Absence Of Tenderness Research Articles

Is Tenderness of Medial Malleolus Circumference a Sign of Syndesmosis Injuries?

Syndesmosis injuries occur in approximately 10% of all ankle fractures. The integrity of the deltoid ligament is important in the decision of surgical treatment of lateral malleolus fractures. Patients who were operated on for Weber B ankle fracture were evaluated retrospectively, and the relationship between tenderness around the medial malleolus and syndesmosis injury was investigated. Patients with visual analog scale, Foot and Ankle Ability Measure daily living, and sports activity scores in their files were included. This study enrolled 38 patients. The patients were divided into two groups. Group 1 consisted of patients with a medial space greater than 4 mm on preoperative radiographs and a positive intraoperative Cotton test, in which a syndesmosis screw was used. Group 2 consisted of patients with a medial space less than 4 mm on preoperative radiographs and negative intraoperative Cotton test, for whom no syndesmosis screw was used. In 17 of 38 patients, syndesmosis screws were used because of intraopeative positive Cotton test. In 21 patients, the Cotton test was negative and the syndesmosis screw was not used. Comparing the groups statistically revealed no statistically significant difference in all scores. Tenderness around the medial malleolus was detected in two patients in group 2 and nine patients in group 1. A statistically significant difference was detected in terms of medial clear space values and tenderness around the medial malleolus between both groups. The absence of tenderness around the medial malleolus in Weber B ankle fractures indicates no syndesmosis injury, whereas the presence of tenderness around the medial malleolus does not mean that there is a syndesmosis injury.

Thyroiditis – A Clinical Update and Review

Purpose: Thyroiditis refers to a set of inflammatory disorders involving the destruction of normal thyroid follicular tissue. Each disorder has distinctive histology and pathology. Understanding each condition in the thyroiditis frame is crucial for physicians. Main: This review categorizes thyroiditis into two groups based on the presence or absence of tenderness: painful and painless. This paper reviews the primary etiologies, diagnostic modalities, and treatment options for each condition. The painful thyroiditis comprises subacute, infectious, radiation, trauma-induced thyroiditis, and rarely Hashimoto’s thyroiditis. The painless group consists of subacute lymphocytic thyroiditis, postpartum thyroiditis, drug-induced thyroiditis, and fibrous thyroiditis. Findings: In the painful group, the primary etiology of subacute thyroiditis is viral, including SARS-CoV- 2, which has been reported recently, and the main etiology of the infectious subgroup is bacterial infections. Symptom management and pain relief are the mainstays of treatment for painful conditions. The painless group typically progresses from transient hyperthyroidism to euthyroidism to hypothyroidism before resolving. Autoimmune and genetics, HLA-DR3, likely contribute to subacute lymphocytic thyroiditis. Certain medications, including interferon-alpha (HVC management), IL2 Tyrosine-kinase inhibitors (cancer management), amiodarone, lithium, and check-point inhibitor immunotherapy (CTLA-4 and PCD-1) are found to be related to thyroiditis. Fibrous thyroiditis is usually associated with systemic fibrous disease. Conclusion: A comprehensive understanding of each thyroiditis condition’s etiology and clinical presentation is important to accurately diagnose, appropriately manage, and counsel patients on the risk for permanent hypothyroidism that may require long-term thyroid replacement therapy

Clinical Course of Bacillus Calmette-Guerin Lymphadenitis.

Bacillus Calmette-Guerin (BCG) vaccination can cause lymphadenitis. The purpose of the current study was to describe patient characteristics and clinical courses of lymphadenitis associated with BCG vaccination. A total of 171 patients who visited a tertiary hospital with a diagnosis of BCG-associated lymphadenitis between January 2012 and June 2017 were included. The diagnostic criteria were a history of BCG vaccination on the symptomatic side, absence of tenderness and raised temperature over the swelling, absence of fever and constitutional symptoms, and isolated axillary (or supraclavicular/cervical) lymph node (LN) enlargement. Treatment strategies included observation, antibiotics, incision and drainage or needle aspiration (I&D/NA), and surgical excision. The median follow-up period was 40 days (range 1–1245 days). The median age at the first visit was 5.5 months (range 0.9–83.7 months). The most common location was the axilla (81.3%). The respective numbers of patients managed via observation, I&D/NA, antibiotics, and surgical excision were 99, 47, 5, and 20. LNs were significantly more enlarged in the I&D/NA group than in the antibiotics group and the observation group. The respective times taken for residual lesions to reduce to < 20% were approximately 3 months, 4 months, and 5 months in the antibiotics, observation, and I&D/NA groups. The surgery group had significantly fewer residual lesions than the observation group at the last visit, but there was no significant difference in current residual lesions between the groups. LNs were significantly larger in the I&D/NA group. The surgery group exhibited the least residual lesions at the last visit, but there was no significant difference in current status.

