The cause of this condition is unknown, but it seems to have a genetic basis, often with a family history. Occasionally the condition appears to be precipitated by the administration of psychostimulant medication such as methylphenidate (Ritalin) or amphetamines which have been prescribed for ‘hyperactivity’ or attentional problems. The condition is associated with learning and behavioural problems, and sometimes language difficulties also occur.

This is a distressing and disabling condition which fortunately is very uncommon, and should not be confused with the common tics described above. Treatment consists of diagnosis and specific medications and ongoing management is best undertaken by a paediatrician or child neurologist. In many cases these children improve as they get older.

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Sputum, or phlegm, is usually present if your child has a chest infection. Most young children cough up the sputum and then immediately swallow it, so it is very difficult to obtain a specimen. Older children are better able to co-operate. The specimen is sent to the laboratory as soon as possible, checked under a microscope, and then incubated in a special culture medium. After 24 hours, any germs present can usually be identified, and after 48-72 hours the antibiotic that will be effective against them can be chosen. This aids both in diagnosis and treatment of chest infections.

STOOL EXAMINATION AND CULTURE

If your child has prolonged diarrhoea, your doctor may advise sending a stool specimen to the laboratory to try and determine which parasite or germ is responsible. This also helps your doctor to decide whether or not to treat the condition with antibiotics, and if so, which drug will be effective against the particular organism. Stool specimens must be sent to the laboratory as soon as possible, so that the organisms can be identified under the microscope or by culture. A stool examination is also used to determine whether there is a problem with absorption of sugar, fats or protein in the small bowel.

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WIFE

Balancing our needs for recreation and the needs of our marital relationship is a relatively new concern in our society. The day-today pressures of surviving used to take up all the time there was. Now we are told to exercise, to play, to have fun because it is healthy. We do want to play, but how do two people play together if interests and capabilities are different?

It was the rare couple in which both partners were equally involved in a recreational or avocational interest. “He golfs, I drive the cart. I enjoy the scenery, but he never sees it,” reported one wife. “To him the landscape is just a place to lose his golf ball.” As this example illustrates, sometimes a spouse will try to “go along” and enjoy the spouse’s enjoyment, but rarely does this completely fulfill one’s own needs for recreation and fun.

Our public schools seldom emphasize couples play. The boys and girls are separated into different gym classes. The activities are typically individual or team sports, seldom a boy and girl playing together. Even in team sports, the individual seems to be the focus in a society that values stars more than constellations, independence and the ability to stand out rather than the important skill of fitting in to enjoy a common purpose.

So how does super marital sex survive the distance that may result by different recreational involvement? One husband reported, “About the only thing we do together is sex. And then, we really have been doing it to each other.” Sex therapists typically ask about individual reports of fulfillment, the most popular question being “Are you orgasmic?” Couples are less often asked about their mutual interaction, the results of togetherness. The only hope is to change, or at least broaden, our view of play to include dyads, two persons playing together.

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Sometimes the part to be removed can be reconstructed. For example, part of the oesophagus (gullet) can be removed and replaced with a piece of intestine. The bladder can be removed and replaced by an artificial one made of a piece of intestine, emptying through an opening in the abdominal wall into a bag (an ileal bladder). The rectum and anus can be removed and the remaining bowel made to empty into a bag through an opening in the abdominal wall (a colostomy).

Luckily we have two of some of the organs whose functions are essential to life— for example, kidneys, lungs and adrenal glands. One healthy kidney, lung or adrenal gland can keep our bodies functioning quite normally.

There are many organs and parts of the body which are not essential to life. Although, of course, their loss results in varying degrees of mutilation, inconvenience and psychological distress, we can live without things like an arm, a leg, an eye, a tongue, a larynx (voice-box), a breast, an ovary, a testicle or a uterus (womb).

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Those glands in the neck are most commonly affected, but the condition may occur elsewhere, particularly in glands along the great blood vessels which are inside the chest or abdomen.

Sometimes the disease appears to be localised and very slowly progressive. In others it appears to be active and widespread right from the start. And in those cases it may be associated with weight loss, fever and often an itch.

Once regarded as invariably fatal, this disorder now may be not only controlled but cured. At present, a cure rate of just over 90% is possible.

It is usual to remove a lymph gland and to look at it under a microscope. It may be necessary to consider an operation on the abdomen to remove the spleen or enlarged glands inside.

