BLUTVOLUMEN, GEFASSBETT UND BLUTVERTEILUNG IN DER LUNGE

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LUNG FUNCTION by J. E. COTES AND F. A. DAVIS,Philadelphia, 1968, 604 pp, $16.00 Studies of lung function began over 300 years ago, and yet today one usually fails to find a well-functioning spirometer in most practicing physicians' offices or clinics. Blood gases are still clouded in mystery and the arterial puncture is considered a major surgical procedure by some. The average practitioner (indeed, the average medical student) does not regularly use terms such as "oxygen tension," "alveolar ventilation," "gas transport" and "ventilation-perfusion abnormalities." This lamentable fact seems even more paradoxic when one finds new instruments appearing at medical meetings each year-indeed, new tests with applications and clinical significance yet to be found, and test. that have never been the subject of a critical study, such as tests for various pulmonary resistances! The immense problem of both acute and chronic l t ~ n g disease and the need for sound physiologic evaluations and tests to guide intensive care emphasize the need for practical lung function tests which are understandable and meaningful not only to those in research, but, more important, to practitioners of medicine. On reading Lung Function, one should look immediately to page 338 where the eminent author states, "When a new laboratory is set up it is usually the intention of those in charge that the items of equipment which are purchased should be cheap, accurate, and portable, also simple to maintain, and operate; they should also yield immediate answers which are appropriate in all circumstances. However, these criteria constih~tea counsel of perfection which is unattainable!" This is a sad commentary on lung function testing as it exists today and underscores the earlier comments in this review. Anyone interested in respiration should understand spirometry, which gives insight into ability to move air in and out of the lungs. Technology has furnished us with superb instruments, which, if only simply explained, could be assimilated by all students of medicine, both young and old alike. The availability of blood gas measurements using new electrodes, tonometers, and oximeters, as well as the safe technique of simple arterial puncture, has revolutionized the field of lung function. Blood gas detern~inationsprovide infonnation about the adequacy of alveolar ventilation and oxygen transport in the lung. The Poz, PC% and pH should be as commonly discussed on morning rounds, including those made by the attending staff, house staff and even nursing staff, as are the blood urea nitrogen, electrolytes and sugar. Although the clinician concerned with chest disease must understand concepts of gas transport, ventilation-perfusion abnormalities and alveolar ventilation, it often suffices just to know that hypoxemia or underventilation is present to institute proper therapy of benefit to the patient. The availability of newer refined ventilators supplies the applied physiologist-clinician with valuable tools to correct blood gas derangements, irrespective of their underlying etiology, in clinical states ranging through a wide spectnun, including chronic airway obstruction, crushed chest, acute neuromuscular paralysis and poisonings. These goals, that is, the practical understanding of pulmonary function, can be met in part by complete and detailed descriptions concerning both theory and applica-

