Pain is the usual obvious symptom. It is initially rather vague, centred around the umbilicus (navel), usually intermittent in character and associated with nausea, vomiting and loss of appetite.

Anorexia or loss of appetite is a constant feature and characteristic of this condition. There may be either diarrhoea or constipation.

If the inflammation progresses and the outside of the appendix becomes involved, the character of the pain changes. It moves to the right lower abdomen and becomes constant.

When the doctor examines the patient, he may find a slight elevation of temperature, the tongue is often furred and the breath is offensive.

Examination of the abdomen usually reveals some tightness of the muscles over the appendix in the right lower side and, if the peritoneum or covering of the organs and the inside wall of the abdomen is inflamed, rebound tenderness is present — when the abdomen is pressed and then let go suddenly, there is a sharp stab of pain.

*205/71/1*

Who, then, is most likely to be a genetic candidate for the disease? Ten to twenty years ago (perhaps longer), the implicit assumption was that endometriosis was a disease carried by and exclusive to white middle-class women who were under stress and career-oriented. No real data was collected on the incidence of the disease within these women’s families. Researchers simply tended to associate it with women who fit this characteristic scenario, and did not probe any further. The first real study was done privately in 1970 by Dr. Brooks Ranney, a South Dakota gynecologist, who first noticed a distinct biological pattern among his patients with endometriosis—many were related to each other. Dr. Ranney sent questionnaires to these women. Based on their responses, he calculated that 22 percent reported relatives (both near and distant) who had undergone surgery for endometriosis.

How coincidental is endometriosis among female relatives, and were Ranney s figures high or low for the general population? A study at Baylor College of Medicine, in Texas, in which 123 women participated, attempted to provide more conclusive evidence. In this 1980 study, researchers attempted to trace lineage patterns of the disease by classifying female relatives into categories, then looking at their medical histories. “First-degree” relatives were defined as mothers, daughters, and sisters; “second-degree” relatives included maternal grandmothers, aunts, and nieces; and “third-degree” relatives were female first cousins.

The results were telling: overall, the Baylor team estimated that women whose first-degree relatives developed endometriosis are seven times more likely to develop the disease. Of that percentage, severe endometriosis involved 61.1 percent of family-related cases and 23.8 percent of nonfamilial cases. This meant, clearly; that a woman whose mother or sister had severe endometriosis was a high-risk candidate for the disease and should be tested for carry detection and treatment.

In 1986 another study, this one at the Medical College of Wisconsin, expanded on Baylor’s investigation. This team added some interesting points. Of women participating in the study who reported other family members with endometriosis, about 79 percent of the cases involved maternal lineage and 7 percent implicated the father’s side. Of the women studied, nearly 35 percent of mothers and 21 percent of sisters suffered from endometriosis, too. For second-degree relatives, numbers were significantly lower: for grandmothers the numbers were 0.4 percent, and for aunts the percentage tallied at 3.1 percent. (Such low numbers among an older generation do not necessarily mean lower incidence of the disease. This generation observed different conventions: they married younger and bore children at an earlier age. Fewer reported cases may have also had to do with fewer available diagnostic methods decades ago.)

What do these studies tell US about coincidence of the disease in families? A hereditary factor does, obviously, exist, but it is not an exclusive indicator of endometriosis. There is a stronger hereditary predisposition toward menstrual cramps than endometriosis and that endometriosis may evolve with them.

*29\43\4*

The treatment of herpes is unsatisfactory. Usually it is simply a minor cosmetic disability and clears rapidly without interference. Otherwise a spirit lotion may encourage the blisters to dry, and is preferable to an ointment. An antispetic cream may reduce the possibility of secondary infection, but will not aid the virus’s normal resolution. Numerous other measures have been tried on both types of herpes infection with variable results. These include: frequent applications of ether, which tends to destroy the virus coating; frequent applications of idoxuridine in spirit or, if available, in D.M.S.O. (dimethyl sulphoxidel— this is very effective in eye infections; photo-inactivation of the virus using dyes, such as proflavine, or neutral red, and exposing it to a light source; either the application of or the intravenous administration of cytosine arabinoside— this is a most useful drug for internal herpetic infection, but as yet, has no place in the treatment of the skin; large doses of zinc and vitamin C. Finally, work is in progress attempting to harness Interferon, a specific anti-viral agent, and also to develop an anti-herpes vaccine.

