Sleep is a modified innate activity. Young babies sleep for about 16 hours a day, waking up about five to six times in the 24 hours for feeding. This multiphasic sleep pattern may be the innate pattern of sleep. Gradually, as we become older, we learn to sleep more at night and to stay awake more in the day. At about one year of age, we wake up only once or twice at night, but stay awake most of the day. When we reach school age, we go to bed at about 8 p.m. and wake up at about 7 a.m. the next day. When we are adults, most of us sleep for seven to eight hours each night at one stretch. Hence, through learning, we change from a multiphasic pattern to a monophasic pattern of sleep. In some countries there is a sleep in the afternoon called the siesta or midday nap. Sleeping at two different times in the 24 hours is known as a biphasic sleep pattern and is more natural and refreshing than a monophasic pattern since it more closely resembles the innate pattern of multiphasic sleep.
Hence learning a sleep pattern is like toilet training. We learn to sleep at certain times of the night. Our parents expect us to sleep at night, and our teachers expect us to stay awake in class. We are modifying the innate ability to sleep in order to fit in with society, the majority of which shows a monophasic sleep pattern.
Nowadays, with the help of the sleep laboratory, we can demonstrate that there is a recurrent 90 minute sleep cycle, discussed in detail in chapter 5 on Two Kinds of Sleep. Every 90 minutes throughout the 24 hours there is a few minutes of sleepiness which has been called the 90 minute window. During this window we can fall asleep easily if we want to. Can this be a vestige of the innate multiphasic sleep pattern?
Since sleep is a modified activity and we learn to sleep when we are very young, various problems are created. We learn a lot of bad sleeping habits. Bad habits are certain behaviours we pick up and incorporate into our routine.
We watch television in bed, we eat in bed, we stay up late at night, and wake up at all sorts of hours in the morning. Yet we expect to be able to sleep well whenever we want to. If we want to have better sleep, these bad habits have to be unlearned and eliminated.
*9\174\4*
Because of their different personalities different individuals express their feelings of affection in varying degrees of emotional and physical closeness. The shy and inhibited introvert habitually defends himself by withdrawing from people. In the early stages of marriage he is simply unable to tolerate a very close relationship. If his partner is emotionally freer, and is not sensitive enough to perceive his need for emotional distance, she may produce extreme tension in the introvert by trying to come too close either emotionally or physically. On the other hand, if the introvert’s partner allows their relationship to develop slowly and easily, he will mature and come to make freer patterns of response which at first would have been quite impossible.
Sexual Pleasure in Causing Pain-The sex act evokes a different mental attitude in the man to that in the woman. The man is active and in a way aggressive, while she is essentially passive and accepting. In men, being active and aggressive may become associated with sexual feelings; but in another way aggressive action is associated with fighting and inflicting pain. In this way sexual pleasure may become unconsciously associated with causing pain, a condition known as sadism. The man with mild sadistic tendencies is rough with his sexual partner, and likes to penetrate roughly and deeply as if to hurt her. Conversely the passive and receptive elements in the woman may be associated with the idea of being hurt. She comes to experience sexual pleasure in being caused pain in her sexual relations. This is known as masochism. If the husband has marked sadistic traits, and if the wife is lacking in the corresponding masochistic elements, there will be tension and anxiety. If on the other hand these attitudes are reversed in an unnatural way so that the woman has the sadistic tendencies, then the tension is likely to be so much the greater because it conflicts more acutely with the male personality.
*35\57\2*
Depression is by its very nature a discouraging condition and the response to anti-depressants in general is often not smooth and linear. Your mood can bob up and down and it may be hard to tell just where you are compared to where you were before you started treatment. In my practice I have used a very simple way to help my patients monitor their mood over time. Just as when you diet it is helpful to weigh yourself regularly so as to see the pattern of response, so it can be very helpful to chart your mood on a daily basis after you start a new type of anti-depressant treatment. And just as when you diet you can gain a pound or two on a particular day, perhaps as a result of water retention, even though you are succeeding in losing weight over the long run, so it is possible to have one or two bad days even though your mood may be better overall. Being able to refer to the chart is helpful in illustrating this overall improvement. Alternatively, if you are not improving, you might be inclined to try and kid yourself that you are. Referring to the chart may reveal this not to be so and prompt you to shift your strategy in finding a different way out of your depression.
