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Manometric diagnosis of gastrointestinal motility disorders
BOOK REVIEWS
Tune 1987
of histologie types of neoplasms are discussed including benign and malignant epithelial tumors as wel1 as a miscellaneous array of mesenchymal and osseous lesions, both benign and malignant. 1~ terms of management, the authors cover surgical aspects as wel1 as radiation therapy and chemotherapy, with a separate chapter devoted to each of the latter topics. The chapters on surgical procedure are again wel1 illustrated both with line drawings and intraoperative photographs, allowing the reader to quite readily follc>w the descriptive text. The book does have a smal1 number of minor flaws. The discussion of treatment for cloacogenic carcinoma does not mention or discuss radiation therapy as adjuvant therapy except for recurrent tumors, although as the authors mention in other sections the therapeutic literature is very confusing dtie to the terminology problems in this area. The discussions of juvenile polyps and Peutz-Jegher polyps make no mention of the malignant potential of polyposis in these conditions in spite of a smal1 but convincing literature that there is some association. The authors dismiss reports discussing cancer associated with Peutz-Jegher polyps as being erroneous. A discussion qf dysplasia occurring in inflammatory bowel disease is wel1 done but no reference is made to the pivotal article by the Inflammatory Bowel Disease Morphology Group in 1983 which was a multiinstitutional investigation taking place over several years addressing the topics that the authors discuss particularly regarding surveillance. A more significant flaw in my opinion is the lack of balance in the discussion of therapy of malignant polyps. The discussion in this area is very brief and does not adequately reflect the available literature. The suggestion that radiation therapy be added following complete resection of malignant polyp is difficult to understand in view of recent literature. In spite of these objections, this is a generally excellent textbook that has the advantage of focusing in considerable detail upon an important group of neoplasms occurring in a complicated anatomie region. 1 highly recommend the book for al1 practitioners engaged in the diagnosis and care of patients with tumors occurring in the anorectal, presacral, and sacral regions. KENNETH BARWICK, M.D.
New Haven, Connecticut
A History and Theory of Informed Consent. By Ruth R. Faden, Torn L. Beauchamp, and N. M. P. King. 392 pages, $29.95. Oxford University Press, New York, New York, 1986. ISBN 0-19-503686-7. Gastroenterologists under age 40 yr, who believe that informed consent has always guided our activities, should look over this book that gives the most readable account of how consent and then informed consent came to take such a prominent plabe in American medical activities. They lay out the arguments between Pernick who judges that meani&ul consent for clinical practice already existed in the 19th century in the United States and Katz who has a hard time believing even today that it is anything more than a mirage or “fairy tale.” They come down on Pernick’s side, which should make US al1 fee1 better about
2047
ourselves if we are old, and about our predecessors if we are not. At any rate, the middle section of the book which runs 179 pages, entitled “A History of Informed Consent,” is the best account that 1 have seen of the events of the past few decades. The first section entitled “Foundation” covers mora1 and legal theory in 49 pages, but it is difficult for me to tel1 that anything new has been added. Qn the other hand, the physician not acquainted with legal theory wil1 find at least the second chapter a useful summary of why lawyers think the way they do. The third section, “A Theory of Informed Consent,” which tries to be the fairest, is the section least likely to be read by gastrointestinal clinicians or researchers simply because it restates many of the genera1 concepts with which we are berraged by philosophers. The unique aspect of this section is that these authors, none of whom are physicians, recognize how ambiguous and uncertain is the application of philosophical concepts to decisions in daily medical practice. They stress àuthenticity which looks for a common thread in a decision, actions which are consistent with a person’s previously accepted values, and behavior. 