ON 
COCCYGODYNIA, 
A Lecture Delivered in Chicago Medical College, March 20th, 1880, 
BY 
EDWARD W. JENKS, M. D., LL. D., 
Professor of Medical and Surgical Diseases of Women and 
Clinical Gynecology, in Chicago Medical College; 
Fellow of the Obstetrical Society of London; 
of the American Gynecological So- 
ciety ; etc., etc. 
“ La Medicine ne s'enrichit que par les fails." 
REPRINTED FROM THE MEDICAL RECORD (OF N. 
YD, YOL. XVII, NO. 16, APRIL 17, 1880. 
CHICAGO 
Bulletin Printing Company, 104 and 106 Madison Street. 
1880. OJNT 
COCCYGODYNIA, 
A Lecture Delivered iu Chicago Medical College, March 20th, 1880, by 
EDWARD W. JENKS. M. D„ EE. D., 
Professor of Medical and Surgical Diseases of Women and Clinical Gyne- 
cology in Chicago Medical College; Fellow of the Obstetrical Society 
of London-, of the American Gynecological Society; etc., etc. 
“La Medicine ne s'enrichit que par les faits'1’ 
REPRINTED FROM THE MEDICAL RECORD (OF N. Y.), VOL. XVII., 
NO 46, APRIL 47, 4880 
Chicago: A 
Buri-etin Print, 104 and 106 Madison StRej*t\ 
1880. R LECTURE ON COCCYGODYNIA 
Delivered in Chicago Medical College 
BY 
EDWARD W. JENKS, M.D., LL.D., 
PROFESSOR OF MEDICAL AND SURGICAL DISEASES OF WOMEN, AND OF CLINICAL 
GYNECOLOGY. 
Reported, Jor the (N. Y.) Medical Record. 
Gentlemen : 
Your attention will be directed to-day to a disease of which 
little has been written, and yet an affection which may be met 
with by every practicing physician, although not very frequently 
by any. The disease is known as coccygodynia, coccyodynia, 
coccygalgia or coccyalgia, and is an affection which seems to be 
peculiar to women. I am prompted to discuss the subject at 
some length now, as one of the patients of our clinic presents 
pronounced symptoms of the disease. 
This patient has been treated for uterine disease—a not uncom- 
mon occurrence—as coccygodynia has many symptoms which are 
frequently attributed to, or are sometimes associated with, either 
uterine or rectal disorders. She complains of pain in the coccyx 
when sitting upon a hard seat, that the pain is aggravated by 
coughing, sneezing or defecation. A physical examination of 
the pelvis and pelvic organs having been made, we find all of her 
pains were aggravated in attempting to move the coccyx. The 
bones are not inflamed, necrosed or apparently diseased in any 
way. When they are in a condition of perfect rest, there is no 
pain, but when moved by my hand or by the contraction of mus- 
cles having a coccygeal attachment, or by change of posture, the 
sufferings are severe. Without dwelling at present upon this 
particular case, I desire to direct your attention to a general con- 
sideration of the disease designated as coccygodynia. 4 
About twenty-five years ago, Sir James Y. Simpson directed 
the attention of the profession, in one of his public lectures, to 
a peculiar form of disease of the coccyx, which had hertofore bad 
no place in medical nomenclature, which he called coccygodynia. 
Since then this affection has been known as coccygodynia, coccy- 
odynia, coccygalgia and coccyalgia. 
The lectures of Simpson on diseases of women were begun 
twenty-two years ago, in the London Medical G-azette and 
Times, and continued to be published in that journal for the fol- 
lowing two years. 
These lectures were first published in the United States in 
1868. In one of his clinical lectures, Prof. Simpson directed 
the attention of his class to a case of disease in the hospital, say- 
ing, “you will find, I believe, no description of it in any book.” 
He further stated that he purposed subjecting the patient to an 
operation on account of her disease, such as, so far as he wras 
aware, had never been performed before, or, as he qualified his 
remark, “ at least under similar circumstances.” 
