ACID-BASE EQUIVALENCEOF THE BLOODIN DISEASES ASSO-CIATED WITH HYPERGLOBULINEMIA; WITH SPECIAL

REFERENCETO LYMPHOGRANULOMAIN-GUINALE ANDMULTIPLE MYELOMA

BY ALEXANDERB. GUTMAN, ETHEL BENEDICT GUTMAN, RUTHJILLSONAND RUSSELLD. WILLIAMS

(Fromn the Department of Medicine, College of Physicians and Surgeons, Columbia University,and the Presbyterian Hospital, New York City)

(Received for publication April 10, 1936)

Attention was called recently (1) to the occur-rence of hyperproteinemia in patients with lympho-granuloma inguinale. Thirty-five cases havenow been examined, in 26 of whom the proteincontent of the serum exceeded 8.0 per cent (TableI). Williams and Gutman (1, 2) pointed out thatthe hyperglobulinemia observed in lymphogranu-loma inguinale would account, in part, for twointeresting phenomena associated with the disease:the increased erythrocytic sedimentation rate,often greatly in excess of that consistent withthe degree of obviously active infection; and anti-complementary properties of the serum, demon-strable in a significant proportion of these pa-tients.

It is desired here to call attention to anotherpeculiarity of the blood in lymphogranuloma in-guinale, thought also to be related to hyperglobu-linemia. Electrolyte partitions of the blood inthis disease (Table II) revealed that in every in-stance in which the serum protein was 9.0 percent or over, there was an associated discrepancyin acid-base equivalence: the sum of the deter-mined acid equivalents exceeded the total base,B-A appeared to be negative.' Further in-vestigation showed that a similar discrepancy inacid-base balance of the blood obtained in diseasesother than lymphogranuloma inguinale in whichthere was marked hyperglobulinemia. It wouldappear from our data that an apparent excess oftotal determined acid equivalents over total baseis, in fact, a peculiarity common to most bloodswith definite hyperglobulinemia, irrespective ofetiology.

1 B -A means total base (m.eq. per liter) minustotal determined acids (m.eq. per liter). As organicacids and sulfate are not determined, B-A should bepositive.

METHODS

Fifty to 60 cc. of blood, collected under mineral oil byvenipuncture as rapidly as possible and with minimalstasis, were delivered under oil into 50 cc. narrow neckcentrifuge tubes. After sealing with rubber caps, theblood was allowed to clot, then centrifuged under oil.Duplicate samples of serum were withdrawn into 1 cc.stopcock pipettes for determination of C02 content by themethod of Van Slyke and Neill (3). A pH of 7.35 wasassumed in the calculation of bicarbonate from the ob-served C02 content of the serum.

The remainder of the serum was then removed andanalysed for the following constituents, all determinationsbeing made in duplicate except in a few instances wherethe amount of serum available was insufficient. Chloridewas determined on 1 cc. samples by the method of VanSlyke and Sendroy as modified by Wilson and Ball (4).Phosphate was determined by the method of Kuttner andLichtenstein (5) on duplicate samples of the trichloro-acetic acid filtrate obtained from 1 cc. of serum. De-termination of protein was made on 1 cc. samples bydifference, using the macro-Kjeldahl technique for esti-mation of the total nitrogen and Folin's method withNesslerization for estimation of nonprotein nitrogen.Albumin, globulin, euglobulin, and pseudoglobulin I andII were estimated in duplicate on 0.5 cc. samples byHowe's method (6), nitrogen being determined by themicro-Kjeldahl technique and titration. Base bound todprotein was calculated as the sum of base bound to al-bumin plus base bound to globulin, using the factors ofVan Slyke, Hastings, Hiller and Sendroy (7). Since apH of 7.35 was assumed throughout,

B protein (in m.eq. per liter) = Albumin (grams perliter) X .273 + Globulin (grams per liter) X .189.

