Vascular Crises Research Articles

Application of Cross-Groin Flap for Coverage of Large Skin and Soft Tissue Defects of the Foot and Ankle in Children

In children with large soft tissue defects of the foot and ankle, it is difficult to cover the wound completely using a local skin flap, and skin grafting of the donor area for repair causes secondary damage. Free skin flaps require good vascular anastomoses and are prone to vascular crises. The authors evaluated the effectiveness and safety of cross-inguinal flaps for the repair of large soft tissue defects of the foot and ankle in children. The records of 15 children who underwent cross-groin flap transplantation between June 2017 and June 2021 were analyzed retrospectively. All the flaps survived without infection, necrosis, or other complications. The flap shape was good, the donor area was sutured directly, and the damage was minimal. This surgical method is simple, effective, and safe and can replace microsurgery, making it suitable for use in primary-level hospitals that are not equipped for microscopic surgery.

Rehabilitative treatment of lower leg injury was studied by using anterolateral free thigh flap with CT scan

ObjectiveIn cases of severe soft tissue loss and deep tissue exposure in the lower part of the leg, microsurgical skin flap transplantation is the primary treatment method. MethodsBased on the anatomy of the descending branch of the lateral circumflex femoral artery and its musculocutaneous perforators, a free, ultra-thin anterolateral thigh perforator flap is designed for the repair of soft tissue defects in hands and feet. This method has been successfully used at our hospital to treat three patients. Postoperative recovery was favorable, with no vascular crises, and all skin flaps survived. ResultsThe aesthetic appearance of the repaired area was approved by patients, and there were no severe complications post-surgery. Patients were followed up for a period ranging from 6 to 24 months, averaging 14 months. The skin flaps were soft and elastic, without swelling, and the color matched that of normal skin, with good sensory function recovery. ConclusionIn surgical treatment of lower leg wounds, prioritizing using a free anterolateral thigh flap can enhance the repair of the wound and expedite functional recovery postoperatively.

Submental Artery Perforator Flap Drained Solely With the Vena Comitans of Facial Artery.

The submental artery perforator flap (SMAPF) is an alternative to reconstruct oral and maxillofacial defects secondary to oral cancers. However, vascular anomalies or surgical damage often lead to vascular crises or harvest failure. Our clinical findings suggest that the vena comitans of the facial artery (cFA) very commonly exist. This study aimed to investigate the reliability of the cFA as a sole venous reflux route for the SMAPF. The patients were from the Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Jilin University. All patients were treated for oral cancer between January 2016 and September 2022. Seventeen SMAPFs were successfully raised to reconstruct the postoperative defects, of which 7 had cFA as the sole reflux route. The size of the flaps varied from 4.0×3.0cm to 12.0×3.0cm. All flaps survived. Patients were followed from 1 month to 5 years. Satisfactory restoration of contour and functional outcomes were achieved at the recipient sites. The scars were well camouflaged in the submental region. No local or regional recurrence was detected during follow-up. Patients had an overall 2-year survival rate of 100% with no suspected flaps-related recurrence. The cFA as the sole venous reflux route for SMAPF is reliable for flap harvesting and is applicable for immediate defect reconstruction secondary to cancer resection.

Combined with the first dorsal (plantar) metatarsal artery pedicle free bilobed flap with a cell scaffold for the repair of a mid-distal adjacent finger defect: a retrospective study

PurposeAssessing the clinical effectiveness of combining with the first dorsal (plantar) metatarsal artery pedicle free bilobed flap with a cell scaffold to repair mid-distal defects in adjacent fingers.MethodsFrom September 2012 to April 2022, 21 patients with 42 mid-distal defects of adjacent fingers underwent treatment using combined with the first dorsal (plantar) metatarsal artery pedicle free bilobed flap with a cell scaffold. The flaps size ranged from 2.1 cm * 1.6 to 4.9 cm * 3.2 cm. Follow-up evaluations included assessing function, sensation, and appearance, etc. of the injured fingers and donor areas.ResultsAll 42 flaps survived in 21 patients without any vascular crises, and the wounds healed in phase I. The mean follow-up time was 12.2 months (range 7–22 months). During follow-up, in injured fingers, according to the Michigan Hand Outcomes Questionnaire (MHOQ), the functional recovery and appearance were satisfactory; in Dargan Function Evaluation (DFE), the results were both “excellent” in fourteen patients, “excellent” and “good” in five patients, both “good” in one patient, “good” and “general” in one. In static two-point discrimination (2PD), the variation ranges from 4 to 9 mm in injured fingers and 6—10 mm in donor toes. Cold Intolerance Severity Score (CISS) is mild in all patients. The visual analogue score (VAS) showed no pain in the injured fingers and donor toes. No deformities or other complications were noted at the donor toes. According to Chinese Manchester Foot Pain and Disability Index (C-MFPDI), there was no morbidity on foot function in all donor areas.ConclusionThe surgical procedure of combined with the first dorsal (plantar) metatarsal artery pedicle free bilobed flap with a cell scaffold for the repair of mid-distal adjacent fingers defect is highly satisfactory. This approach helps the injured fingers to achieve good function, sensibility and appearance, while also achieving satisfactory results in the donor toes.

