Table of Contents
Six Prefaces
Postscript: On being a ''knowledge engineer''

The production of this manual on Surgery was sponsored by the German Federal Ministry for Economic Co-operation within the scope of the Technical Co-operation Agreement with the Republic of Kenya, under project number 78.2048.3-01.100. It was compiled by Maurice King Peter Bewes, James Cairns, and Jim Thornton in close collaboration with Kenyan and other experts.

The manual contains the collective views of an international group of experts. The methods and techniques described correspond to the state of the art with regard to their]] feasibility in rural hospitals, where sophisticated technical]] equipment may not be available. These manuals cannot, however, replace personal instruction by a qualified expert. Neither the editors, nor the publisher may be held responsible for any damage resulting from the application of the described methods. Any liability in this respect is excluded.

Dr. R Korte, GTZ
Department of Health,
German Agency for Technical Co-operation
Postfach 5180D
West Germany.

While every effort has been made to check the dosages in this book, it is still possible that errors have been missed. Furthermore, dosage schedules are being continually revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies' printed instructions before administering any of the drugs recommended in these manuals.

Six Prefaces

Any doctor who has worked in a developing country will not easily forget the widespread and pathetic evidence of surgical neglect in the villages. Huge hernias and hydroceles, unsightly lumps on the faces of women and children, and the compound fractures infested with maggots bear testimony to the failure of so many countries to provide even a basic level of surgical care for their people.[+5]

Samiran Nundy, All India Institute of Medical Sciences.[lr][][+12]

No person is so perfect in knowledge and experience that error in opinion or action is impossible. In the art of surgery, error is more likely to occur than in almost any other line of human endeavour; and it is in this field that it should be most carefully guarded against, since incorrect judgement, improper technique, and a lack of knowledge of surgical safeguards may result in a serious handicap for the rest of the life of the patient, or may even result in the sacrifice of that life. For the surgeon, perfection in diagnostic skill is of equal, if not more, importance than operative skill.[+5]

Max Thorek, Surgical Errors and Safeguards in Surgery.[][+12]

Patients should be treated as close to their homes as possible in the smallest, cheapest, most humbly staffed, and most simply equipped unit that is capable of looking after them adequately.[+5]

Medical Care in Developing Countries, Makerere, 1966.[][+12]

Kenya's Minister for Health

The Kenyan government has decided to make district the focus for all development activities. This is based on the conviction that people should have an input in their development at local level and they should also decide on their developmental priorities locally.

Traditionally, the district hospital has been referral institution for health centres and dispensaries. The challenges that health workers face at district level are many, and varied and often are of the same magnitude as those at provincial and national level. Different district hospitals face acute surgical emergencies that cannot be safely transferred elsewhere for management. It is intended to develop the necessary expertise at district level to enable the district health work to cope with such problems. Safe anaesthesia during surgery is a prerequisite that is often not available. This is one reason among others that makes this handbook valuable to the medical profession. The handbook, I believe, will go a long way towards assisting them in the problems mentioned above. The style and contents of the handbook make it a valuable companion for reference and a source of practical procedures.[+5]

Hon. PCJO Nyakiamo, EBS, MP[[[lr] Minister for Health[[[lr]

Kenya's Director of Medical Services

Going through this manual, which I recommend to all health workers, one is impressed by the meticulous practical details that are so clearly presented. This is the result of a happy collaboration contributed through many workers in Kenya and elsewhere. The setting of the handbook is based on past experience of many health workers. It was written in an environment of one institution in Kenya which provided the necessary local interaction between the authors, clinicians, and other practitioners. The district hospital will in the very near future cope with the problems that would have otherwise been for the provincial hospitals. The handbook is a good contribution towards this end.[+5]

Wilfred Koinange, MBS[[[lr] Director of Medical Services[[[lr]

The Ambassador in Kenya of the Federal Republic of Germany

Good health is the basis of a joyful and fulfilled life, individually as well as socially. It is one of the most important basic requirements of people and therefore represents a most prominent responsibility on the part of governments all over the world.

The Government of the Federal Republic of Germany considers that finding ways and means towards improving the health of people in the developing countries is one of its major tasks. An integral component of German Development Policy is especially geared towards improving primary health care all over the developing world.

