Gale encyclopedia of medicine vol 4 (n s)

stenosis. Acquired spinal
stenosis usually begins with degeneration of the intervertebral disks or the surfaces of the vertebrae or both. In trying
to heal this degeneration, the body builds up the spinal column. In the process, the spinal canal can become narrower.

Diagnosis
The physician must determine that the symptoms are
caused by spinal stenosis. Conditions that can cause similar symptoms include a slipped (herniated) intervertebral disk, spinal tumors, and disorders of the blood flow
(circulatory disorders). Spinal stenosis causes back and
leg pain. The leg pain is usually worse when the patient
is standing or walking. Some forms of spinal stenosis are
less painful when the patient is riding an exercise bike
because the forward tilt of the body changes the pressure
in the spinal column. Doppler scanning can trace the
flow of blood to determine whether the pain is caused by
circulatory problems. X-ray images, computed tomography scans (CT scans), and magnetic resonance imaging (MRI) scans can reveal any narrowing of the spinal
canal. Electromyography, nerve conduction velocity, or
evoked potential studies can locate problems in the
muscles indicating areas of spinal cord compression.

Treatment
Mild cases of spinal stenosis may be treated with
rest, nonsteroidal anti-inflammatory drugs (such as
aspirin), and muscle relaxants. Spinal stenosis can be a
progressive disease, however, and the source of pressure
may have to be surgically removed (surgical decompresGALE ENCYCLOPEDIA OF MEDICINE 2


Computed tomography (CT) scans—An imaging
technique in which cross-sectional x rays of the
body are compiled to create a three-dimensional
image of the body’s internal structures.

Congenital—Present before birth. The term is used
to describe disorders that developed in the fetal
stage.
Doppler scanning—A procedure in which ultrasound images are used to watch a moving structure
such as the flow of blood or the beating of the heart.
Electromyography—A test that uses electrodes to
record the electrical activity of muscle. The information gathered is used to find disorders of the
nerves that serve the muscles.
Evoked potential—A test of nerve response that
uses electrodes placed on the scalp to measure
brain reaction to a stimulus such as a touch.
Magnetic resonance imaging (MRI)—An imaging
technique that uses a large circular magnet and
radio waves to generate signals from atoms in the
body. These signals are used to construct images of
internal structures.
Nerve conduction velocity test—A test that measures the time it takes a nerve impulse to travel a
specific distance over the nerve after electronic
stimulation.
Stenosis—The narrowing or constriction of a
channel or opening.

sion) if the patient is losing control over bladder and
bowel functions. The surgical procedure removes bone
and other tissues that have entered the spinal canal or put
pressure on the spinal cord. Two vertebrae may be fused,
to eliminate improper alignment, such as that caused by
spondylolisthesis. For surgery, patients lie on their sides
or in a modified kneeling position. This position reduces
bleeding and places the spine in proper alignment. Alignment is especially important if vertebrae are to be fused.

Surgical decompression can eliminate leg pain and
restore control of the legs, bladder, and bowels, but usually does not eliminate lower back pain. Physical therapy
and massage can help reduce the symptoms of spinal
stenosis. An exercise program should be developed to
increase flexibility and mobility. A brace or corset may
be worn to improve posture. Activities that place stress
on the lower back muscles should be avoided.
GALE ENCYCLOPEDIA OF MEDICINE 2

Surgical decompression does not stop the degenerative processes that cause spinal stenosis, and the condition can develop again. Nevertheless, most patients
achieve good results with surgical decompression. The
patient will probably continue to have lower back pain
after the surgical procedure.
Resources
BOOKS

Berkow, Robert, ed. Merck Manual of Medical Information. Whitehouse Station, NJ: Merck Research Laboratories, 1997.
Dee, Roger, et al. Principles of Orthopaedic Practice. New
York: McGraw-Hill Health Professional Books, 1997.
Larsen, D. E., ed. Mayo Clinic Family Health Book: New York.
William Morrow and Co., Inc., 1996.

John T. Lohr, PhD

Spinal tap see Cerebrospinal fluid (CSF)
analysis
Spirometry see Pulmonary function test
Spleen, enlarged see Hypersplenism
Spleen removal see Splenectomy

Splenectomy
Definition
Splenectomy is the surgical removal of the spleen,
which is an organ that is part of the lymphatic system.
The spleen is a dark-purple, bean-shaped organ located
in the upper left side of the abdomen, just behind the bottom of the rib cage. In adults, the spleen is about 4.8 ϫ
2.8 ϫ 1.6 in (12 ϫ 7 ϫ 4 cm) in size, and weighs about
4–5 oz (113–142 g). Its functions include a role in the
immune system; filtering foreign substances from the
blood; removing worn-out blood cells from the blood;
regulating blood flow to the liver; and sometimes storing
blood cells. The storage of blood cells is called sequestration. In healthy adults, about 30% of blood platelets
are sequestered in the spleen.

Purpose
Splenectomies are performed for a variety of different
reasons and with different degrees of urgency. Most
splenectomies are done after the patient has been diagnosed with hypersplenism. Hypersplenism is not a specific disease but a group of symptoms, or syndrome, that can
3137

Splenectomy

Prognosis

KEY TERMS


Splenectomy

Spleen

Splenic artery

Stomach
Retractor

Splenectomy is the surgical removal of the spleen. This procedure is performed as a last result in most diseases involving
the spleen. In some cases, however, splenectomy does not address the underlying causes of splenomegaly or other conditions affecting the spleen. (Illustration by Electronic Illustrators Group.)

be produced by a number of different disorders. It is characterized by enlargement of the spleen (splenomegaly),
defects in the blood cells, and an abnormally high turnover
of blood cells. It is almost always associated with
splenomegaly caused by specific disorders such as cirrhosis of the liver or certain cancers. The decision to perform
a splenectomy depends on the severity and prognosis of
the disease that is causing the hypersplenism.
Splenectomy always necessary
There are two diseases for which splenectomy is the
only treatment—primary cancers of the spleen and a blood
disorder called hereditary spherocytosis (HS). In HS, the
absence of a specific protein in the red blood cell membrane leads to the formation of relatively fragile cells that
are easily damaged when they pass through the spleen. The
cell destruction does not occur elsewhere in the body and
ends when the spleen is removed. HS can appear at any
age, even in newborns, although doctors prefer to put off
removing the spleen until the child is five or six years old.
Splenectomy usually necessary
There are some disorders in which splenectomy is
usually recommended. They include:
3138

• Immune (idiopathic) thrombocytopenic purpura (ITP).

ITP is a disease involving platelet destruction. Splenectomy is the definitive treatment for this disease and is
effective in about 70% of chronic ITP cases.
• Trauma. The spleen can be ruptured by blunt as well as
penetrating injuries to the chest or abdomen. Car accidents are the most common cause of blunt traumatic
injury to the spleen.
• Abscesses in the spleen. These are relatively uncommon but have a high mortality rate.
• Rupture of the splenic artery. Rupture sometimes
occurs as a complication of pregnancy.
• Hereditary elliptocytosis. This is a relatively rare disorder. It is similar to HS in that it is characterized by red
blood cells with defective membranes that are
destroyed by the spleen.
Splenectomy sometimes necessary
In other disorders, the spleen may or may not be
removed.
• Hodgkin’s disease, a serious form of cancer that causes
lymph nodes to enlarge. Splenectomy is often perGALE ENCYCLOPEDIA OF MEDICINE 2


• Thrombotic thrombocytopenic purpura (TTP). TTP is a
rare disorder marked by fever, kidney failure, and an
abnormal decrease in the number of platelets. Splenectomy is one part of treatment for TTP.
• Autoimmune hemolytic disorders. These disorders may
appear in patients of any age but are most common in
patients over 50. The red blood cells are destroyed by
antibodies produced by the patient’s own body (autoantibodies).
• Myelofibrosis. Myelofibrosis is a disorder in which
bone marrow is replaced by fibrous tissue. It produces
severe and painful splenomegaly. Splenectomy does not
cure myelofibrosis but may be performed to relieve
pain caused by the swollen spleen.

• Thalassemia. Thalassemia is a hereditary form of anemia that is most common in people of Mediterranean
origin. Splenectomy is sometimes performed if the
patient’s spleen has become painfully enlarged.

Precautions
Patients should be carefully assessed regarding the
need for a splenectomy. Because of the spleen’s role in
protecting people against infection, it should not be
removed unless necessary. The operation is relatively
safe for young and middle-aged adults. Older adults,
especially those with cardiac or pulmonary disease, are
more vulnerable to post-surgical infections. Thromboembolism following splenectomy is another complication
for this patient group, which has about 10% mortality
following the surgery. Splenectomies are performed in
children only when the benefits outweigh the risks.
The most important part of the assessment is the measurement of splenomegaly. The normal spleen cannot be
felt when the doctor examines the patient’s abdomen. A
spleen that is large enough to be felt indicates
splenomegaly. In some cases the doctor will hear a dull
sound when he or she thumps (percusses) the patient’s
abdomen near the ribs on the left side. Imaging studies that
can be used to demonstrate splenomegaly include ultrasound tests, technetium-99m sulfur colloid imaging, and
CT scans. The rate of platelet or red blood cell destruction
by the spleen can be measured by tagging blood cells with
radioactive chromium or platelets with radioactive indium.

nique is used to remove greatly enlarged spleens. After the
surgeon makes a cut (incision) in the abdomen, the artery
to the spleen is tied to prevent blood loss and reduce the
spleen’s size. It also helps prevent further sequestration of

blood cells. The surgeon detaches the ligaments holding the
spleen in place and removes it. In many cases, tissue samples will be sent to a laboratory for analysis.
REMOVAL OF RUPTURED SPLEEN. When the spleen
has been ruptured by trauma, the surgeon approaches the
organ from its underside and fastens the splenic artery.

Partial splenectomy
In some cases the surgeon removes only part of the
spleen. This procedure is considered by some to be a useful compromise that reduces pain from an enlarged
spleen while leaving the patient less vulnerable to infection. Long-term follow-up of the results of partial
splenectomies has not yet been done.
Laparoscopic splenectomy
Laparoscopic splenectomy, or removal of the spleen
through several small incisions, has been more frequently used in recent years. Laparoscopic surgery involves
the use of surgical instruments, with the assistance of a
tiny camera and video monitor. Laparoscopic procedures
reduce the length of hospital stay, the level of post-operative pain, and the risk of infection. They also leave smaller scars. Laparoscopic splenectomy is not, however, the
best option for many patients.
Splenic embolization
Splenic embolization is an alternative to splenectomy
that is used in some patients who are poor surgical risks.
Embolization involves plugging or blocking the splenic
artery to shrink the size of the spleen. The substances that
are injected during this procedure include polyvinyl alcohol foam, polystyrene, and silicone. Embolization is a
technique that needs further study and refinement.

