Всё о Гипертензии(гипертонии)-About Hypertension

Now they should turn on a recorded tape of their own voices, which repeats over and over, “You are the fairest couple of all! You, you, you\ You are the fairest couple of them all! You and only you! No other couple will do! You and you and you\” This recording of their voices continues to play as they make love.

At first the couple may find this game fun, but after a while the repeated message and the image of themselves in the mirror quite likely will begin to grate and arouse other feelings. The game may then seem silly, and they may even want to stop. It is hoped that their motivation, fueled by a desire to achieve a better sex life and a better relationship, will inspire them to suspend judgment and see the game through. They may also become embarrassed, giggle uncomfortably, or get in touch with sadness or anger. Yet by the time they tire of looking at the mirror and shut off the recording, they will have reached a higher plateau of relating, being imbued with the realization that it does not matter whether or not they are the fairest couple in the world—only that they truly love one another.

*121/196/1*

Players: Husband and hysterical wife. Activist: Husband. Setting: Home.

Aim: Use of paradoxical mirroring of wife’s headache maneuver by husband in order to provoke an authentic confrontation.

Game Plan: Like the passive, the hysterical woman gets headaches—often migraines—and uses them as an excuse to refuse sex. However, the hysteric’s headaches^ju?f øÿãåsevere and are sometimes accompanied by fits, “I said I haye a headache, and I mean I have a headache! Don’t you have any consideration or respect for me at all?” The angrier variety of hysteric, therefore, will not respond to the game called “Headache” (see chapter 3) nor to any pleas, demands, or discussions. That type needs a more forceful brand of emotional communication.

In this present game the husband imitates the wife’s behavior in a way somewhat like what children do to one another. He does not ask for sex from her anymore but rather waits until she asks something of him and then refuses—saying “I have a headache.” It can be a small or large request by her which elicits this response. For example, they may be watching television and she may say, “Would you change it to ‘Wheel of Fortune’?”

*96/196/1*

Now he sucks on the right earlobe, runs his tongue around the edge of the ear, and gently bites the top of the rim. Then he asks, “Is that all right?” If it is, he blows lightly into the ear. He then sucks on the left earlobe, runs his tongue around it, and gently bites the top of the rim.

Then he gently bites the calf of her left leg, and asks if that is all right. If so, he licks the area in back of the left knee. Then he bites the calf of her right leg. Then he licks the dimple in back of the right knee. Then he bites the back of her left thigh, then the back of her right thigh. Then he bites her left buttock. Then he bites her right buttock. Then he licks her spine, from her waist all the way up to her neck to where her hair starts.

If by any chance she does not like any of this, then he should persuade her to try it anyway, even if it feels strange or offensive—for only by trying it will she reap the benefits of the massage. It is her depression, he should tell her, that is offended by the massage, for it does not want to receive pleasure, does not feel worthy of it, needs always to negate everything. To overcome this depression, she should go with the massage—even it if does not at first seem enjoyable.

*71/196/1*

The husband, true to his passive-aggressive character, will at first pretend he does not see what he sees.

The wife struts past him, smiling mysteriously, then returns to the desk again to dust off the top. Naturally, she must stoop to do this, and it is also of course necessary for her to wiggle her rear as it protrudes toward her husband. Her naked behind flexes this way and that, and now it is only a few feet from his face. He can smell a new brand of perfume she has apparently dabbed onto her secret region and can hear her humming something softly under her breath.

The wife continues to cross smilingly before him and to stoop provocatively in front of him, wiggling and swaying and dipping and squirming while fooling with the furniture and fixtures, until he cannot help but ask, “What are you doing?”

“Oh, just looking for something I once lost,” she demurely replies.

“For something you once lost? I see.” “You see? What do you see?” She wiggles her rear some more.

At this point he will begin to feel both aroused and frustrated. He may respond by jumping up right then and rushing forth to take her from behind. Or he may get angry and snap at her, “Why don’t you put on some pants? That’s disgusting. You look like a whore.” Or he may walk out of the room to avoid this seduction, which arouses feelings he has long strived to avoid and does not want to deal with.

*46/196/1*

Bored couples are not really bored. They are experiencing a kind of suspended animation. Boredom is a state of mind that occurs when wishes, fantasies, and feelings are being repressed because, if admitted into consciousness, they would cause anxiety.

Generally only one partner is feeling boredom, but on occasion both are. One of my patients, a man in his late thirties, complained to me of being bored by his marriage: “My wife is a very boring lady. She’s a complainer. All she does is complain, complain, complain. But if I say anything to her about her constant complaining, she accuses me of not being empathic enough. She just wants to complain but never wants to really examine herself. She can never be there for me. Even when we .have sex, which isn’t very often, I feel she’s just sort of taking a break between complaints.”

This patient’s boredom was a defense against both the anger he felt toward his wife for constantly complaining and shutting him out and the taboo wishes and fantasies he harbored of a sexual or violent nature. His wife was doing to him what she did to every other man (creating distance and desex-ualizing the relationship), and the patient was doing to her what he did to every woman (subtly rejecting her emotionally, and depriving her by withholding his anger).

