Cramp-like Pain Research Articles

Chronic lower limb ischemia.

Peripheral vascular disease commonly affects the arteries supplying the leg and is mostly caused by atherosclerosis. Restriction of blood flow, due to arterial stenosis or occlusion, often leads patients to complain of muscle pain on walking (intermittent claudication). Any further reduction in blood flow causes ischaemic pain at rest, which affects the foot. Ulceration and gangrene may then supervene and can result in loss of the limb if not treated. The Fontaine score is useful when classifying the severity of ischaemia. #### Fontaine classification of chronic leg ischaemia Stage I Asymptomatic Stage II Intermittent claudication Stage III Ischaemic rest pain Stage IV Ulceration or gangrene, or both Angiogram showing bilateral occlusions of superficial femoral arteries in thighs. Collaterals arising from the profunda femoris artery can functionally bypass this occlusion Although many patients with claudication remain stable, about 150–200 per million of the population progress to critical limb ischaemia (Fontaine III or IV) each year. Many patients with critical limb ischaemia can undergo revascularisation, which has a reasonable chance of saving the limb. A recent audit by the Vascular Surgical Society found a success rate of over 70% for these patients. However, many patients still require major amputation. Rehabilitation of elderly patients after amputation can prove difficult, with high community costs. Critical limb ischaemia has been estimated to cost over £200m a year in the United Kingdom. ### History and examination A history of muscular, cramp-like pain on walking that is rapidly relieved by resting, together with absent pulses, strongly supports the diagnosis of intermittent claudication. Disease of the superficial femoral artery in the thigh results in absent popliteal and foot pulses and often causes calf claudication. Disease of the aorta or iliac artery results in a weak or absent femoral pulse, often associated with a femoral bruit. Disease at this level may cause calf, thigh, or buttock claudication. Method of palpating …

Giant Lipoma of the Hand.

A 70-year-old man was referred by his GP to the hand surgery clinic with an enlarging swelling in the thenar eminence of his left hand. He first noticed this swelling 18 months previously. There was no preceding trauma. He noticed that the size of the swelling was increasing gradually and felt a constant cramp-like pain in his hand with intermittent parasthesia on the ulnar side of the thumb. Examination revealed a soft, nonfluctuant, nontender swelling in the bulk of the thenar eminence with indistinct margins. There was no objective neurological deficit. Plain X-rays showed a radiolucency in the first web space (Figs. 1 and 2). MRI scan showed a mass which gave a signal similar to fat and was well encapsulated, passing behind the flexor tendons in the palm. The high-signal T1 and T2 images were interpreted as typical of lipoma (Figs. 3 and 4). In view of the increase in size of the swelling and the discomfort, marginal excision was done. The mass extended deep into the carpal tunnel and was intimately attached to the lumbrical of the long flexor tendon to the index finger. The common digital nerve to the first web space was stretched over the lump and was dissected free. The lipoma extended underneath the flexor tendons and seemed to have a pedicle arising from the synovium around the deep flexor tendons. The lipoma was 8 cm 5 cm in size. The patient made an uneventful recovery and his symptoms of pain and parasthesia settled within 2 weeks. Histological examination demonstrated a large benign lipoma.

Surgical reduction of bilateral hypertrophy of the masseter muscles

A prominence and thickening of the masseter muscles was first noticed at the age of 13. The unerupted lower third molars were removed at the age of 16. The masseters became progressively more pronounced as time went on and as she grew older the patient became more self-conscious of her appearance. When nearly 21 she began to have cramp-like pains in both muscles, which prompted her to ask if anything could be done to alleviate the condition and improve her appearance. Only then was reduction of both muscles by Obwegeser's intra-oral approach recommended (Figs. I and 2).

Roentgenologic study of Meckel's diverticulum; case report.

