Asthma Sufferers and Cold Weather

QUESTION: With the coming of cold weather, it seems that my child, who
suffers from asthma, has more difficulty than usual in breathing. Why is
this? He gets so upset, I wish I knew more so I could help him better.
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ANSWER: As the temperatures grow colder and the world around us changes,
young asthma sufferers experience difficult times. Not only can the cold
provoke asthma attacks, but the molds from rotting leaves, the increase in
respiratory infections at this time of year, and even the increased "indoor"
time and exposure to house dusts make sensitive children suffer attacks more
frequently. Asthma attacks are anything but fun, as the muscles in the tubes
of the bronchial tree that carry precious air from the mouth to the lungs
contract under the influence of the allergens in the air, and make the
passages narrower than normal. It becomes harder to suck air through these
narrowed bronchial tubes, and the patient may become anxious and frightened as
they must now consciously struggle to get enough oxygen. Children may not eat
and will not lie down, as they direct their exertions to the problem of
respiration. When these signs develop, they are called respiratory distress,
and it's time to seek medical help. Many medications are available that can
effectively open the bronchial tubes and reduce the symptoms. It may take a
visit or two until the right dose of the right medication is established, but
usually a hospital stay can be avoided. Then too, there are the attentions
directed to changing the home environment, reducing house dust, pets or
tobacco smoke, that can have beneficial effects for your son. It is important
that you understand the causes and treatment of the problem and have the child
treated now. It is possible for children to outgrow asthma, but controlling
the situation now will allow him to grow and mature in a normal way, and avoid
the lasting problems that childhood asthma may sometimes provoke.

The Apgar Score and What it Means

QUESTION: My wife recently gave birth to an adorable baby girl, our first.
During one of my visits to the hospital, our physician and all the hospital
doctors came to visit my wife, and I was asked to wait in the corridor. When
they came out they started to talk about my baby's score, something to do
about breathing. I couldn't understand what they were saying, but it seemed
important, and I have continued to wonder what they were talking about. Can
you help me?
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ANSWER: It is amazing what you can hear in a hospital corridor, particularly
when residents (physicians in training) get excited about a case and fail to
withdraw to a more private area before discussing their findings. It is
evident that all went well with your child, and that the conversation was more
for teaching purposes than actual care, but they were evaluating the Apgar
Score that is given to each new born at 1 minute and 5 minutes after birth.
It is named after Dr. Virginia Apgar, an American anesthesiologist who
designed it to evaluate a baby's status after birth and determine the need for
resuscitation, and to aid in the prediction of future brain function based
upon its condition at the time of delivery. Five factors are evaluated, and
each is given a score from 0 to 2, making 10 the perfect score. They are the
baby's color (as a sign of good oxygenation to the tissues); the heart rate,
the rate of respiration (or breathing); the presence of a reflex when a tube
is placed in the nostril; and the muscle tone based on how the baby moves its
arms and legs. Babies rarely get a score of 10, but when low scores change
rapidly to higher ones after a few minutes, the outlook is good. Any newborn
with a score of 7 or below continues to be checked every 5 minutes to provide
a basis for determining the actions and care necessary to correct any
problems. Of course, now there are many other tests which can be used by the
physician to help assure that prompt and effective treatment will be used to
carry the infant past the initial difficult moments of life, and permit proud
Moms and Dads to display their personal miracle to all the world.

Electric Shock for Irregular Heart Rhythms

QUESTION: I have been medicated for an abnormal heart beat for several months
without too much success. My new doctor is advising that an electric shock be
used to correct the beat. It is a frightening thought. May I have your
thoughts on this procedure?
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ANSWER: Our heart beat is regulated by a normal pattern of electrical
activity. There are situations, however, that may alter the regularity and
rhythm of the electrical flow, causing the heart beat to become irregular.
Since the function of the heart, to pump blood to the body, depends upon all
of the heart's chambers contracting in a precise sequence, any abnormality or
alteration in the rhythm reduces the amount of blood that reaches the body's
vital organs. The procedure by which a controlled amount of direct current is
used to restore a normal (or sinus) to the heart is called "Cardioversion".
Although not all irregular rhythms (arrhythmias) may be treated in this
manner, your physician has decided that this treatment is appropriate in your
case. He has used the length of time you have suffered with this abnormality,
the type of arrhythmia, and the effects of various medications you have
already tried as important factors in making this decision. In preparation
for the actual procedure he may prescribe new medications to help your heart
switch back to a normal beat, as well as medication that lowers the ability of
the blood to coagulate, thus preventing possible clot formation. The
procedure usually takes place in a hospital, where you can be closely watched
and where your heart beat can be monitored for several hours after it has been
performed. You will be given an intravenous medication to relax and sedate
you before the actual cardioversion takes place. In most cases, the patient
returns home the same day, and returns to the physician's office for follow up
care. Cardioversion is an accepted, frequently performed technique to correct
your condition, and is considered to be quite safe. I am sure that you will
receive more detailed information from your physician about your personal
condition when you indicate that you are prepared to proceed. Let me know
how you make out, and good luck.

Breast Cancer Surgery and Pregnancy

QUESTION: I lost a breast to cancer before I was thirty, two years ago. I am
now going with a man who loves me very much, but would like to have a family.
How does my past history affect the possibility of pregnancy?
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ANSWER: Since the question may be interpreted in two ways, I'll try to answer
both questions for you. The surgery has had no effect on your ability to
become pregnant. Even with the assumption that you had chemotherapy
(anticancer medication) after the operation, your hormonal functions now may
be considered normal, and the chances of becoming pregnant are the same as
before the operation. The advisability of becoming pregnant is, however,
another important question. In pregnancy, the production and flow of the
female hormones change considerably, and their effect on the breast and cancer
change as well. While some studies show an improved outlook during pregnancy,
the risk of developing cancer in the other breast may be increased. The
possibility of recurrence depends upon a number of important factors, the size
of your first tumor, any signs of spread, the length of time between the
development of the cancer and its treatment, and the kind of tumor are all
considerations, and difficult for me to evaluate without more information. It
is important to know that should a new cancer be discovered while you are
pregnant, immediate and intense therapy would be necessary, and depending upon
the the stage of your pregnancy would expose the fetus to many risks.
However, many women in this situation carry the pregnancy to term, without
harm to the baby. While there are varying opinions amongst the experts, it is
generally advisable to wait at least three years following a course of breast
cancer treatment before trying to conceive. Since there are many factors to
take into consideration, you would be well advised to sit down with your
physician and boyfriend for a full discussion. It's the only way you can come
to the very best decision for yourself, for it is you that must make the final
choice.

Breast Reconstruction After Mastectomy

QUESTION: Despite all my precautions and frequent checkups, I was found to
have breast cancer about a year ago, and had to have my breast removed. At
that time, I only thought of ridding myself of the disease, but now my
thoughts have turned to the possibility of plastic repair. What are my odds
of having things a bit like they were before?
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ANSWER: Plastic repair, or more correctly breast reconstruction, holds real
promise for anyone who has gone through the trial of breast cancer surgery.
The odds are making all as it was depends upon several factors, including the
type of operation, the extent of the surgery, the method of reconstruction
that may be useful in your case, and to a great extent your own expectations
and feelings about what might be considered as cosmetically acceptable. The
discussions you must have with your own surgeon should be based upon a full
understanding of the procedure, and what achievements may reasonably be
expected. If you hold your hopes too high, your odds of being satisfied after
all is done may swing against you. The most common and frequently performed
technique uses a silicone implant to replace lost tissue. It requires that
there be a sufficient amount of skin and other tissue available to cover the
implant, and provide a natural appearance. When there is too little tissue to
permit this approach, a hollow prosthesis may be inserted. Fluid is injected
into this bladder like device over time, increasing its size and making space
for a permanent implant to be placed later. A third, more costly and
difficult procedure uses muscle and tissue from other parts of the body,
buttocks, abdomen or back to construct a living breast that may look quite
natural. This operation is called the free flap approach, and requires a bit
of time to accomplish. All methods are useful in responding to the desires of
patients such as yourself to put things back "a bit like they were before".

