and cartilage from within outward and below upward. When the section has been completed it will be known by a creaking sensation and a separation of the bones from one and one-quarter to one and one-half inches.

"After this step, cover the wound with the gauze, dipped in a bichloride solution of 1 : 4000, and attend to the delivery of the foetus, having at the same time the separation of the innominata antagonized by pressure with the hands of assistants. During the passage of the head ascertain the amount of pubic separation; spray the vagina; and when the placenta is delivered, introduce six or eight interrupted silk sutures into the edges of the wound; dress it with sublimated cotton, 1:2000, and bandage the pelvis and lower extremities."

Pinard' prefers to divide the pubes from without inward with a straight bistoury, protecting the subjacent structures with the index finger of the left hand previously passed behind it.

One would naturally fear that after the section of the symphysis, and the strain put on the sacro-iliac joints by the separation of the innominate bones, subsequent difficulties in locomotion would arise. No mention is made of this in the cases hitherto published, but the point appears to require further investigation.[2]

[FIG. 203.

Harris's symphyseotomy bistoury. This is modelled to conform with the posterior curve of the symphysis from above downward.-ED.]

After the incision is made and the symphysis separated, it may, of course, be necessary to complete delivery either by the high forceps operation or by version.

[Progress and Results of Symphyseotomy.-Until February 4, 1892, this operation was for many years confined to Italy, and for twenty-seven years almost entirely to Naples, in which city there were twelve women delivered under it in 1891. On the date mentioned it reappeared in Paris, and soon commenced to be performed in other countries; but not with the success that had attended it in Italy during 1886-91. Although originally a French operation, it had fallen into very bad repute, and had for many years been considered as beyond the pale of obstetric surgery. In its restoration to favor it again became the operation of Sigault, and was performed by direct incision, and not by the sub-osseous method, which under Morisani and Novi, of Naples, in an experience of twenty-six years (1866-91), had procured it a reputation of success and safety. The successes of Pinard, of Paris, gave the method a new impetus, and it has rapidly spread into other countries, where it has been performed with varying success; but in no locality with the low death-rate of Italy, where 46

1 Symphyseotomy at the Clinique Baudelocque, Lancet, February 18, 1893.

[ Difficulty in locomotion has very rarely followed the operations under antisepsis and pelvic fixation, and the disability has been temporary.-ED.]

deliveries cost the lives of only 2 women and 5 children, dating from 1886.

Although Prof. Pinard did not lose a case until his twentieth died of direct sepsis, no other operator or country out of Naples had this measure of success. France lost 5 out of her first 35, including 8 successes of Pinard; and the United States lost 4 out of her first 25. In sixteen months (February 1, 1892, to June 1, 1893) the operation was tested in eleven countries and upon more than 150 women.

If we include the Italian operations of 1886-91, we find that, up to June of this present year, there were 25 women and 37 children lost under 205 symphyseotomic deliveries, according to the record made by Neugebauer, of Warsaw, with my assistance. This would leave, without the 46 of Italy, 23 deaths in 159 women, and 32 children lost. Not a very encouraging record when compared with the Cæsarean results of Leipzig and Dresden, a mortality of 7 per cent.

Symphyseotomy, although an old operation, is still in the experimental period of its existence in all localities outside of Naples, and we should, in our country at least, be content to follow the directions given by Morisani, as already stated. Several prominent operators have been very much disappointed with the results attained in their hands, while others, more successful, are disposed to commend the method. In our own country it is believed to have a promising future; to secure which the operation by direct incision is to be avoided, as the results in France and Vienna do not commend it.

Having for twelve years studied this operation by correspondence, I am inclined to regard it in the light of its measure of possibility, as shown by the work of the last six and one-half years in Naples, rather than by the actual average of success elsewhere in the past eighteen months. There does not now appear to be any element of danger arising from injury done to the sacro-iliac synchondroses. What they have most to fear in Continental maternities is septic poisoning from the wound in the symphysis, or from lacerations of the cervix, vagina, vulva, and perineum, all of which sometimes occur in the same subject, and particularly in rhachitic primiparæ. It should be borne in mind that in cases where the pelvis is much contracted, the vagina and vulva will usually be found to be of the same character, and an operator cannot be too cautious in making slow and interrupted traction with his forceps.

