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Lorsque le document est trop grand pour Atre reproduit en un seui cllchA. il est filmA d partir de I'angle supArieur gauche, de gauche A droite. et de haut en bas, en prenant ie nombre d'imeges nAcessaire. Les diagrammes sulvants illustrent la mAthode. 1 2 3 1 2 3 4 5 6 F r ' %4 it4 ^1 I n I -4 .■ t' g3B|gj> ""i-'U-i"?'- ' V" i ' ;. "" ' " ■• Jl ! ^.JM m •Jli: m CASE OF SEVERE CONCUSSION FROM A FALL, WITH SUBSEQUENT EXTRAVASATION ON THE SPINAL CORD. DEATH IN THIRTEEN MONTHS AFTER THE INJURY. ■^' y BY ARCH^. HALL, M.D., L.R.C.S.E., Physician to the Montreal Gen. Hospital ; Consulting Physician to the University Lying-in Hospital, &c. FROM THE BRITISH AMERICAN JOURNAL OF MEDICAL AND FHTSICAL SCIENCE— JULY, 1848. MONTREAL: PRINTED BY J. C. BECKET, 211^ ST. PAUL ST.REET. MDCCCXLVUI. » i>il .T^-"'^ f ^ti J,i/: 1 ., / . » ' ' ' " ' i '■ i ■ '■ •«aiifliM||MUi|pi CASE OF SEVERE CONCUSSION FROM A FALL, WITH REMARKS, &c. On the 17th May, 1847, about 11, p.m., while en- gaged in matters of importance in my o.vn house, with Dr. Arnold!, junior, I was hastily summoned to visit Mr. W. F., of Hamilton, C. W., who had, a few minutes previously, fallen on a stone-paved yard, from a gallery about fourteen feet in height, and was then stated to be insensible. He had lain in the yard for several minutes, until his non-appearance in the house, and the sound of heavy breathing, attracted attention to the circumstance. In consequence of the contiguity of Mr, Isaacson's house, in which the accident occurred, Dr. Arnoldi accompanied me, and in the kitchen, into which he had been brought, we found Mr. F. laboring under every symptom of concussion, and surrounded by several gentlemen, occupied in endeavours to re- move his clothes. We had him immediately carried to a Yed in an upper room, and the further process of removing his cloth 3 was undertaken by Dr. Arnoiui, while I returned home for t^e necessary materials to dress any wounds which might have been caused by the fall, in the meanwhile, the symptoms of the con- cussion gradually diminishing, he voluntarily moved his legs ; and, by the time that a trifling scalp wound, which was situated on the left parietal protuberance, had been dressed, his consciousness had so far reco- vered as to enable him to speak. At this period, he complained of no particular pain ; and, after a most rigid and careful examination, not the slightest trace of fracture was any where detectable, nor was there I 4 v. any other lesion apparent save the scalp wound already noticed. With injunctions as to regimen, we left him for a second examination on the ensuing morning. Mr. F. was an exceedingly well developed, healthy young man, a merchant, of regular habits, and aged about 23. Having transacted his business in the city, it was his intention to have returned to Hamilton the following morning. The accident occurred while crossing a gallery, the rails of which had been carried away by a heavy fall of snow a short time previously, a circumstance of which he had been informed. May 18. Patient seen at 6, a.m. Had slept a little during the night. The following symptoms now pre- sented themselves : Pulse 00, full and soft ; conscious ; recollects nothing of the occurrence of the preceding night ; general soreness of the whole body, with ina- bility to move both inferior extremities ; power over superior perfect ; respiration normal ; no headache ; titillation of soles of the feet causes retraction of the legs, from reflex action ; tenderness of the spine, between last cervical and fifth dorsal vertebrae ; scalp wound gives pain, and scalp generally tender ; diffi- culty in moving lefl hand and fingers. On examining arm, found contusion on lefl olecranon, along the ulna, and back of wrist joint and hand. In these latter places, incipient ecchymosis. Evidence of contu- sion, manifesting itself by tenderness, and ecchymosis on sacrum and lefl ilium at the posterior third of its crest. A renewed most careful examination disclosed no evidence of fracture, either of the vertebral column or extremities. An evaporating lotion was prescribed for the head and arm ; leeches to the superior dorsal vertebrsB ; a conrimon cathartic powder to be taken immediately, and as the paraplegia seemed dependant on spinal extravasation, I placed him forthwith on small doses of calomel and tartar emetic, alternating the medicines every two hours, for the double purpose of obviating arterial excitement, which there was the strongest grounds for apprehending, and inducing absorption. At 10, a. m., pulse increased in rapi- dity, but not altered in its character ; slight fever ; w it '1 tt thirst; no operation from powder; marked priapism, with great desire to make water, but inability to pass it. Paralytic condition of the legs more complete. The catheter was introduced, causing no pain or irri- tation, and relieved him of about 5x of water, of nor- mal appearance. An enema was ordered, to assist the cathartic. 