On coccyodynia, and the diseases and deformities of the coccyx

Medical Times and Gazette

1859, 40: 1-7

CLINICAL LECTURES ON THE DISEASES OF WOMEN, LECTURE 17

J. Y. SIMPSON, M.D. F.R.S.E.

Professor of Medicine and Midwifery in the University of Edinburgh

Gentlemen - In the first bed at the right hand corner as you enter the ward for female diseases there lies a patient, whose history is interesting and instructive in more than one respect.

But I call your attention to her case now inasmuch as she presents you with a well-marked instance of a disease of which you will find, I believe, no description in any book, and on account of which I have deemed it necessary to subject her to an operation, such as has not before, so far as I am aware, been performed, at least under similar circumstances. I shall, first of all, briefly relate to you the history of this case; then take occasion from it to make some observations on the nature and symptoms of the disease from which the patient suffers; and, lastly, try to point out to you how it may be most successfully treated.

E. F., a married female, of 40 years of age, has never had any children, but menstruated regularly and painlessly, and enjoyed good general health until about two years ago. At that time her menstrual discharges began to be more profuse and frequent than usual, and to be attended at times with pain. This she for a long time disregarded, believing the phenomena to be due to the "change of life;" but as she was becoming gradually weakened by the excessive losses of blood, she applied at my house for advice, about six or eight months ago, just after recovering from a severe attack of menorrhagia of three weeks' duration. In addition to the bloody discharges, and at the intervals between them, she suffered from a constant, foetid leucorrhoea; and she also complained of occasional shooting pains in the back and lower parts of the abdomen. She was much emaciated, and had a very cachectic appearance; and my nephew, Dr. Alexander Simpson, who then saw her, found the cervix uteri to be very much enlarged, indurated, and ulcerated; and it felt rough and irregular, like a commencing cauliflower excrescence, and bled freely when rudely touched. The ulceration and induration were not distinctly limited to the cervix, however, so that no hope could be entertained of curing the disease by amputation of the cervix uteri. But the dried sulphate of zinc was applied on several occasions, with the happy result of causing nearly the whole of the indurated and infiltrated mass to slough away, and there is now left a firm and healthy cicatrix. The patient does not now suffer from any unusual loss of blood, although she menstruates freely and regularly; and, so far as regards the uterus, she may be considered perfectly well, if we except a small hard knot in the anterior lip of the cervix, which may still, perhaps, be regarded as suspicious.

But as she recovered from her uterine disease, and as the symptoms attendant on it began to disappear, she commenced to complain, after sitting on the damp grass in her avocation as a washerwoman, of a dull, aching pain seated in the very lower extremity of the spinal column, for which my nephew contented himself with prescribing in the first instance a belladonna plaster, and afterwards various local anodynes and general tonics for a space of two or three weeks. As this pain, however, instead of abating, seemed always to become more constant and harassing, and as the patient could not sit down except on one hip at a time, and even then with the greatest suffering, an examination was made the painful part, when it was found that the coccyx was unusually straight and long, so that it reached far backwards and downwards, while the very tip of it was felt through the rectum to be projected suddenly forwards. Pressure of the coccyx and movement of it in any direction caused pain. To subdue this sensibility thirty drops of a watery solution of bimeconate of morphia were twice injected into the soft parts around the bone on two different occasions and, with an interval of several days between each injection. This measure had the effect each time of deadening the pain, but it led to no permanent result. The next step employed for her relief was the separation of the coccyx from all the surrounding muscles, tendons, and ligaments, which was done subcutaneously, with a tenotomy knife.

Three or four weeks afterwards the patient returned, saying that for a time she had felt better, but that during the last week she had suffered as much pain as ever, and was incapacitated for work from it. She was, in consequence, sent into the Hospital; and on Saturday, June 3, I removed the two lower segments, of the coccyx by cutting down upon them though the skin, and dividing the bone with a pair of bone-pliers; and then the separated portion being pushed through the wound by the finger of an assistant passed into the rectum, it was easily detached from the soft parts, and so removed. The edges of the wound were brought together with two iron wire stitches, which were removed some days afterwards, and the wound is now almost closed up.

