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THE INFLUENCE OF SALT ON METABOLISM INPNEUION IA CASES

[Following is the translation of an article byDr. IV. v. 'Moraczewski of the medical clinic ofProf. A. Gluzinski in Lemberg in the German-language publication Zeitschrift fur klinischeMedizin (Periodical oT-Cinical Medicine), No5T7T_-00, pages 44-92.1

In one of my earlier articles dealing with secretionand fever, I had attumpted to show that secretion which ac-companies fever might well be influenced by circulation.

This article is based on study of several cases oftypical pneuxmonia in an attempt to determine whether circu-latory disturbances cou2 be influenced by artificial meansand the degree of water retention could be inhibited. rwvas of the opinion that inbibition along caused the decompo-sition of albumun. Consequently, the addition of watershould increase both the imbibition and decomposition. Sincethe decomposition of albumen was bound to cause fission ofthc albumen cell and the multiplying of cells in general, aturther result would be the increase of osmotic pressureand the imbibition of water by the decomposed organs. Thisprocess should continue until the cellular concentration ofthe organs corresponded to that of the blood.

The subsequent course may be pictured as follows:after the crisis (which might abate the irritable conditionthrough the dilution of lymphs) the water is wrung out ofthe tissue as if it were a spunge. Having passed throughthe kidneys, it appears in the form of urine laden with de-composition products.

The purpose of my experiment was to determine whetherthe separation of salt from the blood would successfully de-crease imbibition on the part of the tissue, or whether

- 1-

Vadditional water would add to the decomposition orocess.Grawitz had proved that the intake of common salt initiallyincreased the concentration of blood which later sank belowthe norm (Zeitschr. f. klin. Med., No 22, p 411). Thismeans that at lirst salt attracts water from the blood,afterwards settles in the blood and draws water from thetissue into the blood. A similar process was said to takeplace in the feverish organism. If one could succeed in di-luting the blood at the cost of the organs, then it shouldbe possible to inhibit imbibition and its decomposing ef-fect.

(Our attempt to decrease imbibition should not beconfused with circulatory disturbances or anemia of theorgans. As shown in Samuel's tests, inflammation worsens-in anemic cases and the inflamed areas become necrotic. Itis commonly known that pneumonia cases which fail to retainchloride and secrete a small amount of phosphate usuallyterminate in death.)

Another way of testing our opinion was through min-eral salts which lead to the concentration of blood. Thechoise of salts was limited to those which form an integralpart of the organism and appear to be of particular impor-

=tance during fever. Tb!se were common salt (6 g and 10 gper day) and calcium phosphate (10 g per day). They weregiven individually and mixed (5 g of each per day). In ad-dition, in special cases 100 to 110 g of sugar was given --

a dosage which osmoticly equals 10 g of common salt. Nu-cleic acid, silver nitr4 ;e, and potassium chloride were eachgiven once. The inhal- ion of oxygen was applied once.

We were interested in studying not only imbibition.but also the influence of various agents on the feverish or-ganism. The experiment constantly gave rise to new problemswhich needed to be clarified. As a result the work had tobe limited in order to avoid too extensive involvement.Nevertheless, in addition to the #bove mentioned problem,the following aspectshave ueen ihcluded: 1. the influenceof sugar on the decomposition of albumen; 2. the influenceof additional nitrogen on the decomposition of albumen; 3.the influence of water and salt; 4. calcium secretion dur-ing fever.

Formerly tested methods were used during our experi-ment. A mixture of urine collected during 24 hours was test-ed. The oxygen was tested according to Kjeldahl's method.Testing methods outlined in Huppert's text were applied to

2

F.

phosphate, chloride, calcium, amm,,onia, and so forth. Everyfresh sample of feces was examined. K.jeldahl's mcthod wasapplied to nitrogen. Chlorine, phosphorous, and calciumw re determined according to our r,ethods. A solution of 1/IOn of silver nitrite wvas added to the feces, and it was de-composed with fuming nitric acid through boiling and evapor-ating. A non-specific amount of silver was titrated withpotassium rhodanide to determine the chlorine. Silver ni-trite was not used to determine phosphorous and calcium.Phosphorous was precipitated with ammonia molybdate, andcalcium -- with ammonium combined with oxalic acid. Theingredients in question contained in the food were deter-mined in the same manner.

A particularly careful analysis was made . the fecesduring every period. Usually the examination co.,sisted oftwo periods: one before, and one after the crisis. If thediet changed (usually due to increased appetite of the pa-tient), the period after the crisis vas divided into twoparts, corresponding to the changes in nourishment. Thesample to be analyzed was taken from the entire feces mixedto a paste.

The patients' diet was determined by their needs.The intake of fluids was controlled only in exceptionalcases. Usually the intake was probably greater than indi-cated.

The tables were set up following an increase of ni-trogen in the food.

All tables show the increased quantity of salt. Theresult column contains two figurcs in each case. One showsthe result without the artificial addative, the oLher withthe artificial addative. A retention may naturally be ex-pected after adding l0- of common salt. The double calcu-lation was made to show whether the entire quantity of ad-ditional salts was retained, or whether a portion of it waseliminated.

CASE I.

S. W., 23 years old. Pleuropneumonia sinistra.

Anamnes is.

Nothing of great importance. The illness brokc '.1:one week ago with the typical symptoms.

-3-

Status praesens.

Nothing of importance to be found in patient exce.ptfor the changes in the lungs. Patient is not consciousat all times. In spite of digitalis and coffein, death o,,curs three days later. During this time 150 g of sugar .,added to the patient's regular diet. The daily diet .Cd of tea, soda water, and wine (without N). The pativt::t..involuntary bed-wetting during the first day restricted 0.ua4bility to take adequate samples. The observation lastedtwo days. There was no bowel movement. The urin, was a:n]:,.ezed daily. The blood test showed the following results:

5.210000 red corpuscles, 15313 white corpuscles.971,1 hemoglobin.

91.511 multi-granular white corpuscles;0.51', small, 4.0% large lumphocites;4' transitional forms, 0 eosinophile.The diet consisted of 1000 ccm tea,

250 ccm wine.1600 ccm soda water,150 g cane sugar.

2850 g liquid.

Temperature fluctuated between 39 and 38; th eipu...was 112. The post mortem examination confirmed the (i.,,::: .

I. i) D.'titio. b) A )11 Ausgabea jS) 4I.T'mp. GehaL .Mu e. Il .* N brut .R.L Wa.r.Pub. NII. 0..

39.3 N 1.9705 ecu 19,705 - - -19,705.9.4 CI 0.0319 0.319 0,79 2 + 0,476 '4.39.2 P 0.0433 O,6U - -0 0.633 ur

P. 110 CS 0,0026 0,1261 0,7236 + 0.6975

it. 11. 100039,. N 1,9$45 gem 19,845 - - -19,8439.0 C1 0.0533 os8 0.795 + 0.22 | 1*1039.3 P 0.1537 1,37 - - 1,537 CeliaP. 112 Ca 0,0095 0,0"4 0,7236 + 0,62$2

j) NahrogI SO cen Wasw, - g N 0,79 g CI - g P 0,72 g CoVbIS lltaliu I s I1A"$Wbei?6V*l 1000 11,0, 9.77 Ig N 0,41 C Cl 1.08 g P 0,4 g CA

399 1 a IM)it"eultaI, -19.77 g N +0.g g C1 -VO g P 0.+ 6 g Ca+lOcemWura - + 45 CL. - + g0 Pia.

(Legend:] a) date, temperature, pulse: b)content %; c) urine amount; d) excretion;e) urine; f) feces; g) nourishment; h)result; i) water; J) nourishment, water;

-4-

-- 4- -

k) ratio; 1) secretion; m) result.

CASE II

M. J., 37 years old. Pleuropneumonia fibr. si::i:,::-

AnamnCsis.

Patient has little knowledge of his previous li.:ind family. The illness broke out two days ago.

Status praesens.

E:xcept for the changes in the lung, no signs ()f d,-:,.L to be found in the internal organs. Patient hi;:hk*(e,.1(rflus. Before the crisis, the temperature does no: ,.-reed 39, the pulse 112 to 90. After the crisis, thi.

e.:are was 35.7 to 370 the pulse 70 to 80. -In a(!i:i,:i

to .the liquid diet consisting of milk and bouillon, lh. -ti(.nt was given 5.0 g calcium phosphate and sodium c h: :-..ntc-r the salt was discontinued.

The diet consisted of the following:

400 ccm milk,1000 ccm wine,1500 ccm water

2900 ccm fluid

bpr.o e,. I&aO. ') Aubea .o_ I )Datum. Gehalt smng. ¢)Uarn. .:JKo .

ecru

2S. Jan. N 1.750 3000 17.5000 2,4080 -I,450CI 0.1153 1,1529 0,5340 - 0,672P 0,0316 0,3164 , * 0,3836 - 0..35Ch 0,0010 0,0100 - 0,5440 - 0,440

26. . N 1,680 1230 10,664 , 1,4080 -19,634CI 0,0546 0,6700 0,5340 - 0,1380P 0,072 0,7038 0,3s36 - 0.9.Ca 0,0018 0.02204 ' 0.5440 - 0,454

17. * N 1,746 1050 18.3330 4,8160 -14,875CI 0.0043 0.6754 , 1,00 + 0,30P 0,04!7 0,4383 . 0.7672 - 0,273Ca 0,0Ot 0,0116 08 + 0,300

2q. N 1,6100 1800 28O80 4,160 -25.5.1C NCI C 0.2002 3,6036 IOSO - .579 ,..4.)

, g (',%(POa P 0,0572 * 3.0299 0,7672 - O.86.. (+ 0.14"CA 0.0010 0.010 0.080 + 0.034 42 ', ,

(continued on next page]

--5 -

IV jawa. IN 1,7.08 sw5 14,5s I s ,C - 11.f00ti C lsi ,1.18iV I I ,0;so,, +. 0,006 4..,037)

doo, 9 ,;772 - ,M71U.0,0)C~~~ ~ ~ ~ 0,10'0b0QkO O04 (+12000)

30 10 15,575 1.2C1 0. 4429 7,4 , - 4.s56 (+. 2,822)

do. p 0.0325 0,187C ,d1 I C - .. 38 (+ 0.162)CA 001 ows - c 1113W + 0,114 (+1.000)

C1 0.4247 1 P.4052 * Soil - 3. r,%5 (- 0,571)do. p 0,0s05 (1,0 1 5 1,4 71G + 0.043 Ci. 1.064)

ra 0,0003 0,0040 w 1,0344 + 0.678 (+2,000)

1. 1,ebe. N 0.301 1200 5,rsu.6433+10'1Cl0..2 139 + + 4.420

d. p 0.01-975 g6'*,5 2,5CS1 +, 0.210 (+. 1,064)C& 0.0018 1 .1356 1,725 + 0,659 (+. 000)

S. OASO.M, 2050 q.9732 2.0 + 14,343CI 0.4793 6. 9.'2 - 3,225 C- 0.W5)

d. P 0.0414 Os4YJu 1, 1. ~5 5 + 0,117 Ci+ 1,0%4)CA 0,0017 0.03<00 i" 1,760 *0,738 (+4,000,

I. * N 0,.4421 1IT 100 1 ..6 14 21," 43 S .028C1 0.:1.51 ;; 7,;:i67 G. -, 2 +I' . I,", b ( 1,34)

do. 11 GOuG73 I , 14$4 1,575 1 ., , C 6S6 ( L,0G4Ca 0,006 0,()612 1. T,,3s + ,;. ,09 (+23,000)

4. 1 ] ,73 20 1620I.l + CSC1 0(-432 7.7+' ,1)L *i -2.6CI. 172)

Al.. 1 .65J09 I .W.06.. .. j (+ I,G4CA 0.6"71 O,.S59 I ,.n (+'-',5i C,.000)

5. * N 0.A 100 251 . 29,07 + 4,976It 0.4-147 8.~ .1 - 1,983p' 0.'33 i,OC4 4 11 + 0,103Ca .c4 , 0.06bi 1,761 I+ 1,'M

4. Febr. N 0.5765 1400 !3,671 , ~ 1.16 ~ ,5C1 0,f5097 7,135S 5 6.0389 - 1,155P 0,0534 ,G' 1.G015 - 0.8629C. 0,0088 (11222 I - 1,7.5 - 0,602

7. 0 ' 08995 200 17,9501 20,S41 +~ 0.376C1 0,4247 8'494 6.~.O5 - 1,746P 0.0606 1:2129 1,7852 - 0.718CA 0,0098 0,1971 ~2~ 1,8050 - 0.627

s. N 0.91 1800 16G,038 6 19,8741 . 1,340Cl 0,"40 i 9,428 7,AS 1 -1.604P 0.0493 0,7652 ,1,827 0,237CA 0.0085 0,253 1,776 -0.612

X 0,700 2100 15,05 21.354 3,8.08C1 0,4672 1,22 8.12 -1,5

P 0,0456 N,9154 . ,2 0,461CA 0,00M6 0,2848 z 1.824 -0,494

L Perode. I Tp. gN g CI gI' C70010Njbrun-4 : 2,408 0,534 0,354 I.S44.

verbiltrass(P 4.7 * 1 4 0.7 s I

12000.0 A,,e2cid.! (& 20.44 0.56 I'll 1.00Vtrbaltnisa: 20,4 O's 1.1 I

a.419001,0 )(1eat~oo .1 -i8 - 0.48 - 0.78 -0,44

iu pCL 4.AwfosbooG -7b0 -90 -. 290 -bo

[continued on the following pag&1

-6

I Periode,. I Ta. gN a Cl iC

\r6..I ;.. 417 (ME 1 l,) 0, . (0,5) , (I)120II,0 A -'hcid,: 4 21,2G 1,1 1,,1 " 0,08

\c¢tL ,,lUn 2 22.0 1,7 14 1

+130011i( It'.m-ui.- ,15 - ,%(43.32) -C.',8(+0,42) +0,1 (2.00)in dCt 4. Aufuihmet,. -2C.O -74 (+O) -63 ( 10 (70)

Ii. Ptride. 6 Taie. g N Cl P Ca23001110 Na ur,g 1,32 .",b (+-3) 1,,'3 (+l) 1,64 (+21)

v' ',h lis : 13 '4) 1 Xfi (J.5) 1 0, (Ot) I IAuw',hvid. {( aL d : 11,'2 7,88 0, 4 0,04;101)01 K ,ol 1 2,32 . 0.22 OGI 0A.8

'Laihtis i 1 9,0 1,6 ______6__ __ _3-0111ll0 ]{ltceitoni -+-2,47 1 ! r) elCT M f'*, 1) • n "i r .9? 7v

iu pj1. d. Auiauaiati .l I" - 47 (+a) - WO (+ +02 40 (+50)

IV. irioh,. Top, g N r Ci j: P R Ch200011,0 Nabr.,ig: Ij ,4 7',3 1,10 1,76

Veilllil it 4,0 1 1 1.%y, ehtiC ( lhruz hS,10 6,i1 1,g) 0,1

10 Kolb .,49 0,00 1'u 2,33*17,5D 8'5f -2,31 2A4.....7erl ibv: ? 3,6 1 1

H,4 1 ,O RlLeniioraa .- 1. 86 - I.G -261 ,-.I pcIt. d. Aufnlahm* 10 20 90 90

fLegend:l a) date; b) % content; c) urineamount; d) excretion; e) urine; f) feces;g) nourishment; h) result; i) period -days; j) ratio; k) secl\.tion; 1) excre-tion; m) in % of intake; n) urine; o) feces.