Diagnostic performance of US for suspected appendicitis: Does multi-categorical reporting provide better estimates of disease in adults, and what factors are associated with false or indeterminate results?

PurposeTo identify factors associated with false or indeterminate US result for suspected appendicitis, and assess whether multi-categorical reporting of US yields more precise estimates regarding the probability of appendicitis. Methods562 US examinations for suspected appendicitis between May 2013-April 2015 were categorized as true (77/562 true positives or true negatives) or false/indeterminate (485/562 false negatives, false positives or indeterminates) based on results from a prior study. Of 541 examinations with images available retrospectively, a category of A–E was assigned as follows: non-visualized appendix with secondary findings (A) absent or (B) present; appendix visualized and considered (C) negative, (D) equivocal, or (E) positive for appendicitis. The following factors were recorded: age; sex; scan time (daytime vs. off-hours); resident/fellow involvement; abdominal subspecialty radiologist; radiologist experience (>5 years or not); and tenderness on interrogation. Associations between factors and US result were assessed (t-tests, Fisher’s exact test and multivariate logistic regression). ResultsThe true group had proportionally more males (18/77 (23.4%) vs. 66/485 (13.6%), p = 0.04) and patients with sonographic tenderness (43/77 (55.8%) vs. 132/353 (27.3%), p < 0.0001). There was no significant difference or association with other factors. On multivariate logistic regression, false/indeterminate results were 1.9 times (95% CIs 1.0–3.5) more likely among females and 3.8 times more likely in the absence of tenderness (95% CIs 2.3–6.4). The proportion of patients with appendicitis in categories A-E was 34/410 (8.3%), 24/44 (54.5%), 0/18 (0%), 0/3 (0%) and 61/66 (92.4%), respectively. ConclusionsFemales and absence of tenderness were associated with a false/indeterminate US. Categorical reporting provides more granular estimates of the post-test probability of appendicitis.

A Clinical Approach to Diagnosing Trigger Wrist.

Trigger wrist is a relatively unusual condition, produced by wrist or finger motion. The various causes of trigger wrist can originate from flexor tendon, extensor tendon, bones, or tumour. A proper clinical approach is required to diagnose and manage patients with trigger wrist. A keyword search was performed across Google Scholar and PubMed. Articles describing trigger wrist conditions were analysed. Based on the information obtain from the articles, the clinical manifestations and approach to diagnosing the cause of trigger wrist is discussed. A detailed history alone may lead to a reasonably accurate diagnosis. Patients can present with trigger wrist occurring during movement of the fingers or with wrist movements. Presence of tenderness around A1 pulley suggest trigger finger. Absence of tenderness over the A1 pulley may suggest trigger wrist. The wrist should be examined for any swelling or malunion around the wrist joint. Palpate for any bony prominence, clicking, or crepitus with the movement of the wrist. Examination for the presence of carpal tunnel syndrome should be performed. A simple radiograph of the wrist joint is needed to see any possible bony pathology such as malunion, instability or arthritis of the carpal bone. For soft tissue assessment ultrasound would be a good choice and can be done during finger or wrist movement. MRI is useful for further assessment of space occupying lesion within the carpal tunnel and is useful for surgical planning. Nerve conduction study is indicated for patients with median nerve compression symptoms. During the initial stage, the patient should be advised for activity modification to reduce the wrist and finger movements. Surgical treatment will depend on the causative factor. Surgery done under local anaesthesia has the advantage of reconfirming with the patient, resolution of triggering during surgery by asking the patient to actively move the fingers or wrist. Trigger wrist is a relatively rare condition compared with trigger finger, which is the most common disorder of the hand. To avoid inadequate and ineffective treatment of patients with trigger wrist, careful examination and proper diagnosis are vital.

The association between synovial fluid serine proteinase activity and response to intra-articular corticosteroid injection in psoriatic arthritis.

