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It is from the toddler period onwards that parents can actively do things to encourage good sleep habits.

1. Avoid exciting or very active games>just before bedtime. It is very difficult for a child to quickly switch from an exciting activity which has the adrenaline flowing to a quiet state conducive to sleep.

2. Develop a regular bedtime routine (see p. 132) and precede this with a period of quiet activity.

3. Sometimes daytime naps mean the child is not tired at bedtime. If this is the case with your child, you may want to limit the amount of daytime sleep.

4. Try to be flexible about the exact time of going to bed. It may be a little later in summer, where darkness descends much later than in winter, or if the child obviously is not tired, or where there is a special occasion.

5. Avoid staying with the child until he falls asleep, or he will never learn to fall asleep by himself. At the end of the bedtime ritual, kiss your child goodnight and leave the room.

6. Night waking should not be reinforced by giving your child a drink or cuddle in the middle of the night. If he wakes, just ensure that he is alright, then make it clear that you expect him to go back to sleep.

*153\90\8*

In men, the urethra, or tube, leading from the bladder to the outside, may be ruptured with a pelvic fracture. The affected person may be unable to pass urine, or there may be a blood-stained discharge from the urethra.

If a fracture of the spine is suspected, the greatest danger is to the spinal cord and, if this is damaged, paralysis, either paraplegia (affecting the lower limbs) or quadriplegia (affecting all four limbs), may result.

Be particularly careful with a person who is injured after diving into shallow water. Dislocation to the spine at the neck may cause damage to the spinal cord.

You must be extremely careful in moving this type of victim. Preferably, leave him to the expert, an ambulance man or a trained first-aider.

*633/71/1*

The liver is involved in most cases but only in about a sixth, does jaundice or yellowing of the skin, appear.

Unfortunately, there is no specific treatment except rest in bed. Aspirin or paracetamol eases the pain and reduces the fever.

Lethargy and depression are common symptoms and, unfortunately, these may persist for months.

Recurrences of glandular fever are not uncommon and can occur weeks or months later.

While the virus has not yet been identified there is some research which seems to indicate that it is identical with an already discovered virus known as Epstein-Barr virus.

One theory is that EBV is a common infection in man normally well tolerated.

A minority which escape infection reach adolescence and then as a result of the virus develop infectious mononucleosis.

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Painful breasts mainly occur at the time of the periods but they also can be unrelated to the menstrual cycle. Pain is often associated with the presence of many tiny lumps throughout the breast tissue.

For severely painful breasts, radical treatment can be used. This involves removing all the breast tissue, leaving the skin and the nipple, and inserting an implant.

Two new drugs have been shown to be of great value in relieving breast pain. One is bromocriptine which, among other uses, can be used to suppress milk production after childbirth.

The other is danazol, which was introduced to treat endometriosis, a disorder where the lining tissue of the womb may occur in other tissues such as the ovary. Both drugs produce relief of breast pain in 70 to 80 per cent of cases.

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‘What gives,’ I asked.

He says he has a stomach ache. Ben never complains of stomach aches, so when he said this and didn’t make any effort to get up this morning, I thought it was time to do something.’

‘Good idea,’ I replied. ‘Fellows of Ben’s age usually do not complain for nothing.’

‘I agree,’ answered Judy. ‘The pain was mainly around his belly button to start with. That was this morning. But new he says it has moved down to the lower right hand side of his tummy region. Excuse my non-technical terms, but that’s how it is.’

‘Might as well use words we all understand,’ I said with a smile. People often worry about not being able to use medical terminology when describing symptoms, but I prefer the simple easy-to-understand terms, and most of my patients prefer this also.

‘Ben didn’t want any breakfast today—quite unusual for him. In fact, he even vomited later in the morning. Not much. But he hasn’t been to the loo either for a bowel action, and he says it’s a bit uncomfortable when he passes his water.’

Ben looked a bit flushed, unhappy and obviously not his usually cheery self.

‘Let’s have a check,’ I suggested, lifting Master Ben on to the examination cot.

I gently prodded his bare tummy. At the same time I watched his face which was screwed up in an unhappy wince. This increased as I pressed a little firmer into his R.I.F. (that is short for right iliac fossa). This is the part located in the lower right-hand side of the abdomen. Draw an imaginery line from the naval to the front part of the hip bone. Now divide this into equal thirds. The critical point is where the middle and lower thirds meet. When I put a bit of pressure over this spot, Ben gave a decided yowl of discomfort.

