Instant ebooks textbook Radiology for medical finals a case-based guide 1st edition edward sellon do
Visit to download the full and correct content document: https://textbookfull.com/product/radiology-for-medical-finals-a-case-based-guide-1st-e dition-edward-sellon/
More products digital (pdf, epub, mobi) instant download maybe you interests ...
Demystifying Interventional Radiology A Guide for Medical Students 1st Edition Sriharsha Athreya (Eds.)
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Printed on acid-free paper
International Standard Book Number-13: 978-1-4987-8216-6 (Paperback)
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without writ ten permission from the publishers.
For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe.
Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com
and the CRC Press Web site at http://www.crcpress.com
For Louise and Lottie, for their constant love, support and belief (ES)
To my dear wife Lara and all the children, Thomas, Ella, Robert and Miles, also to my parents, Ken and Margaret, and remembering fondly Joanna and Christopher (DCH)
Foreword by Professor Malcolm Reed
From the initial discovery of X-rays and their application to medical imaging by Wilhelm Röntgen, imaging has been an increasingly vital part of medical practice. The modern doctor needs a strong understanding of the different modalities and their application in the diagnosis and management of a wide range of medical conditions. While in many situations images are reported by expert radiologists, the ability to understand and interpret radiological images is essential and the vast majority of medical schools will require students to demonstrate fundamental skills in this area.
More importantly, diagnostic and therapeutic imaging opens a window to the internal structure and function of the human body and links the fundamental sciences of anatomy, physiology, and pathology to the patient as a whole presenting with symptoms and signs of disease. The clues gleaned from a careful history and thorough examination lead us to select the most appropriate investigations to expedite a diagnosis, allowing us to inform the patient about their condition and commence appropriate treatment. It is the distinction between normal and abnormal structure and function, which is at the core of radiological diagnosis, that provides an illustrative basis for learning and a truly patient-orientated understanding of medical disorders. As such, the use of radiology in teaching and learning facilitates and enhances the understanding of medicine and is of enormous benefit in preparing for examinations such as medical school Finals. This textbook edited by Edward Sellon and David Howlett provides an invaluable learning resource not just for students preparing for medical school Finals but any doctor preparing for subsequent professional assessments. In addition to the well-illustrated cases and a useful introduction to OSCE-style exams, the real value in this text is in the clearly structured cases based on high-quality radiological imaging, which span the whole spectrum of medicine. The book takes a regional anatomy approach with additional chapters on the normal chest and abdominal X-rays and paediatric cases.
The contributors and editors are to be commended for producing a high-quality, comprehensive compilation of cases with clear and concise questions, answers, and explanatory notes. I would commend this text book to its target audience of final year medical students but also to doctors in training in a wide range of clinical disciplines as well as those in established practice.
Professor Malcolm Reed BMedSci, MBChB, FRCS Dean, Brighton and Sussex Medical School Brighton, UK
Foreword by Dr Giles Maskell
Radiology is an unusual medical discipline in being able to trace its origin precisely to a specific event – the discovery of X-rays by Wilhelm Röntgen in 1895. The practice of medicine was transformed almost overnight by the use of X-rays in diagnosis. The development of further imaging techniques such as ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) followed in the second half of the twentieth century and has led to medical imaging occupying a central place in the management of patients with a very wide range of conditions.
Whatever branch of medicine you pursue as a career, at some stage you will find that an understanding of medical images – X-rays and scans – will be essential to your work. You will need to understand not only the principles of interpretation of tests such as the chest X-ray but also their strengths and limitations and how to make the best use of these tests to benefit your patients.
Although imaging findings can occasionally be so characteristic that they could almost be called “pathognomonic”, one of the most important lessons that you will learn is that the interpretation of an imaging test depends critically on the clinical context. The classic diagnostic sequence – history, examination, tests – is as valid today as it ever has been, despite the increasing sophistication of the imaging tests. The doctor who makes a diagnosis based only on imaging findings without due regard to the clinical context is more than likely to be tripped up.
Radiology is not a discipline that can be learned in isolation from clinical medicine. In this book, David Howlett, Edward Sellon, and their colleagues, renowned educators in this field, have therefore embedded the teaching of radiology in a series of clinical cases, which illustrate not only the specific imaging findings in certain conditions but, importantly, the principles that underpin the effective use of imaging tests in clinical practice.
Although there are encouraging signs with the establishment of undergraduate radiology societies in many medical schools, the teaching of radiology to undergraduates has not always kept up with the progress in medical imaging. I believe that this book will prove invaluable, not only in preparing students for medical Finals, but also in giving them a better understanding of the central role of imaging in modern clinical management, which will serve them well in the early years of their careers as doctors. Maybe some will even be inspired to consider a future career in this most exciting and rapidly developing discipline.
Dr Giles Maskell MA, FRCP, FRCR, FRCPE President, Royal College of Radiologists (2013–2016) Consultant Radiologist
Royal Cornwall Hospitals NHS Trust Truro, UK
Preface
This book has been a long time in the making and is the product of many years of both teaching and examining undergraduate medical students. Over this time there has been an exponential increase in the use of all forms of imaging in both acute and elective patient care and this has been reflected in undergraduate medical school curricula and also examinations. Radiology images feature prominently in both Finals written papers and Objective Structured Clinical Examination (OSCE), and whole OSCE stations may be based upon a chest X-ray for example. Various imaging modalities tend to feature, in particular X-rays of the chest, abdomen, and common fractures, but increasingly CT and MR images. The incorporation of radiology/imaging into Finals reflects the increasing exposure of both medical students and junior doctors to all forms of radiology and the requirement for trainees to be able to provide provisional interpretation of many forms of imaging.
This book is not intended to be an all-encompassing textbook of radiology, and the bibliography provides supplementary reading for those who wish to dig deeper. A case-based approach has been adopted and radiology images in questions have been selected in two broad categories –those that students could expect to encounter in Finals or, alternatively, to cover key learning points/educational aspects of radiology. This structure should allow students and also foundation doctors to approach both Finals and the foundation years with more confidence.
Inevitably within the book there is a strong emphasis on plain film interpretation, as these investigations are the most common form of imaging that students and junior doctors will encounter and they will also often be expected to provide a provisional interpretation. Extensive additional examples are used in case answer sections to explain and reinforce learning points throughout the book. There is widespread use also of common/important CT/MR images, again because these modalities are increasingly frontline; for example, CT head interpretation in stroke care. There is less emphasis on ultrasound and nuclear medicine, as these modalities occur less frequently in Finals, although an understanding of their use is necessary. Ultrasound does feature in some cases reflecting more widespread use of this modality on the wards and in the emergency department.
