On coccyodynia - part 2

This is the remainder of the paper by Simpson, the part that does not concern coccyx pain.

Medical Times and Gazette

1859, 40: 1-7

CLINICAL LECTURES ON THE DISEASES OF WOMEN, LECTURE 17

J. Y. SIMPSON, M.D. F.R.S.E.

Professor of Medicine and Midwifery in the University of Edinburgh

TUMOURS OF THE COCCYX - DOUBLE MONSTROSITY BY INCLUSION.

Fig 2. Sketch of the coccygeal tumour attached to the child

But leaving the mythical and mysterious part of the question, let me call your attention to the sketch (see Fig. 2) of the posterior aspect of an infant, whose entrance into the world created a great deal of noise some three years ago, and regarding whom a paragraph appeared in many newspapers, headed, "CURIOUS MONSTROSITY - A CHILD BORN WITH A TAIL".

The case occurred in the practice of my friend, Dr. Richardson, of Stockton-on-Tees, who relieved the child of its extraordinary appendix by amputation, and who had the kindness to send me the tumour for dissection along with this sketch of the child taken before the performance of the operation.


Fig 3. Sketch of the coccygeal tumour dissected

The tumour, which is of an oval form and about six inches in length by four in breadth, was attached to the skin of the back opposite the middle of the sacrum by a narrow rounded neck of about an inch in diameter, through which two or three small vessels passed into the tumour. At the lower end, which projected slightly beyond the folds of the nates, there was a slight depression, through which a point of bone could be distinctly felt, while from the level of upper extremity, on the surface which was turned towards the back of the infant, there grew a projection about two inches in length, which bore a perfect resemblance to a finger or toe, containing, as it did, two bones like phalanges, and being furnished at the tip with a well-developed nail. The skin of the child's back immediately surrounding the point to which this tumour was attached was altered in character, and resembled in appearance the mucous membrane of the lips, while the skin in contact with this peculiar structure was thickly covered with hair. The child was in perfectly good health; and Dr. Richardson very wisely determined upon relieving it of its extraordinary encumbrance, which he succeeded in doing with perfect safety by first tying a cord round the neck of the tumour, and then cutting it off beyond the ligature. There was no remarkable degree of haemorrhage, only one vessel requiring to be tied; and the infant showed no bad symptoms afterwards, while the wound speedily closed. On dissection, the tumour was found to consist, as you here see (see Fig. 3), of a mass of fat enveloped in skin, and containing in its midst a long bone, running nearly through the entire length of the growth, while a number of vessels and nerves came through the neck and were distributed throughout the mass. The bone was well ossified and invested by periosteum; but it does not present a sufficiently well-marked resemblance to any of the bones in the human skeleton to enable us to decide as to its real nature. It bears more resemblance to a tibia, however, than to any other bone.

Towards the upper end of the one side it has attached to it a portion of tissue, redder in colour and denser in texture than the rest of the substance of the tumour, and almost resembling muscle in appearance.

Now, what is the nature of this curious caudal appendix? It is simply an instance of a kind of malformation which occurs when two ova have been impregnated, and when only one of the foetuses comes to maturity, while the other is blighted at an early stage, and arrested in its development, but becomes adherent to some part of the body of its co-twin where it appears at birth in the form of a tumour. Tumours of this kind may be found adhering to different parts of the bodies of infants, and we occasionally meet with cases where they are attached to the very lower extremity of the trunk and in connexion with the coccyx or region at least of the coccyx. I show you here a drawing of a child (see Fig 4.) with a large sacculated tumour of this description growing from between the nates.


Fig 2. Sketch of a coccygeal tumour which presented at birth

In this case the tumour presented at birth, and proved a source of great difficulty to the practitioner in attendance, who could not make out the nature of the case until the birth of the lower half of the body had been effected. In the practice of Dr. Paterson, of Leith, a similar case occurred about eighteen years ago, when a boy was born with such a tumour growing from the lower part of the back of the pelvis.


Fig 5. Sketch of a coccygeal tumour occurring in a child born eighteen years ago and still living. Dr. Paterson's case.

This tumour (see Fig. 5) was seen by a good many different medical men, and very different opinions were entertained as to its nature, but most were inclined to the belief that it was a case of spina bifida. I had just been reading Meckel's work on Double Monsters, in which he describes some cases of this kind, and came then to the conclusion, which I still believe to be the correct one, that Dr. Paterson's patient was another instance of a foetus born with an undeveloped one attached to it; but the bearer of that supernumerary foetus still lives, and as the tumour was never removed there has been no means of verifying the diagnosis.


