Thorax: first published as 10.1136/thx.20.5.477 on 1 September 1965. Downloaded from

Itorax (1965), 20, 477.

Proceedings of the Thoracic Society

The Summer Meeting of the Thoracic Society was held on 9 and 10 July in the Memorial Hall, the Town Hall, Sheffield. Summaries of the symposium and papers follow.

SYMPOSIUM ON COMPUTERS IN MEDICINE IN A RENAL FUNCTION SURVEY DURING OPEN-HEART SURGERY PRINCIPLES J. C. A. RAISON said that some data of renal function L. C. PAYNE said that management, whether of a during extracorporeal circulation were used in a pilot hospital, the health and welfare of a community, or study to illustrate the possible use of a hospital board of patients, involves information regarding the hos- computer which had been installed originally for pital, the community, and the patients. It involves finance control. The subject and material provided reference information about disease, its incidence and examples of the theoretical advantages of a computer manifestations, about drugs, their doses, toxicities, system for clinical research, incorporating multiple and interactions, about the multiplicity of medical procedures, complex tabulation, multiple calcula- measurements and their interpretations, about the tions, correlation of accumulating data from different aetiology and epidemiology, and so on. It involves sources, and prediction as 'off-line' features, while current information of what is going on while it is 'on-line' facilities might allow ultimately for thera- going on, for no manager will respond to any element peutic control. The acknowledged difficulty of in a developing situation of which he is unaware, and communicating with a machine was heightened by moreover not do so with all the confidence of not that of communication with a non-scientific pro- even knowing he does not know. The computer is grammer, who spent an uneconomic amount of time the most versatile information engine ever contrived; preparing too limited a programme. The Fortran pro- copyright. it can store knowledge on a scale commensurate with gramme desired seemed almost as great an obstruc- what is known rather than what a single human mind tion to the clinician. Without a computer-conversant can absorb. It can enable more complete and up-to- biomedical specialist available, the clinician with date information to be gathered on developing situa- definite but occasional computer problems may best tions, and it means that the computer-aided doctor is hope for the production of 'package-deal' pro- going to be a more effective doctor than one who grammes dealing with the simple mathematical and relies on human faculties alone, whether he is statistical enquiries which he will most often require, http://thorax.bmj.com/ concerned with diagnosis, prognosis, or therapy, with and the occasional use of a small on-line machine to epidemiology or surgery, with patient care or admini- which he can pose his questions directly. stration. The paper explained some of the basic principles and concepts, so that this prospect would IN MEDICAL BIBLIOGRAPHY be more evident. M. M. CUMMINGS said that the explosive growth of IN MEDICAL RECORDS AND EPIDEMIOLOGY the published biomedical literature has exceeded the ability of medical libraries to organize and dis- seminate it effectively. The United States National W. W. HOLLAND considered that electronic com- on September 24, 2021 by guest. Protected puters are particularly suitable for handling a large Library of Medicine has developed a mechanized amount of data and for performing calculations. Epi- medical literature analysis and retrieval system demiological investigations usually involve the collec- (MEDLARS) which permits efficient bibliographic tion of a large number of facts on many individuals. control of the literature by providing computer-pro- Handling this data on conventional punch-card duced monthly indexes of the world's biomedical machinery or manual sorting is tedious. The use of literature as well as selected current awareness ser- electronic computers in evaluating the effect of vices (recurring bibliographies) and one-time demand environment and smoking on chronic respiratory searches of individual medical subjects. These new disease in surveys in this country and in the United modalities of information handling are proving to be States was illustrated. Medical records are a further of great assistance to teachers, students, researchers, possible application for the use of computers. Large and practitioners who have need for ready access to amounts of data are collected which require the medical literature. prolonged storage with immediate availability. The RUPTURE OF THE TRACHEA AND BRONCHI deficiencies of present methods of keeping patient BY CLOSED INJURY records were revealed by a study of their content and handling. Attempts to utilize an electronic computer J. T. CHESTERMAN reported that the causative type to cope with these problems were described. of injury is one of sudden severe compression of a 477 Thorax: first published as 10.1136/thx.20.5.477 on 1 September 1965. Downloaded from

