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These are usually more common in older children and adolescents.

Clinical features

The edge where the nail meets the big toe is red, swollen, tender, and may be draining pus. The corner of the nail pushes against the cuticle or pulp of the toe, causing pain.

Cause

The edge of the nail (usually the outer edge) grows downwards into the pulp of the toe, instead of forwards. This produces an open wound which allows bacteria to enter, resulting in infection. It may be due to tightly fitting shoes, but can also be caused by cutting the nail by rounding the corners, instead of cutting directly across in a straight line.

Treatment

It will be easier for your child if he wears open shoes or sandals until the toe is healed. If he must wear closed shoes, put some protective padding over the toe. After a bath, when the nail is soft, gently push up the corner of the nail away from the cuticle, and try to wedge a small piece of cotton wool soaked in antiseptic solution into the crevice. Strap this around the toe. This method is usually only effective if the infection has not yet set in.

If this treatment does not lead to improvement of the infection within several days, you should see your doctor who will discuss with you the options of antibiotic treatment, and/or surgical removal of part of the nail. This procedure is called a wedge resection. Under local anaesthetic a wedge of the nail and nailbed is cut out, to allow the nail to regrow normally. Daily dressings must be applied for a week after a wedge resection. Most cases of ingrowing toenail will respond to treatment without the need for surgery.

See your doctor if your child has a sore, red toe in which one corner of the nail is growing down into the skin.

Prevention

Cut toenails straight across rather than rounding the corners. Make sure your child wears shoes that fit properly.

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There are -a number of other practitioners who sometimes see children. These include homeopaths, osteopaths, naturopaths, iridologists, and other proponents of ‘natural therapies’. These are areas considered to be outside the mainstream of medicine. Most doctors and many other professionals argue that the theory and practice of many of these areas have no scientific validity, and that they are potentially dangerous in that they postpone the early diagnosis and effective treatment of serious illness.

Often parents take their children to alternative practitioners because they do not like the idea of giving medicines to their children — these are seen somehow as ‘poisoning’ the body, or weakening the immune system. This is quite false. While in a number of minor conditions, such as colds medications are unnecessary and are sometimes prescribed too freely, in other conditions they are lifesaving. When your doctor suggests medications, if you have some reservations about their use, speak to the doctor about them.

While we do not wish to comment on the benefits of alternative treatments for adults, we would recommend strongly against parents taking children to alternative practitioners. While in many cases prescribed remedies are harmless, there have been too many cases of incorrect diagnosis and wrong treatment. This has the potential for tragic consequences, and is best avoided. Find yourself (and especially your child) a good GP to look after day to day illnesses. Your doctor will also be able to refer your child to experts in child health if the need arises.

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I don’t feel like I really have an intense emotional experience. I don’t feel like I have really gotten into and out of something.

It seems like my body comes but I don’t.

The first report is from a wife, the second a husband. Absence of psychasms, that is, an absence of the alteration of conscious and emotional experience through intimate bodily contact with someone else, is related to both hot and cold times, for unless we are in balance in our lives, we are not free to enjoy a variety of consciousness experiences. To do so, we may turn to drugs to help us accomplish such uplifting and mind-altering experiences, but drugs never really work. Only through intimacy and spiritual development can we really transcend the material, physical limitations of day-to-day life. The 881 men and 492 women who had trouble with psychasm were equally distributed in their hot and cold orientations to life both in my sample and in their own daily lives, running both hot and cold at various times.

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I can’t remember what I wanted to be when I grew up. IVe been too busy helping everyone else in this house grow up to pay any attention to that anymore.

HUSBAND

I notice that my husband is never in my dreams.

WIFE

Is there still a reason for the two of you to be married, a reason that applies and has meaning for now and for the future (purposeful)? Or, are you two people with no common dreams or purpose, just going along perhaps with separate and unshared dreams (aimless)?

One of the first questions I ask the couple is “Why are you married?” followed by ‘ ‘Tell me your shared marital dreams.” Our society talks of individual liberty and the pursuit of happiness, and less of unity of purpose and dreams. This sample couple scored high toward the aimless axis. The wife reported, “I have always wanted to finish college. He thinks that’s silly. He says I wouldn’t make enough to make it matter. It matters to me, though.”

