NOTE ON AMPUTATION
3 struck; or, in other words, in those parts of the nervous centres which were in contact with the anterior bony boundaries of the anterior, middle, and posterior fossse of the skull severally; and the portio dura is so situated within the skull as, perhaps, to be more amenable to damage under these circumstances than any other cerebral nerve. The failure to discover any pathological change does not, of course, prove that no damage had been sustained. Further, I do not think it need be assumed
... it need be assumed from the conditions found in this case that the double facial palsy observed in the first case was not due to fracture across the base of the skull, though they prove clearly enough that a blow on the head may cause such paralysis apart from fracture. But the chief interest of the ease, after all, lay elsewhere -namely, in the presence of the group of non-paralytic clinical phenomena, to which nothing similar existed in the first case, and in their explanation. What caused the patient's irritable apathy and apparent enfeeblement of mind? What caused his persistent mental misery? What caused his progressive and rapid emaciation and muscular enfeeblement ? 1 To these questions, I am sorry to say, I can give no satisfactory answer. All the perceptible damage to the surface of the brain was well removed from the generally recognised motor and sensory areae ; a fact which goes to explain the absence of cerebral paralysis and of impairment of the special sensory functions. Cases have been adduced to show that disease of the front part of the anterior cerebral lobes involves a profound alteration of the moral character of the patient and enfeeblement of his intellect. On the other hand, many cases of injury of this part have been met with in which no special symptoms of importance have ensued. "Dr. Crichton Brown, however" (I quote from Ross), "has drawn attention to the fact that during the early stage of general paralysis of the insane, when the convolutions of the frontal lobe are particularly apt to manifest degenerative changes, the characteristic symptoms consist of 'general restlessness and unsteadiness of mind, with impairment of attention, alternating with apathy and drozvsiness. "' These symptoms are identical with some of the special symptoms presented by my own patient ; and on the whole, perhaps, are such as in the present state of our knowledge might be thought likely to follow on such lesions as were found. The gradual wasting and debility, and the rectal trouble, however, seem to me at present inexplicable. I may add that in the tenth volume of the Pathological Transactions I recorded a case pathologically identical with this; but in which the only history obtainable was that the man had been earning his livelihood subsequent to the accident (of which there was no record) which caused the superficial cerebral haemorrhage; and that after a bou1 of driuking he was attacked with epileptiform convulsions, of which he died. MANY years ago, when in India, I called attention to the subject of thrombosis of the pulmonary artery, and the formation of decolourised fibrinous clots in the right cavities of the heart, extending into the ramifications of the pulmonary artery, as a cause of death after surgical operations or injuries, and also during the course of blood-poisoning and certain forms of disease. 1Blv views and experience of this subject are detailed in a work entitled " Pathological Observations in India," and I now revert to it as a subject which merits more consideration than it has hitherto received and i3 entitled to, as a serious and often fatil complication of cas:;s, which otherwise might have terminated more favourably. These decolourised fibrinous clots in the heart and pulmonary arteties have been attributed either to post-mortem coagulation or, when admitted to be of ante-mortem occurrence, they have been considered as merely one of several phenomena which attend the process of dying, and not as an immediate cause of death. This, I venture to contend, is not always the case ; but, on the contrary, that such clot and plugging of the pulmonary artery on the right centres themselves cause death not unfrequently in cases in which without them death could not have occurred. My experience of this subject has been acquired chiefly in India; but it has been confirmed by observation in this country, and I am under the impression that this is a more frequent cause of death, not only in the course of pyaemia, septicaemia, and certain diseases, but also after surgical operations, wounds, and inj uriea. A malarious climate I believe to be an especially predisposing cause, and in the state of malarial cachexia which so frequently results from residence in such countries, even where there may have been no fever, and especially in cases where anaemia is splenic or hepatic incompetency is present, it is prone to happen. But it is by no means confined to persoos so affected, for I have frequently seen it in individuals who presented no cachectic appearance nor in whom was there any obvious indication of visceral disease.