A CONSIDERATION OF ENERGY

6 I 7

A CONSIDERATION OF ENERGYEXCHANGE IN HUMAN TRAUMA*

JOHN M. KINNEYInstructor in Surgery, Harvard 'Medical School; Junior Associate in Surgery,

Peter Bent Brigham Hospital, Boston, Massachusetts

SU2555252. the past decade, new information from various directionshas become available to assist the surgeon in the treat-

a mNment of acute illness and injury. Our knowledge ofwater and electrolyte metabolism has made tremendous

S advances'. Methods for the study of body compositionhave provided a more accurate understanding of the normal body, andhave emphasized the importance of certain major changes which occurwith depletion2. The endocrine alterations that are a standard part ofthe response to trauma have been recently reviewed3. All of this in-formation has contributed both to the growth of human biology, andto the understanding and clinical management of acute disease and in-jury. Continued improvement, however, is limited by the lack of de-tailed information regarding energy exchange.

The human body is, fundamentally, an energy exchange device. Ofthe four common forms of energy: mechanical, electrical, thermal andchemical, only the energy of chemical reactions can be used for therealization of work by the body. The continuous ability to convertchemical energy into cell work, whether osmotic, electrical, mechanicalor synthetic, is fundamental to life. Death may be defined as the irre-versible loss of the ability to perform these vital energy transformations.Likewise, as more refined techniques for study become available, it isreasonable to expect that clinicians will come to regard convalescencefrom illness and injury as the return of the normal capacity to performthese various types of cell work.

Studies using direct and indirect calorimetry around the turn of thecentury provided a large amount of information about the energy

Presented at the Third Annual Postgraduate WVeek on Research Contributtionts to Clinical Practice,of The New York Academy of Medicine, October 7, 1959.From the 1)epartmenit of Surgery of the Harvard Medical School at the Peter Bent Brighaml lospital.This work was supported in part by a grant from the National Institute of Arthritis and MetabolicDiseases (A-815).

Vol. 36, No. 9, September 1960

KINNEY

I I\

40o/0 ;,~~~--OCGEN

I-I-* ROTEIN..DEPOT7.13kg.~~~~~~~~~1 g

TOTAL55% BODY

WATER

5% MINERALSJFig. 1. Approxiimate valuees for a-idult 1odC-compJ)osition, emiiphasizinig the organic

nurnterials.

requirements of the normal human subject under varying conditions4,including certain medical diseases',;. Trauma, however, was not in-cluded in this work. More recently, many authors have stated thatmetabolism is increased by traumaT-. The absence of quantitative in-formation about energy utilization in acute disease and injury has ledto conflicting estimates of the range of caloric expenditure after surgicalprocedures. The knowledge of the effect of trauma on the metabolismof individual foodstuffs has largely been limited to nitrogen balancestudies. The pioneer observations of Cuthbertson on post-traumaticnitrogen loss', "' have been confirmed in many subsequent reports"1 12*Considerable disagreement remains as to what the increased nitrogenloss represents. It has been suggested that carbohydrate metabolism isaltered after trauma because of the tendency toward hyperglycemiaand a diabetic type of glucose tolerance curve1. Indirect evidencehas indicated an increased rate of oxidation of fat following trauma".A significant need still exists for more direct quantitative data in the areaof human energy metabolism following trauma. In addition there is theneed to develop an integrated framework for the application of the factsalready available to the understanding and care of the acutely ill andinjured patient.

It has become common practice, at conferences on metabolism andnutrition, to preface one's remarks with statements such as the following:

"The consideration of fat, carbohydrate and protein as separate foodstuffs hasbecome largely a formality since each can be oxidized for energy and recentstudies have shown many inter-related pathways of metabolism."

Bull. N. Y. Acad. Med.

6 I 8 J. -gI. KINNEY

ENERGY EXCHANGE IN HUMAN TRAUMA

GLYCO GE N

GLUCOSE-6-PO4

TRIOSE-PO4 N

AMINO ACIDS 4- PYRUVATE F

UREA 1

INTERMIEDIATES =±,

qEUTRAL FAT

BATTY ACIDS

/1[c-c] r KETONEL - BODIES'4 06

K C5)Fig. 2. Certain intermediary metabolic pathways of clinical significance. See text for

details.

Such statements, while true in a sense, tend to obscure the unique chemi-cal specialization of each type of foodstuff, and furthermore, theyignore certain key pathways in intermediary metabolism which appeardesigned to exploit this chemical specialization for the benefit of thebody.

