The knife for coccygodynia: a failure

Medical Record (New York)

1896; 1: 154-5.

Bremer, Ludwig.

St Louis.

As a deterrent example of meddlesome and noxious surgery, I will briefly cite this case: A woman about forty years of age slips on the pavement and lands with no very great violence on the buttocks. Barring a nervous and excitable temperament, she has up to the time of the accident enjoyed uninterrupted good health, has healthy children, and is of a cheerful disposition. Immediately following the accident a painful sensation manifests itself at the end of the spine, a coccygodynia has suddenly developed, which persists to the present day, over three years after the accident.

These three years have been a continued martyrdom with the following phases, which may be said to be typical of cases of this kind. In due course of time, after having exhausted all kinds of local applications, the pain becoming more severe as time wears on, she consults a surgeon of repute, a professor in one of the leading colleges of the country, who tells her that the coccyx must be removed and that such an operation, which is a comparatively simple one, cures the affliction nine times out of ten. The operation is performed by a local surgeon, with the result that the pain becomes more intense than ever. In addition to a sore and a sensitive coccyx there now exists an irritable and painful scar. A second operation is advised; for it is claimed the first one has not been thorough enough. Before submitting to this she resolves to try electricity, which is recommended to her as being very effectual in relieving such conditions. The faradic current of medium strength is used, one electrode being placed in the rectum, the other over the sacrum. The result of this single application is a cramping of the rectum, which is added to the already existing pain and which has not left her up to the present day. Stretching of the sphincter ani, which is now resorted to by her physician, instead of affording relief, increases the painful contractions. She becomes unfit for the discharge of her domestic and social duties until her physician prescribes morphine to be given by the rectum. From this day on she knows that, to lead an existence which can at least be tolerated, she has to resort to morphine. Half a grain suffices to render her condition tolerable. It enables her to follow without serious inconvenience her customary pursuits. But her family look upon her as a morphine fiend and she herself smarts under the stigma and self-reproach on account of the habit which, she is told, is worse than the liquor addiction. This constitutes another factor in rendering her existence miserable.

Consequently at the solicitations of her family and friends she makes up her mind to enter a sanatorium to cure her of the morphine habit. For three months the withdrawal of the drug is tried systematically. She becomes sleepless, loses weight and strength to such an alarming degree that the attempt of weaning her from the drug has to be abandoned. Neither massage, hydrotherapy, electricity, nor the other devices in vogue at sanatoriums have had the slightest effect upon her. It takes another three months to regain the strength she had on entering the institution. Since then she has tried all sorts of doctors and methods, has travelled extensively, sojourning at a variety of health resorts and watering-places, all to no purpose. In order to relieve an otherwise unbearable existence she has to resort to the morphine in doses of from one-quarter to one-half a grain a day.

On presenting herself to me for examination and consultation, this patient has the appearance of a healthy, well-preserved matron, whose looks do not betray the slightest trace of the Iliad of woes which she relates in a graphic manner. Knowing by experience with other cases that coccygodynia is almost always one of the symptoms of hysteria, sometimes apparently monosymptomatic, all the other manifestations of the disease being overshadowed or rendered dormant or insignificant by the overtowering dominance of one the excruciating pain, I make the preliminary diagnosis of hysteria.

Of course I look for hysterical stigmata, but there are none; above all, there is an absence of anaesthesia of any kind anywhere, nor is there the slightest indication of a history pointing to hysterical attacks. This woman has been exceptionally healthy all her life. But on close examination I find that travelling and change of scenery lessen the pain, that at times she is slightly aphasic, that there is a tendency to a pulling back of the head, and that often she has "a lump in the throat." I add to this that she is of a gay temperament, and that in spite of the overwhelming pain she has at all times, but which is particularly aggravating in the sitting posture, she does not present the aspect of a sufferer after having sat in my office for a number of hours, and I come to the conclusion that in the present case the coccygodynia is of an hysteric nature.

The text-books on medicine, and those on neurology in particular, describe the affection spoken of as being neuralgic or rheumatic in character. Probably there exist such cases, although among the dozen that during the last twenty-five years have come under my observation not a single one was of such nature. They were all symptomatic of hysteria, some of them apparently but not in reality monosymptomatic. For it is a striking fact that most women thus afflicted positively declare that there is nothing else the matter with them, though closer inquiry brings out the fact that a number of minor complaints exist or have existed, which, however, are ignored or have been forgotten. Hysteria is noted for the tendency to oblivion of ills that have passed.

In all cases of coccygodynia that I have seen, a history could be elicited, if not of hysteria proper or some allied neurosis in the ascendants, at all events of the existence of the hysterical temperament. In all of them an immediate or provoking cause, a provoking agent (agent provocateur of Charcot-Guinon) could be demonstrated. A trauma, severe and prolonged emotional and intellectual strain, infectious diseases, convalescence, parturition and lactation, chronic intoxication (alcoholism, saturnism, etc.) can generally be shown to have existed before or at the time of the cropping out of the trouble. The case briefly reported above is one of traumatic (monosymptomatic) hysteria. The several therapeutic procedures (insignificant in the healthy) acted like so many distinct shocks and provoking agents. The administration of the anaesthetic (in some predisposed individuals this alone suffices to bring about hysteria, transient or lasting) in conjunction with the wound, and later on the irritation set up by the introduction of the electrode into the rectum, sufficed to aggravate a condition which, if left to itself, would probably have remained within the bounds of toleration.

