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Chapter One The Epitome of Risk Cesarean Sections in the Nineteenth Century In 1827 John L. Richmond performed a cesarean section in a tiny town in the southwest corner of Ohio. His harrowing account of the surgery—­the first published account of a cesarean section performed by a physician in the United States—­ appeared in the Western Journal of the Medical and Physical Sciences three years ­later. While Richmond’s experience typified doctors’ encounters with the surgery ­later in the ­century in many re­spects, the case veered from the nineteenth-­ century norm in three crucial ways. The operation occurred in the northern, not the southern, United States; the patient was white; and she survived.1 Other than ­ those anomalies, over the next seven de­ cades, cesarean surgeries­were strikingly like the one documented by Richmond. The setting for the surgery was far from ideal—­ Richmond arrived at the laboring ­ woman’s ­ house during a violent storm, just as night fell. He noted that the ­ woman’s bleak home, with its dirt floor and gaping crevices in the logs that constituted walls, would likely compound the daunting task before him. He immediately exhibited impatience with the midwives who had summoned him, complaining that the two ­women ­were unable to provide useful answers to his questions. The paltry information they did supply—­ that the patient “had fits and the pains did no good”—­ provided nothing useful to help Richmond establish a diagnosis and formulate a treatment.2 During his initial examination, Richmond was unable to find any sign of cervical dilation. The discovery baffled him. The patient seemed to be in the throes of a shockingly strenuous ­ labor. Each contraction culminated in three-­to 18  Cesarean Section­ five-­ minute “general convulsions” followed by “alarming faintings” lasting 10 to 20 minutes. To tame the convulsions, Richmond administered laudanum and sulphuric ether and applied “flannel wet with hot spirits” to the patient’s feet. While the treatments eased the convulsions, they increased the fainting spells.3­ After four hours of futile attempts to trigger productive ­ labor, Richmond still had not pinpointed the source of the prob­ lem. Unconsciously mimicking the action of the midwives he had ridiculed hours earlier, he sent for additional help. The help never arrived. The fierce storm prevented his colleagues from making their way to the cabin. The patient’s obesity compounded the mounting difficulties.4 Eventually, Richmond deci­ ded the ­ woman’s life was likely lost. Only a cesarean section offered a slim hope for survival. He shared his conclusion with every­ one pres­ent: the exhausted, semiconscious patient, the midwives, and the friends and­family members who had convened at the patient’s bedside. Every­one agreed to the plan. As the storm continued unabated, “feeling a deep and solemn sense of my responsibility, with only a case of common pocket instruments,” Richmond commenced the operation with “an incision through the integuments, down to the linea alba from the umbilicus, to within an inch and a half of the pubis.” The­ woman’s friends helped by holding blankets in front of candles to prevent the howling wind from leaving the surgical scene in total darkness.5 Richmond was momentarily heartened when the patient’s convulsions ceased during the surgery. Then he encountered another prob­ lem. The infant was so “uncommonly large” that no amount of force permitted extraction. In a final attempt to remove the child intact through the uterine incision, he passed his hand around the baby’s body to grab the feet. The ­ mother begged him to stop. She could not endure the pain. Reminding himself that “a childless ­ mother [is] better [off] than a motherless child,” Richmond altered course and proceeded to remove the fetus in pieces from the wound in the ­ mother’s abdomen.6 As Richmond’s account attests, his patient suffered during the surgery; the discovery of anesthesia was still two de­ cades away. Although ­ there is no rec­ ord of the ordeal from the patient’s perspective, a letter written by another surgical patient , who underwent not a cesarean but an oophorectomy in 1844, suggests how a ­ woman undergoing surgery without anesthesia, and surviving, might recall the experience. Forty-­ nine years ­ after the removal of her ovaries, Catharine E. Reitzel wrote a letter to the son of her surgeon, John L. Atlee. She praised Atlee as “the happy instrument in the hands of the Almighty” and expressed gratitude for the surgery and Atlee’s skill: “Had I never fallen into...


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