University California Angeles,dm5migu4zj3pb.cloudfront.net/manuscripts/102000/102877/JCI5410… · Bence-Jones protein was pres-ent in the urine and sternal marrow was heavily infil-trated

METABOLICBALANCEINVESTIGATION OF THREECASESOFMULTIPLE MYELOMADURINGACTHADMINISTRATION;

EXCHANGESOF CALCIUM, PHOSPHORUS,NITROGENANDELECTROLYTES'

BY WILLIAM S. ADAMS, EARL D. MASON,AND SAMUELH. BASSETT

(From the Veterans Administration Center, Los Angeles, Calif., and the Department of Medicine,School of Medicine, University of California Medical Center, Los Angeles, Calif.)

(Submitted for publication February 17, 1953; accepted October 8, 1953)

INTRODUCTION

In the course of some preliminary observationson the effect of ACTH in multiple myeloma wewere intrigued by evidence of substantial decreasein the concentration of serum protein and diminu-tion of Bence-Jones proteinuria (1). As in otherforms of malignancy, response to steroid therapyhas proven somewhat varied in the hands of dif-ferent investigators. Pearson, Eliel, and Talbott(2) mentioned the inefficacy of adrenocorticotropinin plasma cell myeloma. Engle and Barr (3)treated three patients with the same substance andnoted little clinical improvement. They found nochange in the electrophoretic pattern or in theconcentration of plasma protein. In other in-stances, the results have been similar to those ofthe authors and include reduction in concentrationof serum protein as described by Bethell (3) andother investigators (4); decreased excretion ofBence-Jones protein (3); disappearance of hyper-calcemia (3, 4); and clinical improvement (suchas loss of bone pain [3r, better appetite with gainin weight [3, 4], and increased hematocrit). Ourown experience also indicates that adrenocortico-tropin diminishes rather than aggravates the rateof skeletal decalcification. This impression hasbeen gained through careful observation of threepatients who were hospitalized for metabolic study.That it may also lead occasionally to a prolongedremission was suggested by the clinical response ofone of our three subjects treated with this hor-mone. Although other workers have investigatednitrogen and mineral exchanges in myeloma (5-

1 Supported in part by a grant-in-aid from the AmericanCancer Society upon recommendation of the Committeeon Growth of the National Research Council, and by theCancer Research Coordinating Committee of the Uni-versity of California.

11), their findings do not appear pertinent to thepresent discussion.

PROCEDUREANDMETHODS

The patients were admitted to the Metabolism Wardwhere they were under continuous observation. Theurine was analyzed daily for sodium, potassium, phos-phorus, chloride, and nitrogen; aliquots of the 24-hourcollections of urine were saved and pooled in periods offive days, and the analyses repeated on the pooled sam-ples. This served as an added check on the accuracy ofthe daily work. Stools were separated at intervals offive days with the use of carmine markers and analyzedfor the same constituents as in the case of urine. Samplediets, duplicating the menus of the patients, were preparedat intervals of ten days, homogenized, sampled, andanalyzed to determine intake. Emeses and dietary re-jects were treated in the same manner as sample diets,analyzed separately, and appropriate corrections of in-take were made. Blood was collected in the postabsorptivestate from an arm vein with the least possible stasis, andafter prompt separation of the serum, determinationswere made of total serum protein, albumin, globulin, so-dium, chloride, potassium, calcium, and phosphorus. Theanalytical methods used were as follows: Aliquots ofdiet, urine, and emesis were ashed in a muffle furnace ata temperature not exceeding 4500 C. Sodium and po-tassium determinations were performed directly on di-luted specimens of urine and (blood) serum, with theuse of the Beckman flame photometer. With the excep-tion of nitrogen and chloride, the other substances weredetermined from the ashed filtrates. Urinary, fecal, anddietary calcium were determined by the gravimetricmethod of Washburn and Shear (12), serum calcium bythe method of Van Slyke and Sendroy (13), phosphorusby the gravimetric method of Washburn and Shear (12),and a modification of the colorimetric method of Fiskeand Subbarow (14), nitrogen by the Hiller, Plazin, andVan Slyke modifications of the Kjeldahl procedure (15),chlorides by modification of the Volhard method (16-18),plasma proteins by a modification of the Howe sodiumsulfate method (19) as described by Majoor (20), andurinary protein by the method of Hiller, Greif, and Beck-man (21), serum and urine uric acid by modification ofthe methods of Kalckar (22) and Praetorius (23).

103

WILLIAM S. ADAMS, EARL D. MASON, AND SAMUELH. BASSETT

CLINICAL MATERIAL

Case summaries

Patient 1 (J. D.) (See Figures 1-4 and Tables I-III.)J. D. was a white male aged 62 who was found to have

multiple myeloma in 1946, while under treatment for lobarpneumonia. Although he was moderately anemic andexhibited hyperproteinemia and infiltration of the bonemarrow with plasma cells, roentgenologic evidence ofskeletal decalcification was not yet apparent. During thesubsequent two years he had repeated respiratory infec-tions and was readmitted to the hospital in June, 1948with right lower lobe pneumonia. At this time theerythrocyte count was 3.8 million per cu. mm., the red cellsshowed increased rouleaux formation, the hemoglobinwas 11.2 Gm. per 100 ml. whole blood, the white bloodcells were 17,000 per cu. mm. with a shift to the left inthe differential formula. Bence-Jones protein was pres-

ent in the urine and sternal marrow was heavily infil-trated with plasma cells. The skull revealed discreteradiolucent areas. The serum proteins were 8.6 Gm. per

cent with 3.2 Gm. per cent albumin and 5.4 Gm. per centglobulin. (The main globulin component could be pre-

cipitated with 18.5 per cent sodium sulfate.) Urethane inthe amount of 135 Gm. given over a period of 45 daysfailed to produce clinical improvement or any alterationsin existing abnormalities detectible in the laboratory.

FIG. 1. PATIENT J. D. EFFECT OF ACTHON NITROGENANDPHOSPHORUSBALANCEANDBODYWEIGHT

Positive balances are indicated by clear areas betweenthe intake line and the sum of urine and fecal excretion.An extension of the line labeled "urinary excretion" abovethe line labeled "intake" denotes a negative balance.

A year after urethane therapy he was admitted to themetabolic ward for a study of the effect of adrenocortico-tropin, the results of which are indicated in tables andcharts. After 15 days of treatment, he suddenly becamefebrile, and metabolic studies had to be discontinued.Signs of meningeal irritation developed and within a fewdays he became semistuporous. His condition becameprogressively worse, and he lapsed into complete comaand died in two weeks.

Cultures of the blood and spinal fluid remained sterile.Autopsy revealed a purulent ependymitis, the cause ofwhich was not ascertained. Examination of the bonemarrow at autopsy confirmed the diagnosis of multiplemyeloma.

Patient 2 (J. M.) (See Figures 5-8 and Tables II-V.)J. M., a white male of 56 years was admitted to the

hospital for the first time in 1947 with severe back painwhich had its inception while he was lifting a heavy ob-ject. There was a pathological fracture of the tenthdorsal vertebra and multiple radiolucent areas scatteredthroughout the skeleton. The diagnosis of multiple mye-loma was substantiated by biopsy of the bone marrow.