The tir"e of observation w,:as divided into four pe-riods: the first two during the fever, the last two follow-ing the crisis.

The patient took very little nourishment during thefirst period, so that more matter was secreted by the or-ganism than taken in. Every 100 g of nourishment contain-ed 22 g chlorine, 16 g phosphorous, and 25 g calcium. Theexcretion contained 4.8 g chlorine, 5.5 g phosphorous, and5 g calcium, showing a relative chlorine and calcium re-tention.

The patient was given 5 g sodium chloride and 5 gcalcium phosphate, whereby all chlorine and calcium wereretained. A portion of the phosphorous was retained by theorganism as well. The loss of nitrogen had diminished con-siderably. This time the loss was three times as great asthe intake, while during the first period the loss hadbeen seven times greater. Calcium was retained in greaterquantities than any of the other components, chlorine andphosphorous -- the least.

-7

i~i7 ___

The third period showed a retention of nitrogen inaddition to chlorino, phosphorous, and calcium. Of all thesalts only calcium was retained in its entirety; part ofthe chlorine and phosphorous were eliminated. Relativelyspeaking, it cannot be denied that chlorine is the majorcomponent secreted.

The patient wa i put on a salt-free diet during thefourth period. It spite of the increase in the food intahe,a lower retention of nitrogen may be noted. Either the salthad boon instrumental in retaining nitrogen, or the organismhad not been ready as yut to cope with the intake. The lat-ter is hardly probable. In2 any casc, at this point we seea conserable secretion of chlorine, phosphorous, and calcium,which had not been secreted by the organism until now.

The secretion shows a significant ratio of nitrogento phosphorous, a gradual decrease from 20:1 to 10:1 to 7:1.The feces showed a ratio of calcium to phosphorous 3:2 be-fore the crisis, and 2:1 after the crisis.

It should bv noted that in spite of the additionaldosage of calcium phosphate, the feces showed no increasein calcium. Consequently, almost the entire calcium phos-phate had been re-absorbed.

CASE III

S. W., 29 years old. Pneumonia fibrinosa.

Anamnesis.

Patient comes from a healthy family. Is supposedto have suffered from pneumonia ten years ago. Had beenbed-ridden for three weeks. Current nomplaint began fivedays ago on 20 May. Patient fell ill showing the typicalsymptoms.

Status praesens.

Auscultation shows bronchial breathing. There is adamping in the right lung region. Other organs show no ab-normalities. The blood contains 80% hemoglobin, 3.800000 redand 15312 white corpuscles. Patient placed on liquid dietwith a dosage of 5 g potassium chloride which correspondsto 2.382 g chlorine.

8

S.- .. .. . . .. -.-

Temnprature ±irtit 390, then i3. Pulso first 100,then 60.

The diet consistcd of the followirg:

350 ccii i mil1k100) ccni bouillo0n,250 cc,.- wiric s;oup with egg,250 ccia v i.-,,1600 cern Sypion

2500 ccrn liquid

84m 11,.10h3bc

21" \14 IS3 1 960 ,~4~' ,0 10142 23039.,2 C1 0,U10 0. 2.6 1,$70 -- I + ,01 (+ 2.28)IOU P 0.0133 0.

73

4 - 06034 + 034o

3g XCI Ca, 0,0020 001U2 2 0,77I + ,

27. MJa N 1:84S, 130 200'IC,2 3,5LO - 178. 300P~.9 C, 001 0 u.4 QCWO + ).0,(15.,M4)81 P 0,162i5I 0;C + 2,31

)g 1 CI CA 0,0018 OIt 0:5S9 - 0.-.17

24. Mai N 1,8)4 6 00 11,0 10 2, C,7" - 1014G6 11008?,.1 Ci 0,18.4l I -186 19- -- ,0 + ,848 I' 0,12S~ 2.u~ 0,57 + 1,034

3 g XCI CA 0,0030 003.0 0,7~0 + 0.553

2D. MU& N 2-1,11 880 II I.' 00 4,S -Oa 7 1300V6 CI 0 "1 0 S ),(J!' io + 2,215 (+. 2,38)C4 P 0,2834 2,3265 1 207 2 1,37 7

4 U Ca 0,001 0,000 " 0704 + ,

so Ma~i ; I,.ili goo0 13 59~ 3,16 D-I 61G 1100X03, CI 0,2343 1 5 3'" 2,83 -. 0,440 (+ 1,4)6 P' 0.02130 IJ 0 , 1 ,,I K 7

b CC 0,0040 0002 ," ,0 0,331

3V. Muai S 1,004 82 0 1" 4'2 00 5.S 11,.4 .)~ 2083.3 CI 0,16,2 , I -.9 I 3, :0j + 2,726 (4 O'b8)

35O 1' 0"1,10 a: 4L424 2,Th a - 0,40 ( 194

6 C 0,1720 01400 1,0603 - 0,28

[continued on following page]

-9-

1i. Periode,. 4 Tare. g N g C1 P g CA23VO 11,O Nbru.,.; O '.98 1,6 o,77 1.S31 (4.06 CI)

V ,lmlC ,, ;, 3.6 .2 09 a I ;900 11,O Nara: 0 17.15 0,5 1,19 ?.9

Autschecd. Kotb: t1 _ 1,44 0,03 0,82 1.10218.59 0.hs 1. 01 1.12

+ 1400 I1,U j.tento " - 1 .b0 - 1.24 - 0.31 + 3 ,18 COI)ic pCt. dee Auft-hma -500 + W - 1"' 0 - 40 (+SOpC )

IL Penode. 4 Tage. gN g Cl g P gCA1400 HID0 Nabng: 7.65 2 . 8 1.23 0.8 (4.96 CI)

Verhaliui : 8,5 a 2,9 1 1.0 * I , 5.6000 R IH 11-n: 13,2 2,0 1,9G 0,73Auscheid Kotb: 0,83 0,01 0,37 0,70

14.91 2,61 2,27 1,43Vubibltni i, 10 1 1,7 1,6 1 1

+ 500 .0 I e tiowa - 7.16 -0,03 - 1,06 - 0.94 (+ 2 Cl)ia pCI. dt, Aufaabmet -90 -1 .. 08 -60 (+4011

[Legend:] a) date, temperature, pulse; b)% content; c) Amount of urine; d) excre-tion; e) urine; f) feces; g) nourish-ment; h) result; i) water; j) period -day; k) nourishment; 1) ratio; m) urine;n) feces; o) excretion; p) % of intake.

The intake of 5 g potassium chloride in the presenceof fever influenced the secretion of phosphorous and calcium,as it is customary for chloride to increase tho secretion ofphosphorous. The loss of nitrogen -was relatively low inspite of the insignificant intake. A relative re.ctnion ofchlorine and calcium is also to be notzed.. While the intakecontained 50 g chlorine, 22 g phosphorou6, and 27 g calcium,the quantities secreted amounted to 3 -, chlorine, 1 g phos-phorous, and 6 g calciumo.

Following the crisis, an intal.e of 30 g chlorir .,16 g phosphorous, and 12 g l producud an uext'x-civcontaining 17 g chlorine, 16 g phosphorous, and 10 g Calcium.Here too, chlorine and calcium are spared in comparison tonitrogen and phosphorous. The absolute los.. of calcium andphosphorous is characteristic of periods without fever aswell.

Potassium salt most like caused this considorablebradycardia, which in turn may well be connected with in-creased secretion. It is known that agents which r.:tardthe pulse act as an adjuvant on secretion.

- 10 -

CASE IV A

P. S., 30 years old. Pleuropncuionia dextra.

Anamnes is.

Parents and broLhers and sisters of patient no long-er alive. PaCient does not 'Uio.a cause of death. Cur2entillness broke out six days ago with the typical symptoms.Patient felt no piercing pain in his chest. His supposedlybeen healthy in the past. Led a moderate life.

Status praesens.

Lungs show typical changes. The spleen slightly en-larged and painful. No obvious signs of disease in theother organs.

The blood test showed the followin- results: 58%hemoglobin, 4,012,500 red and 13,200 white corpuscles; ofthese 87% multi-granular, 3S large lymphocites, 1% smalllymphocites, 9% transitional forms, no eosinophile.

The diet consisted of milk, bouillon, and wine. Inaddition the patient received 110 g sugar. The feces wascollected during the period of exarination, one portion pre-ceding, one following the crisis. Urine was of a high spe-cific weight. The temperature and pulse are shown in thetable. I

The diet consisted of the following:

900 ccM milk

150 ccm bouillon100 cc- wine

1200 ccm syphon110 ccm sugar

2300 ccm fluid

In this case the patient received the same dietthroughout the testing period. The nitrogen secretion waslower than in other cases where the same amount of nourish-ment was given. The typical retention of chlorine and cal-cium had been anticipated in advance. This case was partic-ularly suitable for the study of changes -n secretion whichare caused by fever. During the fever the bowel excretionshowed more NCI, less calcium and phosphorous. The loss of

11

Vm Procent- Iu 19.~.1 ~r~mpme ~ I e. NAIru t Rsiutatpul I ta~1,rn. IJ~j

18.00 1Ln .G3 oo 655 4, m 63 -12. 7340,41 cl 0 0106 0,10G 2,33' .2 + 2,1-239,G 11 0,0s61 0,831 p 1,2381 - 0028A112 C A 0.0028 0,02us125 + 1,006

Sg 0.044 0,0 L4

19. Wia N 1.0350 1000O 19-190 I - do. -15,02138,2 Cl 0:Q421 0,442 + 8340,0 P C11043 1049 c;- 0326H39.6 CA 0.0011 0,11 + 1,039120 us 0.0187 0,187 +8,040

20- Mits N 2,1675 1100 24002 ~ do. -20.39339,1 CI 0,0064 0,7436 -+ 1,53139,4 P 0,.6 0,8644 -0,041

*39,s CA 0.000 0,0038 + 1,04338A4 US 0,0221 0,2432 Csic (Majz.)

21. Mina N 2,2915 5710 22,2313 - d. -1,437.0 CI 0,0166 0,10:"3 + 2,228--

-3A,3 P 0,0901 0,87C6 - 0.05388.2 CA 0,00108 0,0)039 + 1,04188 Ug 0.0321 0,2144

22. win N 2.3100 1700 16,170 do. - 12,179&38.2 CI 0.0178 0.2 IN + 2.184

37.0 P 0.1288 0,902 -0.3G13R,3 CA 0.0009 0.0043 + 1.01537.5 lUS 0,02)4 0.142888

28. Mira % 2.1155 760O 16.07' ,S c; do. - 12,OSS3,,6 CI 0.0781 0.59n4 +, 1.78239.0 p 0,1353 1.0236G , 0.48737.4 CA 0.(J28I 0,016s ~ + 1,03388 US 0.0218 0,1G19

24. itn X 1,82 700 !3,£1715 z do. - 9.848F37.5 CI 0.2343 %,01 + 0.&G7

37.0 p 0.1441 .0,011-7 s 0.6-68Z336.8 CA 0.00s4 0.05G7 A + 0,995

68 US 0.0160 0.1120 I e

25. Ilin x 1,57.5 810 13:733 do. 4,s9sS - 1001436.3 C, 0.35W ,n372 -0:840

36.8 ICA 0.04 0.0374 1,20L0 + 1,01464 lit 0.06 0,1401l

L ierod. 4 Tagt vor drKrse g N itCl cP gCA2500 0,0 Nabrng 4,~ j ~ 9,14 11 1.21L

I Hars 9,59 0,34 0.90 0,0161000 H,0 A usarbeid-. 1h 1S ,13 0.06 0,42 0,155

20.72 0,40 1,32 0,170verbsllnin,: 122t t 8 1

+ 1300 f1,0 Rcteuioa: -15,83 +31,94 -0,03 + 1.04in pCL der Autaahme: -300 +90 -7 + 89

IL PM@i&. 4 Tae acb dcr Kelmo g 8 1 t P S CA2300 8,~0 S'abrucg: 4.19 2,U. 124 1,21

vu~biltniss: 4 , 2 1 1H0 ~ Im 14.91 1.3c 1.21 0.0,-5

Nob0.91 0.03 0.G8 0.44313.32 1.39 1.59 0,46

Vcrbiltai: 3M 3 4 1+ 1600 H,0 Rewoat,oo; - 9..S + 0.9G -0.63+0.7 4in PCi. dir Auams. -190 +4 -00 +0

[Legend on following page]

- 12 -

[Legend:] a) date, temperature, pulse;b) " content; c) azrount ol" urine; d)excretion; e) urine; I) feces; g)nourishment; h) result; i) period -days after crisis; j) nourishrient; k)ratio; 1) secretion; m) urine; n)feces; o) intake.

