What should we describe? What should you be able to do surgically? The limits of this system of surgery

God is in the details. Mies van der Rohe[lr][][+5] Der teufel (the devil) ist im detail Old German proverb In view of the common impossibility of referral, we have tried to describe everything that you, our readers as a whole might have to do[md]if you cannot refer a patient, and which might benefit him; both the ''hot' emergency procdures and the less urgent ''cold' ones. As you will see in the next section, you individually, should not necessarily do everything we describe.

Our contributors have varied greatly in what they thought we should include. Some have considered you can do everything that they can do. Others have done their utmost to keep you away from the patient if they possibly can. Many began by considering that most of the procedures that they do themselves would have to be learnt by expert tuition, and could not be learnt from a manual. In the end they came to see that this manual is necessary. That personal tuition from an expert is the best way to learn anything, we take for granted. But, what if there is no expert? A manual is surely better than nothing.

Somehow, we have had to find a balance, so we have considered each procedure on its merits. Our task has been made no easier by the wide range of your abilities. You range from highly trained surgeons doing unfamiliar operations for the first time, to inexperienced doctors doing your first jobs. We have tried to serve all your needs.

Not the least of our difficulties has been your very different ability to use books. One professor of surgery remarked that these manuals would be very useful for mature general duty doctors of the old school, but not for his students. The ability to do anything out of a book varies greatly, whether it is making a cake, mending a car, or treating a fractured femur. For anyone who is not good at doing things out of books, learning to do so is an ability well worth cultivating[md]over the years it will make a huge difference to your skills.

It has not always been easy to distinguish the tasks which are obviously impossible for you (oesophageal atresia for example), from those which are possibly possible (duodenal or jejunoileal atresia). We have had to balance benefit, risk, and urgency. This has led us to include methods for removing the prostate, for example, but not the thyroid.

Methods have been devised for grading the difficulty of operations. One of them gives the repair of an inguinal hernia a value of one arbitrary unit. On this scale the repair of an episiotomy is given 0.2 units, a clavicle fracture 0.3, a Colles fracture 0.6, an above knee amputation 1.3, the resection of small gut 2.0, and the fusion of a hip (not described here) 3.0 units. Methods of grading were discussed, and this one might be adopted in the second edition. Instead, we have suggested you refer the more difficult cases where you can, and have stressed that some operations are only for the careful caring operator. These include vascular repairs (55.6), a groin flap for the back of the hand (75.27), and Girdlestone's operation for fractures of the neck of the femur (77.13).

Although the common conditions may comprise perhaps 60% of your work, the rest will include many rarer ones. In aggregate the rarities are common. So we have tried to describe as many of the comparative rarities as we can, in the hope that you will find about 98% of the conditions you could hope to treat surgically described here. The edges of this large collection of appropriate methods are inevitably blurred, and it has not been easy to know how rare, or how difficult we should be. For example, you will find no less than 46 hand fractures, and there is even mention of cystic hygroma. We shall probably be criticized for including oesophagoscopy and bronchoscopy, and some cancer chemotherapy. But it is better to include slightly too much rather than slightly too little[md]there is no need for you to do things you don't want to! Tibialis transfer (30.8) is our tour de force, and the great detail with which we have described it should enable our more experienced and caring readers to do it. Some methods, such as tying the major arteries, are seldom used, but are classical, in that no textbook of surgery would be complete without them. Inevitably, some parts of the ''system' are tidier than others. The trauma methods, for example, seem about as complete as anything could be, but not so those for ophthalmology. Nor is there any sharp distinction between what is medicine and what is surgery, particularly in obstetrics (Chapter 17 on ''The medicine of pregnancy').

We have excluded all procedures which require equipment which you are unlikely to have, and could not reasonably expect to buy. We have assumed that you have an X-ray department, but no X-rays in the theatre and no image intensifiers, ultrasound, diathermy, or equipment for any but the very simplest methods of internal fixation. Although we mostly write for hospitals which are short of both money and skill, there are some, such as those run by mines and plantations, where money is less scarce and who should be able to buy even comparatively expensive drugs for cancer chemotherapy, for example. For them all the equipment we list (even bronchoscopes and oesophagoscopes) should not be a problem. Uncertain sterilizing procedures, and limited nursing care have also guided our selection. AO methods of internal fixation are excluded on all these counts (69.3). If you try it, it is likely to live up to the epithet ''Always Osteomyelitis'!

Overall: (1) We have tried to describe a system of practice which includes all the basics, but is ahead of of the practice of many district hospitals, so that even comparatively advanced ones have something to aim for. (2) We have tried to cover most of the range of the ''general surgeon' working in the districts. (3) We have tried to describe this system in complete detail, and in doing so would agree with both the quotations with which this section starts. (4) We have in our mind's eye a concept of ''quality' at the district hospital level; even simple things can and should be done well. Right at the end of this manual there are some indicators to measure this by (34.6).