TRAUMATIC LUXATION OF THE COCCYX1

By CARL S. OAKMAN,2 A.B., A.~I., M.D., MUNCIE, INDIANA

HE patient whose case introduces this pressure, with the patient in a kneeling po­ paper, a Mr. E. H., white, aged 55, sition. Bowel movements were painful for Tmarried, a foundry worker, weight 150 only a few days, but for three or four weeks pounds, sustained an injury to the coccyx on the patient complained of an aching sensa­ May 25, 1929. In the course of his duties, tion. He resumed work in eight weeks. he fell from a step-ladder, landing on his On October 5 he was referred for another buttocks on a wooden box, a corner of roentgen examination, at which time he said which directly struck the coccyx. He experi­ he was free from all pain and ache, except enced immediate pain and was referred to after long automobile rides. Digital exami­ the company physician, who found, the fol­ nation was painless. The roentgen films lowing morning, by rectal examination, an showed the same luxation of the first seg­ unevenness of the anterior surface of the ment, with apparent callus formation ante­ coccyx, and pain upon pressure, both exter­ riorly at the sacrococcygeal junction. nally and in the rectum. He diagnosed a dis­ Medical literature shows few and brief al­ location and referred the patient to me for lusions to roentgen examination of the roentgen examination. Lateral projection coccyx. Careful search failed to reveal any revealed a forward luxation of the first coc­ article in roentgenologic journals, and the cygeal segment, which was displaced a dis­ text-books give little or no information. tance almost equal to its own thickness, the George and Leonard (1), in their recent rest of the coccyx being symmetrically volume, illustrate a case of anterior luxa­ curved. The outlines of the upper coccygeal tion. Jones and Lovett (2) say: "X-ray and the last sacral element indicated that no mayor may not be reliable in this region bony fusion had existed and the remaining and the antero-posterior view shows only segments showed distinct spacing, as if sep­ lateral displacement. To obtain satisfactory arated by cartilage. The antero-posterior definition in a side X-ray is, of course, diffi­ view gave no hint of the luxation, but cult, but often possible with a highly per­ showed a vertical line in the first segment fected technic." Letters written to 94 roent­ that was suspicious of fracture, without dis­ genologists brought few helpful replies. placement. The cornua were not visible; the Coccyx (plural coccyges) is a word de­ transverse processes were very rudimentary. rived from the Greek, meaning a "cuckoo," Four coccygeal segments were plainly regis­ probably because of a fancied resemblance tered, the distal one possibly representing a to a cuckoo's beak. The German equiva­ fusion of two rudimentary elements. The lent is "Steissbein" and the French is identi­ contour of the sacrum and coccyx described cal with the English. Colloquially, it is a normal curvature, except for the luxated called the "tail bone" or "crupper bone." It first segment, and there was no lateral de­ is a small bone of variable length, forming viation. the caudal extremity of the spine, but desti­ On May 27 the attending physician re­ tute of a canal. It comprises four or five duced the dislocation, by intrarectal digital segments (rarely three or six), of which the

lRead before the Radiological Society of Korth America first is the largest and shows some rudiments at the Fifteenth Annual Meeting, at Toronto, Dec. 2-6, 1929. 