In his occupation as a swineherd, Jacob Nufer had performed countless genital surgeries on his pigs. He was an expert gelder. He was convinced he could deliver his child abdominally so that both his wife and child would survive. For this, there was no precedence. Most observers must have believed that Jacob was about to murder his wife and that his child might already be dead. Few people would have had confidence in his success. But Jacob was desperate. Using his gelding tools, Jacob made an incision in his wife’s abdomen, with no anesthesia and rudimentary sanitation, to deliver his infant daughter. Shockingly, the historical record asserts that both mother and child survived the operation. Even more shocking, Elizabeth is recorded as having five more children, all delivered vaginally. Their baby born by cesarean also thrived. She lived to the ripe old age of 77. This is the first recorded incidence of a cesarean section performed where both the mother and child survived the procedure. Or is it? You’ll have to keep listening to find out. Today we’re discussing the surprisingly long history of cesarean birth in western medicine.
Transcript for “None of Woman Born: Cesarean Birth before 1900, A Pre-History”
Marissa: The year was 1500. Jacob and Elizabeth Nufer, a young couple living in Turgau, Switzerland were undergoing the trial of their lives. Elizabeth had been in labor for days. Their local midwife had been unable to deliver the child and had called on several other wise women to assist in the birth. Nearly a dozen women had attempted to deliver the child to no avail. Jacob, a swineherd, was experiencing waves of panic as his wife and unborn child continued to be in danger. Several days into the difficult labor, Jacob Nufer petitioned the authorities for permission to remove the child surgically through the abdomen. This surgery was a known one but was most often performed only after the mother’s death.
Sarah:In his occupation as a swineherd, Jacob had performed countless genital surgeries on his pigs. He was an expert gelder. He was convinced he could deliver his child abdominally so that both his wife and child would survive. For this, there was no precedence. Most observers must have believed that Jacob was about to murder his wife and that his child might already be dead. Few people would have had confidence in his success. But Jacob was desperate.
Marissa:Using his gelding tools, Jacob made an incision in his wife’s abdomen, with no anesthesia and rudimentary sanitation, to deliver his infant daughter. Shockingly, the historical record asserts that both mother and child survived the operation. Even more shocking, Elizabeth is recorded as having five more children, all delivered vaginally. Their baby born by cesarean also thrived. She lived to the ripe old age of 77.
This is the first recorded incidence of a cesarean section performed where both the mother and child survived the procedure. Or is it? You’ll have to keep listening to find out. Today we’re discussing the surprisingly long history of cesarean birth in western medicine.
DISCLAIMER – this episode includes graphic stories of maternal death, infant loss, and infertility. If those issues are upsetting to you, please skip this one or, at the very least, use caution moving forward.
And I’m Sarah.
Marissa: And we are your historians for this episode of Dig.
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Marissa: There are many things to doubt in this story. It was not recorded until 82 years after the event purportedly took place. It claims that 13 midwives, a very unlucky and mythologized number, assisted Elizabeth during her ordeal and that none were able to deliver her. It’s also quite doubtful that, even if a rudimentary cesarean had itself been successful in 1500, that the woman would have been able to safely deliver subsequent children without a uterine rupture. We don’t have details as to how Jacob finished the surgery but most historians agree that it wasn’t until the 18th century that surgeons suggested using sutures to seal the uterus after the operation. And even then, the suggestion was not put into practice for another hundred years. Some historians have suggested that perhaps Elizabeth’s pregnancy was a full-term extrauterine pregnancy. This is a very rare form of ectopic pregnancy that, occasionally, results in a viable fetus. If this were the case, Elizabeth’s baby could have grown outside of her uterus, allowing for the baby to be cut out without incising the uterine wall itself. This would have explained at least part of Jacob’s success and Elizabeth’s subsequent fertility. IN any case, there are several historical records that support this cesarean birth so even if some of the details have been mythologized, the operation may have actually happened.
Sarah: Jacob and Elizabeth Nufer’s story has been repeated many times as the first known cesarean birth with a happy outcome. But, in 2016, obstetrician and medical historian Dr. Antonin Parizek of Charles University, published a paper positing an even earlier case. The pregnancy in question was that of Beatrice of Bourbon. Beatrice was a fourteen-year-old noblewoman who, in 1336, became the second wife of King John of Bohemia. In February 1337, the teenaged Beatrice gave birth to her only child, Wenceslaus.
