The Russell Sage Institute of Pathology 
 
 IN AFFILIATION WITH 
 
 The Second Medical Division of Bellevue Hospital 
 
 CLINICAL CALORIMETRY 
 
 PAGE 
 
 I. A RESPIRATION CALORIMETER FOR THE STUDY OF 
 
 DISEASE 793 
 
 GRAHAM LUSK 
 Scientific Director, Russell Sage Institute of Pathology ' - 
 
 II. THE RESPIRATION CALORIMETER OF THE RUSSELL 
 SAGE INSTITUTE OF PATHOLOGY IN BELLEVUE 
 HOSPITAL 805 
 
 J. A. RICHE 'AND G. F. SODERSTROM 
 
 IIJ. THE ORGANIZATION OF A SMALL METABOLISM 
 WARD 829 
 
 FRANK C. GEPHART, A.B., and EUGENE F. DuBOIS, M.D. 
 
 IV. THE DETERMINATION OF THE BASAL METABOLISM 
 OF NORMAL MEN AND THE EFFECT OF FOOD 835 
 
 FRANK C. GEPHART, A.B., and EUGENE F. DuBOIS, M.D. 
 
 V. THE MEASUREMENT OF THE SURFACE AREA OF 
 MAN 868 
 
 DELAFIELD DuBOIS, B.S>, and EUGENE F. DuBOIS, M.D. 
 
 VI. NOTES ON THE ABSORPTION OF FAT AND PROTEIN 
 
 IN TYPHOID FEVER 882 
 
 WARREN COLEMAN, M.D., and EUGENE F. DuBOIS, M.D. 
 
 VII. CALORIMETRIC OBSERVATIONS ON THE METAB- 
 OLISM OF TYPHOID PATIENTS WITH AND WITH- 
 OUT FOOD 887 
 
 WARREN COLEMAN, M.D., and EUGENE F. DuBOIS, M.D. 
 
 Vin. ON THE DIABETIC RESPIRATORY QUOTIENT 939 
 
 GRAHAM LUSK 
 
 Reprinted from the Archives of Internal Medicine, Vol. 15, Part II, 
 May. 15, 1915 
 
 CHICAGO 
 American Medical Association, Five Hundred and Thirty-Five N. Dearborn St. 
 
 1915 
 
 S^<iCL.XI 
 
 i:)4Uc^fl|XCii.5i+ 
 
 L-^oo 
 
-^^ 
 
 Cornell University 
 Library 
 
 The original of this book is in 
 the Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924067894802 
 
The Russell Sage institute of Pathology 
 
 IN AFFILIATION WITH 
 
 The Second Medical Division of Bellevue Hospital 
 
 CLINICAL CALORIMETRY 
 
 PAGE 
 
 I. A RESPIRATION CALORIMETER FOR THE STUDY OF 
 
 DISEASE 793 
 
 GRAHAM LUSK 
 Scientific Director, Russell Sage Institute of Pathology 
 
 II. THE RESPIRATION CAEORIMETER OF THE RUSSELL 
 SAGE INSTITUTE OF PATHOLOGY IN BELLEVUE 
 HOSPITAL 805 
 
 J. A. RICHE AND G. F. SODERSTROM 
 
 in. THE ORGANIZATION OF A SMALL METABOLISM 
 
 WARD 829 
 
 FRANK C. GEPHART, A.B., and EUGENE F. DuBOIS, M.D. 
 
 IV. THE DETERMINATION OF THE BASAL METABOLISM 
 OF NORMAL MEN AND THE EFFECT OF FOOD 835 
 
 FRANK C. GEPHART, A.B., and EUGENE F. DuBOIS, M.D. 
 
 V. THE MEASUREMENT OF THE SURFACE AREA OF 
 MAN 868 
 
 DELAFIELD DuBOIS, B.S., and EUGENE F. DuBOIS, M.D. 
 
 VL NOTES ON THE ABSORPTION OF FAT AND PROTEIN 
 
 IN TYPHOID FEVER 882 
 
 WARREN COLEMAN, M.D., and EUGENE F. DuBOIS, M.D. 
 
 VIL CALORIMETRIC OBSERVATIONS ON THE METAB- 
 OLISM OF TYPHOID PATIENTS WITH AND WITH- 
 OUT FOOD 887 
 
 WARREN COLEMAN, M.D., and EUGENE F. DuBOIS, M.D. 
 
 VIIL ON THE DIABETIC RESPIRATORY QUOTIENT 939 
 
 GRAHAM LUSK 
 
 Reprinted from the Archives of Internal Medicine, Vol. 15, Part II, 
 May 15, 1915 
 
 CHICAGO 
 American Medical Association, Five Hundked and Thirty-Five N. Dearborn St. 
 
 1915 
 
CLINICAL CALORIMETRY 
 
 FIRST PAPER 
 
 A RESPIRATION CALORIMETER FOR THE STUDY OF DISEASE* 
 
 GRAHAM LUSK 
 Scientific Director, Russell Sage Institute of Pathology 
 
 NEW YORK 
 HISTORICAL 
 
 A respiration calorimeter is an apparatus designed for the measure- 
 ment of the gaseous exchange between a living organism and the 
 atmosphere which surrounds it, and the simultaneous measurement of 
 the quantity of heat produced by that organism. 
 
 The first contrivance of this nature was described by Lavoisier in 
 1780. It will be remembered that Lavoisier was the first to compre- 
 hend the significance of the then newly discovered oxygen. Primitive 
 though the apparatus, yet intellectually inspiring was the mind which 
 so early grasped the principles and understood many of the difficulties. 
 
 Apparatus for the measurement of the respiratory exchange was 
 perfected before that for the measurement of heat production. Thus, 
 Regnault and Rieset^ in 1850 designed an air-tight apparatus in which 
 an animal was placed ; the carbonic acid formed in it was removed by 
 pumping the air into flasks filled with potash, and oxygen was added 
 from time to time as it was required. This is the closed circuit system 
 which in a modified form is used to-day. 
 
 The historic respiration apparatus of Pettenkofer^ and Voit was 
 completed in 1862. This machine was capable of measuring the 
 carbon dioxid output of a man within 1 per cent, of error. As early 
 as 1866 Voit began computing from the substances oxidized in the 
 body the quantity of heat which should have arisen from the destruc- 
 tion of those substances. This method is known as indirect calorimetry. 
 
 In 1885, Rubner, working in Voit's laboratory, published results 
 concerning the calorimetry of foods. Accurate determinations of the 
 
 * From the Russell Sage Institute of Pathology, in affiliation with the 
 Second Medical Division of Bellevue Hospital. 
 
 1. Regnault and Rieset : Ann. d. Chem. u. Pharmakol., 1850, Ixxiii, 92, 129, 
 257. 
 
 2. Pettenkofer : Ann. d. Chem. u. Pharmakol. Supplement 2, 1862. 
 
2 CLINICAL CALORIMETRY 
 
 heat value of urea, and of dry urinary solids were made for the first 
 time. This work established biological standards for the heat values 
 of proteins, carbohydrates and fats which are to-day accepted. 
 
 About the same time a calorimeter for the measurement of the heat 
 production in man was set up in Voit's laboratory and many experi- 
 ments were made with it by Carl Voit and his brother Erwin Voit. 
 The results were apparently not satisfactory, for nothing was ever 
 published on the subject. At this time Atwater was in Voit's labora- 
 tory, and in 1888 published from that laboratory an article on the 
 absorption of the flesh of fish. 
 
 Atwater's interest in nutrition had already been stimulated by 
 Johnson and Brewer at Yale, and through studies in agricultural and 
 physiological chemistry in Berlin in 1869-71. In 1877 he began inves- 
 tigations into dietary requirements of the people. It was Atwater's 
 association with Voit and with Rubner, however, which gave him his 
 knowledge of the principles of the subject of calorimetry as apphed 
 to the living organism. These facts, which are not widely known, 
 emphasize again the overwhelming debt which American science owes 
 to Germany. 
 
 In 1894 Rubner built the first successful respiration calorimeter. 
 He built it largely with his own hands and with the very moderate 
 means available in his laboratory at Marburg where he had become 
 professor of hygiene. Voit, on hearing the news, said that it was the 
 most important invention of its kind since the invention of the ther- 
 mometer. Rubner's calorimeter, which measured the heat production 
 of a dog, was associated with the mechanism of a Pettenkofer respira- 
 tion apparatus which determined the carbonic acid output of the 
 animal. Thus indirect calorimetry could be compared with direct 
 calorimetry. For example, if the nitrogen in the urine and feces of a 
 dog fed with meat and fat were determined, and this nitrogen were 
 multiplied by 6.25, the quantity of protein destroyed could be estimated. 
 Since each gram of protein yields 4.1 calories of heat in the body, the 
 quantity of heat produced from protein would be 
 
 Grams excreted N X 6.25 X 4.1 
 
 To estimate the quantity of fat oxidized the quantity of carbon con- 
 tained in the protein destroyed (which amounts to grams excreted 
 N X 3.28) was deducted from the quantity of carbon contained in the 
 
 3. For the history of animal calorimetry see Rubner : Tigerstedt's Hand- 
 buch der physiol. Methodik. i, 150; Johansson, Abderhalden's Handbuch der 
 biochem. Arbeitsmethoden, Berlin, 1910, iii, 1114. 
 
GRAHAM LUSK 3 
 
 excreta, that is, the sum of that in the urine, feces and respiration. 
 The remainder represented the quantity of expired carbon derived 
 from the oxidation of fat. Since fat contains 76.5 per cent, of carbon 
 and 1 gm. of fat yields 9.3 calories, it was easy to calculate the heat 
 production derived from fat. Recapitulating, one may express the 
 heat produced from fat in the formula : 
 
 Total C — (N X 3.28) divided by 76.5 X 100 X 9.3 
 
 Adding together the heat calculated as that which should have 
 arisen from the protein and fat metabolized, Rubner found that this 
 sum was exactly the amount of heat given off by the animal as 
 measured by the calorimeter. This was the first long-sought demon- 
 stration of the law of the conservation of energy applied to animal life. 
 
 After returning to America, Atwater in 1892 began work on a 
 calorimeter which could measure the heat production in man. In 1894 
 the United States government began to appropriate funds for investi- 
 gations into the nutrition of the people and placed the distribution of 
 these funds in the hands of Professor Atwater. A portion was wisely 
 used in the construction of the Atwater-Rosa* respiration calorimeter, 
 the earlier description of which appeared in 1897. In 1893 C. F. 
 Langworthy and in 1895 F G. Benedict became associated with the 
 undertaking. Shortly after the completion of the apparatus, Rosa, the 
 expert physicist, to whose skill its successful completion was largely 
 indebted, retired from direct association with the enterprise, although, 
 as professor of physics at Wesleyan he was still frequently consulted 
 until, in 1901, he became chief physicist of the Bureau of Standards 
 at Washington. The Atwater-Rosa calorimeter demonstrated that 
 direct and indirect calorimetry agreed in man, not only during rest, but 
 also during periods when mechanical work was performed. 
 
 The original Atwater-Rosa calorimeter was associated with a respi- 
 ration apparatus of the type designed by Pettenkofer, which measured 
 only the carbon dioxid output. Calculated on this basis the production 
 of heat might show a maximum error of 24 per cent., depending on 
 whether carbohydrate or fat was being oxidized. At a later date funds 
 were granted to Atwater by the Carnegie Institution in order to apply 
 the principle of the closed circuit of Regnault and Rieset to the appa- 
 ratus so that the oxygen absorption might also be determined. The 
 modification of the apparatus along these lines was begun in 1902, and , 
 the work accomplished during 1903 to 1905 was done during a period 
 when Atwater was in full control of the undertaking. Atwater's illness 
 
 4. Atwater and Rosa : Report of the Storrs Agric. Exper. Station, 1897, 
 p. 212. 
 
4 CLINICAL CALORIMETRY 
 
 began in 1905, his retirement took place in 1906 and he died 
 in 1907. 
 
 With the improved apparatus, publication^ concerning which fell in 
 1905, not only heat production and carbon dioxid output were accu- 
 rately measured, but the absorption of oxygen as well. It thus became 
 possible to measure not only the non-protein carbon in the respiration, 
 but also to calculate how much of the oxygen absorbed was devoted to 
 the destruction of non-protein material ; that is to say, fat and carbo- 
 hydrate. The value of this knowledge becomes apparent when it is 
 realized that one liter of oxygen used for the oxidation of fat yields 
 4.686 calories, whereas when the same volume is used to oxidize starch 
 5.047 calories are set free, a difference of over 7 per cent. When 
 carbohydrate is oxidized the volume of oxygen absorbed is equal to 
 the volume of carbon dioxid expired and the respiratory quotient 
 equals unity. 
 
 Vol. CO2 
 
 R. Q. equals : ^= 1 
 
 Vol. O2 
 
 When fat is oxidized, however, the respiratory quotient is only 0.70. 
 Respiratory quotients (corrected from protein influence) which run 
 intermediate between 0.70 and 1.00 are deemed to represent the oxida- 
 tion of mixtures of carbohydrates and fats, and the heat value of a liter 
 of oxygen varies accordingly. Thus a quotient of 0.85 represents the 
 oxidation of fat and carbohydrate together in such a proportion that 
 49 per cent, of the calories produced are derived from carbohydrate 
 and 51 per cent, from fat. Under these circumstances, 1 liter of 
 absorbed oxygen represents 4.863 calories liberated in the organism. 
 Tables giving these data were first published by Zuntz." 
 
 The ability to determine the oxygen absorption with exactness 
 abolished a possible error of considerable magnitude in the calculations 
 of indirect calorimetry. This improvement brought the apparatus to 
 a high degree of perfection. The Carnegie Institution of Washington 
 has richly provided for the higher development of the work in the 
 Nutrition Laboratory at Boston, which represents the realization of 
 Atwater's ambition for the establishment of a separate laboratory for 
 this work. Dr. Benedict is here the controlling genius, while the 
 original Wesleyan calorimeter, now removed to Washington, is under 
 the direction of Dr. C. F. Langworthy. 
 
 5. Atwater and Benedict : Carnegie Institution of Washington, 190S, Pub. 42. 
 See also, Benedict and Carpenter: 1910, Pub. 123. 
 
 6. Zuntz and Schumburg: Studien zu einer Physiologie des Marches, Berlin, 
 1901. See also, Williams, Riche and Lusk (Jour. Biol. Chem., 1912, xii, 3S7), 
 for other references. 
 
GRAHAM LUSK 5 
 
 ANIMAL CALORIMETRY AT THE CORNELL UNIVERSITY 
 MEDICAL COLLEGE 
 
 At the time of my appointment to the professorship of physiology 
 at the Cornell University Medical College, the authorities liberally pro- 
 vided for the construction of a respiration apparatus. Dr. Murlin spent 
 a part of the summer with Dr. Benedict in Boston, vi^here he freely 
 received every privilege of the laboratory. After considerable discus- 
 sion, I decided to have a calorimeter constructed which was small 
 enough for use with dogs and babies, work which, up to that time, had 
 not been included in the program of the Boston laboratory. The con- 
 struction of this apparatus was entrusted to the capable management 
 of Dr. H. B. Williams.' Full and grateful acknowledgment is due to 
 Dr. F. G. Benedict, who has ever given all that counsel which his 
 unique experience in calorimeter construction makes of highest value. 
 
 The problem of the measurement of 7 calories of heat produced in 
 an hour by a baby weighing 3 kg. was different from that presented 
 by the measurement of 70 calories produced by an adult. This led to 
 the addition to the calorimeter of certain refinements in technical con- 
 struction which are due to Dr. Williams. The small calorimeter has 
 been successfully used in many experiments on dogs and babies. For 
 the first time direct and indirect calorimetry were found to agree 
 during hourly periods of experimentation. 
 
 The method employed with dogs was to determine the basal metab- 
 olism as measured by that quantity of heat which was produced by the 
 resting animal when there was no food in the gastro-intestinal tract, 
 and to compare this metabolism with that found at times following the 
 ingestion of various foods. It was found that three or four hours of 
 observation sufficed to indicate the influence of ingested food. 
 
 The satisfactory working of the apparatus used in accordance with 
 these principles encouraged me to believe that valuable results might 
 be obtained concerning the nutrition of patients if a similar, though 
 larger, apparatus were placed in Bellevue Hospital. Before embarking 
 on the undertaking, inquiry was made of Dr. Benedict if he did not 
 desire to investigate this field by establishing a calorimeter in the Peter 
 Bent Brigham Hospital in Boston. As^the reply was in the negative, 
 it appeared justifiable to seek money and opportunity for the accom- 
 plishment of this work. 
 
 Sufficient funds were obtained from the Russell Sage Institute of 
 Pathology for a period of five years. The former arrangement between 
 this institute and the City Hospital had just been terminated. A new 
 arrangement was entered into with the trustees of Bellevue Hospital 
 
 7. Williams: Jour. Biol. Chem., 1912, xii, 317. 
 
6 CLIMCAL CALORIMETRY 
 
 which enabled the institute to construct the first respiration calorimeter 
 ever established in a hospital. Dr. Eugene F Du Bois was appointed 
 medical director, and the whole undertaking has enjoyed the faithful 
 service of chemists, mechanics and nurses who have contributed to its 
 success. A factor of especial encouragement has been the personal 
 interest in the undertaking manifested by the visiting physicians, Drs. 
 W. Oilman Thompson, C. L. Dana and Warren Coleman. The last- 
 named has taken part in the actual work of the institute. 
 
 It is also a pleasure to acknowledge with thanks many helpful sug- 
 gestions made by Drs. Langworthy and Milner of Washington. 
 
 Fig. 1. — Respiration calorimeter with the patient half-way in. On his chest 
 can be seen the tube of the Bowles stethoscope strapped over the heart. Coiled 
 up on the wall is the rectal thermometer not yet inserted. Just below this is 
 one of the units of the air thermometer and to the right is the telephone. 
 
 An Atwater-Rosa-Benedict respiration calorimeter, together with 
 the in,struments of precision applied to it by Williams, and certain new 
 modifications which were the result of advice and experience, was 
 established in Bellevue Hospital. The papers which follow are descrip- 
 tive of the calorimeter (Fig. 1) and the results obtained with it. The 
 patient lies quietly for three or four hours on a comfortable bed in the 
 chamber of the apparatus, breathing the purest air, without the possi- 
 
GRAHAM LUSK 7 
 
 bility 01 harm. The long periods of the older respiration chambers and 
 the nose- or mouth-pieces of the short-period apparatus are not dis- 
 turbing factors. For the benefit of those who are interested in the 
 work and who do not care to follow the details of the technical descrip- 
 tion of the apparatus, the following summary will suffice. 
 
 PRINCIPLE OF THE ATWATER-ROSA-BENEDICT RESPIRATION 
 
 CALORIMETER 
 
 The apparatus is divided into two functional parts, one for measuring the 
 gaseous exchange, the other for measuring the heat production of the subject. 
 A schematic presentation is here given (Fig. 2). 
 
 The Gas Analysis. — The inner lining of the apparatus presents an air tight 
 copper box having a capacity of 1,123 liters. One end of the box, through 
 which the patient lying on the bed is admitted, may be closed with a glass 
 plate by means of wax. The air within thjr box is purified by drawing it out 
 of an opening in the box through a rubber' tube and forcing it by means of a 
 rotary blower through a system of absorbers, whence it returns again to the 
 box by another rubber tube. It passes (see diagram) first through sulphuric 
 acid (1), which removes the water, then through moist soda lime (2), which 
 removes the carbon dioxid, and next through sulphuric acid (3), which absorbs 
 the moisture taken from the soda lime. If the bottles be previously weighed, 
 the gain in weight of 1 represents water absorbed, and the gain in weight of 
 2 plus 3 equals the carbon dioxid absorbed. By this method the water and 
 carbon dioxid produced by a man are taken from the air, while oxygen within 
 the chamber is being absorbed by the man himself. This causes a diminution 
 in the volume of the contents of the box. In order to replace the oxygen used, 
 oxygen is automatically fed into the system from an oxygen cylinder which 
 may be weighed before and after the period. The automatic feeding of oxygen 
 into the box is accomplished by means of a spirometer whose interior is con- 
 nected with the interior pf the calorimeter chamber. As the volume of the 
 air in the box decreases, the spirometer falls until a certain point is reached, 
 at which an electric contact releases a clamp, which allows oxygen from the 
 oxygen cylinder to enter the box, causing the spirometer to rise, break its 
 electric contact and clamp off the oxygen supply. So sensitive is. the spirom- 
 eter to the movement of the patient that a device called a "work adder" has 
 been attached to it, which records the subject's movements. 
 
 At the beginning of an hourly period of experimentation an observer at 
 the table calls "time." At this instant the rotary blower is stopped, the air 
 current switched so as to pass through a new set of weighed absorbers and 
 then the rotary blower is started again. At the word "time" an operator also 
 turns a pet-cock which cuts off the respiratory chamber from the spirometer 
 cylinder, which is then filled, always to a given point, with oxygen from the 
 oxygen cylinder. The pet-cock is now opened and a freshly weighed oxygen 
 cylinder is placed in the position of the other, which is removed. Repeating 
 these procedures an hour later, one may determine by difference in weight the 
 gain of water and carbon dioxid by the absorbers and the loss of oxygen by 
 the cylinder. The figures are subject to corrections due to (1) gain or loss 
 of water or carbon dioxid content in the box itself, during the period, which 
 gain or loss must be added to or subtracted from the increase in weight of 
 the absorber system. This gain or loss of water and carbon dioxid in the box 
 also affects the volume of the air in the box and, therefore, the quantity of 
 oxygen admitted, as do, in addition (2), a change in temperature within the 
 box and (3) a change in barometric pressure. These corrections must be 
 made in order to determine whether oxygen is to be added or subtracted from 
 the quantity which has been furnished from the oxygen cylinder. The result 
 
CLIXICAL CALORIMETRY 
 
 gives the quantity of oxygen which the man has absorbed. It is apparent that 
 all the errors of determination fall on the oxygen, and yet the exactness of 
 the method is witnessed by the close approximation in alcohol check experi- 
 ments of the theoretical and actual values for oxygen consumed. 
 
 If a person in the calorimeter moves even the arm during the critical 
 moments just before "time" is called, the increased local heating of the air 
 may cause the spirometer to rise to a considerable height, of which the air 
 
 Fig. 2.— Schematic diagram of the Atwater-Rosa-Benedict respiration 
 calorimeter. 
 
 Ventilating System : 
 
 02, Oxygen introduced as consumed 
 by subject. 
 
 3, H2S04 to catch moisture given 
 off by soda lime. 
 
 2. Soda lime to remove CO2. 
 
 1, H.SOj to remove moisture given 
 off by patient. 
 
 BL, Blower to keep air in circula- 
 tion. 
 Indirect Calorimetry: _ 
 
 Increase in weight of H2SO4 (1) = 
 water elimination of subject. 
 
 Increase in weight of soda lime 
 (2) -f- increase in weight of 
 H.SOi (3) = CO. elimination. 
 
 Decrease in weight of oxygen tank 
 = oxygen consumption of subject. 
 Heat-Absorbing System : 
 
 A, Thermometer to record temper- 
 ature of ingoing water. 
 
 B, Thermometer to record temper- 
 ature of outgoing water. 
 
 V, Vacuum jacket. 
 
 C, Tank for weighing water which 
 has passed through calorimeter 
 each hour. 
 
 W, Thermometer for measuring 
 temperature of wall. 
 
 Al, Thermometer for measuring 
 temperature of the air. 
 
 R, Rectal thermometer for measur- 
 ing temperature of subject. 
 Direct Calorimetry: 
 
 Average difference of A and B X 
 liters of water + (gm. water 
 eliminated X 0.586) ± (change 
 in "temperature of wall X hydro- 
 thermal equivalent of box) ± 
 (change of temperature of body X 
 hydrothermal equivalent of body) 
 ^ total calories produced, 
 Th, thermocouple ; Cu, inner copper 
 
 wall ; Cui, outer copper wall ; E, F, 
 dead air spaces. 
 
GRAHAM LUSK 9 
 
 thermometers inside the box fail to malce compensatory record, and the oxygen 
 determination will be too low in that hour and too high in the next. 
 
 Analysis of the air in the interior of the chamber is made just before the 
 beginning of each hour by passing ten liters of air from the box through three 
 U-tubes containing, respectively, sulphuric acid, soda lime and sulphuric acid, 
 then through a Bohr gas meter and back into the box again. This is called the 
 "residual analysis." 
 
 Under the conditions present in the respiration apparatus, carbon 
 dioxid is measured with the greatest .ease and accuracy. Oxygen is also 
 measured with accuracy if the person within the box lies perfectly 
 quietly for ten minutes before the end of the period, whereas water 
 production is the least accurate of all the determinations, on account of 
 the varying hygroscopic condition of the walls, bedding and other 
 surfaces within the closed spaces of the apparatus. 
 
 The Measurement of Heat Produced. — Roughly speaking, one- 
 quarter of the heat eliminated by a man is present in the water vapor 
 which is absorbed by the first sulphuric acid bottle on the absorber 
 table. At 20 degrees C. 0.586 calories are contained as latent heat in 
 1 gm. of vaporized water. 
 
 The rest of the heat loss takes place by radiation and conduction. 
 It is this heat which is measured by the calorimeter, itself. The mech- 
 anism of the calorimeter is essentially two-fold. In the first place, 
 there is no heat loss through the walls of the apparatus, and, secondly, 
 the heat produced by a man within is removed from the chamber by a 
 current of cold water flowing through copper tubes suspended from the 
 upper wall of the chamber. If the walls allowed no heat to pass, it is 
 obvious that without the cooling effect of the water-pipes the tempera- 
 ture of the air in the box would soon attain the temperature of the 
 human body instead of being about 23 C, at which it is usually held. 
 The apparatus is therefore a constant-temperature, water-cooled calo- 
 rimeter. It is evident that if no heat is allowed to pass through the 
 walls of the calorimeter, then the heat produced within the chamber 
 will be removed in the current of cold water flowing through the heat- 
 absorbing pipes inside the chamber of the apparatus. If the tempera- 
 tures of the ingoing and of the outgoing water are known and the 
 quantity of water which has passed through the heat-absorber during 
 an hour is measured, the quantity of heat carried away in the current 
 of water can be accurately determined. For example, if the difference 
 between the temperature of the ingoing and outgoing water is 2.50 
 degrees, and 20 liters of water have passed through the heat absorber 
 in one hour, then 50 calories of heat have been carried away from the 
 apparatus during the period. If the temperature of the walls within 
 the apparatus has undergone a change this value is subject to correc- 
 tions, but otherwise the total heat elimination of the person is meas- 
 
10 CLIKICAL CALORIMETRY 
 
 ured by the SO calories so determined plus the heat value of water 
 vaporized during the hour. 
 
 To obtain an even flow of water through the heat-absorber the 
 water is supplied from a constant-level tank placed above the calo- 
 rimeter. To obtain ingoing water of an even temperature, Williams 
 passed the previously ice-cooled water current through a Gouy tem- 
 perature regulator and then through a current regulator designed by 
 himself. These improvements allow the ingoing water to enter the 
 calorimeter at a temperature which may not vary more than 0.02 C. 
 during hours of experimentation and, for the first time, permitted the 
 exact measurement of small quantities of heat in this type of apparatus. 
 The temperatures of the ingoing and outgoing water are taken every 
 four minutes by electrical resistance thermometers and are read in 
 connection with a galvanometer and Kohlrausch bridge on an 
 observer's table. The quantity of the water-flow is determined by 
 weighing ; the water is diverted at the call of "time," so that the exact 
 quantity for the hour is collected in a previously weighed receptacle. 
 
 Having learned how the heat produced within the apparatus is 
 carried away, the problem of how to prevent loss of heat through the 
 walls of the chamber remains to be discussed. This was accomplished 
 through a device introduced by Rosa. The calorimeter is constructed 
 of three walls, an inner copper wall which has already been described 
 as the lining of the respiration chamber, an outer copper wall separated 
 from the inner wall by a space of dead air, and an insulating wall 
 (made of two layers of "compo-board," the space between them being 
 filled with cork), which insulating wall is separated from the outer 
 copper wall by a second space containing dead air. It is obvious that 
 if the inner and outer copper walls of the calorimeter have the same 
 temperature there will be no exchange of heat between them. There- 
 fore, to prevent a gain or loss of heat by the inner wall, it is necessary 
 to maintain the outer wall always at exactly the same temperature as 
 the inner wall, under which circumstances the latter cannot gain or lose 
 heat to its neighbor. 
 
 In order to detect differences in temperature between the outer and 
 inner walls Rosa arranged thermo-couples in series between the two 
 walls. In this fashion the top, sides and bottom of the box are succes- 
 sively tested every four minutes by an operator at the observer's table 
 to determine whether there is any difference in temperature between 
 the outer and inner walls. If the outer wall is found to have a different 
 temperature from the inner wall, its temperature is brought to that of 
 the inner wall by the following device. A cooling current of water 
 runs through pipes between the insulating and outer copper wall, and 
 in this same space, along the line of the pipes, run "Therlo" resistance 
 
GRAHAM LUSK 
 
 11 
 
 wires carrying an electric current for the warming of this inter- 
 space (Fig. 1). By varying the intensity of the electric currents which 
 severally supply the spaces to top, sides and bottom, the temperature 
 of these spaces can be so controlled as to heat or cool the outer copper 
 wall and maintain it at exactly the same temperature as the inner 
 copper wall. This is the effective system which prevents a loss or gain 
 of heat through the wall of the calorimeter. 
 
 Resistance thermometers are attached to the inner walls of the 
 calorimeter, and if the temperature of the walls rises or falls between 
 the beginning and end of the experiment, a correction must be made. 
 It has been found that 19 calories are absorbed by the Sage calorimeter 
 v/hen the inner wall rises 1 degree. Conversely, 19 calories are given 
 up by a fall of 1 degree. This is the hydrothermal equivalent of 
 the box. 
 
 ScHEMK OF Employment of Observers in a Calorimeter Experiment 
 
 Period of Obser 
 vation 
 
 Observer 1, at Electrical 
 Control Table 
 
 Observer 2, in Charge of 
 Experiment 
 
 Observer 3, Calculator 
 
 Eight minutes be- 
 fore 
 
 Five minutes be- 
 fore 
 
 Four minutes be- 
 fore 
 
 One-half minute 
 before 
 
 At 'VTime" 
 
 Immediately after 
 "Time" 
 
 Brings wall into exact ther- 
 mal equilibrium 
 
 Takes final reading of air, 
 wall and rectal tempera- 
 ture 
 
 Presses button which diverts 
 stream of water from 
 weighing tank 
 
 Starts taking readings every 
 four minutes of ingoing 
 and outgoing water,* of 
 air, walls, rectal and sur- 
 face thermometers. Reads 
 and adjusts temperature of 
 top, sides and bottom of 
 calorimeter, of the ingo- 
 ing air and water every 
 four minutes, or oftener 
 if necessary. 
 
 Signals subject to lie abso- 
 lutely quiet. 
 
 Starts kymograph record of 
 movements of spirometer 
 
 Sets barometer 
 
 Shuts spirometer off from 
 box. Fills to standard 
 level from oxygen tank. 
 
 Records and sets work- 
 adder. Signals to subject 
 that he may move. Weighs 
 oxygen tank and connects 
 with box again. Weighs 
 sulphuric and soda lime 
 bottles. Connects them up 
 again and tests for leaks. 
 During remainder of hour 
 counts pulse, inspects 
 valves for leaks, adjusts 
 temperature of room, 
 watches subject, etc. 
 
 Starts passing first 1 
 sample of residual 
 through U tubes. 
 
 L. 
 
 Finishes first and starts sec- 
 ond residual 
 Finishes second residual 
 
 Stops ventilating current^ of 
 air. Turns valve to pass 
 air through newly weighed 
 absorbers. Starts ventilat- 
 ing current. 
 
 Weighs water tank which 
 has received all the water 
 from the heat absorber 
 during the past hour. Di- 
 verts stream of water to 
 this tank again. Records 
 barometer. Weighs resid- 
 ual. Calculates results of 
 the hour just finished. 
 
 The temperature of the air entering the box from the absorbing 
 table is always heated to exactly the same temperature as the air 
 leaving the box. 
 
 Finally^ an electric resistance thermometer inserted 10 or 12 cm. 
 into the rectum of the person in the calorimeter gives information 
 regarding the retention or loss of heat in his organism. The specific 
 heat of a man is assumed to be 0.83, that is to say, 0.83 calory raises 
 1 kilogram 1 degree. If, therefore, the body temperature of a man 
 weighing 70 kg. rises or falls 1 degree, the quantity of heat lost or 
 
12 CLINICAL CALORIMETRY 
 
 gained by the body will be 70 X 0.83 or 58.1 calories. This is on the 
 assumption that the rise of body temperature is everywhere the same 
 as takes place in the rectum, a supposition which, unfortunately, is not 
 always true. 
 
 The accompanying scheme (Table 1) gives the details regarding 
 the employment of the three individuals who conduct a calorimeter 
 experiment. 
 
 It may be added that special care has been taken to make the 
 appearance of the calorimeter attractive to the eye, and that the spirit 
 of the small ward in connection with the calorimeter work has been 
 such that the patients have considered themselves especially fortunate 
 when chosen for the diversion offered by a morning's occupancy of 
 the apparatus. 
 
 CONCLUSION 
 
 The story of the Atwater-Rosa-Benedict calorimeter has been told 
 here for the first time in brief, comprehensive, perhaps one might say 
 semipopular language. The WilHams calorimeter has shown the influ- 
 ence of many simple foodstuffs which were given to dogs in health and 
 in induced disease. The Sage calorimeter reports "of the disturbances 
 that Nature works and of her cures," without having, as concerns the 
 sick human being, at any time, in the slightest degree, affected any 
 patient to his disadvantage, but rather having yielded information 
 regarding his condition which has been beneficial in his subsequent 
 treatment. 
 
 It seems appropriate to recall the words with which Pettenkofer 
 and Voit closed their communication regarding diabetes in the year 
 1867: 
 
 Even as anatomy has been separated from physiology, so from pathological 
 anatomy pathological physiology will arise. Only thus will we be able to 
 obtain a more exact knowledge of the character of disease than we now possess. 
 Able pathologists have constantly sought to open up this field. It will gratify 
 us if this work of ours which for the first time presents a complete picture of 
 metabolism in disease shall inspire others to devote their abilities in this 
 direction. 
 
CLINICAL CALORIMETRY 
 
 SECOND PAPER 
 
 THE RESPIRATION CALORIMETER OF THE RUSSELL SAGE 
 INSTITUTE OF PATHOLOGY IN BELLEVUE HOSPITAL* 
 
 J. A. RICHE AND G. F. SODERSTROM 
 
 NEW YORK 
 CONTENTS 
 
 1. Previous descriptions of calorimeters. 
 
 2. The calorimeter room. 
 
 3. The wooden frame. 
 
 4. The copper walls and the insulating wall. 
 
 5. The absorber table, spirometer and heat absorbing system. 
 
 6. Rheostat board and observer's table. 
 
 7. Electric thermometers. 
 
 8. Telephone, fan and bed. 
 
 9. Electric and alcohol control experiments. 
 
 10. Limits of error in measuring heat, carbon dioxid and oxygen. 
 
 11. Determination of water elimination. 
 
 12. Adaptability of calorimeter to varying conditions. 
 
 13. Summary and conclusions. 
 
 During the short time in which the Sage calorimeter has been in 
 operation there have been several requests for the technical details of 
 the construction of the apparatus. It has therefore seemed advisable 
 to publish a brief article for those interested in calorimeters. A com- 
 plete description of the Atwater-Rosa-Benedict type of apparatus will 
 be found in the monograph by Benedict and Carpenter.^ A number of 
 valuable improvements are added in the shorter article by Williams.^ 
 The earlier publications of Atwater and Rosa^ and Atwater and 
 Benedict* describe an apparatus fundamentally the same as that now 
 employed, but for a complete understanding of the modern calorimeter 
 it is necessary to consult the works of Benedict and Carpenter and 
 
 * From the Russell Sage Institute of Pathology, in affiliation with the 
 Second Medical Division of Bellevue Hospital. 
 
 1. Benedict and Carpenter: Respiration Calorimeters for Studying the 
 Respiratory Exchange and Energy Transformations of Man, Carnegie Insti- 
 tution of Washington, 1910, Pub. 123. 
 
 2. Williams, H. B. : Animal Calorimetry, First Paper, A Small Respira- 
 tion Calorimeter, Jour. Biol. Chem., 1912, xii, 317. 
 
 3. Atwater and Rosa: Description of a New Respiration Calorimeter, U. S. 
 Dept. Agriculture, 1899, Bull. 63. 
 
 4. Atwater and Benedict : A Respiration Calorimeter with Appliances for 
 the Direct Determination of Oxygen, Carnegie Institution of Washington, 1905, 
 Pub. 42. 
 
14 CLINICAL CALORIMETRY 
 
 Williams. The description by Langworthy and Milner^ of their ingeni- 
 ous automatic calorimeter should also be consulted. 
 
 The Sage calorimeter resembles Benedict's bed calorimeter, but 
 differs in a few details. On the recommendation of Dr. Langworthy 
 and Mr. Milner of the Department of Agriculture the outside insula- 
 tion was made of pressed cork and "Compo Board." The electrical 
 resistance thermometers for the ingoing and outgoing water were also 
 adopted on their advice. The gas wash bottles, water heating resi-stance 
 and current regulator, water coil and several other improvements were 
 copies of those used by Williams. The soda-lime bottles and spirometer 
 resembled those described by Benedict^ in connection with his small 
 apparatus. 
 
 THE CALORIMETER ROOM 
 
 The small metabolism ward to be described is situated at the south- 
 west corner of the new medical pavilion of Bellevue Hospital. To the 
 north of this is a hall, now converted into a diet kitchen, which leads 
 into the calorimeter room, formerly a small ward for convalescents. 
 The room itself (Fig. 3) is about 5 meters square and 5 meters high. 
 On the west side, opening on a covered balcony, is a large window in 
 front of which stand a thermostat-controlled radiator and a "Simplex" 
 electric heater. These are enclosed in a window box in such a manner, 
 that by means of a blower, fresh air can be drawn in through the win- 
 dow, driven over the heaters and out into the room. Unfortunately, 
 the daylight is not strong and needs to be supplemented by two power- 
 ful tungsten lamps. 
 
 In the center of the room stands the calorimeter, at the side of 
 which is the observer's platform, raised a short distance above the floor 
 to permit the passage of the numerous water pipes and electrical con- 
 duits. On the east side of the room is the panel box where the heavy 
 feed wires are led up from the basement. Next to this panel box are 
 the storage batteries with charging board used in electric checks. On 
 the soiith side of the room, where the door is situated, enough space 
 has been left to wheel a stretcher with a patient to the front of the 
 calorimeter. By making careful use of every inch a great deal of 
 apparatus has been placed in a small room without crowding those 
 who work there. 
 
 THE FRAME 
 
 As the photographs show, the calorimeter was made high enough 
 at the head to allow the subject to sit upright. This increases the 
 
 5. Langworthy and Milner : Year Book U. S. Dept. Agriculture, 1910, 
 p. 307; ibid., 1911, p. 491. 
 
 6. Benedict, F. G. : Ein Universalrespirationsapparat, Deutsch. Arch, f . klin. 
 Med., 1912, cvii, 156. 
 
rtiatt-± 
 
 D^DiQJ an 
 ffl .. 
 
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 I 
 
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 o 
 
 _J 
 <t 
 o 
 I 
 
 M 
 
 
 
 I — I ® 
 
 IZfe 
 
 :f 
 
 
 
 Fig. 3. — The calorimeter room. A, Absorber tabl 
 drawn through meter. CC, Williams bottles contain 
 heater. Z, Sink. O, Observer's table. Ga, Galvano 
 Ti, Ice tank for cooling water running through abso 
 outer copper wall. T4, Large supply tank. Tu, Tank 
 Small tank to hold water from absorber while T5 is 
 constant-level tank near the ceiling. P, Panel box. S 
 Pyrene fire extinguisher. O2, Oxygen tanks. Bi, Ba 
 Balance for U-tubes. 
 
 e. M. Bohr meter, b, Drying tower for air sample 
 ing sulphuric acid. SH, Steam heater. EH, Electric 
 meter. R, Rheostat board. Ti, Gouy regulator tank, 
 rber in calorimeter. T3, Ice tank for water to cool 
 on platform balance (Ba) for weighing water. T«, 
 being weighed, p, Pump to lift water from T4, to 
 B, Edison storage batteries. SP, Charging panel, x, 
 lance for sulphuric bottles, etc. Ba, Barometer. B2, 
 
16 
 
 CLINICAL CALORIMETRY 
 
 volume of contained air and magnifies certain errors, but makes the 
 box much more comfortable and apparently gives better results than 
 if the quarters were cramped. The frame (Fig. 4) was made of wood, 
 as previous experience with the small calorimeter in Cornell had shown 
 that the mass of angle iron between the metal walls made the box very 
 sluggish in responding to temperature changes. To prevent warping, 
 which would be disastrous, the best quality white pattern pine was 
 used and the frame allowed to stand for several months before it was 
 shellacked. The outside timbers were 6.35 by 6.35 cm. square and the 
 braces 6.35 by 1.9 cm. All joints were glued and dowelled. The braces 
 were spaced 30.48 cm. apart to give rigidity to the copper walls which 
 are attached to the wood in many places. 
 
 Fig. 4. — Wooden frame of calorimeter with asbestos board as floor. 
 
 COPPER WALLS 
 
 The inner copper wall (Fig. 5) forms an air-tight box 198.18 cm. 
 long, 76.2 cm. wide, 91.4 cm. high at one end and 45.7 cm. at the 
 other, with a capacity of 1,123 liters. At the head is an opening to 
 serve as a door and on one side an opening for a window. 
 
 The wall is made of "16-ounce" sheet copper, tinned on the inside. 
 It is fastened to the inner side of the wooden frame by means of brass 
 angles soldered to the copper and screwed to the wood. The bottom 
 rests on a long slab of asbetos board 9.5 mm. thick. 
 
 The outer copper wall (Fig. 6) which is screwed directly on the 
 outer side of the wooden frame, does not come in metallic contact 
 with the inner wall at any place except the rim around the large open- 
 ing at the head of the box. This outer wall is made of "14-ounce" 
 copper tinned on the outside, and while the joints are soldered they are 
 not necessarily air-tight. 
 
/. A. RICHE—G. F. SODERSTROM 
 
 17 
 
 Fig. 5. — Inner copper box with brass thimbles for thermopiles. 
 
 Fig. 6. — Outer copper box with leads connecting thermopiles, pipes for cold 
 water and porcelain insulators for resistance wires. The wires themselves are 
 not shown in the photograph. The top and bottom of the wooden box are 
 in position. 
 
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/. A. RICHE—G. F. SODERSTROM 
 
 19 
 
 The braces of the wooden frame divide the dead air space between 
 the walls into compartments about 30.48 cm. square and 6.35 cm. thick. 
 In the center of each compartment is placed a thermopile with four 
 thermocouples in thermal but not in electrical contact with each copper 
 wall. The inner end of this thermopile fits in a brass thimble 25.4 mm. 
 deep soldered to the outer side of the inner wall. The outer end (with 
 its four thermocouples) fits in a brass tube which passes through the 
 outer wall and is closed off from the outside air by P. B. Compound 
 and electric tape. 
 
 Fig. 8. — Calorimeter with front closed. 
 
 In Figure 13 the large opening at the head of the box, measuring 
 76 by 70 cm., is closed by two glass plates 7.5 mm. thick, each sealed 
 after the subject has entered the calorimeter by means of a mixture of 
 5 parts bees-wax and I3/2 parts Venice turpentine. The small window 
 in Figure 6 is permanently closed by glass plates fastened to the copper 
 walls. There are numerous pipes and electric cables entering the box 
 as will be described later. 
 
 On the surface of the outer copper wall are attached the wires 
 connecting the thermopiles. The pipes for cold water are swung on 
 brass angles attached to this surface and the enameled "Therlo'* resis- 
 tance wire is bound on insulators to the same surface, very much as 
 described by Benedict and Carpenter. 
 
20 CLINICAL CALORIMETRY 
 
 INSULATING WALL 
 
 Completely surrounding the outer copper wall and separated from 
 it by a space of 7 cm. is the thick wall intended to protect the calorim- 
 eter from fluctuations in the room temperature. This is constructed 
 of a layer of pressed cork 2.54 cm. thick, between two layers of "Com.po 
 Board," a patented building material made of strips of wood glued 
 between layers of stout paper. This is supported by a framework of 
 white-wood, making panels which are light, yet very effective as heat 
 insulators. The head of the wooden box is provided with a glass 
 window and furnished with handles so that it can be easily removed 
 when the experiment is over and placed on a small shelf on the right 
 of the calorimeter. The frame of this outer box is stained to resemble 
 oak, and the "Compo Board" panels are painted with white enamel. 
 Every effort has been made to make the room and the calorimeter 
 pleasing to the eye, with the result that patients are attracted by the 
 beauty of the apparatus rather than by its resemblance to a coffin. 
 
 THE ABSORBER TABLE 
 
 The absorber table is so arranged that the air current is switched 
 from one set of absorbers to the other by means of a three-way valve. 
 This works satisfactorily and is much quicker than the old style seat- 
 valves. The sulphuric bottles are larger models of the form described 
 by Williams and hold about 1)4 liters of acid, which will remove every 
 trace of moisture until more than 100 grams has been absorbed. The 
 soda-lime bottles resemble those devised by Benedict,^ except for a 
 modification of the tube which carries the entering air. This is divided 
 in such a manner that the soda-lime can be packed about a brass pipe, 
 the lower end of which is perforated and the upper end of which 
 reaches almost to the top of the bottle, where it fits snugly in an elbow 
 attached to the stopper. The Crowell blower is the same as the ones 
 used by Williams and Benedict, but a safety device has been attached 
 to prevent accidental reversal of the blower which would have dis- 
 astrous effects. The two small bicarbonate cans next to the last sul- 
 phuric bottle did not remove entirely the acid vapors and it was neces- 
 sary to place a long cylinder in the vertical pipe which carries the air 
 from the absorber table. This contains about 340 grams of bicarbonate 
 of soda packed between layers of cotton and catches all traces of acid 
 fumes. 
 
 The air enters the box in a pipe which ends in a single opening 
 directed just above the subject's head and leaves through a number of 
 small openings in a pipe which runs across the foot of the box. A 
 small electric fan at the lower end of the calorimeter keeps the air well 
 stirred. 
 
/. A. RICHE—G. F. SODERSTROM 
 
 21 
 
 Fig. 9. — Modified soda-lime bottle. A, Brass tube with perforated bottom 
 and top which fits in brass elbow, B. The bottle is filled with A in position 
 and the rubber stopper D with elbows B and C is then forced into neck of 
 bottle. G and F, Brass couplings. R and Ri, heavy rubber tubing. X and Y, 
 Binding wires. 
 
 Fig. 10. — Safety device to prevent blower from being reversed. P, Pulley 
 for belt to motor. S, Shaft of blower. H, Hub of wheel. K, Key 1, 2, 3, 4, 5, 
 hardened steel rollers which engage when pulley is running in right direction, 
 but disengage when pulley starts in opposite direction. 
 
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/. A. RICHE—G. F. SODERSTROM 
 
 23 
 
 The spirometer on the top of the calorimeter resembles Benedict's^ 
 except that it is provided with a work-adder to record movement of 
 the patient and not the total ventilation of the lungs. The bell is made 
 of very light copper, is suspended in water and is carefully counter- 
 poised. The counterpoise is provided with a writing point which 
 records on a smoked paper the movements of the drum. To the wheel 
 at the top is attached a brass arm with two points which dip into mer- 
 cury cups set at slightly different levels whenever the spirometer bell 
 
 Fig. 12. — Electrical device for shutting and opening valve P. Pi. Push but- 
 tons controlling solenoids S and Si. A and Ai iron cores attached to brass 
 rod V. Valve is shown closed. When current is passed through S the Rod V 
 will be drawn to the left and the narrow portion seen just under Vi will come 
 opposite the pipe leading from receiving can G. 
 
 sinks below a certain mark. One of these cups operates a magnet which 
 opens the attachment that automatically admits the oxygen. This keeps 
 the spirometer within about one centimeter of the same level unless the 
 subject moves and suddenly heats the air locally. It is remarkable how 
 promptly the spirometer rises when the person within the box makes 
 even a slight movement of a hand or leg. In fact, it makes so delicate a 
 
24 
 
 CLINICAL CALORIMETRY 
 
 movement recorder that a Porter work-adder has been attached in such 
 a manner that the downward movement of the counterpoise winds up a 
 thread and the total amount of thread so wound represents the total 
 work done by the patient during that" particular period. By standard- 
 izing various movements of the body such as turning over or lifting the 
 arm it is possible to gain a fairly accurate idea of the amount of mus- 
 
 Fig. 13. — View of open calorimeter. Patient on canvas bed partly in the 
 chamber. On the left can be seen the observer's table and the rheostat board 
 with the galvanometer. The rubber pipes for outgoing and ingoing air lead 
 to the absorber table, a corner of which can be seen on the extreme left. In 
 the background on the right are the storage batteries and charging panel. 
 
 cular movement and express it in centimeters of thread, thus obviating 
 the necessity of printing long graphic records. In order to prevent the 
 work-adder from winding up thread while the oxygen is being admitted, 
 
/. A. RICHE—G. F. SODERSTROM 
 
 25 
 
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26 
 
 CLINICAL CALORIMETRY 
 
 a solenoid is connected with the second mercury cup into which the 
 brass arm on the wheel dips. This solenoid operates a small plunger 
 which holds the work-adder while the magnet opens the oxygen valve 
 and also maintains its hold for the instant after the oxygen has been 
 shut ofif, since the spirometer rises somewhat slowly after the admission 
 of oxygen. This solenoid lag, which corresponds to the spirometer lag, 
 is secured by having the second mercury cup filled slightly more than 
 the cup which controls the oxygen magnet. 
 
 Fig. 15. — Wiring diagram of rheostat board. W, Switch and rheostat to 
 control temperature of ingoing water in water heating resistance, D. A, 
 Ingoing air. B, Bottom of calorimeter. S, Sides. T, Top. Ga, Galvanometer 
 lamp. Ab, Motor on absorber table. P, Motor for pump. G, Lamps in Gouy 
 regulator. M, Miscellaneous parts connected with tube rheostats. O, Oi, 
 Solenoid agitators lifting and dropping platinum contacts with mercury in 
 Gouy and current regulator as the contact is made and broken mechanically 
 at X. Ri, Relay for current regulator. R2, Relay to control heating of lamps 
 in Gouy. 
 
 The heat-absorbing system is the same as that described t>y 
 Williams, the Gouy regulator and Williams' water heating resistance 
 and current regulator giving very satisfactory results. The water coil 
 suspended from the roof of the calorimeter has, however, been wound 
 with brass "jack chain" to increase its absorbing surface. From this 
 coil the water runs to the weighing tank on the platform of a "silk scale" 
 
/. A. RICHE—G. F. SODERSTROM 27 
 
 which is sensitive within 10 grams. The flow of water was formerly 
 cut off by hand at the end of each period, but this is now done by a 
 pair of solenoids controlled by the operator at the observer's table, thus 
 reducing the staff by one man. The stream of water runs constantly 
 through a can which has the capacity of 10 liters, and is provided at its 
 lowest point with a valve that is opened and shut by the pair of 
 solenoids above mentioned. At the end of a period the valve is shut 
 and the water collects in the can while the tank is being weighed. 
 After the weighing is finished the valve is opened and the water runs 
 once more into the tank. 
 
 RHEOSTAT BOARD AND OBSERVER'S TABLE 
 
 The marble rheostat board and the observer's table resemble closely 
 those described by Williams. This rheostat board, the panel box, 
 charging panel for the storage batteries, conduits, wires, etc., were 
 installed by the Electric Construction Supply Company after specifica- 
 tions kindly drawn up for us by the Department of Water Supply, Gas 
 and Electricity of New York City. Directly above the rheostat board 
 is mounted a galvanometer of the d'Arsonval type, provided with 
 prisms so that the ascending ray of light from the lamp below is 
 reflected from the mirror of the galvanometer downward to a scale 
 just above the table. (Siemans and Halske.) This vertical mounting 
 with scale that can be read by daylight saves a great deal of room. 
 The galvanometer is braced securely and does not vibrate. To protect 
 it from the dust it is covered with a thin copper hood. The resistance 
 of the moving system is 45 ohms and there is a ballast resistance of 200 
 ohms in series, which, however, is not used. 
 
 Most of the precision switches used were furnished by Siemans and 
 Halske, Catalogue Number 17327. One of similar design was made in 
 our own shop. A new device which has given great satisfaction has 
 been introduced into the switch connecting thermopiles with galvan- 
 ometer. At the start of the experiment, or at any other time when the 
 temperature differences between outer and inner walls are large, a 
 resistance ,of 300 ohms is kept in series. As soon as the calorimeter is 
 in balance a button on the switch is turned and the resistance short- 
 circuited, making the adiabatic control extremely delicate. The Kohl- 
 rausch bridge provided by the Leeds and Northrup Company of Phila- 
 delphia is similar to the one described by Williams. The 60-step 
 rheostat for controlling the temperature of the ingoing water and the 
 four 4S-step rheostats controlling that of the ingoing air, bottom, sides 
 and top of the outer copper wall, were made by the Simplex Heater 
 Company of Cambridge, Mass. They are mounted on the back of the 
 board with their handles projecting through the board to the observer's 
 
28 CLINICAL CALORIMETRY 
 
 table. Just above them on the back of the marble slab are the five tube 
 rheostats (Siemans and Halske) used to cut dovsm the current to 
 various small pieces of apparatus. On the front of the board are the 
 two relays, one for the Williams water heating resistance and current 
 regulator and the other for the Gouy regulator. 
 
 The thermopiles between outer and inner copper walls are arranged 
 in three groups, thirty-two on the top, thirty on the sides and twelve 
 on the bottom, the area covered by each group being warmed by a 
 strand of enamelled "Therlo Wire," No. 24 B & S gauge, whose tem- 
 perature is controlled by one of the step rheostats. 
 
 One thermopile is arranged with one end in the outgoing air current 
 and the other in the ingoing air. The temperature of the latter is 
 adjusted to that of the former by means of a step rheostat and two 
 55 volt lamps. A similar rheostat controls the temperature of the 
 ingoing water by means of the water heating resistance. 
 
 THERMOMETERS 
 
 All thermometers contain 100 ohms resistance in nickel or platinum 
 wire and are made on the three-lead system, being read on the same 
 galvanometer used for the thermopiles. The water thermometers made 
 by Leeds and Northrup are similar to those constructed by them for 
 the automatic calorimeter of the Department of Agriculture. They 
 are described in the Leeds and Northrup catalogue (Bulletin 811) 
 and also by Dickinson and Mueller' of the United States Bureau of 
 Standards. In our hands they have been most satisfactory, since they 
 are more accurate, easier to calibrate, and easier to read than mer- 
 curials. The Leeds and Northrup air thermometer, similar to that used 
 by Williams, is in eight divisions scattered over the inside of the box 
 so as to give the average temperature of the air. They are connected 
 in series by copper wire covered with rubber and a casing of lead, a 
 combination made especially for us which has given good service. The 
 wall thermometer consisting of eight divisions in series was made in 
 this laboratory. Each division was made of No. 38 double silk covered 
 nickel wire wound around a strip of mica and held 2 or 3 .mm. from 
 the inside of the inner copper wall. Over this was soldered a shallow 
 copper box so that the resistance wire would lie in a small air space 
 completely surrounded by metal at the temperature of the wall. 
 
 The rectal thermometer is of a new design made to respond more 
 rapidly to changes in the temperature than the old type in which the 
 resistance wire was surrounded by a jacket of dead air. The nickel 
 wire with its double silk covering is wound on a small piece of ivory 
 
 7. Dickinson and Mueller : New Calorimetric Resistance Thermometers, 
 Bull. Bureau Standards, 1913, ix, 483. 
 
/. A. RICHE—G. F. SODERSTROM 29 
 
 and dipped in a round ended silver tube filled with molten Wood's 
 fusible alloy at a temperature of 96 C. This is solidified by dipping in 
 water, thus forming direct metallic contact between the outside of the 
 silver tube and the insulated wire. The leads from the thermometer 
 are enclosed in a soft rubber tube. The surface thermometers are 
 made of flat circular buttons of ivory 25 mm. in diameter and 5 mm. 
 thick. One side of the button is hollowed out to a depth of 3 mm., the 
 edges being filleted. On the bottom of this depression is wound con- 
 centrically the resistance wire. On this is poured the molten Wood's 
 metal until it is flush with the original level of the ivory. Two of these 
 units are used in series in each of the two surface thermometers. They 
 are strapped to the skin with adhesive plaster and covered with a pad 
 of cotton wool about 20 cm. in diameter and 4 cm. thick, this also being 
 held in place with adhesive plaster. 
 
 The air thermometers were calibrated by the makers and the wall 
 thermometers made to contain exactly the same resistance. Since they 
 are used only to denote relative changes in temperature, a more exact 
 calibration is not necessary. The rectal, surface and water ther- 
 mometers are standardized several times a year by means of very 
 accurate mercurials, certified by the Physikalische Technische Reichs- 
 anstalt. When calibrating them one notices that the electric ther- 
 mometers all respond to temperature changes much more quickly than 
 the mercurials. 
 
 The flexible rubber covered leads from the surface and rectal ther- 
 mometers and the lead covered wires from the wall and air ther- 
 mometers are carried to a ten-wire cable which perforates the calo- 
 rimeter walls and is distributed on a hard rubber plate attached to the 
 calorimeter and thence carried to the switches on the observer's table. 
 The high tension currents from the calorimeter pass to a small hard 
 rubber plate inside the box, thence in a separate strand cable to a slate 
 board outside the calorimeter, and thence to the rheostat board. This 
 cable carries leads for the telephone, electric 'fan and for the resistance 
 coil used in electric checks. 
 
 ACCESSORY APPARATUS 
 
 The telephone, which has been made as light as possible, is seldom 
 used, since the muscular work involved in telephoning is enough to 
 affect seriously the results in rest experiments. The small electric fan 
 placed in a corner at the foot of the calorimeter stirs the air thoroughly 
 and allows one to get a good sample by drawing off ten liters through 
 the large Bohr meter attached to the outgoing air pipe. The fan is run 
 by the Edison storage batteries, giving off approximately 4.5 calories an 
 hour, the exact amount being determined once an hour by a voltmeter 
 and ammeter. 
 
30 CLINICAL CALORIMETRY 
 
 On the right side of the subject is a small glass shelf for the 
 weighed urine bottles which, after each voiding, are placed on a spring 
 balance that can be read through the window. Two small brass tubes 
 are led through the wall of the calorimeter just below the small window. 
 One acts as an emergency vent to prevent a positive or negative pres- 
 sure at the beginning or end of an experiment when the ventilation is 
 stopped. To the other is attached the Bowles stethoscope, which is 
 strapped over the apex of the heart so that an observer outside can 
 count the pulse at frequent intervals. 
 
 The inside of the calorimeter is formed by the polished tinned 
 copper, the roof being almost hidden by the longitudinal absorber pipes 
 wound with brass "jack chain." The calorimeter is wide enough for a 
 man to turn comfortably from side to side, high enough at the foot to 
 allow him to cross his legs and high enough at the head to allow him 
 to sit upright. 
 
 THE BED 
 
 The bed in its present form is the result of much experimentation. 
 The frame is made of varnished oak raised at the head so that the top 
 is 12.7 cm. from the floor of the calorimeter while it is raised only 
 8.2 cm. at the foot. This allows for the sag of the waterproof canvas 
 laced in the frame and keeps the subject 2 to 3 cm. from the copper 
 floor. At the head is a back-rest with a piece of water-proof canvas, 
 which is usually supplemented by a soft pillow. The bed is mounted 
 on a pair of skids so that it can be pushed from the stretcher into the 
 box. The canvas has proved to be much more comfortable than the 
 springs and blankets formerly employed and has the advantage of 
 absorbing very little water vapor. The varnished wood absorbs some 
 water, the necessary clothing of the patient a great deal more, while the 
 polished walls absorb only a minimum. 
 
 ELECTRIC AND ALCOHOL CONTROL EXPERIMENTS 
 
 The calorimeter has been tested repeatedly by dissipating known 
 amounts of heat in resistance coils and by burning known amounts of 
 alcohol. The apparatus and procedure used correspond almost exactly 
 with those described by Williams and are similar to those previously 
 used by Atwater and Benedict and by Benedict, Riche and Emmes.* 
 In calculating the latent heat of the evaporation of water we have 
 adopted the figures of Smith' and have given the latent heat the value 
 of 0.584 large calories per gram of water evaporated at 23 C, the usual 
 experimental temperature. 
 
 8. Benedict, Riche and Emmes : Control Tests of a Respiration Calorimeter, 
 Am. Jour. Physiol., 1910, xxvi, 1. 
 
 9. Smith, A. W. : Heat of Evaporation of Water, Physical Review, 1907, 
 XXV, 14S. 
 
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32 
 
 CLINICAL CALORIMETRY 
 
 It has seemed advisable to publish all the electric and alcohol checks 
 made with the calorimeter. In publishing control tests the results are 
 much more striking if one selects only the best and leaves out those in 
 which the agreement is not close. This method expresses only the 
 minimum error while the things we really need to know are the average, 
 maximum and total errors. The total error shows the accuracy of the 
 method, the maximum error may occur in the course of any experi- 
 ment, while the average error is with us always. The minimum error 
 
 TABLE 2. — Electric Checks 
 
 
 Length 
 
 
 
 
 
 length 
 
 
 
 
 
 ol 
 
 Calories, 
 
 Calories, 
 
 Per Cent. 
 
 
 of 
 
 Calories, 
 
 Calories, 
 
 Per Cent. 
 