1, p.m., Mr. F. was seen in consultation by Dr. IVIacDonnell, and I will quote the symptoms now present, as extracted from that gentleman's note book : ["May 18, 1847. I was called into consultation by Dr. Hall, on the case of W. F., Esq, aged 23, of strong healthy constitution, and well developed muscular system, who had fallen from a height of about fourteen feet. He had lain in the situation in which he had fallen for about three or four minutes, when he was discovered, in a senseless condition. When Dr. Hall saw him, he presented the usual symp- toms of concussion, and on examination, a slight wound was discovered on the scalp, the edges of which were readily brought together. There were also noticed on various parts of his body, slight contusions. Dr. Hall treated him whilst in this state in the usual manner, and next morning he discovered that there was some tenderness corresponding to the junction of the cervical with the dorsal vertebrae, but in no situa- tion was there the least positive evidence, either of fracture or dislocation, although there was complete loss of power and sensation of the lower extremities, from the hips downwards, paralysis of the bladder, and involuntary escape oi foeces. The penis was in a state of priapism, but there were no seminal emissions, nor tympanitis. The power of motion and sensation were perfect in the upper part of the body, and there was not the least paralysis of any of the muscles sup- plied by the cerebral nerves ; his intellect was unimpaired. The introduction of the catheter gave him no pain. On the feet being pricked or tickled, reflex motion of the limb was induced.'] The enema had operated twice ; patient sensible of •I mm wmmm the operation, but expressed himself as unable to con- trol it. The tenderness of the spine not diminishing, the leeches were re-applied, bleeding freely ; the other treatment persevered in. The diagnosis of the case was, after a careful consideration of all the circum- stances, defined as follows : Concussion of the brain and spinal cord, with subsequent extravasation between the last cervical and 6th dorsal vertebtee, with the possibility of an osseous lesion in the same region, of which, however, there was no positive proof. We were not insensible to the consideration, that laceration of the spinal cord to some slight extent might also have taken place. Regarding the case as one of great mo- ment and danger, we advised that his friends at Hamilton should be notified of his situation without delay. Mr. F. was visited at 3, 8, and 1 1, p.m., at which latter time it was again requisite to have recourse to catheterism. May 19. Patient seen repeatedly throughout the day. Symptoms without any alleviation. Fever increased, and pulse 110, small, yet still soft. A large blister was applied to the upper dorsal vertebrae, and an anodyne pill of hyoscyamus was prescribed at bedtime. May 22. Superadded to the symptoms already de- tailed, there is now another — severe pain at the neck of the bladder, induced by the introduction of the ca- theter, which requires to be used every three or four hours. To obviate the frequent recourse to the instru- ment, the attempt was made to let it remain after introduction, but the pain and irritation excited proved so intense, as to demand its prompt withdrawal. The necessity for its so frequent introduction, seemed to be due to the irritability of the bladder, excited by the presence of even a small quantity of urine in it. In consequence of the insomnia, and as no head symp- toms presented themselves, the anodyne was changed, and composed of the acetum opii as its chief ingredient. The calomel and tartar emetic were still persevered with. May 25. — At the request of his brother, who arrived from Hamilton, Dr. Nelson saw the patient this day, in consultation with Dr. MacDonnell and myself. He n < was again most carefully examined, but with the same negative results, as regards fracture, as obtainid ou previous occasions. The views entertained of the case were fully acquiesced in by this gentleman, and in the plan of treatment pursued he entirely concurred. May 26. Early this morning, Mr. F. was removed to the residence of an intimnte friend, the fatigue of which he bore well. The general train of symptoms still continued unaltered. The constitutional effects of the mercury having exhibited themselves in ptya- lism, this medicine was discontinued, as was also the tartar emetic, and with the view of still promoting absorption of the supposed extravasation, he was placed on the iodide of potassium in five grain doses, repeated every four hours during the day. June 1. From the 26ih to the present date, there was little alteration in the case. Symptoms of myelitis began now to manifest themselves, indicated by re- newed tenderness ir, the region of 2d and 3d dorsal vertebrae ; flying pains extending down the arms, and to the head ; the hoop sensation round the chest, dec. These were combated by recourse to the tartrate of antimony, conjoined with sedatives, and free counter- irritation over the painful vertebral region. The pain of his head, which he described as commencing at the occiput an I darting rapidly to the frontal region, was of the most agonizing character. Concomitant with this alteration of symptoms, the urine began to alter in its quality ; mucus in considerable abundance was mixed with it, as withdrawn by the catheter ; and although he did not complain much when pressure was exerted in the suprapubic region, yet there could be no question of the existence of a slight cystitic afl'ection. Catheterism now proved frequently exceed- ing painful, and not unusually a work of considerable difficulty, in consequence of the violent spasmodic action of the sphincter. I will pass over the reports of several days, until th.it of June 8., when I find the following train of symp- toms. Patient worse, and apparently sinking. Pulse 136, small and weak ; frequent attacks of darting pains i J mm 8 through the head, commencing, as before, at the occiput ; diflicuity