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Idiopathic livedo reticularis may be associated with ulcerations of the lower extremities beginning primarily during the warmer or summer months, as well as the more usual occurrence of winter ulcerations. Summer ulceration apparently is a new and rare entity which has many clinical and histopathologic features similar to winter ulcerations. Hypertension, Raynaud's phenomena, acrocyanosis and thrombosis of digital arteries were noted only in patients with winter ulcerations, while edema of the legs and feet was a more prominent feature in patients with summer ulcerations. Medical treatment, including rest in bed, elastic supportive bandages and a trial of hexamethonium (bistrium bromide) injections, seemed to be the treatment of choice. Lumbar sympathectomy did not seem to be of great permanent value.

This study was undertaken to ascertain whether coarctation of the aorta produces permanent hemodynamic abnormalities that may persist despite resection and end-to-end anastomosis. The results of studies in 10 patients 4 to 7 years after operation are compared to those obtained before and immediately after operation. The most significant finding was continued decrease in residual coarctation, in addition to dramatic immediate postoperative improvement in the degree of circulatory impairment.

This study concerns an evaluation of the anatomicopathologic changes found in blood vessels of the skin in areas of venous insufficiency in the lower legs. These changes have been compared with the vascular structure in comparable areas of skin in normal persons. Apparently evidence of arteriolar damage is more a concomitant finding in the clinical picture of chronic venous insufficiency than are venular changes. This is demonstrated in a study of 30 patients. The vascular changes show no correlation with the condition of the skin at the site from which the biopsy material was taken.

Follow-up information has been obtained from 70 women with Raynaud's disease and 54 women with secondary Raynaud's phenomenon who were subjected to surgical sympathetic denervation of one extremity or more. The results of sympathectomy in the upper and lower extremities are described. The effect of operation on the subsequent course, the complications and sequelae are presented and compared with the reports of others.

Bilateral determinations of the blood pressures were made nonsimultaneously and simultaneously by the indirect method under basal conditions on 447 patients. In this group 26.6 per cent of the paired measurements by the nonsimultaneous indirect method exhibited systolic differences of 10 mm. Hg or greater and 15 per cent exhibited diastolic differences of this magnitude, whereas only 5.3 per cent of the measurements by the simultaneous indirect method had systolic differences and only 4 per cent had diastolic differences of this degree. This indicates that bilateral determinations of blood pressure must be performed simultaneously on patients being examined for possible inequalities of blood pressure. Bilateral differences in blood pressure obtained by the simultaneous indirect and simultaneous direct methods in 14 normal subjects and 53 selected patients were compared. In the normal subjects, 3 of the 42 paired indirect measurements and none of the paired direct measurements in either the radial or brachial arteries had systolic differences of 10 mm. Hg or greater, and none of the diastolic differences were of this level. In the 53 selected patients, 10 per cent of the indirect and 6 per cent of the direct measurements of systolic blood pressure differed by 10 mm. Hg or more and 8 per cent of the paired indirect measurements of diastolic blood pressure and less than 1 per cent of the paired direct measurements differed by this amount. These differences in bilateral blood pressures were characterized by their inconstancy and lack of agreement with subsequent measurements when studied by both the indirect and direct methods, which apparently separates them from those due to altered hemodynamics from pathologic conditions of the aortic arch or its tributaries. Bilateral differences of blood pressure are of clinical importance when they are great and are reproducible by the direct as well as by the indirect methods, as illustrated by a patient encountered in this study. In addition, 1 case of extreme obesity and 1 of advanced arteriosclerosis were reported. Both patients were found to have pseudohypertension, which was detected in this study. A slight increase in the incidence of bilateral differences in indirect blood pressures was found in a group of patients whose blood pressures were measured while they were in the supine and then in the sitting position. A slight increase in the incidence of bilateral differences was found at higher levels of blood pressure by comparing the blood pressures of nonhypertensive and hypertensive patients and of hypertensive patients before and during treatment with antihypertensive drugs. Bilateral inequalities of blood pressure did not appear to be related to the age or sex of the subjects. Likewise, differences in circumferences of the arm or right or left-handedness did not appear to influence these inequalities, and there was no marked side dominance for differences found. Bilaterally simultaneous, indirect measurements of blood pressure should be carried out on patients with hypertension who will be treated with antihypertensive drugs. Bilateral direct measurements may be used to verify the existence of inequality of blood pressures detected by the indirect method and to determine the correct pressure to be followed. This is particularly important in patients being screened for pheochromocytomas, since such differences may produce false-positive results.