Although Simpson was the first to give a significant name to 
this affection, an American surgeon of distinction was the first to 
recognize its existence, as well as operate for it. 
The late Dr. J. C. Nott, of New York, but then a resident of 
Mobile, Ala., was the first to describe this disease in 1844, under 
the name of “neuralgia of the coccyx.” He published the his- 
tory of two cases in the New Orleans Medical Journal, one in 
1844 and the other later, in which the symptoms were fully given. 
In each case the bones of the coccyx were extirpated, resulting 
in the complete relief of the suffering patients. 
In consequence, Dr. Nott receieved many complimentary let- 
ters from prominent members of the profession, among which 
was one from Professor Charles Meigs, of Philadelphia, who at- 
tached great importance to the pathology and treatment of the 
disease brought to notice by Dr. Nott. It is related that the lat- 
ter gentleman, in return for the complimentary remarks by Prof. 
Meigs, sent to him the two extirpated bones, which were annually 
exhibited by Prof. Meigs to his classes, as long as he continued 
to lecture in Jefferson College. 
It was strange, that notwithstanding the publicity given to the 5 
papers of Dr. Nott, they failed to attract sufficient notice to be- 
come known to Simpson, and until quite recently there has been 
no allusion to the disease under consideration in the majority of 
the text-books upon either surgery or diseases of women. 
The name first given to the disorder by Simpson of coccy- 
godynia, was dropped for a time, and it was generally designated 
“ coccyodynia.” In the clinical lectures of Prof. Simpson, pub- 
lished in 1863, the term “ coccyodynia” is employed, but in the 
posthumous work of Professor Simpson, edited by his nephew,* 
coccygodynia is the word again made use of. It has also been 
adopted into the nomenclature of Robert Barnes,f and many of 
the leading European gynecologists. 
Coccygodynia is, etymologically, the correct term, rather than 
coccyodynia, coccygalgia, or coccyalgia, to designate this disease, 
the literal meaning of which is “ pain in the coccyx.” The 
name “ coccygodynia ” does not in the least define the pathology 
of the affection, as it simply means “ pain in the coccyx,” as we 
speak of pleurodynia or mastodynia, to designate pain in the side 
or breast. 
This disorder consists of a peculiar state of the coccyx, or the 
muscles attached to it, rendering their contraction and the move- 
ments of the bone very painful, presenting a condition analogous 
to vaginismus, or fissure of the anus, when disease causes painful 
contractions of the constrictor vaginae, or sphincter ani muscles. 
Coccygodynia is not infrequent, as many cases have been ob- 
served since the attention of the profession has been called to it 
by surgeons who had seen it previously without regarding it as a 
special disorder. 
The most marked peculiarity of coccygodynia is the sensitive- 
ness and pain about the coccyx when there is movement of the 
bone, or pressure upon it. Most of the patients affected by it 
are obliged to sit on one hip, or with one side resting upon a 
chair, and the dread of causing pain to the sensitive part makes 
them awkward and miserable; they dread sitting down, and the 
* Clinical Lectures on Diseases of Women, by Sir James Y. Simpson Bart. Edited by Alex- 
ander R. Simpson, m.d., etc. New York, 1872. 
t A Clinical History of the Medical and Surgical Diseases of Women, by Robert Barnes, M. 
d., etc. Philadelphia, 1878. erect posture, putting some of the muscles upon the stretch, 
causes pain, and thus many patients, able neither to sit or stand 
with comfort, become bedridden, and, as a consequence of the 
supersensitiveness of the coccygeal region, are compelled to 
so support their persons with cushions, that no pressure is allowed 
upon the painful part. A deep inspiration, coughing, sneezing, 
or any sudden muscular movement, causes excruciating pain. 