*21/196/1*

Most of the currently available methods for the psychological treatment of behavioral disturbances (including sexual disturbances) are one of two models, the psychoanalytic or the behavioral. The psychoanalytic methods range from the orthodox free-association and dream interpretation to the newer methods such as primal scream and bioenergetics. All have in common the “freeing” of unconscious forces and feelings and the consequent change in the behavioral disturbance. The behavioral model provides a completely opposite approach. It either denies, ignores, or minimizes unconscious forces and attempts to change the disturbed behavior directly. To understand fully the behavioral approach to the treatment of sexual disorders, the difference between these two models must be examined.

One clarification of the difference between the two models is provided by Wachtel’s consideration of the unconscious processes. He argues that these processes may be viewed as either independent variables or as dependent variables.

When these unconscious processes are considered as independent variables, it is assumed that they are tendencies within the person, locked in the past and unresponsive to current events in the person’s life. They exert a pressure unchanging in quality or intensity. Behavior is the dependent variable in that these unconscious forces influence feelings, perceptions, and actions. Changing the independent variables, the unconscious processes, thus is the only way to change the dependent variables, the behaviors. Insight, conflict resolution, working-through, abreaction, and other methods stemming from the Freudian paradigm are the only means of altering the behavioral disturbance, in a meaningful way.

But when considered as a dependent variable, it is the reverse: the person’s action and life-style influence the unconscious processes. Although the unconscious processes originally may have caused the person to act in certain ways, to form a given life-style, it is these actions and their consequences that now perpetuate and maintain these very same unconscious forces. By deliberately changing specific behaviors (now considered the independent variable), not only may various symptoms be made to disappear, but also the (dependent) intrapsychic forces maintained by these behaviors may be changed. Following this line of reasoning, changing behaviors does lead to “deeper” change even in the Freudian sense of these words. The technology of behavior therapy is the most effective means for achieving these behavioral changes.

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Sex reassignment is a rehabilitative form of therapy, not a cure. It is used because other forms of therapy capable of ameliorating the transsexual’s suffering have not, to date, been proved effective.

Initially the therapeutic goal is for the patient to achieve success in the two-year, real-life test. During this period, hormonal reassignment is instituted. With the exception of deepening of the voice in the female-to-male transsexual, hormonal changes are reversible if the test proves to the patient that his or her transsexualism does not warrant further pursuit of reassignment.

The following male-to-female hormone dosages have been found satisfactory: Estinyl (ethinyl estradiol) 0.02 mg. daily, or Premarin (conjugated equine estrogens) 0.6 to 1.25 mg. daily. Before gonadectomy, the treatment would be every day for a minimum of four to eight months. Following surgery, treatment should be cyclic, for the first three weeks of each month, missing the fourth week.

An alternative to the foregoing would be a commercial product combining estrogen and progestin, for example: Lo-Ovral 1 mg. (norgestrel 0.3 mg. and ethinyl estradiol 0.03 mg.), or Ovral (norgestrel 0.5 mg. and ethinyl estradiol 0.05 mg.). The dosage of those preparations is one tablet daily for the first three weeks of each month.

If the patient prefers not to accommodate to a daily oral therapy, but to an intramuscular one instead, then the following could be prescribed: Delestrogen (estradiol valerate) 5 mg. plus Delalutin (hydroxy-progesterone caproate) 62.5 mg. every two weeks. Another intramuscular combined treatment could be: Depo-Estradiol cypionate 1 mg. plus Depo-Provera 25 mg. every two weeks.

After four to eight months of biweekly therapy, the same dosages could be given once every three or four weeks.

If in the preoperative state, the above dosages prove insufficiently effective after four to six weeks, then the dosage could be doubled. Otherwise, the rule is to use the dosage that is thought presently to be replacement therapy for normal women.

Hormonal feminization of male-to-female transsexuals promotes a female appearance insofar as it brings about a feminine redistribution of subcutaneous fat. It also stimulates breast enlargement (gynecomastia), and may somewhat retard the growth of facial and body hair.

Hormone dosage for female-to-male transsexuals which has provided satisfactory results is: Delatestrel (testosterone enanthate) 400 mg. intramuscularly once a month.

Hormonal masculinization of the female-to-male transsexual induces suppression of the menses, but breakthrough bleeding may eventually occur. Permanent suppression requires castration (ovariectomy) or hysterectomy, preferably both. Other effects of hormonal masculinization include deepening of the voice and growth of facial and body hair. The shrinking effect on the breasts is minimal. The clitoris enlarges, but not sufficiently to permit masculinizing surgical reconstruction as even a very small micropenis. Its erotic sensitivity increases. The feeling of orgasm is reported as increased with no loss of the female capacity for multiple orgasm.

The above hormonal dosage does not prevent menopause-like symptoms following ovariectomy. Control of such symptoms may require additional estrogenic therapy with gradual withdrawal over a period of three to six months.

During the period of the real-life test, male-to-female transsexuals may take voice retraining. They may also begin electrolysis for removal of facial hair and perhaps body hair also. These services are provided by trained and certified experts, usually in private practice, not in a hospital.