2Dr. Oakman died before proof of this paper could be sub­ of the structure of a sacral segment, while mitted to him, so that it is unknown what changes he might have made. the others dwindle into successively smaller 727 728 RADIOLOGY and characterless nubbins of bone (vertebra; to the back of the upper three segments, caudales) . Piersol (3) says that data con­ close to the lateral border; the sphincter ani cerning ossification are very unsatisfactory. externus to the tip; posterior fibers of the Each segment has one center, the first may levator ani and a portion of the coccygeus have two; ossification begins in the first to the lateral borders. piece near birth, and successively later in the The junction of the sacrum and coccyx others, up to puberty. The first segment pre­ completes the fifth posterior sacral foramen sents two cornua, projecting up posteriorly for transmission of the posterior division of behind the posterior surface of the sacrum; the fifth sacral nerve. No nerves emerge it also presents two rudimentary transverse from the coccyx below this. The coccygeal processes. Both the cornua and the processes plexus is composed of the fourth and fifth are variable, sometimes being well-formed sacral nerves (except the visceral branch of and either rugged or slender, and sometimes the fourth anterior sacral), the coccygeus being hardly more than tubercles. The first (anterior and posterior branches), and prob­ segment is somewhat wedge-shaped, and has ably the inferior hemorrhoidal branch of the greater breadth than length or thickness; it internal pubic. On the anterior aspect of the is sometimes asymmetrical. The entire coccyx are two ganglia (Luschka's gland), coccyx is usually more rugged in the male belonging to the pelvic sympathetic system. than in the female. These ganglia are united to each other by a The apices of the sacrum and of the first small filament and are connected by other coccygeal element are connected by fibro­ filaments to the last sacral ganglion of the cartilage, and a few unimportant ligaments. chain forming the pelvic sympathetic (Ha­ This synchrondrosis sometimes shows osse­ mant and Pigache, 7). Jointly these nerves ous fusion, and the distal segments also may supply sensation to the integument over the fuse. Gray (4) says that the last three seg­ coccyx, around the anus, and the intervening ments are usually fused with one another, area, and innervate the levator ani, sphincter and the last may be bifid; complete anky­ ani, and coccygeus muscles. losis is likely to result in fracture in the The subject of dislocation of the coccyx event of trauma. Bony fusion occurs often­ has had much discussion in the past. Stim­ er in the male, and usually at an earlier son (8) says that descriptions given by period. earlier writers were questioned in the early Variations from the normal curve of the part of the twentieth century, and quotes coccyx are common; lateral deviations are Boyer as maintaining that the lesion never very frequent, but apparently never produc­ occurred; the matter was somewhat con­ tive of symptoms; exaggerated forward nected with coccygodynia, as cause and ef­ curve is frequent and occasionally impinges fect, but the actual occurrence of dislocation on the rectum and produces trouble; the was well enough attested by several reports, rarer posterior curving may project beneath mentioned by Stimson (Malgaigne, Roeser the skin and induce pressure changes. Ab­ (9), Bonnafont (10), Mouret, 11), and also sence of the coccyx has been reported (5). reports by Skene (12), Cyriax (13), Jones One hears occasionally of human beings (14), Gehrung (15), Drueck (16), Petit with a coccyx developed into a true tail, but (17), and Hirst (18). Undoubtedly some no authentic report is discoverable in medi­ of the cases reported as dislocation were cal literature. really displacements due to fracture, and the Muscles are attached as follows, accord­ converse may be true. Practically none of ing to Buchanan (6): The gluteus maximus the reports include roentgen evidence, many OAKMAN: TRAUMATIC LUXATION OF COCCYX 729 of them having been made prior to Roent­ terior displacement. The usual causation is gen's discovery, and subsequent writers a fall or a kick. Displacement of the COCC).x largely ignore its application in lesions of the mayor may not be accompanied by tilting, coccyx. An article by Cyriax (13), in 1922, or rotation, or both. Cyriax (13) reports covers the clinical diagnosis, but does not cases of luxation due to rheumatic fever, allude to the