Again, there are other cases where the symptoms are not so ag- 
gravated ; some, when walking, will have pain with every step, 
while others can walk without any painful sensation. Others, 
again feel most pain when the bowels are evacuated, or under 
any circumstances in which the'sphincter, or levator ani, or the 
ischio-coccygeal muscles are called into action. The pain in 
some instances is not acute, whereas in others it becomes per- 
fectly intolerable. 
As the disease has symptoms which are frequently attributable 
to, or even sometimes associated with uterine or rectal disease, 
patients treated without obtaining the expected relief from their 
suffering and trouble despair of being cured, lose faith in thera- 
peutics, and expect, but all in vain, that the menopause will end 
their chronic discomfort. In this connection the mention of the 
menopause is significant of one peculiarity of this disorder, and 
that is the fact that it seems to be found only in women. Men 
may have inflammation or necrosis of the coccyx from traumatic 
causes, being analogous to coccygodynia, but the disease under 
consideration, upon the authority of the limited number of ob- 
servers, when induced by traumatism, seems to be from the class 
of injuries to which the pelves of women alone are liable. It is 
an important fact that the disease frequently manifests itself from 
other causes than traumatic, as many cases occur where there is 
not the least indication of injury, inflammation, or any form of 
disease of the bone itself. 
Drs. Simpson and Nott have found the disease exclusively 
among women; and Thomas, Barnes, Courty, Nonat, Gallard, 
Le Blond, Sindty, and other recent authors, include this disease 
in their several works upon gynecology. 
We have the most convincing proof that the pain of this dis- 
ease is due to the action of muscles attached to the coccyx, and 7 
this development is a necessary consequence of the greater size of 
the female pelvis. Then, again, as already stated, the pelves of 
women are subject to injuries to which the pelves of men are not 
liable. Dr. Simpson says that it is by no means very easy to un- 
derstand why the action of particular muscles should be attended 
with the production of pain in particular instances. It may be 
that the disease is confined to the tendons of the muscles, or the 
portion of the coccyx from which they spring; or possibly, cer- 
tain muscles, during their action, may bring the bone in contact 
with a supersensitive nerve or some inflamed structure, and thus 
give rise to the painful sensation. 
Dr. Nott, in a paper which was published in the American 
Journal of Obstetrics (vol. i., No. 3), and read by him before the 
New York Obstetrical Society, on Coccygodynia, spoke of an 
article taken from Virchow’s Archives of Pathology (I860, vol. 
xviii.), on the “ Glandula Coccygea of Man,” in which an ac- 
count is given of a small gland, usually about the size of a hemp- 
seed, situated on the anterior surface of the end of the coccyx, 
connected with filaments of the ganglion impar of the sympathetic 
nerve, and with the small branches of the arteria sacrialis media, 
between the levator ani and the posterior end of the sphincter 
externus. The gland is rich in nerves derived from the terminal 
branches of the sympathetic, which form microscopic net-works 
perforating the stroma, and are occasionally seen connected with 
ganglion cells. The writer says : “ Although the function of the 
organ is at present unknown, it is already of great interest to the 
pathologist because it is not only the seat of the so-called cocco- 
dynia but also of the hygromata cystica perninealea.” “Upon 
what observation,” adds Dr. Nott, “rests the assertion that 
coceyodynia or coccygodynia is caused by this gland I am not in- 
formed.” Barnes also calls attention to the article just mentioned, 
and adds of the glandula coccygea : “ When we consider its highly 
vascular and nervous elements and its position, we can hardly 
doubt that in some cases iUmay be the seat of coccygodynia.” 
Other writers seem to attach no importance to the “ glandula 
coccygea” as connected with this disorder. 
It is well to bear in mind the anatomy of the parts, in order 
to have a better understanding not only of the phenomena attend- 8 
ing the affection, but of its pathology. There are attached to the 
coccyx, the greater and lesser sacro-sciatic ligaments, the ischio- 
coccygei, the sphincter ani, and levator ani muscles, and some of 
the fibres of the glutei muscles. 
