presents, in most instances, a very sharp
curve near the sacro-iltac joint, and is
often bent double, so as to offer a mere chink
between the sacral and iliac portions. The
iliac wings are generally approximated, the
venter being sometimes doubled into a mere
fissure, and the crest being curved inwards
more than normal, so as to bring the anterior
superior iliac spines nearer together; while
the posterior extremity of the crest, or iliac
tubero$ily y is bent inwards and forwards over
the sacrum, by the weight of the body, acting
through the sacro-iliac ligaments. The planes,
spines, and tuberosities of the ischia are pushed
inwards towards each other, and sometimes
turned more upwards, so as to cause a chink
or acute bend in the ischial plane, passing
downwards and forwards, and which has been
compared by Naegele to the fold made by
bending pasteboard. The superior rami of
the pubes are directed horizontally forwards,
being almost, and, in extreme cases, quite pa-
rallel to each other anteriorly.
This alteration in the direction of the
pubic bones takes place, in many cases, by
an inward curve in the acetabula at the
point of junction of the three pieces of the
innominate bone, as indicated by the ilio-
pectineal eminence, and the form of the brim
will then assume the shape of the letter Y
when the deformity is great. In many in-
stances, however, the superior pubic rami
are bent inwards at an obtuse angle, in the
centre, just above the obturator foramina, the
bones of the opposite sides almost or entirely
meeting at the angle, and continuing parallel
with each other to their articulation. The
form of pelvis resulting from this bend in the
superior pubic ramus has received more par-
ticularly the name of the cocked hat or ros-
trated pelvis; the latter name being applied
from the beak-like projection of the pubis at
the symphysis. It is markedly distinguished
from those" angular deformities in which the
inward bend of the innominate bones takes
place at the acetabular junction of their three
component pieces, and is found exemplified
in most of the specimens exhibiting the
greatest contraction of the diameters.
The pubic symphysis is, in every case, more
or less folded back, straining upon the anterior
ligaments. The bending, however, is seen to
occur in the osseous portions of the articula-
tion forming the pubic angles, generally about
the position of the pubic spine, and it is much
more considerable in the cases where the an-
terior portions of the pubes are parallel to
each other. The sub-pubic arch is, in all
cases, very considerably narrowed by the
parallel position of the superior pubic rami
and the approximation of the ischial tu-
berosities. In many instances, the latter
appear to be pushed forwards and upwards,
so that the contraction of the sub-pubic arch
is greatest at the ischial rami, just above the
tuberosities, above which point the sides of
the arch bulge outwards. In the rostrated
pelvis, it is often completely obliterated or
transformed into a mere chink. The acetabula
are elevated and turned more forwards than
normal, and in many examples of rostrated
pelvis are directed almost quite anteriorly.
The angles of both the superior and inferior
pelvic planes with the vertebral column are
lessened. In a case given by Naegele, the supe-
rior plane was at right angles to the spine.
The axis of the brim is thus rendered more
vertical, and that of the outlet more forward,
than in the standard pelvis. The superior
plane is often bent into two by the elevation
of the acetabula, but, in some instances, the
pubic symphysis is pushed upwards above the
acetabula.
The diameters are all contracted in a greater
or less degree, those of the brim most ex-
tensively. In this kind of pelvis occurs the
greatest diminution of diameters of all the re-
corded examples. The diminution, however,
is such, that if the irregular form were re-
shaped, the diameters would be replaced,
i. e. there is no absolute shortening of the
bones, or not so much as in the rickety pelves.
Examples. The pelvis of Isabel Redman
{fig. 118.), upon whom hysterolomy was per-
formed by Dr. Hull in 1794, and which is said
to present at the brim the most contracted
diameters on record, is affected by this de-
formity in its rostrated form to such an extent,
that a ball Jf inch in diameter would not pass
through it at any part.
At the brim, the 4th lumbar vertebra was
completely sunk into the pelvis, and in-
clined to the left side, and its distance from
188
PELVIS.
the pubic symphysis was 2^ inches. The
distance between the superior pubic rami at
Fig. 118.
Pelvis o Isabel Redman.
the point of angular bend, was $ of an inch.
From the 4th lumbar vertebra at its upper
anterior border, to the left acetabulum, was
only f of an inch ; on the right side f. The
greatest transverse diameter was 5f inches.
At the outlet, the distance between the sciatic
tuberosities was 3| inches ; between the
spines 2f. The greatest contraction of sub-
pubic arch was at the sciatic rami, which
were only T 7 ^ of an inch distant from each
other ; above this, the arch bellied out. The
sacrum was bent double, so that the tip of the
coccyx was only l T T n inch from the sacral
base. The pelvic bones were quite soft, and
lighter than natural.
