One of my patients, a virgin, fell backwards against the leg of a chair, and from this time forth suffered from pronounced coccygodynia, which resisted treatment for a year, and then gradually disappeared.
The chief symptom is pain, which is localized by the patient over the coccyx. Many patients told Scanzoni that the small bones at the anus were painful. The pain was generally localized over the coccyx, and the lower part of the sacrum. The locality was painful to pressure, and more to forward pressure than to backward, from the vagina or the rectum. The patients bore least of all an attempt to push the coccyx from its position. (Scanzoni.) We have already spoken of the influence of men struation and of affections of the genital system.
diagnosis of coccygodynia is not at all difficult. Motion imparted to the bone, especially by the finger, must be painful.
The first two cases of this disease were described by Nott (1844) under the name neuralgia of the coccyx. The patients were cured by extirpa tion of the bone. The one had become subject to the disease, as the re sult of a fall, the other from fracture of the ankylosed coccyx during labor. In the next monograph on this subject, by Simpson (1859), the name coccygodynia was given to it. For the most complete description, however, we are indebted to Scanzoni, 1861. His work records the his tories of twenty-four cases, which he saw within four years.
The prognosis as regards cure is not absolutely good. The majority of the cases have remained uncured, or else passed out of observation be fore cure was effected. In Scanzoni's twenty-four cases cure was noted ten times, nine were improved, two not benefited at all, and in three the result is not stated. Scanzoni noted recurrence in patients who had re mained well for from six to eight months. The difficulty of cure and the frequency of recurrence is explained by the number of muscles which are attached to the coccyx; the coccygeal, the levator ani, the sphincter ani, and muscular bundles from the gluteus maximus. Marked contrac tion of any one of these muscles may irritate anew the coccyx and cause recurrence of the old pain.
Since traction on and movements of the coccygeal joints are the chief causes of the pain, our aim should be directed towards preventing those. Rest in the lateral posture and soft fitcal passages will accomplish much.
In recent eases antiphlogistics are indicated, such as leeches, ice applica tions over the coccyx; after healing of the leech bites, poultices and painting with iodine. Generally, however, the affection is chronic when the gynecologist sees it, and then for the pain suppositories of morphia and belladonna or hypodermatic injections of morphia are indicated. From the use of the latter Scanzoni witnessed the entire disappearance of the symptom. Injections of atropine were also tested by Scanzoni, but he did not find them as effective as the acetate and the double Ineconate of mor phia.
In addition to the above palliative means, there are a number of drugs which may be given in a tentative way. In case of the rheumatic diathe sis Veit recommended the wine of colchicum seeds and vapor baths. Horschelmann gave to his two patients three drops of the tincture of aco nite every two hours night and day. Bergmann has reported a case where eight applications of massage permanently cured.
The ultimo ratio is extirpation, even as Nott did in his first reported case. giving complete rest to the bone by performing subcutaneous tenotomy, and severing all the muscles attached to the bone. The little knife was inserted at the apex of the bone, passed flat along its posterior surface, and the muscles of both sides and of the apex were severed. In many cases it sufficed to cut only the insertion of the gluteus maximus on one or the other side, or else that of the levator and sphincter ani. This subcutaneous tenotomy is simple of perform ance and not painful, and the incisions heal quickly. But all the cases in which it has been resorted to have not been cured. Simpson himself tells us that in one case it failed, and he was obliged to lay bare the coccyx and to remove it at the junction of the second and the third bone. In Nott's operation the bone is dislocated, and then cut out with the knife.
In 1870 Amann reported a similar case which had failed to yield to antiphlogistics, to galvanism, and to tenotomy after Simpson's method. Extirpation was followed by cure. In 1870 a case was also reported by Plum, who removed the entire bone on account of forward dislocation, and where cure eventually resulted.