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Preface It may perhaps be a surprise to many that Essentials has been in continuous publication for forty years. It was the first short book on dental surgery and pathology and published in hard cover by the old-established firm of Churchill. Since then it has survived, among other hazards, successive publishers' takeovers from Churchill, to Churchill Livingstone, to Harcourt Brace and, most recently, to Elsevier Science. The text has been updated, but please remember that by the time you read this does anyone read Prefaces? We are flattered that the previous edition was adopted as a standard text for the MFDS and hope that the present edition will help to bring success to even more candidates sitting this examination. The few exceptions are mostly pictures taken before the advent of colour photography of conditions that are unlikely to be seen now.
The rheumatologic manifestations often present as a large joint polyarthropathy resembling ankylosing spondyli- tis or a small joint fleeting polyarthropathy that is like rheumatoid arthritis.
Inflammatory eye lesions are confined to the anterior chamber, such as uveitis, iritis, episcleritis, and conjunctivitis. A chronic active hepatitis may develop; more seriously, sclerosing cholangitis can progress to cirrhosis.
There is a predisposition to gallstones when terminal ileal disease is present. Physical Examination Physical examination may reveal a nutritional deficiency. The extraintestinal manifestations may be apparent. Abdominal examination may suggest partial bowel obstruction, inflammatory mass, focal areas of tenderness, or ente- rocutaneous fistulae.
Perineal examination may reveal fistulae or abscesses. Perianal skin tags with bluish discoloration may be present.
On rectal exami- nation there may be a stricture, a palpable ulcer, or perirectal abscesses. Bloody diarrhea may be detectable. Clinical features compatible with anemia or hypoalbuminemia may be present.
Hypoalbuminemia may manifest with peripheral edema. APPROACH Plain abdominal radiographs provide important information in the acute pres- entation of symptoms, as they may demonstrate intestinal obstruction or evi- dence of perforation. Biliary or renal calculi, arthropathy, or osteoporosis also may be detected.
Endoscopy of the lower and upper gastrointestinal tract is used to identify disease and provide biopsy evidence. Fistulograms are helpful to surgeons by providing infor- mation about the site of the fistula and the presence of obstruction or abscess cavity in association with it.
Computerized tomography is the mainstay in terms of providing infor- mation about thickened loops of bowel, abscesses, and fistulous tracts. Magnetic resonance imaging, including cholangiography, may be helpful. Ultrasound may reveal thickened terminal ileum, abscesses, and evidence of biliary tract disease.
Ultrasound examination of the renal tract may reveal obstruction or stone formation. Endoscopic ultrasound may be useful in assessing bowel wall involvement and the extent of the disease process. Studies of bone density may be required. Endoscopy allows detailed examination of the mucosa of the upper and lower intestines, with the added advantage of allowing biopsies of abnormal areas to be taken see Figure Capsule endoscopy is an innovation that permits detailed photography of the small intestinal lumen.
There may be elec- trolyte abnormalities in Crohn disease. On occasion it may be very diffi- cult to determine whether a patient has Crohn disease or ulcerative colitis, and in these circumstances the condition often is designated indeterminate colitis.
The fundamental differences between Crohn disease and ulcerative colitis are that Crohn disease begins in the submucosa and ulcerative colitis begins in the mucosa of the gut.
See Table Ulcerative colitis, as its name suggests, is a disease confined to the colon and rectum, whereas, as was stated above, Crohn disease is ubiquitous throughout the bowel. Full-thickness involve- ment of the bowel, although more common in Crohn disease, may occur in both disorders. Fibrosis cicatrization and fistula formation are confined almost exclusively to patients with Crohn disease. The histopathologic fea- ture that differentiates the two conditions is the presence of granulomas in Crohn disease.
Aphthoid ulcers are more likely to occur in patients with Crohn disease. Both conditions are associated with an increased incidence of colon cancer, which, however, is more likely to develop in long-standing ulcerative colitis than in Crohn disease. Many patients develop ulcerative colitis at a young age and therefore may develop cancerous changes in the colon in their forties or fifties. A further important consideration is that patients with inflam- matory bowel disease live with episodes of diarrhea and occasional rectal bleeding so that the heralding features of malignancy may be observed by referring to the underlying inflammatory disease.
Abdominal pain and diarrhea are dealt mostly by addressing intestinal inflammation. Pain may be due to the stretching of nerve endings as a result of distention from obstruction or inflammation. Nonsteroidal anti-inflammatory drugs NSAIDs should be avoided, and nar- cotics lead to addiction in this chronic condition.
