Copyright
Henry J. (Henry Jacques) Garrigues.

A text-book of the science and art of obstetrics online

. (page 44 of 80)
Online LibraryHenry J. (Henry Jacques) GarriguesA text-book of the science and art of obstetrics → online text (page 44 of 80)
Font size
QR-code for this ebook


of the true pelvis narrow from side to side. The brim of the pelvis
is large, especially the true conjugate. The shape of the outlet varies
according to the seat of the kyphosis. In lumbodorsal kyphosis the
conjugate may be normal, or even elongated, but in lumbosacral it is
always shortened. The side wall of the pelvis is high. The pubic
arch is narrow, the symphysis pubis is situated high and pushed
forward. In the neighborhood of the iliopectineal eminence the bone
is much thickened. The ihopectineal line is less curved than normal.
The spine of the ischium is turned sharply inward. The posterior

Fig. 366.




Kyphotic pelvis seen from behind and below. (Author's case.)

superior spines of the ossa ilium are nearer to each other than normal
and project less.

The mechanism by which these abnormalities in the shape of the
kyphotic pelvis are produced is pretty well understood. The primary
cause is a caries of one or more vertebrae. When the corpus of the
vertebra is consumed, the weight of the superincumbent portion of
the whole body causes the column to bend forward, forming an angle
at the diseased part. The stooping produced in this way would be
highly inconvenient and fatiguing, and instinctively the patient obviates
the evil by carrying the head and the upper part of the trunk back-
ward, whereby a lordosis is formed compensating the kyphosis sit-



DEFORMITIES OF THE PELVIS. 479

uated lower down. Through the changed pressure the base of the
sacrum is tipped back and its apex forward, whereby the conjugate of
the brim of the pelvis is elongated and that of the outlet would be
shortened if there were not other factors that counterbalance this
effect. At the same time a compression from side to side takes place
in the bone, the broadest part of the base, which is situated in front,
being squeezed in between the posterior ends of the iliac bones, which
are nearer together than the width of the sacrum, the result of which
is the strong transverse curvature and the narrowness of this bone.
The stretching in the longitudinal direction of the sacrum is doubtless
due to the fact that pressure from above strikes its upper end under
a more favorable angle, and, therefore, works with more power on
that than on the part situated nearer the transverse axis around
which the bone is being tilted, the strong ligaments between the
sacrum and the ilium opposing a powerful resistance to the simple
pushing back of the sacrum in toto.

We have seen that the stooping of the body was obviated by a
corresponding lordosis formed above the seat of the kyphosis, but
still another means is brought into action in order to bring the body
into a more favorable relation to the ground when the individual is
in the upright position. The whole pelvis is tilted backward, turning
on an axis which goes through both hip-joints. This movement can
only be executed by the contraction of the glutei-maximi muscles.
But this backward tilting finds a check in the strong iliofemoral liga-
ment. This ligament being constantly put on the stretch explains the
development of the iliopectineal eminence and the adjacent mass of
bone on which that ligament is inserted. The frecfuent abnormal con-
traction of the gluteus-maximus muscle draws down the posterior part
of the ilium and makes it protrude as a convexity on the upper sur-
face. When the base of the sacrum is tilted back, the strong sacro-
iliac ligaments are stretched and pull the posterior part of the ilium
backward. The combined effect of the contracted glutei maximi
muscles behind and the strained iliofemoral ligament in front is to
push the head of the femur inward and upward. Hereby the os in-
nominatum is stretched and its component parts are brought nearer
to the corresponding points on the other side. Thus the conjugate
diameters become lengthened and the transverse shortened in the
middle and at the outlet of the pelvis. The posterior part of the
acetabulum is pushed more backward, and thereby the spine of the
ischium is turned more inward than would be the result of mere
inward pressure towards the median line.

The tuberosities once brought nearer to each other by the tilting
of the innominate bones will be still more approximated by the press-
ure exercised against them in the sitting posture.



480 ABNORMAL LABOR.

In lumbosacral kyphosis the sacrum is short and narrow, and there
is no real promontory.

Diagnosis. — The diagnosis is based on the presence of the kyphosis
and on pelvimetry. The conjugate of the outlet is found by measuring
the distance from the upper end of the pubic arch to the outer sur-
face of the end of the sacrum, which normally is about 5 inches (12.3
centimetres), and subtracting | inch (1.5 centimetres). If there is an
ankylosis between the sacrum and the coccyx, it is the distance from
the apex of this latter bone which is to be taken. The distance from one
tuberosity of the ischium to the other can also be measured directly.