We hope you will enjoy this book and that it will stimulate and enhance your knowledge and understanding of radiology, and improve your confidence in image interpretation.
Edward Sellon
David C Howlett
Contributors and acknowledgements
Dr Hannah Adams BSc (Hons), MBChB
Radiology Registrar
Brighton and Sussex University Hospitals
NHS Trust, Brighton, UK
Dr Faye Cuthbert MBBS, MRCP, FRCR
Consultant Urogenital Radiologist
Brighton and Sussex University Hospitals
NHS Trust, Brighton, UK
Dr Sarah Hancox MBBS, BSc (Hons)
Resident Medical Officer, Emergency Department
Townsville Hospital, Townsville Queensland, Australia
Dr Vincent G Helyar MBBS, BSc, MSc, FRCR, EBIR
Interventional Radiology Fellow
Guy’s and St Thomas’ NHS Foundation Trust London, UK
Professor David C Howlett MBBS, PhD, FAcadMEd, FRCP (London), FRCP (Edinburgh), FRCR
Consultant Radiologist
Eastbourne Hospital, East Sussex Healthcare
NHS Trust, Eastbourne and
Honorary Clinical Professor
Brighton and Sussex Medical School Brighton, UK
Dr Amanda Jewison BMBS, FRCR
Specialist Registrar in Radiology
Brighton and Sussex University Hospitals
NHS Trust, Brighton, UK
Dr Thomas Kurka BSc, BMBS
Academic Foundation Doctor (Management & Leadership)
Brighton and Sussex University Hospitals
NHS Trust, Brighton, UK
Dr Uday Mandalia MBBS, BSc, MRPCH, FRCR
Consultant Radiologist
Hillingdon Hospital, Uxbridge, UK
Dr Sean Mitchell BMBS, BSc (Hons)
General Practitioner Specialty Trainee Year 2
Brighton and Sussex University Hospitals
NHS Trust
Honorary Clinical Teaching Fellow
Brighton and Sussex Medical School
Brighton, UK
Dr Cristina Ruscanu MBBS
Foundation Year 2 Doctor
East Sussex Healthcare NHS Trust
Eastbourne, UK
Lt Col Edward Sellon BSc (Hons), MBBS, MRCS, FRCR, PgD (SEM), Dip (ESSR), RAMC
Consultant Musculoskeletal Radiologist
Oxford University Hospitals, Oxford and
Consultant Military Radiologist
Centre for Defence Radiology Birmingham, UK
Dr Lucy Shimwell MB BCh, BAO
Resident Medical Officer
Royal Perth Hospital, Perth Western Australia, Australia
Dr Andrew Snoddon MBChB, FRCR
Specialist Registrar in Radiology
Leeds General Infirmary, Leeds, UK
Dr Olwen Westerland MBBS, BSc, FRCR
Consultant Radiologist
Guy’s and St Thomas’ NHS Foundation Trust London, UK
ACKNOWLEDGEMENTS
Two people in particular have been fundamental to the successful production of this book. Nick Taylor, medical photographer, has worked tirelessly and with great skill preparing the images, which are such a vital component of any book on imaging. Also Susi Arjomand who has, with her customary patience and attention to detail, typed up the numerous editing iterations of the manuscript. Thank you both.
The editors would also like to thank Jo Koster, commissioning editor at Taylor Francis, for her support and guidance throughout the publishing process. Dr Gillian Watson and Dr Justin Harris kindly provided some of the radiological images used in the text and Kirstie Leach also helped with manuscript preparation.
Finally, we would like to gratefully acknowledge all the book’s contributors for their hard work and enthusiasm, and for finding the time to prepare their cases amidst busy schedules.
Abbreviations
AA aortic arch
AAA abdominal aortic aneurysm
AAFB acid-and-alcohol fast bacilli
AAST American Association for the Surgery of Trauma
It is helpful for finals to have an understanding of the core imaging modalities you are likely to encounter and to have an idea of the relative strengths/weaknesses and indications/ contraindications for each.
PLAIN FILMS: CHEST X-RAY, ABDOMINAL X-RAY, AND ORTHOPAEDIC BONE/JOINT X-RAYS
Conventional X-ray remains an important diagnostic tool in medicine and remains the most commonly used imaging modality. Plain films are commonly the chest X-ray (CXR), abdominal X-ray (AXR), and orthopaedic bone/joint X-rays (XRs). An XR is relatively inexpensive, time effective, and does not require any special preparation of the patient. There is a degree of ionising radiation associated with X-ray exposure and this radiation dose varies with body part; a lumbar spine XR entails a far higher radiation dose than a wrist XR for example owing to radiation of pelvic organs. However, generally X-ray doses are far lower than those associated with computed tomography (CT). Dose information is included in Chapters 3 and 4. As always ’justify‘ the exposure: does the benefit to the patient outweigh the potential risk of irradiation?
When a radiograph is taken, the X-ray beam passes through the body part onto an X-ray sensitive screen. Bones, owing to their high calcium content, absorb most of the X-rays whereas soft tissues absorb a smaller amount, depending on composition and density. As a result, X-rays from the bones do not reach the screen and appear white on the radiograph, with the soft tissue appearing darker. X-rays pass through the air without being absorbed at all, which is then detected by the screen and appears black on the radiograph.
ADVANTAGES
• I nexpensive.
• Usually quick to perform.
• Painless, noninvasive.
• Good diagnostic tool for many pathologies.
DISADVANTAGES
• Soft tissue, lung, bone resolution much reduced compared with CT/magnetic resonance imaging (MRI).
• Provides a two-dimensional (2D), single image only.
Ultrasound (US) uses sound waves of high frequencies, which are emitted towards the studied tissues and are reflected/echoed back to the probe depending on the tissue density and composition. This signal is then translated into an US image. US is a ‘live’ imaging modality and requires interpretation while the investigation is being carried out. US colour Doppler techniques are used to assess moving blood and are used in vascular assessment, e.g. carotid stenosis.
ADVANTAGES
• No radiation, noninvasive (some US is performed using endocavity probes, e.g. transrectal, transvaginal, transoesophageal).
• Real-time assessment and interpretation of results.
• Relatively inexpensive.
• Useful for imaging of soft tissue and muscles, extremities, testes, breast, and eye, plus abdomen, pelvis, chest, and vascular colour Doppler applications.
DISADVANTAGES
• Requires a skilled practitioner with US interpretation skills, operator dependent.
