Dear Ann Landers,
had to write when I read about the woman whose lunatic husband wants to give his 4-year-old daughter up for adop-tion because she is hyperactive. I am the mother of a 5-year-old hy-peractive child. He used to bite, punch, kick, spit, have violent temper tan-trums, and couldn't play with other children. We took the boy to several doctors before one suggested our state university medical center for evalua-tion. He was placed in a daily thera-peutic program and the results have been fantastic. He is a different child. I am grateful for all the help our son received there but I feel that most of the change was accomplished by love. GRATEFUL FOR HELP IN CONNECTICUT

DEAR CONN,
I'm grateful to you for writing. I caught Holy Ned from hun-dreds of readers because I cautioned mothers against making "little junkies" out of their children. Too often a youngster is put on drugs because it's easier than taking the time to be loving and patient I realize that some chil-dren are truly hyperkinetic and medi-cation can be a godsend, but drugs should not be a substitute for parental time and attention. An excellent book for parents who need guidelines for raising children (not necessarily hyper-kinetic, just normal healthy kids from 1 to 5 years of age) is "Your Young Child and You" (Dutton, $7.95) by Eleanor Weisberger. I've read it from cover to cover and it is superb. Children need daily outside activities such as running, sports or long walks. Keep the home existence organized. Predictable responses by the parents to daily events help the child become more predictable. Avoid fatigue in these children. When they are exhausted, their self-control often breaks down and their hyperactivity becomes worse. 670 THE ANN LANDERS ENCYCLOPEDIA Avoid formal gatherings. Settings where hyperactivity would be extremely inappropriate and embarrassing should be completely avoided. After the child develops adequate self-control at home, these situations can be intro-duced gradually. Maintain firm discipline. The family needs a few clear, consistent, impor-tant rules, with other rules added at the child's own pace. Parents must avoid being after the child all the time with negative comments. Enforce discipline with non-physical punishment Stretch his attention span. Rewarding non-hyperactive behavior is the key to preparing these children for school. Buffer the children against overreaction by neighbors. If he receives a repu-tation for being a "bad kid," it is important that this doesn't carry over into his home life. At home the attitude that must prevail is that he is a "good child with excess energy." credit: Barton Schmitt, M.D., University of Colorado Medical Center, Denver, Colorado. The Hyperactive Child The hyperactive (or hyperkinetic) child has been described as a child who was bom running. From birth he is more active than most infants. As he grows older and is able to walk he seems to be constantly on the move. He jumps from one activity to another. His span of attention is usually brief. This condition is much more common in boys than girls. In school he often finds it hard to concentrate and he may have great difficulty in staying in his seat. Generally he is not a behavior problem if al-lowed to be active but may present difficulties if he is forced to remain still. He may have learning problems in school resulting from his poor span of at-tention and limited ability to concentrate. These learning problems in turn may produce emotional difficulties resulting from frustration when he is una-ble to keep up with the rest of the class. His intelligence is not affected by his hyperactivity and is comparable to that of other children his age. Hyperkinesis, as the condition is called technically, is not a specific disease THE ANN LANDERS ENCYCLOPEDIA 671 but rather a group of symptoms. It probably is the surface manifestation of different types of underlying problems in difficult children. In some children the hyperactivity is a symptom of an underlying emotional disturbance. In these children there will be other evidence of their emotional problems in ad-dition to the hyperactivity and difficulties. In other children the hyperactivity is a result of minimal brain damage and there frequently will be found some neurological evidence of minimal brain dysfunction. Usually, when this is present, the damage is due to a difficult birth process or to something minimally damaging the child's brain in in-fancy. Recently there have been suggestions that some hyperactive children be-come hyperactive because of their being poisoned by food additives. (Food additives are artificial substances added to foods for purposes of coloration, taste, preservation, etc.) As yet there is no evidence that this is true. It was discovered accidentally that the symptom of hyperactivity can fre-quently be helped by the use of stimulant drugs. These are drugs that would actually produce hyperactivity in adults but in children have an opposite effect and act as tranquilizers. These drugs are Benzedrine or other sub-stances that act like Benzedrine, for example Ritalin. Drugs that serve as tranquilizers for adults seem to have little effect on the symptom of hyperac-tivity. If the child is hyperactive but shows no other problems either at home, with peers or at