The husband responded, “I have a clear dream. Living on a lake up north, fishing all day, even at night. I could even use my snowmobile during the winter.”

Two dreams, unshared, and without the appearance of the spouse in either dream. Why are you and your spouse together now? Why do you have sex and intimacy anyway?

Sexually, the couple responded to my question about their”dream sex life” in quite different fashion. The husband reported, “That’s easy. Sex every day, every night, on the floor, in the car, out in the yard, sucking me anyplace and anytime.”

The wife responded, “I kind of see me walking with him on a beautiful beach, say, in Maui. The moon is behind us, the ocean in front of us, the warmth embracing us. We both feel warm, move together, kiss, and move slowly to the sand. No one is near, we are perfectly safe and alone together.”

“That’s no sex fantasy.” The husband laughed. “Don’t you think about garter belts, black panties, some real adventure?”

Sexual interaction has become goal-directed rather than dream-inspired, and the sexual system of your marriage draws its fuel from shared dreams. While too much purpose can force and drive a marriage, stressing it toward future accomplishments, too little common purpose destroys the reason for togetherness. If there is no place to go, we end up searching and lost. If we only look to the destination, our own unshared destination, we will never enjoy the journey.

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Have you ever had a sharp, stabbing pain somewhere and then, when it came back at other times, it caused worry that there was something really wrong with you?

These pains may occur in the chest or back muscles, are sharp and stabbing and usually shortlived, even if severe. They are usually muscular and the underlying cause is usually nervous tension.

Attacks of severe pain in the rectum which occur at irregular intervals and are fleeting or last only a few minutes are similar.

This condition is called proctalgia fugax. The pain may occur at night or following straining at stool or after ejaculation. Examination shows things to be normal and no organic cause can be found.

The pain is thought to arise from a cramp-like spasm of one of the muscles in the pelvic floor and so is similar to the muscle pains. Some researchers believe it is a variant of the irritable bowel syndrome.

The condition may improve with psychotherapy, with tranquillisers or with drugs designed to relieve the muscle spasm.

A full explanation of the benign nature of the disorder may be sufficient to relieve the patient’s anxiety and so relieve the condition.

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Masked depression may show itself as other symptoms such as chronic fatigue, bowel disorders, indigestion or headaches.

Pessimism, despair and withdrawal are usually characteristic of all depressed states.

A reactive depression may last for six to 12 months and then spontaneously lift or the depression may persist for many years, varying a little up or down.

Not only does depression interfere with a patient’s life, taking away his enjoyment and affecting his efficiency and work output, it also has its effect on those around him, particularly his immediate family.

It is important for the doctor, for those who counsel people and for those who work and live with a depressed person to recognise that any depression may lead to suicide if the person feels hopeless.

Other treatment is ineffective unless the correct diagnosis is made.

Anxiety may be associated with depression and may mask it. Only the anxiety may be seen and a tranquilliser prescribed. Most tranquillisers do nothing for the underlying depression. The anxiety state calms down but this allows the depression to well up.

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Whooping cough is much less dangerous in the older child and so immunisation with a high risk of reaction is not warranted.

Diphtheria is due to a bacterium, not a virus, and has a short incubation period of about three days.

The disease may be mild and produce little more than a mild sore throat and a “cold” type illness, but it may cause a severe infection with a high temperature, muscle weakness, aches and pains, confusion and delirium.

When the throat is affected, a typical pearl-grey exudate or membrane may appear on the tonsils or back of the throat.

The affected larynx or voice box may swell and lead to obstruction of breathing. It may be necessary to make an opening in the windpipe or trachea (a tracheotomy) to enable the child to breath.

The heart may be affected by toxins or poisons produced by the germ and lead to heart failure and death. Sometimes the nervous system is affected and this can lead to paralysis of muscles.

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Just as we cannot exactly predict for any individual what organ will be affected by secondary growths, so we cannot exactly predict what will eventually cause death. Most causes of death from cancer fall into one of the two following groups. Firstly, cancer may destroy so much of a vital organ (such as the liver, brain or lungs) that it can no longer carry out its normal function. Secondly, cancer can weaken the body and immune system so much that infections such as pneumonia are fatal. These causes all act gradually. Less commonly, cancer causes death through haemorrhage, blood clots or other more sudden processes.

