[Reprinted from The Medical News, February 18, 1893d 
SYMPHYSIOTOMY VERSUS ITS SUBSTI- 
TUTES; WITH THE REPORT OF A 
CASE OF SYMPHYSIOTOMY.» 
BY CHARLES P. NOBLE, M.D., 
SURGBON-IN-CHIEF, KENSINGTON HOSPITAL FOR WOMEN, PHILADELPHIA. 
The revival of symphysiotomy is due to the 
genius of Morisani, of Naples ; its introduction into 
the United States, to our distinguished Fellow, Dr. 
Robert P. Harris. Now that the results of symphysi- 
otomy are known, as accomplished by the operation 
done under modern aseptic methods, the wonder is 
that the profession could have been blinded by the 
prejudices of the past, arising out of the comparative 
failure of the operation when done without regard 
to a knowledge of scientific obstetrics or surgery. 
The results obtained by Italian operators under the 
influence of Morisani’s teachings took the world by 
surprise. The fact that the work was being done 
was well known, but the profession was supercilious 
and refused to estimate it in a scientific spirit. The 
old, prejudiced belief that symphysiotomy was neces- 
sarily a failure, because it did not permit of an increase 
in the conjugate diameter of the pelvis, and because 
it jeopardized the integrity of the pelvic symphyses, 
1 Read before the College of Physicians of Philadelphia, Feb. i, 2 
was too firmly grounded to be easily set aside, and 
it required the demonstration of the safe delivery of 
thirty women, in Italy, having contracted pelves of 
marked type, before any but Italian surgeons were 
willing to perform the operation. 
The old objections to the operation were : I. That 
in contracted pelves, as a rule, the antero-posterior 
diameter is the shortened diameter; and that this 
diameter is scarcely, if at all, increased by the opera- 
tion. 2. That there is great danger of rupture of the 
sacro-iliac symphyses. 3. That the symphysis pubis 
would not unite properly; and hence that the powers 
of locomotion in women subjected to the operation 
would be greatly lessened. Experience has shown 
each of these objections to be groundless or much 
overstated. Undoubtedly the oblique and transverse 
diameters of the pelvis are increased more than the 
antero-posterior, but this diameter also is increased. 
When the pelvic bones are separated from two to two 
and a half inches, enough room is afforded for the 
rounded head (perhaps the parietal protuberance) to 
project into the opening, thus increasing the work- 
ing space at least half an inch. This increase 
in space, together with the increase in the oblique 
diameters, affords the necessary room for delivery, 
except in cases of very marked deformity. 
The objection that the sacro-iliac joints may be 
ruptured has not been borne out by experience. 
Nevertheless it should not be forgotten that at times 
the pelvic joints are ruptured in cases of difficult labor 
in which symphysiotomy has not been done. This 
should admonish surgeons to be careful in recom- 
mending the operation in cases of marked deformity, 3 
especially if the head of the child seems large and 
well ossified. 
The final objection, that the divided symphysis 
would not unite, is likewise not well founded, as 
experience has demonstrated that it unites with 
pleasing uniformity and facility. 
Since January 8, 1886, there have been fifty- 
seven symphysiotomies, and all the women have re- 
covered, except one. This woman (case of Martino, 
September 22, 1886) had been in labor several days 
when operated upon, and died of metro-peritonitis, 
due to infection of the birth-canal, and not to the 
operation. This fact justifies the conclusion that 
in proper cases when done early, and after the 
antiseptic method, symphysiotomy has no mortality. 
This is true, however, only under the conditions 
laid down. The history of the operation admon- 
ishes us that when done on improper cases, and 
without asepsis, its mortality is high. 
The complications following the operation have 
been urethral and vesical fistulae in a few cases. 
According to Morisani, these were due to a faulty 
technique. Not having had the opportunity myself 
to study the recorded cases of symphysiotomy, to 
discover accidents resulting from it, I wrote to Dr. 
Harris, who has recently studied the literature in 
the preparation of his paper on the subject (Trans. 
Amer. Gynecological Society, 1892). He writes me 
that since the perfection of the technique, in 1886, 
there is no case recorded in which the sacro-iliac 
joints have been injured; no case in which a child has 
been delivered absolutely dead; and no case in 
which it was necessary to practise embryotomy to complete the delivery. Even going back to 1866, in 
125 symphysiotomies there is but one case recorded 
of possible injury to the sacro-iliac joint. This was a 
case of iliac phlegmon, which is by no means neces- 
sarily due to joint-injury. 
