A detailed example of good low tech surgery

[tantric]

There seems to be a general interest in the potential for the application of advanced knowledge in low tech conditions. I ran across this and thought it would be of interest.

This is from: THE DEVELOPMENT OF 'SCIENTIFIC' MEDICINE IN THE AFRICAN KINGDOM OF BUNYORO-KITARA by JNP Davies

The Caesarean Section in Bunyoro in 1879

Indeed it is a strange story. The year I879 was only two years after Lister had moved to London to spread his gospel of antisepsis. Caesarean section was then regarded in England as an operation of the greatest gravity only to be performed in the most desperate of circumstances (Young, I944). Indeed some doubted if it was ever justified. Aseptic surgery was unborn. Felkin remarks that Uganda (presumably Bunyoro) is the only country that he knew of in Central Africa where caesarean section was performed in the hope of saving mother and child. In other areas, as he implies, the mother's life was sacrificed for the child. He was not permitted to examine the woman, indeed he only entered the hut as the operation was starting. The patient was a healthy-looking primipara of about twenty years of age and she lay on an inclined bed, the head of which rested against the side of the hut. She was half intoxicated with banana wine, was quite naked and was tied down to the bed by bands of bark cloth over the thorax and thighs. Her ankles were held by a man who is sketched as squatting on his heels, while another man stood on her right side steadying the abdomen. When Felkin entered the hut the surgeon was standing on her left side holding the knife aloft and muttering an incantation. He then washed his hands and the patient's abdomen first with banana wine and then water. The surgeon gave a shrill cry, re-echoed by the crowd outside, and made a quick cut upwards from just above the pubis to just below the umbilicus severing the whole abdominal wall and uterus so that amniotic fluid escaped. Some bleeding points in the abdominal wall were touched with red hot irons. The surgeon completed the uterine incision, the assistant helping by holding up the sides of abdominal wall with his hand and hooking two fingers into the uterus. The child was removed, and the cord cut and the child was handed to an assistant. The operator then dropped his knife and squeezed the uterus with both hands, and he then dilated the cervix uterus from inside with his fingers. He cleaned the clots and the placenta from the uterus while his assistant was, with no great success, trying to prevent the intestines escaping from the wound. The red hot irons were used to seal off some other bleeding points but Felkin noted specifically that they were used sparingly. The uterus was squeezed till it contracted but was not sutured. A porous grass mat was now tightly secured over the wound and, the restraining hands being removed, the woman was turned over to the edge of the bed and then over the arm of the assistant so that any fluid in the abdominal cavity could drain away. She was put back, the mat removed, and the peritoneal edges were held together and secured, together with the wound edges, by seven well-polished iron spikes which, after insertion, were tied together with skin. The patient, hitherto quiet, uttered a cry as the spikes were inserted. A paste of pulped roots was plastered over the wound, covered with a banana leaf and finally a bandage of cloth was tightly applied thus completing the operation.

Commentary on the Operation

The whole conduct of the operation as Felkin has described it suggests a skilled, long-practised surgical team at work conducting a well-tried and familiar operation with smooth efficiency and unhurried skill. It is this that has so impressed itself on all commentators on Felkin's narrative and which has, in part, made them so dubious. Lister's team in London could hardly have per- formed with greater smoothness. The leader of the team was helped all through by assistants who seemed familiar with their roles. The after treatment followed a clear routine. Moreover, there is clearly shown, even if only in a rudimentary form, an astonishingly advanced conception of surgical technique. There is the use of banana wine, not merely for its stupefying anaesthetic properties, but for washing not only the patient's abdomen but the surgeon's hands. This at a time when there were, it was said, some surgeons in Europe who only washed their hands after the operation! For there is no reason to suppose that banana wine, its alcohol content being up to 7 per cent (or up to 40 per cent if distilled) was not a reasonably efficient cleansing agent under these local conditions. Indeed all through Felkin's narrative can be seen an extraordinary efficient use of convenient local materials, the banana wine, the bark cloth restraining bands, the red hot irons (applied sparingly), the well-polished iron spikes, the porous grass mat, the bark cloth string, the root paste and banana leaf. Equally interesting is the absence of any attempt to suture the uterus, perhaps experience had shown that this was unwise. There would seem to be an appreciation of antiseptic surgery and perhaps even a prevision of aseptic surgery. Were the description of this operation an invention of Felkin's brain he must have had the gifts of a Defoe in his sense of atmosphere and the use of local materials. His other writings do not suggest that this was so

[The Colonel]

Does he mention whether or not the mother survived?