Total base was estimated by determining sodium, potas-sium and calcium and adding to the sum of the milli-equivalents of these cations 2 milli-equivalents (assumed)for magnesium. Recent modifications in the method fordetermination of sodium permit of more accurate resultsby this procedure than by the direct estimation of thetotal base. Sodium was determined by the modificationof Butler and Tuthill (8) of Barber and Kolthoff'smethod, with certain minor changes in procedure byBaxter, Leland and Kurepkat (9). Potassium was esti-

475

476 A. B. GUTMAN, E. B. GUTMAN, R. JILLSON AND R. D. WILLIAMS

TABLE I

Lymphogranuloma inguinale: Serum protein fractions in 35 cases

Pseudo-Frei Wasser- Dmel- Total Albu- Globu- Euglo- globulin Pl afibCase Sex Age Race Clinical findings test mana s r o mi ln bulin

prreaction* action tein ogenI II

grams grams grams grams grams grams gramsyears per per per per per per per

100 cc. 100 cc. 100 cc. 100 cc. 100 cc. 100 cc. 100 cc.

E. A. 9 43 Negro Rectal stricture + - - 11.2 2.9 8.311.210.7 2.9 7.8 4.010.1 3.3 6.8

C. K. 9 34 Negro Chronic glomerulo- + Anti- 10.3 3.1 7.2 3.0 3.3 0.9nephritis. Urethral comp. 8.4 2.3 6.1 2.7stricture 8.3 2.6 5.7

9 Negro Rectal stricture - - 9.5 3.1 6.4 3.0 2.5 0.99.2 3.4 5.8 0.3

E. J. 9 43 Negro Rectal stricture + Anti- 9.5 3.4 6.1 2.3 3.0 0.8comp. 9.3 3.7 5.6

9 Negro Rectal stricture + 9.4 3.6 5.8 2.1 3.0 0.79 Negro Rectal stricture - - 9.4 3.4 6.0 2.3 3.0 0.7

K. W.Negro Elephantiasis vulvae 9.4 3.3 6.1

and rectal stricture 9.3 3.3 6.0 2.6 2.8 0.6F. H. 9 35 Negro Rectal stricture + - 9.2 3.5 5.7D. P. 9 48 Negro Rectal stricture + - - 9.1 4.0 5.1

8.5 3.7 4.8 0.9 3.0 0.9 0.49 Negro Rectal stricture - 9.0 3.6 5.4 1.7 3.0 0.7

C. B. d' 38 Negro Inguinal buboes + + - 8.9 3.8 5.1 2.6E. G. c' 50 Negro Proctitis 4 - - 8.8 3.8 5.0 1.4C. W. 9 49 Negro Rectal stricture + - 8.7 3.3 5.4 1.4 0.5G. J. c' 40 Negro Proctitis 1 + 8.7 3.5 5.2 1.6

8.7 3.6 5.1 1.5G. W. 9 31 Negro Rectal stricture + - - 8.7 3.7 5.0 0.4T. W. ci' 25 Negro Inguinal buboes + - - 8.6 3.5 5.1 1.6C. D. c' 55 White Proctitis + - - 8.6 4.0 4.6

8.0 3.6 4.4 0.89 Negro stricture 8.5 3.9 4.6 1.1 0.6

8.1 3.9 4.2 1.1G. M. 9 55 Negro Rectal stricture + - 8.5J. B. c' 40 Negro Rectal stricture + + - 8.4 4.2 4.2 1.2C. H. c' 46 Negro Inguinal buboes + - + 8.4 4.3 4.1

Negro stricture 8.4f 3.8 4.3 0.3E. R. 9 40 Negro Rectal stricture; + + 8.3 4.1 4.2 1.3

aneurysm (luetic)S. S.

d' 44 White Inguinal buboes + - - 8.2 3.9 4.3

L. D. d' 28 Negro Inguinal buboes + - - 8.1 3.7 4.4F. T. 9 31 Negro Rectal stricture + - - 8.1 4.0 4.1 0.7F. N. c' 35 White Inguinal buboes + - - 7.9 4.3 3.6A. N. 9 46 White Rectal stricture + - 7.8 3.5 4.3 0.6M. G. 9 39 White Rectal stricture + + - 7.8 4.7 3.1 0.8C. H. 9 27 Negro Rectal stricture +_ + 7.6 4.3 3.3 0.8A. L. ci 31 White Inguinal buboes + - + 7.6 4.4 3.2R. L. ci 54 White Rectal stricture + + 7.5 4.2 3.3 0.9J. P. ' 44 Negro Inguinal buboes + + + 7.4 4.6 2.8 0.6I. T. 9 55 Negro Inguinal buboes + -_ 7.3 4.2 3.1 0.7I. Th. ci 42 Negro Proctitis -_ : 6.8 4.6 2.2

* The Wassermann reaction was reported anticomplementary on at least one occasion in 7 cases in this series; in

the 2 cases indicated, every Wassermann test done was reported anticomplementary.t Determinations made on plasma in this case.

