[Reprinted from the Transactions of the American Gynecological Society, 
May, 1894.] 
SYMPHYSEOTOMY VERSUS THE INDUCTION 
OF PREMATURE LABOR. 
BY CHARLES P. NOBLE, M.D., 
Surgeon-in- Chief, Kensington Hospital for Women, 
Philadelphia. 
Until within comparatively recent times, when labor be- 
came seriously or insuperably obstructed, the efforts of the 
obstetrician were directed toward saving the mother. The 
rights of the child received scant attention, and its life was 
deliberately sacrificed in order to diminish its diameters 
whenever the pelvic canal was too contracted to permit the 
passage of the normal foetus. This practice was condemned 
by theologians, more especially the Roman Catholics ; but 
was justified on the ground of expediency, the position taken 
being that, if without the intervention of art both mother 
and child would die when left to the unaided forces of 
Nature, the physician was justified in destroying the child 
that the mother might live. With the revival of the Caesarean 
section, under the influence of modern surgery, this ancient 
position has become very materially altered, and the present 
tendency is most decidedly to give serious regard to the 
rights of the child in unnatural labor. Three problems have 
grown out of this development of the question. 1. Is em- 
bryotomy upon the living child, when deliberately elected 
over the Caesarean section and symphyseotomy, a justifiable 
operation? 2. Is it justifiable, in labor in moderately con- 
tracted pelves, when the obstruction is considerable and yet 
not insuperable, to make such violent efforts at delivery, 
either by forceps or version, as to threaten the serious injury 2 
SYMPHYSEOTOMY VERSUS INDUCTION OF LABOR. 
of either mother or child, instead of resorting to symphyse- 
otomy when judicious and well-directed efforts at delivery 
have failed to accomplish it ? 3. In women known to suffer 
from contraction of the pelves of moderate degree, is it better 
to induce premature labor sufficiently early to permit the 
delivery of a living child, or to allow the pregnancy to go on 
to full term and to effect delivery under symphyseotomy, if 
this proves to be necessary ? 
The first problem, as to the justifiability of embryotomy 
done upon the living child, I take it, has been settled in the 
negative. The question no longer is, Shall both mother and 
child be permitted to die ? nor is it, Shall one be destroyed 
in order that the other may live? The problem now is, 
Shall the effort be made by the Cassarean section or symphy- 
seotomy to save both mother and child, thereby increasing 
the prospective mortality of the mothers from one to three 
per cent, as contrasted with embryotomy ? Or, to put it in 
another way, Shall one hundred children be destroyed in 
order that the lives of from one to three mothers shall not be 
put in jeopardy ? As this question has only a relative bear- 
ing upon the subject under discussion, we shall not consider 
it further at this time. 
The second problem is one which is now only coming up 
for solution, and has been brought to the front partly because 
of the large number of children who perish as the result of 
difficult labors, either during birth or shortly thereafter, and 
partly because of the very considerable number of children 
who are injured for life from the same cause. These are the 
11 spoiled babies,” having sustained injuries to the head, such 
as depressions or fractures, or great distortions of the skull, 
or injuries to the tissue of the brain itself, resulting in hemor- 
rhages and subsequently in localized palsies, epilepsy, or in 
greater or less impairment of mental vigor. 
The comparative safety of symphyseotomy suggests that 
the accepted teachings of the present be critically revised 
with reference to the conduct of labor in cases in which the CHARLES P. NOBLE. 
3 
obstruction is considerable and yet not insuperable. I am 
inclined to believe that in the near future these considerations 
will considerably alter the present rules of practice. In the 
interests of the child, version will be less frequently resorted 
to. And in cases of moderate contraction of the pelvis, in 
which the unaided efforts of the mother, assisted by the judi- 
cious employment of forceps, do not succeed in accomplishing 
delivery, instead of employing violent traction efforts (which 
so generally injure the child and which are liable to injure 
the mother) symphyseotomy will be done. These remarks 
are not made in a dogmatic spirit, but simply indicate the 
drift of my own opinion concerning this subject. 
