DIETARY PROPHYLAXIS OF ALLERGY
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404 can provide any satisfactory check on faecal-fat deter- minations. The Birmingham workers describe cases of non-tropical sprue in which the daily faecal-fat excretion exceeded that ingested (6 g.) for several days after a single loading dose of extra fat. The excess over intake was, however, small, so errors in technique cannot entirely be ruled out-which underlines the need for accurate check on the fat analysis of diet and faeces. To substantiate the hypothesis that the endogenous fat might originate from chyle secreted into the lumen after blockage of the lymphatics, Cooke et al. examined the fat excretion from isolated loops of intestine of dogs before and after ligation of the thoracic duct. They found a distinct increase in the total lipids, accounted for by increased excretion of neutral fat. It is still uncertain, however, whether blockage of the lymphatics in the human adult-for example, in Hodgkin’s disease, carcinoma, and reticulosarcoma-ever causes steator- rhoea without simultaneous involvement of the intestinal wall. Jimenez Diaz and his colleagues 11 have shown that lymphatic blockage can bring about temporary increase of fsecal-fat excretion, and in some of their patients with steatorrhoea the evidence suggested that excretion of endogenous fat was increased. Probably such a mechanism operates, if at all, only in certain types of idiopathic steatorrhoea. We may learn more about the origins of faecal fat from administration of individual fats, or of chemically similar fats, and analysis of the types of fat then excreted, and from further work on the role of the intestinal flora. 12. Pepys, J. Postgrad. med. J. 1953, 29, 351, 517, 564. 13. von Pirquet, C. Münch. med. Wschr. 1906, 30, 1457. 14. Williams, D. A. First International Congress of Allergy, Zürich, 1951. 15. Walzer, M. J. Allergy. 1931, 2, 399. 16. Bernton, H. S. Ann. Allergy, 1949, 7, 13. 17. Rosenau, M. J. Preventive Medicine and Hygiene. New York, 1935. 18. Donnally, H. H. J. Immunol. 1930, 19, 15. 19. Grulee, C. G., Sanford, H. N. J. Pediat. 1936, 9, 233. DIETARY PROPHYLAXIS OF ALLERGY " ALLERGY," as Pepys 12 points out, is a sorely misused word. As used clinically it should imply a hypersensitive state acquired through exposure to a particular allergen, re-exposure bringing to light what von Pirquet 13 termed " an altered capacity to react." This altered capacity manifests itself clinically in any of several ways ; and each of these manifestations may be modified or overlaid by emotional, infective, endocrine, and other factors. Some 10% of the population of Britain are believed to suffer from allergic disorders, which have been found to account for about 5% of the final diagnoses in patients admitted to hospitals.14 In England and Wales deaths from asthma alone averaged 2915 in each of the years 1938-48. In treatment the anti-histamine drugs and cortisone and corticotrophin are proving useful ; but these do not produce a lasting modification of the allergic state. Perhaps the best hope of progress lies in prevention, and notably in- the protection of infants from potential allergens. Control of the mother’s diet during pregnancy, to prevent sensitisation of the foetus, has been proposed ; but this has not yet been proved of value. The newborn infant is particularly susceptible to ingested allergens : its gastro-intestinal tract is " almost like a sieve according to Walzer,15 who found that passive transfer tests became positive while the infant was still feeding from the bottle containing the allergen. Furthermore intestinal absorption of unaltered protein has been demonstrated ; and this may be important in the produc- tion of sensitisation. Yet there seems to be no conclusive evidence for the transmission of allergens through breast- milk 16—a finding which is the more surprising because apparently both drugs 17 and food-proteins 18 may be excreted in the milk. At all events breast-milk is much less likely than cow’s milk to lead to allergy ; Grulee and Sanford,19 for example, have shown that infantile eczema is seven times commoner in infants fed on cow’s milk than in those who are wholly breast-fed. Glaser and Johnstone 20 have devised a diet, consisting of a " milk " prepared from soya-beans with meat base and mineral supplements, to delay the introduction of cow’s milk into the diet. Of 96 infants, 3 were exclusively breast-fed. The remaining 93 were given the soya-bean diet, with cow’s milk added before the age of three months in 24 cases, and between the ages of three and nine months in altogether 67 cases. Follow-up, for periods ranging from seven months to ten years (the majority were observed for more than two years), showed allergic disorders in 15% of these 96 children, compared with 64% of 70 sibling controls and 52% of an unrelated group of 175. The commonest early manifestation of allergy is infantile eczema ; and this may be followed by respira- tory allergic disorders-in 34-56% of cases according to Purdy,21 andin up to 80% of cases according toMacKinney and Glaser.22 These are unwelcome disturbances; but although Glaser and Johnstone found that 85% of infants subsisted well enough on their soya-bean diet, most mothers are unlikely to displace cow’s milk in its favour. 20. Glaser, J., Johnstone, D. E. Ann. Allergy, 1952, 10, 433 ; J. Amer. med. Ass. 1953, 153, 620. 