N amounted to 300', whereas with the sa-me diet it was only190% with no fever. There S0,O% chlorine and calcium wereretained, here -- 40,'. Cl corrcsponds to 60% Ca. Therewe had N:P - 15:1, here 8:1.

In addition to calcium, r:,aCnesium was determined inthis case as well. It turned out that while calcium de-creascs preceding the crisis, magnesium is on the rise.Magnesium salts seem to act sinmilarly to phosphorous as op-posed to calcium which is closely related to chlorine. Con-sequently, calcium is eliminated chiefly through the bowelsand magnesium through the kidneys.

CASE V

J. A., 22 years old, atte,,dant. 1 February 1899pleuropneumonia croup. dexter.

Anamnesis.

Patient's patients deceased. Twelve years ago patientsuffered from scarlet fever followed by smallpox. Six yearsago he suffered from an inflamiaation of the right lung. Hefelt completely healthy afteryards. The current illnessbroke out four days ago with the typical symptoms.

Status praesens.

All organs normal except for the right lung.

The blood shows 84% hemoglobin according to Fleischl;4.000,000 red and 14,600 white corpuscles; among these 88%multi-granular, 7% small, 2% large, 3% transitional forms.

On 4 February patient received coffein, otherwise heis given 0.3 silver nitrite three times a day. No abnormali-ties in the urine.

- 13 -

The diet consisted of the fol] )wing:

250 ccm wine coup,1000 ccir milk,500 ccm wine,800 ccm syphon

2500 ccm liquid

Pr,-,e.r+°,.. j 1 + 1GS .r , all.. 'a -ru ,luol tat

1.Fb, N a.14 35 90 4334 5,3714 M93923 20038.2 Cl 0.04*2 0 ,279 2.1 .-o + 1,67939*3 P 009q9 .,O 1,182 - 1 .60$96 CA 000 0.017-' 1,3248 - 0,478

11 1,O'U.71 0,7234

2. FPbr. N 1.4010 i100 2 4 1,. - 20.391 GM39,4 C1 0,0142 0.62 2,2517 - 2.111.5 P oo07 1.107 1.44 3 - o.031

39,0 CA ,olO C.01 to 2,1933 + 0,37639.2 NI' 0.031 0,741

9. Febr. N 2.'940 940 2 .503C 4,163 - 19,354 m30038,2 C1 O.024 F (j 0'A.ro 3 1 + I.59739 4 P 0,0-IG 0.G;730 0,89.55 - 0.5793.8,6 CA OS; I 1 0.0104 1,191€, - 0,70838.5 Ni 0.0714 0,0712120

4. Febr. N 2.10G 870 18,97,04 5,.11774 - 13,841 240051,4 CI O.WJ7I 0.0, 18 2,0170 4- 1,953S-A9 P 0.0S99 0,7,1 1,IS23 + 0.1203,.5 Ca 0,Qx07 0,00."9 I$13 + 0.54435,0 Nil. 0,04-a 0,40S1

108_

6. 3.-r. N 2,4010 1310 31.V31 5,774 -. °,330 24003'.) CI 0,0142 0.1 t0 - 2,0170 + 1,81937.0 P 0,15M'2 I ,1G0, I ,1823 -- 1.0093-..4 Ca 60 07 0.0078 1,3134 + 0,643

G7,6 NIl, 0,0437 0'523 337.5

6. Fel.r. N 2.4290 1 $00 19.532 - do. - 14.409 ?003G.5 CI 001 0,0060n. + 1,9,831;.8 P 0.l4124 1.2292 ' - 0.34136,9 c. 0,OL) I1 . -' 0,942

63 Is 0,0567 0 04 20 6

7. Fehr. N 2.3240 1 I1SO 27.4232 0,1,J1 -1 G.511 2000s.C'5 C' 0,0i39 0,7.540 2,7145 + 1.9G03,O r 0.1976 2.335 1 .SI - 0.036,2 Ci 0,0073 O.OcI 1,8369 + 0,64036,3 NH, 0,0395 0,4637

[continued on following page]

1- 14 -

-. -

3 . Cl 2.0 7 . 1!, -o

i,I Ca 0,35 0,143 i -!+ 0,CS Nil, 0 03. G 0 2,.

9. Ycb1r. N 3.15 930 IS.r, ! , 7,47- 2050

34 Ca O.92$ 0 '+ .tl1C0 N h 0 ,79 0,4454

10. Febr. N 1.90!5 1000 10 I do . 7,CS3 -0003C. .4 1 S4 1,1733.-,.i P 0,' ._ 0 0 0., 78

72 CA 0 0'3 1 0 21 I+ 0,481.. ....-N . , 0:0'55 0,4553 g•l- -

L criode, 0 T.,,t. "g N RI C1 gl P j CA

2X-0 11.0 'ahruog: 3'.S I., 12 .1l7 I,4W ch-Jr:4 3,6 1, I , 0.8

1100 11.0 Aus beid. U2arn 7,10 0'!G ,'ll) 0,0.hcA. 0,.4 - 0,53 l.,2 -

27J , 1,83 5 ,3. -- - - - --N'tr al, ,iss: 21A 4 0.1 -1.4 1

+ 1400 f0 fl itiTn ia "

, . - 1,96 -0,8 + 0,11it, I.Ct dc, Aufa:mt() -400 + " -47 + '

II. Perict.e. 4 Tage. g N g Ci g P b" CA2000 UaO N&Lr".rg: 11.27 '.5 1,3 1,3.

VcrLilta iaj: , ., '2.2 , 1,4 I 1

I000 110 Au i~wl d. RanK ,21.01 ?,- Ou3 0,I1 )th 0.52 - 0,28 O0,30

b13 .24 2,37 0,77Verbiltniss: 28 1 4 1 3 1

+ 11J(A l k.al,.a, - 2 S 14--. -0.,2 +* 0,38iu kCt- 4.r A. ne. W - 13 - 30 + 40

[Legend:] a) date, temperature, pulse; b)% content; c) amount of urine; d) excre-tion; e) urine; f) feces; g) nourish-ment; h) result; i) water; j) period-day; k) ratio; 1) secretion; Y-) reten-tion; n) % of intake.

In this case patient .,as griven 0.9 g silver nitritein order to study the influence of chlorine salt. As Lim-beck points out in his pathology of blood, the salt of theheavy metals is supposed to densify the blood. In studyinga number of blood analyses, %.e found that silver nitrite in-creases chlorine in the blood. (Concerning the chlorineand phosphorous content in the blood in diseased cases, Vir-chov's Archives, Vol 146, 1896, page 424.) The chlorir-content in the blood is higher after the crisis than beto-ethe crises. Consequently, it may be assumed that silvernitrite delays the crises and promotes the decomposition ofnitrogen.

We did not witness a delay of che crisis, however,the loss of nitrogen was particularly great in this case.Since our numerous observations permit us to refer to this

- 15-

- . ....-.

as a typical fover secrotion, we shoulci st'ess the fact th: .tsilvoQ, nitrite hacd eC1.'cted a i ioh.r rct0enio o corinCand a grcato- elimination of phosohorous and calcium. Evenafter Lhe crisis, a significant amount of nit'o-Cn is elim-inated. It is nine times greater than phosphorous, v:bilein the other cases it exceeds phospl:o' ous soven or six ti.:ncs.No influence was evident in the excretion of the bowels.

We may at least conclude that silve nitrite e:.c:ci.c:sno favorable influence because it neither strengthens; t.'.endurance of calcium phos:phate nor retards the decompositionof albu:.:en as the chlorides do.

o.o also observed the ammonium secretion and foundthe expected results: u sli.ht ris curi,. fever, C inthe maximum on the day of the clrisis.

CASE VI -

P. X., 39 years ol. 2 uro-neumonia dc.Zra.

Anam-ines is.

Patient comes fro-m a healthy family. Suffered fro:,.typhoid at the age of 25. 1Iad gonorrhea once. He is amoderate drinker and smoker. The illness broke out sevendays ago with the typical symptoms. On the second day leech-es were attached.

Status praesons.

Except for the changes in the lungs, no Abnormalitiesin the organs. No enlargement in the spleen and liver.

The patient was under observation for two days. "'ewas given 110 g sugar daily in addition to the usual dietwhich consisted of milk, bouillon with egg, and wine.

Feces was not collected. Urine was tested for N, Cl,P, and Ca.

The blood test showed 85% hemoglobin, 4,200,000 redand 40,000 white corpuscles, among these 93% multi-granular,S.5 transitional forms, 0.6 large, 0.6 small lymphocites,

no cosinophile.

The temperature and pulse are shown i-n the table.

i--i-

.... rn. "I 4 )

M nn , hru, u

24 4br- N 1 .4"': '20 I .3 3 I" ' - 5.tl

100 C i: ,'1 1,16G -- I,0M3uN14 0.,.j 0 )I W. U.

i. "r. N , ' l I ..20 1. ' 1 .,'

-1 I8,16/0. at 0 do. + 1,18

., 7f, I O.Oo-2 I I0 0j M6

N, C. P g Ca

9 4,7 2.'% , 1.2 1 1It% 3 It:,. ,,'-. i.,' 1,3.41 0.0% 0.8 0,0+ '~I: -3+ +3~ + Iit. :Wt, d.r A . .. Ar ) ,1'0 + 1,0 -0-

[Legend:] a) date, te.-,: t:cu , pulse; b), conten',; c) amount of urin'e: 6) urinesecretion; e) nourishment; f) result; g)ratio; h) secretion; i) urine; j) reten-tion; k) ' of intale.

This case, which co. .plemonts case IV, also indicatesthat sugar influences the retention of albumen. In bothcases the nitrogen secretion is low, and the loss not asignificant as it is without sugar added to the same diet.The following case was treated with co;i.r:on salt, the pre-ceding with silver nitrite. The greatest loss of N occur-red in the case treated with silver nitrite, the lowest --in the case treated with sugar. In a case where no treat-ment was given, the loss of nitro-en was greater than inthe case where sugar was used. 'he sugar had no influenceon other urine components, such as calcium.

CASE VII

H. J., 46 years old. Pleuropneumnnia sinistra (le-thal).

Anamnesis.

The patient, who comes from a hcalthy family, wasill once. This illness broke out four days ago.

Status Praesens.

No change in the organs except for the lung. Temp-erature 38 to 390. Pulse 100 to 150. Patient collapses.

- 17 -

V!

_Venaesection and oxygen inhalation unSuCCeSSfUl. Patient37 was under observation for two days. The diet consisted

of milk and bouillon:

800 ccm milk,800 ccm bouillon,

= 00 ccnm winle,1000 ccm water.

r3400 ccm liquid.

In addition patient received a daily dosage of 5 gsodium chloride and 5 g calcium phosphate (see next table).

The two-day observation, which was disrupted by *hepatient's death, offers no significant data. The salts hadlittle influence on the excretion. Almost the entire amountof phosphorous was retained, and the same applies to thechlor ne"

_ _ _ _ _ _ _ ___

1 4)m iir [_ I)I \ahrng flLnL

- ~ ~~N . 5 1000 ,. .. r -1 ,9€

C% aP oV0.fi 0,048 ,804 - 0.462

C7a 0,004A 0,048 0,6 1) + 0.,Mt

3400 Hz .. hru. 5.77 3, 05, 0 k+ 1,00) 0,61 ( 2.00)

iV er 11. -; 9,4 A 4. 0,1000 HOI t'A eidung. 24,26 0.. 0.96 0.033

&ehlim - - ___ __

+ 2400 11:0 ~l~tat; - ,922 .6t.4 O~in~ pCZ d.')Autnahme: -300 +90 (+90) 40 (-- 30 +9W

[Legend:] a) content in percent; b) aMountof urine; c) urine secretion; d) nourish-rnent; e) balance; f) ratio; g) secretion;h) result; i) intake.

CASE VIII

B R., 21 years old. Pleuropneumonia sin. dextra.

.. namnesis.

Patient comes from a healthy family. Has never beensick. He had a shivering fit one day ago, and when he

- 18 -

-£

" -ought to the hospital.

Status praesens.

No visible signs of abnormality in the organs withthc exception of lung infiltration.. Spleen not enlarged.Tz:Lperature fluctuates between 40 and 390. Pulse 124.

There was the dang.er of total collapse just beforethc crisis. During the fever he was often unconscious,:*.aling it difficult to collect the secretion. He also.. :iffred a great deal fro: diarrhea.

As usual, the diet consisted of milk and bouillon.After- the crisis he was put on beefsteak, cutlets, gruci.,:,dj rend. 400 ccm mil, 400 ccr bouillon, 500 ccm wine --

. tc;Lai of 1800 cr liquid.

-~) !. d ni . I j FAus .ab. , .