tions. This is the goal of this book which is written in easy style and in great detail; it contains excellent illustr;~tions~rntl useful nomograms. Unforh~nately,the Radfortl nomogram is still referred to as a gauge for ventilation: this is completely inapplicable to most situations reclr~iring ventilatory assistance today. It is regrettable that st;tntlardization of lung function tests and agreement among different laboratories is poor today. They are desperately needed in the field of respiratory disease to be on a par with other physiologicallyoriented specialities. Principles of gas transport, ventilation perfusion ahnormalities, and the use of oxygen as a pharn~acologicagent, are sr~perhlyhandled. So are considerations of pulmonary disahility and the application of pulnlonary function tests to specific disease entities of both specific and nonspecific n a h ~ r e .NIImerous facts which are sr~ccinctlyexpressed t h r o ~ ~ g h o uthe t book are bolstered by no less than 41 pages of pertinent references. Disc~~ssions of concepts such as oxygen economy and the appropriateness of oxygen consumption for given work will regale the in-depth reader. On balance, one must in some way begrudgtx the complexity of the text, for what is actually required for the practitioner is pulmonary physiology explained in simple and prag~natic terms. For example, although there are three pages on the antiquated Riley-bubble methtxl of gas tension measurement, the practical and now widely accepted technique of straightforward arterial p r ~ n c h ~ rise not mentioned in the book. Simple office spirometers such as the Vitalor or Pnln~onorare not discussed: and thr~s.the casrral reader ~niclit . . get .. the idea that lung function study is restricted to the pr~lmonary physiologist, sequestered away in his ivory tower and surrounded by slide rnles (or, today, a compi~ter!) Perhaps the text is written for students, practitioners and clinical physiologists in the United Kingdom who are capable of understanding and applying all the detail contained. Unforh~nately, this level of sophistication is found wanting among most of the students, interns and residents, and even pulmonary fellows, on this side of the sea. The book is definitive, concise, clear and important. It is a Bible in its realm, but, we need a c;itechism! Nonetheless, the book could f o m ~the basis of knowledge for that still unwritten monograph, to be penned by an unknown author, and entitled, "Why People Breathe the Way They Do and What to Do About It." Thomay L. Petty, h1.D. Denser, Colorotlo BLUTVOLUhlEN, GEFASSBETT UND BLUTVERTEILUNG IN DER LUNGE (Vascular Compartments and Distribution of Blood Volume in the Human Lung) hy RUPERTBACKMANN. Gustav Fischer Verlag, Str~ttgart, 1969, 79 pp, $8.75. (Available in U.S. from Intercontinental Book Corp., New York City.) During the past decade there has been a drastic change in concepts pertaining to pulmonary function. Whereas gas exchange is still expressed in the clinical setting in terms of volunletric considerations, criteria pertaining to the circulation of the pulmonary I x d are being determined with greater frequency, since they provide the best expression of pathophysiologic derange~nents.The crude estimates of pulmonary perfusion which were used by experimenters at the beginning of the present century have long since been replaced by more refined parameters, these in turn being an outgrowth of catheterization nlethodology. The major incentive in the last few years to renewed attacks on the problem of disorders of (Continued on pagc 3.51

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the pulmonary circulation is an outgrowth of very convincing evidence that the lungs are a most important target organ, malfunction of which often determines survival, and which is one of the most difficult to control by currently available therapet~ticmeans. Dr. Backmann's monograph is a very thorough s h ~ d yof the functional aspects of the pulmonary vascular system, with emphasis on comparative anatomy. It furnishes prospective investigators in this sphere of activity an excellent background in scientific methodology, with an inventory of the positive feah~res and disadvantages of various techniques employed during the past few decades. He substantiates many of his conclusions by an impressive amount of data which include morphologic procedures such as postmortem angiography and d y e dilution curves of perfused isolated lungs in various stages of expansion. The excellent illustrations shed interesting insight on the capillary architecture of the lungs. The difference between anatomic and physiologic blood volume of the lungs becomes very apparent from the outcome of various measurements presented by the author. Altl~onghthe n~onographconstitutes a valuable handhook for those who wish to engage in this sphere of study, it suffers from various defects. Thus, there is conspicuous omission of the radioisotope techniques for studying pulmonary blood volume, and this, as has come to be appreciated, is much more precise and more meaningful than some of the standard, but older, devices described by the author. There is very little mentioned about the condition of vascular compart~nentsin different disease states. Indeed, whatever information is proffered is hardly startling, dealing as it does with imbalances related to heart failure and severe anemia. Readers who are a t h ~ n e dto discussions of the pulmonary microcirculation in conditions such as pulmonary embolism, pulmonary trauma, and pulmonary insufficiency associated with openheart sur::ery, will be disappointed to find no allusion to these states. A glaring deficiency of the book is its bibliography, in which only a handful of references are of recent vintage. Finally, regardless of its intrinsic value, a book of this size hardly warrants the price which is asked for it. David C h a ~Schechter, . M.D. New York City