One technique of establishing how wide-spread the disorder is, is to inject radio-opaque dye into the lymph channels in the legs.

The lymphatic system carries fluid from the tissues back through the body, and is interrupted every so often by these lymph glands. Finally the main lymph channel empties into the great vein in the chest. From here the blood is carried back to the heart.

The treatment of Hodgkin’s disease is by X-ray or chemo-therapy, or both.

In chemo-therapy drugs which are designed to kill the cancer cells are administered by mouth or injection. Often two or three of these drugs are used in conjunction, and cortisone is given at the same time to reduce the inflammation.

The success of treatment depends on how early the diagnosis is made and on how wide-spread is the involvement of the glands.

Hodgkin’s disease is uncommon.

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The first sign is a rise in the blood pressure.

High blood pressure or hypertension can be present before pregnancy and then she will need close watching throughout because high blood pressure itself can cause problems.

In pre-eclampsia all three signs are usually present: the rise in blood pressure, the albumin in the urine and the oedema.

The great risk is to the developing foetus. The constriction of the arteries affects the placenta and this interferes with the nourishment of the baby.

If the baby does not receive proper nourishment it may die in the womb, or if born alive, may succumb within the first few weeks.

Pre-eclamptic toxaemia can also cause bleeding behind the placenta where it attaches to the womb.

This bleeding, if large enough, will cause separation of the placenta from the lining of the womb and can damage the baby’s circulation and lead to its death.

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Unfortunately modern man has built a society which presents daily stresses that can make too many demands on us physically, mentally and emotionally. We are simply not adapting to these stresses satisfactorily. If in the middle of the night somebody makes a loud noise outside, we are instantly awake, with oar hearts pounding, breathing deeply—keyed up for action. This a normal reaction to the stimulus. However, today, modern man goes around permanently keyed up in much the same way. This chronic stress, if it continues, causes our body to adapt to it.

From the outside, all looks well. The body has adapted to the stress. However, in order to do this, every defence available has been mustered, and of course this can only last for a short time before it burns itself out. A ‘burn-out’ will happen when all this adaption fails and some organ ‘collapses’. It may take the form of a psychological illness, a peptic ulcer, asthma, hypertension, or a skin disorder.

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Apples (G.I. of 38) • Easy-to-incorporate into the diet as a low G.I. food—an average apple will add 3 grams of fibre to your diet. They are also high in pectin which lowers their G.I. factor. Apple juice (G.I. of 40) • The main sugar occurring in apples is fructose (6.5 per cent) which itself has a low G.I. The high concentration of sugars is known to slow the rate of stomach emptying, hence slowing the absorption and lowering G.I.

Apricots (G.I. of 64, canned; 31, dried) • Apricots are an excellent source of 6-carotene and dried apricots in particular are high in potassium. Like apples, they are high in fructose (5.1 per cent) which lowers their G.    I.

Barley (G.I. of 25) • ‘Pearled’ barley, which has had the outer brown layers removed is most commonly used, it is high in soluble fibre which probably contributes to its low G.I. Available in supermarkets.

Basmati rice (G.I. of 58) • Has a low G.I. attributable to the type of starch it contains (high amylose starch). Available in supermarkets. The only Australian-grown species of rice with a high amylose content is Doongara.

Breakfast cereals • The high degree of cooking and processing of commercial breakfast cereals tends to make the starch in them more rapidly digestible, giving a higher G.I. Less processed cereals (muesli, rolled oats) tend to have lower G.L values. Guardian™ (G.I. of 42) and All-Bran™ (G.I. of 42) (Kelloggs) although processed are not made from milled starch but large flakes of raw bran.

Buckwheat (G.I. of 54) • Buckwheat is available from health foods stores and some supermarkets. It can be cooked as a porridge or steamed and served with vegetables, in place of rice. It can also be ground and used as flour for making pancakes and pasta. Buckwheat in this form is likely to have a higher G.I. than when whole.

Bulgur (burghul) (G.I. of 48) • Is made by roughly grinding previously cooked and dried wheat. Most commonly recognised as a main ingredient in tabbouli. The intact physical form of the wheat contributes to its low G.I.