May these four manuals, which are the product of a world- wide team and were jointly sponsored by the Ministry of Health of the Government of Kenya, and the GTZ, the Agency for Technical Co-operation of the Federal Republic of Germany, be a practical and successful guide to the medical profession and help to contribute their share towards a healthier world.[+5]

Johannes von Vacano[[[lr] German Ambassador[[[lr]

The Head of the Department for Health, Nutrition, and Population Activities, Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH

By the year 2000, 80 per cent of the more than six billion people on our planet will be living in the developing world. Primary Health Care will thus increasingly be the health care for most of mankind. It is however much more than the treatment of the simplest diseases by village health workers, because they need somewhere to refer the patients they cannot treat, who include some with severe injuries or in obstructed labour. The district hospital and particularly its surgical services are therefore essential[md]hence the importance that we attach to these manuals.

A particular feature of Primary Health Care is its emphasis on ''appropriate technology'. The simplest and most cost-effective technologies, such as oral rehydration, immunization and the use of the weight chart, are now being exploited to their limit. Unfortunately, there are not many technologies which are as useful as these, so what do we do next?

The thinking behind these manuals is that we need to look carefully at all the technologies that are practical in particular technical fields, in this case surgery, anaesthesia, and obstetrics in the district hospital, and to promote them intensively. Because there are thousands of of such technologies, far too many to promote individually, they have to be promoted as a systematic, synergistic, practical whole. Tracheal intubation (A 13.2), Perkins traction (74.8), the handbag method for burnt hands (58.29), and symphysiotomy (M 20.7, 18.4) are just a few of the many such technologies which are not applied when they should be, because their details are not known where they ought to be.

There will never be complete agreement on the methods described here. Nevertheless, the reception that has already been given to the manuals that have appeared shows both what a wide degree of consensus can be reached and how valuable this is. Few readers can imagine how difficult it has been to achieve. We should therefore like to thank the editor and his family. To serve the sick he has gone far beyond his original task, and certainly beyond his contract with us. When the project began we knew the task was vast, but we did not know how vast. We expected one book; this is the third of four, which we hope will help you to serve the sick better.

Priv. Doz. Dr. med. Rolf Korte[[[lr] Head of Department of Health,[[[lr] Nutrition and Population Activities, GTZ.

Hugh Dudley, lately Professor of Surgery in St Mary's Hospital, London

These manuals are not a product of the surgical establishment in Africa, India, or Europe, or anywhere else. They are the work of a tiny far-flung band of experienced and highly competent enthusiasts, who work or have worked in the mission hospitals and universities of the developing world. Besides many from Kenya they range from Katete in Zambia (James Cairns) to Kathmandu in Nepal (Gerald Hankins), from Kumasi in Ghana (Josiah Hiadzi) to Kampala in Uganda (the 1983 conference of the Association of Surgeons of East Africa), from Delhi in India (Samiran Nundy) to Durban in South Africa (Hugh Philpott), from Sydney in Australia (Ronald Huckstep) to Seattle in the USA (John Stewart), from Birmingham in England (Peter Bewes) to Beijing in China (Cai Ru Bin), from Hobart in Tasmania (Joe Shepherd) to Laurence Levy in Zimbabwe. All these have given and have not witheld their knowledge.

The contributions of these and many other experts, and they are experts in their own very special approach to surgery, have been woven together into a unified system by an indefatigable editor. Suprisingly, he is a community physician, not a surgeon. As an exercise in ''community surgery', and ''health systems research', he has put himself into your shoes, and during ten years and more than 30,000 hours has asked himself ''What should he be able to do, if he had to do what you must do?'' These two surgical manuals, together with Primary Anaesthesia and Primary Mother Care, are his answer. He has tried to describe everything, in complete relevant detail, that he, or you, might reasonably be able to do.

Many people have wondered why such a task should be attempted by a non[nd]surgeon. There are however several good reasons why it should: (1) No practising surgeon has the necessary time to put a million and a half words through at least 25 drafts. He cannot have his scalpel in one hand and his word processor in the other. So it is not surprising that, during the previous 20 years, seven surgeons have started and abandoned this task, most after only a list of contents, one after several years. Paradoxically, it seems that the commitment, skill, and time to weave the knowledge into a system is at as much of a premium as the knowledge itself. (2) As you will have seen from the Frontispiece, surgery is now so specialized that these manuals have had to cover 20 surgical specialities. The alternative, which is to ask each expert to write a chapter, has been tried once and abandoned. (3) The outsider is much closer to the readers for whom the book is intended than the expert, and is thus much more interested in the critical elementary details. (4) As the postscript explains, the interrogation of the expert by the outsider is the standard way of constructing electronic ''expert systems'; this is a close paper equivalent to them.

