A comparative study of male and female pelves

56

AMERICAN

JOURNAL

OF

OBSTETRICS

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GTNECOLQQY

Complicating respiratory tlifficultp was mentioned in three cases, though this was serious (not fatal) in but one. Two patients went through 2 full-term pregnancies safely, though a third woman had exacerbations in both. It is noteworthy that thoracoplasty has been done successfully during pregnancy in at least, four instances. We found no definite evidence that thoracoplasty had deleterious efYects on pregnancy. There was a rather high incidence of premature labors, but this was in accord with our previous findings in tuberculous The 3 fetal deaths in women regardless of the type of treatment. this group occurred among premature babies. We Surgery

are indebted to the members for many helpful suggestions

of the Departments in the preparation

of Tuberculosis of this paper.

and

Thoracic

R,EF’ERENCES F., Siddall, R. S., and Baker, W. J.: Baa. J. OBST. & GYNEC. (2) 0 ‘B&n, E. J. : J. Thoracie Surg. 3: 159, 1933. O’Brien, E. J., Tuttle, W. M., Day, J. C., and O’Connor, J. P.: Ibid. 8: 1, 1938. (3) Jameson, E. H.: Gynecological and Obstetrical Tuberculosis, Philadelphia, 1935, Lea & Febiger. (4) Alberts, L.: Med. Welt 62: 1137, 1932. (5) Panwcci, G. C.: Gazz. internaz. med.-chir. 44: 15, 1934. (6) Amok, A.: Rev. de Phtisiol. 16: 461, 1934. (7) Boquist, H. S., Simons, 6. H., and Myers, J. A.: Am. Rev. Tuberc. 31: 48, 1935. (8) Blisnjanskaja, A. I., and Lasarevitch, A. I.: GynBc. et obst. 34: 207, 1936. (9) Gtillemin, A., and Chabeaur: Red. med. de Nancy 65: 30, 1937. (1)

Seeley,

W.

37: 741, 1939.

A COMPARATIVE HERBERT (Prom

the

STUDY

AND

FEMAL’E

M.D., AND WILLIAM W. GREULICH, NEW HAVEN, CONN.

THOMS,

Departments

OF MALE

of

cence Study

Obstetrics Unit, Yale

and Gynecology University

School

and Auatomy of Me&&e)

PELVES” PH.D., on the Adoles-

N A recent communication1 we reported the results of a roentgenologic study of the size and shape of the pelvic inIet in 582 primigravid white (clinic) women, 104 nulliparous student nurses from a somewhat different racial stock and a more privileged economic class, and 107 young girls who ranged in age from 5 to 15 years. The pelves of this group were classified according to the Thorns’ system of classification, which is based on the relative lengths of the t.ransverse and anteroposterior diameters of the pelvic inlet as follows:

I

Dolichopellic

posterior

Yesatipellio

poeterior

or Anthropoid

Type:

The transverse diameter is less than the antero-

diameter. The transverse diameter Type: or exceeds it by no more than 1 cm.

or Round

diameter

either equals the antero-

*This investi ation w&s aided by grants from the Fluid Research and Teaching Funds of Yale 8 niversity School of .$&rBe&m and the C+en+?rti-J&hwat-ion Bawd of the Rockefeller Fwndation. Dr. Hugh PI. ‘R%isan, ArusooiaM F?r&wo* of B&to8 og ~ELze aMtie School of Bbedicine, kindly made avaIlable to us tti necessary radio&+ for this study.

THOMS

AND

Brachypellio or Oval Type: by from 1.1 to 2.9 cm. Platypellic or Flat Type: by 3 cm. or more.

GREULICH:

The The

STUDY

transverse transverse

OF

57

PELVES

diameter

exceeds

the

anteroposterior

diameter

exceeds

the

anteroposterior

This classification we have used in clinical practice during the past four years, and it appears to be of greater usefulness, and of more ready comprehension than any other classification with which we are familiar. Nevertheless, for certain comparisons a classification based upon the pelvic index, as suggested by Turner,2 is also of usefulness, as will be noted later. The incidence of the various types of pelves in these 686 adult white women is shown in Table I. TABLE

TYPE

Dolichopellic Mesatipellic Braehypellic Platypellic

I

582

104

CLINIC WOMEN PER CENT

STUDENT NURSES PER CENT

TOTAL 686 ADULT PER CENT

37.5 44.2 18.2 --

18.4 44.7 31.8 4.7

15.0 44.8 34.3 5.6

These findings are of considerable interest if we compare them with what is described as the “normal” female pelvis in textbooks of anatomy. In such texts we find the normal female pelvis described as one in which the transverse diameter of the inlet exceeds the anteroposterior diameter by more than 2 cm. On the basis of this criterion we find that only 14.9 per, cent of the clinic women and 5.7 per cent of the student nurses possess this type of pelvis. Obviously the prevailing concept of the “normal” pelvis of white women needs revision, a matter which we have previously discussed.3 In order to be adequate for clinical purposes’ a survey of the pelvis cannot be limited to a study of the inlet alone, but it must include a description of the remainder of the pelvis as well. During the past year, using improved techniques, we have made such a survey of 200 white women. It is our opinion that not only is the shape of the various segments of the pelvis of importance but that certain diameters are equally important. These diameters are: Pelvic

