CAUSE OF HYPOALBUMINÆMIA IN PATIENTS WITH GASTROINTESTINAL AND CARDIAC DISEASE

343

Macroscopically the placenta was obviously abnormal and like a dry sponge. Microscopically most villi were completely destroyed. In some areas the stroma of the villi remained, though the trophoblast layer was destroyed. The picture was of a non-functioning placenta. To accelerate abortion in seven of the thirteen cases

CAUSE OF HYPOALBUMINÆMIA IN PATIENTS WITH GASTROINTESTINAL AND CARDIAC DISEASE

(see table) oxytocin was given as an intravenous drip. The blood-fibrinogen was normal in all cases, and bleeding was always negligible. In five cases the placenta was retained and had to be removed. No complications were observed before or after abortion. In four cases vaginal smears were studied daily, and this simple and rapid investigation gave as accurate information about the hormonal state as did determination of hormone excretion. The exact value of vaginal smears in missed abortions is under investigation. The purpose of oestrogen treatment in stage 11 is to build up a potent myometrium from a " castrated " state, and this necessarily takes several days. The oestrogen, therefore, should be continued for long enough-i.e., 6-10 days. If abortion has not occurred after 10 days, the hormonal state should be re-checked. The hypothesis of missed abortion was supported, in these cases, by the fact that two stages, characterised by different hormonal conditions, could be distinguished, and by the fact that selected treatment was successful in all cases. This shows that, in human mid-pregnancy, progesterone and oestrogen are of crucial importance for

From the West Middlesex Hospital, Isleworth, and the Postgraduate Medical School of London, Ducane Road, W.12

myometrial activity. Summary A concept of the aetiology of missed abortion is based on the extensive studies of Csapo and his group on the hormonal control of myometrial activity, on Cassmer’s investigation of hormone excretion after foetal death, and on laboratory and clinical findings. Missed abortion occurs only when the foetus dies while the placental function is maintained. In these cases the oestrogen effect on the myometrium is withdrawn before

the progesterone effect. In the first period after foetal death the myometrium remains progesterone-dominated and unable to produce effective contractions (stage i). Later, when the hormonal production of the placenta is extinguished, the myometrium is unable to work effectively, and from an " endocrine point of view it is castrated " (stage 11). The treatment of missed abortion should be as follows: if the myometrium is progesterone-dominated, the

placental function should be destroyed (e.g., by an intrauterine injection of hypertonic solution). When the myometrium is castrated " oestrogen should be given. "

Thus,

effective

treatment

should be

possible in all

cases.

As a rule, no surgical intervention should be necessary to start abortion. Successful treatment of thirteen consecutive cases of missed abortion is reported. This study was supported by a grant from the Swedish Medical Research Council. I am indebted to all colleagues at the obstetrical and gynecological department in Malmö for their invaluable help throughout the investigation. REFERENCES

Alvarez, H., Caldeyro-Barcia, R. (1950) Surg. Gynec.

Obstet. 91, 1.

Appelberg, G. (1952) Nord. med. 47, 670. Battaglino, J. J., Wilson, R. B. (1959) Surg. Clin. N. Amer. 39, Bengtsson, L. Ph. (1957) Amer. J. Obstet. Gynec. 74, 484.

1119.

— (1962) Acta obstet. gynec. scand. 41 (in the press). Schofield, B. M. (1960) J. Reprod. Fertil: 1, 402. Csapo, A. (1962) To be published. Stormby, N. (1962) Acta obstet. gynec. scand. 41 (in the press). -

-

-

M.B.