Most usefully, at a time when surgery seems to be splitting into ever more arcane fragments, this is an attempt to synthesize, to unify our discipline, and to cross specialist boundaries in a way which badly needs doing, and yet to do so practically and in detail. It is far more than a synthesis of existing materials, useful though this is. In many places you will find detailed observations and instructions that are available nowhere else.

To what extent have the contributors and their editor succeeded? This you will have to find out for yourself. I can only say that from the reception given to the experimental editions of these manuals, and to the second volume which has already appeared, you are going to find their completeness, their detail, and their relevance invaluable. You must however use them in the full acceptance of the way in which they were written.

Finally, I hope that this is only the beginning of a great endeavour. How well do these methods work in practice? Can they be improved? What difficulties do you meet in using them? All these questions can only be answered by much fieldwork. That has now to begin.[+5] Hugh Dudley,[[[lr] Lately Professor of Surgery[[[lr] St Mary's Hospital, London[[[lr]

Maurice King, Reader in Community Medicine, the University of Leeds

After the more useful drugs and vaccines, particularly the antimicrobials, there are no more cost-effective, or death- and disability-preventing methods than the simpler forms of surgery.

Almost none of this essential surgery can be done by community health workers, and little in health centres. This leaves three possibilities for most of the surgery that patients in the developing world need: (1) the district hospitals, (2) the provincial hospitals, and (3) the teaching hospital in the capital city. There is much debate as to how much surgery should be done at level (1) by the general duty medical officers (GDMOs) in the districts, and how much should be sent on to the referral hospitals at levels (2) and (3). On this debate depends the scope and nature of ''primary' or district surgery.

There are two approaches to this problem:

  1. To consider district hospital surgery as a narrow range of procedures only, to assume that patients who need more than these can readily be referred, and to emphasize what should not be done in the districts, rather than what can be and has to be done there.

  2. To accept the fact that the ''referral system' that is supposed to exist in determining what, in an ideal world, should be done by whom and where, is, alas, in large part an abstraction convenient to health planners, a myth to save the consciences of doctors, and a figment in the minds of some of the leaders of the profession, who imagine that it is practicable for each particular condition to be treated only by that particular ''board-certified specialist', into whose narrow field it happens to fall. As we point out in Section 1.7, the prospects for referral from the district to the centre, which were never very good, seem to be getting worse rather than better in many developing countries, particularly those in sub[nd]Saharan Africa.

[em][em]These manuals take the second view. They assume that, if the villagers of the developing world are ever to be cared for surgically, the vast majority of the care they need must be done in its district hospitals. If this is accepted, ''Primary Surgery' is a large group of procedures. It includes all those which might benefit a patient who staggers, or is carried, into such a hospital, who cannot be referred onwards, and who has to be cared for by a general-duty doctor. Such then is the thinking behind them. Their aim is to empower the generalist surgically, to increase the quality, range, and quantity of the surgical, anaesthetic, and obstetric care available to the villager, and to bring these disciplines within the scope of the ''Primary Health Care' movement. The knowledge gathered here is is not oriented towards the systematic training of a certified surgeon, but towards the doctor who has to cope with whatever sick are fortunate enough to reach him.

Very early on, we had to decide whether to write an ''add-on book', that would include only information which is not available somewhere, or to attempt a complete system of methods, regardless of whether or not the information it contains can, with difficulty and expense, be found elsewhere. Boldly, we decided to attempt the latter and assemble a ''total system', because we are sure that this is what you need. For example, most of what is said about hand sepsis is already available, but what is said about osteomyelitis is not. Orthopaedics, particularly fractures, causes great problems, so we have given it particular attention. Our aim has been to make your more obvious needs (the acute abdomen, ruptured uterus[...]) carry those you might not yet have thought of (leprosy surgery, cancrum oris, anorectal malformations [...]). To make the task manageable we have have confined ourselves to a detailed description of what you need to do, preceded by a general introduction. Inevitably, there is little room for epidemiology, prevention, anatomy, or physiology. If you look closely you will find that almost everything we describe is slightly different in some way or other, from what it is in the industrial world.

