Boston Medical and Surgical Journal
128: 36-38. January 12, 1893
R. E. Darrah
In view of the infrequency of the occurrence of caries of the coccyx and of the fact that it ís often unrecognized until a late period of the disease, it occurred to me that a report of these cases might be of interest to you. They are three in number, and occurred in the service of Dr. H. L. Burrell, of the Boston City Hospital (whose kindness in permitting me to make use of them I desire here to acknowledge), and were admitted as cases of ischio-rectal abscess and fistula.
Case 1. D. McC, fifty-three years of age, married, carpenter, came under the care of Dr. Burrell, July 7, 1890.
Family history was negative. He always had been well, with the exception of haemorrhoids, which had troubled him for years, bleeding at times, protruding at stool and accompanied with more or less pain.
The following history was obtainable: He had had an abscess, followed by another one-and-one-half years ago. Both broke, and there had been a continuous discharge from them ever since. He had had two operations, the sinus slit up and the sphincters dilated and stretched. The wound had never healed, and he never had been without pain. Within the past four months an abscess had formed again on either side; the one on the right breaking, and there had been a thin watery discharge from it ever since. Appetite poor; bowels constipated. There was no history of injury.
Physical examination showed that posterior to the anal opening there was an old granulation surface - gray, with a moderate amount of purulent discharge from it. On either side of the buttock there was an old wound, from which there was considerable purulent discharge; marked induration and reddening about it. On the left buttock there was a moderate, sensitive, indurated swelling. No faeces through the wound. Flaxseed-meal poultices alternating with iodoform dressing were applied for one month, when he was examined in consultation with Drs. Gavin and Post. An injection into one sinus ran from one sinus to another. A probe was passed backwards toward the coccyx when roughened bone was detected. He complained of much pain in this region. Five days later he was etherized, and the usual antiseptic precautions having been taken, Dr. Burrell made an incision in the median line directly over the coccyx; then a director was passed through the sinuses and they were slit up into the first incision. The periosteum was retracted, and the coccyx was found roughened on the lower surface. The articulation between the sacrum and coccyx was divided with bono forceps and the coccyx dissected out in three pieces. The remaining sinuses were opened into the rectum, and the whole curetted. Deep silk sutures were placed, except on a small portion of the median line, which was packed with iodoform gauze, and iodoform dressing applied.
The recovery was uneventful, the bowels moving on the fifth day. A few of the sutures were removed, and all were out on the tenth day. The wounds were irrigated with corrosive sublimate (1-3000) and dressed whenever the bowels moved. Six weeks later he was discharged from the hospital. There were no subjective symptoms. The wound, which had been allowed to granulate, was nearly healed, with the exception of a small granulating fistulous tract extending directly forward toward the rectum. He returned for a change of dressing a few times. At the end of two weeks the wound was closed.
He was seen at his house about one month ago, and said that the wound remained closed six mouths; then it opened, and from it there was a thin, watery discharge (at times a little blood); that he never had had any pain since the operation, and was enjoying good health. Physical examination shows a line of old cicatrices about the anus, with a sinus in the median line, three-fourths inches therefrom passing directly forward into the rectum. (I think the sinus which closed and broke down again only closed on the external side, never on the rectal. He intends entering the hospital again for closure of the sinus.)
Case 2. H. W. B., twenty years old, single, driver of a milk-cart, was admitted to the hospital September 11, 1890.
Family history negative. Always well until two years ago, when his present trouble began, which he thinks was caused by riding. At that time he began to have pain, and noticed a small swelling on the left buttock near the anus, which increased in size, and broke. Later, another formed; and he was operated on one year ago.
A few weeks ago he noticed another swelling on the same side, which burst and from it there has been a constant discharge ever since. He has had pain varying in severity most of the time - more severe when sitting. Appetite good. Bowels regular. Urine negative.
Physical examination showed on the left buttock an irregular scar three inches long, curvilinear in shape, one inch to the left of the fold of the buttock. The tissue was indurated about this — fluctuating at one spot. From a small opening a sero-purulent fluid was discharged on pressing the surrounding tissues. On the left side of the fold between the buttocks was the cicatrix of an old opening. On the right side, opposite the latter there was some induration of the tissues, which was not well defined.
Two days later, following the usual antiseptic precautions, he was etherized, and Dr. Cragin (Dr. Burrell being present) inserted a director into the sinus, which passed through to an opening on the inner side of the buttock. This was laid open, and pus of a watery consistency evacuated. Another fistulous tract was found, traced to the surface and opened. The walls of the sinuses were apparently cartilagenous in consistency and were cut out.
A passage was found leading down toward the coccyx which was roughened. An incision was made directly over the middle of the coccyx posteriorly, and carried down to it; the periosteum was retracted; and the coccyx then removed by means of bone forceps. Curetted and irrigated with corrosive sublimate (1-3000). The edges of the wound were brought together with deep, heavy silk sutures, and a corrosive dressing applied.