The third problem is the one which immediately concerns 
us to-day, and it is my purpose in this paper to present the 
advantages of symphyseotomy as contrasted with the induction 
of premature labor in the management of cases of labor in 
women having moderately contracted pelves. The class of 
cases more especially referred to is the flat pelvis with a con- 
jugate diameter of three inches or more, and the generally 
contracted pelvis with a conjugate diameter of three and a 
quarter inches or more, and even flat pelves with as short a 
conjugate diameter as two and three-quarter inches. It is 
recognized, of course, that disproportion between the head of 
the child and the pelvis depends not only upon the diameters 
of the pelvis, but also upon those of the head, and that spon- 
taneous labor, or labor assisted either by the forceps or ver- 
sion, is quite possible in this class of cases when the head of 
the child is small or more than usually compressible. Given 
a woman in the eighth month of pregnancy, having a pelvis 
of the class under consideration, what shall be done ? Shall 
labor be induced sufficiently before full term to permit the 
spontaneous delivery of the child, or its delivery assisted by 
forceps or version ; or shall the pregnancy be permitted to 
go on to term, and then, if necessary, symphyseotomy be per- 
formed ? This question, of course, must be studied from 
the standpoint both of the mother and the child. From the 4 
SYMPHYSEOTOMY VERSUS INDUCTION OF LABOR. 
standpoint ot the mother we have to consider the mortality 
and morbidity of the operation of inducing premature labor 
as contrasted with that of symphyseotomy. The general 
mortality of the induction of premature labor is given in the 
text-books as five per cent. The general mortality of symphyse- 
otomy is stated to be about ten per cent. As a matter of fact, 
I believe that both these statements are decidedly erroneous. 
Five per cent, is undoubtedly too high a mortality for the 
induction of premature labor. I have reason to believe that 
in good hands, when the indication for its performance is 
contraction of the pelvis, its mortality does not exceed one per 
cent. The dangers to the mother under these circumstances 
are far less than they are, for example, when the indication 
is puerperal eclampsia or placenta prsevia. On the other 
hand, it is quite as absurd to say that the inherent risks to 
the mother from symphyseotomy are so great as indicated by 
a ten per cent, mortality. It is the old story of the fallacy 
of miscellaneous statistics. For the sake of argument it may 
be admitted that the general mortality of symphyseotomy is 
ten per cent. This represents the results which have been 
obtained under the conditions which exist in the practice ot 
the profession at large. It includes cases in which the indi- 
cation was proper, the operation skilfully done at the right 
time and after a proper technique, by skilful men ; and it 
also includes the “too late” cases, in which the patients have 
been maltreated by mid wives or by careless or ignorant prac- 
titioners before the performance of symphyseotomy, which 
conditions have nothing to do with the inherent risks of the 
operation. In order to contrast the relative dangers to the 
mother of symphyseotomy and the induction of premature 
labor, it will be necessary to analyze the cases. It must be 
recalled that the induction ot premature labor is an opera- 
tion done at a selected time, upon women in good condition, 
almost invariably by an obstetrician of experience. For the 
comparison to be just, only such symphyseotomies should be 
selected in which similar conditions prevail. Under these con- CHARLES P. NOBLE. 
5 
ditions I am satisfied that the maternal mortality will not 
exceed one per cent, under either operation. 
In support of my judgment concerning the slight inherent 
risks connected with symphyseotomy, I have to submit the 
following recent statistics of the operation, kindly furnished 
me by Dr. Robert P. Harris. 
Since March 8,1893, there have been 31 symphyseotomies 
in the United States, with 2 women and 7 children lost. In 
the fatal cases one woman was in labor three days before 
operation, and died of sepsis on the eleventh day. The other 
was in labor thirty-six hours, had a temperature of 102° and 
a pulse of 140, her vagina being oedematous and badly torn 
by forceps before entrance to the hospital. She died of 
marked shock in twelve hours. Three children were dead 
before operation, 2 were delivered by version and died under 
extraction, and 2 died soon after extraction. 
Prof. Paul Zweifel, of Leipzig, has operated 23 times 
without the loss of child or mother. 
The Italian record is incomplete. Since January 1, 1886, 
there have been 55 operations, with 2 women and 8 children 
lost. One woman was in labor ninety-six hours and died of 
septicaemia. The other had a long labor, with shoulder pre- 
sentation and prolapsed cord, and died of metro-peritonitis 
after twelve days. 
These statistics strongly support my statements. The 
fatal cases wrere in bad condition when operated upon, after 
the failure of other methods of treatment, and there was no 
reason in any of the cases to believe that the death was in 
any way due to symphyseotomy. On the contrary, it was 
due to the conditions which were present before its perform- 
ance. These statistics also include many other cases which 
were in bad condition at the time of operation, yet which 
nevertheless recovered. 
I cannot refrain from calling attention to the large num- 
ber of deaths among the children delivered by version after 
symphyseotomy, in this country. It is to be hoped that 6 
SYMPHYSEOTOMY VERSUS INDUCTION OF LABOR. 
this plan of delivery will be abandoned in favor of the 
forceps. 
