Women in parts of India who are kept in purdah welcome the arrival of the menopause as an era of new freedom; now they can cast off their veils, mix with men and travel freely. In China, the sixtieth birthday is a momentous event, celebrating the status and wisdom of the old person. After the menopause, Bantu women may take part in activities previously forbidden to them, and women in Bali can join in ceremonies from which they were barred during their childbearing years. From India to Africa, from China to South America, the end of menstruation brings new freedom to women. Middle-aged and elderly women are an active part of the extended family, they help on the land, they feel useful, needed and valued. Ageing is a gain in wisdom, not just the loss of youth; in the same way that many cultures celebrate the start of a girl’s menstruation, so its ending is a positive event, too. And in countries where older people have enhanced privilege and status, menopausal symptoms are almost unknown.

How different things are in our ‘advanced’ societies of the West. Ours is a society that gives status and emphasis to physical prowess, to attractiveness and to youth. Men and women (but especially men) lose status when they are no longer defined by the job they do. Children grow up and move away, and the busy mother/chauffeur/cook/nanny/ supporter of the PTA/and helper at Brownies suddenly finds her role has disappeared. In these societies, where getting older is seen as a definite minus, 80 per cent of women suffer from menopausal symptoms.

You probably remember the days when ‘black’ was a term of abuse towards people of African and Caribbean origin. Most black people living in white cultures at that time felt themselves to be inferior to whites, accepting their status as second-class citizens. Then black people themselves coined the phrase ‘Black is Beautiful’, and suddenly their image changed. They felt proud of their black heritage and culture, and of the colour of their skin.

Why shouldn’t older people, too, change how they see themselves, and how society sees them? The Gray Panther movement in the United States is a powerful lobby for the rights of retired people, and they certainly don’t see themselves as has-beens.

*77\42\4*

Will I age prematurely if my ovaries are removed?

The answer to this depends on whether you go on hormone therapy, your body size, whether you had your ovaries removed before or after your menopause, and your genetic make-up. Before menopause the ovaries are the body’s main source of hormones such as oestrogen, which has wide-ranging influences on a woman’s body. Some of the areas it affects are:

• the thickness and tone of the vaginal lining and the vagina’s production of secretions

• the fullness, tone and secretions of the vulva, cervix and urethra

• bone structure and growth

• temperament and sexual interest

• the appearance and perhaps function of many other body tissues such as the skin, hair, heart, blood vessels, breasts, liver and joints.

After menopause, most women continue to make measurable and useful amounts of oestrogen in fat and muscle tissue and in the ovaries and adrenal glands (two small organs near the kidneys). How much body fat you have, and your genetic make-up, are among the most important influences on oestrogen levels after menopause.

If you have a slight build and your ovaries are removed before your menopause you are likely to experience more severe, acute menopausal symptoms (such as hot flushes, vaginal dryness, and bladder problems) than if you are well-built and you lose your ovaries after menopause. If you are in the former group, you may also find that your hair seems drier and your skin has less tone and you will also be at increased risk of heart disease and bone thinning (osteoporosis) in later life. For all these reasons you should consider oestrogen replacement therapy (a form of hormone therapy).

Women who are well-built and whose ovaries are removed before menopause tend to experience an intermediate level of symptoms and a slight to moderate increase in their long-term risk of heart disease and osteoporosis. Although such women may find oestrogen supplements useful, they may not be vitally important to their well-being.

*88\198\4*

The myth of sleeping pills needs to be destroyed here. Sleeping pills are useful for two weeks only; after that the body develops a tolerance to the pills and they become less and less effective in inducing sleep. The reason why most people continue to take them beyond two weeks is to avoid rebound insomnia. Rebound insomnia is a withdrawal symptom experienced after sleeping pills are stopped. Rebound insomnia should be distinguished from true insomnia. When the sleeping pills are stopped, rebound insomnia follows immediately, and one must be prepared for not sleeping well for the next few nights. Natural sleep should commence after the rebound insomnia passes. Hence it is most important to stop taking the sleeping pills gradually. The tragedy is that most people stop taking the sleeping pills suddenly, and consequently they cannot sleep because they experience rebound insomnia. They then believe they have lost the innate ability to sleep, and they immediately start taking the sleeping pills again.

*90\174\4*

The word “pain” comes from the Latin word poena which also means punishment. So there is nothing new in the association of these two ideas. The child is educated to a complicated system of values and behaviour which allows him to take his place in society. This is achieved primarily by the process of reward and punishment. Love and physical rewards are given for being good; and hostility and physical punishment for being bad. This is the learning process in its simplest form, and as a means of leading the child to acceptable behaviour it is very effective. However, the constant association of pain with punishment conditions us to lose sight of the biological

purpose of pain as a simple and helpful warning against injury. The child is constantly reminded of this association so that it persists into adult life. If in fact corporal punishment is not inflicted, the threat of it is usually still there, and even if it is not actually threatened it is referred to obliquely, “If you had been properly punished when you were younger, this would not have happened.” This is the child’s ordinary experience, so the two ideas, pain and punishment, become fused together in his mind.

