Scarlet fever does not occur often nowadays, and is a much milder illness than it used to be, for reasons not well understood.

Cause

Scarlet fever is caused by a Streptococcus germ, spread by sneezing and coughing.

Clinical features

Symptoms of scarlet fever vary greatly between children. The commonest symptoms are a mildly sore throat, swollen, tender lymph glands in the neck, a mild fever, and a characteristic rash. The rash covers the whole body and consists of tiny red spots. The tongue may be bright red (strawberry tongue). Nowadays complications of scarlet fever are very rare, due to effective treatment with antibiotics. Rheumatic fever used to be a serious complication, but is rarely seen in association with scarlet fever now.

Treatment

Scarlet fever can be treated effectively with antibiotics of the penicillin group. (If your child is allergic to penicillin, other antibiotics can be used.)

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“Why would a woman let a man put his thing in her?”

When you grow up and can take care yourself and others, there times when a woman wants to love, to hold, and to kiss and touch a man, and a man wants to do the same thing. Sometimes, but not every time, the man and woman want to join together and have the penis inside the vagina. This is one of the most important things to do in all the world, and a baby can start to grow when the sperm goes with the egg. It is a way of loving, a very special grown-up way of sharing yourself with someone, so it should only happen when you are married and going to be together forever.

    ”How can a baby eat in there?”

The baby is inside something like a space capsule, and food and other things needed to live are brought in from the mother. There is a special capsule filter that only lets in what the baby needs to live. The baby grows in this capsule and gets food through a cord attached at her or his belly button. The mother and baby are a team and are living together making each other healthier.

“Why doesn’t the baby drown in the water in the sac?”

You are very smart. Yes, there is something like water made by the mother that the baby floats in inside the uterus. It keeps the baby from getting hurt and keeps the baby safe and healthy. The baby can’t drown because he or she does not breathe through the mouth until he or she comes out. It’s just like a person in space, with all the food and even their oxygen coming in through that special cord.

*319\97\8*

I hate those X-rated videotapes. They are disgusting. A bunch of naked bodies humping each other. I like the parts where you can see some feeling, but that almost never happens.

WIFE WITH HUSBAND PRESENT

I get turned on a lot with those tapes. I feel guilty, but I got one out to look at while he was at work and I masturbated. I know it’s filth, but some parts turn me on.

WIFE IN PRIVATE INTERVIEW

The early perspectives assumed that men looked and women felt. I did not find this assumption to be the case with the couples \ interviewed. Women were aroused by visual stimulation, and sometimes were quite specific in their report. “I love the turn in the shoulders by a man’s neck, sort of the neck and shoulder area. I love to sort of smooth out his suit coat or jacket by running both my hands out from that turn on both sides of his neck to his outer shoulders. I love to look at men in the theater from behind and look at their shoulders.” This wife’s report illustrates a strong visual reaction, and other examples were similar.

The individual love maps of men and women, not their gender, determine what stimuli will elicit a sexual response at any given time. If we tell women that they do not respond visually, then they are likely to report that they do not. If we ask open questions without gender bias, we get the same range of responses in husbands and wives.

Talk together about your reactions to erotica and you will discover that both of you are turned on and off to various visual cues. Asking whether or not a woman is turned on to X-rated material is like asking if someone is turned on to books. It depends! And remember, the sexual-response system is not a closed energy system with an on-and-off switch. It is a flowing, ever-changing system. We do not really get turned on or off, we respond to varying degrees.

When we free our relationship from the mechanical orientation of the early sex perspectives, we learn that we we always “on,” and in control of our response through our selection, sharing, and awareness of our love maps and the variables that determined it.

*146\97\8*

I suppose to you this will sound perverted. We have done almost everything together. We haven’t missed a posture. But we never seem to experience anything together. We sleep next to each other, but not with each other. Our sex life is like masturbating, like using each other to masturbate. You might say we are the founders of the term “completing the act.”

WIFE

Super Marital Sex Rule: Any part of the marriage that is ignored will disappear, and this rule is particularly true for sex. For most couples, the amount of enjoyment they derive from their sexual relationship corresponds with the amount of attention they pay to their sexual interaction. The sexual return from a marriage will usually match the intimacy investment. The following are ten areas in which the couples failed to invest appropriately or enough.

*6\97\8*

In obsessional-compulsive disorder, there may be recurrent ideas or images entering the mind, such as phrases, pictures and disagreeable ideas, often obscene.