school, nothing need be done. The parent should learn to ac-cept the fact that his child is simply more active than the average child. It is important also that the parents request that the teacher of the hyperac-tive child show as much patience as possible, including allowing him to get up and walk around the room at intervals, provided, of course, that the child does not take advantage of this and become a discipline problem. If, in addition to the child's hyperactivity, he also has other symptoms, then the following should be considered: The child should be given a full neurological examination by a pediat-ric neurologist-that is, a doctor who specializes in neurological examina-tions of children. If he decides a stimulant drug is indicated he will prescribe it The parent should not allow anyone but a doctor to prescribe or sug-gest medication for the hyperactive child. Far too many children are being given drugs without a thorough neurological examination. If the child's hyperactivity or other symptoms persist after he has been on medication for a reasonable period of time (for example, three 672 THE ANN LANDERS ENCYCLOPEDIA months), the parent should consider having the child receive a psychiatric evaluation. Most hyperactive children with problems can be helped by medication, psychiatric treatment and a great deal of patience shown by parents and teachers. credit: Ner Littner, M.D., S.C., Institute of Psychoanalysis-Chicago, Coordi-nator, Child Therapy Program. Ten Guidelines for Living with a Hyperactive Child Accept your child's limitations. A parent must accept the fact that his child is intrinsically active and energetic and possibly always will be. The hy-peractivity is not intentional. A parent should not expect to eliminate the hy-peractivity but just to keep it under reasonable control. Any undue criticism or attempts to change the energetic child into a quiet child or "model child" will cause more harm than good. Nothing is more helpful for the hyperactive child than having a tolerant, patient, low-key parent. Provide outlets for the release of excess energy. This energy can't be bottled up and stored. These children need daily outside activities such as running, sports or long walks. A fenced yard helps. In bad weather he needs a recreational room where he can do as he pleases without criticism. If no large room is available, a garage will sometimes suffice. Although the expres-sion of hyperactivity is allowed in these ways, it should not be needlessly en-couraged. Adults should not engender roughhousing with these children. Sib-lings should be forbidden to say, "Chase me, chase me" or to instigate other noisy play. Rewarding hyperactive behavior leads to its becoming the child's main style of interacting with people. Keep the home existence organized. Household routines help the hy-peractive child accept order. Mealtimes, chores and bedtime should be kept as consistent as possible. Predictable responses by the parents to daily events help the child become more predictable. THE ANN LANDERS ENCYCLOPEDIA 673 Avoid fatigue in these children. When they are exhausted, their self- control often breaks down and their hyperactivity becomes worse. Avoid formal gatherings. Settings where hyperactivity would be ex-tremely inappropriate and embarrassing should be completely avoided. Ex-amples of this would be church, restaurants, etc. Of lesser importance, the child can forgo some trips to stores and supermarkets to reduce unnecessary friction between the child and parent. After the child develops adequate self- control at home, these situations can gradually be introduced. Maintain firm discipline. These children are unquestionably difficult to manage. They need more careful, planned discipline than the average child. Rules should be formulated mainly to prevent harm to himself or others. Aggressive behavior and attention-getting behavior should be no more accepted in the hyperactive child than in the normal child. Unlike the expression of hyperactivity, aggressive behavior should be eliminated. Un-necessary rules should be avoided. These children tolerate fewer rules than the normal child. The family needs a few clear, consistent, important rules, with other rules added at the child's own pace. Parents must avoid being after the child all the time with negative comments like "Don't do this" and "Stop that." Enforce discipline with non-physical punishment. The family must have an "isolation room" or "time-out place" to back up their attempts to en-force rules, if a show of disapproval doesn't work. This room can be the child's bedroom. The child should be sent there to "shape up" and allowed out as soon as he has changed his behavior. Without an isolation room, over-all success is unlikely. Physical punishment should be avoided in these chil-dren since we want to teach them to be less aggressive, rather than make ag-gression acceptable. These children need adult models of control and calmness. Stretch his attention span. Rewarding non-hyperactive behavior is the key to preparing these children for school. Increased attention span and per-sistence with tasks can be taught to these children at home. The child can be shown pictures in a book; and, if he is attentive, he can be rewarded with praise and a hug. Next the parent can read