Another remarkable case is recorded in the Edin. Med. and Surg. Journal (April, 1831), for which hysterotomy was performed by Dr. M`Kibbin, Surgeon to the Lying-in Hosp;tal, Belfast. The patient had suffered a on the back when about six or eight years of age, which was followed by pains in the sacral region for a short time afterwards. The ex ostosis was of a conical form, with the base at the sacrum (seefig. 125.), and occupying its whole breadth at about the four lower sacral pieces, its apex projecting towards the pubis, and leaving a space of only inch between it and the lower part of the pubic symphysis. The greatest space was left op posite the superior ramus of the right pubis, where the distance of the tumour from the pubic wall was from to inches, but di minished posteriorly. The patient died soon after the operation ; nor was the child saved.
A less formidable case came under Dr. Murphy's observation. Tire tumour was about the size of an orange, and was connected to the sacrum about its tniddle. It was quite immoveable, and of bony hardness. The pa tient being in labour, craniotomy was per formed ; and the case did well. Another case is recorded by Van Doevern, of an osseous tumour, of the size of haIf a hen's egg, grow ing from the upper piece of the sacrum, and causing the death of both mother and child.
Dr. Kyle, of Cologne, met with a case of a woman who had borne seven children with great ease ; but at the eighth labour the fcetal head became impacted by a hard immoveable tumour, as big as a hen's egg, springing from the upper part of the right sacro-iliac joint, being apparently the result of a pelvic abscess after the last delivery, which had, thrce years before, opened in the groin.
Dr. Lever has seen but one case of pelvic exostosis. It occurred inIn unmarried female lunatic, and grew from the posterior surface of the pubis, producing retention of urine.* Las sus describes processes of bone, of a styloid shape, projecting from the posterior surface of the pubis towards the bladder.-f- These resulted, apparently, from ossification of the anterior ligaments of that viscus. Besides these, an exostosis is mentioned by Velpeau (Tocologie), protruding from the posterior surface of the right pubis, and of the size of a hen's egg a little flattened ; and others by Pimeus, Ruleau, and Portal, from an anky losed symphysis pubis.
One is alluded to by Naegele, which was as large as a filbert, projecting from the ischinin into the pelvic cavity; and others in the same situation by Dr. Campbell and Otto of Breslau, in which indentation of the fcetal 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 Rokitansky, and are to be met with in most musemns 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' rnet 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 defortned 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-sarcontatow tumours sometimes pro duce pelvic obstruction, and generally grow from the joints or ligaments. One case oc curred to Grimmell Kisbaden, and is re corded in a letter to Naegele (Dec. 1835). Cmsarian section was performed in conse quence of a tumour of this kind, weighing It 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 vertebrm 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 diagnusis, 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 fcetal head.