Health and medical information

How much sleep is really enough? The sleep deprivation studies suggest a minimum of perhaps two hours a day. Psychological studies show that it depends on whether we are larks or owls, or a bit of both. Statistically, it is reported that most healthy adults sleep 15 hours a day.

It is now known that how much we sleep each night may be determined by our genes. Studies of identical twins, who share the same genes, reveal that their sleep is similar in quality and quantity even if they live in different environments for years. We can be trained to sleep a shorter number of hours each night, but it appears that we revert to our former number of hours of sleep when the training is over.

It has also been shown that longer sleepers who sleep more than ten hours each night may not be the healthiest group of people. The American Cancer Society carried out a six year survey which showed that the death rate of these long sleepers was nearly double that of those who sleep between seven and eight hours each night The reverse is also true for short sleepers who claim they sleep less than four hours each night; their death rate is two-and-a-half-times that of average sleepers. At present the exact relationship between sleep and health remains a mystery.

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Aggression may be dealt with in various ways. It may simply be dissipated. We see this in simple form when a child is thwarted by his parents. His aggression is aroused, but he cannot give it direct expression or he will be punished. He is not mature enough to sublimate it. His aggression is just dissipated in his behaviour. He stamps about, handles his toys roughly and expresses an aggressive attitude to those about him. In a more sophisticated way in adult life we dissipate our aggression by playing games or by watching sports in which we identify ourselves with the players and experience their emotions.

Aggression can also be displaced, so that our aggressive impulses toward one person or situation are vented on some completely innocent party. The husband is frustrated at work by his boss. His aggression is aroused. He cannot give it direct expression, but on reaching home he blows up and vents it on his unsuspecting wife. Aggression can also be controlled by act of will. In fact, learning to control aggression is one of the most important experiences of childhood and adolescence. But this control, and the awareness of the necessity for it, creates a further stress, and the individual is tense and anxious as a result of it.

The person who is controlling a good deal of aggression is vulnerable to minor additional stresses. This is an important factor in the cause of bad temper. Father tolerates the bickering of the children for a long time, then he suddenly blows up and punishes them more severely than he intended.

An intelligent adult man with a good work record came to see me, saying that he was becoming increasingly on edge so that he was likely to blow up with his wife and family at the least provocation. He had not realized that anything was wrong with himself until a few days previously. He had burst into a temper with his wife, and in the heat of his rage had thrown to the ground the watch which she had given him for his birthday. He then jumped on it until it was broken to pieces. He was humiliated and alarmed that he could have done such a thing.

With further discussion it became clear that he had been becoming more and more tense as a result of increasing pressures at work.

He went about practising the relaxing exercises with real determination. His wife was understanding, and her support did much to relieve his sense of humiliation. She wrote to me some weeks later, saying that he was still doing the same amount of work, but things had never been better.

Many of us, perhaps all of us, have particular topics on which we are especially vulnerable. In these areas we are easily hurt, and our aggression is likely to flare up.

A man in his middle fifties held a responsible executive position, which he filled with reasonable ease and without any sign of undue aggression. He had always been extremely attached to his mother, so much so that it had been a constant source of conflict between him and his wife. The mother had died about a year previously, but instead of being better as one might have expected, things between the husband and wife were so much the worse. The wife had innocently suggested that he put away some of his mother’s personal belongings. He had flown into a blind rage and struck her.

He was encouraged to do the relaxing exercises, and at the same time to concentrate on calm and understanding thoughts about his mother and wife. When I last saw him he was still a little touchy about his mother, but much easier than previously.

Aggression need not be such a destructive force. The same impulse that drives us to feel like punching someone in the nose can be diverted, and used to drive us on in whatever enterprise our life situation places us. By this drive we achieve goals in commerce, industry, and science. In a more personal way we obtain the drive to. seek things out and to understand, both the material aspects of life and the abstract, in art and beauty.

Anxiety is the price we pay when our victory over our aggression is incomplete. But the reader who is seeking relief from mental tension is reminded that the struggle for inner control is not won by a fixed-jaw-and-clenched-fists attempt to discipline oneself at all costs. In this way we may manage to hold our aggression in check, and to stop it from breaking forth, but the effort of holding it in creates tension to the limit of our control. So, we must aim to establish a pattern of life in which our overt aggression is not easily aroused. We can do this by understanding the factors involved, by using our native aggression in creative fashion and by practising our relaxing mental exercises. These three approaches are not separate entities but are a unity in themselves. Understanding, creative use of aggression, and ease of mind are one. This integration is to be our aim.