stories to him. Coloring of pio- tures can be encouraged and rewarded. Games of increasing difficulty can gradually be taught to the child, starting with building blocks and progressing eventually to dominoes, card games and dice games. Matching pictures is an excellent way to build a child's memory and concentration span. The child's toys should not be excessive in number, for this can accentuate his distract- ibility. They should also be ones that are safe and relatively unbreakable. Buffer the child against any overreaction by neighbors. If he receives 674 THE ANN LANDERS ENCYCLOPEDIA a reputation for being a "bad kid" it is important that this doesn't carry over into his home life. At home the attitude that must prevail is that he is a "good child with excess energy." It is extremely important that his parents don't give up on him. He must always feel accepted by his family. As long as he has this, his self-esteem and self-confidence will survive. Periodically get away from it all. Parents must get away from the hy-peractive child often enough to be able to tolerate him. Exposure to some of these children for twenty-four hours a day would make anyone a wreck. When the father comes home, he should try to look after the child and give his wife a deserved break. A baby-sitter two afternoons a week and an occa-sional evening out with her husband can salvage an exhausted mother. A pre-school nursery or Head Start class is another option. Parents need a chance to rejuvenate themselves. credit: Barton Schmitt, M.D., Department of Pediatrics, University of Colorado Medical Center, Denver, Colorado. The word "hypnosis" conjures up an image of dangling watches, rotating spi-rals and mystery. Hypnosis is, in fact, a form of intense receptive concen-tration which is finding growing application in various aspects of medicine, dentistry and psychology. Actually, hypnosis alone is not a profession. Hypnosis is always secondary to a primary professional commitment. For example, the dentist can use hyp-nosis to facilitate his dental work. The surgeon can use hypnosis to alleviate surgical pain. A psychotherapist can use hypnosis to implement appropriate behavior change. But none are hypnotists. They are professionals who use hypnosis. The physicians I know who use hypnosis do not call themselves hypnotists. Usually the quacks or self-designated healers call themselves hypnotists. (It sounds better than "quacks.") Entertainers who use hypnosis as part of a show or a nightclub act are pri-marily actors who use hypnosis. They are not doctors or therapists. In gen- THE ANN LANDERS ENCYCLOPEDIA 675 eral, anybody who presents himself to the public as a hypnotist, implying that he is a therapist, or doctor, without having legitimate training and experience in the basic medical, psychological or psychiatric professions, is likely to be a sad sack groping for something to do to make himself feel important. The use of hypnosis can facilitate the treatment of many common prob-lems, including pain, anxiety, insomnia, smoking and obesity. Because there has been such widespread misunderstanding of what hypnosis is and what its appropriate uses are, we will review ten of the most common misun-derstandings about hypnosis: myth: Hypnosis is sleep. fact: Hypnosis is not only not sleep, but actually the opposite of sleep. It is a form of intense, receptive, focused concentration. For example, none of the electroencephalogram (brave wave) findings of sleep are present in hypnosis. Instead, those tracings typical of alert concentration are found during the hypnotic state. Hypnosis is not like general anesthesia. People are aware of and remember most of what occurs is a hypnotic trance. myth: Hypnosis is projected onto the patient. fact: The hypnotist projects nothing whatever. Instead he taps into the natural capacity to experience trance, which is inherent in many people. This trance capacity is a relatively fixed ability in each adult. Some people have a very high trance capacity; others are not able to be hypnotized. Most people have a capacity to experience trance which is somewhere between these two extremes and which does not change much throughout adult life. Most older children, on the other hand, have a high trance capacity. When a doctor uses hypnosis with a patient, he simply activates this capacity which the patient uses spontaneously at other times during intense concen-tration. myth: Only mentally "weak" or "sick" people are hypnotizable. fact: Wrong. In fact, the opposite is true. It is the mentally healthy person who is more likely to be hypnotizable. While some normal people cannot be hypnotized, in general those who suffer from serious mental or neurological problems are more likely to be unable to concentrate well enough to be hypnotized. The capacity to be hypnotized is a statement of rel-ative mental health. In general highly intelligent and educated people are more hypnotizable. myth: Hypnosis occurs only when a doctor decides to use it. fact: It can occur when the doctor decides to use it if the patient co-operates, but hypnosis often occurs spontaneously, especially when a hypnotizable person is under duress or is concentrating very hard. It is not 676 THE ANN LANDERS ENCYCLOPEDIA uncommon, for example, for a highly hypnotizable patient to