Lung cancer has been one of the most important epidemics of the twentieth century. Late-nineteenth-century physicians and surgeons rarely diagnosed lung cancer and, even though techniques for making the alternative and more frequent diagnosis of tuberculosis were only partly developed at that time, it is unlikely that they were failing to make the diagnosis and much more likely that lung cancer was a medical rarity at that time. Now lung cancer is, in all probability, the commonest cancer in the world, with nearly 700.000 cases per year. In the United Kingdom, it accounts for 25 per cent of cancer deaths.The epidemic has been especially damaging. The disease strikes down men who are still economically productive and have dependent families. Sadly, the outlook for a patient diagnosed as having lung cancer remains one of the most dismal of all cancer diagnoses. Whereas the surgeon may hope to cure a third or a half of all of the patients whom he treats for other common cancers, the situation is quite different with lung cancer. When the diagnosis is made, no more than one quarter of patients have a disease that can be removed by surgery. Even when surgery is carried out and it seems that the cancer has been removed, only about one quarter of those patients are cured. Overall, less than 10 per cent of patients will be cured by surgery.Other means of treating lung cancer have been equally unsuccessful. Radiotherapy has been applied vigorously in a wide range of doses and with a wide range of schedules for the last fifty years. Although the treatments have become simpler and safer, and in many ways more sophisticated, very few patients are cured by radiotherapy alone. The introduction of drugs for the treatment of lung cancer in the 1960s gave rise to great hope for the group of patients with a sub-group of very dangerous cancers known as small-cell lung cancers. Combinations of drugs have proved capable of producing frequent remissions for this group of lung cancer patients. The disease shrinks readily away when the drugs are used and, during the 1970s and 1980s, intensive research was directed to using this effect and trying to turn it into lasting remissions and cures. Such efforts have, however, been met with disappointment. Patients with small-cell lung cancer can usually expect remissions as a result of these combination chemotherapies, but very few are cured.The scale of the epidemic of lung cancer is illustrated in Figure it. The disease started to increase in the 1920s and 1930s and achieved its present epidemic proportions during the 1950s and 1960s. The number of deaths due to lung cancer is however, beginning to show signs of a significant reduction. The graph shows the death rate against the number of cigarettes consumed; we must now accept that this indicates the clearest and most important explanation of this century’s lung cancer epidemic.There is an indisputable and strong link between lung cancer and smoking. In fact, almost all lung cancers are attributable to smoking and, if the smoking habit were dropped, lung cancer would revert to its former status as an infrequent diagnosis, of concern only to the individual patient and doctor. Instead, it remains one of the most overwhelming public-health issues facing the world as it moves towards the twenty-first century.*37\194\4*

Empty calories, which are usually not well hidden, offer little or no nutrition for their caloric content. For example, a tablespoon of peanut butter may have about 100 calories, but it’s a great food—it’s tasty, has little or no cholesterol, is high in nutrients, and isn’t expensive. A piece of candy may have the same 100 calories, but it offers your body nothing but sugar. Those are empty calories. Most junk foods consist of empty calories, which is why eliminating them can make such a dramatic impact on your waistline. Liquor consists of empty calories; most desserts are filled with empty calories.When you are counting calories, you do not have the budget to waste anything. To make your calories go as far as they can, eliminate as many empty calories as possible. Allow yourself (or your man) no more than 100 calories a day for liquor (if he drinks); 100 for a snack (if snacks cannot be eliminated); and 150 for dessert—I don’t think desserts should be eliminated.Look for hidden calories in these foods:• fruits• fruit juices• meatsLook for empty calories in these foods:• candies and sweets• chips, pretzels, etcetera• desserts• sauces, dressings, and toppings• refined-flour products• packaged meats• soft drinks*63/243/1*