478 Proceedings of the Thoracic Society wide area of the upper anterior chest wall. This United States. In many ways coccidioidomycosis produces lateral widening of the chest with distrac- resembles tuberculosis, with the important exception tion of the carinal region which is made greater when that it is non-contagious. Clinically, coccidioido- the lungs are inflated, the glottis is closed, and from mycosis produces two types of illness, a primary the backward displacement of the heart. A few cases benign form and a serious disseminated form with are produced by shearing, and a few by a 'blow out' a high mortality. Treatment, when necessary, is laceration of the posterior wall of the trachea and rather unsatisfactory, consisting of the toxic drug larger bronchi. The symptomatology is as suggestive amphotericin B, which must be given intravenously as the type of injury, but it must be noted that 10% for prolonged periods, and surgery. Illustrative cases show no clinical features. Bronchoscopy is urgently were shown. needed to establish the diagnosis in any suspected case. Conservative surgery gives excellent, if not TRACHEOSTOMY OR ENDOTRACHEAL perfect, results in suitable cases, otherwise resection INTUBATION IN THE POST-OPERATIVE is indicated. MANAGEMENT OF CARDIO-THORACIC PATIENTS MEASUREMENT OF THE TRANSFER FACTOR D. S. ROBERTSON compared and contrasted a survey J. E. COTES said the transfer factor or diffusing of experience of the management of respiratory prob- capacity of the lung is usually measured by the single lems in the post-operative period with his own current breath carbon monoxide method; this has been management. developed successively by Marie Krogh, Forster, The indications for tracheal intubation were dis- Ogilvie, Roughton, Jones and Meade, and others. In cussed; the place of endotracheal intubation was its present form the test provides information on lung particularly encouraged against the background of volumes, uniformity of distribution of inspired gas, the morbidity of tracheostomy. diffusing capacity of the alveolar capillary membrane, Particular emphasis was placed on the value of and volume of blood in the alveolar capillaries. The intermittent positive pressure ventilation via an endo- procedure is simple and acceptable for the subject, tracheal tube for the first 24 to 48 hours post- but technical difficulties have so far limited its operatively. The commoner indications for suchcopyright. application. Some of the difficulties and the ways in treatment are respiratory inadequacy following mitral which they can be overcome, including the use of a valvotomy and after thoracotomy for bronchial new apparatus, were discussed. carcinoma. Its place was considered as a supportive measure following open heart surgery, particularly SELECTIVE BRONCHIAL AND INTERCOSTAL where prolonged perfusion has been a feature. ARTERIOGRAPHY IN LUNG DISEASE NEUROLOGICAL INVOLVEMENT IN http://thorax.bmj.com/ C. S. DARKE and N. A. LEWTAS considered the tech- nical aspects in the light of experience gained from a specially selected group of patients. The procedure C. E. C. WELLS described as a dis- can be accomplished without undue difficulty or risk order of the central, peripheral, and autonomic ner- to the patient. Tumour circulation arising from vous systems, of the meninges and of muscle. Acute systemic vessels, either bronchial or intercostal and chronic phases could be distinguished from one arteries, can be demonstrated in primary broncho- another. This distinction provides a rational basis for genic neoplasms. It provides a new approach to the therapy, and is preferable to the traditional classifica-

investigation of solitary peripheral shadows in the tion on anatomical and regional lines. Examples of on September 24, 2021 by guest. Protected lung and may have diagnostic value. Bronchiectasis both acute and chronic neurosarcoidosis were receives a much increased flow of blood from dilated described with illustrations, and the place of A.C.T.H. and tortuous bronchial arteries. Visualization of these and steroid therapy was discussed. The plight of channels is feasible, and on occasions a pre-capillary patients with chronic disease was emphasized and shunt from the bronchial arteries to the pulmonary contrasted with the infrequent mention of neuro- arteries can be recognized. The dye may travel in a sarcoidosis as a cause of death in epidemiological reverse direction up the pulmonary arteries. The studies. The diagnosis is made clinically and is con- physiological implications of this phenomenon were firmed by orthodox biopsy techniques and by the discussed with particular reference to strain on the Kveim test. The lowered sugar content of spinal fluid left ventricle. is a valuable clue to diagnosis in obscure cases. SAN JOAQUIN VALLEY FEVER AMYLOIDOSIS OF THE MAIN BRONCHI F. S. NORTH described San Joaquin Valley Fever A. G. NORMAN reported three cases of amyloidosis (coccidioidomycosis) as a systemic fungus disease of the main bronchi. This variety of amyloid disease which is caused by the mould Coccidioides immitis. is a primary localized abnormality within the respira- It is endemic in the arid regions of the south-western tory system. There is no evidence of amyloid disease Thorax: first published as 10.1136/thx.20.5.477 on 1 September 1965. Downloaded from