In some cases of female-to-male transexualism, mastectomy is necessary during the period of the real-life test, especially if the patient works as a male in a job in which exposure of a female chest contour, however disguised, is incompatible with continued employment.

A few patients need cosmetic and etiquette counseling, but most are masters of these arts without special help.

To a variable extent, local legal advice may be needed during the period of the real-life test, especially if a divorce is necessary, and also with regard to change of name and sex on documents. Complete legal recognition of the change of sexual status, in the form of a reissued birth certificate, varies according to legal jurisdiction. Usually a medical statement is needed for the legal change, after the sex reassignment has been completed.

The amount of counseling needed during the real-life test varies according to individual need and traveling distance. Patients from far away need a local counselor working in collaboration with the main center.

Some transsexuals disown their families, and others are disowned by their families. The ideal of rehabilitation is to have the reassigned transsexual acceptable to the family, however limited the personal contact. Therefore, family counseling is also a prerequisite. The siblings, especially the young ones, should not be overlooked in the overall plan of counseling. Non-family members, including the lover, personal friends, teachers, and employers also may be given information and advice on how to contribute to the transsexual’s total rehabilitation.

Sex reassignment surgery is too highly technical a procedure to be discussed here in detail. Male-to-female surgery has been reasonably well perfected, though in some cases there are residual problems of contracture and constriction of the vaginal canal requiring an additional operation. The end result can be convincingly feminine in appearance and function. Female-to-male surgery of the external genitalia presents insurmountable problems as great as in the case of congenital aplasia of the penis or accidental amputation of the penis. A plastic surgeon can make a penis of grafted skin, but it requires from five to fifteen surgical admissions, and the end result is a penis that is numb, unable to erect, and subject too easily to urethral constriction and urinary infection. For sexual intercourse, such an organ can penetrate the vagina only if supported, as in a hollow dildo. Thus, there is very good reason for the female-to-male transsexual to settle for a strap-on prosthetic penis and to avoid the expense, pain, and poor result of very time-consuming surgery.

Female-to-male transsexuals who undergo genital surgery do not lose the clitoris and so retain the capacity for orgasm. In fact, the orgasm is enhanced under the influence of androgen therapy. Male-to-female transsexuals lose the kind of ejaculatory orgasm they once knew, but without regret, for it is replaced by a climactic feeling which, even though more diffuse, satisfies them all the more because they are able to satisfy a male partner.

*194/187/5*

Sex and sexual relations are variously understood by Americans through shifts in the respective stress given to the order of nature and the order of culture (or law). Sex may be posed as animalistic. Equally, “proper” sexual relations entail ritualization, order, and control. Even for groups within the population that accept forms of sexual relations more generally viewed as deviant, sex involves ritualized behavior and technique. Within American society, mainstream understandings of sexual relations as an exclusive intimacy enjoyed between wife and husband seem increasingly to be complemented by alternative notions of what sex is or should be. David Kemnitzer) writes about a new cultural construction of sex among young professional and white-collar workers. In analyzing the fact that there is a crucial stress on sex-as-technique among this group, Kemnitzer notes the wide popularity of Masters’ and Johnson’s Human Sexual Response “despite its turgid prose, outlandish price, and lack of pictures”. Although sexual how-to-do-it books proliferate, the essence of the new sexuality may well be not what it initially appears. Kemnitzer concludes: “For sex to be a matter of technique, a form of work an arena for competence, the partner . . . must be rendered a thing, rather than a person”. Precisely among the very groups which mainstream society sees as most animalistic in their sexual behaviors, “technique” and “competence” commandeer sexual relations.

Such alternative sexual patterns notwithstanding, notions of “proper” sex would seem to be predicated largely upon images of sex within marriage and certainly of sex between two adult partners of different gender. Though this image may be of shifting consequence to constraints imposed by law or enacted in behavior, it is sustained as the one sexual relation which receives legal prescription: non-consummation is grounds for annulment or divorce. Until recently sex within marriage was the only form of sexual relation not explicitly prohibited in at least some states. For the most part, the constraints of law within the United States have restricted legal sexual relations to those between particular sorts of people (related in law but not in blood), to particular (private) places, and to particular forms (genital-to-genital contact). “Indeed it has been said,” writes Schur, “that all unmarried adolescents and adults in our society—male and female, heterosexually inclined as well as homosexually oriented—are forced to choose between abstinence and ‘criminality’ “. Almost every sexual act not contained within the rigid definitions of person, place, and form has been defined as criminal. Criminal sexual activities with the wrong person have included incest with relatives (a category which itself is variously defined from state to state), homosexuality with a member of the same sex, fornication or adultery if the partners are unmarried or are married to others, masturbation if with oneself, and sodomy if with an animal. Sex in the wrong place may constitute the criminal act of public lewdness. Perhaps most surprising, even when the partner and the place do not contravene the bounds of legality, the mode of enactment may open the partners to criminal accusation. Anal sex or oral-genital sex variously defined as sodomy or as the “crime against nature,” offer accused parties long jail terms and heavy fines. (Most convictions for this last crime have not involved married partners; however, sodomy, including anal or oral intercourse, has been formally illegal in the United States even between husband and wife.)

