnancy. 3)
dehydration.  4) allergy to iodine-containing dyes (see below).

   Preparation

   A high intake of fluids is recommended for a few days prior to the
test.  (Dehydration increases the chances of a kidney- damaging
effect from the dye.)  Antihistamine and cortisone-type medications
may be prescribed for patients at risk for allergic- type dye
reactions.  Just before the X-ray, foods and liquids are prohibited,
and a laxative or enema is given to assure a clear picture.

   Procedure

   IVP's are performed by X-ray technicians in the hospital or in the
offices of radiologists (X-ray specialists) or urologists (urinary
tract surgeons).  No anesthesia is required.  After a routine X-ray
of the abdomen is taken, the dye is injected into a vein in the arm.
Warmth, slight nausea and a funny taste in the mouth may occur
temporarily.  Over the next hour, timed X-rays are taken with the
patient in different positions.  The last X- ray is usually shot
after the patient has voided.

   Complications

   Reactions to the X-ray dye occur in about five percent of the
patients.  The majority are short-lived effects such as nausea and
vomiting.  Allergic-type reactions include hives, wheezing, shortness
of breath, asthma attack, shock and rarely, sudden death.  They are
more likely to occur in persons with a known dye allergy and,
perhaps, in individuals with other types of allergies, e.g. hay
fever, shellfish.  Dye-induced kidney failure is a complication that
is more likely to occur in older persons, and in patients with
diabetes, dehydration or pre-existing kidney disease.





   COMPUTERIZED AXIAL TOMOGRAPHY

        (CAT or CT Scan)

   The development of the CAT scanner, a computerized X-ray machine
that produces cross-sectional pictures of the human anatomy, was one
of the most important technical achievements in medicine in the
1970's.  For the first time physicians were able to view the body's
internal structures in detail without resorting to an operation.

   The CAT scanner's major advantage over routine X-rays is its
ability to create pictures at multiple levels or cuts through the
body from head to toe.  And unlike X-ray, soft tissues (brain,
muscle, blood vessels, abdominal organs, etc.) can be seen clearly.
CAT scanning has many applications and has already changed the way
physicians practice medicine.

   Applications

   CAT scans of the head and brain have revolutionized neurologic
diagnosis and have had a profound effect upon the clinical approach
to many neurosurgical problems.  Among the disorders for which head
CAT scans are valuable are brain hemorrhages, tumors, and infections;
strokes; head injuries; headaches; seizures; mental status changes;
and eye, sinus and blood vessel abnormalities.  The need for spinal
taps, cerebral arteriography (dye X-rays of blood vessels to the
brain) and radionuclide brain scans has markedly diminished.

   CAT scanners that image the body have been used widely only over
the past few years, but just about every body structure has been
studied.  Presently their major use is the evaluation the organs,
lymph nodes and blood vessels of the neck, chest and abdomen.
Cancers are often detected by this technique, obviating the need for
surgery.  Also the diagnosis of slipped discs and spinal tumors is
facilitated.  Finally CAT scans are used to guide needle biopsies of
various organs.

   Preparation

   The patient is asked not to eat or drink anything for four to six
hours before the test.  Hairpieces, hairpins, jewelry and other
metallic objects must be removed because they interfere with the
X-ray beams.

   Procedure

   The scanner is large; it takes up an entire room.  The part that
concerns the patient is a huge, metallic, doughnut-shaped object
through which passes a table.  Depending on the organ or part of the
body part being studied, an injection of dye may be given prior to
the scan.  With abdominal studies, liquids may be administered.  The
patient is asked to lie quietly on the table while the scanner takes
X-ray pictures.  There is a whirring sound from the scanner but no
pain.

   Complications

   A few patients will feel claustrophobic during the test or may be
unable to lie still for sharp pictures.  Adverse effects may result
from reactions to the X-ray dye.  (Patients should inform their
doctor ahead of time if they have any allergies or previous reactions
to X-ray dye.)  With the newer generations of CAT scanners, the dose
of radiation is comparable or less than that of many other routine
X-rays.





   ULTRASOUND

   Other Names -- sonar, sono, sonography, echo

   Ultrasound is a method for obtaining images of body structures
using sound waves instead of X-rays.  Through a microphone-like
transducer placed on the skin, inaudible high-frequency sound waves
are passed into the body where they bounce off the interfaces between
tissues of different densities: for example, fluid/air, bone/muscle.
The sound wave echoes are detected by the transducer and transmitted
by wires to an ultrasound machine that converts the electrical
impulses into an image.  The procedure can be done as an outpatient,
there is no pain and, as far as anyone knows to date, no side
effects.

   Medical Applications

   In the abdomen, ultrasound is a valuable diagnostic tool for
diseases of the gallbladder, bile ducts, liver and pancreas. About
90-95 percent of gallstones can be detected by this method. And
jaundice, upper abdominal pain, urinary tract obstruction and tumors
of the pancreas and liver can be evaluated.

   Obstetrician-gynecologists employ sonography to diagnose
abnormalities of the uterus, tubes and ovaries.  Suspected cysts,
tumors and pelvic infection are some common indications.  The
pregnant uterus can be seen in detail--including the uterine size,
placental location and some fetal abnormalities.  Fetal age is
calculated very accurately using ultrasonic measurements of fetal
head diameters.  Amniocentesis is done under ultrasonic guidance.

   Among the other disorders for which sonar may be helpful are
breast lumps, scrotal and testicular lumps, thyroid cysts and tumors,
abcesses, aneurysms (enlarged segments of arteries), joint cysts and
eye tumors and infections.  Ultrasound can be also used to guide
needle biopsies of various organs





   THYROIDECTOMY

   Thyroid and Thyroid Disease

   The thyroid is an endocrine gland situated in front of the
windpipe below the level of the Adam's apple.  It produces thyroid
hormone, an iodine-containing substance necessary for the control of
body metabolism.

   Diseases of the thyroid may be treated with thyroid medication,
thyroidectomy (the surgical removal of the gland) or radioactive
iodine.  The latter treatment refers to destruction of the gland by
radioactive iodine which is ingested, then concentrated in the
thyroid.  Although the amount of radiation administered is miniscule
and not known to be associated with adverse effects outside the
thyroid, radioactive iodine is, for the most part, inappropriate
therapy for youngsters and women of childbearing age.

   Hyperthyroidism is overactivity of the thyroid; too much hormone
causes an acceleration in body metabolism.  Its primary symptoms are
weight loss, heat intolerance, fatigue, sweating, palpitation,
thyroid enlargement (goiter) and changes in bowel habits, hair, eyes
and skin.

   In hyperthyroidism due to Graves' disease, the entire gland is
overactive.  Thyroidectomy is indicated for this condition when
anti-thyroid medications are ineffective (about 50-70 percent of the
time) or when radioactive iodine treatment is contraindicated.  With
toxic multinodular goiter or an overactive thyroid nodule, only
localized areas of the gland are involved. Because anti-thyroid
medication doesn't work, either radioactive iodine or thyroidectomy
is required.

   Hypothyroidism, underactivity of the gland, results in too little
thyroid hormone and a slowing of body metabolism.  Its major symptoms
are weight gain, cold intolerance, constipation, dry skin, hoarseness
and, perhaps, a goiter.  Hypothyroidism is commonly a result of
thyroiditis, an inflammation of the gland. Thyroid medication is the
usual treatment, but thyroidectomy may be necessary in addition if a
large goiter causes obstruction to breathing or swallowing.

   Thyroid cancer and hyperthyroidism during pregnancy are other
possible indications for thyroidectomy.

   Preoperative Preparation

   Because overactive thyroid glands have many delicate blood vessels
which are prone to injury, operating on a person with florid Graves'
disease can be hazardous unless anti-thyroid medication is given to
"cool down" the gland.  A two week treatment period is usually
sufficient.

   Procedure

   Thyroidectomy is a difficult operation which demands an
experienced surgeon.  It is performed through a horizontal incision
in the lower neck with the patient under general anesthesia.  For
Graves' disease only part of the thyroid is removed (subtotal
thyroidectomy); the intent is to leave a residual active portion of
the gland.  Thyroid cancer necessitates a total thyroidectomy.
Special care is taken to avoid removing the parathyroids, four tiny
glands which are located near the thyroid and produce a hormone that
controls blood calcium.  The nerves to the vocal cords are also at
risk for injury.  The entire operation can take three hours or more.

   Postoperative Care

   Narcotics are prescribed for pain, and oxygen may be given to make
breathing easier.  The head and neck are supported with pillows, and
activity is limited to ease discomfort and decrease the strain on the
incision.  Because swallowing is painful, a soft diet is required
initially.  There may be temporary difficulty speaking.  The average
length of hospitalization is four to five days.

   Complications

   Respiratory distress, bleeding, infection, hoarseness due to
injury to the nerves to the vocal cords and larynx (voicebox), low
blood calcium due to injury or inadvertent removal of the
parathyroids, collapse of the windpipe due to softening of the
cartilage, trouble swallowing, injury to the major lymph vessels.

   Recurrent hyperthyroidism occurs in one to eighteen percent.
Permanent hypothyroidism results in up to 30 percent of patinets with
Graves' disease.  The overall mortality is zero to three percent.





   BREAST IMAGING

(Mammography, Ultrasound, etc.)

   Approximately one in eleven American women will develop breast
cancer sometime in her lifetime.  Because patients with small tumors
without lymph node involvement have the best prognosis, early
diagnosis and treatment is believed to be important. Breast imaging
techniques are used to evaluate worrisome breast lumps as well as to
screen for early tumors before they grow large enough to be
detectable by manual breast examination. However, these tests are not
meant to replace monthly self breast examinations and regular
physician checkups.  Over 75 percent of breast lumps are still
initially detected by the patient.

   Mammography

   These breast X-rays are the "gold standard" for breast cancer
screening.  They can detect almost 90 percent of malignant breast
tumors, including so-called minimal breast cancers less than one-
quarter inch in diameter.

   The American Cancer Society, the American College of Radiology and
several other medical organizations presently recommend that all
women have a baseline mammogram at age 35-40, at one to two year
intervals between 40 and 50, and annually after age 50.  Although
some physicians fear radiation-induced breast cancer from exposure to
X-rays over many years, available studies support the contention that
regular screening utilizing modern, low-dose (less than one rad for
two views of the breast) mammography techniques is beneficial
overall.

   In women with palpable lumps, mammography can help determine the
likelihood of malignancy, although it does not obviate the need for a
biopsy (tissue sample).  For women with known cancers, it is used to
evaluate the remainder of the involved breast as well as the breast
on the opposite side.

   Ultrasound

   With this method, high-frequency sound waves are reflected off the
interface between tissues of different densities to obtain a picture.
 There are no adverse effects.  Its primary use is to differentiate
solid from cystic (fluid-filled) lumps.  In conjunction with
mammography, this information can help guide the type of biopsy.
Ultrasound is clearly inferior to mammography for screening purposes.

   CAT (CT) Scan

   Computerized tomography of the breast uses cross-sectional X- rays
to create film images.  While this test can evaluate the breast when
a lump is known to be present, it is cumbersome, time-consuming,
expensive and has less resolution than mammography.  The dose of
radiation is prohibitive for screening.

   Thermography

   This safe technique relies on the fact that breast cancers cause a
slight increase in the temperature of surrounding tissues-- about 2.5
degrees F.  Differences in skin temperature can be picked up by
either infrared detectors or cholesteric crystals.  Unfortunately,
thermography is neither specific nor sensitive enough for general
use.  Experimental studies suggest, however, that positive tests may
be a risk factor for breast cancer in an otherwise healthy women.

   Transillumination

   A bright light is shined directly through the breast tissue to
silhouette abnormal masses or lumps.  Although first suggested over
50 years ago, this technique remains experimental.  It is safe, but
its efficacy is unproven.

   Cost: Mammography $75 - $225





   BREAST BIOPSY

   A breast biopsy is a surgical procedure in which a sample of
breast tissue is obtained for microscopic examination.  In most cases
it is done to diagnose or exclude the possibility of cancer.  About
one out of five biopsied breast lumps turns out to be cancerous.

   Major Indications

   1) any discreet, solid breast lump.  2) cystic (fluid-filled)
breast lumps which either recur or do not disappear after they have
been drained with a needle.  3) suspicious areas on mammography, i.e.
breast X-rays.  4) bloody discharge from the nipple.  5) crusting or
ulceration of the nipple.  6) unexplained lymph node enlargement
under the arm.  7) certain types of cancer known to be present in the
opposite breast.

   Procedures

   The traditional method is for the patient to be admitted to the
hospital for an open biopsy under general anesthesia.  The surgeon
either incises (samples a portion of) or completely excises (removes)
the lump through a scar-minimizing incision around the areola, the
pigmented part of the breast surrounding the nipple.  The tissue is
sent to the pathologist for an immediate preliminary interpretation.
If cancer is diagnosed, definitive surgery, i.e. mastectomy, is
undertaken at the same operation.  If the growth is benign, excision
is all that is needed.

   Because the above set of events can be extremely unpleasant for
the patient--namely going into surgery with uncertainty about whether
she will awaken with or without her breast--and because a short delay
is not harmful, most surgeons now do the biopsy as a separate
operation.  Decision about mastectomy is deferred two to three days
until the final pathologic diagnosis is available. In young,
otherwise healthy women with small lumps, the biopsy can be performed
as an outpatient procedure, often with local anesthesia.

   When the suspicion is high that a lump is cancerous, a needle
biopsy can confirm the diagnosis in the majority of cases.  A needle
is inserted directly into the lump through the skin without an
incision.  Unfortunately, because malignancy can be missed 20-50
percent of the time by this method, a needle biopsy is only of value
when it is positive.  A negative result for cancer still requires
confirmation by open biopsy.

   Complications

   Breast biopsies are generally very safe.  Bleeding, infection,
skin sloughing around the edge of the wound and reactions to
anesthetics are the most common adverse effects.





   BREAST CANCER OPERATIONS

(Mastectomy, Lumpectomy, etc.)

   Surgery is the primary therapy for patients with breast cancer
confined to the breast, chest wall and lymph nodes under the arm
(stages I-III).  Operations to remove the tumor may be combined with
chemotherapy and/or radiation (X-ray) therapy.  The choice of
operation to perform and whether to prescribe additional therapy
depends on the age and menopausal status of the woman, the size, type
and extent of the tumor, and the philosophy of the treating
physicians.

   Traditionally, extensive breast excisions have been recommended,
but more recently, limited forms of breast surgery designed to
preserve cosmetic appearance, avoid disfigurement and limit
postoperative disability have been advocated.  Research is ongoing.

   The major operations for breast cancer are detailed below:

   Radical Mastectomy

   This operation has been performed for over 90 years, and up until
the last fifteen years, was considered the standard therapy for
breast cancer.  The entire breast is removed along with the lymph
nodes and the chest muscles under the breast.  Blood transfusions and
skin grafts are often required.  Unfortunately, the patient is left
with a cosmetic deformity which may be difficult to hide by either
reconstructive surgery or artificial breast augmentation.
Frequently, there is arm swelling, weakness and loss of mobility.

   Modified Radical Mastectomy

   This is the most common operation done for breast cancer in the
U.S.  Like the more radical surgery, the entire breast and lymph
nodes under the arm are removed, but the major chest muscle and more
skin are preserved.  Less deformity and disability occur without a
detrimental effect on prognosis.

   Simple or Total Mastectomy

   The breast is removed without the muscles or excessive skin. Lymph
node excision may or may not be performed.  If it is not included,
however, tumor spread to the nodes may go undetected, preventing some
women from being treated with potentially beneficial chemotherapy.
Preliminary studies have shown this operation, with and without
radiation therapy, to be as effective as radical surgery in some
patients.

   Limited Operations

   Three surgical alternatives to removal of the entire breast have
been studied.  They are less disfiguring and disabling.  The
quadrantectomy, removal of only the quarter of the breast in which
the tumor is found, may be as effective as radical mastectomy when it
is combined with lymph node excision and radiation therapy in women
who have tumors less than about an inch in diameter and no lymph node
involvement.  Local excision and wide local excision, sometimes
referred to as "lumpectomy" and "segmental mastectomy," refer to
excision of the only the tumor or the tumor and some surrounding
tissue, respectively. Recent studies suggest that these procedures
combined with lymph node dissection and postoperative radiation
therapy yield good results in women with small tumors.

   Postoperative Care

   Arm exercises and rehabilitation are started right away, and
reconstructive breast surgery is a reasonable consideration for women
who desire it.  With the less radical forms of surgery, cosmetic
reconstruction, e.g silicone implants, is much easier and has better
results.  Although it can be done at the time of the initial surgery,
most surgeons prefer to wait three months and perform a second
operation.  Breast prostheses (padding appliances) are a popular
alternative to cosmetic reconstuction.

   Regardless of the type of operation, there is always a period of
psychological adjustment to having had breast cancer surgery. Normal
sexual activity, socialization and participation in usual activities
are to be encouraged.

   Summary

   There is still great controversy regarding the choice of operation
for women with early stage breast cancer; studies are ongoing.  In
general, many patients will continue to have modified radical
mastectomies.  Women with small tumors located near the edge of the
breast tissue, and those who are unable to tolerate extensive
surgery, are candidates for more limited, less disfiguring operations
combined with radiation treatment. Procedures which do not include
lymph node excision may not allow some women to benefit from
additional chemotherapy.  Regardless of the operation, both physical
and psychological recovery are important.





   SURGERY FOR MORBID OBESITY

   The National Institutes of Health (NIH) has defined morbid obesity
as either 100 pounds of overweight or twice one's ideal weight by
insurance company standards.  This degree of obesity is associated
with a significant increase in overall mortality and a high incidence
of chronic disease, especially in individuals between 20 and 40 years
of age.  Among the conditions found more frequently in the morbidly
obese are diabetes, high blood pressure, gout, gallstones, arthritis,
high cholesterol, heart disease, hernias, certain cancers and
psychiatric illness.

   Unfortunately, conservative weight loss measures such as
supervised dieting, prolong starvation, anti-obesity medication,
hypnosis, psychotherapy and behavioral modification are often
unsuccessful, and jaw wiring is not a permanent solution. Therefore,
invasive procedures are sometimes recommended.

   Gastric Bubble

   The gastric bubble, the most recent treatment for morbid obesity
to receive FDA approval is not a major operation, but an outpatient
procedure.  Using an upper gastrointestinal endoscope (a flexible
lighted scope -- See separate article.), the physician passes an
inflatable polyurethane sac through the mouth into the stomach.  The
cylindrical device is then inflated to full size, about six ounces.
Floating in the stomach like a bubble, it stays in place for up to
four months, after which time it is removed and replaced.

   The bubble works by making the patient feel full.  When combined
with a special program of diet and behavior modification, it can be
an effective means of weight control. But this is still a new
technique.  Additional data should be forthcoming after the bubble
receives more widespread use. Reported side effects include the usual
risks of endoscopy, stomach upset and peptic ulcers.

   Surgical Procedures

   Major surgery is usually the last resort.  Candidates for obesity
operations must be carefully selected.  Besides meeting the NIH
criteria for morbid obesity and failing conservative measures for
weight reduction, they should be emotionally prepared for the
operation and its possible complications. Intensive preoperative
medical and psychological evaluation is required.  Informed consent
is extremely imnportant.

   The major surgical options are discussed below:

   Gastroplasty

   (Stomach Stapling)

  Also known as gastric (stomach) partitioning, these operations
entail stapling or stitching of the stomach into two pouches of
different sizes.  The small upper pouch, about one to two ounces in
volume, communicates with the larger lower portion of the stomach
through a one-half inch opening called the stoma.  As the patient
eats, the small pouch fills up easily and empties slowly through the
stoma into the remainder of the stomach.  The patient's intake of
food is limited by early satiety.  A major modification of the
patient's eating habits is attainable.

   Not surprisingly, the success of the operation is critically
dependent upon the size of the pouches and stoma.  The average weight
loss after a year is about 30 percent; however, at two years, a
significant number will have regained the weight. Failure may be due
to loss of an effective partition, enlargement of the stoma or
dietary indiscretion.  The latter refers to continuous ingestion of
massive quantities of high-calorie liquids (e.g milkshakes) which can
pass freely through the stoma.

   The operative morbidity is ten percent.  Major complications
include dehydration, obstruction of the stoma, partition falling
apart, infection, bleeding, stomach perforation and blood clots. The
overall mortality is one to two percent.

   Gastric (Stomach) Bypass

   As with gastroplasty the stomach is partitioned into two pouches;
however, the small pouch stoma communicates directly with a loop of
small intestine--bypassing the remainder of the stomach, duodenum and
a portion of the proximal small intestine. This operation results in
a 35-40 percent loss in weight.  Almost 95 percent of the patients
will not gain it back.  The morbidity and mortality rates are similar
to those seen with gastroplasty, but vitamin B-12 and iron
deficiencies are more common.

   Intestinal Bypass

   These operations involve either the removal or short- circuiting
(bypass) of 90 percent of the small intestine.  The stomach is
untouched.  The absorptive capacity of the bowel is significantly
reduced as calories and nutrients are lost in the stool.  Although
intestinal bypass reduces weight as effectively as the gastric
operations, the high incidence of side effects is prohibitive.  Among
the complications are death, blood clots, infection, bleeding, kidney
falure, kidney stones, liver disease, arthritis, bowel obstruction,
diarrhea, vomiting and anemia. Gastric operations are preferred.





   PILONIDAL CYST OR SINUS

   A pilonidal cyst is a small, fluid-filled pocket located beneath
the skin near the upper portion of the crack of the buttocks.  While
some are thought to be congenital remnants of incomplete closure of
the spinal canal, most are acquired as a result of deeply ingrown
hair follicles.

   Pilonidal cysts normally are not bothersome, but when they become
infected, pain, redness, swelling and drainage of pus are apparent.
If the cyst communicates directly with the skin or another organ
through a drainage tract, the term pilonidal sinus is used.

   The treatment of this disorder is primarily surgical. Antibiotics
are used in addition if there is evidence of fever or severe
infection.

   Operative Therapy

   Infected pilonidal cysts (abscesses or pockets of pus) require
incision and drainage.  The procedure can be done in the office under
local anesthesia.  The cyst cavity is packed with gauze and hot baths
are advised.

   When the infection resolves, definitive therapy is undertaken to
prevent recurrence.  With the patient lying on his stomach, the cyst
and sinus tract are excised with the aid of local anesthesia.  The
wound is then packed with gauze to keep it open and draining.  The
gauze is changed after four days and every one to two days
thereafter.  Hot baths are recommended after the first week.  The
area should be shaved and kept clean.  Complete healing takes about
six weeks.  Alternative procedures include cryosurgery (freezing),
excision with closure of the wound and wide unroofing (removing the
overlying skin) of the sinus tract.

   Complications

   Despite good surgical technique, recurrence is not unusual. Other
complications include bleeding, severe infection and direct
communication of the sinus tract with the spinal canal or large
intestine.  The latter process is referred to as fistulization.
Rarely a colostomy or major abdominal operation will be necessary.





   BONE MARROW TEST

   (Aspiration and Biopsy)

   The objective is to remove a sample(s) of bone marrow to examine
under the microscope.  Sometimes the specimen is cultured for
evidence of infection.

   Major Indications

   1) blood diseases, especially leukemia.  2) cancers  3)
undiagnosed fever and infections.

   Procedure

   Most family physicians, pediatricians, internists and
hematologist-oncologists (specialists in blood diseases and cancer)
can perform this test.  It may be done in the office.

   Although the specimen can be gotten from the breastbone (sternum),
it is usually obtained from the back of the hip bone adjacent to the
spine.  Sometimes a pain shot is given prior to the test.

   With the patient positioned on his stomach or side, the physician
washes the area of skin over the proposed site with an antiseptic
solution.  Next a numbing local anesthetic is injected into the skin
and over the surface of the bone.  A large needle is then positioned
perpendicularly and pushed into the bone using a screwing motion.
There will be pressure and some pain.

   When the needle is deep enough in the bone to be anchored, a
syringe is attached to its end.  The sample is obtained as the
physician forcefully withdraws the plunger of the syringe.  The
patient feels a brief, sharp pain as about one-quarter teaspoon of
liquid marrow comes into the syringe.  This sample is called a bone
marrow aspiration; it is particularly good for looking at the
characteristics of individual blood-forming cells.

   A bone marrow biopsy is obtained in a similar manner using a
larger needle (about 1/16 of an inch in diameter).  The needle is
screwed into the bone until anchored, but instead of withdrawing
marrow with a syringe, the physician will wiggle the needle back and
forth in order to remove a core sample.  Biopsy specimens are used
for examining the natural architecture of the marrow and looking for
tumors.  Frequently, bone marrow biopsies need to be done on both
hips.

   After the procedure is completed a dressing is applied to the
wound.  The patient experiences some aching for a day or two which
require medication.

   Complications

   Despite how they sound, bone marrow aspirations and biopsies are
very safe tests.  There may be some bleeding, but complications are
unusual.  There is an extremely slight chance that the needle will
penetrate the bone too deeply and injure an important structure such
as a nerve or artery.  Penetration of the breastbone is obviously
more of a concern.





   SKIN BIOPSY

   A skin biopsy is a minor surgical procedure in which a small
sample of skin is excised for examination under the microscope and
other studies.  Dermatologists, family physicians, pediatricians and
internists use this test routinely when a rash or skin growth
(lesion) cannot be diagnosed by appearance alone. Although biopsy is
a valuable aid to diagnosis, many skin disorders show nonspecific
findings.  Ultimately, the final diagnosis may depend on information
obtained from the physical examination, blood tests and cultures, as
well as the biopsy.

   Procedure

   A relatively simple undertaking, the skin biospy is performed in
the office; it takes only a few minutes.  Aside from the minor
discomfort exerienced with the injection of the local anesthetic, the
procedure is painless.

   Punch biopsy is the technique that is most commonly employed.
After cleansing the area with an antiseptic, the doctor numbs the
skin using a needle and syringe.  The punch, a rod-shaped instrument
with a sharp cylindrical cutting edge about one-sixth of an inch in
diameter, is then rotated and advanced perpendicularly into the
lesion, yielding a core of tissue which can be easily removed.  The
bleeding stops with direct pressure Stitches are optional.  Complete
healing takes one week.

   Other techniques are the shave biopsy, in which a flat wafer of
tissue is sliced off with a blade, and the excisional biopsy, in
which a scalpel is used to remove the entire lesion.  The latter is
preferrable when the diagnosis of skin cancer is being considered.

   Complications

   Bleeding, infection, exaggerated scarring or a reaction to the
anesthetic will occur rarely.  Special care must be taken with
lesions on the face and hands.





   HOME CARE AND FIRST AID

   Introduction

   This section includes practical advice and easy-to-follow
instructions for the home care of many common minor health problems.
Although some of the medical conditions included here may require a
visit to your physician for diagnosis or treatment, others can be
managed entirely at home.





   HOW TO TAKE A PULSE

   Physiology

   With each beat the heart contracts and pumps blood into the
circulation.  The force of the pumping action causes pulsation of the
arteries.  Where arteries lie near the surface of the body, a pulse
can be felt with the hand.

   Measurement of the pulse is an important part of assessing health,
especially in emergency situations.  It can provide information about
the heart, blood pressure, blood vessels and a host of disorders.  In
addition, the pulse may be used to monitor a program of physical
conditioning.

   The normal heart rate is approximately 60-100/minute in adults and
120-140/minute in small infants.  It may speed up with emotional
upset, disease, fever or exercise.  A very slow rate is usually
dangerous, except in very highly conditioned athletes who may have
heart rates slower than 40/minute.

   Where to Feel

   The wrist and neck are the two easiest places to feel a pulse. The
pulse of the radial artery is palpable on the palm side of the wrist
at the base of the thumb.  On either side of the neck, the pulse of
the carotid artery is palpable adjacent to the windpipe above the
level of the Adam's apple.  Remember not to feel on both sides of the
neck at once, or you may cut off blood flow to the head.

   How to Feel

   Use the tips of the middle three fingers of either hand; they are
most sensitive.  Avoid using the thumb.  You need to press about as
firmly as you would to compress a loaf of bread, but not too hard or
the pulse will be occluded.  If you press too softly, you won't feel
anything.  Because there may be minor varations between individuals
in the location of the radial artery, you may need to adjust the
position of your fingers until the pulse is identified and easily
felt.

   What to Feel for

   The first step is to count the rate--the number of beats per
minute.  You will need a watch with a second hand.  Count for the
whole sixty seconds or for thirty seconds multiplying by two. Note
whether there are any skipped beats or long pauses between beats.
Try to determine the rhythm of the pulse.  For instance, do the beats
occur at regular intervals?  Finally, try to judge whether the force
of the pulse is strong or weak.  Use your own pulse for comparison.





   TAKING A TEMPERATURE

   Because body temperature is a valuable sign in the assessment of
disease, learning to take a temperature is something everyone should
know how to do.  The normal temperature is 96.5-99.0 degrees F.
(35.8-37.2 degrees C.).  It is important to remember that when rectal
temperatures are taken, they require a different type of thermometer
and are normally about one degree F. higher than temperatures taken
by mouth (oral).

   Rectal Temperatures

   All infants, young children and adults who cannot cooperate with
oral measurements should have their temperature taken rectally.
First, a clean rectal thermometer (It has a short, round bulb.)
should be shaken down to force the liquid toward the bulbed end.
Then, with the person on their stomach or side, the thermometer is
inserted into the rectum up to a depth of about one inch.  Petrolatum
may be used as a lubricant.  After three minutes, the temperature can
be read.  Hold the flat side of the thermometer towards the light,
tilting it until you see the silver or red column.  The glass has
small marks every 0.2 (two tenths) of a degree, and big marks every
1.0 degree.  There may be an arrow at 98.6 degrees.  Match the end of
the column of liquid to the closest mark on the glass to determine
the temperature.

   Temperatures by Mouth (Oral)

   Before you begin, be sure that the person has not eaten or drunken
warm or cold foods, showered or exercised during the preceding half
hour.  All these factors could affect the accuracy of the reading.
Remember to use an unlubricated clean oral thermometer.  Again, the
thermometer must be shaken down before beginning.  It should be
placed beneath the tongue for a period of three minutes.  The person
is asked to breathe through his nose during this time.  Read the
temperature as above.

   Temperature Tapes

   A recently developed method of temperature measurement utilizes a
heat sensitive tape.  Placed on the forehead, the tape changes color
in response to slight alterations in body temperature.  There is
usually an easy to read number scale. Although this method is is
accurate only to the whole degree, it seems to be practical for small
infants.





   TREATING FEVER

   Physiology

   Normal body temperature ranges between 96.5 and 99.0 degrees F.
(35.8-37.2 degrees C.), depending on the individual and the ambient
conditions.  At night the temperature is about one-half a degree
higher than in the morning.  Rectal measurements are almost one
degree higher than those taken by mouth (orally).

   Fever, the elevation of body temperature above normal, is a
valuable sign to follow through the course of an illness.  Its onset
may be the first indication that something is wrong, its
disappearance a sign that things are improving.  Consequently, fever
should not be treated before its cause is known unless the patient is
uncomfortable or the temperature is greater than 102.0 degrees F.
Although brain damage may occur with extremely high temperatures, it
is rare at temperatures below 105 degrees.

   Treatment

   (1)  Document the temperature by measuring it every four hours
while awake.  Be sure to shake down the thermometer before using, and
remember to keep it under the tongue with the mouth closed for three
minutes.  Use a rectal thermometer for infants.  You may want to keep
a record of the temperatures for your doctor.

   (2)  Encourage intake of liquids.  Higher temperatures account for
greater body fluid losses through sweating and evaporation.

   (3)  Aspirin and acetaminophen (Tylenol, Tempra, Panadol) are
equally good at bringing the temperature down.  They can be given
every four hours as needed; follow package instructions for the
dosage.  For children with viral illnesses, acetaminophen is
preferred because the use of aspirin has been associated with Reye's
syndrome, a serious brain and liver disorder.

   (4)  Cool compresses across the forehead and under the arms are
soothing when the temperature is high.  Hourly sponge baths can be
given to infants and small children to keep the temperature below 104
degrees.  Fill the tub with an inch or two of water at around body
temperature.  Rinse the child for ten to fifteen minutes, allowing
the water to run off.

    (5)  Dress warmly, but don't overdo it.

    (6)  Call your doctor if the fever is high, unexplained or
persistent.





   TREATING VOMITING

   Although vomiting is most often due to benign, short-lived
illnesses such as "stomach flu," it may be an early sign of a major
disorder.  One needs to learn how to recognize serious problems as
well as how to prevent dehydration and speed recovery.

   Call Your Doctor If:

   (1)  the cause is uncertain.

   (2)  there is persistent vomiting, abdominal pain, headache, high
fever, dizziness, numbness, unequal pupils, lethargy, unusual
behavior or difficulty speaking, seeing or hearing.

   (3)  the vomited material shoots across the room (projectile
vomiting).

   (4)  nothing at all can be taken by mouth for more than a few
hours.

   (5)  there has been a recent head injury.

   (6)  the abdomen swells up.

   (7)  there is difficulty with bowel movements.

   (8)  there is blood in the vomitus.

   (9)  the medication your doctor gave you is not working.

  (10)  you are not sure that everything is going ok.

   Treatment

   (1)  When vomiting begins, try not to eat or drink anything for
the first four to six hours.  Then begin with clear liquids (ones you
can see through) such as water, "flat" soda pop, tea, gelatin
desserts, broth soups, apple juice and KoolAid.  Start slowly, a few
sips at a time.  Try to drink as much as you can without feeling full
or sick.

   (2)  Avoid solid foods initially.  But after twenty-four hours if
there is improvement, begin easily digestible foods like toast,
cereals, apple sauce, crackers, oatmeal, soft-boiled eggs, bananas
and rice.  Avoid fatty foods, meats and dairy products.

   (3)  After forty-eight hours, advance your diet as tolerated.

   (4)  Prochlorperazine (Compazine), trimethobenzamide (Tigan), or
metoclopramide (Reglan) may be prescribed by your doctor. Please
follow the directions carefully.





   TREATING DIARRHEA

   Diarrhea is characterized by an increase in the frequency, volume
or liquid content of bowel movements.  In most cases it is caused by
a short-lived intestinal infection, but serious diseases may be
responsible.  In addition to treating the underlying cause, therapy
is aimed at putting the gastrointestinal tract to rest and preventing
dehydration.

   See Your Doctor If:

   (1)  the cause is unknown.

   (2)  loose bowel movements last more than a few days.

   (3)  there is persistent abdominal pain or swelling, fever, bloody
stool, lethargy, failure to urinate or weight loss.

   (4)  you suffer from any chronic illnesses.

   (5)  you are not sure that everything is ok.

   Treatment

   (1)  Rest.

   (2)  Increase liquid intake to prevent dehydration.  A lot of
fluid is being lost, especially if there is fever.

   (3)  Begin a clear liquid (ones you can see through) diet. Stick
to water, soda pop, tea, broth soups, jello, sherbet, apple juice,
etc., avoiding solid foods and dairy products initially. This regimen
is usually effective.  For infants, your doctor may recommend a fluid
solution which contains carbohydrates and salts (e.g. Pedialyte).

   (4)  Kaopectate or Pepto-Bismol may be of benefit.  Your doctor
may prescribe diphenoxylate (Lomotil), loperamide (Immodium), codeine
or Paregoric if the symptoms are severe. Most prescription
medications for diarrhea are narcotics.  Follow the directions
carefully.  REMEMBER: If you require medication for more than a
couple of days, you need to be checked by a physician!

   (5)  As the diarrhea slows down, advance your diet to foods that
are easily digestible.  For example--toast, cereals, apple sauce,
crackers, oatmeal, poached eggs, bananas and rice.  Avoid dairy
products, fatty foods, and large heavy meals.

   (6)  After a few days a regular diet can be resumed.





   TOOTHACHE

   Toothache and tooth and gum injuries are some of the most
agonizing pains that one can experience.  While you are waiting to
see your dentist, there are a few steps you can take to minimize the
discomfort:

   (1)  Make an appointment to see your dentist as soon as you can.
Because toothaches may be due to a gum infection, unnecessary delay
will increase the chances of complications. Dental infections which
are ignored may even spread to the brain!

   (2)  Take aspirin or acetaminophen (Tylenol, Datril, Panadol)
every four hours for pain.  Follow dosage intructions on the label.

   (3)  Put ice or cold packs over the jaw on the side that hurts.
Some people find better relief with heat.  See what works for you.

   (4)  If you have had a tooth knocked-out, use ice to decrease
swelling.  Save the tooth in a wet towel and take it with you to the
dentist.

   (5)  For bleeding from the site of tooth injury or recent dental
surgery, bite down firmly on a clean gauze or article of clothing.
(A cool, used teabag may be more effective if you can make one.)  You
may have to keep this up for half an hour or more.

   (6)  Danger Signs: excruciating pain, fever, swelling and redness
of the face, severe headache, stiff neck, eye pain.





   STOPPING A NOSEBLEED

   A bloody nose can be a frightening experience--not to mention
messy and embarrassing.  There are a few simple steps to follow to
stop the bleeding:

   (1)  To prevent choking from the drainage of large amounts of
blood into the back of the throat, keep the person sitting up and
leaning forward.

   (2)  Compress his nose between your fingers.  Continue for fifteen
to twenty minutes.

   (3)  Apply ice wrapped in a cloth directly to the nose.  Cold
helps by constricting the blood vessels.

   (4)  When the bleeding stops, gently release pressure on the nose.

   (5)  See a doctor when the bleeding cannot be stopped, the
nosebleeds are frequent, the bleeding has been profuse, there has
been a history of easy bleeding or bruising, the person takes a
"blood-thinning" medicine or when the nose might be broken.

   (6) Remember: low-humidity heat and nosepicking are the two most
common predisposing factors for spontaneous nosebleeds.  Try a
humidifier.





  TREATING THE COMMON COLD & FLU

   Colds and the flu are viral infections.  Common symptoms of a cold
are fatigue, fever, aches, head congestion, coughing, sore throat and
sneezing.  The flu is characterized by fatigue, aches, fever and
sometimes, nausea and vomiting.  Although there have been many great
medical advances, there still is no cure for the common cold.
Because penicillin is not effective against viruses, it does not
help.  Vitamins are no better.  The therapy, therefore, depends on
doing things to make yourself feel better while you wait for the
infection to go away.

   Treatment

   (1)  Rest.  Stay warm and dry.

   (2)  Measure the temperature with a thermometer every four hours.
A rectal thermometer should be used for young children and infants.
Fevers above 102.0 degrees F., or those which cause discomfort, can
be treated with acetaminophen (Tylenol, etc.) or aspirin every four
hours.  Many authorities advise against using aspirin to treat viral
infections in children because of the possibility of increasing the
risk of Reye's syndrome, a serious brain and liver disorder.
Children with the flu or chicken pox should not be give aspirin at
least until this controversy is resolved.  Sponge baths may be used
for infants.

   (3)  Because fever causes dehydration, drink plenty of fluids.

   (4)  Normal foods can be eaten, but if there is vomiting or
diarrhea, stick to clear liquids (ones you can see through.)

   (5)  For sore throat, gargle with warm salt water every four hours
and use throat lozenges.

   (6)  Aspirin and acetaminophen are good analgesics for relief from
headache and body aches.  Stonger pain relievers should be avoided.

   (7)  A decongestant such as pseudephedrine (Sudafed) can help
decrease sneezing, post-nasal drip and clogged nasal passages. It is
available without prescription.

   (8)  Nonprescription cough medicines containing dextromethorphan
(e.g. Robitussin DM) are effective for suppressing a dry cough.

   (9)  Be sure to consult a doctor if the symptoms are severe, the
diagnosis uncertain or there is persistent vomiting, a bad sore
throat, earache, high or prolonged fever, shortness of breath, chest
pain, a lingering cough or unusual behavior.





   TREATING CROUP

   Croup, a respiratory illness of young children, is characterized
by a brassy, barking cough due to at least partial blockage of the
windpipe.  Frequently it is preceded by or associated with fatigue,
fever, runny nose, hoarseness, sore throat and difficult, "noisy"
breathing.  In severe cases, the airway may close up entirely
creating a life-threatening emergency.

   There are many different forms of croup; most are caused by
infections.  A doctor should determine whether the type your child
has is serious.  You need to know what to watch for and, when the
doctor advises, how to care for your child at home.

   Home Care

   (1)  Follow your doctor's instructions, especially with medicines.

   (2)  Try to comfort your child.  Anxiety can cause coughing
spasms.

   (3)  Keep the child indoors.  Cold air may aggravate the cough.

   (4)  Because croup tends to be worse at night, have your child
sleep near a cool-mist humidifier (atomizer) or vaporizer.  Use a
teapot if that is all you have.

   (5)  Record the temperature every four hours.  Don't mask a fever
with acetaminophen (Tylenol, etc.) or aspirin.

   (6)  Encourage intake of liquids.  Let the child drink only in
your presence, sitting up, taking sips at a time.  Advance the diet
to solid foods over a few days as the condition improves.

   (7)  During coughing spasms, carry the child into the bathroom and
close the door.  Make as much steam as you can by turning on the hot
water in the shower or bath.  The coughing and breathing trouble will
usually remit in 15 - 30 minutes.  Syrup of ipecac can be given to
induce vomiting.  (Surprisingly, vomiting may break the coughing
cycle.)  The dose is one drop for every month of age up to two years,
and one-half to one teaspoon for older children.

   IMPORTANT -- Watch for these signs signs and symptoms and take
your child to the hospital IMMEDIATELY or call an ambulance if any
occur:

   (1)  High fever -- greater than 102 degrees F. (38.9 C.)

   (2)  Restlessness and irritability.  These may be early signs of a
lack of oxygen.

   (3)  Labored breathing.  Be concerned if the rate of breathing
(breaths per minute) suddenly increases or if your child uses his
chest, abdominal or neck muscles to take deep breaths.

   (4)  Stridor.  This is a specific term which refers to a high-
pitched sound or croaking than can be heard as the child takes a
breath in.

   (5)  Blue color (cyanosis) around the lips or fingernails--a sign
of oxygen deficiency.

   (6)  Persistent or worsening condition.

   (7)  Inability to swallow saliva.