Acetaminophen, Tramadol, and Darvocet are used most frequently for pain control. They are more effective in ulcerative colitis than in Crohn disease. Steroids Corticosteroids have been the mainstay in the acute treatment of Crohn disease for many years. Steroids should be used only when more conservative meas- ures fail.
The strategy employed is to induce remission by using high doses prednisolone 60 mg per day in the short term, followed by a temporary regime as soon as remission is induced. Maintenance therapy should employ the lowest dose possible.
Approximately 20 percent of patients require long- term steroids. Second-Line Agents Steroid sparing in long-term management can be achieved with 6-mercaptopurine. This drug is slow to act and unpredictable in terms of achieving a therapeutic response. In doses of 50 to mg daily, bone marrow suppression and other side effects are rare. The antibiotic metronidazole is also used as second-line therapy with a degree of success, particularly in treating fistulae.
In addition to its properties as an antibiotic, the drug has an effect on the immune system. Other antibiotics that have been used to some effect are ciprofloxacin and clarithromycin. The latest, still experimental, strategy in the treatment of Crohn disease involves the role of cytokines. Antitumor necrosis factor has been shown to be effective. Other cytokine therapies, such as the use of interleukin IL and IL, have been reported to be effi- cacious in approximately 30 percent of cases.
Surgery The cumulative risk of undergoing surgery sometime in the lives for patients with Crohn disease is approximately 90 percent, and the cumulative risk of recurrent disease at 20 years is 70 percent. Many recurrences may be asymptomatic, however.
The major indication for surgery is failed medical therapy, usually in the presence of obstruction, fistula formation, and elec- trolyte or nutritional problems.
Controversy still exists over how radical the surgeon should be in treating Crohn disease. Some studies show that the more disease-free the margins are after the resection, the less likely there is to be recurrent disease.
Conversely, there is a danger that overly radical resections will leave the patient with the short bowel syndrome and its nutritional consequences.
Conservative surgery in the form of stricturoplasty for short stenotic lesions that are producing obstructions can be helpful without the loss of any bowel. For longer diseased segments, resection is preferred to bypass. For colonic Crohn disease with severe rectal and anal involvement, a proctocolectomy with ileostomy may be required.
Meticulous care is required in performing anastomoses in patients with Crohn disease, as healing is often impaired and the risk of anastomotic leakage therefore is increased. Which of the following histologic features is most character- istic of Crohn disease? Dilated submucosal blood vessels with focal thrombosis B. Increased thickness of the subepithelial collagen layer C.
Noncaseating granulomas with scattered giant cells D. Numerous eosinophils within the lamina propria E. Aspirin B. Interleukin C. Metronidazole D. Prednisolone E. Surgery [6. Intestinal obstruction resulting from a pericolonic abscess D. Superficial noncaseating granulomas forming hamartomatous polyps E.
Transmural inflammation producing fissures and fistulas Answers [6. Microscopic examination of the abnormal bowel from an individ- ual with Crohn disease will reveal transmural inflammation with fibrosis, but the histologic feature that is most diagnostic of Crohn disease is the presence of noncaseating granulomas.
This characteris- tic histologic feature, however, may be present in only approximately 50 percent of patients; however, the diagnosis of Crohn disease can still be made without finding granulomas by the characteristic clini- cal presentation, which includes the production of fissures, fistulae, and bowel obstruction by the transmural inflammation. In the absence of bowel obstruction or fistula formation, several types of medical therapies have been used to treat the acute inflam- mation associated with Crohn disease.
Corticosteroids, such as high- dose prednisolone, have been used commonly to treat the acute symptoms and induce remissions. In contrast, the antibiotic metron- idazole may be used to treat patients with fistula formation, whereas the use of cytokines such as interleukin is experimental. Surgical resection of bowel usually is done to treat problems such as obstruction.
Another major difference between these two disorders is that with Crohn dis- ease the inflammation, which may form noncaseating granulomas, begins in the submucosa and may involve the entire bowel wall, whereas ulcerative colitis begins in the mucosa and the inflammatory response remains superficial in location and does not involve the full thickness of the wall of the colon.
The inflammation along with repair may form inflammatory polyps with both of these disorders. Skin lesions include erythema nodosum, pyo- derma gangrenosa, aphthous stomatitis, and finger clubbing. Saunders, , —3. Friedman S, Blumberg RS.
Inflammatory bowel disease. He denies being hit or suffering any other trauma. Over the next few hours the pain does not remit but becomes more severe and is local- ized to the lower right quadrant. He also develops nausea and vomiting. He denies diarrhea and has not had similar episodes. The patient lies down in bed, and over the next 24 hours, the pain worsens and he develops fever and chills and is brought to the emergency center. On examination, he has a temperature of His abdomen is mildly distended and has hypoactive bowel sounds.
