Attachment 4 "Excretion of Plutonium Administered Intravenously to Man. Rate of Excretion in Urine and Feces with Two Observations of Distribution in Tissues," copy, 34 p. ACHRE No. DOE-121294-D. (Title and Credit Page) This is a Joint Publication of Work Performed under Contract No. _______________. Los Alamos Scientific Laboratory and Contract No. W-7401-eng-49, The University of Rochester. N.E. Bradberry, Director of Los Alamos Scientific Laboratory Andrew H. Dowdy, Director of Manhattan Department, The University of Rochester EXCRETION OF PLUTONIUM ADMINISTERED INTRAVENOUSLY TO MAN. RATE OF EXCRETION IN URINE AND FECES WITH TWO OBSERVATIONS OF DISTRIBUTION IN TISSUES. Work done by: Report written by: Samuel H. Bassett Samuel H. Bassett Jeanne Carritt Wright Langham Robert Fink Wright Langham Elizabeth Maxwell Arthur Murray III Anne Perley Hannah Silberstein Helen E. Van Alstine With acknowledgement to: William F. Bale, L.H. Hempelmann, William S. McCann, and Stafford L. Warren EXCRETION OF PLUTONIUM ADMINISTERED INTRAVENOUSLY TO MAN. RATE OF EXCRETION AND FECES WITH TWO OBSERVATIONS OF DISTURBUTION IN TISSUES. I. Introduction II. Methods A. Clinical 1. Selection of patients 2. Management of patients a. Control period b. Observation period c. Routine tests (1) Blood tests (2) Urine and kidney function tests, etc. d. Collection and preservation of samples (blood feces and urine). 3. Method of Administration of Plutonium a. Preparation and nature of solutions b. Choice of size of dose c. Techniques of Injection (1) Discussion of actual injection procedure (2) "Dummy" injection for evaluating amount of plutonium give B. Chemical Methods 1. Blood analysis 2. Feces analysis 3. Urine analysis 4. Tissue analysis III. Description of Subject (case reports). Short paragraph about each of 12 giving A. History B. Physical C. Laboratory D. Diagnosis (if known) IV. Results A. Concentration of Plutonium in blood following intravenous administering as Pa+4 Citrate. B. Excretion of Plutonium in the urine following intravenous administering as Pa+4 Citrate. C. Excretion of Plutonium in feces following intravenous administration as Pa+4 Citrate. D. Deposition of Plutonium in tissues following intravenous administration as Pa+4 Citrate. E. Clinical Results V. Discussion and Conclusions A. Correlation between blood concentration and urinary and fecal excretion of Plutonium. 1. Possible significance of one abnormal case. B. Half-time of Plutonium in the body. C. Choice of urinary excretion value for diagnosing exposure by urine assay. D. Discussion of results in relation to tolerance amount of Plutonium in the body. E. Discussion of results in relation to Chicago and California experiments of man. F. Discussion of results in relation to experiments on mice, rats and dogs. VI. Summary of Abstract - 2 - II. Methods A. Clinical 1. Selection of subjects The individuals chosen as subjects for the experiment were a miscellaneous group of male and female hospital patients for the most part with well established diagnoses. Preference was given to those who might reasonably gain from continued residence in the hospital for a month or more. Special treatments and other therapy thought to be of benefit to the patients were carried out in the usual manner. The necessity of studying urinary and fecal rates of excretion of Pu automatically excluded cases of advanced renal disease or disturbance in the function of the gastrointestinal tract. Patients with malignant disease were also omitted from the group on the grounds that their metabolism might be affected in an unknown manner. The life expectancy of the individual was carefully considered. As a rule, the subject chosen was past 45 years of age and suffering from a chronic disorder such that chance of survival for the ten years of more was improbable. By adhering to these criteria it was hoped. (a) That the possibility of late radiation effects developing in the course of ten or fifteen years would be avoided. (b) That an opportunity would present itself to obtain post mortem material within a period of months or at most a few years. Of eleven patients in the Rochester group, ten were past the age of 45. One was only 15 years old but has since died of Cushing's - 3 - Syndrome: a women aged 49 years may have a greater life expectancy than originally anticipated due to an error in the provisional diagnosis. Up to the time of compilation of this report and approximately two years since the initiation of the study, five subjects have died of their disease. Complete autopsies with tissue analyses for Pa were obtained in three instances; one death occurred in another institution with a comp post mortem but no analyses of tissues; one subject died in another hospital and permission for autopsy could not be obtained. 2. Management of patients Two of the twelve subjects were cared for in the special metILLEGIBLE ward of the hospital where they were continuously under observations of the in charge of the experimental work and of a specially trained staff of nurses. One patient HP-11, remained on the general ward. No collections could be ILLEGIBLE because he was in the terminal phase of his illness when the Pu was injected Material from the subject HP-12 was obtained at Oak Ridge. The general plan of procedure with patients resident in the ILLEGIBLE ward was as follows: During a control period the subject was carefully instructed quantitative collection of urine and fecal specimens. He became adjusted ILLEGIBLE ward routine and any necessary modifications in diet, medication, etc., ILLEGIBLE The period of indoctrination usually required about ten days. After the ILLEGIBLE had proven himself capable of cooperation, control - 4 - specimen of urine and ILLEGIBLE ILLEGIBLE were collected. The period of observation following the injection was original set at 22 days, however, as the work progressed, it became evident that more prolonged studies were desirable. Whenever possible these have been carried and include a longer initial period of observation as well as follow-up study made a year or more after the injection. Details are given in the case history (Section III) and in Section IV. Preceding the injection of Pu, the physical examination was reevaluated, blood