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IV) Cesarean Section

History of Cesarean Section:

The origin of the word cesarean, or caesarian (British spelling), is doubtful. The word is rumored to have originated from Julius Caesar, who it is believed, was the first live infant born by this method (in 100 B.C.). This is very doubtful, especially in light of the fact that his mother Aurelia survived his birth, and that written history contains no record of such an event. In fact, Aurelia was still alive when Caesar was 48 years old and reducing Gaul to a Roman province. Her survival is almost certainly incompatible with a cesarean birth, since the maternal mortality (death rate) after cesarean was almost a hundred percent until the early part of this century.

It is almost impossible for us to understand the fear, horror and revulsion that the concept of cesarean birth engendered until relatively recently. To try and understand the history of this operation previously known as the delivery of a child “per viam non naturalem” (by non-natural route), one has to understand something about the surgical practices of previous times. Until early this century the procedure was usually performed without any anesthetic whatsoever. Four or five men would hold the woman down on a table (often a kitchen table), while the surgeon would cut into her abdomen with a dirty kitchen or pocketknife or sometimes a razor blade. This knife or blade was often caked with old blood and grime, while the surgeon’s hands were often even dirtier. Surgeons would walk from patient to patient, and even from corpses to patients, without washing their hands. Their status was to some degree dependent on the built-up gore and blood on their coats. The most important criterion distinguishing a good surgeon from a bad one was the speed at which the particular operation could be performed. The lack of effective and safe anesthetics makes this understandable and logical, but it doesn’t however lend itself to the development of safe and anatomically correct surgical practices.

Until early this century the surgeon would cut through the abdominal wall and through the uterus, would pull the baby out and then sew the skin incision but leave the underlying tissues, including the uterine incision, open. Women almost invariably bled to death, and those few, who survived this stage of the operation, later almost certainly succumbed from overwhelming infection. Remember that antibiotics only date from the 1930s.

As a result of the exceedingly poor maternal outcome, the procedure was usually only performed after the death of the mother or when she was definitely at death’s door. In the Roman Empire the division of the so-called “Justinian Corpus Juris” contained the “Rex Regia” law. This law, enacted by the second king of Rome, Numa Pompilius (715-673 B.C.), stated that it was forbidden to bury a dead pregnant woman before the fetus has been removed; “Negat lex regia mulierem quae praegnans motua sit, humari”. This was also the practice in India, Arabia and Persia and possibly even in early Egypt.

In 1609 Guillemeau, writing of the “happy deliverie of women”, notes that “Lawiers judge them worthy of death, who shall burie a great bellyed-woman that is dead, before the child be taken foorth”. He then goes on to speak of the haste needed to save the baby, but also about the need to ensure that the woman is dead and that “her kinsfolkes, friends and others that are present, do all affirme and confesse, that her Soule is departed”. He himself had twice performed cesarean sections on living mothers, and had seen three more done by three Paris surgeons. All the women died. Nevertheless there are some occasional reports of women surviving their ordeals and even going on to deliver babies vaginally later. In the 18th century 36 living infants were reported to have been delivered by cesarean after their mothers’ deaths, and by the mid-19th century, over 80 more such cases had been reported. Before 1700, assessments are difficult since the Lazarus-like accounts of living babies rescued from their dead mothers’ wombs, some buried for days, strain the credibility of even the most gullible.

Even Shakespeare took note of this interesting operation, in Macbeth, when he writes “Macduff was from his mother’s womb untimely ripped”.

The earliest account of this procedure in any medical textbook of importance appeared about the year 1350, where it is noted to be a proper procedure after the death of the mother. The oldest authentic record of a living child born by cesarean, however, is that of Gorgias, the celebrated orator of Sicily in 508 B.C. Another early cesarean survivor was Scipio Africanus (born in 237 B.C., and also called “Caesar”), the conqueror of Hannibal. His birth was recorded by Gaius Plinius the Elder in his “Historia Naturalis”. He wrote: “Auspicius enecta parente gignuntur; sicut Scipio Africanus prior natus, primusque caesarum, a caeso matris utero dictus: qua de causa et caesones appellati. Simili modo natus est Manilius qui Carthaginem cum wxercitu intravit.”

Greek mythology contains some references to such an unnatural birth. Asclepios, the tutelary god of medicine, was delivered from his mother Coronis in this manner: “Natum flammis uteroque parentis eripuit geminique tulit Chironis in antrum”. (He snatched his son from his mother’s womb, says Ovid, saved him from the flames, and carried him to the cave of the centaur, Chiron). Hermes was the alleged surgeon after Coronis had been killed by her husband Apollo’s sister, Artemis.

Although this operation is mentioned in the Talmud and in the Veda books of India, some noted physicians of antiquity do not even mention it in their works. Aulus Aurelius Cornelius Celsus does not mention the operation in books vii and viii of his “de Medicina” which deal with surgical treatment. Similarly Soranus of Ephesus, regarded as the greatest obstetrician and gynecologist of antiquity, who lived from 98 to 138 AD, and whose published works commanded the utmost respect for 1500 years, did not mention the cesarean method of delivery. Other important obstetricians, among them Aetius of Amida and Paulus Aegineta, who both published important obstetrical works, were silent on the topic. That such eminent physicians of the time ignored the operation suggests that it was an extremely rare occurrence and that it was not part of practical obstetrics. It may also be that the medical politics of the time, or disdain for the almost uniformly poor outcome of the surgery, led to a conscious choice to exclude the topic.