He received therapy with urethane (120 Gm. in 45 days)but failed to improve either from a clinical or laboratorystandpoint. During a subsequent readmission six monthslater, little new was noted on physical examination, ex-

cept for spasm of the erector spinae muscle in the lowerthoracic and upper lumbar regions. X-rays at this timeindicated compression fractures of D-8, D-10, and L-1, the

ACTH 40MG/DAYI~~~~~~~~~~~~~~~

PHOSPHORUS BALNE

_ ~~~~~~~~~~~~~~I=- %.^ Ij

8

6

GM4

4

CALCIUM BALANCE

3 4FIVE -DAY PERIODS

FIG. 2. PATIENT J. D. EFFECT OF ACTHON CALCIUMAND PHOSPHORUSBALANCES

For legend see Figure 1.

104

0

1....... H/1111111111M

METABOLIC STUDY IN MULTIPLE MYELOMA

FIG. 3. PATIENT J. D. EFnFCT OF ACTH ON SODIUMCHLORIDEAND POTASSIUMBALANCES


IAcTH 4OMfA1F.. I. ..._.-SERUMPROTEINS I

I

6K%

FIVE DAY PERIODS

FIG. 4. PATIENT J. D. EFFECTOF ACTHON SERUMANDURINARYPROTEIN

presence of decalcified areas as mentioned previously, andconsiderable demineralization of all the bones. The totalserum proteins were 7.1 Gm. per cent, albumin 3 Gm. percent, globulin 4.1 Gm. per cent with the major abnor-mality in the alpha globulin component (a somewhat un-usual finding but one that has been observed previously[24, 25]). Bence-Jones protein was present in the urinein considerable quantity, and the sternal marrow con-tained 42 per cent plasma cells. He was admitted to the

TABLE I

Nitrogen, calcium, phosphorus, and electrUlyte balances *

J. D. Age 62 Male

Ca P N Na K ClPeriod Therapy Weight

5 days ea. (daily) Gm. mEq. Kg.

I Control -0.176 -0.544 - 4.81 - 54.60 + 0.10 - 0.41 68.52II Control -0.191 -0.916 - 3.53 - 77.30 - 14.60 - 10.20 68.53

III Control -0.176 -0.781 - 0.42 - 48.10 - 0.80 + 20.30 68.38IV 40 mg. ACTH -0.251 -1.796 -18.89 +232.40 -102.20 +155.60 69.97V 40mg.ACTH -0.500 -1.780 -35.66 - 5.40 - 37.79 + 38.57 69.89VI 40 mg. ACTH -0.921 -2.422 -41.27 -225.70 - 57.09 -233.35 70.00

* In computation of these balances average values for dietary intake and fecal excretion have been employed (actualanalyses of both diet and stool having been carried out every five-day period). The diet was calculated to contain72 Gm. of protein, 123 Gm. of fat, and 174 Gm. of carbohydrate, and 2093 calories per day. The average values perfive-day period were as follows:

Calcium (Gm.)Phosphorus (Gm.)Nitrogen (Gm.)Sodium (mEq.)Potassium (mEq.)Chloride (mEq.)

Diet3.1195.30

57.65580.0371.0606.0

Fecal excretion3.2241.5565.087.83

60.456.05

DURING ACTH THERAPY 105

106 WILLIAM S. ADAMS, EARL D. MASON, AND SAMUELH. BASSETT

TABLE II

Urinary proteins

Case J. D. Case J. M. Case S. M.

Therapy Therapy Therapydaily Total daily Total daily Total

ACTH urinary* ACTH urinary* ACTH urinary*Period (mg.) protein (mg.) protein (mg.) protein

I - 15.4 87.6 44.7II 16.0 - 86.5 45.6

III - 15.0 91.2 - 48.4IV 40 15.8 40 94.6 100 48.8V 40 11.0 40 82.8 100 40.2

VI 40 10.8 40 66.0 200 28.6VII 80 37.2 200 11.5

VIII 80 26.9 200 7.9IX 80 22.2 100 3.8X 40 22.3 100 4.6

XI 40 27.1 100 3.6XII 40 28.6 100 3.7

XIII 40 26.6 100 3.3XIV 27.2 100 3.3XV 31.2 100 4.6

XVI 100 3.4XVII - 4.3

XVIII - 6.1

* Grams protein per five-day period.

metabolic unit for studies which were continued for 75 Patient 3 (S. M.) (See Figures 8-13 and Tables II, III,days. During 50 days of this time he received a course V-VII.)of ACTHwhich resulted in marked subjective improve- S. M., a white male of 58 years, entered the hospital inment, although in no sense did it eradicate signs of the March 1949 with a six-month history of pain in the backdisease. Approximately one year later he developed a and shoulders, weakness of and loss of sensation in thesudden paraplegia, "cord" bladder, and fecal incontinence. lower extremities. He had been confined to bed for theCortisone therapy was tried but he became progressively month prior to admission because of inability to move hisworse and died in August, 1951. The diagnosis of multi- legs. On examination, he was found to have a spasticple myeloma was confirmed at autopsy. paraplegia, diminution of sense of pain and touch over

TABLE III

Urinary calcium

Case J. D. Case J. M. Case S. M.

Therapy Therapy Therapydaily daily daily

ACTH Urinary ACTH Urinary ACTH UrinaryPeriod (mg.) Ca* (mg.) Ca* (mg.) Ca*

I - 0.051 1.390 - 0.956II 0.066 1.523 1.116

III 0.051 - 1.466 1.273IV 40 0.126 40 1.244 100 1.294V 40 0.375 40 0.743 100 1.216

VI 40 0.796 40 0.646 200 1.235VII 80 0.591 200 0.994

VIII 80 0.790 200 0.987IX 80 1.021 100 0.672X 40 1.088 100 0.858

XI 40 1.033 100 1.093XII 40 1.029 100 1.098

XIII 40 1.105 100 0.691XIV 0.990 100 0.801XV 0.819 100 1.051

XVI 100 0.956XVII 0.522

XVIII - 0.527

* Grams calcium per five-day period.

