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Management of abdominal hernias
Rook Reviews Management of Abdominal Hernias.
By H. Brendan Devlin. London Butterworths, 1988. 222 pages. $90.00.
Mr. Devlin, a surgeon from the North of England, has written an excellent book that competes with the Nyhus and Condon classic; however, inclusion of previously published material has led to minor disorganization and repetition. Logistics and economics separate anatomy, epidemiology, and etiology from surgery. Umbilical herniation in children is interposed between groin hernias in the young and diagnosis of a lump in the adult. Nevertheless, the content is authoritative and the writing style, excellent. The strength of this volume is education. Sensible comments reinforced by numerous illustrations and voluminous references to the international literature explain complexities in an elegant manner. Some diagrams fail; for instance, McVay’s procedure is poorly represented. Few of the recommendations differ from practice in the United States. The crural approach to femoral hernia would not be preferred over the inguinal for the “occasional or novice surgeon,” spinal anesthesia is not mentioned, and more reducible direct defects are repaired here in the aged. Bilateral preperitoneal prosthetic repair (Stoppa) is beautifully illustrated, but unilateral replacement is absent. I object to the preference for Marcy over Bassini, which is not supported by the facts [Surgery 1980; 88: 682-51. Like other hernia texts, there is a tendency to arcane comment. Two pages are given over to anatomic variations in the external inguinal ring, yet Fowler’s important contribution [Aust N Z J Surg 1975; 45: 81 to the anatomy of the preperitoneal fatty layer and the deep and superficial internal inguinal rings is missing. Three varieties of “reductio en masse” are detailed, a page-anda-half are expended on Maydl’s hernia (double loop or hernia en W). This esoterica is justified by an incidence in third world countries. Interestingly, only one lumbar triangle is described. I have some other cavils. All scro tal hernias in the adult are not con276
THE AMERICAN
JOURNAL
genital. La Roque did not perform preperitoneal repair but a separate herniorrhaphy. “Lipomatas” of the cord may mask sliding hemiation of extraperitonal fat, which needs excision. If carefully done, this does not lead to hydrocele or testicular damage as did excision of pampiniform veins (Halsted’s skeletonization). Devlin decries preperitoneal exposure of Hesselbach’s triangle saying, “ anatomical delineation of direct inguinal hernias is impossible.” Proper modification of McEvedy’s rectus sheath approach eliminates the problem [Am J Surg 1968;I 16:6531.Outstanding chapters in this book are “Incisional Defects,” “Spigelian Hernia,” and “Peristomal Hernia.” The book is reasonably priced, and anyone who aspires to or actually manages abdominal hernias should own or obtain access to it. Raymond C. Read,
MD
Little Rock, AK
Doctors: The Biography of Medicine.
By Sherwin B. Nuland. New York: Alfred A. KnopA 1988. 519 pages. $24.95.
Dr. Sherwin B. Nuland, an active surgeon at Yale, describes “the evolution of the process by which every doctor of today has come to his or her basic suppositions”; thus, it is the historical development of how physicians think. Nuland is a humanist and has chosen to recreate the history of healing through the lives of some of medicine’s landmark contributors. As Thomas Carlyle wrote, “what we have done is only the mirror by which we can see what we are.” The book begins with what has been termed “medicine’s declaration of independence.” Hippocrates insisted on explaining man without resorting to the supernatural. In the Hippocratic Corpus, disease could always be explained by forces within the powers of a physician to understand. Nuland persuasively lures the reader into “breeze-touched gardens . . . where sacred serpents anointed injured limbs, licking and slithering their silent restorative way from one raw wound to another.” Thus, medicine was delivered from magical for-
OF SURGERY
VOLUME
158
SEPTEMBER
mulas and inspirational theotherapy. As Jonathan Swift wrote, “We see far because we stand on the shoulders of giants.” Nuland points out that Galen was a giant with a giant ego. His claim to have answered all scientific questions may have stunted scientific growth for a millenium. Not until Vesalius re-established scientific observation, Harvey proved the blood’s circulation, and Morgagni developed the science of pathology were Galen’s ingenious declarations discredited. For surgeons, Nuland’s perspective is comfortably revealing. In Lister’s day, the operating theater was frequented by frightful tragedies. But “Lister had fallen in thrall to that particular form of enchantment that comes to embrace every surgeon who is any good at his work.” Nuland continues: “. . . what I refer to here is the sheer enjoyment of being a surgeon, an enjoyment made all the more seductive by an awareness that there is a touch of aberrance in it.” Continuing his surgical enfranchisement, Nuland introduces us to William Stewart Halsted as the captain of the Yale football team but a desultory student, writing “His scholastic achievements would be magnified if they were called ordinary.” After much searching, one of his biographers was forced to conclude that “the Yale Library has no record of his having borrowed any books,” Yet, “if ever a deep rooted plant bloomed late, it was this white spatted, bowlered, cravated, flower of the Ivy League, whose do-not-open-tillmedical-school talents were never so much as suspected until almost too late.” Nuland has chosen people to illustrate the evolution of medical thought. He has personalized these biographies to make them delightfully readable; through them, we relive the logic of scientific development and discovery in medicine. During our own century, it is easy to secondguess Nuland’s cast of characters. His stated purpose, however, of producing a geneology of scientific thought in medicine, is successfully accomplished with both authority and wit. Alden H. Harken, MD Demer, CO 1989
By H. Brendan Devlin. London Butterworths, 1988. 222 pages. $90.00.
