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[I have asked a variation of this question already on the Judaism This Site, but am offering a broader version of it here.]
According to US National Library of Medicine, the first recorded instance of a mother and child surviving a C-section is from 16th century Switzerland, but is a somewhat dubious tale. Maimonides, who for a time served as one of the court physicians to the Sultan Saladin in the 12th century, writes that the possibility of even the mother surviving such a procedure is exceedingly rare (Commentary on the Mishna, Bekhorot 8:2).
I would like to know under what sorts of circumstances surgeons even attempted this procedure in the ancient world. There are explicit references to C-sections in the Mishna (such as the passage on which Maimonides is commenting, above), so I know that it at least happened as early as the 3rd century, but what I don't know is why.
Did surgeons only perform this procedure because the woman was already dying and because they wanted to save the baby? Or were there enough situations in which women survived as to allow surgeons to risk operating on healthy mothers as well, in a case where the baby was not expected to survive normal delivery?
There are plenty of problems related to childbirth that will kill both mother and child without intervention. This was considerably reduced by the invention of forceps but that did not happen until the 1600s. Low-tech childbirth is dangerous.
If you're reasonably sure that you're going to lose both mother and child without doing a Caesarean, then doing it for decent odds of saving the child and almost certainly losing the mother may be the best option you have.
Without modern equipment, you don't know all that much about the condition of the child.
Call the (Roman) midwife
Even today, childbirth can be arduous, even dangerous – so how did mothers deal with the challenges in antiquity? Laurence Totelin introduces the midwives of the Roman empire and explores their techniques
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Published: March 26, 2019 at 12:51 pm
Marcus Ulpius Amerimnus and Scribonia Attica, a husband and wife who lived in the second century AD, rest together in their funeral monument at Ostia, near Rome. According to an inscription on the walls of the tomb, Scribonia herself commissioned it for the eternal rest of her family and freed-people. Marcus was a surgeon, as we learn from a bas-relief on the tomb, where he is represented in the act of treating a leg wound, next to his – rather oversized – surgical instruments.
Scribonia, as another of her names, Attica, indicates, had Greek origins, as did her mother Scribonia Callityche their ancestors probably included slaves. But the midwife Scribonia had gone up in the world: she had made a good marriage with a skilled healer, and she had acquired wealth. Like her husband, she had tools, which she brought to women in labour: the birthing chair and the stool on which she sat were hers.
Childbirth in the Roman empire, as everywhere in the ancient world, was women’s business. Female midwives and family members brought children into the world and attended to the care of newborns. However, with the exception of inscriptions or art on funeral monuments such as that of Scribonia, almost no first-person accounts of pregnancy and childbirth in ancient Rome are available our knowledge is mediated instead through the writings of male authors.
Admittedly, some of these men were very well informed, sympathetic to women, and prepared to recognise the skill of midwives. Soranus of Ephesus in Asia Minor (in what’s now Turkey), who was a physician active at the turn of the first and second centuries AD, was such an author. An adherent of the Methodic school of medicine, he favoured gentle treatments over harsh ones – and nowhere is this more apparent than in his Gynaecology, the only one of his treatises to be preserved in full.
The volume opens with a description of the ideal midwife: she should be “literate, with her wits about her, possessed of a good memory, loving work, respectable and generally not unduly handicapped as regards her senses, sound of limb, robust and, according to some people, endowed with long, slim fingers and short nails at her fingertips”.
Just How Old Is C-Section Birth?
An 18th-century Hungarian woman made history this week—her mummified remains preserve the earliest direct evidence of C-section. Sadly, neither she nor her full-term son survived. Which raises the question: Just how old is C-section birth, and when did women and babies start surviving it?
CHILDBIRTH AS EVOLUTIONARY COMPROMISE
Basically since humans started walking upright, childbirth has been difficult for women. The brains of our hominin ancestors got larger and larger, with the result that today’s average newborn has a head 102 percent the size of its mother’s bony pelvis. Yes, you read that right—our babies’ heads are actually larger than our skeletal anatomy.
Obviously, an evolutionary compromise was worked out, so that humans could have large-brained babies and still walk upright. Babies’ skulls bones can slide around and overlap to help them get out. The fetus also goes through a sort of dance when it’s born, wiggling and turning with the help of contractions to make its way through the bony pelvis. And, perhaps most importantly, towards the end of pregnancy, a hormone is released that weakens the cartilage of the joints of the pelvis, letting it widen just enough for the baby to come out.
But we humans also rely on culture for our existence, and the same is often true for birth. The caesarean section—which includes the Latin root word for cut—involves extraction of a baby through a cut into the mother’s uterus. Although the practice dates back thousands of years, women didn’t survive it until comparatively recently.
