206 



PELVIS. 



large as a filbert, projecting from the isckium 

 into the pelvic cavity; and others in the same 

 situation by Dr. Campbell and Otto of Breslau, 

 in which indentation of the foetal head was 

 produced. Other cases are found in Siebold's 

 Journal and Gardien's Traite. 



Dr. A. Farre informs me that an osseous 

 exudation from the anterior surface of the 

 sacrum, consequent upon disease of that bone, 

 had recently occurred in his practice, and 

 compelled him to have recourse to craniotomy 

 to accomplish delivery. Osseous projections 

 at or near the sacro-iliac joints are also men- 

 tioned by Kokitansky, and are to be met with 

 in most museums of pathology. In a large 

 female pelvis, in the King's College museum, 

 is a small exostosis or spinous projection at 

 the angle of the left sacro-iliac joint, in such 

 a position as would produce an impediment to 

 labour in a smaller pelvis. In the Hunterian 

 Museum are two more specimens of this 

 kind, both on the sacro-iliac joint, one in a 

 male, and the other in a female pelvis. Many 

 such exostoses are seen in the subjects 

 brought to the anatomical rooms. They seem 

 to have the same origin as the rheumatic 

 bony projections which are so frequently met 

 with, in old people, in the neighbourhood of 

 the joints, but especially in those of the spine, 

 hip, and shoulder. Rheumatic and gouty 

 patients seem to be predisposed to exostosis. 



The influence of such exostoses upon par- 

 turition approaches closely to that of deformed 

 pelvis, in the contraction of the diameters and 

 the danger or impossibility of their removal. 



The difficulty of distinguishing them, when 

 of considerable size, from pelvic deformities, is 

 sometimes very great. Their hardness is not 

 so characteristic as to mark them from the pro- 

 jections of the sacral promontory; their shape, 

 compared with external measurements and the 

 history and appearance of the patient are the 

 chief means of diagnosis. 



Osteo-sarcomatous tumours sometimes pro- 

 duce pelvic obstruction, and generally grow 

 from the joints or ligaments. One case oc- 

 curred to Grimmell o^ Kisbaden. and is re- 

 corded in a letter to Naegele (Dec. 1835). 

 Caesarian section was performed in conse- 

 quence of a tumour of this kind, weighing 

 li lb., attached to the periosteum only of the 

 right sciatic spinous process and wall of the 

 corresponding acetabulum. It had followed 

 a fall, which had been succeeded by pains in 

 the sacrum, a sense of weight in the right 

 thigh, and ischuria. Stark performed hys- 

 terotomy successfully for a tumour attached 

 to the lower sacral vertebrae and innominate 

 bone. It was immoveable, but soft in various 

 parts, as well as could be detected "per va- 

 ginam" 



This characteristic will distinguish these 

 tumours, in diagnosis, from exostosis ; their 

 partial hardness, from fibrous tumours ; their 

 immobility, from tumours of the soft parts ; 

 and their attachments to the side of the pelvis, 

 from the foetal head. 



Obstructions from fibrous tumours attached 

 to the pelvic ligaments. These are of rare 



occurrence, and have been found chiefly con- 

 nected with the sacro-sciatic ligaments. 



The most remarkable examples are those re- 

 lated by Dr. Drew in the Edin. Med. and Surg. 

 Journal for 1805 (vol. i. p. 20 ). The first of 

 these tumours was taken from the body of a 

 woman, who had died in consequence of its 

 pressure upon the pelvic viscera. It was 16 

 inches in circumference, of a hard, gristly tex- 

 ture, with no appearance of vascularity, and 

 was attached by a strong root, of the same 

 texture, to the left sacro-sciatic ligaments, 

 and interposed between the bones and viscera, 

 but with no other attachment to the sur- 

 rounding parts. The second tumour was ex- 

 cised by Dr. Drew, by a formidable operation, 

 from the pelvis of a woman in labour, who 

 was afterwards safely delivered and recovered 

 perfectly well and very speedily. The tumour 

 was 14 inches in circumference, and weighed 

 2 Ibs. 8 ounces. It grew from the right side, 

 and filled the whole cavity of the pelvis so com- 

 pletely as to admit of one finger only being 

 passed between it and the pubis, considerably 

 interfering with the neck of the bladder and 

 urethra. It was separated easily from the 

 circumjacent tissues. 



A somewhat similar case is related by Dr. 

 Burns ; but, in this instance, the attachments 

 of the tumour were much more extensive ; 

 reaching from the pubic symphysis to the 

 sacrum, and adhering intimately to the pelvic 

 brim, being attached also to the obturator 

 internus muscle, urethra, vagina and rectum, 

 and apparently developed in the recto-vesical 

 fascia. It was hard, somewhat irregular, and 

 scarcely moveable. The patient being in 

 labour, Dr. Burns, by a bold operation, in 

 which but little blood was lost, removed the 

 tumour, which required to be almost dis- 

 sected out. The woman was soon after safely 

 delivered of a still-born child, and, after some 

 peritoneal inflammation, recovered. 



Fibrous tumours attached to the pelvic pa- 

 rietes are distinguished from the foetal head 

 and tumours of the soft parts, by the immo- 

 bility of their attachments ; from exostoses, 

 by their want of bony hardness ; and from os- 

 teo-sarcomatous tumours, by their uniformity 

 of structure to the sense of touch. 



Carcinomatous growths commonly affect the 

 bones of the pelvis, by advancing from the 

 contained viscera, the uterus, rectum or ova- 

 ries. Dr. A. Farre mentioned to me a case 

 in which the innominate bones were so much 

 infiltrated by cancerous matter, from a tumour 

 commencing in the uterus, that they could, 

 with great ease, be cut with the knife, pre- 

 senting a condition very similar to the bones 

 affected with mollities ossium. 



PATHOLOGY OF THE PELVIC JOINTS. 

 The pelvic joints, like all other joints in the 

 body, but much less frequently than many, 

 are subject to inflammation and its conse- 

 quences in such structures viz., ulceration, 

 suppuration, and ankylosis. They are also, 

 probably more frequently, subject to original 

 malformation, coalescence, and anomalous 

 constructions of a congenital origin. 