• No use for bone imaging as sound is attenuated/absorbed by bone.
• Images are degraded by gas and fat, and this restricts US use in the abdomen/pelvis in some patients.
CT uses X-rays, which are emitted from a rotating X-ray source around the patient with multiple detectors to produce a series of 2D axial images of the studied body part. This can then be computer-reconstructed to obtain axial, coronal, sagittal 2D, and three-dimensional (3D) images of the studied body parts. There are other imaging modalities that make use of CT imaging such as positron emission tomography (PET scan).
ADVANTAGES
• Provides 2D cross-sectional images of the body, which are rapidly acquired with the potential to reformat in multiple planes; 3D reformatting is also possible.
• Provides a detailed image of the studied body part and the surrounding tissue.
• High sensitivity and specificity in particular for assessment of the lungs, mediastinum, bones, abdomen/pelvis structures, the brain – especially acute blood.
DISADVANTAGES
• CT scanners are expensive.
• Moderate to high dose of radiation, depending on areas scanned.
• May require intravenous (IV) iodinated contrast use – risk of contrast reaction (allergy, anaphylaxis) and nephrotoxicity in those at risk.
• Chest – detailed imaging of the lungs to detect abnormalities not seen on CXR, used in diagnosis and surveillance of malignancy, pulmonary embolism (CT pulmonary angiogram: CTPA), emphysema, fibrosis. Cardiac – CT to image coronary arteries.
• Abdomen and pelvis – diagnosis, staging, and surveillance of malignancies, bowel obstruction, AAA, pancreatitis, renal calculi (CT kidneys ureters and bladder [CT KUB] and CT IV urogram [CT IVU]).
• CT angiography and venography – for example, suspected limb or mesenteric vascular occlusion, sagittal sinus thrombosis.
• Orthopaedic – complex fractures.
• CT-guided biopsy, surgery, and radiosurgery.
MAGNETIC RESONANCE IMAGING
MRI does not use any X-rays, thus does not expose the patient to ionising radiation. It is superior to CT in obtaining detailed images of the soft tissues and also the brain. MRI uses strong magnetic fields, radio waves, and field gradients to generate the image.
In structural MRI, the images are obtained by proton alignment by an external magnet and a subsequent radiofrequency pulse disrupts the equilibrium, which gives an MRI signal. Details of MRI protocols and sequences are not needed for finals – T1- and T2-weighted are common sequences (in the brain cerebrospinal fluid [CSF] appears bright/white on T2), and IV contrast can also be used (gadolinium).
ADVANTAGES
• No ionising radiation exposure.
• Provides 2D and 3D cross-sectional images of the body.
• Superior to other imaging modalities in obtaining high-resolution images of the brain and musculoskeletal system.
• Ideal for soft tissue structures, cartilage, and ligament imaging.
• Vascular and cardiac applications.
DISADVANTAGES
• Expensive equipment – the most expensive imaging modality.
• Time consuming, requiring patient cooperation, ability to lie still, often for 30–60 minutes.
• Contraindicated in patients with ferrous metal implants – pacemakers, cochlear implants, metallic foreign bodies in the eyes.
• MRI is undertaken in a relatively enclosed space – unsuitable for patients with claustrophobia and young children (may need general anaesthesia).
• Relatively contraindicated in pregnancy, particularly first trimester.
INDICATIONS
• Head and neck – neuroimaging – clear differentiation between the grey and white matter, diagnosis of demyelinating disease, cerebrovascular disease, detailed imaging of malignancies and infectious diseases, epilepsy imaging, functional MRI brain studies. CT is more accurate in the detection of acute blood; new MRI techniques, e.g. diffusion weighting, can detect cerebral ischaemia very early (minutes) when compared with CT.
• Hepatobiliary – liver, pancreas, and biliary lesions, MR cholangiopancreatography (MRCP) for structural imaging of the biliary tree.
• Small bowel – Crohn’s disease diagnosis.
• Knee and other joints – used in cartilage and ligament imaging.
• Angiographic, vascular protocols, cardiac MRI.
• Prostate imaging, diagnosis, and staging of prostate cancer.
• Rectal, gynaecological cancer staging.
NUCLEAR MEDICINE
Nuclear medicine uses injected (or inhaled) radioactive isotopes to diagnose or treat many conditions: endocrine, heart, and gastrointestinal (GI) diseases. It images the emission of isotope radiation from within the body and can construct a 2D/3D image of the areas of the radioactive substance uptake. It is used for functional imaging, rather than structural imaging, as contrast/ spatial resolution is poor. Some nuclear medicine is combined with CT/MRI to improve anatomical detail.
IMAGING MODALITIES
• Myocardial perfusion scan – assessment of the function of myocardium for diagnosis of hypertrophic cardiomyopathy and coronary artery disease, in combination with MRI +/– CT.
• Genitourinary scan – assessment of renal blood flow and function, evaluate renovascular hypertension, and assess vesicoureteral reflux.
• Bone imaging – assessment of bone metastases, infection.
• PET – imaging of metastases, neuroimaging – imaging of brain activity in dementias, combining injection of metabolically active substances, e.g. fluorodeoxyglucose (FDG) and tomography/CT detection.
ADVANTAGES
• Provides functional information of organs and disease processes.
• Advancement of treatment options for cancer patients.
• Allows early or improved detection of metastases (PET).
• Provides detailed and accurate information in hard to reach areas.
• Radioisotopes are used to treat some cancers, e.g. radioiodine and papillary thyroid cancer.
DISADVANTAGES
• High cost.
• Exposure to radiation doses, which may be significant, e.g. PET.
• Not all techniques are widely available, e.g. PET.
FLUOROSCOPY TECHNIQUES
Fluoroscopy combines ionising radiation from X-ray exposure with administration (ingested/ injected) of contrast medium, which is then imaged passing through the structures/organs of interest to assess their function and structure in real time. Examples include:
• Contrast swallow – assessment of the structure and function of the pharynx and oesophagus (largely replaced by oesophago-gastro-duodenoscopy [OGD]).
• Barium follow through – assessment of the structure and function of the small bowel (MRI small bowel replacing).
• Contrast enema – assessment of structure and function of the large bowel and rectum (colonoscopy replacing), used particularly to evaluate the integrity of postoperative bowel anastomoses.
• Tubogram (hysterosalpingography) – assessment of the shape of the uterine cavity and the shape and patency of the Fallopian tubes.
• Arteriogram, venogram (CT/MRI replacing).