Preparation
Preoperative preparation for nonemergency splenectomy includes:
• Correction of abnormalities of blood clotting and the
number of red blood cells.

• Treatment of any infections.

Description
Complete splenectomy
REMOVAL OF ENLARGED SPLEEN. Splenectomy is performed under general anesthesia. The most common tech-

GALE ENCYCLOPEDIA OF MEDICINE 2

• Control of immune reactions. Patients are usually given
protective vaccinations about a month before surgery.
The most common vaccines used are Pneumovax or PnuImune 23 (against pneumococcal infections) and Menomune-A/C/Y/W-135 (against meningococcal infections).
3139

Splenectomy

formed in order to find out how far the disease has progressed.


Splenectomy

KEY TERMS
Embolization—An alternative to splenectomy that
involves injecting silicone or similar substances into
the splenic artery to shrink the size of the spleen.
Hereditary spherocytosis (HS)—A blood disorder
in which the red blood cells are relatively fragile
and are damaged or destroyed when they pass
through the spleen. Splenectomy is the only treatment for HS.
Hypersplenism—A syndrome marked by enlargement of the spleen, defects in one or more types of
blood cells, and a high turnover of blood cells.

Immune or idiopathic thrombocytopenic purpura
(ITP)—A blood disease that results in destruction of
platelets, which are blood cells involved in clotting.
Laparoscope—An instrument used to view the
abdominal cavity through a small incision and perform surgery on a small area, such as the spleen.

Aftercare
Immediately following surgery, patients should follow
instructions and take all medications intended to prevent
infection. Blood transfusions may be indicated for some
patients to replace defective blood cells. The most important part of aftercare, however, is long-term caution regarding vulnerability to infection. Patients should see their doctor at once if they have a fever or any other sign of infection, and avoid travel to areas where exposure to malaria
or similar diseases is likely. Children with splenectomies
may be kept on antibiotic therapy until they are 16 years
old. All patients can be given a booster dose of pneumococcal vaccine five to 10 years after splenectomy.

Risks
The chief risk following splenectomy is overwhelming
bacterial infection, or postsplenectomy sepsis. This vulnerability results from the body’s decreased ability to clear
bacteria from the blood, and lowered levels of a protein in
blood plasma that helps to fight viruses (immunoglobulin
M). The risk of dying from infection after splenectomy is
highest in children, especially in the first two years after
surgery. The risk of postsplenectomy sepsis can be reduced
by vaccinations before the operation. Some doctors also
recommend a two-year course of penicillin following
splenectomy or long-term treatment with ampicillin.
Other risks following splenectomy include inflammation of the pancreas and collapse of the lungs. In some
3140

Pneumovax—A vaccine that is given to splenectomy patients to protect them against bacterial infections. Other vaccines include Pnu-Imune and

Menomune.
Sepsis—A generalized infection of the body, most
often caused by bacteria.
Sequestration—A process in which the spleen withdraws some normal blood cells from circulation
and holds them in case the body needs extra blood
in an emergency. In hypersplenism, the spleen
sequesters too many blood cells.
Splenomegaly—Abnormal enlargement of the
spleen.
Thromboembolism—A clot in the blood that forms
and blocks a blood vessel. It can lead to infarction,
or death of the surrounding tissue due to lack of
blood supply.

cases, splenectomy does not address the underlying causes of splenomegaly or other conditions. Excessive bleeding after the operation is an additional possible complication, particularly for ITP patients. Infection immediately
following surgery may also occur.

Normal results
Results depend on the reason for the operation. In
blood disorders, the splenectomy will remove the cause of
the blood cell destruction. Normal results for patients with
an enlarged spleen are relief of pain and of the complications of splenomegaly. It is not always possible, however, to
predict which patients will respond well or to what degree.
Resources
BOOKS

Hohn, David C. “Spleen.” In Current Surgical Diagnosis and
Treatment. 10th ed. Ed. Lawrence W. Way. Stamford:
Appleton & Lange, 1994.
Packman, Charles H. “Autoimmune Hemolytic Anemia.” In

Conn’s Current Therapy, 1996, ed. Robert E. Rakel.
Philadelphia: W. B. Saunders Co., 1996.
Tanaka, Kouichi R. “Nonimmune Hemolytic Anemia.” In
Conn’s Current Therapy, 1996, ed. Robert E. Rakel.
Philadelphia: W. B. Saunders Co., 1996.
PERIODICALS

Tsoukas, Christos M., et al. “Effect of Splenectomy on Slowing Human Immunodeficiency Virus Disease Progression.” Archives of Surgery 133 (Jan. 1998): 25-31.
GALE ENCYCLOPEDIA OF MEDICINE 2


National Heart, Lung and Blood Institute. P.O. Box 30105,
Bethesda, MD 20824-0105. (301) 251-1222. www.nhlbi.nih.gov>.
Leukaemia Research Fund. 43 Great Ormond Street, London,
WC1N 3JJ. (020) 7405-0101. com/lrf-//>.
OTHER

“Laparoscopic Splenectomy.” Foxhall Surgical Page. www.foxhall.com/lap_sple.htm>.
Non-emergency Surgery Hotline. (800) 638-6833.

Teresa Norris, RN

Splenic trauma
Definition
Splenic trauma is physical injury to the spleen, the
lymphatic organ located in the upper left side of the
abdomen.

Description
The spleen is an organ that produces white blood cells,
filters the blood, stores blood cells and destroys those that
are aging. It is located near the stomach on the left side of
the abdomen. A direct blow to the abdomen may bruise,
tear or shatter the spleen. Trauma to the spleen can cause
varying degrees of damage, the major problem associated
with internal bleeding. Mild splenic subcapsular
hematomas are injuries in which bleeding is limited to
small areas on and immediately around the spleen. Splenic
contusions refer to bruising and bleeding on and around
larger areas of the spleen. Lacerations (tears) are the most
common splenic trauma injuries. Tears tend to occur on the
areas between the three main blood vessels of the spleen.
Because of the abundant blood supply, splenic trauma may
cause serious internal bleeding. Most injuries to the spleen
in children heal spontaneously. Severe trauma can cause
the spleen or its blood vessels to rupture or fragment.
Splenic trauma is more common in children than in
adults. In general, children are prone to abdominal
injuries due to accidents and falls and because their
abdominal organs are less protected by bone, muscle and
fat. Abdominal injuries including splenic trauma are the
most common cause of preventable deaths in children.

Causes and symptoms
The most common cause of injury to the spleen is
blunt abdominal trauma. Blunt trauma is often caused
GALE ENCYCLOPEDIA OF MEDICINE 2

by a direct blow to the belly, car and motorcycle accidents, falls, sports mishaps, and fights. The spleen is the
most commonly injured organ from blunt abdominal
trauma. Penetrating injuries such as those from stabbing,
gunshot wounds, and accidental impaling also account
for cases of splenic trauma, although far less frequently
than blunt trauma.
In adults, ruptured spleens may have been preceded
by conditions causing splenic enlargement, such as infections, cancer, immune system disorders, diseases of the
spleen, or circulatory problems.
Damage to the spleen may cause localized or general abdominal pain, tenderness, and swelling. Fractured
ribs may be present. Splenic trauma may cause mild or
severe internal bleeding, leading to shock and for which
symptoms include rapid heartbeat, shortness of breath,
thirst, pale or clammy skin, weak pulse, low blood pressure, dizziness, fainting, sweating. Vomiting blood,
blood in the stools or urine, deterioration of vital signs,
and loss of consciousness are other symptoms.

Diagnosis
The goal of diagnosis of all abdominal traumas is to
detect and treat life-threatening injuries as quickly as
possible. The physician will determine the extent of
organ damage and whether surgery will be necessary
while providing appropriate emergency care. Initial diagnosis consists of detailing all circumstances of the injury
from the patient and bystanders as well as the close
physical examination of the patient and measurement of
vital signs. Blood tests, urinalysis, stool samples and
x rays of the chest and abdomen are usually performed.
Plain x–rays may show abdominal air pockets that indicate internal ruptures, but are rarely helpful because they
do not show splenic and intra-abdominal damage.

Several other diagnostic tests may be used for the
non-invasive and accurate assessment of splenic damage:
computed tomography scans (CT), magnetic resonance imaging (MRI), radionuclide scanning, and ultrasonography. Ultrasonography has now become a standard
bedside technique in many hospitals to check for bleeding
in the abdomen. Imaging tests allow doctors to determine
the necessity and type of surgery required. The CT scan
has been shown to be the most available and accurate test
for abdominal trauma. MRI tests are accurate but costly
and less available in some hospitals, while radionuclide
scanning requires more time and patient stability. Peritoneal lavage is another diagnostic technique in which the
abdominal cavity is entered and flushed to check for
bleeding. When patients exhibit shock, infection, or prolonged internal bleeding, exploratory laparoscopy is used
for emergency diagnosis.
3141

Splenic trauma

ORGANIZATIONS


Sporotrichosis

Treatment
Not long ago nearly all cases of splenic trauma were
treated by laparoscopy, opening the abdomen, and by
splenectomy, the surgical removal of the spleen. This
approach resulted from the difficulty in assessing the
severity of the injury, the potential dangers of shock and
death, and the beliefs that the spleen healed poorly and
that it was not an important organ. Nowadays, improved

techniques of diagnosis and monitoring, as well as
understanding that removal of the spleen creates future
risk of a lowered capacity to fight infection has modified
treatment approaches. Research over the past two
decades has shown that the spleen has high healing
potential, and confirmed that children are more susceptible to infection after splenectomy (post splenectomy sepsis, PSS). PSS has a mortality rate of over 50% and standard procedure now avoids splenectomy as much as possible. Adult splenic trauma is treated by splenectomy
more often than children’s; for unknown reasons, the
adult spleen more frequently spontaneously ruptures
after injury. Adults are also less susceptible to PSS.
Nonoperative Treatment
In nonoperative therapy, splenic trauma patients are
monitored closely, often in intensive care units for several
days. Fluid and blood levels are observed and maintained
by intravenous fluid and possible blood transfusions. Follow-up scans may be used to observe the healing process.
Operative Treatment
Splenic trauma patients require surgery when nonoperative treatment fails, when major or prolonged internal bleeding exists and for gunshot and many stab
wounds. Whenever possible, surgeons try to preserve at
least part of the spleen and try to repair its blood vessels.

KEY TERMS
Computed tomography (CT) scan—Computeraided x-ray exam that allows cross-sectional views
of organs and tissues.
Laparoscope—An optical or fiberoptic instrument
that is inserted by incision in the abdominal wall and
is used to view the interior of the peritoneal cavity.
Laparoscopy—Procedure using a laparoscope to
view organs, obtain tissue samples and perform
surgery.
Magnetic resonance imaging (MRI)—Imaging
technique using magnets and radio waves to provide internal pictures of the body.

