Principles of Medicine in Africa Third edition; Textbook of Tropical Surgery
Authors: I. Loefler
Journal: Journal of the Royal Society of Medicine (2004)

Principles of Medicine in Africa, in its radically revised third edition, is an excellent volume; one of the few drawbacks is its weight (nearly 5 kg). One need go no further than the contents pages to see the clarity of thought and the consistency in design, and the introductory chapters are witness to the editors' understanding of human ecology in Africa. Over a hundred individual contributors represent experience gathered in various African regions and settings. It is obvious that they were given precise instructions, and the chapters are characterized by concise text, excellent photographs, ingenious tables, easy-to-read maps and a multitude of references. This volume, indeed, is more deserving of the designation 'textbook' than the second book reviewed here, Kamel and Lumley's Textbook of Tropical Surgery. In the surgical volume—which begins with a mission statement in nine languages anticipating the formation of the Global Academy of Tropical Surgery—the essays vary much more in quality of content, language, and illustrative material, with less generous use of colour. The reader, instead of being supplied with references, is directed to 'further reading'. Perusing the table of contents one is struck by titles such as 'Hearing impairment in ancient Egypt', 'Living systems and dynamic complexity' and 'Robotics in videoscopic surgery' that have no obvious connection with the main topic. Many chapters, indeed, have scant relevance to surgery, such as those on viral fevers (haemorrhagic and non-haemorrhagic), yellow fever and legionnaires' disease. There are frequent duplications: for instance, yellow fever is one of the viral haemorrhagic fevers; tetanus is dealt with extensively in a gynaecological/obstetric chapter but has its own chapter as well. With duplications of this kind, contradictions inevitably creep in.

Unlike the physicians, the surgeons (in excess of 250 contributors) seem to have been given a more or less free hand—sometimes with bizarre results. The chapter on anaesthesia is glaringly inadequate, for it offers no practical guidelines at all. Other chapters are distinguished by loquacity, and the prize for chattiness goes to an item on warm-blood-animal bites in the section grandly called 'Tropical morsology'. In this chapter, which sounds like stories told around a campfire, we learn of the man-eating lions of Tsavo, man-eating tigers and leopards. It also has a paragraph on elephants, and another in which the rhino and the hippo are married. We are told the size and weight of many species (and the bountiful flora of their mouths) but there is little useful information about treatment. Obviously a big animal can do more damage than a small one but a bite is a bite. Incidentally, rhinos gore and toss but do not bite. The discussion of snakebites, on the other hand, is much better in the surgical book than in the medical volume. The medical contributor is fixated on snake identification and antivenoms, whereas the surgical author is looking at the victim rather than the snake. This syndromic approach is very sensible: most people are not herpetologists, able to identify the snake that bit them; about a third of snakebite victims are children, and many are bitten at night. Moreover, in the rare instance when the poor snake is killed and taken to the hospital, the staff are unlikely to identify it. A drawback of antivenoms is that they are not available: production is low, they are expensive and they have a limited shelf-life. Also antivenoms can kill faster than venoms. All in all, less than 10% of people admitted to hospital with snakebites would benefit from treatment with antivenom.

The snakebite chapter is not the only one that is better in the surgical book. The physicians are strangely tight-lipped about cancer: the general attitude seems to be that cancers are less frequent in Africa than in western countries and that if they occur they have a near hopeless prognosis. Also there appears to be no appreciation of the fact that some cancers, colonic and rectal for instance, have become very common among urban dwellers in Africa and that young people are affected.

If the neglect of cancers by the physicians is the result of an editorial decision, the defects in the surgical book stem from lack of editorial direction. Oropharyngeal cancer surgery is allotted pages of detail—of procedures in fact— which will be beyond the scope of the readers. On the other hand, mastectomy is not described at all (ironically, reduction mammoplasty is). The medical volume is strong in ecology and geography, the surgical volume in history— especially Egyptian history, doubtless because more than a third of the contributors are from Egypt. History is always interesting and it may contribute to understanding; still, it is difficult to see how a surgeon will be helped by the account of a mummy that has been found to have had a vesicovaginal fistula.

What of the indexes? It is seldom one encounters a book that is well indexed. To find an entry only to be told to 'see under' something else is a bitter experience, exceeded in bitterness only if one cannot find at all what one is looking for. Editors of textbooks ought to attend to this matter, for bad indexing can compromise useability. The medical volume is the better indexed. In the surgical book one finds the usual fare awaiting the index user: under Donovanosis one finds 'see Leishmania donovani'; under Leishmania donovani one finds 'granuloma inguinale', which has nothing to do with Leishmania. Further under Leishmania donovani the index lists 'granuloma venereum', an entity that has nothing to do with either Leishman or Donovan.

One has compassion with Professor Kemal and Professor Lumley, the surgeon editors, who embarked on a task never undertaken before. Both are much-travelled ex-Presidents of the International College of Surgeons, but only Kemal has extensive experience of working in the tropics, and that mainly in Egypt. They relied on a network of acquaintances of the kind one meets at conferences and did not exert sufficient editorial control. All along there was something messianic in this undertaking and it miscarried. A great pity, for many people worked so hard. The physicians, with their solid grounding in tropical Africa, a sharper focus and a comprehensive editorial policy, produced a much better tome—one that is, with respect to Africa, better even than Manson's Tropical Diseases.