The Medical Fortnightly (St. Louis)
Volume 8 number 12 December 1895
E. E. Montgomery
Jefferson Medical College
The second patient you also saw one week ago. She presents the following history: She is thirty-three years of age, married, father and mother living, and in good health. She has three sisters and a brother, all of whom are living and well. She had the common diseases of childhood, small-pox at eleven, rheumatism, pneumonia, and grippe. Menstruated at nine, was regular until twelve, when she says the flow stopped for two years. After this period she was regular. She was married at eighteen, and has had seven children, the youngest is six years old. Instruments were used during the first labor, when she was badly lacerated, also during the last. She has had one miscarriage.
Twelve years ago while working, she slipped and struck the coccyx against the corner of a lounge, which caused a fracture. This united without treatment, but projected somewhat more forward. She had a subsequent injury some two years ago, since which she has suffered much distress.
The history of this patient is interesting from several points of view. In the first place, she gives a history of menstruating at nine years of age. This is an evidence of precocity, as women usually do not menstruate until from thirteen to seventeen. It is well to remember, however, that there are cases upon record in which menstruation has taken place during the first year of the life of the individual, and the child at three years of age has been fully developed, showing all the evidences of a developed woman.
Pain in the coccyx is not an infrequent symptom, and may occur as a result of conditions independent of the coccyx itself. In this patient the trouble is undoubtedly due to the injuries she has received, as there is a history of two injuries, and as we introduce a finger into the rectum and move the coccyx with it, we recognize a distinct grating of bone, as if two bare surfaces were in contact.
Pain may also arise from an inflammatory condition of the sheathe of the muscles attached to the coccyx or in those of the ligaments, from thickening of the periostium of the bone, and in some cases as a reflected pain from diseased conditions of the uterus. It is not an infrequent thing to find a patient complains of pain in the coccyx or anus as a result of a retro-displacement of the uterus. So, too, we find similar conditions in what is known as painful metritis, where the cervix is large, heavy, projects backward and is situated low down. Such patients complain of pain in sitting, also in walking, and moving about.
The pain of coccygodynia is felt directly in the bone and in the muscles about it. It may occur from sitting or from walking, or change of position of the patient in bed, so the patient who has had a recent fracture and suffers from inflammation produced by it may be confined almost to one position, and be unable to change it without giving rise to a great deal of distress. In such cases, the act of defacation is attended with pain.
The coccyx is most frequently injured by a fall or blow, in which the person strikes upon some object which impinges directly against this bone. It may be produced, however, in labor, where labor takes place in individuals late in life, after the bone has become more or less anchylosed. The treatment of the condition will depend very much, of course, upon the cause producing it. Thus, if we find it is due to uterine disease, an effort should first be made to counteract and remedy that, in the hope that in so doing, the irritation in the coccyx will be relieved.
It has been recommended that subcutaneous incision be made, separating the muscles and ligaments from the bone. The plan of treatment, however, is rather ineffective, and consequently, is not frequently resorted to. The only operation in serious cases that affords any certainty of relief is the removal of the coccyx. This procedure consists in making an incision over the coccyx about one and one-half inches in length, extending from just above its articulation to the extremity of the bone, the lower surface of the bone is laid bare, its extremity is pressed against, rendering tense the posterior common ligament, which is cut through, opening the articulation. Having separated the articulation we then grasp the bone with a pair of forceps, and usually this can be done by passing them between the bone and the sacrum and the muscular and ligmentary attachments are cut close to the bone.
In doing this in this patient, we have wounded a branch of the middle sacral artery. This is seized with a hemostat and we pass the sutures around the surfaces so as to secure this vessel, in the first suture. The lower end of the sacrum was somewhat roughened and bare. I propose to cut a portion of this away with the rongeur and push the periostium over the extremity. The wound is then closed with sutures, passing the sutures around the entire surface so as to prevent the possibility of the formation of a cavity in which hemorrhage will occur. Having closed the wound with sutures we now wash it carefully before coating it over with collodion; place over it some gauze which is also sealed down with collodion. The gauze will be held in place by strips of plaster and a bandage. The catheter will be used for the patient for the first few days, after which she will be directed to lie upon her face to evacuate the urine, in order that in this way the dressing shall not be spoiled.
This patient should recover without any unpleasant symptoms and be well at the end of two weeks.