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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. 1 Confusion and uncertainty, both manifested in an extensive article by Lyon 2 in 1910, are demonstrated by the use of such terms as "oedeme hysterique" and "pseudo-edema." We are not concerned in this presentation with the type of lipodystrophy (lipodystrophia progressiva) which is generally felt to be characterized by loss of subcutaneous fat of the upper half of the body and increased deposition of fat in the buttocks and lower extremities. 3 " 6 As a digression, it is worthy of comment that steatopygia (fat buttocks) is considered a manifestation of beauty among the Hottentots. 7 The syndrome which we shall consider in this presentation is definitely not considered a manifestation of beauty in modern "civilized" living. Indeed, it is quite probable that much or all of the distress (both emotional and physical) associated with lipedema would not occur were "fat legs" considered a manifestation of beauty. DESCRIPTION OF THE SYNDROME "LIPEDEMA" The term "lipedema" is one which has been coined by two of us (E. V. A. and E. A. H.) to describe large legs due to the subcutaneous deposition of fat in the buttocks and lower extremities and the accumulation of fluid in the legs (figure 1). Characteristically, there is symmetrical bilateral enlargement of the buttocks and lower extremities which begins almost imperceptibly and progresses gradually. Progressive enlargement of the limbs is ordinarily associated with gain of weight, but evidence of obesity of the trunk, upper extremities, face and neck may be entirely absent; in some instances, there is generalized obesity. The enlargement of the limbs is accentuated by orthostatic activity, particularly in warm weather, and although rest in bed may cause some decrease in size of the limbs, owing to removal of fluid, even prolonged rest in bed will not cause the limbs to become normal in size. Episodes of inflammation, such as are commonly observed in lymphedema, are uniformly absent. The characteristics that distinguish lipedema from lymphedema are given in table 1. The examination ordinarily discloses no abnormalities except those referable to the lower extremities. The legs and buttocks are symmetrically •

The clinical and follow-up data on 520 non-diabetic patients less than 60 years of age who had a clinical diagnosis of arteriosclerosis obliterans of the lower extremities made at the Mayo Clinic in the period 1939 through 1948 were reviewed from the standpoint of pathogenesis, prognosis, and clinical course of the disease. The ratio of males to females was 11 to 1, and the mean concentration of plasma cholesterol in the male patients with arteriosclerosis obliterans was approximately 50 mg. per 100 ml. greater than that of either of 2 control groups of men without clinical evidence of atherosclerosis. The incidence of smoking among the men with this disease was higher than in a comparable group of men without it. Obesity was not commonly associated with arteriosclerosis obliterans, while hypertension was associated with the disease about 3 times as often as in a control group without the disease. The survival rate for patients with arteriosclerosis obliterans was less favorable than that of a normal population of a similar age and sex distribution, and the survival rate for patients with atherosclerotic aorto-iliac occlusion was significantly less favorable than that of patients with atherosclerotic occlusion of the femoral artery. In approximately three fourths of the patients who died, the cause of death was thought to be disease of the coronary arteries. The presence of atherosclerosis elsewhere than in the arteries supplying the extremities, as manifested by clinical coronary artery or cerebrovascular disease at the time of diagnosis, had an adverse effect on survival. Four per cent of the patients required amputation of a leg shortly after the diagnosis of arteriosclerosis obliterans was made at the clinic, and an additional 4.9 per cent subsequently required amputation during the 5-year period following the initial examination. Only 3.0 per cent of patients with intermittent claudication as the only symptom of their disease required an amputation during this period. Eleven and three-tenths per cent of patients who continued to smoke, but none who abstained from smoking, had amputations within 5 years. Since all patients of the series were treated before the advent of direct arterial surgery for segmental arterial occlusion, it is believed that the subsequent course of the disease in these patients may be used as a basis for comparative evaluation of results in patients subjected to direct arterial surgical procedures.

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.

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.

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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.T HE cold pressor test of Hines and Brown1 has been used widely during the past 22 years in the study of essential hypertension2-9 and the toxemias of pregnancy.'0 11 Up to the present, exact knowledge of the nature and significance of the cold pressor response has been limited by the intermittent measurements possible with the sphygmomanometer. However, now that continuous direct recording of arterial pressure is established as an accurate and reliable laboratory procedure, a new tool is available for the study of the cold pressor test.The response of the intra-arterial pressure to the cold immersion stimulus (4 C. for 60 seconds) was studied in 42 healthy young adults, continuous direct arterial pressure recording being used. The cold pressor test of Hines and Brown was applied repeatedly at short intervals, and the direct record was examined with regard to (1) maximal elevation of pressure, (2) time required to reach the maximal pressure and (3) time needed to return to one half the maximal pressure (the last figure was taken as a measure of the recovery time). The difference between the direct and