ADVANTAGES
• Allow a ‘live’ assessment.
• Relatively inexpensive, readily available.
• Relatively noninvasive.
DISADVANTAGES
• Exposure to ionising radiation, which may be significant, e.g. barium enema.
• Poor soft tissue resolution.
• Endoscopy techniques are more accurate in bowel mucosal assessment and allow tissue biopsies.
Hints and tips for finals Objective Structured Clinical Examination
THOMAS KURKA
The OSCE (Objective Structured Clinical Examination) is designed to test clinical and communication skills in a structured environment in real time. Many medical schools use the ‘integrated station’ approach in their OSCE exams, which means that you may be asked to take a focused history, do a part of a clinical examination, and interpret a test result all in one station. This tests your knowledge, skills, and your thinking process towards reaching a working diagnosis. Remember that most people pass their OSCE and you are allowed to fail a small proportion of the stations –your medical school will be able to advise on the specific rules of the exam.
LOGISTICS OF PREPARATION AND THE DAY ITSELF
• P ractice ... practice ... practice! Then practice even more. It is important to have some regular quality group study time before your OSCE. This exam is about your skills and practical experience, and you cannot pass the OSCE if you only study from books.
• You should observe other students practicing OSCE-style scenarios, give each other constructive feedback, and correct mistakes. It is important to be helpful and polite to your colleagues and friends but it is very important to be constructive with your feedback and verbalise what went wrong. Some people may not be aware of their mistakes and cannot improve unless you tell them.
• A lthough it may seem intimidating, do ask doctors to assess you when on the wards. Most are keen to teach and help you pass and it will give you more experience in presenting real cases.
• T he OSCE is a role play, not a real-life scenario. You need to learn to play the game. Speak to previous students who passed finals OSCE at your medical school to understand the structure of the stations and the day.
• H ave a good night’s sleep before the OSCE day. Tiredness decreases concentration and organisational skills and hinders your ability to communicate effectively. The OSCE is a type of performance and you need to be fresh and alert to perform well.
• Read the OSCE station instructions properly and follow the script – this ensures you stay on the topic of the OSCE station and will earn you points. If the station says take a history from the patient you will not score any points on educating or advising the patient. Stay focused on the tasks specified in your station brief.
• Begin every station with a polite introduction of yourself. Knock on the door before entering and say hello with a smile on your face (even a nervous smile counts). Introduce yourself with a full name and your role, and do not forget to articulate. Most feedback from the patients from OSCE stations was that they could not understand the students’ names and introduction because they spoke too fast as they were nervous. Be the one to be remembered for appearing calm, with a smile on your face and a clear introduction.
• Ask your patient’s permission to take their history and/or examine them – there is a mark for gaining a verbal consent.
• Follow up with letting the patient tell you their story – this will allow you to have a minute to catch your breath and to connect with the patient.
• Finally, the staff who are examining you want you to pass and you need to give them the opportunity to give you the points!
YOUR COMMUNICATION SKILLS
• Smile and adopt an approachable body language.
• Make sure that each station is a dialogue between you and the patient. Avoid leading and closed-end questions, especially in the history of the presenting complaint.
• There is a balance between letting the patient explain their symptoms or problems, and them rumbling on for too long, which could be a distraction taking you off the path of the station – keep the conversation focused to the topic of the station but ensure you do not cut the patient off too soon, which could appear impolite and potentially damage the doctor–patient relationship. If you need to interrupt their story, apologise for doing so, acknowledge what they were saying, and offer to return to it if there is time at the end.
• Avoid all medical jargon! It is natural for medical students in the final year to be very familiar and fluent in medical jargon but most patients do not understand these terms and OSCEs will test that you can communicate using simple terms.
• Be clear and succinct when giving advice to the patients and always ensure their understanding – the best way is to ask the patient to repeat it back to you in their own words.
• Do not ever sound patronising or forceful with any advice you give to the patient! Remember, patients have a right to autonomy, which means that you should only advise and they can choose to accept or decline your advice (assuming full mental capacity).
• Many students like to repeat the history back to the patients at the end to summarise and buy some time to think about what next. This may not be recommended in finals especially if your OSCE station is only 8–10 minutes long. During a finals OSCE, you will have more than the history to get through (blood results, imaging or further questions) so do not waste time on repetition as you could run out of time by the end and lose some valuable points.
• OSCE stations are often divided into two sections, an 8-minute station has 4 minutes for history, for example, and then 4 minutes for further questions/looking at results/differential/ further management. The examiner will usually prompt you at 4 minutes if needed.
• Listen to your patients and respond directly to what they are saying. The patient (or actor) is playing by the script and they will not mislead or give you any wrong information.
Another random document with no related content on Scribd:
and children, who were at peace in their own fields and houses, merely to save them from death? 2. Was it to save them from death, that they knock’d out the brains of those they could not bring away? 3. Who occasioned and fomented those wars, wherein these poor creatures were taken prisoners? Who excited them by money, by drink, by every possible means, to fall upon one another? Was it not themselves? They know in their own conscience it was, if they have any conscience left. But 4. To bring the matter to a short issue. Can they say before God, That they ever took a single voyage, or bought a single negro from this motive? They cannot, they well know, to get money, not to save lives, was the whole and sole spring of their motions.
5. But if this manner of procuring and tearing negroes is not consistent either with mercy or justice, yet there is a plea for it which every man of business will acknowledge to be quite sufficient. Fifty years ago, one meeting an eminent statesman in the lobby of the House of Commons, said, “You have been long talking about justice and equity, Pray which is this bill? Equity or justice?” He answered, very short, and plain, “D—n justice: it is necessity.” Here also the slave-holder fixes his foot: here he rests the strength of his cause. “If it is not quite right, yet it must be so: there is an absolute necessity for it. It is necessary we should procure slaves: and when we have procured them, it is necessary to use them with severity, considering their stupidity, stubbornness and wickedness.”
I answer, You stumble at the threshold: I deny that villany is ever necessary. It is impossible that it should ever be necessary, for any reasonable creature to violate all the laws of justice, mercy, and truth. No circumstances can make it necessary for a man to burst in sunder all the ties of humanity. It can never be necessary for a rational being to sink himself below a brute. A man can be under no necessity, of degrading himself into a wolf. The absurdity of the supposition is so glaring, that one would wonder any one could help seeing it.