ONE OF OUR READERS. You may have had very little surgical experience and yet have to operate on severely ill patients. In an emergency you may even have to operate by the light of a hurricane lantern. The light will attract insects, and these will fall into the wound, but even so they are unlikely to influence the patient's recovery. From an illustration kindly contributed by WHO. [em][em]We write for: (1) General-duty doctors with only a year or two of surgical experience, responsible for all the patients clamouring for care in a district hospital. We tell you what to do, and what you could do, if there is no real hope of referring a patient to anyone else. We hope that it will be a useful supplement to the ''see one, do one, teach one' method by which many of you have inevitably had to learn most of your surgery, and which is much less well adapted to the uncommon problems, than it is to the common ones. (2) Medical students anywhere in the world, training to be broadly competent doctors. If you want to be real generalists, here is part of your calling. (3) The 23 000 unemployed doctors in India, and indeed those in the world as a whole, who remain wasted and unfulfilled in the face of the pressing surgical needs of the villagers. Perhaps you feel you would like to help them, but realize that your training has not equipped you to know what you could reasonably do. Here it is. (4) ''General surgeons' at the limit of your technical range, particularly those of you who work in the developing world. (5) Specialists in any of the twenty or more surgical specialties who have to do things in a field which is unfamiliar to you[md]for orthopaedic surgeons coping with ruptured uteri, and gynaecologists treating fractured femurs. Unfortunately, many general surgeons have never done a Caesarean section, and most obstetricians are uncomfortable with an acute abdomen. (6) Any non-specialist ''war surgeon' who has to cope with the casualties from a conventional war under conditions which are usually even more difficult than most of those described here. As this is written there are 12 such wars being fought on any one day, all but one (that in Northern Ireland) in the developing world. This is a wide readership. As you will see in Section 1.6, we have tried to allow for your varying skills. These pages will probably be at their most useful helping a well- grounded doctor to do something he has not done before.

We started with the intention of writing a book of ''basics' for the generalist. As we wrote our scope expanded to include most of the tasks of the general surgeon working in the districts, the ''M. Med. Chir.'s' of East Africa for example.

In the Declaration of Alma Ata, WHO and UNICEF included the care of the common injuries as an essential part of Primary Health Care. In the second of these two manuals we have followed up their concern by describing how all human injuries can be cared for at the ''first referral level', which for the purposes of surgery is the district hospital. About a third of the work of a district hospital is surgical, and of this about half is the surgery of trauma, so it is appropriate that traumatology should occupy so many of our pages.

Everything else that you can do in the other surgical specialties is described here. The methods that you will need to anaesthetize your patients have been described in [f10]Primary Anaesthesia. [f09]We have divided the obstetrics, gynaecology, and family planning into two parts. All the methods which are common to doctors and paramedicals are in [f10]Primary Mother Care [f09](forthcoming 1990), the rest are here. Between them, this ''corpus' of four manuals comprises an integrated system of surgery, obstetrics, and anaesthesia, that we hope can properly be called ''Primary' in that it should be within the reach of all the world's citizens.

In India we hope these manuals will be useful in the taluk hospitals. These have 14 to 20 beds and a theatre, and are staffed by a Primary Health Centre Assistant Surgeon. The female patients are seen by a ''Lady Doctor'.

We are keen to support the ''general practice movement' which is, for example, making rapid headway in Nigeria. The true ''general practitioner', or GP, of the developing world is the omnicompetent ''General Duty Medical Officer', or GDMO, in his own way no less an expert than any of his specialist colleagues remote in the centres of tertiary care. It is sometimes thought that the days of the ''VGP'[md]the ''Very General Practitioner'[md] are over; but in countries where populations are expanding faster than services, this is far from true. These manuals attempt to define your surgical scope as a ''GDMO' or ''VGP', and to enrich your role, which is surely the broadest and most rewarding one in the whole of medicine.

As a general rule, more harm is done by doctors not operating when they should, than operating when they should not. So, if you have some surgical experience, another of our aims has been to encourage you to operate while carefully following the guidelines in Section 1.8. Paradoxically, theatre time, which is often such a critical constraint in provincial or teaching hospitals, is often abundant in the districts. Paradoxically also, because staff morale is often better there, care may be better too. For a patient with a straightforward condition, a good district hospital may therfore be a better place to be sick in than a central one.

Our final aim is to define a pattern of good practice under the difficult circumstances for which we write, and to improve the quality of this ''peripheral care'[md]peripheral it may be when looked at from the centre, but from the patient's point of view, the periphery is indeed the centre!

These manuals would never have been written had not GTZ seen fit to support them. Our particular gratitude is due to Dr Klaus G[um]ordel of the BMZ for so graciously and so willingly providing the funds whenever they were required, to Dr Hans[en]Joerg Elshorst, Dr Peter Muller, and to Dr Klaus[en]Jochen Lampe. I should personally like to thank Dr Rolf Korte, a wonderful chief, for having administered the project for ten years with unfailing efficiency, kindness, sympathy, and generosity, together with a remarkable understanding of its technical scope and of the difficulties that had to be overcome in accomplishing it.

