Symphysiotomy Abuse Claim Unfair to Obstetricians
Irish Medical Times, July 5, 2009 2 Comments
I have rarely been as annoyed by a letter as I have been by that of Marie O’Connor on symphysiotomy.
Symphysiotomy is no longer performed – and has not been since, I think, the 1960s. The world has changed and Ireland has changed!
In the 1950s, I worked for a couple of months in the Admission Unit in St Kevin’s Hospital (now St James’s). My duty was to examine all the patients who were for admission. Most of these patients were from the poorer part of Dublin.
I was appalled at the evidence of malnutrition – low haemoglobin levels and vitamin deficiencies, especially rickets — that I saw. This was the result of poverty and living through the war years.
One of the consequences of rickets was the development of ‘contracted pelvis’. I worked in the National Maternity Hospital, Holles Street as an anaesthetist from the middle 1950s. Contracted pelvis – usually resulting from rickets – was not an altogether rare disorder. No room for the baby to get out!
The options for management were (i) Caesarean section. Fifty years ago this was not without its risks. I served on a Committee on Maternal Mortality. We assessed, on average, between 30 and 40 deaths per annum. Many of these were related to Caesarean section. (Quite a number were due to anaesthetic problems). (ii) An alternative was symphysiotomy. This involved cutting the cartilage at the front of the pelvis. This could be done under local anaesthesia using a gigli saw. A separation of two to three centimetres enabled the pelvic outlet to increase and, hopefully, settle the problem and allow for a vaginal delivery.
Fifty years ago, neither contraception nor sterilisation was tolerated. As a result, it was not infrequent for the woman with the contracted pelvis to become pregnant again. If she had had a Caesarean section, there was a significant risk of a ruptured uterus — especially if she had had a ‘classical section’. This was a very serious problem. On the other hand, had she had a symphysiotomy, she might then have a normal delivery.
As regards the complications of syphysiotomy, I have no doubt there were many. Normal deliveries, too, were not without their problems — stress incontinence, prolapse of the uterus and so on. Papers from orthopaedic surgeons in Ireland and, I recall, from one of the Scandinavian countries, noted that problems following symphysiotomy were relatively infrequent.
Looking back at this era – 50 years ago – and suggesting that this practice in any way resembled the reported abuse of children in some of the industrial and reform schools is grossly unfair to the many caring obstetricians of that era!
John R. McCarthy,
FRCPI FRCA FCA RCSI, Electra, 115,
Marie O'Connor says:
Dr McCarthy has queried my raising of symphysiotomy in the context of abuse victims.
Symphysiotomy was practiced in Ireland until 1984. The surgery severed the pubic bones, unhinging the pelvis. Around 120 mothers today live with the consequences: chronic pain, impaired mobility, incontinence
Many have reported that this operation was performed without their knowledge or consent. This was an abusive use of authority comparable to that described in the Ryan Report, especially since it is clear that symphysiotomy was impelled, not by patient safety, but by Catholic doctrine and, perhaps, obstetric training.
Alex Spain revived symphysiotomy at the National Maternity Hospital (NMH) in 1944. By then, symphysiotomy had long fallen into disrepute. Spain himself admitted that symphysiotomy was ‘an entirely new procedure … that has to be faced against the weight of the entire English-speaking obstetrical world’. By 1944, Caesarean was well
established in that world as the treatment of choice for obstructed labour.
Contrary to what the Institute of Obstetricians and Gymaecologist would have us believe, symphysiotomy was never a norm. It was shunned––also on the continent of Europe–– because of its dangers, which had been amply described in the medical literature. In addition to the prospect of a dead or damaged baby, there was the certainty of a severely injured mother. As far back as 1803, the procedure had been damned by Prof James Hamilton of Edinburgh: ‘in no case whatsoever’, he said, should it be resorted to.
Spain’s successor, Arthur Barry, championed the practice in the 1950s. But it was attacked by British doctors, who counted the number of babies left dead and brain damaged as a result of the surgery. Donal Browne of the
Rotunda also pointed out that Caesarean would result in fewer infant deaths and less maternal injury.
Symphysiotomy was preferred to Caesarean section for ethical reasons. Barry described Caesarean as
‘the chief cause of the unethical procedure of sterilisation’.
Caesarean also encouraged the laity ‘in the improper prevention of pregnancy or in seeking termination’, he told a Catholic medical congress in 1954. ‘If you must cut something, cut the symphysis’, he urged.
Historian Tony Farmar, noting Spain’s contribution to NMH’s postgraduate teaching role as well as his revival of symphysiotomy, commented that the procedure ‘proved enormously useful as a substitute for Caesarean section in conditions in Africa and India where major surgery was not possible’.
Symphysiotomy persisted at the Lourdes Hospital, Drogheda, until 1984. For a hospital that trained medical staff to work in missionary hospitals in developing countries, the educational value of symphysiotomy must have been considerable, but at what cost to the mother?
Where was the gain to the Irish patient in deviating from Caesarean section for obstructed labour? This is a question the Institute of Obstetricians and Gynaecologists should now answer. A review of the victims’ surgery has been blocked since 2001 by the Institute’s advice to the Department of Health conjuring symphysiotomy as a norm for
Author: ‘Emergency: Irish hospitals in chaos’
Sheila martin says:
I read this article with dismay. I did a 50 year study on Symphysiotomy at Our lady of Lourdes dROGHEDA FROM 1949-83, In total up to 400 syphysiotomies were performed. Some were carried during a c/section others were performed as an elective procedure weeks before delivery and when they came back to the hospital were delivered by s/section… surely that defeated the purpose of the dangers of caearean section? Those women were in dreadful pain. It was common knowledge that women had their pelvis measured before delivery and after. The hospital seemed to be obseessed by symphysiotomy. their annual reports were preoccupied with details of symphysiotomy as if it was some sort of thesis or experiment. Symphysiotomy was carried out in the Lourdes up to 1983 a time when modern techniques were in place. Also I take issue with the contracted pelevis, as you refer to Sweeden and symphysiotomy, its a pity Ireland did not adapt the same idea as Sweeden with contracted pelvis, in sweeden they gave out suppliments to help women with this problem. Instead Ireland chopped away with women up to a modern time as 1983. Amazing really when medicine was supposed to be learning new techniques. The Drogheda unit was backwards and no one can really say anything better than that. My 50 years study is from the Hospitals annual reports and they are not lying.