Midpelvic

Pelvic

[ 1. Anteroposterior diameter { 2. Transverse diameter [ 3. Posterior sagittal diameter

Inlet

Plane

Outlet

[ 1. Anteroposterior diameter 2. Transverse diameter (interspinous) sagittal diameter I 3. Posterior ( 1. Transverse 1 2. Posterior

diameter sagittal diameter

For a further discussion of these diameters which they are estimated, the reader is referred cation by one of US.~

(intertuberal)

and the points from to a recent communi-

In the present paler \\-e jvislr 10 repot~t 1he res111ts of an x-ray study of the pelves of 69 white ;rtI~lit 1tu11est~~t~e~~ts.a gro~q) ~711 ich resemble very closely the student ~tlfrses of 0~11’p~*c?viousseries both in eeonomie level and in nat,ionnl clrri\.at iott. SIu~h il s~~rvey has a distinct clinical interest due to the fact that certain features regarded as eharaeteristically male may occur iit female pelvrs. a fact which has been known for many years and whiell has rec*ently been emphasized by Caldwell and Mo~oY.~ Such occurrences may have pronounced obstetric: importance, and may be the cause of severe dystocia. In the first consideration of t,his survey of the male pelvis, we would call attention to the description of the “normal” male pelvis as found in anatomic texts. In genera1 the male pelvic inlet is said to be heartshaped and to have an anteroposterior diameter which is smaller than it,s transverse. A comparative study of our findings may be stated in terms of the pelvic index (P.T. = A.P. x 100)). Trans. The average pelvic index of our group was 100.5. This is considerably higher than the index of 80.8, the average reported for European males, by Turner (77.0)) Verneau (80.0)) Topinard (80.0), and Krause (84.4), whose figures are still cited as typical of white males in modern textbooks of anatomy. Only two of the 69 men in our series had a pelvic index of less than 85 (77.0 and 84.8). According to the Thorns’ ala,ssification, the occurrence of pelvic type in the group was as follows: Dolichopellic Mesatipellic Brachypellic

type type type

20 instances 34 instances 15 instances

or 28.9% or 49.2% or 21.770

Thus, it is seen that in male pelves, as in female pelves, these basic pelvic types appear. 111this limited series the percentage ratio is not greatly unlike that of the student nurse group given above. The various average pelvic; diameters observed in the 69 males and the 2(M) females of our present series are listed in Tables II and III, in which eases are arranged according to pelvic type. TABLE

II.

TYPE

A.P. 12.50 11.75 11.06 9.0

Dolichopellic Mesatipellic Brachypellic Platypellic TABLE

MEAN

III.

VALUES INLET TRANS. imr-5.07 12.32 12.67 ~- 12.67

MEAN

VALUES INLET

FOR PELVIC

1 P.S. 4.48 4.15 2.75

TYPES

A.P. 12.55 12.34 12.01 11.67

FOR PELVIC

IN 200 ___.~ MIDPLANE TRANS. ( ---5.22 9.45 10.34 10.32 10.45 __-__

TYPES

WHITE

P.S. 5.23 5.23 4.71

IN 69 WHITE

DfIDPLANE

WO~IEN OUTLET TRANS. P.S. -7.84 8.95 9.16 7.71 8.92 8.05 9.12 7.58 ___._-.__ MALES OUTLET

THOMS

ASD

GREULICH

The above figures show that in a smaller capacity than that of designate the chief differences are sagittals. The male pelvic inlet

:

STUDY

Ol?

PELVES

xl

each pelvic type the male pelvis has the female. The diameters’ which the bispinous and the three posterior as it occurred in our series is note

Fig. I.-Group I, representative tracings of pelvic inlets of the dolichopellic or Group II, representative tracings of pelvic inlets of the mesatianthropoid group. pellic or round group. Group III, representative tracings of pelvic inlets of the brachypellic or oval group.

60

AMERICAN

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Ol~STF,TXICS

AND

BYNWOLOGF

greatly

difYerent. from t,bai of the fema Ic. The 1crm “heart-shaped ’ ’ be a very inappropriatr designat ioll for the inlet of t,be grcai majority of these male lwlvcs. ‘I’llis is cvi(letIt front t.he tracings of the inlet of representative ]wlves SIIOWJ~ in Fig. 1. ,Ittention also is directed especially to the forrpart of tile pelvic illlet. As will be seen in most instances, this is uot angular but a swrcping curve and is not greatly unlike that seen in most, female pelres. ‘l’be relative shortening of the posterior sagittal. diameter of the inlet,, which is said to be so characteristic of the male pelvis. is not marked in our series, an average of approximately 0.5 cm. lrss lhm the figures for tlir female series. w0ulc1

Fig.

a.-Dolichopellic male

Fig.

or anthropoid type notch, and the sacrum

3.-Mesatlpellic

Lateral view of male pelvis. is composed of six segments.

