There are various investigations which can be carried out at a hospital or special clinic if any disease of the breast is suspected. The more common ones will be described here, before the actual process of diagnosis is explained. All doctors and all hospitals and clinics have their own way of doing things, although there are plans to standardize this care.

Mammography

Mammography involves taking X-rays of the soft tissues of the breast and armpit. It is used for routine breast screening and as a tool in the diagnosis of breast diseases.

The natural contrast due to the breast’s fat content is exploited in mammography. Most breast cancers occur in women over the age of 45, and it is around this age that glandular tissue within the breast begins to be replaced by fat. The appearances of different types of growth vary, allowing quite accurate distinction between some benign and malignant lumps.

Young women, who are concerned about breast cancer, perhaps because they have a family history of this disease, may find that their request for a mammogram is refused; some then arrange for mammography at a private clinic. However, mammograms are not normally helpful in women under the age of 35 as their breast tissue is too dense for most abnormalities to be visible.

Seen on an X-ray, benign breast tumours and cysts tend to have a smooth outline, sometimes surrounded by a ‘halo’ of fat. Malignant tumours, on the other hand, are usually poorly defined, more diffuse masses with diagnostically important tendrils extending randomly into the surrounding tissue. Both types of tumour can contain calcium deposits, but these are more numerous, irregular and less coarse in a malignant growth. If mammography reveals a lump in the breast, it may be followed by further investigations such as a biopsy.

When is mammography necessary?

Apart from its use as a screening tool for women over the age of 50 in the UK, and for those who are particularly at risk of developing breast cancer, mammography is important in the diagnosis of various breast diseases. The following are some signs and symptoms which may need to be investigated by X-ray mammography.

* A lump of unknown origin.

* Several small lumps which can be felt within the breast.

* Unexplained discharge from the nipple.

* Unexplained inversion of the nipple.

When malignant disease is suspected, mammography is also used to:

* confirm the clinical diagnosis,

* determine the extent of the disease – there may be more than one cancer in the breast,

* look for disease which cannot be felt but which may be apparent on a mammogram as areas

of calcification,

* look for cancer in the other breast.

Mammography can also help in the planning of surgical treatment as a lumpectomy will not be suitable for all women. It may also be used to look for signs of recurrent disease or further breast lumps following cancer treatment.

Some small benign lumps, and occasionally cancers, within the central ducts of the breast near the nipple are difficult to detect by mammography, and X-ray following the injection into the duct of a radio-opaque substance may be required if these are suspected.

The process of mammography

You will be asked to remove your clothing down to your waist, and a radiographer will then help to position you for the X-ray. Each breast in turn will be placed on a shelf-like plate on the mammography machine, and another plate will then be lowered onto the breast to compress it. You will be asked to keep very still while the X-ray is taken.

The pressure on the breast as it is compressed between the two plates can be quite uncomfortable, but lasts only a few seconds. Many women are anxious about having a mammogram and so are more than usually sensitive to any discomfort it causes. Some do find the process painful – particularly just before a period – and, rarely, it can cause bruising of the breast and in some cases pain that can last for several days or weeks. However, the pressure of the plates is unlikely to cause any harm, and the radiation level from the X-ray is very low, although higher radiation doses are required to take X-rays of the breasts of young women, who therefore should not have more mammograms than necessary. The benefits of mammography as a diagnostic tool and for breast screening do outweigh any discomfort it may cause.

*5/39/5*

The significant step forward in preventive medicine came with the alarming realization that health was not just a middle-class luxury. In other words the middle and upper classes began to realize that whether they liked it or not their own health and wealth was deeply involved with the health of the ordinary working people. It is perhaps surprising that industrialists did not see the economic link between the poor and unhealthy working classes and low productivity earlier, but they did not and in 1848 when parliament was debating the first Public Health Bill even the Economist magazine did not see the connection between the two. As we have seen, Petty had been talking about exactly this link over a century beforehand but an Austrian, Johann Peter Frank, was the first to make the assertion that governments were strengthened by healthy, happy workers. His thinking produced the world’s first government medical system, in Germany in 1883.