Reconstruction of large-area wounds in limbs using two flow-through anterolateral thigh perforator flaps

IntroductionLimb salvage in large wounds is difficult because the disrupted blood supply does not support a flap. This study evaluated the clinical efficacy of using two flow-through anterolateral thigh perforator flaps for reconstructing large-area limb wounds. MethodsThis retrospective study included 45 patients who underwent reconstruction of large limb wounds using two flow-through anterolateral thigh perforator flaps at Ruihua Hospital between January 2015 and December 2020. Wound areas ranged from 15 cm × 13 cm to 46 cm × 18 cm. Single flap areas ranged from 16 cm × 8 cm to 46 cm × 9 cm. Blood supply locations were identified using color Doppler ultrasound or digital subtraction angiography (DSA) images. Primary outcomes were flap survival and complications at recipient or donor sites during at least 6-months follow-up. ResultsThe overall flap survival rate was 97% (87/90). All donor sites healed by first intention. Three cases developed vascular crises, which were alleviated by reoperation. One case had flexor contracture in left toes, relieved by cutting flexor tendons; 13 cases had flap bloat, relieved by flap thinning at 6 months. All cases showed properly healed wounds and functional reconstruction. ConclusionsReconstruction of large-area limb wounds using two flow-through anterolateral thigh perforator flaps provides safe and satisfactory effects without donor-site morbidity, and with proper healing and restored function.

Valeological relationship of physical workability with health indicators

A theoretical study is written in the form of a short report on approaches to qualitative and quantitative assessment of health and physical performance. Physical, mental, social, sexual health, their relationship to physical performance, and measurability to assess and compare individual and population outcomes are discussed. Separate models of health quality assessment and its formation are noted. Philosophical systems of understanding health, psychological approaches to its study, pedagogical systems of formation are described. It was noted that the level of physical health of a person depends on his ability to maintain the balance of homeokinesis parameters. The significance of adaptation and dysadaptation processes is described. It is proposed to draw up a "vegetative passport" of a person with an indication of the vagosympathetic balance. Physical performance, which is often evaluated together with anthropometric data, aerobic and anaerobic endurance, neuromuscular coordination, flexibility, stress resistance, is taken into account when planning sports training and professional tasks with a difficult physical component. In ordinary life, it can be reduced due to the wide distribution of hypertension, coronary disease and smoking, and frequent vascular crises. Cardiorespiratory capacity (reserves) and exercise tolerance can be carefully determined using special functional tests. The relationship between physical capacity and health indicators determined in the study allows to objectively determine tolerance to physical exertion and compare capacity in the population and in different periods of a person's life. Keywords: models of health diagnosis, adaptation and maladaptation, homeokinesis, tolerance to physical exertion.

The Application of Digital Design Combined with 3D Printing Technology in Skin Flap Transplantation for Fingertip Defects during the COVID-19 Epidemic.