counts, urea clearances, and blood chemistry were obtained. (Details are given in Section III). Routine for collection of blood, urine, and feces Blood Blood was drawn into dry sodium citrate as an anticoagulant. Exactly 15 ml of well mixed whole blood was pipetted into a glass ILLEGIBLE and sealed. As first formalin was added as a preservative but later this was omitted because of the precipitation of protein with the attendant difficulty in removing the material from the ILLEGIBLE. Specimens were drawn before the injection of Pu and at stated intervals thereafter. The schedule evolved was one control specimen and post injection specimens at 4 hours, 24 hours, 3 days, 6 days, 10 days, 15 days, and at the termination of the period of hospitalization. The number of samples contributed by each subject and time relation to injection of Pu appear in the protocol of Section IV. - 5 - Urine Urine was collected by having the subject void directly into a new half gallon fruit jar. The usual collection period for urine was 24 hours except for the day on which the Pu was given, when it was collected in two 12 hour periods. At the completion of each collection a label was affixed to the jar giving the subject's number and the dates and hours of collections. Fifteen ml of 40% formalin was added as a preservative and the specimen heated on the steam bath for about two hours. This sufficed to expel much of the air from the jar which was then sealed and cooled to room temperature. Enough reduction in pressure was obtained in the jar to hold the lid firmly in place and prevent loss in transit. As a further precaution, an adhesive marker was placed at the top level of the liquid in the jar in order that any leakage which might have occurred would be revealed to the person receiving the urine for analysis. The system worked very satisfactorily and losses were negligible. Feces Feces were passed into large (3000 ml) weighted Pyron beakers that had not been used previously for any other purpose. To avoid a mixture of urine with feces the patient was required to empty his bladder as completely as possible prior to defecation. The weight of the fecal specimen was obtained by difference and the date and hour recorded. As a rule the feces were pooled during intervals of four days. Carmine markers were not used. The fresh stool was covered with 6N HCL and boiled for about ten minutes. - 6 - This method of preservation had several advantages: most of the fecal material disintegrated, bacterial decomposition was stopped, and transfer of the resultant suspension to a half gallon fruit jar was readily accomplished. Usually one jar sufficed for all the stools in a four day period. Sealing and marking of the specimen jars was accomplished as described in the case of the urine. Following the administration of Pu the first two or three stools were saved separately rather than in a pool in order that the time of appearance of the tracer in the feces might be determined more accurately. 3. Method of Administration of Plutonium (a) Preparation and nature of solutions. The standard solution of Pu for use in human tracer studies was obtained from Dr. Wright Langhem of Los Alamos and consisted of 5 mg of Pu as nitrate dissolved in 25-ILLEGIBLE3, valence +4. The material was received in a volume of one ml in a sealed glass ILLEGIBLE. The content of the ILLEGIBLE was transferred to a small rubber stoppered vial which in the following text will be referred to as Solution A. As a general check on methods and procedure, a preliminary experiment was carried out on rats. Rat Experiment Six hundredths of a cubic centimeter (0.06 ml) of Solution A were measured with a 0.1 ml pipette into a 10 ml volummetric flask and made to - 5 - Note to Dr. V. Langham The only animal experiments made with the plutonium solution received in Rochester for the ILLEGIBLE work are those recounted on pages 5 and 6. Both Bob Fink and I realize that those are at variance with some of the work you have done and that reported elsewhere. We see no particular reason for its inclusion except that you may wish to mention briefly the range of Pu concentration in the livers of animals at it was known to you when we first started our cooperative study. Please feel free to modify this section of the report in any way you see fit. - 6 - volume with 0.415 sodium citrate 2H2O (This diluted plutonium solution is referred to as Solution 3). Three rate weighing respectively 233, 222, and 236 grams were injected intravenously in the tail vein with 0.5 ml of Solution 3. At the same time, three dummy solutions were prepared, each of which consisted of 0.5 ml of Solution 3 diluted to a volume of 100 ml in a volummetric flask with 25-HCL. Counts were made from these dummies by evaporating 0.1 ml from each on 1 cm2 silver foil. The rats showed no evidence of toxicity and were killed at four days. Their livers were digested in a mixture of nitric acid and hydrogen peroxide and the digest made to a volume of 25 ml in volummetric flasks. 0.1 ml portions of the liver digests were evaporated on 1 cm2 platima foil and counted. The total number of counts on the individual dummy solutions in terms of 0.5 ml of Solution 3 (or 15 Pu) were: ILLEGIBLE/p/m Dummy #1 1,180,000 " #2 1,100,000 " #3 1,060,000 Average 1,113,000 Counts on the rat livers as total counts per liver were: ILLEGIBLE/p/m #1 (233 gm) 22,800 or 1.9% #2 (222 gm) 20,000 or 1.8% #3 (236 gm) 30,500 or 2.5% It is clear that only a comparatively small localization of Pu occurred in the liver which suggested that the Pu remained in a soluble state (probably as a citrate complex) at least temporarily after the injection and had time for good distribution throughout the body. This was felt to be important from the standpoint of the - 7 - human tracer studies where because of possible radiation hazard. It was hoped that the Pu would not be taken up in high concentration by a single organ such as the liver. (b) Choice of size of dose There are no altogether satisfactory criteria at present for estimating the tolerance dose of 94 Pu239. The problem may be approached from several points of view. None of those is free from some criticism since certain assumptions have to be made without support of experimental