Thursday, June 14, 2007
A CUT BELOW
Clearly, for some parents, circumcision of their male children is a religious requirement. For others it is a matter of choice, hopefully after some informed decision-making with a medical professional.
What is not clear is why, after maybe four millennia of men getting along fine with or without a foreskin, a debate rages over the health consequences of what is basically a simple cosmetic procedure. Is this debate just another form of earlier conflicts over circumcision as an identification with antagonistic religious groups, or is it driven by a misinformed and mistaken view of anatomy, physiology, and psychology?
In order to judge the value of arguments for and against, we must understand what circumcision is. Most males are born with an extension of skin from the shaft of the penis, known as the prepuce, which covers all or most of the tip of the penis (glans), which includes the opening of the urinary tube (urethra). This skin is generally loose, and generally slides back on its own somewhat when the penis becomes erect, though in young boys (6 years and under) it may be too inflexible to pull back comfortably. Almost all uncircumcised men can urinate comfortably without having to pull back on the prepuce.
The underside of the skin (against the skin of the glans) has mucus cells and tends to secrete a small amount of lubricating mucus, combined with some sweat and skin cells which forms a whitish goo, called smegma, that keeps the skin surfaces from chafing. There are no large blood vessels in the prepuce, which has instead a network of tiny arteries, capillaries, and veins. During erection, the prepuce fills with blood and swells, though generally not as much as the other penile tissues.
The nerve supply in the prepuce (and glans) is similar to most other skin areas of the body. In other words, the area is sensitive but not as much as, say, fingertips, soles of the feet, or lips.
Surgically removing the prepuce basically uncovers the glans permanently and removes the mucus secretion. Because there are no large blood vessels, doing the procedure to an infant generally requires no special technique to stop the bleeding other than crimping the cut edges (before cutting) or applying a bandage with slight pressure. For older boys and adult men, most often dissolving sutures are used to bring together the cut edges of the wound. When healed there is often some residual loose skin, which may stretch out to a thin layer during erection.
As surgeries go, infant circumcision is relatively simple (even a pediatrician can do it!) and highly successful. The risks of bleeding, infection, and botched surgery are present but extremely small when the procedure is performed by an experienced and skilled practitioner using good aseptic technique. Of course, no one should routinely circumcise a sick baby or one with a congenital malformation of the penis
Reversing a circumcision is highly complicated and never completely possible. Practically speaking, it is a one-way street.
That brings up one of the most fundamental questions in the debate over infant circumcision: Do parents have a right to impose a non-essential cosmetic surgery on their baby boys?
Since American law accepts that parents have a right to abort their unborn fetuses, as well as to decide where, what, when, and how their born children eat, sleep, get an education, it seems logical that the decision to circumcise or not rests with the parents – as long as circumcision is not intrinsically harmful.
If harm means pain, then circumcision (along with immunizations, ear piercing, and delay in feeding) is problematic since it hurts. Ample evidence exists to show that babies react to circumcision the same way as they do to other potentially painful stimuli: heart rate and blood pressure increase, they fidget and frown, and – in case you’ve never noticed – they cry. Measures to relieve pain – local anesthetic injected below the skin at the base of the penis, analgesic cream applied directly to the foreskin, sucking on a pacifier (or the Jewish favorite, a wine-soaked piece of gauze) – are all somewhat effective in reducing the stress reactions, though it is sometimes uncertain if they primarily relieve the adult observers rather than the babies themselves.
Of course, adults don’t like to see babies in any distress. One can see sympathetic grimaces and an undertone of “Ooh!”s in a room of adults witnessing a circumcision, often louder and more intense than the baby’s squeals. Normal, caring adults tend to project their own anxiety about pain and suffering onto the behavior of the little ones, for whom they feel a need to protect.
At any rate, as best as we can tell in a pre-verbal infant, there is pain with circumcision. As mentioned above, the foreskin does not have an over-abundance of sensory nerves, so most grown men who have circumcisions are sore for only 3-7 days afterwards. Arguments have been made that babies are excessively fussy or clingy for weeks after circumcision, but there is no reliable evidence to support this; most babies feed, sleep, pee and poop normally within a few hours of the procedure.
And NO ONE REMEMBERS THE PAIN OF BEING CIRCUMCISED AS A BABY!
Anyone who claims as an adult that he remembers his circumcision as a baby is delusional, demented, or deceiving.
Therefore, in the big picture of pain management, a baby that has temporary pain which produces no memory trace ends up the same as one who never had the pain at all.
So what other harm can come from circumcision?
Disfigurement? Probably a matter of esthetic values (notice I avoided the word “taste” there). Should be weighed against the desire to look the same as other men in the family or tribe. At any rate, since in most civilized societies penises are not publicly displayed, one can easily hide any embarrassment from a circumcision (or lack thereof).
Sexual dysfunction? Much has been written about “decreased sensitivity” of the head of the penis, leading to decreased sexual response in circumcised men, but it is not logical to use a before- and after- comparison in men who have no memory of having a foreskin. To date, there is no reliable evidence of decreased sensitivity nor of sexual dysfunction overall in circumcised men compared to non-circumcised, nor has there been any reliable statistical analysis of the difference in sexual response of their partners. Most of the mythology regarding this issue emanates from medieval religious writings, spiced with the wildly conjectural focus on sex in contemporary Western society since the 1960’s. But no real data.
Balance the highly speculative “loss of sensation” with the very real and not uncommon development of phimosis in adult men, a condition in which the foreskin becomes constricted and inflexible and cannot be pulled back. Many conditions such as infection and connective-tissue disease can cause phimosis, which occurs in about 1 in 1000 uncircumcised men. It frequently causes significant discomfort with erection, sexual dysfunction, and, in severe cases, obstruction of the flow of urine. It can be improved with application of steroid creams, treatment of an underlying condition, or partial surgery, but circumcision is the most reliable treatment and essentially cures the problem.
Preventing foreskin problems is fairly simple, requiring only good skin hygiene, washing off excessive smegma from time to time, having adequate lubrication for sexual intercourse, and avoiding high-risk sex. Although many cases of foreskin infection (“ballanitis” ) can be prevented by these measures, care of the head of the penis is generally simpler after circumcision, which also decreases the rate of penetration into the body by HIV or cancer-causing human papilloma virus. Currently, circumcision is considered one of the most powerful ways to prevent the spread of HIV in Africa.
What’s left in the debate over circumcision, and this has always been the case, is a fairly even balance between the risk of doing the procedure in the first place and the benefits of a possibly healthier penis. It’s a tie, and not only do parents have a choice, but they must look to other reasons – religious, cultural, esthetic, but not medical -- to guide their decisions. Parents who think it is simply wrong to make such a decision for their baby need to realize that if, after growing up, their son wants to be circumcised, he faces a much more difficult and painful operation.
Clearly, for some parents, circumcision of their male children is a religious requirement. For others it is a matter of choice, hopefully after some informed decision-making with a medical professional.
What is not clear is why, after maybe four millennia of men getting along fine with or without a foreskin, a debate rages over the health consequences of what is basically a simple cosmetic procedure. Is this debate just another form of earlier conflicts over circumcision as an identification with antagonistic religious groups, or is it driven by a misinformed and mistaken view of anatomy, physiology, and psychology?
In order to judge the value of arguments for and against, we must understand what circumcision is. Most males are born with an extension of skin from the shaft of the penis, known as the prepuce, which covers all or most of the tip of the penis (glans), which includes the opening of the urinary tube (urethra). This skin is generally loose, and generally slides back on its own somewhat when the penis becomes erect, though in young boys (6 years and under) it may be too inflexible to pull back comfortably. Almost all uncircumcised men can urinate comfortably without having to pull back on the prepuce.