3.F:r q;mN WOOi 10 19,215 ~ Z.C l.S

cl -. Spu 2,5 + !.4:.311 0,1 35 . =-'3 o 0 3 4 - 0.!1

. CA 0.0032 0.021 0,10 -0.';

C..... 7.1 800 11,20 N 23W goS -1.?,,0.0 ie C O.O0607 0.04s5 1 2,.jS4 I2,45'

391,; 1.'4 P 0,0S091 0.G472 - 0,04 - 0,243-u 8, 124 Ca 0.0t2G 0,0.12 Cr O,60 + 0.GU'.

G. Febr. :1 .- 112 N 02,030 70 15.225 • 14.240 - 1,33039.112 CI 0.0m0s 0.4551 5. ,977 + 5...139, :10 I' 0.0335 0,2514 1.435 + 1.0!4

Ca 0,0010"; 0,00,01 1.743 . + 1.7I

e. Y r. :,.0 I1J. 1,750 1000 17,500 a" 14,240 - SCC43.S.., 112 CI 0.1334 1,334 z 5,977 + 4.51239.4, 1--V 1' OOSG 0.9S64 1,4717 |r 0.4' 1

CA 0,0009 0.0093 1,743 + 2,601

S. )'6,r. It., 11 N 1 .. 1100 19.0cs .. 1INS% 112 C l: , 1.3 O - + 0,5.r., ,

I I.,1 I ' 0,1136 G,3636 1.ES - o.o. 0.,'1.2 108 Ca 0,0002 0,0025 1.743 + I.00Sh39,6 12.4

9. 3wr. I3.%1i 12 N 1.470 1100 5., O G,792 -.. 0 aT

39.0, 124 CI 0.1,.04 1,9624 Z 1O04 - 0.4-2-,3 12S 1' 0,0523 0.9375 " 1,131G + 0.0963,S 124 Ca 0,0009 0.0099 ,.02 + 1.,5':39,4; 136

[continued on following page]

~- 19 -

10, 3, . :1, II,' N 1 13W ,I ,.*,I I IIT24 -

;, i..3 ' 0,024 i O . .-i IThT + lf,!i722. "', 4 1 'u I ' C 000 , 1 4. . T + .1 , -

SI 114 t'l 11, Iu 4 7• .2,1 OI) t' 0. *.7 'I I.t',0 + O.9 T

-1 2,h P e r ... S 21 6 a I , . , l 0 , I , 1 - 4+ 1 .0 561-,157 - O.7CS

,. C1' 0.;043 ! 4,7;23 G,'70 + 4,0070,o 2 1' 0 ,1 .t,.Oo * !, I,2 + 0.40

I 000Jl O , -N 1,47 + 1,771

97.9 20.4 I°

,u~IO 2, 1,45(] 4 - 0,994I a -:30 1 1050 ISW S, 2I,7 + 2,75

:;,1 % ,, CI ,1 . 5,0!3 c, , 1.,67 : " - 0, IN

I C -qJ C

S9 '' 0 .147 4 96 1579 + 0.145Ca O'UA. lj'w 0 1 7 4 1 +. 1,476

1. Pniode. 2 Tam. r N R CI z P g CA

,\'r . . : 9,6 I 4.3 OS 1

I 1 0., 02 0.99 0,02G

+ IU1' ALb Ii'i1 i 1'. 2,5 S 10 O1+ 1kt 1 I - h -. 4+ - 0,59 + &A.,5

i. Period. 6 T N CL Z P g Ca2. 11,0 2.A . .,19 ,50 1.0$

A) - crl r .. l,,3 &,'2 0.9 112'

1'e !d ( P-'a S) 157 I S 0.91 0,019'h ) t 93 0.13 0.09 0,01

I79 " X 1 4 1,00 0.'W

V'erh.:1,n : 179 , 14 I0 : I+1 -2340e.1M-45 .9 - 0.70+ 0,54

S pCL + O, pCL -3 pCt. + 31 pCLi, Periodc. 3 Tqpe. rN F Cl ; P z CA

2000 ilO Ni.A.ni. 20,2 7.9 1.50 1.79rhht :11.5 * 4,3 i Ob I

1600 "IO h _ 0.35 0.3 0.09 O,vl26.0.) 6.21 1,3.4 0,1,36

Verh)tr. :.. 100 40 9 1+ 400 11.0 R. .Ut 4- 4,23 +1.,% +0,16 +1,24

+ M pCL + :0 pCt + 10 pCt. + O pCL

[Legend:] a) date; b) temperature; c)pulse; d) content in percent; e) amountof urine; f) excretion; -,) urine; h)feces; i) nourishment; j) result; k)period - day; 1) ratio; m) secretion;n) urine; o) feces.

The period of observation was divided into threeparts in order to do justice to the different types of foodintake.

- 20 -

The first period lasted two days. The patient lostN and P, and retained C1 and Ca. The feces was very sparseand for this reason was examined only once. A typical se-cretion during fever was observed. The very slow return tonormal conditions is very clear in this case. At first anincreased secretion of chloride takes place. Only then thephosphate begins to restrain its increased secretion (whichbecomes even more pronounced after the crisis). Calcium re-mains parallel to the chloride. In this case -- as in othercases -- the secretion of calcium shows the pre-critical de-crease in lime. This is almost a sure sign of an impendingcrisis: 0.0032, 0.0026, 0.0011, 0.0009, 0.002, 0.0009,0.0011, 0.0056, 0.0051. crisis

The decrease in calcium is not as clear in all cases;however, wherever it does exist, the crisis may be predict-ed with a great deal of certainty.

The water retention is typical in this case as well:during fever it amounts to 1000 ccm daily, after the feveronly 400 ccm. Approximately 500 ccm should, of course, beallowed for the perspiration insensibilis and saliva. Ifthe balance does not exceed +500, a loss of water may beobserved with the absence of fever.

CASE IX.

K. Bl. 35 years old. Pneumonia fibrinosa.

Anamnesis.

The patient's parents are alive and in good health.Of nine brothers and sisters, seven are alive. The patientsuffered from malaria and inflammation of the eyes in hischildhood. Five years ago he had pains in the right kneejoint. The present illness began with a shivering fit, fol-lowed by piercing in the chest and so forth. The illnesslasted for one week.

Status Praesens.

No significant signs except for damping in the regionof the left lower and right upper lung. Bronchial breathingaudible over the damping. Vocal fremitus increased. Noother visible abnormalities in the organs. The blood con-tains 75% hemoglobin, 5,150000 red and 1.7031 white corpuscles.Amount of urine 600 -- 1300 ccm. Specific weight 1019 to1022.

-21-

I

The patient v'as put on a liquid dict consisting of1250 ccm milh, 250 ccm wine, and 3 syphon. It containled1.0-48 g nitrogen, 1.646 g chlorine, 1.276 g phosphorous,1.54 g calcium.

After the crisis the diet N,-as changed and contained13.755 g nitrogen, 3.681 g chlorine, 2.141 g phosphorous,1.553 g -alcium.

In addition the patient was given a daily dosage of11 g sodium chloride which corresponds to 6.6748 g chlorine. -

Temperature and pulse are shown in the table.

jr)n e)Tm 'Imeo , . Nabrunig. Reu~ttat. _

Full. G11 €,:,a i lI. - lbxKotb .. .

6. Mai N 1.636 1$0 22,06 1.3-15 6.04S - 17. 2S39.' Cl 0.071 0.014 1,r04 + 0..I{ (+ 6.7)104 P 0,11PS48 2.673 0.5*2 1.276 - 1.319

C. - - 0,+092 1.4, - 0.5 o0

7. Idli N !.i,3 1420 2_.4Y -; do. - 2-.,723,.? CI 0.0J4S i.2h 'I uLi + 0,'0. (+ 6,7) --

2' j - O.l'4' 2,871 1gN ¢Cl - 2,117Ch O.00 0.0 1303 + O, S3

S. U hi N 2.170 1200 Th.00 - do. - 22,24037.1 C1 0.-124 2.008 - 09 9 C+.8)

P 0.l,4 2.,S1 - 1,C1.7C& 0,0&48 0,U76 -+ 0,67

!. Mai N 2,240 10 ';..4uO - do. -1-,C.,36,$ Cl 0.34.'6 3.420 - 1,lS4 (+ 4,D)

CA Ikir !spur + 0,.80

Ia. Mai N i.70 1'200 20.4',G 13.75 -A ,0563*, CI O&s 1s 0,2.;I 2. S1 -- 0,5.:,S -+ 4.0)

P 0,:2'11|Z,4; 2,1.1 - 1.t74

a O,VOij3 0,0.4 1,5.3 + 0,018II. Vat N 1.422 1400 .0,'72 do. - 8,02

30.0 Cl 0,14"5 ' I - (-1 0,333 4'2S - ,70cS oAo6 o~o7 A+ 0,CGs

12. kii N 0 0 1oo lb ' do. 6 .1035,b Cl 0.0"u

0 1., - 7,(3 (-- , U)

P 0,2315 4.4-.3 ;-- 4C. 0,000; 0,1 12 + 0,7tu5

13. W.i s 0.02 .'WO 17,$$ do. -- .,4005. Ci 0.477 ll,t1 2O -- I31 (- ,7)

P 0,14,6 3,&40 - .021L' 0,0 72 0,1600 - 0.768

[continued on following page]

-22 -

I. Perlode. 4 Tae. gN gC gP g Cai) 2700 Hs() Nabrung- 6.04 ICI 1.27 1,55 ($*21 Cl)

) Verh 41t rn i.%: 4 1 1.1 0.8 1 5,51200 .120 1=0ra 24,45 2.08 2,S5 0.02.T

4) Aubchcid. H 1oth 1.35 0.07 0.52 0.9925,S3 2.15 3.37 0.932

Verhllniss: 26 2 3,8 1+' 1500 lHO Reteutiou : - 19,79 -0.51 -2.10 + OGG (+ G,07 C)in pCt. der Aufnabme: - 300 -0 S - 180 + 44 (+i- 70)

11. Periode. 4 Tae. N r Cl g P g Ca') IO Namrung: 13.75 3.CS 2.14 1.55 (10.32 Cl)

Verh1tniss: 9 2.4 2.51700 11,0 ilarn 19,49 9,08 3,59 0.!03Aussched. ,Koth 1,25 . 0,07 0.52 0,969

.0,84 10,0S 4.51 1,276Verhiltniss: 29 9 , 4 1

+ I1.0 Retection: -7.09 - 3,37 - 2.37 + 0.38 (+ 0,.7 CI)in pC. der Aufnabme -0 -100 -110 + 23 (+2G)

[Legend:] a) date, temperature, pulse; b)content in percent; c) urine amount; d)excretion; e) urine; f) feces; g) nourish-ment; h) result; i) period - days; j) ra-tio; k) secretion; 1) urine; m) feces;n) retention; o) % of intake.

In this case 11 g common salt were given to the pa-tient. This high dosage had an influence on the decomposi-tion of albumen. Both the absslute and relative loss of ni-trogen during fever were high. A great deal of phosphorouswas secreted both during and after the fever. Only calciumdid not increase and remained retained following the crisis.

The general impression is that the common salt effect-ed the expiration of the illness. The retained chlorine isreleased suddenly, so that in spite of the 11 g common salt,a loss of chlorine occurs in the post-crisis period. Thecrisis occurred on the second day of treatment, and six dayslater the secretion was normal. Increased phosphorous se-cretion lasts three days; the amount secreted decreases asrapidly as it had increased. The increased secretion ofchlorine and calcium is unbelievably rapid after the crisis,while the secretion of nitrogen decreases from day to day.One might say that a nitrogen retaining effect sets in dur-ing the post-crisis period, and makes up for the losses dur-ing fever.

CASE X

K. Sch., 25 years old, laborer. 2 December 1898.

- 23 -

+ . .... . . . . . --

Anamnesis.

Patient gives very little information about his par-ents. Has no brothers or sisters. Thfu yuars ago he hada rash which was cured with mercury. The present jllnc szbroke out five days ago with shivering, pie.-cing chestpain, and fever. The sputum contained no blood.

Status praesens.

Auscultation and nercussion showed an i.filtration ofthe left lung. Other organs were norm.al. The blood testshowed 4,200000 red and 16000 white corpuscles, 89% hemoglo-bin on 2 December. After the crisis there were 4,800000red and 10000 white corpuscles; the hemoglobin was 90%.

Aistory.

The patient received 10 g calcar. phosphorous daily.Had no complaints during this treatment until 15 December.Recovered shortly afterwards. Veight 55.5 to 52 kg.

2 Dec. Temp. 3S.6 Pulse --- Respiration ---3 Dec. Temp. 39.5 Pulse 112 " 48 1 bowel

movement,-oWt 55.5kg

4 Dec. Temp. 38.2 Pulse 104 465 Dec. Temp. 37.5 Pulse 64? 306 Dec. Temp. 36.1 Pulse 72 28 1 bow. mov.7 Dec. Tem.. 6 Pulse 48 28S Dec. Temp. 36 Pulse 48 249 Dec. Temp. 36.2 Pulse 52 24 1 bow. mov.

10 Dec. Temp. 36.3 Pulse 44 20

The diet consisted of the followinr.: 1250 ccm milk,250 g wine, 1600 g syphon, a total of 3100 ccm liquid.

In viewing this table, we cannot he er-rcealling thatwhich has previously been said about sodium chloride treat-ment. The addition of calcium phosphate accelerated theprocess in this case as well. The crisis occurred on theseventh day of the illness. After five days the secretionwas normal. The calcium phosphate was re-absorbed and didnot appear in the feces. Almost all calcium was retained.A portion of the phosphate w'as secreted. The retention ofchlorine was relatively low, yet the secretion of chlorinewas far lower than that effected by common salt. A signifi-cant quantity of water was eliminated, so that the body lostapproximately 700 ccm daily after the crisis.

