Case of coccyodynia - extirpation of two lower bones of coccyx

The American journal of obstetrics and diseases of women and children

Volume 1, number 3, pages 243-254, November 1868.

Nott, JC.

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The rules of the New York Obstetrical Society require that a candidate for membership should "present, through some member, a specimen of morbid anatomy, accompanied by a written history of the same." In accordance with this requisition, I present this evening to the Society the two terminating bones of an os coccygis, recently removed by me from a lady, and shall proceed to give a brief history of the case:

W. O. S-, a young physician from Alabama, in the latter part of July last (1868), brought his wife on to this city to consult me, for a painful affection of the coccyx and surrounding parts. The following is an abstract of the history of the case as given by him:-

"Age of subject, 24; weight before marriage, 135 pounds, and health perfect in every respect. On the 10th November last, after a very hard labor of 14 hours (8 months before consulting me), was delivered of her first child. The perineum was considerably lacerated; alarming flooding occurred on the fourth day, with great prostration. Was sufficiently recovered to sit up a little in the fourth week, but complained much of pain, with dragging sensations in the pelvic and perineal regions, all of which were much aggravated by the erect posture, or motion. Some injury was inflicted on the vagina, as adhesions were broken up about two weeks after confinement.

"January 12th, about two months after delivery, she was attacked with sudden and severe pains across the back and hips, extending downwards and forwards. Her medical attendant pronounced it inflammation of the womb, with slight prolapse and dislocation of the coccyx. She improved gradually for two weeks, when she was attacked with severe gastritis, accompanied by incessant vomiting for sixty hours. She became excessively prostrated, and rallied slowly. Continued feeble, emaciated, and very complaining; and was confined to her bed until June 11th, when she started by railroad for the mountains of Virginia, and arrived at Wytheville after a journey of great fatigue and suffering, being unable to sit up at all on the way.

"During the six weeks she remained in the mountains her general health improved, and she became well enough, for the first time, to sit up a little and take sufficient nourishment.

"Menstruation, through all her illness, had been normal, except that it usually anticipated the regular period a few days. She had troublesome diarrhoea, which was often profuse, and offensive in character.

"In addition to the foregoing symptoms, there had been, commencing soon after delivery, sever and persisting pains in and around the coccyx in the region of the uterus and bladder, and extending to the perineum and hips- thus presenting all the symptoms of coccyodynia, so graphically described by Professor Simpson, of Edinburgh, in his "Clinical Lectures" -the pains, however, radiating more extensively than is usual in such cases. These pains were at all times brought on, and greatly aggravated by any movement of body or lower extremities which brought into action the muscles connected with the coccyx.

"The sacro-sciatic ligaments, the gluteal and coccygeal muscle, the sphincter ani, and levator ani, are all connected with this bone; and even the sphincter vaginae cannot contract without communicating motion to it; getting up, sitting down - any motion of the body on the hip-joints; coughing, sneezing, defecation - in short, any motion or pressure communicated to the coccyx produced acute suffering."

This case is a typical one, and a fair sample of a class, instances of which are so common that it is difficult to comprehend why they should be so generally ignored by the profession. Professor Simpson's Lectures were published in the London Medical Gazette and Times during the years 1859 - '00 and '61, and were for the first time printed in book form in this country in 1863, only five years ago. In one of these lectures he first names and describes this affection. He remarks to his class, in his lecture on Coccyodynia: " You will find, I believe, no description of it in any book." So far as I know, this statement is correct, and it is, even at the present day, rarely alluded to in our systematic works. If, however, the Professor had chanced to glance his over over the back numbers of the New Orleans Medical Journal, edited by Dr. Bennet Dowler, he would have seen that I had anticipated his printed lectures, some 15 years, by the publication of two cases, in which the symptoms are fully given, and extirpation of the bone recommended for its relief.

My two articles on the subject attracted the attention of the distinguished Dr. Meigs, of Philadelphia, who attached great importance to the pathology and practice I had brought to notice. He wrote me a very kind and complimentary letter on the subject, and in return I sent him my two morbid specimens, which he continued to exhibit to his class annually as long as he lectured in the Jefferson school.

My first case was published in the May No., 1844, of the New Orleans Medical Journal, and was the result of a fall on the coccyx. The second followed fracture, during labor, of an anchylosed coccyx, in a young woman 21 years of age. This case was published two or three years after the other one, but not having a series of the Journal at hand, I cannot give the precise date. The case I now bring before the Society followed a hard labor, with laceration of the perineum, etc.

In the two first cases, the two lower bones of the coccyx were extirpated, and with perfect relief to the coccyodynia; but a reference to the first case will show how much our knowledge of the pathology and treatment of diseases of the genital organs has advanced. Although the coccyodynia was relieved in this case, the patient continued to be tormented by several sensitive spots on the surface of the vagina, such as we now cure by hooking up the mucous membrane at the painful spot, and often with it a little caruncle, and snipping it off with a pair of scissors. Twenty-four years ago these painful caruncles were not understood and described, or at least were not understood by me.

