THREE RECENT SYMPHYSEOTOMIES* 
Charles Jewett, M. D. 
N. O., Irish, aged twenty-eight years, II-para, admitted to 
the Long Island College Hospital January, 1896. In her first con- 
finement she had been delivered in my service after an easy labor, 
the child weighing six pounds. The pelvic measurements were as 
follows: Interspinal, 23.5 centimetres (nine inches and a quarter); 
intercristal, 26.1 centimetres (ten inches and a quarter); external 
conjugate, 17.3 centimetres (seven inches); diagonal conjugate, 10.2 
centimetres (four inches). The woman fell in labor at term, April 11, 
1896. The presentation was primarily a right scapulo-anterior, but 
was subsequently reduced to vertex by manual interference. At the 
close of the first stage axis-traction forceps was applied tentatively, 
but the head could not be brought into the brim. The pubic joint 
was divided as follows: An incision beginning well above the level 
of the pubic bones was carried down over the joint to the clitoris, 
exposing the prepubic fibrous structures. The abdominal wall was 
opened to the extent of an inch or more above the symphysis in 
the median line. A V-shaped incision parallel with the crura of the 
clitoris, and immediately above them, was then made down to the 
bone dividing the suspensory ligament. With a strong, sharp 
double hook, caught in the angle of the V, the clitoris was drawn 
down below the summit of the subpubic arch. A few touches of the 
scalpel exposed the lower end of the symphysis. An improvised 
sharply curved director was passed behind the symphysis close to 
the interpubic disk, pushing back the retropubic vessels. The joint 
was divided with a blunt-pointed bistoury passed on the director, 
and the bones separated two inches and a half. 
There was some haemorrhage from the prepubic incision, but 
* Reprinted from the Transactions of the New York Obstetrical Society, in the 
American Gynecological and Obstetrical Journal for November, 1896. 
Copyright, 1896, by J. D. Emmet, M. D. 2 
Charles Jewett, M. D. 
none from the veins behind and below the joint, and no other com- 
plication. The delivery was effected with the axis-traction forceps. 
The wound was sutured with silkworm gut, the sutures passing 
through the fibrous structures in front of the joint. The pelvis was 
immobilized by means of the usual adhesive straps and muslin 
binder. In addition to this, a firm hair pillow was placed under each 
lateral half of the pelvis. On these lateral supports the pelvis rested 
during the entire period of convalescence. The temperature did not 
exceed the usual normal puerperal limit. Slight suppuration oc- 
curred at one point to the depth of the skin, but, with that excep- 
tion, the wound united promptly throughout. The woman left her 
bed at the end of four weeks with good union of the joint. 
The child, a male, weighed nine pounds and three quarters. Its 
biparietal diameter was four inches, the suboccipito-bregmatic four 
inches and a quarter, and the corresponding circumference fourteen 
inches. The anterior fontanelle was small, and the cranial bones 
firmly ossified. At the last report received from the mother the 
child was living and well. 
Mrs. H., an Englishwoman, aged twenty-five years; II-para. 
First labor terminated by craniotomy. Pelvis ample except at out- 
let. Interspinal diameter, 25.4 centimetres (ten inches); inter- 
cristal, 26.7 centimetres (ten inches and a half); external conju- 
gate, 20 centimetres (seven inches and seven eighths); diagonal con- 
jugate, 12.7 centimetres (five inches); the bis-ischial diameter was 
8.2 centimetres (three inches and a quarter). The child presented 
by the breech. June 17th, several days before the expected date of 
confinement, labor was induced by the use of intra-uterine bougies 
and a cervical tamponade of gauze. On the following day dilata- 
tion, which was well under way, was completed manually. The 
symphysis was then divided by the same method as in the preced- 
ing case, and the bones separated to the extent of two inches and 
three quarters. 
Up to this time there was no haemorrhage from the retropubic 
veins. The child was readily extracted by the feet. The delivery 
was necessarily rapid. The assistants who were intrusted with the 
duty of supporting the lateral halves of the pelvis were inexperi- 
enced, and the bones were permitted to spring widely apart as the 
head came down. The anterior soft parts were completely torn 
through, the laceration running along immediately to the right of 
the urethra and extending into the base of the bladder. There was Three Recent Symphyseotomies. 
3 
considerable bleeding from the torn structures. The bladder wall 
was closed with a running suture of fine catgut, and the vaginal 
wall in a similar manner. The incision was united with silkworm- 
gut sutures, which included the prepubic fibrous structures. A soft 
■catheter was left in the bladder for three days. The patient suffered 
considerable shock, but made a perfect recovery. The incision healed 
without suppuration. The sutures were removed on the seventeenth 
day. The woman was out of bed at the end of a month, and was soon 
after able to walk without pain or inconvenience. Restoration of 
the joint was apparently complete. A urinary fistula persisted for 
nearly four weeks, but had wholly closed at the time the patient left 
her bed. 
