VOLUME REGULATION AND RENAL FUNCTION IN ANALBUMINÆMIA

1169

Summary 111cases of

injury

to

the ankle

were

studied

clinically

and radiologically.

possible clinically to define three radiological examination is unnecessary It is

groups in which

for

determining

treatment.

remaining cases clinical features give only an inaccurate guide to the nature of the injury, and in these radiological examination is necessary. It seems that the whole question of the diagnosis of ligamentous injuries of the ankle requires re-examination. In the

I should like to thank Mr. G. L. W. Bonney for much help and advice in the preparation of this paper.

VOLUME REGULATION AND RENAL FUNCTION IN ANALBUMINÆMIA H. BENNHOLD M.D. PROFESSOR OF MEDICINE IN THE UNIVERSITY OF

TÜBINGEN

AND DIRECTOR OF THE MEDICAL CLINIC

D. KLAUS M.D.

P. G. SCHEURLEN

preglomerular vessels, as shown by the reduction in renal plasma-flow. 2 days after the infusion of 150 g. of human albumin in 3000 ml. isotonic glucose-saline solution, the plasma osmotic pressure rose to an average of 20 mm. Hg; at the same time the renal blood-flow increased. Since the cardiac minute-volume, measured by the method of Broemser and Ranke, showed no change at that time (3600-3200 ml.), it may be assumed that the adaptation of the renal blood-flow to the lowered osmotic pressure is mainly brought about by vasoconstriction of the afferent arterioles. Balance studies were made on two occasions, a year apart. During each study, an intravenous infusion of 150 g. of human albumin in 3000 ml. of isotonic glucosesaline solution was given over a period of 8-9 hours. These studies showed that in analbuminaemia the isotonic expansion of the extracellular space is balanced by a rapid diuresis (see figure). In a healthy person given isotonic or hypertonic albumin solution only a water diuresis results (Strauss et al. 1951, Smith 1957), but in the analbuminaemic patient there is an additional Na+ and Cl-diuresis, so that the water and sodium chloride given is excreted within 24 hours. In analbuminaemia,

M.D. MEDIZINISCHE

UNIVERSITÄTS-KLINIK

UND

POLIKLINIK, TÜBINGEN

DURING the past few years, we have had under observation a brother and sister who, because of a recessive gene, have a complete lack of serum-albumin (Bennhold et al. 1954, Bennhold 1956, Bennhold et al. 1958, Bennhold and Kallee 1959). These two cases of analbuminaemia show no disturbance of water and electrolyte balance, and are clinically healthy, though the plasma osmotic pressure is reduced from the normal of 25-30 mm. Hg to 10-14

mm. Hg. Our examinations showed that this low osmotic compensated by a marked drop in the capillary hydrostatic pressure, so that capillary tests showed some noteworthy findings. The hydrostatic pressure in the glomerular capillaries is lowered, with the result that glomerular filtration is at the lower limit of normal (see table). Normal glomerular filtration is maintained, because the renal blood-flow is already reduced in the pressure is

H18MODYNAMICS AND WATER AND ELECTROLYTE EXCRETION IN TESTS UNDER CLEARANCE-CONDITIONS, 1 DAY BEFORE AND 2 DAYS AFTER INFUSION OF 150 G. HUMAN ALBUMIN.

RENAL

ANALBUMINIEMIA. CORRECTED TO

1-73 sQ.

M. BODY-SURFACE

A% =difference, expressed

day

1.

as a

percentage, between values

on

day

2 and

Urine-volume, electrolytes in serum and urine, aldosterone-elimination, and haematocrit values before, during, and after albumin infusion on July 23 (150 g. human albumin in 3000 ml. isotonic saline-glucose solution, given from 12 noon to 8.15 p.m.).

1170 aldosterone excretion is normal; it decreases after the albumin infusion. There is a definite time-lag, however, between maximum sodium diuresis and a fall in aldosterone excretion (see figure). Clearance studies showed that during the albumin-lack the tubular reabsorption of extracellular electrolyte and of water is diminished. In analbuminsemia, therefore, even small quantities of isotonic saline (200-300 ml.) cause a considerable sodiumchloride diuresis. To achieve equally high excretion fractions in a normal person, saline infusions either 8-10 times greater in volume or 3 times more concentrated would be needed (Strauss et al. 1951, Smith 1957, Ladd

TABLE I-SUBNORMAL TEMPERATURES IN

19

NIGERIAN CHILDREN

(JULY-SEPTEMBER, 1958)

1951a, 1951b). The lowering of the capillary hydrostatic pressure and the rapid sodium-chloride diuresis resulting from small volume changes explains why, as is described in detail elsewhere (Scheurlen and Klaus 1960), in analbuminsemia, no disturbance of the water and electrolyte balance takes place, in spite of the very low osmotic pressure. REFERENCES Bennhold, H., Peters, H., Roth, E. (1954) Verh. dtsch. Ges. inn. Med. — (1956) ibid. 62, 657. Ott, H., Scheurlen, P. G. (1958) ibid. 64, 279. Kallee, E. (1959) J. clin. Invest. 38, 863. Ladd, M. (1951a) J. appl. Physiol. 3, 379.