Amputation of the coccygeal bones has been had recourse to in this patient, as it seemed to afford her the best chance of relief from a peculiar form of disease, which is anything but rare, although no written account of it has, as far I know, as yet appeared. If you will take the trouble to make inquiry of observing men in extensive practice, or if you have the opportunity of making the observation for yourselves, you will find that cases are ever and anon occurring, where the patient complains of pain in the region of the coccyx, very constant, and aggravated by certain movements of the trunk, and usually attributed by the patient to some kind of direct injury, or to exposure to cold. The most common cause of the disease, so far as I have been able to discover it from inquiries addressed to the patients themselves, is injury of the coccyx, inflicted either by falling backwards upon it, or, more frequently still, brought on by sitting down suddenly and forcibly on the corner of a chair or other angled body. Often enough, however, it is impossible to trace it to any traumatic origin; and the patient can only tell you, as in the case of our patient in the Hospital, that she had been sitting on damp grass, or had been otherwise exposed to cold before she began to experience the pain; or she may be altogether unable to adduce any assignable cause. I say she, because all the patients whom I have yet seen affected with this disease have been of the female sex; although I presume it is not entirely confined to them, and it is even not very clear why they should be more subject to it than the members of the other sex.

I have said that when you have been made aware of the possibility of the occurrence of this complaint, and when you begin to look out for it, it is by no means very rare. Diseases, like other objects in nature, sometimes seem rare, not because they are so in reality, but merely because our attention has not happened to be fully called to the recognition of them as they pass before our eyes. I think you will hold me justified in making this remark, when I tell you that within the last three weeks I can count up at least ten cases of this particular malady which I have seen in private or consultation practice. Of course, it is a very unusual. circumstance to meet with so many during such a short period; but it is not more wonderful than what often enough occurs in the experience of all Surgeons in extensive practice, who find that during a short space of time they may have a succession of cases all presenting the same form of injury, as an epidemic, as it were, of fractures or dislocations. and that a long period may elapse before they again meet with a similar case. Such a rapid succession of cases of the kind I allude to is, I repeat, of course an exceptional occurrence. But I know of old, and, on looking back upon many past years of practice, that I have seen and recognised a great many cases of this disease; and I have probably seen many others also, the true nature of which I did not at the time understand. It is, therefore, I believe, by no means an uncommon disease; and if you can discover and succeed in curing it, you will often get much credit to yourselves. That you may be enabled to do so, let me tell you how you are to detect it, or point out to you

THE SYMPTOMS OF THE DISEASE

The leading symptom of the disease is pain in the region of the coccyx experienced by the patient whenever she sits down and rises, and sometimes while she remains in a sitting posture. Most of the patients affected with it are obliged to sit 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; and they are rendered sometimes very awkward and miserable in consequence. Some of them actually dread sitting down - so great is the pain then felt; and not only so, but, as I have hinted already, the pain is in many cases aggravated or renewed whenever it becomes necessary again to resume the erect posture. There are other movements of the coccyx besides, which are liable to be attended in such cases with pain. Thus some patients have pain with every step they take in walking, while in others the movements of progression excite no uneasiness whatever. Others, again, 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 or intolerable; and you will sometimes meet with patients who have borne with it for many years, sometimes without having sought any relief at all, sometimes in despair from the inefficacy of the remedies that have been employed. I have under my care just now a patient suffering from menorrhagia, who tells me she has been annoyed more or less for about twenty years with a pain of this description in the coccyx, not very severe, but which she has never found any means of alleviating, though formerly she consulted various physicians and surgeons on the subject. Again, the pain is not at all times equally severe in the same patient. When in Cumberland lately, I saw a lady who had kept her bed the whole winter, because of the excruciating pain which she experienced in attempting to sit upright or walk about; but who, at the time when I saw her, had got so far relieved as to be able to move about a little. 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 site of the coccyx, to which it is always specially referred by the patient, and where pressure always aggravates it. Pressure and movement of the coccyx too, with the finger in various directions, produces pain, and the kind of movement which is thus attended with suffering, differs in different cases.