HISTORICAL RECORDS OF C-SECTIONS
There is some argument among scholars that C-sections were performed in Egypt around 3000 BCE, but the earliest clear documentation in ancient texts comes from early Rome. The second king, Numa Pompilius (c. 700 BCE) passed a law called the Lex Regia, later renamed the Lex Caesarea and reported in Justinian’s Digest (11.8.2). This law forbade burying a pregnant woman until her offspring had been excised from her body. The reason stated for the law was that there was a small chance the baby would survive, but it is unclear if the law was religious in nature or whether it simply aimed to increase the population of tax-paying citizens. A similar reference to post-mortem delivery comes from Sage Sustra, a practitioner of Hindu medicine around 600 BCE. But in neither case is it clear how often—if ever—this was carried out.
This means that the first person who was born by C-section is also hotly debated. Julius Caesar is often held up as the most famous example, with the assumption that his cognomen—third name or nickname—resulted from his style of birth. Sadly, it seems that the Roman author Pliny either made this up or was referring to a very distant ancestor of the Julii clan. Since women didn’t survive C-sections in ancient Rome, Caesar’s mother Aurelia, who lived well into her 60s, did not deliver him in that way.
Historical records of famous people born by C-section actually go back further than Caesar, though. Some scholars claim [PDF] that the earliest documented C-section produced the orator Gorgias in the 5th century BCE, but the historical evidence is murky. Although Pliny was wrong about Caesar, in his Historia Naturalis (VII.ix) he wrote that the celebrated Roman general Scipio Africanus was born in this manner in 236 BCE. If either of these cases is correct, there is evidence of viable offspring from C-sections nearly 2500 years ago. But these procedures were certainly only done when the mother died or was about to die in childbirth.
It wasn’t until the 1500s that doctors began to expect women to survive the procedure. French physician François Rousset broke with medical tradition at the time and advocated performing C-sections on living women. In practice, though, it was still only performed as a last-ditch effort to save the newborn. Certainly some women survived C-sections from the 16th to 19th centuries, but it was still a very risky procedure that could easily lead to complications like endometritis or other infection. C-sections didn’t become common until the 1940s, following advances in antibiotics that made them survivable.
ARCHAEOLOGY OF CHILDBIRTH AND C-SECTIONS
The infant mortality rate was very high in antiquity, as were rates of mothers dying in childbirth. Consequently, you might expect that archaeologists have found loads of mother-fetus burials. But very few exist. In fact, the number of pregnant female burials in the published archaeological literature from around the world is only about two dozen.
There are several potential reasons for this lack of evidence. First, archaeological methods got significantly more scientific in the 1970s, so more recent excavations are better at finding tiny fetal bones. Second, the mother could outlive the fetus, and the newborn could outlive the mother. Death at different times will not be obvious archaeologically as evidence of childbirth-related complications. Even when the mother and baby both die before birth, though, this may not be evident because of a phenomenon called “coffin birth”—when the gases that build up within a corpse cause post-mortem “birth” of the fetus. And finally, cultural practices could be to blame for our lack of evidence—application of the Roman Lex Caesarea, for example, could result in a woman buried by herself and a viable newborn who grows up and dies much later.
Unfortunately for archaeologists, C-sections usually involve soft tissue only, so it is unlikely that we will ever find direct ancient evidence of it in a skeleton. There are two possible ways to see physical evidence of ancient C-sections. One is cut marks on the pelvis made around the time of the mother’s death by a surgeon. (Normally, C-sections don’t involve cut bones, but symphysiotomies—cutting through the front of the pelvis—can be done with or without accompanying C-sections to aid in delivering a baby.) The second is a mummy with an incision into the uterus and other physical changes associated with pregnancy and labor. At the International Conference on Comparative Mummy Studies earlier in April, the first-ever direct evidence of an early C-section was presented. The case study, presented by anthropologist Ildikó Szikossy of the Hungarian Natural History Museum, involves a woman named Terézia Borsodi, who died in December 1794 during the birth of her sixth child. While historical records suggest that the baby boy was delivered alive, Terézia’s mummy shows she was likely already dead when the C-section was performed. The baby also did not survive, and they were buried together.
CHILDBIRTH IS BIOLOGICAL AND CULTURAL
Childbirth is both a biological and a cultural process, today and in the past. But while biological variation is consistent across all human populations, the cultural processes that can facilitate childbirth are quite varied. A quick glance at the rates of elective C-section around the world demonstrates this easily. So archaeologically, we should also expect to see variation in the lives, deaths, and burials of women and infants.
Archaeologists use skeletons, historical records, medical artifacts, and other clues from burials to reconstruct childbirth practices and interventions in the past. New advances in microscopic analysis of the bones of ancient fetuses are also revealing whether or not the baby was alive or stillborn. As the archaeological record gets better, and as excavation, recording, and analysis techniques advance, we should soon have better methods for understanding this key time in the lives of mothers and infants, and for figuring out when the earliest C-sections occurred.
