RELEASE OF HISTAMINE IN URTICARIA PIGMENTOSA

867

CHEMISTRY

OF ILEOSTOMY EXCRETA

accompanying t,a,ble these observations on the of ileostomy excreta are presented to facilitate assessment of therapeutic needs. It must be emphasised that these figures represent only generalisations because in no two cases were they exactly similar. In the

chemistry

Summary The effect of the

operation of ileostorny on loss of fluid, nitrogen, sodium, potassium, and calcium in the ileostomy fluid was observed, mostly in patients who had ulcerative colitis. The loss of

nitrogen

in this disease

was

reduced

by

ileostomy. daily loss of nitrogen does not exceed 1-2 g., improbable that the quantity of each specific amino-acid excreted is significant, even though several may be essential for growth. The rapid increases in weight seen after ileostomy for ulcerative colitis support this conclusion. The increased volume and the high concentration of sodium in the ileostomy fluid immediately after operation combine to produce a deficit of sodium which may, if not foreseen, induce sudden clinical collapse. This is best treated prophylactically by routine intravenous therapy within the first 4 or 5 postoperative days. For rule-ofthumb calculation of requirements of sodium it is only necessary to know the daily volume of ileostomy output (a simple ward procedure) and to assume that 300 m.eq. of salt has been lost with each litre of fluid. If the patient suddenly collapses without any obvious surgical complication, especially if the excretion-rate has been persistently high, there is probably salt depletion, which should be treated as an emergency. Intravenous double-strength saline solution should be given rapidly, when the condition will quickly be overcome, often within half an the total it seems

hour. It should also be borne in mind that an increase in the output of fluid from t lie ileostomy at a later stage from any cause will be accompanied by an increased loss of salt. Patients should therefore be advised to take extra salt if ever they have an attack of ileostomy diarrhoea. Whereas loss of sodium is aggravated by ileostomy, loss of potassium is usually corrected thereby (figs. 7 and 8). Therefore loss of potassium is mainly a preoperative problem. Ileostomy may even have to be expedited for patients in whom it proves impossible otherwise to correct gross loss of potassium from continued diarrhoea. Since it is impossible to undertake routine analyses of the potassium in the excreta of all the patients, some loss of potassium may be inferred in patients with ileostomy diarrhoea and in those found at operation to have ileitis. In the case complicated by pseudomembranous enteritis the serum-potassium level fell from a normal figure of 4.6 to 3.5 m.eq. per litre in two days. In both patients with an excessive output of potassium the loss was about 30 m.eq. per litre ; this figure should be borne in mind when calculating replacement in such patients. The body’s reserve of calcium is such that loss immediately after operation causes no immediate concern. The continued loss of about 1 g. daily from an established ileostomy raises two points, one physiological and one clinical. Such a loss is more than a healthy person on an average diet loses in the stools daily g.). Is the large bowel in man " inert " as regards calcium metabolism, or does it play some part in absorption ? It is difficult to believe that the loss of the last 2-3 inches of ileum, removed for technical reasons when an ileostomy is undertaken, could explain this difference. The clinical significance of this constant loss of calcium can only be judged when balance studies (now being undertaken) are completed. Four studies now undertaken, including one late in pregnancy, show positive balance.

(04-08

The average daily loss from an established ileostomy had no therapeutic significance for patients on a normal diet.

Potassium

replacement

is

therapeutically

more

impor-

tant before ileostomy, sodium replacement afterwards. About 300 m.eq. of sodium was lost per litre of excreta from a recently established stoma, and 150 m.eq. per litre from an established stoma. The amount of sodium required for restoration may be calculated from the volume output on this average. From the established ileostomy calcium was excreted at a rate of about 1 g. (50 m.eq.) daily by patients on a normal average diet.

