Successful C-Sections in Pre-Colonial Africa: Surgery in Bunyoro Kingdom

Sketch of Caesarean delivery in Uganda in 1879, by Felkin in Edin. Med. J. 1884

Did you know that long ago, when Cesarean sections (C-sections) were deemed dangerous in Europe, Africans were safely performing them on the continent? Did you know that there was an extremely high success rate? Both mother and child lived! And no fancy “modern” equipment was used!

Historically, in Europe, when a c-section was performed upon a living woman, it usually resulted in the death of the mother. It was considered an extreme measure, performed only when the mother was already dead or considered to be beyond help. It was a last resort.

Well, imagine Robert W. Felkin’s surprise when he found out that in the great kingdom of Bunyoro-Kitara in modern-day Uganda, C-sections were considered routine! Imagine his surprise when the “backwards” people he met successfully delivered both mother and child, and had a very sophisticated surgical technique dating back a long time.

Dr. R. W. Felkin

In 1879, the British medical student R W. Felkin who had embarked on a mission led by the Church Missionary Society to Central Africa (probably hoping to rescue the souls of the savage natives) witnessed a C-section in the kingdom of Bunyoro-Kitara. He found out that in the Bunyoro kingdom, this was a routine procedure with extremely high success rates. There, the native healer used banana wine to cleanse his hands and the woman’s abdomen before the surgery. The healer used a midline incision and applied cautery to minimize hemorrhaging. He then massaged the uterus to make it contract, but did not suture it; the abdominal wound was pinned with iron needles (remember that Africans have been masters at iron smelting for centuries) and dressed with a paste prepared from roots. The woman was fully awake during the entire procedure, and recovered well. Felkin recognized that the degree of perfection and precision of the technique implied that it had been in use for a very long time.

His account was received in Europe with shock and skepticism, because after all, if they, Europeans couldn’t do it, how could the ‘backwards’ Africans do it? The account can be found in “The Development of Scientific Medicine in the African Kingdom of Bunyoro-Kitara” by J.N.P. Davies, Med. Hist. 1959, Jan 3 (1) 45 – 47. Felkin gave a lecture to the Edinburgh Obstetrical Society on January 9th 1884 entitled “Notes on Labour in Central Africa” (Felkin, R.W., Edin. Med. J., 1884, XXIX, 922); it is from this lecture that the following account on c-section delivery in Bunyoro kingdom is taken:  

The patient was a fine healthy-looking young woman of about twenty years of age… The woman lay upon an inclined bed, … She was liberally supplied with banana wine, and was in a state of semi-intoxication. She was perfectly naked. A band of mbugu or bark cloth fastened her thorax to the bed, another band of cloth fastened down her thighs, and a man held her ankles. Another man, standing on her right side, steadied her abdomen.

The knife used for the c-section operation in 1879 (Wellcome Historical Medical Museum – “The Development of Scientific Medicine in the African Kingdom of Bunyoro-Kitara” by J.N.P. Davies)

The operator stood, as I entered the hut, on her left side, holding his knife aloft with his right hand, and muttering an incantation. This being done, he washed his hands and the patient’s abdomen, first with banana wine and then with water.

Then, having uttered a shrill cry, which was taken up by a small crowd assembled outside the hut, he proceeded to make a rapid cut in the middle line, commencing a little above the pubes, and ending just below the umbilicus. The whole abdominal wall and part of the uterine wall were severed by this incision, and the liquor amnii escaped; a few bleeding-points in the abdominal wall were touched with a red-hot iron by an assistant. The operator next rapidly finished the incision in the uterine wall; his assistant held the abdominal walls apart with both hands, and as soon as the uterine wall was divided he hooked it up also with two fingers.

The child was next rapidly removed, and given to another assistant after the cord had been cut, and then the operator, dropping his knife, seized the contracting uterus with both hands and gave it a squeeze or two. He next put his right hand into the uterine cavity through the incision, and with two or three fingers dilated the cervix uteri from within outwards. He then cleared the uterus of clots and the placenta, which had by this time become detached, removing it through the abdominal wound. His assistant endeavoured, but not very successfully, to prevent the escape of the intestines through the wound. The red-hot iron was next used to check some further hemorrhage from the abdominal wound, but I noticed that it was very sparingly applied. All this time the chief “surgeon” was keeping up firm pressure on the uterus, which he continued to do till it was firmly contracted. No sutures were put into the uterine wall.

The assistant who had held the abdominal walls now slipped his hands to each extremity of the wound, and a porous grass mat was placed over the wound and secured there. The bands which fastened the woman down were cut, and she was gently turned to the edge of the bed, and then over into the arms of assistants, so that the fluid in the abdominal cavity could drain away on to the floor. She was then replaced in her former position, and the mat having been removed, the edges of the wound, i.e. the peritoneum, were brought into close apposition, seven thin iron spikes, well-polished, like acupressure needles, being used for the purpose, and fastened by string made from bark cloth. A paste prepared by chewing two different roots and spitting the pulp into a bowl was then thickly plastered over the wound, a banana leaf warmed over the fire being placed on the top of that, and, finally, a firm bandage of mbugu cloth completed the operation.

A caesarean section performed by indigenous healers in Kahura, Uganda. As observed by medical missionary Robert William Felkin in 1879

Until the pins were placed in position the patient had uttered no cry, and an hour after the operation she appeared to be quite comfortable. … The child was placed to the breast two hours after the operation, … The wound was dressed on the third morning, and one pin was then removed. Three more were removed on the fifth day, and the rest on the sixth. At each dressing fresh pulp was applied, and a little pus which had formed was removed by a sponge formed of pulp. A firm bandage was applied after each dressing. Eleven days after the operation the wound was entirely healed, and the woman seemed quite comfortable. …

So as you think again of medicine in Africa, think of successful c-sections performed in the Bunyoro kingdom in the 1800s (and probably long before then), and the long traditions and advanced medical training that allowed for such degree of sophistication and precision. This marked the turning point for modern (European) medicine in c-section, and led to the increased success rates we see today. It is however conveniently left out of history books!