SYMPHYSEOTOMY. 
BY 
G. M. Boyd, M. D., 
Philadelphia. 
REPRINTED FROM X*18 
American Gynecological and Obstetrical Journal 
for September, 1896. [Reprinted from the American Gynecological and Obstetrical Journai. 
for September, 1896.] 
SYMPHYSEOTOMY* 
By G. M. Boyd, M. D., Philadelphia. 
The serious problem of how to accomplish delivery in the flat 
and generally contracted pelvis has presented itself to me in its sev- 
eral phases during the past year. Shall we induce premature labor, 
or shall we allow our patient to go to term and resort to one of the 
following operations: High forceps, version, symphyseotomy, or 
the Caesarean section? This question confronts the accoucheur, and 
is a difficult one to decide. It is difficult, in my opinion, because 
each case is a study in itself; no law will govern all. We can de- 
termine the shape and size of the pelvis, but we can not measure 
exactly the size and shape of the foetal ovoid. Some years ago this 
Society discussed at length Forceps vs. Version, in papers ably pre- 
sented by the late Drs. Goodell and Wilson. Harris, Noble, Hirst, 
Longaker, and others have recently contributed papers on sym- 
physeotomy, and many successful Caesarean and Porro operations 
have been reported. One of our Society was the first to perform 
symphyseotomy in preference to the induction of premature labor. 
With this amount of literature contributed, we have taken no 
little part in setting the world to thinking of the best way to termi- 
nate difficult labor, and thereby place craniotomy in the position it 
should occupy-an operation to empty the uterus of its dead foetus. 
Symphyseotomy has been resurrected through our appreciation of 
clean surgery, and it seems to me it has passed the experimental 
stage of its existence, although in the review of a popular text- 
book I read: " The furor that has attended the revival of this opera- 
tion must consume itself in time, and then in the clear light of facts 
and indisputable statistics the right of the procedure to permanent 
position as an operative measure in obstetrics will be demonstrated, 
* Read before the Philadelphia Obstetrical Society, June 4, 1896. 
Copyright, 1896, by J. D. Emmet, M. D. 2 
G. M. Boyd, M. D. 
or the method relegated to its former oblivion." In reviewing 
the journals of the past year, I do not find as many cases reported 
as heretofore. Is this due to the fact that cases have not presented 
themselves for operation, or have the unsatisfactory results made 
the operator fearful of encountering again the same experience? 
As symphyseotomy is only indicated in pelves of moderate con- 
traction, cases in which the forceps and version must also be enter- 
tained, it becomes a difficult problem to decide when it is indi- 
cated. In selecting the operation the history of previous labors, 
if any, will carry great weight. In following the work of the Phila- 
delphia Lying-in Charity since this operation has been revived, I 
have several times met with cases of pelvic contraction indicating 
symphyseotomy, and have been in readiness to sever the pubic 
symphysis if necessary. But in each case, with the intervention of 
the forceps, labor was terminated successfully. I was about con- 
gratulating myself upon the good fortune which followed our work 
when the following case was referred to me: 
Mrs. M., aged thirty-seven years, was admitted to the hospital 
May, 1895, and was expecting her delivery at any time. She was 
a native of Ireland, and had previously given birth to five children, 
all of the labors having been instrumental. In her first labor she 
was delivered by Dr. W. S. Stewart, the child living. The second 
labor, delivered by Dr. E. H. Steer, of Richmond Street, the child 
living. The third labor, she was attended by Dr. W. B. Scull, of 
Richmond Street, a difficult forceps operation, but the child was 
alive. Her fourth delivery, under the care of D. W. B. Scull, was 
in January, 1892. The doctor writes me that he had great difficulty 
in performing the forceps operation. The child was dead and for the 
first time in his experience the forceps slipped. The fifth delivery, 
under the care of Dr. Steer, on December 25, 1893, was again a diffi- 
cult labor. The forceps failed, and he called to his assistance Dr. 