21. Purdy, M. J. Brit. med, J. 1953, i, 1366. 22. MacKinney, L. G., Glaser, J. Ann. Allergy (in the press). 23. Griffiths, J. A. Quart. J. Med. 1953, 22, 405. 24. Laurence, D. R., Stacey, R. S. Brit. J. Pharmacol. 1952, 7, 255. DIABETES AND CONTROLLED HYPOTENSION OPERATION under anaesthesia, is little more risky for the patient with well-controlled diabetes than for any other ; but Griffiths 23 has described 2 cases of severe hypoglycaemia in diabetics when the technique of con- trolled hypotension with hexamethonium bromide was used. Prompted by this experience, he investigated non-diabetic and diabetic patients under standard conditions of anaesthesia. In non-diabetics during superficial operations the blood-sugar level remained constant throughout, while during upper abdominal section there was a rise in the level which was statistically significant though clinically unimportant. When hexa- methonium was administered to non-diabetics for super- ficial operations the blood-sugar was decreased ; in most cases it remained stable at the lower level, but in 2 severe cases hypoglycæmia was precipitated. 3 patients with controlled diabetes undergoing superficial operations had a stable blood-sugar with the standard anaesthetic tech- nique, but a 4th had a precipitous decline in blood-sugar after the injection of hexamethonium. Griffiths has shown that the anaesthetic sequence thiopentone, gallamine, nitrous-oxide/oxygen, and pethi- dine, with full oxygenation throughout, has no effect on blood-sugar in either non-diabetic or diabetic patients, but that major operations may be associated with an increase, presumably because of adrenaline release through autonomic stimuli from the operation site. Laurence and Stacey 24 have shown that, in unanaesthetised man, whether diabetic or non-diabetic, intravenous hexa- methonium potentiates the action of parenteral insulin and masks many of the signs of hypoglycæmia. Griffiths has now confirmed these findings in the anæsthetised patient, and he emphasises that progressive tachycardia is the only constant sign of -even severe hypoglycsemia under anaesthesia. He concludes that controlled hypo- tension with hexamethonium bromide is contra-indicated for diabetic patients. THE INDEX and title-page to Vol. II, 1953, which was completed with THE LANCET of Dec. 26, is published with our present issue. A copy will be sent gratis to subscribers on receipt of a postcard addressed to the Manager of THE LANCET, 7, Adam Street, Adelphi, W.C.2. Subscribers who have not already indicated their desire to receive indexes regularly as published should do so now.
Transcript of DIETARY PROPHYLAXIS OF ALLERGY
404
- can provide any satisfactory check on faecal-fat deter-minations. The Birmingham workers describe cases ofnon-tropical sprue in which the daily faecal-fat excretionexceeded that ingested (6 g.) for several days after asingle loading dose of extra fat. The excess over intakewas, however, small, so errors in technique cannot
entirely be ruled out-which underlines the need foraccurate check on the fat analysis of diet and faeces.To substantiate the hypothesis that the endogenous
fat might originate from chyle secreted into the lumenafter blockage of the lymphatics, Cooke et al. examinedthe fat excretion from isolated loops of intestine of dogsbefore and after ligation of the thoracic duct. Theyfound a distinct increase in the total lipids, accountedfor by increased excretion of neutral fat. It is still
uncertain, however, whether blockage of the lymphaticsin the human adult-for example, in Hodgkin’s disease,carcinoma, and reticulosarcoma-ever causes steator-rhoea without simultaneous involvement of the intestinalwall. Jimenez Diaz and his colleagues 11 have shown thatlymphatic blockage can bring about temporary increaseof fsecal-fat excretion, and in some of their patients withsteatorrhoea the evidence suggested that excretion of
endogenous fat was increased. Probably such a mechanismoperates, if at all, only in certain types of idiopathicsteatorrhoea.We may learn more about the origins of faecal fat from
administration of individual fats, or of chemically similarfats, and analysis of the types of fat then excreted, andfrom further work on the role of the intestinal flora.
12. Pepys, J. Postgrad. med. J. 1953, 29, 351, 517, 564.13. von Pirquet, C. Münch. med. Wschr. 1906, 30, 1457.14. Williams, D. A. First International Congress of Allergy, Zürich,
1951.15. Walzer, M. J. Allergy. 1931, 2, 399.16. Bernton, H. S. Ann. Allergy, 1949, 7, 13.17. Rosenau, M. J. Preventive Medicine and Hygiene. New York,
1935.18. Donnally, H. H. J. Immunol. 1930, 19, 15.19. Grulee, C. G., Sanford, H. N. J. Pediat. 1936, 9, 233.
DIETARY PROPHYLAXIS OF ALLERGY" ALLERGY," as Pepys 12 points out, is a sorely misused
word. As used clinically it should imply a hypersensitivestate acquired through exposure to a particularallergen, re-exposure bringing to light what von
Pirquet 13 termed " an altered capacity to react." Thisaltered capacity manifests itself clinically in any ofseveral ways ; and each of these manifestations may bemodified or overlaid by emotional, infective, endocrine,and other factors. Some 10% of the population of Britainare believed to suffer from allergic disorders, which havebeen found to account for about 5% of the final diagnosesin patients admitted to hospitals.14 In England andWales deaths from asthma alone averaged 2915 in eachof the years 1938-48.