QuackeryThe word ‘placebo’ was used by Geoffrey Chaucer as long ago as 1340. His use refers to a psalm that begins ‘Placebo domino in regione vivorum’ (‘I will please the Lord in the land of the living’). He uses the word in mockery because it was the first word in prayers for the dead which were said by priests and friars who pestered the populace for money to sing these prayers. The derisory use of the word is similar to the phrase ‘hocus-pocus’, which is derived from ‘Hoc est corpus’ (‘This is the body’), which are the first words of the Mass. By the seventeenth century, the word had been adopted by doctors for inactive medicines that greatly impressed their patients. In 1628, Burton writes in the Anatomy of Melancholy: ‘There is no virtue in some remedies but a strong conceit and opinion’. In 1807, President Thomas Jefferson wrote in his diary: ‘One of the most successful physicians I have ever known has assured me that he used more bread pills, drops of coloured water and powders of hickory ash than of all other medicines put together. I consider this a pious fraud.’ Jefferson expresses here a strict division between fraudulent placebos and medicines that were believed at the time to act by a rational mechanism. That division continues to this day, with therapy being judged either a placebo or true.A tiresome and expensive artefactIt is required by law that a new drug be proven superior to a placebo. This perpetuates the separation of true versus imagined. The placebo response was taken by the drug companies as a meaningless error to be dissected out and discarded while attention is monopolised by the powerful action of the therapy, which did not depend on what the patient thought about it. Some therapies, such as surgery, were assumed to be so powerful and dominant that it was not only unethical but ridiculous to test for a placebo component to explain the success of the therapy. This is dualism in practice, as therapy is assumed to readjust body mechanisms while mental processes are assumed to be irrelevant. In this atmosphere, it is not surprising that the placebo response was not studied until very recently. Similarly, it was not considered likely that a patient’s response might be a combination of physical and mental process. This led to the very mention of a placebo trial being taken as a hostile questioning of the logic on which the therapy was based. This hostility is shared by enthusiasts both for academic and for complimentary medicine.The reality of the sensesEveryone assesses their own sanity by cross-checking senses with objective reality and with what other people say. We have special words for mismatches, such as hallucination, delusion, madness and drunkenness. We trust our senses. Pain appears to us as the sensation provoked by injury. A trusted, impressive physician prescribes the very latest analgesic for your pain and the pain disappears. Later, you learn that you were a guinea-pig in a trial and you were in fact given a blank tablet. You are angry, cheated, embarrassed and shaken. I have responded to placebo trials and I am always mortified and ashamed of myself. The pill could have had no action on the reality of my injury and yet my sensation changed.Given these three reasons, it is no wonder that the placebo is an unpopular topic. Some physicians think that anyone who responds to a placebo did not have a ‘real’ pain: they are wrong. Some physicians think that a placebo is the same as no treatment: they too are wrong. Some think that only weak-minded suggestible people in minor pain respond: they are wrong. Even physicians respond to placebos! The placebo response is a powerful and widespread phenomenon. Let us therefore examine it, using four examples.*61\219\2*

Hair loss, no matter what the cause, creates enormous stress and fear of complete baldness. Initial reactions often include avoiding hair washing, changing hair products and taking vitamin or zinc tablets, none of which are successful. In most situations, the hair loss is temporary and new hair will re-grow after a few months without any treatment.If hair loss is caused by iron deficiency, a high iron diet and iron supplements should be taken. Red meat and liver are particularly good sources of iron and are better absorbed than vegetable sources or iron tablets. Vitamin С aids the absorption of iron, so it is wise to include foods such as citrus fruits, tomatoes and raw green vegetables which contain high amounts of vitamin С in your diet.Iron deficiency due to heavy menstrual losses may require gynecological treatment in the form of hormone therapy, curettage of the uterus or even hysterectomy in severe cases.Although hair loss is usually only temporary, a topical preparation called Minoxidil can be used to slow down hair fall and stimulate new hair growth until normal growth returns.People who experience genuine hair loss are generally frightened of dyeing or curling their hair, thinking this may aggravate the condition. On the contrary, it is often useful to have the hair gently dyed or permed to make it appear thicker. Over-conditioning should be avoided, however, as it can make the hair look limp and thin.