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Alcohol itself often complicates the treatment of depression. Although depressed people often report a pleasant buzz after using alcohol, in my experience they often pay for this buzz heavily in the days that follow. This delayed effect is often difficult to discern. If your mood is bad to start with and it feels worse on certain days, there are any number of good reasons to explain the mood worsening. The two or three drinks you had last night or the night before are by now a distant memory and hardly seem to be likely culprits. But careful observation in many patients has shown that once the alcohol is stopped, mood control is often much smoother and better. Now, if you enjoy having several drinks of an evening I hardly expect these mild observations of mine to persuade you to stop doing so, but it’s worth thinking about it. If you’re keeping the mood log I mentioned above, you might note when you drink (including the number and type of drinks you have) and see whether you can detect an impact of the drinks on your mood over the ensuing days.

Quite apart from the potential problem of drinking alcohol if you happen to suffer from depression is the question of whether you can safely drink alcohol if you are on St John’s Wort. The answer is that there is no known negative interaction between St John’s Wort and alcohol. Even so, I always suggest that my patients go easy on the alcohol if they are on any anti-depressant (no more than one or two lagers or glasses of wine or one glass of spirits is what I usually recommend). After all, if these drugs are all working on the brain, it would be strange if they did not affect each other’s actions in one way or another.

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Some chemical compounds are so powerful that they will cause seizures in most of those exposed. War gas which has actually been used in some units to induce seizures in those with severe depression as an alternative to electroconvulsive therapy. In this case the seizure is the required effect, but in all other instances seizures complicating drug therapy are very much an unwanted effect.

Antidepressant drugs of the tricyclic group, including amitryptiline (for example, Tryptizol, Saroten, Domical) and nortryptyline (for example, Allegron, Aventyl) are amongst those which clearly lower the convulsive threshold and precipitate seizures. Other offenders include phenothiazines, isoniazid, and high doses of penicillin. Excessive doses of insulin precipitate seizures through hypoglycaemia (low blood sugar). Any of these drugs may precipitate a first seizure or exacerbate established epilepsy.

Other drugs may precipitate seizures in those with epilepsy on anti-epileptic medication by interfering with the metabolism of these drugs.

Finally, it should be remembered that withdrawal of some drugs, particularly barbiturates, may precipitate seizures.

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Mrs DH, of Gloucester, England wrote…..”I suffered very badly from osteoarthritis of the lower spine with pain at times so bad I did not wish to go on. After completing the course I can only say that my life is completely turned around. I am so mobile and free from pain it feels like a miracle. I hope this letter will in some way convey the gratitude I feel for having my life back again.”

Mrs C, Surrey, England…..“Before taking the [CMO] I had a problem with BPH, which has improved within a fortnight. I also had a problem with leg cramps from a sciatic nerve injury about 10 years ago. Nothing seemed to work, however after a few days of taking CMO the cramps almost completely went and I can sit cross legged for one hour plus.”

Mrs M M, Derbyshire, England. “I have nearly finished my first tub [of CMO], and I can tell you that already they are doing me the power of good, it is a miracle. I can now walk without having to use my stick. I am going to order my second bottle and I will keep you posted of my progress.”

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Symptom

Yellow tinge to the skin and the whites of the eyes

Home care

Watch your newborn baby closely for signs of jaundice in the first week after the baby goes home from the hospital.

Inform the doctor if you suspect jaundice.

Precautions

-    Many newborns develop a normal jaundice in the first week of life; however, jaundice that develops in the first 24 hours after birth is not normal.

-    If the baby develops jaundice – or jaundice worsens – after the baby comes home, consult your doctor.

-    Consult the doctor immediately if your jaundiced baby is nursing poorly, seems excessively drowsy, or is fevered or irritable.

-    If your baby develops jaundice, follow your doctor’s instructions exactly.

The liver transforms a substance known as bilirubin, released when old blood cells are replaced by new cells, into bile. The bile is then passed into the intestine. When damage to the liver prevents or slows down this process, bilirubin accumulates in the body and jaundice results.

Sixty percent of full-term infants and 80 percent of premature babies develop a normal jaundice during the first week of life. This occurs because of the rapid destruction of the excess number of red blood cells with which all healthy babies are born. The jaundice usually begins in the second or third day of life and disappears between the fifth and tenth day. With rare exceptions, this jaundice is harmless. Its major importance is the difficulty distinguishing it from abnormal jaundice.

