A CASE OF DISLOCATION OF THE FOURTH 
CERVICAL VERTEBRA WITHOUT 
FRACTURE. 
BV 
A. M. HOLMES, A.M., M.D., 
OF DENVER. 
FROM 
THE MEDICAL NEWS, 
October 28,1893. [Reprinted from The Medical News, October 28, 1893.] 
A CASE OF DISLOCATION OF THE FOURTH 
CERVICAL VERTEBRA WITHOUT 
FRACTURE} 
By A. M. HOLMES, A.M., M.D., 
OF DENVER. 
In clinical study the success of a diagnostician 
depends to a great degree upon the faculty of close 
observation of minutise and the ability to correctly 
interpret their meaning. In no department of medi- 
cine or surgery do we find a greater need for the 
exercise of this faculty than in that important class 
of cases wherein the functional activity of the 
cerebro-spinal centers has been impaired or de- 
stroyed, either through the various agencies classi- 
fied as diseases, or through the more violent and 
sudden means inducing acute traumatism. In a 
very large percentage of clinical cases reported the 
accounts are so defective, lacking in precision and 
exactness of description, that the true nature of their 
lesion remains in doubt. On the other hand, there 
are those who will not accept any case as authentic, 
unless it is verified by a post-mortem examination. 
The following case is presented for the consider- 
ation of this Society, from the fact of the compara- 
1 Read before the Colorado State Medical Society, Denver, 
June 21, 1893. 2 
tively rare occurrence of others of its kind, and on 
account of the distinct and characteristic symptoms 
accompanying it, so typical of this form of spinal 
injury. If such cases are properly studied, and the 
symptomatology correctly interpreted, they may be 
the means of throwing light upon some of the 
unsolved problems of neurology : 
On February 2d, this year, at 6.30 p.m., the acci- 
dent occurred which furnished the material for this 
paper. The patient, H. P., a male, aged forty-nine, 
weight 160, possessed an excellent physique. The 
previous health and family history were good. 
Being an engineer, it was his routine duty at the 
close of each day's work to climb to the top of a 
water-tank to shutoff the water-supply for the night. 
For this purpose a ladder was placed loosely against 
the tank. On the evening named there were snow 
and ice on the ground, which caused the ladder to 
slip. The man fell backward a distance of sixteen 
feet, the back of the head and shoulders striking the 
ground. The fall produced instantaneous paralysis. 
The man was unable to move a muscle below the neck. 
He retained perfect consciousness, and was able to 
speak. The only pain of which he complained was 
localized, and in the lower cervical region, and was 
increased by movement or manipulation. He was 
carried to his home, only a short distance away, 
and placed upon a cot, in which position he remained 
until I saw him, two hours afterward. 
I found the patient without pain, except in the 
back of the neck. Consciousness was not impaired. 
He had good control of the vocal organs, could 
speak distinctly, but in a weak voice, and with a 
slow, measured accent. To all appearances he seemed 
to be in a condition of extreme shock. His face 
was flushed, there was an anxious expression of 3 
countenance, the surface was cold, and the pulse at 
the wrist was not perceptible. 
On placing my ear over the heart the action of that 
organ was found to be regular, but very weak, and 
only 36 per minute. The temperature under the 
tongue was 9 2.5 0 F. Thinking that there might have 
been a mistake, I took it a second time, using every 
precaution to prevent error, and found it the same. 
Respiration was exclusively diaphragmatic, very 
shallow, but regular, and only 10 per minute. The 
thoracic muscles were paralyzed. The upper part 
of the thorax remained perfectly stationary, while 
the diaphragm performed its functions normally. 
There was total loss of sensation in all parts below 
the neck and shoulders, and not the slightest power 
of voluntary motion in either arm, the body, or 
the lower extremities. The muscles supplied by the 
brachial plexus were all implicated. The line of 
anesthesia extended around the body about two 
inches above the nipples. There was no line of hy- 
peresthesia, but rather a gradual diminution from 
normal sensation to total anesthesia, covering a 
space of one or two inches, which might be termed 
"uncertain sensation." Partial sensation existed 
on the outer surface of each arm, reaching a lower 
point upon the left than upon the right. Soon after 
the accident the patient experienced a sensation of 
tingling in the fingers of the left hand. Well-marked 
priapism and retention of urine and feces existed. 
Sight and hearing were not affected. 
With this formidable array of symptoms, it was 
very evident that we had to deal with a case of 
extreme pressure, or contusion of the spinal cord. 
