COLUMBIA LIBRARIES OFFSITE .HEALTH SCIENCES STANDARD HX00028835 HE ELECTROMETRIC TITRATION OF THE PLASMA AS A MEASURE OF ITS ALKALINE RESERVE DISSERTATION SUBiMlTTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE FACULTY OF PURE SCIENCE OF COLUMBIA UNIVERSITY BY GLENN E. CULLEN 1 NEW YORK 1917 ^?^v Lm College of ^t)?s!idan£i anb ^urgconif Hiljrarp Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/electrometrictitOOcull THE ELECTROMETRIC TITRATION OF THE PLASMA AS A MEASURE OF ITS ALKALINE RESERVE BY GLENN E. CULLEN This work was performed under the auspices of the Biochemical Depart- ment of Columbia University, in partial fulfilment of the require- ments for the degree of Doctor of Philosophy in the Faculty of Pure Science of Columbia University Reprinted from THE JOURNAL OF B-IOLOGICAL CHEMISTRY Vol. XXX, No. 2, June, 1917 Reprinted from The Journal of Biological Chemists t, Vol. XXX, No. 2, 1917 STUDIES OF ACIDOSIS. III. THE ELECTROMETRIC TITRATION OF PLASMA AS A MEASURE OF ITS ALKALINE RESERVE. By GLENN E. CULLEN. {From the Hos-pilal of The Rockefeller Institute for Medical Research.) (Received for publication, April 26, 1917.) It has been definitely established that the reaction of the blood is, under normal conditions, constant (Limdsgaard, 1912) and may be kept constant even under pathological concUtions in- volving great lowering of the alkaline reserve (Michaehs, p. 10.5; Benedict, 1906; Peabody, 1914; for more detailed discussion see Paper I of this series). Consequently, the hydrogen ion concen- tration (CH)~-of the blood as drawn from the veins cannot be taken as an indicator of the alkaline reserve. We may expect, however, that when a given amount of acid is added to the blood, the resultant change in Ch '^'iH be greater the less the reserve alkali; or conversely, that less acid will be necessary to produce a given increase in Cg. The latter prin- ciple is essentially that used in methods for titration of the blood with indicators, acid being added until the Ch is reached at wh^ch the indicator changes color; and titration methods have contributed greatly to our knowledge concerning the alkaline reserve of the blood and its changes in acidosis (Jaksch, Magnus- Levy, Pembrey, and Spriggsj. The interpretation of such re- sults, however, is clouded by two deficiencies inherent in the method. First, the indicators (Bjerrum, 1915), such as methyl orange, which can be used to titrate carbonates as alkah change color at such a high Ch that the titration measures, in addition to the bicarbonate, also an acid binding power of the proteins quite out of proportion to the amounts of acid which these sub- stances can bind "within the Umits of Ch possible in life (the phosphates of whole blood also act as buffers like proteins, but they play a minimal role in plasma) . Second, the proteias dimin- 369 370 Electrometric Titration of Plasma ish by their buffer effect and by absorption of indicator the sharp- ness of the end-points, and thereby decrease the accuracy of the titrations. Attempts to overcome these difficulties by precipi- tating the proteins with neutral agents such as ammonium sulfate are criticized because the precipitated protein carries down with it a considerable part of the alkali (Hoppe-Sejder). Of the above two difficulties the first is inherent in every mode of titrating blood against strong acids. The second, however, can be avoided by determining the Ch of the end-point electrometrically instead of by indicators, so that even with small amounts of blood or plasma results reproducible with a high degree of accuracy can be obtained. The present paper presents the results of an attempt to develop the electrometric titration into a form prac- ticable for use with normal and pathological plasmas, — and the comparison of the method so developed with the determination of the carbon dioxide combining capacity of the plasma (Van Slyke and Cullen, 1917), and of the carbon dioxide tension of the alveolar air (see Paper VI of this series) . The principles of the gas chain method and its practice have been so thoroughly reviewed in recent literature (Soerensen, 1912; Hildebrand, 1913; Michaelis, 1914; Clark and Lubs, 1916) that only the necessary details are given here. Apparatus'. All determinations of the H+ concentration were made by use of the well known gas chain. Saturated KCl The mercury for the calomel cells was purified in the wet way, distilled three times by Hulett's method (1911), and filtered. The calomel was made from this mercury by the method of Loomis and Acree (1911) .^ The n/10 KCl solution was prepared by weight from recrystalhzed Kahlbaum's KCl and the standardi- ^ Electrodes prepared from this calomel have not been very satisfac- tory. In later work with the gas chain the calomel has been prepared electrolytically as described by Ellis (1916). The calomel has been kept under acid and prepared for use by washing by decantation only. Cells prepared from such calomel remain entirely constant for long periods. Hg HgCl n/10 KCl Solution Ho Pt G. E. CuUen 371 zation verified by chloride determinations by the McLean and Van Slyke method. The hydrogen was taken from tanks of the Standard Oxygen Company and was washed thi'ough solutions of HgCl2, KMnO^, pyrogallol (twice), dilute H2SO4, and water. This proved to be a convenient and satisfactory source of hydrogen. The electrodes were made from No. 16 and No. 18 platinum wire sealed into glass tubes and platinized with platinum black. Small Clark electrode vessels of about 2 cc. capacity were used, together with the ingenious Clark shaking de"vice (Clark, 1915). This vessel is similar in principle to that of Hasselbalch (1911, 1913), but is superior to it both practically and theoretically. It is designed to give maximum surface of solution and elimination of dead space, and to reduce the contact potential between the solution and saturated KCl solution to a negligible quantity. It is easily manipulated, requires only a small amount of fluid, and gives such thorough contact of solution and electrode that . equihbrimn is established inside of a few minutes. This appa- ratus is especially convenient when working with carbon dioxide containing fluids, for it allows easy and economical renewal of the solution wdthout change of hydrogen, the procedure proposed by Hasselbalch. The substitution of a 60° 3-way stop-cock with a 2-way key for the lower stop-cock of the Clark vessel is a decided convenience. Several calomel electrodes were kept on hand, and compared frequently with one another. An absolute standard was thus maintained, and the readings corrected with it. Weston cells cahbrated by the Bureau of Standards gave the standard poten- tial. The readings were taken during the earUer part of the ■work with a bridge of 1,110 ohms resistance boxes and electrom- eter as zero point instrument. The external resistance was so adjusted that ohms equalled milHvolts. Later a Leeds and Northrup potentiometer with a galvanometer as zero point instru- ment was installed. The determinations were run at room temperature, 18-24°, and temperature corrections applied. The accuracy of the entire determination was tested often by means of Soerensen's standard phosphate and Walpole's standard acetate mixtures of known hydrogen ion concentration. 