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bruit was ascribed to compression of the abdominalaorta by the tumour; they suggested the term" nancreatico-aortic syndrome ".

CHARLES K. TASHIMA.

GASTRIC HYPOTHERMIA

SIR,-Earlier accounts of the effect of gastric freezing 1raised high hopes of avoiding operation in the treatmentof duodenal ulcer. The treatment has received consider-able publicity in both the lay and medical Press, particu-larly in the United States, where it was recently estimatedthat 1000 gastric-freezing machines had been purchasedand that between 10,000 and 15,000 patients had beentreated. We ourselves 2 reported promising results in anadmittedly small series of patients.We now describe our own experience of the treatment of

32 patients followed up from periods varying from

eighteen months to two months.We used the ’ Swenko’ machine operating with a bag

volume of 650 ml. for a perfusion period of forty-five minutes,achieving an inflow temperature ranging from -14 to - 17’Cand an outflow temperature ranging between -10 and — 13°C.In each case these were the lowest temperatures which could beachieved with the refrigerator unit at its maximum setting. Wehad no grave complications, perhaps because we personallysupervised the procedure throughout, carefully monitoring thetemperature every five minutes. Several patients complained ofpersistent pain in the upper quadrant of the abdomen forseveral days after freezing, and 1 patient had to be admitted sixweeks after treatment on account of an acute flare-up ofdyspepsia which we thought was due to a small high gastriculcer, not visible on previous films. All patients were able toeat a normal midday meal on the day after treatment and to gohome the day after that.

20 men with duodenal ulcer were treated, and, of these 10must be rejected forthwith as complete failures. 2 obtained norelief at all, and the remaining 8 relapsed at an average periodof seven months after the initial treatment. 3 of these under-went refreezing and they relapsed again in an average time oftwo months after the second application. Of these 10, 8 havehad selective vagotomy and pyloroplasty, and now withoutexception express themselves as very well satisfied.

3 patients reported themselves improved at an average periodof three months after treatment, but are still taking alkalies. 2are symptom-free eight and twelve months after treatment,but the ulcer craters are still radiologically demonstrable. 1

man, free from symptoms at eight months, was found onbarium-meal examination to have gross distortion and narrow-

ing of the duodenum, which suggests that he might requireoperation later for obstructive symptoms. 1 man was no betterafter treatment, but his symptoms disappeared and radio-logically his ulcer healed when he gave up shift work. Only 3men display radiological healing of their ulcers and remainsymptom-free over an average period of eleven months.Of 5 women with duodenal ulcer treated, 2 are well and the

radiologist reports that their ulcers have healed; 2 relapsed andneeded operation at an average of six months; the remainingpatient is still having symptoms at eight months but reportsherself substantially improved, the ulcer crater being nolonger visible on X-ray.

Thus, although this series is admittedly small and

uncontrolled, it must be apparent to any clinician of experi-ence that these results are poor and compare unfavour-

ably with those obtained by more orthodox measures. Wewould emphasise too that of those who relapsed aftertreatment and therefore needed surgery, nearly all wereclamorous in their demands for early operation becauseof the severity of their renewed symptoms. It is temptingto suggest that, having once experienced remission of

1. Wangensteen, O. H. Ann. R. Coll. Surg. Engl. 1963, 31, 143.2. Craig, J. D., Tompkin, A. M. B. Lancet, 1964, i, 47.

symptoms, they were no longer prepared to put up witha recurrence, but on the whole we cannot confidentlyrefute the suggestion that these exacerbations were moresevere than their previous ones.

In the light of our experience we cannot recommend thecontinued use of gastric hypothermia in the treatment ofduodenal ulcer and we ourselves propose to abandon the

project.Our results in hiatus hernia, however, are a little more

encouraging, perhaps because, unlike most of our ulcerpatients, none of these patients had initial hypersecretion.1 man whose life was made miserable by severe refluxdyspepsia from hiatus hernia is now completely symptomfree one year after treatment. Of 5 women so treated, 3are well and virtually symptom-free a year later. 1 is

substantially improved, and ten months afterwards is

glad that she underwent the treatment, while only 1 hadrelapsed two months after a second treatment. We willtherefore continue to use gastric hypothermia in the

management of selected cases of hiatus hernia where acidsecretion is within normal limits.

J. DONALDSON CRAIGA. M. B. TOMPKIN.

St. Bartholomew’s Hospital,Rochester, Kent.

LACTASE DEFICIENCY IN THE ADULT

SiR,—The correlation of the blood-sugar concentrationafter ingestion of disaccharides with the level of intestinaldisaccharidase activity demonstrated by Dr. Cuatrecasasand his associates (Jan. 2) has been reported previously inpatients with disaccharidase deficiency.1-3The striking feature in their study, however, is the very low

lactase levels in more than half of adults who apparently hadno intestinal disease. Whereas they found lactase activity tobe only 1 unit per g. dry weight in normal subjects with flatlactose-tolerance curves, reports from at least four other

independent laboratories,2 4-6 including our own, have shownintestinal lactase levels of peroral biopsy specimens from healthyadults to be no lower than 4 units per g. (wet weight) of tissueor 22 units per g. protein. (If dry weight is 17% of wet weight,the equivalent lower level would be 24 units per g. dry weight.)The reason for this discrepancy is not readily apparent,

but it seems unlikely, considering the widespread searchfor patients with disaccharidase deficiency, that such ahigh incidence of lactase deficiency in otherwise normaladults would have been overlooked by other investigators.

GARY M. GRAYWILLIAM WALTER, JR.

United States Army Tropical ResearchMedical Laboratory.

San Juan, Puerto Rico.

SiR,—The interesting article by Dr. Cuatrecasas andhis colleagues has helped to put a number of factorsabout disaccharide intolerance and enzyme deficiency intheir proper perspective.Among these are the facts that (a) acquired lactase deficiency

is very common in adults 7 8; and (b) lactose and glucose-galactose tolerance tests are an accurate way of demonstratinglactase deficiency-this would be useful where facilities for

enzyme assay are not available.But their conclusion that lactase deficiency is an adaptive

phenomenon is not substantiated by their results. Firstly, the1. Auricchio, S., Rubino, A., Landolt, M., Semenza, G., Prader, A.

Lancet, 1963, ii, 324.2. Dahlqvist, A., Hammond, J. B., Crane, R. K., Dunphy, J. V., Littman,

A. Gastroenterology, 1963, 45, 488.3. Sonntag, W. M., Brill, M. L., Troyer, W. G., Jr., Welsh, J. P., Semenza,

G., Prader, A. ibid. 1964, 47, 18.4. Auricchio, S., Rubino, A., Tosi, R., Semenza, G., Landolt, M., Kistler,

H., Prader, A. Enzymol. Biol. Clin. 1963, 3, 193.5. Plotkin, G. R., Isselbacher, K. J. New Engl. J. Med. 1964, 271, 1033.6. Bayless, T. M., Walter, W., Barber, R. Clin. Res. 1964, 12, 445.7. Jeejeebhoy, K. N., Desai, H. G., Verghese, R. V. Lancet, 1964, ii, 666.8. Hammerli, U. P., Kistler, H., Amman, R., Semenza, G., Auricchio, S.,

Prader, A. 7th International Congress of Gastroenterology; vol. I,p. 56. Brussels, 1964.