Certain movements of the body, as defecation, rising from the 
sitting posture, walking, etc., bring these muscles into activity, 
and it is a well-known law that where any chronic irritation is 
brought to bear upon a muscle, there follows a tendency to spas- 
modic contraction, and acute pain is produced whenever an effort 
is made to elongate the contracted muscle. 
I have alluded to the analogy between the disease under con- 
sideration and fissure of the anus and vaginismus. In these 
latter affections, irritation in the region of the muscles causes 
painful contractions. 
I am convinced, from cases coming under my observation, that 
the characteristic pain of coccygodynia is, in some cases at least, 
produced in the same way. Now we know that we can overcome 
the spasmodic contraction of vaginismus and fissure of the anus, 
by anaesthetizing the subject. I observed in one case, very 
markedly, that an attempt to examine a grumbling coccyx with- 
out an anaesthetic, caused the point to be drawn forward, and the 
muscles attached were made very tense, the contraction being 
accompanied by excruciating pain. The administration of ether 
caused the muscles to be relaxed, when the coccyx became exceed- 
ingly movable. Now, there is no pain in vaginismus or in fissure 
of the anus, when there is perfect rest of the parts, neither is 
there in coccygodynia; but, owing to the number of muscles 
attached to the coccyx, a slight movement of the body produces 
pain, because the movement involves their action. 
This leads me to speak of the causes of this disorder. It need 
not be due exclusively to any injuries received during the process 
of parturition, for we find it among those who have never borne 
children, and even in the young and unmarried. Among the 
assignable causes, other than child-bearing, are direct injury 
inflicted upon the coccyx by blows or falls, certain forms of exer- 
cise, as riding on horseback, or undue exercise of any kind, ex- 
posure to cold, and other climatic influences. I am myself con- 
vinced, from observation in several instances, that vaginismus, or 9 
fissure of the anus, or any source of irritation to the muscles 
included in the vaginal, perineal, or coccygeal region, may lead 
to this affection. Courty alludes to the local influence of cold in 
causing the disease, and cites one case caused by the patient’s 
habit of sleeping in bed with her “ seat applied against the wall.” 
Simpson and Scanzoni have observed the disease many times 
where the subjects had recently been in childbed. In nine cases 
mentioned by Scanzoni, the coccygeal pain was manifest imme- 
diately after the application of forceps. 
As previously mentioned, there are some symptoms attending 
coccygodynia similar to those found in uterine diseases, hence the 
danger among a class of diagnosticians who class all troubles of 
women under the one head of uterine disorders, of mistaking one 
for the other, and of attributing the sufferings, of which they 
complain, to the sympathetic pain of affections of the womb. 
Barnes,* writing of coccygodynia, states positively that he 
has “ traced it to retroflexion of the uterus.” 
Nonatf says, that with one of his patients this pain was caused 
by the introduction of a large vaginal speculum. Non it is of the 
opinion that coccygodynia “ presents two forms, differing by the 
nature and by the location of pain.” this pain has 
its seat specially in the sacro-coccygeal artie-Atarion, and then 
it may be of a rheumatic origin, or from a traumatic cause. He 
says that in the first it usually proceeds from exposure to cold, 
whereas in the latter it is usually provoked by some exterior vio- 
lence, as by a blow, a fall, an exaggerated distention of the 
articulation by the head of a foetus, forceps, or speculum. This 
author believes that sometimes the affection is of a nervous nature, 
and offers all the characters of neuralgia. It is then, especially, 
that it is to be ranked along with the neuralgic complication of 
uterine and peri-uterine affections. 