The underside of the skin (against the skin of the glans) has mucus cells and tends to secrete a small amount of lubricating mucus, combined with some sweat and skin cells which forms a whitish goo, called smegma, that keeps the skin surfaces from chafing. There are no large blood vessels in the prepuce, which has instead a network of tiny arteries, capillaries, and veins. During erection, the prepuce fills with blood and swells, though generally not as much as the other penile tissues.
The nerve supply in the prepuce (and glans) is similar to most other skin areas of the body. In other words, the area is sensitive but not as much as, say, fingertips, soles of the feet, or lips.
Surgically removing the prepuce basically uncovers the glans permanently and removes the mucus secretion. Because there are no large blood vessels, doing the procedure to an infant generally requires no special technique to stop the bleeding other than crimping the cut edges (before cutting) or applying a bandage with slight pressure. For older boys and adult men, most often dissolving sutures are used to bring together the cut edges of the wound. When healed there is often some residual loose skin, which may stretch out to a thin layer during erection.
As surgeries go, infant circumcision is relatively simple (even a pediatrician can do it!) and highly successful. The risks of bleeding, infection, and botched surgery are present but extremely small when the procedure is performed by an experienced and skilled practitioner using good aseptic technique. Of course, no one should routinely circumcise a sick baby or one with a congenital malformation of the penis
Reversing a circumcision is highly complicated and never completely possible. Practically speaking, it is a one-way street.
That brings up one of the most fundamental questions in the debate over infant circumcision: Do parents have a right to impose a non-essential cosmetic surgery on their baby boys?
Since American law accepts that parents have a right to abort their unborn fetuses, as well as to decide where, what, when, and how their born children eat, sleep, get an education, it seems logical that the decision to circumcise or not rests with the parents – as long as circumcision is not intrinsically harmful.
If harm means pain, then circumcision (along with immunizations, ear piercing, and delay in feeding) is problematic since it hurts. Ample evidence exists to show that babies react to circumcision the same way as they do to other potentially painful stimuli: heart rate and blood pressure increase, they fidget and frown, and – in case you’ve never noticed – they cry. Measures to relieve pain – local anesthetic injected below the skin at the base of the penis, analgesic cream applied directly to the foreskin, sucking on a pacifier (or the Jewish favorite, a wine-soaked piece of gauze) – are all somewhat effective in reducing the stress reactions, though it is sometimes uncertain if they primarily relieve the adult observers rather than the babies themselves.
Of course, adults don’t like to see babies in any distress. One can see sympathetic grimaces and an undertone of “Ooh!”s in a room of adults witnessing a circumcision, often louder and more intense than the baby’s squeals. Normal, caring adults tend to project their own anxiety about pain and suffering onto the behavior of the little ones, for whom they feel a need to protect.
At any rate, as best as we can tell in a pre-verbal infant, there is pain with circumcision. As mentioned above, the foreskin does not have an over-abundance of sensory nerves, so most grown men who have circumcisions are sore for only 3-7 days afterwards. Arguments have been made that babies are excessively fussy or clingy for weeks after circumcision, but there is no reliable evidence to support this; most babies feed, sleep, pee and poop normally within a few hours of the procedure.
And NO ONE REMEMBERS THE PAIN OF BEING CIRCUMCISED AS A BABY!
Anyone who claims as an adult that he remembers his circumcision as a baby is delusional, demented, or deceiving.
Therefore, in the big picture of pain management, a baby that has temporary pain which produces no memory trace ends up the same as one who never had the pain at all.
So what other harm can come from circumcision?
Disfigurement? Probably a matter of esthetic values (notice I avoided the word “taste” there). Should be weighed against the desire to look the same as other men in the family or tribe. At any rate, since in most civilized societies penises are not publicly displayed, one can easily hide any embarrassment from a circumcision (or lack thereof).
Sexual dysfunction? Much has been written about “decreased sensitivity” of the head of the penis, leading to decreased sexual response in circumcised men, but it is not logical to use a before- and after- comparison in men who have no memory of having a foreskin. To date, there is no reliable evidence of decreased sensitivity nor of sexual dysfunction overall in circumcised men compared to non-circumcised, nor has there been any reliable statistical analysis of the difference in sexual response of their partners. Most of the mythology regarding this issue emanates from medieval religious writings, spiced with the wildly conjectural focus on sex in contemporary Western society since the 1960’s. But no real data.
Balance the highly speculative “loss of sensation” with the very real and not uncommon development of phimosis in adult men, a condition in which the foreskin becomes constricted and inflexible and cannot be pulled back. Many conditions such as infection and connective-tissue disease can cause phimosis, which occurs in about 1 in 1000 uncircumcised men. It frequently causes significant discomfort with erection, sexual dysfunction, and, in severe cases, obstruction of the flow of urine. It can be improved with application of steroid creams, treatment of an underlying condition, or partial surgery, but circumcision is the most reliable treatment and essentially cures the problem.
Preventing foreskin problems is fairly simple, requiring only good skin hygiene, washing off excessive smegma from time to time, having adequate lubrication for sexual intercourse, and avoiding high-risk sex. Although many cases of foreskin infection (“ballanitis” ) can be prevented by these measures, care of the head of the penis is generally simpler after circumcision, which also decreases the rate of penetration into the body by HIV or cancer-causing human papilloma virus. Currently, circumcision is considered one of the most powerful ways to prevent the spread of HIV in Africa.
What’s left in the debate over circumcision, and this has always been the case, is a fairly even balance between the risk of doing the procedure in the first place and the benefits of a possibly healthier penis. It’s a tie, and not only do parents have a choice, but they must look to other reasons – religious, cultural, esthetic, but not medical -- to guide their decisions. Parents who think it is simply wrong to make such a decision for their baby need to realize that if, after growing up, their son wants to be circumcised, he faces a much more difficult and painful operation.
Labels: bris, brit, circumcision, foreskin, milah
Sunday, December 24, 2006
"It's my sinuses, doc . . ."
I can assure you, 100 years ago, maybe only 60 years ago, no one going to the doctor described their chief complaint as "sinus." The concept of a sinus infection, or sinusitis, or even the existence of the paranasal sinuses themselves was not something the general public held at their fingertips. In those good old days, common folks would summarize their upper respiratory syndromes as a cold or the grippe or ague or catarrh or influenza. Or they might give a symptomatic description (which is what doctors really want to hear), such as a runny nose, a fever, sore throat, cough.
Then in the late 1950's and early '60's, paralleling the rise of otolaryngology ("ears, nose , & throat") as a surgical specialty, people started seeing animated heads with outlines of the paranasal sinuses on just about every third TV commercial. Suddenly, the poor little sinuses bore the blame for every aggravated episode of stuffy or runny nose, and sinuses became part of our national consciousness. And every over-the-counter cold concoction known to man had to have the word "SINUS" emblazoned on its label to be considered a serious medicine.
But before I get to explaining the truth, let's see what you readers out there know about the "sinus" concept that you constantly invoke in the presence of your doctor. Take the SINUS QUIZ:
1. What does the word "sinus" mean?
2. Where are the sinuses?
3. Why are they there?
4. What's in the sinuses?
5. How does it get there?
6. How can you tell if the sinuses are infected?
7. What's the best way to treat it?
Give yourself a point for each correct answer. 4 is a passing grade. Don't worry, you probably failed.