report that he often gets so absorbed in watching a movie or reading a good book that he has to take a moment to reorient himself to the world around him when he is finished. This is a kind of spontaneous trance state. myth: Symptom removal means a new symptom. fact: Not necessary. Hypnosis can be used to help in the treatment of a variety of disturbing symptoms and in most cases, if it is done in a non- coercive manner, the patient will feel better and no new symptom will occur. However, if the patient directly or indirectly learns that this is expected, a new symptom may occur as a fulfillment of that prophecy. In most cases, pa-tients who overcome problems such as anxiety or insomnia feel better and often learn to make improvements in other areas of their life as well. myth: Hypnosis is dangerous. fact: Hypnosis itself is not dangerous, but the trance state can be used mischievously. The hypnotic state is a neutral state of attentive concen-tration. If a therapist introduces a therapeutically wrong proposal or unethi-cally exploits the patient, then, of course, harm may result. A scalpel in the hands of an expert surgeon can be a powerful tool for eradicating disease. In the hands of an unprincipled practitioner, it can do serious harm. Likewise, it is the use to which hypnosis is put that counts, not the state itself. People often fear that they can be made to do something against their will in the trance state. It is true that a hypnotized person is less likely to employ his usual critical judgment in deciding whether or not to comply with an in-struction. But such a person is always capable of bringing himself out of the trance, and is likely to do so if given an instruction which runs counter to his usual moral and ethical standards. However, learning that one has a tendency to automatically accept direction from others can become an important de-fense against making mistakes in the future. It is essential that one choose an ethical and well-trained therapist if hypnosis is involved. People also fear that they will become "stuck" in a trance. The entrance and exit from the trance state occur in a matter of seconds, and no one has ever been "lost" in a trance. myth: Hypnosis is therapy. fact: Not at all. At most, the use of hypnosis creates a receptive at-mosphere in which treatment strategy can be used with enhanced effec-tiveness. Being in a state of hypnosis by itself, without an appropriate thera-peutic strategy, offers no particular therapeutic effect unless the patient uses this as an occasion to bring about a spontaneous change in his life. It is espe-cially important to note that a person who calls himself a "hypnotist" is mak-ing a statement about how limited his abilities are. One can learn to produce THE ANN LANDERS ENCYCLOPEDIA 677 a hypnotic trance in a matter of minutes. What counts in choosing someone who uses hypnosis is his or her training and ability as a therapist. This could be a physician, a psychiatrist, a psychologist, a dentist or other trained and responsible clinicians. Determining therapeutic goals and strategies is what counts. The competent clinician who employs hypnosis to this end has one additional tool at his command. A person who is nothing more than a hyp-notist is like a person who has access to an operating room but no knowledge of what to do with it. myth: The hypnotist must be a charismatic, unique or weird. fact: Not so. Of course if the patient senses that the doctor is charis-matic or unusual in some way, he may be inclined to trust him or initially at-tempt hypnosis. But any sound, sober clinician can learn the techniques of in-duction into the hypnotic state. His manner should be natural and appropriate to the treatment setting. Trance induction is teachable and leam- able. In many instances recent learners are as fully effective as experienced practitioners in utilizing hypnosis as long as they are, in other respects, sound clinicians. myth: Women are more hypnotizable than men. fact: This is also untrue. All objective studies indicate that about 70 percent of both men and women are hypnotizable to one degree or another, and the ability to experience hypnosis is an example of real equality of op-portunity for men and women. myth: Hypnosis is only a psychological phenomenon. fact: There is evidence that hypnotic capacity can be inherited and that it is associated with certain patterns of brain functioning such as alpha waves on the electroencephalogram. The ability to concentrate intently which we call hypnosis has been used in the clinical setting for many purposes, for example in helping an individual cope with pain immediately after an injury, or chronic pain associated with such diseases as arthritis and cancer. Many such patients find that by practic-ing self-hypnosis they can learn to pay less attention to the pain even though it may still be there. Hypnosis should not be used to alter the perception of pain until a patient and his doctor are satisfied that they understand the reasons for the pain and have instituted the proper medical treatment. Once this has been done, how-ever, self-hypnosis (the patient practicing his own hypnotic exercise to alter the perception of the pain) can be effective and far safer than the use of vari-ous pain medications if the individual has