Dublin Quarterly Journal of Medical Science
1867, Volume 44, Page 477-481
Geo. H. Kidd
Assistant Master to the Coombe Lying-in Hospital.
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Coccyodynia is the name proposed by Sir James Simpson for a painful affection of the coccyx, of not uncommon occurrence, but not recognized or described in books, till he gave an account of it in the Medical Times and Gazette for 2nd of July, 1859. Since then Erischen, in the fourth edition of his "Surgery," has given a short account of it, founded on Simpson's paper; and Dr. Wast has described it in the third edition of his work " On the Diseases of Women," under the more correct, but not so convenient term of coccygodynia, the name suggested by Scanzoni in a very elaborate paper published in the Wurzburger Medicinische Zeitschrift, and which has been followed by Dr. West in his observations. In this paper Scanzoni gives an account of twenty-four cases, but as many of them were accompanied by various affections of the uterus and neighbouring organs, and the pain ceased on the removal of the associated disease, they can scarcely be considered cases of the affection described by Simpson.
The leading symptom of the disease is, according to Simpson, pain in the region of the coccyx experienced by the patient whenever she sits down and rises, and sometimes while she remains in the 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, 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 the pain is, in many cases, aggravated or renewed whenever it becomes necessary to resume the erect posture. There are other movements of the coccyx besides that 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 circumstance 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 varies as to its severity in the same patient at different periods. It is always increased by pressure on the coccyx, and more so when the pressure is made from the point upwards; and it is always increased by moving the coccyx with the finger, but the kind of movement that most aggravates the pain differs in different cases.
The pathological cause of the pain, according to Simpson, is disease of the coccyx or of the coccygeal joints, or inflammation of the surrounding fibrous tissues, arising in general from some injury inflicted during labour, or in some other way. In one of his cases it was caused by a fall from a horse. Two of Scanzoni's patients referred it to frequent long rides on horse-back. South mentions the case of a gentleman who fractured his coccyx by sitting down suddenly on the corner of a snuff-box, and who was ever afterwards obliged to wear a pad on each tuber ischii to keep off pressure.
In many cases the disease cannot be traced to any definite cause. One of Simpson's patients attributed it to sitting for a long time on damp grass. It may occur in the male or female, in the married or single woman, but the most frequent cause is injury to the part during childbirth. Of Scanzoni's twenty-four cases, eleven of the patients attributed the disease to this cause. When the diseased condition is once established every movement of the muscles, or structures connected with the coccyx, causes pain, and prevents the part from regaining a healthy condition.
For the treatment of the disease Simpson recommends the subcutaneous division of all the muscles and fibres connected with the coccyx, so as to isolate it and allow it to remain at rest, which he has found to give almost immediate relief in most cases, but in some it has failed, or the relief has only been temporary, the pain returning after a time. In one of the cases detailed in his original paper this occurred, and he subsequently removed the coccyx entirely; and I find, by a notice in the Edinburgh Medical Journal, that this woman was exhibited at a meeting of the Edinburgh Obstetrical Society on the 28th March, 1861, and she then stated that, "since the operation had been performed " (two to three years probably) "she had found herself perfectly well, and was now able to do all her ordinary work as a laundress, for which she had been utterly incapacitated."
M. Gosselin has recorded a case that he had under his care in the Hopital Beaujon, in which subcutaneous section of the muscles was tried, but, he says, failed. Hesitating to adopt the extreme measure of removal of the coccyx, he again had recourse to palliative treatment, and suggested the simple use of an india-rubber air-cushion. "After the patient had steadily continued this plan for twelve days, she had so far lost her pains as to be discharged from the hospital in a fair way of convalescence, since nature herself, the stress on the parts being taken off, would doubtless complete the cure, under the favourable auspices of rest." M. Oosselin says it was found necessary to regulate the bowels by a rhubarb aperient, to prevent hard motions passing over the tender part.
The Editor of the Gazette des Hopitaux quotes, in connexion with this case, a similar one, cured, he says, in a similar way, which fell under his observation some years ago; but it will be observed that in M. Gosselin's case the cure was not by any means complete when she left the hospital, and in the case that has been recently under my care, a long-continued and careful trial was made, before the operation, of india-rubber cushions, and other devices for keeping off pressure, without any benefit whatever.
Scanzoni states that leeches to the coccyx, tepid baths, warm fomentations, and, if the pain have a neuralgic character, subcutaneous injections of morphia, have seldom disappointed him in effecting a cure. He never found it necessary to adopt the subcutaneous section. I have already mentioned that in many of his cases the pain appears to me to have been only sympathetic or reflected, and I find that of the twenty-four cases but ten were cured, nine were relieved only, the result in three cases was not known, and in two the evil remained unrelieved by any treatment.
Mr. Bryant has published a case in which he performed the subcutaneous section with perfect success, and Dr. Godfrey, of Sonora, has published a case in the American Journal of Medical Science, in which he had operated also with success. The disease had lasted ten years, and the patient stated "that she had consulted a dozen of the best physicians in Tennessee, under whose treatment she successively was for a good while, without deriving any benefit from it, and finally they pronounced her incurable.''