Together with two illustrators, Derek Atherton and Ivanson Kaiyai, and two secretaries, Sifolosa Ndabi and Attanasia Mugo, I spent five years in a classroom in the training school at the Provincial General Hospital in Nyeri in Kenya, and the spare moments while doing another job during more than another five in the Department of Community Medicine in Leeds. The project owes everything to Peter Bewes, who gave up a large part of four summer holidays to the task, and without whose initial help I should, very properly, never have started. Many of the trauma methods are his; so in a very real sense are all these manuals. During his holidays over several years James Cairns of St Francis' Hospital at Katete in Zambia contributed greatly to almost every section, and reviewed the final manuscript of this volume before it went to press. Jim Thornton contributed extensively to the obstetrics and gynaecology and reviewed it all. Gerry Hankins of the Shanta Bahwan Hospital in Kathmandu sent us 36 tapes and was indefatigable in his encouragement. John Stewart, formerly of the KCMC hospital in Moshi, Tanzania, contributed much of the orthopaedics and reviewed it all. Samiran Nundy visited us for a final critical week in Kenya and did much to adapt it to the villages of India. The advice, contributions, and support of Professor Anne Bayley of the University of Zambia meant more than she can easily imagine. Brian Hancock did a wonderful job on the proctology; Neville Harrison did the same for the urology. June Brady reviewed the section on neonatal resuscitation. Many kind colleagues here in Leeds reviewed parts of it. Other valuable contributors include Ruediger Finger, John Githiari, John Gower, Martin Hobdel, Naim Janmohammed, John Jellis, Imre Loefler, John Maina, Andrew Pearson, Hugh Roberts, Sam Smith, Mamdur Tahir, Patrick Trevor[nd]Roper, and Adil Keskin. The late Sir Michael Wood was kind enough to hand over his own uncompleted manuscript. There is a real sense in which [f10]all [f09]their contributions were essential.

Richard Jolly, Deputy Executive Director of that paragon among international organizations, UNICEF, was unflinching in his support of these manuals (to him they will always be known as ''Cut along the Dotted Line''!). Denis Burkitt called on the project in its first faltering days and was courageous enough to say ''So I have seen the place where it [f10]was [f09]written''. Gerald Richards, Professor of Community Medicine in the University of Leeds, kindly allowed me to spend a large part of five years completing this task, which is hardly ''community medicine' as this is ordinarily conceived. During this time much of my university work was carried on by my colleagues, Mark Baker, Jenny Green, Rangit Bandaranayake, Martin Schweiger, Elizabeth Kernohan, and Chris Newman, without whose support and forbearance it would never have been completed. Anne Mainwaring's kindness and hard work freed many precious hours for this task.

I gathered a huge pile of books, and have drawn extensively on Hamilton Bailey's ''Emergency Surgery', Farquharson's ''Textbook of Operative Surgery', de Palma's ''Fractures and Dislocations' and Perkins' ''Fractures', to name but a few. My thanks are to the authors and publishers of these and many other books, who have kindly allowed us to redraw some of their most useful illustrations. We are particularly grateful to Mrs Joyce Williams of the W.B. Saunders Company, who let us use many of the illustrations from their medical list, and to Jack Lange. Where I have lost the source of some illustrations, or have overlooked their authors or publishers, I hope that, for the good of the sick of the developing world, I shall be forgiven.

The task of assembling such a quantity of diverse material was made possible by recent developments in information technology. Two years from the end of the project, in the very nick of time, it became possible to service word processors in Kenya. Latterly, we had three Osborne One microcomputers, which also enabled us to code the text for immediate photosetting[md]''Wordstar' saved the project; so did Nicholas Ouma, who kept our machines running in Kenya, and John Laker, who did the same in England.

''Primary Anaesthesia' and ''Trauma' went through a limited experimental edition before being formally published. Circumstances have prevented ''Non-trauma' doing the same: it is therefore a ''generation' behind them.

Finally, my thanks are due to my wife and two small sons, who, for nine consecutive years, went on holiday and left ''Dad' at these books.

It is my great regret that it is my role to serve the sick with a keyboard rather than with a scalpel. Paradoxically, had I tried to combine practice with writing, I should never have completed the task. I am thus but the scribe and servant of many skilled surgeons. It is they, not me, that speak to you through these pages. Nevertheless, in the theatre and the wards, I share the pain, the anxiety, and the wretchedness of so many of your patients, and your joy in caring for them.