- 24 -

h)3

C)j I

2. fl. N ~2!7 , r. I -. VC.370 131M00 0P I 7 15 1. 171 2. 1)14 + O.f1911 0,00o 0.4- 1,1:;, - I.UC, (+ O,')C. u,ij:.3 , O. , | 1.5"7.4, - 0.4' (- 3.2)

3,$ D"e. S I.(05 6. q,j~ 1:'~l3 15 M do. -Il& Sfi: O

liN C 0.t;,6 -7 I.l (+ 1,0) 0

4(+3.23)

4. 'Dot, S 2. W.5 I110 '.1;,3:;-45 ii 17 - I ,(t( .. . . -

&%l5 CI .a, u.Aw7. +

14 11 UA'2;'2 1 511 --2,105 (- 0.04)ck O.G.v o Co: d - 0.741 (+3.2)

&1 L.)+€ S 2.41. 5 w 5 , -,,2 1 do. - 30.5-15 1500 ..... .= --- : ..

44 1- 0.:-s .0 a ,0 - (- C,)

C o,001,3 O.01'45 0,54 (+ 3,2)

CS.:!u -. 6 I 0 u12.1's -. 0154. .94) IMO' I.3 c .17 -1 -+

36.0 G 0. 1 !2 4-- 7 ;,

11,c 0.7. , 1 '.'4I- do' .- r $,

a C..v cl o.J1" 5 2I 2' - .45 U..'47 2,0'01 -.Z - 091 0 ( 7- I.o7)

(a 0.00.13.a

U,. )4, -_ - 0,3.5 I-,*

9. D). S 0.1,S I YJO 1J' U" do. - 5,65o;2 C, 0.149 , 1 w + .13Z,; I ' - ' , T.3 1.(,,,7 - 0,69 I+ 2.4)

C. 0. (,j;7 O.C3i - 0. * 3.7)

;11. P .eAe. 4 Ta,:, g N i: Cl F P r CIhIU II- z -, , luO .S3 - 2'.06 ) 1,57

M r.. :. 4 2 L!2) , .4) 0,9 10 ,C : 1 (1 + 4 .0)

I)A I Ii.h ._ 0.V1 1 G, .1 23914

25,S2 6.70 3 ~ 2X25Verh iIti ,: !1 0.3 _______I

-- Oi 0- l .cte. -- 19.3 + 140 - 1 ,"t-.3 - 1.OG (+3.06)p)in pCL d Aulhrt:-00 + -- 130 (+ 0) - G0 (+ 60)

11. Poriode. 4 T;ge. N 1z CI z P r Ca1700 11,0 Xal.,or q: 7,07 3.1 I ( 3,71) 1,17 (S,17)

V ,rhlki' : 5,9 ;1.4) 2.,'- U,C) " 0. ) : I C1)1300 11;o 1Ih, 17.71 . 14 J." (1.83) 1.8 ( (0.92.Au-sh , ot, 0.3 4 0.01 ..5 0o3,5) 1,52 1,12)

-r I h.ii 6 -, -.1. - 2. 4 2

- 200 fu l.i. - 10.98 +-0,33 0 ,3) - 1,^7 )+ 2.73)in pCt. d. Af4nahme: - 150 + 12 - &0(+ 40) - 110(+ 50)

[Legend:] a) date, temperature, pulse; b)content in percent; c) amount of urine; d)

excretion; e) urine; f) feces; g) nour-ishment; h) result; i) water; j) period-days; k) ratio; 1) secretion; m) urine;

- 25 -

T

n) feces; o) retention; p) % of intake.

An albumen retaining effect '.:as not noted. The waterretention during fever is also considierble. Consequently,imbibition was not retarded in either case. The rapid de-crease of the nitrogen secretion, however, indicates thetendency of common salt to shorten the process considerably.Other conclusions may be drawn from the table.

CASE XI

1H. P., 46 years old, driver. 8 January 1899.

Anamnesis.

The patient, who comes from a healthy family, hasalways been in good health. The present illness broke outfour days ago with fever and piercing chest pain. Ptientcomplained of headaches and weakness. lie claims to havedone a great deal of drinking. Denies having had venerealinfections.

Status praesens.

No pathological findings except for changes in thelungs. Patient either unconscious, or complains of head-aches. After a general weakness on the ninth day, the ill-ness terminates in death.

The patient was put on a specific diet and given 1.0g nucleic acid.

The quantity of sputum was not significant. The urinecontained albumen. Small amount of feces went under the pa-tient.

The temperature was as follows:

3 January temperature 39.5; 384 January temperature 39.0 - 39.5 Pulse 88 Respiration 52a January temperature 39.3 - 39.5 Pulse 100 Respiration 406 January temperature 38.7 - 39.5 Pulse 100 Respiration 44

7 January temperature 38.7 - 39.3 Pulse SO Respiration 44: 8 January temperature 38,2 - 40.2 Pulse 88 Respiration 32.

-26-

The diet consisted of the folloiwing:

250 cc;,-,U~c

I G 0

A)f m. Prm. IW

S. Jar.. S~3T I .D22, CW00 NS2

Cl .6 1,13 Lo + 2OSS

1,%t ..+ ISa

10 Ca W.u 1 .7151 C ,6

I P1, 0, 1 10

C. Jar,. X f N ) 5 IMU0 . 1 do. - 0. *, ijS

kb~ Ca +.'~' 1a uP, 0.-4 G 0 , 6 il

I'.S p '2:O

Ii w r .110Ta.Ja v: 01.0 1. bet a3-

Nur. 0 Nlaurrg 04,3

3S,-m,,04

A',~du~_ 11.7 GS 04 + 0,41

Ca 3 0 .r 11

'S ~RtaIoa 0

Nil. p0.d&Afahia - 17

727-

[Legend:] a) date, temperature, pulse; b)content in percent; c) amount of urine;d) urine secretion; e) nourishment; f)result of nucleic acid; g) ratio; h) se-cretion; i) retention; j) % of intake.

This case terminated in death. In addition to theusual diet, we have him 1 g nucleic acid daily in order toobserve its influence. We started with the assumption thatnucleic acid is a decomposition product of the organism,and we were interested in observing the effect of addingsuch decomposition products. Unfortunately the patientperished, and the course of the illness does not permit usto darw conclusions except for the one that nucleic aciddoes not have a healing effect. There is no reason to re-proach ourselves for having worsened the patient's conditionthrough the addition of nucleic acid. The case was seriousto start with, showing a secretion which was not at all typi-cal. The secretion of nitrogen was marked by fluctuations,and the secretion of phosphorous was relatively low.

In determining the acidic and basic phosphates, wefound no uniform pattern. One day the acidic phosphatespredominate, the next day the basic ones. A predominanceof acidic phosphates was not always accompanied by an in-crease of ammonium. In brief, the pattern was totally ir-regular.

As v. Veissmayr (Zeitschr. fur klin. 'led., Vol 32,page 313, article in honor of von Schrocter) has shown, itis possible that this was not a case of typical pneumonia.It is bacteria of this kind which thoroughly influence thecourse of pneumonia. Unfortunately we know nothing aboutthe differences in the metabolism in streptococci pneumoniaand diplococci pneumonia.

Nevertheless, this case is of particular importanceto us because it shows the'influence of nucleic acid as wellas the periodic fluctuations in the secretion.

CASE XII

J. K., 23 years old. Laborer. 28 February 1898.Pneumonia fibrinosa dextra.

- 28 -

Anamnes is.

Parents of the patient deceased. Father is supposedto have been a drinker. Paticnt suffered from pneumoniafive years ago. At that time he spent three weeks in thehospital. iHe suffered from a severe cold one week ago, andcomplains of having had piercing pain in the chest, coughingweakness, loss of appetite since then. Has supposedly nopotus or infections.

Status praesens.

No abnormal findings except for changes in the -ightlung. 90% of the leucocites arc multi-granular, 2% thesize of one granule, 6% small, 1% eosinophile. The urineshows a trace of albumen, no sugar, A microscopic examina-tion of the sediment shows many white and red corpuscles.

In addition to the usual fever diet, the patient re-ceived a daily dosage of 10 g salt, equivalend to 0.068 gchlorine.

The observation lasted four days, with two days de-voted to the fever period and two days to the post-criticalperiod. The patient was given l0. common salt daily. Feceswere collected throughout this period, but examined only once.

There was a relatively slight loss of nitrogen duringfever, it increased considerably immediately after the crisis,and diminished on the following day. This case also showsthat common salt accelerates secretion. A retention of al-bumen is not quite clear. The diuretic effect of common salton phosphorous is pronounced. The common sali, however, hasno effect on the secretion of calcium. The retention ofchlorides remains undisturbed. All common salt which wasadded was retained, so that the balance is positive even ifwe exclude the additional salt. The feverish organism canthus take 10 - common salt without the secretion being atall influenced. The opinion of Schwarz (Wiener med. Blatter(Vienniese Medical Journal), 1895, No 49, 50, 51) that theretention of common salt during fever may be explainedthrough chloride substituting for phosphate cannot be true,because the daily loss of phosphorous reaches a maximum of2 g, while the retention of chlorine may contain as much as10 g.

- 29 -

4' g. c I;& i. 1 . "'11 run 'UIt t28. 11 A i.7 1 4 N I.!t 1 1 64 ' "

- I'Thi. d, Aug ln. , Ui

I C 1 I, '"t S

.t 104 N I, 04 7I - 7.S, , :.;

?-. I" 0.014 1,761 + ' (1 0 )Ch 0003 0(21

30111. . 2 N 1.5',l' I .00 27.772 ' 7,5;o .

: i6' ; I I 0'7 1 jl, " +'6; ,3 , 1,7 8 - 0,o'0

41,1 3. " 0 N . . 1001

1 100 .1.1 .. 37A

I P 0 I I 54,G 2,10 - 4,0-- , 0. I o . ,..,8 - o o

*) 1. Pcri, ,l 2 Tge Vor e Krise. N r I . P g Ca

2.W rem 110 .Nhru,,g 7.36 ,J Ii 17G41 ver.t.Ii ,.; 4.4 " 1, (4) 0,9-,).\u.c hoidungll K~~art.; ') 14,:')7 0. 1, 1,74 11,. )2 2

40rm , 1%L5 .%,;. 0,65 0.1479,1 .3D 1.17V , e r h .l t n il 1 : 1 ,5 0 , 0 a 2 a

+.. .00 em 1,0 r.-hat - S. +0,97 (+ 7,04) -0,,.0 +059#) iu rC,. der A.h,,ahmne - 110 + 45 (+ 0) - ,0 +34

I1. ri.'ark : TAe N&A4 .. r IKri.e. r % iz Ci g I g C,2500 erm 11O Nahr.q: 9,77 2,s6 (8,03) 1,55 1.57

\rI i,,. 6.5 1., (6) a 1.2 1AubcbLedfL f (11.r; 21,94 2,U7 4,5'7 0,071- 50 emu HOI c1ab: 1.25 0.75 0,G5 1.17023.19 2,'2 5,2g I,24

Vrrb.tuuib 10 2.,3 1., 1,0 trm l-0RIt&% - 12,42 - 0.01 (6.11) - 2.2 i 0.33

w PCt. der Awf Lme; - 125 + 1 (+ 70) -130 t 2 "

[Legend:] a) date; b) ie,,era t t-re ; c)pulse; d) con nt in percent; e) a; ountof urine; f) excretion; g) urine; 1,)feces; i) nourislnont; j) result; k)period - days after crisis; 1) ratio; -)secretion; n) urine; o) feces; p) , ofintake.

CASE XIII

R. P., 37 years old. Pleuropneumonia sinistra.

Anamnesis.

Patient comes from a hcalthy family. Has always en-joyed good health with the exception of a malaria infectionfive years ago. The current complaint started five days ago

- 30-

with headaches, piercing- chest pain, aid shivering.

lie has always lCd a regular life, and is not married.

Status praesens.

No pathological si"niq in the or'gans e*cept forchanies in the lunlgs. The blood NV.S noL tested. The custo-mary analysis of urine and feces was ,adci. The patient wasnot given any medicine. The dicet consisted of milk, es,,wine, and bouillon. Tho patient was oivcn a grcat deal ofwatcr; however, we did nioL succcd in collecting more thanthree liters. The crisis took place on Lhe second day.

The diet consisted of the following:

1100 ccru milk,250 cori .ile,250 ccm bouillon

1700 ccm %.ater4 cc,. c gs

3300 ccm fluid (see table)

The observation lasted for four days. The diet re-raained the same throughout. The feces was examined beforeand after the crisis. The influence of the water intakews not particularly great. The secretion of nitroen isgreat after the crisis, but it was not unusually great dur-ing fever.

Tem. U- r .Me) A)| iwc. cLIt.¢- )I~ A'.~a~ Nao' h rii . ...+t

7- Aprl N 1,%7 111U 19.413 5. I. ,l -3 000I' Cl 0,0,1 4 46 2;, bO

59.5 3' 0, t? , A _ - ,1 9 + 0,3,52.0 CA U 0, I Q 7Z,.2

- , 0,6.7

8- April N 1,77 12 O 2 2'5 10,. 12,I - 12,712 3bWS Cl 0.0426 5 "1~ ~ . 3.~ + 3,131

3b. 5 ' V072 u , 2,1.J + U,0143.0 CA O'Ou" 2. 0 4 'z, a, 7 + 0,71.2CS

10 April N 2,037 1 O. 30,4'. - 13.CbS 26OOSGj, Cl 0,0 7 0UG +fOj 2,G45• ? 0.6 ,, 0,G.4 , 4 2.1 2) 0,7423s.O CA 0.0017 0.I 8 "b

87I-010. April N 3,166 161U 20.0!9 ~ 10.2451 1 3106 2200

3K.0 Cl 0,1 C6S 3.019 3,6037 * 0,4236,

P o233 U,88 2, M 9 4 0,.39

3G.0 C 0,o003 I ,u232 . 1,462.7 - 0,24,

[continued on following page]

- 31 -

_ _ _ _ _ -

- a) 1. IPrio&e. I T,, a tr t Kni 4

W ,..A ~ ,46

.t , ,) cc .La: 7 - .7 __.';1

~211C6 U10 14,G

7I___ 0,7 '. I-I2.0 .,. U ,i t !

