Beijing Paradise BBS Backup/PARADISE.ISO/software/BBSDOORW/MED3.ZIP/VDOC.DAT

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*I think I may be suffering from Anxiety...

   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.
!
*I think I may be suffering from 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.
!
*I have a problem with 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 cultural
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 other
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.
!
*I think I may be sufferig from 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.
!
*I may be suffering from a Personality Disorder...

   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.
!
*I think I may be a Manic Depressive...

   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.
!
*Could I have 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.
!
*I think I may have had a 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 caus 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.
!
*I have Tremors and may have Parkinson's Disease...

   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 (312)
664-2344.

   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
!
*I think I may have 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.
!
*I am suffering from Headaches...

    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.
!
*I suffer from Sizures and/or Epilepsy fits...

   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.
!
*I suffer from a Peripheral Nerve Disease...

or
        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.
!
*I have an unknown Neurological Disorder...

          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.
!
*I'm having trouble with 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.
!
*I may have 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.
!
*I have Dandruff... What Can I do?

   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.
!
*I may have 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.
!
*Do I have 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.
!
*I have a Fungal Skin Rash...

   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.
!
*What can I Do About 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.
!
*What can I do about 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.
!
*What can I do about 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.
!
*Do I have 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.
!
*What can I do about 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."
!
*What can I do about 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.
!
*How can I get rid of 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.
!
*I may have Vitiligo (pigment loss)...

   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.
!
*Do I have the Skin Disorder 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.
!
*Do I have the Skin Disorder 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.
!
*How do I cope with 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.
!
*How do I cure 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.
!
*What can I do about 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.
!
*Do I have Chronic Obstructive Pulmonary Disease?


   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.
!
*Do I have 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.
!
*Do I have 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.
!
*Help with 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.
!
*Can you tell me more about 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.
!
*Do I have 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.
!
*My Lung(s) have Collapsed...

   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.
!
*What can I do about 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.
!
*I suspect I may have Cystic Fibrosis...

   A genetic disease once the medical concern primarily of pediatricians, cystic
fibrosis now is seen by many internists and other adult-oriented doctors as
patients are surviving and even thriving into adulthood. In this disease, the
secretory glands, mostly those responsible for production of mucous secretions,
are affected, and this in turn affects the organs which rely on these secretions
for normal function.

   This is an inherited disease characterized as autosomal recessive; this means
that genes from both parents must be present in the child for the disease to
occur.  About 2 to 5% of the population carry one of the abnormal genes, and 1
birth in 2000 has the disease.  An ideal screening test for prospective parents
is not available at this time.

   The mechanism of disease is the presence of abnormal unusually thick mucous
which can clog the bronchi and lungs, leading to infection, collapse, and
scarring.  The other major site of damage is the digestive system, where the
pancreas may suffer congestion and eventual failure, and the liver may become
scarred (cirrhotic) as years of mucus plugging and bile passage blockage lead to
eventual failure of the liver. In the intestines, the abnormal secretions may
cause obstruction of the small intestine. Respiratory sinuses may become plugged
and chronically infected.

    SYMPTOMS

   Almost all patients are diagnosed in childhood.  The earliest symptom
sometimes occurs in infancy as intestinal blockage from a mass of digestive
matter and the abnormally viscous mucus.  Many children go on to develop
repeated infections of the lungs and bronchi, some of which cause progressive
loss of some lung function on a permanent basis. Liver failure may occur in
childhood, and is a worrisome finding.  Inadequate pancreatic function leads to
malabsorption (see digestive disease section) which may lead to malnutrition,
diarrhea, and abdominal pain. The coughing up of blood may occur, separate from
the occurrence of pulmonary infections.

    DIAGNOSIS

   The occurrence of lung problems and pancreatic failure in a young child
suggest the diagnosis very strongly.  The confirmatory test is an analysis of
the chemical content of perspiration, which is stimulated with a device using a
gentle electrical stimnulus. If this test is positive in the proper setting, the
diagnosis is secure.  Occasionally the results are equivocal, especially in
older children and adults, and further analysis of digestive fluid and
pancreatic function may be helpful.

    TREATMENT

   No treatment exists to reverse the underlying abnormal mucus production.
However, treatment of complications has totally changed the approach to this
disease in the last 20 years. Rigorous programs to promote lung drainage include
gentle clapping of the back while the patient assumes various positions to
promote each area of both lungs to drain.  The inhalation of a drug called
acetylcysteine is said to liquify mucus and thereby promote drainage.  These
measures become a part of life for many patients.   When respiratory infections
do occur, early and aggressive antibiotic treatment is given.  Patients and
family are trained to recognize the earliest signs of such infections.

   The pancreas failure may be treated by ingesting replacement enzymes, and by
dietary measures which minimize the need for pancreatic secretions. Supportive
measures are instituted for cirrhosis as discussed for that disease elsewhere in
HealthNet. Digestive blockage is hopefully detected early and treated either
medically or surgically when necessary.

   A comprehensive approach is coordinated by the physician using a wide range
of resources in the community and hospital. Psychological and emotional support
play an important role for the involved families, and contribute much toward
quality of life.

    PROGNOSIS

   With measures such as those mentioned above, this disease has evolved from
one of fatal outcome in childhood for virtually all patients to one of hope for
high quality survival into adulthood.
 Exact figures are difficult to ascertain, but one estimate is that there are
currently some 50,000 adults with cystic fibrosis in the U.S. today, with the
expectation that the numbers will continually increase.  While still a serious
disease with a major impact on the lives it touches, and while it still
mercilessly takes the lives of so many so young, cystic fibrosis is slowly
yielding to modern management.
!
*I suffer from Sleep Apnea...

   For generations, keen observers have noted certain individuals, usually
massively obese, who seemed continuously sleepy, who snored impressively, and
who seemed almost hopelessly slothful.  Pickwick in Charles Dickens writings is
one such example.  It is likely that most such characters suffered from what
would today be called the Sleep Apnea Syndrome.

   Obviously, breathing must be an automatic phenomenon; yet control of
breathing must be carefully regulated if normal levels of oxygen and carbon
dioxide are to be maintained during such widely different states as sleep and
strenuous exertion.  This is accomplished through a series of sensors and
control centers in the blood vessels, brain, and organs of respiration.  Aside
from external factors which can disrupt this control (drugs in particular),
there are some natural diseases which cause chaos in what we so often take for
granted.  Most of these become evident during sleep most often, since this is
when conscious input is least able to compensate for any problems in the
automatic component of breathing.

    SYMPTOMS

   Certain symptoms typical of all of the sleep apnea syndromes include daytime
somnolence due to disturbed sleep.  Sleep is continuously interrupted by
dangerously low oxygen levels, loud forceful snoring during recovery from
repeated periods of cessation of breathing (apnea means absence of breathing),
and sometimes by heart irregularities brought about by the low oxygen levels.
Headaches in the morning are common.  Progressive swelling of the ankles and
feet may be noted if heart failure is present, as it occasionally is from the
constant strain on the heart due to low oxygen levels, constricted pulmonary
vessels, and other factors.

    TYPES OF SYNDROMES

PICKWICKIAN SYNDROME--The combination of massive obesity with decreased
sensitivity of the  brain to abnormal levels of oxygen and carbon dioxide in the
blood cause this syndrome. Weight loss (often achieved only with great
difficulty) clears the problem, but the stress of the obesity seems to be the
straw that breaks the camel's back.  Even when weight is normalized, careful
testing can reveal the under lying brain abnormality.

OBSTRUCTIVE--In these usually obese patients, the excessive weight, loss of
muscle tone during sleep, and uncoordinated upper airway muscles lead to
blockage of the area around the back of the throat which at times totally blocks
the flow of air.  As breathing ceases, progressively greater respiratory force
is generated as the oxygen levels fall; finally a thunderous snore overcomes the
resistance, and the cycle starts again.  Males seem more prone to this.

NEUROGENIC--These patients are similar to the Pickwickian patients described
earlier, except that obesity need not be present.  In the extreme case the term
Ondine's Curse has been used: patients simply must remember to breathe, and with
the onset of sleep or sdatin, death may occr unless measures are instituted to
prevent this.

    DIAGNOSIS

   It is surprisingly difficult to diagnose these syndromes by history alone,
since the common symptoms of fatigue, headache, and obesity are most often due
to other causes.  Nonetheless a clue should be sought, especially from family
who might remark on the excessive snoring or restlessness.  If the diagnosis is
thought of, confirmation requires extensive testing called polysomnography. The
patient enters a SLeep Laboratory for a couple of nights, and is monitored for
blood testing, EKG, brain waves, eye movement, and respiratory pattern during
sleep.  Where such a facility is not available, the observation will at least
include careful nursing observation and monitoring of respiratory pattern and
blood oxygen during sleep.

    TREATMENT

   Weight loss is critical, if difficult. In obstructive types, a tracheostomy
which can be closed during the day, will bypass the site of obstruction and can
be life saving; lesser procedures such as removal of the uvula are sometimes
adequate.  Some centers use a gentle air pumping apparatus applied to the nose
to help overcome the pressure in the throat in such patients, but this is not
widely applied.

   Protryptilline, acetazolamide, progesterone, and other medications which
either stimulate respiration, alter metabolism, or work by unknown mechanisms
have been used with variable success.  Sedation of all types is to be avoided.

   Increasingly, physicians are turning to specialized sleep disorder facilities
to aid in the management of these patients. It seems reasonable to consider
referral to one of these centers if the diagnosis is in question or if the
results of treatment are disappointing. Neurologists are the usual resource for
information about this set of diseases.
!
*What are the risk of Occupational Lung Disease?

   Occupational exposures account for a large number of lung diseases;  this is
not surprising when one considers how vulnerable the lungs are to such toxins.
Unlike the skin, the lungs must allow the air to come into intimate contact with
delicate tissues in order to perform its basic functions. Any protective
"coating" would interfere with this function.

  Most occupational lung diseases are similar in symptoms to either asthma or to
asbestosis of the lungs (not the pleural type), and their individual symptoms,
diagnosis and treatment will not be outlined in this discussion, since such
information is found under the above two sections. Rather this section will
provide an overview of some of the commoner syndromes.

   Diagnosis of these syndromes is often like detective work.  A very detailed
job history with some knowledge of the special products used in each job is
essential.  Since few of the syndromes have aspects which are characteristic or
unique, one is dependent on the association of the symptoms with the exposure,
either acutely or chronically. Smoking aggravates virtually all of these
syndromes; discontinuation of cigarettes and avoidance of the substance are the
obvious main therapeutic principles. Details of treatment are, as noted,
discussed elsewhere.

ASTHMA-LIKE SYNDROMES--CAUSES

Animal dander as in agricultural or pet care professions.

Psyllium (Metamucil)

Castor Oil Beans

Grain products

Cotton

Organic Solvents

Cedar Dust

Fumes from meat wrapping

Gasoline exhaust

Food Dyes

Tobacco products

   This list is far from inclusive and any time asthma symptoms seem related to
occupational exposures, a vigorous search should be made for possible offending
agents.

SCARRING TYPE SYNDROMES

   Like asbestos, many other substance in the work palace can cause scarring of
the lungs. The reader is referred to the section on asbestosis which relates to
the lung involvement from this substance for details of symptoms and treatment.
It is important to note that the pleural disease of asbestos, both benign and
malignant, is unique to that substance, and does not apply to the substances
discussed below.  Furthermore, many of the substances below cause a much milder
syndrome and may even cause no symptoms at all unless the patient is a cigarette
smoker as well. CAUSES

graphite

aluminum

silica

talc

asbestosis

cobalt

tungsten

ALLERGIC PNEUMONIA SYNDROMES

  Some substance induce an allergic reaction in some patients which cause a
pneumonia-like syndrome with fluid in the lungs, sometimes with fever, shortness
of breath, and low oxygen levels.
 Usually this occurs within hours of exposure, and the x-ray may show what
appears to be pneumonia. Treatment with steroids or simple rest and oxygen if
necessary are all that is necessary for most patients, though some require
intensive support.  Repeated exposures can cause progressive, irreversible and
even fatal lung scarring.

CAUSES

Molds

Bird droppings

Detergents

Wood dust (various types)

Tea

Wheat

Mushrooms

Mold in Humidifiers

Fur

Paper products

Coffee

Corn Dust

   This list is not inclusive, and any disease apparently related to
occupational exposures should be thoroughly investigated for possible offending
agents.

SUMMARY

   The work place may be hazardous to health, and it is fortunate that agencies
such the National Institute for Occupational Safety and Health have begun to
establish standards for some of the more obvious hazards.  Nonetheless, many
agents affect only some individuals, and many others are not adequately
controlled in all industrial settings.  From a health standpoint, otherwise
unexplained illness of the lungs in particular should be evaluated as to its
relationship to the patient's occupations, past and present.  An astute
physician and patient together can sometimes detect such hazards and remove them
before serious illness occurs.
!
*Can you tell me about Coronary Artery Disease...

    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.
!
*I suspect I have a Blood Clot...

   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 ay
uffer 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.
!
*What can I do About 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.
!
*What happens if I have 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.
!
*I have an abnormal heartbeat...

    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.
!
*What is 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.
!
*What is 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.
!
*Do I have a Heart Murmur?

   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.
!
*What is 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.

*What is 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

*What is 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.
!
*Do I have 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.
!
*Do I have an 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.
!
*What is 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.
!
*What is Pericarditis?

   The pericardium is a sac-like structure surrounding the heart. Like any other
organ it is subject to a variety of diseases, including infections, inflammation
and injury. Because of its location and nerve supply, pain from the pericardium
can closely mimic heart pain, and for this reason, it often presents as a
frightening syndrome.

   Acute Pericarditis

   The commonest type of pericarditis is the so-called benign variety.  In
essence, this is of unknown cause, although viruses and autoimmune mechanisms
probably play a role in many cases. Young adults are most commonly affected, but
no age group is immune.

   Typically, the patient recalls a cold or the "flu" a week or two before;  the
disease may begin with a vague sense of being ill at ease, rapid heart beat and
fever.  Chest pain may be severe, and is often very severe, sharp, burning or
aching. Often position changes also alter the pain.  Many patients experience
some relief when sitting up.

   The physician may frequently hear a rubbing sound around the heart, and the
electrocardiogram usually shows some abnormalities.  Unfortunately, many cases
do not present in the classical manner, and often the differential diagnosis
includes heart attack, aortic aneurysm, pneumonia, pancreatitis, and other
serious diseases.

   A complication of pericarditis is the collection of excess amounts of fluid
within the pericardial sac around the heart: pericardial effusion.  When mild
this causes no harm, and may be very useful diagnostically.  However, when it
increases, it can put tremendous amounts of pressure on the heart, even reducing
its output to dangerously low or fatal levels; this is known as pericardial
tamponade.

   Once observation, blood tests, electrocardiograms, and other tests have
confirmed the diagnosis, the task remains to find out what is causing it.  In
addition to the unknown cause variety, other possibilities include bacterial
infection, tuberculosis, recent true heart attack, viruses, and even fungi.
Some autoimmune diseases and forms of internal arthritis can cause pericarditis,
including lupus, rheumatoid arthritis, and allergic diseases.  Kidney or thyroid
failure, and radiation exposure are rarer possibilities.

    Treatment

   Naturally, if an infection is diagnosed, therapy is aimed at the offending
germ.  In the typical benign variety, symptom relief is the goal, and aspirin or
other anti-inflammatory drugs are the primary agents.  Rest is often advised,
and the syndrome usually resolves spontaneously within weeks.  Careful lookout
for the formation of an increasing effusion is important, and if any question
lingers about either the diagnosis or the status of the heart, a needle may be
passed through the chest wall, and fluid withdrawn for laboratory analysis.

    Prognosis

   The infectious varieties are serious, but often treatable if diagnosed early.
Prognosis depends on individual factors, and generalizations are meaningless.
For the common benign variety, the prognosis is very good for complete recovery.

   An occasional complication of all forms, but particularly the infectious
types, is the formation of scar tissue with or without chronic fluid
accumulations.  This can lead to symptoms identical to congestive heart failure,
with the important difference that by surgically removing the diseased
pericardium, one can often resolve the problem.
!
*Just what is Myocarditis and Cardiomyopathy?

   Myocarditis is an inflammation of the heart wall muscle itself, as opposed to
the lack of blood supply to the muscle as seen in heart attack and coronary
disease.  Like pericarditis, it can have many causes, some of which are quite
unusual--diphtheria, toxoplasmosis, and trichinosis to name a few.  For the most
part, however, the common variety is caused by a virus, often the so-called
coxsackie virus which causes certain respiratory infections as well.

   If the immune system eliminates the infection readily, which is the usual
case, the patient may never know that the disease was present, or else he or she
may assume that it was just the "flu."  On occasion, though, the inflammation
heals with abundant scar tissue or fibrosis, which replaces the normal
contractile heart muscle cells.  The result is that the heart loses its pumping
ability, leading to heart failure, which is discussed elsewhere.

   Many of the young patients undergoing the widely publicized heart transplant
operation have such heart failure.  It is irreversible, and the surrounding
vessels are generally healthy. Although medications can be temporarily helpful,
severe cases are virtually hopeless.  This is why interest in the procedure
persists, and why the patients are willing to subject themselves to the grueling
ordeal

   Certain other types of cardiomyopathy (this refers to the heart muscle
weakened by myocarditis or other cause) are recognized.  There is a familial
type, a congenital variety effecting children, and a rare variety somehow
precipitated by pregnancy.  The latter often stabilizes with prolonged bed rest.
One of the most commo causes is the direct toxic effect of alcohol in large and
prolonged exposures.  Finally, a variation in which only a part of the heart,
the internal wall or septum, is affected is known. It is important because it
can be treated with either medications or surgery in severe cases; this is known
as "asymmetric septal hypertrophy" or "idiopathic hypertrophic subaortic
stenosis (IHSS)."

   Any young person who develops congestive heart failure without an obvious
cause, such as high blood pressure or known valve or coronary disease, should be
evaluated for the various cardiomyopathies.  They are rare, but devastating at
times. Accurate diagnosis can identify the minority of causes which are
treatable, and establish a prognostic basis for future recommendations.
!
*My lower stomach hurts on the right side...

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.
!
*What is 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.
!
*I suspect I have 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.
!
*Tell me about 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.
!
*I'm having burning sensations in my stomach...

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.
!
*Do I have 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.
!
*Ouch! What can I do about Hemorrhoids?

Hemorrhoids (or "piles") refer to veins in the anal area which become enlarged
or otherwise troublesome.  Everyone is born with these veins, which may enlarge
and be bothersome as early as the mid-teens, in middle age, in the elderly, or
not at all.  The cause of this enlargement is not precisely known; heredity
plays a part, as does chronic constipation and sitting on the toilet for
prolonged periods.  Pregnancy may cause temporary problems, more commonly in the
last three months, or for a few days or weeks after delivery, but only rarely
does this result in chronic problems.  Prolonged lifting and straining at work,
prolonged sitting, sitting on a cold log while hunting, or sitting on cold
concrete are NOT associated with the development of hemorrhoid symptoms.  Most
often, hemorrhoids bother people for unknown reasons.

SYMPTOMS

There are two types of hemorrhoids: internal hemorrhoids and external
hemorrhoids.  External hemorrhoids are veins under the skin around the outside
of the anus.  There are generally three of these, located in the middle of the
left side, the front of the right side, and the back of the right side.  These
only bother people if the veins develop small blood clots, called thrombosis,
which can be painful.  Occasionally, the  swelling caused by the blood clot is
enough to burst through the skin, causing a small amount of bleeding for a few
days, until the blood clot disappears on its own.  This is not dangerous, but
may be frightening.  Internal hemorrhoids are much more common, and are enlarged
veins under the lining of the lower rectum.  This lining is moist, like the
lining of one mouth, unlike the relatively tough skin covering the outside
hemorrhoids. Like the external hemorrhoids, there are three of these also,
located in the same basic areas as the external variety.  Internal hemorrhoids
cause only two symptoms: protrusion (sticking out of the anus) and/or bleeding .
They do NOT cause pain, itching, or burning.

DIAGNOSIS

While everyone may be said to have hemorrhoids, only those which bother people
generally bring one to a physician.  Outside hemorrhoids may appear as soft,
painless skin tags of various sizes when not clotted or thrombosed.  When
thrombosed, they are swollen and painful, and may have a dark bluish
discoloration. Internal hemorrhoids can only be seen externally when they
prolapse out of the anus, and appear as moist areas, pinker or redder than the
surrounding skin.  By using an instrument called an anoscope, a physician can
examine the inside of the anus and lower rectum where internal hemorrhoids
originate, and see those which are not so large as to come all the way out of
the anus.

TREATMENT

Outside (external) hemorrhoids which become thrombosed always get better by
themselves; this may take a few days to a month, and soaking in warm water (sitz
baths) both diminishes pain somewhat and accelerates healing.  Creams,
ointments, suppositories, or medicated pads do nothing to hasten the process,
since the skin overlying the hemorrhoid is intact, and is not penetrated by
these substances.  If pain is severe, the hemorrhoid can usually be surgically
removed using local anesthesia in a doctor's office or emergency room, with
rapid relief of swelling and pain.  This technique also generally keeps the
problem from recurring, at least in the particular hemorrhoid which has
developed the blood clot.  Internal hemorrhoids can also usually be treated with
simple office techniques.  With hemorrhoids which bleed but do not stick out,
injection of the tissue with a substance to scar the inside of the hemorrhoidal
vein is often effective, and usually painless.  For somewhat larger internal
hemorrhoids, the application of tiny rubber bands around the base of the
hemorrhoid causes the hemorrhoid to shrivel and disappear.  Since internal
hemorrhoids are not sensitive to pain, this technique too is generally painless.
Other office treatment methods include freezing or cauterizing the tissue.  When
both internal and external hemorrhoids are present, and are large and
bothersome, surgical removal in the operating room may be the only way to
adequately remove them.  When this is necessary, the procedure can usually be
done with a regional anesthetic, numbing only the portion of the body necessary
to do the surgery, and often does not require an overnight stay in the hospital.
The recovery is somewhat uncomfortable for a few days, but only 1-2% of patients
treated in this manner have any further trouble with hemorrhoids throughout
their lifetime.

SUMMARY

Most cases of hemorrhoids can be approached with the simpler office techniques
as outlined above.  At least initially, all cases should be diagnosed by a
physician, so that other more serious diseases may be ruled out.
!
*I have anal pain...

There are four primary causes of anal pain: thrombosed external hemorrhoids,
anal fissures, anal abscesses, and levator syndrome. The latter is often
difficult to diagnose and is most commonly experienced as a dull, aching pain in
and around the anus, often involving the tailbone.  The pain associated with
levator syndrome typically comes on after prolonged sitting, and is made better
by getting up and walking around.  The pain may also awaken people from sleep,
and take 5 or 10 minutes to improve with various maneuvers.  A variant of this
condition is called proctalgia fugax, or fleeting pain in the rectum, and may be
a sharp, sudden pain lasting only a few seconds.   Levator syndrome is named for
the levator ani muscle, the large funnel-shaped muscle which forms the floor of
the pelvis.  The inner portion of this muscle attaches to the tip of the coccyx,
or tailbone.  The condition was known for many years as coccygodynia, or pain in
the tailbone, on the assumption that the origin of the pain was the bone itself;
it is now believed that the cause of the pain is spasms of the levator muscle,
which can be particularly noticeable where the muscle attaches to the tailbone.
The cause of such spasms is not known, though some attribute it to poor posture,
and others relate it to stress in general, which is known to cause tightening of
many other body muscles as well.