1 think this used to be called character, something that is generally ignored both in considering the patient and, worse, in considering the physician. Although they review philosophical and theoretical backgrounds, they recognize the problem of “information overload.” The alcoholic cirrhotic told at 2 A.M that he must have an endoscopy to tel1 whether he needs sclerosis of esophageal varices is not always in a position to give “informed consent,” and must rely on the character of the professionals attending him. 1 think they understand that many of the aims that my colleague Jay Katz and others write about are just that, ideals which cannot be fully realized in medical practice, and which may not even represent “ideals.” Much touted equality may be equality of personhood, but it is certainly not equality of knowledge or even autonomy when sick person and doctor confer. Al1 in all, although 1 found this third section as hard going as 1 do many philosophical works that don’t come back to the patient, 1 thought it was worth reading. The authors point out how little last minute surgical “informed consent” means. “Who would want, on the eve of surgery after having disrupted one’s life, gathered one’s courage, and entered the hospital, to change one’s mind?” You can see from the foregoing that 1 enjoyed this book. It is not as easy reading as some, but al1 gastroenterologists engaged in clinical research or in obtaining consent from patients for clinical maneuvers, particularly those invasive maneuvers of which we are al1 so fond, should read this book. HOWARD SPIRO, M.D. New
Haven, Connecticut
Manometric Diagnosis of Gastrointestinal Motility Disorders. By Juan-Ramon Malagelada, Michael Camillieri, and Vincenzo Stanghellini. 142 pp., $35.00. Thieme-Stratton, New York, New York, 1986. IBSN 245-2. The Mayo Clinic group bas been in the forefront
in the
2048 BOOK REVIEWS
study of gastric and smal1 intestinal motility and this volume, based on over 800 manometric studies carried on there over the last 5 yr in patients and in healthy volunteers, admirably fulfills its purpose “to produce a diagnostic manual to help both the uninitiated and the experienced manometrist in performing gastrointestinal manometry and interpreting the results.” The normal and abnormal manometric patterns presented, together with their careful interpretations and clinical correlations, constitute the matrix of the book. After a consideration of the physiologic basis of gastric and smal1 intestinal motility disorders and a careful review of the literature, the authors take up in a nuts and bolts chapter how to go about performing gastrointestinal manometry. There follow chapters on normal manometric patterns and on a systematic approach to analyzing manometric tracings. The remainder of the book is devoted to the presentation and interpretation of individual manometric patterns derived from patients with a broad spectrum of gastric or smal1 intestinal motility disorders, or both. This wel1 thought out and designed volume represents the state of the art in an area that almost certainly wil1 become clinically much more important in the next few years. Its price is reasonable. Its appeal wil1 be primarily to those with an interest in basic gastrointestinal tract motility who are already experienced in esophageal manometry.
GASTROENTEROLOGYVol. 92, No. 6
quencies of enteric pathogens in humans and animals with diarrheal disease. Rotavirus is repeatedly documented as the most common pathogen in infantile diarrhea. The infectieus problems of newborn calves and piglets are stressed because of their importante to the economy of developing countries and their utility in studying mechanisms of diarrhea, improving diagnostic tools for identifying pathogens, and initiating preventive (vaccine) trials. In addition to the epidemiologic and microbiologie aspects described above, there are extensive reviews concerning mechanisms of diarrhea, molecular approaches to diagnosis, gut immunology, and prevention of diarrheal disease. The potential use of the attenuated strain of Salmonella typhi (Ty2la) that invades the mucosa to stimulate local antibody production without causing clinical disease is of particular interest, as plasmids of Shigella sonnei and Flexneri may be transferred to it resulting in host protection against these organisms. The information is consistently presented in depth and wil1 be of interest to physicians seeklng an unusually broad discussion of infectieus diarrhea. Tables are used liberally to summarize the data provided. This up-to-date review of the worldwide problem of diarrheal disease, newer diagnostic methods, and vaccine development was extremely interesting to this reviewer. This book should be a part of medical school libraries for students, housestaff, and faculty.
PAUL MANDELSTAM
BARBARA S. KIRSCHNER, M.D.
Lexington, Kentucky
Chicago, Illinois
Infectieus Diarrhoea in the Young: Strategies for Control in Humans and Animals. Edited by S. Tzipori. 514 pp., $123.00. Elsevier Science Publishers B.V., Amsterdam, The Netherlands, 1985. IBSN 0-444-80-720-9.
Computer Tomography of the Gastrointestinal Tract. Edited by Alec J. Megibow and Emil J. Balthazar. 464 pp., 672 figures, $67.50. The C.V. Mosby Company, St. Louis, Missouri, 1986.ISBN 0-8016-3376-1.