*112\57\2*

Q. What about side effects? We seem to read about adverse conditions occurring from time to time. Are these serious?

A. I suppose every known drug has an adverse side effect on somebody somewhere. It is a fact of life. Why, even most foods can be found to disagree with somebody. Considering that by 1984 around 30 million patients are said to have been treated with cimetidine, the number of adverse side effects is surprisingly small. Certainly researchers will dig up a wide range of symptoms which are claimed to have been produced by cimetidine, but in the total picture, these are very small and probably of little consequence.

The same doctors will also point out that simple, old fashioned aspirin, which has been around for nearly 100 years, may cause allergy reactions, asthma, bleeding from the stomach and bowel, nausea and vomiting, diarrhoea, and many other symptoms. But this does not preclude it from being one of the most valuable and widely prescribed drugs of all time.

If adverse side effects occur, then appropriate steps can be taken at once. On the other hand, if they are minimal, then the benefits of treatment will often outweigh any problems.

Q. Are other drugs in this family available, or is cimetidine the only one?

A. In 1982, another drug called ranitidine became available in Australia. Like cimetidine, it is a product of original research in Britain. It is marginally different, works in a similar manner, is claimed to have certain benefits, as all new drugs claim. Time, however, will show if this is really the case. Some major British trials have indicated that it may be of special benefit in the few cases in which cimetidine therapy fails to work. No drug will be effective 100% of times and a related drug may prove effective, this appears to be the case with ranitidine. Another preparation is a drug called oxmetidine, which is also similar in activity. Yet another named omeprazole has also been developed. How these will compare to the others, time will tell. It has all been succinctly put by a Sydney gastro-enterologist who recently wrote in an Australian medical magazine: “It is difficult to envisage that these drugs will be any safer or more effective than cimetidine in equipotent dosage.”

Q. Can the patient still take other medication with cimetidine if necessary?

A. The most likely medication will be antacids, and this is often taken in the early days along with cimetidine. It does little more than reduce pain. As pain disappears, most will cease using antacids, but they may be taken if desired. Often the decision is left with the patient.

It is pointed out that the doctor will be careful in prescribing other non-ulcer type drugs in the event of high dosage levels being required. Sometimes, in severely ill patients, cimetidine is given by injection, either directly into the blood stream (intravenous) or the muscle (intramuscular injection). This helps it work more rapidly.

In ageing patients, when the liver and kidney are not working as efficiently as in younger days, the drug may further reduce their working efficiency, and drugs such as warfarin, phenytoin, theophylline, which go to the liver also, must be taken with care. Nevertheless, this is the doctor’s concern. He is well aware of these special circumstances in certain patients and will offer the appropriate advice.

*15\61\2*

Just because you’re referred to a surgeon does not necessarily mean that an operation will be performed or even suggested. Surgeons will invariably make their own assessment of what they think is best. Although surgeons as a group do tend to have a bias towards their own speciality, they do also recognise that an operation is not always the best nor only answer. It is not rare for someone who was referred to a surgeon to then later on be referred to yet another specialist because the surgeon concluded that this was a case where less intrusive treatment might work just as well.

If surgery remains indicated, there are numerous possible procedures with an excellent track record. However, it also has to be pointed out that every form of surgery carries its own set of risks.

The decision to undergo an operation should therefore always be weighed up most carefully.

To help you make up your own mind about having an operation if one is offered, The National Back Pain Association suggests a number of questions you should ask your surgeon, these including:

What is my exact diagnosis?

Do I have signs of nerve root compression? And are the symptoms that I have directly related to nerve compression?

What are my chances of good pain relief if I opt for a surgical intervention?

Are there any alternatives to conventional surgery that I could try?

How many of these procedures have you performed? What is your success rate for the surgery you have offered me?

What the NBPA is essentially saying through these suggestions is that any patient should make sure that the problem has been fully and accurately diagnosed, that an operation is likely to yield a good result, and that the surgeon is fully experienced in the intended procedure.

Additionally, the NBPA suggests that “the decision as to whether to have surgery and what type, is difficult, and needs very careful consideration. The only person who can really answer your questions about the effectiveness of surgery for your particular problem is your own surgeon. Ensure that you attend appointments well-prepared with your questions written down and, preferably, with someone else to listen to the response.

A similar message comes from the Agency for Health Care Policy and Research, a part of the Department of Health and Human Services in the USA, which somewhat more bluntly states:

Even having a lot of back pain does not by itself mean you need surgery.

Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In some people, surgery can even cause more problems. This is especially true if your only symptom is back pain.

People with certain nerve problems or conditions such as fractures or dislocations have the best chance of being helped by surgery. In most cases, however, decisions about surgery do not have to be made right away.

Most back surgery can wait for several weeks without making the condition worse.

If surgery is recommended, be sure to ask about the reason for the surgery and about the risks and benefits you might expect.

You may also want to get a second opinion.

