New Orleans Medical Journal
May 1844, i, 57-60.
J. C. Nott
Professor of Surgery in Alabama Medical College.
This is Case 2 in a paper, 'Facts illustrative of the practical importance of a knowledge of the Anatomy and Physiology of the Nervous System'.
The text about this case is quoted in: A practical treatise on the diseases of women, T. Gaillard Thomas, 1872, Pages 121-125.
Miss —, aged about 25, had been very much deranged in general health and suffering from neuralgia for ten months, for which she was treated by an eminent physician in Charleston, and afterwards by Prof. Jones in New Orleans. She came under my care the latter part of June, 1843, at which time her condition was a deplorable one; her general health was completely shattered and strength exhausted; dyspepsia; constant nervous headaches; menstruation regular though difficult; excruciating pain at the point of the coccyx; pains in the uterus, vagina, neck of the bladder, and back. The most prominent symptom was the excruciating pain at the point of the coccyx, which became intolerable when she sat up, walked, or went to stool, or in short when motion or pressure was communicated to it in any way. This symptom was so peculiar, that I was led to suspect some organic lesion about the coccyx, and on questioning her closely, she informed me that she had fallen about four years ago and received a blow upon the coccyx, which gave her a good deal of pain at the time and for several weeks afterwards; but these symptoms passed off, and did not return until about ten months before I saw her. This fact had been concealed from her former medical attendants.
I then told her that her physicians had exhausted all the articles of the materia medica which afforded any prospect of relief, and that she had better consent to an examination to ascertain whether the coccyx, either by disease or displacement, had not become a source of irritation to one or more of the nerves in its vicinity. She consented, and on examining the whole course of the spine, I found no tenderness of any consequence until my finger touched the point of the coccyx, when she screamed with pain. I then proposed the extirpation of this bone as the only chance of relief. She had suffered so long and so severely that she did not hesitate, and told me she was in my hands to do what I thought best, and would submit to anything I would advise.
Accordingly, On the 2d of July, I made an incision down to the bone, and extending from the point upwards two inches; I then disarticulated the bone at the second joint, divided the muscular and ligamentous attachments, and without much difficulty dissected out the two terminating bones. On examining the bones after the operation, I found the left one carious and hollowed out to a mere shell; the nerves were exquisitely sensitive, and the operation, though short, was one of the most painful I ever performed. For several hours after, the pains were extremely violent, coming on every ten or fifteen minutes, and accompanied by a sensation of bearing down like labor-pains. Morphine in large doses and other anodynes afforded no relief; the pains became gradually less frequent and less violent; the wound soon healed, and at the end of a month the local disease disappeared and the general health was much improved.
About two months after the operation, she was seized a few days after her catamenial period with violent pains in the back, uterus, vagina, neck of the bladder, etc, but none at the coccyx; these pains continued for about four days, producing a degree of suffering I have never seen surpassed. I gave anodynes internally - used anodyne injections into the vagina and rectum, but they seemed only to aggravate the symptoms. I tried fomentations, blisters, etc., etc., but nothing afforded the slightest relief, except injections of nitrate of silver into the vagina, and this was very partial, the attack seemed to pass off of its own accord. Similar attacks occurred after the two subsequent catamenial periods, and I was induced to suspect some organic lesion of the uterus. On examination, however, I found the uterus to be healthy, except a little morbid sensibility to the touch - there were, however, several points of the vagina (one the side and part next to the rectum,) and the neck of the bladder, exquisitely sensitive, and when touched, she screamed and said these were the seats of her great suffering - when I touched them the pains would dart up to the loins, and all her aggravated suffering be produced. I was then led to the conclusion that these symptoms were all neuralgic and were consequences of the diseased coccyx. I put her on the use of citrate of iron, 5 grains three times a day, and continued it steadily on through the month - the next expected attack did not come on, and I continued the iron twice a day through the second month, when she passed over the second time, and I then discontinued the medicine.
When I saw her last, she had been thre months without an attack - her health, which was always delicate, had become pretty good, and she was riding about and taking her part in society as usual, after more than a year of seclusion.
The case is novel and instructive - I know of no one like it on record. No doubt many similar cases have occurred and their true nature been overlooked. I have another at this moment under my charge, produced by a fall on the sacrum, and almost identically the same in every respect - it will probably also require an operation for relief.