‘Ouch! That hurts,’ he moaned, and a few tears rolled down his cheeks.

‘Okay, Ben,’ I said. That’s nearly all.’

I was pretty convinced Ben had an acute appendicitis, for the appendix lies directly beneath this critical point. In addition, the muscles over the abdomen were fairly tense, another indication that inflammation was active in the depths of his abdominal region. I guessed the appendix was fairly close to his bladder, probably causing some irritation there, too—hence the urinary symptoms his mum had mentioned.

‘Just one more check,’ I said to Master Ben. I then did a quick examination of his rectum, via the back passage. I was very gentle, but inside my finger soon hit a spot that made Ben yelp once again.

This clinched it. I was now quite certain I had touched the vital spot, an inflamed appendix, without doubt.

Ben lay there, with his legs drawn up. Obviously this position gave him some relief from the discomfort. Although a bit pale, he didn’t seem to be running any elevated temperature at this stage— not uncommon in the early hours of this disease.

‘I think there is little doubt about a diagnosis,’ I said to Judy. ‘Ben has appendicitis.’

Treatment

‘What now?’ was the inevitable reply. ‘Will his appendix need to come out?’

‘That would be the best idea,’ I replied. ‘And the sooner the better. I’ll get on the phone to the hospital right away and make the necessary arrangements. Do you want to phone your husband and tell him what we think? Or would you like me to speak to him?’

‘I think I’ll let you talk to him after you’ve fixed it with the hospital,’ Judy said. ‘He’ll ask all sorts of questions, and you’ll be able to answer them more fully.’

It didn’t take long to contact the hospital and my surgeon colleague who would carry out the surgery. Then I gave Ben’s father a ring, told him what I felt about Ben, and got his approval and blessing.

‘Go ahead, and make whatever arrangements you think are best,’ he said. ‘I know you will get a good surgeon.’

I hung up and turned to have a further chat with Judy—and Ben, if he was sufficiently interested, which it happened he was.

Appendicitis is a fairly common disease, but it doesn’t bear playing around with. In fact, statistics show that about 60 Australians perish annually because the diagnosis is overlooked (generally because parents fail to take their children along early enough) and surgery is delayed. It should never occur in these modern days, but it continues to do so, I am sorry to say.

It is probably the most common abdominal disorder that requires surgery in childhood. Most cases are in the 4-12 year age bracket, but nobody is immune. There has even been reported a case in an infant only a few weeks old. Diagnosis at that age is terribly difficult.

The cause

And what is the cause of appendicitis? The doctors are not quite sure. In some cases, the opening of the appendix becomes jammed up with debris from the bowel—little hard lumps called faecoliths. In other cases, especially in children, it can be caused by worms blocking the opening, germs and debris packing up inside and an infection born and rapidly developing into an acute situation.

It is surprising how rapidly the infection can develop. In some acute cases the appendix has increased in size enormously. The walls and contents become filled with pus, dead germs and debris. Unless surgery is carried out as a matter of urgency, then the entire organ may rupture. A mass of debris will spill into the abdominal cavity, and this situation becomes serious, involving peritonitis— infection of the lining of the abdominal cavity.

In the days before the advent of the antibiotics, this was often fatal, though today peritonitis can be prevented. Acute cases are now operated on quickly, for all hospitals are geared with the facilities to handle this common emergency.

Many other cases of appendicitis develop slowly. Starvation, regular fluids and nursing may help. But doctors still do not like taking risks if there is any doubt.

Occasionally sore throats can sometimes give a condition that mimics appendicitis. It is called mesenteric adenitis. The symptoms can be almost identical. Small glands scattered about in the abdominal cavity, called lymph glands, may become infected. They are often preceded by a simple sore throat from which infection spreads. Often there may also have been a respiratory tract infection, which has spread to the abdominal region. In fact, many cases have been misdiagnosed as appendicitis. However, it is better to err on overdiagnosis, most doctors believe, than to miss a serious case of acute appendicitis which may otherwise cause a seriously ill patient, or even a fatality.

By this time Ben had climbed down from the cot, and with mum’s help had dressed.

‘Nothing to eat or drink,’ I cautioned. ‘Straight up to the hospital, and before nightfall the appendix will have been removed. I’m sure there will be an excellent recovery. Within a few days you’ll all be home, together again.’