The Breath-Holding Child

QUESTION: It's frightening and distressing, and most important; I just don't
know what to do about it. My 3 and a half year old, when he gets mad, will
just hold his breath until he passes out. He actually turns blue! Do you
know what this condition comes from and what I can do about it?
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ANSWER: A breath-holding child can be a most alarming experience for a
parent, but while your heart is racing away, the child is doing little damage
to itself. These attacks are benign and don't evolve into more serious
conditions. They are limited to young children, begin between the ages of 6
and 18 months and are over by 5 or 6 years of age. Typically they start from
an event as minor as a fright or minor bump, or even just frustration, and
the child cries vigorously for several moments. Then, suddenly, they gasp,
stop breathing, becoming blue (cyanotic) from lack of oxygen, become rigid and
then lose consciousness. Then normal breathing resumes, and when the child
returns to consciousness the episode is over. In severe cases, there may
even be a seizure, but less severe cases may last for a minute or less. There
may be a family history of this problem about 25% of the time, but a careful
examination by a physician is in order to be sure that this is merely a
breath-holding disorder, rather than epileptic seizures or a condition known
as pallid infantile syncope. Treatment is almost totally in your hands, and
the manner in which you react to these episodes. If you can maintain your
cool, strengthened by the reassurance that there are no terrible results from
the terrifying sequence of events, than you can address the whims of your
child with firm, quiet determination. If you allow your fear to overcome your
good counsel, the child will take over, using the threat of breath-holding to
manipulate you. When you are convinced that breath-holding attacks are
harmless, you will regain control and be able to deal effectively with these
attacks, which are self-limited.

Blood Pressure Examination Anxiety

QUESTION: I have had a terrible time trying to get life insurance because of
the blood pressure examination. Every time someone comes near me with that
thing, I tense up and know my pressure is going to read high. A friend told
me doctors have a name for this, and that understanding it could help. Will
you please enlighten me?
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ANSWER: Your friend is right in one context, but probably wrong in another.
Yes, there is a condition, called "White-coat" hypertension, that yields
higher readings of blood pressure in a doctor's office than occur in real
life, but no, knowing about it may not benefit you at all. Most investigators
believe this to be a chronic situation, and one that can not be resolved by
just telling the patients what they already suspect. It is most probable that
as many as 25% of the patients with high blood pressure readings taken as part
of a normal office visit actually have lower or normal levels when they are
tested by ambulatory monitoring methods which track a patient's pressure
throughout the day. Although monitoring can provide true readings, the cost
of renting the equipment and interpreting the result is high, as much as
$250-300 dollars, a cost high enough to drive your blood pressure up even if
it was normal. You can learn to take your own pressure, though, and if you
become skillful, your own readings may be more valid than those at the
doctor's office, and permit you to obtain a true reading, which in turn may
provide you with the evidence you need to obtain regular risk life insurance.
If this doesn't work, but you are still convinced you do not suffer from
hypertension, consult your own physician about ambulatory blood pressure
monitoring. He may be able to convince your health insurer of its necessity
in your case, and thus obtain insurance payments for you.

Osteomyelitis or Bone Infection

QUESTION: When my leg became tender and red after a minor injury, I didn't
pay much attention. However things got progressively worse, and when I
finally visited my doctor, more than a week had passed. I was both perplexed
and horrified when I was informed that I had a bone infection. How can this
be? I thought bones were made of just calcium.
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ANSWER: Many people believe that the bones which make up our skeleton are
identical to the ones you see hanging in biology labs in school. The truth is
that our bones are very much alive, requiring the ceaseless circulation of
blood that assures nutrition, and constantly are being resorbed and reformed
in a process known as modeling. Thus, as is the case with any living tissue,
bones may be attacked by bacterial infection. Although there are many
conditions which may predispose to bony infection (osteomyelitis) such as
dental abscesses, pulmonary infections, suppression of immune system,
diabetes, fractures, and even human bites, the most common in adults occurs
following an injury or trauma, or near a local infection. The symptoms
include pain and tenderness, fever, swelling and redness and eventually
ulceration and draining pus. The damage to the bone may be seen on x-ray, but
a careful clinical examination is still the best method for an early
diagnosis. Though once considered a killer, the era of antibiotics has
provided physicians with many weapons to attack and conquer osteomyelitis.

Evaluating Benign Positional Vertigo

QUESTION: I have a problem that has been with me for some time now. I get a
feeling that the whole world is spinning, usually when I am getting out of bed
in the morning. That's the worst time, although I can also feel this way when
I get out of a chair or a car that I have been riding in for some time. I
have no other symptoms with this, but am afraid of what the doctor may tell
me. Could I have your opinion first, please? I am a young woman of 71 years.
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ANSWER: Your description of your condition is very helpful, but without the
physical examination that your own physician will be able to conduct, my
opinion is really nothing more than an educated guess, but for what it is
worth here it is. You are describing a true vertigo, a sensation that
everything is moving about you, rather than that you had an episode of
dizziness (which would lead me to another conclusion). They have occurred
repeatedly, over a period of time, yet nothing else has happened, no other
complaints or additional symptoms, so it doesn't sound like a condition that
is getting worse or progressing. I believe you suffer from Benign Positional
Vertigo. It is common in young women of your age, or in people who have
suffered a head injury. It will only occur when you change a position, and
shouldn't last for more than a minute or two if you remain still. What is
lacking for my evaluation is to observe your eye movements while all of this
is going on. Your own physician may be able to provoke the sensation using a
technique called the Hallpike Maneuver (he is the doctor who discussed these
conditions over 35 years ago). By rapidly moving you backward while you are
sitting on the examination table, so that your head extends past the end of
the table and hangs downward at a 45 degree angle, and then turning your head
to the left, your symptoms may be provoked, and the movement of your eyes
observed. If nystagmus occurs (a rapid involuntary movement of the eyeballs,
in this case in a circular pattern) it is most probable that my diagnosis is
correct, and that you have nothing to fear. A series of exercises may be all
you need to reduce your problem considerably, and without the anxiety it has
caused, you will probably feel much better indeed.

Diagnosis and Treatment of Bladder Cancer

QUESTION: My brother finally went to see his doctor months after he began to
see blood in his urine. He was diagnosed as having cancer, but claimed he
never thought it was serious because the bleeding used to stop by itself. You
would be doing your readers a real service to discuss this condition in your
column.
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ANSWER: Thank you for your concerned letter and your sound counsel. Cancer
can only be fought successfully when we all realize that treatment is most
effective when we can make an early diagnosis. Cancer of the bladder is a
common disease of the urinary tract, second only to cancer of the prostate.
As many as 40,000 Americans this year alone will face the diagnosis that your
brother now does. Most of them will be older, between 40 and 80, as the
disease is seldom seen before the age of 40. Three out of every four patients
will be men, possibly as the result of exposure to cancer producing chemicals
encountered in the work place. Some of the tobacco tars that pass through
the urine may also be a cause, for smoking has been shown to increase the
possibility of developing this cancer. However, there is no evidence to show
that the tendency to develop this disease is inherited. The most common
symptom is blood in the urine, that stains the urine red. It may come and go
as in the case of your brother, but usually there are other symptoms such as
frequent urination and pain and burning during urination. They serve as
important signs to indicate the need for a medical examination. The physician
will check the urine for blood, pus and infection, as well as looking for
cancer cells which may come from a bladder cancer. Kidney x-rays are
indicated as well as a cystoscopy, that permits the physician to look directly
into the bladder and search for tumors. Bladder tumors tend to develop in
groups and can recur after being removed, so this process may have to be
repeated often. If the lesions are superficial, they may be removed quite
easily, but cancers that have invaded the bladder wall will require a
combination of surgery and radiotherapy. Bladder cancer can also spread to
other parts of the body, underlining once again the need for early diagnosis
and treatment.

Use of Clot Dissolvers in Treating Heart Attack

QUESTION: Is there such a thing as a "clot dissolver"? Would it be a good
medicine to use if the patient was supposed to be having a heart attack? Is
it very expensive?
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ANSWER: Your questions almost tell me the story, which you didn't include in
your letter, but I am happy to provide this information to you. Yes, there
are such medications, used, in your case I imagine, in the early hours
following a heart attack. Technically a heart attack occurs when one or more
arteries which feed blood to the heart become blocked by a blood clot. The
blood can no longer reach the heart muscle, and the cells die from lack of
oxygen and nutrition. It is this dying process which provokes the pain of the
heart attack. Using medications called "thrombolytics" or clot dissolvers,
physicians attempt to break down that blockage and restore the flow of blood
to the heart muscle. The sooner the medication is administered after the
blockage, the less chance there is of damage to the heart muscle, and the size
of the damaged area my be reduced. This is a relatively new method of
treating new heart attacks and the rules are changing as time goes on.
Although originally used only in the first few hours after the attack, the
time limit is growing longer and longer as we find that patients may benefit
from the medication as late as 6 to 8 hours later. And yes, it may be very
expensive. The latest development in this area is a medication called a
tissue plasminogen activator (TPA) which can effectively dissolve clots, but
may cost as more than $2,000 for a single injection.