*56\44\4*

Despite our personal familiarity with hunger, it is an extremely complex phenomenon. It is not just an empty stomach that causes that nagging feeling. To simplify things, we need to look at a number of levels of control.

The ultimate decision-maker lies in the brain. The hypothalamus is the part of the brain given the tide of ‘master control’, like all good managers, the hypothalamus receives reports from various parts of the body indicating ‘fullness’ or ‘emptiness’. The latter then prompts the drive to eat. Research with flies, which are very simple organisms, shows they have a neural connection from the stomach to the hypothalamus which acts like an eating ‘thermostat’. As the stomach becomes distended, a message is sent to the brain to reduce eating. If this connection is severed surgically, the fly no longer has the feedback response and will eat until it literally bursts.

In humans, the connection is much more complicated. The sometimes difficult task is to sort out relevant signals and make wise decisions about food intake.

*109\186\4*

Menstruation is a normal part of a girl’s development. Some girls start having periods at the age of nine while others do not have a period until they are fourteen or older.

At the time of their period some girls develop bad stomach cramps or pains. Because pain is nature’s way of telling us that something is wrong in our body it should not be ignored.

Many teenagers experiencing period pain are told that every woman has period pain and that it is quite normal. In fact, some women never have cramps while others only have mild discomfort.

Many girls are told that they will grow out of their menstrual pain. Unfortunately, if there is any underlying problem causing your period pain you will not grow out of it. In fact, in time it could get worse.

Others are told that everything will be OK once they have a baby — not very helpful advice for a teenager.

You should visit your GP if your menstrual cramps are so severe that you have to take time off school each month.

Your GP will want to know how you feel throughout your menstrual cycle. Be sure to provide as much accurate information as possible. Write the details down beforehand if necessary. You will be asked how long your period pain lasts, how severe the pain is and whether it stops you from doing your normal activities. You should also be asked if you have any other problems at the time of your period, such as heavy bleeding, backache or pain when you go to the toilet.

If you are not asked these questions and you do have any of these problems then you must say so. If you are sexually active and have found that intercourse is painful you should tell your GP as intercourse is not normally painful.

After your GP has listened to you and asked questions it may be suggested that you try certain tablets such as Panadol to help ease the pain.

It may also be suggested that you try taking anti-prostaglandins such as Ponstan or Naprogesic. Prostaglandins are substances in your body that help control the contraction of your uterus (womb). An imbalance of these prostaglandins may cause your uterus to contract too strongly and therefore cause pain. Anti-prostaglandin tablets may help to dampen down the effect of the prostaglandins and thereby reduce your period pain. Your GP may even prescribe the birth control pill. If you do not ovulate (produce an egg ready for fertilisation) your period pain may not be as severe.

For the majority of teenagers the above treatments will significantly alleviate the pain. However, if none of these treatments help your pain then your GP should refer you to a gynaecologist who specialises in treating women with complaints like this.

If your GP does not suggest that you see a specialist then it is OK for you to ask to see a gynaecologist.

When you visit the gynaecologist you will be asked numerous questions about your menstrual cycle. It will be necessary for you to be examined and the doctor may perform some tests to determine why you are experiencing so much period pain and/or other problems.

One of these tests is called a laparoscopy. This is an operation performed under a general anaesthetic where the gynaecologist inserts a telescope-like instrument into a cut just below your navel. The gynaecologist can then inspect your organs to see if anything is wrong.

During the operation it may be discovered that you have a disease called endometriosis — pronounced EN-DOUGH-MEET-TREE-OH-SIS.

*99\83\2*

When you have your laparoscopy you will be in hospital for one or two days. An increasing number of hospitals are now doing laparoscopies as a day procedure, which means that you will be admitted early in the morning and discharged later the same day.