Proceedings of the Thoracic Society 479 elsewhere in these patients and no amyloidosis in the enlargement. Thus, patients who had all of these lung itself. All three cases were in middle-aged men, features had the greatest reduction in effectively and were thought at first to represent carcinoma of ventilated and perfused lung. There was no evidence the lung, as they presented by blockage of a bronchus, of an association between the radiological features with resulting clinical syndrome. At bronchoscopy in of emphysema and the degree of unevenness of pul- two. abnormal mucosa was seen in the main bron- monary ventilation or blood flow. chus, but it was not recognized as amyloid disease. The diagnosis rested solely on the histological report. LEFT VENTRICULAR HYPERTROPHY IN The histology was so definite that it was considered CHRONIC COR PULMONALE that a sure diagnosis could be made. There has not been any great progression of the disease in these T. LODGE and J. J. DALY said that in a series of 28 three patients while they have been under observation. necropsy cases of cor pulmonale nearly 50% had No satisfactory treatment has been found, apart from heart weights above 500 g. in the absence of hyper- bronchoscopic debridement in one man. tension or valvular or ischaemic heart disease. In a further series of 34 cases of chronic , by SEALS OF THE FARNE ISLANDS radiological investigation using barium swallow and anterior oblique views, the degree of posterior dis- A. G. OGILVIE said that the colony of seals estab- placement of the left ventricle was assessed. In a lished on the Fames, a group of rocky islands off number of patients who died in this series the the coast of Northumberland, dates back at least to necropsy evidence of increased heart weight, left St. Cuthbert's day (seventh century), and is the only ventricular thickness, and left ventricular weight cor- colony of the Grey or Atlantic Seal on the east coast related with the radiological findings. These observa- of the United Kingdom. The ecology of the grey seal tions provide evidence for the occurrence of left is influenced by delayed implantation of the fertilized ventricular hypertrophy in some cases of chronic ovum, so that parturition is followed in three weeks cor pulmonale. by mating, which occurs annually. The mortality in the nursery at the Fames has risen with the increase PULMONARY VASOCONSTRICTION AND copyright. in the size of the colony, but no adequate study of GAS TENSIONS IN THE PULMONARY the mortality or morbidity of the grey seal has been ARTERIAL BLOOD made there or indeed anywhere. He was able to make a study himself by the post-mortem examination of GWENDA R. BARER reported that in experiments on 38 out of 75 dead calves in 1958 and a rather fuller cats, hypoxia, , and acid infusions all study of morbidity in the following year. He con- caused a rise in pulmonary arterial pressure (pul- mean cluded that most seal calves who die, die of starva- monary blood flow was kept constant). The http://thorax.bmj.com/ tion, and that serious morbidity is uncommon. Con- increase was 55% while 10% 02, 50% junctivitis and traumatic sepsis (staphylococcal in all while breathing 10% C02, and 30% during lactic acid cases when swabs were taken) were the usual findings. infusions which caused a similar fall in blood pH to The causes of, and trends in, mortality and morbidity hypercapnia. Hypoxia and hypercapnia caused pul- in the grey seal nurseries cannot be finally determined monary vasoconstriction through local mechanisms, until a complete study has been made. which may be different for the two stimuli. The effect of hypoxia was abolished by catecholamine inhibitors but not by inhibitors of serotonin or histamine (Barer, A NEW APPROACH TO THE MEASUREMENT 1963). Hypercapnia continued to cause pulmonary OF VENTILATION/PERFUSION INEQUALITY vasoconstriction after the effect of hypoxia had been on September 24, 2021 by guest. Protected abolished by phenoxybenzamine. The rise in pul- R. W. B. PENMAN and P. HOWARD said that monary arterial pressure during hypercapnia could separate estimates of the unevenness of pulmonary be abolished by alkaline infusions. ventilation and of blood flow had been obtained in 12 normal subjects and 22 patients with chronic bron- REFERENCE chitis by a method which describes gas exchange in Barer, G. R. (1963). J. Physiol., 169, 102P. terms of the fractional ventilation and perfusion of a three-compartment model' lung. The method is ROLE OF CATECHOLAMINES IN based on estimates of the effective gas tensions, OPEN-HEART SURGERY alveolar dead space, and blood shunt ratios. In the patients, both ventilation and blood flow were J. A. THORNTON said that plasma catecholamine abnormally uneven, although the latter was improved activity had been studied in 17 patients undergoing during voluntary . The distribution cardio-pulmonary bypass for the correction of con- of pulmonary ventilation was most uneven in those genital and acquired intracardiac defects. In all the patients with congestive cardiac failure, whereas patients halothane was the primary anaesthetic agent blood flow was most uneven in patients with electro- employed for the maintenance of anaesthesia; mode- cardiographic or radiographic evidence of right heart rate degrees of hypothermia were employed during Thorax: first published as 10.1136/thx.20.5.477 on 1 September 1965. Downloaded from