Nonat, who has written but little that is valueless, expresses 
himself so positively and clearly on certain points regarding coc- 
cvgodynia, that I quote further from him, not literally, but sub- 
stantially in the abstract as follows : “ When the coccygodynia 
is articular or sacro-coccygeal, it is augmented by pressure upon 
* Op. citat. 
f Maladies de l’uterus, Paris, 1874. 10 
this point, by movements of the extremities of the coccyx, and 
by all changes of position a little ‘ brusque.’ It is also increased 
by a sitting position, and by efforts at defecation. The pain is 
of a lancinating character, and extends to neighboring parts. 
“ It can exist independently of all uterine or peri-uterine affec- 
tions, but if present coincidently with one of these affections, it 
does not receive any modifications by their treatment. 
“ The neuralgic variety of coccygodynia does not occupy any 
seat as exclusive or as limited as the articular. The pain is more 
extended and more diffuse, extending to the parts near to the 
coccyx, sacrum, in the ano-perineal region, and in the direction 
of lumbar and sacral nerves. It is lancinating, and produces an 
hypermsthesia of all of the skin in the sacro-coccygeal region ; it 
is sometimes intermittent, while at other times it presents alter- 
nately, rcmittences and exacerbations. 
“ These exacerbations are sometimes of extreme violence ; they 
coincide more often with fluxionary and inflammatory recrudes- 
cences, which are themselves produced in uterine or peri-uterine 
affections, particularly at menstrual epochs.” 
Neuralgic coccygodynia coexists or alternates sometimes with 
other neuralgic^-pa,?is. 
When coccyb, ..ynia is associated with disorder of the uterus 
or its annexes, it follows often a parallel progress with these dis- 
eases ; increasing or diminishing with them, receiving a favorable 
influence from their treatment, and sometimes cured with them. 
In some cases, however, the coccygeal pain is rebellious, and 
persists long after the uterine or peri-uterine disorder has disap- 
peared. It then demands treatment for itself. Nonat seems to 
have devoted more space in his work than any other French 
writer has done to the consideration of this disorder. One of 
the very latest* volumes by a French author on “ Diseases of 
Women,” which, by the by, is an excellent work in many res- 
pects, devotes less than two pages to coccygodynia. In this 
chapter its pathological anatomy is disposed of in four lines, as 
follows : “ There has evidently been described under this same 
title affections of variable nature. It is thus that there has been 
* Manuel Pratique de Gynsecologie, par le Dr. L’De Sinety, Paris, 1879. 11 
found lesions of the periosteum, or of the sacro-coccygeal articu- 
lation, an abnormal mobility, or an increased length of the 
coccyx.” 
With the exception of this remarkable clause, there is nothing 
on the subject, by this author, but what has appeared many times 
before. 
A careful physical examination enables one to differentiate 
coccygodynia from any of the other disorders to which the region 
is liable. As a rule a valuable diagnostic sign is the extreme 
mobility, especially under the influence of anaesthetics, of the 
supersensitive portion of the bone drawn forward by muscular 
action. 
And now let us turn from the causes and the diagnosis of this 
disease to speak briefly of its treatment. 
Cases of coccygodynia which arise from climatic causes may be 
similar to cases of myalgia in any of the other muscular struc- 
tures of the body, will be of rather an acute type, and yield to 
very much the same treatment as is employed in myalgia. 
Chronic cases of a mild character will sometimes yield to epis- 
pastics or mild blistering, and anodynes administered either by 
the mouth or rectum. 
The hypodermic injection of morphia over the coccyx may 
overcome the irritability and painfulness of the muscles, and 
possibly effect a cure. But if the case does not improve in a 
short time under some of these modes of treatment we must have 
recourse to surgical art. 
So far as my own experience has extended, I agree with the 
majority of those whose observations of the disease are on record, 
that in well-marked cases medicine is of but little avail. 
Hence, we can understand why patients, deeming their disor- 
der incurable, refuse to have further medical attendance. On 
the other hand it will not do to leave the disease to nature, as 
patients gradually become worn-out with pain, and while waiting 
for nature’s tardy reparation, their vigor diminishes, oftentimes 
the chief reason being their inability to take any kind of exercise. 