After you have been admitted to the ward a medical history will usually be taken, your pubic hair may be shaved and the anaesthetist will probably visit you. You will also be given a consent form so you can sign your permission for the operation. You may already have signed the consent form when you discussed the operation with your gynaecologist at an earlier visit.

Before the operation you will not be allowed to eat or drink for at least six hours, and you will be asked to shower and empty your bladder not long before you are due to go to the operating theatre. About an hour before the operation you may also be given an injection, often referred to as a pre-med or a pre-medication, that may make you relaxed and sleepy and will probably make your mouth feel dry.

The operation will be performed under a general anaesthetic and it usually takes 20 to 60 minutes depending on the severity of your endometriosis and whether or not any treatment is done at the time.

When you go into the operating theatre you will be given the general anaesthetic which is injected into a vein in your hand or arm. A tube will be placed in your throat and connected to a machine that breathes for you. You will then be positioned on the operating table so that your head is tilted downwards and lies below the level of your hips. This position is necessary so that the bowel falls away from the pelvic organs and a clearer view can be obtained when the laparoscope is used. A tube may also be inserted into your bladder to drain the urine.

You will be given a pelvic examination and then a D&C will be performed if it has been scheduled. During the D&C your cervix will gradually be opened with a series of instruments, known as dilators, and the lining of the uterus will be scraped off.

An instrument known as a cannula will then be inserted into the opening of your cervix. The cannula allows the gynaecologist to gently move the uterus around during the operation.

A small cut of two to three centimetres will then be made just below, or in the fold of, your navel and a needle inserted. Approximately two to six litres of carbon dioxide gas will then be slowly pumped into your abdomen through this needle. The gas causes the organs in the abdomen and pelvis to lift and separate from each other so that they can be seen more clearly. The needle will then be removed and the laparoscope inserted into the cut.

The gynaecologist will usually make a second small cut just above the pubic hairline so that an instrument, known as a probe, can be inserted and used to move the internal organs around as necessary. Still another cut may be made midway between the navel and the pubic hairline to remove samples of tissue or drain fluid from any cysts.

The gynaecologist will then carry out a thorough inspection of the entire pelvic cavity for traces and signs of endometriosis — in the obvious and the not so obvious places. The probe inserted through the pubic hairline cut and the cannula in the cervix will be used to lift and move the uterus and ovaries around so that their undersurfaces can be clearly viewed.

The gynaecologist will be able to see any implants of endometriosis ranging in size from pinhead-sized spots to large cysts and endometriomas as well as any adhesions and areas of inflammation. If classical endometrial implants and cysts are visible their appearance will usually be sufficient for the gynaecologist to make a definite diagnosis of endometriosis immediately. If atypical implants are present, or if there are no obvious visible implants, it may be necessary to remove one or more tiny samples of tissue, known as a biopsy, from any suspicious areas for later examination and testing under a microscope.

If fertility problems exist, dye may be passed through the tubes to see if they are blocked.

When the examination has been completed and the details recorded, the laparoscope and other instruments will be removed and the carbon dioxide gas will be forced out of the abdomen in much the same way that one deflates a rubber ball. The cuts will then be stitched or stapled and you will be taken to the recovery room and soon afterwards back to your hospital room.

*40\83\2*

Although the above seems like a simple enough question that should evoke an equally simple answer, the truth is that, as is so often the case, experts do have widely differing views. What’s more, what is a good and comfortable bed for one person is not necessarily so for the next, as what suits best does vary greatly from individual to individual. To take two extreme examples, even today many Japanese still sleep on traditional futons, thin strips of flock-filled bedding which are unrolled on the floor at bedtime, while there is a great vogue for waterbeds in many other parts of the world. The contrast between the two sleeping arrangements could hardly be greater – ranging from the sleeper being almost directly in contact with the hard floor to lolling about in the deep moving trough of a waterbed. Yet both methods have their keen proponents who would argue strongly the merits of their choice. The truth is that neither sleeping arrangement is per se the right one – the fact that both are acceptable for many people just shows that the human body can adapt to and accept a wide range of sleeping conditions.