The causes of coccyodynia do not seem to be always identical. Sometimes it follows direct injuries of the coccyx from falls or blows, sometimes injury during labor, at others no cause can be assigned; and it occurs in the single, as well as in those who have borne children; but not in the male, according to Prof. Simpson, and my observation agrees with his. When not the result of direct injury it is most frequently associated with deranged menstruation. In some cases the coccyx has been displaced by fracture; in others it is drawn to one side, or forwards, by irregular muscular contraction; in other cases there is no displacement of bone; and, lastly, there are cases in which the bone is anchylosed and motionless. This last fact removes one surmise from the pathology, at least in some of the cases, viz.: that the pain of coccyodynia is produced by the pressure or friction of the end of the coccyx on a nerve.

The pathology, then, of coccyodynia is so far an unsolved problem. In what tissue, we may ask, is seated the morbid action that produces such intense and prolonged suffering, without giving any external signs or events of inflammation? In my first case, as stated, I discovered, after its extirpation, a little abscess, or rather caries, about the size of a buck-shot, in the centre of the lower bone of the coccyx; but in no other case have I observed any more appearance of disease than you find in the healthy-looking coccyx I lay before you. Prof. Simpson's experience corresponds with mine on this point.

The striking peculiarity of this affection is the sensitiveness in and around the coccyx when pressure or motion is communicated to this bone.

Professor Simpson's lecture on coccyodynia is a very instructive one. He remarks: "Now I have already told you that, in some patients, pain is experienced most severely during these movements, and I think in them the pain is fairly referable to the traction upon the coccyx, exercised by the great glutei muscles" (in sitting down and rising up). "Other patients, again, complain chiefly when the bowels are being moved, and in them the sensation is probably due to the action on the coccyx of the sphincter and levator ani; while, in a third class of cases, pain may very possibly be excited during the contraction of the coccygeal muscles, as in the act of sitting down. It is by no means very easy to understand why the action of particular muscles should thus be attended with the production of pain in particular instances. It may be that the disease is confined to the tendons of the muscles, or the portion of the coccyx from which they spring; or, possibly, certain muscles during their action may bring the bone in contact with a supersensitive nerve or inflamed structure, and in this way give rise to the painful sensation."

While throwing these notes together, a member of the Medical Journal Association very kindly attracted my attention to a short article in the New York Medical Gazette, on the "Glandula Coccygea of Man" taken from Virchow's Archives of Pathology 1860, vol. xviii.. in which an account is given of the discovery of a small gland, usually about the size of a hemp-seed. It is situated at the anterior circumference of the end of the coccygeal bone, connected with filaments from the ganglion impar of the sympathetic nerve, and with small branches of the arteria sacralis media, between the levator ani and the posterior end of the sphincter externus. The gland is rich in nerves, derived from the terminal branches of the sympathetic nerve. They form microscopic networks perforating the stroma, and are occasionally seen connected with ganglion cells.

The writer says: - "Although the function of this organ is at present unknown, it is already of great interest to the pathologist, because it is not only the seat of the so-called 'coccyodynia' but also of the hygromata cystica perinealea."

The above statement is extracted by the Medical Gazette from the "British Medical Journal 1868, No. 367," [May 02, p 424] and I regret that I have not access to the original article.

Upon what observations rests the assertion that coccyodynia, or coccygodynia, is caused by this gland, I am not informed.

It has then been suggested that coccyodynia depends on a morbid condition of the periosteum of the coccyx, of the tendons of the muscles attached to it, of some of the small muscles themselves, of the surrounding fibrous tissues, of the nervous fibrils, and, lastly, of the glandula coccygea; but, so far as I am informed, we have, as yet, no reliable data for determining the pathology of tins affection. If the seat is really this gland, it is a curious inquiry to ascertain whether the gland belongs alone to the female sex.

I will venture to start another suggestion with regard to the pathology. It is a well-known law, that where any chronic irritation is brought to bear on a muscle, a strong tendency to spasmodic contraction results, and acute pain is produced when any attempt to elongate the contracted muscle is made. Familiar examples of this are seen in the sphincters of the anus and vagina, from fissures of anus or ostium vaginae, or other sources of irritation; vaginismus from irritation of the carunculae myrtiformes; or, as sometimes happens, vaginismus from fissure of anus, or from hemorrhoids. In all these, some point of local irritation in the vicinity of the muscle excites spasmodic contraction, and any attempt at dilatation of the circular muscle gives exquisite pain. Future and more careful investigations may possibly show that the pain in coccyodynia is attributable to the spasmodic contraction of some of the muscular fibres connected with the coccyx. There is little pain except when motion is communicated to some one or more of the muscles connected with the coccyx, and in this it differs from true neuralgia.