ACID-BASE EQUIVALENCE IN HYPERGLOBULINEMIA

mated by the method of Tisdall and Kramer (10) withthe exception that the serum was ashed (11), and cal-cium by the method of Kramer and Tisdall as modifiedby Clark and Collip (12). For the estimation of magne-sium an average normal value of 2 milli-equivalents perliter (13) was assumed.

In addition to the above analyses, the following de-terminations were made in occasional cases, as describedin the text. Sulfate was determined by the method ofLoeb and Benedict (14) and fibrinogen by a modifiedCullen and Van Slyke (15) method. Hematocrit de-terminations of blood cell volume were carried out onsamples containing equal and constant amounts of oxalate.

The Frei test on patients suspected of lymphogranulomainguinale was performed with antigen prepared by themethod described by Frei (16) from material obtainedfrom suppurating inguinal buboes. The minimum re-action accepted as a positive response was the develop-ment of a papule with a surrounding area of erythema atleast 6 millimeters in diameter and persisting at least 3days. The cutaneous reaction was examined after 48or 72 hours. Weare indebted to Drs. W. and H. Curth,who carried out and interpreted the Frei tests.

Results of serum electrolyte partitions in normal per-sons. The limits of variation in normal serum sodiumby the method used here have been found by Loeb andhis collaborators to lie between 137.0 and 144.0 m.eq. perliter (unpublished studies). Potassium, calcium andmagnesium total 12 ± 1 m.eq. per liter, giving values of149.0 to 156.0 m.eq. per liter for total base. Total baseusually exceeds total determined acids by 1 to 4 m.eq.per liter. We rarely obtain higher values for total de-termined acids than for total base in normal subjects bythe methods described, i.e. B -A is rarely negative.This experience, however, is contrary to that of Petersand Man (17) who find negative B- A values, in normalsubjects, as large as -6.5 m.eq. per liter, associated withtotal base values (determined by the method of Hald)as low as 142.0 m.eq. per liter.

RESULTS

Hyperproteinemia in lymphogranuloma inguinaleWAhereas the concentration of serum proteins

in normal subjects exceeds 7.5 per cent only inoccasional instances ((18, 19); personal observa-tions), 31 of 35 patients with lymphogranulomainguinale were found to have serum protein val-ues of 7.6 per cent or more, in 10 instances ex-ceeding 9.0 per cent (Table I).2 Our data in-

2 The occurrence of hyperproteinemia in lymphogranu-loma inguinale appears not to have been recorded in theliterature. It is interesting to note, however, that Rowe(20), in an extensive investigation of serum proteins indisease, obtained his highest value (10.4 per cent, afterstasis) in an undiagnosed case of "enlarged inguinalglands." Since inguinal buboes are now known to be a

TABLE II

Lymphogranuloma inguinale: Serum electrolyte partitions in18 cases

Non-

Cane j Cl |HRC°l Pro-PO,E:I N | K Ca TotalI: Tojtal:BKA|oBCase Cl HCO,d P0 aDban acid -iro

gen

m. eq. m.eq. m.s. m . . eq.m..e . upalitff liter ib r zir F s =x liter C erC rc.Ltr itr j Ltrliter iiter liter 1O~