X-ray. Several of the roent­ straining at stool, pelvic cellulitis, and sud­ genologists with whom the writer has corre­ den effort to prevent falling. He thinks sponded stressed the point that X-ray exam­ some cases are perhaps due to over-use of ination is unnecessary, because the diagnosis the sitting position, by which the coccyx is by clinical means is so simple. gradually pushed forward. The chronic Several writers mention that dislocation sitters were mentioned by Ramsbotham is commoner in women than in men, because (21) in 1851, who said: "Ankylosis often the intersegmental cartilages persist longer occurs in women who have been accustomed and allow displacement instead of fracture, to sit the principal part of the day, as is the and because many of these displacements oc­ case with milliners." cur at parturition: Hirst (18) also attrib­ The symptoms of a recently luxated utes man's relative immunity in part to the coccyx are: (1) Pain, aggravated by defe­ higher position of the coccyx and the closer cation, sitting, riding, coughing, walking, approximation of the ischia; he states that and coitus, often causing the victims to sit during labor there is backward stress on the sidewise and to shift position constantly; coccyx, sometimes producing rupture of (2) impairment of bladder function ligaments, dislocation, or fracture. If dis­ (Speed, 19); (3) constipation, usually due placement occurs, it is posterior, whereas di­ to postponement of stool. Further and di­ rect external violence produces anterior dis­ verse symptoms may develop after the lapse placement. Speed (19) says, regarding of time, which will be discussed under a later birth trauma: "Whether there is a true frac­ heading. ture at the sacrococcygeal junction or a Physical signs of a recent case include: stretching of the ligaments which permits (1) Tenderness on pressure externally or the displacement, it is not always possible to by rectum; (2) ecchymosis or other signs decide, even with the help of a roentgeno­ of bruising, though Cotton (22) says that gram." Jolly (20) reported a unique case ecchymosis is rare; (3) deformity, which of escape of the distal segment of the coccyx mayor may not be visible, and is usually de­ through the anus ten days after childbirth. tectable by palpation, either externally or by Cyriax (13) refers to displacements of the rectum, or both; (4) mobility of the dis­ coccyx on the sacrum (i.e., at the sacrococ­ placed coccyx. cygeal joint) but has never seen one distal It may be difficult to differentiate between to this point; he says that minor displace­ a fracture of the coccyx and a dislocation. ments seldom occur after middle life, due to The literature gives scant discussion to this the fact that the sacrococcygeal joint has point, and there is reason to believe that er­ united, although Piersol (3) states that it is rors have been made. The existence of not uncommon for the first segment to re­ crepitus is by no means universal in frac­ main separate, without fusion to the sacrum ture cases; probably fracture affects the or to the second segment. proximal segment far oftener than it does Outside of birth injury, there is very all the others. An ankylosed coccyx is much rarely a posterior luxation of the coccyx. more likely to suffer fracture than a jointed Injuries by direct violence, producing frac­ one. ture or luxation, practically always show an- If a physician sees a case of injured 730 RADIOLOGY coccyx long after the accident, diagnosis and Dinnendahl (37)-that resection is jus­ rna". not be so easy, and he is apt to fall back tified in certain cases of injury, tuberculo­ on the convenient term "coccygodynia." sis, caries, periostitis, etc. It is claimed that This is the word that has been in turn re­ no weakness or perceptible defective func­ spected and later condemned. In 1859 Sir tion ensues after resection. The interest in J. Y. Simpson (23) published his article, coccygodynia and in operative relief was for describing the cases of persistent pain in the a long time