Asthma and Hay Fever

The Bookshelf, continued V4; actually in such a description there is also a lateral component of the infarction; absence of abnormal Q wave in leads V5, V6, I and AVL is the hallmark for diagnosis of anteroseptal myocardial infarction unless there is anterolateral myocardial infarction. I would not agree with another statement that partial right bundle branch block is diagnosed when the QRS pattern is that of RBBB but the QRS complexes are not widened beyond 0.10 sec.; actually in clinical electrocardiography bundle branch block with a QRS duration less than 0.12 sec (namely between 0.10 and 0.12 sec) is arbitrarily designated as incomplete. The statement that left bundle branch block is associated with ischemic and hypertensive heart disease is not complete without mentioning the additional important fact that many cases of LBBB are "mechanical" in nature and not related to coronary artery disease (as was reported by Mahaim and recently emphasized by Lenegre and Lev). There may be a difference of opinion with the statement that a second degree of A-V block complicating sinus rhythm should be considered a digitalis effect separating it from digitalis intoxication. At least it should be emphasized that even though the second degree A-V block is a pharmacologic effect of digitalis it is also an effect which is undesirable, and digitalis should be stopped or be given with caution when this partial heart block occurs during digitalis administration. I would also add to the digitalis-induced arrhythmias the not infrequent "nodal" tachycardia, and the rare but prognostically serious alternating junctional or ventricular tachycardia. It is unfortunate that the author uses the term "interference" as meaning the meeting or collision of two impulses or "mutual impedance;" in such a condensed book this controversial term with so many meanings given by various authors should be avoided in order not to confuse, particularly the beginners. Diagram 129 is incorrect because it depicts the atrial extrasystolic pause as equal to the dominant cycle: in general such a pause following an atrial extrasystole is usually longer than the cycle of the basic rhythm. Even though the author by choice retains the tenn "nodal" rhythm it should be made clear that the term A-V junctional rhythm is used synonymously or exclusively by other cardiologists. In the R on T phenomenon the author mentions the tenn vulnerable period; a short explanation of this term is indicated. The term "ventricular automaticity and irritability," both mentioned within a few lines in connection with the genesis of the ventricular extrasystoles, may cause a little confusion because they are not explained. A short discussion of the reentry mechanism is appropriate even in a book of this size. The significance of carotid sinus pressure in the differential diagnosis of supraventricular from ventricular tachyarrhythmias should also be mentioned. I do not think one dissociated escape beat or one nodal or ventricular extrasystole (occurring "near" synchronously with a sinus impulse) should be designed to be called interferencedissociation. In spite of these remarks and the small criticisms this book will be useful to beginners of electrocardiography as it will familiarize the reader with the general field of the subject in rather broad terms over which a more sophisticated knowledge may be built by reading text-books and articles dealing with the subject. Jules Cohen, M.D. New York, N.Y.

MANAGEMENT OF ARTERIAL OCCLUSIVE DISEASE. Ed. by W. Andrew Dale, Chicago, Year Book Medical Publishers, Inc., 1971, $25.00 Conceive a conference to consider the many facets of a single disease process and its treatment. Imagine an assemblage of pioneering contributors vigorous in leading, interacting, and contributing to three decades of scientific and clinical progress; a group critical in analysis and accurate in presentation of results, thoughtful concerning solutions to future problems, and dedicated to communicating the state of the art with an eye to the future. This describes the national conference on Management of Arterial Occlusive Disease held in Nashville, Tennessee late in 1970. Each of the participants (and contributors to this book) was invited because of his maintained interest in the study of his subject for a period of years, his demonstrated ability to produce good results in the field, and his talent for presenting ideas clearly. The reviewer and editor concur that "this volume presents the best current ideas in the prevention and management of arterial occlusive disease," in topics ranging from the effect of diet and exercise through physiologic evaluation, angiography, medical management, selection of patients for surgical treatment at many specific sites, management of complications, and long-term results. Surely chest physicians are interested in the relation of the internal surface of vessels to the process of thrombosis, and this is presented. They would be interested in authoritative opinion on current contrast media for arterial and venous visualization; it is here. Therapeutic accomplishments following arterial trauma and the results of treatment of vascular diseases at the many sites in the body are recorded. The volume is attractive for its many good qualities: hand book size, the attractive cover, quality paper, highly readable type, beautiful illustrations clearly reproduced, completeness of variety of its presentation, and thorough but not tiringly documented selected references and good index. A critique of the diagrams, photographs and tables assures one of meritorious research activity as well as creditable clinical practice in the specialty of circulation. Every surgeon doing vascular disease will want to own the book. Medical students and all physicians would be well advised of its worth as a reference text and guide to the solution of clinical vascular problems. Roy H. Clauss, M.D. New York, N.Y.

