SYMPHYSIOTOMY: With the Report of an Operation. BY BARTON COOKE HIRST, M.D., PROFESSOR OF OBSTETRICS IN THE UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA. THE MEDICAL NEWS, FROM October 15, 1892 [Reprinted from The Medical News, October 15, 1892.] SYMPHYSIOTOMY, WITH THE REPORT OF AN OPERATION} PROFESSOR OF OBSTETRICS IN THE UNIVERSITY OF PENNSYLVANIA, BARTON COOKE HIRST, M.D., PHILADELPHIA. Symphysiotomy has as remarkable a history as any procedure in surgery. Suggested for the first time in the Surgery published by Pineau in 1598, and first performed upon a living woman in 1777, the idea may be said to be three hundred years old, while its practical application dates back more than a century.2 From the year of the first opera- tion until 1858 symphysiotomy was performed 85 times in different parts of the Continent of Europe and once in England, with a mortality of 33 per cent. The frequency of the operation diminished after the first few years, until in 1858 it had prac- tically died out. It was revived, however, in Italy in 1866, and in the succeeding twenty years 70 operations were performed with a mortality of 24 per cent. Italy continued to be the exclusive field of the operation until a year ago, when it was again tried in Paris by Pinard, whose interest in it was 1 Read at the meeting of the Philadelphia County Medical Society, October 12, 1892. 2 R. P. Harris: Amer. Syst. of Obstet., vol. ii. aroused by a visit of Spinelli from Italy. Ten operations have since been performed in Paris, two in Dresden, and one in Strasburg. From January i, 1886, there have been 52 operations, with only a single death, due to septic infection before the operation was undertaken. Twenty-three symphy- siotomies have been done already this year, and the last 34 women have all recovered. We owe the introduction of symphysiotomy in this country to Dr. Robert P. Harris, who, as is well known, has long been interested in the subject, and at the recent meeting of the American Gyne- cological Society in Brooklyn read a paper tracing the development of the operation, showing by most laboriously collected statistics the present brilliant results achieved by it, and demonstrating, by the description of typical cases, its utility in labors other- wise insuperably obstructed by a contracted pelvis. Ten days after Dr. Harris’s paper was read, on September 30th, the first operation in this country was performed by Dr. Charles Jewett, in Brooklyn. Three days later it was again performed at the Maternity Pavilion of the University Hospital in this city. The position of symphysiotomy is now estab- lished beyond a doubt. Its modern revival I be- lieve to be the most important advance in obstetric surgery since the general adoption of abdominal section for the treatment of early extra-uterine pregnancy. It is applicable in contracted pelves with a conjugate over 67 mm., and, therefore, should be the method employed in almost all cases of the kind in this country, for a greater contraction 3 of the pelvis is rarely seen among us. It should, moreover, almost entirely displace the Cesarean section for a relative indication. It is a much simpler, an easier, and a safer operation. This is also the opinion of Leopold, who cannot be accused of prejudice against Cesarean section, with his bril- liant record in that field. There is and will be for some time, perhaps, an objection to the operation from those who have no experience with it, on the ground that sufficient space cannot be thus gained. In answer to this objection is the fact that the pubic bones may gape 7 cm. after their separation, and the statement of Morisani, that the conjugate is thereby increased from 1.3 to 1.5 cm. But an absolutely conclusive answer is furnished by the subjoined clinical records of some typical cases. Leopold's First Cased—A dwarf, 135 cm. tall, with the following pelvic measurements: Sp. il., 22 cm.; cr.il., 24cm.; tr., 28 cm.; conj. ex., cm. ; conj. diag., cm. ; conj. vera, cm. She had been delivered thrice previously, twice of dead children, once by the induction of premature labor. After a labor of seven hours and twenty minutes, ushered in by rupture of the membranes, symphysiotomy was performed, with the head above the brim. In ten minutes the child was extracted with forceps. The head was of normal size (trans- verse, Bj{; circ., 34). Leopold's Second Cased—A woman, delivered once before by craniotomy. The pelvic measure- ments were as follows: Sp. il., 22; cr. il., 25 ; tr., conj. ext., 16; conj. diag., conj. 1 centralbl. f. Gyn., 1892, No. 30. 2 Ibid. 4 vera, Labor began in the evening; mem- branes ruptured seven hours later; operation three hours later with head above the brim. Extraction of the child in ten minutes with forceps. The head had a circumference of cm. Porak's Case}—A primipara with rachitic pelvis, conjugata diagonalis being 9.6 cm., and pelvis pre- senting some asymmetry, very likely from scoliosis. Labor began on June xoth. About twelve hours later the membranes ruptured, and from eight to ten hours afterward the os was completely dilated. The head rested above the brim of the pelvis. Forceps was applied, but all efforts to engage and extract the head failed. The symphysis was opened, and the head then extracted “with the greatest ease ” by the forceps. Recovery. Freund's Case?—A woman, in labor six days; water drained off for two days. After opening the symphysis the head was delivered in fifteen minutes without instruments. There were two previous deliveries, one of a dead and one of a living child. The pelvic measurements were: Sp. il., 24; or. i 1.,27; tr., 31 ; conj. ext., ; conj. diag., 10 cm.; conj. vera, BTJ.8TJ. The child’s head after birth was found unusually large and hard. B. T., 10 cm.; B. P., 11 cm.; F. 0., 12 cm.; M. 0., 14 cm.; S. 8., 10 cm. Circumference, O. F., 37 cm. Re- covery. Jewett's Case?