maintained chiefly by the gyne­ coccyx, and dignified the condition as a sep­ cologists and proctologists, while the general arate entity under the term "Coccyodynia," surgeons eschewed it. a word which "caught on" and had long In 1914 Yeomans (38) reported a new years of popular use. His description has method of treatment by injections of alcohol hardly been improved upon, since he had a at the site of pain. An article had appeared good understanding of the various kinds of on the same subject by de Vezian in 1907 pathology that may underlie it. He discov­ (39). The successful use of the faradic cur­ ered early reports of coccygeal injury, in­ rent by Seeligmuller and Grafe was men­ cluding those by Smetius, sixteenth century, tioned in the 1904 edition of von Berg­ and Van Meeren and Gahrliep in the seven­ mann's "Surgery." teenth. Simpson did tenotomy for relief of Some of the gynecologists in the past have his first cases, but later did resection. How­ been inclined to ascribe coccygodynia in cer­ ever, the credit for the first resection must tain cases to metritis, salpingitis, prolapsus be given to Nott (24), of New Orleans, uteri, prostatic disease, hemorrhoids, fissure, whose report appeared in 1844, describing a rectal tumor, etc. Hamant and Pigache (7), case of "neuralgia" from caries. Prior to 1914, in a critical study, deplored this incli­ this, in 1841, Blundell (25) had suggested nation. Yeomans (40), 1919, classified the operation. Simpson inspired Scanzoni some cases as "symptomatic," or referred (26) to devote twelve pages to the subject pain, due to disease of the central nervous in his text-book, published in 1861, and laid system, such as hysteria, neurasthenia, irri­ the foundation for what amounted almost to table spine, traumatic neuroses, tabes, toxe­ a fad for coccygectomy. However, the pen­ mia, and "habit pain." dulum swung after a few decades, when it In passing, it should be mentioned that was found that this procedure was not uni­ the original term "coccyodynia" gave way to formly successful, and we find Beach (27), "coccygodynia," which was substituted be­ in 1899, saying that resection in chronic cause it is etymologically more precise. Col­ cases of pain is "an operation notably un­ loquially it is variously known as "neuralgia success ful." In Cotton's work (22), 1924 of the rectum," "rheumatism of the rec­ edition, appears the statement: "Most of tum," "elongated spinal column" (Drueck) the cases, even when there is a history of ( 16). some injury, are essentially localized symp­ It seems to be fairly well agreed that the toms of a psychosis, 'hysteric,' as we name most common cause of coccygodynia is in­ these localized psychoses. In such cases op­ jury, either recent or remote, severe or mild, eration will not help the patient and will single or repeated. Stimson (8) thinks that only discredit the operator." Meanwhile, it dislocation and fracture are commoner than has been shown by various writers-C. the reports indicate. Cyriax (13) stresses Beck and V. S. Cabot (28), Gant ( 29) , minor displacements and the subsequent oc­ Hirst (18), Werner (30), Smith (31), Til­ currence (in either major or minor degree) laux (32), Whitead (33), Blount (34 ) , of synovitis in the sacrococcygeal joint, ad­ Boland (35), Tedenat and Simesael (36), hesions, periostitis, periarticular thickening, OAKMAN: TRAUMATIC LUXATION OF COCCYX 731 and irritation of sensory nerves through dis­ coccygeal joint, but no reliable data are turbance of the coccygeal ganglion. Hirst available, because the exact point of disloca­ (18) remarks that after injury the lesion tion is rarely mentioned in reports, or, if it has a poor chance to heal, because of stress is, the opinion is based on physical examina­ in all the usual activities of life, especially tion, and X-ray evidence is never quoted. defecation, sitting, and rising. Those injuries which, upon roentgen exami­ The case report at the beginning of the nation, show abrupt and pronounced angula­ present article shows so well the