ASTHMA AND HAY FEVER. By OSCAR SWINEFORD JR., Charles C Thomas, Springfield, Illinois, 1971, 484 pp, $19.50 This monograph, designed primarily for graduate and undergraduate medical students and family physicians, is written by an allergist-internist with the philosophy that the care of asthmatics is the responsibility of the allergist. The book has 21 chapters covering almost all the topics related to the syndrome, including a chapter on education of the young physician to enable him to diagnose and treat his patients in an adequate manner. Hay fever is included in three chapters, along with other aspects of asthma. The strongest chapters of the book pertain to immunology and allergy, and contain profound (although sometimes lengthy) discussions of imContinued on page 642-B

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The Bookshelf, continued munology, anaphylaxis, skin testing, elimination diets, hyposensitization, desensitization and inhalant avoidance program. The author uses frequent words of caution regarding the interpretation and use of skin tests, bacterial antigens, avoidance of foods, etc. Other chapters, related to the nonallergic components of asthma, are also very good, but sometimes tend to underestimate the role of the internist, cardiologist and chest physician and contain some statements that can be seriously challenged: "digitalization during an attack of cardiac asthma is seldom necessary," "admit to hospital under care of allergist if status asthmaticus is worse or not better," "the use of bronchoscopy, simple aspiration, in-dwelling catheters or tracheostomy is largely empirical and always risky," "time consuming evaluation of obscure emotional problems is seldom necessary," "a small dose of x-ray therapy occasionally confirms a suspected diagnosis of sinusitis when all other diagnostic procedures fail," etc. The definition of chronic bronchitis leaves something to be desired, and no word or just a passing glance is given to pulmonary surfactant, the behavior of the pulmonary vasculature, and the use of antibiotics, corticosteroids and bronchodilators for long (and I mean long) periods of time, to mention a few topics that should be of interest to those involved in the care of asthmatics. As there are no numbered references in the text, sometimes there is an uneasy feeling of dogma after reading a discussion or a statement, and paradoxic situations like this arise: pulmonary surfactant is barely mentioned in the text and is not included in the index; however, the bibliography contains 9 references on the subject! Although supposedly the book is not directed to him, the chest physician will surely miss quite a few of "his" journals on the list at the end of the book. I agree with the author when he states that "a major problem for the asthmatic is the confusion which results from the lack of communication between allergists and chest physicians," but even though he insists that this gap should be filled, he also insists that the care of the asthmatic is, mainly, the responsibility of the allergist. After carefully reading his book, I was unable to find evidence to support this claim. This in no way pretends to diminish the merit of the book, which I think should be of interest to all students of a most complex problem. For the uninitiated or newly initiated, it represents the opportunity to read a complete review on the subject, probably the best on the market; for the mature physician it will provide for long moments of informative and sometimes amusing reading, and a chance to compare experiences with the author's. Carlos Ibarra-Perez, M.D. Mexico City, Merlco

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THE HEART AND ITS ACfION-ROENTGENKYMOGRAPHICS STUDIES. By GILBERT H. ALExANDER. Warren H. Green, Inc., St. Louis, Missouri, 1970, 259 pp, $22.50 This text provides historic background of the development of the technique of roentgenkymography and results summarizing the author's experience with it since 1957. This technique is clearly described and specific data on exposure and positioning of the patient are provided. Figures demonstrating kymographic illustrations are provided and are of excellent quality. Conditions including intracardiac and extracardiac calcifications, congenital heart disease with left-toright shunts, isolated pulmonary stenosis, Ebstein's malformation and Ubi's anomaly, tetralogy of Fallot, Eisenmenger's syndrome, truncus ateriosus and valvular heart disease are presented. Other chapters are devoted to changes in the kymograph associated with pulmonary regurgitation and hyperactive heart as well as other isolated conditions including eorpulmonale, myocardial disease, pericardial disease and pulmonary thromboembolic disease. A final chapter outlining the potential role of kymography in cardiac diagnosis is presented. It is the author's view that the kymogram with moving grid is very useful in preliminary evaluation of the cardiac patient. The graphic representation of motion is held as a prime factor in the value of this technique. While this technique was found to be of limited value in investigation of myocardial disease such as myocardial infarction or myocardiopathies, unsuspected aortic stenosis with calcified valve in middle aged or older patients was demonstrated quite well. The text is interesting in that it outlines the technique that is not very frequently used. As pointed out by the author, the exposure to x-ray with the use of this procedure is approximately 20 times that of an ordinary roentgenogram of the chest, but in his experience, the exposure per kymogram averaged about 0.5r, and with proper collimation this was not felt to be a large volume dose. It is also pointed out that photofluorography exposes the patient to 4-10 times the exposure of a regular chest film and has gained a general acceptance as a diagnostic test. In the current revival of noninvasive diagnostic procedure, a technique such as this deserves consideration. However, fluoroscopy with image intensification would probably provide as much information and with cine studies does provide a dynamic quality which may be lacking in the kymograph. The book represents a commendable effort on the part of the author to reproduce his findings utilizing this diagnostic aid in a variety of conditions. Arthur B. Landry, lr-. M.D. Hartford, Connecticut