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Figure 2 During its evolution cesarean section has meant different things to different people at different times. The indications for it have changed dramatically from ancient to modern times. Despite rare references to the operation on living women, the initial purpose was essentially to retrieve the infant from a dead or dying mother; this was conducted either in the rather vain hope of saving the baby's life, or as commonly required by religious edicts, so the infant might be buried separately from the mother. Above all it was a measure of last resort, and the operation was not intended to preserve the mother's life. There were, though, sporadic early reports of heroic efforts to save women's lives. And while the Middle Ages have been largely viewed as a period of stagnation in science and medicine, some of the stories of caesarean section actually helped to develop and sustain hopes that the operation could ultimately be accomplished. It was not until the nineteenth century that such a possibility really came within the grasp of the medical profession. Perhaps all of this changed in a tiny village in Switzerland around the year 1500. A sow gelder by the name of Jacob Nufer, dismayed by the agony and pain of his wife's labour, sought the help of no less than thirteen midwives to deliver their child and relieve his wife. For days they tried, and failed. When he could stand no longer to see his wife suffer, Nufer asked his wife if she would have the confidence in him to perform the operation. She agreed. Nufer seeked permission from the local authorities, who initially refused but eventually relented to Nufer's persistant pleas. Nufer's wife lived following the operation and eventually gave birth to five more children, all vaginally, including one set of twins. The history of caesarean section can be understood best in the broader context of the history of childbirth and general medicine histories that also have been characterized by dramatic changes. Many of the earliest successful caesarean sections took place in remote rural areas lacking in medical staff and facilities. In the absence of strong medical communities, operations could be carried out without professional consultation. This meant that caesareans could be undertaken at an earlier stage in failing labor when the mother was not near death and the fetus was less distressed. Under these circumstances the chances of one or both surviving were greater. These operations were performed on kitchen tables and beds, without access to hospital facilities, and this was probably an advantage until the late nineteenth century. Surgery in hospitals was bedeviled by infections passed between patients, often by the unclean hands of medical attendants. These factors may help to explain such successes as Jacob Nufer's.
Iabetic patients have an increased risk of vascular and nerve dysfunction. Vasculopathy results in part from endothelial cell abnormalities involving reduced production or action of vasodilators, such as nitric oxide NO ; , and altered responses to vasoconstrictors 1, 2 ; . Hyperglycemia, oxidative stress, and altered lipid profiles contribute to vascular complications, including peripheral nerve perfusion deficits, which play an important role in the etiology of diabetic neuropathy 2 4 ; . Indeed, epidemiological studies have identified dyslipidemia as an independent, potentially modifiable, risk factor for diabetic neuropathy 2, 5 ; . Aortas from several diabetic animal models show decreased NO-mediated endothelium-dependent relaxation EDR ; to agonists such as acetylcholine ACh ; 6 10 similar deficits have been reported in diabetic patients 2, 11, 12 ; . In addition, both endothelial and nonadrenergic and noncholinergic NANC ; nerve-derived NO-mediated smooth muscle relaxation is diminished by diabetes in corpus cavernosum of animal models and humans 1318 ; . Normal erectile function involves nerve-mediated increases in arterial inflow to corpus cavernosum, relaxation of smooth muscle, and restriction of venous outflow. NANC nerves provide the majority of NO during erection; however, neuropeptides and vasodilators released from the endothelium including NO ; also have a physiological role 13, 14 ; . The most common drugs used in hyperlipidemic patients, including those with diabetes, are HMG-CoA 3-hydroxy-3methylglutaryl coenzyme A ; reductase inhibitors statins ; , which inhibit the rate-limiting step in cholesterol biosynthesis. Statins reduce LDL and VLDL levels, while modestly increasing HDL 19, 20 ; . This protects against coronary artery disease in diabetes 20 23 ; . small, randomized, double-blind study, rosuvastatin RSV ; decreased total plasma LDL cholesterol and triglycerides in hyperlipidemic type 2 diabetic patients 24 ; . Experimentally, statins modulate endothelial function, including increases in NO production, at doses insufficient to lower plasma lipids 2528 ; . However, the detailed effects of statins on vascular function in diabetes remain to be fully elucidated. Moreover, it is not known whether and duloxetine.