60, 630.

-

-

(1951b) ibid. p. 603. Scheurlen, P. G., Klaus, D. (1960)Klin. Wschr. 38, 123. Smith, H. W. (1957) Amer. J. Med. 23, 623. Strauss, M. B., Davis, R. K., Rosenbaum, I. D., Rossmeissl, E. C. (1951) J. clin. Invest. 30, 862. -

COLD

INJURY

AMONG CHILDREN SEVERELY ILL IN THE TROPICS

group of children. The mother was mentally unstable; her husband had left her, and the family would not assist her. The

child had first been seen in 1957 with oedema, puffiness of the face, and the skin changes of kwashiorkor; her mother had been supplied with protein supplements, and the child’s condition had temporarily improved. The protein foods were given intermittently over the next year without much cooperation from the mother; the child’s condition deteriorated, and she started to have diarrhoea towards the end of July, 1958, As she was not brought to the dispensary, I visited her house in the village. She was found lying semi-conscious by the embers of a fire, with only one small piece of cloth over her. She was taken to the dispensary where rectal temperature was found to be only 93-4°F (34-1°C); an attempt was made to warm her up but she died eight hours later.

This

D. C. MORLEY M.A., M.D. Cantab., D.C.H. ASSOCIATE LECTURER IN PEDIATRICS, UNIVERSITY

From the

COLLÉGE,

IBADAN

Guild Hospital,

Wesley Ilesha, Nigeria COLD injury in small infants, as described by Mann (1955), Mann and Elliott (1957), and Bower et al. (1960), is now well recognised by doctors looking after small children in temperate climates. Nassau (1948) also showed that cold injury can arise in subtropical areas, such as Palestine. In the Wesley Guild Hospital, kwashiorkor accounts for a sixth of all the children admitted. A fairly common syndrome in such children is a slow pulse-rate and more than the usual lethargy. This had been noted for more than a year before it was discovered to be sometimes associated with a subnormal temperature. In this paper I shall describe the condition of low temperature, or cold injury, in older children. The

Study I took the temperature 1958, During July-September, of all children who felt cold, using a low-reading clinical thermometer. Any child found to have a temperature below 95°F (35°C) was considered to have cold injury. During the three months 18 such children were seen among the 315 admitted to the children’s ward; in addition 1 child was seen in a village hut. TableI gives some details of these children. All these children felt cold to the hand, but they could be distinguished from children with peripheral circulatory failure because the axilla also felt cold. The most unusual feature of this series is the number of older children that it includes. The following casehistories are examples of subnormal temperatures in such older children: Case 1.-A Yoruba girl of 8 years which the hospital is undertaking a

was seen in a village in longitudinal study of a

only child in this group who was seen with in hypothermia her home and not in hospital, but this is not surprising as doctors in this country rarely get an opportunity of seeing children in their homes. was

the

Case 2.-A boy aged 2 years, with the typical appearance of kwashiorkor, was brought from a village 30 miles from Ilesha by his parents. He had oedema, and small areas of skin changes of the " enamel paint " type. 3 days after admission to hospital his temperature dropped to 94-6°F (34’8°C). He was warmed up, but his temperature was unstable for a further five days. He was sufficiently improved to be discharged home after fifteen days. He was seen only once as an outpatient, and at that time he was recovering well. Case 3.-A 7-year-old boy was admitted comatose and apparently moribund. His parents gave a history of eight hours’ coma, and they had noticed he had become cold in the night. His haemoglobin was 18% (2-7 g. per 100 ml.) He was given an immediate blood-transfusion, and soon recovered consciousness. He was apparently well within twelve hours, and was discharged on the third day. Examination of his blood had shown a high proportion of sickled cells.

The main feature of interest in this group is the number of children, over a year old, with subnormal temperatures. In many of these children the ability to maintain body temperature seemed to be lost for several days. Their temperatures repeatedly fell unless they were well covered with blankets, and for several an electric blanket was used as a temporary external source of heat. The child in temperate climates depends for warmth on a heated house and an adequate supply of clothing. TABLE II-MONTHLY MEAN MAXIMUM AND MINIMUM TEMPERATURES FOR 1958, AT OSHOGBO, 25 MILES FROM ILESHA

(OF)