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Response from the author Idiopathic faecal incontinence - a combination of disturbances of both sphincter motor response and anorectal sensation Dear Sir, The objection of Dr. Kamm that the combination of a normally induced distension reflex and impaired rectal sensation is not only seen in patients with idiopathic faecal incontinence but also in other conditions such as severe constipation does not contradict the conclusion that impaired rectal sensation is the cause of incontinence in these patients. As has been shown by our study, these patients have both impaired anorectal sensation and reduced squeeze and stress pressures compared to the matched controls. Our conclusion was that it is not only the high sensory threshold, as Dr. Kamm pointed out, but in fact a combination of these sensory and motor disturbances that contributes to faecal incontinence. A high sensory threshold prevents early sensation of rectal movements. The expulsion of the faeces cannot be controlled by squeezing because of

the inadequate motor response of the voluntary sphincter of these patients. Thus a combined sensory and motor defect contributes to the soiling of patients with idiopathic faecal incontinence. If it is only the rectal sensation that is impaired and the voluntary sphincter remains normal as in constipated patients, soiling does not result from high sensory threshold but impaction does. The anorectal distension reflex, which independent from sensory impairment is conducted via the intramural intestinal pathway, was not affected in our patients with idiopathic faecal incontinence nor in the controls as is the case in patients with constipation. Yours faithfully, Priv. Doz. Dr. E. Hancke Chirurgische Universit/itsklinik Klinikum GroBhadern Marchioninistrasse 15 D-8000 Miinchen 70 FRG

Book review G. Antes, F. Eggemann: Small Bowel Radiology. Introduction and Atlas. Berlin Heidelberg New York, Springer 1988. 207 pp., 276 Figs., (ISBN 3-540-15263-6), Hardcover, D M 190.-. The current trend for the radiological examination of small bowel still favours the small bowel enema with duodenal intubation. This atlas, some 200 pages in length with 276 illustrations, is based on the authors' experience of over 5,000 such intubation studies. Proponents of the small bowel enema, or enteroclysis, fall into two camps using either a dilute barium suspension as advocated by Sellink, or the Herlinger methylcellulose system. The authors have used both but stipulate a preference for the methylcellulose technique. I note that there is no mention of the after effects of methylcellulose, which produces quite severe diarrhoea. The claim that it produces a "double contrast" picture somewhat overstates the increased transradiancy effect. This is very attractive and clear in normal proximal bowel, but is not so evident in distal diseased bowel where greater mixing between the contrast and methylcellulose just produces a more dilute single contrast effect. I think this is evident in many of the illustrations. The techniques, indications and radiological interpretation of the examination are discussed in the first section of

the book. The second part forms the atlas of small bowel diseases with an outline of the clinico-pathological presentation and radiographic features to accompany the radiographs. All the references are at the end, and provide an up-to-date summation of the body of literature on this subject. The illustrations are of good quality and demonstrate adequately the described pathologies. There is an interesting section on motility disorders as judged from alteration in transit and peristaltic pattern. These changes seem rather non-specific for reliable diagnosis except in more gross examples, but this is an interesting observation that the authors are right to emphasize, though more research is needed to clarify just how meaningful these changes are. The value of compression is mentioned though not emphasized perhaps as much as it should be, as without its use lesions will still be missed even with the enteroclysis technique. There is only passing mention of plain films, angiography, CT and US in the diagnosis of small bowel disease. This, as the illustration on the cover suggests, is an atlas of enteroclysis of the small bowel. It is a concise and readable text, and can be recommended for anyone wishing to embark on this type of examination. C. I. Bartram (London)