The measurements of the pelvis of Jane
Foster, who was saved by the* Caesarian sec-
tion by Mr. Barlow, are given as follows :
From the fibro cartilage between the 4th
and 5th lumbar vertebrae (which is sunk
down so as to occupy the normal position
of the sacral promontory), to the outside of
the projecting pubic symphysis, is 3 inches.
From the same point, to the centre of the
superior ramus of right pubes, f of an inch, of
clear available space. The same measure-
ment on the left side, If inch. From the
same point, to the right acetabulum of
an inch ; to the left acetabulum 1^ inch.
The greatest available space is, from the
left side of the sacral promontory to the
left ilium, and amounts to 1 inch. The
greatest lateral space, following the curve, is
5| inches. At the outlet, the distance
between the sciatic tuberosities is 1 inch.
The coccyx and lower part of the sacrum
are bent upwards, so as to bring the tip of the
coccyx to within 1 inch of the sacral pro-
montory, and to 2i inches from the point of
contact of the ascending ischial rami, which
are so close as to obliterate entirely the sub-
pubic arch.
The dimensions of the rostrated pelvis of
Elizabeth Thomson, who underwent the
Cassarian section at the hands of Mr. Wood
of Manchester, and died in consequence,
are given by Dr. Murphy, as follows :
From the most projecting point of the
sacral promontory to the pubic symphysis,
2 inches. From the same point to the
left pectineal eminence, f of an inch ; to
the right pectineal eminence, f of an inch.
The transverse diameter of the brim, 2 in-
ches ; both the oblique, 3^ inches. Cavity :
antero-posterior diameter, 3 inches ; trans-
verse diameter, 2 inches. Outlet: antero-
posterior diameter, 3 inches ; transverse
diameter, 2f inches. The sub-pubic arch mea-
sured 10 only.
In a specimen of rostrated pelvis given by
Dr. Ramsbotham, the antero-posterior diame-
ter of the brim is diminished by the projection
of the sacral promontory, and the bend in the
pubis, to If inch. The same measurement
on the left side of the promontory, 2f inches ;
on the right side, 2 inches. The longest
transverse diameter is 4 inches. At the outlet,
the nearest points of the ischial tuberosities
are as close as If inch ; but from the tip of
the coccyx to the lower border of the pubic
symphysis measures 4 inches. In the opinion
of this author, a foetus might be extracted
from this pelvis by craniotomy.
In Dr. Cooper's case of Caesarian section,
the pelvis was affected with the angular de-
formity to the extent of reducing'the conjugate
diameter of the brim to 1^ inch.; and the trans-
verse diameter of the outlet to an inch only.*
In Dr. Kellie's unsuccessful case of Caesarian
operation, the pelvis was of the rostrated kind;
the superior pubic rami being as if fractured
in the centre, and held only by ligament.
The lumbar curve was to the right side, and
the 4th vertebra was sunk below the plane of
the pelvic brim. The right lumbo-cotyloid
diameter was only T % of an inch ; the left,
1^. Between the lumbar vertebra , and
the bend of the pubic rami, was only T % of
an inch. At the outlet, the intersciatic
distance was only 2 T 7 o ; antero-posterior,
3 T 4 o inches. The sacrum was doubled, so
that the tip of the coccyx was but 1 inch
from the sacral base. The pelvic bones were
soft ; but the joints and cartilages healthy. In
this case, the patient was only twenty-seven
years old, and had borne four children ; the
last, three years before her death.
In Dr. Radford's two unsuccessful cases of
hysterotomy, the deformities were both from
malacosteon, and the form rostrated. In one,
the circle of space at the brim was only about
f of an inch in diameter; the opening Y -
shaped. The distance between the sciatic tu-
berosities was li inch, and the sub-pubic arch
reduced to a small slit. The subject had previ-
ously undergone nine natural deliveries, and one
by craniotomy. In the other case, the conjugate
diameter was reduced to f of an inch ; and
the superior rami were also bent so as to be
parallel anteriorly. The patient had borne seven
children with great ease previously ; the last
case four years before the operation.f
Dr. Hamilton's case was also rostrated, the
* Med. Observ. and Inq. vol. v. p. 218.
f Edinburgh Med. and Surg. Journal, vol. Iv.
PELVIS,
189
pubic rami being approximated at the angular
bend to of an inch.
In a case which was operated on by Dr.