Charles P. Noble, who finally accomplished the delivery by version 
-another dead baby. The examination of the patient on admission 
to the hospital showed that we had to deal with a contracted flat 
pelvis. 
Intraspinus measurement 26 centimetres. 
Intracrystal measurement 27 " 
External conjugate measurement 19 " 
True conjugate measurement 8.25 " 
Diagonal conjugate measurement 10 " Symphyseotomy. 
3 
The child proved to be of good size and head well ossified. 
With this history of two dead babies, and with the counsel of Dr. 
Noble in regard to her last delivery, we decided to perform pubi- 
otomy should she not be able to deliver herself. She fell in labor 
May 31, 1895, having had slight premonitory pains for a day. After 
seventeen hours of active labor, the head still remaining immovable 
at the brim of the pelvis, she was etherized, and an incision ten centi- 
metres in length made over the pubic symphysis. The insertion 
of recti muscles severed, the finger readily slipped into the pre- 
vesical space. 
After a little difficulty in finding the pubic symphysis, the Gal- 
biati knife was passed behind and below the symphysis, and trac- 
tion made from within out. Very soon we appreciated that the car- 
tilaginous joint was yielding, and lateral pressure was made on each 
hip. Immediately on severing the joint, the head, which had been 
transverse at the brim, descended, the occiput rotating anterior. 
The forceps was now applied, and she was easily delivered of a 
slightly asphyxiated child, which soon recovered. Following the 
incision and manipulation there was considerable haemorrhage, 
which was held in check during the forceps operation by gauze 
packing. The wound was closed with silkworm-gut sutures, the 
pelvis was bandaged with a many-tailed bandage, over this a canvas 
binder was tightly laced. The patient was catheterized for several 
days, complained of no discomfort, and made an uneventful re- 
covery, her temperature never rising above ioo° F. The sutures 
were removed on the tenth day, and at the end of the fourth week, 
the symphysis being firmly united, she was allowed to get out of 
bed. At the end of the fifth week she left the hospital feeling per- 
fectly well. 
I have intentionally delayed the report of this case that I might 
be able to see if any complication developed. It is now one year 
since the operation, and she is perfectly well. She walks well and 
has no bladder trouble. 
In conclusion, I would state that, while I believe we will not 
often find it necessary to sever the pubic symphysis, it must be 
entertained in all cases of flat or contracted pelves, the true conju- 
gate as low as seven or eight centimetres. The operation should 
be explained to the patient, that she may decide whether she is will- 
ing to take the additional risk for the sake of her infant. 4 
G. M. Boyd, M. D. 
Discussion. 
Dr. Longaker: I had the pleasure of seeing this patient while 
she was in labor, and of examining her and seeing the operation. 
There was no doubt at all in my mind, and in the minds of the others 
who saw her, that the delivery of a living child without pubic section 
was an impossibility. At the time the pubic section was made the 
head was still quite high up. The subject of symphyseotomy, of 
course, brings up the entire matter of treatment and management 
of labor in cases of contracted pelves. I agree fully with Dr. Boyd 
in regard to the propriety of the operation in an appropriate case. 
I have myself operated three times with a successful result, so far 
as the infant is concerned, in two cases, and without any bad result 
for the mother in any of the three cases. The mothers all made 
good recoveries. In one the child was lost, because of persistent 
and prolonged traction of the forceps, which also complicated the 
convalescence very much. That is, not the symphyseotomy, but 
the forceps operation did harm. 
The difficulty is in the decision as to the necessity of the opera- 
tion, as to just what degree of contraction, as Dr. Boyd has said, 
will necessitate division of the pubic symphysis. And I realize that 
it is not always possible to say that a given case may not be deliv- 
ered by version or by forceps. (The repeated application of forceps 
and prolonged traction certainly renders the result of symphyse- 
otomy bad.) In two cases since my last operation I have erred 
in choosing the induction of premature labor, expecting that I 
would be able to deliver successfully. In these cases symphyse- 
otomy should have been done. The want of success is only ex- 
plainable by assuming the existence of contraction of the transverse 
diameters of the pelvis, which I did not appreciate from my meas- 
urements. The cases were instances of the generally contracted 
pelvis, and not of the simple flat, as I had concluded. This con- 
clusion was based on the existence of normal or but slightly con- 
tracted external measurements. It is a well-known fact that nar- 
rowing of the transverse pelvic diameters renders the case unsuit- 
able for version. 
