Dr. Blakely on Obstetrics, 1933
Binghamton's Famous Doctor
History of Caesarian Section.
By: Stuart B. Blakely, M.D.
April 6, 1950
This paper will be limited to a discussion of the history of Abdominal Caesarian Section i.e. the removal of the products of conception from the pregnant women by an incision through the abdominal wall and the uterus. It usually implies that the fetus is viable, or nearly so, though, strictly speaking, the term may be applied to such removal at any stage of intrauterine life. Possibly such a procedure in early pregnancy is better called "abortion by abdominal hysterectomy".
The origin of the term "Caesarian Section" is actually not entirely clear. The Latin writer Pliny was undoubtedly confused and did not understand the origin of the term when he states that Julius Caesar was born in this manner, making it the origin of the term. Such a birth in the case of a man so famous as Caesar was would almost surely have been mentioned somewhere in his life story; Caesar's mother was living many years after his birth. Another explanation has been sought in an ancient Roman law (later noted in this paper) that required the removal of the child from the body of any woman dying undelivered. There is no good evidence that this law was ever known as "the law of Caesar", or that it was applied to living women. The most likely explanation of the origin of the word "Caesar" in the term is that it is derived from the Latin word "caedere" which means "to cut". Children born by cutting the dead woman's abdomen were called "Canciones". The term " Caesarian Section" must be considered a pleonasm (both words mean the same). Caesarian on the dead women undelivered of her child was a very ancient practice, even ascribed to Romulus. Its origin is lost in antiquity. Two of the most famous of such births in which the child is claimed to have survived are those of Dionysus (Bacchus) and Aesculapius, as told in Greek mythology. Hermes, at the command of Zeus, cut open the abdomen of Semele, as she lay on her funeral pyres after being struck by lightning, and extracted her seven months fetus, later known as Dionysus. Zeus had the infant sewn into his thigh or body, and so nourished him to term. Another story is that of Aesculapius who, at the command of Apollo, was removed from the uterus of his mother Coronis as she also lay on her funeral pyres. All children born thereafter in this manner are said to have been dedicated to Apollo and to have been endowed with bravery and sagacity.
In ancient India and Israel, the removal of the infant from its mother's dead body before burial was expressly commanded. The idea was embodied in Roman law, ascribed to Nuna Pompilius (713-673 B.C.), the second king of Rome i.e. no pregnant woman who died could be buried before the product of her conception was removed from her body. To become a law such a procedure must have been the custom for a long time. Roman law and Roman power kept the procedure alive for centuries. With the rise of Christianity, the law gained powerful support. Synods and councils commended and commanded the practice in the hope that few infants' souls might be saved by baptism. The Church later gradually abandoned its stand. Pope Gregory XIV, an abbot of St. Gall in the 10th century, and Bishop of Constance are said to have born by Caesarian on their dead mothers.
The origin of Caesarian on the dead is also quite obscure. Of course, it must have been observed at the sacrifice and on the hunt that the unborn might survive its mother's death. It has been suggested that they wanted to give the unborn "the hope of life". It must be remembered, however, that the ancients had very little respect for fetal lute. Caesarian on the dead, at least in the earlier years, was probably performed by slaves, for the physician had a pious fear of the dead and the touch of death was defiling. The performers of the operation knew speed was essential, and that the hope of success depended a great deal on the cause and suddenness of a woman's death. They realized the baby died because of lack of air; hence the custom of propping open the mouth and the vagina, and even injecting air into the uterus. The fact that the cases were so few, and the percentage of success so small (never over 10% and usually much less ) plus the withdrawal of the influence of the Church caused the gradual abandonment of the procedure. But even today a not inconsiderable number of people believe the full term or viable fetus should be buried in the coffin BESIDE the mother, and not left inside her body. At heart, we are still largely pagan in our thought.
