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Partial mastectomy/segmentectomy

A variation of lumpectomy, this operation is done for a larger tumour and involves the removal of a larger wedge of normal tissue. Auxiliary lymph nodes may also be removed.

The advantage of this operation for women with larger breasts is that most of the breast tissue is preserved. There is also unlikely to be much swelling of the arm as most of the auxiliary lymph nodes remain intact. However, the breast may be left flattened or distorted, particularly the nipple.

Radiotherapy is likely to be necessary after a partial mastectomy in case any cancer remains in the breast tissue left behind. Again, radiotherapy must be avoided if all the auxiliary lymph nodes have been removed.

Mastectomy

In simple or total mastectomy, the entire breast is removed, usually together with some or all of the auxiliary lymph nodes. Breast reconstruction should be possible following this operation. Its advantages include the retention of the muscles of the chest wall, which are removed in a radical mastectomy. The risk of arm swelling is increased if the auxiliary lymph nodes are completely excised, or if some of them are removed for staging and then radiotherapy is given.

There is controversy about how many of the auxiliary lymph nodes should be removed. Some surgeons claim that complete removal leads to a very low recurrence rate and makes radiotherapy unnecessary. Others prefer to perform a wide lump excision (removing the lump itself as well as a wedge of the normal tissue surrounding it), with sampling of the auxiliary nodes for prognostication, and follow it up with radiotherapy to a large area around the breast and armpit. This is a quicker operation, involving less risk of damage to the nerves responsible for sensation in the arms.

For pre-menopausal women whose auxiliary nodes are involved, surgery may be followed by adjuvant chemotherapy for 6 to 12 months.

Radical mastectomy

This operation is now uncommon. It involves the removal of the entire breast, the auxiliary lymph nodes, fat, and the pectoral muscles of the chest wall. If metastasis has not already occurred, radical mastectomy can completely remove the malignant cells. However, it does leave a long scar, a hollow chest, restricted movement of the shoulder, and loss of arm strength due to the removal of the muscles which normally allow arm movement.

Modified radical mastectomy (Patey)

In this operation the entire breast, all the lymph nodes in the armpit and the smaller of the two chest muscles are removed.

As all the auxiliary lymph nodes are removed, swelling may occur in the arm, but muscle strength is retained.

Super-radical mastectomy

Another uncommon operation, this involves radical mastectomy as well as removal of further lymph nodes known as the internal mammary and supraclavicular nodes. However, there is no evidence to prove that this operation is more effective than radical mastectomy alone.

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These include things such as stopping smoking, wearing seat-belts reducing alcohol consumption and so on. They are often extremely cheap to implement. A cost-benefit analysis on smoking and alcohol produces dramatic results. The cost of alcohol abuse and smoking accounts for one fifth of all health expenditure. When indirect costs are added the cost of smoking and alcohol abuse accounts for one quart of all the economic costs of illness. These figures would increase even more if the costs of fire losses, ca accidents and crime due to smoking and alcohol were added.

According to Dr John H. Knowles, President of the Rockefeller Foundation:

Over 99 per cent of us are born healthy am suffer premature death and disability only ñ result of personal misbehaviour and environmental conditions. . . . the individual has the ðîã indeed the moral responsibility to maintain own health by observance of simple prudent rules of behaviour. . . life is meant to be enjoyed . . . but the cost of individual responsibility health care now becomes prohibitive. The choice is individual responsibility or social failure. Responsibility and duty must gain some degree of parity with right and freedom.

So much for the costs of alcohol and smoking. The benefits are harder to quantify. The benefit could be the amount people are prepared to pay to indulge in these activities but this is probably an underestimate because presumably people prevented from smoking and drinking would need to do other things to answer the need; they have in the first place. Perhaps the cost of the drug bill would rise proportionately. A prevention plan to reduce smoking and alcohol use would, of course, cost money and there would be transitional costs as the two industries lost profits and put people out of work. Governments could, of course, compensate these industries temporarily in the interests of the nation’s health.

Even allowing for all these costs economists still think the financial advantages could be considerable. To see just how cost-effective a reduction in tobacco and alcohol use would be one need look no further than the Mormons and Seventh Day Adventists in the US who live without these drugs and have provably lower death rates and longer lives. Their healthy eating habits also give them a cancer mortality of between 50 and 65 per cent that of other Americans.

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It wasn’t until Susan Ledford discovered the power of a fresh, sweet orange that she was able to pass up her biggest indulgence and lose 43 pounds.

A member of a big Southern family that loves food, Susan is no stranger to temptation. When special occasions call for family celebrations, “it’s like a race to see who can make the most disgustingly rich casserole,” says the 36-year-old newspaper designer from Tallahassee, Florida.

Such decadent dishes were standard fare while Susan was growing up. But they weren’t kind to her waistline. She gained weight throughout her teenage years, and by her twenties, she was trying all sorts of diets in an effort to slim down. “I’d go on one diet and lose a few pounds only to watch them return when I went back to my normal eating habits,” she recalls. By age 34, she topped out at 168 pounds.