It was also very evident that the lesion was below 
the origin of the phrenic nerve, as the functional 
activity of the diaphragm was not destroyed. It 
was also plain that the lesion was above the origin 
of the brachial plexus, as there was total paralysis 4 
of both upper extremities, and almost complete 
anesthesia. 
I therefore proceeded to examine the spine, but 
previous to the examination I gave hypodermati- 
cally: Morphin sulph., gr. atropin sulph., 
gr. trinitrin, gr. to relieve the pain and 
increase the force of the heart. 
We then turned the patient on his right side, this 
being preferable to the left, on account of the weak 
condition of the heart. 
Beginning at the occiput, I passed my finger 
slowly down the spine, pressing firmly against the 
vertebrae. When the space between the fourth and 
fifth cervical vertebrae was reached there was a dis- 
tinct and abrupt depression, the more marked on the 
left side. Pressure of the finger on this point was 
extremely painful. The spinous process of the next 
vertebra below was quite prominent. Passing the 
finger further down the spine it was impossible to 
detect any other abnormal deviation or painful 
point. 
I examined carefully for crepitus, but was unable 
to detect any, a fact that in itself was not sufficient 
to exclude fracture. There was some swelling of the 
muscles of the neck, but no indication of external 
contusion. The man was very muscular, and I found 
it quite difficult to distinguish the spinous processes, 
especially in the cervical region. In the left oc- 
cipital region there was a contusion of the scalp, one 
inch in length, caused by the fall. 
By a careful consideration of the foregoing his- 
tory and symptoms, I gave a diagnosis of dislocation 
of the fourth cervical vertebra, with or without frac- 
ture, causing extreme pressure, and perhaps contu- 
sion of the cord. 
In such cases the propriety of attempting reduc- 
tion is not questioned by modern surgical opinion. 
Therefore, having the consent of both the patient 5 
and his family, I decided to attempt reduction at 
once, in order to relieve the compression, and as 
affording the only hope of restoring the function of 
the cord, and prolonging life. Considering the very 
low state of the vital powers, the administration of 
an anesthetic was believed to be contra-indicated. 
Having placed the patient on his back, with 
the aid of four assistants I proceeded to exercise 
extension. With an assistant at each lower limb, 
and one at each shoulder, I took my position at 
the head, with one hand on either side, the fore- 
finger of each hand resting below the inferior 
maxilla, and the other fingers supporting the neck 
and occiput. We then began gentle traction, 
which was slowly increased. When the extension 
and counter-extension reached the point that the 
body retained the horizontal position without touch- 
ing the bed, a sudden jar was distinctly felt by each 
of us, and was plainly heard by all who were in the 
room. We then gently lessened our traction, and 
slowly lowered the body to the bed. Neither rota- 
tion nor flexion was practised, from fear that they 
might be the means of increasing the pressure on 
the cord. We were thus keeping within the bounds 
of conservatism, with the least possible risk for the 
patient. But if reduction had not been possible 
without them, I certainly would not have hesitated 
in resorting to them. 
The man complained of no pain during the opera- 
tion, and to all appearances suffered no depressing 
effects from it, being conscious during the entire 
time. Still being in the condition of shock, I ordered 
him to be surrounded with bottles of hot water, and 
brisk friction made over the body and extremities, 
placing also a strong sinapism over the heart, and 
a cantharides plaster over the seat of the injury. 
After an hour the pulse was quite perceptible at 
the wrist, but had diminished in frequency from 36 6 
to 26. Six hours after the accident reaction was 
fairly established, the pulse at the wrist was stronger, 
the cutaneous surface warmer, the voice fuller and 
more audible, the respiratory act increased in 
volume and frequency, and the man began to expe- 
rience a feeling of ease. 
In simple compression of the cord due to disloca- 
tion the symptoms usually disappear promptly after 
the dislocation has been reduced. But upon mak- 
ing another careful test for the return of the func- 
tions of the cord, we found absolute loss of sensation, 
of voluntary motion, and of the reflexes. Therefore, 
I gave a grave prognosis, and insisted on having 
counsel. 
Accordingly, on the following day, eighteen 
hours after the accident, Dr. H. T. Pershing kindly 
saw the case with me, and still later Dr. P. D. 
Rothwell. The patient was much the same as when 
I left him the night before, except that he was de- 
pressed by the awful consciousness of the approach- 
ing crisis. The pulse had increased to 72, and the 
respiration to 26. He had passed a fairly comfort- 
able night; he slept several times with intervals of 
restfulness, and had occasional attacks of emesis. 
