If a woman is at risk of heart disease because of family history or a risky cholesterol pattern, Dr. Notelovitz says, he probably would put her on estrogen for the rest of her life. The leading form of estrogen is Premarin, extracted from the urine of pregnant mares. More recently, doctors have prescribed a plastic bandage-type patch, usually affixed to the buttocks or abdomen. It delivers a synthetic estrogen through the skin. The patch is changed twice weekly, and so is its location, if a skin rash occurs.
When estrogen is taken in pill form, I its level in the blood rises after the pill is taken, then falls as the day passes. But with the patch, a steady estrogen level is maintained, usually causing fewer side I effects.
Valene Crumpley, 55, a registered nurse in Salt Lake City, had her ovaries surgically removed at 37. Ensuing hot I flashes were not relieved by estrogen pills. I She has used the patch since its introduction 6 years ago. As a result, she says, she has “no hot flashes at all.”
In 1966, when Dr. Robert A. Wilson I advocated estrogen therapy in his book Feminine Forever, most doctors pooh-poohed his ideas, but some researchers took them up. Now it’s the treatment of choice for most menopausal women.
Posted by admin
Categories: TAKING ESTROGEN
With the onset of menopause, many women suffer from hot flashes and night sweats. Arlene March, 56, a Los Angeles psychotherapist, says she started getting hot flashes 5 years ago. “I’d be working,” she recalls, “and suddenly feel intense heat all over my body. I’d break out in a sweat. I’d have to stop work. Then Dr. Mishell prescribed estrogen pills, and I’ve not had a day of discomfort.”
Some women experience a drying and thinning of vaginal tissues in the absence of estrogen, making sex painful. They also might suffer urinary tract infections and incontinence. Estrogen therapy often helps.
Among the physicians consulted, the most cautious was Dr. Morris Notelovitz, founder of the nation’s first Menopause Center, at the University of Florida, and head of the Women’s Medical and Diagnostic Center in Gainesville, Florida. He says each symptom needs a different treatment and advises that genital tract problems be given estrogen treatment for a couple of years at most. He also urges special measurements of the bones before prescribing estrogen therapy for osteoporosis.
Posted by admin
Categories: FIGHTING HOT FLASHES
In the past the rules about the bringing up of a baby have probably been a little bit too severe. Exact schedules, weighing after each meal, with worry over low weight, have been common. On the other hand there may be worry that the baby has eaten too much, although here we are told that babies know when they have had enough and that overfeeding is rare in infants. How we do lose that primal wisdom! Pediatricians tell me that babies are kept too warm and lose weight because they sweat it off. Mrs. Eliza Ann Jane Higgins, for forty years superintendent of the Boston Lying-in Hospital, in her latter days used to go about reaching under the bed-clothing and feeling the babies’ feet. She said that if the baby’s feet were warm, the baby was all right.
Fortunately babies are cuddled more now than they were a generation or so ago. In my intern days, or rather nights, I always had my favorite infant whom I picked up and carried about as I made my midnight visit to the infants’ ward. Babies are the better for the human touch and some moving about.
Recently I received a letter from a fond mother in which she asked, “What significance do you attach to a continual rise in temperature (mouth) 99.2 – 99.8 in my six-year-old boy who acts well and eats well? Owing to his negative tests I was told to let him resume his normal activities and throw the thermometer away.” In my answer I agreed with the doctor who told her to throw the thermometer away. “Acts well and eats well” pretty well told the story.
Clinical thermometers are of more use with babies than with grownups, for the former can tell us little and examination is all important. Young parents must remember, however, that a baby’s temperature is not so stable as an adult’s and a high temperature may come quickly when the baby is not really very sick. Babies do react with suddenness, either getting sick or getting well, and they usually look the part of health or sickness. Fully as much as with the six-year-old just mentioned, if they act well, they probably are not very sick.
Wild animals, no matter how abundant food is, do not injure themselves by overfeeding. Babies are wild animals and they do not hurt themselves by taking too much food. It is usually the wrong food that makes trouble, although it is realized, now, that they can take some more kinds than were previously given them. A gentleman with the Hibernian name of Cadogan realized many of these things two centuries ago and he said that the baby should have as much as it would take from both breasts at each time while he pitied those who were “stuffed with pap til they spue.”
