vigorous mercurialization, even in cases of serious and aggressive heart involvement; it is certainly a much safer drug in complications of this nature, and it is to be preferred where time does not seem to be a very critical factor.

My choice of the form of mercury at this period is the salicylate, given in a suspension of sterile albolene and in a dosage of about 1 grain daily, deeply injected into the muscle. I strongly advise that the injection be made slowly and that the area be gently but persistently massaged until no induration remains. Where this method seems inadvisable, as in excessively thin persons, I next prefer inunctions, using large doses of blue ointment, daily repeated. I have also used the bichloride by mouth and intramuscularly, but with less satisfaction. In any case the dosage should be heavy and should be persisted in until definite signs of mercurialization appear. I then allow a few days to elapse, when salvarsan is given if it has not preceded the use of the mercury, for when salvarsan introduces the treatment in all instances it must be followed by the aggressive use of mercury in some form. Mercury is essential in every case, salvarsan usually of great assistance, and, while salvarsan produces an immediate effect, it has been my experience that alone it does not hold the case as does mercury. This applies equally to chronic or slow

as to acute cases.

In the chronic forms of heart complication the manner of treatment differs very little, except that it may not be necessary to confine the patient to bed, especially if mercury is first used. Where the heart is seriously compromised, however, I do not think that salvarsan should ever be employed without keeping the patient in bed and under close observation-a not unwise precaution in any instance. Where mercury is the main drug employed, I strongly advise that at intervals doses of salvarsan be given, to be promptly followed up by resumption of the mercury. Although I have already expressed my preference for the salicylate, given intramuscularly, or for the inunctions, as all therapeutists know, neither of these methods may act well in some individual cases. I have also employed, for example, the proto-iodide with signal success, not occasionally, but very frequently. Similarly, I have used other forms of the drug; in one case the vapors of calomel produced results without toxic symptoms which could not be obtained by any other method used.

Although the iodides are universally admitted to have no direct specific effect in syphilis, in so far as the killing of the organism is concerned, clinical experience has shown their great utility, especially in the long-standing cases of this type. I am not prepared to state how they act, though it is my belief that it is chiefly through promoting absorption of exudate and necrotic tissue, but there can be no question but that they act in a most beneficent way, especially in cardiovascular syphilis. I prefer to employ commonly the familiar salt of potassium, and I use it chiefly after the activity of the process has been checked and either with or subsequent to mercury. can be no dispute as to its efficiency.

There

Treatment in every case must be persistently followed out, not only until all signs of advance have disappeared, but long after. Periods of interruption may be allowed only after such a course, lasting not less than eighteen months. In our experience, when treatment is allowed to subside before such a result is reached less and less definite effects follow subsequent treatment, for the heart lesions seem to acquire an immunity against both salvarsan and mercury, so that decisive effects can be no longer attained.

The usual hygienic and mechanical methods of treatment for the circulatory defect are best delayed until the patient has come well under the influence of the antispecific, after which, occasion indicating, they are to be employed, together with the appropriate drugs indicated, digitalis, strophanthus, caffein, epinephrin, and so on. In certain cases these drugs may be quite properly used before the mercury or salvarsan, but in acute cases I think that bad effects are likely to follow under such conditions, although in chronic cases I use them just as one would treat the heart complication, independent of the etiology. It is unnecessary, with the limited space at our disposal, to go further into this question.

The Results of Treatment.-In acute cases placed under treatment before or even soon after decompensation has taken place, prompt and remarkable results are to be confidently expected, commonly within a day or so. Exceptions exist, however, as in one instance reported by Carrol and myself, in which the most energetic combined treatment utterly failed to even check progress.

In long-standing cases in which it is fair to suppose that muscle fibrosis or gumma formation has taken place, and especially if this

has resulted in serious disturbances of rhythm, less benefit is to be expected, though even in such cases more relief will commonly follow the antispecific treatment than will occur after the customary cardiac measures alone. When these two are combined, the result is even then usually startling, but we have been disappointed in seeing, in many of these old cases, an eventual decompensatory period develop over which neither the specific nor the circulatory methods showed effect. In many instances, however, it is very impressive, when the heart has failed to respond to the digitalis group of drugs, to see how promptly it reacts to them when mercury or salvarsan is added.