The practical point of the matter is the want of some means to 
ascertain the exact degree of pelvic contraction. I know of no 
better method practically than the manual, and I have used internal Symphyseotomy. 
5 
pelvimeters. The pelvimeter of Hirst does not give me exact meas- 
urements. 
Dr. Parish: In reference to the relative merits of symphyse- 
otomy and premature labor, I think so far as the delivery of a liv- 
ing child is concerned, probably in almost every instance in which 
symphyseotomy would promise good results in a case, if the case 
is under observation, premature labor at about the eighth month 
will give a living child with less risk to the mother. I have chosen 
this method in a few instances in preference to symphyseotomy. In 
these instances the child has been born alive, and is, still living. 
Premature delivery in selected cases, and judiciously delivered, 
ought to give good results. If, however, in a premature delivery 
we apply forceps or, if it is necessary, do a version, the chances 
are the child will not be born living, for premature children do not 
stand forceps or version well. In premature labor it is safer to let 
Nature complete delivery after labor has begun. I think there is 
little risk to the mother if aseptic precautions are maintained. The 
old statistics showing great mortality in produced labors doubtless 
depended upon the septic complications at a time when asepsis was 
not appreciated or practiced. 
Dr. Norris: I think there is no problem in practical obstetrics 
more difficult to decide than the proper course of management of 
labor obstructed by a contracted pelvis. If the case is seen before 
term, I agree with Dr. Parish that the induction of premature labor 
is not only justifiable but preferable. It has been so in my experi- 
ence. The care of the child subsequent to its birth will have much 
to do with its future growth and development. A hospital case, 
born two or even three months before term, brought up in the 
slums of the city and improperly fed, stands a poor chance of sur- 
vival; but with proper care of the infant-and I have carefully 
studied the statistics in this country as well as abroad-induction 
of premature labor shows a large proportion of children alive. 
So far as symphyseotomy is concerned, my experience is limited 
to two operations performed by myself, and I have assisted at six 
others, and this experience has convinced me that symphyseotomy 
is not a trifling operation by any means. In my own cases both the 
mothers survived, and are now perfectly well. The first child was 
born dead, the second child was born living, but died of an inter- 
current pneumonia at the end of a year. In all the cases I have had 
an opportunity to observe there has been something about the 6 
G. M. Boyd, M. D. 
operation to convince me that it is not one whose maternal and 
infantile mortality can be classed with that of premature labor. To 
say, as has been claimed, that the mortality for the mother and 
child is better under symphyseotomy I think would not be borne 
out by statistics of published, not to mention unpublished, cases. 
Again, as to the decision of method of procedure when the 
patient is in labor at term. There is a problem besides that of pelvic 
measurements. I take it we have means to measure accurately 
enough the capacity of the pelvis, and to estimate the conjugate 
diameter. Dr. Hirst's pelvimeter-a modification of Schultz' in- 
strument-is a good instrument, but it should be remembered that 
one must know how to use it, and that its successful use requires 
two individuals who understand how to make the measurements. 
After we have obtained the conjugate diameter there are other prob- 
lems. I recall a case with a conjugate of eight centimetres, in which 
the baby was very large; we trusted to version and lost the child. 
Autopsy showed a rupture of the longitudinal sinus. 
The same woman came again to the Preston Retreat, and, in 
spite of the unfortunate result of the first delivery, the size of 
the child decided the choice of version, which was done with good 
results. The first baby weighed nine pounds, the second weighed 
seven pounds. 