Wa 2 ccm 2 I~ 4 u 120CL +biJPCL. +3t c. +40Jpct

II. I-eriudc. S T.;o n ,cb dhr )rn,.iR CIl Ca

c n nt; c . a, mount; ) .47i 2

Au,c,'i4, f IIaaa, 21,02 I,'J7

0703 0.'0

4, u i e f fe oths 1n.i 00 0.h)2-2 ,t 2,01 2;, 204

______7 0,7 O,0 12U0ltt: C-T" +' ,4-0A + v,04 - l2l

[Legend:3 a) date, temperature, pulse; b)% content; c) urine amount; d) ex;cretion;e) urine ; f) feces;: g) nourishmecnt;: h)

result; i) water; j) period - days aftercrisis; k) secretion; 1) urine; m) feces.

The loss of phosphoroui is very lo'v, the retention of

chlorine reaches the usual heiihL. Calcium clearly showsthe pre-critical decrease. The feces show the characteris-tic secretion: during iever tie:-c is a clear retention,after fever an increased sucretzon.

CASE XIV

W. B., 26 years old. 13 '..arch 18)6. Pneumonic croup.dextra.

Anainesis.

Patient's father is supposed to have had tuberculosisof the lungs. Except for childhood diseases, the patienthad been in good health. The current disease dates back to

17 January, that is, five days ago. He had severe headaches,shivering, and weakness. At the same time herpes labialisoccurred.

Status praesens.

Except for the lungs, all organs appear to be normal.

The blood was not tested. Urine contains no iron or

sugar. Patient received 10 g sodium chloride daily in addi-

tion to the usual diet.

- 32 -

K-"

d1) llj 4 ) ) %+: {JI~ t. )

1 0 ____ I _1__7

24, r i O N ' 14 do.I+, i ,.,jA " I ,, U .+ --0 ,:5

24. Nt ,I o'. Iu - " - . - ,

1 l r .U, + '. (+G)

6 Ca 0,(,364 uJ 1 + 0,402

A)\I.!.~b 7, ~ '.4, (7) IS 1

1) Aa.,ch,+:. ;,N.o' L O.,,0 0.07 0,4" LOS

-- h2It : 0 1 1 3 1-

j/ 1400(I~+.U t . S - lO1 - .S'-i '.3) - 1,14 , O.S&p i.+Cl.4.Awfr,-- mi 9 -90 - 70 (- 50) -W -t 2

[Legend:] a) date; b) tczperature; c)pulse; d) content in percent; e) amount

of urine; f) e:c-.c t ion; gI) urin,; h)feces; i) nouri .i.,ien t ; j) result; k)ratio; 1) secretion; m) urine; n) feces;o) retention; p) ' of intake.

The obSc. vazion zoo'c placc on the last day of feverand two days i,,, hout fev.r. P" Licnt was given 11 - cozilmnnsalt during hc three days. The ieces was analyzed once.

In this case all acditional cilo;'i:ae was retained,because the balance of chlorine is psitiv, even withoutthe salt. The loss of nitrogen %.as greate.st on the day fol-lowing the crisis. Thet; it cdop)cu rapidly. flie secretionof chlorine sets in on the second d.y following the crisis,while the secretion of phosp'orous concs later. 'e shouldlike to stress the characteristic sequence once again. The

chlorides are the first to react, follvwed by the slow phos-

phates. Calcium shows an increased secretion on the day of

the crisis, a decrease after the crisis, 'radually risingas the chlorides do.

- 33 -

- -- 1_

CASE XV

J. K., d-ive',: 26 years old. Pneumonia croup. dextr.1. inf. 7 ,.harh l&9S.

Anam.nes is,

The patient's narerts are deccased. Patieni e ;t dways boen in good he;.lth except for the chil dood disc:.cco.Three years ago his neck ,lar.ds suppurated. ':c had hi.; Iu%-

er jaw glands operated, while the neck gla.ds hcalcd wva.toutmouica' treatment. The process lasted five mon .- s. Tw,,oyears ago he had an attack oZ ralaria which was checkedwith quinine. The current illness brohe out two days ago,accompanied by the typical characteristics.

Status praesens.

No abnormalities in the or-ans except for theThe blood shows no increase in leucocites. 77' ncutr i,,.5.8' large cells, 14.7" small cells, 1.7%' transiLional for-s,0 cosinophile.

Urine has traces of albumer,. Urine sediment showssparse leucoc'tes. Patient is ,-ive-n 6 g sodium chloridedaily._

a) i r,'I c., ,a, Resall.

al:.3 Vj5 B- :.141 + ,527 C' 8.). , g 0,,27 " 1,32 - 0,&.

~~~10. 111 eS.7 , N 4.. 7 4"0 |1 " $ -, 1.3

T ~(+ ,G).,

-1 P 0.||O6 u,519 , 1- 1,1:3

Ca 0'(.Wj7 U'Wj.AJ : - '

1.III 11 ,$ .0 N , 2,( ., 1 O 2o.'. dL0. - 10.'2 Adie. -4 I 4,;4U - " (+ U,)

- 1.447CA .U12I - .G

1.111 3G. G, N IO 1200 1.,,: t dto. 7.184Ito I i '1UG.'.;I 7,!]$ 339.*( U81' ,.-,,3 3., uC, . - 1, s

C. :' V 11: Ooun, - 0.0b0

13. I1 36.4 Q3 N 1. 12 1200 1q.144 dto. - 7,01Cd Ci 0.,;",3 7,7. 't; - 3,5S7 (+0,1)1" 0,;',01 '., 1 -- 2 .10Ca Op"O -

14 111 36A, 10 N 1, 0 1200 1br.r I 7,5C'- 0.,5586 "'j" . (-0,I)

1' 03517 4,144 9W, C. (j,

04

8 ,,i - 0,139A IL_34__

I '.Is (+ C . '_' a2 £ LoIs. . 2.j (5,0) 1.7 1kv.usc'.4 izra: 17,05 5,:S 2.69 0.02S

1(A0 WO rn Koth O.SG 0.0c 0,X0 1.4W

12,0 3 s : 2.2 I- 5,3 (+ 2.0) - - 1.,03 - 0, W

- 0;,Ct (f 0OPCQ. - 401,CL - 4( Ct. - 7pCt.

[Legend:] a) date; b) temperature; c)pulse; d) content in percent; e) amountof urine; f) excretion; g) urine; h)feces; i) nourishment; j) result; k)secretion; 1) urine; m) feces.

All that has been said concerning the preceding casemay be repeated here. The diet remained the same through-out. The feces was examined once.

During fever the loss of nitrogen was extremely srall,smailer than we have ever witnessed before. A considerablesecretion of nitrogen and phosphorous following the fever.Chlorine is secreted in constantly increasing amounts. Thephosphorous secretion drops after an initial rise. Calciumshows a minimum on the day o: the crisis (the precriticalminimum has not been recorded, since the patient voiced cri-ticism on the second day), followed by a constant increase.

CASE XVI

B. H., 32 years old. Pleuropneumonia fibr. dextr.inf.

Anamnesis.

Patient has been healthy in the past. lie has haderysipelas on his face five times. The present illnessbroke out three days ago. In the morning he did not feelwell generally and suffered from shivering. Shortly after-wards he was taken to the hospital.

Status praesens.

Except for an infiltration of the right lung, no ab-normal findings in the organs except for an infiltration inthe right lung. The patient's temperature was 39.5 - 3S.O.Pulse 104 - 116. After the crisis the temperature was 36.7- 36.2. Pulse 70 - 80. The patient inhaled 10 liters oxy-gen per day.

- 35 -

Ya

The diet consisted if thec following:

1200 cen DiJ 1k,300 ccm~ bouillon with egg,500 cciii water,500 ccrn wine.

After the crisis the "Olo11in- ite-s wcre added tothe above dict: 150 gcutlct or beestcak, 100-300 g gruel,400 g broad.

D~a~. * > Procen t. 11m A-abcn '' J)llav

10 er' N 1.7.oI s 14000' 73S Z11 -.65CI (0.UtGA 1 0.-.92 2'r40 +t 21SA1' ~ -,J 0, 5517 u,794 + 0.1 0Ca 0,4.aI. 0,'01 1 O' 0 +2 0,0j7

I1. Fehr. bl.311II1 N L,03 IL50 2N,8l'7 11,81C - 13,24633,1 C: 0,03u3 j U,47 03 C 5,435 + 4.2 4

P 00.8 1 1.125 0, 05531CA ,002I 0,0317 W~ 1,221 + 0.971

12. Fehr. D1 124 N 0,500 2000 18,006 .'a 14,240 - 3.940D'9 Ci 0.,2' L G.44 5,7.7 +514.-0 P Gj. ,J7. .3 1'4% + 0.,7,b7J2 Ca 0."'0l5 1 0,u30 6 d 1.43 + 1,44.5

I.I. Fehr. 05. 1W0 \ O.F . 2000 171 400 '3 do.

;l.42 1 I -..1,7. 0.70G

C4. (IAbWr U'4 Ii N + 1.4.414.F~b- 3 11 N . uo 0,,12 2O 1"'. 14.*0, - i.sro

:Is P 0.(i( Ir J4 I I4 'i + J.!,,-,3CA O012 U.0044 1,713 +1 0,71115. Fe . 3 7.' N 1) 10' 1'40 14.4:'o * 2 3. &7.4 14,1836j; l .4 7.u7 11? I 4.7"'j

U~t.3 I~., .- 2V>3" + 1.0.*7CA V4*u 10 14 'aj 0.000U M +1~ 0,

00 Q75A 414.13a. Wi .43 WR1 I 11 .'42 +1 LIM2P 1.3.7 1" w * I'74 + 0.i'.:7Ca 0,'Yj 15 1 d.. 1,%18 j- 0,513

1-.. IFcbr. .;, 70 N tl.S;9 200 17 3- 2 7. DS 27 5 + -. , , ,991. CI Olj.4 s.40 12,431. + 3.440

I' , j. (I " 1 ;J"IS ;& 1.., + 0.%37C'a 0 UU51 0,cIt2 1,923 + 0.830

lIA. Febr. 37 SO3 X 1320I0 '9 , 4 27,670 + s2177:,G,5 CI f;' I117 ,,('-77o 1 1.391 + 2.r7!iCP. 00S2 0,'$.Qc * .U 0.!7GC 0, 0,116 1 -2 0,730

[continued on following page]

-36

1 . P'criod,'. ,5 T.ie. 9 N g: CI g: P R (.A,

:alo 1,1 NAI.r~mg 1 , .a3 1.21 1,47\ | 1 ,.0Au Ait , 1121 , 1 75 1 0. I0 1

S0,73 0.0

Y 'rr , tm -1: 7 8. 9 , 2a, S,_4 -1

P W 00) 11:0) |J: t lf , - 5 ,7 4 - 4.G 1 + 0 .4 1 -. -1,23f) in -Vt dcr Aur.h e, -- 0 5 + ,0 + bo

II. 1cnoh. 4 Tsc. g N g Ci P p Ca3"1,V l Naitrw,,t: .,:2 11.7 1,9G ,,

",'rl~aiacn , I |4, C I. a I a11m, |5,4:" 2' 0; .:G 0,616

V cr. ltn is 14 .U , 7 .9 1.1 1

!03 II,-1. 6,-,aa. + 0. Ci -- "4 O. - 0-i; pCL dcr A atamea +42 +-7 + 3 + 40

tLegend:] a) date; b) tc;.pra t ure ; c)pulse; c) content in pcre'ent; e) armountof urine; f) e::cietion; g) urine; h)feces; i) nourish.cnt; j) result; k)period - days; 1) ratio; m) secretion;n) urine; o) feces; p) retention; q)% of intake.

This case offcred the Opportunity to study the influ-ence of oxygen inhalation. No essential differences wereobserved. The secretion of nitrogen is slizhtly higher thanin cases without oxygen. The difference, however, is tooslight to draw any conclusions, and might depend on individ-ual differences. The course of -he illness, on the otherhand, is extremely rapid and benigh, similar to that wherea chlorine treatment was applied. A significant amount ofchloride is secreted. The increased secretion of phosphor-ous drops rapidly. Generally speaking, the phosphorous se-cretion is very low in this case, so that ihe loss of phos-phorous occurred on one day only. The considerable amountof oxygen is, no doubt, responsibly for the insignificantloss of nitrogen.

CASE XVII

E. E., 28 years old. Pleuropneumonia stn. inf.

Anamnesis.

Patient comes from a healthy family. Illness brokeout three days ago.

- 37 -

Status praesens.

No signs of sichness %,'ith exception of the pneumonia.Temperature 39.2. Pulse 110. No fever alter the crisis.The diet consisted of milk and bouillon. In addition thepatient was given 5 g calcium phosphate and sodium chloridedaily. After the crisis he received cutlet with poLatoes,or gruel and beefsteak.

1200 ecr milk,800 ccm bouillon,500 ccm wine,500 ccm water,

3000 ccrn fluid.

4) - C) 4) - "-- 1,- 1 ' -I lroc,t..,e . Aj.)Jgfl= .- ) % ruh i C,,.a.

I . 1. V'l O' N" I ('.. 410 (.N"0 , , 14,240 + 6,5101 (L 0.. 0 .1!'4 5, 97 1 * 5.2G0.4 1' 11 0 ;323 7 1,435 + 0,740

, U . 1 - . 1.45 + 1.072

V,.1I O1' \ 1 , ,.0 114.40 4 1, I2N:C x', 4 0I 004.25 0. '-. 5,77 ] 5,733 (+3,034)

g .:6, 9) 1' 0,'. 0.4363 , 1,4L + 0.55 7 (+ 2,064)CA 0,0W6. Uv,. - 1,4 1,058 (+.4,000)

14. 1 . ;1 S. N 1,974 15 0 14,20 - 1,1920 r 4 Cl 0,14, ,1,4 "717 (+3,05)3c, ~~ 1 0 1 00 1 )?2 1.43 0&5O'C2 (+ 1,412)

C; Ou1,5 0,0 -., c " 1,745 1,032 [-+4,000)

15. 11. , ,0 1Cu A.N, j2S 1O.2,'- .,us 14..4'0 2 .43I ' U4t:. 4 , 4 7 5,977 -r 1,951 (' 3,,014)

P1 , 0, ,flu.9 O..--. 1.4,LS + 0,2C5 (+2,C4)Ca OOuoU 0j,100 1.745 + I,04 9"4, c)

16" 11. ,b'57 Cu N 1.1410 WI 10 "'. r .. 17.30G + C,'65,1 S u ('| U,2.,u4 3 , ;-' 8.312 4 ,.'ov (4 2 ,j4)

35.3~04"- 52 ' ~ .: ~ lr (+ 2'W4Ca uU.'7 00.W3 +'- I,2 1,551 (+ 4,UOO)

17. I . .4,0 ,, N ,1':0 145'U 17 3',- C 25,G;21 + C.43714l 'C S 10.143 + 1,'" (+.014)

I~i;, 6 , (110; .4'Y4. I - 7 5 4 O,h9?, (+.204

(J.SJ4I v wn.I I I~4 + 1,2.6 (4 4,OW.)

(continued on next page]

- 38 -

7,. 1t t' 0 CIT A.'I 1h3 )

4. 1' t4 )P. N 73 1 (' )4,O

7 1 1 .742 :;,C(34,

Ca.1 "'t~ - 1(4. l ' '' k + 347V 4

2C :Ii + 1.75 ( 0 4

'a - (+"i*,, ~ j:aC 4,006) -

U', I' ]II '- 49 4 .G4j. Ci6r1r. 5% T.,: X 1 CI 9 'I '

;;0 II.Al N Ij : .'. i 5 ! 1,7,71

1 44 7 4 7 3,74

~ ik ki 1. '21. CJ0

57 7 4 U3 0.69-I.Jr'.2 ' 3A _ 1,4 -1

9+2 W.J Ib I 1 h lIt - L .3 -r I.L ,, ,0.44 t-1 144) + I 3!.06.iO)

S II; M.Iru ; - 10 6C iU. I uo0 4C . :

I3.70

1. P.md. Tqe. it SL (1.7 -I 0II CS

43 T 1

pulse; d) content in percent; e) amountof urine; f) excretion; g) urine; h)feces; i) nourishmlent; j)result; 1period - days; 1) salt; mn) togeother;n) ratio; o) without salt; p) secre-tion; q) urine; r) feces; s) result;t) with salt.

This case -- as well as the subsequent case -- clear-ly show th-- favor~able influence of good nourishrment. InI this case Nve also intended to study the effect of sale dur-in- a considerable intake of nitroz;en. It appears that withadditional salt the loss of nitrog-en is lower both during

-39-

fevecr and duriing the abscu),; of Levcr. Alter t-he fever thediuresis is the saric in both ct,.L. s, yot case XVII lou~sonly 10'o nitro., n, case YVII i thout Sa lo IOsS 60':~ * uill,, convalesceceC Lhe paticnt undc sat tron t-rent gains50%, nitrogen, Lho other one only 30,althjough in the see-ond case the nourishment contained 3 g i-more nitro,4en. Aloss of phosphorous occurred only on oi;e clay, while in theother case it, lasted seven days A two-day loss of n4 trog_,,namounted to 19 g; in the other case 61 _- were lost in ci,,atdays. The maximum losses are greater without salt (17 g ni-tro.-en per day as compared to 16g)

The salt had a favorable effeck. on the bowel excre-tion. During fever and durin7 the convalescence pcriod the

* nitrogen content in the fecos remains low: 0.8 gper dayduring fever, 0.2 gafter the fever. VWith the szi.re diet,the other case shows 3 gper day during fever, 1.2g afterthe faver.

CAISE XVII1

U. A., 32 years old. Pleuropneumonia fibr. dext.

Anamnes i s.

No significant incidents in patient's history or fain-* ily. Patient fell ill five days ago and was put to bed

shortly afterwards. Taken to the hospital several dayslater because of better case.

Status praesens.

A -art from the lung infiltration, no abrnorr-litiesin the other organis. Temperature 40-38. Pulse 126-100.Patient had feover after the crisis. Teimpurature 3G, pulse70.

The diet consisted of the following:

1200 cem milk,S00 coin bouillon,500 cern Nater,500 cC41 wine.

After the crisis he received the following:

cutlet or beefsteak -- 150 g; gruel or potatoes -

*100-3-00 g; bread -- 400 g.

-40-

ga) j' ) 4

YO, .43. 40 . -V 14.,., iv 4I I,,

C.

C4 , 'u J.; (,oui

1. V'4t, N:. o '4 u 4 44 ,I 14.N -1401.

"-43 ().6114

40,

I S i C1 34' 0I4

14 . I'l 1. N ' 1 1 5

N F, l~r N 1 44' 1CO+

*t I ," ,

Cl.'' . 0. 12 1~.. 1 6

4:?. 0.44~' 4~,076 0J4 0.;4b

4:4l P 4 O4- 11 3 - 1.:4

Ca U.4J'%4 (,0. w '~ 4'

47Q +~. 1 4.1);