Radionuclide scanning—Diagnostic test in which
a radioactive dye is injected into the bloodstream
and photographed to display internal vessels,
organs and tissues.
Ultrasonography—Imaging test using sound
waves to view internal organs and tissues.

Schwartz, George, MD. Principles and Practice of Emergency
Medicine. Philadelphia: Lea & Febiger, 1992.
ORGANIZATIONS

American Trauma Society. 8903 Presidential Pkwy Suite 512,
Upper Marlboro, MD 20227. (800) 556-7890. www.amtrauma.org>.
OTHER

American Association for the Surgery of Trauma home page.
<>.

Douglas Dupler

Prognosis
The ample blood supply to the spleen can promote
rapid healing. Studies have shown that intra-abdominal
bleeding associated with splenic trauma stops without
surgical intervention in up to two out of three cases in
children. When trauma patients stabilize during nonoperative therapy, chances are high that surgery will be avoided and that spleen injuries will heal themselves. Splenic
trauma patients undergoing diagnostic tests such as CT
and MRI scans have improved chances of avoiding
splenectomy and retaining whole or partial spleens.

Resources
BOOKS

Hohn, David C., “Spleen” In Current Surgical Diagnosis and
Treatment. Ed. Lawrence W. Way, Stamford, CT: Appleton & Lange, 1994.
3142

Split personality see Multiple personality
disorder
Spontaneous abortion see Miscarriage
Sporothrix schenckii infection see
Sporotrichosis

Sporotrichosis
Definition
Sporotrichosis is a chronic infection caused by the
microscopic fungus Sporothrix schenckii. The disease
GALE ENCYCLOPEDIA OF MEDICINE 2


Sporotrichosis

causes ulcers on the skin that are painless but do not heal,
as well as nodules or knots in the lymph channels near
the surface of the body. Infrequently, sporotrichosis
affects the lungs, joints, or central nervous system and
can cause serious illness.

Description
The fungus that causes sporotrichosis is found in

spagnum moss, soil, and rotting vegetation. Anyone can
get sporotrichosis, but it is most common among nursery
workers, farm laborers, and gardeners handling spagnum
moss, roses, or barberry bushes. Cases have also been
reported in workers whose jobs took them under houses
into crawl spaces contaminated with the fungus. Children who played on baled hay have also gotten the disease. Sporotrichosis is sometimes called spagnum moss
disease or alcoholic rose gardener’s disease.

Causes and symptoms
The fungus causing sporotrichosis enters the body
through scratches or cuts in the skin. Therefore, people
who handle plants with sharp thorns or needles, like
roses, barberry, or pines, are more likely to get sporotrichosis. Sporotrichosis is not passed directly from person
to person, so it is not possible to catch sporotrichosis
from another person who has it.
The first signs of sporotrichosis are painless pink,
red, or purple bumps usually on the finger, hand, or arm
where the fungus entered the body. These bumps may
appear anywhere from one to 12 weeks after infection,
but usually appear within three weeks. Unlike many
other fungal infections sporotrichosis does not cause
fever or any feelings of general ill health.
The reddish bumps eventually expand and fester,
creating skin ulcers that do not heal. In addition, the
infection often moves to nearby lymph nodes. Although
most cases of sporotrichosis are limited to the skin and
lymph channels, occasionally the joints, lungs, and central nervous system become infected. In rare cases, death
may result.
People who have weakened immune systems,
either from a disease such as acquired immune deficiency Syndrome (AIDS) or leukemia, or as the result

of medications they take (corticosteroids, chemotherapy drugs), are more likely to get sporotrichosis and are
more at risk for the disease to spread to the internal
organs. Alcoholics and people with diabetes mellitus
or a pre-existing lung disease are also more likely to
become infected. Although sporotrichosis is painless, it
is important for people with symptoms to see a doctor
and receive treatment.
GALE ENCYCLOPEDIA OF MEDICINE 2

Sporotrichosis is a chronic infection caused by the microscopic fungus Sporothrix schenckii. It produces ulcers on
the skin that are painless but do not heal, and nodules or
knots in the lymph channels near the surface of the body.
(Illustration by Electronic Illustrators Group.)

Diagnosis
The preferred way to diagnose sporotrichosis is for a
doctor to obtain a sample of fluid from a freshly opened
sore and send it to a laboratory to be cultured. The procedure is fast and painless. It is possible to confirm the
presence of advanced sporotrichosis through a blood test
or a biopsy. Doctors may also take a blood sample to perform tests that rule out other fungal infections or diseases
such as tuberculosis or bacterial osteomyelitis.
Dermatologists and doctors who work with AIDS
patients are more likely to have experience in diagnosing
sporotrichosis. In at least one state, New York, the laboratory test to confirm this disease is provided free
through the state health department. In other cases, diagnosis should be covered by health insurance at the same
level as other diagnostic laboratory tests.

Treatment
When sporotrichosis is limited to the skin and lymph
system, it is usually treated with a saturated solution of

potassium iodine that the patient dilutes with water or
juice and drinks several times a day. The iodine solution
can only be prescribed by a physician. This treatment
must be continued for many weeks. Skin ulcers should
be treated like any open wound and covered with a clean
bandage to prevent a secondary bacterial infection. The
drug itraconazol (Sporanox), taken orally, is also available to treat sporotrichosis.
In serious cases of sporotrichosis, when the internal
organs are infected, the preferred treatment is the drug
3143


Sports injuries

Prevention

KEY TERMS
Acidophilus—The bacteria Lactobacillus acidophilus, usually found in yogurt.
Bacterial osteomyelitis—An infection of the bone
or bone marrow that is caused by a bacterium.
Bifidobacteria—A group of bacteria normally present in the intestine. Commercial supplements are
available.
Corticosteroids—A group of hormones produced
naturally by the adrenal gland or manufactured
synthetically. They are often used to treat inflammation. Examples include cortisone and prednisone.
Lymph channels—The vessels that transport lymph
throughout the body. Lymph is a clear fluid that
contains cells important in forming antibodies that
fight infection.

amphotericin B. Amphotericin B is a strong anti-fungal
drug with potentially severe toxic side effects. It is given
intravenously, so hospitalization is required for treatment. The patient may also receive other drugs to minimize the side effects of the amphotericin B.

Alternative treatment
Alternative treatment for fungal infections focuses
on maintaining general good health and eating a diet low
in dairy products, sugars, including honey and fruit juice,
and foods, such as beer, that contain yeast. This is complemented by a diet high in raw food. Supplements of
and vitamins C, E, and A, B complex, and pantothenic
acid may also be added to the diet, as may Lactobacillus
acidophilus, bifidobacteria, and garlic capsules.
Fungicidal herbs such as myrrh (Commiphora molmol), tea tree oil (Melaleuca spp.), citrus seed extract,
pau d’arco tea, and garlic (Allium sativum) may also be
applied directly to the infected skin.

Prognosis
Most cases of sporotrichosis are confined to the skin
and lymph system. With treatment, skin sores begin healing in one to two months, but complete recovery often
takes six months or more. People who have AIDS are
also more likely to have the fungus spread throughout the
body, causing a life-threatening infection. In people
whose bones and joints are infected or who have pulmonary lesions, surgery may be necessary.
3144

Since an opening in the skin is necessary for the
sporotrichosis fungus to enter the body, the best way to
prevent the disease is to avoid accidental scrapes and cuts
on the hands and arms by wearing gloves and long
sleeves while gardening. Washing hands and arms well

after working with roses, barberry, spagnum moss, and
other potential sources of the fungus may also provide
some protection.
Resources
BOOKS

Griffith, H. Winter. Complete Guide to Symptoms, Illness &
Surgery. Putnam Berkley Group. 1995.
PERIODICALS

Dillon, Gary P., et. al. “Handyperson’s Hazard: Crawl Space
Sporotrichosis.” The Journal of the American Medical
Association 274 (6 Dec. 1995): 1673+.

Tish Davidson

Sports injuries
Definition
Sports injuries result from acute trauma or repetitive
stress associated with athletic activities. Sports injuries
can affect bones or soft tissue (ligaments, muscles, tendons).

Description
Adults are less likely to suffer sports injuries than do
children, whose vulnerability is heightened by:
• immature reflexes
• inability to recognize and evaluate risks
• underdeveloped coordination
Each year, about 3.2 million children between the
ages of five and 14 are injured while participating in athletic activities, and account for 40% of all sports injuries.

As many as 20% of children who play sports get hurt, and
about 25% of their injuries are classified as serious. More
than 775,000 boys and girls under age 14 are treated in
hospital emergency rooms for sports-related injuries.
Injury rates are highest for athletes who participate
in contact sports, but the most serious injuries are associated with individual activities. Between one-half and
two-thirds of childhood sports injuries occur during practice, or in the course of unorganized athletic activity.
GALE ENCYCLOPEDIA OF MEDICINE 2


Sports injuries

Chauncy Billups, a guard for the Denver Nuggets, grimaces after spraining his ankle during a game. (AP/Wide World Photos.
Reproduced by permission.)

Types of sports injuries
About 95% of sports injuries are minor soft tissue
traumas.
The most common sports injury is a bruise (contusion). It is caused when blood collects at the site of an
injury and discolors the skin.
Sprains account for one-third of all sports injuries. A
sprain is a partial or complete tear of a ligament, a strong
band of tissue that connects bones to one another and stabilizes joints.
A strain is a partial or complete tear of:
• muscle (tissue composed of cells that enable the body
to move)
• tendon (strong connective tissue that links muscles to
bones)
Inflammation of a tendon (tendinitis) and inflammation of one of the fluid-filled sacs that allow tendons
GALE ENCYCLOPEDIA OF MEDICINE 2

to move easily over bones (bursitis) usually result from
minor stresses that repeatedly aggravate the same part of
the body. These conditions often occur at the same time.
SKELETAL INJURIES. Fractures account for 5–6% of
all sports injuries. The bones of the arms and legs are most
apt to be broken. Sports activities rarely involve fractures
of the spine or skull. The bones of the legs and feet are
most susceptible to stress fractures, which occur when
muscle strains or contractions make bones bend. Stress
fractures are especially common in ballet dancers, longdistance runners, and in people whose bones are thin.