 Date 
 
 Period, 
 Min. 
 
 Theory 
 
 Found 
 
 Error 
 
 Date 
 
 Period, 
 Min. 
 
 Theory 
 
 Found 
 
 Error 
 
 3/4/13 
 
 60 
 
 72.2B 
 
 73.19 
 
 +1.2 
 
 11/28/13 
 
 60 
 
 78.22 
 
 77.15 
 
 —1.4 
 
 
 60 
 
 72.25 
 
 72.19 
 
 +0.0 
 
 
 60 
 
 78.22 
 
 77.62 
 
 —0.8 
 
 Average 
 
 
 72.25 
 
 72.69 
 
 +0.6 
 
 
 60 
 
 78.22 
 
 78.67 
 
 +0.6 
 
 4/5/13 
 
 60 
 60 
 
 80.78 
 80.78 
 
 77.26 
 79.31 
 
 —4.4 
 —1.8 
 
 Average 
 
 
 78.22 
 
 77.81 
 
 —0.5 
 
 
 
 
 
 
 1/26/14 
 
 60 
 
 76.92 
 
 75.86 
 
 —1.4 
 
 Average 
 
 •• 
 
 80.78 
 
 78.29 
 
 —3.1 
 
 
 60 
 
 76.92 
 
 77.41 
 
 +0.6 
 
 10/13/13 
 
 30 
 30 
 30 
 SO 
 
 41.74 
 41.74 
 41.74 
 41.74 
 
 42.15 
 41.66 
 41.25 
 41.10 
 
 +1.0 
 —0.4 
 —1.2 
 —1.5 
 
 Average 
 
 60 
 60 
 
 76.92 
 76.92 
 76.92 
 
 77.88 
 77.24 
 77.10 
 
 +1.3 
 +0.4 
 +0.2 
 
 
 80 
 
 41.74 
 
 41.35 
 
 —0.8 
 
 5/11/14 
 
 60A 
 
 78.71 
 
 80.03 
 
 • 
 
 Average 
 
 
 41.74 
 
 41.49 
 
 —0.6 
 
 
 6CB 
 
 78.22 
 
 76.18 
 
 
 10/22/13 
 
 60 
 
 83.98 
 
 83.98 
 
 ±0.0 
 
 
 300 
 
 39.07 
 
 41.35 
 
 
 
 60 
 
 83.98 
 
 83.83 
 
 —0.2 
 
 Total.... 
 
 150 
 
 196.00 
 
 196.56 
 
 +0.3 
 
 
 60 
 60 
 
 83.98 
 83.98 
 
 84.02 
 83.84 
 
 +0.0 
 -0.2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total ol 
 
 
 
 
 
 Average 
 
 
 83.98 
 
 83.92 
 
 —0.1 
 
 all checks 
 
 
 1589.02 
 
 1583.42 
 
 —3.5 
 
 • A, B, C. Temperature changes of wall of calorimeter; A, +0.06 C; B, —0.73 C; C, —0.05 C. 
 Test to verify hydrothermal equivalent. 
 
 is a joy to behold, but it does not occur with the regularity inferred by 
 the prominence it is usually given. If, for instance, we should publish 
 only the electric check of October 22 with an hourly error of 0.2 per 
 cent., and the alcohol check of April 30, in which the total errors in 
 the measurement of heat, oxygen and carbon dioxid are all less than 
 ^ of 1 per cent., we should give a false impression of accuracy. This 
 test shows that the calorimeter is capable of measuring heat, oxygen 
 and carbon dioxid with a maximum error of 1.8 per cent, in three 
 consecutive hours. Even better results could be obtained if greater 
 care were taken to secure an even combustion of alcohol. On the other 
 
/. A. RICHE—G. F. SODERSTROM 
 
 33 
 
 hand, the errors which can occur in hourly periods and in whole experi- 
 ments are shown in Table 3. The average error has been obtained by 
 multiplying each per cent, of error by the number of times it occurs 
 and dividing the total by the number of periods. In the whole series 
 of experiments of three or four hours' duration the average error for 
 heat is 0.9 per cent., for oxygen 1.6 per cent, and for carbon dioxid 
 0.6 per cent., while for the individual hours the error is 1.2 per cent., 
 3.2 per cent, and 1.6 per cent., respectively. The total error in all the 
 
 TABLE 3. — Summary of Errors in Electric and Alcohol Checks 
 
 Per Cent. 
 Error 
 
 Average ol Whole Experiment 
 
 Individual Hours 
 
 Cal. 
 
 Oa 
 
 002 
 
 H2O 
 
 Gal. 
 
 O2 1 CO2 
 
 H2O 
 
 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 4 
 2 
 1 
 
 1 
 1 
 2 
 1 
 
 3 
 
 1 
 I 
 
 2 
 
 1 
 
 1-. 
 
 1 
 
 10 
 15 
 9 
 
 .1 
 7 
 3 
 1 
 
 2 
 2 
 
 1 
 1 
 
 1 
 
 5 
 5 
 5 
 3 
 
 1 
 
 4 
 2 
 4 
 3 
 
 5 
 
 6 
 
 7 
 
 S 
 
 9 
 
 10 
 
 
 
 1 
 
 4 
 
 1 
 
 Total number of 
 experiments or 
 hours 
 
 12 
 
 5 
 
 5 
 
 5 
 
 1 
 39 ! 19 
 
 19 
 
 19 
 
 Average error... 
 
 0.9 
 
 1.6 
 
 0.6 
 
 3.2 
 
 1.2 
 
 3.2 : 1.6 i 3.7 
 
 Total error 
 
 —0.33 
 
 - 
 
 1.69 
 
 —0.68 
 
 +3.09 
 
 
 
 
 
 electric and alcohol checks is: heat, — 0.32 per cent., O, — 1.69 per 
 cent., CO„ — 0.68 per cent. The total error in the water is + 3.09 per 
 cent. 
 
 The electric checks show a smaller error in the measurement of 
 calories than the alcohol, since the dissipation of heat is much more 
 uniform. It is difficult to secure an even flow of alcohol to the burner 
 and the larger errors in the oxygen determination are due to irregu- 
 larities in the flow during the last five minutes of the period. If a 
 slight negative pressure develops within the box toward the end of the 
 period, alcohol is sucked into the burner causing the flame to flare up 
 
34 CLINICAL CALORIMETRY 
 
 and expand the air before the air thermometers record the rise in 
 temperature. This causes an error in the oxygen calculation which, as 
 the tables show, is usually corrected the next hour. With a trained 
 human subject the production of heat and carbon dioxid and the 
 absorption of oxygen are more regular than in the case of an alcohol 
 check and the error presumably not so large. The cause for the nega- 
 tive total error in the measurement of heat, Og and CO2, is not clear, 
 but one cannot help suspecting that a slight absorption of water by the 
 alcohol and a slight evaporation as the alcohol drops from the bottle 
 into the buret may account for most of the error. In experiments on 
 m,an there is another factor which reduces an error in the measurement 
 of oxygen or carbon dioxid considerably. In calculating the indirect 
 calorimetry the factor by which the oxygen or carbon dioxid is multi- 
 plied changes with the respiratory quotient and it happens that a plus 
 error in measurement of the gas is partially offset by a minus change 
 in the factor. This change reduces the error to an extent varying 
 between one-fifth and three-quarters of its original size, unless the 
 errors in both gases are in the same direction, leaving the quotient 
 unaltered. The accuracy of the calorimeter has also been demonstrated 
 by the close agreement of the methods of direct and indirect calorim- 
 etry. This will be taken up in detail in the paper on normal controls, 
 but at this point it may be said that in a total measurement of 4,577 
 calories the two methods agreed within 0.17 per cent., and that in 
 26-hourly periods on the normal control most carefully studied, the 
 agreement was within 5 per cent, in seventeen of the hours. 
 
 In spite of the fact that some of the errors published in the table 
 are larger than those published in connection with other types of 
 apparatus, we feel justified in believing that the Sage calorimeter is 
 the most accurate and most reliable instrument of its size used in the 
 study of the respiratory metabolism. The table includes all the alcohol 
 and electric checks, good, bad and indifferent, made during the period 
 when the machine was used for experiments. The only ones left out 
 are those made at the beginning of the season while the apparatus was 
 being put in order, and actual work was never begun before obtaining 
 a check good enough to publish. To the best of our knowledge this 
 method of publishing all the tests has never been used in connection 
 with other types of respiration apparatus, and we have no detailed 
 information as to their average, maximum and total errors. 
 
 It is to be regretted that we have not been able to make long electric 
 tests to determine the hydrothermal equivalent of the calorimeter. The 
 storage batteries are not powerful enough to furnish current for more 
 than four hours in addition to the preliminary period of 30 to 40 
 minutes, and we have never felt justified in using the house current 
 
/. A. RICHE—G. F. SODERSTROM 35 
 
 with its variations in voltage. Numerous short tests showed that the 
 hydrothermal equivalent was very close to 19 liters of water, and this 
 figure gave results within 0.3 per cent, in the check of May 11 with a 
 large temperature change in the second hour. Incidentally, the advan- 
 tage of a wooden frame is shown by the rapidity with which the box 
 responded to this temperature variation. 
 
 DETERMINATION OF WATER ELIMINATION 
 
 In all types of respiration apparatus the measurement of the water 
 elimination has presented great difficulties. This was studied in detail 
 by Benedict, Riche and Emmes, who found that long experimental 
 periods were required to obtain accurate results. The interior of the 
 Sage calorimeter is tinned and polished and there is very little wood- 
 work and cloth, but still a considerable amount of moisture can be 
 retained within the box. In alcohol checks with a water production of 
 only 10 to 14 grams an hour the air becomes dryer and dryer, and this 
 moisture is given off during the whole test, making uniformly a plus 
 error. In experiments on normal men the water elimination is about 
 twice this amount and the percentage of moisture changes but little 
 from hour to hour. In patients who have a tendency to sweat, the 
 water given off may amount to 35 to 40 grams an hour, and there is a 
 tendency for the percentage in the air to increase steadily and finally 
 reach the point of saturation. We should expect a plus error in the 
 determination as the air becomes dryer, a minus error as the percentage 
 of moisture increases, and no error while equilibrium is being main- 
 tained. After the first hour of an experiment on man it seems fair to 
 expect an error of less than 5 per cent., except in extreme cases of 
 sweating. More accurate results could be obtained only by removing 
 all wood-work, stripping the man naked and increasing the ventilating 
 current. This would involve such artificial conditions that the results 
 would be worthless. 
 
 ADAPTABILITY OF CALORIMETER 
 
 By carefully controlling the rate of flow and the temperature of the 
 water in the heat-absorber it is possible to adapt the calorimeter to wide 
 variations in the heat production of the subjects. For example, on 
 April 23, 1914, an experiment was made on a cretin with an average 
 heat production of 26 calories an hour. The next day the subject was 
 a patient with exophthalmic goiter, whose heat production averaged 
 107 calories. In one case the methods of direct and indirect calorimetry 
 agreed within 0.2 per cent., and in the other within 0.7 per cent. It has 
 also been possible to adapt the calorimeter rapidly to changes in the 
 heat production from hour to hour by changing the temperature of the 
 
36 CLINICAL CALORIMETRY 
 
 ingoing water and in extreme cases by changing the rate of flow at the 
 beginning of a period. 
 
 It has been possible in a long series of experiments for two men to 
 take all the readings and make all the calculations in hourly periods. 
 Three men can handle the apparatus with ease during the trying experi- 
 ments, and most of the alcohol checks, which are much more difficult, 
 have been made with only three in the room. As a rule, the staff arrives 
 shortly before nine o'clock in the morning, makes a three-hour experi- 
 ment, gets everything in readiness for the next day and leaves the 
 calorimeter room about three or four o'clock in the afternoon. It has 
 been possible, on occasions, to make six experiments in a week. The 
 calorimeter has been very seldom out of commission. Between October 
 13, 1913, and May 18, 1914, it was possible to make 113 experiments on 
 man and eight alcohol and electric checks. 
 
 SUMMARY AND CONCLUSIONS 
 
 The original Atwater-Rosa respiration calorimeter with the 
 improvements added by Benedict, Williams and others has been 
 adapted for clinical study in Bellevue Hospital. The form of the 
 apparatus makes it perfectly comfortable for patients. The accuracy 
 is such that in observations lasting three or four hours the heat pro- 
 duction, carbon dioxid elimination and oxygen consumption as deter- 
 mined by alcohol and electric tests can be measured with an average 
 error of 0.9 per cent., 0.6 per cent, and 1.6 per cent., respectively. In 
 periods one hour long the average error for heat measurement was 
 1.2 per cent., for carbon dioxid 1.6 per cent, and for oxygen 
 3.2 per cent. 
 
 The calorimeter never needs more than three men for its operation, 
 and two men have repeatedly made all the readings and all the calcula- 
 tions in hourly periods. 
 
CnNICAL CALORIMETRY 
 
 THIRD PAPER 
 THE ORGANIZATION OF A SMALL METABOLISM WARD* 
 
 FRANK C. GEPHART, A.B., and EUGENE F. DuBOIS, M.D. 
 
 NEW YORK 
 
 All investigators who have attempted to carry on metabolism 
 experiments in hospitals have experienced more or less difficulty in the 
 administration of the diets and the collection of the excreta. The 
 necessity for a special metabolism ward became evident as soon as it 
 was decided to build a respiration calorimeter in Bellevue Hospital. 
 Through the generosity of the trustees of the hospital and the attending 
 staff of the Second Medical Division a small ward holding four or five 
 beds was placed in charge of the medical director of the Russell Sage 
 Institute of Pathology,^ who was also one of the junior members of 
 the attending staff of the hospital. He is directly responsible to the 
 attending physician for the welfare of the patients, and there has 
 always been a spirit of^active cooperation between the small metabolism 
 ward and the large medical wards of the service. 
 
 The calorimeter room described in the preceding paper^ is located 
 on the same floor as the male medical wards of the Second Division 
 in the new Medical Pavilion. The side hall, used as an entrance to the 
 calorimeter room, has been partitioned off to make a small diet kitchen. 
 Next to this is a well lighted ward of four beds used almost exclusively 
 for patients v/hose metabolism is the subject of active investigation. 
 
 The patients are cared for by three graduate nurses, trained in 
 metabolism work and paid by the Institute. The success of the ward 
 is in large measure due to the faithful and intelligent work of the head 
 nurse. Miss Estelle Magill, and her two assistants. They have used 
 the same care in the preparation of food and the collection of excreta 
 that is used in the laboratory and the effort has constantly been made 
 to keep the error within 1 per cent. In order to maintain a high degree 
 of accuracy and at the same time a high standard of nursing it is 
 necessary for the three nurses to devote their whole time to the ward 
 of only four patients. Orderlies, the greatest source of error in metab- 
 
 * From the Russell Sage Institute of Pathology in affiliation with the 
 Second Medical Division of Bellevue Hospital, New York. 
 
 1. Dr. Eugene F. DuBois. 
 
 2. Riche and Soderstrom : See p. 13. 
 
38 CLINICAL CALORIMETRY 
 
 olism work, are excluded from the ward and patients are never allowed 
 in the hospital dining room or kitchen, and only the most trusted are 
 permitted to leave the room at all. These precautions are necessary in 
 order to afford the certainty that the twenty-four-hour specimens of 
 urine are complete and that the patients have not smuggled in outside 
 food. Patients are not allowed out of sight of the nurse in charge for 
 more than a couple of minutes at a time. 
 
 The food supplied to patients in the metabolism ward is all pre- 
 pared by the special nurses, who have become so skilled in the prep- 
 aration of the various dishes that they can even make one-sided diets 
 attractive. In fact, the patients enjoy the cooking so much that they 
 are sent to their homes or to the general hospital ward with difficulty 
 This is a matter of importance when one desires to keep interest- 
 ing cases under observation. The foods are prepared as often as pos- 
 sible from raw materials whose composition is determined from time 
 to time. Milk and cream have been of fairly constant composition, as 
 the analyses over a period of several years have shown. 
 
 By applying some of the principles of business efficiency, the work 
 has been made a great deal easier. The dry cereals, eggs, bacon, etc., 
 are weighed in white enamel dishes and bowls of known weight marked 
 with serial numbers. Milk and cream are measured in measuring 
 cylinders and added to these dishes in which the food is baked, fried 
 or boiled. The dishes with the cooked food are then taken directly to 
 the patient and if by any chance he should leave some of the food it 
 is an easy matter to weigh it back. Egg whites and yolks are weighed 
 separately. Sugars, salt, cocoa, butter, etc., are put up in packages of 
 known weight by the night nurse to save time during the day. 
 
 When a patient first enters the ward the nurses spend a couple days 
 in investigating his dietetic limitations and his dislikes, a matter of 
 great importance. A diet such as the following, for example, is then 
 ordered: 3,000 calories, 15 grams nitrogen, y^ non-protein calories in 
 fat, J^ in carbohydrate. The nurses then work out a diet which will 
 fulfil the .specifications and at the same time be agreeable to the patient. 
 Often by careful work it is possible to educate a patient to a diet that 
 he could not otherwise tolerate. We cannot too strongly emphasize 
 the need of individualization aided by good cooking in experimental 
 metabolism work. 
 
 The method of collecting twenty-four-hour specimens is, we believe, 
 a new one, and since it has proved to be very satisfactory, should be 
 given in detail. A large number of 20-ounce, round, wide-mouthed 
 bottles with cork stoppers are kept in the ward. These have been 
 etched on the side so that one can write on them with a pencil. At 
 5 a. m., the time at which the twenty-four-hour period ends, each 
 
FRANK C. GEP HART— EUGENE F. DU BOIS 
 
 39 
 
 Composition of Foods Used in Metabolism Ward 
 
 Food 
 
 Protein 
 
 Fat 
 
 Carbo- 
 hydrate 
 
 Calories 
 
 per 
 
 Gram 
 
 100 
 Calory 
 Portion 
 
 Beef, chopped 
 
 Beef broth 
 
 Bread, white 
 
 Chicken, minced 
 
 Cabbage, thrice boiled *. . . . 
 Cauliflower, thrice boiled * 
 
 Cocoa, powdered 
 
 Cheese, cottage 
 
 Crackers, soda 
 
 Crackers, sugar 
 
 Cream 
 
 Cream 
 
 Custard 
 
 Custard, hospital diabetic 
 
 Farina, dry 
 
 Flour, hospital diabetic . . . 
 
 Ice cream, vanilla 
 
 Ice cream, chocolate 
 
 Jelly, lemon 
 
 Junket 
 
 Macaroni, dry 
 
 Mammala 
 
 Mammala (separated milk) 
 Mammala (full cream).. . . 
 
 Milk, hospital 
 
 Oatmeal, dry 
 
 Potatoes, mashed 
 
 Pudding, rice 
 
 Pudding, tapioca 
 
 Rice, dry 
 
 Rice, cooked 
 
 Tapioca 
 
 Special Articles — 
 
 Cane sugar 
 
 Corn sirup — glucose 
 
 Corn sirup — glucose 
 
 Gelatin 
 
 Lactose 
 
 Olive oil 
 
 Sherry 
 
 Vinegar 
 
 Whisky 
 
 22.1-48.6 
 
 2.1 
 
 9.8 
 
 18.S 
 
 1.7.=; 
 
 23.1-23.2 
 
 14.9-19.2 
 
 8.3 
 
 6.2 
 
 2.1- 2.9 
 
 2.1-2.9 
 
 5.4 
 
 5.7 
 
 18.9 
 
 23.2 
 
 3.4- 4.8 
 
 3.7 
 
 2.1 
 
 2.1 
 
 13.7 
 
 26.8 
 
 31.7 
 
 10.2 
 
 3.09- 3.1 
 
 15.1 
 
 2.2 
 
 4.1 
 
 5.7 
 
 7.0 
 
 1.4 
 
 2.4-12.8 
 0.2 
 0.3 
 7.2 
 
 19.4-25.2 
 
 0.2- 1.9 
 
 9.3 
 
 10.7 
 
 17.1-19.8 
 
 17.1-19.8 
 3.5 
 5.7 
 0.9 
 1.3 
 
 1.7- 6.9 
 5.5 
 0.2 
 2.1 
 1.2 
 9.6 
 5.4 
 28.2 
 
 3.3- 4.67 
 5.6 
 0.2 
 3.0 
 2.3 
 0.5 
 0.3 
 
 
 
 
 53.5 
 
 
 
 0.24 
 
 0.12 
 48.3-54.0 
 
 
 
 73.2 
 
 80.1 
 
 4.0-5.2 
 
 4.0-5.2 
 
 21.6 
 
 7.3 
 68.2 
 68.2 
 12.2-23.4 
 12.3 
 17.1 
 16.6 
 77.5 
 
 4.10- 4.7 
 71.2 
 18.0 
 24.8 
 14.8 
 81.9 
 13.1 
 91.1 
 
 1.3- 2.0 
 0.1 
 2.6 
 
 l.S- 1.5 
 
 4.8- 5.3. 
 
 0.6- 0.9 
 4.3 
 4.5 
 1.9-2.1 
 1.9-2.1 
 1.4 
 1.1 
 3.7 
 3.9 
 
 1.0- 1.6 
 1.2 
 0.9 
 1.0 
 3.9 
 4.2 
 4.0 
 5.5 
 0.6 
 4.1 
 0.9 
 1.5 
 1.1 
 3.8 
 0.6 
 3.7 
 
 50- 79 
 
 1000 
 
 38 
 
 69 
 
 19-21 
 
 118-164 
 
 24 
 
 22 
 
 48- 53 
 
 48-53 
 
 70 
 
 94 
 
 27 
 
 26 
 
 61-99 
 
 85 
 
 111 
 
 104 
 26 
 24 
 26 
 18 
 
 166 
 24 
 
 118 
 68 
 94 
 27 
 
 159 
 27 
 
 Sucrose 100 per cent 
 
 Glucose, 41.3 per cent. ; dextrin, 33.9 
 
 per cent. ; sucrose, 2.7 per cent. 
 Glucose, 42.4 per cent. ; dextrin, 44.6 
 
 per cent. ; sucrose, 0. 
 
 Lactose, 98.4 per cent 
 
 Alcohol by volume, 19.45 per cent. ; 
 
 Carbohydrate, 1.96 per cent. 
 Acetic acid, 4.07 per cent. 
 Alcohol by volume, 41.76 per cent. 
 
 3.96 
 3.07 
 
 37.0 
 9.52 
 1.46 
 
 2.96 
 
 25.2 
 32.6 
 
 27.0 
 10.5 
 68.5C.C. 
 
 33.8c.c. 
 
 * Cooked in three changes of water. 
 
40 CLINICAL CALORIMETRY 
 
 patient is given a bottle and made to empty his bladder. The 
 bottle is then marked with his name, the date, the hour and minute. 
 The volume is estimated for clinical purposes by comparison with a 
 calibrated bottle of the same capacity. The data are then recorded on a 
 special slip of paper to go to the laboratory and also on the diet chart. 
 A little toluene is added to the urine bottle, which is corked and stored 
 in the ice-box along with the previous voidings of that twenty-four- 
 hour period, each voiding being in a separate bottle. At about 9 o'clock 
 in the morning the laboratory man checks up the bottles with the 
 records on the laboratory slip, and with the nurse's notes takes all 
 the bottles to the laboratory, measures the volume accurately, makes 
 up to volume and analyzes a sample. 
 
 The only disadvantage of this system is the labor of carrying a 
 number of half-filled bottles, although this is not great if suitable 
 carriers are used. The advantages are as follows: 1. There is no 
 chance of a specimen of urine having been poured into another patient's 
 bottle thus spoiling two twenty-four-hour specimens. 2. If a single 
 voiding is lost the urine for the remainder of the day can be accurately 
 analyzed. 3. The urine can be fractionated and the nitrogen elimina- 
 tion determined in hourly periods, as is frequently done in calorimeter 
 experiments. 4. The bottles make excellent urinals, are less apt to spill 
 than the ordinary ward urinal and are not unsightly even when filled 
 with urine. 5. Since the urines are made up to volume in the labora- 
 tory, it is possible to rinse out each bottle with distilled water and 
 collect every drop of urine. 6. The bottles are washed, dried, and, if 
 necessary, sterilized in the laboratory, so that there is no danger of a 
 patient voiding into a urinal containing decomposing urine. 7. The 
 bottles are cheap and can be kept on hand in large numbers, so that the 
 patients need never wait for the urinal. 8. While we have never had 
 occasion to use them in a general ward, there is no reason why they 
 should not be used instead of the common type of expensive and 
 unsightly tirinal. In collecting single specimens for the usual routine 
 analysis the nurse could put a bottle by each bed in the morning and 
 send the desired specimens directly to the ward laboratory without 
 transferring to a special jar. It is surprising how long urines will 
 remain clear if voided into and kept in a clean bottle. 
 
 The collection of feces is somewhat more difficult. Patients who 
 can get out of bed defecate into a weighed bucket in the commode. This 
 bucket is then weighed again. A Httle formalin is added and the whole 
 sent to the laboratory where the specimen is thoroughly mixed and 
 one-tenth removed to be dried and added to the other aliquot portions 
 of that period and analyzed. Bed-ridden patients use a weighed bed 
 pan from which the feces are transferred to a covered bucket for 
 
FRANK C. GEPHART— EUGENE P. DU BOIS 41 
 
 transportation. Most of the patients with acute diseases are given 
 every morning an enema of hypertonic salt solution. Oil and soap 
 enemas of course interfere with the accuracy of the fat analyses ; 
 glycerin enemas make it impossible to dry the feces. To divide the 
 periods, powdered carmin (0.3 gm., 5 grains) is given with the first 
 meal of the period and with the first meal after the period is ended. 
 Experience has shown that it is much easier to determine the exact 
 point of appearance of the carmin in the feces than to find the point of 
 disappearance. When patients are being given enemas it is easier to 
 discover traces of carmin than traces of charcoal. Periods are made 
 as long as possible to minimize the errors of division. 
 
 A special diet sheet has been provided by the hospital on which 
 the nurses record the weights of raw material given to the patient and 
 make the calculations from the table of known composition of the food. 
 On this sheet is a summary column giving carbohydrate, fat and pro- 
 tein grams and calories, total calories, nitrogen of the food, of the 
 urine, of the total excreta and the nitrogen balance; weight of the 
 patient and food calories per kilogram. In another place are columns 
 for recording the time and amount of each voiding and each defecation. 
 
 Patients are weighed at 9.00 a. m. every day or every other day on 
 a "silk scale" accurate to 10 grams. Bed patients are weighed on a 
 platform resting on these scales in the manner described by Coleman.^ 
 The nurse slides the patient on the smooth platform which is just at 
 the level of the bed, weighs him and then makes, up the bed while he 
 is still on the balance. The whole procedure has been found to be a 
 convenience for the nurse rather than a time-consuming task. 
 
 Nitrogen determinations are made by the Kjeldahl method, 
 ammonia, uric acid, creatin, creatinin, and indican by Folin's* methods, 
 urea and glucose by the methods of Stanley R. Benedict.' 
 
 The calorific value of the foods has been determined by means of 
 the Riche° bomb calorimeter. Food fat analyses have been made in a 
 Soxhlet apparatus. Carbohydrates were determined by a difiference 
 using in the later work a new procedure described by Gephart.'' The 
 
 3. Coleman: Diet in Typhoid Fever: Journal Am. Med. Assn., 1909, liii, 
 114S. 
 
 4. Folin: Approximately Complete Analysis of Thirty Normal Urines, Am. 
 Jour. Physiol., 1905, xiii, 4S. 
 
 5. Benedict : The Detection- and Estimation of Glucose in Urine, Jour. Am. 
 Med. Assn., 1911, Ivii, 1193. The Estimation of Urea in Urine, Jour. Biol. 
 Chem., 1910, viii, 405. 
 
 6. Riche : An Improved Type of Calorimeter for use with any Calorimetric 
 Bomb, Jour. Am. Chem. See, 1913, xxxv, 1747. 
 
 7. Gephart, Frank C, and Csonka : In the Estimation of Fat in Feces, Jour. 
 Biol. Chem., 1914, xix, 521. 
 
42 CLINICAL CALORIMETRY 
 
 dried feces were powdered and the fat determined at first by the 
 Kumagawa-Suto method and later by the new saponification procedure 
 described by Gephart/ In calculating food values, Rubner's factors 
 were used, namely : for fat 9.3 calories ; for carbohydrate and protein, 
 4.1 calories per gram. 
 
 8. Kumagawa and Suto: Ein neues Verfahren zur quantitativen Bestim- 
 mungen des Fettes und der unverseifbaren Substanzen in tierschen Material 
 nebst der Kritik einiger gebrauschlischen Material, Biochem, Ztschr., 1908, 
 viii, 212. 
 
CLINICAL CALORIMETRY 
 
 FOURTH PAPER 
 
 THE DETERMINATION OF THE BASAL METABOLISM OF 
 NORMAL MEN AND THE EFFECT OF FOOD* 
 
 FRANK C. GEPHART, A.B., and EUGENE F. DuBOIS, M.D.f 
 
 NEW YORK 
 TABLE OF CONTENTS 
 
 1. Introduction. 
 
 2. Review of literature on basal metabolism. 
 
 3. Review of literature on specific dynamic action of foods. 
 
 4. Experimental procedure. 
 
 5. Description of subjects and details of experiments. 
 
 6. Tables of experimental data. 
 
 7. Discussion of results : 
 
 a. Comparison of direct and indirect calorimetry. 
 
 b. Comparison of surface and rectal temperature. 
 
 c. Selection of the average normal standard. 
 
 d. Variations from this standard found in normal individuals. 
 
 e. Calories per square meter versus calories per kilogram. 
 
 f. Increased metabolism following the ingestion of protein and carbo- 
 
 hydrate. 
 
 8. Summary and conclusions. 
 
 The importance of the normal control has been emphasized so 
 strongly by the serologists and the management of the control has been 
 developed by them to such an art that it has seemed advisable to apply 
 some of their methods of critique to the study of the respiratory 
 metabolism. Serologists insist that a man shall make his own controls 
 with the same apparatus and exactly the same technic as in the experi- 
 ments and they also insist that the controls shall be numerous enough 
 to show individual variations in their true proportions. These precau- 
 tions and many others have been made necessary by the fact that the 
 normal control is usually the point of attack in serological contro- 
 versies. Likewise in the study of metabolism the normal control is 
 coming to be recognized as the weakest part of the experiment. The 
 chemical methods of blanks and duplicates will not suffice; the living 
 organism is the uncertain factor. The literature is notoriously filled 
 with false theories, of which by far the greater part would never have 
 been promulgated if sufficient attention had been given to normal 
 controls. 
 
 * From the Russell Sage Institute of Pathology, in affiliation with the 
 Second Medical Division of Bellevue Hospital. 
 
 t With the technical assistance of G. F. Soderstrom and R. H. Harries. 
 
44 CLINICAL CALORIMETRY 
 
 The three papers immediately preceding have described the Sage 
 respiration calorimeter in Bellevue Hospital and its adjoining metab- 
 olism ward. Before presenting any of the work in pathological con- 
 ditions it has seemed best to study in detail the results obtained on the 
 normal controls. It was the original intention to use a large number of 
 normal subjects and determine the individual variations in metabolism, 
 but this laborious piece of work was gladly abandoned when it was 
 learned that Benedict and his collaborators were engaged in the task. 
 In pathological conditions the work has been confined as ihuch as pos- 
 sible to men between the ages of 20 and 50 who do not depart very 
 markedly from the normal relationship between height and weight. 
 Consequently the normal controls have been selected to comply with 
 these requirements. 
 
 BASAL METABOLISM 
 
 As a basis of comparisons between all normal individuals and 
 groups of patients the heat production in the morning from fourteen 
 to eighteen hours after the last meal with the individual at complete 
 rest, was selected. This has been termed the "nuchtern" metabolism 
 by the Germans, the "post-absorptive" by Benedict and Cathcart,^ but 
 the simplest and most satisfactory term is "basal metabolism," a trans- 
 lation of the German Grundumsatz, as used by Lusk and his coworkers^ 
 in the series of papers published under the heading of Animal Calo- 
 rimetry. 
 
 The literature of the respiratory metabolism of healthy men has 
 been admirably reviewed by Benedict and Carpenter^ in 1910 and 
 Loewy* in 1911. In the former monograph the results of a large 
 number of experiments with the respiration calorimeter of Wesleyan 
 University are gathered in numerous tables. During the so-called rest 
 experim.ents, however, the subjects were allowed to move about the 
 room and indulge in minor muscular activities, something which had 
 
 1. Benedict and Cathcart : Muscular Work, Carnegie Institution of Wash- 
 ington, 1913, Pub. 187. 
 
 2. Lusk: Caloriraetric Observations, Med. Rec, New York, 1912, Ixxxii, 
 925 ; Williams, Riche and Lusk : Animal Calorimetry, Second Paper. Meta- 
 bolism of the Dog Following the Ingestion of Meat in Large Quantity, Jour. 
 Biol. Chem., 1912, xii, 349; Lusk: Third Paper, Metabolism After the Inges- 
 tion of Dextrose and Fat, Including the Behavior of Water, Urea and Sodium 
 Chlorid Solutions, Ibid., 1912, xiii, 27; Lusk: Fifth Paper, The Influence of 
 the Ingestion of Amino-Acids upon Metabolism, Ibid., 1912, xiii, 155; Lusk: 
 Sixth Paper, The Influence of Mixtures of Foodstuffs Upon Metabolism, Ibid., 
 1912, xiii, 185. 
 
 3. Benedict and Carpenter : The Metabolism and Energy Transformations 
 of Healthy Man During Rest, Carnegie Institution of Washington, 1910, Pub. 
 126. 
 
 4. Loewy : Oppenheimefs Handbuch der Biochemie der Menschen und der 
 Thiere, Jena, 1908, iv,' 172. 
 
FRANK C. GEPHART— EUGENE P. DU BOIS 45 
 
 been permitted in practically all the large respiration chambers. Bene- 
 dict and Carpenter measured the increased heat production caused by 
 certain simple movements which their subjects had performed during 
 the experiments. The act of rising from a chair, taking one or two 
 steps, opening the food aperture, removing the food, closing the 
 v/indow and returning to the chair required only 19 to 29 seconds, but 
 involved the expenditure of 1.22 calories. Considering the short time 
 involved in the operation, the heat production was increased from 200 
 to 300 per cent. They also found the metabolism IS per cent higher 
 when the subject was standing than when he was sitting, and from 8 
 to 10 per cent, higher when lying awake than when sleeping. The 
 sleeping periods were between 1 a. m. and 7 a. m., and the waking 
 periods followed immediately in the three experiments which were 
 really satisfactory. During the waking periods there was an increase 
 in the oxygen consumption amounting to 1.7, 0.9 and 11.5 per cent., 
 while the heat production was increased 5.8, 15.2 and 13.1 per cent. 
 Some of this increase may be accounted for by difference in the time 
 of day, some by small muscular movements. Johansson^ found that 
 with complete muscular relaxation the carbon dioxid production was 
 the same as during sleep. The two individuals (H. C. K. and H. R. D.) 
 studied by Benedict and Carpenter produced during sleep 35.2 and 
 36.2 calories per square meter of body surface, whereas only three of 
 the twelve normal men, whose metabolism is recorded in Table 3, pro- 
 duced more than 35.1 calories per square meter per hour. It is obvious 
 that if the metabolism of H. C. K. and H. R. D. were increased 5.8 per 
 cent., 15.2 per cent, and 13.1 per cent., this increase would carry them 
 just so much farther into the zone where it is necessary to assume 
 muscular activity to account for the abnormally high metabolism. 
 
 In anticipation it may be well to mention that the average basal heat 
 production of the individuals we are reporting is 34.7 calories per 
 square meter per hour, the subjects lying awake, at perfect rest during 
 the morning hours. The average heat production of the nineteen sub- 
 jects of Benedict and Carpenter while asleep between the hours of 
 1 a. m. and 7 a. m. was 35.3 calories and of fifty-five individuals while 
 awake and moving from time to time in the calorimeter was 49.2 
 calories per square meter per hour. The fact that their sleeping sub- 
 jects showed a metabolism 3 per cent, higher than our subjects awake 
 may substantiate the conclusions of Johansson. Benedict and Car- 
 penter pointed out at the 'conclusion of their monograph (p. 246) the 
 fact that the figure 49.2 calories per square meter per hour, equaling 
 
 5. Johansson : Ueber die Tageschwankungen des Stoffwechsels und der 
 Korpertemperatur in niichternem Zustande und vollsandige Muskelruhe, Skand. 
 Arch. f. Physiol., 1898, viii, 85. 
 
46 CLINICAL CALORIMETRY 
 
 36.5 calories per kilogram per day, represented not the condition of 
 true rest, but rather that of a person confined for the day to a small 
 room but allowed to dress and undress, sit in a chair, feed himself, etc. 
 Since the appearance of this monograph Benedict and his coworkers, 
 and also other investigators, have insisted more and more strongly on 
 the necessity of absolute quiet in rest experiments and as a check on 
 muscular activity a graphic record of all movements. This eliminates 
 for our purposes practically all the work done in large respiration 
 chambers before 1910 and leaves us only the work done by means of 
 the small types of apparatus, and especially the Zuntz-Geppert appa- 
 ratus, by Magnus-Levy and Falk,^ and by Loewy. The results of the 
 determinations on nineteen normal individuals have been collected 
 in a table by Loewy' which is reprinted by Benedict and Joslin.' 
 Coleman and DuBois,'' in gathering normal controls to compare with 
 their typhoid patients, grouped these cases of Loewy with twenty-seven 
 normal controls taken from the work of Benedict and Joslin, and with 
 two of their own cases. The average heat production of the total 
 forty-eight normal men was 33.7 calories per square meter of body 
 surface per hour. Very recently Benedict, Emmes, Roth and Smith^" 
 published a brief report of their important work on the basal metab- 
 olism of a total of eighty-nine men and sixty-eight women. The early 
 appearance of these determinations has been of great service to us, 
 and we wish to express our appreciation to these investigators for the 
 publication of the most essential part of their data.* All their deter- 
 m.inations were made on healthy subjects in the morning at least twelve 
 hours after the last meal, with the subject at complete rest. Some of 
 the experiments were made in the bed calorimeter of the Nutrition 
 Laboratory of Boston, but most of them^ were short experiments made 
 with the small Benedict "universal respiration apparatus." The fact 
 that this small machine gives results almost identical with the calorim- 
 eter was amply proved by Benedict^ and his coworkers and confirmed 
 by the limited amount of work done with both types of apparatus by 
 
 6. Magnus-Levy and Falk: Der Lungengaswechsel des Menschen in ver- 
 schiedenen Alterstufen, Arch. f. Anat. u. Physiol., 1899, Supp. 314. 
 
 7. Loewy: Oppenheimer's Hand, der Biochemie der Menschen und der 
 Thiere, Jena, 1908, iv,' 179. 
 
 8. Benedict and Joslin : Metabolism in Diabetes Mellitus, Carnegie Insti- 
 tution of Washington, 1910, Pub. 136; A Study of Metabolism in Severe Dia- 
 betes, ibid., 1912, No. 176. Ueber der Stoff- und Energieumsatz bei Diabetes, 
 Deutsch. Arch. f. klin. Med., 1913, cxi, 333. 
 
 9. Coleman and DuBois: The Influence of the High Calory Diet on the 
 Respiratory Exchanges in Typhoid Fever, The Archives Int. Med., 1914, 
 xiv, 168. 
 
 10. Benedict, Emmes, Roth and Smith : The Basal, Gaseous Metabolism of 
 Normal Men and Women, Jour. Biol. Chem., 1914, xviii, 139. 
 
 * A more complete discussion of the work is appearing in the Jour. Biol 
 Chem., March, 1915. 
 
FRANK C. GEPHART— EUGENE F. DU BOIS 47 
 
 Coleman and Du Bois.^ The average heat production of the eighty- 
 nine men was 34.7 calories per square meter per hour, and of the sixty- 
 eight women, 32.2 calories. The lower heat production of women is 
 in accord with the previous findings of Sonden and Tigerstedt.^^ 
 
 The work of Magnus-Levy and Falk" showing the diminution of 
 metabolism in old age and the increase in youth is also confirmed. The 
 two men over 50 years of age produced only 28.9 calories per square 
 meter. The eight youths between 17 and 20 averaged 37.1 calories, 
 nine who were 20 years old, 36.6 calories, seven who were 21 years 
 old, 36.1 calories. 
 
 SPECIFIC DYNAMIC ACTION OF FOODS 
 
 The subject of the specific dynamic action of foods in increasing 
 metabolism is fully discussed by I.usk^^ in his text-book and in a series 
 of papers on animal calorimetry.''' ^' 
 
 From his work on dogs, Lusk has concluded that the specific 
 dynamic action of protein is due to the stimulation of the metabolism 
 of the cells by certain of the amino-acids while the action of fat and 
 carbohydrates is due to the mass action of these metabolites in the 
 circulation. He has found marked differences in the action of the 
 various amino-acids and the various carbohydrates. The study of the 
 specific dynamic action of foods on man is not nearly as far advanced 
 as in the case of the dog. Magnus-Levy^* in connection with his work 
 on dogs found that after giving a man 50 to 60 grams of carbohydrate 
 the metabolism was increased in the first hour from 2 to 12 per cent., 
 in the second hour to 7 per cent. After 140 to 160 grams of starch 
 in bread the increase in the first hour averaged 22 per cent., the second 
 hour 14 per cent., the third hour 16 per cent. After 210 grams of 
 bacon and butter the metabolism was increased 5 to 10 per cent, for 
 seven to eight hours, while after 210 to 250 grams of beef the oxygen 
 consumption rose from 3 to 12 per cent, the first hour and then 15 to 
 34 per cent, in the next six hours. Gigon^' obtained similar results 
 using a Jacquet apparatus. In the period of four to five hours follow- 
 ing the ingestion of 100 grams of dextrose there was an increase of 9.5 
 per cent, in the oxygen consumption. After 50 grams of casein the 
 oxygen was increased 5.5 per cent, and after 100 grams 16.8 per cent 
 
 11. Sonden and Tigerstedt: Untersuchungen iiber die Respiration und den 
 Gesammtestoffwechsel des Menschen, Skand. Arch. f. Physiol., 1895, vi, 99. 
 
 12. Lusk: The Science of Nutrition, Philadelphia, 1909, second edition; 
 Stofifwechsel und Ernahrung; Deutsche Uebersetzung von L. Hess, 1910. 
 
 13. Lusk : The Cause of the Specific Dynamic Action of Protein, The 
 Archives Int. Med., 1913, xxi, 485. 
 
 14. Magnus-Levy: Ueber die Grosse des respiratorische Gaswechsels unter 
 dem Einfluss der Nahrungsaufnahme, Arch. f. d. ges. Physiol. (Pfltiger's), 
 1894, Iv, 1. 
 
 15. Gigon: Ueber den Einfluss der Nahrungsaufnahme auf den Gaswechsel 
 und Energieumsatz, Arch. f. d. ges. Physiol. (Pfliiger's), 1911, cxl, 509. 
 
48 CLINICAL CALORIMETRY 
 
 EXPERIMENTAL PROCEDURE 
 
 The normal controls who were kept in the metabolism ward were 
 given a maintenance ration, the last meal of the day being about 5 p. m. 
 At 5 a. m. they were awakened, given an enema, and instead of break- 
 fast, a cup of coffee without cream or sugar. At about half past nine 
 the calorimeter bed was wheeled to the ward on the weighing platform, 
 which is provided with large' casters, and the subject lifted from his 
 bed, weighed, rolled back to the calorimeter room and slid into the 
 calorimeter, bed and all. He was dressed in a night shirt, thick ward 
 pajamas and thick socks, and, as a rule, the legs were covered with a 
 sheet, although some subjects needed a thin blanket and others required 
 no covering. A soft pillow was placed under the head and sometimes 
 one under the knees. Every effort was made to ensure absolute com- 
 fort, a matter of great importance in work on the respiratory 
 metabolism. 
 
 Those normal controls who lived at home took their evening meal 
 at 6 or 7 o'clock, rose at 6 or 7 a. m., drank a cup of black coffee, 
 took the street car, walked about % mile and arrived at the hospital at 
 9 o'clock. They then undressed, weighed themselves, dressed in warm 
 pajamas and entered the calorimeter. 
 
 As soon as the subject was in the calorimeter the rectal ther- 
 mometer was inserted about 12 cm. in the rectum, giving slight discom- 
 fort for a few minutes, but later remaining in position without the 
 man's being conscious of its presence. The surface thermometers were 
 next fastened tightly to the thorax, axillae or abdomen by means of 
 adhesive plaster and the whole covered with a pad of absorbent cotton 
 abottt 20 cm. in diameter and 3 or 4 cm. thick, this being held in place 
 by strips of adhesive. The Bowles stethoscope was next strapped over 
 the apex of the heart and the whole covered with night shirt and 
 pajamas. When this was finished the bed was shoved all the way into 
 the box, the ventilation started, and at about a quarter past 10 the glass 
 plates were sealed in the end of the calorimeter and the heavy front 
 put in position, making it possible to start the preliminary period 
 shortly after half past ten. 
 
 The actual preparation of the calorimeter had begun long before 
 this. On the previous afternoon all sulphuric bottles, soda-lime con- 
 tainers, etc., had been filled and the oxygen tank weighed so that any 
 leakage over night might be detected. The temperature of the calorim- 
 eter room had been watched every hour by the night nurse and main- 
 tained within 1 degree of the standard experimental temperature of 23 
 C. At nine in the morning the water circulation through the various 
 cooling coils and the absorber had been started and a lighted 32 candle 
 power electric lamp placed in the box until the subject was ready. If 
 
FRANK C. GEPH ART— EUGENE F. DU BOIS 
 
 49 
 
 these precautions had been carefully followed and if the observer had 
 watched the temperature of the various parts of the apparatus, it was 
 possible to bring the box into perfect equilibrium and control fifteen to 
 twenty minutes after the start of the preliminary period. As we shall 
 see later, there is reason to believe that during the first hour after the 
 box is sealed the wooden frame of the bed may absorb a little heat 
 owing to its proximity to the subject's body. 
 
 As a rule the preliminary period lasts thirty to forty minutes and 
 the experiment begins shortly after 11 o'clock. Eight minutes before the 
 start a sign is hung in the window telling the subject to remain abso- 
 lutely quiet and the first residual sample of ten liters of air is drawn 
 through U tubes by means of the Bohr meter. At four or five minutes 
 before the start the second residual is begun and a tracing of the 
 spirometer curve made in the manner first used by Benedict and Car- 
 penter. At "time" the various cocks and switches are turned 
 
 TABLE 1. — The Statistics of the Normal Controls 
 
 Subject 
 
 Weight, 
 Kg. 
 
 Height, 
 Cm. 
 
 Chest 
 
 Circumference, 
 
 Cm. 
 
 Age, 
 Trs. 
 
 G. L 
 
 78.4 
 
 73,6 
 75.5 
 
 56.5 
 
 62.0 
 
 59.5 
 
 51.7 
 
 70.9 
 
 175.5 
 178.8 
 
 173.9 
 177.2 
 170.6 
 
 90.5 
 91.5 
 
 80.2 
 85.3 
 86.6 
 
 47 
 
 E. P. D. B. ... 
 
 31-32 
 
 F. C. G 
 
 E. H. H 
 
 L. 0. M 
 
 29 
 21 
 22 
 
 
 2? 
 
 
 44 
 
 
 
 as described in the previous article. One or two minutes after 
 "time" the subject is allowed to shift his position, and, if neces- 
 sary, void into a tared urine bottle which he then places on a small 
 spring balance so that the exact weight of urine passed can be read 
 through the calorimeter window. During the remainder of the hour 
 he lies as quiet as possible trying not to turn from back to side and 
 vice versa more than once an hour. The work-adder on the spirometer 
 records each movement and the electrical control of the calorimeter is 
 so delicate that the observer in charge of the thermometers can detect 
 such slight activity as turning the head to look out of the window by 
 the rise in the temperature of the air and wall. At the close of the 
 first and subsequent hours the procedure is the same as at the start, 
 except that only one sample of residual air is analyzed. 
 
 The statistics of the normal controls are as shown in the accom- 
 panying table (Table 1). 
 
so CLINICAL CALORIMETRY 
 
 DESCRIPTION OF SUBJECTS AND DETAILS OF EXPERIMENTS 
 
 G. L., physiologist, large frame, slightly adipose. Has taken but little exer- 
 cise during the last few years. Health good, no recent illnesses. Physical 
 examination negative. 
 
 Experiment 1. — March 11, 1913. Although this was the first experiment 
 on man made with the Sage calorimeter, the accuracy of the machine had been 
 thoroughly tested by means of the alcohol checks described in Paper 2. The 
 temperature of the air in the calorimeter was 24.S C. in this experiment instead 
 of the temperature of 23 C. used later. In addition to a suit of pajamas, the 
 subject wore a heavy sweater. The basal metabolism was determined in the 
 first two hours and at the beginning of the third hour he drank a solution of 
 115 grams commercial glucose (dextrose 42.37 per cent., dextrin 44.57 per 
 cent., water 13.50 per cent.) in SCO c.c. water and 10 c.c. lemon juice. The 
 commercial glucose was equivalent in calories to 100 grams dextrose. The 
 subject, who had felt somewhat too warm during the first two hours, perspired 
 profusely after the glucose. He remained very quiet during the five hours. 
 
 E. F. D. B., physician, large frame, moderate adipose. Up to the age of 
 22 in good athletic condition ; since then has exercised in steadily decreasing 
 amounts. During the winter of 1913 took violent exercise for about half an 
 hour twice a week; in 1914 scarcely exercised at all. General health good; 
 no recent illnesses. Heart, lungs, etc., normal. 
 
 Experiment 2. — March 13, 1913. The basal metabolism was determined in 
 the first two hours, and at the beginning of the third hour he drank 115 grams 
 commercial glucose in the same solution as in the experiment on G. L. The 
 temperature of the calorimeter was 22 C. and his clothing consisted of thin 
 undershirt and pajamas. He did not perspire but blew his nose several times 
 each hour, spent a good deal of the time looking out of the window and was 
 distinctly more restless than in the subsequent observations. 
 
 Experiment 25. — May 17, 1913. Basal determination only. Was very quiet 
 during all three hours and dozed from 11:30 to 11:50. 
 
 Experiment 27. — May 22, 1913. At 8:55 a. m., before entering the calo- 
 rimeter, drank 230 gm. commercial glucose (equivalent to 200 gm. dextrose) in 
 500 c.c. water and 15 c.c. lemon juice. Six minutes were required to drink the 
 mixture. Dozed at times during the experiment. 
 
 Experiment 115. — March 30, 1914. Basal metabolism only. This experi- 
 ment was conducted by only two observers, Mr. Soderstrom and Mr. Harries, 
 and the periods were made one and one-half hours long to give them more 
 time for weighings, etc. In the subsequent experiments on this subject these 
 two observers alone were able to make all measurements and keep up with 
 the calculations in hourly periods, a record of which they may well be proud, 
 especially since the agreement between the direct and indirect calorimetry 
 was unusually good. 
 
 Experiment 116. — April 1, 1914. Just before entering the calorimeter between 
 9:45 and 10:07 a. m., the subject ate the following meal containing 10.5 gm. 
 nitrogen: fat-free milk, 600; pot cheese (cottage cheese or Schmierkdse), 150; 
 egg-white, 120; egg-yolk, 20. During this experiment the work-adder was 
 out of order and recorded part of the excursions of the spirometer due to 
 the admission of oxygen to the box. The subject was very quiet, much more 
 quiet than the work-adder record would indicate. 
 
 Experiment 138.— May 8, 1914. Between 10:05 and 10:07 a. m., drank a 
 solution of 200 gm. C. P. Dextrose (Merck) in 400 c.c. water and 35 c.c. 
 lemon juice. No glycosuria resulted in this or any other of the experiments 
 on normal controls. 
 
 Experiment 141. — May 15, 1914. An attempt was made to raise the respira- 
 tory quotient as high as possible by filling the glycogen stores of the body 
 
FRANK C. GEPHART— EUGENE F. DU BOIS 51 
 
 before giving the dextrose. At 11 :30 the night before the experiment and 
 again at 6:15 in the morning the subject ate the following carbohydate meal: 
 shredded wheat, SS gm. ; milk, 100 c.c. ; cane sugar, 10 gm. ; in the morning 
 taking an additional 10 gm. cane sugar in coffee. Between 9:50 and 9:53 he 
 drank a solution of 200 gm. C. P. Dextrose in 400 c.c. water and 35 c.c. lemon 
 juice. 
 
 F. C. G., chemist, thin. At age of 16 had an attack of malaria lasting two 
 weeks. Has not been sick in bed since then and has never weighed over 64 kg. 
 (140 pounds). Has never taken systematic exercise, except baseball from 1900 
 to 1906. Appetite fair, sleeps well. Physical examination : complexion pale and 
 somewhat sallow; hemoglobin normal; state of nutrition rather poor; heart, 
 lungs and abdomen normal. Experiment 142, May 18, 1914. Basal determin- 
 ation. 
 
 Experiment 3. — March 17, 1913. The basal metabolism was determined 
 between 9:02 and 12:02, the subject going into a profound sleep in the second 
 and third hours. The calorimeter was then opened and the subject ate the 
 Haferschleim mixture of Schmidt's test diet. This contained 40 gm. dry oat- 
 meal, 10 butter, 200 milk and one egg, or approximately, protein, 13.1, fat, 10.2, 
 carbohydrate, 35.5 gm. At the end of the observation it was apparent that 
 the respiratory quotients were abnormally low and that the apparent oxygen 
 consumption was much higher than was consistent with the direct calorimetry. 
 The cause for this was found in a leak in the oxygen cylinder, making it 
 necessary to omit the oxygen figures from the data and base the calculations 
 on the direct calorimetry alone. 
 
 Experiment 17. — April 22, 1914. Basal determination. The subject remained 
 very quiet, but took care not to go to sleep. Unfortunately the oxygen cylinder 
 leaked again and the calculation of the indirect calorimetry was not accurate. 
 
 R. H. H., chemist, tall and spare with long and rather thin bones, very little 
 adipose. At the age of 12 had pneumonia, since then always well. Up to 
 four years ago played semiprofessional baseball or basketball almost every 
 day. Since 1910 his exercise has been limited to four to ten miles of walking 
 a day and in summer a swim of about two miles a day. Physical condition 
 good, heart, lungs and abdomen normal. 
 
 Experiment 4. — March 13, 1913. Basal determination. During the experi- 
 ment this subject tried to void at the beginning of each hour but was unable 
 to do so and was slightly more nervous and more active than the other sub- 
 jects. He could not void before his first meal after the experiment and it 
 has therefore been necessary to omit the figures for the urinary nitrogen and 
 base the calculations on the tables of Magnus-Levy," assuming that IS per 
 cent, of the calories were derived from protein. 
 
 Louis M., barber, small frame, short and thin, muscles fairly firm. This 
 subject was in the hospital from September 7 to October 30, 1912, with a 
 moderately severe attack of typhoid fever, and served as a subject of numer- 
 ous observations by means of the Benedict universal respiration apparatus 
 (Coleman and DuBois"). He was born in Germany and came to New Orleans 
 in 1911. There he suffered from a severe attack of malaria but has had no 
 recurrences. His family history shows that one sister is insane. 
 
 After his attack of typhoid he left the hospital in excellent condition and 
 he has been perfectly well for the last four months, although at first he was 
 somewhat weak and easily tired. Physical examination shows heart, lungs, 
 abdomen, etc., to be normal. 
 
 Experiment 7. — March 26, 1913. Basal metabolism. Subject remained in 
 the metabolism ward four days. On the evening previous to this experiment 
 
 16. Magnus-Levy: Von Noorden's Handbuch der Pathologic des Stoffwech- 
 sels, Ed. 2, 1906. 
 
52 CLINICAL CALORIMETRY 
 
 at S p. m., ate a dinner containing protein, 35.1 gm., fat, 37.1, carbohydrate, 
 105.6. During tlie experiment he lay very quiet, dozing most of the time. 
 
 Experiment 8. — March 28, 1913. March 27 his food contained protein, 80.6; 
 fat, 168.9 ; carbohydrate, 268.7 gm. ; the last meal of the day at 6 p. ra. con- 
 taining protein, 28.9; fat, 61.7; carbohydrate, 82.3 gm. Just before entering 
 the box, between 8 :25 and 9 :25 a. m., he ate 725 gm. chopped beef, fried in 
 butter, the whole containing 23.93 gm. nitrogen and 100 gm. fat. During the 
 experiment he slept from 12 : 26 to 1 : 18 p. m. and from 3 : 22 to 3 : 30. There 
 was a small leak from the absorber pipe into the calorimeter, making the 
 apparent water elimination about 1 gram an hour too high. 
 
 John L., dentist, medium frame, medium height, well nourished, muscles 
 flabby. This subject, who was born in Sweden, served as a normal control in 
 the metabolism experiments of Dr. R. A. Cooke," who investigated the func- 
 tional powers of the kidneys. Careful tests showed in this subject a slight 
 delay in the excretion of sodium chlorid, but there were no other signs of kidney 
 disease. He gave a history of moderate indulgence in alcohol. In 1904 he 
 was jaundiced; a few months prior to the experiment he suffered from an 
 infected hand after a dog bite. For the last five years he has been nervous. 
 He was admitted to the hospital Jan. IS, 1914, suffering from a few small 
 boils and a pedicular eruption. His ailments were so slight that he was induced 
 to remain in the hospital as a normal control and, being without a home, he 
 was glad to remain. Physical examination showed a thorax with flaring ribs 
 and an increased anteroposterior diameter of the chest with hyperresonant 
 percussion note and breath sounds somewhat distant. The teeth were in 
 poor condition; blood-pressure, systolic 115 to 130, diastolic 75 to 90. 
 
 Experiment 113. — March 26, 1914. Basal metabolism. During the previous 
 day the diet had contained 11.5 gm. KCl and a minimum of NaCl. The last 
 meal at 6 p. m. had consisted of farina, 25; egg-white, 50; yolk, 50; sugar, 50; 
 cream (20 per cent, fat), 60; KCl, 3.5 gm. Blood-pressure March 25, systolic, 
 140; diastolic, 95; just before the calorimeter experiment, systolic 135, diastolic 
 105. 
 
 L. C. M., laboratory helper, small frame, somewhat short and thin. He 
 was born in Sicily where he lived until the age of 11. Shortly before leaving 
 for this country he suffered from malaria, but since then has been in good 
 health. For the last five years he has worked in the daytime and gone to 
 school at night, consequently has taken but little exercise. Heart, lungs and 
 abdomen normal. 
 
 Experiment 136. — May 4, 1914. Basal metabolism. 
 
 Experiment 137. — May 6, 1914. Between 9 :50 and 9 :53 drank a solution of 
 200 gm. C. P. dextrose in 400 c.c. water and 35 c.c. lemon juice. No glycosuria. 
 
 The subjects have been described in detail above and particular 
 attention has been given to the athletic history, sirice the recent work 
 in Benedict's laboratory (personal communication) has shov/n a differ- 
 ence in the metabolism of athletes and non-athletic individuals. From 
 a study of the results in previous determinations of the normal metab- 
 oHsm one is led to suspect that a few distinctly abnormal cases have 
 crept in. It has, therefore, been our practice to give the normal con- 
 trols as careful physical examination as the patients. The importance 
 of this is manifest if one considers that the onset of hyperthyroidism 
 is usually accompanied by the symptoms of exuberant good health. 
 
 17. Cooke: Unpublished. 
 
FRANK C. GEPHART— EUGENE F. DU BOIS 53 
 
 The details of the individual experiments are given below. The body- 
 weight at the start of the experiment is determined by weighing the 
 subject shortly before he enters the calorimeter and then making the 
 proper corrections for food, urine and insensible perspiration. All 
 calculations are made from this weight, the surface area being reck- 
 oned from Meeh's" formula 12.312 v wt^. Some actual determinations 
 of the surface area of E. F. D. B. have shown that Meeh's formula is 
 14.3 per cent, too high in his case, while it is only 7.3 per cent, too high 
 in the case of R. H. H. Calculated from a new formula, Meeh's figures 
 are 14.5 per cent, too high in the case of G. L., 9.3 per cent, too high in 
 the case F. C. G. and 13.4 per cent, too high in the case of L. C. M. 
 These measurements will be given in detail in a subsequent paper. For 
 purposes of uniformity, however, calculations are based on Meeh's 
 formula, since this has been used in all othet metabolism work. The 
 work-adder was not attached to the calorimeter until May 16, 1913, 
 and an exact record of the activity of the subjects was not obtained 
 before this date. After the work-adder as described in Paper 2 was 
 attached it was possible to compare the activity in different periods and 
 in different experiments and express this in terms of the number of 
 centimeters that the plummet was raised by the expansion of air within 
 the box. The excursion of the plummet for certain movements of the 
 subject was roughly calculated as follows: Raising arm to head, 
 0.3 cm. ; lifting telephone to mouth, 4 cm. ; turning from back to side, 
 7 cm. 
 
 In the tables the final calculations of calories per hour have been 
 based on the indirect calorimetry as calculated from the oxygen con- 
 sumption and the respiratory quotient. In the two experiments on 
 F. C. G., where these were inaccurate the direct calorimetry was used, 
 and in one of the hours in the experiment on G. L. where the CO^ 
 measurement was lost the non-protein R. Q. for the purposes of 
 calculation was assumed to be 1.00. 
 
 In the experiments on E. F. D. B. on May 22 there was an evident 
 error in the division of oxygen between the second and third and the 
 fourth and fifth periods, so these were averaged in the final calcu- 
 lations 
 
 The methods of calculation have been described in Paper 1, but it 
 may be well to remind the reader that the method of direct calorimetry 
 represents the heat eliminated from the body, plus or minus the heat 
 stored in or lost from the body, when the temperature of the body rises 
 or falls. The calculation of the percentage of calories derived from 
 protein, fat and carbohydrate is based on the urinary nitrogen and the 
 non-protein respiratory quotient. 
 
