A CASE OF SLOW AND ONE OF SWIFT 
COMPRESSION OF THE SPINAL CORD 
From Dislocation of the Odontoid 
Process. 
V. P. GIBNEY, A. M„ M. D„ 
Professor of Orthopaedic Surgery in the New York Polyclinic. 
NEW YORK: 
Reprinted from the American Journal of Neurology and Psychiatry. 
1882. THE 
American Journal of Neurology & Psychiatry. 
Editors : 
T. A. McBRIDE, M. D., 
NEW YORK CITY. 
LANDON CARTER GRAY, M.D., 
BROOKLYN, N. Y. 
EDWARD CHARLES SPITZKA, MD., 
NEW YORK CITY. 
LIST OF CONTRIBUTORS. 
Dr. R. W. Amidon, New York City. 
Dr. W. R. Birdsall, " " 
Dr. V. P. Gibney, . " 
Dr. G. M. Hammond, " " 
Prof. W. A. Hammond, " " 
Dr. T. H. Kellogg, " " 
Dr. F. P. Kinnicut, " " 
Dr. Wm. H. Farrington, " " 
Dr. A. J. C. Skene, B'klyn, N. Y. 
Dr. Benj. F. Westbrook, " " 
Dr. A. H. P. Leuf, " 
Dr. J. S. Woodside, P " 
Prof. S. W. Mitchell, Philadelphia, Pa. 
Prof. Roberts Bart holo w, " " 
Prof. Wm. Pepper, Philadelphia, Pa. 
Prof. J. M. DaCosta, " " 
Dr. Chas. K. Mills, " " 
Dr. J. S. Jewell, Chicago, Ill. 
Dr. S. V. Clevenger, " " 
Dr. J. G. Kiernan, " " 
Prof. F. T. Miles, Baltimore, Md. 
Dr. John Van Bibber, " " 
Prof. Robert Edes, Boston, Mass. 
Prof. James J. Putnam, " 
Prof. S. G. Webber, " " 
Dr. H. D. Schmidt, New Orleans, La. 
Prof. Buri G. Wilder, Ithaca, N. Y. 
Dr. Dewey, Kankakee, Ill. 
Dr. H. M. Bannister, Kankakee, Ill. 
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[See 3Y page of cover. A CASE OF SLOW AND ONE OF SWIFT COM* 
PRESSION OF THE SPINAL CORD FROM DIS- 
LOCATION OF THE ODONTOID PROCESS.1 
BY 
V. P. GIBNEY, A.M., M. D. 
Piofessor of Orthopaedic Surgery in the New York Polyclinic. 
CASE I.-Left Hemiplegia of Spinal Origin, with 
Torticollis; Death at End of Fourth Month; 
at the Autopsy, Odontoid Process found Dis- 
placed and Cord Compressed. 
E. D , male, cet. 11 years, was admitted to the Hos- 
pital for the Ruptured and Crippled, March 16, 1882. The 
family history contained nothing bearing upon the case. 
Until a year ago he had been subject to epileptic fits. In 
September, 1881, a playfellow gave him a severe blow on 
the neck with his hand, and on the following day it was 
observed that the head was held a little awkwardly, and pain 
at the occiput was well marked From this dates a torti- 
collis. The cervical glands proceeded to suppuration, and 
two months from the date of the blow above recorded an 
abscess was opened. 