the necessary hypnotic capacity. Hypnosis has also been used effectively in helping people overcome such problems as smoking and overeating. Many people find that they can learn to 678 THE ANN LANDERS ENCYCLOPEDIA use the hypnotic state to reorient themselves in the direction of enhancing their sense of respect for their body and thereby learn to avoid the trap of fighting the urge to eat or smoke. Learning to use self-hypnosis can help indi-viduals troubled with anxiety as well, although it must be noted that anxiety is a signal that something may be wrong in one's emotional and personal life, just as pain is a sign that something may be wrong in one's body. Practicing a self-hypnosis exercise can give an anxious person something to resort to when anxiety builds. Anxiety-related problems like phobias and medical problems which may have psychological aspects such as asthma, ulcers, headaches have been suc-cessfully treated with hypnosis. When patients are taught self-hypnosis, they learn to conduct their own therapy and often one session is sufficient to teach the necessary skills to overcome such problems as smoking and pain. Hypnosis has stirred interest in other areas as well. There has been grow-ing use of the intensity of concentration in hypnosis to enhance the memory recall of witnesses and victims of crimes. On the other hand, it should be clear that hypnosis is not a cure-all. It is rather one means for making better use of an individual's psychological resources. Nothing can be done in therapy with hypnosis that could not be done without it, but the intense concentration of the hypnotic state can help a person with the necessary capacity achieve his goals more quickly. credit: Herbert Spiegel, M.D., Clinical Professor of Psychiatry, Columbia Uni-versity College of Physicians and Surgeons, New York, New York; David Spiegel, M.D., Assistant Professor of Psychiatry and Behavioral Sciences, Stanford Univer-sity School of Medicine, Stanford, California; authors of Trance and Treatment: Clinical Uses of Hypnosis, New York: Basic Books. Hypoglycemia Much publicity has been given to the subject of hypoglycemia in the mass media recently. It has been blamed for all sorts of difficulties such as inability to concentrate, chronic lack of energy, dizziness and uncontrollable weight problems. Although some people with these complaints do indeed have THE ANN LANDERS ENCYCLOPEDIA 679 hypoglycemia, it is more likely that these symptoms are due to other causes such as depression, anxiety, poor eating habits, as well as other medical con-ditions. Hypoglycemia has become a catchall diagnosis. Therefore, it is im-portant to clarify what hypoglycemia actually is. Hypoglycemia literally means "low blood sugar" and refers to a condition in which a person experiences a certain set of symptoms because of an inade-quate supply of sugar (glucose, to be exact). The body, especially the brain, gets much of its energy from sugar. It is therefore important to try to main-tain a good blood sugar level at all times. Two hormones, insulin and glucagon, produced by the pancreas are primarily responsible for this impor-tant task. When the blood sugar rises following a meal, insulin shuttles the extra sugar into various organs of the body (particularly the liver), where it is stored for future use. When there is a shortage and the blood sugar level is low, glucagon breaks down the stored sugar. The sugar released flows into the bloodstream and restores the blood sugar. Glucagon can also stimulate the liver to make sugar anew. The interplay of these two hormones keeps the blood sugar at the right level whether we eat a large meal or skip a meal. The failure of the body to maintain the blood sugar at an adequate level results in hypoglycemia. In such a situation, a person may suffer many symp-toms. A sharp drop in the blood sugar will bring forth a surge of the emer-gency hormone adrenaline. This surge of adrenaline in turn will precipitate many familiar symptoms such as palpitation (pounding of the heart), lightheadedness and sweating. Because of the inadequate supply of sugar to the brain, one may also have mental lapses, blank spells, and may even pass out. Some people become highly emotional and irritable and go into crying spells during hypoglycemic attacks. Severe hypoglycemia, if uncorrected, could precipitate convulsions, coma and permanent brain damage. Two characteristic features help to distingish hypoglycemia from other conditions which cause similar symptoms. The first of these is that people who have hypoglycemia are usually free of symptoms between attacks. The second feature is that the symptoms of hypoglycemia usually disappear promptly, say within five or ten minutes, if one eats some carbohydrate such as orange juice or a candy bar. A thorough evaluation by a physician with the use of a full glucose toler-ance test will be necessary to diagnose hypoglycemia and exclude other con-ditions. The glucose tolerance test will help determine not only whether one has hypoglycemia, but also what kind. There are two types of hypoglycemia, broadly speaking. The first is the so- called "fasting hypoglycemia" in which the attacks tend to occur when a per- 680 THE ANN LANDERS ENCYCLOPEDIA son has not eaten for a while (for example, before breakfast or after