K. N. JEEJEEBHOY * Madras, M.R.C.P., M.R.C.P.E.

IN

hypoalbuminaemia associated with hypertrophic gastritis, Citrin et al. (1957-) observed that injected radioiodinated human serum-albumin (R.I.H.S.A.) could be recovered from gastric aspirates, and they concluded that the hypoalbummaemia was due to loss of albumin into the stomach. Hypoalbuminasmia also occurs with lesions of the small intestine; but R.I.H.S.A. cannot be recovered in measurable amounts because of its rapid digestion and reabsorption. The introduction of 1-polyvinylpyrrolidone (P.v.p.) partly overcame this difficulty (Gordon 1959a and b). Although 1311-p.v.p. can be used to demonstrate intestinal protein loss, the amount of albumin lost per day cannot be measured by this means. 1-p.v.P. has other disadvantages; for its molecular weight is not constant, and partial reabsorption from the alimentary tract has been demonstrated (French et al. 1961). Recently 5lCr-albumin has been introduced to study gastrointestinal protein loss (Waldmann 1961a). Although satisfactory for this purpose, 51Cr-albumin is unsuitable for studying albumin turnover as it seems from the rapid urinary excretion of the label that either the protein is denatured or the label is loosely bound. These methods therefore have the disadvantage of being only semiquantitative, for they do not indicate the precise degree to which gastrointestinal protein loss contributes to total albumin catabolism. Nevertheless these methods have indicated that gastrointestinal protein loss is probably a major cause of hypoalbuminasmia in patients with hypertrophic gastritis (Citrin et al. 1957), ulcerative colitis and regional enteritis (Steinfeld et al. 1960), steatorrhoea (Parkins 1960, London *

In

receipt

of

a

grant from the Medical Research Council.

Bickers, W., Main, R. J. (1941) J. clin. Endocrin. 1, 992. Borglin, N.-E. (1957) Acta obstet. gynec. scand. 36, 512. Bøe, F. (1938) Acta path. microbiol. scand. 5, suppl. 36, 146. Breitner, J. (1954) Arch. Gynœk. 185, 258. Brown, J. B. (1955) Biochem. J. 60, 185. Cassmer, O. (1959) Acta endocr., Copenhagen, 32, suppl. 45. Cross, B. A. (1959) in Recent Progress in Endocrinology and Reproduction (edited by Charles W. Lloyd). New York. Csapo, A. (1955) in Modern Trends in Obstetrics and Gynaecology (edited by K. Bowes). London. (1956) Amer. J. Anat. 133, 145. (1961a) in Progesterone (edited by A. C. Barnes). Augusta, Mich. (1961b) in Progesterone and the Defence Mechanism of Pregnancy (edited by G. E. W. Wolstenholme and M. P. Cameron). London. Fisher, J. J. (1953) Obstet. Gynec. 1, 529. Fuchs, F., Fuchs, A.-R. (1958) Acta endocr., Copenhagen, 29, 615. Hammond, J. (1917) Proc. roy. Soc. B, 89, 534. Heckel, G. P., Allen, W. M. (1938) Amer. J. Obstet. Gynec. 35, 131. Hinglais, H., Hinglais, M. (1954) Pr. méd. 62, 1500. Hodkinson, C. P., Igna, E. J., Bukeavich, A. P. (1958) Amer. J. Obstet. Gynec. 76, 279. Ittrich, G., Igel, H. (1959) Zbl. Gynäk. 81, 255. Jeffcoate, T. N. A. (1940) Lancet, i, 1045. Jensen, C. C. (1958) Acta endocr., Copenhagen, 28, 37. Kalkschmid, W. (1960) Wien. med. Wschr. 110, 546. Klopper, A. (1961) J. Endocrin. 22, 16. Kneer, M. (1948) Zbl. Gynäk. 70, 447. Kurzrok, L. (1948) Amer. J. Obstet. Gynec. 56, 796. Litzenberg, J. C. (1921) ibid. 1, 475. Loudon, J. D. O. (1959) J. Obstet. Gynœc. Brit. Emp. 66, 277. Lubin, S., Waltman, R. (1949) Amer. J. Surg. 77, 202. Malmström, T. (1957) Acta obstet. gynec. scand. 36, suppl. 3. Martin, R. H., Menzies, D. N. (1955) J. Obstet. Gynœc. Brit. Emp. 62, 256. Reynolds, S. R. M. (1949) Physiology of the Uterus. New York. Rongy, A. J., Arluck, S. S. (1921) Surg. Gynec. Obstet. 32, 171. Rowe-Dutton, G., Lubin, S., Reynolds, S. R. M., Waltman, R. (1952) Amer. J. Obstet. Gynec. 63, 650. Schofield, B. M. (1957) J. Physiol. 138, 1. van Wagenen, G., Newton, W. H. (1943) Surg. Gynec. Obstet. 77, 539. de Watteville, H. (1950) Gynec. Obstet. 49, 158. -

