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Excerpt Six years have elapsed since the first report on the clinical use of dicumarol.1Since that time there have been a number of clinical reports by ourselves and others. The literature has been...

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.

We have reported a series of thirteen cases of peripheral vascular disease affecting chiefly the legs and feet which seems to us to be best classified under the term “livedo reticularis,” as described in the literature. The clinical manifestations differ distinctly from those of Raynaud's disease, acrocyanosis, and thromboangiitis obliterans. These patients did not have evidence of tuberculosis or syphilis, and the circulatory disturbance developed during adult life. The etiology in our cases is not known. The available data in our cases and others indicate that in livedo reticularis there are usually organic changes in the arterioles of the skin, with chronic vasospasm, which result in regional atony and dilatation of capillaries and slowing of the blood flow. The condition may be complicated by ulceration of the legs and superficial gangrene of the toes. Lumbar sympathetic ganglionectomy resulted in definite improvement in circulation and prevention of further attacks of gangrene in two of our cases and was unsuccessful in one case. It is our opinion that sympathectomy is a justifiable procedure in cases of livedo reticularis in which (1) no definite etiological factor can be found, and (2) superficial gangrene is present.

The majority of individuals with essential hypertension and some with usually normal blood pressure manifest unusual lability and marked reactions of blood pressure to various internal and external stimuli. This suggests that the mechanism for regulating blood pressure which is possessed by these individuals is hyperreactive. The cold-pressor test is a satisfactory method of determining the reactivity of the blood pressure. The test consists in measuring the reaction of the blood pressure to a standard cold stimulus. 1 In this paper the expression, "person with usually normal blood pressure," will appear frequently. It means a person who does not have persistent hypertension, one whose blood pressure remains within normal limits unless caused to rise by a stimulus. Later in this paper such persons will be divided into the classes called "normal hyporeactors" and "normal hyperreactor."

Dicumarol is a potent and valuable anticoagulant drug. When used properly it appears to prevent intravascular thrombosis in almost all patients. There is considerable and unpredictable variation in sensitivity to dicumarol among different patients. Dosage of dicumarol must be guided by the effect produced in each patient as indicated by the degree and duration of prothrombin deficiency which develops and is indicated by determinations of the concentration of prothrombin in the blood. It is unwise to use dicumarol unless adequate facilities for determining the prothrombin time are available. If the prothrombin is kept between 10 and 30 per cent of normal by administration of dicumarol, thrombosis will almost certainly be prevented and serious bleeding is very unlikely to occur. The action of dicumarol is delayed. When a rapid anticoagulant effect is desired concurrent heparinization is necessary for the first few days. We have found that dicumarol has prevented fatal pulmonary embolism and recurrence or extension of venous thrombosis in patients who have had postoperative nonfatal pulmonary embolism or thrombophlebitis. There is some incomplete evidence to the effect that it will prevent peripheral thrombosis, pulmonary embolism and further coronary thrombosis in patients who have had acute myocardial infarction. Dicumarol with preliminary heparinization is valuable in the treatment of acute arterial occlusion of the extremities. It has also been used safely in patients in whom thrombophlebitis and pulmonary embolism complicated the puerperium and various diseases, in patients with idiopathic recurrent thrombophlebitis and in those with chronic occlusive arterial disease. While statistical confirmation is lacking, it is our impression that in many of these patients thrombosis and embolism have been prevented by administration of dicumarol.

In a previous paper 1 we reported some of the physiologic effects on the circulation of extensive splanchnic sympathectomy and postural change in cases of essential hypertension. The studies to be reported in this paper were made on the same ten patients (Cases 1 to 10). In general, the same air-conditioned room and basic procedure, including the same dates of study, were employed in both instances. This part of the investigation was concerned with modifications of blood pressure and pulse rate by (1) a tight abdominal binder, (2) bilaterally inflated cuffs around the thighs, (3) an abdominal binder plus cuffs around the thighs, (4) exercise of the legs, and (5) the administration of paredrinol sulfate. The blood-pressure-raising effects of some of these agents were compared to similar effects of the cold-pressor test. Controlled observations preceded each of the investigations. Each study was done before and after extensive sympathectomy, and, in most instances, while the patients were in the horizontal and in the 60-degree head-up postures.

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.