Shin splints are characterized by soreness and slight
swelling of the front, inside, and back of the lower leg,
and by sharp pain that develops while exercising and
gradually intensifies. Shin splints are caused by overuse
or by stress fractures that result from the repeated foot
pounding associated with activities like aerobics, longdistance running, basketball, and volleyball.
3145


Sports injuries

A compartment syndrome is a potentially debilitating condition in which the muscles of the lower leg grow
too large to be contained within membranes that enclose
them. This condition is characterized by numbness and
tingling. Untreated compartment syndrome can result in
long-term loss of function.
BRAIN INJURIES. Brain injury is the primary cause
of fatal sports-related injuries. Concussion can result

from even minor blows to the head. A concussion can
cause loss of consciousness and may affect:

• balance

The physician will perform a physical examination,
ask how the injury occurred, and what symptoms the
patient has experienced. X rays and other imaging studies of bones and soft tissues may be ordered.
Anyone who has suffered a blow to the head should
be examined immediately, and at five-minute intervals
until normal comprehension has returned. The initial
examination measures the athlete’s:
• awareness
• concentration
• short-term memory

• comprehension
• coordination
• hearing

Subsequent evaluations of concussion assess:
• dizziness
• headache

• memory

• nausea

• vision

• visual disturbances

Causes and symptoms
Common causes of sports injuries include:
• athletic equipment that malfunctions or is used incorrectly

Treatment
Treatment for minor soft tissue injuries generally
consists of:
• compressing the injured area with an elastic bandage

• falls

• elevation

• forceful high-speed collisions between players

• ice

• wear and tear on areas of the body that are continually
subjected to stress

• rest

Symptoms include:
• instability or obvious dislocation of a joint
• pain
• swelling
• weakness

Diagnosis
Symptoms that persist, intensify, or reduce the athlete’s ability to play without pain should be evaluated by
an orthopedic surgeon. Prompt diagnosis can often prevent minor injuries from becoming major problems, or
causing long-term or lasting damage.
An orthopedic surgeon should examine anyone:
• who is prevented from playing by severe pain associated with acute injury,
• whose ability to play has declined due to chronic or
long-term consequences of an injury,
• whose injury has caused visible deformities in an arm
or leg.
3146

Anti-inflammatories, taken by mouth or injected
into the swelling, may be used to treat bursitis. Antiinflammatory medications and exercises to correct muscle imbalances are usually used to treat tendinitis. If the
athlete keeps stressing inflamed tendons, they may rupture, and casting or surgery is sometimes necessary to
correct this condition.
Orthopedic surgery may be required to repair serious sprains and strains.
Controlling inflammation as well as restoring normal use and mobility are the goals of treatment for
overuse injuries.
Athletes who have been injured are usually advised
to limit their activities until their injuries are healed. The
physician may suggest special exercises or behavior
modifications for athletes who have had several injuries.
Athletes who have been severely injured may be advised
to stop playing altogether.

Prevention
Every child who plans to participate in organized
athletic activity should have a pre-season sports physical.
GALE ENCYCLOPEDIA OF MEDICINE 2

• carefully evaluates the site of any previous injury
• may recommend special stretching and strengthening
exercises to help growing athletes create and preserve
proper muscle and joint interaction
• pays special attention to the cardiovascular and skeletal
systems
Telling the physician which sport the athlete plays
will help that physician to determine which parts of the
body will be subjected to the most stress. The physician
will then be able to suggest to the athlete steps to take to
minimize the chance of getting hurt.
Other injury-reducing game plans include:
• being in shape
• knowing and obeying the rules that regulate the activity
• not playing when tired, ill, or in pain
• not using steroids, which can improve athletic performance but cause life-threatening problems
• taking good care of athletic equipment and using it
properly
• wearing appropriate protective equipment

Sprains and strains
Definition
Sprain refers to damage or tearing of ligaments or a
joint capsule. Strain refers to damage or tearing of a muscle.

Description
When excessive force is applied to a joint, the ligaments that hold the bones together may be torn or damaged. This results in a sprain, and its seriousness depends
on how badly the ligaments are torn. Any joint can be

sprained, but the most frequently injured joints are the
ankle, knee, and finger.
Strains are tears in the muscle. Sometimes called
pulled muscles, they usually occur because of overexertion or improper lifting techniques. Sprains and strains
are common. Anyone can have them.
Children under age eight are less likely to have
sprains than are older people. Childrens’ ligaments are
tighter, and their bones are more apt to break before a ligament tears. People who are active in sports suffer more
strains and sprains than less active people. Repeated
sprains in the same joint make the joint less stable and
more prone to future sprains.

Resources

Causes and symptoms

BOOKS

Taylor, Robert B., ed. Family Medicine Principles and Practice. New York: Springer-Verlag, 1994.
ORGANIZATIONS

American Academy of Orthopedic Surgeons. 6300 North River
Road, Rosemont, IL 60018-4262. (800) 346-2267. www.aaos.org>.
The Institute for Preventative Sports Medicine. P.O. Box 7032,
Ann Arbor, MI 48107 (313) 434-3390. org>.
OTHER

Varlotta, Gerard. “Health Guide 96: Kids Need Physical Exam

to Help Ensure Good Health.” The Daily Herald 6 Nov.
1996. 22 May 1998 < />news/health/med18.htm>.
“Orthopaedics: Soft-Tissue Injuries.” Jeffline Page. Thomas
Jefferson University. 17 May 1998 <.
edu/index-new.html>.
“Shin Splints.” Loyola University Health System. 13 May 1998
<>.

There are three grades of sprains. Grade I sprains are
mild injuries where there is no tearing of the ligament,
and no joint function is lost, although there may be tenderness and slight swelling.
Grade II sprains are caused by a partial tear in the
ligament. These sprains are characterized by obvious
swelling, extensive bruising, pain, difficulty bearing
weight, and reduced function of the joint.
Grade III, or third degree, sprains are caused by
complete tearing of the ligament where there is severe
pain, loss of joint function, widespread swelling and
bruising, and the inability to bear weight. These symptoms are similar to those of bone fractures.
Strains can range from mild muscle stiffness to great
soreness. Strains result from overuse of muscles, improper use of the muscles, or as the result of injury in another
part of the body when the body compensates for pain by
altering the way it moves.

Maureen Haggerty

Sports vision see Vision training
Spouse abuse see Abuse
GALE ENCYCLOPEDIA OF MEDICINE 2

Diagnosis
Grade I sprains and mild strains are usually selfdiagnosed. Grade II and III sprains are often seen by a
3147

Sprains and strains

This special examination is performed by a pediatrician
or family physician who:


Sputum culture

physician, who x rays the area to differentiate between a
sprain and a fracture.

Treatment
Grade I sprains and mild strains can be treated at
home. Basic first aid for sprains consists of RICE: Rest,
Ice for 48 hours, Compression (wrapping in an elastic
bandage), and Elevation of the sprain above the level of
the heart. Over-the-counter pain medication such as
acetaminophen (Tylenol) or ibuprofen (Motrin) can be
taken for pain.
In addition to RICE, people with grade II and grade
III sprains in the ankle or knee usually need to use crutches until the sprains have healed enough to bear weight.
Sometimes, physical therapy or home exercises are needed to restore the strength and flexibility of the joint.
Grade III sprains are usually immobilized in a cast
for several weeks to see if the sprain heals. Pain medication is prescribed. Surgery may be necessary to relieve
pain and restore function. Athletic people under age 40
are the most likely candidates for surgery, especially with

grade III knee sprains. For complete healing, physical
therapy usually will follow surgery.

Alternative treatment
Alternative practitioners endorse RICE and conventional treatments. In addition, nutritional therapists recommend vitamin C and bioflavonoids to supplement a diet
high in whole grains, fresh fruits, and vegetables. Antiinflammatories, such as bromelain (a proteolytic enzyme
from pineapples) and tumeric (Curcuma longa), may also
be helpful. The homeopathic remedy arnica (Arnica montana) may be used initially for a few days, followed by
ruta (Ruta graveolens) for joint-related injuries or Rhus
toxicodendron for muscle-related injuries. If surgery is
needed, alternative practitioners can recommend pre- and
post-surgical therapies that will enhance healing.

Prognosis
Moderate sprains heal within two to four weeks, but
it can take months to recover from severe ligament tears.
Until recently, tearing the ligaments of the knee meant
the end to an athlete’s career. Improved surgical and
rehabilitative techniques now offer the possibility of
complete recovery. However, once a joint has been
sprained, it will never be as strong as it was before.

KEY TERMS
Ligament—Tough, fibrous connective tissue that
holds bones together at joints.

Resources
BOOKS

Burton Goldberg Group. “Sprains.” In Alternative Medicine:

The Definitive Guide, ed. James Strohecker. Puyallup,
WA: Future Medicine Publishing, 1994.
The Editors of Time-Life Books. The Medical Advisor: The
Complete Guide to Alternative and Conventional Treatments. Alexandria, VA: Time Life, Inc., 1996.
PERIODICALS

Wexler, Randall K. “The Injured Ankle.” American Family
Physician 57 (1 Feb. 1998): 474.

Tish Davidson

Sputum culture
Definition
Sputum is material coughed up from the lungs and
expectorated (spit out) through the mouth. A sputum culture is done to find and identify the microorganism causing an infection of the lower respiratory tract such as
pneumonia (an infection of the lung). If a microorganism is found, more testing is done to determine which
antibiotics will be effective in treating the infection.

Purpose
A person with a fever and a continuing cough that
produces pus-like material and/or blood may have an infection of the lower respiratory tract. Infections of the lungs
and bronchial tubes are caused by several types of microorganisms, including bacteria, fungi (molds and yeast), and
viruses. A chest x ray provides visual evidence of an infection; a culture can grow the microorganism causing the
infection. The microorganism is grown in the laboratory so
it can be identified, and tested for its response to medications, such as antifungals and antibiotics.