Prognosis. — The prognosis is bad. It depends chiefly on the size
of the outlet. The kyphotic pelvis is often combined with pendulous
abdomen. Frequently the abdominal surface of the foetus is turned
forward, which probably is due to the retort shape of the uterus in
the pendulous abdomen. The anterior part of the vertex with the
large fontanelle is apt to descend. Even face presentations are com-
paratively frequent in this form of pelvis. A favorable circumstance
is that the transverse diameter of the outlet is apt to become a little
elongated during the passage of the child, which is due to mobility in
the sacro-iliac articulation.

Treatment. — If the patient is seen during pregnancy, the induction
of premature labor may be indicated. Since the contraction increases
downward, the head will descend some and then stick. If the trans-
verse diameter is not too short, the accoucheur may be able to pull
the head through with the forceps. But if the transverse diameter is
less than 3J inches (8 centimetres), the forceps becomes a dangerous
instrument. The vagina may be torn, articulations ruptured, or the
pelvic bones fractured. Under such circumstances it is better to per-
forate or to resort to Caesarean section before any other attempt is
made. Symphyseotomy has also been tried, but is less reliable,
since it is hardly possible to calculate how much space will be gained
at the outlet.

Rhachitic Kyphotic Pelvis. — As we have seen, the common cause
of a kyphotic pelvis is Pott's disease, tuberculosis of the vertebrse.
Much more rarely the kyphosis is due to rhachitis. Since the rha-
chitic pelvis usually has a form that is almost the opposite of that of
the kyphotic, a curious mixture results when the two are combined.
Nearly all the characteristics of a rhachitic pelvis are lost, except that
the ilia are small and wide open in front, leaving a long distance be-
tween their anterior superior spines, and that the sacrum is flat from
side to side instead of being strongly curved.

If the kyphosis is situated in the dorsal region, there is a com-
pensating lordosis in the lumbar region, and the pelvis becomes a
common rhachitic pelvis.



DEFORMITIES OF THE PELVIS.



481



Kyphoscoliotic Rhachitic Pelvis. — The pelvis becomes still more
peculiar if to the kyphosis is added scoliosis in a rhachitic person.
This combination produces a more or less pronounced asymmetric
pelvis. On the side of the scoliosis the inclination of the pelvis is
small, while the opposite side is much inclined. At the outlet the
obliquity is generally just the opposite of what it is at the brim.

Pelvis Obtecta (Fehling), or Spondylizema (Herrgott). — When
the kyphosis is situated between the sacrum and the lumbar vertebrae
or exclusively in the sacrum, the

vertebral column may be so much ^^ ''

bent forward as to cover the en-
trance of the pelvis (Fig. 367).

In consequence of osteitis, gen-
erally of tuberculous nature, the
bodies of the vertebrae affected
become rarefied and are crushed
together by the weight of the upper
portion of the body. The rem-
nants of the vertebral bodies and
the arches form a wedge which
enters the column from behind
and drives it forward. From an
obstetric stand-point the true con-
jugate becomes then the shortest
distance from the symphysis to the vertebral column,
has been found reduced to 1^ inches (4 centimetres).

The women who have such a pelvis are unable to stand upright.
Sometimes they may obtain their equilibrium by bending the knees.
If they stretch the lower extremities, they are obliged to seek support
for their bodies on canes, which they carry in their hands, so that
they virtually are reduced to quadrupeds.

3. Funnel-Shaped Pelvis. — A funnel-shaped pelvis (Fig. 368) is one
that is comparatively large at the brim and narrow at the outlet. Most
funnel-shaped pelves are the result of lumbosacral kyphosis and have
been considered above. But in some cases a similar shape is found
in women who have a normal spine. The contraction is generally
moderate in degree and found only in the transverse direction, but
it may extend over a large portion of the pelvis, and if there is an
ankylosis between the sacrum and the coccyx the space is consid-
erably diminished.

Etiology. — In England this form of pelvis has particularly been
met with among society ladies, and is attributed to frequent horseback
riding indulged in at a tender age, when the pelvis is still pliable. At
all events it is probably a modification of an infantile pelvis.

31




Pelvis obtecta (Tarmer and Budm, 1 e )



This distance



482 ABNORMAL LABOR.

Diagnosis. — The funnel-shaped pelvis is hardly known to exist
before delivery. Then attention is called to it by the head sticking
in the cavity of the pelvis. Exact measurements as described under
kyphotic pelvis clear up the diagnosis.