skipping a meal). The second is called "reactive hypoglycemia" because in this type attacks tend to occur in reaction to a meal. A typical attack usually comes a few hours after eating a meal with a high carbohydrate content. Most people with hypoglycemia have the reactive type. Those who have had a stomach operation for peptic ulcer disease are prone to this type of hypoglycemia. Many obese people with early, mild diabetes also suffer from this type of hypoglycemia, but do not have these underlying conditions. In such people, the cause of hypoglycemia is unknown. Fasting hypoglycemia also occurs under many different conditions. If the liver is not working well, it can neither store nor make sugar, and hypoglyce-mia results. People who abuse alcohol often suffer from hypoglycemia be-cause they don't have good sugar stores and because alcohol interferes with the liver's production of sugar. One of the most important causes of fasting hypoglycemia is a special type of pancreas tumor called insulinoma. Such a tumor produces hypoglycemia by making too much insulin. Diabetic patients who take insulin are the single largest group of people who are subject to hypoglycemia. Severe diabetics in whom the blood sugar level swings widely during the course of a day are particularly vulnerable. Fortunately, most diabetics have warning symptoms of hypoglycemia so that he or she may be able to prevent a severe attack by eating something sweet. With a few diabetics, however, these warning symptoms do not occur, and they can get into serious trouble. This is why a diabetic should always carry sweets and also wear an identifying tag. The treatment of hypoglycemia depends on the type and the cause. In the case of reactive hypoglycemia, avoidance of sweets is essential except during the actual attack. Food high in carbohydrates stimulates too much insulin, thereby precipitating hypoglycemia in a susceptible person. For patients with mild diabetes and hypoglycemia, a weight reduction and diabetic diet are the mainstay of therapy since many of them are overweight. Those who abuse al-cohol should stop drinking and eat properly. Hypoglycemia in patients with an insulin-producing tumor can be cured by removal of the tumor. The fre-quency and severity of hypoglycemic attacks in diabetic patients taking insu-lin can be lessened by the addition of snacks between meals and by changing the dosage and type of insulin given. This maneuver can eliminate hypoglyce-mic attacks associated with exercise, and can be particularly important for the young diabetic who is physically active. Self-diagnosis and self-treatment of hypoglycemia is unwise and can be dangerous. When the presence of hypoglycemia is suspected, the exact cause and type should be determined. Since insulinoma can produce severe hypo- THE ANN LANDERS ENCYCLOPEDIA 681 glycemia without causing any outward physical or other chemical abnor-malities, its presence should be ruled out vigorously in patients with fasting hypoglycemia. Specialists in the field can make the diagnosis with new, so-phisticated tests. Proper treatment of hypoglycemia can be started only after a full evaluation of its cause and the type has been made. credits: Dr. Benjamin Park is an attending endocrinologist at the New York Hospital-Cornell Medical Center and an assistant clinical professor of medicine at Cornell Medical School, New York. Dr. Park practices medicine in Manhattan. Hysterectomy Hysterectomy is the surgical operation of removing the uterus, either through the abdominal wall or through the vagina. It is the most often performed major operation in the United States. Frequency of hysterectomy is increas-ing because a great many women choose to seek relief from menopausal problems, contraception worries and the fear of uterine cancer. Hysterectomy is the procedure of choice for many benign and malignant diseases of the uterus (1) if there are definite indications that call for its re-moval, (2) if the woman is not bothered by the fact that she will no longer be able to produce a child, (3) if there are no medical reasons the operation should not be performed. When done under these circumstance it rids the pa-tient permanently of her disease; it eliminates the necessity of surgical proce-dures in the future; it relieves the symptoms of which the patient was com-plaining and gets rid of the dangers of the gynecologic diseases. It also removes the principal cancer-bearing tissue of the pelvis although the proce-dure is not carried out for this reason. If surgery is indicated, it permits cor-rection of other difficulties. Many times the surgeon performs several different procedures coincidentally with the hysterectomy, such as plastic repair of the vagina. Emotional stresses which might arise in some women who are advised to have (or have had) a hysterectomy can usually be counteracted by free dis-cussion of the function and purpose of the uterus and the role played by menstruation. All this does not mean that hysterectomy is performed without 682 THE ANN LANDERS ENCYCLOPEDIA carefully considering the alternatives. It is performed if conservative manage-ment of the gynecologic disease proves inadequate. If the symptom is one of bleeding, it is performed if curettage (scraping of the uterus) or hormonal therapy fails to correct