CHEST ROENTGENOLOGY

THE BOOKSHELF HEMOPHILUS INFLUENZAE. Edited by SARAH H. SELL and DAVID T. KARzoN. Vanderbilt University Press, Nashville, Tennessee, 1973,325 pp, $15.00 This book represents the proceedings of a Conference on Antigen-Antibody Systems, Epidemiology and Immunoprophylaxis held at Vanderbilt University Medical School, April 24-25, 1972 under sponsorship of that University and the Department of Pediatrics of its medical school. It consists of 25 chapters separated into ten sections, each consisting of one to four contributed papers on related topics followed by an open discussion, edited by each discusser, in which the participants seemed to be "enthusiastic and cooperative". There are 65 tables and 68 text figures, the latter consisting mostly of line drawings, electron micrographs and photographs of immunodiffusion patterns. A list of the participants, adequately identified and a subject index are also provided. Each chapter has a varying number of references, 337 in all; but, as is inevitable from the relatively narrow scope of the book, the same titles often appear in several chapters (e.g. the paper by Fothergill and Wright, published in 1933, is listed after no less than nine chapters), a luxury that could be readily avoided by a single list of references, particularly since each paper is referred to in the text by author and year and they are already arranged alphabetically. However, the inclusion of the full title and inclusive pages are of great help to most interested readers who often go back to the sources for more details and verification. The Conference was prompted by two major recent developments, one is the apparent increase in occurrence of serious infections due to H. influem:ae in the past few years, and the other is the development of a polysaccharide (polyribophosphate) vaccine specifically for type b, the most frequent of the capsular types and the one responsible for nearly all cases of meningitis due to H. in/luenzae in infants and children from six months to five years of age. The contributions were primarily from three groups of workers, namely those at Vanderbilt (five papers from several departments and the Veterans Administration Hospital), the Children's Hospital of Boston (six papers in collaboration with colleagues at nearby Beth Israel Hospital and various departments of the Harvard Medical School, and also a group from the U. of Alabama), and nine papers from the National Institute of Child Health and Development in collaboration with other units of NIH and other workers at Rockefeller University and Charlotte, North Carolina. Two papers from U. of Pittsburgh, two epidemiologic contributions from the Center for Disease Control and one from the U. of Southern California are also included. The major clinical concern regarded infections due to H. influenzoe type b in the pediatric age group, particularly in meningitis, but also in otitis, epiglottitis, other respiratory tract infections and bacteremias, and in the epidemiology of these infections. By far the greatest number of papers and new materials was related to the biochemistry and biology of H. in/luenzoe, the finer morphologic structure, the antigenic components, specific serologic reactions in apparently normal children and those resulting from various infections. Much attention was given to the cross-reacting antigens not only among typable and nontypable strains but also with other species, particularly Escherichia coli. The possible relation between exposure to such antigens and "natural immunity" to

H. influenzoe, including type b, were dwelt on at some length. Of some interest were the conflicting results of studies on racial differences in susceptibility and immunity. Great differences were noted betweeen the races in a southern community but not in a large urban ghetto area in the northeast; the differences were interpreted as being attributable to poverty rather than to race. Readers of this journal will not find any great concentration of new material devoted to the major area of their clinical interests. For a comprehensive review of the relation of H. influenzoe to pneumonia, acute and chronic respiratory disease (chronic bronchitis and acute bronchopulmonary exacerbation ), they would still wish to refer to the monograph by Turk and May published in England in 1967. This book entitled "Haemophilus influenzoe; its clinical significance", and other papers by these authors are referred to in ten of the chapters. The book contains, in addition to much more clinical and epidemiologic material, a good deal of the earlier work on the antigenic structure of H. influenzoe with greater emphasis, however, on nontypable (noncapsulated) strains isolated from patients with respiratory tract infections. Turk and May also considered the possibility of developing an immunoprophylactic agent to prevent such infections and exacerbations. Professor O'Grady in his review of Turk and May's book (he titled his review "Ubiquitous Haemophilus"), called attention to the fact that in spite of the title of that book there was enough of the laboratory aspects to stimulate further exploration by those who are interested. It contains nearly 400 references but the review bemoaned the lack of full titles of the papers. Interestingly enough, it was the work done during the 19308 in the Department of Bacteriology at Harvard Medical School and at the Children's Hospital in Boston which contained the germinating seed in the development of the specific vaccine for the prevention of meningitis due to H. influenzoe type b; the contributions to the Conference in Nashville represent the continuing growth and early fruits which are approaching the ripening stage.

MaxweU Finland, M.D.

Boston, Mauachusetts

CHEST ROENTGENOLOGY (1st ed.) By BENJAMIN FELSON, W.B. Saunders Company, Philadelphia, 1973,574 pp, $17.00. The book is a veritable treasury of diagnostic detail for the X-ray diagnosis of thoracic disease by a radiologist who has either taught, trained or lectured most of America's and many continental X-ray specialists. Hundreds of non-radiologist physicians have also learned to pursue his orderly scheme for analysis of a patient's chest film. Felson has previously published a very successful book, Fundamentals oi Chest Roentgenology, and 30 of his journal papers are listed in his bibliography. The structure of this well-printed book is simple; first, is the X-ray examination adequate, and can more X-raymanship add to diagnosis? Then the thorax is treated by its anatomical units; the lobes and segments, the hila and pulmonary vessels, lymph nodes, the airways, the interstitium, and pleura and the extrapleural space (fine distinctive area), the mediastinum, diaphragm and thoracic wall. A concise bronchographic demonstration of the lung segments is excellent. The book ends with what are actually two appendices; 30 pages on calcifications and 9 pages of Felson's personal analysis of 30,000 normal chest films.