A history of caesarean section: From ancient world to the modern era
Caesarean section has been recorded in history since ancient times in both Western and non-Western literature. Although the first use of the term in obstetrics was from the seventeenth century, its early history is obscured by mythology. The origin of the term caesarean is believed to be from the birth of Julius Caesar however, this is unlikely considering his mother Aurelia Cotta lived for many years afterwards. In ancient times, it was performed only when the woman was dead or dying as an attempt to rescue the fetus. With few exceptions, this was the pattern until the era of anaesthesia in the nineteenth century. Developments in surgical technique from the later nineteenth century and through the twentieth century have refined the procedure, with resulting low morbidity and mortality. As a consequence, the objectives of caesarean section have evolved from rescuing the fetus or for cultural or religious reasons towards concerns for the safety of mother and child as well as considering the mother's preferences.
Historians Question Medieval C-Section 'Breakthrough,' Criticize New York Times Coverage
A few weeks ago, the New York Times ran the piece "A Breakthrough in C-Section History," detailing a recent article in a medical journal about Beatrice of Bourbon's 1337 delivery. But medical historians have criticized the news item as a problematic summary of a questionable analysis.
The study, published in the obscure Czech journal Česká Gynekologie, is by a medical doctor, a philosopher and a medical historian at Charles University in Prague. In it, the researchers, led by first author Antonin Parízek, claim that historical records of the difficult pregnancy and delivery of Beatrice of Bourbon, the second wife of King John of Bohemia, are the earliest recorded evidence of a mother surviving a caesarean section.
There is plenty of evidence for C-section delivery prior to the 14th century, as I've detailed elsewhere. But in these cases, the procedure was done as a last-ditch effort to save the baby when a mother was dead or dying. Doctors did not expect mothers to survive the operation until the 16th century, when French physician François Rousset became the first to advocate for the procedure, and it wasn't until the 1940s with advances in antibiotics that C-sections became routine, survivable surgeries.
Given the longstanding obsession with women's bodies and reproductive capacities in the U.S., it is not surprising to see the New York Times report in their "What in the World" section on a study that is potentially of historical interest. The problem, though, is that the article is presented as having consensus among medical historians. And that is far from the case.
Arizona State University medical historian Monica Green detailed the issues with both the purported historical study and the news coverage in a blog post. "To the historian of medicine," she writes, "the study bears all the pitfalls of amateurish oversight. It takes no account of the past 30 years of scholarly literature in either the history of medieval obstetrics (or women's history more broadly), nor the history of medieval surgery or anesthesia." That is, the article was presumably reviewed by physicians, with seemingly no review by historians.
Painting of Beatrix of Bourbon. (Image from the Bibliothèque nationale de France, via Wikimedia . [+] Commons. Public domain.)
While the interdisciplinary team who wrote this article is impressive, Green says, "the reviewing process should have involved scholars with a similar range of competence" because the study hangs on the "slimmest thread of evidence -- the meaning of the Latin word incolumitate."
Experts in Medieval obstetrical history, including Green and Maaike van der Lugt of Université Paris Diderot, interpret the historical phrase " salva incolumitate corporis" as "without harm to the body," suggesting Beatrice survived a complicated vaginal delivery without injury. On the other hand, Parízek and colleagues interpret it in their article as meaning "without breaching the vagina" and therefore potentially referring to a C-section.
The lack of historical review is particularly problematic in this case, van der Lugt tells me, because the authors misinterpret both the Latin and the Dutch written record for Beatrice's delivery because they take them at face value.
Parízek and colleagues claim that the Brabantse Yeesten, an early 14th century Dutch text with a 15th century addition, refers to prince Wenceslaus being born by C-section and that his mother, Beatrice, survived the ordeal. But van der Lugt points out that this is not an exact account of the birth, and is rather an historical trope, or "a bid to show that Wenceslaus was destined to rule Brabant -- he is the son, brother, brother-in-law, cousin, and uncle of emperors and kings."
The Dutch text refers to a previous imperial C-section, claiming that Julius Caesar's mother survived the procedure. There is, of course, no historical evidence that Caesar was born that way. Rather, the Medieval chronicler was building a case for Wenceslaus's fitness to rule through a false comparison with Caesar. Green adds in a comment in PubMed that "s tories of Caesar were very popular in royal circles at that time, and his birth (by C-section, allegedly, because of a medieval misunderstanding of classical sources) was often depicted in quite elaborately decorated manuscripts. A more interesting question, therefore, is why the legend arose, and why the vernacular histories of the Caesars might have been so influential in this imaginary."
In the end, van der Lugt notes that "apart from the reference to the mother's survival, this description is no different from the many other medieval legends about the exceptional births of medieval princes and saints by C-section. So indeed, there is no reason to revise the history of the caesarean section on the basis of this case."