Intra-articular corticosteroid (IAS) injections are often used for the immediate relief of pain and inflammation in the joint of psoriatic arthritis (PsA) patients. However, studies identifying factors that predict response to the IAS injections are lacking. We aimed to assess the usefulness of serine proteinase activity measurements in PsA synovial fluid (SF) samples obtained at the time of injection in predicting clinical response. The PsA patients with available SF samples from the knee joint were identified from the University of Toronto PsA cohort. Clinical response was defined as an absence of tenderness or swelling in the injected joint at the first post-injection visit, at either 3 or 6months. SF proteinase activity was determined by measuring cleavage of fluorogenic tri-peptide substrates for trypsin-like (VPR-AMC and VLK-AMC) and chymotrypsin-like (AAPF-AMC) serine proteinases. Generalized estimating equation (GEE) models were used to investigate factors associated with response. A total of 32 patients with 60 injected joints and data available for follow-up at 3 or 6months were included in the analysis, with 25 (41.7%) injected joints resulting in clinical response. Age, sex, active joint count, systemic medications and SF serine proteinase activity at the time of injection were included as covariates. Only treatment with biologics was significantly associated with response at 3 or 6months in the multivariate reduced model (OR 3.02, p = 0.027). We could not demonstrate an association between SF serine proteinase activity and response to IAS injection. Biologic agents significantly improve the likelihood of achieving clinical response.

Usefulness of fine needle aspiration cytology in diagnosis of causes of lymphadenopathy in children

Background: The present study was conducted to study the causes of lymphadenopathy, associated clinical findings, usefulness of FNAC in diagnosis of various causes of lymphadenopathy as lymph node biopsy is a difficult and invasive procedure in children attending pediatric department.Methods: A study was done at Katuri medical college and hospital. A total of 50 patients with lymphadenopathy including both local and generalized were studied for a period of 2 years by taking proper history, through physical examination both generalized and systemic and all the patients were subjected for relevant investigations for establishment of diagnosis which is essential for institution of proper treatment. A prospective study consisting 50 patients with lymphadenopathy (&lt;12year) is undertaken to find the incidence of various causes of lymphadenopathy in the affected patients for 2 year.Results: It was observed that 10, 17 and 23 children were having lymphadenopathy in the age groups of 0-3-year, 4-8 year and 9-12 year respectively. Majority of patients were having lymphadenopathy only after 4 year of age, male 28 and female 22. The major symptoms in order of incidence were palpable swelling, fever, cough, weight loss, loss of appetite and sore throat. Duration of lymphadenopathy of less than 1 month was seen in 25 cases ,1-6 months 24 cases and more than 6 months in 1 case. Enlargement of lymph nodes in cervical region, was the major finding in these patients. 47 cases were having local lymphadenopathy mainly in the cervical region and 3 cases were having generalized lymphadenopathy. 80% of the patients were having firm lymph nodes, remaining 20% of the patients were having soft lymphadenopathy. 36 patients were having mobile lymph nodes while 14 patients were having matted lymph nodes. Tenderness was observed in 21 cases against absence of tenderness in 29 cases. Analysis of the FNAC results revealed positive for tuberculosis in 11 cases reactive hyperplasia in 26 cases, granulomatous changes seen in 4 cases and suppurative lymphadenitis in 6 cases.Conclusions: In developing countries like India whenever a patient attends the Department of Paediatrics with lymphadenopathy it is always be prudent to exclude tuberculosis, which is quite prevalent. FNAC is helpful in those with benign conditions like reactive hyperplasia to rule out underlying serious systemic diseases and reassuring the parents.

Oral Plus Local Antibiotics Significantly Reduce the Need for Operative Intervention in Chronic Anal Fissure: a Novel Finding