   TREATING A BAD BACK

   Pain in the lower back can be a frustrating problem for patients
and physicians alike.  In many cases the cause is difficult to
determine.  When muscle strains or spasms, "slipped discs," sciatic
nerve irritation or spinal arthritis are responsible, a structured
program of back care and exercises can be therapeutic as well as
preventive.  Remember: when back pain occurs for the first time,
worsens in severity, persists or is associated with fever, numbness,
muscle weakness or abdominal pain, see your doctor.

   Treatment

   (1)  When the pain is severe, your doctor may advise bedrest.
(Movement puts a strain on the muscles.)  Stay flat on your back. The
harder the mattress, the better; putting a plywood board between the
box spring and mattress can firm up even an old bed.

   (2)  Use a heating pad, blanket or hot water bottle to relax the
muscles.  Be careful not to burn yourself.  Try hot tub baths.

   (3)  Never sleep on your stomach.  Sleep on your back or on your
side with your knees bent towards your chest.

   (4)  Take all prescribed medications.  Aspirin, acetaminophen
(Tylenol, etc.) or ibuprofen (Advil, Nuprin) can provide some relief.

   (5)  Follow your doctor's program of exercise.

   (6)  As you feel better, normal activities should be resumed
gradually.

   General  Measures

   (1)  Wear comfortable, sturdy shoes with low heels.

   (2)  Get plenty of rest; don't overwork.

   (3)  When standing, lean forward slightly.  Shift your weight
frequently.

   (4)  Sit upright in hard, straight-backed chairs with your knees
bent above the level of your hips.  Avoid soft-cushioned chairs and
couches, and try not to stay in the same position for long periods of
time.

   (5)  Assume a similar sitting position while driving.  Your knees
should be bent as you touch the pedals.  Take frequent breaks.

   (6)  Be sure to lift from a squatting position (knees bent), using
your legs, not your back.  Don't bend over from the waist to lift.
Avoid heavy loads.

   (7)  Stretch and warm up before exercising.





   DIAPER RASH (dermatitis)

   Diaper rash or dermatitis is caused by a skin reaction to
irritating diapers and prolonged contact with stool, urine,
perspiration, soaps, detergents or creams.  Typically, the rash
affects the groin around the genitals and buttocks; it is red and
scaly with tiny bumps, blisters or cracks.  The simple steps outlined
below will usually make it go away:

   (1)  Change diapers frequently to avoid wetness.  Throw-away
diapers are a good idea.  Do not use plastic pants as they hold
excretions in contact with the irritated skin.

   (2)  Bathe your infant frequently in warm water, avoiding strong
soaps.

   (3)  After bathing, allow for air drying to be complete.  (You may
want to hold the legs apart for a short time.)

   (4)  Apply petrolatum or a zinc oxide/vitamin A & D ointment
(Desitin) prior to putting on the next diaper.  Don't use baby powder
as young children may breathe it into their lungs.

   (5)  See your doctor if there is no improvement.  A bacterial or
yeast infection may be complicating the situation, or there may be an
allergic cause.  A hydrocortisone ointment can be prescribed for
difficult cases.





   POISON IVY, OAK AND SUMAC

   The term poisonous in reference to ivy, oak and sumac is a
misnomer.  In fact, the common summertime rash results from an
allergic reaction to direct contact with the plants' oily sap or
resin called urishiol.  Like most types of allergies, plant- related
dermatitis (skin inflammation) is not usually severe on the first
exposure.  One to two weeks after the initial contact with the plant,
a linear streaking, intensely itchy, red, blistery rash will occur.
On repeated exposures the rash develops more quickly--within one to
two days--and is more severe.  Typically, the rash persists for
several weeks, then gradually disappears without scarring.
Recognizing and avoiding contact with the plants and their resins may
help prevent a few sleepless nights.

   Prevention

   (1)  Avoid the plants.  Poison ivy, a low spreading bush or vine
with three leaves and green or white berries, is found throughout the
U.S.  Poison oak may stand taller as a bush.  It too has white
berries and is found in the western part of North America.  Finally,
poison sumac inhabits the eastern half of the continent.  It exists
as a bush or small tree with stems consisting of 7-13 leaves arranged
in pairs opposite each other. Again the berries are white.  It might
be a good idea to check out a plant book before outings, or even
better, take one with you.  Learn the plants near your home.

   (2)  Suspicious plants can be tested for the resin using a simple
test which requires only a piece of white paper.  Crush a leaf
between a fold of paper to release the sap.  Urishiol turns black
within five minutes upon exposure to the air.

   (3)  Wear pants and shirts with long sleeves.

   (4)  Minimize the duration and area of skin contact with the
resin.  As soon as you notice the sap on your skin wash it off with
soap and water.  Be sure to do a good job on your nails; they can be
a source of persistent contact with the resin.  Wash all clothing,
work tools, camping equipment and pets for the same reason.

   (5)  Allergic therapy is only occasionally effective and may be
complicated by severe reactions.

   Treatment

   (1)  Cool compresses are soothing.  Avoid hot baths and showers
which tend to increase itching.  Calamine lotion may provide some
relief.  Hydrocortisone creams and sprays are now available without
prescription.  Follow the directions.

   (2)  Contrary to popular belief, the fluid inside of the blisters
does not spread the rash, nor does scratching unless the resin is
still present.  Intense scratching should be avoided, however, to
prevent infection by bacteria on the skin.

   (3)  If you develop a severe reaction, see your doctor for prompt
treatment.  "Cortisone" pills, a shot and/or anti-itch medicine may
be prescribed.





   ATHLETE'S FOOT (Tinea pedis)

   Athlete's foot is a bothersome fungus infection of the toes and
foot--in other words, ringworm of the feet.  It is characterized by
an itchy, scaly, odorous rash between the toes. Cracks, irritation,
redness and bacterial infections may complicate the picture.  There
are special forms which cause yellow blisters and can involve the
soles and sides of the feet.

   A misnomer, athlete's foot is not limited to sports enthusiasts;
anyone can acquire the fungus.  Hot weather and wearing shoes which
do not allow the feet to "breathe" are two predisposing factors.
Most susceptible are people who have previously had the infection,
adult men (The majority are affected.), those whose feet perspire and
persons with weakened immunity to infection.  Interestingly,
children, women and persons who go barefoot do not often contract
this disorder.

   A common misconception about athlete's foot is that locker rooms
and public bathrooms are havens for the fungus.  In reality, this is
often not the case, making the value of special precautions such as
foot sprays and baths debatable.  The exact way in which athlete's
foot is spread is not fully understood.

   Treatment

   (1)  Mild cases can be treated at home without a visit to the
doctor.  The most important part is keeping the feet dry, especially
between the toes.

   (2)  Wear open-toed shoes or sandals when you have to have any
footwear on at all.  Avoid vinyl uppers and athletic shoes with
rubber soles.  Cotton socks are better than synthetics.

   (3)  Wash your feet and soak them in a white vinegar/water
solution (2-4 tablespoons/pint) for twenty minutes, three times
daily.

   (4)  Keep the toes wedged apart with gauze or cotton, and use foot
powder to stay dry.

   (5)  Many non-prescription medications are effective including
powders, sprays, creams and liquids which contain miconazole
(Micatin), tolnaftate (Aftate, Tinactin), and undecylenate (Cruex,
Desenex).  Follow the directions.

   (6)  Be patient.  It may take two weeks to two months for athletes
foot to clear up.

   (7)  See your doctor if you're not sure what is wrong, if you have
a severe case which involves more than just the toes or has blisters,
if there are signs of a bacterial infection or if you think the
treatment isn't working.  Your doctor will rule out other causes and
may prescribe anti-fungus pills such as griseofulvin (Fulvicin) or
ketoconazole.  Sometimes cortisone- type lotions are added to the
treatment.





   INGROWN TOENAIL

   Poor nail trimming practices, tightly fitting shoes and nail
deformities may cause the corner of a toenail to grow into the
adjoining skin.  The area soon becomes infected and very
painful--especially the big toe, which is affected more than any
other.  Therapy usually involves at least partial removal of the
nail.

   Prevention

   (1)  Keep your feet clean and dry.

   (2)  Trim your toenails regularly.  Cut straight across the ends
so that the corners don't grow out.  Not too short.

   (3)  Wear socks.

   (4)  Where good fitting shoes.  Tight shoes push the toes
together.  Avoid high heels if you have this problem.

   Treatment

   (1)  As soon as you notice nail pain, redness and swelling, stay
off your feet as much as possible.  Prop up the affected foot on a
cushion or footstool.

   (2)  Soak in warm water or salt water for ten to fifteen minutes,
three to four times each day.

   (3)  After each soaking insert a small piece of cotton gauze
soaked in betadine (antiseptic) beneath the corner of the nail. Cover
with a light gauze.  Tannic acid solutions (e.g. Outgro) may toughen
the skin to allow you to cut the nail.

   (4)  See your doctor for further therapy.  Nail removal under
local anesthesia and perhaps antibiotics will do the trick.

   (5)  NOTE: Persons with diabetes or circulatory problems can
develop serious infectious complications.  They should be extra
careful!





   BLISTERS

   Blisters are pockets of fluid or blood beneath the outer layer of
the skin.  Constant irritation and rubbing, burns, frostbite, poison
ivy and other skin diseases are most often responsible. Most blisters
will go away by themselves once the cause is remedied, but
occasionally they need to be drained.  Infection is the major
complication.

   Treatment

   (1)  Remove the source of irritation.  For example, avoid tight
shoes and those long, early season tennis or golf matches.

   (2) In general, blisters are better off left alone.  The fluid
inside will be gradually reabsorbed.

   (3) Keep the blister covered with a Band-Aid or gauze and tape.

   (4) If it breaks on its own, wash the area carefully with soap and
water.  Keep it covered, but observe daily for redness, drainage of
pus or swelling.

   (5) If the blister must be opened, clean it first with soap and
water.  Sterilize a needle by heating it over a flame until red hot.
When the needle cools down, pierce the lower edge of the blister
allowing fluid to escape.  Use your finger to squeeze out the
remainder.  Cover with a clean bandage.

   (6) See your doctor if there are signs of infection, the blister
is large or if it was caused by a burn, frostbite or poison ivy.





   HEAD INJURIES - WHEN TO WORRY

   Anytime a person receives a blow to the head, there is the
possibility of serious brain and skull damage.  Because the signs of
brain injury may not show up immediately, differentiating a damaging
blow from an insignificant one may be difficult, even for your
doctor.  In many cases, the initial examination will be normal, only
to have the person deteriorate over the ensuing hours or days.  For
this reason, a period of close observation after the injury is
advisable.

   Instructions

   (1)  Follow your doctors advice.

   (2)  The injured person should be awakened every hour for the
first twenty-four hours to be sure they are ok.  Do not leave them
alone for long periods of time.

   (3)  Take the pulse (number of heart beats per minute) every hour.
 Use the middle three fingers to feel it either adjacent to the
windpipe or on the palm side of the wrist at the base of the thumb.

   (4)  Take the temperature every four hours.

   (5)  Check the pupils of the eyes every hour.  They should be the
same size in each eye.

   (6)  Limit activity, i.e. no work or school.

   (7)  Use only aspirin or acetaminophen (Tylenol, Datril, Panadol )
for pain.  Severe pain may be a warning; it can be dangerous to mask
it with strong medications!

   (8)  Stick to a clear liquid diet for the first day.  After that,
a regular diet may be resumed.

   What to Watch For:

   (1)  persistent or severe headache.

   (2)  vomiting.

   (3)  blurred or double vision.

   (4)  difficulty walking or maintaining balance.

   (5)  lethargy or an inability to arouse from sleep.

   (6)  slurred speech.

   (7)  weakness or inability to move.

   (8)  numbness or loss of sensation.

   (9)  any unusual behavior.

  (10)  bleeding or drainage of fluid from the nose, mouth or ear.

  (11)  unequal pupil size.

  (12)  fever.

  (13)  pulse rate less than 50 in adults, 80 in infants.

IMPORTANT:  Contact your doctor again if you observe any of the
above!




CompuServe

   TREATING EYE INJURIES

   The eye is extremely sensitive to injury from chemicals. Although
prevention is the best therapy, prompt action after the injury has
occurred can minimize the risk of blindness.  Among the common
objects that fly into or get caught in the eyes are eyelashes, wood
chips, metal filings, dust, dirt, gravel and glass.  The doctor may
have to use a cotton swab or instrument to remove these if
spontaneous tearing doesn't do the trick.

   Chemical Injuries

   When chemicals splash into the eye, they cause marked irritation,
tearing and pain.  As soon as possible, rinse the eye with water or
salt water.  Use the faucet, an eye cup or a water fountain, keeping
the lids open all the time.  Continue rinsing for one-half hour or
until a doctor can notified.  Do not use chemical antidotes; the
reaction gives off heat which produces more damage.  For example:
Don't use an acid rinse for an alkaline injury like lye.   Patch the
eye with the lids closed and have someone drive you to the doctor.

   Foreign Objects

   The object may be visible beneath the lid or embedded directly in
the eye.  Water rinses, as above, should be tried first.  Some
particles can be removed with a moistened cotton swab after turning
the lid inside-out.  Difficult to remove and embedded objects,
however, may require special instrumentation.  Patch the affected eye
and see your doctor for a complete examination.



CompuServe

   CUTS AND SCRAPES

   Cuts (lacerations) and scrapes are breaks in the protective
surface of the skin.  Even minor skin injuries can lead to major
complictions if they are not treated appropriately.  Proper wound
care involves the control of bleeding, evaluation of the extent of
injury and facilitation of healing.  Prevention of infection is very
important.

   Immediate Care

   (1)  Stop the bleeding by raising the affected part and applying
constant direct pressure with your hand.  Use a sterile gauze, if you
have one.  It may take five or ten minutes for the bleeding to stop;
don't give up!

   (2)  Cleanse the wound with soap and water to remove visible dirt.
 Hydrogen peroxide is a good antiseptic.

   (3)  Evaluate the extent of injury.  Be sure to note the length
and depth of the wound.  Test your sensation, movement and pulses in
the injured area.  REMEMBER: Deep wounds often cause serious injury
even if they don't look like much.  And cuts on the hands and arms
are frequently associated with tendon and nerve injuries.

   (4)  Apply antiseptic ointment. (e.g. betadine)

   (5)  Apply a sterile bandage.  Try to keep the edges of the wound
together.

   See Your Doctor If:

   (1)  you can't stop the bleeding.

   (2)  there is deformity, persistent pain, numbness or loss of
movement.

   (3)  the wound is deep or long.

   (4)  the wound is very dirty.

   (5)  you think you need stitches.  REMEMBER: Lacerations over
joints may heal slowly because of constant movement!

   (6)  you are especially prone to infection because of chronic
illness, e.g. diabetes.

   (7)  you are unsure that you have had a tetanus shot in the last
five to ten years.

   (8)  you are concerned about the scar.

   (9)  you are not sure that you are ok.

   Follow-up Care

   (1)  If you saw your doctor, follow instructions exactly.

   (2)  Keep the wound clean and dry.

   (3)  Change the dressing daily using sterile bandages.

   (4)  Inspect the wound for signs of infection, such as redness,
swelling or pus.  Fever may indicate a spreading infection.

   (5)  If you had stitches, return to have them removed at the
appropriate time.  Don't take them out yourself or wait too long.





   BUMPS AND BRUISES

   Bruises, or black and blue marks, represent bleeding from the
small blood vessels beneath the surface of the skin.  They are almost
always caused by injuries from direct blows.  Elderly persons, those
with bleeding disorders and individuals taking cortisone-type
medications are particularly susceptible.

   The natural course of a bruise is for it to heal spontaneously
over a period of days to weeks.  As the blood is broken down
chemically and absorbed, the skin will change colors from red to
black to green to yellow before there is complete resolution.

   A contusion is a fancy medical term for an injury to the soft
tissues beneath the skin, i.e. a bump.  The skin is not broken.

   Treatment

   (1)  As soon as the injury occurs, put ice on it.  This will
decrease swelling and pain.

   (2)  Raise the affected area, e.g. arm, above the level of the
heart to decrease bleeding and swelling.

   (3)  After twenty-four hours, apply heat.  This will increase
blood flow to the area to speed healing.

   (4)  Take aspirin, acetaminophen (Tylenol, Datril, Panadol) or
ibuprofen (Advil, Nuprin) for pain.

   (5)  See your doctor if the bruise is slow to heal, you bruise
easily, or if there is a possibilty that a bone has been broken.





   HOW TO REMOVE A SPLINTER

   Splinters or slivers are sharp bits of wood, metal, plastic, glass
or other materials which become lodged beneath the skin. They are
usually visible.  Although the chances of a splinter finding its way
through the circulation to the heart is minimal, it is best to remove
them right away to reduce the chances of infection.

   What to Do:

   (1)  Wash your hands and the affected area thoroughly with soap
and water.

   (2)  Sterilize a pin or sewing needle and a pair of fine tweezers.
 This can be accomplished by boiling in water for five to ten minutes
or by heating over a flame.  If you use the latter method, be sure to
heat the metal until it is red hot.  Don't use these "surgical
instruments" until they have cooled down; wait about a minute.  Once
the sterilization process is complete, be careful not to allow
anything to touch the working ends of the instruments.

   (3)  If you must, you can do the procedure yourself, but if you
let a brave and trustworthy friend or relative do it, the chances of
success are greater.

   (4)  The Procedure:  Prepare the skin with rubbing alcohol. When
the end of the splinter is sticking out, just pull on it gently with
the tweezers.  If you need to dig, use the needle to prick the top
skin away.  There may be some bleeding.  Use the tweezers to pull out
the splinter, keeping steady tension along the line of entry into the
skin.

   (5)  Do not attempt to remove the splinter if you can't see it, it
is deep or if you are not sure the procedure can be done properly and
safely.

   (6)  At the end of the procedure, squeeze a small amount of blood
out of the wound, wash with soap and water, and cover the wound with
a Band-Aid.

   (7)  See your doctor if you can't remove the entire splinter or if
you develop signs of infection such as redness, swelling, drainage of
pus, fever or pain.






SMASHED FINGERTIP WITH BLOOD UNDER THE NAIL

   A smashed fingertip is usually due to careless hammer or door-
slamming injuries.  At the time of impact, damaged vessels in the
nailbed begin to bleed resulting in an accumulation of blood under
the nail which is referred to as a subungual hematoma.  If the blood
cannot escape, the pressure beneath the nail will gradually increase
and cause an intense, painful throbbing. Drainage is required to
relieve the pain.

   Treatment

   (1)  Put the finger in ice immediately to decrease the swelling.

   (2)  Not all subungual hematomas need to be drained.  If the pain
is not severe, you can wait and see what happens.  Often the initial
pain will subside leaving you with just a black nail.  As the nail
grows out over the ensuing few months, the discoloration will
disappear.

   (3)  If an intense throbbing pain develops, and you cannot get to
the doctor, the blood under the nail can be drained out at home.
Sterilize the end of a straightened paper clip by holding it over an
open flame until it is red hot.  Place the still-hot end directly
over the center of the dark spot applying gentle pressure until the
nail has melted through.  This may take several attempts; reheat the
paper clip each time.  Finally, when the nail is penetrated, squeeze
out as much blood as possible, wrapping the finger in a sterile
gauze.  Cover with a Band-Aid.

   (4)  If the nail is loose, do not try to remove it.

   (5)  Buddy-taping.  For protection, tape the injured finger to an
adjacent finger--like fashioning a natural splint.

   (6)  Watch for signs of infection: redness, drainage of pus,
swelling, fever.

   (7)  See your doctor if there is deformity, numbness, tingling,
signs of infection, continued pain or persistent bleeding, if you
cannot completely bend or extend your finger, or if you are uncertain
what to do.






   TREATING SPRAINS

   Sprains occur when a twisting injury causes partial tearing of the
ligaments surrounding a joint.  They may be difficult to
differentiate from fractures because both types of injury cause
swelling, pain and bruising; however, while most fractures show up on
the X-rays, sprains do not.  Sprains should not be regarded lightly.
They may require casting or surgery.  A normal X-ray, therefore, does
not guarantee a minor injury.  The ankle is the most commonly
sprained joint.  Conscientious therapy helps to prevent prolonged
disability.

   Treatment

   (1)  As soon as the injury occurs, stop the activity and apply ice
to the area.  This will help to decrease swelling.  Do not use the
injured joint.

   (2)  See your doctor. In most cases, an X-ray is necessary to rule
out a fracture.

   (3)  If a sling, splint or cast was applied, follow your doctor's
instructions.  With minor sprains, an Ace bandage is sufficient.  Be
sure to wrap the joint firmly, but not too tightly.

   (4)  Use an ice bag (ice in a "baggy") for the first twenty- four
to forty-eight hours.  After that, heat (soaks or pad) helps to
increase blood flow to the area and speed healing.

   (5)  Elevate the joint to diminish swelling.  Try to keep it above
the level of the heart.  For an ankle injury, a footstool or a pillow
is helpful.

   (6)  Rest the joint.  This is most important, as continued use of
the joint delays healing and may cause more injury.  Do not put any
weight on the affected extremity intil the pain is gone! Use crutches
for ankle and knee injuries.

   (7)  If you rest, the pain should not be too severe.  Aspirin,
acetaminophen (Tylenol, Datril, Panadol) or ibuprofen (Advil, Nuprin)
can provide relief.

   (8)  It is not unusual for sprains to take several weeks to heal.
Call your doctor if you have any questions about your progress.






   HOW TO USE CRUTCHES

   Crutches allow one to control the amount of weight placed on an
injured extremity.  Learning to use them safely can be an important
part of the recovery from leg, ankle and foot injuries.

   How to Assure Proper Fit

   (1)  The length of the crutches can be adjusted by hand. Loosen
the wingnuts holding the lower extensions and realign the holes to
get the proper length.  Your armpits should clear the top of each
crutch by one or two inches when the crutches are held six inches to
the side of and just in front of your feet.

   (2)  The hand grips can be adjusted in a similar manner.  With the
crutches underneath your arms and your hands on the grips, your
elbows should be bent comfortably at about thirty degrees.

   (3)  Remember to use the rubber supports for the hand grips and
the top and bottom of each crutch.

   Standing, Walking and Sitting

   (1)  Place the crutches beneath your arms.  Keep both arms free.

   (2)  To support your weight while standing, the tips of the
crutches should be positioned to the side of your feet, about eight
to twelve inches in front of your toes.  Your weight is supported by
your hands and arms, not your armpits.

   (3)  To walk, hold the injured leg off the ground, place the
crutch tips about eight to twelve inches in front of you, and swing
your body through, bearing all weight on the hand grips. Keep a slow
even pace.  Avoid ice, slippery surfaces and steep inclines.

   (4)  If your doctor advises you to bear some weight on the injured
leg, advance it gently with the crutches, swinging your good leg
through as before.

   (5) In order to sit down, put the crutches in one hand and lower
yourself into the chair, leaning against your free hand. Similarly,
you can lean on the crutches to pull yourself up.

   Stairs

   (1)  Go slowly, one stair at a time.  Have someone help you.

   (2)  To climb stairs, step up with your good leg first. Follow
with the crutches placed adjacently on the same step.

   (3)  To descend, lead with the crutches, stepping down with your
good leg.





   MINOR THERMAL BURNS

   Minor burns are common household injuries which require prompt
attention and conscientious care.  Learning to care for them helps to
reduce scarring and speed healing.  Because normal skin acts as a
protective barrier against bacteria, burn wounds are particularly
susceptible to infection.

   A first degree burn involves only the superficial layer of the
skin.  Redness, pain and minimal swelling occur, e.g. sunburn. Second
degree burns have blisters and are more painful.  Third degree burns
involve the full thickness of the skin with charring and damage to
deeper tissues.  They heal by scarring unless a skin graft is
applied.  Many burns are combinations of these three types.

   Immediate Care

   (1)  A person who is on fire should lie on the ground and begin
rolling.  Standing upright or running just fans the flames. If
possible, he should be covered immediately with a rug or blanket.
This will help to smother the fire.

   (2)  Apply cold to burned area.  Ice, cold water or water- soaked
towels may help reduce pain and the extent of injury.  Do not use
home remedies! (Butter has no benefit and it may even increase the
chances of infection).

   (3)  Remove jewelry if an extremity is involved.

   (4)  Cleanse the burn in soap and water.

   (5)  Cover the area with sterile gauze, if available. Otherwise,
use clean sheets or cloth.

   See A Doctor Immediately If:

   (1)  the burn is deep, severe or extensive.

   (2)  the burn covers more than five percent (1/20) of the body
surface area.  For reference, one arm is about ten percent.

   (3)  there is charring, blistering or swelling.

   (4)  the face, eyes or genitals are involved.

   (5)  there is severe pain.

   (6)  there is fever, drainage of pus or a foul odor.

   (7)  there is inability to bend a joint.

   (8)  there is a special concern about scarring.

   (9)  the injured person hasn't had a tetanus shot in the last five
to ten years.

  (10)  you are uncertain about what to do.

   Follow-up Care

   (1)  Follow your doctors advice, using all prescribed medications.

   (2)  Keep the burn clean!  Soak it in soap and water for ten to
fifteen minutes, once or twice a day.  Don't rub the skin hard, but
allow all the loose skin to fall off.  (Dead skin predisposes to
infection.)  Blot dry afterwards.

   (3)  If an antibiotic cream such as silver sulfadiazine
(Silvadene) or mafenide acetate (Sulfamylon) is prescribed, apply it
in a thin layer (1/16 inch) after each cleansing.  Use sterile
gloves.  Cover with a sterile gauze held in place by adhesive tape.
The gloves and bandage materials should be available at any pharmacy.

   (4)  Exercise the burned area to prevent stiffness.  Avoid
strenuous activity.

   (5)  Normal healing may take several weeks.






   MINOR CHEMICAL BURNS

   Although most chemical burns occur at work--especially industrial
or scientific laboratories--the home is also a source of dangerous
chemicals.  Immediate treatment before you get to your doctor may
prevent a lot of misery.  Chemical burns are similar to thermal burns
in regard to the damage they inflict on the skin; however the
treatment, least initially, is different. Dilution with large amounts
of water is indicated in most instances, sometimes followed by a
neutralizing chemical.

   Prevention

   (1)  Keep all chemicals out of reach of children.

   (2)  Before using a new chemical, read the label and be ready to
treat the possible complications.  Have water and the recommended
neutralizing acid or alkali (base) available.

   (3)  Follow the directions for use.  Don't mix chemicals or
ingredients that don't go together.  For example, check to see if
water starts a reaction, e.g. lye.  Watch out for splashes.  Pour
solutions slowly and accurately.

   (4)  Wear gloves and protective clothing if possible.

   (5)  Always know where the container is when you are working.
Place it in a secure place so that it is not easily broken or
toppled.

   (6)  Dispose of the unused portion safely.

   Immediate Treatment

   The most common examples of alkali burns are lye (sodium
hydroxide) and lime (calcium oxide); acids are hydrochloric and
sulfuric.

   (1)  For lye burns, flush the involved area with copius amounts of
water from the faucet, hose, or shower.  Don't splash. Keep it up for
ten to fifteen minutes to dilute the alkali still in contact with
your skin.

   (2)  For lime burns, brush off the residual chemical with a rag
prior to flushing with water.  If you don't, the reaction between the
water and the lime could produce a dangerous amount of heat.

   (3)  For acid burns, flush immediately as above.  A solution of
baking soda and water will help neutralize the acid.  Use it only
after the area has been thoroughly rinsed so as not to produce heat
from the chemical reaction.

   (4)  Follow directions on the label.

   (5)  If your eye has been splashed, rinse it for one-half hour
with water or salt water.  Do not use a neutralizing solution! Patch
the eye afterwards.

   (6)  See your doctor.





   MAMMALIAN ANIMAL BITES

   Almost two million animal bites occur each year in this country.
Most bites involve the extremities, with domestic dogs and cats
accounting for over 90 percent of the total.  Males and young
children are especially at risk.

   It is important to remember that bites are frequently deep wounds
that puncture and tear the tissues, harming structures beneath the
skin.  Furthermore, because the mouths of even household pets harbor
dangerous bacteria, the risk of infection is greater than that seen
with the usual types of cuts and scrapes.  Some mammalian
bite-related infections include tetanus, rabies, rat bite fever, cat
scratch disease (fever) and the plague.  Proper wound care and
attention to infectious complications are important.

   What to Do:

   (1)  Stop the bleeding by raising the injured part and applying
constant, direct pressure with your hand.  Use a sterile gauze or
clean cloth if possible.

   (2)  Cleanse the wound with soap and water, followed by hydrogen
peroxide.  Allow the bubbling to stop, and cover with a sterile
bandage (Band-Aid if small) from the drug store.

   (3)  See your doctor.  The wound may require removal of crushed or
torn tissue.  It may have to be opened up to determine the extent of
injury to tendons, nerves and blood vessels.  You may need
antibiotics, stitches, a tetanus shot or rabies treatment.
Antibiotics are often prescribed prophylactically (to prevent
infection).

   (4)  With regard to rabies, it is important to try to obtain as
much information about the animal as you can.  The animals that are
at the greatest risk for carrying this deadly disease are skunks,
raccoons, wild foxes, cattle, bats, cats and dogs. Interestingly
enough rats, rabbits, squirrels, hamsters and chipmunks rarely
contract rabies.

   Optimally, the animal should be caught alive and confined for a
period of observation.  If the animal is killed, its brain can be
studied for evidence of the disease.  If the bite was from a domestic
animal, the immunization record should be investigated. At least try
to put together a description of the animal and where you saw it
last.  In most instances your doctor will be required to report the
incident to public health authorities.

   (5)  Follow your doctor's instructions about care of the wound.
Watch for pain, drainage, pus, redness, swelling and fever.

   (6)  For more information about specific infections, consult the
Disorders and Diseases section.






   HUMAN BITES

   Human bites can be much more dangerous than those inflicted by
animals.  As many as 50 percent are complicated by serious infection.
 Because they are usually a result of fighting, the hands, arms, head
and neck are most often involved.  One should realize that blows to
the mouth that break the skin on the puncher's hand are, in effect,
the same as a bite.  Prompt, conscientious therapy helps to prevent
infection and speed healing.

   Treatment

   (1)  Stop the bleeding by raising the injured part and applying
constant, direct pressure with your hand.  Use a sterile gauze or
clean cloth if possible.

   (2)  Cleanse the wound with soap and water, followed by hydrogen
peroxide.  Apply no other salves or ointments and cover with a
sterile bandage.

   (3)  See your doctor as soon as you can; waiting will increase the
chances of complications.  You will require a tetanus shot if you're
not up to date (within five years).  The wound will be examined for
damage to important structures beneath the skin. Torn and damaged
tissue can be removed.  Unless it's on the face, the wound will not
be stitched until several days have passed. Early closure of the
edges of the skin actually predisposes to infection.  During the
waiting period, the wound should be kept open and allowed to drain.
Warm salt water soaks and antibiotics are prescribed to prevent
infection.

   (4)  Be sure to watch for pain, drainage, pus, redness, swelling
and fever.  Serious infection may require hospitalization.






   INSECT AND BUG BITES

(Please see the separate articles dealing with lice and scabies)

   While flies, mosquitoes, fleas, chiggers, gnats and ticks are
annoying and may carry some serious diseases, their bites or stings
are rarely dangerous.  Minor swelling, redness and itching may occur,
but allergic reactions are unusual.

   What to Do:

   (1)  Wash the bite in soap and water.

   (2)  Apply ice to decrease the swelling and diminish itching.

   (3)  Try not to scratch; the bite could get infected.

   (4)  Calamine lotion and baking soda and water may be soothing.

   (5)  A special word about ticks.  These small flat, dark,
eight-legged arthropods attach themselves very closely to the skin.
If you try to pull or burn them out, their body will detach, leaving
a portion underneath the skin.  Before removing, pour heavy oil over
the tick to get it to release its grasp.





   INSECT STINGS

   Stings from hymenoptera, the order of insects that includes bees,
yellow jackets, wasps, hornets and fire ants, can be dangerous as
well as troublesome.  There are two things about being stung that are
harmful, the sting itself--which is painful and frightening--and the
injected venom.  Reactions to insect venoms may be both toxic and
allergic in nature.  While most sting victims experience only minor
reactions, a minority will suffer severe reactions such as shortness
of breath, allergic shock (anaphylaxis) or sudden death.

   Toxic reactions refer to those which are due to the direct
chemical effects of the injected venom; they involve mainly pain,
redness and swelling in the area of the sting.  They can be dangerous
depending upon the species of insect, the victim's size and state of
health and the number and location of the stings.

   Allergic reactions are those which are due to an individual's
immune (antibody) response to the venom.  They may be generalized
throughout the body or localized to the site of the sting.  Among the
common reactions attributed to allergy are redness, swelling,
itching, hives, trouble breathing, wheezing, throat swelling,
anaphylaxis and sudden death.

   When stung, it is important to know what to do and when to be
afraid.

   Be Prepared:

   (1)  Learn where the hives are in your neighborhood and avoid
activities in those areas.  Don't go barefoot.

   (2)  Teach your children which are the dangerous insects and
instruct them not to antagonize them.

   (3)  If you have a history of severe allergic reactions, wear a
warning tag or bracelet (Medic-Alert) and carry a card in your
wallet.  Ask your doctor about the advisability of carrying with you
an emergency kit that contains a tourniquet, an injectable dose of
epinephrine (adrenalin) and antihistamine pills.  If you have one
already, be sure that all your family members know how to use it.
Learn cardiopulmonary resuscitation (CPR) techniques.

   What To Do When Stung:

   (1)  Remain calm.  Get to a safe place away from the hive.

   (2)  If a stinger is visible, remove it by scraping with your nail
or a sharp knife.  Try not to squeeze the venom sac.

   (3)  Wash the area in soap and water.

   (4)  Ice packs can decrease swelling and pain.

   (5)  Apply baking soda and water or just cool water to relieve
itching.

   (6)  Watch for severe swelling, swelling around the face, throat
or mouth, trouble breathing, wheezing, difficulty swallowing, nausea
and vomiting, hives, generalized itching and lightheadedness.

   (7)  In the event of an allergic reaction, get right to a
hospital.  If an emergency kit is available, follow the instructions.
 CPR may be required.  Remember: most life- threatening reactions
occur in the first half hour.





   SPIDERS AND SCORPIONS

   Spiders and scorpions are part of the class of arthropods called
Arachnida.  Over 20,000 species produce venom or are poisonous.
Learning to recognize the common species and knowing what to do when
bitten or stung can help save a life.

   Dangerous Arachnids

   Black Widow Spider -- Only the female is dangerous to man. About 1
1/2 inches in diameter including legs, it has a black body with red
spots underneath either in the shape of an hourglass or large
blotches.  In inhabited areas throughout 48 states, the black widow
lives in barns, cellars, woodpiles and outhouses.  When provoked, it
will attack.

   The bite feels like a needle, but it may go unnoticed. Swelling
and redness ensue, followed by severe cramping pain in the abdomen or
chest, lightheadedness, high blood pressure, nausea and vomiting,
headache, trouble breathing and sweating. Pancreatitis is a
recognized complication.  Small children may not recover.

   Brown Recluse Spider -- This normally docile spider is also known
as the fiddler spider because of the dark, violin-shaped marking on
the front of its brown thorax.  In the south central part of this
country, it can be found in dark places, under logs and rockpiles,
and in attics.

   Its bite is mildly painful initially, but after several hours a
bull's-eye shaped pattern appears and a blister forms.  The pain
increases.  Severe symptoms such as fever, nausea, vomiting, fatigue,
joint pains and sometimes shock may ensue.  As with black widows,
small children may die from the complications.

   Tarantula -- These large, "hairy" spiders are becoming popular as
pets.  Despite their scary appearance, they are not very dangerous.
Delayed pain may occur around the bite site.

   Scorpion -- This arachnid resembles a small crawfish with a
stinger poised on the end of its tail.  The scorpion attacks by
bending its tail forward over its back and jabbing until it hits the
mark.  Active only at night, it hides under dark places in the
daytime.  In this country, it is found only in the Southwest.

   The sting is very painful, but the symptoms depend on the species.
 In severe cases, numbness, spasms, blurred vision, nausea, vomiting,
sweating, convulsions paralysis, breathing distress, blackouts, shock
or death may ensue.

   What To Do:

   (1)  First aid for spider and scorpion bites or stings is not very
involved.  You should put ice on the site of the injury and transport
the victim to a medical facility immediately.

   (2)  If shock develops, perform cardiopulmonary resuscitation
(CPR)--if you know how--and call an ambulance.

   (3)  It will be helpful for the treating physician to know what
the spider looked like and when, where and how the bite occurred.
Bring the spider with you if it is possible without wasting time or
risking your safety.  This information may be used to determine if
antivenom is available or will be effective.






   LICE AND CRAB LICE

   Lice are small, blood-sucking parasites that are contracted by
close personal contact and from shared combs, headwear, clothing and
bedding.  Because some forms live on surfaces in public places for up
to ten days, direct person-to-person contact is not always required.
There are three types that live on humans: head, body and pubic
(crab) lice.  The medical term for lice infestation is "pediculosis."

   The head louse is a dark, 1/8 - 1/4 inch long, multi-legged bug
which, despite public health measures and conscientious personal
hygiene, infests the scalps of thousands of school children.  During
its month long lifespan, a single female can glue several thousand
small round, white eggs (nits) to the roots of individual hairs.  The
eggs hatch within ten days and perpetuate the cycle unless treatment
intervenes.  Head lice produce intense itching and often, a scaly
rash.  The diagnosis is frequently made when the nits are found, as
the adult louse may not be visible.

   Body lice resemble head lice in appearance and life cycle, but lay
most of their eggs in the creases and seams of clothing. Older
persons with poor hygiene are most often infested.

   Pubic lice (crabs) are about half the size of head and body lice.
They look like tiny crabs, hence the nickname.  Because sexual
contact is a common mode of acquisition, the groin is usually
involved; however, the eyebrows, lashes and beard may also be
infested.

   Learning to recognize the signs of lice infestation, and following
the instructions for therapy, can help to prevent a health problem of
sometimes epidemic proportions.

   What To Do:

   (1)  Suspect lice if you, your child, your sexual partner or a
family member develops intense itching with or without a rash. Be
especially aware when you hear of other cases at school or among your
child's playmates.  Look for nits and adult lice in clothing and on
hair roots.

   (2)  See the doctor to confirm the diagnosis.

   (3)  Follow the doctor's advice with regard to medications.
Commonly prescribed treatments include lindane (Kwell) shampoo,
lotion, and cream; pyrethins with piperonyl butoxide (Rid); and
malathion lotion (Prioderm) for head lice.  These products have
strict recommendations for their duration of use and frequency of
application.  Often, more than one application is required.

   (4)  Use a fine-toothed comb to removed dead lice and nits from
the hair follicles.

   (5)  Launder all clothing, bed linen and blankets in hot water, or
dry clean.  Clothes burning and burying are not necessary.

   (6)  After using the medicine, it may take a week to ten days to
know if the therapy has been successful.  Don't be discouraged.

   (7)  Remember: Everyone is at risk for contracting lice,
regardless of socioeconomic class, hygiene or background.  The theory
that lice only affect the underprivileged or the underscrubbed is
simply unfounded.





   Scabies (itch mite)

   Scabies is a skin infestation by the itch mite, Sarcoptes scabei.
A slightly different mite causes the animal disease, mange.  Human
beings contract mites either by close personal contact with people
who are already infested or from their clothing or bedding.  Dog
handlers rarely develop the animal form of the disease.

   An adult mite has bristles and eight legs and is less than a
quarter of an inch long.  The female burrows to deposit her eggs
beneath the skin of the webs between the fingers as well as the
groin, waist armpits, elbows, legs, ankles and feet.  The eggs hatch
in three to five days, with the offspring (nymphs) reaching adulthood
a couple of weeks later.

   Scabies, the disease that the mite causes, does not usually
develop until about a month after the bug is contracted.  It is
delayed because it results from an allergic reaction to the mites and
their excretions.  The major symptom is intense itching, especially
at night.  Burrows may be visible in the areas mentioned above, but
sores and a red, bumpy, irritated rash soon develop.  With scratching
or severe infestations, the involved skin can become scaly, crusted
and infected by bacteria. Although scabies is more common in persons
with poor hygiene, no socioeconomic group is spared; anyone who is
exposed to the mite can contract the disease.

   What To Do:

   (1)  Suspect scabies or lice if you, your child, your sexual
partner or a family member has intense itching or a rash-- especially
if it is "going around."

   (2)  See your doctor to confirm the diagnosis.  The mites, eggs or
debris should be identified under a microscope.  Lice infestations,
skin infections and a variety of skin diseases can be confused with
scabies.

   (3)  Follow your doctor's advice about medications.  Commonly
employed creams, lotions or sprays such as lindane (Kwell),
crotamiton (Eurax), benzyl benzoate and sulfur in petrolatum have
strict recommendations for their duration of use and frequency of
application.

   (4)  Wash clothes and bedding in hot water.  Burning and burying
are unnecessary.

   (5)  Do not be discouraged if the itching persists slightly beyond
the eradication of the mite.  For a time there may be a residual
allergic reaction.

   (6)  Remember, reinfection is common.  Be careful not to "ping
pong" the bug back and forth between family members.





   VENOMOUS OCEAN ANIMALS

   Many seaside outings have been disrupted by stings or bites from
venomous ocean creatures.  Learning how to deal with the initial
injury may help you to save a life as well as a vacation. There are
three ways in which poisonous sea animals can administer their venom:

   (1) Nematocysts --  Coelenterates such as the jellyfish and the
Portuguese man-o-war have hundreds of dart-like venom tubes called
nematocysts arranged along the length of their tentacles. When a
bather accidentally comes in contact with one of these pretty but
dangerous animals, the nematocysts fire automatically, penetrating
the skin and releasing their venom.  An intense burning and numbness
follows, and red bumps develop where the nematocysts have entered.
Most cases are not more serious, but the extent of the reaction
depends on the species of the animal, the amount of venom injected
and the allergic reaction of the victim.  Nausea, sweating, chest
pain, trouble breathing, cramps, convulsions, shock or death can
result.

   (2) Biting --  Octopi and their cousins are normally docile. But
when provoked, they are known to bite their victims, releasing a
toxic substance which occasionally results in a fatality.

   (3) Stinging -- The major culprits here are the sea urchin and the
stingray.  Sea urchins have hard, sharp venomous spines that
penetrate the skin when stepped on.  Pain, discoloration, and
infection of the wound are common.  The stingray, a fish related to
the shark, has a flat, wide body and a long flexible tail containing
a sharp, poisonous spine or stinger.  When disturbed in shallow
water, the ray will whip its tail forcefully, catching a surprised
wader in the leg with its stinger.  Severe pain is immediate.  There
may be life-threatening complications.