From the standpoint of the child the advantages all lie with 
symphyseotomy. It has been amply demonstrated that a large 
percentage (about sixty-six and two-thirds per cent., according 
to Winckel) of premature children die within a few months 
of birth. With the incubator the infant mortality in hos- 
pitals was eighteen per cent, in the Leipzig Maternity and 
thirty per cent, in the Paris Maternity. Winckel’s state- 
ment is explained by the large mortality among premature 
infants during the first year of life. The contrast between 
the prospects of a premature child born four or six weeks 
before full term, and those of a child born under symphysi- 
otomy at term, are altogether in favor of the latter, whose 
prospects are nearly as good as the average of infants. This 
fact, and the conviction that the dangers to the mother are 
about equal, have convinced me that symphyseotomy at term 
is to be preferred to the induction of premature labor. 
A paper by Dr. Robert P. Harris, read before the American 
Gynecological Society in 1892, giving detailed reports of the 
results of symphyseotomy in Italy, convinced me of the slight 
risks inherent in the operation. At that time I had under 
my care Mrs. G., who was seven months pregnant with her 
fifth child. She had been delivered once of a small child 
(not weighed) by vigorous traction efforts made with the for- 
ceps, the child being born with its head so injured that it 
lived but a short time. The second labor resulted in the 
spontaneous delivery of a very small child (not weighed). 
The third labor wras a Caesarean section done by Dr. Howard 
A. Kelly, with delivery of a child weighing six and fifteen- 
sixteenth pounds. The fourth labor was induced five weeks 
before term, by Dr. Kelly and myself, and the baby, a girl, 
was delivered by me with great difficulty, after the applica- 
tion of the high forceps. She weighed five and one-thirty- 
second pounds. 
Mrs. G/s pelvic measurements are as follows : Anterior CHARLES P. NOBLE. 
7 
superior spines, 24 centimetres; cristse ilii, 26 centimetres; 
external conjugate, 16.5 centimetres; conjugata diagonalis, 
8.5 centimetres; conjugata vera (estimated), 7 centimetres. 
My thorough knowledge of the capacity of her pelvis, and 
my lively recollection of the difficulties encountered in de- 
livering the premature child by forceps, made me hesitate to 
again induce labor. I decided instead to permit the patient 
to go to full term and then to deliver by symphyseotomy. 
The patient was informed that her labor would be the first 
in which symphyseotomy had been done instead of inducing 
premature labor. My conclusion had the indorsement of 
Drs. Harris and Parish. Symphyseotomy was done on 
December 5, 1892, and was followed by the high application 
of the forceps, and the delivery of a boy weighing eight and 
one-eighth pounds. The details of this symphyseotomy and 
the reasons why it was advised have been reported in a com- 
munication to the College of Physicians.1 The mother made 
a good recovery and again became pregnant. She was de- 
livered a second time under symphyseotomy and the appli- 
cation of the forceps, on March 19, 1894, of a girl weighing 
six and six-sixteenth pounds, and recovered without other 
incident than a mammary abscess. She is thus the first 
woman in the United States upon whom a second symphyse- 
otomy has been performed, as well as the first woman in the 
world upon whom symphyseotomy has been done in prefer- 
ence to the induction of premature labor. 
In conclusion, I submit this paper as a contribution to 
modern obstetrics, in the hope that it may aid in quickening 
the interest of the profession in the rights of the unborn 
child. As the subject is comparatively new, it is probable 
that the general experience of the profession will modify our 
views in certain particulars ; but, as progress is ever forward, 
such changes will almost surely be in the direction of adding 
to the life-saving value of the agencies already at our com- 
mand. 
1 Medical News, vol. i., 1893. 8 
SYMPHYSEOTOMY VERSUS INDUCTION OF LABOR. 
DISCUSSION. 
Dr. R. A. Murray, of New York.—I think that Dr. Noble 
ought to be congratulated on his paper, because it is so thorough, 
and at the same time puts the operation of symphyseotomy in a 
little different light in this country from what has been done be- 
fore. It brings up the question of choice between the induction 
of premature labor and symphyseotomy as elective operations. 
Symphyseotomy has usually been done to help the obstetrician 
out of a bad predicament, to avoid Csesarean section or craniotomy 
on a living child. The patient has generally been long in labor, 
and in such a condition that the result lias not been what we 
have a right to expect from symphyseotomy performed under 
better circumstances. Again, the induction of premature labor 
ought to be almost absolutely successful, and has been so in 
large hospitals. But, in general practice, it has fallen far short 
of that ideal result in the case of the mother, while so far as the 
child is concerned a large number are born dead, and many of 
those born alive have a very uncertain hold on existence. This 
must necessarily be so, for we cannot always determine the degree 
of development of the child by the length of time the mother has 
been pregnant, and her reckoning on this point may be two or 
more weeks out of the way. A few days’ difference in the age 
of the foetus is extremely important in relation to the induction 
of premature labor. 