Courty, writing on the treatment of this affection, begins by 
the statement that “a cure is difficult to obtain.” In illustration 
of this assertion he adds that in twenty-four cases observed by 12 
Scanzoni, ten only were terminated by cure; in nine there was 
simply amelioration; in the remaining five the definite results 
were unknown. The treatment employed was extremely varied, 
including leeches, blisters, belladonna, aconite, chloroform, mor- 
phine, etc.* 
It would seem from this, that he relied only on medication, 
and did not, in a single instance, have recourse to surgical 
measures. 
Courty further states that Ilorschelmann of St. Petersburg, 
“obtained, in 1862, two cures, thanks to aconite,” but both 
were children. This portion of the chapter concludes with the 
assertion that Simpson, who has seen all these means fail, first 
proposed the subcutaneous separation of the coccyx from its mus- 
cular attachments, and when this does not effect a cure he does 
not hesitate to remove a part, or the whole of the coccyx. 
The divisions of the disease by Nonat have a practical bearing 
upon its treatment that should not be lost sight of. 
I took the position several years ago, in a published paper on 
the subject of this lecture, that the disease is not neuralgic, and 
that the majority of cases require surgical treatment only.f 
There was at that time but little literature relating to coccygo- 
dynia, and the conclusions regarding it were based almost exclu- 
sively on my own observations. Increased observation and 
knowledge leads me to believe that there may be typical cases of 
articular and neuralgic coccygodynia, and that medical treatment, 
to be intelligently directed, must depend on their differential 
diagnosis. Further, in every instance therapeutic means should 
be given a full and fair trial before having recourse to any kind 
of surgical operation. I say this on the authority of reliable 
observers, rather than from my own observation; the truth 
being, that while I have had some patients cured by the admin- 
istration and local application of remedies, the majority of my 
patients with coccygodynia have been benefitted only through 
surgical interference. It is taught that the treatment should be 
different in one variety than in the other. For instance : in the 
* Maladies de l’uterus, etc., par A. Oourty, Prof, etc., Paris, 1872. 
f Coccyodynia. A paper read before the Mich. State Med. Soc., June 12,1873. By Edward 
W. Jenks, m.d., etc. 13 
articular form it is important that the patient should repose in the 
horizontal position in bed, thus securing immobility of the pelvis.* 
Each topical application of opium, or belladonna plaster, or 
chloral liniment, may often prove of service, but when the pain 
is severe, more potent remedies are required, such as the hypo- 
dermic injection of morphine, or atropine, or a combination of 
the two. 
In the neuralgic coccygodynia, according to Nonat,f “ if the 
disorder does not yield to the treatment directed to the uterine or 
peri-uterine affection, with which it is so frequently complicated, 
it should then be treated as a simple neuralgia; ” the use of 
topical applications are about the same as mentioned in connection 
with the articular form ; hypodermic injections of morphine, or 
atropine, are essential in this disorder; rectal suppositories of 
opium and belladonna may be used with great advantage. I have 
myself prescribed, with good results, particularly when the coc- 
cygeal pain was aggravated by defecation, suppositories of extract 
of stramonium. If the coccygodynia is of an intermittent char- 
acter, our principal therapeutic reliance is quinine, which should 
be freely and persistently administered. 
Nonat says that two cases treated by him, where all the means 
just mentioned had failed, he succeeded in curing, by the use of 
the actual cautery applied over all of the painful region. This 
author, who seems to have given medical therapeutics a fair and 
impartial trial, also concludes that the refractory cases that do 
not yield to treatment should be operated upon after the method 
proposed by Simpson. 
I have spoken somewhat at length on the medical treatment of 
this disease, for the purpose of informing you how much you can 
reasonably expect from medication, and also to show you by what 
process of reasoning experienced gynaecologists have come to the 
conclusion that while in some instances medical treatment will 
effect cures, there is a limit to it, where surgical aid must be 
sought, and through which radical cures can alone be effected. 