‘I’m much happier now that we know what the problem is,’ Judy said. ‘Thanks for your help.’

*50\87\2*

When lying on his tummy, the five-month old baby will lift the head and chest fairly high off the mattress; he lifts the head and shoulders when lying on his back. Is able to bend his knees and suck his toes. He becomes more and more mobile, readily rolling from his back to the tummy position. He tends to rock and roll the entire body, twist and turn.

If lying on his back, he will press his feet against a hard surface or kick at it forcefully. He can readily be pulled to a standing position, and if supported under the arms, will often jump the body up and down, or stamp the feet alternately on the surface he is standing on. Lying on his tummy, he will extend his limbs and arch the back and rock.

His ability to sit increases and he may now sit in a position, with a firm back, for up to thirty minutes. He keeps his head steady and erect during this time. If he is pulled up, he assists by bending his head forward, flexing his trunk, and drawing his legs towards his tummy. When seated, he is able to grasp objects readily.

His finer hand movements are gradually developing. He tends to grasp for objects with the thumb and index finger. He will play with objects offered, such as a rattle, or he may hold his bottle either with one or both hands. His aim is improving, and he will reach for items he wishes to have, and grasps for them when they are reached. He can readily use both hands, and will tend to exchange items from hand to hand, and frequently waves them in the air.

Talk

Ability at making more understandable noises increases. He makes ‘vowel’ sounds (such as ee, ay, ey, ah, ooh) and a few of the consonants (such as m, 1, b, d).

He tends to sing and talk away to himself, or to his toys and playthings. He often uses baby talk to attract attention.

He still gazes intently at the mouths of others as they talk, and after hearing others talk he will often try to mimic the same sounds. He becomes a good imitator, and indeed this is an integral part of baby’s method of learning how to talk. It is possible for a baby to mimic nearly any audible sound.

He becomes actively responsive to extraneous noises, and will turn his head in the appropriate direction, looking for the person speaking or for the source of the noise.

He has learnt to recognise and understand his own name—a major achievement!

Mind

The baby is becoming more and more mentally alert and is able to remain acute for an hour or even longer. If placed in a new environment, he will look around and size up the situation. He will make a deliberate effort to find the source of sound and to follow it around with his eyes; he will often follow an object until it disappears, such as a person walking from the room.

When he is reaching for objects, his eyes carefully follow the movement to help him. As he reaches for an item, his eyes will dart from his hand to the object until he is successful. He will tend to reach for objects in front of him, bringing his hands together from the sides towards the midline. Often he overreaches or under-reaches, frequently with clenched fists, but his degree of success gradually increases.

If he sees part of an object, he can visualize what it looks like in its entirety. Often he will search for a fast-moving object. If he drops a favourite plaything, he will look around in search for it. If something is impeding his vision close by, he will try to brush it aside.

His ability of remembering familiar objects increases, and he can easily recall immediate past actions, or objects.

He can readily identify his parents’ faces, his brothers and sisters, and he knows strangers are strangers. He may resent the latter, particularly women.

He makes a deliberate effort to mimic noises and movements. This ability steadily increases.

He makes efforts to alter his environmental situation, either by repetition or by additional movements.

If he is playing with blocks, he will grasp one, then suddenly-become interested in a second one. Grasping for the latter, he will then drop the first. This process goes on and on.

Relationships

He tends to show definite mood changes, indicates fear, disgust and anger. He can distinguish faces reflected in a mirror, and will often smile and react to reflections, such as his own or his mother’s.

He increasingly interacts with others, especially human faces and voices that he recognizes. He can discern the familiar and the unfamiliar. He smiles and makes throaty noises as a means of making social contact.

He shows anticipation. He will raise his arm and wave it; will put both arms up indicating he wishes to be held. He likes being close to persons who come near to him and will cling to a person holding him.

He learns to tease, and will give baby talk trying to interrupt others during their conversation. If he is crying, this often ceases when he is talked to.

He may indicate protest—for example, when a person tries to take a toy from him. Enjoys being played with, and will enjoy a good frolic. He plays with his toys, pats his bottle or mother’s breast.

He takes less readily to the breast, preferring solids. He may start to use a cup. Each morning he wakes at a fairly regular hour.

*5\87\2*