The preoperative diagnosis of Meckel's diverticulum is unusual. Pfahler described two cases diagnosed roentgenologically in 1934, and since that time cases have been recorded by Ehrenpreis (1939), Skinner and Walters (1939), Rousseau and Martin, who collected 12 cases beside their own (1943), Hallendorf and Lovelace (1947), Grossman, Fishback, and Lovelace (1950), Elias and Ladin (1950), and Raffensperger and Markunas (1950). The following case is of interest not only because the diagnosis was made prior to operation but because of the detailed fluoroscopic observations, a feature which has been neglected by most writers. Case Report B. S., a woman of 35, had come to the United States in February 1949. Her husband and child had been killed during the war, and she had spent four years in a concentration camp. Her father and mother had died before she reached the age of ten. One sister was living, in a mental institution, As a child, the patient had measles, scarlet fever, and chickenpox. She was hospitalized for a few days in 1935 because of an abscess under the left arm, and in 1936 she had a so-called gallbladder attack, treated at home. For the past three years she had experienced gastric distress coming on one or two hours after meals and not relieved by alkalis. She complained also of a sense of fullness in the lower abdomen and of cramp-like pains occurring sometimes in the right upper quadrant, at times in the right lower quadrant, and again crossing the midline. Laboratory investigations, including a blood count, urinalysis, a Wassermann test, and blood chemistry determinations, were reported as normal. The physical examination was non-contributory. The blood pressure was 108/70. A chest film showed fibrotic lesions in both pulmonary apices, which remained unchanged over a period of three years. A gallbladder examination carried out on March 30, 1951, because of right quadrant pain, showed nothing of significance. Some relief was afforded by dietary measures and antispasmodics. Because of recurrence of pain, a gastrointestinal study was undertaken Nov. 1, 1951. On the four-and six-hour films (Fig. 1) a collection of air was demonstrable within a diverticulum arising from the distal ileum and located within the right upper quadrant. Its location and its relation to the distal ileum were suggestive of a Meckel's diverticulum. The remainder of the digestive tract was normal. Re-examination was done on Nov. 5. Repeated fluoroscopic observations of the small bowel were carried out and finally the diverticulum was again visualized, not in its earlier location but in the pelvis, crossing the mid-line toward the left. It no longer appeared as an air-containing sac but was filled with barium (Fig. 2). Peristalsis altered the outline (Fig. 3) changing the configuration and affecting the base but not the neck. The peristaltic action did not completely empty the diverticular contents during the period of fluoroscopic observation.

Reduction of ileocecal intussusception by hydrostatic pressure.

Intussusception is the prolapse or invagination of one part of the intestine into an immediately adjoining segment; it occurs most frequently during infancy and early childhood. When the intussusception persists, it produces characteristic clinical signs and symptoms. In the individual case, vomiting, severe intermittent cramp-like abdominal pain, melena, and a palpable sausage-shaped mass within the abdominal cavity may be present. Surgical reduction has long been the treatment of choice in this country. Ravitch (1, 2), a surgeon, has reported successful reduction of ileocecal intussusception by barium enema in selected cases. This simple, safe hydrostatic procedure merits thorough clinical trial. During the past two years the barium enema has been used routinely at the Children's Hospital of Pittsburgh in the treatment of ileocecal intussusception. This paper describes the details of administration of the enema, discusses criteria for completeness of reduction, and offers suggestions concerning the role...

OBSTRUCTION OF THE SMALL INTESTINE BY CORPUS LUTEUM CYST

The preoperative diagnosis of the cause of obstruction of the small intestine is often difficult. The following case illustrates an apparently unique cause of this condition. REPORT OF CASE A 46-year-old white woman admitted to New York Hospital in April, 1952, had had increasing cramp-like abdominal pain, nausea, vomiting, abdominal distention, and constipation for four days. The patient had undergone elsewhere the following seven major operations: in January, 1931, appendectomy and suspension of uterus; in January, 1934, bilateral salpingectomy and right oophorectomy; in August, 1937, incision and drainage of left kidney; in January, 1940, amputation of cervix and suspension of bladder; in March, 1949, subtotal gastric resection and cholecystectomy; in February, 1950, hysterectomy; and in April, 1951, left oophorectomy. Following the last operation, the patient had episodes of cramp-like abdominal pain, usually occurring once or twice a month and subsiding within 24 hours. There had been no diarrhea, bloody or