Prognosis. — As the contraction in most cases is of moderate degree,
the prognosis in general is not bad. Still, infantile mortality is much
increased, and even the mother is exposed to considerable danger.
If the head is not helped out in time the soft tissues become inflamed
and gangrenous, and the result may be a vesicovaginal fistula or a
stricture of the vagina, or even the bones forming the pubic arch fall
a prey to caries. If the distance between the tuberosities of the ischia
is less than 3| inches (9 centimetres), the situation is grave.

Treatment. — If the existence of a funnel-shaped pelvis is known
or recognized during pregnancy, it may be proper to avoid trouble by

Fig. 368.




Funnel-shaped pelvis. (Ahlfeld.)

the induction of premature labor. During labor a prompt recourse
to the forceps is indicated, but if the impacted head does not soon
yield to a reasonable amount of traction, and the foetus is alive,
symphyseotomy is likely to give all the enlargement needed in the
transverse direction. Too protracted traction may lead to fracture of
the pelvis, rupture of its articulations, or serious tears of the soft
parts. Caesarean section will hardly ever deserve consideration. If
the foetus is dead, craniotomy or cephalotripsy ' should at once be
performed in the interest of the mother.

§ 3. Incurved Pelvis. — In the incurved pelvis the walls, instead
of being bent outward, are curved inward.

To this class belong, 1, the osteomalacic pelvis and, 2, the pseudo-
osteomalacic rhachitic pelvis.



DEFORMITIES OF THE PELVIS. 483

1. The Osteomalacic Pelvis. — The osteomalacic pelvis is the result
of a disease called osteomalacia, v^^hich is characterized by a softening
of the bones. Unlike rhachitis, with which it formerly was con-
founded, it is a disease of the adult. It generally makes its appear-
ance when the patient is between twenty-five and thirty-five years of
age. It is by far more common in women, but is also found in men,
and is most frequently connected with pregnancy, the puerperal state,
and lactation. It is, however, found also in nulliparous women. Some-
times there are exacerbations at the menstrual periods, but the disease
may make its first appearance after the menopause.

The calcareous matter in the bones is absorbed, and the medullary
substance is encroaching upon the bone. Two forms of the disease

Fl-,. 369.




Sagittal section of an osteomalacic pelvis, showing disappearance of bony tissue. (Ahlfeld



have been distinguished, — viz., osteomalacia cerea, or waxy osteomala-
cia, and osteomalacia fragilis, or brittle osteomalacia ; and the distinc-
tion is, as we shall see, of importance for the practical obstetrician ;
but in reality it is only a question of degree of the same destruction.
If the inner portion of a bone is affected and there remains a thin
bony shell, this is very liable to break, while if the bone is softened in
its whole mass, it will bend and be flexible as wax.

The disease usually begins in the pelvis or the spine (Fig. 369), but
it may gradually implicate most of the skeleton (Fig. 370).

The osteomalacic pelvis is very characteristic. On account of the
disappearance of the lime salts from the composition of the bone, it is
of very light weight, incurved, and often fractured. The same factors
that go to give a normal pelvis its shape— the superimposed weight,
the pressure of the femora against the acetabula, the resistance of liga-



484



ABNORMAL LABOR.



merits, and the traction of muscles — are at work here, but, being ex-
ercised on flexible or brittle bones, they find no resistance, and the
result is that the walls of the pelvis are bent or crushed inside into
the cavity (Figs. 371,372).

The promontory is pressed forward and downward. The sacrum
is strongly curved longitudinally, the apex being turned forward. The
acetabula are approximated, the ascending branch of the pubis bent
inward, likewise the pillars forming the pubic arch, so that the sym-
physis pubis protrudes forward like a trunk. The tuberosities of the
ilia are brought nearer to each other, and may even come in contact

Fig. 370.




Woman affected with osteomalacia. (From an engraving in the MusiJe Dupuytren in Paris.)

with each other. The anterior portion of the ilium is turned inward
and downward. The brim of the pelvis has the shape of the letter Y,
the sacrocotyloid distance and the transverse diameter being much
diminished. There is also some asymmetry in the pelvis. The
deformity increases in the course of time, especially in consequence of
repeated pregnancies. It may become so great that a marble one inch
in diameter cannot pass through the pelvis. Coition may become
impossible and defecation difficult.

Osteomalacia being exceedingly rare in this country, I add an illus-
tration of a specimen in Wood's museum (Fig. 373), although the
deformity is less pronounced.