The Causes of Cirrhosis

QUESTION: A neighbor, living in the same building as we do, has been
diagnosed as having cirrhosis. Many of his friends and acquaintances who
spent a great deal of time in his company feel that they should be doing
something to protect themselves against this disease. Would you explain the
causes of cirrhosis and what means of protection are available to us?
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ANSWER: The liver is the largest organ in our body, averaging about 3 and
1/2 pounds and as big as a large melon. It is literally a chemical factory,
responsible for manufacturing hundreds of enzymes necessary for our body
functions, and detoxifying many poisons and drugs that enter the blood stream,
including alcohol. The term "cirrhosis" is used when changes occur in the
structure of the liver as the result of any one of a number of chronic
diseases. Normal tissue is destroyed and replaced by scar tissue, which
diminishes the ability of the organ to function properly, impeding the
circulation of the blood through the liver and reducing its detoxifying
powers. Cirrhosis is a common disease, ranking fourth as a cause of death
among American adults. Its cause is most varied, from a reaction to prolonged
exposure to environmental toxins to parasitic infections. The most common
cause is chronic alcoholism, and is the one that comes first to mind when
diagnosing this disease in a patient. If this is the case in your neighbor
you would have no need for the anxiety and fears expressed in your letter.
However, several types of viral infections may cause hepatitis, resulting in
the cirrhotic condition. Since this process takes some time, and your friend
has already developed cirrhosis, it is doubtful, again, that you have anything
to fear. It is most probable that you are all thinking of the gamma globulin
injections that are given to protect the closest relatives of a hepatitis
victim from contracting the disease, but only individuals in intimate or daily
contact with the patient need such protection. I would advise an inquiry to
your friend's physician, to obtain the information you need to calm your
fears.

What is "Chewing Gum Diarrhea"?

QUESTION: You seem to delight in explaining conditions with strange names to
us. I must admit I find them interesting, and frequently use them to spice up
conversations that are growing dull. What can you tell us about "Chewing Gum
Diarrhea"?
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ANSWER: I hope you don't intend to use this answer for mealtime discussions!
You are right, however, about my interest in "medical trivia". It provides a
wide range of "collectibles," and chewing gum diarrhea ranks along with the
more interesting. It is caused by eating large amounts of sugar substitutes
used to sweeten food products prepared for those who must avoid regular
sugar. The sugarlike substances, hexitols, sorbitol and mannitol cause
diarrhea by a combination of slow absorption as they speed up the contractions
of the small intestines, speeding the food on its way. The same substances
are also used to sweeten sugar-free gum, giving rise to the name. It is also
called "dietetic food diarrhea," but I guess that is a less interesting name.
Incidentally the diarrhea rapidly disappears as soon as the intake of these
chemicals is stopped.

Chronic Cough and Fear of Medical Examination

QUESTION: My youngster, age 3, has a persistent and chronic cough that just
won't quit. I've tried all the over-the-counter remedies that you see on TV,
but nothing changes. I know I should take him to a doctor, but I dread the
possible things he may tell me. Can't you help?
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ANSWER: I often wonder how many times the fear of an unknown or unwanted
diagnosis keeps patients out of doctors' offices and delays the diagnosis and
treatment of important health problems. It is true that a chronic cough in a
youngster this age may be the symptom of serious disease, but the situation
can only continue to develop, growing ever more difficult to treat and
correct. Most of the common causes of coughing in children are infections,
ranging from the flu to pneumonia or even tuberculosis, but fortunately, there
are effective antibiotics for all of these conditions. It is possible that
the cough is a response to some irritant in the environment, such as tobacco
smoke or fumes from wood burning stoves. Allergy or asthma may be the base
for inflammation, resulting in chronic cough. Some congenital conditions,
involving either the heart or lungs or both, may result in the abnormalities
that provoke a continuing, chronic cough. Less common but still possible are
a long list of conditions caused by the failure of the immune system to
function, resulting in lung conditions like sarcoidosis. Even the presence of
an unidentified foreign body in the esophagus or bronchial tubes can be the
culprit, and can be speedily removed to eradicate that annoying cough. The
list goes on, far too long to include all the possibilities here. All these
problems can be discovered by a careful medical examination, and the
appropriate use of blood tests, pulmonary function tests, and bronchoscopy.
With the diagnosis comes the plan of action that can lead to removing the
causes. The best help I can offer you here is to assure you that the fear is
often greater than the reality and to offer you the very firm recommendation
to hasten and obtain the medical care your child really needs.

Women, Cholesterol, and Heart Attacks

QUESTION: Correct me if I am wrong, but since women are not as prone to heart
attacks as men, and since cholesterol is what causes heart attacks, then it
follows that controlling cholesterol in women is not as important as in men.
Do I have my facts straight?
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ANSWER: I suppose your letter might be classified as "A little knowledge may
be a dangerous thing" for in using facts that are half right to construct your
conclusion, you have come out just about all wrong. But we can straighten it
out together. You are right, women are less prone to heart attacks than men,
but only when you consider the statistics before menopause. Once the
protection that female hormones must afford is finished the picture changes
dramatically, and within 6 to 10 years after menopause the women have caught
up to the men and are suffering heart attacks at about the same rate. You are
right, elevated cholesterol is a factor in heart attack and cardiovascular
disease, but though very important is but one factor and can not be
considered as a direct 1 to 1 relationship. The fact is that the latest
report on the implications of cholesterol on health from the National
Cholesterol Education Program fails to draw any distinction between men and
women, and offers exactly the same guidelines about detection, evaluating and
treatment of high levels of blood cholesterol for both. Blood levels of above
200 mg/dL should be confirmed by a second or third test. If the findings are
over 240 mg/dL, a test for levels of low-density-lipoprotein cholesterol (LDL)
should be run, and its results used to guide the therapy. 160 mg/dL of LDL
and above is classified as high risk, between 130-159 mg/dL is considered
borderline. Appropriate therapy depends upon a variety of factors, but
includes diet as a first line defense followed, when indicated, by medication.

Cholesterol and Kids

QUESTION: It is hard enough to control my teenagers' eating habits when it
comes to calories and junk food. I now see that mothers have to worry about
cholesterol in their kids as well. Won't it be time enough to worry when they
are adults and on their own? I don't see how what they do now can seriously
effect them too much later on when they grow out of it.
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ANSWER: There is more to it than you suspect, but the fact is that what you
manage to instill in your young people now can have a life time benefit for
them. Research has demonstrated that when children between the ages of 8 and
18 with high cholesterol levels were examined as young adults age 20 to 30,
43% were again found to have high cholesterol levels. Family history of heart
disease was another related factor, as was obesity and smoking. It is
therefore not merely a question of learning the basics of good nutrition, but
also establishing the proper life styles and attitudes towards health in
general that will make a big difference in the end. It may be that we can not
always control the genes we pass on to our offspring, but when we establish
the proper home environment that helps teach lessons that lead to healthful
habits, we can feel good about the contribution we have made to the next
generation.

Chicken Pox Diagnosis and Treatment

QUESTION: I am a ten year old girl who has never had chickenpox. 16 days ago
the girl who sits next to me in class broke out with them. Yesterday, I found
two red bumps on my face with sort of a blister in them. I also have cold
like symptoms, such as a full head, sore throat and runny nose. Do you think
I have a very mild case of chickenpox, or should I wait and see if more spots
appear?
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ANSWER: By the time you read this in your newspaper, the verdict will be in,
but your question provides me with the opportunity to review the details of
chickenpox (varicella) for all. Yes, I think you have it, probably in a mild
form. Chickenpox is a highly communicable viral infection, and begins 11 to
15 days after exposure starting with the cold symptoms you described. The
spots are red with a clear "tear drop" blister at first, and rapidly turn to
crusty lesions within 6 to 8 hours. The rash comes in crops with new spots
developing as old ones begin to fade away, and spread all over the body, but
by the fifth or sixth days no new lesions will develop and even the crusts
will be gone in less than 20 days. It's a very itchy disease, but don't
scratch as this can provoke additional skin infection, and leave you with ugly
little scars (pox marks). Usually wet compresses can control the itch. In
severe cases, antihistamines may be used. Since some scratching always
occurs, and since bacterial infection of the skin occurs frequently, it is a
good idea to keep your nails clipped short, and wash your hands thoroughly and
frequently. As with all viral infections in young people, aspirin should not
be taken, to prevent the development of Reyes Syndrome. I hope your case was
a mild one, and that you are now back in school. You can let me know in your
next letter.

What is "Cat Scratch Disease"?

