- Email: [email protected]
BLOOD AND SPORTS
847
should be wary of the implicit assumption that because a medical treatment has been evaluated and found wanting, an untested "traditional" procedure is likely be better. It may indeed -fulfil the aim of giving people control over their lives but will it cure illness? For all its faults, professional medicine is becoming quite vigorous in evaluation of its procedures. Should not the same criteria be applied to self care? LEVIN points out that it is too late to ask whether self care should exist. It does exist. He cites several surveys from the U.K. and the U.S.A. showing that half or more of all illness episodes are treated by self care.5 This is an indication that self care is attempting to meet a social and personal need, but not necessarily that it is effective therapeutically. Most illnesses are short-lived and some become chronic, irrespective of who treats them. Evaluation of self care will not be easy, particularly if self care includes not only treatment but also to
diagnosis. When we come to the third possible area for self-care, the realm of health maintenance and disease prevention, the argument that self care contributes to a feeling of control over one’s life is less generally applicable. There are examples where this is so-most notably offered by the women’s movement which has been active in education as well as in setting up clinics. However, few of us feel demeaned by having sewers provided by Government or by being supplied with clean water, although a vociferous minority objects to having fluoride added to it. In the countries of the developing world, the major advances in health will come from clean water and sewage and from adequate nutrition. Unless the self-care concept expands to include community action on a wide scale, these advances can not all come from self care. Nor is self care likely to do much to improve working conditions or
provide adequate housing. developed world where
In the
Government’s
role
in
some
we
take for granted of public
areas
health-e.g., water and sewage, and setting health standards for the workplace, if not in others such as nutrition—self care is also being pushed in the form of health education. It is interesting that in Britain at a time when Government is seeking to cut public expenditure and stop expansion of the National Health Service the budget of the Health Education Council was increased by 44% (,2 million). The reasoning behind this can perhaps be seen in the D.H.S.S. document Prevention and Health: Everybody’s Business8 (which was published when a different Government was in power). This document was rightly criticised at the time for ignoring the possible role of Government in prevention. For example, when discussing the role of life-style in prevention of coronary heart disease, it said the "prime responsibility for his own health falls on the individual". It adds that the role of the health professions and of Government is limited to ensuring that the public have access to knowledge. If health education 8.
of Health and Social Security. Prevention and health. Everybody’s business. London H.M. Stationery Office, 1976.
Department
only on the individual and ignores the social and environmental influences on life-style, it is unlikely to be effective.9 To take the example of smoking, the General Household Survey’° shows that between 1972 and 1980 the proportion of professional men who smoked fell from 33% to 21%-a welcome decline. By contrast, during the same period, the proportion of unskilled manual workers who smoked went from 64% to 57% in men and 42% to 41% in women. Although smoking is ultimately a personal decision, the fact that social groups defined on the basis of occupation show different preferences for the smoking habit demonstrates the crucial importance of social influences on personal behaviour. As Prevention and Health: Everybody’s Business implies, the other side of individual responsibility in health is blaming the individual if he or she gets sick. Given the persisting social inequalities in health," this seems a barely defensible position. Statements emphasising the importance of the individual in health should not be taken as an argument for neglecting the effects of working conditions, of housing, and of marketing of food, tobacco, and alcohol. ’ concentrates
BLOOD AND SPORTS first described by Fleischer in of the earliest 1881,’ recognised haematological complications of walking or running. Three types of paroxysmal haemoglobinuria were recognised in the 19th century2 and march haemoglobinuria can be easily distinguished from the other two—i.e., paroxysmal nocturnal haemoglobinuria, in which Ham’s test is positive, and paroxysmal cold haemoglobinuria, in which the DonathLandsteiner antibody is present. Eighty years of laboratory investigations, however, failed to pinpoint any typical redcell or serum features in cases of march haemoglobinuria, and attempts were largely abandoned in 1964 when Davidson3 declared that there simply was no abnormality. In a series of experiments he showed that during marching or running red cells in the plantar blood vessels became mechanically damaged, with intravascular haemolysis. It then became apparent why haemoglobinuria did not arise after swimming or after exercise on a stationary bicycle, and why it was not exertional per se, as some had suspected. The haemoglobin released from the lysed red cells initially combines with haptoglobin and is removed from the circulation, but when the haptoglobin becomes exhausted and its serum level falls, MARCH
haemoglobinuria,
was one
haemoglobinaemia
ensues
and
haemoglobin spills into
the
urine. Haemosiderin may also be found in the urine if episodes of haemoglobinuria are frequent. Today’s vogue for walking, jogging, and running has meant more cases of march haemoglobinuria, though not all are being recognised. Some idea of the frequency of the syndrome can be gained from a Danish study. Hunding and his 9. Cohen
CI, Cohen EJ. Health education. Panacea, pernicious or pointless N Engl J Med 1978; 299: 718-20. 10. OPCS Monitor 1981, July 28. 11.
