Pagenstecher affirms that the disease is ushered in with pains in the affected bones, localized in one or both of the tuberosities of the femur. The pain extends successively to the symphysis and ischial spine, then to the sacrum and lumbar region; the hips, shoulders are next affected, and, in order to avoid the pain caused by movements of the joints, the women remain as nearly immovable as possible. As sitting is very painful, the patients lie on one side. Remissions and exacerbations may continue for months and years, when bronchial and gastric catarrh supervene, and be come chronic. The patients become feeble and emaciated, and in some instances, the stature is appreciably diminished. The specific gravity of the urine is below the normal, but there is no increase in the amount of salts. According to Gusserow, women suffering from osteomalacia have a sullen, morose physiognomy, caused by their sufferings, and character istic of the disease.
The osseous deformities, and especially those of the pelvis, concern us most. Tho softened bones of the pelvis, being subjected to pressure from the weight of the body, and to the counter-pressure of the femora, as well as to pressure from external causes, become malformed, bend inwards, fold upon themselves, and give to the pelvis a characteristic form. The deformity is as follows: The ilia become curved upon themselves and present a groove (sometimes bifurcated), directed from above forwards and inwards. Driven inwards by the pressure of the thigh bones, the cotyloid cavities are carried upwards, forwards, and inwards, approach ing at the same time each other, and the promontory. The horizontal rami of the pubes become nearly parallel, leaving between them a mere cleft, narrow above, a little larger below, the symphysis having the shape of a duck's bill. The pubic arch disappears, and is replaced by a sort of deep, narrow fissure, through which the index finger can barely pass.
The ischial tuberosities are driven inwards to an extreme degree, and thus narrow the inferior strait and cavity, while the posterior superior iliac spines are bent inwards, and are so small that they project but slightly behind the sacrum, and lie in the same plane as the spine of the last lumbar vertebra. The sacrum describes an excessive curve in such a way that its middle portion projects posteriorly, wthie its upper end sinks deeply into the pelvis, and the lower end shows a marked tendency to ap proach the upper. In place of the regular concavity, there is a sort of angular groove, surmounted at its upper extremity by the projecting promontory. By reason of the lowering of the latter, the lumbar ver tebrae form at the upper part of the pelvis a projection above the superior strait, that also serves to narrow it. The pelvis assumes a peculiar ap pearance that has caused it to be compared to a trefoil. All the angles are well-marked, and it is deformed and altered in all its parts. The superior and inferior straits and cavity are all affected by the deformity, and often to such an extent that the diameters are reduced to a surprising degree. The conjugate at the brim may preserve entirely its normal
length, while the transverse is so much shortened that there really re mains no opening to be utilized for delivery. The distance between the anterior superior iliac spines is diminished, the breadth of the symphysis is increased, and the concavity of the sacrum is represented by a trans verse groove. The pubic rami are nearly in contact, so that the arch be comes merely a deep fissure.
Osteomalacia is a protracted disease, and at the time of labor the pel vic bones may be so soft as to yield to the pressure of the foetal head, and thus to allow of normal delivery, but these cases are extremely rare.
Obliquely-oval Pelvis.
Naegele (1829) was the first to call attention to the obstetrical impor tance of this deformity, which he described as a shortening of one oblique diameter, with complete anchylosis of one of the sacroiliac synchondroses, and imperfect development of the corresponding half of the sacrum and ilium. The characteristics of such a pelvis are, therefore: 1. Complete anchylosis of one of the sacroiliac joints.
2. Arrest of development of the corresponding half of the sacrum.
3. Diminished size of the femur on the same side.
4. The sacrum is pushed over towards the gncliylosed side, while, at the same time, the symphysis pubis is drawn towards the opposite side in such a way that it is no longer directly opposite to the sacro-vertebral angle.
5. The lateral wall and corresponding half of the anterior wall of the pelvic cavity, on the anchylosed side, are smoother than normal.
The other half of the pelvis is, of course, greatly deformed. The pelvis is obliquely contracted in the direction of the diameter that crosses the one extending from the point of anchylosis to the opposite cotyloid cavity. The distance between the promontory of the sacrum and the upper edge of either cotyloid cavity, as well as that between the top of the sacrum and either ischial spine, is less on the anchylosed side. The distance between the tuberosity of the ischium and the posterior superior iliac spine, on the anchylosed side, and that between the spine of the last lumbar vertebra and the anterior superior iliac spine, are less than those on the opposite side. The walls of the cavity converge in an oblique manner below, and the pubic arch is more or less contracted, while its shape approaches that of the male pelvis. The cotyloid cavity on the flattened side is directed more anteriorly than in a well-jormed pelvis, while the opposite one looks almost directly outward. • Frequency.—This deformity is not so very rare, and it often is unsus pected, especially when the patient recovers. Women with such pelves are young, healthy, and otherwise well-formed, so that they present no appearance that would lead us to suspect the presence of the malforma tion.