 18. Meeh : Oberflachenmessungen des menschlichen Korpers, Ztschr. f. Biol., 
 1879, XV, 425. 
 
TABLE 2.— Experimental— 
 
 Subject 
 Date 
 
 Weight 
 Kg. 
 
 Period 
 
 End of 
 Period 
 
 COa, 
 Gm. 
 
 02 
 
 Gm. 
 
 B. Q. 
 
 H2O, 
 Gm. 
 
 Drine N 
 
 Per 
 Hour, 
 Gm. 
 
 Indirect 
 
 palo- 
 
 rimetry, 
 
 Oal. 
 
 Heat 
 Elimi- 
 nated, 
 
 Oal. 
 
 G. L 
 
 3/11/18 
 
 78.42 
 
 Preliminary 
 1st Hr 
 
 A.M. 
 9:50 
 
 10:50 
 
 25.26 
 
 21.51 
 
 0.85 
 
 37.03 
 
 0.487 
 
 72.35 
 
 76.77 
 
 
 
 2d Hr. 
 
 1st Hr. P. 0. 
 
 11:50 
 P.M. 
 12:50 
 
 26.56 
 29.61 
 
 25.90 
 28.57 
 
 0.75 
 0.75 
 
 37.84 
 37.88 
 
 0.487 
 0.404 
 
 84.85 
 94.12 
 
 86.10 
 
 87.75 
 
 
 
 2d Hr. P. 0. 
 
 1:50 
 
 
 25.75 
 
 
 39.24 
 
 0.404 
 
 86.76* 
 
 92.53 
 
 E. P. D. B. 
 
 3/13/13 
 
 73.6 
 
 3d Hr. P. 0. 
 
 Preliminary 
 IstHr 
 
 2:50 
 
 A.M. 
 
 9:35 
 
 10:35 
 
 30.33 
 27.22 
 
 23.44 
 25.27 
 
 0.94 
 0.78 
 
 38.98 
 27.91 
 
 0.404 
 0.554 
 
 80.86 
 83.52 
 
 95.67 
 
 77.85 
 
 
 
 2d Hr 
 
 1st Hr. P. C. 
 
 11:35 
 P.M. 
 12:35 
 
 25.28 
 29.51 
 
 21.32 
 23.58 
 
 0.86 
 0.91 
 
 26.53 
 31.19 
 
 0.564 
 0.621 
 
 71.75 
 80.27 
 
 71.94 
 84.87 
 
 
 
 2d Hr. P. 0. 
 
 1:35 
 
 31.12 
 
 25.50 
 
 0.89 
 
 30.50 
 
 0.621 
 
 86.42 
 
 82.87 
 
 
 
 3d Hr. P. 0. 
 
 2:35 
 
 30.30 
 
 24.94 
 
 0.88 
 
 30.40 
 
 0.621 
 
 84.41 
 
 81.46 
 
 E. P. D. B. 
 
 B/17/13 
 
 75.51 
 
 4th Hr. P.O. 
 Preliminary 
 1st Hr 
 
 3:35 
 
 A.M. 
 
 9:30 
 
 10:30 
 
 29.92 
 26.41 
 
 24.10 
 22.37 
 
 0.90 
 0.83 
 
 32.02 
 34.22 
 
 0.621 
 0.526 
 
 81.92 
 74.69 
 
 86.02 
 76.83 
 
 E. P. D. B. 
 
 5/22/13 
 
 76.10 
 
 2d Hr 
 
 3d Hr 
 
 Preliminary 
 2d Hr. P. 0. 
 
 11:30 
 P.M. 
 12:30 
 A.M. 
 9:30 
 
 19:30 
 
 25.45 
 25.00 
 
 31.13 
 
 21.95 
 21.24 
 
 23.04 
 
 0.84 
 0.86 
 
 0.98 
 
 32.00 
 30.68 
 
 36.24 
 
 0.526 
 0.526 
 
 0.581 
 
 73.60 
 71.41 
 
 79.77 
 
 76.67 
 74.13 
 
 84.61 
 
 
 
 3d Hr. P. 0. 
 4th Hr. P.O. 
 
 11:30 
 P.M. 
 12:30 
 
 31.53 
 32.45 
 
 25.291 
 22.49J 
 
 0.97 
 
 [36.13 
 135.07 
 
 0.581 
 0.581 
 
 
 165.30 
 
 83.21 
 83.91 
 
 E. P. D. B. 
 
 3/30/14 
 
 74.34 
 
 5th Hr. P.O. 
 6th Hr. P.O. 
 Preliminary 
 l%Hrs 
 
 1:30 
 
 2:30 
 A.M. 
 11:25 
 P.M. 
 12:55 
 
 31.95 
 29.73 
 
 36.10 
 
 28.841 
 18.18J 
 
 32.26 
 
 0.95 
 0.81 
 
 36.63 
 36.78 
 
 45.08 
 
 0.5811 
 0.58lJ 
 
 0.518 
 
 162.04 
 107.30 
 
 84.45 
 84.96 
 
 113.13 
 
 
 
 l%Hrs 
 
 2:25 
 A.M. 
 11:27 
 P.M. 
 12:27 
 
 37.58 
 
 34.88 
 
 0.78 
 
 46.48 
 
 0.518 
 
 115.24 
 
 113.14 
 
 E. P. D. B. 
 
 4/1/U 
 
 74.92 
 
 Preliminary 
 2d Hr. P. 0. 
 
 27.47 
 
 24.30 
 
 0.82 
 
 30.51 
 
 0.856 
 
 80.60 
 
 81.65 
 
 
 
 3d Hr. P. 0. 
 
 1:27 
 
 29.66 
 
 26.17 
 
 0.83 
 
 31.75 
 
 0.830 
 
 86.91 
 
 81.50 
 
 
 
 4th Hr. P.O. 
 
 2:27 
 
 28.13 
 
 25.35 
 
 0.81 
 
 32.87 
 
 0.900 
 
 83.60 
 
 85.98 
 
 
 
 BthHr. P. 0. 
 
 3:27 
 
 28.83 
 
 25.89 
 
 0.81 
 
 33.39 
 
 0.577 
 
 86.11 
 
 82.75 
 
 
 
 6th Hr. P. 0. 
 
 4:27 
 A.M. 
 11:05 
 P.M. 
 12:05 
 
 27.12 
 
 23.86 
 
 0.83 
 
 32.98 
 
 0.577 
 
 79.61 
 
 83.6S 
 
 E. P. D. B. 
 
 5/8/14 
 
 74.75 
 
 Preliminary 
 2d Hr. P. 0. 
 
 30.55 
 
 23.41 
 
 0.95 
 
 32.59 
 
 0.604 
 
 80.53 
 
 76.35 
 
 
 
 3d Hr. P. 0. 
 
 1:05 
 
 30.91 
 
 24.28 
 
 0.93 
 
 33.55 
 
 0.604 
 
 83.08 
 
 79.08 
 
 
 
 4th Hr. P. 0. 
 
 2:05 
 
 29.37 
 
 22.49 
 
 0.95 
 
 32.48 
 
 0.604 
 
 77.33 
 
 75.63 
 
 
 
 BthHr. P.O. 
 
 3:05 
 A. M. 
 
 30.28 
 
 22.06 
 
 1.00 
 
 32.22 
 
 0.604 
 
 76.47 
 
 76.46 
 
 E. P. D. B. 
 
 5/15/14 
 
 75.02 
 
 Preliminary 
 
 10:60 
 
 
 
 
 
 
 
 
 
 2d Hr. P. 0. 
 
 11:60 
 P. M. 
 
 29.60, 
 
 22.91 
 
 0.94 
 
 29.06 
 
 0.B34 
 
 78.74 
 
 77.76 
 
 
 
 Sd Hr. P. 0. 
 
 12:50 
 
 31.35 
 
 22.12 
 
 1.03 
 
 30.02 
 
 0.534 
 
 77.26 
 
 80.09 
 
 
 
 4th Hr. P.O. 
 
 1:50 
 
 31.07 
 
 24.04 
 
 0.94 
 
 30.73 
 
 0.534 
 
 82.67 
 
 80.28 
 
 
 
 BthHr. P.O. 
 
 2:50 
 
 29.95 
 
 22.21 
 
 0.98 
 
 30.87 
 
 0.534 
 
 76.96 
 
 79.99 
 
 
 
 6th Hr. P.O. 
 
 3:50 
 A.M. 
 
 28.46 
 
 22.57 
 
 0.92 
 
 30.46 
 
 0.534 
 
 77.11 
 
 75.02 
 
— Data in Hourly Periods 
 
 Direct 
 
 Oalo- 
 
 rlmetry 
 
 Oal. 
 
 Beetal 
 Temper- 
 ature, 
 0. 
 
 Av. 
 
 Pulse 
 
 Work- 
 Adder, 
 Cm. 
 
 Non- 
 Pro- 
 tein 
 B. Q. 
 
 Per Cent. 
 Calories from 
 
 Calories 
 Per Hour 
 
 Bemarks 
 
 Prot. 
 
 Pat 
 
 Garb. 
 
 Per 
 Kg. 
 
 Per 
 Sq.M. 
 
 
 37.26 
 
 
 
 
 
 
 
 
 
 
 78.95 
 
 37.30 
 
 
 
 0.87 
 
 IS 
 
 37 
 
 45 
 
 0.92 
 
 32.07 
 
 Basal. 
 
 82.80 
 
 87.25 
 
 62 
 
 — 
 
 0.74 
 
 15 
 
 77 
 
 8 
 
 1.08 
 
 37.61 
 
 Basal. 
 
 94.21 
 86.51 
 
 37.28 
 37.20 
 
 88 
 
 
 0.75 
 
 11 
 12 
 
 77 
 
 12 
 
 1.20 
 1.11* 
 
 41.72 
 38.46* 
 
 At 11:63 a. m., 115 gm. commer- 
 cial glucose. 
 
 92.88 
 
 87.17 
 36.88 
 
 
 
 0.96 
 
 13 
 
 U 
 
 76 
 
 1.03 
 
 35.84 
 
 
 78.09 
 
 36.90 
 
 
 
 0.78 
 
 18 
 
 62 
 
 20 
 
 1.13 
 
 38.63 
 
 Basal. 
 
 72.10 
 
 36.91 
 
 59 
 
 
 0.88 
 
 20 
 
 33 
 
 47 
 
 0.98 
 
 33.19 
 
 Basal. 
 
 87.12 
 83.46 
 
 36.84 
 36.87 
 
 57 
 64 
 
 
 0.94 
 0.91 
 
 21 
 19 
 
 16 
 25 
 
 63 
 56 
 
 1.10 
 1.18 
 
 37.13 
 39.97 
 
 At 11:38 a. m., 115 gm. commer- 
 cial glucose. 
 
 85.60 
 
 36.98 
 
 
 
 0.91 
 
 19 
 
 26 
 
 65 
 
 1.15 
 
 39.04 
 
 
 84.64 
 
 36.99 
 86.96 
 
 60 
 
 .... 
 
 0.93 
 
 20 
 
 19 
 
 61 
 
 1.11 
 
 37.89 
 
 
 62.89 
 
 36.81 
 
 57 
 
 22 
 
 0.83 
 
 19 
 
 47 
 
 34 
 
 0.99 
 
 33.95 
 
 Basal. 
 
 77.00 
 
 36.80 
 
 65 
 
 13 
 
 0.85 
 
 19 
 
 41 
 
 40 
 
 0.97 
 
 33.45 
 
 Basal. 
 
 74.42 
 
 36.98 
 
 .. 
 
 10 
 
 0.87 
 
 19 
 
 36 
 
 45 
 
 0.95 
 
 32.46 
 
 Basal. 
 
 72.90 
 
 36.84 
 36.75 
 
 66 
 
 15 
 
 1.03 
 
 19 
 
 
 
 81 
 
 1.05 
 
 36.08 
 
 At 8:55 a. m., 230 gm. commer- 
 cial glucose. 
 
 82.51 
 84.53 
 
 26.84 
 36.95 
 
 63 
 60 
 
 17 
 14 
 
 1.02 
 
 19 
 
 
 
 81 
 
 1.09 
 
 37.38 
 
 
 82.50 
 79.32 
 
 37.01 
 37.00 
 
 68 
 60 
 
 16 
 
 24 . 
 
 0.99 
 
 19 
 
 2 
 
 79 
 
 1.07 
 
 36.64 
 
 
 
 36.91 
 
 
 
 
 
 
 
 
 
 
 110.72 
 
 36.88 
 
 54 
 
 30— 
 
 0.82 
 
 19 
 
 61 
 
 30 
 
 0.96 
 
 32.86 
 
 Basal. 
 
 116.62 
 
 36.99 
 
 56 
 
 37— 
 
 0.78 
 
 18 
 
 62 
 
 20 
 
 1.03 
 
 35.29 
 
 Basal. 
 
 84.05 
 
 36.84 
 36.91 
 
 57 
 
 24— 
 
 0.83 
 
 28 
 
 42 
 
 30 
 
 1.07 
 
 36.79 
 
 At 9:64 a. m., protein meal 
 (10.5 gm. N). 
 
 77.92 
 
 36.89 
 
 57 
 
 28— 
 
 0.83 
 
 25 
 
 43 
 
 32 
 
 1.16 
 
 39.72 
 
 
 86.71 
 
 36.93 
 
 58 
 
 30— 
 
 0.81 
 
 29 
 
 46 
 
 25 
 
 1.12 
 
 38.21 
 
 
 81.62 
 
 36.94 
 
 57 
 
 26— 
 
 0.81 
 
 18 
 
 53 
 
 29 
 
 1.15 
 
 39.36 
 
 
 88.88 
 
 37.04 
 36.66 
 
 68 
 
 33— 
 
 0.83 
 
 19 
 
 46 
 
 35 
 
 1.06 
 
 36.39 
 
 
 75.09 
 83.22 
 
 36.67 
 36.78 
 
 61 
 61 
 
 14.1 
 23.5 
 
 0.99 
 0.96 
 
 20 
 19 
 
 3 
 11 
 
 77 
 70 
 
 1.08 
 1.11 
 
 36.86 
 38.02 
 
 At 10:05-10:07 a. m., 200 gm. 
 dextrose. 
 
 73.61 
 
 36.78 
 
 61 
 
 18.8 
 
 0.99 
 
 21 
 
 2 
 
 77 
 
 1.03 
 
 35.39 
 
 
 76.05 
 
 36.79 
 36.69 
 
 62 
 
 26.0 
 
 1.06 
 
 21 
 
 •• 
 
 79 
 
 1.02 
 
 35.00 
 
 
 78.83 
 78.30 
 
 36.73 
 36.73 
 
 55 
 58 
 
 19.6 
 22.5 
 
 0.97 
 1.09 
 
 :is 
 
 18 
 
 8 
 
 74 
 82 
 
 1.05 
 1.03 
 
 35.95 
 35.28 
 
 At 9:50-9:53 a. m., 200 gm. 
 dextrose. 
 
 79.13 
 81.32 
 
 36.73 
 36.76 
 
 59 
 59 
 
 33.1 
 
 21.8 
 
 0.97 
 1.03 
 
 17 
 18 
 
 8 
 
 75 
 82 
 
 1.10 
 1.03 
 
 37.75 
 35.14 
 
 (Carbohydrate breakfast at 
 6:15 a. m.). 
 
 72.36 
 
 36.74 
 
 57 
 
 34.0 
 
 0.95 
 
 18 
 
 15 
 
 67 
 
 1.03 
 
 35.21 
 
 
 * Estimated from CO2. 
 
TABLE 2.- 
 
 Subject 
 Date 
 
 Weight 
 Kg. 
 
 Period 
 
 End ol 
 Period 
 
 002, 
 
 Gm. 
 
 02 
 
 Gm. 
 
 10:50 
 
 
 
 11:60 
 P.M. 
 12: BO 
 A.M. 
 9:02 
 
 23.92 
 23.85 
 
 21.08 
 21.88 
 
 10:02 
 
 22.80 
 
 
 11:02 
 P.M. 
 12:02 
 
 22.92 
 22.59 
 
 
 1:00 
 
 
 
 2:00 
 
 14.86 
 
 41.521 
 
 3:00 
 
 23.63 
 
 21.08J 
 
 4:00 
 
 A.M. 
 
 9:46 
 
 22.73 
 
 25.27 
 
 10:45 
 
 21.92 
 
 
 11:45 
 P.M. 
 12:45 
 
 22.05 
 21.08 
 
 
 1:46 
 
 21.86 
 
 
 2:45 
 
 A.M. 
 
 9:42 
 
 22.03 
 
 
 10:42 
 
 26.15 
 
 21.59 
 
 11:42 
 A.M. 
 10:10 
 
 27.42 
 
 20.98 
 
 11:10 
 P.M. 
 12:10 
 
 20.53 
 19.95 
 
 18.73 
 17.40 
 
 1:10 
 
 22.44 
 
 20.07 ■ 
 
 2:10 
 
 18.34 
 
 18.05 
 
 3:10 
 
 22.13 
 
 20.71 
 
 4:10 
 A.M. 
 11:14 
 P.M. 
 12:14 
 
 19.36 
 23.43 
 
 19.23 
 22.62 
 
 1:14 
 
 24.27 
 
 22.67 
 
 2:14 
 
 26.84 
 
 25.11 
 
 3:14 
 
 26.44 
 
 25.11 
 
 4:14 
 
 24.86 
 
 23.21 
 
 5:14 
 A.M. 
 11:20 
 P.M. 
 12:20 
 
 26.25 
 21.12 
 
 24.79 
 19,51 
 
 1:20 
 
 21.37 
 
 19.62 
 
 2:20 
 A.M. 
 11:02 
 P.M. 
 12:02 
 
 21.07 
 22.39 
 
 19.97 
 20.71 
 
 1:02 
 A.M. 
 10:52 
 
 22.14 
 
 18.98 
 
 11:52 
 P.M. 
 12:52 
 
 29.94 
 30.30 
 
 23.73 
 22,03 
 
 1:52 
 
 30.65 
 
 21.90 
 
 E. Q. 
 
 H2O, 
 Gm. 
 
 Urine N 
 
 Per 
 Hour, 
 Gm. 
 
 Indirect 
 Oalo- 
 
 rimetry, 
 Oal. 
 
 Heat 
 Elimi- 
 nated, 
 Cal. 
 
 E. F. D. B. 
 
 6/18/14 
 
 P. C. G. .. 
 
 3/17/13 
 
 P. C. G. .. 
 
 3/17/13 
 
 P. C. G. .. 
 
 4/22/13 
 
 E. H. H. .. 
 3/19/13 
 
 Louis M. . . 
 
 3/26/13 
 
 Louis M. .. 
 3/28/13 
 
 John L. ... 
 
 3/26/14 
 
 L. C. M. 
 
 5/4/14 
 
 L. 0. M. 
 5/6/14 
 
 73.70 
 
 64.82 
 
 53.49 
 
 70.94 
 
 60.98 
 
 Preliminary 
 
 1st Hr 
 
 2d Hr 
 
 Preliminary 
 
 1st Hr 
 
 2d Hr 
 
 3d Hr 
 
 Preliminary 
 2d Hr. P. C. 
 3d Hr. P. C. 
 4th Hr. P. C. 
 Preliminary 
 
 1st Hr 
 
 2d Hr 
 
 3d Hr 
 
 4th Hr 
 
 5th Hr 
 
 Preliminary 
 
 1st Hr 
 
 2d Hr 
 
 Preliminary 
 
 1st Hr 
 
 2d Hr 
 
 3d Hr 
 
 4th Hr 
 
 6th Hr 
 
 6th Hr 
 
 Preliminary 
 3d Hr. P. C. 
 4th Hr. P. 0. 
 6th Hr. P. C. 
 6th Hr. P. C. 
 7th Hr. P. C. 
 8th Hr. P, C. 
 Preliminary 
 
 1st Hr 
 
 2d Hr 
 
 3d Hr 
 
 Preliminary 
 
 1st Hr 
 
 2d Hr 
 
 Preliminary 
 2d Hr. P. C. 
 3d Hr. P. C. 
 4th Hr. P. C. 
 
 0.83 
 0.79 
 
 0.85 
 0.78 
 
 0.88 
 0.95 
 
 0.80 
 0.83 
 0.81 
 0.74 
 0.78 
 0.73 
 
 0.75 
 0.78 
 0.78 
 0.77 
 0.78 
 0.77 
 
 0.79 
 0.79 
 0.77 
 
 0.79 
 0.85 
 
 0.92 
 1.00 
 1.02 
 
 28.03 
 28.08 
 
 17.77 
 19.69 
 20.90 
 
 23.05 
 .30.51 
 26.08 
 
 25.40 
 26.85 
 26.26 
 28.59 
 30.09 
 
 27.90 
 28.93 
 
 28.92 
 26.95 
 28.10 
 25.73 
 27.36 
 25.85 
 
 24.08 
 29.15 
 34.80 
 34.38 
 35.42 
 34.71 
 
 26.77 
 24.66 
 24,01 
 
 28.32 
 27.28 
 
 33.43 
 32.38 
 32.94 
 
 0.530 
 0.630 
 
 0.491 
 0.491 
 0.491 
 
 0.491 
 0.491. 
 0.491 
 
 0.522 
 0.522 
 0.622 
 0.622 
 0.522 
 0.522 
 
 0.703 
 0.695 
 0.970 
 1.014 
 1.138 
 1.112 
 
 0.363 
 0.363 
 0.363 
 
 0.634 
 0.534 
 
 0.578 
 0.678 
 0.578 
 
 70.29 
 72.38 
 
 139.35 
 69.69 
 
 73.54 
 72.78 
 
 61.91 
 57.99 
 66.57 
 58,71 
 68.20 
 62.51 
 
 73.76 
 74.44 
 82.02 
 81.70 
 76.38 
 80.53 
 
 64.65 
 65,10 
 65,85 
 
 68,34 
 63.67 
 
 81.05 
 76.45 
 76.21 
 
 67.48 
 69.37 
 
 64.43 
 59.16 
 60.70 
 
 62.52 
 
 58.96 
 61.94 
 62.60 
 63.33 
 68.43 
 
 66.50 
 69.27 
 
 64.64 
 64.44 
 71.00 
 66.51 
 
 64,89 
 75.48 
 79.07 
 77.18 
 83,35 
 81.28 
 
 66.00 
 68.26 
 66.72 
 
 71.73 
 70.36 
 
 73.19 
 74.95 
 77.37 
 
— (Continued) 
 
 
 
 
 
 
 
 
 
 
 Direct 
 
 Calo- 
 
 rlmetry 
 
 Oal: 
 
 Bectal 
 
 remper- 
 
 ature, 
 
 0. 
 
 Av. 
 Pulse 
 
 Work- 
 Adder, 
 Cm. 
 
 Non- 
 Pro- 
 tein 
 B.Q. 
 
 Per Cent. 
 Calories from 
 
 Calories 
 Per Hour 
 
 Remarks 
 
 Prot. 
 
 Pat 
 
 Oarb. 
 
 Per 
 Kg. 
 
 Per 
 Sq. M. 
 
 
 36.76 
 
 
 
 
 
 
 
 
 
 
 67.14 
 
 36.76 
 
 57 
 
 9.8 
 
 0.83 
 
 20 
 
 46 
 
 34 
 
 0.95 
 
 32.48 
 
 Basal. 
 
 70.23 
 
 36.78 
 37.03 
 
 67 
 
 18.2 
 
 0.79 
 
 19 
 
 58 
 
 23 
 
 0.98 
 
 33.45 
 
 
 58.83 
 55.75 
 
 37.15 
 37.11 
 
 
 
 
 
 
 
 1.04 
 0.99 
 
 30.75 
 32.45 
 
 Basal. Profound sleep during 
 second and third periods. O2 
 leak. 
 
 66.99 
 
 37.06 
 37.02 
 
 
 
 
 
 
 
 1.01 
 
 31.43 
 
 
 66.85 
 60.53 
 
 37.17 
 37.00 
 
 
 
 0.86 
 
 19 
 
 39 
 
 42 
 
 1.18 
 .1.07 
 
 36.87 
 33.39 
 
 At 12 m., plate of oatmeal. O2 
 leak. 
 
 60.83 
 
 36.95 
 37.04 
 
 
 
 0.78 
 
 19 
 
 61 
 
 20 
 
 1.08 
 
 33.69 
 
 
 57.28 
 
 37.03 
 
 74 
 
 
 
 
 
 
 1.04 
 
 32.22 
 
 Basal. O2 leak. 
 
 62.68 
 
 37.07 
 
 68 
 
 
 
 
 
 
 1.14 
 
 35.25 
 
 
 60.60 
 
 37.04 
 
 64 
 
 
 
 
 
 
 1.10 
 
 34.08 
 
 
 68.15 
 
 36.94 
 
 66 
 
 
 
 
 
 
 1.06 
 
 32.71 
 
 
 64.88 
 
 36.87 
 36.76 
 
 70 
 
 
 
 
 
 
 1.18 
 
 36.49 
 
 
 69.22 
 
 36.S2 
 
 
 
 
 
 
 
 1.19 
 
 38.12 
 
 Basal. Urine not obtained. 
 
 70.31 
 
 36.86 
 37.18 
 
 
 
 
 
 
 
 1.19 
 
 37.73 
 
 
 58.39 
 
 37.07 
 
 
 
 0.80 
 
 22 
 
 66 
 
 24 
 
 1.20 
 
 36.23 
 
 Basal. 
 
 61.88 
 
 37.04 
 
 
 
 0.84 
 
 24 
 
 40 
 
 36 
 
 1.12 
 
 33.92 
 
 
 76.26 
 
 37.15 
 
 
 
 0.82 
 
 21 
 
 49 
 
 30 
 
 1.29 
 
 38.95 
 
 
 59.27 
 
 37.00 
 
 
 
 0.72 
 
 24 
 
 73 
 
 S 
 
 1.14 
 
 34.35 
 
 
 70.95 
 
 37.08 
 
 
 
 0.77 
 
 20 
 
 63 
 
 17 
 
 1.32 
 
 39.91 
 
 
 62.47 
 
 36.98 
 37.10 
 
 
 
 0.71 
 
 22 
 
 77 
 
 1 
 
 1.21 
 
 36.68 
 
 
 74.89 
 81.49 
 
 37.28 
 37.43 
 
 
 
 0.74 
 0.77 
 
 25 
 26 
 
 68 
 69 
 
 7 
 16 
 
 1.39 
 1.40 
 
 42.20 
 42.59 
 
 8:25-9:25 a. m., 725 gm. choppea 
 beef = 23.93 gm. N -h lOO gm. 
 fat. 
 
 74.67 
 
 37.36 
 
 
 
 0.76 
 
 .31 
 
 55 
 
 14 
 
 1.54 
 
 46.92 
 
 
 78.43 
 
 37.41 
 
 
 
 0.75 
 
 33 
 
 68 
 
 9 
 
 1.54 
 
 46.74 
 
 
 30.09 
 
 37.38 
 
 
 
 0.76 
 
 40 
 
 49 
 
 11 
 
 1.42 
 
 43.12 
 
 
 SI .96 
 
 37.39 
 37-11 
 
 
 
 0.75 
 
 37 
 
 54 
 
 9 
 
 1.51 
 
 46.07 
 
 
 52.70 
 
 86.89 
 
 61 
 
 13.04- 
 
 0.78 
 
 15 
 
 62 
 
 23 
 
 0.91 
 
 30.64 
 
 Basal. 
 
 68.56 
 
 36.94 
 
 55 
 
 13.0-1- 
 
 0.79 
 
 15 
 
 61 
 
 24 
 
 0.92 
 
 30.85 
 
 
 62.04 
 
 36.88 
 36.94 
 
 57 
 
 38.7 
 
 0.76 
 
 15 
 
 69 
 
 16 
 
 0.92 
 
 31.21 
 
 
 66.95 
 
 36.85 
 
 74 
 
 22.0-1- 
 
 0.78 
 
 21 
 
 69 
 
 20 
 
 1.15 
 
 36.41 
 
 Basal, 
 
 73.48 
 
 36.92 
 36.84 
 
 70 
 
 18.2 
 
 0.86 
 
 22 
 
 37 
 
 41 
 
 1.07 
 
 33.87 
 
 
 65.74 
 
 36.70 
 
 85 
 
 19.1 
 
 0.95 
 
 19 
 
 15 
 
 66 
 
 1.33 
 
 42.48 
 
 9:50-9:63 a. m., dextrose, 200 gm. 
 
 73.60 
 
 36.68 
 
 82 
 
 30.1 
 
 1.06 
 
 20 
 
 
 80 
 
 1.25 
 
 40.07 
 
 
 82.69 
 
 36.79 
 
 79 
 
 38.2 
 
 1.08 
 
 20 
 
 
 80 
 
 1.25 
 
 39.94 
 
 
58 CLINICAL CALORIMETRY 
 
 The results are expressed in terms of grams and calories per hour, 
 since this is the length of period used in the Cornell and Sage calorim- 
 eters and is the nearest unit of the length of the actual experimental 
 period used in most of the modem machines. 
 
 DISCUSSION OF RESULTS 
 
 As explained in Paper 1 of this series, the determination of the 
 heat production by the methods of direct and indirect calorimetry 
 have been found to give identical results in the work of Rubner, 
 Atwater and Benedict, Lusk and his coworkers. Rubner demonstrated 
 this on the dog in long periods, Atwater and Benedict on man at rest 
 and at work, Lusk on dogs in hourly periods and Rowland, in Lusk's 
 laboratory, on babies both normal and atrophic. To this list may be 
 added the work of Armsby^^ on cattle in twenty-four-hour experiments 
 and the work of Carpenter and Murlin^" who studied the metabolism 
 of women before and after confinement, in Benedict's laboratory. A 
 comparison of the figures for direct and indirect calorimetry obtained 
 in Benedict's calorimeter shows excellent agreement in the two- and 
 three-hour periods. Out of a total of twenty-eight periods, the two 
 methods were within 5 per cent, of each other in seventeen, while only 
 six showed a disagreement over 10 per cent. 
 
 Table 3 gives in parallel columns the calories in each of our experi- 
 ments as measured by the methods of direct and indirect calorimetry. 
 The totals of all the experiments show that the two methods come 
 within 0.17 per cent, of each other. Even when we consider periods as 
 short as one hour, the agreement may be striking. On the normal 
 control, E. F. D. B., there were a total of 26 one-hour periods. In 17 
 of these the methods of direct and indirect calorimetry agreed within 
 5 per cent., in 6 periods within 6 to 9 per cent., while three isolated 
 periods showed a disagreement of 11, 12 and 16 per cent., respectively. 
 Work with the .Sage calorimeter on normal controls and on patients 
 with a large variety of diseases has shown that in a total measurement 
 of 27,632 calories the direct calorimetry gives a figure only 1.62 per 
 cent, lower than the indirect. There is, therefore, no reason to believe 
 that in long periods, or in the average of a number of short periods, 
 there is any essential difference between the two methods. As will be 
 shown later, there is good reason to believe that indirect calorimetry 
 gives the more accurate results in short periods. 
 
 There are two methods of calculating the indirect calorimetry, both 
 of which involve factors that change with the respiratory quotient. 
 
 19. Armsby: Food as Body Fuel, Pennsylvania State College Agricultural 
 Experiment Station, Bull. 126. 
 
 20. Carpenter and Murlin: The Energy Metabolism of Mother and Child 
 Tiist Before and Just After Birth, The Archives Int. Med., 1911, vii, 184. 
 

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60 
 
 CLINICAL CALORIMETRY 
 
 The first is the standard method of Zuntz and his associates, based on 
 the liters of oxygen consumed, which are multiplied by a factor that 
 increases about 8 per cent, as the quotient rises from 0.72 to 0.97. The 
 second method is based on the liters of COo produced, the figure for 
 which is multiplied by a factor which decreases 24 per cent, as the 
 
 TABLE 4. — Heat Production' of Normal Men, Ages 20 to SO. Com- 
 parison OF Calories per Kilogram and per Square Meter 
 
 
 Weight, 
 Kg. 
 
 Calories 
 
 per 
 Eilogram 
 
 per 
 Hour 
 
 Calorics 
 
 per 
 Sq. Meter 
 
 per 
 Hour 
 
 Percentage Variation 
 from Average 
 
 Calories 
 
 per 
 
 Sq. Meter 
 
 per Hour 
 
 According 
 
 to New 
 
 Surface 
 
 Area 
 Formula 
 
 Per Cent. 
 Variation 
 
 from 
 Average 
 
 Subject 
 
 Calories 
 per 
 Kg. 
 
 Calorics 
 
 per 
 Sq. Meter 
 
 F. G. B.* 
 
 83.0 
 
 1.01 
 
 35.8 
 
 — 4 
 
 + 6 
 
 .... 
 
 
 G. L 
 
 78.4 
 74.3 
 
 1.00 
 0.95 
 
 34.8 
 32.4 
 
 — 5 
 
 — 9 
 
 -1- 2 
 — 6 
 
 40.7 
 
 -f2 
 
 F. A. E.* 
 
 
 E. P. B. B. .. 
 
 74.3 
 
 1.00 
 
 34.1 
 
 — 5 
 
 
 
 39.8 
 
 —0 
 
 John L 
 
 70.9 
 
 0.92 
 
 30.9 
 
 —12 
 
 —10 
 
 
 
 J. J. C* 
 
 67.6 
 
 0.96 
 
 31.7 
 
 — 8 
 
 — 7 
 
 
 
 J. B.* 
 
 66.0 
 
 1.00 
 
 32.8 
 
 — 5 
 
 -* 
 
 
 
 E. H. H 
 
 62.0 
 
 1.18 
 
 37.9 
 
 -1-14 
 
 -1-11 
 
 40.9 
 
 -1-3 
 
 L. C. M 
 
 69.5 
 
 1.11 
 
 35.1 
 
 -1- 6 
 
 + 3 
 
 40.5 
 
 -1-2 
 
 F. C. G 
 
 54.8 
 
 1.10 
 
 34.2 
 
 -f 5 
 
 
 
 37.7 
 
 —5 
 
 Louis M 
 
 51.7 
 
 1.21 
 
 36.7 
 
 -fl6 
 
 -1- 7 
 
 
 
 T. M. C* 
 
 49.0 
 
 1.13 
 
 33.8 
 
 ■f 8 
 
 — 1 
 
 
 
 Average 
 
 
 1.06 
 
 34.2 
 
 ±8.1 
 
 ± 4.6 
 
 39.9 
 
 ±2.4 
 
 79 normal men 
 
 in groupst 
 
 8 weights 
 
 75-85 
 
 1.01 
 
 36.2 
 
 — 7 
 
 + 2 
 
 
 
 20 weights 
 
 66-76 
 
 1.02 
 
 34.1 
 
 — 6 
 
 — 2 
 
 
 
 41 weights — 
 
 65-65 
 
 1.09 
 
 34.7 
 
 -1- 1 
 
 
 
 .... 
 
 
 10 weights 
 
 46-66 
 
 1.18 
 
 35.5 
 
 -1- 9 
 
 + 2 
 
 
 
 Average 
 
 
 1.08 
 
 34.7 
 
 ± 5.8 
 
 ± 1.5 
 
 
 
 * Determinations made by Benedict and Joslin.'^' 
 
 t Taken largely from work of Benedict, Emmes, Eotb and Smith,!" 
 
 quotient rises from 0.72 to 0.97. Tables for this latter calculation are 
 given by Benedict and Talbot,^^ who prefer this method in using an 
 apparatus in which they consider that for short periods the determina- 
 tion of the carbon dioxid is more exact than the determination of 
 
 21. Benedict and Talbot : Studies in the Respiratory Exchange of Infants, 
 Am. Jour. Dis. Child., 1914, viii, 1 ; The Gaseous Metabolism of Infants, Car- 
 negie Institution of Washington, Pub. 201. 
 
FRANK C. GEPHART— EUGENE F. DU BOIS 
 
 61 
 
 oxygen. It is true that in the closed circuit type of apparatus the 
 measurement of the oxygen is subject to many corrections for changes 
 in the barometer, temperature, moisture, etc., and that it is liable to a 
 plus error in the case of leaks. This error affects the quotient and pro- 
 duces such a change in the CO2 factor that one usually obtains better 
 results by basing the calculations on the oxygen. This is brought out 
 clearly in Table 5, which gives a comparison of the methods of calcu- 
 lating the heat production from the oxygen and from the CO2, showing 
 the errors in the results arising from various assumed errors in the 
 measurements. It will be noted that in the great majority of the cases 
 
 TABLE S. — Comparison of Methods of Calculation whth Assumed 
 EitRORS IN Measurement of CO2 and O2 
 
 COa 
 
 O2 
 
 
 Calorific 
 
 Value 
 
 1 Liter ol CO2 
 
 Calorific 
 
 Value 
 
 1 Liter of O2 
 
 Indirect 
 
 Calorimetry 
 
 Based on CO2 
 
 Indirect 
 Calorimetry 
 Based on O2 
 
 
 
 
 
 R.Q. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Liters 
 
 As- 
 sumed 
 Error 
 % 
 
 Liters 
 
 As- 
 sumed 
 Error 
 % 
 
 
 Cal. 
 
 Per 
 
 Cent. 
 
 Change 
 
 Cal. 
 
 Per 
 
 Cent. 
 
 Change 
 
 Cal. 
 
 Per 
 Cent. 
 Error 
 
 Cal. 
 
 Per 
 Cent. 
 Error 
 
 12.94 
 
 
 
 15.64 
 
 
 
 0.83 
 
 5.829 
 
 
 4.807 
 
 
 75.40 
 
 
 76.17 
 
 
 12.94 
 
 
 
 17.20 
 
 -HO 
 
 0.75 
 
 6.319 
 
 -H8.4 
 
 4.708 
 
 —2.1 
 
 81.74 
 
 +8.4 
 
 80.98 
 
 +7.7 
 
 14.23 
 
 -HO 
 
 15.64 
 
 
 
 0.91 
 
 5.424 
 
 -7.0 
 
 4.904 
 
 +2.0 
 
 77.18 
 
 +2.4 
 
 76.70 
 
 +2.0 
 
 12.94 
 
 
 
 16.42 
 
 -f-5 
 
 0.79 
 
 6.062 
 
 +i.O 
 
 4.768 
 
 —1.1 
 
 78.44 
 
 +4.0 
 
 78.13 
 
 +3.9 
 
 13.59 
 
 +5 
 
 15.64 
 
 
 
 0.87 
 
 5.617 
 
 —3.6 
 
 4.855 
 
 +1.0 
 
 76,33 
 
 +1.2 
 
 75.93 
 
 +1.0 
 
 12.29 
 
 —5 
 
 16.42 
 
 +5 
 
 0.75 
 
 6.319 
 
 -f8.4 
 
 4.708 
 
 —2.1 
 
 77.66 
 
 +3.0 
 
 77.31 
 
 +2.8 
 
 13.59 
 
 H-5 
 
 14.86 
 
 —5 
 
 0.91 
 
 5.424 
 
 —7.0 
 
 4.904 
 
 +2.0 
 
 73.71 
 
 —2.2 
 
 72.87 
 
 —3.1 
 
 12,94 
 
 
 
 14.86 
 
 —5 
 
 0.87 
 
 5.617 
 
 —3.7 
 
 4.856 
 
 +1.0 
 
 72.68 
 
 —3.6 
 
 72.15 
 
 —4.0 
 
 cited the error from the use of the oxygen factor is smaller than that 
 from the COv. Even with a plus error of 5 to 10 per cent, in the 
 oxygen and no error in the CO2, the results obtained by using the 
 oxygen are the better, since the minus change in this factor compen- 
 sates for part of the error. In the two instances shown, in which the 
 results obtained by the use of the CO2 factor are closer to the theory 
 than those obtained by the use of the oxygen factor, it will be noted 
 that there is a minus error in the oxygen. This is the least frequent 
 of all the errors. 
 
 Many investigators in seeking for an index nf the heat production 
 express the results in grams or cubic centimeters of CO2, and compare 
 the elimination of thi.s gas in different individuals, apparently with the 
 impression that they are comparing the actual total metabolism. As we 
 have seen above, a man eliminating, say, 3.13 c.c. CO2 per kg. per min- 
 
62 CLINICAL CALORIMETRY 
 
 ute might have a heat production 24 per cent, higher than another man 
 eliminating the same amount of COj whose respiratory quotient was at 
 the other end of the scale. If one uses the oxygen consumption the 
 possible error from this source is diminished to 8 per cent. Since it is 
 such an easy calculation to determine the actual calories by using 
 the oxygen figure and the respiratory quotient, it seems inexcus- 
 able to leave the results at a stage which might give false impressions. 
 It is only in special investigations on the ventilation of the lungs, etc., 
 that the amounts of the gases themselves are of any direct interest. 
 In most experiments it is the actual calories that need to be determined. 
 
 Experience has shown that with careful technic the indirect calorim- 
 etry in hourl;^ periods remains fairly uniform in fasting experiments 
 and shows regular curves in experiments after food. The direct calo- 
 rimetry in hourly periods is a matter of greater technical difficulty on 
 account of the fact that the human body is poorly constructed for 
 accurate thermal measurements. As was shown in Paper 1, a rise or 
 fall of 1 degree centigrade in the average temperature of the body 
 means a storage or loss of about 58 calories af the man weighs 70 kilo- 
 grams. This is based on the assumption that the specific heat of the 
 body is 0.83, a figure which has been accepted for many decades, 
 although without satisfactory experimental support. Rubner^^ has 
 found that the specific heat of lean flesh is 0.828, of fatty tissue 0.53 
 and of pure fat 0.45. Rosenthal"^ at an earlier date had made the 
 following determinations: compact bone 0.30, spongy bone 0.710, 
 defibrinated blood 0.927, dried muscle 0.330. Using these figures and 
 the figures for the average composition of the body as given by 
 Vierort^* one obtains a specific heat of approximately 0.77. A body 
 rich in fat would, of course, approach the figure 0.45 and one rich in 
 water would approach 1.00. Theoretically, one should change the 
 specific heat each time a subject drinks water or voids. This latter 
 would be a matter of small importance, but in the case of a very obese 
 person one-half of whose weight consisted of fat, the true specific heat 
 would not be far from 0.64. 
 
 In normal subjects the temperature changes in hourly periods are 
 small and according to the work of Benedict and Slack,^^ the temper- 
 
 22. Rubner: Kalorimetrie, Tigerstedt's Handbuch der physiologische 
 Methoden, i, 170. 
 
 23. Rosenthal : Ueber die specifische Warme thierische Gewebe, Arch. f. 
 Physiol., 1878, p. 215. 
 
 24. Vierort: Daten und Tabellen. Jena, 1893, p. 249. 
 
 25. Benedict and Slack: A Comparative Study of the Temperature Fluctua- 
 tion in Different Parts of the Human Body. Carnegie Institution of Wash- 
 ington, 1911, Pub. 155. 
 
PRANK C. GEPHART— EUGENE P. DU BOIS 63 
 
 ature curves in different parts of the body are nearly parallel. Lusk''* 
 and his coworkers did not find this to be the case in the dog after the 
 ingestion of large amounts of food since this caused a greater rise in 
 surface than in rectal temperature. When one considers the mechan- 
 ism of the regulation of body temperature in fever it becomes evident 
 that the rise in surface temperature follows that of the internal tem- 
 perature. Every clinician has felt in some patients, particularly those 
 seriously ill, the extremities growing colder and colder while the 
 internal temperature is rising and, conversely, has felt the surface 
 grow warmer while the temperature is falling, demonstrating the fact 
 that the two are not always parallel. 
 
 It was on account of these considerations that the surface ther- 
 mometers described in Paper 2 were used after May, 1913, the two 
 units of the surface thermometer being strapped over the right and 
 left pectoralis major as near as possible to the heart and dome of the 
 liver. They were covered with a thick layer of cotton in an effort to 
 obtain the temperature of the subcutaneous tissue rather than that of 
 the naked skin. After March 12, 1914, a second surface thermometer 
 was added and its two units placed in various parts of the anterior 
 surface of the thorax and abdomen and also in the axillae. The results 
 have been confusing and difificult to interpret, but they have indicated 
 clearly that the different parts of the body do not show parallel tem- 
 perature curves. A fruitless search has been made for some part of 
 the body which will give a true index of the mean temperature 
 change. In the majority of all the experiments the rectal temperature 
 was the more satisfactory, but in typhoid fever the surface gave better 
 results. The method of investigation was as follows : 
 
 In a total of eighty-five experiments satisfactory rectal and surface 
 temperature measurements were made. Twenty-eight of these experi- 
 ments were on typhoid fever patients. For the reasons above stated 
 the heat production as determined by the method of indirect calorim- 
 etry was considered to be the true heat production, and the results 
 of the direct calorimetry as calculated by three different methods were 
 compared with this as shown in the table below. In all three methods 
 the figure for the heat eliminated from the body was, of course, the 
 same. To obtain the heat produced, the heat stored in or lost from the 
 body, as determined by each of the two measurements, and by a mean 
 of the two, has been added to or subtracted from the heat eliminated. 
 
 It will be seen from Table 6 that in the total of 85 experiments the 
 rectal temperature gave the best results, approximating the theoretical 
 more closely than either of its competitors in 36 cases, coming within 5 
 
 26. Williams, Riche and Lusk: Metabolism of the Dog Following the Inges- 
 tion of Meat in Large Quantity, Jour. Biol. Chem., 1912, xii, 349. 
 
64 
 
 CLINICAL CALORIMETRY 
 
 per cent, in 62 cases and involving a total error of only 0.90 per cent. 
 While the surface temperature gave the best results in 24 cases, it 
 showed an error of over 15 per cent, in 5 cases and did not prove as 
 reliable as the mean of surface and rectal. In typhoid fever the honors 
 were more evently divided and all three methods gave surprisingly good 
 results in spite of the large changes in body temperature sometimes 
 encountered. The surface temperature alone gave the best results in 
 13 of the 28 experiments and also the lowest total error. 
 
 TABLE 6.— Comparison of Surface and Rectal Temperatures as an 
 
 Index of Average Body Temperature; Percentage Differences 
 
 BETWEEN Indirect Calorimetry and Direct Calorimetry 
 
 Calculated According to Three Methods 
 
 Percentage 
 Difference in 
 
 Individual 
 Experiments 
 
 to 6 
 
 5 to 10 
 
 10 to 15 
 
 15+ 
 
 Total difference 
 
 Number giving results 
 nearest to indirect 
 
 Number of Experiments Falling in Each Group 
 
 Twenty-Eight Typhoid 
 Experiments 
 
 Eectal 
 Tempera- 
 ture 
 Alone 
 
 18 
 » 
 1 
 
 —1.32 
 
 8 
 
 Surface 
 Tempera- 
 ture 
 Alone 
 
 18 
 9 
 1 
 
 
 —1.17 
 
 13 
 
 One-half 
 Bectal, 
 One-half 
 Surface 
 
 18 
 10 
 
 
 
 
 —1.24 
 
 Eighty-rive Experiments in 
 Various Diseases, Includ- 
 ing the Twenty-Eight 
 Typhoid Observations 
 
 Rectal 
 Tempera- 
 ture 
 Alone 
 
 Surface 
 Tempera- 
 ture 
 Alone 
 
 62 
 
 41 
 
 19 
 
 28 
 
 i 
 
 11 
 
 
 
 5 
 
 — 0.9O 
 
 —1.46 
 
 46 
 
 24 
 
 One-half 
 Bectal, 
 One-half 
 Surface 
 
 53 
 27 
 
 4 
 
 1 
 —1.18 
 
 15 
 
 As a result of the above analysis the rectal temperature has been 
 adopted as the standard indicator of the average body change in hourly 
 periods, but with a full realization of its limitations. In many experi- 
 ments, particularly in those with rapidly changing temperature, better 
 results would be obtained by using the surface temperature, but surface 
 thermometers are more easily displaced than rectal and are not so 
 reHable in the long run. Theoretically, one would obtain the best results 
 by the use of many thermometers placed in the rectum, axillae, groin, 
 on the surface of the body in many areas, giving each measurement an 
 estimated weight, and then calculating the mean temperature change. 
 Our attempt to do this in a small way by giving the rectal and surface 
 equal weights did not lead to better results. For many reasons it seems 
 advisable to attach as little apparatus as possible to the subject, and it is 
 
FRANK C. GEP HART— EUGENE F. DU BOIS 65 
 
 doubtful if the use of many thermometers at one time will ever become 
 a standard method. 
 
 There may be several reasons why these results are not in accord 
 with the conclusion of Benedict and Slack. Working with normal sub- 
 jects who showed comparatively small fluctuations in body tempera- 
 ture, they made many measurements at different depths in the rectum 
 and vagina and found that while there was a sharp fall in temperature 
 between a point 7 cm. within the rectum and a point just within the 
 anus, nevertheless the temperature of points at different depths 
 remained parallel, though at a different level. Temperatures taken in 
 the well-closed axilla and groin were also parallel with the rectal. 
 The mouth was found to be an unsatisfactory place to obtain the 
 mean body temperature. Considerable difficulty was experienced in 
 obtaining satisfactory measurements of the surface of the body and of 
 the hands, and the writers speak of the difficulty of devising a ther- 
 mometer that will be shielded so that it may assume the body tem- 
 perature and yet not interfere with the natural liberation of heat. 
 
 As we have mentioned above, our surface thermometers were 
 covered with a thick layer of cotton wool and represented a subcu- 
 taneous rather than a surface measurement, and therefore not com- 
 parable to the axillary, groin and shallow rectal measurements of 
 Benedict and Slack. All of the latter are in the neighborhood of large 
 blood?-vessels and might be expected to rise and fall simultaneously. 
 
 All of this brings us back to the desirability of using the method 
 of indirect calorimetry as the standard and checking its accuracy by 
 the level of the respiratory quotient and the agreement with the direct 
 calorimetry. All the evidence of this laboratory shows that the 
 quotient rises and falls in regular curves in rest experiments when 
 hourly periods are used. If, therefore, in any experiment the quotient 
 shows a variation not accounted for by recent food, we suspect an 
 error and usually find it compensated for in the next period. This 
 error is almost always found in the calculation of the residual oxygen 
 in the box at the close of the hour. Luckily there is an automatic 
 correction in the method of calculating the indirect calorimetry. If in 
 the first hour the oxygen estimation be too high, the quotient will be 
 too low, and consequently the factor by which the oxygen is multiplied 
 will be diminished. In the second hour when the error has been com- 
 pensated for, the oxygen estimation will be too low, the quotient too 
 high and the factor increased. This is another reason why the indirect 
 calorimetry is more reliable than the oxygen consumption as an index 
 of metabolism. 
 
 The method of direct calorimetry serves as an invaluable check, 
 and if in any two- or three-hour experiment during which the body 
 
66 CLINICAL CALORIMETRY 
 
 temperature changes less than half a degree, the methods of indirect 
 and direct calorimetry do not agree within 5 per cent., one should 
 suspect a defect in the calorimeter. If in the next experiment a 
 similar divergence be found, an alcohol check should be made and the 
 error located. If one can prove that the error was due to any one par- 
 ticular determination, all calculations affected by this must be rejected 
 as in the two experiments on F. C. G. It is by no means necessary 
 to reject the results of the method of calorimetry not affected by the 
 error. There is only one determination that enters into both methods 
 of calculation, but an error in this would cause the two methods to 
 diverge and not to err in the same direction. If through gross careless- 
 ness the first sulphuric acid bottle were allowed to gain so much weight 
 that water vapor passed by into the CO, absorber, the direct calorimetry 
 would be too low and the indirect too high, since both the quotient 
 and the oxygen factor would be increased. 
 
 DETERMINATION OF THE AVERAGE NORMAL 
 
 The selection of the proper normal base line is a matter of extreme 
 difficulty. It is also a matter of prime importance in determining 
 whether or not a patient or group of patients shows a total metabolism 
 which is above or below the normal limits. In dealing with patients 
 suffering from acute diseases it is sometimes possible to wait until the 
 patient recovers completely and then determine his normal heat pro- 
 duction. This is not always practicable and even when it can be done 
 one has no guarantee that the metabolism has returned to normal 
 unless several measurements at considerable intervals be made. In 
 the case of patients with chronic diseases this method is out of the 
 question. The method most commonly used is that of selecting groups 
 of normal controls to correspond as nearly as possible to each indi- 
 vidual patient. This of course is the ideal method if many controls 
 be selected, but it is extremely doubtful if any investigator up to the 
 present date has been able to gather enough satisfactory controls for 
 each patient. The recent work of Benedict, Emmes, Roth and Smith" 
 may remedy this, on account of the large number of individuals whose 
 metabolism was determined. Even with this wealth of material one 
 may err if allowed to pick out a small group. The individual 
 variation is large, as one can see from a careful study of the fiotires. 
 It is, perhaps, unfair to draw many deductions before the full descrip- 
 tion of the subjects is published, but we may rely on the statement that 
 all were in presumably good health. The average heat production of 
 the 89 men was 833 calories per square meter per day or 34.7 calories 
 per square meter per hour. The average heat production of the 12 men 
 studied in the bed calorimeters and grouped in Table 4 was 34.2 calories 
 
FRANK C. GEPHART— EUGENE F. DU BOIS 67 
 
 per square meter per hour. This striking agreement is another proof 
 that the Benedict universal respiration apparatus gives results which 
 are almost identical with the calorimeter. For this reason the 7 sub- 
 jects examined by us have for purposes of calculation been grouped 
 with the 89 of Benedict, Emmes, Roth and Smith. In order to rule 
 out those who were distinctly over- or underweight, the subjects were 
 all plotted in a curve, the height forming the abscissa and the weight 
 the ordinates. All but 9 of the subjects could be grouped between two 
 lines not very far apart. Of the 9, W. S., O. F. M., Prof. C, H. F., 
 F. E. M. and F. A. R. were evidently much heavier in proportion to 
 their height than their fellows, and for this reason excluded from the 
 averages. It is interesting to note that their average heat production 
 was 31.5 calories per square meter. Two of the 9, R. A. C. and 
 B. N. C, were evidently very light in proportion to their height. 
 E. P. C. came just outside the line, but so close to it that he has not 
 been excluded from the averages. All those over 50 years of age were 
 arbitrarily excluded and also those under 20 years. To the remaining 
 72 were added the normal controls of the present paper. This process 
 of exclusion and addition left a fairly homogeneous total of 79 whose 
 average metabolism was 34.7 calories per square meter per hour, or 
 exactly the same as that of the original 89 before the addition of 7 and 
 the exclusion of 17. These 79 have been divided into four groups 
 according to body weight in Table 4. 
 
 If we plot the heat production of all the subjects according to 
 surface area, the range of individual variation becomes apparent. Of 
 the total 79 we find 40 within 5 per cent, of the base line drawn at the 
 average figure 34.7, 28 are from 5 to 10 per cent, from the average and 
 11 are more than 10 per cent, from the average. Of these, 6 were 
 between 10 and 14 per cent, above, and 5 were between 10 and 15 per 
 cent, below. This means that when we speak of a normal average we 
 must remember a normal variation of at least 10 per cent, above and 
 below and realize that in about 14 per cent, of the normal men the 
 variation may be plus or minus 10 to 15 per cent. One cannot help 
 but feel that most of the cases showing a variation of more than 10 per 
 cent, from the average will be found to present some distinct cause for 
 the unusual metabolism, such as an unusual degree of muscular devel- 
 opment or muscular disuse or an unsuspected disturbance of the 
 thyroid secretion, or the ipild infection with tuberculosis which all of 
 us pass through at some time in our lives. At any rate, one can be 
 fairly certain that if the total heat production be 15 per cent, from the 
 average it is distinctly abnormal, and if it be more than 10 per cent, 
 from the average it must be regarded with great suspicion. 
 
68 CLINICAL CALORIMETRY 
 
 It may be argued that some of the variation may be due to differ- 
 ences in body weight. If we study the 24 normal subjects in the table 
 we have been considering, whose weights are between 60 and 65 kg., the 
 same variation is apparent. Of the 24, only 13 are within 5 per cent, 
 of the average, S are between 5 and 12 per cent, above and 6 are from 
 5 to 10 per cent, below. If one investigator chanced to select this 
 last group of 6 for his controls his average would be about 15 per cent, 
 lower than if he selected the group of 5 cases with high metabolism. 
 This of course is an extreme instance. It may still be argued that the 
 factor of height must be considered. In the same table we find an 
 exceedingly homogeneous group of 7 men whose weights are between 
 60.1 and 60.5 kg. and whose heights are between 171 and 175 cm. 
 Even in this group there is a difference of 13 per cent, between the 
 highest and the lowest and a difference of 9 per cent, between the 
 averages of the highest 4 and the lowest 3 in this group. 
 
 This somewhat lengthy discussion is intended to show the chances 
 of serious error in selecting any small group of normal controls to 
 compare with a pathological case. One cannot say just how large the 
 group should be, but it is safe to say that it must exceed 5, should 
 exceed 10 and if possible, 50. It is obviously much better to use all 
 the normal controls so far studied and let personal selection play no 
 part. This can be done by basing all comparisons on the average heat 
 production per square meter of body surface. 
 
 In Table 4 we find a comparison of the heat production calculated 
 according to surface area and according to weight. A study of the 
 percentage variation from the average shows clearly that all four 
 weight groups are within 2 per cent, of the mean heat production per 
 square meter of body surface. In other words, one can determine the 
 average normal by this method by using a group of individuals of any 
 weight within ordinary limits. On the other hand, the figures per 
 kilogram of body weight show the customary diminution as weight 
 increases and there is a difference of 16 per cent, between the heavy 
 group and the light group. In other words, there is no such thing as 
 an average calories per kilogram for normal men, but only a normal 
 average for each weight. To iind the normal for a given man by this 
 method one must consult a curve. To find the normal for a given man 
 by the method of surface area one needs only to remember the 
 figure 34.7. 
 
 Shortly after the experimental work on the normal controls was 
 completed it seemed advisable to investigate the accuracy of Meeh's 
 formula and if possible devise a new formula which could be applied 
 to individuals who depart materially from the average body form. 
 Five subjects were measured and it was found that there was a con- 
 
FRANK C. GEPHART— EUGENE F. DU BOIS 69 
 
 sistent plus error in Meeh's formula which, in the case of a very fat 
 woman, amounted to 36 per cent. In two of the normal controls 
 whose heat production had been determined, the surface area was 
 actually measured and the errors in Meeh's formula were found to be 
 as follows: E. F. D. B., + 14 per cent., R. H. H., + 7 per cent. In 
 three others, G. L., F. C. G. and L. C. M., the surface area was cal- 
 culated by the new formula and fouijd to be, respectively, 14.5 per 
 cent., 9.3 per cent, and 13.4 per cent, lower than the results obtained by 
 Meeh's formula. Since in all four cases the new surface area figures 
 are lower than the old results obtained from Meeh's forrhula, the heat 
 production per square meter of body surface, according to the new 
 formula, would be about 7 to 15 per cent, higher, the average being 
 39.9. As will be seen in the last two columns of Table 3, the new 
 results are somewhat more uniform than the old results, but are on a 
 higher level, and it is quite possible that it may be necessary to adopt 
 a higher normal average than 34.7. The general principle of Meeh's 
 formula seems to be correct for individuals of average shape, and for 
 this reason it may be used as the standard in large groups of sub- 
 jects. In the case of very fat individuals, Meeh's formula would 
 give a figure for the calories per square meter which would be much 
 too low. It seems probable that some of the variations from the 
 average normal figure per square meter can be explained by the varia- 
 ble error in the old formula. Future use of the new formula will, it is 
 hoped, clear up this point. The details of the new method will appear 
 in the following paper. 
 
 There is but little evidence against Rubner's law that metabolism is 
 proportional to surface area. As we have seen there is a plus error in 
 Meeh's formula for determining surface area. Nevertheless, in a 
 group of normal men of approximately average build between the 
 weights of 45 and 85 kilograms the metabolism is, on the whole, pro- 
 portional to the surface area as determined by Meeh's formula. When 
 we come to extend Rubner's law to babies and dogs studied in the 
 modern types of apparatus with the modern scrupulous care to exclude 
 the effect of muscular work, we find the figure for the calories per 
 square meter changed, yet not nearly so much changed as the figure 
 for the calories per kilogram of body weight. Murlin and Hoobler^" 
 have demonstrated that in a group of infants between the ages of 2 
 and 12 months the metabolism is proportional to weight rather than to 
 surface area, and have pointed out the effect of age, showing that 
 among infants of the same age the metabolism is proportional to the 
 
 27. Murlin and Hoobler : The Energy Requirement of Normal and Marasmic 
 Children with Special Reference to the Specific Gravity of the Child's Body, 
 Proc. Soc. Exper. Biol, and Med., 1914, xi, 115. 
 
70 CLINICAL CALORIMETRY 
 
 surface area. Benedict and Talbot^^ believe that the metaboHsm ' of 
 infants is not proportional to surface area, but is proportional to pro- 
 toplasmic mass. Table 7 shows that comparing babies and dogs with 
 adults the method of surface area gives results much closer to the 
 average for men than the method of comparison by weight. It may 
 seem superfluous at this late date to argue at length in support of 
 Rubner's law of surface area, btit this law is becoming the center of an 
 active discussion. 
 
 The percentage of calories derived from protein in the fasting 
 experiments is a matter of some interest in the discussion of 
 the subject of the toxic destruction of protein. The average figures 
 for the basal experiments on the various subjects are as follows: 
 G. L., 16.5 per cent. ; E. F. D. B., 19 per cent. ; F. C. G., 18 per cent. ; 
 Louis M., 22 per cent. ; John L., 15 per cent. ; L. C. M., 21.5 per cent. 
 To this list may be added the figures for several normal controls from 
 the work of Benedict and Joslin:^° F. G. B., 17.6 per cent.; J. R., 
 15.6 per cent. ; J. J. C., 15.7 per cent. ; D. B., 21.6 per cent. ; H. F. T., 
 19.9 per cent. ; Dr. S., 15.5 per cent. ; V. G., 12.7 per cent. ; T. M. C., 
 14.8 per cent. These figures represent largely the effect of the amount 
 of protein in the diet of the preceding day. They are by no means the 
 figures that would be obtained had the subjects been maintained on af 
 protein minimum for a few days before the experiments. 
 