The birth of Wenceslaus was not immediately documented but we have two letters written by Beatrice describing the birth. One was a diplomatic letter to the city of Kolin, and the other was a formal birth announcement sent to regional courts. In both letters, Beatrice took great pains to assure the readers that her son was born “without breaching our body.” All surviving contemporaneous sources treat the birth similarly, with secretive and defensive phrasing.
Marissa: One century later, surviving sources are more direct, acknowledging Wenceslaus’s cesarean birth directly. For example, one early 15th-century chronicle called Brabantsche Yeesten repeats Wenceslaus’s cesarean birth as fact. He marvels that his mother’s wound healed. The Archdeacon of the Verdun Cathedral Richard Wassebourg Antiquitez de la Gaule Belgique writes something similar: “At the birth, his mother Beatrice was opened up without her dying.” Lastly, Tomáš Pešina of Čechorod, who writes in his Mars Moravicus: “John had a son named Wenceslaus, taken from the queen Beatrice of Bourbon, or rather from the maternal womb, without endangering the mother, rarely such a lucky example of recovery [or healthy fertility].”
Sarah: So, like the case of Jacob and Elizabeth Nufer, direct references to cesarean birth appear only after their deaths. But, Parizek argues, there are several reasons to believe Wenceslaus’s birth was an abdominal birth. For one, Beatrice never gave birth to another child, which one would expect from a woman whose uterus had been compromised. Second, Beatrice’s coronation was significantly delayed, possibly because she was recovering from a surgical birth. Third, Prague was, at the time, the medical center of the world and the physicians who attended Beatrice would have been the most educated and skilled practitioners available.
Marissa: Lastly, a detailed analysis of her letters suggest she had a reason to portray Wenceslaus’ birth as a vaginal birth, which is strange considering this should have been a time when vaginal birth was the ONLY method of birth. Beatrice’s letters about the birth include strange wording about her body that has never been seen before in birth announcements. All contemporaneous birth announcements take special care to describe the health of the child and systematically avoid discussion about the mother and her body. But Beatrice assures readers that her son was born vaginallyand that her body was intact. This suggests that there were reasons for her peers to think otherwise. People do not typically deny things unless they have been accused of them.
Sarah: Accusations of cesarean birth may have given Beatrice cause to worry. Parizek believes a cesarean birth would have been perceived as a monstrous birth in Bohemian royal culture and religious doctrine. In the Bohemian church, the royal body was considered inviolate, the embodiment of their undefiled souls and prerogative to rule. Beatrice’s strange letters demonstrate her desperate attempts to portray Wenceslaus’s birth as a typical, vaginal birth. Doing so would have protected his royal birthright but it also would have protected Beatrice. She had given birth before her coronation and she would have wanted to portray herself as worthy of the crown. A monstrous birth and damaged body may have disqualified her.
Marissa: Some historians, including Parizek, believe that Beatrice’s cesarean, if it occurred at all, was accidentally successful. Beatrice was almost certainly thought to be dead or near death. If this had been the case, her attending physicians would have worked quickly to attempt to save the baby by cutting her open or, at the very least, to extract the baby in order to baptize him. It’s not inconceivable that this may have happened and that Beatrice’s status had been mistaken. Perhaps she was merely unconscious and gained consciousness during or shortly after the operation.
This scenario brings us to an important point. For the vast majority of its history, cesarean birth was a post-mortem operation. Evidence suggests that Jacob Nufer performed surgery on his wife in hopes that both she and her child would survive but this hope, if it had indeed been Jacob’s, would have been almost supernatural, a truly desperate desire. In almost all cases before the 19th century, cesarean birth was a dark and sad procedure, most often resulting in the death of both mother and child. Occasionally, the infant survived the procedure but often only by a few hours or days. Keep in mind there was only one way to feed a newborn whose mother had died, wet nursing. If it survived the cesarean birth, the fragile infant would have been given over to the care of a wet nurse But this was only if one with sufficient milk could be found close by. Many babies died of dehydration in the days following birth for lack of a nurse.