372 Electrometric Titration of Plasma The n/50 acid used in the titrations was prepared by weight from a standard HCl prepared by Hulett and Bonner's (1909) method and checked by gravimetric silver chloride determinations. Hasselbalch and Gammeltoft (1915) report that freshly plat- inized electrodes are essential. Our experience entirely corrobo- rates this observation. The electrodes were always carefully cleaned before each determination in accordance with the follow- ing routine. The washed electrodes were placed as cathode in the reducing vessel containing 5 per cent H2S0^ for 3 minutes where the bubbling hydrogen removed a considerable quantity of precipitated protein that could not be washed off. Then they were rinsed with water, placed as cathode in the platinic chloride solution for 2 minutes, rinsed, returned to the reducing vessel for 3 minutes, rinsed thoroughly with tap water, and finally with distilled water. The electrodes were often checked against the standard solutions. Calculation of Results. All H+ concentrations are expressed by Soerensen's symbol pH, the negative Briggs logarithm of the hydrogen ion concen- tration. pH values are more easily visualized and plotted than those of Ch, the actual hydrogen ion concentration. The equation for the calculation of results was: 1 „ E- 0.337 log -7^ = pH = 0.0577 [1 + (t° - 18°) 0.0002] In our work the variations in potential and temperature were such that it was most convenient to construct tables giving pH directly from the observed readings. We used the rounded value- of 0.337 for the n/10 calomel electrode adopted by the Potential Commission (Auerbach). Preparation of Solution. All our determinations have been made on plasma rather than whole or defibrinated blood; because removal of the corpuscles ehminates the greater part of the oxygen and consequently allows much quicker reduction of the solution by the hydrogen electrode. G. E. CuUen 373 The blood was drawn into a tube containing a small amount of powdered potassium oxalate (always less than 0.5 per cent) to prevent clotting, centrifuged at once, and the plasma pipetted off. Experiments proved that the oxalate had no effect on the determination. If it was impossible to run the determination at once, the plasma was placed in a stoppered paraffined tube in the refrigerator. In comparing the alkaline reserve of different plasmas by titra- tion with acid, two methods are available. First, the amount of acid required to bring the plasma to a definite H+ concentration may be determined by a series of determinations and consequent plotting of the titration curve. Or, second, the H+ concentra- tion resulting from the addition of an arbitrarily fixed amount of acid may be found. This is the most economical, both of time and blood, the deciding considerations when series of observa- tions on a number of patients are desired. We therefore used the former only to select suitable conditions to use in this investigation. However, since the initial reaction of all plasmas is practically constant and the titration curve is almost a straight line, it is entirely possible to construct the curve from one determination and from it determine the amount of acid required to bring the plasma to any desired reaction. H2CO3 It is evident from the analysis of the equilibrium • ^^^ that JN axlUUs all samples must be brought to a definite CO2 content. The con- ditions under which the blood is drawn, the time elapsing before determination, etc., are so variable that the plasma cannot be used as it is. Its CO2 content must either be fixed under definite conditions, or the CO2 must be removed. Two procedures have been followed. The first was worked out for and used throughout the investigation of the first series of experiments on diabetic acidosis; the second was developed on the basis of experience with that series. Technique of Determination. Procedure A. — It was found that two successive shakings in an evacuated vessel, as described in the next paragraph, reduced the CO2 content to a fairly constant level. Experiments with 374 Electrometric Titration of Plasma n/50 HCl showed that more than three volumes of this acid per volume of plasma precipitated some of the proteins. The addition of one volume of n/50 acid to one volume of plasma (Fig. 1) brought normal plasma to about the neutral point. Plasma with less than normal alkaline reserve would, under the same conditions, fall on the acid side of the neutral line. The oxalated blood was centrifuged and the plasma pipetted off. About 3 cc. of the plasma were placed in a 300 cc. separatory funnel, which was evacuated by means of a water aspirator to a pressure of about 20 mm. The funnel was then rotated for 3 minutes to insure maximum surface and permit the escape of carbon dioxide from the solution. Air was then admitted, the funnel was evacuated, and was again rotated for 3 minutes. Exactly 1 cc. of this plasma was then measured into a 3 cc. drop- ping funnel, and 1 cc. of n/50 HCl added (cahbrated 1 cc. pipettes were used for both acid and plasma); the funnel was closed by means of a small rubber stopper and the solution mixed, without shaking. The mixed solution was then allowed to flow through a small piece of rubber tubing into the Clark electrode, displacing part of the hydrogen with which the vessel had been filled. The care taken in mixing and introducing the acidified solution was to prevent loss of CO2. The vessel was then shaken for 3 or 4 minutes, the electrode adjusted to minimum contact, and the potential read. The vessel was shaken again 3 or 4 minutes, a fresh contact with the saturated KCl solution was made, another reading taken, and the process was continued until equilibrium was reached, which usually was at the second or third reading. Procedure B. — The method outlined under A is open to the ob- jection that careful attention is required to bring the carbon dioxide to the arbitrary level. This possibihty of error can be eliminated by adding enough acid to complete the reaction NaHCOs + HCl = NaCl + H2CO3, and then removing aU the carbon dioxide by evacuation. The carbon dioxide tension of the plasma is thus eliminated as a factor in the results, and the hydrogen ion concentration is dependent on the equilibrium be- tween the plasma buffers, chiefly the proteins, and the excess of acid not neutrahzed by bicarbonate. It was found that the addi- tion of two volumes of n/50 HCl to one of plasma was sufficient to effect complete decomposition of the bicarbonate, and the re- G. E. CuUen 375 suiting solution after removal of the carbon dioxide showed a Ch of about 10"^-^ (pH = 5.6). At tiiis point the equihbrium in the electrode vessel is obtained much quicker than at the neu- tral point. This procedure has, over A, the advantages of greater rapidity, the use of smaller amounts of plasma, and the elimina- tion of variations in the carbon dioxide content as a source of error. It has the disadvantage, compared with procedm-e A, in that the differences in pH corresponding to given differences in ''alkaUne reserve" are not so great. In procedure B two volumes of n/50 HCl are added to one of plasma (the amounts being usually 2 and 1 cc. respectively) in a small separatory funnel, 25 to 100 cc, the solution is exhausted with a water aspirator to about 20 mm., and agitated for 1 min- ute. One exhaustion completely removes the carbon dioxide. The solution is then transferred to the electrode vessel by a pipette, allowed to displace part of the hydrogen, and the reading obtained in the same manner as in A. EXPERIMENTAL. The Determination of the Optimum Amouiits of n/oO Acid. Samples of oxalated plasmas were exhausted twice with the water aspirator and the H+ of the exhausted plasma determined. Then a series of determinations was made varying the ratio of acid and plasma volume as shown in Fig. 1. /fc/-CcWo.o2 per/cc.p/os/rto (cog exhausted) Fig. 1. 376 Electrometric Titration of Plasma It is evident that the addition of one volume of n/50 acid to one volume of plasma brings normal plasma to about the neutral point. The acidosis plasma affords an extreme example of diminished alkaline reserve. Determination of the Number of Exhaustions Required in Water Aspirator. Samples of plasma were saturated with alveolar air (5.5 per cent CO2), portions were placed in separatory funnels, and ex- hausted on a water aspirator to about 20 nun. for periods of 3 minutes each. During the exhaustion the funnels were rotated constantly to expedite the escape of the CO2 from the solution. Air was admitted to the funnels between exhaustions. 1 cc. por- tions were then mixed with 1 cc. portions n/50 HCl in 3 cc. drop- ping funnels, as described above, and the contents run into the electrode vessels (Table I) . TABLE I. Number of Exhaustions Needed for Procedure A. pH after Adding One Volume n/50 HCl to Exhausted Plasma. Human plasma. Treatment of sample. Saturated with 5.5 per cent CO2. Exhausted once. * Exhausted twice. Exhausted three times. pH pH pH pH 1 6.42 6.67 6.69 6.69 2 6.66 6.76 6.78 6.78 3 6.47 6.63 6.63 6.45 6.62 6.62 4 7.03 7.03 .7.03 * Each exhaustion lasted 3 minutes. It appeared from the above that two exhaustions were sufficient for our purpose, and it was desirable to avoid as far as possible concentrating the plasma by evaporation. Later, however, the perfection of Van Slyke's CO2 apparatus furnished an accurate and convenient means of checking the above experiments. The amounts of carbon dioxide remaining after successive exhaustions were determined. The plasma was placed in large separatory funnels, the exhaustions were carried out as described under pro- G. E. Cullen 377 cedure A, and a 1 cc. sample was removed for analysis after each exhaustion (Table II). TABLE II. Number of Exhaustions Needed for Procedure A. Total Residual CO2 Determined by Van Slyke's Method. Corrected to 0", 760 Mm. a to CO 2 remaining after g 6 . d d . a 6 s 6 d ja a s d d d Human "m "to ■+^ plasma. 