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LACTOSE INTOLERANCE IN TURKEY
151 the thoracic duct. 4.. However, since the liver represents by far the greatest part of the total reticuloendothelial system of the body, most of these antigens will finally be taken up by the Kupffer cells in the liver and disposed of here. We foundan average increase in serum-y-globulin concentration of 25% after portacaval anastomosis in patients with cirrhosis. This rise may primarily be due to the reduction in hepatic blood-flow brought about by this operation,’,’ thereby reducing the filter effect of the liver on the blood-borne antigens. Bispebjerg Hospital, 2400 Copenhagen, Denmark.
HANNE PRYTZ MOGENS BJØRNEBOE.
LACTOSE INTOLERANCE IN TURKEY
SiR,-We read with great interest the letter by Spanidou and Petrakis,9 who found 6 cases of lactose intolerance among 16 Greek students. We have begun a study into the prevalence of lactose intolerance in the Turkish population. We selected 30 healthy students aged between 18 and 37 years, 16 of whom were male and 14 female. After oral administration of 50 g. lactose suspended in 250 ml. of tap-water to fasting subjects, capillary blood samples were taken at 0, 15, 30, 60, and 90 minutes. Blood-glucose was estimated by the SomogyiNelson method. Before the test the subjects were asked whether or not they drank milk; if they did, they were questioned as to frequency of milk consumption as well as presence or absence of symptoms after drinking milk. In addition we recorded the symptoms seen after the lactosetolerance test. We found 11 persons
(37%) in whom the increase in was levels under 20 mg. per 100 ml. after blood-glucose the test dose of lactose. The increase in blood-glucose after lactose load varied between 22 and 74 mg. per 100 ml. in the other 19 subjects. The lactose-tolerance test produced gastrointestinal symptoms in all but 1 of the intolerent subjects as well as in 5 tolerant subjects. Further studies of lactose intolerance among other Mediterranean countries are needed to clarify its distribution. Hacettepe University Medical School, Ankara, Turkey.
ERGÜL TUNCBILEK RIKKAT TÜRÜN BURHAN SAY.
SIGNIFICANCE OF METABOLIC DISORDERS IN SCHIZOPHRENIA SIR,-I refer to the letter of Dr Benjafield and Dr Rutter (April 7, p. 783). They end their first paragraph: " ... have been reported in urine, but others, failing to confirm these or detecting such compounds in normal urine, question their relevance to schizophrenia ". As is confirmed by their own investigations, the only consistent finding in schizophrenia is that, whatever is studied, if
findings,
abnormality is found it is in terms of variability from the norm-either from patient to patient or from test to test. This has been noted many times before. Surely an enormous amount of research of this kind would be rationalised if it were realised by the biochemically 4.
6. 7.
Hildebrand, G. J., Lamanna, C., Wolochow, H., Meyers, C. E. II World Congress of Gastroenterology, Munich, 1962; p. 752. Wolochow, H., Hildebrand, G. J., Lamanna, C. J. infect. Dis. 1966, 116, 523. Prytz, H., Johansen, T. St., Bjørneboe, M. Unpublished. Redeker, A. G., Geller, H. M., Reynolds, T. B. J. clin. Invest. 1958,
8. 9.
37, 606. Benhamou, J.-P., Sicot, C., Erlinger, S. Presse méd. 1971, 79, 185. Spanidou, E. P., Petrakis, N. L. Lancet, 1972, ii, 872.
5.
oriented that " schizophrenia " is a very loose concept, with some clinical meaning, but incorporating, even in terms of behaviour, cases which have very little in common —a " diagnosis " upon which psychiatrists often differ, even if they accept the validity of regarding a particular " human behaviour pattern as a disease ". Is it not likely that we are dealing with a number of very different clinical and biochemical entities which have been grouped because of their incomprehensibility ? Eccentricity of dietary, sexual, and other physiology-modifying behaviour is then to be expected. Your contributors could find more reward from studying the clinical features of biochemically homogeneous groups. Even this is likely to be fruitless unless day-to-day variation and acceleration and deceleration rates of factors are also studied and clinically correlated. There remains, even then, the question of causality-e.g., is the hyporeactivity of chronic schizophrenics the cause or the effect of their behavioural hyporeactivity ? May not each facilitate the other ? Psychiatric Unit, Memorial Hospital, Hastings, New Zealand.