Intestinal Obstruction Caused by an Unusual Foreign Body

Case Report. J. L., a forty-two year old unmarried white male was admitted June 22, 1948 complaining of abdominal pain and vomiting. He had been well until six hours prior to admission when, while working at a power press, he was suddenly seized with severe intermittent cramp-like abdominal pain, worse in the right lower quadrant, and the vomiting of clear yellow fluid. Upon admission his rectal temperature was 101.8°F; pulse 115 per minute, regular; respirations 22 per minute. He was markedly dehydrated and in severe pain. The abdomen was slightly distended and tender throughout, with muscle spasm in the lower half. The maximum tenderness was in the right lower quadrant. The blood and urine were normal. A tentative diagnosis was made of acute appendicitis and the patient was operated on. The appendix was slightly reddened and swollen, but did not appear to be the cause of the patient's trouble. The gallbladder, gastroduodenal and colonic regions seemed to be normal. Several inches of terminal ileum were reddened, swollen and edematous with moderate thickening of the intestinal wall. While palpating this area of intestine there was noted a small localized distended area of terminal ileum which could not be propelled toward the cecum. This was interpreted as being a small loculation of air and intestinal fluid entrapped in the lumen. There was no dilated intestine proximally, nor was there collapsed intestine distally, and a diagnosis of intestinal obstruction was therefore not considered. The assumption was that we were dealing with a mild case of regional ileitis with a good chance for resolution. An appendectomy was done and the abdomen closed. The postoperative course was consistent with regional ileitis. Distention, pain, and vomiting were present, requiring the use of Wangensteen suction. The temperature gradually rose each evening to reach a maximum of 105°F on the fourth postoperative day. On the sixth postoperative day the patient passed many copious brown liquid stools. The abdomen receded somewhat and the patient felt better. However, this condition of marked relief from the obstruction did not last very long, and the patient was again troubled with distention, and intervals of frequent liquid brown stools. Even though it was possible to remove the Miller-Abbott tube ten

The role of the sympathetic nervous system in acutepoliomyelitis: Preliminary report

Summary We have presented clinical evidence showing that sympathetic nervous system involvement in acute poliomyelitis may manifest itself in the cervical region by Horner's Syndrome, in the thoracic region by spasm of the pulmonary blood vessels with dilatation and irregularity of the right side of the heart, in the gastric region by pylorospasm, in the intestinal region by constipation or diarrhea, in the rectal region by intestinal obstruction, in the bladder region by retention or incontinence of urine and in the skin by angioparesis or spasm. Presumptive evidence has been presented to show that the blood vessels in the chronic poliomyelitic extremity behave and respond similar to the angiospasm of Raynaud's disease or the cramplike pain in intermittent peripheral arterial claudication. Conclusive evidence that the blood vessels were in spasm was found inthe twelve patients tested with the oscillometer. The actual excursions were far below the normal. We have also shown that angiospasm was present in the encephalitic, paralytic, and in the nonparalytic extremity of acute poliomyelitis. Pathologic evidence to substantiate the clinical findings was presented by showing involvement of the lateral horn as well as of the sympathetic ganglia. We have demonstrated that short wave diathermy with the rhythmic constrictor dilated the blood vessels and increased the blood supply to the extremity. The muscles relaxed and the pain diminished or subsided only to return when the blood vessels contracted. However, we feel that neither short wave diathermy nor hot packs are the solution for the relief of the muscle spasm and pain in acute poliomyelitis, since these methods do not produce sustained vasodilatation. The method of choice would be a drug that could be administered by mouth, subcutaneously, or by the intravenous route. We fully understand that the subject matter in this paper is debatable.We hope, however, that it will provoke others to investigate further the role of the sympathetic nervous system in acute poliomyelitis, and that it will eventually lead to a better understanding of the clinical picture of the disease and hence to a more scientific therapeutic approach.

An unusual case of quinine idiosyncrasy

A case of quinine idiosyncrasy is reported. The skin reaction to local application of quinine was positive. The main symptoms were: rigor, hyperpyrexia, diarrhoea, cramplike pains in the abdomen, vomiting and headache. The similarity of the rigor to an attack of malaria is stressed.

