James Ross
1881 The Lancet  
904 being taken notto cut orinjure the joint textures and popliteal vessels, as I was anxious to make a careful dissection of them. The patient made a good recovery after the operation, and left the hospital well on the 1st of June. The following is an account of the condition of the amputated limb : When the joint was exposed by dissection it was found that the quadriceps extensor tendon and ligament of the patella were intact. There was a triangular-shaped and lacerated wound of the capsular
more » ... igament on the inner aspect of the joint. This rent measured two inches in the longitudinal direction, and one inch and a quarter transversely, and was situated about half an inch above the upper border of the patella. On reflecting the patella and its ligament so as to open into the knee-joint, the crucial, internal, and external lateral ligaments were seen to be completely torn across, the crucial and other ligaments being severed from their femoral attachments. The semilunar cartilages remained in their normal position, and the connexions of the gastrocnemius muscle to the femur were not altered. Some extravasated blood lay external to the muscles of the calf between the deep fascia and subcutaneous tissue, but there were no signs of any special effusion of blood. Posteriorly the capsular ligament was torn across in its whole extent. The popliteal artery was pervious and normal in its upper part, but for the lower two inches of its extent it was obstructed by a firm clot. The popliteal vein was pervious and normal. On laying open the popliteal artery and gently turning aside the clot which obstructed its canal, a rupture of its two internal coats was seen at a point about one inch and a quarter above its bifurcation into the tibial vessels. The edges of the ruptured coats were curled inwards, and assisted in obstructing the canal. The popliteal and both tibial arteries were affected with atheroma. jRemctr.—Case 1 calls for no special remarks, as it was an example of a simple and uncomplicated dislocation of the knee-joint. Case 2 illustrates an unsuccessful attempt to reduce a dislocation of the knee-joint of eight weeks' standing. I regret, now, that I did not at once amputate the limb after giving the patient and the injured parts time to recover from the efforts to replace the dislocated bones. My reasons at the time for practising excision were : 1. The desire to save the patient's limb, a point in regard to which he himself was very anxious. 2. The hope that the obliteration or alteration of the original joint fOllowing the injury and the employment of antiseptic precautions would render the removal of the condyles of the femur less dangerous than under ordinary circumstances. 3. The healthy condition and good nutrition of the leg. It is true that the patient's age was opposed to an excision, but he was in fair health, and apparently had an excellent constitution. A third course might have been to do nothing, but against this were two arguments : 1. That the limb was causing great pain, and was quite useless, and, I believe, would have remained so. 2. That one or both condyles of the femur would, sooner or later, have, by their pressure on the soft parts, caused ulceration, and their protrusion through the ulcerated opening must have followed. Case 3 illustrates an interesting complication which may accompany a dislocation of the knee-joint. The cause of the gangrene having been judged to depend on an injury to the popliteal artery, any delay in amputating appeared to me to be attended with the serious risk of absorption of putrid matters into the patient's system, and therefore I removed the limb as soon as the existence of the gangrene had been certainly determined. ASSISTANT-PHYSICIAN TO THE ROYAL INFIRMARY, MANCHESTER. My thanks are due to Professor Lund for permission to publish the following case of amnesic aphasia, recently under his care. I am also indebted to Mr. Wilson, house-surgeon, and to Mr. E. S. Reynolds, dresser to Professor Lund, for aid in making observations and taking notes of the case. William Abson, aged forty-four years, pattern designer in a patent machine manufactory, entered the Royal Infirmary on September 21st, 1881, under the care of Mr. Lund. Since his admission the patient has not been able to give a connected account of himself, and consequently it has not been possible to obtain a complete history of his previous life. He appears to have enjoyed good health up to the date of his admission into the infirmary; he has received a fair education, and has been always temperate in his habits, being for many years a total abstainer. On the day of his admission he came, along with other excursionists, to Manchester. During the day he fell, face foremost, from the top of an omnibus, and was conveyed to the infirmary in an insensible condition. On admission he was found to be suffering from the usual symptoms of concussion of the brain. There was extensive ecchymosis of the tissues around the right eye, and extravasation of blood under the conjunctiva of that side. Two superficial scratches, each about an inch in length, were observed, one situated at the margin of the forehead on the right side, and the other a little further back and above the right temple. There was no discharge of blood either from the ear or from the nose. The specific gravity of the urine was 1030; it contained a considerable quantity of sugar, but no albumen. For some days after admission the patient remained in a semi-conscious condition, but as he gradually recovered it was observed that he was suffering from a peculiar defect of speech. In reply to questions he keeps repeating the words "two" and "tooth." Sept. 28th.-The patient was seen to-day for the first time by me, and on asking him to give an account of his accident his reply was mere jargon, in which scarcely a word having a definite meaning could be distinguished. He, however, sat up in bed when requested to do so, and when a book was handed to him he took hold of it with much apparent interest and all the outward signs of intelligence. He was then asked to read the following passage, "0 thou dream of my childhood and my youth, art thou really to be fulfilled? 0 pride and sorrow of my forefathers, sacred priesthood, art thou, indeed, to be revived in their descendant? Praised be Jehovah." The following reading of the passage was written down at the time by Mr. Wilson : -" On though depth of my shouded and my youth, had though reath then to be forgulted or prearned and shoudered of my formeasured, treasured though art indeed to be retethered in thy dishcondereth. Treasured be Jemothered." On being asked to write down his name, he took hold of the pen with the air of one fully accustomed to its use, and wrote with a bold hand, hut with considerable hesitation, "V'uagageag Abreaghrer." As he wrote each letter he named one aloud, but the written and spoken letter never corresponded with one another. He was now asked to copy in writing a sentence beginning with, " With deep feeling." He wrote with great care and deliberation, and in a good hand, "Weeth deap flneearer." Whilst writing he frequently refreshed his memory by looking at the printed page. When once set a-going he can count on his fingers from one up to thirty, and doubtless further if tried. He cannot, however, tell the number after nineteen without beginning to count from one. He can tell that two and two make four, and three and thrpe make six, but states that five and four make thirty-five. He cannot name correctly the simplest object presented to him. He calls a pen a " tooth," a chair he names a "book," and a watch "measures." Indeed, he names most objects presented to him "measures," which is his favourite word to meet all difficulties. The sugar in the urine has greatly diminished. Oct. 1st.-The patient has improved considerably since last report. He makes fewer mistakes in reading, although unusual words of two syllables, and all words of three sBllahles, are mispronounced or represented by gihberish. The first syllable of words of three syllables is often pronounced correctly. On being asked to put his tongue out he does so with the greatest promptitude, but when the same request is presented to him in writing he reads every word carefully and correctly, with the exception of tongue, which he variously pronounces "tog," " tug," &c. When he has read the writing he lays the paper on one side without making any attempt to obey the request. The patient, indeed, has never given evidence that he understands written language, although he has been tested in different ways. On being shown a pen he explains that "it is to write," but cannot name it. On one occasion he dipped the pen with a i-ignificant look in the ink, and showed by pantomime the use of it. When a key was put into his hand he held one end between his finger and thumb, and moved it as if he were passing the free end through the keyhole, he then rotated the key to the right and repeated the word
doi:10.1016/s0140-6736(02)38127-3 fatcat:56mv2sfbqzay7hfvjnopd3dmkm