Woodcut: birth of Antichrist by Caesarian section, c.1483. (Credit: Wellcome Library, via Wikimedia . [+] Commons. CC-BY 4.0.)
Why, then, was this article published, and why did the New York Times cover it uncritically, without fact-checking with medical historians?
Green suspects that the study was meant "to provide an interesting reflection on [Czech] national history to the country's obstetrical specialists. For its original audience, its speculations about the nation's medieval history were no doubt fascinating." The problem, however, lies in the lack of sufficient peer review and in the lack of critical analysis in a news item. "In the case of [the field of] medical history," Green writes, peer review "is a major issue. Researchers who have both MDs and PhDs exist, but are rare."
While physicians have a deep understanding of anatomy and surgery, historians like van der Lugt are key for helping contextualize written records that are not always truthful representations of facts.
More problematic to Green, though, is not the speculative historical study by Parízek and colleagues but rather the New York Times's coverage of the article. "Once its message was amplified internationally," Green notes, "it suddenly became 'a breakthrough,' a major scientific discovery" in spite of the fact that the lead author "seems to be the only person interviewed for the [New York Times] news story."
In short, Green writes, "this is fiction. But, presented as 'fact' by the New York Times , it becomes accepted as truth by a world-wide audience." While the journal article about Beatrice's 1337 delivery and the news coverage of the study are not themselves false per se, "the implication that [the study] reflected any kind of consensus on what historians believe about women’s medical history was absolutely false."
Why Is It Called “Cesarean Section”?
The surgical procedure done to deliver a baby through an incision in a woman&rsquos abdomen and uterus is called a cesarean section, but how did it get that name?
Lots of body parts are named for people, like the Fallopian and Eustachian tubes, which are named after the anatomists who described them, Gabriele Fallopio and Bartolomeo Eustachi, respectively. There are a few types of procedures that are named for the people who developed them, like the Heimlich maneuver, named for Henry Heimlich. But the cesarean section doesn&rsquot fall into either case.
The most common theory is that cesarean sections are named after Julius Caesar because it was said that he had been born in this manner. But, although it seems like a good fit, this idea is probably not true. The link between cesarean sections and Julius Caesar comes from writings by the Roman historian Pliny the Elder and in a Byzantine encyclopedia published in the 10 th century. The encyclopedia says that Caesar&rsquos mother, Aurelia, died in the ninth month of the pregnancy and that she was cut open so that he could be born. The problem with this idea is that Aurelia was known to have lived well into Julius Caesar&rsquos adulthood.
In Rome, even before Caesar was born, there was a law that required that when a woman died in childbirth, the baby was removed from her body so that it could have a separate burial and was also done as a last resort to save the baby&rsquos life after the mother had died. Therefore, it might not have been unheard of for a baby to survive the mother&rsquos death.
So, how did Caesar get associated with a surgical delivery of a baby? One possibility is that an ancestor of Caesar&rsquos was born in that manner and that the family name was associated with that earlier birth. Pliny mentions that a Caesar was born in that way, but does not specifically name Julius.
However, Caesar and his family may have had nothing to do with the name of the procedure. There is a word in Latin, caedare, which means &ldquoto cut&rdquo and the past participle is caesus, thus leading to calling a procedure that cuts into the uterus as a caesarean or cesarean section. (By the way, either spelling is correct.)
Cesarean section births have become commonplace in modern times because of anesthesia and antibiotics. Through most of human history the surgically removal of the baby from the mother was done only if the mother had already died It was considered as a last resort.
But there were accounts of women who lived after they had a cesarean section in ancient history in many cultures around the world. There are many references to cesarean sections in ancient Hindu, Egyptian, Grecian, and Roman medical texts, and in European folklore. There are ancient Chinese etchings that show the procedure being done on women who appear to be still alive.
So, we can separate Caesar from cesarean section, but why is it called a section rather than a surgery or a procedure? The word section is used in medicine to describe the act of cutting. The word is also used to describe a very thin slice of tissue used in microscopic examinations and in radiology to describe images of a view through the body as if the body has been sliced, such as a sagittal section, which divides the body into right and left halves. Despite this root of the word, very few other surgical operations use the term section.
Birth by Caesarean Section in Ancient Times - History
Until the 16th century C.E. the operation of Caesarean section was a mystery and highly controversial in Europe but in the Middle Ages, Muslims wrote about the operation and even illustrated it with pictures. Towards the end of the 12th Century C.E. the European nations were beginning to surpass their rivals in the Islamic East. The increasing strength of the West took full advantage of scientific and literary discoveries of the Muslims. Far from giving any credit to the Muslims or acknowledging their contributions to science, the Western scholars painted a very distorted picture and left highly biased opinions of their predecessors from the Islamic world. This fact can be very easily illustrated by many examples from the history of medicine.