Inequalities in health: Report of working group. London: Department of Health and Social Security, 1980. 1. Fleischer R. Ueber eine neue Form von Haemoglobinurie beim Menschen. Berl Klin Wschr 1881; 18: 691-94. JV The haemolytic anaemias,
2. Dacie
congenital
and
acquired
Part
III-secondary
or
symptomatic haemolytic anaemias London Churchill, 1967: 966-70 3 Davidson RJL. Exertional haemoglobinuria: a report on three cases with studies on the haemolytic mechanism. J Clin Pathol 1964; 17: 536-40.
848
co-workers4surveyed 113 joggers and
runners and found levels in both men and women. Interestingly, anaemia seemed to be common in the trained runners, whereas earlier workers had emphasised the rarity of anaemia in march haemoglobinuria.2Hunding et al. ascribe the athlete’s anaemia to iron deficiency, since iron was lost through haemoglobinuria after long-distance running. This notion deserves further investigation. The frequency of haemoglobinaemia can be related to the distance run.5 Many runners have haemoglobinaemia after 2-6 6 miles (4 km); virtually all marathon runners are affected-for example, of 18 athletes who had run the marathon distance of 26 miles, 18 had haemoglobinaemia and 4 haemoglobinuria. The remedies are simple: shoes with resilient insoles, training to avoid a heavy stamping stride, and avoidance of hard roads in favour of grass or cinder. Some workers suspect that the anaemia of long distance runners is partly due to inhibition of
very low
haptoglobin
6
erythropoiesis-a "functional pseudoanemia". In one of the earliest published series of march haemoglobinuria Dickinson in 1894 described an instance in7 which haemoglobinuria was noticed after tennis. Presumably the mechanism would have been lysis of red cells in the plantar vessels but in the Basque variety of tennis, pelota, damage may also arise in the palmar vessels. This game should be played with a wickerwork racket strapped to the hand, but some people dispense with the racket and get haemoglobinuria.8 Blood vessels in the hand are also injured during hand strengthening exercises for karate. Streeton9 investigated a man of 26 who had haemoglobinuria after each exercise period (15 minutes of chopping the ulnar border of the hand on a wooden stool, and 15 minutes of punching his hand at a blanket spread on a concrete floor). These sessions caused a fall in haptoglobin, haemoglobinaemia, haemoglobinuria, and haemosiderinuria. Finally, mention should be made of the hazards of congadrumming. Drumming sessions often take place daily and are of great physical intensity, lasting 5 hours or more.lo The conga drum has a thick vellum skin which is hit by the fingers and hollow palm. The first recorded instance of drumming-induced haemoglobinuria was encountered by Kaden 11 in a man who had previously indulged in running, without ill-effects. The traumatic origin of conga-drumming haemoglobinuria was confirmed in what must be one of the most unusual clinical research projects ever undertaken.’o Doctors at the University of Pennsylvania admitted a 20-yearold man with post-drumming haemoglobinuria for a series of sessions on conga and bongo drums. Control drummers with no history of haemoglobinuria were also admitted. Three concerts were arranged on days 1, 2, and 7. The first two concerts strikingly reduced the plasma haptoglobin and raised the plasma haemoglobin. The third concert reduced the haptoglobin still further and haemoglobinuria ensued. Drummers in the West Indies do
not seem to
get haemo-
anaemia and iron deficiency Acta Med Scand 1981; 209: 315-18. 5. Gilligan DR, Altschule MD, Katersky EM Physiologic intravascular hemolysis of exercise. Hemoglobinemia and hemoglobinuria following cross-country runs J
4.