Symptoins. — In the begmning the disease is obscure. The first



DEFORMITIES OF THE PELVIS.



485



symptom complained of is pain in the bones of the pelvis or spine,
which pain is increased by pressure. There soon appears a difficulty
in lifting the leg or abducting it, which causes a stumbling and wad-



FiG. 371.




Osteomalacic pelvis, front view. (AhlfeM.



dling gait. The knee-jerk is increased. There is tremor of the
muscles. Next the stature is shortened and bones become soft and
flexible or brittle. Even the soft tissues may become friable, several
operators having reported that the ligatures cut through when applied.

Fig. 372.




The same from below.



Etiology. — The cause of the disease is unknown, and there is great
diversity of opinion as to its true starting-point. Some look upon it
as an osteomyelitis. Others go still further back and suppose that



486



ABNORMAL LABOR.



the cells of the spinal marrow are first affected. Others, again, see
the cause in a pathologic metabolism.

Osteomalacia is endemic in some rather limited localities in
Europe. — the borders of the Rhine near Cologne, and again near its
outlet in Flanders, Schiitt Island in the Danube, and the valley of
the Po in northern Italy. In America it is exceedingly rare. A low,
damp residence seems to be a feature of importance in its causa-
tion. The bones have been searched in vain with the modern tests
for bacteria. The ovaries seem to have a decided influence on the
production of the disease. Sometimes they were found in a hyaline

Fig. 373.




Osteomalacie pelvis. (Wood's Museum, Bellevue Hospital, No. 154.) One-third actual size.



condition, but in other cases they were perfectly normal. Perhaps
they, like other glands, have an internal secretion which is an
important link in the chemistry of the organism.

It has been found experimentally that Avhen the ovaries are
removed from a healthy animal, the excretion of phosphates in the
urine is much diminished. It is also clinically proved that oopho-
rectomy and the administration of phosphorus are most effective in
arresting the disease. The removal of the ovaries therefore saves
phosphorus, and they are suspected, when present, of causing osteo-
malacia by too great oxidation and elimination of phosphorus. It



- DEFORMITIES OF THE PELVIS. 487

must, however, be remembered that the disease may be found in men.
What is sure is that pregnancy, the puerperal state, and lactation
have a decidedly bad influence on the progress of the disease, but it
may be found in women who have never borne a child, and it may
begin after the menopause.

Poor food may contribute to the production of the disease by
lowering the tone of the whole constitution, but does not in itself
cause osteomalacia, which, on one hand, may attack well-fed persons,
and, on the other hand, is nearly unknown in Ireland and parts of
Russia among a large population living in abject poverty.

Diagnosis. — In the beginning osteomalacia is not easily recognized
and is often taken for rheumatism or spinal disease. A point of diag-
nostic importance is that the pain is seated in the bones, especially
the sacrum, the hip-bones, the vertebrae, and the ribs, and is increased
by pressure.

Rickets is a disease of early childhood, osteomalacia appears after
the skeleton is perfectly ossified. In rickets the epiphyses of the
bones are thickened, while in osteomalacia they are of normal dimen-
sions. In rickets there is not much pain, whereas pain is a chief
symptom in osteomalacia. In rickets the lower extremities are more
distorted than any other part of the body, while in osteomalacia they
often escape.

The increased knee-jerk and the impaired power of bending the
legs on the abdomen and of abducting them help to diagnosticate osteo-
malacia at an early date. When the stature diminishes and deformity
sets in, the diagnosis is easy. As to the pelvis, it is a point of great
diagnostic importance that the woman may have given birth to chil-
dren without difficulty before the beginning of the disease which may
distort her pelvis to such an extent that she can be delivered only by
Csesarean section. It is true, carcinoma of the bones of the pelvis
may produce a similar condition, but then there is a history of pre-
vious carcinoma in some other portion of the body.

The diagnosis of the osteomalacic pelvis is in the beginning not
always easy, and can only be made with the half or whole hand, but
later the type is easily recognized. From the lumbosacral kyphotic
pelvis it is distinguished by the well-defined protruding promontory,
the strong curvature of the sacrum, the inward curvature of the
ilium, the Y-shape of the brim, and the trunk-like symphysis. The
promontory may be so low that the common iliac arteries are felt
pulsating, which has been given as a sign of spondylolisthesis ; but
then the whole shape of the pelvis is entirely different from that of the
spondylolisthetic pelvis, as we presently shall see.

