How to use these manuals

You will notice that after three chapters on ''the basics' there are four on draining pus. Then comes the abdomen and hernias, followed by obstetrics, gynaecology, and the breast. After this there is the surgery of ''special departments' (proctology, urology, etc.) then some specifically tropical surgery, a long chapter on oncology, a short one on terminal care, and finaly a miscellaneous chapter. After dealing with injuries of the various regions the second volume ends with a system of closed methods for virtually all human fractures.

In writing these manuals we have tried to make both language and the typography work for us. You will see that we have divided most sections into an initial introductory, or background part in a Roman type like this paragraph, followed by didactic instructions in another typeface. You will also notice that we use the imperative, and refer to ''the patient' and then to ''he', which does in fact usually mean ''he and she'. Alas, English has no personal pronoun which includes both sexes. Our use of ''he' to include both sexes improves clarity, and shortens the text, but we owe our apologies to our lady readers!

Inevitably, we are mostly concerned with technology[md]but behind all this lies the patient himself. That boy with the fractured radius and ulna waiting at the end of the queue might be our own son, that paraplegic our brother, that old lady with the fractured femur, our mother. Tomorrow, we might be that comatose patient with the extradural haematoma in the end bed. These patients are ourselves. Perhaps the thing that we most often miss is any explanation of what is going to happen to us, and any indication that anyone really cares. One contributor considered that such an outright statement of values has no place in a technical compendium, and suggested it be deleted. Instead, believing the compassionate and devoted care of the sick to be one of the noblest human activities, and something of ultimate value for its own sake, we have put it into italic type!

One reader of one experimental edition commented that it had ''[...]enormously improved the treatment of fractures in St Clair's hospital, Sotik[...]''. We were delighted because that is ''our scene''. It also shows that these manuals can be put to good use. They contain much detailed factual information, and although we have done our best to make them as easily understandable as we can, if you want to use them to their best advantage, you will have to read them carefully.

A TALE OF FOUR PEOPLE, Everybody, Somebody, Anybody, and Nobody, which was found on the notice board of the Birmingham Accident Hospital. ''There was an important job to be done and Everybody agreed that it was a job that could be done by Anybody. It was agreed that Somebody should be detailed off to do it, but although Anybody could have done it, it eventually got done by Nobody. Somebody got angry about it, after all (he said) it was Everybody's job. But, while Everybody thought that Anybody could do it, Nobody realized that Everybody was going to assume that Somebody was going to do it. It ended up that Everybody blamed Somebody when Nobody did what Anybody could have done. LESSON. This book is written to benefit Everybody, so that Anybody who is put in charge of surgical patients will know that Somebody cares enough to write down methods of surgery in a way that a ''Nobody' can find that he or she can do Something even if tucked away in the middle of Nowhere''. Fig. 1-9 YOU MAY HAVE TO BE SURGEON AND ANAESTHETIST. Kindly contributed by Nette de Glanville. From the Proceedings of the Association of Surgeons of East Africa. THE PATIENTS ARE OURSELVES

HOW TO USE THESE MANUALS IF YOU ARE A STUDENT, don't be overwhelmed by the mass of necessary detail you will find here. Don't panic, and don't try to learn it all by heart! These pages differ enormously in importance. Try to distinguish between what you should know, and what you can look up when necessary. You must know the emergency procedures, which there will not be time to look up. Study these early in your training. Know your way about these manuals, learn how to use them, keep them and look things up in them.

When you study anatomy, learn the anatomy of the operations we describe, because these are the ones which you will later have to do. Study the anatomical drawings listed below as part of your anatomy course.

Don't sell your dissecting manuals the moment the anatomy exam is over. You know your way about them. So keep them, tainted with the dissecting room though they may be. The ideal textbook of surgical anatomy has yet to be written, and dissecting manuals are the best so far.

Take this book to the wards, clinics, and operating theatre. How does the treatment you see given differ from that described here? The methods of examination we give are summaries only, practise them on a fellow student.

A SUGGESTED INITIAL READING LIST. Start by reading the whole of this chapter. In those which follow, read only the introductory passages in Roman type, and merely glance at the detailed didactic instructions which follow in this typeface[md]read these carefully later when you need to do something. Start with the common things first. We have used 7 degrees of approximate commonness: Very common, common, not uncommon, uncommon, unusual, rare and very rare. This is based on experience in East and Central Africa, but it is mostly applicable to the developing world as a whole.