These three sorts of limitations on sexual behavior (with whom, where, and how), though changing over time and in their specific content and application, allow classification of legislative enactments and judicial decisions pertaining to the legality of sex. Each separately and the three together are part of more pervasive cultural contrasts within American society. The category, spouse, as the most appropriate sexual partner, is based on a classification which separates family from non-family and within the family, a particular relation-in-law (that of spouse) from other relations-in-law and from relations-in-blood. In defining the bedroom or other similar place as that appropriate for sex, a domain of private space is distinguished from one of public space. The third limitation on sexual activity—how—is perhaps the most tricky; on the one hand, culture or law (ordered, prescribed, or prohibited activity) is separated from nature (unordered, even animalistic, activity); the first has been considered appropriate, tolerable, or legal; the second has not. This division is complicated precisely because culturally created notions of proper sexual forms frequently have been justified through the admonition that they are natural. The term “crimes against nature” has served as a euphemism for sodomy (itself a term variously referring to any or all of mutual masturbation, oral intercourse, anal intercourse, and sex with animals). The confusion can be put to rest at least minimally in a cross-cultural perspective. One might note simply that the sexual form upheld as most respectable within the West has elsewhere been tagged the “missionary position” (Bullough). To the extent that proper sex has been conceived as natural, the intent has been not to define natural in opposition to cultural or lawlike, but rather has been based on an equation between that which is natural and that which is approved by the Divinity.

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The clinical study of children who early in their lives show evidences of faulty or deviant gender identity formation is another area of recent exploration. We owe much to the pioneer work done by Money, Hampson, and Hampson, Money and Erhardt, Green and Money, and Stoller. Because of these and similar studies, there now are new ways of looking at sexual development and its fundamental and prevailing influence upon the development of personality.

These investigators began their studies from a clinical perspective. They attempted to understand those individuals with anatomically ambiguous genitalia, such as hermaphrodites, whose condition is due to gonadal, hormonal, and genetic factors. This line of inquiry has its counterpart in the study of transsexualism, the extreme form of gender reversal in which the anatomical male believes he is inwardly female, or the anatomical female considers herself psychologically a male. It appears now that in the development of sexuality and personality, certain influences are responsible for the final patterns of personality functioning, the nature of affectional affiliations, and the individual’s personal identity. A most important question is what influences are responsible for one’s gender identity or, as Stoller puts it, for “one’s sense of masculinity and femininity”, regardless of the individual’s anatomical and biological sex assignment. It would seem that the individual’s gender identity is not based wholly on his or her biological and genetic imprint. Environment, culture, and parents exert a very important and, at times, crucial influence. Children born with anatomically ambiguous genitalia will act, feel, and desire as males or females depending upon their sex assignment by the parents, independent of their genetic sexual make-up. In fact, these individuals in adulthood are not distinguishable from those with an absolutely clear sexual/gender identity. Some whose gender identity is based on the sex role assigned by the parents early in life despite their genetic and biological sex assignment, function normally. Others exhibit gender identity, confusion, and conflicts similar to those observed in neurotics. These conflicts, however, seem to be related to various traumas and early frustrations that are the basis of many neurotic behaviors, rather than to specific disorders of core gender-identity development.

It appears that core gender identity is formed early in life, and that once formed it will endure throughout the individual’s life, highly resistant to environmental or psychotherapeutic intervention. Since the formation takes place over an extremely short period (the first eighteen months of life), many theoreticians use the process of imprinting (borrowed from ethologists) to explain not only the speed of the formation but also the later resistance to modification.

The question of how environment influences gender identity is of particular interest to those developmentalists who are exploring the roots of individuality and the determining forces behind it. There are several character traits that each culture assigns predominantly to either of the sexes. Of course, it is an oversimplification to talk about these traits as either male or female. Observation shows that what is called a male or female trait by the culture is usually present in both sexes, but often a cluster of “feminine” or “masculine” traits tend to predominate in a particular sex. These traits include such behaviors as manner of talking, pattern of postures and expressive body movements, preference for certain toys or tools, and style of grooming and clothing. In other words, it seems that each culture has a way of classifying feminine and masculine behavior, and hat in most instances the members of the culture adopt these behaviors according to their sexual and gender identity. There are a number of individuals within most cultures who for various reasons display behavior normally assigned to the opposite sex. These children with atypical sex-role behavior (Green), by their rigid attachment to the opposite sex’s patterns of clothing, peer-selection, and mannerisms once again provide strong evidence for the link between gender-identity formation and personality-trait development. The scant information about the later development of these children indicates that these early traits have an impact on their adult gender-role and sexual-orientation behavior. For example, Green reports that adult transsexualism could be an extension of early femininity in boys. Bieber reports that two-thirds of a group of adult homosexuals had some history of feminine behavior during their childhood. In another report (Prince and Bentler) there were episodes of cross-dressing during childhood among one-half of all adult transvestites.

To summarize, the development of core gender identity seems to depend upon genetic, gonadal, and early environmental influences. Once it is formed, gender identity and self-concept remain stable throughout life, resisting modification by environmental influences.

