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RED FACES AND RAISED HAEMOGLOBIN
912
carcinogens of other kinds and concentrate on reducing the P.A.H. in smoke. Other pertinent questions are: Is there an association between high A.H.H. inducibility and susceptibility to oral and laryngeal cancer in smokers ? Are people who are homozygous for high A.H.H. inducibility more likely than others to smoke ? Does inhalation of carbon monoxide reduce A.H.H. activity in human lung in the same way as it has been found to do in the liver of mice ? 18 Is susceptibility to skin cancer in workers exposed to tar, pitch, or mineral oils dependent on A.H.H. inducibility ? Questions such as these should be relatively easy to work on and the answers will be eagerly awaited.
fact, quite normal. Thus just over 400,, of patients referred to their clinic as possible cases of polycythaemia vera had this syndrome of a red face, high haemoglobin, and increased packed-cell volume were, in
associated with normal total red-cell volume but decreased plasma volume. In most patients the medical abnormality present was hypertension, and those patients on diuretic treatment showed the lowest plasma volumes. So this syndrome is well worth including in the differential diagnosis of polycythxmia: if preliminary investigation is not decisive, the patient should have the blood and plasma volumes estimated, preferably at a laboratory where such estimations are done regularly.
RED FACES AND RAISED HAEMOGLOBIN
A
is posed by the patient sent to the clinic with a tentative diagnosis of polyhaematology he or she has a red plethoric because cythaemia a complexion, high red-cell count, and a raised The haemoglobin. spleen is not enlarged, but this does not exclude polycythsemia. Other important the absence of obtained are negative signs easily of and the absence leucocytosis any abnormality in In some cases clinical examination marrow smears. reveals hypertension, evidence of poor lung function, incipient renal failure, and even sometimes signs of a cerebellar tumour. Sylvia Davies and her co-workers 19 at Exeter now report that hypertension is the most frequent cause of secondary polycythaemia, and the signs are more evident in patients being treated with diuretics. In addition to the standard tests, Davies et al. estimated total blood-volume, using sodium chromate (5lCr) to label the red cells, and plasma volume with the aid of 1251 conjugated with human-serumalbumin. Results were obtained from 25 patients; in all of them the total red-cell volume was normal, but in most the plasma volume was decreased. Of their 25 patients, 4 (all males) were normotensive; they had haemoglobins between 16-1 and 17-2 g. per 100 ml. and packed-cell volumes (P.c.v.) from 49% to 57%. The lowest normal plasma volume is about 40 ml. per kg.: one patient was normal, the other 3 had figures of 34, 36, and 37 ml. per kg. Untreated hypertensive patients numbered 10, again all males; haemoglobins were from 14-9 to 19-5 g. per 100 ml., P.c.v.s from 46% to 57%; plasma-volumes were below 40 ml. per kg. in 8. 6 women patients and 5 men were being treated for their hypertension; the women had haemoglobin levels between 15-0 and 16-7 g. per 100 ml. and the men 16-4 to 18-9 g. per 100 ml., P.c.v.s for the women were 46-51, and for the men 49-58%; all of them had plasma volumes below normal, between 24 and 39 ml. per kg. These 25 patients with normal total red-cell volumes were members of a group of 57 patients sent to Exeter over a period of 3 years with a diagnosis of polycythaemia. 30 patients had increased red-cell volumes; 15 of these turned out to be genuine cases of polycythxmia vera, with enlarged spleens and other supporting evidence, and the other 15 had hypoxia or evidence of renal disease. The remaining 2 cases PROBLEM
THE MEDICINES BOX
COMMON ground between W. A. Beanland,l council member of the Pharmaceutical Society, and Ivan Illich, radical socialist philosopher, is unexpected: but they agree on two things-on the widespread and erroneous belief that medicine offers a pill for every ill, and on the potential value of well-labelled packs of effective medicines, freely available for family use. There they part company, for Beanland sees self-medication as a necessary evil and his aim is to protect the public both from its own insouciance and from the wiles of the drug industry; his medicines pack would contain simple and unexceptionable remedies-an analgesic, a laxative, a skin cream, and an antacid perhaps. Illich, on the other hand, thinks that nearly all effective medical interventions can be designed and packaged for self-use or for application by family members, and his box would contain (presumably) a very different selection. As he makes clear on p. 918, he is less concerned with widening the accessibility of medical care than with breaking what he regards as a harmful professional monopoly on treatment; he wants to return the initiative to the consumer, as part of a strategy for averting social disaster. Somewhere in the middle ground are those who, like Prof. Carol Buck,2 would make certain drugs more freely available but would indicate clearly the point at which self-treatment must stop and medical advice be sought. In the developed world probably only a third of the symptoms of ill-health are referred to doctors, and without the prop of self-treatment health services would hardly survive. In the Third World, patients attend clinics to obtain certain drugs which are freely available in other societies, and extension of self-care could free doctors from much routine work. Amid the growing preoccupation with drug toxicity, interactions, dependence, and other hazards,3 Illich’s ideas on medicines may seem recondite. Indeed, when asked for practical advice, Illich innocently declares himself a historian and a philosopher. But he deserves an answer when he asks, How far is the disbursement of public funds for curative purposes under the control of guild-members rather than under the control of the consumer ?
212, 382.
18. 19.
Rondia, D. C. r. Acad. Sci., Paris, 1970, 27, 617. Davies, S. W., Glynne-Jones, E., Lewis, E. P. J. clin. Path. 1974, 27, 109.