A thorough examination by a competent physician is important to be sure of the
diagnosis, and to rule out other, more serious conditions which may rarely be
confused with one of the 4 conditions listed above. First, often simply knowing
the cause of the discomfort is often reassuring, and helps to make the pain less
bothersome.  Once the diagnosis is confirmed, there are several ways to improve
this condition.  Unfortunately, muscle relaxants and other medications have
generally not been effective.  Vigorous massage of the muscle by the physician
in the office, electrogalvanic stimulation (a physical therapy technique),
biofeedback, acupuncture, and massage of the muscle in the operating room, with
the patient under an anesthetic, have each been associated with improvement in
30-90% of patients.  One or more of these treatments may need to be considered
to obtain complete relief.
!
*I have Anal Itching...

Itchy skin around the anus, also called pruritis ani, is a minor nuisance for
which no definite is usually found.  An initial minor irritation is often
magnified by scratching, and then usually by vigorous attempts to wash the area
with soap in the belief that poor hygeine is the cause.  Moisture around the
anus is sometimes a factor as well, which may be from sweating, from loose bowel
movements, or from the indiscriminate use of creams or ointments.  Treatment
consists of three things:  first, avoidance of soap, scratching, scrubbing, and
other irritants. Even dry toilet paper is sometimes abrasive enough the keep the
irritation going.  Second, the application of a very small amount of cream
containing 1% hydrocortisone to the area around the anus aids healing.  This
should be rubbed gently into the skin so that no moisture remains.  Third, a
small amount of either cotton or corn starch should be placed in the anal area
and left there, in order to absorb excess moisture.  This treatment program is
successful in about 95% of cases within only a few days. Persistence of the
itching after 3 or 4 weeks should be evaluated by a physician.
!
*I'm having trouble with my bowels...

    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.
!
*What is 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.
!
*What is 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.
!
*I have a Lactase Deficieny...

   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.
!
*Do I have 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.
!
*What is 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.
!
*Tell me about 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.
!
*What is Nephritis?

   The term nephritis is not a precise medical term although it has been used
for years in the non-technical vocabulary.  The term which applies more
accurately to this discussion is glomerulonephritis; this refers to inflammatory
diseases of the functioning units (glomeruli) of the kidneys.  Excluded from
this topic is the entity of pyelonephritis--kidney infection--which is dealt
with in the infectious disease section.

   The glomeruli are units in the kidneys comprised of several distinct parts,
each with its own job to do.  The total function is highly complex, and can be
reviewed in the discussion on kidney failure. Because of their capacity to
filter and concentrate certain substances in the blood, the glomeruli are
especially susceptible to certain injuries. For example, internal allergic
reactions aimed at the glomeruli are seen in hepatitis, strep infections of the
throat and skin, and other diseases. Some of these disorders are discussed in
the following sections.

   The primary functions of the glomeruli which come to the patient's attention
in the course of these diseases are control of body water volume, and retention
of the protein and red cell components of blood as it is filtered into urine.

    CAUSES AND MECHANISMS
   Post-infection--some types of bacteria, notably some strains of streptococcus
(group A beta hemolytic) elicit an immune reaction in the body weeks after
infection.  These antibodies are aimed at the infecting organism, but apparently
that target immunologically resembles certain tissues in the glomerulus.  The
net result is that the glomerulus gets damaged by the body's own defenses, as an
innocent bystander.  Children seem more susceptible to this than do adults.

   Vasculitis--some diseases of blood vessels seem to affect the kidneys
frequently.  These include lupus, and polyarteritis. Acute glomerulonephritis is
the frequent result.

   Idiopathic--a wide variety of other disorders can cause this disease, and
although the various types have been precisely classified in a diagnostic and
pathologic sense, their root cause is unknown. These include membranous
glomerulonephritis,  IgA nephropathy, Goodpasture's syndrome (with lung
involvement as a rule), and hemolytic-uremic syndrome (with platelets and red
cells involved).

    SYMPTOMS

  If detected by chance early in the course, the only finding may be an abnormal
urinalysis, with red blood cells and excess protein in the urine.  As the
syndromes progress, the blood becomes visible, and fluid retention causes ankle
swelling and weight gain.  The blood pressure rises sometimes to alarming
levels.  Blood tests confirm abnormal levels of parameters of kidney function.
In some cases, so much blood protein leaks out in the urine that a form of
protein malnutrition occurs.  Any number of diffuse symptoms may be noted by the
patient, including weakness, nausea, and headache.

    DIAGNOSIS

   It is usually the urinalysis which reveals the diagnosis, with so-called red
cell "casts" seen under the microscope. History of previous strep infection is
important. Additional efforts are aimed at classifying the disease, since
treatment and prognosis may vary considerably.  The blood tests, pressure
readings and general exam will determine the extent of involvement and
complications.  Depending on a number of individual factors, it may be advisable
to perform a needle biopsy of the kidneys to help classify the type of
glomerulonephritis in question.

    TREATMENT & PROGNOSIS

   General measures to reduce the excessive fluid with salt and water
restriction, and with diuretic medications are useful in most cases.  Specific
treatments of some common types are as follows:

Post-infectious--There is no specific treatment for this variety, although the
supportive measures above can reduce complications and enhance patient comfort
as the disease runs its course.  In children and in most adults, the prognosis
is quite good for complete clinical recovery over weeks or months, although
kidney biopsy research has shown that over half of patients do have some
residual permanent kidney damage of which they are usually unaware.

Membranous Glomerulonephritis-- usually affecting young children, this type of
nephritis is sometimes treated with steroid drugs and/or drugs which reduce the
platelet plugging that sometimes occurs in the vessels of the kidneys during the
course of the disease. Unfortunately most patients go on to develop some degree
of chronic renal failure, despite treatment.  This may be quite gradual, and
stabilization is possible at any point.

   Goodpastures and other forms of rapidly progressive glomerulonephritis have
responded to cortisone-like drugs and immunosuppressive agents used in cancer
therapy. Untreated, the prognosis is poor for eventual severe renal failure, so
that intensive and sometimes dangerous drug regimens are used.  A more recent
modality useful in selected cases is that of plasmapheresis in which the
patient's plasma is removed and that of donors is transfused in by a specialized
process, while leaving other blood components intact.  Scientific study of this
form of therapy is underway, but it may hold great promise.

   Therapy and diagnosis of the latter entities is a highly specialized affair,
and often left to nephrologists in referral centers.
!
*What is 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.
!
*What is 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.
!
*Tell me about Hydrocoele and 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.
!
*What can I do about The Common Cold

   The so-called common cold is actually a collection of similar diseases
affecting the lining tissue of the nose, throat, and upper airways including the
trachea and larynx (vocal cords). Many viruses can cause a cold and among the
most common are rhinoviruses, coronavirus, and adenovirus.  The average number
of colds per year varies from around three for most adults to eight or more for
young children in group settings; their mothers may have a similar number.

   The symptoms of a common cold require little elaboration.  The most common
include sneezing, nasal discharge and blockage, cough, sore throat, hoarseness,
and a sense of pressure around the nose, ears, and eyes. Notably absent with a
cold is a fever which, if present at all is rarely more than one degree above
the usual 98.6 degrees Fahrenheit (rectal).  Higher fevers should prompt a
search for complications.

   The incubation period of most of the viruses is 2 or 3 days, and
contagiousness correlates roughly with the degree of symptoms.  In general the
symptom intensity peaks at 3 or 4 days, and the syndrome resolves within a week
or two. Complications are common, and are discussed below; they are generally
caused by bacteria which invade the already inflamed tissues caused by the cold
virus.

 Diagnosis

   The history and findings are so common as to be almost diagnostic.  In
severely symptomatic patients, a search for possible bacterial complications
will include examinations of the ears, sinuses, throat and lungs.  Some
authorities feel that every sore throat should be cultured to look for strep
throat. If a bacterial complication is suspected, appropriate x-rays may be
necessary.

 Treatment

   Viruses are unaffected by the usual antibiotics including penicillin.  Thus
treatment is largely symptomatic.  Some common remedies include the following:

   Sore throat--ice chips, mild anesthetic lozenges, aspirin and acetaminophen,
mild salt water gargles to cleanse mucus from the area, and anesthetic solutions
(these may depress the swallowing reflex and should only be used under a
doctor's supervision if at all).

   Stuffed Nose--nasal sprays for no more than 2 or 3 days, such as
oxymetazoline and xylometazoline, or phenylephrine; oral decongestants such as
phenylpropanolamine or pseudoephedrine are of unproven benefit, but some people
experience relief with them; antihistamines alone or with decongestants are
probably best avoided since they do little except dry out secretions. They
regularly cause drowsiness. Nonetheless, some people find them helpful when
discharge is copious.

   General--aspirin or acetaminophen can be useful for achiness or pain.
Vitamin C has no proven benefit, although the placebo (psychologic) effect is
considerable in some. Rest, plenty of fluids, and avoidance of high personal
contact situations are all prudent.

           Prevention

   No vaccine is likely in view of the many different viruses involved.  Vitamin
C has been shown to be ineffective. Some interesting and promising results in
reducing spread of cold has been noted with specially treated tissues, but the
importance of this is not clear at present.

         COMPLICATIONS

   When the upper respiratory tissues are prevented from draining mucus and air
normally by a cold-related swelling and inflammation, the bacteria normally
present in small numbers may cause infection of a more serious nature. Some of
these are:

# Earache (otitis media)--the middle ear cavity fills with pus, causing pain,
decreased hearing, fever, and even rupture with permanent hearing loss.
Antibiotic treatment, often with amoxicillin, ampicillin, penicillin,
erythromycin or Bactrim is usually curative. Physician management is crucial for
any earache.

# Sinusitis--the boney cavities around the nose can be blocked and fill with pus
much like the middle ear.  Pain around the eyes, cheeks, upper teeth, and nose
can result, sometimes with a bloody or pus-like nasal discharge.  Fever is
common. Antibiotic treatment as for earache is usually curative. Severe or
resistant cases may require a drainage operation to relieve the pressure.

# Strep throat--occurring either alone or with a viral cold can cause severe
throat symptoms, but more importantly can lead to rheumatic fever and heart
disease (see Heart Valve diseases) or to glomerulonephritis (see kidney-
nephritis section).  The only accurate way to rule this out is with a cotton
swab culture of the throat, although it is usually negative with routine sore
throats.

# Laryngitis--hoarseness is the primary symptom.  This occurs from swelling and
mucus collections on the vocal cords. Rarely is specific treatment helpful other
than humidity, voice rest (whispering does not rest the cords).  Occasionally
germs called mycoplasma can cause this and will respond to antibiotics.  In
persistent cases, this may be used.  Any hoarseness for more than 2 weeks
warrants a physician exam to rule out cancer and polyps.

# Bronchitis--often in smokers, but occasionally in nonsmokers, a cold leads to
bacterial overgrowth in the upper airways of the lungs.  When this occurs,
sputum production increases and a cough which brings up large amounts of green,
yellow, gray, or otherwise colored sputum is noted.  Antibiotics are used to
treat this.  Clear, white or moderate amounts of sputum are usually just from
the cold itself.  A physician evaluation is important to distinguish bronchitis
from pneumonia.

# Conjunctivitis (pink eye)-- occurring alone or with a cold usually manifests
as redness of the eye with a yellow discharge which typically pastes the lids
together upon awakening. Physician evaluation is advised to rule out other eye
diseases, and treatment is by eye drops or ointments containing antibiotics.

 SUMMARY

    The common cold is a syndrome of considerable prevalence and importance in
that it causes much time lost from work, annoying symptoms, and occasional more
serious complications.  However, it is self-limited, almost never serious or
life-threatening in otherwise healthy people, and rarely highly disabling.  Thus
the ancient caution "first do no harm" in medicine applies strongly. Treatment
should be minimal or not given in most cases, and complications should be
generally managed under a physician's care.
!
*I might have Pneumonia...

   Pneumonia refers to infections of the air sacs or alveoli of the lungs, as
opposed to the airways, bronchi, or upper respiratory structures. As such
pneumonia is always a disease to be taken seriously, and can be
life-threatening. Since oxygen enters the blood through the alveoli, when these
sacs are filled with pus or fluid they can no longer participate in oxygen
exchange, and blood oxygen levels fall. Furthermore, bacteria in the lungs are
prone to enter the blood itself, causing "blood poisoning" and other
complications.

   Pneumonia can occur as a primary disease or it can occur in someone in the
midst of a cold or other viral infection which interferes with the body's
ability to protect the lungs from invasion by bacteria.  It is the primary cause
of death from infections in the U.S.  Of all causes of death it ranks fifth.
Over three million cases occur each year.  Like every infection, there are many
different varieties depending on the causative germ.  Some of the more common
specific types are discussed below, but many aspects are common to most types.

 General Symptoms

   Most patients with pneumonia develop fever either with or without chills.
Rigors are chills which are especially severe and abrupt, and are seen most
often with bacterial pneumonia as mentioned below.  A cough is usual, and may be
productive of sputum which is thick, yellow or green, and may sometimes be
blood-tinged. Chest pain is common and typically gets worse with deep breathing,
so-called pleuritic chest pain.

   Other common symptoms include shortness of breath first on exertion, later at
rest. General feelings of discomfort, fatigue, and restlessness are seen.  Some
types of pneumonia cause digestive symptoms, confusion.  Often these can provide
diagnostic clues since some symptoms are more common with some germs than with
others.

 Diagnosis

   On exam the lungs usually sound abnormal through the stethoscope in the
involved area.  Unusual crackling sounds, dullness when the examiner taps on the
back over the lung, and changes in the sound of the spoken word as heard through
the stethoscope are common.  Once suspected, pneumonia is confirmed by a chest
x-ray.  The shadows are often characteristic enough to be diagnostically
helpful.  Having diagnosed the pneumonia, the physician will usually attempt to
find out the causative germ, usually by obtaining a sample of sputum. Often
there may be no sputum produced, and the blood may be cultured as well.
Depending on how critically ill the patient is, treatment may be started based
on an educated guess, or further tests may be needed to find the cause.
Bronchoscopy (passing a viewing/sampling instrument into the airways of the
lung) and other procedures are used selectively.

   Treatment

   General measures include intravenous fluids for patients who may have become
dehydrated, oxygen if the blood oxygen is low, and comfort measures including
anti-fever and pain medicines.  In severe cases, ventilator and artificial
breathing measures may be required.

   Specific Common Pneumonias

  Pneumococcal--this is the commonest of the bacterial pneumonias, and is
characterized by sudden onset, severe illness, chills, and high fever in most
cases.  Confusion or even delirium are not rare, and chest pain may be severe.
Copious pus-filled sputum often with blood is typical.  Up to 10% of victims may
die even with treatment, but these are often people who are debilitated or have
chronic lung diseases to begin with. Penicillin is the treatment of choice, or
erythromycin if allergy is present.  Most patients require hospitalization, but
treatment is highly successful for most strains of the germ.

  Viruses--the viruses of influenza, chicken pox, measles, and other diseases
can occasionally cause pneumonia, though these are less common than other types.
They may be quite severe and standard antibiotics are ineffective. Thus
supportive care may be all one can do until the body has enough time to develop
an immune response to the virus.

  Atypical Pneumonia--sometimes called "walking pneumonia" this group is causes
by a group of germs called mycoplasma.  It is the most common pneumonia in
people under age 40, and may cause serious illness although it is rarely fatal.
Headache, fever, a severe dry cough, and chest pain are common. Treatment can
often be given at home, and erythromycin and tetracycline are common effective
antibiotics.

  Legionnaire's Disease--well- publicized in recent years the bacteria causing
this disease has been well described.  The disease varies from minimal to
severe, and typical cases are accompanied by confusion, blood test abnormalities
of liver function, and blood in the urine.  Digestive symptoms may occur as
well. Spread is commonly from contaminated water in cooling systems, and person-
to-person spread seems unusual. Erythromycin is the usual treatment.

   Virtually all cases of pneumonia should be followed closely, and should not
be presumed cured unless a chest x- ray after a month or so is back to normal.
It is the joint responsibility of patient and physician to assure careful
adherence to the prescribed regimen and follow-up plan; these are serious
diseases with many potential complications.

   Recent years have seen the development of a vaccine against most strains of
pneumococcal pneumonia bacteria.  It is recommended for the elderly (over 65),
patients without a spleen, which seems to leave them sensitive to pneumococcus,
and others with decreased resistance to infection or chronic lung diseases. The
vaccine is long lasting (five years or more), and seems to be quite safe.

   Clues to the presence of pneumonia which should lead to prompt medical
consultation include shaking chills, production of blood or pus in the sputum,
chest pain with fever, shortness of breath with a fever, or any "cold" symptoms
which are severe or persistent. Diabetics, the very young or very old, and
patients with chronic lung diseases or other debility are especially at
!
*Tell me about Bladder & Kidney Infections...

   The terms cystitis and pyelonephritis refer respectively to infections of the
urinary bladder and the kidney.  Urinary tract infection (UTI) is a general term
referring to both types of infections.  The usual cause of such infections are
bacteria which are normally found in the large intestine, the commonest of which
is a bacterium called e. coli.

   Probably because of anatomic factors involving the proximity of the urethra
and bladder to the anal area, women are far more prone to UTI's than are men.
Furthermore, intercourse and various hygienic activities can exaggerate this
mechanical- anatomic relationship.  Thus when a woman gets an uncomplicated
urinary infection it is usually not because of some other problem in the urinary
tract; men, on the other hand, rarely get a UTI without some additional urinary
disorder such as an enlarged prostate, a kidney stone, etc.

 SYMPTOMS

   Burning with urination, frequency and urgency, lower abdominal cramping pain,
and occasionally bloody or cloudy urine all are common in bladder infections.
The presence of a fever over 100 degrees, chills, back pain, or severe symptoms
raise the suspicion of kidney involvement, which usually occurs from a bladder
infection climbing up the ureters to the kidney.

 DIAGNOSIS

   The characteristic symptoms will lead to a microscopic evaluation of the
urine in most cases.  The presence of abnormal numbers of white blood cells,
sometimes with red cells suggests infection.  Infections of the urethra (tube
from the bladder to the opening on the outside of the penis or upper vaginal
area) can sometimes be difficult to distinguish from a true bladder infection in
this way.  Many physicians will culture the urine in a special material for a
day or two to confirm the presence of abnormal numbers of bacteria, and to
identify which strain is involved.  Others, knowing that the odds are very high
that the bacteria is one of a very few types, might proceed to treatment without
further studies.  Findings further suggesting that the kidneys may be involved
include tenderness to firm clapping on the flank areas.

 TREATMENT

   A simple bladder infection ma be treated with 90% success using a simple
single dose of any of several antibiotics including ampicillin, amoxicillin,
Bactrim or Septra, sulfa, and others.  In the 10 per cent of patients who fail
to respond to this, the bacteria may be resistant to the drug, early kidney
involvement may already be involved, or some other problem may be complicating
the situation. Some doctors still treat immediately with a full 10 day course of
medication.  If urethritis (see above) is suspected, tetracycline and related
drugs may be chosen since it would cover most of the germs common to both types
of infection.

   If kidney infection, or pyelonephritis, is likely, much more aggressive
therapy and follow-up are used.  Some patients who are able to drink readily and
are not critically ill may be treated at home with oral medication, whereas many
others may require hospitalization for intravenous fluid and medication.
Cultures of urine and blood may be done, and treatment begun with ampicillin,
sulfa or combination drugs, or some of the "-mycin" drugs.  Blood poisoning and
shock may occur, and careful observation is very important.

   Some cases of recurrent, persistent, or unusual types of infection may
require very long courses of therapy, up to 6 months or more.  In selected
cases, lifelong treatment with lower suppressive doses of an antibiotic may be
the only way to control infections.  Other preventive measures for some patients
include ample fluid intake, acidifying of the urine with high doses of vitamin C
under a doctor's supervision, and prompt emptying of the bladder following
intercourse.

   Further diagnostic tests to exclude some of the predisposing conditions
mentioned above include x-rays of the kidneys and cystoscopy of the bladder,
where a viewing instrument is passed into the urethra under local or light
general anesthesia.  Some indications for doing one or both of these include
infections in males, highly persistent or difficult to cure infections, frequent
recurrences without other explanation, or abnormal kidney function.

 INFECTION WITHOUT SYMPTOMS

   From time to time a routine urine analysis will disclose a urinary infection
in a patient with no symptoms.  This may be the first clue to some unsuspected
urinary abnormality, but more often represents a low- grade infection.  Where
there is no other complication present, these patients do not seem to suffer any
serious permanent harm from this, although they are probably at increased risk
for developing symptomatic episodes compared to those with no low-grade
infection.  One exception is pregnant women in whom the presence of bacteria
without symptoms is associated with a 25% incidence of kidney infection later
during pregnancy.  Whether to treat the non-pregnant group is unclear at this
time, but many physicians will do so if there are no contra-indications to doing
so; in the chronic situation where multiple previous episodes have resisted or
recurred after treatment, it may also be prudent to simply observe until such
time that symptoms or kidney dysfunction occur.

 SUMMARY

   As the commonest of all bacterial infections, urinary infections are
experienced by millions of people each year. Careful diagnosis, appropriate
treatment, and adequate follow- up will result in total cure for most of these
patients, and adequate symptomatic relief for almost all of the others.
!
*Do I have Herpes?

   Herpes viruses comprise four groups of disease causing germs, of which two
are discussed in this section: herpes simplex (genital and oral involvement),
and herpes zoster (shingles). Chicken pox and mononucleosis are also herpes
diseases, and are discussed under childhood and miscellaneous infections
respectively.  A third disease, cytomegalovirus, is similar to mononucleosis and
is not dealt with specifically in HealthNet.

         Herpes Simplex

  Type 2: Genital Herpes--this is the infamous herpes which has been the subject
of enormous publicity in recent years, and with good reason: some 10% of the
population has been infected with the virus in recent years largely through
sexual transmission.

   After close contact with an individual with active herpes an incubation
period of 2 to 20 days passes, averaging about a week. The first episode is
usually far more severe than recurrences, and may start with burning or pain in
the affected genital area. Small blister- like sores may then appear on the
genitals or the surrounding areas, including the anus if anal sexual contact
occurred. In the initial episode particularly, pain may be quite severe, and the
surrounding lymph glands may become swollen and tender.  Women may have more
pain than men from the sores. Fever, and general achiness and fatigue are
common.  Pain may last 10 to 15 days, and the sores usually resolve after about
3 weeks.  In a minority of patients, the virus may spread internally, even
causing a type of meningitis, with stiff neck, headache, light sensitivity, and
severe illness.  As long as sores are present, contagiousness is present; in the
absence of active lesions spread should be considered unlikely but not
impossible, since small skin abrasions may occur.