Here goes:
Those sinuses are cavities, open spaces -- that's what the term means -- in your skull. They're there because air is lighter than bone, and a skull made of solid bone would put a powerful burden on our neck muscles. Therefore there are airspaces in the frontal bones (above the eyebrows), the maxillary (cheek) bones -- OK, you knew that -- but also directly behind the nose (ethmoid), behind the eyes (sphenoid), and behind and above the ears (mastoid). Even the middle ear (internal to the eardrum) is a kind of sinus cavity. Yes, we are all airheads -- at least, we're supposed to be.
The air that fills the sinuses, of course, comes from the outside. All the skull airspaces get air from openings in the nose, three in each nostril, plus the internal auditory canals (Eustachion tubes) to the middle ear, which open in the post-nasal passage. The openings are only about a 16th of an inch wide, but enough to let air flow in and out constantly.
Lining the inner surface of the sinuses is a living membrane identical to the moist inner surface of the nose. It secretes a thin layer of mucus and contains cells with little filaments (cilia) that move the mucus along, as well as immune-system cells which secrete histamine in response to allergic stimuli or other noxious things in the air.
If the air openings get blocked, the air in the sinuses gets slowly absorbed by the membranes, while the mucus builds up. Since the whole system is open to the outside, bacteria can potentially get in and, given three or four days, multiply within the goo to the point of causing a pressurized pocket of pus.
Looking at a patient's face, peering in the nose, pressing or tapping on the facial bones or shining a bright light across them cannot really tell a doctor if the sinuses are clogged (even though we commonly go through these motions). Certainly, hearing the patient complain about a clogged or runny nose, a pain in the head or face, feeling run down, feverish, etc. etc, etc. doesn't mean the sinuses are not functioning well. The only reliable way to tell if a sinus is abnormally clogged (short of sticking a sinus endoscope into them) is to get an xray, preferably a CT or MRI scan (which are often faster, much clearer, and not much more expensive than plain xrays).
Furthermore, clogged sinuses may not be infected, but rather partially occluded by a thickened inner membrane, in the same way the nose itself reacts to allergies. And if infected, the infection may be with viruses, which do not respond to anti-bacterial antibiotics, and generally get better without treatment in 7-14 days. Although this last point has been debated by researchers for at least 2 decades, the latest and most reliable studies indicate that only about 5% of upper respiratory infections involve pathogenic bacteria in the sinuses.
Even though 95% of people with any form of cold think they need an antibiotic for their sinuses.
What they need is to make sure the mucus is flowing, because any build-up of infected fluid in a body cavity needs to drain in order to heal. The commonly-used cold-symptom medications all contain a decongestant -- these days the behind-the-counter-but-not-needing-a-prescription pseudophedrine -- which makes mucus less liquidy, thus making the nose feel drier.
This, of course, is a terrible, TERRIBLE way to treat sinus congestion, because it virtually guarantees that mucus will be too thick to flow. By the time patients call me for their "sinus infection" each and every one of them has been taking these worthless preps, from Nyquil to Dayquil to XYZ-Cold-and-Sinus-D (Non-Drowsy Formula!), and have successfully converted a transient annoyance into a sub-acute misery.
What helps mucus flow? Drinking enough fluids helps. Tea, hot soup, or just inhaling some steam is useful. A sterile salt-water nasal spray can be of some benefit, while decongestant sprays (Afrin, etc), plain-old camphor (Vap-O-Rub) or ammonia-based sniffers cause too much irritation to the mucus membrane to help in the short run, and will worsen the condition if used too long.
Guaifenisin, an iodinated compound taken orally, will help if taken in large enough quantities. It's the active ingredient of all expectorants, such as Robitussin, but you'd have to drink an entire 4-ounce bottle of the stuff every day to get a therapeutic dose. Better to take a few concentrated (600 mg) guaifenisin tablets such as Mucinex daily for a week or two.
(NOTE--combinations of guaifenisin and pseudophedrine, which you'll find everywhere, don't make sense and don't work. Plain guaifenisin is what you want.)
When the nose is running -- no matter if the mucus is clear, yellow, green, brown, or bloody -- the sinus cavities will stay aerated. When you try to dry up the runny nose, you risk clogging up the sinus.
If the mucus membranes are thickened by constant nasal allergies or a series of rapid-succession viral colds, the best remedy is a cortico-steroid, either by a long (weeks or months) course of nasal spray or a short (a week or less) course of pills. They cool down the inflammation and shrink the swollen tissues without drying up mucus. Used properly (which means, by the way, NOT injecting them with a needle into the nose) they are virtually harmless, but I've had the hardest time convincing some patients of that. Lots of folks wouldn't think twice of taking pseudophedrine, which is far more dangerous and ineffective, than the steroid that would help them because of an irrationally-perpetuated fear of steroids.
And finally, remember that tobacco and, yes, even marijuana causes the cilia which push mucus along, to stop working, and when that smoke gets up into the sinuses (which it will), the mucus stagnates, just as it does in the depths of a smoker's lungs. Don't complain to me about your sinuses if you're smoking or putting other substances up your nose.
So don't blame the poor sinuses for every headache or cold you get. Don't use Sudafed or anything like it, take some plain Tylenol or ibuprofen for the headache, drink some tea, take some Mucinex if you have to, and go right ahead and blow that nose. Don't ask for unnecessary antibiotics, don't be afraid to take properly-prescribed steroids, get the CT scan when your doctor orders it. The next time you provide a chief complaint say something like "My head hurts and my nose runs"; stay away from the S-word.
I can assure you, 100 years ago, maybe only 60 years ago, no one going to the doctor described their chief complaint as "sinus." The concept of a sinus infection, or sinusitis, or even the existence of the paranasal sinuses themselves was not something the general public held at their fingertips. In those good old days, common folks would summarize their upper respiratory syndromes as a cold or the grippe or ague or catarrh or influenza. Or they might give a symptomatic description (which is what doctors really want to hear), such as a runny nose, a fever, sore throat, cough.
Then in the late 1950's and early '60's, paralleling the rise of otolaryngology ("ears, nose , & throat") as a surgical specialty, people started seeing animated heads with outlines of the paranasal sinuses on just about every third TV commercial. Suddenly, the poor little sinuses bore the blame for every aggravated episode of stuffy or runny nose, and sinuses became part of our national consciousness. And every over-the-counter cold concoction known to man had to have the word "SINUS" emblazoned on its label to be considered a serious medicine.
But before I get to explaining the truth, let's see what you readers out there know about the "sinus" concept that you constantly invoke in the presence of your doctor. Take the SINUS QUIZ:
1. What does the word "sinus" mean?
2. Where are the sinuses?
3. Why are they there?
4. What's in the sinuses?
5. How does it get there?
6. How can you tell if the sinuses are infected?
7. What's the best way to treat it?
Give yourself a point for each correct answer. 4 is a passing grade. Don't worry, you probably failed.
Here goes:
Those sinuses are cavities, open spaces -- that's what the term means -- in your skull. They're there because air is lighter than bone, and a skull made of solid bone would put a powerful burden on our neck muscles. Therefore there are airspaces in the frontal bones (above the eyebrows), the maxillary (cheek) bones -- OK, you knew that -- but also directly behind the nose (ethmoid), behind the eyes (sphenoid), and behind and above the ears (mastoid). Even the middle ear (internal to the eardrum) is a kind of sinus cavity. Yes, we are all airheads -- at least, we're supposed to be.
The air that fills the sinuses, of course, comes from the outside. All the skull airspaces get air from openings in the nose, three in each nostril, plus the internal auditory canals (Eustachion tubes) to the middle ear, which open in the post-nasal passage. The openings are only about a 16th of an inch wide, but enough to let air flow in and out constantly.
