Secondary polycythemia - Carlos was seventy years old when he decided to leave Buenos Aires to join his daughter's family in the Andes. The joy of reunion was short. On the next day Carlos was overwhelmed by prostration and shortness of breath. He remained in bed waiting for the physician to save him. Hitherto he had enjoyed good health, and never experienced sickness. Was his suffering a token of his advancing age? The doctor noticed tachypnea, anxiety, and a slight hardening of the radial artery due to arteriosclerosis. He turned to Carlos: "You lack red blood cells. Here in the Andes, the air is thin, and the body needs more red blood cells to get enough oxygen from the lungs. Don't lose hope, soon their number will rise, the tissues will get their accustomed share of oxygen and you will feel better. Stay in bed until 'The healing force of Nature' (1) fulfills its task."

By the following week Carlos could accompany his grandchildren to the play-ground. After two weeks he nearly forgot the sad incident. There remained only a slight and nagging shortness of breath, that he hoped will soon disappear. Yet it did not. His condition worsened, he felt palpitations, and head throbbing. He took refuge in his bed and waited for the physician to save him. "Your red blood cells are fine", the doctor said, "but the blood has become viscous and your heart is failing to push it through the tissues." In the following weeks the doctor attempted to balance his condition but in vain. Although blood letting would alleviate the burden on his heart, it would deprive his tissues of oxygen. Soon Carlos and his physician realized, that the only solution for his ailment was to return to Buenos Aires. And so he did. He recovered and remained healthy ever after.

What is the cause of Carlos' disease? - This simple narrative illustrates the inadequacy of medical concepts when applied to Carlos' illness. By joining his daughter, his normo-cytemia turned into a relative anemia. And when his blood count rose, to the normo-cytemic level of the Andes, his arteriosclerotic heart failed to cope with it. What was the cause, or etiology of Carlos' disease? Relative anemia, reactive polycythemia, heart failure, or simply his decision to join his daughter's family? And what would be the adequate cure for such an ailment? Blood letting, digitalis, or simply the decision to return to Buenos Aires? Although Medicine regards Carlos' ailment as multi-factorial it continues searching for a single etiology. Yet most diseases lack an unique etiology. Even the concept of cure seems inadequate. Was Carlos really cured? At best the patient regains his balance, or remission. A real cure is only seldom attained.

Essential hypertension - Imagine Carlos in a different setting. At the age of 40, he was a successful broker, manipulating stocks. Sometimes he awakened at night concerned about their volatility. His recent checkup revealed a slightly elevated blood pressure, yet Carlos felt good and continued his hectic life. At the age of 50, Carlos started swallowing capsules despite their small effect on his rising blood pressure.

A crisis in Eastern stock exchanges swept Buenos Aires like a storm. Carlos, who profited mainly from Japanese equity, lost his fortune, and was broke. By then he was 60. He still got a small pension, decided to see the world, and landed up in India. He soon mastered the art of Yoga, and realized that his blood pressure hadreturned to normal.

What is the cause of Carlos' disease? - Was Carlos the broker ill? According to Medicine he was, since essential hypertension is regarded as "the silent killer". On the other hand, a slightly elevated blood pressure might be a pre-requisite for the life-style of some brokers, exactly as a slightly elevated red blood cell count is for living in the Andes. By joining the brokerage, Carlos' normo-tension turned into a relative hypo-tension and he had to raise it to a new level that represents his normo-tension as a broker. His heart was strong, otherwise he would have developed congestive heart failure, like his counterpart in the Andes. What was the cause, or etiology of Carlos' disease? Relative hypotension or reactive hypertension? Or simply his decision to become a broker? And what would be the adequate cure for such an ailment; hypotensive drugs, sleeping pills or simply going to India? Although medicine regards Carlos' ailment as multi-factorial., it is pre-occupied with blood pressure, regarding it as the sole cause, or etiology of his condition, and claiming that the only way to cure essential hypertension is by lowering it.

Prostate cancer - Carlos was always a believer in preventive medicine. "One ought to overpower disease when it starts", he said to himself and sent his blood to have his PSA checked. It was elevated, nourished by a small tumor in his prostate. Suddenly he was declared sick, carrying a deadly illness.

Was Carlos really ill? According to Medicine he was, since cancer is regarded as a killer. Yet this small nodule might be the pre-requisite for the life-style of certain men in their seventies, exactly as a slightly elevated red blood cell count is for living in the Andes. This might also be the reason why every second male above the age of 65 carries an occult cancer nodule in his prostate (2) (3). True, prostate cancer may kill, but not always. Other factors seem to determine who will succumb. As in reactive polycythemia that is generally not accompanied by heart failure. Yet medicine does not regard Carlos' ailment as multi-factorial, and blames only the tumor for his condition.(4). The tumor is only a single facet in a multi-factorial puzzle. Like an elevated red blood cell count in polycythemia, or blood pressure in essential hypertension?

The search for a common pattern in seemingly unrelated diseases illustrates how poor medical reasoning still is (5).

Gershom Zajicek

1. Zajicek G. Healing force of nature. The Cancer J 8, 4-5,1995

2. Zajicek G. Watch your prostate! The Cancer. J 10, 70-71,1997.

3. Zajicek G. Cancer in old age is more benign than in young adults. The Cancer J 9, 64-65, 1996.

4. Zajicek G. Cancer starts as a systemic disease The Cancer J 5, 28,1992

5. Root-Bernstein RS. Rethinking Aids: The Tragic Cost of Premature Consensus. New York Free Press, 1993.