 THE EFFECTS OF FOOD 
 
 The experiments on the effects of food were intended primarily as 
 controls on the effects of similar meals given to patients with typhoid 
 fever and exophthalmic goiter. While the subject of the specific 
 dynamic action of food is one of great interest and importance it was 
 felt that the chief function of the calorimeter in Bellevue Hospital was 
 the investigation of pathological conditions. Consequently, very simple 
 protein and carbohydrate meals which could be given in typhoid fever 
 were the only ones studied, and the study of the effects of fat was 
 postponed. During the season of 1913 commercial glucose containing 
 dextrose 42.37 per cent., dextrin 44.57 per cent, and water 13.50 per 
 cent, was used. This is one of the cheapest of food-stuffs, is readily 
 soluble in water, is not very sweet and on account of its chemical com- 
 position should be rapidly absorbed. It has been found of great service 
 
 28. Benedict and Talbot : Studies in Respiratory Exchange of Infants, 
 Am. Jour. Dis. Child., 1914, viii, 1 ; Gaseous Metabolism of Infants, Carnegie 
 Institution of Washington, 1914, Pub. 201. 
 
 29. Benedict and Joslin : A Study of Metabolism in Severe Diabetes, Car- 
 negie Institution of Washington, 1912, Pub. 176, p. 103. 
 
PRANK C. GEPHART— EUGENE P. DU BOIS 
 
 71 
 
 in feeding many of the patients and in some ways is preferable to the 
 less soluble lactose. In the season of 1914 chemically pure dextrose 
 was used in order to compare its effects with that of the mixture. The 
 chief protein meal used in typhoid consisted chiefly of casein in the 
 form of cottage cheese and fat-free milk with the whites of two or 
 three eggs and some tgg yolk. It did not make a very palatable mix- 
 ture, but it was consumed by most of the typhoid patients without 
 much complaint and it certainly did them no harm. While it might 
 have been more satisfactory to give meat, it did not seem justifiable 
 until we had more experience with its effects in fever. 
 
 TABLE 7. — Comparison of Calories per Kg. and per Square Meters 
 
 OF Body Surface 
 
 Investigator 
 
 Subject 
 
 Calories 
 per 
 Kg. 
 
 Calories 
 
 per 
 Sg. M 
 
 Per Cent. 
 Variation from 
 Average for Men 
 
 Accord- 
 ing to 
 Calories 
 per Kg. 
 
 Accord- 
 ing to 
 Calories 
 per Sp.M. 
 
 Benedict and collaborators 
 
 Lusk 
 
 Lusk 
 
 Lusk 
 
 Lusk and McCrudden 
 
 Howland 
 
 Howland 
 
 Murlin and Hoobier 
 
 Benedict and Talbot 
 
 79 men 
 
 Dogl 
 
 Dog 2 
 
 Dogs 
 
 Dwarf, Wt. 21.3kg. ... 
 
 Baby 1., 
 
 Baby 2 
 
 Average 6 infants 
 
 Average 10 normal in- 
 under 1 month 
 
 Average 11 normal in- 
 fants between 1 and 
 10 months 
 
 1.08 
 1.65 
 1.75 
 1.45 
 1.21 
 2.89 
 3.45 
 2.69 
 1.95 
 2.21 
 
 34 7 
 31.6 
 82.7 
 29.8 
 32.3 
 39.5 
 45.7 
 36.3 
 25.6 
 35.B 
 
 -1-53 
 
 -1-62 
 
 -1-35 
 
 -1-12 
 
 -fl68 
 
 -f220 
 
 -1-150 
 
 -I- SI 
 
 -1-105 
 
 —14 
 — 7 
 -H4 
 -)-31 
 + 5 
 —26 
 -I- 2. 
 
 Two different methods were used in obtaining a base line to repre- 
 sent the metabolism without food. At first the fasting metabolism was 
 determined in the early morning and the food given while the subject 
 was in the calorimeter. This necessitated a sojourn of three or four 
 hours in the box after the food in addition to the two hours before the 
 food. Even normal individuals become tired after three hours of 
 absolute quiet in a calorimeter and it was evident that patients would 
 be restless in such long experiments. Another disturbing factor was 
 the gradual change in the metabolism with the different hours of the 
 day. The method finally adopted has given great satisfaction. It is 
 the method used so successfully by Lusk^ on the dog. The basal 
 metabolism is determined in a two- or three-hour experiment and two 
 
CLINICAL CALORIMETRY 
 
 days later the food is given before the subject is sealed in the box and 
 the metabolism determined during the same hours studied in the fast- 
 ing experiment. The basal metabolism in our experience does not 
 change rapidly enough to make this method inaccurate. The high 
 metabolism in the first experiment on E. F. D. B. was due to restless- 
 ness, and the low metabolism in the first experiment on F. C. G. was 
 due to profound sleep. Between May 17, 1913, and May 18, 1914, the 
 heat production of E. F. D. B. did not vary 3 per cent, in the three 
 
 TABLE 8. — Increase in Heat Production Following Ingestion of 
 
 Dextrose 
 
 Subject 
 
 Hours 
 
 After 
 
 Glucose 
 
 Per 
 Cent. 
 Bise 
 
 Extra 
 Calo- 
 ries 
 
 Extra Calo- 
 ries Irom 
 
 Combustion 
 ot Carbo- 
 hydrate 
 
 Speciflc 
 
 Dynamic 
 
 Action, 
 
 Per 
 
 Cent. 
 
 G. L.: 100 glucose 
 
 0-1 
 
 20 
 
 15.52 
 
 
 
 
 1-2 
 
 10 
 
 8.16 
 
 
 
 
 2-3 
 
 3 
 
 2.26 
 
 
 
 E. P. D. B.: 100 glucose 
 
 0-1 
 
 3 
 
 2.63 
 
 24.66 
 
 11 
 
 
 1-2 
 
 11 
 
 8.78 
 
 22.38 
 
 39 
 
 
 2-3 
 
 9 
 
 6.77 
 
 20.41 
 
 39 
 
 
 3-4 
 
 6 
 
 4.28 
 
 23.96 
 
 18 
 
 Total 
 
 
 > .. 
 
 22.46 
 
 91.31 
 
 Av.25 
 
 E. P. D. B.: 200 glucose 
 
 1-2 
 
 13 
 
 9.18 
 
 41.68 
 
 22 
 
 
 2-3 
 
 17 
 
 11.73 
 
 37.83 
 
 31 
 
 
 3-4 
 
 S 
 
 5.98 
 
 39.22 
 
 15 
 
 
 4-5 
 
 7 
 
 5.12 
 
 40.08 
 
 13 
 
 Total 
 
 
 
 32.01 
 
 158.81 
 
 At. 20 
 
 L. C. M.: 200 glucose 
 
 1-2 
 
 24 
 
 15.09 
 
 33.37 
 
 45 
 
 
 2-3 
 
 16 
 
 10.49 
 
 41.04 
 
 26 
 
 
 3-4 
 
 16 
 
 10.26 
 
 40.85 
 
 25 
 
 Total 
 
 
 
 35.83 
 
 115.26 
 
 At. 31 
 
 tests made. In some of the ward patients studied the metabolism has 
 remained constant from day to day and even in typhoid fever has 
 changed in gradual curves. Two hundred grams of dextrose or its 
 equivalent caused an average increase of 12.5 per cent, in the first three 
 to six hours after its ingestion. One hundred grams caused an average 
 increase of 9 per cent. The casein meal with lO.S gm. N increased the 
 metabolism 12 per cent., the beef with almost 24 gm. nitrogen increased 
 
FRANK C. GEP HART— EUGENE F. DU BOIS 
 
 73 
 
 it 22 per cent.* A more detailed study of the effects of food is given in 
 Tables 8 and 9, which show the effects in the different periods. The 
 percentage increase in metabolism and the extra calories produced are 
 calculated from the nearest basal determination. The extra protein 
 calories produced are calculated from the increase in the urine nitrogen 
 above the average hourly elimination of the nearest basal determina- 
 tion. The extra grams of urinary nitrogen when multiplied by the 
 factor 26.51 give the extra calories from the combustion of protein 
 during that hour. The extra calories produced when divided by this 
 
 TABLE 9. — Increase in Heat Production Following Protein Meal 
 
 Time After 
 
 Protein Meal, 
 
 Hours 
 
 Per Cent. 
 
 Rise in 
 Metabolism 
 
 Extra 
 Calories 
 Produced 
 
 Extra 
 
 Protein 
 
 Calories 
 
 Metabolized. 
 
 Extra 
 
 Urine 
 
 N X 26.51 
 
 E. P. D. B.: 10.5 N 
 
 1% to 2V4 
 
 214 to 3% 
 
 3% to Mi 
 
 »A to S^A 
 
 5% to 61^ 
 
 Total 
 
 Louis M.: After 23.93 N 
 
 2 to 3 
 
 3 to 4 
 
 4 to 5 
 
 5 to 6 
 
 6 to 7 
 
 7 to 8 
 
 Total 
 
 5.93 
 
 8.96 
 
 12.34 
 
 8.27 
 
 9.03 
 
 10.13 
 
 11.54 
 
 1.56 
 
 5.04 
 
 1.56 
 
 43.88 
 
 30.48 
 
 9.68 
 
 4.80 
 
 111.36 
 
 4.59 
 
 17.94 
 
 11.88 
 
 17.62 
 
 13.04 
 
 11.30 
 
 16.33 
 
 16.45 
 
 15.64 
 
 ?3.35 
 
 66.28 
 
 Specific 
 
 Dynamic 
 
 Action, 
 
 Per 
 
 Cent. 
 
 60 
 140 
 
 90 
 
 738 
 
 300 
 
 Av. 144 
 
 203 
 
 225 
 
 151 
 
 135 
 
 69 
 
 loe 
 
 Av. 126 
 
 figure for the extra protein calories metabolized, give the specific 
 d3'namic action in the sense of Rubner (see Note 2, Williams, Riche 
 and Lusk, p. 370), amounting to as much as 144 per cent, and 126 per 
 cent, for the two experiments. The accuracy of this method of cal- 
 culation m.ay be impaired by the lag in the excretion of nitrogen by 
 
 * Since the completion of this paper two more normal men have been given 
 the test meals. Morris S. on Dec. 18, 1914, showed a rise of 6.5 per cent, after 
 a meal containing 9.6 gm. nitrogen. Albert G. on Jan. 6, 191S, showed an 
 increase of 9 per cent, in his metabolism after 115 gm. commercial glucose 
 (100 gm. dry glucose). 
 
74 CLINICAL CALORIMETRY 
 
 the kidneys. In the dextrose experiments the method of calculation is 
 slightly different from the method used by Lusk.^ The extra calories 
 produced by the combustion of carbohydrate are reckoned as follows: 
 In the nearest basal determination the average figure for the calories 
 per hour is multiplied by the percentage of calories furnished by the 
 combustion of carbohydrate. A similar calculation is made in each 
 hour of the experiment in which dextrose was administered and the 
 extra carbohydrate calories metabolized in each hour determined. This 
 figure divided into the extra calories produced gives the specific 
 dynamic action of 25, 20 and 31 per cent, in the three experiments. 
 
 SUMMARY AND CONCLUSIONS 
 
 Seven normal men were studied with and without food as controls 
 for the observations on patients in the metabolism ward. Their aver- 
 age basal metabolism (at perfect rest, fourteen to eighteen hours after 
 their last meal) was 34.8 calories per hour per square meter of 
 body surface. The average basal metabolism of 89 normal men studied 
 by Benedict, Emmes, Roth and Smith^" was 34.7 calories. The average 
 of the 7 men studied in the Sage bed calorimeter in Bellevue and of 
 the 5 men studied in Benedict's bed calorimeter in Boston was 34.2 
 calories. As a result we have adopted the figure of 34.7 calories per 
 square meter of the body surface as the average heat production of 
 normal men between the ages of 20 and 50 5'ears. 
 
 All of the subjects studied in the bed calorimeter were within 
 11 per cent, of this average. Of the 79 men of normal figure between 
 the ages of 20 and 50 studied by Benedict and collaborators, 86 per 
 cent, were within 10 per cent, of the average and the remainder 
 between 11 and IS per cent. If, therefore, the heat production of a 
 given subject suffering from some pathological condition is more than 
 10 per cent, above or below the average it may be regarded as abnor- 
 mal, but cannot be proved abnormal unless the departure from the 
 average is at least 15 per cent. 
 
 Groups of men of weights between 45 and 85 kilograms show a 
 mean heat production within 2 per cent, of the average according to 
 surface area. According to calories per kilogram of body weight the 
 group weighing between 75 and 85 kg. produces 7 per cent, less than 
 the average figure and the group between 45 and 55 kg. produces 9 per 
 cent, more than the average. The conclusion is therefore drawn that 
 among groups of men of varying weights metabolism is proportional 
 to surface area according to Rubner's law and is not proportional to 
 body weight. By using the surface area as a basis one can refer all 
 individuals to a single average normal figure, 34.7. If one uses the 
 body weight as a basis a different normal figure is required for each 
 weight. 
 
FRANK C. GEPH ART— EUGENE F. DU BOIS 75 
 
 The methods of direct and indirect calorimetry in disease agree in 
 two- and three-hour periods ; and in health may be found to agree in 
 hourly periods. In the total measurement of 4,577 calories in the 
 experiments reported in this paper the two methods have agreed within 
 0.17 per cent. In a total of thirty one-hour periods on one normal 
 subject the two methods have agreed within 5 per cent, in twenty-one 
 individual hours and within 10 per cent, in twenty-sevep of the periods. 
 
 The method of indirect calorimetry using the oxygen consumption 
 as a basis gives the best results in hourly periods. The method of 
 direct calorimetry in short periods is made difficult by uncertainty as to 
 the correct specific heat of the body and also by the fact that the differ- 
 ent parts of the body do not always change their temperatures at the 
 same rate. On the average one obtains the best results by considering 
 that the rectal temperature change indicates the mean temperature 
 change of the body, but in typhoid fever the surface thermometers 
 often give a better indication of the mean body change. 
 
 The most satisfactory method of determining the effect of food in 
 increasing heat production in normal subjects and patients is to deter- 
 mine the basal metabolism at frequent intervals, and on days shortly 
 after a basal determination administer the food before the subject is 
 sealed in the calorimeter. It has been found that 200 gm. of dextrose 
 or its equivalent in commercial glucose or a casein meal with 10.5 gm. 
 of nitrogen increase the heat production by about 12 per cent, over a 
 period of three to six hours. The basal metabolism of patients with 
 various diseases and the effects of this same food will be discussed in 
 subsequent publications. 
 
 477 First Avenue. 
 
CLINICAL CALORIMETRY 
 
 FIFTH TAPER 
 
 THE MEASTJrEMENT OF THE SURFACE AREA OF MAN* 
 
 DELAFIELD DuBOIS, B.S., and EUGENE F. DuBOIS, M.D. 
 
 NEW YORK 
 
 Recent work on the basal metabolism of infants and adults has 
 revived interest in Rubner's law that heat production in different indi- 
 viduals and species of animals is proportional to the surface area. This 
 law was first definitely formulated by Rubner^ in 1883, although sug- 
 gested by Bergman'^ many years before. At the time the experimental 
 work in support of this theory was done no record was kept of body 
 movements and men and animals were allowed to move during the 
 periods of investigation. The average heat production per square 
 meter of body surface was about 1,000 calories per day. In modern 
 work, where the influence of muscular activity is absolutely excluded, 
 the figure is in the neighborhood of 830 calories per square meter per 
 day, as has been shown in Paper 4 of this series. With these new- 
 figures it is not unnatural that many investigators have felt that the 
 whole question must be studied anew. Very recently Murlin and 
 Hoobler^ in New York and Benedict and Talbot^ in Boston have all 
 concluded that among infants metabolism is more nearly proportional 
 to body weight than to surface area. If this is true for adults, it is a 
 matter of great theoretical and practical importance. 
 
 It is obvious tliat the whole question rests on the accuracy of the 
 determinations of the basal metabolism and of the surface area. The 
 methods of determining the metabolism have been greatly improved, 
 leaving the surface area the doubtful factor. The number of formulas 
 for surface area determination is large, the number of individuals 
 
 * From the Russell Sage Institute of Pathology, in affiliation with the 
 Second Medical Division of Bellevue Hospital. 
 
 1. Rubner : Ueber den Einfluss der Korpergrosse auf Stoflf- und Kraft- 
 wechsel, Ztschr. f. Biol., 1883, xix, S4S. 
 
 2. Bergman : Warraeokonomie der Thiere, Gottingen, 1848, p. 9. 
 
 3. Murlin and Hoobler : The Energy Metabolism of Normal and Marasmic 
 Children with Special Reference to the Specific Gravity of the Child's Body, 
 Proc. Soc. Exper. Biol, and Med., 1914, xi, IIS. 
 
 4. Benedict and Talbot : Studies in the Respiratory Exchange of Infants, 
 Am. Jour. Dis. Child., 1914, viii, 1 ; The Gaseous Metabolism of Infants, Car- 
 negie Institution of Washington, 1914, Pub. 201. 
 
DELAFIELD DU BOIS— EUGENE F. DU BOIS 77 
 
 whose area has been measured is small. In 1879 Meeh° finished his 
 painstaking and time-constiming work which has remained the standard 
 ever since. He measured six adults and ten children, using a variety 
 of methods. Some parts of the body were marked out in geometrical 
 patterns, which were then traced on transparent paper. The areas of 
 these were then determined by geometry, or, if the pieces of paper were 
 very irregular, by weighing. Some of the cylindrical parts of the body 
 were wound with strips of millimeter paper like a bandage. Funke** in 
 one case covered the skin of a cadaver with adhesive material and 
 pasted over this squares of paper. Fubini and Ronchi'^ measured one 
 man by marking out the anatomical regions of the body and determining 
 the areas geometrically. Bouchard^ used this same method in measur- 
 ing a number of adults. He speaks of a plan of clothing the body in 
 tights made of some thin, flexible, inelastic sort of paper, the area of 
 which could be determined by weighing. Apparently, he was not able 
 to find the right material. He mentions the fact that M. Bergonie 
 measured surface area by means of plates of lead, and that M. Roussy 
 used a very ingenious cylinder with a revolution counter which he 
 passed over the whole .surface of the body. Bouchard also states that 
 D'Arsonval determined the surface area electrically by clothing the 
 man in silk tights and charging him as one would charge a Ley den jar, 
 calculating the surface by applying a ■ metal plate of known area. 
 Lissauer^ measured twelve dead babies by covering the skin with 
 colored adhesive material and then applying silk paper and measuring 
 the area of the paper geometrically or with a planimeter. 
 
 Meeh^ as a result of his own measurements, based his formula for 
 determining surface area on the fundamental mathematical law that the 
 surfaces of similar solids are proportional to the % power of their 
 volumes. Using the body weight to represent volume he determined 
 that the constant 12.312 when multiplied by the cube root of the square 
 of the weight in kilograms gave results which came within 7 per cent, 
 of all his measurements of adults and older children. The constant 
 for infants was 11.9 and for various species of animals still different. 
 Miwa and Stoltzner^" felt the need of introducing linear measurements 
 
 5. Meeh : Oberflachenmessungen des menschlichen Korpers, Ztschr. f. Biol., 
 1879, XV, 425. 
 
 6. Funke: Moleschott's Untersuchungen, z. Naturlehre, 1858, iv, 36. 
 
 7. Fubini and Ronchi : Ueber die Perspiration der CO2 beim Menschen 
 Moleschott's Untersuchungen, z. Naturlehre, 1881, xii. 
 
 8. Bouchard, Ch. : Traite de Pathologie generate, Paris, 1900, iii', 200, 384. 
 
 9. Lissauer, W. : Ueber Oberflachenmessungen an Sauglingen und ihre 
 Bedeutung fiir den Nahrungsbedarf, Jahrb. f. Kinderh., 1902, Iviii, 392. 
 
 10. Miwa and Stoltzner: Bestimmung der Korperoberfiache des Menschen. 
 Ztschr. f. Biol., 1898, xxxvi, 314. 
 
78 CLINICAL CALORIMETRY 
 
 and chose the height (L) and the circumference of the chest (U) at the 
 level of the nipples in men and just above the breasts in viromen, retain- 
 ing the weight (G) as a factor. Using Meeh's measurements they 
 determined by means of the following formula, 
 
 K UGL 
 Surface = o using an average constant (K) of 4.S33S. 
 
 This formula, which might have been simplified to Surface = kvipgl 
 has never been much used, although its originators have shown that it 
 comes closer to Meeh's cases than Meeh's own formula. Lissauer from 
 the measurement of babies, almost all of whom were atrophic, retained 
 the principles of Meeh's formula, but found that the constant 10.3 gave 
 better results than the constant 11.9. This indicated that Meeh's figure 
 was about 16 per cent, too high. The formula of Miwa and Stoltzner, 
 according to Lissauer, gave no better results than that of Meeh. 
 Rowland and Dana,^^ using the measurements of Meeh and Lissauer, 
 have devised a simple formula in which the surface area (y) of the 
 child equals the weight in grams (x) multiplied by a constant 0.483 (m) 
 plus 730 (b). This is expressed in the terms y = mx + b. 
 
 Bouchard found a consistent plus error in Meeh's formula as given 
 in Table 1. In his own formula, which requires twenty-five pages of 
 tables for its application, he uses the body weight, the height and the 
 diagonal circumference of the abdomen from the hollow of the back 
 to a point somewhere above the umbilicus according to the degree of 
 obesity. Bouchard states that a measuring tape passed around the 
 abdomen and moved back and forth will of itself find the right circum- 
 ference, which he calls the "tour de taille." Bouchard's formula has 
 been very little used, as it seems to be difficult to understand and apply. 
 
 Recently Dreyer, Ray and Walker"^ have made many measurements 
 of birds and small mammals and have found that the surface area, 
 blood volume, cross sections of the aorta and trachea are all nearly 
 proportional to the ^ power of the weight. The formula which 
 applies to all these measurements is S == k W", in which S is the sur- 
 face, blood volume, etc. ; k is a constant which varies with the species ; 
 W is the weight, and n is approximately 0.70-0.72 instead of 0.666 which 
 would be the % power. Benedict and Talbot* have suggested that the 
 active mass of protoplasmic tissue develops normally on this ratio. 
 They are convinced that metabolism is determined, not by the body 
 
 11. Howland and Dana: A Formula for the Determination of the Surface 
 Area of Infants, Am. Jour. Dis. Child., 1913, vi, 33. 
 
 12. Dreyer and Ray: Phil. Trans., 1909-10, cci, Series B, p. 133. Dreyer, 
 Ray and Walker : The Size of the Aorta in Warm-Blooded Animals and 
 its Relationship to Body Weight and to Surface Area, Expressed in a Formula, 
 Proc. Roy. Soc, 1912-1913, Ixxxvi, Series B, pp. 39 and 56. 
 
DELAFIELD DU BOIS— EUGENE F. DU BOIS 
 
 79 
 
 surface, but by the active mass of protoplasmic tissue. If both are 
 assumed proportional to the same thing, it will be a difficult matter to 
 prove which is the more important factor. 
 
 As shown in Paper 4 of this series, the metabolism of the normal 
 and pathological subjects studied in the Sage respiration calorimeter in 
 Bellevue Hospital has been expressed in terms of calories per square 
 
 TABLE 1. — Determination of Error in Meeh's Formula as Applied to Measured 
 
 Individuals 
 
 Subject 
 
 Observer 
 
 Weight, 
 Kg. 
 
 Surface 
 Area 
 
 as Meas- 
 ured, 
 
 Sq. Cm. 
 
 Constant 
 
 for 
 
 Meeh's 
 
 ronnula. 
 
 Area 
 Divided 
 by Wt.% 
 
 Error in 
 
 Meeh's 
 
 Formula 
 
 Age, 
 Trs. 
 
 Height, 
 Cm. 
 
 24.2 
 
 8,473 
 
 10.13 
 
 +21 
 
 36 
 
 110.3 
 
 28.30 ' 
 
 11,883 
 
 12.80 
 
 — 4 
 
 13.1 
 
 137.5 
 
 31.8 
 
 12,737 
 
 12.69 
 
 -3 
 
 
 
 35.38 
 
 14,988 
 
 13.17 
 
 — 7 
 
 15.7 
 
 152 
 
 60.00 
 
 17,415 
 
 12.96 
 
 — 5 
 
 36 
 
 158 
 
 50.00 
 
 16,067 
 
 11.84 
 
 + 4 
 
 
 
 51.75 
 
 18,158 
 
 12.96 
 
 — 5 
 
 45 
 
 160 
 
 55.75 
 
 19,206 
 
 13.16 
 
 — 6 
 
 17.7 
 
 169 
 
 59.50 
 
 18,695 
 
 12.27 
 
 + 
 
 ... 
 
 170 
 
 61.6 
 
 18,930 
 
 12.13 
 
 + 2 
 
 ... 
 
 
 62.25 
 
 19,204 
 
 12.01 
 
 + 2 
 
 26.2 
 
 162 
 
 64.0 
 
 16,720 
 
 10.45 
 
 +17 
 
 21 
 
 164.3 
 
 64.08 
 
 18,375 
 
 11.49 
 
 + 7 
 
 22 
 
 178 
 
 65.50 
 
 20,172 
 
 12.48 
 
 — 1 
 
 66 
 
 172 
 
 74.05 
 
 19,000 
 
 10.55 
 
 +14 
 
 32 
 
 179.2 
 
 76.5 
 
 19,484 
 
 10.81 
 
 +14 
 
 
 
 78.25 
 
 22,435 
 
 12.26 
 
 + 
 
 36 
 
 171 
 
 88.6 
 
 21,925 
 
 11.03 
 
 +12 
 
 ... 
 
 
 93.0 
 
 18,692 
 
 9.06 
 
 +36 
 
 
 149.7 
 
 140.0 
 
 24,966 
 
 9.26 
 
 +33 
 
 
 
 Body Form 
 
 Benny L 
 
 Hagenlocher 
 
 Very thin woman 
 
 Eorner 
 
 Schncck 
 
 Adult man 
 
 Nagel 
 
 Pr. Brotbeck ... 
 Naser 
 
 Normal man 
 
 Pr. Haug 
 
 Morris S 
 
 E. H. H 
 
 Porstbauer 
 
 E. P. D. B 
 
 Normal woman.. 
 
 Kehrer 
 
 Large man 
 
 Mrs. McK 
 
 Very fat man... 
 
 D.B. and D.B 
 
 Meeh 
 
 Bouchard 
 
 Meeh 
 
 Meeh 
 
 Pobini and Bonchi 
 
 Meeh 
 
 Meeh 
 
 Meeh 
 
 Bouchard 
 
 Meeh 
 
 D.B. and D.B 
 
 D.B. and D.B 
 
 Meeh 
 
 D.B. and D.B 
 
 Bouchard 
 
 Meeh 
 
 Bouchard 
 
 D.B. and D.B 
 
 Bouchard 
 
 Cretin. Short and 
 
 fat. 
 Medium strong. 
 
 Very thin. 
 
 Muscular. 
 
 ■ Very thin. 
 
 ? 
 
 Somewhat thin. 
 
 Very strong and 
 muscular. 
 
 Somewhat thin, 
 but wen pro- 
 portioned. 
 
 Normal man. 
 
 Strong. 
 
 Short and rather 
 
 stout. 
 TaU and thin. 
 
 StiU very strong. 
 
 Tall, average 
 
 build. 
 Normal woman. 
 
 Corpulent. 
 
 Large strong man. 
 
 Very short and 
 
 very fat. 
 Very fat man. 
 
 meter per hour. The work had progressed but a short distance when 
 it was obvious that no formula based on weight could give the surface 
 area of all the patients with any great degree of accuracy. Among the 
 patients studied were men emaciated from typhoid fever and hyper- 
 thyroidism, men of normal shape and men with acromegaluy, hypo- 
 physial dystrophy and cretinism. Eventually, it is hoped every con- 
 ceivable shape will be studied. A formula such as Meeh's is accurate 
 only for objects of different size, but of similar shape. 
 
80 
 
 CLINICAL CALORIMETRY 
 
 The obvious method for determining surface area is to multiply the 
 length by the average width. An attempt has been made to measure a 
 characteristic length and an average or characteristic circumference of 
 each part of the body and determine the area of the part by multiplying 
 the two and correcting by a constant factor. The sum of the parts will 
 then give the total surface area of the body. When the proper meas- 
 urements have been selected and the constants for each part deter- 
 mined, it is evident that the method can be applied to individuals of 
 varying shape no matter what disproportion may exist between the 
 different parts of the body. 
 
 Fig. 16. — The cretin, Benny L., with mold of his surface area. 
 
 INDIVIDUALS MEASURED 
 
 The five individuals whose surface area was measured differed from 
 each other in bodily form to a marked degree. All of them had served 
 as the subjects of observations in which the basal metabolism was deter- 
 mined. Benny L. was a cretin 36 years old with the general mental and 
 physical development of a boy of 8. As his photograph (Fig. 16) 
 shows, he was short and stocky, with prominent abdomen, short thick 
 extremities and rather small head. Morris S., 21 years old, was meas- 
 ured three months after he was discharged from the hospital, where he 
 
DELAFIELD DU BOIS— EUGENE F. DU BOIS 
 
 81 
 
 had been confined three and one-half months with a severe attack of 
 typhoid fever. He had recovered even more than his usual weight in 
 the hospital and during the subsequent stay in the country. At the time 
 he was measured he was of well rounded figure, almost stout. He was 
 short and of small frame, with small hands and feet. R. H. H., a 
 cheinist, 22 years old, was tall and thin, with long, slim bones, sinewy 
 muscles and very little subcutaneous fat. E. F. D. B., 32 years old, was 
 tall, but of average build. Mrs. McK. was a very short and very fat 
 woman whose metabolism had been studied in great detail by Dr. David 
 
 TABLE 2. — Measurements Used in Formula 
 
 Index Letter 
 ot Part 
 Measured 
 
 Benny L. 
 
 Morris S. 
 
 E. H. H. 
 
 E. P. D. B. 
 
 Mrs. McK. 
 
 A 
 
 67.5 
 
 63.9 
 
 65.0 
 
 67.0 
 
 68.0 
 
 B 
 
 50.2 
 
 54.1 
 
 56.6 
 
 67.8 
 
 66.6 
 
 P 
 
 37.2 
 
 56.7 
 
 65.0 
 
 67.3 
 
 65.0 
 
 G 
 
 20.2 
 
 29.5 
 
 27.5 
 
 32.5 
 
 33.0 
 
 H 
 
 18.7 
 
 24.6 
 
 26.0 
 
 27.5 
 
 27.0 
 
 I 
 
 12.8 
 
 16.7 
 
 16.3 
 
 16.2 
 
 16.5 
 
 J 
 
 13.6 
 
 20.0 
 
 21.6 
 
 20.2 
 
 17.0 
 
 K 
 
 15.2 
 
 20.4 
 
 20.6 
 
 20.5 
 
 17.6 
 
 L 
 
 36.6 
 
 65.0 
 
 55.0 
 
 51.5 
 
 56.0 
 
 M ; 
 
 62.0 
 
 76.2 
 
 72.5 
 
 77.0 
 
 111.0 
 
 N 
 
 63.5 
 
 87.2 
 
 85.8 
 
 96.0 
 
 100.0 
 
 
 
 26.4 
 
 41.7 
 
 47.0 
 
 46.3 
 
 40.0 
 
 P 
 
 35.5 
 
 55.5 
 
 54.0 
 
 59.0 
 
 60.0 
 \ 
 117.0 
 
 Q 
 
 61.0 
 
 96.0 
 
 93.2 
 
 96.5 
 
 E 
 
 29.3 
 
 41.7 
 
 47.0 
 
 49.4 
 
 36.8 
 
 S 
 
 23.7 
 
 35.7 
 
 33.8 
 
 37.0 
 
 41.0 
 
 T 
 
 17.7 
 
 24.8 
 
 26.2 
 
 28.3 
 
 21.5 
 
 U 
 
 16.8 
 
 22.5 
 
 22.2 
 
 23.5 
 
 19.3 
 
 V 
 
 15.7 
 
 21.2 
 
 21.2 
 
 23.5 
 
 22.0 
 
 Edsall and Dr. James H. Means in Boston. We are greatly indebted to 
 Dr. Means for taking the measurements of this subject and for taking 
 the mold of the surface and sending it to us to be measured. 
 
 MEASUREMENTS OF THE BODY 
 
 The individual to be measured was undressed, weighed and placed 
 on a flat table with a vertical foot-board about 30 cm. high. All the 
 measurements were made with the subject flat on his back with his feet 
 against the foot-board. A steel tape was used for all the linear meas- 
 
82 
 
 CLINICAL CALORIMETRY 
 
 urements and a cloth tape for the circumferences. The measurements 
 actually used are given in Table 2 ; those not used are given in Table 3 
 in case other investigators wish to apply different formulas. 
 
 THE MOLD OF THE BODY 
 
 The method of determining the surface area finally adopted con- 
 sisted in making a thin mold of the body, cutting this up in pieces 
 which would lie flat, printing the patterns of these pieces on photo- 
 
 TABLE 3. — Measurements Not Used in Formula 
 
 Index Number 
 ol Part 
 Measured 
 
 Benny L. 
 
 Morris S. 
 
 R. H. H. 
 
 E. P.TD. B. 
 
 Mrs. McK. 
 
 I •. 
 
 24.2 kg. 
 
 64.0 kg. 
 
 64.08 
 
 74.49 
 
 93.0 
 
 II 
 
 110.5 cm. 
 
 164.3 em. 
 
 178.0 
 
 179.2 
 
 149.7 
 
 Ill 
 
 88.3 
 
 135.5 
 
 148.0 
 
 147.2 
 
 125.0 
 
 IV 
 
 81.1 
 83.6 
 
 124.6 
 124.4 
 
 136.5 
 139.0 
 
 135.5 
 141.2 
 
 
 V 
 
 125.4 
 
 VI 
 
 76.5 
 
 115.2 
 
 130.0 
 
 125.5 
 
 107.0 
 
 VII 
 
 65.7 
 
 83.4 
 
 94.0 
 
 95.7 
 
 76.8 
 
 VIII 
 
 46.2 
 
 72.3 
 
 84.5 
 
 85.5 
 
 60.2 
 
 IX 
 
 65.1 
 
 83.5 
 
 80.7 
 
 84.5 
 
 92.0 
 
 X 
 
 40.0 
 
 60.2 
 
 81.5 
 
 67.5 
 
 65.5 
 
 XI 
 
 29.6 
 
 43.6 
 
 48.0 
 
 49.0 
 
 40.0 
 
 XII 
 
 8.2 
 
 11.3 
 
 
 11.7 
 
 15.8 
 
 XIII 
 
 17.0 
 
 24.5 
 
 27.0 
 
 28.0 
 
 21.0 
 
 XIV 
 
 21.2 
 
 33.1 
 
 38.6 
 
 38.6 
 
 32.0 
 
 XV 
 
 18.6 
 17.8 
 
 27.5 
 26.0 
 
 25.3 
 25.0 
 
 30.0 
 29.0 
 
 
 XVI 
 
 30.0 
 
 XVII 
 
 35.5 
 
 50.3 
 
 48.0 
 
 56.5 
 
 56.0 
 
 XVIII 
 
 23.2 
 
 34.7 
 
 32.7 
 
 37.5 
 
 39.0 
 
 XIX 
 
 22.6 
 43.2 
 
 31.0 
 62.0 
 
 31.5 
 48.0 
 
 33.5 
 52.5 
 
 30 6 
 
 XX 
 
 35.5 
 
 XXI 
 
 28.6 
 
 38.0 
 
 36.0 
 
 87.0 
 
 34.2 
 
 XXII 
 
 74.5 
 
 108.0 
 
 99.0 
 
 107.0 
 
 106.0 
 
 graphic paper (Fig. 17) and finding the area of the printed patterns by 
 cutting them out and weighing them. The subject was dressed in a 
 tight-fitting suit of thin union underwear, which covered the body, arms 
 and legs. Socks were put on the feet, thin cotton gloves on the hands, 
 while over the head and neck was slipped a section of the leg of a 
 knitted undersuit held in place by means of bandages. On this ground- 
 work strips of paper were pasted until a flexible inelastic mold of the 
 
DELAFIELD DU BOIS— EUGENE F. DU BO IS 
 
 83 
 
 body was completed. The material used was strong manila paper, about 
 \y2 inches broad, gummed on one side. It is manufactured in large rolls 
 and is used by stores as a substitute for string in doing up small pack- 
 ages and also by some tailors in making models of their customers. 
 For our purposes it was wound in small rolls and placed in a small 
 brass holder which moistened the gummed side as it was applied to the 
 cloth covering the body. It could be applied so quickly that very little 
 
 Fig. 17. — Reduced photograph of the patterns printed from the mold of 
 the head and neck of one of the subjects measured. The patterns of the head 
 marked with one punch were cut out and weighed separately from the pieces 
 of the neck marked with two punches. The dark areas were also weighed as 
 control. 
 
 time was required to cover the body. The head presented no difficulty 
 until the nose was reached. This region was the last to which the paper 
 was applied and a couple of holes were left for the person to breathe 
 through. The mold of the face was then quickly opened by means of 
 curved bandage scissors. In most cases only one arm and one leg were 
 measured. 
 
« 
 o 
 to 
 
 i-i 
 
 (J 
 
 ►J 
 < 
 u 
 
 
 m 
 
 
 o 
 
 w 
 
 
 9 -""S 
 
 M □ (3 <u H 
 5 t3"0 
 
 W |5h 
 
 3 ft"" 
 
 d 
 
 - " "I O- 
 CO 
 
 Q) * ^. 
 
 a G 03 oj (3 
 
 H fH 
 
 aS'O a 3 9 
 
 «i_fa 
 
 
 I + 
 
 + + 1 I 
 
 + + + T I + + 
 
 I + + 
 
 I I + 
 
 3 -^ d 
 
 e3 ^ '^ S D t3 
 
 -gs2B° 
 
 S S S 
 
 S2l 
 
 ^3 3 
 
 ■^ IM to 
 ■^ i-l CS 
 
 W" O ^ flj 0^ 
 
 H ^ d 
 
 ^O o •- ^ ■ 
 
 o c 
 
 Si-; a 
 
 o _, a _( ^H +^ 
 
 3 ;:^ d 
 
 aS'a a 3 B 
 
 <^^m 5 CI 
 
 a a^O 
 
 
 + I + + + + I 
 
 I I I 
 
 o f-4 lA m 
 
 + + + I 
 
 iT; in N 
 
 Jh O 
 
 0.^ 
 
 
 
 
 
 
 T) 
 
 
 a 
 
 53 
 
 M 
 
 ol 
 
 M 
 
 
 
 a <u 
 a to 
 
 a, 2 
 
 
 CJ r- 
 
 '3& 
 
 
DELAFIELD DU BOIS— EUGENE F. DU BOIS 85 
 
 The hands could not be covered satisfactorily with paper, and hard 
 paraffin was used instead. This was melted and applied to the glove 
 with a brush, soaking well into the meshes of the cotton. The melted 
 paraffin was not too warm for the hands, but was uncomfortable for 
 parts of the body which were not so accustomed to heat. Starch was 
 tried in some instances, but dried too slowly; plaster-of-Paris was too 
 stiff. 
 
 Certain portions of the skin were not measured by this mold. The 
 area back of the ears was determined by tracing the back of the ears 
 on a piece of cardboard and correcting by careful measurements. The 
 skin between the toes was measured by tracing. The penis and scrotum 
 were measured and the area determined geometrically. This left 
 unmeasured only very .small portions of the face and ears since the 
 mold did not fit closely into the eye-sockets and the concavities of the 
 ear. This error could not have amounted to more than 10 to 20 square 
 centimeters in a total of fifteen thousand. 
 
 While the mold was still on the subject the landmarks of the body 
 were located through the paper and the different anatomical regions 
 marked off by drawing the borders on the paper. The mold was then 
 removed with bandage scissors or small probe pointed scissors and 
 the inside of the cloth covered with a thin layer of melted paraffin 
 which, when it hardened, left a material much easier to work with than 
 the cloth and paper alone, since this would not lie flat. Next the mold 
 was cut at the borders of the various regions of the body and each of 
 these regions cut into pieces -which would lie flat. These pieces were 
 then marked with a punch for identification and transferred to a large 
 photographic printing frame. After printing in the sun and without 
 developing or fixing, patterns of the pieces of the mold were cut out 
 and weighed to the tenth of a milligram and the blank parts of the 
 sheet weighed as a control. Before this printing each sheet of photo- 
 graphic paper was carefully measured and weighed and the area of 
 each gram of paper determined. By weighing the patterns of each 
 region together it was a simple matter to find the area of that region. 
 A copy of the print made from the mold of the head and neck of one 
 of the subjects is given in Figure 17 showing the method of cutting the 
 paraffined mold so that it would lie flat. 
 
 ACCURACY OF METHOD 
 
 The accuracy of the procedure was tested in several ways. The 
 bottom of a porcelain evaporating dish was measured twice with a 
 difference of 0.1 per cent, between the two measurements. The surfacte 
 of the hand of D.D.B. was measured three times, the glove being 
 covered once with starch and on the two other occasions with paraffin. 
 
86 CLINICAL CALORIMETRY 
 
 The square centimeters of surface area as determined on the three 
 occasions were 555.5, 556.0 and 555.5. The right and left sides of 
 the whole body of Benny L. measured separately, agreed within 0.5 per 
 cent. 
 
 MEASUREMENTS 
 
 The body was divided into the larger regions used by Meeh. An 
 effort was made to select the measurements which represented the 
 length and average breadth of the part. The head region included the 
 ears and the trunk included the neck, the breasts in the female, and 
 the penis and scrotum in the male. 
 
 DETERMINATION OF NEW FORMULA 
 
 Having measured the surface areas of the different parts of the 
 body and the linear measurements of these parts, the formula to 
 determine the surface area of each part was calculated as follows : 
 the various measurements of length were multiplied by various sums 
 of the measurements representing the width; the resulting figure was 
 divided by the surface area as actually measured. The factors resulting 
 from this calculation in each of the five individuals were compared to 
 determine the percentage variation. ' That particular combination of 
 length and breadth measurements which showed the smallest variation 
 was chosen and the reciprocal of the average factor for this combina- 
 tion taken as a constant. Fortunately the best results were always 
 obtained by using measurements which were simple. The factors 
 include the multiplication by two necessary to give the area of the right 
 and left arm, hand, etc. 
 
 measurements used in formula (table 2). 
 Head: AB 0.308. 
 
 A — Around vertex and chin. 
 
 B — Around occiput and forehead, just above eyebrows. 
 Arms: F(G + H + 1) 0.5S8. 
 
 F^ — Outer end of clavicle to lower border of radius. 
 
 G — Circumference at level of upper border of axilla. 
 
 H- — Largest circumference of forearm. 
 
 I — Smallest circumference of wrist. 
 Hands : JK 2.22. 
 
 J — Lower posterior border of radius to tip of second finger. 
 
 K — Circumference of open hand. 
 Trunk: L(M + N) 0.703. 
 
 L — Suprasternal notch to upper border of pubes. 
 
 M — Circumference of abdomen at level of umbilicus. 
 
 N — Circumference of thorax at level of nipples in the male, and just 
 above breasts in the female. 
 Thighs: 0(P + Q) 0.508. 
 
 O— Superior border of the great trochanter to the lower border of the 
 patella. 
 
 P— Circumference of thigh just below the level of the perineum. 
 
 Q — Circumference of hips and buttocks at level of trochanters. 
 
DELAFIELD DU BOIS— EUGENE F. DU BOIS 87 
 
 Legs: RS 1.40. 
 
 R — From sole of foot to lower border of patella. 
 
 S — Circumference at level of lower border of patella. 
 Feet: T(U + V) 1.04. 
 
 T — Length of Foot. 
 
 U — Circumference of foot at base of little toe. 
 
 V — Smallest circumference of ankle. 
 
 MEASUREMENTS NOT USED IN FORMULA (TABLE 3) 
 I— Weight. 
 II— Height. 
 
 Ill — Sole of foot to suprasternal notch. 
 IV — Sole of foot to level of nipples. 
 V — Sole of foot to upper border of axilla. 
 VI — Sole of foot to tip of ensiform process. 
 VII — Sole of foot to superior border of great trochanter. 
 VIII — Sole of foot to perineum. 
 IX — Circumference of body at level of tip of ensiform. 
 X — Tip of second finger to upper border of axilla. 
 XI — Tip of secVjnd finger to tip of olecranon process. 
 XII — Tip of second finger to metacarpo-phalangeal joint. 
 XIII — Tip of olecranon to lower border of radius. 
 XIV — Tip of olecranon to outer end of clavicle. 
 XV — Circumference of arm at the insertion of the deltoid. 
 XVI — Circumference of arm at belly of biceps. 
 XVII — Circumference of thigh half way between anterior superior spine of 
 
 the ilium and the lower border of the patella. 
 XVIII — Largest circumference of calf. 
 XIX — Circumference of foot around heel. 
 
 XX — From back of neck around superior maxilla just below ears and nose. 
 XXI — Around neck just below larynx. 
 XXII — ^Around shoulders at level of heads of humeri. 
 Borders of Regions of Body: 
 
 Head : Lower margin of the mandible to its posterior border, thence to 
 tip of the mastoid process and in a straight line to the external 
 occipital protuberance. 
 Arm: From the acromion process anteriorly and posteriorly to the upper 
 
 border of the axilla. 
 Hand: Line at right angles to long axis of forearm drawn at level of 
 
 tip of ulna. 
 Thigh : From the perineal point going posteriorly in the natal fold to 
 the upper border of the great trochanter, thence medially in a straight 
 line to the perineal point. 
 Leg: Line at level of lower border of patella. 
 Foot: Line at level of tip of lateral malleolus. 
 
 DISCUSSION OF RESULTS 
 
 Table 1 shows that the constant employed by Meeh has not been 
 confirmed by subsequent observers. It gives results which are too high 
 in every case except one very thin woman. Lissauer found Meeh's 
 figure for infants 16 per cent, too high. Bouchard in four of his five 
 cases found it from 2 to 33 per cent, too high, while in our five cases we 
 have found it from 7 to 36 per cent, too high. The majority of Meeh's 
 
88 CLINICAL CALORIMETRY 
 
 subjects seem to have been thin, and the error of the formula is very 
 great in fat individuals. One can perhaps obtain fairly accurate results 
 in using Meeh's formula if one retains the factor of 12.3 for thin sub- 
 jects, 11 to 12 for people of average build, 10 to 11 for the moderately 
 stout and 9 to 10 for the very fat. Possibly at some later date a more 
 accurate factor can be determined by the relationship of weight to 
 height, retaining Meeh's fundamental principle of the Yi power of the 
 weight. 
 
 Miwa and Stoltzner's formula gives results only slightly better than 
 Meeh's. The errors in calculated areas of our five subjects using their 
 formula are as follows : Benny L. -|- 18 per cent., Morris S. + 17 per 
 cent., R. H. H. -\- 8 per cent., E. F. D.B. + 18.5 per cent, Mrs. McK. 
 + 26.5 per cent. If the constant of 3.84 were used instead of 4.5335 
 the results would be much better for this series. 
 
 The series of five individuals measured by us is perhaps too small to 
 determine factors which will remain unaltered by subsequent research, 
 bvit it is doubtful if the changes will be of significance. The range of 
 body shape among our subjects was, however, very great, and the error 
 of the factors comparatively small. The principle of the method has 
 been demonstrated to be sound. Unfortunately, it involves the taking 
 of nineteen measurements, a matter of perhaps fifteen minutes time. 
 Subsequent investigation may reduce the number, but it is difficult to 
 see how one can avoid measuring each part of the body if one wishes 
 to obtain accurate results on people whose shapes do not correspond 
 closely to the average. 
 
 In any discussion as to whether metabolism is proportional to body 
 weight or to surface area it is essential to apply a method of measuring 
 the surface which does not depend entirely on weight. The key to the 
 question may perhaps be found in those individuals whose surface area 
 is not proportional to the % power of their weight, multiplied by a 
 constant determined by measurements of average individuals. 
 
 SUMMARY AND CONCLUSIONS 
 
 The discussion of the relationship of metabolism to surface area has 
 been based almost entirely on Meeh's formula as determined in 1879. 
 Subsequent observers have found a consistent plus error in this for- 
 mula amounting to as much as 36 per cent, in the case of very fat 
 individuals. 
 
 The surface area of the various parts of the body can be determined 
 as follows : A mold of the surface is made by pasting paper over tight- 
 fitting underwear. The area of the mold is then determined by cutting 
 it in pieces, printing a pattern on photographic paper, cutting out the 
 pieces of the pattern and weighing thern. 
 
DELAFIELD DU BOIS— EUGENE F. DU BOIS 
 
 89 
 
 To determine the area of each part of the body by linear measure- 
 ments alone a formula has been devised on the principle of length times 
 the average breadth times a constant. The sum of these parts gives 
 the total surface area of the body. 
 
 Five individuals of widely varying shapes have been measured and 
 the surface area as calculated from the formulas compared with the 
 surface area as actually measured. In the five cases the average error 
 was 1.7 per cent. 
 
 In discussing the question as to whether the basal metabolism is 
 proportional to surface area or to weight it is preferable to determine 
 the surface area by a formula which is not of necessity a function of 
 the weight. 
 
 Note. — Since this article was submitted for publication the formula has been 
 tested on a tall and exceedingly thin boy, 18 years old. This patient, Gerald S., 
 came to the hospital much emaciated from diabetes and was kept for eleven 
 days practically without food, receiving only whisky. The mold of the body 
 was taken on Dec. 1, 1914, shortly after his fast. At this time he weighed 
 4S.2S kg. His surface area according to Meeh's formula was 1.563 square 
 meters. The mold was kindly measured for us by Miss Margaret Sawyer who 
 obtained the following figures : 
 
 
 Actual Area 
 
 as Measured 
 
 sq. cm. 
 
 Area as 
 Calculated from 
 Formula 
 sq. cm. 
 
 Error 
 
 in Formula 
 
 Per Cent. 
 
 Head 
 
 950 
 2,052 
 
 847 
 3,002 
 5,003 
 1,876 
 1,042 
 
 978 i +3 
 
 
 2,047 '• — 
 
 
 875 — 
 
 
 2,677 
 4,158 
 2,144 
 1,055 
 
 —11 
 
 Trunk 
 
 LeffS 
 
 —17 
 + 14 
 
 Feet 
 
 + 1 
 
 Totals 
 
 14,801 
 
 13,934 
 
 — 5.8 
 
CLINICAL CALORIMBTRY 
 
 SIXTH PAPER 
 
 NOTES ON THE ABSORPTION OF FAT AND PROTEIN 
 IN TYPHOID FEVER* 
 
 WARREN COLEMAN, M.D., and FRANK C. GEPHART, A.B. 
 
 NEW YORK 
 
 In the course of other work on metabolism in typhoid fever it 
 became advisable to analyze the feces of the patients. While these 
 analyses constitute only a part of the problem in hand, the paucity of 
 studies on the absorption of food in the febrile state appears to v^^arrant 
 publication of the results as a separate communication. For a complete 
 discussion of the absorption of food in typhoid fever the reader is 
 referred to the paper of Du Bois.^ 
 
 Seven cases in all have been studied. The diets administered were 
 modifications of the high calory diet employed in this clinic, that is, 
 the proportions of fat and carbohydrate were varied to satisfy the 
 requirements of the problem under investigation. 
 
 METHODS OF CHEMICAL ANALYSIS 
 
 Urine and feces were collected in the manner described by Gephart and 
 Du Bois.^ The analysis consisted in the determination of fat and nitrogen in 
 the feces and total nitrogen in the urine. Nitrogen was determined in all cases 
 by the well known Kjeldahl method, fat in the feces was determined in part 
 by the Kumagawa-Suto method, and later by a saponification procedure 
 described by one of us.^ Carbohydrate in the feces was not determined (see 
 work of DuBois). 
 
 CLINICAL DATA 
 
 All of the patients were admitted to Bellevue Hospital during 1913. As 
 is customary on the service, each patient was given an enema every morning. 
 Except when otherwise stated, the patients had from one to two formed or 
 semiformed stools a day. 
 
 Emil C, aged 22 years, was admitted August 23, the fifth day of the' dis- 
 ease. Widal reaction and blood culture positive. Illness, severe. The original 
 fever lasted twenty-three days. After two days of normal temperature, the 
 patient developed a severe relapse of twenty days' duration. 
 
 Thomas B., aged 60 years, admitted October 2, the fifteenth day of the 
 disease. Widal reaction and blood culture positive. Illness, mild. Duration 
 
 *From the Russell Sage Institute of Pathology, in Affiliation with the Sec- 
 ond Medical Division of Bellevue Hospital. 
 
 1. DuBois, E. F.: The Archives Int. Med., 1912, x, 177. 
 
 2. Gephart, F. C, and DuBois, E. F. : The Organization of a Small Metab- 
 olism Ward, p. 829. 
 
 3. Gephart and Csonka: On the Estimation of Fat in Feces, Jour. Biol. 
 Chem., 1914, xix, 521. 
 

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 CLINICAL CALORIMETRY 
 
 of original fever, thirty-one days. After fourteen days of normal temperature 
 the patient developed a relapse which lasted twenty days. The relapse was 
 complicated by acute fibrinous pleurisy. 
 
 Christian M., aged 31 years, admitted September 8, the fifteenth day of the 
 disease. Widal reaction and blood culture positive. Illness, mild. Duration 
 of fever thirty days. 
 
 Ernest H.; aged 30 years, admitted September 16, the fourteenth day of the 
 disease. Blood culture and Widal reaction negative, though clinically the dis- 
 ease was undoubtedly typhoid fever. The illness was mild, the fever lasting 
 twenty-four days. 
 
 Anton K., aged 18 years, admitted September 30, the ninth day of the 
 disease. Blood culture positive. Illness, severe. Duration of fever twenty- 
 five days. The patient suffered from diarrhea from the eleventh to the six- 
 teenth day, passing three to nine stools a day. The first period of the analyses 
 was not begun until the diarrhea had ceased. 
 
 Richard T., aged 14 years, admitted October 6, the seventh day of the dis- 
 ease. Widal and blood culture positive. Illness, severe. Duration of fever 
 twenty-eight days. Mild cholecystitis developed on the twenty-fifth day. After 
 one day of normal temperature a relapse occurred which lasted one week. 
 
 Morris S., aged 21 years, admitted October 17, the seventh day of the dis- 
 ease. Blood culture positive. Illness severe. Duration of fever thirty-four 
 days. The patient suffered two relapses, the first severe, beginning on the 
 thirty-sixth day and lasting twenty days ; the second mild, beginning on the 
 sixty-eighth day and continuing nine days. 
 
 TABLE 2. — Daily Averagus and Percentage Loss 
 
 stage of Disease 
 
 No. of 
 Periods 
 
 Av. Food 
 ■Pai 
 
 Gm. 
 
 Average Daily Loss 
 
 Percentage Loss 
 
 
 Fat, Nitrogen, 
 Gm. Gm. 
 
 [ 
 
 Fat 
 
 Nitrogen 
 
 Cont'd temperature 
 
 Low fat, steep curve 
 
 High fat, steep curve 
 
 Oonvaleseence '. 
 
 3 
 6 
 5 
 8 
 
 204 
 67 
 199 
 220 
 
 6.11 
 4.74 
 7.15 
 6.99 
 
 1.20 
 1.82 
 1.84 
 1.69 
 
 2.9 
 6.9 
 3.8 
 3.4 
 
 10.7 
 12.5 
 11.9 
 10.7 
 
 
 
 
 6.26 
 
 1.57 
 
 4.3 
 
 
 
 
 
 
 DISCUSSION OF RESULTS 
 
 In Table 1 the results are expressed in terms of daily averages for 
 the periods, which lasted from three to twelve days. The stage of 
 the disease is designated by a description of the character of the tem- 
 perature curve rather than by the actual day of the illness. As in 
 previous papers, the stage of ascending temperature corresponds to 
 the "first week," that of continued temperature to the "second week," 
 that of the early steep-curve to the "third week," and that of the late 
 steep-curve to the "fourth week." In the last two columns the losses 
 are expressed in terms of percentage. 
 
 A summary of all the periods, in daily averages according to the 
 stage of the disease, is given in Table 2. 
 
WARREN COLEMAX— FRANK C. GEPHART 93 
 
 ABSORPTION OF FAT 
 
 The total fat in the stools varied from 1.63 to 9.74 gm. 
 
 The mere statement of the amounts, however, conveys but little 
 information; the stage of the disease and the quantity of fat in the 
 food must be taken into consideration for a complete interpretation of 
 the results. Likewise it should be stated that the expression of the 
 results in percentage values is apt to be misleading unless one bears 
 in mind that even the stools of fasting persons contain fat. 
 
 In the ascending and continuous temperature stages when the fat 
 in the food varied from 127 to 273 gm. the total fat lost was from 
 2.53 to 9.19 gm. The percentage loss varied from 2.0 per cent, to 
 4.4 per cent. 
 
 The average total loss for this stage of the disease was 6.11 gm. ; 
 the average percentage loss was 2.9 per cent. 
 
 The results in the early and late steep-curve stages fall into two 
 groups, according to the amount of fat which the patient received in 
 his food. 
 
 Patients receiving from 56 to 74 gm. lost in the stools from 1 .63 to 
 7.04 gm. of total fat, with an average loss of 4.4 gm. Attention should 
 be directed to the unusually small loss of 1.63 gm. when the patient 
 received 57 gm. The average percentage loss for this group was 6.9 
 per cent. 
 
 With patients receiving from 143 to 225 gm. of fat in the food, the 
 total loss varied from 5.02 to 9.74 gm., with an average loss of 7.15 
 gm. In this group the relatively large loss of 9.74 gm. when the patient 
 took only 143 gm. in the food should be noted. The average percentage 
 loss for the group was 3.8 per cent. 
 
 In convalescence the total fat intake varied from 165 to 286 gm. 
 The fat loss varied from 6.53 to 7.60 gm. The percentage loss was 
 from 2.3 per cent, to 4.6 per cent. 
 
 If only those periods be considered in which the fat intake was 
 relatively large, the percentage fat loss in the stools for all stages of 
 the disease was 3.5 per cent. The loss in the febrile stage was 3.3 
 per cent., in convalescence it was 3.4 per cent. In other words, the 
 patients in this series absorbed fat as well in the febrile stage of the 
 disease as in convalescence. 
 
 The average fat loss for all the patients in all stages of the disease 
 amounted to 4.3 per cent. This result is somewhat lower than that 
 obtained by Du Bois, who found the average percentage loss to be 
 6.02 per cent. When the results are considered as a whole the con- 
 clusion appears to be warranted that fat is almost completely absorbed 
 when given in very large quantity. 
 
94 CLINICAL CALORIMETRY 
 
 THE ABSORPTION OF PROTEIN 
 
 The quantity of protein in the diet was kept as nearly uniform as 
 circumstances permitted. The lowest daily average intake of nitrogen 
 was 12.0 gm., the highest was 16.6 gm. 
 
 The total- nitrogen in the stools varied from 0.84 to 2.89 gm. The 
 average total nitrogen for all stages of the disease amounted to 1.57 
 gm. The highest average loss, according to periods, of 1.84 gm. a day 
 occurred in the steep-curve stage. The smallest average loss of 1.20 
 gm. occurred in the stage of continued fever. The quantity of fat in 
 the food appeared to be without influence on the nitrogen loss. 
 
 The average percentage loss of nitrogen according to periods varied 
 from 10.7 per cent, to 12.2 per cent. The average percentage loss for 
 all stages of the disease was 11.2 per cent. This result is higher than 
 that obtained by Du Bois, which amounted to 7.1 per cent. No explana- 
 tion of this difference has been found. 
 
 SUMMARY 
 
 The feces of seven typhoid patients on the high calory diet have 
 been analyzed for fat and protein in seventeen periods of three to 
 twelve days each in length. 
 
 The average total fat loss for all the periods was 6.25 gm., corre- 
 sponding to a percentage loss of 4.3 per cent. No differences were 
 observed in the percentage absorption of fat in the early and later 
 stages of the fever or up to the end of the first week of convalescence, 
 when the intake was relatively large. 
 
 The average total nitrogen loss for all the periods amounted to 
 1.57 gm., corresponding to a percentage loss of 11.2 per cent. 
 
 The constant presence of fat and nitrogen in the feces, even in fast- 
 ing, vitiates to some extent the validity of the results when expressed 
 in percentages. 
 
CLINICAL CALORIMETRY 
 
 SEVENTH PAPER 
 
 CALORIMETRIC OBSERVATIONS ON THE METABOLISM OF 
 TYPHOID PATIENTS WITH AND WITHOUT FOOD* 
 
 WARREN COLEMAN, M.D., and EUGENE F. DuBOIS. M.D. 
 