2^ a "og 3 og OJ °g o3 0;^ ^ 'o'i « 3 11 II oa J3 fi5 ^ g M II CO J3 11 ■§" « &■§ -0 Sta "H gts J3 " _« §■§ cc " P-, cs Ph CO Ph ■* (^ to ^ cc. cc. cc. cc. cc. cc. G 0.79 0.60 76.2 0.54 68 0.49 62 0.48 60 0.45 57 A 0.72 0.53 73 0.43 60 0.40 56 0.38 53 0.38 51 An 0.75 0.55 73 0.45 60 0.41 54 0.38 51 0.775 0.57 74 0.52 67 0.46 59 0.43 55 0.40 51 It is evident from Table II that exhaustion was not complete. This was expected. However, the variations after two exhaus- tions were so small in their effect on pH, as demonstrated in Table I, that accurately reproducible results are obtainable when two exhaustions, carried out as described, are used as the arbitrary standard. That the arbitrarily selected double exhaustion approximates to a constant carbon dioxide content is also evident from the curves constructed from these values in Fig. 2. The carbon dioxide as a source of error has been entirely elim- inated in procedure B by the use of larger amounts of acid and exhaustion after its addition. The following experiment shows this (Table III). Two volumes of n/50 acid were added to one volume of plasma in a separatory funnel. The funnel was exhausted to about 20 mm. for 1 minute, with constant rotation. 1 cc. was taken for analysis and the exhaustion repeated. The amounts of residual gas in column 3 are entirely com- parable with the "dissolved air" correction in this method; therefore no measurable amounts of carbon dioxide were present. 378 Electrometric Titration of Plasma £xhaujfions 4 s Fig. 2. From Table II. TABLE III. Number of Exhaustions in Water Aspirator Needed after Adding Two Vol- umes of n/50 HCl. Dissolved Gases Determined by Van Slyke's Method. 30° and 762 Mm. Sample plasma. Exhausted 3' with shaking. Gas observed. Dissolved air calculated as present. CO2 present. Mixed normal cc. 0.04 0.04 0.045 0.04 0.05 cc. 0.044 0.044 0.044 0.044 0.044 cc. 0.000 Same saturated with 6.3 per cent CO2 0.000 A 000 Dog 0.000 H 000 Comparison of Two Procedures for Removing Carbon Dioxide. Hydrogen ion concentrations were determined on two plasmas. Each was then divided in two portions, one of which was placed in a separatory funnel and was exhausted 3 minutes as in procedure A. 1 cc. samples were then mixed with various vol- umes of n/50 acid and the resulting reaction was determined. To samples of the other portions in separatory fimnels varying volumes of n/50 acid were added and the mixtures exhausted G. E. CuUen 379 for 1 minute. The results are given in Table IV and plotted in Figs. 3 and 4; it is evident that the two series differ but little. TABLE IV. Comparison of Procedures A and B. Plasma n/50 acid per cc. plasma. A (exhausted twice before adding acid). B (exhausted once after adding acid). P. cc. pH = 8.63. 0.5 7.73 7.56 7.74 7.58 1.0 6.74 6.74 6.68 2.0 5.43 5.34 5.42 5.33 3.0 4.54 4.40 4.53 4.40 M. pH = 8.61. 0.5 7.76 . 7.83 1.0 6.88 . 6.87 2.0 5.47 5.48 Ccaoz !/HClpsi'l<^^- p/asmej 'P' (norm at] Fig. 3. 380 Electrometric Titration of Plasma 9 a 6 C C. O.OZ NHCI percc.p/asma"M-(normo/) Fig. 4. Ex-periment to Determine the Effect of Oxalate on the Titration of Plasma. Solutions of m/10 phosphates and of normal plasma were made up with varying concentrations of potassium oxalate. H+ con- centration determinations were made as indicated in Table V. It is evident that in plasma oxalate up to 0.5 per cent does not produce an appreciable change and that the change produced by 1 per cent is within the allowable limits of experimental error. About 0.2 to 0.3 per cent is ordinarily sufficient to prevent clotting. ' TABLE V. Effect of Oxalate. On pH of m/10 phosphate solution concentration. On pH of m/10 phosphate solution + 1 vol. n/50 HCl concentration. On pH of normal plasma treated by procedure B (2 vol. n/50 acid added) concentration. K oxalate. pH. K oxalate. pH. K oxalate. pH. per cent 0.2 0.6 1.0 1.6 2.0 7.50 7.47 7.47 7.44 7.45 7.94 per cent 0.25 0.5 1.0 6.74 6.74 6.74 6.72 per cent 0.5 1.0 2.0 4.0 5.38 5.38 5.39 5.45 5.53 G. E. CuUen 381 Effect of Renewing Solutions in Electrodes. Hasselbalch pointed out the possibility of renewing succes- sively the solutions in the electrode without renewing the Ha as a means of bringing the CO2 content of the electrode gas to equi- hbrium with that of the solution. The following experiment (Table VI) shows that this precaution is unnecessary with the small amount of residual CO2 present under procedure A. TABLE VI. Effect of Renewing Solution without Change of Hn Atmosphere. New Solu- tions Were Run into the Electrode Vessel Displacing the Used Solution without Changing the Hi Bubble. Plasma. pH of 1st determination. pH of renewed solution. . E. s. u. H. M. M. 2. 8.13 8.14 7.11 7.11 6.48 6.48 7.03 7.03 6.55 6.58 6.89 6.91 6.99 6.99 Accuracy of the Method. Clark has pointed out the possibiUty of accuracy attainable with his electrode. With plasma we have considered 1 millivolt = 0.02 pH our permissible error. This amount is very small in comparison with the gross differences we have obtained in the clinical studies. Table VII gives samples of the results obtained in dupHcate determinations. Titration of Plasma Containing Lactic and ^-Oxybutyric Acids. Since a diminished alkaline reserve is the result of the introduc- tion of abnormal acid products of metaboHsm, it seemed desir- able to investigate the effects of adding such acids to a normal plasma in vitro. The results of such experiments are shown in Tables VIII and IX, and Figs. 5 and 6. These experiments were performed as follows: Experiment I. Curves A and B. — A weighed amount of acid was added to a portion of plasma to make the plasma 0.2 per cent acid solution. This solution was then mixed with untreated plasma in varying proportions and the resulting mixtures were 382 Electrometric Titration of Plasma TABLE VII. Duplicate DelerminalionsMade loilh Different Electrodes in Different Vessels. Procedure A. Procedure B Plasma (human) . Date. il H '-3 Pi 0. Plasma. Date. to a •3 °C milli- volts °C. milli- volts A. May 15 23 723 6.57 Dog VIII. 25 630 4.96 23 722 6.55 23 627.7 4.96 W. " 25 24 742 6.87 (( June 14 25 627 4.91 Normal. 23.5 740 6.85 23 626.6 4.93 V. " 26 23 744 6.93 v.* (human). (( 13 25 650.4 5.30 Normal. 23 744 6.93 26 26 652.5 651.6 5.33 5.31 M. " 23 24 749 6.99 26 651.6 5.31 Normal. 749,5 7.00 26.5 652.3 652.2 5.32 5.32 H. March 21 20 723 6.64 21 723 6.62 Dog 2 a. it 10 25 26 620 622.6 4.98 4.91 " 2 b. te 10 25 26 631.5 632 4.98 4.97 " 3. t( 11 22 630 630.1 5.00 5.00 * These six determinations were run with six distinct pipettes, funnels, and electrodes, and in two electrode vessels. titrated by both A and B methods. The acids were analyzed by adding excess n/7 NaOH, warming on a steam bath for a couple of hours, and titrating back with n/7 HCl using phenolphthalein. /9-Hydroxybutyric acid analyzed. Lactic acid analyzed per cent 100 95.2 Experiment II. Curve C. — The acids used in the preceding experiment had not been treated to remove any anhydride that might have been present; the experiment was therefore repeated. G. E. CuUen 383 TABLE VIII. . Effect of Organic Acids on the Titration Curve. Normality of organic acid on basis of plasma volume only. 1 vol. plasma + 1 vol. n/50 acid. Curve A. 1 vol. plasma + 2 vol. n/oO acid. Curve B. /3-Hydroxybutyric acid (Fig. 5). PH pH 6.73 5.34 6.72 5.35 0.0094 6.55 5.16 6.55 5.16 0.024 5.84 4.85 5.84 4.85 0.047 5.08 4.58 5.07 4.57 0.094 4.59 4.29 4.58 4.28 0.189 4.15 4.00 t 4.00 Lactic acid (Fig. 6). 