   Diagnosis of the acute episode revolves around recognition of the appearance
of the sores, and may be confirmed by special microscopic examinations.  Other
diseases such as syphilis may have to be ruled out in selected cases with the
appropriate blood and other tests.

   Some 80 or 90% of patients will develop recurrence of the sores, since the
virus remains latent within the body during remissions.  What precipitates
recurrences is not well understood, but there may be a general tendency for
recurrences to diminish with time. Fortunately, the recurrences are often much
milder than the primary episode.

   Treatment is primarily oriented toward symptom relief, with aspirin,
acetaminophen or mild codeine preparations useful for fever or pain.  Hygiene
should include gentle soap and water cleansing, and sexual activity should be
avoided during the presence of sores. An ointment containing acyclovir (Zovirax)
was approved for use in 1982, and seems to provide limited relief for first
episodes only.  It is expensive and of limited benefit, and the drug is probably
far less useful than the publicity led many to believe.  Nonetheless, it may be
useful to some.

   In January of 1985 the FDA approved an oral form of acyclovir for use in
genital herpes.  Research shows that the drug does in fact reduce symptoms of
both the first attack as well as recurrences. It does not cure the disease, but
does reduce its intensity. It seems most effective when used early in the
attack. Toxicity thus far appears low, but longterm studies are not available.
For the severely impaired sufferer, the drug may be worth a try.  Its routine
use is more questionable, as viral resistance to the drug could become an
increasing problem.

  Type 1: Non-genital herpes-- although this type can occasionally cause genital
sores, it generally is associated with similar sores around the mouth (cold
sores) or elsewhere.  The lesions are similar in appearance to other herpes
sores--small red areas with a blister in the center. They recur regularly, and
last from a few days to two or three weeks on the average.  Again only
symptomatic relief is available, unless a secondary bacterial infection is
present.

   Herpes occurring in the eye or in the newborn infant can be very serious and
require intensive medical attention.

    Herpes Zoster (Shingles)

  After recurring from chicken pox in childhood (discussed elsewhere), most
patients never have any further problems even though the virus remains alive but
dormant in the nerve tissue of the body.  A few individuals do have recurrences
in the form of shingles.

   Symptoms--after several days of tingling or pain in the skin near the area of
recurrence, a rash appears characterized by red patches on which are seen groups
of blisters.  The distribution of the rash follows the course of the nerve it is
emerging from, so that it usually occurs in a band which goes up to but does not
cross the midline of the body.  Common areas affected are the chest abdomen and
head.  The eye can be involved, and requires intensive treatment by an
ophthalmologist to protect vision. Occasionally the rash never appears, and only
the pain occurs, making diagnosis quite difficult; generally the appearance is
sufficiently characteristic for diagnosis.

   Treatment involves soothing lotions to the area, hygiene to reduce the risk
of secondary infection, and pain relievers. Sometimes, pain may be so severe as
to require narcotics. Antihistamines may be useful to reduce itching and
discomfort, especially that which interferes with sleep.

   An occasional complication of shingles is the occurrence of residual pain
after the virus resolves, possibly due to scarring of the involved nerve. This
seems to be more common in older patients, and some studies suggested that the
incidence of the complication can be reduced if the acute flare-up is treated
with a course of cortisone-like drugs for a week or two.  Some doctors advise
this for all patients over 50 with shingles who have no sensitivity to these
drugs.  This very painful condition can be treated with drugs such as
amitryptilline, carbamazepine and others but some patients get little benefit,
and are forced to live with considerable permanent discomfort.
!
*I'm having trouble with my Prostate...

   The basic functions and anatomy of the prostate gland are discussed in the
section on urinary disorders, as are those conditions of the gland which can
cause enlargement without infection.  This section will deal with the disease
known as prostatitis, which is a bacterial infection occurring in a chronic and
an acute form.

 Acute Prostatitis

  When bacteria enter the prostate area from infected urine, an acute
inflammation may occur; ironically, the urine may have become infected in the
first place because of prostatic enlargement as discussed elsewhere.  In the
acute case, symptoms include burning with urination, frequency, urgency, with
fever and marked pain in the anal area.  There may be shaking chills, and
bacteria may enter the blood stream. Diagnosis is sometimes not straight
forward, since in the absence of localizing symptoms only the fever and acute
generalized symptoms may be present. Men of any age are vulnerable.

   Diagnosis is highly suspected when the alert physician performs a rectal
examination and finds a large, highly tender prostate gland; the urine may show
bacteria or white blood cells on microscopic exam.  If the infection has not
extended beyond the prostate, cultures of the urine may be normal.  If
inflammation is severe, there may be total blockage of urine flow.

   Treatment involves high doses of antibiotics either by vein, or by mouth in
milder cases. Many antibiotics fail to penetrate into the prostate, and some of
the more useful ones include trimethoprim, carbenicillin, and tetracycline
derivatives; it appears that during the acute infection penetration may be
greater than in the baseline state.  This is a serious disease requiring urgent
medical attention.  The common bacteria involved include e. coli, proteus, and
klebsiella.

 Chronic Prostatitis

   When the prostate becomes infected with less intensity, symptoms may be
indistinguishable from those of a simple congested or "hypertrophied" prostate,
namely urinary frequency, difficulty initiating the stream which may be weak,
dribbling of urine, and nocturnal awakenings to urinate. However, on analysis of
the urine there may be white blood cells, or a positive culture. Sometimes the
diagnosis is aided by analyzing urine obtained at the beginning, middle, and end
of the urinary process, with prostate disease causing most white cells in the
last collection.

   The disease is important largely because it can predispose to kidney or other
infection, and because it is one of the few reversible factors in prostate
enlargement which does not require surgery to correct. Diagnosis revolves around
the characteristic feel of the prostate gland with consistent symptoms and
urinary findings. Older men are the commonest sufferers.  Treatment is with
antibiotics, and often weeks or even months may be required to eradicate the
infection. Trimethoprim is especially useful in this regard, if the causative
bacteria happens to be sensitive to it.

          Epididymitis

   The epididymis is a small structure attached to the back part of the
testicle.  When infection reaches this area through germs in the urine, the term
epididymitis is used. Symptoms include abrupt painful swelling of the area which
can be mistaken for involvement of the testicle itself.  The entire area
including the scrotum may become red, tender, and hot. Diagnosis can be
difficult, but often the urine shows excessive numbers of white cells, and an
experienced examiner can localize the center of the pain to the epididymis
itself.  There may be pus from the urethra.

   Chlamydia and bacteria are the usual causes, and respond to appropriate doses
of antibiotics such as ampicillin or tetracycline.  When diagnosis is in
question or when the condition does not respond to treatment, a urologist is
often consulted.

           Urethritis

   The urethra leads from the bladder through the penis and thereby to the
outside of the body.  In addition to being involved in bladder infections, it
may be the primary site of infection which is then termed urethritis.  A common
cause of such infection is gonorrhea, which is discussed in another section.
This section deals with the remainder of cases, together called nonspecific
urethritis, or NSU.

   Burning with urination and a white, yellow or green discharge from the penis
are the usual symptoms.  The discharge may be scanty, and only noted by stains
on the undergarments.  This infection does not cause fever, and other diagnoses
should be considered if it is present. Diagnosis is made by making a microscopic
slide from a small sample of the discharge, and culturing this material to see
what germs are present.  The main goal is to distinguish gonorrhea from all the
other causes; chlamydia are the commonest germs in the latter category.

   Tetracycline and related drugs are the commonest treatments. Examples include
doxycycline and minocycline. Erythromycin is an alternate treatment.  Often the
sexual partner(s) may require treatment to avoid recurrent infections. Response
is usually prompt, and residual effects are not usually seen; the natural course
of the untreated disease is not well know.
!
*Tell me about Intestinal Infections...

   Gastrointestinal infections are among the most common encountered in America,
with the term gastroenteritis being used to refer to this group as a whole.  The
commonest symptom in this group is diarrhea which is defined as stools of an
unformed or watery consistency.  The actual frequency of bowel movements is
usually but not necessarily increased. Additional symptoms of nausea, vomiting,
and abdominal cramping pain are variable, as is the occurrence of general
symptoms of fever, malaise, and body aches.

   The actual incidence of most of the syndromes discussed is most difficult to
determine, since it is a highly regional matter; in general, the total
occurrence of these diseases may be said to be second only to that of upper
respiratory syndromes as a cause of minor, and sometimes major, illness in the
U.S.

   In any illness causing loss of appetite, diarrhea, or vomiting, the most
important problem is usually the potential for dehydration, since large amounts
of body fluid can be lost without replacement. In addition, chemicals such as
potassium and bicarbonate may be quickly disrupted in the blood stream, with
dangerous results. Since dehydration itself can cause vomiting and loss of
appetite, a vicious circle may arise.  Patients who are in otherwise good health
rarely suffer such effects from routine infections, but those with underlying
illness, old or very young age, those on diuretics, or those with severe
symptoms are at risk for this.  A few representative syndromes are discussed
below.

   Various symptomatic measures are commonly used.  Fluid replacement with clear
liquids including water and other chemically balanced substances is common.
Anti-diarrhea drugs such as Pepto-bismol, Kaopectate, and others are of
questionable value, except as noted below.  Anti-nausea drugs include Compazine,
Phenergan and others; though somewhat effective, these drugs can have serious
side effects and are probably best reserved for selected cases where the risks
are judged acceptable.  Lomotil, codeine, belladonna and other drugs counter
diarrhea by partially paralyzing the contractions of the intestines. Though
effective symptomatically, they may delay the clearing of toxins and germs, and
in some cases may increase the risk of total intestinal shutdown, a serious
complication.  Thus, simple dietary restriction, fluid replacement by mouth
where possible, and rest are the best first aid for most people.  When these are
not adequate, medical advice is warranted.  In those at high risk, medical aid
is justified immediately.

 SPECIFIC DISEASES

  Travelers Diarrhea--caused in most cases by a special strain of the bacterium
e. coli, this results from a toxic product of the germ within the intestines.
The small intestine is the site of infection.  Symptoms consist of copious
watery diarrhea, usually with no fever or blood. It is common in travelers to
southern countries, but may occur sporadically, and is often spread by
contaminated water or food.

   Treatment revolves around replacing by mouth the fluids lost in the stool;
the disease is usually self-limited to several days.  Clear liquids are best,
and solid food should be avoided. Use of bismuth subsalicylate (Pepto-Bismol) is
shown to be effective in reducing symptoms.  Antibiotics such as tetracycline or
Septra (Bactrim) is probably somewhat helpful, but some authorities advise
against such widespread use, since the emergence of resistant bacteria and
allergic or other reactions may occur. Severe cases may require intensive
medical care, and diagnosis is primarily bases on exclusion, since cultures are
not practical in most cases.

   Both Pepto Bismol and Septra have been used for prevention of this disease,
with the former being less toxic.  Opinion varies amongst medical experts on
whether such treatment is warranted; only the individual traveler's physician
can determine what is suitable in any case.

  Viruses--these are responsible for a high percentage of simple "stomach flu"
especially where community-wide occurrences are noted.  There is little specific
about symptoms, and treatment is as discussed above.  Attempts at eating too
soon after symptoms develop are common and may cause a setback.  Diarrhea, pain,
and vomiting are all possible. Fever is often seen in children, but is less
common in adults. Blood in the stool is not causes by viruses, although diarrhea
can cause bleeding by irritating the skin around the anus.

  Antibiotic-associated Diarrhea--antibiotics can disrupt the normal balance of
bacteria in the colon, thus allowing some unaccustomed species to overgrow.
Simple diarrhea is the result. Cessation of the drug resolves the problem.  The
ingestion of foods containing "good" or harmless bacteria is sometimes
suggested, but the effectiveness is unproven.  Yogurt and buttermilk are among
such foods. An especially severe form of drug-related diarrhea called
pseudomembranous colitis can occur rarely, and is associated with blood in the
stool, severe symptoms, and fever; medical evaluation and specific alternate
antibiotic treatment is necessary.

  Salmonella--this bacteria causes a diarrheal illness which can be severe, and
includes fever and diarrhea.  It is spread by contaminated food. Diagnosis is by
culturing of the stool and microscopic exam. Antibiotics can actually prolong
the presence of the germ, and should be avoided unless severe general symptoms
are present. Hospital treatment with IV fluid may be required in some cases
until the body successfully combats the disease.

  Shigella--a colon infection shigella "dysentery" can be severe, with blood in
the stool and fever.  It is not a rare disease, and is spread by personal or
contaminated food contact.  Stool cultures make the diagnosis, and the disease
may last for weeks untreated. Chloramphenicol, ampicillin, or Bactrim (Septra)
are common antibiotic treatments.

   Campylobacter and yersinia are other bacterial infections which can be
treated specifically.

  Giardiasis--this is a protozoal organism which infects the small intestine.
Once felt to be an exotic disease, it is now recognized that outbreaks may occur
in the U.S. with some regularity, if not frequently. Common symptoms include
diarrhea, bloating, and abdominal cramping.  Flatulence with an especially foul
odor is common.  A chronic state may occur untreated. Diagnosis is difficult,
since the symptoms are so nonspecific. Although many cases may show up with a
positive stool culture or microscopic exam, many others may not.  Definitive
diagnosis requires a biopsy and sample from the duodenum through a swallowed
instrument.  For this reason, some physicians and patients, when the disease is
suspected, will proceed to a diagnostic/therapeutic trial or metronidazole or
quinacrine, which are the drugs of choice.

  Amebic Dysentery--somewhat uncommon except in travelers and homosexual men,
this disease causes severe and usually bloody diarrhea with marked illness. It
is spread by contact with water, food, or body fluids contaminated with the
feces of an infected person (or a carrier without active disease). Diagnosis is
through laboratory examination of the stool, and treatment with quinacrine or
metronidazole is effective.

 SUMMARY

   General measures such as frequent hand washing for food handling and bathroom
usage are obviously important in prevention, as are proper measures of
refrigeration and cooking of food.  When mild or moderate symptoms occur in a
healthy individual who is neither elderly or under two years of age, the simple
general measures mentioned above may be adequate; symptoms should abate within a
day or two.  If fever, blood, severe symptoms, inability to retain oral fluids,
previous illness, extremes of age, chronic medication use, or any other unusual
health factors are present, a physician should be contacted.  Any failure to
promptly improve also warrants medical follow-up.
!
*I have a red rash near the scap and white spots in my cheeks..

 DISEASE: Measles

 INCUBATION: 9-11 days

 MODE OF INFECTION: respiratory droplets.

 COMMON SYMPTOMS:  fever, red eyes with light sensitivity, runny nose, dry and
sometimes severe cough, white spots on the inside fo the cheeks, followed by the
classical red rash near the scalp, later involving the upper body, with mild
peeling.  Symptoms may be severe.

 COMPLICATIONS AND PROGNOSIS: Unusual rashes noted in those immunized between
1963-7 with a partially effective vaccine. Later vaccines highly effective.
Seven to 10 days after rash, most patients make a full recovery.  Pneumonia,
encephalitis, and internal organ involvement occur rarely. Treatment is
symptomatic. No cure known.
!
*I have swelling of the salivary glands in front of my ears...

 DISEASE: Mumps

 INCUBATION: 18 days

 MODE OF INFECTION: respiratory droplets.

 COMMON SYMPTOMS: fever, swelling of the salivary glands in front of the ears
(parotids), achiness, restlessness. Testicular involvement in up to one fifth of
males, especially older patients. Mild meningitis with headache or stiff neck is
not rare.

 TREATMENT: Symptomatic. Highly effective and safe vaccine available.

 COMPLICATIONS AND PROGNOSIS: Occasional late occurrence of encephalitis (brain
infection) can be severe.  Guillain-Barre Syndrome (temporary paralysis)
occasionally seen.  Testicular involvement can lead to sterility.  Some studies
link mumps to occurrence of diabetes, but this is not proven.
!
*I have red spots on my face!

 DISEASE: Chicken Pox (Varicella)

 INCUBATION: 10-23 days

 MODE OF INFECTION: respiratory droplets or fluid from skin lesions.

 COMMON SYMPTOMS: usually children less than nine years old. Low grade fever,
headache. Rash usually first on face, scalp as red dots merging into pus- or
fluid-filled blisters, which form crusts and scabs as they heal in various
stages. Itching may be intense, each pock lasting several weeks. May form scars.
Rash emerges continuously over 4-6 days. Mostly central body, fewer on arms and
legs. Inner mouth sometimes involved.

 TREATMENT: Symptomatic. Aspirin to be avoided as may increase risk of Reye's
Syndrome, a serious brain and liver complication.

 COMPLICATIONS AND PROGNOSIS: Pneumonia can occur, more commonly in adults, and
usually mild. Rare cases of encephalitis seen, sometimes severe.  Rare internal
organ involvement. Most cases resolve uneventfully after several weeks.  A
special form of gamma globulin is available for children with leukemia who are
exposed to the disease, which can be frequently fatal in these patients.
!
*Tell me about Meningitis...

   Meningitis refers to infection of the lining of the spinal column, and of the
spinal fluid which fills the canal around the spinal cord.  As this area is well
insulated from the outside world, most infections come from germs which enter
the blood stream from the respiratory tract or other portals, and lodge in the
meninges (lining tissues). Because of the intimate connections of the spine with
the brain and other crucial nerves of the body, this can be a highly dangerous
disease.

     SYMPTOMS

   Symptoms common to all forms of meningitis include fever and a special form
of neck pain called meningismus.  This is a severe shooting pain down the back
of the neck and sometimes along the spine when the patient bends the neck
forward, or when the physician moves the legs in a special way which also
stretches the spinal cord.  In an involuntary effort to avoid such pain, a stiff
neck often occurs.  This may be so severe in young children as to cause a
virtual arching of the back which is uncontrollable, and termed opisthotonus.
As the infection progresses, headache, vomiting, coma, shock, coma, and death
may occur with certain types of the disease.

     TYPES of MENINGITIS

  Meningococcal--this is the classical bacterial meningitis, and can be a
fulminating disease resulting in death within hours if untreated.  Often it
starts as a simple flu-like illness, with the above symptoms evolving in rapid
succession.  A red rash is common, and the blood stream, adrenal glands and
blood clotting process may be affected.  Seizures occur in up to a quarter of
patients.

   Other bacteria such as pneumococcus and hemophilus can cause a similar
picture.

  Viral or Aseptic--this type of meningitis can cause severe symptoms with
prominent headache and stiff neck, but usually does not go on to cause serious
permanent damage or death.

  Other--tuberculosis, certain fungus germs, and other organisms occasionally
cause meningitis.  Some noninfectious diseases which cause inflammation
(especially of blood vessels) can cause a picture indistinguishable from
meningitis, at least on preliminary evaluation.

     DIAGNOSIS

   If a patient has even the slightest hint of the typical stiff neck in the
presence of fever, or if the physician considers meningitis because of some
other finding, it is imperative that a spinal tap be done without delay.  This
can be done as an outpatient in many cases, and is usually of only minimal
discomfort.  Headaches after this procedure are far less common with modern
smaller needles.  Within minutes, the possibility of meningitis can be excluded
or suspected, although the exact type of germ may take days to determine.  Since
time is of the essence, treatment is often begun immediately even if the type is
undetermined.  Blood cultures may also reveal the bacteria.

     TREATMENT and PROGNOSIS

   If a bacteria is suspected, antibiotics in very high doses by vein are the
treatment of choice; once the specific bacteria is identified, the regimen may
be adjusted to fit the need more specifically. Supportive measures for blood
pressure, respiration, and shock may be required in some cases. Penicillin,
ampicillin, and chloramphenicol are commonly chosen.  Over 85% of treated
patients with meningococcal meningitis survive, although very young or old
patients do less well.  Some residual damage occurs in a few patients, such as
deafness or facial paralysis.

   Viral meningitis rarely requires specific treatment, but intravenous fluids
or other supportive measures may be needed until the patient is well enough to
care for him or herself. Other types are treated according to the available
anti-microbial sensitivity of the germ involved.  Viral meningitis is almost
never fatal or permanently harmful.

     PREVENTION
   Meningococcal meningitis is contagious, and acutely ill patients are
isolated.  Airborne secretions and direct contact are the modes of spread, until
treatment has been given for 48 hours.  Household contacts and other intimate
contacts should be considered for preventive treatment with antibiotics such as
sulfadiazine, rifampin and minocycline depending on the subtype of bacteria.
Casual contacts are often not at risk.

   A vaccine against some strains of meningococcus is available, and is advised
only in some epidemic situations, and other selected settings, but not for
routine use.

   Other types of meningitis are rarely preventable, except where the primary
disease, e.g. tuberculosis, are preventable in a general way.  The key to
successful outcomes is prompt and accurate diagnosis, with initiation of
treatment at the earliest possible moment.
!
*I think I have the flu...

   Although the term "flu" is commonly applied to almost any presumably viral
self-limited infection, influenza is actually a specific set of diseases caused
by two strains of the influenza virus.  It can occur in vast epidemics called
pandemics (type A), or in smaller epidemics or individual outbreaks (type B).
The virus is generally spread by respiratory droplets, and an incubation period
of only 18 to 72 hours is usual.

   Influenza is characterized by the abrupt onset of high fever, lasting 3 to 5
days, headache, diffuse muscle aches, and often a dry cough, sore throat and
stuffy nose.  The latter symptoms may persist for weeks, although the acute
illness rarely lasts longer than a week. Very young, elderly or otherwise
debilitated patients may become seriously and even fatally ill with influenza,
but most victims will recover uneventfully.

   The diagnosis requires special blood tests which are neither widely used nor
necessary except for epidemiologic surveillance. Typical symptoms may be caused
by a number of other viruses, but when they occur in a recognized outbreak, the
diagnosis is more secure.  The high fever for over 3 days is not generally seen
with the common cold, and is a useful clue.

   It is the occasional complication of influenza which causes most of the
mortality, such as that seen in the infamous 1918 epidemic. Pneumonia from the
virus itself or from bacteria (notably staph) which invade the affected airways,
is a dreaded and frequently fatal complication, though not common.  Asthma can
be caused by the viruses' irritating effects on the airways. Sinus and ear
infections with bacteria occur occasionally. Severe muscle inflammation may
cause pain and immobility, and Guillain-Barre Syndrome (progressive temporary
paralysis) may be a severe after-effect weeks after the infection.

   Treatment is generally supportive, with fluids, rest, and acetaminophen for
discomfort.  Aspirin is best avoided until its potential relationship with
Reye's Syndrome is clarified when used for influenza.  If fever is above 104
degrees, sponge baths should be considered to bring it down, especially in young
children, or those with other disorders.  Mild cough suppressants can sometimes
be helpful.  Amantidine is an antiviral agent for type A (epidemic) influenza
which can shorten the course by a day or two, as well as reduce symptoms. It
must be started within the first day or two of symptoms to be useful, and can
cause side- effects of sleeplessness, dizziness.  Those at high risk for
complications should be considered for treatment with amantidine.

