Julius Bonello
Ajoke Iromini
Peoria, Illinois, United States

A procedure that removes a live fetus through an abdominal incision in a pregnant woman is known as a Cesarean section or C-section. Its original intention was to remove a dead baby from a dying or dead mother. Therefore, Julius Caesar (100–44 BC) was not delivered by Cesarean Section as it was intended at the time, since his mother was still alive when he invaded Britain in 55 BC. The most probable explanation for the term was from the Lex Caesaria law (from the Latin verb caedere, “to cut”) made in 715 BC by the second king of Rome, Numa Pompilius. This law prohibited for religious reasons the burial of a woman who had died in pregnancy with the fetus in her uterus. Both mother and fetus had to be separated and buried separately. Another plausible reason for the Lex Caesaria could have been that a man was only allowed to inherit his wife’s wealth after death from childbirth if she produced a living infant.

Before 1500, almost all C-sections were done postmortem, advocated to save the child following the sudden death of a woman late in pregnancy. They were opposed by Muslims, but was supported by the Roman Catholic Church because they would permit the delivery of the child for baptism. The Roman Catholic Church in 1280 and the Venetian Republic in 1608 made postmortem C-sections obligatory.

The first author to use the term “section” in connection with the procedure was Jacques Guillimeau in his textbook on midwifery published in 1598. In 1610 Jeremiah Trautmann of Germany was credited with reporting the first successful C-section on a living woman. Until that time, women who were having unsuccessful labor had only two options: continue the very painful and prolonged labor, or have the physician perform a craniotomy to kill the baby. And, of course, prolonged unsuccessful labor could end with the death of the mother. A C-section became a third option for the attending physician. C-sections at this time usually resulted in the death of both mother and baby—the mother to either hemorrhage or infection, the baby usually from asphyxia.

The 1700s saw important advances in the understanding of labor and delivery. The introduction of obstetrical forceps in 1730 reduced the need for C-sections, and in 1752 the first accurate description of the passage of the baby through the pelvis was described. Only scattered reports of successful C-sections are mentioned around this time.

The first two C-sections performed in the United States took place in the late 1700s and early 1800s. Both will be described here, but historians question whether the Jesse Bennett C-section was fact or folklore.

Case 1

Dr. Jesse Bennett (1769–1842) was born on July 10, 1769, in Frankfurt, Pennsylvania. He completed his medical education at the University of Pennsylvania in 1791. He settled in Edom, Virginia, in the Shenandoah Valley in 1792, and in 1793 he married Elizabeth Hogg.

On January 24, 1794, Elizabeth began labor in her first pregnancy. Her labor was obstructed probably because of a contracted pelvis. Jesse summoned Dr. Humphrey, another physician, to consult. Forceps delivery was attempted without success. A craniotomy was advised, but Mrs. Bennett refused to accept the death of her child. Jesse then suggested a C-section, but Dr. Humphrey refused to perform an unknown highly dangerous procedure.

After many hours of unsuccessful labor, Jesse decided to operate on his wife. After receiving a large dose of opium, she was laid on a table composed of planks supported by two barrels. The patient’s sister held a tallow candle for light while two women aided the doctor. Jesse made an incision in the abdomen and uterus. The female baby was delivered. To prevent this from happening again, Dr. Bennett also removed her ovaries. To everyone’s amazement, Mrs. Bennett recovered, apparently without serious complications. The child lived to be seventy-seven years of age. Years later, when asked why the doctor had never reported the procedure in a medical journal, he is said to have replied, “No doctor with any feelings of delicacy will report an operation he had done on his own wife.”

Case 2

John Lambert Richmond (1785–1855) was born in Chesterfield, Massachusetts. His family moved to New York, where he worked as a farm laborer. In 1806, he married and ten years later was ordained a Baptist minister. He and his wife then moved to Ohio, where he continued to be a laborer and a pastor. One of his jobs was as the janitor at the medical school. He persuaded one of the physicians to accept him as a medical student. After two years of study, he obtained his medical degree in 1822, and served as both physician and pastor in Newtown Ohio.

On Sunday, April 22, 1827, Richmond was called out during church service to see a dying woman in labor who was attended by two midwives. The home turned out to be a cabin built only a week before with unchinked logs and a dirt floor. The only light was a candle. Because the weather was quite stormy, the midwives had to hold a blanket against the wind to keep the candle from blowing out. The midwives reported that the woman had been in labor for thirty hours had been having convulsions, and no progress to her labor. Dr. Richmond gave laudanum and ether to control the convulsions. Because he was now seven miles from home and the surrounding river was high, he realized he could not obtain advice from any other physician.

Having only his pocketknife, Richmond made an incision in her abdomen from umbilicus to pubic bone. He then opened the uterus and tried to deliver the child. However, his uterine incision passed through and destroyed the placenta, robbing the child of a blood supply. Because the patient was obese and the child was too big, Richmond found it impossible to remove the child. He decided that a childless mother was better than a motherless child, and he determined to do all he could for the preservation of the mother. Therefore, he did a destructive operation on the now dead child to deliver it. He then closed the abdomen and dressed the wound. The patient never complained of pain throughout the entire course of the operation. She was placed on bedrest for four days. She began to do some physical work twenty-four days after the operation, and five weeks after the procedure walked a mile and a half home.

The greatest mortality from C-section in the 1800s was from infection of the uterus and contamination from prolonged labor. A series of twenty-two Cesarean deliveries performed in Paris had a 100% maternal mortality rate, mostly due to hemorrhage and infection. With the introduction of ether anesthesia in 1846, and three years later the introduction of chloroform, both safety and survival for C-sections increased. With the advent of germ theory by Pasteur in the 1860s and the successful use of antiseptics by Lister in 1865, the mortality of women decreased significantly but still hovered around 40 to 60%. This was an improvement over the almost 85% mortality before the American Civil War, but improvements were still needed.

Edward Porro of Pavia, Italy, introduced the removal of the uterus and ovaries after C-sections to control post-partum bleeding and reduce the risk of infection in 1876. By 1884, approximately 140 of Porro’s operations were performed across Europe with a mortality rate of 56%. Although this helped to slightly lower maternal mortality rates overall, as one would expect, women who underwent this procedure would not be able to have more babies and were thrown into premature menopause.

The 1900s saw major advances in medicine. The germ theory was finally established and accepted in the United States, rigorous training of surgeons became universal, and the rise of specialties, including gynecology, came to fruition at Johns Hopkins Hospital. Using gloves during surgery along with sterile instruments, masks, and clean clothes decreased the morbidity of all surgical techniques. In 1900, 95% of all births were at home. By 1960, 97% of all births were in hospitals. With better monitoring, coupled with advances in spinal and epidural anesthesia, C-sections now are performed in almost 23% of all pregnancies worldwide.

References

• Grubb, Jr. Md Robert L. “The first successful cesarean section and the first oophorectomy in the Americas.” The West Virginia medical journal 80 10 (1984): 221-3.
• Low, James. “Caesarean section–past and present.” Journal of obstetrics and gynaecology Canada : JOGC = Journal d’obstetrique et gynecologie du Canada : JOGC vol. 31,12 (2009): 1131-6. doi:10.1016/s1701-2163(16)34373-0
• Ostrin, Samuel MD. “The Birthright of Kings and the Legacy of Gods.” Resident & Staff Physician, (1987): 117-119.
• “The Birthright of Kings and the Legacy of Gods.” Resident & Staff Physician, March 1987, 117–19.