of breathing, with frequent sighing; sensation of tightness across the chest, with darting pains through that region ; occasional pains in both shoulders ; shooting pains down his legs; had scarcely slept any during the night, although he had taken three doi^es of the anodyne (each dose contained acet' opii nixv) ; is restless, anxi- ous, and fretful ; had several involuntary motions during the night, the effect of a cathartic pill, followed by an enema. In consultation with Dr. MacDonnell and Dr. Nelson this evening, it wap decided to put him on stimu- lants, and sherry wine was prescribed. This, was done with the sole view of sustaining him until his brother's arrival, who was notified of the patient's state by tele- grapli. At this time we believed him to be sinking rapidly. The iodide o^ potassium was discontinued, and the blistered surface of the back having healed, tartar emetic ointment was ordered to he rubbed freely in. June 9. Since the exhibition of the wine, the pulse has fallen in frequency, and improved slightly in volume. The pains shooting down the arms have ceased, but those of the head continue. He now suffers acute pain in the knees, on the slightest r^tteinpt at flexing the legs. It is necessary to notice that, during this period of his illness, ^stimulating applications had been frequently and freely applied to his legs, such as mustard frictions, hand-rub. bing, &c. &c., and enemata had been employed as fre- quently as circumstances demanded. The exhibition of ordinar}' laxative medicines failed in the desired object, apparently in consequence of the paralyzed condition of the muscular coat of the intestinal canal, and the opera, tion of the enemata was attenf^ed with the same signs of involuntary action as before. June 13. Symptoms still progressing more favourably ; Mr. F. was placed on iodide of potassium again and strychnine —the medicines alternated every two hours. From this period until the beginning of July, nothing of any importance occurred worthy of special notice. The counter-irritation to the back was still kept up, and the medicines just noticed steadily persevered in. The para- plegic symptoms continued unaltered. Muscular 9 twitches were complained of in the legs, hut eepecially the right one, at the knee — the Slightest attempts at flex- ing either inducing them. The respiratory movements became of a more normal character. Necessity compel- led, as before, a frequent recourse to the catheter, never less than three, but most frequently four times a day. The introduction of the instrument was almost always attended with the same spasmodic action ol the sphincter vesicie, experience denvonstrating that unless the opera- tion was rapidly performed, the sp isms set in severely, causing exceswve pain, and the maintainance of the in- strument in situ was yet found a matter of impossihility^ in consequence of the excessive irritation which it en- ^enJ?red, Pus was now constantly 8e«»n in the urine, and followed the last drops of it when withdrawn. The urine was of a highly offensive ammoniacal odour, and crystals of triple phosphate were detected in it by the mi- croscope. Priapism still continued a prominent symp- tom. On the 16th June, recourse was had to galvanism, which v,j,8 continued for several days, without any other marlted effect than the induction of rapid muscular twitches, causing excessive pain. The use of this agent was therefore inte*" - .ed. The appetite appeared to be but very slightly attc . 3d. The diet permitted was ge- nerous, as there appeared to be nothing of any mo- ment ontra-indicating it; but he, nevertheless, ema- ciated. A singular symptom had gradually developed itself, an inability to grasp or seize between the thumb, and index and middle Angers. I'his was undeniably due to defective innervation of the median and radial nerves ; and proved a symptom still further serving as a guide to the proper location of the seat oi actual injury at the time of the accident. Whether a consequence of the exhibitic"; of the iodide of potassium or the strych- nine, about the 30th June the secretion of urine became a".;undant; and, concomitant with this alteration of se- creting action, there was a diminished excretion of mucus and pug globules in ii : the ammoniacal odour became also less. I c(msi(ler it entirely unnecessary to follow the case steadily from day to day through the long period of time ■■■r^/ m during which he was under my care. It will have been observed that I have, in the reports already ^ . en, fol- lowed th'o rule, noting only those periods when new symptoms developed themselves. I pass then on to the middle of July, when we noticed for the first time a slowly but gradually commencing contraction of the flexor muscles of the leg. Notwithstanding this condition of the muscular syhtem of the extremities, it was still deem- ed advisable to have recourse to galvanism, oily inunc- tions, and frequent extensions during the day. The slightest attempt at extension caused acute pain. Bed sores in the sacral region had some time previously to this commenced, requiring the greatest care and attention, by pads, the application of nitrate of silver in solution, &c. &c. to alleviate. CEdema of the feet and ancles now commenced, but his pulse, nevertheless maintained its regularity and its fullness ; his appetite continued unimpaired ; and al- though he continued the iodine, we found it necessary occasionally to intermit the strychnine, and place him during those periods on a mineral