There is no effective treatment for tics. Sometimes relaxation techniques are recommended, and occasionally therapy or counselling for the child, but there is little evidence of their efficacy. It is worthwhile for parents to search for any ongoing stresses for the child in the family, but this must be done with subtlety and discretion, or else it may make matters worse. In most cases it is not immediately possible to locate any particular factors causing stress.

The best advice is to pay absolutely no attention to the tics — to ignore them completely. Some parents believe that if they bring the tic to the attention of the child each time it happens, they will help make the child more aware of his behaviour. They feel that this will be the first step in helping him control the tic. It must be emphasised, however, that the tics are not under any voluntary control that is, the child is unable to control them. Drawing the child’s attention to them is likely to make matters worse by increasing his anxiety and making him even more self-conscious.

When to see your doctor

Many parents will take their child to the doctor when the tics first appear, to make sure that there is no underlying medical cause that can be treated. The doctor will undertake a careful history and perform a physical and neurological examination, and perhaps test the child’s vision, but it is rare to find any medical problem. It is almost never necessary to order any special tests.

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MAGNETIC RESONANCE IMAGING (MRI)

This is a specialised radiological technique which uses radio waves to produce an image of highly detailed anatomy of the brain and spinal cord on a screen. No discomfort or pain is experienced, and there is no exposure to radiation. Smaller children may require sedation in order to keep them perfectly still during the procedure.

SKIN TESTS FOR ALLERGY (SENSITIVITY TESTS)

These tests may be recommended by your doctor if your child suffers from allergic conditions such as hayfever. Tiny amounts of various substances which are known to cause allergic reactions (allergens) are placed on the skin. A tiny needle is then used to prick the skin very lightly through the drop of allergen. After 15 minutes the skin is ‘read’ for allergic reactions. If a child is allergic to a certain substance an itchy, red lump will have formed in reaction to it over the area where it was originally placed. Because the solutions used are so diluted, a full-blown allergic reaction will not occur. Sometimes patch tests are used where a particular substance is placed on a small patch on the surface of the skin.

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Question

Will hypnosis help?

Answer

Hypnotism can produce a very positive response in the short term. The result will not last if we have no understanding of the disorder and don’t know how to manage the attacks and anxiety ourselves. In conjunction with panic/anxiety management skills, hypnotism can help while we work with aspects of the disorder. If we use an audio tape of the hypnosis session during periods of high anxiety and attacks, the tape must teach us how to control the anxiety and the attacks. The control does not come from a cassette tape.

Some people use subliminal tapes in an effort to ease their symptoms. We must know what the subliminal message of the tape is and, more importantly, we should consciously know and learn how to manage anxiety and the attacks ourselves.

Question

I have heard about people becoming housebound. I am the opposite. I can’t bear to be in the house. As soon as my husband goes to work I have to get out of the house. I spend my days travelling on buses or walking around shopping centres. Is this part of the disorder?

Answer

This does happen to some people. If they have difficulty in being alone, going out and being around other people is better than staying home. It can also happen to people who were housebound, but for another reason. As people progress in their recovery, some may go through a stage where the thought of being home all day brings back too many memories of their disorder. They prefer to go out as much as they can. This stage does pass.

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First of all, there are some types of cancer for which complete surgical removal is never feasible. Cancers which start in many different parts of the body at the same time can never be cured surgically. Examples include leukaemias and myeloma (cancers of the bone marrow) and most lymphomas (cancers of the lymph nodes). The other group of cancers which cannot be cured surgically are those starting in a part of the body which is essential to life and the function of which cannot be naturally or artificially replaced. Examples include cancers of most parts of the brain, spinal cord, heart, and cancers which extensively involve the liver.

Then there are some types of cancer which can rarely be cured by surgery on its own because they almost always release cells into the bloodstream very early, before the primary cancer is big enough to be detected. Examples include some primary bone cancers (Ewing’s sarcoma, osteogenic sarcoma), small cell anaplastic (oat cell) cancer of the lung, cancer of muscle (rhabdomyosarcoma), a type of kidney cancer (Wilm’s tumour) and others. With these types of cancer you will make the best decisions if you simply take it for granted that tiny blood-borne seedlings are present, even when no actual secondary growths can be detected. Obviously these types of cancer are rarely cured simply by removal of the primary growth. Usually the best chance of cure is provided by chemotherapy combined with either surgery and/or radiotheraphy treatment.