Objective We aimed to evaluate the advantages of preoperative digital design of skin flaps to repair fingertip defects during the COVID-19 pandemic. We combined digital design with a 3D-printed model of the affected finger for preoperative communication with fingertip defect patients under observation in a buffer ward. Methods From December 2019 to January 2021, we obtained data from 25 cases of 30 fingertip defects in 15 males and 10 females, aged 20-65 years old (mean 35 ± 5 years). All cases were treated by digitally designing preoperative fingertip defect flaps combined with a 3D-printed model. Preoperative 3D Systems Sense scanning was routinely performed, 3-matic 12.0 was used to measure the fingertip defect area ranging from 1.5 cm × 3.5 cm to 2.0 cm × 5.0 cm, and the skin flap was designed. The flap area was 1.6 cm × 3.6 cm to 2.1 cm × 5.1 cm. CURA 15.02.1 was used to set parameters, and the 3D model of the affected finger was printed prior to the operation. Full-thickness skin grafts were taken from donor areas for repair. Results No vascular crises occurred in any of the 25 cases, and all flaps survived. The postoperative follow-up occurred over 3-12 months. All patients were evaluated 3 months after operation according to the trial standard of hand function evaluation of the Chinese Hand Surgery Society. The results showed that 20 cases had excellent outcomes (80%), four cases had good outcomes (16%), and one case had a fair outcome (4%). The excellent and good rate was 96%. Conclusions During the COVID-19 epidemic, fingertip defects were treated with preoperative digital design of fingertip defect flaps combined with 3D printing. Precision design saves surgery time and improves the success rate of surgery and the survival rates of skin flaps. In addition, 3D model simulations improve preoperative communication efficiency, and the personalized design improves patient satisfaction.

Free-flap reconstruction in recurrent head and neck cancer: A retrospective review of 124 cases.

BackgroundFree-flap reconstruction for recurrent head and neck cancer may be challenging depending on the previous treatments, those are, chemotherapy, radiotherapy, and surgery, including neck dissection or free tissue transfer. Specifically, the previous treatment could compromise the neck vessels, thereby making free-flap reconstruction more difficult. This study aimed to investigate the correlation between previous treatments and vascular compromise of the free flap.MethodsIn this retrospective study, 124 free-flap reconstructions in 116 patients for recurrent head and neck cancer between 1993 and 2017 were investigated. The demographic characteristics, previous treatments, flap choices, infections, recipient vessels, and vascular crises were evaluated.ResultsOf the 124 reconstruction cases, 10 had vascular crises. There were six revisions, totaling six flap failures. The success rate of free-flap reconstruction for recurrent cancer was 95.2%, which significantly differed from that for primary cancer (98.8%, p= 0.006). Moreover, in the recurrent cancer group, no correlation was found between previous treatments and vascular crises (p> 0.05). Increased rates of contralateral or uncommon anastomoses were found following neck dissection (p< 0.05).ConclusionPrevious neck dissection or radiotherapy could lead to scarring and tissue damage, which could in turn make microvascular reconstruction more challenging; however, the effect was not definite in this study. Approximately 60% of patients with previous neck dissection had compromised ipsilateral recipient vessels, which resulted in contralateral or uncommon anastomoses. In this study, free-flap reconstruction seems to be quite safe and preferable in patients with recurrent head and neck cancer based on the overall survival rate.

Comparison of morbidity after reconstruction of tongue defects with an anterolateral thigh cutaneous flap compared with a radial forearm free-flap: a meta-analysis

Currently the radial forearm fasciocutaneous flap and the anterolateral thigh flap are among the most popular free flaps used for reconstruction of oral soft tissue. However, there is controversy about their efficacy after reconstruction of tongue defects because of their respective intrinsic properties, so we have compared them in reconstruction of tongue defects using meta-analysis. We conducted a search in Pubmed, EMBASE, OVID, Science Direct, the Cochrane Library, and Chinese National Knowledge Infrastructure, which covered all papers published before January 2015. Twelve clinical papers, that included 366 patients with 198 radial forearm flaps and 168 anterolateral flaps, met the criteria. Relevant data were extracted and analysed using systematic meta-analyses. The results showed that the incidence of localised numbness at the donor site of the radial forearm flap postoperatively was significantly higher and satisfaction with the appearance of the donor site significantly lower than in the anterolateral thigh group. There were no differences in flap survival, incidence of vascular crises in the flap, complications, satisfaction with the appearance of the tongue, or the postoperative clarity of speech and swallowing ability. Results suggested that the anterolateral thigh flap is the ideal soft tissue flap for reconstructing defects in the tongue, as there was minimal numbness at the donor site and patients were much more satisfied. Further research is needed to address details of the site and the extent of surgical defects as well as the relations between dissection of the radial flap and repair of the skin graft.