The minimum conjugate diameter of Morisani of two and fiveeighths inches is too small for this country, where the foetus is on the average of larger size, and should be fixed at two and three-quarters inches; and even this will be found a dangerous measure where the foetus is a male and above the average weight. If a woman is operated upon in good season, and by the sub-osseous section, she should run but a moderate risk for her life, and her child likewise; although the latter has a less degree of safety. According to Dr. Franz Neugebauer, the general average of death for the women is now 12 per cent., and for the children, 18. In the United States the average has been, respectively, 16 per cent. and 24 per cent. This statement has disappointed many of our accoucheurs; but if they will examine into the

causes of death in the four women, they will find encouragement rather than the reverse. Like the Cæsarean section, much will depend upon the length of labor and the condition of the patient when operated on for securing a successful issue. Symphyseotomy ought to be less dangerous than the Cæsarean section has been in our country; and nothing short of this should satisfy those who propose to substitute it for craniotomic infanticide. It is a less formidable operation, and women make less objection to it than they do to the abdominal delivery. It requires less skill in its execution, and is not so shocking in its effects upon the nerves of the accoucheur; but take the whole delivery in many cases, and it will be found that no little skill is required to secure a favorable result.

Operation after Induced Labor.-Where the true conjugate is below the minimum measure, the disproportion between it and the size of the foetal head may be overcome by bringing on labor at the end of the eighth month or a little later. Children thus delivered require extra care in raising, and in the class to which they belong are very often lost at an early period. In exceptional instances they have done remarkably well; but it is a question to be considered, whether it would not be better in the average of cases to deliver by the Cæsarean section at full term.

Unilateral Ischio-pubiotomy.-Following a suggestion of Farabeuf, Prof. Pinard operated upon a V-para of thirty-two at the Clinique Baudelocque on November 9, 1892, so as to deliver a living male foetus, weighing nearly nine pounds, through an oblique Naegele pelvis. He cut down upon the ischio-pubic ramus of the ankylosed side, and divided it with a chain-saw; and repeated a section of the horizontal ramus of the corresponding os pubis at a distance of 5 cm. from the symphysis. This enabled him to open out the front of the pelvis by the separation of the free synchondrosis of the opposite side under the traction of Tarnier's forceps; and a separation of the os pubis to the extent of 4 cm. gave room for the passage of the fœtus. The wound healed by the first intention in eight days; the woman sat up in thirtytwo days, and walked about without inconvenience in two months, the child then weighing eleven pounds. This, in principle, was a repetition of the bi-pubiotomy of Galbiati, of Naples, performed upon both sides on March 30, 1832, with a fatal result; the dwarf of three and one-half feet, having a one-inch conjugate, dying in four days. The operation of Farabeuf had the advantages of antisepsis, and of a slight disproportion of size between the pelvic canal and foetal head. -ED.]

1 Annales de Gynécol. et d'Obstét., Fév., 1893, pp. 139–152.

CHAPTER VIII.

THE TRANSFUSION OF BLOOD.