Roentgen Evidence Suggesting Enterocolitis Associated with Prolonged Cathartic Abuse

The following case is reported because of the extensive changes in the lower part of the small bowel and throughout the large bowel observed in routine gastrointestinal studies. As far as can be determined, the etiological factor was the continued and abundant daily use of irritant cathartics for twenty years prior to the roentgenological examinations. A search of the literature has failed to reveal any other case presenting similar changes, although reference is made to catarrhal colitis resulting from overdosage or continued cathartic abuse from irritants (1, 2). Case Report The patient was a multiparous white female, thirty-six years of age, who for many years had complained of bloating and a feeling of general fullness in the abdomen. She believed that she could not be comfortable without complete evacuation every day. To insure this she had taken proprietary cathartic tablets, the active ingredients of which are phenolphthalein, aloin, and podophyllum, almost daily for the preceding twenty years, i.e., from the age of sixteen until December 1940. This resulted in from two to three watery stools daily, generally in quick succession, producing a feeling of well-being in the abdomen and a sense of complete emptying of the bowels. There had never been involuntary diarrhea. The stools contained mucus at times, but pus and blood were never observed. Unless cathartics were taken the patient experienced constipation, and she never allowed herself to go without an evacuation for more than forty-eight hours without resorting to their use. In July 1932, the patient had an attack of cramp-like pain in the right lower quadrant lasting for several days, which her attending physician thought was possibly due to appendicitis. An abdominal exploration revealed thickening of the terminal ileum and cecum up to the junction of the cecum and ascending colon. Here a constricting band was found, which was separated. The appendix was removed and microscopic examination showed subacute appendicitis. There was no evidence of specific or non-specific granuloma. No biopsy specimen was taken from the thickened bowel but the surgeon and those who subsequently observed the case felt that a hyperplastic tuberculous process was probably present. During the entire twenty-year period there had been no persistent loss of weight, and the patient's general health and nutrition had been relatively good. Her general complaints did not vary to any extent. Because of fear that there might be some organic basis for them, a gastro-intestinal study was made on Nov. 18, 1938. The findings in the upper tract were fairly normal as far as the lower jejunum. The upper jejunum showed slight dilatation (Fig. 1). There was delay in passage of contents through the lower ileum, as it took five hours and a half for the head of the test meal to reach the cecum. The appearance of the terminal ileum and large bowel at seven hours is shown in Figure 2.

INTERMITTENT LIMPING-INTERMITTENT CLAUDICATION; THEIR DIFFERENTIAL DIAGNOSIS

Article1 June 1941INTERMITTENT LIMPING-INTERMITTENT CLAUDICATION; THEIR DIFFERENTIAL DIAGNOSISISIDOR MUFSON, M.D.ISIDOR MUFSON, M.D.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-14-12-2240 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptThe symptom "intermittent limping" has become so associated with intermittent claudication that clinically, to many, the terms have become almost synonymous. The term "intermittent limping" describes a sequence of events in which the patient finds repeatedly that, after walking a few blocks, he must come to a complete halt because of a cramp-like pain or sense of exhaustion in one or both legs. The first physician consulted usually refers the patient complaining chiefly of this symptom to a colleague particularly interested in peripheral vascular diseases. However, the complaint is frequently due to non-vascular causes.An analysis of all such cases... This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Bronx, New York*Received for publication September 4, 1940.From the Department of Medicine, College of Physicians and Surgeons, Columbia University and the Presbyterian Hospital. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byDescription and Pathogenesis of Symptoms and Signs of Arterial Insufficiency 1 June 1941Volume 14, Issue 12Page: 2240-2245KeywordsHospital medicinePeripheral vascular diseaseSurgeonsWalking ePublished: 1 December 2008 Issue Published: 1 June 1941 PDF downloadLoading ...

Abdominal pregnancy near term, operation and hormonal studies of the blood and urine with the placenta left in situ