evidence. One may start with the premise that the maximum permissable dose of radium is 0.1 microgram (1) (2). The alpha particles which are responsible for its chief biological effects are derived not only from radium but also the "daughter" nuclei of the radium series. In the primary step the radium yields 2.21 x 105 disintegrations per minute or 0.1 microcurie. About 45 per cent of the radon thus formed is lost through the lungs but the alpha radiation of the remainder is absorbed in the body together with the alpha particles of the radium A and C disintegration series. The total energy absorbed in the body from the radium series is, therefore, about 14.23 ILLEGIBLE as compared with about 4.79 ILLEGIBLE for radium alone. The ratio of the biologically effective energy liberated by 0.1 microcuries of radium to that derived from 0.1 microcurie of plutonium is the ratio of the ILLEGIBLE of the alpha particles derives from each; i.e. 14.23/5.15 = 2.76. An amount of Pu, that with the same distribution will be - 8 - biologically comparable to 0.1 microgram of Ra will be 4.47 micrograms and may be ILLEGIBLE from the expression: 2.43 x 104/1.59 x 103 x 239/226 x 2.76 x 0.1 = 4.47 *Constants employed in making these calculations are as follows (3): Energy of Alpha particle Half Life Atomic Wt. ILLEGIBLE 4.791 ILLEGIBLE 1.59 x 103 yrs. 226 ILLEGIBLE 3.486 ILLEGIBLE 3.825 days 222 ILLEGIBLE 5.996 " 3.05 min. 215 ILLEGIBLE .............. ......... ... ILLEGIBLE .............. ......... ... Another and highly practical consideration, however, ILLEGIBLE the choice of the dose. While the rate of excretion in man could not be ILLEGIBLE in advance, there was every reason to believe on the basis of animal experILLEGIBLE and one human case, that injected plutonium would be largely retained (4) It was considered probable, moreover, that the rate of elimination in urine feces would prove to be a function of the total amount deposited in the boILLEGIBLE the quantity injected was too small, the absolute amount eliminated would then could be measured with reasonable accuracy by current analytical procILLEGIBLE It was estimated that the necessary data could be obtained with a dose of micrograms. The dilILLEGIBLE of possible late radiation hazard was met by the ILLEGIBLE of subjects believed to have short life expectancies. - 9 - A second method of approximation is to consider the maximum ILLEGIBLE able exposure to radiation from an alpha emitting isotope. The alpha ILLEGIBLE travel but a short distance, exert their maximum effect locally and are ILLEGIBLE almost completely by the soft tissue. It has been customary for this reaILLEGIBLE *Constants employed in making these calculations are as follows (3% ILLEGIBLE Energy of Alpha particle Half Life Atomic Wt. Ra C 7.680 ILLEGIBLE 1.5 x 10-4 Sec 214 Ra D .............. ......... ... Ra ILLEGIBLE .............. ......... ... Pu 5.15 ILLEGIBLE 2.43 x 104 Yrs. 239 The sum of the energies of the alpha particles of radon, ILLEGIBLE A and ILLEGIBLE is 17.164 ILLEGIBLE. However, because of the loss of radon gas through the lungs 55 per cent is absorbed by the tissues or 17.164 x 0.55 = 9.44 Hev. The energy absorbed by the tissues from the alpha radiation of the series ILLEGIBLE ILLEGIBLE Hev (from "daughter" nuclei) + 4/79 Hev (from Radium) = 14.23 Hev. Tolerance at such a level that not more than 0.01 ILLEGIBLE equivalent physical alpha radiation will be received per unit of tissue per day. A dose of this ILLEGIBLE appears to carry little likelihood of injury to cells (ILLEGIBLE). The rate at which energy is received per day from one millicurie an alpha emitter distributed through one gram of tissue may be expressed as follows: 2.80 x 10 (alpha particle energy in Hev) x 24 (6) or 6.72 x 10ILLEGIBLE x (p.e. in Hev) = rep/day - 10 - Since 1 mg of radium yields one millicurie or 2.21 x 109 disintegrations per ILLEGIBLE ILLEGIBLE may calculate the quantity of plutonium required to produce an equal number disintegrations from the expression: 2.43x104/1.59x103 x 239/226 x 1 = 16.1 mg of Pu (approximately The energy of the alpha particle of Pu is 5.15 Hev. (3). Thus 16.1 mg of Pu ILLEGIBLE yield if distributed in one gm of tissue: 6.72 x 104 x 5.15 = 3.46 x 105 rep/day or if evenly distributed in a 70 Kg man, the dose would be: 3.46x105/7x10 = 4.94 rep/gm/day The amount of Pu which will emit tolerance radiation of 0.01 rep/day is: 0.01/4.94 x 16.1 = 0.0326 mg or micrograms The fallacy in any such reasoning is that Pu (as in the case of many other radioactive isotopes) is not evenly distributed throughout the body, but having gains access to the blood stream, is ultimately deposited largely in the bones. Moreover, early localization of a large fraction of the dose in the liver if given intravenously is a distinct possibility (7). Because of its negligible excretion and very slow rate of decay, once deposited in the skeleton, it must continue to irradiate the local tissues with little abatement in intensity during the entire life of the individual. If one considers the skeleton alone as the area subjected to irradiation and computes the tolerable dose on the basis of skeletal mass, one arrives. At a much smaller value. What value one should take for skeletal - 11 - weight is a matter for further debate since the gross (wet) weight of the human skeleton has been measured on but few occasions (g). If we assume the skeleton to be 16 per cent of the total weight of the body, then 32.6 x 0.16 = 5.2 micrograms of Pu that could be given safely to our man of 70 kg. Unfortunately radioautographies reveal a far from uniform distribution of plutonium in bone (9). Deposition appears to occur in the uncalcified matrix, in the ILLEGIBLE region, and in the periosILLEGIBLE. The skeleton cannot be assumed to receive uniformly distributed irradiation. It is quite possible that the total weight of tissue in which plutonium is concentrated may be of the order of 1000 gm. Should this prove to be the case, our hypothetical subject would be receiving ILLEGIBLE radiation from five micrograms of Pu at the rate of 0.11 rep/day in certain areas and little or none elsewhere. These may be, in fact, highly critical ILLEGIBLE. For example, excessive irradiation of the red bone