Haebeke, and described in IS Experience
(No. 140.), the inferior pelvic outlet was
nearly closed up entirely, the ischial tube-
rosities being approximated to within two
lines onlj-, and the coccyx and pubes-admitting
only one finger between them.*
In Mr. Kinder Wood's case, the deformity
was rostrated, the most available space at the
brim being a circle of 1 inch diameter to the
left of the projecting promontory. The antero-
posterior diameter was 1 inch, but less than
f of an inch when the soft parts were at-
tached.f
A somewhat remarkable variety of the ros-
trated pelvis is figured by Dr. Churchill (Jig.
1 1 9.). In this pelvis the superior pubic ramus
Fig. 119.
Oblong rostrated pelvis. {After Churchill.)
is bent at its centre, so as to be nearly ap-
proximated to the opposite pubis at that
point, and the symphysis projects in a rostrum.
The upper part of the sacrum and the pro-
montory is, however, thrown back, the cotylo-
sacral arch spread out, the antero-posterior
diameter increased, and the transverse lessened,
somewhat in the same manner, and, doubtless,
by the same mechanical conditions, modified
only by the yielding of the pubis, as in the
oblong pelvis before described. The acetabula,
in this pelvis are directed principally forwards
and outwards.
Causes of the foregoing pelvic distortions.
The principal causes of the preceding partial
and complete distortions of the pelvis, are two
diseases affecting the osseous system; viz.
" rickets" and " mollifies ossium" or " malacos-
teonr
Rickets is a very common disease of early
life, which is said to be more apt to occur in
scrofulous children about the pe r iod of denti-
tion, but which may occur even after puberty,
according to some authors. It is characterised
* Lancet, 1840.
f Med. Chir. Trans, vol. vii. p. 2G4.
by a simple deficiency of the earthy matter of
the bones chiefly of phosphate and carbonate
of lime ; while the animal constituents, al-
though softened, and rendered less elastic,
retain nearly their normal composition. The
bones thus rendered pliable, which lie in the
lines of weight, pressure, or muscular action,
yield slowly and give way to the operating
forces, bending in such a manner as the re-
sultant direction of pressure and muscular
traction, &c., permits them.
We must refer the reader to the Article
on the PATHOLOGY OF BONE (vol. i. p. 440.)
for a more detailed account of this disease.
In Rokitansky's Pathological Anatomy, the
bones in Rhachitismus infantalis are described
to present two separate pathological conditions.
In one, the bones are very vascular, soft, fragile,
and swollen, with enlarged medullary cavities,
and the areolar spaces filled with, and often
distended by, a pale, reddish jelly, which press-
ing upon the areolar partitions, produces
their absorption, and thus the enlargement
of the cavities by coalescence. This jelly
is also sometimes found effused under the
periosteum. In the second variety, the bone
is more or less reduced to its cartilaginous
elements, the corpuscles (lacunce) empty, the
rays obliterated, and the lamellar structure
wanting, or fallen asunder/, with corpuscles
interposed between the layers. On the
last condition the softening of the bones de-
pends. The periosteum is more vascular
than normal, tumid, and more closely adhe-
rent, so as to tear off with it a portion of the
softened adjacent bone. It is said to differ
from malacosteon in not being a painful
disease, and in being capable of cure, with a
subsidence of the swelling and reabsorption
of the effused substance. In high degrees of
the disease, however, atrophy and fragility re-
main permanently. The osseous structures
affected by rickets are lighter, less marked,
thinner, and more porous than normal, or than
those affected by mollities ossium, according
to Naegele ; appearing as if they had been
steeped in weak acid.
The analysis of a rickety humerus and
scapula, is given by Rokitansky as follows :
Phosphate of lime and magnesia - 15'60
Carbonate of lime - - 2*66
Soluble salts ... 0'62
Total of inorganic matter - 18 '88
Cartilage, vessels and fat - 8T12
100-00
In the humerus, also, was found 10*54 per
cent, of fat. Specific gravity of the bone,
0-612.
Davy found in 100 parts from the tibia
of a rickety child, 74 parts animal and 26
earthy ; and Bostock, in a vertebra affected
with the same disease, 79'75 animal, and 20*25
earthy, in 100 parts.