Ever since Oliver and Schafer 1 (1895) discovered that epinephrine has a pressor effect, the possibility that it may be a factor in hypertension has been considered. Many have tried to prove that the vasomotor mechanism in patients with hypertension is abnormally sensitive to epinephrine, or that excessive amounts of epinephrine are present in the blood of these patients. New evidence in support of the latter possibility has recently been brought forward by Kure, Nakaya, Murakami, and Okinaka, 2 who maintain that atropine has a beneficial effect in hypertension. Hetenyi and Sumegi 3 and Hess 4 have presented experimental evidence that the vasomotor mechanism in patients with hypertension is abnormally sensitive to epinephrine, but their results were not corroborated by Kylin, 5 Deicke and Hulse, 6 Jansen, 7 Gordon and Levitt, 8 and Pickering and Kissin. 9 The observations of previous investigators were made following rather rapid intramuscular or intravenous injection of relatively small doses of epinephrine. It occurred to us that it would be interesting to compare the effects of more prolonged intravenous injections of epinephrine on the blood pressure and pulse rate of persons whose blood pressure was normal and patients with essential hypertension. The results which we obtained form the basis of this report.

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.

Blood pressure, pulse pressure, the difference of blood pressure in thigh and arm, and the pulse rate in 112 subjects in the horizontal posture showed great variability from person to person. The tendency of the diastolic blood pressure to increase while the systolic blood pressure remained essentially the same on changing from the horizontal to the standing position is in agreement with the results reported by others. Fifty-nine and five-tenths per cent of all blood pressures fell within 10 per cent, and 86.5 per cent fell within 20 per cent, of the average for the group. These results are almost identical with those of Strang. 16 Differential blood pressures between thigh and arm revealed a wide range of values; the average was 35 mm., systolic, and 27 mm., diastolic, for the horizontal posture. Assumption of the standing posture resulted in a differential pressure of 78 mm., systolic, and 66 mm., diastolic. No apparent correlation was noted between differential pressures and factors such as age, sex, or occupation. No significant differences were found between blood pressures in the left and right thighs of normal subjects. Knowledge of the range of blood pressure in the normal, nonhyperreacting subject, as contrasted to that in the normal, hyperreacting, or hypertensive, hyperreacting subject, is particularly important for those who are trying to evaluate therapeutic attempts to lower or raise the blood pressure.

THE CLINICAL phenomena associated with venous stasis in the lower extremities and the sequelae thereof are among the commonest of entities seen in the practice of medicine. It has been estimated 1 that 10 to 17 per cent of the population are afflicted with varicose veins and their complications. That there is an important relation between chronic venous insufficiency and the subsequent (or concomitant) development of cutaneous changes in adjacent or overlying areas of skin or both has not been questioned, but the mode of development of such changes has long been a matter of much conjecture. The purpose of this investigation was to determine what, if any, pathologic changes occurred in the blood vessels of the skin of the lower extremities in patients who showed clinical manifestations of chronic insufficiency of the venous return of blood from these areas. CHRONIC VENOUS INSUFFICIENCY Definition. —Chronic venous insufficiency has

Excerpt The syndrome of chronic aorto-iliac occlusive arterial disease begins when the occlusive process impairs the flow of blood enough to cause clinically recognizable symptoms and signs of arte...

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.

Six patients with idiopathic orthostatic hypotension were studied for the effect and mode of action of 9-alpha-fluorohydrocortisone. In 5 patients satisfactory symptomatic control of the hypotension was achieved. In 1 patient it was twice demonstrated that the rise of blood pressure obtained within 48 hours after starting treatment with 9-alpha-fluorohydrocortisone was accompanied by increased sodium retention and potassium excretion, as measured by metabolic balance studies. On long-term observation, while the improvement in blood pressure was maintained, no major alterations in water and electrolyte balance persisted.

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.

Of 300 subjects who had cold pressor tests in 1934, 207, aged 33 to 46 yr, were restudied in 1961. The test was repeated in 151 cases; in others, current information was supplied by subjects' physicians. Thirty-one subjects, hyperreactive in 1934 and retested, remained hyperreactive; 21 previously normal reactors became hyperreactive. Of 40 hyperreactors in 1934, four became hypertensive, whereas none of 167 normal reactors did so. In 1961, the family histories were positive for hypertension for 19 of 27 subjects hyperreactive in 1934 and for 30 of 43 hyperreactive in 1961; for normal reactors, corresponding figures were 37 of 112 and 26 of 96. These findings support the concepts that transient vasoconstriction precedes development of hypertension and that vascular hyperreactivity is inherited and may predispose to hypertension.