0.011 6.26 4.94 6.24 4.94 0.028 5.355 4.565 5.345 4.575 0.056 4.58 4.18 4.18 0.11 4.03 3.83 4.02 3.83 0.22 3.64 3.48 3.65 3.48 0.225 gm. of lactic acid was placed in a flask with 30 cc. of n/10 sodium hydroxide, placed on the steam bath for 2 hours, 50 cc. of n/10 HCl were added, and the solution was diluted to 100 cc. The solution was then n 0.025 to lactic acid and n 0.02 to hydro- chloric acid. 2 gm. of CaZn /S-oxybutyric acid salt were treated with three- fourths of its equivalent sulfuric acid and the hberated acid was extracted with ether in a wet extractor. The ether was evapo- rated off .over water and the solution diluted to 100 cc. The amount of acid was titrated with sodium hydroxide as in lactic THE JOURNAL OP BIOLOGICAL CHEMISTRY, VOL. XXX, NO. 3 384 Electrometric Titration of Plasma acid. 0.130 gm. of tliis acid was then treated with 15 cc. of n/10 sodium hydroxide heated on the steam bath for 2 hours, 25 cc. of n/10 HCl were added, and the solution was dihited to 50 cc. Tins sokition was then n 0.025 to /3-oxybutyric acid and n 0.02 to hj^drochloric acid. TABLE IX. Effect of Organic Acid on the Titration Curve. Solution A. 1 vol. plasma + 2 vol. n/50 HCl. Solution B.* Normality of organic acid on basis of plasma volume only. Lactic acid. Curve C, Fig. 6. ;3-Hydroxybut5n:ie acid. Curve C, Fig. 5. pH pH _ 4.55 4.55 4.0 0.5 0.0055 4.41 4.45 4.0 1.0 0.01 4.32 4.39 4.0 2.0 0.0166 4.20 4.31 3.0 3.0 0.025 4.09 4.24 1.0 3.0 0.037 3.96 4.15 ♦ 0.05 3.85 4.07 * Solution: /8-oxybutyric acid or lactic acid, n 0.025; hydrochloric acid, N 0.02. ao5 oT A/orma//Va o/ fi Mydroyybufaric Ac/i^ Fig. 5. G. E. CuUen 385 The normality figures in A and B do not represent actual amounts of free acid due to the presence of undissociated anhy- dride, but they do indicate the change in the titration curve caused by the accumulation of such acid. Curve C indicates the nature of the decreased reserve in a dog plasma with very low reserve. The normality figures here represent actual values. . 0.05 O.I O.I5 Normolity of Loctic Acid Fig. 6. Range of Normal Values. Table X shows the variations in normal plasma in cUfferent individuals at different tunes. The values m a healthy man may change on titration with one volume of n/50 acid from a pH of 6.75 to 7.00 during the course of the day. The corresponding figures for titration with two volumes of n/50 acid are from a pH of 5.60 to 5.90. Dogs have a lower reserve averaging around a pH of 5.00. The normal base line for titration with one volume of n/50 acid in the accompanying charts is taken at 7.00; with two vol- umes at 5.6. The normal limits for the ''carbon dioxide combin- 386 Electrometric Titration of Plasma ing capacity" is from 55 to 70. The normal alveolar carbon dioxide tension in mm. is about 38. From a number of compari- sons the ratio between plasma carbon dioxide volume per cent and alveolar carbon dioxide tension in mm. has been established as 1.45 (see Paper VI). TABLE X. Table of Normal Variations. Procedure A Procedure B. 1 vol. plasma + 1 vol. n/50 acid. 1 vol. p asma + 2 vol. n /50 acid. Plasma. Time.* pH. Plasma. Time. pH. M. a. m. 6. 80 Dog 1. a.m. 4.81 p.m. 6.80 p. m. 5.02 V. May 15, a. m. 7.04 " 2. a. m. 5.18 p. m. 6.89 p. m. 5.24 " 17, a. m. 6. 96 p.m. 6.94 " 3. a. m. p. m. 4.91 5.23 D. a. m. 7.10 p. m. 7.60 M. May 18 " 22 5.50 5.63 P. a. m. 6.73 p.m. . 6.84 F. 5.69 S. a. m. 2 p. m. 4 6 '.' 6.65 6.74 6.71 6.82 P. 5.50 c. May 19, a. m. p. m. « " 22, p.m. 6.58 6 83 6.83 6.85 * Indicates before and after meals. Application of the Method. The charts of diabetic patients followed for a long period by the electrometric titration of plasma, simultaneously with the deter- mination of CO2 combining capacity of blood and plasma, alveo- lar air, and acid excretion^ are given in Paper VI of this series. G. E. CuUen 387 The values of simultaneous determination of the "carbon dioxide combining capacity" and alveolar carbon dioxide are also shown, since it was one purpose of this series of observations to select the most suitable method for determining the actual amount of "alkaline reserve" in the body. The samples of blood were obtained from the arm, were drawn through a McRae needle into tubes containing a small amount of potassium oxalate, and centrifuged at once. The determina- tions were, with a few exceptions, done at once, but samples may be kept for a considerable time in paraffined tubes. The observations were divided into two periods; the first cover- ing the spring of 1915, the second that of 1916. The electrometric titrations on the first series were done by procedure A — ■ 1 volume of plasma + 1 volume of n/50 HCl; on the second series by procedure B — 1 volume of plasma + 2 volumes of n/50 HCl. This eliminated the theoretical objection of possible error due to the presence of carbon dioxide, but proved to have the disadvan- tage of lessening the sensitivity of the titration, in that for given decrease in carbon dioxide combining power the corresponding change in pH was less than with one volume of acid. CONCLUSIONS. The conclusions are evident from the charts. The two methods of determining the "alkaline reserve" are entirely comparable and furnish a reliable index of the reserve actually existing in the body. The titration of the plasma includes the influence of all the "buffers," not only the sodium bicarbonate, but also the pro- teins and the minute amounts of phosphates. The fact that the electrometric titration of the plasma gives results parallel with the carbon dioxide combining capacity indicates that the latter is proportional to the total "buffer" content of the plasma. SUMMARY. 1. The gas chain method of determining hydrogen ion concen- tration has been utilized in the titration of plasma and the con- ditions for successful operation have been determined. 2. Values for normal and pathological plasmas have been determined. 388 Electrometric Titration of Plasma 3. The method has been compared with that of the carbon dioxide combining capacit}^ in a long series of diabetic patients, and the close agreement of the two methods has been estabUshed. BIBLIOGRAPHY. Auerbach, F., Z. Electrochei7i., 1912, xviii, 13. BjeiTum, N., Samml. Chem. u. Chem.-Tech. Vortr., 1915, xxi, 1. Benedict, H., Arch, ges Physiol., 1906, cxv, 106. Clark, W. M., J. Biol. Chem., 1915, xxiii, 475. Clark, W. M., and Lubs, H. A., /. Biol. Chem., 1916, xxv, 479. Ellis, J. H., /. Am. Chem. Soc, 1916, xxxviii, 737. Fridericia, L. S., Berl. klin. Woch., 1914, li, 1268. Hasselbalch, K. A., Biochem. Z., 1911, xxx, 317; 191.3, xlix, 415; Compt. rend. Lab. Carlsberg, 1911, x, 69. Hasselbalch, K. A., and Gammeltoft, S. A., Biochem. Z., 1915, Ixviii, 205. Hildebrand, J. H., J. Am. Chem. Soc, 1913, xxxv, 847. Hoppe-Seyler, F., and Thierfelder, H., Handb. physiol. u. path. Chem. Analyse, Berlin, 7th edition, 1903. Hulett, G. A., and Bonner, W. D., J. Am. Chem. Soc, 1909, xxxi, 390. Hulett, Physical Rev., 1911, xxxiii, 307. von Jaksch, R., Z. klin. Med., 1888, xiii, 350. Lipscomb, G. F., and Hulett, G. A., J. Am. Chem. Soc, 1916, xxxviii, 20. Loomis, N. E., and Acree, S. F., Am. Chem. J., 1911, xlvi, 585. Lundsgaard, C, Biochem. Z., 1912, xli, 247. Magnus-Levy, A., Arch. exp. Path. u. Pharm., 1899, xlii, 149. McLean, F. C., and Van Slyke, D. D., J. Am. Chem. Soc, 1915, xxxvii, 1128. Michaelis, L., Die Wasserstoffionenkonzentration, Berlin, 1914. Peabody, F. W., Arch. Int. Med., 1914, xiv, 236. Soerensen, S. P. L., Ergebn. Physiol., 1912, xii, 293. Stillman, E., Van Slyke, D. D., Cullen, G. E., and Fitz, R., J. Biol. Chem., 1917, xxx, 405. Walpole, G. S., J. Chem. Soc, 1914, cvi, 2501. Van Slyke, D. D., J. Biol. Chem., 1917, xxx, 347. Van Slyke, D. D., and Cullen, G. E., J. Biol. Chem., 1917, xxx, 289. APPENDIX. (pages 413-456.) Assembly of "charts of diabetic patients" referred to on page 386. (Quoted from a paper by Stillman, Van Slyke, Cullen, and Fitz; Journal of Biological Chemistry, 1917, xxx, 413.) CASES 413 414 Blood, Urine, and Alveolar Air in Diabetes 1. Case 2481. Date. "3 "3 o a 2 2 1 >> O -e O 6 o 03 8 > 6c 1915 gm. gm. gm. mm. mm.xi.45 cc. PH Apr. 30 80 7.5 5.0 37.0 53.6 52.2 1.41 6.66 May 1 160 15.0 10.0 2 Fast day. 3* li a 4 Green veg . only containing 16 21.5 31.2 27.0 1.26 5.76 5 a i( it it 40.5 6 a « It it 60.0 29.2 42.3 44.1 1.51 6.51 7t it it It It 11.5 8 375 29.0 25.0 5.0 9 630 50.0 43.0 it 10 it it (( it 11 it " a it 12 a it a " 40.2 58.2 54.5 1.35 6.67 13 it a a " 14 655 51.5 43.5 10.0 32.4 47.0 50.2 1.55 6.70 15 170t 13.5 12.5 16 Fast day. 17 Green veg . only containing 10.0 18 it it it « 20.0 32.0 46.4 51.9 1.62 6.61 19t it it « It 12.5 20 Fast day. 21 355 24.5 23.5 10.0 27.3 39.6 51.2 1.88 6.50 *Drow8iness. fPartial fast. Stillmarij Van Slyke, Cullen, and Fitz 415 |>H+lHcl PLASMA C02 AUVCOUAR C02XI-45 CASENO.a-4Sl ^0 4 6 idl5APR«L 12 i4 MAY 1. Case 2481, female, age 12. Diabetic less than 3 months, mild, fair ability to burn carbohydrate (shown subsequently by a carbohydrate tolerance test). The curves show a dangerous acidosis when the patient was placed on a fast. This was accompanied by clinical symptoms. The acidosis was ameliorated when a carbohydrate diet was instituted. The drop in alveolar CO2 on the last day was evidently due merely to change in res- piratory control. (From April 30-May 21, 1915.) Group IV. THE JOURNAL OF BIOLOGICAL CHEMISTBT, VOL. XXX, NO. 2 ■E OAg/V- 08 •»*< CO ic d d d ■-H i-H cq 05 CO d lO 05 CO lO 00 to CO CD oq CO CO d CO to d CO oAt^V CD t^ to d d ci CO CO lO ^ d d CM oq d oq d CO 1— ( d T-l »o d 1—1 •jajT[ jad ppv z^ 00 o CO lO 00 CD CO oq 00 1— ( oq ?5 o oq CO 1—1 ■j»^ij J9d EaiQ z o o 00 lO TtH —1 CO -^ CO CO CD o CO to ■^ to oq 00 to . CO to to CO •siq 1-0 -"Sd lOA 8 o o o O ^ CO CO CO lO CO of o •o o CO of o ^^ of to o CO" of of o o CO 73 8 m ■lOH OS/N • I O A a; i^- CO CO t^ o lO CO o d oq 1— 1 to d 00 CO d oq oq d o d CO oq d 9|OqM -00 001 Xq punoq zqq " CO Oi 5! 