It is unfortunate that the Western medical historians have not appreciated the value of the writings of early Muslim scholars. On the contrary, for many centuries they have made positive efforts to discredit the Muslims. As an example, it is a generally held view in the West that surgical advancement was discouraged by great Muslim physicians like Ibn Sina because, in his Al-Qanon he did not emphasise surgical procedures. In these futile efforts it is forgotten that Al-Qanon was primarily a treatise on internal medicine and not on surgery. Many European authors of later ages produced medical texts on similar patterns. Moreover these shortsighted historians completely ignored surgical geniuses and the contributions of people like Abu Qasim (known in the West as Al Bucasis). In this context, the history of Caesarean section presents a good example. In 1863 a French medical historian by the name of C. Rique recorded that the operation of Caesarean section was strictly prohibited in Islam . He went on to say that according to Islamic jurists any child born by such an operation should be killed immediately as a child of the Devil. This author also quoted the name of an unknown Arab to justify his conclusion. But even after exhaustive searches this reference can not be found in the authentic Arabic literature. From the middle of the last century until modem times, Rique's statement has been quoted and referred to by many historians without establishing the truth or its validity. The literature on this subject is littered with references to the above quotation without even referring to the original source. On the contrary, no medical historian has ever mentioned that during the middle ages it was a well known belief in Europe that the devil or the Antichrist would be born by Caesarean section before the end of the world. This legend is mentioned and supported by a picture in a book published in 1898 by R. Procter and can be seen in the British Museum.
Unfortunately worthwhile literature of the early Islamic period is scanty and scattered or else is in the wrong hands. Many valuable manuscripts are either in private hands used only as profitable investments or in museums all over Europe and America. The Islamic states and the statesmen who can easily afford to collect and compile copies of these manuscripts for free circulation have never shown any interest in this wealth of inheritance. Lack of interest and research in these early manuscripts has created an atmosphere of doubt and misinformation.
If someone cared to devote time and effort searching through the available literature, a great a deal of truth could easily be found buried under the sands of time. As regards Caesarean section we know that in the pre-Islamic days the Romans used to perform this operation after the death of a pregnant woman. This practice was strictly governed by law. Jewish religious books have also mentioned various rules in relation to a child born by an operation. If we go further back into history, in India we find that the Buddha was possibly born by an operation. A famous Indian medical man by the name of Susruta wrote about such an operation in 6th or 7th century B.C. All these rich sources relating to Caesarean section were available to Muslim scholars of the Middle Ages, when a vast amount of scientific literature was translated into Arabic. In fact many of the Syriac, Creek and Sanskrit texts were only saved and are available to us because of their Arabic translations whilst the originals are lost forever. Many of the famous translators in the Islamic period were Christians or Jews. We known that an Indian by the name of Manka was appointed to translate Susruta's works into Arabic.
A unique and extremely rare manuscript exists in Edinburgh University Library. It is manuscript number 161 called "Al-Asrar-al-Baqiyah-an-al-Qurun-al-Khaliydh" or the Chronological History of Nations. It was written by the famous Muslim, Al-Beruni, who died at the age of 78 in 1048 C.E. Al-Beruni has also left us a large volume on the history of India and many other texts. He travelled extensively in pre-Muslim India and his writings were greatly influenced by these experiences. In particular he was impressed by medicinal plants form India. In the above manuscript Al-Beruni has mentioned that Caesar Augustus (63 B.C. - 14 C.E.) was born by post-mortem Caesarean section. He also wrote that a folk hero Ahmed-Ibn-Sahl was born by Caesarean section after the death of his mother. Apart from these two very relevant references he actually included a picture of the Caesarean section in his book. Without any question this picture is the first ever illustration of such an operation in a textbook and places its author at least 500 years ahead of others.
Another famous name and contemporary of Al-Beruni was Firdousi (935-1025 C.E.), author of the well known "Shahnama". In this 60 000 verses long poems he described the birth of Rustum by Caesarean section. This lively and fascinating description and use of anaesthesia during the operation is there for everyone to read and provides convincing proof that the concept of Caesarean section was mature and its use was an accepted fact.
When we seek help from the religious authorities we discover no less than the towering figure of Imam Abu Hanifah (699 -767 C.E.) who decreed that an operation on a living or dead woman to save the life of an unborn child is allowed in Islam. This is mentioned in a book called Radd-ul-Mukhtar published in 1844 in Egypt.
Further strong evidence is available in the Fatawa Alamgeeria-a collection of Islamic decrees compiled by Sheikh Nitzam -ud -Din of Burhanpur under the auspices of the Mughal emperor, Aurangzeb, who himself was well versed in Islamic Sharia. In this document there is a decree that if a pregnant woman dies and a child is expected to be alive, then the child must be removed by operation. It goes on to say that the operation should also be performed in order to save the life of a mother when the child is known to be dead.