E. A. 102.6 26.8 22.6 2.1 134.7 5.5 4.6 146.8 154.1 -7.3 26C. K. 98.5 23.4 22.1 2.5 131 6 4.4 5.3 143.3 146.5 -3.2 30P. 8. 106.8 24.4 20.6 1.9 138.8 4.9 5.3 151.0 153.7 -2.7 32E. J. 101.7 27.7 20.8 1.8 137.5 4.4 5.4 149.3 152.0 -2.7 27E. F. 102.9 27.8 20.8 2.1 138.7 4.0 5.0 149.7 153.6 -3.9 26A. Br. 106.7 24.3 20.6 2.3 139.0 5.0 5.4 151.4 153.9 -2.5 25K. W. 104.0 24.0 20.3 1.7 135.6 4.5 5.1 147.2 150.0 -2.8 20A. Bo. 105.8 26.3 20.0 1.8 139.3 4.7 5.3 151.3 153.9 -2.6 30E. G. 101.3 28.0 19.9 1.6 139.7 3.8 5.4 150.9 150.8 +0.1 31G. J. 103.4 28.0 19.4 2.1 140.2 4.0 5.1 151.3 152.9 -1.6 25D. P. 103.2 28.7 19.2 1.7 142.6 5.4 5.1 155.1 152.8 +2.3 24E. R. 106.3 26.3 19.1 2.0 143.3 4.1 5.4 154.8 153.7 +1.1 32Es. D. 105.5 27.4 18.7 1.3 142.0 4.2 5.2 153.4 152.9 +0.5 27C. D. 103.3 25.8 18.1 1.8 138.2 4.5 5.3 150.0 149.0 +1.0 36M. G. 103.3 29.1 18.7 1.7 142.0 4.8 5.4 154.2 152.8 +1.4 28C. H. 103.8 26.4 17.9 1.7 137.8 4.8 5.2 149.8 149.8 0.0 24R. L 105.0 28.5 17.7 1.2 141.2 4.1 5.2 151 5 152.4 -0.9 34L. T. 103.4 27.8 17.4 1.9 141.5 4.5 5.3 153.3 150.5 +2.8 29

dicate that hyperproteinemia is likely to be moremarked in cases with chronic complications, par-ticularly in females with rectal stricture, thoughsuch patients do not invariably present high serumprotein values.

The hyperproteinemia was found to be due toan increase in the euglobulin and pseudoglobulinI fractions. The rise in euglobulin was striking,being 10 times our normal mean value in one in-stance in which euglobulin constituted more than50 per cent of the total globulins. The albumincontent of the serum was moderately or definitelydecreased in several cases. The fibrinogen con-tent of the plasma did not exceed 0.6 per cent inthe 6 cases examined.

The hyperproteinemia found in lymphogranu-loma inguinale corresponds with that described inkala-azar (23, 24) and leprosy (25, 26) in de-gree, fractional distribution and incidence. A

characteristic manifestation of lymphogranuloma in-guinale, it seems not improbable that Rowe's patient wasaffected with this disease.

Turner, in a study of serum proteins in pellagra (21),noted a moderate increase in serum globulin in 4 caseswith co-existing rectal stricture. Lymphogranuloma in-guinale is now known to be a common cause of inflamma-tory rectal strictures.

Nicolau (22) noted an increase in the refractive indexand in the viscosity of the serum in several cases oflymphogranuloma inguinale and considered that thesechanges might indicate an increase in serum albumin.Our findings are not in accord with this inference.

477

A. B. GUTMAN, E. B. GUTMAN, R. JILLSON AND R. D. WILLIAMS

+6 0 Lymphoqr6nulomo, inquincklee Multiple Myelom&

+4 e@MiscelI6neous+3c3 * Normel

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I:e 0 e Oz 0$ s

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FIG. 1. SCATTERDIAGRAMIN WHICHB -A IN MILLI-EQUIVALENTS PER LiTER IS PLOTTEDAGAINST EUGLOB-ULIN CONTENTIN GRAMSPER 100 CC. SERUMIN 10 NORMALSUBJECTS, 18 CASES OF LYMPHOGRANULOMAIN-GUINALE, 4 CASES OF MULTIPLE MYELOMAAND 8 MISCELLANEOUSCASES WITH HYPERGLOBULINEMIA.

In the cases of multiple myeloma with nitrogen retention in which sulfates were determined, the valuesobtained for sulfates have been added to the sum of acid-equivalents.

The figure shows a trend in the direction of increasing excess of total determined acids over total base inbloods containing increasing amounts of euglobulin.

similar increase in euglobulin may occur in ma-laria (27), filariasis (28), syphilis (29, 30), tu-berculosis (31, 32), rheumatoid arthritis (33, 34)and other chronic infections; but the incidence ofpatients presenting hyperproteinemia appears tobe considerably lower, and values over 9.0 percent are exceptional. In multiple myeloma (35),as is well known, the concentration of proteins inthe serum may reach extraordinarily high levels.