The patient's first appearance in the outdoor department 
was on the 27th of February, and from a cursory examina- 
tion I made a diagnosis of left spinal hemiplegia, with 
simple spondylitis, and advised admission to the hospital. A 
more thorough examination was made March 1st. There 
was a half-inch atrophy in both superior and inferior ex- 
1 Read at the last meeting of the American Neurological Association. 2 
P. GIBNEY. 
tremities. The arm hung limp by the side, and the foot 
was brought to the floor, as he walked, with a " flop." Al- 
though not very lame, the gait was characteristically hemi- 
plegic. By great effort he could raise the arm from the 
side a distance of twelve inches, the suprascapular muscles 
seeming to execute the act. He could feebly flex the fore- 
arm, and the finger flexors were so strongly contracted that 
he could not use the dynamometer. The entire limb was 
hyperaesthetic, but the degree of hyperaesthesia was not as- 
certained. All the muscles responded to both currents, 
with diminished contractility in the atrophied groups. The 
tongue, on protrusion, deviated to the left side very per- 
ceptibly, while the uvula deviated to the right. The tonsils 
were very large, and it was with considerable difficulty that 
the posterior pharyngeal wall could be thoroughly explored 
with the finger. This examination, however, was attended 
with absolutely negative results. The head was rotated 
to the left and tilted to the right. Passive movements, if 
carried to extremes, were resisted very much. An unnatu- 
ral projection in the post-cervical region to the left side and 
near the occiput seemed to be the spinous process rotated 
out of the vertical axis. 
The examination was completed on the 16th, the date of 
his admission to the hospital. Moderate spinal concussion 
gave no pain, but on pressure over the projecting spinous 
processes there was decided tenderness. The deltoid was 
much atrophied ; pronation and supination barely possible; 
flexion and extension of the hand and fingers ditto, although 
there was no appreciable atrophy of the hand. The patellar 
reflex and the foot clonus were greatly exaggerated. The 
extensors of the thigh were weak, but not palsied. The 
flexors and extensors of the leg possessed less than normal 
power, and active dorso-flexion of the foot was quite im- 
possible. No contractions about knee or foot existed. He SLOW AND SWIFT COMPRESSION OF SPINAL CORD. 
3 
has had an ulerative keratitis of right eye, with much con- 
junctival hyperaemia. 
His head was suspended in a spring attached to a spinal 
brace, and faradism daily was begun. The keratitis became 
so alarming that by the advice of Dr. Agnew he was trans- 
ferred to the Manhattan Eye and Ear Hospital, April I, 
when it was noted that most decided improvement had 
taken place in the deltoid, and indeed in all the muscles of 
the limb. The head support had proven of undoubted value. 
During his stay in the Manhattan-one week-Dr. Seguin 
very kindly continued the electrical treatment. The eye 
symptoms subsided promptly, and the case altogether did 
well. The parents removed him from our hospital on the 
13th. 
April 22. Dr. Seguin reported yesterday that the patient 
had been re-admitted to the Manhattan, coming under his 
care, and that in a few days he became perfectly helpless. 
The case was discharged, and the mother advised to place it 
again under orthopaedic treatment. His advice was not 
taken. 
The subsequent history was obtained April 30, the day of 
the autopsy, twenty hours after death, Dr. Seguin and Dr. 
Geo. W. Ryan being with me on that occasion. Very soon 
after leaving the Manhattan the paralysis became complete, 
and at times he suffered from violent spasmodic action of 
muscles of the extremities. He complained much of occipi- 
tal and frontal headache, and slowly lost ground up to the 
evening of the 28th, when he passed a restless night, though 
his symptoms did not seem at all alarming. On the follow- 
ing morning, about six, he attempted to rise, gave a wild stare, 
a gasp or two, and expired. He had no convulsion, no facial 
contortion, no squint. 
The spinal column was opened from behind in the upper 
two-thirds of its extent. The spinous and transverse pro- 4 
K. P. GIBNEY. 
cesses of the second cervical vertebra were unusually prom- 
inent, and it was our opinion that they were considerably 
enlarged as well as very hard. No pus ct.vity could be 
found, and the spinal canal throughout its cervical and dor- 
sal regions presented nothing abnormal ; no softening of 
the bodies. The cord was carefully removed and its cover- 
ings presented no pathological changes. The brain was 
examined thoroughly and no lesion discovered. On remov- 
ing the cerebellum with the medulla and upper portion of 
the cord the odontoid process was found tilted backwards, 
almost completely obliterating the spinal canal. The 
accompanying drawing, by Dr. Wm. G. Bull, illustrates the 
appearance of the parts. 
The tip of the little finger could with difficulty be pushed 
through the foramen magnum, and if the head were flexed 
on the sternum it was quite impossible to so introduce the 
finger. The process was not denuded of periosteum, but was 
loose at its base, and the apex tipped towards the left. 