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.

Idiopathic livedo reticularis*may occasionally be associated with ulcerations, especially of the lower extremities, occurring during the winter months.† It has been assumed that in idiopathic livedo reticularis the effect of cold on the blood vessels of the skin accounted for the predominance of the symptoms and the occurrence of ulcerations during the fall and winter months. The purpose of this article is to define a new syndrome associated with idiopathic livedo reticularis in which the ulcerations occur only or predominantly during the warmer months of the year. DEFINITIONS We would define "livedo reticularis" as a condition of the skin characterized by a reddish-blue, mottled, reticular or blotchy discoloration. It persists with a variation of degree regardless of the skin temperature, and has also been described as a marbling or a fish-net discoloration. Synonyms in the medical literature for this condition have been "generalized telangiectasia," ‡ "livedo racemosa," "livedo

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.

The classic paper by Keith, Wagener, and Barker1in 1939 as well as other studies2-7of the natural course of severe hypertension have shown that the prognosis in untreated cases is poor. In the series of Keith, Wagener, and Barker, 79% of 145 patients with malignant hypertension (group 4) were dead within one year and only one patient survived for five years after the diagnosis was made (Figure). Effective hypotensive drugs have been available for nearly ten years, but only recently has enough experience with treatment of large groups of severely hypertensive patients over a long period been available from which the efficacy of prolonged drug therapy can be evaluated. Several such studies indicate that intensive treatment with ganglion-blocking agents prolongs life.5-16The current study was undertaken in an attempt to evaluate the effect of hypotensive therapy for patients with group 3 and group 4 hypertension, for

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.

Excerpt There is little in the literature on abnormal localized depositions of body fat to clarify the syndrome of lipedema of the legs which two of us (E. V. A. and E. A. H.) described in 1940.1Co...

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.

The systemic blood pressure reacts to various forms of external and internal stimulation; consequently, it is subject to considerable variation. This reactivity of the blood pressure can be measured by a standard test in which local cold is used as the stimulus. 1 Excessive variability of the blood pressure may have important significance even though the blood pressure is below accepted maximal levels. Recent studies have indicated that vasomotor reactions, as measured by responses in blood pressure, may be hereditary and that an excessive generalized vasoconstrictor response to stimulation is indicative of a prehypertensive state. 1 Many statistical studies on the blood pressure of children have been carried out in which the usual methods of measuring the levels of blood pressure havebeen applied. 2 There has been considerable disagreement in some of the data obtained by the different investigators. It was felt that some of these differences could be explained on a basis of the latent variability of the blood pressure. Merely to have the blood pressure taken may be a sufficient stimulus to bring it to a maximal level, but since the rise will be maximal in some instances and partial in others the results will not be comparable. For this reason it was believed that it would be of importance to study the range of variability of the blood pressure as well as the actual

Tetanus neonatorum has in past years been given a diversity of names, having been known as the "scourge of St. Kilda," "seven day sickness," "nine day fits," "trismus," "trismus nascentium" and other names of uncertain significance. For many years this disease was a "will-o-the-wisp" for the medical profession, puzzling many of the great scientists. Even to the present day, the pathology and treatment remain in the realms of the uncertain. It is a common belief that the disease is a great rarity. Johnston, in 1928, began his case report by saying, "Tetanus Neonatorum must be an extremely rare disease today." Statistical investigation, however, shows that tetanus neonatorum yet flourishes in some parts of the world, including the United States. The statistical data in this study were obtained from individual correspondence with each State Bureau of Vital Statistics and through the U. S. Bureau of Census. The assimilation of these data

Excerpt Even before facilities were available for measuring the blood pressure it was observed that vascular disease occurred with unusual frequency among members of some families. In 1769, Morgagn...

Excerpt In health there is a balance of the various divisions of the autonomic nervous system that varies with the normal physiologic demands. It is likely that phylogenetic and anatomic factors, a...

Excerpt The advent of arteriosclerosis is one of the inevitable consequences of aging. The existence of arteriosclerosis in one or another part of the vascular tree after the age of 30 is to be exp...