marrow is known to cause ILLEGIBLE and ILLEGIBLE: disturbances of cell function in the perioILLEGIBLE initiated by deposits of plutonium have been found to produce metaplasia and bone ILLEGIBLE in rats (7) (10). Because of the unique distribution of the isotope, it is ILLEGIBLE that even for the skeleton the limit of 0.01 rep/day may be too high if the dose is calculated on the assumption of uniform distribution throughout skeletal tissues. The several imponderables mentioned in the preceding paragraphs have been a source of concern to ILLEGIBLE who were - 12 - responsible who were responsible for the pursuit of this experiment. The data submitted in Section IV supply partial answers to rates of excretion and tissue distribution but leave unanswered the fundamental question of toleranceILLEGIBLE. (e) Techniques of Injection Blank solution for Human Injection - In order that the staff might be familiar with all details of the procedure of injection, material was assembled two or three days prior to the actual administration of Pu and a blank injection was given. Apparatus Required: Sterile 0.1 ml pipette " 0.41 per cent ILLEGIBLE citrate . H20 " 2N - HNO3 " 20 ILLEGIBLE syringe with 20 needle attached " 30 ml syringe with 20 needle " 1 ml tuberculin syringes (two) " 25 ml volummetric flask " ILLEGIBLE 20 and ILLEGIBLE 22 needles " 20 ml rubber capped vial " 0.85 per cent solution of sodium chloride ILLEGIBLEThe provisional allowable deposition ILLEGIBLE plutonium (accumulated total) in the body of workers was set by the Manhattan District at 1.0 microgram (2). - 13 - Using aseptic precautions 0.05 ml of the 2N-HNO3 was transferred to the volummetric flask and diluted to volume with citrate buffer. After mixing 20 ml were transferred to the rubber capped vial. This vial with two tuberculin syringes, sterile needles, sterile saline, etc., was taken to the patient's bed. One tuberculin syringe was filled with sterile saline and 22 needle 1-1/4 inches long attached. The other tuberculin syringe which simulated the one to be used in the actual injection of Pu was filled to the 0.5 ml mark from the vial with citrate. The needle used to withdraw the citrate was discarded and syringe placed carefully in a convenient position. The needle attached to the saline containing syringe was introduced into the patient's median basalis vein and the saline injected slowly to make sure that there was no failure to enter the vein. The syringe was now carefully detached from the needle and the one with the 0.5 ml of citrate solution was substituted. At this point about 0.1 ml of blood usually entered the syringe and give further evidence of free connection with the vein. The solution was then injected rapidly and the plunger slowly withdrawn until blood filled the barrel to the 0.5 ml mark. The blood rinsed the syringe and was returned to the vein after a moment or two. The needle was withdrawn and firm pressure applied for a minute to the site of injection. Injection of Plutonium Solution The ILLEGIBLE apparatus and routine were used in the injection of the plutonium complex. In this case, however, 0.05 ml of Solution A was transferred to sterile 25 ml volummetric flask - 14 - and diluted to the mark with 0.41 per cent citrate a H20 solution. Five tenths of a cubic centimeter of this solution (hereinafter referred to as Solution C) was the amount injected. It contained approximately five micrograms of Pu +4 as citrate complex. Prior to injection the strength of the solution was assayed on the basis of its alpha activity. Dummies were prepared by withdrawing 0.5 ml portions of Solution C into a 1 ml tuberculin syringe fitted with a 22 needle and ejecting into a 25 ml volummetric flask containing 2N HCL. Counts were made on 0.1 ml portions of dummy dried on 1 cm2 silver foil. The actual number of micrograms given to the subject was approximated on the basic of count of past injection dummies prepared by one of the group in attendance at the time of the injection. This individual took careful note of the amount of Solution C withdrawn into tuberculin syringe and watched the technique of injection. In preparation of the dummies the procedure was duplicated in exact detail except that 0.85 per cent NaCl was substituted for the patient's blood. In brief, after injection the syringe and needle used for that purpose was cleaned and dried. The needle was filled with saline to simulate the patient's blood. Solution C was drawn to the 0.5 ml mark through another needle and the latter removed. The needle with saline was attached and a very small amount of saline drawn into the syringe. The plutonium solution was ejected into a 25 ml volummetric flask and the tip of the needle dipped into fresh 0.85 per cent NaCl solution. The saline was drawn to the 0.5 ml mark to rinse the barrel of the syringe once and also ejected into the volummetric - 15 - flask. The flask was filled to the mark with 2N-HCL. Four or five dummies were prepared and counted. The average count was taken as an index of the amount of Pu received by the subject. Counts were made both in Rochester and Los Alamos. Sample Calculation of Dose, Subject HP-2 Counts were made with Simpson Counter #38021. ILLEGIBLE prepared as outlined on page 12. Volume of Dummy-25 ml containing 0.5 ml of Solution C. All plates were counted for two periods of fifteen minutes each. At least two plates were made of each sample. Volume of dummy dried on each plate - 0.1 ml. Dummy No. Volume Counted Average Count Per Minute 1 0.1 ml 1408 2 0.1 ml 1410 2 0.1 ml 1340 4 0.1 ml 1447 4 0.1 ml 1339 Total average count per minute 1401 Since each count represents two disintegrations, the total number of disintegrations per minute in the average dummy was: 1401 x 250 x 2 = 700,500 disintegrations This was taken as the alpha activity of 0.5 ml of Solution C - the quantity injected. - 16 - The amount of Pu required to yield this activity may be calculated as follows: 16.1 ILLEGIBLE gm Pu ILLEGIBLE 1 microcurie or 2.21 x 106 d.p.m. then 7 x 103 (activity of Pu Injected/2.21 x 10ILLEGIBLE x 16.1/1 = 5.1 gm Pu 5.1 u gm of Pu were contained in the volume of Solution C injected. III. Description of Subjects. A. Introduction The material in this section is a ILLEGIBLE of the