     Prevention

   Influenza vaccine is highly effective, and despite the swine flu debacle, is
considered extremely safe.  Since most people are not severely affected by the
disease, it is advised mostly for the vulnerable elderly, diabetics, lung
disease patients, and others with chronic diseases.  In addition, key health
personnel whose services are vital during epidemics often are immunized as well.
Unfortunately, the virus "mutates" slightly each year enough to require a
reformulation of the vaccine.

   Any patient with suspected flu who develops wheezing, productive cough, fever
longer than a week, or other severe symptoms should receive medical evaluation.
!
*Ack! Do I have Mono??

   Most common in teens and young adults, mononucleosis is a viral disease which
derives its name from the appearance in the blood of unusual variants of white
blood cells with one nucleus (mononuclear) as opposed to the divided nuclei of
the majority of white cells normally present (in fact the atypical cell is a
distorted lymphocyte). It is caused by the Epstein-Barr virus.

   Spread is by intimate oral contact, hence the legendary term "kissing
disease."  Almost all patients then develop a sense of being ill and tired, with
a sore throat, at times very severe, being almost as common.  Headache, muscle
aches and cough are also seen regularly.  The virus frequently affects the
liver, as a mild cause of hepatitis, and yellow jaundice may be present. Swollen
lymph glands are present in virtually all patients in the back of the neck, as
well as under the arms, the groin and elsewhere in many.  The spleen may
enlarge, giving a soreness in the left upper abdomen.

   Diagnosis is suspected from the above symptoms, especially if present for 10
days or more, as opposed to a simple cold. Throat cultures will rule out a strep
throat, and the blood count shows the unusual lymphocytes mentioned above.  A
special test for antibodies against the virus will confirm the diagnosis,
although it may require two weeks of illness before the test converts to
positive.

   Some very recent preliminary research suggests that the same virus may cause
a chronic form of illness lasting years, with recurrent fevers, sore throat, and
fatigue.  Its relationship to infectious mononucleosis is not clear.  Most
patients feel considerably better on their own after 2 or three weeks, although
fatigue may persist for 2 months or more.

   Treatment is supportive with aspirin or acetaminophen for discomfort and
fever, pain relievers for severe sore throat, and rest.  Complications are rare,
but include rupture of the swollen spleen, meningitis, and anemia from red blood
cell attack by antibodies.  If the sore throat is so severe as to prevent eating
or obstruct breathing, a short course of prednisone, a steroid drug, may be
helpful.  A peculiar side light is that up to one half of patients with the
disease will develop a rash if given the antibiotic ampicillin; this is not an
allergy, but rather an idiosyncratic reaction.  The drug should be avoided in
patients with confirmed or suspected mono.
!
*Do I have Tuberculosis?

   Once the scourge of mankind and a major killer in all countries of the world,
tuberculosis in America is now an uncommon (but no rare) disease which is highly
treatable and curable.  There are around 30,000 new cases discovered yearly in
the U.S. The cause of tuberculosis is a bacterium called "mycobacterium
tuberculosis."

   Most cases of T.B. are actually reactivations of infections acquired in the
distant past.  At the time of the primary exposure, the infected droplets from
the sputum of an active case are breathed in, and deposited in the lungs where
they rarely cause significant disease, and are successfully contained by the
body's defenses.  Some cases of primary exposure are serious (especially in
young children) but this is unusual.  Only years later, perhaps during a time of
physical stress, aging, debility, or ingestion of an immune suppressing drug,
does the active disease reappear.

   Most cases of tuberculosis appear slowly, over weeks or months, although an
occasional case of sudden pneumonia or spinal infection may be seen rarely.
Weight loss, fever, night sweats (many of the symptoms of some cancers as well)
are common.  A cough productive of sputum and sometimes blood is a later sign,
as are chest pain and breathlessness.  In some cases, the germs will have spread
to other organs, including the kidneys, brain, liver and almost any other
location.  Swollen lymph nodes are often seen. Because of the diverse and
unpredictable nature of the disease, it can be exceedingly difficult to diagnose
if not considered directly.

     Diagnosis

   If the symptoms are mostly respiratory, a chest x-ray is often the best clue
to diagnosis, as the germ causes highly typical changes in the lungs.  Elsewhere
in the body, a biopsy or culture of some body fluid is often the only means of
diagnosis; as often as not the physician is surprised to find tuberculosis.
Cultures of the sputum can also be confirmatory. Persistent and unexplained pus
or white cells in the urine sometimes is caused by tuberculosis, as is
intestinal infection.

   More commonly, tuberculosis is diagnosed some time between exposure and
symptom occurrence by means of a simple skin test applied routinely to patients
under age 35.  A positive test indicates prior primary infection, although all
signs fo the disease are usually absent, and even the chest x-ray is normal.
This represents the mildest form of the "disease," and is easily treated.  The
skin test may miss an occasional case, as it is blocked by even trivial
intercurrent viral illness or other common fevers and illness.  In addition, the
test may rarely be falsely positive from past exposure to germs similar to
tuberculosis, but of no medical concern.

   The untreated patient may develop progressive weakness, spreading infection,
organ involvement and death.  The slow but relentless course has led to the
archaic but apt term "consumption."  Occasionally, bizarre and complex symptoms
may occur, and alternate diagnoses such as depression or cancer are entertained
for long periods before the correct diagnosis is made.

     Treatment

   There are numerous drugs available to treat tuberculosis in virtually any
stage and, properly managed, well over 90% of patients should be cured.
Unfortunately the courses of treatment for this slow growing germ are prolonged,
ranging from 9 to 24 months.  The ideal treatment setting is the office, and the
ideal patient to treat is the one whose only manifestation is a routinely
detected positive skin test, with a negative chest x-ray.  In this event, the
usual treatment is the drug isoniazid, given for one year.  This reduces the
risk of later active infection to the minimal level possible, is quite safe,
inexpensive, and rarely causes side-effects.  The side- effect picture as
patients approach the age of 35, and the potential for a particular form of
drug-induced hepatitis becomes a consideration at that age and beyond.  It is
for this reason that routine skin testing is not done after age 35.

   Health care workers and others at risk may continue to receive skin testing
indefinitely.  Complicated decisions weighing the relative risks of treating
inactive disease versus risk of treatment itself are beyond the scope of this
discussion, but may vary widely.  In actively ill patients there is no
disagreement that treatment is indicated and quite effective. One of the biggest
problems is getting patients to comply with their doctor's advice for 18 months
of therapy.  In active disease, combinations of isoniazid, rifampicin, and
ethambutol (usually the first two) are commonly used, and the trend is toward
shorter course of around 9 months.  In any event, careful follow-up and repeat
cultures are important.

   It may be seen that tuberculosis has become within this century a highly
curable, easily detectable and usually mild disease, compared to the monstrous
and inexorable consumption of yesterday.  The biggest obstacles preventing
eradication of the disease entirely are the failure of patients to seek medical
care in a timely fashion, to comply with medical regimens, and to obtain careful
follow-up surveillance, as well as the societal problems which allow these
circumstances to persist and the inevitable shortcomings of some members of the
medical community who manage the disease.

   A partially effective vaccine is available against tuberculosis and is used
in some other countries.  In America, it has been determined that the relative
rarity of the disease does not warrant the routine use of such a measure,
considering only partial effect, cost, and potential side-effects.
!
*I was bit by a tick and feel bad..

Lyme Disease

Lyme Disease is an infection caused by a bacterium called borrelia burgdorferi,
and has been the subject of increasing attention in recent years.  It is spread
through the bite of the common deer tick, most frequently in the early summer
months.  Between 1982 and 1988, almost 14,000 cases were reported, the actual
number of cases obviously being much greater.

Originally described as an outbreak of arthritis among children in Lyme,
Connecticut, the disease has now been found in almost every state.  It is
particularly widespread in Minnesota, Wisconsin, several Northeastern states,
California and Oregon.

Generally, it is felt that to spread the disease, a tick must attach itself to
the skin of the victim and remain their for a day or more; while a substantial
percentage of confirmed Lyme Disease patients do not recall any tick bites at
all, many have at least a history of exposure to the appropriate outdoor
setting, such as camping, dogs, etc.

Lyme Disease is described as having three clinical disease stages.  In actuality
there is great overlap between the symptoms of each stage, and any symptom can
occur at any time.  The classical stages are described below:

Stage 1 ------- Within 3 to 30 days (average 9) after exposure, the classical
rash occurs. Termed erythema migrans, this is a red area which expands from the
center out, sometimes becoming very large.  Over time, the center of the area
begins to clear a bit, causing a target-like appearance.  Other rashes and
flu-like symptoms such as fever and malaise may occur.  Headache, stiff neck,
muscle and joint aches and chills may occur.  These symptoms usually resolve
without treatment after 3 to 4 weeks.  It is very difficult to diagnose the
disease in this stage, unless a clear history and suggestive rash are present.
The blood test for Lyme Disease (checking for antibodies to the bacteria) may
take 3 to 6 months to appear.

Stage 2 ------- In this stage, which typically occurs weeks to months after
exposure, neurologic abnormalities may be noted.  These include meningitis
causing severe neck pain and fever, encephalitis causing alterations in
consciousness, paralysis of a nerve anywhere on the body, but often one side of
the face.  These often fluctuate, but over time may resolve on their own.

In some cases, the bacteria affect the heart muscle, causing disturbances in the
regularity of the heart beat, or even complete heart block which has
occasionally been fatal.  The eye is also vulnerable, with inflammation and
nerve damage occurring.  Fatigue may be prominent, and joint pain and swelling
can occur.

Stage 3 ------- Usually after many months or years, the symptoms are considered
to be stage 3. This is where the joint symptoms are prominent, with numerous
areas involved. Usually these are large joints such as the knee, hip, and jaw
joints.  For many years the symptoms may come and go, mimicing rheumatoid
arthritis. Neurologic symptoms in stage 3 may continue, sometimes suggesting
multiple sclerosis and other diseases.

Diagnosis --------- A high level of suspicion is needed to distinguish Lyme
Disease from the many other disease which cause similar symptoms.  While a blood
test is available for antibodies to the bacteria, months may go by between the
tick bite and the test turning positive.  Thus, while helpful in later stages
and when positive early, the blood test cannot be relied upon very often.  The
key points are a) proper history of actual or potential tick exposure, b)
recognition of the characteristic rash, and c) knowledge of the symptoms such
that the diagnosis is considered in otherwise confusing patients.

Most authorities advise against treating for potential exposure only, since the
risk/benefit ratio has not been proven.  On the other hand, many patients do
complain of at least a few consistent symptoms when carefully questioned; while
these are undoubtedly often incidental, many physicians would treat for early
disease in the face of tick exposure with symptoms which cannot be otherwise
readily explained.  A more sensitive blood test is needed to help in this
setting, and at present this becomes a matter of judgment.

Prevention ---------- The emphasis on prevention of this disease involves
education.  Avoidance of high risk areas, use of tick repellants, long sleeves
and pants, and careful daily inspection of the skin with prompt removal of any
ticks found are all important.  Treatment with antibiotics (see below) purely on
the basis of a tick bite without other symptoms is not felt to be wise, since
the risk of side effects may be at least as great as the risk of disease in that
setting.  In addition, a 'brief' tick bite (where actual attachment is only for
several hours) is probably not a major risk.  As usual, check with your personal
physician if you feel you have been exposed to Lyme Disease.

Treatment --------- To a greater degree than with many other diseases, early
treatment is highy desirable.  In early or stage 1 disease, a simple 10 to 14
day course of oral antibiotics is highly effective.  Penicillin, tetracycline,
doxycycline, erythromycin, and amoxicillin are all used.  In later stages,
intravenous drugs are needed to gain higher efficacy.  Supportive treatments
such as pain and fever relievers are helpful; depending on complications rare
patients may require heart pacemakers or other measures.

To summarize, Lyme Disease is a highly treatable infection spread to humans by
the deer tick.  Diagnosis can be difficult, but with appropriate education most
potential cases can be recognized and treated readily.  A simple potential or
even actual tick bite is not cause for fear, and many physicians would not even
advise treatment for such an occurrence. While caution is advisable, there
appears to be little need for an alarmist or fearful attitude toward Lyme
Disease or the recreational contexts in which it is found.
!
*PMS...

   PREMENSTRUAL SYNDROME

   The premenstrual syndrome, or PMS, was first described in the medical
literature over 50 years ago.  Perhaps because of its prevalence and the
uncertainty that still surrounds its cause, manifestations, diagnosis and
treatment, it has been the subject of numerous recent reports in the popular
media.  It has even received attention as a possible theory of legal defense for
women accused of violent criminal behavior.  This interest in PMS has coincided
with the growth of clinics specializing in its treatment and has spawned new
research into this troublesome disorder.

   Diagnosis

   From 70-90 % of reproductive age women experience physical discomfort,
behavioral changes or emotional upset in the days preceding their menstrual
periods.  Among the more frequent of the over 100 signs and symptoms reported
are fatigue, headache, breast swelling and tenderness, edema, constipation,
rashes, changes in appetite, irritability and mood swings.

   Premenstrual syndrome can be defined as the cyclic occurrence of one or more
of these complaints such that they are severe enough to affect a woman's
lifestyle or participation in everyday activities.  It should be differentiated
from dysmenorrhea (painful menstruation), and other physical explanations should
be excluded, e.g. fibroids, cysts, endometriosis, and pelvic infection.
Importantly, a strict temporal relationship to monthly periods must be observed:
the symptoms should begin within ten days of menses (usually 3-5) and should
remit within a day or two of the onset of menstrual bleeding.  Anywhere from 2-
40 % of all young women meet these diagnostic criteria.

   Possible Causes

   As noted above, the cause of PMS is not known.  Because it occurs only in
women with intact, functioning ovaries, many researchers believe that an
abnormality in ovarian hormone production is responsible.  Yet unproven, either
a deficiency of progesterone or an excess of estrogen in the latter half of the
menstrual cycle is hypothesized.  Other theories of hormonal imbalance have also
been advocated.  They involve antidiuretic hormone produced by the pituitary
gland, endorphins--the body's natural opiate-like substances and aldosterone--a
salt-retaining adrenal gland hormone.  The diversity of proposed theories is
apparent when one considers that vitamin B6 (pyridoxine) deficiency, blood sugar
abnormalities and psychosocial causes have also been proposed.

   Treatment

   The treatment regimens for PMS are as varied as its theories of causation.
Despite the advertised claims of many clinics, no specific therapy has been
proven efficacious by rigorous scientific study.  Conservative measures include
exercise, low salt/high protein diets, weight loss, stress reduction,
psychological support and reduction of alcohol, tobacco and caffeine use.
Natural and synthetic progesterone preparations, birth control pills, danazol--a
synthetic male hormone, bromocriptine--a medication that changes the levels of
specific neurotransmitters in the brain, spironolactone--a diuretic,
antidepressants and vitamin B6 supplements are just some of the medications that
have had at least anecdotal success.  Recently an ovarian cycle-suppressing
medication was shown to be effective in a small number of patients.  Long-term
studies in a larger group of women are ongoing.

   Overview

   Present theories of causation and treatment are unproven, and PMS remains an
enigma.  The diagnosis, for the most part, relies on the medical history and the
exclusion of other possible causes for the symptoms.  Therapy is individualized,
beginning with conservative measures and progressing to drugs only as needed.
Reassurance and psychological support are important.  The choice of which
medication to use remains controversial.  Most physicians chose modes of therapy
with which they are familiar or most experienced.  How an individual patient
will respond is hard to predict; doctors must be flexible and open-minded in
their approach.  Women should be wary of guaranteed miracle cures and wild,
unsubstantiated claims about "proven" medications.
!
*What are Ovarian Cysts?

   Cysts are fluid-filled pockets within or on the surface of normal tissues.
Those arising from the substance of the ovaries range in size from less than an
inch to large enough to fill the entire abdomen.  Many are derived from remnants
of egg-producing areas of the ovary and are functional in that they secrete
hormones.  Others represent true tumors, benign and malignant. Of the total only
about twenty percent turn out to be cancerous.

   This article will deal only with the common functional cysts and benign
cystic tumors.  Please consult the Disorders and Diseases section on cancer for
more information about ovarian malignancies.

   Signs and Symptoms

   Unless there is a complication (see below) or abnormal hormone secretion,
many cysts produce no symptoms at all.  They may be discovered incidentally
during routine examinations, or at surgery for unrelated or undiagnosed health
complaints. Abdominal fullness and heaviness, pressure on the rectum or bladder,
menstrual irregularities, pelvic pain radiating to the lower back and upper
legs, and infertility are probably the most common symptoms.  Rarely, very large
cysts may become noticeable as a protuberance in the abdomen or an increase in
waist size.

   Certain events may lead to severe symptoms and life- threatening
complications.  Sudden, profuse bleeding into a cyst may be associated with
intense pain, or it may lead to rupture of the cyst into the abdominal cavity.
Rupture may also result from injury or manipulation of the cyst during a pelvic
examination. Depending on the type of fluid in the cyst, peritonitis, an painful
inflammation of the inner membranous lining of the abdominal cavity, may ensue.
Many cysts grow on narrow stalks (pedicles) attached to the ovary.  Twisting or
torsion of the pedicle can compromise the blood supply and venous drainage
causing the cyst to swell.  In severe cases life-threatening rupture and
gangrene occur.  Importantly, torsion of an ovarian cyst must be considered a
possible cause for abdominal pain in young women who have symptoms resembling
appendicitis.  Infection is a rare complication of ovarian cysts, unless the
blood supply has been interrupted.

   Diagnosis

   The pelvic examination often establishes the presence of a mass in the region
of the ovary, although small cysts may be undetectable and large ones difficult
to differentiate from tubal pregnancy or infection, fibroid tumors and various
abnormalities of the intestinal and urinary tracts.  Ultrasound (sonar, echo)
scanning is perhaps the most useful test for localizing a cyst. If a cyst
contains calcified matter, it may show up on routine X- rays.  Hormone blood
tests may indicate that the cyst is functional.  Laparoscopy, the insertion of a
viewing scope into the abdominal cavity, and exploratory surgery not uncommonly
reveal cyst formation in patients without symptoms.  Exact diagnosis usually
requires biopsy or excision and microscopic examination.

   Some of the major types of cysts and benign ovarian tumors are discussed
below:

   Follicle Cyst

   A follicle is the localized area of the ovary in which the egg matures.  When
ovulation (release of the egg) does not occur, the follicle may continue to
grow, forming a cystic mass.  The most common of all ovarian cysts, these benign
growths rarely exceed two or three inches in diameter.  They usually go away on
their own within several months.  Treatment (excision) is not required unless
there is a complication.

   Corpus Luteum Cyst

   The corpus luteum is the progesterone hormone-producing remnant of an ovarian
follicle.  It is formed upon release of the egg at mid-cycle and regresses with
menstruation.  If the corpus luteum fails to shrink away, a cyst forms and the
next menstrual period is delayed.  This delay in menses combined with lower
abdominal pain may simulate a tubal pregnancy.  Fortunately, most corpus luteum
cysts are small and resolve within a few weeks or months.  Note: corpus luteum
cysts are always present early in the course of normal pregnancy.

   Polycystic Ovaries (PCO)

   In the PCO or Stein-Leventhal syndrome, enlarged smooth ovaries containing
multiple, small follicle cysts are associated with absent or diminished
menstruation (amenorrhea), infertility, obesity and male-pattern hair growth.
Teenagers and young women are affected by this unusual disorder in which
ovulation does not occur because of a failure of pituitary hormones to stimulate
the ovaries.  Treatment consists of the medication clomiphene (Clomid) and
sometimes surgery to remove a portion of the ovary.

   Endometrioma

   Representing endometriosis (see separate article) of the ovaries, these cysts
are composed of glandular tissue from the lining of the uterus.  Both ovaries
are involved in about 50 % of the cases.  Classically, the cysts contain old or
degenerated blood resembling chocolate syrup.  Chocolate cysts, however, are not
specific for endometriosis; they may be seen with hemorrhage into any cyst.

   Cystadenomas

   The two types, serous and mucinous, comprise from one-third to one-half of
all benign ovarian tumors.  They occur most frequently in premenopausal women,
but otherwise have no characteristic symptoms.  The serous variety contains a
watery liquid, often affects both ovaries, does not usually grow to immense
proportions and is malignant in about one out of three cases.  The mucinous
cystadenoma contains a mucous-like material, ranges in size up to twenty inches
in diameter, and is less likely to be malignant (ten percent).  The treatment
for both types is surgical excision.

   Dermoid Cyst (Teratoma)

   Also called a benign cystic teratoma, this interesting cyst is often composed
of different types of tissue such as hair, skin, teeth, cartilage and glandular
material.  It is one of the cysts that may show up on routine abdominal X-rays.
The average size is two to four inches.  Struma ovarii is a special type of
dermoid cyst that contains tissue from the thyroid gland.  It is a rare cause of
an overactive thyroid condition.  Therapy is surgical removal.
!
*Tell me about Diabetes...

   Although the most widely recognized manifestation of diabetes is elevation of
the level of blood sugar level, it is a complex and multifaceted disease which
affects virtually every body organ in some patients.  Depending on the
diagnostic criteria one applies, diabetes is said to occur in some six million
Americans, of whom 100,000 are children, and one quarter require daily insulin.

       General Concepts

   Since blood sugar measurements are widely used in the diagnosis of diabetes,
it is important to understand some basic concepts of hormone regulation to
appreciate the mechanism of the various types of diabetes. The hormone in
question is insulin, a complex chemical produced in small clusters of cells in
the pancreas, which lies just behind the stomach.  The insulin is absorbed into
the blood stream where it is carried to the rest of the body.  The actions of
insulin are several: most importantly, it causes the glucose (blood sugar) to
leave the blood and enter the cells of the various body organs.  It is as if
there were a gate between the blood and the organs, and insulin is the key to
the gate.

   In addition to facilitating the passage of sugar from blood to cells, insulin
also allows many other metabolic processes which all work toward the storage of
energy into fat and other substances, and prevent the release of such stores
into the blood.  In the "fed" state, it is obviously advantageous to pack away
for future use any energy or body fuel not immediately needed, and insulin does
this.  Even in very small quantities, insulin can prevent the breakdown of body
stores into energy sources.

   It is possible to thus understand the effects of insufficient insulin.  For
one thing, the level of glucose in the blood will rise, especially after a meal
which causes the digestion and absorption through the intestines of large
amounts of sugar. Nothing stops the glucose from getting into the blood, but
once there, it has no place to go, and levels rise. The kidney is able to block
the passage of sugar into the urine up to a point, but once levels exceed around
180 milligrams per 10 cc of blood, there is some overflow into the urine as
well.

   Without insulin, body organs which depend on glucose for energy are unable to
extract it from the blood and begin to rely on alternate sources of energy.
Among these are some forms of fat.  The breakdown products of these fatty
substances are highly acid in nature, and begin to accumulate in the blood.
Called ketones, these byproducts are responsible for the condition called
ketoacidosis which can occur in untreated diabetes.

   The disordered metabolism in diabetes can alter the way in which the body
handles fats including cholesterol.  Over the years, this leads to an
accumulation of such fats in the small arteries of the body. Characteristically,
the arteries so affected tend to be those of the eyes, the kidney, the heart,
and the brain.  This is what leads to an increased incidence in diabetics of
blindness, kidney failure, heart attack, and stroke. Of course, the better the
degree of control, the less likely the complications, according to most
authorities.