It is a good rule carefully to take the pelvic measurements, then 
to introduce the hand into the vagina, and by combined examina- 
tion to notice how much protrusion of the head there is above the 
symphysis. By careful palpation of the child's cranium one can 
learn its approximate relative size to the pelvis; its hardness, and 
the separation of sutures which indicate the degree of compressi- 
bility of the head; and, finally, the distance between the sagittal 
suture and the sacral promontory when the head is partially en- 
gaged, will indicate whether or not the head can pass the obstruc- 
tion safely. These things must be taken into consideration as well 
as the pelvic diameters. 
When the pelvis measures over eight centimetres, and when 
the size of the head is judged to be approximately normal, often- 
times version will succeed, oftentimes forceps. In my own ex- 
perience more children have been born alive with forceps than by 
version. 
Then as to the position of the woman during labor. It is claimed 
for the Walcher posture that at least a centimetre is gained in the Symphyseotomy. 
7 
conjugate diameter by allowing the woman's legs to hang extended 
over the edge of the bed, the buttocks being slightly elevated, and in 
high forceps operation I always resort to this posture with, I be- 
lieve, distinct advantage. When we have a pelvis below eight centi- 
metres, with a well-formed or large-sized child, the nearer will be 
the indication, I believe, for symphyseotomy. With a conjugate 
of seven centimetres or less, with the same conditions, the Caesarean 
operation should be chosen if the case is in the hands of a man 
competent to do an operation of this kind. 
I was much struck with Dr. Boyd's remarks as to fewer sym- 
physeotomies having been recorded within the last year. I am 
glad this is so. Symphyseotomy is an operation which should be 
reserved for experts and for men with a large hospital experience 
to guide them. I believe that when the cases of minor degrees of 
pelvic deformity are critically studied the indication for symphyse- 
otomy will very infrequently arise. 
So far as induction of premature labor is concerned in my own 
hands, with the facilities offered by the incubator, special care, etc., 
I should prefer to induce labor rather than to allow the woman to 
go to term and do symphyseotomy. 
Dr. L. J. Hammond: I would like to know what has been the 
experience of the members present who have done symphyseotomy 
at the subsequent deliveries-that is, whether the delivery was made 
any easier or not when another child was born. In a case I have 
in mind, where a living child was delivered after symphyseotomy, 
at the next delivery it was found absolutely impossible to get the 
same amount of separation, the result being a stillborn child 
delivered by axis-traction method after a very prolonged labor. 
It is perfectly natural to expect such a condition as this to occur 
in a goodly number of cases, since we would not expect to get the 
same mobility that we would at first operation, especially if suffi- 
cient inflammation be produced in the slightly mobile joints to 
cause complete ankylosis; the capacity of the pelvic outlet would, 
of course, under these conditions, be rather diminished than in- 
creased. 
Dr. Longaker: My third operation was a second operation in 
the same patient; the amount of separation and amount of space 
gained was just as great as in the first operation. The convales- 
cence in that patient was more satisfactory than in the first opera- 8 
G. M. Boyd, M. D. 
tion. Practically it was that of a normal delivery. This in answer to 
a point brought out by the last speaker. 
Dr. Boyd: Symphyseotomy vs. Premature Labor has been dis- 
cussed, I believe, by this Society. While induction of premature 
labor has its advantages, it must be remembered that it is not 
always easy to induce premature labor. The introduction of a 
bougie into the uterus is not always successful, and one difficulty 
that arises is the selection of time for operation. If the labor is in- 
duced much before the two hundred and fiftieth day of gestation, 
the chances for the child are not good. Then, again, if we err in the 
other direction, the object of the operation is lost. The case I oper- 
ated on by symphyseotomy came to me late. I did not have an 
opportunity of considering the induction of premature labor, and, 
even if it could have been considered in that case, I would have 
followed the same course, considering the history. My experience 
with the induction of premature labor has not been very satisfac- 
tory. I induced labor about five or six months ago in a case with 
almost the same history as the one described this evening. Fail- 
ing to bring on labor, after introducing the elastic bougie (it having 
remained twenty-four or forty-eight hours in the uterus), I found it 
necessary to give the patient ether and do dilatation of the cervix. 