D. W. ROWNTREE.
PASSIVE DEATH SIR,-In his intriguing article (June 23, p. 1435) Dr Milton describes premature deaths in patients who have been told that they have malignancies, and he relates this observation to the phenomenon of death by magic spell in primitive societies. I must take issue with Dr Milton’s use of the phrase self-willed death ", for the experience of others with death due to witchcraft1 or death during psychological stress2 suggests that the patient’s " will " has little to do with his demise, except in so far as he perceives his " will " to be ineffectual. Indeed, the critical element would seem to be the belief that his fate has been ordained, not by him, but by higher powers. Leonard, in 1906, for example, described such deaths among tribal peoples of the Lower " Niger: I have seen Kru-men and others die in spite of every effort that was made to save them, simply because they had made up their minds, not (as we thought at the time) to die, but that being in the clutch of malignant demons they were bound to die."33 Deaths during periods of extreme emotional arousal, though outwardly dissimilar from the " passive-death syndrome " (as I would prefer to call such cases as that described by Dr Milton), may be mediated through a similar mechanism, as suggested by Engel. In that regard an experimental observation of Richter 4 comes to mind as a possible contributing factor in premature deaths among patients with malignant tumours. He found that wild Norwegian rats subjected to the stress of whisker-trimming, handling, and confinement to a swimming tank often died suddenly of no apparent cause, though later investigation revealed bradycardia preceding death. Domesticated rats, on the other hand, rarely showed such a death response unless pretreated with cholinergic drugs. In addition, 1/30 of the L.D’6o of morphine brought out the death re4 sponse of domesticated rats. It would be interesting to know what proportion of Dr Milton’s patients were receiving narcotic analgesics as palliative treatment for their malignancies. If the passive-death syndrome is mediated 1. 2. 3.
Cannon, W. B. Am. Anthropologist, 1942, 44, 169. Engel, G. L. Ann. intern. Med. 1971, 74, 771. Leonard, A. G. The Lower Niger and its Tribes; p. 257. London,
4.
Richter, C. P. in The Meaning of Death (edited by H. Feifel); p. 302. New York, 1959.
1906.
HANNE PRYTZ MOGENS BJØRNEBOE.
LACTOSE INTOLERANCE IN TURKEY
SiR,-We read with great interest the letter by Spanidou and Petrakis,9 who found 6 cases of lactose intolerance among 16 Greek students. We have begun a study into the prevalence of lactose intolerance in the Turkish population. We selected 30 healthy students aged between 18 and 37 years, 16 of whom were male and 14 female. After oral administration of 50 g. lactose suspended in 250 ml. of tap-water to fasting subjects, capillary blood samples were taken at 0, 15, 30, 60, and 90 minutes. Blood-glucose was estimated by the SomogyiNelson method. Before the test the subjects were asked whether or not they drank milk; if they did, they were questioned as to frequency of milk consumption as well as presence or absence of symptoms after drinking milk. In addition we recorded the symptoms seen after the lactosetolerance test. We found 11 persons
(37%) in whom the increase in was levels under 20 mg. per 100 ml. after blood-glucose the test dose of lactose. The increase in blood-glucose after lactose load varied between 22 and 74 mg. per 100 ml. in the other 19 subjects. The lactose-tolerance test produced gastrointestinal symptoms in all but 1 of the intolerent subjects as well as in 5 tolerant subjects. Further studies of lactose intolerance among other Mediterranean countries are needed to clarify its distribution. Hacettepe University Medical School, Ankara, Turkey.
ERGÜL TUNCBILEK RIKKAT TÜRÜN BURHAN SAY.