6. This in general. But to be more particular, I ask, 1. What is necessary? And secondly, To what end? It may be answered, “The whole method now used by the original purchasers of negroes, is
necessary to the furnishing our colonies yearly with a hundred thousand slaves.” I grant this is necessary to that end. But how is that end necessary? How will you prove it necessary that one hundred, that one of those slaves should be procured? “Why, it is necessary to my gaining an hundred thousand pounds.” Perhaps so: but how is this necessary? It is very possible you might be both a better and a happier man, if you had not a quarter of it. I deny that your gaining one thousand is necessary, either to your present or eternal happiness. “But however you must allow, these slaves are necessary for the cultivation of our Islands: inasmuch as white men are not able to labour in hot climates.” I answer, 1. It were better that all those Islands should remain uncultivated for ever, yea, it were more desirable that they were altogether sunk in the depth of the sea, than that they should be cultivated at so high a price, as the violation of justice, mercy and truth. But, secondly, the supposition on which you ground your argument is false. For white men, even English men, are well able to labour in hot climates: provided they are temperate both in meat and drink, and that they inure themselves to it by degrees. I speak no more than I know by experience. It appears from the thermometer, that the summer heat in Georgia, is frequently equal to that in Barbadoes, yea to that under the line. And yet I and my family (eight in number) did employ all our spare time there, in felling of trees and clearing of ground, as hard labour as any negro need be employed in. The German family likewise, forty in number, were employed in all manner of labour. And this was so far from impairing our health, that we all continued perfectly well, while the idle ones round about us, were swept away as with a pestilence. It is not true therefore that white men are not able to labour, even in hot climates, full as well as black. But if they were not, it would be better that none should labour there, that the work should be left undone, than that myriads of innocent men should be murdered, and myriads more dragged into the basest slavery
7. “But the furnishing us with slaves is necessary, for the trade, and wealth, and glory of our nation:” here are several mistakes. For 1. Wealth is not necessary to the glory of any nation; but wisdom, virtue, justice, mercy, generosity, public spirit, love of our country.
These are necessary to the real glory of a nation; but abundance of wealth is not. Men of understanding allow, that the glory of England was full as high, in Queen Elizabeth’s time as it is now: although our riches and trade were then as much smaller, as our virtue was greater. But, secondly, it is not clear, that we should have either less money or trade, (only less of that detestable trade of man-stealing) if there was not a negro in all our Islands, or in all English America. It is demonstrable, white men, inured to it by degrees can work as well as them: and they would do it, were negroes out of the way, and proper encouragement given them. However, thirdly, I come back to the same point: better no trade, than trade procured by villany. It is far better to have no wealth, than to gain wealth at the expence of virtue. Better is honest poverty, than all the riches bought by the tears, and sweat and blood of our fellow-creatures.
8. “However this be; it is necessary when we have slaves, to use them with severity.” What, to whip them for every petty offence, till they are all in gore blood? To take that opportunity, of rubbing pepper and salt into their raw flesh? To drop burning sealing-wax upon their skin? To castrate them? To cut off half their foot with an axe? To hang them on gibbets, that they may die by inches, with heat, and hunger, and thirst? To pin them down to the ground, and then burn them by degrees, from the feet, to the head? To roast them alive?— When did a Turk or a Heathen find it necessary to use a fellowcreature thus?
I pray, to what end is this usage necessary? “Why, to prevent their running away: and to keep them constantly to their labour, that they may not idle away their time. So miserably stupid is this race of men, yea, so stubborn and so wicked.” Allowing them to be as stupid as you say, to whom is that stupidity owing? Without question it lies altogether at the door of their inhuman masters: who give them no means, no opportunity of improving their understanding: and indeed leave them no motive, either from hope or fear, to attempt any such thing. They were no way remarkable for stupidity, while they remained in their own country: the inhabitants of Africa where they have equal motives and equal means of improvement, are not inferior to the inhabitants of Europe: to some of them they are greatly
superior Impartially survey in their own country, the natives of Benin, and the natives of Lapland. Compare, (setting prejudice aside) the Samoeids and the Angolans. And on which side does the advantage lie, in point of understanding? Certainly the African is in no respect inferior to the European. Their stupidity therefore in our plantations is not natural; otherwise than it is the natural effect of their condition. Consequently it is not their fault, but your’s: you must answer for it, before God and man.
9. “But their stupidity is not the only reason of our treating them with severity. For it is hard to say, which is the greatest, this or their stubbornness and wickedness.”——It may be so: But do not these as well as the other, lie at your door; are not stubbornness, cunning, pilfering, and divers other vices, the natural, necessary fruits of slavery? Is not this an observation which has been made, in every age and nation?——And what means have you used to remove this stubbornness? Have you tried what mildness and gentleness would do? I knew one that did: that had prudence and patience to make the experiment: Mr. Hugh Bryan, who then lived on the borders of SouthCarolina. And what was the effect? Why, that all his negroes (and he had no small number of them) loved and reverenced him as a father, and chearfully obeyed him out of love. Yea, they were more afraid of a frown from him, than of many blows from an overseer. And what pains have you taken, what method have you used, to reclaim them from their wickedness? Have you carefully taught them,
“That there is a God, a wise, powerful, merciful being, the Creator and Governor of heaven and earth? That he has appointed a day wherein he will judge the world, will take an account of all our thoughts, words and actions? That in that day he will reward every child of man according to his works: that “then the righteous shall inherit the kingdom prepared for them from the foundation of the world: and the wicked shall be cast into everlasting fire, prepared for the devil and his angels.” If you have not done this, if you have taken no pains or thought about the matter, can you wonder at their wickedness? What wonder, if they should cut your throat? And if they did, whom could you thank for it but yourself? You first acted the villain in making them slaves, (whether you stole them or bought
them.) You kept them stupid and wicked, by cutting them off from all opportunities of improving either in knowledge or virtue: and now you assign their want of wisdom and goodness as the reason for using them worse than brute beasts!
1. It remains only to make a little application of the preceding observations.—But to whom should that application be made? That may bear a question. Should we address ourselves to the public at large? What effect can this have? It may inflame the world against the guilty, but is not likely to remove that guilt. Should we appeal to the English nation in general? This also is striking wide; and is never likely to procure any redress for the sore evil we complain of.—As little would it in all probability avail, to apply to the Parliament. So many things, which seem of greater importance lie before them that they are not likely to attend to this. I therefore add a few words to those who are more immediately concerned, whether captains, merchants or planters.