The results to the children delivered by symphysi- 
otomy have been equally good. No child has been 
born absolutely dead, but six children out of fifty- 
seven died shortly after birth. 
Having thus disposed of the questions heretofore 
raised concerning the operation, it remains to con- 
sider its true field of usefulness and its relation to 
Cesarean section, the induction of premature labor, 
and to embryotomy. 
The operation has been done, heretofore, princi- 
pally in cases of flat pelves, and the measurements 
hereafter given refer to that deformity. Other varie- 
ties of deformity are rare, but fortunately the oper- 
ation is even better adapted in them to facilitate 
delivery, excepting cases of Naegele or Robert pelves. 
The conjugate diameter in the women heretofore 
operated upon has varied from 66 mm. in.) 
to 97 mm. (3yf in). There is a general agreement 
among surgeons to limit the field of symphysiotomy 
in flat pelves to cases having at least inches in 
the conjugate diameter. I find myself in agreement 
with this opinion. My own experience in delivering 
a child weighing eight pounds and two ounces through 
a pelvis of inches has admonished me that less 
room would entail very great danger of death to 
the child, and would put more strain on the sacro- 
iliac joints than would be judicious. 
In this field symphysiotomy comes directly into 
4 5 
competition with the Cesarean operation, done for 
the relative indication. I am convinced of the 
beneficent nature of the modern Cesarean operation, 
when done secundem artem, and that it has a very 
low if not a nil mortality in the hands of an expert. 
Nevertheless, it must be acknowledged that the 
Cesarean operation is a more formidable operation 
than symphysiotomy, and that its possibilities of mor- 
bidity and mortality are undoubtedly greater. Hence 
I unhesitatingly pronounce in favor of symphysiotomy 
in this field, and believe that it will soon supplant 
the Cesarean operation performed for the relative 
indication. Aside from its absolute claims for pref- 
erence, there are several relative claims which I be- 
lieve will prove of great service in practice. The 
practitioner will not have to overcome a popular pre- 
judice, as is the case with the Cesarean operation. 
Symphysiotomy is to the public a new operation ; 
hence the public is prepared to estimate its risks as 
tedpresen by the profession. This is not true of 
the Cesarean operation, for the modern operation 
has to bear the evil name of the old operation, and 
is believed by the public to be almost necessarily 
fatal. These considerations will render it more 
easy to gain consent for the performance of symphy- 
siotomy than it has been for the Cesarean section. 
Another advantage will be that the failure of the 
natural forces, assisted by art, to accomplish deliv- 
ery, will prove a convincing argument in favor of 
the necessity for symphysiotomy. And, happily, the 
operation can then be done with success, whereas, 
in the case of the Cesarean operation the favorable 
time would already have passed by. 6 
Symphysiotomy likewise fills the field heretofore 
occupied by embryotomy done on the living child. 
perfection of the technique of the Cesa- 
rean operation, in common with many others, I have 
denied the justifiability of embryotomy done on 
the living child. With the addition of symphysi- 
otomy to scientific obstetrics I believe that the 
slaughter,[of the innocents will ceas$. The old 
excuse for embryotomy, that it is justifiable to kill 
the child to save the mother, no longer holds, for 
both can be saved either by the Cesarean operation 
or by symphysiotomy. As I have recently discussed 
this phase of the subject in a paper read before the 
Philadelphia County Medical Society (.A?ner. Journ. 
of Obstet., 1893) entitled “ Cesarean Section and its 
Substitutes,” I have only to add that I believe the 
greatest good which will be accomplished by sym- 
physiotomy will be that it will put a stop to the killing 
of unborn infants. Courageous and expert surgeons 
could save both mother and child by the Cesarean 
operation, but apparently they could not do away 
with the practice of embryotomy. 
Symphysiotomy, also, has been performed in the 
same classes of pelves in which, heretofore, the in- 
duction of premature labor has been practised. 
Hence these two operations come into competition. 
