Discussion 269 



whatsoever of chronic respiratory disease, and that a severe respiratory 

 infection, for some reason that I do not know, may cause acute tubular 

 necrosis, for which there is autopsy proof in one case. 



Black : This would really bring it into the whole group of peripheral 

 circulatory changes. 



McCance: This seems to me a matter which is wide open to experi- 

 mental attack, and it might be coupled with stress tests. 



Davson : The trouble is that the energy required for these active trans- 

 port processes is a small fraction of the whole and when the energy sup- 

 plies are interfered with to such an extent that active transport is affected, 

 the cell will be dead long before you can obtain any useful information. 



Borst: We have just had an autopsy on a very obese patient who died 

 with bilateral cortical necrosis. I am ashamed to say that she had been 

 under-examined. As in Dr. Black's cases she was admitted with a 

 respiratory infection which was treated with penicillin, and in a few days 

 the infection was under control. She was up and about until we dis- 

 covered that she was producing no urine. On autopsy no abnormality 

 in the lungs was found. The necrosis involved a great part of the renal 

 cortex; there was no evidence of other renal disease. We thought that 

 it was a case of Pickwick's syndrome. 



It was reported about 20 years ago that giving oxygen to patients with 

 respiratory failure resulted in an increased sodium output. In our cases 

 there was no definite effect on sodium output in spite of the fact that the 

 general condition of some of the patients improved markedly. 



Bull: I was hoping that Dr. Black was going to bring evidence of a 

 normal decline in respiratory function, because in our patients both 

 renal and respiratory deaths are common, and there are many cases of 

 the combination of the two. If someone could show that respiratory 

 function declined in roughly the same way that renal function does that 

 would help us to understand this situation. I believe that tissues other 

 than the kidney must undergo a similar decline in function at the same 

 sort of rate with age to account for this rather remarkable mortality 

 experienced. We have now confirmed our findings on over 3,000 cases, 

 and we get exactly the same effect as we did eight years ago. 



Black : There are indeed plenty of references to the decline of respira- 

 tory function with age. A summary has been given by Stuart-Harris and 

 Hanley (1957. Chronic Bronchitis, Emphysema, and Cor Pulmonale. 

 Bristol: Wright & Son). 



Scrihner: As regards renal compensation, we had one patient with a 

 remarkable ability to compensate for respiratory acidosis. We were 

 interested in finding out whether high pCOg or low pH caused the coma- 

 like condition that patients with respiratory acidosis may develop when 

 treated with oxygen. Our interest began when we tried treating acute 

 renal failure by putting a cellophan bag in the stomach, a technique first 

 suggested by Dr. Schloerb of Kansas City. With this technique of gastro- 

 dialysis it is possible to remove tremendous amounts of hydrogen ion, 

 in fact usually so much that you have to put hydrochloric acid in the 

 dialysis fluid to prevent alkalosis in the patient. We turned this around 

 and applied it therapeutically to the respiratory acidosis patients in an 