This presentation begins with the development of a preliminaryframework for considering human energy exchange. Some cases studiedby the measurement of daily energy exchange before and after surgicaloperation will be presented and discussed in the light of the proposedframework.

HUMAN ENERGY TRANSFORMATIONS

The division of the normal adult human body into organic and in-organic materials is shown in Figure i. Approximately 40 per centof the body consists of protein and depot fat, with a few hundred gramsof glycogen representing carbohydrate stores. Figure 2 indicates certainmajor pathways that relate fat, carbohydrate and protein. Many detailsof intermediary metabolism have been deliberately omitted from this


6 I 9

620 J. M. KINNEY

figure in order to emphasize certain clinical aspects of the pathwaysshown. It is recognized that the tissue amino acids include moleculeswhich are ketogenic or neutral as well as the glycogenic ones indicatedin the diagram, but the contribution of the carbohydrate intermediatesfar outweighs that of "two-carbon" fragments when amino acids aredeaminated. The nonessential amino acids, which require carbon chainsto be synthesized in the body, are almost synonymous with the glyco-genic amino acids. It is important to note that the pathway frompyruvate to the "two-carbon" fragment (acetyl coenzyme A) is a one-way reaction which is of both biochemical and clinical significance. Theintermediates indicated as adjacent to the tricarboxylic acid cycle referto alpha-ketoglutaric acid and some of the four-carbon acids, whichare known to contribute directly or indirectly to carbohydrate inter-mediates. Note that all three foodstuffs can supply "two-carbon" frag-ments, which represent the basic "unit of fuel", but that carbon chainsfrom fatty acids cannot provide a net gain of carbohydrate or protein.

It is important to summarize nutritional demands of the body in thelight of intermediary metabolic pathways. Nutritional studies in man,and isotope work in animals and isolated systems are consistent withthe concept that the human body handles its energy sources on a prioritybasis, which normal nutrition tends to mask15. These priorities are re-vealed only with a significant degree of undernutrition. The body'sneeds for foodstuffs may be listed in decreasing order of importanceas follows:

I. Obligatory for immediate survival:a) "two-carbon" fuel for the Krebs tricarboxylic acid cycle to

provide usable energy,b) a continuous supply of intermediates for the Krebs cycle, andc) maintenance of blood glucose levels.

2. Obligatory for ultimate survival:a) synthesis of body protein, which seems to have its own spec-

trum of importance, ranging from hemoglobin and certainof the enzymes and hormones to plasma proteins and, ulti-mately, to a wide variety of cell proteins.

3. Energy storage in the form of:a) glycogen in liver and muscle, andb) fat depots.


6 2 0 J. M\. KINNEY


INTERMEDIARY COUPLI NGMETABOLISM

' MECHANICAL WORK

HEAT > HEAT

F CHEMICAL WORK -~HEATHEAT - HEAT

OSMOTIC WORK-"HEATHEAT - HEAT

ELECTRICAL WORK-So HEAT+

HEAT -. HEAT

24 HOURENERGY UTILIZATION

Fig. 3. Energy arising from oxidation passes to A'1'1' and is utilized in 1)0th the basalmetabolic expenditure (BME) within the body and muscular activity. The dotted lineindicates mechanical work done on the environment which does not yield heat the bodymust dispose of. Body tem)eratllre is the balance between heat )roduction and heat loss

(shown as radiation conduction and vaporization in the bar on the right).

Trauma probably does not introduce new pathways or new priorities,except for inserting the wound high on the list for protein synthesis.

Human energy utilization is summarized in Figure 3. XWhen chemi-cal energy in the form of food is combined with oxygen, the reactionsnot only yield carbon dioxide, water and heat, but also result in theformation of a certain number of high-energy phosphate bonds. Thisfigure indicates the utilization of this "energy currency" to performvarious kinds of work in the human body. The actual work output ofthe entire body under resting conditions is probably one-third or lessof the normal basal energy expenditure. Note that all of the energy

introduced in the form of foodstuffs decays to heat, either directly, as a

part of the inefficiency of the reaction involved, or indirectly becausethe energy represented by the various forms of work within the bodyultimately decays to heat. The single exception is mechanical work whichis performed on the environment, as indicated by the dotted line. Theintermediary pathways involved in oxidizing food or tissue materials are

only effective if the chemical energy is produced and stored in a usableform. This "energy currency" is the high-energy phosphate bond whichis produced in the link which couples oxidation with energy utilization.


IIGI-6-P

Ot t tTrioseP N.Fat

i I it 14

A.A.-Pyr. F.A.