Retention of urine and well-marked priapism contin- 
ued. We passed a silver catheter its full length, and 
failed to draw urine. The irritation of the catheter 
increased the priapism to such a degree that it 
deceived us into the belief that there was suppression 
of urine, and therefore we did not persist with other 
attempts. 
Later in the day, twenty hours after the accident, 
Dr. Rothwell saw the patient, and found him very 
uneasy. He passed a long flexible catheter, and 
succeeded in drawing off over a pint of urine. Dr. 
Pershing carefully traced the line of anesthesia, and 
found it somewhat higher than on the night before. 
He also tested thoroughly for the deep and superb- 7 
cial reflexes, and has kindly furnished me with the 
following notes : 
"The line of anesthesia ran, in front, between the 
first and second ribs ; behind, along the spines of the 
scapulae. On the right side it ran over the acromion; 
on the left it extended downward about two inches 
from the acromion, leaving a triangular space of 
normal sensibility over the deltoid muscle. There 
was total loss of both deep and superficial reflexes." 
There was occasional emesis of a very peculiar 
variety during the first twenty-four hours. The 
abdominal and thoracic muscles took no part 
in the act. It was produced by an involuntary 
contraction of the diaphragm and the muscles 
of the stomach itself, to all appearances, without 
any effort or exertion on the part of the patient. 
Deglutition was not impaired. Liquids were given 
in small quantities at frequent intervals. The 
tongue when extended did not deviate to either side, 
and was devoid of any tremor. The muscles of the 
face and neck performed their normal functions. 
The backward and forward movements of the head, 
as well as the lateral and rotatory movements, were 
not impaired. 
One hour before death the line of anesthesia varied 
but little from that of the previous day. Priapism 
was slightly marked, though less than on the pre- 
vious visits. The patient complained of feeling un- 
comfortable, and we passed a catheter, and drew off 
sixteen ounces of urine. The pressure of the dis- 
tended bladder against the diaphragm, interfering 
with respiration, undoubtedly was the cause of the 
discomfort. In passing the catheter he did not feel 
the slightest sensation. When the instrument 
reached the sphincter vesicse muscles it met with an 
obstruction. There being no history of stricture, it 
indicated that the sphincter vesicse muscle was firmly 
contracted, and consequently not paralyzed. 8 
Another very important point was also noticed in 
this connection. If in the latter part of the act the 
end of the catheter was raised above the level of the 
bladder the urine ceased to flow, but as soon as it was 
lowered the urine began to flow again. This would 
certainly indicate paralysis of the detrusor urinae 
muscle, the elasticity of the bladder being alone 
sufficient to expel the urine when it was completely 
distended. The temperature had risen to 1020 F.; 
the respiration was 28, the pulse 82. The man was 
perfectly rational. The voice was distinct, but he 
spoke with greater difficulty and less force. The 
face was much flushed. Respiration was very shal- 
low; there were bronchial rales; the throat was 
filled with mucus; and there was inability to cough 
or expectorate. Death from asphyxia occurred 
forty-three hours after the accident. 
The autopsy was conducted by Dr. Pershing 
twenty-four hours after death. There was a separa- 
tion between the fourth and fifth cervical vertebrae, 
with complete rupture of all the ligaments and 
muscles of the right side, and separation to such an 
extent that the dura could be distinctly seen. The 
inferior articular process of the fourth vertebra 
passed forward and in front of the superior artic- 
ular process of the fifth, lodging in the interver- 
tebral notch between the body and the superior 
process of the fifth. Thus the interlocking of the 
articular processes maintained the dislocation, pro- 
ducing what Stimson terms " a complete unilateral 
dislocation." 1 
The cord and membranes were severely compressed 
between the lamina of the fourth cervical vertebra 
from behind, and the upper part of the body of the 
fifth in front, thus compressing them into nearly one- 
half of their former space. The meninges were not 
torn. There was no extra-dural hemorrhage. The 9 
entire cervical spine was removed, and has been 
preserved. 
After the removal of the cervical portion of the 
spine, by using a little extension and counter-exten- 
sion, rotating the upper segment, the parts could 
readily be displaced, the right inferior articular 
process of the fourth cervical vertebra slipping over 
and lodging in front of the superior articular pro- 
cess of the fifth. In reversing the order, using ex- 
tension and counter-extension, and rotating the 
upper segment to the left, the parts went into posi- 
tion again with a distinct snap that could be plainly 
heard for a distance of several feet. 