Sarah: In some cases it was clear that the mother’s health was good but that the infant was stuck, dead, or dying. In these cases, another form of surgical birth was attempted, a craniotomy. This procedure was performed with sharp tools which surgically crushed the fetus’s head and removed its entire body from a woman’s uterus. The fetus was essentially disarticulated and pulled out piece by piece. This procedure had better outcomes for the mother and could often save her life but it always resulted in the fetus’s death.
Marissa: These dark and sad outcomes shrouded the cesarean operation, and other forms of surgical birth, in morbid mystery for centuries (millennia really, but that was too many Ms). It’s not surprising, then, that a robust mythology formed around the operation and the occasional live births it made possible. Let’s start with the most glaringly obvious myth; the myth that Julius Caesar was born by cesarean and that his birth was what gave the procedure its name. This will burst the bubble of so many Buzzfeed articles but this just isn’t true. The myth derives from a 10th-century mistranslation of Pliny’s Natural History Book VI, Chapter 7. This passage actually says that Caesar’s family got their name because its founding member was cut (caedo) from his mother’s womb. So it wasn’t Julius Caesar, but a forebear, who was cut from his mother’s womb and the procedure wasn’t named after him but, rather, he after the procedure (get it together, medieval translators!). The term cesarean comes from a Roman legal code called the lex Caesare. The lex Caesare was one of many royal laws that were issued in the 8th century BCE and it prescribed that an infant should be cut from its mother’s womb should she die before birth.
Sarah: Even though Pliny was mistranslated for centuries, his story is itself dubious. The first in the line to take the name Caesar was Sextus Julius Caesar who lived around 200 BCE. There is no documentation that he was born by cesarean and there are many other reasons why the name Caesar may have been added to his other names. Etymologists have suggested that a member of the family may have been born with a luxuriant shock of hair called caesaries or that they had blue or bluish-grey eyes, oculi caesii. Either of these seems more likely than a cesarean birth that resulted in a live baby, though that would have been possible. It would not, however, have been possible for Julius Caesar himself to have been born by cesarean since his mother, Aurelia, outlived him.
There is some debate about whether cesarean operations were something other than a post-mortem operation within the ancient world. The 12th-century Jewish scholar Maimonides wrote that the Romans knew how to perform the cesarean operation without killing the mother but that it was rarely done. This is very unlikely, however, since contemporaneous physicians such as those in the Hippocratic school and the great Galen of Pergamon, fail to address the procedure. Galen mentions it one time in his compiled works as something that he had read about but never experienced in real life: “‘… the way in which the abdomen of the pregnant woman must be cut open and the child helped out while it is still fixed to the uterus, is not of our invention but has been described by many of the early authors.” Apparently, none of those early authors’ works have survived.
Marssa: Most medical historians and historically minded physicians agree that, prior to the nineteenth century, an incision to the abdomen would have been deadly in virtually all cases. If the patient did not hemorrhage (which was very likely with no cauterization or clamping), they almost certainly would have died from shock (also likely with no anesthesia and ineffective sedation), or secondary infection (almost certain with little or no antiseptic practice). At this point in history, cesareans were acts of desperation, meant to sacrifice the mother in order to baptize the infant or bury the mother and infant separately. If the mother’s death was imminent, midwives were trained to make an abdominal incision in the mother to retrieve the fetus. Few midwives expected the fetus to survive but they performed the operation all the same in order to baptize the infant, ideally before death. Even if the infant died prior to being extricated, the midwife performed a post-mortem baptism in hopes of saving the poor infant’s soul.
Sarah: These grim outcomes are confirmed time and again by the cesareans that are best documented prior to the nineteenth century. For example, the Catalan saint Raymond Nonnatus was born in 1204 by cesarean. His mother did not survive the grisly procedure. He was given the name Nonnatus (literally not born) because of his abdominal birth. Likewise, in 1316, Scotland’s Robert II was born via cesarean and the operation resulted in death for his mother, Marjorie Bruce. Many suspect that Robert’s cesarean birth inspired the character Macduff in Shakespeare’s Macbeth. As the story goes, Macbeth is given the prophecy: “none of woman born shall harm Macbeth.” Initially he believed this meant he was safe from harm until he learns that Macduff was “from his mother’s womb untimely ripp’d,” meaning that he was not “of woman born.”