The diagnosis of Raynaud's disease was suspected in 756 female patients at the Mayo Clinic from 1920 through 1945. The diagnosis was substantiated from the records of the initial examination or from the follow-up data or examination in 474. The clinical characteristics, including diagnostic criteria, clinical course, complications, and sequelae are discussed.

The response of the intra-arterial pressure to the cold immersion stimulus was studied in 42 healthy young adults, continuous direct (arterial-pressure) recording being used. The average systolic elevation was 22.6 mm. Hg and the average diastolic elevation was 16.3 mm. Hg. The difference between direct and indirect methods of measuring blood pressure was studied in 351 simultaneous determinations in 35 of these young adults. The direct systolic pressure averaged 9.7 mm. Hg higher and the diastolic pressure was 7.3 mm. Hg lower than the indirect measurement.

The cold pressor test was performed three times at 15-minute intervals on 65 normotensive subjects and on 60 patients with essential hypertension both before and during treatment with antihypertensive drugs. The arterial pressure was recorded directly from the radial artery. On the basis of differences in the cold pressor response among individuals in the control group, the criteria for normal reaction and for hyperreaction were modified. The cold pressor response in the patients with essential hypertension was markedly depressed by the ganglionic blocking agents, but was not affected by various combinations of hydralazine, protoveratrine and reserpine.

A study of transbrachial digital arteriography led to the development of a technique that includes the use of an intra-arterial vasodilator (tolazoline) measurement of circulation time, direct roentgenographic magnification and serial exposures of long (14 by 35-inch) films in cassettes. This technique permitted study of the fine details of digital arteriograms of 34 patients with clubbing of the fingers or peripheral occlusive arterial disease. The ulnar artery was nonopacified in 13 cases and segmental areas of nonopacification of digital arteries were seen in 17 of the entire group, in many instances in the absence of symptoms of occlusive arterial disease. The technique is recommended for more adequate study of the peripheral microangiopathies.

In cases of aortic coarctation determinations of the wall-to-lumen ratio were made for the arterioles of the thyroid, pancreas, kidney and periadrenal tissue and compared with those for arterioles from the same organs in control cases. As in primary hypertension, there was, on the average, an increase in the wall-to-lumen ratio in each of the regions studied in the cases of coarctation as compared with the same tissues of the control group. This means that for arterioles of the same wall size the lumen was narrower in the cases of coarctation than in the control cases.

Two hundred seventy-one patients with unequivocal systemic scleroderma for whom the diagnosis was first established at the Mayo Clinic between January 1, 1945, and December 31, 1952, have been studied. Follow-up information was obtained 5 to 13 years after the diagnosis at the clinic concerning 236 of these patients, 115 of whom were dead. The cases were analyzed in an effort to determine what factors had a bearing on prognosis. The following seemed to bear little relation to the ultimate prognosis: sex, mode of onset, Raynaud's phenomenon, involvement of lungs and periodontal membrane, calcinosis cutis, and trophic changes. The following were considered poor prognostic omens: cardiac or renal involvement, significant elevation of the erythrocyte sedimentation rate, and anemia. The prognosis in systemic scleroderma was found to be worse than previous reports had indicated. This study yielded no basis for the subdivision of systemic scleroderma into acrosclerosis and generalized progressive scleroderma.

The case history of a patient with apparent spontaneous rupture of the posterior tibial artery is presented, with a brief review of the previously reported cases.