The spinal cord and the lower portion of the medulla 
in this vicinity were very soft, quite limp, and a marked 
indentation was seen in front, caused apparently by the 
odontoid process. It was not learned how the ligaments 
became involved, but it was presumed that the spondylitis 
had brought about their detachment. 
Dr. Birdsall has made a report on the sections I made, and 
to him I am likewise much indebted for the drawings which 
accompany his report. 
Report by Dr. W. R. Birdsall.-The specimens pre- 
sented to me by Dr. Gibney for examination consisted of 
sections, stained in carmine, and mounted in balsam, from (a) 
the decussation, 0) the superior cervical- cord-compressed 
portion-and (r) the middle cervical cord. 
In a no evidences of disease were observed. In b, repre- 
sented by Figs, i and 2, Plate I., the whole section presents Fig. i (see note, p. 6). 
Fig. 3 (see note, p. 6). 
Fig. 2 (see note, p. 6). 
See p. 4. 
See p. 4. 
See p. 4. 
Fig. i, p 7 SLOW AXD SWIFT COMPKESSIOX OFSPIXAL COED. 
5 
a cloudy appearance, the usually distinct outline of the 
axis cylinders and their medullary envelope being absent ex- 
cept in the peripheral portions or at the extreme margins of 
the lateral columns. In all other portions there exist, in va- 
rying degrees, swelling of the medullary sheath and also of 
the axis cylinders, great numbers of lymphoid elements, 
myelin drops, granule cells and granular detritus, the latter 
forming in certain portions small, irregular, yellowish 
patches of completely disorganized matter (represented in 
deep black. Fig. 11, occupying the inner portion of the left 
crossed-pyramidal tract, involving the neighboring gray mat- 
ter. Another less marked patch exists in the corresponding 
column of Burdach. and a few specks in the right crossed- 
pyramidal tract. The lateral portions of the left crossed- 
pyramidal tract exhibit, to a marked degree, the changes 
above described, and. in addition, hypertrophy of the neu- 
roglia. the septa, and the walls of the blood-vessels. The 
right crossed-pyramidal tract presents similar changes, though 
much less marked. Other portions of the lateral and 
posterior columns are irregularly streaked, as shown in 
Fig. i ; the darker portions representing the parts most 
affected. The most decided changes exist in the central 
portion of the columns of Burdach and the gray mat- 
ter about the central canal, involving the central gray 
columns, showing in some portions almost complete disor- 
ganization. all traces of the neural elements having disap- 
peared. leaving a mass of granules, granule cells, lymphoid 
elements, myelin drops, with numbers of hypertrophic and 
occluded blood vessels. (The latter appear in Fig. I as black 
dots, and in Fig. 2 more highly magnified.) These vessels are 
a striking feature of the specimen. All the layers seem to 
be involved in the hypertrophy. Complete occlusion may 
be frequently observed. No perivascular spaces are to be 
seen, but many vessels appear to be encased by one or more 6 
K P. GIBNEY. 
layers of lymphoid elements. The extreme portions of 
the anterior horns appear normal, while the posterior horns 
are richly infiltrated with lymphoid elements. 
An interesting feature is that the central portions of the 
cord, and not the periphery, suffered most from the compres- 
sion. The vascular changes were decided in this region only. 
The interference with the circulation of this, most vascular 
region of the transverse area of the cord is probably the most 
important factor in the production of the lesion. 
In c, below the point of compression, the column of Tiirck 
and the greater part of the remaining portion of the anterior 
columns, the posterior columns, and the direct cerebellar 
tract are normal. The crossed-pyramidal tracts, particu- 
larly the left, exhibit hypertrophy of the neuroglia and septa, 
distinguishable from sclerosis of chronic myelitis by the ab- 
sence of Deiters' cells and induration of the neuroglia and 
septa. The neural elements are in a fair state of preserva- 
tion, and the decided vascular changes seen in the compressed 
portion are absent. The gray matter, with the exception of 
increased vascularity, is normal. In other words, the changes 
are limited to the crossed-pyramidal tract, except when 
they involve the anterior portion of the left lateral column, 
or most abnormal side. The outline of the direct cerebellar 
tract is as distinct in the specimen as represented in Fig. 3, 
and the asymmetry in the anterior horns is correctly repre- 
sented. 