There are two operations possible for the cure of this painful 
disorder, neither of which are attended with any great risk to 
* Nonat, op. citat., p. 1620. 
f Op. citat., p. 1020, 14 
the patient. The first I shall mention is a subcutaneous opera- 
tion, originated by Simpson, which has for its object “ the com- 
plete separation from the coccyx of the muscular and tendinous 
fibres that are in connection with it,” upon a principle somewhat 
similar to common operations for fissure of the anus and for 
vaginismus. To effect this, a tenotomy knife may be passed un- 
derneath the skin at the inferior portion of the coccyx, then 
turned flat upon the bone, and all the muscular and tendinous 
attachments severed, first upon one side and then on the other, as 
far up as the sacro-coccygeal articulation. The operation is 
quickly and easily performed, attended with but little pain or 
loss of blood, and by this simple proceeding patients are not un- 
frequently instantly relieved from their sufferings, and perma- 
nently cured. 
Simpson relates one case of a lady who had long suffered from 
coccyodynia, where, while he was performing this operation, the 
slender knife broke deep in the tissues. 
He told the patient of it, and she at once raised herself up, 
alarmed to hear of the calamity ; “ but,” he adds, “ before I had 
done telling her of what had happened, she had time, in sitting 
up, to discover that she had been cured of her disease, and, re- 
joiced at the discovery, quickly replied : ‘ Oh ! never mind, my 
pain is gone—let the knife remain and there, for aught I 
know, it remains to-day.” 
The other operation is the extirpation of part or the whole of 
the coccyx. In very fleshy women the proceeding just men- 
tioned is not easily performed, and in the case of patients where 
the subcutaneous operation may have relieved for a time, but not 
permanently cured, amputation of the coccyx should be resorted 
to, as it effects a radical cure. 
There are certain conditions where I would perform the latter 
operation instead of prefacing it by the former, as when we have 
reason to think the bone is diseased, and in such cases, as with 
one of my own, where the coccyx was extremely painful and 
movable, and with the point drawn forward by the action of the 
muscles, so that the mobile portion was about at a right angle to 
the remaining part, acting as a foreign body and as a constant 
irritant. I also deem it better to remove the bone when it is both 15 
supersensitive and anchylosed, which, however, is an exceptional 
condition. 
The mode of operating for amputation of the coccyx is as fol- 
lows : Anaesthetize the patient, and place her upon her right 
side, that the index finger of the left hand may be introduced 
into the rectum to press the coccyx backward, and as a guide 
during the progress of the operation. 
Cutting down to the bone with a scalpel, it can be further 
separated from its attachments by means of scissors, or a knife, 
as we may choose, and selecting the location where amputation 
is to be made, we can then disarticulate at the joint, or follow 
the mode of Simpson, who used the bone-forceps and cut the 
bone without reference to joints. 
By one of the procedures mentioned, namely, separation or 
amputation, we can confidently expect a cure; and as neither 
is attended with danger, we are also able to class these opera- 
tions among the satisfactory ones of surgery. 
I cannot conclude without giving you two important points re- 
lating to amputation, which were taught me by my earliest opera- 
tions, as follows : 1st. In case you amputate the bone by means 
of cutting forceps, remember that,the bone of the stump should 
be “ rounded off,” so that there will be no sharp points to prick 
and annoy the patient whenever the 'skin of that region is made 
tense. In one patient I operated upon, where the removal of the 
bones of the coccyx put an end to a long period of sulfering in 
every respect, except the one just named, a second operation be- 
came a necessity. 
2d. I believe that disarticulation is the better plan ; and if 
you decide to operate by this mode, remember that in case there 
is articular cartilage on the stump, it should not be allowed to 
remain intact; on the contrary, you should cut away thin slices 
of the cartilage, by reason of which the process of healing will 
be quickened and made more perfect. 
70 Monroe Street, Chicago.