[reprinted from the medical age, AUG. 25, 1892. 
MECHANICAL SUPPORT IN FRACTURE AND 
DISLOCATION OF THE SIXTH CER- 
VICAL VERTEBRA.* 
Gentlemen:—I have the pleasure of bring- 
ing before you to-day a profound mechanical 
problem, which is, in addition, a thoroughly 
unique one. I venture to say that this is 
the first time such a case has been presented 
before a clinic. Dr. H. E. Hadra, of Gal- 
veston, Texas, who had charge of the man, 
read the report of the case at a meeting of 
the Texas Medical Association. In order 
that you may understand the case perfectly, 
I shall read you a briel abstract of his his- 
tory, as presented at that time. 
“ To give a short history of the case, it 
may be stated that a man thirty years of age, 
working as a waiter in a restaurant, fell to 
the floor, striking with great force on his 
buttock. Immediately after, he felt intense 
pain in his neck, and was unable to move it. 
On examination, the sixth cervical vertebra 
BY H. AUGUSTUS WILSON. M.D.f 
*A clinical lecture delivered at the Jefferson 
Medical College Hospital. 
Lqcturer on Orthopedic Surgery. 2 
was found pushed forward and turned around 
its vertical axis to the right, whilst the spin- 
ous process of the seventh vertebra appeared 
unusually prominent. Patient could not 
open his mouth more than an inch; from 
what cause I could never understand. 
“ Extension was made by the head, and, as 
the parts seemingly returned to their normal 
position, the neck was put in a firm cravat. 
“Patient, from reasons of no medical inter- 
est, left the St. Mary’s Hospital (Galveston, 
Texas) a few days after his admission, and 
returned to his former occupation, wearing 
constantly his apparatus, getting along well 
enough with an occasional hypodermatic 
injection of morphine. But once, when he 
imprudently bent his neck in a rapid and 
forcible way, the cravat having been left 
away, he fainted, and on recovering could 
not stand upright. His head and neck 
were turned to the right and kept perfectly 
stiff; right hand became numb, right arm 
weak; girdle pains around his upper abdo- 
men; bladder not fnlly under control; slight 
priapism. In such a condition he came to 
the John Scaly Hospital on November i, 
1890, ten months after the first accident. 
His face flushed up on the slightest provoca- 3 
tion; his mouth could not be opened over art 
inch; the left portion of the trapezius muscle 
was hard and protruding, forming a tumor; 
his right hand colder than the left; extreme 
hyperaesthesia on the right side; head was 
rolled around to the right, and the vertebra 
in same position as on the first observation; 
muscles, though, reacted alike on both sides 
of the body to either current. Patient was 
put under chloroform, not being able to 
stand any manipulation without an anaes- 
thetic. Head and upper portion of neck 
very movable, and crepitation distinctly 
heard. Reduction was easy, and the stiff 
cravat was applied again. In spite of fre- 
quent adjustment and modification of the re- 
taining apparatus, patient grew speedily 
worse. Pains in back, arms, and around ab- 
domen became unbearable, and walking im- 
possible. He was in such a pitiful condition 
that he insisted upon any operation which 
would give the faintest hope of relief. I 
finally consented to cut down on the place of 
injury, which I did on December 22, 1890 
(thirteen months after injury). My plan was 
to remove loose bones, if present; to sever 
the posterior ligaments, if they should be 
thickened and contracted; and finally, to 4 
wire the spinous processes, in order to steady 
the vertebral column. 
“From the improvement setting in every 
time the bones were well adjusted, I inferred 
that there was no serious change within the 
vertebral canal, nor in the cord itself. I 
therefore did not consider the opening of the 
canal called for. Not finding loose bones, 
I severed the ligamentum nuchae and the 
interspinous ligaments transversely in 
several places, so as to expose the spinous 
processes fully, and also in order to remove 
the interference of the perhaps thickened 
and contracted ligaments which could have 
acted as an impediment to the replacement 
and retention of the dislocated parts, exactly 
as in other fractures or dislocations. 
