DR. SCHWARTZ AND OTHERS: REFERENCES

Abels, I., Woldring, M. G., Vegter, I. I. M., Nieweg, H. O. (1957) Science,126, 558.

Adams, J. F. (1958) Brit. med. J. i, 644.Allgén, L.-G., Tomenius, J. (1958) Svenska Läkartidn. 55, 437.Bastrup-Madsen, P. (1957) Nord. Med. 34, 1233.Berlin, R., Berlin, H., Brante, G. (1957) Congress of the European Society

of Hæmatology, abstract 227.Blackburn, E. K., Cohen, H., Wilson, G. M. (1955) Brit. med. J. ii, 461.Holdsworth, E. S., Coates, M. E. (1956) Nature, Lond. 177, 701.Jørgensen, I. Den perniciøse anæmis vedligeholdelsesbehandling og

prognose i Danmark. København (thesis), 1949.Killander, A. (1958a) Acta med. scand. 160, 339.

— (1958b) Acta Soc. Med. Uppsala, 63, 1.Kristensen, H. P., Lund, J., Søeborg Ohlsen, A., Pedersen, J. (1957) Lancet,

i, 1266.Lous, P., Schwartz, M. (1957) Ugeskr. Lœger. 119, 477.Lowenstein, L., Brunton, L., Shapiro, L., De Leeuw, N., Dufresne, M.

(1957) Canad. med. Ass. J. 77, 923.Meulengracht, E. (1953) Ugeskr. Lœger. 115, 809.

— (1955) ibid. 117, 883.Nieweg, H. O., Arends, A., Mandema, E., Castle, W. B. (1956) Proc. Soc.

exp. Biol., N.Y. 91, 328.Nørregaard, S. (1955) Ugeskr. Lœger. 117, 850.Schwartz, M. (1958) Lancet, ii, 69.

— Lous, P., Meulengracht, E. (1957a) ibid. i, 751.— — — (1957b) Ugeskr. Lœger. 119, 899.

Stokes, J. B., Pitney, W. R. (1958) Brit. med. J. i, 322.Taylor, K. B., Morton, J. A. (1958) Lancet, i, 29.

1204

THE SIGNIFICANCE OF

BASEMENT-MEMBRANE CHANGES INTHYROID DISEASE

ANGUS E. STUARTM.B. Glasg., M.R.C.P.E.

W. S. A. ALLANM.B. Edin., M.R.C.P.E.

From the Department of Pathology, University of EdinburghIN 1957 Doniach and Roitt demonstrated thyroid

antibodies in Hashimoto’s disease and suggested that thestimulus for their production was the slow liberation ofcolloid from the thyroid follicles. More recently similarantibodies have been described in thyrotoxicosis (Goudieet al. 1957) and in subacute thyroiditis (Felix-Davies1958). It appears that thyroglobulin is immunologicallyinert when contained within the follicles but is treated

by the host as a foreign protein when extravasated intothe interstitial tissues. The reason for leakage of colloidfrom the follicle is not understood, but the process may beanalogous to the escape of protein through the damagedglomerular basement membranes in nephritis. The pur-pose of this paper is to determine the relation, if any,between basement-membrane changes in the thyroidgland and the presence of a high thyroid-antibody titre.

Material

Thyrotoxicosis.-8 thyroid glands from patients with highantibody titres were studied histologically, and likewise 10

Fig. 1-Photomicrograph of thyroid gland to show the normalrelationship of the basement membrane to the capillary vessels.(Silver. x 650.)

thyroid glands from patients without antibodies served as

controls. At least four blocks were taken from each gland, and,without knowledge of the antibody titres, the sections weregraded according to the degree of basement-membrane injury.

Hashimoto’s disease.-l0 thyroid glands, all showing diffuseAskanazy-cell change, lymphoid follicles with interstitialround-cell infiltration, and various degrees of fibrosis, werestudied.

Subacute (de Quervain’s) thyroiditis.-3 typical cases were

investigated.MethodsHistology.-Routine paraffin sections of tissues fixed in

formol corrosive were stained with a modified silver stain

BASEMENT-MEMBRANE INJURY IN 18 THYROID GLANDS FROM PATIENTSWITH THYROTOXICOSIS

The injury is assessed as minor or absent (-), moderate (+), andsevere (+ +). ).

(Slidders, Fraser, and Lendrum 1958). This method wasselected after trial of many other basement-membrane stains,because it gave clear and constant results.

Serology.-Antibodies were detected by the tanned-cell

haemagglutination technique using human group 0 cells andpurified thyroglobulin. The end-point was taken as the lasttube to show a broad even carpet of agglutinated cells. Theterm " high titre " in this paper means a serum-titre of over1/5000.