     Types and Causes

   The causes of diabetes are not known, although some clues are available.
Most cases fall into one of two types, which may be quite distinct in their
causes.  The first type, or Type I, is generally acquired in childhood, and
usually is found to be a near total lack of internal insulin production.  If
untreated, patients often will develop the potentially urgent complication of
ketoacidosis (discussed elsewhere).  Such patients are usually thin, and always
require insulin administration to sustain life. The other type, Type II, is
generally acquired in adulthood, is most common in obese patients, and may be
treated with dietary measures or occasionally oral medication, with only a small
minority requiring insulin. Although severe short and long-term complications
and symptoms may occur in the untreated case, ketoacidosis in unlikely.

   Type I diabetes is of unknown cause; it may be caused by a preceding virus
which affects the pancreas, or an autoimmune process within the body. Although a
genetic factor may play a role in some way the relationship is not clear or
overwhelming. In genetically equivalent identical twins, only a third to a half
of siblings with type I diabetes will also develop the disease. Perhaps a
vulnerability is inherited, and only those exposed to some offending agent go on
to develop the disease.

  Type II diabetes is highly genetic, with a nearly 100% occurrence in identical
twins of affected patients.  The actual cause is unknown, and it often occurs in
patients with no family history of the disorder. Clearly obesity plays a
critical role in bringing out the disease in susceptible patients.  In general
these patients retain the ability to produce some insulin, but in response to a
meal, the response is long delayed, and often inadequate. In addition, many
patients are resistant to the action of insulin even when it is present,
especially if obesity is present; in these cases, the insulin level may actually
be higher than normal, yet diabetes occurs due to insulin resistance.  The
incidence of Type II diabetes increases with age.

     Symptoms

   Symptoms of increased blood sugar include fatigue, increased appetite if
enough blood sugar is wasted into the urine, and increased urination as the
sugar causes the kidney to produce higher volumes to dissolve the excess load.
When the latter occurs, thirst is increased as well to make up for the lost body
fluid.  As levels of blood sugar rise and ketosis occurs (see above), the body
fluids become excessively acid.  One of the defenses against acidity is to
decrease the carbon dioxide in the blood, which is accomplished by increasing
the rate and depth of respiration.

   The full blown picture of ketoacidosis is a dehydrated, obtunded or even
comatose patient, who is breathing heavily with a characteristic odor to the
breath from the ketones in the blood.  The lesser symptoms are as above.

   Diabetics are prone to symptoms from the complications due to arterial
blockage discussed above.  Vision loss, heart problems, and loss of kidney can
occur.  Nerves in the legs, arms, and face can become painful or numb for weeks,
months, or permanently. Many of these complications require the presence of the
disease for decades or more.

      Diagnosis

   Once the diagnosis is suspected, or an elevated sugar is detected on
screening lab work, certain criteria have been established for doctors to
follow.  Typical numbers for adequate diagnosis in an appropriate setting might
include a fasting sugar over 150 mg.%, or repeated after-meal levels over 200 mg
%.  The normals vary with age, and certain factors can interfere with the test.
A controlled glucose "tolerance" test involves the administration of a measured
amount of oral glucose, followed by checks of the blood every 30 to 60 minutes
for 2 or more hours. Newer normal references consider many factors, and the
ultimate diagnosis often requires repeated checks and judgment on the part of
the treating physician.

     Treatment

   General measures common to all diabetics include reduction to normal body
weight if obesity is present, moderate or even vigorous activity if this is
considered safe from a general health standpoint (exercise has an insulin-like
effect), and dietary discretion.

   Years ago, diabetic diets were strictly controlled formulae of rigid
proportions of fat, carbohydrates, and protein organized into "exchanges" which
made the diabetic's life highly structured around the diet. Today, diet remains
crucial in a comprehensive management program, but it is recognized that much
more flexibility is possible without harm.  Total calories are determined,
ranging usually from 1500 to 3000 per day.  Sweets are largely avoided, but not
entirely so, and carbohydrates are allowed liberally, as is dietary fiber.
Vegetable fats are encouraged instead of animal or dairy fats, and should be
moderate. Generally, one fifth of the days calories are taken at breakfast, with
two fifths each at lunch and supper, or adjusted to allow for a small snack in
between. This oversimplification is largely adjusted for individual variations,
and a comprehensive dietary educational program of a personal nature is vital.
Dietary professionals often provide such training as part of a larger diabetes
program.

   When diet and exercise alone are inadequate to normalize blood sugars, one
alternative for type II diabetics is the use of pills which lower blood sugar
either by acting like insulin, stimulating the pancreas to produce more insulin,
or making body cells more sensitive to insulin.  A long-running controversy
exists over the report that these drugs can increase the risk of sudden death
(presumably due to heart attacks), but the data is not clear at this time.  Most
authorities agree that the drugs have a genuine place in the management of the
disease, especially in symptomatic elderly patients who can not or will not
follow a dietary program, or who do not respond to such a program. Excellent
control is rarely achieved, but the ease of use and lesser concern about overall
life expectancy may outweigh the theoretical risks.  This issue is always best
decided by the physician and patient considering all the individual factors
involved. Chlorpropamide, tolazimide, tolbutamide, and gliburide are examples of
such drugs.  Some physicians avoid these drugs altogether.

   Insulin is the main means of controlling diabetes which is not responding to
diet, and is the necessary treatment for type I disease.  Various types are
available, varying in their peak onset of action, duration, etc. Often, two
types are given in combination.  Insulin is given by the patient as an injection
under the skin using disposable very small needles and syringes, after
appropriate training. Although the prospect seems drastic at first, diabetics
quickly accept this as a routine part of their regimen.  In the initial phase,
many adjustments are necessary, sometimes in the hospital, until the right doses
are determined.  Side effects include allergic reactions and hypoglycemic (low
blood sugar) episodes.

   Modern medicine stresses the importance of near-normal blood sugars in the
prevention of complications of diabetes.  The optimal patient checks her own
blood tests through a finger stick one or more times daily, checks occasional
urine samples for sugar, follows a consistent diet and activity program, and
adjusts the insulin dose as needed within guidelines established by the
physician. When problems arise, the physician is consulted as a resource, and
regular medical follow-up is scheduled routinely.  The effects of various
stresses, both physical and emotional, are anticipated and allowed for.
Occasional low sugar episodes are accepted as a price of good control, but are
usually easily reversible with a light snack.

   Some diabetics use a portable insulin pump which injects insulin through an
intravenous tube around the clock.  It is felt that this is comparable to, but
not necessarily superior to, a carefully applied program of standard injections
of long- acting insulin with frequent blood sugar monitoring and appropriate
adjustment.

   The pregnant woman with diabetes requires special control, since even modest
blood sugar elevations are potentially harmful to the fetus.  Stricter criteria
apply, and closer management is in order.  In some women, diabetes appears under
the physiologic "stress" of pregnancy, only to improve after childbirth.  Some
such patients go on to develop long-standing diabetes in later years.

   Only rarely are things as smooth as the above description, but most diabetics
will do very well under the guidance of a concerned team of a physician,
dietician, nurses, and other professionals.  Many become highly sophisticated
about their disease, and groups such as the American Diabetes Association and
local resources offer invaluable support.  Preventive measures such as
immunizations, foot care (diabetes predisposes to infections of the feet), and
travel precautions are also important.

     Prognosis

   It is very difficult to generalize about the prognosis of diabetes since it
is such a variable disease.  It seems fair to say that the disease decreases
life expectancy, and diminishes quality of life through its complications and
treatment requirements.  Only recently has the concept of very rigid control
been feasible through home blood glucose monitoring, and there is much evidence
and great hope that tomorrow's diabetic can look forward to a near-normal life
if such control is maintained.

     Horizons

   Research is proceeding in several directions which may provide breakthroughs
in diabetes, though none is currently available for general application.  One is
an artificial pancreas which takes regular readings of the blood sugar, and
automatically injects through an intravenous tube the appropriate amount of
insulin needed on almost an instantaneous basis.  Another is the possibility of
transplanting pancreatic tissue from a donor into the diabetic patient, although
the troublesome rejection problems are seen here as in most transplant
procedures.  HealthNet will keep you alert to any meaningful advances in this
area.
!
*I think I have low Blood Sugar...

          HYPOGLYCEMIA

          Definitions

   Hypoglycemia literally means low blood sugar (glucose). There are two types:
fasting and reactive (postprandial) hypoglycemia. The former refers to the
development of low blood glucose concentrations during periods of food
deprivation, while the latter occurs 2 - 4 hours after eating (postprandially).
The normal range for blood sugar is 60 - 100 mg./dl.  Levels below 60 mg./dl.
are considered to be in the hypoglycemic range.

        Signs & Symptoms

   When the blood sugar falls, the body's glands react by secreting a number of
hormones, especially adrenalin.  The symptoms result as much or more from this
surge of adrenalin and other hormones as they do from the lack of glucose.  They
include nervousness, sweating, blurred vision, irritability, fatigue, hunger,
palpitations, and numbness.  Because the brain is acutely sensitive to low blood
sugar levels, confusion, seizures, blackouts, and even coma may occur.  While
minor symptoms are rapidly relieved (within 5 - 20 minutes) by eating, severe
cases may require hospitalization.

      Fasting Hypoglycemia

   Accidental or intentional overdose of insulin or blood sugar-lowering pills
by diabetics and other individuals is the most common cause of fasting
hypoglycemia in adults. All the other causes are rare. Among them are
insulin-producing tumors, severe liver disease, Reye's syndrome, kidney disease,
alcohol ingestion, pituitary and adrenal gland underactivity, cancers,
medications, extreme malnutrition, and inherited enzyme deficiencies.

   Insulinoma deserves special mention.  This tumor of the pancreas secretes
excessive amounts of insulin even though there may be a dangerous effect on
blood glucose levels.  The diagnosis can be a tricky one to make, and the
condition can be difficult to differentiate from surreptitious insulin
injection. Special blood tests and dye X- rays of the pancreatic arteries are
necessary to confirm the presence and location of this rare tumor.

     Reactive Hypoglycemia

   Reactive hypoglycemia is due to an oversecretion of insulin from the pancreas
in reaction to meals.  Although it is known to develop in persons who have had
previous stomach or intestinal surgery, in children with certain enzyme
deficiencies (galactosemia, fructose intolerance), and perhaps in individuals in
the early stages of diabetes, this condition is rare in otherwise healthy
adults.  In fact, many hormonal disease experts question whether reactive
hypoglycemia even exists outside of the above- mentioned situations.  Claims in
popular media that hypoglycemia is exceedingly common and often responsible for
such health complaints as headaches, fatigue, nervousness, personality changes,
depression, and an inabiltity to concentrate are simply unfounded.  High
protein, low carbohydrate, low fat diets - to decrease insulin secretion - are
often prescribed for persons with these complaints when the diagnosis is
unjustified.

   Part of the problem seems to be the reliance upon the glucose tolerance test
(GTT) as a method of diagnosis.  In this test blood sugar levels are determined
at set time intervals following the ingestion of a standard amount of liquid
glucose.  While falls in the blood sugar as low to as 45 mg/dl. are not
uncommon, they are seen in healthy persons about as often as those people who
have meal-related symptoms. Furthermore, a drop in blood sugar on the GTT is not
enough: the symptoms must occur concomitantly with the low sugar levels.
Frequently, there is no correlation.  Tests using standardized meals instead of
glucose, and measuring hormone as well as sugar levels, are more reliable.

           Treatment

   When a hypoglycemic attack does comes on, the treatment is eating or
intravenous glucose administration.  Ideally, the diagnosis should be confirmed
and the underlying cause treated specifically, e.g. removing the insulinoma,
stopping the implicated medication, treating adrenal insufficiency, etc. When
true reactive hypoglycemia is unrelated to previous intestinal surgery or
incipient diabetes, small, frequent low- carbohydrate meals may be of benefit.
Other touted therapies are unproven.
!
*Do you have an Overactive Thyroid Gland?

   The thyroid gland is a butterfly-shaped organ located at the base of the
neck, just above the collar bone.  Most people are unaware of its presence, but
careful examination will sometimes reveal its spongy presence. The main function
of this gland is to produce the iodine- containing hormone thyroxine (thyroid
hormone).  Thyroxine acts to control the rate and intensity of most physiologic
functions of the body.  It is akin to the "volume control" of the body.  Heart
rate, sweating, digestive action, body temperature, calorie consumption and many
other activities depend in part on this hormone for regulation.  In its absence
or deficiency, metabolism may slow down to fatal levels.

   The thyroid itself depends on the pituitary gland at the base of the front of
the brain for control.  Thyroid stimulating hormone (TSH) from the pituitary is
necessary for the thyroid gland to produce thryoxine.  As if this were not
complicated enough, the pituitary TSH production is in turn dependent upon the
chemical "thyrotropin releasing hormone" from the hypothalamus higher in the
brain for its production.  Thus there is a complex set of delicate interactions
which oversee the thyroid's function, and many physical and emotional factors
can play a role.

     CAUSES

   Overactivity of the thyroid gland generally arises from one of three
conditions: a functioning growth or tumor, such as a benign nodule or cancer, a
self-limited inflammation of the gland from a probable viral infection, or
Graves' Disease.

   Thyroid nodules arise either as isolated benign growths or as part of a
multi-nodular thyroid. These are discussed under the section on thyroid growths.
Cancers are a rare cause of hyperthyroidism, and are discussed in the cancer
section of HealthNet.

   Subacute thyroiditis is the usual cause of hyperthyroidism of the short-lived
type.  It is a probable viral infection which inflames the cells of the gland,
which then are destroyed. In the process, they release all at once the thyroxine
they have been storing for future use. Healing occurs within a few weeks.

   Graves' Disease is the commonest form of hyperthyroidism.  It is common in
young patients, usually female, and is caused by the production in the blood of
thyroid antibodies which have a stimulating effect on the gland. This same
process causes the deposition of a thick substance within the skin, behind the
eyes, and elsewhere.  It is felt to be the result of an autoimmune process, in
which some unknown factor stimulates antibody production which has the undesired
effects.  A genetic component may predispose to the condition, as it seems more
common in relatives of patients previously affected.

     SYMPTOMS

   Symptoms caused by excess thyroid hormone include pounding, rapid heart
beats, sweating, irritability, diarrhea, weight loss with increased appetite,
trembling, and nervousness. Sleeplessness, fever, and "jumpiness" are seen. The
physician may note an abnormal widening of the eyelids, overactive reflexes,
elevated blood pressure and other findings.  In the most extreme form, called
"thyroid storm," the symptoms may lead to cardiac arrest or circulatory
collapse, with a fatal outcome.

   Symptoms characteristic of subacute thyroiditis include soreness of the
gland, sometimes mimicking a sore throat.  Graves Disease may cause bulging
outward of the eyes, swelling of the ankles, and changes of the nails.  In both
diseases the thyroid gland may be enlarged.

     DIAGNOSIS

   The above symptoms and findings will usually lead to a blood test for thyroid
hormone and related substances.  Once the elevation is documented, further tests
are dictated by particular circumstances.  One common test is a thyroid scan, in
which slightly radioactive iodine is injected, and its presence monitored over
the thyroid gland.  This can distinguish thyroiditis from Graves' Disease in
most cases. If a gland is nodular, the active nodule often stands out on the
scan.

     TREATMENT

   The symptoms of thyroid excess from any cause can usually be relieved with
the beta-blocker drugs such as propranolol, where there is no contraindication
to the drug. This does not affect the underlying disease, but usually makes the
patient much more comfortable.  Depending on the extent of the disease, this may
be given orally or intravenously as an emergency measure.

   Subacute thyroiditis usually requires little else, except for the use of
aspirin or similar drugs to reduce inflammation while the disease runs its
course.

   More definitive treatment is required for Graves' Disease or functioning
nodules.  There are generally three approaches: medications, radioactive iodine
treatment, and surgery. Medications (usually propylthiouracil or methimazole)
act by interfering with the chemical production of the hormone within the gland.
Such treatment probably does not affect the underlying disease, although some
authorities dispute this.  The trend is toward shorter courses of treatment, but
most will continue therapy for a year or more.  By that time most cases of
Graves' Disease will have run their course.  Unfortunately about 70% of patients
relapse after the drugs are stopped. Side effects are uncommon but may be
severe.

   Surgery to remove all or most of the overactive thyroid gland is an
acceptable alternative, with the advantage of being definitive, relatively
short, and involving minimal drug or x- ray exposure.  Prior to surgery, the
patient usually receives medications to control the excess hormone, since the
operation itself would be dangerous in this circumstance. An experienced surgeon
is necessary, and occasional complications are seen.

   Radioactive iodine administration is a long- standing therapy with a very
high success rate, an enviable safety record, and avoids surgery and prolonged
drug exposure.  The hypothetical risk of long-term cancer or other radiation
effects has been carefully sought and is not known to occur.  Perhaps this is
because the iodine is highly selective for the thyroid itself, with little
exposure to other organs.  The possibility exists for some genetic damage so
subtle that it has not yet been identified; for this reason this therapy is not
advisable for pregnant women.

   The choice of therapy is highly individual and should be a joint decision of
the patient and her doctor, taking into account many factors.  Each mode of
treatment carries the risk of leaving the patient with an underactive thyroid
gland months to years after treatment (as do the underlying diseases
themselves), and careful follow- up is needed in case thyroid supplement pills
will be needed. Almost all cases can be successfully managed by one or more of
the modern approaches outlined above.  In Graves' Disease the eye complications
may progress even if the thyroid excess is controlled, and ophthalmologic
treatments may be needed.
!
*I have a large lump in my throat!

      THYROID ENLARGEMENT
            (GOITER)

   The thyroid gland is described in some detail in its function and  location
in the sections on Hyperthyroidism and Hypothyroidism.  Its location at the base
of the neck just below the "Adam's apple" makes any enlargement of the gland
obvious to most patients, who may become aware of an actual lump, or simply a
tightness of the collar.  The gland may enlarge either in one small area, or in
its entirety.  The latter case is commonly

   In actuality, thyroid enlargement is not a disease itself, but rather a
symptom of some other disease.  Those which also affect the function of the
gland are discussed in the appropriate section, and Cancer or malignant tumors
are discussed in that section of HealthNet.  This discussion will focus on
general aspects of goiter and thyroid nodules.

      Diffuse Enlargement

   When the whole gland enlarges, symptoms depend on the size and rapidity of
its growth. Some patients have no symptoms, and the goiter is detected on
physical exam.  Diseases which can cause such enlargement include some which
cause overactivity of the gland (Graves' Disease, Subacute Thyroiditis, and
Toxic Nodular Goiter).  The common Hashimoto's Thyroiditis, which generally
causes hypothyroidism is another cause of thyroid enlargement. Cancers which
infiltrate the whole gland can also present in this way.

   Multinodular goiter is a disease of unknown cause in which the gland is
replaced with many small round nodule filled with fluid. Usually thyroid
function remains normal. Occasionally a nodule will become injured and bleed a
bit into its hollow center, causing temporary pain and acute swelling.  It may
be a slowly progressive disease with cosmetic consequences as well as
interference with speech or swallowing.

   Treatment of multinodular goiter may range from simple observation to
administration of thyroid hormone pills.  It is felt that by relieving the
natural thyroid and pituitary gland of the need to produce the hormone, the
glands are put to "rest." In fact many such patients notice a shrinkage or at
least a stabilization of the goiter from this suppressive treatment.

        Isolated Nodules

   When the physician or patient notices a smaller area of enlargement in an
otherwise normal thyroid gland, several possibilities are considered. Thyroid
scans can determine whether the nodule is "hot" (produces thyroid hormone at
higher levels than normal), "warm" (produces hormone normally), or "cold" (fails
to produce hormone).  Ultrasound tests determine if the nodule is solid or
cyst-like.

   The major effort is to determine the likelihood that the nodule may be
malignant and require surgical removal, or whether it is benign and can be
observed.  Since this is a very common finding, it is crucial to avoid
unnecessary operations without overlooking the rare cancer.

   Certain factors raise the probability of a nodule being cancer; these include
a history of radiation therapy in childhood (not simple x-ray pictures, but
treatments for tonsillitis, acne, cancer, etc.), a "cold" nodule (see above)
especially in a male, a large nodule which is solid, and swollen glands around
the thyroid.

   Depending on a combination of the above factors, the clinical findings, and
blood test results a choice is made as to whether to operate, perform a biopsy
under local anesthesia, or just observe with or without treatment.  If any
significant doubt remains about the possibility of cancer, surgery is usually
recommended.
!
*My joints ache.

   DEGENERATIVE ARTHRITIS

     (Osteoarthritis)

   The inner surfaces of a joint are lined by a smooth, shock- absorbing
cartilage that allows the ends of the bones to glide over one another as the
joint move.  Over long periods, the wear- and-tear stresses of daily physical
activity may damage the protective cartilage causing it to weaken and lose its
elasticity and resiliancy.  If the degenerative process continues, the bones may
grate together, develop cysts and grow bony prominences called spurs.  This
long-term damage, known as degenerative joint disease (DJD) or osteoarthritis,
is a major source of disability. The most common arthritic condition, DJD
affects about one out of every six Americans, including 80 percent of persons
over the age of 70.

   Predisposing Factors

   Although osteoarthritis is considered a disorder of old age, it is not
limited to the elderly.  In particular certain predisposing conditions can
hasten the degenerative process in young persons.  They include obesity (more
stress on weight- bearing joints), bone deformities (abnormal mechanical forces
across the joint), previous cartilage injury, joint infection, certain types of
inflammatory arthritis (rheumatoid, gout), diabetes mellitus and acromegaly
(excess growth hormone). Repetitive occupational or exercise-related joint
movements can play a role in some individuals.

   Signs and Symptoms

   Degenerative joint disease is manifested by joint aching and stiffness.
Typically the pain is aggravated by movement and weight-bearing on the involved
joint.  Although swelling may occur, warmth and redness usually imply an
inflammatory-type of arthritis.  The hips, knees, ankles, neck, low back and
hands are the most common joints affected.  Hip pain can be especially severe,
making walking difficult.  The fingers often develop a knobby and gnarled
appearance from enlargement of the farmost knuckles (Heberden's nodes).  And DJD
of the spine is a common cause of chronic pain and decreased neck and back
mobility.  In some cases, large bone spurs may compress the spinal cord or
"pinch" its nerves.

   Characteristically, the physical examination reveals joint enlargement,
tenderness and sometimes swelling.  X-rays may show narrowing of the joint space
and new bone formation adjacent to the joint.  Because of the prevalence of DJD
in the general population, the presence of X-ray changes does not necessarily
implicate osteoarthritis as the cause of joint pain.  Many individuals with
abnormal X-rays experience few, if any, symptoms, and other types of arthritis
may produce similar X-ray findings.

   Treatment

   The goals are to reduce pain while preserving mobility. Aspirin or
anti-inflammatory medications such as ibuprofen (Motrin, Advil, Nuprin),
indomethacin (Indocin) and naproxen (Naprosyn), etc. are the mainstay of therapy
along with heat, moderate exercise, physical therapy and weight reduction.
Attention must also be paid to the underlying conditions that aggravate or place
undue stress on the joints.