In conclusion it can be proved that Caesarean section has never been prohibited by any Muslim authority. On the contrary, the Muslims in the Middle ages were the first to write about it in text and poetry and to illustrate the operation in pictures. They also formulated rules governing religious matters to allow such a procedure when the need arose.
References: Partial restoration of the microbiota of cesarean-born infants via vaginal microbial transfer. Dominguez-Bello MG, De Jesus-Laboy KM, Shen N, Cox LM, Amir A, Gonzalez A, Bokulich NA, Song SJ, Hoashi M, Rivera-Vinas JI, Mendez K, Knight R, Clemente JC. Nat Med. 2016 Feb 1. doi: 10.1038/nm.4039. [Epub ahead of print]. PMID: 26828196.
Funding: NIH’s National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Cancer Institute (NCI), and Office of the Director (OD) C&D Research Fund Sinai Ulcerative Colitis: Clinical, Experimental & Systems Studies and the Crohn’s and Colitis Foundation of America.
How Did Caesarean Sections Get Their Name?
The story that the C-section originates—either in practice or in name, depending on who’s telling the story—with the birth of everyone’s favorite Roman Consul has been around for a while and gets repeated often. The 10th century Byzantine-Greek historical encyclopedia The Suda reads, “For when his mother died in the ninth month, they cut her open, took him out…” Even the Oxford English Dictionary gives that story as the term’s origin. Almost every other historical and etymological source, though, is stacked behind the answer “probably not.”
To start, Gaius Julius Caesar (we’ll call him GJC from here on out) certainly wasn’t the first person born via C-section. The procedure, or something close to it, is mentioned in the history and legend of various civilizations—from Europe to the Far East—well before his birth. He wasn’t even the first Roman born that way. By the time GJC entered the world, Romans were already performing C-sections and Roman law reserved the operation for women who died in childbirth (so that the woman and her baby could be buried separately) and as a last resort for living mothers in order to save the baby’s life during deliveries with complications.
Among the still-living mothers, no Roman or other classical source records one surviving the procedure. The first known mother to make it through the ordeal was from 16th century Switzerland (her husband, a professional pig castrater, performed the delivery), and before that the mortality rate is presumed to be 100 percent. This is an issue because GJC’s mother, Aurelia Cotta, is known to have lived long enough to see her son reach adulthood and serve him as a political advisor, despite what The Suda says. Some sources even suggest she outlived him. If little GJC really was born via C-section, Aurelia was exceptionally lucky to not only survive the delivery but also not have anyone make a fuss about it and record her accomplishment for posterity.
Does the C-section at least take its name from GJC? Again, probably not. While The Suda mistakenly has Aurelia Cotta die in childbirth, it does hint at a strong candidate for the origin of “Caesarean section.” The rest of the passage quoted above goes, “…and named him thus for in the Roman tongue dissection is called ‘Caesar.’” Not quite right, but going in the right direction. In Latin, caedo is “to cut,” so Caesar, both as the name for the man and for the procedure, might derive from some form of the word (like caesus, its part participle). The Roman author Pliny the Elder notes that origin for both Caesar and Caesones, the name of a branch of the Fabian family.
But if “Caesarean section” comes from a word for cut, and GJC wasn’t born that way, how’d the two get connected? That might come from some confusion about Pliny’s writings. Pliny refers to a Caesar being born by C-Section, but not GJC. Pliny was actually talking about one of GJC’s remote ancestors, specifying that he was the first person to bear the name Caesar* (who exactly that was is unclear) that “was so named from his having been removed by an incision in his mother’s womb.”
But wait, there’s more! The name Caesar may not have necessarily come from the way any of them was born. The Historia Augusta, a collection of biographies of Roman emperors, suggests a few alternate origins for the name:
“…he who first received the name of Caesar was called by this name either because he slew in battle an elephant, which in the Moorish tongue is called caesai, or because he was brought into the world after his mother’s death and by an incision in her abdomen, or because he had a thick head of hair [caesaries is a Latin term for hair] when he came forth from his mother’s womb, or, finally, because he had bright grey eyes [caesiis is Latin for “blind,” and “grey eyes” may refer to glaucoma]…”
If the first Caesar was named for an elephant, his hair or his eyes, the C-section might still be named for the Latin caedo, or actually take its name from the man. In that case, the story that started this whole explanation is a little closer to reality, but simply mixes up its Caesars.
The Disturbing, Shameful History of Childbirth Deaths
Photo by Martin Valigursky/iStockphoto/Thinkstock
Read the rest of Laura Helmuth’s series on longevity.
