The American Journal of the Medical Sciences
1876, Vol.71 (141), pp. 122-124
Nyack, N. Y.
The number of cases on record of ablation of the coccygeal bones for the cure of coccygodynia are few, though the disease is of comparatively frequent occurrence. I have had occasion to resort to it twice, in otherwise incurable cases, with the following results:-
CASE 1 - Miss W., aged 29 years, a strong built, muscular woman, fell, in March, 1872, from a chair upon which she was standing, to the floor, striking heavily upon her fundament. The contusion of the soft parts was quite severe, and the pain and soreness which followed confined her to the bed for several weeks, when it partially subsided. Since then her health has failed her, and she has lost flesh and strength.
Failing to get relief from her suffering, she finally came under my care in May, 1873, fourteen months subsequent to the injury. She then complained of severe pains through the pelvis, but more particularly in the region of the rectum, which were always aggravated by walking, by rising from the sitting posture, during defecation, by pressure, and by any motion which brought the muscles of the parts into play. She also complained of dragging pains in both ovarian regions, and of great irritability of the bladder. Upon examination per rectum I found great tenderness upon pressure against the coccyx, the two lower bones of which were displaced and pulled forward towards the rectum. Upon examination per vaginam, I found the uterus acutely anteflexed - the fundus pressing upon the bladder and very sensitive to the touch. Menstruation was regular, but very painful, the pain extending through the whole of the pelvic organs. She informed rue that previous to her fall she had never suffered pain during the menstrual period, nor from any uterine ailment. I am, therefore, inclined to believe that the flexion was produced by the fall - suddenly - in the same manner that retroversion and retroflexion are produced by like causes. The nature of the disease and the remedy for it were explained to the patient. She assented to an operation, and accordingly, on June 2, 1873, I proceeded to remove the two displaced bones. After anaesthesia by ether the patient was placed on her right side, the nates being brought close to the edge of the bed; the index finger of the left hand was introduced into the rectum, and the bones pressed well back, when, with a scalpel, an incision two inches in length was made in the median line down to the bone, and its attachments severed from it as far as possible. The left hand was then disengaged and the bones seized with a strong forceps, drawn outwards, their remaining attachments severed, and the bones removed without difficulty.
Severe pains shooting through all the pelvic organs followed the operation for several days, requiring the liberal use of opium. There was also retention of urine for three days, rendering the use of the catheter necessary. The wound was dressed with a weak solution of carbolic acid; the discharge from it was very profuse for ten days, and nearly six weeks elapsed before it healed.
CASE 2 - Miss S., aged about 25 years. Four years ago she missed her footing and slipped down a fight of stairs, injured her coccyx, and severely contused the neighbouring soft parts. For two weeks she was confined to the bed. Since that time she has been more or less of an invalid by reason of pain located in the region of the rectum, and radiating through the pelvis. The pain, as in the previous case, was increased by any act which caused pressure on, or motion in, the parts. She also suffered severely from dysmenorrhoea. Upon examination per rectum I found the parts in the vicinity of the coccyx very painful to the touch, the two lower bones were freely movable, but not displaced. The uterus was in its normal position - the fundus much congested and very sensitive.
She, like Case 1, had consulted several physicians without obtaining much relief, as the true nature of the disease had not been recognized.
May 31, 1875. I removed the two lower bones of the coccyx as in the preceding case.
The wound was dressed with lint soaked in solution of salycilic acid in oil. Severe pain followed the operation for more than two weeks. There was retention of urine for eight days, requiring the use of the catheter. The wound of operation did not heal until two mouths after.
Remarks. - The result of these operations was a cure of the coccygodynia, and relief from its disagreeable attendants. The subject of Case 1, after appropriate treatment, entirely recovered from the uterine complication, and is now in perfect health. Of Case 2, the patient is still under treatment for her .dysmenorrhoea with what result remains to be seen.
The operation is simple and easy of performance, but the constitutional disturbance following it is out of all proportion toils magnitude - though as far as I am aware it is devoid of danger. The subsequent pain is very severe, and lasts for days. The wound is slow to heal, and the discharge is profuse and thin. This condition of things may depend upon general debility induced by disturbed nutrition following long-continued pain.
Since the differentiation of this disease by Drs. Nott and Simpson, the coccygeal bones have been occasionally removed for the cure of it, and with successful results, especially in eases of traumatic origin. Five cases have come under my observation - two the result of falls, and three from difficult parturition; of the latter class there was neither fracture nor displacement of the bones. Two of these were cured by palliative means after long-continued treatment. The third is still under observation. In the majority of cases the disease is of traumatic origin, and, when fracture or dislocation of the bones has occurred, the only remedy is excision. Subcutaneous section of the attachments of the coccyx may be sufficient in other eases, especially those of neurotic origin, where no palpable lesion exists, and of this class of cases many may be cured without resort to surgical procedure, though it is the most efficient method of treatment.