Prevention
Sprains and strains can be prevented by warming-up
before exercising, using proper lifting techniques, wearing properly fitting shoes, and taping or bracing the joint.
3148

Description
Based on the clinical condition of the patient, the
physician determines what group of microorganism is
GALE ENCYCLOPEDIA OF MEDICINE 2


Bacterial culture
A portion of the sputum is smeared on a microscope
slide for a Gram stain. Another portion is spread over
the surface of several different types of culture plates,
and placed in an incubator at body temperature for one
to two days.
A Gram stain is done by staining the slide with purple and red stains, then examining it under a microscope.
Gram staining checks that the specimen does not contain
saliva or material from the mouth. If many epithelial
(skin) cells and few white blood cells are seen, the specimen is not pure sputum and is not adequate for culture.
Depending on laboratory policy, the specimen may be
rejected and a new specimen requested. If many white
blood cells and bacteria of one type are seen, this is an
early confirmation of infection. The color of stain picked
up by the bacteria (purple or red), their shape (such as
round or rectangular), and their size provide valuable
clues as to their identity and helps the physician predict
what antibiotics might work best before the entire test is
completed. Bacteria that stain purple are called grampositive; those that stain red are called gram-negative.
During incubation, bacteria present in the sputum
sample multiply and will appear on the plates as visible
colonies. The bacteria are identified by the appearance of
their colonies, by the results of biochemical tests, and

through a Gram stain of part of a colony.
A sensitivity test, also called antibiotic susceptibility
test, is also done. The bacteria are tested against different
antibiotics to determine which will treat the infection by
killing the bacteria.
The initial result of the Gram stain is available the
same day, or in less than an hour if requested by the
physician. An early report, known as a preliminary
report, is usually available after one day. This report will
tell if any bacteria have been found yet, and if so, their
Gram stain appearance—for example, a gram-negative
rod, or a gram-positive cocci. The final report, usually
available in one to three days, includes complete identification and an estimate of the quantity of the bacteria and
a list of the antibiotics to which they are sensitive.
GALE ENCYCLOPEDIA OF MEDICINE 2

Fungal culture
To look for mold or yeast, a fungal culture is done.
The sputum sample is spread on special culture plates that
will encourage the growth of mold and yeast. Different
biochemical tests and stains are used to identify molds
and yeast. Cultures for fungi may take several weeks.
Viral culture
Viruses are a common cause of pneumonia. For a viral
culture, sputum is mixed with commercially-prepared animal cells in a test tube. Characteristic changes to the cells
caused by the growing virus help identify the virus. The
time to complete a viral culture varies with the type of
virus. It may take from several days to several weeks.
Special procedures
Tuberculosis is caused by a slow-growing bacteria

called Mycobacterium tuberculosis. Because it does not
easily grow using routine culture methods, special procedures are used to grow and identify this bacteria. When a
sputum sample for tuberculosis first comes into the laboratory, a small portion of the sputum is smeared on a
microscope slide and stained with a special stain, called
an acid-fast stain. The stained sputum is examined under
a microscope for tuberculosis organisms, which pick-up
the stain, making them visible. This smear is a rapid
screen for the organism, and allows the physician to
receive a preliminary report within 24 hours.
To culture for tuberculosis, portions of the sputum
are spread on and placed into special culture plates and
tubes of broth that promote the growth of the organism.
Growth in broth is faster than growth on culture plates.
Instruments are available that can detect growth in broth,
speeding the process even further. Growth and identification may take two to four weeks.
Other microorganisms that cause various types of
lower respiratory tract infections also require special culture procedures to grow and identify. Mycoplasma pneumonia causes a mild to moderate form of pneumonia,
commonly called walking pneumonia; Bordetella pertussis causes whooping cough; Legionella pneumophila,
Legionnaire’s disease; Chlamydia pneumoniae, an atypical pneumonia; and Chlamydia psittaci, parrot fever.
Pneumocystis carniicauses pneumonia in people with
weakened immune systems, such as people with AIDS.
This organism does not grow in culture. Special stains are
done on sputum when pneumonia caused by this organism
is suspected. The diagnosis is based on the results of these
stains, the patient’s symptoms, and medical history.
Sputum culture is also called sputum culture and
sensitivity.
3149

Sputum culture

likely to be causing the infection, and then orders one or
more specific types of cultures: bacterial, viral, or fungal
(for yeast and molds). For all culture types, the sputum
must be collected into a sterile container. The sputum
specimen must be collected carefully, so that bacteria
that normally live in the mouth and saliva don’t contaminate the sputum and complicate the process of identifying the cause of the infectious agent. Once in the laboratory, each culture type is handled differently.


Sputum culture

Preparation
The specimen for culture should be collected before
antibiotics are begun. Antibiotics in the person’s system
may prevent microorganisms present in the sputum from
growing in culture.
The best time to collect a sputum sample is early in
the morning, before having anything to eat or drink. The
patient should first rinse his or her mouth with water to
decrease mouth bacteria and dilute saliva. Through a deep
cough, the patient must cough up sputum from within the
chest. Taking deep breaths and lowering the head helps
bring up the sputum. Sputum must not be held in the
mouth but immediately spat into a sterile container. For
tuberculosis, the physician may want the patient to collect
sputum samples on three consecutive mornings.
If coughing up sputum is difficult, a health care
worker can have the patient breathe in sterile saline produced by a nebulizer. This nebulized saline coats the respiratory tract, loosening the sputum, and making it easier
to cough up. Sputum may also be collected by a physician during a bronchoscopy procedure.
If tuberculosis is suspected, collection of sputum

should be carried out in an isolation room, with all
attending healthcare workers wearing masks.

Normal results
Sputum from a healthy person would have no growth
on culture. A mixture of microorganisms, however, normally found in a person’s mouth and saliva often contaminate the culture. If these microorganisms grow in the culture, they may be reported as normal flora contamination.

Abnormal results
The presence of bacteria and white blood cells on
the Gram stain and the isolation of a microorganism from
culture, other than normal flora contamination, is evidence of a lower respiratory tract infection.
Microorganisms commonly isolated from sputum
include: Streptococcus pneumoniae, Haemophilus
influenzae, Staphylococcus aureus, Legionella pneumophila, Mycoplasma pneumonia, Klebsiella pneumoniae, Pseudomonas aeruginosa, Bordetella pertussis, and
Escherichia coli.
Resources
BOOKS

Isada, Carlos M., et al. Infectious Diseases Handbook. Hudson,
OH: Lexi-Comp., 1995.
Koneman, Elmer W., et al. Color Atlas and Textbook of Diagnostic Microbiology. 4th ed. Philadelphia: J. B. Lippincott
Co., 1992.
3150

KEY TERMS
Acid-fast stain—A special stain done to microscopically identify the bacteria that cause tuberculosis.
Culture—A laboratory test done to grow and identify microorganisms causing infection.
Gram stain—Microscopic examination of a portion of a bacterial colony or sample from an infection site after it has been stained by special stains.
Certain bacteria pick-up and retain the purple
stain; these bacteria are called gram-positive.

Other bacteria loose the purple stain and retain
the red stain; these bacteria are called gram-negative. The color of the bacteria, in addition to their
size and shape, provide clues as to the identity of
the bacteria.
Normal flora—The mixture of bacteria normally
found at specific body sites.
Pneumonia—An infection of the lungs.
Sputum—Material coughed up from the lower respiratory tract and expectorated through the mouth.
Sensitivity test—A test that determines which
antibiotics will kill the bacteria that has been isolated from a culture.

Pagana, Kathleen Deska. Mosby’s Manual of Diagnostic and
Laboratory Tests. St. Louis: Mosby, Inc., 1998.
Shulman, Stanford T., et al., eds. The Biologic and Clinical
Basis of Infectious Diseases. 5th ed. Philadelphia: W. B.
Saunders Co., 1997.
PERIODICALS

Buono, Nancy J., et al. “The Fight Against TB: A New Laboratory Arsenal Fights Back.” Medical Laboratory Observer
(Aug. 1996): 38-40, 42, 44, 46, 48, 50, 52.
Skerritt, Shawn J. “Diagnostic Testing to Establish a Microbial
Cause is Helpful in the Management of CommunityAcquired Pneumonia.” Seminars in Respiratory Infections
(Dec. 1997): 308-321.

Nancy J. Nordenson

Squam see Skin cancer, non-melanoma
Squint see Strabismus
SSPE see Subacute sclerosing panencephalitis
SSRIs see Selective serotonin reuptake

inhibitors
GALE ENCYCLOPEDIA OF MEDICINE 2


St. John’s wort

SSSS see Staphylococcal scalded skin
syndrome
St. Anthony’s fire see Erysipelas

St. John’s wort
Definition
Hypericum perforatum is the most medicinally
important species of the Hypericum genus, commonly
known as St. John’s wort. There are as many as 400
species in the genus, which is part of the Guttiferae family.
Native to Europe, St. John’s wort is found throughout the
world. It thrives in sunny fields, open woods, and gravelly
roadsides. Early colonists brought this valuable medicinal
to North America, and the plant has become naturalized in
the eastern United States and California, as well as in Australia, New Zealand, eastern Asia, and South America.
The entire plant, particularly the round, black seed,
exudes a slight, turpentine-like odor. The woody, branched
root spreads from the base with runners that produce
numerous stalks. The simple, dark green leaves are veined
and grow in opposite, oblong-obvate pairs on round,
branching stalks that reach 3 ft (91.4 cm) high. Tiny holes,
visible when the leaf is held to the light, are actually transparent oil glands containing the chemical photo sensitizer
known as hypericin. These characteristic holes inspired the
species name, perforatum, Latin for perforated. The bright

yellow, star-shaped flowers, often clustered in a trio, have
five petals. Each blossom has many showy stamens. Black
dots along the margins of the blossom contain more of the
red-pigmented chemical hypericin. The herb is also useful
as a dye. The flowers bloom in branching, flat-topped
clusters atop the stalks in mid-summer, around the time of
the summer solstice. St. John’s wort, sometimes called
devil’s flight or grace of God, was believed to have magical properties to ward off evil spirits. It’s generic name
hypericum is derived from a Greek word meaning “over
an apparition.” The herb was traditionally gathered on
mid-summer’s eve, June 23. This date was later christianized as the eve of the feast day of St. John the Baptist. This
folk custom gave the plant its popular name. The AngloSaxon word wort means medicinal herb.

Purpose
St. John’s wort has been known for its numerous
medicinal properties as far back as Roman times. It was a
valued remedy on the Roman battlefields where it was
used to promote healing from trauma and inflammation.
GALE ENCYCLOPEDIA OF MEDICINE 2

St. John’s wort flowers. (Photo Researchers, Inc. Reproduced
by permission.)

The herb is vulnerary and can speed the healing of
wounds, bruises, ulcers, and burns. It is popularly used
as a nervine for its calming effect, easing tension and
anxiety, relieving mild depression, and soothing emotions during menopause. The bittersweet herb is licensed
in Germany for use in cases of mild depression, anxiety,
and sleeplessness. It is useful in circumstances of nerve
injury and trauma, and has been used to speed healing

after brain surgery. Its antispasmodic properties can ease
uterine cramping and menstrual difficulties. St. John’s
wort acts medicinally as an astringent, and may also be
used as an expectorant. The hypericin in St. John’s wort
possesses anti-viral properties that may be active in combating certain cancers, including many brain cancers. An
infusion of the plant, taken as a tea, has been helpful in
treating night-time incontinence in children. The oil,
taken internally, has been used to treat colic, intestinal
worms, and abdominal pain. The medicinal parts of St.
John’s wort are the fresh leaves and flowers. This valuable remedy has been extensively tested in West Ger3151


St. John’s wort

KEY TERMS
Antispasmodic—Relieves mild cramping or muscle spasm.
Expectorant—Promotes the discharge of mucus
from respiratory system.
Nervine—Soothes and calms the nervous system.
Vulnerary—Heals wounds, bruises, sprains, and
ulcers.

many, and is dispensed throughout Germany as a popular
medicine called, Johnniskraut. Commercially prepared
extracts are commonly standardized to 0.3% hypericin.
Clinical studies
A 1988 study at New York University found the
antiviral properties in hypericin, a chemical component
of Hypericum, to be useful in combating the virus that
causes AIDS. Additional studies are under way through

the Federal Drug Administration (FDA) to determine the
effectiveness of the herb as a treatment for AIDS. Hypericin extract has also been reported to inhibit a form of
leukemia that sometimes occurs after radiation therapy.
Numerous clinical studies have found hypericum preparations to have an antidepressive effect when used in
standardized extracts for treatment of mild depression.
Clinical trials continue with this important herbal antidepressant, particularly in view of its relative lack of
undesirable side effects in humans.