I shall not discuss the methods of inducing premature labor or 
of performing symphyseotomy. As the author has said, pre- 
mature labor is generally induced by men who are capable ot 
doing major operations in obstetrics, so that if the latter pro- 
cedure is chosen as an elective operation it should, under the 
circumstances, be attended by next to no danger whatever. The 
patient is left without any complications, and the only added 
risk in letting her go to term, and then resorting to symphyse- 
otomy, is the possibility that she may be afflicted with convul- 
sions or other conditions which now and then complicate ordinary 
labor, and which would not arise if the uterus had been emptied 
earlier. I believe, then, that we shall soon have the same results DISCUSSION. 
9 
for the mother from symphyseotomy which we have heretofore 
had from premature labor, while the chances of the child will 
be much better. 
Dr. Charles Jewett, of Brooklyn.—I did not have the 
privilege of hearing the paper, but shall say for symphyseotomy 
that I do not believe that we have yet realized the possibilities of 
the operation. When it comes to be done by the simple method of 
Morisani, where that is practicable, is confined within its proper 
limits, and is done early, the percentage of deaths, I feel sure, 
will be far less than at present. Premature labor, on the other 
hand, to say nothing of the high foetal death-rate, is not entirely 
free from maternal mortality. 
Dr. George J. Engelmann, of St. Louis.—I take pleasure 
in stating that it is my belief that we can safely predict that 
symphyseotomy in these cases will prove even more satisfactory 
than is hoped by Dr. Noble in his able paper. Every operation 
must, in the beginning, undergo a variety of tests and trials, and 
in the American statistics quoted in the paper a number of un- 
favorable cases appear which in the future will, I can safely pre- 
dict, not be treated by this method, and such results thus elimi- 
nated. For instance, after the death of the child I see no reason 
for symphyseotomy, the decaying tissues endanger the wound, and 
craniotomy is then in place. In general, the limit of the antero- 
posterior diameter of the pelvis should not be below 6.7 centi- 
metres, some allowance being made, of course, for the size of the 
child’s head; if this be very large the antero-posterior diameter 
should not be below eight or even nine centimetres. The opera- 
tion should be performed when labor has just begun, before the 
membranes have ruptured, and never after the death of the child, 
or when labor has been in progress some days, or laceration of 
the parts or of the uterus has taken place, lacerated or bruised 
tissues being an active danger and rendering speedy union im- 
possible. Notwithstanding the strong points made by Dr. Noble 
he has not yet presented the most favorable statistics, which are 
the last, those reported by Morisani at the recent meeting of the 
International Medical Congress ; they have not yet reached us in 
published form. By prolonged experience Morisani has gradu- 
ally limited symphyseotomy to a suitable class of cases until the 10 
SYMPHYSEOTOMY VERSUS INDUCTION OF LABOR. 
results have been decidedly better than even those named in the 
paper. Experience may also extend the field for the operation, 
and I shall merely suggest a class of cases not mentioned to-day— 
those in which Csesarean section might perhaps have been re- 
sorted to—the narrowing of the pelvis by solid tumors, in which 
further experience may show symphyseotomy a desirable substi- 
tute. But for the present it would seem that too much has been 
attempted, and that the proper sphere of symphyseotomy is one 
which is limited within narrow bounds and should be closely 
defined. 
Dr. Malcolm McLean, of New York.—Dr. Noble has 
treated this subject in a broad, fair-minded way, having given 
both operations due weight, and I thoroughly agree with him, 
except with regard to one point, and that is the rather drastic 
way in which he speaks of version, which he thinks should be 
cast aside in favor of forceps. He gives as his reason the neces- 
sarily large percentage of infantile deaths from version. But 
there should be no such record of deaths from version or delivery 
by the feet as now exists. It is not uncommon to hear men 
admit that they have lost one in five or six children extracted in 
this manner. Now, this is totally unnecessary, and if delivery 
be properly performed such statistics will not exist. 
Dr. Noble.—I have been very much pleased with the spirit 
with which my paper has been accepted. I had had some fears 
that my views were in advance of the period, and that some 
gentlemen might question the ground on which I stood. 
With reference to version, I feel myself that it is the cause of 
a multitude of foetal deaths every year, and my own judgment 
is that in the future version will be very much less frequently 
resorted to in the interest of the child. It is not a question of 
the results in Dr. McLean’s hands, but in the hands of the pro- 
fession at large.