The dislocated neck

This remarkable story was told in a French publication, the Journal Complémentaire du Dictionnaire des Sciences Médicales, in 1830. The author of the report was a German doctor, Dr Ehrlich, who had apparently treated the young man in question some forty years earlier:

Luxation of two vertebrae

A young man of sixteen, of a strong constitution, attempted to carry on his back a sack of flour weighing possibly a hundred and sixty pounds up to a loft four storeys above the ground. To prove his strength and agility he wished to climb the staircase faster than his comrades who were also loaded with burdens like his, and began to run ahead of them, carrying his sack on his left shoulder. It was raining, which had made the steps of the stairs wet and slippery.

A young man carrying his own weight in flour, running up a slippery flight of stairs. What could possibly go wrong?

In this reckless race he clattered his burden against that of somebody else and slipped, and, carried by the weight of the bag, fell backwards from four steps up and into a corner of the staircase. The bag, which he tried to hold on to, rolled over his head and face, and fell to earth to his right, before he was himself laid out on the ground. At the same moment, the head of this unfortunate creature disappeared from sight of the witnesses of the accident, who immediately called for help.

By happy chance, Dr Ehrlich was only a short distance from the scene of the accident, and in less than five minutes was by the young man’s side.

I found him unconscious, in the corner of the staircase, half standing, with his knees lying on the sack. His chest was bent forward; but his head, which had been jerked violently backwards from left to right by the weight of the sack, rested on the shoulder-blade, so that one did not notice it from in front when one climbed the stairs. At the front part of the neck, on the left, I found a swelling produced by the second cervical vertebra.

It is difficult to see how a bone in the spine could produce a swelling at the front part of the neck. The vertebra in question, also known as the axis, has a long process or extension known as the dens, and it is just possible that this had fractured and rotated in some way, creating a swelling beneath the ear.

The head had lost all stability, so that its own weight made it loll on all sides. The face was a dark and vivid blue, like that of a hanged man; the eyes were protruding, though the eyelids were closed; the tongue hung out of the mouth, from which flowed copious bloody foam; the lower jaw was open, and the veins of the neck, engorged with blood, looked like cords. The limbs were motionless, and were already paralysed; breathing was only apparent by loud sounds, repeated every three minutes; the pulse was intermittent and barely detectible; the faeces and urine were discharged without the knowledge of the patient.

It sounds a highly unpleasant injury, and the bystanders must have thought that their friend was dead, or about to be. Even to the lay person this sounds like a broken neck – a catastrophic cervical fracture causing paralysis and death.
The doctor came to a slightly different conclusion. He believed that the injury was not a fracture but a dislocation – known clinically as a luxation. The sudden pressure on the neck had damaged the ligaments holding the first and second vertebrae together, pushing the bones apart and compressing the spinal cord rather than ripping it apart. Nasty; but, if his analysis was correct, not necessarily fatal.

I had the unfortunate man immediately stretched out on his back, and I instructed an assistant to hold his head in his hands, and make the extension, while another was told to seize his shoulders, in order to operate the counter-extension; I myself put one leg obliquely over the body of the wounded man, with the palms of both my hands on the back of his skull, and at the same time with the atlas projecting backwards, and then put both thumbs on the front of the neck, on the protrusion produced by the second cervical vertebra.

The atlas is another name for the first cervical vertebra (C1), the bone immediately underneath the skull. Beneath it is the axis, the second cervical vertebra (C2). It was the joint between these two bones which Dr Erhlich believed had dislocated. He approached the problem as if it were a dislocated knee or shoulder – essentially, brute force.

Having done this, during the extension I tried to replace the atlas, which was displaced backwards and to the right, with my fingers; and, with the thumbs, to push back the vertebra, which was thrust forward. After several unsuccessful attempts, I finally managed to retract the vertebrae into their articulations, which took place with a crack which was audible to all those present.

Ouch. But it seems to have done the trick:

Scarcely had this reduction been effected when the unusual protrusions in the neck disappeared; the head resumed its solidity on the trunk; the tongue returned into the mouth, the jaw closed, and the arms began to move; but the patient seemed to be in a deep sleep. Full of hope that we could save him, I observed all these circumstances with the most minute attention, and examined the pupils, which in both eyes I found to be dilated.

Not a good sign; but, on the other hand, the boy started to breathe easily and with less noise.

Bloody foam no longer appeared from his mouth when he exhaled; but he began to cough, with which blood was expectorated. The pulse was greatly accelerated and irregular. Any questions asked by me or by others remained unanswered, and any sensations received by the organ of hearing seemed not to be reaching the brain, or at least consciousness had not yet returned.

Notice that little attention is paid to immobilising the spine to prevent further injury to the cord – this would be a priority today. Instead, the doctor started to think about alcohol.

I cautiously gave the patient a little wine, in the hope that he might recover by means of a more regular and uniform flow of blood; but the organs of swallowing appeared to refuse to do their job; for very little wine was swallowed, and it was impossible to be sure whether the liquid had actually reached the stomach, or remained in the back of the throat. For the moment I did not persist with such attempts, and made it my priority to place the injured man in a safe position, and to secure his head appropriately. With this in mind, I passed several long compresses around the neck, and applied a clean bandage to maintain the head upright. Then we undressed and washed the patient, and had him carried to bed with the greatest care, where I placed him almost in a seated position, his head supported and immobilised by carefully-arranged cushions.

Medicines were then administered. The doctor wafted ammonia in front of the boy’s nose, and placed ten drops of ether in the boy’s mouth every half hour – at this date ether was often used as a stimulant, though its anaesthetic properties were as yet unknown. A poultice of aromatic herbs in wine was applied to the head and neck.

After the application of these remedies the patient managed to open his eyes from time to time, expectorate with more force when the cough troubled him, and swallowed better. He then became less tranquil, and made efforts to turn around; but an intelligent nurse always stopped him, according to my strict instructions.

Cream of tartar was then prescribed in the hope of preventing inflammation and opening the bowels.

The next day, I learned that the patient had had a little quiet sleep during the night, he had coughed a few times, but produced little blood. He understood what I said to him, and answered my questions; but he did not remember anything of what had happened to him. He complained only about pain in both sides of the neck, and discomfort in the left side of the chest.

To reduce the neck pain, the doctor boiled aromatic herbs in milk with saffron, and placed the sweet-swelling mixture under the boy’s nose and mouth. A poppy-seed emulsion (essentially a weak preparation of opium) was prescribed as well – and was probably considerably more effective than the herbs. Twelve leeches were applied to the neck, but the doctor refrained from opening a vein, suspecting that taking too much blood might be counterproductive. The results, after a week or so, were spectacular:

The patient could then sit up in bed, and he took light meals with a great appetite without the least difficulty in swallowing. From then on the recovery was rapid. There remained no other trace of this serious injury than an awkward stiffness of the neck accompanying sudden lateral movements of the head.

If the doctor was correct in his assessment, the youth had suffered type of injury called an atlantoaxial dislocation. This is vanishingly rare, with only around a dozen cases recorded in the last fifty years. It usually entails a heavy impact to the head at such an angle that the neck takes most of the force: similar injuries are often associated with mistimed tackles in football or rugby.

Such a serious injury to the neck can cause complete paralysis or even death. In this case the boy was apparently restored to something like perfect health: given that most patients in his position today would need major surgery, his recovery must have been close to miraculous.

Diagram of the spine

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