tonic, which was either a mild preparation of iron, the sulphate of zinc, or oxide of silver. About the end of July, feeling himself equal to the exertion, although there was little remission in the more prominent symptoms, we raised him to a semi- recumbent position in his bed ; and about the middle of August we got him out of bed and comfortably seated in an arm chair, in which he remained nearly a whole morning. The tonic flexion of the legs, however, had by this time increased considerably ; and the pain caus- ed by a similar change of position, was such as to prevent its future repetition. At this time the irrita- bility of the bladder had apparently so far dimini«hed, as to permit the retenlion of the catheter during the night. The desire to pass water was always followed by exces- sive pain, which appeared to be a consequence of a vio- lent muscular effort of the bladder itself, and was quite involuntary. Occasionally the propul:*ive effort was ef- fectual in evacuating a portion of the contents of the bladder, even when the catheter was not introduced, and it remained as long, apparently, as any quantity of urine I 11 iiemained in the viscus. Mr. F. continued in this state without any alteration of symptoms, and under a treat- ment varied according to circumstances, but ever based on the indications, until the 23d of September, when I accompanied him to Hamilton, and placed him under the care of Dr. John Muckelcan of that city. November 2. Received from Dr. M'K., a letter con- taining the following report of the case to that period: — EXTRACT. Hamilton, Oct. 29, 1847. My Dear Sir, — I have delayed longer than I intended to give you an account of Mr. F.'s progress since you left him here. Two or three days after he arrived here, he was troubled with frequent nausea and vomiting, and the enemata produced little or no effect, a small quantity of very hardened foeces only passing. On examination pe anum, I Tound the rectum filled with a mnss as large as a cricket ball, and on removing that, with some difiRculty, two similar masses successively descended into the rectum, which were also removed, when the enemata passed into the colon without difficulty, and relieved the bowels efficiently. The sickness then ceased, and his iiealth, which had been a good deal shaken by this state of things, gradually improved. He is now gaining strength, his pulse varying from 72 to 80 ; his urine more abundant and o.' better quality, but still passed only by spasmodic action of the bladder. Indeed, I believe the L*Iadder never empties itself properly, and that the partml expulsion of the urine takes place only when the bladder is distended, by which it is stimulated to a violent effort, which expels as much of the urine as gives temporary .elief, but that, partaking of the paralysie, it is unable to accomplish a regular and natural contraction. I have passed the catheter several times immediately after four or five ounces have been expelled by a spasm, and have drawn off eight or ten more. His lower extremities are still as much contracted as ever, and he suffers a good deal of pam in the right one, parti- cularly about the patella. There is no cedematous swelling of the feet, but I cannot perceive any material increase of the power of voluntary motion. I have contented myself with carefully regu- lating the bowels, giving the Spt. aether, nit. with hyoscyumus and strong camphor mixture, and at night the acet. opii., gradually diminishini; the dose, as I think so much opium must be injurious to hini, and calculated to prevent the return of nervous energy, unless the loss of that power depends upon mechanical injury of the spinal cord, when, of course, the use of opium could do nei- ther good nor harm. *XSome lemarkshere follow, having reference to a water bed for Mr. F ) 18 I shall report to yoa any interesting features which may occor in Mr. F.'s case. — I am, &c., John Magkelcan. Dr. Hal], Montreal. Report of case of Mr. W. F., after his arrival in Hamilton, four months subsequent to his accident. By J. Mackelcan, M.I)., Hamilton. A few days after bis arrival, affected with nausea and occasional vomiting, the nurse reported that the enemata, which had been exhibited twice a week, did not act efficiently ', administered them then myself with a patent apparatus, instead of the common syringe which had been previously used ; found great resistance to passage of enema, and slight effect from it. Ex- amined abdomen externally, and felt hardened foeces throughout whole course of colon ; made then examina- tion per rectum, and found it impacted with foeces, which were removed by manual operation, after which copious evacuations were produced by enemata ; the colon was thus thoroughly emptied, and the vomiting ceased. The appetite then returned, and the patient continued to improve in flesh and strength for three months ; his pulse fell from about 90 to 72 ; his urine improved in quantity and quality, and the bladder acquired the power to expel its contents ; the catheter has not been passed since the first month of residence here, and during that month only occasionally. The action of the bladder was, however, throughout pecu- liar ; it was termed a " spasm " by the patient ; it came on suddenly, and with scarcely any power of retaining its contents. During the three months above men- tioned, the voluntary power in the left lower extremity improved, and sufficient was acquired on the right to lifl the foot from the bed ; the contraction of the lower extremities was also gradually yielding to gentle extension and friction. The general treatment during this period consisted of relieving the bowels by ene- mata on alternate days, and an occasional aloetic pur- gative, gradually diminishing the quantity of opiate which the patient had been accustomed to take when 13 hia sufferings were greater ; he also took spt. SEftber. r and tinct. hyos. in camphor mixture three times a day. Shortly before Christmas, 1847, unfavourable symptoms again appeared ; loss of appetite, nausea, and vomiting erne on, with furred tongue, and weref not relieved by miiCii« 'n**s intended to improve the digestive organs. On agah; examining the abdomen carefully, a firm tumour was found c< CMoying the right lumbar region, in front of the kidney of th..