NOMENCLATURE OF THE DISEASE

If it be desirable, as I think it is, to give the disease which I have described a distinct designations, I think that by availing ourselves of the Greek (odyni, pain), which enters into the composition of several names already sufficiently familiar to our ear we can construct a name for this disease that will serve for admission into a nosological list. We are constantly in the habit of speaking of pain in the side as pleurodynia and the designations gastrodynia and mastodynia are in common use for pains in the stomach and pains in the mammae; and following this analogy, it seems to me that we might very conveniently refer to this painful affection of the coccyx under the analogous name of coccyodynia. Besides that it is sufficiently terse to be easy of use, the designation presents this great advantage, that it involves no pathological theory as to the nature of the affection, but simply expresses its most striking symptom. But what theory can we form as to its proximate cause? or what, in other words, is

THE PATHOLOGICAL NATURE OF THE DISEASE?

I believe that the pain which is the characteristic of coccyodynia is excited during the action of particular muscles, or particular sets of muscles, and that when the coccyx, or rather the coccygeal joints, have been in any way injured, or when it or its surrounding fibrous tissues have become the seat of inflammation, or other morbid change leading to super-sensitiveness of the part, any action of the muscles in connexion with it which causes motion of the coccygeal bones will, at the same time, give rise to a feeling of pain. Now, in order to understand aright the circumstances under which pain is likely to be produced by the action of muscles on an inflamed or otherwise diseased coccyx, I must beg of you to recall to mind your knowledge of its normal anatomy; and to revive your recollections on this subject, I show you here a sketch of the coccyx in its muscular and tendinous relations, which has been obligingly drawn for me by our able demonstrator, Dr. Cleland, from a dissection made for the purpose by my former class-assistant, Dr. Peter Young. (See Fig. 1.)

Fig 1. Sketch of the anatomical relations of the coccyx

This will serve to remind you that the coccyx gives attachment along either side to portions of the greater (a) and lesser (b) sacro-sciatic ligaments; and that as regards muscles it has inserted into it, 1. the internal extremity of the fibres of the ischio-coccygei (f), which arise at their outer extremity from the inner surface of the tuberosities of the ischia, and pass directly inwards to be attached to the outer border of the coccygeal bones along its anterior aspect; so that when both muscles are in action at the same time their tendency is to draw the coccyx somewhat forward, and when only one is in action the coccyx will be drawn to the corresponding side. Then, 2. from the extremity of the bone spring the tendon of the sphincter ani (d), and some of the fibres of the levator ani (e) which have a powerful effect in pulling the end of the coccyx inwards whenever any straining action of the muscles that close in the pelvis becomes necessary, as in defecation, coughing, etc. But, 3. the most powerful muscles connected with the coccyx are the large gluteal muscles (h) of either side, some of the tendinous and muscular fibres of which rise directly from the posterior surface of the bone (c), while others may come to act upon it indirectly by means of their origin from the great sacro-sciatic ligament.

In sitting down and in rising up the glutei of both sides are simultaneously in action, and during progression when the body is swayed from side to side they act in succession. Now I have already told you that in some patients pain is experienced most severely during these movements, and I think that in them the pain is fairly referable to the traction upon the coccyx exercised by the great glutei muscles. Other patients, again complain of pain 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 to the portion of the coccyx from which they spring; or, possibly, certain muscles during their action may bring the bone into contact with a super-sensitive nerve or inflamed structure, and in this way give rise to the painful sensation. Again, the fact or the disease being more common in women than in men, or being confined indeed almost exclusively to the former, may be due to the greater development of the gluteal muscles, which results from the larger size of the female pelvis. It is not necessarily due to lesions sustained during parturition, although sometimes so produced; for it occurs as frequently in the young and unmarried as in those who have passed through one or more confinements; and more probably it is dependent in some way on the peculiar form and large size of the female pelvis, and on the greater development of the gluteal and perineal muscles which result therefrom. But, however that may be, we have most convincing proof that the pain is elicited by the action of the muscles in the fact that separation of the fibres of these muscles from the coccyx often affords the most effectual and instantaneous relief. And this leads me to speak next of

THE TREATMENT OF THE DISEASE.