the bleeding; if due to myomas (benign fibromuscular tumors of the uterus; fibroids) if myomectomy is not suitable. Age and desire for pregnancy will certainly affect the choice of the surgical procedure. No treatment is preferable to a hysterectomy in some instances even though it is acknowledged that the latter might eventually be necessary. The ovaries should not be removed in pre-menopausal women unless definite ovarian disease exists. Ovaries continue to function after hyster-ectomy. They seldom create problems if left intact. Opinion regarding the need for hysterectomy has certainly come a long way since the mid-1800s when the London Medical-Chirurgical Review stated, "Extirpation of the uterus, not previously protruded or inverted, is one of the most cruel and unfeasible operations ever projected or executed by the head or hand of man." The other extreme is shown in a statement in a medical textbook published in 1969: "the uterus has but one function, repro-duction, and after the last planned pregnancy, the uterus becomes a useless, bleeding, symptom-producing, potentially cancer-bearing organ and therefore should be removed." Both statements, of course, are nonsense. The view of the situation regarding hysterectomy that best puts it into focus is by Dr. Joseph Pratt of the Mayo Clinic. He said, "Hysterectomy, re-moval of the uterus, is usually performed to relieve symptoms and to improve the quality of life. It does not necessarily have to be life-saving." In spite of adverse publicity regarding hysterectomy that one reads in the media today, most women are quite receptive to the benefits of hysterectomy. The main emphasis seems to be elimination of the possibility of cervical and endometrial cancer, relief of pelvic pain, incapacitating menstrual cramps and sterilization. Total abdominal hysterectomy, removing both the body and the cervix of the uterus, is the operation of choice for patients with benign uterine disease who have completed their childbearing and for patients with benign uterine disease that may be potentially dangerous. Examples of these diseases are ab-normal uterine bleeding (which has failed to respond to simpler means of treatment either curettage or hormonal), uterine fibromyomata (fibroids), endometriosis and chronic pelvic infection. In addition, the uterus is fre-quently removed when the patient is being operated on for coincidental disease, particularly tumors of the ovary and lesions of the vagina. If the patient is being treated for malignant disease, particularly endometrial (lining THE ANN LANDERS ENCYCLOPEDIA 683 of the uterus), then total hysterectomy and bilateral salpingo-oophorectomy (removal of both tubes and ovaries) is the recommended treatment Total hysterectomy is also used for treatment of pre-invasive cancer of the cervix and an extensive or radical hysterectomy with lymph node dissection may be the treatment for invasive cancer of the cervix, although radiation might be the treatment of choice. One of the confusing terms for the non-medical person is total or complete hysterectomy. By this we mean removal of the entire uterus: neck and body. If the ovaries and tubes are also removed we call this a total hysterectomy and bilateral salpingo-oophorectomy. However, for years a complete hyster-ectomy to the lay public meant removal of the ovaries. It should be made clear that the ovaries are removed only if they are diseased. When they ap-pear normal they are left alone unless the patient is postmenopausal. Vaginal hysterectomy may be performed in preference to the abdominal operation when it is being performed in conjunction with a repair or plastic operation for the cure of prolapse (falling) of the uterus, repair of relaxation lesions of the vagina, particularly cystocele (hernia of the bladder into the vagina) and rectocele (hernia of the rectum into the vagina), or if one is simply removing a malfunctioning uterus that is not too large to be removed vaginally. The postoperative course of a vaginal hysterectomy alone without repair is more comfortable than an abdominal procedure, which necessitates an abdominal incision. Hie vaginal approach is not desirable if one is operating primarily for ovarian disease, or if there are large uterine tumors which are best removed via the abdominal route and there has been extensive previous pelvic surgery or infections. The question of hysterectomy as a form of sterilization is being asked many times today and it is our feeling that the operation is far too drastic as a routine means of sterilization. As Ralph Reis once said, "One does not crack chestnuts with sledgehammers." With tubal ligation being so readily available today-a quick, simple and easy operation, done abdominally through either the laparoscope, or a mini-laparotomy incision, or vaginally- ligation is much more sensible than the major procedure of a hysterectomy with all its inherent potential complications. However, if the patient is one who will eventually need further gynecologic surgery such as a patient with small fibroids, a moderate degree of prolapse or abnormal bleeding, it would be better to do a hysterectomy right away rather than to subject this patient to a second hospitalization, anesthetic and operation in the future. To answer charges that too many hysterectomies