An International Seminar on Diarrhoeal Disease in South East Asia and the Western Pacific Region was held in Geelong, Australia in February 1985.This publication is a compilation of papers presented at that meeting. The importante of infant diarrhea is established by citing that approximately one billion episodes of diarrhea occur annually in children <5 yr of age, which contribute to almost 5 million deaths, most secondary to dehydration. The recent effectiveness of ORT (oral rehydration therapy) in decreasing hospitalization and death by 50% is documented. The range of topics covered is extensive and discussed in depth, The important relationship between diarrhea and malnutrition is emphasized in several reports. For example, undernutrition was observed in 30%--50~h of children wjth diarrhea in Indonesia. In New Guinea, the lower prevalente of malnutrition in breast-fed infants with diarrhea (26%) compared with 69% in artificially fed infants resulted in the Baby Food Supplies Act (1977) which permits commercial formulas by prescription only from registsred health workers. In addition to supporting breast feedipg, the necessity of programs that improve water sanit&on and personal hygiene are emphasized. Participants included both medical and veterinary scientists. Much data is provided regarding the relative fre-
When this book arrived on my desk, 1 selected it to review myself because 1 have been convinced that barium radiology was about ready to be outmoded by computer tomography and that we gastroenterologists had to prepare ourselves to grasp what goes on in a film made by CT as readily as we do films made in more familiar ways. Maintaining that “pattern recognition” is what counts for a clinician, 1 try to get those who work with me to learn to walk rapidly by a viewbox and find the pathology at a glance. It obviously takes hard work to whip the neurobiologic network into shape. In any event, 1 thought that this new book would be my chance to get myself to be able to read gut CT on my own. Alas, it did not prepare me for that adventure, which mdy be my fault, although this review wil1 suggest that it is the authors’. A major reason for my failure is a regrettable lack of diagrammatic cross-sections of the gut and what 1 can only take to be a contemptuous neglect to put arrows in many of the illustrations, notably those of the stomach and duodenum. A book like this, replete with pictures, which purports to be for “the student in radiology. . . . the clinic genera1 practiradjologist, and . . . the gastroenterologist, tioner and genera1 surgeon” should have aimed at that audience. We stil1 need diagrams and arrows, not just pictures. If we grasped the pictures, we would be bored by
Tune 1987
of histologie types of neoplasms are discussed including benign and malignant epithelial tumors as wel1 as a miscellaneous array of mesenchymal and osseous lesions, both benign and malignant. 1~ terms of management, the authors cover surgical aspects as wel1 as radiation therapy and chemotherapy, with a separate chapter devoted to each of the latter topics. The chapters on surgical procedure are again wel1 illustrated both with line drawings and intraoperative photographs, allowing the reader to quite readily follc>w the descriptive text. The book does have a smal1 number of minor flaws. The discussion of treatment for cloacogenic carcinoma does not mention or discuss radiation therapy as adjuvant therapy except for recurrent tumors, although as the authors mention in other sections the therapeutic literature is very confusing dtie to the terminology problems in this area. The discussions of juvenile polyps and Peutz-Jegher polyps make no mention of the malignant potential of polyposis in these conditions in spite of a smal1 but convincing literature that there is some association. The authors dismiss reports discussing cancer associated with Peutz-Jegher polyps as being erroneous. A discussion qf dysplasia occurring in inflammatory bowel disease is wel1 done but no reference is made to the pivotal article by the Inflammatory Bowel Disease Morphology Group in 1983 which was a multiinstitutional investigation taking place over several years addressing the topics that the authors discuss particularly regarding surveillance. A more significant flaw in my opinion is the lack of balance in the discussion of therapy of malignant polyps. The discussion in this area is very brief and does not adequately reflect the available literature. The suggestion that radiation therapy be added following complete resection of malignant polyp is difficult to understand in view of recent literature. In spite of these objections, this is a generally excellent textbook that has the advantage of focusing in considerable detail upon an important group of neoplasms occurring in a complicated anatomie region. 1 highly recommend the book for al1 practitioners engaged in the diagnosis and care of patients with tumors occurring in the anorectal, presacral, and sacral regions. KENNETH BARWICK, M.D.
