John H. Mulholland

Flow rate and composition of thoracic-duct lymph in patients with cirrhosis.

IN the 1908 Christian Herter Lectures at Bellevue Hospital, Starling1 emphasized the important influence of changes in hepatic interstitial-fluid formation on flow and composition of thoracic-duct ...

Controlled study comparing ethacrynic acid to mercaptomerin in the treatment of acute pulmonary edema.

Abstract In a controlled study comparing the therapeutic effectiveness of intravenous ethacrynic acid to intramuscular mercaptomerin in patients with acute pulmonary edema, all 39 patients were tre...

Some observations on the treatment of trauma to the pancreas

Abstract Injury to the pancreas can be one of the most obscure and difficult of all intra-abdominal surgical problems. The gland is a soft, yielding, deeply placed structure which, offhand, seems well protected. It is, however, vulnerable not only to the violent forces of major accidents but also, surprisingly, to many milder forces which are accurately directed. The diagnosis of injury is not difficult if the possibility is kept in mind. Serum amylase determinations and prompt aspiration and examination of all fluid collections are most important. Juice which pours from a ruptured pancreatic duct is easily characterized by simple laboratory tests. The objective of operative treatment is to provide for a path of lesser resistance to flow into areas where the juice can do no harm. This becomes of major urgency when pancreatic juice is activated and difficult to accomplish in the face of inflammation, necrosis and hemorrhage. In some instances of leakage of unactivated juice, operative provision by anastomosis of the pseudocyst to the gastrointestinal tract may be simple. In Case IV, such a procedure would probably have been sufficient. In instances of leakage of activated juice, however, such a maneuver is frequently not possible. Here, the principle of establishment of flow through a nonresistant pathway into the duodenum is applicable. Sphincterotomy and intubation of the pancreatic duct through the ampulla of Vater, an area not involved in the destructive process, will reverse flow promptly and bring about collapse of the pseudocyst. It has been demonstrated that intubation extended into the distal severed pancreas will provide for healing of the fracture and preservation of important glandular tissue. Knowledge of the exact site and the extent of injury is easily obtained by pancreatograms performed through a tube in the pancreatic duct. No hazardous operative exposure of the inflamed area is needed. Even if the leaking juice were unactivated, manipulation necessary to expose the source of leak can trigger a disastrous activation and later necrosis. Logical steps in management of abdominal injury wherein the pancreas is always a likely site of damage include: 1. 1. Establishment of the diagnosis by amylase determinations in serum, in aspirates of fluid collections in the peritoneal cavity, thorax or in drainage fluid. 2. 2. Operative diversion of the flow of pancreatic juice from a torn duct to the gastrointestinal tract. This can be accomplished simply and directly by sphincterotomy and intubation of the pancreatic duct. 3. 3. Accurate assessment of the damage by roentgenographs of radiopaque material injected into the pancreatic duct in its uninjured portion.

Intubation of the pancreatic duct in the human.

Summary A technique is described for intubating the duct of Wirung in the human during the operative procedure of transduodenal sphincterotomy. Through this tube the pancreatic duct can be drained and also visualized roentgenographically. Quantitative studies of the composition of the pancreatic juice under various conditions can be carried out at will.

SKIN HOMOGRAFT SENSITIVITY CROSS REACTIONS IN MAN

The genetic disparity encountered in the random populations of normal human subjects employed in previous studies concerned with the mechanisms of homograft rejection in man has introduced inescapable variables into interpretations of the observed results.lS2 Since there is no large series surveying the specificity of the homograft response in comparable to the array of data on this subject available in experimental animals,6-10 we have been prompted to study further this aspect of homograft sensitivity in man. The application of a skin homograft to a normal recipient results in its initial survival, followed within 8 to 12 days by a characteristic pattern of rejection which has been termed the homograft rejection phenomenonP These changes are associated with the development in the host of a state of generalized sensitivity to further skin homografts obtained from the same donor. If the host is challenged with a subsequent skin homograft from the same donor, he will exhibit either the accelerated rejection reaction, with ensuing hemorrhagic necrosis of the graft within the first 4 to 5 postoperative days, or the white graft reaclion, characterized by complete nonvascularization and a parchment white appearance of the graft.5 The duration of the latent period allowed between rejection of the first-set graft and application of the following graft from the same donor conditions the type of response observed. A short latent period of 1 to 5 days results in a white graft, while a longer period of 10 to 26 days elicits the accelerated rejection reaction. The development of objective criteria for the evaluation of skin homograft reactions in man has made possible an attempt to evaluate the influence of individual specificity on the response of the host to skin homografts. This paper presents data collected on the fate of 147 skin homografts performed in normal human subjects in the course of a comprehensive study of the immunology of skin homograft reactions in man, with particular reference to possible means of detecting individual or group specific factors concerned with homograft sensitization in man.

Measurement of Pancreatic Enzymes in Human Thoracic Duct Lymph

Summary In patients whose thoracic ducts had been cannulated, the intravenous injection of secretin produced a marked rise in concentration of amylase and lipase of the lymph without significant changes in the serum levels of these enzymes. Morphine given with the secretin augmented the effect on lymph enzyme levels.

Intravenous infusions into human subjects of fractionated coconut oil emulsions.

Summary 1. Emulsions of the glycerides of the short chain fatty acids were toxic when injected intravenously into human subjects. 2. The glycerides of the high molecular weight fatty acids, lauric, myristic, palmitic and stearic acids were non-toxic when injected jin emulsion form. 3. Inclusion with the latter of small concentrations of the fatty acid esters of the type of oleic and linoleic acids did not affect the toxicity of the emulsions.

Intravenous infusions of concentrated combined fat emulsions into human subjects.

Summary Two types of combined fat emulsions, one containing 15% fat and the other 20% fat, were infused into 25 human subjects. A total of 51 of these concentrated fat emulsions were administered intravenously. The incidence of constitutional reactions was 27%. A variety of laboratory and clinical observations were made in conjunction with these infusions.

Intravenous infusions of a combined fat emulsion into human subjects.

Summary The method of preparation of a 10% combined fat emulsion used in the present investigation was described. A combined fat emulsion with a potency of approximately 1300 calories per liter was infused intravenously into 76 human subjects. A variety of laboratory tests and clinical observations provided evidence in favor of its suitability as an intravenous emulsion.

Oxygen Consumption Studies with Intravenous Infusions of the Combined Fat Emulsion.

Summary (1) Sixteen serial oxygen consumption studies were conducted in a group of 7 adult humans who received one or more of 6 types of intravenous preparations. (2) Maximal increases in oxygen consumption above the initial pre-infusion levels attained their greatest values in recipients of the 10% combined fat emulsion when compared with a variety of intravenous preparations of a lesser caloric or energy value. (3) With fat as the prime contributing factor to the increased energy value of the 10% combined fat emulsion, it is justifiable to conclude that the intravenously infused fat is utilized for energy production when in part it undergoes oxidative combustions which are ultimately measured in terms of oxygen consumed.