*37/150/5*

Those who care for someone in pain are involved in a sequence of reactions that can stretch out for very long periods. It begins with fear, which can grow into terror and a sense of catastrophe. Fear is infectious. At first there may be anxiety about the pain and its meaning and consequences. This anxiety can generalize into the carer being anxious about everything, and can show itself as agitation. We have seen the way the initial period of vigorous escape melds into a quieter period in which the victim guards the painful area and avoids movement. This can be a time of inactivity, doziness, loss of appetite and a desire to be left alone. After operations or accidents, this phase can continue, even when the pain has gone, into a state where the patient feels flattened, with no energy and a feeling of apathy. This time had not been well studied until recently. It was believed to be the long period of healing and was certainly marked by surprise and frustration when the patients longed to get up and resume their normal activity. This stage of apathy certainly irritates the patients and their carers when expectation predicts recovery but it does not come. The condition has similarities with chronic fatigue syndrome, although that state is not usually preceeded by dramatic illness. Exercise seems to make the condition worse and the patient is faced with a prolonged, irritating period of passivity with the fading hope that it will eventually go, although it normally does. Self-limiting and puzzling epochs of stillness have in the past attracted little sympathy or attention from doctors and are trying times for patient and carer.Professor Hall and his team in the Anaesthetic Department at St George’s Medical School in London recently began a special study of the phenomenon. They compared the course of recovery of patients who had had a hip replacement with those who had had an abdominal operation. Hip replacement these days may be thought of as a routine operation but, in fact, it involves first the exposure of the hip joint, which is buried deep in the mass of muscle making up our upper leg, and then sawing off the top of the large femur bone and its joint, before replacing it with a plastic and metal prosthesis. By contrast, operations on the abdomen may seem minor in terms of the amount of tissue disturbed by the surgery. The abdominal wall, which is quite thin, is cut open to expose the viscera. These organs in the abdomen and pelvis have a limited supply of sensory nerves. The diseased parts are located and removed and the abdominal wall is sewn up. The speed of eventual full recovery was compared in the two types of operation and a striking difference was observed, with the hip-replacement patient bouncing back far more quickly than those with abdominal operations. It is clear that the amount of damaged tissue cannot be the factor that leads to the prolonged exhaustion.Patients who will have a hip replacement have usually gone through a very long period of developing distress resulting from the slow onset of osteoarthritis. It begins with pain in the upper leg on movement and with aching at the end of the day. As it develops, movement becomes more and more limited and there is extreme difficulty in walking and a nagging pain at rest which begins to disturb sleep. Analgesics help to ease the pain in the early stages but have little effect on the movement, and eventually these patients become crippled and exhausted by their struggle and lack of sleep. They have a very positive attitude to the operation and have good reason to look forward to relief from pain and a return of movement. Many have already experienced the operation on their other hip, and most will have witnessed their fellow suffers make a splendid recovery.By extreme contrast, people who have their abdomens opened and explored by surgeons have a far more worrying and doubt-provoking experience. They have suffered growing vague discomfort, sometimes not even frankly painful, seeming to originate from somewhere in the depths of their mysterious bodies. They feel poorly and frightened by the very vagueness of what is wrong and what the prognosis might be. Doctors peering into one’s various orifices can be a shaking invasion of one’s guarded personal space. Even more so, surgeons rooting around among one’s viscera is ultimately frightening by itself, and who knows what they found or missed?The St George’s group believe that it must be the fundamental difference in patient’s attitude which explains the striking difference of their long-term postoperative recovery time. They may be right but one must not forget that the nature of the tissue that has been disturbed by the operation is very different. It could be that the body’s recovery and defence mechanisms are very different when muscles and joints are damaged from when organs within our bodies suffer. It is crucial that we accept this phenomenon of sickness malaise as a problem to be understood and controlled, rather than ignored as it has been in the past. Apathy in growing children is famous for driving parents to distraction when their offspring exhibit contemptuous boredom with the very events which lit up the parents