An interesting and remarkable accident

This is one of those cases that at first reading seems inherently unlikely – but, bizarre as it sounds, has a perfectly rational medical explanation. It took place in the 1830s but was only reported in any detail three-quarters of a century later. This article was contributed to the Buffalo Medical Journal by Dr Roswell Park, the founder of the world’s first institution devoted solely to cancer research:

An interesting and remarkable accidentThere came into my possession some twenty years ago, perhaps longer, the subjoined statements regarding the nature of a very unusual accident, with still rarer sequels, which befell Dr. James P. White, one of the founders of the Buffalo General Hospital, during the year 1837.

James Platt White
James Platt White (1811-1881)

James Platt White was an influential gynaecologist, a founding professor of the University of Buffalo and a prominent member of Buffalo society in the mid-nineteenth century. He was the first American medic to use a live birth as a teaching aid in the classroom.

In December of that year something happened to the stage-coach in which he was riding, near Batavia, and he was violently thrown, and in such a way as to seriously injure his head and neck. I have not been able to learn any of the details either of the event or of his subsequent symptoms.

So all we have so far is that Dr White injured his head and neck in a stagecoach accident. Of the next six weeks of his life, nothing is known. But after that something truly extraordinary happened to him: he coughed up part of his own spine. We know this from a short statement published in the Medical News in November 1886 by one Joseph Pancoast. It was written as a certificate confirming the authenticity of a highly unusual pathological specimen:

“A front segment of the atlas vertebra, a little more than an inch on the superior margin, a little less below, with the facette which received the odontoid process.”

The atlas vertebra, known today as C1, is the topmost bone of the spine. It is named after Atlas, the Titan who in Greek mythology supported the sky on his shoulders. It’s a structure of crucial importance, protecting part of the brain stem. Its mobility also allows us to turn our heads and nod.

The odontoid process or peg is a protuberance from C2, the second vertebra of the neck. The ‘facette’ (now usually spelled facet) is the joint between the two vertebrae.

Atlas vertebra
The atlas vertebra (C1) from Gray’s Anatomy (1918)

It is probable that the transverse ligament retained its hold on the two extremities of the remaining fragment of the atlas, thus protecting the spinal marrow from injury.

So this lump of bone was not the entire C1 vertebra – just a large chunk of it. Dr White retained just enough of the bone to protect a critical part of his spinal cord from potentially fatal injury.

This bone in possession of Professor Pattison I repeatedly saw and carefully examined; he exhibited it to his class, and it was mislaid or lost.

What a shame! This would have been quite an artefact.

The bone was in our possession in 1838-39-40, or thereabouts. I then understood and believed (since confirmed by conversation with Professor White) that it came from his throat, coming out through the mouth as a consequence of ulceration, the result of an accident while riding in a stagecoach on the morning of December 17th, 1837.  The bone was discharged at the expiration of forty-five days after receipt of the injury.

If there was ‘ulceration’ at the back of the throat it is likely that Dr White was in considerable discomfort. There are very few comparable cases on record, but in all of them the patient had great difficulty eating or drinking, was in severe pain and bedbound.  But can you imagine what it must have been like suddenly ‘discharging’ a large piece of your spine through your mouth?

Of his condition during the forty-five days previous to the extrusion of the fragment there is no account, neither is there of the time elapsing before his restoration to his usual activity; but inasmuch as he died in 1881, having passed the subsequent part of his life in a most active professional career, it is legitimate to conclude that he suffered little, if at all, from the consequences of his injury.

In 2005 this case prompted an article by an eminent orthopaedic surgeon working at White’s old hospital in Buffalo, Eugene Mindell. After considering all the available evidence of White’s injury, Mindell concluded that he had suffered an injury known as a Jefferson fracture, in which the atlas vertebra is shattered by a sharp impact. A few fragments of bone burst through the wall of the pharynx, causing an open wound which then caused an infection of the exposed portion of vertebra. Eventually the infection had caused necrosis, when the dead portion of bone (known technically as a sequestrum) had come free and been coughed up (yuck). Finally, scar tissue had formed (or the two adjacent vertebrae C1 and C2 fused together) and the wound healed.

It’s pretty amazing that Dr White was so little affected by this accident that he was able to return to work and live a normal life for more than thirty years afterwards. An ‘interesting and remarkable case’ indeed.

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