The abdomen is diffusely tender to palpation, par- ticularly in the right lower quadrant. A year-old man complains of midline abdominal pain. Over the next few hours, the pain worsens and is localized to the lower right quadrant. He also develops nausea and vomiting and, after 24 hours, develops fever and chills and an acute abdominal pain. He originally had mild right lower quadrant abdominal pain, but it worsened, and after 24 hours he developed fever and chills. The chills probably reflect bacteremia.
The emergency physician should expeditiously manage this situation, because delay could lead to morbidity or mortality, particularly in a geriatric patient. The blood pressure is not mentioned, but the patient could be in septic shock.
Treatment should be addressed in a systematic manner: Blood work to be obtained includes a complete blood count and a chemistry panel to assess electrolytes and serum creatinine for kidney function.
After stabilization, the patient should be taken to the operating room. If the diagnosis is unclear, a CT scan of the abdomen some- times can help distinguish other abdominal pathologies, such as diverticulitis.
Definitions Appendicitis: Inflammation of the vermiform appendix. Inflammation of an outpouching of the diverticulum. A condition of outpouching of the large bowel near the tae- niae coli where the blood vessels penetrate.
Complications include hem- orrhage lower gastrointestinal bleeding and inflammation. The incidence of the disease in the United States has fallen considerably over the last 30 years; however, it remains the most com- mon abdominal emergency in childhood, adolescence, and early adult life.
Fewer than 5 percent of cases of acute appendicitis occur in patients over age 60 years. The pathologic process begins on the mucosal surface of the appendix, and there is often an element of obstruction of the appendicular lumen by a fecalith.
This may lead to pressure necrosis of the mucosa and invasion of the appendicular wall by bacteria. Common causes of obstruction include elonga- tion or kinking of the appendix, adhesions, and neoplasias such as carcinoma and carcinoid tumors, both of which are rare.
Some cases spontaneously resolve, but more commonly, infection of the wall of the appendix progresses, leading to impairment of its blood supply. When the pathologic process has extended throughout the wall of the appendix to involve the parietal peri- toneum, the pain and tenderness are classically over the McBurney point at the site of the appendix.
The pathologic process may continue and produce gangrene, perforation, and more generalized peritonitis. Once perforation has occurred, the advancing bacteria may be controlled by the ability of the omen- tum to wall off the inflammation; alternatively, the peritonitis may become more widespread.
In advanced appendicitis, a mass may develop; alternatively, generalized peritonitis may lead to the septic inflammatory response syn- drome SIRS , ultimately with the development of multiple organ failure and death. The site of the pain in appendicitis may vary.
When the appendix is retro- cecal in position, somatic pain may be perceived in the flank and loin rather than in the right lower quadrant. Anorexia is an almost invariable symptom in association with appendicitis. The presence of hunger usually eliminates this diagnosis.
In association with anorexia, nausea is common and tends to pro- ceed to vomiting. Diarrhea sometimes occurs and may be a result of the appen- dix lying in a pelvic position. Laboratory investigations commonly performed include the peripheral white blood cell count, which may be elevated with a predominance of poly- morphonuclear leukocytes.
The urinalysis is usually normal. A CT scan of the abdomen may show thickening of the appendix with periappendicular inflam- mation and the presence of intraperitoneal fluid. The differential diagnosis includes acute gastroenteritis, which typically has vomiting and diarrhea as prominent symptoms and abdominal pain that is less well defined. Mesenteric adenitis may mimic appendicitis closely but is associated with a generalized viral illness and causes less severe pain.
Inflammation of Meckel diverticulum may pro- duce symptoms remarkably similar to those of appendicitis, and laparoscopy or laparotomy may be needed for the diagnosis. Crohn disease may closely simulate appendicitis; affected patients generally have intestinal obstruction, and usually conservative management is the best therapy. Gynecologic disor- ders such as pelvic inflammatory disease with cervical motion tenderness and adnexal tenderness may present similarly to appendicitis.
Ureteral colic is associated with pain and tenderness of the flank area, radiating to the groin region. Other conditions include acute diverticulitis, colonic carcinoma, acute cholecystitis, and pancreatitis.
Appendicitis in the elderly may have a more rapid course. Gangrene and perforation are more common in those over age 60 years, and this may be due to a delay in diagnosis. A classic picture of the appendicitis may be lack- ing, and the pain may be a less prominent feature. Overall, although there has been a decline in the incidence of peritonitis, paradoxically, it has increased among the elderly.
Thus, appendicitis should be at the forefront of the differ- ential diagnosis in males with right lower quadrant pain and tenderness. The treatment of uncomplicated appendicitis is surgical, consisting of an appendectomy. The abdomen is opened, and if the appendix is found to be normal in the absence of any other pathology, it should be removed prophy- lactically.
