Subcutaneous division of the coccygeal attachments

of the external sphincter and the levatores ani for laceration of sphincter in one case, and prolapsus ani in another

The Lancet

Volume 63, Issue 1608, 24 June 1854, p 671

John Hilton

10, New Broad-street

We find this operation described in the "Guy's Hospital Reports" for 1853, and cannot help thinking, from the results of the same, and the anatomical reasons given by the operator, that it might in similar cases be beneficially imitated. In the first case, the sphincter ani was, after delivery by the forceps, lacerated anteriorly, the rent extending through the perineum; and in the second, there was prolapsus of the uterus and rectum. Both cases did well; we subjoin Mr. Hilton's letter to Dr. Lever, (the latter having had the obstetrical care of the patients.)

"My Dear Lever, I certainly think the cases of lacerated perineum are worth publishing, and I have great pleasure in sending to you a statement of tne reasons which induced me to adopt the operation performed in each of the cases. As far as I know, such an operation had not been done before that period, 1848, with the purpose of relieving the distress and annoyance to which these patients were exposed, but in this opinion regarding the originality of the operation I may be wrong, if so, your better information will set me right.

"When you requested my assistance to determine what had best be done in a surgical direction, remembering that. the levatores ani have one firm and fixed attachment to bone near the arch of the pubes, and another at the coccyx, and that the external sphincter ani might be regarded anatomically nearly in the same light in relation to its effects upon the injury to the perineum, and bearing in mind that all muscles contract towards their more fixed point, no matter how that fixity of position may have been acquired, it occurred to me, if I could, by a simple and uncomplicated operation, disengage the coccygeal attachments of the levatores ani, I might allow them to retract the anal aperture and adjacent structures in a direction towards the pubes, as it were, to bury the perineal injury deeply in the pelvis, thus enabling the lower fibres of those muscles (which blend with the muscular parietes of the vagina, rectum, and perineum) to assume the office of a sphincter to the lacerated opening, by approximating the edges of it, and drawing it upwards toward the pubic arch. In reference to the external sphincter ani, I concluded that, by taking away or separating the coccygeal fixed point of that muscle, I should necessarily change the direction of its contractile power from the coccyx towards the vagina, and thence to the pubes; this I hoped would help to occlude the lacerated opening between the vagina and rectum. Whether I had reasoned rightly or not, the results were as satisfactory, and indeed more so, than I had anticipated. It seemed to myself, that two ulterior purposes might be held in view by such an operation; the first was to ascertain how much of complete relief could be afforded by an operation which promised to be altogether free from both the danger and the severity of the ordinary operation for such cases, and secondly, should no important immediate benefit be derived, it would certainly tend to the advantage of the patient, by putting the parts into a better state (by relaxing them, and so taking off tension) for the easy and perfect accomplishment of the usual but more formidable operation of paring the edges of the lacerated wound, and maintaining them in contact for a time by sutures.

"The method of proceeding was as follows:A narrow sharp-pointed knife was introduced through the skin on one side of the point or free extremity of the coccyx, about half or three-quarters of an inch from its end; it was then passed into the pelvis, between the concave surface of the coccyx and the rectum, special care being taken not to puncture the intestine; the cutting edge of the knife was now made to sweep over the sides and end of the coccyx, so as to separate from it the coccygeal attachments of both the sphincter and levatores ani; the knife was then withdrawn through the same small opening by which it had been introduced; scarcely any blood escaped at the wound, but a compress of lint supported by adhesive plaster was applied over it, to keep the parts quiet, and to intercept the flow of blood.

"That the operation had accomplished its intention of detaching the muscles from the coccyx, was obvious enough, by examining with the finger upon the skin, the median line between the end of the coccyx and the posterior margin of the anus, the resistance which the muscles naturally give to pressure in that position had disappeared, and the anal aperture became retracted or drawn up into the pelvis.

"During the time I had the opportunity of seeing the patients after the operations, I have no hesitation in saying they were much benefited by what had been done for them, so much so, that no farther treatment was deemed necessary. How far the operation may have succeeded ultimately and persistently, I do not know.

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