T HE patient, who was thirty-four years of age and of Italian extraction, was admitted to the Norwegian Hospital on Nov. 18, 1935. Her physician had advised hospital care because of the severity of nausea, vomiting, constipation, and painfulness of fetal movements. Her past history aside from her menstrual, marital, and obstetric history was irrelevant. Her menses began at thirteen, occurred regularly at twenty-eight-day intervals and were of four-days duration, being associated with moderate dysmenorrhea. She had first married in 1919 and two pregnancies occurring shortly thereafter were terminated by induced abortions at three months and apparently were not followed by sepsis. After living with this husband for two years she divorced him and remarried in 1924. She did not conceive again until 1929 at which time a left salpingectomy was performed for a ruptured ectopic gestation. There were no pregnancies from then on until the one under consideration. The last menstrual period began on March 15, 1935 at the expected date and was normal in all respects. About four weeks later she began to spot and experienced cramplike pain such as she would have during her periods. This spotting and pain continued for the next two weeks, the bleeding on one occasion amounting to a definite flow for several hours. There was no further bleeding during the remainder of the pregnancy. Pain along the entire right side of the abdomen and chest was present at intervals associated with attacks of weakness. The pain was often relieved by enemas. Nausea and vomiting were a prominent symptom throughout, the patient losing eighteen pounds in weight. Constipation was a persistent symptom also. In the last trimester the fetal movements caused the patient great distress in the upper abdomen. I first saw her in consultation on November 27, three and one-half weeks prior to her estimated date of confinement. The patient was found to be a poorly nourished individual with a diminished hemic component, who did not appear well. Her temperature was 98.2” F., pulse 85, respirations 20, and blood pressure 116/76. Physical examination revealed no abnormalities aside from evidences of weight loss, the breast signs of pregnancy and the abdominal findings. The abdomen was greatly enlarged as though by a twin pregnancy. What first appeared to be the fundus uteri was found to be 27 cm. above the symphysis, and there seemed to be a marked widening of the upper portion of the abdomen. Palpation revealed, however, that the child was in the upper abdomen lying transversely with the head on the left side just beneath the co&al margin. The fetal parts were unduly prominent. The right lower quadrant of the abdomen was occupied by a semisolid fixed mass with a rounded upper edge which extended upward to slightly above the umbilicus and appeared to arise from the pelvis. This mass seemed to fuse with another mass which was also present in the lower abdomen to the left of the first mass extending over into but not completely filling the left lower quadrant and rising to the level of the umbilicus. The fetal heart was heard in the upper left quadrant. On vaginal examination the cervix was found high up

Unruptured interstitial pregnancy

I NTERSTITIAL pregnancy is sufficiently rare to merit the report of the following case. Mrs. F., aged twenty-eight years, was first seen in the office, Dec. 24, 1935. The chief complaints were: intermittent attacks of profuse vaginal bleeding since November 2 and cramplike pain in the left lower abdomen. The patient had been married three years and had practiced birth control until September, 1935. At this time she wished to become pregnant. Her menstrual periods had always been very irregular, occurring from sixty to ninety days apart, and for the first two days of each period she had been confined in bed with severe abdominal cramps. The last menstrual period was September 1. The surgical and venereal histories were negative. Five years ago she had an attack of nephritis.

Pathological Rarities in Cancer

AS OUR contribution to this symposium, we wish to put on record two unusual cases which have recently come to autopsy. In both instances, only the postmortem examination supplied the correct diagnosis. Gelatinous Carcinoma of the Duodenum Case 1. The patient, K. U., a colored female, 59 years ol age, was sent to us from another hospital on Jan. 21, 1935, with a clinical diagnosis of carcinoma of the stomach with liver metastases. In August, 1934, she had begun to experience cramp-like pains following meals, attended by nausea, a feeling of fullness, belching, and occasional vomiting of undigested food. Symptomatic treatment relieved her until October, 1934, at which time all her symptoms returned with an additional feeling of substernal pressure after eating. She complained of all these things on admission to our hospital, as well as a loss of 50 pounds in the previous five months. She had never vomited “coffee-ground” material. There was no jaundice, nor did she have unnatural stools. On physical examina...