*87\75\2*
Whatever the ’cause’, most people with epilepsy analyse their day to day lives in an attempt to detect factors which precipitate seizures.
Virtually every conceivable life event may be blamed by some people with epilepsy, who may become overly obsessional about avoiding factors they consider important. For example, a man had each of his two seizures on railway trains. He firmly believes that in some way trains make him have seizures. It is likely that this occurrence is just coincidental, but we cannot be entirely sure that he is wrong!
There are, however, a number of factors which do seem to precipitate seizures in at least some people with epilepsy.
Sleep and lack of sleep-The electroencephalogram (EEG). At this stage, it is only necessary to know that it records the changes in voltage resulting from activity of cerebral nerve cells. The EEGs of people without epilepsy change during the passage from normal wakefulness, through drowsiness, to sleep. Sleep is not constant, as judged by body movements and EEG patterns, throughout the night. At various intervals one pattern of brain waves occur in association with rapid movements of the eyes. Through waking patients at this time we know that it is during this stage of sleep that dreams occur.
The changing electrical activity of the brain during drowsiness and sleep may allow seizure discharges to ‘escape’. Indeed, those analysing EEGs hope that their patients drop off to sleep during the procedure as the possibility of recording an abnormality is considerably enhanced.
Some subjects have all or virtually all the seizures whilst asleep—but they can never be entirely sure that a daytime attack will not occur. A follow-up study of one group of people with ‘nocturnal’ epilepsy showed that about a third had a daytime seizure in the next five years. The effects of depriving people of sleep have also been studied by keeping volunteers continuously awake, or by waking them up every time the EEG showed the pattern of rapid eye movement sleep. In each case EEGs on subsequent undisturbed nights showed that the subjects were catching up on the rapid eye movement sleep they had missed. Deprivation of sleep, therefore, has been shown to alter cerebral electrical activity, and it is not surprising that this is another factor in precipitating seizures. In practical terms, repeatedly staying up late may precipitate seizures in young adults.
*26\188\2*
Mr J.P. of Michigan writes: “Though I’m only 36 years old, I had suffered for years with arthritis in my knees as a result of a number of old sports injuries. At the restaurant where I work I often have to get things from the walk-in cooler downstairs, sometimes as much as twenty times a day. The frequent stair climbing is bad enough in itself. Add to that the freezing air from the meat cooler, especially on these cold Michigan winter days, and you’ve got a killer combination for arthritis.
“I often had to use a knee brace to help me along. Actually, I began to wonder just how long I would be able to hold on to my job before my knees gave out. Well, thanks to you and CMO my knees are just fine now. So much so, I even packed away my knee brace a couple of months ago.” [Editor's note: Mr J.P. took CMO in February 1996 and has needed no further treatment to this day.]
Mrs. J.L., age 65, of Michigan experienced a sudden onset of arthritic symptoms in her hands, shoulders, and hips. In less than a year her fingers became gnarled and twisted out of shape. She wrote, “I’m in pain all the time. My fingers and hands cramp up as well as my feet and legs.” She sometimes took as much as 40mg of Prednisone and 100 mg of Darvocet, but found them only somewhat helpful. With CMO her fingers straightened so well she sent us before and after pictures. [We regret they're not of publication quality.] Another benefit, her blood pressure dropped from 160/90 to a normal 110/70 – further proof that CMO is an immunomodulator that can normalize a number of different functions within the body. [Editor's note: This normalization of blood pressure is very common in people who take CMO. Specific controlled studies of this effect are being planned.]
*47\142\2*
Signs and symptoms
The toe becomes red, painful, and tender to the touch. The wound produces a thin, watery pus that works its way under the nail. The tenderness, redness, pain, and swelling gradually get worse, eventually involving one entire side of a toenail. Often the nail becomes partly covered by raw, red tissue and a wet crust.