There may be aggressive impulses to hit or injure someone, suicidal thoughts, a desire to swear in church or to take off one’s clothes.

With phobias, there may be extreme anxiety and an unreasonable fear of an object or a situation. These are regarded by the sufferer as groundless and irrational but he cannot control them.

Some phobias are clear-cut, and psychotherapy can often reveal the repressed anxiety that caused the fear of the phobic situation. The connection may be subtle but easy to recognise.

In other cases, there is no clear connection between what caused the repressed fear or anxiety and the resulting phobia.

In treating phobias, behavior modification and learning techniques may be required. Another method is desensitisation.

In this, the person is exposed, initially in thought, to the situation which he most fears. He starts by thinking of himself in that situation in a mild way, then mentally removes himself before the anxiety is severe. This goes on until he imagines himself in the worst possible situation, without anxiety.

Next, he is placed in the real situation, for a short time and removed as soon as he shows anxiety. Finally, he can be fully exposed and able to cope without anxiety.

Another technique is implosion, the reverse of the slow process of desensitisation.

Here the person is placed, at once, into the worst possible situation he can imagine. This creates extreme anxiety and it is believed the shock is so great that the anxiety disappears.

*514/71/1*

A further operation is lumbar sympathectomy, which involves cutting the sympathetic nervous chain in the lower back. This chain controls the tone in the arterial wall. When the nerves are cut, the arteries permanently dilate and blood flow can increase. Sometimes both operations are combined.

The bypass operation is the same principle as in coronary bypass surgery, where atheroma blocks one of the coronary arteries and a vein is used to bypass the obstruction.

There is no doubt about the marvels of modern medicine, but how can we convince our patients to avoid the bad habits that lead to many of these problems?

Changing our diet and avoiding smoking would reduce the incidence of atheroma.

The diagnosis of intermittent claudication can be made on the history alone. When the doctor examines the legs, he may be unable to feel the pulses in the feet. This indicates obstruction to blood flow.

In the past, various drugs were used in an effort to dilate the narrowed arteries and improve the blood flow. Unfortunately, these have proved disappointing.

*258/71/1*

The more severe cases will require admission to hospital. They are perhaps better in a psychiatric ward or hospital rather than a general hospital. Most will respond to encouragement and supervision of meals rather than to forced feeding. However if the weight loss is extreme and the general physical condition is poor then intravenous feeding may be necessary.

Apart from the attention to the physical state, the emotional side of this disorder needs treatment. The girl herself may need intensive psychotherapy. Often the family, especially the parents, may also need counselling, and it may be better in these cases for parents to have a different therapist to the girl herself.

Anorexia nervosa rarely results in death now unless as a result of suicide, but associated depression is not unusual.

*5/71/1*

Let me give you an example. A doctor recommends a course of chemotherapy to a woman with extensive breast cancer, without offering any alternatives. For her, the alternatives in fact might include: a more or less intensive course of chemotherapy, use of different chemotherapy drugs; use of hormones; radiation treatment to the painful spots; no specific anti-cancer treatment at all; concentrating on controlling her pain with a suitable painkiller; prayer; a grape diet; or taking an overdose of her painkillers. To any one particular person, some of these will be attractive, others will be out of the question. To make the best decision, this woman needs to know the pros and cons of each alternative, and consider them in the light of her own particular life situation and beliefs. The best choice is not the same for everyone.

After getting all the information about these options, one young mother of three might decide to have intensive chemotherapy because she feels convinced that this has the best chance of prolonging her life. Another young mother of three might decide to have no chemotherapy at any stage because she has decided that, for her, the likely side effects are too great compared to the likely benefit. A third might decide to have the radiation treatment at this stage and the chemotherapy later when her symptoms come back. Each of these could be the best and most appropriate decision for each woman at that time.

As time goes by they may revise their decisions according to their own individual experiences. For example, after several months of chemotherapy, the first woman may decide the side effects she has experienced are too great to warrant continuing with it. The second woman might get to know a few other patients who have had successful chemotherapy and decide to try it herself. Again, these could be the best and most appropriate decisions for these women at that time.

*15/40/1*

You have probably noticed in life that every silver lining has a cloud! In the case of HRT, the cloud is called progestogen (a synthetic form of the hormone progesterone).

Up to now it has all looked pretty good: whether you have hot flushes, vaginal and bladder problems, mood changes, or even feelings of insects crawling over your skin, replacing oestrogen gives you a good chance of ending these troublesome symptoms of the menopause. HRT even protects you against osteoporosis, and reduces your chance of having a heart attack. It all sounds too good to be true.

