The intervals between the tests should be shortened as the pregnancy advances, and, should abnormal symptoms appear at more frequent intervals. The test should not be omitted during the puerperium, as at this time the patient may develop serious toxemia and eclamptic attacks.

Pregnant patients should have the blood-pressure test applied at least as frequently as the urine is examined. It would be advisable to apply the sphygmomanometer as often as practicable. So employed, and with the records properly charted, blood-pressure tests may furnish a far more adequate indication of the seriousness of a pregnancy nephritis and the urgency of inducing labor, than the usual urinalysis.

THE NORMAL BLOOD-PRESSURE DURING PREGNANCY

Most observers agree that the average systolic bloodpressure during most of the period of pregnancy is in the neighborhood of 120. John C. Hirst1 in the study of 100 cases obtained a general average systolic pressure of 118.

H. C. Bailey arrived at the same average. While these same authorities look upon a persistent pressure of over 145 with suspicion, Arthur J. Benedict3 believes that a pressure of over 125 in pregnancy is abnormal and indicates toxemia.

I have private records of 205 observations made upon thirty-four cases of normal pregnancy, in which the diastolic and pulse pressure readings as well as the systolic were made simultaneously, with complete urinalyses. The following is a summary of the results obtained:

1 N. Y. Med. Jour., June 11, 1910, p. 204.

2 Surg. Gyn. and Obstet., Vol. xiii, 5, 1911, p. 485.

3 Brit. Med. Jour., Dec. 3, 1910.

The following is a summary of 124 urinalyses made upon

the same group:

Thirty-four normal cases.

One hundred and twenty-four examinations.

Eight or 23.5 per cent. (of cases) showed no albumin at any time.

Sixteen or 47.9 per cent. showed albumin during first five months.

Sixteen or 47.9 per cent. showed albumin during last four months. The albuminuria bore no definite relation to the pressure reading or the period of gestation.

The specific gravity ran from 1005 to 1036-average 1018.

Twenty-one or 61.7 per cent. showed at some time casts or cylindroids in small numbers. Three showed granular casts which had apparently no significance. Four cases which showed indican had an average systolic pressure of 105 mm.

The opinion is generally held that there is but slight change in the systolic pressure until the later months of pregnancy and that then a slight rise occurs.

In four abnormal cases under my care involving six pregnancies, the average systolic pressure was 158, while the urine ranged from a mere trace to a solid mass of albumin in the tube after boiling. The microscope showed all varieties of abnormal morphologic elements.

Naturally the individual readings must vary greatly within certain limits, as these patients are subject to the

same influences which affect the reading in other individuals, so that rapid variations are probably insignificant unless they exceed 30 mm. above the average and remain persistently at or above the high normal limit.

EFFECT OF LABOR ON BLOOD-PRESSURE

During the first stage of labor, at the recurrence of pains there is a marked rise in pressure which falls in the intervals, but usually during the first and second stages the level remains at from 140 to 150 even between pains (Bailey).

Hirst had noted that a fall of pressure coincides with rupture of the membranes, sometimes amounting to 50 or more millimeters, usually accompanied by marked relief from headache and epigastric symptoms. This is temporary, as the pressure gradually rises as labor continues. There is a second fall of 60 to 90 mm. immediately after childbirth, which is also temporary, the pressure soon returning almost to the level attained before birth. Profuse hemorrhage or the supervention of exhaustion will interfere with this rise, the degree of reduction in pressure indicating the seriousness of these complications. Obstetric operations, according to Cook and Briggs, which involve the introduction of the hand into the vagina or uterus, and instrumental deliveries, cause a sharp reflex rise which has been known to result in rupture of a cerebral vessel.

COMPLICATIONS AFFECTING BLOOD-PRESSURE DURING

PREGNANCY

Albuminuria.-Albumin in small quantities appearing in the urine during pregnancy cannot be considered pathologic, as in a large percentage of cases it appears from time 1 Johns Hopkins Hosp. Rep., 1903, Vol. xi, 451.

FIG. 84.-Aged twenty-five. Two pregnancies the first toxic, the second not.

At (A) five months pregnant (March, 1911). Normal to this date. At (B) beginning development of edema, headaches, albuminuria unrestrained by dietetic regulations between (B) and (C).

At (C) hot-packs begun, with slight reduction in systolic pressure but failure to relieve cardiac over-action as shown by the continued elevation of pulse pressure.

(D) Gradual failure of eliminative measures. Symptoms more marked but not considered urgent.

(E) Labor induced on account of continued elevation and rapidly increasing nervous symptoms, high-grade albuminuria and kidney failure. (F) Delivered without serious complications.

(G) Final examination. Patient passed from observation still showing edema, dyspnea, with albumin and casts in the urine.

(A1) Between five and six months pregnant (April, 1913) with marked signs of kidney failure. Dietetic and eliminative measures instituted.

to time and seems of itself to have no relativity to the subsequent course of the case. In a series of thirty-four normal cases which I have recorded, albumin appeared in sixty-two examinations of 50 per cent. The combination of traces of albumin with a rising systolic pressure will give the obstetrician pause, and a rising pressure plus albumin which fails to respond to treatment is an indication for the forced termination of pregnancy2 (Fig. 84).

Pernicious Vomiting. Donaldson's3 observations lead to the belief that, while this condition may demand the induction of labor, the blood-pressure is not elevated; which plainly suggests that the toxemia in these cases differs from that occurring in eclamptics.

Glycosuria.-Donaldson reports nothing abnormal in the blood-pressure readings in glycosuria, which coincides with my own experience and is shown in the accompanying chart (Fig. 85).

Hemorrhage.-Wallich' considers that elevation of pressure during pregnancy tends to hemorrhage and that this accounts for the hemorrhagic lesions so common in eclampsia. On the other hand, estimation of blood pressure is important in suspected hemorrhage as in cases of ectopic

(B1) All symptoms subsided. Patient on rigid diet and hygiene. Condition satisfactory. Urine shows only slight evidence of renal irritation. (C1) Delivered at term.

(D1) Two months after delivery. Condition excellent. Urine practically normal, no evidence of kidney insufficiency.

Note, January, 1916, patient has not been pregnant again, has enjoyed good health and shows no evidence of kidney involvement.

1 Franklin S. Newall, Jour. A. M. A., Jan. 30, 1915, lxiv, 5.

2 M. Donaldson, Jour. Obstet. and Gyn., London, September, 1913, xxiv,

3; and J. D. Lippincott, Jour. A. M. A., Aug. 10, 1912, lix, 6.

3 Loc. cit.

4 V. Wallich, Annal. de Gynae. et d'Obstet., November, 1913, xxxix, No. 11.