2. And, first, to the captains employed in this trade. Most of you know, the country of Guinea: several parts of it at least, between the river Senegal and the kingdom of Angola. Perhaps now, by your means, part of it is become a dreary uncultivated wilderness, the inhabitants being all murdered or carried away, so that there are none left to till the ground. But you well know, how populous, how fruitful, how pleasant it was a few years ago. You know the people were not stupid, not wanting in sense, considering the few means of improvement they enjoyed. Neither did you find them savage, fierce, cruel, treacherous, or unkind to strangers. On the contrary, they were in most parts, a sensible and ingenious people. They were kind and friendly, courteous and obliging, and remarkably fair and just in their dealings. Such are the men whom you hire their own countrymen, to tear away from this lovely country; part by stealth, part by force, part made captive in those wars, which you raise or foment on purpose. You have seen them torn away, children from their parents, parents from their children: husbands from their wives, wives from their beloved husbands, brethren and sisters from each other. You have dragged them who had never done you any wrong, perhaps in chains, from their native shore. You have forced them into your ships like an herd of swine, them who had souls immortal as your own:
(only some of them, leaped into the sea, and resolutely stayed under water, till they could suffer no more from you.) You have stowed them together as close as ever they could lie, without any regard either to decency or convenience. And when many of them had been poisoned by foul air, or had sunk under various hardships, you have seen their remains delivered to the deep, till the sea should give up its dead. You have carried the survivors into the vilest slavery, never to end but with life: such slavery as is not found among the Turks at Algiers, no nor among the Heathens in America.
3. May I speak plainly to you? I must. Love constrains me: love to you, as well as to those you are concerned with. Is there a God? You know there is. Is he a just God? Then there must be a state of retribution: a state wherein the just God will reward every man according to his works. Then what reward will he render to you? O think betimes! Before you drop into eternity! Think now, He shall have judgment without mercy that hath shewed no mercy. Are you a man? Then you should have a human heart. But have you indeed? What is your heart made of? Is there no such principle as compassion there? Do you never feel another’s pain? Have you no sympathy? No sense of human woe? No pity for the miserable? When you saw the flourishing eyes, the heaving breasts, or the bleeding sides and tortured limbs of your fellow-creatures, was you a stone, or a brute? Did you look upon them with the eyes of a tiger? When you squeezed the agonizing creatures down in the ship, or when you threw their poor mangled remains into the sea, had you no relenting? Did not one tear drop from your eye, one sigh escape from your breast? Do you feel no relenting now? If you do not, you must go on, till the measure of your iniquities is full. Then will the great God deal with you, as you have dealt with them, and require all their blood at your hands. And at that day it shall be more tolerable for Sodom and Gomorrah than for you! But if your heart does relent, though in a small degree, know it is a call from the God of love. And to-day, if you will hear his voice, harden not your heart. To-day resolve, God being your helper, to escape for your life. Regard not money! All that a man hath will he give for his life! Whatever you
lose, lose not your soul: nothing can countervail that loss. Immediately quit the horrid trade: at all events, be an honest man.
4. This equally concerns every Merchant, who is engaged in the Slave-trade. It is you that induce the African villain to sell his countrymen; and in order thereto, to steal, rob, murder men, women and children without number: by enabling the English villain to pay him for so doing; whom you over pay for his execrable labour. It is your money, that is the spring of all, that impowers him to go on: so that whatever he or the African does in this matter, is all your act and deed. And is your conscience quite reconciled to this? Does it never reproach you at all? Has gold entirely blinded your eyes, and stupified your heart? Can you see, can you feel no harm therein? Is it doing as you would be done to? Make the case your own. “Master,” said a Slave at Liverpool (to the Merchant that owned him) “what if some of my countrymen were to come here, and take away my mistress, and master Tommy and master Billy and carry them into our country, and make them slaves, how would you like it?” His answer was worthy of a man: “I will never buy a slave more while I live.” O let his resolution be your’s! Have no more any part in this detestable business. Instantly leave it to those unfeeling wretches, “Who laugh at human nature and compassion!” Be you a man! Not a wolf, a devourer of the human species! Be merciful, that you may obtain mercy!
5. And this equally concerns every gentleman that has an estate in our American plantations: yea all Slave-holders of whatever rank and degree: seeing men-buyers are exactly on a level with men-stealers. Indeed you say, “I pay honestly for my goods: and I am not concerned to know how they are come by”: nay but you are: you are deeply concerned to know they are honestly come by. Otherwise you are partaker with a thief, and are not a jot honester than him. But you know, they are not honestly come by: you know they are procured by means, nothing near so innocent as picking pockets, housebreaking, or robbery upon the high-way. You know they are procured by a deliberate series of more complicated villany, (of fraud, robbery and murder) than was ever practised either by Mahometans or Pagans: in particular by murders of all kinds; by the blood of the
innocent poured upon the ground like water Now it is your money that pays the Merchant, and through him the Captain, and the African butchers. You therefore are guilty, yea principally guilty, of all these frauds, robberies and murders. You are the spring that puts all the rest in motion: they would not stir a step without you: therefore the blood of all these wretches, who die before their time, whether in the country or elsewhere, lies upon your head. The blood of thy brother, (for, whether thou wilt believe it or no, such he is in the sight of Him that made him) crieth against thee from the earth, from the ship, and from the waters. O, whatever it costs, put a stop to its cry before it be too late: instantly, at any price, were it the half of your goods, deliver thyself from blood-guiltiness! Thy hands, thy bed, thy furniture, thy house, thy lands are at present stained with blood. Surely it is enough; accumulate no more guilt: spill no more the blood of the innocent! Do not hire another to shed blood: do not pay him for doing it! Whether you are a Christian or no, shew yourself a man! Be not more savage than a lion or a bear!
6. Perhaps you will say, “I do not buy any Negroes: I only use those left by my father.” So far is well: but is it enough to satisfy your own conscience? Had your father, have you, has any man living, a right to use another as a slave? It cannot be, even setting revelation aside. It cannot be that either war, or contract, can give any man such a property in another as he has in his sheep and oxen. Much less is it possible, that any child of man, should ever be born a slave. Liberty is the right of every human creature, as soon as he breathes the vital air And no human law can deprive him of that right, which he derives from the law of nature.
If therefore you have any regard to justice, (to say nothing of mercy, nor the revealed law of God) render unto all their due. Give liberty to whom liberty is due, that is to every child of man, to every partaker of human nature. Let none serve you but by his own act and deed, by his own voluntary choice. Away with all whips, all chains, all compulsion! Be gentle toward all men, and see that you invariably do unto every one, as you would he should do unto you.