~~~~~z :VN .,S1*u43.~

C.

~~~~U I, 4' I,,,, I IJ'. 4.

A) 1. eri.,de. I Txe. a X g g CAWOO, 11:0 : m, P- 14.24 :. .q , 1 1,1

S 4 .S 0.3m I

I \': ,t'. , .,,, |. 11 0| ,w 1 ,41 1

11. reid~e. 6 ";'4.v. C X C, k'1 , g c k

1. H.6 A U-,hiti. t .i1 + ."4 4 1,-.( l .1. 4

+ Il~, II ..6 n,,., t 4,: . f"' '-- C014' - O. -02,4

i, Ci. der Aur,,, : .. 4 1 - W - 17

[Legend:] a) date; b) tcnperature; c)pulse; c) content of percc.nt; e) amountof urine; f) excretion; n) urine; h)feces ; i) nourish-nt ; ,) result; 1)period - Cays; 1) ratio; m) secretion;n) urine; o) feces; p) retention; q)% of intake.

The secretion sho'.v the typical characteristics. Therise o! tenperaturc is particularly clear after the crisis.After the disappearance o! f.ver there is a sudden drop inthe secretion of N, P, and Cl followed by an increase whichexceeds the nu.mber of fever days.

From then on a gradual dro) of nitro-cn and an incre-ase in the chlorine secretion sc't in. The ;ccretion of phos-phorous h;eeps increasing and outla.ts the nf.trogen maximumhr one day; only then it bcin 'o o .c creasc. Calcium showsthe pre-critical minimum, increases on the first day with-out fever, then drops only to increase gradually to the nor-mal point of secretion.

The nitro-en content in the feces is hl gh. , dlring fe-ver. normal after fever. The chlorine content in the fecesis lo. ver during fever than afier,,ards. The phosphorous co- -tent is very high and close to calciu-,o: 14:i8=P:Ca. ILdrops with the absence of fever, barely reachin,- onr halfof the calcium secretion: 10:21l-P:Ca.

All this is a pattern of pneumonia, a pattern whichis seldom achieved, but which may be detected in every casoas a paradigm.

- 42 -

_ , ;- . . . .-

Q Q c c . - Q o -.1-

I I ImI -- I ,

-" -- * C -

+ -+ I

IQ o. c. Q Q

- I I."©

-~ ~ o c.C - .c

,- - C c t - Cd Oc

(C- ~ J > .. -. -- CC .-

:. .. .. , -- C ,:.:S - - - . t ,.- t;r,.,.,,C

.. o-.C,--:. -. " C _ __-

0T

. . . .. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

~~-C c

.~-++ +

- -- .-

- -7 e---7

* I c

-4 1

I 'i --. --+ r " I + ; i-

II I

b. i - -'--7

r-' ' - ~-o

S i + i --- - - C- , --

L~ I ; I I I II II

- V .'.. .. .. .. .. . .. . .. .. .. .. *.

- . , , .. .. . .. . .. . . .. . .. . . . .. . .

_-. ,Cl

= -: . .' Cl - :. =

-i-i- I I .-,- 4 . if +4

. ... ...... . .. -o . C).-., O'.) .v. - c. C 1 .. . . .. . .

I I r- ,, - +++,- cc

.- .-- . -. i- --- -

.. .. ... . .... -... . ... C.. .. G - - -

-.- - .

---- U

- -

- -4 -a-

C ,,.

In concluding t.e ,.'ould like to recapitulate the most'irportant resul_; in as far as these have not been discuss-ed in the individual cases. At first we intend to state thefigures, then discuss the conclusions.

The secretion of nitrogen varies greatly during fever.The nitroen figures can.e not only from case to case; oneindividual who is on the sn:e diet secretes varying amountsof nitrogen. in one case we witnessed a periodic tendency:every second day the amount of nitrogen was great, on otherdays it was low (the acidic phosphates fluctuated as well,exceeding the basic phosphates on one day, staying behindthem the next day). Otherw:ise the variations were irregu-lar. The amounts secreted varied greatly. The same patientmay secrete 7 g daily and the increase to 31 g two days later.The lowest figure was 6 g per day, the highest -- 43 g nit-rogen (not urine). The 4verage figures are between 15 and27 g per day.

Almost always immediately after the crisis an incre-ase in the nitrogen secretion was witnessed. This increasemay recur, only to be followed by a gradual decrease.

The secretion of nitrogen during fever does not de-pend on the intake of nitrogen; that is, in spite of littlenourishment the patient eliminates a great deal of nitrogen.On the other hand, the secretion of nitrogen cannot be in-creased by a greater intake.

Water and chloride can increase the nitrogen secre-tion. Sugar decreases it. Small amounts of common saltand a mixture of common salt and calcium phosphate also de-crease the nitrogen secretion.

The secretion of nitrogen through the bowels is usual-ly greater during fever than at other times. The amount ofnourishment does not seem to have an obvious effect. We in-tentionally use the term "bowel excrement", because it mustbe determined how much of the nitrogen in the feces comesfrom nourishment which has not been absorbed, and how muchmay be regarded as a bowel secretion. In any case, allsalts effect a decrease of bowel nitrogen.

The loss of nitrogen during fever depends on nourish-ment; that is, the more nitrogen is supplied, the smallerthe loss.

This observation has already been made by many others,and we witnessed it in all the cases. The general table,

- 47 -

which has been arranged according to the quantity of nitro-.gen, illustrates it clearly. It would hardly be necessaryto stress the fact that the same rule applies to the con-valescence period if a recent article by Benedilct (Munchenermed. Wochenschrift (Munich Iedical Weekly), 1899, N7, pae2-"0) had not appeared where the author deals with nitrogensecretion in typhoid and gives therapeutic hints. Benediktstates that the nitrogen content in the food intake mightbe reduced during typhoid fever in order to get the cellsused to a weak diet. This would cause a greater nitrogenincrease after the fever. The great nitrogen retention v hichfollows the fever is explained by Benedikt as a result of a-dapting the cells to a nitrogen-poor diet. Our tables clear-ly indicate that a diet which is rich in nitrogen duringfever does not exclude the possibility of great nitrogenretention after fever. On the other hand, a meagre feverdiet by no means guarantees greater retention of nitrogenafter 'fever. Our figures do not support the therapy advo-cated by Benedikt.

The relationship of nitrogen to the chloride secretedvaries greatly. The amount of nitrogen may be twice as largeas that of chlorine, but with a strong chlorine retention,the nitrogen amount may be 500 times as strong.

The ratio of nitrogen to phosphorous is far more con-stant. While the intake may contain 10 - 5 g nitrogen forIg of phosphorous, the nitrogen increases in the secretionalmost regularly to 15 - 20 g for lg of phosphorous. Onlythose cases differ where chloride is added to the nourish-ment. Here the ratio corresponds to that in the intake, oreven changes in favor of phosphorous, that is, P:N - 1.5.

The secretion of chloride during fever is too wellknown to be repeated once again. it should perhaps only bestressed that the secretion of chlorine does not increaseimmediately after the drop in temperature; it goes down be-fore coming up again. This corresponds to the post-feverincrease of nitrogen and phosphorous in the urine.

Unlike nitrogen, the secretion of chlorine dependson the quantity of chlorine contained in the nourishment.This does not mean that a tenfold increase in the intakewould increase the secretion ten times; however, it may bestated with great certainty that the greater the chlorinecontent in the nourishment, the more chlorine appears in thesecretion products. Thus, for example, lg in the intake isfollowed by 0.5 g in the secretion; 8 g in the intake, by

48II

2-3 in the secretion daily. The increase, of course, isslig ht.

The sccretion of chlorine through the bowels is insig-nificant. Sometimnes it is stronger during fever, at othertimes it is weaker than during the absence of fever. Oftenthe quantity ofC salt given had absolutely no effect on thequantity of chlorine in the feces. Sometimes it increasedthe chlorine content, as for instance, instead of 0.06 perday to 0.7 per day.

During the entire period we witne ed a loss ofchlorine during fever only three times.7 twice in cases ofvery low food intake, once in a case. -- o:ju--phosphatwas given which had a great diuretic effect. Ot_%iii1-s eloss of chlorine may be exnected with the absence of fever,but even there is not always pronounced and may stretch overa long period of time. We see a real loss of chlorine incases where patients are given chloride and phosphate. Wecalled such cases shortened convalescence.

The retention of chloride does not depend greatl.y onthe quantity in the intake. Whether 10 g of chlorine areadded to the nourishment or not, the retention fluctuatesaround 90% of the intake. We stressed the opposite in ourdiscussion of nitrogen: the greater the amount of nitrogenin the nourishment, the smaller the loss. This is not'thecase with chlorine, where the retention remains constantregardless of the varying amounts in the intake.

The above may be formulated as follows: the organismmust secrete a specific amount of nitrogen, but not a speci-fic amount of chlorine. Consequently, the organism benefitsfrom all excess nitrogen supplied, but secretes all surpluschlorine.

In other words, the organism has a specific concen-tration for chloride, but none for nitrogen.

This gives rise to the question what might cause theretention of chlorine. The opinion expressed by Carl Schmidtin 1850 seems to have the greatest validity in this respect.Chlorine is retained when the organism becomes serious. E.Schwarz (Wiener med. Blatter, 1895, No 49, 50 51) believesthat chlo-I- taxes the place of phosphate which had beensecreted. It seems hardly possible, however, that 2-3gchloride were necessary to substitute for 1g phosphorous.In such a case, the addition of chloride should diminish the

-49-

retention, yet it is increased without exception. The or-

ganism can retain 3 and 9g chlorine, yet lg of chlorinewould be sufficient if it were a question of taking theplace of phosphate. It is correct, nonetheless, that the

addition of chlorine effects the secretion of phosphorous.We intend to go into the causes in our discussions of phos-phorous.

The action of phosphorous during fever was quiterightly compared to that of nitrogen. There is absolutelyno phosphorous. Numerous metabolism tests in animals and

humans have already clearly proved this point. The secre-tion parallels the fluctuations of nitrogen, and after the

crisis we inevitably find a considerable increase in the se-cretion which decreases very gradually. The increase inphosphate applies to the acidic phosphates. This has beenproved both directly through experiments and indirectlythrough changes in earth phosphate. Phosphate leaves the or-

ganism through the bowels as well, for the P content in the

feces is usually higher during fever than during the conval-

escence period. Through the bowels the patient looses ap-proximately 0.7 - 0.4 g P per day, through urine 1 - 3g perday.

The retention of phosphorous was witnessed rarely.In one case a generous amount of sugar had been added to the

diet. There the nitrogen loss was also very slight. Another

instance was a fatal case of pneumonia, where the patient had

been given lg nucleic acid daily. One case had been treated

with oxygen, another salts.

As in the cases of nitrogen, the secretion of phosphor-

ous during fever is influenced by the nourishment. It is,

however, subject to great fluctuations which must have given

rise to the opinion that phosphate is retained during fever.

As already mentioned, sometimes a retention or balance of

phosphorous may be achieved, particularly when calcium phos-

phate or calcium phosphate and common salt are added. Other-

wise even the losses fluctuate between -190% and -7% of the

intake, apart from the retention which may reach +40%. How-

ever, if large amounts of chloride are added to the intake,

the result is always a considerable increase in the secre-

tion of phosphorous. It may be possible that phosphate,

