- Email: [email protected]
A FOLK ILLNESS (SUSTO) AS AN INDICATOR OF REAL ILLNESS
1362
phospholipids.7 Unpublished
work in our laboratory has shown nervous tissue phospholipids with the central cross-reactivity The and association between a false cephalin sphingomyelin. positive VDRL test and transverse myelopathy in patients with the Jamaican neuropathy8 and lupoid sclerosis9led us to speculate that direct antibody-mediated damage to phospholipid-containing structures in the central nervous tissue may play a role in the pathogenesis of these disorders.l0 The association between antiphospholipid antibodies and the Guillain-Barre syndrome in this case suggests that serological and CSF studies for this association be undertaken in further patients with this disorder and other demyelinating diseases.
E. N. HARRIS H. ENGLERT G. DERUE G. R. V. HUGHES A. GHARAVI
Department of Medicine, Royal Postgraduate Medical School, Hammersmith Hospital, Ducane Road, London W12 0HS
A FOLK ILLNESS (SUSTO) AS AN INDICATOR OF REAL ILLNESS
throughout the world, in the in isolated rural areas.l-3 One such illness is susto, a syndrome with high prevalence (5-10% in endemic areas) and wide distribution throughout Latin America and among Americans of Mexican descent.4-6 Susto is considered by susceptible populations to be a spiritual illness caused by the separation of soul and body. It is associated with a broad array of symptoms that fit no specific diagnosis or set of diagnoses, but anorexia, weight loss, debility, and lack of motivation are reported frequently. Most studies of this problem have been descriptive with very little follow-up, and while the afflicted populations and many attending physicians recognise its importance, this has not been demonstrated. To study the morbidity and mortality implications of such a diagnosis, anthropologists identified 50 adult ambulatory patients with susto in three communities in the State of Oaxaca, Mexico. Susto sufferers (asustados) were self-identified or identified by lay healers when they sought care for their complaints. Each patient with susto was paired with an ambulatory patient of the same age, sex, and community affiliations. Each control had symptoms for which she or he sought care, but had not implicated susto as part of the complaint. Only patients 18 years or older were selected for the study; 72% of the sample were women, 28% men. All members of the susto and control groups were examined by a physician who took a medical history and made a physical examination; blood was tested for haemoglobin and haematocrit values, and a stool specimen was examined for parasites. Clinical data and laboratory results were studied by two other physician evaluators who made diagnoses using the International Classification of Diseases. Subsequently the evaluators used an index specially developed to translate qualitative assessments of gravity into quantitative measures predicting survival. The higher the number of points assigned to abnormal SIR,-Folk illnesses
most
cosmopolitan
are common
cities
as
well
as
Thiagarajan P, Shapiro S, DeMarco L. Monoclonal immunoglobulin M coagulation inhibitor with phosphohpid specificity: Mechanism of alupus anticoagulant. J Clin Invest 1981, 66: 397-405. 8. Montgomery RD, Cruikshank EK, Robertson WB, McMeneney WH. Clinical and pathological observations on Jamaican neuropathy: a report on 206 cases. Brain 1964; 87: 425-69 9 Fulford KWM, Catterall RD, Delhanty JJ, Daniach D, Kremer M. A collagen disorder of the nervous system presenting as multiple sclerosis. Brain 1972; 95: 373-86. 10. Wilson WA, Hughes GRV Aetiology of Jamaican neuropathy. Lancet 1975; i: 240. 1. Martinez C, Martin HW. Folk diseases among urban Mexican-Americans. JAMA
findings reported in the history, physical examination, and laboratory tests, the more serious the illness. The physican evaluators identified 515 diagnoses among members of both groups and assigned diagnoses to fifteen ICD categories. While there were differences between the study and the control groups in 11of the 15 categories, none was significant. Among susto patients haemoglobin levels averaged II. 7 g/dl with controls averaging 12’44 g/dl; haematocrit levels averaged 36,6 among asustados and 376in the control group; parasite infestation found among 79% of the experimental group and 68% of the others. Langner’s standardised screening score for psychiatric 7 impairment failed to discriminate between the two groups. Seven years later the villages were visited again by two independent collaborators to evaluate the outcome (survival) of study and control patients. The evaluators were unaware of the study category of the patients. The survival status of 95 patients was ascertained (47 asustados and 48 controls). The two samples were found to differ significantly in four ways: (1) There were 280 diagnoses among the susto sufferers and 235 in the controls (p<0 01); on average, those with susto had 5 -7 diagnoses each and the controls 4 -6. (2) The syndrome most commonly identified with susto (anorexia, weight loss, debility, and lack of motivation) was found in 32% of asustados but only 10% of controls (p<0 0 1). (3) The gravity index showed that those with susto were more gravely ill: asustados scores averaged 7 -42, controls 4 -58 (p
Faculty of Medicin, Universidad Nacional Autónoma de México,
Mexico City, Mexico and School of Social Science,
University of California Irvine, Medical Center, Irvine, California 92717, USA
ARTHUR J. RUBEL
University of Notre Dame, Notre Dame, Indiana
CARL W. O’NELL
State
Michigan University, East Lansing, Michigan
7.