This is a phase of the subject which heretofore has 
attracted no attention. This fact renders it inex- 
pedient to dogmatize at this time. But I believe 
that symphysiotomy is destined to supplant the 
induction of premature labor, especially as a hos- 
pital operation and in practice among the ignorant 
and the poor. Embryotomy heretofore has been 7 
employed to terminate arrested labors amongst the 
poor having deformed pelves. Such people, as a 
rule, employ midwives or physicians who do not 
devote much study to their cases prior to the onset 
of labor. As a result premature labor is seldom 
induced among this class in private practice. Sym- 
physiotomy will now supplant embryotomy among 
them. 
In hospital practice the choice of operation will 
depend on the mortality of the mother and the child 
under the two operations. The advantages appear 
to be decidedly on the side of symphysiotomy. 
The maternal mortality from the induction of pre- 
mature labor is variously stated by authorities. 
For example, according to Wyder’s statement 5 per 
cent, of the mothers and 50 per cent, of the children 
die. Winckel states that of children born at from 
seven and a half to eight months only 33 per cent, 
are actually kept alive. Under the use of the incu- 
bator at the Leipzig maternity there was an infant- 
mortality of 18 per cent, in the hospital, and at the 
Paris Maternite there was a mortality of 30 per cent. 
It is also well known that the mortality of prema- 
ture infants among the poor is very high in the first 
year of infancy, so that Winckel’s estimate is prob- 
ably correct. 
In my judgment 5 per cent, is an excessive esti- 
mate of the maternal mortality of the induction of 
premature labor. One per cent., or certainly 2 per 
cent., should cover the mortality in careful hands. 
The showing under symphysiotomy is much 
better. The maternal mortality is zero, and the 
fetal mortality is six in fifty-seven, or less than 11 per 8 
cent. The chances of the mature child delivered 
under symphysiotomy to reach maturity are likewise 
far greater than those of the immature child de- 
livered about the thirty-fourth week of gestation. 
This is especially true of the children of the poor. 
Among the intelligent and well-to-do, premature 
labor will probably be elected for a time ; but if 
symphysiotomy continues as successful as it promises, 
it will supplant the induction of labor even in this 
class of cases. Intelligent people will not care to 
run the risk of losing their children from prema- 
turity, or, what is worse, having them suffer from 
hydrocephalus (which is common in such children), 
and from various neuroses, if a mature child can be 
delivered with less risk to the mother under sym- 
physiotomy. 
The technique of the operation can be considered 
conveniently in connection with the report of a case 
of symphysiotomy which follows. 
Mrs. X., the subject of this report, is a small 
woman, weighing one hundred pounds. She is 
thirty years of age, and has had five children, the 
last of which was delivered by symphysiotomy. A 
complete history of her five labors would be a fairly 
full consideration of dystocia due to deformity of 
the pelvis, together with the obstetric procedures 
used to complete such unnatural labors. The fol- 
lowing are the measurements : 
Height, 4 feet, 8 inches. A. S. S., 24 cm.; Cr. 
II., 26 cm.; Tr., 29 cm. ; D. B. (ext. conj.), 16.5 ; 
C. D.,8.5; C. V. (estimated), 7 cm. 
The first child, a boy, was born after a labor of 
19 hours’ duration. Delivery was accomplished 
by the forceps, the head being so injured by the 
vigorous compression and traction employed that 9 
the infant died shortly after birth. The child was 
not weighed. The second child, a girl, was de- 
livered alive, spontaneously, after a hard labor of 
14 hours. She was not weighed, but was so tiny 
that she was not expected to live. It is safe to say 
that she did not weigh more than five pounds. 
The third child, a girl, was delivered by Dr. Howard 
A. Kelly by Cesarean section. She weighed six 
pounds, fifteen ounces. The fourth child, a girl, I 
delivered, after the induction of labor at the thirty- 
sixth week, by a high application of the forceps. 
The baby weighed five and one-thirty-second pounds. 
The B. P. of the fetal head was 7.5 cm.; B. T. 6.5. 
The labor was extremely difficult, lasting 27 *4 hours. 
(Vide Amer. Journ. of Obstet., 1890, p. 418). 
I met Dr. Kelly in consultation, and concurred in 
the opinion that Mrs. X.’s third delivery could be 
accomplished only by craniotomy or the Cesarean 
operation. Dr. Harris also had expressed the same 
opinion. Mrs. X. and her husband unhesitatingly 
elected the Cesarean operation. Even had her medi- 
cal advisers recommended craniotomy she would 
have rejected it. This was largely due to the fact 
that she is a Roman Catholic ; but doubtless it was 
partly owing to the horrible death of a sister (who 
also had a deformed pelvis) under embryotomy—a 
combination, I believe, of version, craniotomy, and 
decapitation. The sister died from loss of blood. 