SIGNIFICANCE OF METABOLIC DISORDERS IN SCHIZOPHRENIA SIR,-I refer to the letter of Dr Benjafield and Dr Rutter (April 7, p. 783). They end their first paragraph: " ... have been reported in urine, but others, failing to confirm these or detecting such compounds in normal urine, question their relevance to schizophrenia ". As is confirmed by their own investigations, the only consistent finding in schizophrenia is that, whatever is studied, if
findings,
abnormality is found it is in terms of variability from the norm-either from patient to patient or from test to test. This has been noted many times before. Surely an enormous amount of research of this kind would be rationalised if it were realised by the biochemically 4.
6. 7.
Hildebrand, G. J., Lamanna, C., Wolochow, H., Meyers, C. E. II World Congress of Gastroenterology, Munich, 1962; p. 752. Wolochow, H., Hildebrand, G. J., Lamanna, C. J. infect. Dis. 1966, 116, 523. Prytz, H., Johansen, T. St., Bjørneboe, M. Unpublished. Redeker, A. G., Geller, H. M., Reynolds, T. B. J. clin. Invest. 1958,
8. 9.
37, 606. Benhamou, J.-P., Sicot, C., Erlinger, S. Presse méd. 1971, 79, 185. Spanidou, E. P., Petrakis, N. L. Lancet, 1972, ii, 872.
5.
oriented that " schizophrenia " is a very loose concept, with some clinical meaning, but incorporating, even in terms of behaviour, cases which have very little in common —a " diagnosis " upon which psychiatrists often differ, even if they accept the validity of regarding a particular " human behaviour pattern as a disease ". Is it not likely that we are dealing with a number of very different clinical and biochemical entities which have been grouped because of their incomprehensibility ? Eccentricity of dietary, sexual, and other physiology-modifying behaviour is then to be expected. Your contributors could find more reward from studying the clinical features of biochemically homogeneous groups. Even this is likely to be fruitless unless day-to-day variation and acceleration and deceleration rates of factors are also studied and clinically correlated. There remains, even then, the question of causality-e.g., is the hyporeactivity of chronic schizophrenics the cause or the effect of their behavioural hyporeactivity ? May not each facilitate the other ? Psychiatric Unit, Memorial Hospital, Hastings, New Zealand.
D. W. ROWNTREE.
PASSIVE DEATH SIR,-In his intriguing article (June 23, p. 1435) Dr Milton describes premature deaths in patients who have been told that they have malignancies, and he relates this observation to the phenomenon of death by magic spell in primitive societies. I must take issue with Dr Milton’s use of the phrase self-willed death ", for the experience of others with death due to witchcraft1 or death during psychological stress2 suggests that the patient’s " will " has little to do with his demise, except in so far as he perceives his " will " to be ineffectual. Indeed, the critical element would seem to be the belief that his fate has been ordained, not by him, but by higher powers. Leonard, in 1906, for example, described such deaths among tribal peoples of the Lower " Niger: I have seen Kru-men and others die in spite of every effort that was made to save them, simply because they had made up their minds, not (as we thought at the time) to die, but that being in the clutch of malignant demons they were bound to die."33 Deaths during periods of extreme emotional arousal, though outwardly dissimilar from the " passive-death syndrome " (as I would prefer to call such cases as that described by Dr Milton), may be mediated through a similar mechanism, as suggested by Engel. In that regard an experimental observation of Richter 4 comes to mind as a possible contributing factor in premature deaths among patients with malignant tumours. He found that wild Norwegian rats subjected to the stress of whisker-trimming, handling, and confinement to a swimming tank often died suddenly of no apparent cause, though later investigation revealed bradycardia preceding death. Domesticated rats, on the other hand, rarely showed such a death response unless pretreated with cholinergic drugs. In addition, 1/30 of the L.D’6o of morphine brought out the death re4 sponse of domesticated rats. It would be interesting to know what proportion of Dr Milton’s patients were receiving narcotic analgesics as palliative treatment for their malignancies. If the passive-death syndrome is mediated 1. 2. 3.
Cannon, W. B. Am. Anthropologist, 1942, 44, 169. Engel, G. L. Ann. intern. Med. 1971, 74, 771. Leonard, A. G. The Lower Niger and its Tribes; p. 257. London,
4.
Richter, C. P. in The Meaning of Death (edited by H. Feifel); p. 302. New York, 1959.
1906.