Marissa: Very rarely did a cesarean result in a live birth. Children who were born as a result of this post-mortem operation were called caesones, “not of woman born,” “the unborn,” or “the Fortunate.” As is alluded to in Macbeth, caesones were very rare and, in various ways, marked by their unconventional birth. Thus, pre-Victorian people born via cesarean carried with them a stigma or mythical status of sorts.
Sarah: Despite the early modern period’s rapid growth in anatomical dissection and scientific medicine, safe cesarean births were not achieved. Vesalius’s De Corporis Humani Fabrica, published in 1543, sparked widespread interest in human anatomy. This anatomical revolution laid the groundwork for a new field of operative obstetrics that grew in the following centuries but the cesarean operation remained theoretical. We do, however, have evidence that the operation was discussed more widely by medical scientists in the early modern period.
Marissa: In 1581, the French physician Francois Rousset published “The extraction of the child
through a lateral incision of the abdomen and the uterus of a pregnant woman who cannot otherwise give birth. And that without endangering the life of the one or the other and without preventing subsequent fertility.” (I know, early modern titles were so extra). Most historians agree that Rousset’s book marks a turning point in the history of the cesarean because it shifted from being a purely cultural phenomenon to being a question of medical science. Before Rousset’s work, cesarean was performed for several reasons– legal statutes pertaining to burial and baptism of the child were the two most common– and neither of them were medical. Rousset thought about cesarean differently. According to him, cesareans were indicated whenever fetuses were large, malformed, or dead, in the case of twins, malpresentation, or if the mother was very old, very young, narrow-hipped, or inelastic. Physician Samuel Lurie writes that “these indications reflect the emerging awareness of maternal and fetal safety.”
Sarah: In another one of these published discussions about cesareans, the operation received a new name, the cesarean section. Jacques Guillemeau’s 1598 treatise on midwifery used the term “section” and from that point forward, the operation was routinely called a cesarean section rather than a cesarean operation. Despite the work of Rousset and Guillemeau, cesarean outcomes remained grim, resulting in close to 100% mortality rate for mothers. Eventually, medical scientists lost hope of ever being able to perform a cesarean that left both mother and baby alive. Many mainstream obstetricians regarded the procedure as barbarous. Francois Mauriceau, the most famous obstetrician of the seventeenth century, stated: ‘‘I do not know that there was ever any law, Christian or civil in which both ordain the martyring and killing the mother to save the child.’’
Marissa: During the 1600s, operative obstetrics advanced in other ways with the advent of the forceps and ever-improving tools to improve outcomes of craniotomies. But the safe and effective cesarean section remained elusive. We have scattered records of cesarean attempts throughout the 1600s but they mostly took place in remote areas without access to trained personnel and equipped facilities. Some scholars believe that these remote areas had better surgical outcomes than one might have in a hospital because of the lower incidence of infection in the countryside. Some historians have also argued that remote areas without trained professionals tended to have fewer options to try before turning to the last ditch effort, cesarean. This would, theoretically, mean that people attending births in remote areas would turn to cesarean sooner rather than later, at a time when the mother and fetus were in less distress. This may have accounted for some happier outcomes for cesareans in remote areas during the 1600s.
Sarah: Still, this optimism is probably unwarranted. During the 1600s, surgeons avoided uterine closure, typically done with sutures, in favor of leaving the uterine wound open before closing the abdomen. This would have certainly increased the likelihood of hemorrhage or uterine rupture in future pregnancies. They did so for two reasons: (1) they believed that natural uterine contractions would promote the necessary healing of the tissues and (2) they feared that if they introduced sutures into the body where they could not be removed, that infection would necessarily follow. They had a point. As suture material they used braided animal intestines or, if you were fancy, silk. And with limited means of sterilizing these materials, infection probably would have been common.