Formerly, before I knew much of the nature of the complaint, I used to have recourse to many different remedies, and many different modes of treatment, in order to procure for my patients relief from their pain. Opium, in its various forms, belladonna, hyoscyamus, and a variety of other sedatives, were all administered internally, or applied locally; but only in general with the most temporary benefit. Suspecting that the pains might have somewhat of a rheumatic character, I in some instances caused the patient to make use for a length of time of the remedies which are usually most efficacious in the treatment of diseases dependent on the rheumatic diathesis; and in other cases I have administered the various preparations of iron, zinc, arsenic, and other antineuralgic tonics for a lengthened period; but generally none of these modes of treatment seemed to afford any real relief, and by none of them have I ever succeeded in effecting a permanent cure, except in it very limited class of cases.

There are some cases where the pain seems to be due to acute inflammation, probably of the sacra-coccygeal articulation, or of some of the joints between the several segments of the coccyx itself; and in such cases I have seen great benefit result from the application of leeches over the part, followed by counter-irritation, while the patient was kept at perfect rest, and subjected to other antiphlogistic treatment. I have I sometimes tried the use of acupuncture needles; and not infrequently I have had recourse to the subcutaneous injection of a solution of morphia into the tissues around. the coccyx; and this plan of treatment, which is usually so successful in the treatment of local neuralgias, has comparatively seldom had the effect in this disease of relieving the pain, and never, so far as I can remember, of producing a perfect and permanent cure.

All kinds of constitutional treatment, and most forms of topical applications, are often, however, almost or altogether of no avail for the cure of this disease; and the only means of obtaining radical relief - and happily it is a means which proves successful in almost every case - is the complete separation from the coccyx of the muscular and tendinous fibres that are in connexion with it. To effect this, 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 round the tip of it. It is not in every case necessary to make such a free division as I have indicated. In some instances division of the fibres of the gluteus maximus of one or the other side will suffice, or detachment from the coccyx of the sphincter and levator ani may be all that is requisite for a cure. This simple operation is easy and rapid of performance, like other examples of subcutaneous surgery is not attended with bleeding, and is attended with no great degree of suffering; and the result is in almost every case instant relief of the pain, and in most cases a perfect and permanent cure of the disease. In illustration of these remarks, perhaps you will allow me to read you the history of a case of this disease which was cured in the manner I have described to you. The patient was a lady from India, who came under my care several years ago; and the history of her case, which I am now about to read to you, was drawn up for me by the lady herself.

"On the 6th November, 1862, while taking my usual morning ride on my favourite horse, about fifteen hands in height, he suddenly shyed. I was thrown, and so severely shaken and injured that I fainted on the spot, and could not suffer to be touched or moved for a considerable time thereafter. On being taken home I fainted again, from the excessive pain in the lower extremity of my body, which baffled all and every remedy to alleviate or remove; and for six weeks I could neither turn nor attempt to move from my couch. At length I began to get about again, suffering great inconvenience from my accident both in a sitting and reclining posture - the latter especially, which in travelling caused me intense and most excruciating torture. Indeed, after travelling some hours in a carriage, I quite dreaded getting up to step out of it, as I could not do so without severe spasms. I returned to England early in 1853, and hoped its bracing climate would speedily rectify all that was amiss with my back; but in this sanguine expectation I was disappointed, and still doomed to drag on a miserable and wretched existence up to the 4th March, 1855, when, as if by magic, I obtained immediate relief from a slight operation performed upon me by Dr. Simpson."

The treatment in this case consisted, I say, of the isolation of the coccygeal bones from the surrounding tissue by means of a tenotomy knife; and the result of this simple operation has proved as satisfactory and permanent as the relief obtained by it was instantaneous and complete. In the case of another lady, from India, who had long suffered from coccyodynia, while I was performing the same simple operation to effect her relief, an accident occurred. I was dividing the last fibres of the coccygeal attachments, when the slender knife gave way, and broke among the dense structures. I told the patient of it, and she at once raised herself up in alarm to hear of the calamity; but before I had done telling her of what had happened, she had had time in sitting up to discover that she had been cured of her disease, and rejoiced at the discovery. She quickly replied, "Oh! never mind; my pain is gone - let the knife remain." And there, for aught I know, it remains to this day - an illustration of a pathological law to which I have already directed your attention in the course of these lectures - viz, that pieces of iron and other metals may remain in contact with the living tissues, and may lie imbedded in their midst for any length of time, without giving rise to any marked degree of inflammatory action.