-

-

344 al. 1961), and cardiac disease (Davidson et al. 1961). It has been suggested by all these workers that the inability of the liver to synthesise sufficient albumin to compensate for gastrointestinal protein loss contributes to a low serum-albumin level. Ideally any method used to study hypoalbuminaemia in patients with gastrointestinal disease should be able to assess these two parameters of albumin metabolism. Albumin turnover is best studied by injecting tracer amounts of R.I.H.S.A. Measurement of faecal radioactivity after such injection is an unsuitable index of the amount of R.I.H.S.A. lost into the gastrointestinal tract, as normally it is digested rapidly and the degradation products are reabsorbed. This difficulty has been overcome by the method of Jeejeebhoy and Coghill (1961). In this technique an ion-exchange resin is given by mouth to prevent the reabsorption of the degradation products of R.I.H.S.A., with the result that measurement of faecal radioactivity provides a good index of the amount of R.I.H.S.A. lost into the alimentary tract. The advantages of this method are that the amount of albumin catabolised in the gastrointestinal tract (exogenously) can be measured separately from that catabolised inside the body (endogenously), and an indication of the rate of albumin synthesis can also be obtained from the albumin turnover data. I report here the results of using this method to study the relative contribution of gastrointestinal protein loss and of the synthetic activity of the liver in the production of hypoalbuminaemia. The conclusion reached is that, in the majority of cases either with or without gastrointestinal protein loss, hypoalbuminsemia is due to the liver being unable to synthesise enough albumin to maintain a normal endogenous turnover. In a few cases the hypoalbuminaemia was due to an abnormal distribution of albumin between the vascular and extravascular spaces. et

Methods and Materials Serum-albumin Albumin estimation was performed by the HABA (2-[4’hydroxybenzeneazo] benzoic acid) dye method (Ruthstein et al. 1954). The procedure was carried out in an autoanalyser calibrated against known standards of crystalline human albumin. Radioiodinated Human Serum-albumin (R.LH.S.A.) This was obtained from the Radiochemical Centre at Amersham, iodinated by a modified jet method of McFarlane

(1956). Plasma and Urine Radioactivity 3 ml. aliquots of plasma or urine were counted in a welltype counter containing a thallium-activated sodium-iodide crystal. The counter was connected to an IDL 1700 scaler which has a single-channel pulse-height analyser.

Faecal Radioactivity Each three-day collection was counted in a ring of 6 GeigerMuller tubes (Veall and Vetter 1952). Total Exchangeable Albumin (T.E.A.), Albumin Turnover, and Fcecal Excretion of R.LH.S.A. Each patient was given 10 minims of Lugol’s iodine twice daily for two days before the test, and for its duration. 20-30C of R.I.H.S.A. was injected intravenously from a calibrated syringe. Simultaneously’Amberlite’ resin IRA-400 was administered orally, 5 g. four-hourly, and continued for the duration of the test-a period of seven to ten days. The T.E.A. and turnover were determined by the method of Matthews (1957). Total exchangeable albumin (T.E.A.) is the body-albumin, vascular and extravascular, in which the tracer is distributed. The value for the T.E.A. is obtained by adding the intravascular albumin to that in the two extravascular pools calculated by mathematical analysis (Matthews 1957). The albumin turnover is the amount of albumin catabolised and synthesised per day. The amount of albumin catabolised is obtained directly from the urinary and faecal excretion of radioactivity. In a state of equilibrium anabolism equals catabolism. For the purposes of this study equilibrium was assumed to be present if the ratio of extravascular to intravascular radioactivity at equilibrium-time remained constant on two successive turnover studies. Then total albumin turnover was differentiated into exogenous and endogenous turnovers.