7. O thou God of love, thou who art loving to every man, and whose mercy is over all thy works; thou who art the Father of the spirits of
all flesh, and who art rich in mercy unto all; thou who has mingled of one blood, all the nations upon the earth; have compassion upon these outcasts of men, who are trodden down as dung upon the earth! Arise and help these that have no helper, whose blood is spilt upon the ground like water! Are not these also the work of thine own hands, the purchase of thy Son’s blood? Stir them up to cry unto thee in the land of their captivity; and let their complaint come up before thee; let it enter into thy ears! Make even those that lead them away captive to pity them, and turn their captivity as the rivers in the South. O burst thou all their chains in sunder; more especially the chains of their sins: Thou, Saviour of all, make them free, that they may be free indeed!
The servile progeny of Ham Seize as the purchase of thy blood! Let all the Heathens know thy name, From Idols to the living God; The dark Americans convert, And shine in every Pagan heart.
F I N I S
Transcriber’s Note
Clear printer’s errors have been corrected by the transcriber; as far as possible, however, original spelling and punctuation have been preserved.
*** END OF THE PROJECT GUTENBERG EBOOK THOUGHTS UPON SLAVERY ***
Updated editions will replace the previous one—the old editions will be renamed.
Creating the works from print editions not protected by U.S. copyright law means that no one owns a United States copyright in these works, so the Foundation (and you!) can copy and distribute it in the United States without permission and without paying copyright royalties. Special rules, set forth in the General Terms of Use part of this license, apply to copying and distributing Project Gutenberg™ electronic works to protect the PROJECT GUTENBERG™ concept and trademark. Project Gutenberg is a registered trademark, and may not be used if you charge for an eBook, except by following the terms of the trademark license, including paying royalties for use of the Project Gutenberg trademark. If you do not charge anything for copies of this eBook, complying with the trademark license is very easy. You may use this eBook for nearly any purpose such as creation of derivative works, reports, performances and research. Project Gutenberg eBooks may be modified and printed and given away—you may do practically ANYTHING in the United States with eBooks not protected by U.S. copyright law. Redistribution is subject to the trademark license, especially commercial redistribution.
START: FULL LICENSE
THE FULL PROJECT GUTENBERG LICENSE
PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK
To protect the Project Gutenberg™ mission of promoting the free distribution of electronic works, by using or distributing this work (or any other work associated in any way with the phrase “Project Gutenberg”), you agree to comply with all the terms of the Full Project Gutenberg™ License available with this file or online at www.gutenberg.org/license.
Section 1. General Terms of Use and Redistributing Project Gutenberg™ electronic works
1.A. By reading or using any part of this Project Gutenberg™ electronic work, you indicate that you have read, understand, agree to and accept all the terms of this license and intellectual property (trademark/copyright) agreement. If you do not agree to abide by all the terms of this agreement, you must cease using and return or destroy all copies of Project Gutenberg™ electronic works in your possession. If you paid a fee for obtaining a copy of or access to a Project Gutenberg™ electronic work and you do not agree to be bound by the terms of this agreement, you may obtain a refund from the person or entity to whom you paid the fee as set forth in paragraph 1.E.8.
1.B. “Project Gutenberg” is a registered trademark. It may only be used on or associated in any way with an electronic work by people who agree to be bound by the terms of this agreement. There are a few things that you can do with most Project Gutenberg™ electronic works even without complying with the full terms of this agreement. See paragraph 1.C below. There are a lot of things you can do with Project Gutenberg™ electronic works if you follow the terms of this agreement and help preserve free future access to Project Gutenberg™ electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the Foundation” or PGLAF), owns a compilation copyright in the collection of Project Gutenberg™ electronic works. Nearly all the individual works in the collection are in the public domain in the United States. If an individual work is unprotected by copyright law in the United States and you are located in the United States, we do not claim a right to prevent you from copying, distributing, performing, displaying or creating derivative works based on the work as long as all references to Project Gutenberg are removed. Of course, we hope that you will support the Project Gutenberg™ mission of promoting free access to electronic works by freely sharing Project Gutenberg™ works in compliance with the terms of this agreement for keeping the Project Gutenberg™ name associated with the work. You can easily comply with the terms of this agreement by keeping this work in the same format with its attached full Project Gutenberg™ License when you share it without charge with others.
1.D. The copyright laws of the place where you are located also govern what you can do with this work. Copyright laws in most countries are in a constant state of change. If you are outside the United States, check the laws of your country in addition to the terms of this agreement before downloading, copying, displaying, performing, distributing or creating derivative works based on this work or any other Project Gutenberg™ work. The Foundation makes no representations concerning the copyright status of any work in any country other than the United States.
1.E. Unless you have removed all references to Project Gutenberg:
1.E.1. The following sentence, with active links to, or other immediate access to, the full Project Gutenberg™ License must appear prominently whenever any copy of a Project Gutenberg™ work (any work on which the phrase “Project Gutenberg” appears, or with which the phrase “Project
Gutenberg” is associated) is accessed, displayed, performed, viewed, copied or distributed:
This eBook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.org. If you are not located in the United States, you will have to check the laws of the country where you are located before using this eBook.
1.E.2. If an individual Project Gutenberg™ electronic work is derived from texts not protected by U.S. copyright law (does not contain a notice indicating that it is posted with permission of the copyright holder), the work can be copied and distributed to anyone in the United States without paying any fees or charges. If you are redistributing or providing access to a work with the phrase “Project Gutenberg” associated with or appearing on the work, you must comply either with the requirements of paragraphs 1.E.1 through 1.E.7 or obtain permission for the use of the work and the Project Gutenberg™ trademark as set forth in paragraphs 1.E.8 or 1.E.9.
1.E.3. If an individual Project Gutenberg™ electronic work is posted with the permission of the copyright holder, your use and distribution must comply with both paragraphs 1.E.1 through 1.E.7 and any additional terms imposed by the copyright holder. Additional terms will be linked to the Project Gutenberg™ License for all works posted with the permission of the copyright holder found at the beginning of this work.
1.E.4. Do not unlink or detach or remove the full Project Gutenberg™ License terms from this work, or any files containing a part of this work or any other work associated with Project Gutenberg™.
1.E.5. Do not copy, display, perform, distribute or redistribute this electronic work, or any part of this electronic work, without prominently displaying the sentence set forth in paragraph 1.E.1 with active links or immediate access to the full terms of the Project Gutenberg™ License.