It is apparent that the hyperproteinemia occur-ring in lymphogranuloma inguinale is not the re-sult of a decrease in the volume of circulatingfluids since this would not account for the altera-tion in A: G ratio. Moreover, hematocrit deter-minations of blood cell volume, carried out in 3cases, gave normal values. None of the patientsin this series presented the clinical picture of de-hydration. It is probable that the hyperglobuline-

mia observed in lymphogranuloma inguinale, likethat noted in other. chronic suppurative infections,reflects the response of the organism to certaintypes of infection.

Hyperproteinemia is neither as constant nor asspecific a manifestation of lymphogranuloma in-guinale as is the Frei reaction. It is apparent,however, that the possibility of lymphogranulomainguinale should be considered in cases presentingunexplained hyperproteinemia, particularly in ne-groes, and that this possibility should be ruled outby means of the Frei test."

8 In a disease as widespread as lymphogranuloma in-guinale appears to be in the negro population of theUnited States (36, 37), it is of course possible that theassociation with hyperproteinemia may be wholly coinci-dental, the exciting cause being in reality some co-existinginfection such as syphilis, chancroid or tuberculosis. The

478

ACID-BASE EQUIVALENCEIN HYPERGLOBULINEMIA

Serum electrolyte partitions in lymphogranulomainguinale

Complete serum electrolyte partitions were car-ried out in 18 cases of lymphogranuloma inguinale(Table II). In 10 instances the sum of the de-termined acid equivalents exceeded the total base,i.e. B -A appeared to be negative. Every caseof lymphogranuloma inguinale in this series inwhich the euglobulin fraction was increased to 1.4per cent or more exhibited this apparent discrep-ancy in acid-base equivalence.4 There was, infact, a fairly well defined tendency for the dis-crepancy in acid-base balance to be more markedas the euglobulin content increased, a relationshipapproximately linear. This trend is illustrated ina scatter diagram in which the euglobulin contentof sera containing normal and increased amountsof euglobulin is plotted against total base minustotal determined acids (Figure 1).

Consideration of the individual constituents ofthe acid-base balance in these cases of lympho-granuloma inguinale (Table II) reveals little ofsignificance with the exception of protein wherethis was elevated. In several instances, the so-dium content of the serum fell to 136 m.eq. perliter or below, for reasons wholly obscure. Whilethe fall in sodium may contribute to the apparentexcess of total determined acids over total base, inmost cases the discrepancy in acid-base equiva-lence was associated with sodium values withinnormal limits. In several cases, the serum albu-min was definitely decreased (Table I). For themost part, the decrease was associated with pro-teinuria (1), notably in Cases E. A. and C. K.

Wassermann reaction of the blood was positive in 12 ofour 35 cases, the Dmelcos test was positive in 6 patients.Evidence of tuberculosis was noted in only 2 cases, butno systematic investigation in this direction was carriedout. Parenteral administration of arsenic, bismuth andgold compounds may affect the level of serum proteins,it is said, but hyperglobulinemia was observed in 24 pa-tients in this series before such treatment was begun.

4The term "euglobulin" as used in this paper appliesto the protein complex precipitated from serumn by a con-centration of IM sodium sulfate, according to Howe'sprocedure. It is appreciated that the chemical identityof the euglobulin fraction is not established, that thesalting-out process does not allow of sharp fractionationand that separation of the several protein fractions prob-ably causes reversible changes in the several protein com-ponent systems.

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A. B. GUTMAN, E. B. GUTMAN, R. JILLSON AND R. D. WILLIAMS

In Case C. K., the marked proteinuria was due toglomerulonephritis, was associated with edema andwas probably unrelated to the co-existing lympho-granuloma inguinale. The decrease in serum al-bumin in these cases would, of course, result in a

decrease in protein acid-equivalents and hence ofitself tend to make B - A more positive.

