The Pancreas: Biology, Pathobiology and Disease

Most one author textbooks eventually succumb to multiauthorship. Spiro's first edition was in 1970. His fourth edition is now half written by his colleagues. Their names (Atterbury, Barwick, Gorelick, Gryboski, Kapadia, Reuben, Sundaram, Traube, and Zeman) appear opposite the title page. Spiro retains final responsibility for the contents and has even changed their words or recommendations. The book is still aimed at the practitioner who is reminded that 80% of all patients' complaints are psychosocial in origin. A six page introduction ('let patients tell in their own words what is going on') is followed by 57 chapters from oesophagus to liver as well as 112 beautiful colour photographs, four to a page by Pier Luigi Marignarni: would their omission reduce the cost and increase the sales? The other changes are an expansion of physiology, updating of references, and use of non-sexist plurals. Of course I have not read the whole of this book, any more than I have my dozen other gastroenterology textbooks, but I did test what Spiro has to say on topics discussed recently in our meetings. The causes and treatment of pneumatosis cystoides intestinalis and indications for colonic polypectomy and subsequent follow up were clear. The description of haemangioma of the liver was also clear but goes on to say 'obviously liver biopsy is ordinarily contra-indicated although several brave physicians have reported using a Chiba needle for such purposes'. This is despite the Brown University group having shown the safety of image guided liver biopsy in 38 such patients. I also looked at two parts (peptic ulcer and inflammatory bowel disease), which Spiro has not assigned to colleagues. His chapter on duodenal ulcer exemplifies the virtues and faults of the book. Yes, this wise clinician and profound humanist emphasises that patients with duodenal ulcers should be treated by physicians as human beings. Yes, he hints at the current scientific model that both acid and Helicobacter pylori are needed for duodenal ulceration. Then he abandons his therapeutic logic, devotes almost all of 20 columns of medical treatment to combating acid, and only one column to H pylon eradication, for which the only remedy recommended, grudgingly, is triple therapy to which he gives four lines. No doubt, only a few American gastroenterologists currently treat, and prevent recurrence of, duodenal ulcers in their patients by eradication therapy. Should a textbook recommend the empirical practices of the past or the rational achievements of the present? Similarly, for ulcerative colitis. Yes, Spiro emphasises 'the relationship between physician and patient plays a powerful role in the recovery of some patients', but then undermines this message by dissembling: 'physicians r longer like to regard themselves as therapeutik agents'. I do so regard myself and I suspect so does Dr Spiro. Yet when the reader looks for clear therapeutic advice he is told to stop sulpliasalazine maintenance treatment in asympto.rnatic patients even though 'the drug will probably have to be reinstituted during the next six months because of relapse in about 50 to 70 per cent of patients', and that 'many physicians advise some patients to keep on talking sulphasalazine prophylactically for many years'. Surely, clinicians deserve a clearer message of maintenance therapy for colitis indefinitely? And when he does give clear diktats I am sometimes unconvinced. Thus, Spiro tells us that 'colectomy with ileoanal anastomosis is preferable to immunosuppresant drugs', and he dismisses radionuclide scans in seven lines as 'misleading'. This one man textbook was a triumphal portrayal of the theories and practices of a distinguished clinical gastroenterologist. I am sure he was right in his fourth edition to ask colleagues to write sections of the book, which he then edited to his satisfaction. Perhaps in the next, fifth, edition Spiro will repay the compliment and permit his colleagues to edit his sections to their satisfaction. J H BARON