In treatment the anti-histamine drugs and cortisoneand corticotrophin are proving useful ; but these do notproduce a lasting modification of the allergic state.
Perhaps the best hope of progress lies in prevention, andnotably in- the protection of infants from potentialallergens. Control of the mother’s diet during pregnancy,to prevent sensitisation of the foetus, has been proposed ;but this has not yet been proved of value. The newborninfant is particularly susceptible to ingested allergens :its gastro-intestinal tract is " almost like a sieve
according to Walzer,15 who found that passive transfertests became positive while the infant was still feedingfrom the bottle containing the allergen. Furthermoreintestinal absorption of unaltered protein has beendemonstrated ; and this may be important in the produc-tion of sensitisation. Yet there seems to be no conclusiveevidence for the transmission of allergens through breast-milk 16—a finding which is the more surprising becauseapparently both drugs 17 and food-proteins 18 may beexcreted in the milk. At all events breast-milk is muchless likely than cow’s milk to lead to allergy ; Gruleeand Sanford,19 for example, have shown that infantile
eczema is seven times commoner in infants fed on cow’smilk than in those who are wholly breast-fed. Glaserand Johnstone 20 have devised a diet, consisting of a" milk " prepared from soya-beans with meat base andmineral supplements, to delay the introduction of cow’smilk into the diet. Of 96 infants, 3 were exclusivelybreast-fed. The remaining 93 were given the soya-beandiet, with cow’s milk added before the age of threemonths in 24 cases, and between the ages of three andnine months in altogether 67 cases. Follow-up, for
periods ranging from seven months to ten years (themajority were observed for more than two years), showedallergic disorders in 15% of these 96 children, comparedwith 64% of 70 sibling controls and 52% of an unrelatedgroup of 175.The commonest early manifestation of allergy is
infantile eczema ; and this may be followed by respira-tory allergic disorders-in 34-56% of cases according toPurdy,21 andin up to 80% of cases according toMacKinneyand Glaser.22 These are unwelcome disturbances; butalthough Glaser and Johnstone found that 85% of infantssubsisted well enough on their soya-bean diet, mostmothers are unlikely to displace cow’s milk in its favour.
20. Glaser, J., Johnstone, D. E. Ann. Allergy, 1952, 10, 433 ; J.Amer. med. Ass. 1953, 153, 620.
21. Purdy, M. J. Brit. med, J. 1953, i, 1366.22. MacKinney, L. G., Glaser, J. Ann. Allergy (in the press).23. Griffiths, J. A. Quart. J. Med. 1953, 22, 405.24. Laurence, D. R., Stacey, R. S. Brit. J. Pharmacol. 1952, 7, 255.
DIABETES AND CONTROLLED HYPOTENSION
OPERATION under anaesthesia, is little more risky forthe patient with well-controlled diabetes than for anyother ; but Griffiths 23 has described 2 cases of severehypoglycaemia in diabetics when the technique of con-trolled hypotension with hexamethonium bromide wasused. Prompted by this experience, he investigatednon-diabetic and diabetic patients under standardconditions of anaesthesia. In non-diabetics duringsuperficial operations the blood-sugar level remainedconstant throughout, while during upper abdominalsection there was a rise in the level which was statisticallysignificant though clinically unimportant. When hexa-methonium was administered to non-diabetics for super-ficial operations the blood-sugar was decreased ; in mostcases it remained stable at the lower level, but in 2 severe
cases hypoglycæmia was precipitated. 3 patients withcontrolled diabetes undergoing superficial operations hada stable blood-sugar with the standard anaesthetic tech-nique, but a 4th had a precipitous decline in blood-sugarafter the injection of hexamethonium.
Griffiths has shown that the anaesthetic sequencethiopentone, gallamine, nitrous-oxide/oxygen, and pethi-dine, with full oxygenation throughout, has no effect onblood-sugar in either non-diabetic or diabetic patients,but that major operations may be associated with anincrease, presumably because of adrenaline release throughautonomic stimuli from the operation site. Laurence andStacey 24 have shown that, in unanaesthetised man,whether diabetic or non-diabetic, intravenous hexa-methonium potentiates the action of parenteral insulinand masks many of the signs of hypoglycæmia. Griffithshas now confirmed these findings in the anæsthetisedpatient, and he emphasises that progressive tachycardiais the only constant sign of -even severe hypoglycsemiaunder anaesthesia. He concludes that controlled hypo-tension with hexamethonium bromide is contra-indicatedfor diabetic patients.
THE INDEX and title-page to Vol. II, 1953, which wascompleted with THE LANCET of Dec. 26, is publishedwith our present issue. A copy will be sent gratis tosubscribers on receipt of a postcard addressed to theManager of THE LANCET, 7, Adam Street, Adelphi, W.C.2.Subscribers who have not already indicated their desireto receive indexes regularly as published should do so now.