Hunding A, Jordal R, Paulev P-E Runner’s
Clin Invest 1943; 22: 859-69. 6. Dressendorfer RH, Wade CE, Amsterdam EA 7.
8. 9. 10. 11.
Development of pseudoanemia in marathon runners during a 20-day round race. JAMA 1981; 246: 1215-18. Dickinson W. Haemoglobinuria from muscular exertion. Trans Clin Soc Lond 1894; 27: 230-33. Laporte G, Dunat L Une nouvelle cause d’hémoglobinurie traumatique: la pelote basque a mains nues Nouv Presse Med 1972; 1: 2404. Streeton JA Traumatic haemoglobinuria caused by karate exercises. Lancet 1967; ii: 191-92. Furie B, Penn AS. Pigmenturia from conga drumming. Ann Intern Med 1974; 80: 727-29. Kaden WS. Traumatic haemoglobinuria in conga-drum players. Lancet 1970; i 1341.
globinuria whilst those in the U.S.A. do. In the West Indies the drums are often placed on absorbent earth, whilst in the U.S.A. they are placed on hard floors.
HEARING LOSS AND PERCEPTUAL IN SCHIZOPHRENIA As
long
occurrence
DYSFUNCTION
ago as 1915, Emil Kraepelin recorded the 1 of persecutory delusions in the hard of hearing.’
Since his time, there have been occasional references to an association between deafness and paranoid symptoms in schizophrenic patients,2,3 and there have also been reports of a higher prevalence of hearing disorders in patients with schizophrenia and paranoid psychoses (especially those developing late in life) than in groups with affective illnesses.4,5 Cooper and others6 examined this association, in two unselected samples of elderly patients with paranoid and affective psychoses, by means of pure-tone audiometry and clinical measures of social deafness.6 It emerged that the patients with paranoid psychosis had a greater degree of hearing loss and were more often socially deaf than those with affective illness, who resembled the general population. In the paranoid group a significantly higher proportion of patients had severe longstanding deafness, most commonly due to chronic middle-ear disease. Hearing impairment had begun long before the onset of the illness and personality and social data7 indicated that chronic deafness was an important independent factor in the aetiology of paranoid hallucinatory psychoses in later life. These clinical findings have-lately been followed up in the laboratory by Zimbardo and others.8 In a social setting, a group of normal subjects rendered partly deaf by hypnotic suggestion, but unaware of the source of their deafness, was compared with two control groups. In one of these, partial deafness was iriduced in subjects who were aware of its source and in the other a posthypnotic suggestion unrelated to deafness was experienced. Partial deafness without awareness of its source was associated with changes in cognitive, emotional, and behavioural functioning in that, on various measures, the experimental subjects became significantly more paranoid and grandiose than controls and rated themselves as more irritable, hostile, and unfriendly. Though admitting that their laboratory procedure was artificial, Zimbardo et al. suggest that functionally analogous situations do arise in everyday life. Hearing often deteriorates without the individual realising it and the social stigma attached to deafness sometimes encourages denial, especially among the elderly. Paranoid thinking may emerge as a cognitive attempt to overcome the difficulty in hearing what other people are saying, and misunderstandings provoke frustration and anger. Observers may regard such responses as evidence of bizarre thinking so that, over a long period, the deaf person may become progressively isolated, and lose the corrective 1. Kraepelin E. Psychiatrie. Leipzig: Barth, 1915. 2. Priteker B. Paranoid und Schwerhörigkeit. Schweiz Med Wschr 1938; 7: 165-66. 3. Houston F, Royse AB. Relationship between deafness and psychotic illness J Ment Sci 1954; 100: 990-93 4. Kay DWK, Roth M. Environmental and hereditary factors in the schizophrenias of old
age. J Ment Sci 1961; 107: 649-86 5. Post F Persistent persecutory states of the elderly London: Pergamon, 1966 6. Cooper AF, Curry AR, Kay DWK, Garside RF, Roth M. Hearing loss in paranoid and affective psychoses ofthe elderly. Lancet 1974; ii 851-54. 7. Kay DWK, Cooper AF, Garside RF, Roth M. The differentiation of paranoid from affective psychoses by patients’ premorbid characteristics. Br J Psychtatry 1976, 129: 207-15. 8. Zimbardo PG, Andersen SM, Kabat LG. Induced hearing deficit generates experimental paranoia. Science 1981; 212: 1529-31
should be wary of the implicit assumption that because a medical treatment has been evaluated and found wanting, an untested "traditional" procedure is likely be better. It may indeed -fulfil the aim of giving people control over their lives but will it cure illness? For all its faults, professional medicine is becoming quite vigorous in evaluation of its procedures. Should not the same criteria be applied to self care? LEVIN points out that it is too late to ask whether self care should exist. It does exist. He cites several surveys from the U.K. and the U.S.A. showing that half or more of all illness episodes are treated by self care.5 This is an indication that self care is attempting to meet a social and personal need, but not necessarily that it is effective therapeutically. Most illnesses are short-lived and some become chronic, irrespective of who treats them. Evaluation of self care will not be easy, particularly if self care includes not only treatment but also to