I have not been able to find in our systematic treatises or journals, any references to the disease beyond those I have noticed thus briefly, and I believe the disease has not hitherto been described by any of our Irish writers, nor has Simpson's operation for it been performed in Dublin, so far as I can learn, except in the following case, in recording which I beg it will be understood I make no claim as to novelty of observation or peculiarity of treatment.
On the 23rd June, 1866, I attended a young lady in her first labour. She had a very long and an unyielding perineum, and when the head came to press on it, there was very considerable delay, though the uterus acted strongly, and I feared there would be laceration, which, however, did not take place. The case was one in which I might now be inclined to adopt the practice suggested by Dr. Beatty in the paper he read before the Obstetrical Society, on rigid perineum, at the beginning of this Session. Convalescence took place without impediment, but when the lady began to move about, she found she suffered great pain in the coccyx. This pain corresponded exactly to the description given by Sir J. Simpson. It was greatest in sitting down and rising up, and it continued all the time she sat. Walking sometimes pained her, but she had no pain when lying or in defecation.
On several occasions I made most careful examinations of the part and surrounding organs. There was no disease to be detected in the uterus, or its appendages, nor did the rectum present anything abnormal. There was some thickening at the articulation of the coccyx with the sacrum, and pressure here caused great pain, more so than at any other part. I confined this lady to the sofa for sometime when she first complained, and gave iodide of potassium, and applied iodine over the part, but though this was continued as long as her general health would permit, she derived no benefit. I then allowed her to sit up and move about a little, making her use an air-cushion, but this gave no relief. She thought a firm cushion of a horse-shoe shape, and stuffed with hair, was better than the air-cushion, but neither this nor the local use of sedatives, nor tonics, and change of air, were of any real service. At length I determined to suggest the subcutaneous section of the muscles, being influenced to do so, in a great degree, by hearing from Dr. Beatty, in the course of a conversation on the subject, that all the patients he had met having this disease had died of phthisis, and I saw that my patient was daily losing strength and flesh from the constant pain she suffered. When I proposed it, she at once consented, and told me then, for the first time, that her mother, though she recovered ultimately, had suffered from the same disease for many years of her life, and was often obliged to kneel at table instead of sitting down.
On the 30th of March last, I proceeded to perform the operation assisted by Mr. Maurice Collis. Having congealed the skin over the part with Richardson's apparatus, I introduced a narrow long-bladed tenotome at the point of the coccyx, and passed it on the flat, close to the right side of the bone, to above the part that I had found tender on pressure. I then turned the edge so as to cut from behind forwards, and, keeping close to the bone, divided all the tissues on that side. I now carried it round the apex, cutting all the fibres attached there, and, without taking out the knife, passed it up on the left side, and divided the tissues there in the same way as on the right. Only a few drops of blood escaped through the small aperture in the skin, and I applied a compress and bandage to limit the subcutaneous hemorrhage, which was, notwithstanding, considerable, and was followed by inflammatory hardness and swelling, so that she could not sit, but even before this was gone, she found, greatly to her delight, that all the old pain had disappeared, and she has remained perfectly free from it ever since, and has improved in strength and condition. I may mention, as showing her freedom from pain, that on the 16th of May, she drove for five hours on a common outside car through the County Wicklow, without any inconvenience.
8th June, 1867.
P.S. - Since this paper was read at the Obstetrical Society, I have received a copy of a most valuable work, by Warren, of Boston, entitled "Surgical Observations, with Cases." The author has devoted a section to injuries of the coccyx, and details six cases illustrative of the severe and long-continued symptoms arising from injury to this bone. Mr. Warren believes these resemble most closely the acute pains which attend periosteal inflammation. "Scarcely an instance," he says, "can be said to have resulted in perfect recovery, and many of them have caused severe local symptoms for some months, and even years, afterwards.'' In the first case the injury was caused by a fall on the stairs, "the pain and inability to sit lasted more than a year, and the sensitiveness of it continued for ten years after the accident." In the second case, also caused by a fall on the stairs, there was some displacement of the bones, which was adjusted at the time; at the end of six or seven months the patient was able to walk a little about the room with support - " she did not recover from the immediate effects of the accident for one or two years, and now, at the end of eight years, is not able to ascend stairs without suffering." Another of the patients had the coccyx fractured and displaced some years before. "At the time, she was confined about five weeks with very severe symptoms, and never ceased to suffer in the part since." Remarking on these cases, Mr. Warren says Dr. Simpson has described the affection, "and in some obstinate cases, after having tried all remedies in vain, proposed, and practised with success, the girdling of the coccyx by subcutaneous section, just above the diseased part, so as to cut off all nervous communication with it." Mr. Warren does not seem to have performed any operation for the disease himself, and it will be seen from the foregoing he has not correctly apprehended Simpson's operation, or the objects proposed to be attained by it. I may further mention that the lady I operated on continues, now October, 1867, perfectly free from pain.