Lectures on the Theory and Practice of Midwifery

The Lancet

Vol. 10 No. 244, May 03, 1828 p 129-136

Blundell, J.

Note - this is an early reference to the removal of the coccyx

Sacro-coccygeal joint

The sacro-coccygeal joint is a moveable joint; allowing the os coccygis to recede considerably, -moving on the sacrum,- so as to enlarge the outlet of the pelvis posteriorly, to the extent of an inch. This joint, constituted in the same manner as the other joints of the body, has articulating surfaces, invested with cartilage, covered also with synovial membrane;- the ends of the two bones being connected by capsular ligament; which, rising all round from the extremity of the sacrum, is inserted all round into the extremity of the coccyx, and completes the articulation. It sometimes happens that this sacro-coccygeal joint is the subject of disease or accident; and hence its principal interest to the accoucheur.

Anchylosis of the Os Coccygis. - In obstetric works, you will find mention made of the anchylosis of the os coccygis (from [Greek], to bend);- a disease under which, in consequence of an ossification of the joint, the sacrum and the os coccygis become consolidated with each other. This anchylosis of the sacro-coccygeal joint, I conceive to be of very rare occurrence; and, I believe, it still more rarely happens that this anchylosis produces any serious obstruction to parturition; yet, should it so happen that the coccyx were placed at right angles with the sacrum, and thus became anchylosed, - encroaching on the capacity of the inferior aperture of the pelvis, - it might certainly, if the child's head were large, considerably obstruct transmission. Such difficulties, perhaps, have now and then occurred. It more frequently happens that, instead of anchylosis, you have a rigidity of the part. A woman may be forty years of age before she marries; and perhaps she has a child at forty-one; her health may have been vigorous, her flesh firm, her fibre rigid and unyielding; so that the sacro-coccygeal joint, the perineum, and all the parts, may be indisposed to give way. Now, rigidity of the sacro-coccygeal joint, together with rigidity of the parts adjacent, is a very formidable, obstruction to the passage of the foetus; nor is it an unlikely occurrence in country practice; and where it does occur, unless properly managed, it is not infrequently destructive to both the mother and the child. Should it be my lot, in practice, to meet with a case allied to those I have been describing; - a case in which, for anchylosis of the sacro-coccygeal articulation, or general rigidity, the birth of the head was obstructed, - the following would be my practice. Laying it down as an axiom, that can never be too often iterated, that meddlesome midwifery is bad midwifery, - provided no dangers occurred, clearly requiring immediate delivery, - I should, for four-and-twenty hours after the discharge of the waters, give a fair trial to the natural efforts. Should dangerous symptoms urge, or should the twenty-four hours pass before the delivery was accomplished, if the vulva were relaxed, and the obstruction arose from anchylosis, I should, with forceps, and by moderate efforts, co-operating with the uterine, endeavour to extract, the child, - frequently examining the pulse and the countenance, and bearing in my mind the fatal. consequences of obstetric violence. The yielding of the anchylosis under moderate effort, would not, perhaps, be undesirable. Room might thus be obtained; and the child might now and then be saved. Should. the forceps fail, or should the rigidity of the vulva preclude their use, - if urgent and dangerous symptoms demanded immediate delivery, - I should then, though unwillingly, have recourse to that murderous instrument, the perforator; but if no dangers threatened, - anxious not to cover my hands with the blood of an innocent infant, - unless I believed the child to be dead, I should wait until the woman had been in strong labour for eight-and-forty hours after the discharge of the liquor amnii; then, at length, laying open the cranium, should it still not pass away.

Disruption of the Sacro-Coccygeal Joint.- It sometimes happens, that a disruption of the sacro-coccygeal joint occurs. The head perhaps is large, the pelvis is small, the pains are violent, and suddenly the head emerges from the pelvis; and when it does so, - there being a very strong pressure on the coccyx, - the joint may be torn asunder. With a case of disruption I never met myself; but cases where the sacro-coccygeal joint has been thus torn, are mentioned in Denman's work; - it may be sometimes heard to give way.

Should disruption occur, it may be soon detected. Put the fore finger of the right hand into the rectum, - pushing it up to the joint; and apply the thumb over the joint in opposition externally; when the chasm between the two bones may be easily ascertained. Such a case should be managed on the general principles of surgery; hut let me add obstetrically that, during the cure, you should so place your patient as not to throw the os coccygis directly forward; because, from the preceding remarks, it seems desirable that the os coccygis should not unite with the Sacrum rectangularly, but under the ordinary bearing; - so. as to form a part of the general curve.

Inflammation of the Joint. - Patents are sometimes affected with inflammation of this joint; examples of which, both acute and chronic, I have myself seen. Wholly unconnected with pregnancy or parturition, inflammation may occur; and still. more frequently it be brought on in consequence of the passing of a large head; where there has been vehement straining; and the joint, though not torn, has been strained. If inflammation of the coccygeal joint occur, you will know it by the patient's complaining of pain there; and more especially by her stating, that whatever moves this little bone behind, gives a sudden pang of uneasiness; -in sitting, in rising, in turning round on her bed, pain may be produced. I remember on visiting a patient in whom labour had been laborious, being not a little surprised to find her seated on the frame-work of a chair, from which the bottom had been removed. On asking her why she seated herself in a manner so extraordinary, I learnt that unless she had recourse to this expedient, - which you will perceive, removed pressure from the coccyx, - she was continually uneasy.

Taking an intimation from this observation, 1. made an accurate examination of the joint; and then ascertained, - more especially by moving the coccyx on the sacrum, - that the articulation with its ligaments was in a state of inflammation, and that the slightest disturbance occasioned pain.

Treatment - Leeches, clysters, cupping (perhaps from the loins and sacrum), diaphoretics, digitalis, low diet, and bleeding from, the arm provided the inflammation runs high), - these will constitute your principal remedies; and the joint should be kept still. It is remarkable that, where there has been this inflammation, it seems to be afterwards affected by the weather; and more especially when there is an east wind; - which is worthy of recollection. Patients of this kind will complain of pains in that way for years afterwards; as I had occasion to observe in the patient whose case I have related.

Suppuration of the Joint. - In scrofulous subjects, it sometimes happens that the sacro-coccygeal joint partakes not merely of an inflammatory, but of a suppurative action; and the parts may fall into a sort of malignant condition; so that the disease will not yield. In a case of this kind, should all other attempts fail I may remark, by way of suggestion, that you might perhaps remove the os coccygis altogether; for this bone does not appear to be of any very great importance in the skeleton. You should afterwards pare away the diseased extremity of the sacrum, till you reach the sounder parts more disposed to the healing process. The hint may be worth recollecting; but beware of temerity. Here, perhaps, I may take the liberty of observing, that malignant actions are sometimes confined to a few films of structure only; so that if you can but destroy those few films, you will at once come down upon a healthier organisation which will heal; whereas, if you left the case to itself, it would go on working to the patient's destruction. A chancre treated by lunar caustic, is an illustration of this.


This text from the Lancet was repeated in Principles and Practice of Obstetric Medicine (second edition, revised) by Blundell, J. carefully revised and corrected, with numerous additions and notes by Alexander Cooper Lee and Nathaniel Rogers, pages. 9-12. London. J. Butler. 1834

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