* side ; con- sidering that it might again be impaction in iu** colon, which the enemata had not reached, more copious quantities of fluid were injected, but without effect upon the tumour and its position ; its feel, some tenderness on pressure, and the symptoms produced, led me to the suspicion that a renal calculus had formed ofconsider> able size, and that the prognosis was decidedly unfavor- able. The pulse strength declined, and he rapidly lost flesh, with little hope of benefit ; iodine frictions were used, and after a short time the tumour diminished, and was reduced to the feel and situation of a some- what enlarged and indurated kidney.* Bed sores now again made their appearance, and spread rapidly in the sacrum, the ischia, and left tro- chanter, with deep sloughing. The nausea and vomiting ceased, but the appetite never returned to any extent, nor did the patient ever regain flesh. Finding that no expedient which could be adopted benefitted the bed sores, a water bed was obtained from New York, and then only the sloughing was arrested, and granulation commenced. The puru- lent discharge was very great, and a month before his death large quantities of pus mixed with blood, and of most offensive odour, passed per anum for days in suc- cession, and the pulse which had for some time been rising in frequency until it reached 120, became jerk- ing, and there were frequent profuse perspirations. * The autopsy showing the kidney to be but moderately enlarged, and tiie calculi Bmall ; of what nature was the greater part of the enlargement 7 Could it have been urine detained in the tubes and cavities of the kidney, by the calculus, which just fitted the pelvis, and thus obstructed the water ? ■«*- - *( ■ 14 During this period, also, the contraction of the lower extremities returned, and gradually became worse, until the leti thigh lay along the side of the abdomen, and the right knee almost rested on the axilla, while the heel was drawn against the nates. The right limb was less contracted, but he suffered much pain in the groin of ttiat side ; and during the whole of his illness he complained of much pain in the right sciatic nerve, greatly aggravated by laying on that side, and accom* panied sometimes with severe pain in the right heel. * His suflerings were so great during the last two months, that he could not be moved for several days together, and the accumulation of pus under him greatly aggravated the bed sore on the sacrum, and no doubt led to that state of the parts which was found afler death. The reflex action of the spinal marrow was at all times ea^ ily excited, and especially during the last four monts; the slightest movement of the bed-clothes produe 'ig painful twitching of the lower extremities. He ui^d June 6th, having sunk rapidly during the previous 24 hours. Hamilton, June 20, 1848. Mr. F. died on the 6th June, 1848, and, through the kindness of Dr. Craigie of Hamilton, I have been fur- nished with the following report of the post mortem ex- amination, 26 hours afler death : * Soon after the patient's arrival in Hamilton, I suspected that a transverse fracture of the lower part uf the sacrum had occurred at the time of the accident, and timt the apex bcinp^ pressed slightly inwards, eppecially towards the right side, it had united at a very obtuse angle. I considered this as of no other impor. tance than as probably accounting for the constant pain in the course of the right sciatic nervc^ as should the fracture be in the line of any of the anterior foramina of the sacrum, which was the part most likely to give way, the root of that nerve might be interfered with. Had such an occurrence taken place, of course nothing could have been done to replace the bone. The post mortem ezamini/i,ion failed to illustrate the point, as the lower part of the aacrum was destroyed by caries commencing acroM the line of the 4th anterior foramina. 15 The ppine being the original pert of injury, was first examined. The extensor muscles on each side of the spinal column were much wasted and in a state of fatty degeneration ; the spinal canal was opened from the second dorsal vertebra to its sacral extremity ; a considerable quantity of adipose matter was found between the theca vertebralis, and tendinous lining of the canal ; the veins of the latter were turgid, and the theca presented no morbid alteration. On opening the theca, a quantity of slightly reddish serum efcaped, and thai part of the medulla spinalis, op- posite the two last dorsal vertebrae appeared enlarged (quite filling the theca) and indurated, and its vascularity greater than any other portion. From th«:nce downward (being that portion when the cord separates into bundles of nervous fibres), the bulk was much diminished, not