New Haven, Connecticut
A History and Theory of Informed Consent. By Ruth R. Faden, Torn L. Beauchamp, and N. M. P. King. 392 pages, $29.95. Oxford University Press, New York, New York, 1986. ISBN 0-19-503686-7. Gastroenterologists under age 40 yr, who believe that informed consent has always guided our activities, should look over this book that gives the most readable account of how consent and then informed consent came to take such a prominent plabe in American medical activities. They lay out the arguments between Pernick who judges that meani&ul consent for clinical practice already existed in the 19th century in the United States and Katz who has a hard time believing even today that it is anything more than a mirage or “fairy tale.” They come down on Pernick’s side, which should make US al1 fee1 better about
2047
ourselves if we are old, and about our predecessors if we are not. At any rate, the middle section of the book which runs 179 pages, entitled “A History of Informed Consent,” is the best account that 1 have seen of the events of the past few decades. The first section entitled “Foundation” covers mora1 and legal theory in 49 pages, but it is difficult for me to tel1 that anything new has been added. Qn the other hand, the physician not acquainted with legal theory wil1 find at least the second chapter a useful summary of why lawyers think the way they do. The third section, “A Theory of Informed Consent,” which tries to be the fairest, is the section least likely to be read by gastrointestinal clinicians or researchers simply because it restates many of the genera1 concepts with which we are berraged by philosophers. The unique aspect of this section is that these authors, none of whom are physicians, recognize how ambiguous and uncertain is the application of philosophical concepts to decisions in daily medical practice. They stress àuthenticity which looks for a common thread in a decision, actions which are consistent with a person’s previously accepted values, and behavior. 1 think this used to be called character, something that is generally ignored both in considering the patient and, worse, in considering the physician. Although they review philosophical and theoretical backgrounds, they recognize the problem of “information overload.” The alcoholic cirrhotic told at 2 A.M that he must have an endoscopy to tel1 whether he needs sclerosis of esophageal varices is not always in a position to give “informed consent,” and must rely on the character of the professionals attending him. 1 think they understand that many of the aims that my colleague Jay Katz and others write about are just that, ideals which cannot be fully realized in medical practice, and which may not even represent “ideals.” Much touted equality may be equality of personhood, but it is certainly not equality of knowledge or even autonomy when sick person and doctor confer. Al1 in all, although 1 found this third section as hard going as 1 do many philosophical works that don’t come back to the patient, 1 thought it was worth reading. The authors point out how little last minute surgical “informed consent” means. “Who would want, on the eve of surgery after having disrupted one’s life, gathered one’s courage, and entered the hospital, to change one’s mind?” You can see from the foregoing that 1 enjoyed this book. It is not as easy reading as some, but al1 gastroenterologists engaged in clinical research or in obtaining consent from patients for clinical maneuvers, particularly those invasive maneuvers of which we are al1 so fond, should read this book. HOWARD SPIRO, M.D. New
Haven, Connecticut
Manometric Diagnosis of Gastrointestinal Motility Disorders. By Juan-Ramon Malagelada, Michael Camillieri, and Vincenzo Stanghellini. 142 pp., $35.00. Thieme-Stratton, New York, New York, 1986. IBSN 245-2. The Mayo Clinic group bas been in the forefront
in the
2048 BOOK REVIEWS
study of gastric and smal1 intestinal motility and this volume, based on over 800 manometric studies carried on there over the last 5 yr in patients and in healthy volunteers, admirably fulfills its purpose “to produce a diagnostic manual to help both the uninitiated and the experienced manometrist in performing gastrointestinal manometry and interpreting the results.” The normal and abnormal manometric patterns presented, together with their careful interpretations and clinical correlations, constitute the matrix of the book. After a consideration of the physiologic basis of gastric and smal1 intestinal motility disorders and a careful review of the literature, the authors take up in a nuts and bolts chapter how to go about performing gastrointestinal manometry. There follow chapters on normal manometric patterns and on a systematic approach to analyzing manometric tracings. The remainder of the book is devoted to the presentation and interpretation of individual manometric patterns derived from patients with a broad spectrum of gastric or smal1 intestinal motility disorders, or both. This wel1 thought out and designed volume represents the state of the art in an area that almost certainly wil1 become clinically much more important in the next few years. Its price is reasonable. Its appeal wil1 be primarily to those with an interest in basic gastrointestinal tract motility who are already experienced in esophageal manometry.