1966, 196: 161-64. 2. Kleinman A, et al. Culture, illness and care. Clinical lesions from anthropological and cross-cultural research. Ann Intern Med 1978; 88: 251-58. 3. Snow L Folk medical beliefs and their implications for care of patients. Ann Intern Med 1974; 81: 82-96 4. Rubel AJ Epidemiology of a folk illness: Susto in Hispanic America. Ethnology 1964; 3: 268-83 5. Rubel AJ, O’Nell CW. Difficulties of presenting complaints to physicans: Susto illness as an example. Bull Pan Am Health Org 1979; 13: 134-38. 6. Mull JD, Mull DS. Residents’ awareness of medicine beliefs of their Mexican patients. J Med Educ 1981; 56: 520-22.
ROLANDO COLLADO ARDÓN
Department of Family Medicine
RAYMOND H. MURRAY
LOCAL HAEMOSTASIS FOR ORAL BLEEDING IN PATIENTS WITH COAGULOPATHY
SIR,-Several problems associated with dental extraction in patients with haemophilia and other coagulopathies have been overcome by antihaemophilic concentrates, antifibrinolytic agents, and other concentrates, but the volume of replacement infusions should be kept low to reduce the risk of infection by hepatitis virus, antibody formation, and the other complications. A local haemostatic procedure is more important than replacement therapy in the management of local and superficial minor bleeding such as oral haemorrhage in such patients. Several topical drugs bring about haemostasis for oral bleeding, but 7.
a
local haemostatic procedure has
not
been established for
Langner T A twenty-two item screening score of psychiatric symptoms indicating impairment. J Health Hum Behavior 1962, 3: 269-76
phospholipids.7 Unpublished
work in our laboratory has shown nervous tissue phospholipids with the central cross-reactivity The and association between a false cephalin sphingomyelin. positive VDRL test and transverse myelopathy in patients with the Jamaican neuropathy8 and lupoid sclerosis9led us to speculate that direct antibody-mediated damage to phospholipid-containing structures in the central nervous tissue may play a role in the pathogenesis of these disorders.l0 The association between antiphospholipid antibodies and the Guillain-Barre syndrome in this case suggests that serological and CSF studies for this association be undertaken in further patients with this disorder and other demyelinating diseases.
E. N. HARRIS H. ENGLERT G. DERUE G. R. V. HUGHES A. GHARAVI
Department of Medicine, Royal Postgraduate Medical School, Hammersmith Hospital, Ducane Road, London W12 0HS
A FOLK ILLNESS (SUSTO) AS AN INDICATOR OF REAL ILLNESS
throughout the world, in the in isolated rural areas.l-3 One such illness is susto, a syndrome with high prevalence (5-10% in endemic areas) and wide distribution throughout Latin America and among Americans of Mexican descent.4-6 Susto is considered by susceptible populations to be a spiritual illness caused by the separation of soul and body. It is associated with a broad array of symptoms that fit no specific diagnosis or set of diagnoses, but anorexia, weight loss, debility, and lack of motivation are reported frequently. Most studies of this problem have been descriptive with very little follow-up, and while the afflicted populations and many attending physicians recognise its importance, this has not been demonstrated. To study the morbidity and mortality implications of such a diagnosis, anthropologists identified 50 adult ambulatory patients with susto in three communities in the State of Oaxaca, Mexico. Susto sufferers (asustados) were self-identified or identified by lay healers when they sought care for their complaints. Each patient with susto was paired with an ambulatory patient of the same age, sex, and community affiliations. Each control had symptoms for which she or he sought care, but had not implicated susto as part of the complaint. Only patients 18 years or older were selected for the study; 72% of the sample were women, 28% men. All members of the susto and control groups were examined by a physician who took a medical history and made a physical examination; blood was tested for haemoglobin and haematocrit values, and a stool specimen was examined for parasites. Clinical data and laboratory results were studied by two other physician evaluators who made diagnoses using the International Classification of Diseases. Subsequently the evaluators used an index specially developed to translate qualitative assessments of gravity into quantitative measures predicting survival. The higher the number of points assigned to abnormal SIR,-Folk illnesses