Of course he lived in the days when it was taken for granted that the mother or wet nurse would give the baby breast milk. This pretty well persisted until less than a half century ago. Those who recall Edwardian days will remember that it was not so uncommon for the bosom of the nursing mother to be shyly exposed, whether in drawing room or public conveyance, in response to the infant’s need.
There is not one correct answer to any one of these problems. More babies should be nursed than has been the recent custom; an occasional mother has a good reason for not nursing. The baby should have something to say as to when he gets his nourishment; this does not mean that every time he whimpers he should be shut up by the breast or the bottle. He is almost always the best judge as to when he has had enough; but, if he is grossly overweight, remember that almost all grownups and a few babies can get the habit of eating too much.
But in feeding and in everything else dogmatic routines (typical of this perhaps over-organized age) are no substitute for judgment. Routines can be overworked; they are a reaction against the days when the doctrine of laissez faire (“Let nature take its course”) was popular. It is now in absolute disrepute. All this is largely evident in the upbringing of children. Regimentation is not only overdone in infancy but it is carried on into childhood and even adolescence. It was formerly said that the cat was the ideal mother. As long as her kittens really needed her, they got unremitting attention. After that, they were cuffed and sent on their way.
Fifty years ago the method of the cat was somewhat applied to human children. When school-time came, they were started out in reasonable condition and were expected to get themselves to and from school. There was no transportation even for Bill and Lena Johnson, who lived two miles away in the woods, or for a scion of wealth who had the same distance to go in New York City. Had the words “supervised play” been uttered on Cape Cod they would have been meaningless to our more than ordinarily intelligent parents. But a generation back, the organizers began to take hold. Twenty years ago the mother was not allowed to pick up the crying baby and pet him, and she was expected at all costs to get him clean in the first year - and preferably in the first month of his regimented life. Today she is encouraged by some doctors to pick him up the minute he cries, and to let him get clean at his leisure.
The Oxford team’s research revealed that the surgery and suturing involved in an episiotomy lead to more bleeding, infection, and tearing of tissue than when no episiotomy is done.
As for cesarean deliveries, there is mounting evidence that more than half of all C-sections performed in this country may be unnecessary.
In the United States, C-sections exceed 30 percent of all births. In England, they total 9 percent. As do many American researchers, the Oxford team says that there is no reason to rule out natural vaginal birth for a mother just because she has had a cesarean.
How did the Oxford team members arrive at the findings? They focused on studies on childbearing done from 1950 onward that were published in 60 key scientific journals, then wrote to the authors of these studies and to 18,000 obstetricians to obtain unpublished data.
Finally, they subjected the studies to meticulous mathematical evaluations. In particular, they were looking for research that used random and controlled techniques.
For example: Suppose a researcher wants to evaluate the safety and effectiveness of shaving pubic hair before birth. (Such an experiment was conducted in 1922.) As women come through the hospital, they are assigned by a coin toss: shaved or not shaved. That makes their selection random, eliminating bias in selection. The effects are evaluated later by individuals unaware of who was and was not shaved: they were “blinded” with respect to who received what. This prevents conscious or unconscious bias. The unshaved patients become the comparison or control patients. A statistician later sums up the results. If there is no difference between shaved and unshaved patients -as the 1922 test concluded – then shaving should be abandoned. (Of course, in any trial, if the number of subjects is too small, it cannot be concluded that there was no difference between them.)
Frederick Mosteller of Harvard University, one of the nation’s leading statisticians, strongly endorses the Oxford methods. “I am very impressed with the magnitude and strength of the effort and experts brought into play,” he says. “One of the things I like about their work is that they cared deeply whether the patient was pleased. This more tender and humanitarian interest is quite surprising in a book concerned with quantitative analysis. They emphasized letting the patient participate in decisions.”
Despite the findings of the Oxford team and others, many obstetricians and pediatricians -especially those with practices away from large research centers – have been slow to change their methods.
“I am shocked that 10 percent of Canadian hospitals still shave women,” says Dr. Enkin, “or did so until very recently. Though the story on shaving has long been known, doctors didn’t change their habits until women began to complain and ask why it was being done.”
