A Clinical History of the Medical and Surgical Diseases of Women.
1874, Philadelphia, H. C. Lea.
St Thomas's Hospital, London
Archive.org copy of the book
A not uncommon attendant symptom of chronic metritis is the "Coccygodynia" of Simpson. This is sometimes so distressing that the sufferer cannot sit in the ordinary way, but is obliged to rest upon one or other ischium; and some women on this account constantly use an air-cushion. Pain is often felt on defecation. Since the metritis to which this pain is due, itself probably arose after labor, it is natural to conjecture that the sacro-coccygeal joint received injury during labor, and became the seat of chronic inflammation. In some instances this is really the case. But in most no evidence, beyond the pain, will be found of local mischief. It is a form of neuralgia. It is, however, desirable to determine the local condition by examination. For this, the forefinger of one hand is passed into the rectum, whilst the other hand feels along the sacrum or down the joint externally. In this way the joint is closely approached on either side, and the relation of its constituent bones, the mobility of the coccyx, the condition of the joint can be accurately made out. The removal of this sacro-coccygeal neuralgia must be waited for in the same way as the subsidence of other nervous disorders, when the causing disease is cured.
Page 767 - 769 Coccygodynia.
This disease has become familiar to gynaecologists through the writings of Sir James Simpson ("Diseases of Women," 1872, vol. ii, edited by A. R. Simpson). But Dr. J. C. Nott, of New York, in an interesting memoir on the subject, refers to two cases published by himself in the New Orleans Medical Journal fifteen years before Simpson's first communication.
The name is derived from coccyx and dynia, pain. The leading symptom is pain in the region of the coccyx felt by the patient whenever she sits down and rises, and sometimes when she remains in a sitting posture. Most of the patients affected with it are obliged to sit on one hip, or with only one side resting on the edge of a chair, or with the weight partially supported by a hand on the chair. Some patients dread sitting down. There are other movements of the coccyx liable to be attended by pain. Thus, patients have pain with every step they take, whilst in others walking causes no uneasiness. Others feel the pain most when the bowels are being evacuated, or under any circumstances in which the sphincter or levator ani, or the ischio-coccygeal muscles are called into action. The pain is not in every case very acute, nor at all times equally severe. The distinguishing feature of the disease in every case is that the pain is felt at the lowest part of the spine, or rather in the seat of the coccyx, and where pressure always aggravates it. Pressure and movement of the coccyx too, with the finger in various directions, produce pain, and the kind of movement which is then attended with suffering differs in different cases.
Simpson believes the pain is due to inflammation of the coccygeal joint, or other morbid change, when any action of the muscles in connection with it, by moving the joint, produces pain.
We might naturally look for the origin of this disease in some injury of the part; and in a considerable proportion of cases injury can be traced. But it is remarkable that the disease occurs in the unmarried, and where no history of injury can be made out. I, myself, have known several aggravated cases follow labor. In these I cannot doubt that the joint received injury during the passage of the child's head. In some cases we know the sacro-coccygeal joint is anchylosed, the tip of the coccyx projecting so much forwards as to form an angle with the lower part of the sacrum. The anchylosis is likely to give way during labor. And where there is no anchylosis, as the head emerges, the coccyx may be felt to be stretched very much backwards, and under the strain some of the fibres of the anterior ligaments which bind this bone to the sacrum may be torn, and in the joint thus exposed and injured inflammation is very apt to be set up. Simpson saw abscess follow.
The coccyx again is liable to fracture or dislocation from direct violence, as from a fall on the seat. Patients have complained that " a bone grows in," and so it is found. It is also liable to malformations, to deficient development, to tumors, and even double monstrosity by inclusion.
But in a certain proportion of cases no local lesion can be made out, and we are driven to conclude that the disease is a neurosis, a form of neuralgia, the expression, perhaps, of some remote morbid condition. But latterly some new light seems to be cast upon these more anomalous cases. In Virchow's Archiv, 1860 (Die Steissdriise des Menschen), Luschka gives an account of a small gland situated just at the anterior end of the coccyx ; it is in immediate relation with the hindermost part of the levator ani, and is connected with filaments from the ganglion impar of the sympathetic nerve, and with small branches of the middle sacral artery, between the levator ani and the posterior end of the external sphincter. The gland is rich in nerves, which form a network perforating its stroma.
This, the "glandula coccygea," Luschka says, is probably the seat of the hygroma cystica perinealea. And when we consider its highly vascular and nervous elements, and its position, we can hardly doubt that it may in some cases be the seat of coccygodynia.
Some cases called coccygodynia I have found to be due to fissure of the anus, and to the conditions which induce the spasmodic action of the vulvar and perineal muscles, and known as "vaginismus." I have also traced it to retroflexion of the uterus.
The diagnosis is made out by local examination. The forefinger introduced into the rectum is applied to the inner aspect of the sacro-coccygeal joint, whilst a finger of the other hand is applied to the outer aspect. The bones and the joint thus embraced between the two fingers are completely explored, and the seat of pain and the condition of the parts are easily determined.
The treatment, according to Simpson, is surgical. But I have met with cases which, after long and intense suffering, got well spontaneously, or when uterine disease and general disorder were removed. At the same time, I am satisfied that surgical treatment is occasionally essential to relief. One may exhaust sedatives, neurotics, and tonics, and still the pain persists. When there is evident inflammation, leeches will be serviceable, followed by counter-irritation. Temporary ease may be obtained by the local subcutaneous injection of morphia. The surgical treatment is to completely separate from the coccyx the muscular and tendinous fibres that are in connection with it. This is done by a tenotomy -knife passed under the skin at a short distance from the tip of the coccyx, and made to shave along the posterior aspect of the bone, and then to divide the muscular and tendinous attachments, first on one side, then and lastly all round the tip of it. It is not in every case necessary to make the division so free. In some instances the division of the fibres of the gluteus maximus of one or the other side, or detachment from the coccyx of the sphincter and levator ani may be enough. No bleeding attends the operation, which possesses also the other advantages of subcutaneous sections. Simpson admits that this operation occasionally fails, and that he consequently suggested the removal of the coccyx.
Dr. J. C. Nott prefers extirpation of the bone. Simpson's subcutaneous incision around the coccyx would divide the nervous branches which supply Luschka's gland, and in this way its success in some cases may be explained.