GASTROENTEROLOGYVol. 92, No. 6
quencies of enteric pathogens in humans and animals with diarrheal disease. Rotavirus is repeatedly documented as the most common pathogen in infantile diarrhea. The infectieus problems of newborn calves and piglets are stressed because of their importante to the economy of developing countries and their utility in studying mechanisms of diarrhea, improving diagnostic tools for identifying pathogens, and initiating preventive (vaccine) trials. In addition to the epidemiologic and microbiologie aspects described above, there are extensive reviews concerning mechanisms of diarrhea, molecular approaches to diagnosis, gut immunology, and prevention of diarrheal disease. The potential use of the attenuated strain of Salmonella typhi (Ty2la) that invades the mucosa to stimulate local antibody production without causing clinical disease is of particular interest, as plasmids of Shigella sonnei and Flexneri may be transferred to it resulting in host protection against these organisms. The information is consistently presented in depth and wil1 be of interest to physicians seeklng an unusually broad discussion of infectieus diarrhea. Tables are used liberally to summarize the data provided. This up-to-date review of the worldwide problem of diarrheal disease, newer diagnostic methods, and vaccine development was extremely interesting to this reviewer. This book should be a part of medical school libraries for students, housestaff, and faculty.
PAUL MANDELSTAM
BARBARA S. KIRSCHNER, M.D.
Lexington, Kentucky
Chicago, Illinois
Infectieus Diarrhoea in the Young: Strategies for Control in Humans and Animals. Edited by S. Tzipori. 514 pp., $123.00. Elsevier Science Publishers B.V., Amsterdam, The Netherlands, 1985. IBSN 0-444-80-720-9.
Computer Tomography of the Gastrointestinal Tract. Edited by Alec J. Megibow and Emil J. Balthazar. 464 pp., 672 figures, $67.50. The C.V. Mosby Company, St. Louis, Missouri, 1986.ISBN 0-8016-3376-1.
An International Seminar on Diarrhoeal Disease in South East Asia and the Western Pacific Region was held in Geelong, Australia in February 1985.This publication is a compilation of papers presented at that meeting. The importante of infant diarrhea is established by citing that approximately one billion episodes of diarrhea occur annually in children <5 yr of age, which contribute to almost 5 million deaths, most secondary to dehydration. The recent effectiveness of ORT (oral rehydration therapy) in decreasing hospitalization and death by 50% is documented. The range of topics covered is extensive and discussed in depth, The important relationship between diarrhea and malnutrition is emphasized in several reports. For example, undernutrition was observed in 30%--50~h of children wjth diarrhea in Indonesia. In New Guinea, the lower prevalente of malnutrition in breast-fed infants with diarrhea (26%) compared with 69% in artificially fed infants resulted in the Baby Food Supplies Act (1977) which permits commercial formulas by prescription only from registsred health workers. In addition to supporting breast feedipg, the necessity of programs that improve water sanit&on and personal hygiene are emphasized. Participants included both medical and veterinary scientists. Much data is provided regarding the relative fre-
When this book arrived on my desk, 1 selected it to review myself because 1 have been convinced that barium radiology was about ready to be outmoded by computer tomography and that we gastroenterologists had to prepare ourselves to grasp what goes on in a film made by CT as readily as we do films made in more familiar ways. Maintaining that “pattern recognition” is what counts for a clinician, 1 try to get those who work with me to learn to walk rapidly by a viewbox and find the pathology at a glance. It obviously takes hard work to whip the neurobiologic network into shape. In any event, 1 thought that this new book would be my chance to get myself to be able to read gut CT on my own. Alas, it did not prepare me for that adventure, which mdy be my fault, although this review wil1 suggest that it is the authors’. A major reason for my failure is a regrettable lack of diagrammatic cross-sections of the gut and what 1 can only take to be a contemptuous neglect to put arrows in many of the illustrations, notably those of the stomach and duodenum. A book like this, replete with pictures, which purports to be for “the student in radiology. . . . the clinic genera1 practiradjologist, and . . . the gastroenterologist, tioner and genera1 surgeon” should have aimed at that audience. We stil1 need diagrams and arrows, not just pictures. If we grasped the pictures, we would be bored by