value of tion, sometimes as much as 90 degrees, but precise knowledge, as furnished by roentgen little or no slippage at the joint, are very examination, that it needs no argument to puzzling, because some normal coccyges urge the more widespread use of this show similar angulation. Therefore it be­ method. Clearly, the lateral view is re­ comes difficult to say in any given case of quired, and with modern refinements of injury whether the angulation is pathologic technic it ought to be possible to obtain such or not. It is well known that coccygodynia views in all cases of suspected injury. It is sometimes occurs without detectable signs true that the interpreter must guard against of displacement, due to conditions such as being deceived by the anatomical variations, arthritis, periostitis, necrosis, etc., and such but I have seen in the literature no mention conditions may affect a coccyx that is nat­ of variation that simulates true luxation. urally angulated, especially after trauma. The recorded variations include lateral de­ Dervieux and Belot (41), in 1926, report­ viations and increased angulation, either ing a case of coccygeal injury, say that the forward or backward. In antero-posterior roentgen reading of these cases must be projections centering over the pelvis, such guarded; but if lateral roentgen examina­ as are taken for any bony pathology in this tion should be made routinely, and the data area, or for the lower part of the urinary accumulated, it would undoubtedly result in tract, there is always an image of the coccyx. a greater power of discrimination. The variations in contour, length, number These cases of injury sometimes have an of segments, ossification, and deviation from important bearing in industrial work, atten­ the midline have been noted by everyone, tion being called to this point in 1910 by but it is well known that luxation practically Courtois-Suffit and Bourgeois (42). The never occurs laterally, so that error in that value of roentgen evidence in compensation respect can hardly occur. A series of lateral disputes or damage procedures is well projections on healthy subjects was recently known. Dr. Podlasky's case (cit. supra) was made by the writer, and there was found to one of industrial accident and it led to a be great divergence in the degree of curva­ long period of suffering and finally to surgi­ ture, but nothing resembling a dislocation. cal resection. These anomalous curvatures show an intact In making film records of the coccyx, the sacrococcygeal joint, and intact interseg­ presence of a distended bladder or of gas in mental joints, whereas a luxation will show the rectum usually impairs the detail of the an abrupt irregularity at some one of these antero-posterior view. Kaisin (43), how­ joints in the lateral view. In films loaned ever, recommended the injection of air into by Dr. H. B. Podlasky the antero-posterior the rectum. The best films are usually ob­ view showed an over-lapping of the first and tained with the Potter-Bucky diaphragm, second coccygeal segments that seemed quite using a restricting cone, a fine focus tube, positive evidence of dislocation. No lateral careful immobilization, especially for the view was taken. It seems probable that dis­ lateral, and the maximum practical distance. location may occur oftenest at the sacro- In the resulting image by the antero-poste- 732 RADIOLOGY

rior view, it is usually possible to note the Lateral views are almost necessary in a number of coccygeal segments, though the film study of this area. lateral view may sometimes be necessary The normal coccyx has many vanations for a correct count. The antero-posterior of length, curvature, fusion, and bony view also shows the characteristic shape of markings, which may cause confusion in in­ the first segment, its transverse processes, terpretation. and occasionally its cornua, and it registers Complete and true dislocations, either of all lateral deviations. If the curvature is ex­ one segment or of the entire coccyx, can cessive, the coccyx will appear foreshort­ probably be easily detected on the films. Mi­ ened, the segments seeming to overlie each nor displacements may create doubt.