480 Proceedings of the Thoracic Society perfusion. The blood levels of catecholamines were primum defects had pressures over 75 mm. Hg, and comparable with the findings of previous workers. in this group there were two deaths. Operative treat- The evidence suggested that sympathetic activity is ment on a small series of patent ducts and ventricular maintained throughout prolonged perfusion despite septal defects showed that, in the former group, pul- hypothermia. There was no correlation between monary hypertension of the severest degree was not plasma levels and blood-pressure. associated with mortality, but in the latter group there was a significant increase. Post-operative cardiac catheterizations in general showed a considerable Before During After long-term reduction in pulmonary artery pressure, but Bypass Bypass Bypass there were exceptions. Despite successful closure, Mean level of nor-adrenaline (pig. 1.) 0 9 0 4 0 7 pulmonary artery pressure remained at the pre- Mean level of adrenaline (,ug. 1.) 09 1 8 1-7 operative high level. PULMONARY ARTERY BANDING FOR There appears to be no contra-indication to the use SEPTAL DEFECTS of halothane as an anaesthetic agent on the evidence of this study. D. VEREL, R. G. GRAINGER, and D. G. TAYLOR said that septal defect had been diagnosed by cardiac INFLUENCE OF PULMONARY HYPERTENSION catheterization in 60 children under the age of 3 ON CARDIAC SURGERY years. In 48, pulmonary artery banding with ligation of patent ductus arteriosus and excision of coarcta- D. S. TAYLOR said that in a series of 400 closed tion, where necessary, was performed. These children mitral valvotomies there were 44 in which the pul- had been followed for nine to 54 months. There had monary artery pressure exceeded 75 mm. Hg. There been 18 deaths. Successful pulmonary artery banding were six hospital deaths in this group, giving a morta- relieves cardiac failure and allows the child to thrive. lity of 13%. Of the remaining 356 cases, the mortality may occur after an interval as a result of was 3-5%. One-fifth of the hypertensive survivors had either the development of Eisenmenger reactions or been catheterized one year after operation, and all inadequacy of the orifice in the pulmonary artery.copyright. showed a marked reduction in pulmonary artery Despite these complications and the relatively high pressure. In a group of 80 atrial septal defects, there mortality from intercurrent infection, when the pro- were 13 of primum type and 67 of secundum type. gress of the 12 unbanded infants was considered, the Two of the secundum type defects had pulmonary procedure appeared to be a life-saving measure for artery pressures in excess of 75 mm. Hg. Five of the certain children. http://thorax.bmj.com/ on September 24, 2021 by guest. Protected