BILATERAL FORWARD DISLOCATION OF THE FIFTH CERVICAL VERTEBRA WITH REDUCTION BY MANIPULATION
Journal of the American Medical Association (JAMA)
of liver, arteriosclerotic nephrosis, neoplasm of kidney, and papilloma of urinary bladder. When the left kidney was removed, a cyst was incised and about ISO c.c. of very turbid light red fluid was freed. The kidney was somewhat smaller than the right, weighed 130 gm., and consisted of a small amount of kidney tissue surround¬ ing four cystic cavities from 3 to 5 cm. in diameter. Embedded in the parenchyma were several masses of soft, white, fleshy tissue. The kidney pelvis and ureter were
... and ureter were some¬ what dilated, but the linings were smooth and glistening. The parenchyma of the left kidney was destroyed by two factors : (1) a severe chronic inflammatory reaction with con¬ nective tissue replacement of the tubules and round cell infil¬ tration, and (2) infiltration by a tumor. The tumor occupied the greater part of the kidney volume, extending from the pelvis toward the cortex. The structure of the tumor varied with the amount of accompanying stroma. Where this was profuse it had a glandular appearance and resembled a scirrhous carcinoma of the breast. In certain areas the tumor was more cellular and open, and there the cells were arranged about a central fine strand of fibroblasts, being placed radially in several irregular layers. In these regions the tumor was indistinguishable from the bladder tumor to be described. The cells were everywhere much the same, showed numerous mitotic figures, and had moderate sized oval and irregular nuclei whose staining varied from moderate to very deep. There was a small zone of protoplasm about the nucleus. The tumor would seem to be a metastasis by way of the lymphatics of the ureter from the bladder tumor. The bladder tumor was a fairly typical, not very vascular papillary carcinoma of the bladder. The villi were closely packed, and had numerous irregularly layered cell strata. Mitotic figures were abundant and especially clear. The cells varied more as to size of nuclei and amount of protoplasm than did those of the kidney tumor, but certain areas were very similar. There was no particular invasion of the bladder wall. The ureter between the two neoplasms was normal ; hence the two growths were not causally connected by direct exten¬ sion. It is improbable that a tumor cell carried in the urine would become attached to the bladder wall and begin to grow there. Metastasis through the lymphatics is a more probable explanation. Eisendrath and Schultz2 have shown that lymphatics pass from the bladder to the kidney pelvis in the ureteral wall, and that it is a frequent route of infection of the renal pelvis. Therefore the assumption seems justified that in this case the neoplasm was primary in the bladder wall and not in the kidney. Aug. 5, 1920, C. O., aged 28, a truck driver, was injured in an automobile accident. He was found pinned underneath an overturned truck with his head and neck bent forward. He was not unconscious when helped out, but became so for a few minutes while he was being moved. He thought that this had something to do with movement of his head, and instructed the helpers to keep his head straight and immovable while they were carrying him to the hospital. Examination there disclosed considerable interference with respiration, which was greatly improved by traction on the neck. The patient was in severe shock. Four hours after injury, he had recovered sufficiently to answer questions, at which time I was called in consultation. Roentgenograms of the cervical spine had been taken, and the lateral view revealed a bilateral forward dislocation of the fifth cervical vertebra on the sixth, with a slight impaction of the body of the fifth. Anteroposterior views, although excel¬ lent stereoscopic plates, revealed nothing that would have been definite enough to permit a diagnosis without the lateral 2. Eisendrath, D. N., and Schultz, O. T.: J. M. Res. 35:295 (Jan.) 1917. view. The symptoms present were priapism; numbness and tingling in the right hand and forearm and over the entire left lower limb, and frequent coughing with some fresh blood in the sputum. The knee jerks seemed normal. There was no motor paralysis and no gross eye findings. Respiration was still difficult. Attempt at reduction by manipulation was suggested and agreed to. Five and a half hours after the injury the patient was anesthetized with ether. When well relaxed, he was slid upward on the table, so that I could hold his head in my hands, free of any other support. The method of Walton was followed, which attempts to slip the articular facet, first of Fig. 1.-Bilateral forward dislocation of fifth cervical vertebra on ;he sixth, with slight impaction of the body of the fifth. one side and then of the other side, back into position on the facets of the vertebra below. To reduce the right side, the neck was flexed to the left and then rotated to the right. This was accomplished by approximating the head to the left shoulder and then rotating the chin toward the right shoulder. The same movements were then carried out for reduction of the left side. As these were finished, a distinct chug was heard and felt in the neck. This was more like a dull bump than a snap or click. Immediately afterward, the movements of the neck were free in all directions. It was felt that reduc¬ tion had been accomplished, and this was verified a little later Fig. 2.-Appearance of vertebrae after reduction by manipulation. by roentgenograms. He was put back to bed with the head, neck and shoulders supported by large, heavy sandbags. The next day the priapism disappeared and the numbness and tingling began to decrease. On the fourth day the patient's condition was so much improved that, with a plaster cast, which supported the weight of the head on the shoulders and protected the neck, he was allowed to sit up. On the seventh day he was allowed to walk a little. The cough was much improved, and the numbness and tingling had almost disappeared. On the fourteenth day, he was discharged from the hospital, walking well, with no discomfort, although still somewhat weak. His strength 'improved rapidly, and at the end of the sixth week the plaster support was removed.