The growth of preventive and public health measures in any industrialized country appears to follow a fairly predictable pattern as the country becomes industrialized. First, there is a rush for power, then an increase in exploitation which is difficult to control. Along with this, rural people and even those from outside the country migrate to the major cities, become separated from their own food supply and depend on cash as wages. At the same time death rates rise dramatically and the value placed on individual life is low. But such a system, whether it occurs in nineteenth-century England or twentieth-century Third World countries, produces wealth and makes money available for those who want to spread it around. Historically, individual philanthropists started creating better conditions for their workers and indeed for whole communities and this, combined with the new egalitarianism born as a result of the French and American Revolutions, made the upper classes more aware of the value of keeping the masses healthy.

At the turn of this century another truth began to dawn. About 60 per cent of all the men who volunteered for the British army’s fight in the Boer War were unfit for service. This appeared to shake people’s long-held attitudes almost more than any other single factor and led Sidney Webb to write:

We have become aware, almost in a flash, that we are not merely individuals but members of a community, nay and citizens of the world. . . . In short, the opening of the twentieth century finds us all, to the dismay of the old-fashioned, individualist, thinking in communities!

Slowly, the notion that society was a collection of communities began to develop-rather more slowly in the US than in the UK, partly because of the individualistic frontiersman thinking in the former. But things were on the move and the time was ripe for the second phase in the development of preventive medicine -the scientific approach.

Until this time facts and figures about health were poor, so few lessons could be learned. Simple ‘Bills of Mortality’ had been collected in London since 1603 but it was not until the establishment of the office of the Registrar General in 1837 that guesswork was replaced by real statistics. The availability of verifiable facts now made it possible to enact regulations to prevent frankly harmful behaviour and to promote healthy behaviour and practices. Ordinances to abate noise, control sewage and dispose of decayed matter, dead bodies, filth and stagnant waters go back as far as 1388 and in colonial times several American communities enacted laws to quarantine ships and isolate smallpox. Baltimore organized America’s first board of health in 1793. But effective public health administration was impossible in either country because local parishes and communities overruled national goals. As so often occurs in history, the activities of one man changed all this.

*3/72/5*

Pastor Kneipp combined hydro treatment with the old culture of bathing in aromatics and healing bath oils. ” Herbal bathing” is especially healthy because the healing power of herbs affects the body on different levels. The active ingredients of the medicinal herbs are absorbed through the skin and therefore directly into the blood. Up to 30 times more active ingredients are taken through the blood during a bath. The body will absorb so many etheric oils, that these are often enough for the treatment but without having any negative side affects on the digestive organs. Parts of the etheric oils are absorbed through the lungs when breathing. The herbal steam affects the limbic part of the brain through the sense of smell, which is regarded as the connection between body and soul. In Kneipp’s day, it was common for everyone to collect their own herbs in nearby forests, on field edges and in meadows.

*200\81\8*

Description and Possible Medical Problems

Since the primary function of the liver is to detoxify the blood, if the livet fails to do its job properly, the problem will immediately become evident through a routine blood test. An abnormal liver function test can be caused by many diseases, including hepatitis, viral inflammation of the liver, an injury to the liver, such as cancer or alcohol abuse, gallbladder disease, and certain medications, such as Cognex and Mevacor.

Treatment

Since each specific liver disease requires its own individual treatment, if your doctor discovers a problem with your liver, he will immediately order a regimen for you. This may include medication such as corticosteroids to reduce inflammation, a diet that’s restricted in protein, fat, and alcohol, and rest. Some liver diseases, such as viral hepatitis, can be highly contagious, so your doctor may recommend that your family members receive immune globulins against hepatitis.

*564\167\8*

Description and Possible Medical Problems

The triglyceride level is nothing more than the amount of fat that is found in the bloodstream. A test to determine your triglyceride level will be included as part of a cholesterol test; triglycerides alone pose very little risk to your health. I feel the value should be 150 or less. Currently, there is a lot of controversy in the medical establishment over whether an elevated triglyceride level alone increases the risk of heart disease. Even though I believe that for good health the triglyceride level should be at 150 or less, an elevated triglyceride level will be treated only if it is extremely high, in excess of 800 milligrams/100cc, which is an indication of a pancreatic problem or advancing arteriosclerosis. Elevated triglycerides are often caused by heredity, but, like the HDL and LDL cholesterol levels, more often than not they’re a result of a high-fat diet, uncontrolled diabetes, and heavy smoking—particularly in women.

Treatment

The primary treatment for a high triglyceride level is medication, but again, only if the level is above 800. Your doctor will also prescribe a low-fat diet and moderate exercise program for you to follow. However, an underlying condition, such as diabetes, must also be treated in order to bring the triglycerides down to a normal level. I’ve found that in some rare cases a triglyceride level above 200 is caused by taking a medication such as Accutane, which is used to treat acne. In this case, discontinuing the medication will lower the triglyceride level to its previous state.

