778 there is no sign of hereditary syphilis; nor is ther any reason to suppose, from the appearance of the patient that she has any phthisical tendencies. The posterio two-thirds of the hard palate, the whole of the anterio surface of the soft palate and uvula, the inner aspec of both tonsils and faucial pillars, and the inner surface of the right cheek are covered with a thick layer o granulation tissue, which is soft and spongy and project: in parts considerably above the level of the

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... mucous membrane. In some portions there is very dis tinct ulceration going on. This is particularly the caSi on the cheek, where it appears to be produced by th( irritation of some carious teeth, and on the inner aspec1 of the left tonsil. She suffers from a slight cough. ThE chest is well formed, both sides move equally well, and there is nothing abnormal except an occasional rate at th left base posteriorly. The other organs of the body arc apparently quite healthy. Inhalations of calomel were tried ; but, as they caused some irritation and no apparent benefit, they were discontinued. Applications of cocaine, morphia, and iodoform were applied. These relieved her pain, but apparently produced no effect on the condition of the growth. It was then determined to make an attempt to destroy the growth with the cautery, and for this purpose she was transferred to Dorcas ward, under the care of Mr. Arbuthnot Lane. On January 28th the whole of the granulating surface was gone over many times with the large blade of the Paquelin's cautery; and as the margin of the growth on the sides of the pharynx could be reached, there was no difficulty in doing this very thoroughly, particularly as the posterior surface of the soft palate was unaffected, the disease not extending beyond its free margin. The growth on the cheek approached very closely to the orifice of the duct of the parotid gland, but it was possible to destroy it without injuring this channel. Although much time was spent over the operation, it was felt desirable to repeat the process after the inflammation resulting from the cauterisation had subsided, and in that way to secure if possible the complete destruction of the growth. Another circumstance that necessitated this was the great amount of irritation of the larynx which was produced by the intense heat of the cauterv. This caused a certain amount of swelling of the upper aperture of the larynx, which was controlled by the application of a large ice-bag to the neck. On Feb. 2nd the whole surface was again thoroughly and deeply cauterised. On Feb. 15th she was sent to a convalescent home, from which she returned at the end of a month. It was then apparent that the growth had been completely destroyed, the affected parts appearing quite normal except for the presence of some faint cicatrices. Before proceeding to the destruction of the growth a piece was removed for microscopical examination. This was submitted to a careful examination by Dr. Washbourn, but no bacilli could be detected. We think that the case is of much interest on account of bhe rarity of the disease, the doubtful condition of one of bhe incisor teeth, the apparent absence of any strumous conlition, and the satisfactory result of the treatment adopted. I PERHAPS no cases coming under the observation of medical men excite more interest, both as regards diagnosis and treatment, than do those of acute intestinal obstruction ; the interest arising, in the first place, from the difficulty of making a correct diagnosis, and, in the second place, if, as is often the case, the diagnosis can only be put in the range of probabilities, from the question arising, Shall the abdomen be opened? Nor does the interest only end there, e for in not a few cases, even with an opened abdomen, the t, exact cause cannot clearly be made out. The case about to )r be related presents several points of interest which can be )r dwelt on after the history has been given. t On Oct. 25th, 1888, I received a telegram from my friend :e Dr. Keighley of Batley, asking me if I would see a case of )f acute intestinal obstruction with him and come prepared to ;s operate. On reaching the Batley Cottage Hospital, we tt found the patient with an anxious expression of countenance, :-and looking thin and haggard. She was lying on her back, e with the knees drawn up, and complained of abdominal e pain, which came on in paroxysms, beginning on the right t side and thence radiating over the abdomen. When the e pain was present, irregular peristalsis could be seen starting din the right iliac region. In the intervals of the spasms the e pain was not severe, and there was no tympanites. The e patient was much depressed, and had a feeble, rapid pulse. e Whilst we were examining the abdomen a large quantity of t stercoraceous matter was vomited. There was no sign of !, any external hernia, although she had had a right inguinal r hernia several years previously, for which she had worn a f truss, which, however, had been discarded some months. before her present illness on account of the non-appearancethe rupture. The history kindly furnished by Dr. Keighley was tha f the patient had been apparently quite well up to ten days ; previously, when she was suddenly seized with right iliac ; pain whilst performing her ordinary household duties; this t was accompanied by a feeling of sickness followed by vomit-, ing, and by marked tenderness of the abdomen. She was , not seen by Dr. Keighley until Oct. 19th (six days before ; operation), when there was marked tenderness over the ) abdomen, a feeble rapid pulse, an anxious countenance, and Ta normal temperature. On manipulation of the abdomen, ! a sensation of fulness was felt in the right iliac fossa, and borborygmi were elicited. On the 20th an enema was i followed by the escape of some fcecal matter, but the same evening the vomit became stercoraceous. As the symptoms did not yield to treatment, being only slightly relieved by the administration of opium, the patient was removed to the Cottage Hospital on Oct. 24th. The members of the staff present had no difficulty in agreeing with Dr. Keighley that, as medical treatment had failed, and as there was evidently some internal obstruction, laparotomy would give her the only chance of recovery. Under full antiseptic precautions, including the spray, chloroform being administered by Dr. Brown, and with the assistance of Drs. Keighley, Bayldon, and Shirley, laparotomy was performed by an incision of two inches in the middle line below the umbilicus, when distended coils of bowel at once appeared. The index and middle finger of the right hand were passed down into the right iliac fossa, where something abnormal was felt to be attached to the abdominal parietes about an inch above the crest of the ilium. As the nature of the abnormality could not be satisfactorily made out by touch alone, the opening was enlarged to the extent of three inches and a half, and on retracting the right side of the incision, whilst the bowels were held out of the way on the left by means of a large flat sponge, the abnormality was found to be a coil of small intestine passing into an unusual opening in the parietal peritoneum. On one side of the constriction was. seen distended bowel, whilst on the other side the gut was empty and collapsed. Gentle traction was employed in order to bring the ring into view before dividing it; but before the blunt end of the hernia knife could be passed through the stricture, the constricted loop escaped, and immediately a faecal odour was noticed, which was perceptible to all present; fortunately, the other coils of bowel were well protected by the large fiat sponge, and immediately sponges were so placed as to prevent soiling' of the peritoneum; it was then found that where the small' knuckle of bowel, including nearly its entire circumference, had been tightly nipped, ulceration had taken place; and on the sudden withdrawal of the constricted loop the intestine had ruptured to the extent of one-third of an inch. The peritoneal surface of the bowel was carefully wiped with a carbolised sponge, and, as the constricted loop presented no signs of gangrene, enterorraphy was performed by means of six Lembert's sutures, which completely occluded the opening. After carefully sponging the part again, the bowel was returned and the parietal wound closed. As the patient seemed to be suffering rather severely from shock, an injection of one-hundreth of &