Caesarian on the dying has been done many times without question, but our present mores do not sanction the procedure. The obstetrician today must wait till life is extinct in the mother, thereby markedly lessening the chances of the infant's survival. It might be well to call attention to the wisdom of never doing a Caesarian on a woman, living, dying or dead, without proper and complete aseptic preparation of all concerned. Caesarian on the living women has probably been done on occasion for centuries. The idea must have occurred to the observer of women in labor, unable to deliver her baby, that an incision in her abdomen would be an easy way to solve her difficulty. But don't forget that it was only 400 years ago that a pair of tongs or forceps was so constructed that a child could be delivered from below with reasonable safety and without the child's inevitable destruction. It has been tempting to believe that primitive peoples performed Caesarian on living women. There are stories of such among the American Indians and the Maoris of New Zealand. One of the most popular stories of such primitive practice is the description and drawing of a Caesarian section witnessed by a physician explorer named Belkin in Uganda in Central Africa in 1879. It was performed by a specialist of the Katanga tribe, a tribe advanced in many ways. The patient was a twenty-year-old gravida I. All the attendants were men. The operator washed his hands and the patient's abdomen with banana wine and gave some of it to the patient to drink. He incised the abdominal wall and the uterus, each with a single stroke of the knife; removed the child and placenta; held the uterus firmly in his hands till it contracted; turned the women on her side so that the blood and fluid would run out; closed the abdominal wall with seven acupressure nails and figure- of- eight sutures; dressed the wound with a paste of the chewed roots of two trees. During the operation, an assistant touched bleeding points in the uterus with a hot iron. The women's temperature and pulse postoperatively remained within the normal range, and the wound was healed in eleven days. The question has been asked how many years or centuries it took to develop such a technic.
There is no unimpeachable evidence that Caesarian section on living women was ever done by the Egyptians, Greeks, and Romans. It was pretty definitely performed in ancient India, was known to Israel before 140 B.C. and is spoken of in the Talmud. The description of a Caesarian done in 935 A.D. under wine anesthesia has come down to us rather vaguely, and one has been reported as having been performed in the 13th century. In the 16th century two ideas, both originating in France, had a far-reaching influence on the practice of obstetrics; 1. The rediscovery of version by Ambroise Pare; and 2. the awakening of interest in Caesarian Section as a means of terminating obstructed labor to obtain a living child. Incidentally, it is of interest to know what the great Pare thought of Caesarian Section. He said, "I would never advise doing such work where there are so great danger and not a single hope".
In that century (the 16th) without question, French Physicians performed Caesarians on living women. Scipio Mercurio (1568-1615), a former Dominican monk who practiced in Rome, witnessed Caesarians in France. Probably many of these operations consisted of removal of infected abdominal pregnancies that pointed through the abdominal wall. This is probably the case of the reports of two Caesarians, one by an Italian surgeon, Christopher Bain, in 1540; and the other by Paul Dirlewang of Vienna in 1549. In 1581 Francis Rousset, a French surgeon reported 15 cases of Caesarian on the living, none of which he had witnessed or done himself. His purpose was to overcome prejudice against the operation and to point out its value. His indications sound very modern, and he was the first treatise entirely on Caesarian Section. In 1586 Casper Bauhin, a physician of Bale or Basel in Switzerland translated Rousset's book from French into Latin for the wider use of Physicians generally. In an appendix to this Bauhin relates the story of Jacob Nufer, or Nueffer, a Swiss swine Gelder, as having delivered his own wife by Caesarian section in the year 1500.
Nufer lived in Siegershausen in Switzerland. It was his wife's first pregnancy, and she had been in labor several days. Thirteen midwives and several stonecutters were in attendance. The patient's condition was desperate. Nufer obtained the reluctant consent of the authorities for the operation. All but two of the midwives were of "faint heart" and left the room; the stone cutters remained, all being of "stout heart". Nufer shut the door, offered a prayer, laid his wife on the table and with one stroke of the knife delivered the baby without wounding it. When the midwives outside heard the baby cry, they all wanted to come in. Nufer would not allow this till the baby had been cleaned and the abdomen closed "like a veterinary way" by sutures. The child lived to the age of 77 years.
This has been generally accepted as the first actual recorded (?) Caesarian section. If the story is to be believed at all, and it was told 86 years after its alleged occurrence, it was also probably a case of extrauterine intra-abdominal pregnancy for the women later had a pair of twins and four other children. Anyway, it has captured the imagination and is the second of our popular stories about Caesarian section.
The first authentic, historically believable case of Caesarian Section on a living woman, described in detail by Prof. Dan Sennett, was performed by Jeremias Trautman at Wittenberg in Germany in 1610. The patient died twenty-five days postpartum. The child lived for nine years. The idea of a Caesarian section has always intrigued the medical profession, but its mortality, even up to very recent years, prevented its general acceptance. But many men kept working at the problem, approaching it from many angles. In 1751 Leveret tried to put the indications for a Caesarian section on a more scientific basis. He held that the single absolute indication was high-grade pelvic narrowing which had been named as an indication if the pelvic hand could not be withdrawn when grasping a foot. He thought that most Caesarian was unnecessary, and if frequently resorted to, indicated a poor obstetrician. To use slang, Leveret "had something there".
The surgeons gradually came to realize that the greatest source of their Caesarian mortally before Lister was the drainage of the open uterus into the peritoneal cavity, especially the higher in the uterus the incision was made and the higher in the abdomen the drainage occurred. A sure and lasting separation of the uterine cavity and its secretions from the general peritoneal cavity was the goal to be striven for. The problem was approached in three ways.