QUESTION: A friend of mine (age 18) recently had what his doctor believed was
a cancerous tumor removed from his neck. Later tests revealed that he in fact
had "Cat Scratch Disease". What is this and how does one get it? Thank you
for satisfying my curiosity!
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ANSWER: At least your story has a happy ending, but strange lumps and masses
that develop anywhere on the body deserve a full investigation. Cat Scratch
Disease is not that rare, with about 2,000 cases reported each year in the
United States alone, usually occurring in the fall or winter months. It is an
infection caused by a gram-negative bacteria, and most frequently produces a
swelling in a single lymph gland. Children are the usual victims, and
kittens, which scratch more readily, are reported as the offenders in a large
number of cases. A few days after even a small scratch, a liquid-filled
pimple develops at the scratch site, which may last for several weeks.
Approximately two weeks later, a lymph gland, in the area near the scratch,
will begin to swell, sometimes growing as large as a golf ball. When they are
firm, they may resemble a tumor, and when the patient isn't the owner of the
kitten, and has forgotten about the little scratch inflicted perhaps three
weeks before, the physician may suspect a cancer. There are no blood tests to
aid in the diagnosis, but a careful examination of the tissue under a
microscope will make the diagnosis clear. Although the swelling may be
accompanied by slight fever and headache, it is a mild episode that passes by
itself. No treatment is necessary, and even antibiotics do not help. It may
take from 2 to 5 months for the swelling to disappear completely, without
lasting effects.

Carpal Tunnel Syndrome

QUESTION: I thought to use some spare time in a useful way, and returned to
my favorite hobby of carpentry, only to develop a painful wrist and a burning
feeling in my fingers. My physician has made a diagnosis of "Tunnel
Syndrome," but I need some explanations. Will you please discuss this
disease?
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ANSWER: Both your history and the description of your complaints make the
diagnosis of "Carpal Tunnel Syndrome" a most likely one. The condition is a
common and painful one that affects people in their 50's and 60's most often,
and usually is seen in women more often than men. It is caused by pressure on
the median nerve which passes through a structure called the "carpal tunnel,"
which is formed by the bones of the wrist (carpal bones) and a tough, fibrous
ligament which attaches to these bones. The median nerve carries impulses to
the muscles that control the action of the thumb and sensations from the
thumb, index and middle finger, and half of the ring finger. After unusual or
unaccustomed activity of a repetitive nature, like using a hammer, the
symptoms of this condition may develop. Although your history is typical,
some testing is necessary to assure the diagnosis and help direct the therapy.
A test that measures the speed of nerve impulses in the median nerve
(electromyography) can confirm the diagnosis with great accuracy. You will
have to give up your hobby for a while, and probably wear a splint to provide
support to your wrist for as long as three weeks. Your physician may choose
to inject a cortisone like steroid into the carpal tunnel, or attempt to
reduce the inflammation with oral medications, such as nonsteroidal
anti-inflammatory drugs (NSAIDs). Vitamins (B6) are sometimes of help as
well. If these treatments do not help after a 6 month period, or if the
condition worsens, a surgical procedure the cuts the tunnel open may be
necessary. The treatment offers almost immediate relief of the pain and is a
permanent cure.

Concern About Mercury in Teeth Fillings

QUESTION: I have been reading some disturbing information about teeth
fillings that may be poisonous, and would like your opinion. If mercury can
be poison to the body and is used to fill teeth, doesn't that mean you could
be poisoned and should have all those fillings removed?
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ANSWER: A great deal of time and effort has be spent to examine just this
question, whether or not mercury as used in fillings (called a dental amalgam)
should be a concern for patients, and, more specifically, if such fillings
should be replaced by other materials such as silver. I, too, have read
articles which discussed this situation, and apparently, so have the members
of the dental profession, as well as other interested groups. Using the
research that is now available, The American Dental Association, The National
Institute of Dental Research, the Public Health Service and Consumers' Union
found that "except in individuals sensitive to mercury, there is no reason why
a patient should seek to have amalgam restorations removed." As if this was
not clear enough, the House of Delegates of the American Dental Association
in 1986 also stated "Advocating the removal of clinically serviceable dental
amalgam restorations solely to substitute a material that does not contain
mercury is unwarranted." That would seem to translate to "If it isn't broken
don't fix it," even if it contains mercury. So according to those who should
know what they are talking about, it would seem that having a few fillings in
your teeth that contain mercury poses no special risks for the patient. For
the future, new methods of filling teeth and new formulas for amalgams
probably have completely eliminated the possibilities of problems.

Demyelination and Nerve Disease

QUESTION: Could you please discuss the meaning of the word "Demilonization"
as it refers to nerve disease. Naturally we have a specific person in mind,
but if we can just understand this last piece of information, we are sure we
can put the whole story into place. Thank you.
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ANSWER: Sometimes it is the last piece of the puzzle that makes the picture
clear. "Demyelination" is a process we see in nerve disease where the
insulating sheath that covers many nerve fibers and which is called "myelin"
is either injured or degenerates because of lack of oxygen, toxic agents, or
metabolic disorders. Myelin is composed of layers made of lipoprotein (fats
and protein combination), and promotes the transmission of the electrical
nervous impulses along the axon of the nerve. When the myelin degenerates,
the axon dies, and the impulses can no longer prompt muscles to work or carry
the sensory sensations to the brain. Some types of metabolic congenital
disease, such as Tay-Sachs, Niemann-Pick and Gaucher's Disease, affect the
developing myelin sheath, causing widespread neurological disease. When
demyelination occurs in the central nervous system as a basic cause of several
diseases, they are known as primary demyelinating disease. Multiple sclerosis
is perhaps the most common of these diseases. In many cases of these
disorders, the myelin can regenerate and repair itself with the return of
nerve function or remission. Unfortunately, degeneration can recur with the
pattern of disease, exacerbation and remission being common. It is difficult
to know from your letter exactly what you wish to know, but I hope this
information is helpful.

What is a Cutdown?

QUESTION: Our mother was very ill recently, and required a great deal of
care. They had a great deal of trouble with giving her intravenous fluids,
because her veins were so hard to find. At one time they discussed using "a
cutdown", but fortunately a young resident doctor managed to put the needle
back in, and the cutdown was never used. We are still wondering what it is,
and how they were going to use it. Please explain?
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ANSWER: A cutdown is a minor surgical procedure, not a thing. It is used
when it is impossible or dangerous to locate a vein large enough to put a
needle into. In older patients and the very young, or in obese patients, or
when veins are collapsed because the patient is dehydrated, a cutdown may be
the only method to find a suitable vessel that can serve to administer the
vital fluids necessary for care and treatment. Other methods which permit the
placing of catheters in the larger or more accessible veins of the body are
replacing the surgical cutdown, but there are times when it is the only
solution available. The name comes from the technique which, under local
anesthetic and with sterile precautions, incises the skin and "cuts down" to
the location of a vein which may be found deeper in the arm or leg. The vein
is punctured and a cannula (a small tube) is inserted and tied in place. The
end of the cannula is then connected to the plastic tubes that lead to the
bottles of fluid. The cannula is usually changed frequently to prevent
inflammation, but as soon as the condition of the patient permits, the cutdown
is removed and replaced by a routine I.V. (intravenous) needle and tube.

Diagnostic Fears of Respiratory Symptoms

QUESTION: Like so many of your readers, I too have symptoms that are
bothersome, but fear the diagnosis more. But my shortness of breath is
worsening and I can't rid myself of this cough. Now I have begun to wheeze
and wonder if the time has not come to see my doctor. What's your advice?
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ANSWER: I think you have already made up your mind, and just need a few words
of encouragement from me before making that all important appointment with
your physician. Although there are a number of possible diagnoses, the three
symptoms you describe--shortness of breath, cough and wheezing--make Chronic
Obstructive Pulmonary Disease (COPD) the most likely choice. Usually a
mixture of chronic bronchitis and emphysema, this frequently seen disease
strikes about 1 in 14 people over the age of 45. It develops gradually, as in
your case, and may first be detected by a physician when a bad cold or the flu
strikes and a visit to the office is needed. It tends to run in families, and
its number one cause is smoking. Other factors, such as exposure to dust,
chemical fumes or other irritants, can contribute to its development. The
lung passages become inflamed and swollen, produce mucus, which blocks the
flow of air to and from the lungs, and produce all the symptoms that are
bothering you. While there is no cure, many treatments are available that
will reduce the symptoms and make you feel better. The cigarettes must go,
and there are a few other life changes that can dramatically improve your
outlook for the future.