Exogenous turnover.-Each three-day collection of fmces was measured for radioactivity and expressed as a percentage of the injected dose. The mean daily faecal excretion was divided by the mean plasma activity over the three days of collection and multiplied by 100. The result so obtained was an expression of the faecal excretion as a percentage of intravascular activity. The amount of albumin excreted in the faeces was calculated by reference to the vascular albumin content. For example, if the mean daily faecal excretion was 2 % of the injected dose and the 2

faecal excretion of albumin 8 x vascular albumin content. Endogenous turnover.-The endogenous turnover was obtained by subtracting the exogenous turnover from the total =

turnover.

Subjects Studied 35 subjects were

studied by this method. The albumin metabolism in these subjects was in equilibrium as was evidenced by little variation either in serum-albumin or in the volume of distribution of the tracer in the intravascular and extravascular compartments. Control subjects.-These included 2 normal volunteers and 6 hospital patients with no gastrointestinal disease (cases 1-8 in table i). Patients with gastrointestinal disease.-There were 10 patients with normal serum-albumin levels (cases 9-18,

TABLE I-FINDINGS IN CONTROL

*

Result of total

turnover not

x 25 100 = 8 %

of the intraplasma activity was 25%, then vascular activity was excreted per day. Vascular albumin= plasma-volume x serum-albumin concentration; therefore

mean

included in

SUBJECTS

mean

and range.

345 TABLE II-FINDINGS IN GASTROINTESTINAL DISEASE WITHOUT HYPOALBUMINNMIA

table 11) and 14 patients with hypoalbuminasmia (cases 19-32, table ill). In this study hypoalbuminasmia was considered to be present if the serum-albumin level was below 3-5 g. per 100 ml. Effects of albumin infusion.-200 g. of human albumin obtained from the Lister Laboratories, Elstree, Herts, was infused in 4 patients with hypoalbuminxrriia (cases 28-31, table iv), at the rate of 25 g. on alternate days. The albuminturnover studies were repeated one month after infusion. Patients with’intestinal resection.-2 patients (cases 23 and 33, table v) were studied after intestinal resection. 1 of these patients (case 23) had suffered from hypoalbumin2emia associated with intestinal lymphectasia, and albumin turnover studies were repeated after five feet of jejunum had been resected. The other patient (case 33) had had a large ileal resection on account of Crohn’s disease, which had not recurred. Patients with cardiac disease.-2 patients (cases 34 and 35, table vi) were cases of chronic cardiac failure associated with hypoalbuminaemia. The nature of the cardiac lesion is shown in table VI. Results Control Subjects The results of albumin-turnover studies in 8 control subjects are shown in table i. The control values of serumalbumin ranged from 3-5 to 4.2 g. per 100 ml. The T.E.A. in these subjects ranged from 3-8 to 5-0 g. per kg. bodyweight, the mean value being 4-2 g. per kg. Excluding the

patient with rheumatoid arthritis (case 8) the mean total turnover was 218 mg. per kg. per day, with a range of 144 to 298 mg. per kg. per day. The fxcal excretion of albumin varied between 1-1 and 3-8 g. per day with a mean of 2-2 g. per day. This faecal excretion of albumin corresponded to an exogenous turnover of 28 to 62 mg. per kg. per day with a mean value of 47-5 mg. per kg. per day. The endogenous turnover, derived by subtraction, varied between 100 and 242 mg. per kg. per day, the mean value being 176 mg. per kg. per day. Therefore even in the normal subject there is evidence that a proportion of albumin is catabolised in the gastrointestinal tract. A patient suffering from active rheumatoid arthritis (case 8) is considered separately. In this patient the endogenous turnover was much increased to 509 mg. per kg. per day. This must have been due to some extraintestinal cause-possibly the steroid therapy. Despite this rapid endogenous turnover the gastrointestinal protein loss was within normal limits, being 61 mg.per kg. per day. Gastrointestinal Disease with Normal Serum-albumin Levels In all the 10 patients with gastrointestinal disease (table 11) the serum-albumin level and the T.E.A. were within normal limits. In 7 patients (cases 9-15) both exogenous and endogenous turnover were also within the