METABOLIC STUDY IN MULTIPLE MYELOMADURING ACTH THERAPY

I * 2 ' 3 ' 4 ' S 6 7 8 * 9 IO * II Z 1-5D -

RO5 DAY PERIOD$

FIG. 5. PATIENT J. M. EFFECT OF ACTHON NITROGENAND PHOSPHORUSBALANCESFor legend see Figure 1.

the legs, and multiple osteolytic lesions which involvedthe skull, ribs, vertebrae, pelvis, and proximal portions ofthe femora. There was an expansile tumor of the in-ferior portion of the right scapula. The urine containedBence-Jones protein; the serum proteins showed a slightincrease in the alpha globulin fraction but were not other-wise remarkable. Smears of the sternal marrow revealed

22 per cent plasma cells, some of which were multi-nucleated. Although the diagnosis of multiple myelomaappeared to be well substantiated, it was decided to at-tempt to relieve the paraplegia by laminectomy. Theoperation was performed in April, 1949, and an infiltratingmass, which proved to be a plasmacytoma, was removedfrom the spinal cord at the level of D-1. Use of graded

FIG. 6. PATENTJ. M. EFFECT OF ACTHON CALCIUM AND PHOSPHORUSBALANCES


ACTH ACTH ACTH40 MG/IAY 80 MG/DAY 40 MG/DAY

NITROGEN BALANCE l

4~~~ ~ ~ ~ ~ ~~~~.RAtI IC,O I

P(CATEXCREI I I

PHOSPHORUSI BAILANCE I18~~~~~~~~~~~~~UIARE""^XCRETION

G0S,. .........R;6-l04 1llllllllllll!ll1lllllIIIIIIIII||e w |--A ^l e w slkilUilI- 1 | l 19| ^- 4 1

107


W7 '8 ' 9 "' IO I I' E!' 13'14FIVE -DAY PERIODS

FIG. 7. PATIENT J. M. EFFECT OF ACTH ON SERUMANDURINARY PROTEIN

exercises and physiotherapy led to a gradual recovery offunction in the lower extremities which was nearly com-plete a year later. Repeated episodes of severe rib andback pain continued, however, and in January, 1951, heentered the Metabolic Unit for treatment with adreno-corticotropin. The results of studies conducted at thistime are illustrated in figures and tables. A remissionin the course of the disease followed the administration ofthe hormone and now, two years later, he is active andsubjectively well. However, bone marrow and roentgenevidence of myeloma persists.

ACTH

GMS.7I

6

5

4

3

2 Fi2 3 4 5 6 7 89 10 11 I 14 1X

5 DAY PERIODS

A

METABOLICSTUDIES

The alterations in the exchanges of nitrogen, cal-cium, phosphorus, and electrolytes associated withthe administration of ACTH2 to these three pa-tients, were in many respects similar to the effectsobserved in normal subjects and in various other

2 The ACTHused in this study was supplied by Armour& Company. All dosages are expressed in terms ofArmour's standard LA-1A.

B

a'

FIG. 8. A. PATIENT J. M. EFFECT OF ACTHON FECAL Loss OF NITROGEN, CALCIUM, ANDPHOSPHORUS

B. PATIENT S. M. EFFECT OF ACTHON FECAL Loss OF NITROGEN, CALCIUM, ANDPHOSPHORUS

108


TABLE IV

Nitrogen, cakium, and phosphorus balances *

J. M. Age 56 Male

P PCa Theoretical Actual N

Period Therapy Weight5 days ea. (daily) Gm. Kg.

I Control -1.094 -1.01 -1.036 - 7.68 64.84II Control -1.227 -0.71 -0.063 - 2.45 64.47

III Control -1.170 -1.01 -0.658 - 7.03 64.38IV 40 mg. ACTH -0.918 -0.93 -0.719 - 7.65 65.18V 40 mg. ACTH -0.447 -0.93 -0.240 -10.79 65.05

VI 40 mg. ACTH -0.350 -0.67 -0.568 - 7.47 65.45VII 80 mg. ACTH -0.295 -1.23 -0.483 -15.90 66.06

VIII 80 mg. ACTH -0.494 -1.20 -0.655 -14.12 65.94IX 80 mg. ACTH -0.725 -1.39 -0.833 -15.71 65.19X 40 mg. ACTH -0.792 -0.93 -0.634 - 8.49 64.31

XI 40 mg. ACTH -0.737 -0.42 -0.329 - 1.43 63.25XII 40 mg. ACTH -0.733 -0.20 -0.779 + 1.88 63.32

XIII 40 mg. ACTH -0.809 -0.25 -0.378 + 1.66 63.85XIV Control -0.694 -0.20 -0.981 + 1.64 62.03XV Control -0.523 +0.08 -0.987 + 4.57

* In computation of these balances average values for dietary intake and fecal excretion have been employed (actualanalyses of both diet and stool having been carried out every five-day period). The diet was calculated to contain68.8 Gm. of protein, 119.1 Gm. of fat, 210.1 Gm. of carbohydrate, and 1919 calories per day. The average values perfive-day period were as follows:

Calcium (Gm.)Phosphorus (Gm.)Nitrogen (Gm.)

diseases (4, 26). There were, however, certainunique features, such as marked changes in theconcentration of plasma proteins and in the amountof protein excreted in the urine (1, 3, 4). Sincethe reactions of each individual differed substan-tially, the data for each will be described separately.

Diet

5.9967.403

59.1

Fecal excretion5.703.133.10

Patient J. D.A. Nitrogen balance: The weight of the patient

remained nearly constant (68.5 to 68.4 Kg.) dur-ing three control periods on a diet of 72 Gm. pro-tein and 2093 calories per day. Small amounts ofnitrogen were lost for the first ten days followed

TABLE V

Nitrogen to phosphorus ratios

Case J. M.

Period

III

IIIIVV

VIVII

VIIIIXXIXIIXIII

XIVXV

XVIXVII

XVIII

Actual P-P with Ca

-0.546-0.080-0.128-0.309-0.040-0.408-0.353-0.415-0.513-0.284

0-0.449-0.018-0.671-0.757

000

N

- 7.68- 2.45- 7.03- 7.65-10.79- 7.47-15.90-14.12-15.71- 8.49- 1.43+ 1.88+ 1.66+ 1.64+ 4.57

Case S. M.

N/P

14.0730.6354.9224.7626.9718.3145.0434.0230.6229.89

Actual P-P with Ca

-0.149-0.217-0.256- 1.045-1.048-2.617-2.540-1.880-0.825-1.028-1.215

0000

- 1.425-0.088-1.732

N

- 0.04- 1.52- 0.48+ 2.36- 0.60-20.71-32.97-35.56-30.45-25.59-31.26-15.38- 6.99+ 0.33+ 1.49-18.35-16.54-13.05

N/P

0.277.011.88

0.577.91

12.9818.9136.9024.9025.72

12.8818.79

7.53

Average

109

30.9 13.56


two65

.432

FIG. 9. PATIENT S. M. EFFECT OF ACTHON NITROGEN, PHOSPHORUS,POTASSIUM, BALANCESAND BODYWEIGHT


a

4

lERw

4 p~

S

IMA

3~~~~~~~~~~~~~~~~~~~~~~~~~......,..

1'2 '31 '45 66'7'8 9 10 11 12'13'14 15'16'17'18FIVE - DAY PERIODS

FIG. 10. PATIENT S. M. EFFECTOFACTHONCALCIUMANDPROSPHORUSBALANCES AND THE CONCENTRATIONOF CALCIUM AND PHOSPHORUSIN

SERUM


110

ICTN.@OuIOA,£IhtACT" *Ct0 O""AYYAC"tC Wo |

PHOSPHORUSBALANCE_-..-- ---______aseI £.wTm

2............I~~~~~~~~~~~~~~~~~~~IX X IIIVIII mi I.