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The figures on the Redbook wives who had had extramarital sex by different ages are somewhat different, as one would expect, given the nature of the sample. Twenty-nine percent of the total sample had had extramarital sex, the accumulative incidence rising from 20% of the under-twenty-five wives to 40% by age forty and over. A very important variable not mentioned in the other studies was employment of the wife. Full-time employed wives were far more likely to have had extramarital relations than were stay-at-home wives. Among wives in their late thirties, for example, 53% of those employed had had extramarital sex, compared to only 24% of the housewives. Religion was also a factor, with more than twice as many non-religious women as devout women reporting such activity.

Other findings in these studies, which we will briefly summarize, relate to number of partners, frequency of orgasm, and overall pleasure of extramarital sex compared to marital sex, reported by those with both kinds of experience.

Kinsey did not report on any of these variables for his male sample. The data for the number of extramarital partners for both the Kinsey and the Hunt females are almost identical: about 40% in each had had only one partner, and more than 80% had had five or fewer. For the Redbook women, the corresponding percents are 50% and 40%.

The only data comparing marital and extramarital frequency of orgasm are from the Hunt female sample. These women who had had extramarital sex reported that they had orgasm all or almost all the time in 53% of their marital coitus, compared to only 39% of their extramarital coitus, and that they had orgasm almost none or none of the time in 7% of their marital coitus but in 35% of their extramarital coitus. These data suggest that extramarital intercourse is considerably less satisfying than marital intercourse. It is likely that factors such as guilt, haste, anxiety, and inexperience with the partner enter to some extent in these findings.

Related to the figures on orgasm are some data from Hunt’s survey on overall pleasure of marital and extramarital relations. Males rated both marital and extramarital sex more pleasurable than females did, and both sexes gave their marital sex higher ratings than their extramarital experiences.

While adultery seems to be an enduring and intimate aspect of marriage, the data are skimpy, indeed, to support a conclusion that it is increasing, compared to other forms of sexual experience such as premarital or postmarital sex. The exception is its rather dramatic rise among young married women, and this may portend a trend for future observations. As for the other parameters, though one must be very cautious in generalizing from the research, it appears that women, at least, who have extramarital experiences, tend to have few partners rather than many and share with men the experience of being less orgasmic and getting less pleasure from their extramarital encounters than from their sexual relations at home.

*83/187/5*

Male potency is one of the last sexual topics in America left in the closet. Men who have trouble getting an erection have told us over and over that no one knew about their problem. “I’ve never even told my best buddy,” says one man. Confides another: “I discussed it briefly with some male friends. But I couldn’t carry it any further. Men just aren’t comfortable discussing it.”

If s not surprising that most men don’t discuss sexual potency among themselves except to brag about their exploits or their size. For many men, being potent is an essential, basic ingredient of their self-image: what makes a man a man. But men should have a reliable, accurate source of information about potency. They should know that impotence, whether temporary or long-term, is a very common problem. That being “normal” isn’t being a superstud, able to perform on command. That few men get great erections every time. That if there is a long-term problem, there’s a 90 percent chance it can be treated successfully.

Most changes in potency aren’t a problem, but do require some adjustment. “When I was in college I could play a couple of games of soccer, run a few laps around the track and make love three times in the same day—no problem!” says Gene, a stocky, muscular 40-year-old man. Smiling a bit wistfully at the memory he adds, “Of course, that was 20 years ago. Times have changed and so have I.” Joseph, a divorced college professor, says, “When I was in my 20′s, I could take a woman out after a long day at work, have dinner and a few drinks, go dancing and then go home with her and make love.” He shakes his head incredulously and says, “Now, in the same scenario, 25 years later, there’s a big difference. By the time I get her home, I’m exhausted from work, dinner and making a good impression—never mind the dancing. I just want to go to sleep! But,” Joseph continues, grinning, “the next morning I’m ready. Really ready.”

Joseph’s behavior is common among men, and nothing to worry about. A man’s sexual response changes as he matures, along with other physical attributes like eyesight, hair color and skin tone. But the emphasis is on the word “change,” because with good health and a willing partner, a man should be able to enjoy sex no matter what his age.

*2\184\8*

Each year, middle-aged and older individuals spend fortunes on creams and lotions, massage, hot packs, wax and mud treatments, and special soaps in the quest of wrinkle-free skin. For the most part these treatments are more beneficial to those supplying the treatments than to the individuals receiving them. Although moisturizing creams and lotions may help you look and feel better temporarily, they have no permanent effect on the skin’s texture or appearance.

During the past few years, there has been some evidence that tretinoin (Retin-A ®) cream may be effective in decreasing the wrinkling of the skin and improving its texture and appearance in a more long-lasting manner. The changes noted in the skin of some people treated with this agent have been subtle but measurable and a great deal of enthusiasm has been generated about this product. Some users develop redness, irritation, and swelling where tretinoin cream is applied but this eventually subsides. The skin may become more sensitive to the sun during treatment, so it is recommended that sunscreens be used diligently during this period.