in their youth. Caring for a friend who sinks into a torpor of apathy and abandons their former pleasures can be equally irritating.Carers must take an attitude to a form of intense activity exhibited by some pain sufferers: the search for cure. This can become an obsession, with the patient being consumed with certainty that somewhere, someone has the complete answer. When doctors are involved, this state can move from the sad to the frankly dangerous. The insistence of a pitiful wreck of a patient puts tremendous pressure on physicians and surgeons. Desperation breeds desperate measures. An escalation of invasion can result in the repetition of failed operations and the use of untested dramatic new procedures. The Sloane-Kettering cancer hospital in New York believes that 2,3 per cent of the pain problems they witness are caused by the therapy. It has been one of the clear advantages of the pain clinics to be discussed later that they have protected patients from excessive overenthusiastic therapy.A more gentle and innocuous response of patients is to turn to the wide variety of complementary medicine after their physicians and surgeons have failed to relieve their pain. No matter how barmy the theory, these practices flourish. In Chapter 9, I promoted the merits of the placebo. The effective alternative therapists have a number of advantages on their side. They can give more time to the patient than the overstretched health professionals. They often maintain an exuberant enthusiasm, which has faded in their jaded academic colleagues. They can therefore offer more warmth, optimism and attention to patients who are beginning to feel lonely and abandoned. The younger alternative therapists tend to be lovely people, whereas cynicism can settle on their seniors.When pain persists, it is almost inevitable that depression is added to anxiety. With no end in sight and the progressive decrease of possible activity, the patients naturally turn in on themselves. They are sad and it becomes more difficult for others to cope with the sadness. The patient becomes crotchety, particularly with the well-meaning efforts of others to get them out of their shells. This cycle leads to a sense of loneliness and alienation. ‘Why me?’ they ask angrily. ‘No-one cares.’ ‘They don’t believe I am in pain.’ ‘What is going to happen to me?’. These descents into melancholy need professional treatment. In the meantime, those who care are themselves pushed to desperation and even anger and retreat. The carers face burn-out and need relief, a break and a community to share their problems.I write as a warning to carers about what may happen, not about what inevitably happens. There are those in pain and their friends who have a built-in genius for coping. Their secret is never to deny the pain or its consequences, but face both with reality. They observe and experiment with what makes it better with no expectations of miraculous cure. They become expert at spotting diversions which give brief relief and then expand these periods of distraction until they become a way of life.*81\219\2*

The latest approach to eating to keep the blood glucose levels stable and therefore reduce Cortisol levels – is the Glycaemic Diet: this is similar to the diet already discussed but places more of an accent on the ratio of protein to carbohydrate. The work of American Dr Elias Ilyia has proven that this eating plan reduces the stress on the body by balancing the level of insulin produced. It therefore reduces Cortisol levels. Dr Ilyia suggests eating a ratio of one part protein to seven parts carbohydrate, although Dr Andrew Wright in his leaflet ‘Glycaemic Eating’ suggests that it is more effective with a higher ratio of protein: one and half parts protein to two parts carbohydrate. His book on this diet stresses the importance of choosing ‘good’ – slowly absorbed – carbohydrates (such as whole grains) and gives recipes. This book is due to be published in 1999.Although it might seem simplistic, eating to keep the blood sugar levels stable is the first step in lowering Cortisol levels and therefore bringing DHEA levels into balance. By eating in a way which puts the pancreas under stress, you start the chain reaction which upsetsthe output of many other hormones. If you are anxious or have any stress-related symptoms you cannot afford to ignore this. You might say, ‘but I have skipped breakfast, had a sandwich for lunch and a large evening meal for years’ – exactly! You are paying the price for that now with anxiety, fatigue, mood swings and so on. These are symptoms of hypoglycaemia. Try running your car without petrol or expecting an empty ink cartridge to print out your letters. This is exactly what you are doing to your body. It won’t stand for this for ever and will complain with the symptoms mentioned. Hypoglycaemia also increases the risk of degenerative illnesses and maturity-onset diabetes.*106\326\8*