Preliminary

Communication

RELEASE OF HISTAMINE IN URTICARIA PIGMENTOSA TiiE idea that urticaria pigmentosa is a systemic disease with manifestations from different organs, has received considerable support in recent years. It has been shown that tissue mast cells may be present in very large numbers in many organs, thus causing a Several workers have studied the niastocytosis." mastocytomas occurring in dogs. "

Riley1 reviewed the question of histamine, heparin, and hyaluronic acid in mast cells. Pernow and Waldenstrom2 described a patient with widefoci in the skeleton and a flush resembling that seen after an injection of histamine. This patient’s urine contained large amounts not only of histamine but also of 5-hydroxytryptamine and 5-hydroxyindole acetic acid. Waldenstrom et al.3-later gave a detailed description of this case, and reported finding increased amounts of histamine in the urine of a patient with typical urticaria pigmentosa.

spread sclerotic

Some months ago I examined a young woman who of idiosyncrasy to acetylsalicylic acid.

complained

She said that she " nearly died " after taking 0-5 g. of acetylbut " her doctors would not believe " this statement. Careful examination showed a few small skin lesions resembling urticaria pigmentosa. Dr. N. Brogren, of the dermatological department, confirmed this clinical diagnosis, which was verified on biopsy (Dr. G. Bjorkman). Radiographic examination of the skeleton showed definite signs of sclerosis, especially in the vertebrae and pelvis. The picture resembled that described by Schorr et awl. in urticaria pigmentosa. Sternal puncture, however, did not reveal any increase in mast cells. The patient was interested in knowing if she could use acetylsalicylic acid, and therefore volunteered to take a test dose. Accordingly on Jan. 17 she was given 0-25 g. of this substance by mouth. Her blood-pressure remained constant at 120/70 but in the next 20 minutes her mm. Hg for 20 minutes ; systolic pressure fell to 60, her diastolic pressure was not measurable, and her pulse-rate rose from about 90 to 150. The systolic blood-pressure was lowest an hour after administration, when it was 30 mm. Hg. Just before the severe drop

salicylic acid,

Riley, J. F. Lancet, 1954, i, 841. Pernow, B., Waldenström, J. Ibid, 1954, ii, 951. Waldenström, J., Pernow, B., Silwer, H. Acta med. scand. 1956, 156, 73. 4. Schorr, S., Sagher, F., Liban, E. Acta radiol., Stockh. 1956, 46, 1. 2. 3.

575.

868 in blood-pressure the patient felt nauseated and the wkin of her face became red. She began vomiting intensoly. Unfortunately the vomitns was not measured until run hour had elapsed. Thn total amount vomited botweon then and 15 hours Jatcr, Avhcn vomiting ocaaad, was 2150 ml. The vomitus was strongly !M’i() (pH 2). The patient’s tcmporatnro. whif’h had been 98.6°F before the test doso, foil to U6-1"F 1 hours aftpr t,lio tablet was taken. After a further hour it rose to 99.6 °F, and3 hours after the tablet was taken it was 101°F. The bloodpressure slowly rose after intravenous administration of 11 glucose drip. and after 2 hours was 100/50 mm. Hg. The putsc-rate fell to 80 only after more than 2 days had elapsed. After 3 days she was afebrile.

Obviously this patient is very severely hypersensitive acetylsalicylic acid. Many data seem to indicate that the syrmptoms may have been caused by liberation of histamine. The pronounced circulatory shock with low blood-pressure, high pulse-rate, flushed face, and vomiting of enormous amounts of strongly acid gastric contents, to

and the demonstration of continuous histaminuria all support the diagnosis of histamine liberation by the action of acetylsalicylic acid. This substance is not a

Medical Societies OPHTHALMOLOGICAL SOCIETY OF THE UNITED KINGDOM THE 77th annual congress of the

Society of the United Kingdom April 11-13, with the president,

Ophthalmological

held in London on Mr. J. J. HEAI.Y, in lie chair. Visitors included members of the International Council of Ophthalmology, which met in London on April 10. was

Intra-ocular Circulation and

Hypertension

In his presidential address Mr. HEALY described the intra-ocular circulation in arteriosclerosis and lylrertcusion. He discussed the :etiological and pathogenic theories of hypertension, which were largely based on the evidence of experimentally produced and secondary hypertension, and he noted that although physiopathological i-eseircil had made some progress, no definite results had yet emerged. Arteriosclerosis might be present as a senile regression in the retinal and choroidal vessels, and essential hypertension might supervene or arise as a separate entity. Mr. IIealy analysed tlie changes in 200 outpatients’ fundi and assessed them with special reference to angiospasm, arterioloselerosis. and arteriolonecrosis ; and he made a plea for greater liaison between

physician, ophthalmologist,

and

pathologist.