other, and only a lateral film will reveal REFERENCES3 them and their interspaces separately. The (IN TEXT) lateral view will sometimes register the coc­ (1) GEORGE, ARIAL W., and LEONARD, RALPH D.: cygeal and sacral cornua. Fractures are The Vertebras Roentgenologically Consid­ most likely to occur in the first segment, and ered (Including a Study of Industrial As­ cident Cases). Vol. VIII of Annals of be visible in the antero-posterior view, be­ Roentgenology. Paul B. Hoeber, Inc., 1929. (2) JONES, SIR ROBERT, and LOVETT, ROBERT W.: cause the line of fracture is most often ver­ Orthopedic Surgery. William Wood and tical. In Butler's (44) case the fracture is Co., 1924. (3) PIERSOL, GEORGE A.: Human Anatomy. J. B. visible in both views, but the displacement is Lippincott Co., 7th Ed., 1919. visible only in the lateral. Luxation may (4) GRAY, HENRY: Anatomy. 21st Ed .• 1924, pp. 109 and 112. readily escape detection in the frontal pro­ (5) BLOOM, CHARLES J., STONE, RUSSELL E., and jection. In the writer's case it is probable HENRI1QUES, ADOLPH: Congenital Absence, Backward Deviation and Shortening of that the coccygeal cornua were broken off, Coccyx. Arch. Ped., July, 1917, XXXIV, 514. allowing the forward slipping of the first (6) BUCHANAN, ALEXANDER MAC G.: Manual of segment. Anatomy: C. V. Mosby Co., 5th Ed., 1927. (7) HAMANT and PIGACHE, R.: Etude critique In the course of correspondence with sur la Coccygodynie. Rev. de Chir., 1914, nearly a hundred roentgenologists on the XLIX, 70. (8) STIMSON, LEWIS A.: Practical Treatise on subject of this article, replies were received Fractures and Dislocations. Lea and Febi­ ger, from fifty-nine, and films or prints were * (9) ROESER: Froriep's Notizen, 1857, II, 10. loaned by eight. Fifteen others stated that (Abstr. in For. Med. Chir. Rev., 1857, xx. 414). they had seen cases, but for various reasons (10) BONNAFONT: Deux observations de luxation the film record was not available. Four du coccyx, suivies de quelques reflexions. L'Union Medicale, 1859, I, 136. mentioned that roentgen examination is un­ *(11) MOURET: Rec. de Mern, de Med, Chir. et Pharrn. militaires, 1859, I, 350. necessary because the diagnosis is so easy (12) SKENE, ALEXANDER, ]. c.: Treatise on the by physical examination. I wish to take this Diseases of Women. D. Appleton and Co., 1898, 172. opportunity of thanking all my colleagues (13) CYRIAX,! EDGAR F.: Minor Displacements of who have answered my appeal, and especial­ the Coccyx. Glasgow Med. jour., August, 1922, XCVIII, 118. ly those who sent roentgen records, includ­ *(14) JD.NES, G. W.: Effects of Dislocation of the Coccyx. Trans. Gynec. Soc., Boston, 1905, ing Dr. H. B. Podlasky, Dr. G. W. Grier, 152. Dr. P. F. Butler, Dr. W. E. Chamberlain, (15) GEHRUNG: Dislocation of Coccyx. St. Louis Cour. Med., 1888, XX, 544. Dr. P. M. Hickey, Dr. W. A. Evans, Dr. (16) DRUECK, CHARLES].: The Coccyx: Malfor­ Lawrence Reynolds, Dr. H. A. Spilman, Dr. mations, Fractures, and Dislocations. Am. Jour. Clin. Med., February, 1924, XXXI, 99. Samuel Brown, and Dr. T. A. Groover. (17) PETIT, G. c.: Des accidents lies aux deplace­ ments du coccyx consecutifs aux fractures CONCLUSIONS et aux luxations anciennes de cet os. These de Paris, 1900.

Little attention has been paid in the past 3The entries marked by an asterisk (*) cannot be verified, and it is impossible to say from what source Dr. Oakman to the roentgen examination of the coccyx. drew the citations. OAKMAN: TRAUMATIC LUXATION OF COCCYX 733