And the striking effects of this simple operation for the cure of coccyodynia are not confined to those cases where it is had recourse to at a comparatively early period of the disease. I have under my care just now a patient who has been a martyr to it for twelve years past, and who night and day used to suffer great pain whenever she made any movement of the body. Yet in her case, isolation of the coccyx in the manner I have described to you, produced immediate relief, and ever since the operation was performed, a fortnight ago, she has been perfectly free from pain.

I have met with one or two cases of coccyodynia, however, which I have failed to cure by means of this operation; and where division of the muscular and tendinous fibres - even the most complete - and thus setting the coccyx perfectly free and perfectly at rest for a time, has merely eased the pain temporarily without relieving the patient of it altogether. In our patient in the Hospital the operation proved thus unsuccessful, and, therefore, I put in practice, what I had often thought of having recourse to, the more radical measure of removing altogether the coccyx or a portion of the bone. This amputation of some of the segments of the coccyx was resolved on the more readily in her case, because in her the several bones of it seemed firmly anchylosed, and it at the same time projected unusually low down, and was turned suddenly inwards at the tip. Making an incision of about two inches in length through the skin stretched tightly over the end of the bone, I exposed the latter, and having separated it from its connexion with the soft parts, and divided it between the second and third of its vertebrae with a pair of bone pliers, its two lower segments were easily removed. I have another patient suffering from this disease, in whom I have repeatedly had recourse to the isolation of the coccyx by means of the tenotomy knife, but always with the effect of producing only a temporary relief; and in her case I have long proposed to perform an operation similar to that performed in the patient in the ward, if the results prove as favourable as we desire, and as there seems at present every reasonable prospect of attaining. Removal of portions of the coccyx is an operation that has been performed more than once before, in cases of necrosis in some of its segments; but I believe its performance under the circumstances I have been describing to you, is altogether novel.

I have said, that as a general rule, the result of constitutional treatment of any kind affords us little hope of being able to cure this disease by its adoption. But, as I have already hinted there is a class of cases, of which I have seen a few rare instances, where the pain seems to partake somewhat of a neuralgic character, and where I think I have seen the patient benefited by the use of the remedies which are usually employed for the cure of neuralgic affections. At all events, wherever you find a patient complaining of pain the coccyx, who at the same time is affected with pains in the other parts of the body, and who has the unhealthy chlorotic aspect common to those subject to neuralgia, you would do well in such a case to put your patient through a course of iron, arsenic, zinc, manganese, or other nervine tonics, or to make her use some of them in combination for a time. By this means you may possibly succeed in curing the coccyodynia and in dispelling her other symptoms; and should that plan of treatment fail in effecting a cure, it will still form a very good and safe measure preliminary to the adoption of the severer but more certain operative procedure. I would only add, in connexion with this point, that there is a leash of nerves lying all round the coccyx; and I once imagined that the relief obtained by isolation of the bone was due to section of these nervous cords; but now the explanation of the phenomenon which I have already given you seems to me to me the more probable, and that when the coccyx is separated from the surrounding tissues, no more pain is experienced, because the bone is by this means freed from the action of the muscles formerly in connexion with it, and is thus placed in a condition of absolute rest.

As I am speaking of the coccyx, you will allow me to add that, if more attention were directed to the pathological and anatomical history of this organ than has hitherto been accorded to it, it would probably be found to be subject to diseases and disorders such as have hardly been even suspected. In the wide field of anatomical and pathological investigation, gentlemen, there is still much room for original observation and research; and the corner of it, to which I am now trying to turn your attention, has hitherto remained entirely unexplored. We have no thesis or monograph of any kind on the subject of the coccyx in its pathological relations; yet the organ is subject to various morbid conditions which are well worthy of careful examination. I have been telling you something about one of these morbid states, to which I have ventured to give a name and a place in pathology; and now, to interest you still more in the matter, and to show you in what direction inquiry might be most profitably directed, let me briefly indicate to you some of the other lesions to which the coccyx is liable. And, first, a word or two as to the

INJURIES OF THE COCCYX IN CONNEXION WITH PARTURITION.