are being performed, it has been shown that many of these charges are based on the lack of patho- 684 THE ANN LANDERS ENCYCLOPEDIA logic findings in the excised tissue. These are simply not relevant. A dysfunc-tional uterus, one that is either badly prolapsed and is hanging out of the va-gina along the patient's thigh, or one that is bleeding profusely, would probably be considered "normal" by certain tests, but the woman who under-goes hysterectomy in such a case is not healthy and would have needed the operation. In addition to prolapse, other indications would of course include extremely heavy menstruation; not life-threatening, but still dangerous or partly disabling. Hysterectomy can be a matter of great psychological consequence in the life of a woman. It is understandable that die uniquely female organ is often greatly valued. The psychologic effect of the uterus was first recognized in an-cient times with the origin of the words "hysterectomy" and "hysteria" being exactly the same in the Greek, meaning "womb." In order to understand the reaction of a patient to hysterectomy, it is necessary for the patient to know the realistic anatomical and physiologic changes dependent upon a particular operation: the patient's own private physiologic and anatomic beliefs about the function, value and importance of the organ, and the patient's major pat-terns of adaptation that may be disrupted by both realistic and irrational effects of hysterectomy. Delay in seeking medical care is due to a wide range of conscious and un-conscious psychological factors. The loss of any organ is cause for fear. And this organ particularly (the uterus) is believed by some women to be vitally necessary to achieve complete sexual gratification. The amount of bleeding, pain and weakness that a woman ignores or tolerates before seeking medical care tells us something about her fears. Other fears which are not specifically related to the loss of the uterus are fear of surgery itself and fear of anesthe-sia. (Anesthesia and complications from anesthesia are now considered some of the most dangerous aspects of any operation.) Then there is the fear of cancer-some women would rather not know if they have it so they stay away from doctors. An obvious concern about removing the uterus is the loss of childbearing ability. While many women feel it makes them less "womanly" others wel-come freedom from unwanted pregnancy and the burdens of contraception. The expected termination of menstrual periods brings varying responses. Many women regard the loss of menstruation as relief. Others consider men-struation good for the body, because it's a cleansing procedure. The majority of women in one study expressed genuine regret that menstruation would cease, yet many of my patients say, "I'm glad to be through with it." Anxiety concerning the effect of hysterectomy on sexual activity is ex-pressed by many patients. Some fear they will lose sexual desire. Others fear THE ANN LANDERS ENCYCLOPEDIA 685 they will be unable to respond to their husbands. Still others worry about the loss of sexual attractiveness. The opposite is usually true. Many women will be more interesting to their husbands because they will be able to have sexual intercourse without contraception. Moreover, the problem of bleeding will no longer be present. Nor will the pain and anxiety make for a depressing bed partner. There are many misconceptions regarding the anatomy, physiology and function of the uterus and these must be counteracted. It should be empha-sized that the uterus has essentially no hormonal function and removing the uterus will not bring on "change of life." The hormonal function is in the ovaries. If these are left in, the patient should not need sex steroid hormones. If, on the other hand, the ovaries must be removed, the hormones can be re-placed by medication and the woman will still maintain her femininity. Many women have fears from talking to members of their family and friends that after a hysterectomy, they will become fat, their skin will become dry and they will look much older. They have heard that the pain of surgery is terri-ble and that they might go insane after the operation. All of these miscon-ceptions are just that-misconceptions. The uterus is an organ of repro-duction in which the baby is incubated and has no other function. Following a hysterectomy, the patients usually feel remarkably better mainly because they no longer have the symptoms for which they were being operated on- bleeding, pain, pressure and the dropping out of the womb. Hysterectomies are performed in a hospital and require a stay of at least five days-perhaps six or seven, barring complications and depending on the recuperative powers of the patient. Another ten days of partial bed rest is ad-vised, if the patient feels like it. Some patients leave the hospital after five days and within a week are back to their normal patterns of living-healthier and happier. credit: Albert B. Gerbie, M.D., Professor of Obstetrics and Gynecology, North-western Medical School, and Attending Obstetrician-Gynecologist, Prentice Women's Hospital, Chicago; Chief, Division of Obstetrics and Gynecology, Chil-dren's Memorial Hospital, Chicago. 686 THE ANN LANDERS ENCYCLOPEDIA HYSTERECTOMY IS HISTORY, BUT MATE REMEMBERS