Allergic Conjunctivitis in the Fall and Spring

QUESTION: Every year when I return to school, I find myself suffering with a
case of red eye yet again. The mystery is that I get it again when I go home
at Easter time. Does that mean I am allergic to both school and home?
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ANSWER: Well, you have one thing right; you are suffering from a type of
allergic conjunctivitis, but of a special type. It's called vernal (derived
from the Latin word vernalis, meaning "pertaining to spring") conjunctivitis.
But it is a bad name, as this condition crops up both in the fall and the
spring. It's an annoying condition, marked by intense itching, sensitivity to
light, and a thick discharge, as well as the characteristic red eye. Chances
are that you are a male between the ages of 5 to 20, for statistics say that
those are the most common victims. The symptoms become milder as each year
progresses and finally the year rolls around when they fail to return. During
acute attacks eye drops containing a corticosteroid (cortisone-like)
medication used every two hours will do a great deal to relieve your distress,
but you will have to see your own doctor, for that's a "by prescription only"
medication.

Diagnosis and Treatment of Congenital Syphilis in a Baby

QUESTION: I am a bit too embarrassed to ask this question from our physician,
but circumstances make the answer very important to me. I would like to know
something about the signs of congenital syphilis in a baby. How may a
diagnosis be made, and is there any effective treatment available?
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ANSWER: Congenital syphilis is transmitted to the baby from the mother by way
of the placenta. The risk of this infection depends upon the stage of the
mother's infection. If the mother is in the early, untreated stage, the baby
almost invariably contracts the disease. However, if the mother is in the
latent or tertiary stage, the risk is much less. In early congenital syphilis
the baby fails to thrive, and may develop a characteristic "old man" look.
Skin lesions are common, a copper colored lesion is evident on the soles of
the feet and palms of the hand, while papular lesions are frequent around the
nose, mouth and diaper area. While many such patients remain in a latent
stage throughout life, others develop ulcers of nose, nasal septum and hard
palate. Bony changes may be seen on x-ray, and the nervous system may be
attacked, resulting in mental retardation and blindness should the optic nerve
become involved. Early stages of the disease in infants may be diagnosed by
finding the cause of the disease, Treponema pallidum, in scrapings from skin
or mucosal lesions. When the disease is diagnosed, both mother and child
should be treated with appropriate injections of penicillin in large doses.
The outlook is good for the baby if serious damage has not already occurred,
but continued watching must go on well into adult life.

Colposcopy Confusion

QUESTION: The results of my recent PAP smear were not all that either my
physician or I could have wished for. Now he is proposing a colposcopy
examination, but I thought that was for rectal cancer. Can you please explain
what he is suggesting, what he hopes to accomplish and if you think it is a
good idea?
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ANSWER: You have got your scopes just a bit confused, but that's
understandable. It is a colonoscope that is used for rectal and colon
examinations. The colposcope (from the Greek word kolpos--referring to the
vagina) is very much like a binocular microscope with special ability to light
the vagina and particularly the cervix at the end of the vagina. The tissue
that forms the covering of the cervix may be clearly seen, and it was this
tissue covering that gave rise to the cells seen on your pap smear that are
causing the anxiety. With this instrument, your physician can identify any
abnormal patches of tissue, take small pieces for examination (biopsy), and
determine the presence of any precancerous growth or an actual cancer. Since
it is performed in the office, it is much cheaper than a hospital stay, and
the side effects are minimal. Your physician is attempting to make an
accurate diagnosis in a manner that is least disturbing to you, to plan his
therapy. I think it is a fine idea.

Colonoscopy Procedure Recommendation

QUESTION: I have been having an ongoing problem with my bowels, and have been
most diligent in following my physicians' (I now have more than one)
instructions. We have been through a barium enema and a sigmoidoscopy, and
now a colonoscopy is being suggested. My problems are real ones, and I will
go forward, but can you tell me the reasons this test may be necessary.
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ANSWER: You sound like a reasonable patient, and your physicians appear to be
doing a step by step evaluation of your problem. That's fine; it's the best
way to get to the answers you need for a diagnosis and proper treatment. I
can't second guess your doctors, nor would I want to, so my answer will be
straight from the text book. Please don't interpret any of these indications
as a diagnosis, for that you must obtain directly from your personal
counselors. Colonoscopy is an excellent procedure for diagnosing difficult
cases of bowel trouble, since it enables the physician to directly view almost
the entire length of the colon. It is particularly valuable to clarify
findings of a barium enema which may have been too indistinct to interpret
with any degree of certainty. It is possible to obtain tissue samples during
the colonoscopy (a biopsy) that may be analyzed under a microscope. When
chronic, slight bleeding is the worrisome sign, the exact site may be located
through the scope. Should the source of the bleeding be from a small polyp,
it can be easily removed during the examination. Some individuals with
chronic situations such as ulcerative colitis and inflammatory bowel disease
may require colonoscopy to discover the extent of their disease, or if changes
that could lead to malignancy are occurring. Many physicians develop methods
of evaluation and diagnosis that use their personal skills most effectively,
and will recommend procedures that are of the greatest benefit to their
patients. You have apparently come a long way, hopefully the answers you seek
are just around the corner.

Use of Someone Else's Codeine Prescription

QUESTION: I am a 40 year old woman who for the past three months had been
taking a prescription (someone else's): codeine tablets for a back problem.
The problem has since gone, but I have come to enjoy the effects of the drug.
Am I in any way doing harm to myself? I take about 4-6 tablets every day.
Thank you for your reply.
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ANSWER: Frankly speaking, you are breaking every rule in the book, and may be
in serious trouble. The first no-no is to take another person's prescription
medicine. No such medication is safe without the examination and testing that
leads to the diagnosis that precedes any consideration of possible medication.
Second, you are taking a powerful medicine without a physician to counsel and
guide you. Third, and most important in your case, you are taking a potent
narcotic, an addictive substance, merely for the enjoyable effects, rather
than to suppress pain. All signs point to the possibility that you may
already be hooked. I wonder to myself how you are obtaining the drug for this
length of time? At any rate, the time has come to quit, which may be more
difficult than you imagined, but either alone or with help and guidance, you
must stop before further damage is done.

Recommended Methods for Removing Eye Specks

QUESTION: Every so often I get a speck of dirt in my eyes at work. When I
try to remove it alone, I get several unrequested tips for getting the
irritating speck out. I decided you might be the person to ask for the
correct manner to employ in this regard. What is the recommended method?
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ANSWER: I suppose the method that works best may be considered the method of
choice, and there are lots of ways of doing it right, as well as many that can
cause more harm than good. Too begin, if your occasional problems stem from
an occupational environment where there is a lot of specks flying around, it
may well be that you require real eye protection, safety goggles on the job.
If, however, there are just the ordinary hazards to deal with, here are some
tips for ridding yourself of the annoying speck. First try blinking rapidly,
to produce some tears and hopefully wash the speck away. If this doesn't
solve the problem, you will need lots of light and a good mirror to look into,
leaving both hands free. To remove a speck you have to find it. If it feels
like it is under the lower lid, pull the lower eyelid down and away from the
eyeball, and see if you can spot the offending particle. If it feels as if it
is under the upper lid, pull the eyelid down and away from the eyeball and
fold the eyelid back up, using a swab or paper clip to help. There is a piece
of cartilage in the upper lid that will help. If the speck can be observed,
it can be removed using a moistened clean handkerchief, piece of gauze or
cotton swab. If such maneuvers are not effective, try to flush the particle
out with sterile water, eyewash or artificial tears. All of these struggles
are much easier with someone to help you. However, if these simple steps do
not work, you are best advised to have a professional look in that eye. There
are times when infections may be present which just provoke a sensation of a
nonexistent speck that warrant special care.

Increased Physical Activity and Longevity

QUESTION: I guess there is no doubt that increased physical activity can
certainly make you feel better, and help fight heart disease. I think a more
important question is whether or not it will help you live longer? I would
like to think all this concentrated activity will give me a few extra years
here with my loved ones.
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ANSWER: A most interesting question with a bit of a new point of view. You
really made me do my homework. There are a number of research projects that
shed some light on this question, and here is a summary of one that may be a
bit controversial. Dr. Juha Pekkanen and associates from the National Public
Health Institute in Helsinki conducted a 20 year follow up of a 1964 study of
636 men between the ages of 45 and 64. These individuals had been grouped
according to their level of activity covering both exercise and work habits.
Work was classified as sedentary (desk job), moderate (truck drivers and shop
keepers), heavy (farmers) and very heavy (mostly lumberjacks). This broke the
group into two levels, 250 men with high overall level of activity and 386 men
with a low level overall. Follow up studies were conducted at 5, 10 and 20
years after initial examination and classification. For the first 2/3rds of
the study the men that had high physical activity had lowered mortality rates,
but this began to even out as the 20 year period approached. When adjustments
were made for smoking, blood pressure and cholesterol, the active group had
lived only a 2.1 years longer, but deaths from heart disease was lower in the
active group. Actually smoking was a greater predictor of risk of death,
increasing constantly with the years. Conclusion? Keep your exercise program
going, but be sure to stop smoking to obtain your goal.