1.E.6. You may convert to and distribute this work in any binary, compressed, marked up, nonproprietary or proprietary form, including any word processing or hypertext form. However, if you provide access to or distribute copies of a Project Gutenberg™ work in a format other than “Plain Vanilla ASCII” or other format used in the official version posted on the official Project Gutenberg™ website (www.gutenberg.org), you must, at no additional cost, fee or expense to the user, provide a copy, a means of exporting a copy, or a means of obtaining a copy upon request, of the work in its original “Plain Vanilla ASCII” or other form. Any alternate format must include the full Project Gutenberg™ License as specified in paragraph 1.E.1.
1.E.7. Do not charge a fee for access to, viewing, displaying, performing, copying or distributing any Project Gutenberg™ works unless you comply with paragraph 1.E.8 or 1.E.9.
1.E.8. You may charge a reasonable fee for copies of or providing access to or distributing Project Gutenberg™ electronic works provided that:
• You pay a royalty fee of 20% of the gross profits you derive from the use of Project Gutenberg™ works calculated using the method you already use to calculate your applicable taxes. The fee is owed to the owner of the Project Gutenberg™ trademark, but he has agreed to donate royalties under this paragraph to the Project Gutenberg Literary Archive Foundation. Royalty payments must be paid within 60 days following each date on which you prepare (or are legally required to prepare) your periodic tax returns. Royalty payments should be clearly marked as such and sent to the Project Gutenberg Literary Archive Foundation at the address specified in Section 4, “Information
about donations to the Project Gutenberg Literary Archive Foundation.”
• You provide a full refund of any money paid by a user who notifies you in writing (or by e-mail) within 30 days of receipt that s/he does not agree to the terms of the full Project Gutenberg™ License. You must require such a user to return or destroy all copies of the works possessed in a physical medium and discontinue all use of and all access to other copies of Project Gutenberg™ works.
• You provide, in accordance with paragraph 1.F.3, a full refund of any money paid for a work or a replacement copy, if a defect in the electronic work is discovered and reported to you within 90 days of receipt of the work.
• You comply with all other terms of this agreement for free distribution of Project Gutenberg™ works.
1.E.9. If you wish to charge a fee or distribute a Project Gutenberg™ electronic work or group of works on different terms than are set forth in this agreement, you must obtain permission in writing from the Project Gutenberg Literary Archive Foundation, the manager of the Project Gutenberg™ trademark. Contact the Foundation as set forth in Section 3 below.
1.F.
1.F.1. Project Gutenberg volunteers and employees expend considerable effort to identify, do copyright research on, transcribe and proofread works not protected by U.S. copyright law in creating the Project Gutenberg™ collection. Despite these efforts, Project Gutenberg™ electronic works, and the medium on which they may be stored, may contain “Defects,” such as, but not limited to, incomplete, inaccurate or corrupt data, transcription errors, a copyright or other intellectual property infringement, a defective or damaged disk or other
medium, a computer virus, or computer codes that damage or cannot be read by your equipment.
1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGESExcept for the “Right of Replacement or Refund” described in paragraph 1.F.3, the Project Gutenberg Literary Archive Foundation, the owner of the Project Gutenberg™ trademark, and any other party distributing a Project Gutenberg™ electronic work under this agreement, disclaim all liability to you for damages, costs and expenses, including legal fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE PROVIDED IN PARAGRAPH
1.F.3. YOU AGREE THAT THE FOUNDATION, THE TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH DAMAGE.
1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a defect in this electronic work within 90 days of receiving it, you can receive a refund of the money (if any) you paid for it by sending a written explanation to the person you received the work from. If you received the work on a physical medium, you must return the medium with your written explanation. The person or entity that provided you with the defective work may elect to provide a replacement copy in lieu of a refund. If you received the work electronically, the person or entity providing it to you may choose to give you a second opportunity to receive the work electronically in lieu of a refund. If the second copy is also defective, you may demand a refund in writing without further opportunities to fix the problem.
1.F.4. Except for the limited right of replacement or refund set forth in paragraph 1.F.3, this work is provided to you ‘AS-IS’, WITH NO OTHER WARRANTIES OF ANY KIND, EXPRESS
OR IMPLIED, INCLUDING BUT NOT LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.
1.F.5. Some states do not allow disclaimers of certain implied warranties or the exclusion or limitation of certain types of damages. If any disclaimer or limitation set forth in this agreement violates the law of the state applicable to this agreement, the agreement shall be interpreted to make the maximum disclaimer or limitation permitted by the applicable state law. The invalidity or unenforceability of any provision of this agreement shall not void the remaining provisions.
1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the trademark owner, any agent or employee of the Foundation, anyone providing copies of Project Gutenberg™ electronic works in accordance with this agreement, and any volunteers associated with the production, promotion and distribution of Project Gutenberg™ electronic works, harmless from all liability, costs and expenses, including legal fees, that arise directly or indirectly from any of the following which you do or cause to occur: (a) distribution of this or any Project Gutenberg™ work, (b) alteration, modification, or additions or deletions to any Project Gutenberg™ work, and (c) any Defect you cause.
Section 2. Information about the Mission of Project Gutenberg™
Project Gutenberg™ is synonymous with the free distribution of electronic works in formats readable by the widest variety of computers including obsolete, old, middle-aged and new computers. It exists because of the efforts of hundreds of volunteers and donations from people in all walks of life.
Volunteers and financial support to provide volunteers with the assistance they need are critical to reaching Project
Gutenberg™’s goals and ensuring that the Project Gutenberg™ collection will remain freely available for generations to come. In 2001, the Project Gutenberg Literary Archive Foundation was created to provide a secure and permanent future for Project Gutenberg™ and future generations. To learn more about the Project Gutenberg Literary Archive Foundation and how your efforts and donations can help, see Sections 3 and 4 and the Foundation information page at www.gutenberg.org.
Section 3. Information about the Project Gutenberg Literary Archive Foundation
The Project Gutenberg Literary Archive Foundation is a nonprofit 501(c)(3) educational corporation organized under the laws of the state of Mississippi and granted tax exempt status by the Internal Revenue Service. The Foundation’s EIN or federal tax identification number is 64-6221541. Contributions to the Project Gutenberg Literary Archive Foundation are tax deductible to the full extent permitted by U.S. federal laws and your state’s laws.
The Foundation’s business office is located at 809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up to date contact information can be found at the Foundation’s website and official page at www.gutenberg.org/contact
Section 4. Information about Donations to the Project Gutenberg Literary Archive Foundation
Project Gutenberg™ depends upon and cannot survive without widespread public support and donations to carry out its mission of increasing the number of public domain and licensed works that can be freely distributed in machine-readable form