Serum electrolyte partitions in multiple myelomaand in a group of miscellatVeous diseases

The results of serum electrolyte partitions in6 cases of multiple myeloma are summarized inTable III.5 In Cases J. B. and A. T., there was

definite hyperproteinemia, due chiefly or solely toan increase in euglobulin. The apparent excessof total determined acids over total base in thesecases varied from 3.4 to as much as 8.2 m.eq. perliter. In the remaining cases in this group, theacid-base balance was complicated by co-existingrenal insufficiency (indicated by definite nitrogenretention, as noted in Table III) with accumula-tion of sulfates in the blood. In Cases S. E. andG. D., in which hyperproteinemia was not noted,the amount of sulfate in the blood was determined(Table III). It will be seen that adding the val-ues for sulfate to the sum of total determined

6 Reports of studies on acid-base balance on 2 cases ofmultiple myeloma, neither with hyperproteinemia, werefound in the literature (39, 40). In both instances veryhigh figures were reported for B -A (37.0, 39.1 m.eq.per liter in one instance, 38 and 39 in the other). Dif-ferences in method preclude direct comparison with theresults recorded here.

acids in these cases still leaves a positive value forB A. In Case P. F., in which B A appearedto be positive although the serum protein was 9.9per cent, the amount of sulfate in the blood asso-

ciated with the marked nitrogen retention presentwas not determined. It is not known whether, inthis instance, total determined acids plus sulfatesexceeded the total base.

Table IV summarizes our results on 11 cases ofhyperglobulinemia of diverse and, in part, un-

known etiology. The results are, in general, con-

sistent with those obtained in lymphogranulomainguinale and multiple myeloma, the sum of totaldetermined acids exceeding the total base. InCase E. P., in which the euglobulin fraction was

within normal limits, and on one occasion in CaseA. S., B A was positive. In Case J. D., theequivalents of total determined acids equalled ap-

proximately the total base.The diseases represented are so varied as to

suggest that the association of marked hyper-globulinemia with a negative B A is a phenome-non of general significance.

DISCUSSION

The consistency of the association of the dis-crepancy in acid-base equivalence with hyper-globulinemia is noteworthy since it has been theexperience of this laboratory, using the analyticalmethods previously described, that B-A isnegative otherwise only occasionally, either innormal subjects or in disease. As to the cause of

TABLE IV

Miscellaneous cases uith hypergiobulinemia. Serum electrolyte partitions, serum protein fractions

P04Na K Ca ~~Total Total Non- TotalAl- Glob- EunirlobCane Age |3ex Diagnosi| Cl HCOs|o PO|NBAK Cprote in p i In| ntoin ban acid ii~~~~~itrogen tein n li

m.eq. m.eq. m.eq. m.eq. m.es. m.eq. m.eq. m.eq. m.eq. m.oq. mgm. gram. grams gras gramsyeanr per eer per per Per Per per per perliter &ter Uiter liter

t

i't f liter oo cc. too cc. too cc. too cc. too cc.J. P. 48 (P Lymphosarcoma (autopsy) 99.8 21.1 25.4 2.3 137.1* 1486 -11.5 25 12.1 2.9 9.2J. C. 50 d' Undiagnosed 101.6 29.4 19.8 1.8 136.2 4.4 4.5 147.1 152.6 -5.5 28 9.5 2.2 7.3 5.0

26 9.3 3 4 5.9N. L. 48 d' Undianosed 97.5 26.3 19.9 2.3 133.8 4.2 5.6 145.6 146.0 -0.4 29 9.0 3.4 5.6 1.8B. S. 37 9 Undiagnosed 105.0 25.4 20.4 1.4 138.5 3.3 4.9 148.7 152.2 -3.5 27 8.9 4.2 4.7 1.4H. F. 23 9 Undiagnosed 100.8 25.9 19.6 2.5 137.7 4.5 4.8 149.0 148.8 -0.2 25 8.8 3.5 5.3J. H. 63 9 Lymphosarcoma (biopsy) 97.3 32.7 20.3 2.6 139.5 5.1 5.4 152.0 152.9 -0.9 32 8.7 4.6 4.1A. 8. 34 9 Th. lyphadenitia (biopsy) 100.8 25.8 19.4 2.1 134.9 4.0 5.0 145.9 148.1 -2.2 24 8.5 4.0 4.5