---i_____ _ CALCIWd BALANCE II ,I!-, -

I I

a

II h In I ix i II -.

ACT" 100M^tu&

L.. IItI

MEITABOLIC STUDY IN MULTIPLE MYELOMADURING ACTH THERAPY

FIG. 11. PATIENT S. M. EEFFCT OF ACTHON SODIUM CHLORIDE ANDPOTASSIUMBALANCES


by a period of nitrogen equilibrium. The responseto ACTHat a dosage of 40 mg. per day intra-muscularly was prompt. Urinary nitrogen in-

creased markedly and the nitrogen balance becamestrongly negative (Table I). The patient con-tinued to lose nitrogen in progressively increasing

FIG. 12. PATIENT S. M. EmcT OF ACTHON SERUMAND URINARYPROIN

III


:.0

%t;

) 0s -_q tX_; _4 U_

U)

o ) Ue0 U). 00

0\ 0

I

0010

I e U

e

-0 '0 0

I c I aI

00

Cqa0 0 0

00 0% C

0 0 U) 0 0

- -0 -

e' - U)

- o X4

0 0 U) U)U) 00 t.. I'0

*0 *6 *. a.

0%

V-

U)

10

0

-4

(-

0

'0

UoU)

a-.

~o9-xU)

eq-

-4

Cs

Uo

0

00U)

0

0%

-4

U)

(qW)

Cg

)

-

-

*. .%

vo o

-

o+ oE o~

eq

-)

eq

*;

-

so

-

0%e

f

U) U)

00 00

-

U)

-

0

0~~~ o*- a* *

u e, .14 e t CR>etRX8 8

112

mU

m-*

x4

ng%

1-:1

uiCIP)

irzU)C)

1-45- %) .2" co94 >b4m U.

Q'.4 %Z.,.9 m-3; 4.Q

.A:b19

I.

I

METABOLIC STUDY IN MULTIPLE MYELOMADURING ACTH THERAPY 113

"̂aw| b I U)o I I II

-x1 - - - I

gol co oU U 000 f) c.

F.

H. 00WWq q

t- coW o 4

0. 0) 0 0

C4o _o _ o c

ffi u0 - 0 tb

-IX0E ¢E X0 -EX XI

rz~~~~~~ _ eq '000~~~~~~~~~~~~~~~0

' 00 00

U) 0 U)~~~~, 0eXUbl 0 >if 00b'0bU0 if 0 0 t' ei '

U<4-l -U S4 a 40 e 0U X 00

M-4au-) V-if ~ 44 if)if


FIVE- DAY PERIODS

FIG. 13. PATIENT S. M. EFFECT OF ACTHON SERUMURIC ACID AND EXCRETIONOF URICACID IN URINE

amounts for the next 15 days when the study hadto be discontinued due to an acute intercurrent in-fection.

B. Calcium balance: The average calcium intakewas 624 mg. per day with a calcium/phosphorusratio of 0.6. The calcium balance was consistentlynegative since the amount excreted in the stoolwas slightly in excess of the intake. (Figure 2and Table I.) Urinary calcium averaged 50 to 60mg. during control periods but increased con-siderably while the patient was receiving ACTH(Table III). Whether this increase should beattributed to ACTHor to the acute inflammatoryprocess from which he ultimately succumbed isuncertain. There were no important changes inthe concentration of serum calcium, and fecal ex-cretion of calcium remained relatively constant.

C. Phosphorus balance: The administration ofACTHincreased both the urinary and fecal ex-cretion of phosphorus and the balance becamestrongly negative. (See Figure 1 and Table I.)The theoretical phosph6rus balance and the ni-trogen/phosphorus ratios have not been reportedfor this patient since the balance study was short

and complicated in its terminal phases by an acutefebrile illness.

D. Sodium, chloride, and potassium balances:Moderate losses of sodium unaccompanied by simi-lar losses of chloride occurred in control periods.During the first period on ACTH both sodiumand chloride were retained in large amounts (Fig-ure 3 and Table I). Chloride continued to be re-tained in the second ACTH period although inmuch smaller amounts. "Escape" from the effectof the hormone occurred in the final period withrelease of large and approximately equivalent quan-tities of both elements. The potassium balancefollowed that of nitrogen rather closely and wasstrongly negative during administration of corti-cotropin. No significant changes in the concen-tration of serum electrolytes occurred.

E. Serum proteins: Prior to therapy withACTH the concentration of serum protein aver-aged 12 Gm. per cent, of which 7.5 Gm. per centprecipitated as globulin at 18.5 per cent saturationwith sodium sulphate (Figure 4). After ten daystreatment with corticotropin, the globulins separat-ing at 18.5 per cent saturation were reduced to 4

114


Gm. per cent and the total serum protein had de-creased to approximately 8 Gm. per cent.

F. Urinary proteins: The amount of protein ex-creted in the urine of J. D. was much less than thatof the other two patients, although his concentra-tion of serum proteins was the highest. Despitethe marked catabolic effect associated with ACTH

therapy and decrease in concentration of serumprotein, the urinary protein upon termination oftreatment continued to be excreted at about two-thirds of the control level (Figure 4 and Table II).More prolonged and intensive administration ofACTHwas accompanied by greater proportionatereductions in the proteinuria of J. M. and S. M.

TABLE VII

Nitrogen, cakium, phosphorus, and ekctrolyte balances *S. M. Age 56 Male

P PCa Theoretical Actual N Na K Cl

Period Therapy Weight5 days ca. (daily) Gm. mEq. Kg.

I Control -1.021 -0.459 -0.605 - 0.04 +100.86 + 19.35 + 86.10 68.61II Control -1.026 -0.560 -0.677 - 1.52 - 36.29 + 3.15 + 7.10 68.54

III Control -0.619 -0.312 -0.536 - 0.48 + 50.84 + 12.55 + 76.20 68.38IV 100 mg.ACTH -0.729 -0.170 -1.375 + 2.36 +145.19 - 28.85 +124.20 69.45V 100 mg. ACTH -1.039 -0.506 -1.514 - 0.60 + 22.58 - 22.85 + 39.30 69.39

VI 200 mg. ACTH -1.701 -2.163 -3.380 -20.71 +156.78 -199.40 + 77.80 69.00VII 200 mg. ACTH -1.173 -2.80 -3.066 -32.97 +103.45 -111.25 + 0.20 68.16

VIII 200 mg. ACTH -0.962 -2.85 -2.310 -35.56 -139.57 +165.95 -132.10 66.18+K(1)

IX 100 mg. ACTH -0.884 -2.47 -1.225 -30.45 +104.55 +161.25 +213.10 66.25+K(2)

X 100 mg. ACTH -1.044 -2.208 -0.349 -25.59 +175.98 - 86.55 + 88.30 66.33XI 100 mg. ACTH -1.201 -2.659 -1.754 -31.26 -130.63 -103.35 -223.30 65.46

XII 100 mg. ACTH -1.222 -1.588 +0.161 -15.38 -256.11 +335.75 - 66.70 63.6550 mg. Testosterone