   Patients with severe pain refractory to conservative treatment may be
candidates for operations to repair damaged cartilage and bone.  Artificial
total joint replacement--e.g. hip, knee, ankle--is an alternative for some
patients with extreme disability.

   Despite recent advances, no present therapeutic measure is 100 percent
effective.  Most patients must learn to endure at least some long-term pain and
stiffness.  Fortunately, DJD tends to progress very slowly.
!
*My Joints still Hurt...

   BURSITIS AND TENDONITIS

   Bursitis

   A bursa is a pocket of connective tissue found adjacent to a joint.  Lined by
a smooth inner surface, it facilitates the gliding movements of muscles and
tendons over bony prominences.

   Bursitis is inflammation of a bursa which results in pain, tenderness,
stiffness and in some cases, swelling and redness. Any bursa can be affected by
the inflammatory process, but bursitides involving the shoulder (subacromial),
elbow (olecranon), hip (trochanteric) and knee (prepatellar) are most common.

   Although the cause of this condition is unknown, repetitive direct pressure
over a bursa can be a predisposing factor.  In particular, certain activities or
occupations are associated with specific bursitides because of the nature of the
physical stress placed on the bursa: e.g. housemaid's knee (kneeling), student's
elbow (leaning).  Infection of a bursa by bacteria or fungi is termed "septic
bursitis."  This serious condition may cause intense swelling, redness and
fever.

   Subacromial bursitis, the most common type of bursitis, deserves special
mention here.  It is characterized by an aching pain localized on the outside of
the top of the shoulder.  The pain is intensified by lifting and backwardly
rotating the arm. Typically, the patient notices stiffness in the morning which
dimimishes with heat and routine activities.

   Although X-rays occasionally show calcium deposits in the tendons, this
finding is not specific.  (Bursas themselves don't show up on routine X-rays.)
The diagnosis of bursitis, therefore, relies upon the physician's medical
history and physical examination.

   Mild bursitis may respond to rest and aspirin or other non- steroidal
anti-inflammatory medications (e.g. indomethacin, ibuprofen).  With improvement,
physical therapy should be instituted to prevent joint stiffness and limitation
of motion. Many patients require one or several bursal injections of
cortisone-type steroid medications to alleviate their discomfort. Septic
bursitis is treated with antibiotics and drainage of fluid that accumulates in
the bursal sac.

   Tendonitis and Tenosynovitis

   Strictly defined, tendonitis is tendon inflammation, while tenosynovitis
refers to inflammation of the smooth outer sheath that surrounds a tendon.  Both
may occur spontaneously or in association with injury, work and sports
activities, certain types of arthritis or infection.  As with bursitis, the
shoulder is most commonly affected.  The attachment of the biceps tendon at the
shoulder is especially vulnerable to this condition. Bicipital tendonitis is
manifested by aching along the biceps muscle that radiates up to the shoulder
and down to the forearm. The pain is worse with movement.  Among the other
common locations for tendonitis are the elbow, wrist, hand, knee, and ankle
(Achille's).

   Treatment consists of rest, heat and anti-inflammatory medications.  Steroid
injections and even surgery may be necessary in refractory cases.
!
*Could I have Lupus?

   Systemic lupus erythematosus (SLE or lupus) is a rare chronic disease
manifested by inflammation of multiple organ systems including the joints, skin,
kidneys, heart, blood, blood vessels and brain.  Ninety percent of the patients
with this often- disabling illness are young women; men comprise only ten
percent of the cases.

   Cause

   While the cause of SLE remains unknown, blood test abnormalities tend to
implicate an autoimmune mechanism: i.e. antibodies are produced against one's
own tissues, cells or chemical constituents.  The characteristic laboratory
finding is the presence of antibody to DNA, the basic genetic material, and
other substances within the nuclei of individual cells.  In addition to these
anti-nuclear antibodies (ANA), there may be antibodies to blood cells and
various proteins present in the circulation.  Although the antibodies do not
damage intact cells or their nuclei directly, they may set off the inflammatory
process in response to their reaction with small amounts of circulating
antigens--the specific substances against which they are formed.

   Why some persons develop auto-antibodies is not known.  Data from animal
experiments suggest that a remote virus infection may induce abnormal antibody
formation in susceptible individuals. Because it has been observed that lupus
and lupus-like illnesses can run in families, heritable factors may be
important.

   Signs and Symptoms

   Joint pains, swelling and tenderness are the most common early findings,
occurring in over nine out of ten patients. Typically the arthritis is not
deforming, but it can be severe and debilitating.

   Skin rashes appear in the majority of patients.  The classic manifestation is
a pink, butterfly-shaped eruption over the nose and cheeks that is aggravated by
sun exposure.  A similar rash, bruising, hives, blisters or ulcers may be
present in other areas.

   Kidney disease (glomerulonephritis) affects about one-half of lupus sufferers
and accounts for a major part of the morbidity and mortality associated with
this condition.  In severe cases kidney failure necessitates long-term dialysis
(kidney machine).

   Involvement of the heart and lungs can lead to inflammation of the membranes
surrounding those organs (pericarditis, pleurisy). Fluid collections at the
bottom of the lungs and around the heart may be associated with chest pains and
trouble breathing.  Heart valve abnormalities and lupus pneumonia are rare
complications.

   When the brain and spinal cord are affected, a variety of neurologic events
may ensue: headache, convulsions, confusion, mental deterioration, mood swings,
nerve palsies, stroke, etc.

   Other manifestations are fever, swollen lymph glands, fatigue, weight loss,
diminished appetite and recurrent infections.

   Anemia, a low white blood cell count, an elevated erythrocyte sedimentation
rate (ESR) and a positive ANA test are some of the associated laboratory
findings.

   Individual patients vary greatly in the number and severity of the
complications of their disease.  While some have only mild symptoms which remit
spontaneously, others run a progressive downhill course with involvement of many
organs.  Flare-ups may be noted during the later stages of pregnancy and after
delivery. A pattern of remission and relapse is most common, with nervous system
involvement and kidney failure tending to be the most debilitating consequences
of the disease.

   Diagnosis

   Because SLE affects so many different organs and has such a varying course,
the diagnosis may not be immediately apparent. And many of the signs and
symptoms are similar to those seen with other arthritic or immunologic
disorders.  A positive ANA alone does not confirm the diagnosis, as there are
several other diseases (rheumatoid arthritis, scleroderma, Sjogren's syndrome)
that can cause this abnormality.  In addition, a reversible, ANA- positive,
lupus-like illness can be induced by the following medications: hydralazine,
procainamide, phenytoin, methyldopa, INH, etc.

   Treatment and Prognosis

   Although mild symptoms may be treated with rest and aspirin, nonsteroidal
anti-inflammatory medications or antimalarial medicines, prednisone (a steroid
drug) is usually necessary to control the inflammatory process.  Unfortunately,
therapeutic doses of prednisone given over long periods of time have a multitude
of adverse effects including swelling, weight gain, diabetes, high blood
pressure, muscle weakness, bruising, thinning of bones, tendency to infection
and cataracts.

   Kidney disease may require aggressive therapy with high doses of prednisone
combined with immunosuppressive drugs such as azathioprine (Immuran) or
cyclophosphamide (Cytoxan). Plasmapheresis, a procedure whereby blood plasma is
removed and replaced with antibody-free plasma, may be effective in some
individuals.

   About 80 percent of SLE patients survive five years, but as yet, no cure is
known.
!
*My bones are easy to break and don't heal fast.

   OSTEOPOROSIS

   Osteoporosis is a group of disorders characterized by a slowly progressive
thinning and loss of calcium content of the bones. Gradually the skeleton
becomes brittle and susceptible to fractures from seemingly minor injuries or
even everyday activities.  A major public health problem of the elderly,
osteoporosis affects approximately twenty million Americans and represents a
threat to more than one-half of all women over the age of 60.  Each year over
one million fractures are directly attributable to this condition.

   Calcium and Bone

   Of the two to four and one-half pounds of calcium in the body, over 98
percent is deposited in the skeleton along with other minerals.  The remainder
is distributed in the tissues and bloodstream and plays an important role in
blood clotting and the activity of muscle and nerve cells.

   To sustain life, the level of calcium in the bloodstream must be kept within
a very narrow range.  This is accomplished by a complicated system that adjusts
for dietary factors, intestinal absorption, urinary excretion and hormonal
functions as well as growth, physical activity and disease.

   Under the influence of vitamin D and parathyroid hormone (PTH) produced by
the parthyroid gland, skeletal calcium is kept in a state of equilibrium with
the circulating blood pool.  A slight drop in blood calcium stimulates the
release of calcium from the bones and its absorption from the intestine and
decreases its loss into the urine.  The process is reversed and bone mineral
content is continuously being replenished and reformed through the actions of
vitamin D, calcitonin (produced by the thyroid gland), estrogens and other
hormones.

   Age-Related Bone Loss

   The skeleton reaches its peak mass at around age 35.  Men have about 30
percent more bone mass than women, and blacks have ten percent more than whites.
After the fourth decade, the rate of bone resorption (calcium loss) excedes
formation, and bone content is lost at the rate of one to two percent per year.
This process is markedly accelerated after menopause such that by age 65, most
women have lost 30-50 percent of their skeletal mass. Men are affected to a
lesser degree.  Cigarette smoking, lack of exercise, underweight, diminished
calcium intake, alcohol use and a number of disease states are contributory.
The overall severity of age-related osteoporosis depends upon the the starting
point of maximum bone mineral content as well as the degree of bone loss.

   Causes of Osteoporosis

   As implied above, senile or postmenopausal bone loss is the most common cause
of osteoporosis; however, young persons of either sex may develop this condition
as a complication of other disorders.  A partial list includes overactivity of
the thyroid or adrenal gland, sex hormone (testosterone or estrogen) deficiency,
prolonged bedrest or inactivity, scurvy, calcium deficiency and inherited bone
diseases.  Heparin, steroid drugs, and Dilantin are some of the medications
which may be responsible.  Among the associated diseases are diabetes, chronic
lung disease, rheumatoid arthritis, convulsive disorders, poor nutrition and
alcoholism.  Idiopathic osteoporosis refers to accelerated bone loss not
attributable to any known cause.

   Signs and Symptoms

   Because ostoporotic bone loss tends to be most severe in the spinal
vertebrae, the clinical manifestations relate mainly to the back.  Sudden
collapse of the vertebrae occurs spontaneously or is precipitated by activities
such as lifting or jumping.  The pain is sharp, aggravated by body movement and
can persist for months.  Some patients experience chronic back pain with
intermittent exacerbations.

   Over the years multiple vertebrae in the mid to lower back become compressed
or wedged producing a forward curvature of the spine called kyphosis, or a
"dowager's hump."  Compression fractures also account for the loss of height
seen with advancing age.

   Fractures of the hip, arm and wrist are common.  Almost one- third of women
who reach age 90 will suffer a hip fracture, usually as a result of a fall.
Surgery and rehabilitation for these individuals is often marked by
complications; the one year mortality rate is almost twenty percent.

   Diagnosis

   The typical presentation of back pain and kyphotic deformity in an elderly
women suggests the diagnosis.  In advanced cases, X-rays reveal thin bone of
decreased density, vertebral wedging, and old fractures, but because a 30
percent bone loss is required for changes to be seen on routine X-rays, more
sensitive bone studies such as dual-photon absorptiometry or dual energy
quantitative CT (CAT-computerized axial tomography) scans may be necessary.
Sometimes, the physician must even resort to a biopsy of the hip bone.  Blood
and urine tests are usually normal.  The presence of cancers involving the
bones, overactivity of the parathyroid glands, pure calcium deficiency and other
primary bone diseases must be excluded.  The underlying causes discussed above
should be ruled out.

   Prevention

   Monthly cycles of estrogen hormones, e.g. Premarin, are an effective means of
retarding postmenopausal bone loss, whether the menopause is natural or a result
of ovarian surgery or disease.  Several studies have shown a significant
decrease (50%) in the incidence of fractures in postmenopausal women treated in
this manner.  Although estrogens do slow down bone loss, especially if given
within six years of the cessation of menstruation, they cannot rebuild bone mass
that has already been lost.  And the beneficial effects of estrogen replacement
must be weighed against their potential long-term complications: uterine cancer,
gallstones, blood clots, etc.

   More recent studies suggest that the increased incidence of uterine cancer in
postmenopausal women treated with estrogens can be nullified by the
administration of progesterone hormone during the last ten days of the cycle.
(For more information about this controversial subject, please consult the
article about menopause.)  Most physicians reserve estrogen replacement for
women who have had their ovaries removed surgically, for women with severe
menopausal symptoms, or for selected individuals who are at high risk for
symptomatic osteoporosis.

   Calcium supplements are a simple, effective means of decreasing menopausal
bone loss.  But like estrogens, they cannot reverse damage already done.
Although the current recommended daily allowance (RDA) for non-pregnant women is
800 milligrams per day, most experts recommend a daily intake of 1,000 to 1,500
milligrams of elemental calcium for all women beginning several years before
menopause.  The major dietary sources of calcium are milk, cheese and other
dairy products.  It is important to remember that many calcium pills are only
10-40 percent calcium on a per weight basis.  (Tums contain 200 mg. of elemental
calcium per 500 mg. tablet.)  Additional twice weekly vitamin D supplements are
recommended for patients with a deficiency of this vitamin.

   Calcitonin is also effective in preventing osteoporosis, but it is expensive
and must be administered by injection.  Sodium fluoride and calcium, thiazide
diuretics (water pills) and diphosphonates are being studied.

   In addition to the above measures, regular exercise, cessation of tobacco and
maintenance of normal body weight are advised.

   Treatment

   Rest, heat and painkillers are indicated for acute fractures of the
vertebrae.  The pain may last four to six weeks.  Other fractures are treated
with casting or surgery as necessary. Preventive measures are instituted to
retard further skeletal loss.  Osteoporosis attributable to an underlying cause
may respond to therapy specific for the disorder.  While combinations of
fluoride, calcium and vitamin D may stimulate new bone formation in some
patients, this regimen is still considered experimental.
!
*Tell me about AIDS...

   AIDS, the acquired immunodeficiency syndrome, is a major public health
problem.  Over 40,000 persons in the U.S. have contracted this deadly disease
since 1981, and the number of new cases in the U.S. is doubling every twelve to
fifteen months. Although drug therapy can prolong survival in some cases, there
is no cure.  The death toll stands at over 20,000.  A rational program of
prevention requires a basic knowledge of the disease and practical intervention
to limit spread of the virus--not ignorance, hysteria or discrimination.

   AIDS is caused by the human immunodeficiency virus (HIV, formerly HTLV-III or
LAV).  The virus is transmitted by way of intimate sexual contact or exposure to
body secretions such as blood, semen or vaginal fluid.  It is estimated that one
to two million Americans have already contracted the virus; up to a third or
more these persons will develop AIDS in the next two to five years, the usual
incubation period.

   High Risk Groups

   The major population groups at risk for AIDS are male homosexuals,
intravenous drug users (shared needles), prostitutes and persons who have
hemophilia or other diseases which require frequent blood transfusions.  More
than ninety percent of AIDS patients have been members of one of these high risk
groups. However, all of us are potential victims.  The virus can be acquired
through heterosexual contact, especially with a member of high risk group, and
via blood transfusion, artificial insemination or organ transplantation.  In
addition, pregnant women who carry the virus may pass it on to their unborn
children; infants infected at birth account for approximately four out of five
pediatric cases of AIDS.

   Haitians and residents of Central Africa have an increased incidence of HIV
infection and AIDS.  Available evidence suggests, however, that known risk
factors account for the increased prevalence of the disease in these
populations.  That the frequency of AIDS in Africa and Haiti is approximately
equal between men and women supports the contention that heterosexual
transmission is an important mode of spread in these areas.

   AIDS and Medical Personnel

   AIDS is also an occupational hazard for healthcare workers. Fortunately, the
risk is very small.  The few well-documented cases of HIV infection linked to
on-the-job exposure occurred as a consequence of inadvertent deep needle
injection or accidental exposure to laboratory samples or large volumes of
blood. Unprotected open wounds or sores may play a role in the contraction of
HIV by medical personnel.  Therefore, gloves are recommended when handling
hospital specimens.  In special instances, gowns or masks may be required when
caring for AIDS patients.  The risk of contracting HIV from an infected
healthcare worker, even one who has the full-blown disease, is negligible.

   Transfusions & Transplants

   Since the advent in the last few years of blood tests which measure the
presence of antibody to HIV (prior exposure to the virus and potential
infectivity), the safety of blood transfusion, organ transplantation and
artificial insemination has been nearly assured.  Almost all transfusion-related
cases of AIDS derive from transfusions received in the late 1970's and the first
half of this decade.  The chance of contracting HIV following transfusion from
the currently available public blood supply is estimated to be less than 1 in
100,000.  Donating blood NEVER has been a source of contracting AIDS!

   A Rational Approach

   The best way to prevent AIDS is to limit spread of the virus from those
individuals that already harbor the virus, including those with the full-blown
syndrome and persons who are infected but do not have the disease.  For most
adults and children, this can be done safely and effectively without drastically
altering one's lifestyle or unfairly discriminating against high risk segments
of the population.

   The AIDS virus is inactivated by exposure to air and heat. Toilet seats,
water fountains, doorknobs and desktops do not spread the virus.  Although
mosquitoes may harbor the virus, they do not spread the disease to humans.
Similarly, other insects have not been implicated.

   Close, casual contact with HIV antibody-positive individuals is not a risky
undertaking.  Non-sexual contact with AIDS patients or viral carriers--i.e.,
working in the same office, meeting in public, using public transportation,
handling papers, sharing a locker room, attending school, etc.--does not spread
the disease.  Neither does sharing food, cooking utensils or glassware.
(Restaurant outbreaks have not been described.) Hugging, handholding, light
kissing and massage are safe.  Tears and saliva may contain small amounts of the
virus, but not enough to spread the infection.  There is no evidence to suggest
that young children are at risk when they play, or attend school, with either
AIDS patients or HIV carriers.  Even family members who live in the same home
with AIDS patients (and are not otherwise in a high risk category) have an
incidence of HIV disease no greater than that of the general population.

   Prevention - Advice

   When there is a question of contagion, razor blades and toothbrushes should
not be shared.  Countertops or bathroom fixtures soiled with body secretions can
be cleaned with household bleach (1/10 dilution with water), rubbing alcohol,
peroxide or Lysol.  These products kill the AIDS virus.

   Intravenous (IV injection) drug use should be discouraged. Addicts should at
least use sterile needles that they do not share with others.  Cleansing of
needles with household bleach or other products may provide some protection.
Some respected authorities have recommended that drug addicts be allowed legal
access to sterile syringes and intravenous needles, but this public health
measure has met with stiff opposition from substance abuse officials.

   "Safe" Sex

   Although effective, celibacy is not a acceptable alternative for most people.
Obviously, masturbation is safe, as are all forms of heterosexual and homosexual
intercourse if both partners are known to be faithful and free of the virus.  If
there has been no possibility of HIV exposure during the previous six to eight
months, a negative blood test assures the absence of HIV infection in most but
not all cases.  Persistent false negative AIDS tests have been reported, albeit
rarely.

   The following common sense information and advice applies to persons who are
uncertain about whether their sex partner(s) harbors the virus:

   1)  Know your sex partners:  Promiscuity--especially for bisexuals,
heterosexual women and gay men--increases the chances of contracting the virus.
Still, no one is guaranteed to be safe.

   2)  Avoid anal sex and fellatio:  Small tears or openings in the membranes of
the rectum and mouth are believed to be a common site of viral entry into the
bloodstream.

   3)  Heterosexual and bisexual women may contract the virus via "traditional"
vaginal intercourse.  Although female to male transmission is less common in the
U.S., heterosexual men have also contracted the disease from intercourse.  The
increased incidence of positive HIV antibody tests seen in female prostitutes is
a likely indication that AIDS will spread further among drug-free heterosexuals.

   4)  Condoms and Spermicidal Foam or Gel:  Latex rubbers provide some
protection and are strongly encouraged for oral sex as well as intercourse.
Before sex, be sure to examine the condom for defects or irregularities; all
suspicious prophylactics should be discarded.  Only water-based (not vaseline,
oils or cold cream) lubricants should be used, and care must be taken to put the
condom on before penetration and keep it on over the entire length of the penis
until withdrawal.  Rubbers should never be used more than once.  But even if you
are very careful, there is no guarantee: condoms often break or fall off. The
failure rate may be as high as seventeen percent.

   5)  Heavy Kissing -- Although the virus is present in saliva only in small
quantities in some AIDS virus carriers, exchanging saliva may be a way to
contract the disease, especially if you have mouth sores or abrasions.

   6)  Cuts and Abrasions -- The virus may gain access to the bloodstream
through breaks in the skin.  Protect them from contact with body secretions
(semen, blood, stool, saliva).

   7)  If you already know that you are HIV antibody-positive, your virus-free
lover(s) are at extreme risk from sexual contact with you.  They must be
informed.

   8)  HIV antibody-positive women should use an effective method of birth
control if they want to avoid pregnancy which could produce an HIV infected
infant. --

   BLOOD TESTS FOR AIDS

   Two serologic tests for AIDS, the acquired immunodeficiency syndrome, have
been commercially available since 1985.  They are the enzyme-linked
immunosorbent assay (ELISA) and the Western blot test.  Both measure antibody
which is produced by the immune system in reaction to exposure to the HIV or
human immunodeficiency virus, the agent which causes AIDS.  They do not detect
the actual presence of the AIDS virus--only previous exposure.  Therefore, a
positive test may indicate past infection which has been cleared by the body's
defenses, asymptomatic infection, AIDS or an AIDS-related disorder.  Other
laboratory studies for AIDS either have had limited use or are at present
reserved for clinical research purposes.

   When a first ELISA test is positive, duplicate tests are repeated with the
same specimen; the final result is reported as positive only if one of the two
repeated tests is also positive. In other words, two of three tests on the same
sample must react positively.  Designed to be an initial screening test, the
ELISA is relatively sensitive, i.e., it fails to identify very few subjects who
carry the antibody.  But it is not very specific; depending on population being
studied, up to eighty-five percent of positive ELISA tests are false.  A
positive ELISA test is more likely to represent true antibody-positivity when
high risk AIDS population groups are tested.

   Positive ELISA tests require confirmation by another method, usually the
Western blot test.  This test is more specific than the ELISA--a positive test
confirms HIV antibody positivity; however, it is a poor screening test because
it misses too many antibody-positive patients.  It is used mainly as a
confirmatory test for persons who have a positive ELISA.

   Because it usually takes four to twelve weeks for HIV antibodies to form
after exposure to the virus, serologic tests for AIDS may be negative during the
first few months after the virus has been contracted.  In some instances, this
"open window"--during which the person may be contagious--lasts six months or
longer.  To be reasonably sure that a person is free of the virus, serologic
tests must be negative following a six month period of abstinence from behaviors
known to contract HIV.