— The first symphysiotomy in America, performed by Dr. Charles Jewett, of Brooklyn, on September 30, 1892. Woman, a native American, primipara, fell in labor September 30, 1 o’clock a.m.; at 10 a.m. the occiput appeared 1 Annales de Gynecologic, September, 1892. 2 Miillerheim : “ Ueber die Symphysiotomie,” Centralbl. f. Gyn., 1892, No. 30. 3 Personal communication. 5 at the vulva, but was held fast by an approximation of the ischiac tuberosities, reducing the bisischiac diameter to three inches. Nine hours later Dr. Jewett first saw the patient. The forceps had been vigorously used in vain. Symphysiotomy was per- formed two and one-half hours later, or eleven and one-half hours after the impaction of the head of the outlet. Delivery was effected by supra-pubic pressure and by shelling the head out with the fingers in the rectum The woman is now in good con- dition, but unfortunately the child died twenty-four hours after birth, from the compression to which the skull had been subjected during its long impaction in the pelvis. The University Maternity Case.— A German woman, aged nineteen, pregnant for the first time, was admitted to the University Maternity, September 24th. The examination by the resident physician and the students showed the child to be presenting by the head, the back to the right. The pelvic meas- urements were: Sp. il., 25 cm.; cr. il., 27 cm.; tr., cm.; conj. ext., 18 cm. The internal examination made by myself just before operation showed the conjugata diagonalis to be cm.; conj. vera, cm. The girl fell in labor Saturday morning, October Ist. The pains, recurring all day, on Sunday became very vigorous. On Monday morning, when my attention was first called to the case, the contraction-ring was high, the uterus stood almost straight out from the body, and the child’s head was movable above the superior strait. The membranes were unruptured. By no justifiable degree of force could the head be made to enter the pelvis. The fetal heart-sounds were good. It was evidently, therefore, a choice of Cesarean section, craniotomy, or symphysiotomy. The last was done, with the assistance of Dr. R. C. Norris and the valuable advice of Dr. R. P. Harris, 6 who kindly consented to be present. The child was delivered with forceps in one hour and four minutes from the time the operation was begun. I purposely took my time, for the os was only the size of a dollar, and was very rigid, so that a more rapid extraction would have seriously injured the cervix. Head measurements: B. T., 7", B. P., 9; F. 0., 12 ;M. 0~ child are well. The technique of symphysiotomy is simple and easy. After thoroughly cleansing the field of oper- ation and disinfecting the vagina as well, a short vertical incision is made on the abdominal wall, reaching to about three-quarters of an inch above the symphysis. The attachments of the recti mus- cles are severed just sufficiently to admit one finger. The forefinger of the left hand is passed under the symphysis, and upon this as a guide the curved knife of Galbiati is inserted until its beak projects under and in front of the symphysis. The joint is then cut upward and outward. To avoid injury to the urethra, a metal catheter is inserted and pressed by an assistant downward and a little to the right, while the knife is placed a little to the left; but with Galbiati’s knife I should think that there is little likelihood of cutting the urethra or the plexus of veins in its neighborhood. I at first thought that an ordinary probe-pointed, curved bistoury would serve my purpose well enough, but I quickly laid it aside, and was glad to avail myself of Galbiati’s knife, an illustration of which is appended, which I happened to possess—at the time one of the three, I believe, in the country. 7 As soon as the joint has been severed, the wound should be covered with iodoform-gauze, and then the child extracted with forceps, or allowed to be delivered naturally, as seems best in the individual 8 case. I should, I think, almost always prefer the forceps. It is well to have the trochanters supported by assistants during the passage of the child through the pelvis, so that the sacro-iliac joints shall not be injured. As soon as the delivery is completed the wound is sewed up, the lowest stitch, if desired, passing through the top of the symphysis. How the whole symphysis can be stitched up, as Leopold claims to have done, Ido not understand. After closing the wound and dressing it, rubber adhesive strips are placed around the hips and the lower abdomen, and a tight binder applied. The symphysis unites surprisingly soon, and three weeks after the oper- ation the patient can walk as firmly and as well as ever. There is only one disturbing thought in connec- tion with the introduction in this country of an operation destined to do so much good. The charge of superficiality lies with some justice against us. We are too ready to reach out toward the top without a sufficient basis of solid preparation, and I fear that symphysiotomy may be undertaken by many who cannot correctly measure a pelvis and who have not the experience to decide whether a head can pass through the pelvis in which it is about to enter or in which it is engaged. There is conso- lation, however, in the reflection that if symphysi- otomy should be done needlessly the results are not likely to be so disastrous as in the case of Cesarean section, which, to my knowledge, was done several times unnecessarily during the excitement produced among medical men by the improved results of the Sanger operation. Established in 1843. A WEEKLY MEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The Medical News. The American Journal OF THE Medical Sciences. A MONTHLY MEDICAL MAGAZINE. Subscription, s4.ooper Annum. Established in J&2O COMM VTA TION RA TE, $7 jo PER ANNUM. LEA BROTHERS & CO PHILADELPHIA.