Lining the inner surface of the sinuses is a living membrane identical to the moist inner surface of the nose. It secretes a thin layer of mucus and contains cells with little filaments (cilia) that move the mucus along, as well as immune-system cells which secrete histamine in response to allergic stimuli or other noxious things in the air.
If the air openings get blocked, the air in the sinuses gets slowly absorbed by the membranes, while the mucus builds up. Since the whole system is open to the outside, bacteria can potentially get in and, given three or four days, multiply within the goo to the point of causing a pressurized pocket of pus.
Looking at a patient's face, peering in the nose, pressing or tapping on the facial bones or shining a bright light across them cannot really tell a doctor if the sinuses are clogged (even though we commonly go through these motions). Certainly, hearing the patient complain about a clogged or runny nose, a pain in the head or face, feeling run down, feverish, etc. etc, etc. doesn't mean the sinuses are not functioning well. The only reliable way to tell if a sinus is abnormally clogged (short of sticking a sinus endoscope into them) is to get an xray, preferably a CT or MRI scan (which are often faster, much clearer, and not much more expensive than plain xrays).
Furthermore, clogged sinuses may not be infected, but rather partially occluded by a thickened inner membrane, in the same way the nose itself reacts to allergies. And if infected, the infection may be with viruses, which do not respond to anti-bacterial antibiotics, and generally get better without treatment in 7-14 days. Although this last point has been debated by researchers for at least 2 decades, the latest and most reliable studies indicate that only about 5% of upper respiratory infections involve pathogenic bacteria in the sinuses.
Even though 95% of people with any form of cold think they need an antibiotic for their sinuses.
What they need is to make sure the mucus is flowing, because any build-up of infected fluid in a body cavity needs to drain in order to heal. The commonly-used cold-symptom medications all contain a decongestant -- these days the behind-the-counter-but-not-needing-a-prescription pseudophedrine -- which makes mucus less liquidy, thus making the nose feel drier.
This, of course, is a terrible, TERRIBLE way to treat sinus congestion, because it virtually guarantees that mucus will be too thick to flow. By the time patients call me for their "sinus infection" each and every one of them has been taking these worthless preps, from Nyquil to Dayquil to XYZ-Cold-and-Sinus-D (Non-Drowsy Formula!), and have successfully converted a transient annoyance into a sub-acute misery.
What helps mucus flow? Drinking enough fluids helps. Tea, hot soup, or just inhaling some steam is useful. A sterile salt-water nasal spray can be of some benefit, while decongestant sprays (Afrin, etc), plain-old camphor (Vap-O-Rub) or ammonia-based sniffers cause too much irritation to the mucus membrane to help in the short run, and will worsen the condition if used too long.
Guaifenisin, an iodinated compound taken orally, will help if taken in large enough quantities. It's the active ingredient of all expectorants, such as Robitussin, but you'd have to drink an entire 4-ounce bottle of the stuff every day to get a therapeutic dose. Better to take a few concentrated (600 mg) guaifenisin tablets such as Mucinex daily for a week or two.
(NOTE--combinations of guaifenisin and pseudophedrine, which you'll find everywhere, don't make sense and don't work. Plain guaifenisin is what you want.)
When the nose is running -- no matter if the mucus is clear, yellow, green, brown, or bloody -- the sinus cavities will stay aerated. When you try to dry up the runny nose, you risk clogging up the sinus.
If the mucus membranes are thickened by constant nasal allergies or a series of rapid-succession viral colds, the best remedy is a cortico-steroid, either by a long (weeks or months) course of nasal spray or a short (a week or less) course of pills. They cool down the inflammation and shrink the swollen tissues without drying up mucus. Used properly (which means, by the way, NOT injecting them with a needle into the nose) they are virtually harmless, but I've had the hardest time convincing some patients of that. Lots of folks wouldn't think twice of taking pseudophedrine, which is far more dangerous and ineffective, than the steroid that would help them because of an irrationally-perpetuated fear of steroids.
And finally, remember that tobacco and, yes, even marijuana causes the cilia which push mucus along, to stop working, and when that smoke gets up into the sinuses (which it will), the mucus stagnates, just as it does in the depths of a smoker's lungs. Don't complain to me about your sinuses if you're smoking or putting other substances up your nose.
So don't blame the poor sinuses for every headache or cold you get. Don't use Sudafed or anything like it, take some plain Tylenol or ibuprofen for the headache, drink some tea, take some Mucinex if you have to, and go right ahead and blow that nose. Don't ask for unnecessary antibiotics, don't be afraid to take properly-prescribed steroids, get the CT scan when your doctor orders it. The next time you provide a chief complaint say something like "My head hurts and my nose runs"; stay away from the S-word.
Monday, November 06, 2006
SORE FEET
Anyone who has ever stubbed his/her toe knows that our feet are vulnerable to injury. Therefore, since before recorded history, humans have worn shoes. What seems to be a modern medical novelty is the amount of foot damage caused by the very shoes we wear to protect our feet--and all because of a basic misunderstanding about our feet.
Shoes cause damage primarily by being too tight and too hard. If the toes are mushed together, the larger toenails will tend to grow into the surrounding skin, causing painful infections; the large toes will be pushed toward the outer (lateral) side of the foot, causing a permanent bony deviation known as a bunion; the outer foot will develop calluses; the middle toes will deviate up and down, causing more calluses, nail problems, and, ultimately, a foot so misshapened that it doesn't fit into any shoe.
To compensate for the pain and imbalance of a damaged foot, a person will twist the lower leg and apply more pressure to the other foot when standing or walking, thus putting more stress on knees, hips, and low back. Every part of the body will start to feel the strain of not standing properly on two feet. All from shoes that are too tight.
Solution? GET BIGGER SHOES!!
It really is as simple as that. It will prevent feet from being damaged, and even for already-damaged feet, alleviate some pain.
So why doesn't everybody do that? Why are chronic foot injuries from improper shoes so prevalent that corrective podiatric surgery to is on the rise every year? There are several reasons, facts that people never learned, forgot, or got wrong from the beginning:
1. Feet don't stay one size. Throughout one's life, even after attaining one's full adult height and weight, the feet tend to get bigger. Therefore, when buying shoes, one has to constantly remeasure the feet with the expectation that they may be longer and wider than expected.
2. Shoes are not precisely built to size. If a certain shoe says it is a size 10 but feels too tight to be a size 10, it's entirely possible that it isn't a size "10," so don't try to cram your foot into it!! Give it up, get a larger size--don't blame your foot or the socks or the "new leather" or whatever. Give your feet the benefit of the doubt and don't try to kill them just because you are convinced that they should fit a particular shoe. Whatever you do, don't accept a pair of tight shoes just because the salesperson says they're the right size for you; believe it or not, this may be a ploy to get a quick sale.
3. Shoes do not have to be tight to be useful. Extra space in a shoe can be filled with thicker socks, which are soft and pliable, allowing the toes to move (if your toes cannot spread apart within the shoe, the shoe is too small).
4. One pair of shoes cannot be used for all activities. Kids who go everywhere and do everything in one pair of sports shoes almost always end up with skin and nail problems in their feet, since the shoe they wear for walking and standing is not going to be big enough for running and jumping (which require more room in the heel and toe and usually more flexibility of the sole) and the interior of these shoes become very moist from sweat. Workers who have to wear steel-toed shoes cannot expect their feet to enjoy walking long distances in them. The inconvenience and cost of changing shoes for different occasions is always going to be outweighed by the benefit of keeping the feet comfortable.