Preparations
An oil extract can be purchased commercially or
prepared by combining fresh flowers and leaves of St.
John’s wort in a glass jar and sunflower or olive oil.
Seal the container with an airtight lid and leave on a
sunny windowsill for four to six weeks, shaking daily.
The oil will absorb the red pigment. Strain through
muslin or cheesecloth, and store in a dark container.
The medicinal oil will maintain its potency for two
years or more. The oil of St. John’s wort has been
known in folk culture as “Oil of Jesus.” This oil makes
a good rub for painful joints, varicose veins, muscle
strain, arthritis, and rheumatism. Used in a compress it
can help to heal wounds and inflammation, and relieve
the pain of deep bruising.
An infusion is made by pouring one pint of boiling
water over 1 oz (28 g) of dried herb, or 2 oz (57 g) of fresh,
minced flower and leaf. Steep in a glass or enamel pot for
3152

five to 10 minutes. Strain and cover. Drink the tea warm. A
general dose is one cupful, up to three times daily.

Capsule: Dry the leaves and flowers and grind with
mortar and pestle into a fine powder. Place in gelatin capsules. The potency of the herb varies with the soil, climate and harvesting conditions of the plant. A standardized extract of 0.3% hypericin extract, commercially prepared from a reputable source, is more likely to yield
reliable results. Standard dosage is up to three 300 mg
capsules of 0.3% standardized extract daily.
A tincture is prepared by combining one part fresh
herb to three parts alcohol (50% alcohol/water solution)
in glass container. Set aside in dark place, shaking the
mixture daily for two weeks. Strain through muslin or
cheesecloth, and store in dark bottle. The tincture should
maintain potency for two years. Standard dosage, unless
otherwise prescribed, is 0.24–1 tsp added to 8 oz (237
ml) of water, up to three times daily.
A salve is made by warming 2 oz (59 ml) of prepared oil extract in double boiler. Once warmed, 1 oz (28
g) of grated beeswax is added and mixed until melted.
Pour into a glass jar and cool. The salve can be stored for
up to one year. The remedy keeps best if refrigerated
after preparation. The salve is useful in treating burns,
wounds, and soothing painful muscles. It is also a good
skin softener. St. John’s wort salve may be prepared in
combination with calendula extract (Calendula officinalis) for application on bruises.

Precautions
Consult a physician prior to use. Pregnant or lactating women should not use the herb. Individuals taking
prescribed psychotropic medications classified as selective serotonin reuptake inhibitors, or SSRI, such as
Prozac, should not simultaneously use St. John’s wort.
Many herbalists also discourage use of St. John’s wort by
individuals taking any other anti-depressant medication.
Cattlemen dislike the shrub because there have been
some reports of toxicity to livestock that over-graze in
fields abundant with the wild herb. Toxic effects in livestock include reports of edema of the ears, eyelids, and

the face due to photosensitization after ingestion of the
herb. Exposure to sunlight activates the hypercin in the
plant. Adverse effects have been reported in horses,
sheep, and swine and include staggering, and blistering
and peeling of the skin. Toxicity is greater in smaller
mammals, such as rabbits.

Side effects
When used either internally or externally, the herb
may cause photo-dermatitis in humans with fair or senGALE ENCYCLOPEDIA OF MEDICINE 2


Interactions

Stanford-Binet intelligence
scales
Definition
The Stanford-Binet intelligence scale is a standardized test that assesses intelligence and cognitive abilities
in children and adults aged two to 23.

Purpose

St. John’s wort can interact with amphetamines,
asthma inhalants, decongestants, diet pills, narcotics,
and amino acid tryptophan and tyrosine, as well as certain foods. Reactions range from nausea to increased
high blood pressure. Consult a practitioner prior to using
St. John’s wort.

The Stanford-Binet intelligence scale is used as a
tool in school placement, in determining the presence of a

learning disability or a developmental delay, and in tracking intellectual development. In addition, it is sometimes
included in neuropsychological testing to assess the brain
function of individuals with neurological impairments.

Precautions

Resources
BOOKS

Blumenthal, Mark. The Complete German Commission E
Monographs, Therapeutic Guide to Herbal Medicines.
American Botanical Council, Boston: Integrative Medicine Communications, 1998.
Bown, Deni. The Herb Society of America, Encyclopedia of
Herbs & Their Uses. New York: D. K. Publishing, Inc.,
1995.
Foster, Steven and James A. Duke. A Field Guide to Medicinal
Plants. New York: Peterson Field Guides, Houghton Mifflin Company, 1990.
Hoffmann, David. The New Holistic Herbal. Massachusetts:
Element Books, 1992.
McIntyre, Anne. The Medicinal Garden. New York: Henry Holt
and Company Inc., 1997.
McVicar, Jekka. Herbs For The Home. New York: Penguin
Books, 1995.
“Prevention’s 200 Herbal Remedies.” Excerpted from The
Complete Book of Natural & Medicinal Cures. Pennsylvania: Rodale Press Inc., 1994.
PERIODICALS

Hoffmann, David. Herbal Alternatives to Prozac, Medicines
from the Earth, Protocols for Botanical Healing Official
Proceedings, Gaia Herbal Research Institute, Harvard,

MA. 1996
ORGANIZATIONS

American Botanical Council. PO Box 201660, Austin, TX
78720-1660.
OTHER

Herb Research Foundation. <>.

Clare Hanrahan

St. Vitus’ dance see Sydenham’s chorea
GALE ENCYCLOPEDIA OF MEDICINE 2

Although the Stanford-Binet was developed for children as young as two, examiners should be cautious in
using the test to screen very young children for developmental delays or disabilities. The test cannot be used to
diagnose mental retardation in children aged three and
under, and the scoring design may not detect developmental problems in preschool-age children.
Intelligence testing requires a clinically trained
examiner. The Stanford-Binet intelligence scale should
be administered and interpreted by a trained professional, preferably a psychologist.

Description
The Stanford-Binet intelligence scale is a direct
descendent of the Binet-Simon scale, the first intelligence
scale created in 1905 by psychologist Alfred Binet and
Dr. Theophilus Simon. This revised edition, released in
1986, was designed with a larger, more diverse, representative sample to minimize the gender and racial inequities
that had been criticized in earlier versions of the test.
The Stanford-Binet scale tests intelligence across four

areas: verbal reasoning, quantitative reasoning, abstract/
visual reasoning, and short-term memory. The areas are
covered by 15 subtests, including vocabulary, comprehension, verbal absurdities, pattern analysis, matrices, paper
folding and cutting, copying, quantitative, number series,
equation building, memory for sentences, memory for digits, memory for objects, and bead memory.
All test subjects take an initial vocabulary test,
which along with the subject’s age, determines the number and level of subtests to be administered. Total testing
time is 45–90 minutes, depending on the subject’s age
and the number of subtests given. Raw scores are based
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Stanford-Binet intelligence scales

sitive skin when exposed to sun light or other ultraviolet light source. There have been some reports of
changes in lactation in some nursing women taking
the hypericum extract. Changes in the nutritional quality and flavor of the milk, and reduction or cessation of
lactation have also been reported. It can also cause
headaches, stiff neck, nausea and vomiting, and high
blood pressure.


Stapedectomy

Resources

KEY TERMS
Norms—Normative or mean score for a particular
age group.
Representative sample—A random sample of people that adequately represents the test-taking population in age, gender, race, and socioeconomic
standing.

Standard deviation—A measure of the distribution
of scores around the average (mean). In a normal
distribution, two standard deviations above and
below the mean includes about 95% of all samples.
Standardization—The process of determining
established norms and procedures for a test to act
as a standard reference point for future test results.
The Stanford-Binet test was standardized on a
national representative sample of 5,000 subjects.

on the number of items answered, and are converted into
a standard age score corresponding to age group, similar
to an IQ measure.
The 1997 Medicare reimbursement rate for psychological and neuropsychological testing, including intelligence testing, is $58.35 an hour. Billing time typically
includes test administration, scoring and interpretation,
and reporting. Many insurance plans cover all or a portion of diagnostic psychological testing.

BOOKS

Maddox, Taddy. Tests: A Comprehensive Reference For Assessments in Psychology, Education, and Business. 4th ed.
Austin: Pro-ed, 1997.
Shore, Milton F., Patrick J. Brice, and Barbara G. Love. When
Your Child Needs Testing. New York: Crossroad Publishing, 1992.
Wodrich, David L. Children’s Psychological Testing: A Guide
for Nonpsychologists. Baltimore: Paul H. Brookes Publishing, 1997.
ORGANIZATIONS

American Psychological Association (APA). 750 First St. NE,
Washington, DC 20002-4242. (202) 336-5700. www.apa.org>.

Paula Anne Ford-Martin

Stapedectomy
Definition
Stapedectomy is a surgical procedure in which the
innermost bone (stapes) of the three bones (the stapes,
the incus, and the malleus) of the middle ear is removed,
and replaced with a small plastic tube of stainless-steel
wire (a prosthesis) to improve the movement of sound to
the inner ear.

Purpose
Normal results
The Stanford-Binet is a standardized test, meaning
that norms were established during the design phase of
the test by administering the test to a large, representative
sample of the test population. The test has a mean, or
average, standard score of 100 and a standard deviation
of 16 (subtests have a mean of 50 and a standard deviation of 8). The standard deviation indicates how far
above or below the norm the subject’s score is. For example, an eight-year-old is assessed with the Stanford-Binet
scale and achieves a standard age score of 116. The mean
score of 100 is the average level at which all eight-yearolds in the representative sample performed. This child’s
score would be one standard deviation above that norm.
While standard age scores provide a reference point
for evaluation, they represent an average of a variety of
skill areas. A trained psychologist will evaluate and interpret an individual’s performance on the scale’s subtests
to discover strengths and weaknesses and offer recommendations based upon these findings.
3154

A stapedectomy is used to treat progressive hearing
loss caused by otosclerosis, a condition in which spongy
bone hardens around the base of the stapes. This condition fixes the stapes to the opening of the inner ear, so
that the stapes no longer vibrates properly; therefore, the
transmission of sound to the inner ear is disrupted.
Untreated otosclerosis eventually results in total deafness, usually in both ears.