*568\167\8*

Since, like many Americans, you may have been fighting excess body weight for most of your life, you may be heartened to discover that weight loss is a common part of the aging process. However, this weight loss begins when people reach their mid to late 60s, and it usually amounts to only a few pounds a year, if that. Even though your scale says you weigh less, any pounds that are lost due to the aging process are mostly lean body mass or muscle mass, not fat. This leaves most people with less strength than they had just a few years before. Since the process is usually slow, the weight loss usually goes unnoticed except for when they are weighed in at their annual checkup or observe a change in their physical stature.

The time you and your doctor should become concerned about weight loss, however, is when both your weight and your general health rapidly deteriorate over a short period of time. If you have lost 10% of your weight over a period of a month or two, I usually become quite concerned, and the younger my patient, the more concerned I become.

If a person who is quite overweight loses a couple of pounds without trying, the loss might not initially seem serious, but this too can be the sign of a medical problem.

As with the case of malaise, weight loss can occur because of either the normal physiological changes of aging or a more serious illness.

That’s why a complete medical history and physical exam with the necessary diagnostic tests are extremely important in any instance of unexplained weight loss. Thyroid problems may cause you to feel overheated, while cancer or a hidden infection may be responsible for a fever or night sweats. If you are coughing or feel short of breath, you may have emphysema ot lung cancer. There is also the possibility that if weight loss is accompanied by a cough, swollen glands, a fever, and/or a general feeling of malaise, you might have been exposed to the HIV virus, which can lead to the development of AIDS.

If you have tecently lost weight without trying, either a few pounds or 10 or more, you should ask yourself the following questions:

1. Over how long a time has the weight loss occurred?

2. Have I also experienced a change in my appetite or bowel habits?

3. Do I suffer from heat intolerance, nervousness, or heart palpitations?

4. Do I have night sweats, occasional fevers, or newly enlarged glands?

5. Am I coughing a lot lately? Do I suffer from shortness of breath?

6. Do I have a prior history of a serious illness?

7. Do I regularly use alcohol or tobacco?

8. Have I ever had an unsafe sexual encounter, shared a hypodermic needle, or had a blood transfusions?

*572\167\8*

Laboratory/Diagnostic Procedures

High-risk groups. Fasting plasma glucose for the markedly obese, persons with a family history of diabetes, or women with a history of gestational diabetes.

Syphillis test VDRL or RPR for prostitutes, persons who engage in sex with multiple partners in areas in which syphilis is prevalent, or have contacts with persons with active syphilis.

Urinalysis for bacteriuria for persons with diabetes.

Chlamydial testing for persons who attend clinics for sexually transmitted diseases, attend other high-risk health care facilities (e.g., adolescent and family planning clinics), or have other risk factors for chlamydial infection (e.g., multiple sexual partners or a sexual partner with multiple sexual contacts).

Gonorrhea culture for prostitutes, persons who have multiple sexual partners or a sexual partner who has multiple contacts, sexual contacts of persons with culture-proven gonorrhea, or persons who have a history of repeated episodes of gonorrhea.

Counseling and testing for HIV for persons seeking treatment for sexually transmitted diseases; homosexual and bisexual men; past or present intravenous drug users; persons with a history of prostitution or multiple sexual contact; women whose past or present sexual partners were HIV-infected, bisexual or IV drug users; persons with long-term residence or birth in an area with a high prevalence of HIV infection; or persons who had a blood transfusion between 1978 and 1985.

Tuberculin skin test (PPD) for household members of persons with tuberculosis or others at risk for close contact with the disease (e.g., staff of tuberculosis clinics, shelters for the homeless, nursing homes, substance abuse treatment clinics, dialysis units, correctional institutions); recent immigrants or refugees from countries in which tuberculosis is common (e.g., Asia, Africa, Central and South America, Pacific Islands); migrant workers; residents of nursing homes, correctional institutions, or homeless shelters; or persons with certain underlying medical disorders (e.g., HIV infection).

Electrocardiogram for men with two or more cardiac risk factors (high blood cholesterol, hypertension, cigarette smoking, diabetes mellitus, family history of coronary artery disease); people who would endanger public safety were they to experience a sudden cardiac event (e.g., commercial airline pilots); or sedentary or high-risk males planning to begin a vigorous exercise program.