106.3 23.3 18.2 1.9 139.4 4.7 5.4 151.5 149.7 +1.8 29 7.9 3.9 4.0 0.9A. B. 41 9 Cirrhosis of liver (autopsy) 100.0 29.7 17.9 2.0 136.7 4.4 4.6 147.7 149.6 -1.9 27 8.4 2.4 6.0 2.1E. P. 38 9 Undiagnosed 105.3 24.0 18.7 2.2 140.4 4.6 5.5 152.5 150.2 +2.3 25 8.0 4.3 3.7 0.5M. A. 33 9 Leprosy (biopy) 107.1 25.0 17.3 1.9 138.8 4.9 4.9 150.6 151.3 -0.7 29 7.5 3.7 3.8 1.1J. D. 25 d' Cirrhos of ler; jaundice 106.8 24.5 15.5 1.9 137.8 4.3 4.7 148.8 148.7 +0.1 26 7.2 2.2 5.0 1.7

* Total base in this case determined by a modification of Fiske's method.

480

481ACID-BASE EQUIVALENCE IN HYPERGLOBULINEMIA

this discrepancy, we are unable for the presentto do more than suggest certain possibilities andindicate which seems to us most probable.Changes in pH of the serum or alteration in thecontent of organic acid radicles of the blood as

possible factors may be excluded at the outset,since our analyses give no indication of such al-terations in the blood.

Peters and Man (17) presented evidence forthe existence of lipoid-chlorine in serum and were

able in this manner to account, in part, for nega-

tive values for B A which they obtain in normal

sera. It is possible that the presence of lipoid-bound chlorine might contribute to the apparent

excess of total determined acids over total base

observed in our cases of hyperglobulinemia. Of

interest in this connection is the fact that euglobu-

lin is thought to contain a large, loosely-bound

lipoid component. However, none of our cases

presented definite hyperchloremia, nor were we

able to discern any correlation between the degree

of excess of total determined acids over total base

and the level of chloride in the blood.Obviously, negative analytical errors in the

estimation of total base (or of sodium where, as

in this study, total base is calculated as the sum of

determined cations) result in falsely low values

for equivalents of base and consequently may

cause an apparent excess of total determined acids.

In only 3 of our 10 cases of lymphogranuloma in-

guinale in which B- A was negative (Table II)

was the blood sodium below the minimum normal

value obtained by the analytical method used

( 137.0 m.eq. per liter). The low values for blood

sodium in these 3 instances were confirmed by

repeated analyses.Consideration of the data in Table II reveals

that in addition to the above-mentioned cases in

which the blood sodium was below normal, values

for total base tend to be lower in our cases in

which B - A was negative than in those cases in

which B - A was positive. In fact, a fair nega-

tive correlation can be made out between total baselevels in the blood and the degree of excess of

total determined acids over total base. This raisesthe question as to whether or not the apparent dis-crepancy in acid-base equivalence noted by us inassociation with hyperglobulinemia should be at-

tributed to loss of base resulting from disease.This explanation is contrary to the experience ofthis laboratory in a large number of cases withmoderate, or even marked, loss of base occurringin a variety of diseases. With the apparent ex-ception of the cases with hyperglobulinemia pre-sented in this paper, loss of base has been found tobe associated almost invariably with a compen-satory loss of chloride and bicarbonate so thatB - A remains p1ositive irrespective of the levelof total base in the blood. It should be pointedout, moreover, that whereas B -A has beenfound to be negative consistently in cases pre-senting definite hyperglobulinemia, we rarely findB -A negative in diseases exhibiting a loss intotal base, except where there is a concomitantmarked increase in serum globulin.

The discrepancy in acid-base equivalence is so

constantly associated with hyperglobulinemia, inour experience, as to suggest some relationshipbetween them, particularly since both phenomenaare of themselves distinctly uncommon. As al-ready pointed out, the individual electrolyte com-ponents of the blood, other than protein, exhibitedno obvious deviation from the normal in suchcases, except lowering of the sodium and of albu-min in some instances. B - A was invariablypositive in cases of lymphogranuloma inguinale or

multiple myeloma in which the serum globulin was

not increased.The precise nature of the relation between the

apparent excess of total determined acids over

total base and hyperglobulinemia is uncertain butthe authors attach significance to the fact that inno case of lymphogranuloma inguinale did theseruifi calcium exceed the limits of normal varia-tion, despite increases in serum protein up to 11.2per cent. In the absence of hyperphosphatemia,or of any evidence for a decrease in ionized cal-cium, this fact is interpreted to mean that theadded euglobulin increment bound no calcium.