[C - C]'ADPT

RAD.

VA

HEATLOSS

6 2 I

622

The bar on the right indicates the continuous heat loss which isrequired of the body to maintain a normothermic environment for thetissues. The body temperature represents the balance between heat pro-duction and heat loss. Since the human body in a normal environmentenjoys considerable reserve in its heat loss mechanism, the heat pro-duction from basal metabolic processes may undergo major changesWithout any significant change in body temperature.

CLINICAL MEASUREMENT OF ENERGY EXCHANGE

Direct calorimetry is not in active use at the present time for humaninvestigation. However, it has made two very important contributionsin the past. The first was to demonstrate that the human body obeysthe principle of the conservation of energy stated in the first law ofthermodynamics. The second was the finding that when indirect calo-rimetry (calculated from oxygen consumption, carbon dioxide produc-tion and nitrogen excretion) was measured at the same time as thedirect heat loss, the energy expenditure by the two methods was foundto be in excellent agreement. The problem still remained, however, ofstudying sick and injured patients, when isolation for energy measure-ments wvas obviously impractical for periods of more than a few minutes.Therefore, over the past three years, we have developed and used amodification of indirect calorimietry'6. The method is based on the briefmeasurement, each hour of the waking day, of the oxygen consumptionand carbon dioxide production of the subject, using samples of expiredair. A five-minute sample of expired air is collected in a plastic bag.The expired air is analyzed with electronic equipment, to provide CO2concentration and 02 concentration, while total gas volume is obtainedwith a wet test flow meter. After suitable corrections have been made,these raw data provide the oxygen consumption and the carbon dioxideproduction over the period of the expired air collection. These hourlyresults are plotted, and curves constructed for each 24 hour period.The total area under each curve is determined by use of a plani-meter, and provides a 24 hour value for oxygen utilization and carbondioxide production. These data and an accurate knowledge of food in-take allow the calculation of a daily balance of total calories and of eachindividual foodstuff.

Unfortunately, there has been no means of determining the accuracyof this method comparable to the combustion of a known amount of


62 2 J. M. KINNEY

ENERGY EXCHANGE IN HUMAN TRAUMA 62 3

R.W.H. 21yr. f #3N34 CONTROL

WEIGHT 66r

(Kg) 64L

TOTAL CALORIE BALANCE

CALORIE o6-BALANCE

-400Pro-Sal.CHO Bal-

2400 Fat Bal.

2000

1600-

1200- iiiCALORIES FAl

IN 8300

400l

CALORIES

0 ~OREB2000L~,

1 2 3 4 5 6 7 8 9 l: 11 12 13

DAYS

Fig. 4. A normal 21 year old male subject, hospitalized for a 13 day control study.While eating a constant mixed diet, his energy expenditure was measured as described

in the text"'.

alcohol in a bomb calorimeter. Figure 4, however, presents a normal 2Iyear old male who was hospitalized on the metabolic ward for 13 days,with a uniform food intake. A similar control study was performed ona 33 year old normal female, hospitalized on the metabolic ward foriI days. In each case, the mean caloric expenditure, throughout thestudy, accounted for go per cent or more of the measured intake.


624 j. M. KINNEY

l.R 46yr. # N7749

96

WEIGHT 94(Kg.)

92-

+400r

CALORIEBALANCE _

CALORIESIN

/

CHO Bal. -

Fat BalPro. Bal.

8001

400

0

400

800CALORIES

OUT 1200

1600

2000

PRE-OP1 2 3 4 5 6 7

DAYS POST-OP

Fig. .5.

Energy exchansge measuremients on an o 1ese ni aear ()Id female un(lergoing an electivecholecy-stectomiy. She '.was on a 1300 calorie reducing (liet before operation an(1 had a

)romlt rettarn of aIII)buIatioln all(l oral intake .after oIperatin.(1.


0 0

6 2 4 J. MA. lKINNEY

1200r-

ENERGY EXCHANGE IN HUMIAN TRAU.MA

CLINICAL STUIEVS

Eighteen patients, with various forms of surgical disease and injury,have now been studied by this method. I shall present four examples ofpatients undergoing elective major surgical procedures. Figure 5 showsa 46 year old obese nurse, who was placed on a I200 calorie reducingdiet prior to an elective cholecystectomy. Before operation, she was innegative caloric balance, the extra caloric expenditure coming from herdepot fat. On the day of surgery, she continued to burn a very similaramount of carbohydrate, but then had three days of distinct positivecarbohydrate balance. This woman had considerable physical activityby her second postoperative day. It is significant that the total metabolicexpenditure on the day of surgery and the first postoperative day is verysimilar to, or slightly reduced from her preoperative levels. WAe believethat the increase shown on postoperative days 2, 3 and 4 represent herperiod of ambulation. There is a moderate increase in nitrogen excretionfor three days following operation.