Fig 6.

Here is still another drawing (see Fig. 6) of a case of this nature, occurring in the person of a girl, who came into the Hospital several years ago with a cystic mass attached to the back opposite the sacrum and coccyx, which had been there at birth, and which still continued to grow. A portion of the growth was removed, and it was found to consist chiefly of a few large cysts, which gave out an intolerably offensive secretion. There are some preparations of this kind in the museum of St. Bartholomew's Hospital in London, and among others a preparation of a supernumerary undeveloped foetus, which was removed from the lower part of the back of an adult female by Mr. Wormald. The tumour in this case, Mr. Wormald writes me, seemed to come from the interior of the pelvis, and as it grew the sacrum and coccyx were turned upwards and backwards. It was of enormous size, requiring an incision on each side of twenty-five inches in length for its removal, and on examination afterwards it was found to be composed of a mass of cysts, some of them containing a watery fluid, others steatomatous matter, hairs, fat, and osseous deposits. The patient gradually recovered from the operation; but the sacrum and coccyx never returned to their normal position. A gentleman died a few years ago, the heir to a Scottish earldom, who had a tumour growing from the lower and back part of the trunk, regarding which endless consultations had been held during his lifetime. It was often discussed whether it would be safe and proper to remove it; and when he died, at the age of forty, it was found that this tumour, which had been a source of discomfort and uneasiness to him all his life, might very easily have been removed.

If you inquire into the nature of these tumours you will find them to vary very much as regards their structure. Sometimes they consist of masses of fatty substance alone; sometimes they contain bones, rudimentary, or more or less developed; or they may contain teeth. Some of them have been found having a jaw-bone with teeth in the sockets. Portions of intestine and portions of other organs and parts of the body have at times been found in them, all tending to show that they are merely instances of secondary blighted foetuses attached to well developed ones, and obtaining nourishment from them. Some of these secondary foetuses remain in the most rudimentary condition possible, presenting only a cellular mass. Others again contain tissues more highly organised; and some of them present traces of parts approaching in development to the organs and parts of their more perfect mates. These additional foetuses attached to the sacrum and coccyx form a puzzle, however, to teratologists in this respect, that they cannot be found to be regulated in any way by a law which holds good in the case of double monsters of almost every other description. In all the common types of double monsters it is a law that like is always attached to like in the two bodies. Thus the chest of one child is always attached to the chest of another, the back to the back, a sternum to a sternum, an occiput to an occiput, an artery to an artery, a nerve to a nerve, the corresponding bone, muscle, artery, nerve, etc. of one body, to exactly the same corresponding bone, muscle, artery, nerve, etc. of the other body of the double monster. But to this law there are some few and rare exceptions. Thus I have in my hand the skeleton of a fully developed kitten which has the pelvis and posterior extremities of a secondary foetal kitten attached to the lower end of the sternum. Such a union of unlike parts is very rare, and we may perhaps deduce a lesson from it in transcendental anatomy, as to the analogy between the pelvic and sternal bones. And the coccygeal tumours in question form also, I repeat, a very striking exception to a law which is so general; for in them you have parts and tissues of the secondary foetus attached to parts and tissues of the developed child that are not at all similar. What are we to do in the way of

TREATING OF THESE COCCYGEAL TUMOURS?

When they can be removed with safety to the infant, it will, of course, always be advisable to do so; but it is not always very easy to decide upon the safety of the operation. In such a case as that of Dr. Richardson, where the tumour was pediculated and attached by a narrow neck, and where no tissue of importance was present in the isthmus, the operation was safe, and the result satisfactory. The same may be said of Mr.Wormald's case, and of some others; but sometimes, as I have told you, portions of intestine pass out from the body of the child into the coccygeal tumour, and whenever there is any suspicion of the presence of such a communication the operation had better be left undone. Where removal is to be effected at all, it is best to do it as Dr. Richardson did, as soon after birth as possible. In the case of the girl in the Hospital, bad ulcers formed in the opened tumour, and exhaled such odours as to render her presence intolerable to all the other patients. In the case of Dr. Paterson's patient, nothing at all was done, and the cystic mass has shrunk up and become reduced in size, instead of becoming developed along with the rest of the body; and the young man, who is now a clerk in a public office, works all day at his desk sitting upon, and in one sense at least supported by, this undeveloped brother.

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