W T hen this is contrasted with the norma
proportions of the osseous constituents in the
child, as given by Schreger viz. 47'20 parts
animal, and 48*48 earthy (or about one half
192
even before incineration, left, after exposure
to a red heat for some time, a very porous
and light inorganic structure. The following
results were obtained by thus burning off the
organic components 100 grains of bone,
From the body of an upper lumbar verte-
PELVIS.
work before cited, of a portion of bone af-
fected with this disease we find in 100 parts :
Phosphate of lime and magnesia - 17*48
Carbonate of lime and soluble salts """""
grs.
bra left of earthy matter
the last lumbar vertebra
lower end of the sacrum
ilium (cotylo-sacral rib)
ischium (near tuberosity)
pubes (near acetabulum)
head of the femur
neck of the femur
31
27
40
36
33
22
25
Total of inorganic matter 23*80
Cartilage vessels and fat - 76' 20
Specific gravity of the bone 0'721.
Among the reasons adduced in favour of the
supposition that this disease is sometimes a
malignant one, besides the general and violent
pains that usually precede the deformity, its
incurability and unchecked course towards
a fatal termination, have been given. That
this result is not invariably the case, the fol-
shaft of the femur (below trochant) 58 lowing case quoted from Naegele will show,
When we compare the foregoing proppr- j n tne f act tnat tne p e l v ic bones had regained
tions of the two constituents of bone with tne j r norma i hardness. In the pelvis whence
those given by Schreger, as the normal pro- tne foregoing analysis was taken, the bones
portions of adult bone viz., 20*18 animal, had, m0 st probably, at some former period
and 74*84 earthy matter the diminution of the ^ een mucn softer than they were at the time
inorganic constituents appears very striking, o f death. Such cases also show, that though
and still greater when compared with those of very frequently, the pelvic bones distorted by
aged bone ; although less so than in the re- m oilities are so soft and pliable as to yield,
suits of the analysis of Dr. Leeson, in the sometimes considerably, to the foetal head ;
extreme case recorded by Mr. Solly before vet tnat t his j s Dv no means always the case,
given. nor should it be taken, as it is by some ob-
The femurs were perfectly normal in shape, stetricians, as a characteristic mark of this
as also were the bones of the lower leg, but
the pelvis was a rostrated one, the superior
disease affecting the pelvis.
A very minutely detailed case of pelvic dis-
pubic rami being bent in the middle nearly at tortion, resulting clearly from one or other
|_ A _i .,! ,,,,K s1s\ti*rY-i-fts^ c\r\f\ r*r\r\ t i f jy** ! I XT 1~ dfc
right angles, and much deformed and con- ^ m( j o f mo inties ossium, is given by Naegele.*
tracted in all its diameters. It was remark- j|-, e su bj ec t of the case, after having borne
able, that, at the bend of the superior pubic s * x children (five healthy, full sized, and living,
rami, and at the suture of the ischio-pubic an d the sixth still born), became affected with
rami, there was a complete deficiency of t his disease, which brought about such exten-
osseous matter, so that after maceration, the s i ve p e l v i c distortion and contraction, that,
pubes separated at these points ; showing that at the seventh labour, the Caesarian operation
the connection and continuation of the bone was rendered necessary, from the conse-
in these places was purely ligamentous, or q uence s of which the patient died after the
by organic matter, as if resulting from an un-
united fracture.
fourth day. The shortness of the time m
which the pelvis became so much distorted,
The sudden diminution of the hard con- together with the extent of the deformity,
stituents in the head and neck of the femur, an j t h e f ac t that, at the time of the patient's
as compared with its shaft, is worthy of ob- decease, it had regained its normal hardness,
servation 'in reference to the bending and render the case a very remarkable one.
fracture of the femoral neck in old people. Nae^ele considered it as the most contracted
The smaller proportion of earthy matter in p e i v f s that had ever come under his observa-
the pubes, as compared with the ilium, and
in the sacrum and lumbar vertebrae, as com
tion.
The anterior wall was pushed upwards and
pared with the femoral shaft and pelvis, will t j )e "posterior downwards, the superior plane
account for the greater yielding and deformity being bent at the acetabula, so that the
which are observed in these parts in the U pp er border of the pubic symphysis was
angular pelvic distortion, especially in the j eve | w j tn the upper surface of the 4th lumbar
rostrated variety, and will be referred to pre- ve rtebra ; and a line drawn from one anterior
sently in the consideration of the mechanism Sl ,p e rior iliac spine to the other, cut the
of pelvic deformities. upper surface of the 3rd lumbar vertebra at
In the analysis made by Dr. Bostock of j t8 posterior half. The innominate bones were
the dorsal vertebrae of a woman affected pus h e d together, and presented the acute fur-
by moilities, he found, that the proportion
row?
cracked pasteboard, on their inner
of the earthy constituents amounted to only sur f ace s. The sacrum was bent almost
one-fifth of the whole weight in one part of double. The measurements are given by the
the bone, and to one-eighth only in another ; aut hor, as follow f:
while in a healthy bone from the same part,
they amounted to more than one half the * Erfalmmgen und Abhandlungen ; and Appen-
whole weight.*
In the analysis given, in Rokitan sky's
* Med. Chir. Trans, vol. iv.
dix to Das SchrJig Verengte Becken.
| The measurements used by Naegele, (Rhineland
or Prussian,) are very slightly larger than the
corresponding English ones.