+K(3)XIII 100 mg. ACTH -1.144 -0.988 +0.226 - 6.99 +219.94 - 31.55 +225.50 65.51

50 mg. TestosteroneXIV 100 mg. ACTH -1.163 -0.50 +0.210 + 0.33 +270.28 + 23.05 +159.70 67.53

50 mg. TestosteroneXV 100 mg. ACTH -0.922 -0.312 +0.303 + 1.49 - 26.66 + 10.18 -112.70 67.88

+K(4)XVI 100 mg. ACTH -0.915 -1.658 -1.835 -18.35 -109.58 - 94.45 - 7.40

XVII Control -0.600 -1.394 -.0.357 -16.54 -626.22 +776.25 - 73.00+K(5)

XVIII Control -0.786 -1.240 -2.084 -13.05 +105.09 - 83.75 + 55.20 65.62

* In computation of these balances average values for dietary intake and fecal excretion have been employed (actualanalyses of both diet and stool having been carried out every five-day period). The diet was calculated to contain69 Gm. of protein, 108 Gm. of fat, and 170 Gm. of carbohydrate, and 1930 calories per day. The average values perfive-day period were as follows:

Calcium (Gm.)Phosphorus (Gm.)

Nitrogen (Gm.)Sodium (mEq.)

&Potassium (mEq.)Chloride (mEq.)

Diet

2.9624.885

55.05675.15 (Per. I-VI)506.5 (Per. VII-XVIII)336.25

648.0 (Per. I-VI)480.5 (Per. VII-XVIII)

Fecal excretion

2.8901.110 (Per. I-III)2.565 (Per. IV-XVIII)6.50

10.0

36.35 (Per. I-Ill)72.0 (Per. IV-XVIII)

4.0

* The dietary potassium was supplemented as follows:Period mEq. of potassium per period

VIII-K(1) 409.6 potassium citrate orallyIX-K(2) 614.4 potassium citrate orally

XII-K(3) 614.4 potassium citrate orallyXV-K(4) 53.7 potassium chloride intravenously

XVII-K(5) 1024.0 potassium citrate orallyNote: Somefood was rejected in Periods XV-XVIII inclusive. The rejects were pooled

for each period, analyzed, and appropriate corrections of the intake were made.

115


Patient J. M.

A. Nitrogen balance: On admission the patientweighed 64.8 Kg. and was in slightly negativenitrogen balance, while ingesting a daily diet of1,919 calories and 68.8 Gm. protein (Table IV).The loss of nitrogen increased slightly when hewas given 40 mg. of ACTHa day intramuscularly.The daily dose of corticotropin was then increasedto 80 mg. with a further moderate increase in theloss of nitrogen (Figure 5). The dose of ACTHwas then reduced to the initial level of 40 mg. perday with gradual decrease in urinary nitrogen un-til equilibrium was established at the end of tendays. No further change in nitrogen balance wasobserved when hormone was discontinued.

B. Calcium balance: Calcium intake averaged1200 mg. per day with a calcium/phosphorus ratioof 0.81 and hence conformed to currently acceptedstandards for optimum dietary requirements.Both the concentration of calcium in serum andthe amount excreted in the urine decreased some-

what during ACTHadministration (Figure 6 anuTable III). Fecal calcium, on the other hand, in-creased moderately so that the net balance was

negative both during the control periods and dur-ing periods of therapy (Figure 8). However, theloss of calcium was greater during the initial con-

trol periods than at any other time.C. Phosphorus balance: Administration of

ACTHin amounts of 40 and later 80 mg. per daywas associated witb a negative phosphorus balance(Figure 5 and Table IV). It was of some interestthat the excretion of phosphorus in urine did notincrease appreciably and that the loss of phosphoruswas largely the result of a considerable increase infecal phosphorus (Figure 8). Computation of thetheoretical phosphorus balance and the nitrogen/phosphorus ratios suggested that during periodsof corticotropin therapy a tissue poor in phos-phorus was being catabolized (Tables IV and V).

D. Serum proteins: The alpha globulin com-

ponent of the serum proteins was markedly in-creased initially, averaging 3 Gm. per cent. Therewas a gradual decrease in this fraction during thecourse of ACTHadministration to a final value of2.0 Gm. per cent (Figure 7).

E. Urinary proteins: The urinary protein(Bence-Jones) decreased during therapy from an

average control value of 17.7 Gm. in 24 hours to

4.4 Gm. in period IX. Thereafter, with a decreasein the dose of ACTHfrom 80 to 40 mg. per daythere was a small and probably insignificant in-crease in urinary protein (Table II).

Patient S. M.A. Nitrogen balance: The patient weighed 68.6

Kg. at the outset of the balance program and in-gested a diet providing approximately 1,930 cal-ories and 69 Gm. of protein a day. On this regimenhe was essentially in nitrogen equilibrium during thefirst three control periods and during the first twoACTHperiods when he received 100 mg. of hor-mone daily. However, upon increasing the doseto 200 mg. a day, a marked catabolic effect was ob-served, and this effect continued despite reductionin the dose from 200 to 100 mg. in periods IX, X,and XI. Administration of 50 mg. of testosteroneproprionate daily (periods XII through XIV)gradually reversed the strongly negative nitrogenbalance and brought about nitrogen equilibriumdespite continuation of ACTHin amounts of 100mg. (Figure 9 and Table VII).

B. Calcium balance: The average daily calciumintake was 590 mg. and the calcium/phosphorusratio was approximately 0.6. The amount of cal-cium intake and calcium/phosphorus ratio weresomewhat suboptimal according to current con-cepts of calcium requirement (27). However,there is no reason to suppose that a normal subjectingesting a similar diet would have been in negativecalcium balance. Nevertheless, the patient was inconsistently negative calcium balance throughoutcontrol periods and periods of ACIH administra-tion. Urinary calcium was reduced from an aver-age daily control value of 223 mg. to 175 mg. dur-ing ACTHperiods IX, X, and XI (Table III).The concentration of serum calcium fell progres-sively from a control value of 10.1 mg. per cent toa low of 7.2 mg. per cent (Figure 10 and TableVI). The latter value was observed when theconcentration of the serum proteins had fallen to4.7 Gm. per cent and was quite possibly related tothe hypoproteinemia. Fecal excretion of calciumremained relatively constant (Figure 8) .

C. Phosphorus balance: The administration ofACTH increased both the urinary and fecal ex-cretion of phosphorus, and the balance becamestrongly negative (see Figures 9 and 10). As withpatient J. M., the theoretical phosphorus balance

116


was calculated according to the method of Reifen-stein, Albright, and Wells (28) (See Tables V andVII). During the first three periods (Control)there was very little unaccountable phosphorus.In the next four ACTHperiods, there were lossesof phosphorus in excess of what one would predictfrom the nitrogen and calcium balances, suggestingcatabolism of a phosphorus rich tissue. Thesewere followed by four periods (VIII, IX, X, andXI) when the theoretical phosphorus balance wasmore negative than the actual phosphorus balanceand hence possibly indicated catabolism of tissueof low phosphorus content. The simultaneous ad-ministration of both testosterone propionate (50mg. per day) and ACTH (100 mg. per day) ledto phosphorus retention in spite of a continuednegative calcium balance and nitrogen equilibrium(Periods XII through XV). Thus, it is apparentthat under the experimental conditions the anaboliceffect of testosterone was exhibited more stronglywith respect to phosphorus than to nitrogen.Whether this points to resynthesis of myelomatissue or has a different explanation cannot be de-termined from the information available.

