1886. Volume 128, Issue 3281, 17 July, Pages 112-113
Surgeon to the Manchester Royal Infirmary
The following two cases which have recently occurred in my practice illustrate the advantages, under certain circumstances of excision of the coccyx.
CASE 1. - X. Y., aged fifty-nine, male, has for the last twelve years suffered from distressing pain in the seat. He has consulted various surgeons both in London and in the provinces, but without obtaining relief, and his various advisers had failed to diagnose any sufficient cause for his symptoms. I was asked to see the case with Dr. Livy, of Bolton, the patient's private medical adviser, who told me that the case was one of ischia-rectal abscess suspected to be associated with some diseased condition of the coccyx. An examination confirmed this opinion, and I determined to cut down upon and investigate the condition of the parts. This I did two days after first seeing the patient.
An opening which had been previously made into the abscess, above and just within the right tuber ischii, was freely enlarged, and a sinus leading into the rectum just above the internal sphincter was laid open. A second sinus was now found, which, on exploration with the finger, was ascertained to lead to a necrosed coccyx. An incision was then made immediately over that bone in the middle line, and through it were removed the last three segments. The wounds were thoroughly scraped so as to remove all unhealthy granulation tissue, and they were then plugged with iodoform gauze.
Immediately after the operation, the temperature, which had previously ranged as high as 105°, fell to the normal, and never again rose above 100°, at the same time the general health of the patient improved rapidly. The pain from he which he had previously suffered disappeared at once, and has not returned, and the wound healed well and rapidly.
CASE 2. - E. R., aged thirty-seven, male, on consulting me, gave the following account of himself. His occupation is that of a piano dealer and tuner. For the last fifteen years he has been subject to attacks of pain, at first infrequent, at intervals of about a month, and not very severe; latterly these attacks have been as frequent as once or twice weekly, and his pain has been much more severe. The pain is always brought on by the commencement of the act of defecation and is in the region of the anus; when it occurs he has severe tenesmus and a desire to further empty the bowel, . the pain meanwhile increasing in intensity, and often detaining him in the closet for two hours at a time. After such an attack more or less pain will remain throughout the day, and even during the whole of the following night. He can suggest no cause for the origin of these symptoms, except that he has always had a tendency to constipation.
Some time since, however, he fell and struck the coccyx against a piano, but this appears to have been subsequent to the onset of the disease. He has hitherto found a certain amount of relief from the use of a warm sitz-bath, but this has not been of great efficacy, and all other measures have proved futile. On examination and especially on pressure over the posterior part of the rectum, pain is caused exactly similar to that caused by defecation. Finding that the seat of the pain was apparently the coccyx, and discovering that bone bent at a right angle, and having the history of an injury, I excised it by a median incision, without opening the rectum. The parts healed at once, relief from pain was complete, and there has been no return since the time of the operation.
In addition to these two cases in males, I had under my care, about ten years ago, five cases of coccygodynia in females, all produced by injury during parturition, and in all of which I removed the coccyx, with immediate and complete cure of the disease.
The treatment of coccygeal pain falls under three heads, viz.: 1. By means of rest and anodynes. 2. By complete or partial separation of the bone from its muscular connexions. 3. By excision of the bone. As in other cases our method of treatment must always be guided by the nature of the case. Thus in those where the pain is due to hysteria or to reflected irritation, owing to uterine or ovarian disease, it would obviously be unsurgical to remove the coccyx. There are, however, a large number of other cases, in which surgical interference will probably be required, and which may be arranged under the following heads: Old fractures and dislocations, in which the bone has become fixed in a faulty position, either that of flexion or of extension; congenital elongation of the coccyx; necrosis, whether traumatic or otherwise; tumours connected with the coccyx; and, finally a large group of cases of obscure pathology, in some of which there appears to be periostitis of some or all of the segments in others inflammation of the sacro-coccygeal joint. In an old fracture or dislocation with displacement, we can hope for no improvement apart from operation, and here also Simpson's operation of separation of the attached muscles cannot be expected to succeed in relieving the patient.
Skey1 attempted to remedy an old dislocation backwards with consequent extreme flexion of the coccyx, by means of traction made by passing a loop of wire over the apex of the bone and connecting this loop with a splint attached to the spine; but the pain produced by this method was so great that it had to be abandoned. It might appear possible in such cases to separate the displaced bone at its abnormal angle, and endeavour thereafter to retain it in position by a plug introduced into the rectum, but the difficulty of preventing a return of the displacement must necessarily be great if not insuperable. Hence in such cases I should advise excision of the bone.
Further, if congenital elongation be a cause of pain, removal of the part is clearly indicated. So also in cases of necrosis, as in the first of my patients, we are following the ordinary surgical method in removing the sequestrum. Cases of tumour involving the coccyx must be treated on general surgical principles. But it is in cases where there is no obvious lesion that there is the greatest room for diversity of opinion as to the method of treatment to be adopted. Here we would naturally try, before resorting to operation, the effects of rest and of the various anodynes. But if this treatment should fail, as it had done in my cases before they came under my observation, what is to be done? Hilton recommended separation of the fibres of the sphincter ani from the apex of the bone, and thus undoubtedly made possible more perfect rest. Simpson went further and completely divided the muscular connexions of the coccyx by means of subcutaneous section, and he was thus able to cure a considerable number of cases. But he himself admits that in some instances this operation was insufficient, and he then resorted to the procedure, which had long before been advocated by Nott, of removal of the coccyx. In nearly all cases the latter method seems to have effected a cure, and I should therefore be inclined to adopt it at once, instead of. running the risk of wasting time by the subcutaneous isolation.
The operation of excision of the coccyx is sufficiently simple and without danger: it is more easily performed than the subcutaneous division of muscles; its result is apparently universally good, providing that the diagnosis be correct; and the loss of the bone does not seem in any case to have caused inconvenience. On these grounds, therefore, I would advocate excision in all cases of coccygeal pain where non, operative treatment has failed to give relief, unless the pain is due either to some constitutional condition as hysteria or to some reflex influence as in uterine and ovarian disease.