THE FOOD REQUIREMENT OF THE SICK 43 



followed by similar periods of increased N-excretion. This phenomenon is 

 particularly frequent and familiar when the subject is on a regime rich in 

 albumin (more than 20 grams of N in the daily food). 



In contrast with these irregularities of the excretion of nitrogen in the 

 urine which occasionally occur in the healthy, and more frequently in renal 

 disease and in gout, we have the N-retention which is observed in cachectic 

 patients during the formation of transudates and edemas. 



Concerning this quite a number of investigations have been made, par- 

 ticularly in patients with hepatic cirrhosis. Several times during the reae- 

 cumulation of an ascites (after paracentesis) the nitrogen balance has been 

 estimated ( Schubert,^ Marischler and Ozarkiewicz - ) . That the N-retention 

 which is noted in these cases does not indicate an actual albumin accumulation 

 is clear. The retained nitrogen is not utilized as albumin to build up tissue 

 but goes to form edema or ascites. Authors have therefore often spoken of 

 a " pathological " N-retention, and explained it by the hypothesis that while 

 the organism normally possesses the faculty of destroying albumin and digest- 

 ing it, this function is now lost. Most probably, however, purely mechanical 

 disturbances of absorption here play a role in causing the retention of N. 

 These disturbances depend upon changes in the amount of mineral salts in 

 the fluids of the body, the osmotic changes being dependent upon variations 

 ia the concentration of these salts which cooperate with the active properties 

 of the endothelia to govern absorption. 



There is no considerable interest in the often-discussed question whether 

 the albumin in these re-accumulating transudates (ascites) comes from the 

 albumin of the food, or whether the body albumin is utilized. The question 

 becomes meaningless if we discard Voit's differentiation of two varieties of 

 albumin in the body (organic albumin and circulating albumin). This deci- 

 sion cannot be arrived at by analysis of the mineral metabolism in such cases, 

 for the albumin of the food has been absorbed, taken up into the fluids of 

 the body, and thence also into the cell protoplasm ; thence together with the 

 organic albumin it issues in the fluids of pathological transudates. 



DISTURBANCES IN THE ABSORPTION OF FOOD 



In determining the food requirement of a patient, we must consider (a) 

 changes in the amount of oxidation due to the disease, (b) consumption of 

 albumin due to toxic influences, and (c) other factors, important among 

 which are the losses of energy which the body suffers by giving off food sub- 

 stances which it should retain. 



These losses are so manifold and so various that it is impossible to place 

 them side by side as equivalents. Some of these losses are not susceptible to 

 quantitative estimation; on the other hand, in so far as they are due to 



1 Schubert, " Ueber den N- und Cl-Umsatz wahrend der Bildung und nach der Punk- 

 tion des Ascites bei Lebercirrhose." Dissert., Breslau, 1895. 



2 Marischler und Ozarkiewicz, " Stoffwechsel bei abnehmendem und zunehmendera 

 Ascites," Arch. f. Verdauungskrankh., vol. v, p. 222, 