1—1 to d CD to 00 oq 05 too '•^I'^ 'tnui tQO 'Bras'B|d ot;bh ■^ CO lO lO T-l I— 1 I— 1 CO 05 CD 00 ! ^ o oq •„0K ^B Bra -s^id '00 001 Xq pnnoq SQO s CO o -^ d CO CO CO lO T-l o 05 00 to ■* s to to d CO ■COO -iBIoaAiv X s s 05 rH CO CO CO 00 CO CD CO CO to CO to oq oq d 0<) CO s ci CO CO CO o 00 05 o i-H CO to oq 1— ( CO 00 d 01 - 2 2 ^ "S d o o o > 2 2 O to d o 1— 1 o oq bO a '2 o o o • M ^^ H 2 :: •ure^oij lO -. ^ - t^ - - -- to t^ to o CO •saTJo['BO i^ijox O o o 00 CO 1-H CO Q to S • * » * -Q CO ■* lO CD « (M (N (M (N 1^- 00 05 C^ (M (M oi CO ■* to iO !>. 00 Oi o 1— 1 1— ( 1— 1 oj CO 1— 1 1—1 -* to 1—1 1— ( 416 PH 65 45. 6 so 454ff-l 40 4.9 do So - 50 45" 25 PLASMA ^H+aHel ' ■ ■_■ 'J ' 23 25 Sa isieree. ' ' ' ' ' ■ ' ' t ' ■ I 6 d lO IS IS OAg^-08 !M 05 05 (M (M CO CO ^_l Oi t^ (M Tt^ o lO o o CSI - 0Ag\ 00 1-1 >0 00 05 GO oi 03 T— 1 00 lO ■* CO Ol C'l > o ■* ■* 00 o t^ lO lO 'is%-ii Jed ■Baifi as CO CO CD CO CD CO o 03 b <>q ^ O lO o »o o o iO o lO o o Tt< t- o CM CO CD •sjq ^0 Md "lOA u oo o> -* CO CO o (M CO r-i (M CO CO CO CO CO CO lo CD 00 lO o CD »o 05 aioqM. 00 001 g ^ t^ Oi CO CD ^ ,_, 1^ 7-H Aq pnnoq ZQO oq (M CO ■o CD CO lO to lO >« ^ O CO Tt< CO lO CO (M CO CO V CO CO CO t^ ,_i (M CO 00 00 (M CO CO CO ^ ■* T}^ "* TJI ■ZQO iBioaAiv s CO o o 03 CO (M 00 CO CO CD >o CO lO 00 Oi a> CO CO T— 1 (M Cfl cq (M c^ c<\ CO CO CD 05 CO -* O Tf* 00 00 00 •;q3isAi j^pog Cn lO lO lO >^ CD t^ CD lO U5 in IM C^ (M CQ (M (M (M c^ (M (N o o o o O O o o o o o o o o o •e^BjpXqoqjBQ i CVl CO ■* lO CD t- 00 05 O ^ CM CO ^ lO 6D c c •^'Bd: s ■a OS o "* " ■* " ■* N. V* " ~* V. N. >- ■* - 5 CJ c N» V« %« ^« N* >• s. s« >« N* ^« >« v« ^ •nieioJ, o > V. V. - .- ^ N. y. >- V. N. V, ,^ ~- V. as ^ Z Ti a Oj •SaiJOJBO {'B^OJ, CO N. »- s. a; 2 - S 3 2 ^ ^ 2 :: ^ ^ ^ ^ ^ o 6 to -C -^ lO CD ^- 00 OS cq CO ■* lO CO t^ 00 o o rH (M CO Tf< lO oi o o '^ lO ^ rt CM CO 1— 1 ■># o c^ lO o J-, >o lO o lO CM o to Oi ct\ CM lO CM o ■J3}T( aad 'Bajf]^ tr- ^^ CO ^^ CM_^ 05 (N^ 05 a> io o lO lO lO o o o to ■sjqf.2J9Cl-ioA lO '^ CO CM rt 00 fVl CO o 00 kO o o -^ r- CO t- 00 oq c^ c^ CM CM CM CM CM CM lOH (M r- o C5 ^ CO lO CO Og/M ■ lOA CO CO CO CM CM oq CO •^ 2 + BmsBij lO lO lO lO lO lO lO to •„ig ^B pooiq CO CO o o o CO lO 05 ^ aioqM -DO 001 g oq !M t- ■^ lO CO -^ t— o Xq punoq JQO -*i ■* -* -o CO CO CO CM O) 200 'B'nsBicl O o 'I o o CM o T3 oriBy: 05 CM CM CO CM CM CM O "oOS *'B Bin CO "* CO CO 00 CM O ,-H 05 pq -sB|d -00 001 ^ o CO tr- CO r- lO 00 -* o> Aq punoq zqO lO lO io lO CO lO lO CD to ^*- CM o Oi C3 00 00 00 X ,_l o 00 00 o 1—4 ,_, s TJH ■* CO CO ^ '^ TfH •ZQO MloaAiv Tj< CO 00 00 i-( 00 00 s 00 r- CO CO 00 00 GO CM CM t>\ CM CM CM CM o Th CM o t- o c» CO CM •^qSiaAi Xpog 00 t- t- GO r- 00 t- r- t- CO CO CO CO CO CO CO CO CO •{oqoojv 8 lO -- ^ :: CO - lO - ^ - CO lO . . . §. :: i: :: :i • ac^'BJpXqoqjBQ & o :: - - o :: s o :: ^ 2 3 lO lO »0 >0 O lO lO lO o ■q •^B^ Co CO ^ ■- " CO w ^ lO lO Oi O CO o ^ CM to " aj o iC j^ >o o lO +3 lO o >o o o to o •nia^otj g c^ c^ :: :: cS CM - lO r- crl N. - LO CM lO - -* r- ^ T^ o t^ CO lO O CO rH '^ ^ lO lO CO ■* - CM CO CO - o -S 50 rO (M fO -* lO CO t- 00 05 o .— 1 CM CO •* lO CO r- 00 Oi O i-H Q> (B CM CM Q "^ fH + 2HCI 55 So 4S 40 35- C02, 65 €0 55 - SO - 45- 35 ■5-3 -SX -*-9 J — I I I I I ' ' .1. I I I. 1 ,1 I ,1. I I J 11 14 16 18 21 2 4 7 V ALVEOLAR * C02'-i 00 !M CO O ■^^ ^*t ^H "^ t^ s CO 00 CM CO CM 10 CO t- co s •ja}T[ jad ppv o ^ 00 00 (N c^ CS (M .-H C3 T-H 1-H .-H s CO CO 00 CO CM Tt* CO ' 00 1— 1 (4 •lajH -lad ^HN 2 O t^ (M 1-H 1— 1 1— 1 <£> 00 CO CO CO Tf< CO oo CO CO CO CO CM CM CO 10 00 T-H CO I— 1 CO I— 1 C5 CO •lejif m6. ■Bejfi lO (M 00 00 >— 1 CO ^ 00 Oi t^ t^ 00 CM 00 eq CO 00 CO CO CO CM ^ -* C-1 CO CO •siq ^2 lad -[oa S O O O "O CO -H O ^ lO C2^ !>-_ T-H^ CO ■>*" T^" oo" CO CO CO 00 cO__ Co"" CO T-H CO CO cm" of 00 CM CO 10 CO 'lOH 09/N • I O A 2 + •BOISBIJ ^ Cq lO t^ 00 00 00 Ci Tt^ ^ '^ "^ CO CO C^l id 01 lO CD id •„ig :)B pooiq aioqAi 30 001 Aq pnnoq sqO li t^ LO CO 00 oq CO 00 r^ CO CO CO 00 00 00 CO t^ ^ ^ 10 O ^OO '^P Kica 500'Bcag'B[d ^ TtH CO O CO 02 C^ r-( ,-H CO C3 CO T— 1 ^ 00 CM CO 00 00 ffl •„0S ^« ■Btn -SBjd -03 oor Aq punoq zqO s CO CO ^ o 00 GO O CO M CO ■* TJH CO Ci o CO id 10 CD 10 CD •^00 J13I03AIV X s CO M C5 O O CRi (M CO C^ 1> CO CO CO OO 00 CO CM 00 10 CO CO CM I— 1 •<* g O (Xi CO CO id CM C^l CM 00 00 CM CM Id 06 CM 10 id CO CS5 CO 06 CM •;t|§t3Ai Apog ■« 00 o '^ o t^ CO lo id C^l CM (M (M »o CM o id C-1 CO »d CM CO 00 CO CD CO CM CM ■^OOH'BN g lO O O O O lO ■* lO CO CO iM i-( • aiBjpXqoqjBQ o o - rH C^l - lO ^ ^ CM - - 10 00 CO CO • 00 lO >-l CM - "If^ g ^:: :: . . . 2 's - - PI bi) > a; Sh 2 2 2 ^ ^ :: 00 bJO "s - - a > u :: •nta;oij •sauoiBO ib;ox fe Q * * * -4— -f— Co 422 o ^ ^ O O «^ Oio PHZ «0 •5.3 ' ' «_ ' ' ' ' MAR. 'I'll' I I I 1 .1 65 - 60 55 SO 4Sr 40 35-- 30 25 20 23 25 WS- 1916 FEB. 6 8 lO 13 15^ !5:-1I^ PUASMA (N -"Ji Tfi CD CD IC O oaS/V CO 00 lO CD -* ■* o o O 00 CO '— 1 T-i lO (M kO CD CD CD CD lO Tj< CO CO CO 1— ( Oi CO CO CO o la^Ti lad ppv ^ (M (M ■* 00 00 O '^ lO lO CO ^ O O »0 CO IM (N (M (M (N 1— 1 o CO o .CD CO 00 I— 1 00 CM i8:tTI J9d f HN O Cq JO lO lo CO Tt^ r:^ 5 S S "^ "^ <^^ '"i, ^ ^ '-1 i^ 00 CD CO CO lO C33 § 00 00 Oi a:jil J9d ■eajfi O O O »C O lO o t^ 00 --1 CO --H 00 -* •* ■* O 00 05^ CD CI>_ CO CO -^ CO CO cz to o 00 o of »o o CO o lO 05 o i-T jq^ZJed-pA s O lO O O lO lO lO CO t^ 00 (M O 03 t^ 1— 1 t^ Ol CO O CO CO .-H CO CO co"" M<" co" co"" o CO o o »o Co" CO o o m CO g Co"" CO CO lO CO" lOH S/N • 1 A CD t^ 00 CD 00 00 00 00 Oi 03 00 lO lO CO CO >o lO lO lO CO ^iS ■;« poojq oqM 00 001 q punoq »oO g O CO ■* CD ^ 00 o "O CO CO -* •* CO CO CO CO b CO >o d lO 03 00 'A^B niui 100 «nisBid o ^H 00 1— 1 00 Ci CD l> CD 00 ^ o Oi o CO CO CO 00 T— 1 00 05 00 1— ( ■„0Z *« 'Bm ^\d -00 001 q punoq ^OO g Tfi(MCOOiCCO»C dC^COCO-^-^iOCD 05 (M . o lo ^ 00 CD CD »o (N CO CD CM O CO O -* ^ 00 CM CM CM 03 CM 00 CM CD CJi 00 CD CD O o t^ 00 r-! CO ^^ ^^ "^r ^T^ ^^ '^ '^^ •OOH'BN I 03 CO ^ s. to 1—1 CM ■- - '-I O O "O O iCi O CO T-H r-( ^ CM CM CO to V. - 'S 'S • II! o o >i "3 ■ o tJD « : > CI Qj : o o CO r- 1 »o iC (M >— 1 CM ^ O CO ^ (.N S -SoiQr-iCMCO^iOCOt^OO 2^ .^.-hCMCMCMCMCMCMCMCMCM 424 i-H CM CO TtH O CO t^ 00 05 o iS-4-7 l5-4.« ■ ■ ■ ■ ■ ' ' '''.,' j 19 21 24 26 28 1 iflisrtB. "^R ' ' ■ ■ ' 3 6 C. Case 2414, male, a,e 17. Diabetic 1 yZ." ^ ^^'ifllTJZ^l . T!.,t„^. ..iHn»i« oi his firs t admission iMarch 19, 1915), lesponfleo^ 7. Case UU- Date. 15 o 1 o 6 •5 >> o o o o o O o < 6 o "o < >> m o o d o 6 '.3 (S 03 "5. o o > "3 S S -HO SoO 1015 gm. gm. gm. em. cc. mm. mm. XI 45 cc. PH Mar. 19* 245 Fast day with whiskey. 10 35 17.9 26.0 23.8 1.33 20t 560 " 30 80 28.0 40.6 34.1 1.22 21 " " 30 80 31.5 45.7 46.8 1.49 22 525 " 10 75 35.2 51.1 58.5 1.66 23 560 " 80 31.5 45.7 52.4 1.66 24 385 " 55 33.7 48.9 60.6 1.80 25 35.4 51.4 58.0 1.64 26 30.2 43.8 52.4 1.73 27 50.4 28 30.6 44.4 29 33.3 48.3 54.0 1.62 30 Green veg. only containing 10 31.1 45.1 53.4 1.72 31 a it (( a a Apr. 1 20 34.2 49.6 55.2 1.62 2 <( 35.9 52.0 55.2 1.54 3 30 35.9 52.0 64.8 1.80 4 50 5 70 6 80 38.5 55.8 65.6 1.70 7 90 41.4 60.0 52.9 1.28 8 100 35.4 51.4 51.4 1.45 9 150 39.4 57.2 59.5 1.51 10 " 11 ti 12 175 13 a 41.7 60.5 62.1 1.49 6.60 14 it 15 200 41.0 59.5 66.6 1.62 6.80 16 Fast day. 17 765 33 56 25 18 1,240 48 100 19 1,670 147.5 38.7 56.1 58.5 1.51 6.63 20 a i< 21 a i( 22 (( ii 37.8 54.8 62.1 1.64 6.97 23 it (I 24 1,700 50 149.5 * Drowsiness; hyperpnea. t Drowsiness. 426 7. Case UU— Concluded. s 6 >i m -HO Date. '3 6 O O o o o > +^ "3 2 C3 o OS o C3 -a o 1 > ■^ocs 62 S ^i a § >|I| H PL, fe o '.