The gruesome truth about medieval caesareans

In 1477, Giovanni di Francesco Tornabuoni, a Florentine banker, wrote a letter to Lorenzo de’ Medici, expressing his heartache over the recent death of his wife. “I am so oppressed by grief and pain on account of the bitterest and unimaginable misfortune that befell my sweetest wife that I do not know where I am. As you will have heard, as it pleased God, she passed from this life in childbirth yesterday at the twenty-second hour. Having cut her open, we extracted the dead foetus from her body, which doubled my grief.”

For those of us who tuned into the first episode of House of the Dragon last night, Tornabuoni’s account may be strikingly familiar. The Game of Thrones prequel has shocked TV audiences with graphic depictions of an unplanned caesarean delivery. Viewers witnessed gushing blood and a screaming mother – Queen Aemma Targaryen (Sian Brooke) – pinned down by nuns, followed by shots of her brutalised body. Aemma does not survive and her baby dies several hours later, leaving King Viserys I Targaryen (Paddy Considine) without a wife or an heir.

George RR Martin, the novelist and creator of Game of Thrones, has always prided himself on the supposed realism of his franchise. In a 2015 interview with Entertainment Weekly, he said: “I wanted my books to be strongly grounded in history and to show what medieval society was like […] Most stories depict what I call the ‘Disneyland Middle Ages’ – there are princes and princesses and knights in shining armour, but [the writers] didn’t want to show what those societies meant and how they functioned.”

But while House of the Dragon may seem true to Martin’s vision of a dark and gritty Middle Ages, its first episode raises several questions about the real experience of medieval childbirth. Is there historical evidence for caesareans? Who performed them? Why were they performed? And in that era, could mothers ever expect to survive them?

The caesarean is not a modern procedure. Throughout history, there have been numerous references to fictional and mythological people being born by caesarean section. In Greek mythology, the gods Asclepius, Adonis and Dionysus are each rescued from their deceased mother’s wombs. In 15th-century German art, the Antichrist lives up to his scriptural title of “son of destruction” by entering the world through the “unnatural” means of a caesarean. In Shakespeare’s Macbeth, the character of Macduff is said to have been “untimely ripp’d” from his mother’s womb.

It was also believed that Julius Caesar was born via a caesarean section (even if this is a misunderstanding, perpetuated by scholars such as Isidore of Saville). Yet the term “caesarean birth” does not appear in the historical record until 1581, when the French surgeon François Rousset mentions the operation in his Traité de l’hysterotomotocie ou enfantement caesarien. Before that time, medieval people had simply referred to “sectio in mortua”.

This term, which literally translates as “section of the dead”, reveals the biggest difference between medieval caesareans and that depicted in House of the Dragon: real medieval caesareans were only performed after a mother had died, as a last-ditch attempt to save the child. Nor, as caesareans were enacted on a deceased woman, were they considered medical procedures. The operation was not taught to medical students at medieval universities, and it is not discussed by physicians in medical treatises.

The limited instances in which learned physicians mention caesarean births concern the health of the living baby, rather than the deceased mother. For example, in his 1353 Grande chirurgie, Guy de Chauliac stated that midwives should hold open the mouth and cervix of the dead body while a razor is used to cut into the abdomen. Midwives should then insert their hands into the body to remove the child.

Unfortunately, and as House of the Dragon correctly shows, babies born of caesarean sections did not tend to survive for more than a few hours. In 1462, an Italian builder named Gasparo Nadi witnessed his wife Catalina die in childbirth. He wrote in his diary that afterwards “the doctor Master Giovanni of Navarre extracted the child from her body; it was a boy, and it pleased God that it was fated that he die after little more than an hour”. Nonetheless, this hour could have been crucial in providing a window for baptism – which was, after all, the essential goal of medieval caesareans. Although Gasparo and the doctor could not save the child’s earthly body, there was solace in the fact that, through baptism, they could save the baby’s immortal soul.

Throughout the Middle Ages, it was generally accepted that if a child died before baptism they would be barred from entering heaven. In his Divine Comedy, based heavily on St Thomas Aquinas’s theology, Dante Alighieri explains that unbaptised souls reside in Limbo – the first circle of Hell. Here, souls do not experience physical torment but are deprived of God’s salvation eternally. As Virgil, Dante’s guide through the poem, points out: “They have not sinned. But their great worth alone was not enough, for they did not know baptism, which is the gateway to the faith you follow.

The first reputable evidence we find for the operation being performed on a living woman dates from 1610, over a century after the end of the Middle Ages. In this instance, Ursula Opitz was prevented from giving birth vaginally due to an abdominal hernia, so was given a caesarean section by the physician Jeremiah Trautmann. Although Opitz initially survived the ordeal, she died only 25 days later from an infection. Not until the 19th century would caesareans be regularly undertaken with the expectation of survival for both mother and child.

Why then, if medieval caesareans were only performed post-mortem with the purpose of baptising a child, does House of the Dragon choose to depict the procedure on a living woman? One suggestion might simply be “entertainment”: the Game of Thrones franchise has long been criticised for its graphic violence against women, who are regularly tortured, raped and humiliated. In a 2016 interview, the TV critic Caroline Framke said that the problem with Game of Thrones “is less that horrible things happen to women than when horrible things happen to women, they’re filmed for shock value, and there’s often very little use in that story beyond how horrible it is”.

Framke’s point remains relevant today. King Viserys I Targaryen’s fictional grief could have been as effectively demonstrated without the anachronistic performance of a caesarean on his living wife. While difficult, distressing experiences of childbirth were a part of the medieval woman’s experience, House of the Dragon has already left the real Middle Ages behind. The onscreen mutilation of a woman may provide an excellent prompt for audience debate – but it isn’t good history.

Dr Rachael Gillibrand is a historian of pre-modern health and the body at the University of Leeds. House of the Dragon continues on Mondays at 2am/9pm on Sky Atlantic/NOW