“If a doctor believes that our data do not tell the truth,” Dr. Keirse asserts, “then that critic must mount his own randomized, blinded, controlled trials to prove he is right and we are wrong.”
Daniel M. Fox heads the Milbank Memorial Fund, based in Manhattan, which is sponsoring conferences and an information network to encourage putting the study’s results to work.
“As the medical world learns more of what this Oxford team has done,” Mr. Fox says, “there could be a revolution in obstetrical practice. And that could save many babies and mothers, and billions of dollars.”
Here are some other new views their research has provided:
• Diet and pregnancy-induced hypertension (pre-eclampsia). There is no evidence that dietary intervention prevents this condition.
• Routine use of iron supplements. It is unnecessary and probably harmful.
• Giving steroid hormones to mothers in labor to relieve breathing problems in their low-weight babies. Proponents say this could save billions by replacing more costly care for the infants later.
As the Oxford team’s work gains recognition, it seems logical that we will be seeing more infants born at home or in birthing centers, attended to by mid-wives or physicians’ assistants. Hospitals will provide emergency backup for births, but their primary role will be to provide care for high-risk patients.
Posted by admin
Categories: RESEARCHES AND FINDINGS
In the latter part of pregnancy the child has very cramped quarters in the uterus and therefore takes a position which will result in his occupying the least possible space. The legs, which to anatomists are only the parts from the knees to the ankles, are folded one upon the other. The hips are fully flexed; that is, the thighs are brought up snug against the belly. The knees are also flexed so that the calves are close to the back of the thighs. Then as the legs cross each other the sole of each foot is pressed against the opposite buttock. The feet are rolled in and they are in the position which all of you speak of as toeing in. As the child’s head is also held with the chin down on the chest, he comes pretty close to being a ball.
Baby’s unnatural-looking shapes
All of this results in the baby, when born, having a shape which just does not look natural to the uneducated eye. The appearance of the foot is often very suggestive of the ordinary type of club foot. But in club foot the tendons or ligaments are badly contracted and early and careful treatment is needed.
The turned-in foot of the normal child needs no treatment. The early painters, particularly when showing the Madonna and child, had the latter a miniature replica of a physically perfect man, beautifully proportioned and straight as an arrow. The newborn baby may indeed be beautiful but not at all with the proportions of the adult. If you look into the advertising pages of a modern magazine where there are good portraits of babies, you will see that the head is proportionately far larger than when the child has grown up.
Many children adopt the pre-natal folded-up attitude for some time after birth, particularly when asleep. Possibly this position delays the development of a mature shape but it is doubtful and anyway not important. Many races have adopted constriction and binding to influence the bodily shape. This causes abnormalities such as the misshapen foot of the ancient Chinese woman: it never aids in normal development. The infant who doubles himself into a ball and sleeps in the prone position – that is, with the back up – is a normal one. Several years ago I made a night flight across the Atlantic. Some time after midnight and several miles in the air I went back along the dimly lit aisle and saw in front of me on the floor an infant thus slumbering. The young mother said he refused to drop off to sleep in any other position and this was the only space she could find to accommodate him. So she cooperated with nature, with a wisdom attained by few of us.
Many doctors must have been consulted by anxious mothers who thought their children bowlegged. The crossing of the legs in the womb really does result in some bowing of the tibia, or large bone of the leg, which will straighten out later. These babies do not have rickets. When they begin to toddle about, it will be found that they have flat feet, another condition which has caused a lot of unnecessary perturbation. Many people certainly do worry about flat feet, and I tell them that it is unnecessary in these cases. And, along with the flat feet, the youngster has the habit of toeing in. Most of this effect usually occurs at the hip joint which, at this age, allows more of a rolling in of the whole limb than usually is present later. Many of these children are probably somewhat overweight which is not so bad as at a little later period.
If these specimens of childhood shapes really worry their parents, a gentle moving about of their limbs when asleep will show if they can be put easily into normal position. If that is so, the parents may be reassured that these conditions, which they think are deformities, will gradually correct themselves. Highbred dogs of the most graceful breeds are clumsy puppies to begin with. So it is with humans.
Posted by admin
Categories: BRINGING UP BABY