The issue of the case demonstrated the wisdom of 
the advice given, as delivery would clearly have 
been impossible without diminishing the head of a 
baby weighing 6||- pounds. This operation met 
with much unfavorable criticism, part of which was 
due to ignorance of the exact facts in the case, 
and to the prejudices arising from so called con- 
servatism, and part of which was due probably to 
animosity on the part of the critics. After this 10 
lapse of time those who were immediately con- 
cerned in the case can look back upon this opera- 
tion with equanimity. Undoubtedly it had much 
to do with popularizing the Cesarean operation 
performed for the relative indication in this country. 
Had there been a question as to the available 
room in this pelvis it would be settled by the fourth 
labor, in which a premature child, weighing 
pounds, was delivered with extreme difficulty. 
This head was delivered with the bi-temporal 
diameter engaged, and there was no room to spare. 
The fit was so tight that I feared it would be impos- 
sible to deliver the undiminished head. Yet this 
fetal diameter measured but 6.5 cm.1 
The fifth labor is the subject of this report. Mrs. 
X. consulted me when seven months pregnant. I 
found that already the head was so large that it 
could not be pressed into the pelvis. Two weeks 
later this disproportion was evidently greater, and 
a careful palpation of the child made at this time 
led me to believe that it was large rather than small. 
Knowing the deformity of the pelvis, and having a 
lively recollection of the difficulties encountered at 
the preceding delivery, I became convinced that 
it would be wiser to do symphysiotomy at full time 
than to induce premature labor. I so advised the 
woman, but asked her to reserve her decision until 
she had consulted Dr. Parish, who agreed with me in 
advising symphysiotomy as against the induction of 
premature labor. So far as I know, this is the first 
time in which symphysiotomy has been elected over 
the induction of premature labor. 
I opened the symphysis, and delivered by a high 
application of the forceps, December 5, 1892, at the 
Kensington Hospital for Women. The cervix being 
1 For a full consideration of the history of this case, vide Amer. 
Journ. of Obstet., 1890, pp. 237 and 418. 11 
well dilated after a labor of eleven hours, the patient 
was put in the lithotomy position for operation. 
The bowels and bladder had been emptied, the lower 
abdominal, pubic, and pudendal regions cleaned, 
shaved and disinfected, and the vagina douched. 
The membranes were now ruptured. It was not 
considered worth while to try forceps delivery 
before proceeding with the operation, because the 
head was free at the superior strait, and clearly too 
large to engage. 
The operation was commenced by making an 
incision an inch in length in the median line of the 
abdomen and terminating at the symphysis pubis. 
This was carried down to and through the muscular 
and aponeurotic structures. More room was now 
afforded by detaching the muscle from the pubic 
bones by cutting transversely with scissors until the 
left index finger could be passed behind the pubes. 
The connective tissue back of the pubes is so loose 
that the finger encountered no resistance, and was 
easily passed below the pubic arch. The urethra being 
now depressed and dragged to one side by a cath- 
eter in the hands of an assistant, the Galbiati knife 
was passed along the finger as a guide, and hooked 
under the symphysis. This was divided by traction 
on the knife in an upward and forward direction. 
Much difficulty was encountered, as apparently the 
ligamentous structures were not abundant, and the 
knife became wedged between the bones. The 
symphysiotomy lasted twenty-six minutes. As 
there was considerable venous oozing, a sponge was 
packed behind the symphysis and gauze was laid over 
the wound. 
The forceps was now applied, and the baby, a boy, 
was delivered after an extremely difficult forceps- 
labor, lasting thirty-seven minutes. This is ex- 
plained by the fact that the baby weighed 8}£ 
pounds, and that the head measurements were B. P., 12 
9.5 cm. ; B. T., 9 cm. ; S. O. B. 9.5 cm. After 
the symphysis was divided the bones separated one- 
fourth of an inch. After vigorous traction with the 
Hodge forceps they separated two inches, and the 
head became well engaged. The Tarnier forceps 
was now applied, when the head descended into the 
cavity of the pelvis, and a separation of inches 
was obtained. Two assistants now supported the 
pelvis by pressing on the trochanter upon either side, 
and drawing upon the ilium of the opposite side. 