When the concentration of potassium in the se-rum fell below 3 mEq. per liter during ACTHtherapy, extra potassium as citrate was given onthree separate occasions (see Figure 9). Theurinary phosphorus decreased each time coincidentwith potassium administration. The ingestion ofpotassium did not alter the nitrogen balance whichremained strongly negative and hence in this re-spect also did not parallel the phosphorus exchange.

D. Sodium, chloride, and potassium balances:The response to prolonged ACTHadministrationwas variable and complicated as shown by the so-dium and chloride balances (Figure 11 and TableVII). An initial strongly positive salt balanceoccurred in Period IV when the hormone was firstgiven and was followed by a state approachingequilibrium in Period V. With the increase inACTH dose to 200 mg. per day in Period VI,salt retention again became marked, only to befollowed by salt loss in Period VIII. It seemsprobable that the negative balance in the latter pe-riod represented "escape" at least in part from theaction of the hormone since the increase in uri-nary sodium and chloride preceded ingestion ofsupplementary potassium. Although administra-

tion of potassium was continued into Period IX,a cycle of salt accumulation developed again whichlasted through most of Period X. The reversephenomenon was noted in Periods XI and XII.Thus, the entire duration of ACTHand testoster-one therapy seems to have been characterized byalternating cycles of salt retention and loss whichmay well be related to the transient shifts of water,sodium, and chloride into the extracellular spaceas described by Levitt and Bader (29). The finaldiscontinuance of ACTH in Period XVII wasdictated by a toxic psychosis and hypopotassemiafor which potassium citrate was given for the thirdtime in doses equivalent to 8 Gm. of potassiumdaily. As a result, more than 700 mEq. of po-tassium were retained and 600 mEq. of sodiumwere lost in five days. The effect on the chloridebalance was comparatively minor and amountedto a negative balance of 73 mEq. As sodium andchloride loss and potassium retention are distinctivefeatures of ACTHwithdrawal, it is probable thatthe unusually large storage of potassium may havepromoted a loss of cell sodium and, therefore, anexceptionally large sodium diuresis. The usualexcretion of potassium in excess of intake wasobserved during administration of corticotropin(Figure 11). Extra potassium as citrate was givenorally in Periods VIII, IX, XII, and XVII, andas chloride intravenously (Period XV) to combathypopotassemia. Although potassium was retainedduring the time of administration of each supple-ment, the effect on the concentration in serum wasfleeting.

E. Serum proteins: This patient was the onlyone of the three who had a relatively normal pat-tern of plasma proteins, both by electrophoresisand by the method of salt fractionation (see TableVI). At the outset of the balance study the gammaglobulin components were slightly elevated. How-ever, during prolonged administration of ACTHthe concentrations of both albumin and globulindecreased progressively (Figure 12) and a mod-erate hypoproteinemia developed. Simple dilu-tion was not considered to be a causal factor sincethe value of the packed erythrocytes remained es-sentially unchanged, and the body weight decreased.

F. Urinary proteins: There was a significantreduction in the excretion of Bence-Jones proteinin the urine (Figure 12). An average of about 9

117


Gm. of protein was recovered per day from theurine during control periods and there was littlechange after administering ACTHfor ten days indaily doses of 100 mg. When the dose of ACTHwas increased to 200 mg., the proteinuria decreasedafter eight days to approximately 2.0 Gm. per day,and by the fifteenth day from 0.7 to 0.8 Gm. perday, within which range it remained until the pa-tient left the hospital two months later (Table II).

G. Uric acid: Quantitative determinations ofthe excretion of uric acid were made only in thecase of S. M. (Figure 13). The control value av-eraged 497 mg. per day (Period III) just prior toadministration of ACTH, and increased to a maxi-mumdaily average of 1021 mg. in Period VIII.While there were marked fluctuations in theamounts eliminated during 24 hours, the highestrates of excretion coincided fairly well with thelarger doses of adrenocorticotropin. The concen-tration of uric acid in the serum decreased pro-gressively from 12.0 mg. per cent to 4 mg. per cent.

DISCUSSION

Response to therapyIt has been suggested that the variable response

of different patients with multiple myeloma tochemotherapeutic (and hormonal) agents maypoint to different chemical mechanisms within themyeloma cells and that the diverse plasma proteinpatterns may be an expression of these cellular pe-culiarities (3). Although our patients revealed nouniform derangement in the plasma protein com-ponents, all responded similarly to adrenocorti-cotropin. One patient had considerable increasein the plasma protein fraction which "salted" outas gammaglobulin.8 In another, the alpha globu-lin fraction was distinctly increased, and in a thirdthe several components were essentially normalin distribution. Bence-Jones proteinuria, how-ever, was a characteristic finding in each and wasmarkedly decreased during therapy in two pa-tients and slightly decreased in the third. Theconcentration of plasma protein fell also, withthe most pronounced effect on the abnormal globu-

8 Salt fractionation was utilized to partition the variousplasma protein components. Admittedly, errors are in-herent in the method and the designation of globulins asalpha, beta, or gamma refers only to the fact that theseproteins "salted" out as alpha, beta, or gamma fractions.

lin fraction in the two patients who exhibited thisdeviation. The regression in Bence-Jones pro-tein in the urine did not strictly parallel the de-crease in plasma protein, but in one patient, S. M.,appeared to be more closely related to the develop-ment of a strongly negative nitrogen balance. Thefailure of some investigators to observe changes inplasma protein or proteinuria in myeloma may in-dicate inadequate dosage or duration of applicationof the therapeutic agent rather than refractorinessof the disease. This seems to be born out in theresponse of J. M. and S. M. who showed little ef-fect of treatment with small doses of adrenocorti-cotropin and definite effects when the dosage wassubstantially increased.