Making the incision in the lower uterus, by various methods minimizing the opening of the general peritoneal cavity. This has been the basis of plenty of our technical advances, for the idea was sound. All pelvis tissues are more resistant to infection; the incision is in a part of the uterus that does not undergo contractions postpartum, and the uterine incision can be more completely covered by peritoneum. But it took a long time to arrive at our present status and knowledge of low section. F.B. Osiander in 1805 put his hand in the vagina, pushed the fetal head up against the lower abdominal wall and made his incision low in the uterus. A century later Hugo Sellheim cleared up the anatomy of the lower uterine segment. Frank of Cologne in 1907 operated through an extra-peritoneal pocket by incising the parietal peritoneum transversely and suturing it to a flap of visceral peritoneum turned up from over the lower uterine segment. This is a type of "exclusion" Caesarian which may be done in several ways. Kroening said that the good in Frank's technic was the fact that the uterine incision was covered with peritoneum -- a partial but not the whole truth. It was Kroening who introduced low section as we know it, using a vertical incision in the uterus. Kerr in 1926 suggested the transverse incision. There have been numerous variations introduced. Dr. Joseph B. De Lee, as well as Beck of Brooklyn, were great advocates of the procedure.
In about 1820 Ritgen did a real extra-peritoneal laparotomy. He had many bladder and bladder and ureter injuries, a mortality of 50% and the operation was gradually abandoned. Gaillard Thomas in 1870 rescued the procedure from oblivion, still with a mortality of 50%. The name of Latzko and Waters have been closely identified with the extra-peritoneal section in more recent years.
By removing the uterus. In 1808 Michaelis of Hamburg suggested that the uterus be removed at the time of a Caesarian. Eduardo Porro of Pavia and Milan opened up a new era with the popularization of this idea. He pulled the unopened uterus out onto the abdominal wall, sutured the parietal peritoneum about it amputated the uterus supracervical and sutured the stump into the lower angle of the abdominal wound. With one stroke he solved the question of uterine suture, as well as taking a long step forward in the prevention of hemorrhage and infection. His mortality was 25-50%. The removal of the uterus has some obviously undesirable features but the procedure still has a definite place in obstetrics. We continue to use the term "Porro" though the stump today is closed as in any supracervical hysterectomy and dropped back into the abdomen.
By closing the uterine incision. It is more than strange that for so long the incision in the uterus was not sutured but left open. Sutures in the uterus were considered dangerous, irritating and unnecessary. Naegele as late as 1867 and Zweifel as late as 1881 did not close the uterine wound. However, uterine suture had been employed by many men at various times. Lebas in 1770, Frank Polin in 1853 (silver wire), Simon Thomas in 1869; it had been used in the United States before 1800. It remained for Max Saenger of Prague in 1882 to make forever afterward the suture of the uterine incision a part of a proper Caesarian section. He used silver wire or silk and closed his incision, which was in the upper uterine segment, as follows. 1.) Excision of a strip of uterine muscle on each side of the wound and the undermining of the serosa on both sides; 2.) Muscular muscularized sutures avoiding the mucosa and suturing the undermined serosa inverting its edges. There was little or nontensioned in his sewing. He pointed out that it was not dangerous, but as a matter of fact, quite the contrary if properly and aseptically done. The objections raised against Saenger's suturing seem silly today: danger of peritonitis if an infection was present; postoperative intestinal complications; adhesions; rupture of the scar; higher mortality. Saenger's operation became known as the "Conservative Caesarian Section; Porro's, the "Radical Caesarian Section".
Five types of abdominal Caesarian section have emerged.
1. Classic, the incision is made in the upper uterine segment. 2. Lower Segment Transperitoneal, Extraperitoneal Exclusion; 3. Before the uterus is incised the area is closed off from the general peritoneal cavity by some type of peritoneal suture. 4. Porro in which the uterus is removed. 5. Portes operation: a French surgeon, who in the presence of an infected uterus temporarily exteriorized the uterus on the abdominal wall. Mortality of Abdominal Caesarian Section.