   Population Statistics

   There have been many studies to determine the prevalence of HIV
antibody-positivity in various groups.  The numbers vary greatly between
different geographic areas as well as between segments of the population.  The
following data represent approximations:

   1) General Population.......................: .040 percent
   2) Males, ages 18-45........................: .070 percent
   3) Females, ages 18-45......................: .007 percent
   4) Male Homsexuals..........................: 20-65 percent
   5) Intravenous (IV) Drug Users..............: 60-90 percent
   6) Hemophiliacs.............................: 50-75 percent
   7) Female Prostitutes.......................: 5-55 percent
   8) AIDS patients............................: 70-100 percent
   9) Female sexual partners of AIDS patients..: 30-35 percent
  10) Infants born to HIV-positive mothers.....: 50-60 percent

   Diagnosing AIDS

   Serologic testing is valuable in the diagnosis of AIDS and related disorders
in persons who demonstrate signs or symptoms of infection.  At the same time,
the diagnosis of AIDS requires more than a just positive test, but an entire
constellation of signs, symptoms or related infection.  Confirmed negative tests
do help to rule out AIDS and point the medical evaluation in other directions.
As noted above, however, some patients with the full-blown syndrome remain or
become antibody-negative.  Antibody levels may decline over time.

   Screening Programs

   Medically, morally, legally and financially--this is a very controversial
area.  In general, testing should be made available to all who request it.
Voluntary screening, with full informed consent, should be encouraged for all
members and sexual partners of persons in high risk groups.  These include male
homosexuals and bisexuals, intravenous drug users and hemophiliacs.  Others who
can benefit from voluntary testing include patients at venereal disease or drug
abuse clinics; women in the first three months of pregnancy, especially those in
high-risk areas; persons who seek family planning counseling in high-risk areas;
and candidates for surgery or other invasive procedures.

   Mass voluntary testing for everyone is not advisable for several reasons.
First, the prevalence of HIV antibody- positivity is low enough in the general
population that too many non-infected individuals would have falsely positive
tests and too many infected persons would have falsely negative tests. This
would create a great deal of unnecessary fear and confusion. Secondly, the time
and expense required to institute such a program would be prohibitive and would
sap energies and monies from more productive undertakings such as patient
education and basic research.

   There is no disagreement that testing should be mandatory for blood donors
and those who donate organs for tranplantation, or sperm or eggs for artificial
insemination or "test tube" fertilization.  Many authorities also recommend
mandatory testing of military personnel, federal and state prisoners, and new
immigrants to the U.S.

   Although several states legislatures have introduced bills to require HIV
antibody testing for all applicants for a marriage license, this practice is
neither an effective nor efficient use of the limited funds available for AIDS.
Compulsory testing for persons in groups at high risk for AIDS should also be
discouraged.  Mandatory testing could serve to frighten away from the medical
care community just those persons whom it wishes to attract.
 Confidentiality

   AIDS tests performed in the hospital or a doctor's office become a part of
the patients official medical record and should remain confidential.  HIV
counseling and testing sites (formerly called "alternative test sites"), which
offer anonymous testing under a code available to a limited number of medical
personnel, are available in many states.  As with many communicable diseases,
positive AIDS tests may be routinely reported to public health authorities.

   Interpretation & Counseling

   The most important parts of AIDS testing are interpreting the results and
educating the patient.  There are three possible outcomes of ELISA/Western blot
testing:

   1) If the ELISA is negative, no further testing is necessary. In a low risk
individual, HIV exposure is unlikely unless the exposure has been relatively
recent.  This person's blood or tissues can be used for donation.

   2) If the ELISA is positive and the Western blot is negative, the patient has
probably not been infected, but his or her blood should not be donated at
present.  Equivocal results should be repeated in six months.

   3) If both the ELISA and Western blot test are positive, the presence of HIV
antibody is confirmed.  Antibody-positive individuals can be told that they are
infected with the HIV and are contagious, but that they do not have AIDS.  They
do have approximately a one out of three chance of developing it in the ensuing
six to eight years.  Presently there is no way to predict which HIV
antibody-positive persons will suffer the full-blown syndrome.
!
*I'm feeling Depressed..

   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.
!
*I have these feelings of 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.
!
*I can't get to sleep...

   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.
!
*I have these 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.
!
*I have poor eyesight / Blindness in my eye(s)

   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.
!
*I have Double Vision.

   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.
!
*I see spots or small floating material in my eye...

   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.
!
*I have an Earache.

   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.
!
*I can't hear as well as I could..

   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.
!
*My ears are ringing!

      (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.
!
*I have a bad nosebleed!

   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.
!
*Yuck.. a runny nose!

   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.
!
*I can't smell things or things smell wrong.

   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.
!
*I can't taste well or things taste funny...

   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.
!
*I have sores in my mouth.

   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.
!
*I have a 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.
!
*My voiceis Hoarse..

   Hoarseness is due to disorders of the larynx or voicebox that result in an
inability of the vocal cords to vibrate normally. Although almost always just an
annoying, temporary complication of a viral upper respiratory infection,
hoarseness may persist or increase in severity.  When this occurs, medical
consultation is advised.

   Major Causes

Acute Laryngitis -- Inflammation of the larynx due to viral infections is the
most common cause of short-lived hoarseness.

Cancer -- Tumors of the vocal cords disrupt normal function. Smoking is a major
risk factor.

Vocal Cord Growths -- Ulcers, polyps, nodules and benign tumors are often due to
voice abuse, i.e. yelling, singing, etc.

Injury -- Direct trauma to the voice box during automobile accidents has been
occurring more frequently since the advent of lapbelts.

Inflammatory Diseases -- Tuberculosis, syphilis, leprosy, fungus infections and
disorders of the immune system may involve the vocal cords.

Vocal Cord Swelling -- e.g. from allergy, heart failure, blockage of veins in
the neck, radiation therapy, neck surgery, poor nutrition, liver, kidney and
thyroid disease, diabetes, leukemia.

Neurologic Disease -- For normal sound production, the voice box requires intact
coordination of the tiny muscles that move the vocal cords.  Strokes, muscular
dystrophy and other degenerative diseases of the nervous system must be
considered.

Vocal Cord Paralysis -- Inability of a vocal cord to move can result from damage
to its nerve.  Thyroid and heart surgery, injury from tubes placed into the
lungs for artificial respiration, tumors, and brain disorders may be implicated.
Often, the cause is unknown.

Miscellaneous -- Foreign objects lodged in the larynx and congenital disorders
should be considered in children.

   Evaluation

   Persistent hoarseness requires a complete examination with attention directed
toward the throat, neck and nervous system. Because the voice box and vocal
cords can only be viewed with the aid of special instruments (laryngoscope), an
ear, nose and throat specialist is usually consulted.

   Treatment

   Therapy of the underlying cause is indicated.  Please consult the Disorders
and Diseases section for more information. Laryngitis due to viral infections
may respond to increased humidity and voice rest.  Many vocal cord abnormalities
require surgery and voice rehabilitation.
!
*I'm having Heart 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.
!
*I have 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 oxygn- 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.
!
*I have a bad 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.
!
*I am coughing up blood!

   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.
!
*I have the croup and/or bad 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.
!
*I have a poor appetite...

   "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.
!
*I feel nauseas and/or am 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.
!
*I'm vomiting up blood.

   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.
!
*I have trouble 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.
!
*I have Heartburn / 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.
!
*I'm gaseous.

   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.
!
*My rectal is Bleeding...

   "Hematochezia" is the medical term for bright red rectal bleeding.  It is
usually indicative of hemorrhage into the lower gastrointestinal tract.  Because
blood which enters the upper part of the gastrointestinal tract mixes with acid
in the stomach and turns the stool to a tarry black (melenotic stool) color,
hemorrhage from sites in the esophagus, stomach and upper part of the small
intestine does not cause bright red blood in the stool, unless the bleeding is
profuse.

   When rectal bleeding is prolonged, it produces a fall in the blood count
(i.e. anemia), fatigue, weakness and pallor.  Profuse bleeding from the rectum
is a frightening experience.  It can lead swiftly to low blood pressure, shock
and death.

   Major Causes

Hemorrhoids -- These swollen rectal blood vessels are the most common cause of
rectal bleeding.  Straining at the passage of a bowel movement causes them to
burst producing small amounts of blood to appear on the surface of the stool,
toilet paper and toilet water.

Anal Fissures and Proctitis -- Inflammation of the rectum and anus due to
inflammatory diseases or infection can produce intermittent bleeding from raw
spots or cracks.

Colon Cancer -- Tumors of the large intestine are a significant cause of rectal
bleeding in adults.  Weight loss, constipation and abdominal pain may be
associated.

Colitis -- Inflammatory diseases of the bowel typically produce abdominal pain,
fever and bloody diarrhea.

Infectious Diarrheas -- Intestinal infections can be hard to differentiate from
noninfectious colitis.

Polyps -- Benign growths in the colon can also bleed.

Arteriovenous Malformation -- This cumbersome term refers to a tangled mass of
blood vessels which can break open into the bowel.

Diverticula -- Outpouchings of the colon are seen in the majority of Americans
over the age of fifty.  On occasion they cause profuse hemorrhaging.

Miscellaneous -- rectal injury, anticoagulation medicines, cancers of the small
intestine, bowel infarction (lack of oxygen), foreign objects in the rectum.

   Evaluation

   Because hemorrhoids are so common, the presence of rectal bleeding should not
be attributed to them unless there no are other causes.  Tests of the stool for
blood, digital rectal examination, proctoscopy (direct visualization of the
rectum via a scope placed through the anus), barium enema (lower
gastrointestinal X-rays) and colonoscopy (direct visualization of the large
intestine via a flexible scope placed through the anus) may be required to
document the source of bleeding. Arteriography, a dye X-ray study of the vessels
of the bowel, is helpful in detecting abnormal or actively bleeding blood
vessels.

   Treatment

   Once the source of bleeding is determined, effective therapy can be
individualized.  Please consult the Disorders and Diseases section for specific
treatment regimens.  Life-threatening hemorrhage requires hospital care, blood
and fluid transfusions, and sometimes emergency surgery.
!
*I have blood in my Urine...

   "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.
!
*It hurts when I pee...

   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.
!
*I can't pee!

   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.
!
*I'm Dizzy.

   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.
!
*I feel Faint / Light-Headed...

   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.
!
*I'm shaking...

   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.
!
*I feel so weak...

   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 cut, 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.
!
*I have numbness and/or tingling on my skin...

   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.
!
*I have a Lump in my Breast...

   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.
!
*My scalp Itches...

   Itching is a bothersome symptom which is familiar to everyone. The medical
term is "pruritis."  It can be generalized or limited to certain areas of the
skin.  Although itching is usually harmless and short-lived, it may indicate a
serious disease.

   Major Causes

   Itching associated with a rash, bite or sore is usually due to a disorder of
the skin.   Common examples are eczema, psoriasis, hives, insect bites,
infections, infestations (e.g. lice) and sunburn.  When no skin abnormality is
apparent, the diagnosis is more difficult to make.  The most likely explanation
is dry skin due to the natural aging process or low-humidity winter heating.
Medications, drug withdrawal, kidney failure, liver diseases, tumors, parasitic
infections and blood disorders are other possibilities.  Emotional stress can
bring on pruritis which is psychological in nature.

   Evaluation

   If a skin rash is characteristic of a specific diagnosis, no testing may be
required apart from the examination.  A skin biopsy (removal of a small bit of
skin for microscopic examination) can be helpful when the cause of the rash is
in doubt.  A complete examination and blood tests are utilized to rule out
serious diseases.

   Treatment

   As usual, the therapy depends on the cause.  Treatment is poor when the cause
cannot be identified or reversed.  A combination of camphor, phenol, menthol and
Nivea cream may be helpful.  When dry skin is responsible, mild soaps (e.g.
Basis, Neutragena), emolients and a home humidifier can provide relief.
Antihistamines such as diphenhydramine are effective treatment for hives.
!
*I'm losing my Hair!!

   Hair loss usually reflects normal changes in body physiology seen with
physical maturity and aging.  However, significant hair loss may be a reaction
to disease, poor nutrition, stress or medication.  It may take the form of
increased hair shedding or baldness (alopecia).  In our appearance-conscious
society, the cosmetic repercussions are increasingly important.

   Major Causes

Male-pattern baldness -- The presence of a receding hairline and bald spot with
advancing age is influenced by genetic factors, light, climate and the effects
of male hormones.  Women are affected to a lesser degree.

Newborn Babies -- Baldness and increased loss of hair occur normally in babies
in the first few months of life.  The adult pattern of hair growth develops at
six to twelve weeks.

Pregnancy -- Many women notice significant hair loss in the third month after
childbirth.  This reflects an adaptive negative reaction to the increase in the
percentage of actively growing hair follicles seen during pregnancy.  Baldness
rarely ensues.

Alopecia Areata -- In this disorder well-demarcated patches of hair loss are
noted on the scalp or other body locations.  The whole scalp may become
involved.  The cause is unknown.

Telogen Effluvium -- Marked sudden hair loss is seen as a reaction to severe
disease, injury or emotional stress.  The normal cycle of hair growth and rest
is temporarily disturbed.

Nutritional Factors -- Extreme weight loss, "crash" dieting and protein, calorie
and iron deficiencies have been implicated.

Hormonal Disease -- e.g. pituitary and thyroid disorders.

Skin Disorders -- Tinea capitus (ringworm), eczema, psoriasis, and seborrhea may
produce localized  hair loss and inflammation. Skin cancers, infections and many
other diseases can lead to irreversible hair loss.

Medications -- e.g. cancer chemotherapy, colchicine, "blood thinners," thyroid
medicines.

Hair Injury -- Damage to the scalp, skin, and hair fibers from burns, freezing,
radiation, acids, hair treatments, rollers and curlers, etc. is largely
preventable.

   Congenital and hereditary abnormalities of the hair fibers or follicles are
too numerous to detail here.

   Evaluation

   The medical history, in conjunction with inspection of the scalp or areas of
hair loss, will usually yield the diagnosis. Biopsy of the skin site, blood
tests and cultures are important when the cause is not obvious.  A dermatologist
may be consulted.

   Treatment

   Many types of hair loss will cease or reverse with therapy of the underlying
cause.  Hair transplants, weaves and pieces are gaining popularity for
irreversible baldness.  Minoxidil, a high blood pressure medication, has some
ability to stimulate new hair growth when it is applied directly to the scalp.
But news reports of its efficacy have been somewhat overblown.  And despite
sensational media claims by purveyors of other products, the miracle hair
restorer has not yet been developed.
!
*I have too much hair!

   Hirsutism is the excess growth of body hair in women.  When severe, the
pattern of hair distribution resembles that seen in men, i.e. facial, chest,
body hair.  Other signs of masculinization may be present.  In the majority of
cases, hirsutism represents a variation of normal which has only genetic and
cosmetic implications.  However, hormonal disorders, tumors and medications may
be responsible.

   Major Causes

   In both men and women the distribution of hair growth is under the influence
of male hormones called androgens.  Hair follicles in different parts of the
body grow in response to exposure to varying types and concentrations of
androgens.  Body and facial hairs respond mainly to testosterone, a potent
androgen produced in large quantities in the testes.

   Because women make only small amounts of testosterone and weaker androgens in
the ovaries and adrenal glands, they develop less body and facial hair than men.
Masculinizing disorders in women, however, may produce excessive body hair,
acne, deepening of the voice, balding, cessation of menstruation, enlargement of
the clitoris, decreased breast size and loss of the female shape. Among the
possible explanations for these changes are:

Genetics -- The amount of body hair is in part hereditary.  It tends to run in
families as well as along racial lines.  Dark- skinned whites tend to be more
hirsute than blacks, Asians and American Indians.

Pregnancy -- Increased body hair is seen in women during the first three months
of pregnancy.

Ovarian Disorders -- Polycystic ovarian disease (Stein-Leventhal syndrome) may
result in hirsutism and abnormal menstruation. Tumors and benign growths of the
ovary can also secrete large amounts of androgens.

Adrenal Disorders -- Overproduction of androgens is seen with a variety of
adrenal tumors and growths, e.g. Cushing's syndrome.

Medications -- e.g. dilantin, minoxidil, steroids, progesterone

   In the majority of women with increased body hair, no cause can be
identified.

   Evaluation

   The medical history may disclose an obvious cause (medication), but attention
should be paid to signs of defeminization and masculinization.  Sophisticated
hormone tests are required to diagnose most disorders.  A gynecologist and/or
endocrinologist (hormone specialist) may have to be consulted.

   Treatment

   Therapy is directed at the underlying cause.  Depilatories, shaving, plucking
and electrolysis are sometimes helpful.
!
*I have Swollen Lymph Glands...

   Swollen glands are not glands at all, but enlarged lumps of lymph tissue
called nodes.  Lymph nodes are comprised mainly of blood cells that act as part
of our system of immunity against infection and tumors.  They are located
throughout the body and are connected by lymph vessels which empty directly into
the bloodstream.

   When nodes enlarge, they may be felt on the head and face, in the neck, under
the arms, above the elbows and knees, and in the groin.  The spleen (and to a
lesser extent the liver) is also a lymph organ; when it enlarges, it can be felt
in the upper abdomen beneath the left ribcage.  Lymph nodes become noticeable
when they grow in size or ache.  Because they may be a sign of a serious
disorder, they should not be ignored.

   Major Causes

Infection -- Nodes enlarge in response to infections of all kinds.  Common
examples are strept. throat, infectious mononucleosis (Mono), tuberculosis,
viral hepatitis and skin infections.  The area of nodal enlargement corresponds
to the part of the body which harbors the infection, e.g. swollen glands in the
neck from throat infections, enlarged groin nodes from leg or venereal
infections, spleen enlargement from bloodstream infections.

Cancer -- Tumors of the blood (leukemia) and lymph system (lymphoma) may present
initially as enlarged nodes and spleen that fail to shrink away.  Breast, lung,
head, neck and bowel cancers are just some of the tumors that cause swelling of
lymph nodes as they spread throughout the body.  For instance, breast cancer
often involves the nodes in the armpit.

Miscellaneous -- some forms of arthritis; reaction to Dilantin, a seizure
medication; sarcoidosis, a disease associated with inflammmation of many organs;
benign lymph node diseases; inherited disorders; hormonal diseases; AIDS and
AIDS-related complex (ARC).

   Evaluation

   In most cases enlarged lymph nodes are obviously due to minor infections of
the throat or skin.  They usually resolve within a couple of weeks.  Lymph node
swelling that persists, affects more than one node area, involves unusual
locations without an obvious reason or is associated with fever, weight loss,
fatigue or enlargement of the spleen requires intensive investigation.  A
complete examination, including chest X-ray, and blood and skin tests, is
required.  Often scans of the liver and spleen, bone marrow tests, and biopsy of
the involved lymph node(s) will determine the cause.

   Treatment

   The therapy is directed at the underlying cause.
!
*I have a Headache...

   Headache, one of the most common of all human ailments, is a cardinal symptom
of disorders of the brain.  Despite this frightening prospect, most headaches do
not have serious consequences.  The majority are insignificant but annoying
interruptions in our everyday sense of well-being.

   Major Causes

   Headache pain has its source in the blood vessels, muscles, nerves and joints
of the head, face and neck.  The eyes, ears and sinuses are other important
sources.  Perhaps surprisingly, the brain is unable to sense pain directly.

Tension Headache -- These constant, dull headaches tend to be continous in
nature and located in the neck and both sides of the head.  They may last for
days or weeks.  The pain is associated with tension of the muscles of the head
and neck; it is brought on by nervousness, anxiety and depression.

Migraine Headache -- These one-sided, sharp, pounding headaches are
intermittent.  They may be ushered in by a warning or aura of flashing lights,
weakness or numbness.

Infections -- Meningitis, brain abscess and encephalitis are often associated
with fever, altered mentation and a stiff neck.

Sinus Headaches -- Blockage or infection of the sinuses may cause pain in the
forehead and under the eyes.  It is aggravated by bending over and by pressing
on the overlying skin.

Tumors -- The headache associated with a brain tumor is nonspecific in nature;
it becomes more severe over time. Vomiting occurs late in the course of the
disease.

Cerebrovascular -- Strokes, aneurysms (enlarged blood vessels), and brain
hemorrhages represent life-threatening causes of headache.  With the latter, the
headache is extremely severe.

Head Injury -- Concussion, brain contusion, skull fractures

Cluster Headache -- These headaches are recurrent one-sided, intense pains
located behind the eye.  They occur at night and are marked by tearing, runny
nose and redness of the cheek.

Miscellaneous -- eye pain, fever, high blood pressure, altitude sickness,
medications, tooth infections, recovery from a spinal tap, vasculitis (group of
diseases which cause blood vessel inflammation), jaw pain, neck arthritis,
neuralgia.

   Evaluation

   Headache is a difficult problem to diagnose.  The character, location and
timing of the pain give the best information. Careful eye and neurologic
examinations may provide the answer, but they are usually normal.  Sinus X-rays,
brain wave tests, brain scan, CAT scan (computerized cross-sectional X-ray) or
MRI (magnetic resonance imaging) of the head, and cerebral arteriograms (dye
X-ray study of the blood vessels in the brain) may be indicated.

   Treatment

   First, the cause must be determined.  Specific medication or surgery is
indicated for many of the above disorders.  Adjunctive measures include rest,
cool compresses, aspirin or acetaminophen, relaxation techniques and
biofeedback.
!
*I'm having Chest Pains...

   Although pain in the chest may be minor and of little consequence, it is a
cardinal symptom of heart and lung disease. It should not be taken lightly.
Chest pain is said to be "pleuritic" when it is made more severe by taking a
deep breath.

   Major Causes

   Almost any structure in the chest and upper abdomen can produce chest pain.
The heart and lungs, and the muscles, ligaments and bones of the chest, neck and
shoulders are the source of chest pain in the majority of patients.  The common
explanations for chest pain are listed below:

Angina Pectoris -- This is pain due to insufficient blood supply to the heart
muscle.  Typically, it is described as a dull pain or pressure which is located
behind the breastbone, brought on with physical exertion and relieved by
nitroglycerin.

Myocardial Infarction (heart attack) -- The pain of a heart attack resembles
angina pectoris.  However, it is of longer duration and is often associated with
shortness of breath, nausea and sweating.

Pericarditis - Inflammation of the pericardium, the membrane which surrounds the
heart, produces a sharp, pleuritic chest pain which is relieved by sitting
upright.

Aortic Aneurysm - Rupture of aorta, the major artery exiting the heart, results
in a severe, sharp tearing pain which radiates through to the back.

Pulmonary Embolism (blood clot in the lungs) -- When this disorder produces
chest pain, the pain tends to be sudden in onset, pleuritic in nature, and
associated with cough and shortness of breath.

Pleuritis (pleurisy) -- Inflammation the pleura, the membrane lining the lungs,
causes sharp pleuritic chest pain, cough and fever.  Pleuritis is often related
to upper respiratory infections and pneumonia.

Pneumothorax (collapsed lung) -- This may occur spontaneously or with injury to
the chest.  Shortness of breath is frequently associated.