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Hodgkin’s disease was first described by Thomas Hodgkin, a pathologist at Guy’s Hospital, London, in the early 19th Century

It has been regarded as a malignancy, or cancer, affecting the lymph nodes.

Lymphoid tissues are scattered throughout the body, usually in localised collections such as the tonsils, the adenoids, the spleen, in the wall of the small bowel, and in the lymph nodes or glands in the neck, under the arm and in the groin.

This tissue is concerned with the body’s defence against infection and foreign tissue introduced into the body.

It is part of the immune system and is full of lymphocytes, which are white blood cells — present in the blood and bone marrow and in these collections of lymphoid tissue.

The lymphocytes produce antibodies.

Hodgkin’s disease is now regarded as perhaps two or three different but related disorders.

It occurs more commonly in males than in females. And although it may occur at any age, there are three peaks where it’s more common — in middle childhood, young adulthood and in old age.

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Pregnancy, labor and delivery are usually normal and uncomplicated.

One of the prices we pay for medical control is that pregnancy and childbirth can be thought of as an illness.

But it is only by close monitoring of the mother and the developing baby that complications can be prevented or recognised early and controlled.

A complication that appears to have arisen as part of our highly developed, over-fed civilisation is the condition of toxaemia of pregnancy, or preeclampsia.

The cause of this is unknown but it is rare in

underdeveloped countries and during war time when food is rationed.

In pre-eclampsia there is a generalised constriction of all the blood vessels of the body and a rise in the blood pressure. At least 15 per cent of women with their first pregnancies will develop some rise in blood pressure.

This can damage the kidneys, usually temporarily but occasionally permanently, and shows by the protein albumin leaking out in the urine. As well, sodium along with water is retained in the tissues and causes oedema or swelling.

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Anxiety is a feeling similar to fear. It is the appropriate emotional response to the perception of a danger. The danger may be external, such as an alarming situation or a natural catastrophe; or it may be internal, such as when an individual is in a conflict situation, either real or imagined, with his own conscience and moral standards of behaviour.

Internal dangers are the principal source of human anxiety. Often the patient is unaware of what he is afraid. He may assign his anxiety to his wife, his boss, or a nuclear threat, but these are conscious rationalizations for the most part. The real conflict is usually hidden from the patient, and concerns the self-imposed, unconscious inhibition of instinctual impulses which are regarded as unacceptable. His real fear may lie in the possibility of his carrying out his primitive instinctual drives, particularly those related to sexuality and aggression. The failure of an instinct to find an appropriate outlet may result in its inappropriate discharge, causing tension to be built up to the point where some means of relief must be found. This may result in peptic ulceration, hypertension, migraines, or a skin disorder.

The body, however, conforms to a general biological principle, that of homeostasis. This means that there are automatic regulatory mechanisms which keep the internal environment constant and relatively uninfluenced by sudden external environ-mental shifts. Similarly, in the mind, internal or external dangers are ‘buffered’, the defence being a neurotic reaction. This of course entails a price in discomfort, as does the defensive reaction of a fever (high pulse rate etc) in serious infections. These defence reactions take place spontaneously and automatically. As far as we are concerned the psychosomatic defence reaction to various anxieties is manifested by dysfunction in the skin.

The person with an unsightly skin disease has, however, a special cross to bear because of the irrational and often cruel attitudes of society towards skin abnormalities. We may be sure that repugnance and disgust, in most cases so out of proportion to the medical significance of the skin disorder, is a defensive social response growing out of unconscious fears connected with unhealthy skin. The best example of social irrationality of this kind is that associated with the disease leprosy. Affected persons, though not appreciably contagious or ill, are banished to live in leprosariums, supposedly to render others safe but fundamentally because humans are driven to excesses combating their unconscious fear of skin disease. It would seem, then, that mankind regards the skin as the psychological symbol of spiritual and moral purity. A blot upon it, therefore, may be unconsciously interpreted as a sign of moral impurity. Skin lesions are typically and irrationally regarded as ‘dirty and highly contagious’.