(18) HIRST, B. c.: Coccygodynia. University Ann. de med legale de Criminologie, 1926, Med. Mag., Philadelphia, May, 1900, XIII, VI, 545. 153. (42) COURTOIS-SUFFIT, and BOURGEOIS, FR.: Deux (19) SPEED, KELLOGG: A Text-book of Fractures Cas de Coccygodynie d'Origine traumatique. and Dislocations. Lea and Febiger, 2nd Lancette Francaise Gaz. des hopitaux, Dec. Ed., 1928. 13, 1910. LXXXIII, 1945. (20) JOLLY, W. J.: Fracture of the Coccyx and *(43) KAISIN: Un pcrfectionnement technique Passage of the Segment per anum. Med. dans l'examen roentgenographique de la re­ Rec., Dec. 17, 1887, XXXII, 762. gion sacro-coccygienne. Jour. de Radiol., (21) RAMSBOTHAM, FRANCIS H.: Principles and July 31, 1909, III. Practice of Obstetric Medicine and Surgery. (44) BUTLER, P. F.: Personal communication. 3rd Ed., London, 1851. (22) COTTON, FREDERIC J.: Dislocations and Joint REFERENCESs Fractures. W. B. Saunders Co., 2nd Ed., (NOT CITED IN TEXT) 1924, p. 145. (23) SIMPSON, J. 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Zentralbl. f. Gynak., Nov. 10, 1928, LII, 2886. Am. Med. Assn., June II, 1927, LXXXVIII, 15. JACKSON, J. N.: Fracture of Coccyx. Langs­ 1883. dale's Lancet, Kansas City, 1896, I, 299. (36) TEDENAT and SIMESAEL, ALBERT: Coccygody­ 16. JORDAN, HARVEY E., and KINDRED, JAMES E.: nie. Bull. de la Soc. d'Obst. et de Gynec. de A Text-book of Embryology. D. Appleton Par., 1925, XIV, 404. and Co., New York, 1926. *(37) DINNENDAHL: These de Kie1, 1901. 17. KEIBEL, FRANZ, and MALL, FRANKLIN: Manual (38) YEOMANS, F. c.: Coccygodynia: ANew of Human Embryology. J. B. Lippincott Method of Treatment by Injections of Al­ Co., Philadelphia, 1910-12, I, 355. cohol. Proctologist, St. Louis, 1914, VIII, 18. KOHLER, ALBAN: Rontgenology, Turnbull's 211. translation. Bailliere, Tindall and Cox, Lon­ (39) DE Vi:SIAN: Un cas rebelle de coccygodynie, don, 1928, p. 247. traite et gueri par des injections d'alcool a 19. LEWIN, PHILIP: The Coccyx, its Derange­ 0 60 • Rev. Prato de Gynec., d'Obst. et de ments and Their Treatment. Surg., Cynec, Pediat., Par., 1907, II, 260. and Obst., November, 1927, XLV, 705. (40) YEOMANS, FRANK c.: Coccygodynia: Fur­ 20. bELL, EDWARD N.: Excision of the Coccyx for ther Experience with Injections of Alcohol Fracture and Necrosis, with a Report nf in its Treatment. Surg., Gynec. and Obst., Four Cases. Med. News, March 13, 1897, December, 1919, XXIX~ 612. LXX, 332. (41) DERVIEUX, and BELOT: Lesion of the Coccyx 21. MARRO, ETIENNE: Essai sur la coccygodynie. From Falling Down Stairs. (In French.) These de Paris, 1912. 734 RADIOLOGY

22. MONNIER, L.: Osteomyelite du Coccyx. Rev. In the study of these cases one finds many d'Orthopedie, 1904, XV, 161. variations from the generally accepted normal, 23. MOWELL, JOHN W.: Fracture of the Sacrum and Coccyx. Internat. Clinics, 1921, II, 192 but most of them will be found to be due to (Illustration of X-ray by Dr. Hollis Potter). anatomical variations. In our hospital series 24. ODELL, W.: A Case of Removal of the Coccyx. Lancet, 1887, I, 1088. a number of cases were operated upon, but, 25. PEISER, A.: Technic for Removal of Coccyx. unfortunately, only one of these cases had had Zentralbl. f. Chir., April 11, 1925,. LII, 789. *26. PERAIRE: Acad. de Med. de Paris, 1920. X-ray examination previously and the roent­ *27. PHOCAS: Arch. provo de chir., November, 1892. genograms were negative for fracture or dis­ 28. POSSI, SAMUEL J., and JAYLE, F.: Traite de gynecologic clinique et operatoire, 1905-07, location. 4th Ed., Vol. II, p. 1326. From the patient's standpoint, coccygodynia 29. QUAIN: Elements of Anatomy. Longmans, Green and Co., l lth Ed., 1915, Vol. IV, pt. is a very important condition because of the I, p. 25. severe pain of which complaint is made. In 30. ROBERTS, JOHN B., and KELLY, JAMES A.: Treatise on Fractures. }. B. Lippincott Co., these cases, however, several conditions should Philadelphia, 1916. be considered. First, we believe that many of *31. ROCKWELL: Note on Three Cases of Traumatic Coccygodynia. Proc. Med. Soc. King's Co., these cases are associated with hysteria and Brooklyn, 1876, 239. psychosis of some type. In the second place, 32. Rouvrsnz, H.: Anatomie Humaine. Masson et Cie, 1924, I, 518. some of these patients are found to have dis­ 33. SMITH, A. L.: Coccygodynia. Montreal Med. ease in the sacro-iliac articulation or lumbar Jour., 1909, XXXVIII, 815. 