550 FRANCIS W. PEAJ3ODY AND EDNA H. TOMPKINS 



Zugsmith and Kahn(a)) contains evidence of this, but the results are by 

 no means constant. The most complete studies of the nitrogen balance in 

 patients with heart disease and circulatory failure are those of Husche 

 (1894). His observations include both the nitrogen intake and output, 

 but owing to the difficulty of keeping sick patients on a diet which was 

 sufficient to meet their caloric needs, as well as the great variation in the 

 volume of urine from day to day, it is impossible to draw accurate conclu- 

 sions with regard to the nitrogen metabolism. Even when, as frequently 

 happened, the nitrogen excretion exceeded the intake, it was more plausible 

 to explain this on the basis of insufficient diet, or a washing out of 

 nitrogen by diuresis, than to consider it evidence of increased nitrogen 

 metabolism. When the disturbance of compensation was of short duration 

 Husche usually found little retention of nitrogen in spite of marked re- 

 tention of fluid, but in other cases there was retention of nitrogen and a 

 washing out when the volume of urine increased. Rise and fall in nitro- 

 gen elimination are in general associated with similar changes in the 

 urine volume, but the two do not run exactly parallel, for accumulation 

 and excretion of nitrogen is usually more rapid than is that of water. 

 Husche found the percentage of urea and ammonia nitrogen in the urine 

 were essentially normal, but in a number of cases the uric acid was both 

 relatively and absolutely increased. He regards this as due to uric acid 

 retention during periods of decompensation, and not as evidence of in- 

 creased uric acid formation. Lindemann determined the excretion of 

 endogenous uric acid in three cases of juvenile asthma, and states that it 

 was at a low normal level. The elimination of uric acid administered 

 to these patients was slow. Zugsmith and Kahn made very complete 

 observations on the metabolism in two cases of asthma, and concluded 

 that asthmatic individuals seem "to suffer from a condition of tissue sub- 

 oxidation." The indications of this were an increased excretion of neutral 

 sulphur and a low excretion of creatin. There was no evidence of an in- 

 creased nitrogenous metabolism for both patients had a positive nitrogen 

 balance. Stadtmiiller and Rosenbloom, on the other hand, studied the 

 neutral sulphur excretion as an index of endogenous nitrogen metabolism, 

 and found it to be increased in a case of bronchial asthma, but normal in a 

 case of chronic myocarditis with broken compensation. Ryffel examined 

 the urine of five cases of heart disease, all of whom were in bed, and one 

 with marked cyanosis, for lactic acid, but did not find it in amounts which 

 were above normal. According to him, French, Pembrey and Ryffel found 

 an apparent increase in two cases of congenital heart disease with cyanosis. 

 Ryffel says: "It thus appears that in these cases the lactic acid of the 

 blood rarely rises high enough to cause active excretion by the kid- 

 ney. The acid of the blood during life has been found increased 

 in heart disease by Ziilzer, but it is in the cyanosis of acute pul- 

 monary disease that the highest values of lactic acid should be expected, 