Electrical Muscle Stimulators

QUESTION: I am thinking of purchasing an electrical muscle stimulator, that I
may use to tone up my stomach muscles without those painful situps. What do
you think of the idea?
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ANSWER: Not much, I am afraid, and neither does the FDA. They have been
stopping the sale of such devices for years and even seized a number of muscle
stimulators in the early 1980's to prevent them from reaching the marketplace.
While the devices may contract your muscles for you, there is little gain if
muscles do not contract against resistance. That means work, and work means
sweat, without which there rarely is gain. A few indications under medical
supervision do exist for such devices. They are helpful in relaxing muscle
spasms, preventing blood clots in patients confined to bed, and preventing
muscle atrophy in a paralyzed arm or leg. Their cost does not provide you
with a bargain for a short cut to bulging muscles

Hairdryers and Loss of Hearing

QUESTION: I recently read a booklet about loss of hearing due to loud noises.
Does that mean the dryer at my hairdresser may be a dangerous device that can
be robbing me of my hearing?
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ANSWER: The effects of loud sounds upon hearing depend upon two factors, the
intensity of the sound (how loud, measured in decibels) and the amount of time
you are exposed to the sound. Obviously all dryers do not make the same
amount of sound, but you may assume that if the noise level is high enough to
interfere with understanding speech, it may be high enough to do some damage,
but only if you are exposed to it for a long enough period of time. I doubt
that either the intensity or exposure time to beauty parlor hair dryers
qualify. The amount of discomfort you may be suffering can not help us
evaluate the situation, as that does not relate directly to the possible
damage. You may be wise, however, to obtain a pair of ear plugs, or use
wadded cotton in your ears to reduce your hazard.

Do Dreams Mean Anything at All?

QUESTION: I don't dream very frequently, but my girl friend does almost all
the time. She claims that her dreams can predict the future, and takes them
very seriously. Do dreams mean anything at all, and how can you tell?
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ANSWER: Through the ages, the images seen in dreams have had almost a
mystical attraction for many. Sigmund Freud, the Austrian psychoanalyst,
thought that dreams expressed the wishes and feelings of the unconscious mind,
and were frequently linked to sexual feelings. Carl Jung, a Swiss
psychiatrist, and a disciple of Freud's, disagreed, and felt that dreams were
the result of all the tensions, stresses and frustrations experienced by both
the conscious and unconscious. No one is sure just what dreams do mean. I
doubt that many scientists believe that they predict the future, and while
most agree that there are some meanings hidden in our dreams, the exact
significance and purpose of dreams is still unclear. Many dreams seem to be
built of a day's activities and pressure, while others take us back into
experiences of the past. Some students of dream interpretation feel that
problems may be solved in the world of sleep, or that dreams may set the mood
for the next day's activity and actions. Dreams will sometimes explain the
cause of external noises and disturbances in a fanciful way, to help protect
the sleeping mind from awakening. Some dreams, nightmares, are frightening
and upsetting. Recurring, regular episodes of frightening dreams may affect
our daytime activity to the point where professional help is indicated. There
is much debate about the symbolism in dreams and whether certain objects have
specific meanings. Dreams only occur during the REM or rapid eye movement
stage of sleep, which has led to the initiation of research into the
biological and physiological as well as the psychological aspects of dreaming.
Therefore, it may be a while before I can answer your question as completely
as we might both desire.

Dieting Problems

QUESTION: I am forever dieting, between small losses and big gains. Each
morning I weigh myself, but the scale never reflects the effort I felt I put
in the day before, even going up after a day when I practically fasted. Why
can't I be like the girl in the ad in the paper and on TV?
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ANSWER: The weight never seems to drop as fast as we would like it to; and
even the reminder that the weight, which represents years of over eating,
can't be lost overnight doesn't help much. No matter what the fad diets
offer, the simple fact is that the body must burn between 3000 and 3500
calories more than it receives through eating for you to lose a pound. Your
daily caloric need, the amount you burn by daily activities, will vary as it
reflects your weight, age and the amount of physical activity you perform.
Sorry, mental work doesn't count, or there would be a great many skinny folks
around. The morning scale weigh, in addition to the benefit of helping you
track your progress, does have a negative side as well. Frequently you may be
discouraged as you see a weight gain, when the previous day was one of great
self control and food restriction. This may be a reflection of the amount of
salt you ingested, for the salt provokes water retention, and leads to the
message from your scale. Many home electronic scales can only show weight in
pounds, and can not reflect a loss of less than a whole pound from the
previous day's weigh in, though you may have made important progress. As for
the gal in the ad, why do you suppose she is there? Few people achieve those
extreme results, and you will realize your goals if you persist and are
patient.

Tips on Caring for Every Day Diarrhea

QUESTION: Although many articles appear about taking care of diarrhea that
comes on when traveling, little is said about the every day homegrown variety.
Surely many more of us suffer from this inconvenience than the other kind.
Won't you please give us some tips on caring for the problem?
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ANSWER: You know, you are right. The fact is that most questions that are
addressed to me do express anxiety about meeting up with diarrhea while
voyaging to foreign countries. Actually the information that is contained in
answers to those questions contain important tips about your "homegrown"
variety, but I am happy to address that problem now. The most common cause of
diarrhea, with its frequent large amounts of loose and watery stools, is
viral infection. However, the same symptoms can be caused by bacterial
infections, allergies to certain food products, or digestive intolerance to
certain foods. The dangerous effect of prolonged and excessive watery
movements is the loss of body fluids and dehydration, much more serious in
children. Therefore we pay a lot of attention to the replacement of liquids.
Fruit juices and sweet liquids are NOT a good idea, and can make the condition
worse. Water is not too helpful either, for it lacks some of the important
chemicals, sodium and potassium (electrolytes) that are lost in the liquid
stool. Nonfat chicken soup is a good replacement fluid, as is Gatorade, and
children may be given special solutions prepared for them after checking with
the physician. Stay away from spicy or hard to digest foods. Stay at home
and rest, for you may easily pass on your condition to fellow workers or
family you may come in contact with. When you begin to feel better, resume
your normal diet gradually, starting with rice, crackers and toast, cooked
potatoes and carrots, then on to broiled skinless chicken and fish. It may
take a while to get everything back to normal, but slow progress is better
than the discomfort of a recurrence because your battered system needs more
rest.

Physician Warnings about Diabetes Control

QUESTION: I suffer from diabetes and visit my physician regularly. He
constantly scolds me and warns me that if I don't control things better, the
complications of diabetes will get me. I've a little knowledge of these
problems, but are they really as bad as my doctor makes them out to be?
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ANSWER: I think you want me to reassure you, so that you may continue to take
some of the admonitions of your physician lightly. I can't do that in good
conscience, for all the statistics reveal that the results of poorly
controlled diabetes are frightening indeed. Here are just a few from some
recent publications and research. Patients that suffer from diabetes are more
than twice as likely to suffer from coronary artery disease than the general
population. More than half of all amputations that are not the result of
injury are in diabetic patients. Kidney disease is prevalent in as many as
10% of diabetics within 20 years of the diagnosis, and patients who have
diabetes comprise about 25% of all patients in programs that treat end-stage
(the most severe) renal disease. And your eyes may suffer, with diabetes as
the leading cause of blindness in adults. Almost 50% of patients with the
noninsulin dependent form of diabetes show retinal disease within 10 years of
diagnosis. And I could go on and on with statistics about nerve disease,
circulatory problems, foot problems and impotence. The answer to all of this
remains with preventive actions, early diagnosis, well planned therapies that
include not only medication but exercise and diet as well, and an
understanding between patient and physician that aids people like you in
carefully managing their disease.