During the 1700s, medical scientists continued to develop their surgical practice and research. They performed craniotomies, embryectomies, ovariotomies, ovariectomies, hysterectomies, etc. but their cesarean attempts were few and successes even fewer. They did, however, begin keeping meticulous records of their attempts and, toward the end of the century, started using statistical studies to improve surgical outcomes. One record suggests that between 1787 and 1876, (a span of almost 90 years) not one woman in all of Paris survived a cesarean section. It is unclear how many were attempted.
Marissa: Similar to the great origin debates with syphilis, which were very political, so too are the great origin debates tied to cesarean section. The late 18th- and early-19th centuries marked a time when European nation states built global empires. One consequence of this rampant imperialism was their rapid assimilation of indigenous cultures and expertise. We’ve seen this time and again in our episodes. For example, I discussed the use of Native American culture and expertise in the smokeless tobacco episode. Some historians argue that European advances in cesarean section were preceded by indigenous African successes with the surgery and that, perhaps, their medical expertise was assimilated by the European empires who subjugated them. There is some evidence that cesareans were practiced successfully in Uganda and Tanzania by indigenous healers in the 1800s. As it turns out, these claims appear to be overblown and, frankly, dubious. Amateur historians and disability rights activist Aradia Wyndham runs a blog called The Baby Historian which is super good by the way. She has a blog post about media literacy and the argument about indigenous African c-sections that I think is genius. So please know I’m borrowing heavily from her here and I could not tell the story nearly as well as her. She essentially calls out a facebook post written by a non-historian named Juniper Russo who claimed that cesarean sections were invented by women practitioners in Uganda. Her claims were shared far and wide by doulas, history geeks, and racial justice activists everywhere. She makes many claims about this and does not cite any sources. Anyway, Wyndham tracks down one of her sources, which is an essay written for the US National Library of Medicine (which also contains some dubious claims) and she tracks down all of the original sources and explains how these erroneous interpretations occur. Anyhow, here’s the story:
Sarah: In 1880, anthropologist Robert Felkin visited Central Africa and was given the opportunity to witness several childbirths. Most of the time, he wasn’t invited. He writes, “Many a time I have been denied admission during a labour; but I must confess that not infrequently I have gone by stealth and acted ‘peeping Tom’,” (Gross!) But anyway, one day he was invited to come “see a woman cut open.” He enthusiastically agreed and witnessed the following event:
“So far as I know, Uganda is the only country in Central Africa where abdominal section is practised with the hope of saving both mother and child. The operation is performed by men, and is sometimes successful; at any rate, one case came under my observation in which both survived. The knife used is represented in Fig. 19. It was performed in 1879 at Kahura. The patient was a fine healthy-looking young woman of about twenty years of age. This was her first pregnancy. I was not permitted to examine her, and only entered the hut just as the operation was about to begin. The woman lay upon an inclined bed, the head of which was placed against the side of the hut. 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 things, and a man held her ankles. Another man, standing on her right side, steadied her abdomen (see fig 17). 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.”
Marissa: Wyndham points out that this was hardly evidence of germ theory, which was one of the things that Russo implied. The water would had recontaminated the area after applying the wine so, rather than applying wine to kill germs, these Ugandan practitioners were probably using wine for ritualistic purposes. Felkin’s story continues:
“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 in 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 had become detached, removing it through the abdominal wound. His assistant endeavored, 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.”
Sarah: Felkin continues: “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 slipping 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 acupression needles, being used for the purpose, and fastened by string made from bark cloth (see Fig. 18). 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 top of that, and, finally, a firm bandage of mbugu cloth completed the operation.”
Marissa: According to Felkin’s notes, the woman had a fever within 48 hours of the surgery and her milk never came in so she had a friend nurse the child. She did, however, recover as far as he knew:
“Eleven days after the operation the wound was entirely healed, and the woman seemed quite comfortable. The uterine discharge was healthy. This was all I saw of the case, as I left on the eleventh day. The child had a slight wound on the right shoulder; this was dressed with pulp, and healed in four days.”