At the present time, most appendixes are removed laparoscopically rather than in an open operation. Diverticulitis Diverticula are blind pouches involving the bowel. They result from hernia- tion of the mucosa through the circular muscle at the site of small pene- trating blood vessels. Their walls consist of an outer layer of serosa and an inner mucosa. There is no muscle in the wall of the diverticulum. Diverticular disease is associated with increased intraluminal pressure in the large intestine with hypertrophy of both circular and longitudinal muscle lay- ers.
Diverticula can occur anywhere in the large bowel and small bowel but are found most commonly in the sigmoid colon. Muscle hypertrophy predates the development of diverticula and results in a narrowing of the bowel and, con- sequently, an increase in the intraluminal pressure. Diverticular disease may produce central or left lower quadrant abdominal pain together with an alteration in bowel habit with occasional rectal bleeding. The diagnosis is confirmed by barium enema or colonoscopy, which will show muscle thickening and multiple diverticula with small orifices emerging through the colonic wall.
Diverticular disease of the colon is common in Western countries and rare in central Africa, the Middle East, the Far East, and the Pacific islands. The incidence of the disease in Japan is increasing, possi- bly because of the adoption of a more westernized diet. Pathophysiology of diverticular disease.
Cross- sectional drawing of the colon, showing principal points of diverticula forma- tion between mesenteric and antimesenteric teniae.
Epidemiologic studies support the concept that the disease is not racially determined but is related to changes in the environment and to dietary factors. Postmortem studies in the Western countries report an incidence of approximately 40 percent overall and one as high as 60 percent in those over age 60 years. Acute or chronic inflammation within a diverticulum is designated diverti- culitis.
It is estimated that the approximately 20 percent of patients with diver- ticulosis will manifest diverticulitis. Localized inflammation, or even perforation and peritonitis, may occur. CT imaging of the abdomen remains the primary method of diag- nosing the acute process, whereas barium enema and endoscopic examinations are relatively contraindicated during acute infection.
Known complications of diverticulitis include bleeding, abscess forma- tion, peritonitis, and fistula formation. Colonic obstruction can also occur. The treatment of diverticulitis includes broad-spectrum antibiotics, intra- venous fluids, and nothing by mouth until the condition settles. Frank peri- tonitis or abscess formation usually requires surgical intervention, commonly involving excision of the affected area, such as a sigmoid colectomy. Postoperatively, patients should be instructed to eat a high-residue diet and drink plenty of liquids.
Physical examination finds a mild fever, and laboratory evaluation finds an increased periph- eral leukocyte count. She is taken to surgery, where an appendectomy is performed. Which of the following histologic changes is most likely to be present in her appendix? Amorphic mucinous material within the lumen B. Caseating granulomas within the periappendiceal fat C. Hyperplastic lymphoid follicles within the lamina propria D. Multinucleated giant cells within the epithelium E.
Numerous neutrophils within the muscular wall [7. Physical examination finds a low- grade fever, and laboratory evaluation finds increased numbers of neu- trophils in her peripheral blood. Appendicitis B. Cholecystitis C. Colitis D. Diverticulitis E. Pancreatitis [7.
Abdominal colic caused by intestinal obstruction B. Iron deficiency anemia caused by chronic blood loss C. Megaloblastic anemia caused by vitamin B12 deficiency D. Steatorrhea caused by malabsorption of fat E. The histologic hallmark of acute inflammation, such as that seen with acute appendicitis, is the presence of numerous acute inflamma- tory cells, namely, neutrophils.
Therefore, histologic sections of an appendix surgically removed from an individual with acute appen- dicitis will reveal numerous neutrophils within the muscular wall.
The inflammation can be so marked that it causes complete destruc- tion of the muscular wall, which can lead to perforation and peritonitis. Acute inflammation of diverticula diverticulitis will produce the sudden onset of left-sided abdominal pain accompanied by fever and peripheral leukocytosis mainly neutrophils.
These clinical signs are essentially the same as those seen with acute appendicitis except that the abdominal pain is on the left side rather than the right side. As such, diverticulitis sometimes is referred to as left-sided appendicitis. Diverticulosis refers to the presence of numerous diverticula in the colon. The diverticula usually are located in the sigmoid colon in older individuals.
Although they may become inflamed and produce signs of acute diverticulitis, more often they produce chronic blood loss as a result of chronic bleeding, which will lead to heme-positive stools and iron deficiency anemia. Saunders, Silen AW. Acute appendicitis and peritonitis. She also is icteric and is suspected of having cirrhosis. Investigation into the cause of her cirrhosis reveals negative hepatitis antibodies but elevated antimitochondrial antibodies. A year-old woman has cirrhosis and elevated antimitochondrial antibodies.
