Doctor's Review: Medicine on the Move

August 22, 2017
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The kindest cut

Medical pioneers who plunged into their patients' uteri for the sake of saving lives

Once upon a time, babies were born by being pushed out into the world through their mothers' vaginas. Not too long ago, most doctors would have had a good laugh at any suggestion otherwise. But oh, how times have changed. According to the Canadian Institute for Health Information, 22.5 percent of all Canuck kiddies born in hospitals between 2001 and 2002 were delivered via caesarean section.

Indeed, the rise in c-sections -- up from 15 percent a mere 12 years earlier -- has been nothing short of shocking. Some analysts suggest that the rate may not level off until it reaches 40 percent, and that we may even hit that mark within a decade.

The reasons behind the increase are controversial. Sky-high malpractice insurance rates, the dubious reliability of fetal monitoring, and the recent trend toward elective surgeries are some of the main factors contributing to the debate.

While the precise rate of elective c-sections is not currently recorded, estimates suggest they account for about 1.5 percent of all births in Canada, though the number may in fact be higher due to inaccurate reporting. Both critics and proponents of elective caesarian sections agree that this is where the numbers could explode, potentially pushing the national average through the roof. Few would argue that we have the likes of Britney Spears and various body-conscious Spice Girls to thanks for touting the benefits of surgery by choice and bringing it to the public's attention.

But long before reed-thin celebrity mamas-to-be elected to prioritize their vaginal integrity under the watchful eye of tabloid journalists, a few hardy medical pioneers plunged blindly into their patients' uteri for the sake of saving lives. Then, as today, the primary goal of the obstetrician was to ensure a successful outcome for both mother and baby. Vanity and economics aside, the caesarian section has saved countless maternal lives, and brought forth safely into the world babies who would otherwise not have fared so well. So who exactly was it that started this trend, one which would eventually change the way babies are born?

Et Tu, Doc?
First things first: Julius Caesar was born the old-fashioned way. Despite her doubtlessly fabulous togas, the future emperor's mother Aurelia was not too posh to push, as reliable information assures us that she was in fact around during his military conquests.

Perhaps the rumour arose from the law during Caesar's reign which required doctors to cut babies out of the wombs of women who were either already dead or certain to end up that way. Unfortunately, since that last bit was open to interpretation, the Roman custom of prioritizing population growth, and therefore the life of the baby over the life of the mother, certainly led to an untimely maternal death or two.

Those kids who were born this way were tagged caesones, from the Latin word caedre, for "cut," a moniker which may have contributed to the rumour that Caesar was born this way himself.

It's also possible that the Ancient Romans -- as well as the numerous other ancient civilizations whose medical texts and mythologies make reference to living babies being cut from their mothers' abdomens -- found their inspiration in the first-known reference to the caesarian section.

The Ancient Greek god, and amateur obstetrician, Apollo was said to have delivered his son Asclepius by cutting him out of his dead mother Arsinoe's womb before the flames of her funeral pyre consumed him. Perhaps that's what inspired Asclepius's interest in the healing arts, as he eventually would become known as the god of medicine.

Over the centuries, many reports exist of surgeries to remove living babies from the wombs of dead or dying mothers. A British royal -- Scotland's Robert II -- was apparently born this way in 1316 after his mother, Marjory Bruce, couldn't deliver naturally. Poor Marjory died a few hours later and was probably glad of it, considering the anesthetic options at the time were quite limited, to say the least.

The real trick of the caesarian, of course, was to end up with at least two living patients after all was said and done. The first documented case of this actually happening was in 1500. The unlikely obstetrical hero in question was one Jacob Nufer, a Swiss peasant. After summoning all 13 local midwives and two lithotomists (surgeons "expert" in removing bladder stones, usually killing their patients in the process) to aid in his wife's delivery, all to no avail, he decided to do the job himself.

Armed with nothing but a knife, some thread and expertise in his chosen profession (pig castrator), Jacob did the deed. Mrs. Nufer not only survived, but reportedly bore her husband several more kids including twins in what is surely the first reported, though unsubstantiated case of VBAC!

 

A few more flukey, apparently successful c-sections were scattered throughout Europe over the next few centuries. Ever the experts in anatomy, the Italians apparently had some luck with the procedure. The Italian physician Scipione Mercurio (1540-1615) claimed to have a technique which worked (involving "four strong men" to hold the patient down).