nearly filling the theca, and the substance was flaccid. No morbid alteration was discoverable in the tendi- nous sheath of the canal, except the venous turgescence before mentioned, and no displacement or fracture of any of the ver- tebrae. On opening the abdomen, the viscera generally were healthy, the intestines empty, and the ascending colon contracted. The right kidney exhibited disease ; it was enlarged, surrounded with dense adipose substance, and, on being laid open, was found to be of a pale yellow colour, with scarcely any healthy structure re- maining : its pelvis was of a dark colour, and filled with a calcu- lus, and there were several smaller calculi in the infundibula. Pus was also found in these cavities. The contents of the pelvis were then removed : the bladder was much contracted, containing pus, and its mucous membrane of a dark leaden hue. The rectum was distended into the form of a pouch, the cellular substance around it much indurated and containing pus. The pubis having been removed, and the ligaments \n front of the right sacro-iliac symphisis divided, the handle of a scalpel passed between the biines for half an inch without difficulty, and moderate force sepa- rated them, and their oppoping surfaces were denuded of cartilage. On the left side the union was closer ; but, after the division of the ligaments, it also was separated, but on the application of greater force than was used on the right side, and the cartilage, nous covering of the surfaces was present. A large bed sore occupied the region of the sacrum, the promi- nent parts of which were denuded, and its two lower sections, as well as the os coccygis, were destroyed by caries- The tuber- osities of the ischia were also denuded by bed sores, and likewise the left trochanter major. The body generally was much emaciated, and the lower extre- mities a3dematous, particularly the right, and much contracted. (Signed,) John Mackelcan, M.D. William McGarqow, Surgeon. Hamilton, June 7, 1848. We were present at the exammation of the body of Mr. W, F.j and concur generall)' in the above refort, with, however ^ le ihe following exceptions. We know nothing of " the origiiiHl seat of injury." Injury of the spinal marrow was suspected, but so far as that was examined, none was found. The lower part of the spinal marrow and Cauda equina are preserved, for the sj- tisfaclion of those interested. Time did not permit of 'he exami- nation of the cervical portion of the spinal marrow and medulla oblongata. We could perceive no difference between the two eacro-iliac sychondroses. The right was more easily 'orn open than the left, in consequence of the longer lever power, it having been first opened. Their surfaces, when exposed, appeared and felt exactly the same. No mark of fracture, displacement, or injury of any of the bones of the pelvis could be detected, other than caries affecting the sacrum. (Signed) W. G. Dickenson. W. Craigie. June 22. Received this day from Dr. Mackelcan, the kidney and lower part of the spinal cord of the deceased. The kidney was sui rounded with a considerable quan- tity of fat, was larger, and its texture seemed more in- durated, than natural. The pelvis contained a calculus of large size, and there were removed from it and the infundibula about twenty smaller ones. The calculi were examined, both microscopically by Dr. MacDonnell, and chemically by myself. They were found to be compos- ed, exclusively, of triple phosphate, and in this respect the case affords no exception to the rule which seems to connect the phosphatic urinary deposits with spinal disease. The part of the spinal cord received, extended from about the 10th dorsal vertebra downwards. It was slit open by Dr. MacDonnell, in the presence of Dr. Mount and myself, and was subsequently examined by Drs. Arnoldi, Nelson, Campbell, and Sutherland. It was ascertained to demonstrate unequivocal evidence of ra- tnollissement for about one mch and a half downwards from its superior cut margin. How far above the lOtli tlorsal vertebra this ramollissement extended, it is impos- sible to say, in the absence of proof, but I have not the slightest doubt that, had the portions of the spinal cord, between the last cervical and sixth dorsal vertebra?, been examined in the same manner, a similar abnormal con- «liiion would have been detected there also ; this having 17 been the seat of the original tenderness, and in which every symptom, at a very early period, indicated myelitis to have existed. The existence of " adipose"' matter along and exterior to the theca, is not only an exceedingly anomalous de- posit in such a situation, but naturally suggests the in- quiry how far it might have been due to the suspected extravasated blood, absorption of the red particles having taken place, leaving the fibrine, which had subsequently changed into adipose tissue. And such a change would be in strict accordance with what has been observed with reference to fibrinous tissue in the contiguity of de- generated nervous structure. The fatty degeneration of muscular tissue (observed also in this particular case,) supplied by, and in the neighbourhood of, nerves, whose structure has become impaired by di^'ease, has been fre- quently noticed, and the adipose matter deposited exte- riorly to the theca would indicate the operation of a similar modifying agency on the fibrine deposited in the neighbourhood of the diseased cord. One thing now must strike forcibly even the most careless reader — the complete verification