Sarah: After hearing this story, it’s tempting to wax poetically about the merits of indigenous medicine (there were many) but it’s going a bit too far to imagine a long-held tradition of cesarean sections in remote Central African communities. There just isn’t enough there. This doesn’t mean it’s NOT true. Just that we need more information before we make that claim. What we can say for sure is that this particular c-section happened in Uganda in 1880 and that the mother survived at least 11 days but the claim that African women invented c-sections and practiced them happily for centuries is currently unsupported.
Marissa: Even though Juniper Russo’s claims are somewhat dubious, it’s likely that European physicians’ experiences in their imperial travels did influence their medical practice and research. There is a long history of European imperial powers colonizing indigenous medicine and bodies as well as their communities. Such might have been the case for physician James Miranda Stuart Barry who performed the first authenticated c-section within the British Empire. We’ll be doing a biographical episode about Barry in the future; he was a fascinating person. Barry is best remembered in history for being assigned female at birth but living his entire adult life as a man in order to go to medical school.
Sarah: Barry was trained at the University of Edinburgh Medical School (at the time, #1 in the world) in genital surgery (specifically hernias). Shortly after passing his exams, he joined the British Army and worked as an army doctor for several decades, eventually achieving the rank of Inspector-General of British Hospitals. He traveled all over the British Empire, serving as a colonial physician and medical authority in Cape Town, South Africa, St. Helena, Jamaica; Malta, and Canada.
Marissa: During his tenure as Medical Inspector in Cape Town, in the 18-teens and early 20s, Barry revolutionized the city’s medical facilities and culture, introducing cutting-edge sanitation techniques and modern facilities. He performed the first authenticated, successful cesarean section within the British Empire. In late July 1826 a woman from an old colonial family, Wilhelmina Munnick, went into labor, and it was going poorly. After days of no progress and extreme pain, her husband, Thomas Munnick, called for Dr. Barry. Barry was known to be an impressive accoucheur but his reputation had faltered somewhat in recent months in the Cape.Upon assessing Mrs. Munnick, Barry made the gutsy move of option for a cesarean birth. For Thomas Munnick, this must have filled him with dread. He would have known that neither his wife, nore his child, were likely to survive the operation.
Sarah: We know that at the time he performed the surgery, Barry had never seen the operation done in real life. He had only read essays on the procedure written by his former mentor, Dr. James Hamilton at Edinburgh. Nonetheless, Barry performed his ritualistic hygienic practices for which he’d become known in the Munnicks’ kitchen. That is where Barry cut open Mrs. Munnick’s abdomen, separated her muscles, cut gently into the uterine wall, and extracted her writhing fetus, followed by the placenta. Through Barry’s decisive action and skilled work, both mother and baby survived the operation. Under his care, they continued to do well during the dangerous post-operative period. Barry refused to be compensated for his heroic feat but asked, instead, that the Munnicks name their baby after him. The lucky infant was named James Barry Munnick.
Marissa: While Barry performed the surgery on an elite European colonial, and it’s fair to say that he drew from his Edinburgh training, Barry may have owed some of his success to indigenous and formerly enslaved midwives. The historical record is not very specific here but we know that in the early 19th-century, Cape Town was only starting to grow into something more than a frontier town. Colonial physicians in the Cape did not have the luxury of ignoring or shunning midwives like their counterparts in the metropole. Barry was known to cooperate with the Cape’s midwives who were either indigenous or imported from Malaysia. At least one was a formerly enslaved woman named Hanna whose freedom was purchased by Barry himself. It’s unclear (but entirely likely) that Barry assimilated indigenous and/or Malaysian knowledge into his surgical practice.
Sarah: Despite Dr. Barry’s success in Cape Town, c-section mortality rates were still appallingly high in the remainder of the nineteenth century, somewhere near 75%. In the first half of the century, cesareans were reserved for mothers whose labors had not progressed for days and only after there were signs of intrauterine fetal death. This means that by the time cesareans were considered by providers, the mother was already in danger of sepsis, hemorrhage, and blood clots. This can account for the extremely high mortality rate despite incredible surgical advancement and impressive expertise on the part of the surgeon.
Marissa: But this was about to change in the middle of the 19th century with the introduction of revolutionary anesthetics like ether and chloroform. (For more on ether and chloroform during birth, listen to Sarah’s episode from last week.) These drugs sedated and anesthetized much more effectively than the opium and alcohol that had been used in previous centuries. They also made it possible to perform c-sections without the risk of shock, which was often the surgeon’s most immediate concern when c-sections were attempted.