Read particularly the first section of each chapter and the following: The major theatre (2.1), aseptic theatre technique (2.3), autoclaving (2.4), antibiotics in surgery (2.7 to 2.9), the control of bleeding (3.1 and 3.2), bloodless limb operations (3.9), the instruments (4.1 to 4.5), suture materials, sutures and needles (4.6 to 4.8), drains (4.9), instrument sets (4.10), ''pus' (5.1 to 5.4), empyemas (6.1), peritonitis (6.2), PID (6.6), pyomyositis (7.1), osteomyelitis (7.2 to 7.5), septic arthritis, especially the positions of rest and function (7.16), hand infections (8.1), abdominal surgery (all Chapter 9), the acute abdomen and intestinal obstruction (10.1 to 10.6), appendicitis 12.1), inguinal and femoral hernias (14.1 and 14.6)[...]

In Volume Two on trauma, read Chapters 51 to 54, especially Sections 54.1 to 54.3 on wounds. Read the first section in each chapter, and particularly the sections on amputations (56.1), skin grafts (57.1 to 57.5), the entire chapters on burns (Chapter 58) and fractures (Chapter 69) especially ''adequate function with minimum risk' (69.3) and bony injuries in children (69.6 and 69.6a), and catastrophes with casts (70.4). Then read about some of the more common and important injuries: dislocation of the shoulder (71.8), fractures of the humerus (71.17), dislocation of the elbow (72.4), supracondylar fractures in children (72.6), midshaft fractures of the radius and ulna (73.6), the compartment syndrome (73.7), stiffness in hand injuries (75.2), pelvic fractures (76.2), hip and femur injuries (77.2), Perkins traction (78.4), open fractures of the tibia and fibula (81.12), and malleolar fractures (82.6).

THE ABBREVIATIONS you will meet are these: AAFB, acid and alcohol fast bacilli (tubercle bacilli). AAKS, atypical African Kaposi's sarcoma (32.21). AIDS, acquired immune deficiency syndrome. BIPP, bismuth iodoform and paraffin paste (4.11). CPD, cephalopelvic disproportion (18.6). DIP, distal interphalangeal joint. PIP, proximal interphalangeal joint. MP, metacarpophalangeal joint. EIT, examination in the theatre. EUA, examination under anaesthesia. IOP, intraocular pressure. HCG, human chorionic gonadotrophin. HIV, human immunodeficiency virus. IVU, intravenous urogram, also called an intravenous pyelogram (IVP). NSAID nonsteroidal anti-inflammatory drug. PID, pelvic inflammatory disease (6.6). ]]PPNG, penicillinase-producing Neisseria gonorrhoeae. PPH, postpartum haemorrhage. STD, sexually transmitted disease. VVF, vesicovaginal fistula. RVF, rectovaginal fistula.

Three capital letters in brackets, for example (TAL), refers to the addresses of the suppliers in Appendix B, in this case Talc, Teaching Aids at Low Cost. THE MAIN ANATOMICAL DRAWINGS are: the dermatomes (A 6-8, A 7-8, 64-2), the major arteries, (3-5 etc), the scalp (63-12), the orbit (5-4), the optic discs (24-4), the cheek (61-5), the maxillary antrum (25-6), the mandibular region (5-7), the teeth (26-4 etc), the anterior abdominal wall (9-1, 23-17a), the peritoneal cavity (6-3), the biliary tract (13-29), the blood supply of the colon (66-22), the anorectum (22-1), the lower urinary tract (68-1), the relations of the ureter (20-16), the ''ligaments' of the pelvis (20-17), the peritoneal attachments in the region of the bladder (18-10), the uterine blood vessels (18- 13a), the inguinal region (14-2, 14-3), the nerve supply of the hand (75-3), the bones of the hand (75-11), the tendon sheaths (8-7).

There are also the following transverse sections: the upper arm (56-8), the forearm (7-8, 73-11), the wrist (27-14a, 75-24), the hand (8-1), the finger (75-6), the thigh (7-9, 56-11), the calf (7-10, 7-11, 81-14), the ankle (27-11).