diagnosis. When we come to the third possible area for self-care, the realm of health maintenance and disease prevention, the argument that self care contributes to a feeling of control over one’s life is less generally applicable. There are examples where this is so-most notably offered by the women’s movement which has been active in education as well as in setting up clinics. However, few of us feel demeaned by having sewers provided by Government or by being supplied with clean water, although a vociferous minority objects to having fluoride added to it. In the countries of the developing world, the major advances in health will come from clean water and sewage and from adequate nutrition. Unless the self-care concept expands to include community action on a wide scale, these advances can not all come from self care. Nor is self care likely to do much to improve working conditions or
provide adequate housing. developed world where
In the
Government’s
role
in
some
we
take for granted of public
areas
health-e.g., water and sewage, and setting health standards for the workplace, if not in others such as nutrition—self care is also being pushed in the form of health education. It is interesting that in Britain at a time when Government is seeking to cut public expenditure and stop expansion of the National Health Service the budget of the Health Education Council was increased by 44% (,2 million). The reasoning behind this can perhaps be seen in the D.H.S.S. document Prevention and Health: Everybody’s Business8 (which was published when a different Government was in power). This document was rightly criticised at the time for ignoring the possible role of Government in prevention. For example, when discussing the role of life-style in prevention of coronary heart disease, it said the "prime responsibility for his own health falls on the individual". It adds that the role of the health professions and of Government is limited to ensuring that the public have access to knowledge. If health education 8.
of Health and Social Security. Prevention and health. Everybody’s business. London H.M. Stationery Office, 1976.
Department
only on the individual and ignores the social and environmental influences on life-style, it is unlikely to be effective.9 To take the example of smoking, the General Household Survey’° shows that between 1972 and 1980 the proportion of professional men who smoked fell from 33% to 21%-a welcome decline. By contrast, during the same period, the proportion of unskilled manual workers who smoked went from 64% to 57% in men and 42% to 41% in women. Although smoking is ultimately a personal decision, the fact that social groups defined on the basis of occupation show different preferences for the smoking habit demonstrates the crucial importance of social influences on personal behaviour. As Prevention and Health: Everybody’s Business implies, the other side of individual responsibility in health is blaming the individual if he or she gets sick. Given the persisting social inequalities in health," this seems a barely defensible position. Statements emphasising the importance of the individual in health should not be taken as an argument for neglecting the effects of working conditions, of housing, and of marketing of food, tobacco, and alcohol. ’ concentrates
BLOOD AND SPORTS first described by Fleischer in of the earliest 1881,’ recognised haematological complications of walking or running. Three types of paroxysmal haemoglobinuria were recognised in the 19th century2 and march haemoglobinuria can be easily distinguished from the other two—i.e., paroxysmal nocturnal haemoglobinuria, in which Ham’s test is positive, and paroxysmal cold haemoglobinuria, in which the DonathLandsteiner antibody is present. Eighty years of laboratory investigations, however, failed to pinpoint any typical redcell or serum features in cases of march haemoglobinuria, and attempts were largely abandoned in 1964 when Davidson3 declared that there simply was no abnormality. In a series of experiments he showed that during marching or running red cells in the plantar blood vessels became mechanically damaged, with intravascular haemolysis. It then became apparent why haemoglobinuria did not arise after swimming or after exercise on a stationary bicycle, and why it was not exertional per se, as some had suspected. The haemoglobin released from the lysed red cells initially combines with haptoglobin and is removed from the circulation, but when the haptoglobin becomes exhausted and its serum level falls, MARCH
haemoglobinuria,
was one
haemoglobinaemia
ensues
and
haemoglobin spills into
the
urine. Haemosiderin may also be found in the urine if episodes of haemoglobinuria are frequent. Today’s vogue for walking, jogging, and running has meant more cases of march haemoglobinuria, though not all are being recognised. Some idea of the frequency of the syndrome can be gained from a Danish study. Hunding and his 9. Cohen
CI, Cohen EJ. Health education. Panacea, pernicious or pointless N Engl J Med 1978; 299: 718-20. 10. OPCS Monitor 1981, July 28. 11.