The heart has its own natural “pacemaker”- a system inside the heart that functions in much the same way as an electrical circuit in a house or automobile. Impulses develop periodically and are carried throughout the heart by “wires” (nerves) which end in the small heart muscle fibers. These impulses signal the muscle to contract. The origin of the normal impulse is the sino-atrial or S-A node in the right atrium. This pacemaking structure can be likened to the distributor in an auto engine, which sends signals to the spark plugs and causes them to fire.There are only two main “wires” in the heart which link the natural pacemaker to the ventricles, which pump the blood. Just as in a two-cylinder engine, if one of the spark plug wires were cut, only a single spark plug would fire. If both spark plug wires were cut, even though the distributor still functioned, the engine would be dead.The two wires (nerves) in the heart are called the right and left bundle branches. When one of the wires is not functioning, the problem is identified by the term right or left bundle branch block. A typical electrocardiographic picture is produced by these malfunctions which, of course, aids in the diagnosis. If both of the wires are nonfunctional, the patient is said to have a complete heart block. In this circumstance the natural pacemaker will still be functioning, but the message will not be transmitted to the ventricles. The ventricles will either not beat at all, or a secondary natural pacemaker in the ventricle itself may take over and initiate a periodic heart beat. This standby secondary pacemaker is always very slow, producing only 30 to 40 beats per minute, which may or may not be adequate to provide blood flow in sufficient quantity to allow the body to function. In some instances, the primary natural pacemaker fails – and no impulse is then generated to flow through the wires, a circumstance called sinus arrest.Interruptions in function may occur suddenly and be permanent, or may occur intermittently, with normal heart function in the interim. The usual symptom is faintness or fainting due to inadequate blood flow to the brain. The patient is usually not aware of a change in his heart beat before the faint. During the period of unconsciousness, the patient may have a convulsion, again due to inadequate blood flow to the brain.These problems with the heart’s pacemaker or with the conducting wires usually occur in people who have atherosclerotic heart disease. Rarer instances concern people who have had heart disease due to diphtheria or other infections of the heart (myocarditis), rheumatic heart disease, or some forms of congenital heart disease (heart defects that children are born with). A complete heart block can occur as a complication of an acute heart attack can develop several years later.The treatment of this condition is based primarily upon its recognition. Of course, every person who faints does not have a heart block. Some people faint at the sight of blood or with pain or sudden fright. This involves another mechanism and is harmless unless the person hurts himself when he falls. But if a person who is over 35 or 40, and who is feeling fine, suddenly faints, this is probably a serious symptom.Once the condition is recognized, the treatment is to replace the heart’s electrical circuits with a mechanical device as soon as possible. Some degree of haste is in order because there is no way to predict when the next heart stoppage will occur, and the next episode may be the last.The device used is called a pacemaker. Many misconceptions exist concerning them. The most common one is that the pacemaker is an artificial heart. It is not. It does not pump blood, nor does it prevent a person from having another heart attack or from dying of heart disease in another form. A pacemaker is an electronic unit with its own power supply (battery) connected to a wire (or wires) that are attached to the inside or the outside of the heart. The pacemaker regularly supplies an impulse that is carried by the wires to the heart muscle, where the impulse stimulates the heart to beat. If the heart is too weak from disease to contract, the pacemaker will not cause a heartbeat to be produced.Some forms of pacemakers beat constantly and other forms operate only on demand. The latter form samples each of the heart’s own beats and if one or more are missed, the pacemaker functions to supply the missing impulses as needed.The pacemaker unit itself is usually placed within a pocket just beneath the surface of the skin of the chest or abdomen. This location is chosen to facilitate replacement of the electronic unit or batteries. A wire runs from the pacemaker to the heart. The original method for establishing this connection was to perform chest surgery, opening the chest cage and sewing the end of the wire to the surface of the heart. A newer technique has been developed to avoid a major operation. The wire is threaded through a vein and directed to the interior of the heart. The wire is usually started in a vein in the neck or the shoulder. The progress of the wire is followed by a fluoroscope. When the tip of the wire reaches the interior of the heart, it is lodged in a corner of the right ventricle. The other end of the wire is connected to the pacemaker. The exposed piece of wire between the pacemaker and the neck vein is covered with skin, so that the entire system is beneath the body surface.Batteries must be replaced every one to three years, and in some instances the pacemaker unit itself must be replaced if it malfunctions. Physicians are usually able to test the function of the units by means of an electrocardiogram and external magnets, which temporarily alter pacemaker function in a predictable manner. This permits batteries and units to be replaced before serious failures occur.*21/309/5*