Primary biliary cirrhosis. The etiology of primary biliary cirrhosis is not known; however, evidence points toward an autoimmune basis to the disease. The first priorities in her management include ABC: She should receive oxygen by a nasal cannula, and two large- bore intravenous lines should be established.
Her blood pressure and heart rate should be monitored to assess for volume loss and replacement with blood as needed. Transfusion with coagulation factors and initiation of vitamin K may be indi- cated. Endoscopic examination to determine the etiology of the upper gas- trointestinal bleeding is paramount.
Bleeding esophageal varices may be treated with sclerotherapy injected into the bleeding vessels. Also, a tampon- ade may be attempted with special esophageal devices. After the acute situation has been addressed, attention should be directed to the etiology of her liver disease.
A careful history and physical examination and selected laboratories usually yield the diagnosis. Toxic effects such as with alcohol use and infections such as with hepatitis viruses are the most common causes of cirrhosis. These findings are consistent with primary biliary cir- rhosis. Careful history may reveal pruritus years before frank cirrhosis. A chronic progressive cholestatic liver disease associated with intrahepatic biliary tree destruction and finally cirrhosis.
Chronic liver disease: Liver disease that lasts for 6 months or more and includes chronic hepatitis and cirrhosis. Progressive and irreversible condition of the liver in which hepatocyte damage and destruction occur. Regenerating hepatocytes form nodules. Aberrant human lymphocyte antigen HLA class II molecules are expressed in the biliary epithelium of patients with PBC; this might be responsible for the triggering of an inflamma- tory response.
Defective immunoregulation allows cytotoxic T cells to damage bile ducts. A liver biopsy usually shows a portal tract infiltrate composed of mainly lymphocytes and plasma cells see Figure In approximately half Figure Microscopic pictograph of primary biliary cirrhosis.
Courtesy of Dr. Aaron Han, Reading, PA. Destruction of medium-sized bile ducts with bile ductular proliferation will be evident. With time, hepatocyte necrosis and fibrosis are apparent. After years to decades, the clinical features of cirrhosis will be present. Most patients have antimitochondrial antibodies in their serum, with the antigen M2 being specific to PBC.
The role of this antibody in the pathogen- esis of PBC is not clear. Features of cholestatic liver disease dominate the initial clinical picture.
This includes pruritus, which may precede jaundice by years. High serum alkaline phosphatase with normal or nearly normal alanine aminotransferase ALT and aspartate aminotransferase AST is characteristic in the early part of the disease. Secondary hypercholesteremia with features such as xanthelasma may be seen. After a variable amount of time usually years , the features of cirrhosis, such as icterus, bleeding, and ascites, may become apparent.
Table shows the laboratory findings that are consistent with a diagnosis of PBC. Management Treatment addresses the symptoms and disease course of the patient. Because the disease is thought to be autoimmune, corticosteroids have been tried. These agents improve the biochemical and histologic picture of the disease but lead to significant osteoporosis. Patients with primary biliary cirrhosis are prone to osteoporosis caused by cholestasis and subsequent impaired malab- sorption of vitamin D.
Complications associated with cirrhosis requires man- agement. Liver transplantation remains the specific treatment and has a 5-year survival of at least 80 percent. High serum alkaline phosphatase 2.
High serum cholesterol 3. High serum IgM 4. High antimitochondrial antibodies; M2 antibody is specific 5. In chronic hepatitis, inflammatory cells consisting of lymphocytes, macrophages, and plasma cells are present in the portal tract. Interface hepatitis and bridging necrosis are signs of active liver damage. Lymphoid aggregates are seen in cases caused by hepatitis C virus. The hallmark of irre- versible liver damage is deposition of fibrous tissue.
This brings about the onset of cirrhosis. Initially, the fibrosis is periportal. With time, bridging fibro- sis between lobules is seen. Regenerating nodules from surviving hepato- cytes complete the picture of cirrhosis.
Based on the size of the nodules, there are two types of cirrhosis: Micronodular cirrhosis is seen in alcoholics, whereas macronodu- lar cirrhosis is seen after hepatitis. Autoantibodies such as antinuclear, anti-smooth muscle and anti-liver kidney microsomal antibodies anti-LKM are frequently present. Serum IgG levels may be elevated. Deficiency results in liver damage and emphy- sema, especially in smokers. Serum levels are low, and liver biopsy shows periodic acid-Schiff PAS positive diastase-resistant globules within the hepatocytes.
