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Cholelithiasis: causes and treatment

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    Cholelithiasis: causes and treatment. Nakayama F. (Pp 298; illustrated; $69.00.) Tokyo: Igaku-Shoin, 1997. ISBN 4-260-14334-4.

    Now and again a doctor-scientist becomes so infatuated by gallstones that he gives his or her life to them (a recent example of this rare breed is a Romanian lady). The only cure is to write a monograph. Why do people get this illness? There are many reasons, but money is not one of them. Gallstones make surgeons rich, not scientists. The trouble is gallstones don’t kill people, except the occasional academic whose grant application has been turned down for the fifth time. If they did kill people—or if they disabled people or disfigured them—there would be Chairs of Cholelithology and aJournal of Cholelithology.

    The disease is certainly common enough. In some places it afflicts up to 70% of women if they live long enough. But, despite this, gallstones are a fringe discipline attracting only those of a scholarly bent and with a sense of history. Gallstones have a history all right. Being durable things, they have been found in Egyptian mummies. And they have plagued historical figures in all times. Walter Scott, the novelist, was so racked by pain from his gall bladder he turned his face to the wall and begged to die. In the middle of our own century, four American presidents suffered the same torture and begged to be cut open (Hoover, Truman, Eisenhower, Johnson). You won’t learn these facts from this book. It is a book with a laboratory flavour and a distinctly oriental one. For example, it contains all you could ever want to know about hepatolithiasis (ever seen a case?).

    In the days when people put up with pain and laughed at stinging nettles, gallstones presented in dramatic ways. Like fistulating right through the abdominal wall. A 19th century GP recalled a breathless child arriving at his door saying “Doctor, come quickly! Grandma’s gallstones are rolling down the stairs”. In my own professional lifetime patients sometimes failed to trouble the doctor until a large stone had filled the gall bladder with pus, then eroded through its wall and the wall of the adjacent duodenum and then wafted down to the terminal ileum where, finally, it impacted with a sickening jolt—a life-threatening situation ineptly termed gallstone ileus. Again, you won’t find this in Nakayama’s book—it is not a book for the clinician. It is true there is a chapter on treatment, but it is largely about minority sports like lithotripsy and bile acid therapy.

    Part of the trouble is bile. To understand gallstones you have to understand bile, and bile is fiendishly complicated. Bile is like liquorice; you either love it or you hate it, and most people hate it. But some, like Nakayama, are fascinated to distraction by its kaleidoscopic contents and their subtle interactions. Once we all thought gallstones could be explained by plotting of three of bile’s constituents on a triangle and seeing where the value lay—above or below a magic line which represented the cholesterol-holding capacity of bile. Now we know there is a host of factors determining whether bile flows serenely on its way or whether it starts insidiously dropping crystals of various shapes. We know too that lots of factors determine whether the gall bladder manages to flush out these crystals or is left with irritating, gritty lumps lying in wait till the evil day when they impact in the neck of the gall bladder or the common bile duct—and cause mayhem. If this is the sort of thing you want to know about, then this book is for you. It is very strong on the biochemistry behind gallstones, quite strong on the biophysics and the physiology. It also parades many facts on the epidemiology of gallstones (but, curiously, ignores the best British work). All in all, it is a great repository of arcane knowledge as it was in 1993/94, when the references stop.

    Nakayama earns 9 out of 10 for scholarship but, I fear, barely 1 out of 10 for presentation. In this age of marketing one wonders about the input of his publishers. To attract new converts bile and gallstones need the tricks of the salesman. No way does this book provide them. Rather, it bludgeons the brain. Dense blocks of text up to two pages long cry out for paragraphs, subheadings, pithy summaries and illustrations. And look elsewhere for wit and humour.Letters, Book reviews, Notices

    So who is this book for? Not for beginners, unless they have the stamina of a marathon-runner. Nor for researchers wanting the latest advances and a glimpse into the future. Only I suspect for scholars wanting comprehensive coverage and a massive bibliography. They, however, will be in clover.

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