*13\124\2*

Although people in good health need only about 50 micrograms of folic acid every day, the need for this important member of the vitamin B complex increases dramatically (seven to 20-fold) during bacterial infections and after loss of blood. Extra folic acid is used whenever new cells are formed in large numbers anywhere in the body.

Thus, when the bone marrow produces many extra white blood cells to fight an infection or forms many new red blood cells to make up for blood lost during surgery or hemorrhage, it suddenly uses much more folic acid than usual. If this increased need is not recognized and met, the patient will be unable to produce all the necessary white cells, red cells, and platelets, or to recover completely from a serious infection, even though transfusions and antibiotics are employed.

A report in Critical Care Medicine (8:500) points out that during a serious illness, the bone marrow uses up its folic acid stores so fast that it becomes deficient in this essential vitamin even though folic acid levels in the blood and other tissues remain normal.

It may not be possible for patients to obtain all the vitamins they need by mouth when they are seriously ill, and to facilitate recovery, daily injections of folic acid (10 milligrams) may be required. Another reason that folic acid in tablet form may not be recommended, the American Family Physician (32#4:290) reports, is that it may cause a deficiency of zinc. If present in the stomach to excess, it is thought, folic acid combines with all of the zinc contained in our food, thus rendering it insoluble and less easily absorbed.

Foods such as peanut butter, beans, nuts, liver, and green leafy vegetables are natural sources of folic acid.

*221\143\2*

Sudden Infant Death Syndrome (SIDS) is a medical mystery. Otherwise known as cot death, it seems SIDS is not a new phenomenon. It was referred to in the Bible (by another name) and was well described in medical journals over 150 years ago. In Australia, about one in every 500 babies dies of SIDS in their first year of life, usually between the first and fifth month.

SIDS is medically defined as the unexpected death of an apparently healthy baby for whom an autopsy fails to identify the cause of death. In other words, it is not known why the baby died. It seems that the baby simply dies within about five minutes, usually while asleep, without any indication of pain or distress.

There are over 100 theories about the possible causes of SIDS. To date none have been proven. One day, through research, we may be able to determine some or all of the causes of SIDS and identify those babies who may be at risk. Statistics reveal that SIDS occurs most often in the winter months, and it affects more boys than girls. The baby has sometimes had a mild respiratory infection and may not have been feeding well in the preceding months. Even though these and other factors are more common in children who die from SIDS, it does not necessarily mean they are the direct cause of SIDS. Many infants die from SIDS with no indication of these factors being present. Also, in cases where these factors are present, most babies do not die. This may sound rather confusing but indicates the current state of knowledge. These factors may however give clues to researchers about further lines of investigation. Despite extensive research there is nothing known as yet that can be done to prevent a baby dying from SIDS.

*208/84/5*

«The job. How can you complain about not having enough to do? It seems too stupid for words. But that’s what it is. Just plain bored. Sounds silly. Instead of just sitting and doing nothing, I get irritable. Irritable with myself. Irritable with the people around me. Irritable with a society that lands me in a job like this. Worse than all that, I bring the irritability home with me to my wife and kids. Snap at them. Then I feel guilty. Then more on edge than ever. »

They laugh about the civil service. Joke about it. But there is often that glimmer of truth in the things we laugh about most readily.

Man. As a species we have survived. We have survived because we have learned to assert ourselves against an inhospitable environment. If we graduate into a changed environment of continuing calm and ease, we are left without the normal challenges of life to which we have become accustomed over countless generations. It demands that we adjust to a new way of living in which our innate assertiveness has no external outlet. We seem to be lost. Our brain is alerted, but there is no outlet for mental or physical activity. And we experience this deprivation as boredom.

Other interests and hobbies are a help. Not much to do at work and our mind can run on enjoying the challenge of our hobby. The same applies when our work is mainly repetitive, requiring little mental effort on our part.

*6/98/5*

Large areas of eczema should be treated with baths. Colloidal baths are used for acute eczema. They may consist of:

Bran: Very hot water is allowed to run into a tub over a cheesecloth bag containing one to three pounds of wheat bran. The tub is filled with water, and the bag is squeezed occasionally to introduce the bran into the water.

Cornstarch: One pound of cornstarch is stirred into a tub full of water.

Oatmeal: Two cups of boiled oatmeal are put into a cheesecloth bag, and then the bag is used as a washcloth on the skin.

Tar baths which are helpful in sub-acute eczema are made with three ounces of a solution of crude coal tar, N.F., put into a full tub of water. Sodium bicarbonate baths are soothing for very irritated and itchy skin. One cup of sodium bicarbonate to a tub of water is used. Magnesium sulfate baths may be used, one cup to a tub of water, for acutely inflamed skin which is oozing.

Failure in the treatment of eczema may be caused by a bacterial or a fungal infection, a concomitant contact dermatitis, seborrhea, an endocrine disturbance, an immunological disorder, a situation of stress, or a drug eruption that takes place at the same time as the eczema.

Tranquilizers are a radical part of the treatment of any form of eczema. Atarax or Vistaril are generally chosen in syrup form to be given by mouth in teaspoonfuls three or four times daily for a period of three to four months.

*36/99/5*