The role of protein nutrition in the convalescence of surgical patients has been emphasized by many authors during the past 15 years, and much of this work has recently been ably reviewed by Lund (1). The observations of Cuthbertson (2), confirmed by Howard and his co-workers (3), that fractures of long bones resulted in a marked negative nitrogen balance which could not be overcome by substantial increases in the protein intake, raised certain questions regarding the possible effects on nitrogen requirements and nitrogen balance of extensive surgical operations. It seemed important to know how soon after operation a positive nitrogen balance could be re-established, and what levels of nitrogen and caloric intake would be required to accomplish this.Many of the previous concepts of the protein nutrition of surgical patients have been based on changes which were found in the serum protein concentration at different periods. It is generally acknowledged that the use of such data may lead to erroneous conclusions, but they have continued to be used by many investigators chiefly because of the difficulties in carrying out the more informing balance studies. In this project, additional technical aid made it possible for us to carry out both types of study. Our results indicate that the serum protein concentration may, at times, increase in spite of a negative nitrogen balance during the period of study.It has also been possible to compare the effectiveness of whole protein with various preparations

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For some years it has been a common practice for surgeons to insert a drainage tube into the common duct after choledochotomy for calculi, stricture, chronic pancreatitis, suppuration or even malignancy. Whether such drainage is always necessary if the obstruction has been relieved, has often been questioned by those who believe that primary closure of the duct can often be done without danger to the patient, especially where the obstruction is not complete. There appears to be no general agreement as to how long the drainage should be continued in the various conditions, nor is there any general unanimity of opinion as to whether prolonged biliary drainage is dangerous.Wangensteen (1) has called attention to the effect on patients of prolonged biliary drainage and Walters and Parham (2) have commented on the development of cholerrhagia as an unfavorable sequel to surgical drainage of the biliary tract. Two more recent papers by Walters, Greene and Frederickson (3) and Greene, Walters and Fredrickson (4) have again emphasized the necessity of a careful study of the entire problem in an effort to improve surgical end-results in cases of the type under discussion.During a period when we were studying the anion-cation concentrations of human gallbladder bile removed from normal and diseased gallbladders during life, we obtained and studied the bile from 18 patients who had obstruction of the common duct from calculi, stricture, malignancy or infection, and who lived at least five days after operation. Four died after this period and 14 recovered. The specimens were collected daily, measured, and analyzed for certain of their constituents. The drainage was continued for a variable period, the longest being 191 days.

In an earlier paper (1) we discussed the anion-cation concentration of normal hepatic bile when subjected to the activity of the dog's normal gallbladder. Under these conditions the chloride and bicarbonate concentrations and the pH of hepatic bile decrease, while the base, bile salt and calcium concentrations increase. In every instance fluid is absorbed. In a very limited number of observations we have found the depression of the freezing point of hepatic and gallbladder bile approximately the same, although the total anion-cation concentration was increased considerably in the latter.As a prelude to the anion-cation studies we had studied the effect of gallbladder activity on certain of the individual constituents of hepatic bile when placed in the normal bile-free gallbladder of the unanaesthetized dog (2) (3) (4). It was observed that when the gallbladder became infected the activity of the membrane on the constituents studied was altered considerably. In such instances, water was only slowly absorbed; or, in the more severely damaged organ, fluid actually poured into its lumen, the latter action being a complete reversal of the normal mechanism. Under these circumstances chloride and bicarbonate entered the gallbladder lumen with the inflowing fluid, the chloride concentration of the secreted fluid being about plasma level while the total CO2 concentration was often several times the normal plasma level. Calcium, introduced as calcium lactate, was precipitated, partly in the gallbladder lumen, and partly in the gallbladder wall. Cholesterol in either a colloidal suspension, or in hepatic bile, increased in concentration, but not in total amount when placed in the normal gallbladder. The same was true of bile pigment. When, however, the gallbladder was infected the total amount of cholesterol increased, while the total amount of bile pigment decreased (5).These isolated observations made at a time when we were chiefly concerned with normal function convinced us that a study of the anioncation changes in hepatic bile subjected to the activity of an abnormal 1 Harriet M. Frazier Fellow in Research Surgery. 67