The two most frequent causes of abnormal jaundice in the newborn are blood poisoning and erythroblastosis fetalis. Blood poisoning, a generalized infection caused by bacteria or viruses, causes jaundice in the newborn by destroying red blood cells and injuring the liver. Erythroblastosis fetalis is due to an incompatibility between the child’s blood and that of the mother. The mismatch may be in the Rh factor (for example, when the mother is Rh-negative but the infant is Rh-positive), in the ABO factors (when the mother’s blood is type Î but the baby’s is type A or B), or in rarer blood factors. Because of the incompatibility, the mother’s blood forms antibodies (protective substances that form to fight off disease or anything the body interprets as an attacking organism). These antibodies rapidly destroy the infant’s red blood cells.

Breast-fed newborns may also develop jaundice because a substance in the mother’s milk interferes with the proper function of the baby’s liver. This form of jaundice by itself usually is harmless. There are many other causes of jaundice in the newborn, including certain forms of anaeimia, hepatitis, and German measles, but jaundice due to these causes is rare.

Because either erythroblastosis fetalis or blood poisoning can be fatal to newborn babies if not treated immediately, a doctor’s diagnosis must be made promptly. Other forms of jaundice can also be serious if the bilirubin in the blood exceeds a safe level. If jaundice is suspected, a doctor must monitor the bilirubin level closely.

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What is it?

Glaucoma is an eye disorder in which the eyeball becomes harder and the area of vision is narrowed down. It occurs in about one in 100 people over the age of 40. About 20,000 people are blind as a result of glaucoma in England and Wales alone. It is about ten times as common in close relatives as it is in the general population, and it is not catching. It can be treated, and loss of sight prevented, if it is caught early. Treatment is by eye drops, tablets and operation. Glaucoma usually affects both eyes, though frequently one more than the other.

What causes it?

Watery fluid is normally formed in the eye and then drains back into the bloodstream through a sieve-like area of tissue. If this becomes partly blocked the fluid gets dammed up in the eye and presses on the sight nerve. Parts of this nerve go out of action and this causes a loss of vision around the edge of the field of vision. Eventually, if untreated, only the centre of the field of vision is left, and it can even blind you.

Prevention

• Vitamin Ñ can lower the pressure and stem the disease. Research has shown that healthy people who consume about 1.2 g vitamin Ñ a day tend to have lower pressure inside their eyes than those who consume only 75 mg of the vitamin a day. Take 1 g a day to be sure.

• Thiamine (vitamin Bi) may also help glaucoma sufferers. A recent Californian study found that people with glaucoma usually have lower amounts of thiamine in their blood. A study in Guyana in the 1950s found that East Indians living there who ate a largely vegetarian diet, rich in  vitamins, rarely suffered from glaucoma while their fellow countrymen living on a different diet often developed the disease. This researcher relieved the effects of glaucoma with large injections of thiamine (100 mg a day for ten days) and followed this up with oral supplements.

• Modern medicines prevent the glaucoma from getting worse, even making an operation unnecessary, and saving sight. Possible side-effects of the drops are an increase in urine passed and a tingling in the fingers and toes. They generally work for only a limited time and have to be repeated every six hours or so, though the latest drops last longer and only need to be used twice a day. Tablets boost the effects of the drops and are needed in some patients.

This ‘medical’ treatment may make your eyes a little better and will certainly stop them getting worse. If you take certain tranquillizers or steroid drugs (including the contraceptive pill) you will have to be aware that your glaucoma could get worse and get your optician to measure your eye pressure more frequently than he otherwise would.

• Regular testing of your eyes for glaucoma is a simple and painless procedure which should be done every two years ii there is glaucoma in the family and every three years or so as part of a regular eye check-up for anyone over 40. This enables the condition to be caught early before irreparable damage is done to the eyesight. Screening for glaucoma, especially among ‘at risk’ groups, is an example of preventive medicine at its best. There are about 100,000 people diagnosed as having glaucoma in the UK but it is estimated that there are about 150,000 people who have the disease yet don’t know it. Given that this is a major preventable cause of blindness, as soon as you are diagnosed as having the condition do everything you can to ensure that your close family all have an eye test.

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Sarah is 36 years old, married, with two children aged 11 and 12.

Two and a half years ago, she was relaxing after a bath when she felt a lump in the upper part of her breast. Although she was not very concerned about it, she went to see her doctor the following day. Sarah’s G.P agreed that the lump was probably nothing to worry about, and was likely to be related to the fact that her period was soon due. She suggested Sarah return a week later. As the lump was still there the following week, Sarah was referred to a consultant.