One must, however, beware of blaming all skin disorders on conflicts within the psyche. The flare-up of a skin disorder following an emotional upset is not proof that it is therefore a psychologically-caused (psychogenic) disorder. It is well known that exacerbations of many skin disorders occur under stress, diseases which may well have a real organic basis. For example, psoriasis, acne, or leprosy, which are by no means without their deep organic basis, may all be aggravated by anxieties or stress. On the other hand, the failure to identify an intense stress prior to the onset of symptoms by no means excludes the possibility that the disorder is psychocutaneous. In fact this pattern occurs more often than is realized. Prolonged tension without the benefit of a clear cause, will sooner or later become symptomatic. Patience and skill are necessary to detect the underlying anxiety in some individuals whose typical defence is a superficial serene equanimity. On occasions the skin lesion so successfully defends against the anxiety that the patient is actually unaware of the anxious feelings. Without time and psychological sensitivity, the doctor may fail to realize that emotional illness can be concealed behind such facades. The complete ‘poker face’ more often than not is evidence of repression of anxieties rather than psychic peace.

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It is important to eat a high carbohydrate and low-fat diet The following practical tips which we have set out in an easy A to Z format will help you reduce the fat content of some of your favourite recipes at the same time as you are lowering their G.I. factor.

Milk. Many people dislike skim milk, particularly when they taste it on its own or in their coffee! However, you can use skim milk in a recipe and no one will notice—and the fat saving is great. For convenience you might want to keep powdered skim milk in the pantry so that can be made up to the desired quantity when you need it. It will taste more like fresh milk if you mix the powder and water according to directions and refrigerate the milk overnight before using it UHT (long life) milk is handy in the cupboard, too.

Nuts. They are valuable for their content of vitamin ?, but they are also high in fat To keep the fat content of a recipe low, the quantity of nuts has to be small.

Oil. Most of our recipes call for no more than 2 teaspoons of oil. Any polyunsaturated or monounsaturated oil is suitable. Cooking spray or brushing oil lightly over the base of the pan is ideal. If you find the amount of oil insufficient, cover your pan, or add a few drops of water and use steam to cook the ingredients without burning. It is a good idea to invest in a nonstick frying pan if you don’t have one!

Pasta. A food to eat more of and a great source of carbohydrate and B vitamins. Fresh or dried, the preparation is easy, lust boil in water until just tender or ‘al dente’, drain and top with a dollop of pesto, a tomato sauce or a sprinkle of Parmesan and pepper. There are many wonderful pasta cookbooks now available. It is definitely worth investing in one to find all sorts of exciting ways to prepare this fabulous low G.I. food. Pasta may appear in your menu as a side dish to meat, as noodles in soup, as a meal in itself with vegetables or sauce or even as an ingredient in a dessert.

Reduce the fat content of minced meat by browning it in a nonstick pan, then placing the meat in a colander and pouring boiling water through it to wash away the fat Return to the pan to continue cooking. It is a good idea to buy the better quality minced beef with less fat.

Stock. If you are prepared to go to the effort of making your own stock —good on you! Prepare it in advance, refrigerate it then skim off the accumulated fat from the top. Prepared stock is available in long-life cartons in the supermarket Stock cubes are another alternative. Look for brands that have reduced salt.

To saut?. Heat the pan first, brush with the recommended amount of oil or less, add the food and cook, stirring lightly over a gentle heat.

Vinegar. A vinaigrette dressing (1 tablespoon vinegar and 2 teaspoons of oil) with your salad can lower the blood sugar response to the whole meal by up to 30 per cent The best types of vinegars for this purpose are red or white wine vinegar or use lemon juice if you prefer.