If you have had a hysterectomy, you can skip this slightly depressing chapter, because progestogen is not a word that need bother you. But if you still have a uterus (womb) and are considering taking HRT.

Progesterone is produced in the ovaries after the ovulation phase of the menstrual cycle, and in pregnancy. Its main function is to prepare the womb for a fertilised egg, and to maintain the pregnancy. It also thickens the lining of the womb, reduces secretions from the cervix (the neck of the womb), prevents ovulation, contributes to the retention of water and salt, and works with oestrogen to stimulate milk cells in the breasts. During a menstrual cycle that doesn’t result in pregnancy, it is the production of progesterone that contributes to the pre-menstrual feelings of bloatedness, breast tenderness, and general irritability. So although it has an important role to play in the menstrual cycle and pregnancy, progesterone is not exactly an unmixed blessing, and its presence in HRT causes the single most important reason why women who have not had a hysterectomy either don’t want this form of treatment at all, or don’t stay on it for more than a few months.

*21\42\4*

Various procedures have been developed in recent years which aim to destroy the endometrium in women experiencing excessive bleeding that is resistant to control by drug therapy. The heavy or prolonged bleeding may be caused by fibroids, adenomyosis, postmenopausal hormone therapy or drugs designed to thin the blood (anticoagulant therapy). These procedures do not appear to be helpful in relieving pain associated with menstruation.

The destruction process is carried out using a hysteroscope, an instrument described previously in this chapter. A fibre optic camera threaded through the hysteroscope records the view which is seen by the surgeon on a video screen. The surgeon, who needs good hand-eye coordination, watches the image on the screen, enabling him or her to guide various instruments in the confined space of the uterus. These instruments can include a ball heated by an electrical current (called a rollerball), an electrically heated wire loop (called a resectoscope) or a laser. The procedure is referred to as an endometrial resection when the electrically heated ball or wire loop is used to produce electrocoagulation (also called diathermy) of the endometrium, and an endometrial ablation when heat from a laser is used. The rollerball method of endometrial resection destroys the endometrium by rolling the coagulating ball over it like a paint roller, the electrocoagulation loop removes or ploughs several furrows in it, and the laser vaporises it. In the case of endometrial ablation, light from the laser passes down an optical fibre inserted into the hysteroscope and the surgeon moves the tip of the laser to draw a fine beam of light across the endometrium. In radiofrequency ablation, high energy radio frequency waves are applied to the endometrium instead of the high energy laser beam. A thermal method of removing the endometrium which involves passing hot water into the uterus is also being developed. Early studies suggest it is just as effective as methods using laser or electrocoagulation and may have advantages over them in terms of safety.

Comparisons of the resectoscope and the laser suggest that the former is cheaper, more readily available in hospitals, faster to use, takes less time for doctors to become competent with, is more robust and results in fewer complications. As the techniques alter, however, claims to superiority may be short-lived. A study comparing the newer ablation technique of radiofrequency with endometrial resection claims the former is simpler to perform, less time-consuming and possibly safer. However its cost is higher and the success rate is comparable.

Women having these procedures can receive either a general anaesthetic or a local anaesthetic with light sedation, although, for the laser treatment, a general anaesthetic is currently the norm. A few women bleed heavily immediately after the operation; but, for most, light post-operative bleeding gradually turns into a light discharge that disappears completely over about four to six weeks. Periods may continue, and in most cases they are light. Most women are in hospital for a day or overnight, and many have resumed work within a week or two. A year after an endometrial ablation or resection, about 85% of women report having reduced their use of sanitary pads or tampons by more than half; some have no bleeding at all, while for others heavy bleeding is still a problem. Looked at over a ten-year time frame, there is still a dearth of data.

The endometrium is well-known for its regenerative powers, provoking speculation that removing the endometrium is just ‘one more operation of doubtful value* that women are being encouraged to have. One study of more than 400 women who had endometrial resections for fibroids, endometriosis or adenomyosis found that about 20% developed a recurrence of heavy bleeding within four years, in some cases within a few months of the procedure.10 Some of these women chose to have the procedure repeated but, after a second try, about 40% of this group were still having bleeding problems. Overall, about one in every eight women who had an endometrial resection ended up having a hysterectomy within four years. Women who had a repeat resection were even more likely to resort to hysterectomy, with more than one in three such women eventually having the operation.

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