01‘ round

type

of

male

shows

typical

pelvis.

The most typical made characterishics in pelvic contour in our series mere the shape of the sacrosciatic notch and the angle formed by the pubie rami. The sacroseiatic notches, showed typical male features in all subjects examined, although in a few eases a wideness was present to the extent that the female type was suggested. The subpubic angle was not studied roentgenologically in all cases, but in those in

THOMS

AND

GREULICH:

STUDY

OF

PEL.VES

61

which this was done it was found to be typically masculine. A word should be added concerning the bituberal or outlet transverse diameters given above. In the women this diameter was determined by palpation, but in t.he male series it was determined by s-ray. The findings show clearly the result of the lack of uniformity in designating that part of the tubera ischii from which measurements should be taken and suggest studies to correct this error. Because of these discrepancies the intertuberal diameters of the two groups are not comparable.

Fig.

Fig.

5.-The

pelvis lateral

I.-Brachypellic

or

inlet shows a tendency aspect shows changes

oval

type

to the suggestive

of

male

“heart-shape.” of rachitic

pelvis.

The influence.

sacrum

in

its

A study of the sacrum in this series as se.en ill its lateral aspect revealed the presence of six segments in 9 instanc*es (so-called high assimilation). These mere equally divided in the three types, although in our opinion this variation is more often seen ill association with t,he dolichopellic type pelvis in women. A study of the curve of the anterior sacral surface from above downward showed the usual deviations from a normal sweeping curve, which we also noted in our female series. In seven instances the upper two-thirds of the anterior sacra.1 surface showed a lack of the usual concavity with the exaggeration of the forward curve of t,he lower one-third of this surface. In two instances the entire anterior surface

of the sacrum was straight or (convex iti its lateral outline from above downward, and the inlet in these cases rhowetl a tkfiuite tendency lo the heart-shaped form with relatively shortened posterior sagittal diameters (3.3-3.3)> Fig, 5. These ~wc~ralfindings strongly suggest to IIS changes due to rachitic illfiuenw. We may summarize our fitrdinps ill this comparative st,udy of male and female pelves as follows: 1. The pelvic boues in males are heavier than t,hose found jn :females, and in general the whole pelvis of the former has a more angular appearance. 2. The pelvic inlet in males appears in general more circular, and the posterior sagittal diameter in this plane is slightly shorter than that seen in female pelves. This is due to a slight. displacement posteriorly of the widest transverse diamet.er. The forepart of the pelvic inlet differs but, slightly from that seen in female pelves and the socalled “heart-shaped ” pelvic inlet was not characteristic of the great majority of pelves in our series. 8. The constant characters seen in male pelves were the structural heaviness and prominentre of the ischial spines with narrowing of the pelvic side walls from above downward, the angular pelvic arch with a relatively narrow subpubic angle and the type of sacrosciatic notch which has been described as characteristically male. 4. The three main pelvic types which we have found in female pelves, i.e.. dolichopellic. mesatipellic, and brachypellic. were also found to owur in male pelves. REFERENCE8 Tg:;l)T

GFlich. , .: a.ad Twaddle, a. ix.: Yale AK J. OBST.

Jackson,

W. W., rind Thom.s, H.: Trans. N. Y. Acad. SC. 1: 12, 1935. (2) J. A%nnt. & Physiol. 20: 125, 1886. (3) Gredich, W. W., Thorns, I?., J. A. M. A. 112: 485, 1939. (4) Thorns, H., and Wilson, X. C.: (5) Ca~ldwell, W. IL and Moloy, H. C.: J. Biol. Med. 11: 379, 1939. & GYNFIC. 26: 479, 19.73.

Ed. : Prophylaxis

for Ophthalmia

Neonatorum,

Am.

.T. 01~11th.

21:

438.

1938. The prevention of ophthalmi:~ neonatorum due to the gonoc~occus has been very widely provided for in laws and regulations of health departments. The instillation of silver nitrate solution at the time of birth has been most generally prescribed. Silver nitrate is a severe irritant to the conjunetiva and cornea and cases have occurred in which it has caused serious conjunctivitis when no gonococcal infection was present. Its use at too short intervals, more than one application in twenty-four hours, has also caused permanent opacities of the cornea. Jackson feels that the more recent introduction of silver acetate as a safer and more widely efficient prophylactic should be welcomed by the profession. It would be particularly useful in sparsely settled districts where frequent renewal of the silver nitrate solution cannot be obtained without delay. J. P. GREENHILI,.