conspectus of researchon copper metabolism and requirements

A CONSPECTUS OF RESEARCH ON COPPER
METABOLISM AND REQUIREMENTS OF MAN
KARL E. MASON -
Consultant—NIAMDD, National Institutes of Health,
Bethesda, Maryland 20014
Pages 1979-2066
THE JOURNAL OF NUTRITION
VOLUME 109, NUMBER 11, NOVEMBER 1979
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

TABLE OF CONTENTS
PAGE
Introduction 1981
Copper in the human body 1982
Copper proteins 1983
Ceruloplasmin (ferroxidase I ) 1984
Superoxide dismutase 1986
Cytochrome c oxidase 1987
Lysyl oxidase 1987
Tyrosinase (phenoloxidase ) 1987
Dopamine /?-hydroxylase 1988
Metallothionein 1988
Other cuproproteins 1988
Absorption of copper 1989
Mechanisms 1990
Amount 1991
Transport of copper 1991
Intestine to liver 1991
Metabolism and distribution 1992
Copper in blood 1993
Excretion of copper 1994
Biliary excretion 1995
Salivary excretion 1996
Gastrointestinal excretion 1996
Urinary excretion 1997
Sweat loss 1997
Menstrual loss 1997
Copper in the diet 1997
Copper in foods 1997
Dietary intake of copper 1998
Copper metabolism in prenatal and postnatal life 2000
Influence of pregnancy 2000
Influence of oral contraceptives 2001
Placental transfer 2002
Infancy and childhood 2002
Dietary copper deficiency 2004
Menkes' disease 2005
Manifestations 2005
Metabolic abnormalities 2007
Therapy 2008
Animal models 2009
Wilson's disease 2009
Nature of the disease 2009
Metabolic abnormalities 2010
Therapy 2012
Related disorders 2013
Hypocupremia 2014
Hypercupremia 2015
Copper toxicity 2020
Interrelationships between copper and other elements 2022
Human requirements 2024
Infants 2025
Young children and adolescents 2030
Adults 2032
Resume 2036
Acknowledgments 2039
Literature cited . . 2039
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

INTRODUCTION
The discovery of copper, following that
of gold and silver, goes back to the post
glacial epoch in southwestern Asia, espe
cially the semi-arid regions of Central
Anatolia and Iran, during the period 6000
to 3000 B.C. (834). The later Bronze Age
(3000-1000 B.C.) takes its name from the
use during this period of bronze, an alloy
of copper and tin. The word copper is de
rived from the Latin cuprum, a corrup
tion of cyprium, named after the island of
Cyprus which was an important source of
copper about 3000 B.C. Thus, aside from
gold and silver, which were employed
chiefly for ornamental purposes, copper
represents the first metal to be used by
mankind for more practical purposes. The
alloys of copper and tin (bronze), copper
and zinc (brass), and of copper, zinc and
nickel (nickel silver or German silver),
have had a tremendous impact upon
human development over many past
centuries.
Beginning about the time of Hippocrates
(400 B.C.) copper compounds were com
monly prescribed in the treatment of men
tal, pulmonary and other diseases. During
the 19th century many different copper
compounds came into use in the unsuc
cessful treatment of a wide variety of
human diseases (447). Copper amulets
were also in vogue. Not until about 150
years ago was copper recognizd as a nor
mal constituent of blood. And as early as
1900, Abderhalden (1) recorded that ani
mals kept on a whole milk diet developed
an anemia that could not be prevented by
additions of inorganic iron, and recog
nized the fact that some other mysterious
substance, probably organic, was wanting.
But the thought that copper should ever
be considered an important component of
the diet for either animals or man was
quite remote until the second decade of
this century, following closely on the heels
of the discovery of vitamins A, B, C, D
and E. At this time there appeared the
reports of Hart et al. (311, 312) and Waddell
et al. (812) corroborating the obser
vations of Abderhalden and indicating that
1981
either extracts or the ash of dried cabbage,
corn meal and chlorophyll, all essentially
iron-free, definitely favored assimilation
and utilization of iron in hemoglobin build
ing in rabbits fed a whole milk diet. Also,
at about this same time, McHargue (507)
recorded results of studies on rats fed puri
fied diets deficient in copper, zinc and/or
manganese in which he employed impro
vised glass-lined cages. This represents the
first known use of cages of this type. Mc
Hargue concluded that manganese in par
ticular, and possibly copper and zinc, have
important functions in animal metabolism.
There followed the classic studies of
Hart, Steenbock, Waddell and Elvehjem
(313) demonstrating that rats fed ex
clusively on milk developed an anemia
which was responsive to iron only after the
addition of copper; also, that the same
relationships prevailed in chicks fed diets
of milk and rice ( 187). Later came evi
dence from experimental studies with pigs
( 188) that whereas impure organic salts of
iron cured nutritional anemia, the pure
salts failed to do so unless supplemented
with small amounts of copper. Recognition
of the clinical importance of these early
observations was first given by Mills (520,
521) and Josephs (389) who reported that
copper supplements accelerated hemo
globin synthesis in hypochromic anemia of
infants treated with iron salts. Although
several investigators were not in agree
ment (274, 275, 476), others confirmed
these findings (186, 399, 455, 799) and ex
tended them to hypochromic microcytic
anemia of adults (521). The early history
and later developments are detailed in
several reviews (99, 540, 693). During this
same period appeared Tompsett's report
( 785 ) of the first copper balance study car
ried out on 17 human subjects, indicating
that the normal daily intake appeared to
vary from 2.0 to 2.5 mg/day. In the same
Received for publication October 16, 1978.
1 Requests for reprints should be directed to Nutri
tion Institute. Science and Education Administration,
Building 307. Room 217, USDA. Beltsville. Maryland
20705.
- Deceased December S. 1978.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

1982 KARL E. MASON
year Daniels and Wright (142) reported
the first balance study on young children
(4-6 years old) indicating an average in
take of 1.48 mg/day and a requirement
not less than 0.10 mg/kg/day. These esti
mates are in remarkably good agreement
with those recorded in the later literature
(see p. 2032). Thus, the stage was set
for an extensive exploration of the metab
olism, deficiencies, excesses and require
ments of copper in man witnessed during
the past half century.
An overview of what has transpired dur
ing this period should include: 1) a vast
number of studies on copper depletion
and effects of copper supplementation in
laboratory animals; 2) recognition of natu
rally occurring deficiency of copper in farm
animals, especially cattle and sheep, in geo
graphic areas where there exists a defi
ciency of copper in the soil and vegeta
tion; 3) exhaustive analyses of the copper
content of plant and animal tissues, in
cluding those of man; 4) recognition of
states of copper deficiency in the human
infant reared on diets similar to those em
ployed in inducing copper deficiency states
in experimental animals, combined with
states of protein calorie malnutrition, in
fection and other metabolic disorders;
5) the effects of parenteral alimentation,
especially in infants suffering from devel
opmental anomalies of the alimentary tract
and post-surgical stresses; 6) recognition
of two genetically determined abnormali
ties of copper metabolism in man ( Menkes'
kinky-hair, or steely-hair, syndrome affect
ing primarily young infants and Wilson's
disease, affecting the adolescent and adult,
together with therapeutic measures for the
same; and 7) exhaustive studies of the
many copper-containing proteins distrib
uted throughout the blood and other tissues,
and their role in metabolic processes of
man and lower animals.
In the present review it is not possible
to consider the first three categories of re
search mentioned above, other than to
make reference to certain observations
which have particular relevance to the un
derstanding of copper metabolism and re
quirements of man. For additional infor
mation on the first areas of research men
tioned the reader is referred to a rather
extensive series of reviews (6, 7, 32, 71,
99, 139, 140, 185, 211, 257, 319, 461, 493,
779, 798).
COPPER IN THE HUMAN BODY
Many opinions have been expressed con
cerning the total copper content of the
human body. More than 40 years ago Chou
and Adolph (115), in studies based upon
analyses of nine organs from two adults at
autopsy, in which they found an average of
about 116 mg, estimated that the human
body contained between 100 and 150 mg
of copper. Since then estimates have been
reduced. Cartwright and Wintrobe (105)
considered 80 mg of copper to be a more
reasonable estimate for a 70-kg man. Sass-
Kortsak (666), on the basis of data of
Tipton and Cook (781), calculated a mean
of 75 mg, with a range of 50 to 120 mg.
A slightly lower estimate of 70 mg has been
given recently by Sumino et al. (762),
based upon analyses of 18 different organs
and tissues of 30 Japanese subjects, victims
of accidental deaths, 28 of whom ranged
in age from 20 to more than 60 years.
These investigators also estimated that
about one-third of body copper was in the
liver and brain combined, one-third in the
musculature, and the remaining third dis
persed in other tissues. The mean content
of copper in human liver is about \5% of
total body copper (668).
It has long been recognized that the
liver and brain contain a much higher con
centration of copper than other organs and
tissues, amounting to about 8 mg in each
of these organs ( 105). The liver content
is, in large part, related to its function as
a storage organ for copper and also as the
only site of synthesis and release of ceruloplasmin.
Copper is unevenly distributed
in the brain. While some investigators re
port very little difference in the copper
content of grey and white matter of the
cerebral cortex (102, 138, 613), others have
found a considerably higher content in the
grey than in the white matter ( 134, 138,
178, 780, 828). The substantia nigra and
locus ceruleus, both components of the
grey matter, are exceptionally rich in cop
per ( 134, 178). Possible relationships of
the pigmented nerve cells of the locus
ceruleus to their content of melanin and
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 1983
to tyrosinase have been suggested and ex
plored by in vitro studies with no positive
results, possibly due to the use of necropsy
material rather than fresh tissue (178).
Gubler et al. (285) record mean copper
values (in terms of /*g/g wet weight) of
6.3, 6.5, 5.7, 4.2, 2.6 and 1.7, repsectively,
for whole brain, cerebellum, basal ganglia,
cerebral cortex, brain stem and cervical
spinal cord. These data are based on five
adult males who died following traumatic
injuries.
Compared to the liver and brain, lesser
levels of copper are found in the heart,
kidney, pancreas, spleen, lungs, bone and
skeletal muscle, diminishing generally in
the order mentioned (102, 115, 182, 208,
285, 397, 509, 691, 762, 786). Gubler et al.
(285 ) give mean values (/¿g/gwet weight )
of 5.3, 3.2, 2.2, 1.0 and 0.9, respectively, for
liver, heart, kidney, spleen and skeletal
muscle. The total copper content of the
whole liver, brain, kidney, heart and
spleen, respectively, is estimated to be 8.0,
8.0, 1.2, 0.9 and 0.1 mg (105).
In the fetus and infant, the distribution
of copper is quite different from that in the
adult. During fetal life there is a progres
sive increase in percentage of copper and
iron in the body, while that of zinc re
mains relatively constant (704), such that
at birth the liver and spleen contain about
1/2 the copper, l/4th the zinc and l/8th
the iron in the whole body (846). Liver of
the newborn has an exceptionally high con
centration of copper, approximately 6 to
10 times that of adult man (538, 844, 846).
After the first few months of life these con
centrations decrease rapidly to those of the
adult (69, 565, 845). During the transition
from infancy to the early years of life, there
is a decrease in copper concentration in
kidney, heart and spleen and an increase
in brain (69, 845), which is relatively low
in the newborn (780).
On the basis of analyses of major organs
of man in different geographic areas Forssen
(222) states that the Finns have some
what lower copper levels than Americans,
and that peoples of Africa and the Near
and Far East have levels 1.5 to 2 times
those of the Finns. Whether these obser
vations may or may not reflect differences
in soils, dietary habits or ethnic factors is
not clear. They are in accord with earlier
observations of Schroeder et al. (691) who
found that other races have larger mean
amounts of copper in aorta, kidney, liver,
lung and spleen than do Americans, Swiss
and African Caucasoids, and that Orientals
have especially high values.
The levels of copper in human hair have
been the subject of numerous studies in
the hope that such information might pro
vide some measure of the copper status of
the body, especially states of copper de
ficiency. Wide individual variations with
respect to age and sex (415), to hair pig
mentation (357) and to exogenous con
tamination (298) have indicated that cop
per levels in hair have little meaningfulness
in evaluating the status of copper in
man (798). However, a recent report
(378) states that determination of copper
in hair may be useful in evaluating total
liver content of copper.
COPPER PROTEINS
Many proteins in tissues have the ca
pacity to form copper complexes. Some of
these do not occur in mammalian species,
but appear only in lower animal forms and
plants (e.g., hemocyanin, lacease, ascorbic
acid oxidase, polyphenol oxidases, turacine).
There have come to be recognized a
large number of cuproproteins of mam
malian species in which copper is part of
the molecular structure and in which there
is a characteristic ratio between moles of
protein and atoms of associated copper.
By virtue of these characteristics and the
fact that the contained copper does not
dissociate during isolation of the protein,
these cuproproteins function as enzymes
and are often grouped with other metalcontaining
enzymes, all of which are re
ferred to as "metalloproteins." Those ac
cepted in this category include ceruloplasmin,
Superoxide dismutase, cytochrome c
oxidase, lysyl oxidase, tyrosinase and dopamine
ß-hydroxylase. One other important
metalloprotein, metallothionein, lacks enzymic
properties but is capable of binding
copper as well as certain other heavy
metals. Several plasma and connective tis
sue oxidases isolated from mammalian
organs and tissues are at least copper de
pendent (monoamine oxidase, spermine
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

1984 KARL E. MASON
oxidase, diamine oxidase, benzylamineoxidase,
etc.) but their significance in hu
man metabolism is rather obscure. These
proteins will be discussed in the general
order mentioned. It may be noted that this
panorama of cuproproteins has been sub
ject to frequent changes in identification,
description, terminology and functional at
tributes over recent years. Hence, some
statements and views expressed may be con
sidered in a state of flux subject to consid
erable revision as new advances are made.
Ceruloplasmin (ferroxidase I)
The classic studies of Holmberg and
Laurell (346, 347 ) described a blue plasma
copper-containing protein which they
named "ceruloplasmin." They reported that
it was an «-globulinrepresenting almost all
the copper present in mammalian plasma,
and differed remarkably from all other
such proteins in its molecular weight of
about 151,000 daltons, its copper content
of about 0.32% and its content of eight
atoms of copper per molecule. Human
ceruloplasmin has been highly purified and
crystallized as tetragonal crystals (537).
According to Scheinberg and Morell (676),
who provide an excellent review of the sub
ject, its molecular weight may vary from
132,000 to 160,000, depending upon the
method employed. More recently, it has
been reported that its molecular weight is
134,000 ±3,000, and that the number of
copper atoms varies from 6 to 6.6 (653).
Of these, about one-half are in the cupric
and the other half in the cuprous state
(395). The nature of the copper-protein
bond is not known. It is also recognized
that ceruloplasmins from different animals
show some cross-reactivity (395) and that
they differ in p-phenylenediamine oxidase
activity (502). Two other blue oxidases,
ascorbate oxidase and lacease are enzymes
found only in the plant world, where
ceruloplasmin does not exist. An excellent
comparison of the chemical structure and
physiological properties of these three ox
idases is given by Dawson et al. (151).
Ceruloplasmin contains about 8% car
bohydrate, composed principally of glucosamine,
mannose and galactose. Almost,
if not all, of its oligosaccharide side chains
are terminated by a sialic acid residue, ap
parently essential for its survival in the cir
culation (550). Copper is incorporated into
ceruloplasmin only at the time of its syn
thesis in the liver and the liver is its only
site of synthesis (439, 742, 824). In the
blood stream ceruloplasmin does not ex
change its copper with other copper com
plexes in the serum or blood cells. In vitro,
copper is released from ceruloplasmin only
after acidification, indicating strong protein
binding of copper. Ceruloplasmin is hetero
geneous, existing in several forms depend
ing upon its prosthetic carbohydrate
groups (65, 535).
A moderate oxidase activity of cerulo
plasmin toward a variety of substrates, of
which p-phenylenediamine is the best, was
recognized by Holmberg and Laurell (348)
in 1951. This enzyme reaction, as employed
in the method of Ravin (629), has pro
vided a useful means of qualitatively mea
suring ceruloplasmin in body fluids. There
has also been developed an immunological
method using highly purified human ceru
loplasmin as an antigen to incite specific
antibody, usually in rabbits (339, 490, 674).
Careful studies of Rosenberg et al. (644)
demonstrate that both methods yield com
parable results. Although ceruloplasmin is
primarily a plasma protein, it is found also
in synovial, ascitic and cerebrospinal fluids
(744).
Much interest has centered around this
protein not only because of the mystery
surrounding its true physiological functions
but also because of impairment of its syn
thesis and other possible derangements in
Wilson's disease (p. 2009) and its low plasma
levels associated with Menkes' kinky-hair
(steely-hair) syndrome, a genetically de
termined copper-deficiency disease in chil
dren (p. 2005). It is of interest that in the
early studies of Holmberg and Laurell,
who were aware of recent evidence of
abnormalities of copper metabolism in
Wilson's disease, ceruloplasmin plasma
levels were found to be normal in a pa
tient said to have Wilson's disease but who,
several years later, was found not to be a
victim of that disease. Hence, as stated by
Scheinberg (671 ), "The capstone of physi
ological significance to these discoveries
ironically and undeservedly eluded them/'
This same type of study carried out by
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 1985
Scheinberg and Gitlin (674) laid the basis
of the concept that Wilson's disease is
usually characterized by a lifelong defi
ciency or absence of ceruloplasmin, and
that this deficiency is autosomal recessive
in nature.
Advances in knowledge concerning ceru
loplasmin, as well as the role of copper in
human metabolism, have in large part been
the consequence of intensive research on
the nature, cause and treatment of Wilson's
disease, resulting in truly voluminous lit
erature. In contrast, investigations con
cerning Menkes" disease have focused
largely on the role of metallothionein-like
cuproproteins and defects in intestinal ab
sorption of copper. Here also, in the in
terim since its first recognition in 1962
(513), an extensive literature has evolved.
On the other side of the ledger are ad
vances made during the past 12 years in
elucidating the role of copper in iron me
tabolism. These have, in large part, re
solved questions in the minds of those
investigators of 50 years ago (311, 313)
who first recognized the important role of
copper in nutrition.
The role of ceruloplasmin in biological
processes began to receive some rational
explanation about 1960, with evidence that
in vitro it catalyzed the oxidation of fer
rous iron ( 141). Further investigation of
this oxidase activity of ceruloplasmin pro
vided indications that it represented an
enzyme in human plasma responsible for
oxidation of ferrous iron, and that the latter
was the substrate for its greatest activity
(504, 583, 585). Based on these findings,
Osaki et al. (583) proposed that the name
ferroxidase may be more useful than desig
nating this enzyme as a "sky-blue substance
from plasma." Since then, ceruloplasmin
and ferroxidase I have become synonymous
terms. However, in the discussion to follow
the more common designation "ceruloplas
min" will be used.
The hypothesis proposed was that by
this mechanism ceruloplasmin may play an
important biological role in the release and
transfer of iron from storage cells to plasma
transferrin. This concept was promptly
supported by studies on copper-deficient
swine (445, 446, 625), and by liver per
fusion studies on dogs and swine (584).
The studies on copper-deficient swine
clearly demonstrated the effectiveness of
ceruloplasmin in counteracting the defec
tive movement of iron from hepatic cells,
reticuloendothelial cells and the intestinal
mucosa to the plasma. This general subject
has been extensively discussed and re
viewed elsewhere (211, 226-230, 390, 446).
The current concept of ceruloplasmin
function in iron metabolism appears to be
as follows. For normal hemoglobin syn
thesis iron must be transported from stor
age sites in the liver, reticuloendothelial
system and intestine to the bone marrow
by transferrin. In the storage sites iron is
present in the ferric state, as ferritin. This
iron can be reduced by reduced riboflavin
and riboflavin derivatives, liberating fer
rous iron from the ferritin. This ferrous
iron is then oxidized catalytically back to
ferric iron by virtue of the ferroxidase ac
tivity of ceruloplasmin, allowing the Fe3*
to combine with apotransferrin, as the
initial step in the mobilization of stored
iron.
The mechanism of iron transfer from the
storage cell to transferrin has not been
clearly established. It is possible that Fe2+
and ceruloplasmin interact to form a ferric
intermediate that transfers iron to apo
transferrin by a specific ligand exchange
reaction (850). In any case, Fe3* combines
with transferrin and provides the progeni
tors of the erythrocytes in the bone mar
row with the necessary iron for hemoglobin
synthesis. As has been expressed (230),
the life cycle of the copper in ceruloplas
min is a one-time journey to the tissues or
a return to the liver for resynthesis.
Ceruloplasmin is a multifunctional pro
tein involved not only in the mobilization
of plasma iron but also in copper transport
and in regulation of biogenic amines. The
suggestion of Broman (65) that it func
tions as a copper-transport protein has been
well substantiated by animal studies indi
cating that its copper atoms are trans
ferred to cytochrome c oxidase and prob
ably to other copper-containing proteins of
body tissues (230, 365). Close correla
tions between low serum ceruloplasmin
and low cytochrome c oxidase in leuco
cytes in Wilson's disease (715) suggest
that the same is true in man. Ceruloplas-
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

1986 KARL E. MASON
min also has the capacity to oxidize natu
rally occurring substances such as sero
tonin, melatonin, epinephrine and norepinephrine,
and may possibly play an
important role in the control of blood and
tissue levels of biogenic amines (585).
There are also suggestions that abnormali
ties in copper metabolism may be involved
in Parkinson's disease (34). For further
details concerning the multifunctional na
ture of ceruloplasmin, its biological func
tions and catalytic activity the reader is
referred to the recent reviews of Frieden
and Hsieh (230) and of Sass-Kortsak and
Beam (668).
Ceruloplasmin is not the only compound
with ferroxidase-like activity in human
plasma. In 1969, Lee et al. (444) reported
the presence of citrate, differing from
ceruloplasmin in that it is not inhibited by
azide and yet has the same capacity to
accelerate oxidation of ferrous ion to ferric
ion and, possibly, to accelerate the rate of
reaction of ferric ion with transferrin. Ad
ditional mechanisms, perhaps not involving
copper directly, have been implicated in
iron translocation (56a). A deterrent to
recognition of a role of ceruloplasmin in
hematopoietic functions of man has been
the finding that many subjects suffering
from Wilson's disease may have no demon
strable plasma ceruloplasmin and yet show
no evidence of iron-deficiency anemia.
This anomaly seems now to have a reason
able explanation with the isolation of an
other cuproprotein from human serum by
Topham and Frieden (788) which nor
mally accounts for about 1% of the total
ferroxidase activity. It has a molecular
weight of about 800,000 daltpns and con
tains approximately 0.8% copper. Its desig
nation as ferroxidase II seems quite appro
priate. It is a lipoprotein with a cholesterol
and phosphatidylcholine content of ap
proximately 207o- It differs from cerulo
plasmin also in its yellow color and its lack
of p-phenylenediamine oxidase activity,
and may be responsible for the mainte
nance of near-normal iron metabolism,
despite low-levels or absence of plasma
ceruloplasmin, in Wilson's disease. Whether
citrate plays a comparable role is still a
question. Furthermore, most of the new
postulations with respect to the roles of the
ferroxidases and citrate are based upon in
vitro studies on human blood and observa
tions on experimental animals. Their appli
cability to man seems reasonable but re
mains to be established.
Other intriguing aspects of ceruloplas
min are: 1) its increased plasma levels in
response to estrogenic hormones, as in
users of oral contraceptives and pregnant
women; 2) its very low levels in plasma
of the fetus and newborn; 3) its rapid
synthesis by the newborn infant through
utilization of a special neonatal hepatomitochondrocuprein
not found at any other
stage of life; 4) its stabilization at adult
plasma levels at or about puberty; 5) its
low serum levels in the genetically deter
mined Wilson's and Menkes' diseases;
and 6) suggestions that copper is incor
porated into cytochrome c oxidase only if
it is presented to the cell as ceruloplasmin
(3, 65). These topics will be considered
later.
Superoxide dismutase
Almost 40 years ago, Mann and Keilin
(486) isolated two blue copper proteins
from bovine erythrocytes and liver which
they designated hemocuprein and hepatocuprein,
respectively. Both proteins had
molecular weights of about 35,000 daltons
and contained 0.34% copper. Similar pro
teins were later isolated from human eryth
rocytes (erythrocuprein) by Markowitz et
al. (490), from human brain (cerebrocuprein)
by Porter and Ainsworth (612)
and from adult human liver (hepatocuprein)
by Porter et al. (616).
Subsequently, Carneo and Deutsch (95)
clearly demonstrated that these copper
proteins were identical and proposed the
term cytocuprein to encompass them. They
later considered the term inappropriate,
since the protein also contained 2-g atoms
of zinc per mole (96). On the basis that
these cuproproteins catalyze the dismutation
of superoxide-free radical ions, and
thus have true enzymatic function, the
designation "superoxide dismutase" was
proposed by McCord and Fridovich (500,
501), and is now in common usage. The
primary function of superoxide dismutase
appears to be that of scavenging the inter
mediates of oxygen reduction in aerobic
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 1987
organisms, namely Superoxide aniónradical
(500). Superoxide dismutase catalyzes the
conversion of the Superoxide radical to
hydrogen peroxide plus oxygen and the
hydrogen peroxide is removed by catalyses
and peroxidases. Thus, Superoxide dismu
tase helps protect the cell from the damag
ing effects of oxygen toxicity.
Cytochrome c oxidase
Although cytochrome c oxidase has been
recognized as a copper and heme contain
ing protein for almost 40 years, the state
and function of its copper component have
been very difficult to clarify. The history
of these explorations, up to 1966, has been
well reviewed by Beinert (43) and Wharton
and Gibson (837). It has not yet been
possible to clearly establish its molecular
weight, or whether it contains one or two
copper ions and one or two heme groups.
This enzyme is found in all aerobic cells
and is mainly responsible for the introduc
tion of oxygen into the oxidative machinery
that produces energy for biochemical syn
thesis and for physical activity. As the
terminal enzyme in the electron transport
chain, it catalyzes the oxidation of reduced
cytochrome c by molecular oxygen and, in
the process, oxygen is reduced to water. It
represents an enzyme vital to essentially
all forms of life, by virtue of serving as the
terminal enzyme in the oxidative phosphorylation
process of living cells.
A significant decrease in cytochrome c
oxidase activity is considered a major cause
of neural and cardiac abnormalities ob
served in the offspring of different animal
species fed diets deficient in copper. Neural
lesions varying from defective myelination
to necrosis occur in lambs and goats (361,
798), in the guinea pig (201, 202) and in
the rat (92, 401 ). Myocardial abnormalities
ranging from focal failure of tissue respi
ration to myocardial hypertrophy and
acute cardiac failure occur in cattle (798),
swine (707) and rats (3, 92, 241, 316).
Lysyl oxidase
This copper-containing enzyme, lysyl
oxidase, is one of the amine oxidases (308 )
but is given separate consideration here
because of its well established status and
special importance. It has now been par
tially purified from several sources (308,
601, 648a, 650, 716). Its major function
appears to be to catalyze the oxidative deamination
of e-amino groups of peptidyl
lysine or hydroxylysine to form «-aminoadipic-S-semialdehyde
derivatives as a first
step in the cross-linking of immature elastin
and collagen into stabile fibrils. In collagen,
the cross-links are derived from either ly
sine or hydroxylysine. In elastin, however,
hydroxylysine and hydroxylysine-derived
cross-links are not present.
The story of lysyl oxidase goes back to
early studies of experimental copper-defi
ciency in the chick (331, 571, 734) and
pigs (93, 94, 129, 707) in which dissecting
aneurisms and sometimes rupture of the
aorta and large vessels were noted. These
vascular defects were ascribed to abnor
malities of the elastic component of the
vascular wall and to low tissue levels of
copper. These observations coincided in
time with the demonstration by Partridge
et al. (594) that the vital crosslinking
groups in elastin, which they named "desmosine"
and "isodesmosine," were formed
from lysine. Other studies on copper-defi
cient chicks (117) gave evidence of a role
of copper in crosslinking of collagen. It is
now clear that the basis for these observa
tions was the role of copper as a cofactor
for lysyl oxidase (648a).
Further, a foundation was laid for the
development of current concepts related
to the role of copper with respect to bio
chemical and structural abnormalities seen
in collagen and elastin in experimental ani
mals, livestock (798) and non-domestic
animals (219). Furthermore, one can ob
serve an example of application of knowl
edge gained from experimentally induced
deficiency in the chick and lower animals
to a better understanding of human dis
orders, since many of the manifestations
of Menkes' kinky-hair syndrome (513), a
congenital state of copper-deficiency in
young children, are also characterized by
vascular and skeletal defects. For further
details, the reader is referred to several
recent reviews (93, 130, 568-570, 648a,
650) and top. 2009.
Tyrosinase ( phenoloxidase )
This cuproprotein enzyme contains about
Q.2c/f copper, or 1 atom per molecule (68),
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

1988 KARL E. MASON
and has a molecular weight of about 33,000
daltons. Actually it may represent a series
of cuproproteins which catalyze a series of
reactions that convert tyrosine to melanin
(213, 479). The enzymatic activity is
thought to be associated with the mitochondrial
component of cells. The skin and
uveal tissues of the eye in human albinos
have no demonstrable tyresinase activity;
hence, the absence of melanin. Decreased
production of tyrosinase is responsible for
the loss of hair pigmentation in animals
deficient in copper and in infants with
Menkes' steely-hair syndrome.
Dopamine ß-hijdroxylase
This cuproprotein (3,4-dihydroxyphenylethylamine
ß-hydroxylase) is an oxidase
containing 4 to 7 copper atoms per mole
cule and having a molecular weight of
about 290,000 daltons (232). It was origi
nally isolated from beef adrenals and later
from cattle brain and hearts. In experimen
tal animals it appears to serve a function
in catalyzing the conversion of dopamine
to form norepinephrine (568, 570). A com
parable role in man may be assumed but
has not been proven.
Metallothionein
The rather tortuous history of identifica
tion and nomenclature of copper proteins
leading up to the proper recognition of
Superoxide dismutase has been somewhat
paralleled by the history of metallothionein.
This designation was given by Kagi
and Vallee (392, 393) to a protein iso
lated from equine and human kidney, with
a molecular weight of about 10,000 daltons,
a content of 26 sulfhydryl groups per mole,
and a capacity to bind zinc and cadmium
as well as copper. Metallothionein is not
an enzyme. By virtue of its high content
of sulfhydryl groups it binds copper by
forming mercaptides. In fact, it may repre
sent a family of metallothioneins specifi
cally designed for the binding of either
one metal or specific groups of metals such
as copper, zinc and cadmium.
Accumulating knowledge of metallothionein
or metallothionein-like proteins, with
variable affinities for copper, especially as
they occur and function in the intestinal
mucosa and liver, may well add greatly to
our understanding of the two clinical dis
orders of copper metabolism in man;
namely, Wilson's disease and Menkes'
steely-hair syndrome. For example, one
recognized and basic defect in Menkes'
disease is an inadequate transport of cop
per across the intestinal mucosa (145,
147). It is possible that the retention of
abnormal amounts of copper in the in
testinal mucosa involves increased affinity
of a mucosal metallothionein or of another
protein not normally involved in copper
transport (351). Furthermore, there is evi
dence that the usual metallothionein con
cerned with storage and release of ab
sorbed copper in the liver may, in Wilson's
disease, be of an abnormal type with a
binding constant about four times greater
than normal ( 197).
An unusual variant of metallothionein,
referred to as neonatal hepatomitochondrocuprein,
has been isolated from immature
bovine liver and from human newborn
liver (615). It contains 25% cystine and
about 49¿copper, which is at least 10 times
that of adult hepatocuprein. It increases
just before birth and decreases rapidly
during the first few months of postnatal
life, as it is released for synthesis of ceruloplasmin,
which is present in plasma in
small amounts at birth. It is thought to
represent a special storage type of protein
to tide the newborn infant over the early
period of life when breast milk does not
meet normal requirements (610 ). Although
concentrated in the heavy mitochondrial
fraction, it is not a true mitochondrial con
stituent in that some of it may be localized
in lysosomes of a "heavy" type, and prob
ably represents a polymer of metallothio
nein (614).
Other cuproproteins
Since the identification and characteriza
tion of a sulfhydryl-rich cuproprotein in
human liver with a molecular weight of
8,000 to 10,000 daltons, designated L-6D
(536, 703), there have been described
similar cuproproteins derived from chick
intesane (733), rat liver (856), rat intes
tine ( 198), adult human liver ( 74 ) and
human fetal liver (654). These proteins
differ somewhat with respect to estimated
molecular weight, copper content and
amino-acid components, especially cysteine
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 1989
and thionein, which may reflect differences
in methods employed in isolation and
analysis as well as species differences in
composition. There is good reason to be
lieve that they have important functions
in copper-homeostatic mechanisms such as
storage, transport and detoxification, espe
cially in the intestine and liver. Unques
tionably, future research will clarify many
of these differences and delineate more
clearly the physiological and biochemical
role(s) of these low-molecular weight cuproproteins.
Monoamine oxidases. Aside from lysyl
oxidase, there are other amine oxidases that
are present in connective tissues (116, 330,
334, 335). It is now presumed that these
oxidases serve in deamination of norepinephrine,
serotonin and histamine. Amine
oxidases, presumably containing copper,
derived from beef and swine plasma have
been highly purified and crystallized (73,
308, 649, 807, 867). A monoamine oxidase
from human plasma has also been purified
(505) and is said to increase in states of
congestive heart failure and parenchymal
liver disease (506). However, whether or
not this enzyme is copper dependent is not
clear.
Diamine oxidase. Purification of diamine
oxidase from pig kidney has been carried
out by many investigators since 1943. Its
crystallization was first reported by
Yamada et al. (866) who described it as a
pink copper-protein containing 2.17 atoms
of copper per molecule, capable of oxidiz
ing histamine, cadaverine, putrescine and
other like substances. The identity of this
enzyme with histiminase had previously
been proposed by Mondovi et al. (534).
Whether this enzyme plays a role in human
metabolism remains to be determined.
Albocuprein I and II. These two color
less cuproproteins, neither of which possess
enzyme activity or undergo alterations in
pathological states, have been isolated
from human brains (238). Both contain
hexoses. Albocuprein II may be the pri
mary copper-containing protein of the
brain (550).
Uncase (urate oxidase}. This cuproprotein,
found in the kidney and liver of lower
mammals, has a molecular weight of about
110,000, a copper content of 0.6% and is
involved in the catabolism of uric acid.
There are no recognized effects of its de
ficiency or excess in animals. It does not
occur in primates (478).
Tryptophan-2,3-dioxygenase. This heme
protein with a molecular weight of 167,000
daltons and 2 cuprous atoms per molecule,
isolated from rat liver cytosol (694), is
said to catalyze the insertion of molecular
oxygen into the pyrrole ring of L-tryptophan
(58).
Pink copper protein. A pink copper pro
tein with a molecular weight of about
32,000 has been isolated from human erythrocytes
(631). The biological function of
this protein still remains to be demon
strated.
Mitochondrial monoamine oxidase. This
enzyme, previously obtained in highly puri
fied form from many sources (beef and hog
plasma, human plasma, rabbit serum, liver
and kidney of several animal species, and
human placenta) has been isolated from
human liver, and identified as a flavoprotein
with a molecular weight of 64,000
(563). It is said to have the ability to
oxidize epinephrine and serotonin. On the
other hand, its status as a cuproenzyme has
since been questioned (730).
The large number of cuproproteins and
the multiplicity of their enzymatic func
tions, as well as the homeostatic mecha
nisms involved in normal metabolism of
copper, emphasize its great importance in
mammalian nutrition. For further aspects
of cuproproteins, the reader is referred to a
series of reviews (191-195, 211, 308, 309,
350, 458, 550, 568-570, 634, 650, 663, 671,
676).
ABSORPTION OF COPPER
As is true of most metals, absorption of
copper is regulated at the level of the in
testinal mucosa and excretion is predomi
nantly through the intestinal tract, either
via the bile or as nonabsorbed copper.
Urinary excretion is negligible in normal
healthy man, amounting to about 1 to 2%
of the intake.
Although the site of maximal absorption
of copper varies among different mam
malian species, in man absorption occurs
primarily in the stomach and duodenum.
This conclusion is based upon observations
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

1990 KARL E. MASON
that after oral administration of radio
active copper the isotope appears rapidly
in the blood, reaching maximum levels
within 1 to 3 hours, as further discussed
below. Concepts of the processes of absorp
tion of copper from dietary sources in man
are based in large part upon studies of
experimental animals.
Animal studies indicate that at least two
mechanisms are concerned in copper ab
sorption ( 132, 256 ). One of these, pre
sumably an energy-dependent one, in
volves the absorption of complexes of cop
per and amino acids. There is also evidence
that L-amino acids facilitate the absorption
of copper, and that absorption progres
sively decreases with increasing molecular
size of copper-amino acid complexes (408 ).
The other mechanism is an enzymatic one
involving the binding of copper to, and
successive release from, macromolecular
proteins.
Studies of experimental animals indicate
that mechanisms of copper storage and
transfer involve not only metallothionein as
first identified in the chick intestinal mu
cosa (733), but that there also may exist
a variety of metallothioneins, differing
slightly in amino-acid content and metalbinding
characteristics (518, 562). There
is real need for better determination of the
extent to which findings in experimental
animals have application to the problem of
copper absorption and metabolism in man.
This applies also to the many factors in
animals which are known to interfere with
copper absorption through various mecha
nisms (competition for binding sites by
zinc, perhaps to a much lesser extent by
cadmium; interactions between molyb
denum, sulphates and copper; the effects of
dietary phytates, and the influence of
ascorbic acid intake). In the case of the
latter, dietary deficiency results in in
creased liver and plasma copper (337),
whereas increased oral intake decreases
the absorption and retention of copper in
the chick (333), rabbit (370), pig (254)
and rat (199). Moreover, in the pig, high
intake of ascorbic acid can overcome the
effects of excess copper either by inter
fering with copper absorption or by in
creasing the absorption and utilization of
iron (254). Such evidence raises questions
as to whether due consideration has been
given to the secondary effects that may be
related to the somewhat astronomical hu
man intakes of ascorbic acid currently in
vogue. It is also important to note that the
type, configuration and degree of polymeri
zation of amino acids present in the in
testine can influence the absorption of cop
per (798). Moreover, little is known re
garding the chemical forms of copper in
foods, and the influence of different meth
ods of cooking upon its availability.
The great difficulty in determining that
portion of dietary copper which is ab
sorbed becomes apparent when one con
siders the many variable factors affecting
copper absorption such as: competition for
protein-binding sites in the intestinal lumen
and mucosa; inhibition of binding at these
sites; difficulties in measuring the amount
of copper secreted by the bile, by accessory
glands of the digestive tract and by the in
testinal mucosa; and possible reabsorption
by the intestinal mucosa of some of the
secreted copper. Excellent reviews of this
subject have been presented by Dowdy
(169), Evans (192), Hambidge and Wairavens
(301) and Van Campen (804).
Mechanisms
The general concept of the mechanism
involved in copper absorption is as follows:
from ingested foodstuff copper is released
either as ionic copper or as a copperamino
acid complex. In the intestinal
lumen there exists a high molecular weight
protein which binds copper and preferen
tially releases it to the plasma membranes
on the luminal side of the absorptive cells
of the mucosa. Within the absorptive cells
is metallothionein (or metallothionein-like
proteins) rich in sulfhydryl groups, which
binds copper through formation of mercaptide
bonds. Since this cuproprotein
serves as a storage depot and also releases
copper to the plasma cell membrane on the
serosal side, it is considered to provide one
of the protective and regulatory mecha
nisms in copper homeostasis. However, it
is not quite that simple, since its binding to
copper is constantly in competition with
other trace elements and can also be in
fluenced by other dietary components such
as the sulphate radical, phytates, fiber and
ascorbic acid.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 1991
Dynamic studies with radioactive cop
per have yielded important information. In
man, oral administration of 64Cu or 67Cu is
followed by a prompt appearance of the
isotope in the blood serum, indicating at
least major absorption from the stomach
and duodenum (40, 42, 80, 179, 387, 832).
Within 1 or 2 hours the isotope is bound
to serum albumin and amino acids (41,
80). There follows a sharp decline as the
isotope is taken up by the liver. Subse
quently, there occurs increased activity of
the serum for 48 to 72 hours as the liver
incorporates the radioisotope into newly
synthesized ceruloplasmin and releases it
into the blood (40, 41, 80, 179). That not
immediately extracted by the liver remains
in the serum attached to albumin or amino
acids, or is used to maintain erythrocyte
copper levels.
Amount
The proportion of dietary copper that is
actually absorbed is very important in the
making of judgments on balance studies
and their bearing upon normal human re
quirements for copper. Unfortunately the
information currently available is both
meager and somewhat inconclusive. Van
Ravensteyn (805) estimated that about
25% of copper (as CuSO4) added to the
diet of normal men, is absorbed. Later,
Cartwright and Wintrobe ( 105) stated that
about 32% of ingested copper is absorbed.
Early studies employing oral and intra
venous administration of 64Cu to small
numbers of control subjects in investiga
tions primarily designed to determine
whether or not there is an absorption de
fect in Wilson's disease gave quite variable
results, in terms of the percentage of the
dose recovered in the feces over periods
of 3 to 4 days (41, 80, 498). Furthermore,
since radio-copper is both excreted into
and absorbed by the gastrointestinal tract,
fecal excretion provides a measure of re
tention but not of true absorption. Assum
ing that after 48 hours the serum concen
tration of 64Cu is proportional to either an
intravenous dose or to a certain fraction of
an oral dose absorbed, Sternlieb (736)
estimates that on the basis of studies on
49 normal subjects the mean absorption of
an oral dose of 2 mg of copper daily, is
0.8 mg, or 40%. Weber et al. (832), em
ploying similar methodology, concluded
that the net absorption of orally administerred
copper varies from 15 to 97%, with
a mean of about 60%. A more sophisticated
approach by Strickland et al. (752), in
volving four normal adults given 64Cu
orally and ti7Cu intravenously, with copper
absorption calculated by whole body
counting and by plasma 64Cu and 07Cu
concentrations, gave a mean copper ab
sorption value of 56% (range 40-70%). It
was their opinion that if Sternlieb (736)
had made allowance for a 20%) fecal ex
cretion of copper (753), the three studies
mentioned would have been in close agree
ment. Quite recently King et al. (407) re
ported an overall copper absorption of 57%
based upon balance studies with the stable
isotope 65Cu. On the basis of the evidence
presented above, it seems reasonable to
assume an absorption of 40 to 60% of the
oral intake of copper, accepting the fact
that there is wide individual variation.
Copper absorption may be significantly
impaired in states of severe, diffuse disease
of the small bowel produced by sprue,
lymphosarcoma, or scleroderma (739), or
protein calorie malnutrition (474). In
Menkes' steely-hair syndrome defects in
intestinal transport and release constitute
one of the primary bases for this disorder
(p. 2007). Information concerning the role of
the lymphatics in the absorption of copper
is sadly lacking. Sternleib et al. (748) re
port that in the dog and man the amount
of an oral dose of 64Cu absorbed by the
intestinal lymphatics is negligible. On the
other hand, Trip et al. (789) found con
centrations of copper ( non-ceruloplasmic )
in the thoracic duct of three patients
equivalent to or higher than in serum. It
must be noted that these subjects suffered
from carcinoma and Hodgkin's disease and
cannot be considered normal. Regrettably,
the impossibility of obtaining thoracic duct
lymph from normal healthy subjects offers
little hope of determining the role of the
intestinal lymphatics in absorption of
copper.
TRANSPORTOF COPPER
Intestine to liver
Following release from the intestinal
mucosa, copper becomes bound to albumin
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

1992 KARL E. MASON
and to amino acids in the portal blood. In
the form of these complexes it can be mea
sured colorimetrically following reaction
with diethyldithiocarbamate, a copper
chelator. It is referred to as "direct react
ing" or "labile" copper. By virtue of its
homeostatic mechanisms the liver allows a
portion of these loosely bound copper com
plexes to pass directly to the systemic cir
culation, where they constitute about 1%
of plasma copper. Upon arrival at the liver,
copper is released from albumin to hepatocyte
cell membrane receptors from which it
is transferred to the cytosol where it is
bound to metallothionein (or metallothionein-like
cuproproteins ).
Metabolism and distribution
Copper apparently binds also to pro
teins other than metallothionein in the hepatocytes,
as revealed by analyses of subcellular
fractions of the liver of laboratory
animals. How applicable these findings are
to man is not clear. In a review of the sub
ject Evans (192) lists four different frac
tions as follows: 1) microsomal fraction
containing about 10% of liver copper, most
of which is probably located in newly syn
thesized cuproproteins being prepared for
transport to other sites; 2) nuclear frac
tion, with about 20c/( of total liver copper,
which may represent a temporary site of
storage; 3) large granule fraction, with
about the same amount of copper, contain
ing both mitochondria and lysosomes, the
latter being especially involved in seques
tering copper prior to biliary excretion; and
4) the cytosol, containing about one-half
of total liver copper, in which a small per
centage is in copper-dependent enzymes
and the predominant portion in the form of
a copper-binding protein similar to metal
lothionein. Evans (192) also describes in
teresting differences in the copper content
of these cell fractions in the newborn and
during postnatal development, and also
changes observed in animals given dietary
excess of copper. The latter studies indi
cate that in metallothionein there is prefer
ential binding, after which excess copper
is distributed to other fractions. He notes
that the binding capacity of metallothio
nein is limited, and that the lysosomes and
nuclear proteins assist in maintaining cop
per homeostasis.
Marceau and Aspin (488, 489) have
shown that when rats are given [07Cu]ceruloplasmin
intravenously the 67Cu is
taken up by all tissues, but primarily by
the liver where it appears in a specific
protein fraction of the hepatocyte cytosol
having a molecular weight of 30,000 to
40,000 daltons and exhibiting Superoxide
dismutase activity. It also becomes tightly
bound to cytochrome c oxidase in the mito
chondria. Since no [G7Cu]ceruloplasmin is
demonstrable in the cell, it is assumed that
copper is released at or within the cell
membrane. In contrast, the G7Cuof [n7Cu]albumin
complexes with proteins of about
10,000 daltons in the soluble cell fraction
and becomes loosely bound to cytochrome
c oxidase. Similar distribution of the two
plasma proteins is observed in the rat brain
and spleen.
In addition to serving as the major path
way of copper excretion via the biliary
tract, the liver releases copper to maintain
the labile pool of copper in the serum and
blood cells. This pool provides copper for
incorporation into Superoxide dismutase
and into the many other copper-containing
enzymes of body tissues, some of which
may be synthesized in the liver itself. How
ever, a major function of the liver is the
synthesis of ceruloplasmin. This form of
tightly bound copper is referred to as "in
direct reacting" copper, since it requires
acidification to release its 0.3% copper
which can then be measured, as in the case
of "direct reacting" copper, by the diethyl
dithiocarbamate reaction. Its more reliable
measurement by enzymatic and immunological
methods has been discussed earlier
(p. 1984). Once synthesized, ceruloplasmin
is released by the liver such that it com
prises approximately 93r/f of plasma cop
per. In healthy adult humans this level is
remarkably constant. There is no inter
change in the blood stream between ce
ruloplasmin copper and other forms of
copper (742). Animal studies (741) indi
cate that the liver microsomes are the site
of ceruloplasmin synthesis. Despite evi
dence that almost 0.5 mg of copper is in
corporated into ceruloplasmin daily, close
to the estimated daily absorption from the
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 1993
diet (742), the physiological role of ceruloplasmin
has only recently begun to be clari
fied (pp. 1984-1986).
Copper in blood
The first evidence of the presence of
copper in blood, that of the ox, was re
corded in 1830 by Sarzeau (665). The first
demonstration of copper in human serum
was reported almost 100 years later by
Warburg and Krebs (827) and Krebs
(426), who employed a catalytic method
developed by Warburg. Although the
values obtained were somewhat below
those currently accepted, they did recog
nize lower levels in normal males (aver.
0.82 /xg/100 ml) than in females (aver.
0.98 ^ig/100 ml), and also increased levels
in pulmonary tuberculosis (aver. 1.55 /¿g/
100 ml) and in the later stages of preg
nancy (aver. 2.07 /¿g/100ml). Quite com
parable values were reported by Locke et
al. (464 ), who were among the first to em
ploy diethyldithiocarbamate as a reagent
for the detection and estimation of copper.
While not recognized at the time, the rou
tine acidification of samples necessary for
release and measurement of copper in
ceruloplasmin did not make it possible to
recognize that the increased levels in preg
nancy and infectious states were due pri
marily to increases in ceruloplasmin.
Because of the diversity of chemical, bio
physical and immunological methods for
the estimation of copper and ceruloplas
min in blood and other tissues for over
more than 50 years, the values presented
in the literature for whole blood, plasma,
serum and red cells show considerable
variation. An excellent description and ap
praisal of methods used up to 1965 has
been presented by Sass-Kortsak (666).
There has not come to the author's atten
tion a comparable review and critique of
methods developed since that time. Even
with the employment of a single method
such as atomic absorption spectrometry
values obtained for copper levels in serum,
plasma and urine vary considerably, due
in large part to differences in preparation
of the sample (763).
Blood levels of copper are commonly
expressed either as serum or plasma levels,
with little or no distinction made be
tween the two. Cartwright ( 100) states
that since the ratio of the volume of erythrocytes
to leukocytes and platelets in nor
mal blood is about 47/0.7, failure to sepa
rate the latter from erythrocytes results in
an insignificant difference in copper values
obtained. It must be recognized, however,
that white blood cells do contain a small
amount of copper (about l/4th the con
centration in erythrocytes) even though
they represent a rather small component
of total blood cells. A recent report (646)
records significant differences between
serum and plasma copper levels in 28 adult
subjects studied on the same day, mean
values being 119 and 127 /ug/100 ml, re
spectively. These findings require con
firmation. Investigators suggest that cop
per might be released from platelets,
leukocytes or erythrocytes during coagu
lation and clot reaction.
Heilmeyer et al. (319) summarized 10
prior studies on adult humans employing
six different methods and proposing nor
mal values ranging from 65 to 200 /¿g/lOO
ml in blood serum. Their own studies
yielded mean values of 106.2 /¿g/100ml for
15 males and 106.9 /¿g/100ml for 15 fe
males, thus failing to reveal the sex differ
ences reported in later studies. In a review
of the literature up to 1950, Cartwright
( 100) gives data from seven different
studies involving a total of 184 males and
274 females from which can be calculated
average mean values of 106 and 114 /¿g/
100 ml for plasma of males and females,
respectively. Neale et al. (551 ) report cor
responding mean serum levels of 100 and
108 jug/100 ml for 53 normal subjects of
each sex. Wintrobe et al. (857) record
plasma copper values, of 105 ±16 and
116 ±16 /xg/100 ml for males and females,
respectively. An increase in serum copper
with age is said to occur in males but not
in females (871), but no adequate ex
planation is offered.
In plasma (or serum) most of the cop
per is bound to ceruloplasmin as indirect
reacting copper (119, 286). In man it was
first estimated that this represents 96% of
total plasma copper (286). There are later
estimates of 93% (105) and of 90% (75,
321). Most investigators now accept 93%.
The remaining copper, constituting the
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

