Caesarean section is almost certainly one of the oldest operations in surgery with its origins lost in the mists of antiquity and mythology – as historians are wont to say when they don’t know. It has probably been performed by traumatic accident or postmortem for several millennia. Ancient myth and legend has it that Aesculapius and Bacchus, the Gods of Medicine and Wine respectively, were born by caesarean section. Thus, at least in legend, those born by caesarean section are in good company.

The origin of the word ‘caesarean’ is unclear. The weak myth that Julius Caesar was born by this route is contradicted by the fact that his mother survived his birth by many years. It is likely that the term comes from the lex regia or royal law legislated by one of the early kings of Rome, Numa Pompilius in 715 BC. This law proclaimed that women who died before delivering their infant had to have the infant removed through the abdomen before burial. This law continued under the ruling Caesars when it was called lex caesarea.

Traumatic caesarean sections have probably occurred throughout the course of history during war, acts of violence and accidents. Among the more well documented are those in which the horns of cattle have torn open the woman’s abdomen and uterus. One of the best known cases was reported from Zaandam, Holland, in 1647, in which a bull attacked a farmer and his wife, tearing open her abdomen and uterus with its horn. The woman and her husband later died but the infant survived. Self-performed caesarean section has probably been carried out for many centuries as some women, alone and in desperation, sought to relieve the unrelenting pain of non-progressive labour. Authentic cases are reported from the 18th century. Caesarean section performed by lay persons also has a long history. One of the earliest reported cases in 1500 was by Jacob Nufer, a swine gelder, who delivered his wife after several days of apparent labour. There was some doubt whether this was an abdominal pregnancy or a caesarean section. Apparently both the mother and infant survived. In Northern Ireland in 1738 Mary Donnally, an illiterate but experienced lay midwife, carried out the first caesarean with survival of the mother in the British Isles.

During the 15th and 16th century caesarean section was carried out after the mother’s death, primarily to fulfil religious edicts that were proclaimed in order to save the soul of the infant by baptism. The first medical text advocating caesarean section before the mother was in extremis was published in 1581 by the French physician Francois Rousset (c1530−1603). Rousset advised caesarean section in the living woman, when it was obvious that she could not deliver vaginally, and before she became so moribund that her death and that of her baby was inevitable. For his temerity he was widely criticised, and with considerable vitriol, by the medical establishment of the day. His book has recently been published in English and with a commentary of caesarean delivery in that era.

The first witnessed and documented caesarean section by a physician was performed by Jeremias Trautmann in Wittenberg, Germany in 1610. However, a number of obstetric texts in the 16th and 17th centuries described the rare performance of caesarean section in cases of contracted pelvis. From the 16th to the 18th centuries the prevailing medical wisdom was strongly against caesarean section, with its almost inevitable fatal outcome for the mother. This viewpoint is summed up in the quote by the prominent Dublin obstetrician Fielding Ould (1710–1789) in 1742: ‘Repugnant, not only to all rules of theory or practice, but even of humanity’.

The reason for the high mortality in the pre-anaesthetic era was that caesarean sections were usually performed after prolonged labour on women who were dehydrated, exhausted and infected. In addition, after removal of the fetus the uterus was not sutured, adding haemorrhage to the morbidity equation. Jean Lebas first advocated suturing the uterus in 1769 but his advice was not followed for a century. In addition to haemorrhage, sepsis was the commonest cause of death. Eduardo Porro (1842–1902) of Pavia, Italy, carefully studied this problem and, after experiments with animals, he performed a caesarean section followed by subtotal hysterectomy in 1876. He sutured the cervical stump to the lower end of the abdominal wound to control the haemorrhage and to exteriorize any septic drainage. By controlling the haemorrhage and sepsis Porro dramatically reduced the maternal mortality by about half from its usual rate of 80–90%.

Throughout the 19th century obstetricians devised techniques to try and reduce the risk of sepsis and to preserve the uterus; including a lateral extraperitoneal approach by Ferdinand Ritgen (1787–1867) of Giessen in 1821. Fritz Frank (1856–1923) modified the transperitoneal operation by suturing the edges of the incised lower uterine segment visceral peritoneum to the margins of the abdominal wall incision to contain any sepsis and promote its drainage.