The coccyx is, as you know, articulated to the lower end of the sacrum by a joint resembling those which unite together the several vertebrae higher up in the spinal column; and this sacro-coccygeal articulation is sometimes found to be inflamed, as a result of injury sustained during the parturient process. While labour is going on, as the head of. the child descends along the . floor of the pelvis; the coccyx can often be felt to be stretched very much backwards, and under the strain to which they are subjected some of the fibres of the anterior ligaments which bind this bone to the sacrum may be torn and give way; and in the joint thus exposed and injured inflammation is very apt to be set up. I have seen it swell up and become very painful from this cause after delivery; and in one case the inflammation thus set up led to the formation of an abscess. Or without producing any such immediately bad effects, the inflammatory process may subside and end merely in the production of anchylosis of the sacrum and coccyx, and then the evil effects of it may pass unnoticed till the patient comes again to be in labour, when it will be found that the unyielding bone presents a great obstruction to the progress of the foetal head. A good many cases have been put on record where it was averred that fracture of the coccyx had occurred during labour, and where, probably, the accident was of this nature, that the sacrum and coccyx had become anchylosed together as a result of some foregoing inflammation in the joint; and under the pressure to which the coccyx was subjected during parturition the morbidly adherent bones became again disunited. If the coccyx be turned very much inwards toward. the cavity of the pelvis at the time when it becomes united to the lower end of the sacrum, the obstruction which it then otters to labour will be much greater than when it remains in its normal position after anchylosis had taken place and it may then be found necessary to have recourse to some operative measure to promote the progress, and to admit of the termination of the labour. What operation should be performed in such a case? Some say that it then becomes necessary to destroy the child, and to effect delivery of the mother by means of craniotomy; but if you will observe the course pursued by nature when allowed to terminate such a case unaided, you will find that she has a much simpler plan, which you can easily imitate, and by following which you may succeed in bringing the labour to a successful termination, without having recourse to the dreadful operation of craniotomy. What nature does in such cases I had once an opportunity of observing in a patient who was confined in the old Lying-in Hospital here. In a former labour this patient had suffered some injury of the coccyx, which ended in its becoming anchylosed to the sacrum at such an angle a to cause it to project inwards towards the cavity of the pelvis where it now formed a firm and unyielding obstacle to the progress of the foetal head. For when the head descended t the point in the floor of the pelvis, where the point of the coccyx was protruding, it was there arrested, and remained fixed and immovable for a length of time, when at last during a strong contraction of the uterus, the projecting bone gave way under the pressure of the child's head, the adherent bones were separated from each other, and the child was speedily expelled. And in every case of this kind, I think it would be better to break up artificially the morbid union that exists between the sacrum and the coccyx, than to have recourse to the deadly alternative of the destruction of the infant.

SURGICAL INJURIES OF THE COCCYX

by which I mean fractures and dislocations of the bone occurring accidentally and independently of the parturient process are not of very frequent occurrence in ordinary everyday practice, although a good many cases have been put on record. They were mostly produced by the patient having fallen backwards; and the striking features peculiar to every case are - 1. The intense pain suffered by the patient when the coccyx was moved, as in the act of defecation, coughing or walking; and 2. The instantaneous and complete relief afforded by the reduction of the displaced bone. I should like to cite to you two of the cases of this kind that have been published - one, because you have all the more common symptoms of the injury very concisely and touchingly recorded; the other because of the peculiar manner in which reduction of the dislocation was effected.

Smetius, a Professor of Medicine in the University of Heidelberg in the end of the sixteenth and beginning of the seventeenth century, has left a kind of diary on record of some of the most interesting cases that fell under his observation during the space of forty-eight years, and among the entries there occurs the following delectable entry:- "1588, October 27th .- My wife has fallen backwards, and so injured the coccygeal bone, that she cannot sit without great gain, nor can she empty the bowel or the bladder, or cough without much distress." In the "Ephemerides Medico-Physicae" one Gustavus Casimirus Gahrliep tells of an accident that befell his father-in-law, an old septuagenarian, who in descending the steps of a palace when they were slippery with ice and snow, lost his footing, and fell with the lower end of the trunk against the stone stairs. He sustained a fracture of the os coccygis in consequence, but said nothing about it to his daughter, a young girl, who was the only person living with him at the time. He could get no passage in his bowels; and. his daughter, believing this to be the cause of the distress which she saw him labouring under, administered some aperients, but without affording any relief. He had become seriously ill on the fifth day. When he spoke of his accident to a sagacious friend, who told him that perhaps his spine was injured and advised him to allow himself to be rolled and tumbled and pushed about, as he lay on a wooden couch, by two robust women. He followed his friend's advice, and with the happiest result; for by the jostling the end or the os coccygis which was bent inwards was restored to its situation, and the obstruction being removed the bowels were moved cum impetu sumno.