1994 KARL E. MASON
labile pool, is less firmly bound in large
part to albumin and in smaller part to
amino acids (553), especially to histidine,
threonine and glutamine (554). The
smaller portion of "free" copper bound to
amino acids, the existence of which was
first demonstrated by Neumann and Sass-
Kortsak (553, 554) and Sakar and Kruck
(658), may be important as a transport
form of copper in the blood, capable of
actively diffusing across cell membranes
such as those of erythrocytes, whereas al
bumin-bound copper preferentially releases
its copper to receptor proteins of the
plasma membrane of hepatocytes and other
cells. After exposure of human serum to a
centrifugal force greater than necessary to
sediment albumin, copper may be demon
strated in serum in the form of mixed
amino acid-complexes consisting of one
atom of copper and two different amino
acids, predominantly complexes of cop
per wittìhistidine, threonine and glutamine
(553, 554). Moreover, in ultrafiltrates of
human serum there can be identified not
only these complexes but also a mixed com
plex of histidine-copper-threonine (554).
In the red blood cells copper exists both
in a labile pool, much like that in the
plasma but proportionately much larger,
and also in a firmly bound form, almost
entirely as erythrocuprein ( Superoxide dismutase).
Total erythrocyte copper in nor
mal man is about 89 ±11.4 /¿g/100ml of
packed red cells (492). The labile pool
represents copper complexed with amino
acids, freely dialyzable and probably in
volved in providing copper for Superoxide
dismutase. It contains about 4Q% of the
erythrocyte copper. The remaining 60% is
almost entirely bouYid to erythrocuprein, a
cuproprotein first isolated by Markowitz et
al. (490), described more fully by Kimmel
et al. (406), and later identified as superoxide
dismutase by McCord and Fridovich
(501). In addition, a small amount of cop
per is thought to be bound to a pink cop
per-binding protein isolated by Reed et al.
(631). This may correspond to the nonerythrocuprein
copper fraction observed in
human red blood cells by Shields, et al.
(708). This protein has no amine oxidase
or Superoxide dismutase activity, and its
biological function remains to be demon
strated.
It is apparent that neither whole blood,
blood cell nor blood plasma levels of cop
per provide useful information regarding
nutritional copper status in man. The
erythrocyte copper of both compartments
is remarkably stable regardless of dietary
intake, and is not involved in transport of
copper to tissues. The latter function is
mainly ensured by the small compartment
of plasma copper (about 7c/f of the total)
bound largely to albumin and to a lesser
degree to amino acids, the latter com
plexes being essential for active transport
of copper across cell membranes. The al
bumin and amino acid-bound forms of
plasma copper, together with minute
amounts of free ionic copper, represent the
direct reacting copper of serum which may
increase with intake only temporarily be
fore liver homeostasis comes into play. The
much larger compartment of ceruloplasmin
copper is generally not influenced by di
etary intake of copper but does react to a
great variety of conditions responsible for
states of hypocupremia and hypercupremia,
as discussed later (pp. 2014-2020).
A small diurnal variation in plasma copper
has been reported (434, 460).
EXCRETION OF COPPER
As previously stated (p. 1991) in normal
man perhaps up to 40 to 60% of dietary
copper is actually absorbed, with the gas
tric and duodenal mucosa playing the
major role. Such estimates are, in large
part, based upon differences between oral
and intravenous intake and fecal excretion,
since urinary excretion of copper plays a
very minor role. Therefore, the real prob
lem in evaluating these differences lies in
determining what fecal excretion truly
represents. Presumably, it represents unabsorbed
dietary copper plus copper ex
creted via the biliary tract (a major fac
tor), salivary glands and gastric and in
testinal mucosae, minus copper which may
be reabsorbed by the gastrointestinal tract
in the course of transit. Aside from these
considerations are losses of copper via
sweat and the menses, which are measur
able with a limited degree of accuracy. It
is hoped that the discussion to follow may
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 1995
delineate the state and lack of current
knowledge concerning many of the physi
ological mechanisms mentioned.
Biliary excretion
Sheldon and Ramage (705) were the
first to note the presence of copper in bile
and to suggest that this represents a chan
nel of excretion. They also hypothesized,
on the basis of the high values obtained
from gall bladder bile, that the body may
attempt to conserve its supply of copper
by reabsorption through the highly vascu
lar wall of the gall bladder. The latter re
mains an unsettled question. An isolated
report of phenomenally high concentra
tion in pigment gall stones (689 ) seems not
to have been confirmed.
In 1944 Van Ravensteyn (805) stated
that "We could not find in the medical lit
erature any data on copper excretion with
the bile or via the intestinal wall in man
after administration of copper by mouth
or by intravenous injection of copper com
pounds." In his studies he found that, un
like iron, oral copper had little effect upon
blood levels, but caused a marked increase
in bile and feces. He also discussed the
possible reabsorption of biliary copper by
the small intestine and of fecal copper by
the colon. For the latter there is little or no
evidence. This suggestion was based upon
his observations that biliary excretion and
fecal excretion did not run parallel, follow
ing intravenous injections of a non-toxic
organic salt of copper. For the duodenal
bile of eight normal subjects, Van Raven
steyn found the average copper content to
be 0.118 mg/100 ml (range 0.03-0.20 mg/
100 ml). These may be compared to an
average content of 0.2 mg/100 ml (range
0.06-0.32 mg/100 ml) for common duct
bile in three subjects, and of 0.48 mg/100
ml (range 0.09-1.07 mg/100 ml) in gall
bladder bile from 19 cases of chronic chole
cystitis, obtained at the time of operation
for bladder stones, as reported the same
year by Judd and Dry ( 391 ).
As noted by the next investigators to
contribute to this subject ( 105), a number
of factors makes it very difficult to deter
mine with a reasonable degree of accuracy
the amount of copper excreted via the
biliary tract. The daily outflow is inter
mittent and may vary from 250 to 1,100
ml/day. Bile cannot be collected quanti
tatively from normal subjects, even those
with exterioration of the bile duct or in
dwelling T-tube, since in these situations
the volume of bile flow is not normal.
Moreover, copper in bile aspirated from
the gall bladder during surgery or post
mortem is considerably concentrated as
compared to liver bile or duodenal bile,
and the latter is subject to contamination
by duodenal contents and the tubes used
for the collection. It is reported ( 105) that
copper in gall bladder bile obtained post
mortem from six normal subjects ranged
from 0.024 to 0.54 mg/100 ml, with an
average value of 0.329 mg/100 ml. One
subject with a cutaneous bile fistula follow
ing complete obstruction of the common
duct excreted an average of 0.46 mg/100
ml copper per day. Another subject with
primary biliary cirrhosis and T-tube drain
age, gave an average value of 0.05 mg/100
ml (range 0.03-0.95 mg/100 ml) in bile
collected daily for 17 days. No data on
total daily output of copper were obtained.
In their conclusions, Cartwright and
Wintrobe ( 105) state that assuming a daily
intake of 2.0 to 5.0 mg of copper, 0.6 to 1.6
mg (32%) is absorbed. From 0.01 to 0.06
mg is excreted in urine, 0.1 to 0.3 mg
passes directly into the bowel, and 0.5 to
1.3 mg is excreted in the bile. The latter
estimate is, in reasonable accord with a
later report of Frommer (235) indicating
that in 10 control subjects biliary excretion
approximated 1.2 mg/day, based upon bile
aspirated from the duodenum after over
night fasting. Walshe (822) states that in
subjects with external biliary drainage up
to 107' of ingested labeled copper can be
recovered in the bile within 24 hours.
Human bile is said to contain copperbinding
complexes of low and high molecu
lar weight, the former predominating in
hepatic bile and the latter in gall bladder
bile (263, 266). However, the high molecu
lar weight fractions may represent artifacts
in Chromatographie procedures, and essen
tially all of the copper may be bound to
complexes of low molecular weight (4,000-
8,000 daltons) (236), as observed in bile
of the rat ( 196) which, by the way, pos
sesses no gall bladder. The question of an
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

1996 KARL E. MASON
enterohepatic circulation of copper, con
sidered unlikely on the basis of the macromolecular
complexes of copper predomi
nating in the gall bladder bile (266), now
justifies more critical study.
More recently evidence has been found
that the mechanism of copper excretion
may involve its complexing with taurochenodeoxycholate
in the liver, thereby
preventing its reabsorption from the upper
intestine, with subsequent splitting of the
complex in the lower intestine where reabsorption
of the bile acid but not of cop
per may take place (454). Other evidence,
also based upon bile from T-tubes, sug
gests that orally administered 04Cu be
comes combined with conjugated bilirubins
(503 ). It is obvious that there is still much
more to be learned about the binding of
copper in bile and its possible reabsorbability.
Salivary excretion
Little or no attention had been given to
the presence of copper in saliva until 1952
when Dreizen et al. ( 170) reported finding
in the whole saliva of 14 normal humans
(48 samples) a mean copper concentration
of 25.6 /Ag/100 ml. In general agreement
with these findings are those of De Jorge
et al. (157) based on 40 normal, fasting
subjects, giving a mean value of 31.7 /¿g/
100 ml, and of Gollan et al. (264) based on
18 normal subjects and providing a mean
value of 29 /¿g/100ml. The ' copper of
saliva is in the labile form, since reactions
for ceruloplasmin are negative (157). If
one considers the daily output of saliva to
be 1.5 liters (range 1-2 liters), the total
daily excretion of copper would amount to
from 0.38 to 0.47 mg, on the basis of the
data recorded above. There is also evi
dence that the copper-binding substances
in saliva retain their activity after transit
through the stomach to the site of absorp
tion in the small intestine. De Jorge et al.
(157) also report mean copper values of
submaxillary, parotid and pancreas re
moved from 10 postmortem cases as 1.43,
0.55 and 0.85 mg/100 g dry weight of tis
sue, respectively.
Gastrointestinal excretion
In his pioneer studies on the metabolism
of copper in man, Van Ravensteyn (805)
found an average copper concentration of
0.023 mg/100 ml (range 0.01-0.04 mg/100
ml) in gastric juice of eight normal sub
jects. Some 27 years later, other data were
provided by Gollan et al. (265) who, in
four normal subjects, found a mean con
centration of 0.034 mg/100 ml (range 0.02-
0.96 mg/100 ml). In the latter studies
gastric juice free of swallowed saliva and
nasopharyngeal secretions was aspirated
from fasting subjects, and particulate mat
ter was removed by centrifugation at 2,000
X g for 20 minutes. Accepting the values
reported by Gollan et al. (265), employing
exacting collecting and analytical pro
cedures, and considering current estimates
that the daily volume of gastric secretions
approximates 3 liters (range 2-4 liters), it
can be calculated that the gastric mucosa
secretes approximately 1.0 mg/day.
The only recorded study of duodenal
secretion of copper is that of Gollan (263 ).
Normal and secretin-stimulated aspirates
of the duodenum, obtained from fasting
normal subjects through a tube positioned
such as to exclude gastric contents (and
presumably to also exclude bile and pan
creatic secretions) indicates the presence
of copper-binding substances of low molec
ular weight such as also found in saliva
and gastric juice. Gollan presents evidence
that the latter binding substances retain
their activity after transit through the
stomach to the site of absorption in the
small intestine. He also postulates that
these secretions, through their capacity to
solubilize the metal at an alkaline pH, may
enhance the availability of copper for ab
sorption.
Relatively little attention has been given
to, or estimates made of, the amount of
copper released into the feces via the ex
tensive dehiscence of epithelial cells of the
intestinal mucosa. In these cells there is a
considerable amount of copper bound to
metallothionein or metallothionein-like pro
teins, functioning in copper storage and in
protection against excess copper intake.
Considering that the absorptive cells lining
intestinal villi are replaced every 5 to 6
days in man (475), this contribution of
copper to the intestinal contents and to
the fecal output may be quite significant,
since it is thought to be nonabsorbable
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 1997
(192). It may represent 17% of the daily
fecal excretion (301). It certainly justifies
more consideration as a factor in evaluat
ing copper excretion and maintenance of
copper balance in the human organism.
Questions arise concerning the fate of
the large amount of copper bound to sub
stances of low molecular weight (amino
acids and peptides) which is excreted via
the saliva, gastric juice and duodenal se
cretions. Unfortunately, studies presented
record many data but make few predic
tions as to what the findings may mean
with regard to copper absorption or metab
olism. Some of this copper may be reabsorbed
and some may be added to the
fèces, but the relative amounts are un
known. And, in addition, the physiological
catabolism of ceruloplasmin may add
about 0.1 mg to fecal excretion of copper
per day (814).
Urinary excretion
Estimates of copper lost in the urine are
somewhat variable, apparently due to dif
ferences in sensitivity and accuracy of
methods used, and possible contamination
from extraneous sources. Early reports are
summarized by Butler and Newman (83)
who, in a study of 12 healthy adults, re
ported mean excretion values of 18.0 jug/
day, (range 3.9-29.6 fig/day). Values re
ported since that time are in reasonable
accord with these results. If one selects
from the literature those reports based
upon 10 or more adult subjects, chrono
logically recording results in terms of
/«.g/dayexcreted in the urine, the values
are: 18 (113); 18 (765); 20 (253); 37
(398) and 52 (153). These values are all
within the range of 10 to 60 /¿g/daypro
posed by Cartwright and Wintrobe ( 106).
Thus, urinary excretion of copper, amount
ing to approximately 0.5 to 3.0$ of the
daily intake, places the main excretory re
sponsibility on fecal excretion. There still
remains the possibility that the human
kidney possesses the capacity for tubular
reabsorption of copper.
Sweat loss
The loss of copper through sweat has
received limited consideration. The pioneer
studies of Consolazio et al. ( 122) record
that on a constant dietary intake of copper
(3.5 mg) and in an environment of 37.8°
and humidity of 50$;, three normal sub
jects showed a significant negative copper
balance. During 10 days of observation the
sweat loss from the men averaged 1.6 mg/
day, or about 45% of their total dietary in
take. Consequently, the negative balance
averaged 1.1 mg/day. Mitchell and Hamil
ton (528) found an average of 58 /¿g/li ter
in the sweat of four adult males under hot,
humid conditions. Another report (343)
records for 33 males after sauna bathing
an average excretion of 550 ±350 /^g/liter
in the sweat. In view of these data it ap
pears that the loss of copper through sweat
is much greater than heretofore recog
nized. In fact, Hohnadel et al. (343) and
Sunderman et al. (764) extol the possible
virtues of the sauna bath as a therapeutic
method for increasing the excretion of toxic
metals, such as copper in Wilson's disease.
Technical methods defy measurements of
copper loss through insensible perspiration.
Menstrual loss
Data on the loss of copper via menstrual
flow is likewise meager. For four menstrual
periods in three subjects values of 0.19,
0.24, 0.39 and 0.61 mg per period (aver.
0.47 mg) are given by Ohlson and Daum
(572). Comparable average values of 0.32,
0.48, 0.65 and 0.74 mg copper for four
consecutive periods in four different sub
jects are recorded by Leverton and Binkley
(452), and a mean of 0.11 ±0.07 mg
per period for 12 adolescent girls is re
ported by Greger and Buckley (278 ).
COPPER IN THE DIET
Copper in foods
Copper is ubiquitous in plants and ani
mals. Its widespread occurrence in food
was demonstrated in the early reports of
Lindow et al. (462) and of Hodges and
Peterson (341) on the copper-content of
samples of commonly used food in the
USA, and that of Adolph and Chou (8) on
Chinese foods. It is well recognized that
the copper in foods varies greatly, depend
ing upon the soils from which they have
been obtained, and on contamination be
fore and after reaching the market place.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