OAKOAK relates to the soul potential of strength & endurance. In the positive OAK state the person is endowed with the qualities of Endurance, steadfastness, strength and common sense. Such people are brave and go on fighting against odds without loss of hope or effort. But they use their common sense to find out before hand, whether the job they are going to take in hand is possible of execution by human effort.In the struggle of life they possess all the attributes of a winner—innate power of resistance, indomitable will power, super human endurance, courage, devotion to duty, unbroken hope and high ideals. They are fine people, an asset to their families and an asset to the society—who take pleasure in helping others out of difficult situation and feel sorry if due to health reasons they cannot do what is expected of them.In the negative OAK state, the patient believes in the maxim “nothing is impossible”. They become overconfident and start dabbling in pursuits of which they do not have even the elementary knowledge. Thus for example, an OAK patient would open up an expensive watch or an electronic device to repair it without proper instrument, without the requisite knowledge and spoil the unit.He not only believes that nothing is impossible, he is confident that he can handle any job. If the doctor says that according to all clinical tests, his condition will not respond to any treatment, the ‘OAK’ patient will shun the doctor and may even change the treatment, but will continue some other treatment with fuil faith.Even if he has lost everything in races, he would still like to have “one last go” even on borrowed money. Yudhishter of the Mahabharat even staked his wife after losing all his assets to Duryodhan in gambling—a historical Oak character.*149\308\8*

Physicians and researchers once believed osteoarthritis was an inevitable part of the “wear and tear” of aging. Today we know that even though osteoarthritis is more common in older people (by age 75, almost everyone has some degree of osteoarthritis), it is not simply caused by wear and tear on joints. Osteoarthritis affects weight-bearing joints, which are the parts of the body that bear the majority of weight, including the hips, knees, and feet. Osteoarthritis also commonly appears in the fingers and spine and is often worse on one side of the body. If you’ve been noticing pain in your knees as you climb the stairs, or find yourself walking like John Wayne after you’ve been sitting still for a period of time, you may be getting acquainted with osteoarthritis.Conventional treatments for osteoarthritis include non-steroidal anti-inflammatories, or NSAIDs (drugs like aspirin, ibuprofen, and Naprosyn), as well as acetaminophen, a medication that relieves pain but does not affect inflammation. While these usually reduce symptoms to some extent, none of these conventional treatments slow the progression of osteoarthritis, and some may even speed up its rate of progression. In contrast, several natural supplements not only relieve symptoms, but, according to preliminary evidence, may also prevent the disease from getting worse. Chondroitin sulfate has the best evidence for such a “disease-modifying” effect, but glucosamine and S-adenosylmethionine (SAMe) have also been suggested as possibilities. *3/306/5*

Before considering what your blood glucose level is, it is important for you to know what the numbers mean. What glucose level, for example, means that you have diabetes? What level is undeniably in the non-diabetic range? This distinction has occupied many committees for many years. The World Health Organization has produced the most widely agreed guidelines.The diagnosis of diabetes must be made before any treatment is begun. The internationally agreed guidelines assume that people are eating their usual diet and not taking glucose-lowering medication. If you have symptoms of diabetes (for example, thirst and passing a lot of urine), a single laboratory measurement of glucose in a sample of blood taken from a vein is sufficient to make the diagnosis of diabetes. If the glucose concentration is 7.8 mmol/1 or more (140 mg/dl in America) if you have fasted overnight, or if the glucose is 11.1 or more (200 mg/dl) if you have eaten, then you have diabetes.If you have no symptoms of diabetes, two blood samples must show a glucose concentration above these levels before the diagnosis of diabetes can be confirmed.If your fasting blood glucose is below 6.7 mmol/1 (120 mg/dl) or a sample after food is below 7.8 mmol/1 (140 mg/dl) you do not have diabetes. There is a grey area in between these figures and those which define diabetes. People whose blood glucose levels fall within this grey area are said to have impaired glucose tolerance. You may return to normal, stay as you are or progress to definite frank diabetes.
*2/102/5*