4. Style must be secondary to comfort. It never pays to hurt your feet just to be able to show them in a particular pair of shoes. No human should ever walk about in high heels.
Again, don't be fooled by unscrupulous shoe salesmen: they will tell you anything in order to sell a pair of shoes quickly!
5. Any other padding you give your feet, such as thick socks, inserts and heel cushions, will probably help, and your shoes should be big enough to accomodate them. Don't hang on to a pair of shoes you can only wear with thin socks or nylons.
6. Whenever you can walk around comfortably without shoes, you should take off your shoes and give your feet a break. Bunions do not occur in people who walk barefoot.
Anyone who has ever stubbed his/her toe knows that our feet are vulnerable to injury. Therefore, since before recorded history, humans have worn shoes. What seems to be a modern medical novelty is the amount of foot damage caused by the very shoes we wear to protect our feet--and all because of a basic misunderstanding about our feet.
Shoes cause damage primarily by being too tight and too hard. If the toes are mushed together, the larger toenails will tend to grow into the surrounding skin, causing painful infections; the large toes will be pushed toward the outer (lateral) side of the foot, causing a permanent bony deviation known as a bunion; the outer foot will develop calluses; the middle toes will deviate up and down, causing more calluses, nail problems, and, ultimately, a foot so misshapened that it doesn't fit into any shoe.
To compensate for the pain and imbalance of a damaged foot, a person will twist the lower leg and apply more pressure to the other foot when standing or walking, thus putting more stress on knees, hips, and low back. Every part of the body will start to feel the strain of not standing properly on two feet. All from shoes that are too tight.
Solution? GET BIGGER SHOES!!
It really is as simple as that. It will prevent feet from being damaged, and even for already-damaged feet, alleviate some pain.
So why doesn't everybody do that? Why are chronic foot injuries from improper shoes so prevalent that corrective podiatric surgery to is on the rise every year? There are several reasons, facts that people never learned, forgot, or got wrong from the beginning:
1. Feet don't stay one size. Throughout one's life, even after attaining one's full adult height and weight, the feet tend to get bigger. Therefore, when buying shoes, one has to constantly remeasure the feet with the expectation that they may be longer and wider than expected.
2. Shoes are not precisely built to size. If a certain shoe says it is a size 10 but feels too tight to be a size 10, it's entirely possible that it isn't a size "10," so don't try to cram your foot into it!! Give it up, get a larger size--don't blame your foot or the socks or the "new leather" or whatever. Give your feet the benefit of the doubt and don't try to kill them just because you are convinced that they should fit a particular shoe. Whatever you do, don't accept a pair of tight shoes just because the salesperson says they're the right size for you; believe it or not, this may be a ploy to get a quick sale.
3. Shoes do not have to be tight to be useful. Extra space in a shoe can be filled with thicker socks, which are soft and pliable, allowing the toes to move (if your toes cannot spread apart within the shoe, the shoe is too small).
4. One pair of shoes cannot be used for all activities. Kids who go everywhere and do everything in one pair of sports shoes almost always end up with skin and nail problems in their feet, since the shoe they wear for walking and standing is not going to be big enough for running and jumping (which require more room in the heel and toe and usually more flexibility of the sole) and the interior of these shoes become very moist from sweat. Workers who have to wear steel-toed shoes cannot expect their feet to enjoy walking long distances in them. The inconvenience and cost of changing shoes for different occasions is always going to be outweighed by the benefit of keeping the feet comfortable.
4. Style must be secondary to comfort. It never pays to hurt your feet just to be able to show them in a particular pair of shoes. No human should ever walk about in high heels.
Again, don't be fooled by unscrupulous shoe salesmen: they will tell you anything in order to sell a pair of shoes quickly!
5. Any other padding you give your feet, such as thick socks, inserts and heel cushions, will probably help, and your shoes should be big enough to accomodate them. Don't hang on to a pair of shoes you can only wear with thin socks or nylons.
6. Whenever you can walk around comfortably without shoes, you should take off your shoes and give your feet a break. Bunions do not occur in people who walk barefoot.
Sunday, October 29, 2006
OK, this little Jeremiad (call it what you will) shows more than a bit frustration and a measure of pique that some readers will find, well, unattractive. I wrote it years ago, and it has not received favorable local reviews, but I stand by the truths therein, and the truth sometimes hurts. So now you know how I really feel.
At least, most of my medical colleagues will likely agree.
Why Your Doctor Doesn't Spend More Time With You
Since the 1970's, when the image of doctors first began to decline, polls of patients have revealed a general perception that doctors cut short their time spent with their customers, to the detriment of patient health. Patients questioned after meeting with their doctors, whether in an office, a clinic, or a hospital room, almost uniformly feel that they were short-shrifted, that the doctor came in and left in a flash. The implication is that the doctor is uncaring, is missing vital information, is greedy.
But the truth is that doctors, like any other professionals, regard patients as jobs, as work to be done, as problems to be solved. Doctors assume, after all, that that is precisely what the patients want--someone to help them in a way they cannot help themselves. So, if the doctor spends enough time with their patients to do their job correctly, isn't that good enough?
Doctors who treat patients have to be able to do three tasks correctly: they have to listen and observe, retrieve and correlate information, and think (i.e.--put it all together logically, figure out the next step). Yes, they also have to perform (procedures), and, these days, to document (a process that often takes as long as all the others combined). And, of course, they have to communicate. It's this final task that is considered lacking in the modern medical doctor.
Why?
First of all, it is not entirely clear that the actual time and effort spent communicating with patients is lacking at all. In a clever study, patients questioned as they left the doctor's office thought the amount of time spent in the encounter with the doctor was much shorter than was actually measured. Other studies have repeatedly shown that patients immediately after leaving the doctors' office recalled less than half of what the doctors actually told them specifically to remember. So, who's to blame here when a patient walks out not knowing what medicine to take when, what the test results mean, where to go next?
I have resigned myself to the fact that many patients cannot grasp as simple a concept as a prescription to take a single pill once a day until they've been told this two or three times on different occasions. In educational psychology, the term is "blocking"; people can be mentally blocked from receiving information or instruction, and no amount of time, repetition, nor visual aids is always going to break through.
The irony, however, is that doctors receive (and often accept) the blame for this phenomenon; the patient never admits that he's simply oblivious. The clinical medical profession has spent enormous effort and money trying to solve this dilemma, so far to no avail. There are courses in how to communicate, training exercises, patient-education materials galore in every media, but nothing seems to help. It is a universal, cross-cultural phenomenon, not even restricted to the prima donna American patients. It's probably unsolvable.
When a doctor perceives that the patient just doesn't get it, the doctor is best advised to make sure the patient is made no worse by whichever course is taken, schedule another visit or punt the patient along to another doc, and move on to the next patient.
Furthermore, it is only important to do all this communicating, to empower the patient with information, if it makes a difference in the patient's health, isn't it? After all, (real) doctors are a poor choice for just entertainment. There has to be a reason for doctors to spend more time talking with their patients (and families), a provable difference in health outcome.
Certainly a doctor who spends less time visiting and more time studying the medical facts may be a better choice when it comes down to critical health problems.
Why do we long for the halcyon days when a doctor stayed at the bedside for hours and held the patients' hand?
Why do we value the alternative health professionals who are pleasantly chatty while providing scientifically worthless "treatment"?
Why do we regard a doctor who analyzes and decides quickly as callous, while a deliberate, unhurried doctor must be caring and compassionate?
What's really important here--the doctor's competence or compatability?