Knowing that Susan was unhappy with her figure, a friend suggested that she join Weight Watchers. The program taught Susan how to make healthy food choices and control her portion sizes. Within a year, she took off 43 pounds.

Thrilled to have finally reached her goal weight of 125 pounds, Susan was determined to stay there. But she had one dietary hurdle to overcome. Susan loved to bake cookies for her family and friends, especially around the Christmas holidays. She especially enjoyed licking the bowl and sampling each batch fresh from the oven.

Realizing that her taste-testing ways would do nothing for her hard-earned figure, Susan decided to have a healthy snack before baking. Her food of choice: a fresh, juicy orange. She found that the intense flavor of the fruit quashed her cravings for cookies. She was i able to bake to her heart’s content without eating a thing.

Thanks to her ingenious strategy, Susan had an easier time sticking with her healthy eating habits. Her weight has held steady at 125 pounds since 1998.

WINNING ACTION

Feed your sweet tooth an orange. Susan’s strategy has real scientific merit. According to Marilyn C. Majchrzak, R.D., food-development manager at the Canyon Ranch Spa/Health Resort in Tucson, Arizona, intensely flavored foods such as oranges tend to be more satisfying than bland foods. So snacking on something sweet and juicy will help reduce temptation. Keep lots of oranges, fresh pineapple, strawberries, or your favorite tastebud-shocking fruit in your fridge.

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The main drug in this group is ipratropium (Atrovent) which is taken by inhalation. Side-effects are rare except at high doses. They include dry mouth, difficulty in passing urine and constipation. Other anti-cholinergics include butethamate and atropine. Anti-cholinergics help to reduce the amount of mucus present in the airways as well as relaxing the muscles,

and may be useful where asthma and bronchitis occur together.

Sympathomimetics, such as adrenaline and ephedrine, are sometimes combined with anticholinergics in inhalers. Atropine is combined with adrenaline and a muscle relaxant in Brovon and Rybarvin. Butethamate is combined with ephedrine in CAM, which is taken by mouth. Ipratropium is combined with the bronchodilator fenoterol in Duovent.

Other bronchodilators

Sympathomimetics were once the main drugs used for bronchodilation, but they are much less specific for the bronchial muscles than the drugs described above. They produce side-effects more easily than modern bronchodilators and are much less used now. They include adrenaline, ephedrine and phenylephrine. Typical side-effects include nervousness, anxiety, tremor, irregular heartbeat and dry mouth.

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For anyone with multiple food sensitivities, avoiding all their culprit foods can be very difficult. And it may mean that they eat too much of other foods, with die attendant risk of developing new sensitivities. Even those who are intolerant of just one or two foods may find it difficult to avoid them, especially if they eat away from home a lot. So there have been many attempts to develop alternative methods of treatment.

Given the lack of knowledge about how food intolerance arises, these attempts are largely a ’suck-it-and-see’ exercise: trying out treatments and seeing if they work. No treatment has yet been devised which is 100 per cent effective for all patients, and there are some on offer from ‘alternative’ practitioners that are quite ineffective and even potentially dangerous (eg urine therapy). However, there are two methods currently being tried out by some doctors, known as neutralization or desensitization treatments, that are worthy of further investigation.

In some studies, these treatments have performed quite well, but in others they have been less successful. Consequently such techniques are controversial and many doctors feel that they should not be used until there is more evidence that they work. But given the complex nature of food intolerance, and the evidence suggesting that it is caused in several different ways (see Chapter Twelve), perhaps it is not surprising if a treatment gives varying results – it might be expected to work for some patients and not for others. Our own experience suggests that such methods are effective for a proportion of people with food intolerance. But they are probably not worth trying unless there is no reasonable dietary alternative.

These methods have also had some success in treating classical allergies, and in this context they may be very useful. The traditional method of desensitization, once widely used for hay fever and other allergies, cannot now be given by family doctors in Britain. This method involved injecting minute, but gradually increasing, doses of the allergen over a period of many months. There is a risk of collapse, due to anaphylactic shock, with this method, and a few patients have died as a result. Such desensitization treatment can now only be given in hospital, where resuscitation equipment is available.

Other uses claimed for these techniques include desensitization to environmental chemicals, such as exhaust fumes, and desensitization to Candida, where there is a sensitivity to the yeast’s products as a consequence of candidiasis.

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Most of the cross-reactions that are seen (or suspected) in patients do not match so well with the biological classification. For many foods, the use of the family group to predict cross-reactions is more a matter of faith than science, but it is still the most useful guide we have. There are also some unexpected cross-reactions, which do not tally with classification schemes.

If you have reason to suspect any food before starting on your elimination diet (because you eat it in large amounts, for example) you should check the food-family list to discover which family it belongs to. All its relatives should be excluded during the first phase of the diet, along with the food itself. The food families may also be useful later, in interpreting your reactions to tested foods, and in planning your diet afterwards – just as you should not eat too much of any one food, you should not eat too much from any one food family either.