Calcium and phosphorus exchangesSkeletal decalcification in multiple myeloma is

commonly observed as a late manifestation of thedisorder and appears in part in the form of dis-crete osteolytic lesions and in part as generalizedosteoporosis. The discrete areas of decalcificationare produced by nests of tumor cells which causereabsorption of the surrounding bone salts. Thedegree of calciuria may well be a reflection of thisprocess (30, 31), and as such, an indication of theactivity and extensiveness of the disease. Whenhypercalcemia occurs one may suspect, as sug-gested by Albright and Reifenstein (32), that thedissolution of bone salts is contributing calcium tothe blood stream at a more rapid rate than it canbe cleared by the kidneys. Since renal function isoften seriously impaired in the terminal phases ofmyeloma, both hypercalcemia and hyperphospha-temia may occur without marked hypercalciuria.This appears to have been the situation in thecase studied by Bulger, Dixon, and Barr (5).Another factor in our patients which may havecontributed to the loss of calcium, was the pres-ence of bone pain and pathological fractures intwo individuals, J. M. and S. M. Both were rela-tively inactive and spent a considerable portion oftheir time in bed prior to therapy. Some of thedecalcification in these men could well have beenthe result of the partial immobilization associatedwith their discomfort, since this in itself leads tonegative calcium balance even in healthy subjects(33). None of the three had serious impairment

of renal function nor hypercalcemia. The excretion

118


of calcium in urine was greatest in J. M. (291 mg.per day) during his control periods when, be-cause of a recent collapse of a vertebral body, hewas obliged to remain practically immobile in bed.J. D., on the other hand, had little bone pain andwas quite active during control observations. Hisurinary calcium was the lowest of the three andaveraged 13 mg. per day prior to treatment. Al-though ACTH is considered to have a cataboliceffect on bones (26) as well as other tissues, asevinced by production of negative balances underintensive therapy, it appeared to increase the rateof decalcification only in J. D. The other two pa-tients who became more active due to euphoria,increased feeling of well-being, and later toxicpsychosis associated with the administration of thehormone, showed a moderate decrease in calciuria.The possibility must not be overlooked that a re-cession in the activity of the tumor growth mayhave been a contributing factor also. In favor ofthis was the observation that Bence-Jones protein-uria was greatly lessened in both these men, muchmore so than in patient J. D. In one, S. M., therewas a gradual fall in the level of serum calcium,but whether this represented a decrease in the ac-tivity of the osteolytic process or in the calciumbinding by plasma protein, which also decreasedin concentration, is not clear. Loss of calciumfrom the body appears to have been mainly byexcretion in the urine, since fecal excretions wereon the average nearly equal to intake. However,in J. M. the mean fecal calcium increased duringthe periods of ACTH therapy, while in S. M. itrevealed only the usual period-to-period fluctuation.

In the case of phosphorus, ACTHnot only in-creased the amount in the urine, but also that ap-pearing in the stools. This was particularly notice-able in patient S. M. who about tripled his excre-tion of fecal phosphorus during the time the largerdoses of hormone were given (Figure 8A and B).Excessive amounts of calcium did not appear inthe stools of this man so that the shift in partitionof phosphorus from urine toward feces cannot berelated to calcium. It is of some interest that theexcretion of phosphorus in urine was sharply re-duced during those days when a positive potassiumbalance was achieved by the ingestion of potassiumcitrate. The possibility that the decrease in uri-nary phosphorus resulted from alkalinization in-

duced by potassium citrate must be considered.While it is generally conceded that acidosis in-creases the excretion of urinary phosphate, theobservations of Pitts and Alexander (34) on thedog do not support the view that the converse isproduced by alkalosis. It would seem that thephosphate buffer system is equally important,both in states of acidosis and alkalosis and thatthe availability of phosphorus might be the majorfactor determining its excretion. The interde-pendence of potassium and phosphorus in cellu-lar metabolism may have required retention of thelatter when potassium was entering cells. Thecatabolic effect on nitrogen excretion, however,was not abolished by potassium and in this respectdiffered from the action of potassium chloride inthe rat, as reported by Whitney and Bennett (35).

The agitation and anxiety which had graduallydeveloped on prolonged treatment of two patientswith adrenocorticotropin and which was at firstsuspected to be associated with the hypopotassemia,seemed to be little influenced by potassium reten-tion accompanying supplementation of the diet, andwe were unable to confirm the temporary im-provement in psychotic behavior reported (36)when potassium deficiency was relieved. It is truethat the concentration of potassium in the serumincreased each time the element was ingested inlarge doses, but there was no salutary effect onthe patient's behavior. Possibly, more prolongedor more vigorous potassium therapy was indi-cated and in view of the observations of others (36)would seem to warrant further investigation.

Although one of our three patients has sustaineda remission in the course of his disease, the au-thors wish to emphasize that no conclusion shouldbe drawn as to the therapeutic benefit of ACTHinmultiple myeloma.

SUMMARY

1. Three cases of multiple myeloma are reportedin whomthe effect of administration of ACTHwasobserved during hospitalization in the MetabolicUnit.

2. Decreases in the concentration of serum pro-teins were observed in all three patients duringtherapy. In two, the effect was mainly on theabnormal globulin, while in the third all compo-nents of the serum proteins decreased. Proteinuriaalso decreased and in one patient at least, the di-

119


minished excretion of protein appeared to coin-cide with the development of a strongly negativenitrogen balance during administration of ACTH(Patient S. M.).

3. Negative phosphorus balances were notedduring the course of treatment in all instances.However, the dose required to produce this effectvaried considerably from individual to individual.In general, the phosphorus exchange was not re-markable except for marked decrease in urinaryphosphorus which occurred in periods when sup-plementary potassium was administered because ofpotassium deficiency.

4. Calcium balances were consistently negativein the two subjects who excreted the larger quan-tities of calcium in the urine. Subject J. D. wasin calcium equilibrium during the preliminary pe-riods of observation, and the balance became nega-tive only during ACTHadministration. ACTHdid not appear to increase calcium excretion in theother two patients. The serum calcium of one in-dividual (S. M.) decreased in approximate pro-portions to the decrease in concentration of his se-rum proteins.

5. The ingestion of 200 mEq. per day of extrapotassium relieved the hypopotassemia which wasobserved during the therapy of S. M. but did notrelieve a concomitant mild toxic psychosis.

6. ACTH therapy was associated with a re-mission in one subject (S. M.) which has con-tinued for more than two years, but since continuedevidence of the myelomatous process is still presentin the bone marrow, the disease cannot be con-sidered cured.

ACKNOWLEDGMENT

The authors wish to acknowledge the editorial assistanceof Mrs. Hans Jordan and her contribution in the trans-lation of bibliographical material. They are also indebtedto Mr. William J. McCandless, Mrs. Pauline Schatz,Mrs. Betty Yost, and Mrs. Frances Davis for technicalassistance, and to Miss Sophie Bloom for the preparationof the manuscript.

REFERENCES

1. Adams, W. S., Bassett, S. H., Goldman, R., andLawrence, J. S., The use of ACTH in multiplemyeloma. Veterans Administration Conference onCortisone Research, A symposium, August 1950,Washington, D. C., Merck & Co., 1951, 69.

2. Pearsan, 0. H., Eliel, L. P., and Talbott, T. R., Jr.,The use of ACTHand cortisone in neoplastic dis-

ease. Bull. New York Acad. Med., 2nd Series,1950, 26, 235.

3. Engle, R. L., Jr., and Barr, D. P., Multiple myelomatreated with ACTH. Proc. of the Second Clin.ACTH Conf., J. R. Mote, ed., N. Y., Phila.,Blakiston Press, 1951, 2, 209; Bethell, F. H., Dis-cussion of Engle, R. L., and Barr, D. P., Multiplemyeloma treated with ACTH. Ibid., 1951, 2, 216.