Wilson Disease Wilson disease is inherited as an autosomal recessive condition. The copper- transporting protein ceruloplasmin is reduced in amount because of poor syn- thesis. There is also failure of biliary excretion of copper.
As a result, free copper is deposited in various sites, including liver basal ganglia and cornea with resultant Kayser-Fleischer rings , resulting in damage to those organs. Urinary excretion of free copper also is increased. Acute hepatitis, chronic hepatitis, cirrhosis, and extrapyramidal features caused by basal ganglia damage are the usual clinical features. Hereditary Hemochromatosis Hereditary hemochromatosis also is inherited as an autosomal recessive con- dition.
There is an association with HLA-A3. Excessive iron absorption results in iron deposition and damage to various organs including liver, pancreas, heart, joints, and pituitary gland. At the same time excess iron deposition is observed in the skin. This results in bronze discoloration of skin. This, along with diabetes resulting from pancreatic damage, explains the synonym of hemochromatosis, bronze diabetes.
Other features include cirrhosis, car- diomyopathy, hypogonadism, and arthropathy. As females lose iron through blood loss from menstruation, the features are milder or are seen later in them. Alcoholic Liver Disease The spectrum of alcoholic liver disease includes fatty liver, acute hepatitis, and cirrhosis.
Fatty liver hepatic steatosis consists of microvesicular lipid droplets in the liver cells, displacing the nucleus to the periphery. Refraining from alcohol gen- erally leads to reversal of these changes. In acute hepatitis, there is infiltra- tion with polymorphonucleocytes and hepatocyte necrosis.
Cytoplasmic inclusions resulting from intermediate filaments known as Mallory bodies are seen. Eventually, fibrosis ensues. Finally, cirrhosis develops as an end-stage result of chronic alcohol use. The liver is small and shrunken.
Microscopy reveals fibrous septae that create a micronodular and macronodular pat- tern with regeneration. Clinically, the patient may develop portal hyperten- sion, ascites, jaundice, and peripheral edema. Laboratory evaluation finds the presence of antimitochondrial antibodies in her serum, but the tests for viral hepatitis antibodies were negative.
A biopsy of her liver reveals numerous lymphocytes in the portal tracts, along with occasional granulomas. Which of the substances listed below is most likely to have markedly elevated serum levels in this individual? Acid phosphatase B. Alanine aminotransferase C.
Alkaline phosphatase D. Aspartate aminotransferase E. Conjugated bilirubin [8. Physical examination finds that she has uncontrolled choreiform movements of the arms, and a rust-colored ring is seen at the periph- ery of both corneas. Laboratory examination finds increased serum and urine levels of copper with decreased levels of ceruloplasmin.
Budd-Chiari syndrome C. Primary biliary cirrhosis D. Whipple disease E. Wilson disease [8. Black cartilage B. Blue sclera C. Bronze skin D. Red pupils E. The presence of antimitochondrial serum antibodies, particularly to the M2 antigen, in an individual with liver disease is highly sug- gestive of primary biliary cirrhosis. Individuals with this autoimmune disorder, which is more common in women, develop clinical signs of cholestatic liver disease with pruritus.
Before the development of jaundice, however, patients will have high serum levels of alkaline phosphatase with normal or nearly normal levels of ALT and AST. Increased serum levels of copper with decreased levels of cerulo- plasmin in a patient with liver disease are diagnostic of Wilson dis- ease. This autosomal recessive disorder is characterized by the deposition of copper in multiple sites, which include the liver, the basal ganglia, and the cornea of the eye.
Destruction of the basal gan- glia leads to extrapyramidal signs such as choreiform movements, whereas deposition of copper at the periphery of the cornea produces characteristic Kayser-Fleischer rings. Patients with hereditary hemochromatosis develop clinical signs because of the deposition of excess iron in many organs. The classic triad of clinical signs includes a bronze skin color, diabetes mellitus, and cirrhosis.
The combination of the bronze skin color and diabetes mellitus sometimes is referred to as bronze diabetes. The abnormal skin color results from the deposi- tion of iron in the skin. In addition, deposition of iron in the adrenal cortex leads to decreased cortisol levels.
Deposition of iron and organ damage occurs in liver, pancreas, heart, joints, and pituitary gland. Cytoplasmic inclusions caused by intermediate filaments known as Mallory bodies are seen. Cirrhosis and its complications.
Crawford JM, Liu C. She also has noted vaginal spotting after intercourse. She had gone through menopause 2 years earlier and took an oral contraceptive for 10 years.
She has smoked one pack of cigarettes per day for 20 years. She denies a cough or dyspnea. She complains of right back pain and right leg swelling. The speculum examination shows a 4-cm irregular fungating mass arising from the cervix. A year-old postmenopausal woman has a 6-month history of an odiferous vaginal discharge and postcoital spotting.