of the diagno- sis, made nearly thirteen months previously ; — and in concluding this part of my subject, I cannot forbear ex- pressing to Drs. Craigie and Dickenson my grateful ac- knowledgments for the trouble which they incurred on my account, in being presei#at the post mortem examma- tion oi the deceased, and in superintending its various stages to see that due and impartial justice was rendered to an absent brother practitioner. And here I would most cheerfully have terminated my remarks, had not circumstances originated out of the case which have forced upon me an imperious but most un- pleasant duty. Linked together in the purnsuit of similar objects, practitioners of medicine constitute a brotherhood, between every member of which there should exist no * Erratum — For "adipose," read "a considerable quantity of adipose." The omission of tlie additional words necesciary to complete the quotation from the post mortem report, which it was intended to be, was accidental, and was not dclf ' ed until th« .Tuurnal had been put to press. mmmmmmm t8 rivalry, but of the most honourable kind ; whose errors, if committed, should be viewed by its members in the most charitable light ; and the reputation of each indivi- dual most carefully cherished. The assassin's weapon can scarcely produce a more dangerous wound than the envenomed tongue of the detractor, which may effect its purpose in many ditferent ways. The physician lives upon his reputation ; strike at that reputation, and you rob him of that — his good name — " which makes him poor indeed," The personal advancement of the de- tractor, as the cherished object of pursuit, may be suc- cessfully attained ; but that success cannot be permanent which is achieved by such unholy means ; it will soon flag and fail, because unsustained by the only sure sup- j)ort — an acquaintance with his profession, tact and readiness in applying its resources, and the due fulfillment of every moral and religious obligation. While in other cases I have freely opened the pages of this Journal for the vindication of professional character, when unwor- thily assailed, I may be pardoned if circumstances com- pel me to have recourse to the same means in vindication of my own. I desire, however, to avail myself of no undue privilege. The answer of the party implicated, shall have tree insertion, no matter what its nature, no matter how complete its repudiation of the act of its author, which, for the honour of the profession, I sincerely hope it may prove. % I will now proceed with the details, and in the first place 1 will observe, that a difficulty occurring in the settlement of my claim for professional services rendered to Mr. F. when in Montreal, which were, to those who knew their nature and extent, of the most harassing de. scription,and which were very inadequately requited, Mr. F. in a letter to me dated Hamilton, Nov. 12, 1847, stated — " I am happy to inform you that I am and feel much better. My general health is good ; and, were it not for the unfortunate position my legs were placed in in Montreal, I might now. Dr. Mackelcan assures me, have been walk- ing about on crutches. Dr. Mackelcan has discovered that my hinch-bone is considerably injured, and that the small bones of my sacrum are smashed to pieces, which 1« facta seem to have escaped your notice." My answer to this communication was, after tn authenticated copy of it had been retained, a return of the letter by next post ; while, in a note alluding to it addressed to the gentleman in whose house he had resided in Montreal, and dated November 16, I remarked, " That the imputa- tion of most questionable character on the professional skill of Drs. MacDonnell, Arnoldi, Nelson, and myself, was to me a matter of less consequence than the id that one for whom," &c. &c. The original, or a (;npy of this note, is, I believe, now in possession of Mr. F.'s late partner.* On the 18th Nov., 1847, 1 received a private letter from an old and esteemed fellow-student, dated Hamil- ton Nov. 14. This letter observes — " As there are various reports here respecting your treatment of Mr. F., unfavourable to you, I wish you would give me a history of the case ; that is, the nature of the disease, what parts are injured, and how injured, so that T may be enabled to explain to his brother, or any other party interested, the treatment he has received at your hands, should you desire it. I consider it my duty to write to you, as an old friend, in case any thing should eventually transpire that you might require to take notice of." An answer * The note from which the following is an extract, was pat into my hands by Dr. MacDonnell. It was written by the late Mr. F.'s brother, Mr. E. J. F., now in Hamilton, to Dr. MacD. The note is dated Hamilton, Nov. 12, 1847 : — " I am happy to say my brother has been a great deal better for the last ten days, much better than he has been since the acci- dent occurred. His bowels are now in a healthy state. His blad- der much better : passes water more freely, in large quantities and not accompanied by spasms; his appetite is very good, and he seems to relish what he ems. There is no doubt his general health has very much improved since be came up here. His limbs are somewhat better: the greatest difficulty seems to be in stretching them, but I think Dr. Mackelcan will overcome that in time, as he has already partially succeeded. I regret to say that Dr. Mackelcan has observed, what seems to have escaped the ob- servation of yourself and Dr. Hall, viz., i(Aa< there ia a piece of the hinch-bone broken off, and the small bones of the sacrum smashed to pieces, which I am very much afraid may retard hia recovery. — I am, &c., E. J. F, (The italics are the writer's own. — A. H.) I- was returned to this, giving substantially the diagnosis of the case as detailed in the early part of this paper, and to which this gentleman has been, since Mr. F.'s decease, requested to give publicity.