Up to 40% patients with chronic fissure-in-ano require operative intervention. As of today, antibiotics, local or oral, have no role in the treatment of chronic fissure-in-ano. In a prospective study, fissure-in-ano was classified as follows: acute 6-week duration with normal/low anal tone, and acute-on-chronic >6-week duration with high anal tone. The resting anal tone was assessed clinically on an objective scale—DRESS score—the digital rectal examination scoring system. Local and oral antibiotics with avoidance of constipation (LOABAC) treatment was advocated for 6 months. For refractory cases, liquid paraffin and, for high anal tone, diltiazem cream along with sitz bath were prescribed. Non-responders underwent a MRI to look for fissure deepening (presence of sinus/fistula). Healing of fissure-in-ano was assessed by absence of pain, burning, itching, or spasm after defecation and absence of tenderness on per-rectal examination. Out of 109 fissure-in-ano patients recruited over 20 months, 90 (M/F—50/40) were finally included. Mean age was 37.6 ± 12.3 years. Conservatively managed, 86.7% (78/90) patients had significant relief and were cured without requiring any further intervention. Twelve out of ninety (13.3%) patients had no/minimal relief and underwent a MRI which revealed a fissure-sinus/tract in 10/90 (11.1%). MRI was normal in 2/90 (2%). Five out of ten patients with sinus underwent surgery (laying open of the sinus) and became alright subsequently. The rest of the five patients were lost to follow-up. In chronic fissure-in-ano, the regimen of local and oral antibiotics with avoidance of constipation significantly decreases the need for operative intervention.

Comparison of three enthesitis indices in a multicentre, randomized, placebo-controlled trial of golimumab in ankylosing spondylitis (GO-RAISE)

To compare the abilities of three enthesitis indices to detect improvement in entheseal tenderness with the TNF antagonist golimumab in AS. Adult patients with active AS were randomly assigned to receive s.c. injections of placebo or golimumab (50 or 100 mg) every 4 weeks. Patients with inadequate week 16 responses were switched (blinded) from placebo to golimumab 50 mg or from golimumab 50 mg to 100 mg. At week 24, all patients still receiving placebo crossed over to golimumab 50 mg. Enthesitis data through week 52 are reported herein. Enthesitis was measured by a trained, independent assessor who recorded the presence or absence of tenderness in 27 entheses, which allowed simultaneous determination of three different indices [12-point Berlin Index, 17-point University of California, San Francisco (UCSF) Index and 13-point Maastricht AS Enthesitis Score (MASES)]. Three hundred and fifty-six AS patients were randomized to placebo (n = 78), golimumab 50 mg (n = 138) or golimumab 100 mg (n = 140); 355 had enthesitis data available for analysis. Using the UCSF Index, significant improvement from baseline vs placebo was observed for golimumab 100 mg at weeks 14 and 24. Using the MASES, significant improvement for golimumab 100 mg vs placebo at week 14 and a trend toward improvement at week 24 were observed. Using the Berlin Index, significant improvement for golimumab 100 mg vs placebo at week 14 was observed. Effect size determinations for changes to weeks 14, 24 and 52, respectively, in the Berlin (-0.27, -0.34, -0.42), UCSF (-0.44, -0.61, -0.55) and MASES (-0.30, -0.55, -0.39) indices suggested small to moderate effect sizes. In patients with active AS, the UCSF Index appeared most sensitive in detecting the effect of golimumab 100 mg vs placebo on enthesitis. clinicaltrials.gov, http://www.clinicaltrials.gov, NCT00265083.

Risk factors for malignant spinal cord compression and leptomeningeal metastases in cancer patients presenting to an urgent care center

9606 Background: Malignant spinal cord compression is an oncologic emergency that is associated with considerable morbidity including irreversible loss of neurologic function. As many of the presenting signs and symptoms of spinal cord compression are common to other less-threatening conditions, it would be helpful to identify early clinical predictors specific for spinal cord compression. Methods: The medical records of all patients who presented to the emergency department of a cancer center and required spine MRI imaging in 2003 were reviewed. MRI findings were correlated with neurologic presentation. Results: There were 176 MRIs performed on 164 patients (84 men, 80 women; median age 63, range 22–96) with breast (n=31, 19%), prostate (n=29, 18%), lung (n=26, 16%), colon (n=9, 5%), myeloma (n=9, 5%), or other malignancies (60, 37%). Fifty two (29.6%) MRIs demonstrated spinal cord compression (SCC, defined as thecal sac compression with associated T2 signal change in cord) and 13 (7.4%) demonstrated incidental leptomeningeal metastases (LM). Multivariate logistical regression analysis identified four independent predictors of SCC: male gender (OR=2.95, 95% CI= 1.27–6.85, p=0.01), prior history of vertebral fracture (OR=9.09, 95% CI= 3.90–21.17, p< 0.0001), severe back pain (OR=4.21, 95% CI= 1.76–10.06, p= 0.001), and abnormal sensory exam (OR=9.45, 95%CI= 3.29–27.20, P<0.0001). SCC was noted in 13% of patients with only one risk factor and 90% of patients with 3 or more risk factors. Of note, 21 (40%) of scans demonstrating SCC were performed in patients without clinical evidence of weakness. The three independent risk factors associated with the presence of LM include: age less than 55 (OR=5.52, 95% CI= 1.40–21.7, p=0.02), extensor plantar reflex (OR=10.96, 95% CI= 2.77–43.46, p<0.001), and absence of tenderness upon palpation of spine (OR=8.02, 95% CI= 2.06- 31.23, p=0.003). Conclusions: Some of these findings are consistent with prior retrospective studies and provide a useful framework for assessing cancer patients in whom the diagnosis of SCC or LM are considered. In particular, absence of leg weakness does not exclude SCC, and the high rate of incidental LM demonstrates the importance of performing contrast enhanced scans. No significant financial relationships to disclose.