This brought on labor, but, unfortunately, the breech presented, 
and through the rapid delivery that followed the cord became pro- 
lapsed, and this serious complication caused a disastrous result. 
From the history of the case I have narrated this evening the 
operation would not seem a difficult one. The only difficulty in this 
particular case was probably from my inexperience-that is, in not 
reaching the symphysis when the knife was first inserted. CASE OF SECTION.* 
G. M. Boyd, M. D., 
Physician to the Philadelphia Lying-in Charity. 
An ideal operation is one which is premeditated. The patient's 
history is carefully studied, elaborate preparation is made, and with 
a corps of assistants and nurses in readiness, each step goes on 
uninterruptedly. In very many of our obstetric operations it is 
not possible to fix the day and hour; but we are called upon often 
at night, tired out with a long labor, to perform some of the gravest 
procedures in surgery. Sometimes it is after two or three have 
attempted the forceps operation, the patient already infected; again, 
it is after the patient has been in labor days, the attendant hoping 
Nature may still be equal to her task. The case which I have to 
relate is an illustration of this condition of affairs-an operation 
in extremis. Her history is as follows: Mrs. M., a colored married 
woman, a primipara, was admitted into the Philadelphia Lying-in 
Charity May 21, 1896. She had been in active labor two days. I 
found that she was pregnant at term, and that it was complicated 
by subperitoneal myomata; several tumors could be easily felt 
through the wall of the abdomen, one decidedly pedunculated. 
Foetal heart could not be heard. On internal examination, the 
cervix was found to be dilated to the size of a silver dollar. A 
foul discharge issued from the uterus, indicating that decomposition 
had been going on some time. Careful measurement of the pelvis 
developed another phase of the case-we were not only dealing with 
a case of impossible labor, due to myomata, but with a flat rhachitic 
pelvis. The following were the measurements: 
* Read before the Philadelphia Obstetrical Society, June 4, 1896. 10 
G. M. Boyd, M. D. 
Intraspinus measurement 21 centimetres. 
Intracrystal measurement 22 
External conjugate measurement 17 
Diagonal conjugate measurement 8 
True conjugate measurement 6.5 
Caesarean section was immediately performed, the patient's con- 
dition not justifying delay. With the assistance and counsel of my 
colleague, Dr. Oliver Hopkinson, the abdomen was opened. The 
uterus, which was the seat of many fibroids (intramural, subperito- 
neal, and pedunculated), was then delivered. An incision was made 
into it, and with this a quantity of foul-smelling gas escaped. The 
dead infant was easily but slowdy removed, that the uterine wall 
might contract gradually upon its contents, the placenta. Now 
the lower segment of the uterus was grasped by Dr. Hopkinson, 
and pressure made upon the uterine arteries. The removal of the 
uterus just above the internal os was rapidly and easily performed. 
The right and left broad ligaments tied and cut, the peritonaeum 
was stripped from the front and back of the mass. A ligature was 
now thrown around both uterine arteries, and rapidly with the knife 
the uterus was removed, leaving a stump seven by five centimetres. 
The cervical canal was now disinfected, and a cuplike depression of 
the uterine tissue cut away. The cervical canal was closed, and 
finally the peritonaeum brought together over the stump by inter- 
rupted sutures of fine silk. The peritoneal cavity was freely washed 
with large quantities of sterile water, and the abdominal wound 
closed with interrupted through-and-through silkworm-gut sutures. 
The patient's pulse was 150 before the operation, and when placed 
back in bed it was about 180. We rather despaired of her reacting 
from the shock of the operation, but to our surprise, at the end 
of twenty-four hours, her condition was much improved, tempera- 
ture normal, pulse 140. Large rectal injections of normal salt solu- 
tion did much, I believe, to bring about her good condition. She 
is now in her third week, and is rapidly convalescing. In practicing 
pelvimetry, we always feel a little doubtful of the accuracy of the 
measurement of the true conjugate, but, with the abdomen opened 
and the uterus removed, we were able to make a direct measure- 
ment of 6.5 centimetres.