   What To Do:

   (1)  First, prevent drowning by getting the victim out of the
water.  Most deaths occur in the water.

   (2)  If necessary, administer advanced life support
techniques--cardiopulmonary resuscitation (CPR)--but only if you know
how.

   (3)  Arrange for transportation to a health care facility when the
reaction or wound is severe, or if you are uncertain about what to
do.

   (4)  To remove coelenterate tentacles without causing more
nematocysts to discharge, wash them with sea water, alcohol, ammonia
or vinegar, being sure to use gloves or a towel.  Do not use fresh
water or sand, or touch the tentacles with an unprotected hand.  If
the tentacles remain, apply a paste made of baking soda or talc, then
scrape them off with a knife or shell. Ask the lifeguard for help.

   (5)  With stingray wounds, it is important to act fast so that the
venom doesn't get into the bloodstream.  Place the injured part in
water as hot as the victim can tolerate.  Keep this up for 30-60
minutes to help to inactivate the poison.  Cleanse with soap and
water.  If spines are visible in the wound, let the doctor remove
them.

   (6)  Similarly, embedded sea urchin and coral spines must be
removed by a doctor.





   SUNBURN AND TANNING

   About five percent of the sunlight that reaches the earth is made
up of invisible ultraviolet (UV) light rays, UVA and UVB. UVA, the
long wave ultraviolet, causes tanning by increasing the production of
the natural skin pigment, melanin.  UVB, the middle wavelength
ultraviolet, is the major cause of sunburn.  The sunlight between the
hours of 10:00 AM and 3:00 PM is most direct, has the highest amount
of UVA and UVB, and presents the greatest risk for sunburn.

   Whether one burns depends on a number of factors: skin color, the
time of day, the duration of sun exposure, clouds, smog, altitude,
the amount of reflected light, medications, protective clothing and
sunscreens.  As with most conditions, "an ounce of prevention is
worth a pound of cure."

   Prevention

   (1)  Recognize the risk factors.  You are more likely to burn if
you are light-skinned, it is the first time you have been out for the
year, you stay out a long time during peak hours, you are nearer the
equator--more direct sunlight, you are at high elevations (Each 1,000
feet in altitude adds four percent to the intensity of the sunlight),
or if you are taking certain medictions, e.g. tetracycline, sulfa
antibiotics, diuretics.

   (2)  Don't be fooled by the clouds or wind.  Sure, clouds and smog
do block out some of the ultraviolet light, but at the same time they
absorb some of the heat.  You might feel cooler on a cloudy day, but
you still have significant exposure to UVB. Similarly, a cooling
breeze can be deceptive and make you think that you can stay out
longer.  A windburn may aggravate the situation.

   (3)  Water is no protection, either.  UVB light penetrates at
least three feet deep.

   (4)  Watch out for reflected light.  Indirect light bouncing off
sand, snow, white surfaces and metals can hit you even if you are in
the shade or under an umbrella.  Unless the sun is directly overhead,
water does not reflect much light.

   (5)  Wear dry, dark, tight knit clothing.  Although warmer, it
blocks out more light.  Hats and visors are a good idea.

   (6)  Keep small children and infants covered and out of direct
light, except for short periods.

   (7)  Sunscreens (Blockers) -- The chemical types usually contain
para-aminobenzoic acid (PABA), padimate O or a benzophenone in the
form of a cream, lotion or gel.  They work by partially absorbing
ultraviolet light: benzophenones absorb UVA and UVB, PABA and
padimate O just UVB.  The physical sunscreens work by blocking out
sunlight.  They usually contain titanium dioxide or zinc oxide in the
form of an opaque white paste which can be placed on the nose and
lips.

   The protective ability of sunscreens is quantified by what is
called the "Sun Protection Factor," or SPF.  The SPF, a number from
two to twenty or more, is a ratio of the exposure time required to
produce skin redness using the sunscreen divided by the exposure time
required to produce the same degree of redness without the sunscreen.
 The higher the number, the more protection.  For example a sunscreen
with an SPF of ten allows you to stay out twice as long as one with a
rating of five.

   Before using a sunscreen, read the label to get the SPF, and
method of application.  Remember, all sunscreens must be reapplied
after swimming, sweating or exercise.  Watch for allergic reactions.
Ask your doctor for advice about which sunscreen to use if you have a
skin disease or are taking a medication which causes sun sensitivity.

   Treatment

   Once sunburn has occurred, cool compresses, aspirin and vaseline
or hydrocortisone lotion may provide relief.  Severe sunburn may
require stronger pain medication, "cortisone-type" pills and
sometimes even hospitalization.

   Tanning

   Contrary to popular expectations, suntanning lotions do not
increase skin pigmentation.  And the "tanning" preparations which are
touted to work without the sun are nothing more than dyes. However,
sunscreens may diminish tanning especially if they affect both UVA
and UVB light.

   The best way to tan is to do it slowly by gradually increasing
your sun exposure time each day.  Begin with a high-SPF (15)
sunscreen which does not block UVA light.  As you tan, the increased
melanin in your skin acts as a natural sunscreen allowing you to use
a blocker with a lower SPF (10) until you have reached the desired
tone.  After that, use the high-SPF preparation and a good
moisturizer.

   Keep in mind that although you may look nice with that deep dark
tan, prolonged sun exposure has many long-term adverse effects, i.e.
skin cancers, non-malignant skin tumors, abnormal pigmentation,
wrinkling and early "aging."

   One final point.  Indoor tanning parlors, which advertise UVA
light, have at least the potential to cause eye injury, light
sensitivity and premature aging and cancers of the skin.  But all the
answers aren't in: it may take years to document long-term effects.





   HEAT CRAMPS

   Heat cramps are painful spasms of the muscles brought on by
physical exertion in hot weather.  The calves are most commonly
affected, although any active muscles can be.  The major predisposing
factor is intense sweating followed by the drinking of salt-free
fluids, e.g. water.  Fatigue, poor general health, being "out of
shape," alcohol and poor nutrition may also play a role.

   It is not simply low levels of salt in the blood that cause heat
cramps, but an imbalance between body salt (sodium) and water is felt
to be important.  The exact cause is unknown.

   Heat cramps are usually brief self-limited discomforts; however,
they may be early signs of heat exhaustion or heat stroke, two
serious complications of prolonged heat exposure. Those who work or
exert themselves in hot weather should be prepared to recognize and
deal with this painful condition.

   Prevention

   (1)  Don't overexert yourself in hot weather, especially if you're
not in shape.  Know your physical limitations.

   (2)  Dress appropriately.

   (3)  Stretch before exercising.

   (4)  If you are prone to heat cramps, you will want to either eat
salty foods or add salt at the table prior to exertion.  Salt tablets
are not usually necessary.

   (5)  Stop to drink fluids with at least some salt in them during
intense exercise, e.g. carry a refreshment bottle. Afterward, take in
salt-containing foods and liquids--not just water.

   When Cramps Occur:

   (1)  Stop immediately and rest in a cool place.

   (2)  Stretching the involved muscles may provide immediate relief.
 With calf cramps, try forcing your foot back so that your toes point
toward your head.  A good way to do this is to lean against a wall
with your hands, keeping your feet about four feet from the base of
wall.  Then force your hips forward, keeping your knees straight and
your heels on the ground.

   (3)  Massage the painful muscle.

   (4)  Drink high salt-containing fluids and foods.  Salt tablets
may give you an upset stomach, but take them along if you are in an
isolated area.

   (5)  See you doctor if the cramps are severe, persistent or
recurrent.





   HEAT EXHAUSTION & DEHYDRATION

   Heat exhaustion is a condition caused by the depletion of body
salt and/or water.  Hot weather and exertion often contribute to its
development, but any process which leads to dehydration may be
responsible.  The symptoms are fatigue, lightheadedness, thirst,
muscle cramps and spasms, nausea and vomiting.  Although the victim
may be listless, mental functioning is normal.  Low grade fever (99
to 102 degrees F.), a rapid pulse and dehydraton are often present.

   Heat exhaustion must be differentiated from life-threatening heat
stroke.  With the latter condition the temperature is very high--104
to 106 degrees F. or more.  It is associated with mental confusion,
unusual behavior, convulsions or coma. Frequently, the blood pressure
is dangerously low (shock).

   Immediate Care

   (1)  Move the person to a cool or air-conditioned place and have
him lie down on his back.  A fan may help.

   (2)  Remove or loosen tight clothing.

   (3)  Place cool compresses or ice on the forehead and neck, and
under the arms.  You can sprinkle water, but don't immerse the person
entirely.

   (4)  If vomiting occurs, give nothing by mouth.  Otherwise, have
the victim drink cold, salt-containing liquids.  You can improvise by
mixing four teaspoons of salt (one tsp./glass) in one quart of water
and administering four ounces every fifteen minutes.

   (5)  Transport the victim to a health care facility.
Hospitalization for intravenous (IV--through the veins) fluids may be
required.





   FROSTBITE

   Frostbite is an injury caused by exposure to cold temperatures.
Damage to tissues occurs from direct freezing of cells and/or from
spasm of the vessels that supply blood to the affected area.  In
severe cases, loss of limb and life can result.  Although rapid
rewarming and conscientious skin care after the injury are valuable,
prevention is even more important.

   Prevention

   (1)  If you are hiking, mountaineering or cross-country skiing,
study the map before you leave.  Don't go off alone.

   (2)  Check the weather report.  About nine out of ten cases of
frostbite occur at temperatures below +20 degrees F.  The wind is
also important because of the cooling effect of convective heat loss.
 The wind-chill factor, an index relating the wind speed to the
ambient temperature to arrive at an equivalent chill temperature, is
highly predictive.  Wind-chill temperatures below -20 degrees (e.g.
+10 degrees, 15 mph wind) can freeze exposed flesh in less than a
minute even if you are properly clothed. Note the precipitation.
Getting wet causes you to lose 25 times more heat at the same
temperture.

   (3)  Dress warmly in multiple layers.  Your outerwear should be
waterproof.  Be careful not to overdress or you will sweat and feel
even colder.  Take extra clothes along, if you can.

   (4)  Your toes, feet, hands, face, ears and nose are most
susceptible to frostbite.  Wear a hat, cover your ears, and use
mittens instead of gloves if possible.  Warm, waterproof boots and a
good pair of wool socks are a must for outdoor winter activities.

   (5)  Learn to recognize frostbite.  Initially the skin is red and
painful, then white and numb.  Blisters may develop.

   (6)  Don't overexert yourself or stay out too long.  Take regular
breaks.  Fatigue, accidents, injuries and long duration of exposure
to cold greatly increase the risks.

   (7)  Don't let bare metal come into contact with unprotected skin.

   (8)  Avoid tobacco and alcohol until you're back inside. Tobacco
causes constriction of blood vessels.

   (9)  Individuals with previous cold injuries, atherosclerosis or
bad circulation are particularly at risk.

   Immediate Treatment

   (1)  While still outside, cover the involved area with extra
clothing.  Put your hands under your armpits or between your legs.
Do not rub the area with anything, especially not snow!

   (2)  Get inside.  Transportation to a hospital should be arranged
emergently for all but the mildest cases (frostnip).

   (3)  Rapid rewarming is the recommended therapy, but don't let it
delay the trip to the hospital.  Soak the affected part in water that
is between 104 and 108 degrees F. (slightly above body temp.) for a
period of twenty minutes.  The pain will increase during this time.
Warmer temperatures can be harmful as are heating pads, hot water
bottles and direct flames.  Do not allow refreezing.

   (4)  Elevate affected extremities and exercise them to increase
the circulation.  Do not walk.

   (5)  Drink hot liquids: tea, coffee, cocoa, etc.






   INTRODUCTION

   HealthNet welcomes an important new section to its reference
library, "Obstetrics and Reproductive Medicine."  The Normal
Pregnancy menu includes articles about the physiology, signs,
symptoms, diagnosis, nutrition and routine evaluation of
uncomplicated pregnancy.  Prenatal care, natural childbirth, and home
and hospital deliveries are discussed.  When this section is
completed, it will also contain information about contraception,
infertility, genetic counseling, labor and delivery, high risk
pregnancy and postpartum care.

   Obstetrics and Reproductive Medicine is authored by Drs. Jeffrey
L. Stern and Susan J. Bertolli.  Dr. Stern is Assistant Professor of
Obstetrics, Gynecology and Reproductive Medicine at the University of
California at San Francisco.  He is also the Director of Gynecologic
Oncology at the San Francisco General Hospital.  His major areas of
interest are malignant and premalignant diseases of the female
reproductive tract.  Dr. Bertolli practices obstetrics, gynecology
and infertility at the Kaiser Foundation Hospital in San Francisco.





   PREGANCY TESTS AND DIAGNOSIS

Jeffrey L. Stern, M.D., University of California at San Francisco

Susan J. Bertolli, M.D., San Francisco, California

   Pregnancy is easily diagnosed in most women because the symptoms
and the findings on physical examination are characteristic.  In
early pregnancy, blood and urine tests are helpful in confirming the
diagnosis.

   Amenorrhea

   Amenorrhea, the cessation of normal, regular menstruation, is the
most obvious symptom of early pregnancy.  However, some pregnant
women have vaginal spotting at the time they expect their period.  As
a rule the bleeding is not clinically significant.  For women who
normally have irregular or occasional menstrual periods, amenorrhea
may not be a reliable symptom.

   Morning Sickness

   Approximately fifty percent of pregnant women will experience mild
to severe nausea associated with vomiting.  This intestinal upset
usually develops between the second to sixteenth week of gestation
and decreases in severity thereafter.  Historically, it is most
common in the morning, but it may occur throughout the day.

   Breast Symptoms

   Even in early pregnancy, the breasts begin to enlarge. Swelling,
soreness, and increased sensitivity similar to the changes that many
women experience prior to normal menstrual periods may be associated.

   Pelvic Symptoms

   Frequent urination during the daytime and at night is common,
especially in the first third of pregnancy.  This is believed to
result from hormonal changes and from pressure on the bladder by the
enlarging uterus.  Many women experience pelvic pressure and
heaviness.

   Pregnancy Tests

   Pregnancy tests actually measure blood or urine levels of human
chorionic gonadotropin (HCG), a hormone produced by fetal and
placental tissues.  The sensitivity of these tests is determined by
when HCG can first be detected.  HCG is present in small amounts
beginning one or two days after implantation of the embryo.  Peak
levels are not reached until eight to twelve weeks of gestation.

   There are many types of pregnancy tests.  In general, blood tests
are much more sensitive that urine tests.  The most sophisticated
blood tests can be positive as early as several days after conception
and are nearly 100 % accurate.  Extremely sensitive urine pregnancy
tests have been developed recently that may be able to diagnose
pregnancy prior to the absence of a normal menstrual period; however,
most urine tests are not sensitive enough to detect HCG until one to
two weeks after the first missed period.

   Home pregnancy test kits are available at most drug stores. They
are easy to use, take less than an hour to perform, and cost only ten
to fifteen dollars.  They can detect HCG in the urine about two weeks
after the first missed menstrual period.  Most home kits contain a
solution which when mixed with urine from a pregnant woman forms a
dark ring in a test tube--a positive test. The test is negative if
the color ring does not develop.  When proper technique has been
used, a negative test makes pregnancy unlikely unless it is too early
to detect very low levels of HCG. Repeating the test in a week or two
may be advisable.  A test may be falsely positive if the woman is
near menopause, taking antidepressant medications, or having
irregular menstrual periods.

   Pregnancy tests can sometimes be helpful in determining whether an
early pregnancy is still viable.

   Fetal Heart Sounds

   Beginning at about twelve weeks, an electronic amplifying device
called a Doptone can be placed on the abdomen to hear fetal heart
tones.  This instrument is safe and can be used right in the doctor's
office.  Fetal heart sounds cannot be heard with a regular
stethoscope until approximately twenty weeks.

   Fetal Movement

   Movement of the fetus first becomes apparent to the expectant
mother at approximately twenty weeks.  It is felt initially as a
fluttering or even a gas-like sensation.  Women who have previously
been pregnant may be able to sense fetal movements somewhat earlier.

   Sonography (Ultrasound)

   Sonography is a safe, painless test that utilizes sound waves to
visualize internal body organs.  An ultrasound examination can detect
a pregnancy as early as six weeks after the last menstrual period.
Movements of the fetus can first be seen at approximately twelve
weeks of gestational age.

   Duration of Pregnancy

   Although pregnancy lasts for nine months, physicians discuss
gestational age in terms of trimesters and weeks.  Pregnancy is
divided up into three trimesters of roughly twelve to thirteen weeks
duration.  The average pregnancy lasts forty weeks, but any
gestational age of greater than thirty-seven weeks is considered
full-term.  Only a very small percentage of women actually deliver on
their due date.  Prematurity refers to births between the
twenty-sixth and thirty-seventh weeks.  Despite recent medical
advances, fetuses delivered prior to twenty-six weeks of gestational
age rarely survive.





   MATERNAL-FETAL PHYSIOLOGY

Jeffrey L. Stern, M.D., University of California at San Francisco

Susan J. Bertolli, M.D., San Francisco, California

Fertilization and Implantation

   Ovulation is the extrusion of an unfertilized egg from an ovary.
Upon its release from the ovary, the egg passes into the fallopian
tube and begins to make its way toward the uterus. Only during the
first few days of its passage through the tube is the egg susceptible
to fertilization.  Semen deposited in the vagina and cervix during
intercourse takes several hours to reach the tube.  When a sperm
comes into contact with the egg, fertilization occurs and an embryo
is formed.  All other sperm are then prevented from penetrating the
egg.  In an idealized menstrual cycle, ovulation occurs on the
fourteenth day; the duration of pregnancy is actually 266 days (280
days minus 14). The embryo takes five to six days to reach the
uterine cavity after fertilization.  It is free-floating for another
24 hours before it implants in the surface of the uterine cavity.

   Studies in laboratory animals have determined that many early
pregnancies are spontaneously miscarried.  Most of these early
miscarriages either have no symptoms or are manifested only by an
irregular or heavy menstrual period.  Defective chromosomes or
abnormalities of uterine implantation are believed to be responsible.

   The Placenta

   The placenta or afterbirth develops soon after implantation of the
embryo in the uterus.  It attaches itself to the uterine wall and
grows as the fetus grows.  Among its functions are communication with
the maternal circulation, maternal-fetal oxygen/carbon dioxide
exchange, nutrient supply to the fetus, and elimination of fetal
waste products.

   Small placentas are associated with poor fetal growth; very large
placentas may indicate syphilis or Rh disease (maternal- fetal blood
incompatibility).  If the placenta overlies the cervical opening--a
condition called placenta previa--severe maternal hemorrhage and
fetal death may ensue and vaginal delivery may be difficult.  When
the placenta separates from the wall of the uterus before the birth
of the infant, similar complications may result.  The latter disorder
is known as placental abruption.

   Blood or urine levels of the hormone estradiol can be used to
evaluate the function of the fetal-placental-maternal unit. Daily,
weekly, or biweekly estradiol measurements can be monitored.
Although these values may be unreliable, a 50 % decrease suggests
that severe obstetrical complications are likely.

   The Umbilical Cord

   The umbilical cord connects the fetus to the placenta and contains
blood vessels that carry oxygen and nutrients to the fetus from the
maternal circulation.  Its average length is twenty to twenty-five
inches.  Alterations in the length of the cord can be hazardous.  A
long cord can wrap around a fetal body part and cause congenital
malformations or it may fall through (prolapse) the open cervix at
the time of delivery and cut off the blood supply to the fetus.  An
cord that is too short occasionally causes difficulties during
delivery.  Knots in the cord are not usually a problem; however, if a
knot is very tight or if there are multiple knots, fetal growth may
be impaired.

   Fetal Membranes

   The fetus is contained within a membranous, fluid-filled structure
called the amniotic sac.  This "bag of waters" is bordered on one
side by the placenta and its attachment to the wall of the uterus.
Comprised of thin membranes which help to form and retain the
amniotic fluid, the sac provides room for unrestrained fetal growth
and allows for fetal movements which are necessary for muscular
development and tone.  During the onset of labor, and occasionally
before, the fetal membranes rupture and release amniotic fluid.

   Amniotic Fluid

   Amniotic fluid is derived from constituents of the maternal
bloodstream and the fetal urine.  The fluid is constantly changing:
at full-term the exchange of water between the fetus and the mother
is approximately three and one-half liters per hour.  Abnormalities
in the volume of amniotic fluid can be associated with significant
clinical problems.  Absent or small amounts of amniotic fluid--as
seen, for example, with fetuses that lack kidneys--is frequently
associated with poor fetal growth.  Too much amniotic fluid
(hydramnios) may be a sign of a neurologic malformation or a blood
disorder such as Rh disease.

   Trimesters

   There are three stages or trimesters of fetal growth and
development.  The first trimester begins at fertilization and lasts
twelve weeks.  By the end of this time period, all fetal organ
structures have been formed.  Therefore, most birth defects manifest
themselves during these critical first twelve weeks of pregnancy.
The second trimester lasts from the twelfth week to the twenty-fourth
week of pregnancy.  Although little organ development occurs after
the twelfth to sixteenth weeks, the organs significantly increase in
size and weight.  The third trimester starts at the twenty-fourth
week and ends at delivery.

   Abortion and Miscarriage

   The termination of pregnancy prior to the twentieth week is known
as abortion.  Health care professionals use the term spontaneous
abortion (popularly called a miscarriage) when the termination is a
natural result of abnormal fetal development or other fetal or
maternal disorders.  Approximately ten to fifteen percent of all
known pregnancies end in spontaneous abortion. When a pregnancy
terminates prior to the twentieth week and the fetus weighs less than
500 grams (about eighteen ounces), the infant never survives.

   Stillbirths

   An infant born after the twentieth week of pregnancy who shows no
sign of life at birth is called a stillborn.  The stillbirth rate is
defined as the number of stillborn infants per 1,000 live births.  In
the U.S. the stillbirth rate is approximately ten. The major causes
of stillbirths in decreasing frequency are placental and umbilical
cord abnormalities, unknown causes, fetal disease,
maternal-obstetrical complications, congenital malformations, and
maternal illnesses.

   Newborn and Infant Mortality

   The infant mortality rate is defined as the number of infants that
die within the first year of life per 1,000 live births. The neonatal
mortality rate is the number of live born infants that die within the
first twenty-eight days.  The infant mortality rate in the U.S. is
approximately fourteen and the neonatal mortality is ten.  The
perinatal mortality rate is defined as the number of stillbirths plus
the number of neonatal deaths per 1000 live births.  The major causes
of infant death at present are post-natal asphyxia and lung problems;
immaturity; congenital malformations and infection.  Approximately
forty percent of all infant deaths occur within the first day of
life.





   PRENATAL CARE AND EVALUATION

Jeffrey L. Stern, M.D., University of California at San Francisco

Susan J. Bertolli, M.D., San Francisco, California

   For information about medications, weight, activity and exposure
to known teratogens (birth defect-producing agents), etc., please
consult "General Advice" --> menu choice 4.

   Introduction

   Over the past century, improvements in prenatal care and routine
maternal examinations have made a significant contribution to the
decline in the maternal and newborn mortality rates.  Regular
prenatal check-ups may prevent major maternal and fetal
complications.

   Initial Evaluation

   At the first visit to the doctor, a detailed medical history is
obtained with specific reference to the reproductive history,
inherited disorders, and current and past illnesses.  An attempt
should be made to accurately estimate the time of conception so that
the the true age of the pregnancy can be known.  The height, weight,
blood pressure, and pulse are recorded and a general physical
examination is performed with particular attention given to the
heart, lungs, abdomen, and pelvis.  The pelvic examination includes a
Pap smear and estimation of the size of the uterus and pelvis.  The
doctor can correlate the gestational age on examination with the date
of the last menstrual period.

   Routine laboratory studies include a test for syphilis, gonorrhea,
complete blood count, blood chemistries, blood-typing, and urine
tests.  A "rubella titer" is ordered to determine whether or not the
women is immune to rubella (German measles). This usually benign
viral illness can cause major birth defects if it affects a pregnant
woman during the first trimester.  In some states, a test for
phenylketonuria (PKU), a rare metabolic defect, is required.  Mothers
with PKU may give birth to mentally retarded infants if they do not
follow a special diet.  Ashkenazi Jews can be checked for Tay-Sachs
disease, but it is preferrable that the testing be done prior to the
pregnancy.

   Follow-up Visits

   Most women are advised to make monthly appointments up until
approximately twenty-eight weeks.  Thereafter check-ups are scheduled
every three weeks for several visits, then every two weeks, and after
the thirty-sixth week, every week until delivery.

   At each office visit the weight and blood pressure are charted and
a specimen is obtained for the measurement of sugar and protein in
the urine.  The average blood pressure is unchanged during pregnancy
except for a mild transient decrease during the second trimester.
Importantly, a condition known as pregnancy- induced hypertension or
preeclampsia must be ruled out in women who develop high blood
pressure during pregnancy.  The other hallmarks of this dangerous
condition include protein in the urine and edema (swelling).

   After about the fourteenth week of pregnancy, the fetal heart beat
can be heard and timed.  The average fetal heart rate is about 140
beats per minute; the normal range is between 120 and 160 beats per
minute.

   If there are any unusual symptoms, or the uterus fails to grow, an
ultrasound or sonogram (sonar) examination may be performed to
confirm the gestational age and to detect fetal- placental
malformations.  In some states, blood levels of alpha- fetoprotein
will be ordered.  This blood test can help to predict whether or not
a fetus has a defect in growth or in the development of the spinal
cord or brain, e.g. spina bifida.

   Fetal Well-being Tests

   During the third trimester of pregnancy, if there is a major
medical illness or if there is concern that the fetus is not growing
normally, tests of fetal well-being may be indicated. They include
the non-stress test, nipple stimulation test, oxytocin challenge
test, and the biophysical profile.  These tests can usually be done
on an outpatient basis without overnight hospitalization.

   The non-stress test consists of evaluating the changes in fetal
heart rate following fetal movement.  It is performed by placing the
mother at rest with an external monitor attached to her abdomen.  The
electrical monitor records both fetal movement and heart rate on a
paper strip for interpretation by the physician.

   Both the nipple stimulation test and the oxytocin challenge test
evaluate the fetal heart rate response to stress caused by the
squeezing force of the uterus during contractions.  With the nipple
stimulation test, uterine contractions are produced by reflex action
as the nipples are squeezed.  Oxytocin (Pitocin), a pituitary hormone
administered by injection, causes the uterus to contract during an
oxytocin challenge test.

   The biophysical profile provides an ultrasonic picture of the
fetus.  The criteria for determining the status of the infant include
the degree of flexion of the extremities, the number of spontaneous
fetal movements, and the presence of fetal breathing motion.

   Amniocentesis

   This is a genetic study in which fluid from the uterine cavity is
removed through a long needle inserted through the wall of the
abdomen.  When it is performed at fifteen to sixteen weeks of
gestation, chromosomal defects and other genetic disorders may be
detected.  In addition, it is possible to screen for selected
metabolic derangements and to determine the sex of the fetus. For
more information about this test, please consult the "Surgeries,
Tests, and Procedures" section.

   Prepared Childbirth

   Prepared childbirth education classes are invaluable to expectant
couples.  The Lamaze method is the one most widely available.  Not
only do the classes have the advantage of imparting information which
makes pregnancy, labor, and delivery a less anxiety provoking
experience for women, but they also encourage husbands and
significant others to participate in the pregnancy.  Prepared
childbirth helps women deal with the discomfort of labor in a
positive way.

   Warning Signs

   Uterine Cramping -- Generally reported as a mild lower abdominal
cramping, rhythmic pelvic pressure, or low back pain, this symptom
may herald the onset of labor.

   Vaginal Bleeding -- This is an emergency at any point during the
pregnancy.  The obstetrician should be notified immediately!

   Rupture of the Membranes -- This is noted either by a trickle or a
sudden gush of clear fluid coming from the vagina.

   Headache -- A persistent headache which does not respond to the
usual remedies should be brought to the attention of the
obstetrician.  It may be one of the first signs of preeclampsia.

   Swelling of the feet and ankles is a fairly common problem during
pregnancy.  It is not serious unless it develops rapidly or is
associated with other signs of preeclampsia.

   For more information about prenatal care, please consult "General
Advice" article --> menu choice 4.





   GENERAL ADVICE

Jeffrey L. Stern, M.D., University of California at San Francisco

Susan J. Bertolli, M.D., San Francisco, California

   For the pregnant woman, the importance of following sound advice
with regard to maternal diseases, medications, nutrition, weight,
activity and exposure to known teratogens (birth defect- producing
agents) cannot be overestimated.

   Weight Gain

   Unless a woman is extremely obese, most obstetricians recommend a
weight gain of about one-half to one pound per week, or approximately
twenty-five to thirty pounds for the entire pregnancy.  Both
insufficient and excessive weight gain are associated with a variety
of obstetrical complications.  Too little weight gain can result in
an underweight baby, while excess body weight may aggravate maternal
diabetes.  Women who gain a significant amount of weight during the
last trimester are usually retaining fluid.  This may be a warning
sign of preeclampsia or toxemia of pregnancy.

   Indigestion

   Indigestion or heartburn, a burning sensation in the upper part of
the abdomen, is common in early and late pregnancy.  It is easily
relieved with milk or antacid medication, but if the problem
persists, a doctor should be consulted.

   Nausea

   Nausea or morning sickness is extremely common in the first
trimester.  In general, this symptom is easily controlled with
frequent small meals which include plenty of liquids.  If it is
severe, a medication may be prescribed.  For the majority of women,
morning sickness subsides after the first trimester of pregnancy.

   Bladder and Bowel Function

   Because of the changes in the reproductive hormones during early
pregnancy as well as the enlarging uterus, many women have to urinate
more frequently than normal.  In addition, they may lose control of
their urine when they move or cough.  Urinary tract infections are
also more common during pregnancy. Consequently, burning upon
urination requires prompt medical attention.

   Constipation is another common symptom.  Generally it can be
controlled with adequate fluid intake and dietary supplementation
with fiber from bran, fruits, vegetables and salads.  Staying active
is also helpful.

   Breast Changes

   Enlargement of the breasts occurs early in pregnancy. Tingling and
excessive sensitivity of the nipples is often associated.  No
specific breast care is required, but if breast heaviness is a
problem, a well-supporting bra is advisable.  A nipple discharge may
develop during the latter part of pregnancy and this is considered
normal.  In women who are planning to breastfeed, daily massage of
the nipples in the last six weeks of pregnancy may help to toughen
the nipple and prevent injury due to sucking.

   Pelvic Pain and Backache

   Because of the enlarging uterus, pregnant women often report a
pressure-like sensation in the pelvis sometimes associated with low
back pain.  This discomfort is more common in the latter part of
pregnancy and is more likely to be problematic in women who have poor
posture.  Increasing one's rest periods during the latter part of
pregnancy, wearing shoes with good support and gentle massage can
provide symptomatic relief.  Rarely, medication is required.

   Varicosities and Hemorrhoids

   Because of the hormone changes, the increasing size of the uterus,
and the normal increase in blood volume during pregnancy, many women
report difficulties with varicose veins in the legs, external
genitalia, and abdominal wall.  Not a serious problem, it can
generally be relieved, at least in part, by the use of elastic
stockings and by elevation of the legs whenever possible. For similar
reasons, hemorrhoids may also be aggravated during pregnancy.
Regulation of bowel movements with a high fiber/roughage diet is
recommended.  Occasionally, medicated suppositories (Anusol, etc.)
may be necessary.

   Tobacco, Alcohol and Caffeine

   Women who smoke cigarettes are more likely to have low birth
weight and growth retarded infants than nonsmokers.  In addition,
heavy smoking is associated with an increased rate of bleeding during
pregnancy, premature rupture of the membranes, and premature
delivery.  Women are routinely advised to discontinue smoking.  Heavy
smokers should at least make an attempt to curtail the number of
cigarettes smoked per day.

   The Food and Drug Administration recommends that pregnant women
limit their alcohol consumption to two drinks or less per day.  Many
obstetricians take issue with this recommendation, feeling that even
two drinks is excessive.  An occasional alcoholic beverage during
pregnancy is without obvious harm; however, if one consumes more than
three ounces of alcohol (six or more drinks) per day, the baby may be
affected with minor and major birth defects--the fetal alcohol
syndrome.

   The ingestion of caffeine during pregnancy has been associated
with birth defects in animals, but at present there is no clear
information regarding its effects on human fetuses.  Moderation is
again recommended.

   Medications and Drugs

   As a rule it is best not to take medicine during pregnancy without
professional advice.  Medications taken after the first sixteen weeks
of pregnancy usually will not cause birth defects; however, there are
many medications, which if taken chronically, can result in poor
fetal growth and development.  It is prudent to check with one's
physician regarding the safety of taking regular prescribed
medications.

   Aspirin, acetaminophen (Tylenol) and over-the-counter cold
remedies, when used in moderation, are not contraindicated in
pregnancy.  But one should avoid the use of aspirin in the last
trimester of pregnancy, as it may interfere with blood clotting. It
can also prematurely close vital connections between major blood
vessels near the fetal heart.

   Illicit drugs such as marijuana, speed, cocaine, LSD and heroin
should be avoided.  There is little information in the medical
literature concerning the side effects of these drugs on the human
fetus.  Infants born to mothers addicted to heroin or methadone will
also be addicted to narcotics.

   X-rays

   If at all possible, X-rays should be avoided during pregnancy,
especially in the first trimester.  When X-rays are absolutely
required to diagnose and manage maternal disorders, they may be
performed, but the number and type of X-ray studies should be chosen
judiciously by the physician.  The total amount of radiation to which
the fetus is exposed seems to be critical. Ten rads should not be
exceeded.  (The average chest X-ray exposes the mother to
appoximately 0.25 rads.)  During dental and other X-ray procedures,
the abdomen should be shielded with a lead apron.

   Sexual Activity

   Sexual intercourse during pregnancy is not believed to be harmful.
 Women who have repeated miscarriages or premature births or who are
experiencing vaginal bleeding may benefit from abstaining from
intercourse while they are pregnant.  For some women a hormone in the
semen which may cause uterine contractions.  Trauma to the vagina and
cervix may increase bleeding.

   Exercise

   During vigorous exercise, the muscles receive much of the blood
flow that would ordinarily go to the uterus.  In addition, the fetus
may be stressed by the increases in maternal body temperature and
heart rate.  Therefore strenuous activities such as long distance
running and competitive swimming should problably be avoided.  SCUBA
diving is contraindicated.  Sports that require a significant amount
of dexterity, such as horseback riding and skiing, should be
performed in moderation because excessive weight gain may impair
timing and coordination.  A moderate amount of exercise during
pregnancy is beneficial: stretching, aerobic conditioning classes
tailored for pregnant women and short distance jogging and swimming
are safe and healthful.

   Saunas and Hot Tubs

   As a rule, hot tubs and saunas should be avoided in the first
twelve weeks of pregnancy, but during the second and third
trimesters, moderate use of these facilities does not appear to be a
problem.  Pregnant women should not sit in a hot tub or sauna for
more than ten minutes at a time in order to avoid excessive
elevations of body temperature.  The water temperature should be no
greater than 100 degrees F.

   Travel

   Automobile trips are completely acceptable.  During long journeys,
it is wise to stop periodically to stretch and walk. Air travel is
not a problem except during the last month of pregnancy when it is
not advisable to fly because of the possibility of the onset of
labor.  There is no known association between air flight and
premature labor.

   Employment

   There are very few jobs which are contraindicated during
pregnancy.  Women whose work is extremely strenuous or requires great
agility should be considered on an individual basis.  The pamphlet,
"Guidelines on Pregnancy and Work," published by the American College
of Obstetricians and Gynecologists may help to determine whether or
not one's job is unsuitable during pregnancy.





   NUTRITION AND PREGNANCY

Jeffrey L. Stern, M.D., University of California at San Francisco

Susan J. Bertolli, M.D., San Francisco, California

   General Information

   Good dietary habits are essential during pregnancy.  Well-
designed studies have shown that nutritional counseling and dietary
supplementation significantly improve the outcome for both the mother
and infant.  A pre-conception visit to the obstetrician is the best
time to discuss nutrition for a planned pregnancy.

   Snack foods that are high in calories and low in nuturition, fad
foods and unusual diets should be avoided.  Weight loss diets,
diuretics (water pills) and restriction of salt intake are
contraindicated unless prescribed by a physician.  All women are
advised to take vitamins, iron and mineral supplements.  Protein and
calorie supplementation is indicated for women with pre- existing
protein malnutrition, mulitiple closely-spaced pregnancies, nausea
and vomiting in early pregnancy, and for women who are expecting
twins.

   Body Weight

   The average woman gains about twenty-five to thirty pounds during
pregnancy, two to four pounds in the first trimester and
approximately a pound a week thereafter.  The excess weight is
attributable to the fetus (approximately 7 lbs.), placenta (1 1/2
lbs.), amniotic fluid (2 lbs.), increased weight of the uterus (2
lbs.), increased breast size (1 lb.), increased maternal blood volume
(about 3 lbs.), body fluid (4 lbs.), and fat (8 lbs.). Women who
maintain the appropriate weight during pregnancy have a lower
incidence of preeclampsia (toxemia), a higher percentage of normal
vaginal deliveries and fewer Cesarean sections.  Although gestational
age is the primary determinant of infant birth weight, maternal
weight gain and pre-pregnancy weight are known to play a role.  The
association of low birth weight with increased neonatal mortality and
a higher incidence of cerebral palsy is well established.

   Approximately three-fourths of the weight gained during pregnancy
is lost in the first week after delivery.  Most women are back to
their pre-pregnancy weight at the end of the third postpartum month.
Weight loss diets should not be instituted until at least two to four
weeks after delivery for mothers who are bottlefeeding, or two to
four weeks after the cessation of breastfeeding for mothers who are
nursing.

   Calories

   Caloric requirements vary greatly depending upon the woman's
activity, age, height and pre-pregnancy weight.  Most women need
about 2500 calories per day prior to delivery.  The caloric
requirements for breastfeeding are proportional to the amount of milk
produced each day: approximately 1000 calories per liter. However,
only an additional 500 calories per day are recommended for those who
breastfeed after delivery because of the extra weight gained during
gestation.

   Protein

   Pregnant women require approximately seventy-five grams of protein
per day.  The value is somewhat higher for teenagers who are still
growing.  An additional twenty grams of protein per day are
recommended during breastfeeding.  Good quality protein is found in
eggs, milk, meat and soy products.  Some inexpensive sources include
eggs, cheese, beans, peas and peanut butter. Highly processed foods
with multiple additives and little nutritional value should be
avoided.  It is possible to meet protein requirements for pregnancy
with a strictly vegetarian diet which allows for milk products and/or
eggs.

   Vitamins

   The fat soluble vitamins are A, D, E and K.  The recommended daily
allowance (RDA) for vitamin A is approximately 5000 international
units (IU).  Vitamin A is found in butter, egg yolks, and milk
products.  The RDA for vitamin D is 400 IU. Vitamin D is also found
in butter, egg yolks, and of course, vitamin D-fortified milk.  Water
soluble vitamins can accumulate in the body if taken in megadoses.
Birth defects have been reported in animals fed high doses.

   The water-soluble vitamins include vitamin C, folic acid, thiamine
(B-1), riboflavin (B-2), vitamin B-6, niacin, and vitamin B-12.  Most
obstetricians prescribe folic acid supplements during pregnancy to
correct the anemia which often develops from a deficiency of this
vitamin.  Anemia is more common in women who have twins, those who
are taking anti- convulsant medications, and in women who had been on
birth control pills prior to pregnancy.  The water-soluble vitamins
are rapidly excreted by the kidneys.  Therefore, overdose is less
common than with the fat-soluble vitamins.

   Minerals

   Additional iron is necessary because many young women start out
their pregnancy with already depleted stores.  In addition, a
significant amount of iron is lost during pregnancy and
breastfeeding.  The RDA is approximately fifty milligrams of
elemental iron.  This is usually prescribed as ferrous sulfate
tablets--300 milligrams, two to three times per day.  The RDA for
calcium is approximately 1,200 milligrams.  Dairy products are the
primary source.  Other minerals such as zinc, manganese, magnesium
and copper are provided in multipurpose prenatal vitamins.





   METHODS OF NATURAL CHILDBIRTH

Jeffrey L. Stern, M.D., University of California at San Francisco

Susan J. Bertolli, M.D., San Francisco, California

   Introduction

   The childbirth practices of western civilization date back to the
time of the ancient Greeks.  Therefore, modern attitudes and
expectations about childbearing reflect the influences of societal
and cultural evolution over the last three millennia.

   According to some natural childbirth theorists, the development of
civilization and modern culture has adversely affected our reactions
to childbirth by introducing incongruous fears and anxieties about
labor and the birthing process, and by reinforcing these experiences
as ones that are painful and dangerous.  It is hypothesized that
these fears and the anticipation of pain produce inner tension which
interferes with the natural events of childbearing.  Modern natural
childbirth practices invoke mechanisms to release this inner tension
to overcome fear and to eliminate pain.

   In the United States, the four most popular methods of natural
childbirth are those developed by Drs. Grantley Dick Reed, Ferdinand
Lamaze, Frederick Leboyer, and Robert Bradley.  In general, all of
these methods try to reduce or prevent discomfort by education,
relaxation, diversion, creating positive attitudes toward birth,
active participation of the male partner, self- control, partial
self-direction of the labor and delivery, and by achieving rapport
with the physician or midwife.

   Reed Method

   Dr. Reed, an English physician, is thought of as a pioneer of a
more sensible approach to childbearing.  He believed that no
physiologic body function, including childbirth, should cause pain if
one is in good health.  In order to explain why some women suffered
and others remained comfortable during labor, therefore, he surmised
that it was not the nature of labor that was responsible for a
woman's reactions, but the individual's underlying emotional state
and her perception of the sensations associated with the birthing
process.

   The goal of the Reed method of natural childbirth is to overcome
the fears and expectations of pain by relaxing the mind and body.
This is achieved primarily through education.  The learning process
includes detailed instruction in the anatomy and physiology of labor
and delivery, relaxation training, breathing exercises, and a program
of general physical fitness.  This method also focuses attention on
the mothers' psychological needs and calls for expectant fathers to
take a more active role in labor and delivery.