Two thoroughly treated cases which came to ultimate autopsy from associated lesions have been studied by us, and we have been able to demonstrate completely-healed syphilitic foci in the walls of the heart. In our opinion, complete cure of the specific end of the lesions may be confidently expected in the average case, but it is, of course, impossible to remove adult scar tissue, once it has formed in the heart tissues, or to repair losses of parenchyma from necrosis.

In a certain number of cases a negative Wassermann may follow treatment, and in early cases I believe that this may remain permanently so. In the average case (chronic) the Wassermann becomes weakly positive or conclusively negative during or soon after treatment, but in the greater number of cases eventually returns to positive, although clinical cure may have apparently been attained. A few cases remain Wassermann positive during the entire treatment, yet some of these show great benefit and even clinical cure. I do not regard a negative Wassermann as an essential proof of clinical cure. There are cases which have thus far resisted the most vigorous treatment. One case of syphilis cited to me by Fordyce has had, in addition to thorough mercurial treatment, a total of 20 Gm. of old salvarsan; it is still strongly Wassermann positive, though now free from all clinical signs of the infection.

As a result of our study of this subject, based now on a total of over three hundred cases, we have reached the following conclusions, given as abstracted from the various articles which Dr. Carrol and myself have published:

1. Serious involvement of the heart is a frequent complication of syphilis.

2. Any or all portions of the heart may be involved, but the most constant lesion is of the muscle.

3. Heart complications may develop very early in the infection, or they may appear at any subsequent stage. Symptoms resulting from early lesions may not appear until late.

4. The signs and symptoms are those of cardiac disorder, and little beside history, general aspects, and the Wassermann reaction, may indicate the true etiology.

5. Early cases may be entirely cured, irrespective of the character of the lesion, by vigorous specific treatment alone.

6. Even late and well-established instances usually respond to specific treatment with cure or marked benefit.

7. The most satisfactory treatment is one which combines the use of mercury, salvarsan, and the iodides. The usual circulatory methods are best employed after specific treatment has been established.

8. Successful treatment rests primarily on the recognition of the cause of the disease.

CLINICAL SIGNIFICANCE

OF VARIATIONS IN THE

SYSTOLIC AND DIASTOLIC BLOOD-PRESSURES AND
THE PULSE-PRESSURE

BY EDWARD E. CORNWALL, M.D.

Attending Physician to the Williamsburgh and Norwegian Hospitals; Consulting Physician to the Bethany Hospital, Brooklyn, New York

UNTIL quite recently examination of the blood-pressure for clinical purposes was limited almost exclusively to observations of the systolic pressure. It is now becoming generally recognized that in order to appreciate the clinical significance of blood-pressure variations it is necessary to study them in the three phases of systolic pressure, diastolic pressure, and pulse-pressure.

In studying these three phases of blood-pressure in their variations we should bear in mind what they mean in terms of the circulation. The systolic pressure is the measure of the force of the ventricular contraction modified by the arterial resistance and less important factors. The diastolic pressure is the lowest pressure between the ventricular contractions, and may be taken as the residual pressure maintained by the tonicity of the arterial system; it measures the resistance against which the systolic pressure is raised. The pulsepressure is the difference between the systolic and diastolic pressures.

The first clinical question which arises in connection with the study of these three phases of the blood-pressure is, What is their relation to the efficiency of the circulation?

The measure of circulatory efficiency is the quantity of blood passing through the tissues in a given time. That depends on a number of factors, chief of which are the quantity and quality of the blood delivered to the heart, the force and frequency of the ventricular contractions, the elasticity of the arteries, and the amount of the peripheral resistance. An exact estimate of the combined, coördinated action of these factors is impossible. A very useful, though only partial, index to the efficiency of the circulation, however, is afforded by the systolic and diastolic pressures considered in their numerical