1998 KARL E. MASON
The richest sources in human dietaries are
liver (especially calf, lamb and beef),
crustaceans and shell fish (especially
oysters). Of somewhat lesser content, and
roughly in descending order, are nuts and
seeds, high-protein cereals, dried fruits,
poultry, fish, meats, legumes, root vege
tables, leafy vegetables, fresh fruits and
non-leafy vegetables. One of the lowest of
commonly used foods is cow's milk. The
exceptionally high copper content of the
Atlantic coast oyster, which may vary
widely with the season and with degrees
of contamination of environmental waters,
is not true of the Pacific or the Australian
oyster (290).
Throughout the literature one repeatedly
finds the statement that the average North
American diet provides 3 to 5 mg of copper
per day. Because of the widespread pres
ence of copper in foods and in drinking wa
ter, especially that obtained via copper
pipes, it is difficult to devise a balanced diet
composed of natural foodstuffs that contains
less than 1 mg per day (50 /¿g/cal/day),
according to Schroeder et al. (691) who
give extensive data on copper in foods,
beverages and water of many types. They
also state that to provide such a diet the
following foods must be avoided; most
meats, shellfish, vegetables, phospholipids,
legumes, fruits, nuts, some grains, gelatin,
tea, coffee, soft drinks, beer and distilled
liquors. Such a diet would be low in pro
tein, monotonous and marginally deficient
in several essential trace metals. In con
trast, they estimate that a diet of only 1,200
calories, with 100 calories from each of the
high copper foods (oysters, clams, pork,
margarine, turnips, carrots, mushrooms,
rhubarb, papaya, nuts, grapenuts and
orange juice) would contain approximately
34 mg of copper.
There have been many other published
lists giving the copper content of com
monly used foods. A rather extensive list
of copper and other inorganic elements in
foods used in hospital menus has been
presented by Gormican (273). A recent
and complete compilation of data pertain
ing to the copper content of foods, as re
corded by investigators worldwide, is that
of Pennington and Galloway (595). Of the
222 references used in their literature sur
vey only 104 specified the methods used,
many of which represented individual
modification of other methods. Methods of
expressing values obtained were indeed
numerous and often difficult to reduce to
a common denominator. Aside from vari
able contamination of water, reagents and
glassware in analytical procedures, factors
such as copper content of soil, water source,
season, and use of fertilizers, insecticides,
pesticides and fungicides raised serious
questions concerning the validity of values
reported for the copper content of the vast
list of food items recorded.
Hughes et al. (366) give analyses for
copper in a great variety of commercially
prepared baby foods. Highest levels were
found in those containing beef liver and
high protein cereals (2.64 and 1.85 mg/100
g, respectively). Next in order were other
precooked cereal foods (range 0.78-0.26
mg/100 g), as compared to 0.04 to 0.30
mg/100 ml in human milk (pp. 2025-2026).
Vegetables, fruits and desserts were vari
ably lower. Cooked cereals, which fre
quently are the first non-milk foods offered
to infants, if they are of high protein quality,
will provide a large part of their require
ment. It was their opinion that by the time
infants reach 6 months of age the variety
of supplementary foods normally offered
should, in most cases, meet or exceed the
generally accepted requirement of 0.05
mg/kg/day.
From what has been said, it is apparent
that most populations appear to have an
adequate dietary intake of copper, which
well justifies previous opinions that a recog
nizable state of copper deficiency in adult
man is not likely to be recognized. But
this does not imply that some diets may
not be decidedly marginal, as discussed in
the following section. Such matters are con
stantly of concern in any review of reports
on dietary intake and on balance studies
which represent the basic information
necessary for the determination of human
copper requirements.
Dietary intake of copper
Before progressing to a discussion of
human dietary needs of copper for adult
man it may be pertinent to review what
has been recorded concerning the usual
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 1999
dietary intake in various countries of the
world. At the beginning it should be recog
nized that in the vast majority of such
analyses copper has often been only one of
many trace elements under investigation
and often has been secondary compared to
iron, zinc, and other elements. Unfortu
nately, there have been almost no studies
in which copper has been the only, or
even the primary, focus of attention.
On the basis of studies conducted in
England, New Zealand and the United
States, Underwood (798) estimates that
most western-style mixed diets provide
adults with 2 to 4 mg/day. Guthrie and
Robinson (292) think that the copper
status of some New Zealanders may be
inadequate. In India, in adults consuming
rice and wheat diets, the copper intake
may be as much as 4.5 to 5.8 mg/day
(154). Estimated daily intakes for adults
in other countries have been reported as:
2.26 to 7.3 mg (mean 4.10) in Kiev and 11
other cities of the Ukraine (239); 1.29 to
6.39 mg for inmates of old people's homes
in Switzerland (688); about 2.0 mg for
New Zealanders (511); 1.5 mg for inhabi
tants of an isolated Polynesian island (510);
2 to 4 mg for Japanese (543) and about
2.0 mg for Taiwanese (793). In the latter
study, a control subject maintained on a
low copper diet for 2 weeks, providing a
daily intake of 1.34 mg, maintained a posi
tive copper balance of 0.12 mg. Unfortu
nately, the methods employed for analysis
of copper were not stated. On the other
hand, it is estimated that in 20 USDA diets
examined the mean copper intake would
provide 1.05 mg/day (419).
Recent and well planned studies based
upon analyses of copper and zinc content
of duplicate samples of daily diets of 22
subjects ( 14-64 years of age ) over a 14-day
period, provide valuable information (344,
860). Considering a 6-day average (after
8 days of adjustment) for each subject,
the mean daily intake of copper was 1.01
mg day ±0.4. This is considerably below
estimates of 1.62 mg/day given by Hartley
et al. (314), and 1.34 mg/day by Tu et al.
(793), but in good agreement with the
estimates of 1.05 mg by Klevay et al. (419).
There has also been an increasing aware
ness of an inadequacy of not only copper
but also other trace elements and certain
vitamins in the usual hospital diets (67,
273, 419). It is true that most patients are
hospitalized over a sufficiently short period
such that they can rely on liver and other
tissue storage to compensate for inade
quate intake. The problem of long term
parenteral nutrition is a separate issue
which will be discussed later (pp. 2028,
2034). However, it may be noted that a
recent study of regular, vegetarian and
renal diets in a hospital situation, based on
diets collected over 7 consecutive days, in
dicate a mean daily copper intake of 0.90,
1.10 and 0.51 mg (67), respectively. For
subjects with Wilson's disease such diets
would be most desirable. For others, they
may be marginal or inadequate.
Analyses of school lunches have given
but rather fragmentary evidence of the
copper content of the American diet for
children and adolescents. A survey of such
lunches served 6th grade children in 300
schools in 19 states of the USA (544, 545)
indicates an average content of 0.34 mg/
day (range 0.06-2.19 mg). Considering
one-third of the daily intake represented,
the average intake would amount to about
1.0 mg/day. These values are somewhat
less than those reported in metabolic
studies of 7 to 9 year-old children fed diets
typical of low income groups in the south
eastern USA, recording mean daily intakes
of 1.67 mg/day (618). On the basis of mg/
kg/food consumed, values given for insti
tutionalized children in Samarkand are
0.46 to 1.62 (620), and for the same in 28
USA cities are 0.44 to 0.87 (548).
Waslein (830) reports that data col
lected on the copper content of the diet of
377 babies from the USA indicated a wide
range of from 7 to 170 /*g/kg body weight,
or 0.18 to 0.92 mg/day. Total daily intakes
of copper ranged from an average of 0.16
for 1-month old infants to 0.38 mg for
6-month old infants, 50 to 607o of the in
take coming from milk. Furthermore, in
takes of children participating in balance
studies or living in institutions in the USA
or USSR had mean copper intakes of 0.9
to 2.2 mg/day, and similar studies on
adults in the United Kingdom and New
Zealand gave values of 1.7 and 2.4 mg/day,
respectively. However, the average copper
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2000 KARL E. MASON
intake of 5.8 mg/ day from diets in India,
determined on composites made from selfselected
diets in a dozen locations through
out the country ( 154), is more than double
the mean found for diets in developed
countries, for which no explanation is
given. In evaluating such reported data
one must consider not only the differences
in methods of assay and of care against
contamination but also differences in sam
ple preparation and differences in food
preparation in different countries. There
is also need to consider phytate and fiber
content of diets, which may influence ab
sorption or utilization of dietary copper.
From what has been said, it is quite ap
parent that data based upon the daily in
take of copper by peoples in different parts
of the globe give relatively little guidance
as to what the minimal or optimal level of
intake may be.
COPPER METABOLISM IN PRENATAL
AND POSTNATAL LIFE
A preceding section has dealt with the
labile and the more firmly protein-bound
types of copper in the blood cells and
blood serum or plasma of normal adult
man. Briefly stated, the labile pools repre
sent about 40 and 1%, and the proteinbound
pools (superoxide dismutase and
ceruloplasmin ) approximately 60 and 93$,
of the copper present in blood cells and
plasma, respectively. The ratio of cell to
plasma copper is about 0.70 ( 100). The
copper content of the red blood cells re
mains remarkably constant, little influenced
by dietary intake or metabolic stresses
(286, 435). That of the plasma is subject
to rather remarkable changes during preg
nancy, reflecting the influence of hormones,
particularly estrogens, upon the synthesis
and release of ceruloplasmin.
There exists a vast literature dealing
with 1) the increase of maternal blood
copper levels during pregnancy and the
influence of estrogenic hormones; 2) the
role of the placenta in transfer of copper
to the fetus; 3) the role of fetal liver in
storage of copper to meet inadequacies of
mammary transfer during early lactation
and 4) postnatal changes in blood copper
levels in the infant and adolescent. Knowl
edge and interpretation of these processes
are of importance not only in determining
the role of copper in reproductive physi
ology and neonatal development in man,
but also in obtaining a better understand
ing of human requirements of copper for
the infant and adolescent. It is the pur
pose of this section to review briefly what
has been learned concerning the rather
complex changes, not yet clearly under
stood, which occur in the pregnant mother,
fetus and young infant.
Influence of pregnancy
It seems remarkable that the first investi
gators to demonstrate the presence of cop
per in human blood (827) should also
have been the first to recognize not only
normal sex differences but also increased
levels of copper in the blood of pregnant
women (426). These observations were
soon verified by many other investigators
( 181, 184, 206, 294, 318, 345, 348, 434, 464,
556, 561, 577-579, 655, 660, 787). However,
the significance of these findings remained
obscure until evidence was presented that
similar increases occur in infants receiving
diethylstilbestrol therapeutically for treat
ment of hemophilia (794), and in adults of
either sex receiving estrogens (183, 245,
368, 651) but not in those receiving pro
gesterone or androgens (183). These in
vestigations suggest that increased plasma
copper levels in pregnancy could be ex
plained by increased levels of estrogens,
but this may not be the total story.
Beginning during the first trimester of
pregnancy, there occurs a progressive in
crease in maternal plasma copper levels.
In groups of pregnant women at successive
lunar months of gestation, values have
been reported to increase progressively
from 146.1 to 277.6 jig/100 ml (181), and
131 to 213 Mg/100 ml (757), and from 172
to 273 /ig/100 ml (54). Similar data are
presented by others (158, 524). The in
creased plasma copper levels of pregnancy
have been well documented (23, 54, 77,
152, 231, 255, 318, 320, 324, 527, 574, 578,
686, 687, 847, 858, 878). The copper con
tent of erythrocytes of mother and fetus
remains remarkably constant ( 181, 345 ).
Hence, the striking rise in plasma copper
during pregnancy to about 2 to 3 X normal
is attributable almost entirely to increased
synthesis of ceruloplasmin (324, 491, 673).
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2001
Since there are no known alterations in
absorption or excretion, the major source
of the non-dietary copper for this synthesis
is presumably the maternal liver. Direct
evidence in support of this assumption is
the much lower concentration of copper
in the liver (as compared to other organs
examined) in pregnant as compared to
nonpregnant women, all victims of acci
dental death (524), and very low liver
copper levels in women succumbing to
late toxemia of pregnancy associated with
unusually high serum ceruloplasmin levels
(628). Assuming also increments of about
25% in plasma volume during gestation
(166), maintenance of high plasma copper
levels places special demands upon ma
ternal tissue stores. Associated with in
creased plasma ceruloplasmin levels of
copper there occurs a reciprocal decrease
in plasma zinc levels both in states of
pregnancy (152, 300, 324, 388, 843) and
following use of oral contraceptives (297),
although the latter statement has been
questioned (579). Differences in competi
tive binding of these two elements under
special circumstances may explain these
inverse relationships of zinc and copper
during gestation.
Richterich et al. (638), comparing their
data with that of prior investigators (338,
491, 673), indicate general agreement that
1) ceruloplasmin blood levels in pregnant
women are two to three times those of
nonpregnant women, and that 2) the
levels in mothers at term are approximately
eight times those in umbilical cord blood.
Ceruloplasmin values recorded are quite
comparable, whether obtained by the en
zymatic method of Ravin (629) or the
immunological method of Hitzig (339).
Maternal serum copper levels return to
non-pregnant levels over a period of 4
weeks or more following legal abortion
(54) and normal delivery (388, 561, 777).
Since estrogen production and serum
ceruloplasmin levels are not proportional
during pregnancy, and since blood estro
gens decrease rapidly after abortion or
delivery compared to ceruloplasmin levels,
questions are raised as to whether estrogenie
stimuli alone are responsible for the
increase of serum copper in pregnancy. A
similar dilemma relates to the increase in
serum copper levels, over and above those
of normal pregnancy, observed in pre
eclampsia and eclampsia (205, 527, 552,
578, 628, 777, 847, 858, 868), and in a case
of hydatidiform mole (318). Evidence that
maternal serum copper levels show even
greater increases with intervening infec
tious diseases and malignant processes has
led to suggestions that increased serum
copper levels in pregnancy reflect a re
sistance reaction of the maternal organism
to continuous invasion of the fetus into the
maternal circulation (181). Another con
cept relates these changes to a conse
quence of hormonal adaptation of the
maternal organism to the increased meta
bolic and hormonal demands of pregnancy
(167).
Influence of oral contraceptives
Reference has been made to early ob
servations (183, 651, 794) of the thera
peutic use of estrogens and the ensuing in
crease in plasma levels of ceruloplasmin
which, in turn, suggested an explanation
for the comparable phenomenon observed
previously in pregnant women. To this
may be added evidence (98) that in nor
mal individuals oral contraceptives cause
marked increases in serum copper levels
involving increased synthesis of ceruloplas
min, often greater than that observed in
the state of pregnancy. Since that time
there has arisen a rather extensive litera
ture on the effect of oral contraceptives
and intrauterine copper devices in the
human female.
Since this topic has been well reviewed
in recent years (589, 723, 771), it will not
be subject to further consideration here.
However, it must be emphasized that the
continued use of oral contraceptives has
been, and will continue to be, an impor
tant factor in influencing copper homeostasis
in women. Estrogens, whether en
dogenous or exogenous, have a remark
able capacity to stimulate synthesis of
ceruloplasmin in the liver and to increase
urinary excretion of copper. The extent to
which prolonged use of oral contraceptives
may decrease body copper storage and
modify the daily copper requirement has
not been examined. It does justify special
study.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2002 KARL E. MASON
Placental transfer
Nonceruloplasmin copper readily crosses
the placenta by passive diffusion, and its
concentration in erythrocytes and plasma
of mother and fetus is relatively constant
throughout gestation (181, 673). Total
copper in cord blood is about 1/4 to 1/5
that in maternal blood (181, 464, 552, 556,
561, 660, 673, 686). Studies in which blood
of the umbilical vein (placenta to fetus)
and umbilical artery (fetus to placenta)
have been analyzed for copper give values
of 53.4 to 40.0 fig/100 ml (556), 54.9 and
40.2 Mg/100 ml (167) and 74.4 and 41.8
/ig/100 ml (770), respectively. Such find
ings clearly indicate an important role of
the placenta in transfer of copper from
mother to fetus. The high copper concen
tration in the placenta (525, 605), liver
and other fetal organs and tissues, referred
to later, indicates the efficiency of this
transfer.
Questions of placental transfer and of
fetal synthesis of ceruloplasmin have never
been satisfactorily clarified. It has been
assumed that its large molecular size pre
cludes placental transfer (673), although
this may not be a valid conclusion (339).
There are possibilities that with pro
nounced thinning of the hemoendothelial
membrane of placental villi, and/or tiny
breaks therein during late phases of ges
tation, some ceruloplasmin may be trans
ferred to the fetal circulation (552). Also,
one cannot exclude the possibility that
ceruloplasmin may actually cross the pla
centa, and that its rate of utilization and
breakdown may be equivalent to or greater
than its rate of transfer (666). Although
apoceruloplasmin can be identified immunologically
in plasma of the newborn
(496, 714), there is no evidence that ce
ruloplasmin can be synthesized by the
fetus. It is assumed that synthesis by the
fetal liver does not begin until shortly
after birth. In the domestic pig neither
apoceruloplasmin nor ceruloplasmin ap
pear in die piglet serum until about 15
hours after birth (108, 109). In view of
these facts, the presence of small amounts
of ceruloplasmin in cord blood of the new
born (338, 606, 639, 673) suggests its
transport from placenta to fetus. If this be
so, the time over which this transfer may
take place and its magnitude is unknown,
and almost impossible to determine. A
question which naturally arises is whether
the fetus has or needs a ferroxidase type
of enzyme, as a substitute for lack of
ceruloplasmin, to provide for the intensive
hemopoietic activities of the fetal liver,
spleen and bone marrow during fetal life.
Somewhat ancillary to this discussion are
observations of Widdowson et al. (842)
that copper concentration in the liver of 30
fetuses representing the 20th to 41st weeks
of gestation were consistently high (aver
age 6.4, range 3.5-9.3 mg/100 g fresh
tissue), as compared to values of 0.5 mg/
100 g fresh tissue for adult human liver,
lyengar and Apte (377) give values of
4.76, 4.37, 4.38 and 4.23 mg/100 g fresh
tissue for livers of 38 fetuses of gestational
ages less than 28, 28 to 32, 33 to 36 and
37 to 40 weeks, respectively. On the other
hand, Sultanova (761) reports that the
more premature the infant the lower are
the fetal liver reserves, while Butt et al.
(85) find lower hepatic copper values in
full term infants than in prematures.
Neither study provides the firm data char
acterizing the first two studies (377, 842)
mentioned. Significantly lower levels of
total copper and ceruloplasmin in cord
blood of neonates of undernourished
mothers compared to those of well nour
ished mothers suggest that poor nutri
tional states of the mother are reflected in
reduced capacity of the fetal liver to syn
thesize proteins in general, and cerulo
plasmin in particular (429).
According to one investigator (526),
amniotic fluid contains copper and other
bioelements in about the same concen
tration as in the maternal plasma and, by
virtue of its being swallowed in appre
ciable amounts, provides an additional
supply to the developing fetus. However,
other investigators report the presence of
very small amounts or only traces of cop
per in this fluid (303, 321, 324, 564),
which is in accord with the concept of the
amniotic fluid as a protein-poor dialysate
diluted with fetal urine.
Infanctj and childhood
Following normal delivery a series of in
teresting and not fully explained events
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2003
occur in mother and infant. Maternal levels
of serum copper decrease to non-pregnant
levels during the first 2 weeks postpartum
(100, 206, 293, 294, 561). This is ascribed
to the abrupt cessation of estrogenic
stimuli for ceruloplasmin synthesis. At the
same time, infant levels of serum copper,
which are lower at birth than at any pe
riod of life, promptly increase until adult
levels are attained between the 2nd and
3rd months of life (91, 293, 325, 690).
This is due almost entirely to increased
synthesis of ceruloplasmin by the infant's
liver. In other studies, estimates of the age
at which adult values are reached vary
from about 3 to 6 months (338, 494, 638),
to 9 to 12 months (411, 606). Several in
vestigators report that after adult serum
copper levels are attained during the first
2 or 3 months of life, these levels rise sig
nificantly above normal after the 4th
month (758 ) or during the 2nd year of life
(131, 362, 656), and then gradually de
cline to adult levels at puberty. Sass-
Kortsak (666) gives mean values of 140,
129 and 117 /¿g/100ml for 2-, 6- and 10year
old children. Hrgovic and Hrgovic
(362) record mean values of 179, 151, 133
and 111 Mg/100 ml for age groups 0 to 5,
5 to 10, 10 to 15 and 15 to 18 years. No
sex differences are apparent until puberty,
after which the effect of female estrogens
on increased serum copper levels becomes
manifest. Similar observations have been
reported by other investigators (573, 776).
Neither the reason for, nor the significance
of these fluctuations in early life has been
elucidated.
Immunological methods have identified
an apoceruloplasmin in newborn infant
plasma in concentrations similar to that
of ceruloplasmin in the adult, thus indi
cating that only the inability to charge the
apoprotein with its normal complement of
copper is underdeveloped at birth (714).
Similar observations have been made in
studies with piglets (108, 109, 523).
On the other hand, remarkable changes
occur in the liver of the newborn, which
contains about one-half the copper in the
body and a concentration, in terms of cop
per per unit weight, 5 to 10 times that of
the adult liver (843, 846). A large com
ponent of this copper is bound to hepatic
initochondrocuprein, first isolated and de
scribed by Porter et al. (615). This cop
per-storage protein, found only in the fetus
and newborn, is thought to represent a
copper-rich polymerized form of metallothionein
which sequesters copper prior to
birth (611, 614). Liver copper rapidly
disappears during the first few months of
life (69, 627, 846), releasing copper for
ceruloplasmin synthesis and the general
needs of tissues of the rapidly growing in
fant. The ceruloplasmin synthesized by the
neonate is identical to that of the adult
(870). Thus there is a logical explanation
for the early reports of Kleinman and
Klinke (414) and Morrison and Nash
(538) that the concentration of copper in
the liver of newborn and young infants is
6- to 18-fold that of adults.
Although copper and ceruloplasmin
blood levels are lower in the newborn than
at any other period of life, the copper con
centration in fetal and neonatal organs and
tissues is much higher than in the adult
(207, 248, 414, 565, 781). The studies of
Fazekas (207), based upon analysis of 29
different organs and tissues of 109 fetuses
and full-term infants of varied gestational
age, indicate that in addition to liver, the
concentration of copper in muscle, skin,
adrenal glands and thyroid is particularly
high compared to that of adults. The cop
per content of the placenta is also rather
high (525, 605). The high concentrations
of copper in organs and tissues of the
newborn decrease gradually to normal
levels during the first year of postnatal life
(69, 248, 565).
The unusually high concentrations of
copper in liver and other tissues of the
neonate appear to represent a reserve to
assure an adequacy of copper for syn
thesis of ceruloplasmin and other coppercontaining
proteins to meet metabolic
needs for hematopoietic, maturational and
other functions in the rapidly growing in
fant and adolescent prior to puberty. These
changes naturally create difficulties in
reaching definitive conclusions concerning
the dietary requirements during these early
years of human development. For other
details concerning the role of copper in
pregnancy, and in prenatal and postnatal
development, the reader is referred to a
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2004 KARL E. MASON
number of informative reviews (461, 533,
666, 843).
DIETARY COPPER DEFICIENCY
There appear repeated statements in the
literature that in view of the ubiquitous
occurrence of copper in foods of every
type, and lack of evidence of any recog
nized manifestations of copper deficiency
such as commonly observed after dietary
depletion of copper in experimental ani
mals or under natural conditions in farm
animals, man appears to be free of hazards
of a state of copper deficiency. However,
there has developed convincing evidence
that a copper deficiency state can occur in
man, even though it may be of rare oc
currence and as the result of rather special
types of situations.
A syndrome characterized by hypocupremia,
hypoferremia, hypoproteinemia,
edema and hypochromic anemia, respon
sive to oral copper but not to iron, has
been observed in infants fed diets limited
largely to milk (432, 437, 758, 796, 797,
874). In certain cases, especially those of
Ulstrom et al. (796, 797), a fundamental
defect in protein metabolism at the cellular
level may have been a primary factor,
rather than exhaustion of neonatal copper
stores (874). The fact that infants 6 to 18
months of age usually have been involved
suggests a relation to periods of life when
initial liver storage of copper has been
depleted, combined with prolonged main
tenance on milk diets and increased de
mands for copper during a period of rapid
growth. However, the possibility of de
grees of protein depletion sufficient to im
pair retention of dietary copper deserved
consideration.
Maintenance of two infants (one 8 days
old with multiple congenital anomalies,
and the other 10 months old) for 4 to 5
months on a milk diet identical to one
which produced copper deficiency in pig
lets, caused neither anemia nor hypocupremia
(101). Comparable results were
obtained in the studies of Wilson and
Lahey (854) involving seven premature
infants with mean body weight of 1.24 kg
fed a similar milk diet for 7 to 10 weeks.
It was concluded that small premature in
fants fed a diet providing approximately
15 /xg/kg/day of elemental copper over a
2 to 3-month period do not differ, by any
of the criteria used, from prematures fed
five or more times this amount. However, it
should be recognized that at this period
such infants could be utilizing liver stores
of copper, and that the depletion period
was much shorter than that required for
production of a deficiency state in piglets
with a relatively more rapid rate of growth.
Not until 1964 was a state of dietary
copper deficiency documented in humans
when Cordano et al. (126, 128) reported
finding in infants, recovering from maras
mus on exclusive milk diets, deficiency
manifestations (anemia, decreased plasma
copper and ceruloplasmin levels, intermit
tent neutropenia, severe osteoporosis and
pathological fractures) quite comparable
to those observed after experimental cop
per deficiency in pigs (436). Similar find
ings were observed in a 6-year old child
with severe chronic intestinal malabsorption,
who gave a dramatic response to cop
per therapy (127). In a later report,
Graham and Cordano (276) state that in a
series of 173 infants suffering from severe
malnutrition and chronic diarrhea, admit
ted to the British American Hospital, Lima,
Peru, over a period of 6 years, 62 instances
of copper deficiency were identified, of
which 44 were judged to have been de
pleted of copper prior to admission. The
peak incidence was at 7 to 9 months of
age. Responses to oral copper therapy in
dicated that repletion of total serum cop
per was more important than restoration of
ceruloplasmin in correction of the defi
ciency state (352). Instances of copper de
pletion have also been observed in infants
with chronic diarrhea in the United States
(354).
There have also appeared more recent
reports of neonatal copper deficiency in a
premature infant 3 months old (17), in
three very small premature infants during
their third month of life (280), in a pre
mature infant 3 months of age (700), and
in a premature infant at 6 months of age
(25). Neutropenia, low plasma ceruloplas
min and osteoporosis have been among the
manifestations regularly observed. Favor
able response to oral copper has usually
been reported. Although none of the in-
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2005
vestigators make reference to it, the clini
cal and pathological findings reported bear
striking resemblance to many of those
characteristic of Menkes' steely-hair syn
drome (p. 2007). A comparable picture
has been observed in an infant maintained
for some months on total parenteral nutri
tion following surgery for ileal atresia
(394) and in others treated likewise for
protracted diarrhea (463). Also, a state
of copper deficiency has been described
in a 12-year old child and an adult after
prolonged total parenteral therapy follow
ing extensive bowel resection ( 177). In
all cases there was a good response to cop
per therapy.
It is worthy of note that in all instances
where a naturally occurring copper de
ficiency has been observed, as described
above, only premature infants have been
involved. This is in accord with the fact
that premature infants do not benefit from
the additional copper storage in the liver
and other tissues acquired by the fullterm
infant, and are customarily main
tained for longer periods on natural milk
or milk formulae before having access to
cereals and other foods. Furthermore, pre
matures have much lower copper reserves
in the liver and spleen than do full-term
infants, and show a negative copper bal
ance during the first month of life which
tends to become positive only after the
second month of life (761). Suggestions
that consideration should be given to
special supplementation of the premature
infant formula with copper (843) appears
to be well justified.
The major manifestations of copper de
ficiency in infancy, and their relationship
to decreased activity of copper-containing
proteins, justify brief summarization.
1) Neutropenia and hypochromic anemia
responsive to oral copper but not to oral
iron are early manifestations of deficiency,
in large part the result of lowered levels of
ceruloplasmin and impaired release and
transport of iron from body stores.
2) Osteoporosis, with enlargement of
costochondral cartilages, is also an early
phenomenon, followed by cupping and
flaring of metaphyses of long bones with
spur formation and submetaphyseal frac
ture, periosteal reactions and spontaneous
fractures, especially of the ribs. These are
usually referred to as "scurvy-like" changes,
and may also suggest the "battered child
syndrome." Deficiency of copper-contain
ing oxidases, essential for the cross-linking
of bone collagen, adequately explains these
manifestations.
3) Decreased pigmentation of the skin
and general pallor of copper-deficient in
fants, can be attributed to decreased activ
ity of tyrosinase, necessary for the produc
tion of melanin.
4) In later stages of deficiency there
may be neurological abnormalities such
as hypotonia, episodes of apnea and pos
sible psychomotor retardation, generally
attributed to decreased levels of cytochrome
c oxidase.
MENKES' DISEASE
This progressive brain disease inherited
as a sex-linked recessive trait was first
recognized in five young boys (siblings),
and its major clinical and pathological
manifestations described in 1962 by Menkes
et al. (513). Other cases were soon re
ported by Bray (59) and Aguilar et al.
(11). While subsequently referred to as
"kinky-hair" disease and "trichopoliodystrophy"
(225), the currently accepted des
ignation is "steely-hair" disease (or syn
drome) proposed by Danks et al. who
( 145) in 1972, first recognized the disease
as an inherited defect in copper absorp
tion; in fact, a congenital copper deficiency.
Since the term "kinky-hair" implied
crimped hair like that of the black races,
whereas that of affected infants more
closely resembled depigmentation and
loss of crimp in wool observed in copperdeficient
sheep (252), "steely-hair" appears
to be more appropriate ( 146). It is said to
occur in 1 of 35,000 live births (145). As of
1977, Ahlgren and Vestermark (12) list 42
cases reported in the literature.
Manifestations
Symptoms of Menkes' disease usually ap
pear between birth and 3 months of age,
followed by death prior to the 4th or 5th
year of life. The age of onset is somewhat
earlier in prematures than in full-term in
fants. Occurrence as late as the 6th year
has been reported (28). Characteristics of
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2006 KARL E. MASON
the disease, as originally recorded by
Menkes et al. (513), are: short, broken,
spirally twisted scalp hair (pili torti) with
loss of pigment; frequent convulsive sei
zures, failure to thrive or poor weight gain,
mental retardation and, at necropsy, wide
spread degenerative changes in the cere
brum and cerebellum. To these manifesta
tions have since been added: hypothermia
(56, 72, 145, 148, 168, 225, 530); marked
tortuosity, associated with defects of the
internal elastic lamina and hyperplasia of
the overlying intima, of large muscular
arteries, particularly those supplying the
brain and its appendages (4, 12, 114, 145,
146, 422, 582, 713, 717, 808, 817); excessive
Wormian bone formation (283, 645, 732,
835) and pronounced changes in certain
long bones similar to those of scurvy and/
or the battered child syndrome (56, 145,
168, 669, 713, 717, 732). Biochemically,
there is increased copper content of the
intestinal mucosa ( 145, 148, 470 ) ; greatly
reduced levels of serum copper and ceruloplasmin
(55, 72, 148, 168, 310, 530, 713,
817) despite normal copper levels in
erythrocytes, and much reduced levels of
copper in the liver ( 145, 148, 329, 817) and
brain (145, 817).
Other reports have made reference to
deficient visual functions and ocular ab
normalities (49, 310, 453, 697, 717, 863)
and to neurogenic bladders with diverticulum
formation (306, 838), presumably due
to defective innervation or vascular abnor
malities. In the only known case of Menkes'
disease in a black infant, Volpintesta (809 )
observed a remarkable light skin in con
trast to the dark-skinned parents, an un
usual mottled skin pigmentation in a 7-year
old female sibling, and a small degree of
pili torti in the mother and two female
siblings. Manifestations typical of Menkes'
syndrome, except for the absence of steely
hair, have been reported in a Japanese in
fant by Osaka et al. (582) who question
whether some cases of the disease may go
unrecognized because of too great a re
liance on the hair abnormality as a diag
nostic feature.
Several new observations have special
relevance to early diagnosis of Menkes'
disease. A recently described method for
measuring ceruloplasmin using a dried
blood clot (21) may have value in screen
ing for early diagnosis, but only when ap
plied at 3 months of age or later (495).
An intense metachromasia
sue cultures of fibroblasts
in primary tis
has interesting
possibilities as a genetic marker in early
diagnosis and in identification of homozy
gotes and hétérozygotes in affected fam
ilies (145, 147). This defective cellular
metabolism
dicated by
of copper in fibroblasts is in
other observations that cul
tured skin fibroblasts from subjects
Menkes' disease have an abnormally
with
high
copper content (259) and also can incor
porate much greater amounts of 84Cu from
the medium than do fibroblasts of un
affected subjects (358). The copper con
tent of the culture medium may be critical
in such evaluations. Regrettably, there
exist rather limited prospects that im
provements in early diagnosis will be paral
lelled by more effective therapeutic mea
sures. Widespread degeneration of cerebral
grey matter, secondary to degeneration of
cerebral white matter and diffuse atrophy
of the cerebral cortex, associated with
bizarre changes in shape and arrangement
of Purkinje cells, as first described by
Menkes et al. (513), has been confirmed by
later neuropathologic studies ( 11, 251, 336,
624, 802, 810). Nerve tracts of the spinal
cord may sometimes be involved (11, 251).
Peripheral nerves are not affected. It is
proposed that these lesions reflect two
types of change; viz., cerebral necrosis due
to abnormalities of the extracranial arteries,
and typical dystrophic lesions in the
cerebellar cortex (810). Confirming and
extending the original descriptions of the
cerebellar lesions by Menkes et al. (513)
and Aguilar et al. (Il), ultrastructural
studies of the bizarre elaboration of perisomatic
dendrites of Purkinje cells sug
gest retarded development of the somal
membrane of these cells (336, 624). Such
evidence is cited in support of the concept
that the disease process is operative in
utero (340).
A careful light and electron microscopic
study of the eye has revealed degeneration
of retinal ganglion cells, loss of nerve fibers,
optic atrophy, abnormal pigment epithe
lium and abnormal elastin in Bruch's mem
brane (863). A similar study of aorta and
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2007
skin in Menkes' disease has demonstrated
abnormalities of elastic fibers similar to
those observed in animal studies on copper
deficiency (566). Reported ultrastructural
changes in skeletal muscle (251) have not
been confirmed (717). Neurochemical
studies on two infants whose neuropathology
was described by Aguilar et al. (Il)
record abnormally low levels of polyunsaturated
glycerophosphates, especially in
the frontal gray matter, and accumulation
of oxidized lipid products in the neurones,
suggesting an interference with the molec
ular machinery of the cells (567). These
observations have been both challenged
(469) and confirmed (645). French et al.
(224, 225) who proposed the term "trichopoliodystrophy"
report much reduced
levels of cytochrome a and a3 in mitochon
dria of brain, muscle and liver, and con
clude that deficient terminal respiration
and failure of tissue energetics, secondary
to diminished body copper content, may
explain some of the neuropathology of
Menkes' disease. Significantly reduced
levels of erythrocyte Superoxide dismutase
and of dopamine ß-hydroxylasemay have
bearing upon manifestations of the disease
(645).
Metabolic abnormalities
Danks et al. (145, 147) propose that the
primary defect in Menkes' disease is dimin
ished ability to transfer copper across ab
sorptive cells of the intestinal mucosa to
the serosal side and the portal circulation.
While considering this an important factor,
Bucknall et al. (72), based upon studies
on a 3-month old infant, speculate that
neurological damage may occur in utero,
perhaps as a result of defective placental
transport of copper. This is supported by
reports of the occurrence of one or more
manifestations of Menkes' disease at term
or within the week thereafter (283, 513,
530). However, defective placental trans
port may not provide the total answer.
Heydorn et al. (329) and Horn et al.
(359) consider that defective binding of
copper in the fetal liver or atypical distri
bution in fetal tissues may be involved.
The conclusions of Heydorn et al. (329)
are based upon tissue analyses of a fetus
suspected of Menkes' disease, obtained by
therapeutic abortion at 18 weeks gesta
tion. Compared to four normal fetuses of
15 to 21 weeks gestation, copper concen
trations in brain, lung, spleen, kidney, pan
creas, muscle, skin and placenta were
several times greater than, but liver cop
per was only about one-third, that of con
trols. Yet, the estimated total copper con
tent of all fetuses was essentially the same.
These findings, until substantiated, do not
eliminate possibilities of defective placental
transfer. However, they do raise questions
regarding copper storage in fetal liver and
atypical distribution of copper in other
fetal tissues and organs in Menkes' disease
(329, 635).
Menkes' disease and nutritional copper
deficiency have certain features in com
mon; 1) usual occurrence in infancy;
2) subnormal plasma levels of copper and
ceruloplasmin; 3) tortuosity and defects in
elastin of the aorta due to lack of lysyl
oxidase; 4) scorbutic-like changes in costochondral
junctions and epiphyses of long
bones; and 5) decreased pigmentation of
skin or hair. Menkes' disease differs from
the state of dietary copper deficiency in
the following respects: 1) alterations of
hair structure and decreased pigmentation
of hair, the latter attributable to lack of
tyrosinase; 2) highly variable and often
extensive lesions involving both white and
gray matter of the cerebrum and cerebel
lum, usually ascribed to lack of cytochrome
oxidase and Superoxide dismutase which,
in turn, may also be factors involved in
3) hypothermia, a frequently observed
phenomenon; and 4) the almost routine
occurrence of convulsive seizures and
mental retardation. To these may be added
5) absence of anemia and neutropenia and
6) unresponsiveness to orally administered
copper other than significant increases in
plasma levels of copper and ceruloplasmin.
Separate oral and intravenous adminis
tration of '"Cu, permitting calculation of
the percentage of dose absorbed, indicates
that children with Menkes' disease absorb
only 11 to I3c/c of oral copper as com
pared to 46^ by unaffected controls, sug
gesting a reduced absorption of copper as
an important factor in the disorder ( 159).
Also, most of the copper absorbed is re
tained by the liver for extended periods of
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2008 KARL E. MASON
time and excretory loss is reduced, thus in
creasing the biological half-life in the body
by two to three times, as compared to nor
mal controls (159, 160). Under similar
circumstances subjects with Wilson's dis
ease show normal absorption of copper
but, because of reduced biliary excretion,
the half-life is increased to about the same
degree as in Menkes' disease ( 160 ). Hence,
these two diseases have dissimilarities re
lating to intestinal absorption but similari
ties in inability to release copper acquired
by the liver.
Although a defect in the intestinal trans
port of copper undoubtedly plays an im
portant role in postnatal life, it does not
provide an adequate explanation for the
diverse manifestations of Menkes' disease.
With impressive evidence that this disease
begins in utero, it would appear that vary
ing degrees of genetic expression may ex
plain differences in postnatal age when
manifestations, such as frequent seizures,
make their appearance. There remain many
important questions the answers to which
will be difficult to obtain. For example,
is there defective placental transfer of cop
per comparable to that proposed in the in
testine? Is placental transfer normal, but
the types of fetal protein to which copper
becomes bound abnormal? For this or for
other reasons, is the concentration of nor
mally or abnormally bound copper in cer
tain tissues and organs significantly de
ranged? Are there abnormalities in the
production of copper-containing enzymes
or in membrane receptors in certain cells
and tissues? Obviously, knowledge of the
underlying metabolic disturbances in Men
kes' disease is in a state of immaturity, but
offers many challenges for future research.
For further details the reader is referred to
some recent reviews (75, 143, 144, 272,
301, 351, 818).
Therapy
Oral administration of copper salts to
infants with Menkes' disease has been
reported to cause slight clinical improve
ment, such as reduced hypothermia and
improved hair color, and slight increase in
serum copper levels (148, 467, 468), but
other investigators find no beneficial effect
(72, 243, 566, 833, 849). Intramuscular
injections of copper complexed with EDTA
can cause a significant increase in serum
copper and serum ceruloplasmin (146,
817, 838), as also can a slow subcutaneous
drip of copper sulphate over a period of
2 hours every 3 to 4 days (161). In one
case so treated for 5 months a moderately
encouraging clinical response was obtained
( 161). However, Wheeler and Roberts
(838) report that while intramuscular in
jections of a copper-EDTA complex main
tained reasonably normal serum copper
and ceruloplasmin levels for 8 months in
one infant, no clinical improvement was
apparent.
Intravenously administered copper in
various forms (copper sulphate, copper
acetate, copper-albumin, copper-EDTA
complexes and human ceruloplasmin) has
produced increases in serum copper and
ceruloplasmin to values approaching nor
mal (72) or essentially normal (146, 161,
282, 283, 833, 849), or no significant change
(243, 244). Usually the period of treat
ment has been short (7-10 days) or inter
mittent over somewhat longer periods. In
one instance normal serum copper levels
and subnormal ceruloplasmin levels were
maintained for more than 9 months by
weekly intravenous infusions (833). A
similar experience with 427 days of subcutaneously
administered copper as a
CuClo + L-histidine complex, has also been
reported (849). However, in all cases the
disease has pursued its relentless course.
But a faint gleam of hope comes from a
report of Grover and Scrutton (282, 283)
who, employing repeated infusions of cop
per sulphate once or twice weekly in an
infant diagnosed as having Menkes' disease
at 3 days of age, obtained mental func
tional levels equivalent to 4 months at 6
months of age. However, similar treatment
of another infant beginning at 4 months of
age and continued for 9 months provided
no improvement. Hence, the answer is
equivocal. Excessive urinary excretion of
copper observed after parenteral therapy
(242, 243, 849) is attributed to decreased
hepatic uptake of copper, reflecting an ab
normality of transport comparable to that
in the intestinal mucosa. These observa
tions suggest that a defect in membrane
transport could explain both the in utero
and postnatal deprivation of copper at
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2009
multiple organ levels including placenta,
intestine and liver; however, a favored
alternative is that of a defect in intracellular
transport in intestine, liver and
kidney due to abnormalities in the trans
port and storage protein, metallothionein
(242, 244).
From the information currently available,
it seems questionable whether institution
of any type of therapeutic measure during
the period of gestation, if such were pos
sible, would significantly alter the course of
this genetically determined abnormality of
copper metabolism.
Animal models
It seems obvious that there is still much
to be learned regarding the metabolic de
fect in Menkes' disease. Challenging op
portunities for future research are pro
vided by several genetic animal models of
this disease. One model is a recessive gene
mutation (crinkled, CR) in mice. Such
mice have a smooth coat with thin skin,
delayed pigmentation, early mortality, and
hair changes closely resembling those of
Menkes' disease (374). In fact, all three
types of hair abnormalities found in
Menkes' disease are demonstrable (373).
The observation that increased dietary in
take of copper during pregnancy and lacta
tion favorably altered the expression of the
mutant gene (374) is certainly worthy of
further exploration. Another model, a sexlinked
"brindled" or "mottled" (MO"r)
mutant in the mouse, is characterized by
subnormal levels of lysyl oxidase (648),
plasma ceruloplasmin, decreased copper
levels in brain and liver, increased copper
in the intestinal wall and virtual absence
of hair pigmentation (371). Moreover, a
recent study (200) indicates that in the
affected homozygous male both intestinal
absorption and hepatic uptake are im
paired, and that in the heterozygous fe
male they are intermediate between the
affected male and normal mice. Danks
(143, 144) and Holtzman (351) present
excellent reviews of the literature and in
teresting comparisons of altered copper
metabolism in the mottled mutant mouse
and infants with Menkes' disease. A third
mouse mutant called "quaking" manifests
some of the neurological signs of copper-
deficient animals. Dietary copper decreases
their tremors, indicating that copper me
tabolism is involved in expression of the
gene (396).
Furthermore, Prohaska and Wells (621)
describe striking similarities between bio
chemical abnormalities in the brain of suck
ling young of copper-deficient rats and
those observed in Menkes' disease. These
involve slow growth, abnormal behavior,
decrease in myelin, reduction in cerebellar
cytochrome c oxidase and Superoxide dismutase
and a 5-fold reduction in brain
copper. Extensive lesions of the cerebral
cortex and mid-brain have also been de
scribed in copper-deficient rats (92). In
the guinea pig, which undergoes consid
erable myelination in utero, copper de
ficiency causes gross brain abnormalities,
aneurisms, agenesis of the cerebellum,
ataxia, wiry nature and depigmentation of
hair, abnormal behavior patterns, and de
creased liver copper (201). Morphologi
cally, there is underdevelopment of myelin
and cellular derangement and loss of neural
elements in the cerebellum (202). Further
study of the copper-deficient rat and
guinea pig might well shed further light on
the nature of Menkes' disease.
WILSON'S DISEASE
A vast literature has dealt with the na
ture, diagnosis and treatment of Wilson's
disease. The findings have been well re
corded in a number of reports and reviews
(37, 38, 46, 137, 262, 267, 555, 666-668,
672, 678, 679, 683, 684, 737, 740, 744, 747,
756, 791, 821, 822). What follows is largely
a summation of early observations concern
ing the nature of the disease, current con
cepts concerning the metabolic abnormali
ties involved and therapeutic measures.
Nature of the disease
The history of this disease, as well out
lined by Goldstein and Owen (262), goes
back to 1912 when Wilson (855) de
scribed a familial disease associated with
cirrhosis of the liver and neurological mani
festations, occurring predominantly during
the first few decades of life. The term
"hepatolenticular degeneration" was coined
in 1921 by Hall (296), who also recognized
the recessive mode of inheritance of the
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2010 KARL E. MASON
disease. This designation has since been
largely replaced by the term "Wilson's dis
ease." Not until 1953, through the more
extensive studies of Beam (36), was the
autosomal recessive nature of this inborn
error of metabolism
i.e., that both parents
clearly established;
of an affected sub
ject must be hétérozygote carriers of the
abnormal gene, and that their siblings have
a one to four chance of receiving both
genes; i.e., in being homozygous abnormal.
For these reasons, the number of affected
individuals is maintained at a relatively
low level in the population, accentuated
only by consanguinity. Other studies over
the period (1912-1954) provided valid
evidence that this disease represented a
state of copper toxicosis characterized by
1) abnormally high levels of copper in the
liver and brain (102, 134, 258, 316); 2) in
creased urinary excretion of copper (163,
485, 499, 609, 731, 873); 3) aminoaciduria
(123,
serum
136, 163, 499, 608, 735);
levels of ceruloplasmin
4) low
(674);
5) decreased fecal excretion of copper (41,
80, 581, 753, 873) and 6) the occurrence
of Kayser-Fleischer rings (134, 258) which
had been shown as early as 1934 to repre
sent excessive accumulations
around the cornea (249).
of copper
Symptoms of the disease are decidedly
variable in nature, time of onset and degree
of severity. In the experience of some in
vestigators the predominance of hepatic
and neurological manifestations is about
equally divided. In that of others, one or
the other has been predominant. An excel
lent discussion of laboratory findings and
clinical manifestations
Strickland and Lev
has been given by
(756), Sass-Kortsak
and Beam (668) and Tu (791). How
genetic determinants hold in check the
metabolic and clinical expression of the
disease for such variable periods of post
natal life, and often for many decades, is
unexplained.
Wilson's disease
Heterogeneity
may be an
of
important
the gene
fac
for
tor. One may consider the fact that while
hétérozygote carriers (parents of patients
with Wilson's disease ) cannot be identified
clinically, they do differ from normal indi
viduals in showing a prolonged biological
turnover of 67Cu (580, 753), reduced
biliary excretion of copper (581), hyper-
cupriuresis after penicillamine loading
(792) and certain renal dysfunctions (448).
Metabolic abnonnalities
The classic form of this relatively rare
inborn error of copper metabolism is char
acterized by: 1) usual, but not universal,
low serum levels of copper, primarily of
ceruloplasmin, suggesting defective syn
thesis of this cuproprotein by the liver;
2) abnormally high storage of copper in
the liver, associated with decreased fecal
excretion and chronic liver disease, reflect
ing impaired biliary excretion of copper
and/or abnormal copper protein binding
by the liver; 3) progressive accumulation
of copper in the brain, leading to a wide
variety of neurological disorders; 4) ac
cumulation of copper in the kidney, asso
ciated with renal damage, cupruresis and
aminoaciduria; 5) deposition of copper in
the cornea, leading to the formation of
Kayser-Fleischer rings and, occasionally,
sunflower-type cataracts (87); and 6) epi
sodes of hemolysis reflecting a rather sud
den release of copper from a supersatu
rated and cirrhotic liver. Since in normal
man concentration of copper is higher in
the liver, central nervous system and kid
ney than in other organs and tissues
(p. 1982) it might be expected that these
levels would be significantly increased in a
state of copper toxicosis. The report of a
high concentration of copper in the skin of
two patients with Wilson's disease (113)
warrants verification.
Of particular interest is recent evidence
that in subjects with this disease there is
in the liver an abnormal metallothionein
having a binding constant for copper about
4-fold that in normal liver (197). It is
felt that the increased binding affinity of
this protein alters normal homeostasis such
that decreased biliary copper excretion and
decreased ceruloplasmin synthesis result,
and with saturation of binding sites in
hepatocytes non-ceruloplasmin copper is
released to the serum. Whether this pro
tein, or the presence of an abnormal pro
tein of similar nature, may explain copper
accumulation in non-hepatic organs and
tissues is an unresolved question.
In view of the fact that low serum ceru
loplasmin levels are characteristic of young
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2011
infants and subjects with Wilson's disease,
it is not possible to diagnose this disease
(other than perhaps by liver biopsy) and
to institute therapeutic measures, prior to
the 3rd month of life (638). Largely for
this reason little has been learned about
the presymptomatic manifestations of the
disease during early and late infancy.
However, the report of Scheinberg and
Sternlieb (682) that copper concentrations
in the liver of a 3M-year old child with
Wilson's disease were at least 40-fold nor
mal adult levels, does indicate progressive
liver storage prior to clinical manifestation
of the disease and supports the concept
that the liver is the primary site of the dis
order. The latter is characterized by a dis
ruption of the normal homeostatic mech
anisms for utilization and excretion of
copper. Possibly at fault is the presence of
either an abnormal protein with high
avidity for copper, as proposed by Uzman
et al. in 1956 (801), a similar protein un
usually rich in sulfhydryl groups and given
the designation L-6D (536) or a metallothionein-like
protein with a protein-binding
constant about 4-fold that of normal man
(197). The concept that the metabolic
defect in Wilson's disease is liver-based is
supported by observations that in two
teen-age boys with Wilson's disease treated
with orthoptic liver transplantation the
extrahepatic manifestations of the disease
were significantly reduced (281 ). A similar
response to the same procedure is reported
in a 11-year old boy in whom there was
strong but not incontrovertible evidence of
Wilson's disease (172).
In the normal infant liver stores of cop
per are gradually decreased and serum
copper levels increased during the first 3
or more months of life, until a close to zero
copper balance is maintained. According to
a recent evaluation of Wilson's disease
(672), there may be an early arrest of
these postnatal processes, especially abili
ties to synthesize normal amounts of ceruloplasmin
and to excrete the normal frac
tion of dietary copper through hepatic
lysosomes (normally an important func
tion of lysosomes) into the biliary system.
As a result, copper progressively accumu
lates in the liver, leading to inflammatory
reactions, hepatic cell necrosis and post-
necrotic cirrhosis. Meanwhile, excessive
amounts of non-ceruloplasmin copper
cause, in an unpredictable manner, ac
cumulation and injury to different regions
of the brain, the kidney and the cornea.
It is somewhat academic to ask whether
administered estrogens or those of preg
nancy can significantly influence the low
serum ceruloplasmin levels in Wilson's
disease. Beam (37) finds that synthetic
estrogens may have a significant effect in
some patients but not in others, with no
influence on urinary copper excretion. With
somewhat larger oral doses of a different
estrogen, German (250) reports improve
ment in some cases and accentuation of
symptoms in others, and also notes a cupriuresis
in some cases correlated with in
creased serum levels of direct reacting cop
per but not with ceruloplasmin. Subjects
with Wilson's disease have been able to
complete gestation with delivery of normal
infants (14, 33, 47, 104, 155, 680). There
is a report of one untreated case in which
there was an appreciable increase in ceru
loplasmin, reaching a maximum at delivery
( 104). Effects of pregnancy upon the clini
cal status of the mothers have been
equivocal. In instances where penicillamine
treatment was discontinued prior to gesta
tion (155) and after the first trimester
(680), neither ceruloplasmin levels nor
clinical symptoms were improved. In fact,
in one case occurrence of hemolytic anemia
during the 5th month required restoration
of therapy (155). In three other instances,
where therapy was maintained throughout
pregnancy, Aere is reported definite ameli
oration of clinical manifestations which
continued postpartum for periods of a few
weeks (14), 3 months (47) and 6 months
(706). Data on serum ceruloplasmin are
fragmentary. The ocurrence of several
spontaneous abortions during therapy, both
prior to (47) and following (14) preg
nancies, raises questions concerning pos
sible deleterious effects of penicillamine
upon the fetus.
Although the copper-binding capacity of
bile is not altered in Wilson's disease
(233), there is increasing evidence that
decreased biliary excretion of copper repre
sents a major metabolic defect (234, 235,
581, 752, 753), and also that this defect
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2012 KARL E. MASON
may reside in the hepatic cell lysosomes
(260, 261, 749, 755) whose catabolic func
tions and importance in transfer of copper
to the bile canaliculi are well recognized.
It appears that early in the disease copper
is diffusely distributed in hepatocytes, later
as more discrete granules, and that when
hepatic damage is more widespread it be
comes more localized in the lysosomes,
where it may be less toxic ( 261 ). Delay in
this uptake by lysosomes could be a key
factor in the defective liver transport of
copper in Wilson's disease (721). Ques
tions still remain as to whether abnormal
copper-binding proteins or lack of un
known cell enzymes involved in transfer
of copper to, or in release of copper from,
the lysosomes are responsible. The inter
esting observations of Goldfisher and Sternlieb
(161) have raised the hypothesis that
Wilson's disease may prove to be a "lysosomal
disease," as discussed in some detail
by Sternlieb et al. (749) and Strickland et
al. (755). f
Major results of reduced biliary excre
tion are increased copper accumulation in
hepatocytes, varying degrees of pathology,
jaundice and episodes of hemolytic anemia,
the latter being secondary to release of
copper from an overloaded and damaged
liver into the blood stream. If this release
is sudden, there can be severe damage to
circulating erythrocytes, resulting in repet
itive or fatal episodes of hemolytic anemia.
A recent report (516) tabulates pertinent
data on 18 reports involving 28 subjects.
Of these, six presented hemolysis prior to
any diagnosis of Wilson's disease and 20
showed evidence of hemolysis at the time
of diagnosis. Evidence of hepatic dysfunc
tion was noted in at least 22, whereas
neurological dysfunction was recognized in
only three or four. A more recent report of
two cases of fulminating hemolysis in
Wilson's disease calls attention to acute
renal failure as well as hepatic failure
(302). Hence, this hemolytic manifestation
of Wilson's disease has become a more
common phenomenon than previously rec
ognized. In view of the fact that there is
an associated marked increase in the cop
per content of erythrocytes and in the
number of Heinz bodies during periods of
crisis, hemolysis is attributed to increased
oxidative stress due to an excessive ac
cumulation of copper in the cells (155,
508). Whether this is primarily a mem
brane defect is still an open question
(516). It has been considered (102, 155,
508) a counterpart of the well known
"enzootic jaundice" in sheep, the history
and nature of which has been presented
by Underwood (798). This concept is
strongly supported by a recent study of
controlled, experimental copper poisoning
in sheep demonstrating extensive forma
tion of Heinz bodies, predominantly mem
brane-attached, as the first morphological
alteration observed (725). Hepatocellular
and renal tubular necrosis were also noted.
Therapy
The chance observation of Mandelbrote
et al. (485), in a study of copper mobiliza
tion in multiple sclerosis, that one of the
control subjects who was later found to
have Wilson's disease was greatly benefited
by treatment with BAL (/3,/3-dimercaptopropanol),
known to have properties of a
chelator, provided the first therapeutic
measure, introduced by Cumings in 1948
( 135). While daily intramuscular injections
proved effective in increasing the urinary
output of copper (39, 46, 135, 163), there
was no effect upon the aminoaciduria or
other clinical manifestations. The same was
true when BAL treatment was combined
with intravenous casein hydrolysate and
oral potassium sulfide, the latter forming
an insoluble copper compound in the di
gestive tract (102); and also when EDTA
( ethylenediamine-tetra-acetic acid, or "ver
sene") was extensively tested (46). Nine
weeks of estrogen treatment of an adult
male with Wilson's disease failed to im
prove serum copper or ceruloplasmin
levels (652). Intravenous use of a purified
concentrate of human ceruloplasmin also
proved ineffective (681). These discourag
ing results, together with the adverse side
effects of BAL therapy, stimulated search
for better measures.
In 1956 Walshe (820) described the re
markable effectiveness of oral DL-penicillamine
as a chelating agent capable of mark
edly increasing the urinary output of
copper. A few years later die less toxic
D-penicillamine (ß,/3-dimethylcysteine) be-
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2013
came available and has since been ex
tensively used, often in combination with
low-copper diets, in the treatment of Wil
son's disease. If instituted during early
phases of the disease, especially in asymp
tomatic patients, it can gradually reduce
excessive tissue levels to reasonably nor
mal levels and provide assurance of a nor
mal life expectancy provided no adverse
reactions occur (24, 156, 745, 746, 821). In
such instances, which are rare, Walshe
(823) proposes the use of tetraethylene
tetramine dihydrochloride. This compound,
which is cheap and easy to prepare, has
not been found to be associated with toxic
reactions. It is very effective as a chelating
agent, and its mobilization of copper may
differ from the action of penicillamine
(823). It has not been produced commer
cially, but would seem to justify more
thorough testing as an inexpensive thera
peutic agent. Beneficial effects of L-dopa
as an adjunct to a copper-deficient diet
and oral penicillamine are reported (246)
but not verified.
Despite disappearance of disease symp
toms and remarkable improvement in liver
function following penicillamine therapy
for 2 to 7 years (277) and 9 to 13 years
(156), hypocupremia, hypoceruloplasminenia
and hypercupruria have persisted
( 156) and no more than limited improve
ment in liver morphology has been ob
served in most cases (277). One exception
is that of a 10-year old girl in whom 27
months of penicillamine treatment not only
abolished clinical symptoms but greatly
improved liver morphology (204). Mitochondrial
abnormalities of hepatocytes
characteristic of Wilson's disease are less
pronounced or absent after 3 to 5 years of
therapy, which may have relevance to im
proved liver function, but liver structure
is not significantly influenced (738).
Penicillamine has the properties of a
lathyrogen, with ability to not only chelate
copper but also to inhibit cross-linking in
collagen (381, 560). Grand and Vawter
(277) suggest that penicillamine may re
tard the formation of permanent scars if
begun prior to the onset of the cirrhotic
process, as it appears to do in the case of
chronic active hepatitis (440). Once cir
rhosis is established one might expect some
thinning of fibrous scars with prolonged
therapy (277). It is disappointing that
morphological and ultrastructural studies
on biopsies of liver exposed to many years
of penicillamine therapy make no com
ment on changes observed in liver col
lagen (204, 738 ). Another feature of peni
cillamine action that justifies further ex
ploration is the generalized loss of taste
acuity in a variable number of subjects
with scleroderma, rheumatoid arthritis,
cystinuria and idiopathic pulmonary fibrosis
given penicillamine treatment, and
the restoration to normal after oral admin
istration of copper (323). That only 4% of
Wilson's disease subjects under the same
treatment show hypogeusia is attributed to
the fact that only rarely are their tissue
stores of copper sufficiently reduced (323 ).
A further complexity is presented by a
case of hypogeusia in a patient with mul
tiple myeloma which responded effectively
to either oral copper or oral zinc (322).
The role of copper in taste acuity is still
questionable.
Low-copper diets often used in addition
to penicillamine treatment of patients with
Wilson's disease, usually providing 1.0 to
1.5 mg copper, not only exclude a number
of generally consumed foods but also are
monotonous and of low nutritional value
(90). In predominantly rice-eating coun
tries, such as Taiwan, preparation and
acceptance of such diets present no great
problem (754, 755, 793). A vegetarian diet
is said to be highly effective in decreasing
positive copper balance and in increasing
fecal output, due perhaps to copper bind
ing to some unabsorbed component of the
diet (90). There appears to be no confir
mation of these observations.
Related disorders
Two other abnormalities of copper me
tabolism, both associated with low serum
levels of ceruloplasmin justify brief men
tion. Gahlot et al. (240) describe 15 cases
of primary retinitis pigmentosa unrespon
sive to conventional treatment. Serum
ceruloplasmin levels were very low and
urinary copper excretion very high, al
though serum copper levels were normal
or nearly normal. The investigators sug
gest that this retinal pigmentary distur-
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2014 KARL E. MASON
bance, in certain cases at least, may not be
an abiotrophy but a condition of chronic
copper toxicity reflecting an inborn error
in copper metabolism. The results of
penicillamine treatment, said to be in
progress, and further exploration of these
observations by others, will be anticipated
with much interest.
There has also been described, in three
brothers, a hereditary disorder character
ized by dementia, spastic dysarthria, verti
cal eye movement paresis, gait disturbance,
splenomegaly and an abnormal metabolism
of copper (851). The disorder is prepubertal
in onset and progresses slowly
over many years. Copper kinetic studies
the unique combination of dementia,
splenomegaly, and abnormalities of speech,
vision and gait favor the view that this
condition represents a new syndrome dis
tinct from Wilson's disease. As far as can
be determined, no comparable cases have
since been reported. Both abnormalities
may possibly prove to be variants of Wil
son's disease.
Wilson's disease is not the only disorder
in which high liver levels of copper occur.
Chronic active liver disease closely resem
bles Wilson's disease in changes in hepatic
function and morphology, but can be dif
ferentiated from the latter in that ceruloplasmin
levels are elevated in about 50 %
of the cases and not below normal levels
in others (442), and the cupriuria after
penicillamine treatment is comparable to
that of normal individuals (473).
One other liver disease requires special
consideration. Levels of liver copper quite
comparable to and even greater than those
found in Wilson's disease occur in pri
marily biliary cirrhosis (215, 369, 721, 722,
862), a chronic, slowly progressive disease
with evidence of extrahepatic biliary ob
struction (223). Unlike the situation in
Wilson's disease, plasma clearance and
liver uptake of intravenous 84Cu are normal
(721). Similar conclusions were reached
by Fleming et al. (215) on the basis of
other evidence, including a new observa
tion that patients with primary biliary cir
rhosis also had significantly increased levels
of copper in the renal cortex and spleen.
In a study involving an extensive evalua
tion of 81 patients with primary biliary
cirrhosis, Kayser-Fleischer rings were found
in three cases, and also in another patient
with chronic active liver disease (216). In
the three patients mentioned, copper in
serum, urine and liver were significantly
elevated, resembling conditions seen in
Wilson's disease except for the high serum
copper and capacity to incorporate radiocopper
into ceruloplasmin. Concentration
of liver copper above a specified level of
250 /Ag/g of dry tissue, previously consid
ered as one of the four or five criteria for
diagnosis of Wilson's disease, now appears
to have limited value with accumulated
indicate similarities to those of hétérozyevidence
that such elevated concentrations
gote carriers of Wilson's disease. However, occur in the two types of liver disease just
mentioned. Furthermore, the presence of
Kayser-Fleischer rings can no longer be
considered pathognomonic of Wilson's
disease.
HYPOCUPREMIA
Previous sections have dealt with
Menkes' syndrome and states of copper de
ficiency in premature infants in which low
blood levels of copper, especially of cerulo
plasmin, are associated with various other
manifestations of copper deficiency. States
of hypocupremia without any evidence of
dietary copper deficiency characterize Wil
son's disease and occur, somewhat in
frequently, in a variety of other metabolic
and disease situations. Certain of these
justify recording.
The terms "hypocupremia" and "hypercupremia"
were introduced by Sachs et al.
(655) whose excellent review of early
studies on copper and iron in human blood,
and their newer contributions, are worthy
of note. Hypocupremia is defined as a
serum copper level of 80 ¿ig/100ml or less
(106). Since 93% of serum copper is nor
mally bound to ceruloplasmin, hypocu
premia must of necessity be synonymous
with hypoceruloplasminemia, except in un
usual circumstances. A syndrome charac
terized by hypocupremia, hypoferremia,
hypoproteinemia, edema and hypochromatic
anemia has been described in infants
and children and attributed to either a
dietary deficiency of copper and iron, with
hypoproteinemia considered a secondary
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2015
effect of iron depletion (432, 437, 759,
874), to a transient dysproteinemia (796,
797), or to inability to synthesize the apoenzyme
of ceruloplasmin (412). Other
studies by Schubert and Lahey (692),
based upon 14 infants with the above men
tioned syndrome and 54 infants with irondeficiency
anemia but no hypocupremia,
led to the hypothesis that an initial severe
deficiency of iron results in marked anemia
and consequent protein depletion which,
in turn, causes impaired copper retention
and resultant development of the complete
syndrome.
Reduced serum levels of copper, cerulo
plasmin, iron and protein are also charac
teristic of kwashiorkor (76, 180, 269, 305,
402, 433, 632, 664) and marasmus (305,
402, 532). Only one investigator reports
no significant change in marasmus (269).
There are other findings that in kwashior
kor and marasmus both plasma and erythrocyte
copper levels are significantly re
duced (402). There is general accord that
the hypocupremia is not due to dietary in
sufficiency of copper but is secondary to a
state of hypoproteinemia and inability to
provide adequate amounts of the apoprotein
for ceruloplasmin synthesis. Opinions
differ as to whether in kwashiorkor the
copper content of hair is significantly de
creased (269, 474) or unaffected (76,
443). A report describing marked hypercupremia
in Filipino children and attrib
uted to states of malnutrition (750) may
well be ascribed to faulty methodology
and inadequate controls.
Hypocupremia has also been described
in subjects with non-tropical sprue (78,
101, 284, 739), tropical sprue and macrocytic
anemia (86, 106), malabsorption due
to small bowel disease (739), and with
both hyperchromic and hypochromic
anemia (315). There are also isolated re
ports of hypocupremia associated with ex
cessive gastrointestinal loss of protein
(814, 869), celiac disease (27), cystic fibrosis
of the pancreas (702) and the
nephrotic syndrome (78, 101, 106, 491).
In the latter disorder hypoceruloplasminemia
comparable to that in Wilson's dis
ease may occur, attributable primarily to
high urinary loss of ceruloplasmin. In the
other states of hypocupremia mentioned
above decreased levels of serum cerulo
plasmin are characteristic, suggesting qual
itative or quantitative abnormalities of
protein metabolism rather than insufficient
intake or absorption of copper.
HYPERCUPREMIA
Since the early observations of Krebs
(426 ) that hypercupremia is associated not
only with the state of pregnancy but also
with many acute and chronic infections,
there has accumulated an extensive litera
ture on a wide variety of diseases and ab
normal physiological states in which hyper
cupremia, predominantly due to hyperceruloplasminemia
occurs. It is beyond the
scope of this review to discuss these obser
vations in detail, especially since there
have been provided no well accepted hy
potheses or explanations of the mechanisms
involved in this apparent stimulus for in
creased synthesis and release of ceruloplas
min. However, comments will be made on
certain disease states involving hypercu
premia which appear relevant to the pur
pose of this review.
Infectious diseases. Hypercupremia has
been recorded as a phenomenon commonly
associated with chronic and acute infec
tious diseases of man. The lists recorded
by various investigators are bewildering.
There is general agreement that it is cerulo
plasmin which is primarily increased and
that during the recovery period, whether
spontaneous or the result of therapy, nor
mal levels are restored. This has been well
demonstrated, for example, in cases of
tuberculosis (61, 319, 542, 593, 655), lep
rosy (403), viral hepatitis, and pneumonia
and chickenpox (413). In many instances
there has also been recorded a decreased
serum level of iron (61, 63, 103) and of
zinc (718), reflecting differences in the
proportions of circulating albumins and
globulins to which these metals may be
bound.
Hématologie disorders. Hypercupremia
is commonly associated with iron deficiency
anemia (100, 103, 319, 879) hemorrhagic,
aplastic and pernicious anemias ( 100, 103,
237, 319) and sickle cell anemia (576). In
most anemias there is an inverse relation
ship between serum copper and iron ( 100,
655, 657), but both may be increased in
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2016 KARL E. MASON
pernicious anemia, aplastic anemia and
thalassemia major ( 103). It should be kept
in mind that in view of decreased blood
iron levels in anemia, the increased copper
levels may be more apparent than real. In
iron deficiency anemia, pernicious anemia
and leukemia, as well as in chronic infec
tions, there is an increased copper level in
whole blood, red blood cells and plasma,
and only in iron deficiency anemia is there
an increase in the ratio of erythrocyte to
plasma copper (100, 592). Aside from
states of copper toxicity, blood cell copper
remains quite constant. Since direct react
ing copper of serum is only about 1% of
the total, both hypo- and hypercupremic
states reflect changes primarily in ceruloplasmin
copper. To the present there have
been proposed no acceptable explanations
of the basic mechanisms involved, of the
tissues from which the copper is mobilized,
or the function(s) that hypercupremia
serves. An extensive literature on this sub
ject has been well reviewed elsewhere (7,
44, 100, 211, 319, 666).
Neoplasms. Hypercupremia is a common
feature of acute and chronic leukemia
(100, 162, 630, 773), lymphatic leukemia
(255), Hodgkin's disease (100, 328, 363,
364, 386, 774, 775), malignant tumors
(255) and of multiple and acute myeloma
(255, 268, 456, 457). In leukemia of chil
dren plasma zinc levels are low, and the
ratio of zinc to copper may prove useful
in monitoring the response to treatment
( 162 ). In Hodgkin's disease blood cop
per levels are valuable in evaluating the
disorder itself and the effects of therapy
(363, 364, 774, 775, 778, 829).
Cases of multiple myeloma appear to
present special abnormalities of copper
metabolism. Goodman et al. (268) report
a case in a 69-year old woman whose
serum copper levels ranged from 20- to 40fold
normal, due entirely to a phenomenal
increase in nonceruloplasmin copper. Evi
dence indicated its association with an
abnormal monoclonal immunoglobulin.
More recently, Lewis et al. (457 ) recorded
a quite similar hypercupremia, with blood
copper levels as much as 14-fold normal,
in a 41-year old woman manifesting an
early, clinically asymptomatic stage of mul
tiple myeloma. Liver (biopsy) was normal
in structure and copper concentration. In
both cases there was extensive copper in
filtration of the cornea and of the anterior
and posterior surface of the lens, not un
like that seen in the Kayser-Fleischer ring
of Wilson's disease. These observations
raise questions regarding the pathognomonic
value of the latter and also the pos
sible recognition of a unique variety of
multpile myeloma, both of which justify
further exploration.
Largely in the hope of finding an addi
tional diagnostic criterion of value, atten
tion has been given to serum levels of cop
per, and in some studies to zinc and iron,
in subjects with varied types of neoplasia.
In osteosarcoma, serum copper and copperzinc
ratios are increased in the primary
phase, further increased following metasta
sis, and approach normal levels in patients
whose tumor is amputated and show no
clinical sign of the disease (212). Also,
copper in the bone of osteogenic carcinoma
is significantly greater than in normal bone
(384). In lung and breast carcinoma the
serum copper/iron ratio is high (602, 769 ).
In gastric and pulmonary carcinoma serum
copper levels are significantly increased,
but not in cases of tumors of the large in
testine (670). Only one study reports no
differences between the serum copper con
tent of healthy humans and those suffering
from malignant tumors (22 ). Other reports
indicate increased serum copper in lymphomas
and certain other malignancies
(539), and no change in prostatic carci
noma prior to or during radiation therapy
(363). In Hodgkin's disease, leukemia and
lymphomas, there is general agreement
that serum copper levels have merit in
diagnosis and in evaluation of therapy
(162, 375, 386, 421, 539, 592, 773), as
is also true of osteosarcomas (212). How
ever, in none of the studies referred to
above has a clear explanation, or even a
challenging hypothesis, been provided
toward explaining the possible mechanisms
involved.
'Neurological diseases. Recognition of low
serum ceruloplasmin and copper levels as
one criterion of Wilson's disease led to nu
merous studies on a wide variety of neuro
logical diseases and disorders, many directed
toward hopes of finding other conditions
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2017
wherein increased or decreased levels of
copper might provide a useful diagnostic
measure of the disease state. On the whole,
these efforts have proved rather unfruit
ful. Considerable controversy has arisen
regarding schizophrenia and other psy
chotic states, following an early report of
high serum copper levels in the majority
of 27 cases of schizophrenia and in cases
of manic depression and epilepsy (319).
Subsequent studies have indicated a tend
ency toward significant increases in ceruloplasmin
serum levels in schizophrenia (2,
675, 677), in manic depression and senile
psychosis (13), but values obtained over
lap with those of normal subjects to vari
able degrees. Since the activity of copper
oxidase is reduced as serum ascorbic acid
increases, it is felt that the increased levels
observed in many states of mental illness
may reflect low ascorbate intake in sub
jects institutionalized for prolonged pe
riods ( 13, 20 ). Other investigators find no
significant changes in serum copper in
schizophrenia (30, 31, 360, 575), or in
brain tissue (279 ). These differences might
relate to the fact that schizophrenics are
very heterogeneous biochemically, such as
in serum levels of histamine, in serum
levels of zinc and manganese, and in re
actions to penicillamine and to contracep
tive estrogens in particular (596, 597). In
any case, serum copper levels have no
diagnostic value (677).
In epilepsy there is said to be an increase
in serum copper (70, 89) involving whole
blood, serum and blood cell levels (800).
Cerebrospinal fluid copper is reported to
be decreased (89) and increased (800),
and urinary and fecal copper increased
(800). These unverified and somewhat
variant observations probably have little
relevance.
Cardiovascular diseases. More than 25
years ago Vallee (803) reported a pro
nounced hypercupremia during the acute
phase of myocardial infarction, which sub
sided during recovery, and later Adelstein
et al. (5) demonstrated a linear relation
ship between the serum copper, ceruloplasmin
and copper oxidase activity. These
findings have been well confirmed (405,
806, 831), and a reciprocal decrease in
serum zinc has been noted (806, 831). In
myocardial infarction, but not in angina,
coronary insufficiency or myocardial
ischemia, there is also a marked elevation
in serum of the zinc-dependent enzymes,
malic and lactic dehydrogenase (811), and
in benzidine oxidase (760). Such findings
naturally raise questions as to whether in
creases in serum ceruloplasmin represent
anything other than a reaction to acute
stress.
There are but a few unconfirmed reports
indicating hypercupremia in atherosclerosis
(53, 659), arteriosclerosis (81, 82) and
hypertension (287); also, decreased levels
of copper in the wall of larger arteries
(404) and coronary arteries (836) of sub
jects with atherosclerosis. There is also
described a linear decrease in the copper
content of the wall of larger arteries with
increase in degree of atherosclerosis (404),
and a questionably significant lower level
of copper in the coronary artery of sub
jects with atherosclerosis and myocardial
infarction (836), which may reflect de
creased metabolic activity of the altered
arterial tissue.
Hemolysis associated with hypercu
premia, usually transient and self-limiting,
is a well recognized manifestation of Wil
son's disease (see p. 2014). It may occur
also as a fulminating event secondary
to acute liver failure (643), sometimes
combined with acute renal failure (302).
It can be attributed to sudden release of
nonceruloplasmic copper from a damaged
liver and excessive accumulation in erythrocytes,
resulting in acute oxidative stress
upon the cells and cell membranes (155,
302, 643).
Liver diseases. Considering the key role
of the liver in initial storage of absorbed
copper, in the synthesis and release of
ceruloplasmin, and in excretion of copper
via the biliary system, it is to be expected
that metabolic and pathologic dysfunctions
of this organ might well be reflected in
atypical levels of copper in the serum, and
also perhaps in erythrocytes of the circu
lating blood. This has been well demon
strated. Serum copper levels are signifi
cantly elevated in portal cirrhosis, biliary
tract disease and hepatitis (62, 245, 255,
271, 285, 600), possibly reflecting inter
ference with the normal excretion of cop-
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2018 KARL E. MASON
per via thèbile and consequent release of
an excess into the circulation. Although
states of hypocupremia are rare in liver
disease, low serum copper levels are re
ported in hemolytic jaundice, hemochromatosis
and some types of liver cirrhosis (255,
824), presumably the result of reduced
capacity of the damaged liver to synthesize
ceruloplasmin (824).
Liver biopsies from subjects of long
standing hepatic diseases due to biliary
obstruction regularly show in periportal
hepatocytes accumulations of coarse gran
ules staining with the rubeanic acid
method and the Mallory-Parker hematoxlin
method for copper, and reacting positively
to orcein, which indicates the presence of
sulfhydryl groups, all of which suggest the
binding of copper to a metallothionein
type of protein (661, 719, 720). Rubeanic
acid-staining granules of similar type have
been described in the livers of vineyard
sprayers exposed for many years to copper
sulfate sprays (599), but this staining pro
cedure is not a particularly reliable test for
liver copper. In view of the role of copper
as a hepatoxin in sheep (784), it is pos
sible that copper may contribute to the de
velopment of liver cirrhosis in long-stand
ing liver cholestasis (661). It should be of
interest to explore the possible relation of
these granules to hepatic lysosomes, and
also to learn what effect penicillamine may
have upon their histochemical picture.
Liver copper levels are not altered in
extrahepatic biliary obstruction (862) or in
acute hepatitis, steatosis of the liver, he
patic amyloidosis or hemochromatosis
(640). In viral hepatitis, serum copper
levels are said to be significantly increased
during the acute phase according to one
report (270) and during improvement of
the clinical state according to another
(326 ), but no change in liver copper levels
has been reported. Patients with chronic
active hepatitis respond favorably to 5
months or more of penicillamine therapy
(440).
Rheumatic diseases. For many centuries
copper amulets have been worn, hopefully,
for relief from arthritis, rheumatism and
many other afflictions of man, and copper
has been a common component of folk
remedies for arthritis in particular. There
is reported (815) a recent correspondence
and questionnaire type of study, involving
240 sufferers of arthritis/rheumatism, half
of whom were previous wearers of copper
bracelets and the other half not, randomly
allocated to three treatment groups wear
ing copper bracelets or placebo (anodised
aluminum) bracelets, or neither. Prelimi
nary results of psychological analyses of
the questionnaire responses indicate that
"previous users seem to be significantly
worse when not wearing their copper
bracelets." However, convincing evidence
of beneficial effects of copper bracelets
does not yet exist. These studies did reveal
that surprisingly large amounts of copper
(average of 13 mg/month from a 14-g
bracelet) can be absorbed through the
dermis, which would give in 12 months
more than the total amount estimated to be
present in the human body. The rationale
for copper therapy in rheumatic diseases
is not at all clear, and little or no infor
mation exists concerning copper metab
olism in such states other than in rheuma
toid arthritis, and that is somewhat con
flicting.
In rheumatoid arthritis, serum copper
levels are said to be appreciably increased
(133, 423, 559, 604, 622, 623) and in the
synovial fluid there is an increased level of
ceruloplasmin copper, as well as of iron
and zinc (558, 559). On the other hand,
mean values for the copper levels and
Superoxide dismutase activity of erythrocytes
of male and female subjects with
rheumatoid arthritis do not differ signifi
cantly from normal controls (696). A
marked elevation of nonceruloplasmin
serum copper reported by Lorber et al.
(466) has not been substantiated (743),
which may be due to differences in meth
odology (465). However, the more recent
studies of Bajpayee (29) in which serum
ceruloplasmin levels were significantly in
creased in rheumatoid arthritis patients on
estrogens, but were normal in female
patients not on estrogens and in male
patients, raise serious questions concern
ing the validity of data previously reported.
Bajpayee points out that in prior investi
gations no effort was made to segregate,
from the populations studied, those females
who were on estrogen treatment.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2019
Nevertheless, copper has received much
attention in the treatment of rheumatoid
and other forms of arthritis. The claimed
efficacy of intravenous administration of
an organic salt of copper (221) is not
substantiated (795). Penicillamine has
been used with some response in about
80% of cases after 6 months or more of
treatment (88, 380). Efforts have been
made to enhance the effectiveness of
aspirin, salicylates and penicillamine by
forming with them copper coordination
compounds. As tested only by the rat
model for evaluating inflammatory and
antiulcer potentials, these have given
somewhat equivocal results (626, 728,
729 ) depending upon the route of adminis
tration and the degree of tissue irritation
produced. The hypothesis of Sorenson
(728, 729) that anti-inflammatory drugs
might react in vivo with available copper
to generate more effective complexes for
regulation of inflammatory or non-inflam
matory states certainly justifies further
exploration. So also does the question of
whether the higher serum copper levels in
females as compared to males bears any
relation to the high female to male ratio
seen in rheumatoid arthritis. Spontaneous
remissions of rheumatoid arthritis are
associated with obstructive biliary/liver
disease and with pregnancy, characterized
by increased serum ceruloplasmin levels.
These questions are raised by Whitehouse
(841) in his review and critical discussion
of the topics referred to above. Obviously,
there are fertile fields for new explorations
of the possible role of copper in arthritis
and related diseases.
Pellagra. Krishnamachari (427) de
scribes in pellagrins in India a hypercupremia
uniquely due to increase in nonceruloplasmin
copper and associated with
wide variation in urinary copper excretion,
both of which return to normal levels after
oral administrations of nicotinic acid. On
the basis of evidence that the high leucine
content of the millet Sorghum vulgäre,a
staple food of populations in India, is
causally related to pellagra, healthy adult
volunteers were given 5-g L-leucine for 6
consecutive days. They showed compar
able degrees of hypercupremia and urinary
loss both of which disappeared after leu-
cine withdrawal. This investigator sug
gests that leucine enhances the absorption
of dietary copper in normal subjects. From
the same area of India is the report of
Deosthale and Gopalan (164) that certain
varieties of sorghum also greatly increase
serum copper levels and urinary copper
excretion, attributable to the high molyb
denum content of the sorghum samples.
Unfortunately, serum levels of direct react
ing copper and ceruloplasmin were not
determined. Hence, there is need for more
critical study of the possible role of leucine
and, or molybdenum excesses in producing
the hypercupremia and hypercupriuria de
scribed in pellagrins, and for confirmation
that the hypercupremia is due primarily
to increased nonceruloplasmin copper.
Bantu pellagrins in South Africa are said
to manifest a hypercupremia which is re
duced rapidly after an intramuscular in
jection of pantothenic acid, but not after
oral nicotinamide (210). The latter obser
vations carried out 20 years ago, seem not
to have been denied or confirmed.
Skin disorders. Elevated serum copper
levels occur in psoriasis (400, 430, 531,
751, 859, 872, 875) but not in other derma
toses (872). Although these levels have
been generally attributed to increased
ceruloplasmin, as a reaction to disturbed
keratinization (751, 876), several reports
state that ceruloplasmin levels are normal
(400, 438) unless associated with condi
tions of arthritis (423). The tissue copper
levels of psoriatic lesions are no different
from those of uninvolved skin, although
zinc levels are increased (529, 531). After
beneficial response to heliotherapy or
thalassotherapy most patients show clini
cal improvement, with return of serum
copper ceruloplasmin levels toward nor
mal (875). The mechanisms involved are
unknown. With regard to vitíligo,informa
tion is both limited and contradictory.
This disorder is said to be characterized
by hypercupremia, which is reduced in
subjects responding favorably to helio
therapy (247, 876), whereas others find
that in about 39% of subjects both albu
min-bound and ceruloplasmin serum cop
per levels are below the normal range
(372). Again the question of methodology
arises.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2020 KARL E. MASON
The states of hypercupremia to which
reference has been made clearly indicate
the remarkable homeostatic mechanism in
copper metabolism. These involve to a
large degree the increased synthesis of
ceruloplasmin in response to a variety of
body stresses, including hormonal influ
ences (44). Also, in body states involving
inflammatory reactions, ceruloplasmin may
function in the role of an "acute phase
reactant" (48, 636, 637).
COPPER TOXICITY
Hemochromatosis. There is a long history
of acute and chronic toxicity of copper in
man. Some of this was recorded in 1891 by
Lehmann (448) who was one of the earli
est investigators to test the effects of vari
ous copper salts on experimental animals.
He also states that two of his students
showed no ill effects of additions of up to
10 to 20 mg of copper sulfate and up to
5 to 30 mg of copper acetate to their daily
beer. This is somewhat greater than a
current estimated toxic level of 10 to 15
mg of inorganic copper for adult man
(75, 865). In 1898, Baum and Seeliger
(35) described extensive deposition of
blood pigments, then designated hematoidin
and hemosiderin, in the liver cells
of the goat, sheep, dog and cat fed copper
salts. These observations were more ex
tensively explored by Mallory et al. (480-
484) who reported that chronic oral intake
of copper acetate in the rabbit, sheep and
monkey produces a condition comparable
to hepatic hemosiderosis in man.
Mallory (481) described in detail the
hepatic changes characteristic of human
hemochromatosis (pigment cirrhosis) based
upon 19 necropsies, presenting circum
stantial evidence of copper toxicity as
basically involved. These interpretations
were supported by other pathologists re
porting liver copper levels up to 10-fold
normal in a large series of cases of hemo
chromatosis (295, 327, 586). Yet Mills
(522) found no evidence of hemochroma
tosis in 100 necropsies of Korean people
using copper and brass utensils routinely
in daily life. Although the animal studies
of Mallory and coworkers (480, 482, 484)
on which their hypothesis of the cause of
hemochromatosis was based were also con
firmed by certain investigators (295, 519),
others attempted in vain to duplicate their
results (218, 587, 607). Differences in sus
ceptibility and in levels and duration of
exposure to copper salts were proposed
(482) to explain the discrepancies in the
experimental findings.
Copper poisoning in man The oral in
gestion of excess copper produces a metal
lic taste in the mouth, nausea, vomiting,
epigastric pain, diarrhea and, to variable
degrees, jaundice, hemolysis, hemaglobinuria,
hematuria and oliguria. The vomitus,
stool and saliva may appear blue or green.
In severe cases, anuria, hypotension and
coma occur. The ingested copper is
promptly absorbed from the upper gut and
rapidly and dramatically increases the level
of direct reacting copper in the blood, due
in large part to its accumulation in the red
blood cells. When this accumulation
reaches a certain level, hemolysis occurs,
whether it be the result of oral ingestion
(120, 203, 641), absorption through de
nuded skin (353), dialysis procedures (51,
52, 376, 487) or exchange transfusions
(50). This hemolysis is comparable to that
commonly seen in Wilson's disease, which
is attributed to a sudden release of copper
into the blood stream from a liver dam
aged by an increasing load of copper un
able to be utilized in ceruloplasmin syn
thesis or excreted via the biliary system
(97, 155, 508, 516). This hemolysis may
reflect, to variable degrees, inhibition of
erythrocyte glycolysis and of glucose-6phosphate
dehydrogenase, oxidation of glutathione
and denaturation of hemoglobin
with Heinz body formation (203). A
variety of other factors may be involved
(588). Manifestations of slow copper
poisoning of a non-fatal type as seen in
copper and brass workers are well de
scribed by Chatterji and Ganguly (111).
There are symptoms of laryngitis, bron
chitis, intestinal colic with catarrh and
diarrhea, general emaciation and anemia.
Since much of the information on cop
per toxicity comes from instances of acci
dental or intentional intake (mostly sui
cide), data concerning oral intake neces
sary to produce symptoms of toxicity are
decidedly meager. Ingestion of 10 to 15
mg of inorganic copper will cause nausea,
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2021
vomiting and diarrhea and, in larger doses,
intravascular hemolysis (75, 865). It has
also been stated ( 685 ) that in India, where
copper sulfate is a frequent mechanism for
suicide, such symptoms are seen when
about 10 mg of cupric ion are ingested.
Yet, Roberts (641), in reviewing cases of
copper sulfate poisoning admitted to a
large city hospital over 7 years, describes
one individual who knowingly consumed
an estimated 20 g of copper sulfate two
to three times weekly over a period of 4
months (total of about 600 g of the crys
tals, or about 1.25 g of anionic copper per
day). Aside from the usual symptoms of
toxicity, there was an associated hemolytic
anemia, possibly the earliest recorded as
due to copper toxicity. There was reason
ably rapid recovery under conventional
procedures of that period. Two possible
explanations for this unusually high degree
of tolerance to copper are that the subject
greatly overestimated his previous intake
of copper sulfate or that he had adapted
to a high copper intake similar to that oc
curring in pigs (767 ).
There are numerous reports of accidental
and suicidal poisoning from oral intake of
copper sulfate in India (111, 118, 120, 288,
813). In one hospital in India, of all cases
of accidental poisoning admitted, copper
sulfate poisoning represented 33.6% of 238
admissions in 1961 (120) and 26.5% of
admissions in a 9-month period during
1969-1970 (112). In cases of acute copper
poisoning, analyses of urine and feces for
copper give exceedingly high values (111).
Under more normal circumstances of
daily living, varied degrees of copper tox
icity have been recorded, as for example:
1) in young infants presumably exposed
via drinking water and cooked foods, to
water derived from all-copper storage and
conduit systems (662, 816); 2) in children
given tablets containing sulfates of copper,
iron and manganese (220) or accidentally
consuming a solution of copper sulfate
(819); 3) in workers imbibing tea made
from water contaminated by corroded
geysers (557, 701); 4) in consumers of
carbonated beverages from post-mix type
of vending machines with defective valves
(356, 450), or from bottles with corroded
pouring spouts (512); 5) in consumers of
alcoholic beverages left in copper-lined
containers (865) or brewed at home in
metal containers (633); 6) in children
given copper sulfate as an emetic (355 ) ;
and 7) in subjects after exchange trans
fusions (50) and hemodialyses (51, 52,
376, 471, 472, 487, 497), due to copper
present in tap-water used, or to coppercontaining
valves and stopcocks used, in
the conduits. Copper can cross dialyzing
membranes, even against a concentration
gradient, and rather small traces of copper
introduced intraveneously are highly toxic.
Frequently, the result is hemolytic anemia.
Hemodialysis has proved to be ineffective
in treating acute copper poisoning, but
this may have been due to a delay of 13
hours in instituting treatment (10). Bremner
(60) reviews the toxicity of copper
and other heavy metals and Cohen (121)
discusses health hazards from industrial
exposure to copper.
At times it may be difficult in young
infants to determine whether a state of
toxicosis is attributable to an early phase
of Wilson's disease or to high levels of
copper in the family drinking water from
copper pipes (816). Ever since the devel
opment of metal conduits for potable
water, man has been exposed to possibili
ties of zinc poisoning from galvanized
pipes, and of copper poisoning from copper
conduits and storage tanks. In certain city
water supplies, copper salts are added to
maintain a concentration of about 0.06
ppm to restrict the growth of algae in the
reservoirs (550). It is also recognized that
soft waters tend to leach copper conduits
more than do hard waters. An impressive
analysis of complexities involved in engi
neering design of copper conduit systems
to reduce the corrosion process itself, and
to minimize the retention time of water in
small-bore tubes, has been presented by
Page (591). Nevertheless, these problems
are more or less controlled by cosmetic
considerations, since water with high cop
per content develops a surface scum due
to formation of insoluble copper com
pounds. It is generally accepted that a
limit of 1 ppm of copper in supplies of
drinking water is safe and acceptable.
Copper represents one of the earliest
additives for enhancement of the appeal of
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2022 KARL E. MASON
foods such as green peas, beans and
pickles. The early studies of Drummond
(171) failed to demonstrate in experimen
tal animals (dogs, cats) any deleterious
effects from consumption of such "greened"
vegetables. It is now generally accepted
that in the processes of cooking, canning
and storage of foods and beverages any
increment in copper content is largely re
lated to contact with copper in the vessels
and conduits utilized. In present day
societies hazards are reduced to a mini
mum. These and other aspects of copper
toxicity are well reviewed by Lieh (459).
INTERRELATIONSHIPS BETWEEN COPPER
AND OTHER TRACE ELEMENTS
Studies on laboratory and farm animals
have revealed numerous interrelationships
between copper and other trace elements
and substances (notably iron, zinc, molyb
denum, cadmium and ascorbic acid) in
mammalian metabolism ( 332, 333 ). On the
basis of some of these reactions, Hill and
Matrone (332) advanced the thesis that
"those elements whose physical and chemi
cal properties are similar will act antago
nistically to each other biologically." This
concept has since been well substantiated.
Davies ( 149, 150) classifies interactions
between trace elements as non-competitive,
and multi-element reactions. The noncompetitive
type is exemplified by the re
quirement of dietary copper for mobiliza
tion of iron for hemoglobin synthesis, as dis
cussed earlier (pp. 1985-1986), and by inter
actions between molybdenum, sulfur and
copper in ruminants as recently reviewed
by Suttle (766) and Pitt (603). Inter
actions of this type are not predictable
from a knowledge of the chemistry of the
elements in question, as are those of the
competitive type. The latter type is evident
in the mutually antagonistic effects of cop
per and zinc, such as the protective effect
of copper in reducing toxicity resulting
from high dietary intakes of zinc in chicks
(332); and the effect of increased dietary
intake of zinc in increasing the tolerance
of pigs to excess intake of copper (767,
768). The multi-element type of inter
action is seen in studies with chicks where
dietary zinc induces or exacerbates a con
ditioned deficiency of copper which in
turn restricts the utilization of iron (332).
Speaking in general terms, in non-rumi
nants interactions of copper with iron and
zinc are of particular significance whereas
in ruminants interactions of copper with
molybdenum in the presence of sulfur take
precedence, especially in terms of practical
considerations in animal husbandry. Molyb
denum toxicity, long recognized in grazing
cattle in many parts of the world, causes
biochemical and pathological changes
closely resembling those of copper defi
ciency, as well recognized in the pioneer
studies of Davis (150). They are readily
prevented or cured by copper sulfate.
Compared to cattle, sheep are less suscept
ible to high dietary intakes of molybdenum
and more susceptible to low intake of
molybdenum, which can lead to chronic
copper poisoning (798). Species reactions
vary greatly (603).
Non-ruminants are much more tolerant
of excess molybdenum and of high copper
intake than are ruminants. Moreover, ef
fects of high dietary copper can be accen
tuated by low levels of zinc and iron, and
low copper intake by ascorbic acid which
is thought to interfere with the absorption
of copper. An interesting difference is that
in ruminants dietary sulfur potentiates a
copper-molybdenum antagonism such that
tissue copper levels are decreased, whereas
in non-ruminants sulfur alleviates this an
tagonism. Moreover, the capacities of di
etary sulfur to accentuate or ameliorate the
toxic effects of molybdenum vary with the
copper status of the animal. Among the
proposals offered to explain the basic
mechanisms involved have been: 1) for
mation in the rumen of unabsorbable com
plexes such as thiomolybdate, cupric sulfide
or cupric molybdate; 2) interference
of liver uptake of copper by molybdenum
and sulfur; and 3) formation of stable
complexes of copper and molybdenum in
the plasma. Obviously, much remains to be
clarified.
Copper is quite routinely incorporated
in mineral mixtures added to commercial
livestock feeds to increase rate of weight
gain and food efficiency and is recognized
as a safe ingredient (up to a level of 15
ppm), but regulations prohibit molyb
denum additions. Under conditions in
which both forage and feeds are naturally
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2023
low in molybdenum, states of copper
toxicity, often fatal, have occurred in
flocks of sheep (798). This practice of add
ing excess copper without molybdenum to
livestock and poultry feeds represents a
potential hazard to the consuming public,
especially to the young infant consuming
baby foods made from liver (71). The
practical as well as the purely scientific
aspects of trace element interactions, com
plex as they may be, fully justify some
consideration. For further information on
the complex interrelationships between
molybdenum, sulfate and copper, the
reader is referred to a number of reviews
on the subject (71, 110, 140, 165, 493, 517,
603, 766, 798) and to a series of recent
research reports (110).
In man, there is but fragmentary evi
dence of significant interrelationships of
copper and molybdenum, and of a role of
molybdenum in human nutrition. By virtue
of molybdenum being a component of
xanthine oxidase, it may participate in the
reduction of cellular ferric to ferrous fer
ritin such that high copper-molybdenum
ratio may contribute to abnormalities of
iron metabolism and utilization (698, 699).
It is postulated that high copper-molyb
denum ratios in the American diet may
contribute to iron-deficiency anemias and
may also have influence upon metabolic
abnormalities of copper metabolism such
as seen in Wilson's disease (699). From
India come several interesting reports
dealing with high molybdenum-copper
ratios. Volunteers fed diets containing
sorghum with increasing content of molyb
denum showed increasing levels of urinary
copper excretion, which appeared to reflect
mobilization of copper from body stores
(164). In regions where creation of large
dams brings about marked changes in trace
element balance in the soil, food grains and
drinking water tend to acquire a high
molybdenum-copper ratio as molybdenum
is leached out by alkaline conditions and
the ratio possibly increased further by
high fluoride content of soils. As a result
the poorest groups of the population whose
staple food is sorghum, which accumulates
more molybdenum than rice or wheat, be
come victims of genu valgum and osteo
porosis of the long bones (9, 428). Genu
valgum, previously considered the result of
fluoride toxicosis, now appears to represent
either a state of molybdenosis or one of
copper deficiency induced by excess mo
lybdenum, or a modification of either by
high fluoride intake. In experimental and
farm animals there are characteristic dif
ferences in osseous lesions in these two
conditions, as well described by Asling and
Hurley (26). In the studies discussed
above no reference is made to the status
of farm animals in the same localities, or
to any plan to test effects of the sorghum
versus other diets upon experimental ani
mals. Returning to the capacity of molyb
denum to reduce tissue copper levels and
to increase urinary excretion of copper,
Suttle (766) has questioned whether or
not molybdenum might have therapeutic
value in the treatment of Wilson's disease,
apparently unaware of one report (74) of
its ineffectiveness in four cases of the dis
ease treated for 4 to 11 months.
In the case of trace elements occurring
mainly in ionic form, such as molybdenum,
selenium and iodine, deficiencies and ex
cesses are readily reflected in components
of the food chain and in not only grazing
animals but also in man himself (515). An
interesting example of this and of coppermolybdenum
interactions may be cited. In
mountainous areas of Russia where the
soil is notoriously high in molybdenum, a
high incidence of molybdenum toxicity,
characterized not by genu valgum but by
increased blood xanthine oxidase and uric
acid, and urinary uric acid, leading to
symptoms of gout, was observed in the
population of one province but not in that
of another where molybdenum intake was
equally high; the difference was ascribed
to significantly higher blood copper and
resultant lower blood molybdenum levels
in the non-affected population (424, 425).
Data pertaining to these studies are sum
marized by Mertz (515). The explanation
proposed is in accord with extensive knowl
edge of such interactions in experimental
and farm animals.
Interactions between copper and zinc
have long been recognized in animals and
man. Excess of one is often associated with
diminution of the other in body fluids and
liver. Competition for binding sites on
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2024 KARL E. MASON
metallothionein or metallothionein-like
proteins, complex as these interactions ap
pear to be (518), provides the best ex
planation. These proteins are present in
the liver, kidney, intestinal mucosa, pan
creas and spleen. They play an important
role in copper homeostasis. In man, these
reciprocal interactions are less apparent
than in animals where the intake and im
balance of the elements can be more spe
cifically controlled. However, a striking
example is the reported occurrence of typi
cal copper deficiency, with microcytic hypochromic
anemia and leukopenia, in one
patient, and very low levels of serum cop
per in 7 of 13 others, receiving unusually
high levels of zinc for the treatment of
sickle cell anemia (64). All responded
favorably to daily supplements of copper.
The question of the dietary ratio of zinc
to copper has been given considerable at
tention by Kelvay (416-418, 420) in sup
port of a hypothesis that high zinc to cop
per ratio and the associated hypercholesteremia
increase the risk of ischemie heart
disease, and may also play an important
role in the genesis of arteriosclerosis. This
hypothesis has received limited support
(81, 82). Of some relevance are recent ob
servations that myocardial lesions associ
ated with hypercholesteremia occur in rats
fed a copper-deficient diet for 7 to 9 weeks
after weaning (16). Cardiac hypertrophy,
subendocardial hemorrhage, necrosis of
muscle fibers, abnormalities of elastic tis
sue of the aorta but not of the coronary
arteries, and occasional heart rupture are
described. In other studies with copperdeficient
rats similar lesions have been ob
served and ascribed to a marked reduction
in cytochrome c oxidase activity (3, 401).
With repletion of copper, cytochrome c
oxidase activity is normalized, after which
cardiac hypertrophy and splenomegaly are
greatly reduced (3). Unquestionably, in
terest has been stimulated, but there is
need for specific research on man directed
toward the possible role of zinc/copper
ratios and cholesterol status in ischemie
heart disease.
HUMAN REQUIREMENTS
In discussing requirements of any nu
trient, a variety of terms are in common
usage, such as "basic," "minimal" and
"optimal" requirements; and "recom
mended" allowances. An excellent discus
sion and definition of these terms has been
presented by Mertz (514). According to
his interpretation, the "basic" requirement
for a trace element represents that daily
intake permitting absorption of an amount
just sufficient to prevent a state of de
ficiency; whereas the "optimal" require
ment represents that daily intake which
will allow maintenance at a near-optimal
level of all biological and physiological
functions in which the element is involved,
under the various stress conditions of life.
The somewhat intermediate term "mini
mal," traditionally used in balance studies,
is defined as that daily intake which equals
the daily excretory loss from the body.
This term best fits the nature of the data
on which estimates of human requirements
for copper are based. The term "optimal"
is somewhat comparable to the term "rec
ommended dietary allowance." According
to Harper (307), the RDA represents esti
mates of the amount of an essential nu
trient which "each person in a healthy
population must consume in order to pro
vide reasonable assurance that physiologi
cal needs will be met."
In the case of copper requirements, the
problem is not as simple as it might ap
pear. Most difficult to evaluate are the
reported differences in the copper content
of foods, diets, body fluids and tissues
attributable to the great variety of analyti
cal methods employed over the past half
century, and to possible contamination of
samples prior to or during analytical pro
cedures. An excellent discussion and criti
cal appraisal of methods in use up to 1965
for the determination of copper and ceruloplasmin
in biological materials is presented
by Sass-Kortsak (666). The methods de
scribed have been variably modified and
newer ones introduced. In some instances
there is rather remarkable agreement be
tween early and later reports. In other
instances there appear differences which,
on inspection, might reflect variable sensi
tivity of the methods employed. Any ef
fort to identify and evaluate methodolo
gies used in particular studies would be
rather futile.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2025
What has been outlined in this con
spectus, up to this point, has been an
assessment of past and current knowledge
regarding the role that copper may play in
the metabolism of man, with occasional
reference to ancillary information gained
from observations on laboratory and farm
animals. Attention has been called to the
distribution of copper in the body; the
vast array of cuproproteins and evidence
as to their roles in maintaining functional
and morphological integrity of specific tis
sues and organs; the absorption, transport
and excretion of copper; its omnipresence
in foods; its important roles in prenatal
and postnatal life, and; the nature of states
induced by naturally occurring, experimen
tally induced and congenitally determined
copper deficiency. It is hoped that this
digest of knowledge will provide an ade
quate basis for considerations of the mini
mal copper requirements of man.
In considering human requirements for
copper there are many factors whose in
fluence is exceedingly difficult to evaluate
because of limited knowledge available. A
few examples may be cited. That portion of
dietary copper which is actually absorbed
probably varies considerably, depending
upon its chemical state in the foods con
sumed and the influence of other dietary
components. Best estimates indicate an
absorption of 40 to 60% of the oral intake
(p. 1991). In addition to the unabsorbed
copper and biliary copper components of
the feces, inadequate consideration has
been given to contributions provided by
secretions of the salivary glands, gastric
and intestinal mucosa and pancreas, and
by dehiscence of epithelial cells of intesti
nal villi. At least, the extent of reabsorption
of copper released via these various
pathways has not been clearly determined.
Despite frequent statements in the litera
ture that some of the copper in bile may
be reabsorbed, there exists other evidence
that this copper is so firmly bound to pro
teins that it is not reabsorbed by the gall
bladder or intestinal mucosa in any signifi
cant amounts (266).
Balance studies are limited by the pre
cision with which intake and output can
be measured. For an element such as cop
per which has a slow rate of turnover, a
variable degree of intestinal absorption,
strong homeostatic mechanisms and an
almost exclusive output via the feces, in
terpretations of balance studies becomes
very difficult. The sporadic nature of defe
cation and rather wide individual variation
make balance studies of 7 to 14 days neces
sary for obtaining valid data. Replacement
of carmine by polyethylene glycol 4000, as
a fecal marker, should shorten this time
period (848).
Biological availability is also an impor
tant but largely unknown factor. Little is
known about the chemical nature of cop
per in foods, the extent to which it may
react with chelating substances such as
dietary fiber, or how its absorption may be
influenced by the protein-binding poten
tialities of other trace elements such as zinc
and molybdenum. To these factors must
be added the inflence of acute and chronic
infections, use of antimicrobial agents, dys
function of the gastrointestinal tract and
other stress states. Usually, in well con
ducted copper balance studies on man,
healthy subjects are selected and as many
as possible of the above mentioned in
fluences are eliminated. The discussion to
follow will focus on accumulated evidence
from balance studies and from experiences
with total parenteral nutrition as to what
may represent the minimal requirements
of man for copper during infancy, child
hood and adulthood.
Infants
Specific requirements of healthy human
infants for copper have been difficult to
determine with any degree of accuracy.
To provide a picture of the problem, it
seems appropriate to review current infor
mation with respect to: 1) milk as a source
of copper for the premature and full-term
infant; 2) copper balance studies on in
fants; 3) naturally occurring states of cop
per deficiency; and 4) studies on infants
largely or totally dependent upon total
parenteral nutrition (hyperalimentation )
for extended periods of time.
Milk as a source of copper. It has long
been recognized that the copper content
of human milk is two to three times higher
than that of cow's milk, and that the con
tent of human colostrum is two to three
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2026 KARL E. MASON
times that of later milk (437, 449, 541,
647, 877). Moreover, the somewhat lower
ratio of zinc to copper (about 4:1) in
human milk may significantly enhance cop
per absorption in breast-fed infants (843).
Cow's milk has a very low content of
copper. Values recorded by different in
vestigators have varied widely, and their
documentation would serve no useful pur
pose. Suffice it to say that three of the
more recent reports (546, 598, 843) give
values within a range of 0.04 to 0.30 mg/
liter. Difference in forage and in season of
the year are largely responsible for varia
tions in values obtained. Special attention
may be called to analyses of commercial
milk samples from 65 cities throughout the
USA giving a national mean of 0.086
(range 0.04-0.19) mg/liter (547).
The first serious study of the copper
content of human milk, by Zondek and
Bandmann (877), indicated levels of 0.5 to
0.6 mg/liter in 85 samples obtained during
the first 2 months of lactation. Munch-
Peterson (541), who carried out 74 analy
ses of milk from 10 mothers during the
first 8 days of lactation, recorded a mean
content of 0.48 mg/liter. He also found
that intravenous administration of a watersoluble
compound containing 19% of cop
per given to seven other mothers had no
influence on the copper content of the
milk, even though serum copper levels
were greatly increased. This confirmed the
early report of Elvehjem et al. (189) that
a 5 to 10-fold increase in dietary intake of
copper had no demonstrable effect on its
level in the milk of the cow or goat. This
restriction in mammary transfer of copper
might reflect a homeostatic mechanism for
protection of the neonate. Rottger (647)
reported a mean value of 0.44 ( range 0.27-
0.84) mg/liter for 15 samples of human
milk during early phases of lactation.
Munch-Peterson (541) and Rottger (647)
independently estimated a daily intake of
about 0.25 mg/Cu by young infants. In
comparison, other investigators have re
ported higher values for early milk (107,
437, 449) and others give values approxi
mately one-half or less than those recorded
above, for mature human milk not identi
fied as early milk (275, 546, 598, 843). A
striking decrease in copper content of milk
at successive months of lactation (11.2,
7.3, 5.4, 4.6 and 1.5 /¿g/100ml) is reported
by Kleinbaum (410). Similar data are
given by Hambidge (299).
Noteworthy is the recent and extensive
study of Picciano and Guthrie (598), based
on analyses of 350 milk samples from 50
lactating, healthy women (seven samples
each). Copper content varied considerably
among women and with the same woman.
Several samples taken over periods of days
or weeks were necessary to provide a re
liable estimate of the copper content of
milk from any individual. Their mean value
of 0.24 (range 0.09-0.63) mg/liter is essen
tially the same as that reported by Murthy
and Rhea (546); namely, about 0.24 ±
0.03 mg/kg, on analyses of 22 milk sam
ples from lactating women.
Picciano and Guthrie (598) calculated
that breastfed infants less than 3 months
of age, with a body weight of 4 kg and a
daily milk intake of 850 ml, would ingest
approximately 0.2 mg/day ( or 0.05 mg/kg/
day). These estimates are in good agree
ment with the values of 0.25 mg/day of
Munch-Peterson (541) and Rottger (647),
also based upon human milk. They are also
slightly less than estimates of 0.05 to 0.10
mg/kg/day based on balance studies with
young children 3 to 6 years of age (142,
695), the estimate of 0.08 mg/kg/day by
Cartwright ( 100), and the statement of the
Committee on Recommended Dietary Al
lowances of the National Research Council
(549) that "The requirements of infants
and children have been estimated at be
tween 0.05 and 0.1 mg/kg of body weight
per day; an intake of 0.08 mg/kg/day ap
pears to be adequate." The World Health
Organization in its 1973 report (861)
recommends 0.08 mg/kg per day for in
fants and young children and 0.04 mg/kg
per day for older children. It would seem
that under normal circumstances the cop
per provided by nature in human milk is,
when supplemented by storage in the new
born liver, a reasonably good measure of
optimal requirements during early life.
The premature infant presents special
problems. According to Widdowson et al.
(843) about % of fetal copper is trans
ferred during the last 10 to 12 weeks of
gestation. As a consequence, premature in-
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2027
fants of 28 to 30 weeks gestation, weighing
about 1 kg, have much smaller reserves of
copper in the liver, spleen and other tissues
to be called upon postnatally than do fullterm
infants. Sultanova (761) has carried
out copper analyses of livers and spleens
from groups of premature infants with
birth weights of 1.0 to 1.5, 1.5 to 2.0 and
2.0 to 2.5 kg, and term infants dying soon
after birth. In successive groups there
were definite increases in the copper levels
per gram of tissue in both organs. Hence,
the smaller the premature the lower the
copper concentration in its tissues. As an
other handicap, the premature is usually
obliged to subsist on an exclusive milk
diet for much longer periods than the fullterm
infant. Although in newborn prema
tures copper deficiency is unknown, their
status does place them in a more pre
carious situation than full-term infants
when states of malnutrition intervene. To
compensate for this, Widdowson et al.
(843) have suggested that premature in
fants be provided a special milk formula
which might assure a retention of at least
0.085 mg of copper per day. Cordano
( 124) feels that for prematures the recom
mended 0.06 mg/100 kcal for infants (18)
should be increased to 0.09 mg/100 kcal
(i.e., 0.1 mg/kg/day). This is the current
recommendation of the American Academy
of Pediatrics ( 19) for low-birth-rate in
fants.
Balance studies. A pioneer balance study
of copper in infancy, to which relatively
little has since been added, is that of
Kleinbaum (409), who studied six breast
fed full-term infants over the 13th to 23rd
days of life. Birth weights averaged 3.4
kg, but later weights are not given. Total
copper intake and output for the 10-day
period averaged 4.74 and 4.72 mg, respec
tively. Three infants showed a negative
and three a positive copper balance.
Hence, these data might be interpreted as
indicating that healthy full-term infants
during the first month of life require an
intake of approximately 0.5 mg/Cu/day to
keep in positive balance. The 10-day bal
ance study of Priev (619) on two infants
8 and 3 months of age indicates require
ments of 0.30 and 0.42 mg/day, respec
tively. Similar 10-day balance studies of
Kleinbaum (409) on 31 premature infants
initiated at ages of 2 to 82 days, and with
average intakes of 0.28 mg reveal a slightly
negative balance in all instances. Hence in
the balance studies described there is
reasonably good accord with a requirement
of approximately 0.05 mg/kg/day for
maintaining a positive copper balance in
young infants of the six infants weighing
in the range of 6 to 10 kg.
States of copper deficiency. In studies
with experimental animals, while the daily
intake necessary to prevent development of
a deficiency of a nutrient provides the most
reliable estimate of basic requirements, a
determination of the smallest intake neces
sary to effect cure of an early stage of
deficiency also provides the next best esti
mate of minimal requirements. Such pro
cedures are, for many reasons, not applica
ble to man at any age. Even though an
arbitrary level of therapy might prove to
be marginal in effect, deficiencies or even
excesses of other nutrients, together with
malabsorption and diarrhea, are usually
present and a simple deficiency state such
as obtainable in experimental animals does
not exist.
Such a situation characterizes the pio
neer studies of Cordano et al. ( 126) on
four malnourished infants manifesting
anemia, neutropenia, scurvy-like bone
changes and hypocupremia. Rehabilitation
on high caloric diets supplemented with
iron, ascorbic acid, folie acid and other
vitamins was incomplete without the addi
tion of elemental copper. In fact, it was
later recognized that the increased growth
rate resulting from the improved diet
greatly decreased the protective effect of
the low levels of copper provided by the
milk diet (28-42 ,ug/kg body weight). On
the basis of varied levels of copper supple
mentation it was estimated that for rapidly
growing infants 6 to 9 months of age, with
inadequate stores of copper and main
tained exclusively on milk diets, the daily
requirement for copper was greater than
0.042 mg but less than 0.135 mg/kg body
weight. Since each of the children weighed
approximately 10 kg at the beginning of
supplementation, these values are slightly
higher than those derived from balance
studies but approximate the estimated re-
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2028 KARL E. MASON
quirements of 0.077 to 0.11 mg/kg body
weight for growing pigs (772). In later
studies on 21 similar infants 4 to 19 months
of age ( 128), daily supplements of greater
than 0.15 mg/kg proved quite adequate
to correct for neutropenia, considered to be
the earliest manifestation and most sensi
tive indicator of adequacy of treatment
of copper deficiency in man. Subsequently,
oral supplements of 2.5 mg/day were
usually employed as a routine measure to
assure much more than estimated require
ments (276).
On the basis of his personal experiences,
Cordano (124, 125) recommends that
manufactured formulas for premature in
fants be supplemented with copper such
as to provide 0.09 mg/100 kcal, rather than
the 0.06 mg/100 kcal recommended by the
Committee on Nutrition of the American
Academy of Pediatrics (19) which, since
then, has recognized this need. This pro
vides approximately 0.1 mg/kg/day, and
is somewhat less than the supplement of
0.1 to 0.5 mg/day proposed by Ashkenazi
et al. (25) for prematures subsisting on
milk only. In such considerations there has
been recognized a need to make provision
for such commonplace factors as intestinal
interactions between copper and iron in
iron-fortified formulas (700), régurgita
tion, prolonged diarrhea and infections. On
the basis of the evidence presented, it
seems that the daily requirement of cop
per for young and reasonably healthy in
fants may be met by daily intakes of 0.05
to 0.1 mg/kg/day.
Total parenteral nutrition. The develop
ment of a procedure for providing "total
Sarenteral nutrition" by means of an injsate
of nutrients introduced via an in
dwelling catheter inserted into a large cen
tral vein by Dudrick et al. (176 )and Wilmore
et al. (852, 853) ushered in a new
era in therapeutic nutrition. Its original
application in conjunction with surgical
treatment of catastrophic gastrointestinal
anomalies of infants has since been widely
extended to the management of a variety
of gastrointestinal disorders, burns, infec
tions and other situations in which subjects
are unable to meet nutritional needs by the
oral route. By appropriate modifications,
this procedure has been effectively ex
tended from its hospital applications to
the prolonged maintenance of subjects in
the home environment (66, 304, 385, 441,
711, 724). Total parenteral nutrition, espe
cially when prolonged in infants and
adults, has provided much new and help
ful information concerning copper require
ments of man.
However, problems arise in the interpre
tation of the results. One must first assume
that copper introduced parenterally sub
stitutes for that portion of orally ingested
copper absorbed by the intestinal tract and
transported to the liver and to the systemic
vascular system. While, as discussed pre
viously (p. 1991), it is generally accepted
that roughly 40 to 60% of ingested copper
is absorbed, wide individual variations
exist, due to differences in gastrointestinal
functions, nature of the diet, derangements
of metabolism and states of stress.
It is noteworthy that in their classic
studies with infants, Dudrick et al. (175,
176) and Wilmore et al. (853) took care
to provide in their parenteral fluids both
vitamins and minerals. The latter included
zinc, copper, manganese, cobalt and iodine.
Copper was provided at a level of 0.22
mg/kg body weight. This represents a
rather generous supply when compared to
estimated requirements of 0.05 to 0.10 mg/
kg/day. In any case, failure to follow these
guidelines resulted in occurrence of sev
eral cases of copper deficiency in infants
(25, 394, 463) and in adults (177, 808).
Although traces of copper are present in
fibrin and casein hydrolysates and in crys
talline amino acid mixtures commonly used
in parenteral solutions, direct analyses (57,
317, 342, 590) demonstrate their variability
and inadequacy to meet nutritional needs
for copper. The proposed use of plasma
transfusions given twice weekly (209 ) does
not compensate for this (704). What is
said of copper is also true of zinc (57, 342,
590 ). Investigators now add trace elements
to the basic hyperalimentation formulae
(174, 214, 367, 382, 383, 709, 710, 712,
724) providing copper in approximately
the amount (0.22 mg/kg body weight)
originally proposed by Wilmore et al.
(853). Essentially the same supplement is
recommended by Ricour et al. (639),
Wretling (864) and by Karpel and Peden
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2029
•-•-ig"S —
S—
•£I2co tì t-.
o—
Csaaili
C's» CO
Tf00
osSi•§!$§§ri—
- '
CIo^*«aBilO•<
J>HiI0011îX'Ss-
pofeft-go
"e0-S13
*7LI"3!'S
CU13S
•3'So
,K81
-gë§x•f
äM^Q
o3§gS'£à 1
feP
£S !r
|>o
Ö-^
t»0 •^
1—4*aOi
co
»O IO
•BT31
1ÃŒli8l +
MS W JaS^. o
^.ctîctcoCi+Joc^
C*tt
^-^!>
oo1
1—
31
1*
SO i%r
_;"o í»OO
—Ì
fc'SbO ü*3C
**-O
05c3
>,^í V
"¿o
x
Ö •>i£^
^os
CO5 CO
P2
"3*-* "«3
v111¿ceS v
à HhJoh
o"§0COs?c.
1$£r*- ofincome group,
2-sfc't»^i
before balance s•tì'Sco1
ci?ìOSOo^n§01
CO^PCDO+_"coMC»gV2•