   The Reed method has aided many patients, and in at least one
study, women trained in this method had shorter labors and fewer
mid-forceps deliveries.  But its efficacy is controversial.  It has
been suggested that the benefits may be entirely psychological.  This
method has also been criticized for too firmly supporting the
importance of non-artificial delivery without the aid of drugs.
Consequently, many women have feelings of failure and weakness of
character if they require medication during labor.

   Lamaze Method

   The Soviet physician, Lamaze, has proposed a "psycho-
prophylactic" method of childbirth in which the approach to relief of
discomfort requires an understanding of the physiologic cause of and
one's psychologic reaction to pain.  During labor and delivery,
contractions of the uterus produce nervous impulses which are
transmitted to the brain for interpretation.  With the development of
modern civilization, these impulses have gradually become associated
with pain reflexes such that normally pain-free uterine contractions
are perceived as the onset of pain. According to proponents of the
Lamaze theory, what makes these conditioned reflexes special is that
they are not acquired by personal experience, but rather by continued
cultural and societal reinforcement of the misguided belief that
childbirth is inherently unpleasant and painful.  Through education,
common knowledge, social pressures, and the subtleties of language,
women have been victimized by this negative view of childbirth.

   The initial goal of the Lamaze method is the elimination of the
painful, negative feelings associated with the process of childbirth.
 This is done by diverting attention away from these unpleasant
feelings and toward uterine contractions as the leading phenomena.
Rather than considering uterine contractions as a stimulus for pain,
students of the Lamaze method are instructed to think of them as the
most important physiologic function responsible for dilatation of the
cervix and expulsion of the fetus.  Once the negative aspects of
uterine contractions have been neutralized, a new response to these
stimuli must be developed.  Women are taught to link the onset of
uterine contractions with changes in the rhythm of their breathing
such that the contractions become the signal for this special type of
breathing, rather than for pain.  Not only does the new breathing
technique serve as a distraction, but it also acts to relieve pain.
The final goal of the Lamaze method is to strengthen the inhibition
which limits the spread and duration of a painful focus.  This is
accomplished by formation of a new reflex associated with learning
the modified breathing techniques.

   Leboyer Method

   Couples that follow the childbirth methods of Reed and Leboyer
often request gentle birth using techniques first described by Dr.
Frederick Leboyer in his 1975 book "Birth Without Violence." The
major principle of gentle birth is to diminish the stress of being
born by simulating the intrauterine environment in the delivery room.
 Although this concept of "non-violent" birth originated in France,
it has received widespread attention in the U.S.  With the Leboyer
method, a dim light is used in the delivery room and the newborn
infant is placed immediately the mother's abdomen to achieve warmth
and physical closeness.  The umbilical cord is not severed until it
stops pulsating so the maximum amount of oxygen is allowed to pass
into the newborn infant.  Finally, the baby's back is massaged and
he/she is placed in a water bath at body temperature.

   There is sufficient evidence that this technique adds to the
enjoyment of the birth experience for all concerned and that it is an
important conditioning step in the methods of childbirth previously
described, but at present, there are no valid scientific data that
either support or detract from its value. Proponents feel that labor
and delivery should be made as acceptable and pleasant as possible
within the confines of the hospital and that the Leboyer method helps
to make this a reality.  Detractors believe that there is no evidence
to support the delay in cutting the cord or the massage of the
infant.  In addition, they are concerned that the low intensity light
may make it difficult to evaluate the infant and that the warm bath
may endanger the infant by reducing sensory input which may be a
necessary stimulus for the initiation of breathing.

   Bradley Method

   The major aim is to eliminate the need for pain medication by
achieving relaxation through abdominal breathing.  The women are
taught specific exercises for muscle development as well as how to
synchronize their breathing with uterine contractions.  In order to
ameliorate the pain, they are encouraged to think pleasant thoughts
unrelated to labor.  Couples begin Bradley classes at the six month
of pregnancy, meeting weekly until delivery.  The instruction is
similar to other psycho- prophylactic methods of prepared childbirth;
however, major emphasis is placed on involving the male partner as a
labor coach and on avoiding the use of medications.

   The most common psycho-prophylactic method used in the U.S. is
some combination of the Lamaze and Bradley methods.

   Benefits

   Although natural childbirth education is still somewhat
controversial, women who participate in these programs generally have
shorter labors, less need for analgesics, and a more positive
attitude toward their newborn.  If there are any disadvantages to
prepared childbirth, it is that some women have feelings of failure
and diminished self worth when they have to resort to analgesia or
anesthesia during labor and delivery.





   MIDWIFERY AND HOME BIRTHS

Jeffrey L. Stern, M.D., University of California at San Francisco

Susan J. Bertolli, M.D., San Francisco, California

   Nurse-Midwifery

   A certified nurse-midwife (CNM) is a person who is educated,
trained, and competent in both nursing and midwifery and who has met
the qualifications of the American College of Nurse-Midwives.
Nurse-midwives manage normal women and newborns during pregnancy,
labor and delivery, and the post-partum period.  They work in a
variety of settings including private practice, university teaching
hospitals, city and county hospitals, rural clinics, health
maintenance organizations (HMO's), health departments, the military,
family planning centers, alternative birth centers, and occasionally,
delivery at home.  As a rule, CNM's are employed within a health care
system which allows for medical consultation, collaborative
management with physicians and referral to specialists.

   Like physicians, CNM's provide comprehensive prenatal care
including childbirth psychoprophylaxis and information concerning
parenthood.  In general they try to facilitate the natural aspects of
labor in a non-interfering manner to ensure that the couple's birth
plans are achieved as long as the labor and delivery are progressing
normally.  CNM's perform normal vaginal deliveries and they may
perform and repair episiotomies with the patient under local
anesthesia.  In addition, nurse-midwives can provide postpartum care
for the mother and can manage the newborn, including resuscitation if
necessary.  Some nurse- midwives provide normal gynecological
services including Pap smears, breast examinations, and general
physical examinations. Midwives are not qualified to perform Cesarean
sections or forceps deliveries.  Nor do they manage women with major
medical or obstetrical disorders.  In many settings, however, they
may care for these patients in collaboration with an obstetrician.

   Home Births

   Over the last twenty years the home birth movement, led primarily
by educated, medium and upper income women, has gained popularity the
United States.  This renewed interest in home births grew out of a
general opinion that modern hospitals and organized obstetrics are
sterile, scientific, uncaring, and chauvinistic institutions that
detract from the joys of childbirth and limit family participation.

   Despite these criticisms, most obstetricians and the majority of
midwives still believe that home deliveries are an unwise practice.
This sentiment is based on the fact that approximately one-third of
infants admitted to newborn intensive care units are delivered from
normal women who develop an unexpected complication during
labor--nearly seven percent of all obstetrical patients.  In
addition, emergency transportation of a sick newborn from home to the
hospital is frequently difficult and dangerous.  Since the first ten
to twenty minutes after birth may be the most critical period, speed
is especially important.

   In reaction to the increased interest in home delivery,
obsetricians, midwives, and hospitals have modified the setting in
which labor and delivery occur.  In the mid-1970's, the concept of a
birth center, a home-like setting located right in the hospital,
began to emerge.  The birth center encourages family members to be
present throughout labor and delivery and allows women to labor in
any position that is comfortable.  Most women end up delivering in
the same bed in which they labor.  In general, obstetricians feel
that the birth center is a safe alternative for women at low risk for
obstetrical and perinatal complications.  At present, less than one
percent of all births take place at home.



CompuServe

   HOSPITAL BIRTHS

Jeffrey L. Stern, M.D., University of California at San Francisco

Susan J. Bertolli, M.D., San Francisco, California

   Despite the recent trend toward home deliveries, most births still
occur in the hospital where the situation is more controlled and
emergency services are readily available.  One of the most common
questions that women have near the end of their pregnancy is, "When
should I come to the hospital?"  Although the answer can be provided
only by one's personal physician, most obstetricians recommend coming
to the hospital at the onset of labor.

   Onset of Labor

   The medical definition of labor is a change in effacement and/or
dilatation (thinning and opening) of the cervix that occurs in the
presence of of good uterine contractions.  There are several signs
that herald the beginning of labor:

   Uterine Contractions -- The first sign of labor is the onset of
regular uterine contractions.  Women who are pregnant for the first
time should consider coming to the hospital when the contractions
occur every three to five minutes and have been present for at least
one to two hours.  Women who have previously given birth should come
to the hospital as soon as uterine contractions begin.

   Ruputure of the Membranes -- Another sign of impending labor,
which may occur in the absence of uterine contractions, is rupture of
the fetal membranes.  This may be felt as a gush or trickle of clear
fluid from the vagina.  The physician should be notified as soon as
this happens so that a decision can be made about hospitalization.
The risk for uterine infection is an important factor to consider.
Some obstetricians allow their patients to remain at home for up to
twenty-four hours, waiting for the spontaneous onset of contractions.
 However, most physicians recommend immediate hospitalization for
induction of labor, especially if the woman is at high risk for the
development of an intauterine infection.

   Bleeding or Mucous Discharge -- Frequently the earliest sign of
labor is a small amount of vaginal bleeding or thick mucous
discharge.  As the cervix begins to dilate, the ounce or so of mucous
contained in the cervical canal is extruded.  Generally, this is not
cause for alarm unless it is associated with more than a teaspoon of
blood.  If there is heavy bleeding, the patient should call her
physician or come to the hospital as soon as possible.

   Being Prepared

   To make the hospital stay more pleasant and comfortable, one
should bring the following items from home: a toothbrush, nightgown,
bathrobe, slippers, something to read, and any materials used in the
prepared childbirth classes.  An outfit for the infant to wear home
is also recommended.  During the hospital stay, the newborn will be
provided with clothing.

   Alternative Birth Centers

   Another common question is, "What will happen to me once I arrive
at the hospital?"  Dissatisfaction with the traditional modes of
hospital labor and delivery in the late 1960's and early 1970's
brought about significant changes in routine procedures such that
hospital labor and delivery is now much more acceptable to patients.
At present, many hospitals have one, and sometimes two, alternative
birth centers--rooms set up have a more home- like in atmosphere and
be more comfortable than traditional labor and delivery facilities.
They are located in the hospital, usually in close proximity to the
labor and delivery suite where serious complications can be managed
more effectively. Alternative birth rooms are generally occupied on a
first come, first serve basis.  But in many hospitals, it is
necessary to make a reservation.  For those who prefer not to use, or
are unable to use, the alternative birth centers, regular labor rooms
are assigned.

   Conduct of Labor

   Once a patient is admitted either to the alternative birth center
or to a normal labor room, a nurse will be assigned to her care.
Formerly, women were instructed to labor while lying on their backs,
whereas today's patients are advised to labor in the position they
find most comfortable.  Many patients are even allowed to walk during
their labor as long as they return periodically for monitoring of the
fetal heart tones, blood pressure checks, and cervical examinations.

   Fetal Monitoring

   Continuous monitoring of the fetal heart beat with an abdominal
microphone or with an electrode placed on the head of the fetus can
allow trained health care personnel to determine the condition of the
fetus.  The resting heart rate and variabilty of the rate in response
to contractions of the uterus can provide important information about
fetal well-being.  It is now standard practice to offer this safe,
painless procedure to all pregnant women.  Physicians' opinions vary
somewhat regarding the necessity for fetal monitoring in all
patients, but monitoring is routine in many hospitals.  Most
obstetricians and nurse-midwives and feel that the benefits of
routine fetal monitoring far outweigh the minor inconvenience to the
patient.

   Intravenous (IV) Lines

   In the past, all patients had intravenous (IV) lines in place
during labor to facilitate the administration of medication, prevent
dehydration, and transfuse blood and fluids in the event of serious
hemorrhage.  Today, many women are allowed to labor without them;
routine IV lines are reserved for high risk patients.

   Enemas

   Formerly it was also common procedure to give each woman an enema
upon her arrival to the labor and delivery suite.  Although enemas
are still offered, many women find them distasteful. Because fecal
contamination of the episiotomy site leading to infection is an
uncommon complication, most physicians have abandoned their use.
Routine enemas remain a matter of personal taste and aesthetics.

   Perineal Shave

   When a Cesarean section is anticipated, shaving of the pubic hair
may decrease the incidence of infection of the wound.  In addition,
the opening and closing of incisions in the lower portion of the
abdomen are facilitated if the obstetrician doesn't have to avoid the
pubic hair.  Routine perineal shaving is no longer considered
necessary for vaginal deliveries.

   Diet

   Ideally, nothing or a light snack should be eaten prior to the
onset of labor.  After labor has begun, nothing at all should be
taken by mouth, except possibly small amounts of water.
Unfortunately, because the majority of women cannot anticipate the
start of their labor, they are unable to follow these dietary
restrictions.  Patients with a full stomach are at increased risk for
aspiration (going down the windpipe into the lungs) of stomach
contents during labor and/or a Cesarean delivery. Consequently, all
patients who are scheduled for Cesarean sections are advised not to
eat for at least 8 - 12 hours priot to delivery.

   Length of Hospital Stay

   Following an uncomplicated vaginal delivery, many patients can be
discharged home from the hospital the same day.  Others may remain in
the hospital for up to two days.  Of course, complications can
prolong the length of hospitalization.  The average hospital stay for
women who undergo uncomplicated Cesarean sections is four to seven
days.

   Family Members

   The number of family members that may accompany a woman to the
labor room varies from hospital to hospital.  At most centers at
least one or two support persons are allowed.  If one chooses to
deliver in an alternative birthing room, the entire family may be
allowed to attend.  Friends are frequently invited, as well.
Following the birth of the baby, it is routine in most hospitals to
provide a rooming-in service.  This means that the infant stays in
the same room as the mother from the movement it is born.

   Conclusion

   Over the past decade, changes in hospital and physician attitudes
toward labor and delivery have made the modern practice of childbirth
much more acceptable to women.  However, these improvements are not
universal.  To avoid major disappointments, each patient should
discuss her expectations for labor and delivery with her physician.





   INTRODUCTION TO OPHTHALMOLOGY

   This section contains a wealth of information about eye care, eye
care professionals, common eye disorders and diseases, glasses,
contact lenses, eye signs and symptoms, and ophthalmologic surgeries,
tests and procedures.

   Notably, the eye section is not an encyclopedia of the huge volumn
of ophthalmologic information; that data would fill many textbooks.
But the articles should be educational and they can serve as a ready
reference source for patients and their families.  Although no
substitute for a dialogue with one's doctor, the information provided
here may allow for a greater, more effective interaction.

   OPHTHALMOLOGY has been authored by James D. Reynolds, M.D.,
Assistant Professor of Ophthalmology at the University of Arkansas
School of Medicine.  Dr. Reynolds is a practicing eye surgeon who is
actively involved in medical education and clinical research.  His
major areas of interest are congenital glaucoma, retinopathy of
prematurity and strabismus.





   EYE CARE PROFESSIONALS

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   The  patient/consumer is presented with a bewildering array of eye
care professionals, each with different training and abilities.
Ophthlamologist, optician, optometrist, ophthalmic technician,
orthoptist: the terminology often confuses the uninformed.  This
article will highlight the differences between the various providers
and help to make you a better eye care consumer.

                         Ophthalmologist

   A physician and surgeon, the ophthalmologist has the most
extensive education and formal training of all the eye care
professionals.  The order of education is as follows: four years of
college to complete an undergraduate bachelor's degree, four years of
medical school culminating in an M.D. degree, one year of internship,
three to four years of residency training, and sometimes, one to two
years of subspecialty fellowship training. A total of twelve to
fifteen years of education and advanced training is required.

   An ophthalmologist is a licensed physician, and as such is subject
to the principles of practice outlined by state and professional
organizations.  Licensure is granted by the individual state medical
board after the physician applicant achieves a passing grade on a
comprehensive examination of general medical knowledge.  The American
Board of Ophthalmology, a national organization dedicated to
excellence in ophthalmologic care, also requires written and oral
specialty examinations for certification.  Finally, hospital staff
privileges must be obtained in order to treat patients in the
hospital.  The quality of care provided is constantly reviewed and
assured by the medical staff.

   An ophthalmologist has the training and expertise to perform a
complete ophthalmologic exam, give prescriptions for glasses and
medications, and diagnose and treat all diseases and disorders of the
eye by both medical and surgical means.  In addition, as an M.D., he
is able to evaluate the effect that systemic disorders have on the
eye and assess the risk of eye treatment on the patient's general
health.  Lastly, ophthalmologists have instant access to other
medical specialists when the need arises.

                            Optician

   This individual is a skilled technician whose education is usually
a two year course at a community or technical college. Additional
apprentice work may be optional or required, depending on the
location of practice.

   Some states issue licenses, but the requirements and regulations
for practice are variable.  Two organizations, the Optician
Dispensing Guild and the Optician Association of America, offer
guidelines for training and practice.

   When given a prescription, an optician is qualified to make, fit,
and dispense eyeglasses and contact lenses, either in an optical
laboratory or for retail sale to the public.  Opticians do not
examine patients or actually write prescriptions.

                           Optometrist

   These professionals fill an intermediate position somewhere
between an optician and an ophthalmologist.  Their education is a
four year college undergraduate degree followed by four years of
optometry school.  Their degree is an O.D., or Doctor of Optometry.
Individual states require licensing examinations, and the American
Academy of Optometry admits fellows or diplomates. At present there
is no national board certification.

   Optometrists are able to prescribe and dispense eyeglasses and
contact lenses, perform eye examinations, and do some diagnostic
work, such as screening for glaucoma or cataract.  In general, they
do not prescribe therapy for eye disorders; however, a small minority
of states now have laws which permit optometrists to prescribe eye
medication.  If an ocular disease is discovered, the patient is
usually referred to a physician, the ophthalmologist.

                      Ophthlamic Technician

   As a skilled assistant, an ophthalmic technician usually works
with an ophthalmologist.  Two years of training at a technical school
are the minimum necessary for certification by the appropriate board.
 But many techs are not certified; they learn their job in a more
informal fashion.

   The duties include a range of activities under the supervision of
a physician.  Among them are the performance of tests, such as
ultrasound and electrophysiology, and sometimes, refractions for
glasses and contact lens fitting.

                           Orthoptist

   An orthoptist is another skilled health care member.  Again, they
work under the supervision of a physician, an ophthalmologist.  The
education required is a two year technical program, often in
conjunction with an opththlamic technician course.  Certification is
by the Orthoptic Council.

   Duties include a variety of tasks.  Often, the orthoptist assists
a subspecialist, the pediatric ophthlamologist. Orthoptists receive
special training in some childhood eye conditions that may be
valuable to pediatric eye surgeons.

                           Conclusion

   It is often eye-opening and always worthwhile to become aware of
the different types of eye care available.  Similar titles imply
similar abilities, but there are very clear and important
differences.  An informed patient is a good patient.





   REFRACTIVE ERRORS

(Near-sightedness, Far-sightedness, Astigmatism and Presbyopia)

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   A refractive error or ametropia is simply the need for glasses or
contact lenses in order to see clearly.  More precisely, it is a
relative imbalance between an eye's focusing power and its size.
Refractive errors uncomplicated by other eye diseases can be
corrected to 20/20 or "perfect" visual acuity.

   Classification

   There are three basic types of refractive errors: myopia or
near-sightedness; hyperopia or far-sightedness; and astigmatism, a
general distortion.  Myopic individuals see better close up than far
away.  Hyperopic people see better far away. Astigmatism produces
visual blurring at both near and distance. Presbyopia, a special type
of refractive error, is an age-related loss of the ability to focus
closely or accomodate at near ranges, i.e. reading distances.

   Physiology and Physics

   The eye is a specialized sensory organ containing many intricate
structures.  It can be thought of as a supporting structure designed
to focus light upon the retina, the thin membrane lining the inside
of the back of the eye.  The retina converts light images into
electrical impulses which are transmitted along the optic nerve to
the visual centers in the brain where what we see is processed and
interpreted.

   When an object in our visual environment is hit by light, the
light rays bounce off that object in all directions.  The reflected
light diverges or spreads out and strikes the surface of our eyes.
To form a clear image these divergent light rays must be forced to
converge to a focal point, in other words focused upon the retina.
Before finally striking the retina, however, the light rays must pass
successively through the refractive media of the eye: the cornea,
aqueous, pupil, crystalline lens, and vitreous.  The aqueous and
vitreous are fluid media, the cornea and lens are solid, and the
pupil is simply a hole in the iris.  The cornea and lens provide the
eye's focusing power; the corneal power is static, but the lens power
is variable.  If the cornea and lens cannot focus light upon the
retina, then the image is blurred and a refractive error or ametropia
exists.

   Hyperopia

   Far-sightedness occurs when the refractive powers of the cornea
and lens are not great enough to focus a clear image onto the retina
because either the focusing powers are too weak or the eyes are too
small.  As a result of this imbalance between focusing power and eye
size, the image's theoretical focal point is located behind the
retina   Far-sighted people usually see better at distance than near
because of the extra focusing power near viewing requires.  Treatment
simply involves the introduction of convex or convergent lenses in
front of the eye to properly focus the image onto the retina.  This
can be achieved by spectacles or contact lenses.

   Children typically are born far-sighted because their eyes tend to
be smaller.  Never-the-less, children have so much inherent focusing
power in their crystalline lens, that they do not require correction
with glasses unless the condition is extreme or associated with other
eye diseases, especially esotropia or "crossed eyes."  The average
age of onset of far- sightedness needing optical correction is the
teens to twenties. The less reading one does, the less apparent the
need.

   Myopia

   Near-sightedness occurs when the refractive power is too great
relative to the length of the eyes.  Light rays are over- converged
to a focal point located somewhere in front of the retina.  Myopic
persons tend to have eyes that are longer than average.  They see
better up close because near objects produce divergent light rays
which require more focusing power than light rays reflected from
objects at a distance.  Hence an over-focused eye will have a
distance where the focusing power is in balance. This is called the
far point and is at some finite, close distance.

   Treatment involves interposing diverging lenses in front of the
eye to counterbalance the overly strong convergent power of the eye.
Although individuals can be born with myopia, typically it arises
during the pre-teen or teen growth spurt.  It progresses as the child
grows, then levels off, and finally remains stable for many years.

   A small subset of people suffer from a condition termed high
myopia.  This is an exaggerated near-sightedness often associated
with an abnormally long eye.  In some cases, the eye can be so large,
stretching the structures within it, that the retina becomes thin and
develops vision-threatening holes or detachments.  Unfortunately, if
the myopia is great enough, glasses may not be able to correct the
eye to perfect 20/20 vision.

   Astigmatism

   Astigmatism is a general distortion of the visual image.  It
occurs when the cornea is more an ellipse rather than a perfect
sphere.  The non-spherical shape produces a different focusing power
in different meridians, e.g. light entering the eye at 90 degrees is
focused differently than light entering at 180 degrees.  Again this
is correctable by introducing special lenses with compensatory
refractive power.  These lenses are called cylinders.

   Presbyopia

   As we age, the natural focusing power of the eye's crystalline
lens deteriorates.  The closest point where we are able to focus on
an object moves away progressively.  Thus, the near point of
accomodation recedes with age.  This inevitable aging process
actually begins at birth, but we have so much reserve focusing power
that a large percentage of it must be lost before the effects are
noticeable.

   Treatment usually is necessary some time after 40 years of age.
Simple reading glasses or bifocals, strengthened every few years, are
all that is required.

   Miscellaneous

   A refractive error is easily diagnosed with a routine eye exam.
Adults and older children are able to respond and assist in the
refraction process of picking proper glasses.  Young children or
infants can be examined without their assistance by a simple process
called retinoscopy.  If the examiner is experienced, a child of any
age can have a very accurate pair of glasses.

   Finally, "overuse" of one's eyes cannot worsen myopia, hyperopia,
or astigmatism.  Early detection and treatment are beneficial because
they provide clear vision, but progression or worsening of the
refractive error is not influenced by the amount of reading, or the
wear or non-wear of glasses.





   COLOR BLINDNESS

  (Color Deficiency)

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Defective color vision may be hereditary or acquired.  The
hereditary variety, what we commonly think of as color blindness, is
present at birth and affects primarily males.  Its course is stable,
variable in severity, and not associated with other eye
abnormalities.  Acquired color deficiencies do not occur as isolated
disorders, but are always associated with other ocular diseases.
They will not be discussed in this review.

   Physiology

   Photoreceptor cells in the retina convert light energy into
electrical energy that is transmitted to the brain.  Two types exist:
rods and cones.  The cones are the cells that are responsible for
encoding color.  Their ability to do this is postulated in the
trichromatic theory of color.  Each cone contains structures, or
visual pigments, sensitive to one of three wavelengths of light.  One
group codes red, one green, and one blue.  Normal individuals are
able to match all the colors of the spectrum by mixtures of only
three fundamental color sensitivities.  Hence, the huge variety of
hues we perceive stems from the cone cells' response to different
compositions of sensitizing wavelengths of light.

   Classification

   Defects in color vision occur when one of the three cone cell
color coding structures does not function properly.  One of the
visual pigments may be present and functioning abnormally, or it may
be absent altogether.  Persons with the former condition are called
anomalous trichomats; those with the latter condition are termed
dichromats.

   The three color sensitivities have been arbitrarily named for the
Greek words meaning first, second, and third.  Red is protos, green
is deuteros, and blue is tritos.  Suffixes have been attached to
these prefixes to describe the various types of color deficiency.  An
abnormally functioning visual pigment is called "anomaly"; an absent
pigment is called "anopia".  Hence, the following classification:

   Anomalous Trichromats ==> protanomaly (red), deuteranomaly
(green), tritanomaly (blue).

   Dichromats ==> protanopia (red) deuteranopia (green), tritanopia
(blue).

   Heredity and Incidence

   Gender is determined by one's compliment of sex chromosomes.
Females have two X chromosomes (XX), while males have one X and one Y
(XY).  In addition to the genes for gender determination, the X
chromosomes carry genes that code for many other traits, including
color blindness.  When females carry a defective gene on one of their
X chromosomes, they are protected from expressing the trait by the
presence of the normal gene on their other X chromosome.  On the
other hand, males manifest the trait when their single X chromosome
contains the defective gene. Consequently, X-linked traits such as
color deficiency are expressed more often in males.  Females may be
carriers, but males are more commonly affected.

   For practical purposes, all color deficient individuals have
varieties of red or green deficiency.  Tritan problems are very rare.
 Protan and deuteran deficits have an X-linked inheritance. The
incidence of the types of color deficiency are deuteranomaly -- 5 %,
deuteranopia -- 1 %, protanomaly -- 1 %, and protanopia -- 1 %.
Thus, about 8.0 % of males and 0.5 % of females are color deficient.
(Females can have two abnormal X chromosomes.)

   Symptoms

   Color deficient individuals are not completely red or green blind.
 Compared to persons with normal color vision, they have some
difficulty differentiating between certain hues, but the severity of
the color deficiency is variable.  Also, color sense is very
subjective.  In general, protanopes and deuteranopes confuse red,
green, and yellow.  Red may be seen as brown or black.  Protanomals
and deuteranomals may be unaware of their defect, but protanomals
typically perceive red as dingy or gray.

   Diagnosis

   Diagnosis is by clinical color vision testing.

   Treatment

   There is no treatment.  Color deficient individuals usually
compensate well for their defect and function well in a colorful
world.  In fact, color deficiency may actually be beneficial for
certain military personnel who have to see "through" camouflage.





   EYE INFECTIONS

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Infections of the eye can involve the lid, conjunctiva, cornea,
socket, and the inside of the eyeball.  They may range in severity
from mild, self-limited nuisances to devastating, vision-destroying
disorders.

   Causes and Physiology

   Ocular infections can be caused by bacteria, viruses, fungi, or
parasites.  These offending agents may produce significant eye damage
by two mechanisms: directly and by inciting the body's immune
defenses and reparative functions.  The response to infection serves
to clear organisms, repair damage, and form a scar.  Although these
functions are usually a beneficial part of the healing process for
infections of the skin, lungs, brain, etc., they have the potential
to permanently injure the eye. They can actually produce a greater
decrease in ocular function than direct damage from the infecting
organism.  For example, one cannot see through a scar on the cornea,
the normally transparent outer covering over the iris.  Hence, both
types of damage must be considered.  Their relative importance
depends on type and location of the infection.

   Conjunctivitis ("Pink Eye")

   Conjunctivitis or "pink eye" is an inflammation of the membrane
covering the white of the eye and the inside of the lids.  It may be
irritative, allergic, or infectious.  The conjunctiva may be infected
by viruses, bacteria, or a special in-between group, called
chlamydia.  Fungi and parasites are very rare in the U.S.  Most of
these infections are self-limited and require no treatment.

   The signs and symptoms of conjunctivitis are redness over the
white of the eye, watery or mucoid discharge, mild irritation, and
crusting or mattering of the lid margin.  Vision is not affected.

   Viral infections are most common.  There is no specific anti-
viral medication presently available except for the Herpes virus.
Therefore, treatment is supportive and aimed at minimizing spread of
the disease.  A few viruses are very contagious, notably the
adenovirus, and can easily spread to the second eye and other family
members.

   Bacterial conjunctivitis is also usually self-limited, but
occasionally, a virulent organism can cause significant problems if
left untreated.  Gonorrhea and pseudomonas bacteria are especially
dangerous.  Serious bacterial infections will have a thick, pus-like
discharge.  Antibiotic therapy with eye drops is usually curative.
Gonococcal infection requires antibiotics by mouth.  The instillation
of eye medicine at birth is legally mandated preventive therapy for
possible gonorrhea.

   Chlamydia infection is also quite common.  The signs and symptoms
resemble a viral infection, but they are not self- limited.  A
chronic, indolent infection leading to scarring of the cornea may
result.  Treatment is antibiotic drops and pills.

   Despite the temporary nature of the majority of these conjunctival
infections, any that have a pus-like discharge or deteriorate rather
than improve with a few days, probably require an ophthalmic exam and
treatment.

   Corneal Infection

   Inflammation of the cornea is called keratitis.  The infectious
causes include bacteria, viruses, and rarely fungi. All infections of
the cornea are serious.  The signs and symptoms are the same as for
conjunctivitis, except that there is considerable pain, vision may be
affected, and the corneal surface may be dull or whitish, rather than
glisteningly clear.

   Viral keratitis is usually the mildest.  Most patients do well
with the exception of those infected by the Herpes virus.  This virus
provokes a corneal immune response that can, over time, produce
marked scarring and visual loss.  Herpes keratitis is thus the single
most important corneal infection.  For information about Herpes eye
infections, please consult the separate article on that subject.

   Bacterial keratitis is serious and potentially vision-
threatening.  Specific antibiotics in conjunction with cortisone-
type steroid therapy are the mainstay of treatment. Hospitalization
is often necessary.  The visual outcome is determined by the degree
of scarring.

   Endophthalmitis

   (Inner Eye Infection)

   Endophthalmitis occurs in three ways: after eye injury or surgery,
and bloodborne.  The latter is uncommon except in individuals with
compromised immunity to infection, e.g. cancer, transplant, or AIDS
patients.  Post-traumatic and post-operative endophthalmitis are
essentially the same.  Violation of the eye's integrity occurs via
injury or surgery.  Infectious agents are introduced in sufficient
numbers to produce infection.  The signs and symptoms are pain,
redness, visual loss, discharge, and clouding within the eye.

   Endophthalmitis is an ophthalmologic emergency!  Most patients
require admission to a hospital with topical, oral, and intravenous
antibiotics.  Steroid therapy is often necessary to decrease the
immune response and prevent scarring.  Occasionally, surgery is
necessary to clean out the seat of infection.

   Lid and Orbital Infections

   These infections range in severity from stys to preseptal and
orbital cellulitis.  Stys are eyelid gland infections that produce a
red, painful, swollen area in the lid.  They require no specific
therapy beyond warm soaks to aid self-drainage.  Stys are also
discussed in the article dealing with lid disorders.

   Preseptal cellulitis is a more widespread infection of the lid and
surrounding tissues with greater swelling and pain.  The lid may be
swollen shut and a low-grade fever, about 100 degrees F., is common.
This infection is treated with antibiotic drops and pills effective
against the likely organism(s).  Most adults can be treated as an
outpatient, but small children may have a more serious variety that
requires admission to the hospital for intravenous therapy (i.e.
antibiotic injections).

   Orbital cellulitis is an infection in the bony socket around the
eye.  This is a serious emergency!  It presents with pain, proptosis
or protuberance of the eye, decreased eye movement, redness,
swelling, and a high fever of about 102-103 degrees F. The optic
nerve may be damaged.  Without treatment, the infection can spread to
the brain and produce meningitis, a life- threatening infection.
These patients require immediate hospital admission, intensive
antibiotic therapy, and occasionally surgery to drain an abscess, a
localized collection of pus.  The outcome is usually good if proper
therapy is instituted in time.





   OCULAR HERPES

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Herpes infections of the eye have the potential to be recurrent,
disabling, and vision-threatening.  The cornea, the clear outer
covering of the eye, is the primary site of damage.

   General Information

   The Herpes simplex virus (HSV) is much smaller than a bacterium.
Within its "body" is a core of DNA, the molecule carrying the genetic
code for the individual organism.  Although the DNA contains the
master plan for viral function, the virus lacks molecules essential
for reproduction.  These it obtains from the host or infected cell.
Points of entry of the HSV into human cells are commonly the mouth,
genitalia, and eyes. Classically, HSV has been divided into HSV I and
II.  Type I was "above the waist" and type II "below" or genital.
This distinction is becoming less useful.  The virus particle enters
the host cell, then uses the cell's metabolic "factories" to
reproduce.  When many virus particles have been made, the host cell
may rupture and die.

   Perhaps surprisingly, 90 % of all individuals have previously been
exposed to the HSV and have already become "infected." Although,
nearly all of these are "above the waist."  Once this happens, there
are several possible outcomes.  Many persons have only short-lived
symptoms that run their course without gaining much attention: a
low-grade fever, malaise, and it's over. Others may have a more
bothersome infection called primary or first-time herpes.  After
either of these initial infections resolves, the body appears to be
free of the virus.  But unfortunately, this is not the case.  Instead
of being eradicated, the virus lies hidden or dormant within certain
nerve cells.  During this hibernation-like period the host cell is
not damaged and the individual is not contagious.  This dormancy may
continue indefinitely or the infection may reactivate.

   Three types of herpetic disease affect the eye: congenital,
primary, and recurrent.  It is mainly the recurrent ocular disease
that can be vision-threatening.

   Congenital Herpes

   Congenital herpes is rare, but unfortunately its incidence is
increasing.  The virus is contracted at birth from mothers with
active genital infections, either primary or recurrent disease.
Unfortunately, the mother may have no symptoms at all to suggest a
genital infection.  The newborn acquires the virus after the "water
breaks" or as one passes through the birth canal.

   Newborn herpes infection typically is an overwhelming, deadly
disease.  The brain, liver, kidneys, and eyes are affected.  The
brain damage may be most significant.  The mortality is high, and if
survival does occur, the child is often mentally retarded or has
other permanent disabilities.  Congenital ocular problems center on
damage to the retina, but may also involve the conjunctiva, cornea,
lens, and optic nerve.

   Primary Ocular Herpes

   Primary eye infection occurs in children, adolescents, and less
frequently, in adults.  If noticeable, it presents as a skin
infection around the eye and lids.  The signs are low-grade fever,
malaise, and inflammatory vesicles or blisters on the skin.
Eventually, the blisters break and form scabs or crusted lesions.
The eye itself may become red and irritated with conjunctivitis.
Rarely, corneal infection or keratitis complicates the picture.

   Because most cases of primary herpes are mild and self- limited,
management is usually aimed at the prevention and treatment of
corneal disease.  Specific eye drops or ointment effective against
the HSV are prescribed.

   Recurrent Ocular Herpes

   A small percentage of patients who carry the dormant HSV in the
nerve cells of their brain will have a recurrence of ocular
infection.  Many persons never have a recurrence, or they have only
one.  A few unfortunate individuals will have many. Reactivation
produces a corneal infection called Herpes keratitis.  The symptoms
are redness, pain, and a watery discharge with blurring of vision.
The eye may feel as though there is a painful foreign body present.

   As discussed in the article dealing with general ocular
infections, the eye is so delicate that not only does it suffer
damage from the virus directly, but also it incurs injury from the
body's reaction to the infection.  Our immune system may damage the
eye as part of the attempt at healing and repair. Nowhere is this
more true than with recurrent Herpes keratitis. With each episode,
the likelihood of permanent corneal scarring increases.

   Treatment is designed to eliminate the actively replicating HSV,
decrease the inflammatory damage, and limit the length of disability.
 The mainstay of therapy is anti-viral medication in the form of
drops or ointment instilled in the eye several times a day until
healing occurs.  There are now three different ocular anti-herpetic
medicines commercially available: idoxuridine, vidarabine, and
trifluridine.  They all work by interfering with the metabolism of
the HSV.  Acyclovir is a new anti-herpetic soon to be available in
drop form.

   After several recurrences or a particularly prolonged course of
infection, inflammatory scarring becomes a major problem.  It is
treated with cortisone-type steroid drops.  But because steroids can
potentiate and worsen the actual herpes infection, they should only
be used when absolutely necessary.  Steroid use for an early initial
recurrence could lead to marked deterioration.

   Unfortunately, multiple recurrences with scarring can permanently
reduce vision.  At this point, a corneal transplant is often
necessary.  This is a major eye operation with all the attendant
risks and complications.  Penetrating keratoplasty is dealt with in a
separate article.  For more information about other Herpes
infections, please refer to the article in the "Disorders and
Diseases" section of the HealthNet Reference Library.





   AMBLYOPIA ("Lazy Eye")

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Amblyopia or "lazy eye" is a loss of vision which affects
approximately 2.5 % of all children.  It results from a loss of
function in the part of the brain which "sees" or responds to the
image that is processed by an individual eye.  It occurs when one eye
does not receive input that is equal to that of the other eye.  In
other words, when one eye is used less or has "disuse" compared to
the other.  Unfortunately, amblyopia often presents without symptoms.

   Physiology

   When we look at an object, called the "object of regard," each eye
forms an image of the object on the retina, the light- sensitive
membrane lining the inside of the back of the eye.  The image
produced is termed the "image of regard."  After being processed in
the retina, it is converted into electrical impulses which are
transmitted along the optic nerve to the visual centers of the brain.
 Although the brain is presented with a pair of images of the same
object, one from each eye, it fuses the two images into one.  The
result of this process is what we think of as our vision.

   A child's eye-brain system is amazingly plastic or pliable and is
not completely mature until the child reaches eight or ten years of
age.  But this does not imply that a younger child's vision cannot be
normal.  Indeed, the average child has 20/20 visual acuity by the age
of nine months.  None-the-less, subtle development does occur in this
system until the child is considerably older.

   Each eye has brain cells associated with it that respond only to
that eye.  There are other cells in the brain that respond only to
stimuli from both eyes.  These are termed binocular cells.  Because
of the plasticity of these eye-brain connections in younger children,
both types of cells need continuous input to ensure proper maturation
of the visual system.  Any disruption in this maturation process may
cause problems.  Amblyopia is the term for a major interference with
this visual development.

   In some ways each eye is designed to be competitive with its
counterpart, i.e. there is a rivalry between the two eyes for the
brain's attention.  When something interferes with one eye's imaging
and processing functions, that eye can lose vision and become
amblyopic.  The eye itself may function normally without any
permanent damage, but the brain becomes less and less attentive to it
and begins to rely more and more on stimuli from the other eye.  An
actual loss of cells, including binocular cells, occurs in the brain
area serving the amblyopic eye.

   Causes

   Any condition that interferes with normal retinal processing or
clear vision can produce amblyopia.  There are three main ways that
this interference can occur:

   1.  Strabismus -- A constantly crossed eye does not image the
object of regard.  Therefore, a child with esotropia, or crossed
eyes, who always looks at the world with his left eye while his right
eye is crossed does not receive the same visual information in each
eye.  The deviated right eye receives deprived information.  Because
of the rivalry in the brain, the visual input from the constantly
deviating eye is ignored or shut off and more and more the brain
depends on visual information from the straight eye.  Ultimately, the
constant deviation and poor visual processing in one eye leads to
amblyopia in the brain cells serving that eye.

   2.  Deprivation -- Anything that prevents a clear picture from
reaching the retina can produce amblyopia.  A classic example is a
cataract in a child.  When an adult develops a cataract, surgical
treatment usually corrects the vision to 20/20 whether the cataract
had been present for one month, one year, or even ten years.  But in
a child, even if a cataract has been present for a short time--even a
matter of weeks--surgery to remove the cataract may not restore good
vision.  The youngster's visual brain cells, having not received
clear images through the cataract, may already have become amblyopic.
 Other disorders that can cause deprivation are corneal scars and
opacities, and opacifications elsewhere in the system caused by a
variety of eye diseases.

   3.  Anisometropia -- This is very common, and unfortunately, a
very insidious type of amblyopia because it is without any sign or
symptom in a child.  Anisometropia is by definition an imbalance
between the refractive error of each eye.  That is, one eye has a
need for a stronger spectacle correction than the other eye.  For
instance, the right eye may have two units of farsightedness, whereas
the left eye may have four units of farsightedness.  Consequently,
the left eye receives a more blurred image than the right.  That
image is ignored and the brain cells serving that eye deteriorate
while the brain concentrates on the clearer image from the right eye.
 This process may also occur with astigmatism or nearsightedness.

   Diagnosis

   The diagnosis of amblyopia requires a complete ophthalmologic
exam.  As noted above, a normal child does not reach 20/20 visual
acuity until nine months of age; however, the vision can be checked
as early as three to four months of age.  The symmetry of vision
rather than absolute acuity is assessed initially.  This comparison
between the two eyes may detect a difference in their ability to see
clearly.

   Ideally, most children will receive an initial visual assessment
from their pediatrician or family physician at approximately six
months of age.  If a problem is detected, or if there is a suspicion
of an abnormality, a complete ophthalmic examination by an
ophthalmologist is recommended to assess the visual acuity of each
eye, to look for the presence of any eye disease, such as strabismus
or cataract, and to determine the refractive error or power of
glasses that might be prescribed.

   Another common source of amblyopia diagnosis is a screening
program which may be carried out by certain organizations, clubs, or
day care centers, etc.  If a child goes through a screening program
and an abnormality is suspected, he should receive a referral to an
ophthalmologist.  Primary care physicians and group screening centers
can only suspect the problem; it is the ophthalmologist that must
confirm the diagnosis and carry out the definitive treatment.