Porcelain Gallbladder Surgery

QUESTION: My mother's physician has diagnosed her condition as a "porcelain"
gall bladder and now wants to remove it. She has no symptoms at present and I
know that surgeons take out a lot of gall bladders unnecessarily. Since she
has no problems now, do you think she needs this operation?
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ANSWER: I know that slogan "If it isn't broken, don't fix it", but it really
doesn't fit these circumstances. A porcelain gallbladder is the term used to
describe the situation where the gallbladder itself is calcified, rather than
merely containing stones. As it is now, this gall bladder cannot function in
a normal way by collecting bile, and then spilling these digestive juices into
the small intestine when they are needed, since the walls of the gallbladder
can no longer contract. In addition there is a greatly increased risk of
gallbladder cancer in this case, with the chance of it developing reaching as
high as 25%. Cancer of the gallbladder is a nasty disease, starting without
many symptoms and spreading rapidly, with a poor prognosis. In this case,
your surgeon is advising you properly, and though gallbladder surgery is high
in the United States, this is one case where it is most advisable. And I
believe most experts on this condition would agree with that advice.

Alternatives to Gallstone Surgery

QUESTION: When my doctor told me that the cause of all my trouble was
gallstones, I could have fainted. I am deathly afraid of anything that even
resembles surgery, and I don't even want to go to a hospital for treatment. I
know there must be another way, a diet or a medicine or something, that will
let me stay at home and be treated there. Do you know of anything that can
help me?
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ANSWER: Your question resembles so many others. When a diagnosis is made
that can be corrected with surgery, we all begin to seek other means of
ridding ourself of the ailment or disease. Very often it is the only way to a
cure, and I recommend that path, confidant that skilled surgeons exist
throughout our land with well equipped hospitals to assure the care and
treatment necessary. You, dear reader, however, have "lucked out" if you
will, for a new medication is available that may be able to help you. It's
called ursodiol (Actigall manufactured by Ciba-Geigy), and comes in pill form.
It is useful to dissolve noncalcified stones that are transparent
(radiolucent) on x-ray. You will have to check with your physician to be sure
that the stones causing your pain are the type that this medication will work
on. You will need a 300 mg dose twice a day, and may experience some mild
diarrhea as a side effect, although from your letter I doubt that this will
bother you half as much as your fears. I hope this will work for you,
otherwise you will have to rethink your position, for painful gallstones are
not easy to live with.

Frostnip and Frostbite

QUESTION: During a recent skiing vacation, one of the instructors kept
harping on the prevention of "frostnip". We thought it was a cute term for
"frostbite" but after returning home began to wonder if it represented some
other problem. Have you ever come across this term, or know what it refers
to?
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ANSWER: A true frostbite, improperly treated or ignored, may take a large
chunk of tissue as its price. A "frostnip" is a little bite, if you will, and
refers to a superficial or less damaging frostbite. Frostnip only affects the
surface cells of the body, and with proper care no tissue is lost. Though the
affected tissue may look white and waxen and feel cold, it is still soft and
springy to the touch. The frozen part should be warmed promptly, but never
rubbed with snow, or even massaged vigorously, as this friction can break the
skin and open the path to infections. Warm water or the body heat obtained
from an unaffected hand may be used to gradually return the tissue to normal.
Of course prevention is the best method of treating any cold injury, with
proper clothing as the first line of defense. A bit of reading on this
subject before your next outing seems advisable.

Heart-Shaped Tongue: Causes and Treatment

QUESTION: My 7 month old daughter was born with a "heart-shaped" tongue. The
tissue that connects under the tongue extends all the way to the tip of her
tongue. What is this called? Is it painful? How might it affect her? What
is the recommended treatment? What causes this?
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ANSWER: Slow down, mother, and we will try to answer all your concerned
queries. If we are both on the same wavelength, and I understand your
description correctly, the name of this tissue is a "Frenulum" or "frenulum
linguae" to be specific. The name comes from a Latin word that means "a
bridle or curb". It usually causes no pain, but observing your baby should
convince you about that. In the past it has been associated with a condition
called "tongue-tied" that provoked speech difficulties, but this does not
always occur. It is a rather simple procedure to cut this thin, fragile
tissue, and release the tongue completely. Your own physician is the best
advisor on this, for an examination is the only way to fully evaluate the need
for this. There is no specific "cause" for the existence of a frenulum;
everyone has one. It's just that it develops more in some babies than others.
Here is an interesting side light. Many of us have used dissecting kits
during our educations, in high school biology, for example. Those kits
usually came with a probe, useful for exploring anatomical structures. One
side of the probe had a flattened, heart-like shape, provided with a slit down
the middle. This was originally designed to hold up the tongue, placing the
frenulum in the slit, and making cutting this tissue a real breeze. With a
simple procedure to correct any problems, it shouldn't be as frightening to
you any more, and I hope you are feeling better about it now.

Causes of Gas and Flatulence

QUESTION: It is a terribly embarrassing situation to ask a question about,
and I wonder how you might answer it in a newspaper column, but I bet a lot of
people would be glad to have your advice. I suffer from gas, and break wind
at the most awkward times. Is this normal? What can I about it? Please
help.
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ANSWER: There is always an appropriate way to respond to a serious question,
even when the subject is not one frequently discussed, and I know you are
right in thinking that many people will be interested in the answer. My mail
proves that. The medical word for the problem is "Flatulence," and simply
means the passage of gas through the rectum. No one is exempt from this
occurrence as the body produces from 400 to 2400 cc of flatus (gas) each day
and must get rid of it, one way or another. Most of the gas in our intestinal
system comes from swallowed air, which frequently leaves the way it comes when
it is belched out. Air swallowing occurs when we eat rapidly, chew gum, or
have dentures that fit poorly. Additional gas comes from drinking soda or
beer, or any carbonated drink. Any gas remaining after belching travels
forward into the intestinal system to be joined by that produced during the
digestion of food. Our choice of foods may be part of the cause, since beans,
cabbage, cauliflower, brussels sprouts, and the now famous bran are only
partially digested in the small intestine. When the undigested particles
reach the colon, a process called fermentation results in the production of
still more gas. All of these are normal processes that produce enough gas to
explain your problem. However, some medical conditions involving digestive
enzymes may be the cause, and your physician can help you sort that out. If
you have read all of this quite carefully, you will see that there are a
number of things you can do. Have your dentist check your dentures for proper
fit, stay away from gas producing foods, and stay away from carbonated
beverages. Eat your food slowly, chew it well, swallow it carefully, and take
chewing gum out of your daily routine. Carefully following these suggestions
can do much to help. As for medications, while simethicone may help, the
usual antacids offer little relief for your problem.

Can Cigarettes and Coffee Harm a Fetus?

QUESTION: It seems as if everyone is now down on cigarette smokers. It's the
in thing. I am now pregnant, and just received a lecture about the damage to
my baby from cigarettes and coffee from a girl friend. Is she just spouting
off the party line, or is there real evidence that I can harm my baby? Please
help.
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ANSWER: You probably received an earful, but your girl friend was trying to
help, and was not merely telling a story but telling you the "straight dope".
There are many articles in the medical literature that speak to the effects on
fetal growth from cigarette smoking, and more recently an article in the
American Journal of Obstetrics and Gynecology which reported on the effects of
caffeine and the combined effects of caffeine and smoking upon fetal growth.
913 women completed questionnaires that revealed their use of caffeine, based
upon intake of coffee, cola and chocolate, and were divided into two groups;
those who consumed less than 300 mg per day, and those who were over. The
smokers were divided into three groups; nonsmokers, 14 cigarettes a day or
less, and those who smoke 15 cigarettes or more a day. The babies were
evaluated by birth weight, measurement of head circumference, length of the
newborn, as well as placental weight and ratio. This provided a great deal of
data for evaluation, and all the results demonstrate that when mothers smoked,
babies suffered. The birth weights were lowered in all four of the smoking
mothers' groups, and cigarette smoking caused smaller head circumferences and
body length. Smoking mothers who also consume more than 300 mgm of caffeine
put their babies at even higher risk for impaired development. We are really
not on your case when we strongly advise no smoking and low caffeine intake,
but are trying to make a case for a healthy head start for your newborn.

Complaint of Fatigue

QUESTION: I know it must be a common complaint, but I am always tired. I am
not sure what type of doctor to see, or what he could do, so thought I would
ask you first. My letter is a long one, but perhaps you can offer some
advice.
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ANSWER: Physicians do hear the complaint of fatigue very, very frequently as
it ranks as number 7 in the list of physical complaints. And while your
"book" does give much information, you have the cart before the horse. It is
most necessary to see your physician (a Family Physician, of course!), but can
be best prepared for your visit if you do a bit of homework first. Try asking
yourself a few questions, because their answers will be revealing and will
help your physician home in on the possible causes of your problem. Are you
really getting enough sleep? When the body does not have the rest it needs,
fatigue is the result, and it is easy to overlook this most important clue.
Reflect on your patterns of sleep or difficulty in falling to sleep, and be
prepared to discuss this with your physician. Are you taking any medications,
including over-the-counter preparations? Make a list of all of them, as they
may be the cause of an abnormal fatigue. Have you given up smoking? If not,
your body is not able to use your oxygen intake properly, and you lose a bit
of your vitality. How is your emotional life? If there are reasons for
feeling blue, a lost job, a broken relationship, then emotional
stress--possibly depression--can be at the root cause of a fatigue problem.
Have you abandoned your plans for a rational exercise program? If your job is
one that requires you to remain planted at a desk, then the need for some
planned exercise is a priority consideration. There are many more items we
could discuss here, but I am hoping you will have a full physical examination
and an intensive history taking session with you own physician which will
uncover medical problems such as diabetes, endocrine disorders and hidden
infections which can also bring about the symptoms you describe. Once the
cause is established, there is much that can be accomplished in cooperation
with your physician to alleviate your present condition.