2Ü30 KARL E. MASON
(394) after experiences in compensating
for a copper deficiency state developing in
an infant with ileal atresia and short bowel
syndrome maintained on total parenteral
nutrition for the first 6.75 months of life.
In current practice for complete intrave
nous feeding of premature infants of less
than 1,050 g birth weight, James and Mac-
Mahon (383) provide 50 ¿u.g/kg/day of
copper. Quite in accord with these opinions
are those of Ashkenazi et al. (25), record
ing copper deficiency in a premature infant
6 months old fed a diet of only whole milk
and 5% cane sugar, and in a premature
infant subjected to bowel surgery and
maintained on parenteral feeding for 3
months. Both responded rapidly to oral
copper, and investigators recommended
that small premature infants be given sup
plements of 0.1 to 0.5 mg of copper daily
while milk is their only food, or during pro
longed intravenous feeding.
On the basis of the evidence cited above,
it seems reasonable to assume that the
daily requirement of intravenous copper
for infants, beyond the age at which they
can depend upon prenatal tissue reserves
( about 2 months ), may be in the range of
0.1 to 0.2 mg/day. On the assumption that
approximately 40^ of orally ingested cop
per is absorbed, this requirement would
be the equivalent of 0.25 to 0.5 mg/day of
oral copper. For a 10-kg infant this would
represent 0.025 to 0.05 mg/kg/day. Thus,
the information provided by parenteral
nutrition is in general concordance with
that from studies in milk intake, copper
balance and recovery from deficiency
states, which indicate requirements of
about 0.025 to 0.05 mg/kg/day for healthy
full-term infants during early years of life,
with somewhat more generous allowances
for premature and low-birth-rate infants.
Young children and adolescents
The basis for determining the minimal
daily requirements of copper for young
children and adolescents is decidedly lim
ited, as is indicated in table 1. Two pioneer
studies on 3- to 6-year old children (142,
695), although carried out 40 or more
years ago, warrant special consideration.
Daniels and Wright ( 142) studied five
boys and three girls and employed two
diets, one high in meat and cereals and the
other high in cereals without meat, but
similar in copper content. After 3 days of
adjustment to the diet, 5-day balance
studies were made. Mean copper intakes,
fecal plus urinary excretions and balances
were, respectively, 1.48, 1.03 and +0.45
mg/day. It was concluded that diets for
children of pre-school age should include
not less than 0.10 mg/kg/day of copper.
Scoular (695) carried out similar balance
studies on three boys of the same age,
based upon three different but well con
trolled diets. On the average, copper in
takes, fecal and urinary losses and reten
tions were, respectively, 1.36, 0.60, and
+0.76 mg/kg/day. In their best judgment,
the minimal requirement of boys of that
age would be between 0.053 and 0.085
mg/kg/day. Similar conclusions were
reached by Macy (477) in balance studies
on school children 8 and 11 years of age.
It may be noted that both of these esti
mates fall within the range of estimated
copper requirements for infants (0.05-0.1
mg/kg/day) as discussed above.
Balance studies carried out by Engel et
al. (190) on groups of 12 girls 6 to 10
years of age, during summer months of
1956, 1958 and 1962, employing liberal pro
tein, low animal protein and vegetarian
type diets, leave open questions concern
ing requirements. Calculations made (by
writer) from the data given indicate that
the first two of these diets provided aver
age copper intakes of 0.04 and 0.037 mg/
kg/day and copper balances of —0.01and
—0.08mg/day, respectively. Comparable
values for the vegetarian diet were 0.12
mg/kg/day and +1.02 mg/day. These data
would suggest a minimal intake somewhat
less than proposed in the two studies just
described. However, Engel et al. ( 190)
estimated, by regression analysis, that the
daily intake in their studies was 1.3 mg/
day, and that the suggested allowance be
2.5 mg/day. In this suggestion was in
cluded a sweat loss of 0.5 mg/day and a
safety margin of 0.7 mg/day, added to the
1.3 mg/day intake. For matters of com
parison, sweat loss was not incorporated in
other balance studies recorded, and the
estimated loss appears to be more than
generous for the subjects. Furthermore, the
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

s
&5°.S0
0lì»"oPH
o^—•3'S
tT"*
i•«OaM
d."io i«^-v-— * ^3
|W
8tJ
-gPQ
S<
•§H
».WI.111*^
|
ÈS15":»1
1Jjfe
COPPER METABOLISM AND REQUIREMENTS OF MAN 2031
£S3 *
ss<
Weo» W
«".^.§
00«g
mW00s,
•8 'e°
1
~.co
^ca*"1 p ^.Ã2- , ^" u
—° e *'ß c
l.0"!'^Sili M'S'S
-si"ìr^!i?^o s'S
"*^~ 35 S o-Sá? "Si
^S >*j^"O*JL'2s
COC^iO^feB
='a
§>"'&!z
^«"JZ
UŒZ•I2
g—
'S '
' »rt
to•a as
c«IJJte
«t£
**-•suaifefefe^"èr-H
u «JL'"ffiffiSfeC C£M
^^NS2¿^ ^ï
•,^^t^~O×eL5
^v
o«tí
||O
0)•C'C"S
o' o
-H-H-HO3-H
Oo' --ÃŒt~ -i
•*'—•
^^V
C.>^.S5X!
«aCJa
a1"ca^T^|il|"-- gì
-2.t- * ^S's
^-1 ^- u
¿ o3^it^03
^d • C • S
"^>
3~'&
'"g
^"H"3
"*«
'S«
*î
1£ "o
P3 K£
3OÜ¡II«•

2032 KARL E. MASON
cant changes in copper requirements occur.
Considering the rather bizarre food intakes
and eating habits of this segment of popu
lations, there is real need for copper bal
ance studies on pre-college teenagers.
Except for the inconclusive observations of
Dawson et al. ( 152 ), no consideration has
been given to the special nutritional re
quirements, including those of copper, in
teen-age pregnancies. Considering that in
such situations there is need to meet
growth requirements of the adolescent
mother as well as those of the developing
fetus, it may be assumed that requirements
are appreciably greater than in adult preg
nant women.
Adults
Since adults are past the growing phase
of life, copper requirements are expressed
in terms of mg/day rather than as mg/kg/
day, as in the case of infants and adoles
cents.
Dietary intake. An earlier section (pp.
1998-1999) deals with the wide variation in
copper content of human diets in various
countries and of individuals of different
ages. Table 2 summarizes additional data
from studies in which the daily dietary
intake of copper (often as only one of
many trace elements), exclusive of copper
balance, was of primary concern. Indian
diets, which are predominately vegetarian
in composition, are notably high in copper
content. Analyses of diets of ovovegetarian
and nonvegetarian populations in India by
Soman (727) indicate, by writers's calcu
lation from the data given, intakes of about
5.7 and 7.1 mg/day, respectively. An ex
ceptionally high content of copper in
Indian diets is also reported by De ( 154)
as shown in table 3. These values are con
siderably in excess of those reported from
other countries. Only in the studies of
Guthrie (289, 291) is mention made of the
influence of liver, well known to be much
higher in copper than other food constitu
ents. In other studies in which composi
tion of the diet employed is given, liver has
not been listed as an ingredient. Somewhat
surprising are the low copper levels found
in student diets (White), hospital diets
(Gormican; Brown et al.) and self-selected
diets (Holden et al.). The values reported
are appreciably lower than those for com
parable types of diets in the balance
studies recorded in table 3. The studies
summarized in table 2 merely give some
picture of variations in the copper intake of
small groups of individuals in several dif
ferent countries. They provide no valid in
formation concerning requirements for
copper, since there is no evidence of their
ability to maintain positive balance over
long periods of time. To a certain extent
the same may be said of traditional balance
studies such as recorded in table 3, but
the latter do provide data on copper re
tention, in terms of intake less fecal excre
tion. While they provide data over only a
limited period of days or weeks, they do
represent a measure of daily requirements
somewhat equivalent to that provided by
total parenteral nutrition.
Balance studies. Table 3 summarizes, in
chronological sequence, data pertaining to
balance studies on human adults. In 6 of
the first 10 studies, extending from 1934 to
1954, the estimated requirement ranges
from 2.0 to 2.6 mg/day. These data pro
vided the basis for the wide acceptance of
2.0 or 2.0 to 2.5 mg as the daily require
ment of copper for adult man. However,
Cartwright and Wintrobe (106) later state
that at lower levels of intake adjustments
may be made to reduce copper excretion
such that the daily requirement would be
less than 2 mg and might even be negli
gible. Presumably, a major factor in this
adjustment would be a call upon copper
stores in the liver and other organs.
The levels of copper intake reported by
Holt and Scoular (349) are truly excessive
and the investigators, noting the much
lower values recorded by Leverton and
Binkley (452) for college students fed
similar diets, somewhat naively attribute
this difference to "a regional effect upon
the composition of food." Considering also
the unreasonably low fecal and urinary
loss and high retention values (calculated
from tabular data reported but not com
mented upon in the report) the atypical
results recorded suggest unknown defects
in methodology. The somewhat high cop
per content of Indian diets of De ( 154) is
in accord with the observations of Soman
(727), table 1. Whether the predominantly
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

î1co
1stW
»a«a3
COPPER METABOLISM AND REQUIREMENTS OF MAN 2033
„" -g^
CO>•
co'ig "OC«*--H
^I5
2>B•S C^12 t
7?ow^^îs-cS. i^^1-3y.gìY
Et»fe s
QJO ni O Cu
®MCßO
£Ci PU O C»
ci•9VSogC4O
IOIMICihO1feT(M8?2!1
i-*O
JgoJ
NVV11«~.£cc|sUfieu
*T3•S
-wr- -^
c's•
C—>% . .— 0) ^
O"or -Q-^- V
î"S„^
O ^ *fe
tí-t-s aizo"oUZ