She also complains of right back pain and right leg swelling. The speculum examination shows a 4-cm irregular fungat- ing mass arising from the cervix.
Oral premalignancy Oral cancer Neoplastic and non-neoplastic diseases of salivary glands Common benign mucosal swellings Soft-tissue mesenchymal neoplasms Anaemias, leukaemias and lymphomas Haemorrhagic diseases Immunodeficiencies and HIV disease Allergy and autoimmune disease Cervical lymphadenopathy Cardiovascular disease Respiratory tract disease Gastrointestinal and liver disease Nutritional deficiencies This is quite apparent, and involves reputed power of exertingthis influence on1 nothing peculiar to the magnetical influpersons unconscious that they are the sub- ence.
But what seems special to this ject of your attempts, although in the room state is, that the magnetized person is aswhere the process is apparentlv 1 erformed serted to be capable of maintaining a ceron another. The author of the Thesis tain kind of connexion with the external already quoted, mentions the case of a world, while otherwise completely insenyoung lady on whom thi concealed experi- sible.
Thus he has been known to hear ment was made, and so far succeeded, that, and answer connectedly, various questions without hecomingtorpid, she experienced and observations proposed to him by one several of the symptoms which indicate the individual, while he remains insensible to working of this pretended fluid. This case, the loudest noises, the most exciting rehowever, proves nothing. There can be marks of all the other persons about him. It very little difficulty in supposing that cer- is difficult not to admit, that this has haptain nervous events would be very readily pened in several cases.
I have not seen produced in a frightened girl, by the bare the fact myself, but I have, in the course of performance in her presence of the passes ini readinj, met with several instances of it so question.
It is nothingmore than whatt well authenticated, that I should not be happens in epilepsy, and a variety of otherr justified in refusing to believe it. But is convulsive affections. On the whole, then,this sufficient to compel us to admit the exyou see that as far as we have yet gone istence nfa npc,,iili2. What is the cause of any two individuals placed in this position this influence, what the effects it produces, of exclusive conversation!? I think not. There are too many events of analogous In addition to the effects I have already import passing before our eyes, to permit described, there are many others not yet us to strain our imaginations to this pitch noticed.
One of these is the production of of belief. How often do we see, for examcertain convulsive movemenrs. This I see ple, two persons in a crowded and clamorno reason to doubt, It is nothing more than ous assembly, so intently occupied with the mere excitement of imagination is ade- each other, with their minds so mutually quate to account for. It has occurred at all concentrated, that they are perfectly insenepochs of miracles, at the period of the sible to all that is passing around them; dancers of the middle ages, at the tomb ofthey have no eyes, no ears, no tongues, but the prophet of Paris, and everywhere else for each other!
Questions are put to them where high moral excitement of any de- in vain. Sometimes they do not hear them scription has been in operation. The fact; at all ; or if they do, they do not understand even gave the name of convulsionaire to the; thrir import.
Now this is a familiar in.. Another series of pheno-day, and it is one which, undoubtedly, dimena related to the supposed cure of vari-- vests the ecstatic symptom of much of its releous diseases. Now all this I think veryrvancy to the subject of animal magnetism.
It is the occasional occurrence, with vividness and accuracy to the mind, during the ecstatic access, of a remarkable and be articulated with perfect precision. I saw, yesterday, a young lady the paroxysm. It is unquestionable, that who has been repeatedly magnetized, and in several nervous affections, in hysteria, for who, on my visit, presented some very re- example, delicate females have, for a time, markable circumstances.
After a fit of in- acquired almost prodigious power. There digestion, she fell into the ecstatic state, can be no doubt, however, but that we are in which she continued when I saw her. It is, indeed, gravely told eyes were open, like animals in whom the of the hysteric nuns of Paris, that they fifth pair of nerves has been divided. She sprung an extraordinary distance into the could perceive light, knew the difference air; in point of fact, that they were seen to between day and night for instance, but she fly during their paroxysms.
You may, howcould see and distinguish nothing else. She ever, believe just as much of this as you could not speak, but by signs expressed think convenient. To recur to the hallucithat her intellect was unusually active. Sometimes the entranced see halos she presented, was a singular exaltation of around the heads, and a luminous vapour the sense of hearing. So extraordinarily emanating from the bodies, of the magnedelicate had this become, that she dis- tizers ; but it is worthy of remark, that this tinctly perceived sounds inaudible to my- appearance has only been seen by those who self, and several other persons.
This is a believed that the magnetic essence itself was very curious case, but we shall presently a brilliant and subtle liquid. Others will see that it is far from being beyond the pale tell you, that by this agent they have seen of natural things.