There was some delay in arranging an appointment with the consultant, and Sarah was eventually seen by a hospital doctor about 4 weeks later. The doctor did a needle biopsy to remove some cells from the lump, and Sarah returned the following week for the results of this test. Unfortunately, the biopsy had failed to provide any conclusive evidence about the nature of the lump, apart from indicating that it was not a cyst and contained no fluid. Another needle biopsy was done and another appointment made for the following week. This time she saw the consultant, who told her that the second needle biopsy had also failed to provide any useful information. He then did a Tru-Cut biopsy to remove a piece of tissue from the lump. Sarah was due to return to the hospital to receive the results of this biopsy a week later, but in the meantime the consultant rang her to suggest that she should take a suitcase with her to her next appointment as, whatever the results of the biopsy, he felt that the lump should be removed.

It was only then that Sarah began to feel concerned about the possibility that the lump could be cancer.

At her next clinic visit, Sarah and her husband learned that the tissue biopsy had revealed cancer, and the consultant asked if she would like to go home for a few days to consider whether she would prefer to have a lumpectomy or a mastectomy. He himself was in favour of a mastectomy, and they all agreed that she should have this operation the following day.

The breast care nurse took Sarah and her husband to the ward and explained to them what was going to happen.

The next morning, Sarah’s breast was removed, together with several lymph glands from under her arm. The lump was between 2 and 3 cm in width (about 1 inch). She was in hospital for about 4 days, and before she left she was fitted by the breast care nurse with a temporary soft prosthesis to put in her bra. While she was in hospital, a physiotherapist also showed her how to do some exercises to help her regain the movement in her arm.

She felt shocked and exhausted for the first few days she was at home. Her wound was quite painful for several days, but regular painkillers helped. She was given sleeping tablets which she took for the next 10 nights, while awaiting her follow-up appointment with the consultant. When she returned to the clinic, she was told there had been no evidence of spread of the cancer beyond her breast, and she would not need to have further treatment.

About 10 days after her operation, the stitches were removed from Sarah’s wound at her local health centre, and 4 weeks after her mastectomy, she was fitted with a permanent external silicone prosthesis.

A few weeks later, having watched a television programme about cancer, Sarah developed a fear of her breast cancer recurring. During the next few months she had a bone scan after developing back ache and headaches, as well as a variety of other tests to investigate the causes of various aches and pains. About 3 months after her operation, she started having dizzy spells and her doctor, who felt that anxiety could be the cause of some of Sarah’s problems, started her on anti-depressants. She continued taking the anti-depressants for about a year, gradually stopping when she felt better able to cope.

Sarah had a great deal of support from her breast care nurse, as well as from her GP and consultant, all of whom took her worries seriously. She also saw a counselor for a while when her anxiety was becoming difficult for her to deal with. However, for 18 months after her operation, every ache or pain Sarah suffered added to her terror of the cancer returning. She feels that it has taken her about two and a half years to recover completely psychologically, although it was only about 4 to 6 weeks before she had recovered physically from the operation. She now feels able to live her life without constantly thinking about what she will do if the cancer recurs, and has decided to face any problems if and when they arise.

Her breast care nurse arranged for pockets to be sewn into her bras (and her swimsuit) following an embarrassing experience at her daughter’s sports day. She did try an adhesive prosthesis, but found the strips that stick to the skin, and to which the prosthesis itself attaches, uncomfortable.

Sarah returned to her consultant for check-ups every 3 months to begin with, and then every 6 and she will now see him once a year. She wishes that there was some test that could be done so that she could be told categorically that there is no more cancer in her body, but realizes that this is not possible. Since her operation, she examines herself regularly to check for any breast abnormality.

Sarah and her husband have not told their children that she has had breast cancer, only that she had to have a lump removed from her breast. They will do so when they feel their daughters are old enough to cope with this knowledge.

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Conservative laparotomy procedures vary and are changing all the time. The nature of your surgery will depend on a number of factors including the extent and location of your disease, your symptoms, your desire for future childbearing and your gynecologist’s training, experience and preferences.

The procedures, which will be performed as part of a laparotomy, may include any of the following:

• removal or destruction of implants and small cysts

• removal or destruction of large cysts and endometriomas

• removal of adhesions

• removal of an ovary or an ovary and fallopian tube

• removal of the appendix

• surgery on any other affected organs such as the bowel or bladder

• suspension of the uterus

• pre-sacral neurectomy or utero-sacral neurectomy

• any surgery necessary to correct other abnormalities found.

Implants and small cysts

Where possible any superficial implants and small cysts on the ovary and peritoneum will be removed or destroyed by cutting, cauterization or vaporization, provided that there is no danger to any underlying organs such as the bowel or bladder.

