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CLUES TO DIAGNOSIS IN CONGENITAL HEART DISEASE
The Bookshelf, continued
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
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