Home care
If you catch it early, you can treat an ingrown toenail successfully by gently cutting out the spur or the ingrown corner of the nail, and then frequently soaking the toe in warm water for long periods. Even if the toe is so tender to the touch that you cannot remove the embedded nail, prolonged soaking in a strong Epsom salts solution (one cup to one liter of water) may cure the condition. Cover the lower foot and toe with a bandage or cloth and soak both foot and bandage thoroughly in the solution. Then cover the dripping foot with plastic wrap or encase the foot in a plastic bag. In this manner the nail can soak for hours with little effort on your part. Because of the delicacy of the nails involved, the ingrown toenail of an infant can often be cured by wiping the area several times a day with rubbing alcohol, and then soaking the toe in clear warm water.
Precautions
• If your child repeatedly develops ingrown toenails check his or her shoes; they may be too small or too pointed.
• Teach your child to trim the toenails straight across without leaving sharp spurs that may cause problems.
• An infection near the nail that lasts for more than a few days is probably an ingrown nail.
Medical treatment
If an ingrown toenail doesn’t clear up with home treatment, your doctor can remove the embedded piece of nail. If the toe is very painful, the doctor may apply a local anesthetic before removing the ingrown area of the nail. If ingrown toenails occur frequently your doctor may suggest minor surgery to narrow the nail and make in-growing less likely.
*133/84/5*
What is it?
The accumulation of tissue fluid in the body. It is most noticeable in the fingers (rings become tight), around the eyes (eyelids look and feel puffy), and in the abdomen (belts become tight). It is a condition that affects millions of women, often around their period times.
About 60 per cent of the body’s weight is water, which is distributed in the various fluids inside and outside the cells. The average person takes in about 2-3 quarts of fluid a day and the body’s balancing mechanisms ensure that the loss through urine, sweat and on the breath keep the total body water steady. A healthy person can handle at least 8 quarts of fluid a day without retaining any but people with heart disease, liver disease, kidney disease and certain hormonal problems retain fluid abnormally. Water is retained in places that offer least resistance, particularly around the eyes or where gravity exerts its main influence (such as around the feet and ankles). If, when you poke your fingertip into a swollen ankle it leaves a depression, you have about 8-9 lb of water too much in your body overall.
Immediately before a period many women, because of their hormonal changes, retain water-sometimes putting on up to a stone in weight. This produces swollen, tender breasts, pelvic pain, headaches, stomach swelling, nervousness, irritability, a feeling of mental dullness, insomnia and poor concentration. Even the eyeballs can swell and make the wearing of contact lenses impossible. During pregnancy ankle swelling is also common.
What causes it?
• Hormone changes in the premenstrual phase of a woman’s cycle.
• Long periods of standing and walking can cause foot and ankle swelling.
• Pregnancy causes ankle swelling as a result of the pressure of the heavy uterus on the pelvic veins, which reduces their ability to collect fluid from the legs.
• Heart disease (especially heart failure, in which the reduced pumping efficiency of the heart means a smaller blood flow to the kidneys to produce urine).
• Steroid hormones (which cause salt to be retained by the body along with water to dissolve it in). This includes the contraceptive Pill, of course.
• Kidney diseases in which the capability of the kidney to put out normal amounts of urine is impaired.
• Certain allergies cause local fluid retention. This is especially seen in urticaria (hives). The swelling may be generalized, or may affect only the hands, feet and face.
• Too much sodium in the diet. Water always goes hand in hand with sodium so if you eat too much sodium (salt) you will automatically retain too much water.
• Stress and emotional conditions can cause (in men as well as women) too high a production of anti-diuretic hormone which causes the retention of water.
• Very hot weather, especially if humid too, can make some people retain water.
*151/72/5*
Discharge from hospital
When you are Discharge from hospital ready to be discharged from hospital, the ward receptionist will ask you to pay any outstanding charges such as those not covered by the hospitalization charge. Before you leave you will be given any medical items you may need from the hospital pharmacy.
Adjuvant therapy
Although adjuvant treatments for breast diseases, such as radiotherapy and chemotherapy, can be undertaken in private care, not all private hospitals have the facilities to carry these out. For example, very few can offer on-site radiotherapy, and this treatment is likely to be given at an NHS centre.