The cost of tretinoin treatment is considerable but many people feel it is worthwhile. Whether this particular antiaging, antiwrinkling skin treatment will withstand the test of time is not yet clear. Meanwhile, if you (with medical supervision) choose to try this treatment, it does not diminish the need to eliminate cigarette smoking, cut down on sun exposure, and use protective sunscreens in an attempt to avoid further skin damage, which ultimately results in wrinkling and a more aged appearance. Prevention will always be preferable to cure; it is best to begin to care for and protect your skin as early as possible.

Some people, as part of their quest for youth, undergo many cosmetic surgery procedures. There is no doubt that such surgery can improve the wrinkled appearance of the skin, may relieve the baggy look around eyelids, and may change the sagging appearance that sometimes accompanies aging. For some people these results are very important. Such surgery does not improve the quality of the skin or make it younger, although it may improve one’s appearance.

It is possible to inject small amounts of collagen around the wrinkled sides of the mouth or sides of the eyes to decrease the appearance of wrinkling. This procedure is relatively easy and safe and can be readily done in the office by a dermatologist. If such wrinkles are very bothersome to you, it is something to consider.

Whatever procedures you carry out to improve your appearance, remember that the protection of the skin from the harmful effects of the sun’s rays and proper cleansing and moisturizing should be part of a total program of good skin care.

*258\166\2*

Blood consists of plasma, a fluid that carries red blood cells (erythrocytes) and white blood cells (leucocytes). Red blood cells carry oxygen and carbon dioxide, which are necessary for respiration and metabolism, whereas white cells protect the body from infection. Many elements are contained in the plasma, including important salts, proteins, antibodies, nutrients, and many by-products of metabolism. Platelets are small cell-like particles that help the blood clot when there is an injury to a blood vessel.

The diseases of the blood that can affect older people are the result of a decrease in the red or white blood cells or an increase of blood cells that may not be working normally. Another problem includes a disturbance in the clotting ability of the blood, which can lead to abnormal bruising or bleeding. Sometimes the blood may clot (thrombose) within normal blood vessels for no apparent reason and deprive a part of the body of its blood supply.

*247\166\2*

The endocrine glands, distributed throughout the body, produce hormones, which help to control the chemical reactions of the body’s cells. We often use the word metabolism to describe the different cell processes. The most important endocrine glands are the thyroid gland, the two adrenal glands, the pancreas, the four parathyroid glands, and the pituitary gland. The sex glands (ovaries and testicles) also produce hormones, but they are usually considered separately from the endocrine system.

Each of the endocrine glands produces its own special hormone or hormones, which help keep the cells of the body functioning properly and efficiently. When an endocrine gland becomes diseased, it may produce too much or too little of its hormone and upset the body’s metabolism. In most cases the diseases that develop are treatable.

The thyroid gland, found in the neck just below the Adam’s apple, is shaped like a butterfly; the two “wings” are called the thyroid lobes. The thyroid gland produces thyroid hormone (thyroxine), a substance necessary for metabolism.

Certain blood tests measure the amount of thyroid hormone in the blood and help in diagnosis of thyroid disorders. It is sometimes necessary to do a radioactive thyroid uptake and scan in order to diagnose some disorders completely. In many instances thyroid disease requires repeated tests. Unfortunately, disease of the thyroid gland can be very subtle as you grow older. Both overactivity and underactivity can be confused with other conditions, which means that diagnosis and successful treatment are too often unnecessarily delayed.

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Arthritis and rheumatism describe many different diseases, but the features that they all share are pain, swelling, and interference in the normal movement of either one or more joints. Some kinds of arthritis affect only one joint, whereas others affect many simultaneously. Some are more common in older people, and others are rare in people of all ages. Many older people often assume that their aches and pains are the result of arthritis, and that arthritis is a natural consequence of aging. Both of these assumptions are far from the truth.

The most common type of arthritis in the older individual is osteoarthritis, which usually affects one joint at a time, although many joints can gradually become involved. Some studies suggest that this condition affects from 15 to 25 percent of people over the age of 65. Osteoarthritis is caused by a gradual but progressive wearing down of the usually smooth covering (cartilage) of the joint bones. The cause of the destruction is not completely known: in some people it appears to be the result of a previous injury or trauma; in others it appears for no apparent reason. The end result, however, is that the joint surfaces become painful when they move. Often, the large joints that support much of the body’s weight become affected first, frequently the hips, knees, and back. Sometimes it affects the smaller joints of the hands and feet. The joint becomes swollen as opposing bones become widened and fluid accumulates. If the joint is badly damaged, it may not move or support weight properly, and this can interfere with walking or bending. Sometimes a joint that is affected but not uncomfortable may suddenly become swollen and painful as the result of inflammation or infection. This must be treated immediately.

Rheumatoid arthritis occurs less commonly for the first time in the older person, but if you have suffered from this illness during your younger years, it may continue to afflict you as you grow older. This illness can affect many parts of the body simultaneously, in addition to the joints. More than one joint is usually involved, often the smaller joints of the hands, wrists, feet, neck, and jaw. Some people with rheumatoid arthritis develop fever, loss of appetite, weight loss, and heart and lung problems. The joints, however, are the most obvious and painful focus of the disease.