CLUES T O DIAGNOSIS IN CONGENITAL HEART DISEASE by A. S. G o o c ~ , V. ~ ~ A R A N H A OA N D H. GOLDUERG. Philadelphia, F. A. Davis, 1969, 336 pp, $15.00 This text, designed for the "non-cardiologist who has an interest in congenital heart disease," presents a series of brief case reports culled from the authors' rich experience and arranged in random fashion. Each patient is descrihed in a two-page unit with the clinical information preceding the diagnostic interpretation, a format that lends itself to abundant self-testing. The overall context is good, and the graphic data and angiocardiograms are s ~ ~ p e r h ldemonstrated y in large, clear figures. A few references are listed after each case report allowing the reader to consult then1 directly without interrupting his thought pattern. In essence, I have only two recommendations to offer that may increase the value of the text; first, the differential diagnoses for many of

the cases should be discussed in more detail, and second, some of the complex cyanotic disorders probably don't belong in a book aimed at the "non-cardiologist." Some of the cases merit special attention hecause of the lucid narrative and the striking display of the graphic data: Case 42, an example of unmasking of peripheral pr~lmonic stenosis following successful surgery for tetralogy of Fallot; case 68, an instance of severe right heart failure following similar surgery; and case 131, a marvelously concise analysis of a commonly encountered syndronie that includes a benign ejection murmur, an electrocardiogram with RSR' in right chest leads and a chest x-ray showing borderline dilatation of the main pulmonary artery. Other descriptions are somewhat nebulous, occasionally referring to debatable points in a rather dogmatic fashion. For example, the repeated statement that murmurs whose intensity changes with respiration are of innocent origin may be challenged. Some clinicians may disagree with the remark that a pr~lmonicejection click may be distinguished from one of aortic origin by "its selective decrease in intensity with inspiration." hiany of us feel that the electrocardiogram in secundum type of atrial septa1 defect represents right ventricular hypertrophy rather than "incomplete right hundle branch hlock." In case 89, the authors state that "the right aortic arch can be suspected by palpation.'' I think that most of us would have considerable difficulty in confirming this physical finding. In case 136, the plain chest film is said to be of "little help" in the diagnosis of coarctation of the aorta; inspection of the film, however, reveals the characteristic dilatation of the left subclavian artery and absence of the roof of the aortic knob. Case 19 indicates that a large left atrium is present "without evidence of left atrial enlargement on the ECG." The electrocardiogram shows a P wave with significant terminal negativity in right chest leads; this is reasonably good evidence for left atrial abnormality in a child. Case 10, an example of severe pulmonic stenosis, indicates that "the lung fields have diminished vascular markings" in this entity; many feel that "diminished vascular markings" occur in pulmonic stenosis only if there is an associated right-to-left shunt. The description of case 64, a child with moderately severe aortic stenosis, gives the reader the impression that the electrocardiogram in the figure is entirely normal; I think most of 11s would interpret this tracing as consistent with left ventricular hypertrophy based on the QRS contour in chest leads. Case 84, a complicated cyanotic anomaly is a puzzler; there is abdominal s i h ~ sinversus but the right atrium is in its normal location. Xiy in~pressionhas always been that the right atrium remains loyal to the liver regarding its geography. Finally, the x-ray in case 9 5 is either invertcd or the patient has s i h ~ sinversus totalis. The hook is replete with a number of folksy, quaint thoughts such as: "We d o not know what to call this anomaly (case 24);" "We are not always skillful enough or lucky enough to be able to obtain angiocardiograms that are of diagnostic quality, and this fact is illustrated below (case 41);" "We would prefer to have no phonocardiograms than these (case 43);" and "There are many people in the world with long, thin extremities and visual defects, and more specific information is needed to establish a diagnosis (case 105 ) ." Despite these minor issues, this book achieves its goal of demonstrating the application of clinical information to the diagnosis of congenital heart disease and is recommended to all of those with an interest in this area. Edwin L. Rothfekl, X1.D. Netoark, Neu: Jersey