clinical history and recent status of the subjects. Where follow-up studies have been complete any pertinent change in the physical condition is mentioned and laboratory data interest have been included. Death of the individual is indicated by the sign following the HP member. When known, the anatomical diagnosis is given. If no comment on change in physical status appears in the report, it may be assumed ILLEGIBLE there has been no material change in condition up to the time of preparation of manuscript. HP-1 Intravenous injection of 4.6 ILLEGIBLE of Pu +4 as citrate complex on Oct. 16, ILLEGIBLE Case History White male of 67 years with a nine year history of peptic ulcer. Entered hospital on September 20, 1945 following a hemorrhage so severe as to require transfusion. X-ray examination revealed a ILLEGIBLE ulcer and traction diverticulum of the - 17 - HP-1 (continued) ILLEGIBLE at the level of the ILLEGIBLE ILLEGIBLE. Examination ILLEGIBLE=37 C: P=72; ILLEGIBLE=18; B.F. = 115/70 ILLEGIBLE- ILLEGIBLE ILLEGIBLE ILLEGIBLE Generally well preserved for his years. Some ILLEGIBLE of ILLEGIBLE membranes inconstant pulse at the base of lungs; moderate tenderness in the ILLEGIBLE without space. No other findings of note. Studies were conducted during ILLEGIBLE from October 2, 1945 to December 10, 1945. Before Injection After Injection Urine - Negative except for trace of protein Stool - Positive ILLEGIBLE reaction at first but later negative Blood Wassermann Reaction - Negative - 18 - HP-1 (continued) Before Injection After Injection Blood Counts - Oct. 4, 1945 Blood Counts - Oct. 19, 1945 Red Blood Cells - 4.47 x 106 per cm..........4.55 x 106 per cm. Hemoglobin - 13.9 gm/100 cc.................13.7 gm/100 cc White Blood Cells - 7,100...................................7,000 Differential: Polymorphs - 71 per cent.......................54 per cent Small Lymphs- 17 per cent........................9 per cent Inter. Lymphs- 2 per cent........................25 per cent Honocytes- 9 per cent.........................7 per cent ILLEGIBLE 1 per cent.........................4 per cent Basophiles ...................................1 per cent Blood Non-Protein Nitrogen 31 mg. % Total plasma 6.2 ILLEGIBLE % Urea Clearance - Oct. 10, 1945 Urea Clearance - Oct. 22, 1st Hour Standard 52cc/minute or 96% of Normal48cc/minute or 90% 2nd Hour Standard 54cc/minute or 100% of Normal57cc/minute or 105% Blood Urea Nitrogen 21mg %.......................... 23.5 mg. % Clinical Diagnoses Ulcer, DuodILLEGIBLE Hemorrhage, gastrointestinal Anemia, secondary to hemorrhage Diverticulum of the esophagus ILLEGIBLE Intravenous injection of 5.1 ILLEGIBLE of Pu +4 as citrate complex on October 23, 1945. Case History White male of 40 years with a history of hemophilia. Entered hospital on October 5, 1945 for the 38th time for special blood studies, preadmissions having been for episodes of bleeding and complaints referable to hypertension which was first noted in 1929, but produced no marked symptoms until 1943. - 19 - HP-2 (continued) Termination T = 36.9 C: P=96; R=20; Rt. 161 cm; Wt. 69 Kg; B.P. ILLEGIBLE Well developed, well nourished ILLEGIBLE. Eyes show slight ILLEGIBLE ILLEGIBLE is enlarged with an apical systolic ILLEGIBLE. There are scattered ILLEGIBLE ILLEGIBLE bilaterally which clear on coughing. External ILLEGIBLE ILLEGIBLE are present. There is a deformity of the left hip, and joint changes are present in both arms and legs. Studies were conducted from October 10, 1945 to November 19, 1945 while on program for hemophiliac studies and therapy. A follow-up period concurred January 5, 1946 to January 14, 1946 while bleeding from the intestinal tract. - 20 - HP-2 (continued) Laboratory Data Before Injection After Injection Oct. 5, 1945 Jan. 5 - 14, 1946 Blood Counts - Oct. 6, 1945 Blood Counts - Nov. 7, 1945 Red Blood Cells - 4.7 x 106 per cm...........4.06 x 106 per cm. Hemoglobin - 15 grams/100 cc.............14.5 grams/100 cc White Blood Cells - 9,050...................................7,350 Differential: Polymorphs - 57 per cent.......................68 per cent Small Lymphs- 20 per cent........................4 per cent Inter. Lymphs- 8 per cent........................18 per cent Honocytes- 2 per cent.........................2 per cent ILLEGIBLE 8 per cent.........................8 per cent Basophiles ...................................1 per cent Blood Non-Protein Nitrogen 42 mg. % Total plasma 6.1 grams % Urea Clearance - Oct. 11, 1945 Urea Clearance - Oct. 22, 1945 1st Hour maximum 50cc/minute or 74% of Normal24cc/minute or 44% 2nd Hour Standard 23cc/minute or 43% of Normal28cc/minute or 52% Blood Urea Nitrogen 25mg %............................ 23 mg. % Clinical Diagnoses Hemophilia Hypertension, essential Heart Disease, Hypertension Coronary Insuffiency Arthritis, Chronic This man has been hospitalized on several occasions since January 14, ILLEGIBLE ILLEGIBLE ILLEGIBLE Severe hemorrhages from the intestinal tract. In each case he has recovered ing multiple transfusions. He is in regular attendance at the outpatient cILLEGIBLE and his condition otherwise remains essentially unchanged. - 21 - HP-3 Intravenous injection of 4.9 ILLEGIBLE of Pu +4 citrate complex on November 27, 194___ White women of 49 years, complaining of acneform ILLEGIBLE ILLEGIBLE over thighs, buttocks, trunk, and face; pigmentation of skin, puffiness the face and swelling of the ankles and feet. Diet has been of rather poor for a considerable period. No history of alcoholism. Examination T=37 C; P=ILLEGIBLE; R=20; B.P.-120/80; Ht. 157.5 cm; Wt. 6ILLEGIBLE Skin of dark tan color with some increased pigmentation in the creases of ILLEGIBLE palms; many small papule-pustular lesions on the chest, abdomen, back, upper and thighs; liver edge at right costal margin; slight pretibial and pedal Initial studies were carried out between November 13, 1945 and December 15, ILLEGIBLE Readmitted for follow-up studies on October 13, 1946 to October 15, 1946. Laboratory Data Before Injection After Injection Urine - No abnormalities noted Stool - Bile pigment present Blood Wassermann Reaction - Negative - 22 - HP-3 (continued) Blood Counts - Nov. 2, 1945 Blood Count - Oct. ILLEGIBLE Red Blood Cells - 4.3 x 106 per cm............5.6 x 106 per cm. Hemoglobin - 14.5 grams/100 cc............................ White Blood Cells - 5,700...................................6,800 Differential: Polymorphs - 59 per cent.......................69 per cent Lymphs- 39 per cent.......................25 per cent Eosinophilies- 2 per cent................................... Honocytes- ...................................5 per cent Basophiles ...................................1 per cent Before Injection After Injection Non-Protein Nitrogen 34 mg. %.........................31 mg % Total Protein 4.8 gm %.......................5.8 gm. % Alb/Glob 3.4/1.4..........................4.3/1.5 Icterus ILLEGIBLE 18 ....................................7 P.S.P. 15 min. 35 per cent.................................. 2 hrs. 70 per cent total............................ Urea Clearance 1st Hour Standard 38cc/minute or 70% of Normal................. 2nd Hour Standard 35cc/minute or 64% of Normal................. Ceph. Floc - negative Thymol Turbidity - 23ILLEGIBLE Alkaline ILLEGIBLE Bodanzky Units Clinical Diagnoses Hepatitis ILLEGIBLE (unknown) Hypoproteinemia Dermatitis (cause unknown) When last examined in October 1946, she appeared to be in excellent health. - 23 - HP-4 Intravenous injection of 4.9 of Pu +4 as citrate complex on November 27, 1943. Case History Eighteen year old white girl with a history of Cushing's Syndrome since 1941. Entered hospital on October 29, 1945 for the fifth time for further treatment of that condition. Chief complaints this time wre headaches and back pain referable to her hypertension and osteoporosis. Studies were carried out between October 29, 1945 and December 20, 1945 with follow-up periods on February 11, 1946 to February 17, 1946 when she was given penicillin for a urinary tract infection, and March 13, 1947 to March 29, 1947 while under treatment for heart ILLEGIBLE Examination T=36.9 C; P=100; R=22; B.P.=205/130; Ht. 145.5 ILLEGIBLE Short heavy set female with florid complexion, buffalo type obesity, dry, ILLEGIBLE thin skin with purple ILLEGIBLE over trunk and back and multiple purpuric areas extremities. Marked hirsutism over face, sparse pubic, axillary, and scalp OphthalILLEGIBLE exam shows narrowed and tortuous vessels. Heart is enlarged Tenderness over spine and in right lower quadrant of abdomen. Laboratory Data Before Injection - Oct. 29, 1945 After Injection - Mar Urine - Alb C; 2-10 ILLEGIBLE and occasional Alb 3+ granular cast Stool- ILLEGIBLE negative Hyalin and Granular Blood Wassermann Reaction - Negative Blood Counts-Oct. 30, 1945 June 30, '46 Dec. 31, '46 - 24 - HP-4 (continued) Red Blood Cells -5.3 million..................................... per ILLEGIBLE Hemoglobin 15 gms per 100 cc.....................16 gm/100 ml White Blood Cells 10,000 6,900.........................7,350 Differential: Polymorphs - 77 per cent 74 per cent...................... Lymphs- 20 per cent 22 per cent....................... Monocytes 2 per cent 4 per cent....................... Basophiles 1 per cent.................................... Hemat. 47% R.F.C. Serum ILLEGIBLE ILLEGIBLE Nov. 1, 1945 March 29, 1947 Blood Protein (plasma) 6.3 gm %.................................. Blood Non-Protein Nitrogen 35 mg. %......................64 mg. % Urea Clearance - Nov. 1, 1945 1st Hour Max. 29 cc/minute or 38% of Normal 2nd Hour Max. 39 cc/minute or 52% of Normal March 25, 1947 Renal blood flow 44.5/min ILLEGIBLE ILLEGIBLE 17.1 Maximum tubular capacity 2.88 Norman ILLEGIBLE 594 117 77 P.S.P. Test 60% in two hours. Clinical Diagnoses Cushing's Syndrome (Basophile ILLEGIBLE of the pituitary gland) Hypertension Heart Disease, Hypertensive Osteoporosis Urinary Tract Infection S. albua Nephropathy, Hypertensive Uremia The course was progressively downward during the one and a half years following administration of Pu. Heart failure and Uremia characterized the terminal ILLEGIBLE her illness. Our final - 25 - HP-4 (continued) collections of urine were made during March 1947, at time the urine contained sufficient protein to give a 3+ reaction. ILLEGIBLE in ILLEGIBLE on April 29, 1947. Anatomical Diagnoses Basophilic adenoma of pituitary gland Hypertrophy of the left ventricle Atrophy of thyroid gland Hypertrophy of adrenal glands Hypoplasia of uterus and ovaries Osteoporosis of spine and pelvis Chronic Nephritis No tissues were obtained for analysis for Pu since death occurred in another HP-5 Intravenous injection of 5.1 ILLEGIBLE Pu +4 as a citrate complex on Nov. 30, 19ILLEGIBLE Case History White male of 56 years with a three year history of increasing generalized weakness and difficulty in walking and swallowing. Entered hospital on November 19, 1945 for study. Examination T=35.6 C; P=72; R=32; B.P.=126/92; Ht. 172.9 cm.; Tall thin man with tremor of hands, slow speech, and obvious muscular fission Bilateral Babinski's with hyperactive deep tendon reflexes. No other funding note. Studies were carried out on November 19, 1945 to December ILLEGIBLE, ILLEGIBLE. - 26 - HP-5 (continued) Laboratory Data Before Injection After Injection Urine - No abnormalities found Stool - ILLEGIBLE Negative Blood Wassermann Reaction - Negative Blood Counts Red Blood Cells - 4.6 x 106 per ILLEGIBLE Hemoglobin - 16.3 gm./100 cc. White Blood Cells - 7,400 Urea Clearance - Nov. 29, 1945 1st hour standard 52 cc/minute or 96% of normal 2nd hour standard 37 cc/minute of 69% of normal Blood Urea Nitrogen 14.6 mg % B.N.R. - 12%; -28% Clinical Diagnoses Amyotrophic Lateral Sclerosis Death occurred on April 29, 1946 Anatomical Diagnoses ILLEGIBLE lateral ILLEGIBLE ILLEGIBLE, bilateral Emaciation ILLEGIBLE Atrophy of Viscera Arteriosclerosis, generaliILLEGIBLE Renal cysts ILLEGIBLE of right kidney ILLEGIBLE ulcers Thrombi of periprostatic ILLEGIBLE - 27 - HP-6 Intravenous injection of 5.3 of Pu +4 as citrate complex on Feb. ILLEGIBLE, ILLEGIBLE Case History White male of 45 years with a history of Addison's Disease six January, 1945. Had pellets of ILLEGIBLE implanted on October 31. Admitted to hospital again on December 14, 1945 because of multiple staphyILLEGIBLE infections on eyelids and toes. Examination T=36.7C; P=60; R=20; B.P. 122/78; Ht. 170 cm.; Wt. 49 Kg. Well developed but thin male with deeply pigmented skin; generalized lymphadenopathy; both