And, no, you can't always have both. Especially when you're very sick, your doctor does not want to spend all his time around you. The truth is no one does, since sickness is unpleasant, but at least your doctor has a vision of your returning to health or greater comfort and can stick with you until you achieve it. That's all you can or should expect. That's what you, through your insurance, pay your doctor for.
Get someone else to provide the comfort, to hold your hand and give you a hug and a "There, there . . ." (If you have no one else, you're really in sorry shape; call in a social worker.) Get your five minutes with the doctor and listen carefully!
If the doctor says, "Hmm!" and walks out without a word, don't worry--you'll be fine.
At least, most of my medical colleagues will likely agree.
Why Your Doctor Doesn't Spend More Time With You
Since the 1970's, when the image of doctors first began to decline, polls of patients have revealed a general perception that doctors cut short their time spent with their customers, to the detriment of patient health. Patients questioned after meeting with their doctors, whether in an office, a clinic, or a hospital room, almost uniformly feel that they were short-shrifted, that the doctor came in and left in a flash. The implication is that the doctor is uncaring, is missing vital information, is greedy.
But the truth is that doctors, like any other professionals, regard patients as jobs, as work to be done, as problems to be solved. Doctors assume, after all, that that is precisely what the patients want--someone to help them in a way they cannot help themselves. So, if the doctor spends enough time with their patients to do their job correctly, isn't that good enough?
Doctors who treat patients have to be able to do three tasks correctly: they have to listen and observe, retrieve and correlate information, and think (i.e.--put it all together logically, figure out the next step). Yes, they also have to perform (procedures), and, these days, to document (a process that often takes as long as all the others combined). And, of course, they have to communicate. It's this final task that is considered lacking in the modern medical doctor.
Why?
First of all, it is not entirely clear that the actual time and effort spent communicating with patients is lacking at all. In a clever study, patients questioned as they left the doctor's office thought the amount of time spent in the encounter with the doctor was much shorter than was actually measured. Other studies have repeatedly shown that patients immediately after leaving the doctors' office recalled less than half of what the doctors actually told them specifically to remember. So, who's to blame here when a patient walks out not knowing what medicine to take when, what the test results mean, where to go next?
I have resigned myself to the fact that many patients cannot grasp as simple a concept as a prescription to take a single pill once a day until they've been told this two or three times on different occasions. In educational psychology, the term is "blocking"; people can be mentally blocked from receiving information or instruction, and no amount of time, repetition, nor visual aids is always going to break through.
The irony, however, is that doctors receive (and often accept) the blame for this phenomenon; the patient never admits that he's simply oblivious. The clinical medical profession has spent enormous effort and money trying to solve this dilemma, so far to no avail. There are courses in how to communicate, training exercises, patient-education materials galore in every media, but nothing seems to help. It is a universal, cross-cultural phenomenon, not even restricted to the prima donna American patients. It's probably unsolvable.
When a doctor perceives that the patient just doesn't get it, the doctor is best advised to make sure the patient is made no worse by whichever course is taken, schedule another visit or punt the patient along to another doc, and move on to the next patient.
Furthermore, it is only important to do all this communicating, to empower the patient with information, if it makes a difference in the patient's health, isn't it? After all, (real) doctors are a poor choice for just entertainment. There has to be a reason for doctors to spend more time talking with their patients (and families), a provable difference in health outcome.
Certainly a doctor who spends less time visiting and more time studying the medical facts may be a better choice when it comes down to critical health problems.
Why do we long for the halcyon days when a doctor stayed at the bedside for hours and held the patients' hand?
Why do we value the alternative health professionals who are pleasantly chatty while providing scientifically worthless "treatment"?
Why do we regard a doctor who analyzes and decides quickly as callous, while a deliberate, unhurried doctor must be caring and compassionate?
What's really important here--the doctor's competence or compatability?
And, no, you can't always have both. Especially when you're very sick, your doctor does not want to spend all his time around you. The truth is no one does, since sickness is unpleasant, but at least your doctor has a vision of your returning to health or greater comfort and can stick with you until you achieve it. That's all you can or should expect. That's what you, through your insurance, pay your doctor for.
Get someone else to provide the comfort, to hold your hand and give you a hug and a "There, there . . ." (If you have no one else, you're really in sorry shape; call in a social worker.) Get your five minutes with the doctor and listen carefully!
If the doctor says, "Hmm!" and walks out without a word, don't worry--you'll be fine.
Monday, October 23, 2006
As the winter season gets into full gear, cold outside air and dry indoor heating make us start to scratch and scratch. This reminds me of an essay I wrote about 10 years ago for BUNK (the unpublished book).
Many, many Americans are walking around with dry itchy skin, for which they constantly seek medical attention.
Aside from those who work in sea water (like Polynesian divers or Hawaiian kayak paddlers you see on National Geographic TV shows), dry skin is entirely unnecessary, and may be the result of a strange advertising campaign aimed at the peculiar obsession with household cleanliness which Europeans imported to the U.S.
Remember that Twentieth Century culture was pervaded by efforts to sell detergent, a sulfhydryl compound of calcium carbonate (lime) which was popularized in the late 1800's as an alternative to soap (a sodium salt of organic fat). A lot of newspapers and electronic media were sold on the basis of advertising detergent, and, indeed, huge corporations developed on the backbone of clean clothes, clean floors, clean toilet bowls, and, ultimately, squeaky clean hair and skin. The cultural culmination of this obsession is the soap opera, a literary genre all its own (metaphorically with dirty intrigues by all sorts of clean-cut characters).
The detergentizing of the human body, however, is a physiologic nightmare for the skin, the largest organ of the body.
Skin is supposed to have a protective layer of sebum, an oily substance, which in turn covers layers of keratinized epithelium--dead superficial skin cells. It is a natural, virtually perfect covering that is flexible, water-proof, sun-screening, temperature-regulating, and attractively shaded. Without the oily covering, the dead cells rapidly deteriorate and flake off, exposing a live layer of quickly-reproducing epithelial cells and the supportive structures, such as blood vessels, fat, strands of muscle, pigmented cells, nerve endings, etc. These cell-layers, with nothing on top of them, will now work over-time to keep out the toxins of the external world, and will, therefore, overgrow with inflammatory cells and substances, taking on the red hue of blood, which looks bad and feels worse.
Once again a penchant for healthy cleanliness, taken too far, creates a health problem. But despite the evidence, advertising goes on and on, with bath soaps compared side by side to see which is more effective in cleaning glass.* Many of these soaps have trade names which conjure up images of nerves on end (Zest, Irish Spring), while others (Coast, Lifebuoy) recall the dried out skin of seafarers. The most ironic name in this class is Shield, which does all it can to destroy the shielding effect of the skin.
The skin of the scalp is oiler than that of the rest of the body, and the hair collects and retains this oil. Therefore, a little detergent in the form of shampoo is useful for the scalp, beard and genital areas (not under the arms, please), but "body shampoo" can be as harmful as detergent soaps. Live skin is not glass, and using a soap which leaves only squeak and no slick is a good way to end up at the doctor's.
* Indeed, the first use of Gamble's Soap was to clean up automobile windshields, a new invention of the late 1800's. A promoter named Proctor bought the patent and marketed the product as a body soap, naming it Ivory and emphasizing its purity as a sure sign that it is good for your health.
It's not.
Dry, Itchy Skin
Many, many Americans are walking around with dry itchy skin, for which they constantly seek medical attention.
Aside from those who work in sea water (like Polynesian divers or Hawaiian kayak paddlers you see on National Geographic TV shows), dry skin is entirely unnecessary, and may be the result of a strange advertising campaign aimed at the peculiar obsession with household cleanliness which Europeans imported to the U.S.