34. SOBOTTA, JOHANNES, and McMuRRICH, J. PLAY­ spine, with referred pain to the coccyx. FAIR: Atlas of Human Anatomy. G. E. I wish again to congratulate Dr. Oak­ Stechert and Co., New York, 1927, I, 8. 35. SPALTEHOLZ, WERNER: Hand Atlas of Human man upon his presentation of this subject. Anatomy. Transl. by Lewellys F. Barker. }. B. Lippincott Co., Philadelphia, 2nd Ed., I, 76. DR. JOHN T. FARRELL, JR. (Philadelphia): 36. STEINDLER, ARTHUR: Diseases and Deformities of the Spine and Thorax. C. V. Mosby Co., Dr. Doub has congratulated Dr. Oakman upon 1929. his presentation of this subject, but I think the 37. TOLDT, CARL: An Atlas of Human Anatomy: For Students and Physicians. Rebman Co., Society is to be congratulated upon receiving N ew York, 1904, Pt. I, Sec. B. such a scholarly discussion of such an impor­ 38. WILSON, PHILIP D., and COCHRANE, WILLIAM tant subject. A.: Fractures and Dislocations. J. B. Lip­ pincott Co., Philadelphia, 1925, p. 446. Pain in the back is very important to the *39. WORMS, }.: Coccygodynie. Dictionnaire de Dechambre, 1876. patient, and it is also important to the doctor. This is particularly true in the case of indus­ DISCUSSION trial accidents. DR. H. P. DOUB (Detroit): I believe that We have all known that variations exist in Dr. Oakman is to be congratulated for bring­ the coccyx, and I think that Dr. Oakman has ing this subject before us, for discussing the well pointed out the importance of fundamen­ literature so thoroughly, and for presenting tal anatomical knowledge. It seems to me that the collective opinion of the roentgenologists the diagnosis of fracture of the coccyx is rare­ of the country concerning this condition. It is ly going to be made without clinical assistance one which is rather infrequently met with, but, and digital examination. nevertheless, is very important because of the There is one point which occurs to me, many cases referred to us for evidence of pos­ though it seems almost too obvious to men­ sible injury, indicated by pain in this area. tion, and that is the matter of technic. So The principal point in this whole discussion many of us in dealing with conditions of the is to be able to distinguish between traumatic spine in clinics are confronted by men who luxation, fracture, and the anatomical varia­ refer patients for just general spinal examina­ tions which are very common in this bone. tion. It is true that it is often impossible to This is especially important because these pa­ localize the lesion, but in general I think we tients who come for examination often have may say that the smaller the film in relation to severe symptoms, so that one must make a the area of suspected involvement, so much definite roentgenological diagnosis. more exact will be the information that is ob- DISCUSSION 735 tained. I do not think these studies should ditions. I think that a more common-sense ordinarily be made on a 14 by 17 film, a size view is now prevalent, which attributes almost which would include the entire lumbar column. all cases of coccygeal pain to coccygeal pa­ It is our practice to make them on a 10 by 12, thology. to cover the painful area, and I think the in­ The subject of coccygeal pain is of occa­ formation we obtain is apt to be more definite. sional importance in industrial work. This This, of course, predicates co-operation on the was brought out some seventeen years ago by part of the surgeon, the attending physician, a French writer, and numerous cases are re­ and the receiving ward. corded in the literature, cases wherein inju­ ries to the coccyx have proved to be compensa­ DR. OAKMAN (closing): Dr. Doub, in his tion cases. discussion, referred to certain indications One or two writers have insisted that dislo­ which are associated with coccygeal pain. It cations have never occurred except at the is quite true that the profession at one time, sacro-coccygeal junction. Some of the slides and in particular the gynecologist, was very which I have shown indicate that a dislocation apt to attribute coccygeal pain to pelvic con- may occur at other points.