The course of rheumatoid arthritis varies: some people contract a severe case in the beginning; for others it may be mild and create little disability. The symptoms may come and go, with severe bouts followed by long periods of comfort, which are again aggravated by episodes of pain and poor health. Unfortunately, self-diagnosis and treatment for arthritis symptoms is common. This can interfere with a proper assessment and a well-designed plan of treatment, which often results in great improvement and relief of symptoms.

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Light enters the eye through the transparent cornea, located at the very front of the eye. It then passes through the pupil, the black center of the eye. This in fact is the aperture in the iris, which gives eyes their color. The iris can open and close, thereby causing the size of the pupil to change. By varying the size of the opening, the amount of light entering the eye can be controlled. If the light is very bright, the pupil is small and, when it is dark, the pupil is wide open.

After light passes through the pupil, it is focused by the lens, behind the iris. The focused light rays are directed to the retina, which is located at the back of the eye and contains special cells that translate the light images into nerve messages. These are carried by the optic nerves from the retina to the brain, where they are interpreted.

Illness can affect one or many parts of the eye. Some problems, such as infection, affect people at any age, whereas others are more likely to occur as you grow older. In the older person a decrease or loss of vision can be devastating because it interferes with feelings of self-worth and exaggerates the effects of isolation, dependency, and loneliness. If you are not able to read or watch television, you may become cut off from the everyday activities of the world. You should have a thorough periodic examination by a physician or ophthalmologist to ensure that your vision has not deteriorated as the result of disease. Any sudden change in vision should be checked immediately, because many illnesses that cause blindness can be prevented or treated.

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The nervous system is made up of the brain, spinal cord, and nerves. The brain and spinal cord are protected from injury by the surrounding bones of the skull and vertebral column (spine). Nerves leave the spinal cord and make their way through small outlet holes in the vertebral column to supply the muscles and organs.

Motor nerves bring impulses, or messages, from the brain and spinal cord to the body. Sensory nerves convey messages from the body to the spinal cord and brain. The motor and sensory nerves sometimes travel together for part of their journey through the body but usually divide when they enter the spinal cord and brain. The brain and spinal cord contain nerve cells that interconnect with each other and send messages to different parts of the nervous system. Unfortunately, nerves cannot repair themselves once they have been severely damaged. However, some can be lost without significant impairment of function. If many are damaged at the same time, there will usually be some permanent interference in the working of that part of the nervous system. If the blood supply to the brain and spinal cord is disrupted, there can be serious damage to the nervous system.

Older people are more prone to suffer from diseases of their nervous system because of the increased tendency to degenerative disorders and blood vessel disease. These ill nesses account for a large number of the older individuals who require institutionalization. For many people, incapacitating nervous system disease is their greatest fear. Much of the thrust of present research is directed to avoid, postpone, or prevent disorders of the nervous system. Steps taken to control atherosclerosis, hypertension, and diabetes mellitus (diet, exercise, smoking, and alcohol cessation) may decrease some of the risks for some kinds of neurological disease.

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A great deal has been written about lung cancer. Almost everyone knows that a strong association exists between lung cancer and cigarette smoking. There are, in fact, a number of varieties of lung cancer. Those that originate in the lung have a very high correlation with cigarette smoking. Although an unusual type of lung tumor is sometimes found in older individuals who have never smoked, in general those who have smoked heavily for many years are the most susceptible.

Cancer from another part of the body can eventually spread to the lungs as metastases. This of course has nothing to do with smoking and may be one of the reasons that people have the impression that nonsmokers run the same risk of getting lung cancer as smokers. This is not so. If you smoke, your chances of getting lung cancer are many times higher than if you do not. It is too late to stop after you already have the disease. How often I have heard the lament, “I’ll never touch another cigarette,” when such a decision was no longer of any use.

Of the varieties of lung cancer associated with smoking, some are more lethal than others. If the diagnosis is made after symptoms of cancer have begun, the possibility of cure is small. An increase in the amount of cough or recurring chest infections are warning signs that something more serious than a simple infection is involved. The expectoration of blood may be the first sign of lung cancer. Weight loss, impairment of appetite, or undue fatigue may be early symptoms. Sometimes the illness first presents itself because it has already spread to other parts of the body, such as the brain or bones. Headaches, weakness of limbs, or fractures for no apparent reason may be manifestations of the disease.

If the illness is discovered early (as may be the case if it is found accidentally during a routine chest X-ray), treatment has a better chance of being successful. The first suspicion of the disease may be an X-ray that reveals a “shadow,” in which case the physician will take a sputum sample to see if the cells are abnormal. It may be necessary to perform a bronchoscopy and biopsy to see whether a tumor is present and whether it has spread. Very often, if surgery is considered, many X-rays and scans will be done to ensure that the cancer has not spread to other parts of the body.

The results may show no evidence of tumor spread, and the growth may be small. Especially if found by chance, there is a possibility that in some types of lung tumors surgical removal of part of the lung may be successful in curing the disease. Unfortunately, many people with lung cancer also have chronic bronchitis and emphysema, which makes surgery more hazardous.