Differences and similarities
The main aim of the staff of any private hospital is the same as that in an NHS hospital – to make your stay as pleasant and as comfortable as possible. Because the staffing ratio is higher in private hospitals, more emphasis can be placed on privacy and comfort.
The consultant surgeons and anesthetists almost always work in an NHS hospital as well as in a private hospital, so you will receive the same expertise and skill under both systems. However, in an NHS hospital you may not actually be operated on by the consultant surgeon who heads the surgical team and, indeed, you may not see the consultant at all during your stay.
Private hospitals arrange their operating lists differently from NHS hospitals. The NHS hospitals have ’sessional bookings’ for their operating theatres. This means a particular day is set aside at regular intervals for a specialist in one type of surgery to perform operations. In private hospitals, the consultants can book the use of an operating theatre (and the assistance of the staff who work in it) on any day, at any time that suits them. Therefore, your operation can take place privately with minimum delay, and at a time that is convenient to you and your consultant.
It is also possible, even if you are already on an NHS waiting list, to tell your GP or consultant at any time that you would like to change to private care. If the consultant you have already seen under the NHS does not have a private practice, you can ask to be put in touch with a consultant who can see you privately.
Although some private hospitals may have their own breast care nurses, the majority do not. However, if you would like to talk to a breast care nurse, the hospital should be able to arrange this. Bearing in mind how important the role of these specialist nurses has been recognized to be, it may be a good idea to request this service. The same applies to counseling services, which will probably be made available if you request them.
There are several reasons why, if they can, some women choose to have their operations done privately, either paid for by private health insurance or from their own pockets. Some find it much more convenient to be able to have a say in when their operation is to take place. The NHS, under which the majority of people are treated, naturally has longer waiting lists. If time is an important factor for you, you may be happy to pay to have your operation done at a time that you find convenient.
Some people simply prefer the smaller, more intimate setting they are likely to find in a private hospital. Private hospitals rarely deal with accidents and emergency treatment; the operations carried out in them are normally planned, at least a day or two in advance. Therefore, they do not have the bustle of an NHS hospital which has to deal with emergency admissions as well as the routine admissions for non-emergency operations.
*66/39/5*
Precisely what will happen when you have your laparotomy will depend to some degree on what sort of surgery you are having, the practices of your gynecologist and the practices of the hospital. What follows should only be used as a guide.
You will probably be in hospital for about five to seven days if you are having a conservative laparotomy, or seven to ten days if you are having a hysterectomy.
You will usually be admitted to the hospital the day before the operation. After you have gone through the formalities of being admitted to the ward someone will probably take your medical history. A nurse will take and record your temperature, pulse, breathing rate and blood pressure. An electrocardiogram and blood and urine tests may be taken, particularly if you are having a hysterectomy. Your pubic hair and the lower part of your abdomen will usually be shaved and you may be given a suppository if you have not opened your bowels that day.
A physiotherapist may visit you and teach you some breathing and foot and leg exercises to do after the operation, especially if you are a smoker, an asthmatic or prone to chest infections.
The anesthetist will visit you to discuss the operation and ask you about any allergies and previous problems that you may have had with a general anesthetic, such as nausea.
Some time before your operation you will be given a consent form to sign so that you can give your permission to undergoing the operation. You may have previously signed the consent form when you discussed the operation with your gynecologist during an earlier visit.
At bedtime you may be offered a sleeping tablet to help you sleep in the unfamiliar hospital ward. It is important to have a good night’s sleep before your operation so it is advisable to take the sleeping tablet if it is offered.
You will not be allowed to have any food or drink for at least six hours before the operation. Shortly before the operation you will be asked to shower and put on a gown and you will be asked to empty your bladder. About an hour before you are due to go to the operating theatre you will probably be given an injection, known as a pre-med or a pre-medication, which will probably make you feel relaxed and sleepy and make your mouth dry.
If you are apprehensive about your surgery you may like to ask if you can have your partner or a friend or a close relative come to stay with you for the hour or two before you go into theatre.
Immediately before the operation you will be taken to the operating theatre. In the operating theatre an intravenous drip will be inserted into your arm and you will be given the general anesthetic. After you have lost consciousness a tube will be placed in your throat and connected to a machine that breathes for you.