After removing the cord and membranes from the 
canal, the gross lesion showed distinctly where the 
crushing of the cord had taken place. A distinct 
circular constriction extended entirely around the 
cord at a point corresponding to the lower level of 
the fourth vertebra, or between the fifth and sixth 
cervical segments of the cord. 
The cord has been preserved in Muller's fluid, 
but the pathologic analysis of its interior, showing 
the minute lesions by transverse sections, has been 
delayed on account of not wishing to destroy the 
identity of the gross lesion. 
The discovery of the total absence of fracture was 
also a notable feature of the autopsy. 
Dr. Axtell's notes of his examination of the cord 
are as follows : 
On the anterior surface there is no macroscopic 
appearance of any trouble. On the posterior sur- 
face, opposite the fourth cervical vertebra, there is 
a depression in the cord, clean cut, looking as 
though a small tape had been bound over the cord. 
No inflammatory products are found in the mem- 
branes or on the cord. At the point of depression 
in the cord it can be made to move readily, for- 
ward, backward, and laterally. 10 
Specimen showing an anterior dislocation of the fourth cervical 
vertebra on right side. 
a. Body of fourth cervical vertebra displaced forward. 
b. Inferior articular process of fourth cervical vertebra. 11 
This is the only point where the cord can be thus 
bent. The cord has been imperfectly hardened in 
Muller's fluid. Thick sections of the cord just 
above and below the lesion present evidences of 
acute myelitis. The consistency of the cord is 
diminished, the bloodvessels are distended and the 
distinction between the white and gray matter is 
very slight. At the point of depression the cord is 
softened, and no sections can be made, as the tissue 
crumbles before the sharpest edge. Both the white 
and the gray matter seem to be a soft, crumbling 
mass, especially in the posterior half. Just beneath 
the membranes on the anterior surface the cord is 
of fair consistency. 
Careful examination of the softened portion shows 
much granular matter, masses of myelin and nu- 
merous granule-corpuscles. 
In this report I have endeavored to adhere as 
closely as possible to the true clinical phenomena. 
As a rule it is not well to generalize upon individual 
cases; but as the lesion is one of such rare occur- 
rence, and the symptoms in this case were so typical 
and distinctly marked, and an autopsy also having 
been made to demonstrate the accuracy of the diag- 
nosis and the character of the lesion, it seems worth 
while to make a brief review of some of the most 
important points. 
In the first place the distinct vasomotor disturb- 
ance, indicated by the flushed face, the slow and 
feeble pulse, and the marked subnormal temperature 
would clearly indicate vasomotor paralysis, very 
probably due to injury of the cervical ganglia, sit- 
uated on each side and in front of the cervical spine. 
In spinal surgery the reflexes are among the most 
valuable diagnostic signs that we possess, although 12 
there is a wide difference of opinion among observers 
as to their diagnostic significance. Dr. Thorburn, of 
Manchester, England, who has made some excellent 
observations in this department of surgery, claims 
that in total transverse lesions of the spinal cord 
both the superficial and deep reflexes below the 
functional level of the injury are permanently and 
entirely abolished; while in partial lesions the re- 
flexes are retained, perhaps exaggerated. He further 
claims that if the lesion causes complete paralysis 
and anesthesia the deep reflexes are always lost.2 
One of the most important questions in this con- 
nection is the effect upon the spinal centers of 
isolating them from their cerebral connections. If 
there has been no error of observation in this case, 
I think it will bear me out with the statement that 
the functional activity of all the spinal centers below 
the lower level of the lesion were totally abolished 
with the exception of two: " the sexual reflex cen- 
ter " and " the tonic center of the sphincter vesicse 
muscle." The proof that the first was not totally de- 
stroyed is demonstrated by the fact that the local irri- 
tation of passing the catheter increased the priapism 
to a very marked degree. The most plausible theory 
of priapism is that of Dr. Bramwell,3 who claims 
that it is probably due to irritation of the " excitor" 
fibers, which pass from the cerebrum to the sexual 
reflex center. In other words, it is "a reflex act," 
produced by an irritation of these fibers at the 
point of the contusion of the cord. The fact that 
the local irritation of the catheter increased the 
condition tends to prove Dr. Bramwell's theory, in 
opposition to the old one of "vasomotor paralysis." 13 
The proof that the second center was not paralyzed 
is very evident from the fact of the persistent retention 
of urine, without any dribbling whatsoever, notwith- 
standing the fact that the bladder was distended to 
such a degree that the pressure against the diaphragm 
from below quite seriously interfered with respiration. 