It was interesting to observe that the labor followed 
the mechanism of the flat pelvis. The head de- 
scended semi-flexed, with the occiput to the right 
ilium and the sinciput to the left ilium, until it 
began to distend the pelvic floor, when flexion and 
internal rotation took place. The child was de- 
livered asphyxiated, and required careful attention 
for ten minutes before it was resuscitated. The use 
of suspension, head downward, dipping in warm 
and sprinkling with cold water finally brought it 
around. The placenta was now delivered, and the 
vagina and the uterus were douched with sublimate 
solution, t : 2000. The sponge was removed from 
the operation-wound and the hemorrhage found 
to be controlled. Several silkworm-gut sutures were 
passed through the skin and muscle in each lip of the 
wound, which came nicely together. In the mean- 
time the pelvic bones were pressed together by the 
assistants. A dressing of aristol and gauze was 
applied over the wound, over this rubber adhesive 
plaster, and finally a stout binder coming well below 
the trochanters. The legs also were tied together 
for some days. The patient was put to bed without 
shock. 
In performing the operation I had the advantage 
of the counsel of Drs. Harris and Parish, and Drs. 
Boyd and Parish kindly took charge of the baby. 13 
The operation was witnessed by a number of physi- 
cians, among others the venerable Dr. J. G. Allen. 
The after-history was absolutely uneventful—a 
normal puerperium. Tender and abraded nipples 
interfered with the baby’s nursing, which pre- 
vented him from thriving for a time; but at the 
present writing he is fat and well. The extreme 
asphyxia present at birth probably influenced his 
nutrition for some weeks. 
It was interesting to observe the entire absence of 
pain in the divided symphysis. I had expected con- 
siderable pain from the stretching of tissues, espe- 
cially below the pubic arch; but the patient ex- 
pressed herself as being perfectly comfortable. 
The after-management of the case was somewhat 
troublesome, owing to the necessity of using a wide 
binder to preserve immobility of the pelvic bones. 
The vulva was washed twice daily with sublimate 
solution, and well dusted with boric acid. The 
vagina was douched on alternate days, more espe- 
cially to assist in the rather troublesome task of 
keeping the parts clean. This was troublesome, 
because it was thought best to keep the legs together. 
As a matter of convenience, I used two binders. 
The one next the skin was of two thicknesses of 
heavy muslin, made with “ three tails.” The outer 
one was of canvas. The bandages were secured 
with safety-pins, and finally when the muslin bandage 
was dispensed with, straps and buckles were attached 
to the canvas bandage. 
In cleaning the patient the outer binder was un- 
fastened, and also the lower tail of the muslin binder. 
The legs were then separated just enough to permit 
cleansing the vulva. About every third day it 
became necessary to apply a clean muslin binder. 
The patient was rolled on her side, the legs being in 
apposition, and the pelvis supported, when the 
soiled binder was removed, and the opportunity 14 
embraced to wash the region of the buttocks. A 
clean binder was then placed in position, the pelvis 
well supported, and the patient rolled on her back, 
when the two binders were fastened. In this way it 
was possible to keep the patient clean, and at the 
same time keep the pelvis immobile. 
Union of the joint was apparently complete in 
two weeks. The sutures were removed in six days. 
Wishing to run no risks of poor union, the patient 
was kept in bed four weeks, then sent home, and 
confined to bed for another week. Shortly after- 
ward she was doing the housework for a family of 
six. 
2134 Hancock Street. 
In the discussion following the reading of the paper 
Dr. R. P. Harris said : Dr. Noble’s patient came under 
my observation May, 1888, when I saw her in consulta- 
tion with Dr. H. A. Kelly at her own house, and recom- 
mended that she should go to the Kensington Hospital 
for Women, and there be delivered by the Cesarean 
operation, which was performed a few days later. When 
she was pregnant for the fifth time I had become con- 
vinced of the value of symphysiotomy, and thought it 
adapted to her case, because of the form and size of her 
pelvis, and recommended that it should be selected as a 
preparation for delivery. 