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To cater for the dynamic nature of energetics in living systems, a second phase of thinking in the field incorporated rates of change, i.e:

Rate of change of energy stores= Rate of energy intake (EI) – Rate of energy expenditure (EE)

The use of ‘rates’ in this equation allows for changes with time and hence allows for the effects of changing body mass on EE and EI. This would mean that a small change in energy balance (e.g. an increase in food) would not lead to a large increase in body fat because as body mass increases, there will be an increase in EE (through increased metabolic rate and the increased energy costs of moving a bigger body around). This will then balance the increased energy intake and the individual would thus again be in energy balance, although at a slightly higher body weight. Using this approach, it has been calculated that the extra slice of toast for the man mentioned above would only add around 2.7kg of weight over 40 years, which is clearly a much more realistic figure. This approach highlights the need to look for the cause of a chronic imbalance between energy intake and expenditure, rather than small, absolute differences of either one (which is the ‘calorie counting’ approach). However, this model still offers no clues about what causes a chronic energy imbalance in the first place. For that, a further explanation became available in the 1980s.

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Who is suitable for a conservative laparotomy

The reasons for having a conservative laparotomy vary widely and they may include any of the following:

Moderate or severe disease

Endometriomas or cysts greater than two centimetres in diameter

Adhesions, especially if they are causing pain or distortion of the reproductive organs

Involvement of other organs such as the bowel or bladder

Moderate or severe symptoms that have not responded to other treatments

Inability or unwillingness to take hormonal treatment

Desire to conceive immediately

Desire to avoid hysterectomy

Woman’s preference

Gynaecologist’s preference.

A conservative laparotomy is often the most appropriate form of treatment for more severe forms of endometriosis, particularly if large cysts or adhesions are present. Some gynaecologists believe that a conservative laparotomy is of little benefit for those with minimal or mild endometriosis and that in those cases it should only be used as a last resort if hormonal treatment or laparoscopic surgery is unsuccessful.

Hormonal treatment has little or no effect on adhesions or large cysts and endometriomas greater than two centimetres in diameter as they are made up largely of scar tissue. Surgery is the only way to remove or destroy any adhesions or large cysts and endometriomas.

If your endometriosis involves nearby organs such as the bowel or bladder, surgery may be necessary to ensure the normal functioning of those organs.

Things to discuss before conservative laparotomy

Before your operation it is important that you discuss with your gynaecologist what is intended to be done during the operation. Also ask any other questions or voice any concerns that you may have. In particular, you should make sure that you both agree on the purpose of the surgery and you should discuss what procedures are proposed and you should make it clear if there are any procedures that you particularly do or do not want carried out. You also need to remember that, because each case of endometriosis is unique, until your gynaecologist actually starts the surgery it is difficult to be certain what procedures will be needed.

If your symptoms are manageable and if you are contemplating becoming pregnant soon it may also be worthwhile discussing the timing of your surgery with your gynaecologist. Most infertile women with endometriosis who conceive following a conservative laparotomy do so in the first 12 months after their surgery and you are more likely to conceive after the first bout of surgery than subsequent surgeries. Some gynaecologists believe that, if possible, a conservative laparotomy should be timed for when the woman wishes to become pregnant.

What happens with conservative laparotomy

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

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

Removal or destruction of implants and small cysts

Removal or destruction of large cysts and endometriomas

Removal of adhesions

Removal of an ovary or an ovary and fallopian tube

Removal of the appendix

Surgery on any other affected organs such as the bowel or bladder

Suspension of the uterus

Pre-sacral neurectomy or utero-sacral neurectomy

Any surgery necessary to correct other abnormalities found.

Implants and small cysts

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

Large cysts and endometriomas

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

Adhesions

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

Ovaries

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

Appendix

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

Bowel and bladder

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

Suspension of the uterus

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

Pre-sacral and utero-sacral neurectomy

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

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

Other

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

Effectiveness of a conservative laparotomy

It is difficult to give an indication of the success rates of a conservative laparotomy due to the lack of large-scale studies carried out to evaluate its effectiveness. There are few statistics on the success of surgery in terms of relieving the symptoms or on the proportion of women who experience a recurrence of their symptoms following surgery. Almost all of the available statistics are concerned with the proportion of women desiring pregnancy who conceived following surgery. Although the reported figures vary widely those statistics indicate that on average approximately 60% of women with mild disease, 50% of women with moderate disease and 40% of women with severe disease, can expect to conceive following a conservative laparotomy.

Risks and complications of a conservative laparotomy

The risks and complications of a conservative laparotomy are the same as those outlined for a laparotomy.

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