   Treatment

   Treatment for amblyopia is twofold: correction of the underlying
problem and therapy of the amblyopia itself. Obviously the treatment
for the underlying disease, whether that be a strabismus, an
anisometropia, or a unilateral cataract, depends on the particular
condition that is present.  But the treatment for amblyopia is the
same, regardless of the cause. Usually the child is placed in glasses
and occlusion or patch therapy to cover the good eye is begun.
Several non-prescription elliptical eye patches are commercially
available.  Like BandAids, they stick directly to the skin with their
own adhesive.  They cannot be stuck to the glasses, as the child will
simply look over the top of the frames.  Occluding the good eye
forces the brain to rely on the amblyopic eye, slowly reversing the
brain cell deterioration.  Recovery usually takes several months,
although it can occur in a shorter period of time in very young
children.  Eye patches may be worn for anywhere from several hours
per day to all the waking day.  Some ophthalmologists prefer
intermittent patching, i.e. five hours per day, eight hours per day,
etc., while others advise full-time occlusion.

   The most important concept in the treatment of amblyopia is the
age of the child.  Therapy for amblyopia is usually highly successful
prior to age four.  Between ages four to six, most children can be
cured.  Between six to nine years, it is difficult, but not
impossible to treat this condition, and after age nine, it is
essentially impossible to achieve a therapeutic success.  The above
age limitations relate to the plasticity of the brain that was
mentioned earlier.  The eye-brain is flexible enough to reverse the
cell deterioration in the first few years of life, but after that
crucial time period, the amblyopic condition can no longer be
remedied.

   There is one other form of amblyopia treatment that is much less
commonly employed than occlusion, that is penalization therapy.  It
involves placing an eye drop in the good eye causing the vision to
blur in that eye more than the other eye.  As with patching, the idea
is to stimulate the brain's attentiveness to the amblyopic eye.  Most
ophthalmologists use this method sparingly as it is not very
effective.

   Conclusion

   Amblyopia is a very common, serious disease of childhood that
often has no signs or symptoms.  Without early and proper treatment,
it can produce a lifetime visual disability.  It is extremely
important that all children have, at the very minimum, a screening
exam to prove that their eyes see equally.  In addition, all children
should have a complete ophthalmologic exam by age two to three years
to rule out amblyopia and underlying eye diseases.  If the diagnosis
of amblyopia is made, it should be properly treated: the earlier, the
better.  Children absolutely cannot "grow out" of "lazy eye."





   STRABISMUS ("Crossed Eyes")

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Strabismus can be defined as an alteration of binocularity or
two-eyed vision manifested by improper alignment of the eyes. About
four percent of the population suffers from this disease.

   Physiology

   Although all normal individuals function with a binocular visual
system, each eye is a separate unit able to process visual input.
Objects that we view form an image on the retina of each eye.  The
retinal images are processed separately, then transmitted along the
optic nerve to the brain.  The brain integrates the two messages, one
from each eye, into a single picture of the world.  This process of
integration is called fusion.  Hence, it is not in our eye, but in
our brain where we truly "see."

   Each eye has six muscles attached to it.  The muscles are
responsible for moving the eye up, down, left, and right.  The brain
oversees these movements: many on a conscious level and many on a
subsconscious level.  Both eyes normally move in unison as a result
of a very complex interplay of forces between messages originating in
the brain and feedback from the eyes. The point of this complex
system is the fusion process.  If the process is disturbed, our
binocularity suffers.

   Classification

   Strabismus is a heterogeneous disorder.  Typically,
ophthalmologists classify it in a variety of ways.  One method of
classification is the direction of eye deviation.  If one eye is
straight and the other is crossed inward, that is called esotropia.
If one eye is straight and the other is crossed outward, that is
called an exotropia.  If one eye is straight and the other is turned
upward, that is called hypertropia, and if one eye is straight and
the other is turned downward, that is called hypotropia.

  Another way to classify strabismus is the frequency of the
deviation.  Commonly, the deviation is present all the time; this is
called a constant tropia.  Alternatively, the deviation may be
present only intermittently, i.e. sometimes the eyes are straight and
cooperating well with each other and sometimes there is frank
deviation.  This is called an intermittent tropia.

   Finally, there is a type of deviation that is latent or hidden
most of the time.   It may be manifested infrequently or not at all.
This tendency toward deviation or latent deviation is called a
phoria.

   Possible Causes

   The basic cause of strabismus is unknown, but there are several
theories.  Controversy centers upon whether the underlying cause is
motor or sensory.  A motor abnormality would imply a defect in the
eye muscles themselves or the neurologic input to those muscles.  A
sensory abnormality would imply that the eyes develop a strabismus
secondary to a perceptual defect. For instance, there may be a defect
in the brain's fusional ability.  Heredity may also play a role.
Although not truly a disease coded for by a single gene that is
passed from one generation to the next, strabismus seems to have a
genetic/familial component.

   Importantly, any associated eye disease that produces prolonged
poor vision, for years in an adult or months in a child, can result
in strabismus.  Individuals can also develop strabismus from such
things as major head trauma, brain damage, thyroid disease,
myasthenia, brain tumors, diabetes, blood vessel disorders, and
others.  These cases represent a distinct minority.

   Symptoms

   Strabismus is most common in children.  It is a silent problem
that the child will not notice, although the parent may be aware that
the eyes do not look straight.  In adults, on the other hand,
strabismus that has its onset after age ten is associated with double
vision.  A child's brain prevents the youngster from seeing double;
it shuts off the double image in the eye that is not straight.  An
adult's brain, having already established its visual pathways, is not
able to suppress the input from the crossed eye, and hence, double
vision or diplopia results.

   Diagnosis

   The pediatrician is very important in the initial suspicion of
strabismus in childhood.  If the pediatrician suspects strabismus, he
should refer that patient to an ophthalmologist. An adult will
usually notice double vision and consult an ophthalmologist directly.
 Only an ophthalmologist can reliably diagnose and treat strabismus
in all of its manifestations.

   Treatment

   Treatment of strabismus is straightforward, but involves multiple
therapies.  The first and most important aspect is assuring that the
vision is equal and optimal in both eyes.  This is a routine part of
the ophthalmologic exam.  Most children with strabismus will require
glasses as the first step in therapy. Occasionally, some patients do
not require glasses, or if under one year of age, are too small to
wear glasses.  For these infants, eye drops may be prescribed as a
temporary measure until the child is old enough to wear glasses, at
twelve to eighteen months of age.  Glasses are a more integral form
of therapy for esotropia or crossed eyes than other forms of
strabismus, but the best possible vision must be assured with glasses
before other treatment can proceed.  Many children with esotropia are
completely corrected by glasses alone.  These children may have
markedly crossed eyes without glasses, but when the glasses are worn,
their eyes are perfectly straight.  This is the easiest treatment for
strabismus.

   Despite glasses, many children need further therapy to straighten
their eyes.  The mainstay of this treatment is surgery, but two other
forms of therapy should be mentioned here. The first is eye
exercises.  By and large, they are not useful for the vast majority
of adult and pediatric strabismus patients. Occasionally they can be
helpful for intermittent exotropia, when the patient is under the
care of an ophthalmologist.  Occlusion therapy or eye patching is
very useful in the child with strabismus.  Although in the vast
majority of cases it is not a treatment for strabismus per se, it is
effective for amblyopia, the poor vision associated with strabismus
in young children. (Please review the separate article on this
subject.)

   Strabismus Surgery

   At present, strabismus surgery is a safe procedure, most often
performed in the outpatient setting without overnight
hospitalization.  There is usually no need for eye patches or drops,
although some ophthalmologists may use anti-inflammatory drops
routinely.  General anesthesia is preferred, but in adults the
operation can be performed under local anesthesia.

   The operation itself involves making an incision through the
membrane that covers the sclera or white of the eye.  The six muscles
of each eye attach to the sclera much the way muscles in the arms and
legs attach to the bones.  The muscle is then isolated and grasped
with instruments, and either weakened or tightened to straighten the
eye.  Strabismus surgery has a success rate of 85 - 90 %.  Ten to
fifteen percent of the patients will require a second surgery because
the eyes are not completely aligned.

   Complications are infrequent; approximately one per 3,000 - 5,000
patients has a vision-threatening complication.  Probably one in
about 10,000 have a complication from anesthesia that would cause
some permanent damage to the heart or brain. Approximately five
percent of patients have superficial cyst formation that is easily
treated with drops.  If a second surgery is needed, it has
essentially the same risks, complications, and success rate as the
initial procedure.  (See the separate article on strabismus surgery
for more information about this subject.)

   Comment

   One final emphasis: children will not "grow out" of strabismus!
It is imperative that therapy be initiated as early as possible to
assure the best possible chances for success. Children are never too
young for an eye examination and it is never too early for treatment
of an eye condition.





   EYELID DISORDERS

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   The eyelids play an integral part in protection of the eyes.
Abnormalities of lid function are numerous and varied.  This article
will review ptosis (drooping), entropion (inversion), ectropion
(eversion), tumors, blepharospasm (forced closure), and stys.

   Anatomy and Physiology

   The eyelids have several layers.  Just beneath the outer skin is
the circular orbicularis muscle which contracts to close the lids.
The next major layer is the tarsus, a fibrous "skeleton- like"
structure that gives the lid rigidity and form.  The innermost layer
is the conjunctiva or membrane which coats the inside of the lid and
the outside of the eye.  Another important structure is the levator
muscle which originates deep in the bony socket and travels forward
and attaches to the tarsus.  This muscle is responsible for elevating
or opening the upper lid. Meibomian glands, lash follicles, and other
glands also insert into the tarsus and orbicularis muscle.  Finally,
the lacrimal or tear drainage system begins in the inner corner of
the upper and lower eyelids.

   The function of the lids is primarily one of active protection,
beginning with the lids' opening and closing actions. The eyelashes
or cilia serve as a sensitive warning system when they are touched
and they also prevent large particles from entering the eye.  The
glands of the eye secrete substances that help form the tear film
which constantly covers the eye.  The film is spread evenly across
the eye's surface and prevents it from drying by the pumping action
of the lids as they open and close.  Abnormalities of the tear film
may produce severe damage to the eye's surface.

   With such varied activities, it is not surprising that disorders
of the lids can be both disfiguring and vision- threatening.

   Lid Drooping (Ptosis)

   Lid drooping, or ptosis, may be congenital or acquired. Congenital
cases are the small majority.

   Congenital ptosis is usually present at birth or near birth. It is
non-progressive, variable in the amount of droop, and can affect one
or both eyes.  Although the droop itself almost never produces visual
loss, it can be associated with other disorders that can threaten
vision such as anisometropic amblyopia, eye muscle paralysis,
microphthalmus, and other more extensive cosmetic disorders.  Because
of these associated conditions, children with ptosis require
ophthalmologic examination in the first months of life.  Congenital
ptosis can be corrected surgically when the child is two to four
years of age, occasionally earlier.  This operation is discussed in
detail in another article.

   As its name implies, acquired ptosis is not present at birth, but
appears later in life, usually in older individuals.  The most common
cause is a weakness or dehiscence (loosening) of the levator muscle.
Other causes include myasthenia gravis, nerve paralysis from tumors,
strokes, injuries, and direct trauma. Once the underlying cause has
been determined, surgery is corrective.

   Lid Eversion (Ectropion)

   Ectropion is an eversion or turning outward of the margin of the
eyelid, usually the lower lid.  It may be due to senile or
age-related relaxation of the tissues, cicatricial or scarring
changes, or several other uncommon conditions.  Eversion of the lower
lid is unsightly and often associated with persistent tearing,
redness and irritation.  Such "baggy" lower lids can be corrected
surgically, but the age-related variety is much simpler to repair
than the scarring type.

   Lid Inversion (Entropion)

   Entropion is an inversion of the margin of the lid, either the
upper or lower lid.  The lashes are turned in toward the eye's
surface.  As with ectropion, there are two major types: senile and
cicatricial.  Entropion is unsightly, but the prominent symptom is
irritation from the lashes striking the eye.  Redness is also common.
 Fortunately, serious scarring of the cornea with visual loss is
rare.  Entropion is amenable to surgery when it is significant.

   Lid Tumors

   Lid tumors are primarily skin tumors, benign or malignant. The two
common skin cancers involving the lids are the basal and squamous
cell carcinomas.  Malignant lid tumors can present as very slow
growing, painless masses or "bumps" on or near the lids.  They may or
may not cause redness and inflammation of the skin.  Benign lesions
can present in a similar fashion, except they are usually more rapid
in onset.

   New or unusual masses on or near the lids require prompt
evaluation and therapy.  Many of these tumors require surgical
excision, and this is best when they are small.  Large, neglected
tumors often necessitate disfiguring surgery.

   Involuntary Lid Closure

   (Blepharospasm)

   Blepharospasm is an uncommon disorder of the middle-aged or
elderly.  It is characterized by uncontrollable, relatively constant,
tight lid closure.  The spasm can be so pronounced that manual
elevation of the lid is required.  The cause of blepharospasm is not
definitely known.  It is occasionally dismissed by physicians as
psychological in origin.

   The mainstay of therapy has been either observation or surgery,
but traditional operations have not been completely effective.
Within the last three years a new form of therapy has been developed.
 It involves the injection of the paralyzing drug, botulinum,
directly into the spastic muscles.  Although the effects last only a
matter of months, repeat injections offer good control.

   Stys and Chalazions

   Stys are acute inflammations of the oil glands within the eyelids.
 They present as swollen, red, painful areas that often point or
produce a head just like a pimple.  Occasionally, they spontaneously
drain a pus-like substance.  Stys are self-limited infections which
usually require no treatment.  Sometimes cellulitis, a generalized
lid infection, can mimic a sty; it requires antibiotic therapy.  If
one is not sure how to differentiate a sty from cellulitis, a
physician visit may be necessary.

   Unusually, a sty forms a chalazion, a hard non-infected, localized
mass within the lid.  This arises when a sty fails to drain.
Although harmless, it can be a nuisance, and persist for some time.
Simple surgical drainage is curative for large or unresolving
chalazions.





   NASOLACRIMAL DISORDERS

   (Tear System)

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Acquired and congenital disorders of the lacrimal system involve
the abnormal production, maintenance, and/or drainage of tears.  They
can produce either a "dry eye" or a "wet eye".

   Physiology of Tearing

   Tears are produced in the lacrimal and accessory lacrimal glands.
The lacrimal gland is located in the upper outer portion of the eye
socket (orbit) and deep lid.  The accessory lacrimal glands are found
in the conjunctiva, the membrane covering the white of the eye and
the inner aspect of the lids.

   Tears are composed of a superficial oily layer, a middle tear or
watery layer, and a deep mucoid layer.  The watery layer is the
largest and is produced by the lacrimal glands, while the other two
layers are produced in small quantities by other specialized glands
and cells.  All three layers are important for good tear function, an
absolute necessity.  They provide moisture, protection, and
nourishment for the surface of the eye, and a clear optical medium.
They also prevent the cornea and conjunctiva from drying and becoming
cloudy.

   Since the tear film is constantly being produced, there must be a
drainage system, one which allows for a constant turnover of the tear
film.  In the inner corner of each upper and lower lid margin is a
tiny hole termed the lacrimal punctum.  A "plumbing system" leads
away from this punctum, underneath the skin and tissues, to enter the
nose.  A good demonstration of this nasolacrimal communication is the
"runny nose" one gets when crying.

   Abnormalities of tear production, or tear film maintenance and
function, produce vision-threatening "dry eye" symptoms. Disorders of
tear drainage produce a "wet eye," which can be extremely bothersome
and unsightly, but does not affect vision.

   Dry Eye Disease

   Lack of the proper quantity or quality of tears can cause dry eye
complications.  Also, improper eyelid function may impede full
wetting of the eye's surface.  Decreased or abnormal tear function
can occur gradually as an isolated phenomenon or it may be secondary
to other eye or systemic diseases.  Ocular scarring due to injury,
disease, or systemic illness such as rheumatoid arthritis are some
examples.

   Symptoms include chronic redness, irritation, loss of corneal
luster or glistening, possible decreased vision, and paradoxically
increased tearing.  Excess tearing can occur with dry eyes when the
quality rather than quantity of the tear film is inadequate.

  Treatment entails using artificial tear drops, ointment, home
vaporizers, and avoiding dry climates.  In severe cases, surgery is
indicated to close the tear drainage ducts so that better use can be
made of existing tears.  If there is enough corneal damage, usually
from severe scarring disease, corneal transplantation may be
necessary.  Penetrating keratoplasty, or corneal transplantation, in
persons with dry eye disease is notoriously difficult.

   Lastly, if an underlying condition is related to or responsible
for the dry eye--for example, an abnormal lid contour or rheumatoid
arthritis--treatment of the basic problem may be beneficial.

   Wet Eye Problems

   Excessive tearing is caused by oversecretion or inadequate
drainage of tears.  The former is very rare, except when lid
malformations are present; it will not be reviewed here.

   Inadequate drainage of tears through the puncta and duct system to
the nasal cavity, termed complete or partial nasolacrimal duct
obstruction, occurs in two age distributions. Congenitally, it
appears in newborns.  As an acquired disease, it affects the
middle-aged and elderly.

   Congenital obstructions are frequent.  The newborn presents with
wet eyes, increased tear lake along the lid margin, frequent tearing
termed epiphora, mucous or pus-like discharge, crusting of the lid
margins and eyelashes, and rarely, swelling and redness of the
lacrimal sac.  The latter is a structure situated at the junction of
the nose and inferior portion of the lower eyelid.  It functions to
collect tears from the puncta. Infection of the lacrimal sac is
called dacrocystitis.

   Duct obstructions may open spontaneously in the first few months
of life, but if they do not disappear on their own, operative therapy
is required to open the blocked duct system. After six months of age
the chances of spontaneous resolution are slim.  Although somewhat
controversial, six months seems to be a reasonable cutoff point after
which surgery can be recommended.

   There are three types of surgical treatment.  Simple probe and
irrigation is a five minute, negligible risk and high success
operation performed under anesthesia on youngsters six to eighteen
months of age.  After this age, its success rate drops and silicone
intubation of the nasolacrimal duct system can be utilized.  There
are circumstances, however, when intubation might be the preferred
procedure earlier on: for instance, a three month old who has had
dacrocystitis.  This procedure involves inserting a one millimeter
diameter tube through the tear duct system and looping it through the
upper and lower punta.  The silicone tube is then tied in the nose
and left in place for several months.  Rarely in childhood a major
surgical procedure called dacryocystorhinostomy is necessary when
more conservative operations are not indicated or have already
failed.

   Acquired adult onset nasolacrimal duct obstruction comes on more
gradually.  Middle-aged women are the prime candidates. Tearing is
the major symptom and often requires constant dabbing of the eyes.
When the symptoms become enough of a nuisance, treatment is
advisable.  Unlike in infants, probing and irrigation is not
effective and silicone intubation is uncommonly utilized.  The
mainstay of therapy is dacryocystorhinostomy.  A major undertaking,
this surgery is covered in more detail in the section on eye
surgeries, tests and procedures.





   CATARACT

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   A cataract is simply an opacity or clouding of the crystalline
lens of the eye.  There are many different types and causes, but the
common denominator is opacification of the normally transprent lens.
Cataract extraction is the single most commonly performed surgery in
the U.S.  Several hundred thousand such operations are done each
year.

   Physiology

   Upon entering the eye, light passes through, in order, the cornea,
anterior chamber, pupil formed by the ring-like iris, crystalline
lens, and the vitreous gel before finally hitting the retina and
being converted into electrical energy.  The lens functions to
transmit and focus light rays upon the retina.  The ability to change
one's point of focus from a few inches to a distance of many feet is
dependent upon normal lens function.  A tiny muscle in the eye, the
ciliary muscle, changes the shape of the lens to allow for
adjustments in focusing power.  This process is called accommodation.
 Opacification or clouding of any of the structures in front of the
retina, including the lens, can decrease visual acuity.

   Major Causes

   The vast majority of cataracts result from an age-related change
in the lens unassociated with other disease processes. As we age, the
structure and function of the lens begin to degenerate.  Through a
complex series of chemical events, opacification ensues.

   Cataracts may be secondary to other eye disease.  Intraocular
inflammation, retinitis pigmentosa, glaucoma, and many others can be
associated with lens opacity.

   Cataracts may be toxic, i.e. drug-induced.  Cortisone-type
steroids are the most commonly implicated medications.

   Injury is a major cause of cataracts in early life.  Lens
opacification may complicate both blunt and penetrating eye injuries.
 Rapidly forming cataracts usually occur after direct injury to the
lens from an object that penetrates or cuts open the eye.

   Systemic illnesses have also been associated with cataract
formation.  Diabetes mellitus may be the most common, but the list
includes Down's syndrome, myotonic dystrophy, Marfan's syndrome,
allergic dermatitis, and many other diseases.

   Congenital or infantile cataracts can occur spontaneously as a
primary disorder, or secondary to systemic diseases.  Among the
associated conditions are maternal infection with rubella (German
measles) or other agents, metabolic disturbances such as
galactosemia, hereditary disorders, neurologic diseases, and rarely,
birth injury.

   Symptoms

   The vast majority of cataracts are age-related.  Therefore, the
symptoms usually begin around age 55-70.  A gradual diminution or
blurring of vision occurs.  Glare from sunlight or nighttime driving
can be a significant problem.

   Symptoms may start at a much younger age if cataract- associated
diseases are present.  Congenital cataracts may be dense enough to
preclude useful vision beginning at birth.

   Treatment

   Therapy for cataracts is entirely surgical: the crystalline lens
is removed.  There are no effective medications.

   Surgery should be considered when the cataract is dense enough to
alter the person's ability to perform daily activities, but the
decision must be individualized.  For example, a 50 year old watch
repairman or long haul trucker may need an operation much sooner than
an elderly, bed-ridden patient.

   In today's society, cataract surgery is available to all
individuals.  A variety of surgical procedures are performed.  An
important pre-operative consideration is the choice of optical
correction needed after surgery.  There are three ways to replace the
focusing power of the lens.  The oldest, now relatively uncommon, is
aphakic spectacles or cataract glasses.  Contact lenses that ride on
the surface of the cornea are used frequently, but intraocular lens
replacement is rapidly becoming the preferred procedure by most
ophthalmic surgeons.

   Both cataract surgery and post-operative optical correction are
described in a separate article.





   GLAUCOMA

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   There are many varieties of glaucoma.  Their common denominator is
a dangerously increased intraocular (within the eye) pressure.

   Physiology

   The eye is a closed, fluid-filled compartment.  It has many
specialized solid structures, but they take up little space when
compared to the amount of fluid.  Some of the fluid is in the form of
a gel, called the vitreous, but most is water and essential salts.
This water-based fluid, called aqueous, is constantly being produced
inside the eye by the ciliary body, a small circumferential structure
behind the iris.  It then circulates through the pupil and over the
iris before being drained out of the eye at the angle between the
iris and cornea through very intricate "plumbing" termed the
trabecular meshwork. This circulation of the aqueous furnishes
nutrients and performs other functions for the eye.  The ease of
drainage of the fluid out of the eye is the eye's outflow facility.
When too little drainage occurs relative to the amount of aqueous
produced, there is an increased intraocular pressure and glaucoma
supervenes.

   Classification

   The three major classes of glaucoma are: Open Angle Glaucoma,
Angle Closure Glaucoma, and Congenital or Infantile Glaucoma. Each of
these has many subtypes and can occur in association with other eye
or generalized diseases.  Open Angle Glaucoma simply means that the
drainage angle is open, but the fluid reaching it is not able to
percolate through.  The "plumbing" itself is not fully functional.
Angle Closure Glaucoma is very different.  In this disease, the angle
structures including the trabecular meshwork are blocked, typically
by the iris.  This prevents aqueous from reaching the drainage
channels, although the meshwork itself is functional.  Congenital
Glaucoma is an inborn anomaly of the drainage structures, i.e. an
abnormally developed filtration angle that prevents proper outflow
facility or drainage.

   Signs, Symptoms & Statistics

   About one percent of people over age 40 suffer from glaucoma.
Primary Open Angle Glaucoma, the variety not associated with other
diseases, comprises the large majority, accounting for 60 - 70 % of
the cases.  It also produces about 10 - 20 % of all blindness in the
U.S.  When both the primary and secondary forms are considered, these
figures are considerably higher. Unfortunately, the symptoms are
often minimal or absent.  A chronic, insidious, bilateral disease, it
gradually destroys the optic nerve with constriction of one's field
of vision ("tunnel vision") as well as scotoma formation or "holes"
in one's visual field.  Lastly, central or reading vision is
affected, but by this time, the glaucoma is far advanced.

   In contrast, Angle Closure or Narrow Angle Glacoma is much less
common.  It usually presents as an acute or sudden event. The
drainage angle is occluded, usually by iris, and the pressure rise is
rapid and dramatic.  This produces pain, blurred vision, haloes
around light, redness, and pupil abnormalities.  Acute angle closure
attacks tend to occur in smaller, far-sighted eyes. Very rarely the
attacks can be brought on by dilating drops, but they usually occur
spontaneously.  Some patients may have prodromal or subacute
episodes.

   Congenital Glaucoma is exceedingly rare.  The average eye surgeon
will see only one or two cases in his entire career. About 60 percent
present before six months of age, at least 80 percent before one year
of age.  The early signs are epiphora or tearing, photophobia or
light sensitivity,  and blepharospasm or tight lid closing.  In
nearly all cases, the cornea imbibes fluid, becomes cloudy or hazy,
and abnormally enlarges or stretches.  An analogy is a balloon
filling up with water, stretching as the pressure increases.

   Diagnosis

   Along with a complete ophthalmologic exam, the key to the
diagnosis of glaucoma is the measurement of intraocular pressure.
Many employers and shopping malls offer free screening programs to
test for Open Angle Glaucoma.  A glaucoma screening test is called
tonometry.  It is a painless, quick, and simple method of determining
intraocular pressure.  All individuals over age 40 need yearly, or
near yearly, glaucoma checks.  Those especially at risk are blacks,
diabetics, highly near-sighted individuals, older people, and
relatives of glaucoma patients.

   Angle Closure Glaucoma cannot be detected prior to an attack, but
the tendency for this disease may be seen during a complete
ophthalmologic exam.

   Congenital Glaucoma, being so rare and so different from adult
glaucoma, is difficult to diagnose.  Because the usual intraocular
pressure readings may be unreliable, a thorough examination under
anesthesia and the participation of a pediatric ophthalmologist or
glaucoma specialist are often required.

   Treatment

   Treatment involves a variety of means: medical, surgical, and
LASER.  Medical methods include topical or drop medications,
occasionally pills, and rarely medicine by injection for acute angle
closure.  Drugs work by one of two mechanisms.  They decrease aqueous
production and/or increase the outflow facility. The first group
includes timolol, epinephrine, and oral carbonic anhydrase
inhibitors.  The latter includes pilocarpine and similar drugs.  All
of these can be used in combination. Although side effects are
infrequent, they must be monitored. Timolol, for example, should be
used with care in asthmatics. The most frequent, often unavoidable
side effects of pilocarpine in younger patients are headache and
temporarily blurred vision.

   If medical management fails, then either surgery or LASER therapy
is the next step.  Their success rates are variable depending on the
severity and subtype of glaucoma.  If medical drug therapy cannot
prevent continued eye damage, there is often little alternative to
proceeding with surgery or LASER therapy, despite the risks.  In
general, drug therapy is usually reserved for Open Angle Glaucoma,
while Angle Closure Glaucoma and especially Congenital Glaucoma are
surgical diseases.  For more information about the use of surgery and
LASER for glaucoma, please consult the separate articles dealing with
these subjects.

   Finally, the most important factor is early detection.  Early
screening programs are indispensible to lessening the costly effect
of glaucoma on the individual and society.





   OCULAR TRAUMA (Eye Injury)

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Major and minor injuries to the eye socket, lids, nasolacrimal
tear ducts, conjunctiva, cornea and the deeper structures of the eye
occur with both blunt and sharp trauma.  The eye, although somewhat
protected by the facial bones, can be injured by a wide variety of
mechanisms.

   Eyelids

   The eyelids represent the next line of protection for the eyes
after the bones of the nose and brow.  Blunt injury, such as that
produced by a tennis ball or a blow from a fist, can damage the lids
without lacerating the skin.  A "black eye" results.  This represents
hemorrhaging and swelling beneath the skin. Interestingly, the blood
may dissect across the nose to "blacken" the other eye.  This
resolves without treatment.

   Lid lacerations or cuts may be minor or serious.  If superficial
and away from the margin of the lid, they may not even require
stitching or suturing.  However, all lacerations involving the lid
margin are serious and require meticulous surgical repair, often in
the operating room rather than the emergency department.  More
extensive damage may require complex surgery and multiple operations.

   Nasolacrimal Duct

   Nasolacrimal (tear duct) lacerations can occur when a cut involves
the area between the inner angle of the eyelids and the nose.  If the
duct system is lacerated and not repaired, chronic tearing will
result. (See "Nasolacrimal Disorders".)  Hence, these injuries
require meticulous operative repair.  Often a one millimeter diameter
silicone tube is inserted into the duct to promote proper healing.
Occasionally, the injury is so extensive that immediate repair is not
possible.  The definitive procedure is performed later on.

   Ocular Surface Injuries

   The conjunctiva is the clear membrane which covers the white of
the eye and the inside of the lids.  Both the conjunctiva and the
cornea can be injured as a result of foreign bodies, scratches, and
superficial, non-perforating lacerations.

   A conjunctival foreign body, such as a wood chip, eyelash, or dust
particle, can usually be removed by the individual or it is washed
out naturally.  On the other hand, corneal foreign bodies often stick
to, or imbed within, the cornea.  They are quite painful and need to
be removed by a physician.

   Conjunctival lacerations are harmless and need not be repaired;
however, it is important to be sure that no deeper eye structures are
cut.  If significant blood collects on the white of the eye, then
careful examination and even surgical exploration may be necessary to
rule out more serious injury.

   Non-perforating corneal lacerations or superficial scratches
usually require only minor treatment.  These are quite painful,
giving a distinct foreign body sensation.  Treatment involves a
thorough exam, antibiotic drops to prevent infection, and patching of
the eye for 24 to 48 hours.

   Chemical burns to the cornea, such as acid or lye, can be very
serious.  These require immediate and liberal flushing with water.
Lye injuries, being worse than acid injuries, require prolonged
irrigation.  When irrigating one should use only water or salt water
and not attempt neutralizing an acid burn with alkali or vice-versa.
Both acid and lye burns should receive emergency treatment by a
physician, preferrably an ophthalmologist.

   Thermal burns of the cornea are not usually serious.  The lids can
be significantly burned while the cornea is spared. Superficial
corneal burns require antibiotic instillation and possibly patching,
depending on the condition of the burns to the lid and face.

   Deep Injuries

   A perforation occurs when the eye's outer surface is violated. A
penetration is when the surface is violated and the inside of the eye
is entered.  It may be a seemingly minor, tiny puncture or a major
laceration with obvious deep ocular damage.  This type of injury is
always serious.

   All persons who have suffered a penetrating injury to the eye
require thorough examination by an eye surgeon, an ophthalmologist.
X-rays are often performed to rule out a foreign body.  Surgery is
necessary to repair damaged structures. The outcome of the operation
and the chances of preserving vision depend on the extent of injury.
Intraocular foreign bodies, such as glass, metal, sticks, etc., are a
significant complicating factor.  Attempts at removal meet with
varying success.  Often, hospital therapy with antibiotic drops and
injections and tetanus prophylaxis are required.

   Blunt Eye Injury

   The contents of the eye can be damaged from concussive forces.
Uveitis, hyphema, swelling, hemorrhage, and other damage can affect
the iris, lens, retina and optic nerve.

   Uveitis, an inflammation of the pigmented structures inside the
eye, is covered in a separate article in this section.

   A hyphema is bleeding into the anterior chamber, the compartment
between the cornea and iris.  With bedrest and other supportive
measures, most hyphemas clear without difficulty. Occasionally,
glaucoma supervenes or rebleeding occurs and surgery is necessary to
evacuate the clot.

   Swelling and bleeding deeper in the eye, within the vitreous or
retina, can be serious.  A simple "wait and see" attitude is
appropriate, as subsequent damage cannot be prevented. Occasionally,
persistent blood in the vitreous can be surgically removed after a
suitable time has elapsed.

   Contusion of the optic nerve can be vision-threatening.  There is
usually no therapy, but if it is recognized very early, then steroid
medication or surgical therapy may be advantageous. Surgery is
presently controversial.





   UVEITIS

   (Inner Eye Inflammation)

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Uveitis is an inflammatory disorder of the pigmented structures of
the eye, including the iris, ciliary body, and choroid.  If the
former two are involved, the condition is termed anterior uveitis;
inflammation of the choroid is called posterior uveitis.  Although
there are many possible causes, a specific etiology is not identified
in the majority of cases.

   Physiology

   The uveal tract contains the portions of the eye that are very
rich in blood vessels.  It is also heavily laden with melanin, the
same pigment that colors our skin.  Uveal structures can become
inflammed spontaneously, after injury, or in association with
specific ocular and systemic diseases.  Contiguous structures within
the eye are often involved and subject to damage.

   The iris is the blood vessel rich membrane that gives us our "eye
color": blue, brown, hazel, etc.  It controls the size of the pupil,
and hence, regulates the amount of light entering the eye.  The
ciliary body is a circumferential structure situated behind the iris.
 Among its specialized activities are aqueous humor (fluid)
production and focusing.  The blood rich choroid lies between the
retina and sclera (white of the eye) and provides nourishment and
metabolic support.

   Signs and Symptoms

   Uveitis typically produces a red, acutely painful eye.  The pain
is aching and constant in character.  Vision can be decreased and
photophobia or sensitivity to light is common. There is minimal or no
discharge.  Uveitis is differentiated from an infection by its
greater pain, photophobia, and lack of discharge.

   Causes

   Most cases of uveitis, especially anterior uveitis, are
idiopathic, i.e. without apparent cause.  They occur spontaneously,
respond to therapy, and occasionally relapse. Anterior and sometimes
posterior uveitis can follow blunt eye injury, such as that caused by
a tennis ball or a punch. Specific causes include rheumatoid
arthritis, sarcoidosis, tuberculosis, syphilis, parasitic infection,
ulcerative colitis, psoriasis, ankylosing spondylitis, and other eye
and systemic conditions.

   Diagnosis

   A complete ophthalmologic exam and a battery of tests selected to
find the most likely cause are required.  The evaluation may include
blood tests, X-rays, special studies to check for arthritic diseases,
and consultation with various specialists. In the majority of cases,
no underlying cause is found.

   Treatment

   The goal of therapy is to prevent the complications of chronic
uveitis.  Without prompt treatment, permanent damage to the delicate
structures in the eye may occur: e.g. cataracts, retinal scarring and
detachment, dense scar membrane formation, macular edema, optic
neuritis, and others.

   The mainstay of treatment is medication to decrease or eliminate
inflammation.  Cortisone-type steroids in the form of drops, local
injections, or pills give progressively greater anti-inflammatory
effect.  Eye drops are usually all that is required.  Possible ocular
complications of steroid use are glaucoma and cataract.  For this
reason, these medicines should not be used lightly or for extended
periods unless it is absolutely necessary.

   Other anti-inflammatory drugs, ranging from aspirin to potent
anti-cancer medicines, are occasionally used.  Topical cycloplegics
are employed as adjunctive therapy.  They dilate the pupil and
paralyze accommodation or focusing ability to put the inflammed eye
at rest.





   TUMORS OF THE EYE

  (Intraocular Tumors)

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Tumors are uncontrolled growths of tissue that can originate in
any organ of the body.  Malignant tumors or cancers differ from
benign tumors mainly in their ability to metastasize or spread to
other organs from their primary site.  Although there are many
varieties of intraocular tumors, both benign and malignant, only
three types occur with any sizeable frequency. They are metastatic
disease of the eye, malignant melanoma, and retinoblastoma.
Metastatic disease may be the most common eye tumor, while malignant
melanoma is the most common primary eye tumor (i.e. originating in
the eye), and retinoblastoma is the most common intraocular
malignancy of childhood.

   Metastatic Disease

   Many different primary malignant tumors may spread to the eye,
especially cancers of the breast and lung.  Gastrointestinal tract,
kidney, and prostate cancers are some of the others. Metastatic eye
disease is more common in women, perhaps because of the high
incidence of breast cancer.  These tumors tend to be bilateral,
occurring in both eyes nearly 25 % of the time.

   Metastatic tumors may be entirely without symptoms, but many cause
decreased vision, pain, redness, glaucoma, or other complaints.  The
most important feature of metastatic eye disease is the need to
recognize it as such.  These tumors can resemble primary eye tumors,
so the diagnosis may be a difficult one to make, even for an
experienced ophthalmologist.  Once recognized, however, the the eye
can be treated symptomatically, while the known primary tumor
undergoes definitive therapy.

   Occasionally, a patient will present with metastatic eye disease
before the site of the primary tumor is diagnosed.  In this case,
proper evaluation and treatment can be lifesaving.

   Malignant Melanoma

   This tumor is a cancer of the melanin-containing cells in the eye.
 It may originate in the iris or ciliary body, but more commonly, it
arises from the choroid, a blood vessel-filled structure in the back
of the eye.  It is analgous to the malignant melanoma of the skin.
Like this deadly tumor, it can arise either spontaneously or from a
nevus or mole, a localized collection of melanin-containing cells.

   Any age may be affected, but the average age of onset is about 55
years.  Whites are much more frequently affected than blacks.
Bilateral tumors are unusual.  The most frequent symptom is decreased
vision, and inflammation, redness, and glaucoma, may occur.  The
ophthalmologic examination discloses a mass or abnormal growth.

   This tumor has a high mortality when it occurs in the skin, but
the prognosis in the eye is better.  When diagnosed early, it remains
confined to the eye which has prevented its spread. Unfortunately,
there is a significant mortality even with proper therapy.

   The treatment of ocular malignant melanoma is fairly standardized.
 When a growth in the eye has a high probability of being a malignant
melanoma, because of its appearance, growth, etc., the eye is usually
removed entirely, tumor and all.  When the diagnosis is unclear, a
period of observation may be required prior to surgery.  Rarely the
tumor is treated without removing the entire eye.  Chemotherapy or
radiation therapy is sometimes added to the regimen.

   Retinoblastoma

   This is a malignant eye tumor of childhood.  There are about 350
cases in the U.S. each year.   There are two types, hereditary and
sporadic.  The hereditary type tends to run in families and is often
bilateral.  All bilateral tumors, even without a family history,
should be considered hereditary; the patient's future children may be
affected.  The sporadic type is more common, not inherited,
unilateral, and occurs later.  The average age of onset of the
hereditary variety is about one year, while it is about two years for
the sporadically occurring tumors.  Most importantly, these tumors
are primary eye cancers. They demand immediate attention or the
child's life will be threatened.

   The usual presentation is one of leukokoria, or white pupil, i.e.
the pupil appears whitish or grayish rather than black. Leukokoria
represents the tumor itself visible through the pupil. Since this
cancer arises in the retina, it is usually very large by the time
this occurs.  Another frequent sign is strabismus or crossed eyes.
As the tumor destroys vision, the eye crosses. Among the other
findings are redness, pain, and inflammation.

   Treatment depends on the size of the tumor and whether one or both
eyes are affected.  Almost all unilateral tumors are large at the
time of diagnosis.  The eye is enucleated or removed entirely.  In
children with bilateral tumors, the more severely affected eye may be
removed and the other eye treated with radiation.  Rarely, both eyes
are involved symmetrically and both eyes are irradiated.  The goal is
to save some vision while preventing further spread of the cancer.

   Although the survival rate is high, possibly over 95 % in most
centers in the U.S. today, once spread of the tumor has occurred, the
disease is uniformly fatal.  No delay in treatment is acceptable!

   Rarely, the diagnosis is in doubt and the eye is enucleated even
though the ophthalmologist is not 100 % positive that a malignancy is
present.  This is because, occasionally, vision can be destroyed by a
lesion that highly mimics retinoblastoma.  When this happens, it is
usually unavoidable.  Because of this difficulty in diagnosis and
treatment, management of these tumors usually is conducted by a team
of specialists at a large referral center.





   DIABETIC RETINOPATHY

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Diabetes mellitus is a serious illness that affects many different
organ systems.  Its major long-term complications are related to
damage to small and large blood vessels in the heart, brain, kidneys,
nerves, extremities, and elsewhere.  The retina, the light-sensitive
membrane lining the inside of the back of the eye, is rich in tiny
blood vessels.  Diabetic changes in these retinal vessels often
mirror the circulatory abnormalities that occur throughout the body.
These can be observed directly with an ophthalmoscope.  Diabetic
retinopathy constitutes the spectrum of retinal disease associated
with diabetes mellitus.

   Incidence and Risks

   Diabetic retinopathy is one of the leading causes of blindness in
the United States.  Its onset is dependent upon the age at which
diabetes is first diagnosed as well as the duration of the disease.
Insulin-dependent (Type I) juvenile diabetics take longer to develop
retinopathy than persons first diagnosed to have diabetes as adults,
whether the latter are treated with insulin, diet, and/or pills.  But
a higher percentage of juvenile diabetics suffer from retinopathy
since these individuals live a long time with their disease.  For
example, a juvenile onset diabetic with a twenty year history of the
disease may develop retinopathy at age 25 and have significant visual
loss by age 35, while a newly diagnosed 50 year old diabetic may
develop retinopathy at age 55 and visual loss soon thereafter.

   Although some diabetics show no evidence of retinopathy, the
majority are affected.  Population groups at risk include blacks,
women, persons with high blood pressure, perhaps pregnant diabetics,
and others.  There is no conclusive evidence that strict control of
the blood sugar influences the onset or course of diabetic
retinopathy.  Intense clinical research is ongoing.

   Mechanism of Injury

   Exactly what causes blood vessel disease in diabetes is unclear.
What is known, however, is that the small blood vessels, capillaries
and tiny veins or venules, seem to be affected first.

   There are two basic types of diabetic retinal vascular disease:
background or non-proliferative, and proliferative retinopathy.  The
former refers to the damage occurring in the normal retina and
retinal vessels.  The latter is a more dangerous stage in which new,
abnormal blood vessels grow or proliferate--a process called
neovascularization.