ВПЛИВ ЧИННИКІВ РИЗИКУ НА ВИНИКНЕННЯ ПЕРВИННОГО ГОСТРОГО ІШЕМІЧНОГО ІНСУЛЬТУ У ПАЦІЄНТІВ З МЕТАБОЛІЧНИМ СИНДРОМОМ ТА БЕЗ ТАКОГО

&lt;p&gt;&lt;strong&gt;Мета:&lt;/strong&gt; виявити предикторні чинники ризику виникнення первинного гострого ішемічного інсульту за наявності і відсутності метаболічного синдрому.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Матеріали і методи&lt;/strong&gt;. Використовувалися функціональні, антропометричні, лабораторні, статистичні методи.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Результати&lt;/strong&gt;. Визначені предикторні чинники ризику виникнення мозкового інсульту: поєднання артеріальної гіпертензії з атеросклерозом, товщина та ущільненість стінки внутрішньої сонної артерії, церебральні судинні кризи, які підсилюються залежністю від метаболічного синдрому. &lt;/p&gt;&lt;p&gt;&lt;strong&gt;Висновки&lt;/strong&gt;. Васкулярні та неваскулярні чинники ризику серед пацієнтів з метаболічним синдромом мають виразний вплив та всі передумови у виникненні первинного ішемічного інсульту, що в подальшому позначається на перебігу та важкості церебральної катастрофи.&lt;/p&gt;&lt;p&gt;КЛЮЧОВІ СЛОВА&lt;strong&gt;&lt;em&gt;: &lt;/em&gt;мозковий інсульт, метаболічний синдром.&lt;/strong&gt;&lt;/p&gt;

Management of vascular crisis of free flaps after reconstruction of head and neck defects caused by tumor resection

To discuss the management of vascular crisis of free flaps after reconstruction of head and neck defects caused by tumor resection. A total of 259 cases of free flap reconstruction performed in the Cancer Hospital of Chinese Academy of Medical Sciences from 2010 to 2013 were retrospectively analyzed, including 89 cases of anterolateral thigh flaps, 48 cases of radial forearm flaps, 46 free fibula flaps, 5 cases of inferior epigastric artery perforator flaps, 5 cases of free latissimus dorsi flaps, one case of lateral arm flap, and one case of medial femoral flap. The surveillance frequency of free flaps was q1h on post-operative day (POD) 1, q2h on POD 2 and 3, and q4h after POD 3. Vascular crises were reviewed for analysis. The incidence rate of vascular crisis was 8.1% (21/259), with 15 males and 6 females. The average age was 54.8 years old (17-68), and the average time of vascular crisis was 100.8 h post-operation (3-432). There were 7 cases of free jejunum flaps and 14 dermal free flaps. Seven of these 21 cases with vascular crisis were rescued by surgery. The success rate of salvage surgery within 72 hours from the primary operation was 54.5% (6/11), significantly higher than that of salvage surgery performed later than 72 hours from primary operation (10.0%, 1/10, P=0.043). There were 14 cases of flap necrosis, two of which died of local infection. Early detection of vascular crisis can effectively improve the success rate of salvage, so as to avoid the serious consequences caused by free flap necrosis.

Replantation of hand multi-level severances with 17 segments

Traumatic injuries of the hand and fingers might be devastating with irretrievable functional and psychological consequences in injured individuals. We present a case of successful replantation of hand multi-level severances with 17 segments to address the best way of treatment of such injury.The patient was 18-year-old female with multi-level severances due to cutting injury. During the surgery, we adopted unifying coordination and grouping surgery. Moreover, we tried to improve the quality of vascular anastomosis with various measures and shorten operative time. Postoperatively, we closely observed the patient to effectively prevent and treat vascular crises. Furthermore, we acquired utmost hand function recovery through enhancing functional rehabilitation exercise. The case was followed-up regularly. As a result, the replanting palm and all fingers survived successfully. Abdominal pedicle flaps were used to repair the skin of the distal end portion of thumb and middle finger due to severe injury. At 5-year follow-up, the prehension function of the hand was restored and the patient was capable of general labour and normal activity with the replanted hand.This report demonstrated our experience of successful treatment of a rare and severe case of hand injury. Accordingly, we recommend grouping surgery, closely coordination, effective and comprehensive intra-operative and post-operative technical operations and treatments. Postoperative functional rehabilitation exercise can restore utmost hand function.