* On the 25th March, 1848, in a letter received from a medical friend in Hamilton, I have the following obser- vation — *' You were not four hours from Hamilton before he (Dr. Mackelcan) found fault with the legs being drawn up." Several letters again allude to the fact, that the diffi- culty experienced in the settlement of my claim for pro- fessional services, was due to Dr. Mackelcan's most unprofessional interference in the matter. One letter most explicitly states, " that had it not been for Dr. Mackelcan's interference, your account would have been long ago adjusted." I have already published Dr. Mackelcan's letter to * Having written for a copy of this letter, dated Montreal, No- vember 20, 1847, the medical gentleman to whom it was address- ed has kindly sent me the original, from which I make the follow- ing extracts : — " My opinion, however, frequently expre8S< d to Mr. F. himself, his brother I think, and others of his friends, was, that a fracture did probably exist ; but, if any where, then about the lower part of the cervical vertebrsB.and this idea based exclu- sively on the symptoms which prevailed. Paralysis, however, ra- pidly came on, and continued for a length of time, giving rise to the 'idea that extravasation had taken place on the cord due to laceration or rupture : certainly there was severe spinal concussion : but, excepting the probability of fracture of the spine, there was no evidence of such a state detectable on the most careful manipulation ; and this, too, by three of us (excluding Dr. Ar- nold!, who first saw the case with me,) every one of whom were anxiously looking for it. / need not say that we might have been mistaken, but this I will say, that it is more likely that we were all right," {and so the event has proved.) In another part of the same letter I remarked that " one of the strongest arguments in favour of the disease being above the 6th dorsal vertebra, and be- low the origin of the phrenic, is the priapism which he (Mr. F.) had for the three or four weeks subsequent to the accident, and the absence of all derangement of respiration." Again, " I feel per- fectly satisfied of the correctness of the opinion which I formed of Mr. F.'s case ; and it strikes me that Dr. Mackelcan has placed himself in very equivocal circumstances, if he has originated the rumours, and I can hardly think they could have received any substantiality without the assistance of his very mobile tongue." -.Mi».*w%*f,-.,-H.rf <» • 21 me dated October 29, and it will be observed that he is silent in it as relates to the detected fracture of the sa- crum, injury to the ilium, or other improper treatment, all circumstances of which his duty should have prompted a communication with me, before even hinting them to Mr. F. Kia end, however, would not have been gained by this too honest act. I will only IisUy observe, that rumours of my alleged mismanagement of this case, based upon Dr. Mackel- can's remarks, had reached uie as being current in Toronto, and matter of conversation even in the hotels at Hamilton ; while more than one person, even in this city, had addressed me on the subject. Dr. Mackel- can's diagnosis of the case would thus appear to have had most extensive circulation, and tUs to the prejudice of all who were concerned in the case in this city, but of myself especially. But now, how stands the case ? — that Dr. Mackelcan has been most grossly wroiig, and that we have been right, almost to the letter — a Aict, however, for which 1 would have taken no credit, in so simple a case as the preceding, had it not been for the circum- stances which I have been reviewing. Dr. Mackelcan's critical acumen, however, has travelled widely through this Province, and he has, doubtless, received great credit for detecting, five months after the receipt of injury, a fracture of the sacrum which never existed. He must, therefore, pardon me if I aid still further in circulating his brilliant diagnostic tact, and expose him to the admi- ration of the profession of this continent and Great Bri- tain, as the brilliant surgical luminary which shines in the firmament of Hamilton, and for the possession of which, the inhabitants of that city can scarcely feel themselves sufficiently grateful. When I recall to mind the circumstances which transpired at Hamilton in De- cember )84<6, the result of which was, that the Hamilton Gazette, December 31, 1846, contained the public an- nouncement of the profession of Hamilton to decline ])rofessional intercourse with Dr. McK., in consequence of unprofessional conduct, I fear much that the practice pursued by Dr. Mackelcan towards his brother practi- tioners is a systematic one ; and the present instance of W*" • r like miRConduct towards myself will demonstrate, both to him, and to all others who strive to acquire a reputa- tion by the b&me means, that it is a dangerous one, and liable to recoil upon the aggressor with a tenfold retribution. Montreal, June 22, 1848. -#;■ li : -.tStViSiXSir: :wffsnm 't \-> ^.,r ■■ * '» - 3; iu0^— — ^** .-' ^^A ..•#i>t ^ V >4«» «W>,