Remember that Twentieth Century culture was pervaded by efforts to sell detergent, a sulfhydryl compound of calcium carbonate (lime) which was popularized in the late 1800's as an alternative to soap (a sodium salt of organic fat). A lot of newspapers and electronic media were sold on the basis of advertising detergent, and, indeed, huge corporations developed on the backbone of clean clothes, clean floors, clean toilet bowls, and, ultimately, squeaky clean hair and skin. The cultural culmination of this obsession is the soap opera, a literary genre all its own (metaphorically with dirty intrigues by all sorts of clean-cut characters).
The detergentizing of the human body, however, is a physiologic nightmare for the skin, the largest organ of the body.
Skin is supposed to have a protective layer of sebum, an oily substance, which in turn covers layers of keratinized epithelium--dead superficial skin cells. It is a natural, virtually perfect covering that is flexible, water-proof, sun-screening, temperature-regulating, and attractively shaded. Without the oily covering, the dead cells rapidly deteriorate and flake off, exposing a live layer of quickly-reproducing epithelial cells and the supportive structures, such as blood vessels, fat, strands of muscle, pigmented cells, nerve endings, etc. These cell-layers, with nothing on top of them, will now work over-time to keep out the toxins of the external world, and will, therefore, overgrow with inflammatory cells and substances, taking on the red hue of blood, which looks bad and feels worse.
Once again a penchant for healthy cleanliness, taken too far, creates a health problem. But despite the evidence, advertising goes on and on, with bath soaps compared side by side to see which is more effective in cleaning glass.* Many of these soaps have trade names which conjure up images of nerves on end (Zest, Irish Spring), while others (Coast, Lifebuoy) recall the dried out skin of seafarers. The most ironic name in this class is Shield, which does all it can to destroy the shielding effect of the skin.
The skin of the scalp is oiler than that of the rest of the body, and the hair collects and retains this oil. Therefore, a little detergent in the form of shampoo is useful for the scalp, beard and genital areas (not under the arms, please), but "body shampoo" can be as harmful as detergent soaps. Live skin is not glass, and using a soap which leaves only squeak and no slick is a good way to end up at the doctor's.
* Indeed, the first use of Gamble's Soap was to clean up automobile windshields, a new invention of the late 1800's. A promoter named Proctor bought the patent and marketed the product as a body soap, naming it Ivory and emphasizing its purity as a sure sign that it is good for your health.
It's not.
Tuesday, October 17, 2006
Settling Your Stomach
Although unpleasant subjects, stomach and intestinal disorders are important to know about.
The sudden onset of cramps, diarrhea, nausea, and vomitting are among the most frequent afflictions in otherwise healthy people. For some reason, however, many people with these symptoms stop listening to their bodies and make the worst mistake possible--namely, they immediately try to put stuff, food and medicine, back into their stomachs.
The impetus for this behavior may well be the plethora of oral (and occasionally rectal) remedies for intestinal maladies, a situation as old as medicine itself. In some cases, it's a fear of dehydration or starvation. In every case it's wrong.
In developed countries, the cause of most acute diarrhea and vomitting is infection of the stomach and intestines by one of two common viruses (Rotavirus and Norwalk agent). Occasionally, it can be caused by bacteria (Salmonella, Shigella, and Campylobacter speces), by parasites (Giardia and others), by food tainted by bacterial growth (Staphylococcal food poisoning, so-called "ptomaine poisoning"), or by conditions of the intestinal tract itself (including chemical gastritis, gall stones, inflammatory bowel disease, appendicitis). In less-developed countries, infections with Typhus and even cholera still occur.
But regardless of the cause, when your body starts expelling the contents of the intestinal tract, it means that your body doesn't "want" what's in there. It's usually best to let your body do its thing--the vomitting and diarrhea slow down or stop as soon as you empty out. To let your mind overrule your body, just because you saw a recent PeptoBismol or Dramamine commercial, is not wise.
An irritable stomach will throw up anything you put in it, and the more you throw up, the more irritated it becomes. An infected or inflamed intestine loses its ability to reabsorb water, and the more you feed it, the less time it has to recover.
There is only one logical step in this situation: DON'T EAT!!
That's all--don't eat, don't even drink.
Ninety percent of patients can cure themselves if they take that first initial step, and the rest will make their condition much easier to manage. If you wonder how long a person can go without eating or drinking, it's likely to be much longer than you think. Certainly no one with a moderate level of activity gets into trouble by fasting for four or five hours, not even children, not even babies.
Most adults can safely avoid eating and drinking for up to twelve hours on a regular basis (remember that Hakeem Alajuwon, a seven-foot-two, three-hundred-pound star basketball player for the Houston Rockets played a championship series while fasting twelve hours daily for the month of Ramadan). Diabetics who check their blood sugar may be surprised to find that they do not get seriously hypoglycemic even with medication "on board." Most of us carry a calorie reserve that will sustain us for two to three days, and enough water in our blood stream for a whole day.
The second and perhaps more crucial step in aiding the recovery of your stomach and intestines is to replenish your water and food loss slowly and with the simplest and easiest-to-digest substances possible. The most readily available substances of this type are what we call clear liquids, i.e.--foods that are already in solution. This includes clear carbonated beverages (e.g.--ginger ale or 7-Up), clear soup broth, Italian ice or Popsicles, and gelatin, Gatorade, as well as a number of commercial products designed specifically to replace lost fluids (Pedialyte, Kao-Lectrolyte, and others).
These all provide water, sugar for energy, and salts which keep the cells functioning properly. They are clear because these simple chemicals are in solution.
If you cannot see through the liquid or food, it contains other substances such as fat (as in milk) or complex carbohyrates (as in oatmeal) or fiber (as in pulpy juice), which your stomach, in this situation, is not ready to tolerate. You start with clear liquids and continue until the nausea or diarrhea stops--usually for twelve to twenty-four hours. Though they are not particularly satisfying, clear liquids can sustain a person for days if necessary.
The next step is to try low-fiber complex carbohydrates--starchy foods such as rice, potatoes, bread, usually for a full day.
After that you can eat any fruits and vegetables, as well as low-fat meats, but no dairy products for another five days; it will take that long for your intestinal tract to tolerate lactose, the main sugar in most milk products. Even people who digest lactose can have a temporary lactose intolerance after a viral infection or some other assault on the intestinal tract, and drinking milk is the worse thing one can do in that situation.
If you respond to an episode of gastroenteritis by wolfing a ham-and-cheese sandwich and washing it down with a glass of milk, you're doomed to five more days of misery. Just rest your gut for a few hours, gently replace the water and salts with clear liquids, start foods gradually and stay away from milk--and you're better in no time.
Although unpleasant subjects, stomach and intestinal disorders are important to know about.
The sudden onset of cramps, diarrhea, nausea, and vomitting are among the most frequent afflictions in otherwise healthy people. For some reason, however, many people with these symptoms stop listening to their bodies and make the worst mistake possible--namely, they immediately try to put stuff, food and medicine, back into their stomachs.
The impetus for this behavior may well be the plethora of oral (and occasionally rectal) remedies for intestinal maladies, a situation as old as medicine itself. In some cases, it's a fear of dehydration or starvation. In every case it's wrong.
