CASE OF ULNAR PARALYSIS; ULNAR-MEDIAN ANASTOMOSIS; RECOVERY
880 As the aneurysm was large and dangerously near the surface, exposing him to risk of copious haemorrhage on extrusion of plug, I ligatured common carotid on following day. No change visible in face on tightening of ligature. On removal of gauze plug from wound considerable venous haemorrhage took place. The sac was freely exposed and the veins leading thereto, including internal jugular, were grouped together above and below and ligatured. As the haemorrhage was thereby completely arrested,
... mpletely arrested, the artery which had been undisturbed at seat of injury was not ligatured distally. Missile not searched for. No post-operative symptoms. Noises in head had disappeared completely; no trace of paralysis or aphasia. He was transferred to base on tenth day after operation, and three months later wrote that missile had been extruded on Oct. lat through small sinus at seat of original wound without operation, and he was about to have a board with view to return to active service. The third case was undertaken for an enlarging tumour which proved to be an abscess in the laminse of the original aneurysmal sac, and unfortunately ended fatally. CASE 3.-Private, wounded on right side of neck by shell fragment on Oct. 24th, 1916. He was admitted as a walking case to No. 44 Casualty Clearing Station eight hours after being hit, with temperature 1020 F. and pulse 120. Wound small and in mid-line of sterno-mastoid immediately below level of cricoid. No external haemorrhage after admission, but patient said it had bled freely at first and then stopped of its own accord. A small deep pulsating tumour felt; distinct aneurysmal thrill and also a bruit, which was, however, more easily audible over temporal artery than through fascial and muscular layers. The tumour increased in size for two days but caused very little discomfort, temperature and pulse falling steadily. On third day it was visibly smaller and continued to decrease in size until seventh day, when he felt " champion" and talked and ate with great gusto. On evening of eighth day pulse rose from 68 to 84 and temperature from 98'6° to 99'80, the swelling being slightly larger. He slept well, however, and felt better the following morning. He complained of tiredness; towards evening respiration appeared slightly interfered with. The slight irritative cough which had affected him throughout sounded harsher. On following morning pulse had dropped from 96 to 82, temperature 990, and he felt again a little better, but swelling had increased considerably towards root of neck, and lips and ears showed a slight degree of cyanosis. I decided to operate, and through long oblique incision first disarticulated and removed portion of inner end of right clavicle to have ready access to artery in event of rupture of sac. The common carotid was ligatured about 11 inches above innominate bifurcation. The tumour caused vessels of neck to curve outwards, while trachea and oesophagus were pressed over to left of middle line. The large tumour was then incised, and out flowed several ounces of creamy pus. When this had been mopped away an inner tumour about size of large hen's egg became visible-the actual aneurysm. The pus cavity, developed in intermediate laminse of original aneurysmal sac, surrounded the aneurysm on all sides except posteriorly, and stretched up behind sterno-mastoid muscle to mastoid bone. Two fingers could be easily passed between aesophagus and prevertebral fascia. The aneurysmal sac was then incised and a finger placed upon bifurcation of carotid immediately below which lay an oval slit about 15 mm. in length on anterior aspect. Jugular vein appeared unwounded. A distal ligature was applied and the wound left open. The patient never rallied and died four hours later. Post mortem: Jugular vein found intact, but bound down with the vagus nerve in dense inflammatory tissue. Nothing beyond slight comparative congestion of left cortex observable in brain. Smear of pus showed numerous micrococci and several z ' organisms closely resembling B. perfringens. PericBlrdium contained 152 c.c. of clear fluid. The small fragment of metal lay embedded ' , in some enlarged deep cervical glands on left side. The heart tires with great rapidity under even a small I I ! degree of respiratory embarrassment due to obstruction of the air-passages in the neck, whether the cause be aneurysmal or a wound of larynx or trachea. The facts of the external ' , wound having practically healed over the sterno-mastoid, ' , the masking of the presence of the pus stratum by the deep fascia, and the patient's appearance and sense of wellbeing until the morning of operation, appeared to justify the hope that a second diminution might occur. Delay in operation was disastrous, and the experience of this case would lead me in future to operate at once upon an aneurysm which, having become quiescent, again commences to enlarge. THE MEDICAL REGISTER.-The official Register just issued contains the names of 43,481 persons, of whom 54'2 per cent. are on the local Register for England, 31'8 per cent. for Scotland, and 14 per cent. for Ireland. 1202 names (including 123 colonial and 7 foreign registrations) were added during the year, and 59 names were restored. 1005 names I have been removed from the Register during the year: 983 ' , , on evidence of death, 14 under Sec. XIV. and 8 under I Sec. XXVIII.-IX. of the Medical Act, 1858. This accounts for all the removals, it being significant that no registered I medical man has formally removed his name as having ' i ceased to practise. I DOWN DISTRICT ASYLUM, DOWNPATRICK.-During ' ' 1916 the total daily average number of residents in the e lunatic asylum at Downpatrick was 778, 412 men and 366 women. The patients admitted were seven less than in the previous year and the net average cost per head showed an increase of only C2 16s. 9d. as compared with 1915, the amount received for the maintenance of paying patients being exceptionally large. From the farm there was a net profit for the year which ended March 31st, 1917, of X2142 4s. 9d.