Treatise on the diseases of women

Coccyodynia

1899, New York, D. Appleton and company. Page 172-175

Skene, AJC.

This affection was first described as a neuralgia of the coccyx by Dr. Nott in the "North American Medical Journal," May, 1844, [Note - in fact it was in the New Orleans Medical Journal] but it attracted little attention until 1801, when Sir James Y. Simpson revived the subject and gave it the name which it now bears.

Pathology.

Pain upon moving the coccyx and contracting the muscles attached to it is the chief characteristic of this disorder. The morbid conditions found are variable. Fracture and dislocation of long standing and caries of the coccyx have been discovered in some cases; in others, no appreciable lesions can be detected. It is presumed that, in the absence of structural changes of the bone and muscles, the pain may be due to rheumatism of the tendons of the muscles or neuralgia of the nerves distributed to them.

Symptomatology.

There is little or no suffering while the patient is at rest, but upon rising, sitting down, or evacuating the bowels, pain over the coccyx is experienced. Sitting is painful in some cases, owing to pressure upon the bone. Any sudden movement is attended with suffering. Some patients are unable to rise from a low seat without assistance.

Physical Signs.

Tenderness upon pressing and moving the coccyx is the chief diagnostic sign. Painful haemorrhoids, fissure of the anus, and spasm of the adjacent muscles caused by ascarides in the rectum, may be mistaken for this affection, but they can be excluded by physical examination.

Prognosis.

Some cases of coccyodynia are slight, and wear away on time without special treatment; but, though the disease may not perceptibly injure the general health of the patient, it is often of such long duration, and occasions so mnch suffering and inconvenience, that it is necessary to resort to surgical means for relief.

Causation.

Women who have borne children are the most frequent, though not the only, sufferers from this disorder. Injuries sustained in parturition, or blows upon the coccyx, exposure to cold, and diseases of the ovaries and uterus, are its chief causes.

Treatment.

The surgical methods of treatment are those practiced by Prof. Simpson and Dr. Nott. Neither of them is dangerous, and one or the other is certain to give satisfactory results.

By Prof. Simpson's method an ordinary tenotomy-knife is inserted at the lowest point of the coccyx, and passed flatwise between the skin and cellular tissue till its point reaches the juuction of the sacrum and coccyx. Then the knife is turned and withdrawn, making a subcutaneous incision which entirely severs the muscles over one side of the coccyx. The same operation is repeated on the other side. No hemorrhage is to be feared in subcutaneous operations unless some large vessel should be cut.

An easier operation, and one more likely to effect a cure, is performed by exposing the coccyx through an external incision, raising the extremity of the bone, and severing the muscles with a pair of scissors. The subcutaneous operation, always difficult, is nearly impossible where the bone is covered with much adipose tissue.

Should the bone itself be diseased, section of the muscles would not effect a cure. In such cases the coccyx must be laid bare, disarticulated by the knife, and amputated, according to the method of Dr. Nott

The complete removal of the coccyx is the only method which has proved satisfactory in my practice. Nott's method of operating is to expose the coccyx, detach the muscles, and then take it off from the sacrum with the bone-forceps. In this operation there is danger of injuring the sacrum, and causing a subsequent necrosis. I therefore prefer to disarticulate with the knife or scissors, cutting through the cartilage.

While all my operations have been finally successful, I have several times seen great suffering and slow healing follow.

The subjoined cases will illustrate the pain and suffering which may follow the operation.

Illustrative cases

Removal of the Coccyx and Lower Segment of the Sacrum; Recovery.

A married lady, twenty-four years of age, was thrown from a carriage and injured by falling upon her back and side, bruising the lower end of the spine, and having what was supposed to be a fracture of the neck of the femur. After recovering from the immediate effect of the accident, she suffered from severe pain in the coccyx. At first the pain in that region was almost continuous, and greatly aggravated by locomotion. For about six months from the time of her accident she was tolerably comfortable while resting, but suffered greatly when moving around, especially upon rising from a chair or sitting down or turning in bed. She also had severe attacks of sick headache and pains in the back of the neck.

On physical exploration it was found that the coccyx and lowest segment of the sacrum projected inward at nearly right angles to the axis of the sacrum. In this dislocation the coccyx was firmly fixed. The dislocation and the tenderness gave rise to violent pain on defecation.

The operation consisted in removing the coccyx and the lowest segment of the sacrum. A free incision was made and all the muscles and attached ligaments were separated, and then the part to be removed was carefully disarticulated without any injury to the bone. The operation was done with all antiseptic precautions, all haemorrhage was controlled, and the edges of the wound were brought together with sutures, and dressed with absorbent cotton.

On recovering from the anaesthetic she complained of the most agonizing pain in the lower half of the back, pelvis, and limbs. This pain continued for the first three days, and was only partially controlled by largo hypodermics of Magendie's solution, ten minims, every two to four hours.

An effort was made to relieve the pain with opium given by the mouth, but, although seven grains were given in twelve hours, it was necessary to repeat the hypodermics to give her relief. During all this time of suffering the wound appeared to be healing, there was no undue inflammation, and no suppuration. Five days after the operation the pain was more easily controlled by the morphine, and then the sutures were removed, and the pain from this time onward diminished quite rapidly. At this time the wound appeared to be completely healed, but a portion of the cicatrix broke down, and subsequently healed by granulation. From this time on her progress was entirely satisfactory, the pain subsided in the neighborhood of the wound and spinal column, and she was entirely relieved from her sick headaches.

Removal of Coccyx; Extreme Pain after Operation; Delayed Healing of the Wound; Final Recovery.

This was a married lady who had one child about eight years old. She had suffered from pelvic cellulitis following miscarriage, so that her health was very much impaired. She fell down-stairs and injured her coccyx about two years before she came under my observation.

She recovered completely from her pelvic cellulitis. She developed all the symptoms and physical signs of coccyodynia. The operation was performed in the usual way, and every care taken to secure a good result. After ligating the small vessels, which bled rather freely, there was a little serous oozing, so, before closing the wound with sutures, I introduced a few strands of catgut for drainage, and dressed the wound with borated cotton.

From the time of the operation she had a great deal of pain and tenderness in the region of the wound; this pain and tenderness increased until it was necessary to giVe anodynes liberally to relieve them. After about five days the violent pain subsided, but the wound was still exceedingly sensitive; the drainage-threads were removed about the second day, and the sutures at the end of one week. The union was complete, except a sinus in the center which extended downward the depth of the original wound. This promptly closed up after a few more weeks, but there was still great tenderness remaining there. She returned to her home thirty days after the operation, with the wound apparently healed but still tender. She was free from her occipital headaches and from most of her distressing symptoms.

Some time after her return home the wound reopened, and, although every care was taken of the case by the physician in charge, it was nearly six months before it healed entirely. Through all this time she was free from the suffering which she had before the operation, but the wound was still tender. Since then she has been perfectly well.

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