   Background retinopathy is first seen after small vessels have
already sustained some damage.  Capillaries undergo structural damage
to their walls and vessels begin to leak fluid.  Tiny outpouchings or
microaneurysms form, first in the venules and then in the tiny
arteries.  Larger blood vessels can begin to show damage.
Hemorrhages or bleeding can occur, but these are usually
self-limited.  Tiny infarcts, retinal cell damage from lack of
oxygen, are another complication of this non- proliferative stage.
Eventually, the blood vessels can become so leaky that fluid
accumulates between the layers of the retina. Unfortunately, this
free fluid has a tendency to collect in the macula, the specialized,
best-seeing "20/20" portion of the retina.  When this happens, there
can be a significant deterioration in one's visual acuity.
Background retinopathy can continue for years in this manner without
entering the more ominous proliferative stage described below.

   With proliferative retinopathy, the tiny arterioles and
capillaries have sustained widespread damage and the blood flow is
poor.  Neovascularization probably develops in response to severe
retinal hypoxia or oxygen starvation.  Whether the retina produces a
"hypoxic factor" that stimulates new vessel growth or whether the
stimulus occurs locally is not known.  Whatever its cause,
neovascularization is dangerous because the new vessels have a
tendency for major bleeding which has the potential to produce
sudden, dense visual loss.  Repeated episodes of retinal hemorrhage
can occur with intermittent clearing and rebleeding. Retinal
detachment from scarring or traction can follow this sequence of
events and may lead to total blindness.

   Treatment

   Regular examinations by an ophthlamologist and careful management
of the patient's general medical condition are the most important
aspects of treatment.  The timing and choice of therapy is best made
in light of the natural history, onset, and progression of the
individual's condition.

   The mainstay of therapy after simple observation is LASER
treatment.  Background retinopathy can require LASER therapy when
macular edema or swelling is present or when the general retinopathy
is severe.  Proliferative retinopathy nearly always requires LASER
treatment.

   By using LASER photocoagulation, the eye surgeon can apply tiny
burns to the retina to dry up leaking areas, wall them off, or
destroy the stimulus for neovascularization.  The procedure can be
accomplished with mimimal discomfort and without general anesthesia
or overnight hospitalization.  Its success is in part determined by
the severity of the underlying disease as well as the duration of the
specific abnormality, such as macular edema. Often, vision is not
improved, but progression and greater visual loss can be prevented.
Overall, LASER therapy is very effective and can be sight-saving.
For more information about LASER, please refer to the article in the
"Eye Operations & Procedures" section.

   Other forms of therapy, such as surgical vitrectomy or retinal
detachment repair, are reserved for severe complicatons of diabetic
retinal disease.





   HYPERTENSIVE RETINOPATHY

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Definition

   Hypertensive retinopathy is the term used to describe the adverse
effects of high blood pressure on the tiny blood vessels in the
retina, the light-sensitive membrane lining the inside of the back of
the eye.

   Causes

   Hypertension or high blood pressure, a common disorder, is known
to be a significant risk factor for the development of heart disease,
stroke, and kidney failure, among other serious complications.  The
effects of prolonged or severe elevations in the blood pressure are
manifested primarily as damage to blood vessels in various organs.
The retina is not immune to these effects.

   Hypertensive retinopathy is primarily a disease of older
individuals.  Therefore, it is often found in conjunction with
arteriolosclerosis.  These two disorders can produce retinal damage
evidenced by narrowing or focal constriction of the vessels, tiny
hemorrhages, edema or fluid leakage, and small retinal infarcts or
cell death due to decreased oxygen.  Rarely, in severe accelerated or
malignant hypertension, the bleeding and cell injury can be great
enough to actually decrease vision.

   Treatment

   Since the majority of patients with high blood pressure have few
eye symptoms due to their disease, the ocular changes present in
hypertension or arteriolosclerosis very rarely require therapy.  The
basic goal is control of the underlying blood pressure condition with
diet and medication.  Regular ophthalmologic examinations can be
valuable in the monitoring of the hypertension itself, because the
retinal changes serve as a barometer for blood vessel damage
elsewhere in the circulatory system.

   For more information about hypertension, please read the general
article in the "Disorders and Diseases" section of the Reference
Library.





   MACULAR DEGENERATION

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Macular degeneration can be considered a scarring of the macula,
the best-seeing "20/20" area of the retina.   It is one of the most
common causes of loss of vision.  A disease of older individuals, it
rarely strikes people under age 50.

   Physiology

   The retina is the light-sensitive membrane that coats the inside
of the back of the eye.  It converts light energy into electrical
energy and transmits the message to the brain via the optic nerve.
The retina is not homogeneous, however.  Resolving power, as
reflected in one's visual acuity, is much better in the center of the
retina than in the periphery.  In the very center of the retina is a
highly specialized area termed the macula.  It is approximately 1.5
millimeters (1/16 in.) in diameter.  Maximum resolving power or
visual acuity is achieved by only about 0.3 millimeters of this
structure.  The retina outside the macula is used for peripheral
vision.  Every object that one actually focuses on forms a light
image on the macula.  We read, watch television, sew, look at our
friends' faces with our maculas. Obviously, this tiny structure is
essential to our vision.

   Causes and Types

   The aging process affects many different organ systems.
Degeneration occurs in the skin, hair, joints, blood vessels, and so
on.  The macula is also subject to degenerative change. This
association with aging has led to the name senile macular
degeneration.  (Contrary to popular usage, the term "senile" simply
connotes age and has nothing to do with mental abilities.) With this
disorder, the normal anatomic architecture in the macular area
degenerates and thins.  The highly discriminating color vision cone
cells atrophy, and cysts or holes may develop in the retinal layers.
Luckily, only a minority of individuals are affected.

   Disciform macular degeneration is a considerably less common
variety of macular degeneration.  It can affect younger adults.
Although its appearance is similar to the senile variety, the changes
are not truly age-specific.  New abnormal blood vessels are often
involved in the process.  They grow underneath the macula, so-called
subretinal neovascularization.  They tend to bleed and rebleed
leading to scarring of the macular structures.

   Signs and Symptoms

   Macular degeneration produces a bilaterally symmetrical, slowly
progressive, painless loss of fine central vision, leaving peripheral
vision intact.  Disciform degeneration may be unilateral or
asymmetric, and if an acute bleeding occurs, the vision may suddenly
deteriorate.  Senile degeneration strikes people over age 65;
disciform is usually confined to those over 50.

   Treatment

   Unfortunately, there is no treatment for senile macular
degeneration, other than low vision aides, such as hand held
magnifiers, and support from eye care professionals and various
social agencies.

   Disciform degeneration has recently been found to be treatable
with LASER therapy.  LASER is able to eliminate subretinal
neovascularization without destroying the sensitive macula.  This can
be a sight-saving procedure.  Please refer to the article on LASER
therapy for more information.





  OCULAR ARTERY & VEIN OCCLUSION

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   The arteries and veins of the retina are subject to disorders that
obstruct blood flow.  The occlusion may be sudden or gradual, but it
is usually ominous for vision and possibly, general health.

   Arterial Occlusive Disease

   Several types of occlusive disease affect the retina: carotid
artery stenosis, retinal artery emboli, retinal artery occlusion, and
giant cell or temporal arteritis.  These disorders are reviewed
below:

A. Carotid Artery Stenosis

   The two carotid arteries, one on each side of the neck, supply
blood to the head.  External branches of these arteries supply the
tissues of the face and internal branches feed the deeper structures,
including the brain and eye.  Narrowing or stenosis of the internal
carotid artery can decrease the blood flow to the eye and produce
symptoms periodically.

   Decreased blood flow to the brain can result in transient ischemic
attacks (TIA's).  The importance of a TIA is that it serves as a
warning signal of an impending stroke.  The signs and symptoms may
include numbness, tingling, weakness, confusion, speech difficulties,
or others.  They can occur repeatedly.  A special TIA involving the
eye is called amaurosis fugax.  It presents as a sudden and painless,
one-eyed loss of vision often resembling the lowering of a curtain.
The episode(s) lasts for only a few minutes before normal vision
returns.  Diagnostic and therapeutic intervention is necessary to
prevent permanent disability.

B. Retinal Artery Embolization

   Retinal artery emboli are fragments of blood clots and other
material that break loose into the circulation and become lodged in
the retinal artery.  They may cause complete or incomplete
obstruction to blood flow.  Incomplete closure may cause no symptoms,
but complete blockage usually is associated with significant visual
loss.  Unfortunately, this sudden, painless loss of vision cannot be
treated unless therapy is begun within minutes.  Even so, the success
rates are unpredictable and controversial.  Underlying circulatory
disorders should be investigated.

C. Retinal Artery Occlusion

   Occlusion of the retinal artery without embolization is related to
the above diseases.  It can occur as a manifestation of generalized
arteriosclerosis, much in the way a coronary artery occlusion causes
a heart attack.  Again a painless, usually permanent loss of vision
develops suddenly.  Treatment is directed at the underlying disease
process.

D. Giant Cell Arteritis

   Giant cell or temporal arteritis is a chronic inflammatory disease
of the arteries throughout the body.  It affects mainly the elderly.
The inflammation can produce tissue damage by blocking the flow of
blood to vital organs.  Generalized symptoms of this disorder include
headache, scalp tenderness, low grade fever, loss of appetite, weight
loss, fatigue, confusion, jaw pain, depression, and others.  When the
arterial supply of the eye is involved, marked visual loss can
result, including permanent blindness.  The timely use of
cortisone-type steroids can be sight-saving.  Often one eye is
blinded before the diagnosis is made, but the other eye can be saved
with proper management.

   Venous Occlusive Disease

   The cause of occlusive disease of the veins of the retina is not
known with certainty.  Some process produces a partial or complete
blockage of a branch or central retinal vein.  Since the artery
remains intact and blood can flow into the retina, but cannot be
drained out, a significant amount of bleeding and swelling occurs.
Visual loss is sudden and painless.  If the bleeding is extensive, it
can take weeks or months to clear.  The disability can be permanent,
but occasionally there is partial recovery of vision.

   Treatment consists of defining the underlying systemic disease, if
any, and observing for the possible complications. These include
glaucoma, formation of fragile new blood vessels in the retina, and
retinal detachment.  LASER therapy may decrease the complication
rate.





   RETINAL DETACHMENT

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   A retinal detachment or RD occurs when the retina comes away from
its connections to the underlying layers of the back of the eye.  It
occurs in approximately one per 10,000 people per year. A relative
ophthalmologic emergency, a RD requires surgical repair.

   Anatomy and Physiology

   The retina is the inner-most layer of the coats of the eye. It is
a thin, highly specialized structure where light energy is converted
into electrical impulses for transmission to the brain. An often used
analogy is that the retina is like the film in a camera.

   The bulk of the spherical volume of the eye is filled with a gel
termed the vitreous.  The outer-most shell or skeleton of the eye is
the sclera, the visible white of the eye.  Between the inner vitreous
gel and the outer sclera lie successively the sensory retina, pigment
epithelium, and choroid.  The latter is a nourishing structure rich
in blood vessels.

   Normally the sensory retina is closely adherent to the pigment
epithelium with no fluid in between.  However, the connections are
tenuous and various disturbances can disrupt them, causing fluid to
accumulate in the potential space between the two layers.  A RD is
produced in this manner as the retina lifts away from the pigment
epithelium.  Since the retina requires the participation of the
pigment epithelium in order to function, a detachment produces an
immediate loss of retinal activity which can be permanent if not
promptly repaired.

   Mechanisms of Detachment

   The majority of RD's are rhegmatogenous.  That is, they are caused
by a break (tear or hole) in the retina itself.  Non- rhegmatogenous
RD's occur without a full-thickness retinal break and can be caused
by traction or leakage of fluid.  These two types of detachments
require very different therapies.

   This discussion will center on the more common rhegmatogenous
detachments.  Liquifaction of the vitreous gel can cause it to
collapse and separate from its tenuous connections to the retinal
surface.  Termed posterior vitreous detachment, this may occur with
advancing age, after cataract surgery, with high myopia or
near-sightedness, and following trauma or injuries.  The collapse and
contracture of the vitreous can produce a tear in the retina. When a
tear occurs, fluid may fill the space beneath the retina, and then a
detachment occurs.

   Retinal holes, unlike tears, are usually associated with atrophy
of a localized area of the retina, either isolated or associated with
a degenerative disorder.  These full-thickness holes are less likely
to produce a retinal detachment.

   Finally, a particular kind of tear called a dialysis can occur
spontaneously or due to trauma.  Special only in their location, they
are easily treatable unless massive.

   Symptoms

   Symptoms of a RD fall into two groups, those that occur when the
retina tears and those actually associated with the detachment.  A
retinal tear caused by a posterior vitreous detachment can produce
flashes of bright light, but more commonly it produces floaters.
Floaters are spots, often showers of them, that appear in one's field
of vision as the eye moves.  They represent collections of vitreous
debris or blood that cast a shadow onto the retina and hence appear
as bouncing spots in space.

   The truest symptom of a retinal detachment is the sudden loss of
peripheral or central vision.  This is often described as a curtain
descending over one eye.  Unfortunately, many individuals are not
aware of the loss of a single eye's peripheral vision until it is too
late.

   Predisposing Conditions

   Among the major conditions that predispose to rhegmatogenous
detachment are certain degenerative eye diseases, myopia or near-
sightedness, cataract surgery, advancing age, blunt trauma, or
penetrating eye injuries.  The common denominators are posterior
vitreous detachment and thinning or stretching of the retina.
Disorders associated with non-rhegmatogenous detachments include
diabetes, retinopathy of prematurity or retrolental fibroplasia, and
others.  Some conditions can produce both types of detachment.
Exudative RD's are associated with tumors, and inflammation within
the eye, among other disorders.

   Treatment

   Therapy may occur at any of three points in the disease process:
prophylactic, or preventive therapy; management of tears and holes;
and treatment of the actual retinal detachment. Prophylaxis may
involve treatment of an area of degeneration in the periphery of the
retina either in a myopic patient or in one who is about to undergo
cataract surgery when no actual holes or tears are present.  This
controversial approach is rarely employed.  Treatment of tears and
holes is also controversial. Because many of these retinal defects
never go on to produce a detachment, the decision to treat often
depends on the individual eye surgeon and patient.  The presence of
bothersome symptoms or one or more risk factors for detachment may
make the surgeon more inclined to treat.  The vast majority of RD's
are acute and mandate surgical intervention.  Rarely, a retinal
detachment that is old, walled-off, and without symptoms may be
observed without aggressive treatment.

   The surgical procedures for this disorder are discussed in a
separate article.  They are nearly 90 % successful in some studies.
The treatment of exudative detachments is directed toward the
underlying disorder, i.e. tumor or inflammation.





   RETINITIS PIGMENTOSA

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Retinitis pigmentosa or RP is a group of genetically- determined,
progressive degenerations of the rods and cones of the retina.  The
term retinitis pigmentosa was coined in 1857 by Donders, and like
many older terms, it is a misnomer.  Despite the "itis," there is no
inflammatory or infectious component to this group of diseases.  RP
classically occurs as an isolated, hereditary condition, but it can
be associated with a variety of other diseases.

   Physiology

   The retina is the actual sense organ of the eye.  The rest of the
eye provides support, nourishment, and focusing power.  The retina
contains several layers of cells, but the group of cells that
initially responds to light are the rods and cones.  These extremely
specialized and sensitive cells transform light energy into
electrical energy which is processed in the retina and transmitted to
the brain via the optic nerve.  Compared to the cones, the rods are a
more sensitive, less discriminating cell population.  They function
best in the dark or near dark.  The cones are less sensitive, but
more discriminating.  They function in well-lighted conditions and
are the cells which provide us with our optimal 20/20 vision.  The
cones are also the cells responsible for the perception of color.
These two groups of cells form a complimentary dual system.

   Classification

   Generalized rod-cone degenerations are classified in a variable
way and few authors agree completely on the classifications.  The
following grouping is somewhat simplified:

   1) Congenital RP or Leber's Congenital Amaurosis.  2) Autosomal
Recessive RP.  3) Autosomal Dominant RP.  4) X-linked or Sex-linked
Recessive RP.  5) Sporadic RP.  6) RP Associated with Systemic
Diseases.

   The first is manifested at birth or shortly thereafter.  The next
three are hereditary, follow different patterns of inheritance, and
have a variable onset.  The fifth occurs without a familial pattern,
and the last is found in conjunction with other generalized or
systemic illnesses.

   Clinical Manifestations

   The most classic symptom is night blindness or nyctalopia. This
occurs because the rod system is affected long before the cone
system.  There is also a gradual constriction of the visual field
until it begins to appear as though one is looking down the barrel of
a gun.  In other words, one's periperal or side vision progressively
decreases.  Finally, central vision or one's fine, detail reading
vision may be affected.  This is usually late in the course of the
disease.  Unfortunately, some individuals can progress to near or
even total blindness.

   The onset and progression and, to some degree, the order of the
symptoms depends on what type is present.  The congenital form
presents with the full-blown disease at birth; these children have
stable but persistent visual loss.  Fortunately, this is quite rare.
The recessively inherited types usually have their onset in childhood
or the early teens and the outlook or prognosis is poor.  The
dominant form is likely to be a milder condition and the sporadic
type is variable.  The types associated with other illnesses often
occur early, are severe, and have early central vision loss.  The
systemic illnesses are all rare, often life-threatening diseases.

   Diagnosis

   Although a complete ophthalmologic exam can be highly suggestive
of RP, it is impossible to make a definitive diagnosis without
further testing.  This is especially true in early cases. The
essential diagnostic test is an electroretinogram or ERG.  A dynamic
test of retinal function, the ERG is a measure of the retina's
electrical activity in response to light stimulation. The procedure
requires a contact lens with electrodes attached. The electrodes
monitor the retinal response to a series of light flashes under both
light and dark conditions.

   Treatment

   Unfortunately, no therapy is presently available for the vast
majority of people with RP.  Attention is directed toward low vision
aids, and proper social and governmental programs for the
visually-impaired.

   Genetic Counseling

   Parents who have a child with a recessive disease who are normal
themselves can expect that 25 % of their future children will be
affected.

   Unaffected parents who have a child with an X-linked disease have
a 50 % risk of having affected male children.  Females only carry the
X-linked gene, while males suffer from the disease.  A better known
example of this pattern of inheritance is color blindness.

   Dominantly inherited disease is manifested in all individuals who
carry the gene.  Thus one parent is usually affected as are 50 % of
the children.

   Sporadic diseases are new mutations and the particular inheritance
is unclear until further generations exhibit the trait.

   Conclusion

   RP, or the more appropriately named rod-cone generalized
dystrophy, is a varied group of disorders characterized by hereditary
retinal rod and cone degeneration.  There are many other hereditary
retinal degenerations that are more rare than RP and have quite
different clinical findings.  Because much remains unknown about
these conditions, research is very active in this area.





   RETINOPATHY OF PREMATURITY

   (Retrolental Fibroplasia)

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Retinopathy of prematurity (ROP), formerly known as retrolental
fibroplasia, is a potentially vision-threatening scarring of the retina of
premature newborns.  It remains uncommmon, but the recent improvement in the
survival rate of vry small premature newborns has significantly increased
its incidence.

   History

   The history of ROP is informative.  First described by Dr. T.L. Terry in
Boston in 1942, it remained relatively unknown until the late 1940's when it
rapidly became the most common cause of childhood blindness.  By the early
1950's, this condition had reached epidemic proportion.  To explain this
sudden rise in the number of cases, many investigators studied the
predisposing factors.  A large collaborative study led by Dr. V.E. Kinsey
linked the disease to the amount of oxygen administered to newborns in the
premature nursery.  Recognition of this harmful effect of high concentration
oxygen therapy subsequently led to a pronounced drop in ROP.

   Over the last fifteen to twenty years, the development of the subspecialty
of neonatology and the widespread availability of neonatal intensive care
units have greatly contributed to the care of premature infants, such that
more and more newborn babies weighing less than 1000 grams (2.2 pounds) are
surviving.  This medical advance could not have occurred, however, without
some easing of the oxygen restriction.  Hence, the incidence of ROP has
increased again.

   Physiology

   A baby's weight at birth is normally 2,500 grams or larger. Newborns
weighing less than 500 grams, about one pound, are normally considered
incapable of existence independent of the mother.  This critical size is
achieved around a gestational age of 24 weeks--about the fifth to sixth month
of pregnancy.  Highly technical medical care is presently capable of saving
infants weighing more than 500 grams, but the mortality remains high. Indeed,
between 500 and 1000 grams it approaches 50 %.

   None of these highly premature infants could survive without supplemental
oxygen, temperature regulation, blood transfusions, and a number of other
advanced therapies.  Unfortunately, even today's neonatal intensive care
units cannot reproduce the mother's uterine environment and these children,
if they do not die, often have permanent disabilities, one of which may be
ROP.

   The retina is supplied with blood vessels which grow outward from the
optic nerve to the edge of the retina.  This blood supply or vasculature does
not reach maturity until 40 weeks gestational age (9th month), or even
shortly after birth. Exposing an immature retina to the environment often
does not allow normal development to continue.  If this retinal maturation is
arrested, retinal scarring or ROP may be the result.

   Pathology

   Once normal retinal blood vessel development has been interrupted, several
step-wise events may occur.  Abnormal connections can develop between the
small arteries and veins and capillary growth can halt leading to oxygen
starvation. (The actual role of oxygen is highly controversial.)  The next
more serious step is neovascularization, or the growth of new abnormal blood
vessels that have a tendency to bleed.  This can produce a fibrovascular scar
which in turn may cause a retinal detachment. In the most severe cases, the
end stage is complete retinal detachment and blindness.

   It is very important to stress that stabilization may occur at any stage
without progression to the next, and there may actually be regression of the
retinal damage.  The degree of permanent scarring determines the final visual
outcome.

   Incidence

   There is appreciable disagreement in the literature regarding the
incidence of this disease.  The fraction of premature children affected with
ROP in a neonatal intensive care unit ranges between three and twenty
percent.  The incidence of blindness in that specific population is about one
percent.  The lower the birthweight, the higher the incidence.

   Risk Factors

   This is also controversial.  Birthweight is clearly the single most
important link to ROP.  Inspired oxygen is also a risk factor, i.e. the
higher concentration of oxygen delivered to the infant, the higher the risk
of ROP.  In contrast, the child's blood oxygen levels have never been
conclusively linked to ROP. Other risk factors include seizures, chronic lung
disease, brain hemorrhage, etc.

   Treatment

   Fortunately, most infants who develop acute ROP have mild conditions that
either regress or stabilize without affecting vision.  These children need
periodic eye examinations to check for amblyopia, refractive errors, and
other associated abnormalities, but they retain the potential for 20/20
vision. When acute ROP advances to the vision-threatening stage, it still may
regress, but progression to visual loss, either mild or marked, is not
unusual.  Treatment at this or later, more advanced stages, is highly
controversial.  Several authors report that early surgery, late surgery, and
cryotherapy or freezing treatment, may be effective, but none of these modes
of therapy have been universally accepted.  Some may carry the potential for
greater harm than good; most are controversial.  Presently, most authorities
are not treating ROP until the active phase has ceased and a stable scar has
formed.  At this point, high risk surgery may be beneficial in some blind or
near-blind children.

   The more answers that are found, the more questions arise. ROP is an area
of intense research.  With continued effort, definitive answers as to cause,
prevention and treatment may be forthcoming.





   LASERS IN OPHTHALMOLOGY

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   The word LASER is an acronym for Light Amplification by Stimulated
Emission of Radiation.  A LASER is a physical technique for producing
pure, coherent beams of light.  It has a wide variety of industrial,
scientific and medical applications.

   Physics of Light and LASER

   All electromagnetic radiation travels at the speed of light and
has a frequency and wavelength that are inversely proportional.
Visible light represents only part of the spectrum of electromagnetic
radiation.  Other examples are the lower frequency radio waves or
microwaves and higher frequency x-rays and gamma rays.

   Visible light is transmitted in finite bits called photons.  A
photon, or unit of light, possesses considerable energy proportional
to its frequency.  The wavelength of visible light is 400-700
nanometers; ultraviolet and infrared light are found on opposite
sides of the visible spectrum.  The energy of a beam of light is a
measure of the number of its photons and is typically measured in
joules.  A joule equals 0.00001 calories. Power is defined as the
rate at which energy is delivered.  It is measured in watts.  One
watt equals one joule per second.

   Natural and man-made sources produce electromagnetic radiation.
But this radiation occurs in a wide variety of wavelengths and is all
"mixed-up."  For example, as you read this you are emitting
radiation, mainly in the form of infrared heat. A jumble of radiation
wavelengths spreads out from your body in all directions.

   A LASER can be thought of as a generator and harnesser of
radiation.  It can allow for tremendous power.  To do this, all
LASER's have three components: an energy source, an active medium,
and a resonant cavity.  The active medium may be liquid, solid or
gas, but only certain media have the requisite molecular
characteristics.  An effective medium must be comprised of atoms or
molecules which are capable of easy and simultaneous excitation by
the energy source.  When more atoms are "excited" than not, a
population inversion has occurred and the process is primed for
stimulated emission.  These excited atoms or molecules give off
photons.  This often excites more photon production. The photons then
pass back and forth along the mirrored resonant cavity, collecting
more and more photons.

   The unique part of LASER energy is that the photons emitted are
not "all mixed-up."  They are monochromatic and coherent.  In other
words, they all have the same wavelength, move in the same direction,
and are in phase or "sync."  Hence, what gives LASER radiation its
extreme power is the collimation or lining up of its energy packets
into a very bright focusable beam.

   Types of LASER

   The first true LASER, demonstrated in 1960, was the Ruby LASER.
Its active medium was a ruby.  Newer LASERS have also been named by
their active medium.  These include the Argon, CO2 or Carbon Dioxide,
Krypton (which may or may not be harmful to Superman), and the
Neodymium: Yttrium-Alluminum-Garnet or Nd-YAG LASER's.

   Effects on Biological Tissues

   Depending on the particular LASER and the qualities of the tissue,
a variety of actions can occur in living tissue.  The most useful and
easiest to understand is the thermal effect, or burn.  Absorption of
LASER light by tissue--e.g. red blood absorbing a green wavelength of
Argon LASER--causes energy dissipation in the form of heat.  Another
LASER-induced effect is called an acoustic transient.  This is a
pressure wave which can be set up to disrupt tissue.  Furthermore,
vaporization and optical breakdown can be achieved by an intense
LASER beam. Breakdown is the ionization of the medium through intense
electric fields.  It is also associated with generation of an
acoustic wave.  In summary, a LASER can burn, cut or obliterate
living tissue.  One last point, a LASER beam can be non- destructive
if a low enough energy level is achieved.  Non- destructive beams can
be used for imaging of living tissue rather than destruction.

   LASER Magic in Ophthalmology

   LASER therapy is now highly effective for several ocular diseases
and conditions.  The major uses will be treated separately.  (For
additional information on these conditions please consult Eye
Disorders and Diseases.)

   Diabetic Retinopathy

   Diabetes mellitus is a chronic, sometimes severe disease of sugar
metabolism.  A major long-term complication is damage to small and
large blood vessels throughout the body, leading to premature
atherosclerosis, heart attack, stroke, kidney failure and eye
disease.  Rich in tiny blood vessels, the retina, the light-sensitive
membrane lining the inside of the back of the eye, is highly
susceptible to this complication.  Diabetic retinopathy is one of the
leading causes of blindness in the United States.

   Initially, the retinal blood vessels become damaged and begin to
leak.  Then tiny capillaries are lost until the tissue actually
becomes oxygen "starved."  This deprivation induces
neovascularization, the formation of fragile new blood vessels which
have a tendency to bleed.  Recurrent hemorrhage from these new
vessels and retinal scarring can eventually cause total blindness.

   LASER treatment of diabetic retinopathy is two-pronged.  It can be
employed to dry up leaking vessels or to destroy diseased retinal
tissue.  Diabetic retinopathy is usually treated with the Argon
LASER, but the other LASER's are also used.  The treatment is called
photocoagulation.  The process is one of thermal injury.  If a blood
vessel or group of tiny vessels is leaking fluid or blood, and this
is interferring with vision, then an Argon LASER can be used to ring
or enclose the area with thermal- induced scars.  If the retinopathy
has advanced to the point of neovascularization, then much more
extensive photocoagulation is necessary.  Eliminating unhealthy,
oxygen "starved" tissue by thermal scarring can cause the abnormal
blood vessels to dry up and wither.  This is indeed sight-saving.

   Senile Macular Degeneration

   The other major cause of blindness in the United States is senile
macular degeneration.  This is an age-related change that produces a
scarring in the macula of the eye.  The macula is the tiny
specialized part of the retina which gives us our best visual acuity,
i.e. 20/20.  Although LASER's cannot help all of these patients, a
small subset can have dramatic results.  The patients who respond to
LASER have a common cause for the macular scarring process,
subretinal neovascularization.

   Beneath the retina lie Bruch's membrane, then pigment epithelium,
then choroid.  The choroid contains many nourishing blood vessels
which are tightly separated from the retina.  When breaks occur in
the pigment epithelium and Bruch's membrane, a subretinal collection
of blood vessels invades, bleeds and causes scarring.  These blood
vessels can be directly treated and eliminated by LASER therapy.

   Although the Argon LASER's thermal scarring has been utilized for
this purpose, the new Krypton red light LASER offers some advantages.
 The Argon blue-green LASER produces heat by pigment absorption in
the inner retina.  But the Krypton red LASER is absorbed only by
melanin pigment present deep in the retina. This is where subretinal
neovascularization is found.  Hence, the Krypton LASER delivers its
burn to the target tissue, while sparing the delicate, non-diseased
inner retina.

   Glaucoma Trabeculoplasty

   There are several types of glaucoma, all of which may require
surgical intervention if drug treatment fails.   Now LASER therapy is
an alternative to surgery in many glaucoma patients.

   The eye constantly produces fluid which must drain out of the eye.
 When the drainage angle or trabecular meshwork, lying at the inner
juncture of the cornea and iris, fails to function properly, the
drainage capacity or outflow facility is lessened. This produces a
pressure build-up inside the eye characteristic of open-angle
glaucoma.  If medicine is not able to renew this outflow facility,
then surgery is necessary.

   LASER photocoagulation can be used to "open" the drainge meshwork.
 Tiny burns are placed lightly on the meshwork to cause a mild
scarring.  Consequent to the scarring, the meshwork opens and normal
fluid dynamics are re-established.  The patient is then saved a
riskier eye operation.

   Posterior Capsulotomy

   The single most commonly performed operation in this country is
cataract surgery.  Although many new techniques have recently been
developed, the surgery itself does not involve the use of LASER.  But
after the common cataract procedure, extracapsular cataract
extraction, the posterior membrane or capsule or "skin" of the
cataractous lens is left behind.  This opacifies gradually over a few
months in many patients and impedes good vision.

   Previously, posterior capsulectomy, an intraocular surgical
procedure was required to eliminate this.  That meant that even with
the newest techniques in eye surgery, many patients would require two
operations.

   The introduction of posterior capsulotomy utilizing the unique
Nd-YAG LASER has changed all this, however.  This procedure is fast
becoming the most common use of LASER in ophthalmology.  The new
ND-YAG LASER has an incredibly powerful beam of energy which produces
optical breakdown or electrical ionization together with acoustic and
shock waves.  Material struck with its focused beam just disappears.
Although extremely powerful, this LASER is useful because of its
ability to focus its destruction.  An intraocular lens resting nearly
on top of the opacifed posterior capsule is not harmed by a carefully
aimed "explosion."

   Technique

   The technique of intraocular LASER surgery is similar regardless
of disease.  The awake patient sits comfortably at a slit-lamp, a
specialized eye microscope, with LASER delivery hooked up to it.  A
contact lens is often placed on the eye to assist in visualization
and focusing.  Usually no anesthesia is necessary, but occasionally a
local anesthetic is given.  The surgeon focuses the LASER with a
focusing beam of light and then delivers several bursts to the
target.  This might be 50-100 "shots" for glaucoma or several hundred
for retinal work.  The procedure lasts approximately five to twenty
minutes and is usually painless.  Occasionally a brief, sharp pain
can occur. The patient can walk or drive home after appropriate
follow-up care is arranged.

   Complications

   LASER's are designed to avoid traditional surgical complications;
nonetheless, there are problems associated with their use.  One such
problem is damage to tissues adjacent to the target area due to too
much energy or loss of focus.  Other complications include bleeding,
opacification of the fluid-gel inside the eye, stimulation of new
retinal blood vessel formation, cataract, inflammation, transient eye
pressure elevations and visual loss.

   LASER's are in the forefront of ophthalmic research and therapy.
They are now used to treat previously untreatable disorders and to
improve on older means of therapy.  This is a field in flux which
will continue to evolve.





   RETINAL DETACHMENT SURGERY

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   A retinal detachment is a separation of the retina from its
support structures at the back of the eye.  This occurs in about one
per 10,000 people per year.  Rhegmatogenous detachments, those
detachments associated with retinal tears or holes, require surgical
repair.  (See Eye Disorders and Diseases for additional information.)

   Indications

   Essentially any new or recent rhegmatogenous retinal detachment
necessitates an urgent operation.  There is no acceptable
alternative.  Old detachments may be observed for progression if they
appear to be stable and walled-off.

   Contraindications

   A longstanding, complete retinal detachment in a blind eye offers
little or no hope for restoration of sight.  Surgery should be
avoided in this situation.  Likewise, the extremely rare retinal
detachment may be so complicated or associated with such marked eye
injury that repair is impossible or inadvisable. Individuals with
non-rhegmatogenous detachments (no hole or tear) may not need
surgery.

   Procedure

   The treatment of retinal detachments offers the eye surgeon a
variety of choices: often more than one approach is used on a single
individual.  The operation can be highly complex, occasionally
requiring surgery on both the outside and inside of the eye.  It is
typically performed under general anesthesia with the patient totally
"asleep," although local anesthesia may be used.  The procedure lasts
one or several hours depending on the complexity.

   The basic premise is to produce a scar or adhesion in the area of
the retinal tear or hole.  Either heat (thermal) or cold (cryo)
therapy is used.  Next the surgeon brings the retina back into
position.  This is usually performed by indenting the back of the eye
with a spongy material and placing a buckle or belt around the eye.
These steps are done underneath the membrane which covers the white
of the eye and, hence, require an incision, but often the inside of
the eye need never be entered.

   Complicated cases require more heroic or unusual methods, such as
fluid drainage from underneath the retina, air injection inside the
eye or major intraocular surgery (vitrectomy).

   Lastly, pre-detachment disease in the same or fellow eye may need
preventive treatment such as LASER or cryotherapy.

   Recovery

   At one time, retinal detachment surgery mandated a long hospital
stay.  This is no longer true.  Now a short stay of one to three
days, or even oupatient surgery, is increasingly common. This is
individualized.  Post-operatively eyedrops are necessary and
strenuous activity should be avoided.

   Complications

   Although not uncommon, most surgical and postoperative problems
are manageable.  The more difficult the case, the more likely the
complications.  These include inability to repair the detachment or
continued detachment, bleeding, glaucoma, infection, visual loss,
double vision, redetachment, excessive inflammation and scar
formation.

   Results

   In some studies nearly 90 percent of operations for retinal
detachment are successful in restoring vision, but the results are
variable.  The main factor is not the complications, but the
preoperative condition of the detachment.

   Surgical Fee: $2000-3000





   CATARACT SURGERY

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   A cataract is an opacity of the crystalline lens located inside
the eye behind the pupil.  The lens focuses images onto the retina in
order to produce clear pictures.  Any clouding of this structure can
decrease the quality of the image and, consequently, one's visual
acuity.

   Adult cataract surgery is the single most common surgical
procedure performed in the United States.  Many hundreds of thousands
of people undergo surgical removal of cataracts each year.  It is a
highly successful, relative uncomplicated procedure.

   Indications

   Although there are several reasons for having cataract surgery,
some of which may represent emergencies, there is only one important
reason for the majority of patients: the cataract itself must produce
a decrease in vision that significantly affects the individual's
ability to function.  This obviously will vary from person to person.
 A young pilot or diamond cutter could tolerate less visual
impairment than could an elderly bedridden patient.  The important
point is that the individual must feel that he requires better vision
in order to maintain the quality of his lifestyle.  The simple
presence of a cataract is not reason enough for surgery.

   Contraindications

   If the eye is affected by another disease, such as a retinal or
optic nerve disorder, the eye surgeon must decide whether the
cataract or the other disease is the major cause of the poor vision.
In the latter case, surgery would not be helpful. Occasionally, this
is a very difficult judgment.  The condition of the other eye also
impacts on the decision to operate.  A retinal detachment in a
previously operated eye might favor delaying surgery on the second
eye.  A blind fellow eye and a perfect fellow eye also require
different judgements.  One eyed patients are often approached more
conservatively.  Finally, there are a few eye diseases that carry
such a high risk that cataract surgery may be better delayed as long
as possible, e.g. intraocular inflammation or severe dry eye
conditions.

   Procedure

   There are three basic procedures still in use.  These are
intracapsular cataract extraction, extracapsular cataract extraction,
and either with implantation of an intraocular lens. The surgery is
often done as an outpatient or with only a single overnight stay in
the hospital.  These operations can be done under local (just the
eye) or general anesthesia ("asleep") in adults.  Children must be
put to "sleep."  The operating time is approximately 30-60 minutes,
with additional time for preparation and induction of anesthesia.

   It is a common misunderstanding that LASER is employed to remove
cataracts.  Except when a secondary membrane or "after cataract"
forms following extracapsular extraction, none of these surgeries
involves the use of LASER.

   (A) Intracapsular Extraction

   The lens is surrounded by a capsule or membrane. Intracapsular
surgery removes the lens and capsule in one piece. Until the early
1980's this was the most common type of cataract surgery.  A large
incision is made into the eye at the junction of the clear cornea and
the sclera (white of the eye).  The entire lens is then removed from
the eye through this incision in a single maneuver.  The incision is
closed with stitches that usually stay in place for a few weeks to
many months.

   (B) Extracapsular Extraction

   As the name implies, the cataract is removed without its capsule.
This operation has superseded intracapsular surgery in popularity.
The lens is not removed in one piece, but is sucked out.  An
irrigating and aspirating machine with or without ultrasonic breakup,
or phacoemulsification, of the lens material is utilized.  Compared
to intracapsular extraction, this surgery often requires a smaller
incision.

   (C) Intraocular Lens Implant

   This is the actual implantation of a artificial, substitute
plastic-like lens inside the eye.  It can accompany either
intracapsular or extracapsular removal.  The IOL allows for good
vision without thick glasses or contact lenses.

   Recovery & Visual Rehabilitation

   Cataract surgery has taken great strides in the last few years,
and so has recovery.  Because the eye heals rapidly, greater and
earlier activity and mobility are allowed. Initially bending, lifting
and other strenuous activity is discouraged.  Eyedrops are used for a
few weeks.  Full normal activity is usually resumed in four to six
weeks.

   Visual rehabilitation involves one of three choices: glasses
alone, contact lenses plus glasses, or intraocular lenses plus
glasses.  The glasses alone are thick and heavy; getting used to them
may be difficult.  They are not an ideal form of rehabilitation.
Contact lenses and intraocular lenses with normal glasses, usually
bifocals in addition, each give excellent visual rehabilitation.  The
advantage of an intraocular lens is that ongoing care is not required
as it is with contacts. Contact lens care is easy for many; however,
it can be challenging and a nuisance for others.  Visual improvement
is immediate and constant with an IOL, but contacts and glasses
require some waiting time.  Vision is also poor when glasses or
contacts are not worn.

   Complications

   As with all surgery, one must weigh the potential benefits and
risks.  The present technological advances have minimized the risks
of routine cataract surgery such that most eye surgeons and patients
are guided by the possible benefits.  Nonetheless, complications can
occur.  These include, but are not limited to the following:
endophthalmitis or infections inside the eye, retinal detachment,
glaucoma, mild or massive hemorrhage, corneal damage, retinal edema
or fluid collection, poor wound healing or breakdown, persistent
inflammation, reacations to anesthesia or medication

   These complications are rare.  For routine operations in persons
with otherwise healthy eyes, significant problems are encountered
less than five percent of the time.  In persons with other eye
disease, the risks increase.  Highly near-sighted patients, for
example, have a much higher incidence of retinal detachment.

   Approximate Surgical Fee: $1500-2000

   For additional information about cataracts, see Eye Disorders &
Diseases.





   GLAUCOMA SURGERY

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   As discussed in the Eye Disorders and Diseases section, persons
with glaucoma often require an operation.  Surgery is indicated in
almost all cases of Angle Closure Glaucoma and Congenital Glaucoma.
In Open Angle Glaucoma it is reserved for patients who do not respond
to medication.

   Angle Closure Glaucoma

   The two basic types of surgery for this entity are iridectomy and
filtering operations.  The iridectomy is a peripheral iridectomy, and
the common filter is a trabeculectomy.  An iridectomy is performed to
permanently cure an acute angle closure attack; no further attacks
will occur.  It is also done in the fellow eye to prevent attacks and
to cure the predisposing anatomical abnormality.  A trabeculectomy is
performed when an acute angle closure attack has been present long
enough to actually damage, rather than simply block, the drainage
angle. This filtration surgery, or filter, bypasses the trabecular
meshwork and creates a new drainage track or fistula, permitting
fluid to flow out of the eye.

   Congenital Glaucoma

   Congenital glaucoma is one of the most challenging disorders to
treat in all of ophthalmology.  Almost exclusively a surgical
disease, it usually requires multiple eye operations on each eye.
Often it cannot be controlled without complications.  The two basic
types of surgery for this condition are direct drainage angle
surgery, either goniotomy or trabeculotomy, and filtration surgery,
commonly trabeculectomy.

   Open Angle Glaucoma

   Filtration surgery is the one basic operation for this disease,
again commonly a trabeculectomy.  As previously noted a
trabeculectomy establishes a new filtration site and bypasses the
diseased trabecular meshwork.  LASER therapy has also been employed
and is often utilized earlier than surgery.  Many cases are
refractory to LASER treatment, however, and require surgery. (For a
detailed discussion of LASER therapy, see the article in this
section.)

