THE STORY OF CAESARIAN SECTION

I hope you remember my esteemed senior colleague from Thrissur, Prof. Hirji Adenwalla. He told us the story of Cortisone and Insulin. Now this is another gem from the master story teller!

It is difficult to comprehend today that up to the year 1867 if a woman survived a caesarian section it was considered a clinical curiosity and the hundreds of years before that you could count on the fingers of one hand the number of women who lived after a caesarian. A few of the babies thus delivered  survived, the majority died because these caesarians were conducted on an already dead or a dying mother as a last resort, and on the part of the surgeon it was considered as sheer surgical bravado. The Catholic Church had issued a diktat that no mother should be buried with a child in utero. The child should be removed, baptized and then the mother and child were to be buried. Can you imagine that this was one of the indications for a caesarian? Compare this depressing scenario with the mortality reported less than a hundred years later in 1949. The University of Zurich reported a mortality of 0.66 percent. Today in the 20th Century the mortality is almost infinitesimal and an obstetrician would hang his head in shame if he lost a mother after a caesarian.

          

 It is erroneously believed that Caesar was delivered by a caesarian section. The word caesarian is derived from the Latin “Caeso matris utero” which means “cutting of mother’s uterus”. All that Caesar had to do with it is that he passed a law legalising the performance of this operation. It figures in Greek mythology, Apollo is supposed to have cut Aesculapius, the Roman God of Medicine out of the womb of his mother Korina. Aesculapius lived but what happened to the mother we do not know. The written chronicles of many ages and peoples contain reference to “Birth by section”. The Rig-Veda of the Hindus, the Talmud of the Jews and the records of the Romans, the Persians and the Arabs contain reference to this operation. It was mentioned that the history of child birth has ever been filled with pain. Now what was the cause of the death of these unfortunate women? The onus is laid at the door of one Francois Rousset surgeon to the Duke of Savoy. His was considered a classic text book of obstetrics and he was the first to recommend a caesarian section in a living mother for obstructed labour. He laid down certain rules that were followed without question by generations of obstetricians. He dogmatically stated that the womb should never be sutured as the after pains would tear open the incision. Only the abdomen had to be closed. If the mother did not die due to severe bleeding from the un-sutured incision in the uterus, she would die of surgical sepsis which was rampant in the pre-Listerine era. However, it was later discovered that Rousset himself had never done a Caesarian section, he had probably never even witnessed one. But his book became the Bible for any surgeon who dared to undertake a caesarian. They followed him unquestioningly like dumb driven cattle, so women continued to die of severe haemorrhage  as a result.

           

Rousset’s original book was in French but was translated into Latin the language of science by a man called Gaspard Bauhin and he related a number of fantastic cases which he said inspired Rousset to write his book. One of the stories was about a Swiss Butcher named Jacob Sigerhausen who in the year 1500 performed a caesarian on his wife and saved both mother and child. The woman went on to bear five more children whom she delivered normally-a statement which casts grave doubts upon the veracity of his story. From the end of the 17th century there is only one documented case of a caesarian performed on the 21st of April 1610 by a German surgeon in Wittenburg. His name was Trautmann. The caesarian was performed on a Cooper’s (barrel makers) wife, Ursula Opitz. The child survived but the mother died. These inevitable fatal outcomes of caesarian sections gave it ill repute.  Yet no one, no one, asked why women who were operated on according to Rousset’s instructions always died. No one ever doubted the teaching of this death dealing theoretician. Why did nobody make an effort to suture the wound which was the natural thing to do?

The stage now shifts to the San Matteo Hospital in Pavia, Italy and the main actor in this dramatic story is a young 33 year old surgeon trained at the University of Pavia and now held the post of Professor of Obstetrics in the same University. He was a fervent Italian nationalist and had served under Garibaldi. He was a thin earnest man with a pale high forehead and a heavy black beard. His eyes shone with a natural kindness which endeared him to his patients whose suffering he found difficult to bear. His name was Eduardo Porro (1842-1902). It must be admitted that Porro’s concept was originally suggested by a Florentine surgeon named Joseph Cavallini who proved on dogs that the uterus was not essential to life and could be removed with impunity.

            

On April the 27th 1876 a 25 year old girl who had obviously suffered from congenital rickets entered the San Matteo in Pavia to deliver her first baby. The girl was badly stunted and deformed. Porro examined the girl, she was four weeks overdue, she had a severe rachitic pelvis, her diagonal conjugate was 7 cm and her true conjugate was 4 cm or even less. Besides this she had a spondylolisthesis  of the lumbar spine forming a roof over the pelvic inlet. Seeing the girl he was not surprised at these findings. He knew for sure that he could never deliver this baby through the normal passage. A caesarian was imperative to save the baby but the mother would surely die of either haemorrhage or surgical sepsis. This kindly man patted the mother on the shoulder and said, “don’t worry the baby is alive these things take time”. He then let his students examine her, they adjourned to an adjacent room and the case was thrown open to discussion. His students were well trained by him and they all gave him a grave prognosis. At the end of it all a student asked him, “What will you do sir?”, “I will perform a caesarian of course I know the woman will die but we might save the child”. At the back of Porro’s mind was the knowledge that in the last 10 years not a single mother had survived a caesarian section. Porro also knew that caesarians were performed on dead mothers to baptise the children one of the edicts of the Catholic Church. Porro had read about the work of Jean Rena Sigault who proposed expanding the constructed pelvic girdle by cutting open the symphysis pubis, his research told him that it did not work. Sammuel Merriman of England advocated precipitating premature labour when the baby was very small. All the babies died and so did most of the mothers. John Aitken a British gynecologist who died insane in an asylum in the year 1790 proposed that all infection came from the air and therefore, caesarians should be performed under water. Porro said to his students “Gentlemen each proposal is wilder and more desperate than the previous one”. “Gentlemen”, he said “we must put all this aside and listen to what the French surgeon Lebas has to say for he has the answer. Listen to that what he writes. “In all the autopsies that I have performed the incision in the uterus was not closed and did not close on its own as Rousset believed. It was from this highly vascular area of the uterus that the women bled to death and died of shock even before sepsis could carry them away. I have tried to close the wound in the uterus but I did not have the adequate suture material, the after pains caused the incision to open up again”. Of course all these were classical caesarian sections.