^ < < o c fL, 1915 STO. 9TO. ffm. gm. cc. mm. mm. XI 45 cc. PH Apr. 25 Fast da y- 26 1,835 53 156.5 40 27 1,845 55 " 11 28 i< " (< " 29 ii a " a 30 1,840 52.5 it " 39.3 57.0 65.6 1.67 6.86 May 1 it ** It a 2 Fast day. 3 1,840 52.5 156.5 40 4 1,985 75.5 162.5 a 37.2 54.0 62.3 1.67 6.77 C02 70 65" 60 55 50 4S-- 40.. 35-- 3o- •70 o 62 a o "S d a PL, 1915 gm. gm. gm. cc. mm. mm. Xl-45 cc. pH Mar. 18 1,285 41.0 71.5 65 32.4 47.0 47.3 1.46 19 1,815 62.5 115.0 70 30.0 43.5 20* 1,635 53.0 123.0 50 25 20.5 29.7 25.9 1.26 21*t Fast day. 90 35 15.8 22.9 22*t (( a 24.9 (Death.) * Drowsiness; hyperpnea; nausea. t Moribund. Stillman, Van Slyke, Cullen, and Fitz 429 so U AS - 40 - 30 - a? I- zo PLASMA _ COJL =0 ALVEOLAR C02X\.45-c^ CASENaa293 iB id 20 21 22 " 1915 MAR. 8. Case 2293, male, age 29. Diabetic 2 years, of the severest type in intolerance of any food. Complicated at the end by pulmonary tuberculosis. The curves show failure of response to large doses of NaHCOs. Death occurred March 22, 1915. (From March 18-22, 1915.) Group III-IV. 9. Case 2358. Date. i 'a a o a "S 1 O ■e- o 6 o < IS III 6SS ■ o o oO cs a 6 o > 'a a a Mi 1915 gm. gvi. gm. mm. mm. XI. 45 cc. pH Apr. 16 1,915 62.5 178.5 37.2 54.0 45.8 1.23 17 li « li 18 Fast day. 19 1,325 49.0 118.5 5 20 « <( 21 it " 22 ii ii 23 n " 24 ii a 25 Fast day. 26 1,350 50.0 119.0 10 27 (( (( (( <( 35.4 51.5 45.3 1.28 28 325* 21.0 26.0 29 Fast day. 30 ti a 26.5 38.4 44.1 1.61 May 1 a a 2 1,020 29.0 92.5 10 24.1 35.0 41.6 1.73 3 1,350 50.0 119.0 ii 4 a (( a »" 40.8 59.2 56.8 1.39 6.76 5 a a a << 6 1,375 52.0 a 15 40.7 59.0 57.0 1.40 6.73 7 1,495 52.5 131.5 a 8 " " a a 9 Fast day. 10 1,535 54.0 132.0 20 11 (( a « a 12 a a a " 38.8 56.3 52.7 1.36 6.67 13 a a a a 14 1,595 57.0 133.0 30 36.8 53.4 55.2 1.50 6.76 15 250* 13.5 21.0 36.1 52.4 60.8 1.68 6.72 16 Fast day. 17 a a 18 a a 19 715* 25.0 50.0 10 26.2 38.0 45.9 1.69 6.41 20 1,035 60.5 80.5 u 21 a a " " 36.0 52.2 56.9 1.58 6.64 *Partial fast. 430 Stillman, Van Slyke, CuUen, and Fitz 431 IS 27 3e2 4 6 2913 APaW. MA-y 9. Case 2358, age 11. Diabetic 1 year, of severe type in intolerance of any food. The curves show a sudden development of acidosis on two separate fasting periods of 3 days each with a return to normal on the resumption of diet. (From April 16-May 21, 1915.) Group III. oAg/V-os CC lO 00 o o m 05 t^ o o CO Ol 1—1 T-H tCi 00 ,_l 1^ CD ■* -* lO lO lO lO -<*< to iO >o 1 OA^N ^ lO IM o o lO I— I CO o o C-l CO t^ cr> 05 ^ ^ 00 CO -* a' CO CO CA (M OA CO (M o o cq CO CO (N J_J 00 o ^ CO •J9;i| jad piov ^^ 00 lO CO h- OS o t^ 00 OS i <-H 1— 1 *"* h O o t^ !M (M OS 'l^ lO i o CO CO CO CO CO -r»< 1^ OS lO CO . o "3 o CO CO '^ T^ CO o 00 iC o o lO ^ lO >o 00 U5 CO CO CO (M ^ •jG^yi J3d B9I£1 15 05 ^ lO m IC OS Tf< (N •^ 8 '-' '-' '-' '"' ""* '"' '"' '"' O o U5 o o o lO lO lO IC (M 05 CO 00 r- 00 to Tt< Tfl CO •wq^jjadioA g (M l^ CO t- o (M 00 CO lO OS o (M 00 CO CO Tf< lO o CO CO lO 00 CO '^ o 1— ( CO epqAi -00 001 g 00 C35 OS »o r^ lO o CO (M 5? Xq panoq iQO CO CO -* -tl* ■* Th TfH ^ lO '00 •'^l^ 'nixii I— 1 00 CO CO 00 ^ CO 00 (M OS g too eras^id OI^BH 1—1 '"' 1—1 1— ( 1—1 '~' ""^ 8 -.OC IB BUI 00 .-< CO l^ t- (M •o CO OS CO P5 -SBid -03 001 u o ,_, o CO 02 lO (N OS Q to Xq pnnoq tQO IC lO CO lO lO lO to to CO >o -^ ■lO 05 CO TI< 00 00 00 (M t^ X ?? ^ ^ ^ CO ^ ^ S ^ ■ZOO^IO^MV ^ S 1— ( o lO t^ ^ _ OS CO CO •CO CO ?? cq CO 00 o iC CO IM CO CO (M (M CO CO CO 00 CO lO o o o CO o (N o •!}q3raM Xpog Oi "* lO lO t^ (^ l^ t^ ^ r^ 00 CO CO CO CO CO CO CO CO CO •loqooiv «■ CO lo to in lo -* CO "5 ;§, , =: - - •e^'BjpXqoqjBQ o - z ^ - - - - - - - lO lO o o o lO "n iC o io lO k; o S •^■B^ CO 00 CO CO CO -* >> 03 o (M OS o3 o 1— ( CO - CO - J^ 2 - >> J> ^^ ■^ TS -*-= lO •+i LO to "O iC o lo -1-3 "O o o •^l^:^oI(J s m ^ ^ lO o - lO (N to -* (M l>i IM l>i (M ^ ^ tn g lO o CO ta '^ - CO tM T— 1 o o »o o IC o »o o to m to lO o lO o o o •seuo[BO ^B^ox lO CO lO lO (^l w Oi »o r^ m t^ O (M lO s. - lO 00 00 oo oo lO 00 - CO ^ CO ^ iO iO CO CO CO - - CO CO CO t^ i OS Q to 5 ■i ^ CO ■* lO CO t- 00 05 o T— 1 1—1 (M 1— t CO ^ 1—1 1—1 lO CO 1—1 1—1 ir- ao OS R 1— ( (M (M CO •*■* CM CM CO CO CO CO ■* LO CD aA|,V o o ic CO o_o o b-' ■* CD O C5 o o CD q CO CO o CD o CO o CO CO (N CO CO »0 lO O Tt< Tfl TfH CO CM ^"^ o o o lO lO lO lO lO o in 00 o lO lO o ■J9;i[ J8d pToy k;~ CO >o lO O 05 ^ CO t- o O CO r^ ':*< 05 lO lO CO CO kO 03 C5 CO t^ t^ t^ m lO o O lO (M O CO O lO 00 >re o 00 en o o ■jajTI Jad B9Jfi ^ lO 1-1 00 t^ 03 CT> 00 ^ lO ^ o lO ,-1 ^ CO O o 00 y o o to o o o o ^ in ■sjq fz -lad [OA ir? >— 1 t^ CO 00 l^ CM lO CM O ^H 1^1 ^ lO O ,-H CD — 1 00 (M 05 ,-1 CO !>. CO CM lO 1—1 (M —1 M r-i cq 1-1 CM CO CM CM CM CM '"' CM ■e02 "J^ BOl OO (M lO 00 »o C^l -* CO CO C5 1-1 O 00 O -SBid 00 001 g t^ 00 ^ CO cq lO o -* ^ IC OO o CM 00 Xq ptinoq iqO ■* '^ CO CO CM CO CO CO '^ o lO O CO O (M t^ 1-1 CO t^ CO CO CO CM C. o ^ ^ »o O >o lO lO >>v, -- - ^ •uia^tojj s lO O ^ o - —H CO 4< CO lO CM rH CM !> c3 - - t3 > -t^ a> Oi CQ V, V. 0) w ^ ^ ^ S3 - " (h >^^ „ >> >, fe o c3 ^ S o3 w 03 TS O O >0 lO »o o TS o o ' o O O O lO CD CM t^ CM .. -* CO CO -*l (—> g. . CM CM ^ M ^ CO O lO ~- ^ 00 03 r-l C-l lO ^ »o o3 :: 2 T— 1 1—1 CM ^ cs :: cri ^ fe \^ 6 50 fl cq CO ■<*< lO CO t^ 00 o O 1-1 * CM CO ■* iC CO r^ 00 05 o 1—1 CM CO 1* »o P i-s 1— ( i-H T-l rH CM cq CM CM CM CM 434 Stillm'an, Van Slyke, Cullen, and Fitz 435 & I- < It. PLASMA, CO2 60^^[o^ W '''''''«'''''''''«''>«'■»''''''''■■■' 2 3 4 5 6 7 8 10 12 X4 n 19 25- 2 4 7 1916JAK FEB. 11. Case 2684, female, age 43 (the same case as No. 10). Diabetic of extreme severity with marked emaciation. A mild acidosis was present . on admission (January 1, 1916). The curves show a dangerous response to a moderate protein-fat (car- bohydrate-free) diet, which was accompanied by clinical manifesta- tions of severe acidosis. At the end of 9 days' fasting the patient may be considered past danger from an acidosis point of view, as is indicated by the rise of the curves. The curves show consistent parallelism between acid excretion and plasma bicarbonate. (From January 2-25. 1916.) Group II. 2AgV_, O fO «D 00 "0 <» O C2 00 lo 00 lO 00 to CC AO ■* lO Tt< , ■^ lO to 0Ag,V o t^ •* c^ 00 CO Tt< CO 05 O o CO CO ■^ (N 00 (N CO CO (M (M o (N 00 00 o o to 00 to :s 6 •J3jt] J9d ppv Z O -* CO .—1 ■r}< lO I^ CO CO (M t2 o (N lO 00 lO 1-H (M lO o o o o lO CO ^ 05 00 M^ TjH •sjqf.jJ3d-ioA u t^ -* 05 CO 05 lO 02 t^ >— ( t- -<*< CO CO CO CO ^ -* o "oZ6 5« pooiq 02 -* 00 Tt< O ■**! »o t- o oioq.vi OD 001 u Oi 00 00 00 lO (M CO to (M Aq pnnoq tQO (M -* CO CO -* -* ^ -* lO ■X3 O o CQ •„06 ?^ ^™ CO —1 o (N >C (M CO CO to -SB[d 00 001 g CO o lo 00 -"H o cq 00 CO Jiq puRoq ZQO CO o Tti -<*< lO lO lO lO to o o o to 00 »o o t- ■* •iqSraM Xpog o. 1^ o t^ to to 1:^ 00 t^ to CO CO CO CO CO CO CO CO CO •'OOH^N la o CO o o o o •a^BipAqoqJBO g i-H o lO lO 05 5 iBJ s t^ CO 00 00 CO a ^ to -* CO s - >• ** -f^ (3 o o •niaioij § c3 - - (M T}H o o Id 1> o 0) :: :: ^ nci 1 > kC 03 :: ^ o o iC o •s9uoiBa l^jox CO (M O ^ 00 lO o to to N. ^ [^ o 33 to (J * s 03 O ^ O --H Q '~' g.^ (M ^t3 oS ^ 03 ^ •^ o CI (-1 03 o O _o .2 G 03 O (B -is c -^ H >> S *- -I^ 2 o a s -S "C <» nabi las in p etwe X! Qi a Ti ^ 43 o o a fl ? "s "— ■-^ > -^ Ji rity bse t in aral a> o as a, > i^ •'' S^'^^ a 03 -^^ . 03 43 O ^ J;^ (M ra -*^ "^ 03 ^, h t, 4) ■3 ^ g 1 ra ^ „, J- c3 -^ r2 ^-^ " ° ^ M-B « O 03 ^ f3 iabeti of sti effec ohyd D loss rous carb 2 ^ S) C3 o a 03 S t3 ^g"-^ g ■"3 .i-H ,U >>H a ^ fe ^ .2 S 5 =« cc m oo'-'Ts "= >:> m 03 (M 03 m -^ C t^ aee 21 mark curve lined o .2 »4 03 O -t^ bC 5 Uh ^ S) * -I— 2 :SH S p. o u O COjt es 60 55 5e AC 30 )3H •55 -5-3 ■SI '4-9 ^ o z ^ BuOOD C02 _L_1 I I L_J I ,1 I t — L-_L. 20 22 24 57 S 51 isoernAi? 65 60 55 5© 40 I- 35 SO £5- L <:Ase^^o.2l2e 437 13. Case Date, M o 3 o d 'S o Ph 4J Carbohydrate. i 8 < 6 o > < OS a oO 8 13 a a PM 1915 pm. gm. gm. cc. mm. mm.xi.4s cc. pH Apr. 7 Green veg. only containing 15.0 15 32.0 46.4 46.3 1.45 6.33 8 « (< (( It 20.0 32.2 46.7 45.3 1.41 6.32 9 « (( u tt 30.0 10 U CI cc it 49.0 33.5 48.6 49.0 1.46 6.55 11* ii It it it 19.0 12 2,440 85.5 224.5 13 2,440 92.5 222.0 35.9 52.1 48.4 1.35 6.55 14 2,500 97.0 226.5 15 2,440 88.0 224.0 38.8 56.2 63.1 1.63 6.73 16 2,440 92.5 121.5 17 2,440 85.5 224.5 18 Fast day. 19 2,440 92.5 221.5 38.0 55.1 54.0 1.42 6.70 20 2,440 92.5 221.5 21 2,440 85.5 224.5 22 2,420 93.0 219.5 23 2,440 85.5 224.5 38.3 55.6 56.0 1.46 6.68 24 2,440 92.5 221.5 25 Fast day. 26 2,210 92.5 196.5 27 2,210 92.5 196.5 28 2,185 93.0 194.5 36.4 52.9 56.0 1.53 6.62 29 Fast day. 30 It it 37.0 53.7 57.3 1.55 6.80 May 1 it it 2 it It 3 Green veg. only cc ntaining 20.0 28.7 41.6 45.1 1.57 6.46 4 it it tt 40.0 35.2 51.0 53.2 1.52 6.64 5 It It tt 50.0 6 tt it it 60.0 32.7 47.4 63.0 1.93 6.75 7 it it it 70.0 36.4 52.8 56.0 1.54 8 it it it 80.0 9 ii it it 90.0 10 it it it 100.0 « 11* it it it 24.5 438 IS. Case 2S82— Concluded. Date. _o o "a 2 t 1 O i 8 6 o 03 "o > < o 'S 03 03 "5, o o > a 03 ■ . 