Metastable Polymerization of Sickle Hemoglobin in Droplets

Sickle cell disease arises from a genetic mutation of one amino acid in each of the two hemoglobin β chains, leading to the polymerization of hemoglobin in the red cell upon deoxygenation, and is characterized by vascular crises and tissue damage due to the obstruction of small vessels by sickled cells. It has been an untested assumption that, in red cells that sickle, the growing polymer mass would consume monomers until the thermodynamically well-described monomer solubility was reached. By photolysing droplets of sickle hemoglobin suspended in oil we find that polymerization does not exhaust the available store of monomers, but stops prematurely, leaving the solutions in a supersaturated, metastable state typically 20% above solubility at 37 °C, though the particular values depend on the details of the experiment. We propose that polymer growth stops because the growing ends reach the droplet edge, whereas new polymer formation is thwarted by long nucleation times, since the concentration of hemoglobin is lowered by depletion of monomers into the polymers that have formed. This finding suggests a new aspect to the pathophysiology of sickle cell disease; namely, that cells deoxygenated in the microcirculation are not merely undeformable, but will actively wedge themselves tightly against the walls of the microvasculature by a ratchet-like mechanism driven by the supersaturated solution.

Application of vascularized free tissue transplantation in emergency repair of traumatized limbs: report of 86 cases

目的 报道应用吻合血管的游离组织移植急诊修复四肢创伤的效果.方法 1988年4月至2004年8月,进行急诊游离组织移植86例,修复肢体54例,再造拇指32例.移植的组织包括背阔肌肌皮瓣、股前外侧皮瓣、小腿内侧皮瓣、足背皮瓣、足底内侧皮瓣、废弃肢体的复合组织块及(足母)趾皮甲瓣.手术在伤后1～5 d内进行.结果 术后发生血管危象8例,均行血管探查手术,5例危象解除,3例失败.移植组织的成功率为96.5%(83/86).随访1～16年,平均7.5年.修复的肢体均保留或恢复了有用的功能,再造拇指功能优良率为87.5%.结论 急诊游离组织移植是实现创伤肢体急诊修复及拇指再造的有效方法。

Toxic Unbound Iron and Membrane Injury in b-Thalassemia and Sickle Cell Disease: Elevated Non-Transferrin Bound Iron (NTBI) and Malondialdehyde (MDA).

Objective: Chronic red blood cell transfusion therapy is life-saving for patients with β-thalassemia (THL) and sickle cell disease (SCD), but often results in severe iron overload. Clinical observations suggest that organ dysfunction (heart, liver, endocrine dysfunction, bone disease) resulting from iron overload is seen more often in patients with THL than SCD. This study examines the possible correlation between increased organ injury in these patients and oxidative stress, iron metabolism, inflammation and plasma vitamin E.Methods: Markers of oxidant stress were compared in 18 subjects with THL (7M, 24 ± 9 yrs) and 11 with SCD (7M, 13 ± 4 yrs) with 10 disease-free controls (5M, 27 ± 12 yrs). All THL and SCD patients admitted to the study were healthy and had not had a recent medical event including vascular crises for SCD within the last 4 months. Blood was drawn from fasted subjects, prior to blood transfusion, and plasma, serum and cells were separated by centrifugation. Plasma levels of malondialdehyde (MDA), a marker of lipid peroxidation, were determined by GC-MS. Non-transferrin bound iron (NTBI), protein carbonyls and tocopherol content were measured by HPLC. C Reactive Protein (CRP) was determined by ELISA. Liver iron content was analyzed by ICP-mass spectrometry from disease patients.Results: Table 1Values are means ± SD (subject n). Within a row, underlined values are significantly different from control and starred values are significantly different between THL and SCD (P<0.05).ParameterControlTHLSCDFerritin, ng/ml65.0 ± 70.9 (10)1915.0 ± 1030.6 (18)†2514.7 ± 1152.6 (11)†NTBI, μM−1.0 ± 0.4 (9)4.0 ± 1.6 (16) *†1.9 ± 2.1 (11) (c)†MDA, pmol/ml20.3 ± 14.2 (9)36.4 ± 20.5 (18)†27.0 ± 11.4 (11)ALT, U/l34.9 ± 7.7 (9)59.2 ± 31.1 (18) *†36.1 ± 11.0 (11)†α-tocopherol, μM22.7 ± 3.4 (10)14.9 ± 4.6 (17)†15.3 ± 4.0 (11)†γ-tocopherol, μM1.8 ± 0.7 (10)3.5 ± 2.2 (17)†5.5 ± 1.4 (11) *†CRP, mg/L0.8 ± 0.7 (11)1.1 ± 1.2 (18)2.7 ± 3.2 (10)†carbonyls, nmol/mg0.6 ± 0.1 (10)0.7 ± 0.3 (17)0.6 ± 0.1 (11)Values are means ± SD (subject n). With* in a row, daggered † values are significantly different from control and starred * values are significantly different between THL and SCD (P<0.05)MDA, ALT, and NTBI, were higher in THL despite evidence for lower body iron burden in THL relative to SCD (liver iron: 9 ± 7.1 vs. 15 ± 5.6 mg/g dry weight). In contrast, evidence for inflammation such as ferritin and CRP were significantly higher in SCD. g-tocopherol was significantly higher in SCD relative to THL.Conclusions: These preliminary findings suggest that THL patients have higher levels of toxic free iron and more evidence for tissue injury than SCD. SCD patients may be protected, in part, by greater inflammation and unique antioxidant reserves. The prospective Multicenter Study of Iron Overload in SCD and THL will determine whether these biomarkers are predictors of differences in end organ failure in these two diseases.