It is, of course, hazardous to draw from thecapacity of a globulin to bind calcium any deduc-tions concerning its capacity to bind total base. Itis suggested, however, that the apparent discrep-ancy in acid-base equivalence noted by us in as-sociation with hyperglobulinemia would be ex-plained if the serum globulin in such cases bound

A. B. GUTMAN, E. B. GUTMAN, R. JILLSON AND R. D. WILLIAMS

significantly less base at the pH of the blood thandoes normal serum globulin. This would lead toerroneously high values for base bound to pro-tein when the factor ordinarily used to calculatebase bound to globulin is applied to such sera.

It will be appreciated that the application tosera with definitely increased globulin content ofa factor derived fronm titration curves of normalserum globulin (7) involves the assumption thatthe base binding capacity of the serum globulinin hyperglobulinemia is identical at the pH ofthe blood with that of normal serum globulin.The validity of this assumption is open to doubt.As is well known, any appreciable increase in theglobulin content of the serum involves a qualita-tive as well as quantitative change in serum glob-ulin, since the euglobulin fraction almost in-variably constitutes most or all of the added in-crement. Thus whereas in normal serum, eu-globulin may comprise as little as 15 per cent orless of the globulin fraction, in multiple myelomaand in certain chronic infections 60 per cent ormore of the serum globulin may consist of eu-globulin. There is, moreover, evidence that insuch pathological sera, the euglobulin may differin properties (and, presumably, in structure) fromnormal euglobulin.

The authors are of the opinion that the excessof determined acids over total base encounteredin sera with definitely increased globulin contentis apparent only and is the result of erroneouslyhigh values for protein acid-equivalents. The er-ror is introduced by the application to pathologicalserum globulin (which usually contains a largeproportion of abnormal euglobulin), of a factorfor calculating base bound to globulin which wasderived from normal serum globulin.

The problems arising in connection with theestimation of B protein in hyperproteinemia ap-pear, in fact, to be analogous in some ways tothose which came to the fore when acid-base bal-ances were first attempted in blood with decreasedprotein content. Since the decrease in serumprotein affected chiefly or solely the albumin frac-tion, and since B albumin greatly exceeds Bglobulin at the pH of the blood, errors were in-troduced in estimating B protein by the use of acommon factor which was derived from sera with

normal albumin: globulin ratios. This source oferror was eliminated by determining the albuminand globulin fractions and applying to them sep-arate factors for the estimation of B albumin andB globulin (7).

The data presented in this paper suggest thata further correction of the factor ordinarily usedto calculate B globulin is necessary when thatfactor is applied to sera with markedly increasedglobulin content; otherwise the values obtainedfor protein acid-equivalents in such sera are toohigh and B - A appears to be negative.

CONCLUSIONS

1. The concentration of serum proteins wasfound to exceed 8.0 per cent in 26 of 35 patientswith lymphogranuloma inguinale. The euglobulinand pseudoglobulin I fractions, as determined byHowe's method, were increased.

2. Electrolyte partitions of the sera of 18 pa-tients with lymphogranuloma inguinale revealedan apparent excess of determined acid equivalentsover total base in those cases presenting definitehyperglobulinemia. A similar apparent discrep-ancy in acid-base equivalence was observed inassociation with hyperglobulinemia due to multi-ple myeloma and, occasionally, to other causes.The apparent discrepancy in acid-base equivalencewas not noted in cases of lymphogranuloma in-guinale or of multiple myeloma not presentingdefinite hyperglobulinemia.

3. The discrepancy in acid-base equivalence isprobably the result of erroneously high values forprotein acid-equivalents; the error being intro-duced when the factor ordinarily employed toestimate base bound to globulin is applied to serawith markedly increased globulin content.

4. It is suggested that when the factor now ingeneral use for estimating base bound to globulinis applied to sera with definite hyperglobulinemia,a correction is necessary.

We are indebted to Dr. Robert F. Loeb, Dr.Forrest E. Kendall and Dr. Dana W. Atchley formany helpful suggestions; and to the Misses M.Kurepkat, A. Barman, M. Willkomm and B. Bax-

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ACID-BASE EQUIVALENCE IN HYPERGLOBULINEMIA

ter who carried out certain of the determinationsincorporated in the tables.

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