Mr. Devlin, a surgeon from the North of England, has written an excellent book that competes with the Nyhus and Condon classic; however, inclusion of previously published material has led to minor disorganization and repetition. Logistics and economics separate anatomy, epidemiology, and etiology from surgery. Umbilical herniation in children is interposed between groin hernias in the young and diagnosis of a lump in the adult. Nevertheless, the content is authoritative and the writing style, excellent. The strength of this volume is education. Sensible comments reinforced by numerous illustrations and voluminous references to the international literature explain complexities in an elegant manner. Some diagrams fail; for instance, McVay’s procedure is poorly represented. Few of the recommendations differ from practice in the United States. The crural approach to femoral hernia would not be preferred over the inguinal for the “occasional or novice surgeon,” spinal anesthesia is not mentioned, and more reducible direct defects are repaired here in the aged. Bilateral preperitoneal prosthetic repair (Stoppa) is beautifully illustrated, but unilateral replacement is absent. I object to the preference for Marcy over Bassini, which is not supported by the facts [Surgery 1980; 88: 682-51. Like other hernia texts, there is a tendency to arcane comment. Two pages are given over to anatomic variations in the external inguinal ring, yet Fowler’s important contribution [Aust N Z J Surg 1975; 45: 81 to the anatomy of the preperitoneal fatty layer and the deep and superficial internal inguinal rings is missing. Three varieties of “reductio en masse” are detailed, a page-anda-half are expended on Maydl’s hernia (double loop or hernia en W). This esoterica is justified by an incidence in third world countries. Interestingly, only one lumbar triangle is described. I have some other cavils. All scro tal hernias in the adult are not con276
THE AMERICAN
JOURNAL
genital. La Roque did not perform preperitoneal repair but a separate herniorrhaphy. “Lipomatas” of the cord may mask sliding hemiation of extraperitonal fat, which needs excision. If carefully done, this does not lead to hydrocele or testicular damage as did excision of pampiniform veins (Halsted’s skeletonization). Devlin decries preperitoneal exposure of Hesselbach’s triangle saying, “ anatomical delineation of direct inguinal hernias is impossible.” Proper modification of McEvedy’s rectus sheath approach eliminates the problem [Am J Surg 1968;I 16:6531.Outstanding chapters in this book are “Incisional Defects,” “Spigelian Hernia,” and “Peristomal Hernia.” The book is reasonably priced, and anyone who aspires to or actually manages abdominal hernias should own or obtain access to it. Raymond C. Read,
MD
Little Rock, AK
Doctors: The Biography of Medicine.
By Sherwin B. Nuland. New York: Alfred A. KnopA 1988. 519 pages. $24.95.
Dr. Sherwin B. Nuland, an active surgeon at Yale, describes “the evolution of the process by which every doctor of today has come to his or her basic suppositions”; thus, it is the historical development of how physicians think. Nuland is a humanist and has chosen to recreate the history of healing through the lives of some of medicine’s landmark contributors. As Thomas Carlyle wrote, “what we have done is only the mirror by which we can see what we are.” The book begins with what has been termed “medicine’s declaration of independence.” Hippocrates insisted on explaining man without resorting to the supernatural. In the Hippocratic Corpus, disease could always be explained by forces within the powers of a physician to understand. Nuland persuasively lures the reader into “breeze-touched gardens . . . where sacred serpents anointed injured limbs, licking and slithering their silent restorative way from one raw wound to another.” Thus, medicine was delivered from magical for-
OF SURGERY
VOLUME
158
SEPTEMBER
mulas and inspirational theotherapy. As Jonathan Swift wrote, “We see far because we stand on the shoulders of giants.” Nuland points out that Galen was a giant with a giant ego. His claim to have answered all scientific questions may have stunted scientific growth for a millenium. Not until Vesalius re-established scientific observation, Harvey proved the blood’s circulation, and Morgagni developed the science of pathology were Galen’s ingenious declarations discredited. For surgeons, Nuland’s perspective is comfortably revealing. In Lister’s day, the operating theater was frequented by frightful tragedies. But “Lister had fallen in thrall to that particular form of enchantment that comes to embrace every surgeon who is any good at his work.” Nuland continues: “. . . what I refer to here is the sheer enjoyment of being a surgeon, an enjoyment made all the more seductive by an awareness that there is a touch of aberrance in it.” Continuing his surgical enfranchisement, Nuland introduces us to William Stewart Halsted as the captain of the Yale football team but a desultory student, writing “His scholastic achievements would be magnified if they were called ordinary.” After much searching, one of his biographers was forced to conclude that “the Yale Library has no record of his having borrowed any books,” Yet, “if ever a deep rooted plant bloomed late, it was this white spatted, bowlered, cravated, flower of the Ivy League, whose do-not-open-tillmedical-school talents were never so much as suspected until almost too late.” Nuland has chosen people to illustrate the evolution of medical thought. He has personalized these biographies to make them delightfully readable; through them, we relive the logic of scientific development and discovery in medicine. During our own century, it is easy to secondguess Nuland’s cast of characters. His stated purpose, however, of producing a geneology of scientific thought in medicine, is successfully accomplished with both authority and wit. Alden H. Harken, MD Demer, CO 1989