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For the older baby, early weaning may be the answer, although it involves the risk of sensitizing the child to even more foods or – if all the high-risk foods are avoided – failing to give the child an adequate diet. Early weaning is only recommended if the baby is suffering quite badly and you have exhausted all other possibilities. It would not be appropriate, for example, in the case of a colicky baby who was otherwise well and growing normally. If you decide to try early weaning, remember the following points:

1. Certain foods seem to contain more potent allergens than others. Do not give the child eggs, fish, chocolate, wheat, oranges, peanuts or other nuts for at least the first six months, and preferably for the first year of life. If you introduce them before a year old, do not give them every day. Test out beef and chicken cautiously, as these can cross-react with milk and eggs respectively. If they seem to cause no problems, you can include them in the child’s diet.

2. Formula feeds commonly contain maize (corn) and tapioca, as well as cow’s milk, so your child may have become sensitive to these. Avoid these foods for at least six months and then try them out carefully. Maize comes in many guises, including cornflour, cornflakes, corn oil, corn syrup, sweetcorn, corn-on-the-cob and popcorn. Some medicines contain corn syrup: ask your pharmacist for advice if you are concerned about avoiding all corn products.

3. No food should be eaten in very large quantities, and it is best not to give any one food every day. This means using your imagination and buying some fairly unusual items. Foods such as millet and sweet potatoes make a good basis for baby foods, and if the baby does become sensitive to them, at least they are no trouble to avoid in later years.

4. Do not force the child to eat any food that is obviously disliked. Most children reject new foods the first time they are offered, but if your child clearly finds the food disagreeable, even after trying it three or four times, then don’t serve it up again. A dislike of the taste is sometimes an early sign of sensitivity.

5. If a child is not eating eggs, milk or fish, there is a risk of protein being in short supply. Make sure that you include other protein-rich foods, such as lamb, pork and other meats. Beans are a good source of protein, but they are also rather indigestible and cause wind; chickpeas (p303) are less of a problem, and have a milder taste.

6. Your child will probably need a calcium supplement, and the overall diet should be checked by a paediatric nutritionist to see if it contains enough of other minerals, as well as vitamins. Ask your doctor to arrange this for you.

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Anyone who lives in a town or city will have been kept awake, at some time or another, by the sound of a burglar alarm ringing endlessly in an empty shop or house. The alarm is only meant to ring if someone breaks in, but it is triggered off by some other quite innocent event, such as a strong wind or the vibrations of a passing lorry. This is more or less what happens in the case of allergies. The mast cells, which are meant to respond to invasion by parasites, are triggered off by an innocuous substance such as eggs or cow’s milk. But why should this happen?

The answer is that the body misguidedly makes IgE antibodies that fit the antigens in these substances. A very complex and intricate set of controls normally prevent the body from making IgE in response to such harmless materials, but in the allergic individual something goes awry and the control mechanisms break down.

In the case of Jane, her body had mistakenly made IgE antibodies to an antigen in peanuts, probably a protein. The strange symptoms that she experienced on eating peanuts were all produced by mediators released from her mast cells. Mast cells in the tissues of the mouth were triggered as soon as the food came into contact with them, producing symptoms almost immediately. Her lips and tongue swelled up because tiny blood vessels inside them became leaky, allowing fluid to seep out into the surrounding tissues.

The cause of Jane’s collapse (anaphylactic shock) when she ate peanuts again was a sudden drop in blood pressure, likewise produced by the mediators. This time, it seems, more IgE was present and far more mediators released. By making the blood vessels all over her body expand, and at the same time become more leaky, the mediators left her without enough blood pressure to keep the vital organs functioning.

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Petasites is one of the best, if not the best, natural remedies, often giving better results than one hopes and expects in cases of tumours, especially those of suspected cancer or actual cancer. If it is taken together with Viscum album, the reliable fresh plant extract from mistletoe, or in the form of a combination remedy made up of these two remedies, it is possible to experience satisfactory results even in cases where chemotherapy has no more to offer.

So when the doctor says that he has done everything possible, and that there is no hope left for an improvement in a patient’s condition, remember Petasites and Viscum album. These two remedies, together with an appropriate diet containing plenty of fruit juices and vegetable juices, can often achieve an improvement in the patient’s general well-being. At any rate, this treatment can definitely reduce sensitivity to pain and make life easier.

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The importance to our health and well-being of caring for the feet will be clear from the preceding sections. Other interesting points will also be explored in the following pages. However, this section sets out to provide some useful guidelines on caring for the feet in general, as discussed above, as well as dealing with specific problems that may be experienced.

1. To start with, go and buy yourself shoes that are sensible and fit the foot rather than the fashion.

2. In the second place, take note of the following three points:

Wash your feet daily; afterwards knead and massage the muscles, then rub the feet with a little foot oil, such as Juniperosan.

If you suffer from rheumatism, arthritis or an ailment that causes water to accumulate in the feet, it is useful to add a tablespoon of herbal sea salt to a foot bath. This bath should last 15—30 minutes, at a constant temperature of 37°C (98.6°F).

Sore feet should be bathed in an infusion of mallow or sanicle.

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