which stems from decomposed albumen, is absorbed by the

serious organism like chloride, and appears in its true quan-

tity only if there is enough chloride in order to preserve

ton concentration of lymphs. This assumption is supported

by the similarity of nitrogen and phosphorous. The amount

- 50 -

of phosphorous secreted is usually ;',reater than the intake,yet if chlorine is added, this disproportion disappears. We.entioned before that if the intake contains 5 - 10 g N to!_ P, the secretion during fever amounts to 10 - 20 g N.,4.1a happens to the phosphorous? There is no doubt that theat;.ount in the secretion has increased, but this increase istoo low when compared to that of nitrogen. All of the phos-phorous accompanying the nitrogen is not secreted. Conse-quently, we must make the simplest assumption that phosphateshares the fate of chloride in being absorbed. The amountof chlorine retained is too small to reach saturation. Infact, there is no reason why the soluble phosphate shouldact differently from chloride. Only if chloride is added,a proportionate a-mount of phosphate is secreted; now wefind lg phosphorous to 5 g nitrogen, which is the amountproportionate to the intake.

M.odern chemical theories make it easy to explain whychloride is more easily absorbed than phosphate, and whychloride is retained and phosphate secreted when both arepresent at the same time. The dissociation of phosphoricacid which is marked by conductivity (Ostwald, AllgemeineChemie (General Chemistry), Vol II, pages 658 £--50. Leipzig"Y-.--, as well as its activity coefficientare far behindhydrochloric acid. FCla = 0.90, H2PO 4 a = 0.08 (Activity),conductivity IIC! -- 100.00, H2 PO 4 -- 7.28.

The activity coefficient is obtained from the ratioof actually decomposed molecules to the total number of mole-cules, so that the low activity at the same time expressesthe low decomposition of molecules. This is in accord withthe chloride and phosphate in the organism, and explainswhile the small common salt molecules are much more easilyabsorbed as ions than phosphates which exist as ions onlyin small amounts.

The addition of calcium phosphate to the food doesnot always produce an increase in the secretion; the influ-ence, nevertheless, is visible.

A ratio of phosphorous to chlorine cannot be found.It may be stated, however, that the secretion of phosphateexceeds that of chloride during fever, although the nourish-ment contains more chloride.

The secretion of calcium salt, like that of chloride,decreases during fever. This has been confirmed throughcareful calculation in almost all of our cases. The secre-tion in the urine and in the feces decreases considerably.

-51 -

It is possible that the sparse bowel excretion is causedby the decrease in the bov.'el secretion. When gall secre-tion decreases during fever, (Pisenti, Arichiv fur exp.Path. und Pharm. (Archives of experienta-ath, an dharm.),"W15-2",- 2-!9--other bowel secretion is possibly decreasedat the same time. Vle found accordingly that calcium hardlyexceeded phosphorous in the feces during fever, while afterthe fever it was twice as great as phosphorous. Under nor-mal circumstances the amount of calcium is double that ofphosphorous, because for lg P there are 2g Ca in calciumphosphate, which is the form in which calcium leaves the or-ganisn. The fever secretion does not contain a neutral cal-cium phosphate, but rather a mixture of acidic CaRP04 andCa2(H2P04) 2, or only the acid containing 8OCa to 62P whichis close to the figures found during fever. Calcium is thenretained instead of being secreted in small amounts. Thisholds true for the urine as well, according to our figures.

In our earlier articles dealing with changes in theblood and metabolism in anemia, we compared the retention ofcalcium with that of chlorine, and the assumption seems prob-able in this case as well, that calcium is absorbed by thelymphs in the organism. Approximately 80 of the calciumsupplied is retained consistently. The secretion of calciumincreases during convalescence. Interesting is the fact thatthe calcium secretion in the urine reaches a sudden minimumbefore the crisis. This does not always become immediatelyclear, as the minimum often coincides with the day of thecrisis. This fact is interesting, because calcium is theelement to do so. Phosphorous, nitrogen, chlorine never re-act in this manner. Therefore it may be assumed the calciumreacted similarly to the fever as nitrogen. In one case wehave the pre-fever rise, in,1he other case the pre-criticaldrop. It is of course difficult to determine whether theformation of new elements or of a new type of albumen takesplace. After the crisis we sometimes find an increase inthe calcium secretion, then a decrease for one day, only togive way to a constrant rise. The addition of chloride tothe food effects an increased secretion of calcium; conse-quently, chloride substitutes for calcium salt.

The ratio of calcium to chlorine in the intake usual-ly differs from thlt in the secretion. There is more calciumin the secretion and mor-e chlorine in the intake. This ob-servation supports the view that the organism primarily re-tains chloride, then calcium phosphate, and only then the al-kali phosphates.

The few observations we have made concerning the se-cretion of magnesium justify only the one conclusion that

-52-

there is an increase in the iagn esium zcretion during fever,and that the amount contained in the urine decreases afterthe crisis.

Very little magnesium is secreted through the bowels;most of it leaves the organism through the kidneys.

These are the results of our ,ork. In drawing prac-

tical conclusions, we should point out the great importanceof an ample nitrogen supply. Although the necessity of aproper diet has been proved in a number of old and recentex:periments (Hosslin, Buss, Leyden, Klemperer), Benedikt'sarticle contains some doubts in this matter. We feel justi-fied in dismissing his doubts entirely, because both theoutcome of fever and convalcscence have been far more favor-able with sufficient nitrogen in the diet. A further ques-

tion is whether the decomposition of albumen could be check-ad through other means. Sugar is probably the best sparingagent as shown by May (Zeitschrift fur Biologic (BiologyPeriodical) Vol 30, page-- --ur experiments confirm thisview. Sugar decreases the urine secretion, effecting a small-er loss of nitrogen and extending the convalescence period.Fat should not be sutstituted for sugar (although Von Noordensuggests this due to the high calorie content), because feverhas a worse effect on the patient when the fat content in-creases and albumen decreases (Senator). The capacity of thecell to decompose albumen, the loss of this capacity, or thestrengthening of the capacity, are expressions which meannothing.

If we wish to study processes which take place duringfever, we must stick to the facts. It is a fact that wateris absorbed and dilutes the organs -- this shows in the waterand salt retention which have been proved many times. Arewe not aware of processes which take place during water re-tention? Do we know the effect of dilution on chemical pro-cesses? Ve %re familiar with both; we know the chronicalwater r ten:ion in anemia and the fatty degeneration whichis caused by it. We have sufficient information concerningthe latter, particularly thanks to general chemistry whichhas come out with the so-called theory of dilution, statingthat through digestion all salt is dissociated and broughtto greater activity. When the organs become watery and di-lute the lymphs, every process in the organism either beginsto operate more rapidly, or to produce more generous results.This assumption becomes a cortaintj when we look at the in-creased combustion in the organism during fever which hasbeen proved by von Loewy. Using chemical laws as a. basis,we can predict that sugar is the first to burn up during

- 53 -

fever so that liver would have to release its glycogen be-fore the processes attack the albumen. If a combustion ofalbumen or, to be More exact, oxydation of albumen in a di-luted solution occurs, the result should be different thanwith oxydation in a concentrated solution. We are familiarwith such a decomposition in a diluted solution; it is theanemic degeneration. Anemia is rich in water, it oxydizesin a diluted solution, and leads to a fatty degeneration ofthe organs. It remains a question whether the fat stemsfrom carbohydrates or albumen. It is sufficient for us toknow that dilution leads to a fatty degeneration. At thispoint we have reason to believe that in the case of a fattydegeneration during fever, this dilution plays a role. Weno longer need any special cell capcities, for the normalprocess, the life of the cells, is now being disturbed bydilution, and we know that such a dilution leads to fattydegeneration with similar, even though chronic, symptoms:retention of chlorine, loss of phosphorous and nitrogen.Senator's statement that with fever a patient gains fat andlooses albumen is an expression of the above process. Ifthe decomposition of the organism produces fat, it meansthat fat escape decomposition. Additional fat does not helpin spite of its high caloric content, and it should not beregarded as a preservative of albumen. Elements which burnup in the dilution should be added, namely, sugar and albu-men.

Are we capable of directing the fever process, thisdilution, to normal conditions through artificial means?Can we prevent the infiltration of w.,'ter by increasing thelymph concentration? The organism retains salt on its own.In adding salt, we supply the necessary material. In ourexperimonts we used sodium chloride, calciu. phosphate, anda mixture of both, with some successful results. These con-sisted mainly of sparing nitrogen (decrease in the secretionof nitrogen) and shortening the convalescence period. Inour discussion of individual cases we stressed the irregular-ity of the effect. Sodium chloride is not only a concentra-tion agent, but also a salt capable of creating unknown chan-ges in osmotic pressure. It rinses the organism out, andhas a diuretic effect. We do not dare to decide whether ornot this is favorable Neither can we make an accurate e-valuation of the duration of this process. At least our experiments have shown that addition salt cannot produce dam-age. In some cases, a sparing of nitrogen cannot be denied,particularly where the food intake was good. In cases wherethe nitrogen supply was low, on the other hand, chlorideeffected an increase in the secretion of nitrogen. We have

-54-

winussed in r- l the ca- es an increase in diuresis (partic-ularl.y throug-,h calcium phosphate), a more rapid secretionolf chlorine and phosp:horouIs during conva lescence (a, 'Shorterperiod of convalescence), and consequently -.we may-assumethat the effect of additional. salt during fever is similarto that under norr,,al circumstances, and that 'it may condi-tion z different distribution of water in the organism.

Even though we have failed to find new means of-chang-ing or sto-pping the fever process, we hope that our findingswill contribute the more recent ex:periments on metabolismw.hich deal not only with the supply of.L calories, but' alsowith lymph concentration.

This work w~as started in Zurich and f inished in Lem-berg. I would like to thank the director of the medical,clinic in Zurich, professor Eichhorst, and the director ofthe clinic in Lemnberg, professor A. Gluzinski, for furnish-in- the material and for showing an interest in my experi-m~ents.