IF YOU ARE A GENERAL DUTY MEDICAL OFFICER, don't be ashamed to refer to these manuals. A patient will be more grateful for being correctly treated than for being wrongly treated because you could not remember something and had to guess! For example, you cannot possibly remember all the steps in the general method for a spinal injury (64.3), or a hand injury (75.1), so why not refer to them in front of a patient until you have examined so many patients that the necessary clinical routines become automatic? If he is difficult to diagnose, ask him to wait until the end of the clinic, and then use the routines we give here to try to diagnose him.

Keep these manuals in the theatre. If a procedure is long or difficult, sit in an armchair and study it in peace, before you try to do it. Then study it again after you have done it. Don't expect to be able to do everything we describe immediately. Progressively extend your practice, little by little.

Don't let things you cannot do, because you do not have the necessary equipment or drugs, prevent you from doing the things you can do.

Whenever you refer a patient, try to learn from the person you refer him to. If possible, be there when he is examined. In the same way, if someone refers a patient to you, he should be there so that you can teach him.

What methods are your staff using? For example, if medical assistants treat fractures in your hospital, study the methods they use and encourage them to use those described here. If they might find this manual useful, see that they have a copy and go through it with them.

If a patient dies and you are not sure of the diagnosis, try to get permission for a post-mortem examination.

Make good use of the endpapers and charts (A 2-4, A 5-1, A 15-4, A 15-6) you find in these manuals. Where convenient photocopy them and stick them up on the wall, or have them printed.

IF YOU ARE A SURGICAL TEACHER, try to integrate these manuals into your teaching, and base your examination questions on them. Aim, less that the students should know these manuals, than that they should know their way around them, and be prepared to use them.

YOU TOO ARE PART OF THESE MANUALS [s7]HELP TO WRITE FURTHER EDITIONS! One of the limitations of the project on which these manuals were written was that although it lasted 5 years in Kenya and most of another 5 in Leeds, it was not possible to do all the intensive fieldwork that would have been ideal. The result is that we do not really know what difficulties you will have with the ''handbag method for treating burns', for example, or if there are important disasters which we should have warned you about, and have not. What is missing? What is redundant? We look forward to knowing what your experiences are with the methods we describe, and to getting out the floppy discs to improve them for a second edition. Any contribution, large or small, sent to me (MHK) care of Oxford University Press will be welcome. Ideally, send an annotated copy of this manual, for which we will be happy to return you a clean one, and to include you among the contributors on the cover of the next edition. We look forward to hearing, both from ''experts' and from ''very general practitioners'!

Some TALC (TAL) slide sets on particular surgical conditions would be particularly welcome.

TRANSLATIONS of these manuals or entirely new ones covering the same field are needed in French, Spanish and Portuguese. Primary Anaesthesia is available in French as [ac]El[ac]ements d'anesth[ac]esie pratique from Arnette, 2 rue Casimier Delavigne, 75006 Paris, France. If you are insistent enough, they might perhaps translate the other manuals.

DIFFICULTIES [s7]WITH THE REFERENCES If you have TROUBLE LOOKING THINGS UP, this section will probably help you. You will see that section numbers have dots in them (for example, 3.6), while figures have a dash (3-6). Where, for example, we have added a section or sections, say between sections 2.3 and 2.4, we have called them 2.3a, or 2.3b etc. References with an A in them not followed by a comma, as for example (A 2.1), refer to ''Primary Anaesthesia'. An A followed by a comma, as for example (A, 2-7) refers to the first illustration in a particular figure. References to ''Primary Mother Care' have an M (M 2.1).

Some of the sections are long, and many of the problems and difficulties that you may want to look up are at the end of them. So the keywords in the ''Difficulties' are in capital letters (see immediately above), and the section number in the index has a ''D' after it. For example, ''trouble looking things up' is indexed under 1.14D. So, if there is a ''D' in an index entry, go to the ''Difficulties' end of that section.

These paragraphs of ''Difficulties' are also a convenient place for a variety of assorted information that does not fit earlier in the section. Some chapters, such as those on urology and tropical surgery have an entire final section devoted to ''other problems'[md]see Section 23.30 on ''Other urological problems'.

IF YOU ARE A STUDENT, LEARN THE IMPORTANT THINGS FIRST Fig. 1-10 A PATIENT'S RECORDS, as kept by Peter Bewes. Good notes are an excellent indication of quality of care[md]see Section 34.6.