(Energy exchange data for three other cases, to be presented else-where1", were reviewed briefly at The New York Academy of Medicinemeeting.)

Another case is shoxvn in Figure 6, which follows the pre- and post-operative course of a 57 year old, muscular male who underwent anabdominoperineal resection for cancer of the rectum. While his urinenitrogen excretion data suggested incomplete urine collections on certaindays, there is a definite increase in nitrogen loss following his operation.\Vith good oral intake, this condition was reversed between the seventhand tenth days. Again we note an increase in total caloric expenditureat the resumption of ambulation. On the eleventh postoperative day,the patient was given the same medication which he had received be-fore induction of anesthesia on the day of operation, in order to testthe effects of this medication on his total ventilation. Since this resultedin his sleeping through lunch, the patient's caloric intake wvas reducedon that day, though it included all three foodstuffs in two normal meals.

DIscussioN

It is important to state that the cases presented represent uncompli-cated, anesthetized, surgical trauma, and that the postoperative caloricintake has been approximately 400 calories of intravenous carbo-


6 2 5

6z6M. KINNEY

C.S 57yr. W4*M945

WEIGHT 80o(Kg.) 75L

+t800 _

CALORIEBALANCE

_400-~~~-

-B00F .. | ark ~~~~~~CHO 61 - ------12000

4600

C A LO R I E A2BOHYDR

CALOORIES e 1*OUT-0 DAYS .

Fig. 6. :Energy exchange measurements on a 57 year old male undergoing an abdomnino-perineal resection for cancer of the rectulni7

hydrate per day until the resumption of oral feeding. Figure 7 is acomposite chart of our experience to date, in postoperative energy ex-change. WVe have shown a representative patient in neutral balance forfat, carbohydrate and protein on the two days before operation, al-though certain patients have appeared to show some decrease in carbo-hydrate utilization even before surgery. Postoperatively, the total caloricexpenditure in these patients does not show an increase! The total caloricexpenditure was usually slightly less than before operation, and then in-creased as ambulation was added to the convalescent program.


6 2 6 J. M. KINNEY

ENERGY EXCHANGE IN HUMAN TRAUMA62A

2000

1600-CABHDT

CALORIES3IN~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~4400 .

0

400-CALORIES

800~~~~~~~~~~~~~~~~~~~~~~~.

1200

1.600

2000

-2 1 1 2 3 4 5 6 7 8 9 10 1, 1 2PRE- OP DAYS POST- OP

Fig. 7. A composite chart representing average energy exchange values for an adulteating a normal mixed diet prior to undergoing a major, uncomplicated, elective surgicalprocedure. This individual is depicted as receiving a limited intake of intravenouscarbohydrate from the day of operation, until resumption of oral intake on the third

postoperative day.

Clinicians have commonly explained post-traumatic nitrogen loss as aresponse to starvation, with body protein being torn down to providemore fuel. This manner of charting emphasizes a particular point in thisregard. The increase in nitrogen loss following trauma is not associatedwith any significant caloric contribution to the postoperative patient.The major change in caloric contribution is due to an increase in theoxidation of fat, which corresponds to the interval when less carbo-hydrate is being oxidized.

It is suggested that the post-traumatic nitrogen loss serves an im-portant role in providing carbohydrate intermediates during a periodof potential or actual starvation. During such tinle fat can supply fuel,but not these intermediates, which are obligatory for immediate survival.

Cope and others18 have presented evidence that brief daily measure-ments of oxygen consumption during the postoperative course tendedto indicate a temporary rise of 5 to I 5 per cent in basal levels during thefirst week following surgery. The postoperative interval studied, both byCope's group and by ours, covered the period during which there wvasusually an increase in protein oxidation, as evidenced l)y nitrogen excre-


6 2 7

j. M. KINNEY

152 Fract~ure 130-38X_ - _X 34 ~~~~~~~~~~~Calculated

Total 148- ~~~~~~~~~~~~~~proteinmetalb 148 / 2675abois/daI'm 144 /Mai

Mean bod 3601?J 3541 -X Xweight g,4Li~ ~ 2 r I

340EMean food 268 --~~-intake(g.) 264 x'

-4 -2 0 2 4 6 8 10 12_ ~~~~DaysPre-fracture Post-fracture

period period

Fig. 8. The parallel response of heat production and nitrogen loss in a rat sustaining afracture of a1 long bone'7. (This is reproduced with the kind permission of Dr. D. P.