Inequalities in health: Report of working group. London: Department of Health and Social Security, 1980. 1. Fleischer R. Ueber eine neue Form von Haemoglobinurie beim Menschen. Berl Klin Wschr 1881; 18: 691-94. JV The haemolytic anaemias,
2. Dacie
congenital
and
acquired
Part
III-secondary
or
symptomatic haemolytic anaemias London Churchill, 1967: 966-70 3 Davidson RJL. Exertional haemoglobinuria: a report on three cases with studies on the haemolytic mechanism. J Clin Pathol 1964; 17: 536-40.
848
co-workers4surveyed 113 joggers and
runners and found levels in both men and women. Interestingly, anaemia seemed to be common in the trained runners, whereas earlier workers had emphasised the rarity of anaemia in march haemoglobinuria.2Hunding et al. ascribe the athlete’s anaemia to iron deficiency, since iron was lost through haemoglobinuria after long-distance running. This notion deserves further investigation. The frequency of haemoglobinaemia can be related to the distance run.5 Many runners have haemoglobinaemia after 2-6 6 miles (4 km); virtually all marathon runners are affected-for example, of 18 athletes who had run the marathon distance of 26 miles, 18 had haemoglobinaemia and 4 haemoglobinuria. The remedies are simple: shoes with resilient insoles, training to avoid a heavy stamping stride, and avoidance of hard roads in favour of grass or cinder. Some workers suspect that the anaemia of long distance runners is partly due to inhibition of
very low
haptoglobin
6
erythropoiesis-a "functional pseudoanemia". In one of the earliest published series of march haemoglobinuria Dickinson in 1894 described an instance in7 which haemoglobinuria was noticed after tennis. Presumably the mechanism would have been lysis of red cells in the plantar vessels but in the Basque variety of tennis, pelota, damage may also arise in the palmar vessels. This game should be played with a wickerwork racket strapped to the hand, but some people dispense with the racket and get haemoglobinuria.8 Blood vessels in the hand are also injured during hand strengthening exercises for karate. Streeton9 investigated a man of 26 who had haemoglobinuria after each exercise period (15 minutes of chopping the ulnar border of the hand on a wooden stool, and 15 minutes of punching his hand at a blanket spread on a concrete floor). These sessions caused a fall in haptoglobin, haemoglobinaemia, haemoglobinuria, and haemosiderinuria. Finally, mention should be made of the hazards of congadrumming. Drumming sessions often take place daily and are of great physical intensity, lasting 5 hours or more.lo The conga drum has a thick vellum skin which is hit by the fingers and hollow palm. The first recorded instance of drumming-induced haemoglobinuria was encountered by Kaden 11 in a man who had previously indulged in running, without ill-effects. The traumatic origin of conga-drumming haemoglobinuria was confirmed in what must be one of the most unusual clinical research projects ever undertaken.’o Doctors at the University of Pennsylvania admitted a 20-yearold man with post-drumming haemoglobinuria for a series of sessions on conga and bongo drums. Control drummers with no history of haemoglobinuria were also admitted. Three concerts were arranged on days 1, 2, and 7. The first two concerts strikingly reduced the plasma haptoglobin and raised the plasma haemoglobin. The third concert reduced the haptoglobin still further and haemoglobinuria ensued. Drummers in the West Indies do
not seem to
get haemo-
anaemia and iron deficiency Acta Med Scand 1981; 209: 315-18. 5. Gilligan DR, Altschule MD, Katersky EM Physiologic intravascular hemolysis of exercise. Hemoglobinemia and hemoglobinuria following cross-country runs J
4.
Hunding A, Jordal R, Paulev P-E Runner’s
Clin Invest 1943; 22: 859-69. 6. Dressendorfer RH, Wade CE, Amsterdam EA 7.