In some instances surgery can be successfully performed, and occasionally it completely removes the tumor. All factors must be taken into account first, including the kind of cancer, the evidence of spread to other parts of the body, and the general health of the patient. But surgery should not be discarded as a possibility because of age alone.

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The bladder can store sufficient quantities of urine so that you normally have to empty it only four or five times a day. Nerves that come from the spinal cord, and which are partially controlled by the brain, stimulate the bladder to empty.

The bladder can be injured by urinary tract diseases, or by illnesses that interfere with its ability to empty completely and efficiently. When your bladder is not working properly, your health as well as your social life can be severely affected. Men and women have slightly different bladder disorders, but the results are often similar.

If a man suffers from prostate enlargement, he may develop an overstretched bladder until the blockage is corrected. If this is done early enough, the bladder can be retrained and made to work efficiently and normally again.

Both men and women can develop bladder tumors. These usually become evident when blood is seen in the urine. The color of the urine may be bright red or lightly wine colored. Although some of these tumors may be malignant and can spread, many of them are benign or minimally malignant. They can often be treated by fulguration (destroying by electrical current) through a cystoscope passed through the urethra into the bladder. The earlier the tumors are treated, the better the result. Whenever you see blood in your urine, report it to your physician immediately.

Occasionally the tumors are malignant. In this case the bladder may have to be removed and a “new bladder” made out of a piece of intestine. This procedure is usually done by a urologist, and it is often successful, especially if the tumor has not spread from the bladder to other parts of the body. Radiation can also be used successfully.

Women who have had many pregnancies may develop a weakness of the pelvic muscles that surround the vagina. Being overweight aggravates the problem. In such cases the bladder protrudes into the vagina and causes a feeling of something “falling down,” dragging, or pressing, especially when you stand or walk. This is called a cystocele or prolapse.

The cystocele may cause you to suffer from stress incontinence, which means that you lose control of your urine when you laugh, cough, sneeze, or strain yourself, as when pushing or carrying heavy items. You will be more likely to develop bladder infections if the cystocele is fairly large and the urine stagnates because it is not completely emptied.

The condition is treated by a gynecologist, either through the use of a pessary, doughnut-shaped device that holds the bladder in place, or a surgical repair. Many women can benefit from surgery and it should be considered if the prolapse is very uncomfortable.

Urethral Stricture In men the urethra passes through the penis, and in women it is just above the vagina. The urethra can become narrowed in both men and women and the results are similar. This sometimes occurs after injury, childbirth, prostate surgery, or infection. Urine builds up in the bladder and stretches it. This increases the tendency to infection and may lead to difficulties in passing urine or incontinence.

Diagnosis usually depends on a cystoscopy. Treatment consists of dilating the urethra gradually by passing instruments of increasingly large diameters through it. Sometimes treatment must be repeated periodically. Symptoms are often successfully controlled with this therapy.

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Antibiotics are effective only in the treatment of infections caused by bacteria and some other more unusual germs. They are not at all effective in the treatment of illnesses caused by viruses, and they should not be used to treat the ordinary cold or flu, both of which are caused by viruses.

Some people think that an antibiotic can prevent a cold or flu from developing into a more serious bacterial infection. In fact, the antibiotic may damage normal bacteria and result in a disease more dangerous than the one for which it was unnecessarily taken.

Antibiotics should not be taken without the advice of a physician, and they should be used only after it has been clearly established that the illness is caused by bacteria. And they should not be reused at a later date without consulting a physician. Some antibiotics lose their effect with age or even become dangerous. Except under special circumstances, such as if you suffer from chronic bronchitis, and have prearranged a treatment program with your physician, self-medication with these drugs is potentially harmful. Often, a specimen of your throat, urine, or sputum will be examined before an antibiotic is prescribed.

One elderly woman began to experience fever and weakness a few weeks after she had dental surgery Although she knew she had a heart murmur, she failed to mention this to the dental surgeon and therefore did not receive antibiotic therapy. When she eventually went to her own physician with a fever, she did not mention that she had received dental treatment a few weeks before. Her physician prescribed antibiotics because he found evidence of an infection in her urine. Within a few days she felt better and her fever improved. She stopped taking the antibiotics on her own.

About two weeks later she developed fever again and assumed that it was from the same infection. She took her remaining antibiotics without consulting her physician. Her fever decreased, and once again she felt well. A week later the fever returned. Fortunately, she had used all the antibiotics before and had to return to a physician, who found that she was suffering from bacterial endocarditis. The diagnosis and treatment had been unnecessarily delayed because she diagnosed and treated herself with antibiotics without medical supervision.

The way antibiotics are given usually depends on the severity of the infection and your ability to take the drug by mouth. For mild infections the antibiotic is usually quite effective when taken as pills or syrup.

If the infection is serious or if you are in shock or are weak, they will be given as injections or intravenously. It may be continued later by mouth. If extremely large doses of antibiotics are necessary, as in the case of blood poisoning or bacterial endocarditis, they are given intravenously.

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