The Transfusion of Blood in desperate and apparently hopeless cases of hemorrhage offers a possible means of rescuing the patient which merits careful consideration. It has again and again attracted the attention of the profession, but has never become popularized in obstetric practice. The reason of this is not so much the inherent defects of the operation itself-for quite a sufficient number of successful cases are recorded to make it certain that it is occasionally a most valuable remedy-but the fact that the operation has been considered a delicate and difficult one, and that it has been deemed necessary to employ a complicated and expensive apparatus, which is never at hand. when a sudden emergency arises. Whatever may be the difference of opinion about the value of transfusion, I think it must be admitted that it is of the utmost consequence to simplify the process in every possible way; and it is above all things necessary to show that the steps of the operation are such as can be readily performed by any ordinarily qualified practitioner, and that the apparatus is so simple and portable as to make it easy for any obstetrician to have it at hand. There are comparatively few who would consider it worth while to carry about with them, in ordinary every-day work, cumbrous and expensive instruments which may never be required in a life-long practice; and hence it is not unlikely that, in many cases in which transfusion might have proved useful, the opportunity of using it has been allowed to slip. Of late years the operation has attracted much attention, the method of performing it has been greatly simplified, and I think it will be easy to prove that all the essential apparatus may be purchased for a few shillings, and in so portable a form as to take up little or no room; so that it may be always carried in the obstetric bag ready for any possible emergency.

History of the Operation. The history of the operation is of considerable interest. In Villari's Life of Savonarola, it is said to have been employed in the case of Pope Innocent VIII., in the year 1492, but I am not aware on what authority the statement is made. The first serious proposals for its performance do not seem to have been made until the latter half of the seventeenth century. It was first actually performed in France by Denis, of Montpellier, although Lower, of Oxford, had previously made experiments on animals which satisfied him that it might be undertaken with success. In November, 1667, some months after Denis's case, he made a public experiment at Arundel House, in which twelve ounces of sheep's blood were injected into the veins of a healthy man, who is stated to have been very well

after the operation, which must, therefore, have proved successful. These nearly simultaneous cases gave rise to a controversy as to priority of invention, which was long carried on with much bitterness.

The idea of resorting to transfusion after severe hemorrhage does not seem to have been then entertained. It was recommended as a means of treatment in various diseased states, or with the extravagant hope of imparting new life and vigor to the old and decrepit. The blood of the lower animals only was used; and, under these circumstances, it is not surprising that the operation, although practised on several occasions, was never established as it might have been had its indications been better understood.

From that time it fell almost entirely into oblivion, although experiment and suggestions as to its applicability were occasionally made, especially by Dr. Harwood, Professor of Anatomy at Cambridge, who published a thesis on the subject in the year 1785. He, however, never carried his suggestions into practice, and, like his predecessors, only proposed to employ blood taken from the lower animals. In the year 1824 Dr. Blundell published his well-known work entitled Researches, Physiological and Pathological, which detailed a large number of experiments; and to that distinguished physician belongs the undoubted merit of having brought the subject prominently before the profession, and of pointing out the cases in which the operation might be performed with hopes of success. Since the publication of this work, transfusion has been regarded as a legitimate operation under special circumstances; but, although it has frequently been performed with success, and in spite of many interesting monographs on the subject, it has never become so established as a general resource in suitable cases as its advantages would seem to warrant. Within the last few years more attention has been paid to the subject, and the writings of Panum, Martin, and De Belina on the Continent, and of Higginson, McDonnell, Hicks, Aveling, and Schäfer in Great Britain, amongst others, have thrown much light on many points connected with the operation.

Nature and Object of the Operation.-Transfusion is practically only employed in cases of profuse hemorrhage connected with labor, although it has been suggested as possibly of value in certain other puerperal conditions, such as eclampsia or puerperal fever. Theoretically it may be expected to be useful in such diseases; but, inasmuch as little or nothing is known of its practical effects in these diseased states, it is only possible here to discuss its use in cases of excessive hemorrhage. Its action is probably twofold: first, the actual restitution of blood which has been lost; second, the supply of a sufficient quantity of blood to stimulate the heart to contraction, and thus to enable the circulation to be carried on until fresh blood is formed. The influence of transfusion as a means of restoring lost blood must be trivial, since the quantity required to produce an effect is generally very small indeed, and never sufficient to counterbalance that which has been lost. Its stimulant action is no doubt of far more importance; and if the operation be performed before the vital energies are entirely exhausted, the effect is often most marked.