lids of left eye red and swollen with scaling conjunctivae markedly injected; Right big toe nail ingrown on medial aspect with swelling, redness, and heat in surrounding area; purulent discharge in corner of nail bed. Other toes developed evidence of infection and all were treated with compresses and surgical excision of nails. While convalescing, studies were carried out from January 27, 1946 to February 23, 1946. Follow-up studies during June, 1947. Condition was unchanged. Laboratory Data Before Injection After Injection Urine - Negative except for 10 WBC per high powers field. Stool - Comiac Negative Wassermann Reaction - Negative - 28 - HP-6 (continued) Blood Counts Red Blood Cells - 3.98 million/cm. Hemoglobin - 13 gms. % White Blood Cells - 3,300 Differential Polymorphs 38 per cent Lymphs 48 per cent Eosinophiles 11 per cent Honocytes 3 per cent Urea clearance - January 29, 1946 1st hour Standard - 56 cc/minute or 103% of Normal 2nd hour Standard - 51 cc/minute or 95% of Normal Blood Urea Nitrogen 14.5% Mg. % Blood Non-protein Nitrogen 27 mg. Clinical Diagnosis Addison's Disease HP-7 Intravenous injection of 6.3 of Pu +4 as citrate complex on Feb. 8, 1946 Case History White female of 59 years with a history of Rheumatic heart disease for twenty years and an overactive thyroid since 1944. She had been treated in this hospital during April and November, 1945 and was readmitted on January 21, 1946 for further treatment because of heart failure. Examination T=36.6C; P=76; R=22; B.P.=128/60; Ht. 165.3 cm.; Wt. 6 Kg. Well developed, fairly well nourished woman who is ILLEGIBLE and coughs frequently; Neck vessels are distended with visible pulsations; marked pitting edema from feet to hips; Prominent nodule above sternal end of right clavicle; heart is markedly - 29 - HP-7 (continued) enlarged to left, rhythm is totally irregular with a systolic manner audible overall of ILLEGIBLE. P2 is ILLEGIBLE; Signs of fluid at right lung base; Liver is palpated 2-3 cm. below costal margin and is tender. Laboratory Data Before Injection After Injection Urine - Alb. 1 plus; no RBC or Caste Stool - ILLEGIBLE Negative Wassermann Reaction - Negative Blood Counts - January 23, 1946 February 20, 1946 Red Blood Cells - 3.26 x 106 per cm......................... Hemoglobin - 12.6 gm. %..................................... White Blood Cells - 4,750..............................5,250 Differential Polymorphs 64 per cent..................64 per cent S. Lymphs 19 per cent..................22 per cent L. Lymphs 5 per cent...............I.L. 3 per cent Honocytes 6 per cent....................9 per cent ILLEGIBLE 3 per cent.............................. Regenerated 3 per cent....................2 per cent Blood Non-Protein Nitrogen 26 mg. % Total Plasma Protein 6.5% WBC range from 3,400-6,100 B.H.P. plus 6% plus 7% during hospital stay. Differential remained essentially as reported. Urea Clearance - Feb. 8, 1946 1st Hour Standard 51cc/minute or 94% of Normal 2nd Hour Standard 52cc/minute or 96% of Normal - 29 - HP-7 (continued) Clinical Diagnoses Rheumatic Heart Disease Toxic Modular Coiter Myocardial Insufficiency Mitral Insufficiency Auricular Fibrillation Death occurred on October 27, 1946 in another hospital. No post mortem could be obtained. Probable cause of death - Lobar Pneumonia. HP-8 Intravenous injection of 6.5 ILLEGIBLE of Pu +4 as citrate complex on March 9, 1946 Case History White female of 41 years with a history of scleroderma since January 1945. In addition she has suffered from peptic ulcer, proven by ILLEGIBLE to be in the duodenum, at intervals since May 1944. Entered this hospital for treatment on February 19, 1946. Studies were carried out from February 19, ILLEGIBLE to May 13, 1946. Examination T=36.5C; P=82; R=20; B.P.=128/76; Ht. 163.5 gm; Thin and pale female with important findings limited to the skin; On the facILLEGIBLE is a loss of the nasolabial folds, eyelids are tight and the skin is drawn an the mouth. Over the eternal and clavicular regions, it is thick and pigmentILLEGIBLE particularly about the sites of the bilateral ILLEGIBLE. Skin over hands fingers is thick and tightly stretched so that approximation of fingers to the is impossible, and there is blanching over bony prominances. Similar conditions but to lesser extent exists over - 30 - HP-8 (continued) lower extremities. Laboratory Data Before Injection After Injection Urine - Negative except for a rare hyaline cast Stool - ILLEGIBLE Negative Blood Wassermann Reaction - Negative Blood Counts - February 22, 1946 Blood Counts - Aug. 22 Red Blood Cells - 4.7 x 106 per cm.......4.05 million per cm Hemoglobin - 13.9 gm. %..........................14.5 gms. % White Blood Cells - 9,500.............................11,900 Differential Polymorphs 71 per cent..................88 per cent S. Lymphs 8 per cent.............................. L. Lymphs 14 per cent..................12 per cent Honocytes 1 per cent.............................. Monocytes 6 per cent.............................. Total Plasma Protein 6.3% gms. % Blood Non-protein Nitrogen 30.0 mg. % Blood Urea Nitrogen 10.0 mg. % Calcium 10.0 mg. % Phosphorus 3.0 mg. % Urea Clearance - Feb. 20, 1946 1st Hour Standard 41cc/minute or 76% of Normal 2nd Hour Standard 51cc/minute or 94% of Normal Clinical Diagnoses Scleroderma Ulcer, duodenal, chronic HP-9 Intravenous injection of 6.3 ILLEGIBLE Pu +4 as citrate complex on April 3, 1946 Case History White male of 66 years with history of generalized dermatitis and increasing muscle weakness since fall of 1945. All attempts at therapy produced no permanent benefits. - 31 - HP-9 (continued) Examination T=36.4C; P=84; R=20; B.P.=128/76; Ht.169 cm; 63 kg. Man appears chronically ill, skin is dry and loose with many rough, ILLEGIBLE popular areas on trunk, neck and extremities, face is red, and eyelids and ears are red and edanatous. Extremities show diminished muscle power with some degree of atrophy. Initial studies carried out March 11, 1946 to May 9, 1946. Follow-up on May 1, 1947 to May 27, 1947. Laboratory Data Before Injection After Injection Urine - No abnormalities found Stool - ILLEGIBLE Negative Wassermann Reaction - Negative Blood Counts - March 13, 1946 Blood Counts - January 25, 1947 Red Blood Cells - 3.9 x 106 per cm.............4.1 x 106 cm. Hemoglobin - 12.3 gm. %.......................12.2 gm/100 ml White Blood Cells - 6,250....................7,300 ILLEGIBLE Differential Polymorphs 70 per cent..................61 per cent S. Lymphs 12 per cent.................