 NEW YORK 
 CONTENTS 
 
 1. Previous investigations. 
 
 2. Methods used. 
 
 3. Case histories. 
 
 4. Experimental data. 
 
 5. Discussion of results. 
 
 A. The law of the conservation of energy in fever. 
 
 B. The basal metabolism in typhoid fever. 
 
 C. The specific dynamic action of food in typhoid fever. 
 
 D. The relationship of heat production and heat elimination. 
 
 E. A comparison of caloric intake and caloric output. 
 
 F. Summary and conclusions. 
 
 PREVIOUS INVESTIGATIONS 
 
 In a previous communication^ the respiratory metabolism of typhoid 
 patients as determined by means of the small Benedict respiration 
 apparatus was discussed in detail. The literature of the subject was 
 also reviewed, making repetition here unnecessary. Following this 
 earlier work it was possible to continue the study of the typhoid 
 patients by using the respiration calorimeter of the Russell Sage Insti- 
 tute of Pathology in Bellevue Hospital. In the immediately preceding 
 papers of the series^ the calorimeter and the metabolism ward have 
 been described in detail and data have been given in regard to the 
 normal controls and the absorption of food in typhoid fever. The 
 patients studied were all in the metabolism ward and the calorimeter 
 experiments were conducted in the manner described in the paper on 
 normal controls. In our previous work on the general effect of the 
 high calory diet on respiratory metabolisrn it was difficult to control 
 the nourishment of the patients so as to determine the basal metabolism 
 and the quantitative effects of different foods. It was, however, pos- 
 
 * From the Russell Sage Institute of Pathology in affiliation with the Second 
 Medical Division of Bellevue Hospital, New York. 
 
 1. Coleman and DuBois : The Influence of the High Calory Diet on the 
 Respiratory Exchanges in Typhoid Fever, The Archives Int. Med., 1914, xiv, 
 168. 
 
 2. Clinical Calorimetry, Papers 1 to 6, this number. Brief preliminary 
 reports were published in Jour. Am. Med. Assn., 1914, Ixiii, 827, and ibid., 1914, 
 Ixiii, 932. 
 
96 CLINICAL CALORIMETRY 
 
 sible to demonstrate that the heat production of typhoid patients on a 
 liberal diet was practically the same as that of fasting patients. 
 
 Patients with fever have been studied before in various calorime- 
 ters. Isaac Ott^ of Philadelphia as early as 1892 made observations 
 on a patient with malaria using a rather simple type of calorimeter 
 which required a plus correction of 16 per cent. Likatscheff and 
 Avroroff* in 1902 made classical experiments on a similar case. In 
 1909 Benedict and Carpenter^' studied a few cases of mercurial poison- 
 ing with fever in the Middl'etown calorimeter. An excellent summary 
 of the literature is given in the Russian publication.* It is sufficient 
 to say that the rise and fall of body temperature have been ascribed 
 at various times to every possible combination of increase and decrease 
 in heat production and heat elimination. The Russians used the 
 Paschutin calorimeter in which the patient was kept for twenty-two 
 hours, feeding herself and apparently moving about the chamber during 
 the day whenever she felt inclined to do so. The heat elimination was 
 measured in periods of two hours each and the body temperature was 
 determined every two hours, apparently by means of a mercurial ther- 
 mometer in the axilla. The COj and water elimination were measured 
 in two-hour periods but the oxygen consumption and consequently the 
 respiratory quotient could only be determined by the change in body 
 weight during twenty-two hours. This method seems to have given 
 satisfactory results, since the quotients correspond to those usually 
 found under similar conditions and calculation of the indirect calorim- 
 etry in the three experiments gives results which come within — 6 
 per cent. -|-6 per cent, and +12 per cent, of the direct calorimetry. 
 The Russians themselves calculated the total heat production by adding 
 the calories stored in or lost from the body as the temperature rose 
 and fell to the calories eliminated by means of radiation, conduction 
 and vaporization. They came to the conclusion that the rise of body 
 temperature was due to an increase in heat production. Benedict and 
 Carpenter studied their fever patients under similar conditions, but 
 determined the oxygen, COg and the heat elimination in periods from 
 two to six hours in length. If one takes the periods when their subjects 
 
 3. Ott, Isaac: The Modern Antipyretics, Ed. 2, Easton, Pa., 1892; Fever, 
 Its Thermotaxis and Metabolism, New York, 1914. 
 
 4. Likatscheff and Avroroff : Investigations of Gaseous and Heat Exchange 
 in Fevers. Reports of the Imperial Military Academy, St. Petersburg, 1902, v, 
 parts 3 and 4. We are indebted to Dr. F. G. Benedict of the Carnegie Nutrition 
 Laboratory for permission to consult his translation of this important work. 
 Excellent abstracts in English have been published in a paper by A. I. Ringer 
 (Physiology and Pathology of Fever, Am. Jour. Med. Sc, 1911, cxlii, 485) 
 and in the monograph on Fever by Ott. 
 
 5. Benedict and Carpenter : Preliminary Observations on Metabolism Dur- 
 ing Fever, Am. Jour. Physio'l., 1909, xxiv, 203. 
 
WARREN COLEMAN— EUGENE F. DU BOIS 97 
 
 had a body temperature of 38 C. or over and calculates the indirect 
 calorjmetry, using the oxygen and quotients, it is easy to determine the 
 divergence of the direct from the indirect calorimetry. The percentage 
 differences are as follows: +5. -|-10- — 9 +9. +2. 
 
 METHODS USED 
 
 The present work with the calorimeter was undertaken to extend 
 the previous observations and clear up some doubtful points which 
 could be settled only by a most careful control of the diet and by a 
 comparison of the direct and indirect calorimetry. The fact that it 
 was impossible to bring typhoid patients into nitrogen equilibrium 
 unless the diet greatly exceeded the heat production as calculated from 
 the oxygen consumption, suggested the possibility that the method of 
 calculating the indirect calorimetry might be incorrect. There remained 
 also the old work on fever in which abnormally low respiratory quo- 
 tients were obtained, leading several investigators to believe that the 
 metabolism in fever was radically different from that in health. 
 Finally, it was hoped that it would be possible to determine whether the 
 rising body temperature was due to an increasing heat production or 
 to a decreasing heat elimination. 
 
 Ihe subjects studied were typhoid patients who entered Bellevue 
 Hospital in 1913 and 1914. There was some selection of cases in an 
 effort to obtain men in the early stages of the disease who were intelli- 
 gent enough to cooperate. Most of the patients were taken to the 
 metabolism ward so early in the disease that it was impossible to 
 predict whether the fever would run a mild or severe course. Several 
 patients were transferred from the First Medical Division through the 
 kindness of Dr. Norrie and Dr. Miller to whom we are much indebted. 
 
 All of the patients were put on the high calory diet described in 
 previous publications^ and trained to take the large amounts of food. 
 The very large amounts formerly given to some patients were not 
 administered and the calories seldom exceeded 3,000 a day. An attempt 
 was made to keep the food nitrogen at 15 grams. The stools exceeded 
 two a day only on the occasions mentioned in the histories, and there 
 was seldom abdominal distention. None of the patients was tubbed, 
 although cold sponges were occasionally given to make the patient 
 
 6. Shaffer and Coleman: Protein Metabolism in Typhoid Fever, The 
 Archives Int. Med., 1909, iv, 538-600; Coleman: Diet in Typhoid Fever, Jour. 
 Am. Med. Assn., 1909, liii, 1145; The High Calory Diet in Typhoid Fever — A 
 Study of One Hundred and Eleven Cases, Am, Jour. Med. Sc, 1912, cxiiv, 659; 
 DuBois : The Absorption of Food in Typhoid Fever, The Archives Int. Med., 
 1912, X, 177; Coleman: Weight Curves in Typhoid Fever, Am. Jour. Med. Sc, 
 1912, cxliv, 659 ; Diet and Metabolism in Fever, Trans. Fifteenth Internat. Cong, 
 on Hyg. and Demog., 1912. 
 
98 CLINICAL CALORIMETRY 
 
 feel more comfortable when the temperature reached 104. Nervous 
 symptoms were not prominent in any case, although one or two of 
 them were mildly delirious for a few days. Most of the patients 
 were cheerful throughout their illness and read the daily papers. It 
 is estimated that their activity increased their metabolism about 10 
 per cent, above the basal level, although this figure is necessarily only 
 an approximation. 
 
 CASE REPORTS 
 
 Case 1. — Morris S. (severe typhoid) tailor, English Hebrew of Russian 
 extraction, 21 years old, admitted October 17, discharged January 30. 
 
 History. — Previous history unimportant; patient is not alcoholic. He landed 
 from England Sept. 28, 1913. October 10 he began to suffer from pain in his 
 abdomen, chest and back. On the thirteenth he had a nose bleed. Since the 
 onset of symptoms he has had no appetite and has been constipated. 
 
 Physical Examination. — Patient is a well-nourished young man of small 
 frame and short stature, being 164 cm. tall. There is slight cyanosis of lips 
 and ears, the tongue is heavily coated, tonsils hypertrophied and congested. 
 There is an occasional subcrepitant rale at the apex of the left lung. The spleen 
 is palpable. 
 
 Blood taken October 18 gave a negative Widal test but developed a growth 
 of typhoid bacilli. The spleen edge was felt 4 cm. below the costal margin and 
 a few rose spots were present. October 24 the Widal was positive. The next 
 day there were a few sibilant and sonorous sounds over the chest, clearing up 
 by the twenty-seventh. The patient had been on a diet with high carbohydrate 
 and low fat, and on October 23 and 24 had shown abdominal distention with 
 about four liquid stools a day. The distention and diarrhea ceased when the 
 fat was increased and the very large amounts of carbohydrate stopped. For 
 the next month he had only one or two movements a day. October 30 he 
 became a little irrational and his color was grayish, his pulse soft and very 
 dicrotic. November 3 he was irrational in the calorimeter and wrote several 
 notes about the animals which he saw in his hallucinations. The next day he 
 was in much better condition, the pulse was stronger and his physical con- 
 dition improved steadily. 
 
 November 16 the temperature began to rise after it had been practically 
 normal for five days. He felt perfectly well and was bright and cheerful, in 
 spite of a temperature of 104, until the evening of the eighteenth when he had 
 a sharp pain in the right side of the abdomen. This disappeared the next day. 
 This relapse was almost as severe as the original infection, but the patient was 
 not quite so toxic and was never irrational. The temperature remained normal 
 from December 7 to 17. From November 23 to 26 he had frothy stools but 
 these became formed once more when the fat in the diet was increased. 
 
 December 17 a second relapse began and lasted until the 27th. During the 
 period of rising temperature he was somewhat apathetic and suffered from 
 headache and was fretful during the two days of high fever. His general con- 
 dition remained excellent and he never realized that he was having a relapse. 
 Following this, convalescence was rapid, since he had lost practically no weight 
 during his illness. During the next year he reported at the hospital several 
 times, always in excellent condition and five or ten pounds heavier than ever 
 before in his life. 
 
 In December, 1914, he returned to the metabolism ward for two days, giving 
 us the opportunity to determine his basal metabolism and the specific dynamic 
 action of the protein meal. 
 
WARREN COLEMAN— EUGENE F. DU BOIS 99 
 
 This history is given in detail since Morris S. was placed in the 
 calorimeter twenty-four times. He was an exceptional patient, in 
 that he ate the prescribed diet practically every day and enjoyed the 
 distinction of going in the calorimeter more often than his fellow 
 patients. Nothing made him happier than the extra attention he 
 received on calorimeter days, and as a result he did exactly what he 
 was told to do. We were particularly fortunate in being able to deter- 
 mine the specific dynamic action of protein and the basal metabolism 
 while he was in perfect health, a year after his infection. 
 
 Case 2. — Charles F. (severe typhoid), elevator constructor, born in New 
 York, 24 years old, admitted November 4, discharged January 12. 
 
 History. — Lives in same house as his nephew Howard F., who has similar 
 symptoms. On October 28 he began to suffer from anorexia, malaise and head- 
 ache. On November 3 he had a nose bleed. He did not take to bed until 
 admitted to the hospital. 
 
 Physical Examination. — Fairly well-nourished young man of medium frame, 
 166 cm. tall. He is moderately prostrated; there are several rose spots and the 
 spleen edge is palpable 4 cm. below the costal margin. 
 
 Blood taken the day after admission gave a positive Widal test and showed 
 a growth of typhoid bacilli. November 7 and again on the eighth he had a 
 small intestinal hemorrhage of about 200 c.c. His general condition remained 
 fair; he was rational and the toxemia not marked. He was given a daily sponge 
 for his high temperature. At this time he took his food very badly and after 
 the hemorrhages ceased it was impossible to give even 2,000 calories. Novem- 
 ber 14 to 17 he had a severe follicular tonsillitis and his toxemia was marked. 
 Rose spots appeared in crops. On the nineteenth he had a hemorrhage of about 
 250 c.c. and was very toxic and apathetic, for the next week. His pulse was 
 very soft, systolic blood pressure being 95 mm. mercury. By December 3 the 
 temperature was normal, he was much improved and was reading the paper 
 every day. Convalescence was rapid. Throughout the disease he had one 
 formed stool each day. 
 
 This patient was very intelligent and was anxious to help us in 
 every way possible but his digestion made it difficult for him to take 
 the food. He was very quiet while in the calorimeter. 
 
 Case 3. — Howard F. (typhoid fever of moderate severity), schoolboy, born 
 in New York, 12 years old, admitted November 4; discharged January 22. 
 
 History. — Lives in the ' same house as his uncle, Charles F. He was per- 
 fectly well until October 26 when he had a severe headache. On the twenty- 
 eighth he felt so sick that he took to bed. The next day he had a chill ; vomited. 
 He had nose bleed on the thirty-first and on the day of admission. 
 
 Physical Examination. — Patient is a tall, slender boy who has not yet reached 
 the age of puberty ; height 160 cm. ; the cheeks are flushed and he looks acutely 
 ill. Heart apex in the fourth space 8.5 cm. to the left of the midline. There 
 are several rose spots on the abdomen; the spleen is not palpable. 
 
 On November 14 the blood culture showed typhoid bacilli. November 12 
 showers of subcrepitant rales appeared at the left base and the next day sibilant 
 and sonorous sounds were heard all over the chest. His general condition was 
 good, and although he was very apathetic, he was perfectly rational. He took 
 his food very poorly, vomiting often. By the seventeenth he was very thin, 
 quite toxic, very drowsy but rational. The pulse was soft but of fair quality. 
 
100 CLINICAL CALORIMETRY 
 
 The sibilant and sonorous sounds persisted until the twenty-fourth, by which 
 time the temperature was falling, the appetite much better and the patient able 
 to read the paper. Convalescence progressed rather slowly. On December 10 
 he passed two ascarides. The heart action was rapid on exertion and on the 
 eighteenth the apex was in the fourth space 9.S cm. from the midline. He left 
 the hospital in good condition. Throughout his illness he had one stool a day. 
 The boy was very intelligent and made a good subject for the calorimeter. 
 
 Case 4. — Karl S. (typhoid fever of moderate severity), stoker on steamer 
 to South America, German, 24 years old, admitted December 29 ; discharged 
 Feb. 18. 
 
 History. — Returning on a voyage from Brazil he landed at San Domingo 
 for a few days, reaching New York December 20. Two days later he began to 
 suffer from headache, weakness, lassitude, anorexia and nausea. On the twenty- 
 fourth he began to have daily chills. 
 
 Physical Examination. — One hundred and sixty-eight cm. tall, muscular and 
 well nourished. His face is flushed and he looks stuporous. No spots, spleen 
 not palpable. Blood taken the day after admission gave a negative Widal but 
 positive growth of typhoid bacilli. January 1 rose spots appeared and the spleen 
 became palpable. On the third he was prostrated, apathetic and showed slight 
 subsultus tendinum. The pulse was soft and dicrotic and the abdomen dis- 
 tended. When carbohydrates were pushed too high he became distended, but 
 this trouble disappeared when the amounts were decreased. By January 7 he 
 was anxious about his condition and easily frightened. On the tenth his con- 
 dition was satisfactory and by the twenty-sixth he was afebrile and was read- 
 ing and studying every day. He was very hungry during his rapid convales- 
 cence. February 14 he developed tonsillitis. The temperature rose to 101 and 
 the pulse became rapid. He did not feel sick and resented being confined to 
 bed. On the seventeenth he became insubordinate and was discharged from 
 the hospital. Two weeks later he returned on a visit in good condition. 
 
 This patient was a rough sailor of sullen disposition and made a 
 rather restless subject for the calorimeter. During most of the obser- 
 vations on this man one of the water thermometers was being repaired 
 and the method of direct calorimetry could not be used. 
 
 Case S. — Thomas B. (typhoid fever, mild; followed by acute fibrinous 
 pleurisy). Laborer, Irish, 60 years old, admitted October 2, discharged Decem- 
 ber 8. 
 
 History. — Moderately alcoholic. About September 18 began to suffer from 
 malaise, anorexia and fever. 
 
 Physical Examination.— Large well-nourished man, who looks acutely ill. 
 He is apathetic and slightly cyanotic. 
 
 Blood taken the day of admission gave a positive Widal and showed a 
 growth of typhoid bacilli. Many rose spots appeared but the spleen was never 
 palpable. He took his food well and was never very ill. From October 22 to 
 November 6 the temperature was normal. Then it rose gradually to 104 and 
 fell slowly reaching normal on the twenty-sixth. During this time he developed 
 dulness, bronchial voice and breathing at the left base, the signs being attributed 
 to a pleurisy rather than pneumonia. He made a rapid convalescence. 
 
 Case 6. — Richard T. (mild typhoid). Mulatto boy, born in New York, 14 
 years old, admitted October 6, discharged November 24. 
 
 History.^Ahout September 30 began to suiTer from headache, weakness, 
 constipation and occasional abdominal pains. 
 
WARREN COLEMAN— EUGENE F. DU BOIS 101 
 
 Physical Examination. — Well nourished active boy who has not yet reached 
 puberty. There are a few rose spots and the spleen is palpable. 
 
 The day after admission the blood culture gave a positive Widal and showed 
 a growth of typhoid bacilli. The disease ran a mild and uneventful course, in 
 spite of high evening temperatures, until October 25, when he developed slight 
 pain and tenderness over the gall bladder, lasting two days. The temperature 
 reached normal October 29, but rose again in a mild relapse lasting till Novem- 
 ber 6. Convalescence was rapid. 
 
 The boy was somewhat mischievous and was very active throughout his stay 
 in the hospital. While in the calorimeter he spent most of his time looking 
 out of the window and was not as quiet as most of the patients. 
 
 Case 7. — Anton K. (mild typhoid), factory worker, Austrian, 18 years old, 
 admitted September 30, discharged November 18. 
 
 History. — September 22 he began to have daily chills and fever, lost his 
 appetite, felt exhausted and had severe pains in the epigastrium. 
 
 Physical Examination. — ^This showed a well-nourished man, apathetic and 
 acutely ill. Typhoid bacilli were found in the blood. At the height of his fever 
 he was prostrated and developed slight subsultus tendinum. He took his food 
 well and was in good condition on October 16, the first day of normal tem- 
 perature. 
 
 Case 8. — Rose G. (severe typhoid), born in New York, 12 years old; admitted 
 September 19, discharged November 26. 
 
 History. — Menstruation has not yet begun. The girl is tall and very thin 
 and is somewhat deficient mentally. She went through a severe course of 
 typhoid, with marked emaciation. Blood culture showed typhoid bacilli. Dur- 
 ing the disease she had rales at both bases and developed bed sores because 
 she had all her life been incontinent of urine. Temperature reached normal 
 October 29, and she was up and about on November 17. During convalescence 
 she ate enormous amounts of food, with very slight gain in weight. She was 
 not in the metabolism ward and exact figures for the food were not obtainable, 
 but it seemed as if the discrepancy between food and gain in weight could be 
 accounted for only by a greatly increased metabolism. The first hour she was 
 in the calorimeter she was quiet, but during the second hour she voided in bed 
 and began to cry, making it necessary to end the observation. 
 
 Case 9. — Edward B. (severe typhoid), longshoreman, born in Ireland, 36 
 years old; admitted October 3, 1914, discharged February, 191S. 
 
 History. — He remembers no previous illnesses. October 1 he began to suf- 
 fer from headache, pains all over the body and abdominal cramps, with diarrhea 
 and three to. four stools a day. He had no nausea and the appetite was good. 
 
 Physical Examination. — Well-nourished man of medium frame, fairly muscu- 
 lar. He is dull and apathetic and moderately prostrated. The heart is rapid, 
 not enlarged, the lungs are clear, abdomen soft, spleen palpable. There are a 
 few rose spots. 
 
 The blood on October 4 was sterile, but gave a positive Widal test. On the 
 sixth he was very drowsy; by the tenth he was comfortable and eating well. 
 October 13 the temperature had again risen, the pulse rate had jumped to 120 
 and the quality of the pulse was poor. On the twentieth he was much better 
 and was taking his food well, but the abdomen was slightly distended. By 
 November 1 the temperature was almost normal and the general condition 
 excellent in spite of a small rapid weak pulse. By November 7 the temperature 
 was up again, and he was beginning to feel indisposed. The appetite was poor 
 and the pulse rate between 138 and 148. During the next few days the pulse 
 was very rapid, slightly irregular, and very weak. He was very toxic but was 
 rational except for short periods when the mind was a little hazy. November 
 16 he had a small hemorrhage with a short period of collapse, but recovered 
 quickly. His condition improved steadily until December 3 when the temper- 
 
102 CLINICAL CALORIMETRY 
 
 ature rose once more and he suffered from a moderately severe relapse, last- 
 ing until December 21. Following this was a period of three days of normal 
 temperature and then a fourth relapse, very mild in character lasting only three 
 days. During the whole period of his illness his nutrition remained good ; he 
 was always cheerful and read the newspaper almost every day. 
 
 Case 10.— John K. (typhoid fever, mild), deck hand, Polish, aged 35; 
 admitted Dec. 12, 1914, discharged Jan. 27, 1915. 
 
 History. — December 2, began to suffer from malaise. December S had a 
 severe chill and took to bed; since then has had chills almost every day. Has 
 had continuous headache, has vomited frequently and has been constipated. 
 
 Physical Examination. — Tall and thin, fairly muscular. Tongue dry, coated, 
 fissured. Heart and lungs clear, spleen palpable, many rose spots. 
 
 Decem.ber 12, the blood culture was sterile but the Widal positive. On the 
 thirteenth he had his last chill, on the sixteenth he was apathetic and pros- 
 trated, pulse was slow and dicrotic, there was a patch of herpes on the upper 
 lip. As the temperature fell during the next few days his condition improved 
 rapidly, but the apathy remained until the temperature was normal, and he was 
 unusually quiet, remaining almost motionless all day long. Convalescence was 
 rapid. 
 
 DISCUSSION OF RESULTS 
 
 Law of Conservation of Energy in Fever. — The law of conservation 
 of energy has been shown to apply to the lower animals, to normal 
 men and to babies, and has been discussed in the previous paper 
 (Paper 6) on normal controls, in which it was demonstrated that with 
 normal men a satisfactory agreement between the direct and indirect 
 calorimetry could be obtained in periods as short as one hour. While 
 there are few who doubt that the law applies to men with fever, it 
 may not be superfluous to bring forward proof. 
 
 An agreement of the direct and indirect calorimetry within the 
 limits of experimental error indicates that protein, fat and carbo- 
 hydrate are oxidized to the same or approximately the same end 
 products as in health and that in the oxidation they give off the 
 standard amounts of heat. The method of calculating the indirect 
 calorimetry depends on the assumption that the calories furnished by 
 each gram of protein, fat and carbohydrate correspond to the standard 
 figures of Loewy,^ protein 4.32, fat 9.46, starch 4.18. The results 
 obtained by the method of direct calorimetry, which is dependent only 
 on fundamental laws of physics, must remain the standard method of 
 comparison when considering large groups of experiments. Once the 
 agreement has been proved for the group, the method of indirect 
 calorimetry is preferable for individual experiments as has been shown 
 in previous papers on account of the technical difficulty of the method 
 of direct calorimetry in short periods. 
 
 Table 1 gives a summary of the percentage divergence of the direct 
 and indirect calorimetry in all the experiments on the typhoid patients. 
 
 7. Loewy : Der respiratorische und der Gesamtumsatz, Oppenheimer's Handb. 
 der Biochem, 1911, iv, 280. 
 
WARREN COLEMAN— EUGENE F. DU BOIS 
 
 103 
 
 the great majority of them being three hours long. In all cases the 
 indirect method was used as a standard. If we consider the total 
 measurement of 12,822 calories, we find the direct method, as calculated 
 from the rectal temperature, gives results only 2.2 per cent, lower 
 than the indirect. In almost half of the experiments the body tem- 
 perature was measured by a thermometer of two units strapped on the 
 thorax in the region of the apex of the heart and just below the right 
 nipple, each unit being covered by a pad of cotton about 15 cm. square 
 and 4 cm. thick. The rectal thermometer was inserted about 12 cm. 
 beyond the sphincter. In a previous paper attention has been called to 
 the fact that in these typhoid cases in which both methods were tried 
 
 TABLE 1. — Percentage Divergence of Direct from Indirect Caloeimetry 
 IN the Individual Experiments 
 
 
 Number ot Experimenta Falling in Each Group 
 
 Percentage 
 Divergence 
 
 According to Eectal Temperature 
 
 According to Surface Temperature 
 
 
 -1- Divergence 
 
 — Divergence 
 
 Total 
 
 + 
 
 — 
 
 Total 
 
 0-5 
 
 6-10 
 
 17 
 3 
 
 1 
 
 22 
 15 
 8 
 
 39 
 18 
 
 1 
 
 11 
 2 
 
 
 7 
 7 
 1 
 
 18 
 
 
 11-17. 
 
 
 
 
 Total 
 
 Average Error.. 
 
 
 
 61 
 
 ±4.9% 
 
 •■• 
 
 •• 
 
 28 
 ±4.0% 
 
 Indirect 
 
 Direct* 
 
 Divergence 
 
 Total calories measured in all experiments 
 
 Excluding first periods 
 
 Calories measured in febrile experiments excluding all 
 first periods 
 
 12,822.03 
 8,470.93 
 6,720.21 
 
 12,539.67 
 8,488.97 
 5,583.55 
 
 —2.2 
 -i-0.2 
 —2.4 
 
 * According to rectal temperature. 
 
 slightly better results were obtained by using the surface thermometers 
 to give the temperature changes of the body than by using the rectal. 
 In the long run the rectal thermometer is the more reliable, since it is 
 not so easily displaced by bodily movement, but enough evidence has 
 been accumulated to show that the rectal temperature does not always 
 change in the same degree and not always in the same direction as the 
 average body change. As the body cools off there may be a relative 
 increase in the heat near the surface of the body, since this is the place 
 that most of the heat is dissipated. The opposite takes place when the 
 temperature is rising. On account of the rapid circulation of blood 
 
104 CLINICAL CALORIMETRY 
 
 there is, of course, a tendency for the temperature curves of the dif- 
 ferent parts of the bod)"^ to follow the deep temperature as measured 
 in the rectum. 
 
 In the sixty-one experiments in which the rectal temperature was 
 measured the average divergence of the indirect calorimetry from the 
 direct calorimetry (as based on the rectal temperature) is only ±4.9 
 per cent. In twenty-eight of these experiments it was possible to base 
 the calculations on the changes in the surface temperature, with an 
 average divergence of 4.0 per cent, using this latter method. This 
 divergence of 4 or 5 per cent, is not more than one often finds among 
 normal controls, since the technic is difficult even with trained subjects. 
 The reason for the total minus error of 2.2 per cent, is not clear. The 
 largest part of this error frequently falls in the first hour, especially 
 in patients with fever, and we have been led to suspect that the subject 
 continues to give out heat to the wooden bed frame and to the bedding 
 even after he has been on the bed for an hour. If we excluded from 
 our calculations the first periods, while the calorimeter is still coming 
 into thermal equilibrium, we find that the direct and indirect methods 
 agree within 0.2 per cent. If we consider only those experiments made 
 during the febrile period, we find a larger proportion show a minus 
 error in the direct calorimetry than when we take all the experiments 
 put together. Excluding the first hours of each experiment, however, 
 the direct calorimetry gives a total only 2.4 per cent, lower .than the 
 indirect. The diiference is so small that it might be found in a group 
 of normal controls. It may be entirely accounted for by the difficulty 
 in measuring the average body temperature during fever. 
 
 Basal Metabolism in Typhoid Fever. — In Paper 4 of this series 
 the reasons have been given for the selection of the standard of the 
 average normal basal metabolism. The figure of 34.7 calories per 
 square meter per hour as based on Meeh's formula has been used in all 
 the calculations. It was impossible to use the new surface formula as 
 a standard since this was not devised until most of the typhoid work 
 had been completed. 
 
 The relationship of the basal metabolism of the typhoid patients in 
 the various stages of the disease to the normal is shown in Table 2. 
 This corresponds in a striking manner with the averages of the fasting 
 typhoid patients investigated by Kraus, Svenson, Grafe and Roily and 
 collected by us in a previous publication.^ It is evident from the gen- 
 eral trend of the results that the total metabolism increases and falls 
 in a curve roughly parallel with tlie body temperature, and that the 
 period when it drops below normal in many patients corresponds with 
 the period of subnormal temperature which occurs so often in the first 
 week of convalescence. From a study of the results obtained by the 
 
WARREN COLEMAN— EUGENE F. DU BOIS 
 
 105 
 
 calorimeter and by various smaller types of respiration apparatus, it 
 is apparent that there is considerable variation in the heat production 
 of different patients and the same patient at different stages of the 
 fever. While we can state that the average increase in typhoid, fever 
 is approximately 40 per cent., we must remember that figures over 50 
 per cent, are frequently encountered. This should make us cautious 
 in drawing too many deductions from feeding experiments unaccom- 
 panied by determinations of the respiratory metabolism. It should 
 also be remembered that typhoid fever is the only fever which has 
 been thoroughly investigated and that if variations occur in this one 
 disease the variations may be quite different in other febrile diseases 
 such as erysipelas, pneumonia, puerperal fever, etc. 
 
 TABLE 2. — Basal Metabolism, According to Periods of Typhoid Fever 
 
 Periods 
 
 Ascending temperature 
 
 Continued temperature ... 
 
 Early steep curve 
 
 Late steep curve 
 
 Belapse— 
 
 Ascending temperature 
 
 Continued temperature 
 
 Early steep curve 
 
 late steep curve 
 
 Convalescence— 
 
 First week 
 
 Second week 
 
 Third week 
 
 Pourtti week 
 
 Filth week 
 
 Number 
 
 ol 
 Patients 
 
 Number o£ 
 Observa- 
 tions 
 
 Average 
 Per Cent. 
 Bise Above 
 Average 
 Normal 
 31.7 Oal. 
 per Sg. M. 
 
 Average 
 Besplra- 
 
 tory 
 Quotient 
 
 2 
 
 +37 
 
 0.79 
 
 7 
 
 +42 
 
 0.77 
 
 i 
 
 +26 
 
 0.82 
 
 3 
 
 +16 
 
 0.82 
 
 3 
 
 +25 
 
 0.82 
 
 2 
 
 +51 
 
 0.76 
 
 i 
 
 +36 
 
 0.78 
 
 I 
 
 +16 
 
 0.79 
 
 4 
 
 — 2 
 
 0.91 
 
 5 
 
 + 6 
 
 0.88 
 
 1 
 
 +17 
 
 0.81 
 
 2 
 
 +15 
 
 0.86 
 
 2 
 
 + 4 
 
 0.81 
 
 Benedict and his co-workers in all their recent publications have 
 drawn attention to the fact that pulse rate and total metabolism show 
 curves which are roughly parallel. As might be expected this parallel- 
 ism is not as apparent in typhoid fever as in the conditions they have 
 studied. Typhoid is characterized by a slow pulse in the first two 
 weeks when the metabolism is high. The experiments here reported do 
 not show any striking agreement in the rise and fall of the two curves. 
 
 The Specific Dynamic Action of Food. — When studying the effects 
 of the high calory diet in typhoid fever with the small Benedict respira- 
 
106 
 
 CLINICAL CALORIMETRY 
 
 tion apparatus, the writers noted the fact that the metabolism of 
 liberally fed typhoid patients was scarcely raised above the metabolism 
 of fasting typhoid patients. The conclusion was drawn that food 
 exhibits little or no specific dynamic action in typhoid fever. One of 
 the chief objects of the present research was to study this striking 
 phenomenon more closely, inasmuch as some observers, among them 
 Von Noorden,' have stated that the specific dynamic action of food 
 was increased in fever, exophthalmic goiter and several other condi- 
 tions. 
 
 We have seldom kept typhoid patients in the calorimeter for periods 
 exceeding three or four hours. After this length of time the patients 
 often become restless and bored, making the results unreliable. This 
 
 TABLE 3. — Specific Dynamic Action of Protein and Carbohydrate in 
 Health, Fever and Convalescence 
 
 Subjects 
 
 Number of 
 Experi- 
 ments 
 
 Average 
 
 Gm. of 
 
 Nitrogen 
 
 or 
 Glucose 
 in Food 
 
 Average 
 
 Gm. Food 
 
 per Kg. 
 
 Body 
 
 Weight 
 
 Nitrogen or 
 
 Glucose 
 
 Average 
 Per Cent. 
 Bisein 
 Metab- 
 olism 
 
 Protein meal 
 Two normal men* 
 
 2 
 6 
 6 
 
 8 
 4 
 3 
 
 10.1 
 8.6 
 10.2 
 
 116.0 
 115.0 
 115.0 
 
 0.147 
 0.174 
 0.217 
 
 1.6 
 2.2 
 
 2.7 
 
 9.S 
 
 Four febrile patients 
 
 4.5 
 
 Four convalescents 
 
 Commercial glucose 
 Three normal men* 
 
 16.6 
 9.1 
 
 Two febrile patients 
 
 1.0 
 
 Three convalescents 
 
 9.8 
 
 * Since the completion of Paper 4 two more normal controls have been given the test 
 meals. Morris S. on Dec. 18, 1914, showed a rise of 6.5 per cent, after a meal containing 
 9.6 gm. N. : Albert G. on Jan. 6, 1915, showed an increase of 9.0 per cent, in his metabolism 
 after 115 gm. commercial glucose. 
 
 has made it impossible to determine the basal metabolism in a two hour 
 experiment and follow it immediately by a three or four hour experi- 
 ment to find out the effect of food. Moreover, in such a long period 
 the temperature might change several degrees, making the results dif- 
 ficult of interpretation. In the case of normal controls, the basal 
 metabolism is so uniform from day to day that very accurate results 
 can be obtained by determining the basal metabolism and the metabo- 
 lism after food on different days. In fever the change in the level of 
 metabolism from day to day makes the results less accurate but the 
 error will be small if certain precautions are taken. The level of basal 
 heat production changes in a fairly gradual and uniform curve and 
 
 8. Von Noorden : New Aspects of Diabetes, New York, E. B. Treat & Co., 
 1912, p. 20. 
 
WARREN COLEMAN— EUGENE F. DU BOIS 
 
 107 
 
 there is but a small change in twenty-four hours unless the temperature 
 or the general condition of the patient changes markedly. For this 
 reason the effect of a given meal has been determined sometimes the 
 day before, sometimes the day ifter and sometimes the day between 
 basal experiments. The protein meal was given six times in the febrile 
 period and the glucose meal four times. It is against the laws of 
 probability that the basal metabolism should take a sudden change in 
 the same direction on all these days. 
 
 The fact that the average amount of protein given in the febrile 
 period was less than that given in health was due to the poor appetite 
 of the patients at the height of the disease. Even in health and in 
 
 TABLE 4. — Chart Showing Negative Nitrogen Balances in Typhoid 
 
 Patients who Receive Food Calories in Excess of Calculated 
 
 Heat Production 
 
 Patient 
 
 Dates or Days 
 ol Disease 
 Inclusive 
 
 Days 
 
 jn 
 Period 
 
 Eange ol 
 
 Maximum 
 
 Temperature, 
 
 Degrees F. 
 
 Calcu- 
 lated 
 Heat 
 Pro- 
 duction, 
 Oal.* 
 
 Food 
 Calo- 
 ries* 
 
 Food 
 
 N, 
 6m.* 
 
 Nitrogen 
 
 Balance 
 
 6m.* 
 
 Morris S. 
 
 Oct. 23-Nov. 3 
 
 12 
 
 102.8-104.6 
 
 2,266 
 
 2,863 
 
 16.4 
 
 —4.4 
 
 
 Dee. 19-24 
 
 6 
 
 101.9-106.1 
 
 2,085 
 
 2,989 
 
 13.2 
 
 —2.4 
 
 Charles P. 
 
 Nov. 28-30 
 
 3 
 
 101.2-103.4 
 
 1,752 
 
 2,458 
 
 12.0 
 
 —4.6 
 
 KarlS. ... 
 
 Jan. 12-18 
 
 7 
 
 101.0-105.0 
 
 2,197 
 
 2,985 
 
 16.1 
 
 —3.2 
 
 
 Jan. 19-22 
 
 4 
 
 98.8- 99.0 
 
 1,678 
 
 2,818 
 
 14.6 
 
 —1.9 
 
 John K.... 
 
 Jan. 15-20 
 
 6 
 
 103.2-104.0 
 
 2,568 
 
 
 
 
 Frank W.t 
 
 Days of Disease 
 11-14 
 
 4 
 
 104.0-105.4 
 
 2,200 
 
 2,250 
 
 11.3 
 
 -5.0 
 
 
 15-19 
 
 5 
 
 103.0-104.0 
 
 2,238 
 
 3,320 
 
 15.3 
 
 -3.3 
 
 
 20-23 
 
 4 
 
 101.0-103.6 
 
 2,054 
 
 2,362 
 
 15.9 
 
 —1.5 
 
 * Figures given are averages for twenty-four hours, 
 t Taken from Coleman and DuBois.^ 
 
 convalescence the meal is a large one, containing almost as much 
 protein as most people consume in a day. We must remember also that 
 the normal controls weighed 75 and 63 kg. when they took this meal 
 and that the typhoid patients weighed 51, 58, 35, and 54 kg., respec- 
 tively. As is shown in Table 3 the controls received less nitrogen per 
 unit of body weight than the fever patients. We can therefore state 
 that protein and glucose exhibit a much smaller specific dynamic action 
 in typhoid fever than in health, while in convalescence from the disease 
 the specific dynamic action seems to be greater than normal. In the 
 case of glucose there was practically no specific dynamic action in 
 fever, and in the case of Morris S. the specific dynamic action of the 
 protein was very slight. 
 
108 
 
 CLINICAL CALORIMETRY 
 
 The cause for this phenomenon has not yet been definitely ascer- 
 tained but the most plausible theory was stated by Dr. Graham Lusk' 
 in the discussion on the symposium on nutrition at Atlantic City in 
 1914. He called attention to the well known fact that if the metabolism 
 be increased by lowering the environmental temperature there may be 
 
 B 
 
 Edward 
 
 Nov 6 
 
 John K 
 
 Dec 15 
 
 Morris S 
 OCT 2 1 
 
 MORRIS S. 
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 Hr. 
 40f^ 
 39.6 
 592 
 38.8 
 
 Cal. 
 
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 80 
 70 
 
 
 
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 NOV 17 
 
 Morris S. 
 Dec 10 
 
 MORRIS S. 
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 Chart 1. — Curves showing the relationship of heat production and heat elim- 
 ination in fever. Rising temperature. The uppermost line shows the rectal 
 temperature as measured every twenty minutes. The heavy continued line 
 represents the heat production in hourly periods as determined by the method 
 of indirect calorimetry. The dotted line gives the heat elimination as deter- 
 mined by the measurement of the calories of radiation, conduction and vapor- 
 ization. The difference between the levels of these two lines represents the 
 heat stored in the body as the temperature rises. Note the fact that in every 
 case except one the heat elimination increases with a rising temperature. 
 
 no specific dynamic action as usually induced by ingested food. In like 
 manner if the metabolism be raised in fever, food ingestion may cause 
 no increase. He also stated that since protein metabolism in fever 
 
 9. Lusk: Jour. Am. Med. Assn., 1914, Ixiii, 831, foot of page. 
 
WARREN COLEMAN— EUGEXE F. DU BOIS 
 
 109 
 
 can never be reduced to as low a level as is present in the normal 
 organism, therefore protein ingestion in fever often merely serves to 
 replace the protein already breaking up in increased quantity, and such 
 protein ingestion would not then serve to increase the heat production. 
 The Regulation of Body Temperature. — The study of the regulation 
 of body temperature is one that demands the utmost accuracy of 
 technic. The question at issue is whether a rise in temperature is due 
 to an increase in heat production or a decrease in heat elimination. 
 Previous investigators have tried to solve this problem on data obtained 
 from the direct calorimetry alone, or from the indirect calorimetry 
 accompanied by measurements of body temperature. In either of 
 these two methods the whole calculation would depend on the exact 
 
 
 Morris 5 
 
 OCT 2 9 
 
 
 Morris S. 
 
 NOV. 5 
 
 
 
 Howard 
 
 Nov, 20 
 
 F 
 
 
 Karl 3 
 Jan. 5 
 
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 Chart 2. — Curves showing the relationship of heat production and heat 
 elimination in fever. (See legend Chart 1.) Temperature level or falling. In 
 the last two experiments it will be noted that the heat elimination rises above 
 the production. 
 
 measurement of the average change in body temperature, the exact 
 calculation of specific heat of the body and the amount of heat stored 
 in or lost from the body. It has been shown in this and preceding 
 papers that these measurements and calculations are the weakest points 
 in the science of calorimetry and it is only very recently that the technic 
 has been so developed that investigators have attempted a comparisun 
 of the methods of direct and indirect calorimetry in periods shorter 
 than six to twelve hours, periods obviously too long for the study of 
 the problem in question. If, in a period of experimentation, the results 
 obtained by the method of indirect calorimetry and by the method of 
 
110 CLINICAL CALORIMETRY 
 
 direct calorimetry, using either the rectal or the surface temperature, 
 do not agree within 5 per cent., we must suspect some error, probably 
 in the measurement of the average body temperature change. For this 
 reason we have eliminated from the discussion all experiments in 
 which the two methods do not agree within 5 per cent. It is also pref- 
 erable to eliminate all experiments after the taking of food and all 
 experiments in which the subject was not quiet. This gives us eleven 
 experiments during the febrile period in which the technic left nothing 
 to be desired. 
 
 In Chart 1 are grouped those experiments in which there was a 
 rising body temperature. The dotted line shows the total heat elim- 
 inated from the body by means of radiation, conduction and vaporiza- 
 tion. The continued line shows the heat production as determined by 
 the method of indirect calorimetry, which does not use a single factor 
 that affects the dotted line. With a rising body temperature the heat 
 production within the body must be greater than the elimination to 
 provide for the storage of heat in the tissues. Many are of the opinion 
 that the rise in temperature is chiefly due to a decrease in the heat 
 elimination. This we find to be the case only in the last hour of one 
 of the seven observations, there being a sharp drop in both heat pro- 
 duction and elimination towards the end of the experiment on Morris 
 S. on October 24. In all the other periods the rising temperature was 
 accompanied by an increasing heat production which outweighed the 
 increasing heat elimination. 
 
 In Chart 2 which shows periods in which the body temperatures 
 were fairly level the production and elimination were about equal and 
 constant. In the two observations with falling temperature the heat 
 production remained fairly level while the elimination was increased. 
 
 Heat Production, Weight and Nitrogen Equilibrium. — In the cases 
 here studied it is possible to make a comparison of the caloric intake 
 and the caloric output. The intake consists of the calories of the food. 
 The output is made up of many factors, but principally of calories lost 
 by radiation, conduction and the evaporation of water. The first and 
 most important consideration is the determination of the basal heat 
 production as measured by the methods of direct and indirect calorim- 
 etry. As has been shown above, the two methods agree within 2 per 
 cent. The actual heat production during the different hours of the 
 day can depart from the basal as a result of various factors. We have 
 shown above that the ingestion of large amounts of food causes but a 
 slight increase in metabolism, averaging less than 5 per cent, in the case 
 of protein and only 1 per cent, in the case of carbohydrate. These 
 increases may be considered the maxima since the amounts of foods 
 given were the largest the patient could take and the hours of the 
 
WARREN COLEMAN— EUGENE P. DU BOIS 111 
 
 observation were the hours of the greatest specific dynamic action. 
 The exact percentage rise caused by the stimulation of the food taken 
 during the whole day is problematical but may be estimated as about 
 3 per cent. The percentage of calories lost in the feces has been studied 
 in two previous papers and has been found to be practically normal. 
 The calories lost as urea and in the feces are taken into consideration 
 in the calculation of the fuel values of the food. In the one case in 
 which there was alimentary glycosuria (Frank W.)/ the calories lost 
 as dextrose have been subtracted from the intake. In a previous paper 
 the writers have discussed the evidence against an abnormal loss of 
 partially oxidized carbon compounds in the urine and have come to the 
 conclusion that this factor is negligible. The entire absence of abnor- 
 mal respiratory quotients supports this view. The lowest quotient 
 found was 0.72, the highest 1.04, obtained respectively during fasting 
 and high carbohydrate ingestion, and thus exhibiting entirely normal 
 relations. 
 
 The most uncertain factor is the variation in heat production caused 
 by changes in the muscular activity. It is quite possible that a patient 
 who is very delirious and very restless might produce twice as many 
 calories as when quiet. The total heat production of such patients 
 could be determined only by the Middletown type of experiment in 
 which the subject was kept in a respiration calorimeter for days at a 
 time. Such experiments are obviously impossible in typhoid fever. 
 The question remains as to whether we obtain a fair sample of the 
 day's metabolism by making two or three observations a week between 
 the hours of 11 in the morning and 2 or 3 o'clock in the afternoon. 
 This period includes some of the morning hours when the metabolism 
 is said to be low and some of the afternoon hours when it is said to 
 be high. During the experiment the activity of the patient has been 
 almost the same as the activity observed in the ward during the greater 
 part of the day between the hours of 5 in the morning and 8 in the 
 evening. In the calorimeter the subjects are allowed to turn from side 
 to side several times during the hour and they shift their position often 
 enough to make themselves comfortable, which is exactly what they do 
 in their beds in the ward. Part of the time they doze and part of the 
 time they are awake and are looking out of the calorimeter window. 
 In the ward they are kept flat in bed and are never allowed to sit up 
 untilthe temperature has been normal for several days. They are 
 never given cold tubs and hardly ever given cold sponges. Their food 
 is served on trays and they help themselves with a minimum of exer- 
 tion. In the morning the nurse gives each patient an enema, sponges 
 
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114 CLINICAL CALORIMETRY 
 
 him off with warm water, slides him from his bed to the weighing 
 platform, makes up his bed and slides him back again. During the 
 rest of the day he is seldom disturbed and he spends his time dozing, 
 reading or talking with his neighbors. A few of the patients have been 
 mildly irrational for a few days at a time and such occurrences have 
 been noted in detail in the histories. Subsultus tendinum and jactita- 
 tion have rarely been observed. On the other hand, there must be a 
 reduction of the metabolism at night since the patients sleep soundly 
 and are seldom disturbed. In a previous paper we have estimated 
 that the bodily activity increases the metabolism during the whole day 
 to an average of 10 per cent, above its basal metabolism. Since that 
 time we have had the opportunity of making two observations on 
 patients who were irrational and restless. November 3 Morris .S. was 
 in the calorimeter for three hours. During the first hour he was 
 unusually quiet, during the second hour he was restless and tossed 
 about the bed, during the third hour he was evidently irrational, tossed 
 about and wrote three or four long notes which he held up to the calo- 
 rimeter window to tell us about the animals that were biting him with 
 their sharp teeth. 
 
 In spite of this unusual activity his metabolism during the three 
 hour period was only 43 per cent, above the normal and was only 5 
 per cent, higher than during the quiet basal observation made two days 
 later, when the temperature was lower. Edward B. on Nov. 10, 1914, 
 was in the calorimeter with a temperature of 40.3 C, and during the 
 second and third hours was restless and mildly irrational. His heat 
 production was only 51 per cent, above the average normal. These 
 two observations, which are fair samples of the severest symptoms 
 observed in the typhoid patients presented in this paper, do not indicate 
 any unusual degree of increase of heat production from the moderate 
 activity. There may be an uneconomical expenditure of energy in 
 typhoid in the performance of a certain task but even so the total 
 expenditure is not great in these cases. It is hoped that at a later date 
 the question of muscular efficiency in fever may be solved by having 
 typhoid patients and normal controls do a stated amount of work on 
 an ergometer while in the calorimeter. 
 
 A detailed consideration of all the factors is of importance when 
 one attempts to draw conclusions from a discrepancy between the 
 calculated intake and the calculated output. It is necessary to consider 
 the possible errors in the various determinations and it is necessary to 
 select somewhat arbitrary average percentages for the various factors. 
 The measurement of the food intake is unusually accurate. Most of 
 
WARREN COLEMAN— EUGENE F. DU BOIS 
 
 lis 
 
 the foods such as cereals, bread, sugars, egg white and egg yolk, butter 
 and crackers vary but slightly from the samples analyzed. The other 
 foods given, such as milk, cream, and dried apples are not subject to 
 large enough variations to afi'ect the results. Foods subject to signifi- 
 cant variations are carefully avoided. 
 
 The methods of preparation and weighing have been described in 
 another paper and they are believed to be accurate within 2 per cent. 
 It is doubtful if this error combined with the error in the variation 
 of the individual foods exceeds plus or minus 5 per cent, and there is 
 no factor to throw the error on one side of the scale more often than 
 on the other. The heat production of the patients as determined by 
 the method of indirect calorimetry is not subject to an error of more 
 than 1 or 2 per cent, on the average, although it is possible that some 
 individual observations may show an error of 5 per cent. The collec- 
 tion of the twenty-four hour specimens of urine and the estimation of 
 
 M«vrMi>f» 
 
 Olc. 
 
 r, ■' i T l <t I it) I ill I i|» I ih l ikl ikl r|«| il7| i|« | i b|?ki I aiT?> a^ jg g» ?tT?7 gi» ga ^a 
 
 ^s^^^i^l, 
 
 98 = 
 
 .^-^- 
 
 d = ^ 
 
 i'A 
 
 ^^^ 
 
 5 
 
 ;^ 
 
 t?S 
 
 Chart 4. — Charles F. Temperature curve. 
 
 the nitrogen are so carefully controlled by duplicate analyses and checks 
 in the collection of specimens and in the calculations that there is no 
 chance for an error greater than 1 per cent. In the cases in which the 
 feces were not analyzed the method of estimating the feces nitrogen as 
 10 per cent, of the food nitrogen gives a plus or minus error of less 
 than half a gram a day while there is possibly as great an error in the 
 fact that we do not take into account the nitrogen losses through the 
 skin. 
 
 In order to estimate the caloric output of typhoid patients on whom 
 respiration experiments were made, one can add to the basal metabo- 
 lism on average 3 per cent, for the specific dynamic action of the food 
 and 10 per cent, for muscular activity. We can, therefore, calculate 
 with reasonable accuracy the heat production for the day by adding 13 
 per cent, to the figures obtained in the febrile basal experiments and 10 
 per cent, to the figures obtained in the experiments after food. In the 
 cases in which several observations were made it seems fair to plot a 
 smooth curve and consider that the heat production of the non-experi- 
 
116 
 
 CLINICAL CALORIMETRY - 
 
 mental days was the same as on the days in which actual determina- 
 tions were made. 
 
 If we look now at Table 4 and Charts 3, 6 and 8, it 
 hecomes evident that three of the patients reported in this paper 
 and one reported in a previous paper^ showed a distinct negative 
 nitrogen balance when they were receiving cofisiderably more 
 ■calories than were sufficient to cover the calculated heat produc- 
 tion. A glance at the food charts will show that the typhoid 
 patients were given 12 to 16 grams of nitrogen a day and that the 
 proportions of fat and carbohydrate were well balanced. The only 
 criticism of the manner of feeding is that on the days of the basal 
 determinations it v/as necessary for the patient to fast sixteen to twenty 
 hours. One might expect a slight negative nitrogen balance at such 
 times, but this should be offset by a positive balance the next day. As 
 a matter of fact the negative balance is not much greater on the experi- 
 
 MoVFMFjFI? 
 
 li " 11 <b in M 19 \li 14. rS IS 17 M n 20 21I 22 2S 24- 15 2A 27 2A 
 
 
 
 ffl'^' K ' . 
 
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 102- =huL^ jJZti ^^^^:5^^S5Zj^5I^'^..^T1 j. 4 it 
 
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 inf ^ a ' t i^ \k VpT 
 
 ^^^__^^==__== — =^_^^^^ ^___LS.^£tt^c ^ 
 
 ^^^^^^^ = = ^==^^^^=^^^^r^^^^_ , 1 1 1 1 1 1 1 _1.^.\.^_^Z^ 
 
 Chart 5. — Howard F. Temperature curve. 
 
 mental days. Moreover, as was pointed out in the previous paper, 
 many patients who have not been the subject of respiration experi- 
 ments have shown a persistent negative nitrogen balance on a diet much 
 greater than the estimated heat production and have not come into 
 nitrogen equilibrium until the theoretical requirement was exceeded by 
 from 50 to 110 per cent. 
 
 In another place^ when touching on this subject we referred to the 
 possibility of a storage of fat while there was a negative nitrogen 
 balance and loss of body weight. The body weight is notoriously a poor 
 index of gain or loss of body tissue except in long periods of observa- 
 tion. The body changes its content of water so easily and so rapidly 
 with changing diets and changing periods of the disease that it would 
 be very easy to store 1 or 2 kilograms of fat without noticeable effect 
 on the weight. We must remember that 1 kilogram of fat represents 
 about 9,300 calories. Even without assuming a change in the water con- 
 centration of the body, it is possible to account for the storage of the 
 excess calories. In the tables one can find several periods of almost con- 
 
WARREN COLEMAN— EUGENE F. DU BOIS 
 
 117 
 
 stant body weight when the patient was losing nitrogen. If we con- 
 sider that for every 3 grams of nitrogen lost the patient loses about 100 
 grams of muscle tissue, it is possible to calculate the total muscle tissue 
 lost. If this were replaced by fat the weight would remain constant 
 and the storage of the excess calories could easily be accounted for. 
 For example, Morris S. between October 23 and November 3 lost 
 about 1,770 grams of muscle tissue, which could be replaced by enough 
 fat to represent 15,900 calories. 
 
 Chart 6. — Karl S. Temperature and body weight. Food nitrogen, continu- 
 ous line ; excreta nitrogen, dotted line. The columns at base represent calories 
 in food. Protein calories crossed diagonals, fat calories blank, carbohydrate 
 calories vertical lines. Dot-dash line represents the estimated heat production 
 in calories for twenty-four hours, dashes being placed on the days of the 
 calorimeter observations. Note the negative balance during the last days of 
 the fever when the patient was receiving in food more calories than the 
 estimated heat production. 
 
 In none of the cases were the protein and carbohydrate calories 
 together sufficient to cover the heat production, so it is not necessary 
 to assume the transformation of carbohydrate into fat, although we 
 have shown that this is possible during fever in one patient^ (Salva- 
 
 tore L.). 
 
 The Toxic Destruction of Protein. — The proof of the fact that 
 typhoid patients show a negative nitrogen balance on a diet which 
 furnishes more calories than the heat production, is perhaps the most 
 
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WARREN COLEMAN— EUGENE F. DU BOIS 
 
 119 
 
 important piece of evidence which has yet been presented in the discus- 
 sion of the so-called toxic destruction of protein. Clinicians have long 
 been aware of the large excretion of nitrogen in fever and have attrib- 
 uted it to an abnormal destruction of protein caused by the toxins of 
 the disease. It is not necessary in this connection to review the older 
 clinical work, since that is admirably presented in the standard discus- 
 
 DfrFN/tRFR 
 
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 Chart 8.— John K. Temperature, body weight, food and excreta nitrogen. 
 Food calories and dot-dash line showing estimated heat production. 
 
 sions of metabolism in fever. The results of the large number of 
 investigations made on lower animals, while important, cannot with 
 certainty be transferred to man. 
 
 The question of the toxic destruction of protein took on a new 
 aspect when in 1909 Shaffer and Coleman^ showed that it was possible 
 
120 CLINICAL CALORIMETRY 
 
 to obtain nitrogen balance in typhoid patients, even during the second 
 and third weeks of the disease. This they accomplished only by 
 making the total caloric value of the food very high, from 60 to 90 
 calories per kilogram, and the food nitrogen from 9 to 15 grams. In 
 their discussion of the results they expressed the opinion that "... .it 
 is perhaps improbable that the total heat production reached the values 
 represented by the larger amounts of food." This work proved that 
 there was no toxic destruction in the sense of a nitrogen loss which 
 could not be counterbalanced by the nitrogen intake. 
 
 The question of the average heat production of typhoid patients 
 was fully discussed in last year's paper^ and attention was drawn to 
 the fact that typhoid patients did not come into nitrogen equilibrium 
 until their theoretical caloric requirement was exceeded by from 50 
 to 110 per cent. Grafe^° in 1911 had shown that his typhoid patients 
 when studied in a respiration chamber, ten to sixteen hours after their 
 last meal, derived about 10 to 20 per cent, of their calories from pro- 
 tein, a percentage usually found in normal men. From this Grafe con- 
 cluded that he had shown that the protein metabolism in fever was not 
 abnormal. The percentage of calories derived from protein on the first 
 eighteen hours after food ingestion depends largely on the previous 
 level of the protein ' metabolism. Normal individuals who have been 
 taking 15 to 19 grams of nitrogen a day will naturally derive about 15 
 to 20 per cent, of their calories from protein as is shown in Paper 4 
 of this series. Normal individuals who have been maintaining them- 
 selves in nitrogen balance on 4 to 5 grams a day will derive only 5 
 per cent, of their calories from protein. The comparison should have 
 been made between normal men and typhoid patients while both were 
 on their nitrogen minima. This will be shown later in a discussion of 
 Kocher's work. 
 
 RoUand"^^ working under Grafe's direction brought several fever 
 patients into nitrogen balance by means of a caloric intake which she 
 believed to be equal to the heat production as estimated from the aver- 
 ages of other patients. Respiration experiments were not made on the 
 patients themselves. Our reasons for believing that the food intake 
 was above the requirement have been set forth in another place^ 
 (p. 38). 
 
 Recent work from Friedrich Muller's clinic has thrown important 
 light on the subject. Graham and Poulton" established themselves 
 
 10. Grafe E. : Untersuchungen iiber den Stoff- und Kraftwechsel im Fieber, 
 Deutsch. Arch. f. klin. Med., 1911, ci, 209. 
 
 11. RoUand, Anne: Zur Frage des toxogenen Eiweisszerfalls im Fieber des 
 Menschens, Deutsch. Arch. f. klin. Med., 1912, cvii, 440. 
 
 12. Graham and Poulton : Influence of Temperature on Protein Metabolism, 
 Quart. Jour. Med., 1912, vi, 82. 
 
WARREN COLEMAN— EUGENE F. DU BOIS 121 
 
 on a minimal nitrogen elimination of 4 to 5 grams a day and found 
 no increase in the elimination when they raised their temperatures to 
 about 40 C. by means of a steam bath. Kocher^^ in two normal sub- 
 jects established a nitrogen minimum at a similar level and found no 
 increase when he raised the heat production by means of a 60 kilometer 
 walk. All of these experiments were made on a caloric intake calcu- 
 lated to cover the requirement. They indicate that rise in temperature 
 alone or increase in heat production alone will not cause an increased 
 protein metabolism, at least when applied for a portion of one day. 
 Kocher then attempted by means of a diet amply sufficient to cover the 
 calculated requirement to bring down the nitrogen elimination of fever 
 patients to the low level obtained in normal men. This he found to 
 be impossible until the active stage of the disease was passed. Grafe^* 
 in a recent paper has criticized these experiments. 
 
 To all of the patients in Table 4 food was given which had an 
 energy content much greater than the amount required by the patients 
 as measured directly when they were in the calorimeter. Although the 
 protein content of the diet, as represented by an intake of 15 grams 
 of nitrogen, was ample to establish nitrogen equilibrium had the diet 
 been given to normal men, it did not accomplish this in typhoid fever. 
 It is difficult to see in this anything except the proof that there is an 
 abnormal destruction of protein in typhoid fever. In some cases the 
 protein destruction continued several days after the temperature had 
 reached a low level. It is impossible to escape the conclusion that the 
 destruction of protein is caused by the toxins of the disease. 
 
 SUMMARY AND CONCLUSIONS 
 
 The heat production of typhoid patients has been measured by the 
 methods of direct and indirect calorimetry in a series of sixty-one 
 experiments. The two methods agreed closely, the total divergence 
 being 2.2 per cent, and the average divergence in the individual experi- 
 ments being 5 per cent. This and the entire absence of abnormal 
 respiratory quotients indicate that in typhoid fever protein, fat and 
 carbohydrate are oxidized to the same or approximately the same end 
 products as in health, and in their oxidation give off the standard 
 
 13. Kocher, Rudolph A.: Ueber die Grosse des Eiweisszerfalls bei Fieber 
 und bei Arbeitsleitstung, Deutsch. Arch. f. klin. Med., 1914, cxv, 82. 
 
 14. Grafe, E. : Zur Genese des Eiweisszerfalls im Fieber, Deutsch. Arch. f. 
 klin. Med., 1914, cvi, 328. 
 
TABLE S.— Clinicai^ 
 
 Subject 
 
 Date 
 Weight 
 
 Period 
 
 End of 
 Period 
 
 Oarbon- 
 
 dioxid, 
 
 Gm. 
 
 Oxygen, 
 Gm. 
 
 R.Q. 
 
 Water, 
 Gm. 
 
 Drine N 
 
 per 
 Hour, 
 Gm. 
 
 Indirect 
 Oalo- 
 
 rimetry, 
 Oal. 
 
 Heat 
 EUmi- 
 nated, 
 
 Oal. 
 
 Direct 
 
 Oalo- 
 
 rimetry 
 
 (Bectal 
 
 Temp.) 
 
 Oal. 
 
 Bectal 
 
 Temp. 
 
 0. 
 
 Morris S 
 
 Oct. 24, '13 
 51.60 kg. 
 
 Prelim. 
 
 1 
 
 11:35 
 12:35 
 
 30.06 
 
 30.02 
 
 .73 
 
 47.84 
 
 0.713 
 
 97.69 
 
 83.41 
 
 84.28 
 
 89.86 
 39.93 
 
 
 2 
 
 1:35 
 
 27.82 
 
 26.13 
 
 .77 
 
 46.72 
 
 0.713 
 
 85.89 
 
 84.68 
 
 81.00 
 
 39.89 
 
 
 3 
 
 2:35 
 
 26.20 
 
 24.04 
 
 .79 
 
 39.48 
 
 0.713 
 
 79.28 
 
 74.63 
 
 85.72 
 
 40.17 
 
 Morris S 
 
 Oct. 25, '13 
 51.22 kg. 
 