Sarah: Cesarean attempts also would have benefited from 19c advancements in antiseptic techniques. During the late 1860s, British surgeon Joseph Lister perfected a new antiseptic system using carbolic acid to disinfect the operating theatre, surgeons’ hands, instruments, and wound dressings. Lister’s techniques were highly criticized because they were inconvenient and carbolic acid was a caustic irritant. Adding insult to injury, germ theory, on which Lister based his techniques, was only in its infancy.
Between 1860 and 1864, French chemist and microbiologist Louis Pasteur experimented with the idea that microbial pathogens caused infection. During this phase of experimentation, Pasteur proved that puerperal fever was caused by the pathogen pyogenic vibrio in the blood and that boric acid could be used to kill these pathogens during childbirth and confinement.
Marissa: While this news was welcomed by some, many medical scientists remained skeptical and the general public even more so. Think about how bizarre it would be to learn that the cause of infectious disease was tiny organisms invading and reproducing in your body. It must have been a wild sounding idea to a world unfamiliar with microbes.
This was a very dangerous time for c-sections despite this advancement. This is often the case following path-breaking advancements in medical science. There’s a period of risk-taking that goes sideways because medical scientists have enough knowledge to make dangerous attempts but not enough experience to make those attempts successful. The improved sedation and antiseptic systems at mid-century meant that doctors had more enthusiasm and more tools at their disposal to perform what the French came to call Accouchement forcé, or violent delivery. During this experimental time, doctors experimented with forced dilation of the cervix, increased use of forceps, episiotomy, symphisiotomy or pubiotomy (listen to Averill’s episode on sympisiotomy in this series if you haven’t already).
Sarah: These violent interventions increased maternal mortality from hemorrhage and sepsis because, despite the rapid advancement of medical science at this time, so many of the issues with performing successful surgical births had not yet been resolved. For example, by 1870, obstetricians still believed that uterine closure was unnecessary. Fleetwood Churchill, a British obstetrician, recorded in 1872 “no sutures are required in the uterus; as it contracts, the wound will be reduced to 1–2 inchescand the lips will come into opposition, if it be healthy.”
Marissa: The first obstetrician to resolve this issue did so in 1876, but at extraordinary cost to his patients. Eduardo Porro, Professor of Obstetrics at Pavia advocated hysterectomies following all cesarean births. Porro was a cesarean pioneer in Italy. Prior to his practice, not a single woman had survived a cesarean in Pavia. Porro first performed the procedure on Julia Cavillini, a 25-year-old woman with dwarfism whose pelvic configuration was incompatible with vaginal birth. Porro sedated Cavillini with chloroform and made a vertical incision in her abdomen. After removing her infant son, he amputated her uterus. Cavillini’s recovery was rocky but she eventually recovered. Both she and her son survived the procedure. Porro published the results of Cavillini’s case in 1876.
Sarah: Within the next several years, dozens of children were born using the Porro method. Around 58% of the mothers survived and 86% of the fetuses survived. By today’s standards, these statistics appear quite grim, but this was a considerable improvement from the 75%-100% mortality rates calculated for previous decades. So even though Porro was able to reduce maternal mortality, his method resulted in permanent infertility. Moreover, the procedure was still risky so most obstetricians who used the Porro method did so when there was no other choice. For example, the first Porro method cesarean in the USA was performed by Robert Harris in 1881, also on a woman with dwarfism. The first in Australia was performed at Melbourne in 1885 on a woman whose pregnancy was complicated by a cancerous vaginal growth that completely blocked her vaginal canal. In this case, the mother survived but the child did not.
Marissa: It wasn’t until 1882 that a feasible method of uterine closure was developed. American obstetrician J. Marion Sims developed a silver-based wire for gynecological suturing. (It should be noted that he did so by experimenting on enslaved women who had incurred genital injuries when they were raped or experienced violent births. For more on this, check out Medical Bondage by Deirdre Cooper Owens). Obstetricians Adolf Kehrer and Max Sänger developed, independent of one another, a method of uterine closure using Sims’s silver wire as a suture. Silver has antimicrobial properties so it prevents infection and inflammation, even when it’s not removed like traditional sutures. This became known as a “concervative cesarean” as opposed to Porro’s more radical method.