Thirty one possibly successful cases were compiled and reported by the French obstetrician Jean-Louis Baudelocque (1746-1810) in 1801. But the c-section certainly wasn't a viable option until the incredible Dr James Barry came along to change the face of obstetrics (and sexual politics) forever.

The Yentl Of Medicine?
James Miranda Stuart Barry (1795-1865) was the Victorian version of Yentl, only she wanted to study medicine, not the Talmud. She dressed up as a man in order to gain admission to the University of Edinburgh medical school in 1809, where she excelled and specialized in surgery.

After graduating, she joined the British Army, still posing as a man, of course, and proceeded to ply her trade around the world. The Napoleonic Barry had an incredibly bad temper, carried a huge sword, and wore three-inch lifts in her shoes, all part of her plan to avoid detection, which she somehow managed to do for more than four decades.

Barry lived in South Africa from 1816 to 1827, serving as the colony's medical inspector. It was in 1826 that she performed one of the first-known and certainly the best-documented c-sections at that time. As a tribute, the elated mother christened her new son James Barry Munnik, and even commissioned a portrait of her medical miracle-worker, the only one known to exist.

Because of Barry's surgical expertise, people excused her strangeness (she was a staunch vegetarian, for example, and never went anywhere without her goat, whose milk she claimed was the key to health). Despite a few rumours of homosexuality, Barry somehow even managed to gain a reputation as a ladies' man.

Years later in 1857, the amazing Dr Barry actually lived for a time in Montreal, where she was posted as an inspector of military hospitals, championing the rights of soldiers and reforming hospital conditions. She somehow managed to elude detection her entire life, always refusing to be examined if she fell ill, and attributing her small stature and smooth face to genetic bad luck.

Upon her death in 1865, her secret was of course discovered, and Dr Barry unwittingly became a posthumous poster child for women's rights, proving beyond a doubt that she was as mentally manly in medicine as her male counterparts. Though some claim a post-mortem examination of Dr Barry's remains revealed that she may even have been a mother herself, the army graciously turned the other cheek and buried her with full military honours.

Certainly Dr Barry's widely reported accomplishments with the caesarian section contributed to other doctors undertaking the procedure, many with some success, but it was only once the arts of anesthesia (courtesy of American dentists Horace Wells (1815-1848) and William Morton (1819-1868) in the 1840s) and asepsis (courtesy of Ignaz Semmelweis (1818-1865) in 1847) fortuitously combined by the late 1900s, that surgical birth could truly be considered a viable option for mothers who found themselves in an emergency situation.

Add a little penicillin into the mix and the c-section virtually guaranteed a successful outcome. Of course, it probably would have happened sooner if the old Biblical belief that women were meant to suffer in childbirth hadn't gotten in the way. C-sections remained an emergency procedure until relatively recently, when diagnostic prenatal techniques had evolved to the point where complications to both mother and child could be predicted and therefore averted by its use.

Do-It-Yourself Surgery
Recently, a bizarre footnote was added to the history of the caesarian section. On March 5, 2000, Inés Ramírez Pérez did something no one had ever done before, or probably will again. As if a c-section wasn't complicated enough when performed by a qualified obstetrician in a modern operating room, this hardy Mexican peasant performed one on herself! More amazing still, both she and her son, Orlando, survived.

After 12 agonizing hours of labour alone in her isolated mountain cabin, InÄs decided to take matters into her own hands, since she had no phone to call for help and her husband was out carousing in the village many miles away.

She'd previously had a stillborn baby and was afraid history would repeat itself if she didn't act fast. In an optimistic attempt at self-anesthetizing, InÄs downed a few swigs of rubbing alcohol and set to work. It took her a full hour to slice diagonally into her own abdomen using what was essentially a steak knife (no bikini-cut for her!), finally extracting her baby boy and somehow managing to cut the umbilical cord before passing out.

After a brief rest, she woke up and sent her six-year-old-son Benito for help. He returned a few hours later with a stunned medic who sewed up her 18-centimetre incision with a needle and thread. She was finally transported to the hospital and made a full recovery.

The story, though believed by many to be a hoax, was in fact reported in the March 2004 issue of the International Journal of Gynecology and Obstetrics and confirmed as authentic, proving once more that truth is stranger than fiction, especially when it comes to the history of medicine.

 

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