Allow me to quote a third case, which will show you in what a simple manner this accident may sometimes be occasioned. Jobi Meek'ren, an old Surgeon of Amsterdam, gave to the world in his "Medico-Chirurgical Observations," among other cases, one in which this accident - dislocation of the caudal bones - took place. The patient, he tells us, was a female, addicted to the sect of the Anabaptists, who went to the watercloset, and not knowing that the lid was down, suddenly injured her coccyx, so that she could neither sit nor stand, and was obliged to be carried to bed. On the second day the pain became greater, and she fevered and got convulsions; and then Meekren was called in in consultation with her ordinary attendant. They suspected the nature of the case, but the modest lady would not allow herself to be touched.

But during the night her sufferings became so intolerable that her medical advisers had to be summoned again early in the morning; and this time they were allowed to reduce the dislocation which afforded her instantaneous and complete relief. But besides being liable to be turned forwards, whether as a result of inflammation or injury during the process of parturition, or as the effect of direct violence from a fall or blow, the coccyx is found in some cases to project unusually far backwards. I do not refer now to those cases of which there are some few on record, and in which this dislocation of the coccyx backwards has been produced during labour, and has remained afterwards as a permanent but usually painless condition; the variety I allude to belongs rather to the class of

MALFORMATIONS OF THE COCCYX.

In the woman in the hospital the coccyx was unusually straight, and the general inclination of the bone was somewhat backwards, although the last segment of it was turned rather abruptly forward and projected towards the rectum. In her case it is not easy to determine whether this condition of the bone was present from birth, or was the result of some injury in after life. But in a late number of the Dublin Medical Press, Dr. Wilson gives an account of a patient with a projection resembling a tail, attached to the lower end of the spinal column; and in the last number of the same journal there is a paper by Dr. Jacob, reprinted from the Dublin Hospital Reports, in which he describes a tumour of this kind that had been amputated by his father, and in which he speaks of a family several of whose members presented this remarkable variety of malformation. In the "Chronicles of Lanercost" it is related that the Norman sailors used to believe the Englishmen to be furnished with tails, and when they had to execute them they hung them always with a dog alongside, thus anticipating the principle of similia similibus.

DEFICIENT DEVELOPMENT OF THE COCCYX

has sometimes been seen as a rare instance of deformity. The number of segments is liable to much deviation ; but its total want, or its existence in a merely rudimental condition, is rare. Perhaps the most frequent and striking instances of this kind of deformity occur in the domain of Comparative Anatomy. Thus in the Isle of Man there is a breed of cats all the members of which are born without tails, the coccygeal bones being reduced in number to a very few, and these rudimentary in character. Absence of the caudal bones, I repeat, in man is a rare phenomenon, although their existence at all is not often suspected by those who have no knowledge of anatomy, some of whom have entertained the most singular ideas on the subject. Perhaps no theory was more singular than that of Lord Monboddo, an old Scottish judge, who believed that the absence of the tail was a phenomenon peculiar to the modern human races, and that the modern curtailment of this appendage was a result of their higher degree of civilization. The worthy judge, at an early period of his investigations, believed that we must all be still born with tails, and that possibly the wise women and the doctors cut or twisted them off the moment the child was born. It used even to be told against his Lordship, that on one occasion when an addition was about to be made to his own family, he was caught hiding in the bedroom, in some corner of which he had secreted himself with a view of watching all the proceedings, and witnessing for himself the removal of the new-born infant's tail.

The remainder of the paper concerns congenital tumours of the coccyx, not coccyx pain.

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