TABLE III-FINDINGS IN GASTROINTESTINAL DISEASE WITH HYPOALBUMINaeMIA

346 TABLE IV-FINDINGS BEFORE AND AFTER ALBUMIN INFUSION

normal range. These patients were in a state of clinical remission. In 3 patients with active gastrointestinal disease (cases 16-18) the total albumin turnover was increased. Gastrointestinal disease was associated with a high exogenous turnover, and the endogenous turnover was either normal or high. In these patients the serumalbumin and T.E.A. were therefore maintained by an increase of albumin synthesis despite appreciable gastrointestinal protein loss. Gastrointestinal Disease with Hypoalbumincemia The results in the 14 patients with subnormal

serum-

albumin levels are presented in table ill. 2 patients had a normal T.E.A. (cases 19 and 20).

In

intestinal protein loss. In the 2 patients in whom studies carried out (cases 28 and 29) the fsecal nitrogen was extremely high, being greater than 10 g. per day. Effect of Albumin Infusion In the 4 patients to whom intravenous human albumin was given, the serum-albumin levels rose to 3-7 g. per 100 ml. or more (table iv). In each patient, as was shown by studies repeated a month later, the endogenous turnover increased whereas the fsecal excretion and the exogenous turnover were unaffected. On follow-up, in 3 of the 4 patients there was evidence of a sustained rise in the synthetic activity, since despite an increased turnover the serum-albumin was maintained at a normal level for three to five months after the infusion.

were

TABLE V-FINDINGS AFTER RESECTION

raised, whereas the either raised (case 19) or endogenous turnover was normal (case 20). These patients, like those in the previous group (cases 16-18), maintained a normal T.E.A., despite increased gastrointestinal loss, by raising the synthesis-rate. Hypoalbuminxmia in these patients was due to an uneven distribution of albumin between the intravascular compartment and the extravascular pools. Normally up to twice the intravascular albumin content may be present in the extravascular space (Cohen et al. 1961). In cases 19 and 20 3-1 and 2-6 times the intravascular albumin content, respectively, were present in the extravascular space as determined by the mathematical analysis of pool size (Matthews 1957). 12 patients (cases 21-32) had a low T.E.A. Of these patients 7 (cases 21-27) had a high exogenous turnover but the endogenous turnover was low. Thus in these patients the synthesis-rate was insufficient to maintain a normal endogenous turnover in the presence of appreciable gastrointestinal loss. 5 patients (cases 28-32) had a normal exogenous turnover and in addition the endogenous turnover was low. In these patients there was a deficiency of albumin synthesis without excessive gastroboth the exogenous

turnover was

Effect of Intestinal The

Resection

within normal limits in both the patients In the patient with a jejunal resection (case 23) the exogenous turnover was reduced to a quarter of the lowest normal value, whereas it was normal in the patient in whom the ileum had been removed (case 33). The endogenous turnover was within normal limits in both T.E.A. was

(table v).

cases.

Cardiac Disease

Both the patients had low serum-albumin levels and low T.E.A. (table vi). The exogenous turnover was increased above the control range, whereas the endogenous turnover was low. These patients had excessive gastrointestinal protein loss and an inability to raise the rate of albumin synthesis sufficiently to maintain a normal

a

endogenous

turnover.

Discussion These results illustrate again how the administration of amberlite with injected R.I.H.S.A. may be used to study albumin metabolism in man. By this technique it is

possible to obtain a separate and accurate measurement of the amount of albumin catabolised in the gastrointestinal

TABLE VI-FINDINGS IN CARDIAC DISEASE

347

(exogenously) endogenously. tract

in addition

to

that

catabolised

Control Subjects have shown that in normal catabolism occurs in of the albumin subjects proportion This is confirmed by these tract. the gastrointestinal Between 29 and 62 studies. mg. per kg. body-weight of the gastrointestinal tract in albumin was degraded daily in control subjects with normal gastrointestinal tracts. In the normal person the site of albumin catabolism in the gastrointestinal tract appears to be in the stomach and jejunum (Wetterfors et al. 1960). The results in patients subjected to intestinal resection are in keeping with this concept. The patient with a large jejunal resection (case 23, table v) showed a much decreased gastrointestinal protein catabolism, whereas in the patient with a large ileal resection the exogenous turnover was normal.