Dr. Lidell has observed that in these cases retention 
of urine is almost certain to exist for a time, to be 
succeeded by incontinence as soon as the sphincter 
muscle becomes paralyzed? If the inhibitory fibers 
of the sphincter have been severed or destroyed, 
any voluntary inhibitory impulse sent from the 
brain will meet with resistance at the lesion. Con- 
sequently, if the sphincter is inhibited after there is 
total transverse lesion above the tonic center, it 
must be by "Gowers' reflex,"5 that is, by sensory 
stimuli from the mucous membrane of the bladder 
itself. But in this case I think we have shown con- 
clusively that both the motor and sensory power of 
the bladder-walls were paralyzed. Therefore, it 
seems to me evident, as the tonic center remains 
in force after the cord is completely crushed above 
it, that it is, at that time, an independent spinal 
center, isolated from any cerebral connection. Dr. 
Hughlings Jackson has observed that the highest 
centers of the nervous system, those that are the 
last to develop in the process of evolution, are the 
first to fail in dissolution and are the most readily 
affected by sudden irritation.6 Reasoning from this 
data the natural inference is that " the sexual reflex 
center" and "the tonic center of the sphincter 
vesicse muscle " are the most stable'centers of the 
cord, as they are almost always the last to lose their 14 
functional activity after total transverse lesion of the 
cord. 
So far as the prognosis is concerned in these cases 
there is very little to be hoped for. Dr. Thorburn 
states that it is hopeless to expect that the crushed 
cord can recover.2 
Some suggest that the two segments might be 
innervated by transplantation of the spinal nerve 
roots, and thus restoring the function of the cord.7 
But this seems to be entirely too radical a measure, 
increasing the dangers to life, without offering any 
reasonable chance for improvement. 
From the foregoing history, and from a rather 
careful review of the sparse literature upon the sub- 
ject, I make the following deductions: 
i. In acute traumatic lesions of the spinal cord, 
when there is instantaneous and total paralysis of 
both sensation and voluntary motion, the proba- 
bility is in favor of crushing of the cord rather 
than of compression. 
2. When the cord is totally crushed, there being 
instantaneous and total loss of sensation and 
voluntary motion below the lesion, there is also 
total loss of the reflexes (the opinion of many 
good authorities to the contrary notwithstanding.) 
3. When the cord is once completely crushed, as 
indicated by the foregoing symptoms, viz , instan- 
taneous and total loss of sensation, of voluntary mo- 
tion, and of the reflexes, reduction will not improve 
the symptoms, and surgical interference will very 
likely only shorten life, without offering any reason- 
able hope of improvement. 
4. Priapism is probably due to a reflex act, rather 
than to a vasomotor paralysis, or to a combination 15 
of both, as demonstrated by the local irritation of a 
catheter. 
5. Usually there is marked vasomotor paralysis, 
indicated by the flushed face, slow and feeble pulse, 
and profound depression of temperature, soon fol- 
lowed by hyperpyrexia. 
6. Usually there is retention of urine, to be fol- 
lowed, sooner or later, by incontinence, unless the 
lesion is low enough to involve the tonic center 
of the sphincter, or unless the associated concussion 
has been sufficient to impair the function of this cen- 
ter. In either case there is paralysis of the sphincter 
and incontinence of urine from the first. 
7. It is a characteristic peculiarity of acute trau- 
matic lesions of the Spinal cord that consciousness 
and the power of speech are very seldom lost, a 
very important contra distinction to similar injuries 
of the cerebrum. 
8. "The sexual reflex center" and "the tonic 
center for the sphincter vesicae muscle" are very 
probably the most stable centers of the cord, as 
demonstrated by their persistence of action after 
complete isolation from their cerebral connections. 
i. Stimson: Treatise on Dislocations, 1888. 
2. Thorburn : Surgery of the Spinal Cord. 
3. Bramwell: Diseases of the Spinal Cord, 1886, 2d ed. 
4. Lidell: International Cyclopedia of Surgery, 1889 edition 
vol. iv. 
5. Gowers: Diseases of the Nervous System. 
6. Starr: Reflex Neuroses, The Medical News, March 22, 
1890. 
7. Dana: Transactions of the New York Academy of Medi- 
cine, The Medical News, July 26, 1890. 
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