The best person I know almost died in childbirth. We met during college when we both volunteered at a commune in Georgia, the place Habitat for Humanity grew out of. Being a do-gooder was an anomaly for me, but it’s how Gwen has spent her life—she’s wise and kind and generous. She works in a mental health agency for HIV-positive people. When she was seven months pregnant, her diaphragm, the band of muscle that separates the chest from the abdomen, split, and a piece of stomach pushed up through it and necrotized. She went into labor, gave birth to her daughter, and had emergency surgery followed by massive doses of antibiotics. If this had happened even a few decades ago, she and the baby would both be dead. Instead, she’s fine, and her daughter is a wise, kind, generous child who wants to be a scientist.
Courtesy of Thomas Raynalde/Tradition of Science/Leonard C. Bruno/Library of Congress
Bearing a child is still one of the most dangerous things a woman can do. It’s the sixth most common cause of death among women age 20 to 34 in the United States. If you look at the black-box warning on a packet of birth control pills, you’ll notice that at most ages the risk of death from taking the pills is less than if you don’t take them—that’s because they’re so good at preventing pregnancy, and pregnancy kills. The risk flips only after age 35 because birth control pills increase the risk of stroke. (Psst, guys, you know what makes an excellent 35 th birthday present for your partner? Getting a vasectomy.)
In the United States today, about 15 women die in pregnancy or childbirth per 100,000 live births. That’s way too many, but a century ago it was more than 600 women per 100,000 births. In the 1600s and 1700s, the death rate was twice that: By some estimates, between 1 and 1.5 percent of women giving birth died. Note that the rate is per birth, so the lifetime risk of dying in childbirth was much higher, perhaps 4 percent.
Evolutionarily, childbirth seems like an exceptionally bad time to die. If by definition the ultimate measure of evolutionary success is reproducing successfully, the fact that women and newborns frequently died in childbirth suggests that powerful selective forces must be at work. Why is childbirth such an ordeal?
Compared to other primates, human infants are born ridiculously underdeveloped they can’t do much more than suck and scream. They would be better off if they could gestate longer—but the mother wouldn’t be. The classic explanation for why human infants are born at such an early stage of development has to do with anatomical limits on women’s hips. If the fetal head had time to grow any larger in utero, the baby wouldn’t fit through the pelvic girdle. And the pelvic girdle can’t get any wider or women wouldn’t be able to walk efficiently.
This is called the “obstetric dilemma” hypothesis and it’s been dominant for years, but it’s almost certainly wrong, or at least not the full story. Anthropologist Holly Dunsworth and her colleagues found that broadening the pelvis wouldn’t actually interfere with walking, and they point out that gestation is actually pretty long in humans compared to other primates (even though newborns’ brains are relatively less developed). Other researchers suggest that the problem of “obstructed labor”—when a baby basically gets stuck in the birth canal—seems to have become common fairly recently in human history.
The real reason women give birth when they do, Dunsworth says, is that it would take too much energy to feed a fetus for any longer. This is the “metabolic hypothesis” and it’s based on the finding that the maximum metabolic rate people can sustain is about 2 or 2.5 times their standard rate of using energy. During the third trimester, that’s exactly how much metabolic activity the pregnancy demands. Carrying a fetus for those final few months “is like being an incredibly good athlete,” Dunsworth says. No wonder it’s so exhausting.
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By the late stages of pregnancy and during childbirth, almost anything can go wrong. Pregnant women are sapped of energy. They are susceptible to infectious disease. The baby’s head is enormous. Labor takes much longer in humans than in other primates women often pushed for days. Historically, women died of puerperal fever (also called childbed fever, or postpartum sepsis, an infection usually contracted during childbirth), hemorrhage, eclampsia (dangerously high blood pressure and organ damage that’s what killed Sybil on Downton Abbey), and obstructed labor.
Given all the dangers, how did deaths in childbirth fall to about one-fiftieth of the historic rate? Life expectancy in the United States and the developed world basically doubled in the past 150 years, and a decrease in maternal mortality is ultimately a big reason for our longer, healthier lives. But the history of childbirth death rates is complicated and disturbing. It’s a story of hubris, mistrust, greed, incompetence, and turf battles that live on today.
The death rate in the overall population started dropping at the end of the 1800s, and it dropped most dramatically during the first few decades of the 20 th century. Childbirth deaths were different. They actually increased during the first few decades of the 20 th century. Even though pregnant women had less exposure to disease and were more likely to have clean water, proper nutrition, safe food, and comfortable housing than at any previous time in human history, they died in droves in childbed.
For most of European and U.S. history, midwives had attended births. Some were incompetent, some were skilled. The best ones wrote and read reports on techniques and treatments, and there’s some evidence they were becoming better trained and having better outcomes during the early 1800s. Doctors had little to do with childbirth—they were all men, and it was considered obscene for a man to be present at a birth.
As the profession of medicine grew during the 1800s, though, doctors started to edge their way into the potentially lucrative business of childbirth. The first ones were general practitioners who had no training and little experience in childbirth. It was considered a low-status specialty and wasn’t taught well or at all in most medical schools.