Spinal disorders -- Arthritis, deformities or "slipped discs" can irritate or
compress the nerves which supply the chest wall.  The pain is usually dull in
nature, with sharp twinges brought on by movement of the spine.

Costochondritis (Tietze's syndrome) -- Inflammation of the cartilaginous joints
where the ribs attach to the breastbone produces a sharp, usually pleuritic,
chest pain which is increased in severity by palpation of the involved area.

Esophageal Pain -- Inflammation or spasm of the esophagus can produce a dull or
burning pain which is often confused with angina pectoris.  It may be
precipitated by eating.

Other causes of chest pain are rib fractures, muscle tears, shingles, shoulder
arthritis, breast diseases and peptic ulcers. Many people experience fleeting
episiodes of sharp chest pain for which no cause can be identified.

   Evaluation

   The description of the pain is important.  Knowledge of its relationship to
meals, exertion or a history of injury can help to narrow down the possible
explanations.  A past history of heart disease cannot be ignored.  Thorough
examination is required.  Chest x-ray and electrocardiogram (EKG) provide
important information.  Hospitalization for further testing and observation may
be necessary.

   Treatment

   Pain relievers should not be taken until the diagnosis is assured.  Specific
therapy depends on the cause.  Heat, rest and anti-inflammatory medications are
effective for musculoskeletal disorders.
!
*My Stomach Hurts...

   Abdominal pain is a symptom which we have all experienced at one time or
another.  The discomfort may described as burning, aching, stabbing, cramping or
pressure.  It can be located anywhere from the bottom of the ribcage to the
pubic bone, in the middle or to one side.  When severe, prolonged, or recurrent
it requires prompt physician evaluation.

   Major Causes

   The most common disorders responsible for abdominal pain are listed below by
organ, structure or process involved:

Esophagus -- esophagitis (inflammation), ulcers, tumors.

Stomach -- gastritis (inflammation), ulcers, tumors.

Intestines -- "stomach flu," irritable bowel syndrome, ulcers, colitis,
appendicitis, bowel obstruction, constipation, diverticulitis, tumors.

Liver, Gallbladder, Spleen -- gallbladder attacks and stones, hepatitis, liver
and spleen enlargement, tumors.

Pancreas -- pancreatitis (inflammation), tumors.

Kidneys, Urinary Tract -- infection, stone, tumor, obstruction.

Uterus, Tubes, Ovaries -- infections, tumors, cysts.

Peritonitis -- Inflammation of the membrane lining the abdominal cavity is
usually caused by infection after surgery, or perforation of ulcers, intestine,
gall bladder, etc.

Abdominal Wall -- muscle strain, spasms.

Blood Vessels -- decreased oxygen delivery to intestines from blood clots,
atherosclerosis or ruptured aneurysm.

Nerves -- shingles, neuropathy from spinal arthritis.

Metabolic -- diabetes, kidney failure, porphyria.

Referred abdominal pain --  This is pain which has its origins in sttuctures
which lie outside of the abdomen.  Genital infections and tumors, heart attack,
pneumonia and blood clots in the lungs are sometimes marked by discomfort in the
abdomen.

   Evaluation

   For abdominal pain the character, intensity, duration, location and
associated symptoms provide a great deal of information about the possible
causes. It is helpful to note when the pain comes on; how long it lasts; whether
it moves around; what makes it worse (e.g. meals, body position); what makes it
better (e.g. medication, bowel movements, meals); and whether it is associated
with fever, changes in appetite or bowel movements, nausea, vomiting, painful
urination, or recent injury. Examination of the abdomen, rectum, genitals, chest
and heart is crucial.  Although X-rays and blood tests may be diagnostic, the
physician must rely mainly the findings of the examination. Emergency surgery
may be required.

   Treatment

   Strong pain killers should not be given prior to confirmation of the
diagnosis.  They may mask the real cause.  Please consult the Disorders and
Diseases section for information about the specific diseases.
!
*My lower back hurts...

   Pain in the lower back is one of the most common afflictions of modern life.
Due to the difficulty pinpointing its cause, relieving the discomfort and
preventing recurrence, it can lead to great frustration on the parts of both
patients and physicians.  Persistent backache is a significant cause of
disability and lost time from work.  Partly for this reason, it frequently has
important medical-legal implications in our increasingly litigious society.

   Major Causes

Lumbar-Sacral Strain -- Injury to the low back muscles, ligaments or tendons is
the most common cause of backache.  Poor posture, obesity, weak musculature and
spinal deformities may be contributory.  Often the injurious event can not be
recalled.

Lumbar Disc Disease -- Herniation or "slippage" of a disc typically results in
back pain (sciatica) that moves down the leg and is associated with numbness,
tingling or weakness in the extremity.  Contrary to popular belief, a history of
injury is not apparent in the majority patients.

Spinal Arthritis -- Degenerative arthritis of the lower spine is extremely
prevalent in the elderly.  Other forms of arthritis can attack age group, e.g.
ankylosing spondylitis.

Spinal Defects -- Congenital or acquired abnormalities of the vertebrae can lead
to persistent back ache, disc and nerve injury, and arthritis.  Examples are
spondylolysis and spondylolisthesis.

Fractures -- Injury to the back can crush the vertebrae in the lower spine, but
spontaneous compression fractures due to either age-related thinning of the
bones (osteoporosis) or tumors are not unusual.

Tumors -- Cancers of the spine and spinal cord can produce severe, unrelenting
pain and nerve damage.

Infections -- e.g. spinal meningitis, bone and disc infections.

Abdominal Causes -- Sometimes the pain originates in the abdomen, but is
perceived to come from the back.  Pain that radiates to the back can be seen
with kidney tumors and infections, ulcers, gall bladder pain, cancers, aneurysms
and disorders of the uterus, tubes and ovaries.

Miscellaneous -- fibrositis (inflammation of soft tissues), bad posture,
shingles, hypochondriasis, malingering.

   Evaluation

   The examination focuses on the abdomen, back, legs and nervous system.
X-rays of the spine are indicated when there is a history of injury or
persistent, severe pain.  CAT scan (computerized cross-sectional X-ray) of the
spine and myelography (dye X-ray of the spinal canal) are employed to document
spinal cord and nerve root compression.  Unfortunately, many persons with back
pain remain undiagnosed.

   Treatment

   Specific therapy depends on an accurate diagnosis.  Rest, heat and analgesics
are recommended for strains.  Special exercises, a hard mattress, and weight
loss can help to prevent recurrences.  The efficacy of chiropractic manipulation
in chronic back pain is uncertain, yet some people appear to benefit.  For
practical advice about dealing with a bad back, please consult the section on
Home Care and First Aid.
!
*My muscles ache and cramp.

   Muscles aches and cramps are common complaints of persons who overexert
themselves.  Yet, they are also prominent symptoms of a number of different
illnesses.  "Myalgias" is the term ascribed to a generalized aching and soreness
of the muscles.  A cramp is a sharp, intense pain from muscular spasm.

   Major Causes of Myalgias

Physical Activity -- Overexertion or strenuous use of unconditioned muscles
produces stiffness and pain.

Infections -- Fever, fatigue and muscle soreness complicate many viral,
bacterial and parasitic infections including influenza, chickenpox, measles,
shingles and trichinosis.

Tendonitis/Fibromyositis -- Inflammation of the muscles due to minor injury,
overuse or cold exposure causes pain in localized areas.  The neck, back and
shoulder are most often involved. Fibromyositis or fibromyalgia is a disorder of
unknown cause that affects mainly young women.  It is characterized by localized
points of pain, morning stiffness, fatigue and insomnia.

Rheumatic Diseases -- Many types of arthritis also cause muscle pain.
Polymyalgia rheumatica is a specific disease that affects older individuals.

Medications -- cortisone and other steroids, "water pills" that decrease blood
potassium, hydralazine, procainamide, anticonvulsants.

Miscellaneous -- alcoholism, underactive or overactive thyroid, tumors, low
blood calcium, inherited deficiency of muscle enzymes, psychological causes.

   Major Causes of Cramps

   Cramps are usually short-lived, localized pains which are relieved with rest,
heat and massage.  The common causes are heat, dehydration, strenuous activity
and pregnancy.  Leg cramps brought on by walking may be due to decreased blood
supply (atherosclerosis) to the muscles.  This symptom is known as intermittent
claudication.  When cramps or spasms are persistent, severe, recurrent or
involving many muscles at once, the following disorders may be responsible: low
blood calcium or magnesium, hyperventilation, tetanus, neuromuscular diseases,
black widow spider bites, psychiatric medications.

   Evaluation

   For muscle aches, a complete health history and examination will usually
reveal an obvious cause such as overuse, infection or medication.  Localized
tenderness is characteristic of fibromyositis.  Blood tests are required to
diagnose thyroid disorders, chemical deficiencies and rheumatic diseases.  Blood
tests and neurologic evaluation are indicated for persistent spasms.
Measurement of the electrical activity of individual muscles (EMG), and biopsy,
may be necessary.  Intermittent claudication or exertional leg cramps require
special tests to diagnose narrowing of the arteries.

   Treatment

   Therapy depends on the cause.  Myalgias due to overuse respond well to heat,
rest, massage and aspirin or other anti- inflammatory medications.  Exercise
programs and stretching are preventive.  Cramps may be relieved by stretching
the involved muscle.  Quinine occasionally helps recurrent unexplained cramps.
!
*I feel fatigued.

   Fatigue is one of the most common health complaints in the general
population.  Not to be confused with muscular weakness, it is often described as
a lack of energy, lassitude, general weakness, tiredness or exhaustion.  Fatigue
from lack of sleep, strenuous physical activity or emotional stress is to be
expected, but unexplained weariness may be a sign of serious disease.  Although
medical evaluation is indicated to exclude a physical explanation, psychological
and situational factors are usually responsible.

   Major Causes

   Fatigue is such a nonspecific symptom that its presence alone gives little
clue to its cause.  Almost any major or minor illness can be implicated.  Among
the disorders that should be considered are:

Psychological -- Malaise occurs with anxiety states, depression, emotional
stress and apathy.  Headache, poor appetite and weight loss are often
associated.  Insomnia may compound the problem.

Anemia -- Fatigue is a cardinal symptom of patients with low blood counts, i.e
decreased hemoglobin, the oxygen-carrying protein in red blood cells.  Insidious
in onset, it may also cause shortness of breath and chest pains in persons with
heart or lung disease.

Chronic Infection -- e.g. hepatitis, tuberculosis, pneumonia

Hormonal Diseases -- e.g. diabetes, thyroid disease

Medications -- Fatigue may be a side effect of blood pressure pills,
anti-depressants, sleeping pills, tranquilizers, etc.

Miscellaneous - cancer, kidney failure, emphysema, heart failure, cirrhosis,
malnutrition, pregnancy, neurologic disorders.

   Evaluation

   The variety of illnesses that may cause fatigue is so great that a complete
medical history and examination is necessary. Psychosocial factors are stressed,
i.e. mood, work situation, finances, family relationships, sexual activity,
sleeping habits, drug use, etc.  General screening blood and urine tests, EKG,
and chest X-ray may provide some information.  In the majority of cases, no
physical cause is identified.

   Treatment

   Therapy is directed at the underlying cause.  When no physical explanation is
confirmed, attempts can be made to modify pyschosocial factors: for example,
changing jobs, going on vacation, marital and family counseling.  Regular
exercise, adequate sleep and a balance diet are recommended.
!
*I'm losing too much weight.

   A calorie is a unit of energy.  Maintenance of body weight is dependent upon
the balance between caloric intake and energy expenditure.  When expenditures
exceed intake, weight loss ensues.  The loss of one pound is approximately equal
to a 3,500 calorie deficit.  The deficit may be a result of decreased food
ingestion, decreased nutrient utilization, increased energy requirements or a
combination of factors.  This article will consider only unintentional weight
loss.

   Major Causes

Cancer -- Malignant tumors are one the most common causes of weight loss when
other explanations are not immediately apparent. The intestinal tract is often
involved.

Gastrointestinal Disease -- Many disorders of the esophagus, stomach and
intestines are manifested by weight loss.  The mechanism may be decreased
appetite, inability to absorb nutrients and/or inflammation.

Diabetes Mellitus -- Insulin is required for the utilization of nutrients and
the synthesis of fats and proteins.  Diabetics lose calories in their urine in
the form of sugar and have an accelerated breakdown of body tissues.

Hyperthyroidism -- Overactivity of the thyroid gland leading to excess thyroid
hormone causes weight loss due to an increase in the basal metabolic rate. This
means that the body's chemical reactions use up a greater number of calories.
Nervousness and increased physical activity may be contributing factors.

Infection -- Decreased appetite and increased energy demands are associated with
most serious or chronic infections.  Tuberculosis (TB) is a classic example.

Psychological Factors -- Almost any emotional disturbance can affect one's
appetite (e.g. depression, anxiety, excitement). Diseases such as anorexia
nervosa have weight loss as a cardinal manifestation.  Decreased food intake is
responsible.

Miscellaneous -- Weight loss can be a part of almost any chronic illness.
Examples are kidney disease, emphysema, cirrhosis, severe arthritis and hormone
deficiencies.

   In about one-third of patients with unexplained weight loss, no explanation
is ever elucidated.

   Evaluation

   The amount of weight lost should be documented by actual measurement over a
period of time.  Changes in clothing size may be a clue.  When there is a
question about food intake, calorie counting may be informative.  Most weight
loss is associated with a poor appetite; however, increased food ingestion may
be seen with diabetes, hyperthyroidism and intestinal malabsorption. Blood tests
and X-rays are usually necessary to detect a hormone imbalance or cancer.

   Treatment

   Specific therapy is dependent upon the cause.  Intravenous feedings are used
when the intestinal tract is not functioning. Nutritional supplements are
important.
!
*I'm gaining too much weight.

   Most overweight Americans eat too much and exercise too little.  However,
recognizing some of the medical disorders that lead to weight gain may help some
individuals win the "battle of the bulge."  Weight gain may reflect an increase
in tissue mass, body fluid, or both.  In healthy persons, a one pound gain in
tissue mass requires a 3,500 calorie intake in excess of expenditure.  A pound
of fluid weight is equal to about one pint in excess fluid accumulation.
Obesity can be defined as body weight exceeding 120 percent the ideal as
determined by age, height, body type and gender.  Morbid obesity can be defined
as greater than 200 percent the ideal.

   Major Causes

   Rapid weight gain implies fluid accumulation.  Heart, kidney and liver
diseases are the most likely explanations.  Some women gain water weight each
month around the time of their menstrual period.  Steroid hormones (e.g.
cortisone) are notorious for their ability to cause water and salt retention.

   Increases in body weight due to an increase in tissue mass tend to occur more
gradually.  By far the most common cause is overeating.  Occasionally, the
following disorders are implicated:

Hypothyroidism -- Decreased production of thyroid hormone due to underactivity
of the thyroid gland is the most common medical condition accounting for weight
gain.  It has a predilection for women and tends to be insidious in onset.  A
goiter, hoarseness, intolerance to cold, constipation and changes in the skin
and hair may be associated.

Cushing's Syndrome -- This disorder refers to a number of different diseases
which result in an excess blood concentration of adrenal steroid hormones
(cortisol).  Fat tissue tends to be exaggerated around the face, neck and trunk.
High blood pressure, fatigue, increased body hair and skin changes are
associated.  Pituitary or adrenal tumors are usually responsible.

Hypogonadism -- Decreased production of sex hormones produces typical changes in
the secondary sexual characteristics as well as obesity.

Insulin-producing Tumors (Insulinoma) -- These rare tumors result in episodic
hypoglycemia (low blood sugar).

Brain Tumors -- Rarely, growths in the hypothalamus, the part of the brain which
controls appetite and satiety, can cause a gain in weight.

   Evaluation

   Weight gain in excess of two pounds per day implies fluid accumulation.
Because many people don't appreciate their love of eating until they keep a food
diary, calorie counting may help determine if a person is overindulging.
Specialized blood and hormone tests are required to rule out physical
explanations.

   Treatment

   Diet, exercise and psychological support groups are helpful. Hormone
replacement and diuretics (water pills) should be employed only when indicated.
!
*I bruise too easily.

   Bruises represent bleeding into the tissues near the surface of the skin.
Depending on the amount of blood that needs to be absorbed, they may last a few
days to a few weeks.  In healthy individuals bruises result from direct injury
to the affected area.  However, insignificant injuries often go unnoticed, and
all of us have had the experience of discovering bruises for which we have no
ready explanation.  When bruising is severe, frequent, unrelated to injury, or
associated with other forms of hemorrhage, medical care should be sought to
exclude a bleeding disorder.

   Major Causes

   The control of bleeding requires that three conditions be met: intact blood
vessels, effective blood clotting, and normal numbers of functioning platelets.
Platelets are tiny bits of cellular material produced in the bone marrow.  They
circulate in the bloodstream where they plug up holes in injured blood vessels.
The first line of defense once hemorrhaging begins, they start to work even
before the clotting system is activated. Bruising may occur when any of the
above three vital conditions are not met.

   Causes of weak blood vessels include the aging process, cortisone-type
steroid medications, vitamin C deficiency (scurvy) and vasculitis.  The latter
refers to a group of diseases characterized by blood vessel inflammation
throughout the body.  The bruising associated with vasculitis is called purpura,
and typically it is raised off the surface of the skin (palpable).  Vasculitis
usually affects many organs, causing fevers, arthritis and kidney disease.

   Defective blood clotting may be either inherited (e.g. hemophilia) or
acquired.  A personal or family history of bleeding disorders, easy bruising or
profuse bleeding after surgery is suggestive.  Besides easy bruising, bleeding
into the mucous membranes, urine, stool and joints is characteristic. Acquired
abnormalities of blood clotting can be due to liver disease, "blood-thinning"
medications such as warfarin (Coumadin), malnutrition, multiple blood
transfusions and diseases of the immune system.

   Defective or decreased numbers of platelets may be caused by a variety of
conditions: reactions to medications, infections, cancers, nutritional
deficiencies, transfusions, immune diseases, inherited diseases (e.g. von
Willebrand's), chemotherapy, radiation, and most prominently, diseases of the
blood and bone marrow.  Aspirin and similar anti-inflammatory medicines that
block the action of prostaglandins, a substance necessary for normal platelet
function, are frequently implicated.  The effects may last for days even after
the medication has been discontinued.

   Evaluation

   In the vast majority of cases, nothing is wrong and all that is needed is
reassurance.  If the findings of the initial medical history and examination are
significant, blood tests including a platelet count and clotting studies
(Protime and PTT) may be ordered.  A skin biopsy can help to diagnose
vasculitis, and a bleeding time is used as a general screen for platelet
function. More complicated testing, such as special clotting studies and bone
marrow examinations, are not routinely required unless the above tests are
abnormal.

  Treatment

   As usual, therapy must be directed at the underlying cause.
!
*I have the hiccups.

   Hiccups are intermittent, reflex spasms of the muscles of inspiration
associated with closure of the windpipe such that little air is inhaled.
Generally, they are benign and last only a few minutes.  Intractable hiccups, a
rare disorder, is referred to as "singultus."  Many people don't realize that
recurrent hiccups or singultus can be a sign of a serious illness.

   Major Causes

   Because episodic contraction of the diaphragm, the flat respiratory muscle
that separates the chest cavity from the abdomen, is the primary abnormality,
any disorder that either stimulates or irritates this structure or its (phrenic)
nerves can cause hiccups.  Inflammation or infection of the liver (i.e.
hepatitis); tumors of the liver, diaphragm, and lung; distention of the stomach;
abscesses beneath the diaphragm; intestinal bleeding; pneumonia or pleurisy at
the base of the lung(s); diseases of the esophagus; heart attacks; and
compression of the nerves to the diaphragm have all been implicated.  Strokes,
brain tumors, kidney failure and general anesthesia are some other causes.

   Evaluation

   Occasional, transient hiccups are a normal part of everyone's life; they
should be of little concern, except for some embarrassment.  When protracted or
recurrent, a search should be made for one of the above disorders.  Chest,
abdominal and intestinal x-rays and an electrocardiogram may be required.

   Treatment

   Home remedies can be tried, but their efficacy is uncertain. Recommended
techniques have included drinking a glass of water, swallowing a teaspoon of
sugar, vinegar, breathing into a paper bag, holding one's breath, pain and
fright.  For refractory hiccups or singultus, chlorpromazine (Thorazine),
methylphenidate or metoclopramide (Reglan) may be effective.  A drastic step is
the surgical severance of the phrenic nerve.  It should be reserved only for the
most severe cases.
!
*I have chronic bad breath.

   We are constantly being reminded of the social implications of bad breath.
However, making a good impression may require more than using the right
mouthwash.  Dental or medical consultation may be the answer.

   Major Causes

   Foul-smelling bacterial infection and chronic mouth inflammation are the most
common causes of bad breath.  Dental cavities and mouth, tongue, and gum
infections head the list. Bronchiectasis, an infection and enlargement of the
bronchial tubes, and lung abscess also produce halitosis.  Frequently, smokers
have bad breath that is unrelated to mouth and lung infection.

   Three serious illnesses give specific mouth odors.  Liver failure causes a
fishy odor (fetor hepaticus), kidney failure an ammonia odor, and diabetic coma
(ketoacidosis) a fruity odor. Finally, many healthy individuals have persistent
bad breath for no apparent reason.

   Evaluation

   Examination of the mouth will yield the diagnosis when dental infection is
responsible.  A history of cough, fever and weight loss suggests bronchiectasis
or lung abscess.  A chest X-ray may be diagnostic.  Diabetic ketoacidosis, liver
disease and kidney failure each have a characteristic constellation of symptoms
and physical and laboratory abnormalities.

   Treatment

   Teeth brushing, flossing, mouthwashes and breath mints are effective in most
instances.  When an underlying illness can be identified, specific therapy is
employed.  Dental consultation is useful.
!
*Tell me about Cataract Surgery.

   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.
!
*Tell me about Face Lifts...

   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.
!
*Do I need Ear Tubes?

   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.
!
*Do I need to have my Tonsils removed?

   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.

!
*About Donating Blood...

   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!
!
*How do I get rid of Varicose Veins?

   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.
!
*How do I get rid of a Hernia...

   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.
!
*Tell me about Back Surgery...

   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.
!
*How do I take a Pulse?

   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.
!
*How do I take 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.
!
*How do I treat a Fever?

   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.
!
*How do I treat 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.
!
*How do I stop 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.
!
*What can I do for a 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.
!
*How do I stop 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.
!
*How do I treat the 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.
!
*How can I get relief from 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.
!
*How do I treat Diaper Rash?

   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.
!
*How do I treat Poison Ivy?

   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.
!
*What can I do about Athlete's foot?

   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.
!
*How can I treat a painful 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!
!
*How can I treat 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.
!
*I've hurt my eye.... what should I be worried about?

   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.
!
*How do I treat a Cut?

   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.
!
*OOWW! I smashed my finger and fingernail!

   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.
!
*I sprang something...

   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.
!
*I burned myself.

   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.
!
*A bug bit me!

   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.
!
*I got Stung!

   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.
!
*How do I treat a Sunburn?

   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.
!
*Treating 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.
!
*Treating 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.
!
*How do I treat 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.
!