Lymphadenitis in an 18-Month-Old Traveler to Mexico

Lymphadenitis in an 18-Month-Old Traveler to Mexico

Rational Approach to Diagnosis and Management of Blunt Scrotal Trauma

To provide a rational approach to the diagnosis and management of blunt scrotal trauma to aid clinicians in the selection of patients for surgical exploration. We performed a retrospective evaluation of the medical records of 44 patients from two metropolitan tertiary referral hospitals. A total of 29 patients were recruited from July 1, 1993 to June 30, 2003 at one institution and an additional 15 patients from February 1, 1991 to January 31, 1999 at the second. Scrotal ultrasound scans were retrieved and reviewed by a uroradiologist unaware of the treatment regimen and outcome. The presence of both testicular swelling and tenderness suggested more significant testicular injury; however, testicular rupture was present in the absence of tenderness. Three patients with operatively confirmed testicular rupture had only swelling on clinical examination. Five patients with intratesticular hematoma were successfully treated conservatively with interval ultrasound scans recommended to assess for resolution. All patients with operatively confirmed testicular rupture had a combination of the following ultrasound features: the presence of hematocele, disruption of the tunica albuginea, and/or extrusion of the seminiferous tubules. Patients presenting after blunt scrotal trauma with clinical hematocele should progress directly to exploration. The remainder should undergo scrotal ultrasonography. Those with large hematoceles or suspected rupture on ultrasonography should also proceed to exploration. Those without hematocele, a clearly distinct tunica albuginea, and a lack of fracture planes within the testes are a subgroup that can be successfully treated conservatively.

Periorbital and orbital infections.

1. Ellen R. Wald, MD* 1. *Professor of Pediatrics and Otolaryngology, University of Pittsburgh School of Medicine; Chief, Division of Allergy, Immunology, and Infectious Diseases, Children’s Hospital of Pittsburgh, Pittsburgh, PA After completing this article, readers should be able to: 1. Describe the specific causes of preseptal cellulitis. 2. Discuss the management of preseptal cellulitis. 3. Know the specific manifestations of postseptal cellulitis. 4. Recognize the orbital septum as a connective tissue extension of the periosteum (or periorbita) that is reflected into the upper and lower eyelids. 5. Identify the usual signals of orbital involvement. Practitioners frequently have the opportunity to manage the child whose chief complaint is a “swollen eye.” Some children have trivial or self-limited disorders, but others can have sight- or life-threatening problems. The noninfectious causes of swelling of or around the eye include: 1) blunt trauma (leading to the proverbial “black” eye), 2) tumor, 3) local edema, and 4) allergy. In cases of blunt trauma, the history provides the key to the diagnosis. Eyelid swelling continues to increase for 48 hours and then resolves over several days. Tumors that characteristically involve the eye include hemangiomas of the lid, ocular tumors such as retinoblastoma and choroidal melanoma, and orbital neoplasms such as neuroblastoma and rhabdomyosarcoma. (1) Tumors usually cause a gradual onset of proptosis in the absence of inflammation. Hypoproteinemia and congestive heart failure cause eyelid swelling due to local edema. Characteristic findings are bilateral, boggy, nontender, nondiscolored soft-tissue swelling. Allergic inflammation includes angioneurotic edema or contact hypersensitivity. (2) Superficially, these problems can resemble acute infection. However, the presence of pruritus and the absence of tenderness are helpful distinguishing characteristics. The anatomy of the eye is important for understanding its susceptibility to spread of infection from contiguous structures. Veins that drain the orbit, the ethmoid and maxillary sinuses, and the skin of the eye and periorbital tissues (Fig. 1) represent an anastomosing and valveless network. (1) This venous system provides opportunities for spread of infection from one anatomic site to another and predisposes …