“ I am satisfied that this part of the opera- 
tion was not only unnecessary, but that it 
caused all the following inflammatory symp- 
toms, as a good deal of laceration was un- 
avoidable. The main aim of the operation, 
the wiring of the sixth and seventh spinous 
processes, was done with silver wire, carrying 
it four or five times around in a figure-of-8. 
The wound, which extended from the occiput 
down to the first dorsal vertebra, was then 
closed, a small drainage tube inserted right 5 
over the place of wiring, and the stiff cravat 
reapplied. Patient did not improve for 
several days, but then gradually got better. 
After come weeks I thought that the wire 
had become loose, because he began to ex- 
hibit some of his former symptoms. He was 
put under chloroform again, and the wire 
removed and a new one fixed on. Oft this 
occasion it was easily seen that the lower 
end of the fractured spine slipped away from 
the upper for about one and a half inches 
to the right. 
“ From now on, improvement went on 
more rapidly. Patient was able three weeks 
ago (that is, twelve weeks after the opera- 
tion) to move his head in a normal way in 
every direction without pain. He could 
open his mouth fully, walk as well as any- 
body else; no headache; no trouble with 
bladder or bowels. The right arm remained 
somewhat weaker, but was otherwise normal 
in all its functions and of normal sensation. 
“ The favorable condition, though, made 
me, I fear, too careless. I allowed him to be 
without the bandage occasionally, and re- 
moved the wire, as it kept a fistulous ulcer 
from closing. He became worse again, and 
has now considerable pain in his right arm 6 
and shoulder. The spinous process of the 
sixth cervical vertebra is very tender on 
pressure, and requires further attention as 
the probable cause of the new trouble. 
Otherwise patient is well and can make use 
of his neck without any difficulty. 
“ This is my case, which shows that the 
operation (wiring fractured vertebrae) is 
feasible and effective. But I would be a 
poor surgeon if I had felt satisfied with my 
method and the course of my case.” 
This, gentlemen, is the early history of our 
case. The history subsequent to this, and 
since he came into the hospital on Septem- 
ber 21st, has been made by Dr. E. W. Egan, 
our resident physician. 
The patient is a widower. At the age of 16 
years, he says, he had chancre, with secondary 
syphilis manifesting itself three weeks later. 
Five months later had lumps on his head, 
and severe pains in arms and legs which were 
always relieved by potassium iodide. 
Since his admission to the wards of Jeffer- 
son Hospital, on September 21, 1891, he has 
suffered from pain in cervical region, with 
dull, numb sensations in occipital region. 
He on one occasion, while walking across 
the floor at night, fainted and fell. On 7 
several occasions the spinous process of the 
seventh cervical vertebra has been noticed 
to be unduly prominent, and at this time 
there is more severe pain diffused over the 
entire body. The reduction of this undue 
prominence by a peculiar manipulation is 
always followed by a cessation of his pain 
and discomfort. 
Professor John H. Brinton, M.D., the sur- 
geon on duty, has referred the case to the 
Orthopaedic Department for mechanical sup- 
port, as he does not faver further surgical 
procedure. 
I candidly tell you that we have been un- 
able to explain his present condition, but 
accept the statements of Dr. Hadra, and we 
will to-day consider him solely as a mechani- 
cal problem—that is, we are required to pre- 
vent the motion of the fractured and mis- 
placed cervical vertebrae. 
I wish to show you first the condition pos- 
teriorly, where you may see the cicatrix pro- 
duced by the sloughing after the operation 
described in the history. By this spinal 
column you will notice how the spinous pro- 
cesses of the cerebral vertebrae are held in 
position; and you can see how impossible it 
would be, without cutting away the inter- 8 
spinous ligaments, to pass a wire around the 
spinous processes (as was so ingeniously done 
by Dr. Hadra) so as to render them immo- 
bile ; therefore the necessity for the opera- 
tion to which Dr. Hadra resorted in order to 
secure the vertebrae. As to the method he 
adopted, it may be made clear by this model. 