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In the delightfully named book Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank, Randi Hutter Epstein describes the state-of-art treatment: “Before forceps, babies stuck in the birth canal were dragged out by the doctor, often in pieces. Sometimes midwives cracked the skull, killing the newborn but sparing the mother. Sometimes doctors broke the pubic bone, which often killed the mother but spared the baby. Doctors had an entire armamentarium of gruesome gadgets to hook, stab, and rip apart a hard-to-deliver baby. Many of these gadgets had an uncanny resemblance to medieval torture tools.”
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The biggest danger to expectant mothers was infection. Before the germ theory of disease, people suspected puerperal fever could somehow be contagious, and they knew that some midwives and doctors had worse records than others, but no one knew how it was transmitted. (“Putrid air” was one popular hypothesis.) To avoid blame for maternal deaths, doctors lied on death certificates—they’d attribute a new mother’s death to “fever” rather than “puerperal fever” or mention hemorrhage without mentioning that the hemorrhage was caused by childbirth.
In the mid-1800s, Ignaz Semmelweis discovered that doctors in his hospital in Vienna were spreading puerperal fever when they went directly from performing autopsies to delivering babies—but his work was mostly ignored. There were many reasons for this: He was apparently a real pill, the methods he suggested for sanitizing the hands were caustic and difficult, and most doctors attending births at home hadn’t been near a corpse. Doctors were also offended by the accusation that their filth was responsible for deadly disease: Gentlemen didn’t have dirty hands.
The best source of historic information on this subject is a book called Death in Childbirth: An International Study of Maternal Care and Maternal Mortality 1800-1950, by Irvine Loudon. (If you are pregnant, whatever you do, do not read this book.) It’s a very serious work, rich in data and graphs and analysis, but you can tell he’s furious about all the unnecessary deaths at the beginning of the 20 th century. Here’s how he described puerperal fever: “A woman could be delivered on Monday, happy and well with her newborn baby on Tuesday, feverish and ill by Wednesday evening, delirious and in agony with peritonitis on Thursday, and dead on Friday or Saturday.” During the 1920s in the United States, half of maternal deaths were caused by puerperal fever. For a disease that was “preventable by ordinary intelligence and careful training,” he wrote, “these figures were a reproach to civilized nations.”
One piece of evidence Loudon uses to attribute blame for unnecessary early 20 th century deaths to doctors is that rich women were more likely to die in childbirth than poor women. (Mary Wollstonecraft was one victim of an incompetent doctor she died of puerperal fever after delivering a daughter who would grow up to write Frankenstein.) For almost any other cause of death, the poor were more likely to die than the rich. But for childbirth, poor women could afford only midwives. Rich women could afford doctors. Doctors in turn had to justify their fees and distinguish themselves from lowly midwives by providing new tools and techniques.
Things got worse as obstetricians started professionalizing and coming up with new ways to treat—and often inadvertently kill—their patients. Forceps, episiotomies, anesthesia, and deep sedation were overused. Cesarean sections became more common and did occasionally save women who would have died of obstructed labor, but often the mother died of blood loss or infection. (Fun fact: Julius Caesar wasn’t born of a C-section. As Hutter Epstein points out in Get Me Out, until recently the technique was used to extract a baby from a dying woman. “Cesarean sections were death rituals, not lifesaving procedures. If a doctor suggested a cesarean, you knew you were on the way to the morgue.”) Women giving birth in hospitals were at greater risk than those delivering at home. Disease and infections spread more readily in hospitals, and doctors were all too eager to use surgical equipment.
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Too many doctors and midwives were chasing after a limited number of pregnant women, and they gained market share by touting dazzling new techniques and bad-mouthing their competitors. Exacerbating the problem, there was little government oversight of medical care or education in the early part of the 20 th century. As Loudon explains, “Medical care in the United States was dominated by the belief in the virtues of competitive free enterprise combined with an intense distrust of government interference.”
“If I was forced to identify one factor above all others as the determinant of high maternal mortality in the USA,” Loudon wrote in Death in Childbirth, “I would unhesitatingly choose the standard of obstetric training in the medical schools.” They instilled an attitude of carelessness, impatience, and unnecessary interference. These deaths were “a blot for which the leaders of the medical profession are wholly to blame.”
Death rates in childbirth finally began to drop in the 1930s with the introduction of sulfa antibiotics that were highly effective against the streptococcal bacteria responsible for most cases of puerperal fever.
Doctors cleaned up their acts, too. A series of reports in the 1940s linked high death rates to improper medical procedures. Training improved, and doctors abandoned the most dangerous techniques. Complications from C-sections declined steadily. Medical researchers now rigorously evaluate success rates and risks of new techniques and drugs.