most
cosmopolitan
are common
cities
as
well
as
Thiagarajan P, Shapiro S, DeMarco L. Monoclonal immunoglobulin M coagulation inhibitor with phosphohpid specificity: Mechanism of alupus anticoagulant. J Clin Invest 1981, 66: 397-405. 8. Montgomery RD, Cruikshank EK, Robertson WB, McMeneney WH. Clinical and pathological observations on Jamaican neuropathy: a report on 206 cases. Brain 1964; 87: 425-69 9 Fulford KWM, Catterall RD, Delhanty JJ, Daniach D, Kremer M. A collagen disorder of the nervous system presenting as multiple sclerosis. Brain 1972; 95: 373-86. 10. Wilson WA, Hughes GRV Aetiology of Jamaican neuropathy. Lancet 1975; i: 240. 1. Martinez C, Martin HW. Folk diseases among urban Mexican-Americans. JAMA
findings reported in the history, physical examination, and laboratory tests, the more serious the illness. The physican evaluators identified 515 diagnoses among members of both groups and assigned diagnoses to fifteen ICD categories. While there were differences between the study and the control groups in 11of the 15 categories, none was significant. Among susto patients haemoglobin levels averaged II. 7 g/dl with controls averaging 12’44 g/dl; haematocrit levels averaged 36,6 among asustados and 376in the control group; parasite infestation found among 79% of the experimental group and 68% of the others. Langner’s standardised screening score for psychiatric 7 impairment failed to discriminate between the two groups. Seven years later the villages were visited again by two independent collaborators to evaluate the outcome (survival) of study and control patients. The evaluators were unaware of the study category of the patients. The survival status of 95 patients was ascertained (47 asustados and 48 controls). The two samples were found to differ significantly in four ways: (1) There were 280 diagnoses among the susto sufferers and 235 in the controls (p<0 01); on average, those with susto had 5 -7 diagnoses each and the controls 4 -6. (2) The syndrome most commonly identified with susto (anorexia, weight loss, debility, and lack of motivation) was found in 32% of asustados but only 10% of controls (p<0 0 1). (3) The gravity index showed that those with susto were more gravely ill: asustados scores averaged 7 -42, controls 4 -58 (p
Faculty of Medicin, Universidad Nacional Autónoma de México,
Mexico City, Mexico and School of Social Science,
University of California Irvine, Medical Center, Irvine, California 92717, USA
ARTHUR J. RUBEL
University of Notre Dame, Notre Dame, Indiana
CARL W. O’NELL
State
Michigan University, East Lansing, Michigan
7.
1966, 196: 161-64. 2. Kleinman A, et al. Culture, illness and care. Clinical lesions from anthropological and cross-cultural research. Ann Intern Med 1978; 88: 251-58. 3. Snow L Folk medical beliefs and their implications for care of patients. Ann Intern Med 1974; 81: 82-96 4. Rubel AJ Epidemiology of a folk illness: Susto in Hispanic America. Ethnology 1964; 3: 268-83 5. Rubel AJ, O’Nell CW. Difficulties of presenting complaints to physicans: Susto illness as an example. Bull Pan Am Health Org 1979; 13: 134-38. 6. Mull JD, Mull DS. Residents’ awareness of medicine beliefs of their Mexican patients. J Med Educ 1981; 56: 520-22.
ROLANDO COLLADO ARDÓN
Department of Family Medicine
RAYMOND H. MURRAY
LOCAL HAEMOSTASIS FOR ORAL BLEEDING IN PATIENTS WITH COAGULOPATHY
SIR,-Several problems associated with dental extraction in patients with haemophilia and other coagulopathies have been overcome by antihaemophilic concentrates, antifibrinolytic agents, and other concentrates, but the volume of replacement infusions should be kept low to reduce the risk of infection by hepatitis virus, antibody formation, and the other complications. A local haemostatic procedure is more important than replacement therapy in the management of local and superficial minor bleeding such as oral haemorrhage in such patients. Several topical drugs bring about haemostasis for oral bleeding, but 7.
a
local haemostatic procedure has
not
been established for
Langner T A twenty-two item screening score of psychiatric symptoms indicating impairment. J Health Hum Behavior 1962, 3: 269-76