   Procedures

   A)  Iridectomy -- This is done with local or general anesthesia
and can be done as an outpatient procedure or with a short
hospitalization.  A total operating room experience of twenty to
forty minutes is required.  Under sterile conditions a one to two
millimeter (less than 1/4 inch) incision is made into the eye at the
corneal-scleral junction, near where the white of the eye meets the
iris.  A section of peripheral iris is then excised, leaving a direct
communication or hole between the chambers in front of and behind the
iris.  This allows for decompression of the iris, which is blocking
the drainage angle. The incision is then closed with one or two
stitches.

   Post-operatively eyedrops are necessary for several days.
Strenuous activity should be avoided for a few days.

   Possible complications are rare.  They include flat anterior
chamber, persistent fistula or leakage, hyphema or bleeding,
posterior synechia or inflammatory adhesions, cataract formation,
continued glaucoma, and infection.  The overall complication rate is
less than five percent.

   B)  Goniotomy -- This is performed with the patient under general
anesthesia and sterile conditions and requires thirty to sixty
minutes in the operating room.  An operating microscope is required.
First, a special prism lens is placed or sutured on the surface of
the eye.  This is needed to visualize the drainage angle.  A tiny
needle-knife is then used to pierce the cornea and anterior chamber
(in front of the iris.)  After the knife has entered the eye, it is
moved across the iris and pupil into the drainage angle on the
opposite side of the iris.  The trabecular meshwork is then opened by
a sweeping motion left and right. Once this is completed, the knife
is withdrawn.

   Most patients are hospitalized for one to two days.  Eyedrops are
used after surgery for two to four weeks.  Normal activity is can be
resumed right away.

   The complications are unusual, but include hemorrhage, cataract
formation, and infection with possible continued loss of vision.

   C)  Trabeculectomy -- This can be done with local or general
anesthesia and sterile conditions.  Total operating room time is
sixty to ninety minutes.  The membrane covering the sclera, the white
of the eye, is incised or opened.  A scleral dissection is then
performed.  This is essentially a triangular or rectangular
"trap-door" flap, usually about one-half thickness of the outer wall
of the eye.  The dissection is carried up to and slightly into clear
cornea.  Once this flap is created, an inner block of tissue, the
remaining thickness of the sclera and cornea, is excised or cut out.
Thus, a direct communication from the inside to the outside of the
eye is established.  A peripheral iridectomy is then often performed.
 Next the outer scleral "trap-door" is loosely sutured.  It is
designed to function essentially as a flap valve, allowing frequent
or continuously slow egress of aqueous fluid out of the anterior
chamber of the eye.  The final step is closure of the membrane or
conjunctiva which covers the white of the eye.  Fluid is now free to
circulate from the inside of the eye, out through the trap door,
underneath the conjunctiva and away.

   Although this surgery is rarely performed as an outpatient
procedure, most patients are hospitalized for two to three days.
Strenuous activity such as bending and heavy lifting should be
avoided for one to four weeks.  Eyedrops are used for several weeks.

   Trabeculectomy is much more involved than iridectomy or goniotomy
and is a considerably greater violation of the eye. Complications
include persistent flat anterior chambers due to over-filtration,
cataract formation in up to one third of patients (although many of
these are mild cataracts and affect vision only slightly), scarring
of the filter site causing failure and continued glaucoma, early or
late infection, hemorrhage, inflammation, and others.  The patient is
worse off than before the operation in probably less than five to ten
percent of the cases.  The total complication rate is somewhat
higher, but most problems are mild and amenable to treatment.

   It is always important to emphasize that no surgical procedure is
100 percent effective.  All have potential complications.  The
decision to operate must be based on reasonable consideration of the
potential benefits versus the risks.

   Surgical Fees: Iridectomy $500-800, Goniotomy $600-1000,
Trabeculectomy $1200-1500.





   STRABISMUS SURGERY

   ("Crossed Eyes")

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Introduction

   Strabismus is a misalignment or deviation of one's eyes caused by
an imbalance in the eye muscles.  An eye may turn in ("crossed"),
out, up, or down.  About four percent of the population, mostly
children, is affected.

   Many individuals with strabismus can be treated with non- surgical
means, such as glasses.  On the other hand, many will require an
operation for optimal management.  For more information about this
disorder, please read the article in Eye Disorders & Diseases.

   Anesthesia & Hospital Stay

   Eye muscle surgery can be done under local or general anesthesia.
Children require general anesthesia, that is being totally "asleep,"
but adults may be awake with only the eye area anesthetized.

   In most cases adults are sedated ahead of time for relaxation.
Children are often taken to the operating room fully alert.  This
actually is safer and produces less anxiety for youngsters.  An I.V.
or intravenous line is required, but since the children are put to
"sleep" before this happens, they do not have the anxiety and pain of
a needle.

   Most strabismus surgery is done as an outpatient without an
overnight hospital stay.  At most two nights of hospitalization are
necessary.

   Procedure

   There are six muscles on each eye.  These muscles insert or are
attached to the sclera, or white of the eye.  Each muscle has a
different action.  When they contract, they exert a force upon the
sclera to pull the eye into the desired position.

   The surgical procedure involves making an incision through the
membrane or conjunctiva which covers the white of the eye.  After the
eye surgeon opens the conjunctiva, the muscle can be grasped. This is
done by simply rotating the eye normally.  The eye is never removed
from its socket!  Once the muscle is grasped and isolated from
surrounding structures, it can be weakened or strengthened as
necessary to bring the eyes into alignment.

   Weakening or strengthening of an eye muscle typically involves
passing absorbable or self-dissolving sutures through it,
disinserting or disattaching it, then suturing or sewing it back to
the sclera in a modified position.  The conjunctival membrane is then
either closed with sutures or left open to heal itself naturally.

   Strabismus is a two eye disease.  Although only one eye may seem
to be abnormal, it is always out of position in relation to the other
eye.  Therefore, surgery is often done on both eyes. Usually at least
two eye muscles are operated upon, one or more on each eye.

   About twenty minutes is required to put a child to "sleep" and
about ten minutes to wake the child up.  The surgery lasts from 30-60
minutes depending on the difficulty and number of muscles operated
on.  Therefore, the whole operating room experience takes about 60-90
minutes.

   Recovery

   Expected side effects include redness and swelling for seven to
ten days, bloody drainage for 24 to 36 hours, mild discomfort and
soreness with eye motion and, occasionally, transient double vision.
There need be no limitation of activity afterward, and no special
postoperative care is required.

   Results

   Routinely 85-90 percent of strabismus surgery is successful in
achieving straight eyes, but that means that ten to fifteen percent
of the patients are not properly aligned.  The failure rate may be
even higher in unusual or complicated forms of strabismus.  There is
no certain way to predict preoperatively which patients will have
unfavorable results.  This minority responds atypically from the
expected.  Fortunately, the large majority of these persons with
initially poor responses can be successfully aligned with additional
surgery.

   Complications

  Eye muscle surgery is relatively safe and effective with few
complications.  Approximately one child in 5,000-10,000 has a major
anesthetic complication while undergoing routine strabismus surgery.
This may involve permanent heart or brain damage; it may even be
life-threatening.  Fortunately, this is extremely rare.

   About one in 3000 develops a vision-threatening complication such
as infection or bleeding inside the eye, retinal detachment, or
related problems.  Specific risk factors may increase this
likelihood: high myopia (a severe form of near-sightedness), arterial
disease or others.

   Around five percent of patients develop a superficial complication
such as cyst formation or surface infection.  These usually are
easily treated with eye drops.  Persistent redness is an uncommon
problem, but with re-operations it can occur more often.

   Noticeable alterations of the lid positions can also occur, but
are quite rare in routine cases.

   Lastly, persistent double vision is a rare but particularly
troublesome side-effect, much more common in adults than children.
Further surgery is often required.

   Conclusion

   Although all major operations have risks and complications,
strabismus surgery holds promise of great benefits at low risk. It is
safe and effective.  Continuing dialogue between patient and
physician is needed for mutual understanding and optimal results.

   Surgical Fee: $800-1200





   CORNEAL TRANSPLANT

   (Penetrating Keratoplasty)

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Introduction

   Many different disorders can affect the cornea, the clear outer
covering over the iris.  When corneal clarity is significantly
diminished or a disease process becomes severe, corneal
transplantation can bring new life to the diseased eye.

   A corneal transplant is the replacement of a diseased cornea (host
cornea) by a donor cornea.  Like kidney and liver transplants, the
donor corneal tissue comes from individuals who die and donate their
organs for the benefit of others.  Organ donation is extremely
important.  It saves lives and restores sight to others.

   Unlike kidney and liver transplants, the corneal graft need not go
through an extensive typing procedure in order to match donor and
host.  The most important factors for the selection of the donor are
age, cause of death, length of time between death and transplant, and
the presence of donor eye disease, such as herpes, AIDS or previous
eye surgery.

   Indications

   The basic indication for a transplant is loss of vision due to
corneal opacification--in other words, the inability to see through a
diseased cornea.  Among the causes of corneal opacification severe
enough to limit eyesight are injury, infection, inherent corneal
disease such as keratoconus or corneal dystrophy, and corneal damage
from previous eye surgery. Other indications are relief of pain or
discomfort, immediate repair of infectious or degenerative
perforations in the cornea, and possibly cosmetic reasons.

   Contraindications

   There are probably no absolute contraindications to this surgery.
Many eye surgeons would not operate on a person who has an eye that
is already blind, although a chronically swollen and painful cornea
in a blind eye could be replaced for comfort and appearance.  The
patient would need to be willing to take the risk while feeling that
the alternatives were unacceptable.

   Other contraindications are relative and depend on the general
condition of both eyes.  A patient with glaucoma or ongoing eye
inflammation should have these conditions controlled before
considering transplant.  The presence of an anterior chamber
intraocular lens (see Cataract Surgery) might necessitate removal of
the lens before a corneal graft could survive.

   Procedure

   The surgery involves the partial or total replacement of the host
cornea with a donor cornea.  Total replacement is much more common.
The operation can be done under general or local anesthesia and is
increasingly being done as an outpatient without an overnight stay in
the hospital, but most still require one to two days hospitalization.
 The operating time is approximately 60-90 minutes.

   First, donor tissue is obtained and the recipient prepared in the
operating room.  A round button of donor cornea is then cut to the
desired size with an instrument called a trephine.  A matching round
button of host cornea is also cut, its precise depth being finely
controlled.  Next, the host button is completely cut away with
scissors, and the donor cornea button is sewed into the defect
created by removal of the diseased cornea. Tiny hair-thin sutures or
stitches are used to anchor the graft to the host tissue.

   Recovery & Results

   The postoperative recovery is a long one, but most patients do
well.  Strenuous activity such as lifting, bending or straining
should be avoided for several weeks.  A protective shield is required
and eyedrops are prescribed for several months.  The sutures are
removed between six months and two years.

   The final improvement in vision is gradual and occurs six to
twelve months postoperatively.  The results and success in restoring
vision usually depend more on the state of the original disease than
the actual surgical manipulation.  Some corneal diseases, such as
keratoconus, are more likely to have a favorable outcome, while
others, such as lye injuries, are not. In quantitative terms success
rates vary from 90-95 percent in uncomplicated cases to 5-10 percent
in severe lye burns.

   Complications

   As with all intraocular surgery, operative and postoperative
problems can occur.  These include infection, bleeding, glaucoma,
retinal detachment, poor wound healing, cataract formation,
inflammation and adverse reactions to anesthesia.  The overall
complication rate is very low.

   Two complications unique to transplant surgery are host rejection
of the graft and recurrence of the original corneal disease in the
transplanted tissue.  The donor cornea is recognized by the host as
foreign and causes the recipient's immune system to mount a variably
severe inflammatory reponse. Rarely, the inflammation is great enough
to destroy the clarity and health of the graft.  This must be
controlled.  The mainstay of anti-rejection therapy is suppression of
the immune response by cortisone-type steroid medication, usually in
the form of eye drops.  Recurrence of disease in the donor graft is
uncommon and limited to certain types of diseases, like corneal
dystrophy. However, this may be so severe as to necessitate a second
transplant.

   Approximate Surgical Fee: $1200-2500





   RADIAL KERATOTOMY

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Radial keratotomy, corneal surgery designed to improve visual
acuity in myopic or near-sighted individuals, is an area of intense
interest among physicians and laypersons.  Ideally, the surgical
correction of near-sightedness would result in 20/20 vision unaided
by spectacles or contact lenses.

   Indications

   The basic requirement is that the patient be near-sighted enough
to require optical aids, glasses or contact lenses for good function.
 This might be approximately -2.00 diopters (approx. 20/80).  Highly
myopic patients who can see only well enough to count fingers, e.g.
-8.00 and greater, cannot expect the same results.  Otherwise healthy
eyes, good motivation and a well-informed patient help to make
successful surgery.

   Contraindications

   Minimal myopia is a relative contraindication.  Persons with with
glaucoma or pre-glaucomatous eyes, corneal or chronic conjunctival
disease, lenticular rather than corneal astigmatism, or possibly some
other conditions should not be subjected to this procedure.  Finally,
lack of full informed consent is a contraindication.

   Procedure

   The technique requires a meticulous preoperative examination. The
surgical plan is based on a number of factors which require
error-free  measurements and calculations.  The operation is usually
done as an outpatient without hospitalization.  Local anesthesia is
used.  The length of surgery is approximatedly thirty minutes per
eye.

   The actual procedure involves making tiny linear incisions in the
cornea, the clear outer covering over the iris.  These incisions
produce a minute change in configuration of the cornea that favorably
alters its optical properties.  The incisions are variable in number
and proceed from near the center outward in a radial fashion.  Hence
the name of the procedure: "radial" for direction, "kerato" for
cornea, and "otomy" for incision.  The operative technique must be
meticulous.  The incisions are now done with highly specialized
knives, but the use of LASER cuts is on the horizon.

   Recovery

   Recovery is very rapid.  An optional patch is used for twenty-
four hours.  Eyedrops are prescribed for about one week.  Normal
activity is immediate and full activity is acceptable in two to four
weeks.  Some surgeons caution against receiving hard blows directly
to the eye.

   Complications

   There are several potential complications with this surgery. Most
are either transient, relatively insignificant, or very rare.  These
include pain, light sensitivity, fluctuation in visual acuity,
inflammation, over-correction, under-correction, glare, corneal
surface problems, induced astigmatism, and the rare serious problems
of endophthalmitis, corneal infection, cataract formation and visual
loss.  These latter complications, although quite rare, certainly are
tragic when the eye is healthy.

   Over-correction and under-correction deserve further discussion.
Even when meticulously done, radial keratotomy may produce
unpredictable changes in visual acuity.  It is only possible to
predict with confidence the range of vision and refraction.  For
example, a -3.00 myope would be an excellent candidate.  Without
optical aids preoperative vision might be 20/200, and
postoperatively, the vision might be in the range of -1.00 to +1.00.
But further extremes are possible.  The worst possible situation
would be an overcorrection to far-sightedness, e.g. from -3.00 before
the surgery to +1.00 or +3.00 afterward. Many adults would feel worse
off than before the operation since both distance and reading vision
would be impaired without glasses.

   Visual acuity can vary from a perfect 20/20 to 20/200 or no
improvement at all.  Fortunately, the large majority of patients do
improve their vision, although the refraction and vision do fluctuate
postoperatively.

   Perhaps the bottom line is patient satisfaction.  About 90 percent
of patients are satisfied with the results.  The remaining ten
percent, by and large, have not achieved the hoped for improvement.
Few patients actually suffer ill effects from the procedure.

   The important point with this still relatively unproven surgery is
buyer beware.  The patient and eye surgeon must have realistic
expectations and a good understanding of possible risks and benefits.

   Surgical Fee: $500-2000.  The average is $1200 per eye.

   Reference

   Waring, G.O. and the PERK study group.  Summary of initial results
of the prospective evaluation of radial keratotomy (PERK) study.
Ophthalmic Forum 2: 177 (1985).





   EYELID SURGERY

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Surgery on the upper and lower eyelids is not a single procedure.
Different diseases require different operations. This article will
deal with surgical correction of ptosis (lid droop), entropion
(inversion of the lid margin), ectropion (eversion of the lid
margin), and new treatment of blepharospasm (involuntary lid
closure).  For more information about these disorders, see the Eye
Disorders and Diseases section.

   General Information

   Adult patients can undergo any of the procedures reviewed below
under local anesthesia, i.e. awake with only the eye anesthetized.
In fact this is often preferrable because it allows better "fine
tuning" of the surgeon's judgment.  Children must be totally
"asleep."  The duration of the surgeries is quite variable depending
on the complexity, but most of the procedures last 45-90 minutes.
These operations can be performed as an outpatient or with one or
seldomly two overnights in the hospital.  Postoperatively eye
ointments are instilled for several days to a few weeks until healing
and adaptation to a new lid position occur.  No special activity
restrictions are necessary.

   Ptosis Surgery

   Indications

   Ptosis surgery is indicated when one or both eyelids droop enough
to be a functional or cosmetic problem.  Functional impairment might
be loss of the upper visual field.  Cosmetic reasons are obvious.

   Contraindications

   Ptosis surgery is relatively contraindicated when a a "crossed
eye" muscle problem or strabismus is present.  This requires
correction before lid repair.  Dry eyes or improper tear production
or function may place the eye at inordinate risk because of the
propensity for drying of the cornea following ptosis repair.
Abnormal corneal sensation also carries increased risks for loss of
vision.  The presence of an abnormal nerve supply (jaw-wink
phenomenon) presents a challenge and requires careful consideration
before surgery.

   Procedures

   Three different procedures are used for ptosis repair. The
Fasanella-Servat procedure is used for small amounts, the levator
resection for moderate to large amounts, and the frontalis suspension
or sling for extreme amounts of ptosis.

   Fansanella-Servat is a single, short procedure that involves
excising a portion of the lid from the inside without incising the
skin.  This shortens and elevates the lid.  Surgical fee: $800-1000.

   The sling procedure is also relatively simple from a technical
standpoint.  It involves the use of several small lid incisions and
placement of a sling or suspension material beneath the skin to
mechanically lift and suspend the lid from the brow.  Surgical fee:
$800-1100.

   Levator resection is the most involved.  It is the actual removal
of part of the muscle that elevates the eyelid.  Usually some surface
skin is also excised.  The resultant shortening of the levator muscle
lifts the lid.  Surgical fee: $1000-1400.

   Complications

   Possible complications are under-corrections, over-corrections and
abnormal lid contours.  Bleeding, infection, excessive scarring,
excessive corneal drying, visual loss, poor lid closure, and loss of
the lashes rarely occur.  The rate of unacceptable under- or
over-correction requiring additional surgery is approximately ten to
fifteen percent.  The other complications are distinctly less common.

   Entropion & Ectropion Repair

   Ectropion, common in older individuals, is an outward turning lid
margin.  Entropion is the opposite, an inward turning of the lid
margin so that the lashes touch and irritate the eye.

   Indications

   Ectropion repair is indicated for cosmetic appearance, tearing,
lid redness and ulceration, and general discomfort associated with
lid eversion.

   Entropion is more serious; it needs repair when the lashes are
irritating or damaging the surface of the eye.  Redness, irritation,
foreign body sensation, scar formation, tearing and visual loss can
be alleviated or prevented.

   Contraindications

   It they exist, underlying causes should be identified and treated
before entropion or ectropion repair is considered.  This is unusual.

   Procedure

   The proper choice of surgical procedures is important.  Age-
related changes require a different approach than relief of scarring
due to injury.  Ectropion repair can involve simply excision of a
portion of baggy eyelid or more extensive scar excision with skin
grafting.  Entropion repair is varied and again can involve excision
of parts of the lid, placement of stitches to rotate the lid outward,
or scar removal and grafting. The surgical fee is usually $800-1200.

   Complications

   Over- and under-corrections can occur.  Others include infection,
bleeding, poor cosmetic appearance and late recurrence.

   Blepharospasm

   Involuntary forced lid closure can be a disabling problem, and
traditional surgical approaches have been unsatisfactory.  Since
about 1983, however, an ingenious new therapy has been beneficial.
Botulinum toxin, derived and purified from the bacterium that
produces botulism poisoning, is injected into the eyelid to partially
paralyze the spastic muscle.  This procedure supplants all other
forms of therapy.

   Indications

   All patients with organic blepharospasm that is functionally
disabling are candidates.

   Contraindications

   Non-organic, psychological blepharospasm should not be treated
surgically.

   Procedure

   Relief of blepharospasm is achieved by a series of injections of
purified botulinum toxin directly into the eyelid.  The injection is
a simple, office procedure which is not done in an operating room.
Although the effect is transient, repeat injections, sometimes every
few months, are effective.  The cost for the first injection is
$250-350, and subsequent injections are $100-150.

   Complications

   The reported complications have all been mild and short-lived,
such as temporary ptosis.  No systemic ill-effects from the poison
have occurred.





   CONTACT LENSES

James D. Reynolds, M.D., Univ. of Arkansas School of Medicine

   Contact lenses are in a revolutionary phase.  The last few years
have seen incredible advances in contact lens technology. Lenses are
being made from new materials and are being worn in new ways for new
solutions to old problems.  In fact, the contact lens wearer and
fitter are presented with a bewildering array of choices.

   Basics

   Contact lenses are of three basic types: hard, soft or gas
permeable.  Hard lenses get their name from the fact that they are
firm and hold their shape.  Soft lenses are soft, flexible and
moldable.  Gas permeable lenses are somewhat in-between.

   Contact lenses are a substitute for eyeglasses.  They are used
because of convenience, vanity or other reasons.  Like glasses, they
correct refractive errors.  They can correct far-sightedness
(hyperopia), near-sightedness (myopia) or astigmatism.  (See the Eye
Disorders and Diseases Section.)

   There are distinct eye conditions in which contacts are more than
just a substitute for spectacle glasses.  For example, patients with
aphakia (after cataract surgery), high myopia (excessive
near-sightedness) and corneal diseases such as keratoconus have much
better vision with contacts than glasses.

   Indications

   The indications for contact lenses are many and varied.  These
include substitution for spectacles because of personal reasons,
improvement of vision beyond that by which glasses are capable,
vocational and avocational considerations (e.g. sports), and as
bandage lenses to promote healing of an underlying eye condition.

   Contraindications

   Fortunately, these are uncommon.  The contraindications include an
inability to handle the lenses (e.g. due to age or physical ailment),
poor motivation, poor psychological prepation, active eye disease
such as dry eye, recurrent inflammation inside the eye, recurrent
corneal herpes, chronic conjunctivitis ("pink eye"), and possibly
highly allergic conditions.

   Choosing the Right Contacts

   Classically soft lenses are used for near- and far-sightedness and
small amounts of astigmatism.  Compared to hard lenses, they tend to
be more comfortable, easier to tolerate, and can be worn for longer
periods.  However, they are less durable, lasting one to two years,
and more expensive.

   Hard lenses can correct near- and far-sightedness and larger
amounts of astigmatism or unusual astigmatism.  Although well
tolerated by many, they typically require shorter wear schedules than
soft lenses.  But they have a much longer life, about five or even
more years, and are easier to work with, i.e. handle, insert and
clean.

   Gas permeable lenses, having some advantages of both hard and soft
lenses, are in-between in terms of patient comfort.  They are easy to
handle, but not fragile.  Hence, they last longer. Essentially they
wear like soft lenses, but can be treated like hard lenses.

   Good Wear and Hygiene

   Hard lenses are worn an average of twelve hours per day.  Each
night a cleaning regimen is followed involving three solutions. Upon
removal of the lenses, one cleans them with a cleaning solution.  The
overnight storage is done in a soaking- disinfecting solution.  In
the morning they are rinsed in a wetting solution before placement.

   Gas permeable lenses follow the same ritual as hard lenses except
specific solutions for this type of lens are required. They can be
worn about sixteen hours per day.

   Soft lenses have an all day wearing schedule and are usually
removed at bed time.  There are three different care routines. The
cold care method involves a cleaning solution upon removal, a
soaking-disinfectant solution overnight and a wetting or rinsing
solution of commercial saline (salt solution) before placement.
Importantly an additional two to four hour, weekly enzymatic
treatment is necessary.  The second method is the heat care routine.
 This entails cleaning upon removal then heat disinfection with a
special heating unit.  After heat treatment they can be rinsed in
commercial saline and placed.  The weekly enzyme process is also
required.  Lastly a peroxide system utilizes a cleaning solution
followed by peroxide soak overnight and immediate placement in the
morning.  Weekly enzyme treatments are needed.

   Extended wear lenses can be treated the same as soft lenses except
heat is not advised.  In fact heat disinfection in general is losing
favor.  The recommended wear schedule is not more than one week
between removal.

   The following contact lens simple do's and don't's help assure
safe, longlasting lens wear:

   DO:

   1) Wash hands each time you insert the lens.

   2) Follow the care instructions.

   3) Get regular checkups.

   4) Report any eye irritation or redness to the doctor.

   DON'T:

   1) Use home-made saline solutions.

   2) Wet your contact lenses with saliva.

   3) Overwear your lenses.

   New Developments

   Extended-wear contact lenses have been around a for few years, but
are just now beginning to capture a large share of the market.  Their
major advantage is overnight wear.  However, some patients cannot
tolerate this wearing schedule, and the complication rate is
significantly higher than for daily wear lenses.  Close medical
supervision is very important.

   Toric or astigmatism-correcting lenses are now available, as are
bifocal lenses.  Each of these requires a stable non-rotating
position in the eye.  The advantages are obvious, but the lenses are
new and expensive.

   Complications

   As a foreign object on the surface of the eye, contact lenses have
associated problems.  Probably the most common is a corneal abrasion,
a scratch of the clear covering over the iris.  This arises from
improper insertion or fit, or overwear.  Abrasions can be painful and
require medical attention.  Contact lenses wear must be interrupted
until the cornea is completely healed.

   Other problems include wear irritation such as tearing, light
sensitivity, blinking, itching, redness, burning, corneal edema
(swelling) from overwear or improper fit, blurred vision and optical
aberrations.

   Two uncommon, but important, serious complications are corneal
infection and corneal allergies to the lens.  The incidence of these
is higher with extended-wear lenses.  Permanent visual impairment is
possible.

   Conclusion

   Contact lenses are a tremendous benefit to many persons, but for
optimal use, safety, and vision, they require patient responsibility.
 Sound judgement, proper care and handling, regular check-ups and a
prompt medical evaluation when problems initially arise can produce
years of safe, effective contact lens wear.

   Cost: This is highly variable depending on the lens provider and
service agreement.  Range is $50-350/pair.





   THE PHYSIOLOGY OF EXERCISE

   Exercise places extraordinary demands on the human body when
compared to the resting state. It is a marvel of evolution that our
bodies can adapt to such a wide range of energy expenditure, with
little or no harm to health.  In fact, it could be argued that lack
of exercise is more harmful than its presence, since we were
"designed" to handle the active lifestyle of our primitive
ancestors--constant roaming, climbing, working, and moving about.

   Every part of the body is affected by exercise.  This discussion
will focus primarily on that type of exercise called "aerobic" as
opposed to isometric.  In isometric training, a muscle group is
generally working against a resistance, and little movement occurs.
Although great gains in the strength and size of the muscle may be
achieved in this way, little general effect is derived by the rest of
the organ systems, except for a brief fluctuation in blood pressure
and heart rate during the exercise itself.  The reader is referred to
articles on weight lifting for further details of this type of
exercise.

           Metabolism

   Aerobic, or "dynamic" exercise, involves the abrupt need for
increased amounts of raw fuel. Some tissue, notably skeletal muscle,
may increase its metabolic rate up to 4000% or more during vigorous
exercise!  The primary fuels required are oxygen and glucose, along
with a few other energy sources such as fatty acids.  In order to
meet the glucose demands, the body turns to pre- stored carbohydrates
mainly in the muscles and the liver, with the blood stream acting
mainly as a delivery service.  Most adults have enough such energy in
storage to perform the equivalent of about a five or six mile jog.
Any energy required after that comes from the breakdown of fat tissue
through the action of adrenalin and other chemicals.

   Oxygen is the other component of the body's fuel requirements. Of
course the lungs derive ample amounts of oxygen from the air. The
accumulation of metabolic products produced during exercise stimulate
the brain's respiratory center and hasten the rate and depth of
breathing. There comes a point, however, when the intensity of
exercise is so great that the muscles require more oxygen than the
blood supply can provide.  The biochemical results "switch" the type
of metabolism to that called anaerobic.
 Though only a fraction as efficient as aerobic metabolism for energy
production, this provides additional energy sources for the muscles.
Unfortunately it also produces acid byproducts which ultimately cause
pain in the muscles, fatigue, and cessation or limitation of the
exercise.

   Aerobic exercise seems to have an insulin-like effect on the body,
mimicking many of the effects of that chemical by lowering blood
sugar, and increasing breakdown of fatty tissues.  Most diabetics
notice that their insulin requirements decrease when they exercise.
Additional effects on metabolism include the lowering of cholesterol
levels somewhat, and the elevation of high density lipoprotein
cholesterol (HDL- cholesterol).

    Heart and Blood Vessels

   Among the most interesting results of exercise are manifest in the
heart and the blood pressure.  As noted above, the fuel requirements
of exercise must be met through markedly enhanced delivery systems in
addition to increased supplies. The body provides this through
changes in the circulation. Blood vessels dilate wide open to
maximize delivery of blood, whereas those in the organs of digestion
sacrifice some of their usual relative proportion of the circulation.
 Instead of pumping the usual 4 or 5 liters of blood each minute at
rest, the heart may pump as much as 20 liters each minute during
exercise.

   The increased cardiac output is generally accomplished through
increased heart rate. The stimulus to faster rates is a combination
of emotional factors, accumulation of metabolic products of exercise,
and other factors.  Naturally, there is a limit to the maximal heart
rate, and a commonly quoted rough estimate is to subtract one's age
from 220 (beats per minute).  A typical resting pulse is around 72
per minute.  With increased training, the heart becomes a much more
efficient "pump," and can move a bigger volume of blood with each
beat.  Thus, at rest or with less than maximal exercise, a highly
trained person has (and requires) a slower pulse rate than a
sedentary one.  During vigorous exercise the blood pressure may rise
markedly, only to fall to baseline levels within minutes after
resting.

   The latter phenomenon is one example of the training effect. This
refers to continuous changes in the body occurring after adequate and
persistent exercise in the threshhold range.  Other such changes
include the cholesterol reductions mentioned above, lowering of the
resting blood pressure in some, and increased reserve circulation of
the muscles.  The degree of exercise necessary to cause these and
other changes is in the range of three to five weekly workouts each
of which achieves 75% of the predicted maximal heart rate for periods
of time exceeding 20 minutes continuously.  For most sedentary
adults, this must be achieved gradually.

   ANY PERSON CONSIDERING A CONDITIONING PROGRAM OR ANY OTHER CHANGE
IN HIS OR HER USUAL LEVEL OF PHYSICAL ACTIVITY SHOULD DETERMINE WHAT
HEALTH RISKS ARE INVOLVED.  THIS IS AN INDIVIDUAL MATTER, AND CAN
ONLY BE DETERMINED AFTER CONSULTATION WITH A PERSONAL PHYSICIAN.  IN
SOME CASES CERTAIN TESTS MAY BE NECESSARY TO ASSESS THE RISKS OF
EXERCISE, AND SUCH RISKS MAY MAKE EXERCISE DANGEROUS OR EVEN FATAL
FOR A FEW INDIVIDUALS. CHECK WITH YOUR DOCTOR BEFORE EMBARKING ON ANY
EXERCISE PROGRAM.

   The degree of training effect is often measured as the ability of
a person to consume oxygen during exercise.  Alas, within 3 or 4
weeks of discontinuation of exercise, many of the training effects
begin to decline markedly.

           Conclusion

   It may thus be appreciated that exercise is a very complex
physiological event, permitting enormous capabilities over and above
the resting state, at the price of increased metabolic consumption.
Much is still to be learned about the physiology of exercise,
although its risks and benefits are becoming increasingly clear.
Further aspects of these are addressed in other areas of this
section.





 EXERCISE STRESS TESTING IN THE APPARENTLY HEALTHY ADULT

  (ANY PERSON CONSIDERING A CONDITIONING PROGRAM OR ANY OTHER CHANGE
IN HIS OR HER USUAL LEVEL OF PHYSICAL ACTIVITY SHOULD DETERMINE WHAT
HEALTH RISKS ARE INVOLVED.  THIS IS AN INDIVIDUAL MATTER, AND CAN
ONLY BE DETERMINED AFTER CONSULTATION WITH A PERSONAL PHYSICIAN.  IN
SOME CASES CERTAIN TESTS MAY BE NECESSARY TO ASSESS THE RISKS OF
EXERCISE, AND SUCH RISKS MAY MAKE EXERCISE DANGEROUS OR EVEN FATAL
FOR A FEW INDIVIDUALS. CHECK WITH YOUR DOCTOR BEFORE EMBARKING ON ANY
EXERCISE PROGRAM).

   Exercise stress testing refers to the controlled monitoring of
various vital signs, electrocardiogram, and physical findings of an
individual while he or she undergoes a pre-defined and carefully
monitored amount of graded exercise.  As a rule, the form of exercise
given involves either a treadmill or a stationary bicycle.  The
details of performing the test from the patient's perspective are
discussed in the Surgery and Procedures section of HealthNet. This
discussion will deal with the indications for and implications of
such testing in individuals who have no apparent disease of the
heart.

   The common indication of such testing is either prior to
initiation of an exercise program, or as a "screening" maneuver.
Occasionally, an individual at very high risk for coronary disease
will undergo the procedure to look for occult disease in the absence
of symptoms.

   Several factors are important in understanding the limitations of
exercise testing.  First, it is important that the test be properly
performed, and that the patient exert sufficient effort to reach 85%
of the maximum predicted heart rate.  Technical aspects of the EKG
and blood pressure recording must be satisfactory.  All symptoms must
be recorded, and certain drugs such as diuretics and many other blood
pressure medications can interfere with the results. There are
numerous other factors which must be taken into account, but usually
an adequate exercise test can ultimately be achieved if all these
factors are understood.

   The goal of testing is to determine that it is safe and reasonable
for an individual to exercise vigorously.  Two major dangers are felt
to potentially increase the risk of sudden death during vigorous
exercise: sudden disturbances in heart rhythm such as ventricular
fibrillation, and a heart attack brought about by the sudden demands
of exercise in the face of plugged up coronary arteries. The theory
is that by detecting the early signs of such problems during an
exercise test, the severe problems can be identified and possibly
corrected.

   Unfortunately, there are many uncertainties about the ability of
exercise testing to meet these goals.  In asymptomatic individuals
with proven significant coronary artery blockage (detected with
catheterization) only 65% have an abnormal exercise test; i.e. 35% or
so will be missed by the test. Furthermore, especially in younger
patients, and more in women, there is a 10% incidence of falsely
positive results, i.e. detected abnormalities on exercise EKG in
patients who are then catheterized and found to have essentially
normal coronary arteries.

   It is imperative to point out that in patients with symptoms or
some other reason to suspect that coronary disease may be present
even before the test is done, the implications of the results may be
totally different.  In this setting, various techniques involving
radioactive isotopes injected into a vein while the test is performed
can enhance the accuracy of the study.  At present, few if any
authorities are proposing that such radioactive techniques be applied
to the asymptomatic patient simply wondering whether he or she can
safely exercise.

   Certain benefits can be derived from a stress test. First of all,
there are a number of patients with marked coronary disease with no
symptoms during their sedentary lives, who first come to light during
a routine stress test, and are then advised to avoid rigorous
exercise or undertake further tests and treatments. Critics point out
that most of these patients can be identified with a careful history,
risk factor assessment, cholesterol level, and resting EKG.
Nonetheless, a few will be found only upon stress testing.

   Countering this aspect is the fact that sudden death during
exercise may occur despite a recently normal exercise test, with or
without the finding of coronary disease at autopsy. Thus, a negative
exercise test can be falsely reassuring.

   A final unpleasant but real aspect of exercise testing is the
medicolegal atmosphere prevailing in many areas of the country, which
may lead some physicians to advise stress tests for fear that if
something untoward should happen to a patient during exercise, a
normal test would provide retrospective support for any litigation
which may ensue. This is clearly not a sound medical indication for
ordering a test, but must be addressed in any discussion of the
topic.

   Lastly, the cost of exercise testing ranges from $60.00 to $200.00
or more.  Multiplied by tens of thousands annually, this factor
cannot be ignored in today's cost-conscious environment.

   In the face of such ambiguity, it is difficult to determine
whether an exercise stress test should be performed prior to
beginning a vigorous exercise program.  Only the personal physician
who knows the patient individually can give sound advice, and this
remains the only proper source of information. Many doctors will
suggest that such testing be limited to those people who, by reason
of age and risk factors, are more likely to be harboring unsuspected
problems.  These might include patients with a strong family history
of heart disease, diabetes, elevated cholesterol levels, cigarette
smoking, or those first exercising over the age of 50 (some
authorities would use a lower age limit).
          Conclusions

   There is insufficient knowledge to determine what benefit, if any,
is gained from the performance of a standard exercise stress test in
asymptomatic individuals about to embark on a vigorous exercise
program.  The test has definite limitations, and many authorities
advise limiting such testing to those individuals whose risk for
coronary disease based on epidemiologic factors is considerably above
the average risk.  The proper source and only proper source for such
advice for any individual is his or her personal physician.





  RISKS & BENEFITS OF EXERCISE

(ANY PERSON CONSIDERING A CONDITIONING PROGRAM OR ANY OTHER CHANGE IN
HIS OR HER USUAL LEVEL OF PHYSICAL ACTIVITY SHOULD DETERMINE WHAT
HEALTH RISKS ARE INVOLVED.  THIS IS AN INDIVIDUAL MATTER, AND CAN
ONLY BE DETERMINED AFTER CONSULTATION WITH A PERSONAL PHYSICIAN.  IN
SOME CASES CERTAIN TESTS MAY BE NECESSARY TO ASSESS THE RISKS OF
EXERCISE, AND SUCH RISKS MAY MAKE EXERCISE DANGEROUS OR EVEN FATAL
FOR A FEW INDIVIDUALS. CHECK WITH YOUR DOCTOR BEFORE EMBARKING ON ANY
EXERCISE PROGRAM.)

   It is easy to become skeptical about both sides of the exercise
"question" when it comes to its health effects. Proponents claim
everything from increased longevity to euphoria, whereas less
enthusiastic observers question whether exercise is in fact harmful
to health.  As is often the case, a balanced and objective assessment
will reveal that the truth is somewhat complex.

   Since exercise affects each body system in a different way, it is
useful to examine some of these effects separately.  In addition, a
person who has some underlying disease must consider exercise in a
totally different way, since many effects of exercise which are not
harmful to a healthy participant may be quite deleterious to someone
whose body is weakened in some way.

The Risks

   Although the vast majority of harmful effects of exercise are
musculoskeletal in nature, most of these risks can be reduced by
sensible programs of gradual conditioning, adequate warmup and
cool-down periods, proper clothing and equipment, and, most
importantly, common sense. As these injuries and risks are dealt with
elsewhere, little else will be said here except as it relates to the
possible development of permanent disorders related to the exercise
itself.

   Repeated minor injury or trauma is felt to be one potential factor
in the development of osteoarthritis, the commonest type of arthritis
in the country.  Other factors seem to relate to biochemical
properties of cartilage. Clearly, some individuals are prone to
pre-arthritic conditions such as chondromalacia patella (a painful
but usually temporary knee condition) when they exercise.  However,
it is unknown whether this is confined to those with some hereditary
anatomic or biochemical predisposition to the disease. Current
theories tend to emphasize the biochemical factors, although the
importance of repeated trauma cannot be dismissed.  There is even
postulation that lack of exercise may hasten the disease or,
conversely, that regular exercise may act to preserve the cartilage
against the development of osteoarthritis by enhancing circulation
and other chemical processes.

   At present there is no convincing evidence that regular exercise
leads to osteoarthritis in individuals who are initially healthy and
without joint abnormalities which have been associated with the
disease. Whether such a tendency will be recognized in the future, or
whether a degree of protection is in fact afforded remains to be
seen.

   The cardiovascular risks of exercise, once predisposing diseases
such as coronary artery blockage, heart failure, and unstable heart
rhythm are ruled out, are probably not significant.  There are
occasional anecdotes of sudden death in well-conditioned athletes
during vigorous activity, but many of these cases can be explained
either on the basis of some previously identified disease, or as
statistical flukes.  Other cases had major risk factors which
probably should have led to vigorous screening procedures. In young
victims, a condition called IHSS (idiopathic hypertrophic subaortic
stenosis) is seen with some frequency. This is a congenital
abnormality which can often be detected on exam.  Heat stress under
extremes of temperature and inadequate fluid intake is apparently the
cause in a few cases.  Despite these explanations some cases remain
of unknown origin.

   What is the proper perspective on the risk of sudden death during
vigorous exercise?  Most rigorous studies of large numbers of
patients conclude that without other risk factors, the risk of sudden
death is probably no greater during exercise than the risk of sudden
death by chance alone, even without exercise.  Even in the studies
showing a slightly increased risk during long distance running, the
group had an overall lower risk of sudden death than a comparable
nonexercising population.  It appears that the general benefits of
exercise overshadow any small risk which its performance might
entail, when the risk of sudden death is considered.

  Most of the remaining general risks of exercise for healthy people
are unusual and idiosyncratic.  A few develop an allergy-like
reaction to exercise with hives and itching. Even anaphylactic
reactions have been reported, with near- suffocation and collapse.
Asthma may worsen or only occur during exercise. Bleeding into the
urine or digestive tract may occur may apparently be a result of
exercise, and is of benign prognosis; other potential source of the
bleeding must of course be ruled out.  Menstrual irregularities or
absence may occur with vigorous training, through the effects on
hormone levels.  Pregnancy appears to be unaffected by exercise in
general.

Benefits of Exercise

   It is not especially fruitful to debate the subjective benefits of
exercise, although many describe them in glowing terms.  It is common
to report an increased sense of well- being, a "high" or sense of
euphoria during exercise, and an improved body image.  Some of these
sensations may be related to changes in the brain chemicals known as
endorphins, which have some effects akin to those of narcotics.
Studies on the psychologic effects of exercise can be difficult to
interpret, but do suggest a beneficial effect on depression and some
other symptoms.