In developed countries, the cause of most acute diarrhea and vomitting is infection of the stomach and intestines by one of two common viruses (Rotavirus and Norwalk agent). Occasionally, it can be caused by bacteria (Salmonella, Shigella, and Campylobacter speces), by parasites (Giardia and others), by food tainted by bacterial growth (Staphylococcal food poisoning, so-called "ptomaine poisoning"), or by conditions of the intestinal tract itself (including chemical gastritis, gall stones, inflammatory bowel disease, appendicitis). In less-developed countries, infections with Typhus and even cholera still occur.
But regardless of the cause, when your body starts expelling the contents of the intestinal tract, it means that your body doesn't "want" what's in there. It's usually best to let your body do its thing--the vomitting and diarrhea slow down or stop as soon as you empty out. To let your mind overrule your body, just because you saw a recent PeptoBismol or Dramamine commercial, is not wise.
An irritable stomach will throw up anything you put in it, and the more you throw up, the more irritated it becomes. An infected or inflamed intestine loses its ability to reabsorb water, and the more you feed it, the less time it has to recover.
There is only one logical step in this situation: DON'T EAT!!
That's all--don't eat, don't even drink.
Ninety percent of patients can cure themselves if they take that first initial step, and the rest will make their condition much easier to manage. If you wonder how long a person can go without eating or drinking, it's likely to be much longer than you think. Certainly no one with a moderate level of activity gets into trouble by fasting for four or five hours, not even children, not even babies.
Most adults can safely avoid eating and drinking for up to twelve hours on a regular basis (remember that Hakeem Alajuwon, a seven-foot-two, three-hundred-pound star basketball player for the Houston Rockets played a championship series while fasting twelve hours daily for the month of Ramadan). Diabetics who check their blood sugar may be surprised to find that they do not get seriously hypoglycemic even with medication "on board." Most of us carry a calorie reserve that will sustain us for two to three days, and enough water in our blood stream for a whole day.
The second and perhaps more crucial step in aiding the recovery of your stomach and intestines is to replenish your water and food loss slowly and with the simplest and easiest-to-digest substances possible. The most readily available substances of this type are what we call clear liquids, i.e.--foods that are already in solution. This includes clear carbonated beverages (e.g.--ginger ale or 7-Up), clear soup broth, Italian ice or Popsicles, and gelatin, Gatorade, as well as a number of commercial products designed specifically to replace lost fluids (Pedialyte, Kao-Lectrolyte, and others).
These all provide water, sugar for energy, and salts which keep the cells functioning properly. They are clear because these simple chemicals are in solution.
If you cannot see through the liquid or food, it contains other substances such as fat (as in milk) or complex carbohyrates (as in oatmeal) or fiber (as in pulpy juice), which your stomach, in this situation, is not ready to tolerate. You start with clear liquids and continue until the nausea or diarrhea stops--usually for twelve to twenty-four hours. Though they are not particularly satisfying, clear liquids can sustain a person for days if necessary.
The next step is to try low-fiber complex carbohydrates--starchy foods such as rice, potatoes, bread, usually for a full day.
After that you can eat any fruits and vegetables, as well as low-fat meats, but no dairy products for another five days; it will take that long for your intestinal tract to tolerate lactose, the main sugar in most milk products. Even people who digest lactose can have a temporary lactose intolerance after a viral infection or some other assault on the intestinal tract, and drinking milk is the worse thing one can do in that situation.
If you respond to an episode of gastroenteritis by wolfing a ham-and-cheese sandwich and washing it down with a glass of milk, you're doomed to five more days of misery. Just rest your gut for a few hours, gently replace the water and salts with clear liquids, start foods gradually and stay away from milk--and you're better in no time.
Welcome to Bunk!
It's time to get this blog rolling.
My primary goal here is to inform readers (including, but not limited to, some of my own patients) about the perils of following many common practices and ideas about health care. These essays have been culled from innumerable in-office lectures I have given patients in over 25 years of practicing family medicine.
Forgive me if the style seems a little acerbic and supercilious, but, hey, that's how we doctors are when we are passionate about being right.
And I am right. You may disagree with what I say, but then you'll be wrong. (Go ahead -- dare you to comment!)
These subjects are not always about the glamorous leading-edge, high-tech areas of Modern Medicine. But they are about important aspects of living: the way we bathe, the clothes we wear, how we respond to the most common illnesses, the way we make love.
And how we interact with doctors and other HCP's (health care professionals). For that part, I am always in learning mode and invite stories, comments, and questions.
This is not an Owner's Manual. I'm not out to teach you everything about the body (especially since there is a lot we don't yet know), but more to stimulate your mind to question how and why your body suffers from what you think you're doing to help it. Hopefully, you'll learn something, explain it to another, and we'll all become a healthier society.
BUNK -- Myths, Mistakes, and Misinformation that can be harmful to your health -- will discuss specific health care topics.
A future blog (BALONEY -- Don't Believe All You Hear About Modern Medical Science) will tackle Big Pharmaceuticals, health care insurance, and self-promoting "research."
And hopefully, we'll sample from BULL -- The Hype about the "Best" Doctors and Hospitals, which will be something of a guide for medical service consumers.
It's time to get this blog rolling.
My primary goal here is to inform readers (including, but not limited to, some of my own patients) about the perils of following many common practices and ideas about health care. These essays have been culled from innumerable in-office lectures I have given patients in over 25 years of practicing family medicine.
Forgive me if the style seems a little acerbic and supercilious, but, hey, that's how we doctors are when we are passionate about being right.
And I am right. You may disagree with what I say, but then you'll be wrong. (Go ahead -- dare you to comment!)
These subjects are not always about the glamorous leading-edge, high-tech areas of Modern Medicine. But they are about important aspects of living: the way we bathe, the clothes we wear, how we respond to the most common illnesses, the way we make love.
And how we interact with doctors and other HCP's (health care professionals). For that part, I am always in learning mode and invite stories, comments, and questions.
This is not an Owner's Manual. I'm not out to teach you everything about the body (especially since there is a lot we don't yet know), but more to stimulate your mind to question how and why your body suffers from what you think you're doing to help it. Hopefully, you'll learn something, explain it to another, and we'll all become a healthier society.
BUNK -- Myths, Mistakes, and Misinformation that can be harmful to your health -- will discuss specific health care topics.
A future blog (BALONEY -- Don't Believe All You Hear About Modern Medical Science) will tackle Big Pharmaceuticals, health care insurance, and self-promoting "research."
And hopefully, we'll sample from BULL -- The Hype about the "Best" Doctors and Hospitals, which will be something of a guide for medical service consumers.
Sunday, June 18, 2006
Introduction to BUNK
Welcome. We'll use this space in the near future to discuss medical information which you likely don't know because, hey, you're not a doctor, and because what most people not educated in medicine think is scientific truth is often a concoction of folklore, commercial hype, and poetry (e.g.--"Feed a fever, starve a cold!").
We'll cut through the BUNK and give you practical approaches to common ailments and conditions.
We won't be discussing esoterica of complicated and rare medical problems (such as liver transplantation), or trying to alarm you with doomsday prophecies of pandemic and poison. We won't sell anything except our ideas. This is about making everyday lives more understandable and perhaps healthier.
Stay tuned.
Welcome. We'll use this space in the near future to discuss medical information which you likely don't know because, hey, you're not a doctor, and because what most people not educated in medicine think is scientific truth is often a concoction of folklore, commercial hype, and poetry (e.g.--"Feed a fever, starve a cold!").
We'll cut through the BUNK and give you practical approaches to common ailments and conditions.
We won't be discussing esoterica of complicated and rare medical problems (such as liver transplantation), or trying to alarm you with doomsday prophecies of pandemic and poison. We won't sell anything except our ideas. This is about making everyday lives more understandable and perhaps healthier.
Stay tuned.