1915 gni. gm. gm. cc. mm. mm. X 1.45 cc. piy May 12 555 24.0 44.5 10.0 27.8 40.3 54.5 1.96 6.61 13 930 43.0 72.0 20.0 34.4 49.9 50.9 1.48 6.42 14 1,230 47.0 105.5 15.0 15 1,370 62.0 113.5 15.0 16 555* 21.5 49.0 3.0 17 935* 46.5 80.0 12.5 18 1,530 78.0 123.0 15.0 39.3 57.3 61.3 1.56 6.64 19 1,520 60.5 130.5 15.0 20 1,450 70.0 123.5 3.5 21 1,430 71.0 122.5 22 1,425 60.5 127.0 37.7 54.7 62.3 1.65 6.76 23 Fast day. 24 1,425 53.0 130.0 35.6 51.6 60.6 1.70 6.83 *Partial fast. PLASMA ' C02 - ALVEOLAR CASE N0.23eZ 1 1 i,m luj I Nj I ij M I 111 1 1 1 m 1 1 1 1 1 It I n I i.Li I III ^ 4i ii"^^^ 7 io J3 15 19 23 8303 6 MAY 2^ 13, Case 2382, male, age 40. Diabetic 8 years, severe in intolerance of food, with a tendency to a low grade chronic acidosis. The curves are peculiar in that they are high during a period of relatively high fat feeding, and show an unstable and low level during a carbohydrate tolerance test, due perhaps to the 4 days' fast which pre- ceded this test. (From April 7-May 24, 1915.) Group III. 439 440 Blood, Urine, and Alveolar Air in Diabetes H. Case Date. 1 2 -^ £ 1 O u 05 O o o < 6 o < .^ So- o g'S 52 3 c5 •^ 03 q "a o o > a a PL, ms gm. gm. gm. cc. mtn. mm. XI 46 ce. PH Mar. 25 1,720 91.5 58 30 97.5 44.7 64.8 64.6 1.22 26 1,725 85.5 61 a tt 27 n 91.5 58.5 It 28 682 Fast day. tt 29 2,180 111.0 99.0 30 " 30 2,215 111.5 102.5 tt tt 33.3 48.3 42.7 1.28 31 2,250 112.5 105.5 It " Apr. 1 2,215 112.0 102.5 tt tt 38.6 55.8 54.4 1.41 2 2,385 114.0 115.0 40 tt 44.6 64.7 54.4 1.22 3 it « (( it " 45.9 66.6 61.6 1.34 4 700 Fast day. 100.0 5 2,370 116.0 111.0 40 It 6 2,410 114.0 116.0 tt 7 2,890 115.0 167.0 tt 42.9 62.2 52.4 1.22 6.46 8 2,660 (( « 67.5 9 1,920 88.0 150.0 47.6 69.0 61.0 1.28 6.92 10 1,975 86.0 156.5 11 157 Fast day. 22.5 12 1,975 87.0 156.5 40 13 2,025 90.5 156.0 50 47.6 69.0 60.6 1.27 6.60 14 2,060 90.0 160.0 It 15 2,085 91.5 173.5 tt 46.8 67.7 59.5 1.27 6.69 16 2,145 90.5 169.0 tt 17 2,095 89.0 164.0 tt 18 Fast day. 19 2,035 91.5 156.5 50 40.1 58.2 51.4 1.28 6.78 20 1,975 89.0 155.5 40 21 2,010 79.0 174.5 tt 22 1,955 89.0 153.5 tt 23 1,945 87.5 (( It 43.5 63.1 63.1 1.46 6.84 24 1,975 90.0 155.5 tt 25 Fast day. | 26 1,970 90.0 161.0 25 27 2,000 ti 165.0 tt 28 2,165 93.5 180.5 tt 43.6 63.2 59.0 1.35 6.58 29 2,110 93.0 175.0 tt 30 2,140 92.5 178.5 tt 43.7 63.4 64.9 1.49 6.74 Stillman, Van Slyke, Cullen, and Fitz 441 Coi ]pH no 65 AtVEOLAR co^Vi.4j n\ \ ^ PLASMA ^ - 6-8 <*. /\. // \ \ j^ \ f„ *^^2 ■ 60 -«* \ ]\lt\KS4^' 5f 50 \ l\ \ \ / "- \\f "^ 45 .6.0 Y 40 -.5.5 1 1 1 1 1 1 1 1 1 1 1 1 ! 1 1 M 1 1 M r J 1 t 1 1 1 1 1 1 ! 1 I p i^ASE f^* ^3 2. air 301s 7S 2315 19 23 2Qad 1^15 m?;. APRIL. 14. Case 2332, age 42._ Diabetic 8 years, of mild type, complicated by furunculosis and carbunculosis. During the period over which the chart is drawn, the patient suffered a rather intense gastrointestinal upset of unknown origin. This is re- flected in the instability of the curves. Following the recovery from this attack, the curves continue on a high lerel up to the time of discharge from the hospital. (From March 25-April 30, 1915.) Group I. 15. Case 234S. Date. o "3 "3 1 c S 2 1 >, O u o § < 6 o < 6 ■ft 6 > "3 a a 1-10 Ah 1916 gm. gm. gm. cc. mm. mm. X i.iS CC. VH Mar. 30 1,940 98.5 83.5 15.0 100 36.2 52.2 60.5 1.67 31 1,940 80.5 91.0 a 100 33.9 49.2 47.8 1.41 Apr. 1 1,965 100.0 84.0 20.0 100 37.1 53.8 51.6 1.39 2 1,965 82.0 91.0 -6d jaH+lHcl ALVEOLAR PUASMA — CO2 45 -6.0 40 -SS CASE NO. 2343 so i 3 6 e 10 is 16 19 zi iSlS^iAR. APRIL 26^ * MAV 15. Case 2343, male, age 44. Diabetic 9 years, mild in type, without evidence of acidosis before the institution of active treatment. The curves show an unstable and rather low level, following a 2 months' period of very low diet, and a gradual rising and uniformity of the curves when the patient was placed on an adequate diet. (From March 30-May 4, 1915.) Group I. 16. Case 2128. Date. i la a 'S o d fe 6 "S -d >> J3 o .Q OS O o o K 6 o 03 > < o o oO ■-3 cj ca a 0. c5 o "3 H S ■-HO 1915 em. gm. gm. gm. mm. mm.X1.4S cc. PH Apr. 15 2,040 142 145 26.5 20 35.9 52.1 54.0 1.50 6.53 16 2,830 202.5 204 26.0 « 36.4 52.8 51.4 1.41 6.72 17 2,780 155.0 223 18.0 (( 18 1,845 129.0 133 19.0 « 19 1,370 47.0 104.5 50.5 (t 20 Fast day. It 21 a a 10 22 2,005 8.0 201.5 24.0 40.8 59.2 57.5 1.41 6.72 23 2,225 32.5 186.0 89.5 24 2,430 40.5 202.0 95.0 25 1,000 39.0 58.0 74.0 26 Green veg. on taining ly con- 75.0 27 a 38.3 55.5 54.0 1.41 28 1,855 2.6 155.5 75.0 29 a i( t( a 30 930 100.0 38.7 56.1 58.8 1.52 6.92 May 1 1,440 29.5 . 141.5 1.0 2 1,450 30.5 142.0 " 31.3 45.4 45.1 1.44 6.49 3 1,075 i( 102.0 " 4 1,040 26.0 100.0 « 38.0 55.1 48.6 1.28 6.55 5 815 24.0 80.0 " 6 1,095 37.0 78.0 54.0 42.0 60,9 57.0 1.36 6.78 7 Fast day. 8 1,095- 32.5 67.0 83.0 9 1,075 33.0 66.5 67.5 10 1,060 29.0 66.0 81.0 11* 175 Fast ay. 12 870 26.5 44.0 86.5 38.8 56.3 51.8 1.35 6.60 13 930 32.5 40.0 104.0 14 875 29.5 40.0 93.0 15 1,180 45.0 45.5 140.0 16 465 50.0 17 1,130 43.5 46.5 124.5 18 950 42.0 29.0 123.5 39.3 57.0 51.9 1.32 6.57 *Alcohol, 25 cc. 444 Stillman, Van Slyke, CuUen, and Fitz 445 €5 60 ..68 66 55""6-4 SO' 6-2 4ff-eo I ii_i Hi III i'i_L"J'iM' L« ""_L' "" t9lS"AP!ilL. ' A";^'i'4 ' ^""'A""'i'a |3H+1HC| AUV POLAR COaJ^'-^S" PLASMA CASE NO. a 12 6 MAY 16. Case 2128, female, age 18. Diabetic 3 years, of severe type in in- ability to metabolize carbohydrate or fat, though maintaining a fair state of nutrition and strength. (From April 15-May 18, 1915.) Group III-IV. oy^^^-m 00 o 3 CO CO lO C3 CO CO lO 56.5 CO aA§)V 00 o 00 00 1-1 CO CO est d i •jo^ij wd pToy <= ^ 1-H o 1— 1 g O 00 00 CO CD 1— 1 r-H t3 •jain lad iHN o ^ CO in lO lO o CO CD 1 ■jajij lad Baifi CO co" eo" o CD o 00 lO 00 CO co" o o lO CO co" •gjq^3i9d-iOA s CO T-l § - O 05 lO CO_^ lO 1 lOH 09/N lOA 00 CO CO CO lO lO CO 00 CO CO id CO CO to LO ajoqAV 00 001 Aq punoq ^00 ^ CO o 00 t^ CO o lO CD CD ■* ^ CO '00 '^1'^ nun ZQO ■EOISBld -ffBid 00 GOT iCq pnnoq iqO =00 -iBlosAi V ■%v[2i3M. jtpog ■a^BjpXqoqiBQ ■^^^ araiojj •99UOJB0 i^^ox fe 5 ^ (M CO fa l>. 00 Oi O >— I M 446 rt* lO CO t^ 00 05 Stillman, Van Slyke, CuUen, and Fitz 447 coz ear h5-5 60 55 f53 SO 45 40 -5.1 PLASMA C02 )3H+2HCl BLOOD I I I I I I I. I I 1 I I I I I ,1. I I I 2 4 7 5916 FEB. COj 65 eo 55 50 45 40 35-J Qo-i^ Plasma COg ALVgOLAK eo2>«i-45 CASK MO.g'^O© . „.j 17. Case 2480, female, age 28. Diabetic 5 years, formerly of a mild type, but latterly developing into an obstinately progressive form, with emaciation and inability to tolerate calories enough to maintain existence in an aglycosuric state. A low grade acidosis has been present for 15 months of observation. During the period shown the patient was temporarily free from acidosis as the result of unusual response to treatment. The acid excretion cor- responds to the plasma bicarbonate, but the alveolar CO2 is consistently too low. (From February 2-21, 1916.) Group IIL OA^\-08 00 (M CO O t^ t^ oAg/V M 00 T)< o 00 o o -* o CO ■* 1-H ^ CO o r^ r^ -* '^ -^ CO (M (M •ja^tl J9d pioy ^■ CO 00 CO CO O) M CO c •E g o ;d ^ O 00 (M CO (N 05 00 ^ a[oqAi 00 001 g CO 00 CO CO CO '^l CO Aq punoq ^qO "* Tt< lO iO lO lO lO ^00 'Al^ •min 00 t- ^ Q ^ SQO 'BmsBjd 00 t^ o o 00 °^ -6 oi^Ea ^^ '^ (N IM (M « •„03 C^E BtH I— 1 »c CO C5 00 '^ ,—1 -SB|d -00 001 u CO »o (N CO 00 o 1 Xq punoq zqO CO CO t^ t- CO t^ t- xa ~* •* CO CO CO 00 Tfl X o 02 CO Oi CO t^ »o iCi lO 'Tt* lO lO ■JOO JBioaAiv s 00 Oi o (M IM CO '^ o t^ -* Oi Ol CO Tt< CO CO CO CO o (M o q3iaM Xpog 00 00 00 00 00 00 05 •* ^ 'CtH Tt< Tj< TJH -* o o o o o o o o o o o o o o lO • (M CO CO !>• 00 Oi o "H OJ CO •* lo •a:jBjpjCqoqiBQ " 1— ( I— ( 1—1 bO a •*«5 s '3 " :: s 2 3:: 2 2 2 2 ci 3 2 :: ^ +^ o o >> •nie^oj^j fei a - o > c •souoiBO p^ox V. - w - - ■* ■* " " " V. ,, ^ s. V. „ - O to a o» -D N CO -* lO CD t^ 00 OJ o T-H OQ CO ■* lO CO o 448 coa 1>H 90 85 -59 80 75 -5.7 70 65 SS 60 55-5.3 50 45 51 ^H+2HCl PLASMA CO 2 > BLOOD ■t-Ht- I I I I I I ,1 CO5 75-- 70- €5- 60- 55- SO- 45- 4oL- 1916 FEB. 9 II 14 1€ ao-|v7lc /^ PLASMA CO2 LVEOLAR C02«l-*5 CASS NO. 223-* 449 19. Case 237 J^. Date. i 'u O o a o PL, Fat. Carbohydrate. 