There was very little pain following the operation. On the sixth day the stitches were removed, the greater part of the wound having united by first intention. There was a symetrical area of slough about the region of the old scar. Iodoform dressing. Three weeks later the wound was healed, with the exception of a small shallow sinus, which was dressed with iodoform; and he was discharged from the hospital.
Two weeks ago he forwarded a statement, saying that the wound closed one week from the time he arrived home; that he had had no trouble since, until four months ago, when a small abscess, about the size and shape of a bean, appeared in the old cicatrix; that he had lanced it himself, and there was a discharge of blood; that it healed readily in a few days and was then perfectly well. He considers himself cured.
Case 3. P. J., thirty-eight years of age, single, carriage-driver, was admitted to the hospital October 10, 1890. Family history was negative. Always well until eight months ago, when he noticed a hard lump on the left side of the buttock which gradually increased in size, and broke four months ago; from this there has been a thin, watery fluid discharging ever since. He has had pain varying in severity since the lump appeared. No history of injury, appetite fair. Bowels constipated. Urine negative.
Physical examination showed, just to the left of and posterior to the anus, a small red infiltrated area in which there was a very small opening.
Through the kindness of Dr. Burrell, I operated on the patient the following day. The usual antiseptic precautions having been taken, he was etherized and a probe passed into the opening, which went posteriorly toward the coccyx, and roughened bone was detected. A director was passed along the sinus, and it was thoroughly laid open down to its origin, the coccyx. Excision of the coccyx was considered, but it was thought unadvisable, as the patient's permission for the removal of it had not been obtained. The roughened bone was thoroughly curetted as well as the whole fistulous tract. The wound was irrigated with corrosive sublimate (1-3000) and the edges brought together with silk sutures and a sublimate dressing (1-3000) applied. Very little pain followed the operation. The sutures were removed on the seventh day. The wound was irrigated and dressed whenever the bowels moved. Twenty days from the time of the operation he was discharged at his own request. There remained a small granulation area from which there was considerable discharge. He reported to-day that the wound healed a year and a half later. During this time there had been a thin, watery discharge, but no pain.
In reviewing the literature of the subject I have been able to find only twenty cases reported since the first operation was performed for removal of the coccyx in this class of cases. The operation for removal of the coccyx was performed by Dr. J. C. Nott, in Mobile, in 1844. A resume of his case may be interesting as it illustrates the type of cases occurring in females. A woman fell striking on the coccyx. Pain persisted for two years. Within this time she was delivered of a child. Continuous pain and tenderness over the coccyx and abnormal mobility were the principal symptoms noted.
Including the cases I have reported to-night, nine cases have occurred in males and fourteen cases have occurred in females. There was a history of injury in all except four cases. Pain (which was continuous) existed in all the cases except two (not noted by the reporter whether it was present or not). In some of the cases it was the only symptom noted; this was especially noticeable in cases occurring in females, following parturition.
Multiple and persistent sinuses occurred in twelve cases, including all the males. Excision of the coccyx was performed in all the cases except four. In three cases there was no relief from the operation. One complicated with uterine disease, and one complicated with tubercular disease of the hip and spine, died. One died, following incisions and curretting, of sepsis. One recovered after incision and curetting.
From the above, I think, we can draw the following conclusions.
(1) That caries of the coccyx occurs very infrequently.
(2) That it is more common in females than males.
(3) That there are these important points in considering the diagnosis of these cases: (a) history of injury; (b) constant pain; (c) multiple and persistent sinuses (not always present); (d) that persistent sinuses should lead one to suspect caries of the coccyx; (e) that excision of the coccyx is the best treatment for all cases when there is disease of that bone.
Note. — Precautions taken previous to operation: bowels moved with cathartic the day previous to operation, and by enema on the day of operation. Parts should be scrubbed with soap and water, alcohol, ether and corrosive sublimate (1-3000).
Guy's Hospital Report, London, 1889, xxxi, 191-196.
Edinburgh Obstetric Journal, 1884-85, x, 183.
British Gynaecological Journal, London, 1885, i, 319.
Excision of the coccyx. Lancet, 1886. Volume 128, Issue 3281, 17 July, Pages 112-113. Walter Whitehead
Canadian Practitioner, 1880, xii, 253.
Transactions Medical Society, Newark, N. J., 1880, 228.
A case of removal of the coccyx; remarks. The Lancet, May 28, 1887, Vol. 129 No. 3326 p 1088. William Odell
Philadelphia Medical Times, 1887, xviii, 351.
Homeopathic Journal of Obstetrics, Now York, 1888, x, 9, 124, 199. 308.
Edinburgh Medical Journal, 1885-6, xxxi, 318.
New York Medical Journal, 1879, xxx, 517.
Boston City Hospital Records, 1890, C, i; 1, 209; ii, 145.