           

Porro traumatised  by the misery he saw all around him had turned all this over in his mind a thousand times and came to the conclusion that if he could not close the uterus he had only one option and that was to remove it. The choice was a grim and a mutilating one. But if the choice was between certain death and survival by mutilation. The choice was obvious. What made Porro ultimately make his decision in the case of Julie Covallini? Was it the look of suffering of a timid child in her eyes? Or was it the conscience of a brave man accusing himself of being a coward when he knew full well that the only chance he had of saving the woman was by removing the uterus.

           

On the morning of the 21st of May 1876 a nurse reported to Porro that the Covallini woman’s pains had begun. At 10 AM he was informed that her sac had burst. At 20 minutes to five that evening Porro made his incision under chloroform anesthesia, it is recorded that he undertook some half- hearted antiseptic precaution that was slowly creeping into the surgery of those days. There was hardly any bleeding when he opened the peritoneum. But when he made the vertical incision of a classical caesarian section and delivered the baby, he was in a deluge of blood. All the conventional methods of massaging the uterus to make it contract to stop the bleeding were tried, but it was to no avail. For a long moment Porro hesitated then he made his decision. After putting a tourniquet like instrument on the cervix called a “Cintrat serre- naeud” which controlled the haemorrhage and then with a few bold cuts he whipped out the uterus. By today’s standards if you go through the detailed description of the operation which he later wrote, it was crude surgery, but you could say that it was a sub-total Hysterectomy.

           

For days after surgery Julie Covallini hovered between life and death, and Porro hardly left her bedside. For days she remained febrile. Infection had set in, she was delirious and there were several ups and downs when Porro thought he had nearly lost her. However, on the 33rd day after surgery the temperature settled down and at noon the same day Porro found her out of bed for the first time. Both mother and child had survived. A couple of months later Porro published his historical paper titled “Della Amputazione utero-ovario come compliment dal Taglio cesareo”. (utero-ovarian extirpation as a complement to caesarian section). It was carefully written and with extreme restraint. Unlike Semmelweis’s work it created a tremendous stir in the Mecca of Medicine-Vienna.

          

Throughout Europe and America in a short time the operation became a routine procedure, of the first 134 caesarians recorded by Porro’s method, the survival rate was 44%. This was phenomenal success and pinpointed the cause of death to the inability of the surgeon to close the uterus which led to fatal haemorrhage. It also focused the attention of the surgical fraternity to the undeniable fact that if they wanted to avoid the mutilation of a hysterectomy they must find a way to suture the uterus. The blind spot that Francois Rosset had created in the minds of surgeons was for ever removed.

           

As techniques improved and stronger suture material evolved surgeons were able to close the classical vertical opening in the body of the uterus. The credit for first successfully closing the uterus goes to Max Sanger of the University of Giessen in the year 1881 and so Porro’s operation enjoyed centre stage for only six years. But during that time the lives of thousands of women were saved. Marion Sims further improved the technique of suturing the uterus.

           

It was Ferdinand Adolf Kehler of Guntersblum  also a German who first advocated the technique of opening the lower segment of the uterus. Kehler’s operation was first performed in the town of Mackesheim on a 26 year old woman on the 25th of September 1881. With the lower segment caesarian section the classical caesarian section went completely out of vogue, and complications and mortality were further reduced to infinitesimal proportions. This today is the operation of choice performed uniformly all over the world.

           

There is a lesson to learn from this story. The mistake of Francois Rousset and all the mistakes of other like minded  men who postulate without proof have delayed the progress of science and have cost the loss of millions of lives. It was Lord Moynihan who said “there is no greater impotency of mind than the passive acceptance of facts”.

           

What Rousset wrote in 1581 without proof was accepted for 300 years without question and women died by the thousands. No one questioned Rousset. Generations of surgeons were like dumb driven sheep jumping over a fence without a thought. Only one man, a French surgeon by the name of Lebas said that Rousset was wrong, terribly wrong. He said either suture the uterus or remove it otherwise your mothers will continue to die, and it required the courage of one man Eduardo Porro to do what he thought he had to do. Eduardo Porro would have been criticised and ostracised if Julie Covallini and her baby had died. But luck was on the side of this brave man and on the side of millions of women that are alive today after a caesarian section. After this, men like Pasteur, Koch and Joseph Lister marched on to eliminate surgical sepsis and through them a new dawn broke on the surgical horizon.