6 o -3 "o o _> < >1 CO SI s c5 "a > "3 a 1915 gm. gm. gm. mm. mm. X H5 cc. PH Apr. 15 Green veg. only containing] 10 41.0 59.5 55.4 1.35 6.77 16 <( (( (( It 11 17 « (( (( it et 18 Fast day. 19 700 25 . 57.5 1 5 40.8 59.2 56.4 1.38 6.80 20 1,190 44.5 101.7 21 « ii tt i 22 1,380 63.5 114.0 23 (( it it t 39.8 57.8 33.4 1.34 6.72 24 1,325 65.0 107.5 25 Fast day. 26 1,550 65.5 131.5 1 5 27 1,605 64.0 138.0 ( 28 1,530 66.0 130.0 ' 37.7 54.7 59.0 1.57 6.53 29 (( a " ' < 30 1,595 (< 136.0 I May •1 1,540 73.5 126.5 I 2 Fast day. 3 1,625 75.0 133.0 2 40.8 59.2 61.8 1.51 6.85 4 1,665 (( 137.0 ' 5 1,705 67.5 145.5 t 6 2,090 76.0 182.0 ' 41.0 59.5 63.6 1.55 7 1,975 72.5 175.0 1 3 8 1,820 68.5 165.5 9 Fast day. 10 1,910 66.5 169.5 1 5 11 503* 20.5 44.0 2 12 Fast day. 13 ii ti 41.4 60.0 57.7 1.39 6.80 14 U tl 15 675* 32.5 54.0 1 40.4 58.6 59.0 1.46 6.75 16 1,040 45.0 98.0 17 1,250 63.5 102.5 18 " (( (( 40.0 58.0 58.3 1.46 6.57 19 « (f tt 20 1,260 72.5 99.5 21 1,575 75.0 132.0 22 1,805 83.5 153.5 23 Fast day. 24 1,570 1 57.0 140.0 1 1 40.4 60.0 58.5 1.41 6.71 *Partial fast. 450 StillmaD, Van Slyke, Ciillen, and Fitz 451 COj, f>H 70 1-0 65- 6-6 55- S 4 V) pH*mcU VEOLAg COa. " — ^ PLASMA „ ^ C02 ~ Q CASE NO. 2 37^ .1' ' '1' "J ' I Ml I I I 1 I I I M I I It 1 1 I I I I I H I I I I IS 19 23 2d I 3 6 IS 15 Id 24 19I5APRIU MAV 19. Case 2374, age 61. Diabetic 11 years, of a mild type, apparently arrested until the year before admission, when, following a physical shock, the patient showed signs of marked acidosis. The curves illustrate the absence of acidosis in a mild diabetic responding satisfactorily to treatment. (From April 15-May 24, 1915.) Group I. 20. Case 2389. Date. H 'S S a t-, >, c« 6 . ri 6 > "a a E as J, ■ P4 191!^ gm. gm. ff7ra. mm. mm.X14S CC. pi/ Apr. 14 1,805 46.5 165 20 38.8 56.2 58.5 1.51 6.50 15 1,860 50.0 i< 30 16 1,815 56.5 ii 20 40.7 59.0 62.6 1.54 6.75 17 1,795 " 163.5 « 18 Fast day. 19 1,910 46.0 176.5 20 37.2 53.9 57.5 1.55 6.58 20 a a a « 21 u " a a 37.1 53.8 61.6 1.66 6.65 23 a i< (f a 24 11 a <( " 25 Fast day. 26 1,910 46.0 176.5 20 27 (( it it (( 28 2,040 60.0 185.0 a 29 2,025 67.0 180.5 « 39.0 56.6 67.2 1.72 6.99 30 u it (( « May 1 1,910 66.0 167.5 « 2 Fast day. 3 4 5 1,995 70.0 170.0 30 36.5 53.0 58.7 1.61 6.81 1,990 61.0 173.5 6 2,020 60.0 177.5 7 2,025 81.0 168.5 39.3 57.0 58.8 1.50 8 2,020 70.5 173.0 9 Fast day. • 10 2,020 70.5 173.0 30 11 2,045 80.0 171.0 " 12 2,040 62.5 178.5 u 37.9 55.0 57.0 1.50 6.79 13 1,920 65.5 169.0 20 14 1,930 69.5 172.5 a 36.1 52.4 59.0 1.63 6.62 15 (( (f u " 16 400* 20.0 34.0 17 Fast day. 18 i( u 19 1,450 =• 34.0 136.0 11 32.5 46.4 . 58.2 1.82 6.62 20 1,805 45.0 168.0 15 21 u (( <( (I 41.0 59.5 60.6 1.48 6.69 *Partial fast. 452 Stillman, Van Slyke, Cullen, and Fitz 453 COg^ ^H lo -lO A^ H 6S 60 ^ s/ \ 5 pH+lHcl=x 55 -6.4 r \ ^- --^. . 7^ lAusf Solar ^ V-^^ V \ f- C_C>2.^' ^^ 5o "62 A ^ 45- -60 • U 40 U ' 1 M 1 III 1 II 1 II 11 1 II III M 11 III .,,, CASEN0.2389 i4! li a 29 1 i 7 iiw 19 ii (9I5APRIU MAY 20. Case 2389, male, age 35. Diabetic 4^ years, of moderate severity as shown by low tolerance for carbohydrate. The curves show the absence of acidosis in a case which responds satisfactorily to treatment. The alveolar CO2 following fasting on May 18-19, shows on the 19th a false drop, due not to fall in blood bicarbonate, but to the nervous effect of fasting. (From April 14-May 21, 1915.) Group I. 454 Blood, Urine, and Alveolar Air in Diabetes 21. Case Date. i o q '3 o -5 >, o -s as O 6 o S 1 < 62 a u Ratio plasma COi mm. alv. CO2 —10 iSlS gm. gm. gm. mm. mm.XHt cc. vH Apr. 1 1,175 34.5 50.0 150.0 43.6 63.2 63.2 1.45 2 (( (( « It 3 4 1,300 40.5 45.0 175.0 45.9 66.7 69.8 1.52 5 Fast day. 6 785 29.0 61.5 25.0 42.1 61.1 59.1 1.40 7 1,290 50.0 106.0 (( 37.7 54.7 49.4 1.31 6.59 8 1,425 70.0 111.5 tt 44.6 64.7 46.3 1.04 6.47 9' 1,780 69.0 150.0 t( 41.7 60.5 56.4 1.35 6.92 10 « " it " 11 Fast day. 12 2,110 76.0 171.5 50.0 13 2,105 68.5 174.0 46.1 66.9 60.6 1.31 6.52 14 2,100 74.5 171.0 tt , 15 2,545 71.0 220.0 43.2 62.6 59.5 1.38 6.60 16 2,585 76.5 221.0 17 2,575 69.5 224.0 18 Fast day. 19 2,615 84.5 223.0 50 45.1 65.4 62.6 1.39 6.90 20 2,620 77.0 226.0 21 2,640 80.0 228.5 - 22 2,660 86.0 226.0 23 2,710 95.5 217.5 45.7 66.3 62.1 1.36 6.71 24 2,715 85.0 232.5 25 Fast day. 26 2,590 84.0 219.5 50 27 2,525 77.5 215.0 it 28* 2,205 74.0 184.0 21 42.9 62.2 61.6 1.44 29 Fast day. 30 1.735** 60.5 161.0 22 41.5 60.2 60.3 1.45 6.86 May 1 2,385 80.5 210.5 25 2 Fast day. 3 2,380 80.0 210.0 25 4 2,370 79.0 209.0 tt 46.6 67.6 65.9 1.41 6.91 *Alcohol, 15 cc. ♦♦Partial fast. Stillman, Van Slyke, Cullen, and Fitz 455 PUASMA ^ // coz. " O /kcAl-VEOUAR C02.X( 4-5 45 -6.0 40 - 5-8 III Mil I III 11 II lllll I MM Ml.llll IJL i 3 6 d 19 IS 19 23 2830 4 CASE NO. 239'4 ld»5 APRIU MAf 21. Case 2394, male, age 30. Diabetic 1? years, of mild type without any evidence of acidosis. The chart shows a fall in the curves to below normal during the period of adjustment following a high carbohydrate diet. Following this period the curves remained normal throughout. (From April 1-May 4, 1915.) ■ Group I 456 Blood, Urine, and Alv6olar Air in Diabetes 65-1 6« 6o< 55 ■«4- So--e-2 45.^0 40.. 35 -se 30 2^ -54 rpLASMA CO 2^ CASE N0.23«6 I > I I I I I I I I I I I M I I I I I I I I I I I I I I I I 1 I I I M I I I I I I I I I I I II IjJ I l_ n 14 J8 21 El 29 IdlS MAR. APRIL 14 1921 2d 2 7 22. Case 2366, male, age 26. Lobar pneumonia, empyema, acute ne- phritis. Acute nephritis was discovered February 12, 1915, during con- valescence from a severe attack of lobar pneumonia followed by empyema. Typical course of severe acute nephritis with evidence of marked change in renal function followed recovery. The chart shows the curves in a patient with the acidosis of acute nephritis, with return to normal as renal function improved. These curves are of especial interest because they show an effect of disease on respiration exactly opposite to that often encountered in severe diabetes. The alveolar CO2 was consistently much too high to indicate the real ex- tent to which the alkaline reserve was lowered. (March 21-May 21, 1915.) Nephritic. VITA. Glenn Ernest Cullen was born April 1, 1890, at Isle St. George, Lake Erie, Ohio. He attended the public schools, passed the Boxwell Patterson examinations for a high school scholar- ship, and graduated from Sandusky (Ohio) High School in 1907. He entered the University of Michigan in 1908 and was gradu- ated in 1912 with the degree of A.B. He returned to the same University for graduate work in chemistry and engineering, and obtained the degree of B.Ch.E. in 1913. At the University of Michigan he was assistant in Qualitative Analysis 1910-12, and teaching assistant in General Chemistry 1912-13, and was elected to Phi Lambda Upsilon and to Sigma Xi. He has been on the Scientific Staff of The Rockefeller Institute 1913-17, and is now an Associate in the Physiological Chemistry Laboratory of The Rockefeller Institute Hospital. He is a member of the American Chemical Society and of the American Society of Biological Chemists. He matriculated in the Faculty of Pure Science of Columbia University in 1914. He has collaborated in the following publications: The Mode of Action of Urease and of Enzymes in General, D. D. Van Slyke and G. E. Cullen, Jo^ir. Biol. Chem., 1914, xix, 141. A Permanent PrepareAion of Urease, and Its Use in the Determination of Urea, D. D. Van Slyke and G. E. Cullen, Jour. Biol. Chem., 1914, xix, 211. The Determination of Urea by the Urease Method, D. D. Van Slyke and G. E. Cullen, Jour. Biol. Chem., 1916, xxiv, 117. The Amino-Acid Content of the Blood and Spinal Fluid of Syphilitic and Non-Syphilitic Individuals, A. W. M. Ellis, G. E. Cullen, and D. D. Van Slyke, Jour. Amer. Med. Assoc, 1915, Ixiv, 126. The Urea Content of Human Spinal Fluid and Blood, G. E. Cullen and A. W. M. Ellis, Jour. Biol. Chem., 1915, xx, 511. The Formation of Urea in the Liver, D. D. Van Slyke, G. E. Cullen, and F. C. McLean, Proc. Soc. E.v.per. Biol, and Med., 1915, xii, 93. The Nature and Detection of Diabetic Acidosis, D. D. Van Slyke, E. Stillman, and G. E. Cullen, Proc. Soc. Exper. Biol: and Med., 191.5, xii, 165. COLUMBIA UNIVERSITY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C2a(638)MS0 QP91 C89 Cullen The electronetricJtiir&i.iDrL_QiL.±li£