The child is living and in robust health. Five days after birth 
its weight was seven pounds and three quarters. The birth weight 
was not taken, but must have exceeded eight pounds. The bipari- 
etal diameter was four inches, the suboccipito-bregmatic circum- 
ference thirteen inches, the occipito-frontal fourteen inches. 
M. K., an Austrian woman, aged thirty-one years, V-para, ad- 
mitted to the Long Island College Hospital July 27, 1896. Pre- 
vious labors difficult; all the children lost. General health good. 
Presentation vertex, left occipito-anterior. Perinseum torn to mu- 
cous membrane of rectum. Rectocele and cystocele. Interspinal 
diameter, 25.4 centimetres (ten inches); intercristal, 28 centimetres 
(eleven inches); external conjugate, 18 centimetres (seven inches 
and a quarter); diagonal conjugate, 10.8 centimetres (four inches 
and a quarter). Labor began at term, September 3, 1896. Twenty- 
nine hours later, the pains for several hours having been of the most 
vigorous description, the head was found arrested at the brim in 
transverse position, with the occiput to the left. Foetal heart fairly 
strong. Symphyseotomy was decided on, and was performed as in 
the foregoing cases. The symphysis was to the right of the median 
line. Having no suitable director at hand, the joint was divided with 
the blunt-pointed bistoury, guided by the finger in the retropubic 
space. Free bleeding, controlled by gauze packing. Separation of 
pubic bones about two inches. Child easily extracted with forceps 
in a condition of partial asphyxia. 
The wound, which was closed with a single row of silkworm- 
gut sutures, healed per primam. Temperature scarcely above the 
normal throughout. The coaptation of the bones was maintained 
as in the preceding cases. The use of the catheter was at no time 4 
Charles Jewett, M. D. 
required. The sutures were removed September 15th, and the pa- 
tient was out of bed October 1st. Satisfactory union of the joint 
was obtained, and the pelvic organs were in as good condition as 
before operation. In this, as in most cases that I have examined 
within a few weeks after symphyseotomy, there was a barely per- 
ceptible motion of the pubic bones on each other when the patient 
stood and rocked the body, putting her weight first on one foot, 
then on the other. The woman, however, was wholly unconscious 
of any defect in the joint, and she walked without difficulty on the 
third day after getting out of bed. Some relaxation of the symphy- 
sis may be demonstrated ?fter labor in many women delivered with- 
out symphyseotomy. The child weighed seven pounds and three 
quarters, and measured twenty inches in length. Directly after 
birth the head measurements were as follows: Biparietal, bi- 
temporal, suboccipito-bregmatic, 4J; occipito-mental, 5J. A 
few days after birth a superficial skin slough over the left parietal 
bone marked the point where the head had rested against the 
promontory. • At the date of this report the child weighed nine 
pounds and three quarters, and was thriving. 
Discussion. 
Dr. Bache Emmet inquired whether, after having performed 
symphyseotomy, it would not be desirable to retard the delivery so 
as to bring the parts to the same dilatation as would occur naturally, 
and thus spare the injury which took place by the extraction of the 
head before the parts were made to yield at all. He would like to 
know whether any injury would follow by making the extraction 
slowly, instead of drawing through with possible haste. 
Dr. Jewett replied that the general opinion was in favor of deliv- 
ering promptly. He thought it was better to deliver by the forceps, 
as a rule; the danger of injury to the soft parts was less by this means 
than by version. With reference to the dilatation of the parts, that 
should be provided beforehand. The cervix should be fully dilated, 
and so should the vagina. In case of anticipated difficulty at the 
introitus, episiotomy cuts might be made on either side to take the 
strain off the anterior soft parts. Injury of the kind reported, he 
thought, might be prevented by some apparatus to hold the lateral 
halves of the pelvis more securely during delivery than was possible 
manually. The French had an instrument for the purpose. Many Three Recent Symphyseotomies. 
5 
such accidents had no doubt occurred; they were spoken of by all 
writers as very liable to happen, and he was surprised that it could 
so easily take place as in his case. The tear might come from the 
strain on the perineal fascia by the separation of the bones, and not 
necessarily by the pressure of the child. A breech extraction in- 
creased the risk of laceration, since the delivery must be rapid and 
considerable manipulation was required within the passages. 
Dr. Dudley, alluding to Dr. Jewett’s cases of symphyseoto- 
my, said that he had discussed the subject with Dr. Morisani, at 
the International Gynaecological Congress, who was very decided 
about repeating operations. The speaker had narrated the case 
reported by him in the spring, where he had such difficulty in 
delivering the child after having made symphyseotomy, and asked 
Dr. Morisani whether he would do a second symphyseotomy in such 
cases. The reply was that he would, by making an open incision, 
wiring the bones together after delivery. As to whether he would 
repeat symphyseotomy in preference to Caesarean section or Porro’s 
operation, or delivering a dead foetus, Morisani said that he would.