 Prelim. 
 
 1 
 
 ll:0O 
 12:00 
 
 29.65 
 
 26.82 
 
 .80 
 
 42.10 
 
 0.671 
 
 88.95 
 
 78.03 
 
 90.06 
 
 39.21 
 39.49 
 
 
 2 
 
 1:00 
 
 28.63 
 
 25.87 
 
 .81 
 
 39.10 
 
 0.671 
 
 85.77 
 
 80.11 
 
 88.09 
 
 39.69 
 
 
 3 
 
 2:00 
 
 31.75 
 
 25.46 
 
 .91 
 
 42.82 
 
 0.671 
 
 86.62 
 
 90.07 
 
 78.55 
 
 39.49 
 
 Morris S 
 
 Oct. 28, '13 
 51.60 kg. 
 
 Prelim. 
 
 1 
 
 11:10 
 12:10 
 
 34.12 
 
 28.35 
 
 .88 
 
 43.31 
 
 0.732 
 
 95.71 
 
 92.00 
 
 75.53 
 
 39.62 
 39.27 
 
 
 2 
 
 1:10 
 
 32.64 
 
 24.82 
 
 .96 
 
 42.41 
 
 0.732 
 
 85.31 
 
 94.67 
 
 76.33 
 
 38.87 
 
 
 3 
 
 2:10 
 
 30.25 
 
 22.89 
 
 .96 
 
 39.40 
 
 0.732 
 
 78.60 
 
 86.73 
 
 84.65 
 
 38.81 
 
 
 4 
 
 3:10 
 
 29.93 
 
 24.33 
 
 .90 
 
 34.39 
 
 0.732 
 
 82.34 
 
 78.47 
 
 93.97 
 
 39.20 
 
 
 5 
 
 4:10 
 
 28.38 
 
 22.06 
 
 .94 
 
 31.75 
 
 0.732 
 
 74.59 
 
 74.35 
 
 90.84 
 
 39.65 
 
 Morris S 
 
 Oct. 29, '13 
 49.86 kg. 
 
 Prelim. 
 1 
 
 11:10 
 12:10 
 
 26.76 
 
 23.77 
 
 .82 
 
 33.11 
 
 0.658 
 
 79.00 
 
 81.19 
 
 76.49 
 
 39.63 
 39.60 
 
 
 2 
 
 1:10 
 
 27.49 
 
 26.95 
 
 .77 
 
 34.03 
 
 0.658 
 
 86.28 
 
 84.48 
 
 85.73 
 
 39.54 
 
 Morris S 
 
 Oct. 31, '13 
 60.28 kg. 
 
 Prelim. 
 
 1 
 
 11:00 
 12:00 
 
 28.96 
 
 25.45 
 
 .83 
 
 32.13 
 
 1.058 
 
 84.11 
 
 74.09 
 
 68.27 
 
 39.06 
 38.94 
 
 
 2 
 
 1:00 
 
 29.69 
 
 24.17 
 
 .89 
 
 36.41 
 
 1.058 
 
 81.16 
 
 79.19 
 
 79.96 
 
 39.08 
 
 
 3 
 
 2:00 
 
 29.57 
 
 26.58 
 
 .80 
 
 36.76 
 
 1.058 
 
 87.50 
 
 77.70 
 
 87.13 
 
 39.43 
 
 Morris S 
 
 Nov. 3, '13 
 48.53 kg. 
 
 Prelim. 
 
 1 
 
 10:30 
 11:30 
 
 24.91 
 
 20.42 
 
 .89 
 
 28.68 
 
 0.499 
 
 69.20 
 
 66.44 
 
 72.99 
 
 38.63 
 39.05 
 
 
 2 
 
 12:30 
 
 28.70 
 
 26.23 
 
 .80 
 
 33.10 
 
 0.499 
 
 83.77 
 
 74.39 
 
 77.80 
 
 39.15 
 
 
 3 
 
 1:30 
 
 27.63 
 
 27.90 
 
 .72 
 
 42.11 
 
 0.499 
 
 90.92 
 
 86.25 
 
 71.74 
 
 38.81 
 
 Morris S 
 
 Nov. 5, 'IS 
 48.45 kg. 
 
 Prelim. 
 
 1 
 
 11:20 
 12:20 
 
 26.42 
 
 23.10 
 
 .80 
 
 29.99 
 
 0.491 
 
 76.70 
 
 77.98 
 
 81.34 
 
 38.08 
 38.19 
 
 
 2 
 
 1:20 
 
 26.42 
 
 23.05 
 
 .83 
 
 38.62 
 
 0.491 
 
 77.19 
 
 74.76 
 
 67.00 
 
 38.01 
 
 
 3 
 
 2:20 
 
 25.60 
 
 23.65 
 
 .79 
 
 39.13 
 
 0.491 
 
 78.29 
 
 72.89 
 
 75.34 
 
 38.10 
 
 Morris S 
 
 Nov. 17, '13 
 47.99 kg. 
 
 Prelim. 
 
 1 
 
 11:10 
 12:10 
 
 21.90 
 
 19.01 
 
 .84 
 
 24.39 
 
 0.336 
 
 63.87 
 
 67.98 
 
 62.77 
 
 38.48 
 38.61 
 
 
 2 
 
 1:10 
 
 23.68 
 
 20.82 
 
 .82 
 
 24.44 
 
 0.336 
 
 69.76 
 
 60.70 
 
 69.71 
 
 38.82 
 
 
 3 
 
 2:10 
 
 23.79 
 
 22.28 
 
 .78 
 
 26.06 
 
 0.336 
 
 73.79 
 
 66.08 
 
 72.85 
 
 39.00 
 
 Morris S 
 
 Nov. 18, '13 
 48.77 kg. 
 
 Prelim. 
 1 
 
 11:00 
 12:00 
 
 24.40 
 
 22.01 
 
 .81 
 
 26.65 
 
 0.567 
 
 73.01 
 
 67.36 
 
 64.94 
 
 39.72 
 39.67 
 
 
 2 
 
 1:00 
 
 26.37 
 
 21.38 
 
 .90 
 
 28.16 
 
 0.667 
 
 72.56 
 
 71.65 
 
 82.60 
 
 39.98 
 
 
 3 
 
 2:00 
 
 25.91 
 
 23.67 
 
 .80 
 
 28.88 
 
 0.667 
 
 78.11 
 
 72.05 
 
 77.47 
 
 40.15 
 
 Morris S 
 
 Nov. 24, '13 
 46.69 kg. 
 
 Prelim. 
 
 1 
 
 11:13 
 12:13 
 
 29.17 
 
 26.27 
 
 .78 
 
 29.24 
 
 0.614 
 
 83.66 
 
 67.60 
 
 68.12 
 
 39.54 
 39.59 
 
 
 2 
 
 1:13 
 
 26.91 
 
 24.54 
 
 .75 
 
 32.68 
 
 0.514 
 
 85.26 
 
 75.16 
 
 64.72 
 
 39.33 
 
 
 3 
 
 2:13 
 
 26.41 
 
 25.48 
 
 .75 
 
 35.00 
 
 0.514 
 
 83.64 
 
 80.48 
 
 73.52 
 
 39.16 
 
— Caloeimetry in Typhoid Fever 
 
 Suiface 
 
 Temp., 
 
 0. 
 
 Aver- 
 age 
 
 Pulse 
 
 Work 
 
 Adder., 
 
 Cm. 
 
 Non- 
 
 ProMin, 
 
 B.Q. 
 
 Per Cent. 
 Calories Irom 
 
 Calories 
 Per Hotu- 
 
 
 Pro- 
 tein 
 
 Pat 
 
 Oarbo- 
 hyd. 
 
 Per 
 Kg. 
 
 Per 
 Sq. M. 
 
 
 
 96(f) 
 
 36.0 
 
 .71 
 
 24 
 
 75 
 
 1 
 
 1.90 
 
 67.33 
 
 Basal. 
 
 
 96 
 
 21.0 
 
 .77 
 
 28 
 
 58 
 
 14 
 
 1.67 
 
 50.40 
 
 
 
 
 105 
 
 17.0 
 
 .79 
 
 31 
 
 49 
 
 20 
 
 1.54 
 
 46.53 
 
 
 
 101 
 96 
 
 30.0+ 
 21.5 
 
 .80 
 
 .81 
 
 20 
 21 
 
 54 
 52 
 
 26 
 27 
 
 1.74 
 1.68 
 
 52.36 
 50.48 
 
 9:30-10:00 a. m., protein 
 meal. 9.0 gm. N. 
 
 
 105 
 
 18.0 + + 
 
 .94 
 
 21 
 
 17 
 
 62 
 
 1.69 
 
 60.98 
 
 
 
 
 119 
 113 
 108 
 
 35.0 
 
 25.0+5? 
 30.5 
 
 .90 
 1.01 
 1.02 
 
 20 
 23 
 25 
 
 29 
 
 51 
 77 
 75 
 
 1.88 
 1.68 
 1.55 
 
 66.70 
 50.54 
 46.66 
 
 At 10:22, 115 gm. com. 
 glucose = 100 gm. dex- 
 trose. Asleep Irom 
 3-3:40. 
 
 
 108 
 
 18.0 
 
 .93 
 
 24 
 
 19 
 
 57 
 
 1.62 
 
 48.78 
 
 
 
 
 107 
 
 9.0 
 
 .99 
 
 26 
 
 3 
 
 71 
 
 1.47 
 
 44.19 
 
 
 
 105 
 
 24.0 
 
 .82 
 
 22 
 
 47 
 
 31 
 
 1.58 
 
 47.17 
 
 Basal. 
 
 
 106 
 
 17.5 
 
 .76 
 
 20 
 
 65 
 
 15 
 
 1.70 
 
 60.91 
 
 
 
 101 
 102 
 
 10.0 (?) 
 11.2+ 
 
 .84 
 .95 
 
 33 
 35 
 
 36 
 12 
 
 31 
 53 
 
 1.68 
 1.62 
 
 50.16 
 48.39 
 
 8:40-9:20, protein meal; 
 10.3 gm. N. 
 
 
 98 
 
 9.5 
 
 .81 
 
 32 
 
 44 
 
 24 
 
 1.74 
 
 62.1fi 
 
 
 
 106 
 111 
 106 
 
 11.7 
 32.0 
 8.0+ 
 
 .91 
 
 .79 
 .70 
 
 19 
 16 
 
 15 
 
 25 
 69 
 85 
 
 56 
 26 
 
 1.42 
 
 1.71 
 1.86 
 
 42.09 
 50.96 
 65.30 
 
 Basal. 1st. hr. quiet, 2d. 
 hr. restless, 3d. hr. 
 restless; wrote 3 or 4 
 notes. 
 
 
 98 
 
 5.5 
 
 .80 
 
 17 
 
 56 
 
 27 
 
 1.58 
 
 46.89 
 
 Basal. 
 
 
 109 
 
 8.0 
 
 .84 
 
 17 
 
 45 
 
 38 
 
 1.59 
 
 47.18 
 
 
 
 112 
 
 8.0 
 
 .78 
 
 17 
 
 61 
 
 22 
 
 1.62 
 
 47.86 
 
 
 37.29 
 
 
 
 
 
 
 
 
 
 
 37.52 
 
 100 
 
 11.0 
 
 .84 
 
 14 
 
 45 
 
 41 
 
 1.33 
 
 39.28 
 
 Basal. 
 
 37.83 
 
 113 
 
 6.8 
 
 .83 
 
 13 
 
 61 
 
 36 
 
 1.45 
 
 42.90 
 
 
 37.94 
 
 112 
 
 3.0 
 
 .77 
 
 12 
 
 68 
 
 20 
 
 1.54 
 
 45.38 
 
 
 38.89 
 
 
 
 
 
 
 
 
 
 
 38.98 
 
 lU 
 
 0.3 
 
 .81 
 
 21 
 
 62 
 
 27 
 
 1.50 
 
 44.44 
 
 Basal. 
 
 39.27 
 
 117 
 
 14.7 
 
 .92 
 
 21 
 
 20 
 
 59 
 
 1.49 
 
 44.16 
 
 
 39.16 
 
 124 
 
 13.7 
 
 .80 
 
 19 
 
 55 
 
 26 
 
 1.60 
 
 47.64 
 
 
 
 
 12.0 
 
 .78 
 
 16 
 
 64 
 
 20 
 
 1.77 
 
 52.32 
 
 Basal. 
 
 
 122 
 
 0.0 
 
 .74 
 
 16 
 
 73 
 
 11 
 
 1.81 
 
 53.39 
 
 
 
 126 
 
 0.5 
 
 .74 
 
 16 
 
 73 
 
 11 
 
 1.78 
 
 52.37 
 
 
TABLE S. — Clinical Calorimetry- 
 
 Subject 
 
 Date 
 Weight 
 
 1 
 
 Period 
 
 End of 
 Period 
 
 Carbon- 
 
 dioxid, 
 
 Gm. 
 
 Oxygen. 
 6m. 
 
 B.Q. 
 
 Water, 
 6m. 
 
 Urine N 
 
 per 
 
 Hour, 
 
 6m. 
 
 Indirect 
 
 Calo- 
 rimetry, 
 Oal. 
 
 Heat 
 Elimi- 
 nated, 
 Oal. 
 
 Direct 
 Calo- 
 rimetry 
 (Bectal 
 Temp.) 
 Oal. 
 
 Bectal 
 
 Temp. 
 
 0. 
 
 Morris S 
 
 Nov. 25, '13 
 47.24 ]jg. 
 
 Prelim. 
 
 1 
 
 11:20 
 12:20 
 
 28.17 
 
 24.45 
 
 .84 
 
 29.86 
 
 0.618 
 
 81.79 
 
 71.86 
 
 66.66 
 
 39.40 
 39.30 
 
 
 2 
 
 1:20 
 
 30.38 
 
 26.92 
 
 .82 
 
 47.61 
 
 0.618 
 
 89.78 
 
 91.51 
 
 78.22 
 
 38.97 
 
 
 3 
 
 2:20 
 
 29.26 
 
 27.94 
 
 .78 
 
 48.78 
 
 0.618 
 
 89.93 
 
 88.95 
 
 95.35 
 
 39.13 
 
 Morris S 
 
 Nov. 26, '13 
 46.11 kg. 
 
 Prelim. 
 
 1 
 
 10:50 
 11:50 
 
 26.29 
 
 24.80 
 
 .77 
 
 27.88 
 
 0.329 
 
 82.10 
 
 
 
 69.08 
 
 52.60 
 
 39.61 
 39.19 
 
 
 2 
 
 12:50 
 
 25.68 
 
 24.64 
 
 .76 
 
 34.79 
 
 0.329 
 
 81.28 
 
 79.19 
 
 71.14 
 
 38.99 
 
 
 3 
 
 1:50 
 
 25.70 
 
 24.85 
 
 .75 
 
 42.13 
 
 0.329 
 
 81.84 
 
 88.38 
 
 79.59 
 
 38.77 
 
 Morris S 
 
 Dec. 12, '13 
 48.61 kg. 
 
 Prelim. 
 
 1 
 
 10:56 
 11:66 
 
 23.45 
 
 20.22 
 
 .84 
 
 18.48 
 
 0.272 
 
 68.20 
 
 61.73 
 
 
 
 53.71 
 
 37.01 
 36.82 
 
 
 2 
 
 12:56 
 
 23.88 
 
 20.96 
 
 .SS 
 
 21.26 
 
 0.272 
 
 70.44 
 
 64.58 
 
 69.48 
 
 36.95 
 
 
 3 
 
 1:56 
 
 24.99 
 
 21.42 
 
 .85 
 
 24.01 
 
 0.272 
 
 72.36 
 
 66.64 
 
 69.52 
 
 37.03 
 
 Morris S 
 
 Dec. 13, '13 
 48.07 kg. 
 
 Prelim. 
 
 1 
 
 10:36 
 U:36 
 
 18.99 
 
 16.89 
 
 .82 
 
 18.84 
 
 0.323 
 
 
 
 56.39 
 
 58.07 
 
 50.93 
 
 37.07 
 36.90 
 
 
 2 
 
 15:36 
 
 20.10 
 
 17.29 
 
 .85 
 
 19.31 
 
 0.323 
 
 58.16 
 
 58.63 
 
 63.06 
 
 37.02 
 
 
 3 
 
 1:36 
 
 20.76 
 
 - 18.90 
 
 .80 
 
 20.26 
 
 0.323 
 
 62.88 
 
 61.95 
 
 63.59 
 
 37.07 
 
 Morris S 
 
 Dee. 15, '13 
 48.17 kg. 
 
 Prelim. 
 
 1 
 
 10:52 
 11:52 
 
 24.51 
 
 18.29 
 
 .98 
 
 18.41 
 
 0.384 
 
 63.45 
 
 58.74 
 
 47.60 
 
 37.30 
 37.03 
 
 
 2 
 
 12:52 
 
 26.76 
 
 18.98 
 
 1.03 
 
 20.90 
 
 0.384 
 
 66.42 
 
 63.52 
 
 64.97 
 
 37.10 
 
 
 3 
 
 1:52 
 
 26.83 
 
 18.82 
 
 1.04 
 
 22.07 
 
 0.384 
 
 65.97 
 
 64.19 
 
 67.97 
 
 37.23 
 
 Morris S 
 
 Dec. 16, 'IS 
 47.86 kg. 
 
 Prelim. 
 1 
 
 11:06 
 12:06 
 
 22.51 
 
 17.81 
 
 .92 
 
 20.83 
 
 0.299 
 
 61.10 
 
 63.36 
 
 61.62 
 
 37.32 
 37.30 
 
 
 2 
 
 1:06 
 
 21.91 
 
 18.33 
 
 .87 
 
 21.42 
 
 0.299 
 
 62.12 
 
 62.76 
 
 63.36 
 
 37.33 
 
 
 3 
 
 2:06 
 
 22.37 
 
 19.33 
 
 .84 
 
 21.79 
 
 0.299 
 
 65.08 
 
 63.87 
 
 60.35 
 
 37.25 
 
 Morris S 
 
 Dec. 19, '13 
 48.74 kg. 
 
 Prelim. 
 1 
 
 11: 10 
 12:10 
 
 27.38 
 
 21.99 
 
 .91 
 
 22.55 
 
 0.493 
 
 74.94 
 
 70.40 
 
 67.95 
 
 39.10 
 39.14 
 
 
 2 
 
 1:10 
 
 30.04 
 
 22.70 
 
 .96 
 
 25.64 
 
 0.493 
 
 78.51 
 
 75.00 
 
 84.00 
 
 39.41 
 
 
 3 
 
 2:10 
 
 29.47 
 
 23.61 
 
 .91 
 
 27.26 
 
 0.493 
 
 80.32 
 
 74.21 
 
 87.13 
 
 39.75 
 
 Morris S 
 
 Dec. 20, '13 
 48.52 kg. 
 
 Prelim. 
 1 
 
 10:40 
 11:40 
 
 23.69 
 
 22.51 
 
 .77 
 
 23.81 
 
 0.547 
 
 73.93 
 
 67.11 
 
 76.36 
 
 39.29 
 39.53 
 
 
 2 
 
 12:40 
 
 25.60 
 
 23.42 
 
 .80 
 
 25.60 
 
 0,547 
 
 77.57 
 
 70.95 
 
 78.45 
 
 39.70 
 
 
 3 
 
 1:40 
 
 25.51 
 
 23.84 
 
 .78 
 
 27.47 
 
 0.547 
 
 78.68 
 
 72.88 
 
 72.56 
 
 39.77 
 
 Morris S 
 
 Dec. 22, '18 
 48.87 kg. 
 
 Prelim. 
 
 1 
 
 11:16 
 12:36 
 
 37.28 
 
 28.77 
 
 .94 
 
 37.28 
 
 0.705 
 
 98.85 
 
 97.57 
 
 112.39 
 
 38.65 
 39.05 
 
 
 2 
 
 1:36 
 
 28.84 
 
 22.32 
 
 .94 
 
 28.28 
 
 0.529 
 
 76.65 
 
 73.08 
 
 88.66 
 
 39.47 
 
 
 3 
 
 2:36 
 
 28.86 
 
 22.21 
 
 .96 
 
 29.24 
 
 0.529 
 
 76.39 
 
 74.60 
 
 78.88 
 
 39.69 
 
 Morris S 
 
 Dec. 23, '13 
 48.60 kg. 
 
 Prelim. 
 1 
 
 11:06 
 12:06 
 
 23.51 
 
 
 
 21.45 
 
 .80 
 
 26.82 
 
 0.428 
 
 71.21 
 
 68.75 
 
 73.19 
 
 38.04 
 38.16 
 
 
 2 
 
 1:06 
 
 23.94 
 
 21.92 
 
 .80 
 
 26.39 
 
 0.428 
 
 72.73 
 
 70.84 
 
 80.86 
 
 38.46 
 
 
 3 
 
 2:'06 
 
 24.35 
 
 22.79 
 
 .78 
 
 25.38 
 
 0.428 
 
 76.32 
 
 69.86 
 
 76.84 
 
 38.66 
 
 Morris S 
 
 Jan. 2, '14 
 49.26 kg. 
 
 Prelim. 
 
 1 
 
 11:16 
 12:16 
 
 19.10 
 
 16.62 
 
 .84 
 
 19.75 
 
 0.386 
 
 65.63 
 
 68.53 
 
 52.15 
 
 36.97 
 36.86 
 
 
 2 
 
 1:16 
 
 19.27 
 
 17.07 
 
 .82 
 
 20.20 
 
 0.386 
 
 56.94 
 
 57.89 
 
 64.93 
 
 37.05 
 
 
 3 
 
 2:16 
 
 1 19.80 
 
 18.38 
 
 .78 
 
 22.05 
 
 0.386 
 
 60.77 
 
 61.64 
 
 60.88 
 
 37.07 
 
-IN Typhoid Fever — (Continued) 
 
 1 
 
 Surface 
 
 Temp., 
 
 0. 
 
 Aver- 
 age 
 Pulse 
 
 Work 
 
 Adder., 
 
 Om. 
 
 Non- 
 Protein, 
 E.Q. 
 
 Per Cent. [ 
 Calories from 1 
 
 1 
 
 Calories 
 Per Hour 
 
 Remarks 
 
 Pro- 
 tein 
 
 Fat 
 
 6arbo- 
 hyd. ' 
 
 Per 
 Kg 
 
 Per 
 Sq. M. 
 
 38.37 
 
 
 
 
 
 
 
 
 
 
 .<)8.6(i 
 38.12 
 37.76 
 
 112 
 122 
 119 
 
 18.6 
 
 12.2 
 
 9.5 
 
 .85 
 .83 
 
 .78 
 
 20 
 18 
 18 
 
 42 
 49 
 62 
 
 38 ! 
 
 33 
 
 20 
 
 1.72 
 1.89 
 1.90 
 
 50.83 
 65.80 
 55.89 
 
 9.36:10:15, protein meal; 
 8.7 gm. N. Began to 
 sweat at end of second 
 hour. 
 
 38.87 
 
 
 
 
 
 
 
 
 
 
 SS.aH 
 38.18 
 
 112 
 119 
 
 5.5 
 11.0 -h 
 
 .77 
 .75 
 
 11 
 
 11 
 
 70 
 75 
 
 19 
 14 
 
 1.79 
 1.77 
 
 51.83 
 61.31 
 
 Basal. Patient restless 
 in second period. 
 
 37.53 
 
 123 
 
 12.0 
 
 .75 
 
 11 
 
 77 
 
 12 '. 
 
 1.78 
 
 51.67 
 
 
 35.60 
 
 
 
 
 
 
 
 
 
 
 S5.62 
 35.69 
 
 91 
 94 
 
 3.8 
 18.6 
 
 .85 
 .83 
 
 n 
 
 10 
 
 46 
 51 
 
 43 
 39 
 
 1.40 
 1.45 
 
 41.59 
 42.95 
 
 9:03-9:30, protein meal; 
 10.6 gm. N. 
 
 35.73 
 
 98 
 
 14.5 
 
 .85 
 
 10 
 
 45 
 
 45 
 
 1.49 
 
 44.12 
 
 
 35.82 
 
 
 
 
 
 
 
 
 
 
 35.64 
 35.82 
 
 74 
 88 
 
 9.0 
 9.2 
 
 .82 
 .85 
 
 15 
 15 
 
 52 
 43 
 
 33 
 42 
 
 1.17 
 1.21 
 
 34.64 
 35.73 
 
 Basal. Asleep in first 
 period. 
 
 36.98 
 
 87 
 
 7.6 
 
 .80 
 
 14 
 
 59 
 
 27 
 
 1.31 
 
 38.62 
 
 
 35.98 
 
 
 
 
 
 
 
 
 
 
 36.54 
 35.72 
 
 83 
 102 
 
 6.0 
 5.1 
 
 1.01 
 1.07 
 
 16 
 IS 
 
 
 84 
 85 
 
 1.32 
 1.38 
 
 38.95 
 40.77 
 
 At 10:13, 115 gm. com- 
 mercial glucose. 
 
 35.75 
 
 100 
 
 1.2 
 
 1.09 
 
 15 
 
 
 85 
 
 1.37 
 
 40.50 
 
 
 35.94) 
 
 
 
 
 
 
 
 
 
 
 35.93 
 
 84 
 
 5.7 
 
 .94 
 
 13 
 
 18 
 
 69 
 
 1.28 
 
 37.66 
 
 Basal. 
 
 35.95 
 
 87 
 
 2.5 
 
 .88 
 
 13 
 
 35 
 
 52 
 
 1.30 
 
 38.27 
 
 
 .W.OO 
 
 93 
 
 7.0 
 
 .85 
 
 12 
 
 46 
 
 42 
 
 1.36 
 
 40.10 
 
 
 37.52 
 
 
 
 
 
 
 
 
 
 
 37.29 
 37.64 
 
 105 
 
 121 
 
 0.3 
 7.3 
 
 .93 
 1.00 
 
 17 
 17 
 
 20 
 1 
 
 63 
 
 82 
 
 1.54 
 1.61 
 
 45.64 
 47.81 
 
 At 10:26, 115 gm. com- 
 mercial glucose. 
 
 37.71 
 
 121 
 
 2.0 
 
 .94 
 
 16 
 
 19 
 
 65 
 
 1.65 
 
 48.92 
 
 
 37.49 
 
 
 
 
 
 
 1 
 
 
 
 
 37.59 
 
 108 
 
 1.6 
 
 .76 
 
 20 
 
 67 
 
 13 
 
 1.65 
 
 45.13 
 
 Basal. 
 
 37.87 
 
 114 
 
 8.1 
 
 .79 
 
 19 
 
 67 
 
 24 
 
 1.63 
 
 47.36 
 
 
 37.91 
 
 117 
 
 2.2 
 
 .77 
 
 18 
 
 64 
 
 18 
 
 1.65 
 
 48.00 
 
 
 36.85 
 
 
 
 
 
 
 
 
 
 
 .37.44 
 37.67 
 37.71 
 
 109 
 120 
 120 
 
 9.2 
 6.5 
 1.2 
 
 .98 
 .97 
 .98 
 
 19 
 18 
 18 
 
 6 
 8 
 6 
 
 75 
 74 
 76 
 
 1.62 
 1.57 
 1.57 
 
 45.07 
 46.61 
 46.44 
 
 At 10:24, 115 gm. com- 
 mercial glucose. First 
 period 1 hr. 20 min. 
 because patientmoved 
 at end of hour. 
 
 36.64 
 
 
 
 
 
 
 
 
 
 
 .'56.62 
 
 99 
 
 1.2 
 
 .80 
 
 16 
 
 58 
 
 26 
 
 1.46 
 
 43.42 
 
 Basal. 
 
 .36.80 
 
 100 
 
 9.2 
 
 .79 
 
 16 
 
 59 
 
 25 
 
 1.50 
 
 44.35 
 
 
 37.07 
 
 105 
 
 4.0 
 
 .77 
 
 15 
 
 66 
 
 19 
 
 1.55 
 
 45.93 
 
 
 35.49 
 
 
 
 
 
 
 
 
 
 
 35.57 
 
 69 
 
 8.8 
 
 .84 
 
 18 
 
 44 
 
 38 ' 
 
 1.13 
 
 33.63 
 
 Basal. 
 
 35.57 
 
 76 
 
 1.6 
 
 .83 
 
 18 
 
 49 
 
 33 
 
 1.15 
 
 34.43 
 
 
 35.71 
 
 79 
 
 4.6 
 
 .78 
 
 17 
 
 57 
 
 26 
 
 1.23 
 
 36.74 
 
 
TABLE 5. — Clinical Calorimetry — 
 
 Subject 
 
 Date 
 Weight 
 
 Period 
 
 End ol 
 Period 
 
 Carbon- 
 
 dioxid, 
 
 Gm. 
 
 Oxygen 
 Gm. 
 
 B.Q. 
 
 Water, 
 Gm. 
 
 Urine N 
 
 per 
 Hour, 
 Gm. 
 
 Indirect 
 
 Calo- 
 rimetry, 
 Cal. 
 
 Heat 
 Elimi- 
 nated, 
 
 Cal. 
 
 Direct 
 Calo- 
 rimetry 
 (Bectal 
 Temp.) 
 Cal. 
 
 Bectal 
 
 Temp. 
 
 C. 
 
 Morris S 
 
 Jan. 27, 'U 
 57.50 kg. 
 
 Prelim. 
 1 
 
 11:45 
 12:45 
 
 19.39 
 
 17.28 
 
 .82 
 
 21.44 
 
 0.365 
 
 57.63 
 
 69.67 
 
 66.44 
 
 87.06 
 36.79 
 
 
 2 
 
 1:45 
 
 22.28 
 
 19.73 
 
 .82 
 
 21.96 
 
 0.365 
 
 65.98 
 
 71.20 
 
 73.22 
 
 36.90 
 
 
 S 
 
 2:45 
 
 22.21 
 
 19.73 
 
 .82 
 
 22.74 
 
 0.366 
 
 65.94 
 
 70.02 
 
 72.00 
 
 36.97 
 
 Morris S 
 
 Dec. 17, '14 
 61.21 kg. 
 
 Prelim. 
 
 1 
 
 11:27 
 12:27 
 
 21.46 
 
 19.30 
 
 .81 
 
 25.58 
 
 0.381 
 
 64.27 
 
 70.65 
 
 64.61 
 
 36.89 
 36.70 
 
 
 2 
 
 1:27 
 
 23.26 
 
 21.17 
 
 .80 
 
 27.85 
 
 0.381 
 
 70.42 
 
 72.99 
 
 70.69 
 
 36.79 
 
 
 3 
 
 2:27 
 
 23.02 
 
 20.62 
 
 .82 
 
 27.74 
 
 0.381 
 
 68.53 
 
 72.30 
 
 68.84 
 
 36.81 
 
 Morris S 
 
 Dec. 18, '14 
 62.81 kg. 
 
 Prelim. 
 
 1 
 
 11:00 
 12:00 
 
 27.66 
 
 22.40 
 
 .90 
 
 31.97 
 
 0.409 
 
 76.31 
 
 77.07 
 
 71.53 
 
 37.02 
 36.92 
 
 
 2 
 
 1:00 
 
 29.29 
 
 24.39 
 
 .87 
 
 34.09 
 
 1.101 
 
 81.43 
 
 84.04 
 
 82.67 
 
 36.94 
 
 
 3 
 
 2:00 
 
 23.14 
 
 19.14 
 
 .88 
 
 29.33 
 
 1.101 
 
 63.60 
 
 76.85 
 
 73.79 
 
 36.89 
 
 
 4 
 
 3:00 
 
 25.29 
 
 21.01 
 
 .88 
 
 31.79 
 
 1.101 
 
 69.82 
 
 78.61 
 
 74.47 
 
 36.85 
 
 Charles P 
 
 Nov. 10, 13 
 S7.73 kg. 
 
 Prelim. 
 1 
 
 11:10 
 12:10 
 
 26.83 
 
 24.23 
 
 .81 
 
 26.28 
 
 0.614 
 
 80.56 
 
 66.11 
 
 79.70 
 
 38.94 
 39.21 
 
 
 2 
 
 1:10 
 
 27.37 
 
 25.06 
 
 .79 
 
 28.78 
 
 0.514 
 
 83.17 
 
 71.87 
 
 73.83 
 
 39.26 
 
 
 3 
 
 2:10 
 
 27.91 
 
 25.99 
 
 .78 
 
 43.30 
 
 0.514 
 
 86.96 
 
 88.09 
 
 77.90 
 
 39.06 
 
 Charles F 
 
 Nov. 11, "13 
 58.22 kg. 
 
 Prelim. 
 1 
 
 11:20 
 12:20 
 
 28.97 
 
 24.68 
 
 .86 
 
 26.84 
 
 0.930 
 
 82.03 
 
 67.32 
 
 78.05 
 
 38.82 
 39.05 
 
 
 2 
 
 1:20 
 
 30.21 
 
 26.74 
 
 .82 
 
 31.12 
 
 0.930 
 
 88.58 
 
 77.70 
 
 86.96 
 
 39.26 
 
 
 S 
 
 2:20 
 
 31.40 
 
 27.66 
 
 .83 
 
 31.13 
 
 0.930 
 
 91.78 
 
 82.04 
 
 99.99 
 
 39.63 
 
 Charles P. ... 
 
 Nov. 14, '13 
 
 57.94 kg. 
 
 Prelim. 
 
 1 
 
 11:10 
 12.10 
 
 S2.69 
 
 26.60 
 
 .89 
 
 32.29 
 
 0.813 
 
 89.98 
 
 83.73 
 
 83.31 
 
 39.62 
 39.62 
 
 
 2 
 
 1:10 
 
 31.92 
 
 25.64 
 
 .91 
 
 32.26 
 
 0.813 
 
 87.23 
 
 81.28 
 
 68.87 
 
 39.37 
 
 
 3 
 
 2:10 
 
 32.24 
 
 26.33 
 
 .89 
 
 32.95 
 
 0.813 
 
 88.98 
 
 89.47 
 
 91.35 
 
 39.49 
 
 Charles F 
 
 Nov. 15, '13 
 57.03 kg. 
 
 Prelim. 
 
 1 
 
 11:16 
 12:16 
 
 28.26 
 
 26.44 
 
 .78 
 
 28.84 
 
 0.657 
 
 87.09 
 
 75.09 
 
 82.25 
 
 39.77 
 39.93 
 
 
 2 
 
 1:16 
 
 28.23 
 
 26.08 
 
 .79 
 
 32.35 
 
 0.667 
 
 86.12 
 
 86.12 
 
 74.34 
 
 39.88 
 
 Charles P 
 
 Nov. 29, '13 
 60.36 kg. 
 
 Prelim. 
 
 1 
 
 11:26 
 12:26 
 
 21.39 
 
 18.31 
 
 .85 
 
 29.25 
 
 0.483 
 
 61.69 
 
 61.79 
 
 59.74 
 
 36.71 
 36.67 
 
 
 2 
 
 1:26 
 
 22.06 
 
 20.15 
 
 .80 
 
 28.24 
 
 0.483 
 
 67.01 
 
 63.78 
 
 75.00 
 
 37.00 
 
 
 3 
 
 2:26 
 
 21.90 
 
 19.44 
 
 .82 
 
 27.10 
 
 0.483 
 
 66.08 
 
 63.75 
 
 72.92 
 
 37.26 
 
 Charles P 
 
 Dec. 8, '13 
 50.99 kg. 
 
 Prelim. 
 1 
 
 11:10 
 12:10 
 
 25.97 
 
 19.63 
 
 .96 
 
 21.83 
 
 0.817 
 
 66.98 
 
 62.72 
 
 52.64 
 
 36.90 
 36.67 
 
 
 2 
 
 1:10 
 
 26.73 
 
 21.61 
 
 .90 
 
 25.30 
 
 0.817 
 
 72.92 
 
 70.29 
 
 75.47 
 
 36.86 
 
 
 3 
 
 2:10 
 
 25.97 
 
 21.12 
 
 .90 
 
 29.04 
 
 0.817 
 
 71.13 
 
 74.23 
 
 76.85 
 
 36.95 
 
 Charles P 
 
 Dec. 9, '13 
 
 60.38 kg. 
 
 Prelim. 
 1 
 
 11:06 
 12:06 
 
 22.60 
 
 18.06 
 
 .91 
 
 19.36 
 
 0.380 
 
 61.66 
 
 58.80 
 
 55.10 
 
 36.78 
 36.70 
 
 
 2 
 
 1:06 
 
 22.10 
 
 17.29 
 
 .93 
 
 22.22 
 
 0.380 
 
 59.30 
 
 64.40 
 
 69.90 
 
 36.87 
 
 
 3 
 
 2:06 
 
 21.98 
 
 17.63 
 
 .91 
 
 22.36 
 
 0.380 
 
 60.16 
 
 61.83 
 
 61.66 
 
 36.88 
 
 Charles P 
 
 Dec. 10, '13 
 51.09 kg. 
 
 Prelim. 
 
 1 
 
 11:10 
 12:10 
 
 26.98 
 
 20.24 
 
 .97 
 
 22.40 
 
 0.362 
 
 70.28 
 
 62.46 
 
 58.29 
 
 36.89 
 36.80 
 
 
 2 
 
 1:10 
 
 27.70 
 
 19.45 
 
 1.04 
 
 24.37 
 
 0.362 
 
 68.24 
 
 68.32 
 
 64.48 
 
 36.76 
 
 
 3 
 
 2:10 
 
 25.68 
 
 18.90 
 
 .99 
 
 28.76 
 
 0.362 
 
 65.28 
 
 72.63 
 
 60.44 
 
 36.60 
 
—IN Typhoid Fever — {Continued) 
 
 Surface 
 
 Temp., 
 
 0. 
 
 Aver- 
 age 
 Pulse 
 
 Work 
 
 Adder., 
 
 Cm. 
 
 Non- 
 Protein, 
 B.Q. 
 
 Per Cent. 
 Calorics from 
 
 Calories 
 Per Hour 
 
 
 Pro- 
 tein 
 
 Pat 
 
 Carbo- 
 hyd. 
 
 Per 
 Kg. 
 
 Per 
 
 Sq. M. 
 
 
 35.61 
 
 
 
 
 
 
 
 
 
 
 35.11 
 
 60 
 
 0.5 
 
 .82 
 
 17 
 
 51 
 
 82 
 
 1.00 
 
 31.29 
 
 Basal. 
 
 35.15 
 
 71 
 
 5.6 
 
 .82 
 
 15 
 
 61 
 
 34 
 
 1.15 
 
 35.82 
 
 
 35.37 
 
 68 
 
 5.2 
 
 .82 
 
 15 
 
 62 
 
 33 
 
 1.15 
 
 35.80 
 
 
 
 62 
 
 4.0 
 
 .81 
 
 16 
 
 56 
 
 29 
 
 1.06 
 
 33.61 
 
 Basal. 
 
 
 65 
 
 6.0 
 
 .80 
 
 14 
 
 68 
 
 28 
 
 1.15 
 
 36.83 
 
 
 
 62 
 
 6.0 
 
 .82 
 
 15 
 
 62 
 
 33 
 
 1.12 
 
 36.03 
 
 
 
 74 
 
 5.0 
 6.0 
 
 .91 
 .92 
 
 14 
 36 
 
 21 
 
 17 
 
 66 
 
 47 
 
 1.22 
 1.30 
 
 39.23 
 41.87 
 
 At 8:40-9:40 a. m., pro- 
 tein meal; 9.6 gm. N. 
 
 
 70 
 
 6.0 
 
 .95 
 
 46 
 
 9 
 
 46 
 
 1.01 
 
 32.66 
 
 
 
 62 
 
 6.0 
 
 .93 
 
 42 
 
 14 
 
 44 
 
 1.11 
 
 35.90 
 
 
 
 76 
 
 8.5 
 
 .81 
 
 17 
 
 56 
 
 28 
 
 1.40 
 
 43.81 
 
 Basal. 
 
 
 76 
 
 2.0 
 
 .79 
 
 16 
 
 60 
 
 24 
 
 1.44 
 
 46.23 
 
 
 
 82 
 
 9.0 
 
 .78 
 
 16 
 
 64 
 
 20 
 
 1.49 
 
 46.74 
 
 
 37.69 
 
 
 
 
 
 
 
 
 
 
 38.24 
 38.25 
 
 77 
 86 
 
 3.6 
 13.0 
 
 .88 
 .83 
 
 30 
 
 28 
 
 28 
 42 
 
 42 
 30 
 
 1.41 
 1.52 
 
 44.34 
 
 47.88 
 
 9:10-10:10, protein meal; 
 Nitrogen 6.6 gm. 
 
 38.34 
 
 84 
 
 4.0 
 
 .83 
 
 27 
 
 41 
 
 32 
 
 1.57 
 
 49.61 
 
 
 38.79 
 
 
 
 
 
 
 
 
 
 
 38.90 
 
 38.68 
 
 87 
 
 96 
 
 15.0 
 8.3 
 
 .93 
 .94 
 
 24 
 25 
 
 19 
 16 
 
 67 
 60 
 
 1.56 
 1.62 
 
 48.80 
 47.31 
 
 At 10:21 a. m., 116 gm 
 commercial glucose. 
 
 38.79 
 
 96 
 
 25.0 
 
 .92 
 
 24 
 
 21 
 
 66 
 
 1.66 
 
 48.25 
 
 
 38.92 
 
 
 
 
 
 
 
 
 
 
 39.10 
 
 90 
 
 17.0 
 
 .77 
 
 20 
 
 63 
 
 17 
 
 1.63 
 
 47.75 
 
 Basal. 
 
 39.04 
 
 88 
 
 15.5 
 
 .78 
 
 20 
 
 69 
 
 21 
 
 1.61 
 
 47.22 
 
 
 
 80 
 
 13.2 
 
 .86 
 
 21 
 
 37 
 
 42 
 
 1.23 
 
 36.81 
 
 Basal. 
 
 
 86(?) 
 
 16.5 
 
 .79 
 
 20 
 
 56 
 
 24 
 
 1.33 
 
 39.98 
 
 
 
 84 
 
 18.8 
 
 .83 
 
 20 
 
 47 
 
 33 
 
 1.30 
 
 38.83 
 
 
 38.24 
 
 
 
 
 
 
 
 
 
 
 36.54 
 36.16 
 36.37 
 
 74 
 
 72 
 
 84(92) 
 
 36.6 
 20.3 
 15.0 
 
 1.05 
 .94 
 .94 
 
 32 
 30 
 30 
 
 13 
 
 15 
 
 68 
 67 
 55 
 
 1.31 
 1.43 
 1.40 
 
 39.64 
 43.06 
 41.99 
 
 9:03-9:46, protein meal; 
 10.5 gm. N. Work 
 adder too high on ac- 
 count of rapid changes 
 in barometer. 
 
 
 75 
 
 22.S 
 
 .93 
 
 16 
 
 19 
 
 65 
 
 1.23 
 
 36.72 
 
 Basal. 
 
 
 76 
 
 23.0 
 
 .96 
 
 17 
 
 12 
 
 n 
 
 1.18 
 
 36.32 
 
 
 
 84 
 
 9.7 
 
 .93 
 
 17 
 
 20 
 
 63 
 
 1.20 
 
 35.83 
 
 
 
 73 
 
 87 
 
 10.0 
 23.5+2? 
 
 1.00 
 1.08 
 
 14 
 14 
 
 
 86 
 86 
 
 1.38 
 1.34 
 
 41.46 
 40.26 
 
 At 10:22, 116 gm. com- 
 mercial glucose. 
 
 
 81 
 
 38.0+2? 
 
 1.02 
 
 15 
 
 
 85 
 
 1.29 
 
 38.81 
 
 
TABLE S. — Clinical Calorimetry- 
 
 Subject 
 
 Date 
 Weight 
 
 Period 
 
 End of 
 1 Period 
 
 Carbon- 
 
 dioxid, 
 
 6m. 
 
 Oxygen 
 Gm. 
 
 B. Q. 
 
 Water, 
 Gm. 
 
 Urine N 
 
 per 
 
 Hour, 
 
 Gm. 
 
 Indirect 
 
 Calo- 
 rimetry, 
 Oal. 
 
 Heat 
 rumi- 
 nated, 
 
 Cal. 
 
 1 i 
 ! Direct 1 
 
 Oalo- Bectal 
 rimetry 1 Temp. 
 (Bectal 0. 
 : Temp.) 
 Cal. 
 
 Charles ¥ 
 
 Dec. 26, '13 
 
 65.87 kg. 
 
 1 
 
 Prelim. 
 
 1 ^ 
 
 11:12 
 12:12 
 
 23.76 
 
 19.16 
 
 .90 
 
 26.72 
 
 0.275 
 
 i 
 
 65.56 
 
 76.4? 
 
 75.27 
 
 36.84 
 36.90 
 
 
 2 
 
 l:12 
 
 21.98 
 
 18.86 
 
 .85 
 
 26.23 
 
 0.275 
 
 63.65 
 
 69.83 
 
 67.08 
 
 36.86 
 
 
 3 
 
 2:12 
 
 22.11 
 
 20.10 
 
 ..80 
 
 25.14 
 
 0.275 
 
 67.03 
 
 70.63 
 
 69.23 
 
 36.85 
 
 Charles F 
 
 Dec. 31, '13 
 55.98 kg. 
 
 Prelim. 
 
 1 
 
 1:40 
 2:40 
 
 21.85 
 
 19.82 
 
 .80 
 
 22.56 
 
 0.403 
 
 65.85 
 
 66.09 
 
 59.70 
 
 37.08 
 36.95 
 
 
 2 
 
 3:40 
 
 22.81 
 
 21.14 
 
 .78 
 
 26.98 
 
 0.403 
 
 69.98 
 
 69.09 
 
 68.75 
 
 36.95 
 
 Howard F 
 
 Nov. 7, '13 
 35.47 kg. 
 
 Prelim. 
 
 1 
 
 11: 16 
 12:16 
 
 22.09 
 
 20.53 
 
 .78 
 
 22.79 
 
 
 68.25 
 
 67.28 
 
 56.71 
 
 39.74 
 39.73 
 
 
 2 
 
 1:16 
 
 21.02 
 
 19.76 
 
 .77 
 
 24.24 
 
 
 65.63 
 
 64.17 
 
 63.90 
 
 39.73 
 
 
 3 
 
 2 :16 
 
 20.86 
 
 
 
 24.06 
 
 
 65.03 ? 
 
 64.99 
 
 60.30 
 
 39.58 
 
 Howard F 
 
 Nov. 12, '13 
 34.98 kg. 
 
 Prelim. 
 
 1 
 
 11:24 
 12:24 
 
 22.06 
 
 19.37 
 
 .83 
 
 20.58 
 
 0.612 
 
 64.40 
 
 68.89 
 
 61.38 
 
 39.64 
 39.74 
 
 
 2 
 
 1:24 
 
 23.23 
 
 20.40 
 
 .83 
 
 23.38 
 
 0.612 
 
 67.88 
 
 63.72 
 
 65.61 
 
 39.89 
 
 
 3 
 
 2:24 
 
 22.55 
 
 21.27 
 
 .77 
 
 23.60 
 
 0.612 
 
 69.78 
 
 63.49 
 
 70.09 
 
 40.15 
 
 Howard P 
 
 Nov. 13, '13 
 34.19 kg. 
 
 Prelim. 
 
 1 
 
 11:00 
 12:00 
 
 19.45 
 
 17.76 
 
 .80 
 
 22.30 
 
 0.436 
 
 68.81 
 
 57.80 
 
 69.64 
 
 39.76 
 39.84 
 
 
 2 
 
 1:00 
 
 19.64 
 
 18.48 
 
 .77 
 
 22.62 
 
 0.436 
 
 60.86 
 
 58.19 
 
 57.19 
 
 39.82 
 
 
 3 
 
 ' 2:00 
 
 20.20 
 
 19.24 
 
 .76 I 
 
 23.66 
 
 0.436 
 
 63.22 
 
 63.74 
 
 62.17 
 
 38.78 
 
 Howard F 
 
 Nov. 20, '13 
 32.54 kg. 
 
 Prelim. 
 1 
 
 11:30 
 12:30 
 
 18.43 
 
 17.26 
 
 .78 
 
 27.43 
 
 0.354 
 
 56.98 
 
 55.72 
 
 55.87 
 
 39.31 
 39.33 
 
 
 2 
 
 1:30 
 
 18.27 
 
 17.42 
 
 .76 
 
 27.31 
 
 0.354 
 
 67.30 
 
 63.70 
 
 58.16 
 
 39.14 
 
 
 3 
 
 2:30 
 
 17.96 
 
 17.42 
 
 .75 
 
 25.62 
 
 0.354 
 
 57.10 
 
 59.76 
 
 53.97 
 
 38.94 
 
 Howard F 
 
 Dee. 1, '13 
 32.93 kg. 
 
 Prelim. 
 1 
 
 11:06 
 12:06 
 
 19.35 
 
 14.68 
 
 .97 
 
 18.80 
 
 
 
 0.292 
 
 50.60 
 
 45.34 
 
 42.26 
 
 37.03 
 36.93 
 
 
 2 
 3 
 
 1:06 
 
 2:06 I 
 
 39.56 
 
 29.26 
 
 .98 
 
 37.03 
 
 0.292 
 
 101.68 
 
 46.88 ■ 
 60.17 . 
 
 97.14 
 
 36.96 
 36.97 
 
 Howard F 
 
 Dec. 2, '13 
 33.06 kg. 
 
 Prelim. 
 1 
 
 11:12 
 12:12 
 
 15.46 
 
 12.42 
 
 .91 ' 
 
 17.57 
 
 0.234 
 
 42.40 
 
 44.03 
 
 42.30 
 
 36.84 
 36.79 
 
 
 2 
 
 1:12 
 
 18.09 
 
 13.48 
 
 .98 
 
 18.64 
 
 0.234 
 
 46.86 
 
 60.53 
 
 52.20 
 
 36.93 
 
 Howard F 
 
 Dec. B, '13 
 34.74 kg. 
 
 Prelim. 
 
 1 
 
 11:06 
 12:06 
 
 22.13 
 
 17.28 
 
 .93 
 
 21.01 
 
 0.614 
 
 58.86 
 
 56.03 
 
 51.80 
 
 37.07 
 36.97 
 
 
 2 
 
 1:06 
 
 24.24 
 
 17.61 
 
 1.00 
 
 21.99 
 
 0.614 
 
 60.75 
 
 61.84 
 
 64.82 
 
 37.17 
 
 
 3 
 
 2:06 
 
 24.72 
 
 19.43 
 
 .93 
 
 23.61 
 
 0.614 
 
 66.21 
 
 64.12 
 
 66.52 
 
 37.25 
 
 Howard F 
 
 Dec. 6, '13 
 33.78 kg. 
 
 Prelim. 
 
 1 
 
 10:56 
 11:56 
 
 18.20 
 
 13.44 
 
 .98 
 
 17.44 
 
 0.267 
 
 46.71 
 
 47.88 
 
 46.67 
 
 37.02 
 36.99 
 
 
 2 
 
 12:66 
 
 19.17 
 
 14.84 
 
 .94 
 
 18.30 
 
 0.267 
 
 51.14 
 
 51.87 
 
 51.43 
 
 37.06 
 
 ■Howard F ! 
 
 Dec. 18, '13 
 37.17 kg. 
 
 Prelim. 
 1 
 
 11:06 
 12:06 
 
 19.11 
 
 16.10 
 
 .86 
 
 18.73 
 
 0.314 
 
 64.38 
 
 63.61 
 
 52.94 
 
 37.11 
 37.10 
 
 
 2 
 
 1:06 
 
 21.42 
 
 18.19 
 
 .86 
 
 20.94 
 
 0.314 
 
 61.42 
 
 58.80 
 
 63.36 
 
 37.29 
 
 
 3 
 
 2:06 
 
 20.93 
 
 18.62 
 
 .81 ■ 
 
 23.84 
 
 0.314 
 
 62.26 
 
 65.14 
 
 63.04 
 
 37.25 
 
-IN Typhoid Fever — {Continued) 
 
 Surface 
 
 Temp., 
 
 0. 
 
 Aver- 
 age 
 Pulse 
 
 Work 
 
 Adder., 
 
 Om. 
 
 Non- 
 Protein, 
 E.Q. 
 
 Per Gent. 
 Calories from 
 
 Calories 
 Per Hour 
 
 Reniarks 
 
 Pro- 
 tein 
 
 Fat 
 
 Oarbo- 
 liyd. 
 
 Per 
 Kg. 
 
 Per 
 8q. M. 
 
 ^v^rfi^^x tm^ «LD 
 
 36.02 
 
 
 
 
 
 
 
 
 
 
 86.09 
 
 76 
 
 23.2 
 
 .92 
 
 11 
 
 26 
 
 63 
 
 1.18 
 
 36.44 
 
 Basal 
 
 36.38 
 
 
 18.3 
 
 .85 
 
 11 
 
 44 
 
 45 
 
 1.14 
 
 35.38 
 
 
 35.74 
 
 .. 
 
 10.2 
 
 .80 
 
 11 
 
 61 
 
 28 
 
 1.20 
 
 37.26 
 
 
 36.90 
 
 
 
 
 
 
 
 
 
 
 35.98 
 
 78 
 
 4.0 
 
 .80 
 
 16 
 
 57 
 
 27 
 
 1.18 
 
 36.38 
 
 Basal. 
 
 36.68 
 
 81 
 
 
 .78 
 
 15 
 
 64 
 
 21 
 
 1.25 
 
 38.66 
 
 
 
 100 
 103 
 
 10.0 
 6.0 
 
 
 
 
 
 1.91 
 1.83 
 
 51.35 
 49.31 
 
 Basal. Urine not ob- 
 tained; 02 lost in 
 third period. 
 
 
 106 
 
 2.0 
 
 
 
 
 
 1.8S(?) 
 
 48.93(?) 
 
 
 39.01 
 
 
 
 
 
 
 
 
 
 
 39.13 
 39.30 
 
 105 
 104 
 
 2.5 
 9.5 
 
 .84 
 
 .84 
 
 25 
 24 
 
 41 
 
 42 
 
 34 
 
 34 
 
 1.84 
 1.94 
 
 48.90 
 51.55 
 
 9:10-9:40, protein meal; 
 6.5 gm. N. Asleep 
 most ol first period. 
 
 39.76 
 
 105 
 
 5.9 
 
 .76 
 
 23 
 
 63 
 
 14 
 
 2.00 
 
 52.99 
 
 
 
 108 
 
 1.0 
 
 .79 
 
 20 
 
 66 
 
 24 
 
 1.72 
 
 45.34 
 
 Basal. 
 
 
 108 
 
 2.5 
 
 .77 
 
 19 
 
 65 
 
 16 
 
 1.78 
 
 46.92 
 
 
 
 104 
 
 7.7 
 
 .75 
 
 18 
 
 79 
 
 IS 
 
 1.85 
 
 48.74 
 
 
 39.14 
 
 
 
 
 
 
 
 
 
 
 38.89 
 
 103 
 
 9.6 
 
 .77 
 
 16 
 
 65 
 
 19 
 
 1.75 
 
 45.41 
 
 Basal. 
 
 38.68 
 
 102 
 
 9.6 
 
 .75 
 
 16 
 
 70 
 
 14 
 
 1.76 
 
 45.66 
 
 
 38.88 
 
 92 
 
 9.5 
 
 .74 
 
 16 
 
 75 
 
 9 
 
 1.75 
 
 45.60 
 
 
 37.19 
 
 
 
 
 
 
 
 
 
 
 37.16 
 36.63 
 37.21 
 
 98 
 97 
 97 
 
 2.6 
 5.1 
 6.0 
 
 1.00 
 1.02 
 
 15 
 15 
 
 1 
 
 84 
 85 
 
 1.63 
 1.55 
 
 39.92 
 40.19 
 
 At 10:19, 115 gm. com- 
 mercial glucose; second 
 and third periods aver- 
 aged. 
 
 36.92 
 
 
 
 
 
 
 
 
 
 
 36.83 
 36.60 
 
 75 
 76 
 
 2.5 
 15.6 
 
 .92 
 1.01 
 
 15 
 13 
 
 22 
 
 63 
 87 
 
 1.28 
 1.42 
 
 33.39 
 36.90 
 
 Basal. Asleep most ol 
 first hour. 
 
 
 91 
 
 90 
 
 7.0 
 20.5 
 
 .99 
 1.08 
 
 28 
 27 
 
 3 
 
 69 
 73 
 
 1.70 
 . 1.75 
 
 44.90 
 46.34 
 
 9.00-10:00, protein meal; 
 10.2 gm. N. Asleep 
 first period. 
 
 
 93 
 
 6.6(?) 
 
 .97 
 
 25 
 
 3 
 
 67 
 
 1.91 
 
 60.61 
 
 
 
 73 
 76 
 
 6.6 
 14.2 
 
 1.02 
 .96 
 
 15 
 14 
 
 11 
 
 85 
 75 
 
 1.38 
 1.51 
 
 36.31 
 39.76 
 
 Basal. Asleep one-hall 
 first period. 
 
 36.61 
 
 
 
 
 
 
 
 
 
 
 36.82 
 37.00 
 
 104 
 112 
 
 5.5 
 13.0 
 
 .87 
 .87 
 
 15 
 14 
 
 37 
 40 
 
 48 
 46 
 
 1.46 
 1.65 
 
 39.66 
 44.79 
 
 Basal. Asleep first 
 period. 
 
 36.76 
 
 105 
 
 17.3 
 
 .82 
 
 13 
 
 63 
 
 34 
 
 1.68 
 
 45.40 
 
 

 
 
 
 
 
 TABLE S. 
 
 — Clinical Caloeimetry — 
 
 Subject 
 
 Date 
 Weight 
 
 Period 
 
 End ol 
 Period 
 
 Oarbon 
 
 dioxid, 
 
 Gm. 
 
 Oxygen 
 Gm. 
 
 E.Q. 
 
 Water, 
 Gm. 
 
 Urine N 
 
 Hour, 
 Gm. 
 
 1 
 
 Indirec" 
 
 Calo- 
 
 rimetry 
 
 Oal. 
 
 Heat 
 Elimi- 
 nated, 
 1 Oal. 
 
 Direct 
 
 Oalo- 
 
 rimetry 
 
 : (Bectal 
 
 Temp.) 
 
 ' Oal. 
 
 Bectal 
 
 Temp. 
 
 0. 
 
 Howard F 
 
 Dec. 30, '13 
 39.40 kg. 
 
 Prelim. 
 1 
 
 1:30 
 2:30 
 
 19.66 
 
 17.18 
 
 .83 
 
 22.46 
 
 0.278 
 
 57.68 
 
 62.50 
 
 ! 65.92 
 
 37.29 
 37.10 
 
 
 2 
 
 3:30 
 
 20.74 
 
 18.62 
 
 .81 
 
 23.93 
 
 0.278 
 
 62.21 
 
 60.31 
 
 61.45 
 
 37.17 
 
 Karl S 
 
 Jan. 5, '14 
 54.64 kg. 
 
 Prelim. 
 1 
 
 11:50 
 12:60 
 
 30.78 
 
 29.50 
 
 .76 
 
 39.97 
 
 0.720 
 
 96.73 
 
 101.70 
 
 : 91.12 
 
 40.14 
 39.92 
 
 
 2 
 
 1:60 
 
 29.73 
 
 28.53 
 
 .76 
 
 42.23 
 
 0.720 
 
 93.48 
 
 104.45 
 
 93.93 
 
 39.70 
 
 Karl S 
 
 Jan. 6, '14 
 54.52 kg. 
 
 Prelim. 
 
 1 
 
 12:30 
 1:30 
 
 34.01 
 
 29.51 
 
 .84 
 
 26.77 
 
 0.879 
 
 98.46 
 
 87.72 
 
 112.04 
 
 39.63 
 40.08 
 
 
 2 
 
 2:30 
 
 35.13 
 
 31.49 
 
 .81 
 
 34.31 
 
 0.879 
 
 104.43 
 
 104.39 
 
 99.22 
 
 40.06 
 
 
 3 
 
 3:30 
 
 35.32 
 
 S1.56 
 
 .81 
 
 38.70 
 
 0.879 
 
 104.75 
 
 107.68 
 
 105.06 
 
 40.02 
 
 Karl S 
 
 Jan. 16, '14 
 52.21 kg. 
 
 Prelim. 
 
 1 
 
 10:50 
 11:50 
 
 26.55 
 
 25.94 
 
 .74 
 
 26.51 
 
 0.786 
 
 84.44 
 
 
 
 38.29 
 38.32 
 
 
 2 
 
 1:02 
 
 32.49 
 
 28.88 
 
 .82 
 
 38.71 
 
 0.943 
 
 95.01 
 
 
 
 38.22 
 
 
 3 
 
 1:60 
 
 21.52 
 
 19.72 
 
 .80 
 
 32.34 
 
 0.655 
 
 64.72 
 
 
 
 38.14 
 
 Karl S 
 
 Jan. 19, '14 
 .^1.19 kg. 
 
 Prelim. 
 1 
 
 10:50 
 11:50 
 
 20.70 
 
 16.34 
 
 .92 
 
 12.72 
 
 0.522 
 
 55.62 
 
 
 
 36.36 
 36.54 
 
 
 2 
 
 12:60 
 
 22.08 
 
 18.41 
 
 .87 
 
 28.28 
 
 0.522 
 
 62.03 
 
 
 
 38.55 
 
 
 3 
 
 1:50 
 
 22.63 
 
 19.41 
 
 .84 
 
 32.55 
 
 0.622 
 
 64.98 
 
 
 
 36.67 
 
 Karl S 
 
 Jan. 21, '14 
 51.29 kg. 
 
 Prelim. 
 