4. Thorn, G. W., Forsham, P. H., Frawley, T. F., Hill,S. R., Jr., Roche, M., Staehelin, D., and Wilson,D. L., The clinical usefulness of ACTHand corti-sone. New England J. Med., 1950, 242, 824.

5. Bulger, H. A., Dixon, H. H., and Barr, D. P., Thefunctional pathology of hyperparathyroidism. J.Clin. Invest., 1930, 9, 143.

6. Blatherwick, N. R., Calcium and Bence-Jones proteinexcretion in multiple myeloma. Am. J. M. Sc.,1916, 151, 432.

7. Seegelken, C., Ueber multiples Myelom und Stoff-wechseluntersuchungen bei demselben. DeutschesArch. f. Klin. Med., 1897, 58, 276.

8. Williams, 0. T., Some observations on the nature ofthe Bence-Jones' protein. Biochem. J., 1911, 5, 225.

9. Hopkins, F. G., and Savory, H., A study of Bence-Jones protein, and of the metabolism in three casesof Bence-Jones proteinuria. J. Physiol., 1911, 42,189.

10. Allard, E., and Weber, S., Ueber die Beziehungender Bence-Jonesschen Albumosurie zum Eiweiss-stoffwechsel. Deutsche Med. Wochenschrift, 1906,32, 1251.

11. Currie, R. A., Case of Bence-Jones proteinuria, withnote on urinary excretion of mineral elements.Glasgow M. J., 1927, 107, 31.

12. Washburn, M. L., and Shear, M. J., Composition ofbone; XIII. Direct gravimetric determination ofCa, Mg, and PO. J. Biol. Chem., 1932, 99, 21.

13. Van Slyke, D. D., and Sendroy, J., Jr., Gasometric de-termination of oxalic acid and calcium, and its ap-plication to serum analyses. J. Biol. Chem., 1929,84, 217.

14. Fiske, C. H., and Subbarow, Y., The colorimetric de-termination of phosphorus. J. Biol. Chem., 1925,66, 375.

15. Hiller, A., Plazin, J., and Van Slyke, D. D., A studyof conditions for Kjeldahl determination of nitro-gen in proteins. Description of methods with mer-cury as catalyst, and titrimetric and gasometricmeasurements of the ammonia formed. J. Biol.Chem., 1948, 176, 1401.

16. Eisenman, A. J., A note on the Van Slyke method forthe determination of chloride in blood and tissue.J. Biol. Chem., 1929, 82, 411.

17. Harvey, S. C., The quantitative determination of thechlorides in the urine. Arch. Int. Med., 1910, 6,12.

18. Van Slyke, D. D., The determination of chlorides inblood and tissues. J. Biol. Chem., 1923, 58, 523.

120


19. Howe, P. E., The determination of proteins in blood-a micro method. J. Biol. Chem., 1921, 49, 109.

20. Majoor, C. L. H., The possibility of detecting indi-vidual proteins in blood serum by differentiation ofsolubility curves in concentrated sodium sulfatesolutions. II. Comparison of solubility curves withresults of electrophoresis experiments. J. Biol.Chem., 1947, 169, 583.

21. Hiller, A., Greif, R. L., and Beckman, W. W., De-termination of protein in urine by the biuret method.J. Biol. Chem., 1948, 176, 1421.

22. Kalckar, H. M., Differential spectrophotometry, ofpurine compounds by means of specific enzymes.I. Determination of hydroxypurine compounds. J.Biol. Chem., 1947, 167, 429.

23. Praetorius, E., An enzymatic method for the deter-mination of uric acid by ultraviolet spectrophotom-etry. Scandinav. J. Clin. & Lab. Invest., 1949, 1,222.

24. Lfidin, H., Zur Kenntnis der Eiweissstoffwechsel-st6rung beim Plasmocytom. Schweiz. med.Wchnschr., 1947, 77, 190.

25. Wuhrmann, F., Wunderly, C., and Wiedemann, E.,Ueber das alpha-globulin-plasmocytom. Schweiz,med. Wchnschr., 1948, 78, 180.

26. Sprague, R. G., Power, M. H., Mason, H. L., Albert,A., Mathieson, D. R., Hench, P. S., Kendall, E. C.,Slocumb, C. H., and Polley, H. F., Observations onthe physiologic effects of cortisone and ACTH inman. Arch. Int. Med., 1950, 85, 199.

27. Hawley, E. E., and Maurer-Mast, E. E., The futida-mentals of nutrition, Springfield, Ill., Charles CThomas, 1940, Chapter IV, The normal diet, p. 51.

28. Reifenstein, E. C., Jr., Albright, F., and Wells, S. L.,The accumulation, interpretation, and presentationof data pertaining to metabolic balances, notably

those of calcium, phosphorus and nitrogen. J. Clin.Endocrinol., 1945, 5, 367.

29. Levitt, M. F., and Bader, M. E., Effect of cortisoneand ACTHon fluid and electrolyte distribution inman. Am. J. Med., 1951, 11, 715.

30. Laszlo, D., Schulman, C. A., Bellin, J., Gottesman,E. D., and Schilling, A., Mineral and protein metab-olism in osteolytic metastases. J. A. M. A., 1952,148, 1027.

31. Schilling, A., and Laszlo, D., Rate of urinary calciumexcretion following its intravenous administration asan indicator of bone metabolism. Proc. Soc. Exper.Biol. & Med., 1951, 78, 286.

32. Albright, F., and Reifenstein, E. C., Jr., The para-thyroid glands and metabolic bone diseases. Se-lected Studies. Baltimore, Williams & Wilkins Co.,1948.

33. Whedon, G. D., Deitrick, J. E., and Shorr, E., Modi-fication of the effects of immobilization upon meta-bolic and physiologic functions of normal men bythe use of an oscillating bed. Am. J. Med., 1949,6, 684.

34. Pitts, R. F., and Alexander, R. S., The renal reab-sorptive mechanism for inorganic phosphate in nor-nal and acidotic dogs. Am. J. Physiol., 1944, 142,648.

35. Whitney, J. E., and Bennett, L. L., Inhibition of thecatabolic effect of adrenocorticotropic hormone(ACTH) in rats by a diet high in potassium chlo-ride. Endocrinol., 1952, 50, 657.

36. Ransohoff, W., Brust, A. A., Reiser, M. F., Mirsky,I. A., and Ferris, E. B., The effect of sodium andpotassium on the metabolic and physiologic re-sponses to ACTH. Proceedings of the SecondClin. ACTH Confer., J. R. Mote; N. Y., Phila.,Blakiston Co., 1951, 1, 160.

SPECIAL NOTICE TO SUBSCRIBERSPost Offices will no longer forward the Journal when you move.

Please notify The Journal of Clinical Investigation, BusinessOffice, 622 West 168th Street, New York 32, N. Y. at once whenyou have a change of address, and do not omit the zone number ifthere is one.

121

Documents

University California Angeles,dm5migu4zj3pb.cloudfront.net/manuscripts/102000/102877/JCI5410… · Bence-Jones protein was pres-ent in the urine and sternal marrow was heavily infil-trated