2034 KARL E. MASON
vegetarian type of diet, differences in cop
per content of soil and/or water, contami
nation through common use of tinned-cop
per cooking utensils, or some combination
of these factors can provide an explanation
is speculative. The estimated minimal re
quirement of 2.0 mg is based upon statisti
cal analyses of the balance data ( 154). The
data of De ( 154) clearly support observa
tions of others (100, 451, 452) that as di
etary copper intake increases there is an
increase in the amount retained, up to an
intake of about 8 mg/day. It should also
be noted that in the diets used by Butler
and Daniel (84) a mineral and baking
powder mix was added, providing at two
meals a total of 2.37 mg of copper per day,
thus explaining the high levels of intake
and output. However, there is no valid
basis for their concluding statement that
"a copper allowance of 4.5 to 5.0 mg is
needed to cover the requirements of all
healthy young women, depending on cli
matic conditions."
The study of Kyer and Bethel (431) is
the only known report on copper require
ments of the pregnant woman. In view of a
2- to 3-fold increase in serum ceruloplasmin
during gestation, presumably attained
through calls upon storage depots of the
liver and other organs and tissues, an in
crease in daily intake of copper to replace
this tissue depletion would be anticipated.
In this study a healthy young woman was
maintained during the last 3 months of her
pregnancy and for 2 weeks after delivery
on a uniform diet providing a daily intake
of about 2.2 mg of copper. At this level of
intake she was able to meet normal needs
for pregnancy and early lactation.
Balance studies carried out during the
past 14 years, represented by the last eight
listed in table 3, indicate that levels less
than 2 mg and sometimes not greatly in
excess of 1 mg may maintain positive cop
per balance. Such conclusions are in gen
eral accord with information provided by
parenteral nutrition studies, as discussed
in the following section. Nevertheless, it is
important to bear in mind that at these
low levels of intake there is, as yet, no
means of determining to what extent body
mechanisms of copper homeostasis may in
volve decreases of copper stored in the
liver and other tissues of the body.
Total parenteral nutrition. The advent of
total parenteral nutrition (hyperalimentation)
and its application to problems of
post-surgical nutrition and gastrointestinal
disorders has added greatly to knowledge
of copper utilization and requirements. A
number of observations which have par
ticular relevance to adult human require
ments for copper warrant consideration at
this point.
Shils et al. (712) report the case of an
adult male, with bowel resected from the
third part of the duodenum to the ascend
ing colon, who was maintained in good
nutritional status solely on parenteral feed
ing for many months. The basic parenteral
fluid was essentially devoid of copper, but
was supplemented with various trace ele
ments which included 0.40 mg copper/day.
Bergstrom et al. (45) describe a 43-year
old woman suffering from epilepsy and
cerebral damage due to CO^. intoxication
from a fire, who was maintained for 7
months and 13 days on total parenteral
nutrition, with an estimated daily intake
of 0.10 mg/day of copper.
Perhaps more impressive is similar treat
ment of a 36-year old woman during a 10month
period in a hospital following resec
tion of her intestinal tract between the
duodenum and descending colon (790).
During her hospitalization she gained 34
pounds. Subsequently, after mastering the
technique of administering her parenteral
fluids at home, she was able to carry out
her household duties effectively. Through
out the postoperative period her parenteral
solution provided 0.018 mg/day of copper.
The only other source of copper, the 100
mg of protein hydrolysate, might have
provided about 0.075 mg/day and ac
counted for a total intake of 0.093 mg/day.
Essentially the same experience, with em
ployment of a similar parenteral fluid sup
plemented with 0.06 mg/day is reported
by Langer et al. (441) in the management
of two women, 21 and 34 years of age, fol
lowing extensive intestinal resection. These
two reports (441, 790) appear to indicate
that the minimal daily intravenous require
ment for adult man may well be less than
the proposed additions of 0.3 to 0.4 mg/day
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2035
to solutions used for total patenterai nutri
tion for prolonged periods (177, 711, 712,
864). To these, of course, must be added
the amount contributed by the casein hydrolysate
or other protein components of
the infúsate. These vary considerably in
their copper content. Somewhat contrary
to these estimates is the report of Mc-
Kenzie et al. (511) that in seven adult
patients in a surgical intensive care unit a
parenteral infúsate providing 0.09 to 0.8
mg of copper resulted in a negative bal
ance in all cases.
Some useful information has also come
from studies concerned with copper levels
required to compensate for states of cop
per deficiency resulting from an inade
quacy in parenteral fluids. An excellent
example is the study of Vilter et al. (808).
In a 56-year old woman with malabsorption
and severe systemic sclerosis of the
intestine, maintained on total parenteral
nutrition for 2.5 months, they observed
typical manifestations of copper deficiency.
For 4 months she had shown leucopenia,
neutropenia and a hypocellular bone mar
row, considered typical manifestations of
copper deficiency. Serum copper was very
low (0.02 fig/ml ) and serum ceruloplasmin
was not demonstrable. Intravenous admin
istration of 1 mg/day for 7 days resulted in
an excellent response, still evident 90 days
later. Hence 7 mg of copper sulfate dis
tributed over 90 days, equivalent to 0.077
mg of copper per day, represented more
than minimal requirements for this woman.
Here again, a reasonable estimate of cop
per acquired via the protein hydrolysate
component might increase the uptake to
approximately 0.1 mg/day.
Dunlap et al. ( 177) describe a state of
copper deficiency in a 45-year old woman
and a 12-year old girl receiving long-term
parenteral nutrition following extensive
bowel surgery. The older subject, after
almost total dependence on parenteral
feeding for about 17 months, developed
anemia and neutropenia which responded
rapidly to oral copper sulfate (5 mg CuSO4
or 1.25 mg elemental copper) daily, which
was continued for 45 days. With discon
tinuation of copper-therapy for about one
month, deficiency symptoms were again
apparent and responded well to 1.6 mg
copper sulfate (0.4 mg/day) given intra
venously. After 2 weeks the daily dose was
increased to 1 mg copper for 5 weeks. Sub
sequently, she was on a parenteral dose of
0.4 mg copper daily and showed no evi
dence of recurrence of hématologieabnor
malities. The younger subject, who had
been dependent entirely on parenteral
nutrition for only 4 months, showed neutro
penia (but no anemia) which also re
sponded to oral copper therapy. The fact
that oral copper was effectively absorbed
by both subjects, in whom the duodenum
had been anastomosed to the transverse
colon, provides additional evidence that
the stomach and duodenum play a major
role in the absorption of copper in man.
Of special interest are the data derived
from studies on the older subject clearly
indicating that a daily parenteral intake of
0.4 mg of elemental copper effected a
rapid recovery from a deficiency state.
The observations of Vilter et al. ( 808 ), also
carried out on a single adult woman, are in
close agreement with those of Dunlap et
al. (177).
One conclusion that may be justified
from these two studies is that the "uncom
plicated" minimal intravenous requirement
of copper for man may well be less than
0.4 mg per day. By "uncomplicated" is
meant under situations where ingested
copper is not being subjected to the in
fluence of many other components of the
diet (other trace elements which compete
for binding sites, dietary fiber, phytates,
etc.) or may otherwise interfere with maxi
mal absorption. Assuming a 40 to 60% ab
sorption of oral copper, this would repre
sent an oral intake of approximately 1 mg/
day.
Two recent examples of the inadequacy
of parenteral infusâtescommonly in use in
hospitals can be cited. Weekly serum cop
per determinations on eight adult patients
receiving total parenteral nutrition for 3 to
13 weeks revealed a progressive decrease
of serum copper and three patients showed
severe hypocupremia. The infúsate had no
detectable copper. All responded rapidly to
oral copper feeding (217). Another study
(726) describes a progressive decline in
plasma copper (and also zinc) in 13 sub
jects with active gastrointestinal disorders
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2036 KARL E. MASON
maintained on total parenteral nutrition for
8 days to 7.5 weeks (mean, 4.5 weeks).
The infúsate, providing nitrogen as crystal
line L-amino acids, contained no copper
detectable by a method sensitive to 20
itg/liter. Usually more than 2 months of
total parenteral nutrition with unsupplemented
infusâtesare required before clini
cal evidence of copper deficiency becomes
apparent (590 ). The need for more general
inclusion of trace elements, especially cop
per and zinc, in parenteral fluids is obvious.
Despite the widely recognized need for
adequate provision of copper and other
trace elements in intravenous solutions,
recommendations and practices of differ
ent investigators reveal wide variations.
According to the calculations presented
by Jacobson and Wester (379), the rec
ommendations for copper in trace element
mixtures per 24 hours in total parenteral
nutrition for 70 kg adults vary from 1.54
mg (173), 1.0 mg (709, 710), 0.11 mg
(367), 0.3 mg (864) and 0.1 mg (379). It
is the opinion of Jacobson and Wester
(379) that a daily intake of 0.3 mg repre
sents the best recommendation. This again
represents an oral intake less than 1 mg/
day.
It is of particular interest to find that
data based upon milk intake in infants and
upon balance studies and prolonged main
tenance with total parenteral nutrition
have shown remarkably good agreement.
Briefly stated, the evidence suggests that
copper requirements for the maintenance
of good health lie within the range of
0.025 to 0.05 mg/kg for young infants,
0.05 to 0.1 mg/kg for older children and
adolescents, and in the neighborhood of
1.0 to 1.5 mg/day for adult man.
RESUME
There has been presented a review of
research findings relative to the distribu
tion of copper in the human body: the
nature and function of a large array of
cuproproteins; the omnipresence of copper
in foods; its absorption, transport and ex
cretion; naturally occurring states of cop
per deficiency; dietary interrelationships
and states of toxicity; the congenital dis
orders of Menkes' disease and Wilson's
disease; copper metabolism of pregnancy,
neonatal and postnatal life; and copper re
quirements of infancy, adolescence and
adulthood as determined by balance
studies and data derived from experiences
with parenteral nutrition.
The human body contains approximately
75 mg of copper, about one-third of which
is present in the liver and brain. Lesser
concentrations exist in the heart, kidney,
pancreas, spleen, bone and skeletal muscle.
In organs and tissues copper is bound to a
wide variety of cuproproteins, most of
which have properties of enzymes. Among
the trace elements copper is unique in
terms of the large number of metabolically
important enzymes of which it is an essen
tial component, and the wide variety of
organs and tissues in the mammalian
organism whose functional and structural
integrity are dependent upon these en
zymes. Of these, ceruloplasmin, Superoxide
dismutase, cytochrome c oxidase, lysyl
oxidase, tyrosinase and neonatal mitochrondrocuprein
are recognized as impor
tant in human metabolism. Metallothionein
and similar low molecular weight cupro
proteins, non-enzymatic in nature, have
roles in copper storage and detoxification.
Still awaiting further investigation are
other cuproproteins some of which might
well prove to have important but as yet
unrecognized roles in human metabolism.
Ceruloplasmin, whose biological role has
long been a mystery, is now recognized as
a multifunctional cuproprotein possessing
a broad spectrum of oxidase activity. Its
role as feroxidase I in the mobilization of
plasma iron provides a satisfying answer to
questions raised 50 years ago concerning
the role of copper in nutritional anemia.
Its role as a cuproprotein transferring cop
per to tissues for the synthesis of vitally
important enzymes, the most important
of which is cytochrome c oxidase, has been
relatively unexplored. The same may be
said of the possible capacity of ceruloplas
min to maintain and control blood and tis
sue levels of biogenic amines. In view of
the importance of these amines in normal
brain functions and the neurological defi
cits found in both Wilson's and Menkes'
disease, this will unquestionably be a fruit
ful area for future investigation, both ex
perimental and clinical.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2037
Cytochrome c oxidase, an enzyme vital
to essentially all forms of life, has been
clearly shown in experimental and farm
animals to be involved in the myelination
of nerve fibers and in maintaining struc
ture and function of myocardial tissue.
What relevance such observations may
have to brain and cardiac functions in man
offer challenging avenues for future re
search. Aside from lysyl oxidase, well rec
ognized as essential for the cross-linking
of elastin and collagen, are other monoamine
oxidases in mammalian tissues which
future research may well show to be of
great importance in the metabolism of
man.
Metallothionein, a nonenzymic cuproprotein,
may well prove to be merely one
of a family of cuproproteins of relatively
low molecular weight playing important
roles in the mechanisms of intestinal ab
sorption and transport, and of liver storage
and transfer. There is urgent need for bet
ter identification of such proteins and in
creased knowledge of their metabolic roles.
New information of this nature may add
greatly to understanding the nature and
treatment of the two well recognized in
born errors of copper metabolism and
possibly of other disorders not yet well
recognized.
Copper is ubiquitous in nature and its
relative amount in different foods is well
established. Very little is known regarding
the chemical forms in which it exists in
foods or the influence which methods of
processing and cooking may have upon its
availability. In man, there is only limited
knowledge of how absorption of available
copper may be influenced by interactions
in the gut between it and other trace ele
ments, metallothionein-like proteins, di
etary phytates, sulfates and ascorbic acid.
Copper is absorbed chiefly by gastric and
duodenal mucosa, and approximately 40
to 60r/c of that ingested is actually ab
sorbed, bound to albumin and amino acids
and transported to the liver. The liver
serves as the control center for copper
metabolism and homeostasis by virtue of
its functions as a major storage depot, the
major site of copper excretion via the bile
and the only site of ceruloplasmin syn
thesis.
In blood, the ratio of copper in red cells
to that in plasma is approximately 0.7. Of
that in erythrocytes, which is remarkably
constant in normal man, 40% is in a labile
form bound to amino acids and 60% is
more firmly bound in Superoxide dismutase.
Of the copper in blood serum, about
1% is labile, bound more to albumin than
to amino acids, the remaining 93% being
firmly bound as an important component
of ceruloplasmin, synthesized only by the
liver.
States of hypocupremia in man are rela
tively rare, occur usually in children and,
except for high urinary loss of ceruloplas
min in the nephrotic syndrome, are gen
erally due to hypoproteinemia and inabil
ity to provide adequate amounts of apoprotein
for ceruloplasmin synthesis. On the
other hand hypercupremia, due almost ex
clusively to hyperceruloplasminemia, is
commonly observed in pregnancy, after
oral intake of contraceptives and in associ
ation with innumerable disease states and
disorders. Elevated serum ceruloplasmin
in states where inflammation is involved re
flects its function as an "acute phase reactant";
in non-inflammatory states reasons
for its increase are shrouded in mystery.
There are unsettled questions concern
ing placental transfer of ceruloplasmin.
But of far greater importance is the need
for much more information on fetal copper
metabolism, including the distribution and
nature of protein binding of copper in dif
ferent organs and tissues of the fetus. Such
information is of particular relevance to a
better understanding of the basic defect in
Menkes' disease. Because of ethical and
other restrictions, the answers may have to
come from studies on lower primates
which, to date, have not been utilized in
studies on copper metabolism.
Menkes' steely-hair disease, first de
scribed in 1962, represents a state of cop
per deficiency induced in young infants by
a sex-linked recessive defect in copper me
tabolism. The primary metabolic defect is
unknown. Some findings suggest a block in
the transfer of copper across absorptive
cells of the intestinal mucosa, but there are
possibilities of a defect in placental trans
fer of copper or the presence of an atypi
cal protein-binding of copper in the liver
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2038 KARL E. MASON
and other organs of the fetus and infant.
An intrauterine defect could explain why
even in infants with early postnatal diag
nosis, therapeutic measures of varied types
have done little more than improve serum
copper and ceruloplasmin levels, while the
disease process continues unabated. The
recent discovery and study of two genetic
animal models in mice with striking simi
larities to Menkes' disease, combined with
continued study of dietary copper defi
ciency in the rat and guinea pig, offer
challenging opportunities for further inves
tigation of the metabolic defect(s) under
lying this disease and some remote possi
bility of more effective therapeutic mea
sures than currently exist, even though
intervention in utero may be the only
recourse.
Mystery also still surrounds the primary
defect in Wilson's disease (hepatolenticu-
lar degeneration), an autosomal recessive
inborn error of metabolism first described
in 1912 and characterized by the accumu
lation of excessive and often toxic amounts
of copper in the liver, central nervous sys
tem, kidney and other tissues. Accumulat
ing evidence points to the liver as the site
of metabolic derangement, and decreased
biliary excretion of copper the basic reason
for the progressive increase of liver copper
to toxic levels. Hypotheses proposed sug
gest: 1) the presence in the liver, and
possibly in other affected tissues, of an
intracellular protein having greatly in
creased affinity for the binding of copper;
2) defects in a liver protein or peptide
serving in a specific "carrier mechanism"
for copper or, 3) defective intracellular
transport of copper secondary to dysfunc
tion of hepatocyte lysosomes. The further
pursuit of these concepts should open new
vistas concerning the metabolic defect in
Wilson's disease. As an example, recent
evidence of dramatic improvement in extrahepatic
manifestations of Wilson's dis
ease following orthoptic liver transplanta
tion also supports the concept that the
metabolic defect in Wilson's disease is
liver-based. For more than 20 years the
therapeutic use of D-penicillamine, a cop
per chelator, has led to slow clinical im
provement, especially when instituted in
early states of the disease. A real need
exists for an improved method for diag
nosis of asymptomatic cases of the disease,
replacing liver biopsy and radiocopper
studies, to permit earlier establishment of
therapeutic measures. The possible exist
ence of a more effective therapeutic agent
seems not to have been given the attention
deserved. There is recent evidence that at
least two liver diseases, primary biliary
cirrhosis and chronic active liver disease,
resemble Wilson's disease with respect to
elevated levels of liver copper. Whether in
these disorders benefits may be derived
from penicillamine therapy has not been
established.
In the development and practical appli
cation of total parenteral nutrition over the
past 10 years, isolated instances of states
of copper deficiency occurring in children
and adult man have emphasized the need
for more serious attention to the content
of copper and other trace elements in
parenteral solutions. Information gained
from experiences with parenteral nutrition
have given strong support to conclusions
reached by balance studies concerning the
minimal requirements of copper for infants
and adults. A much greater hazard has
been created by copper-contaminated tap
water or copper-containing valves and
stopcocks in conduits employed in hemodialysis,
due to the high toxicity of intra
venous copper. There are sporadic reports
of accidental and suicidal poisoning from
oral intake of copper salts. There is little
or no evidence of toxicity from industrial
sources.
Extensive evidence based upon the cop
per content of human milk (approximately
three times that of cow's milk ), copper bal
ance studies and experiences with total
parenteral nutrition indicate that copper
requirements for young full-term infants
are 0.025 to 0.05 mg/kg/day, and that
those for premature infants are somewhat
greater. Rather limited data, based largely
on balance studies, suggest requirements
in the range of 0.05 to 0.10 mg/kg/day for
young and adolescent children. There is a
serious lack of information concerning
copper requirements of teenagers, and
especially pregnant teenagers. It has long
been felt that an adult man requires 2.0
to 2.5 mg copper daily. Balance studies of
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2039
the past 12 years suggest that a copper in
take not much in excess of 1 mg/day may
represent the minimal requirement.
There is recent evidence that interactions
between zinc and copper, and between
molybdenum and copper can seriously in
terfere with absorption and/or utilization
of copper in man, as is well known to be
true of domestic and laboratory animals.
ACKNOWLEDGMENTS
Preparation of this conspectus was car
ried out under Contract No. E-13357-ARS-
76 with the Nutrition Institute, United
States Department of Agriculture. This is
the last of a series of conspectuses by the
Nutrition Institute, USDA, Beltsville, MD
on the nutritional requirements of man for
protein, amino acids, vitamin A, calcium,
zinc, vitamin C, iron and folacin. All have
been published in previous issues of The
Journal of Nutrition. The Nutrition Insti
tute wishes to acknowledge the great as
sistance and cooperation of the Editors and
reviewers of The Journal of Nutrition in
making the publication of these conspec
tuses possible.
The writer wishes to thank Drs. Walter
Mertz, Robert D. Reynolds and G. Thomas
Strickland for their valued judgments and
constructive criticism of the manuscript,
and Mrs. Shirley Cress for her patience and
painstaking preparation of the same. Trib
ute is also paid to the late Dr. Isabel Irwin
who, prior to her death March 25, 1975,
had collected an extensive literature on the
subject of this conspectus.
LITERATURE CITED
1. Abderhalden, E. (1900) Die Beziehungen
des Eisens zur Blutbildung. Ztschr. ßiol.
39, 482-523.
2. Abood, L. G., Gibbs, F. A. & Gibbs, E.
( 1957 ) Comparative study of blood ceruloplasmin
in schizophrenia and other dis
orders. A.M.A. Arch. Neurol. Psychiat. 77,
643-645.
3. Abraham, P. A. & Evans, J. L. (1972)
Cytochrome oxidase activity and cardiac
hypertrophy during copper depletion and
repletion. In: Trace Substances and Envi
ronmental Health (Hemphill, D. D., ed. J,
vol. V, pp. 335-347, Univ. Missouri, Colum
bia.
4. Adams, P. C., Strand, R. D., Bresnan, M. J.
& Lucky, A. W. (1974) Kinky hair syn
drome: serial study of radiological findings
with emphasis on the similarity to the bat
tered child syndrome. Radiol. 112, 401-407.
5. Adelstein, S. J., Coombs, T. L. & Vallee, B.
L. ( 1956 ) Metalloenzymes and myocardial
infarction. I. The relation between serum
copper and ceruloplasmin and its catalytic
activity. New Engl. J. Med. 255, 105-109.
6. Adelstein, S. J. & Vallee, B. L. (1961)
Copper metabolism, in man. New Engl. I.
Med. 265, 892-897; 941-946.
7. Adelstein, S. J. & Vallee, B. L. (1962)
Copper. In: Mineral Metabolism (Comar,
C. L. & Bronner, F., eds.), vol. 2, part B,
pp. 371-401, Academic Press, New York.
8. Adolph, W. H. & Chou, T. (1933) Cop
per in Chinese food materials. Chinese J.
Physiol. 7, 185-188.
9. Agarwal, A. K. (1975) Crippling cost of
India's big dam. New Scientist 65, 260-261.
10. Agarwal, B. N., Bray, S. H., Bercz, P.,
Plotzker, R. & Labovitz, E. (1975) Inef
fectiveness of hemodialysis in copper sul
phate poisoning. Nephron 15, 74-77.
11. Aguilar, M. J., Chadwick, D. L., Okuyama,
K. & Kamoshita, S. (1966) Kinky hair
disease. 1. Clinical and pathological features.
J. Neuropath. & Exper. Neurol. 25, 507-
522.
12. Ahlgren,
Menkes' kinky
P. &
hair
Vestermark,
disease. Neuroradiol.
S. (1977)
13,
159-163.
13. Akerfeldt, S. (1957) Oxidation of N.Ndimethyl-p-phenylenediamine
by serum from
patients with mental disease. Science 125,
117-119.
14. Albukerk, J. N. (1973) Wilson's disease
and pregnancy. A case report. Fértil.Steril.
24, 494-497.
15. Alexander, F. W., Clayton, B. E. & Delves,
H. T. (1974) Mineral and trace metal
balances on children receiving normal and
synthetic diets. Quart. J. Med. 43, 89-111.
16. Allen, K. G. D. & Klevay, L. M. (1978)
Cholesterolemia and cardiovascular abnor
malities in rats caused by copper deficiency.
Atheroscler. 29, 81-93.
17. Al-Rashid, R. A. & Spangler, J. (1971)
Neonatal copper deficiency. New Engl. J.
Med. 285, 841-843.
18. American Academy of Pediatrics, Committee
on Nutrition ( 1976 ) Commentary on
breast feeding and infant formulas, includ
ing proposed standards for formulas. Pedi
atrics 57, 278-285.
19. American Academy of Pediatrics, Committee
on Nutrition ( 1977 ) Nutritional needs of
low-birth-weight infants. Pediatrics 60, 519-
530.
20. Angel, C., Leach, B. E., Martens, S., Cohen,
M. & Heath, R. G. (1957) Serum oxida
tion tests in schizophrenic and normal sub
jects. A.M.A. Arch. Neurol. Psychiat. 78,
500-504.
21.
screening
Aoki, T. &
method
Nakahashi,
for Wilson's
M. J1977)
disease
New
and
Menkes' kinky-hair disease. Lancet 2, 1140.
22. Arachi, H., Tornii, S. & Mega, T. (1974)
Studies on the copper in the human serum
and organs. J. Nara. Med. Assn. 25, 171-
179.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2040 KARL E. MASON
23. Ardelt, W., Dehnhard, F. & Shussler, J.
( 1973 ) Serumkupfer und hitzestabile alka
lische Phosphatase bei normaler und patho
logischer Schwangerschaft. Ztschr. Geburt
shilfe Perinatal. 177, 188-192.
24. Arima, M. & Komiya, K. (1970) Preven
tion of Wilson's disease: a long term followup.
Paediatr. Univ. Tokyo 18, 22-24.
25. Ashkenazi, A., Levin, S., Djaldetti, M.,
Fishel, E. & Benvenisti, D. (1973) The
syndrome of neonatal copper deficiency.
Pediatrics 52, 525-533.
26. Asling, C. W. & Hurley, L. S. (1963) The
influence of trace elements on the skeleton.
Clin. Orthop. Related Res. 27, 213-262.
27. Axtrup, S. (1946) The Blood Copper in
Anaemias of Children with Special Reference
to Premature Cases. P. H. Lindstedts Universitets-Bokhandel,
Lund.
28. Baerlocher, K., Nussbaumer, A., Werder,
E. A. & Spycher, M. (1974) Menkes'
kinky hair disease: confirmation of copper
deficiency. Pediat. Res. 8, 135.
29. Bajpayee, D. P. (1975) Significance of
plasma copper and caeruloplasmin concen
trations in rheumatoid arthritis. Ann. Rheum.
Dis. 34, 163-165.
30. Bakwin, R. M., Mosbach, E. H. & Bakwin,
H. ( 1958 ) Ceruloplasmin activity in serum
of children with schizophrenia. Pediatrics
22, 905-909.
31. Bakwin, R. M., Mosbach, E. H. & Bakwin,
H. ( 1961 ) Concentration of copper in
serum of children with schizophrenia. Pedi
atrics 27, 642-644.
32. Baldassi, G. ( 1940 ) Le funzioni biologiche
del rame (Rassegna). Quad. Nutrizione 7,
250-270.
33. Baldi, E. M. & Gonzales-Somoza, E. ( 1957)
Enfermedad de Wilson y ciclo gravidopuerperal.
Obst. Ginecol. Latino-Amer. 15, 27-
31.
34. Barrass, B. C., Coult, D. B. & Pinder, R. M.
( 1972 ) 3-Hydroxy-4-methoxyphenethylamine:
the endogenous toxin of parkinsonism?
J. Pharm. Pharmacol. 24, 499-501.
35. Baum, & Seeliger (1898) Die chronische
Kupfergiftung. Arch. Thierheilk. 24, 80-127.
36. Beam, A. G. (1953) Genetic and bio
chemical aspects of Wilson's disease. Am. J.
Med. 15, 442-449.
37. Beam, A. G. (1957) Wilson's disease.
An inborn error of metabolism with multiple
manifestations. Amer. J. Med. 22, 747-757.
38. Beam, A. G. (1960) A genetical analysis
of 30 families with Wilson's disease (hepato-
lenticular degeneration). Ann. Hum. Genet.
24, 33-43.
39. Beam, A. G. & Kunkel, H. G. (1952) Bio
chemical abnormalities in Wilson's disease.
J. Clin. Invest. 31, 616.
40. Beam, A. G. & Kunkel, H. G. (1954)
Localization of MCu in serum fractions fol
lowing oral administration: an alteration in
Wilson's disease. Proc. Soc. Exp. Biol. &
Med. 85, 44-48.
41. Beam, A. G. & Kunkel, H. G. (1955)
Metabolism studies in Wilson's disease using
"Cu J. Lab. Clin. Med. 45, 623-631.
42.
L.
Beckner,
& O'Reilly,
W. M.,
S.
Strickland,
(1969) External
G. T., Leu
gamma
M
scintillation
and other
counting
sites in
of "7Cu over
patients with
the liver
Wilson's
disease, family members
Nucí.Med. 10, 320.
and controls. T.
43. Beinert, H. (1966) Cytochrome c oxidase:
present knowledge of the state and function
of its copper components. In: The Biochem
istry of Copper (Peisach, J., Aisen, P. &
Blumberg, W. E., eds.), pp. 213-234, Aca
demic Press, New York.
44. Beisel, W. R. & Pekarek, R.
Acute stress and trace element
Internat. Rev. Neurobiol. Suppl.
S. (1972)
metabolism.
1, 53-82.
45. Bergstrom,
S. (1972)
K., Bloomstrand, R. & Jacobson,
Long-term complete intravenous
nutrition
118-149.
in man. Nutr. Metab. 14, (Suppl.),
46. Bickel, H., Neale, F. C. & Hall, G. (1957)
A clinical and biochemical study of hepatolenticular
degeneration (Wilson's disease)
Quart. J. Med. 26, 527-558.
47. Bihl, J. H. (1959) The effect of preg
nancy
son's disease).
on hepatolenticular
Report of
degeneration
a case. Amer.
(Wil
J.
Obst. & Gynecol. 78, 1182-1188.
48. Billingham, M. E. J. & Gordon, A. H.
( 1976 ) The role of the acute phase reac
tions in inflammation. Agents Actions 6,
195-199.
49. Billings, D. M. & Degnan, M. (1971)
Kinky hair syndrome. A new case and a re
view. Am. J. Dis. Child. 121, 447-449.
50. Bloomfield, J. (1969) Copper
tion in exchange transfusions.
731-732.
contamina
Lancet 1.
51. Bloomfield, J., Dixon, S. R. & McCredie, D.
A. (1971) Potential hepatotoxicity of cop
per in recurrent hemodialysis. Arch. Int. Med.
128, 555-560.
52. Bloomfield, J., McPherson, J. & George, C.
R. P. (1969) Active uptake of copper
and zinc during haemodialysis. Brit. Med. J.
2, 141-145.
53. Bober-Vandzhura, I. P. (1968) Copper
metabolism in atherosclerotic
Arh. 40, 64-66 (Russian).
patients. Terap.
54. Borglin, N. E. & Heijkenskjold, F. (1967)
Studies on serum copper in pregnancy. Acta
Obstet. Gynecol. Scand. 46, 119-125.
55. Bourgeois, J., Galy, G., Baltassat, P. &
Béthenod,M. ( 1974 ) Maladie de Menkes.
Etude métabolismedu cuivre dans une ob
servation personnelle. Pédiatrie29, 573-594.
56. Bourgeois, J., Vittori, F., Collombel, C. &
Béthenod,M.
Présentation clinique
(1974)
d'une
^ Maladie
observation
de Menkes.
per
sonelle. Pediatrie 29, 561-572.
56a. Bowering, J., Sanchez, A. M. & Irwin, M. I.
(1976) A conspectus of research on iron
requirements of man. J. Nutr. 106, 985-1074.
57. Bozian, R. C. & Shearer, C. (1976) Cop
per, zinc and manganese content of four
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2041
ammo acid and protein hydrolysate prepa
rations. Am. J. Clin. Nutr. 29, 1331-1332.
58. Brady, F. O., Monaco, M. E., Forman, H. J.,
Schutz, G. & Feigelson, P. (1972) On
the role of copper in activation of and cataly
sis by tryptophane -2,3-dioxygenase. J. Biol.
Chem. 247, 7915-7922.
59. Bray, P. F. (1965) Sex-linked neurodegenerative
disease associated with monilethrix.
Pediatrics 36, 417-420.
60. Bremner, I. ( 1974 ) Heavy metal toxicities.
Quart. Rev. Biophys. 7, 75-124.
61. Brendstrup, P. (1953) Serum copper,
serum iron and total iron-binding capacity
of serum in acute and chronic infections.
Acta Med. Scand. 145, 315-325.
62. Brendstrup, P. (1953) Serum iron, total
iron-binding capacity of serum and serum
copper in acute hepatitis. Acta Med. Scand.
146, 107-113.
63. Brenner, W. (1948) Beiträgezur Kenntris
des Eisen-und Kupferstoffwechsels im Kinde
salter. Serumeisen und Serumkupfer bei
akuten und chronischen Infektionen. Ztschr.
Kinderheil. 66, 14-35.
64. Brewer, G. J., Shoomaker, E. B., Leichtman,
D. A., Kruckeberg, W. C., Brewer, L. F. &
Meyers, N. ( 1977 ) The use of pharmaco
logical doses of zinc in the treatment of sickle
cell anemia. In: Zinc Metabolism: Current
Aspects in Health and Disease (Brewer, G.
J. & Prasad, A. A., eds.), pp. 241-258, A. R.
Liss, Inc., New York.
65. Broman, L. (1964) Chromatographie and
magnetic studies on human ceruloplasmin.
Acta Soc. Med. Upsalien 69 (Suppl. 7), 1-
85.
66. Broviac, I. W. & Scribner, B. H. (1974)
Prolonged parenteral nutrition in the home.
Surg. Gyn. Obst. 139, 24-28.
67. Brown, E. D., Howard, M. P. & Smith, J. C.,
Jr. ( 1977 ) The copper content of regular,
vegetarian and renal diets. Federation Proc.
36, 1122.
68. Brown, F. C. & Ward, D. N. (1959)
Studies on mammalian tyrosinase. II Chemi
cal and physical properties of fractions puri
fied by chromatography. Proc. Exp. Biol.
Med. 100, 701-704.
69. Brückmann, G. & Zondek, S. G. (1939)
Iron, copper and manganese in human organs
at various ages. Biochem. J. 33, 1845-1857.
70. Brunia, C. H. M. & Buyze, G. (1972)
Serum copper levels and epilepsy. Epilepsia.
13, 621-625.
71. Buck, W. A. & Ewan, R. C. (1973) Toxi
cology and adverse effects of mineral im
balance. Clin. Toxicol. 6, 459-485.
72. Bucknall, W. E., Haslam, R. H. A. & Holtzman,
N. A. (1973) Kinky hair syndrome:
response to copper therapy. Pediatrics 52,
653-657.
73. Buffoni, F. & Blaschko, H. (1964) Benzylamine
oxidase and histaminase: purification
and crystallization of an enzyme from pig
plasma. Proc. R. Soc. London Ser. B 161,
153-167.
74. Bühler,H. O. & Kägi,H. R. ( 1974 ) Hu
man hepatic metallothioneins. FEBS Letters
39, 229-234.
75. Burch, R. E., Hahn, H. K. J. & Sullivan, J.
F. (1975) Newer aspects of the roles of
zinc, manganese and copper in human nu
trition. Clin. Chem. 21, 501-520.
76. Burger, F. J. (1974) Changes in the traceelement
concentration in the sera and hair
of kwashiorkor patients. In: Trace Element
Metabolism in Animals—2 ( Hoekstra, W. G.,
Suttie, J. W., Ganther, H. E. & Mertz, W.,
eds.), pp. 671-674, University Park Press,
Baltimore.
77. Burrows, S. & Pekala, B. (1971) Serum
copper and ceruloplasmin in pregnancy.
Amer. J. Obstet. & Gynecol. 109, 907-909.
78. Bush, J. A. (1956) The role of trace ele
ments in hemopoiesis and in the therapy of
anemia. Pediatrics 17, 586-595.
79. Bush, J. A., Mahoney, J. P., Gubler, C. J.,
Cartwright, G. E. & Wintrobe, M. M.
(1956) Studies on copper metabolism.
XXI. The transfer of radiocopper between
erythrocyte and plasma. J. Lab. Clin. Med.
47, 898-906.
80. Bush, J. A., Mahoney, J. P., Markowitz, H.,
Gubler, C. J., Cartwright, G. E. & Wintrobe,
M. M. ( 1955 ) Studies on copper metab
olism. XVI. Radioactive studies in normal
subjects and in patients with hepatolenticular
degeneration. J. Clin. Invest. 34, 1766-
1778.
81. Bustamante Bustamante, J., Martin Mateo,
M. C. & DeQuiros, F. B. (1975) Estudio
del cobre, ceruloplasmina y cinc en relación
con el metabolismo de los lipidos en arterioscleroticos.
Rev. Clin. Española 139, 243-
246.
82. Bustamante Bustamante, J., Martin Mateo,
M. C., DeQuiros, F. B. & Manchado, O. O.
( 1977 ) Valores séricosde cobre, cerulo
plasmina y lipidos en ancianos: Estudio
comparativo con enfermos arterioscleróticos.
Rev. Clin. Español 146, 27-30.
83. Butler, E. J. & Newman, G. E. ( 1956) The
urinary excretion of copper and its concen
tration in the blood of normal human adults.
J. Clin. Pathol. 9, 157-161.
84. Butler, L. C. & Daniel, J. M. (1973) Cop
per metabolism in young women fed two
levels of copper and two protein sources.
Am. J. Clin. Nutr. 26, 744-749.
85. Butt, E. M., Nusbaum, R. E., Gilmour, T. C.
& DiDio, S. L. (1958) Trace metal pat
terns in disease states. II. Copper storage
diseases,
rhosis, Wilson's
with consideration
disease, and
of
hepatic
juvenile
copper
cir
of the newborn. Am. J. Clin. Pathol. 30,
479-497.
86. Butterworth, C. E., Gubler, C. J., Cartwright,
G. E. & Wintrobe, M. M. (1958) Studies
on copper metabolism. XXVI Plasma copper
in patients with tropical sprue. Proc. Soc.
Exp. Biol. Med. 98, 594-597.
87. Cairns, J. E., Williams, H. P. & Walshe,
J. M. (I969) "Sunflower cataract" in
Wilson's disease. Brit. Med. J. 3, 95-96.
88. Camus, J. P., Bénichou, C., Guillien, P.,
Crouzet, J. & Lièvre, J. A. (1971) Traite-
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2042 KARL E. MASON
ment de la polyarthrite rhumatoide com
mune par la D-pénicillamine. Rev. Rhum.
Mal. Osteoartic. 38, 809-820.
89. Canelas, H. M., Assis, L. M., De Jorge, F.
B., Tolosa, A. P. M. & Cintra, A. B. U.
( 1964 ) Disorders of copper metabolism in
epilepsy. Acta Neurol. Scand. 40, 97-105.
90. Canelas, H. M., De Jorge, F. B. & Tognola,
W. A. (1967) Metabolie balances of cop
per in patients with hepatolenticular degen
eration submitted to vegetarian and mixed
diets. J. Neurol. Neurosurg. Psychiat. 30,
371-373.
91. Cantarutti, F. & Panzion, F. (1975) Le
modificazioni della cupremia nal periodo
postnatale. Lattente 25, 721-723.
92. Carlton, W. W. & Kelly, W. A. (1969)
Neural lesions in the offspring of female
rats fed a copper-deficient diet. J. Nutr.
94, 42-52.
93. Carnes, W. H. (1971) Role of copper in
connective tissue metabolism. Federation
Proc. 30, 995-1000.
94. Carnes, W. H., Coulson, W. F., Smith, D.
W. & Weissman, N. (1968) The role of
copper in the circulatory system. In: Trace
Substances in Environmental Health II
(Hemphill, D. D., éd.),pp. 29-40, Univ. of
Missouri, Columbia.
95. Carrico, R. J. & Deutsch, H. F. (1969)
Isolation of human hematocuprein and cerebrocuprein.
Their identity with erythrocuprein.
J. Biol. Chem. 244, 6087-6093.
96. Carrico, R. J. & Deutsch, H. F. (1970)
The presence of zinc in human cytocuprein
and some properties of the apoprotein. J.
Biol. Chem. 245, 723-727.
97. Carr-Saunders, E. & Laurence, B. M. (1965)
Wilson's disease presenting as an acute
hemolytic anemia. Proc. Roy. Soc. Med. 58,
614-615.
98. Carruthers, M. E., Hobbs, C. B. & Warren,
R. L. ( 1966 ) Raised serum copper and
caeruloplasmin levels in subjects taking oral
contraceptives. J. Clin. Pathol. 29, 498-500.
99. Cartwright, G. E. (1947) Dietary factors
concerned in erythropoiesis. IV. Minerals.
Blood 2, 256-298.
100. Cartwright, G. E. (1950) Copper metab
olism in human subjects. In: A Symposium
on Copper Metabolism (McElroy, W. D. &
Glass, B., eds. ), pp. 274-314, Johns Hop
kins Press, Baltimore.
101. Cartwright, G. E. (1955) The relation
ship of copper, cobalt and other trace ele
ments to hemopoiesis. Am. J. Clin. Nutr. 3,
11-17.
102. Cartwright, G. E., Hodges, R. E., Gubler,
C. J., Mahoney, J. P., Daum, K., Wintrobe,
M. M. & Bean, W. B. (1954) Studies on
copper metabolism. XIII Hepatolenticular
degeneration. J. Clin. Invest. 33, 1487-1501.
103. Cartwright, G. E., Huguley, C. M. Jr.,
Ashenbrucker, H., Fay, J. & Wintrobe, M.
W. ( 1948 ) Studies on free erythrocyte
protoporphyrin, plasma iron and plasma cop
per in normal and anemic subjects. Blood 3,
501-528.
104. Cartwright, G. E., Markowitz, H., Shields,
G. S. & Wintrobe, M. M. (1960) Studies
on copper metabolism. XXIX. A critical
analysis of serum copper and ceruloplasmin
concentrations in normal subjects, patients
with Wilson's disease and relatives of pa
tients with Wilson's disease. Am. J. Med.
28, 555-563.
105. Cartwright, G. E. & Wintrobe, M. M. ( 1964)
Copper metabolism in normal subjects. Am.
J. Clin. Nutr. 14, 224-232.
106. Cartwright, G. E. & Wintrobe, M. M. ( 1964)
The question of copper deficiency in man.
Am. J. Clin. Nutr. 15, 94-110.
107. Cavell, P. A. & Widdowson, E. M. (1964)
Intakes and excretions of iron, copper, and
zinc in the neonatal period. Arch. Dis. Child.
39, 496-501.
108. Chang, I. C., Lee, T. P. & Matrone, G.
( 1975) Development of ceruloplasmin in
pigs during the neonatal period. J. Nutr.
105, 624-630.
109. Chang, I. C., Milholland, D. C. & Matrone,
G. (1976) Controlling factors in the de
velopment of ceruloplasmin in pigs during
the neonatal growth period. J. Nutr. 206,
1343-1350.
110. Chappell, W. R. & Peterson, K. K. (1976)
Molybdenum in the Environment, vol. 1,
Dekker, New York.
111. Chatterji, S. K. & Ganguly, H. D. (1950)
Copper in human urine and faeces. Indian
J. Med. Res. 38, 303-314.
112. Chawla, S. C. & Mehta, S. P. (1973) A
study of host and environmental factors in
cases of accidental poisoning admitted in
Irwin hospital. Indian J. Med. Res. 61, 724-
731.
113. Ch'en, P. ( 1957 ) Abnormalities of copper
metabolism in Wilson's disease. A prelimi
nary report. Chinese Med. J. 75, 917-924.
114. Chiossi, F. M., Bertolini, A. & Guarino, M.
(1977) Aspetti angiografiei ed istologici
della malattia di Menkes. Gasimi 9, 65-70.
115. Chou, T. & Adolph, W. H. (1935) Copper
metabolism in man. Biochem. J. 29, 476—479.
116. Chou, W. S., Rucker, R. B., Savage, J. E. &
O'Dell, B. L. (1970) Impairment of col
lagen and elastin crosslinking by an amine
oxidase inhibitor. Proc. Soc. Exp. Biol. Med.
234, 1078-1082.
117. Chou, W. S., Savage, J. E. & O'Dell, B. L.
( 1968 ) Relation of monoamine oxidase
activity and collagen crosslinking in copperdeficient
and control tissues. Proc. Soc. Exp.
Biol. Med. 228, 948-952.
118. Chowdhury, A. K. R., Ghosh, S. & Pal, D.
( 1961 ) Acute copper sulphate poisoning. J.
Ind. Med. Assn. 36, 330-336.
119. Chugh, T. D., Gulati, R. C. & Gupta, S. P.
( 1973 ) A study of serum copper and
ceruloplasmin in normal healthy individuals.
Indian J. Med. Sci. 27, 309-312.
120. Chuttani, H. K., Gupta, P. S., Gulati, S. &
Gupta, D. N. (1965) Acute copper sulfate
poisoning. Am. J. Med. 39, 849-854.
121. Cohen, S. R. (1974) A review of the
health hazards from copper exposure. J.
Occup. Med. 26, 621-624.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2043
122. Consolazio, C. F., Nelson, R. A., Matoush,
L. O., Hughes, R. C. & Urone, P. (1964)
The Trace Mineral Losses In Sweat, pp. 1-
14, U.S. Army Med. Res. Nutr. Lab. Report
No. 284.
123. Cooper, A. M., Eckhardt, R. D., Faloon, W.
W. & Davidson, C. S. (1950) Investiga
tion of the aminoaciduria in Wilson's disease
(hepatolenticular degeneration): demonstra
tion of a defect in renal function. J. Clin.
Invest. 29, 265-278.
124. Cordano, A. (1974) The role played by
copper in the physiopathology and nutrition
of the infant and the child. Ann. Nestle 33,
2-16.
125. Cordano, A. (1978) Copper deficiency in
clinical medicine. In: Zinc and Copper in
Clinical Medicine (Hambidge, K. M. &
Nichols, B. F., Jr., eds.), pp. 119-126,
Spectrum, New York.
126. Cordano, A., Baertl, I. M. & Graham, G. G.
( 1964 ) Copper deficiency in infancy.
Pediatrics 34, 324-336.
127. Cordano, A. & Graham, G. G. (1966)
Copper deficiency complicating severe
chronic intestinal malabsorption. Pediatrics
38, 596-604.
128. Cordano, A., Placko, R. P. & Graham, G. G.
(1966) Hypocupremia and neutropenia in
copper deficiency. Blood 28, 280-283.
129. Coulson, W. F. & Carnes, W. H. (1963)
Cardiovascular studies on copper-deficient
swine. V. The histogenesis of the coronary
artery lesions. Am. J. Pathol. 43, 945-954.
130. Coulson, W. F. (1972) Copper deficiency,
with special reference to the cardiovascular
system. In: Methods and Achievements in
Experimental Pathology (Bajusz, E. & Jas
min, G., eds.), vol. 6, pp. 111-138, Karger,
Basel.
131. Cox, D. W. (1966) Factors influencing
serum ceruloplasmin levels in normal indi
viduals. J. Lab. Clin. Med. 68, 893-904.
132. Crampton, R. F., Matthews, D. M. & Poisner,
R. (1965) Observations on the mechanism
of absorption of copper by the small intes
tine. J. Physiol. (London) 178, 111-126.
133. Crouzet, J., Nafziger, J., Guillien, P., Camus,
J.-P. & Lièvre, J.-A. (1973) Étudedu
métabolisme du cuivre dans la polyarthrite
rheumatoide et de l'influence du traitement
par la D-pénicillamine. Rev. Rhuma. 40,
485-489.
134. Cumings, J. N. (1948) The copper and
iron content of brain and liver in the normal
and in hepato-lenticular degeneration. Brain
71, 410-415.
135. Cumings, J. N. (1951) The effects of
B.A.L. in hepatolenticular degeneration.
Brain 74, 10-22.
136. Cumings, J. N. ( 1954 ) Copper storage in
hepatolenticular degeneration and allied dis
eases. Proc. Roy. Soc. Med. 47, 152-154.
137. Cumings, J. N. (1959) Heavy Metals and
the Brain. Part 1: Copper: hepatolenticular
degeneration, pp. 1-74, Blackwell Sci. Pub.,
Oxford.
138. Cumings, J. N. (1968) Trace metals in
the brain and in Wilson's disease. J. Clin.
Pathol. 21, 1-7.
139. Cunningham, I. J. (1931) Some biochemi
cal and physiological aspects of copper in
animal nutrition. Biochem. J. 25, 1267-1294
140. Cunningham, I. J. (1950) Copper and
molybdenum in relation to diseases of cattle
and sheep in New Zealand. In: A Symposium
on Copper Metabolism (McElroy, W. D. &
Glass, B., eds.), pp. 246-272, Johns Hop
kins Univ. Press, Baltimore.
141. Curzon, G. & O'Reilly, S. (1960) A
coupled iron-caeruloplasmin oxidation sys
tem. Biochem. Biophys. Res. Comm. 2, 284-
286.
142. Daniels, A. L. & Wright, O. E. (1934)
Iron and copper retentions in young chil
dren. J. Nutr. 8, 125-138.
143. Danks, D. M. (1975) Steely hair, mottled
mice and copper metabolism. New Engl. J.
Med. 293, 1147-1149.
144. Danks, D. M. (1977) Copper transport
and utilisation in Menkes' syndrome and in
mottled mice. Inorgan. Persp. Biol. Med. I,
73-100.
145. Danks, D. M., Campbell, P. E., Stevens,
B. J, Mayne, V. & Cartwright, E. (1972)
Menkes's kinky hair syndrome. An inherited
defect in copper absorption with widespread
effects. Pediatrics 50, 188-201.
146. Danks, D. M., Cartwright, E. & Stevens,
B. J. (1973) Menkes' steely-hair (kinky
hair) disease. Lancet 1, 891.
147. Danks, D. M., Cartwright, E., Stevens,
B. I. & Townley, R. R. W. (1973) Menkes'
kinky hair disease: further definition of the
defect in copper transport. Science 179,
1140-1142.
148. Danks, D. M., Stevens, B. J., Campbell, P.
E., Gillespie, J. M., Walker-Smith, J., Blomfield,
J. & Turner, B. (1972) Menkes'
kinky-hair syndrome. Lancet 1, 1100-1103.
149. Davies, N. T. (1974) Recent studies of
antagonist interactions in the aetiology of
trace element deficiency and excess. Proc.
Nutr. Soc. 33, 293-298.
150. Davis, G. K. (1950) The influence of
copper on the metabolism of phosphorus and
molybdenum. In: A Symposium on Copper
Metabolism (McElroy, W. D. & Glass, G.,
eds.), pp. 216-229, J. Hopkins Press, Balti
more.
151. Dawson, C. R., Strothkamp, K. G. & Krul,
K. G. (1975) Ascorbate oxidase and re
lated copper proteins. Ann. N.Y. Acad. Sci.
258, 209-220.
152. Dawson, E. B., Clark, R. R. & McGanity,
W. J. (1969) Plasma vitamins and trace
metal changes during teen-age pregnancy.
Am. J. Obstet. Gynecol. 104, 953-958.
153. Dawson, J. B., Ellis, D. J. & Newton-John,
H. ( 1968 ) Direct estimation of copper in
serum and urine by atomic absorption spectroscopy.
Clin. Chim. Act. 21, 33-42.
154. De, H. N. ( 1949) Copper and manganese
metabolism with typical Indian dietaries
and assessment of their requirement for
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2044 KARL E. MASON
the Indian adult. Indian J. Med. Res. 37,
301-309.
155. Deiss, A., Lee, G. R. & Cartwright, G. E.
( 1970 ) Hemolytic anemia in Wilson's dis
ease. Ann. Intern. Med. 73, 413-418.
156. Deiss, A., Lynch, R. E., Lee, G. R. & Cartwright,
G. E. (1971) Long term therapy
of Wilson's disease. Ann. Intern. Med. 75,
57-65.
157. De Jorge, F. B., Canelas, H. M., Dias, J. C.
& Cury, L. ( 1964 ) Studies on copper
metabolism. III. Copper contents of saliva
of normal subjects and of salivary glands
and pancreas of autopsy material. Clin.
Chim. Acta 9, 148-150.
158. De Jorge, F. B., Delascio, D. & Antunes, M.
L. ( 1965 ) Copper and copper oxidase
concentrations in the blood of normal preg
nant women. Obstet. Gynecol. 26, 225-227.
159. Dekaban, A. S., Aamodt, R., Rumble, W. F.,
Johnston, G. S. & O'Reilly, S. (1975)
Kinky hair disease. Study of copper metab
olism with use of "Cu. Arch. Neurol. 32,
672-675.
160. Dekaban, A. S., O'Reilly, S., Aamodt, R. &
Rumble, W. F. (1974) Study of copper
metabolism in kinky hair disease ( Menkes'
disease ) and in hepatolenticular degenera
tion (Wilson's disease) utilizing '"Cu and
radioactivity counting in the total body and
various tissues. Trans. Am. Neurol. Assoc.
99, 106-109.
161. Dekaban, A. S. & Steusing, J. K. (1974)
Menkes' kinky hair disease treated with sub
cutaneous copper sulphate. Lancet 2, 1523.
162. Delves, H. T., Alexander, F. W. & Lay, H.
( 1973 ) Copper and zinc concentration in
the plasma of leukaemic children. Brit. J.
Haematol. 24, 525-531.
163. Denny-Brown, D. & Porter, H. (1951)
The effect of BAL ( 2,3-dimercaptopropanol )
on hepatolenticular degeneration (Wilson's
disease). New Engl. J. Med. 245, 917-926.
164. Deosthale, Y. G. & Gopalan, C. (1974)
The effect of molybdenum levels in sorghum
(Sorghum vulgäre Pers.) on uric acid and
copper excretion in man. Brit. J. Nutr. 31,
351-355.
165. De Renzo, E. C. (1962) Molybdenum. In:
Mineral Metabolism—An Advanced Treatise
(Comar, C. L. & Bronner, F., eds.), vol. 2,
part B, pp. 483-498, Academic Press, New
York.
166. Dieckmann, W. J. & Wegner, C. R. (1934)
The blood in normal pregnancy. I. Blood and
plasma volumes. Arch. Intern. Med. 53, 71-
86.
167. Dokumov, S. I. (1968) Serum copper and
pregnancy. Am. J. Obstet. Gynecol. 101,
217-222.
168. Dorn, G., Neuhäuser, G., Heye, D. & Kielhorn,
A. ( 1973 ) Das Kinky-Hair Syndrom
von Menkes. Klin. Paediatr. 185, 480-489.
169. Dowdy, R. P. (1969) Copper metabolism.
Am. J. Clin. Nutr. 22, 887-892.
170. Dreizen, S., Spies, H. A., Jr. & Spies, T. D.
( 1952 ) The copper and cobalt levels of
human saliva and dental caries activity. J.
Dent. Res. 31, 137-142.
171. Drummond, J. C. (1925) The absorption
of copper during the digestion of vegetables
artificially coloured with copper salts. Ana
lyst 50, 481-485.
172. Du Bois, R. S., Giles, G., Rodgerson, D. O.,
Lilly, J., Martineaux, G., Halgrimson, C. G.,
Shroter, G., Starzl, T. E., Sternlieb, I. &
Scheinberg, I. H. (1971) Orthotopic liver
transplantation for Wilson's disease. Lancet
l, 505-508.
173. Dudrick, S. J. & Rhoads, J. E. (1971)
New horizons for intravenous feeding. J. Am.
Med. Assn. 225, 939-949.
174. Dudrick, S. J. & Ruberg, R. L. (1971)
Principles and practice of parenteral nutri
tion. Gastroenterology 61, 901-910.
175. Dudrick, S. J., Groff, B. & Wilmore, D. W.
( 1969 ) Long term venous catherization in
infants. Surg. Gynecol. Obstet. 129, SOS-
SOS.
176. Dudrick, S. J., Wilmore, D. W., Vars, H. M.
& Rhoades, J. E. (1968) Long-term total
parenteral nutrition with growth, develop
ment and positive nitrogen balance. Surg.
64, 134-142.
177. Dunlap, W. M., James, G. W., Ill, & Hume,
D. M. (1974) Anemia and neutropenia
caused by copper deficiency. Ann. Intern.
Med. 80, 470-476.
178. Earl, C. J. (1961) Anatomical distribu
tion of copper in human brain. In: Wilson's
Disease, Some Current Concepts, (Walshe,
J. M. & Cumings, J. N., eds.), pp. 18-23,
Blackwell, Oxford.
179. Earl, C. J., Moulton, M. J. & Seiverstone, B.
( 1954 ) Metabolism of copper in Wilson's
disease and in normal subjects: studies with
Cu-64. Am. J. Med. 17, 205-213.
180. Edozien, J. C. & Udeozo, I. O. K. (I960)
Serum copper, iron and iron binding capacity
in kwashiorkor. J. Trop. Pediat. 6, 60-64.
181. Effkemann, G. & Rottger, H. (1950) Ãœber
den Kupferhaushalt während der Schwanger
schaft. Klin. Wochenschr. 28, 216-220.
182. Eggleton, W. G. E. (1940) The zinc and
copper Contents of the organs and tissues of
Chinese subjects. Biochem. J. 34, 991-997.
183. Eisner, P. & Hornykiewicz, O. (1954) Die
beeinflussbarkeit der p-Polyphenoloxydaseaktivität
des menschliehen Blutserums durch
Sexualhormone. Archiv. Gynäkol. JÃ85,251-
257.
184. Eisner, P., Hornykiewicz, O., Linder, A. &
Niebauer, G. ( 1953 ) Ãœberdas vorkommen
einer polyphenoloxydase in serum nicht
gravider und gravider frau. Wien. Klin.
Wochenschr. 65, 193-195.
185. Elvehjem, C. A. (1935) The biological
significance of copper and its relation to iron
metabolism. Physiol. Rev. 15, 471-507.
186. Elvehjem, C. A., Duckies, D. & Mendenhal!,
D. R. ( 1937 ) Iron versus iron and copper
in the treatment of anemia in infants. Am.
J. Dis. Child. 53, 758-793.
187. Elvehjem, C. A. & Hart, E. B. ( 1929) The
relation of iron and copper to hemoglobin
synthesis in the chick. J. Biol. Chem. 84,