Acute Appendicitis in Infants: Still a Diagnostic Dilemma

Acute Appendicitis in Infants: Still a Diagnostic Dilemma

Clinical findings in a population with back pain Relation to one-year outcome and long-term sick leave

Objective - To investigate whether physical examination findings can be used in predicting recovery from back pain and new episodes of sick leave. Design - One-year prospective study of a single cohort. Settings - Semi-rural Swedish county. Population - A cross-section of a general population with back pain (207 women, 176 men) between 20 and 59 years of age. Main outcome measures - Cumulative incidence of sick leave due to back pain, cumulative incidence of sick leave due to back pain > 30 days, incidence of recovery from back pain. Results - For recovery from pain, the absence of tenderness in the trapezius muscle (OR 0.33; CI 0.1-0.5) was predictive. New sick leave was predicted by tenderness in the trapezius muscle (OR 2.67; CI 1.5?4.9), and had a tendency to be associated with a flattened lumbar lordosis and a restricted cervical range of motion. For long-term sick leave, the same findings and also observation of scoliosis (OR 3.44; CI 1.1?10.5) were predictive. Conclusion ? There are subgroups with back pain predisposed to development of more persistent symptoms and a higher risk for sick-listing.

The lack of importance of Lanwei point in the diagnosis of acute appendicitis

Fifty patients with a presumptive diagnosis of acute appendicitis based on usual Western medicine criteria (e.g., McBurney point tenderness, increase WBC, history of nausea, etc.) were examined prospectively for tenderness of the Lanwei acupoint, just prior to the administration of general anesthesia, to evaluate this well known ‘Appendix’ point as a useful aid to diagnosing appendicitis. The presence or absence of tenderness was statistically not a good indicator of appendicitis.

Is epigastric tenderness a sign of peptic ulcer disease?

This study was designed to determine whether epigastric tenderness on palpation is indicative of active peptic ulcer disease and to determine whether eliciting tenderness by different examiners is reproducible. Eighty-eight patients (52 males and 36 females) who complained of upper abdominal pain suggestive of peptic ulcer disease were the subjects of this study. Two to 72 h before endoscopy patients were tested for pain reaction to light and deep palpation by two independent examiners unfamiliar with them. There was complete agreement on the presence or absence of tenderness between the two examiners in 74 of 88 patients on superficial and in 75 out of 88 patients on deep palpation. Patients in whom there was disagreement were excluded, and the rest were classified according to whether or not they had tenderness on palpation. On the basis of subsequent endoscopic findings the patients were subdivided into three groups. Group 1: normal (upper abdominal pain but no endoscopic abnormalities), 37 patients; group 2: peptic ulcer disease, 25 patients; group 3: esophagogastroduodenal disease without gastroduodenal ulcer (esophagitis, gastritis, duodenitis, etc.), 26 patients. To determine the value of the clinical sign, sensitivity, specificity, and negative and positive predictibility of epigastric tenderness on light and deep palpation were calculated for each group. It was concluded that the physical sign of epigastric tenderness on light or deep palpation is insensitive, not specific, and has a low predictive value for peptic ulcer disease (group 2) or other esophagogastroduodenal disease (group 3). This sign may also be present in many (70% on deep palpation) individuals who complain of pain and who have no endoscopic or other evidence of organic gastrointestinal disorders (group 1) and therefore probably suffer from functional gastrointestinal disease.

ILEUS.

<h3>Mechanic ileus.</h3> —In the diagnosis of internal strangulation, no matter from what cause, we have exactly the same symptoms as in strangulated hernia, except the physical signs are different. The symptoms of internal strangulation are as follows: Pain in the abdomen which comes on suddenly, gradually increasing in intensity for the first half hour, followed by nausea and vomiting, and inability to produce bowel movement. If the strangulation be severe, there is an increase in the frequency of the pulse (but as a rule in the early stage the pulse is not accelerated),<i>absence of temperature</i>, absence of tenderness. As the case advances, if the strangulated coil be large, it can be recognized through a moderately thin abdominal wall by its distension; the coil of the intestine leading to it may also be recognized by a circumscribed elevation of the abdominal wall. In twenty-four hours all of these symptoms will