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For the last fifteen years a group at the Mayo Clinic have been interested in the difficult problem of diffuse arterial disease with hypertension. Periodically an unusual case of this disease is encountered which upsets prevailing ideas and compels an alteration of views with regard to the general problem. In this paper we wish to describe and discuss 2 such cases. They are undoubtedly extreme examples, but they present interesting features that are not altogether typical and accentuate important points which may add to the knowledge of the group of more general examples. The patients were both physicians in the prime of life, and diffuse arterial disease was the cause of death in both cases. The clinical course and the retinal and pathologic data will be stressed in this report.Case 1.—On May 15, 1936, the first patient, a physician 46 years of age, came to the clinic complaining of

DURING the past century the clinical identities of rheumatic fever and the frequently encountered progressive form of articular rheumatism which is now designated "rheumatoid arthritis" have been established with a fair degree of certainty. However, the etiologic agents responsible for these two diseases remain unknown, and no specific tests have been devised to distinguish them.In classic instances, the clinical and pathologic manifestations of the two diseases are strikingly different. Rheumatoid arthritis in its usual form is characterized by the progressive and chronic character of its articular lesions. Joints are visibly damaged in the early stages, and this damage is apt to increase with the passage of time. From a clinical point of view, the heart usually seems to be spared. Articular inflammation of patients with rheumatic fever, on the contrary, is fleeting and migratory. After acute attacks, joints appear normal. Cardiac complications are regularly encountered in rheumatic fever and

SYSTEMIC involvement of lymphoid tissue is a well-recognized feature of rheumatoid arthritis.1 Among patients with rheumatoid arthritis, 50 to 75% may be found to have palpable lymph nodes.2 These nodes usually are painless, nontender, discrete, and movable under the skin. They may vary from small pea-sized structures to sizable lymph nodes (up to 3 cm.) which immediately attract clinical attention. They may be at the usual sites of clinically discernible lymph node enlargement, such as in the axillary, epitrochlear, cervical, and inguinal areas. Some patients, however, show enlarged lymph nodes at unusual sites, such as along the course of vascular channels of mid-arm or mid-thigh.3 It is now generally believed4 that the lymph node involvement represents participation of the lymphatic apparatus in the systemic disease, which rheumatoid arthritis is believed to be, rather than regional lymphadenopathy secondary to drainage from diseased joints. This belief is further strengthened by the finding

We wish to describe an unusual, oft recurring disease of joints and adjacent tissues, 34 cases of which have been studied in the arthritis service of the Mayo Clinic since 1928. Its outstanding features are multiple afebrile attacks of acute arthritis and periarthritis, and sometimes also of para-arthritis, with pain, swelling, redness and disability generally of only one, but sometimes of more than one, small or large joint, in an adult of either sex. The attacks appear suddenly and develop rapidly. They generally last only a few hours or days and then disappear completely, but they recur repeatedly at short or long, irregularly spaced intervals. Despite the frequent recurrences and the transitory presence (in some cases at least) of an acute or subacute inflammatory polymorphonuclear exudate in the articular tissues and cavity, little or no constitutional reaction or abnormality is revealed by laboratory tests, and no significant functional, pathologic or

In 1931 a bulletin was published under the auspices of the California Department of Public Health in which the subject of infection with the fungus Coccidioides immitis was reviewed.1 This bulletin was documented with 172 references and indicated that 286 instances of the disease among human beings had been observed up to that time. By 1938 Dickson and Gifford2 reported that 495 instances of the disease had been observed in California alone and that the disease had caused 249 deaths. Up to the time of writing (April 1941), 19 additional reports concerning this disease have been listed in the Quarterly Cumulative Index Medicus.Despite this large number of reported cases of coccidioidomycosis and the extensive literature concerning it, only 3 instances of the disease have been recognized at the Mayo Clinic. In the first case, reported by Foley, Love, Broders and Heilman,3 the patient had coccidioidal osteomyelitis

Opinions as to the presence and nature of cardiac lesions associated with chronic infectious (rheumatoid) arthritis have been varied. Fuller1 and Garrod2 have stated that, as a rule, the heart is not injured in rheumatoid arthritis. Fuller stated that he had never seen a case in which he could attribute pericarditis or endocarditis to rheumatoid arthritis. Garrod observed that if patients with rheumatoid arthritis have valvular insufficiency, one can assume a previous attack of rheumatic fever has been the cause of the lesion.Strümpell3 and Pribram4 stated that in rheumatoid arthritis of slow, insidious onset cardiac involvement does not occur, but when the disease is ushered in by an acute febrile attack of arthritis the heart is often implicated.Barjon,5 on the other hand, estimated that the number of cardiac complications is just as high in the cases of rheumatoid arthritis with chronic onset as

As a result of the original concepts of Volhard and Fahr,1 a malignant (bösartig) form of hypertension was separated from the general group in 1914. In 1924, however, Wagener and Keith2 described a syndrome of malignant hypertension and showed that this condition deserves the distinction of an entity, differing from chronic glomerulitis and benign hypertension on the basis of age incidence, a characteristic retinal picture, absence of anemia and frequent persistence of adequate renal function. This clinical concept of Wagener and Keith was further developed in investigations at the Mayo Clinic, the results of which were published in 1927,3 1928,4 1929,5 and 1931,6 and various pathologic studies of this disease have been reported from this institution by Cain,7 Morlock8 and Odel.9 None of these works included any comprehensive data regarding the brain. The purpose of the present study has been to survey the brain in cases of malignant hypertension, to