Simple Glaucoma The Bowman lecture was instituted by the council of the society in 1883, in recognition of Sir William Bowman’s distinguished work in ophthalmology and other branches of medicine and in commemoration of his valuable services to the society, of which lie was the hrst president. The 35th lecture was given by Sir STEWART DUKE-ELDER, who spoke on the :etiology of simple

glaucoma. Sir Stewart discussed the mechanism of the formation of the aqueous humour in the light of recent biochemical and pathological research, with particular reference so the extensive work carried out under his direction at t lie Institute of Ophthalmology. He then turned to the variations in intra-ocular pressure produced especially by peripheral and central nervous stimulation, and he indicated the factors responsible for the instability and range of variation of the intra-ocular pressure characteristic of the glaucomatous eye. Ile traced the development of the initial functional and consequent organic changes with their terminal ischæmic effects upon the structures of the anterior and posterior segments of the eye and the optic nerve, and lie examined their respective roles in the

histamine liberator, but on the other Itand tlx’ conditions in this case were peculiar: the amount of histamine stored in the patient’s body may be very large, for the osteoselerotic process is obviously intimately linked with the presence of mast cells. I therefore asked three other patients with widespread urticaria, pigmentosa whether they had ever observed intolerance of salicylic acid. Their answer was No. It therefore, seems probable that the supposed action of acetylsalicylic acid as a histamine liberator may be particular to this patient. The question of intolerance to acetylsalicylic acid being caused by histamine release and not by a iruo allergic (antigen-antibody) reaction will be discussed in a fortheoming paper. B. Pernow and H. Dunér (personal communication) have demonstrated considerable histaminuria in five further cases of urticaria pigmentosa. ’Y are titerefore of the opinion that histaminæmia in mastocytosis is a counterpart to hyperhydroxytryptaminæmia in carcinoidosis. Medical Clinic, Allmänna Sjukhuset, BENGT HAMRIN, Lund

commonly recognised

University,

Malmö. Sweden

M.D.

development of clinical simple glaucoma. Glaucoma should not be regarded purely as an ocular disease, but rather as a local manifestation of a more general disorder. Advances in thescientific aspects had not been accompanied by similar advances in either medical or surgical treatment, which had made little progress during the past twenty

years.

Congenital Cataract this subject was introduced by Mr. J. H. symposium DOGGART, who said that although some slight opacity was A

on

visible in most human tenses, even among the newborn, most of these partial cataracts were harmless and stationary. Nevertheless, they could not be dismissed as insignificant because (a) they might be misinterpreted and (b) they had supplied clues for embryological investigation. Differentiation of the various congenital cataracts from other kinds of opacity was impossible without careful study of the living lens. Mr. A. B. NUTT emphasised that the results of surgery for congenital cataract were disappointing and that the prognosis must therefore be guarded. Having classified the cases requiring surgical treatment, he gave a brief resume of the operations commonly employed, their complications, and the methods adopted to avoid them. He thought that the poor functional results were in many cases due to associated congenital anomalies. Ocular

Aspects of Diabetes

J’rof. G. I. ScoTT classified the retinal changes of diabetes and discussed their possible aetiology. This form of retinopathy could occur in the absence of any evidence of hypertension or arteriosclerosis and its incidence seemed to depend primarily upon the length of time that the patient had suffered from the disease. Dr. J. D. N. NABARRO expressed some alarm at the increasing incidence of serious visual defects due to diabetic ocular disease. The speed with which vision deteriorated in patients with established retinitis was extremely variable and it was uncertain whether it could be influenced by treatment. Strict diabetic control was essential, but there was no evidence that vitamins or sex hormones had any effect. Hypophysectomy and pituitary destruction were being undertaken in a few centres, but their value was still uncertain. Dr. NORMAN ASHTON dealt with the experimental side of diabetic vascular disease, with special reference to its ocular and renal manifestations. He attempted to assess the bearing of experimental findings on the relationship between diabetic retinopathy and glomerulosclerosis. Retinal Detachment the role of intravitreal vitreous injection in retinal detachment, Mr. P. McG. MOFFATT and Mr. C. DEE SHAPLAND described the technique for obtaining the donor vitreous and its subsequent injection under pressure into the recipient eye. Mr. Shapland analysed the results obtained in a smidi series of his own cases and those of Mr. Moffatt.

Discussing