PELVIS.
193
From the anterior inferior iliac spine, to the
opposite point on the iliac crest posteriorly
on the left side, 2 inches 4 lines ; on the
right side, 2 inches 6 lines. From the apex to
the upper surface of the sacrum, 16 lines only ;
to the junction of the 1st and 2nd sacral pieces,
1 Oi lines. From the left superior pubic ramus a
little internal to the pectineal eminence, to the
body of the 4th lumbar vertebra on the same
level, only 2i lines. Between the same points
on the right side, 6 lines. The sides of the
sub -pubic arch were only 3 lines apart, and
more contracted near the sciatic tuberosities
than above, by these processes being pushed
inwards. The pubes in this pelvis, as repre-
sented in the drawings given by the author,
are bent in the middle of their superior rami,
thus producing the rostrated form.
A like case of progressive pelvic deformity
from mollities ossium is described by Dr.
Cooper.* The patient. Elizabeth Foster,
had perfectly easy delivery in her three first
labours ; before the fourth, she had, while
pregnant, rheumatic fever, and afterwards
constantly suffered from universal pains of a
rheumatic character, followed by gradual spinal
distortion. From the fourth to the sixth labours,
they were increasingly difficult, and in the se-
venth and eighth she was obliged to be delivered
by craniotomy, the sacro-pubic diameter being
reduced to 2 inches. Three years after, she
again became pregnant, when the sacro-pubic
diameter was found to be reduced to 1^ inch,
becoming gradually narrower on each side.
Caesarian section was performed, under which
she sank. After death, the sub-pubic arch
was found to be so much contracted, that the
sciatic rami were little more than an inch
apart. The pelvis was so soft and spongy,
that the finger could be easily pressed into its
substance, and at the place of attachment of
some of the muscles, the osseous substance
was found raised into eminences, as if pulled
out.
Eight similar progressive cases were ob-
served by Barlow. One woman, on whom
he performed hysterotomy unsuccessfully, had
given birth to two children, and afterwards
had become lame and bed-ridden for four
years. In another case of Caesarian section,
also resulting from malacosteon, the woman
had previously borne children, and been deli-
vered by the crotchet. In this instance, the
conjugate diameter was reduced to ]i inch ;
the right sacro-cotyloid, to 2 ; the left, to
] inch. The last lumbar vertebra and sa-
cral promontory formed a great tumour-like
curve in the pelvic cavity, which he was able
to distinguish from an exostosis only by its
yielding easily to the pressure of the fingers,
which a tumour of that nature would not do.f
Other cases of this progressive kind have been
before alluded to.
The question as to whether the rickety
pelvis ever assumes the angular or cordifonn
shape, is one which has occupied consider-
ably the attention of many obstetricians.
* Med. Observations and Inquiries, vol. v.
t Essays, p. 355.
Supp.
It was very ingeniously advocated by Dr.
Hull in his Letters to Symmonds, and laid
down by the younger Stein and others on the
Continent, that the ovate form of pelvic dis-
tortion with contraction of the diameters of
the inlet and enlargement of those of the
outlet of the pelvis, was the characteristic
and invariable form of rickety disease; as
that of the angular cordiform shape, with
contraction of both outlets, was of malacosteon;
and the opinion seems to be still frequently
held by obstetricians both abroad and in this
country.
Dr. Murphy considers that, though the oval
pelvis is not the necessary consequence of
rickets, nor the cordiform of mollities ossium,
yet that " of necessity, the softened adult pel-
vis would take the shape called cordiform,
while the infant pelvis would be transversely
lengthened;" unless in the infant, "the
spine be softened and bent as well as the
pelvis," so as to throw the weight of the body
more upon the pelvic cavity, as by a " backward
curvature " such as he has figured, in which
cases he supposes that angular deformity takes
place in the child.* This conclusion he draws
from the hypothesis that in the child, because
of the straightness of the spine, a line passing
through the centre of gravity, and conse-
quently the weight of the spine, would fall
altogether I'M advance of the pelvic cavity, and