Even in Britain, where the overwhelming majority of people favour what might be called ‘ordinary’ beds consisting of a base and mattress, there is wide variation in what people find comfortable. Experts, however, agree that to play its part in easing or preventing back pain or sciatica, your bed should meet the following criteria:

It must provide ‘good’ support for the whole body and so prevent the spine from sagging.

It must be of a height that makes it easy to get into and out of bed. The height is also of importance when it comes to making the bed or changing bedding – a low bed means there will be more bending over than with a comparatively high one.

It must be large enough to allow plenty of room for movement during the night. Naturally, if you share your bed it should then be big enough to provide adequate space for two.

Let us now look at these key points in greater detail.

*45\124\2*

The voice on my answering machine says, T am calling to cancel my appointment for tomorrow. I am just too upset to come in and talk about it.’ This is the paradox of severe depression. It is a downward spiral. You feel so bad you have no wish to seek assistance nor any hope that it will help. You become more isolated and depressed. Work and relationships suffer, compounding the problem, and so it goes. You can be helped but you have to get to the doctor if this is to happen. And sometimes, if you can’t manage to do so yourself, a loved one or friend must take you there. Often this takes relatively little work on the friend’s part, but what a difference it can make!

Someone rings me to ask me to ask to see his friend, who is very depressed and needs help immediately. I am closed to new referrals, I say, but something in the friend’s voice changes my mind. If someone has a friend who cares so much for him, somehow that makes me care more too. I become involved, recruited to be a member of the team and help the friend out of his depression. Two months later the friend is completely well (on Lustral, incidentally, not St John’s Wort. It was too acute and serious to warrant my trying the herbal anti-depressant, though, in future, as we learn more about the herb it may become a first-line treatment even for more serious depression). Serious depression can cost a person his or her life. It can wreak havoc with relationships and jobs. It is a medical emergency – and it is treatable. So it is clearly a reason to seek out medical help without delay. And if you have a friend or loved one who is severely depressed, do go the extra mile or two to connect him or her with a good doctor. It is really worth the trouble and effort to do so.

*61\75\2*

It is important for anyone undertaking this program of prevention to maintain a constructive point of view. These problems are predominantly physical and external in origin, yet to the extent that psychological factors come into play, it is important to maintain a positive attitude. The necessary changes in lifestyle should be made of one’s own free will, since no one such as a parent, spouse, or business associate can really make such important decisions for another person. At some point they must be self-motivated. Second, the patient should not be excessively sorry for himself. Anyone can learn to live a relatively healthy life in a less polluted environment. Despite the temporary difficulties, life can be made simpler and more enjoyable for the susceptible person. The aid and comfort of patients who have brought their own problems under control can be of great assistance.

These suggestions are offered as proposals for improving your health by changing the physical environment. They are not a panacea. Some people may need intensive care by a clinical ecologist or even temporary hospitalization before any real improvement is seen. For the most part, however, following these ten suggestions can make a big dent in a longstanding health problem, ward off any future cumulative chemical exposures, and help one to have a happier, safer, and more carefree existence.

*113\110\2*

Common in Florida from early February through late August every year, outbreaks of ciguatera fish poisoning occur after ingestion of certain types of ocean fish, especially grouper and snapper. Beginning two to 30 hours after a meal, this illness usually starts with diarrhea and vomiting, which may cause such severe dehydration that hospitalization for intravenous fluid treatment becomes necessary. Some victims first complain of itching, with weakness and aching of the legs and thighs. Sooner or later, nearly everyone experiences reversal of temperature sensations (cold fluids in the mouth feel hot), hypersensitivity of the teeth, and sensations of burning in the palms and soles. Although many ciguatera fish poisoning victims may continue to feel weakfor many months, fatalities have not been reported.

The larger and more mature fish, according to the Journal of the American Medical Association (244:254) are more likely to cause ciguatera poisoning. For this reason, Floridians have learned to avoid big specimens of grouper and snapper during the season of risk. Since frozen fish can be stored for many months and is trucked all over the country, avoid grouper or snapper unless you are in Florida and can be certain that it has been freshly caught during safe months of the year.

*190\143\2*