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Chapter Two Still Too Risky? 1900–1930s By the end of the nineteenth ­century, medical developments allowed physicians to view cesarean surgery as a rational, although still rare, option rather than a desperate, last-­ditch effort. The introduction of ether in 1846, followed by the discovery of the anesthetic properties of chloroform in 1847, allowed surgeons to discard the makeshift mea­sures they had used traditionally to ease their patients’ agony during surgical procedures. Even more far-­reaching, affecting ­every corner of medical practice, was ac­ cep­ tance of the germ theory of disease.1 The cause of postsurgical infection had always mystified doctors. They mulled many possibilities over the years—­ predisposition of the individual, seasonal change, environmental miasmas, overcrowding, and exposure to sewer gas, to name only a few. Not ­ until 1857, when Louis Pasteur’s investigation of a catastrophe befalling the French wine industry led him to connect bacteria with pathological change in organic ­ matter, did anyone suggest that invisible organisms caused illness in ­ people.2 Even then, physicians did not link Pasteur’s discovery to surgical practice ­until 1865, when Joseph Lister became one of the first physicians to adopt aseptic techniques . Lister, an En­ glish surgeon who worked variously in Glasgow, Edinburgh, and London, theorized that just one microscopic germ might prompt sepsis. He explained, “Upon this princi­ple, I have based a practice.” Lister’s success was soon manifest. Using carbolic acid as an antiseptic during amputations, he saw mortality in his surgical practice drop 67 ­ percent—­ from 46 to 15 ­ percent of cases. 46  Cesarean Section Although many in the medical community remained skeptical of the germ theory, attentive surgeons on both sides of the Atlantic began to adopt the practices that came to be known collectively as “Listerism.” Institutional ac­ cep­ tance was slower in coming; the first sterile surgical room in the United States did not open ­ until 1889, when surgeons at Johns Hopkins Hospital inaugurated it. The establishment of that lone room, however, signaled a sea change. By the end of the nineteenth ­ century, routinely disinfecting surgical instruments, donning sterile gowns, and dressing wounds postsurgically with an antiseptic ­ were universal practices.3 Before anesthesia and asepsis, surgeons performed operations quickly, hoping to minimize patients’ suffering and reduce their chance of infection. By quelling pain and diminishing postoperative sepsis, the life-­ saving combination of anesthesia and Listerism afforded surgeons an opportunity to work methodically as opposed to frantically. For ­mothers undergoing cesareans, this meant fewer postpartum infections, nicked intestines, and wounded offspring. Indeed, women undergoing cesarean surgery prob­ ably profited from the increase in surgical safety more than the average surgical patient; not wasted by disease, their odds of recovery­ were greater than the majority of patients who underwent abdominal surgery due to a ravaging illness. As one physician observed, cesarean surgery had fi­ nally been “shorn of its terrors.”4 Although still rare, cesarean births ­rose accordingly. At the New York Nursery and Child’s Hospital, cesareans increased from 2 in 1,000 deliveries in 1910 to 25 in 1,000 in 1927; at the Chicago Lying-­In Hospital, while 6 in 1,000 births ­were by cesarean in 1915–1916, 30 in 1,000 ­were by cesarean in 1928 and 1929. Similarly, at Johns Hopkins Hospital in Baltimore, from 1899 to 1921 doctors performed 183 cesareans in about 20,000 deliveries, a rate of 0.9 ­ percent. Then, from 1921 to 1926, doctors performed 180 cesareans in 8,000 births—­ a 146 ­ percent increase. The Manhattan Maternity and Dispensary saw comparable statistics. From 1905 through 1919, Dispensary physicians attended 6,212 births that included 103 by cesarean—­ a 1.66 ­ percent rate. In the following de­ cade, from 1920 through 1932, the Dispensary saw a 73 ­ percent increase—342 cesareans in 11,896 births.5 Ongoing Caution All urban hospitals seemed to be seeing at least some upsurge in the surgery. The increases, however, even among institutions in the same city, varied enormously . In 1929, Boston Lying-­ In Hospital was at one end of the spectrum, with 1 in 12 births a cesarean. At the other end was New York Lying-­ In, with 1 in Still Too Risky?   47 585 births a cesarean. In between the outliers ­ were San Francisco Hospital (1 in 40 births), Cook County Hospital in Chicago (1 in 88), Long Island College (1 in 125), and Detroit Hospital (1 in 217).6 The variations could be attributed to three ­ factors: patient population, the experience of each...


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