 1 
 
 12:30 
 1:30 
 
 24.09 
 
 19.71 
 
 .89 
 
 32.46 
 
 0.868 
 
 66.11 
 
 
 
 
 36.72 
 36.65 
 
 
 2 
 
 2:30 
 
 23.96 
 
 19.57 
 
 .89 
 
 26.79 
 
 0.858 
 
 65.65 
 
 
 
 36.39 
 
 
 3 
 
 3:30 
 
 26.95 
 
 21.45 
 
 .91 
 
 32.17 
 
 0.858 
 
 72.55 
 
 
 
 38.46 
 
 Karl S 
 
 Jan. 22, '14 
 50.63 kg. 
 
 Prelim. 
 1 
 
 12:40 
 1:40 
 
 18.66 
 
 15.37 
 
 .88 
 
 16.87 
 
 0.428 
 
 51.92 
 
 
 
 
 36.75 
 36.54 
 
 
 2 
 
 2:40 
 
 21.01 
 
 16.98 
 
 .90 
 
 20.51 
 
 0.428 
 
 67.70 
 
 
 
 36.40 
 
 
 3 
 
 3:40 
 
 20.54 
 
 17.06 
 
 .88 
 
 22.17 
 
 0.428 
 
 57.62 
 
 
 
 .S8.48 
 
 Karl S 
 
 Peb. 6, '14 
 53.30 kg. 
 
 Prelim. 
 1 
 
 11:05 
 12:05 
 
 23.15 
 
 20.28 
 
 .83 
 
 23.98 
 
 0.324 
 
 68.07 
 
 67.32 
 
 58.11 
 
 37.15 
 36.95 
 
 
 2 
 
 1:05 
 
 21.97 
 
 18.82 
 
 .85 
 
 22.85 
 
 0.324 
 
 63.43 
 
 67.46 
 
 68.97 
 
 36.72 
 
 
 3 
 
 2:05 
 
 25.49 
 
 24.36 
 
 .76 
 
 27.16 
 
 0.324 
 
 80.44 
 
 74.45 
 
 80.28 
 
 36.86 
 
 Karl S 
 
 Feb. 7, '14 
 54.4B kg. 
 
 Prelim. 
 
 1 
 
 10:46 
 11:46 
 
 27.92 
 
 22.71 
 
 .89 
 
 32.41 
 
 0.581 
 
 77.05 
 
 77.13 
 
 60.51 
 
 37.35 
 36.99 
 
 
 2 
 
 12:46 
 
 27.33 ■ 
 
 21.87 
 
 .91 
 
 29.12 
 
 0.581 
 
 74.43 
 
 79.33 
 
 74.46 
 
 36.89 
 
 
 3 
 
 1:46 
 
 26.23 
 
 21.16 
 
 .90 
 
 32.41 
 
 0.581 
 
 71.85 
 
 79.75 
 
 76.71 
 
 36.83 
 
 Thomas B 
 
 Oct. 15, '13 
 73.62 kg. 
 
 Prelim. 
 1 
 
 10:48 
 11:48 
 
 24.87 
 
 22.60 
 
 .80 
 
 23.50 
 
 0.505 
 
 75.00 
 
 48.97 
 
 70.72 
 
 36.79 
 37.13 
 
 
 2 
 
 12:48 
 
 27.05 
 
 22.82 
 
 .86 
 
 24.88 
 
 0.505 
 
 76.95 
 
 58.97 
 
 72.61 
 
 37.38 
 
 
 3 
 
 1:48 
 
 26.46 
 
 24.69 
 
 .78 
 
 26.46 
 
 0.505 
 
 81.57 
 
 63.67 
 
 74.67 
 
 37.58 
 
 
 4 
 
 2:48 
 
 28.39 
 
 24.58 
 
 .84 
 
 28.78 
 
 0.505 
 
 82.49 
 
 67.68 
 
 79.68 
 
 37.78 
 
 Thomas B 
 
 Oct. il. '13 
 72,56 kg. 
 
 Prelim. 
 
 1 
 
 10:24 
 11:24 
 
 22.98 
 
 20.14 
 
 .83 
 
 24.71 
 
 0.407 
 
 67.43 
 
 
 62.61 
 
 36.69 
 36.71 
 
 
 2 
 
 12:24 
 
 24.90 
 
 19.11 
 
 .95 
 
 29.65 
 
 0.407 
 
 65.88 
 
 66.03 
 
 63.75 
 
 36.71 
 
 
 3 
 
 1:24 
 
 26.13 
 
 20.21 
 
 .94 
 
 30.15 
 
 0.407 
 
 69.58 
 
 68.06 
 
 62.32 
 
 36.84 
 
-IN Typhoid Fever — (Continued) 
 
 Surface 
 
 Temp., 
 
 C. 
 
 Aver- 
 age 
 
 Pulse 
 
 Work 
 
 Adder., 
 
 Om. 
 
 Non- 
 Protein, 
 K.Q. 
 
 Per Cent. 
 Calories trom 
 
 Calories 
 Per Hour 
 
 
 Pro- 
 tein 
 
 Pat 
 
 Oarbo- 
 hyd. 
 
 Per 
 Kg. 
 
 Per 
 Sq.M. 
 
 
 36.57 
 
 
 
 
 
 
 
 
 
 
 36.14 
 86.60 
 
 109 
 
 107 
 
 6.5 
 8.5 
 
 .84 
 .81 
 
 13 
 12 
 
 48 
 57 
 
 39 
 31 
 
 1.47 
 1.58 
 
 40.49 
 43.67 
 
 Basal. Asleep greater 
 part ot both periods. 
 
 39.24 
 
 
 
 
 
 
 
 
 
 
 38.97 
 
 114 
 
 8.4 
 
 .75 
 
 20 
 
 69 
 
 11 
 
 1.77 
 
 54.93 
 
 Basal. 
 
 38.67 
 
 109 
 
 6.7 
 
 .75 
 
 20 
 
 69 
 
 11 
 
 1.71 
 
 63.08 
 
 
 88.60 
 
 
 
 
 
 
 
 
 
 
 39.61 
 89.39 
 
 107 
 99(?) 
 
 8.8 
 14.6 
 
 .85 
 .81 
 
 24 
 22 
 
 39 
 60 
 
 37 
 28 
 
 1.80 
 1.92 
 
 55.62 
 69.00 
 
 9:45-10:12, protein meal! 
 10.6 gm. N. 
 
 39.27 
 
 119 
 
 13.0 
 
 .82 
 
 22 
 
 49 
 
 29 
 
 1.92 
 
 59.18 
 
 
 
 92 
 96 
 96 
 
 12.2 
 
 21.0-1-3? 
 
 11.0 
 
 .72 
 .82 
 .77 
 
 26 
 26 
 26 
 
 70 
 44 
 67 
 
 5 
 30 
 17 
 
 1.62 
 1.53 
 1.65 
 
 49.09 
 46.03 
 45.15 
 
 Basal. Water tier, 
 broken. Second period 
 72 min. long on ac- 
 count movement. 
 
 
 76 
 
 10.6 
 
 .96 
 
 25 
 
 9 
 
 66 
 
 1.09 
 
 82.74 
 
 Basal. 
 
 
 76 
 
 14.8-1-4 
 
 .89 
 
 22 
 
 28 
 
 50 
 
 1.21 
 
 36.51 
 
 
 
 78 
 
 16.8 
 
 .86 
 
 21 
 
 39 
 
 40 
 
 1.27 
 
 88.26 
 
 
 
 73 
 69 
 
 9.8 
 5.7 
 
 .94 
 .94 
 
 34 
 35 
 
 14 
 13 
 
 52 
 52 
 
 1.29 
 1.28 
 
 38.89 
 38.62 
 
 9:35-11:36, protein meal; 
 10.0 gm. N. 
 
 
 74 
 
 17.0 
 
 .97 
 
 31 
 
 7 
 
 62 
 
 1.42 
 
 42.68 
 
 
 
 59 
 57 
 
 4.0 
 11.7 
 
 .91 
 .93 
 
 22 
 20 
 
 25 
 20 
 
 53 
 60 
 
 1.03 
 1.14 
 
 30.81 
 34.24 
 
 Basal. Asleep first 
 period. 
 
 
 68 
 
 9.2 
 
 .90 
 
 20 
 
 29 
 
 51 
 
 1.14 
 
 34.20 
 
 
 36.20 
 
 
 
 
 
 
 
 
 
 
 36.62 
 35.86 
 
 81 
 79 
 
 15.5 
 9.4 
 
 .84 
 .86 
 
 13 
 
 14 
 
 49 
 42 
 
 38 
 44 
 
 1.28 
 1.19 
 
 39.0.? 
 36.37 
 
 Basal. A si 6 e p about 
 SO min. in first period 
 and 50 min. in second. 
 
 35.97 
 
 82 
 
 26.2 
 
 .76 
 
 11 
 
 74 
 
 15 
 
 1.61 
 
 46.12 
 
 
 36.40 
 
 
 
 
 
 
 
 
 
 
 36.58 
 35.97 
 36.24 
 
 94 
 90 
 86 
 
 12.4 
 
 7.2 
 
 11.0 
 
 .92 
 .94 
 .93 
 
 20 
 21 
 21 
 
 22 
 16 
 19 
 
 58 
 63 
 60 
 
 1.41 
 1.37 
 1.32 
 
 43.66 
 42.07 
 40.62 
 
 7:30-7:40, 44.3 gm. pro- 
 tein; 9:35-9:37, 15.6 gm. 
 protein; total, 9.6 gm. 
 N. Asleep most ol the 
 tiipe. 
 
 
 81 
 
 8.0 
 
 .80 
 
 18 
 
 66 
 
 26 
 
 1.02 
 
 34.67 
 
 Basal. 
 
 
 85 
 
 14.0 
 
 .88 
 
 17 
 
 35 
 
 48 
 
 1.05 
 
 35.58 
 
 
 
 84 
 
 7.6 
 
 .77 
 
 16 
 
 65 
 
 19 
 
 1.11 
 
 37.71 
 
 
 
 91 
 
 21.0 
 
 .85 
 
 16 
 
 43 
 
 41 
 
 1.12 
 
 38.14 
 
 
 
 73(?) 
 
 12.0 
 
 .84 
 
 16 
 
 47 
 
 87 
 
 0.93 
 
 .S1.48 
 
 Basal. 
 
 
 78 
 
 19.0 
 
 .98 
 
 16 
 
 6 
 
 78 
 
 0.91 
 
 30.76 
 
 
 
 84 
 
 
 .97 
 
 16 
 
 9 
 
 75 
 
 0.96 
 
 32.48 
 
 
TABLE 5. — Clinical Calorimetry — 
 
 Subject 
 
 Date 
 Weight 
 
 Period 
 
 End of 
 Period 
 
 Oarbon- 
 
 dioxid, 
 
 Gm. 
 
 Oxygen, 
 Gm. 
 
 R.Q. 
 
 Water, 
 Gm. 
 
 Drine N 
 
 Hour, 
 Gm. 
 
 Indirect 
 
 Calo- 
 rimetry, 
 Oal. 
 
 Heat 
 Elimi- 
 nated, 
 Oal. 
 
 Direct 
 Calo- 
 rimetry 
 (Bectal 
 Temp.) 
 .Cal. 
 
 Bectal 
 
 Temp. 
 
 C. 
 
 Richard T 
 
 Oct. 18, '13 
 36.49 leg. 
 
 Prelim. 
 
 1 
 
 9:48 
 10:48 
 
 20.39 
 
 18.59 
 
 .80 
 
 30.29 
 
 0.403 
 
 61.65 
 
 43.77 
 
 67.62 
 
 38.18 
 38.60 
 
 
 2 
 
 11:48 
 
 21.05 
 
 18.24 
 
 .84 
 
 21.24 
 
 0.403 
 
 61.12 
 
 42.57 
 
 66.86 
 
 39.50 
 
 
 3 
 
 12:48 
 
 20.49 
 
 18.68 
 
 .80 
 
 26.61 
 
 0.403 
 
 61.95 ? 
 
 45.94 
 
 62.35 
 
 39.74 
 
 Richard T 
 
 Oct. 20, '13 
 3S.37 kg. 
 
 Prelim. 
 
 1 
 
 10:16 
 11: 16 
 
 18.98 
 
 15.18 
 
 .91 
 
 31.21 
 
 0.499 
 
 51.48 
 
 42.37 
 
 68.44 
 
 37.68 
 38.24 
 
 
 2 
 
 12:16 
 
 21.25 
 
 18.39 
 
 .84 
 
 31.41 
 
 0.499 
 
 61.49 
 
 47.46 
 
 68.51 
 
 38.63 
 
 
 3 
 
 1:18 
 
 19.90 
 
 17.96 
 
 .81 
 
 29.74 
 
 0.499 
 
 69.49 
 
 48.42 
 
 46.90 
 
 38.64 
 
 Anton K 
 
 Oct. 16, '13 
 60.56 kg. 
 
 Prelim. 
 
 1 
 
 11:16 
 12:16 
 
 22.48 
 
 18.64 
 
 .88 
 
 30.88 
 
 0.479 
 
 62.98 
 
 61.00 
 
 61.00 
 
 36.99 
 36.99 
 
 
 2 
 
 1:16 
 
 21.65 
 
 19.08 
 
 .83 
 
 33.40 
 
 0.479 
 
 63.64 
 
 66.46 
 
 72.34 
 
 37.14 
 
 
 3 
 
 2:16 
 
 23.57 
 
 19.73 
 
 .87 
 
 30.29 
 
 0.479 
 
 66.57 
 
 64.84 
 
 68.61 
 
 37.24 
 
 Rose G 
 
 Nov. 22, '13 
 30.11 kg. 
 
 Prelim. 
 
 1 
 
 11:04 
 12:04 
 
 17.77 
 
 16.73 
 
 .82 
 
 28.24 
 
 
 
 
 62.81 
 
 51.24 
 
 63.76 
 
 37.04 
 37.15 
 
 
 2 
 
 12:34 
 
 9.28 
 
 7.28 
 
 .93 
 
 17.44 
 
 
 24.98 
 
 28.36 
 
 24.99 
 
 37.02 
 
 Edw. B 
 
 Oct. 23, '14 
 65.76 kg. 
 
 Prelim. 
 
 1 
 
 12:07 
 1:07 
 
 25.02 
 
 22.61 
 
 .81 
 
 30.22 
 
 0.187 
 
 76.66 
 
 62.23 
 
 70.20 
 
 38.07 
 38.25 
 
 
 2 
 
 2:07 
 
 25.51 
 
 23.48 
 
 .79 
 
 28.78 
 
 0.187 
 
 78.30 
 
 64.70 
 
 81.43 
 
 38.62 
 
 
 3 
 
 3:07 
 
 27.24 
 
 26.69 
 
 .77 
 
 29.84 
 
 0.187 
 
 85.03 
 
 70.05 
 
 71.67 
 
 38.88 
 
 Edw. B 
 
 Oct. 26, '14 
 66.10 Jcg. 
 
 Prelim. 
 
 1 
 
 11:24 
 12:24 
 
 23.13 
 
 19.68 
 
 .86 
 
 31.21 
 
 0.264 
 
 66.36 
 
 61.58 
 
 66.23 
 
 37.54 
 37.66 
 
 
 2 
 
 1:24 
 
 24.87 
 
 23.79 
 
 .76 
 
 29.49 
 
 0.264 
 
 78.72 
 
 60.08 
 
 67.98 
 
 37.83 
 
 
 3 
 
 2:24 
 
 25.18 
 
 22.90 
 
 .80 
 
 30.36 
 
 0.264 
 
 76.47 
 
 66.46 
 
 73.34 
 
 38.01 
 
 
 4 
 
 3:24 
 
 26.12 
 
 23.21 
 
 .82 
 
 31.13 
 
 0.264 
 
 77.87 
 
 70.55 
 
 84.46 
 
 38.32 
 
 Edw. B 
 
 Oct. 27, '14 
 56.84 kg. 
 
 Prelim. 
 1 
 
 11:20 
 12:20 
 
 24.80 
 
 21.91 
 
 .82 
 
 30.89 
 
 0.662 
 
 73.08 
 
 60.09 
 
 69.69 
 
 37.40 
 87.46 
 
 
 2 
 
 1:20 
 
 23.76 
 
 22.13 
 
 .78 
 
 29.26 
 
 0.552 
 
 73.01 
 
 61.33 
 
 70.63 
 
 37.68 
 
 
 8 
 
 2:20 
 
 23.24 
 
 22.30 
 
 .76 
 
 28.83 
 
 0.552 
 
 73.13 
 
 63.78 
 
 73.06 
 
 37.91 
 
 Edw. B 
 
 Nov. 4, '14 
 68.72 kg. 
 
 Prelim. 
 1 
 
 11:15 
 12:15 
 
 24.00 
 
 19.79 
 
 .88 
 
 31.79 
 
 0.337 
 
 67.32 
 
 64.06 
 
 64.69 
 
 37.16 
 37.18 
 
 
 2 
 
 1:15 
 
 25.03 
 
 21.77 
 
 .84 
 
 31.06 
 
 0.337 
 
 73.17 
 
 65.16 
 
 69.21 
 
 37.27 
 
 
 3 
 
 2:15 
 
 24.89 
 
 21.98 
 
 .82 
 
 31.62 
 
 0.337 
 
 73.72 
 
 70.13 
 
 74.19 
 
 37.36 
 
 Edw. B 
 
 Nov. 6, '14 
 69.78 kg. 
 
 Prelim. 
 
 1 
 
 11:15 
 12:15 
 
 26.21 
 
 23.22 
 
 .82 
 
 27.40 
 
 0.336 
 
 77.76 
 
 62.39 
 
 81.16 
 
 38.84 
 39.28 
 
 
 2 
 
 1:15 
 
 26.65 
 
 23.45 
 
 .83 
 
 28.17 
 
 0.336 
 
 78.07 
 
 64.20 
 
 69.44 
 
 39.41 
 
 
 3 
 
 2:15 
 
 26.61 
 
 23.39 
 
 .82 
 
 30.30 
 
 0.336: 
 
 78.33 
 
 68.49 
 
 72.76 
 
 39.62 
 
 Edw. B 
 
 Nov. 10. '14 
 66.87 kg. 
 
 Prelim. 
 
 1 
 
 11:15 
 12:15 
 
 30.59 
 
 30.14 
 
 .74 
 
 35.32 
 
 0.626 
 
 98.74 
 
 88.66 
 
 86.50 
 
 40.32 
 40.33 
 
 
 2 
 
 1:15 
 
 29.62 
 
 27.49 
 
 .78 
 
 36.30 
 
 0.626 
 
 90.99 
 
 87.53 
 
 91.26 
 
 40.43 
 
 
 3 
 
 2:15 
 
 30.25 
 
 
 
 39.64 
 
 0.625 
 
 
 94.67 
 
 86.34 
 
 40.26 
 
 John K 
 
 Dec. 15, '14 
 63.81 kg. 
 
 Prelim 
 
 1 
 
 11:56 
 12:66 
 
 30.97 
 
 28.17 
 
 .80 
 
 34.02 
 
 1.258 
 
 92.29 
 
 85.30 
 
 94.23 
 
 39.00 
 39.26 
 
 
 2 
 
 1:56 
 
 30.59 
 
 30.08 
 
 .74 
 
 39.95 
 
 1.258 
 
 97.14 
 
 91.58 
 
 87.82 
 
 39.22 
 
-IN Typhoid Fever — {Continued) 
 
 Surface 
 
 Temp., 
 
 0. 
 
 35.75 
 36.05 
 36.10 
 
 Aver- ' Work 
 age ' Adder., 
 Pulse Cm. 
 
 Non- 
 Protein, 
 B. Q. 
 
 81 
 
 102 
 95 
 
 76 
 81 
 
 80 
 
 79 
 
 118 
 115 
 116 
 
 105 
 117 
 126 
 123 
 
 106 
 109 
 107 
 
 102 
 104 
 105 
 
 124 
 124 
 
 141 
 142 
 140 
 
 31.4 
 16.2 
 18.5 
 
 22.0 
 30.0 
 17.0 
 
 21.0 
 19.0 
 13.0 
 
 16.0 
 9.0 
 
 12.0 
 17.0 
 24.0 
 
 11.0 
 10.0 
 10.0 
 19.0 
 
 14.0 
 22.0 
 14.0 
 
 10.6 
 
 14.0 
 25.0 
 
 31.0 
 
 5.0 
 
 12.0 
 
 24.0 
 30.5 
 16.0+ + 
 
 16.0 
 14.0 
 
 .80 
 .85 
 .80 
 
 .95 
 .85 
 .81 
 
 .81 
 .79 
 .77 
 
 .87 
 .76 
 .80 
 .82 
 
 .83 
 .78 
 .75 
 
 .90 
 
 .84 
 
 .73 
 .78 
 
 .70 
 
 Per Cent. 
 Calories from 
 
 Pro- 
 tein 
 
 Pat 
 
 Carbo- 
 hyd. 
 
 17 57 
 
 17 43 
 
 17 i 57 
 
 26 
 22 
 22 
 
 20 
 20 
 19 
 
 19 
 19 
 19 
 
 13 
 
 12 
 12 
 
 11 
 11 
 11 
 
 14 
 15 
 
 36 
 34 
 
 13 
 40 
 50 
 
 28 
 46 
 32 
 
 49 
 67 
 73 
 
 47 
 61 
 
 54 
 51 
 64 
 
 79 
 64 
 
 43 
 66 
 
 40 
 26 
 
 61 
 
 34 
 
 49 
 
 44 
 27 
 21 
 
 50 
 17 
 29 
 35 
 
 3i 
 20 
 12 
 
 57 
 40 
 37 
 
 35 
 38 
 36 
 
 7 
 21 
 
 21 
 
 
 Calories 
 Per Hour 
 
 Per 
 Kg. 
 
 1.69 
 1.68 
 1.70 
 
 1.25 
 1.26 
 1.32 
 
 1.75 
 1.66 
 
 1.36 
 1.40 
 1.53 
 
 1.18 
 1.40 
 1.36 
 1.39 
 
 1.29 
 1.29 
 1.29 
 
 1.15 
 1.25 
 1.26 
 
 1.30 
 1.31 
 1.31 
 
 1.74 
 1.60 
 
 1.45 
 
 1.52 
 
 Per 
 Sg. M. 
 
 Bern arks 
 
 45.60 
 45.11 
 45.72 
 
 1.45 38.79 
 
 1.74 46.34 
 
 1.68 44.83 
 
 37.42 
 37.81 
 39.55 
 
 44.32 
 41.93 
 
 42.10 
 43.57 
 47.32 
 
 36.78 
 43.64 
 42.39 
 43.17 
 
 40.16 
 40.12 
 
 40.18 
 
 36.19 
 39.34 
 39.64 
 
 41.32 
 41.48 
 41.62 
 
 54.31 
 50.05 
 
 46.94 
 49.41 
 
 Basal. Somewbat rest- 
 
 Basal. 
 
 Basal. 
 
 Basal. Bestless. Second 
 period ^ br. long be- 
 cause patient voided 
 in bed. 
 
 Basal. 
 
 10:25 a. m., 79 gm. olive 
 oil = 760 calories. 
 
 Basal. 
 
 Basal. Bising temp. 
 
 Basal. Very high temp. 
 Mildly delirious. 
 
 Basal. 
 
TABLE 6.— Clinical Data 
 Charles F. 
 
 Date, 
 
 Pooa 
 
 Pood N., 
 Gm. 
 
 Urine N., 
 Gm. 
 
 Excreta 
 N., Gm. 
 
 Nitrogen 
 Bal., Gm. 
 
 Body 
 Wt., Kg. 
 
 Urine 
 
 1918 
 
 Total 
 Calories 
 
 Carbohy- 
 drate, Gm. 
 
 Fat, 
 Gm. 
 
 Vol., O.C. 
 
 Nov. 6.... 
 
 1,465 
 
 88.0 
 
 96.0 
 
 8.3 
 
 14.68 
 
 16.61t 
 
 —7.21 
 
 58.66 
 
 1,270 
 
 Nov. 7.... 
 
 
 
 
 
 16.62 
 
 
 
 
 1,600 
 
 Nov. 8.... 
 
 1,866 
 
 116.0 
 
 123.0 
 
 9.1 
 
 21.10 
 
 22.01 
 
 —12.91 
 
 
 2,300 
 
 Nov. 9.... 
 
 2,066 
 
 130.0 
 
 136.0 
 
 10.8 
 
 20.45 
 
 21.63 
 
 —10.73 
 
 
 1,870 
 
 Nov. 10.... 
 
 1,088 
 
 80.0 
 
 69.0 
 
 4.4 
 
 16.22 
 
 16.66 
 
 -12.26 
 
 67.76 
 
 1,205 
 
 Nov. 11.... 
 
 2,027 
 
 214.0 
 
 87.0 
 
 13.2 
 
 22.28 
 
 23.60 
 
 —10.40 
 
 58.25 
 
 1,740 
 
 Nov. 12.... 
 
 2,610 
 
 261.0 
 
 144.0 
 
 9.8 
 
 18.92 
 
 19.90 
 
 —10.10 
 
 
 2,110 
 
 Nov. 18.... 
 
 2,265 
 
 218.0 
 
 118.0 
 
 10.2 
 
 17.37 
 
 18.39 
 
 —8.19 
 
 57.88 
 
 1,900 
 
 Nov. 14.... 
 
 1,399 
 
 208.0 
 
 60.0 
 
 3.8 
 
 16.03 
 
 16.41 
 
 —12.61 
 
 67.60 
 
 1,236 
 
 Nov. 15.... 
 
 1,286 
 
 148.0 
 
 60.0 
 
 4.6 
 
 18.64 
 
 19.00 
 
 —14.40 
 
 66.86 
 
 1,270 
 
 Nov. 16. . . . 
 
 1,440 
 
 161.0 
 
 72.0 
 
 6.7 
 
 18.89 
 
 19.46 
 
 —13.76 
 
 
 1,960 
 
 Nov. 17.... 
 
 1,492 
 
 128.0 
 
 83.0 
 
 7.6 
 
 17.82 
 
 18.58 
 
 —10.98 
 
 
 2,110 
 
 Nov. 18.... 
 
 1,749 
 
 133.0 
 
 107.0 
 
 8.1 
 
 20.34 
 
 21.15 
 
 —13.05 
 
 56.01 
 
 1,470 
 
 Nov. 19.... 
 
 1,019 
 
 63.0 
 
 68.0 
 
 5.2 
 
 22.13 
 
 22.65 
 
 —17.45 
 
 
 1,360 
 
 Nov. 20.... 
 
 1,328 
 
 93.0 
 
 76.0 
 
 8.7 
 
 22.41 
 
 23.28 
 
 —14.58 
 
 
 1,380 
 
 Nov. 21. . . . 
 
 1,426 
 
 74.0 
 
 98.0 
 
 8.1 
 
 22.81 
 
 23.62 
 
 —16.52 
 
 
 
 1,380 
 
 Nov. 22.... 
 
 1,970 
 
 122.0 
 
 128.0 
 
 10.9 
 
 20.50 
 
 21.69 
 
 —10.69 
 
 
 1,900 
 
 Nov. 23.... 
 
 1,787 
 
 112.0 
 
 115.0 
 
 10.6 
 
 18.16 
 
 19.22 
 
 —8.62 
 
 
 1,680 
 
 Nov. 24.... 
 
 1,696 
 
 117.0 
 
 101.0 
 
 10.4 
 
 18.16 
 
 19.20 
 
 —8.80 
 
 52.02 
 
 1,580 
 
 Nov. 25.... 
 
 2,443 
 
 159.0 
 
 155.0 
 
 13.8 
 
 18.95 
 
 20.33 
 
 —6.53 
 
 
 1,910 
 
 Nov. 26.... 
 
 2,695 
 
 174.0 
 
 160.0 
 
 15.4 
 
 18.92 
 
 20.46 
 
 —6.06 
 
 51.48 
 
 20.50 
 
 Nov. 27.... 
 
 2,345 
 
 173.0 
 
 142.0 
 
 12.3 
 
 18.41 
 
 19.64 
 
 —7.34 
 
 
 1,920 
 
 Nov. 28. . . . 
 
 2,646 
 
 223.0 
 
 160.0 
 
 13.1 
 
 16.65 
 
 17.96 
 
 —4.86 
 
 60.98 
 
 2,120 
 
 Nov. 29.... 
 
 * 1,903 
 
 129.0 
 
 126.0 
 
 7.8 
 
 13.91 
 
 14.69 
 
 —6.89 
 
 50.29 
 
 1,150 
 
 Nov. 30.... 
 
 2,825 
 
 236.0 
 
 158.0 
 
 16.2 
 
 15.68 
 
 17.10 
 
 —1.90 
 
 
 1,700 
 
 Dee. 1.... 
 
 3,491 
 
 314.0 
 
 195.0 
 
 14.9 
 
 14.12 
 
 15.61 
 
 —0.71' 
 
 60.50 
 
 1,760 
 
 Dec. 2.... 
 
 8,126 
 
 310.0 
 
 160.0 
 
 14.3 
 
 12.83 
 
 13.76 
 
 +0.64 
 
 
 
 1,480+ 
 
 Dec. 3.... 
 
 2,695 
 
 279.0 
 
 118.0 
 
 ]3.7 
 
 11.99 
 
 13.36 
 
 +0.34 
 
 60.79 
 
 1,600 
 
 Dec. 4.... 
 
 3,408 
 
 382.0 
 
 150.0 
 
 17.4 
 
 12.69 
 
 14.43 
 
 +2.96 
 
 
 1,480 
 
 Dec. 6 — 
 
 2,683 
 
 362.0 
 
 87.0 
 
 15.0 
 
 12.05 
 
 13.55 
 
 +1.45 
 
 
 1,580 
 
 Dec. 6. . . . 
 
 2,827 
 
 390.0 
 
 88.0 
 
 15.9 
 
 12.67 
 
 14.26 
 
 +1.64 
 
 49.83 
 
 1.401 
 
 Dec. 7.... 
 
 8,223 
 
 446.0 
 
 106.0 
 
 16.0 
 
 12.72 
 
 14.32 
 
 +1.68 
 
 49.83 
 
 1,740 
 
 Dec. 8.... 
 
 2,182 
 
 346.0 
 
 94.0 
 
 20.0 
 
 16.27 
 
 18.27 
 
 +1.73 
 
 61.02 
 
 1,220 
 
 Dec. 9.... 
 
 2,426 
 
 308.0 
 
 91.0 
 
 12.5 
 
 12.04 
 
 13.29 
 
 —0.79 
 
 50.41 
 
 695 
 
 Dec. 10.... 
 
 2.906 
 
 432.0 
 
 88.0 
 
 12.3 
 
 10.01 
 
 11.24 
 
 +1.06 
 
 ' 50.80 
 
 1,100 
 
 Dec. 11.... 
 
 3,485 
 
 603.0 
 
 107.0 
 
 16.7 
 
 9.47 
 
 11.14 
 
 +6.56 
 
 
 1,640 
 
 Dec. 12.... 
 
 3,768 
 
 656.0 
 
 116.0 
 
 16.3 
 
 9.92 
 
 11.55 
 
 +4.75 
 
 
 1,600 
 
 Dec. IS.... 
 
 4,025 
 
 619.0 
 
 129.0 
 
 18.2- 
 
 10.48 
 
 12.30 
 
 +6.90 
 
 68.16 
 
 1,880 
 
 Dec. 14.... 
 
 3,660 
 
 649.0 
 
 105.0 
 
 16.8 
 
 10.69 
 
 12.27 
 
 +4.53 
 
 
 1,470 
 
 * Estimate heat production 1,726. 
 
TABLE 6. — Clinical Data — (Continued) 
 Charles F. — (Continued) 
 
 Date, 
 
 
 Pood 
 
 
 Pood N., 
 Gm. 
 
 Urine N., 
 6m. 
 
 
 191S 
 
 Total 
 Calories 
 
 Carbohy- 
 drate, Gm. 
 
 Pat, 
 Gm. 
 
 N., Gm, 
 
 Dec. 15.... 
 
 4.032 
 
 585.0 
 
 124.0 
 
 18.8 
 
 9.93 
 
 11.81 
 
 Deo. 16.... 
 
 3.921 
 
 573.0 
 
 118.0 
 
 18.6 
 
 11.67 
 
 13.53 
 
 Dec. 17.... 
 
 3,539 
 
 510.0 
 
 109.0 
 
 16.9 
 
 11.15 
 
 12.84 
 
 Dee. 18.... 
 
 3,869 
 
 572.0 
 
 113.0 
 
 18.2 
 
 11.64 
 
 13.36 
 
 Dec. 19.... 
 
 4,085 
 
 630.0 
 
 112.0 
 
 17.9 
 
 10.39 
 
 12.18 
 
 Dec. 20.... 
 
 3,901 
 
 699.0 
 
 105.0 
 
 18.5 
 
 11.04 
 
 12.89 
 
 Dec. 21.... 
 
 4.017 
 
 620.0 
 
 105.0 
 
 19.3 
 
 11.43 
 
 1-3.36 
 
 Dec. 22.... 
 
 3,361 
 
 282.0 
 
 189.0 
 
 17.1 
 
 12.33 
 
 14.04 
 
 Dec. 23.... 
 
 3,722 
 
 241.0 
 
 249.0 
 
 16.4 
 
 11.46 
 
 13.10 
 
 Dec. 24.... 
 
 3,739 
 
 228.0 
 
 254.0 
 
 17.5 
 
 13.14 
 
 14.89 
 
 Dec. 25.... 
 
 
 
 
 
 9.28 
 
 
 Dec. 26.... 
 
 2,122 
 
 163.0 
 
 137.0 
 
 12.4 
 
 9.40 
 
 10.64 
 
 Dec. 27.... 
 
 3,636 
 
 254.0 
 
 224.0 
 
 20.0 
 
 12.16 
 
 14.16 
 
 Dec. 28.... 
 
 3,614 
 
 247.0 
 
 226.0 
 
 19.4 
 
 12.86 
 
 14.80 
 
 Dec. 29.... 
 
 3,818 
 
 221.0 
 
 269.0 
 
 19.0 
 
 12.78 
 
 14.66 
 
 Dec. 30.... 
 
 4,899 
 
 256.0 
 
 347.0 
 
 24.2 
 
 11.49 
 
 13.91 
 
 Dec. SI.... 
 
 2,131 
 
 202.0 
 
 103.0 
 
 13.3 
 
 11.63 
 
 12.86 
 
 Jan. 1 — 
 
 3,949 
 
 S47.0 
 
 161.0 
 
 18.6 
 
 11.54 
 
 13.40 
 
 Jan. 2.... 
 
 3,587 
 
 287.0 
 
 202.0 
 
 22.0 
 
 8.10 
 
 10.30 
 
 Nitrogen 
 Bal., Gm. 
 
 Body 
 Wt., Kg. 
 
 Urine 
 Vol., O.c. 
 
 +6.99 
 
 62.81 
 
 1,330+ 
 
 +6.07 
 
 54.06 
 
 1,280 
 
 +4.06 
 
 
 1,470 
 
 +4.84 
 
 
 1,800 
 
 +6.72 
 
 
 1,600 
 
 +6.61 
 
 
 1,760 
 
 +5.94 
 
 
 1,860 
 
 +3.06 
 
 66.43 
 
 1,700 
 
 +3.30 
 
 
 1,180 
 
 +2.61 
 
 
 1,440 
 1.300 
 
 +1.76 
 
 65.91 
 
 1,940 
 
 +5.84 
 
 
 
 1,600 
 
 +4.60 
 
 
 1,640 
 
 +4.34 
 
 
 1,820 
 
 +10.29 
 
 
 1,480 
 
 +0.44 
 
 56.43 
 
 1,571 
 
 +5.20 
 
 
 1,000 
 
 +11.70 
 
 
 860 
 
 t Excreta nitrogen estimated as urine nitrogen + 10 per cent, of food nitrogen. 
 
TABLE 6. — Clinical Data — (Continued) 
 Morris S. 
 
 
 Esti- 
 mated 
 
 Heat 
 Produc- 
 tion per 
 24Hra. 
 
 Pood 
 
 
 
 
 
 
 
 
 
 Date, 
 1913 
 
 Total 
 Calories 
 
 Carbo- 
 hydrate, 
 Gm. 
 
 Pat, 
 Gm. 
 
 Pood 
 
 N., 
 Gm. 
 
 Urine 
 
 N., 
 Gm. 
 
 Feces 
 N., 
 Gm. 
 
 Excreta 
 N., 
 Gm. 
 
 Bal., 
 Gm. 
 
 WeigM 
 Kg. 
 
 Volume, 
 C.c. 
 
 Pat 
 
 Oct. 23 
 
 
 2,962 
 
 419.0 
 
 76.0 
 
 20.8 
 
 16.13 
 
 3.1* 
 
 18.2 
 
 H-2.6 
 
 49.69 
 
 1,280 
 
 
 Oct. 24 
 
 2,376 
 
 1,2S9 
 
 169.0 
 
 28.0 
 
 11.8 
 
 19.56 
 
 1.7* 
 
 21.3 
 
 —9.5 
 
 61.60 
 
 2,860 
 
 
 Oct. 25 
 
 2,299 
 
 2,371 
 
 364.0 
 
 36.0 
 
 21.3 
 
 13.59 
 
 8.2* 
 
 16.8 
 
 -1-4.5 
 
 51.22 
 
 1,710 
 
 
 Oct. 26 
 
 
 4,375 
 
 471.0 
 
 101.0 
 
 19.6 
 
 20.34 
 
 2.9 
 
 23.2 
 
 -3.7 
 
 
 3,000 
 
 
 Oct. 27 
 
 
 3,194 
 
 321.0 
 
 152.0 
 
 18.2 
 
 21.60 
 
 2.7 
 
 24.3 
 
 —6.1 
 
 51.26 
 
 2,170 
 
 
 Oct. 28 
 
 2,200 
 
 2,332 
 
 242.0 
 
 116.0 
 
 10.0 
 
 17.43 
 
 1.5 
 
 18.9 
 
 —8.9 
 
 61.18 
 
 1,390 
 
 
 Oct. 29 
 
 2,228 
 
 2,876 
 
 258.0 
 
 150.0 
 
 16.4 
 
 20.38 
 
 2.5 
 
 22.9 
 
 —6.5 
 
 60.17 
 
 1,465 
 
 
 Oct. 30 
 
 
 8,031 
 
 318.0 
 
 141.0 
 
 16.5 
 
 18.72 
 
 2.31 
 
 21.03 
 
 —5.5 
 
 49.85 
 
 1,680 
 
 9.74 
 
 Oct. 31 
 
 2,225 
 
 2,784 
 
 224.0 
 
 149.0 
 
 18.0 
 
 22.28 
 
 2.31 
 
 24.59 
 
 —6.6 
 
 60.32 
 
 1,830 
 
 9.74 
 
 Nov. 1 
 
 
 3,089 
 
 827.0 
 
 147.0 
 
 14.8 
 
 17.48 
 
 2.31 
 
 19.79 
 
 —6.0 
 
 49.82 
 
 1,600 
 
 9.74 
 
 Nov. 2 
 
 
 3,039 
 
 324.0 
 
 142.0 
 
 16.2 
 
 16.76 
 
 2.31 
 
 19.07 
 
 —3.9 
 
 
 1,600 
 
 9.74 
 
 Nov. 3 
 
 2,206 
 
 3,039 
 
 324.0 
 
 142.0 
 
 15.2 
 
 17.39 
 
 2.31 
 
 19.70 
 
 —4.6 
 
 48.83 
 
 1,870 
 
 9,74 
 
 Nov. 4 
 
 
 8,039 
 
 324.0 
 
 142.0 
 
 15.2 
 
 16.86 
 
 2.31 
 
 18.17 
 
 -3.0 
 
 49.63 
 
 1,220 
 
 9.74 
 
 Nov. 5 
 
 2,104 
 
 3,024 
 
 324.0 
 
 139.0 
 
 16.4 
 
 16.57 
 
 2.31 
 
 17.88 
 
 —2.5 
 
 48.48 
 
 1,160 
 
 9.74 
 
 Nov. 6 
 
 
 3,039 
 
 325.0 
 
 147.0 
 
 15.4 
 
 13.51 
 
 2.3 
 
 16.8 
 
 -0.4 
 
 49.03 
 
 1,310 
 
 
 Nov. 7 
 
 
 3,034 
 
 327.0 
 
 140.0 
 
 15.0 
 
 12.39 
 
 2.3 
 
 14.7 
 
 -1-0.3 
 
 
 1,220 
 
 
 Nov. 8 
 
 
 3,018 
 
 319.0 
 
 142.0 
 
 16.0 
 
 11.24 
 
 2.3 
 
 18.6 
 
 -H.5 
 
 48.73 
 
 1,810 
 
 
 Nov. » 
 
 
 3,048 
 
 321.0 
 
 144.0 
 
 15.4 
 
 11.71 
 
 2.3 
 
 14.0 
 
 -1-1.4 
 
 
 1,240 
 
 
 Nov. 10 
 
 
 2,969 
 
 305.0 
 
 144.0 
 
 14.9 
 
 12.05 
 
 2.2 
 
 14.3 
 
 -^o.6 
 
 
 2,000 
 
 
 Nov. U 
 
 
 3,004 
 
 324.0 
 
 140.0 
 
 14.8 
 
 10.23 
 
 2.2 
 
 12.4 
 
 -f2.4 
 
 48.05 
 
 1,220 
 
 
 Nov. 12 
 
 
 2,998 
 
 314.0 
 
 142.0 
 
 16.2 
 
 12.78 
 
 2.3 
 
 16.1 
 
 -fO.1 
 
 
 1,880 
 
 
 Nov. 18 
 
 
 2,998 
 
 314.0 
 
 142.0 
 
 16.2 
 
 11.43 
 
 2.3 
 
 13.7 
 
 -1-1.6 
 
 
 1,480 
 
 
 Nov. 14 
 
 
 S,181_ 
 
 331.0 
 
 142.0 
 
 15.4 
 
 10.64 
 
 2.3 
 
 12.8 
 
 -1-2.6 
 
 
 1,390 
 
 
 Nov. 15 
 
 
 2,994 
 
 313.0 
 
 142.0 
 
 16.2 
 
 10.42 
 
 2.3 
 
 12.7 
 
 H-2.5 
 
 
 2,000 
 
 
 Nov. 16 
 
 
 8,134 
 
 841.0 
 
 144.0 
 
 16.3 
 
 11.44 
 
 2.8 
 
 13.7 
 
 -H.6 
 
 
 1,820 
 
 
 Nov. 17 
 
 1,875 
 
 S,«6 
 
 333.0 
 
 142.0 
 
 15.2 
 
 18.82 
 
 2.3 
 
 15.6 
 
 -0.4 
 
 48.80 
 
 1,690 
 
 
 Nov. 18 
 
 2,022 
 
 1,987 
 
 217.0 
 
 95.0 
 
 8.0 
 
 16.19 
 
 1.2 
 
 16.4 
 
 —8.4 
 
 49.06 
 
 1,440 
 
 
 Nov. 19 
 
 
 1,355 
 
 148.0 
 
 61.0 
 
 7.7 
 
 16.47 
 
 1.2 
 
 16.7 
 
 —9.0 
 
 
 2,280 
 
 « 
 
 Nov. 20 
 
 
 1,727 
 
 199.0 
 
 79.0 
 
 7.0 
 
 16.18 
 
 1.1 
 
 16.2 
 
 —9.2 
 
 
 1,300 
 
 
 Nov. 21 
 
 
 1,805 
 
 171.0 
 
 95.0 
 
 8.4 
 
 14.74 
 
 1.3 
 
 16.0 
 
 —7.6 
 
 
 900 
 
 
 Nov. 22 
 
 
 2,292 
 
 153.0 
 
 152.0 
 
 10.1 
 
 14.86 
 
 1.6 
 
 16.4 
 
 —6.8 
 
 
 800 
 
 
 Nov. 23 
 
 
 2,392 
 
 192.0 
 
 132.0 
 
 10.7 
 
 15.69 
 
 1.6 
 
 17.3 
 
 -6.6 
 
 
 840 
 
 
 Nov. 24 
 
 2,282 
 
 2,016 
 
 173.0 
 
 117.0 
 
 8.5 
 
 13.08 
 
 1.3 
 
 14.4 
 
 —6.9 
 
 46.98 
 
 890 
 
 
 Nov. 25 
 
 2,301 
 
 2,298 
 
 187.0 
 
 123.0 
 
 15.1 
 
 18.66 
 
 2.3 
 
 16.0 
 
 -0.9 
 
 47.47 
 
 925 
 
 
 Nov. 26 
 
 2,217 
 
 2,087 
 
 172.0 
 
 126.0 
 
 8.0 
 
 10.32 
 
 1.2 
 
 11.6 
 
 —3.5 
 
 45.84 
 
 780 
 
 
 Nov. 27 
 
 
 2,747 
 
 242.0 
 
 148.0 
 
 14.8 
 
 18.58 
 
 2.2 
 
 20.8 
 
 —6.0 
 
 
 820 
 
 
 Nov. 28 
 
 
 2,741 
 
 256.0 
 
 14O.0 
 
 15.0 
 
 12.44 
 
 2.3 
 
 14.7 
 
 -fO.S 
 
 47.26 
 
 980 
 
 
 Nov. 29 
 
 
 3,038 
 
 324.0 
 
 142.0 
 
 15.0 
 
 11.82 
 
 2.3 
 
 14.1 
 
 -fO.9 
 
 
 1,370 
 
 
 Nov. 30 
 
 
 3,153 
 
 834.0 
 
 147.0 
 
 16.0 
 
 10.76 
 
 2.4 
 
 18.2 
 
 -1-2.8 
 
 
 1,060 
 
 
 Dec. 1 
 
 
 3,091 
 
 333.0 
 
 142.0 
 
 16.7 
 
 9.81 
 
 2.4 
 
 12.2 
 
 -1-3.6 
 
 47.08 
 
 1,180 
 
 
 Dec. 2 
 
 
 8,090 
 
 340.0 
 
 142.0 
 
 15.3 
 
 9.69 
 
 2.3 
 
 12.0 
 
 -1-3.3 
 
 
 1,660 -f 
 
 
 * Peces analyzed October SO to November 6. Peces nitrogen averaged 14.8 per cent, of food nitrogen. On all 
 other days the feces nitrogen was calculated as 15 per cent, of food nitrogen. 
 
TABLE 6. — Clinical Data — (Continued) 
 Morris S. — (Continued) 
 
 
 Esti- 
 mated 
 
 Heat 
 Produc- 
 tion per 
 24Hrs. 
 
 Pood 
 
 
 
 
 
 
 
 
 
 Date, 
 1913 
 
 Total 
 Calories 
 
 Carbo- 
 hydrate, 
 Gm. 
 
 Fat, 
 Gm. 
 
 Pood 
 N., 
 Gm. 
 
 Urine 
 N., 
 Gm. 
 
 Peces 
 
 N., 
 Gm.* 
 
 Excreta 
 
 N., 
 
 Gm.* 
 
 Nitrogen 
 
 Balance, 
 
 Gm. 
 
 Body 
 
 Weight, 
 
 Kg. 
 
 Urine 
 
 Volume, 
 
 O.c. 
 
 Pat 
 
 Dee 3 
 
 
 3,189 
 
 366.0 
 
 141.0 
 
 16.0 
 
 8.52 
 
 2.4 
 
 10.9 
 
 +5.1 
 
 47.31 
 
 930 
 
 
 Dee. i 
 
 
 3,11S 
 
 250.0 
 
 180.0 
 
 16.0 
 
 8.70 
 
 2.4 
 
 11.1 
 
 -1-4.9 
 
 
 1,600 
 
 
 Dec. 5 
 
 
 2,977 
 
 156.0 
 
 209.0 
 
 15.0 
 
 8.74 
 
 2.3 
 
 11.0 
 
 -1-4.0 
 
 
 1,520 
 
 
 Dec. 6 
 
 
 
 2,998 
 
 161.0 
 
 209.6 
 
 15.0 
 
 9.75 
 
 2.3 
 
 12.1 
 
 -1-2.9 
 
 46.55 
 
 1,340 
 
 
 Dec. 7 
 
 
 3,297 
 
 202.0 
 
 221.0 
 
 16.0 
 
 9.08 
 
 2.4 
 
 11.5 
 
 +i.5 
 
 
 1,640 
 
 
 Dec. 8 
 
 
 3,914 
 
 206.0 
 
 289.0 
 
 14.9 
 
 8.55 
 
 2.2 
 
 10.8 
 
 -1-4.1 
 
 
 1.340 
 
 
 Dec. 9 
 
 
 3,989 
 
 219.0 
 
 290.0 
 
 15.2 
 
 7.65 
 
 2.3 
 
 10.0 
 
 -1-5.2 
 
 47.63 
 
 1,140 
 
 
 Dec. 10 
 
 
 3,989 
 
 219.0 
 
 290.0 
 
 15.2 
 
 8.85 
 
 2.3 
 
 11.2 
 
 -1-4.0 
 
 
 1,650 
 
 
 Dec. 11 
 
 
 3,989 
 
 219.0 
 
 290.0 ■ 
 
 15.2 
 
 9.31 
 
 2.3 
 
 11.6 
 
 +3.6 
 
 48.46 
 
 1,850 
 
 
 Dec. 12 
 
 1,867 
 
 3,652 
 
 222.0 
 
 226.0 
 
 21.3 
 
 9.87 
 
 3.2 
 
 13.1 
 
 4-8.2 
 
 48.64 
 
 1,700 
 
 
 Dec. 13 
 
 1,604 
 
 2,925 
 
 395.0 
 
 104.0 
 
 13.1 
 
 12.64 
 
 2.0 
 
 14.6 
 
 —1.5 
 
 48.10 
 
 1,935 
 
 
 Dec. U 
 
 
 3,256 
 
 475.0 
 
 95.0 
 
 16.5 
 
 9.47 
 
 2.5 
 
 12.0 
 
 -1-4.5 
 
 
 1,100 
 
 
 Dec. 15 
 
 1,723 
 
 8,117 
 
 511.0 
 
 74.0 
 
 13.0 
 
 8.68 
 
 2.0 
 
 10.7 
 
 -f2.3 
 
 47.87 
 
 1,229 
 
 
 Dec. 16 
 
 1,703 
 
 2,132 
 
 275.0 
 
 76.0 
 
 11.6 
 
 10.24 
 
 1.7 
 
 11.9 
 
 -0.3 
 
 47.91 
 
 802 
 
 
 Dec. 17 
 
 
 3,985 
 
 440.0 
 
 193.0 
 
 15.5 
 
 9.30 
 
 2.3 
 
 11.6 
 
 -f3.9 
 
 
 1,240 
 
 
 Dec. 18 
 
 
 3,499 
 
 266.0 
 
 224.0 
 
 14.4 
 
 10.82 
 
 2.2 
 
 13.0 
 
 -H.4 
 
 
 1,670 
 
 
 Dec. 19 
 
 2,058 
 
 2,868 
 
 248.0 
 
 173.0 
 
 9.6 
 
 11.34 
 
 1.4 
 
 12.7 
 
 —3.1 
 
 48.34 
 
 1,282 
 
 
 Dec. 20 
 
 2,081 
 
 2,748 
 
 150.0 
 
 190.0 
 
 141 
 
 13.41 
 
 2.1 
 
 15.5 
 
 —1.4 
 
 48.55 
 
 1,343 
 
 
 Dec. 21 
 
 
 3,426 
 
 204.0 
 
 232.0 
 
 16.0 
 
 17.32 
 
 2.4 
 
 19.7 
 
 —3.7 
 
 48.55 
 
 1,560 
 
 
 Dec. 22 
 
 2,217 
 
 3,034 
 
 345.0 
 
 140.0 
 
 12.2 
 
 14.42 
 
 1.8 
 
 16.2 
 
 —4.0 
 
 48.60 
 
 1,223 
 
 
 Dec. 23 
 
 1,982 
 
 2,499 
 
 121.0 
 
 186.0 
 
 10.7 
 
 11.94 
 
 1.6 
 
 13.5 
 
 —2.8 
 
 48.54 
 
 883 
 
 
 Dec. 24 
 
 
 3,357 
 
 206.0 
 
 226.0 
 
 16.5 
 
 13.06 
 
 2.5 
 
 15.6 
 
 -1-0.9 
 
 
 1,480 
 
 
 Dec. 25 
 
 
 
 
 
 .... 
 
 10.90 
 
 
 .... 
 
 
 
 1,200 
 
 
 Dec. 26 
 
 
 8,560 
 
 189.0 
 
 263.0 
 
 17.1 
 
 10.48 
 
 2.6 
 
 13.1 
 
 -f4.0 
 
 49.70 
 
 1,680 
 
 
 Dec. 27 
 
 
 3,180 
 
 159.0 
 
 227.0 
 
 16.4 
 
 11.10 
 
 2.5 
 
 13.6 
 
 -1-2.8 
 
 
 1,930 
 
 
 Dec. 28 
 
 
 3,128 
 
 157.0 
 
 224.0 
 
 15.5 
 
 11.43 
 
 2.3 
 
 13.7 
 
 -H.8 
 
 
 1,740 
 
 
 Dec. 29 
 
 
 3,109 
 
 157.0 
 
 222.0 
 
 15.5 
 
 11.77 
 
 2.3 
 
 14.1 
 
 -1-1.4 
 
 
 1,380 
 
 
 Dec. 30 
 
 
 3,277 
 
 170.0 
 
 235.0 
 
 15.5 
 
 11.72 
 
 2.3 
 
 .14.0 
 
 -1-1.5 
 
 
 1,710 
 
 
 Dec. 31 
 
 
 2,990 
 
 293.0 
 
 143.0 
 
 17.9 
 
 12.61 
 
 2.7 
 
 15.3 
 
 -t-2.6 
 
 
 1,600 
 
 
 1914 
 Jan; 1 
 
 
 2,991 
 
 256.0 
 
 166.0 
 
 15.4 
 
 12.11 
 
 2.3 
 
 14.4 
 
 -H.O 
 
 
 2,120 
 
 
 Jan. 2 
 
 1,567 
 
 2,078 
 
 141.0 
 
 132.0 
 
 10.7 
 
 10.01 
 
 1.6 
 
 11.6 
 
 -0.9 
 
 49.22 
 
 1,340 
 
 
 Jan. 3 
 
 
 3,051 
 
 ■158.0 
 
 216.0 
 
 is'.e 
 
 12.27 
 
 2.3 
 
 14.6 
 
 -1-1.0 
 
 
 2,160 
 
 
 Jan. 4 
 
 
 3,070 
 
 162.0 
 
 216.0 
 
 16.7 
 
 10.40 
 
 2.4 
 
 12.8 
 
 -f2.9 
 
 
 1,730 
 
 
 Jan. 5 
 
 
 
 
 
 .... 
 
 11.21 
 
 
 
 
 
 1,580 
 
 
 Jan. 6 
 
 
 3,044 
 
 158.0 
 
 215.0 
 
 15.5 
 
 12.69 
 
 2.3 
 
 15.0 
 
 -fO.5 
 
 
 2,330 
 
 
 Jan. 7 
 
 
 3,045 
 
 158.0 
 
 215.0 
 
 15.5 
 
 11.66 
 
 2.3 
 
 14.0 
 
 -1-1.5 
 
 
 1,800 
 
 
 Jan. 8 
 
 
 3,068 
 
 162.0 
 
 215.0 
 
 15.6 
 
 11.77 
 
 2.3 
 
 14.1 
 
 -1-1.5 
 
 
 1,460 
 
 
 Jan. 9 
 
 
 3,063 
 
 162.0 
 
 215.0 
 
 15.6 
 
 11.66 
 
 2.3 
 
 14.0 
 
 -1-1.6 
 
 
 1,660 
 
 
 Jan. 10 
 
 
 3,475 
 
 268.0 
 
 208.0 
 
 17.3 
 
 12.10 
 
 2.6 
 
 14.7 
 
 +2.6 
 
 
 1,460 
 
 
 Jan. 11 
 
 
 3,739 
 
 354.0 
 
 191.0 
 
 19.8 
 
 12.22 
 
 3.0 
 
 15.2 
 
 +i.e 
 
 
 1,560 
 
 
 Jan. 12 
 
 
 3,551 
 
 344.0 
 
 177.0 
 
 19.5 
 
 12.61 
 
 2.9 
 
 15.5 
 
 -1-4.0 
 
 
 2,350 
 
 
 Jan. 13 
 
 
 4,198 
 
 382.0 
 
 222.0 
 
 22.1 
 
 11.49 
 
 3.3 
 
 14.8 
 
 -1-7.3 
 
 
 1,520 
 
 
 * Exei 
 
 eta nitrog 
 
 en estimat 
 
 ed as urin 
 
 e nitrogen 
 
 -1- 15P 
 
 er cent ( 
 
 )1 food 
 
 nitrogen 
 
 . 
 
 
 
 
TABLE 6. — Clinical Data — (Continued) 
 Howard F. 
 
 Date, 
 
 Food 
 
 Food N., 
 Gm. 
 
 Urine N., 
 Gm. 
 
 Excreta 
 N., Gm. 
 
 Nitrogen 
 Bal., Gm.* 
 
 Body 
 Wt., Eg. 
 
 Urine 
 
 1913 
 
 Total 
 Calories 
 
 Carbohy- 
 drate, Gm. 
 
 Pat, 
 Gm. 
 
 Vol., O.C. 
 
 Nov. 6.... 
 
 1,264 
 
 83.0 
 
 81.0 
 
 6,7 
 
 12.83 
 
 13.50 
 
 —6.80 
 
 36.06 
 
 970 
 
 Nov. 7.... 
 
 918 
 
 62.0 
 
 59.0 
 
 4.4 
 
 12.05 
 
 12.49 
 
 —8.09 
 
 35.74 
 
 640 
 
 Nov. 8.... 
 
 1,538 
 
 87.0 
 
 107.0 
 
 7.0 
 
 12.75 
 
 13.45 
 
 —6.45 
 
 35.79 
 
 840 
 
 Nov. 9.... 
 
 1,454 
 
 106.0 
 
 88.0 
 
 7.7 
 
 12.61 
 
 13.38 
 
 —5.68 
 
 
 760 
 
 Nov. 10.... 
 
 1,401 
 
 115.0 
 
 78.0 
 
 8.1 
 
 12.67 
 
 13.48 
 
 —5.38 
 
 
 680 
 
 Nov. 11.... 
 
 925 
 
 93.0 
 
 38.0 
 
 7.5 
 
 13.79 
 
 14.54 
 
 —7.04 
 
 34.60 
 
 750 
 
 Nov. 12.... 
 
 950 
 
 98.0 
 
 40.0 
 
 7.3 
 
 13.12 
 
 14.15 
 
 —6.85 
 
 35.01 
 
 830 
 
 Nov. 13.... 
 
 1,260 
 
 134.0 
 
 60.0 
 
 5.8 
 
 12.52 
 
 13.10 
 
 —7.30 
 
 34.22 
 
 610 
 
 Nov. 14.... 
 
 580 
 
 52.0 
 
 30.0 
 
 3.4 
 
 10.42 
 
 10.76 
 
 —7.36 
 
 
 500 
 
 Nov. 15. . . . 
 
 1,162 
 
 83.0 
 
 69.0 
 
 6.6 
 
 11.10 
 
 11.76 
 
 —5.16 
 
 33.36 
 
 900 
 
 Nov. 16.... 
 
 1.096 
 
 150.0 
 
 40.0 
 
 4.4 
 
 9.98 
 
 10.42 
 
 —6.02 
 
 
 500 
 
 Nov. 17.... 
 
 1,462 
 
 123.0 
 
 83.0 
 
 7.2 
 
 9.30 
 
 10.02 
 
 —2.82 
 
 33.12 
 
 400 
 
 Nov. 18. . . . 
 
 1,688 
 
 128.0 
 
 91.0 
 
 8.5 
 
 10.20 
 
 11.05 
 
 —2.55 
 
 32.93 
 
 590 
 
 Nov. 19.... 
 
 984 
 
 63.0 
 
 62.0 
 
 5.7 
 
 10.65 
 
 11.22 
 
 —5.52 
 
 
 780 
 
 Nov. 20. . . . 
 
 1,288 
 
 74.0 
 
 75.0 
 
 7.S 
 
 10.25 
 
 10.98 
 
 —3.68 
 
 32.57 
 
 550 
 
 Nov. 21.... 
 
 1,466 
 
 91.0 
 
 95.0 
 
 8.1 
 
 11.32 
 
 12.13 
 
 —4.03 
 
 
 700 
 
 Nov. 22.... 
 
 1,198 
 
 73.0 
 
 94.0 
 
 8.8 
 
 11.12 
 
 12.00 
 
 —3.20 
 
 
 800 
 
 Nov. 23.... 
 
 1,789 
 
 92.0 
 
 121.0 
 
 11.6 
 
 11.15 
 
 12.31 
 
 —0.71 
 
 
 660 
 
 Nov. 24.... 
 
 1,846 
 
 146.0 
 
 145.0 
 
 10.6 
 
 10.82 
 
 11.88 
 
 —1.28 
 
 
 820 
 
 Nov. 25. . . . 
 
 2,060 
 
 138.0 
 
 129.0 
 
 11.4 
 
 9.81 
 
 10.95 
 
 +0.45 
 
 32.14 
 
 940 
 
 Nov. 26.... 
 
 2,686 
 
 176.0 
 
 168.0 
 
 15.7 
 
 10.42 
 
 11.99 
 
 +3.71 
 
 
 
 780 
 
 Nov. 27.... 
 
 2,240 
 
 211.0 
 
 118.0 
 
 10.9 
 
 9.47 
 
 10.56 
 
 +0.34 
 
 
 
 570 
 
 Nov. 28.... 
 
 2,742 
 
 245.0 
 
 145.0 
 
 16.0 
 
 9.98 
 
 11.48 
 
 +3.52 
 
 32.25 
 
 920 
 
 Nov. 29. . . . 
 