The Bookshelf, continued The illustrations are often coned down to the area being studied, like the "spot films" in GI tract studies; this makes detail very good. The true value of this book is that it is relatively short for a book completely covering the thorax, and Felson's plan of attack on both normal and abnormal changes is aimed at diagnosis; frequency tables for specific changes aid one along a contracting path towards a rational differential and often specific diagnosis. The book is written for the serious medical student, residents dealing with the thorax, and specialists in pulmonary physiology, surgery, medicine and roentgenology. Would that other writers in the x-ray field could achieve the relative brevity of this book, i.e. in orthopedics, angiography, etc. and give the reader a similar perceptive, normal-sized and easy-tobold book. L. E. Hawes, M.D. Boston, Mas86Chusetts BASIC AND CLINICAL PHARMACOLOGY OF DIGITALIS. Proceedings of a Symposium, edited by BERNARD H. MARKS and ARNOLD M. WEISSLER. Charles C Thomas, Springfield, Ill., 1972, 328 pp, $21.00

This book consists of papers presented at a symposium held at Ohio State University, September 29 and 30, 1970. Papers presented at a symposium often do not adapt well to publication, but this book is an outstanding exception. For the II\ost part the papers are very readable; most internists and cardiologists will find that the book enhances the scope and depth of their understanding. In viewing the two centuries during which digitalis has been used by Western medicine one can discern three widely overlapping eras. The first or purely clinical era was by far the longest and during this period careful observation led to assumptions which described rather accurately the effect of digitalis on the circulation. The next era, the study of cardiac dynamics, put the clinical assumptions into physical terms and provided an approach to quantitation. The current era of cellular and molecular biology has transfonned our clinical and hemodynamic assumptions into tools which add greatly to the usefulness of this time-honored drug. Lipid soluble glycosides are absorbed from the intestines more rapidly than polar glycosides, and all appear to be absorbed primarily by way of the portal vein. The nonpolar lipid soluble and the polar g1ycosides appear to be absorbed by a nonsaturable transport process with no evidence for active transport. Digitoxin and digoxin have an important enterohepatic circulation in the rat. Cholestyramine binds considerable amounts of digitoxin and digoxin in vitro; in experimental animals it accelerates fecal excretion of these g1ycosides and their metaholites, and in man it decreases the metabolic half-life and enhances the dissipation of digitoxin cardiac effects as measured by systolic intervals. The effect of cholestyramine is probably mediated by an interruption of the enterohepatic circulation of the glycoside. Digitoxin, being nonpolar, is almost completely absorbed, and owing to its extensive enterohepatic circulation, has a prolonged half-life. The fact that it is 90 percent protein bound in the serum contributes to this phannacokinetic property. It is excreted largely in the urine. On the other hand, digoxin is less well absorbed and has virtually no enterohepatic circulation; therefore, it has a very short half-life, and is excreted largely unmetabolized. The increase or decrease

of renal excretion of digoxin accounts for many situations in which, because of these changes in the rate of excretion, patients appear either resistant as in hyperthyroidism, or unusually susceptible as in hypothyroidism. Resistance in hyperkalemia is probably related to a decreased myocardial up-take, and in hypokalemia there is a true increase in sensitivity. Studies of the accumulation and binding of digitalis drugs show that there are specific membranous binding sites in cardiac membranes where accumulation is sensitive to sodium and potassium concentrations and requires metabolic energy. In addition, some glycosides have nonspecific accumulation in membranes and as more information develops about these differences, a more rational basis for the therapeutic choice of drugs may be available. Studies on the role of Na-, K+-ATPase inhibition in digitalis activity suggests that there is a dissociation between the positive inotropic effects of digitalis and NA+, K+ATPase inhibition, as well as between the inotropic and electrophysiologic effects of digitalis. It may be that there is a receptor for positive inotrophy not related to inhibition of cardiac transport ATPase, and another binding site related to the effect of digitalis on rhythm. The latter may be due to inhibition of cardiac transport ATPase. Very interesting data is presented suggesting that part of the inotropic effect of the glycosides is related to events secondary to the primary binding of the cardiac glycoside to membrane sites associated with N+, K+-ATPase activity leading to membrane changes; these in-tum altering calcium binding sites and the releasable calcium pool. Digitalis does not increase the efficiency of the heart muscle, but it augments contraction by increasing the velocity and force of contraction and shortening the duration of systole. The positive inotropic action of digitalis is highly specific for myocardium and is not secondary to the release of catecholamines from sympathetic nerve endings. Action on membrane Na-, K+-ATPases cannot account for the positive inotropic effect of the drugs on heart muscle. Both time dependent and contraction dependent relationships can be defined as part of the positive inotropic effect, but the contraction dependent one seems to predominate. The beneficial effects produced by digitalis glycoside are largely related to the enhanced contractile state in either normal or failing hearts, but this is associated with an increase in energy utilization by the myocardium. An exception may be the failing heart which, as a result of reduction in size, may actually decrease its energy requirements. Because digitalis increases peripheral arterial resistance as well as myocardial contractility, cardiac output does not always increase. Thus, in normal man, increased peripheral resistance may prevent a rise in cardiac output even in the face of increased contractility. Systolic time intervals determined from simultaneous recording of ECG, phonocardiogram, and carotid arterial pulsation are dose dependent and parallel the contractile response determined from the ventricular pressure curve. Thus, the systolic time intervals offer a measure of the cardiac contractile response to digitalis and pennit quantitation of the effect over prolonged study periods. This brief overview of the material presented in the symposium cannot adequately reflect the wide spectrum of important information now available in one place. The book should have a high priority on the reading list of all physicians engaged in treating patients with heart disease. Frank D. Gray, lr., M.D. Philadelphia, Pa.,

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