131-141.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2045
188. Elvehjem, C. A. & Hart, E. B. (1932) The
necessity of copper as a supplement to iron
for hemoglobin formation in the pig. J. Biol.
Chem. 95, 363-370.
189. Elvehjem, C. A., Steenbock, H. & Hart, E. B.
(1929) The effect of diet on the copper
content of milk. J. Biol. Chem. S3, 27-34.
190. Engel, R. W., Price, N. O. & Miller, R. F.
( 1967 ) Copper, manganese, cobalt, and
molybdenum balance in pre-adolescent girls.
J. Nutr. 92, 197-204.
191. Evans, G. W. (1971) Function and no
menclature for two mammalian copper pro
teins. Nutr. Rev. 29, 195-197.
192. Evans, G. W. (1973) Copper homeostasis
in the mammalian system. Physiol. Rev. 53,
» 535-570.
193. Evans, G. W. (1973) The biological regu
lation of copper homeostasis in the rat.
World Rev. Nutr. Diet. 17, 225-249.
194. Evans, G. W. (1977) Metabolic disorders
of copper metabolism. In: Advances in Nu
tritional Research, (Draper, H. H., Broquist,
H. P., Henderson, L. M., Kritchevsky, D.,
Pitt, G. A. J., Sandstead, H. H. & Somogyi,
J. C., eds.), vol. 1, pp. 167-187, Plenum,
New York.
195. Evans, G. W. (1978) New aspects of the
biochemistry and metabolism of copper. In:
Zinc and Copper in Clinical Medicine
(Hambidge, K. M. & Nichols, B. F., Jr., eds.),
pp. 113-118, Spectrum, Jamaica, New York.
196. Evans, G. E. & Cornatzer, W. E. (1971)
Biliary copper excretion in the rat. Proc. Soc.
Exp. Biol. Med. 136, 719-721.
197. Evans, G. W., Dubois, R. S. & Hambidge,
K.M. (1973) Wilson's disease: Identifica
tion of an abnormal copper binding protein.
Science 181, 1175-1176.
198. Evans, G. W. & LeBlanc, F. N. (1976)
Copper-binding protein in rat intestine:
Amino acid composition and function. Nutr.
Rep. Internat. 14, 281-288.
199. Evans, G. W., Majors, P. F. & Cornatzer,
W. E. (1970) Ascorbic acid interactions
with metallothionein. Biochem. Biophys. Res.
Comm. 41, 1244-1247.
200. Evans, G. W. & Reis, B. L. ( 1978 ) Im
paired copper homeostasis in neonatal male
and adult female brindled (Mobr) mice. J.
Nutr. 108, 554-560.
201. Everson, G. J., Huang-Chan, C. T. & Wang,
T. ( 1967 ) Copper deficiency in the guinea
pig. J. Nutr. 43, 533-540.
202. Everson, G. J., Shrader, R. E. & Wang, T.
(1968) Chemical and morphological changes
in the brains of copper-deficient guinea pigs.
J. Nutr. 96, 115-125.
203. Fairbanks, V. F. (1967) Copper sulphateinduced
hemolytic anemia. Inhibition of glucose-6-phosphate
dehydrogenase and other
possible etiologic mechanisms. Ann. Intern.
Med. 120, 428-432.
204. Falkmer, S., Samuelson, G. & Sjolin, S.
(1970) Penicillamine-induced normaliza
tion of clinical signs, and liver morphology
and histochemistry in a case of Wilson's dis
ease. Pediatrics 45, 260-268.
205. Fattah, M. M. A., Ibrahim, F. K., Ramadan
M. A. & Sammour, M. B. (1976) Ceruloplasmin
and copper level in maternal and
cord blood and in the placenta in normal
pregnancy and in pre-eclampsia. Acta Obstet.
& Gynecol. Scand. 55, 383-385.
206. Fay, J., Cartwright, G. E. & Wintrobe, M. M.
(1949) Studies on free erythrocyte protoporphyrin,
serum iron, serum iron-binding
capacity and plasma copper during normal
pregnancy. J. Clin. Invest. 28, 487-491.
207. Fazekas, I. Gy., Romhányi, I. & Rengei, B.
( 1963 ) Copper content of fetal organs.
Kiserl. Orvostud. 15, 230-238. (Hungarian)
208. Fell, G. S., Smith, H. & Howie, R. A. ( 1968)
Neutron activation analysis for copper in
biological material applied to Wilsons dis
ease. J. Clin. Pathol. 21, 8-11.
209. Filler, R. M., Eraklis, A. J., Rubin, V. G. &
Das, J. B. (1970) Long-term total parenteral
nutrition in infants. New Engl. J. Med.
281, 589-594.
210. Findlay, G. H. & Venter, I. J. (1958) An
effect of pantothenic acid on serum copper
values in human pellagra. J. Invest. Dermatol.
31, 11.
211. Fisher, G. L. (1975) Function and homeo
stasis of copper and zinc in mammals. Sci.
Total Environ. 4, 373-412.
212. Fisher, G. L., Byers, V. S., Shifrine, M. &
Levin, A. S. (1976) Copper and zinc levels
in serum from human patients with sarcomas.
Cancer 37, 356-363.
213. Fitzpatrick, T. B., Seiji, M. & McGugan, A.
D. ( 1961 ) Melanin pigmentation. New
Engl. J. Med. 265, 328-332; 374-378; 430-
432.
214. Flack, H. L., Gans, J. A., Serlick, S. E. &
Dudrick, S. J. (1971) The current status
of parenteral hyperalimentation. Am. J. Hosp.
Pharm. 28, 326-335.
215. Fleming, C. R., Dickson, E. R., Baggenstoss,
A. H. & McCall, J. T. (1974) Copper and
primary biliary cirrhosis. Gastroenterology
67, 1182-1187.
216. Fleming, C. R., Dickson, E. R., Wahner, H.
W., Hollenhorst, R. W. & McCall, J. T.
( 1977 ) Pigmented corneal rings in non-
Wilsonian liver disease. Ann. Intern. Med.
86, 285-288.
217. Fleming, C. R., Hodges, R. E. & Hurley, L.
S. (1976) A prospective study of serum
copper and zinc levels in patients receiving
total parenteral nutrition. Am. J. Clin. Nur.
29, 70-77.
218. Flinn, F. B. & Von Glahn, W. C. (1929)
A chemical and pathologic study of the ef
fects of copper on the liver. J. Exp. Med.
49, 5-20.
219. Flynn, A., Franzmann, A. W., Arneson, P.
D. & Oldemeyer, J. L. (1977) Indications
of copper deficiency in a subpopulation of
Alaskan moose. J. Nutr. 107, 1182-1189.
220. Forbes, G. (1947) Poisoning with a
preparation of iron, copper and manganese.
Br. Med. J. 1, 367-370.
221. Forestier, J. & Certonciny, A. (1946) Le
traitement des rhumatismes chroniques par
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2046 KARL E. MASON
les sels organiques
54, 884-885.
de cuivre. Presse Med.
222. Forssen, A. (1972) Inorganic elements in
the human body. 1. Occurrence of Ba, Br,
Ca, Cd, Cs, Cu, K, Mn, Ni, Sn, Sr, Y and
Zn in the human body. Ann. Med. Exp. Biol.
Fenniae 50, 99-162.
223. Foulk,
H. R.
W. T.,
(1964)
Baggenstoss, A. H. & Buit,
Primary biliary cirrhosis: re-
224.
evaluation by clinical and histologie study
of 49 cases. Gastroenterology 47, 354-374.
French, J. H., Moore, C. L., Ghatak, N. R.,
Sternlieb,
( 1973 )
L,
Trichopoliodystrophy
Goldfischer, S. & Mirano,
( Menkes'
A.
kinky hair syndrome): A copper dependent
deficiency of mitochondrial energetics. Pediat.
Res. 7, 386.
225. French, J. H., Sherard, E. S., Lubell, H.,
Brotz, M. & Moore, C. L. (1972) Tri
chopoliodystrophy. 1. Report of a case and
biochemical studies. Arch. Neurol. 26, 229-
244.
226. Frieden, E. (1970) Ceruloplasmin, a link
between copper and iron metabolism. Nutr.
Rev. 28, 87-91.
227. Frieden, E. (1971) Ceruloplasmin, a link
between iron and copper metabolism. In:
Bioinorganic Chemistry, Advances in Chem
istry Series (Gould, R. F., ed.), pp. 292-
321, American Chemical Society, Washing
ton, D.C.
228. Frieden, E. (1973) The ferrous to ferric
cycles in iron metabolism. Nutr. Rev. 31,
41-44.
229. Frieden, E. (1974) The biochemical
evolution of the iron and copper proteins.
In: Trace Element Metabolism in Animals—
2. (Hoekstra, W. G., Suttie, J. W., Ganther,
H. E. & Mertz, W., eds.), pp. 105-118,
University Park Press, Baltimore.
230. Frieden, E. & Hsieh, H. S. (1976) Cerulo
plasmin: the copper transport protein with
essential oxidase activity. In: Advances in
Enzymology and Related Areas of Molecular
Biology (Meister, A., ed.), vol. 44, pp. 187-
236, Wiley, New York.
231. Friedman, S., Bahary, C., Eckerling, B. &
Gans, B. (1969) Serum copper level as
an index of placental function. Obstet.
Gynecol. 33, 189-193.
232. Friedman, S. & Kaufman, S. (1965) 3-4dihydroxyphenylethylamine
/3-hydroxylase : a
copper protein. J. Biol. Chem. 240, 552-554.
233. Frommer, D. J. (1971) The binding of
copper by bile and serum. Clin. Sci. 41, 485-
493.
234. Frommer, D. J. (1972) The measurements
of biliary copper secretion in humans. Clin.
Sci. 42, 26P. (Abstract).
235. Frommer, D. J. ( 1974 ) Defective biliary
excretion of copper in Wilson's disease. Gut
15, 125-129.
236. Frommer, D. J. (1977) Biliary copper ex
cretion in man and the rat. Digestion 15,
390-396.
237. Fukushima, K., Senda, N., Uenoyama, T.,
Inui, H., Ishigami, S., Kariya, A., Naka, K.,
Iwasaki, T. & Sakao, K. (1951) Copper
deficiency anemia in human adults. Med.
Osaka Univ., English ed. 2, 157-170.
I
238. Fushimi, H., Hamison, C. R. & Ravin, H. A.
(1971) Two new copper proteins from
human brains. J. Biochem. 69, 1041-1054.
239. Gabovich, R. D. (1966) Contents of some
trace elements in the food in certain cities
and towns of the USSR. Hygiene Sanitation
31 (7), 41-47.
240. Gahlot, D. K., Khosla, P. K., Makashir, P. D.,
Vasuki, K. & Basu, N. (1976) Copper me
tabolism in retinitis pigmentosa. Br. I.
Ophthal. 60, 770-774.
241. Gallagher, C. H. (1957)
and biochemistry of copper
Vet. J. 33, 311-317.
The pathology
deficiency. Austr.
242. Cárnica,
Parenteral
A.
copper
D. &
in
Fletcher,
Menkes'
S.
kinky-hair
R. (1975),
syn
drome. Lancet 2, 659-660.
243. Cárnica, A. D., Frías,J. L., Easley, J. F. &
Rennert, O. M. (1974) Menkes kinky
hair disease. A defect in metallothionein me
tabolism? In: Birth Defects: Original Article
Series (Bergama, D., ed.), vol. 10, pp. 149-
155.
244.
Studies
Cárnica,
of
A.,
Ceruloplasmin
Frías,J. & Rennert,
in Menkes'
O. (1973)
kinky
hair disease. Pediat. Res. 7, 387 (Abstr.).
245. Gault, M. H., Stein, J. & Aronoff, A. ( 1966)
Serum Ceruloplasmin in hepatobiliary and
other disorders: significance of abnormal
values. Gastroenterology 50, 8-18.
246. Gelmers,
(1973) Wilson's
H. J., Troost,
disease:
J.
modification
& Willemse,
by
J.
L-dopa. Neuropaediatrie 4, 453—457.
247. Genov, D., Bozhokov, B. & Zlatkov, N. B.
(1972) Copper pathochemistry in vitíligo.
Clin. Chem. Acta 37, 207-211.
248. Gerlach, W. (1934) Untersuchungen
den Kupfergehalt menschlicher (und
scher) Organe. Virch. Arch. Pathol.
Physiol. 294, 171-197.
über
tieri
Anat.
249. Gerlach,
Besteht
W.
das
& Rohrschneider, W. (1934)
pigment des Kayser-Fleischer-
Schen Hornhautringes
Wochenschr. 13, 48-49.
aus Silber. Klin.
250.
ation
German,
in copper
J. L., III.
metabolism
(1961)
ease. In: Wilson's Disease,
in
Induced
Wilson's
vari
dis
Some Current
Concepts ( Walshe, J. M. & Cumings, J. N.,
eds.), pp. 198-204, Blackwell, Oxford.
251. Ghatak, N. R., Hirano, A., Poon, T. P. &
French, J. H. (1972) Trichopoliodystrophy.
II Pathological changes in skeletal muscle
and nervous system. Arch. Neurol. 26, 60-
72.
252. Gillespie, J. M. (1973) Keratin structure
and changes with copper deficiency. Austr.
J. Derm. 14, 127-131.
253. Giorgio, A. J., Cartwright, G. E. & Wintrobe,
M. M. (1964) Determination of urinary
copper by means of direct extraction with
zinc dibenzyl dithiocarbamate. Am. J. Clin.
Pathol. 41, 22-26.
254. Gipp, W. F., Pond, W. G., Kallfelz, F. A.,
Taster, J. B., Van Campen, D. R., Krook,
L. & Visek, W. J. ( 1974) Effect of dietary
copper, iron and ascorbic acid levels on
hematology, blood and tissue copper, iron
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2047
and zinc concentrations and MCu and Te
metabolism in young pigs. J. Nutr. 104,
532-541.
255. Gisinger, E. (1955) Beiträgezum Kupfer-
Stoffwechsel. Wein Ztschr. Inn. Med. 36,
168-183.
256. Gitlin, D., Hughes, W. L. & Janeway, C. A.
( 1960 ) Absorption and excretion of copper
in mice. Nature 188, 150-151.
257. Glass, B. (1950) A summary of the sym
posium on copper metabolism. In: A Sym
posium on Copper Metabolism, (McElroy,
W. D. & Glass, B., eds.), pp. 7-36, J. Hop
kins Press, Baltimore.
258. Glazebrook, A. J. (1945) Wilson's disease.
Edinb. Med. J. 52, 83-87.
259. Goka, T. J., Stevenson, R. E., Hefferan, P.
M. & Howell, R. R. (1976) Menkes dis
ease: A biochemical abnormality in cultured
human fibroblasts. Proc. Nat. Acad. Sci.
U.S.A. 73, 604-606.
260. Goldfischer, S. (1965) The localization of
copper in the pericanalicular granules (lysosomes)
of liver in Wilson's disease (hepato-
lenticular degeneration). Am. J. Pathol. 46,
977-983.
261. Goldfischer, S. & Sternlich, I. (1968)
Changes in the distribution of hepatic cop
per in relation to the progression of Wilson's
disease (hepatolenticular degeneration). Am.
J. Pathol. 53, 883-902.
262. Goldstein, N. P. & Owen, C. A. (1974)
Introduction: Symposium on Copper Metab
olism and Wilson's Disease. Mayo Clinic
Proc. 49, 363-367.
263. Gollan, J. L. (1975) Studies on the nature
of complexes formed by copper with human
alimentary secretions and their influence on
copper absorption in the rat. Clin. Sci.
Mofee. Med. 49, 237-245.
264. Gollan, J. L., Davis, P. S. & Deller, D. J.
(1971) Binding of copper by human ali
mentary secretions. Am. J. Clin. Nutr. 24,
1025-1027.
265. Gollan, J. L., Davis, P. S. & Deller, D. J.
(1971) Copper content of human alimen
tary secretions. Clin. Biochem. 4, 42-44.
266. Gollan, J. L. & Deller, D. J. (1973) Studies
on the nature and excretion of biliary copper
in man. Clin. Sci. 44, 9-15.
267. Gollan, J. L., Stocks, J., Dormandy, T. L.
& Sherlock, S. (1977) Reduced oxidase
activity in the caeruloplasmin of two families
with Wilson's disease. J. Clin. Pathol. 30,
81-83.
268. Goodman, S. L, Rodgerson, D. O. & Kauffman,
J. (1967) Hypercupremia in a pa
tient with multiple myeloma. T. Lab. Clin.
Med. 70, 57-62.
269. Gopalan, C., Reddy, V. & Mohan, V. S.
(1963) Some aspects of copper metabolism
in protein-calorie malnutrition. J. Pediat.
63, 646-649.
270. Gorczynska, Z. ( 1973 ) On the disturbances
of the iron and copper metabolism in the
course of viral hepatitis. Rocz. Akad. Bialymstoku,
18, 93-112 (Polish).
271. Gordon, A. H. & Rabinowitch, I. M. (1933)
Yellow atrophy of the liver. Report of a case,
with particular reference to the metabolism
of copper. Arch. Intern. Med. 51, 143-151.
272. Gordon, N. (1974) Menkes' kinky-hair
(steely-hair) syndrome. Devel. Med. Child.
Neural. 16, 827-829.
273. Gormican, A. (1970) Inorganic elements
in foods used in hospital menus. J. Am. Diet.
Assn. 56, 397-403.
274. Goiter, E. (1933) Copper and anemia.
Am. J. Dis. Child. 46, 1066-1075.
275. Gorter, E., Grendel, F. & Weyers, W. A. M.
( 1931 ) Le role du cuivre dans l'anémie
infantile. Rev. Franc. Pediat. 7, 747-765.
276. Graham, G. G. & Cordano, A. (1969)
Copper depletion and deficiency in the mal
nourished infant. J. Hopkins Med. J. 124,
139-150.
277. Grand, R. J. & Vawter, G. F. (1975)
Juvenile Wilson's disease: Histologie and
functional studies during penicillamine
therapy. J. Pediatrics 87, 1161-1170.
278. Greger, J. L. & Buckley, S. (1977) Men
strual loss of zinc, copper, magnesium and
iron by adolescent girls. Nutr. Rep. Internat.
16, 639-647.
279. Greiner, A. C., Chan, S. C. & Nicolson, G. A.
( 1975 ) Human brain contents of calcium,
copper, magnesium and zinc in some neuro
logical pathologies. Clin. Chim. Acta 64,
2Ã1-213.
280. Griscom, N. T., Craig, J. N. & Neuhauser,
E. B. D. (1971) Systemic bone disease
developing in small premature infants. Pedi
atrics 48, 883-895.
281. Groth, C. G., Dubois, R. S., Corman, J.,
Gustafsson, A., Iwatsuki, S., Rodgerson,
D. O., Halgrimson, C. G. & Starzl, T. E.
( 1973 ) Metabolism effects of hepatic re
placement in Wilson's disease. Transplant.
Proc. 5, 829-833.
282. Grover, W. D. & Scrutton, M. C. (1974)
The effect of prolonged intravenous therapy
on copper metabolism in trichopoliodystrophy.
Pediat. Res. 8, 389.
283. Grover, W. D. & Scrutton, M. C. (1975)
Copper infusion therapy in trichopoliodystrophy.
J. Pediat. 86, 216-220.
284. Gubler, C. J. (1956) Copper metabolism
in man. J. Am. Med. Assn. 161, 530-535.
285. Gubler, C. J., Brown, H., Markowitz, H.,
Cartwright, G. E. & Wintrobe, M. M.
(1957) Studies on copper metabolism.
XXIII. Portal (Laennec's) cirrhosis of the
liver. J. Clin. Invest. 36, 1208-1216.
286. Gubler, C. J., Lahey, M. E., Cartwright,
G. E. & Wintrobe, M. M. (1953) Studies
of copper metabolism. IX. The transporta
tion of copper in blood. J. Clin. Invest. 32,
405-414.
287. Gumbatov, N. B. (1972) The content of
cobalt, copper, zinc and iron in the blood
of patients suffering from hypertension.
Terap. Arkh. 44 (4), 65-68 (Russian).
288. Gupta, P. S., Bhargava, S. P. & Sharma, M.
L. ( 1962 ) Acute copper sulphate poison
ing with special reference to its management
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2048 KARL E. MASON
with corticosteroid therapy. J. Assn. Phys.
India 10, 287-292.
289. Guthrie, B. E. (1973) Daily dietary in
takes of zinc, copper, manganese, chromium
and cadmium by some New Zealand women.
Proc. Univ. Otago Med. School. 51, 47^9.
290. Guthrie, B. E. (1975) Chromium, man
ganese, copper, zinc and cadmium content
of New Zealand foods. N.Z. Med. J. 82,
418-424.
291. Guthrie, B. E. & Robinson, M. F. (1977)
Dietary intakes of manganese, copper, zinc
and cadmium by New Zealand women. Br.
J. Nutr. 38, 55-63.
292. Guthrie, B. E. & Robinson, M. F. (1978)
The nutritional status of New Zealanders
with respect to manganese, copper, zinc and
cadmium: a review. N.Z. Med. J. 87, 3-8.
293. Hagberg, B., Axtrup, S. & Berfenstam, R.
( 1953 ) Heavy metals ( iron, copper, zinc )
in the blood of the fetus and the infant.
ÉtudesNéo-natal.2, 81-90.
294. Hahn, N., Paschen, K. & Haller, J. (1972)
Des Verhalten von Kupfer, Eisen, Magne
sium, Calcium und Zink bei Frauen mit
normalem Menstruationscyclus, unter Ein
nahme von Ovulationshemmem und in der
Gravidität. Arch. Gynakol. 213, 176-186.
295. Hall, E. M. & Butt, E. M. (1928) Experi
mental pigment cirrhosis due to copper
poisoning. Its relation to hemochromatosis.
Arch. Pathol. 6, 1-25.
296. Hall, H. C. (1921) La dégénérescence
hépato-lenticularie; maladie de Wilson-
pseudo-sclérose, pp. 190-192, Masson, Paris.
297. Halsted, J. A., Hackley, B. M. & Smith, J.
C., Jr. ( 1968 ) Plasma-zinc and copper in
pregnancy and after oral contraceptives.
Lancet 2, 278.
298. Hambidge, K. M. (1973) Increase in hair
copper concentration with increase distance
from the scalp. Am. J. Clin. Nutr. 26, 1212-
1215.
299. Hambidge, K. M. (1976) The importance
of trace elements in infant nutrition. Current
Med. Res. Opin. 4 (Suppl. 1), 44-53.
300. Hambidge, K. M. & Droegemueller, W.
( 1974 ) Changes in plasma and hair con
centrations of zinc, copper, chromium, and
manganese during pregnancy. Obstet. &
Gynecol. 44, 666-672.
301. Hambidge, K. M. & Walravens, P. (1975)
Trace elements in nutrition. In: Practice of
Pediatrics, vol. 1, chap. 29, pp. 1-40, Harper
& Rowe, Hagerstown, Maryland.
302. Hamlyn, A. N., Gollan, J. L., Douglas, A. P.
& Sherlock, S. (1977) Fulminating Wil
son's disease with haemolysis and renal
failure: copper studies and assessment of
dialysis regimens. Br. Med. J. 2, 660-663.
303. Hankiewicz, J. & Sevecek, E. (1974)
Untersuchungen über den Kupfer- und
Zeruloplasmingehalt bei Frauen während der
Schwangerschaft und bei solchen mit gewis
sen gynäkologischen Krankheiten. Zentralbl.
Gynäk.96, 905-909.
304. Hankins, D. A., Riella, M. C., Scribner, B.
H. & Babb, A. L. (1976) Whole blood
trace element concentrations during total
parenteral nutrition. Surgery 79, 674-677.
305. Hansen, J. D. L. & Lehmann, B. H. (1969)
Serum zinc and copper concentrations in
children with protein-calorie malnutrition.
S. African Med. J. 43, 1248-1251.
306. Harcke, H. T., Jr., Capitanio, M. A., Grover,
W. D. & Valdes-Dapena, M. (1977) Blad
der diverticula and Menkes' syndrome.
Radiology 124, 459-461.
307. Harper, A. E. (1976) Basis of recom
mended dietary allowances for trace ele
ments. In: Trace Elements in Human Health
and Disease ( Prasad, A. S. & Oberleas, D.,
eds.), vol. 2, pp. 371-378, Academic Press,
New York.
308. Harris, E. D. & O'Dell, B. L. (1974) Cop
per and amine oxidases in connective tissue
metabolism. In: Protein-Metal Interactions
Friedman, M., éd.),pp. 267-284, Plenum,
New York.
309. Harris, E. D., Rayton, I. K. & De Groot, J.
E. (1977) A critical role for copper in
aortic elastin structure and synthesis. Adv.
Exp. Med. Biol. 79, 543-559.
310. Harris, W. O., Jr., Kopp, J. E., Rinaldi, I.
& Peach, W. F., Jr. ( 1975 ) Menkes' kinky
hair syndrome. Va. Med. Monthly 102, 725-
728.
311. Hart, E. B., Elvehjem, C. A., Waddell, J. &
Herrin, R. C. (1927) Iron in nutrition.
IV. Nutritional anemia on whole milk diets
and its correction with the ash of certain
plant and animal tissues or with soluble iron
salts. J. Biol. Chem. 72, 299-320.
312. Hart, E. B., Steenbock, H., Elvehjem, C. A.
& Waddell, J. (1925) Iron in nutrition. I.
Nutritional anemia on whole milk diets and
the utilization of inorganic iron in hemo
globin building. J. Biol. Chem. 65, 67-80.
313. Hart, E. B., Steenbock, H., Waddell, J. &
Elvehjem, C. A. (1928) Iron in Nutri
tion. VII. Copper as a supplement to iron
for hemoglobin building in the rat. J. Biol.
Chem. 77, 797-812.
314. Hartley, T. F., Dawson, J. B. & Hodgkinson,
A. ( 1974 ) Simultaneous measurement of
Na, K, Ca, Mg, Cu and Zn balances in man.
Clin. Chim. Acta 52, 321-333.
315. Hasegawa, M. & Ito, S. (1954) The im
portance of copper in the treatment of
anemia. Keio J. Med. 3, 25-34.
316. Haurowitz, F. (1930) Ãœbereine Anomalie
des Kupferstoffwechsels. Hoppe-Seyler's
Ztschr. Physiol. Chem. Ã90,72-74.
317. Hauer, E. C. & Kaminski, M. V. (1978)
Trace metal profile of parenteral nutrition
solutions. Am. J. Clin. Nutr. 31, 264-268.
318. Heijkenskjold, F. & Hedenstedt, S. (1962)
Serum copper determinations in normal
pregnancy and abortion. Acta Obstet. Gyne
col. Scand. 41, 41-47.
319. Heilmeyer, L., Keiderling, W. & Stüwe,G.
( 1941 ) Kupfer und Eisen als KÃrperigene
Wirkstoffe und ihre Bedeutung beim Krank
heitsgeschehen. Fisher, Jena.
320. Hejduk, J. (1963) Untersuchunger über
das Verhalten von Eisen und Kupfer im
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2049
Blutserum der Frauen in der Schwanger
schaft, unter der Geburt, im Wochenbett
sowie bei Neugeborenen. Geburtsh. Gynaek.
160, 187-199.
321. Henkin, R. I. (1971) Newer aspects of
copper and zinc metabolism. In: New Trace
Metals and Nutrition ( Mertz, W. & Cornatzer,
W., eds.), pp. 255-312, Marcel Dekker,
New York.
322. Henkin, R. I. & Bradley, D. F. (1969)
Regulation of taste acuity by thiols and
metal ions. Proc. Nat. Acad. Sci. U.S.A. 62,
30-37.
323. Henkin, R. I., Reiser, H. R., Jaffe, I. A.,
Sternlieb, I. & Scheinberg, I. H. (1967)
Decreased taste sensitivity after D-penicillamine
reversed by copper administration.
Lancet 2, 1268-1271.
324. Henkin, R. I., Marshall, J. R. & Meret, S.
(1971) Maternal-fetal metabolism of cop
per and zinc at term. Am. J. Obst. Gynecol.
110, 131-134.
325. Henkin, R. I., Schulman, J. D., Schulman,
C. B. & Bronzert, D. A. (1973) Changes
in total, nondiffusible and diffusible plasma
zinc and copper during infancy. J. Pediat.
82, 831-837.
326. Henkin, R. I. & Smith, F. R. (1972) Zinc
and copper metabolism in acute viral hepa
titis. Am. J. Med. Sci. 264, 401-409.
327. Herkel, W. (1930) Ãœber die Bedeutung
des Kupfers (Zinks und Mangans) in der
Biologie und Pathologie. Beitrag. Pathol.
Anat. Allg. Pathol. 85, 513-551.
328. Herring, W. B., Leavell, B. S., Paixao, L. M.
& Yoe, J. H. (1960) Trace metals in hu
man plasma and red blood cells. A study of
magnesium, chromium, nickel, copper and
zinc. II. Observations of patients with some
hématologie diseases. Am. J. Clin. Nutr. 8,
855-863.
329. Heydorn, K., Damsgaard, E., Horn, N., Mikkelsen,
M., Tygstrup, I., Vestermark, S. &
Weber, J. (1975) Extra-hepatic storage
of copper. A male foetus suspected of
Menkes' disease. Humangenetik. 29, 171-
175.
330. Hill, C. H. (1969) A role of copper in
elastin formation. Nutr. Rev. 27, 99-100.
331. Hill, C. H. & Matrone, G. (1961) Studies
on copper and iron deficiencies in growing
chickens. J. Nutr. 73, 425-431.
332. Hill, C. H. & Matrone, G. (1970) Chemi
cal parameters in the study of in vivo and
in vitro interactions of transition elements.
Federation Proc. 29, 1474-1481.
333. Hill, C. H. & Starcher, B. (1965) Effect
of reducing agents on copper deficiency in
the chick. J. Nutr. 85, 271-274.
334. Hill, C. H., Starcher, B. & Kim, C. (1967)
Role of copper in the formation of elastin.
Federation Proc. 26, 129-133.
335. Hill, J. M. & Kim, C. S. (1967) The de
rangement of elastin synthesis in pyridoxine
deficiency. Biochem. Biophys. Res. Comm.
27, 94-99.
336. Hirano, A., Liena, ]. F., French, J. H. &
Ghatak, N. R. (1977) Fine structure of
the cerebellar cortex in Menkes' kinky-hair
disease. X. Chromosome-linked copper malabsorption.
Arch. Neurol. 34, 52-56.
337. Hitier, Y. (1976) Répercussions de la
carence en acide ascorbique sur la céruloplasmine
et le cuivre tissulaire. Internat. J. Vit.
Nutr. Res. 46, 48-57.
338. Hitzig, W. H. (1960) Das Bluteiweissbild
im Säuglingsalter. Habilitationschrift, Zurich
(cited by Richterich, réf.638).
339. Hitzig, W. H. (1961) Das Bluteiweissbild
beim gesunden Säugling.Spezifische Proteinbestimmungen
mit besonderer Berücksich
tigung immunochemischer Methoden. Helv.
Paediat. Acta 16, 46-81.
340. Hockey, A. & Masters, C. L. (1977)
Menkes' kinky (steely) hair disease. Aust.
J. Dermatol. 18, 77-80.
341. Hodges, M. A. & Peterson, W. H. (1931)
Manganese, copper and iron content of
serving portions of common foods. J. Am.
Diet. Assn. 7, 6-16.
342. Hoffmann, R. P. & Ashby, D. M. (1976)
Trace element concentrations in commer
cially available solutions. Drug Intell. Clin.
Pharmacol. 10, 74-76.
343. Hohnadel, D. C., Sunderman, F. W., Jr.,
Nechay, M. W. & McNeely, M. D. (1973)
Atomic absorption spectrometry of nickel,
copper, zinc, and lead in sweat collected
from healthy subjects during sauna bathing.
Clin. Chem. 19, 1288-1292.
344. Holden, J. M., Wolf, W. R. & Mertz, W.
(1979) Dietary levels of zinc and copper
in self selected diets. J. Am. Diet. Assn. 75,
23-28.
345. Holmberg, C. G. (1941) Ãœber die Ver
teilung des Kupfers zwischen Plasma und
roten BlutkÃrperchen bei extremen physio
logischen Verschiebungen im Cu-Gehalt des
Blutes. Acta Physiol. Scand. 2, 71-77.
346. Holmberg, C. G. & Laurell, C. B. (1948)
Investigations in serum copper. II. Isolation
of the copper containing protein, and a de
scription of some of its properties. Acta
Chem. Scand. 2, 550-556.
347. Holmberg, C. G. & Laurell, C. B. (1951)
Investigations in serum copper. III. Coeruloplasmin
as an enzyme. Acta Chem. Scand.
5, 476-480.
348. Holmberg, C. G. & Laurell, C. B. (1951)
Oxidase reactions in human plasma caused by
coeruloplasmin. Scand. J. Lab. Invest. 3,
103-107.
349. Holt, F. & Scoular, F. I. (1946) Iron and
copper metabolism of young women on selfselected
diets. J. Nutr. 35, 717-723.
350. Holtkamp, H. C. & Van Eijk, H. G. (1975)
Over het vorkomen en de functie van koper
in het menselijk lichaam. Maandschr. Kindergeneeskd.
43, 36-55.
351. Holtzman, N. A. (1976) Menkes' kinky
hair syndrome: a genetic disease involving
copper. Federation Proc. 35, 2276-2280.
352. Holtzman, N. A., Charache, P., Cordano, A.
& Graham, G. G. (1970) Distribution of
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2050 KARL E. MASON
serum copper in copper deficiency. Johns
Hopkins Med. J. 126, 34^2.
353. Holtzman, N. A., Elliot, D. A. & Heller, R.
H. (1966) Copper intoxication: report of
a case with observations on ceruloplasmin.
New Engl. J. Med. 275, 347-352.
354. Holtzman, N. A., Graham, G. G., Charache,
P. & Haslam, R. (1967) Effect of copper
on ceruloplasmin concentration. Pediat. Res.
1, 219.
355. Holtzman, N. A. & Haslam, R. H. A. ( 1968)
Elevation of serum copper following copper
sulfate as an emetic. Pediat. 42, 189-193.
356. Hopper, S. H. & Adams, H. S. (1958)
Copper poisoning from vending machines.
Pub. Health. Rep. 73, 910-914.
357. Horcieko, J., Borovansky, J. & DuchÃn, J.
( 1973 ) Verteilung von Zink und Kupfer in
menschlichen Kopfhaar verschiedener Farb
tÃne. Dermatol. Monatsch. 159, 206-209.
358. HÃrn, N. ( 1976) Copper incorporation
studies on cultured cells for prenatal diag
nosis of Menkes' disease. Lancet 1, 1156—
1158.
359. Horn, N., Mikkelsen, M., Heydorn, K.,
Damsgaard, E. & Tygstrup, I. (1975)
Copper and steely hair. Lancet 1, 1236.
360. Horwitt, M. K., Meyer, B. J., Meyer, A. C.,
Harvey, C. C. & Haffron, D. (1957) Serum
copper and oxidase activity in schizophrenic
patients. Arch. Neurol. Psychiat. 73, 275-
282.
361. Howell, J. McC. & Davison, A. N. (1959)
The copper content and cytochrome oxidase
activity of tissues from normal and swayback
lambs. Biochem. J. 72, 365-368.
362. Hrgovcic, R. & Hrgovcic, M. (1969) Nor
mal serum copper levels during childhood.
Jugoslav. Pedijat. 11, 83-94 ( Serbo-crotian ).
363. Hrgovcic, M., Tessmer, C. F., Thomas, F. B.,
Fuller, L. M., Gamble, J. F. & Shullenberger,
C. C. ( 1973 ) Significance of serum copper
levels in adult patients with Hodgkin's dis
ease. Cancer 31, 1337-1345.
364. Hrgovcic, M., Tessmer, C. F., Thomas, F. B.,
Ong, P. S., Gamble, J. F. & Shullenberger,
C. C. ( 1973 ) Serum copper observations
in patients with malignant lymphoma. Can
cer 32, 1512-1524.
365. Hsieh, H. S. & Frieden, E. (1975) Evi
dence for ceruloplasmin as a copper trans
port protein. Biochem. Biophys. Res. Comm.
67, 1326-1331.
366. Hughes, G., Kelley, V. J. & Stewart, R. A.
(1960) The copper content of infant foods.
Pediatrics 25, 477^184.
367. Hull, R. L. (1974) Use of trace elements
in intravenous hyperalimentation solutions.
Am. J. Hosp. Pharm. 31, 759-761.
368. Humoller, F. L., Mockler, M. P., Holthaus,
J. M. & Mahler, D. L. (1960) Enzymatic
properties of ceruloplasmin. J. Lab. Clin.
Med. 56, 222-234.
369. Hunt, A. H., Parr, R. M., Taylor, D. M. &
Trott, G. G. (1963) Relation between
cirrhosis and trace metal content of liver:
with special reference to primary biliary
cirrhosis and copper. Br. Med. J. 2, 1498-
1501.
370. Hunt, C. E., Carlton, W. W. & Newberne,
P. M. (1970) Interrelationships between
copper deficiency and dietary ascorbic acid
in the rabbit. Br. J. Nutr. 24, 61-69.
371. Hunt, D. M. (1974) Primary defect in
copper transport underlies mottled mutants
in the mouse. Nature 249, 852-854.
372. Huriez, C., Bizerte, D. & Bialais, M. (1972)
Les troubles du métabolismedu cuivre dans
la vitíligo. Ann. Dermatol. Syphil. 49, 29-
40.
373. Hurley, L. S. (1976) Interaction of genes
and metals in development. Federation Proc.
35, 2271-2275.
374. Hurley, L. S. & Bell, L. T. (1975) Ameli
oration by copper supplementation of mutant
gene effects in the crinkled mouse. Proc.
Soc. Exp. Biol. Med. 149, 830-834.
375. Ilicin, G. ( 1971 ) Serum copper and mag
nesium levels in leukemia and malignant
lymphoma. Lancet 2, 1036-1037.
376. Ivanovich, P., Manzler, A. & Drake, R.
(1969) Acute hemolysis following hemodialysis.
Trans. Am. Soc. Artif. Intern.
Organs. 15, 316-318.
377. lyengar, L. & Apte, S. V. (1972) Nutrient
stores in human fetal livers. Br. J. Nutr. 27,
313-317.
378. Jacob, R. A., Klevay, L. M. & Logan, G. M.
( 1978 ) Hair as a biopsy material. V. Hair
metal as an index of hepatic metal in rats:
copper and zinc. Am. J. Clin. Nutr. 31, 477-
480.
379. Jacobson, S. & Wester, P. O. (1977) Bal
ance study of twenty trace elements during
total parenteral nutrition in man. Br. J. Nutr.
37, 107-126.
380. Jaffe, I. A. ( 1968 ) Penicillamine in rheu
matoid disease with particular reference to
rheumatoid factor. Postgrad. Med. J. 44
(Suppl.), 34-40.
381. Jaffe, I. A., Merriman, P. & Jacobus, D.
(1968) Copper: relation to penicillamineinduced
defect in collagen. Science 161,
1016-1017.
382. James, B. E. & MacMahon, R. A. (1970)
Trace elements in intravenous fluids. Med. J.
Australia 2, 1161-1163.
383. James, B. E. & MacMahon, R. A. (1976)
Balance studies of nine elements during com
plete intravenous feeding of small premature
infants. Austr. Pediat. J. 12, 154-162.
384. Janes, J. M., McCall, J. T. & Elveback, L. R.
( 1972 ) Trace metals in human osteogenic
sarcoma. Mayo Clin. Proc. 47, 476-478.
385. Jeejeebhoy, K. N., Zohrab, W. J., Langer,
B., Phillips, M. Jv Kuskis, A. & Anderson,
G. H. (1973) Total parenteral nutrition
at home for 23 months, without complication
and with good rehabilitation. A study of
technical and metabolic features. Gastroenterology
65, 811-820.
386. Jensen, K. B., Thorling, E. B. & Andersen,
C. J. ( 1964) Serum copper in Hodgkin's
disease. Scand. J. Hematol. 1, 63-74.
387. Jensen, W. N. & Kamin, H. (1957) Cop
per transport and excretion in normal sub
jects and in patients with Laennec's cir-
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2051
rhosis and Wilson's disease: A study with
Cu64. J. Lab. Clin. Med. 49, 200-210.
388. Johnson, N. C. (1961) Study of copper
and zinc metabolism during pregnancy. Proc.
Soc. Exp. Biol. Med. 108, 518-519.
389. Josephs, H. (1931) Treatment of anaemia
of infancy with iron and copper. Bull. J.
Hopkins Hosp. 49, 246-258.
390. Josephs, H. W. (1971) The effect of cop
per on iron metabolism: A clinical study.
Johns Hopkins Med. J. 129, 212-235.
391. Judd, E. S. & Dry, T. J. (1934) The sig
nificance of iron and copper in the bile of
man. J. Lab. Clin. Med. 20, 609-615.
392. Kagi, J. H. R. & Vallee, B. L. (1960)
Metallothionein: a cadmium and zinc-con
taining protein from equine renal cortex. J.
Biol. Chem. 235, 3460-3465.
393. Kagi, J. H. R. & Vallee, B. L. (1961)
Metallothionein: a cadmium and zinc-con
taining protein from equine renal cortex.
II. Physico-chemical properties. J. Biol.
Chem. 236, 2435-2442.
394. Karpel, J. T. & Peden, V. H. (1972) Cop
per deficiency in long-term parenteral nu
trition. J. Pediat. 80, 32-36.
395. Kasper, C. B. & Deutsch, H. F. (1963)
Physiochemical studies of human ceruloplasmin.
J. Biol. Chem. 238, 2325-2337.
396. Keen, C. L. & Hurley, L. S. (1976) Cop
per supplementation in quaking mutant
mice: reduced tremors and increased brain
copper. Science 193, 244-246.
397. Kehoe, R. A., Cholak, J. & Story, R. V.
( 1940 ) A spectrochemical study of the
normal ranges of the concentration of certain
trace metals in biological materials. J. Nutr.
79, 579-592.
398. Kehoe, R. A., Cholak, J. & Story, R. V.
( 1940 ) Manganese, lead, tin, aluminum,
copper and silver in normal biological ma
terial. J. Nutr. 20, 85-97.
399. Keil, H. L. & Nelson, V. E. (1931) The
role of copper in hemoglobin regeneration
and in reproduction. J. Biol. Chem. 93, 49-57.
400. Kekki, M., Koskelo, P. & Lassus, A. (1966)
Serum ceruloplasmin-bound copper and nonceruloplasmin-bound
copper in uncompli
cated psoriasis. J. Invest. Dermatol. 47, 159—
161.
401. Kelly, W. A., Kesterson, J. W. & Garitón,
W. W. ( 1974 ) Myocardial lesions in the
offspring of female rats fed a copper defi
cient diet. Exper. Molec. Pathol. 20, 40-56.
402. Khalil, M., Kabiel, A., El-Khateeb, S., Aref,
K., El Lozy, M., Jahin, S. & Nasr, F. ( 1974)
Plasma and red cell water and elements in
protein-caloric malnutrition. Am. J. Clin.
Nutr. 27, 260-267.
403. Khaire, D. S. & Magar, N. G. (1972)
Copper in leprosy blood plasma concentra
tion and urinary excretion. Indian J. Med.
Res. 60, 1697-1701.
404. Khandekar, J. D., Mukerji, D. P., Naik, G.
D. & Sepaha, G. C. (1972) Regional
variation in copper content of arterial wall.
Experientia 28, 917.
405. Khandekar, J. D., Mukerji, D. P. & Sepaha,
G. C. ( 1972 ) Serum copper and iron in
ischemie heart disease. Ind. J. Med. Sci 26
813-818.
406. Kimmel, J. R., Markowitz, H. & Brown, D.
M. (1959) Some chemical and physical
properties of erythrocuprein. J. Biol. Chem.
234, 46-50.
407. King, J. C., Raynolds, W. L. & Margen, S.
( 1978 ) Absorption of stable isotopes of
iron, copper and zinc during oral contra
ceptive use. Am. J. Clin. Nutr. 31, 1198-
1203.
408. Kirchgessner, M., Weser, U. & Muller, H. L.
(1967) Cu-Absorption bei Zulag von Glucon-,
Citronen Salicyl- und Oxalsäure.7. Zur
Dynamik der Kupfer absorption. Ztschr.
Tierphysiol. Tierenahrung Futtermittelk. 23,
28-30.
409. Kleinbaum, H. (1962) Kupferstoffwech
selbilanzen bei Säuglingen. Ztschr. Kinderheilk.
87, 101-115.
410. Kleinbaum, H. (1962) Ãœber den Kupfer
gehalt der Nahrungsmittel des Kindes.
Ztschr. Kinderheilk. 86, 655-666.
411. Kleinbaum, H. (1963) Überdie Coeruloplasmin-oxydase-Aktivät
im Serum bei ge
sunden Kindern verschiedener Atersklassen.
Ztschr. Kinderkeilk. 88, 11-21.
412. Kleinbaum, H. (1963) Vorübergehende
Hypoproteinamine mit Hypocuprämie und
Eisenmangelänemie bei dystrophen Säuglin
gen. Ztschr. Kinderheilk. 88, 29-34.
413. Kleinbaum, H. (1968) Coeruloplasmin,
direkt reagierendes Kupfer und Gesamptkupfergehalt
bei verschiedenen Infectionskrankheiten
und entzündlichen Zustandsbildern.
Ztschr. Kinderheil. 102, 84-94.
414. Kleinmann, H. & Klinke, J. (1929) Ãœber
den Kupfergehalt menschlicher Organe.
Virch. Arch. Path. Anat. Physiol. 275, 422-
435.
415. Klevay, L. M. (1970) Hair as a biopsy
material. II. Assessment of copper nutriture.
Am. J. Clin. Nutr. 23, 1194-1202.
416. Klevay, L. M. (1974) An association be
tween the amount of fat and the ratio of
zinc to copper in 71 foods: inferences about
the epidemiology of coronary heart disease.
Nutr. Rep. Internat. 9, 393-399.
417. Klevay, L. M. (1975) Coronary heart
disease: the zinc/copper hypothesis. Am. J.
Clin. Nutr. 28, 764-774.
418. Klevay, L. M. (1975) The ratio of zinc
to copper of diets in the United States.
N'utr. Rep. Internat. 11, 237-242.
419. Klevay, L. M., Reck, S. & Barcome, D. F.
( 1977 ) United States diets and the copper
requirement. Federation Proc. 36", 1175.
420. Klevay, L. M., Vo-Khactu, K. P. & Jacob,
R. A. ( 1975 ) The ratio of zinc to copper
of cholesterol-lowering diets. In: Trace Sub
stances in Environmental Health—IX.
(Hemphill, D. D., éd.),pp. 131-138, Univ.
of Missouri, Columbia.
421. Kolaric, K., Rogujic, A. & Fuss, V. (1975)
Serum copper levels in patients with solid
tumors. Tumori 61, 173-177.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2052 KARL E. MASON
422. Kopp, N., Tommasi, M., Carrier, H., Pialat,
J., Gilly, J. & Hervé,C. (1975) Neuro
pathologie de la trichopoliodystrophie (Mala
die de Menkes ) : une observation anatomoclinique.
Rev. Neurol. (Paris) 131, 775-789.
423. Koskelo, P., Kekki, M., Virkunen, M., Lassus,
A. & Somer, T. (1966) Serum ceruloplasmin
concentration in rheumatoid arthritis,
ankylosing spondylitis, psoriasis and sarcoidosis.
Acta Rheum. Scand. 12, 261-266.
424. Kovalskiy, V. V. & Yarovaya, G. A. (1966)
Molybdenum: infiltrated biochemical prov
inces. Agrokhimiya 8, 68-91 (Russian).
425. Kovalskiy, V. V., Yarovaya, G. A. & Shmavonyan,
D. M. ( 1961 ) Changes in purine
metabolism in man and animals under con
ditions of molybdenum biogeochemical prov
inces. Zh. Obsch. Biol. 22, 179-191 (Rus
sian ).
426. Krebs, H. A. (1928) Ãœberdas Kupfer im
menschlichen Blutserum. Klin. Wochenschr.
7, 584-585.
427. Krishnamachari, K. A. V. R. (1974) Some
aspects of copper metabolism in pellagra.
Am. J. Clin. Nutr. 27, 108-111.
428. Krishnamachari, K. A. V. R. (1976) Fur
ther observations on the syndrome of en
demic genu valgum of South India. Indian
J. Med. Res. 64, 284-291.
429. Krishnamachari, K. A. V. R. & Rao, K. S. J.
(1972) Ceruloplasmin activity in infants
born to undernourished mothers. J. Obst.
Gynaecol. Br. Commwlt. 79, 162-165.
430. Kushnir, M. P. (1972) The role of dis
orders of copper and vitamin C metabolism
in the pathogenesis of psoriasis. Vestn. Derm.
Vener. 46, (4), 23-26 (Roumanian) (cited
in Nutr. Abstr. Rev. 43, 1026, 1971).
431. Kyer, J. L. & Bethell, F. H. (1936) The
requirement of iron and copper and the in
fluence of diet upon hemoglobin formation
during normal pregnancy. J. Biol. Chem. 114,
lx-lxi.
432. Lahey, M. E. (1957) Iron and copper in
infant nutrition. Am. J. Clin. Nutr. 5, 516—
526.
433. Lahey, M. E., Behar, M., Viteri, F. & Scrim
shaw, N. S. (1958) Values for copper,
iron and iron-binding capacity in the serum
in kwashiorkor. Pediatrics 22, 72-78.
434. Lahey, M. E., Gubler, C. J., Cartwright, G.
E. & Wintrobe, M. M. (1953) Studies on
copper metabolism. VI. Blood copper in
normal human subjects. J. Clin. Invest. 32,
322-328.
435. Lahey, M. E., Gubler, C. J., Cartwright, G.
E. & Wintrobe, M. M. (1953) Studies on
copper metabolism. VII. Blood copper in
pregnancy and various pathologic states. J.
Clin. Invest. 32, 329-339.
436. Lahey, M. E., Gubler, C. J., Chase, M. S.,
Cartwright, G. E. & Wintrobe, M. M.
(1952) Studies on copper metabolism. II.
Hématologie manifestations of copper de
ficiency in swine. Blood 7, 1053-1074.
437. Lahey, M. E. & Schubert, W. K. (1957)
New deficiency syndrome occurring in in
fancy. Am. J. Dis. Child 93, 31-34.
438. Lai, S., Rajagopal, G. & Subrahmanyam, K.
(1971) Serum caeruloplasmin in psoriasis.
Indian J. Derm. 16, 103-104.
439. Lang, N. & Renschler, H. E. (1958)
Untersuchungen zum Ort der Coeruloplasminbildung
mit Radiokupfer ("Cu). Ztschr.
Exp. Med. 130, 203-214.
440. Lange, J., Schumacher, K. & Wischer, H. P.
(1971) Die Behandlung des chronisch—
aggressiven Hepatitis mit d-penicillamine.
Deutsch. Med. Wochenschr. 96, 139-145.
441. Langer, B., McHattie, J. D., Zohrab, W. J.
& Jeejeebhoy, K. N. (1973) Prolonged
survival after complete bowel resection using
intravenous alimentation at home. J. Sure.
Res. 75, 226-233.
442. La Russo, N. F., Summerskill, W. H. J. &
McCall, J. T. (1976) Abnormalities of
chemical tests for copper metabolism in
from
chronic
Wilson's
active
disease.
liver disease:
Gastroenterology,
differentiation
70,
653-655.
443. Lea, C. M. & Luttrell, V. A. S. (1965)
Copper content of hair in kwashiorkor.
Nature 206, 413.
444. Lee, G. R., Nacht, S., Christensen, D., Hansen,
S. P. & Cartwright, G. E. ( 1969) The
contribution of citrate to the ferroxidase ac
tivity of serum. Proc. Soc. Exp. Biol. Med.
131, 918-923.
445. Lee, G. R., Nacht, S., Lukens, J. N. &
Cartwright, G. E. (1968) Iron metabolism
in copper deficient swine. J. Clin. Invest. 47,
2058-2069.
446. Lee, G. R., Williams, D. M. & Cartwright,
G. E. (1976) Role of copper in iron me
tabolism and heme biosynthesis. In: Trace
Elements in Human Health and Disease
(Prasad, A. S. & Oberleas, D., eds.), vol 1,
pp. 373-390, Academic Press, New York.
447. Lehmann, K. B. (1891) Kritische und ex
perimentelle Studien über die hygienishe
Bedeutung des Kupfers. Munch. Med.
Wochenschr. 38, 631-633.
448.
Renal
Leu, M.
function
L. &
in
Strickland,
hétérozygotes
G. T.
for Wilson's
(1971)
disease. Am. J. Med. Sci. 263, 19-24.
449. Leu, M. L., Strickland, G. T. & Gutman, R.
A. (1970) Renal function in Wilson's
disease: response to therapy. Am. J. Med.
Sci. 260, 381-398.
450. Le Van, J. H. & Perry, E. I. (1961) Cop
per poisoning on shipboard. Pub. Health
Rep. 76, 334.
451. Leverton, R. M. (1939) The copper me
tabolism of young women. J. Nutr. 17, 17.
452. Leverton, R. M. & Binkley E. S. (1944)
The copper metabolism and requirement of
young women. J. Nutr. 27, 43-53.
453. Levy, N. S., Dawson, W. W., Rhodes, B. J.
& Gamica, A. ( 1974 ) Ocular abnormali
ties in Menkes' kinky hair disease. Am. J.
Ophthalmol. 77, 319-325.
454. Lewis, K. O. (1973) The nature of the
copper complexes in bile and their relation
ship to the absorption and excretion of cop
per in normal subjects and in Wilson's dis
ease. Gut 14, 221-232.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2053
455. Lewis, M. S. (193I) Iron and copper in
the treatment of anemia in children. J. Am.
Med. Assn. 96, 1135-1138.
456. Lewis, R. A., Falls, H. F. & Troyer, D. O.
( 1975 ) Ocular manifestations of hypercupremia
associated with multiple myeloma.
Arch. Ophthamol. 93, 1050-1053.
457. Lewis, R. A., Hultquist, D. E., Baker, B. L.,
Falls, H. F., Gershowitz, H. & Penner, J. A.
( 1976 ) Hypercupremia associated with
monoclonal immunoglobulin. J. Lab. Clin.
Med. 88, 375-388.
458. Li, T. K. & Vallee, B. L. ( 1968 ) The bio
chemical and nutritional role of trace ele
ments. In: Modem Nutrition in Health and
Disease. (Wohl, M. G. & R. S. Goodhart,
eds.), p. 377, Lea & Febiger, Philadelphia.
459. Lieh, N. P. (1971) Effets toxiques de
certains oligo-éléments.Aliment. Vie 59,
103-153.
460. Lifschitz, M. D. & Henkin, R. I. (1971)
Circadian variation in copper and zinc in
man. J. Appi. Physiol. 31, 88-92.
461. Linder, M. C. & Munro, H. N. (1973)
Iron and copper metabolism during devel
opment. Enzyme 15, 111-138.
462. Lindow, C. W., Elvehjem, C. A. & Peterson,
W. H. (1929) The copper content of
plant and animal foods. J. Biol. Chem. 82,
465-471.
463. Lloyd-Still, J. D., Scwachman, H. & Filler,
R. M. (1973) Protracted diarrhea of in
fancy treated by intravenous alimentation. 1.
Clinical studies of 16 infants. Am. J. Dis.
Child. 125, 358-364.
464. Locke, A., Main, E. R. & Rosbash, D. O.
( 1932 ) The copper and non-hemoglobinous
iron contents of the blood serum in disease.
J. Clin. Invest. 11, 527-542.
465. Lorber, A. (1969) Communication in
response to Sternlieh et al. 1969. Arth.
Rheum. 12, 459-460.
466. Lorber, A., Cutler, L. S. & Chang, C. C.
( 1968 ) Serum copper levels in rheumatoid
arthritis: relationship of elevated copper to
protein alterations. Arth. Rheum. 11, 65-71.
467. Lott, I. T., DiPaolo, R., Schwartz, D.,
Janowska, S. & Kanfer, J. N. (1975) Cop
per metabolism in the steely-hair syndrome.
New Engl. J. Med. 292, 197-199.
468. Lott, I. T., DiPaola, R., Schwartz, D., Kan
fer, J. N. & Moser, H. W. (1975) The
pathogenesis and treatment of copper de
ficiency in steely-hair syndrome. Trans. Am.
Neurol. Assn. 100, 151-154.
469. Lou, H. C., Holmer, G. K., Reske-Nielsen, E.
& Vagn-Hansen, P. (1974) Lipid compo
sition in gray and white matter of the brain
in Menkes* disease. J. Neurochem. 22, 377-
381.
470. Louis, J., Blanckaert, D., Desbonnets, P.,
Farriaux, J. P. & Fontaine, G. (1975)
Anomalies originales dans une nouvelle ob
servation de maladie de Menkes. Nouv.
Presse Med. 15, 1138.
471. Lyle, W. H. (1967) Chronic dialysis and
copper poisoning. New Engl. J. Med. 276,
1209-1210.
472. Lyle, W. H., Payton, J. E. & Hui M.
(1976) Haemodialysis and copper fever.
Lancet 1, 1324-1325.
473. Lynch, R. E., Lee, G. R. & Cartwright, G.
E. (1973) Penicillamine-induced cupriuria
in normal subjects and in patients with
active liver disease. Proc. Soc. Biol. Med.
142, 128-130.
474. MacDonald, I. & Warren, P. J. (1961)
The copper content of the liver and hair of
African children with kwashiorkor. Br. I.
Xutr. 15, 593-596.
475. MacDonald, W. C., Trier, J. S. & Everett, N.
B. (1964) Cell proliferation and migra
tion in the stomach duodenum, and rectum
of man: radiographie studies. Gastroenterology
46, 405-417.
476. MacKay, H. M. M. (1933) Copper in the
treatment of nutritional anemia in infancy.
Arch. Dis. Childhood 8, 145-154.
477. Macy, I. B. (1944) Feeding school chil
dren to meet dietary needs. J. Am. Dietet.
Assn. 20, 602-608.
478. Mahler, H. R. (1963) Uricase. In: The
Enzymes ( Boyer, P. D., Lardy, H. & Myrback
eds.), vol. 8, part B, pp. 285-296,
Academic Press, New York.
479. Mallette, M. F. (1950) The nature of the
copper enzymes involved in tyrosine oxida
tion. In: A Symposium on Copper Metab
olism (McElroy, W. D. & Glass, B., eds.),
pp. 48-75, J. Hopkins Press, Baltimore.
480. Mallory, F. B. (1925) The relation of
chronic poisoning with copper to hemochromatosis.
Am. J. Path. 1, 117-133.
481. Mallory, F. B. (1926) Hemochromatosis
and chronic poisoning with copper. Arch.
Intern. Med. 37, 336-362.
482. Mallory, F. B. & Parker, F., Jr. (1931)
Experimental copper poisoning. Am. J.
Pathol. 7, 351-364.
483. Mallory, F. B. & Parker, F., Jr. (1931)
The microchemical demonstration of copper
in pigment cirrhosis. Am. J. Pathol. 7, 365-
371.
484. Mallory, F. B., Parker, F., Jr. & Nye, R. M.
(1921) Experimental pigment cirrhosis due
to copper and its relation to hemochromatosis.
J. Med. Res. 42, 461-496.
485. Mandelbrote, B. M., Stanier, M. W., Thomp
son, R. H. S. & Thruston, M. N. (1948)
Studies on copper metabolism in demyelinating
diseases of the central nervous system.
Brain 71, 212-228.
486. Mann, T. & Keilin, D. (1939) Haemocuprein
and hepatocuprein, copper-protein
compounds of blood and liver in mammals.
Proc. Roy. Soc. Lond., Series B., 126, SOS-
SIS.
487. Manzler, A. D. & Schreiner, A. W. (1970)
Copper-induced acute hemolytic anemia. A
new complication of hemodialysis. Ann. In
tern. Med. 73, 409-412.
488. Marceau, N. & Aspin, N. (1973) The
intracellular distribution of the radiocopper
derived from ceruloplasmin and from albu
min. Biochim. Biophys. Acta 328, 338-350.
489. Marceau, N. & Aspin, N. (1973) The as
sociation of the copper derived from cenilo-
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2054 KARL E. MASON
plasmiti with cytocuprein. Biochim. Biophys.
Acta 328, 351-358.
490. Markowitz, H., Cartwright, G. E. & Wintrobe,
M. M. (1959) Studies on copper
metabolism. XXVII. Isolation and properties
of erythrocyte cuproprotein ( erythrocuprein).
J. Biol. Chem. 234, 40-45.
491. Markowitz, H., Gubler, C. J., Mahoney, J. P.
Cartwright, G. E. & Wintrobe, M. M.
(1955) Studies on copper metabolism. XIV.
Copper, ceruloplasmin and oxidase activity
in sera of normal human subjects, pregnant
women, and patients with infection, hepatolenticular
degeneration and the nephrotic
syndrome. J. Clin. Invest. 34, 1498-1508.
492. Markowitz, H., Shields, G. S., Klassen, W.
H., Cartwright, G. E. & Wintrobe, M. M.
( 1961 ) Spectrophotometric determination
of total erythrocyte copper. Anal. Chem. 33,
1594-1598.
493. Marston, H. R. ( 1952 ) Cobalt, copper and
molybdenum in the nutrition of animals and
plants. Physiol. Rev. 32, 62-111.
494. Masi, M., Paolucci, P., Vecchi, V. & Vivarelli,
F. ( 1975 ) La ceruloplasminemia nel
bambino normale. Minerva Pediat. 27, 1175-
1180.
495. Matsuda, I. (1978) Screening for Wilson's
disease. Lancet 1, 562.
496. Matsuda, I., Pearson, T. & Holtzman, N. A.
( 1974 ) Determination of apoceruloplasmin
by radioimmunoas^ay in nutritional copper
deficiency, Menkes' kinky hair syndrome, Wil
son's disease, and umbilical cord blood.
Pediat. Res. 8, 821-824.
497. Matter, B. J., Pederson, J., Psimenos, G. &
Lindeman, R. D. (1969) Lethal copper
intoxication in hemodialysis. Trans. Soc.
Artif. Intern. Organs 15, 309-315.
498. Matthews, W. B. (1954) The absorption
and excretion of radiocopper in hepatolenticular
degeneration (Wilson's disease).
J. Neurol. Neurosurg. Psychiat. 17, 242-246.
499. Matthews, W. B., Milne, M. D. & Bell, M.
( 1952 ) The metabolic disorder in hepatolenticular
degeneration. Quart. J. Med. 21,
425-446.
500. McCord, J. M. & Fridovich, I. (1969)
Superoxide dismutase. An enzymic function
for erythrocuprein (hemocuprein). J. Biol.
Chem. 244, 6049-6055.
501. McCord, J. M. & Fridovich, I. (1970) The
utility of Superoxide dismutase in studying
free radical reactions. II. The mechanism of
the mediation of cytochrome c reduction by
a variety of electron carriers. J. Biol. Chem.
245, 1374-1377.
502. McCosker, P. J. (1961) Paraphenylenediamine
oxidase activity and copper-levels in
mammalian plasmas. Nature 190, 887-889.
503. McCullars, G. M., O'Reilly, S. & Brennan,
M. (1977) Pigment binding of copper in
human bile. Clin. Chim. Acta 74, 33-38.
504. McDermott, J. A., Huber, C. T., Osaki, S.
& Frieden, E. (1968) Role of iron in the
oxidase activity of ceruloplasmin. Biochem.
Biophys. Acta 151, 541-557.
505. McEwen, C. M., Jr. (1965) Human
plasma monoamine oxidase. 1. Purification
and identification. J. Biol. Chem. 240, 2003-
2010.
506. McEwen, C. M., Jr. & Harrison, D. C.
( 1965 ) Abnormalities of serum monoamine
oxidase in chronic congestive heart failure.
J. Lab. Clin. Med. 65, 546-559.
507. McHargue, J. S. (1926) Further evidence
that small quantities of copper, manganese
and zinc are factors in the metabolism of
animals. Am. J. Physiol. 77, 245-255.
508. Mclntyre, N., Clink, H. M., Levi, A. J.,
Cummings, J. N. & Sherlock, S. (1967)
Hemolytic anemia in Wilson's disease. New
Engl. J. Med. 276, 439-444.
509. McKenzie, J. M. (1974) Tissue concen
tration of cadmium, zinc and copper from
autopsy samples. N.Z. Med. J. 79, 1016-
1019.
510. McKenzie, J. M., Guthrie, B. E. & Prior,
I. A. M. (1978) Zinc and copper status
of Polynesian residents in the Tokelau
Islands. Am. J. Clin. Nutr. 31, 422-428.
511. McKenzie, J. M., Van Rij, A. M., Robinson,
M. F. & Guthrie, B. E. (1976) Trace ele
ment balance studies during total parenteral
nutrition. In: Trace Substances in Environ
mental Health, X. University of Missouri,
Columbia.
512. McMullen, W. (1971) Copper contami
nation in soft drinks from bottle pourers.
Health Bulletin (Scotland) 29, 94-96.
513. Menkes, J. H., Alter, M., Steigleder, G. K.,
Weakley, D. R. & Sung, J. H. (1962) A
sex-linked recessive disorder with retarda
tion of growth, peculiar hair, and focal
cerebral and cerebellar degeneration. Pedi
atrics 29, 764-779.
514. Mertz, W. (1972) Human requirements:
basic and optimal. Ann. N.Y. Acad. Sci. 199,
191-201.
515. Mertz, W. (1976) Defining trace element
deficiencies and toxicities in man. In: Molyb
denum in the Environment. The Biology of
Molybdenum. (Chapell, W. R. & Peterson,
K. K., eds.), vol. I, pp. 267-286, Marcel
Dekker, New York.
516. Meyer, R. J. & Zalusky, R. (1977) The
mechanisms of hemolysis in Wilson's disease:
study of a case and review of the literature.
Mt. Sinai J. Med. 44, 530-538.
517. Miller, R. F. & Engel, R. W. (1960) In
terrelations of copper, molybdenum and sul
fate sulfur in nutrition. Federation Proc.
19, 666-677.
518. Mills, C. F. (1974) Trace-element inter
actions: effects of dietary composition on
the development of imbalance and toxicity.
In: Trace Element Metabolism in Animals—
2 (Hoekstra, W. G., Suttie, J. W., Ganther,
H. E. & Mertz, W., eds.), pp. 79-90, Uni
versity Park Press, Baltimore.
519. Mills, E. S. (1924) Hemochromatosis
with special reference to its frequency and
to its occurrence in women. Arch. Intern.
Med. 34, 292-300.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2055