Unfortunately for the facility of its extraction, the 
fetus proved to be a male, and much larger than any of 
her former children, so that it made a very narrow 
escape for its life, being deeply cyanosed and difficult 
of resuscitation. It, however, thrived well during its 
mother’s recovery, which was free from any pelvic pain 
or uneasiness. No convalescence after parturition could 
have been more devoid of symptoms indicative of the 
enlargement to which her pelvis had been subjected ; 
and when I examined her on the twenty-second day I 
found pubic union firm and solid. 15 
Dr. Noble’s case is one of the most interesting on 
record, because of its historic character, as symphysi- 
otomy was brought into contrast with the improved 
Cesarean section and with delivery under induced labor 
in the same subject, and all with entire success to 
mother and child. I know of no parallel case in my 
obstetric readings, and of no evidence in contrast that 
is more to the credit of the recently introduced method 
of delivery. 
Under an improved technique and proper antiseptic 
precautions, the operation of Sigault has been robbed of 
all traumatic dangers, and would appear to be devoid 
of any risk, when regarded from a surgical aspect. 
Deaths have taken place since the operation was per- 
fected by Prof. Morisani, and no doubt will continue to 
take place, when women are operated upon in ex- 
tremis; just as deaths follow after delivery by the 
forceps or in cases in which craniotomy has been per- 
formed. What we contend is that the prior condition 
of a parturient woman is not rendered the more likely to 
prove fatal by reason of the section and opening of her 
symphysis to aid delivery. 
During the past seven years, four women out of 
seventy have died, in whose cases delivery was ac- 
complished with the aid of symphysiotomy: one in 
Naples in 1890; one each in Helsingfors, Russia, and 
in Paris, in 1892, and one in the United States this year. 
The Neapolitan woman was in labor for several days 
when taken to hospital; the shoulder presented and the 
cord prolapsed; delivery was accomplished by version, 
and death took place in twelve days from metro-perito- 
nitis. The Helsingfors patient died of heart-disease and 
other organic complications on the second day. She was 
forty years old, and in her ninth pregnancy. The Paris 
case had been in labor three days with her fourth child ; 
the forceps had been applied three times at her own 
home, and four times in hospital; one of the last, antero- 16 
posteriorly. She died the day after delivery, and a 
small perforating laceration was found .leading from the 
uterine cavity into Douglas’s cul-de-sac. The fourth 
death was in a woman almost moribund, having a pulse 
of 150. The children were lost, except in the cardiac 
case and the fourth that died. Certainly death could 
not be ascribed to symphysiotomy in any of these cases. 
Since September 29, 1892, this operation has been 
performed ten times in the United States and once in 
Canada, saving ten women and eight children. One 
child died in twenty-four hours, from the effect of long- 
continued pressure upon its head in the lower pelvis, 
and one in three days, from meningeal hemorrhage: the 
third has not been reported. 
The American operations have been performed, in 
chronological order, by Prof. Charles Jewett, of Brooklyn ; 
Prof. Barton Cooke Hirst, of Philadelphia; Prof. Anna 
E. Broomall, of Philadelphia; Prof. Edwin J. Michael, 
of Baltimore; Dr. Charles P. Noble, of Philadelphia; 
Dr. J. A. Springle, of Montreal; Dr. Harry McKennan, 
of Paris, Illinois; Prof. Henry J. Garrigues, of New 
York; Dr. John Milton Duff, of Pittsburg; Prof. William 
T. Lusk, and Prof. Henry C. Coe, of New York. In 
Dr. McKennan’s operation, not having a sufficiently 
strong bistoury, the symphysis was divided by means of 
a narrow metacarpal saw, guarded by the index finger. 
We may arrange the history of symphysiotomy into 
three periods, viz.: 1777 to 1858; 1866 to 1886, and 
1886 onward. In the first period there were over 100 
operations; in the second there were 73; and in the 
third, as far as heard of, there have been 70, of which 
36 were in the year 1892, divided as follows : In France, 
13; in the United States, 7; Italy, 6; Germany, 5; 
Russia, 2; Canada, 1; Ireland, 1, and Austria, 1. As 
Italy had 12 in 1891, it is probable that there were as 
many as 40 in 1892, as against 12 in 1891. 
Some men cannot comprehend my statistics, and are 17 
led to believe that some of the unfavorable cases must 
have been hidden away from those who aided me in 
their collection, in order that the improvement in re- 
sults should appear so remarkable. We have only to 
state that a large proportion of the reports were copied 
from hospital records, and that many other statements 
came through correspondence. An examination into 
the diminished mortality of ovariotomy, the Cesarean 
section and abdominal hysterectomy will show what 
marvellous changes have been effected within a few 
years, in the reduction of the death-rate, under anti- 
septic management. 