Cuithbertson and the editor of the Brit. J. exp. Pathol.)

tion. Cairnie and co-workers'9 have reported that rats sustaining afracture of a long bone have an increased total metabolism for the fol-lowing week which closely parallels the calculated protein metabolism(Figure 8). Our evidence in surgical patients is in agreement with thisfinding.

In Figure 9, the caloric intake is exactly the same as that shown inFigure 7 and the total caloric expenditure is the same, but the apparentform of energy utilization is plotted below the line, instead of the par-ticular amounts of each foodstuff oxidized per day. An adult male whomight have a preoperative basal metabolic expenditure of i6oo calorieswould probably have an additional I so calories for specific dynamic ac-tion and perhaps 250 calories for the limited activity he would have inthe hospital. Following a major operation, as shown here, the caloriesdevoted to specific dynamic action and to activity are removed and,therefore, the total caloric expenditure may be expected to equal thebasal metabolic expenditure. Between the second and fourth postopera-


6 2 8 ,J. MN. KINNEY


CALORIES

IN IL~~~~~~~~~~~~~~~~~~~RTI400 -

0

400 EXPENDECALORIES

800 _OUT BASAL METABOLIC EXPENDITUREi200_ ~~~~~~~(B M E)

ZOO0-2-I 1 2 3 4 5 6 a 9 to 11 12

PRE-OP DAYS POST-OP

Fig. 9. A composite sli(le corresl)onding to Fig. 7, but indicating the apparent post-op)erative energy uitilization of a paitient undergoing major, iinconii)licated, elective

surgery.

tive day, there are additions to the patient's energy expenditure becauseof ambulation. WVe estimate that the basal metabolic expenditure hasincreased from i6oo to around i900 calories for the first two or threepostoperative days and then returns to normal levels within seven to tendays following surgery.

The increase in the total caloric expenditure in the first week afteroperation represents the summation of a small, but increasing, amountof physical activity on a basal metabolic expenditure which is elevatedfrom preoperative levels, but returning toward normal. The postopera-tive increase in protein oxidation from 300 to 450 calories, and returnto normal, parallels the apparent basal metabolic expenditure.

The changes we have summarized occur following both surgicaltrauma and relative starvation. Is this largely secondary to tissue starva-tion? We agree with Dr. William Abbott and others that significantamounts of the postoperative weight loss which our patients have showncould be prevented with a high calorie, high protein intake during theearly postoperative course. Nevertheless, we feel that major, uncompli-cated surgery is followed by an increase in basal metabolic expenditurewith an associated increase in breakdown of tissue protein. During a peri-od of increased basal metabolic expenditure, intake of calories and proteingreatly exceeding the preoperative needs are required to approach pro-


6 2 9

tein balance. Herein lies what is perhaps a significant error in our con-cepts of postoperative nutrition. Because calorie and protein intakes oftwo to three times normal have been found necessary to achieve neutralor positive nitrogen balance when the basal metabolic expenditure hasbeen increased following major trauma, it has been assumed that thesehigh caloric intakes represent the actual level of metabolic expenditureof the patient due to the trauma per se.We and others are currently involved in obtaining more objective

data in this area. However, at the present time it appears that the dailycaloric expenditure of the traumatized patient with an elevated basalmetabolic expenditure is not as much as the high caloric demands forachieving protein balance. Providing the early postoperative patientwith 3,500 to 5,000 calories per day of parenteral carbohydrate, alcoholand fat emulsions without definite evidence of a comparable caloricexpenditure (i.e., high fever with invasive sepsis, etc.) probably doesnot represent optimum nutritional support. Hence further studies, fol-lowing various forms of trauma, are needed to determine the actualcaloric expenditure and to guide our nutritional therapy in assisting thebody through convalescence, and back to its normal function as anenergy exchange device.

SUMMARYi. Pathways of intermediary metabolism are discussed in relation to

certain nutritional priorities which appear to exist in the human body.2. The fundamental relationship between the basal metabolic ex-

penditure and the rate of protein oxidation as indicated by nitrogenexcretion, is emphasized.

3. Representative energy exchange studies are presented and dis-cussed, for patients undergoing major, uncomplicated, elective surgicalprocedures.