Description
With the patient under local or general anesthesia,
the surgeon opens the ear canal and folds the eardrum
forward. Using an operating microscope, the surgeon is
able to see the structures in detail, and evaluates the
bones of hearing (ossicles) to confirm the diagnosis of
otosclerosis.
Next, the surgeon separates the stapes from the
incus; freed from the stapes, the incus and malleus bones
can now move when pressed. A laser (or other tiny
GALE ENCYCLOPEDIA OF MEDICINE 2


Cochlea—The hearing part of the inner ear. This
snail-shaped structure contains fluid and thousands of microscopic hair cells tuned to various
frequencies, in addition to the organ of Corti (the
receptor for hearing).
Conductive hearing loss—A type of medically
treatable hearing loss in which the inner ear is
usually normal, but there are specific problems in
the middle or outer ears that prevent sound from
getting to the inner ear in a normal way.
A human stapes bone (located in middle ear) extracted during a stapedectomy. (Custom Medical Stock Photo. Reproduced by permission.)

instrument) vaporizes the tendon and arch of the stapes
bone, which is then removed from the middle ear.
The surgeon then opens the window that joins the
middle ear to the inner ear and acts as the platform for
the stapes bone. The surgeon directs the laser’s beam at
the window to make a tiny opening, and gently clips the
prosthesis to the incus bone. A piece of tissue is taken
from a small incision behind the ear lobe and used to
help seal the hole in the window and around the prosthesis. The eardrum is then gently replaced and repaired,
and held there by absorbable packing ointment or a
gelatin sponge. The procedure usually takes about an
hour and a half.
Good candidates for the surgery are those who have
a fixed stapes from otosclerosis, and a conductive hearing loss at least 20 dB. Patients with a severe hearing loss
might still benefit from a stapedectomy, if only to
improve their hearing to the point where a hearing aid
can be of help. The procedure can improve hearing in
more than 90% of cases.

Preparation
Prior to admission to the hospital, the patient will be
given a hearing test to measure the degree of deafness,
and a full ear, nose, and throat exam.
Most surgeons prefer to use general anesthesia; in
this case, an injection will be given to the patient before
surgery.

Aftercare
The patient is usually discharged the morning after

surgery. Antibiotics are given up to five days after
surgery to prevent infection; packing and sutures are
removed about a week after surgery.
GALE ENCYCLOPEDIA OF MEDICINE 2

Incus—The middle of the three bones of the middle ear. It is also known as the “anvil.”
Malleus—One of the three bones of the middle
ear. It is also known as the “hammer.”
Ossicles—The three small bones of the middle
ear: the malleus (hammer), the incus (anvil) and
the stapes (stirrup). These bones help carry sound
from the eardrum to the inner ear.
Vertigo—A feeling of dizziness together with a
sensation of movement and a feeling of rotating in
space.

It is important that the patient not put pressure on the
ear for a few days after surgery. Blowing one’s nose, lifting heavy objects, swimming underwater, descending
rapidly in high-rise elevators, or taking an airplane flight
should be avoided.
Right after surgery, the ear is usually quite sensitive,
so the patient should avoid loud noises until the ear
retrains itself to hear sounds properly.
It is extremely important that the patient avoid getting the ear wet until it has completely healed. Water in
the ear could cause an infection; most seriously, water
could enter the middle ear and cause an infection within
the inner ear, which could then lead to a complete hearing loss. When taking a shower, and washing the hair,
the patient should plug the ear with a cotton ball or
lamb’s wool ball, soaked in Vaseline. The surgeon
should give specific instructions about when and how

this can be done.
Usually, the patient may return to work and normal
activities about a week after leaving the hospital,
although if the patient’s job involves heavy lifting, three
weeks of home rest is recommend. Three days after
surgery, the patient may fly in pressurized aircraft.
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Stapedectomy

KEY TERMS


Staphylococcal infections

Risks
The most serious risk is an increased hearing loss,
which occurs in about one percent of patients. Because
of this risk, a stapedectomy is usually performed on only
one ear at a time.
Less common complications include:
• temporary change in taste (due to nerve damage) or
lack of taste

Staphylococcal infections
Definition
Staphylococcal (staph) infections are communicable
conditions caused by certain bacteria and generally characterized by the formation of abscesses. They are the
leading cause of primary infections originating in hospitals (nosocomial infections) in the United States.

• perforated eardrum
• vertigo that may persist and require surgery
• damage to the chain of three small bones attached to the
eardrum
• temporary facial nerve paralysis
• ringing in the ears
Severe dizziness or vertigo may be a signal that
there has been an incomplete seal between the fluids of
the middle and inner ear. If this is the case, the patient
needs immediate bed rest, an exam by the ear surgeon,
and (rarely) an operation to reopen the eardrum to check
the prosthesis.

Description
Classified since the early twentieth century as
among the deadliest of all disease-causing organisms,
staph exists on the skin or inside the nostrils of 20–30%
of healthy people. It is sometimes found in breast tissue,
the mouth, and the genital, urinary, and upper respiratory tracts.
Although staph bacteria are usually harmless, when
injury or a break in the skin enables the organisms to
invade the body and overcome the body’s natural defenses, consequences can range from minor discomfort to
death. Infection is most apt to occur in:
• newborns

Normal results

• women who are breastfeeding

Most patients are slightly dizzy for the first day or

two after surgery, and may have a slight headache. Hearing improves once the swelling subsides, the slight
bleeding behind the ear drum dries up, and the packing is
absorbed or removed, usually within two weeks. Hearing
continues to get better over the next three months.
About 90% of patients will have a completely successful surgery, with markedly improved hearing. In
8% of cases, hearing improves, but not quite as patients
usually expect. About half the patients who had ringing
in the ears (tinnitus) before surgery will have significant relief within six weeks after the procedure.
Resources
BOOKS

The Surgery Book: An Illustrated Guide to 73 of the Most Common Operations. Ed. Robert M. Younson, et al. New York:
St. Martin’s Press, 1993.
ORGANIZATIONS

American Academy of Otolaryngology-Head and Neck
Surgery, Inc. One Prince St., Alexandria VA 22314-3357.
(703) 836-4444. <>.
Better Hearing Institute. 515 King Street, Suite 420, Alexandria, VA 22314. (703) 684-3391.

Carol A. Turkington
3156

• individuals whose immune systems have been undermined by radiation treatments, chemotherapy, or medication
• intravenous drug users
• those with surgical incisions, skin disorders, and serious illness like cancer, diabetes, and lung disease
Types of infections
Staph infections produce pus-filled pockets (abscesses) located just beneath the surface of the skin or deep
within the body. Risk of infection is greatest among the
very young and the very old.

A localized staph infection is confined to a ring of
dead and dying white blood cells and bacteria. The skin
above it feels warm to the touch. Most of these abscesses
eventually burst, and pus that leaks onto the skin can
cause new infections.
A small fraction of localized staph infections enter
the bloodstream and spread through the body. In children, these systemic (affecting the whole body) or disseminated infections frequently affect the ends of the
long bones of the arms or legs, causing a bone infection
called osteomyelitis. When adults develop invasive staph
infections, bacteria are most apt to cause abscesses of the
brain, heart, kidneys, liver, lungs, or spleen.
GALE ENCYCLOPEDIA OF MEDICINE 2


Staphylococcal infections

Staphylococcus aureus
Named for the golden color of the bacteria grown
under laboratory conditions, S. aureus is a hardy organism
that can survive in extreme temperatures or other inhospitable circumstances. About 70–90% of the population
carry this strain of staph in the nostrils at some time.
Although present on the skin of only 5–20% of healthy people, as many as 40% carry it elsewhere, such as in the throat,
vagina, or rectum, for varying periods of time, from hours to
years, without developing symptoms or becoming ill.
S. aureus flourishes in hospitals, where it infects
healthcare personnel and patients who have had surgery;
who have acute dermatitis, insulin-dependent diabetes, or
dialysis-dependent kidney disease; or who receive frequent allergy-desensitization injections. Staph bacteria can
also contaminate bedclothes, catheters, and other objects.
S. aureus causes a variety of infections. Boils and

inflammation of the skin surrounding a hair shaft (folliculitis) are the most common. Toxic shock (TSS) and scalded
skin syndrome (SSSS) are among the most serious.
TOXIC SHOCK. Toxic shock syndrome is a lifethreatening infection characterized by severe headache,
sore throat, fever as high as 105°F, and a sunburn-like
rash that spreads from the face to the rest of the body.
Symptoms appear suddenly; they also include dehydration and watery diarrhea.

Inadequate blood flow to peripheral parts of the
body (shock) and loss of consciousness occur within the
first 48 hours. Between the third and seventh day of illness, skin peels from the palms of the hands, soles of the
feet, and other parts of the body. Kidney, liver, and muscle damage often occur.
SCALDED SKIN SYNDROME. Rare in adults and most
common in newborns and other children under the age of
five, scalded skin syndrome originates with a localized
skin infection. A mild fever and/or an increase in the
number of infection-fighting white blood cells may occur.

A bright red rash spreads from the face to other parts
of the body and eventually forms scales. Large, soft blisters develop at the site of infection and elsewhere. When
they burst, they expose inflamed skin that looks as if it
had been burned.
MISCELLANEOUS INFECTIONS. S. aureus can also

cause:
• arthritis
• bacteria in the bloodstream (bacteremia)
• pockets of infection and pus under the skin (carbuncles)
• tissue inflammation that spreads below the skin, causing pain and swelling (cellulitis)
GALE ENCYCLOPEDIA OF MEDICINE 2

A close-up of a woman’s finger and nail cuticle infected with
Staphyloccus aureus. (Custom Medical Stock Photo. Reproduced by permission.)

• inflammation of the valves and walls of the heart (endocarditis)
• inflammation of tissue that enclosed and protects the
spinal cord and brain (meningitis)
• inflammation of bone and bone marrow (osteomyelitis)
• pneumonia
Other strains of staph
S. EPIDERMIDIS. Capable of clinging to tubing (as in
that used for intravenous feeding, etc.), prosthetic
devices, and other non-living surfaces, S. epidermidis is
the organism that most often contaminates devices that
provide direct access to the bloodstream.

The primary cause of bacteremia in hospital patients,
this strain of staph is most likely to infect cancer patients,
whose immune systems have been compromised, and
high-risk newborns receiving intravenous supplements.
S. epidermidis also accounts for two of every five
cases of prosthetic valve endocarditis. Prosthetic valve
endocarditis is endocarditis as a complication of the
implantation of an artificial valve in the heart. Although
contamination usually occurs during surgery, symptoms
of infection may not become evident until a year after the
operation. More than half of the patients who develop
prosthetic valve endocarditis die.
STAPHYLOCOCCUS SAPROPHYTICUS. Existing within and around the tube-like structure that carries urine
from the bladder (urethra) of about 5% of healthy males
and females, S. saprophyticus is the second most common

cause of unobstructed urinary tract infections (UTIs) in
sexually active young women. This strain of staph is
responsible for 10–20% of infections affecting healthy
outpatients.

