[Reprinted from The Medical News, August 5, 1893.] 
THE LOWEST LIMIT OF PELVIC CONTRACTION 
ADMITTING 0 F SYM P H YSIO TO MY. 
By BARTON COOKE HIRST, M.D., 
PROFESSOR OF OBSTETRICS, OF PENNSYLVANIA, 
PHILADELPHIA, PA. 
An impression prevails that symphysiotomy is the 
proper operative treatment for labor obstructed by a 
moderate degree of contraction in the pelvis, in which the 
other alternatives are the induction of premature labor and 
craniotomy. This view was expressed without contradic- 
tion at a recent meeting of a prominent medical society 
at which the operation was the sole topic of discussion. 
Increasing experience, however, demonstrates that sym- 
physiotomy is to be depended upon in the case of a pelvis 
symmetrically contracted, that a few months ago would 
have been thought quite impassable for a living child, 
even though the symphysis were cut. Leopold has re- 
cently delivered in this way a woman with a pelvic 
conjugate of only 6 cm., and more than a month ago in 
the Philadelphia Hospital I delivered without difficulty 
a rhachitic dwarf, a primipara, feet high, whose 
conjugate was, I think, very little if at all over 65 mm. 
The diagonal was a scant g cm,, but the conjugato- 
symphyseal angle was so increased that 2% cm. was, 
in my judgment, a sum scarcely sufficient for the sub- 
traction. To be on the safe side I induced labor two 
weeks before term ; then dilated the cervix, performed 
version after opening the symphysis, and extracted the 
child in a few minutes. It weighed 6 pounds, 4 ounces. 
The head-measurements were: Bi-temporal, 8 cm,; bi-parietal, 9 cm.; occipito-frontal, cm.; occipito- 
frontal circumference, 33 cm. The woman had an 
absolutely afebrile convalescence and the child is 
thriving. 
The combination of delivery before term and sym- 
physiotomy will give us entire control over any grade 
of symmetrically contracted pelvis that we are likely to 
see in this country, and whenever possible the two 
should be combined. In a very large experience with 
the induction of labor from two to four weeks before term 
I have found the mortality for the children no greater 
than in delivery at full maturity, whereas the slight dim- 
inution in head-diameters and the compressibility make 
a vast difference in the ease of delivery. Another, and 
a very great advantage in the induction of labor when 
symphysiotomy is contemplated is the fact that a con- 
venient hour can be selected by the operator for the 
delivery, and all preparations can be made for the 
appointed time, as in an abdominal section. The plan 
adopted in the case here reported, and always followed 
by me if practicable, was as follows : Early in the morn- 
ing a bougie is inserted and an ounce of glycerin injected 
alongside of it. Twenty-four hours later the lower ab- 
domen is cleaned and shaved. By this time, if the pelvis 
is so contracted that the head cannot enter the inlet, the 
cervix will be softened but scarcely at all dilated. The 
cervical canal is then dilated with three sizes of water- 
bags, the largest twice the size of the largest Barnes’s 
bag, each left in for about an hour. This is most con- 
viently done by an assistant. At about the time that the 
artificial dilatation is completed the operator arrives 
prepared to operate and deliver as soon as the patient 
is anesthetized, the vagina is disinfected, and the in- 
struments are sterilized.