Weighing. What’s the weight of the meat you’ve buying? Start noticing the weight that appears on the butcher’s scales and consider bow many serves it will give you. With something like steak, that is basically all edible meat,) 20 to 150 grams per serve is sufficient Half a kilogram is more than enough for four serves. Choose lean cuts of meat. Trim the fat off before cooking or before you put it away. Alternate meat or chicken with fish once or twice a week.

Yoghurt. Yoghurt is a valuable food in many ways. It is a good source of calcium, and ‘friendly bacteria’, protein and riboflavin and unlike milk, is suitable for those who are lactose intolerant Low-fat natural yoghurt is a suitable substitute for sour cream. If using yoghurt in a hot sauce or casserole, add it at the last minute and do not let it boil, or it will curdle. It is best if you can bring the yoghurt to room temperature before adding to the hot dish, lb do this, mix a small amount of yoghurt with a little sauce from the dish then stir this mixture back into the bulk of the sauce.

Zero hit is unhealthy, so speak with the professionals (dietitians) about bow to get just the right amount you need. Our bodies need essential fatty acids that can’t be sythesiscd and must be supplied in the diet Pat does add flavour—use it to your advantage.

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Traditional thinking: The physics model. It has always been thought that the main causes of excess body fat are simply too little exercise and/or too much food. The traditional model for defining this has been encompassed by the formula:

Change in energy stores = Energy intake (EI) – Energy Expenditure (EE)

Where EI = calories from food, EE = resting metabolic rate (MR) + thermogenesis + daily physicalactivity.

There are now a number of reports that have established this is clearly inadequate for describing weight gains and losses in living organisms. According to the above calculation, for example, it has been estimated that a 75kg man who is in energy balance and who then adds an extra slice of toast and butter (100kcal) a day to his diet for 40 years would gain around 189kg over that time—a prediction which is clearly not sensible. The discrepancy results because energy is more closely balanced in free living organisms than was once thought. This comes about because there are changes in EE and EI with changing weight (e.g. changes in metabolic rate and the energy cost of activity, or changes in food intake with changes in physical activity). The above formula then needs to be modified to reflect rates of change, thereby allowing for the effects of changing energy stores on energy expenditure. It is now clear that initial differences between EI and EE (such as a modest increase in total calorie intake) do not lead to unbounded changes in body mass, hence the insufficiency of the physics approach.

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A laparotomy is a major operation involving a cut in the abdomen. Both conservative laparotomy and hysterectomy are performed as part of a laparotomy. This section describes what will happen before, during and after a laparotomy.

Conservative laparotomy and hysterectomy for endometriosis are described in detail later in this chapter.

Things to think about before a laparotomy

Before your operation it is important that you make sure that you and your gynaecologist agree on the purpose and nature of your surgery and that you have resolved any questions or concerns that you may have. If necessary you should make a special visit to discuss these issues. Ideally, the preparation for your surgery should involve preparing yourself physically and emotionally for the operation itself as well as planning for your recuperation period afterwards.

The healthier you are before surgery the more quickly you are likely to recover afterwards. It might be worthwhile taking a few steps to improve your general health if necessary.

Measures that might be worth considering include eating a nutritious diet, taking vitamin and mineral supplements, particularly vitamins B, E and C, and exercising regularly.

If you are a smoker it would be advisable for you to quit smoking at least one to two days before your operation to reduce the likelihood of anaesthetic complications. If you are taking the oral contraceptive pill it may be best to stop taking it for a month or so before your surgery to reduce the risk of complications, particularly thrombosis. If you are overweight, losing some weight will help reduce the risk of complications.

You should also make sure that you are completely happy with your decision to have the surgery. Do not hesitate to seek the advice and support of others if necessary.

Before you go into hospital you should arrange to have some help with household tasks such as cooking, laundry and cleaning when you return home.

What happens with a laparotomy

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 gynaecologist 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 anaesthetist will visit you to discuss the operation and ask you about any allergies and previous problems that you may have had with a general anaesthetic, 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 gynaecologist 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 premedication, 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 anaesthetic. 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 centimetres 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 gynaecologist 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 gynaecologist 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.