Fastening the wire to the spinous process of 
the seventh vertebra, he wound it around 
the spinous process of the sixth cervical 
vertebra in the form of a figure 8. This was 
an extremely ingenious process, and the 
operation a very successful one, as is proved 
by the fact that the man lives in the com- 
paratively comfortable state in which you see 
him. That he is not entirely well is not due 
to any failure in the operation, but to the 
intense gravity of his case and to unfortu- 
nate subsequent injury. You will remember 
that there are no wires attached to the frac- 
tured vertebrae now, for the history says that 
the first wire slipped off, and the second was 
removed because it kept up a fistulous open- 
ing. The man now comes to us because of 
severe pain in the cervical region, and danger 
of the slipping of the movable sixth verte- 
bra, which has, I believe, occurred three 
times in six weeks since he came into this 
hospital. 9 
Here is an apparatus, such as is ordinarily 
used in Potts’ disease, which permits of the 
movement of the jaws and of the entire head, 
and as well lateral and rotary motion of the 
head to a limited extent, but it allows the 
head to be flexed and extended. These very 
movements of the head, which are desirable 
in certain cases of Potts’ disease, in this 
case will give rise to all of the man’s symp- 
toms for which he now seeks relief. The 
apparatus I have devised especially for this 
case has been constructed by our apparatus- 
maker, A. Gustaf Gefoert. It has a firm 
foundation, resting upon his pelvis, and upon 
this four upright bands are arranged connect- 
ing the minerva or collar. The head rests in 
this, and not on the cervical vertebrae, and 
the weight of the head is carried to the pel- 
vis. These bands are arranged with screws 
so that their length may be adjusted to suit 
the requirements of any changes that may 
occur. 
As the apparatus is now applied, it will be 
perceived that he cannot-move his jaws, for 
if he did he would move the occipital region 
and cause a movement of the vertebrae. 
Hence we have applied this strap over the 
forehead, which will hold the head immova- 10 
ble and relieve the chin of all necessity of 
support. The chin portion is so arranged 
that it can be dropped out of the way when 
the strap is in use over the forehead. The 
chin can move without disturbing the posi- 
tion of the head. He can eat and manage 
his food, while wearing this apparatus, with 
the greatest ease. Therein lies the novelty 
of the apparatus, which is thoroughly original 
in design, and I bring the case before you 
chiefly to impress upon you the necessity of 
adapting all our apparatus to the peculiari- 
ties of the case. The man has entire relief 
from all his symptoms while wearing his 
apparatus, clearly indicating the benefit 
which he derives from its use. 
One week later the patient was taken be- 
fore the class, when the following remarks 
were made: 
He has worn his apparatus constantly 
during the day, wearing at night a simpler 
form of collar merely to prevent dislocation 
and a sudden termination to his existence. 
He moves about the house at will, and 
we have put him to work at easy tasks 
simply to satisfy ourselves of his ability 
to be dismissed from the hospital. The ap- 11 
paratus has answered every requirement; it 
has prevented separation of the portions of 
the broken sixth vertebra; it has caused his 
pains and other symptoms to entirely disap- 
pear; it has enabled him to eat by the appli- 
cation of the head band; and, as I have said, 
I wish to show you that it has met all the 
indications of the case. There is one problem, 
however, which has presented itself. The 
application of the steel brace from the hips 
has rendered it impossible for him to stoop. 
The only way that he can do so is by lower- 
ing the whole body, and this, as you see, is 
attended with considerable muscular tremor. 
To avoid this, the instrument-maker has con- 
structed for him an elongated finger on the 
plan of the extension ladder. By means of 
this he can pick up any object from the floor 
without bending his body, and when folded 
he can readily carry it in his pocket. 
The prognosis is decidedly unfavorable, 
and the best that I can hope for is ankylosis 
of all the cervical vertebrae, and this may 
occur to prevent his constantly recurring 
mishaps when he is not on his guard. 
Philadelphia, Pa.