Alcohol-free beer and the irreversible monoamine oxidase inhibitors

Three cases of vascular crises associated with the use of MAOIs and the ingestion of alcohol-free beer are reported.

Anticoagulants in Open Prostatectomies

The prevention of vascular crises in open prostatectomies with prophylactic measures is the logical approach in susceptible patients. Low dose heparin was used in 150 cases and compared to 160 cases that had no heparin. The comparison proved that low dose heparin will eliminate many vascular crises and reduce the mortality rate. Therefore, there is not an increase but a decrease in complications, and improved morbidity and mortality rates. Low dose heparin should be used in all urological cases.

VASCULAR CRISES ASSOCIATED WITH MONOAMINE-OXIDASE INHIBITORS.

The authors gave 1,223 courses of antidepressant medication, and in 692 courses MAO inhibitors were used. Prior to Sept. 7, 1963, 8.4% of patients receiving MAO inhibitors experienced acute hypertensive crises featured by intense occipital headache and palpitation. After Sept. 7, 1963, patients receiving MAO inhibitors were advised not to eat cheese and the incidence of acute reactions fell to 3.3%. Of the 8 reactions in the latter series, 5 followed the ingestion of cheese, despite our warning, 2 followed the taking of cream in fairly large quantity and one occurred immediately after drinking 17 oz. of draught beer on an empty stomach after sunbathing. The highest incidence of these reactions occurred with tranylcypromine, but nevertheless this drug is being used more frequently than any other MAO inhibitor and is regarded as indispensible in the treatment of depressive illness. Acute vascular crises, when they occur, are immediately relieved with intravenous phentolamine, but where the associated cervic...

DIASTOLIC HYPERTENSION WITH INCREASED BASAL METABOLIC RATE

Although the cause and nature of hypertension are still unknown, certain groups of cases have been differentiated from the general mass of those with high blood pressure, and certain clinical associations have been established. Thus, it is generally accepted that patients with glomerulonephritis and hypertension, or with the vascular crises of lead, eclampsia or tabes, must be sharply distinguished from those with so-called essential hypertension. Among those belonging to the latter category, certain subgroups have been described: hypertension associated with myxedema, 1 and hypertension associated with tumors of the suprarenal cortex. 2 There is another syndrome, in which hypertension is one of the presenting signs, but in which there is a concomitant group of symptoms which serve to separate it sharply from the ordinary picture of hypertension, and which warrant its classification as a distinct disease entity. The signs and symptoms characteristic of this syndrome may briefly be enumerated as

ANGINA PECTORIS AND ABDOMINIS.

While many cases of angina pectoris are attended with sclerosis of the coronary arteries, the latter condition is not rarely encountered independently of symptoms of the former. It would thus appear that some other factor must be responsible for the clinical picture, and existing evidence supports the view that this resides in increased vascular tension. Symptoms of angina pectoris have been observed also in association with obvious vasomotor phenomena in the extremities, without demonstrable disease of the heart. Dr. J. Pal,¹as a result of clinical studies, considers the phenomena in the peripheral vessels as an integral part of the attack of true angina, which he includes among the vascular crises. He recognizes two typical varieties, namely, the pectoral and the abdominal. The latter is comparable, in his opinion, with the abdominal crises of tabetic patients and with lead-colic, the symptoms of which he attributes to contraction of the