Reprinted from The Brooklyn Medical journal, November, 1892. 
A CASE OF SYMPHYSIOTOMY. 
BY CHARLES JEWETT, M.D., 
Professor of Obstetrics and Diseases of Children, Long Island College Hospital. 
On September 30th, by the courtesy of Drs. Hunt and Carley, I 
was requested to see the following case of difficult labor. On 
reaching the case, about 7 p. m., they gave me the following his- 
tory: The patient, a healthy, robust woman twenty-two years of 
age and a primipara had fallen in labor at one o'clock in the morn- 
ing. At ioa.m. the occiput appeared at the vulvar orifice. For 
two or three hours from that time the pains were of the most vig. 
orous character but the head remained fixed in the grasp of the 
pelvic outlet. Attempts to extract with forceps had been of no avail. 
The instrument could not be locked upon the head. While all else 
was obviously ample there was a marked transverse narrowing of 
the outlet, the bisischial diameter measuring about three inches. 
To deliver the child intact through this space was clearly impos- 
sible. Craniotomy could have been easily done without risk to the 
mother, but the foetal heart was still strong though the rate was 
somewhat rapid, ranging from 150 to 170 to the minute. The 
mother's pulse had not risen above 100 and the temperature was 
substantially normal. All shared alike the repugnance to the sac- 
rificial operation. All including the friends of the patient, assented 
to symphysiotomy. The operation was clearly indicated-a less for- 
midable one than Caesarean section and in the conditions present 
quite as promising for both mother and child. The necessary in- 
struments were sent for but the messenger lost the way and the 
operation was delayed till 9.30. During the intervening time the 
foetal heart had not apparently lost force nor had it increased in 
frequency. The pubes had been shaved and carefully cleansed and 
was for about two hours kept carefully covered with a compress 
wet with a 1-2000 mercuric iodide solution. An incision of about 
an inch-and-a-quarter in length was carried down to the upper end 
of the symphysis. A strong probe-pointed bistoury was then 
passed down behind the joint, keeping the point pressed strongly 
against the symphysis. The joint structures were cut through 
mainly from behind forward, and partly from bel >w upward, the 
knife being withdrawn as soon as the bones were felt to give way. 
Delivery was then easily accomplished. The head was shelled out 
by the fingers in the rectum while powerful pressure was applied 
above the pubes. The wound meantime was protected by a few 2 
CHARLES JEWETT, M.D. 
layers of sterilized gauze wet with the mercurial solution. The 
separation of the joint did not apparently exceed an inch. On ex- 
amination the bladder and urethra were found uninjured. The 
incision through the overlying soft structures was closed with silk 
sutures and the wound dressed. The vagina was douched with 
the mercurial solution followed with a plain water douche and the 
introitus and vulva dusted with iodoform. The pelvis was im- 
mobilized by a firm muslin bandage. The uterus contracted well, 
the bladder emptied itself on the following morning and the patient 
up to this time has scarcely had a bad symptom and is making a 
perfectly satisfactory recovery. 
The child, which was a well-developed male, was resuscitated 
with little difficulty but died at the end of about twenty-four hours 
from the effects of the long-continued pressure, mainly from cere- 
bral injuries. The head was enormously disfigured. The position 
was a left occipito-anterior. A deep sulcus extended from the top 
of the right auricle to the front of the bregma, corresponding to the 
position of the right ischio-pubic ramus. The occipital pole 
beyond this line had been moulded to a long, narrow cylinder. 
There was also a marked asymmetry of the face. On the following 
day the occipito-mental diameter measured six-and-a-half inches, 
the occipito-frontal five-and-a-half, the biparietal three-and-a-half, 
the sub-occipito bregmatic circumference thirteen-and-a-half inches. 
In conclusion I may say that owing to the prolonged pressure 
of the head at the outlet, the condition of the passages was not 
promising for symphysiotomy. The obviously impaired viability 
of the child too would have been sufficient justification for crani- 
otomy, but as the foetal heart was fairly strong at the time of 
operating, we preferred the course pursued rather than the only 
alternative of taking the child's life, or what we regarded as still 
worse, the subterfuge of waiting for it to die. 
The condition of the mother could not have been more satis- 
factory had the child been extracted by craniotomy-the incision 
shows no sign of infection though the patient has not wholly 
escaped the effects of the prolonged pressure at the lower portion 
of the birth-canal. 
This, so far as is known, is the first symphysiotomy in America. 
Three days later a similar operation was done by Prof. Barton G. 
Hirst of the University of Pennsylvania. 
Dr. Robert P. Harris, to whom we are indebted for the revival 
of symphysiotomy in this country, has kindly given me the statis- 
tics of the. modern antiseptic operation as follows: Total 51. 22 
during the present year. Paris it, Italy 6, Germany 3, U. S. A. 2. 
No death in the last 33 consecutive cases.