As mentioned the origin of the word “caesarian” is very uncertain and it is unlikely that there will ever be a unanimous opinion. I already mentioned that Julius Caesar was unlikely to have been born by “caesarian”. The word further pre-dates him by centuries, since Scipio Africanus was also named “Caesar” and Pliny’s “Natural History” records a Caesar before the Samnite wars in about 340 B.C. Gaius Pliny the Elder was the first to use the term Caesonis indicating “one cut from his mother’s womb” and, in this respect, Scipio Africanus could be said to be the first Caesar.

The derivation of the term is unclear however, and several far-fetched theories have been suggested. These range from caesa, which means “elephant”, in the Moorish and Punic languages (Julius Caesar was a large man), to caesaries, (a bushy head of hair), to caesius, (to have blue-grey eyes). In Roman use, the term Caedere indicated killing, slaying or destroying on a grand scale (which could easily be understood to be associated with the “Caesar”), whereas secare or incidere meant to cut or incise. After the murder of Julius Caesar (definitely a caedes), his assassins took on the name Caesar, thus belying any supposed connection between the name and any specific manner of birth quite convincingly.

Further picking at the word caesarian reveals other interesting meanings. Caesarianus means belonging to Caesar, whereas caesariatus means long-haired. Caesareus also depicts an ownership of, or being part of Caesar.

It was the Jesuit, Théophile Raynaud, who first used the term caesareus in the title of his book, which was the first to be written on the “caesarean” operation. François Rousset gave the first verifiable account of a successful cesarean section, which resulted in the survival not only of the child, but also of the mother, sometime in the 1500s, although he called the operation a “hysterotomotokie”. This term is more in line with current use of the term “hysterotomy”, which is a similar operation to a cesarean but done for a non-viable fetus, or any incision into the uterine cavity, even in the non-pregnant woman. Anyway, this “hysterotomotokie” was performed by none other than a sow-gelder, named Jacob Nufer of Siegertshaufen, which is about 20 kilometers south-west of Augsburg, Germany. He did this around 1500 AD on his own wife, and used a razor blade. Apparently she had been in labor for many days, and over a dozen midwives and barbers had failed to deliver the baby. Even though his wife was in favor of the attempt, since she believed that she was dying anyway, the authorities turned deaf ears to his petitions. Nufer, in desperation, proceeded anyway. After laying her on a table with the necessary attendants to hold her down, Nufer made the incision, extracted the child and apparently sutured the abdominal wall. Almost miraculously his wife recovered, but just as remarkably went on to bear twins at a later date and four more children, all of whom were delivered normally.

Although the operation was repeated intermittently through the following centuries in different countries, it was always done as a last resort on a living mother. As a result of the extremely high maternal mortality, most eminent obstetricians not only frowned on the procedure but also openly condemned it, so no progress or uniformity of technique was achieved. There was even an active anti-cesarean movement, called “Ecole anti-Cesarienne” led by Sacombe in post-revolution France.

As is common with most human endeavors, jealousy and rivalry enter into the history of this remarkable operation. Although it is widely believed that Jesse Bennett of Mason County, West Virginia, performed the second wholly successful cesarean in the world and the first in the New World in 1794 (again on his own wife), this same honor is also claimed for John Lambert Richmond (near Cincinnati, Ohio) for 1827. Other claims place this second event in Martinique, of all places, in 1805.

The accounts and assessments of Bennett’s operation contain allegations of fraud, intrigue and all the necessary ingredients for a good story. For one thing, it is alleged he graduated from the University of Pennsylvania, but apparently there are no records of any such graduation. The accounts of the operation and of Bennett’s life supposedly hinge on the article by A.L. Knight entitled “The Life and Times of Jesse Bennett, M.D.”. This was published 50 years after Bennett’s death and the only source of information was apparently what either Bennett or his sister in-law, Mrs. Nancy Hawkins, had told Knight at least 53 years earlier. This would have made A.L. Knight between fourteen and eighteen years old!

Each individual country has divergent histories about the progress of the operation before this century. So for instance, in Great Britain the first operation of this kind, where the life of the mother was saved, was performed by a surgeon, James Barlow of Lancashire, while he worked in Chorley in 1793. In Sweden, the first recorded cesarean section was performed in 1360 A.D.. This section was performed post-mortem, thus after the death of the mother. During the years 1758-1875, 13 cesarean sections were performed in Sweden. All of these women died. During 1882-1890, 13 more cesarean sections were performed using a new method and with the loss of about 54 percent of the women. The first cesarean on a living woman in Australia was performed in 1872, and, in South Africa, sometime between 1815 and 1821. The South African child, James Barry Munnik, survived, and his grandson, James Barry Munnik Hertzog (1866-1942), later became the Prime Minister of South Africa from 1924 to 1939.

During the subsequent decades tremendous medical advances were made in the fields of microbiology, which led to increasingly effective antiseptic technique, surgical technique and anesthetics. As the figures for maternal mortality after cesarean section plummeted, the procedure became more accepted and established.