Large cysts and endometriomas

Any endometriomas will usually be removed by cutting them out. This often involves removing a small amount of the surrounding ovary as well to ensure that all the endometrial tissue is removed. Sometimes, endometriomas will be destroyed by puncturing them and then cauterizing or vaporizing their lining. Large cysts on the peritoneum will be removed by cutting them out.

Adhesions

Any adhesions will be cut, cauterized or vaporized and separated so that the normal positioning of the reproductive organs can be restored.

Ovaries

Sometimes an ovary will have to be removed because an endometrioma lying within it cannot be removed safely. Similarly, if one ovary and fallopian tube are severely diseased they may be removed, provided that the other ovary and tube are normal. The removal of an ovary and tube on one side does not seem to decrease the likelihood of pregnancy following surgery but does seem to reduce the risk of the disease recurring.

Appendix

Some surgeons routinely remove the appendix during a conservative laparotomy, especially if the endometriosis is extensive, but most will remove it only if endometrial implants are present.

Bowel and bladder

Most small implants on the bowel and bladder are superficial and can be removed or destroyed without any danger of damaging the underlying organs. If the implants have penetrated the wall of the bowel or bladder they must be carefully cut out and the affected area repaired. Occasionally a section of the bowel will have to be removed if the implants have surrounded and constricted it; if there is any possibility of this being done it is highly advisable that a bowel surgeon be on hand to assist.

Suspension of the uterus

Suspension of the uterus involves tightening or shortening the utero-sacral and/or the round ligaments in an attempt to hold the uterus in its normal position. This procedure is not commonly performed by gynecologists in Australia though it is quite common in America.

Presacral and utero-sacral neurectomy

A pre-sacral neurectomy and an utero-sacral neurectomy are two similar procedures which are only occasionally performed by gynecologists in this country, although they are performed much more commonly overseas. Both procedures involve cutting the nerves that transmit pain from the uterus to the brain. The same nerves are cut in both procedures but in the case of an utero-sacral neurectomy the nerves are cut closer to the uterus than is the case with a pre-sacral neurectomy. The two procedures are performed to relieve chronic pelvic pain but they are usually only effective for a maximum of about twelve months as by then the nerves have re-grown.

If you are contemplating a pre-sacral neurectomy or an utero-sacral neurectomy it is worth remembering that pain is one of the body’s warning mechanisms. If you cannot feel pain in the pelvic area you may not be aware that your endometriosis could be worsening or recurring. If you go into labour you may not be able to feel the contractions which signal the onset of labour. In addition, both procedures can occasionally interfere with normal bowel and bladder function.

Other

If your fallopian tubes are damaged or if you have any other disease or abnormality of the reproductive organs these will usually also be repaired.

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In a sense, automatic thoughts are just the tip of the iceberg. Lurking beneath the surface are some implicit rules by which the patient operates. These rules spring from deeply held assumptions, beliefs, and values.

Dr. Christopher Fairburn has come up with a list of the most common of these attitudes:

-”I must be thin, because to be thin is to be successful, attractive, and happy.”

-”I must avoid being fat because to be fat is to be a failure, unattractive, and unhappy.”

-”Self-indulgence is bad because it is a sign of weakness.”

-”Self-control is good because it is a sign of strength and discipline.”

-”Anything less than total success is utter failure.”

In therapy we bring these attitudes to the surface, analyze them, and challenge them. We try to discover both the advantages and the disadvantages of holding on to such beliefs. For example, there are reasons why people may base their feelings of self-esteem on their weight. After all, measuring weight and judging oneself accordingly, is a simple task. Weight is one thing about themselves that people can have some control over. Besides, gaining weight gives a good excuse for failure in other areas of life: “Of course no one asks me out; I’m a fat pig aren’t I?”

The downside of this attitude is that the patient will never be satisfied with her weight-and thus herself-for long. Focusing on weight distracts one from working on real problems in forming and keeping relationships. By concentrating on dieting, a person can avoid having to deal with issues of low self-esteem or other bad feelings.

In therapy we look for insight into how these attitudes arose. What influence did the patient’s family, friends, and social forces have on her thinking? When did these beliefs begin? How did they take root and grow? What else was going on in her life at the time the attitude started? One way to shed light on such questions is for the patient to talk to friends of long standing, or look at old family photos or diaries.

The desire to be in control often overwhelms the patient’s ability to think clearly. She believes that if she can’t control her body functions, such as hunger, menstruation, or sexual drive, then catastrophe will result. Such an attitude is one of the hardest to shake.

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