It is the case, for exam- water changed into wine, and other equally ple, with certain animals, that the smell miraculous events to occur. There is noshould be permanently exalted, apparently thing wonderful in all this. They believed at the expense of the acuteness of the other they saw these things, that is all.
These senses. I shall, however, notice more exam- delusions are of every-day occurrence, espeples of this kind as we proceed. Hallucinations, for i these things without taxing their imaginainstance, are not unfrequent. These gene- tions to believe all the conceits of their pa. But among all the pretences of the mag. I influence they are thrown into the state in mean the instinct of remedies, whether for question. These hallucinations may, of the cure of themselves or others, with which course, be of as many varieties as the they pretend that the magnetized are en.
Now in the whole of the statements A remarkable development of intelligence on this point, I must confess that I can may also be often witnessed, and,it may be again see nothing but the acme of imposireadily understood when we reflect on tion, juggling, and quackery.
We can at the phenomena so frequently observed in once see the humbug of all this matter, by other nervous diseases. The memory has comparing the medical indications of the thus been known to become so heightened magnetized at two periods, when opposite during the magnetic or ecstatic seizure, that popular medical hypotheses were in reputathe individuals spoke fluently in languages tion.
Twenty years ago, what did they to which they had never paid much atten- prescribe? Purgatives, emetics, tonics, tion. This circumstance has been adroitly and stimulants. But now a-days the tables turned to account by the magnetizers, who are turned, and they tell you that the mupretend that their patients acquired the cous membrane of the stomach is red and faculty of speaking languages they had fiery ; and leeches, bloodletting, cups, and All this is never learned or even heard.
Durthe accession she snng with precision two pieces singular circumstance, that during the pa- in; of church music, although when in a state of health roxysm the memory may be for a period so she appeared to be incapable of articulating with I wonderfully heightened, that sounds and correctness a siDgle bar of music of any description pa- a firm step, and avoid completely the immi.
Broussais excited nent dangers by which they were surround. At least ed. They have been known to dress themthis is the favourite practice of the somnam- selves, to ride, to read, to write, in utter darkness.
But it is not proved that they bulists of Paris at the present day. The assertion that these individuals can do this by seeing the objects in question. Neither is there better they will often be unable to make another authority for the notion, that they can re- step with safety. To revert, then, to the cognise colours in the dark, or in another alleged faculty of the magnetized seeing place where they cannot see them. All the with their eyes shut, or seeing objects out facts related to sustain this allegation, are of the field of ordinary vision, there are so imperfect, that they admit of many ex- some simple tests which suffice to prove planations besides that the magnetizer ad- how unfounded is the assertion; ask the vances.
Several persons are known, for person, for example, to tell the number of example, to acquire such an extraordinary teeth in the mouths of various other indidelicacy of touch, that they can distinguish viduals, and you will soon find how very varieties of form in the dark, altogether im- limited is his peculiar faculty of vision. I perceptible to others. This exaltation ofshall conclude this subject in the next lectouch may often become a substitute for ture.
There Vision continued. The fact, however, of the sanie Character. Ifwe descend, howa Believer in from Magnetism. These accessoryfaculty of seeing without the assistance of nerves, however, have as yet been only de.
The facts adduced by the animal tected in the organs of hearinsr and smell-. Never, as far as I know, have they with very few exceptions, altogether valuebeen found to exist in the eye, The fifth less. At any rate, superficial examination of touch.
It is only by rigid and rigoursleep-walkers have, by some, been thoughtt ous investigation, that we succeed in obto corroborate the assertions of the mag.. It is well proved, that these indi. This is, however, for ness, and endeavour not to allow ourselves many reasons, far from being conclusive.
The a young lady in whom, togestate, this supposed cataleptic eyes, in which the magnetized individual per- faculty existed. But she could also, it was forms it, is by having the substance to be stated, practise this mode of vision in the When De Luc asked, seen, placed in contact with some part of the intervals of the fits. The facts opened. A book was then presented to which merit attention as indicative of the her, opened at a chance page.
She traexistence of this power, are chiefly those versed the leaves with the tips of her fingers and read correctly. Thus far I think the experiment not conThe first is related by Petetin of Amiens, in which city the event took place, and was clusive. Independently of the extreme published by him as an example of " animal delicacy of touch of which some persons electricitv. But whether that the operator was deceived.
A clever young any source of deception lurked beneath anxious to attract attention, could, these details, is another point for consideration. The followingthen, are the circum- without much trouble, steal a glance at the stances described: But the next of her was more curious.
She was asked if she circumstances to Petetin, who, in order verify them, made several experiments. Again, he demanded what object he also read the third.
Now, in all this, I adheld in his hand?