Fig. i.-Transverse section of cord in the superior cervical re- 
gion, compressed portion. Right side represents left half of cord. 
Fig. 2.-A portion of the column of Burdach, adjoining pos- 
terior commissure, showing hypertrophied artery. No. 6 Verick, 
Obj., No. 3, a. 
Fig. 3.-Transverse section of cord in middle cervical region, 
below compressed portion. Right side represents left half of cord. SLOW AND SWIFT COMPRESSION OF SPINA L CORD. 
7 
CASE II.-Caseous Ostitis at the Occipito-Atloid 
Articulation and of the Body and Odontoid 
Process of the Atlas. 
This case has been used in a paper by Dr. Yale1 to illus- 
trate disease in the upper cervical vertebra, and the notes 
1 then furnished him are reproduced in this communication. 
It furnishes such excellent specimens of myelitis of the an- 
terior horns that I have reserved the cord and the drawings 
for a future report. The gross appearances are well repre- 
sented in the drawing made by Dr. Amidon. | Fig. i.] 
The history is as follows : 
January 19, 1880.-For at least a week the patient, a 
male, cet. 15, has had a stiff neck, which is thought to have 
come from a cold. Later, it was discovered that a week 
before the appearance of the symptoms he had fallen back- 
ward, striking his head against the floor with considerable 
force. Liniments ineffectual. No infiltration ; tenderness 
along ligamentum nuchae ; blister to nape. 
January 21.-No relief from blister. Ergot 3 ss., t.i.d. 
No appreciable rise in temperature ; pulse and respiration 
normal. Keeps bed simply from holding head erect. 
January 22.-Ergot not retained. 
January 26.-Still unrelieved. In fact there now appears to 
be a subacute cellulitis, probably involving the cervical fas- 
cia. No enlargement of vertebrae to be felt in the fauces ; 
and no prominence to be felt posteriorly, and, indeed, a 
careful examination fails to detect any vertebral disease. 
January 28.-Belladonna lotion. Ergot again, not borne ; 
followed by a blister. 
On February 8, the entry is continued: "No material 
change. * * * * Can this be a case of pachymening- 
itis cervicalis hypertrophica, with extension of disease along 
1 Medical Record, Nov. 13, 1880, p. 553. 8 
r. P. GIBNEY. 
nerve sheaths, causing a peripachymeningitis, or is it simply 
a rheumatic form of an inflammation affecting cervical 
fascia ?" 
February 9.-On right side, just back of the mastoid pro- 
cess, is a tumor barely perceptible. 
February 10.--Spinal brace and head spring applied. Is 
now out of bed. 
February 15.-Gets much support from the head spring, 
but dislikes the body brace very much. Tumor enlarging 
slowly. Some tenderness. 
March 30.-Incision made an inch deep before pus is 
reached. Leech and poultice. Temperature, 1030. 
March 31, A. M.-In an attempt to enlarge the opening, 
a branch of the occipital artery (probably the princeps cer- 
vicis) is divided and at least a half ounce of blood lost. 
Compress proves effectual; brandy freely administered. 
Temperature, P. M., 1030. 
April 2.-Discharge very slight. He suffers so much that 
he begs to sleep in his rolling-chair, the pain on lying down 
being excessive. 
April 5.-A probe inserted fully two inches into the 
sinus touches bare bone, and with this instrument passed 
three times daily the deep parts are kept open. He com- 
plains of great pain in the neck on the left side, but nothing 
more than glandular enlargement can here be discovered. 
April 9.- Pains so great as to require the constant use of 
iced cloths. The patient dislikes morphia, and potassium 
bromide in forty grain doses is employed instead. 
April 11.-Delirium, due apparently to the extreme 
degree of anaemia. The discharge is more free and he looks 
every way better. 