   The effects of exercise on survival and longevity are intriguing.
Many suggestive studies in animals show a clear reduction in heart
disease; human studies have proven vexingly difficult to perform and
interpret due to the fact that populations are difficult to control,
compliance with study requirements are poor, and so many other
factors come into the picture that "pure" conclusions become more a
dream than a reality.  The best of these studies tend to show a
benefit in survival, at least for men; the results cannot be
considered conclusive.

   It is probably accurate to state that there is no proof that
regular exercise prolongs life or decreases the risk of developing a
heart attack;  this absence of proof does not mean that that is not
the case, only that the case has not been proven.  The consensus of
the vast majority of experts in the field, many of whom are hardened
and objective scientists, is that it is just a matter of doing the
right study.  For now, the skeptics have a reasonably defensible
position.

   A few additional benefits of exercise are its probable role in
increasing bone density and reducing the risk of osteoporosis for
white women, calorie consumption ("a hundred calories a mile")
leading to weight loss or maintenance, and enhanced ability to
tolerate illness should it occur.

   In summary, each individual must determine with his or her medical
provider whether the time, risks (if any), expense, effort, and
physical burden of a sensible exercise program are justified by the
subjective and objective benefits likely to accrue.  Exaggerated
claims of risks and benefits do little to make this decision easier,
but a reasoned assessment of the available data suggest that, for
many, exercise is a worthwhile investment.





  FITNESS TRAINING GUIDELINES

   Once a decision has been made to train for cardiovascular fitness,
and once a qualified health advisor has determined that it is
medically prudent and safe for an individual to undertake such an
endeavor, certain guidelines are useful for determining the type and
amount of exercise required. Many doctors will provide an exercise
"prescription" for each patient, and this should always take
precedence over any general guidelines such as these.

   The three major factors in judging the "quality" of a training
method are its duration, intensity, and how often it is done.  In
addition, the mechanical aspects of the activity must be considered
from a safety standpoint.

Intensity

   In order to promote cardiac fitness, an exercise must "stress" the
heart and circulation sufficiently to achieve the training effect.
Just as lifting a pencil will not build up bulky arm muscles no
matter how often it is done, neither will a leisurely stroll build
fitness.

   Authorities are not sure exactly what level of intensity is
universally best, but most agree that optimal training should be
vigorous enough to raise the pulse to at least 75% of the predicted
maximum for your age.  Lower intensities may be suitable for many, as
noted below, but this goal is appropriate for many dedicated
individuals who are interested in improving performance as well as
fitness.  The maximum heart rate is approximated by subtracting one's
age from 220. Thus, a 40 year old would strive for 75% of [220-40],
i.e. 135 beats per minute. As one's fitness increases, a given amount
of exercise raises the pulse less and less, and this is one mark of a
successful program.

   Another approach is to choose an intensity equal to 5 or 6 METs.
METs are a measure of oxygen consumption, and the various METs of
selected activities are listed in another section of this area of
HealthNet.  As an example, even moderately brisk walking and cycling
achieve this level of intensity.

   Finally, the more casual candidate can simply perform to the point
where she is aware of "working hard" but still able to speak fairly
comfortably, and without excessive breathlessness. One point is
clear: intensity must be sufficient for a sense of physical exertion
to occur, though this need not, and sometimes should not, be severe.

Duration

   Depending upon the intensity of exercise chosen, the activity
should be performed for at least 20 minutes at a time, and
continuously during that period. Longer sessions up to an hour are
naturally more effective. Many choose to alternate a slightly more
intensive 20 to 30 minute work-out with a longer but less vigorous
session the next time.  There is considerable flexibility here, as
long as a 20 minute minimum is maintained.

   Stop-and-go activities are surprisingly inefficient, even if
prolonged and fatiguing. Thus, a 3 hour doubles tennis match where
actual motion occurs irregularly and intermittently is not a very
effective training activity when compared to 20 minutes of jogging,
handball, swimming or other similar activity.  The social value and
sense of muscular fatigue may have recreational merit, but no praise
is earned for fitness.

Frequency

   It is advisable to work out at least three times a week. Lesser
frequencies allow for some deconditioning between sessions, and are
much less effective overall.  Many competitive athletes will train 6
or 7 days a week, and although their conditioning is accelerated, it
is recognized that the incidence of musculoskeletal injuries
increases markedly as frequency increases above 3 times weekly.

   There is some practical and theoretic advantage to skipping a day
between sessions.  Minor injuries and inflammation of ligaments,
tendons, muscles and other tissues have a chance to subside, and
injuries are less frequent.  The psychologic burden of discipline is
reduced, and this enhances the likelihood of sticking with the
program. In this hurried world, the total time spent in exercise can
sometimes cause conflicts, and an alternate day regimen allows for
some flexibility of scheduling.

     Warm-Up and Cool Down

   A few minutes spent in slowly stretching the muscles to be used
can reduce the chances of "sprains, strains, and pains." Sustained
stretches are preferable to "bouncing" types of calisthenics.  A
brief session of deep breathing will expand the lungs and stretch the
muscles of respiration.

   Even more important than the above is a period at the end of the
work-out in which the intensity of activity is allowed to gradually
decrease--a "cool down."  Either by simply slowing down or repeating
the simple warm-up types of exercise, a sudden cessation is avoided.
This is crucial since during exercise, high levels of adrenalin can
build up in the blood.  This is rapidly consumed during vigorous
activity, but when the activity stops, these chemicals may accumulate
for a few minutes.  In a few sensitive individuals, such
accumulations may be dangerous to the heart. The cool down allows for
the controlled metabolism of the substances while their production is
decreased, thereby sparing the heart from such exposure.

         Fluid and Food

   Circulation to the digestive organs diminishes during exercise,
and food in the stomach is likely to cause discomfort. Thus, training
should occur at least 90 minutes after the last meal or snack. Fluid
in the form of water seems to cause little trouble despite anecdotes
to the contrary, and especially in warm conditions or during
sustained exercise, ample water should be consumed both before and
during exercise.

   Dehydration can occur rapidly through perspiration, and thirst (or
its absence) has been shown to be a poor guide to the level of
hydration during exercise. Damage to kidneys, low blood pressure, and
chemical imbalances can occur from too little fluid, and most
authorities advise athletes to drink often. There is no advantage to
fluids other than water in this context.

           The Novice

   It may seem obvious, but the guidelines in the above discussion
are for the conditioned person, and the newcomer to exercise may
require 6 weeks or more just to achieve the minimal fitness
conditions outlined.  Since fitness is a lifelong habit, this is not
really a long time, but some will be eager to rush things along.  It
is NEVER safe to extend one's activity to the point of non-trivial
pain or lightheadedness, or severe fatigue. Of course, unexplained
pain in the chest, neck, arm, abdomen, jaw, or back demands urgent
medical attention.  Any athlete who appears to be confused or
disoriented during exercise should likewise be brought to medical
attention. Common sense and caution are imperative.

   Within these guidelines, almost any individual can enjoy lifelong
fitness, an improved sense of well-being, and the many other
advantages of fitness discussed elsewhere.  It is safer to exercise
regularly than to avoid fitness altogether, and the risks of exercise
itself can be minimized through adequate medical screening, sensible
guidelines, and attention to the signals of the body.





ENERGY COSTS--VARIOUS ACTIVITIES

   The energy requirements of a given activity are often measured in
METS, a unit of oxygen consumption for a given weight over a minute.
It is useful to remember that 1 MET is the amount of energy required
at rest during one minute.  An intensity of no less than 5-6 METS is
desirable for training.

   ANY PERSON CONSIDERING A CONDITIONING PROGRAM OR ANY OTHER CHANGE
IN HIS OR HER USUAL LEVEL OF PHYSICAL ACTIVITY SHOULD DETERMINE WHAT
HEALTH RISKS ARE INVOLVED.  THIS IS AN INDIVIDUAL MATTER, AND CAN
ONLY BE DETERMINED AFTER CONSULTATION WITH A PERSONAL PHYSICIAN.

 ACTIVITY               METS

 Standing                1.5
 Desk Work               1.5
 Slow Walking            1.5
 Moderate Walking        3
 Slow Cycling            3
 Golf, Using Elec. Cart  3
 Cycling, Moderate       4
 Fishing, Light          4
 Golf, Hand Cart         4
 Sailing                 4
 Walking, Brisk          5
 Golf, Carrying Clubs    5
 Tennis, Doubles         5
 Ping Pong               5
 Gardening, Light        5
 Calesthenics, Light     5
 Walking, Rapid          6
 Cycling                 6
 Ice Skating, Moderate   6
 Tennis, Singles         6
 Lawn Mowing, Hand       6
 Skiing, Downhill        7
 Skiing, XC, Slow        7
 Square Dancing          7
 Jogging 12min./mile     8
 Skiing, Downhill,brisk  8
 Basketball, Moderate    8
 Hockey                  8
 Racketball              8
 Carrying 80 lbs.        8
 Cycling 5min./mile      8
 Skiing, XC, Moderate    9
 Basketball, Vigorous    9
 Handball, Moderate      9
 Handball, Competitive   10
 Skiing, XC, Vigorous    10
 Running--10min./mile    10
 Running--8.5min./mile   11.5
 Running--7.5min./mile   13.5
 Running--6.6min./mile   15
 Running--6min./mile     17





       SPORTS NUTRITION

   The recent and apparently sustained national interest in vigorous
exercise has focused attention on the role of nutritional factors in
performance and safety for those who engage in rigorous activity.
The discussion of exercise physiology addresses some basic issues of
energy requirements. Here, the more general relationships between
what you eat and your performance and health will be addressed.

     Carbohydrate "Loading"

   Marathon runners and other endurance athletes often practice
carbohydrate loading. In its most extreme form, this consists of a
regimen of several days of vigorous exercise with avoidance of
carbohydrates, followed by several days of light exercise with a high
carbohydrate intake.  The theory is to deplete skeletal muscles of
their primary storage form of energy, glycogen, thereby making them
"avid" for the substance. The high carbohydrate intake thus loads the
muscles with glycogen, while the lighter exercise regimen allows this
accumulation to be sustained until the "big race."

   Studies have shown that even without the preceding relative
carbohydrate fast, a large carbohydrate meal can increase muscle
glycogen by almost 80% over baseline.  Endurance may indeed by
enhanced by a high carbohydrate diet, although speed is only
questionably affected.  The safety of the practice is not thoroughly
studied, but for short periods in well conditioned individuals, no
unusual dangers are noted if all other dietary and health factors are
normal.  Though amazingly low levels of blood sugar (hypoglycemia)
can occur, this does not seem to adversely affect most athletes.  One
wonders if this contributes to the runner's "high."

   In contrast to the marathon style athlete, the competitive sports
athlete tends to rely more heavily on short spurts of intense
activity, with a moderate baseline activity in between. For these
athletes, comfort and blood glucose considerations are such that only
light food intake is best taken in the 60 to 90 minutes before the
game, with liberal fluids as below.

             Fluids

   Through perspiration and rapid respiration, very large amounts of
body fluid can be lost during exercise, especially in warm and dry
environments. Furthermore, during vigorous exercise, many have
observed that the normal thirst perception is altered, and that
thirst becomes a poor guide to the body's fluid needs.  Up to 2000
cc. per hour may be lost in some people; almost 4 1/2 pounds of
fluid!

   Sweat is rather dilute relative to internal body fluid, and the
bloodstream chemical balance becomes concentrated. The stoical and
outdated coaching attitude of avoiding fluids to prevent "cramps" has
made this a major problem in some areas.  In fact, it has been shown
that dehydration decreases performance greatly. Copious amounts of
fluid before, during, and after vigorous exercise are desirable, and
probably maintain or even enhance performance.  Any program which
discourages this must be questioned.  Wrestlers trying to "make a
lower weight class" and similar misguided athletes are jeopardizing
their health.

   Water is the best fluid replacement vehicle.  Various glucose or
salt containing products offer no advantage, and some may cause
dangerous chemical disturbances under certain circumstances.

            Vitamins

   Despite commercial exploitation of the "stress" of vigorous
exercise, there is no convincing evidence that athletes require any
higher doses of any vitamin than those contained in a standard
American diet.  Trace minerals such as zinc and magnesium, along with
potassium and sodium are of similar abundance.  The occasional
individual who is following a narrow or limited diet for some reason
or other, or who fails to attend to even the rudiments of dietary
prudence may choose to take a single standard multivitamin
preparation daily.

 General Dietary Considerations

   Total calorie requirements in athletes are increased in proportion
to the level of activity, with additional requirements of around 100
calories per mile covered on foot, or its equivalent in other
activities.  The other dietary recommendations do not differ from
those of a prudent American diet  little or no added salt, general
avoidance of high cholesterol and saturated fat  containing foods,
balanced intake of the several food groups, and of fats,
carbohydrates and protein. Women who are white, and/or slight of
build might consider calcium supplements of around 1000 mg. daily to
help prevent osteoporosis is their doctor finds no contraindications
to this.
           Conclusion

   Athlete need not be overly concerned about special dietary and
nutritional requirements in most cases.  The simple principles
outlined above point out that the general diet of most Americans is
more than adequate for the vast majority of the exercising
population, and that special measures are not often necessary.  A
prudent diet suitable for the general population is equally suitable
for the athlete.  Except in the most competitive environments, no
extraordinary measures are warranted.  rg 5/85





   RUNNING

   The last two decades have seen running become the most popular
form of aerobic conditioning.  Millions of people of all ages have
taken to the streets, parks and tracks in their pursuit of better
health, slimmer bodies and perhaps longer lives.

   Running is a particularly attractive form of exercise because it
requires little technical athletic ability and no complicated lessons
or expensive equipment other than a good pair of shoes. The most
important prerequisites are the desire to run and the compulsion to
sustain a regular training schedule.

   When performed continuously three or more times a week for at
least fifteen to twenty minutes at an intensity high enough to raise
the pulse rate to approximately seventy percent the maximum predicted
heart rate reserve for age, it is  along with swimming, cycling,
cross country skiing and some other sustained action sports  an
excellent way to improve one's cardiovascular fitness. Other
beneficial effects of running may include stress reduction, weight
loss, lower blood pressure, better cholesterol profile, and a sense
of accomplishment.  Running does little to develop the muscles of the
upper body, and contrary to claims in the popular media, there is no
solid proof that running either decreases the risk of heart attack or
prolongs life.  (But it hasn't been disproven either.)

   For each minute of running, approximately ten to fifteen calories
are expended  about 100 per mile depending on one's speed.

   Choosing Proper Shoes

   One of the best ways to avert injuries is to select the
appropriate pair of running shoes.  Good shoes must fit well, and
should be light and flexible, yet durable enough to hold up under
constant battering.  Some of the other characteristics one should
look for are a resilient heel wedge, reinforced heel cup, molded
achilles tendon pad, flexible midsole, padded tongue and a studded
rubber sole.  There are hundreds of different brands and models; no
single type of shoe is best for all runners, and the most expensive
or nicest looking shoes are not necessarily the safest.  Court and
dance shoes should never be used for long distance running.

   Getting Started

   Persons that are either over age thirty five or have a chronic
illness should check with their doctor before starting.  A specific
exercise plan may be prescribed.  Otherwise, the following program is
a reasonable way to get running:

   Begin each training session with a ten minute stretching and
warmup period, and follow the run with a similar period of stretching
and cooling down.  When running outside, choose a safe route that is
soft, flat and easy to negotiate.

   Start with a walk or slow jog, trying to complete a 1 1.5 mile run
in fifteen to twenty minutes, three to five times weekly.  If you are
unable to run the entire distance, alternate running with intervals
of brisk walking.  The pace is not that important as long as you
achieve a continuous pulse rate of approximately seventy percent your
predicted maximum heart rate reserve (150 for a thirty year old).

   With regular training, you will soon be able to run the entire
distance.  Don't increase the pace or distance too rapidly: after two
to three miles have been achieved, the mileage should not be
increased by more than a ten percent a week.

   Common Injuries

   Almost sixty percent of runners will experience at least one
injury that is severe enough to temporarily prevent them from
training.  Most of these injuries are little more than minor
annoyances, but some are serious.  Factors that predispose to injury
are inappropriately designed or worn out shoes, uneven running
surfaces or inclines, increasing one's distance or speed too rapidly,
overtraining, inperfections in one's technique and underlying
structural abnormalities of the musculoskeletal system.  Injuries are
more likely to occur during competition.

   The knee is the most common site involved, accounting for almost
one out of three injuries.  Chondromalacia, a wear and tear
degeneration of the cartilage on the undersurface of the kneecap, is
manifested by pain, aching and swelling in the front of the knee.
The symptoms are aggravated by weight bearing and stair climbing.
This condition may result from overuse or from a malalignment of the
kneecap over the joint.  Treatment consists of rest, anti
inflammatory medications, special thigh muscle strengthening
exercises and sometimes surgery.

   Some other common knee injuries are the iliotibial band friction
syndrome (ITBFS) and tendonitis.  ITBFS, an inflammatory condition of
a strip of connective tissue, causes pain and stiffness on the
outside of the knee during running.  Ice, stretching, rest and
avoiding hills and hard running surfaces provide relief in most
cases, but some patients require shoe wedges (orthotics), cortisone
injections or surgery.

   The lower leg and calf account for the second greatest number of
running injuries.  Shin splints is manifested by pain along the shins
when running.  Poor condition, overuse, worn shoes and running on
hard or slanted surface are often implicated.  The treatment is rest
and ice; orthotic devices may also be helpful.

   Achilles tendonitis afflicts about one out of five regular
runners.  The pain is located in the back of the lower leg where the
calf muscles attach to the heel.  Running on hills, wearing shoes
with inflexible soles and certain foot abnormalities can predispose
to this injury.  Rest, ice, exercises, orthotic devices or shoe
modifications are helpful.

   The usual cause of heel pain in runners is plantar fasciitis, or
the heel spur syndrome.  Typically, the pain is worse at the
beginning of a run, diminishes thereafter, then recurs later on. When
ice, rest and heel pads or cups are ineffective, cortisone injections
may be indicated.  A variety of foot disorders including corns and
calluses, black toes (blood beneath the toenails from repetitive
injury), strains and fractures are also possible.

   Miscellaneous running injuries include ankle and knee sprains, low
back pain, stress fractures, muscle strains and bursitis of various
joints.  Among the other physiologic events occasionally associated
with long distance running are menstrual irregularities (usually
missed periods), diarrhea, intestinal bleeding and blood in the
urine.

   Recent studies suggest, contrary to popular opinion, that long
distance running does not predispose to degenerative arthritis.

   Exertional Heat Injury

   With careful planning, dehydration, heat cramps, heat exhaustion
and heat stroke are largely preventable.  Wearing light outer
clothing, avoiding hot and humid weather, drinking liquids during
long runs on warm days and avoiding extreme fatigue are important.
Picking up the pace before the end of the run can be hazardous.  On
hot days, runners should drink about eight ounces of fluid fifteen
minutes before a race and every two miles during the run.

   Runner's High

   The subject of controversy among avid joggers and sports medicine
experts, runner's high refers to a favorable affective experience
that develops during the course of a run.  Pleasant feelings, a sense
of relaxation and even euphoria have been described.  The high
usually comes on several miles into the run, after the pulse and
breathing have become regular and unlabored and the muscles and
joints have had time to loosen up.

   The chances of feeling runner's high seem to increase with the
distance covered.  Unfortunately, not all runners have this
experience, and even many well trained runners doubt its existence.
Studies have suggested that runner's high may be caused by the
effects of endorphins, the body's natural opiate substances, but
research on this subject has been inconclusive. A compulsive attitude
toward running and knowing what to expect may be more important
factors than complicated physiologic explanations.





   SWIMMING

   One of the more enjoyable forms of exercise, long distance
swimming is also a good way to improve one's aerobic conditioning and
cardiovascular fitness.  Because the large muscles of the upper and
lower extremities are worked simultaneously, a great deal of energy
is expended.  For the average swimmer, each mile requires
approximately 600 calories of energy.  Swimming the crawl at one mph
burns off about ten calories per minute, a rate comparable to running
five times as fast.

   Another advantage for swimmers is the protection from serious
orthopedic injuries.  The swimmer's buoyancy in water reduces the
bone jarring stresses on weight bearing joints and ligaments and
makes fractures, sprains and strains relatively uncommon.

   Getting Started

   All that is required is a pool, lake or ocean, a swimsuit, and
reasonable swimming skills.  The ideal water temperature is 70 74
degrees F.; warmer water diminishes effective heat loss, while cooler
temperatures can lead to hypothermia (low body temperature).  As with
other forms of exercise, large meals should be avoided prior to
workouts.  Pool swimmers can protect their eyes from the irritating
effects of chlorine by using goggles.  Nose and ear plugs are
optional.

   For aerobic training, the crawl or backstroke are advised. (The
sidestroke and breaststroke are not vigorous enough for training
unless the glide interval is minimized, and the butterfly is
considered mainly a racing stroke.)

   Begin with three to five sessions a week, aiming for approximately
thirty minutes per workout.  Try to swim a slow crawl stroke or
backstroke for the entire time period.  If you tire, either stop to
rest or alternate laps with the sidestroke or breaststroke until you
are able to complete the entire session.  Do not attempt to finish
the swim if you are hurting or extremely fatigued.

   Untoward Effects

   Overuse can lead to swimmer's shoulder as well as tendonitis of
the knee and ankle.  Rarely ankle injuries may result from flip turns
against the wall of the pool.  More common problems include dry hair
and skin, chlorine allergy and swimmer's ear (a bacterial infection
of the ear canal).  The latter is easily treated with antibiotic
drops, but it can be prevented by the use of water tight earplugs.

   Drowning, the most serious consequence of any water sport, is an
unusual occurrence unless the victim is ill, injured or intoxicated.
Open water swimmers should never train alone and must be constantly
alert for dangerous marine animals.





   TENNIS

   Tennis, the recreational racquet sport enjoyed by millions of
people worldwide, can also be a worthwhile form of aerobic exercise.
While not traditionally thought of as a means of conditioning because
of the stop and start nature of the game, a competitive singles match
can raise a player's heart rate above sixty percent his maximum
predicted value for age.  If it is played at a moderate intensity for
an hour or more three times a week, improved cardiovascular fitness
can be achieved.

   Many tennis buffs find this form of exercise preferrable to the
"drudgery" of running and other repetitive activities. Unfortunately,
casual Sunday afternoon games of doubles or leisurely singles often
lack the vigor to produce a significant training effect.
Intermediate level singles tennis players burn approximately nine
calories per minute during active play.

   Tennis Elbow

   A form of tendonitis also known as epicondylitis, this condition
is caused by microscopic tears, inflammation and scarring of the
tendons and soft tissues attached to the bony prominences
(epicondyles) of the elbow.  Despite its popular name, tennis elbow
is not limited to racquet sports participants in racquet: it may
result from any sport or repetitive activity that places stress on
the elbow.  Manual labor, baseball, golf, weight training, rowing and
bowling are just a few examples.

   About one in three regular tennis players develops epicondylitis
at some point in his playing career.  Overuse and excessive torque
applied to the elbow are the major causes. Predisposing factors
include daily play, older age and a higher level of tennis skill.
Neophytes are less likely to be afflicted than more experienced
players.

   In the majority of cases, the pain is located on the outer or
lateral epicondyle, brought on arm and wrist activity, and associated
with stiffness.  Advanced level players, who have a more forceful
serve, often have inner or medial epicondyle inflammation.

   The initial treatment consists of rest from tennis, ice, anti
inflammatory medications and physical therapy.  Cortisone injections
may also be indicated.  Well over 90 percent of the sufferers respond
to conservative measures, but occasionally surgery is required.

   When play is resumed, a sturdy elbow brace is recommended. Other
steps to prevent recurrence include being sure not to grip the
racquet too tightly, adjusting the string tension to between fifty
two and fifty five lbs., using dry resilient balls, avoiding too much
wrist rollover when attempting to hit a topspin shot and learning to
hit a two handed backhand.

   Other Injuries

   Among the other tennis injuries are calluses, blisters, sprains,
bursitis, stress fractures and eye trauma.  Attention to stretching
and loosening up before and after matches is very important.  Choose
a light, durable tennis shoe and be sure that the court is dry and
even.  Do not play when fatigued.  Lessons to improve your technique
not only help you win, but also reduce the chances of injury.





   RACQUETBALL

   One of the fastest growing sports, racquetball is enjoyed by more
than ten million Americans.  And in the near future almost twice that
many racquet happy people are expected to take up the game.  Part of
racquetball's attraction is its ability to allow even the most
inexperienced players to have a fun and competitive match.  Although
the walled court is only twenty by forty feet in dimension, the ball
is lively and the action is typically fast and furious.

   When played aggressively, singles play (and doubles to a lesser
degree) can be a vigorous aerobic workout.  Recent studies have shown
that despite the fact that the ball is kept in play only about one
half the total match time, the competitors are able to exercise above
sixty percent of their maximum heart rate reserve for prolonged
periods of time.  Approximately ten calories are expended during each
minute of play for the average participant.

   Injuries

   Injuries sustained during the course of a raquetball game can be
divided into two categories: nonfacial and facial.  Nonfacial
injuries include fractures or sprains of the ankle, foot, toe and
wrist; sprains of the knee, shoulder, fingers, back and neck; bruises
of the legs and ribs; and inflammation of the tendons inserting at
the elbow (tennis elbow) or of the sac (bursa) surrounding the elbow
joint.  By far the most common of these are ankle sprains and
fractures, which comprise almost half. Injuries to the face may have
more serious consequences.  These include bruises or cuts to the face
itself, eye injuries, broken nose, tooth fractures and bruises or
cuts to the scalp.

   Causes of Injury

   The single most common cause of nonfacial injuries is crashing
into a wall; injuries to the face are usually caused by a misplaced
racquet.  In over half the instances of players being struck in the
face by a racquet, the poor souls bopped themselves!  Of note when
considering racquetball injuries is that only one out of ten
individuals suffering an injury to the face is wearing protective
gear.  In addition, in eighty percent of the of injuries, it is the
contestant of lesser ability that suffers the blow.  Other factors
contributing to injury include poor technique, fatigue, overly
aggressive play, ill fitting shoes and a dirty or wet court.

   Prevention

   A little preparation can make the game safer, and perhaps, prevent
you from testing the limits of your health insurance policy:

   1)  Take some time to learn how the game is played. Supervised
instruction, if you can afford it, is a wise investment.
   2)  Choose an opponent of equal ability.
   3)  Warm up and stretch before playing.
   4)  Don't forget to use the racquet wrist strap.
   5)  Wear a protective eyeguard, preferably the closed variety that
meets the standards of the Eye Safety Committee of the American
Society of Testing and Materials (ASTM).
   6)  Wear properly fitted shoes that are sturdy and allow you to
move laterally as well as straight ahead.  Running shoes are not
appropriate footwear for racquetball.
   7)  Don't play if your are fatigued.
   8)  Check the condition of the court before starting play.





   AEROBIC DANCE

   Originally intended in the late 1960's as a televised exercise
program for servicemen's wives, aerobic dance rapidly gained
nationwide popularity as a fun fitness alternative to running,
swimming or cycling.  Now over one million persons  both women and
men  enjoy this activity through programs on TV and videocassette and
classes in health clubs, spas and YMCA's.  Most of the participants
prefer the lively music, choreography and social aspects of group
dance exercise to what they feel is the boredom of more traditional
aerobic activities.  Many of these enthusiasts rely upon aerobic
dance as their only form of fitness training.

   Aerobic dance classes vary widely depending upon the instructor.
A typical session might include ten minutes of stretching, thirty
minutes of dance exercise and a ten minute cool down period.  The
music and choreography as well as the length, intensity and
characteristics of the workouts are determined by the instructor.
Running and jumping in place and calisthenics are often combined with
more formal dance routines.

   Benefits
   When performed at an intensity great enough to increase the
dancer's heart rate to 60 90 percent of his predicted maximum heart
rate reserve for at least fifteen to twenty minutes, three to five
times weekly, an aerobic dance exercise program can improve
cardiovascular fitness.  Low intensity sessions and programs with
frequent or long rest periods may not provide the sustained
elevations in heart rate required for aerobic conditioning.  Other
potential benefits include increased flexibility, leg strength and
calorie expenditure  about ten calories per minute.  Some regimens
also emphasize upper body development.

   Injuries

   Although aerobic dance is a relatively safe endeavor, orthopedic
injuries are not unusual.  About forty percent of the student
participants experience an injury which either causes pain or limits
activity; the figure is somewhat higher for instructors.
Fortunately, most of the injuries are minor in nature, often not
requiring medical care.

   Over one half of dance exercise injuries involve the legs below
the knees: shinsplints, foot pains, plantar fasciitis (heel spur
syndrome), ankle sprains, stress fractures, etc. Back, hip and knee
problems may also occur.  Injuries are more common in participants
who exercise for more than four sessions per week and in persons over
age thirty five.  Strenuous workouts, resumption of exercise after a
long layoff, poor technique and inappropriate footwear also increase
the chances of injury. (Running shoes, court shoes and bare feet are
not acceptable for this activity.)  Finally, the type of floor is
important: the surface should be firm, yet cushioned for resiliency.

   Another factor that may contribute to injuries is the inexperience
and lack of formal training on the part of some instructors.
Guidelines for the certification of instructors are still in their
infancy, and national standardization in this area is sorely needed.





   SCUBA - GENERAL CONCEPTS

Benjamin H. Gorsky, M.D., Chief of Anesthesia, Shriners Hospital for
Crippled Children, Honolulu, Hawaii

   Medical questions about SCUBA diving arise in two general areas.
First, individuals who consider beginning a diving training program
wish to know if they are medically fit to dive. Second, divers want
and need to understand the medical hazards of their sport.  This
article discusses some general concepts about the physics and
physiology of diving as well as who should and should not dive.
Sinus and ear squeeze, motion sickness, lung collapse and air
embolism, nitrogen narcosis and decompression sickness (the "bends")
are reviewed in a companion article.

   Ambient Pressure

   At sea level ambient pressure (caused by the weight of the entire
column of air above a designated area) is equal to one atmosphere (A)
or fifteen pounds per square inch (PSI).  With increasing
elevation--for example, during a climb through space in an
unpressurized aircraft--pressure continuously decreases. At about
18,000 feet the pressure is only one-half an atmosphere. Descending
into a body of water has the opposite effect.  For each 33 feet of
salt water (or 34 ft. fresh water) the pressure increases by one A.
Thus, at a depth of 33 feet a person is exposed to two A; at 66 feet
to three A; at 99 feet to four A; and at 120 feet (generally
considered the limit for sport diving) to five A of pressure.

   Effects of Dissolved Nitrogen

   Divers are also subject to the effect of dissolved nitrogen. At
sea level all the tissues in the body are in equilibrium with
nitrogen in the air.  Since air is 80 percent nitrogen, one is
constantly exposed to 4/5 A of nitrogen.  With increasing depth the
diver is exposed to greater pressures of nitrogen.  At 120 feet, for
example, one is exposed to 0.8 X 5 or 4 A of nitrogen. Nitrogen has
two important effects on divers: nitrogen narcosis and decompression
sickness or the "bends."  These disorders are discussed in a separate
article.

   Fitness for Diving

   This question is answered differently by various authorities.
Physicans who examine military and commercial divers usually take a
very conservative position, stating that only completely healthy
individuals should dive.  Those who deal with sport divers often take
a more liberal view.

   Virtually all diving physicians agree that individuals with any
form of obstructive lung disease (e.g. emphysema) should not dive.
These people are subject to an unacceptable risk of collapsed lung no
matter what precautions they may take.  Those with ruptured ear drums
or blocked sinuses may not dive until the problem resolves.
Similarly, persons with vertigo should not dive.

   Beyond the above disorders, medical clearance for diving must be
decided on an individual basis.  Any persons who cannot perform
strenuous exercise should probably be discouraged from diving.
Unanticipated open water conditions may arise which require strength
and agility, even on the simplest dives. Individuals who take
medications for diseases such as diabetes or high blood pressure may
or may not be permitted to dive.  These persons are certainly at
increased risk; however, many physicians feel that if their patients
understand diving physiology and know their limits, they should be
able to enjoy the sport in a limited way.  As in many other areas of
medicine the answer lies in the balance between the anticipated risk
versus the expected gain.

   When Not to Dive

   One should not dive while acutely sick with any illness.  Even
minor colds can affect the small airways in the lung, trapping air in
tiny sacs which cannot vent their contents to adapt to changes in
pressure.  To be sure it is safe to resume diving after a major
illness, it is best to consult a physician who knows diving medicine.

   As more women become sport divers, concerns about diving during
pregnancy are being expressed.  There are very little data on this
subject, and until there is more information, the safest course is
for pregnant women not to dive.

   Diving can be a family sport, so it is necessary to decide at what
age children can begin.  Youngsters should be mature enough to
exercise reasonable judgment in difficult situations and have the
physical strength to help themselves or fellow divers.  Young
children should not be subjected to any harmful effects of diving on
growth.  Unfortunately there are too little data to make a scientific
determination of any of these factors.  Again prudence dictates a
conservative course.

   Stresses of Diving

   Although sport diving is supposed to be "fun," it is also
stressful, both physically and psychologically.  Physical stress
comes not only from the pressure and gas problems already mentioned,
but also from the occasional need to swim vigorously to overcome
current, ocean swells or surf.  Psychic stress due to unfamiliarity
with the environment and equipment, and the nervousness associated
with any new experience, is to be expected.  Divers who recognize
their unease are usually quite safe, while those who do not may try
to exceed their limitations.





   SCUBA - MEDICAL HAZARDS

   Benjamin H. Gorsky, M.D., Chief of Anesthesia, Shriners Hospital
for Crippled Children, Honolulu, Hawaii

   This article reviews the common medical hazards associated with
SCUBA--sinus and ear squeeze, motion sickness, lung collapse and air
embolism, nitrogen narcosis and decompression sickness. For general
information about diving and fitness for diving, please see "SCUBA -
GENERAL CONCEPTS."

   Sinus and Ear Squeeze

   Pressure itself has virtually no effect on the body; however, it
does affect the gases contained in body spaces.  The sinuses (so well
portrayed on TV commercials for cold and headache remedies) are
gas-containing spaces in the skull.  Each has an orifice or opening
through which gas enters and exits.  Similarly the eustachian tube
connects the gas-filled middle ear with the back of the throat.

   In healthy divers the passageways to the sinuses and ears are
open.  Since the SCUBA regulator matches breathing gas pressure to
the pressure under water (in order to make it possible to inhale
against the force of pressure at depth), the pressure on the inside
of these spaces remains equal to the (water) pressure on the outside.
 Unfortunately, allergies and viral infections often cause
inflammation and blockage of the delicate sinus passageways.  Ear or
sinus pain may occur if a sinus orifice or eustachian tube is
occluded when the individual is exposed to changes in pressure.

   Boyle's gas law states that pressure and volume are inversely
related: in other words, a volume of gas subject to a doubling of
pressure, must halve its size.  At a depth of 33 feet, gas which had
entered a sinus or the middle ear under one A of pressure at sea
level, is exposed to two A of pressure, twice the ambient pressure at
the surface.  Therefore, in order to satisfy Boyle's law, gas in the
enclosed space must shrink to one-half its original volume.  If the
sinus and middle ear passageways are blocked, the internal and
external pressures cannot be equalized, pain is immediate, and the
dive cannot be continued.

   The pain from a sinus or the middle ear trying to conform to
changes in pressure is known as sinus or middle ear squeeze. Novices
learn how to equalize internal and external pressures in diving
certification courses.  When the recommended procedures are followed,
sinus and ear squeeze is easily relieved.  For most divers this
problem is only a minor nuisance.

   Motion Sickness

   Many divers travel to dive sites by boat, and some are sensitive
to motion sickness.  Unfortunately there is no effective medication
which is safe for divers.  Drugs like dramamine all produce some
drowsiness which can make one too lethargic to dive safely.
Scopolamine sold as ear patches is effective but also dangerous.  It
dries secretions in the airways, can cause air to be trapped in the
lung, and thus may predispose to air embolism.  Furthermore, in some
people scopolomine produces behavioral changes and even brief
psychosis, clearly not safe side effects to have while diving.

   Lung Collapse & Air Embolism

   The effect of pressure on gas in the lungs is important because it
can be dangerous.  As the diver descends, the regulator provides air
at ever increasing pressure so that the diver can breathe--if this
were not done, inhalation against the force of water pressure on the
chest would be impossible.  As the diver ascends, gas in the lung
expands and must be exhaled or the lung will burst like a balloon.

   If a lung or even a very small portion of one should burst, the
escaping gas finds its way into the adjacent tissues.  Gas which
enters the space around the heart and major vessels in the chest
(pneumomediastinum) often escapes easily into the tissues of the neck
and face.  This is not always hazardous.  But gas which accumulates
in the space between the lung and chest wall (a pneumothorax) may
squeeze and collapse the lung, and make it impossible to breathe.

   The most serious complication occurs when air enters the
circulatory system.  Little bubbles of gas eventually lodge in blood
vessels and interrupt the flow of blood to various organs in the
body.  This process is called air embolization; the specific effect
of an embolus depends on which organ system is involved--e.g. the
brain, heart, etc.  Unconsciousness, paralysis or death can result.

   Although air embolism can occur at any depth, the risk is greatest
at shallow depths, since in water nearer the surface a given change
in depth produces a greater fractional pressure difference than the
same change in depth in deeper water.  In 33 feet of water, a 15 foot
ascent represents a 25 percent reduction in pressure.  At 99 feet one
would have to ascend 33 feet to attain a similar drop in pressure.
Because the fractional water pressure change is related to the
fractional volume change in the lung, physical stress on the lung is
greatest when ascending in shallow water.

   Divers can avoid air embolism and rupture of a lung while
ascending by breathing continously and never holding their breath or
shutting their airway (e.g. when clearing the ears or swallowing).
If divers take shallow rather than deep breaths with their airway
open, the lungs will never expand to full capacity, and so will not
burst.

   Nitrogen Narcosis

   Much is made of "raptures of the deep" or nitrogen narcosis in
popular novels.  And the problem does exist: nitrogen is narcotic
which becomes more potent with increasing depth.  But the effects are
not uniform.  Some divers are influenced more than others, and the
symptoms vary from dive to dive.  Divers should always be on guard
when breathing air (80% nitrogen) at depth.  The signs and symptoms
are insidious, like those of alcohol.  Generally they are not
appreciated by the individual at the time; a feeling of euphoria or
great well being--in spite of any real danger--is quite common.

   The Navy considers nitrogen narcosis to be a major factor a depths
below 120 feet.  Consequently, their divers breathe a mixture of
helium and oxygen on deeper dives.  Sport divers who limit their
dives to depths of 100 or 120 feet rarely, if ever, experience any
symptoms.  Those which are noted are mild.  The best advice for sport
divers is to limit depth, terminate the dive, and ascend to the
surface (in a controlled fashion) at any time a "funny" feeling
begins.

   Decompression Sickness
       (The "Bends")

   As a dive progresses nitrogen gas is dissolved in all tissues.
Those parts of the body which receive a lot of blood flow, such as
the major organs, absorb and eliminate nitrogen quickly, while
relatively bloodless tissues, such as fat, loose nitrogen very
slowly.  During ascent at the end of a dive, nitrogen dissolved in
the tissues is released.  If the ascent is rapid, such that the
ambient nitrogen pressure is permitted to fall precipitously,
nitrogen bubbles form in the tissues.  These bubbles are what
produces decompression sickness or the "bends."  The symptoms which
appear may be mild--itching in the skin or minor joint pain.  But if
the bubbles evolve in the brain or heart, they can be
life-threatening.  Unconsciousness or cardiac arrest requires
immediate resuscitation and recompression in a hyperbaric chamber.

   Studies have shown that body tissues completely eliminate their
nitrogen without medical complications if the ambient nitrogen
pressure is not permitted to drop suddenly by more than one-half.
The navies of the world have published tables which are based on this
principle.  The tables show the maximum time allowed at depth for
which direct ascent to the surface is safe. For example, the U.S.
Navy tables permit a stay of 30 minutes at 90 feet or 60 minutes at
60 feet without decompression.  If a dive exceeds this
"no-decompression" limit, the diver must stop the ascent at certain
depths for specified lengths of time in order to eliminate nitrogen
to a safe level before proceeding.

   Avoiding the "bends" is relatively simple.  In the first place
most sport divers do not carry out decompression dives; they stick to
the no decompression limits.  When deep dives are being contemplated,
however, the following guidelines seem reasonable:

   1) Adhere to the no decompression diving limits CONSERVATIVELY!
It is important to remember that data for the tables were derived
from young healthy men in excellent physical condition, and that the
tables do not predict all instances of difficulty.  Even when the
tables are followed, decompression sickness does occur on occasion.
The safety-minded sport diver should allow for a little leeway in the
tables to account for age, lack of excellent physical condition, and
to avoid ANY possibility of the "bends."

   2) Cut back one category on every dive.  If you are diving to 90
feet, limit the dive to 25 rather than the "recommended" 30 minutes.

   3) Consider the entire time under water, not the time from entry
to the start of ascent, as permitted in the tables.

   4) Make a safety stop: stop for two to three minutes at ten feet
on the first dive of the day, and longer on subsequent dives.  If
there are large waves, make the stop at fifteen feet so as not to
spend too much time in shallow water where pressure changes from
waves passing overhead are greatest.  As an added precaution stopping
time should be included in the total time of the dive.

   Recently many strategies have been mentioned by diving
organizations for "multi-level" diving.  The Navy tables are built on
the idea of a dive to a single depth.  Navy divers usually descend to
certain depth, complete their work, and ascend directly to the
surface at the end of the dive.  On the other hand sport divers
generally proceed to the deepest point of a given dive, spend some
time there, and then spend additional time at various shallower
depths during ascent.

   The standard tables assume that an entire dive takes place at the
deepest point.  Logic dictates that this is too stringent a limit
when sport divers DO spend time in shallower water.  Since some time
is spent in shallower water, it should be safe to increase the
duration the entire dive.  While this may be true, the question
becomes--by how much?  No one knows.

   Each of the methods which permits longer multi-level dives,
whether derived from the navy tables, built around different tables,
or dependent on a decompression meter is largely untested.  None has
been evaluated to the same extent as the Navy tables.  Sport diving
is supposed to be just that--a sport.  As a rule sport divers should
try to minimize risk, and not try to see how close they can slide to
disaster.

   Diving Safely

   Common sense, a good assessment of one's own physical and psychic
limits, knowledge about diving physiology, good training, and a
conservative approach combine to make diving a safe, enjoyable sport.
 Go get wet.