1. See Pharmac. J. 1974, 2. Conference held by Panel May 2, 1974. 3. Lancet, 1973, i, 1297.
on
Self-Care, Royal Society of Medicine,
carcinogens of other kinds and concentrate on reducing the P.A.H. in smoke. Other pertinent questions are: Is there an association between high A.H.H. inducibility and susceptibility to oral and laryngeal cancer in smokers ? Are people who are homozygous for high A.H.H. inducibility more likely than others to smoke ? Does inhalation of carbon monoxide reduce A.H.H. activity in human lung in the same way as it has been found to do in the liver of mice ? 18 Is susceptibility to skin cancer in workers exposed to tar, pitch, or mineral oils dependent on A.H.H. inducibility ? Questions such as these should be relatively easy to work on and the answers will be eagerly awaited.
fact, quite normal. Thus just over 400,, of patients referred to their clinic as possible cases of polycythaemia vera had this syndrome of a red face, high haemoglobin, and increased packed-cell volume were, in
associated with normal total red-cell volume but decreased plasma volume. In most patients the medical abnormality present was hypertension, and those patients on diuretic treatment showed the lowest plasma volumes. So this syndrome is well worth including in the differential diagnosis of polycythxmia: if preliminary investigation is not decisive, the patient should have the blood and plasma volumes estimated, preferably at a laboratory where such estimations are done regularly.
RED FACES AND RAISED HAEMOGLOBIN
A
is posed by the patient sent to the clinic with a tentative diagnosis of polyhaematology he or she has a red plethoric because cythaemia a complexion, high red-cell count, and a raised The haemoglobin. spleen is not enlarged, but this does not exclude polycythsemia. Other important the absence of obtained are negative signs easily of and the absence leucocytosis any abnormality in In some cases clinical examination marrow smears. reveals hypertension, evidence of poor lung function, incipient renal failure, and even sometimes signs of a cerebellar tumour. Sylvia Davies and her co-workers 19 at Exeter now report that hypertension is the most frequent cause of secondary polycythaemia, and the signs are more evident in patients being treated with diuretics. In addition to the standard tests, Davies et al. estimated total blood-volume, using sodium chromate (5lCr) to label the red cells, and plasma volume with the aid of 1251 conjugated with human-serumalbumin. Results were obtained from 25 patients; in all of them the total red-cell volume was normal, but in most the plasma volume was decreased. Of their 25 patients, 4 (all males) were normotensive; they had haemoglobins between 16-1 and 17-2 g. per 100 ml. and packed-cell volumes (P.c.v.) from 49% to 57%. The lowest normal plasma volume is about 40 ml. per kg.: one patient was normal, the other 3 had figures of 34, 36, and 37 ml. per kg. Untreated hypertensive patients numbered 10, again all males; haemoglobins were from 14-9 to 19-5 g. per 100 ml., P.c.v.s from 46% to 57%; plasma-volumes were below 40 ml. per kg. in 8. 6 women patients and 5 men were being treated for their hypertension; the women had haemoglobin levels between 15-0 and 16-7 g. per 100 ml. and the men 16-4 to 18-9 g. per 100 ml., P.c.v.s for the women were 46-51, and for the men 49-58%; all of them had plasma volumes below normal, between 24 and 39 ml. per kg. These 25 patients with normal total red-cell volumes were members of a group of 57 patients sent to Exeter over a period of 3 years with a diagnosis of polycythaemia. 30 patients had increased red-cell volumes; 15 of these turned out to be genuine cases of polycythxmia vera, with enlarged spleens and other supporting evidence, and the other 15 had hypoxia or evidence of renal disease. The remaining 2 cases PROBLEM
THE MEDICINES BOX
COMMON ground between W. A. Beanland,l council member of the Pharmaceutical Society, and Ivan Illich, radical socialist philosopher, is unexpected: but they agree on two things-on the widespread and erroneous belief that medicine offers a pill for every ill, and on the potential value of well-labelled packs of effective medicines, freely available for family use. There they part company, for Beanland sees self-medication as a necessary evil and his aim is to protect the public both from its own insouciance and from the wiles of the drug industry; his medicines pack would contain simple and unexceptionable remedies-an analgesic, a laxative, a skin cream, and an antacid perhaps. Illich, on the other hand, thinks that nearly all effective medical interventions can be designed and packaged for self-use or for application by family members, and his box would contain (presumably) a very different selection. As he makes clear on p. 918, he is less concerned with widening the accessibility of medical care than with breaking what he regards as a harmful professional monopoly on treatment; he wants to return the initiative to the consumer, as part of a strategy for averting social disaster. Somewhere in the middle ground are those who, like Prof. Carol Buck,2 would make certain drugs more freely available but would indicate clearly the point at which self-treatment must stop and medical advice be sought. In the developed world probably only a third of the symptoms of ill-health are referred to doctors, and without the prop of self-treatment health services would hardly survive. In the Third World, patients attend clinics to obtain certain drugs which are freely available in other societies, and extension of self-care could free doctors from much routine work. Amid the growing preoccupation with drug toxicity, interactions, dependence, and other hazards,3 Illich’s ideas on medicines may seem recondite. Indeed, when asked for practical advice, Illich innocently declares himself a historian and a philosopher. But he deserves an answer when he asks, How far is the disbursement of public funds for curative purposes under the control of guild-members rather than under the control of the consumer ?
212, 382.
18. 19.
Rondia, D. C. r. Acad. Sci., Paris, 1970, 27, 617. Davies, S. W., Glynne-Jones, E., Lewis, E. P. J. clin. Path. 1974, 27, 109.
1. See Pharmac. J. 1974, 2. Conference held by Panel May 2, 1974. 3. Lancet, 1973, i, 1297.
on
Self-Care, Royal Society of Medicine,