[tantric]

Felkin was able to observe the progress of mother and child for eleven days. The child had sustained a small cut on the shoulder which was dressed and was healed after four days. The fact that it was presumably a breech presentation may have been the indication for performing the operation. The mother's temperature rose on one occasion only, the uterine discharge was healthy but the milk supply was scanty. On the third day the wound was dressed and one of the spikes pulled out, on the fifth day three were removed, the remainder on the sixth day. A fresh dressing was applied each time and a little pus was squeezed out. Felkin could not continue his observations owing to his departure

After eleven days, I'd guess she was out of the woods. It sounds terrible, but apparently it compared well to what was being done in Europe only a short time before.

[The Colonel]

Originally Posted by tantric

After eleven days, I'd guess she was out of the woods. It sounds terrible, but apparently it compared well to what was being done in Europe only a short time before.

I would expect that if sepsis had not set in by that point, it would have required extreme ill luck for it to do so thereafter ... seems to be a pretty successful operation for the time: IIRC it would be into the C20 before a woman could remain fertile after a Caesar and within the last 20-30 years that technique allowed a natural delivery to follow a Caesar. I would guess most European surgeons couldn't be sure of their patient in 1879 and, as you say, would have probably been less effective prior to that.

[Agemegos]

Originally Posted by The Colonel

IIRC it would be into the C20 before a woman could remain fertile after a Caesar and within the last 20-30 years that technique allowed a natural delivery to follow a Caesar.

My mother had a Caesarian in 1949 followed by vaginal deliveries in 1951, 1953, 1954, 1957, and 1964. It wasn't even considered especially remarkable.

[sir_pudding]

I'm not sure if the procedure described actually qualifies as TL 4 or less. I realize that Uganda probably wasn't TL5 in 1879 overall, but this procedure seems to have most of the features of late TL5 (or even early TL6, though without anesthesia) surgery...

[Flyndaran]

Originally Posted by Agemegos

My mother had a Caesarian in 1949 followed by vaginal deliveries in 1951, 1953, 1954, 1957, and 1964. It wasn't even considered especially remarkable.

Could that be your mother misremembering a bit? Memory is rather biased especially if she was ever warned about the dangers and chose to ignore or refuse to believe them.
No insult intended. Everyone's memory changes over time.
Heck, it could have been dangerous and her doctors downplayed the danger erroneously.

[Flyndaran]

That story made me cross my legs and I'm a guy.
Being nearly immune to opiates, I've found that one can not over emphasize the horrors of recovering from surgery without modern pain management.

[sir_pudding]

Originally Posted by Flyndaran

Could that be your mother misremembering a bit?

I think it's highly unlikely that she misremembered the dates of Brett's and siblings births, or that the first was a C-section. These things tend to be the sort of details people retain. Presumably the dates were celebrated annually...

[Agemegos]

Originally Posted by Flyndaran

Could that be your mother misremembering a bit?

Her recollection tallied with my father's, and also with my and my sibling's birth certificates and the little tags that were tied to us in the hospital nurseries. There is a whole bunch of circumstantial detail tied up in which obstetrician delivered which baby in which hospital and why, which I won't bore you with. Suffice it to say: no. My eldest brother was born in 1949, by Caesarian, in Sydney. My older sister was born in 1951 by instrumental delivery, in Sydney. The rest of us were born in 1953, 1954, 1957, and 1964, in Kempsey, by vaginal delivery in induced labour twenty-one days short of term.

Heck, it could have been dangerous and her doctors downplayed the danger erroneously.

Unlikely to have been the case. My father was an able obstetrician and gynaecologist, and I feel sure he would have intervened if he thought Mum's doctors were giving her dangerous advice.