For nearly 400 years after 1500, the mortality averaged 60%. In the 18th and 19th centuries the mortality was 54%. In Europe, from 1750 to 1839 the general mortality was 62%; in the hospitals, 72%. In the 19th century, there is said to have been no successful Caesarian in Paris, and up to 1877 in the maternity hospital in Vienna, none survived. In Great Britain between 1739 and 1845, there were 38 Caesarians of which 4 survived. In 1871 Harris of Philadelphia reported 59 Caesarians of which maternity mortality of 48%. It is no wonder that symphysiotomy, induction of labor and craniotomy were preferred and resorted to. Caesarians were rarely performed; they were an event. Of course, asepsis and antisepsis are tremendous factors in reducing maternity mortality, but that was not enough. Possibly 25 years ago 25% of all maternal deaths in the State of Massachusetts followed the Caesarian section. The work and study of many men have reduced the dangers of a Caesarian section to such an extent that in many hospitals today the numbers of patients delivered by Caesarian section may be as much as 5%. It is not uncommon to see reports of 100 consecutive Caesarian without a maternal death. In spite of it all, it is still the most dangerous way to have a baby.
Before the final closing of this discussion of abdominal Caesarian Section, there are a few disconnected notes on the subject that may be of interest. A great deal of ingenuity and ink has been expended through the centuries on the question of the type and direction of the incision, not only in the abdominal wall but also in the uterus itself.
There have been numerous authentic cases of the patient doing a Caesarian on herself. In a few instances, the pregnant uterus has been opened when gored by the horns of cattle. It is barely possible that Shakespeare had this in mind when he speaks of Macduff as one "who was from his mother's womb untimely ripped".
The term "Caesarian Section" was first used in a book by Theophile Raynaud in 1637. The first illustration of a Caesarian as in 1506 in a non-medical book, "Lives of the Twelve Caesars", by Suetonius.
Jane Seymour, one of the wives of Henry VIII, is supposed to have been delivered of Edward I by a Caesarian from which she died of puerperal sepsis. The king is reported to have said: "Save the child by all means; for I shall be able to get women enough".
Garrison in his History of Medicine says that the first Caesarian in the United States was done in 1827. However, there is no question but that Dr. Jesse Bennett, In the backwoods of Virginia, did a Caesarian 0n his wife, January 14, 1794. She was out of bed on February 9th and walked February 15th. He was assisted by Dr. Alexander Humphreys who had been a preceptor of Dr. Ephraim Mc Dowell. Dr. Bennett took out her ovaries so that she would never have to go through it again. When asked why he did not report the case, Dr. Bennett is said to have answered: "No doctor of any feeling of delicacy would report any operation he had done on his wife". Also, that "No strange doctor would believe that such an operation could be done in the Virginia backwoods and the mother live, and he'd be damned if he would give them a chance to call him a liar".
In looking back over the history of the development of abdominal Caesarian section certain things stand forth with clearness and are worthy of a brief review. One of the most interesting is how the introduction of new studies, new ideas, new experiments, new technics advanced now one, now another phase or type of the operation. Methods and procedures exhibited longer or shorter cycles of disuse, dormancy or oblivion alternating with periods of prominence and popularity. Of the recent resurgence of extraperitoneal section.
The three great causes of death following Caesarian section have always been and still are shock, hemorrhage, and infection. How have these problems been attacked?
Shock it is only very recently that the nature of shock has been at all well understood, timely measures taken for its prevention and adequate and scientific methods employed in its treatment.
Hemorrhage as far as we know, nothing outside of uterine massage was employed until the introduction of hysterectomy and uterine suture. The use of blood in shock and hemorrhage is, comparatively, very modern.
Infection the procedures of Porro and Saenger, the placing of the incision in the lower uterine segment, the adequate covering of the uterine wound with peritoneum and the retroperitoneal approach all contributed to its prevention. Aseptic and antiseptic surgery brought nearer the conquest of infection, but not its entire elimination. The better conduct of early labor by today's obstetrician is a tremendously important factor in making Caesarians safer. We know that vaginal examinations and procedures, long and exhausting labor, long rupture of membranes add very greatly to the risk. The use of antibiotic is an additional safety factor.
The widening of the indications for a Caesarian section is a remarkable, comparatively recent development. It is hardly within the province of this paper to enter into a discussion of its wisdom.
One of the important factors that have made Caesarian safer is the rise of the obstetric surgeon which has almost completely eliminated from this field the general surgeon who is rarely familiar with any other type of Caesarian section except the classic operation. This study has impressed the writer with the old fact that very few things are entirely new. We stand on the shoulders of the many men who have thought and labored through the many years that have gone before. We, in turn, will be such men.
A history of the Caesarian section is largely a recital of the efforts made to make the operation safe. It has always intrigued the interest of the medical profession. The attitude of the obstetrician toward the problems of a Caesarian section has been like the attitude of the climber of Mt. Everest who, when asked why he persisted in face of defeat (to say nothing of danger) replied: "Because it's there". The final chapter on the development of the Caesarian section has not been written.
Read before an obstetric conference at the City Hospital, Binghamton, N.Y., April 6, 1950,