Carcinoma of the Stomach in a Girl 21 Years of Age

The patient, M. M., aged 21 years, first consulted her physician in April, 1933, for a stomach upset with vomiting, which she ascribed to something she had eaten. He found nothing unusual on physical examination and gave her cerium oxalate and antacid, asking her to return for further examination. She called him a few days later saying that she was completely recovered. On Oct. 25, 1933, she called her physician again, complaining of continuous vomiting which she had had for one week, at times containing food she had eaten two days before, and also gas and cramplike pains in the upper abdomen. Her past history showed that she had always had stomach trouble and she was described as “picking” at her food rather than eating it. Her mother had died of a probable cancer of the stomach; the remainder of the family were alive and well. Physically, she was a small, thin girl, somewhat undernourished, with a dry tongue. On palpation, there was found a tender mass in the epigastrium in about the position of the stomach, the size being reduced by gastric lavage, and a large amount of undigested food and fluid was obtained. An x-ray examination the following morning showed the stomach to fill with poor tone and without any waves being seen. The meal stayed entirely on the left side of the abdomen, with a sharp tapered end in place of the usual antral shadow. Pressure on the media, in the manner used to fill the cap, caused a small amount of barium to shoot through a narrow canal and then outline the sphincter and duodenal cap. None of the barium remained in the canal. A mass was then palpated in the filling defect, which was movable and moved with the stomach (Figs. 1 and 2). At six hours, there was a large residue with similar findings (Fig. 3). At 24 hours, there was still a residue but the patient had vomited. The patient was operated upon on October 29. A large infiltrating mass was found to occupy the lower third of the stomach, particularly the greater curvature. A partial gastric resection with closure of the duodenum and posterior gastro-enterostomy was done. A transfusion was given and the patient was returned to her bed with a permanent venoclysis running into the leg. The post-operative course was uneventful until the fourth day, when a phlebitis appeared at the site of the venoclysis. The cannula was removed and the patient began to take fluids by mouth. Early in the morning of the eighth day, she was seized with a sudden sharp pain in the lower left chest, made a violent outcry, and sat up, becoming pulseless, cyanosed, cold, and clammy for an hour. On recovery, she complained of crampy pain in the lower abdomen, and an x-ray of the chest and abdomen showed some hazing in the lower left lung, with air beneath the left diaphragm. There was no evidence of infarct.

Neurogenic appendicitis: A study of 195 cases of appendicular neuromas

1. 1. This study is based on 344 consecutive vermiform appendices removed at operations, showing no gross or microscopic evidences of acute or chronic inflammation. Forty-eight per cent of all appendices had a partially or completely obliterated lumen. 2. 2. There were 195 cases or 56.7 per cent of axial neuromas, proved microscopically. In a few instances, the neuroma produced a clubbing of the tip of the appendix. After proper fixation and staining by the Masson method, 69.2 per cent of these neuromas were found to occur in obliterated appendices and 30.8 per cent in non-obliterated ones. The incidence of neuromas for all obliterated appendices would then be 82 per cent. 3. 3. Age appears to have no etiologic importance. The youngest patient was eight years old and the oldest seventy-nine years. The largest number of neuroma cases occurred between the ages of twenty-one and fifty, which was also the age incidence for all appendectomies. 4. 4. No definite conclusions can be drawn as regards the importance of sex from this series of cases. 5. 5. All gradations from severe cramp-like pains to mere discomfort were present in the different cases. In 8.2 per cent, the pains were cramp-like and agonizingly severe. In 19 per cent, the pains were still acute not so extreme. In 7.7 per cent, there was definite pain but not acute. In 10.3 per cent, there was a complaint of dull ache in the right lower quadrant. Three and one tenth per cent complained only of a discomfort in the right lower abdomen or epigastric distress. 6. 6. These pains may start as a generalized abdominal condition or in the epigastrium or in the umbilical region, later shifting to the right lower quadrant. Or, it may start in the right lower quadrant from the very beginning and radiate to the epigastrium, umbilical region or even to the back. 7. 7. The acute pains were as a rule momentary or intermittent, to be replaced later by a dull ache. The milder symptoms of distress or discomfort or ache were either constant, intermittent or periodic. 8. 8. Nausea alone was present in 12.8 per cent, vomiting alone in 2.6 per cent, both in 10.8 per cent; or a total of 26.2 per cent where either one or both were present. The nausea may be mild or considerable; the vomiting varied in number from one to many. 9. 9. Tenderness, usually in the right lower quadrant, was elicited in 39 per cent and varied from slight to considerable. There was marked tenderness in 9.2 per cent. There was definite rebound tenderness in 3 cases and positive psoas test in 2 cases. 10. 10. Fourteen and nine-tenth per cent showed right rectus rigidity. It was slight in 9 cases, moderate in 9 and marked in 11. 11. 11. The temperature was normal in the great majority of cases (93 per cent). 12. 12. The pulse was normal in 50 per cent of the cases, 61 to 90 per minute in 27 per cent, and 91 to 100 per minute in 23 per cent. 13. 13. The respiration was normal in over 77 per cent of the neuroma cases, 21 to 24 per minute in 22 per cent. 14. 14. The white blood and differential counts tended to be within normal limits. This and the normal temperature are important points in the differential diagnosis of non-suppurative (neurogenic) from suppurative appendicitis. 15. 15. Constipation of varying degrees was present in 18.5 per cent. In a few cases, there was diarrhea which may alternate with constipation. 16. 16. Before an appendix is pronounced microscopically negative for neuroma or neuromatosis, the Masson trichrome stain should be used.