4. The postoperative caloric expenditure is usually highest whilethe basal metabolic expenditure is elevated. Estimates of the postopera-tive caloric needs, based on the level of calories required to achievepositive nitrogen balance during an elevated basal metabolic expenditure,appear to be higher than the basal caloric needs resulting from the trauma.

5. It is suggested that the increased nitrogen loss following traumais an inadequate source of additional calories, but is part of a basic re-action to stress which insures an adequate supply of top priority inter-mediates, which are unavailable from fat.


6 3 0 J. M. KINNEY

ENERGY EXCHANGE IN HUMAN TRAULMA 6 3 I

REFERENCES

1. Elkinton, J. R. and Danowski, T. S.Body fluids-basic physiology and prac-tical therapeutics. Baltimore, Williamsand Wilkins Co., 1955.

2. Moore, F. D., McMurrey, J. 1)., Parker,H. V. and Magnus, I. C. Body comn-position (symp.), Metabolism a5:447-67,1956.

3. Moore, F. D. Hormones and stress.Endocrine changes after anesthesia,surgery and unanesthetized trauma inman. Receint Progr. Hormone Res. 13:511-82, 1957.

4. Lusk, G. Elementts of the science ofnutrition. Philadelphia, AV. B. SaundersCo., 4th ed., 1928.

5. Benedict, F. G. and ,Joslin, E. P. Studyof metabolism in severe diabetes. Car-negie Inst. Wash., Publ. 176, 1912.

(;. Meyer, A. L. and DuBois, E. F. Clini-cal calorimetry: basal metabolism inpernicious anemia, A rch. intern. Med.17:965-79, 1916.

7. Cuthbertson, D. P. Observations on thedisturbance of metabolism produced byinjury to the limbs, Quart. J. Med. 1:233-46, 1932.

8. Cope, 0. Metabolic response to trauma.In Fractures and other injuries. E. F.Cave, edit. Chicago, Year Book Pub-lishers, 1958, chapt. 3.

9. Moore, F. D. Endocrine and metabolicbasis of surgical care. In Surgery,principles (i11(1 practice. ,J. G'. Allenand others, edits. Phila., J. B. Iippin-cott, 1957, chapt. 15.

10. Cuthbertson, D. P. and Robertson, J. S.Metabolic response to injury, J. Physiol.89:53P-54P, 1937.

11. Moore, F. D. and Ball, M. R. Metabolicresponse to surgery. Springfield, Ill.,

C. C Thomnas, 1952.12. Peters, J. P. Protein metabolism. In

Clinical physiology. A. Grollman, edit.New York, McGraw-Hill, 1957, chapt. 4.

13. Levenson, S. M., Pulaski, E. J. and Up-john, H. L. Metabolic changes associ-ated with injury. In Physiologic prin-ciples of surgery. L. M. Zimmermanand R. Levine, edits. Phila., W. B.Saunders, 1957, chapt. 1.

14. Wilson, G. N., Moore, F. D. and Jep-son, R. P. Metabolic disturbances fol-lowing injury. In Metabolic disturbancesin clinical medicine. G. A. Smart, edit.Boston, Little, Brown and Co., 1958,chapt. 4.

15. Kinney, J. M. Influence of intermediarymetabolism on nitrogen balance andwNeiglht loss: some considerations basicto an understanding of injury, Metabo-lism 8:809-26, 1959.

1i6. Kinney, J. M., Zaremn, H. A. and Rog-ers, R. L. Energy expenditure andutilizntioa of carbohydrate, fat andprotein in hospitalized patients (abstr.),J. cliti. Intvest. 38:1017, 1959.

17. Kinney, J. M., Zaremn, H. A. andNichols, S. Energy exchange in hospitalpatients; daily studies of the pre- andpost-operative balance of fat, carbo-hydrate and protein, Surq. (hen er.

Obstet. In preparation.18. Cope, 0. and others. Metabolic rate and

thyroid function following acute thermaltraumnia in miman, Ann. Surg. 137:165-74,1953.

19. Cairnie, A. B., Campbell, R. M., Pullar,J. D. and Cuthbertson, D. P. Heat pro-duction consequent on injury, Brit. J.exp. Path. 38:504-11, 1957.

ACKNOWVLEDAIENTS

The energy exchange studies reported here were done with Dr. Harvey Zarem,Miss Sheila Nichols, Miss Mary Lou Piche and Miss Margaret Ball. The continuedsupport and encouragement of Dr. Francis Moore has made this work possible.


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A CONSIDERATION OF ENERGY