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Staphylococcal infections

• Lymph nodes in the neck, armpits, or groin become
swollen or tender.
• An area of skin that has been cut or scraped becomes
painful or swollen, feels hot, or produces pus. These
symptoms may mean the infection has spread to the
bloodstream.
• A boil or carbuncle appears on any part of the face or
spine. Staph infections affecting these areas can spread
to the brain or spinal cord.
• A boil becomes very sore. Usually a sign that infection
has spread, this condition may be accompanied by
fever, chills, and red streaks radiating from the site of
the original infection.
• Boils that develop repeatedly. This type of recurrent
infection could be a symptom of diabetes.

Diagnosis
A micrographic image of Staphylococcus aureus. (Photograph by Oliver Meckes, Photo Researchers, Inc. Reproduced
by permission.)

Causes and symptoms
Staph bacteria can spread through the air, but infection is almost always the result of direct contact with open
sores or body fluids contaminated by these organisms.
Staph bacteria often enter the body through inflamed
hair follicles or oil glands. Or they penetrate skin damaged by burns, cuts and scrapes, infection, insect bites,
or wounds.
Multiplying beneath the skin, bacteria infect and
destroy tissue in the area where they entered the body. Staph
infection of the blood (staphylococcal bacteremia) develops
when bacteria from a local infection infiltrate the lymph
glands and bloodstream. These infections, which can usually be traced to contaminated catheters or intravenous
devices, usually cause persistent high fever. They may cause
shock. They also can cause death within a short time.
Warning signs
Common symptoms of staph infection include:
• pain or swelling around a cut, or an area of skin that has
been scraped
• boils or other skin abscesses
• blistering, peeling, or scaling of the skin; this is most
common in infants and young children
• enlarged lymph nodes in the neck, armpits, or groin.
A family physician should be notified whenever:
3158

Blood tests that show unusually high concentrations
of white blood cells can suggest staph infection, but diagnosis is based on laboratory analysis of material removed
from pus-filled sores, and on analysis of normally uninfected body fluids, such as, blood and urine. Also, x rays
can enable doctors to locate internal abscesses and estimate the severity of infection. Needle biopsy (removing
tissue with a needle, then examining it under a microscope) may be used to assess bone involvement.

Treatment
Superficial staph infections can generally be cured
by keeping the area clean, using soaps that leave a germkilling film on the skin, and applying warm, moist compresses to the affected area for 20–30 minutes three or
four times a day.
Severe or recurrent infections may require a seven to
10 day course of treatment with penicillin or other oral
antibiotics. The location of the infection and the identity
of the causal bacteria determines which of several effective medications should be prescribed.
In case of a more serious infection, antibiotics may
be administered intravenously for as long as six weeks.
Intravenous antibiotics are also used to treat staph infections around the eyes or on other parts of the face.
Surgery may be required to drain or remove abscesses that form on internal organs, or on shunts or other
devices implanted inside the body.

Alternative treatment
Alternative therapies for staph infection are meant to
strengthen the immune system and prevent recurrences.
GALE ENCYCLOPEDIA OF MEDICINE 2


• Garlic (Allium sativum). This herb is believed to have
anitbacterial properties. Herbalists recommend consuming three garlic cloves or three garlic oil capsules a
day, starting when symptoms of infection first appear.
• Cleavers (Galium aparine). This anti-inflammatory
herb is believed to support the lymphatic system. It may
be taken internally to help heal staph abscesses and
reduce swelling of the lymph nodes. A cleavers compress can also be applied directly to a skin infection.
• Goldenseal (Hydrastis canadensis). Another herb
believed to fight infection and reduce imflammation,
goldenseal may be taken internally when symptoms of

infection first appear. Skin infections can be treated by
making a paste of water and powdered goldenseal root
and applying it directly to the affected area. The preparation should be covered with a clean bandage and left
in place overnight.
• Echinacea (Echinacea spp.). Taken internally, this herb
is believed to have antibiotic properties and is also
thought to strengthen the immune system.
• Thyme (Thymus vulgaris), lavender (Lavandula officinalis), or bergamot (Citrus bergamot) oils. These oils
are believed to have antibacterial properties and may
help to prevent the scarring that may result from skin
infections. A few drops of these oils are added to water
and then a compress soaked in the water is applied to
the affected area.
• Tea tree oil (Melaleuca spp.). Another infection-fighting herb, this oil can be applied directly to a boil or
other skin infection.

Prognosis
Most healthy people who develop staph infections
recover fully within a short time. Others develop repeated infections. Some become seriously ill, requiring longterm therapy or emergency care. A small percentage die.

Prevention
Healthcare providers and patients should always
wash their hands thoroughly with warm water and soap
after treating a staph infection or touching an open
wound or the pus it produces. Pus that oozes onto the
skin from the site of an infection should be removed
immediately. This affected area should then be cleansed
with antiseptic or with antibacterial soap.
GALE ENCYCLOPEDIA OF MEDICINE 2

KEY TERMS
Abscess—A cavity containing pus surrounded by
inflamed tissue.
Endocarditis—Inflammation of the lining of the
heart, and/or the heart valves, caused by infection.
Nosocomial infections—Infections that were not
present before the patient came to a hospital, but
were acquired by a patient while in the hospital.

To prevent infection from spreading from one part of
the body to another, it is important to shower rather than
bathe during the healing process. Because staph infection
is easily transmitted from one member of a household to
others, towels, washcloths, and bed linens used by someone with a staph infection should not be used by anyone
else. They should be changed daily until symptoms disappear, and laundered separately in hot water with bleach.
Children should frequently be reminded not to
share:
• brushes, combs, or hair accessories
• caps
• clothing
• sleeping bags
• sports equipment
• other personal items
A diet rich in green, yellow, and orange vegetables
can bolster natural immunity. A doctor or nutritionist
may recommend vitamins or mineral supplements to
compensate for specific dietary deficiencies. Drinking
eight to 10 glasses of water a day can help flush diseasecausing organisms from the body.
Because some strains of staph bacteria are known to
contaminate artificial limbs, prosthetic devices implanted

within the body, and tubes used to administer medication
or drain fluids from the body, catheters and other devices
should be removed on a regular basis, if possible, and
examined for microscopic signs of staph. Symptoms may
not become evident until many months after contamination has occurred, so this practice should be followed
even with patients who show no sign of infection.
Resources
BOOKS

Bennett, J. Claude, and Fred Plum, eds. Cecil Textbook of Medicine. Philadelphia: W. B. Saunders Co., 1996.
3159

Staphylococcal infections

Among the therapies believed to be helpful for the person with a staph infection are yoga (to stimulate the
immune system and promote relaxation), acupuncture
(to draw heat away from the infection), and herbal remedies. Herbs that may help the body overcome, or withstand, staph infection include:


Staphylococcal scalded skin synddrome

Civetta, Joseph M., et al., eds. Critical Care. Philadelphia: Lippincott-Raven Publishers, 1997.
Harrison’s Principles of Internal Medicine. Ed. Anthony S.
Fauci, et al. New York: McGraw-Hill, 1997.
The Editors of Time-Life Books. The Medical Advisor: The
Complete Guide to Alternative and Conventional Treatments. Alexandria, VA: Time Life, Inc., 1996.

Maureen Haggerty

Staphylococcal scalded

skin syndrome
Definition
Staphylococcal scalded skin syndrome (SSSS) is a
disease, caused by a type of bacteria, in which large
sheets of skin may peel away.

Description
SSSS primarily strikes children under the age of
five, particularly infants. Clusters of SSSS cases (epidemics) can occur in newborn nurseries, when staff in
those nurseries accidentally pass the causative bacteria
between patients. It can also strike other age groups who
have weakened immune systems. Such immunocompromised patients include those with kidney disease, people
undergoing cancerchemotherapy, organ transplant
patients, and individuals with acquired immunodeficiency syndrome (AIDS).

Causes and symptoms
SSSS is caused by a type of bacteria called Staphylococcus aureus. This bacteria produces a chemical
called an epidermolytic toxin ( “epiderm,” deriving from
the Greek words epi, meaning on, and derma, meaning
skin, refers to the top layer of skin; “-lytic,” deriving
from the Greek word lysis, which literally denotes the act
of undoing, means breaking or destroying; a toxin is a
poison). While the bacteria itself is not spread throughout
the body, it affects all of the skin by sending this toxin
through the bloodstream.
SSSS begins with a small area of infection. In newborn babies, this may appear as a crusted area around the
umbilicus, or in the diaper area. In children between the
ages of one and six, a small, red, crusty bump appears
near the nose or ear. The child may have no energy, and
may have a fever. The skin becomes sensitive and

uncomfortable even before the rash is fully visible. The
rash starts out as bright red patches around the original
area of crusting. Blisters may appear, and the skin may
3160

look wrinkled. When the blisters pop, they leave pitted
areas. Even gently touching these red patches of skin
may cause them to peel away in jagged sheets. The skin
below is shiny, moist, and bright pink. Within a day or
two, the top layer of skin all over the body is peeling off
in large sheets.
The dangers of this illness include the chance that a
different kind of bacteria will invade through the open
areas in the skin and cause a serious systemic infection
(sepsis). A lot of body fluid is lost as the skin peels away,
and the layer underneath dries. Dehydration is a danger
at this point.

Diagnosis
Although good patient care includes taking specimens of blister fluid and smears from the nose or throat,
no bacteria are usually demonstrated. SSSS is usually
diagnosed on the basis of the typical progression of
symptoms in a child of this age, prone to this disorder. A
sample of skin (skin biopsy) should be taken, prepared,
and examined under a microscope. If the patient’s disease is truly SSSS, the biopsy will show a characteristic
appearance. There will be no accumulation of those cells
usually present in the case of a bacterial infection.
Instead, there will be evidence of disruption of only the
top layer of skin (epidermis).

Treatment
Treatment involves careful attention to avoid the
development of dehydration. A variety of lotions and
creams are available to apply to areas where the epidermis has peeled away. This both soothes the sensitive
areas, and protects against drying and further moisture
loss.

Prognosis
Most patients heal from SSSS within about 10–14
days. Healing occurs without scarring in the majority of
patients. Death may occur if severe dehydration or sepsis
complicate the illness. About 3% of children die of these
complications; about 50% of immunocompromised
adults die of these complications.

Prevention
As always, good hygiene can prevent the passage of
the causative bacteria between people. In the event of an
outbreak in a newborn nursery, members of the staff
should have nasal smears taken to identify an adult who
may be unknowingly carrying the bacteria and passing it
on to the babies.
GALE ENCYCLOPEDIA OF MEDICINE 2