A Case of Leiomyosarcoma of the Cecum

F. M., a male bookkeeper, aged nineteen, was admitted March 24, 1931. His family history was negative for cancer. At the age of six years he had had scarlet fever and bilateral mastoiditis. The present illness had begun one month previously with severe cramp-like abdominal pain, nausea, and vomiting, which were relieved to some extent by a laxative. During the previous twelve days he had had many such attacks. They were not relieved by calomel, although its administration had resulted in bowel movements. The pain was localized in the left side of the abdomen. There had been no loss of weight. Physical examination revealed a palpable tumor in the left lumbar region, the size and shape of a kidney, slightly tender, and freely movable. There were a moderate leukocytosis and a low septic temperature. Exploratory laparotomy revealed a tumor at the ileo-cecal junction, about 6 cm. in diameter and almost blocking the lumen of the bowel. There was intussusception of the distal portion of the ileum, the cecum, and the ascending colon into the transverse colon. The cecum was resected, and the ascending colon and ileum anastomosed end-to-side. There were no postoperative complications.

A Case of Thallium Poisoning Following the Prolonged Use of a Depilatory Cream

The Journalrecently published an article 1 bringing to the attention of the medical profession the sale of a depilatory cream which was found to be particularly high in thallium acetate content. This article led to the correct diagnosis in the following case: REPORT OF CASE A white woman, aged 24, came to the Cleveland Clinic complaining of severe pain over the soles of both feet and ankles, weakness of both feet and legs, and intense burning of both feet, most marked in the third, fourth and fifth toes. She had been receiving treatment elsewhere for arthritis of both feet and ankles. Four and one-half months prior to entering the clinic, the patient had first noticed intermittent epigastric pains which gradually increased in severity to sharp, cramplike pains throughout the entire abdomen. These pains were associated with nausea, several attacks of vomiting, loss of appetite and substernal pain, but were unrelated

A CASE OF THALLIUM POISONING FOLLOWING THE PROLONGED USE OF A DEPILATORY CREAM

The Journalrecently published an article 1 bringing to the attention of the medical profession the sale of a depilatory cream which was found to be particularly high in thallium acetate content. This article led to the correct diagnosis in the following case: REPORT OF CASE A white woman, aged 24, came to the Cleveland Clinic complaining of severe pain over the soles of both feet and ankles, weakness of both feet and legs, and intense burning of both feet, most marked in the third, fourth and fifth toes. She had been receiving treatment elsewhere for arthritis of both feet and ankles. Four and one-half months prior to entering the clinic, the patient had first noticed intermittent epigastric pains which gradually increased in severity to sharp, cramplike pains throughout the entire abdomen. These pains were associated with nausea, several attacks of vomiting, loss of appetite and substernal pain, but were unrelated

TORSION OF GREAT OMENTUM

F. L. B., a farmer, aged 38, American, single, 5 feet 6 inches (167.6 cm.) tall, weighing 135 pounds (61 Kg.), entered St. Clare Hospital, June 1, 1930, complaining of cramplike pain in the abdomen beginning the day before. His health had always been good. He had measles at the age of 10, and in 1913 fractured the right tibia. This was repaired with a silver plate, which was still in place. He never drank, he smoked moderately, he had always lived in Montana and he never had gonorrhea or syphilis. The day before admission he arose feeling fine, had breakfast, finished milking, and went to the granary for a sack of chicken feed weighing 100 pounds. He had the sack on his right shoulder, when a cramp began in his abdomen causing him to sit down. This pain settled gradually to his right side, continuing all next day. It