Wetterfors

et

al.

(1960)

a

Patients without

Hypoalbuminamia

The T.E.A. was within the normal range in all patients with normal serum-albumin levels. As would be expected, albumin metabolism was normal in every respect in many of these patients (cases 9-15, table 11). The results in 3 patients (cases 16-18) are of particular interest since the T.E.A. was normal despite gastrointestinal protein loss. .

Patients with

Hypoalbuminaemia

The results in these patients indicated that hypodbuminsmia might be associated either with a normal or an increased gastrointestinal albumin loss (table ill). In 2 patients (cases 19 and 20) the T.E.A. was normal despite an increased albumin loss. Their turnover data were similar to those in the patients with gastrointestinal protein loss (cases 16-18, table 11) who had normal In these 2 patients the total serum-albumin levels. was but a greater proportion was normal, body-albumin in the extravascular space. Of the patients in whom the T.E.A. was low, those with increased gastrointestinal albumin loss had normal or increased total turnover figures, whereas in patients not losing albumin the total turnover was decreased. In both these groups, however, the endogenous turnover was below the normal range. In this group of patients hypoalbuminaemia was due either to the synthesis of albumin being insufficient to maintain a normal endogenous turnover or to the uneven distribution of albumin. The endogenous turnover was low, irrespective of the presence or absence "of gastrointestinal" protein loss. In fact, in the so-called hypercatabolic patients endogenous catabolism was diminished. In a state of equilibrium, catabolism is equal to anabolism. The patients described in this paper were in equilibrium as there was little variation in the serumalbumin or in the volume of distribution of R.I.H.S.A.

Fig. 2-Relation of T.E.A.

to exogenous turnover.

during the period of study. Hypoalbuminaemia can then regarded as an effect of the body being unable to synthesise enough albumin to maintain a normal endoThis may be due to depression of genous turnover. synthesis or to gastrointestinal albumin loss. In the latter case, most of the synthesised albumin goes to replenish the loss, and little is left to maintain a normal endobe

In consequence there is

a fall of T.E.A. mechanism compensatory restoring equilil5rium. The nature of this mechanism can be seen by studying the relation between T.E.A. and endogenous turnover shown in fig. 1. There was a high degree of correlation (r+0-9). When, however, the exogenous turnover is plotted against the T.E.A. (fig. 2) no correlation is seen (r+0-2). It can therefore be postulated that whenever a negative balance is established between synthetic activity of the liver and albumin degradation, whether due primarily to excessive catabolism or to reduced synthetic activity, a fall occurs in the T.E.A. which results in a reduction of endogenous turnover until equilibrium is re-established. Conversely once the T.E.A. has fallen, if the synthetic activity is reduced, a low endogenous turnover can be restored to normal by infusing albumin intravenously. This is well illustrated by the 4 patients with hypoalbuminaemia without gastrointestinal albumin loss (table vi), whose endogenous turnovers were restored to normal by infusing albumin. In the cases with post-gastrectomy steatorrhoea (cases 28, 29, and 31) the primary lesion was malabsorption of protein, associated with a poor intake of protein due to anorexia. Even when a high protein diet was taken for a month, no effect was seen on the T.E.A. or turnover. Infusion of 200 g. of albumin, however, raised the serumalbumin to normal and resulted in a pronounced rise in turnover (table iv). Case 29 has maintained her serumalbumin for over three months. Case 28 maintained a normal serum-albumin level for six weeks while in hospital, but the level dropped to 2-4 g. per 100 ml. one month after she returned home. In her case anorexia prevented her from taking a normal protein diet once she was discharged from the ward regimen. Case 30 probably developed hypoalbuminaemia due to protein loss secondary to ulcerative colitis, but it persisted after the colitis had healed. He also was given a high-protein diet in the ward for one month, but no improvement resulted in his clinical condition or in the serum-albumin level. Infusion of albumin was followed by a distinct rise of the endo-

genous turnover.

which

acts

as

a

Case 31, in whom similar results were obtained, has also maintained a normal serum-albumin level-so far for three months. genous turnover to normal levels.