Results

The normal appearance of the basement membranes ofthe thyroid follicles is seen in glands from patients withoutantibodies (fig. 1). The membrane stains intensely andevenly. It measures 0-1 to 0.2 y, in width, and is closelyapplied to the base of the epithelial cells, forming a con-tinuous unbroken lining and completely sealing off thefollicle from the capillary vessels. The latter appear asovoid or polygonal spaces bounded by the basement mem-brane, whose inner surface is lined by flattened endo-thelial cells. Even in hyperplastic papillary processes the

Fig. 2-Fragmentation of the basement membrane in thyroidtissue from a patient with thyrotoxicosis and a high antibodytitre. (Silver. x 500.)

1205

Fig. 3-Severe basement-membrane damage in Hashimoto’s disease.(Silver. x 400.)

Fig. 4-Apparently normal basement membrane in Hashimoto’sdisease. (Silver. xl20.)

basement membrane closely follows the proliferativeepithelium.

Thyrotoxicosis.-In this series abnormal basementmembranes are seen mainly in thyroid glands frompatients with a high antibody titre. The table shows theresults of grading the 18 glands from thyrotoxic patientsaccording to the degree of basement-membrane injury.8 of the 10 thyrotoxic patients without antibodies showedno significant degree of basement-membrane damage,whereas 7 of the 8 patients with high antibody titresshowed extensive areas of injury.The damage is entirely focal and consists of frag-

mentation, beading, and duplication of the basementmembrane.

Fragmentation is seen as sharp breaks in continuity, and isoften associated with a wavy irregular appearance (fig. 2) quiteunlike the straight smooth line of a normal membrane. Frag-mentation must be distinguished from artefact caused by afaulty block or knife. Artefact appears as parallel rows ofargentophil fibres attached at right-angles either to a basementmembrane or to the interlobular fibrous tissue, in such a waythat it resembles the teeth of a garden rake.The term " beading " is borrowed from Sommers and

Meissner (1954). Beading is often seen as minute argentophildots or globules, and is probably caused by failure of adjacentparts to stain with silver.

In duplication the basement membrane is split into two ormore layers. This is seen more often in subacute thyroiditisthan in either Hashimoto’s disease or thyrotoxicosis. All three

types of damage are usually present together.Hashimoto’s disease.-The changes are qualitatively

similar to those in thyrotoxicosis, but they are diffuse andmore severe. Fig. 3 shows typical widespread changeswith severe fragmentation. The basement membrane isnot always damaged as much as this; fig. 4 shows anapparently normal pattern, but the typical fragmentationand irregularity can be seen under a higher magnificationin fig. 5.

In this series all 10 patients with Hashimoto’s diseasehad very high antibody titres, and all showed severediffuse injury to the basement membrane.

Subacute thyroiditis.-The appearances are ratherdifferent here. There is an increase of reticulin-like fibresbetween the follicles, and the fragmentation seems muchcoarser (fig. 6) than that previously described. In folliclesshowing giant cells or swollen epithelium there is usuallyconsiderable duplication of the membrane, whereas intactand normal-looking follicles show no such change.

Only 1 of the 3 patients had an appreciable titre ofantibody, although all showed quite severe basement-membrane changes.

Fig. 5—High-power view of fig. 4 revealing typical fragmentationof the basement membrane. (Silver. x 625.)

Fig. 6-Duplication and coarse fragmentation of the basementmembrane in subacute thyroiditis. (Silver. /. 500.)

1206

Discussion

In most cases damage to the basement membranes ofthe thyroid follicles was closely associated with a round-cellinfiltration of lymphocytes and plasma cells; fig. 5 showsplasma cells intimately associated with a breach in thefollicle. In a few glands extensive basement-membranedamage was seen in areas which did not contain chronicinflammatory cells. This was also found by Sommersand Meissner (1954), who pointed out that " basement-membrane changes need not be associated with lympho-cytic nodules ".Our findings establish a clear relation between base-

ment-membrane damage, as shown by silver impregnationmethods, and the presence of antibodies in significanttitre. Admittedly most silver-staining methods are

notoriously fickle and the problem of artefact is serious.Nevertheless in our experience this new modified silvermethod is remarkably free from the usual defects.The possibility that the fragmentation may be an

artefact due to infolding of the thyroid follicle in a

particular plane of section was excluded by criticalexamination of thyroid tissue in serial section.The cases of thyrotoxicosis were chosen because of the

great difference in antibody titre. In one group the titreswere high, and in the other no antibodies were present.This was the only way in which the relation between anti-bodies and histological changes could be established, sincethe intermediate group of glands was difficult to classify.Our findings appear to establish a relation between

irregularity and lack of continuity of the follicular base-ment membrane, and the escape of colloid into theinterstitial tissue with consequent inflammatory-cellreaction. Thus there seems to be a case for regardingbasement-membrane damage as the anatomical basis ofthyroid-antibody formation.The state of the basement membrane in epithelium