520. Mills, E. S. (1930) The treatment of
idiopathic ( hypochromic ) anaemia with iron
and copper. Cañad. Med. Assn. J. 22, 175-
178.
521. Mills, E. S. (1931) Idiopathic hypochromemia.
Am. J. Med. Sci. 182, 554-565.
522. Mills, R. G. (1925) The possible rela
tion of copper to disease among the Korean
people. J. Am. Med. Assn. 84, 1326-1327.
523. Milne, D. B. & Matrone, G. (1970) Forms
of ceruloplasmin in developing piglets. Biochem.
Biophys. Acta 212, 43-49.
524. Mirzakarimov, M. G. (1957) Blood cop
per of women during pregnancy. Akusn.
Ginekol. 1, 55-85 (Russian).
525. Mischel, W. (1958) Die anorganischen
Bestandteile der Placenta. VII. Der Kupfer
genalt der reifen und unreifen, normalen
und pathologischen menschlichen Placenta.
Arch. Gynakol. 191, 1-7.
526. Mischel, W. (1960) Die anorganischen
Bestandteile des menschlichen Fruchtwassers.
Geburtsh. Frauenheilk. 20, 584-594.
527. Mischel, W. (1961) Ãœber das Verhalten
des Serumkupfers bei der Frau in der nor
malen und gestÃrten Schwangerschaft, im
Wochenbett, in der Nabelschnur sowie bei
verschiedenen gynäkologischen Erkrankun
gen. Ztschr. Geburtsch. Gyn. 155, 197-215.
528. Mitchell, H. H. & Hamilton, T. S. (1949)
The dermal excretion under controlled en
vironmental conditions of nitrogen and min
erals in human subjects, with particular
reference to calcium and iron. J. Biol. Chem.
178, 345-361.
529. Molin, L. & Wester, P. O. (1973) Cobalt,
copper and zinc in normal psoriatic epi
dermis. Acta Dermatol. Venereol. 53, 477-
480.
530. M011ekaer, A. M. (1974) Case report.
Kinky hair syndrome. Acta Paediat. Skand.
63, 289-296.
531. Molokhia, M. M. & Portnoy, B. (1970)
Neutron activation analysis of trace ele
ments in skin. V. Copper and zinc in psoria
sis. Br. J. Dermatol. 83, 376-381.
532. MÃnckeberg, F., Vildósola, J., Figueroa, M.,
Oxman, S. & Meneghello, J. (1962) Héma
tologie disturbances in infantile malnutrition.
Values for copper, iron, paraphenelene di
amine oxidase and iron-binding capacity in
the serum. Am. J. Clin. Nutr. 11, 525-529.
533. Mondorf, A. W., Mackenrodt, G. & Halber
stadt, E. (1971) Coeruloplasmin. Teil I:
Die Biochemie des Coeruloplasmins. Teil II:
Der Einfluss von Ãstrogenen auf den
Coeruloplasmingehalt des Serums. Klin.
Wochnschr. 49, 61-70.
534. Mondovi, B., Rotilio, G., Finazzi, A. &
Scioscia-Santoro, A. ( 1964 ) Purification
of pig-kidney diamine oxidase and its
identity with histaminase. Biochem. J. 91,
408-415.
535. Morell, A. G. & Scheinberg, I. H. (1960)
Heterogeneity of human ceruloplasmin. Sci
ence 131, 930-932.
536. Morell, A. G., Shapiro, J. R. & Scheinberg,
I. H. ( 1961 ) Copper binding protein from
human liver. In: Wilson's Disease, Some
Current Concepts. (Walshe, J. M. & Cumings,
J. N., eds.), p. 36-42, Blackwell, Ox
ford.
537. Morell, A. G., Van Den Hamer, C. I. A. &
Scheinberg, I. H. (1969) Physical and
chemical studies on ceruloplasmin. VI.
Preparation of human ceruloplasmin crys
tals. J. Biol. Chem. 244, 3494-3496.
538. Morrison, D. B. & Nash, T. P., Jr. (1930)
The copper content of infant livers. J. Biol.
Chem. 88, 479-483.
539. Mortazavi, S. H., Bani-Hashemi, A., Mozafari,
M. & Raffi, A. (1972) Value of
serum copper measurement in lymphomas
and several other malignancies. Cancer 29,
1193-1198.
540. Müller,A. H. (1935) Die Rolle des Kup
fers im Organismus mit besonderer Berück
sichtigung seiner Beziehungen zum Blut.
Ergebn. Inn. Med. 48, 444-469.
541. Munch-Petersen, S. (1950) On the copper
content of mother's milk before and after
542.
intravenous copper
Paediat. 39, 378^388.
Munch-Petersen, S.
administration.
(1950) On
Acta
serum
543.
copper in patients with pulmonary tuber
culosis. Acta Tuberc. Scand. 24, 132-153.
Murakami, Y. ( 1973 ) A study on the cop
per content in daily food consumption in
Japan. Osaka Shiritsu Daiagku Igaku Zasshi,
22, 13-48 (Japanese).
544. Murphy,
(1971)
lunches.
E. W., Page, L. & Watt, K. B.
Trace minerals in type A school
J. Am. Diet. Assn. 58, 115-122.
545. Murphy, E. W., Watt, B. K. & Page, L.
(1971) Regional variations in vitamin and
trace element content of type A school
lunches. In: Trace Substances in Environ
mental Health, IV. (Hemphill, D. D., ed.),
pp. 194-205, University of Missouri, Colum
bia.
546. Murthy, G. K. & Rhea, U. S. (1971) Cad
mium, copper, iron, lead, manganese, and
zinc in evaporated milk, infant products, and
human milk. J. Dairy Sci. 54, 1001-1005.
547. Murthy, G. K., Rhea, U. S. & Peeler, J. T.
( 1972 ) Copper, iron, manganese, strontium
and zinc content of market milk. J. Dairy
Sci. 55, 1666-1674.
548. Murthy, G. K., Rhea, U. S. & Peeler, T. T.
( 1973 ) Levels of copper, nickel, rubidium,
and strontium in institutional total diets.
Environ. Sci. Technol. 7, 1042-1045.
549. National Research Council ( 1974 ) Recom
mended Dietary Allowances, 8th rev. ed.,
128 pp., Food and Nutrition Board, National
Academy of Sciences, Washington, D.C.
550.
551.
National Research Council (1977) Cop
per. Committee on Medical and Biological
Effects of Environmental Pollutants, 115 pp.,
National Academy of Sciences, Washington,
D.C.
Neale, F. C. & Fischer-Williams, M. ( 1958)
Copper metabolism in normal adults and in
clinically
Wilson's disease.
normal
J.
relatives
Clin. Pathol.
of patients
11, 441with
447.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2056 KARL E. MASON
552. Neri, A., Eckerling, B. & Bahary, C. (1969)
The copper and copperoxidase content of
maternal and infant umbilical arterial and
venous blood serum at delivery. Gynaecologia
138, 40-48.
553. Neumann, P. Z. & Sass-Kortsak, A. (1963)
Binding of copper by serum proteins. Vox
Sang. 8, 111-112.
554. Neumann, P. Z. & Sass-Kortsak, A. (1967)
The state of copper in human serum: Evi
dence for an amino acid-bound fraction. J.
Clin. Invest. 46, 646-658.
555. Neumann, P. Z. & Silverberg, M. (1967)
Metabolic pathways of red blood cell cop
per in normal humans and in Wilson's dis
ease. Nature 213, 775-779.
556. Neuweiler, W. (1942) Ãœber die fetale
Resorption von Kupfer aus der Placenta.
Klin. Wochenschr. 21, 521-522.
557. Nicholas, P. O. (1968) Food-poisoning
due to copper in the morning tea. Lancet 2,
40-42.
558. Niedermeier, W., Creitz, E. E. & Holley, H.
L. ( 1962 ) Trace metal composition of
synovial fluid from patients with rheuma
toid arthritis. Arthr. Rheum. 5, 439-444.
559. Niedermeier, W. & Griggs, J. H. (1971)
Trace metal composition of synovial fluid
and blood serum of patients with rheuma
toid arthritis. J. Chron. Dis. 23, 527-536.
560. Nimni, M. E. & Bavetta, L. A. (1965)
Collagen defect induced by pencillamine.
Science 150, 905-907.
560. Nielsen, A. L. (1944) On serum copper.
IV. Pregnancy and parturition. Acta Med.
Scand. 118, 92-96.
562. Nordberg, G. F., Nordberg, M., Piscator, M.
& Vesterberg, O. (1972) Separation of
two forms of rabbit metallothionein by isoelectric
focusing. Biochem. J. 126, 491-498.
563. Norstrand, I. F. & Glantz, M. D. (1973)
Purification and properties of human liver
monoamine oxidase. Arch. Bioch. Biophys.
158, 1-11.
564. Nusbaum, M. J. & Zettner, A. (1973) The
content of calcium, magnesium, copper,
iron, sodium, and potassium in amniotic
fluid from eleven to nineteen weeks' gesta
tion. Am. J. Obstet. Gynecol. 115, 219-226.
565. Nusbaum, R. E., Alexander, G. V., Butt,
E. M., Gilmour, T. C. & Oidio, S. L. ( 1958)
Some spectrographic studies of trace ele
ment storage in human tissues. Soil Sci. 85,
95-99.
566. Oakes, B. W., Danks, D. M. & Campbell, P.
E. (1976) Human copper deficiency:
ultrastructural studies of the aorta and skin
in a child with Menkes' syndrome. Exp.
Mol. Pathol. 25, 82-98.
567. O'Brien, J. S. & Sampson, E. L. (1966)
Kinky hair disease. II. Biochemical studies.
J. Neuropath. Exp. Neurol. 25, 523-530.
568. O'Dell, B. L. (1976) Biochemistry of
copper. Med. Clin. N. Am. 60, 687-703.
569. O'Dell, B. L. (1976) Biochemistry and
physiology of copper in vertebrates. In:
Trace Elements in Human Health and Dis
ease (Prasad, A. S. & Oberleas, D., eds.),
vol. 1, pp. 391-413, Academic Press. New
York.
570. O'Dell, B. L. (1976) Copper. In: Nutri
tion Reviews. Present Knowledge in Nu
trition, 4th éd.,pp. 302-309, The Nutrition
Foundation, New York.
571. O'Dell, B. L., Hardwick, B. C., Reynolds,
G. & Savage, J. E. (1961) Connective tis
sue defect in the chick resulting from copper
deficiency. Proc. Soc. Exp. Biol. Med. 108,
402-405.
572. Ohlson, M. A. & Daum, K. (1935) A
study of the iron metabolism of normal
women. J. Nutr. 9, 75-89.
573. Ohtake, M. & Tamura, T. (1976) Serum
zinc and copper levels in healthy Japanese
children. Tohoku J. Exp. Med. 120, 99-103.
574. Olatunbosun, D. A., Adadevoh, B. K. &
Adeniyi, F. A. ( 1974 ) Serum copper in
normal pregnancy in Nigerians. J. Obst.
Gynaecol. Br. Commonw. 81, 475-478.
575. Olatunbosun, D. A., Akindele, M. O., Ada
devoh, B. K. & Asuni, T. ( 1975 ) Serum
copper in schizophrenia in Nigerians. Br. J.
Psychiat. 127, 119-121.
576. Olatunbosun, D. A., Isaacs-Sodeye, W. A.,
Adeniyi, F. A. & Adadeovh, B. K. (1975)
Serum-copper in sickle-cell anaemia. Lancet
1, 285-286.
577. O'Leary, J. A. (1969) Serum copper
levels as a measure of placental function.
Am. J. Obstet. Gynecol. 105, 636-637.
578. O'Leary, J. A., Novalis, G. S. & Vosburgh,
G. J. (1966) Maternal serum copper con
centrations in normal and abnormal gesta
tions. Obstet. Gynecol. 28, 112-117.
579. O'Leary, J. A. & Spellacy, W. N. (1969)
Zinc and copper levels in pregnant women
and those taking oral contraceptives. Am. J.
Obstet. Gynecol. 103, 131-132.
580. O'Reilly, S., Strickland, G. T., Weber, P. M.,
Beckner, W. M. & Shipley, L. (1971) Ab
normalities of the physiology of copper in
Wilson's disease. I. The whole body turn
over of copper. Arch.' Neurol. 24, 385-390.
581. O'Reilly, S., Weber, P. M., Oswald, M. &
Shipley, L. (1971) Abnormalities of the
physiology of copper in Wilson's disease.
III. The excretion of copper. Arch. Neurol.
25, 28-32.
582. Osaka, K., Sato, N., Matsumoto, S., Ogino,
H., Kodama, S., Yokoyama, S. & Sugiyama,
T. ( 1977 ) Congenital hypocupraemia syn
drome with and without steely hair: Report
of two Japanese infants. Develop. Med.
Child. Neurol. 19, 62-68.
583. Osaki, S., Johnson, D. A. & Frieden, E.
( 1966) The possible significance of the fer
rous oxidase activity of ceruloplasmin in
normal human serum. J. Biol. Chem. 241,
2746-2751.
584. Osaki, S., Johnson, D. A. & Frieden, E.
(1971) The mobilization of iron from the
perfused mammalian liver by a serum cop
per enzyme, ferroxidase I. J. Biol. Chem.
246, 3018-3023.
585. Osaki, S., McDermott, J. A. & Frieden, E.
( 1964 ) Proof for the ascorbate activity of
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2057
ceruloplasmin. J. Biol. Chem. 239, 3570-
3575.
586. Oshima, F. & SchÃnheimer, R. (1929)
Ãœber den Kupfergehalt der normalen Leber
und der Leber bein Hämochromatose, sowie
von Gallensteinen und Gesamptblut. Ztschr.
Physiol. Chem. 180, 254-258.
587. Oshima, F. & Siebert, P. (1930) Experi
mentelle chronische Kupfergiftung, ein
Beitrag zur Frage der Pathogenese der
Hämochromatose. Beitrag. Path. Anat. Pathol.
84, 106-111.
588. Oski, F. A. (1970) Chickee, the copper.
Ann. Int. Med. 73, 485-486.
589. Oster, G. & Salgo, M. P. (1977) Copper
in mammalian reproduction. Adv. Pharmacol.
Chemotherapy 14, 327-409.
590. Ota, D. M., Macfadyen, B. V. Jr., Gum, E.
T. & Dudrick, S. J. (1978) Zinc and cop
per deficiencies in man during intravenous
hyperalimentation. In: Zinc and Copper in
Clinical Medicine, ( Hambidge, K. M. &
Nichols, B. L., eds.), pp. 99-112, Spectrum,
New York.
591. Page, G. G. (1973) Contamination of
drinking water by corrosion of copper tubes.
N.Z.J. Sci. 16, 349-388.
592. Pagliardi, E., Giangrandi, E. & Vinti, A.
(1958) Erythrocyte copper in iron defi
ciency anemia. Acta Hematol. 19, 231-240.
593. Panvalkar, R. S., Kalgi, V. H. & Registe, M.
D. ( 1961 ) Serum copper level in normal
human subjects and in tuberculosis. Prelimi
nary report. Indian J. Med. Sci. 15, 456-
459.
594. Partridge, S. M., Elsden, D. F., Thomas, J.,
Dorfman, A., Telser, A. & Ho, P-L. ( 1964)
Biosynthesis of the elemosine and isodesmonsine
cross-bridges in elastin. Biochem. J.
93, 30c.
595. Pennington, J. T. & Calloway, D. H. (1974)
Copper content of foods. J. Am. Diet. Assn.
63, 143-153.
596. Pfeiffer, C. C. & Cott, A. (1974) A study
of zinc and manganese dietary supplements
in the copper loaded schizophrenic. In:
Clinical Applications of Zinc Metabolism
(Pories, J., Strain, W. H., Hsu, J. M. &
R. L. Woosley, eds.), pp. 260-278, Thomas,
Springfield, Illinois.
597. Pfeiffer, C. C. & Hiev, V. (1972) A study
of zinc deficiency and copper excess in the
schrizophrenias. Internat. Rev. Neurobiol.
1 (Suppl), 141-165.
598. Picciano, M. F. & Guthrie, H. A. (1976)
Copper, iron and zinc contents of mature
human milk. Am. J. Clin. Nutr. 29, 242-254.
599. Pimentel, J. C. & Menezes, A. P. (1977)
Liver disease in vineyard sprayers. Gastroenterology
72, 275-283.
600. Pineda, E. P., Ravin, H. A. & Rutenberg,
A. M. (1962) Serum ceruloplasmin: ob
servations in patients with cancer, obstruc
tive jaundice, and other diseases. Gastroenterology
43, 266-270.
601'. Pinnell, S. R. & Martin, G. R. (1968) The
cross-linking of collagen and elastin: enzy
matic conversion of lysine in peptide link
age to a-amino-adipic-a-semialdenyde (allysine)
by an extract from bone. Proc. Nat.
Acad. Sci. U.S.A. 61, 708-716.
602. Pirrie, R. ( 1952 ) Serum copper and its
relationship to serum iron in patients with
neoplastic disease. J. Clin. Pathol. 5, 190-
193.
603. Pitt, M. A. (1976) Molybdenum toxicity:
interactions between copper, molybdenum
and sulphate. Agents Actions 6, 758-769.
604. Plantin, L. O. & Standberg, P. O. (1965)
Whole-blood concentrations of copper and
zinc in rheumatoid arthritis studied by acti
vation analysis. Acta Rheum. Scand. 11, 30-
34.
605. Poczekaj, J., Hejduk, J. & Chodera, A.
(1963) Behaviour of copper in trophoblast
and in placenta at term. Gynaecologia 155,
155-159.
606. Pojerová, A. & Továrek, J. (1960) Cerulo
plasmin in early childhood. Acta Paediat. 49,
113-120.
607. Poison, C. J. (1929) Chronic copper
poisoning. Br. J. Exp. Pathol. 10, 241-245.
608. Porter, H. (1949) Amino acid excretion in
degenerative diseases of the nervous system.
J. Lab. Clin. Med. 34, 1623-1626.
609. Porter, H. (1951) Copper excretion in the
urine of normal individuals and of patients
with hepatolenticular degeneration (Wilson's
disease). Arch. Biochem. Biophys. 31, 262-
265.
610. Porter, H. (1966) The tissue copper pro
teins: cerebrocuprein, erythrocuprein, hepatocuprein,
and neonatal hepatic mitochondrocuprein.
In: The Biochemistry of Copper,
(Peisach, ]., Aisen, P. & Blumberg, W. E.,
eds.), pp. 159-174, Academic Press, New
York.
611. Porter, H. (1974) The particulate halfcystine-rich
copper protein of newborn liver.
Relationship to metallothionein and subcellu
lar localization in non-mitochondrial particles
possibly representing heavy lysosomes. Bio
chem. Biophys. Res. Comm. 56, 661-668.
612. Porter, H. & Ainsworth, S. (1959) The
isolation of the copper-containing protein
cerebrocuprein I from normal human brain.
J. Neurochem. 5, 91-98.
613. Porter, H. & Folch, J. (1957) Brain copperprotein
fractions in the normal and in Wil
son's disease. A.M.A. Arch. Neurol. Psychiat.
77, 8-16.
614. Porter, H. & Hills, J. R. (1974) The halfcystine-rich
copper protein of newborn liver
probable relationship to metallothionein and
subcellular localization in non-mitochondrial
particles possibly representing heavy lyso
somes. In: Trace Element Metabolism in
Animals—2 ( Hoekstra, W. G., Suttie, J. W.,
Ganther, H. E. & Mertz, W., eds.), pp. 482-
485, University Park Press, Baltimore.
615. Porter, H., Sweeney, M. & Porter, E. M.
( 1964 ) Neonatal hepatic mitochondrocuprein.
II. Isolation of the copper-containing
subfraction from mitochondria of newborn
human liver. Arch. Biochem. Biophys. 104,
97-101.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2058 KARL E. MASON
616. Porter, H., Sweeney, M. & Porter, E. M.
( 1964 ) Human hepatocuprein. Isolation of
a copper protein from the subcellular soluble
fraction of adult human liver. Arch. Biochem.
Biophys. 105, 319-325.
617. Price, N. O. & Bunce, G. E. (1972) Ef
fect of nitrogen and calcium on balance
of copper, manganese, and zinc in pré
adolescent girls. Nutr. Rep. Internat. 5, 275-
280.
618. Price, N. O., Bunce, G. E. & Engel, R. W.
( 1970 ) Copper, manganese, ana zinc bal
ance in préadolescent girls. Am. J. Clin.
Nutr. 23, 258-260.
619. Priev, I. G. (1966) Daily copper require
ments of children and adults. Vopr. Pitan.
25 (3), 61-63 (Russian).
620. Priev, I. G. & Krasny, B. A. ( 1966) Cop
per and iron content in the ready-to-eat
dishes at children's institutions and in nu
tritional treatment dishes of some in-patient
departments of the city of Samarkand. Vop.
Pitan. 25, (5), 22-26 (Russian).
621. Prohaska, J. R. & Wells, W. W. (1974)
Copper
brain: a
deficiency
possible model
in the
for Menkes'
developing
steely-
rat
hair disease. J. Neurochem. 23, 91-98.
622. Pshetakovsky, I. L. (1972) Clinical value
of studying trace elements (Cu, Ni, Mn)
and their pathogenetic role in rheumatoid
arthritis. Terapeut. Arkhiv (Moscow) 44,
(6), 23-27 (Russian).
623. Pshetakovsky, I. L. (1973) Pathogenetic
role of trace elements (Cu, Ni, Mn) and
their diagnostic value in ankylosing spondyloarthritis
(Bechterew's disease). Vop.
Rheum. 13 (2), 17-20 (Russian).
624. Purpura, D. P., Hirano, A. & French, J. H.
(1976) Polydendritic Purkinge cells in
X-chromosome linked copper malabsorption:
a Golgi study. Brain Res. 117, 125-129.
625. Ragan, H. A., Nacht, S., Lee, G. R., Bishop,
C. R. & Caitwright, G. E. (1969) Effect
of ceruloplasmin on plasma iron in copperdeficient
swine. Am. J. Physiol. 217, 1320-
1323.
626. Rainsford, K. D. & Whitehouse, M. W.
(1976) Concerning the merits of copper
aspirin as a potential anti-inflammatory drug.
J. Pharm. Pharmacol. 28, 83-86.
627. Ramage, H., Sheldon, J. H. & Sheldon, W.
( 1933 ) A spectrographic investigation of
the metallic content of the liver in child
hood. Proc. Roy. Soc. London, Series B, 113,
308-327.
628. Rasuli, Z. M. (1963) Copper metabolism
in toxemia of late pregnancy. Akush. Ginek
39, 63-66 (Russian).
629. Ravin, H. A. (1961) An improved colonmetric
enzymatic assay of ceruloplasmin. J.
Lab. Clin. Med. 58, 161-168.
630. Rechenberger, J. (1957) Serumeisen und
Serumlcupfer bei akuten und chromischen
Leukämien sowie bei Morbus Hodgkin.
Deut. Ztschr. Verdann. Stoffwech. 17, 78-
85.
631. Reed, D. W., Passon, P. G. & Hultquist, D.
E. (1970) Purification and properties of a
pink copper protein from human erythrocytes.
J. Biol. Chem. 245, 2954-2961.
632. Reiff, B. & Schnieden, H. (1959) Plasma
copper and iron levels and plasma paraphenylene
diamine oxidase activity (plasma
copper oxidase activity) in kwashiorkor.
Blood 14, 967-971.
633. Reilly, C. (1972) Zinc, iron and copper
contamination in home-produced alcoholic
drinks. J. Sci. Food Agrie. 23, 1143-1144.
634. Reinhold, J. G. (1975) Trace elements:
a Selective Survey. Clin. Chem. 21, 476-
500.
635. Reske-Nielsen, E., Lou, H. O. C., Anderson,
P. & Vagn-Hansen, P. (1973) Braincopper
concentration in Menkes' disease.
Lancet 1, 613.
636. Rice, E. W. (1960) Correlation between
serum copper, ceruloplasmin activity and
C-reactive protein. Clin. Chim. Acta 5, 632-
636.
637. Rice, E. W. (1961) Evaluation of the
role of ceruloplasmin as an acute-phase reactant.
Clin. Chim. Acta 6, 652-655.
638. Richterich, R., Rossi, E., Stillhart, H. &
Gautier, H. (1961) The heterogeneity of
caeruloplasmin in the newborn. In: Wilson's
Disease. Some Current Concepts (Walshe,
J. M. & Cummings, J. N., eds.), pp. 81-
95, Blackwell Sci. Pub., Oxford.
639. Ricour, C., Dunhamel, J. F., Gross, J.,
Mazihère, B. & Comar,
éléments chez l'enfant
D.
en
(1977)
nutrition
Oligoparenterale
Arch.
exclusive: estimation des besoins.
Franc. Pediat. 34, (Suppl. 7), xcii-c.
640. Ritland,
Hepatic
cretion,
disease.
S., Steinnes, E. & Skrede, S. (1977)
copper content, urinary copper ex
and serum ceruloplasmin in liver
Scand. J. Gastroent. 12, 81-88.
641. Roberts, R. H. (1956) Hemolytic anemia
associated with copper sulfate poisoning.
Mississippi Doctor 33, 292-294.
642. Robinson, M. F., McKenzie, J. M., Thom
son, C. D. & van Rij, A. L. (1973) Meta
bolic balance of zinc, copper, cadmium, iron,
molybdenum and selenium in young New
Zealand women. Br. J. Nutr. 30, 195-205.
643. Roche-Sicot, J. & Benhamou, J. P. (1977)
Acute intravascular hemolysis and acute liver
failure
Wilson's
associated
disease. Ann.
as a
Intern.
first manifestation
Med. 86, 301of
303.
644. Rosenberg, E. B., Strickland, G. T., Feng,
Y. S. & Blackwell, R. Q. (1971) Compari
son
for
of
ceruloplasmin
immunologie
quantitation
and enzymatic
in
methods
Wilson's
disease. J. Formosan Med. Assn. 70, 49-53.
645. Rohmer, A., Krug, J. P., Mennesson, M.,
Mandel, P., Mack, G. & Zawislak, R. (1977)
Maladie de Menkes: Etude de deux enzymes
cupro-dependantes. Pediatrie 32, 447-456.
646. Rosenthal, R. W. & Blackburn, A. (1974)
Higher copper concentrations in serum than
in plasma. Clin. Chem. 20, 1233-1234.
647. Rottger, H. ( 1950 ) Kupfer bei Mutter und
Kind. Arch. Gynakol. 177, 650-660.
648. Rowe, D. W., McGoodwin, E. B., Martin,
G. R., Sussman, M. D., Grahn, D., Paris, B.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2059
& Franzblau, C. (1974) A sex-linked de
fect in the cross-linking of collagen and
elastin associated with the mottled
mice. J. Exp. Med. 139, 180-192.
648a. Rucker, R. B. & Murray, J. (1978)
locus in
Crosslinking
amino acids in collagen and
Am. J. Clin. Nutr. 31, 1221-1236.
649. Rucker, R. B. & O'Dell, B. L.
elastin.
(1971)
Connective tissue amine oxidase. I. Purifica
tion of bovine aorta amine oxidase and its
comparison with plasma amine oxidase. Biochem.
Biophys. Acta 235, 32-43.
650. Rucker,
elastin.
R. B. & Tom, K.
Am. J. Clin. Nutr.
(1976) Arterial
29, 1021-1034.
651. RUSS, E. M. & Raymunt, J. (1956) In
fluence of estrogens on total serum copper
and caeruloplasmin. Proc. Soc. Exp. Biol.
Med. 92, 465-466.
652. Russ, E. M., Raymunt, J. & Pillar, S. (1957)
Effect
concentration
of estrogen
in a man
therapy
with
on
Wilson's
ceruloplasmin
disease.
J. Clin. Endocrinol. & Metab. 17, 908-909.
653. RydénL. & BjÃrk,I. (1976) Reinvestiga
tion of some physico-chemical and chemical
properties of human ceruloplasmin (ferroxidase).
Biochem. 15, 3411-3417.
654. Rydén,L. & Deutsch,
ration and properties
H. F. (1978)
of the major
Prepa
copperbinding
component in human fetal
identification as metallothionein.
Chem. 253, 519-524.
liver. Its
J. Biol.
655. Sachs, A., Levine, V. E. & Fabian,
( 1935 ) Copper and iron in human
Arch. Intern. Med. 55, 227-253.
A. A.
blood.
656. Sachs, A., Levine, V. E. & Fabian, A. A.
(1936) Copper and iron in human blood.
IV. Normal children. Arch. Intern. Med. 58,
523-530.
657. Sachs, A., Levine, V. E., Hill, F. C. &
Hughes, R. ( 1943 ) Copper and iron in
human blood. Arch. Intern. Med. 71, 489-
501.
658. Sakar, B. & Knick, T. P. A. (1966)
per-am ino acid complexes in human
Cop
serum.
In: Biochemistry of Copper (Peisach, J.,
Aison, P. & Blumberg, W. E., eds.), pp.
183-196, Academic Press, New York.
659. Sakharchuk, V. M., Yatsula, G. S. & Rakitskaya,
N. V. ( 1972 ) Clínico-experimental
studies of the content of some trace elements
in atherosclerosis. Kardiologiya 12 (1), 131-
133 (Russian).
660. Sala, I. & Cambara, L. (1957) Contenuto
in rame e attività ossidasica del plasma ma
terno e funiculare. Lattante 28, 458-470.
661. Salaspuro, M.
Demonstration
P.
of
& Sipponen, P.
an intracellular
(1976)
copperbinding
standing
787-790.
protein by
cholestatic
orcein staining
liver diseases.
in long
Gut 17,
662. Salmon,
Chronic
disease.
M. A. & Wright, T. (1971)
copper poisoning presenting as pink
Arch. Dis. Child. 46, 108-110.
663. Sandstead, H. H. (1975) Some trace ele
ments which are essential for human nutri
tion: zinc, copper, manganese and chromium.
Prog. Food Nutr. Sei. l, 371-391.
664. Sandstead, H. H., Shukry,
A. S., Gabr, M. K., Hifney,
A. S., Prasad,
A. E., Mokhtar,
N. & Darby, W. J. (1965) Kwashiorkor
in Egypt. I. Clinical and biochemical studies,
with special reference to plasma zinc and
serum lactic dehydrogenase. Am. I. Clin.
Nutr. 17, 15-26.
665. Sarzeau, A. (1830) Sur la présencedu
cuivre dans les végétaux et dans le sang. J.
Pharm. Sci. Accessoires 16, 505-518.
666. Sass-Kortsak, A. (1965) Copper metab
olism. Adv. Clin. Chem. 8, 1-67.
667. Sass-Kortsak, A. (1975) Wilson's disease.
A treatable liver disease in children.
Clin. North. Amer. 22. 963-984.
668. Sass-Kortsak, A. & Bern, A. G.
Pediat.
(1978)
Hereditary
[Wilson's disease
disorder
( hepatolenticular
of copper metabolism.
degen
eration) and Menkes' disease (kinky-hair or
steely-hair syndrome)]. In: The Metabolic
Basis of Inherited Disease (Standbury,
Wyngaarden, J. B. & Fredrickson,
eds.), pp. 1098-1126, McGraw-Hill,
York.
J. B.,
D. S.,
New
669. Sato, F., Shimura, Y.,
M.,
( 1975
Takita,
) Menkes'
S., Yabuta,
kinky
Yokota, J., Suzuki,
K.
hair
&
disease.
Fukuyama,
A re
Y.
port of the first Japanese case and review of
literature. No To Hattatsu (Brain & De
velop.) 7, 132-145.
670. Scanni, A., Licciardello, L., Trovato, M.,
Tomirotti, M. & Biraghi, M. (1977) Serum
copper and ceruloplasmin levels in patients
with neoplasias localized in the stomach,
large intestine or lung. Tumori 6*3, 175-180.
671. Scheinberg, I. H.
A review. In: The
(Peisach, J., Aisen,
eds.), pp. 513-524,
York.
(1966) Ceruloplasmin.
Biochemistry of Copper
P. & Blumberg, W. E.,
Academic Press, New
672. Scheinberg, I. H. (1976) The effects of
heredity and environment on copper metab
olism. Med. Clin. N. Amer. 60, 705-712.
673. Scheinberg, I. H., Cook, C. D. & Murphy,
J. A. (1954) The concentration of copper
and ceruloplasmin in maternal and infant
plasma at delivery. J. Clin. Invest. 33, 963.
674. Scheinberg, I. H. & Gitlin, D.
ficiency of ceruloplasmin in
hepatolenticular degeneration
(1952)
patients
(Wilson's
De
with
dis
ease). Science 116, 484-485.
675. Scheinberg, I. H., Harris, R. S., Morell, A.
G. & Dubin, D. (1958) Some aspects of
the relation of ceruloplasmin to Wilson's dis
ease. Neurol. 8 (Suppl. 1), 44-51.
676. Scheinberg, I. H. & Morell, H. G.
Ceruloplasmin. Inorganic Biochem.
319.
(1973)
1, 306-
677. Scheinberg, I. H., Morell, A. G., Harris,
R. S. & Berger, A. (1957) Concentration
of ceruloplasmin in plasma of schizophrenic
patients. Science 126, 925-926.
678. Scheinberg, I. H. & Stemlieb, I. (1959)
The liver in Wilson's disaese. Gastroenterology
37, 550-564.
679. Scheinberg, I. H. & Sternlieb, I. (1960)
Copper metabolism. Pharmacol. Rev. 12,
355-381.
680. Scheinberg, I. H. & Stemlieb, I. (1960)
The long term management of hepatolen-
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2060 KARL E. MASON
ticular degeneration (Wilson's disease). Am.
J. Med. 29, 316-333.
681. Scheinberg, I. H. & Stemlieb, I. (1960)
Environmental
illness: Wilson's
treatment
disease. Ann.
of a
Intern.
hereditary
Med.
53, 1151-1161.
682. Scheinberg, I. H. & Stemlieb, I. (1960)
The pathogenesis and clinical significance of
the liver disease in hepatolenticular degen
eration (Wilson's disease). Med. Clin. N.
Amer. 44, 665-679.
683.
The
Scheinberg,
dual role
I.
of
H.
the
&
liver
Stemlieb,
in Wilson's
I.
Med. Clin. N. Amer. 47, 815-824.
disease.
(1963)
684. Scheinberg, I. H. & Stemlieb, I. (1975)
Wilson's disease. In: Biology of Brain Dys
function (Cauli, C. E., ed.) vol. 3, p. 247-
264, Plenum, Pub., New York.
685.
Copper
Scheinberg,
toxicity
I. H.
and
& Stemlieb,
Wilson's disease.
I. (1976)
In:
Trace Elements in Human Health and Dis
ease (Prasad, A. S. & Oberleas, D., eds.),
vol. I, pp. 415-438, Academic Press, New
York.
686. Schenker, J. G., Jungreis, E. & Polishuk, W.
Z. ( 1969) Serum copper levels in normal
and pathological pregnancies. Am. J. Obst.
Gynecol. 105, 933-937.
687. Schenker, J. G., Jungreis, E. & Polishuk, W.
Z. (1972) Maternal and fetal serum cop
per levels at delivery. Biol. Neonate. 20,
189-195.
688. Schlettwein-Gsell, D. & Seiler, H. (1972)
Analysen und Berechnungen des Gehalts
der Nahrung an Kalium, Natrium, Calcium,
Eisen, Magnesium, Kupfer, Zink, Nickel,
Cobalt, Chrom, Mangan und Vanadium in
Altersheimen und Familien. Mitteil Gebiete
Lebensmittel. Hyg. 63, 188-206.
689. Schonheimer, R. & Herkel, W. (1931)
Ãœber das Vorkommen von Schwermetallen
in menschlichen Gallensteinen. Klin. Wchnschr.
10, 345-346.
690. Schorr, J. B., Morell, A. G. & Scheinberg, I.
H. ( 1958 ) Studies of serum ceruloplasmin
during
96, 541.
early infancy. Am. J. Dis. Child.
691. Schroeder, H. A., Nason, A. P., Tipton, I.
H. & Salassa, J. J. (1966) Essential trace
metals in man: Copper. J. Chron. Dis. 19,
1007-1034.
692. Schubert, W.
Copper and
ing hypoferric
24, 710-733.
K. & Lahey, M. E. (1959)
protein depletion complicat
anemia of infancy. Pediatrics
693. Schultze,
and blood
M. (1940) Metallic elements
formation. Physiol. Rev. 20, 37-
67.
694. Schutz, G. & Feigelson, P. (1972) Puri
fication and properties of rat liver tryptophan
oxygenase. J. Biol. Chem. 247, 5327-5332.
695. Scoular, F. I. (1938) A quantitative
study, by means of spectrographic analysis,
of copper in nutrition. J. Nutr. 16, 437-450.
696. Scudder,
(1976)
P., Stocks, J. & Dormandy, T. L.
The relationship between erythrocyte
Superoxide
erythrocyte copper
dismutase activity and
levels in normal subjects
and in patients with rheumatoid arthritis.
Clin. Chim. Acta 69, 397-403.
697. Seelenfreund, M. H., Gartner, S. & Vinger,
P. F. ;(1968) The ocular pathology of
Menkes' disease (kinky hair disease). Arch.
Opthalm. SO, 718-720.
698. Seelig, M. S. (1972) Review: relation
ships of copper and molybdenum to iron
metabolism. Am. J. Clin. Nutr. 25, 1022-
1037.
699. Seelig, M. S. (1973) Proposed role of
copper-molybdenum interaction in irondeficiency
anemia and iron-storage diseases.
Am. J. Clin. Nutr. 26, 657-672.
700. Seely, J. R., Humphrey, G. B. & Matter, B.
J. (1972) Copper deficiency in a prema
ture infant fed an iron-fortified formula. New
Engl. J. Med. 286, 109-110.
701. Semple, A. B., Parry, W. H. & Phillips, D.
E. (1960) Acute copper poisoning. An
outbreak traced to contaminated water from
corroded geyser. Lancet 2, 700-701.
702. Shahidi, N. T., Diamond, L. K. & Schwachman,
H. ( 1961 ) Anemia associated with
protein deficiency. A study of two cases
with cystic fibrosis. J. Pediat. 59, 533-542.
703. Shapiro, J., Morell, A. G. & Scheinberg, I.
H. ( 1961 ) A copper-protein of human
liver. J. Clin. Invest. 40, 1081.
704. Shaw, J. C. L. (1973) Parenteral nutri
tion in the management of sick low birth
rate infants. Pédiatrie Clin. N. Amer. 20,
333-358.
705. Sheldon, J. H. & Ramage, H. (1931) A
spectrographic analysis of human tissues. J.
Biochem. 25, 1608-1627.
706. Sherwin, A. L., Beck, I. T. & McKenna, R.
D. (1960) The cause of Wilson's disease
(hepatolenticular degeneration) during preg
nancy and after delivery. Cañad.Med. Assn.
J. 83, 160-163.
707. Shields, G. S., Coulson, W. F., Kimball, D.
A., Carnes, W. H., Cartwright, G. E. &
Wintrobe, M. M. (1962) Studies on cop
per metabolism. XXXII. Cardiovascular
lesions in copper-deficient swine. Am. J.
Pathol. 41, 603-621.
708. Shields, G. S., Markowitz, H., Klassen, W.
H., Cartwright, G. E. & Wintrobe, M. M.
( 1961 ) Studies on copper metabolism.
XXXI. Erythrocyte copper. J. Clin. Invest.
40, 2007-2015.
709. Shils, M. E. (1972) Guide lines for total
parenteral nutrition. J. Am. Med. Assn. 220,
1721-1729.
710. Shils, M. E. (1972) Minerals in total
parenteral nutrition. Drug Intel. Clin. Pharm.
6, 385-393.
711. Shils, M. E. (1975) A program for total
parenteral nutrition at home. Am. J. Clin.
Nutr. 28, 1429-1435.
712. Shils, M. E., Wright, W. L., Turnbull, A. &
Brescia, F. ( 1970 ) Long-term parenteral
nutrition through an external arteriovenous
shunt. Report of a case. N. Engl. J. Med.
283, 341-344.
713. Shinomiya, N., Yasuda, T., Arimura, A.,
Aoki, T., Haraoka, K., Niwa, N. & Matsu-
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2061
shima, Y. (1977) Menkes' kinky hair dis
ease—two cases report. No To Shinkei
(Brain & Nerve) 29, 331-339.
714. Shokeir, M. H. K. (1971) Investigations
in the nature of ceruloplasmin deficiency in
the newborn. J. Clin. Genet. 2, 223-227.
715. Shokeir, M. H. K. k Schreffler, D. C.
( 1969 ) Cytochrome oxidase deficiency in
Wilson's disease: A suggested ceruloplas
min function. Proc. Nat. Acad. Sci. U.S.A.
62, 867-872.
716. Siegel, R. C., Pinnell, S. R. & Martin, G. R.
(1970) Cross-linking of collagen and
elastin. Properties of lysyl oxidase. Biochem
istry 9, 4486-4492.
717. Singh, S. & Bresnan, M. J. (1973) Menkes'
kinky-hair syndrome ( trichopoliodystrophy ).
Low copper levels in the blood, hair, and
urine. Am. J. Dis. Child 125, 572-578.
718. Sinha, S. N. & Gabrieli, E. R. (1970)
Serum copper and zinc levels in various
pathologic conditions. Am. J. Clin. Pathol.
54, 570-577.
719. Sipponen, P. (1976) Orcein positive hepatocellular
material in long-standing biliary
diseases. I. Histochemical characteristics. II.
Ultrastructural studies. Scand J. Gastroent.
11, 553-557.
720. Sipponen, P., Hjelt, L., TÃrnkvist, T. &
Salaspuro, M. (1976) X-ray microanalysis
of copper accumulation in liver in secondary
biliary cirrhosis. Arch. Pathol. 100, 664-666.
721. Smallwood, R. A., Mcllveen, G., Rosenoer,
V. M. & Sherlock, S. (1971) Copper
kinetics in liver disease. Gut 12, 139-144.
722. Smallwood, R. A., Williams, H. A., Rosenoer,
V. M. & Sherlock, S. (1968) Liver-copper
levels in liver disease. Studies using neutron
activation analysis. Lancet 2, 1310-1313.
723. Smith, J. C., Jr. & Brown, E. D. (1976)
Effects of oral contraceptive agents on trace
element metabolism: a review. In: Trace
Elements in Human Health and Disease
(Prasad, A. S. & Oberleas, D., eds.), vol. II,
pp. 315-345, Academic Press, New York.
724. Solassol, CL, Joyeux, H., Etco, L., Pujol, H.
& Romieu, Cl. ( 1974 ) New techniques
for long-term intravenous feeding: an arti
ficial gut in 75 patients. Ann. Surg. 179,
519—522
725. S01i, N. E. & Nafstad, I. (1976) Chronic
copper poisoning in sheep. Structural
changes in erythrocytes and organs. Acta
Vet. Scand. 17, 316-327.
726. Solomons, N. W., Layden, T. J., Rosenberg,
I. H., Vo-Khactu, K. & Sandstead, H. H.
(1976) Plasma trace metals during total
parenteral alimentation. Gastroenterology 70,
1022-1025.
727. Soman, S. D., Panday, V. K., Joseph, K. T.
& Raut, S. J. (1969) Daily intake of
some major and trace elements. Health
Physics 17, 35-40.
728. Sorenson, J. R. J. (1976) Copper chelates
as possible active forms of the antiarthritic
agents. J. Med. Chem. 19, 135-148.
729. Sorensen, J. R. J. (1977) Evaluation of
copper complexes as potential anti-arthritic
drugs. J. Pharm. Pharmacol. 29, 450-452.
730. Sourkes, T. L. (1972) Influence of spe
cific nutrients on catecholamine synthesis
and metabolism. Pharmacol. Rev. 24, 349-
359.
731. Spillane, J. D., Keyser, J. W. & Parker, R. A.
( 1952 ) Amino-aciduria and copper metab
olism in hepatolenticular degeneration. J.
Clin. Pathol. 5, 16-24.
732. Stanley, P., Gwinn, J. L. & Sutcliffe, J.
Menkes'
(1976)
syndrome.
The osseous
Ann. Radiol.
abnormalities
19, 167in
172.
733. Starcher, B. C. (1969) Studies on the
mechanism of copper absorption in the chick.
J. Nutr. 97, 321-326.
734. Starcher, B., Hill, C. H. & Matrone, G.
( 1964 ) Importance of dietary copper in
the formation of aortic elastin. J. Nutr. 82,
318-322.
735. Stein, W. H., Bearn, A. G. & Moore, S.
( 1954 ) The amino acid content of the
blood and urine in Wilson's disease. J. Clin.
Invest. 33, 410-419.
736. Sternlieb, I. (1967) Gastrointestinal cop
per absorption in man. Gastroenterology 52,
1038-1041.
737. Sternlieb, I. (1972) ^volution of the
hepatic lesion in Wilson's disease (hepato
lenticular degeneration). In: Progress in
Liver Disease, ( Popper, H. & Schaffner, F.,
eds.), vol. 4, pp. 511-525, Gruñeand Stratton,
New York.
738. Sternlieb, I. & Feldmann, G. (1976) Ef
fects of anticopper therapy on hepatocellular
mitochondria in patients with Wilson's dis
ease. An ultrastructural and stereological
study. Gastroenterology 71, 457-461.
739. Sternlieb, J. & Janowitz, H. D. (1964)
Absorption of copper in malabsorption syn
dromes. J. Clin. Invest. 43, 1049-1055.
740. Sternlieb, I., Morell, A. G., Bauer, C. D.,
Combes, B., de Bobes-Stemberg, S. &
Scheinberg, I. H. ( 1961 ) Detection of the
heterozygous carrier of the Wilson's disease
gene. J. Clin. Invest. 40, 707-715.
741. Sternlieb, I., Morell, A. G. & Scheinberg, I.
H. ( 1962 ) The uniqueness of ceruloplas
min in the study of plasma protein synthesis.
Trans. Assoc. Amer. Physicians 75, 228-234.
742. Sternlieb, I., Morell, A. G., Tucker, W. D.,
Greene, M. W. & Scheinberg, I. H. (1961)
The incorporation of copper into ceruloplas
min in vivo: Studies with copper" and
copper". J. Clin. Invest. 40, 1834-1840.
743. Sternlieb, I., Sandson, J. I., Morell, A. G.,
Korotkin, E. & Scheinberg, I. H. (1969)
Nonceruloplasmin copper in rheumatoid
arthritis. Arth. Rheum. 12, 458-459.
744. Sternlieb, I. & Scheinberg, I. H. (1961)
Ceruloplasmin in health and disease. Ann.
N.Y. Acad. Sci. 94, 71-76.
745. Sternlieb, I. & Scheinberg, I. H. (1964)
Penicillamine therapy for hepatolenticular
degeneration. J. Am. Med. Assn. 189, 748-
754.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2062 KARL E. MASON
746. Stemlieb, I. & Scheinberg, I. H. (1968)
Prevention of Wilson's disease in asympto
matic patients. N. Engl. J. Med. 278, 352-
359.
747. Stemlieb, I. & Scheinberg, I. H. (1974)
Wilson's disease. In: The Liver and Its
Diseases (Schaffner, F., Sherlock, S. &
Leevy, C. M., eds.), pp. 328-336, Inter
continental Medical Book Corp., New York.
748. Stemlieb, I., van den Hamer, C. J. A. &
Alpert, S. (1967) Role of intestinal lym
phatics in copper absorption. Nature 216,
824.
749. Stemlieb, I., van den Hamer, C. J. A.,
Morell, A. G., Alpert, S., Gregoriadis, G. &
Scheinberg, I. H. (1973) Lysosomal de
fect of hepatic copper excretion in Wilson's
disease ( hepatolenticular degeneration). Gastroenterology
64, 99-105.
750. Stransky, E., Dauis-Lawas, D. T. & Lawas
I. L. ( 1952 ) On serum copper level and
its importance in childhood. Ann. Paediat.
179, 1-11.
751. Stratigos, J., Kasimatis, B., Panas, E. &
Capetanakis, J. (1976) Le cuivre et la
céruléoplasminedans le sérumdes psoriasiques.
Ann. Dermatol. Syphil. 103, 584-
587
752. Strickland, G. T., Beckner, W. M. & Leu,
M-L. ( 1972 ) Absorption of copper in
homozygotes and hétérozygotes for Wilson's
disease and controls: Isotope tracer studies
with "Cu and "Cu. Clin. Sci. 43, 617-625.
753. Strickland, G. T., Beckner, W. M., Leu,
M-L. & O'Reilly, S. (1972) Turnover
studies of copper in homozygotes and hétéro
zygotes for Wilson's disease and controls:
Isotope tracer studies with "copper. Clin.
Sci. 43, 605-615.
754. Strickland, G. T., Blackwell, R. O. & Watten,
R. H. (1971) Metabolie studies in Wil
son's disease. Evaluation of efficacy of
chelation therapy in respect to copper ballance.
Am. J. Med. 51, 31-40.
755. Strickland, G. T., Frommer, D., Leu, M-L.,
Pollard, R., Sherlock, S. & Comings, J. N.
( 1973 ) Wilson's Disease in the United
Kingdom and Taiwan. Quart. J. Med. 42,
619-638.
756. Strickland, G. T. & Leu, M-L. (1975)
Wilson's disease: Clinical and laboratory
manifestations in 40 patients. Medicine 54,
113-137.
757. Studnitz, W. von & Berezin, D. (1958)
Studies on serum copper during pregnancy,
during the menstrual cycle, and after ad
ministration of oestrogens. Acta Endocrinol.
27, 245-252.
758. Sturgeon, P. ( 1954 ) Studies on iron re
quirements in infants and children: 1. Nor
mal values for serum iron, copper and free
erythrocyte protoporphyrin. Pediatrics 13,
107-125.
759. Sturgeon, P. & Brubaker, C. (1956) Cop
per deficiency in infants: a syndrome char
acterized by hypocupremia, iron deficiency
anemia, and hypoproteinemia. Am. J. Dis.
Child. 92, 254-265.
760. Sullivan, J. F. & Hart, K. T. (1960)
Serum benzidine oxidase. J. Lab. Clin. Med.
55, 260-267.
761. Sultanova, G. F. (1970) Peculiarities in
copper metabolism in the prematurely bom
infants of the first months of life. Pediatrija
49 (10), 14-18 (Russian).
762. Sumino, K., Hayakawa, K., Shibata, T. &
Kitamura, S. (1975) Heavy metals in
normal Japanese tissues. Amounts of 15
heavy metals in 30 subjects. Arch. Environ.
Health 30, 487-494.
763. Sunderman, F. W., Jr. (1973) Atomic ab
sorption spectrometry of trace metals in clini
cal pathology. Hum. Pathol. 4, 549-582.
764. Sunderman, F. W., Jr., Hohnadel, D. C.,
Evenson, M. A., Wannamaker, B. B. & Dahl,
D. S. ( 1974) Excretion of copper in sweat
of patients with Wilson's disease during
sauna bathing. Ann. Clin. Lab. Sci. 4, 407-
412.
765. Sunderman, F. W., Jr. & Roszel, N. O.
( 1967 ) Measurements of copper in bio
logical materials by atomic absorption spec
trometry. Am. J. Clin. Pathol. 48, 286-294.
766. Suttle, N. F. (1974) Recent studies of
the copper-molybdenum antagonism. Proc.
Nutr. Soc. 33, 299-305.
767. Suttle, N. F. & Mills, C. F. (1966) Studies
of the toxicity of copper to pigs. 1. Effects
of oral supplements of zinc and iron salts
on the development of copper toxicosis. Br.
J. Nutr. 20, 135-137.
768. Suttle, N. F. & Mills, C. F. (1966) Studies
of the toxicity of copper to pigs. 2. Effect of
protein source and other dietary components
on the response to high and moderate in
takes of copper. Br. J. Nutr. 20, 149-161.
769. Tani, P. & Kokkola, K. (1972) Serum
iron, copper, and iron-binding capacity in
bronchogenic pulmonary carcinoma. Scand.
J. Resp. Dis. (Suppl. 80), 121-128.
770. Taradaiko, Y. V. (1963) The content of
copper in the organism of the mother and
fetus. Akush. Ginek. 39, 59-63 (Russian).
771. Tatum, H. J. (1974) Copper-bearing in
trauterine devices. Clin. Obst. & Gynecol.
17, 93-119.
772. Teague, H. S. & Carpenter, L. E. (1951)
The demonstration of a copper deficiency
in growing pigs. J. Nutr. 43, 389-399.
773. Tessmer, C. F., Hrgovcic, M., Brown, B. W.,
Wilbur, J. & Thomas, F. B. (1972) Serum
copper correlations with bone marrow.
Cancer 29, 173-179.
774. Tessmer, C. F., Hrgovcic, M., Thomas, F.
B., Fuller, L. M. & Castro, J. R. (1973)
Serum copper as an index of tumor response
to radiotherapy. Radiol. 106, 635-639.
775. Tessmer, C. F., Hrgovcic, M. & Wilbur, J.
( 1973 ) Serum copper in Hodgkin's disease
in children. Cancer 31, 303-315.
776. Tessmer, C. F., Krohn, W., Johnston, D.,
Thomas, F. B., Hrgovcic, M. & Brown, B.
( 1973 ) Serum copper in children ( 6-12
years old): An age-correction factor. Am. J.
Clin. Path. 60, 870-878.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2063
777. Thompson, R. H. S. & Watson, D. (1949)
Serum copper levels in pregnancy and in
pre-eclampsia. J. Clin. Pathol. 2, 193-196.
778. Thorling, E. B. & Thorling, K. (1976) The
minations
clinical usefulness
in Hodgkin's
of serum
disease.
copper
A retrospec
deter
tive study of 241 patients
Cancer 38, 225-231.
from 1963-1973.
779. Thornton, I. & Alloway, B. J. (1974)
Geochemical aspects of the soil-plant-animal
relationship in the development of
element deficiency and excess. Proc.
Soc. 33, 257-274.
trace
Nutr.
780. Tingey, A. H. (1957) The iron, copper
and manganese content of the human brain.
J. Mental Sci. 83, 452-460.
781. Tipton, I. H. & Cook, M. J. (1963) Trace
elements in human tissue. Part II. Adult sub
jects from the United States. Health Phys.
9, 103-145.
782. Tipton, I. H., Stewart, P. L. & Dickson, J.
( 1969) Patterns of elemental excretion in
long term balance studies. Health Phys. 16,
455-462.
783. Tipton, I. H., Stewart, P. L. & Martin, P. G.
( 1966 ) Trace elements in diets and excreta.
Health Phys. 12, 1683-1689.
784. Todd, J. R., Gracey, J. F. & Thompson, R. H.
( 1962 ) Studies on chronic copper poison
ing. I. Toxicity of copper sulphate and cop
per acetate in sheep. Br. Vet. J. 118, 482-
491.
785. Tompsett, S. L. (1934) The excretion of
copper in urine and faeces and its relation
to the copper content of the diet. Biochem.
J. 28, 2088-2091.
786.
"inorganic"
Tompsett, S.
iron
L.
contents
(1935)
of
The
human
copper
tissues.
and
Biochem. J. 29, 480-486.
787. Tompsett, S. L. & Anderson, D. F. (1935)
The copper content of the blood in preg
nancy. Br. J. Exp. Pathol. 16, 67-69.
788. Topham, R.
Identification
W.
and
& Frieden,
purification
E.
of
(1970)
a nonceruloplasmin
ferroxidase of human serum.
J. Biol. Chem. 245, 6698-6705.
789. Trip, J. A., Que, G. S., Botterweg-Span, Y.
& Mandema, E. (1969) The state of cop
per in human lymph. Clin. Chim. Acta 26,
371-372.
790. Tsallas, G. & Baun, D. C. (1972) Home
care total parenteral alimentation. Am. J.
Hosp. Pharm. 29, 840-846.
791. Tu, J-B. (1963) A genetic biochemical
and clinical study of Wilson's disease among
Chinese
81-104.
in Taiwan. Acta Paediat. Sinica 4,
792. Tu, J-B. & Blackwell, R. Q. (1967)
Studies on levels of penicillamine-induced
cupriuresis in hétérozygotes of Wilson's dis
ease. Metabolism 16, 507-513.
793. Tu, J-B., Blackwell, R. Q. & Watten, R. H.
treatment
( 1965 ) Copper
of patients
balance
with
studies
Wilson's
during
disease.
the
Metabolism 14, 653-666.
794. Turpin, R., Schmitt-Jubeau, H. & Jerome,
H.
sur
355.
(1950) Action
la cuprémie.C.R.
du diéthylstilboestrol
Soc. Biol. 144, 352-
795. Tyson, T. L., Holmes, H. H. & Ragan, C.
(1950) Copper therapy of rheumatoid
arthritis. Am. J. Med. Sci. 220, 418-120.
796. Ulstrom, R. A., Smith, N. J. & Heimlich,
E. M. (1956) Transient dysproteinemia in
infants, a new syndrome: I. clinical studies.
A.M.A. J. Dis. Child. 92, 219-253.
797. Ulstrom, R. A., Smith, N. J., Nakamura, K.
& Heimlich, E. (1957) Transient dyspro
teinemia in infants. II. Studies of protein
metabolism using amino acid isotopes.
A.M.A. J. Dis. Child. 93, 536-547.
798. UnderwooA, E. J. (1977) Trace Elements
in Human and Animal Nutrition, 4th ed.,
Academic Press, New York.
799. Usher, S. J., MacDermot, P. N. & Lozinski,
E. (1935) Prophylaxis of simple anemia
in infancy with iron and copper. Am. J. Dis.
Child. 49, 642-657.
800. Utin, A. V. (1970) Copper metabolism
and its significance in epilepsy. Zn. Nevropatol.
Psikhiat. S.S. Korsakova 70, 721-727
(Russian) (cited in Nutr. Abstr. rev. 41,
662, 1971)
801. Uzman, L. L., Iber, F. L., Chalmers, T. C.
& Knowlton, M. (1956) The mechanism
of copper deposition in the liver in hepatolenticular
degeneration (Wilson's disease).
M. J. Med. Sci. 231, 511-518.
802. Vagn-Hansen, P. L., Reske-Nielsen, E. &
Lou, H. C. (1973) Menkes' Disease: a
new leucodystrophy (?). A clinical and
neuropathological review together with a
new case. Acta Neuropathol. 25, 103-119.
803. Vallee, B. L. (1952) The time course of
serum copper concentrations of patients with
myocardial infarctions. I. Metabolism 1, 420-
434.
804. Van Campen, D. R. (1971) Absorption
of copper from the gastrointestinal tract.
In: Intestinal Absorption of Metal Ions,
Trace Elements and Radionucleotides
(Skoryna, S. C. & Waldron-Edward, D.,
eds.), pp. 211-227, Pergamon Press, Oxford.
805. Van Ravesteyn, A. H. (1944) Metabolism
of copper in man. Acta Med. Scand. 118,
163-196.
806. Versieck, J., Barbier, F., Speecke, A. & Hoste,
J. (1975) Influence of myocardial infarc
tion on serum manganese, copper, and zinc
concentrations. Clin. Chem. 21, 578-581.
807. Vidal, G. P., Shieh, J. J. & Yasunobu, K. T.
( 1975 ) Immunological studies of bovine
aorta lysyl oxidase: evidence for two forms
of the enzyme. Biochem. Biophys. Res.
Commun. 64, 989-995.
808. Vilter, R. W., Bozian, R. C., Hess, E. V.,
Zellner, D. C. & Petering, H. G. (1974)
Manifestations of copper deficiency with
systemic sclerosis on intravenous hyperalimentation.
New Engl. J. Med. 291, 188-
191.
809. Volpintesta, E. J. (1974) Menkes' kinky
hair syndrome in a black infant. Am. J. Dis.
Child. 128, 244-246.
810. Vuia, O. & Heye, D. ( 1974) Neuropathologic
aspects in Menkes' kinky hair disease
(trichopoliodystrophy ). Neuropadiarie. 5,
329-339.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2064 KARL E. MASON
811. Wacker, W. E. C., Ulmer, D. D. & Vallee,
B. L. ( 1956 ) Metalloenzymes and myocardial
infarction. II. Malic and lactic dehydrogenase
activities and zinc concentra
tions in serum. N. Eng. J. Med. 255, 449-
456.
812. Waddell, J., Elvehjem, C. A., Steenbock,
H. & Hart, E. B. (1928) Iron in nutrition.
VI. Iron salts and iron-containing ash ex
tracts in the correction of anemia. J. Biol.
Chem. 77, 777-795.
813. Wahl, P. K., Mittal, y. P. £ Bansal, O. P.
( 1965 ) Renal complications in acute cop
per sulphate poisoning. Indian Pract. IS,
807-812.
814. Waldman, T. A., Morell, A. G., Wochner,
R. D., Strober, W. & Sternlieb, 1. (1967)
Measurement of gastrointestinal protein loss
using ceruloplasmin labeled with "copper.
J. Clin. Invest. 46, 10-20.
815. Walker, W. R. & Keats, D. M. (1976) An
investigation of the therapeutic value of the
"copper bracelet:" dermal assimilation of
copper in arthritic/rheumatoid conditions.
Agents Actions 6, 454-459.
816. Walker-Smith, J. & Blomfield, J. (1973)
Wilson's disease or chronic copper poison
ing? Arch. Dis. Child. 48, 476-479.
817. Walker-Smith, J. A., Turner, B., Blomfield,
J. & Wise, G. (1973) Therapeutic impli
cations of copper deficiency in Menkes's
steely-hair syndrome. Arch. Dis. Child. 48,
958-962.
818. Walravens, P. A. (1977) Trace element
nutrition and brain development. In: Proc.
4th Internat. Congress, Internat. Assn. Sci.
Study Mental Deficiency (Mittler, P., ed.),
vol. Ill, pp. 355-364, University Park,
Baltimore.
819. Walsh, F. M., Crosson, F. J., Bayley, M.,
McReynolds, J. & Pearson, B. J. (1977)
Acute copper intoxication. Pathophysiology
and therapy with a case report. Am. J. Dis.
Child. 131, 149-151.
820. Walshe, J. M. (1956) FPenicillamine, a
new oral therapy for Wilson's disease. Am. J.
Med. 21, 487-495.
821. Walshe, J. M. (1967) The physiology of
copper in man and its relation to Wilson's
disease. Brain 90, 149-176.
822. Walshe, J. M. (1972) The biochemistry
of copper in man and its role in the pathogenesis
of Wilson's disease (hepatolenticular
degeneration). In: Biochemical Aspects of
Nervous Diseases (Cumings, T. N., ed.),
pp. 111-150, Plenum, New York.
823. Walshe, J. M. (1973) Copper chelation
in patients with Wilson's disease, a compari
son of penicillamine and tetraethylene
tetramine dihydrochloride. Quart. J. Med.
42, 441-452.
824. Walshe, J. M. & Briggs, J. ( 1962) Caeruloplasmin
in liver disease. A diagnostic pitfall.
Lancet 2, 263-265.
826. Walshe, J. M. & Potter, G. (1977) The
pattern of the whole body distribution of
radioactive copper ("Cu, wCu) in Wilson's
disease
J. Med.
and various control groups.
(New Series) 46, 445-462.
Quart.
827. Warburg, O. & Krebs, H. A. (1927) Ãœber
locker gebundenes Kupfer und Eisen in
Blutserum. Biochem. Ztschr. 190, 143-149.
828. Warren, P. J., Earl, C. J. & Thompson, R.
H. S. (1960) The distribution of copper
in human brain. Brain 83, 709-717.
829. Warren, R. L., Jelliffe, A. M., Watson, J. V.
& Hobbs, C. B. (1969) Prolonged obser
vations
Hodgkin's
on variations
disease. Clin.
in the
Radiol.
serum copper
20, 247in
256.
830. Waslein, C. I. (1976) Human intake of
trace elements. In: Trace Elements in Hu
man Health and Disease, (Prasad, A. S. &
Oberleas, D., eds.), vol. 2, pp. 347-370,
Academic Press, New York.
831. Webb, J., Kirk, K. A., Jackson, D. H.,
Niedermeier, W., Turner, M. E., Rackley,
C. E. & Russell, R. O. (1976) Analysis
by pattern recognition techniques of changes
in serum levels of 14 trace metals after acute
myocardial infarction. Exp. Molec. Pathol.
25, 322-331.
832. Weber, P. M., O'Reilly, S., Pollycove, M. &
Shipley, L. (1969) Gastrointestinal ab
sorption of copper: studies with "Cu, MZr,
a wholebody counter and the scintillation
camera. J. Nuclear. Med. 10, 591-596.
833. Wehinger, H., Witt, I., Lose], I., Denz-
Seibert, G. & Sander, C. (1975) Intra
venous copper in Menkes' kinky-hair syn
drome. Lancet 1, 1143-1144.
834. Wertime, T. A. (1964) Man's first en
counter with metallurgy. Science 146, 1257-
1267.
835. Wesenberg, R. L., Gwinn, J. L. & Barnes,
G. R., Jr. (1969) Radiological findings in
the kinky-hair syndrome. Radiology 92, 500-
506.
836. Wester, P. O. (1971) Trace elements in
the coronary arteries in the presence and
absence of atherosclerosis. Atherosclerosis
13 (3), 395-412.
837. Wharton, D. C. & Gibson, Q. H. (1966)
Spectrophotometric characterization and
function of copper in cytochrome c oxidase.
In: The Biochemistry of Copper (Peisach,
J., Aisen, P. & Blumberg, W. E., eds.),
pp. 235-244, Academic Press, New York.
838. Wheeler, E. M. & Roberts, P. F. (1976)
Menkes' steely hair syndrome. Arch. Dis.
Child. 51, 269-274.
839. White, H. S. (1969) Inorganic elements
in weighed diets of girls and young women.
J. Am. Diet. Assn. 55, 38-43.
840. White, H. S. & Gynne, T. N. (1971) Utili
zation of inorganic elements by young
women eating iron-fortified foods. J. Am.
Diet. Assn. 59, 27-33.
841. Whitehouse, M. W. (1976) Ambivalent
role of copper in inflammatory disorders.
Agents Actions 6, 201-206.
842. Widdowson, E. M., Chan, H., Harrison, G.
E. & Milner, R. D. G. (1972) Accumula
tion of Cu, Zn, Mn, Cr and Co in the
human liver before birth. Biol. Neonate. 20,
360-367.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