Fig. I-Relation of T.E.A.

to

endogenous

turnover.

348

These observations are consistent with the findings of Gitlin (1957), who showed that protein catabolism was a first-order reaction-i.e., the amount catabolised is proportional to the total mass present. The endogenous turnover would be expected to follow this order of reaction, whereas the degree of exudation of serumprotein from an injured intestinal surface would be independent of the mass of albumin present in the body, although dependent on concentration. In conclusion the patients with hypoalbuminxmia could be divided into three groups: (1) those with excessive gastrointestinal protein loss, in whom synthetic activity was unable to maintain a normal endogenous turnover; (2) patients with no evidence of gastrointestinal protein loss in whom the synthetic activity was subnormal; (3) patients in whom the hypoalbuminaemia was apparently due to uneven distribution of albumin between vascular and extravascular compartments. The concept of hypoalbuminaemia presented in this paper could be used to explain the lack of correlation observed by Parkins (1960) between the degree of 1311P.v.p. excretion and the degree of hypoalbuminaemia. Patients with gastrointestinal protein loss who are able to increase albumin synthesis show little or no hypoalbuminsemia. Hypoalbuminsemia occurs only when the amount of albumin synthesised cannot keep pace with the amount catabolised in the bowel. The conclusion of Dawson and Williams (1961) that " increased loss of protein into the gut rather than impaired synthesis" is an important factor in causing hypoalbuminaemia is contrary to the findings reported in this paper, but their conclusions were based on indirect evidence. They had no data from albumin turnover studies to substantiate their conclusions. In other work where albumin turnover studies have been undertaken in patients with gastrointestinal protein loss (Jarnum and Schwartz 1960, Jarnum and Petersen 1961, Steinfeld et al. 1960) it can be seen that the maximum possible rate of albumin synthesis found by Margen and Tarver (1956) and by Waldmann (1961b) to be 0.4 g. per kg. per day had not been attained-i.e., albumin loss was not effectively compensated despite a possible reserve of albumin synthesis. The factors, at present unknown, responsible for this variation in synthetic activity remain an important aspect for future study.

Summary the

of

By Coghill (1961) use

turnovers were

a

technique described by Jeejeebhoy and exogenous and endogenous albumin

estimated

separately.

Normal subjects and patients with hypoalbuminasmia with and without gastrointestinal protein loss were studied. A positive correlation between endogenous turnover and total exchangeable albumin (T.E.A.) was shown. It is suggested that when the synthetic activity of the liver is insufficient to compensate for albumin catabolism, the T.E.A. falls. The fall in T.E.A. will then reduce the endogenous turnover until equilibrium is restored. The effect of albumin infusion in a group of 4 patients with low T.E.A. and slow albumin turnover was studied. Albumin infusion raised the serum-albumin to normal levels in these patients, and the endogenous turnover became normal. Of the 4 patients the serum-albumin levels have remained normal in 3 over several months’ observation. I am grateful to Dr. N. F. Coghill of the West Middlesex Hospital, Isleworth, and to Dr. C. C. Booth of the Postgraduate Medical School

of London, for allowing these studies to be undertaken on patients under their care, and for helpful advice in preparing the text of this paper; to Dr. J. F. Goodwin, of the Postgraduate Medical School of London, for allowing me to study cases 34 and 35; to Dr. T. D. Kellock, of the Central Middlesex Hospital, London, and to Dr. L. V. Roberts, of Lewisham Hospital, London, for allowing me to study cases 18 and 23 respectively; and to Dr. M. Lubran for undertaking serum-albumin estimations and for helpful technical advice on many aspects of the study. REFERENCES

