History of Medicine

A HISTORY OF CESAREAN SECTION

       The origin of the name "cesarean section" is unknown. Three principal explanations have been suggested.                                                                                            1)   Legend says that Julius Caesar was born in this manner, hence the name "Caesarean".  There are several reasons to doubt this.  First, the mother of Julius Caesar lived for many years after his birth and in 100 B.C. the survival rate for the procedure was

Birth of Julius Caesar, 1506 French woodblock (Wellcome Library)

essentially zero.  Second, the operation, whether performed on the living or the dead, is not mentioned by any medical writer before the Middle Ages.                                                 

 2)   It may have been derived from a Roman law, supposedly created by Numa Pompilius (eighth century B.C.), ordering that the procedure be performed upon women dying in the last few weeks of pregnancy in the hope of saving the child.  This explanation then holds that the lex regia, as it was called at first, became the lex caesarea under the emperors, and the operation itself became known as the caesarean operation. The German term Kaiserschnitt reflects this derivation.                                                                                       3)   The word caesarean was possibly derived sometime in the Middle Ages from the Latin verb caedere, "to cut."  This explanation of the term caesarean seems most logical, but exactly when it was applied to the operation is uncertain. Since "section" is derived from the Latin word seco, which means "cut", the term Cesarean section seems redundant

     In reference to abdominal delivery in antiquity, it is pertinent that no such operation is mentioned by Hippocrates, Galen, Celsus, Paulus, Soranus, or any other classical medical writer. If cesarean

Soranus of Ephesus (Nat Library of Medicine)

section were employed at that time, it is surprising that Soranus, whose extensive work of the second century A.D. covers all aspects of obstetrics, does not mention cesarean

section.                                          

     Several references to abdominal delivery appear in the Talmud (Jewish civil and religious law writings) between the second and sixth centuries A.D., but whether they were used in a clinical setting is doubtful. Cesarean section on the dead appears to have been practiced, however, soon after the Catholic Church gained dominance, to enable baptism of the child. Locally, two records of postmortem sections are known, one at Mission Dolores in San

C Section on expired woman (Wikipedia)

Francisco in, 1805, and another at the Santa Clara Mission, in 1825. Neither infant survived.

     The earliest cesarean section done on a living woman was reported in 1500, performed by Jacob Nufer, a castrator of pigs at Sigerehausen, Switzerland. The patient (his wife) and the baby both survived, but since the mother subsequently delivered five more children vaginally there is doubt about the report's validity. Dr. Robert Harris reported on the first known cesarean operation in the U.S. A fourteen-year-old quadroon performed it on herself in a snowbank in Nassau, New York, using an L-shaped incision, dressed by her employer. Mother and baby survived.                                                                                                                        

         Credit for the first Cesarean section performed by an American physician goes to Dr. John Lambert Richmond. Growing up impoverished, he educated himself during childhood, eventually gaining entrance to the newly organized Medical College of Ohio. Under its founder, the formidable Daniel Drake (see blog of 9/16/2019), he received his M.D. degree in 1822. He also studied to become an ordained Baptist minister. Called to a house on the

Article by Richmond (Hathi Trust)

evening of April 22, 1827, Dr. Richmond found a primigravida exhausted from a thirty-hour labor, with no cervical dilation, and with seizures (probable eclampsia). He was seven miles from home, in a storm. In Richmond's own words, "…with only a case of common pocket instruments, about one o'clock at night I commenced the cesarean section. Here I must….relate the condition of the house, which was made of logs that were green and put together not more than a week before. The crevices were not chinked, there was no chimney, nor chamber floor. The night was stormy and windy, insomuch that the assistants had to hold blankets to keep the candles from being blown out." Under the precarious candlelight, Richmond made a vertical incision, removed the placenta, and delivered a large infant that did not survive. He found no opening between uterus and vagina. The uterus was not sutured closed (custom at the time), and the abdominal wall closed in two stages. The only complication to the mother was an infected hematoma, drained. She returned to work 24 days after the operation.

     Maternal mortality rates from cesarean section in the 19th century were 85 percent or higher, with the operation done as a last resort to save the life of the mother. Dr. Harris noted that as late as 1879, cesarean section was more successful when performed by the patient herself (or ripped open by a bull's horn). He compared nine such cases from the literature, with five recoveries, to twelve cesarean sections done in New York City during the same period with only one recovery.

     The turning point came in 1882 when Max Saenger, a 28-year-old assistant to Dr. Credé at the University Clinic in Leipzig,

Max Saenger (Wikipedia)

introduced suturing of the uterine wall, using silver wires. Eight out of seventeen mothers survived their sections, remarkable for the time. New surgical techniques, antibiotics, and blood transfusions have lowered the risk dramatically since then. In 1950, D'Espo reported 1000 consecutive cesarean deliveries without a single maternal death. The frequency of the operation rose, from 5 percent of births in 1970 to 23 percent in 1985. The CDC reports a rate of 31.9 percent of births for 2018.

     The present state of cesarean section surgery enables millions of women to avoid otherwise difficult childbirths with a safe and healthy outcome.

                                                                         Michael Shea MD

SOURCES:

Creasy, R K. and Resnik, R. Maternal Fetal Medicine Principles and Practice. 1984; W.B. Saunders Company.

Cunningham, F. G, MacDonald, Paul C. and Gant, Williams, J W. Williams Obstetrics. 1989; Appleton and Lange.

Eastman, N J and Helman, L M.  Obstetrics. 1961; Appleton-Century-Crofts Inc.

Harris, Henry. California's Medical Story. 1932; Carles C. Thomas.

Speert, Harold. Obstetrics and Gynecology in America: A History. 1980; Waverly Press.

King, A G. "America's First Cesarean Section". Obstetrics and Gynecology 1971; 37(5): 797-802.

Harris, R P. "A Study and Analysis of One Hundred Cesarean Operations Performed in the United States During the Present Century and Prior to the Year 1878". Am J Med Sci 1879; 77: 43-65.