April 17.--Under hot fomentation he seems to get relief 
from pain. Complains of difficulty in breathing, of soreness 
of the throat, and for a week or two he has been unable to SLOW AND SWIFT COMPRESSION OF SPINAL CORD. 
9 
take solid food; takes liquid food even with a tube. 
Breathes heavily in sleep. 
April 19.-Complains this morning of being unable to 
breathe through his nose, and an examination reveals a post- 
pharyngeal abscess. A bistoury is promptly inserted and 
fully two ounces of pus evacuated. The pus is thick, and 
towards the end about a drachm of caseous material like 
bone detritus flows out of the incision. The sac is washed 
with a weak solution of acid carbolic, and the dyspnoea is 
immediately arrested. 
April 22.-No discharge from the mastoid abscess and the 
tumefaction greatly diminished. The fomentations are dis- 
continued, and by 10 P. M. there is great increase in size of 
the tumor. 
May 2.-He is simply vegetating, is growing more and 
more emaciated, and while the discharge is thin and less 
profuse the tenderness of the parts is as great. 
May 3.-By reason of his loss of flesh, it is next to impos- 
sible to fit any form of apparatus that will be at all comfort- 
able. His position in the chair is a painful one; yet-he 
dreads going to bed, and much against his will he is placed 
in the dorsal decubitus, all apparatus being removed. He 
asks to be turned on his side, and as this is done he screams 
aloud, and the agony is so great that'his eyes seem to start 
from their sockets. The extreme helplessness of the limbs 
becomes very noticeable. After awhile he gets into an easy 
position and he lies with little suffering until 4 P. M., when 
his speech becomes difficult ; he faints away, and then rallies 
a little under stimulants. 
At 5 P. M. the nurse reports that he attempted to turn his 
head and raise himself from the pillow, when he suddenly be- 
came deathly pale; the respiration ceased, and on reaching 
his bed a few moments later I found life nearly extinct. He 
was lying on his back, chin on sternum. After a few pulse 10 
V. P. GIBNEY. 
beats and gasps he died. After death I explored the pharynx 
with my finger, finding the sac of the abscess empty and the 
glottis clear. 
Autopsy, twenty hours after death, Dr. E. G. Janeway su- 
perintending. Present: Dr. Poore and the house staff. Tho- 
rax and abdomen not examined. Spinal canal exposed by 
sawing through the arches and removing the spinous pro- 
cesses throughout the whole length. The cord is carefully 
removed. No evidence found at any point of meningitis, 
acute or chronic ; no tubercles ; in the upper portion of 
the cervical region, anteriorly, the dura was a little thicken- 
ed, due, perhaps, to an old pachymeningitis externa. Sec- 
tions of the cord made in the lumbar enlargement, and all 
that could be discovered microscopically is a cloudiness of 
the gray horns anteriorly, with a diminution in their size. 
This condition exists apparently throughout the whole of 
the lumbar portion. There are, however, no very marked 
changes discovered. The cephalo-rachidian fluid normal in 
quantity and appearance. The bodies of the vertebrae are 
carefully examined from behind, and no evidence of caries 
found. As the mastoid abscess is enlarged and explored 
with the finger there can be felt one or two bits of rough, 
hard bone, probably separated by saw and chisel. The 
condyles of the occiput are felt bare and eroded. 
The dura of the calvarium is found very firmly adherent. 
On removing the cephalic mass nothing abnormal is encoun- 
tered until the medulla is reached. Against its anterior sur- 
face, just below the decussation, a bony process is found 
projecting, which proves to be the odontoid. After removal 
of the brain quite a depression is recognized in the medulla 
at its junction with the cord. 
On flexing the head upon the spine, the odontoid can be 
seen plainly moving backward and forward. On inserting 
finger into the foramen magnum there is felt, toward the SLOWAND SWIFT COMPRESSION OF SPINAL CORD. 
11 
right side, a small bit of eroded bone, found to be the 
point of insertion of the check ligaments, both these and the 
transverse ligament being, to all appearance, separated by 
disease of the bones at their attachments, thus allowing the 
displacement described. The mastoid process seems normal. The American Journal of Neurology and Psychiatry is intended to serve as 
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