Another interesting tidbit: Adolf Kehrer recommended a low, transverse incision which is typical today but few obstetricians recognized its merits until the 20th century. They continued to use a vertical incision down the middle of the abdomen. Now, the Kehrer incision is the standard cesarean incision.
Sarah: Cesarean outcomes improved dramatically during the 1880s. By this time, Lister’s antiseptic system and even more effective aseptic techniques were becoming standard in all surgical settings. Obstetricians also came to realize that they had been waiting too long to initiate a cesarean and that the mother’s blood loss and exhaustion was contributing to maternal mortality. They finally felt like the procedure was safe enough to use it as something other than a surgical hail mary. These less emergent procedures improved maternal outcomes further.
There was also considerable decrease in violent birth techniques. In 1888, Murdoch Cameron performed a high risk cesarean at Rotten Row lying-in hospital in Glasgow. His patient was a woman with both advanced rickets and dwarfism. Cameron practiced non-intervention early in the labor which eventually ended in a successful cesarean. He went on to publish a paper about how the all-too-common use of forceps early in delivery resulted in increased maternal mortality if surgical birth was ultimately needed. Decreased interference in early labor continued to become more popular. (This was only temporary though, violent birth techniques came back into fashion in the 20th century).
Marissa: Still, many aspects of complicated pregnancy were beyond turn-of-the-century medical science. For example, during the 1880s, some obstetricians in Britain and Ireland, such as Birmingham obstetrician Lawson Tait, favored cesareans as a method of preserving the mother’s life when she suffered placenta previa. Placenta previa could cause extensive bleeding and, at a time before safe blood transfusions, hemorrhage could often lead to death. Tait performed cesareans early in the pregnancy, however, when the placenta problems became obvious, so the fetuses did not survive. It wasn’t until the 1940s, when blood transfusion was perfected, that both mother and fetus with placenta previa were likely to survive. By that time, women with placenta previa were admitted to the hospital, transfused regularly with blood, and then subjected to a cesarean section at 38 weeks when it was most likely the fetus would survive.
Sarah: In 1800, the general maternal mortality rate had been 65%-75%, cesarean mortality hovered between 75%-100%. By 1900, general maternal mortality had dropped to 5% and cesarean maternal mortality rate had dropped to 10%. These improvements are remarkable and they really made cesarean section a feasible birth option for many. The twentieth century is often when histories of the cesarean section truly begin because it’s the period in medical history when cesarean became practical and routine rather than a theoretical last resort.
Marissa: During the 20th century, we see the return of violent, intervention-heavy birthing in the 1920s, twilight sleep births (covered in Sarah’s episode in this series), epidurals, spinal blocks and most importantly, the advent of antibiotics in the 1930s and 1940s which transformed obstetrics and pediatrics entirely. There’s still more to say about cesareans and their role in second wave feminism, the natural birth movement, and appalling high maternal mortality rates in the contemporary USA; not to mention their historical role in racial health disparities. There’s also more than enough out there to do an episode on cesarean in Eastern medicine and maybe even one on decolonizing the cesarean in Africa, Polynesia, and the Americas. Though I’ve given you a preview, I’m sure you can see there’s more than enough there for a history of cesarean birth part two, and three! Something to look forward to!
Prague 1337: the first successful caesarean section in which both mother and child survived may have occurred in the court of John of Luxembourg, King of Bohemia
Pliny On Natural History, Book VI, Chapter 7
TODMAN, Donald. 2007. “A History of Caesarean Section: From Ancient World to the Modern Era A History of Caesarean Section”. Australian and New Zealand Journal of Obstetrics and Gynaecology. 47, no. 5: 357-361.
Samuel Lurie The changing motives of cesarean section: from the ancient world to the twenty-first century
The History of Cesarean Birth From 1900 to 2016
Epidural Anesthesia and Cesarean Section The Question of Choice, 1970s to the Present
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