A tube known as a catheter may be inserted into your bladder to drain the urine.
A horizontal cut about ten centimeters in length will usually be made across the abdomen along the pubic hairline. Sometimes the cut will be made vertically between the middle of the pubic hairline and the navel, particularly if you have previously had a vertical cut or if bowel surgery is likely.
The gynecologist will then thoroughly inspect the pelvic cavity for any signs of endometriosis, adhesions and other damage so that she or he can plan the operation and decide which procedures need to be carried out.
When the surgery has been completed the gynecologist will stitch up the wound and the tube in your throat will be removed. You will then be taken to the recovery room for about half an hour before being taken back to your bed in the ward.
*49/41/5*
In anorexia, the first goals are to stop the patient from starving and to reverse her weight loss. Only then can we work on the emotional problems that led to the disorder in the first place.
Another goal is to show her how to reduce anxiety, not just about weight gain, but about food and eating as well. For an anorexic, who also binges and purges, an additional goal is to stop her bulimic behavior. Although some of the methods described below are for inpatient treatment, they can also be adapted for use with outpatients.
As in bulimia, there are three phases of behavioral treatment. First is the evaluation. During this time we conduct medical tests and get to know the patient. We draw up the treatment contract, which spells out the goals for weight gain and which both the patient and her parents sign. In this early phase, we tell the patient she must maintain at least the same weight she had when she was admitted. Otherwise she will be confined to her bed to save precious calories.
Once things have settled down we move into the next phase, during which we work toward the goal of bringing her weight back up to a healthier level. The contract specifies this target range, which is not subject to further negotiation because it is based on what we believe will be physically healthy for the patient.
We monitor the patient’s progress by weighing her daily. To get the most accurate reading, we weigh her in the morning, before breakfast and after she has gone to the bathroom. She wears only a robe. If knowing her weight will make her anxious, she faces away from the scale. We reward her for actual weight gain, rather than for her eating behavior during meals. The reason for focusing on weight rather than eating behavior is that the patient may give the appearance of eating all she is being served but may be getting rid of the food when no one is looking.
Our usual inpatient contract asks that the patient gain one half-pound a day. Such a goal is both reasonable and safe. Gaining weight too fast can cause edema or cardiac failure. If the patient reaches this goal, and is in no medical danger, she earns full privileges, such as complete recreation and visiting privileges. A gain of between a quarter and half a pound means only partial privileges. No gain-back to bed. This isn’t a punishment-bed is simply the safest place for a starving person to be. We also negotiate other incentives for weight gain at various points along the way: new clothes or records, special trips outside the hospital, and so on.
Gaining weight requires more calories than simply maintaining weight. Patients gradually work up to eating perhaps four thousand calories a day. Since the goal is not to teach someone to eat huge quantities of food or become bulimic, I usually add high-calorie liquid supplements such as Sustecal or Ensure to her normal amount of solid food.
Instead of requiring a specific daily weight gain, some doctors use a graph. A curve on the graph represents what the patient should weigh as time progresses. As long as her weight stays above that line, she earns full privileges. This method has one advantage over a daily weight-gain requirement. Especially during the early phases, a patient’s weight may fluctuate quite a lot, even if she is eating well, due to changes in water balance. A graph can take such fluctuations into account, which may keep the patient from being unfairly penalized.
Critics of the behavioral contract point out that an anorexic needs to develop a sense of self. She must find an identity that doesn’t depend on starvation. The contract, they claim, robs her of the opportunity to grow by imposing on her a mechanistic, prefabricated set of rules.
I disagree. My experience convinces me that many people with eating disorders welcome intervention by others, so long as it is done in a way that genuinely respects their individuality. A contract sets up boundaries and limits. It gives shape and focus to a world that is spinning out of control. The patient knows what to expect and what the consequences of her actions will be. I’m not saying that she necessarily likes those limits. Sometimes one benefit of the contract is to give her something to react to-or against. She finally has a focus for her anger. This in turn might help her to express anger rather than turn it inward. For people with an eating disorder, recognizing and dealing with anger is a good step in the right direction.
*74/35/5*
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