Division of the muscles in question, as in fissure of the anus and in vaginismus, gives relief - The three cases I have here spoken of particularly, maybe called traumatic: one from fall on coccyx; one from fracture of coccyx in labor; and the third from hard labor with laceration of perineum. Other cases have occurred to myself, as well as to Professor Simpson, in which no cause could be assigned.

Baker Brown asserts that the most common cause of vaginismus is fissure of anus. In the case of Mrs. W. O. S-, the sphincter vaginae was drawn like a bow-string across the vagina, and pressed so hard on the urethra as often to render the passage of urine difficult.

In vaginismus J. Marion Sims tells us the sphincter ani is so contracted that it feels like an ivory ball. These facts show the sympathies which exist in this little circle of muscles, and how a point of irritation may radiate its influence. A direct injury to the coccyx by a fall or blow; an injury done in labor; a fissure of the anus or haemorrhoid; a fissure of the fourchette at the ostium vaginae; a sensitive condition of the caruncle myrtiformes as in vaginismus; vaginitis; in short, any point of irritation bearing on parts so sensitive as the rectum and vagina may excite spasmodic and painful contraction of the sphincters or muscles connected with the coccyx. In the case of Mrs. W. O. S-, the sphincter vaginae was so tightly drawn

across the ostium vaginae, and pressed so firmly on the urethra, that her husband thought it a cicatrix resulting from the laceration of perineum; in this, however, he was mistaken, as a careful examination showed the injury of perineum to have been slight, and the cicatrix almost imperceptible. The sphincter vaginae being intimately connected with that of the anus, its contraction drew the point of the coccyx directly forward, toward the pubes.

My attention has not been attracted to this point before, nor does Professor Simpson allude to contraction of the sphincter vaginae in cases of coccyodynia, and I must therefore leave this question for future investigation. I confess that I knew little about vaginismus before the book of Dr. J. Marion Sims was published, and might well have overlooked the contraction of the vaginal sphincter in my earlier cases.

Medication, local or constitutional, is of little avail in these cases, and nothing short of a surgical operation affords permanent relief. Prof. Simpson recommends two operations, the first of which I have no experience with, having always resorted to extirpation of the bone instead of the simple subcutaneous division of its muscular and fibrous attachments. His first operation consists in a complete separation of the coccyx from all its attachments. "To effect this," he says, "you must introduce a tenotomy knife underneath the skin, at a short distance from the tip of the coccyx, pass it along the posterior aspect of the bone, and then divide the muscular and tendinous attachments, first on one side and then on the other, and finally all around the tip of it."

This operation is simple, easy, and often, but not always, successful in giving relief. When this fails, he recommends the removal of the whole or part of the coccyx, according to circumstances. The latter operation, so far as I know, I was the first to perform for coccyodynia. I have performed it a number of times, always with more or less perfect relief, and in no case has it been followed by unpleasant consequences.

My method of operating is a little different from that of Prof. Simpson, and the operation performed on Mrs. W. O. S- will illustrate the method usually adopted by me. There was free motion only in the middle articulation of the coccyx, and when the finger was introduced into the rectum and motion communicated to this point, severe pain was instantly produced. I therefore determined to amputate at the movable articulation. The patient was placed on the right side, with the nates drawn close to the edge of the bed. The index-finger of the left hand was introduced into the rectum and made to press the coccyx firmly outward. With a short strong scalpel, an incision was made in the median line, down to the bone, extending a little beyond the articulation above and the tip of the bone below - the attachments of the bone throughout its whole length were freely separated on each side, and the knife passed through the articulation so as completely to separate the bones; the left hand was then disengaged, and the upper end of the detached bone being seized with Ferguson's bull-dog forceps, it was pulled firmly outward, and by passing the knife behind, it was lifted from its bed.

I have never before had any trouble with haemorrhage in a similar case, and although in this there was no visible artery, the haemorrhagic tendency (from the condition of the system) was so great that blood continued to ooze from every pore, and it became necessary to plug the wound with cotton steeped in persulphas ferri. This was an unfortunate necessity, as it caused irritation and pain, ami prevented healing by first intention, which usually takes place.

The wound was a month in healing, and while the parts were still very tender, the patient, feeble and unable to sit up, was compelled, by circumstances I need not specify, to start on a journey of a thousand miles by railroad. The result of the case, therefore, is yet to be learned, but I hope at some future time to be able to give satisfactory information. When she recovers sufficiently I have advised that the contracted sphincter vaginae be divided subcutaneously on each side of the fourchette, should the vaginismus continue.

I fear that I may not be up with the literature of this subject. I was at the South during the war, where the blockade was so complete that for four years I did not see a new book or journal, and since the war I have been roving about looking for a country and a home. I have not tried the simple operation of Dr. Simpson, but shall certainly do so, should a suitable case present itself.

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