8. 9. 10. 11.
Development of pseudoanemia in marathon runners during a 20-day round race. JAMA 1981; 246: 1215-18. Dickinson W. Haemoglobinuria from muscular exertion. Trans Clin Soc Lond 1894; 27: 230-33. Laporte G, Dunat L Une nouvelle cause d’hémoglobinurie traumatique: la pelote basque a mains nues Nouv Presse Med 1972; 1: 2404. Streeton JA Traumatic haemoglobinuria caused by karate exercises. Lancet 1967; ii: 191-92. Furie B, Penn AS. Pigmenturia from conga drumming. Ann Intern Med 1974; 80: 727-29. Kaden WS. Traumatic haemoglobinuria in conga-drum players. Lancet 1970; i 1341.
globinuria whilst those in the U.S.A. do. In the West Indies the drums are often placed on absorbent earth, whilst in the U.S.A. they are placed on hard floors.
HEARING LOSS AND PERCEPTUAL IN SCHIZOPHRENIA As
long
occurrence
DYSFUNCTION
ago as 1915, Emil Kraepelin recorded the 1 of persecutory delusions in the hard of hearing.’
Since his time, there have been occasional references to an association between deafness and paranoid symptoms in schizophrenic patients,2,3 and there have also been reports of a higher prevalence of hearing disorders in patients with schizophrenia and paranoid psychoses (especially those developing late in life) than in groups with affective illnesses.4,5 Cooper and others6 examined this association, in two unselected samples of elderly patients with paranoid and affective psychoses, by means of pure-tone audiometry and clinical measures of social deafness.6 It emerged that the patients with paranoid psychosis had a greater degree of hearing loss and were more often socially deaf than those with affective illness, who resembled the general population. In the paranoid group a significantly higher proportion of patients had severe longstanding deafness, most commonly due to chronic middle-ear disease. Hearing impairment had begun long before the onset of the illness and personality and social data7 indicated that chronic deafness was an important independent factor in the aetiology of paranoid hallucinatory psychoses in later life. These clinical findings have-lately been followed up in the laboratory by Zimbardo and others.8 In a social setting, a group of normal subjects rendered partly deaf by hypnotic suggestion, but unaware of the source of their deafness, was compared with two control groups. In one of these, partial deafness was iriduced in subjects who were aware of its source and in the other a posthypnotic suggestion unrelated to deafness was experienced. Partial deafness without awareness of its source was associated with changes in cognitive, emotional, and behavioural functioning in that, on various measures, the experimental subjects became significantly more paranoid and grandiose than controls and rated themselves as more irritable, hostile, and unfriendly. Though admitting that their laboratory procedure was artificial, Zimbardo et al. suggest that functionally analogous situations do arise in everyday life. Hearing often deteriorates without the individual realising it and the social stigma attached to deafness sometimes encourages denial, especially among the elderly. Paranoid thinking may emerge as a cognitive attempt to overcome the difficulty in hearing what other people are saying, and misunderstandings provoke frustration and anger. Observers may regard such responses as evidence of bizarre thinking so that, over a long period, the deaf person may become progressively isolated, and lose the corrective 1. Kraepelin E. Psychiatrie. Leipzig: Barth, 1915. 2. Priteker B. Paranoid und Schwerhörigkeit. Schweiz Med Wschr 1938; 7: 165-66. 3. Houston F, Royse AB. Relationship between deafness and psychotic illness J Ment Sci 1954; 100: 990-93 4. Kay DWK, Roth M. Environmental and hereditary factors in the schizophrenias of old
age. J Ment Sci 1961; 107: 649-86 5. Post F Persistent persecutory states of the elderly London: Pergamon, 1966 6. Cooper AF, Curry AR, Kay DWK, Garside RF, Roth M. Hearing loss in paranoid and affective psychoses ofthe elderly. Lancet 1974; ii 851-54. 7. Kay DWK, Cooper AF, Garside RF, Roth M. The differentiation of paranoid from affective psychoses by patients’ premorbid characteristics. Br J Psychtatry 1976, 129: 207-15. 8. Zimbardo PG, Andersen SM, Kabat LG. Induced hearing deficit generates experimental paranoia. Science 1981; 212: 1529-31