Reflections of surgical practices in rural hospitals fifty years ago, making use of appropriate technology and available resources
A group of rural station hospitals were built in the country as far back as 1965, upgraded from existing rural health centres and isolated rural clinics or dispensaries, hospital buildings or superstructures built at the cost of the communities. But surgical instruments and other facilities were mostly not available and nursing staff consisted only of a senior staff nurse mostly trained in district or regional or divisional hospitals and consequently found to be competent.
I was posted to one such station hospital, Latyetma, in Myaing township of Magway Division. Communication in the area was with only one earth road crossing the township from north to south for about twelve miles that would take a lorry of war remaining Chevrolet type at least two hours on rugged soggy earth road from the town centre to my village of station hospital. No wonder the patients were reaching the rural hospital in an extremely late stages of disease pathogenicity. But one advantage was that the cases could be recognized and diagnosed easily. Actually, diagnosis was sometimes difficult and may not be obvious in complex situations and the rural doctor may not have enough experience or might even have never seen similar cases in medical school. . Furthermore, some cases were locally prevalent and usually not seen in the teaching hospitals. Diagnostic facilities were very limited and medical officers had to rely on their own clinical acumen and rational judgment based on memory recall from the textbooks he had read in medical school, the professors’ lectures and experiences shared during teaching sessions.
Although cases usually presented at a late stage of disease pathogenesis and diagnosis obvious and straight forward, this was not always the case due to unusual presentations and absence of diagnostic facilities. One useful diagnostic tool was a wide-bore needle which could be inserted into any cavity or space, cyst or any collection of fluids anywhere in the body. Other instruments used for specific functions could be used in different situations with similar structures or function. In my experience in the rural hospitals I used uterine sounds to detect bladder stones which were usually located at the base of the urinary bladder and the sound was inserted through the urethra and it struck the stones in the neck of the bladder. But I have to confess or apologize the profession for wrong diagnosis of having stone in a female when the sound touched the wide pubic rami which was broad and hard to be mistaken as a stone and bladder incision was made. Another case was a tumour of the rectum for diagnosis and Cusco speculum was inserted through the anus and through the blades pouted the cauliflower liked fungating mass or carcinoma of the rectum. Diagnosis was clinched.
Preparation for surgical operation
Allow me to elaborate on some preparations made for surgery in the village community in my experience in the surgical practices in the rural station hospital. The operation table was not the standard one but made of wood, with a hole or thug in the table so it could be tilted. Before any operation- minor or major- my staff and three menials washed or scrubbed the walls and floors with antiseptic soap water and take a bath. The next step was the availability of surgical sterilized materials. A barrel half the height of the normally used oil or petrol barrel, which my mother-in-law used for keeping cheroots and other things was converted into a “sterilizer” by the tinsmith of the village market . There was a lid and the barrel could accommodate the linen and surgical cotton and gauze. Then the goldsmith put a knob / lock made of silver. Now we were ready to sterilize linen by steaming for a period of one hour, while other steel metallic instruments were boiled.
Availability of surgical instruments was another headache and we started with the artery forceps of three midwives and a needle holder. Since surgical instruments were available in the open-air market in Yangon, I drew the instruments and somebody who went to Yangon from the village bought the correct instruments. The earlier aesthetic ether mask was made of bamboo and lint cloth inserted; and looked like the muzzle of cows. Later, we bought genuine ether mask of Schimelbach types, even for adults and children, from the open market. We knew the contact and bought obstetric forceps, both low forceps and mid-cavity forceps donated by old patients. One old lady fractured her patella falling on the hard plain ground meant for drying the harvest of sesame seeds and others. The patella was removed and she donated a Thomas splint which was made by the blacksmith of the district town from the design given to him. This was very useful fracture of femur, common conditions resulting from fall from heights as high up as the top of a toddy or palm tree, climbing and cutting toddy being a common occupation in upcountry dry zone.
Paracentesis
I had known the procedure for diagnosis (paracentesis) only recently. Aspiration of fluids in the pleural cavity or aspiration of ascites fluid was common practice in the district or rural hospitals using sterilized infusion or drip set by clipping the rubber tubing. But I remember that an aspiration set was available in the district hospital in 1978.
Aspiration of fluids in obstetric emergencies has been reported by me earlier. The wide- bore needle was inserted into the Pouch of Douglas, Aspiration revealed old blood, which indicated ectopic tubal pregnancy. The case presented only with repeated episodes of fainting and pallor. Yelling tenderness was elicited, now called cervical excitation.
Another case was rupture of the uterus and just inserting the wide-bore needle let off the drops of blood. The case was rupture of the uterus of about 24 weeks pregnancy, caused by the mother being trod on the abdomen to relieve colicky pain of dysentery. Pregnancy sac extruded from the rent only when the abdomen was incised and the atmospheric pressure was exposed. Subtotal hysterectomy was done.
One aspiration of the abdomen showed up oozing of pus-like materials, too thick or viscid to be aspirated by wide-bore needle. But still the diagnosis was quite sure and laparotomy done. Even then, the pus was very thick and when the abdomen was mechanically tilted, the pus came out just like water pouring out of a pot. The source of the pus was never known, as no infectious source was identified during laparotomy. There was a sporadic outbreak of lobar pneumonia in the villages around. Complications like pleural effusion or empyema were managed in our rural hospital. My staff nurse recognized the condition by seeing marked displaced apex of the heart.
Pseudocyst
The patient presented with a history of abdomen pain three weeks prior. Obvious finding was marked fullness in the epigastrium. As usual, aspiration of the abdomen was done. Aspirate revealed a typical textbook picture of fluid of green bile- stained and small flakes of soup- like materials. At that moment diagnosis was confirmed and laparotomy proceeded. The anterior wall of the stomach was opened but the confusion and hesitation flashed out and so I closed the opening. One thought urged me to aspirate the opening of the lesser sac and diagnosis was confident and operation proceeded. The anterior wall was reopened and the posterior wall was then opened; a gush of fluid poured out, letting out torrential fluids of greenish yellow and the diagnosis of pseudocyst of the pancreas was confirmed. Marsupialization was the procedure of choice but access was found to be difficult and the gape left as it was as no active bleeding was present. The postoperative period was uneventful.
Removal of bladder
In the area of the dry zone of upcountry of Pakokku district, five urinary bladder stones were detected in the locality with catchment population of two thousand. The age- affected ranged from 10 to 50. They presented with long history of low urinary tract infection. The stone sizes ranged from the size of a quail egg to that of duck eggs. The procedure of removal of the stones was shared by a cousin of the staff-nurse. The bladder was instilled with a large volume of potassium permanganate solution until the bladder rose from the pelvic cavity into the abdominal cavity. Suprapubic incision was made. Stones were extracted manually though special or forceps were available in the district hospital
Aspiration or paracentesis was useful for diagnostic procedures in rural hospitals and medical officers should have enough clinical acumen. In the present day ultrason ography should be available for rapid diagnosis and early treatment.
Author Information
Ye Hla
Department of Medical Research, Central Myanmar