COPPER METABOLISM AND REQUIREMENTS OF MAN 2065
843. Widdowson, E. M., Dauncey, J. & Shaw,
J. C. L. (1974) Trace elements in foetal
and early postnatal development. Proc. Nutr.
Soc. 33, 275-284.
844. Widdowson, E. M. & Dickerson, J. W. T.
( 1964 ) Chemical composition of the body.
In: Mineral Metabolism, an Advanced
Treatise, (Comar, C. L. & Bronner, F.,
eds. ), chap. 17, pp. 1-247, Academic Press,
New York.
845. Widdowson, E. M., McCance, R. A. & Spray,
C. M. (1951) The chemical composition
of the human body. Clin. Sci. IO, 113-125.
846. Widdowson, E. M. & Spray, C. M. (1951)
Chemical development in utero. Arch. Dis.
Child. 26, 205-214.
847. Wilken, H. (1960) Serumkupfer bei
Spätschwangerschaftstoxikosen. Aren. Gynäkol.
194, 158-164.
848. Wilkinson, R. (1971) Polyethylene glycol
4000 as a continuously administered nonabsorbable
faecal marker for metabolic bal
ance studies in human subjects. Gut 12,
654-660.
849. Williams, D. M., Atkin, C. L., Frens, D. B.
& Bray, P. F. (1977) Menkes' kinky hair
syndrome: studies of copper metabolism and
long term therapy. Pediat. Res. 11, 823-826.
850. Williams, D. M., Lee, G. R. & Cartwright,
G. E. (1974) Ferroxidase activity of rat
ceruloplasmin. Am. J. Physiol. 227, 1094-
1097.
851. Willvonseder, R., Goldstein, N. P., McCall,
J. T., Yoss, R. E. & Tauxe, W. N. (1973)
A hereditary disorder with dementia, spastic
dysarthria, vertical eye movement paresis,
gait disturbance, splenomegaly and abnormal
copper metabolism. Neurology 23, 1039-
1049.
852. Wilmore, D. W. & Dudrick, S. J. (1968)
Growth and development of an infant re
ceiving all nutrients exclusively by vein.
J.A.M.A. 203, 860-864.
853. Wilmore, D. W., Groff, D. B., Bishop, H. C.
& Dudrick, S. J. (1969) Total parenteral
nutrition in infants with catastrophic gastro
intestinal anomalies. J. Pediat. Surg. 4, 181—
189.
854. Wilson, J. F. & Lahey, M. E. (1960)
Failure to induce dietary deficiency of cop
per in premature infants. Pediatrics 25, 40-
49.
855. Wilson, S. A. K. (1912) Progressive len
ticular degeneration: a familial nervous dis
ease associated with cirrhosis of the liver.
Brain 34, 295-309.
856. Winge, D. R., Premakumar, R., Wiley, R.
D. & Rajagopalan, K. V. (1975) Copperchelatin:
purification and properties of a
copper-binding protein from rat liver. Arch.
Biochem. Biophys. 170, 253-266.
857. Wintrobe, M. M., Cartwright, G. E. &
Gubler, C. J. (1953) Studies on the func
tion and metabolism of copper. J. Nutr. 50,
395-419.
858. Wojcicka, J. & Zapalowski, Z. (1963) The
serum-copper level in the blood of pregnant
women in cases of normal and complicated
pregnancies. Ginek. Polska 34, 693-697
(Polish).
859. Wolf, P. I. (1975) An investigation of
serum copper in dermatologie conditions.
Lab. Invest. 32, 461.
860. Wolf, W. R., Holden, J. & Greene, F. E.
( 1977 ) Daily intake of zinc and copper
from self selected diets. Federation Proc.
36, 1175.
861. World Health Organization. Technical Re
port Series No. 532 ( 1973 ) Trace ele
ments in human nutrition. Report of a WHO
Expert Committee, 65 pp., World Health
Organization, Geneva.
862. Worwood, M., Taylor, D. M. & Hunt, A. H.
( 1968 ) Copper and manganese concentra
tions in biliary cirrhosis of liver. Br. Med.
J. 3, 344-346.
863. Wray, S. H., Kuwabara, T. & Sanderson, P.
(1976) Menkes' kinky hair disease: a light
and electron microscopic study of the eye.
Invest. Ophthalmol. 15, 128-138.
864. Wretlind, A. (1972) Complete intravenous
nutrition. Theoretical and experimental back
ground. Nutr. Metabol. 14, (Suppl.), 1-57.
865. Wylie, J. (1957) Copper poisoning at a
cocktail party. Am. J. Pub. Health 47, 617.
866. Yamada, H., Kumagai, H., Kawasaki, H.,
Matsui, H. & Ogata, K. (1967) Crystalli
zation and properties of diamine oxidase
from pig kidney. Biochem. Biophys. Res.
Commun. 29, 723-727.
867. Yamada, H. & Yasunobu, K. T. (1962)
Monoamine oxidase. II. Copper, one of the
prosthetic groups of plasma monoamine ox
idase. J. Biol. Chem. 237, 3077-3082.
868. Ylostalo, P. & Reinila, M. (1973) Serum
copper in normal and complicated pregnan
cies compared with urinary estrogens. Ann.
Chirurg. Gynaecol. Fenniae 62, 117-120.
869. Yoshida, T., Konno, T. & Arakawa, T.
( 1969 ) Hypocupremic infant associated
with mental retardation and hepatic cir
rhosis: probably a copper malabsorption
syndrome. Tohoku J. Exp. Med. 98, 229-
239
870. Young, S. N. & Curzon, G. (1974) Neo
natal human caeruloplasmin. Biochim. Bio
phys. Acta 336, 306-308.
871. Yunice, A. A., Lindeman, R. D., Czerwinski,
A. W. & Clark, M. (1974) Influence of
age and sex on serum copper and cerulo
plasmin levels. J. Gerontol. 29, 277-281.
872. Zackheim, H. S. & Wolf, P. (1972) Serum
copper in psoriasis and other dermatoses. J.
Invest. Dermatol. 58, 28-32.
873. Zimdahl, W. T., Hyman, I. & Cook, E. D.
( 1953 ) Metabolism of copper in hepatolenticular
degeneration. Neurology 3, 569-578.
874. Zipursky, A., Dempsey, H., Markowitz, H.,
Cartwright, G. & Wintrobe, M. M. (1958)
Studies on copper metabolism. XXIV. Hypocupremia
in infancy. A.M.A.J. Dis. Child.
96, 148-158.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013

2066 KARL E. MASON
875. Zlatkov, N. B., Bozhkov, B. & Genov. D. Kupfer in Frauenmilch und Kuhmilch. Klin.
(1973) Serum copper and ceruloplasmin in Wochenschr. 10, 1528-1531.
patients with psoriasis after helio- and 878. Zudikova, S. I. (1967) Copper in blood of
thalassotherapy. Arch. Derm. Forsch. 247, pregnant women with late toxicosis. Vop.
289-294. Omrany Mater. Det. 12 (12), 69-70 (Rus-
876. Zlatkov, N. B., Petkov, I., Genov, D. & sian).
Bozhkov, B. (1971) Kupferstoffwechael 879. Zurukzoglu-Sklavounou, S. (1953) Hypobei
Kranken mit Vitíligonach Héliothérapie. chrome Anämie im Kindesalter: Studie auf
Dermatologica (Basel) 143, 115-120. Grund von 373 Fallen. Helvet. Paediat.
877. Zondek, S. G. & Bandmann, M. (1931) Acta 8, 251-275.
Downloaded from
jn.nutrition.org
by guest on February 27, 2013