56 METABOLISM IN SEVERE DIABETES. 



during 1907. On January 24, 1908, 0.3 per cent of sugar was present; in April 

 of the same year Prof, von Noorden found difficulty in making the urine 

 sugar-free despite vegetable days and oatmeal days, and following the patient's 

 visit to Vienna the sugar was invariably present. Along with the gradual 

 increase in acidosis which was first noted in 1908, the diet was gradually 

 relaxed, and apparently each time with benefit. During the latter part of 

 December 1911 tuberculosis appeared and the weight fell rapidly. With the 

 appearance of the tuberculosis there was a gradual increase in the tolerance for 

 carbohydrates and a decrease in the acidosis, a condition similar to that which 

 occurred in Case A. Similar occurrences have been recorded by various writ- 

 ers. All data relating to the case from the beginning of observation, June 27, 

 1910, until death on March 14, 1912, can be considered absolutely reliable. 



Physical examination. Greatest weight, 66.7 kilos, without clothing; 

 June 27, 1910, 60.5 kilos, without clothing. Height, 181 cm. Pupils equal 

 and reacted to light. Teeth in excellent condition, undoubtedly due in part 

 to cleansing by dentist every 6 weeks. Lungs normal. Heart, apex in mammil- 

 lary line, systolic at base and apex. Blood-pressure, 126. Pulse-rate, 96. 

 Right kidney large and palpable throughout. Liver, spleen, and left kidney 

 not palpable. No note of abnormality of knee-jerks. 



Urine data. The reaction of the urine was acid throughout the period of 

 our observation, but according to von Noorden's records, it had previously 

 been alkaline several times. The acidosis was extreme from June 1910 until 

 the last few months of life. In no other case coming under our observation has 

 the quantity of /3-oxybutyric acid been greater than with this patient, increas- 

 ing to over 50 grams in March, April, August, September, November, and 

 December 1911, the amount on Christmas Day being 54.8 grams. Although 

 the amount of nitrogen in the diet was kept at a moderate level, the ammonia 

 was high from the first, reaching 8 grams in February 1911, notwithstanding 20 

 grams of sodium bicarbonate were being taken daily. The quantity of sugar 

 steadily rose from approximately 50 grams in June 1910 up to 200 grams in 

 March 1911, but subsequently somewhat decreased, falling far below this in 

 the spring of 1912, coincident with the presence of tuberculosis. A minus car- 

 bohydrate balance was present from June 1910 until the last two months of 

 life. The body-weight slowly fell from 60.5 kilos, on June 29, 1910, to 34.5 

 kilos, on March 23, 1912. The urinary record is given in table 65. 



EXPERIMENTS WITH CASE R. 



With this subject one calorimeter experiment was made, in which the sub- 

 ject fasted and the bed calorimeter was used; three respiration experiments 

 were also made, each of which was preceded by the ingestion of food. The 

 vital statistics were as follows: 



Date of birth, March 16, 1863; height, 181 cm.; range in body-weight 

 without clothing during experiments, 55.3 to 58.2 kilos. 



Respiration Experiment No. Rl. 



Date, August 1, 1910. Body-weight without clothing, 56.4 kilos. 



This was intended to be only a trial experiment, since it was the first 

 respiration experiment with this subject. After a breakfast consisting of 36 

 gms. of Quaker oats (weight uncooked), 125 c.c. of cream, 2 eggs, one-half 

 biscuit, and 2 cupfuls of coffee containing 100 c.c. of sugarless diluted milk, 

 also 4 grams of sodium bicarbonate in water, the subject came to the labora- 

 tory and lay down upon the couch at 9 h 50 m a. m. The experiment included 

 but one period of 12 minutes, beginning at 9 h 55 m a. m. and ending at 10 h 07 m 

 a. m. The pulse-rate ranged from 95 to 100, and the respiration-rate from 

 15 to 17. The results of the experiment are given in table 66. 