The ‘natural history’ of an illness means what happens if there is no treatment. It is important’ to have some idea of how your cancer might behave without any treatment before you decide what, if any, treatment to have. Of course, cancer behaves in exactly the same way if it is not sensitive to the treatment chosen. Unless you are cured, your cancer will behave like this sooner or later.

As we have learnt, a cancer starts with one or a few cells. These have to double (each one split into two) about thirty times for the cancer to reach the size of a 1cm cube. It is unusual to detect a cancer smaller than this. This means that by the time a cancer is diagnosed, even when it is very tiny, it has actually been there for quite a while. It would be at least a few weeks even in the case of very rapidly-growing cancers and many months or even years for some of the slower-growing types.

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There is a list of relative contraindications to HRT, that is those conditions in which you and your doctor will need to consider the balance between the risks and the benefits:

• Endometriosis can lead to a difficult decision having to be made. If you had an oophorectomy, then you will probably have particularly troublesome hot flushes, and if you had the operation before about the age of 45 you will be at a much greater risk of developing osteoporosis, so HRT would seem an important treatment for you. However, the excess tissue that built up in endometriosis may get worse on HRT, even many years after the menopause, suggesting that you should not use this form of treatment. This is obviously something you should talk over with your doctor.

• If you have a family history of cancer of the breast or uterus, your doctor will want to consider what your chances are of developing either of these diseases if you take HRT. Once again, only you can decide by weighing the relative risks against the relative benefits. Benign breast disease needs careful monitoring, but HRT needn’t always be ruled out.

• Fibroids tend to get worse in the presence of oestrogen, and may enlarge if you take HRT. But this doesn’t usually cause extra problems and most women with fibroids who are on HRT find they just have heavier periods.

• The presence of gallstones means HRT has to be prescribed with caution, as it can lead to an increased risk of this condition becoming worse. A non-oral route, such as the patch or implant, avoids the digestive system, so may be acceptable. Oestrogen can make gallbladder disease worse.

• High blood pressure should be investigated before starting on HRT, but once it has been brought under control, your doctor will probably feel it is alright for you to be on HRT. High blood pressure is not in itself a contraindication.

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The preceding discussion has assumed heterosexual sexual behaviour. However, not everyone is primarily attracted to members of the opposite sex; some people, both males and females, are aroused by and form homosexual relationships with members of their own sex. Research on the effects of hysterectomy on the sexual relationships of lesbian women is extremely limited and deserves more attention.

Another area in which knowledge is limited is the previously mentioned role of the uterus in sexual response. Direct stimulation of the cervix during sexual intercourse also seems to have a role in the sexual response of some women and men.

More information exists about the effects of changes in hormone production after hysterectomy. Even when the ovaries are retained, oestrogen levels seem to be affected by hysterectomy in some women. About a quarter of women whose ovaries remain after hysterectomy experience early loss of ovarian function (on average four to five years earlier than in comparable women who have not had a hysterectomy) which can lead to vaginal dryness and hot flushes. In a bid to prevent or overcome these problems, many women with indications of low oestrogen levels are prescribed oestrogen therapy after a hysterectomy whether or not their ovaries have been removed.

A woman’s attitudes — and those of her partner — can be an extremely important influence on sexual relations after hysterectomy. In the aftermath of her hysterectomy, Kay was already questioning her femininity and attractiveness. She had regarded her main role in life as childbearing and suddenly, without the ability to do this, her life lost meaning. But her agitation grew when Kevin failed to respond to her attempts to arouse him sexually. She worried that she was now less attractive to him and new tensions entered their relationship. This unfortunate chain of events continued until the couple sat down and communicated their feelings and fears; Kevin explaining that he was worried about causing Kay pain when they made love, Kay coming to grips with the reasons why Kevin and others valued her.

In the case of Vin, talking did not help a great deal. He thought his wife Mary was less of a woman after undergoing hysterectomy but found it difficult to say exactly why. He understood that Mary had tried many other approaches to resolving her medical problems without success, and that something had to be done to relieve her pain and bleeding. In cases such as this, it can be helpful if a spouse or partner is involved in the decision-making

process, thus providing opportunities to discuss any concerns with the doctor. It may also alert women to the need for a concerted effort on all sides to overcome unforeseen barriers to reestablishing a satisfactory sexual relationship.

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