Ferdinand Kehrer (1837–1914) of Hiedelberg is one of the under-appreciated contributors to the development of the modern caesarean section. In 1881 he performed a transverse lower segment caesarean section, virtually as it is done today. He emphasized the need for careful suturing of the uterine muscle and a separate suture of the peritoneum over the lower uterine segment – the Doppelnaht or ‘double layer’ technique. About a year later Max Sänger (1853–1903), working in Leipzig, emphasized the need for careful suturing of the uterine incision which he performed longitudinally in the uterus and called the classical caesarean incision. It was Sänger’s classical caesarean section that held sway while Kehrer’s transverse lower segment technique was forgotten. The classical caesarean section was adopted in Britain, most notably by Murdoch Cameron in Glasgow. Cameron was confronted by a great demand for the procedure because his city had seen an enormous growth of population, especially of poor migrant workers. Many of his patients lived in conditions guaranteed to produce skeletal rickets. Poor housing, poor diet, atmospheric pollution and consequent lack of exposure to sunlight meant that vitamin D deficiency was rife. In 1888 he began a series of elective classical caesarean sections on rachitic dwarfs which was immediately and dramatically successful. In the first 2 years, all but one of the 23 mothers and all the infants survived ( Fig 13-1 ).

The first three cases in Murdoch Cameron’s historic series of elective classical caesarean section performed on rachitic women with gross pelvic deformities. The photograph was taken outside Glasgow Royal Maternity Hospital and the windowsill on which the flowerpots stand is approximately one metre from the ground.

In addition to careful suturing of the classical uterine incision, Cameron owed his success to two factors. The first was his recognition that the procedure should be carried out before the mother’s condition was compromised by exhaustion and the associated infection of a long obstructed labour. This required that the diagnosis of a hopelessly contracted pelvis should be made before, or at least early in labour. This required the refinement of the clinical science of pelvimetry in the era before x-rays, and depended on the digital assessment of the shape and capacity of the pelvis. The first case was the subject of fierce argument among Cameron and his colleagues, the pelvis being considered ‘borderline’ with an obstetric conjugate of 4 cm! Cameron’s second advantage derived from his use of a vulcanized rubber ring which he effectively applied as a tourniquet around the lower part of the uterus after delivery of the infant, constricting the blood flow to the uterus while the wound was repaired. The success of this series of cases resounded across and beyond Europe and was a milestone in the operation’s journey from a desperate and usually futile gesture to an acceptable clinical option.

Munro Kerr was a 20-year-old medical student when Murdoch Cameron began his celebrated series and would have undoubtedly attended the Glasgow Royal Maternity Hospital at around that time. He cannot possibly have been unaware of this dramatic development and seems likely to have been attracted to obstetrics by the work of Cameron, whom he would succeed 39 years later as Regius Professor of Midwifery in that city. Indeed, it was Munro Kerr who would be largely responsible for the change from the classical incision to the low transverse incision. When Kehrer performed his low transverse procedure it was to reduce and contain the risk of sepsis. Kerr’s main argument was that the healed incision was stronger and less liable to rupture in a subsequent pregnancy. As he wrote:

‘I make no claims to originality as regards the incision and I recommend it only because I believe the cicatrix that results will be less liable to rupture. The advantages of the incision are that one cuts through a less vascular area … In the second place it is thin and consequently the surfaces can be readily brought together … The third advantage, and it is a very important one, is that the wound in this area is at rest during the early days of the puerperium. Lastly, there is great advantage that owing to the fact that the lower uterine segment does not become fully stretched until labour is well advanced, the scar is in a safer region than the ordinary long­itudinal one.’

Munro Kerr performed his first transverse lower segment caesarean operation in 1911 and reported his results in the 1920s and 30s. Acceptance came slowly and for many years he was a lone voice in his advocacy for the lower segment procedure, although he later had an ally in McIntosh Marshall (1901–1954) of Liverpool. Indeed, after its widespread adoption, the lower segment operation was known in Europe for many years as ‘Kerr’s operation’. Belated acknowledgement of Kerr’s achievement in popularizing the lower segment procedure came at the time of the 12th British Congress of Obstetrics and Gynaecology, held in London in 1949, several years after he had retired from clinical practice. He was invited to the lecture platform and lauded for his achievement. In a dramatic response he raised his arms and declared: ‘Alleluia! The strife is o’er, the battle done!’