bacl~, in which constant dragging pain ill the abdomen had been at once relieved (after two previously unsuccess- ful exploratory operations) by removing just such an adhesion ; I aecordirgly asked the surgeon to separate and remove it, and this was done. The patient's convalescence was, unfortunately, interrupted by a severe at, tack of pneumo~d~ which set in on the teuth day after operation ; but prior to this she had been able to take almost normal food for three or four" days, and after the subsidence of the pneumonia again returned to normal food. Still Jater, I regret to say, some of her s:ymptoms returned, and even now, some moT~ths after the operation, she suffers from some regurgitation of the stomach contents at night, but she is able to eat fairly well and no longer suffers from nausea during the day.

Whether the adhesion was the partial cause of her illness and aggravated the symptoms resulting from the entero- ptosis or not is a matter upon which it is hard to be dogmatic, but to my mind an adhesion of this sort should be quite capable of producing reflex emesis, and as I understand tha t it is far from uncommon I think it is worth looking for as a routine in cases of exploratory laparotomy performed for unexplained and persistent vomiting. If not specially looked for it may be easily missed.

ART. XII . - -Case o/ Puncture Wound over the Right Clavicle, causing Loss o/ Pulsation in the Arteries o/ the Arm. By HENRY STO~ES, M.D. Univ. Dubl.; F.]~.C.S.I . ; Surgeon to the Meath Hospital and Cour/ty Dublin Infirmury.

CASE.--Thomas K., a labourer, aged thirty-three years, was admitted to the Meath Hospital on 2rid August, 1913, suffering from a wound above the centre of the right clavicle. He stated that while working in a hay field he had tripped and fallen on to a prong of a tumbling rake (a machine used for collecting hay) on whioh he was susgended, being unable

252 Case o/Puncture Wound over the Right Clavicle.

to reach any support with his hands. He further said that he had to be lifted off by his companions, and tha t on account of great weakness they brought him to the hospital.

On examinatior~ the patient was found to be a strong, heavy man of about 14 stone weight, short necked and broad chested. There was a punctured wouud three-quarters of an inch long over the right clavicle discharging a small quant i ty of blood. There had bem~ no coughing of blood. The house surgeon paiuted the wound and the neck with t incture of iodine and applied a dressing.

On the next morning emphysema had developed in the upper half of the right side of the chest, and no pulsations could be felt in the radial, ulnar, brachial and axillary arteries of tha t side although there was a very distinct pulsation in the carotids and in all the other arteries. The pat ient looked very ill, and had considerable pain in the right side of his chest.

During the next ten (lays the temperature kept continually above normal, varying from 99 ~ to 102 ~ his pulse running from 115 to 140, and the respirations about 35 a minute.

On the 8th of August a careful examination showed tha t there had been no nervous lesion, and tha t there was a large area of dullness underlying She emphysema and extending down to the base of the right hmg. Oft the 16th of August Dr. Boxwell, who was asked to see the ca.se ,suspected an empyema, but on four occasions the aspirating hypodermic needle drew off pure blood. The patient 's temperatv.re kept varying from 97 ~ to 102 ~ for three weeks, doubtless due to the absorption of the hmmorrhage, the dulness slowly disappeared, and personally he felt much better. On the 7th of September he was allowed up, and he was discharged convalescent on the 12th of September. Art examination on tha t date failed to reveal any trace of pulsation in the arteries of his right arm. At ao t ime was there any swelling, pulsation or murmur in 'the neighbourhood of the puncture wound.

T h e above e~se opens up many difficult quest ions. F i rs t , was the subclavian a r te ry per fora ted? This does not seem to be probable, as it is very unl ikely tha t the pat ieni would not have rapidly bled to death. Secondly, if any branch of the subclavian had been perforated, would the pressure of the resul t ing h~emorrhage have caused occlu-

Certain Preparation8 o/Spleen, Pancreas, &c. 253

~ion of the subclavian. This also seems unlikely, as there was no turnout in the neck, no venous congestion in the arm ; the only large hmmorrhage was into the pleural cavity. Thirdly, was the absence of pulsation in the arteries of the right arm of old standing? It is, in the absence of evidence, impossible to answer this question, but as the arm was well developed, strong anit muscular, it is not probable, and no congenital malformation could account for pulsation not being felt somewhere in the arm.

The patient is beint4 kept under observation, the prognosis as regards the development of an aneurysm being regarded as very grave.

ART. X I I I . - - 0 n ~he Every-day dpplica~ion o] Certa, in Preparations o[ Spleen, Pancreas, ~'e. By G. W. CARNRICK, Hornsey, London, ~ .

THE results of almost innumerable experiments prove that not a few diseases are due to the partial or complete loss of certain internal secretions or hormones. Physiologists have devoted years of experiment to show the relations of the internal secretions, and thus have paved the way for their successful application in the treatment of disease.

Twenty years of experience with thyroid extract has placed it among our few specific remedies, and it is a panacea for certain conditions due to a lack of this par- ticular secretion. The study of the suprarenal gland and the physiologic influence of its extracts has also assmned a definiteness which cannot be gainsaid ; and we are learn- ing successfully to procure and use various other hormones in conditions presumed to be due, in part at least, to a corresponding lack.

The writer has done much experimental work in apply- ing this idea to the treatment of diabetes, and the sugges- tions initiated ten or more years ago are now rapidly becoming " rational." Opinions change; and numerous personal communications, as well as published articles, have emphasised my conclusions that a certain secretion