Citrin, Y., Sterling, K., Halsted, J. A. (1957) New Engl. J. Med. 257, 906. Cohen, S., Freeman, T., McFarlane, A. S. (1961) Clin. Sci. 20, 161. Davidson, J. D., Waldmann, T. A., Goodman, D. S., Gordon, R. S. (1961) Lancet, i, 899. Dawson, A., Williams, R., Williams, H. S. (1961) Brit. med. J. ii, 667. French, A. B., Pollard, H. M., Dickson, B. (1961) Proceedings of the annual meeting of the American Gastroenterological Association, May 26-27.

Gitlin, D. (1957) Pœdiatrics, 19, 657. Gordon, R. S. (1959a) Lancet, i, 325. (1959b) and others. Ann. Intern. Med. 51, 553. Jarnum, S., Petersen, V. P. (1961) Lancet, i, 417. Schwartz, M. (1960) Gastroenterology, 38, 769. Jeejeebhoy, K. N., Coghill, N. F. (1961) Gut, 2, 123. London, D. R., Barnforth, J., Creamer, B. (1961) Lancet, ii, 18. Margen, S., Tarver, H. (1956) J. clin. Invest. 35, 1161. Matthews, C. M. E. (1957) Phys. Med. Biol. 2, 36. McFarlane, A. S. (1956) Biochem. J. 62, 135. Parkins, R. A. (1960) Lancet, ii, 1366. Ruthstein, D. D., Ingenito, E. F., Reynolds, W. E. (1954) J. clin. Invest 33, 211. Steinfeld, J. L., Davidson, J. D., Gordon, R. S. (1957) ibid. 36, 931. Green, F. E. (1960) Amer. J. Med. 29, 405. Veall, N., Vetter, H. (1952) Brit. J. Radiol. 25, 85. Waldmann, T. A. (1961a) Lancet, ii, 121. (1961b) Personal communication. Wetterfors, J., Gullberg, Liljedahl, S.-O., Plantin, L.-O., Birke, G., Olhagen, B. (1960) Acta. med. Scand. 168, 347. -

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LOSS OF TISSUE-SPECIFIC AUTOANTIGENS IN THYROID TUMOURS R. B. GOUDIE Glasg., M.R.C.P.

M.B.

LECTURER

H. MORAG MCCALLUM M.B. Glasg. LECTURER

UNIVERSITY DEPARTMENT OF WESTERN

PATHOLOGY,

INFIRMARY, GLASGOW

IF there is any truth in the immunological theory of formation (Green 1954), it might be possible to demonstrate loss of tissue-specific antigens in tumour cells; for it is an essential conclusion of the theory that tumours arise as a result of the escape of cells from the restraining influence of autoantibodies. The loss of tissuespecific antigens in tumour cells has already been described by Weiler (1959) and Nairn et al. (1960), but these workers used antibodies prepared by immunising other species. A similar demonstration, using naturally occurring cytotoxic autoantibodies, is an advance on this; and we report here such a demonstration using antithyroid cytotoxic sera (Pulvertaft et al. 1959b) in benign and malignant thyroid tumour

tumours.

Investigations and Results Tissue Culture Cells from thyroid obtained at operation or postmortem (within 8 hours of death) were dispersed with trypsin by the method of Pulvertaft et al. (1959a), and suspended in Tc 199 solution (Glaxo). All observations were made in duplicated 4 x 1/2 in. test-tubes, each containing 0-8 ml. of cell suspension, 0-1 ml. of human serum (or serum dilution), and 0-1 ml. of fresh undiluted guineapig serum. The tubes were stoppered and incubated in tilted racks at 37°C for 16 hours. The lower surfaces of the tubes were then searched for cells spreading on the glass to form a monolayer, and the results were recorded as: =no cells seen spreading; ± ==1 to 9 cells seen. -

+ = 10 or more single cells seen, but few clumps. + + =numerous clumps; + + + ==con8uent clumps.