showing Askanazy-cell change (which is characteristic ofHashimoto’s disease) is of special interest. In this studyAskanazy-cell change was nearly always associated withlymphocytes and plasma cells, but in 2 cases there was nosignificant degree of round-cell infiltration and in both ofthese the basement membranes were normal. This findingsuggests that the nutritional change leading to the forma-tion of the Askanazy type of epithelium does not neces-sarily result in impairment of the basement membrane.The factors responsible for basement-membrane

damage remain obscure, although in some conditions-such as a virus-induced thyroiditis-it is probablysecondary to severe epithelial damage. If the basement-membrane deficiency in other forms of thyroiditis is alsosecondary to epithelial injury, it would seem reasonableto invoke the action of thyroid antibodies which are

generally assumed to be responsible for the parenchyma-tous damage in Hashimoto’s disease (British Medical

Journal 1958). But it is difficult to believe that these

circulating antibodies possess any significant cytotoxiceffect, since they are present in high titre in some patientswith thyroid hyperfunction. In such cases one would

expect their cytotoxic effects to result in suppression offunction. Accordingly it seems probable that the anti-bodies are related to phagocytosis of extravasated colloid,and that the primary defect in Hashimoto’s disease is afailure of the integrity of the basement membrane, asSommers and Meissner (1954) suggested.In both Hashimoto’s disease and thyrotoxicosis there

is a reasonably good correlation between pathological

changes in the basement membrane and the presence ofantibodies, although some exceptions were found. The

relationship is less definite in subacute thyroiditis, butperhaps a larger series of cases is required to elucidatethis point.

Summary and ConclusionsBasement-membrane changes are widespread and

severe in Hashimoto’s disease and subacute thyroiditis,and are seen to a lesser degree in thyrotoxicosis.Basement-membrane damage is usually associated with

lymphocytic and plasma-cell infiltration, but it may beseen independently, possibly because it arose at an earlierstage of the disease.

In this series of 31 cases, there is a direct relationshipbetween basement-membrane irregularities and highantibody titres.

If the function of the basement membrane is to maintainthe immunological integrity of the follicle by preventingaccess of colloid to the interstitial tissue, a break in thecontinuity of the membrane, as observed in this series,would provide an anatomical basis for thyroid-antibodyformation.

We wish to thank Prof. G. L. Montgomery for his help, MissSheila Heath for assistance with the silver stains, and Mr. T. C.Dodds for the photomicrographs.

REFERENCES

British Medical Journal (1958) i, 936.Doniach, D., Roitt, I. M. (1957) J. clin. Endocrin. 17, 1293.Felix-Davies, D. (1958) Lancet, i, 880.Goudie, R. B., Anderson, J. R., Gray, K. B., Clark, D. H., Murray, I. P. C.,

McNicol, G. P. (1957) ibid. ii, 976.Slidders, W., Fraser, D. S., Lendrum, A. C. (1958) J. Path. Bact. 75, 478.Sommers, S. C., Meissner, W. A. (1954) Amer. J. clin. Path. 24, 434.

NEGATIVE L.E.-CELL PHENOMENON IN

TRUE SYSTEMIC LUPUS ERYTHEMATOSUS

P. FORMIJNEM.D. Amsterdam

PROFESSOR OF INTERNAL MEDICINE, UNIVERSITY OF AMSTERDAM

F. VAN SOERENM.D. Amsterdam

ASSISTANT INTERNAL MEDICINE, UNIVERSITY OF AMSTERDAM

The chance that a phenomenon has a significance.—J. BARCROFT.Features in the Architecture of Physiological Function.

IN discussing the significance of phenomena, muchmore interest is usually paid to their presence than theirabsence; and this is true for the lupus-erythematosus(L.E.)-cell phenomenon. While its presence in certaindiseases has often been described, its absence in provedor probable lupus erythematosus has received scarcelymore than a mention (Dubois 1953, McGehee andShulman 1954).

Case-historyA man of 53 was admitted to hospital in September, 1957.

He presented the typical picture of systemic lupus erythe-matosus.

In January, 1957, both ankle-joints had become stiff, red,painful, and swollen. After a few weeks, a continuous highfever developed and multiple hemorrhages appeared on thelegs. In May the patient became dyspnoeic and oedema waspresent in both legs.

In September there was found a sharp systolic murmur atthe apex of the dilated heart, moist rales at the base of bothlungs, a firm palpable liver and spleen, free fluid in the

peritoneal cavity, and oedema and hxmorrhages in both legs.Laboratory investigations.-White cells 8000 per c.mm..

normal differential count. Red cells 4 million per c.mm..

haemoglobin 78%. Platelets 300,000 per c.mm. Bleeding-ume3 min., clotting-time 4 min. Urine: protein+, urobilin - -- ; z