The diagnosis between the two varieties, osteomalacia cerea and
osteomalacia fragilis, is of importance in regard to prognosis and



488 ABNORMAL LABOR.

treatment. In the flexible variety it is often possible, without causing
much pain, to separate the tuberosities of the ischia or to bend the
crest of the ilium back towards the spine.

Prognosis. — The prognosis is much better now than it was twenty-
five years ago. We know that the disease is curable, and we have
gained considerable control over it by medical and surgical means.

In regard to labor, not a few cases .end favorably by nature's sole
efforts. Others demand more or less dangerous operations or may
lead to death by rupture of the uterus. In half of the reported cases
the patient succumbed.

Treatment. — Taking into consideration the gravity of labor and the
unquestionably bad influence of pregnancy and the puerperal state,
the writer takes it to be justifiable to provoke abortion if the case is
seen so early that the foetus can be easily removed by the natural
way. After that the patient should occupy a dry, sunny house and
have as substantial food as possible, of which milk should form a
large ingredient. The chief remedial- agent is phosphorus, of which
gY, ^L to yV (3-4 milligrammes) should be taken three times a day.
Another important remedy is the extract of red bone marrow, a table-
spoonful three times a day. Cod-liver oil is also said to have effected
a cure. Protracted and repeated inhalation of chloroform has in
some cases proved very effective, while in others it has been useless.
Frequent tepid baths with chloride of sodium or sulphur may be used
as adjuvants. They relieve pain and keep the skin in good condition.
It need hardly be added that pregnancy should be avoided, in which
respect the only reliable methods are abstinence from sexual inter-
course or the use on the male organ of a rubber protector.

If, in spite of prophylaxis, diet, regimen, and drugs, the disease
is not cured, recourse should be had to surgical means. The ovaries
should be removed, and perhaps it is still better to amputate the
uterus at the same time.

If the patient is seen late in pregnancy, our conduct must depend
on the degree of deformity present and the variety of the disease.
If there is only slight deformity, and if the disease is of the flexible
variety, perhaps the induction of premature labor may be indicated.
In the higher degrees of deformity Csesarean section should be per-
formed a couple of weeks before the normal end of pregnancy.

Finally, if the case comes under observation after labor has begun
and the deformity is great, Ctesarean section should be performed at
once. If, on the other hand, there seems to be room for the child to
pass, we may hope that the bones may yield some, and see what
nature can do. If necessary, we help with the forceps or perforate
and extract with forceps or cranioclast.

When Csesarean section is performed the ovaries should be re-



DEFORMITIES OF THE PELVIS.



489



moved so as to prevent future impregnation and eliminate the delete-
rious influence of these glands on the metabolism ; or the uterus may
be amputated at the internal os or totally extirpated.^

2. PsEUDo-OsTEOMALAcic Rhachitic Pelvis. — A fomi of pelvis
much like the osteomalacic may be produced by rhachitis, and is then

Fig. 374.




Pseudo-osteomalacic pelvis, front view. (Clausius.)

called the pseudo-osteomalacic pelvis (Figs. 374, 375). The brim is
triangular, the acetabula are pressed inward, the symphysis protrudes
forward, the ascending branch of the pubis is bent inward, the tuber-
osities of the ischia are approximated to each other, and the pubic
arch is narrow. The rhachitic origin is shown by the smallness of

Fig. 375




Pseudo-osteomalacic pelvis seen from above. (Clafisius.)



the bones, especially the ilium, their flat position, and, as a rule,
their anterior gaping ; but sometimes even that may be absent, and the
anterior part of the ilium may be turned inward as in osteomalacia.
The bones of the pelvis are more compact, solid, and heavy. The
most distinctive point is, however, to be found in Ihe liistory, rhachitis

* Garrigues, Diseases ofWomen, third cil., ji. 517.



490



ABNORMAL LABOR.



being a disease of childhood, appearing before ossification is finished,
and osteomalacia occurring in the adult and consisting in the emolli-
tion of the already hardened bone. Exceptionally, there may, how-
ever, with the rhachitis, be an osteoporosis, a reabsorption of already
formed bony tissue ; but that is then really a combination of osteo-
malacia and rhachitis.

The pseudo-osteomalacic pelvis is produced if the lower extremi-
ties are much used at a time when the pelvic bones are very soft in
consequence of rhachitis.

It is a very rare form of pelvis. The coarctation may be quite



Online LibraryHenry J. (Henry Jacques) GarriguesA text-book of the science and art of obstetrics → online text (page 44 of 80)