It was at one time thought that a Porro-Cesarean sec- 
tion, with the stump treated intra-peritoneally, was 
almost equivalent to a sentence of death, because only 
one woman was saved out of the first eleven, and yet 
25 operations in order, covering the years 1888, 1889, 
1890, 1891, proved fatal to only three women. This 
week brought me a letter from Prof. Leopold, of Dres- 
den, stating that he had performed the Porro operation 
eight times without the death of a mother, and that 42 
improved Cesarean sections in the Frauenklinik had 
cost the lives of but four women. 
The results of obstetric surgery in the hands of very 
skilful men are certainly trying to the faith of the casual 
observer, but they are none the less worthy of credit. 
Dr. Hubert Riedinger, of Briinn, Austria, was an early 
operator after the Porro method, having commenced in 
1878; and his records show that he has performed 15 
sections, saving all of the women and losing but one child. 
The late Karl Braun (13), the late August Breisky (8), 
and Drs. Riedinger (15), and Leopold (8), had collec- 
tively 44 Porro operations, and lost but 3 women and 8 
children. Such records show the possibility of the 
operation, but a general hospital report, as of the Mater- 
nities of Leipzig, Dresden, and Vienna, is of much more 
value in the estimation of risks. 18 
If puerperal celio-hysterotomy and celio-hysterec- 
tomy have been so largely reduced in their rates of 
mortality, why should it be regarded as almost incredi- 
ble that the operation of symphysiotomy, upon women 
in a proper condition, should have no mortality ? If 
what was once regarded as “ the murderous operation 
of bi-pubiotomy" has been recently revived in Paris, 
under Prof. Adolphe Pinard, with the saving of both 
mother and child, why should we fear the traumatic re- 
sults of a simple symphysiotomy ? In Pinard’s case 
there was a true conjugate of 8.5 c.m., but one sacro- 
iliac symphysis was ankylosed, and the pelvis was 
oblique, hence the change of method. This operation 
originated with Prof. Galbiati, of Naples, who performed 
it on March 30, 1832, upon a dwarf three and a half feet 
high, having a one-inch conjugate; the child was dead, 
the woman died in four days of gangrene of the geni- 
talia and vagina. Ten years later, Dr. Ippolito repeated 
the operation in Naples, with the same result. Prof. 
Pinard evidently thought that this operation originated 
with Dr. Farabeuf, of Paris, who proposed it to him, 
and he recommended that it be called by his name in- 
stead of ischio-pubiotomy, by which he reported it before 
the French Academy of Medicine, on January 10, 1893, 
Dr. Barton Cooke Hirst said: Without doubt this 
operation has now become firmly fixed among justifiable 
obstetric procedures. There have already been ten 
operations in this country, and I shall probably add 
another to-morrow. I have only one remark to make 
to-night in regard to this matter. After my own opera- 
tion, which I have already reported, I had a conversa- 
tion with the President, and received from him a very 
original and brilliant suggestion. Dr. Mitchell asked 
me if there were not some way of permanently enlarg- 
ing the pelvis in the operation of symphysiotomy. It 
seemed to him that by the insertion of ivory pegs, or by 
other means, the widening of the pelvis could be main- 19 
tained. This is a brilliant idea, and I had hoped to have 
had before now the opportunity of trying it upon ani- 
mals. The proposition is very interesting and deserves 
careful consideration. The enlargement of the pelvis 
in symphysiotomy is considerable. A recent German 
experimenter has examined, post-mortem, the pelves of 
three or four women within a few days after delivery, 
and has found that with a separation of the symphysis 
to seven centimeters, symphysiotomy gave an increase 
of three centimeters in the oblique and transverse diame- 
ters, and of over one centimeter in the antero-posterior 
diameter. This enlarges the capacity of the pelvis 
materially. It would be a brilliant achievement if this 
could be made permanent by the operation, and if 
by medical skill we could transform the previous ana- 
tomic condition of the patient. It seems almost like 
sacrilege to think of it. It reminds one of adding a 
cubit to one’s stature, but it seems possible, and I hope 
soon to have an opportunity of testing Dr. Mitchell’s 
suggestion upon pregnant animals.