Hearing test for persons frequently exposed to excessive noise.

Fecal occult blood sigmoidoscopy for persons aged 50 and older who have first-degree relatives with colorectal cancer; a personal history of endometrial, ovarian, or breast cancer; or a previous diagnosis of inflammatory bowel disease, adenomatous polyps, or colorectal cancer.

Fecal occult blood colonoscopy for persons who have a family history of familial polyposis coli or cancer-family syndrome.

Bone mineral content for perimenopausal women who have an increased risk for osteoporosis (e.g., Caucasian race, bilateral ovary removal before menopause, slender build) and for whom estrogen replacement therapy is not recommended.

*576\167\8*

Tetanus-diphtheria (TD) booster.

High-risk groups. Hepatitis B vaccine for homosexually active men, intravenous drug users, recipients of some blood products, or people in health-related jobs who are frequently exposed to blood or blood products.

Pneumococcal vaccine for persons who have medical conditions that increase the risk of pneumococcal infection (e.g., chronic cardiac or pulmonary disease, sickle-cell disease, nephrotic syndrome, Hodgkin’s disease, asplenia, diabetes mellitus, alcoholism, cirrhosis, multiple myeloma, renal disease, conditions associated with immunosuppression).

Influenza vaccine for residents of chronic care facilities and persons suffering from chronic cardiopulmonary disorders, metabolic diseases (including diabetes mellitus), hemoglobinopathies, immunosuppression, or renal dysfunction.

This list of preventive measures is not exhaustive. It reflects only those topics reviewed by the U.S. Preventive Services Task Force. Your doctor may wish to add other preventive measures on a routine basis, after considering your medical history and other individual circumstances. Examples of conditions not specifically examined by the Task Force include:

Chronic obstructive pulmonary disease.

Hepatobility disease.

Bladder cancer.

Endometrial disease.

Travel-related illness.

Prescription drug abuse.

Occupational illness and injuries.

*580\167\8*

When the game becomes more actively played by both, it takes off on its own. The dirty talk will have a liberating effect on both partners, since this forbidden language, as well as the ideation behind it, are being repressed and hence are blocking both true love and sex. The language and the sex alike become more abandoned with each playing of the game.

The final step is to discuss the significance of the dirty talk—what it means to both partners, how it “feels,” and even where it comes from. This step is very important, for without it the game will simply be an enactment of the fantasies without resolving the block that creates the need for the fantasies. This reminds me of the male patient I wrote about in the book’s Introduction, who was seduced by the young woman who wanted him to talk dirty to her while she sucked her thumb. While such enactment of one’s sexual fantasies is gratifying, it is not therapeutic. Instead, it becomes a repeating pattern that feeds upon itself while never really achieving the ultimate satisfaction of a real connection.

Talking about the experience of using common language during sex—discussing one’s need to talk dirty or to hear dirty talk—leads to insight about how one’s natural feelings about sex got to be derailed and one’s capacity for unhindered tenderness was blocked. It moves the experience out of the level of compulsive acting-out to a higher level of awareness, trust, and bond-building. When that happens, sex transcends the realm of ritual and becomes rich with a deeper meaning.

*104/196/1*

The two begin as they normally would when making love. When they are aroused, they sit or lie opposite one another and begin to bring each other to orgasm using either hands or mouth—whichever they deem best. (Hand sex may be best for couples who have problems accepting oral sex or with achieving orgasm through intercourse.) In either case, as soon as the sex—of whatever kind—begins, the race is on. The partners set about trying to make their partner come first, and so each, of course, tries to resist letting go. The first person to achieve orgasm loses—and thus, of course, the person who causes the other to come wins. To spice up the game, the winner may get a prize—i.e., he or she will be the other’s slave.

This game will provoke feelings that have lain dormant. Some people, when asked to make sex competitive, will scoff.

Others will suddenly have orgasms with a vengeance, whereas they previously had difficulty in obtaining them. Still others will take great pride in getting their partner (their opponent) to come first. In addition, the game puts each person into a conflict: to win the game the participants must try to make their mate come, yet on another level, the one who has the orgasm wins. Hence, either way they are both winning and losing. The person who comes first wins by losing; the other loses by winning. This conflict is not present in only this game, but also underlies the sexual block itself, and is unconsciously present whenever the participants have sex. All this game does is bring the conflict to the surface.

*79/196/1*