Can Rash be Caused by Mental State?

QUESTION: I recently visited my mother, who is suffering a depression since
my father died two months ago. I found her arms covered with crusty sores,
and she complained of fierce itching. My aunt says the rash is coming from
her mental state. Can that be true?
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ANSWER: Your aunt is on the right track, although it isn't a simple cause and
effect situation. As with all dermatological situations, it is difficult to
make a diagnosis without seeing the rash, but if they seemed to be in straight
lines on the outside or back of the arms, they would conform to a description
of a factitial dermatitis, or one that is produced by the patient herself,
usually unintentional. And that can be the case in certain conditions where
the stress of a recent loss can be the underlying cause for the beginning of
an intense itch or pruritus. This type of psychosomatic skin disease requires
an alert clinician to find the elements of the problem in a careful, complete,
case history when the characteristics of the rash provide the first clue. The
"rash" is really an excoriation or a hollowed out area caused by scratching,
rubbing or picking. As part of the healing process, a crust is formed to
protect the underlying tissue, but frequently that too is picked away. Your
mother needs the reassurance of her physician that all will be well, and
perhaps a tranquilizer and a bland cream to place on her sores. All will be
well, but it make take up to 6 months to achieve.

Risks of Contact with Herpes Patients

QUESTION: My husband has a bad case of herpes and the rash looks terrible.
Since we are always together, I am worried that I might catch the same thing,
since the doctor called it a viral infection. What risks am I running if I
continue to care for my husband?
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ANSWER: Your risks are probably not great, although herpes (also called
herpes zoster) is a contagious disease. It all depends upon whether or not
you have developed an immunity to the virus such as that gained from having
chickenpox. Both chickenpox and shingles are caused by the same virus (the
varicella-zoster virus), and since most adults have been exposed to this virus
as children, shingles is rarely transmitted from adult to adult. It's a
different story with children though, and there are many reports of children
developing chickenpox after contact with an adult suffering from shingles, so
this is not the time for visits by your grandchildren. When children with
severe herpes zoster require hospitalization, they are isolated from other
patients on the children's floor, to prevent additional infections. With
ordinary hygiene measures, you may continue to care for your husband without
undue fears.

Hernia As a Result of a Fall

QUESTION: As a result of a fall, followed by some pain in my abdomen, I
consulted my physician. I was amazed when he told me that I had suffered a
hernia and needed surgery. I thought only men could have hernias and that
they were caused by trying to lift a heavy object. Would you try to clear
this up for me?
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ANSWER: I can provide you with some answers, but believe that it will take a
surgeon to "clear up" your physical problem. The term "hernia" is a general
one and applies any time a portion of an organ or tissue protrudes through an
abnormal opening in the body. Abdominal hernias are a most common situation
for which major surgery is performed as a means of correcting the problem, and
abdominal hernias come in many forms: inguinal, direct and indirect, femoral,
umbilical, epigastric and incisional. Inguinal hernias do occur in men about
8 times more frequently than women, as the normal opening through which the
spermatic cord passes becomes abnormally enlarged and permits a section of
bowel to slide down into the scrotum. But umbilical (around the belly button
or navel) hernias can occur in infants and are more common in women.
Fortunately, they generally close by themselves in infants, and require no
surgical repair. Hernias do develop as the result of repeated elevation of
the pressure inside the abdomen that may be provoked by lifting or straining,
but also as a result of chronic cough or constipation. In your case, the fall
may have caused some enough pressure to force open a weakened portion of the
muscles that make up the abdominal wall and allowed the hernia to form.
Although you do not mention it in your letter, previous surgical incisions
sometimes fail to heal completely, and incisional hernias develop at those
sites. Femoral hernias are the least common of groin hernias, but do occur
more frequently in women than in men. They frequently become incarcerated,
where the bowel or tissue found in the hernia becomes trapped, and can not be
pressed back into place. For this reason, surgical repair of these hernias is
advised. With all this general information you may now obtain more precise
details of your condition from your own surgeon.

Tanning and Cold Sores

QUESTION: I recently spent several sessions in a local tanning parlor,
despite the advice of my friends. In addition to an improvement in my tan, I
also developed a painful cold sore. Are these two things related, and if so
what should I do about it?
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ANSWER: Apparently they are, for recent research has discovered that exposure
to ultraviolet (UV) light in amounts sufficient to cause a sunburn on your
face will also reactivate an infection of oral herpes, or a cold sore. These
sores will only pop out in areas where they have appeared before, and so you
are not suffering from a new infection but rather from another attack of
herpes in a previously affected spot. Herpes virus infections remain quiet
over long periods of time and only recur when the virus is stimulated to
regrow within nerve cells where it lies dormant. Then the rash that signifies
the infection reappears when the virus travels down the nerve to infect the
skin. You have two choices, as I see it. Stay out of the tanning parlor and
do your skin a favor. Remember the damage you do now may show up later in
life as a skin cancer. If good sense can not prevail, then use a strong
sunscreen cream on all skin areas where you have previously had a herpes sore.
This may offer enough protection to prevent the development of the infection
and rash.

Hot Tubs and Herpes Transmission

QUESTION: Recently my husband and I purchased a hot tub. A frequent visitor
to our house has herpes. We don't want to hurt feelings if there is no risk
involved, but is our family at any risk if they share the tub, or if the
visitor uses the tub? Please answer as soon as possible as we are eager to
know the answers to our questions.
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ANSWER: I am going to assume that your visitor suffers from genital herpes
caused by a virus known as HSV-2. There are other forms of herpes, "cold
sores" for example and they are usually caused by the HSV-1 herpes virus. The
human herpes viruses are very widespread and extremely difficult to control.
I'll bet just about every one you know has had a cold sore at one time or
another. However, we believe that genital herpes is spread by direct contact
with the infected secretions that are produced in the sores that are the most
evident sign of the disease. Thus, an individual who is suffering through the
active phase of the disease, with sores present, must be considered as a
source of infection. During the dormant periods, when no lesions are present,
contagion is certainly less of a possibility, but certain authorities
speculate that the virus can be transmitted even when sores are not present.
The possibility of an indirect spread through the communal waters of a hot
tub is even less certain. I would like to spare your visitor's feelings, but
I can't think of a polite way of asking if their lesions are active when they
are visiting. Besides, I think hot tubs must be shared with a bit of
discretion, a little like sharing a tooth brush. Though there is only a
remote chance of there being danger to your family if no lesions are present,
I suspect you may sleep a bit better if your hot tub is "closed for repairs"
during your visitor's stay.

Ulcerative Colitis, Complications, and Cancer

QUESTION: Our adult son has just been diagnosed with ulcerative colitis and
we are very concerned. Would you please tell us if there can be serious
complications with the disease, and can it cause cancer? We want to find out
all we can so that we can help him.
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ANSWER: This is a chronic disease, which frequently is first noticed in the
period between 15 and 30 years of age. It usually starts as a series of
attacks of crampy abdominal pain, frequent urge to move the bowels, and
diarrhea containing mucus and blood, which can be exceedingly acute. Thus
hemorrhage is the most frequent local complication. Frequent complications
which may occur outside of the colon include arthritis, an inflammation of the
eye called iritis or episcleritis, as well as skin sores and ulcers. At times
a fever may develop, usually when there is a flare up of other colitis
symptoms. All patients do not get all these complications, nor need they be
severe. Cancer of the colon need not be a consequence of colitis, but the
risk seems confined to patients with long-standing, extensive ulcerative
colitis of more than ten years' duration. It is for this reason that regular
colonoscopic examinations are recommended for these patients, best taking
place during quiet periods when the disease is not active. When the course of
the disease is mild, life expectancy is normal. When cancer does occur, the
outcome of treatment is about the same as for any other colon cancer patient.
There are many effective treatments available that can help moderate the
discomfort and pain of colitis, as well as improve the prognosis