After a laparotomy

After your operation you will have an intravenous drip in your arm to provide you with fluids so that you do not become dehydrated as you will not be allowed to drink. You will usually have a catheter draining your bladder for the first day or two if you have had a hysterectomy. You may also have a tube coming out of the surgical wound to drain any excess fluid and debris from the area of the operation.

For the first twenty four hours after your operation the nurses will observe you closely. They will chart your pulse, breathing rate, blood pressure and temperature frequently and check your wound and record any vaginal bleeding. During this time your gynaecologist will come and discuss the operation with you.

The physiotherapist may visit you again to help you with your breathing and foot and leg exercises.

You may experience some nausea and/or vomiting immediately after the operation. To help relieve this you may require an injection.

You will usually feel drowsy and experience pain for the first few days following your surgery, particularly from your wound. The tube that was placed in your throat may give you a sore throat for the first day or so. Two to four days after your operation you will probably experience wind pain which can be very unpleasant and uncomfortable.

For the first day or two you will either be given painkilling drugs continuously through your intravenous drip or you will be given painkilling injections every four to six hours. You will then progress to painkilling tablets.

When you first start to drink again you will be allowed only to suck ice and sip small quantities of fluid. Once you are able to cope with fluids and any nausea and vomiting has ceased your intravenous drip will be removed. When you have passed wind you will be able to progress onto a light diet of semi-solids and then onto a normal diet if you have no problems. You will probably not open your bowels for the first two to four days after your operation but if constipation becomes a problem you may be offered suppositories.

You will sit out of bed for a short time on the day after your operation and you will be encouraged to move around a little more each day as your condition improves.

When you return home you will then require another three to five weeks of recuperation if you have had a conservative laparotomy, or another three to seven weeks if you have had a hysterectomy. It is important that you do not just rest in bed but that you move and walk around each day and gradually increase your activity level as you recover and feel better.

You may tire quickly for the first week or two, so you will need some help with household tasks for the first one to three weeks, especially if you have children. When you start to do the household jobs again you should do a little at a time and still have plenty of rest. Do not try to be a superwoman as it will only slow down your recovery in the long-term.

For the first week or two after you return home you may still have some discomfort or pain so a mild painkiller such as Panadeine or Panadol may be necessary. The vaginal discharge, if you have had it, usually persists for about two weeks after surgery but it may last for up to six or eight weeks following a hysterectomy.

Most of the healing of the wound occurs in the first two weeks after surgery. After that you can lift light loads but it is probably best to avoid lifting heavy loads if possible for the first month or so. You can drive the car again when you are fit enough to do light gardening and walk up stairs quickly, generally about three to six weeks after surgery. You can have sexual intercourse again when your doctor has examined you about six weeks after your operation.

You should notify your gynaecologist immediately if you develop any of the following symptoms:

A fever

Your wound becomes tender, swollen and red

A discharge appears from your wound

Severe abdominal pain or cramps

Urinary frequency and scalding when passing urine

Pain or bleeding when using your bowels

Your vaginal discharge develops an unpleasant odour

Your vaginal discharge persists beyond six to eight weeks

Tenderness and/or swelling in your calf muscles

Increasing soreness of the calf muscles when walking

Shortness of breath, chest pain or pain when breathing.

Risks and complications of a laparotomy

The risks associated with a laparotomy are greater than those associated with a laparoscopy but they are still fairly low. Most of the complications are relatively minor and they usually resolve themselves fairly quickly.

The complications which may occur at the time of surgery include an allergic reaction to the anaesthetic, uncontrolled bleeding and accidental damage to internal organs such as the bowel or bladder.

Complications which may develop after the operation while you are still in hospital include constipation, bleeding at the wound site, urinary infection, wound infection, chest infection, heavy vaginal bleeding, difficulty emptying the bladder, and thrombosis (when a blood clot forms in a vein, usually in the pelvis or a leg) and embolism (when a blood clot lodges in the lung).

Complications which may develop after you return home include wound infection, bleeding from the wound, urinary infection, a vaginal discharge with an unpleasant odour and a change in bladder and/or bowel function which may persist for one to two months.

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