 2,581 
 
 211.0 
 
 152.0 
 
 11.9 
 
 8.62 
 
 9.71 
 
 +2.19 
 
 
 620 
 
 Nov. 30.... 
 
 2,922 
 
 273.0 
 
 153.0 
 
 14.8 
 
 9.53 
 
 11.01 
 
 +3.79 
 
 
 1,220 
 
 Dec. 1.... 
 
 2,681 
 
 309.0 
 
 . 112.0 
 
 10.6 
 
 7.77 
 
 8.83 
 
 +1.77 
 
 
 870 
 
 Dec. 2 
 
 2,298 
 
 247.0 
 
 110.0 
 
 10.0 
 
 7.69 
 
 8.69 
 
 +1.31 
 
 33.09 
 
 900 
 
 Dec. 3.... 
 
 3,689 
 
 423.0 
 
 163.0 
 
 17.2 
 
 9.25 
 
 10.97 
 
 +6.23 
 
 
 900 
 
 Dec. 4 
 
 3,627 
 
 441.0 
 
 • 147.0 
 
 17.7 
 
 9.0O 
 
 10.77 
 
 +6.93 
 
 
 1.130 
 
 Dec. 5.... 
 
 2,671 
 
 S37.0 
 
 81.0 
 
 21.0 
 
 13.01 
 
 15.11 
 
 +5.89 
 
 34.77 
 
 1,500 
 
 Dec. 0.... 
 
 2,476 
 
 333.0 
 
 83.0 
 
 12.9 
 
 9.20 
 
 10.49 
 
 +2.41 
 
 33.81 
 
 775 
 
 Dec. 7.... 
 
 3,621 
 
 496.0 
 
 119.0 
 
 19.0 
 
 10.45 
 
 12.35 
 
 +6.65 
 
 
 1,600 
 
 Dec. 8.... 
 
 3,391 
 
 434.0 
 
 112.0 
 
 17.8 
 
 9.89 
 
 11.67 
 
 +6.13 
 
 
 1,270+ 
 
 Dee. 9.... 
 
 3,042 
 
 386.0 
 
 108.0 
 
 18.0 
 
 10.73 
 
 12.53 
 
 +6.47 
 
 35.51 
 
 1,300 
 
 Dec. 10.... 
 
 2,986 
 
 394.0 
 
 101.0 
 
 16.8 
 
 10.51 
 
 12.19 
 
 +4.61 
 
 
 1.450 
 
 Dec. 11.... 
 
 3,149 
 
 ' 405.0 
 
 114.0, 
 
 17.8 
 
 10.79 
 
 12.57 
 
 +5.23 
 
 35.99 
 
 1,450 
 
 Dec 12.... 
 
 3,100 
 
 417.0 
 
 101.0 
 
 17.5 
 
 10.36 
 
 12.11 
 
 +5.39 
 
 
 1,610 
 
 Dec. 13.... 
 
 3,544 
 
 472.0 
 
 122.0 
 
 18.5 
 
 10.03 
 
 11.88 
 
 +6.62 
 
 36.65 
 
 1,280 
 
TABLE 6. — Clinical Data — {Continued) 
 Howard F. — (Continued) 
 
 
 I'ood 
 
 rood N., 
 Gm. 
 
 Urine N., 
 Gm. 
 
 Excreta 
 N., Gm. 
 
 Nitrogen 
 Bal., Gm.' 
 
 Body 
 Wt., Kg. 
 
 
 1913 
 
 Total 
 Calories 
 
 Carbohy- 
 drate, Gm. 
 
 Eat, 
 Gm. 
 
 Vol., C.C. 
 
 Dec. U.... 
 
 3,338 
 
 402.0 
 
 133.0 
 
 17.8 
 
 11.01 
 
 ' 12.79 
 
 +5.01 
 
 
 1,880 
 
 Dea. 15.... 
 
 3,280 
 
 510.0 
 
 130.0 
 
 19.2 
 
 12.98 
 
 14.90 
 
 +4.30 
 
 37.54 
 
 1,890+ 
 
 Dec. 16.... 
 
 3,5U 
 
 444.0 ■ 
 
 129.0 
 
 35.2 
 
 13.28 
 
 15.20 
 
 +4.00 
 
 
 1,580 
 
 Dec. 17.... 
 
 3,170 
 
 845.0 
 
 139.0 
 
 18.0 
 
 9.95 
 
 11.75 
 
 • +6.25 
 
 39.10 
 
 1,720 
 
 Dec. 18.... 
 
 2,008 
 
 248.0 
 
 78.0 
 
 10.5 
 
 8.57 
 
 9.62 
 
 +0.88 
 
 37.17 
 
 1,600 
 
 Dec. 19.... 
 
 3,550 
 
 411.0 
 
 144.0 
 
 20.3 
 
 11.89 
 
 13.92 
 
 +6.38 
 
 
 2.050 
 
 Dee. 20 
 
 2,671 
 
 110.0 
 
 197.0 
 
 15.0 
 
 8.10 
 
 9.60 
 
 +5.40 
 
 
 1,540 
 
 Dec. 21.... 
 
 2,383 
 
 104.0 
 
 175.0 
 
 12.6 
 
 10.65 
 
 11.91 
 
 +0.69 
 
 
 1,250 
 
 Dec. 22.... 
 
 2,936 
 
 159.0 
 
 198.0 
 
 17.3 
 
 13.23 
 
 14.96 
 
 +2.34 
 
 37.21 
 
 1,150 
 
 Dec. 23.... 
 
 3,620 
 
 239.0 
 
 235.0 
 
 13.9 
 
 9.19 
 
 10.58 
 
 +3.32 
 
 
 1,200 
 
 Dec 24.... 
 
 3,605 
 
 219.0 
 
 243.0 
 
 17.4 
 
 10.70 
 
 12.44 
 
 +4.96 
 
 
 1,700 
 
 Dec. 25.... 
 
 
 
 
 
 
 10.42 
 
 
 
 
 1,370 
 
 Dee, 26.... 
 
 3,152 
 
 219.0 
 
 199.0 
 
 15.6 
 
 9.77 
 
 11.33 
 
 +4.27 
 
 39.46 
 
 2,100 
 
 Dec. 27.... 
 
 3,303 
 
 257.0 
 
 196.0 
 
 16.8 
 
 10.03 
 
 11.71 
 
 +5.09 
 
 
 1.600 
 
 Dec. 28.... 
 
 2,946 
 
 20O.0 
 
 186.0 
 
 15.4 
 
 7.51 
 
 9.06 
 
 +6.35 
 
 
 1.080 
 
 Dec. 29.... 
 
 4,199 
 
 265.0 
 
 278.0 
 
 20.5 
 
 10.87 
 
 12.92 
 
 +7.68 
 
 
 1,640 
 
 Dec. 30.... 
 
 2,325 
 
 165.0 
 
 145.0 
 
 11.4 
 
 7.81 
 
 8.96 
 
 +2.45 
 
 39.39 
 
 987 
 
 Dec. 31.... 
 
 3,569 
 
 317.0 
 
 192.0 
 
 18.5 
 
 11.77 
 
 13.62 
 
 +4.88 
 
 
 1,500 
 
 Jan. 1.... 
 
 2,912 
 
 236.0 
 
 169.0 
 
 14.5 
 
 9.02 
 
 10.47 
 
 +4.03 
 
 
 1,600 
 
 Jan. 2.... 
 
 2,891 
 
 224.0 
 
 166.0 
 
 16.0 
 
 8.74 
 
 10.34 
 
 +5.66 
 
 
 
 1,540 
 
 ■ Excreta nitrogen estimated as urine nitrogen + 10 per cent of iood nitrogen. 
 
TABLE 6. — Clinical Data — (Continued) 
 Karl S. 
 
 
 Esti- 
 mated 
 
 Heat 
 Produc- 
 tion per 
 24 Hrs. 
 
 Food 
 
 
 
 
 
 Nitrogen 
 
 Balance, 
 
 Gm. 
 
 Body 
 
 Weight, 
 
 Kg. 
 
 Urine 
 
 Volume, 
 
 O.c. 
 
 Date, 
 1914 
 
 Total 
 Calories 
 
 Carbo- 
 hydrate, 
 Gm. 
 
 Fat, 
 Gm 
 
 Food 
 N., 
 6m. 
 
 N., 
 Gm. 
 
 N.. 
 Gm. 
 
 N., 
 Gm.* 
 
 
 
 
 
 
 10.8 
 
 20.62 
 
 
 21.60 
 
 —10.80 
 
 
 880 
 
 Jan. S 
 
 
 2,038 
 
 104.0 
 
 146.0 
 
 
 
 
 
 
 
 
 Jan. 4 
 
 ... 
 
 1,301 
 
 113.0 
 
 71.0 
 
 6.9 
 
 21.72 
 
 
 22.41 
 
 —15.51 
 
 
 1,240 
 
 Jan. 5 
 
 2,579 
 
 1,119 
 
 95.0 
 
 64.0 
 
 6.4 
 
 
 
 
 
 54.67 
 
 726 
 
 Jan. 6 
 
 2,707 
 
 1,332 
 
 167.0 
 
 32.0 
 
 13.6 
 
 22.36 
 
 
 23.72 
 
 —10.12 
 
 64.31 
 
 1,010 
 
 Jan. 7 
 
 
 
 1,942 
 
 93.2 
 
 136.0 
 
 11.3 
 
 
 
 
 
 
 810 
 
 Jan. 8 
 
 
 
 2,331 
 
 136.0 
 
 156.0 
 
 12.5 
 
 16.03 
 
 
 17.28 
 
 —4.78 
 
 
 860 
 
 Jan. 9 
 
 
 1,892 
 
 114.0 
 
 126.0 
 
 9.8 
 
 23.84 
 
 
 24.82 
 
 —15.02 
 
 62.99 
 
 1,700 
 
 Jan. 10 
 
 
 2,910 
 
 223.0 
 
 174.0 
 
 14.6 
 
 
 
 
 
 
 
 Jan. 11 
 
 
 3,018 
 
 318.0 
 
 • 139.0 
 
 16.4 
 
 
 
 
 
 
 
 Jan. 12 
 
 
 
 3,017 
 
 322.0 
 
 138.0 
 
 16.2 
 
 18.15 
 
 1.6 
 
 19.8 
 
 -3.6 
 
 
 2,310 
 
 Jan. 13 
 
 
 2,966 
 
 326.0 
 
 128.0 
 
 17.2 
 
 13.94 
 
 1.7 
 
 15.6 
 
 -1-1.6 
 
 
 1,820 
 
 Jan. 14 
 
 
 2,802 
 
 313.0 
 
 118.0 
 
 16.4 
 
 17.06 
 
 1.6 
 
 18.7 
 
 —2.3 
 
 
 1,830 
 
 Jan. 15 
 
 
 3,129 
 
 323.0 
 
 149.0 
 
 16.2 
 
 18.65 
 
 1.6 
 
 20.3 
 
 ^.1 
 
 62.74 
 
 1,920 
 
 Jan. 16 
 
 2,208 
 
 2,448 
 
 226.0 
 
 132.0 
 
 11.5 
 
 19.11 
 
 1.2 
 
 20.3 
 
 —8.8 
 
 52.24 
 
 1,960 
 
 Jan. 17 
 
 
 3,398 
 
 340.0 
 
 166.0 
 
 17.9 
 
 19.16 
 
 1.8 
 
 21.0 
 
 —3.1 
 
 
 1,940 
 
 Jan. 18 
 
 
 3,138 
 
 329.0 
 
 146.0 
 
 17.1 
 
 17.26 
 
 1.7 
 
 19.0 
 
 —1.9 
 
 
 1,920 
 
 Jan. 19 
 
 1,651 
 
 2,795 
 
 268.0 
 
 145.0 
 
 13.6 
 
 14.72 
 
 1.4 
 
 16.1 
 
 —2.5 
 
 51.21 
 
 1,260 
 
 Jan. 20 
 
 
 2,965 
 
 S13.0 
 
 138.0 
 
 15.7 
 
 14.61 
 
 1.6 
 
 16.1 
 
 -0.4 
 
 
 1,550 
 
 Jan. 21 
 
 1,798 
 
 2,912 
 
 S15.0 
 
 129.0 
 
 16.3 
 
 17.67 
 
 1.6 
 
 19.2 
 
 —2.9 
 
 S1.52 
 
 1,870 
 
 Jan. 22 
 
 1,612 
 
 2,605 
 
 253.0 
 
 133.0 
 
 12.8 
 
 13.25 
 
 1.3 
 
 14.6 
 
 -1.8 
 
 51.18 
 
 1,194 
 
 Jan. 2S 
 
 
 3,033 
 
 324.0 
 
 140.0 
 
 15.9 
 
 11.99 
 
 1.6 
 
 13.6 
 
 +2.S 
 
 
 
 1,360 
 
 Jan. 24 
 
 
 2,982 
 
 315.0 
 
 138.0 
 
 15.8 
 
 13.06 
 
 1.6 
 
 14.7 
 
 -1-1.1 
 
 
 1,960 
 
 Jan. 25 
 
 
 2,967 
 
 316.0 
 
 139.0 
 
 15.8 
 
 13.17 
 
 1.6 
 
 14.8 
 
 -1-1.0 
 
 
 1,400 
 
 Jan. 26 
 
 
 3,641 
 
 408.0 
 
 155.0 
 
 16.7 
 
 12.64 
 
 1.7 
 
 14.3 
 
 H-2.4 
 
 64.64 
 
 1,620 
 
 Jan. 27 
 
 
 3,999 
 
 439.0 
 
 191.0 
 
 16.3 
 
 13.06 
 
 1.6 
 
 14.7 
 
 -H.6 
 
 
 1,460 
 
 Jan. 28 
 
 
 4,025 
 
 439.0 
 
 194.0 
 
 16.3 
 
 11.88 
 
 1.6 
 
 13.5 
 
 -f2.8 
 
 
 1,280 
 
 Jan. 29 
 
 
 3,975 
 
 438.0 
 
 190.0 
 
 16.1 
 
 11.32 
 
 1.6 
 
 12.9 
 
 -1-3.2 
 
 52.54 
 
 1,460 
 
 Jan. 30 
 
 
 3,991 
 
 439.0 
 
 191.0 
 
 16.2 
 
 10.65 
 
 1.6 
 
 12.S 
 
 -1-3.9 
 
 
 1,600 
 
 Jan. 31 
 
 
 3,922 
 
 418.0 
 
 193.0 
 
 16.2 
 
 10.93 
 
 1.6 
 
 12.5 
 
 +3.7 
 
 
 1,400 
 
 Feb.- 1 
 
 
 3,940 
 
 418.0 
 
 194.0 
 
 16.3 
 
 10.63 
 
 1.6 
 
 12.2 
 
 -1-4.1 
 
 
 1,600 
 
 I-eb. 2 
 
 
 3,808 
 
 419.0 
 
 180.0 
 
 16.0 
 
 11.21 
 
 1.6 
 
 12.8 
 
 +S.2 
 
 
 
 1,910 
 
 Feb. 3 
 
 
 3,808 
 
 419.0 
 
 180.0 
 
 16.0 
 
 11.15 
 
 1.6 
 
 12.8 
 
 -1-3.2 
 
 
 
 1,980 
 
 Feb. 4 
 
 
 3,971 
 
 442.0 
 
 188.0 
 
 16.0 
 
 10.87 
 
 1.6 
 
 12.5 
 
 -f3.5 
 
 
 1,870 
 
 Feb. 5 
 
 
 3,974 
 
 438.0 
 
 191.0 
 
 16.0 
 
 9.29 
 
 1.6 
 
 10.9 
 
 -1-6.1 
 
 
 1,640 
 
 Feb. 6 
 
 1,916 
 
 3,232 
 
 330.0 
 
 165.0 
 
 13.3 
 
 1U.24 
 
 1.3 
 
 11.6 
 
 -H.8 
 
 63.33 
 
 1,360 
 
 Feb. 7 
 
 1,965 
 
 3,526 
 
 387.0 
 
 148.0 
 
 22.1 
 
 
 2.2 
 
 17.3 
 
 -1-4.8 
 
 64.48 
 
 2,300 
 
 Feb. 8 
 
 
 4,018 
 
 474.0 
 
 178.0 
 
 16.3 
 
 11.67 
 
 1.6 
 
 13.3 
 
 -1-3.0 
 
 
 1,440 
 
 ' Excreta nitrogen estimated as urine nitrogen + 10 per cent, oi food nitrogen. 
 
6. — Clinical Data — {Continued) 
 Thomas B. 
 
 
 
 
 Food 
 
 
 
 
 
 
 
 
 
 Date 
 
 Temperature 
 
 Total 
 Calories 
 
 Carbo- 
 hy- 
 drate, 
 Gm. 
 
 Pat, 
 Gm. 
 
 Food 
 N., 
 Gm. 
 
 Urine 
 N., 
 Gm. 
 
 Feces 
 N., 
 Gm. 
 
 Excreta 
 N., 
 Gm. 
 
 Nitrogen 
 
 Balance, 
 
 Gm. 
 
 Body 
 
 Weight, 
 
 Kg. 
 
 Urine 
 
 Volume, 
 
 C.c. 
 
 Fat 
 
 191S 
 
 Max. 
 
 Min. 
 
 
 Oct. 7 
 
 103.0 
 
 101.4 
 
 8,052 
 
 168.0 
 
 212.0 
 
 16.0 
 
 24.56 
 
 2.09 
 
 26.64 
 
 —11.64 
 
 76.08 
 
 1,240 
 
 9.19 
 
 Oct. 8 
 
 103.6 
 
 101.2 
 
 8,010 
 
 163.0 
 
 210.0 
 
 16.0 
 
 25.50 
 
 2.09 
 
 27.59 
 
 —12.69 
 
 75.61 
 
 1,270 
 
 9.19 
 
 Oct. 9 
 
 104.0 
 
 101.6 
 
 3,010 
 
 163.0 
 
 210.0 
 
 15.0 
 
 21.29 
 
 2.09 
 
 23.38 
 
 -8.38 
 
 75.73 
 
 1,120 
 
 9.19 
 
 Oct. 10 
 
 103.6 
 
 101.6 
 
 3.030 
 
 163.0 
 
 212.0 
 
 15.0 
 
 23.67 
 
 2.09 
 
 26.76 
 
 —10.76 
 
 76.02 
 
 1,740 
 
 9.19 
 
 Oct. 11 
 
 103.0 
 
 101.0 
 
 3.014 
 
 479.0 
 
 71.0 
 
 14.9 
 
 20.12 
 
 1.89 
 
 22.01 
 
 —7.11 
 
 74.85 
 
 1,500 
 
 5.80 
 
 Oct. 12 
 
 102.8 
 
 101.6 
 
 3,018 
 
 480.0 
 
 71.0 
 
 15.0 
 
 17.77 
 
 1.89 
 
 19.66 
 
 —4.66 
 
 
 1,960 
 
 6.80 
 
 Oct. 13 
 
 102.4 
 
 100.6 
 
 3,014 
 
 479.0 
 
 71.0 
 
 14.9 
 
 18.77 
 
 1.89 
 
 20.66 
 
 -6.76 
 
 74.24 
 
 1,980 
 
 5.80 
 
 Oct. 14 
 
 103.0 
 
 100.0 
 
 3.046 
 
 173.0 
 
 212.0 
 
 14.2 
 
 18.21 
 
 1.28 
 
 19.49 
 
 —6.29 
 
 74.38 
 
 1,220 
 
 5.02 
 
 Oct. 15 
 
 102.2 
 
 98.6 
 
 2,670 
 
 130.0 
 
 187.0 
 
 U.7 
 
 18.61 
 
 1.28 
 
 19.89 
 
 -8.19 
 
 
 1,040 
 
 6.02 
 
 Oct. 16 
 
 101.0 
 
 99.4 
 
 3,068 
 
 168.0 
 
 212.0 
 
 16.4 
 
 21.04. 
 
 1,28 
 
 22.32 
 
 -6.92 
 
 
 1,010 
 
 5.02 
 
 Oct. 17 
 
 101.6 
 
 99.4 
 
 3,211 
 
 484.0 
 
 78.0 
 
 15.6 
 
 17.79 
 
 
 19.35* 
 
 —3.76 
 
 73.10 
 
 1,120 
 
 
 Oct. 18 
 
 100.6 
 
 99.0 
 
 2,998 
 
 478.0 
 
 71.0 
 
 16.0 
 
 15.69 
 
 
 17.19 
 
 —2.19 
 
 
 1,100 
 
 
 Oct. 19 
 
 99.6 
 
 98.6 
 
 3,019 
 
 481.0 
 
 71.0 
 
 15.0 
 
 16.30 
 
 
 16.80 
 
 —1.80 
 
 
 1,220 
 
 
 Oct. 20 
 
 99.6 
 
 98.6 
 
 3,002 
 
 468.0 
 
 75.0 
 
 15.0 
 
 15.24 
 
 
 16.74 
 
 —1.74 
 
 72.82 
 
 1,880 
 
 
 Oct. 21 
 
 98.6 
 
 99.4 
 
 2,675 
 
 412.0 
 
 68.0 
 
 13.0 
 
 15.76t 
 
 
 
 
 
 1,610+ 
 
 (?) 
 
 Oct. 22 
 
 99.6 
 
 98.8 
 
 2,943 
 
 462.0 
 
 71.0 
 
 15.0 
 
 16.32 
 
 
 17.82 
 
 —2.82 
 
 
 1,480 
 
 
 Oct. 23 
 
 99.6 
 
 98.6 
 
 3,062 
 
 449.0 
 
 76.0 
 
 21.2 
 
 16.76 
 
 
 18.88 
 
 +2.32 
 
 
 1,230 
 
 
 Oct. 24 
 
 99.6 
 
 98.6 
 
 3,396 
 
 641.0 
 
 60.0 
 
 20.0 
 
 13.34 
 
 
 15.34 
 
 +4.66 
 
 72.86 
 
 1,640 
 
 
 Oct. 25 
 
 99.6 
 
 98.6 
 
 3,211 
 
 493.0 
 
 71.0 
 
 20.0 
 
 16.69 
 
 
 18.59 
 
 +1.41 
 
 
 1,120 
 
 
 Oct. 26 
 
 99.0 
 
 98.2 
 
 3,066 
 
 164.0 
 
 215.0 
 
 15.5 
 
 18.90 
 
 
 20.45 
 
 -4.96 
 
 
 1,320 
 
 
 Oct. 27 
 
 99.6 
 
 98.4 
 
 3,159 
 
 164.0 
 
 219.0 
 
 17.5 
 
 17.65 
 
 
 19.40 
 
 —1.90 
 
 
 2,280 
 
 
 Oct. 28 
 
 99.0 
 
 98.2 
 
 3,277 
 
 182.0 
 
 220.0 
 
 18.5 
 
 14.18 
 
 
 16.03 
 
 +2.47 
 
 73.69 
 
 1,220 
 
 
 t This is the total lor 19% hours. 
 * Excreta nitrogen estimated as urine 
 
 nitrogen + 10 per cent, of food nitrogen. 
 
 TABLE 6. — Clinical D.^ta — (Continued) 
 Richard T. 
 
 
 
 
 Food 
 
 
 
 
 
 
 
 
 
 
 Temperature 
 
 Total 
 Calories 
 
 Carbo- 
 hy- 
 drate, 
 Gm. 
 
 Fat, 
 Gm. 
 
 N., 
 Gm. 
 
 N., 
 Gm. 
 
 N., 
 Gm. 
 
 N., 
 Gm. 
 
 Nitrogen 
 
 Balance, 
 
 Gm. 
 
 Body 
 
 Weight, 
 Kg. 
 
 Urine 
 
 Volume, 
 
 C.c. 
 
 Feces 
 Fat 
 
 1913 
 
 Max. 
 
 Min. 
 
 
 Oct. 17 
 
 103.6 
 
 101.4 
 
 1.666 
 
 248.0 
 
 38.0 
 
 11.3 
 
 13.95 
 
 0.84 
 
 14.79 
 
 —3.49 
 
 36.09 
 
 2,290 
 
 1.63 
 
 Oct. 18 
 
 104.2 
 
 100.8 
 
 1,143 
 
 115.0 
 
 49.0 
 
 8.4 
 
 12.48 
 
 0.84 
 
 13.32 
 
 —4.92 
 
 
 1,145 
 
 1.63 
 
 Oct. 19 
 
 103.2 
 
 10O.8 
 
 2,131 
 
 327.0 
 
 49.0 
 
 13.0 
 
 14.40 
 
 0.84 
 
 15.24 
 
 —2.24 
 
 
 1,720 
 
 1.63 
 
 Oct. 20 
 
 104.0 
 
 100.0 
 
 2,020 
 
 280.0 
 
 55.0 
 
 14.0 
 
 14.63 
 
 0.84 
 
 15.37 
 
 —1.37 
 
 
 1,005 
 
 1.63 
 
 Oct. 21 
 
 102.8 
 
 100.0 
 
 2,369 
 
 360.0 
 
 61.0 
 
 16.0 
 
 15.13 
 
 0.84 
 
 16.97 
 
 +0.03 
 
 
 1,320 
 
 1.63 
 
 Oct. 22 
 
 102.4 
 
 99.4 
 
 2,092 
 
 315.0 
 
 46.0 
 
 14.7 
 
 14.74 
 
 0.84 
 
 15.58 
 
 —0.88 
 
 35.57 
 
 1,200 
 
 1.63 
 
 Oct. 23 
 
 103.0 
 
 99.0 
 
 2,576 
 
 369.0 
 
 67.0 
 
 17.4 
 
 16.30 
 
 0.84 
 
 17.14 
 
 +0.26 
 
 35.70 
 
 1,670 
 
 1.63 
 
 Oct. 24 
 
 102.0 
 
 99.4 
 
 2,153 
 
 3S3.0 
 
 35.0 
 
 18.0 
 
 15.69 
 
 0.84 
 
 16.53 
 
 +1.47 
 
 
 1,340 
 
 1.63 
 
 Oct. 25 
 
 101.0 ' 
 
 98.4 
 
 2,619 
 
 228.0 
 
 125.0 
 
 16.0 
 
 16.32 
 
 0.84 
 
 17.16 
 
 —1.16 
 
 
 1,260 
 
 1.63 
 
 Oct. 26 
 
 100.6 
 
 99.0 
 
 2,093 
 
 115.0 
 
 133.0 
 
 15.0 
 
 16.53 
 
 
 * 18.03 
 
 —3.03 
 
 
 1,100 
 
 
 Oct. 27 
 
 100.2 
 
 98.6 
 
 2,163 
 
 121.0 
 
 136.0 
 
 15.7 
 
 16.34 
 
 
 17.91 
 
 —2.21 
 
 35.30 
 
 1,200 
 
 
 Oct. 28 
 
 99.6 
 
 98.6 
 
 2,009 
 
 124.0 
 
 117.0 
 
 16.0 
 
 16.47 
 
 
 18.07 
 
 —2.07 
 
 35.60 
 
 1,460 
 
 
 Oct. 29 
 
 100.0 
 
 98.6 
 
 3,276 
 
 348.0 
 
 157.0 
 
 15.2 
 
 14.01 
 
 
 16.53 
 
 —0.33 
 
 
 1,370 
 
 
 Oct. 30 
 
 100.0 
 
 99.0 
 
 2,969 
 
 302.0 
 
 144.0 
 
 15.1 
 
 11.77 
 
 
 13.28 
 
 +1.82 
 
 35.38 
 
 1,195 
 
 
 Oct; 31 
 
 101.6 
 
 99.2 
 
 2,954 
 
 310.0 
 
 142.0 
 
 15.6 
 
 12.05 
 
 
 13.60 
 
 - +1.90 
 
 
 1,420 
 
 
 Not. 1 
 
 102.0 
 
 10O.4 
 
 3,069 
 
 334.0 
 
 142.0 
 
 14.6 
 
 11.32 
 
 
 12.77 
 
 +1.73 
 
 36.08 
 
 1,320 
 
 
 Not. 2 
 
 10^.4 
 
 99.6 
 
 2,996 
 
 325.0 
 
 138.0 
 
 14.6 
 
 11.74 
 
 
 13.19 
 
 +1.31 
 
 
 1,900 
 
 
 Not. 3 
 
 101.0 
 
 99.6 
 
 2,984 
 
 316.0 
 
 140.0 
 
 15.1 
 
 11.99 
 
 
 , 13.60 
 
 +1.60 
 
 36.27 
 
 1,270 
 
 
 Not. 4 
 
 100.2 
 
 99.4 
 
 3,037 
 
 320.0 
 
 144.0 
 
 15.2 
 
 12.22 
 
 
 13.74 
 
 +1.46 
 
 36.42 
 
 1,560 
 
 
 ♦ Excreta nitrogen estimated as urine nitrogen + 10 per cent, of food nitrogen. 
 
TABLE 6. — Clinical Data — (^Continued) 
 Edward B. 
 
 Excreta nitrogen estimated as urine nitrogen -I- 10 per cent, ol food nitrogen. 
 
 TABLE 6. — Clinical Data — {Continued) 
 John K 
 
 
 Esti- 
 mated 
 
 Heat 
 Produc- 
 tion per 
 24Hrs. 
 
 Pood 
 
 
 
 
 
 ' 
 
 
 Date, 
 
 1914 
 
 Total 
 Calories 
 
 Carbo- 
 hydrate, 
 Gm. 
 
 Fat, 
 Gm. 
 
 Pood 
 N., 
 Gm. 
 
 Urine 
 N., 
 Gm. 
 
 Excreta 
 N., 
 Gm.* 
 
 Nitrogen 
 
 Balance 
 
 Gm. 
 
 Weight, 
 Kg. 
 
 Volume, 
 Co. 
 
 Oct. 14 
 
 
 3,901 
 
 214.9 
 
 284.8 
 
 14.5 
 
 14.61 
 
 15.96 
 
 -1.46 
 
 56.29 
 
 1,180 
 
 Oct. 16 
 
 
 4,171 
 
 212.9 
 
 309.3 
 
 16.4 
 
 11.39 
 
 13.03 
 
 -1-3.4 
 
 
 1.415 
 
 Oct. 16 
 
 
 
 4,003 
 
 662.0 
 
 97.2 
 
 15.0 
 
 11.49 
 
 12.99 
 
 -f2.0 
 
 56.36 
 
 1,665(?) 
 
 Oct. 17 
 
 
 1,561 
 
 236.3 
 
 43.8 
 
 7.28 
 
 8.65 
 
 9.37 
 
 —2.09 
 
 56.94 
 
 1,140 
 
 Oct. 18 
 
 
 2,976 
 
 94.5 
 
 236.9 
 
 15.0 
 
 11.08 
 
 12.68 
 
 —2.42 
 
 56.01 
 
 1,690 
 
 Oct. 19 
 
 
 4,217 
 
 111.0 
 
 • 362.1 
 
 13.9 
 
 16.17 
 
 17.56 
 
 —3.66 
 
 .56.98 
 
 2,230 
 
 Oct. 20 
 
 
 4,097 
 
 114.9 
 
 348.9 
 
 14.80 
 
 10.96 
 
 12.44 
 
 4-2.36 
 
 66.67 
 
 1.520 
 
 Oct. 21 
 
 
 3,686 
 
 518.9 
 
 114.7 
 
 16.20 
 
 9.17 
 
 10.69 
 
 -h4.51 
 
 57.21 
 
 1,250 
 
 Oct. 22 
 
 
 3,076 
 
 579.6 
 
 54.2 
 
 7.68 
 
 7.85 
 
 8.61 
 
 —0.93 
 
 56.60 
 
 1,170 
 
 Oct. 23 
 
 2,160 
 
 3,462 
 
 152.8 
 
 269.1 
 
 12.90 
 
 8.21 
 
 9.60 
 
 -1-3.40 
 
 65.76 
 
 835 
 
 Oct. 24 
 
 
 4,072 
 
 220.6 
 
 299.4 
 
 15.0 
 
 n.94 
 
 13.44 
 
 -fl.56 
 
 66.84 
 
 1,465 
 
 Oct. 25 
 
 
 4,114 
 
 220.9 
 
 303.1 
 
 16.1 
 
 11.20 
 
 12.70 
 
 4-2.40 
 
 66.73 
 
 1,615 
 
 Oct. 26 
 
 1,976 
 
 2,704 
 
 161.4 
 
 124.1 
 
 6.9 
 
 6.75 
 
 7.44 
 
 -^M 
 
 
 663 
 
 Oct. 27 
 
 1,982 
 
 3,844 
 
 109.1 
 
 334.5 
 
 11.1 
 
 8.61 
 
 9.72 
 
 -1-1.38 
 
 
 1,125 
 
 Oct. 28 
 
 
 4,056 
 
 223.4 
 
 295.7 
 
 15.2 
 
 8.19 
 
 9.71 
 
 -1-6.49 
 
 67.51 
 
 2,155 
 
 Oct. 29 
 
 
 4,185 
 
 314.8 
 
 266.7 
 
 16.5 
 
 8.70 
 
 10.35 
 
 4-6.15 
 
 57.46 
 
 1,960 
 
 Oct. 30 
 
 
 3,643 
 
 364.7 
 
 179.0 
 
 18.8 
 
 10.30 
 
 12.18 
 
 4-6.62 
 
 57.83 
 
 2.310 
 
 Oct 31 
 
 
 3,893 
 
 402.6 
 
 191.4 
 
 18.0 
 
 9.72 
 
 11.52 
 
 4-6.48 
 
 
 1.656 
 
 Nov. 1 
 
 
 4,394 
 
 455.7 
 
 218.4 
 
 19.3 
 
 11.05 
 
 12.98 
 
 4-6.32 
 
 68.63 
 
 2,450 
 
 Nov. 2 
 
 
 4,491 
 
 451.6 
 
 225.8 
 
 21.0 
 
 11.80 
 
 13.9 
 
 4-7.1 
 
 68.76 
 
 1,770 
 
 Nov. 3 
 
 
 4,836 
 
 491.9 
 
 244.6 
 
 21.2 
 
 12.20 
 
 14.32 
 
 4-6.88 
 
 59.52 
 
 2,406 
 
 Nov. 4 
 
 1,936 
 
 2,209 
 
 209.4 
 
 119.7 
 
 9.2 
 
 9.20 
 
 10.12 
 
 -0.92 
 
 
 979 
 
 Nov. 6 
 
 
 3,960 
 
 390.6 
 
 196.9 
 
 17.0 
 
 10.69 
 
 12.29 
 
 4-5.71 
 
 
 1,665 
 
 Nov. 6 
 
 2,117 
 
 1,907 
 
 219.6 
 
 85.9 
 
 8.0 
 
 10.96 
 
 11.76 
 
 —3.76 
 
 
 1,623 
 
 Nov. 7 
 
 
 1,006 
 
 101.2 
 
 49.8 
 
 5.05 
 
 12.13 
 
 12.63 
 
 —7.68 
 
 69.23 
 
 1.076 
 
 Nov. 8 
 
 
 398 
 
 64.0 
 
 11.8 
 
 1.08 
 
 10.34 
 
 10.44 
 
 —9.36 
 
 
 665 
 
 Nov. 9 
 
 
 617 
 
 94.8 
 
 20.0 
 
 1.68 
 
 11.26 
 
 11.42 
 
 -9.74 
 
 67.06 
 
 646 
 
 Nov. 10 
 
 2,632 
 
 1,103 
 
 104.3 
 
 51.2 
 
 6.0 
 
 14.72 
 
 15.32 
 
 —9.32 
 
 
 833 
 
 Nov. 11 
 
 
 1,646 
 
 96.0 
 
 84.2 
 
 9.7 
 
 16.73 
 
 17.70 
 
 —8.0 
 
 57.11 
 
 1,230 
 
 Nov. 12 
 
 
 2,196 
 
 166.9 
 
 119.3 
 
 10.7 
 
 14.79 
 
 16.8 
 
 —5.1 
 
 
 1,250 
 
 Date, 
 1913 
 
 Total 
 Calories 
 
 Carbohy- 
 drate, Gm. 
 
 Pat, 
 Gm. 
 
 Pood N., 
 Gm. 
 
 Urine N., 
 Gm. 
 
 Excreta 
 N., Gm. 
 
 Nitrogen 
 Bal., Gm. 
 
 Body 
 Wt., Kg. 
 
 Urine 
 Vol., O.c. 
 
 Dec. 16.... 
 
 • 2,194 
 
 139.1 
 
 148.9 
 
 9.3 
 
 24.68 
 
 26.61 
 
 —16.21 
 
 63.81 
 
 1,152 
 
 Dec. 16.... 
 
 3,309 
 
 145.1 
 
 246.8 
 
 16.3 
 
 21.45 
 
 23.08 
 
 —6.78 
 
 63.55 
 
 1,180 
 
 Dec. 17.... 
 
 3,621 
 
 181.9 
 
 268.1 
 
 14.6 
 
 22.37 
 
 23.83 
 
 —9.23 
 
 63.27 
 
 3,110 
 
 Dec. 18.... 
 
 3,205 
 
 181.9 
 
 223.6 
 
 14.8 
 
 19.30 
 
 20.78 
 
 —6.98 
 
 63.35 
 
 3,040 
 
 Dec. 19.... 
 
 3,788 
 
 251.6 
 
 249.6 
 
 17.0 
 
 19.40 
 
 21.10 
 
 —4.10 
 
 63.05 
 
 8,230 
 
 Dec. 20 
 
 3,916 
 
 269.7 
 
 267.1 
 
 18.0 
 
 18.26 
 
 20.06 
 
 —2.06 
 
 62.37 
 
 3,460 
 
 Dec. 21.... 
 
 4,134 
 
 342.5 
 
 238.4 
 
 20.0 
 
 19.33 
 
 21.33 
 
 —1.33 
 
 63.04 
 
 4,285 
 
 Dec. 22.... 
 
 4,558 
 
 378.4 
 
 267.2 
 
 20.4 
 
 18.00 
 
 20.04 
 
 4-0.36 
 
 62.64 
 
 4,265 
 
 Dec. 23.... 
 
 4,838 
 
 393.9 
 
 286.8 
 
 22.0 
 
 17.93 
 
 22.13 
 
 -0.13 
 
 63.26 
 
 3,210 
 
 Dec. 24.... 
 
 4,450 
 
 373.1 
 
 259.1 
 
 19.9 
 
 18.78 
 
 20.77 
 
 —0.87 
 
 63.32 
 
 3,350 
 
 • Estimated heat production, 2,668 calories. 
 

 1 
 
 
 
 
 
 
 
 
 
 
 
 Ti 
 
 
 
 
 
 
 
 
 TJ 
 
 
 
 
 
 
 1 
 
 _c 1 
 
 
 
 
 
 
 
 
 
 
 
 fl 
 
 
 
 
 
 
 
 
 C3 
 
 
 
 
 
 
 MOO 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Bas 
 nati 
 lor 
 riso 
 
 
 
 
 
 
 
 
 
 
 
 (N 
 
 
 
 
 
 
 
 
 s 
 
 
 
 
 
 
 ay ot 
 termi 
 Used 
 ompa 
 
 
 ^ 
 
 en 
 
 
 s 
 
 
 
 
 
 
 o 
 
 
 S 
 
 
 O 
 
 
 ci 
 
 
 C3 
 
 
 
 
 
 iH 
 
 OS o 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 O 
 
 
 o 
 
 
 
 
 
 
 <1 
 
 
 M 
 
 
 « 
 
 
 p 
 
 
 ^OT 
 
 
 
 
 P 
 
 Per 
 Cent. 
 Rise 
 Above 
 Patient's 
 Own 
 Basal 
 Metab- 
 olism 
 
 
 OT 
 
 «5 
 
 
 ■>w 
 
 
 
 
 
 
 CM 
 
 
 r-t 
 
 
 i-- 
 
 
 M 
 
 
 t- 
 
 
 
 
 
 lO 
 
 
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 + 
 
 
 
 
 
 
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 + 
 
 
 00 
 
 
 + 
 
 
 O 
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 + 
 
 Per 
 
 Cent. 
 
 Rise 
 
 Above 
 
 Normal 
 Aver. 
 Basal 
 ol S4.7 
 
 Oal. per 
 Sq. M. 
 
 28 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 (H 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 -1- 
 
 
 
 ■+ 
 
 
 + 
 
 + 
 
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 it's 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 IH 
 
 H 
 
 
 
 
 00 
 
 ■^ 
 
 rH 
 
 
 -tl 
 
 OT 
 
 
 
 
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 Cent. DIv 
 
 ol Direct 
 
 om Indire 
 
 Calories 
 
 
 
 
 
 
 
 
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 -1- 
 
 1 
 
 + 
 
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 ' 
 
 + 
 
 -f 
 
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 + 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ■HSmp. 
 
 8 bog S 
 
 ^.aSg 
 
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 i-l 
 
 r-< 
 
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 ca 
 
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 i-H 
 
 iH 
 
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 iM 
 
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 r^ 
 
 
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 t- 
 
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 ■* 
 
 szu 
 
 1 
 
 1 
 
 + 
 
 1 
 
 
 1 
 
 1 
 
 1 
 
 + 
 
 1 
 
 1 
 
 
 1 
 
 -1- 
 
 1 
 
 1 
 
 -f 
 
 1 
 
 -1- 
 
 + 
 
 + 
 
 + 
 
 + 
 
 + 
 
 f^S 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 >> 
 
 aa 
 
 9 
 
 S 
 
 S 
 
 S 
 
 s 
 
 s 
 
 s 
 
 S 
 
 8§ 
 
 § 
 
 I— 1 
 
 s 
 
 § 
 
 03 
 
 O 
 
 £ 
 
 s 
 
 00 
 
 s 
 
 is 
 
 g 
 
 g 
 
 s 
 
 3 
 
 Indirect 
 alorimetr 
 Average 
 per Hour 
 
 S5 
 
 s 
 
 g 
 
 § 
 
 
 g 
 
 § 
 
 5: 
 
 S 
 
 S 
 
 s 
 
 3 
 
 a 
 
 s 
 
 •§ 
 
 s 
 
 g 
 
 ft 
 
 s 
 
 s 
 
 31 
 
 CO 
 
 S 
 
 ^ 
 
 fe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A ■ 
 
 
 
 
 
 s 
 
 s 
 
 
 
 (rt 
 
 
 S 
 
 00 
 
 UT- 
 
 
 o 
 
 ^ 
 
 o 
 
 . 
 
 ia 
 
 ri 
 
 t^ 
 
 o 
 
 o 
 
 «> 
 
 
 ■5? 
 
 
 
 CD 
 
 a: 
 
 
 
 
 
 
 •^ 
 
 
 CO 
 
 CO 
 
 
 
 
 
 
 
 
 
 
 ■s« 
 
 I-t 
 
 T-i 
 
 iH 
 
 iH 
 
 tH 
 
 r-l 
 
 iH 
 
 tH 
 
 r-l 
 
 I-H 
 
 iH 
 
 r-t 
 
 I-H 
 
 iH 
 
 T-i 
 
 iH 
 
 tH 
 
 rH 
 
 iH 
 
 iH 
 
 iH 
 
 r-f 
 
 tH 
 
 iH 
 
 
 o 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Aver- 
 age 
 Respir- 
 atory 
 Quo- 
 tient 
 
 K 
 
 ;?^ 
 
 S 
 
 e 
 
 -* 
 
 S 
 
 S 
 
 QC 
 
 f?. 
 
 s 
 
 ES 
 
 S 
 
 00 
 
 ga 
 
 s 
 
 §8 
 
 CO 
 
 CT> 
 
 S 
 
 OS 
 
 e 
 
 g 
 
 S 
 
 S 
 
 SB 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 '"' 
 
 
 
 
 
 
 
 
 
 
 Aver- 
 age 
 Pulse 
 Rate 
 
 S 
 
 s 
 
 iH 
 
 s 
 
 s 
 
 00 
 
 S 
 
 S 
 
 S 
 
 "tj< 
 
 Ot 
 
 S 
 
 s 
 
 ffl 
 
 tn 
 
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146 CLINICAL CALORIMETRY 
 
 amounts of heat. Therefore the law of the conservation of energy 
 applies to fever patients. 
 
 The rectal temperature does not always give an accurate indication 
 of the average change in body temperature, and better results are often 
 obtained by well covered surface thermometers. 
 
 The basal heat production rises and falls in a curve roughly parallel 
 with the temperature. At the height of the fever it averages about 40 
 per cent, above the normal but in some cases rises to more than 50 per 
 cent, above the normal. 
 
 The specific dynamic action of protein and carbohydrate is much 
 smaller in the febrile period of typhoid than in health and in some cases 
 seems to be absent. In convalescence it may be greater than normal. 
 
 In a majority of cases a rise in temperature is accompanied by an 
 increasing heat production and an increasing heat elimination. 
 
 Typhoid patients can store body fat on an abundant diet while losing 
 body weight and body protein. Loss in weight and loss of protein are 
 usually though not necessarily parallel. 
 
 There is a toxic destruction of protein in typhoid fever. This is 
 shown by the fact that patients have a distinctly negative nitrogen 
 balance on a diet which contains more than enough calories to cover 
 the heat production. 
 
 The writers wish to express their thanks to their associates, without whose 
 assistance this work would have been impossible. The analyses of food and 
 urine were made by Mr. Frank C. Gephart, with the assistance of Messrs. R. H. 
 Harries, L. C. Mazzola and R. H. Stone ; all the electrical measurements in the 
 calorimeter experiments were made by Mr. G. F. Soderstrom. We are indebted 
 to Mr. R. H. Harries and Dr. A, L. Meyer for making the residual analyses of 
 air in the calorimeter experiments and for making most of the calculations, 
 and to Miss G. W. Sims for the painstaking work in checking all these calcu- 
 lations. We are indebted to Miss Estelle Magill and to her assistants, especially 
 Miss A. Honold and Miss M. M. Fauquier, for their skillful administration of 
 the diets and for the collection of the specimens. We wish also to thank Miss 
 M. Sawyer for her aid in the preparation of the charts. 
 
 477 First Avenue. 
 
CLINICAL CALORIMETRY 
 
 EIGHTH PAPER 
 ON THE DIABETIC RESPIRATORY QUOTIENT* 
 
 GRAHAM LUSK 
 
 NEW YORK 
 
 The respiratory quotient, or the ratio of the volume of carbon 
 dioxid expired to the volume of oxygen inspired, in the case of protein 
 oxidation is stated by Loewy^ to be 0.801. This relation depends on 
 the net result of the oxidation of the many amino-acids of which pro- 
 tein is composed. It is apparent that when some of these amino-acids 
 are converted into glucose which is eliminated in the urine, the respira- 
 tory quotient for protein will not hold true. It has been shown^ that 
 the carbon of glycocoll and alanin is completely converted into glucose 
 in the diabetic organism, and that three of the carbon atoms which are 
 contained in aspartic and glutamic acids are similarly convertible into 
 glucose. Dakin^ states that prolin and arginin yield glucose comparable 
 in quantity to that yielded by glutamic acid. According to this author 
 cystin and serin also yield glucose. 
 
 The reactions involving the conversion of amino-acids into sugar 
 and urea may thus be written :* 
 
 Glycocoll 6CH2NH2.COOH -I- 3CO2 + 3H..0 = 2CoH,=06 + 3CH.N.0 + 
 
 3O2 
 
 Alanin 2CH,,CHNH»C00H + CO. + H=0 — CsH^Oc -t- CH4N2O 
 
 Aspartic Acid 2COOH.CH,.CHNH2.COOH -t- H=0 = CcHisO, -|- CH4N2O + 
 
 CO2 
 Glutamic Acid 2COOH.CH2.CH2.CHNH2COOH + 30.= GHi^Oo + CH4N2O 
 
 + 3CO2 + H2O 
 Prolin 2CH=.CH,.CH2.CH.COOH -|- 50= = GHi^Oc + CH.N.O + 
 
 3CO2 -I- H2O 
 Arginin 2NH2.C.NH.CH2.CH2.CH2.CHNH2COOH + 50= = CeHi^Oo + 
 
 NH 
 4CH4N2O -I- 2CO2 
 
 Osborne and Jones' have reported an analysis of 100 grams of ox 
 meat containing 16.18 per cent, of total nitrogen. This analysis will 
 
 *From the Russell Sage Institute of Pathology, in Affiliation with the Sec- 
 ond Medical Division of Bellevue Hospital, New York City. 
 
 1. Loewy: Handb. d. Biochem., 1911, iv. No. 1, 279. 
 
 2. Ringer and Lusk : Ztschr. f. physiol. Chem., 1910, Ixvi, 106. 
 
 3. Dakin : Jour. Biol. Chem., 1913, xiv, 321. 
 
 4. For more complete theoretical details consult: Lusk, Jour. Am. Chem. 
 Soc, 1910, xxxii, 671 ; and Dakin and Dudley, Proc. Seventeenth Internat. Cong. 
 Med., 1914, Sec. ii. Part H, 127. 
 
 5. Osborne and Jones : Am. Jour. Physiol., 1909, xxiv, 438. 
 
148 
 
 CLINICAL CALORIMETRY 
 
 be found below together with the respiratory quotients, both normal 
 and diabetic, of the individual amino-acids. 
 
 TABLE 1. — Analysis of 100 Grams Ox Meat with Respiratory Quotients 
 
 
 In 100 Gm. Meat 
 gm. 
 
 Respiratory Quotient 
 
 
 Normal 
 
 Diabetic 
 
 Glycocoll 
 
 Alanin 
 
 2.06 
 3.72 
 0.81 
 
 11.65 
 5.82 
 3.15 
 4.51 
 
 15.49 
 ? 
 
 2.20 
 7.47 
 1.76 
 7.59 
 1.07 
 Present 
 
 1.00 
 0.83 
 0.75 
 0.73 
 0.82 
 0.87 
 1.17 
 1.00 
 
 6.89 
 0.73 
 0.90 
 0.71 
 
 0.87 
 
 * 
 
 Valin 
 
 
 
 
 Prolin 
 
 0.60 
 
 Phenylalanin 
 
 Aspartic acid .... 
 
 Glutamic acid 
 
 Serin 
 
 t 
 1.00 
 
 
 
 
 0.40 
 
 Histidin 
 
 Lysin ... 
 
 
 Ammonia 
 
 Tryptophan 
 
 
 Total 
 
 67.30 
 
 
 * R. Q. depressed below that of fat if glycocoll or alanin be ingested, 
 t R. Q. increased above that of fat if aspartic acid be given. 
 
 A glance at the above table shows how the respiratory quotient of 
 0.801 for protein is based on the sum of the results of the oxidation of 
 many different substances, and also that the respiratory quotients 
 usually tend to fall when certain of the' amino-acids are converted 
 into sugar. 
 
 A clear idea of this fall in the respiratory quotient can only be 
 obtained if the respiratory metabolism of those amino-acids which are 
 convertible into glucose is contrasted, the normal with the diabetic 
 condition. 
 
 It will be noted in the foregoing table that only 67 per cent, of the 
 ox protein was recovered as amino-acids. This is explained by the 
 deficiency in the method; for Osborne and Jones^ have analyzed a 
 specially prepared mixture containing known quantities of a large 
 number of amino-acids and have recovered only 66 per cent, of the 
 substances present. As regards those amino-acids which are con- 
 vertible into glucose, the following percentages were recovered from 
 the mixture: Alanin, 46 per cent., prolin 72 per cent., aspartic acid, 
 42.5 per cent., glutamic acid 69 per cent., arginin 65 per cent. If one 
 assumes that the quantity of glycocoll is at least double that found. 
 
 6. Osborne and Jones; Am, Jour. Physiol., 1910, xxvi, 325. 
 
GRAHAM LUSK 
 
 149 
 
 one arrives at values from which one may compute the quantity of 
 sugar which should in theory arise from these acids. This appears in 
 Table 2. 
 
 Since the 100 gm. of the ox muscle analyzed contained 16.18 gm. 
 of nitrogen, the D:N equals 2.75:1. 
 
 TABLE 2. — Calculation Showing the Origin of Glucose from Protein 
 
 Substance 
 
 Osborne 
 
 Recalculated , 
 
 Glucose 
 
 GlycocoU 
 
 2.06 
 3.72 
 4.51 
 15.49 
 5.82 
 7.47 
 
 4.0 
 
 8.1 
 
 10.6 
 
 22.3 
 
 8.0 
 
 11.5 
 
 64.5 
 
 32 
 
 Alanin 
 
 82 
 
 Aspartic acid 
 
 Glutamic acid 
 
 Prolin 
 
 7.2 
 13.6 
 63 
 
 Arginin 
 
 59 
 
 
 44.4 
 
 TABLE 3. — Respiratory Exchange in the Normal and Diabetic Condition of Six Amino-Acids, 
 
 AS THEY are CONTAINED IN 100 Gm. OF Ox MeAT, AND WHICH ARE CONVERTIBLE INTO 44.4 
 
 Gm. of Glucose, D : N = 2.75 
 
 
 Grams 
 
 Normal 
 
 Diabetic 
 
 
 Oxygen 
 gm. 
 
 Carbon 
 
 Dioxid 
 
 gm. 
 
 Oxygen 
 
 Carbon Dioxid 
 
 Substance 
 
 Absorbed 
 gm. 
 
 Elimin- 
 ated in 
 Reaction 
 gm. 
 
 Absorbed 
 
 in_ 
 
 Reaction 
 
 gm. 
 
 Elimin- 
 ated 
 gm. 
 
 GlycocoU . . . 
 
 Alanin 
 
 Aspartic acid 
 Glutamic acid 
 
 Prolin 
 
 Arginin 
 
 4.0 
 
 8.1 
 
 10.6 
 
 22.3 
 
 8.0 
 
 ll.S 
 
 64.5 
 
 2.56 
 
 8.75 
 
 7.65 
 
 21.85 
 
 12.25 
 
 11.63 
 
 64.69 
 
 3.52 
 10.01 
 12.27 
 30.04 
 13.77 
 11.63 
 
 81.24 
 
 'o'.o' 
 
 0.0 
 7.30 
 5.57 
 5.32 
 
 18.19 
 0.85 
 
 17.34 
 
 0.85 
 0.85 
 
 1.17 
 2.00 
 
 3.17 
 
 1.75 
 
 10.03 
 
 4.59 
 
 2.91 
 
 19.28 
 3.17 
 
 16.11 
 
 R. Q. 
 
 0.915 
 
 0.675 
 
 When the D :N ratio is 3.65, 59 gm. of glucose, or 14.6 gm. more 
 than the quantity above estimated, are eliminated in the urine when 100 
 gm. of protein are destroyed. These 14.6 gm. represent an additional 
 amount of glucose whose origin is unexplained and which is equal to 
 24 per cent, of the total maximal production. Such sources of sugar 
 might be cystin, which if all the sulphur in protein were in that form 
 
ISO CLINICAL CALORIMETRY 
 
 might at most yield 2 gm. of glucose and serin whose solubility has 
 prevented any accuracy of determination. 
 
 Having determined the approximate quantities of the various sugar 
 yielding amino-acids, one may now compute the difference between 
 their oxidation normally and in the diabetic. This is shown in Table 3. 
 
 This table signifies that when glycocoll, alanin, aspartic acid, glu- 
 tamic acid, prolin and arginin, together aggregating nearly two-thirds 
 by weight of the protein complex, are oxidized in the normal organism 
 in the proportion in which they may exist in meat, the respiratory quo- 
 tient is 0.915, whereas if 44.4 gm. of glucose is formed from them the 
 respiratory quotient sinks to only 0.675. 
 
 Of those amino-acids which do not yield glucose, three, valin, 
 leucin and lysin, which together aggregate 20 gm. according to 
 Osborne's (uncorrected) analysis of 100 gm. of meat, have 
 respiratory quotients of 0.75, 0.73 and 0.71, respectively, whereas 
 three others, phenylalanin, tyrosin and histidin, together amount- 
 ing to only 7.1 gm., yield respiratory quotients of 0.87, 0.89 
 and 0.90. Furthermore, the 1.07 gm. of ammonia liberated would tend 
 to reduce the quotient through urea formation. It is therefore obvious 
 that the respiratory quotient for protein in diabetes is made up pre- 
 dominately of the oxidation of the remnants of the sugar forming 
 amino-acids and from the oxidation of other amino-acids having in 
 the main respiratory quotients of 0.75 to 0.71. As actually calculated, 
 the above named mixture of non-sugar producing amino-acids would 
 yield 48.25 gm. of COa and require 45.86 gm. of oxygen for oxidation, 
 showing a respiratory quotient of 0.76. 
 
 The aggregate quotient of the non-sugar forming amino-acids as 
 
 . set forth above may be indirectly obtained by deducting the estimated 
 
 respiratory exchange of the sugar-forming amino-acids from that of 
 
 the total involved in the normal oxidation of 100 gm. of ox protein, 
 
 as shown in Table 4. 
 
 TABLE 4. — Aggregate Quotient of Non-Sugar Forming Amino-Acids 
 
 Carbon 
 
 Oxyen Dioxid Resp. 
 
 gm. gm. Quot. 
 
 Normal oxidation of 100 grams of beef protein 138.18 152.17 0.801 
 
 Estimated oxidation of the sugar forming 
 
 amino-acids 64.69 81.24 0.915 
 
 73.49 70.93 
 
 Add CO. for urea formation from 1.07 gm. NHa 1.39 
 
 Estimated oxidation of non-sugar forming 
 
 amino-acids 73.49 72.32 0.716 
 
 Although the last respiratory quotient 0.716 closely approximates 
 that of leucin (0.73) and lysin (0.71), the dominant non-sugar forming 
 amino-acids, it is evident that the influence of the other non-sugar 
 
GRAHAM LUSK 151 
 
 forming amino-acids would tend to raise the quotient to a higher level, 
 to 0.76 in the before mentioned calculation. Therefore, the present 
 figures can only be regarded as an attempted solution of the problem 
 lather than as a precise analysis. 
 
 When the mixture of six sugar-forming amino-acids, aggregating 
 64.5 gm., is normally oxidized 
 
 02 = 64.69 gm. and C02 = 81.24 gm. 
 
 and when it is converted into 44.4 gm. of glucose 
 
 02=17.34 gm. and C02= 16.11 gm. 
 
 the difference between these two sets of figures will represent the 
 quantities of respiratory gases which would not be involved in the 
 respiratory exchange in diabetes and would amount to 
 
 02 = 47.35 gm. and 00^ = 65.13 gm. 
 
 If one takes the grams of respired gases in the normal combustion 
 of 100 grams of protein as given by Loewy, and deducts from these 
 the quantity not eliminated according to the above computation, one 
 arrives at the following results for the diabetic respiratory quotient: 
 
 TABLE 5. — Protein Respiratory Quotient with D : N = 2.75 
 
 Carbon 
 Oxygen Dioxid 
 gm. gm. 
 
 Normal oxidation 100 grams beef protein 138.18 152.17 
 
 Deduct for intermediary production of 44.4 grams of 
 glucose 47.35 65.13 
 
 90.83 87.04 
 
 R. Q. = 0.697. 
 
 Proceeding now to the consideration of the cases of diabetes in 
 which the D:N is 3.65, calculations have been made the relations of 
 which may be thus presented : 
 
 TABLE 6. — Protein Respiratory Quotient with D : N = 3.65 
 
 (1). Normal oxidation of 100 grams of beef protein. 
 Deduction, if 16.28 grams N X 3.65 = 59.41 glucose. 
 
 
 Carbon 
 
 Oxygen 
 
 Dioxid 
 
 gm. 
 
 gm. 
 
 138.18 
 
 152.17 
 
 63.38 
 
 87.15 
 
 74.80 65.02 
 
 R. Q. = 0.632. 
 
 The respiratory quotient for fat is 0.707, and since fat forms the 
 main recourse of the diabetic, the respiratory quotient will be found 
 nearer to that of fat than to 0.632 for protein. Thus, in a diabetic 
 dog with a D :N ratio of 3.54 in which 23 per cent, of the total heat 
 production was derived from protein and 77 per cent, from fat, the 
 
152 CLINICAL CALORIMETRY 
 
 respiratory quotient was 0.687, the non-protein respiratory quotient 
 being 0.704, which closely approximates that of fat. In the case of 
 a diabetic patient with a low protein metabolism whose urinary D :N 
 was 3.6, Du Bois has found during a three hour period a respiratory 
 quotient of 0.697. In another diabetic man with approximately the 
 same D :N ratio but whose protein metabolism was higher (13 per cent, 
 of the total energy) the R. Q. was 0.691. 
 
 Magnus-Levy' has called attention to a possible reduction in the 
 respiratory quotient when beta-oxybutyric acid is formed from fat. 
 He estimates that the maximal quantity of beta-oxybutyric acid deriv- 
 able from 100 gm. of fat is 36 gm. Under these circumstances, the 
 respiratory quotient for fat would be reduced from 0.707 to 0.669. 
 The case is not so simple, however, for if the 36 gm. of acid formed 
 neutralized sodium bicarbonate, 15.23 gm. of carbon dioxid would 
 be eliminated. 
 
 These relations are shown in Table 7: 
 
 TABLE 7. — Theoretical Respiratory Quotient with Beta-Oxybutyric 
 Acid Formed from Fat 
 
 Oxygen Carbon Dioxid 
 
 Liters Liters R. Q. 
 
 100 gm. fat 201.9 142.73 0.707 
 
 36 gm. beta-oxybutyric acid 34.8S 30.96 0.889 
 
 167.05 111.77 0.669 
 
 Add for 15.23 gm. CO2 from NaHCOs 7.74 
 
 Possible end result 167.05 119.51 0.715 
 
 Since other bases than sodium bicarbonate may be used for the 
 neutralization of beta-oxybutyric acid, it is apparent that the exact 
 determination of the theoretical respiratory quotient when this acid 
 is produced in large amounts in human diabetes is at present impos- 
 sible. 
 
 This discussion has been prepared in order to further the under- 
 standing of a forthcoming description of metabolism in diabetes mel- 
 litus. 
 
 7. Magnus-Levy: Ztschr. f. Win. Med., 1905, Ivi, 83.