But it is just at this point where a fatal idiosyncrasy of hysteric patients plays such a baleful part. If it is true that there is such a thing as the Juror operandi among surgeons, it is equally true that there is a class of women who actually itch for an operation, the bloodier the better. This is one phase of hysteria. The desperate monotony of an excessively painful and annoying affection engenders a craving for something phenomenal. They look upon their suffering as unique in atrociousness and unexampled in medicine, and nothing short of an extraordinary measure will, in their opinion, be of any avail. As a rule, nothing short of an operation will satisfy them, and generally they do not meet with any difficulty in finding a surgeon who is willing to operate. It is needless to add that he is convinced of the appropriateness of surgical interference in cases of this kind, only he is mistaken as to indication and disappointed as to outcome.

The following case will furnish additional proof of this proposition and help to elucidate the subject more fully.

A woman of about thirty-five, whose mother is still living and is suffering from hysterical hemiplegia, and whose father died of apoplexy at the age of thirty-five, presents herself with this history: Up to about two years ago she has been healthy. She always has been of a hopeful, mercurial disposition. For a number of years she has nursed an invalid husband who died with consumption. After his death she has taught school and worked very hard. While thus engaged in work with which she never has been familiar, a pain constantly increasing in severity gradually develops at the sacrum and in the coccygeal region. In due course of time she is operated upon. The coccyx, which the surgeon says points inward to an unusual degree, is excised. Then the trouble gets worse. To the deep-seated pain a hypersensitive cicatrix is added. A specialist for rectal diseases now examines her to see whether any rectal trouble exists that may account for the pain. Nothing is found; but from the time of the examination an additional painful spastic condition of the rectum develops. There is also a drawing and gnawing sensation in the skin over the hips. She is in a deplorable condition, not only physically but mentally. The exacerbation of the pain affects in an indescribable manner her mind, so she claims.

In this case there are also a tendency to retraction of the head and an alleged impairment of memory, which on closer examination proves to be partial aphasia. She craves sympathy and thinks nobody understands her case or has any idea of her sufferings. With any and everybody she discusses her strange malady, though she is a woman of tact and refinement. There are no positive hysterical stigmata; only one side of the body, the left, gets numb at times and is weaker than the other side.

In this case there is well-established heredity, which by grief, anxiety, and hard work is developed into hysterical coccygodynia of a grave form.

The symptoms on which the diagnosis hysteria is made in these cases may seem to some to be insufficient, but they are fully conclusive to the neurologist, when properly grouped and interpreted in the light of Charcot's teachings. What Charcot and his school have not mentioned in their classic delineations of the syndromes of hysteria are the spastic tendency of the retractors of the head and a trace more or less noticeable of aphasia. I consider them as stigmata of a subtle character, the anaesthesias being of a coarser kind. They are very common in hysterical females and sometimes the only obvious ones in a chaos of indistinct and undefinable malaise.

To use a knife on such patients is a grave mistake. To cut off a painful coccyx is as irrational as the removal of the ovaries in hysterical ovarialgia. The time will come when another generation of medical men will look upon such operations as one of the most remarkable aberrations of the science of medicine. The trouble is in the brain, but not at the periphery, neither bone nor skin. It is projected from the centre to the periphery, as an irritation of the ulnar nerve at the "crazy bone" is to the little and fourth fingers.

Some cases of hysterical coccygodynia get well by the most divergent and heterogeneous remedies, such as hydropathy, faith cure, hypnotism, etc. Others never recover under any treatment. In such cases there is only one course left to render life tolerable, that is the use of opium. The substitution of a lesser evil for a greater one is the last refuge for the unfortunate sufferer. Many will, through a physician's prescription or by their own doing, resort to this drug. If they do not take more than half a grain a day, preferably by the rectum, they may live in comparative comfort. But generally hysteric people have a morbid dread of opiates. The fear of becoming a morphine fiend and the unpleasant untoward effects of morphine in customary doses, say one-quarter of a grain, has a deterring effect which on the whole is very wholesome. But there are cases in which moderate morphinism is preferable to a life of constant agony, not only to the patient herself but also to her family.

That even severe cases of coccygodynia may get well I have witnessed in the instance of a woman of thirty-seven. The operation had been decided upon, when her husband, who was well-to-do, failed in business. The operation was postponed and never performed. The necessity of hard work brought about a cure. The change from an idle, fashionable existence to the cares and responsibilities of running a restaurant effected a gradual but permanent cure. She herself considers her husband's failure a windfall. I know of another case of medium severity which was cured by the bicycle.

Excision of the coccyx is also practised to some extent on hypochondriacs. Here the diagnosis generally reads: "The coccyx points strongly inward, is partially detached, and probably necrosed." What a revelation in pathology!

I do not mean to say that never and under no circumstances has the removal of the coccyx been successful in curing the pain. Perhaps there are cases in which the operation has been beneficial. Personally I do not know of any. Even in cases of success the question is legitimate : Would not other and simpler means have been equally effective? Generally speaking, the results of coccygodectomy are as hopeless as neurectomy in facial neuralgia.

Will there be any fewer operations performed for hysterical coccygodynia on the strength of the foregoing remarks? I do not believe it. Like osteopathy and faith cure, the knife will continue to have its sway in the treatment of hysterical ailments. An age that has given rise to that crowning glory of surgical fakes, orificial surgery, proudly termed by its advocates the American operation, will continue to hunt at the periphery for that which lies in the centre. But a protest is always in order. Besides, I know that conservative surgeons repudiate the reckless and uncalled-for use of the knife.

In spite of this, the indiscriminate extirpation of wombs and ovaries, the slitting and enlarging of orifices of the male urethra, the excision of imaginary strictures, the clipping of the eye muscles, the cutting out of pockets of the rectum, circumcision, and the removal of the coccyx will go on with unabated vigor all of which is the outcome of an exaggeration and misinterpretation of the import and meaning of the law of the reflexes. In the name of the reflexes a multitude of surgical misdemeanors are constantly committed.

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