(9 per cent) L. Lymphs 5 per cent.....................( total ) Honocytes 13 per cent..................17 per cent Eosionphiles 0 per cent...................12 per cent Basophiles 0.............................1 per cent Platlets in ILLEGIBLE abundant Urea Clearance - March 16, 1946 1st Hour Max 54cc/minute or 72% of Normal 2nd Hour Standard 20 cc/minute or 37% of Normal (Patient had difficulty in voiding for last specimen) Clinical Diagnoses Dermatomyositis Death on July 2, 1947 from aspiration pneumonia. - 32 - HP-9 (continued) Anatomical Diagnoses Generalized muscular atrophy Dermatitis Purulent Bronchitis Jejunal polyp Bronchopneumonia Bilateral Helanosis Coli Hypertrophy and dilation of heart Prostatic hypertrophy Passive congestion of liver and spleen HP-10 Intravenous injection of 6.1 of Pu +4 as citrate complex on July 16, 1946 Case History Negro male of 52 years with a history of heart disease since 1926. He has had both rheumatic fever and syphilis. First bout of severe decompensation occurred in 1935, but none followed until 1944, since when failure has been repeatedly present. Entered this hospital March 24, 1946 in severe cardiac decompensation, and subsequently suffered from an acute rheumatic process. While convalescing, studies were carried out from July 9, 1946 to August 15, 1946. Examination T=36C; P=92; R=22; B.P. =168/84; Ht. - Wt. 71 kg. Well developed, fairly well nourished negro, slightly ILLEGIBLE and ILLEGIBLE Heart is enlarged to the left, rate is regular; systolic murmur at apex, and a protodiastolic gallop; Lungs showed a few scattered rales at both bases; Slight pitting ILLEGIBLE in lower extremities. - 33 - HP-10 (continued) Laboratory Data Before Injection After Injection Urine - No abnormalities found Stool - ILLEGIBLE Negative Blood Wassermann - Negative on one occasion; 2 plus with cholesterinized antigen Blood Counts - July 9, 1946 Blood Counts - Aug. 13 Red Blood Cells - 5.49 million per cm....................... Hemoglobin - 13.3 gms. per 100 cc........................... White Blood Cells - 5,650................................... Differential Polymorphs 31 per cent..................42 per cent S. Lymphs 46 per cent..................28 per cent L. Lymphs 6 per cent...................17 per cent ILLEGIBLE 5 per cent....................3 per cent Basophiles 2 per cent....................2 per cent Monocytes 7 per cent....................8 per cent Degenerated 3 per cent.............................. Urea Clearance - July 9, 1946 1st Hour Max. 67.4cc/minute or 90% of Normal 2nd Hour Max. 62.4cc/minute or 84% of Normal Urea Clearance - Aug. 1, ILLEGIBLE 1st Hour Standar 40 cc/min or 66.9 cc/minute c Non-protein Nitrogen 22 mg.% Urea ILLEGIBLE. 11 mg. % Clinical Diagnoses Heart Disease, probably rheumatic Syphilis, latent, treated Sinusitis, ILLEGIBLE and frontal Dental caries luetic - 34 - HP-11 Intravenous injection of 6.5 of Pu +4 as citrate complex on Feb. 20, 1940 Case History White male of 68 years with a history of alcoholism along with inadequate diet dating back many years and possible cardiac disease for seven months. Entered the hospital December 12, 1945 because of persistent difficulties in breathing and increase in the size of his abdomen. T=36.5 C; P=90; R=20; B.P.=130/50; Ht. 171 cm.; Wt. Poorly nourished, weak, thin male who is slightly confused; some generalized ILLEGIBLE; few basilar rales bilaterally; liver down 7- 9 fingerILLEGIBLE below costal margin, tender, knobby, with blunt edge; no other findings of no Laboratory Data Before Injection After Injection Urine - Dark in Color with no abnormal findings Stool - ILLEGIBLE negative on admission Blood Counts Red Blood Cells - 4.62 million per ILLEGIBLE. Hemoglobin - 14.8 gms. per 100 cc. White Blood Cells - 9,400 Differential Polymorphs 75 per cent Lymphs 20 per cent Monocytes 4 per cent Basophiles 1 per cent Blood Non-protein Nitrogen 49 mg. % Total Plasma Protein 6.7 gm. % Alb/Grob 3.2/3.5 II 4 BSP dye retained 72 per cent Death on February 26, 1946 at 4:50 A.M. - 35 - Anatomical Diagnoses (Autopsy done 5 hours after death) Cirrhosis of the liver Ascites Thrombosis Pertal Vein IV. Results A. Clinical Results Acute toxic effects from the small dose of Pu administered were neither expected nor observed. Because of specific localization of the metal in the liver and skeleton, these are the tissues most likely to be affected. There was no evidence that anemia developed or that the white blood cell count was ILLEGIBLE. With regard to ultimate effects, it is too ILLEGIBLE to predict what may occur. Clinical evidence suggestive of liver damage has not appeared. ILLEGIBLE specific tests of liver function have not as a rule been listed in the ILLEGIBLE the possibility that injury to this organ might appear has been considered. margin of safety in the liver is so large that so-called liver function too usually do not give positive results until there is actual evidence of ILLEGIBLE decompensation. Symptoms and signs are often as reliable as other methods assessment. Two of our subjects undoubtedly had liver damage prior to inj (HP-3 and HP-7). HP-3, a women, was recovering from a low grade hepatitis injected and continued to make satisfactory recovery afterward. Subject ILLEGIBLE also a women, died without an autopsy but from the clinical history, there but little doubt that she suffered from chronic passive congestion of the ILLEGIBLE and probably had cardiac cirrhosis. She remained - 36 - under close observation ILLEGIBLE shortly before death and no signs suggestive of a deterioration in her ILLEGIBLE status were noted. Admittedly this is no proof that plutonium in the amount given fail to inflict further damage on already diseased livers, but there was certainly no acute or severe insult to that organ. In summary, it may be stated that within a period of two years, the intravenous injection of a single dose of 5 to 6 gamma of Pu +4 complexed with citrate was without subjective or object clinical effects.