On admission: February 13 B. P. Sys. 200 Di. 140 Urine 1024, alb. 10 per February 14 B. P. Sys. 194 Di. 140 cent. tube casts, blood epithelium, etc. Urine 1029 6 per cent. alb. Urine 2 per cent. albumin. Treatment consisted of bleeding on admission, with purgation, followed by sweats in cabinet for thirty minutes, three times a day for seven days and then once a day for a week. Eclampsia shows a very high blood pressure. The examination of the blood pressure of pregnant women gives us information of this condition of as much value, or more than the examination of the urine. A pressure of 160 m.m. during late pregnancy should always be considered highly suspicious and lead to the same careful and repeated observations that the finding of albumin does. A further rise, particularly if rapid, and associated with marked headache or vomiting, should probably be the signal for terminating pregnancy. After delivery, in normal cases, the blood pressure falls promptly to normal or below. The persistence of high pressure post partum must always be considered a danger signal, and continued watchfulness should not be relinquished until the blood pressure is normal. HEART DISEASE. It is in heart disease that the greatest disappointment in blood pressure estimations is experienced. In aortic regurgitation alone do we find any definite diagnostic information. In this condition the systolic pressure is high, the diastolic low; that is pulse pressure, which is the difference between the two, is greater than normal. In determining the working capacity of a diseased heart, several methods have been advocated, but none have yet been proven to be of consistent value. Moderate exercise raises pressure in normal hearts and this rise is sustained during it, if not unduly severe or prolonged. In weakened heart muscle from any cause a primary rise may occur, but is quickly followed by a fall; in the worse a fall occurs from the first. Dr. James MacKensie, in his book on "Diseases of the Heart," writes as follows: "It is a mistake, and one made frequently, to begin treating the high blood pressure as if it were a disease. Happily, the efforts employed to reduce the blood pressure are usually of little value. In order to appreciate the meaning of high blood pressure, it is well to consider the condition associated with its production, for I think it has a significance beyond that of being a manifestation of disease. Manifestly in heart failure induced or aggravated by high pressure, the best line of treatment is to ease the load and give the heart rest, to regain some store of reserve force." PATHOLOGIC LOW PRESSURE. In general, it may be said that lowered blood pressure has its greatest significance after hemorrhage or during surgical shock. Lowsley shows low tension in conditions of physical exhaustion. Munzer in cachexia, exopthalmic goiter and Addison's Disease. Edgecombe finds hypotension in subjects with poor circulation, cold hands and feet, liable to chillblains, neurasthenics, weak heart. Dr. Barker has stated that he has come unconsciously to think of tuberculosis as a probability when hypotension is present. Emerson has shown by clinical work that: hypotension or subnormal blood pressure is universally found in advanced pulmonary tuberculosis, in which the condition, emaciation, may play a part in its causation. Hypotension is found in almost all cases of moderately advanced tuberculosis, or in early cases in which the toxaemia is marked, except when arterio-sclerosis, the so-called arthritic or gouty diathesis or chronic nephritis complicate the tuberculosis and bring about a normal pressure or a hypertension. Potain and his followers assert that when we record a persistent abnormally low pressure for which we can find no other cause, we must consider the case as probably one of incipient tuberculosis, and that such a condition of the circulation may precede local signs of temperature elevation. This opinion has not been accepted generally or verified fully, and yet for generations one of the earliest signs characteristic of tuberculous infection has been alteration in the rate and quality of of the arterial pulse. As to the diagnostic usefulness of tachycardia and hypotension, we find the French writers in general consider that persistent hypotension, unexplained by other causes, is a fact of definite diagnostic value, and they assert that it precedes stethoscopic signs of pulmonary tuberculosis. The German writers, on the other hand, admit the occurrence of hypotension in pulmonary tuberculosis. They pretty generally agree that it cannot be determined constantly enough to serve as an early sign, or at any event before physical signs of the disease can be made out. From our observation, we would place more reliance on the results of a thorough physical examination of the chest than on blood pressure tests, but many more early, unsuspected or well developed cases would be identified as tuberculosis, if it were as much a matter of routine to make careful blood pressure tests, as it is to observe pulse-rate and temperature. The causes of low blood pressure in tuberculosis are probably primarily a toxic action on the vasomotor center in the medulla allowing of a vasoparesis or stimulating an active vasodilatation and secondarly progressive atrophy and degeneration. Gibson, of Edinburgh, is studying the relation of blood pressure to pulse and respiration, has endeavored to make some rule that would be of assistance in the treatment of pneumonia, or at least could be used as a warning of a beginning lack of equilibrium in the cardiovascular circulation or even heralding a collapse. He has concluded that as a general rule, the pressure in pneumonia is a little below normal, with considerable variation throughout the course of the disease. A pressure that is appreciably below normal is invariably of evil omen and any considerable fall bodes disaster. He says: "When the arterial pressure expressed in millimeters of mercury does not fall below the pulse rate expressed in beats per minute, the fact may be taken as of ex cellent augury, while the converse is equally true. That is, when the pulse rate per minute is higher than the pressure of the millimeters of mercury, the equilibrium of the circulation is seriously disturbed." We do not feel that a fatal result always accompanies a blood pressure lower than the pulse rate, nor do we regard a blood pressure higher than pulse rate as an indication of ultimate recovery. In cases of arterio-sclerosis or nephritis, or in any condition usually associated with an increase in blood pressure, the patient may have in pneumonia a higher pressure than normal, yet for that individual the pressure is relatively low. Prognostically, we believe that in the absence of a condition producing hypertension, if the pressure remains above the pulse rate, a favorable outcome is to be expected, and there will be little use for stimulation. On the other hand, a pressure lower than the pulse rate, while not to be regarded from a fatalistic viewpoint, nevertheless offers a relatively accurate indication for administration of cardiac stimulants. Dr. B. Raymond Hoobler had made blood pressure observations on children with various diseases, and in various stages of such diseases, taken indoors and after being in the open air, and the findings which he reported applied only to lobar and broncho-pneumonia, but were applicable to nearly all forms of acute respiratory conditions. As a general rule the blood pressure was increased when the child was removed from a warm room to the open air. The amount of such a rise was dependent upon several factors: (1) The more sick the child, the higher the blood pressure increase; (2) The higher the temperature, the higher the rise of pressure; (3) The warmer the indoor temperature and the colder the outdoor temperature, the higher the rise of pressure; (4) The lower the blood pressure before placing the child in the cold air, the higher would be the rise. During my service at the City Hospital, we made frequent use of the sphygmomanometer and of the fresh air treatment in our cases of pneumonia in adults and children. I believe the blood pressure records are of distinct service in pointing out when stimulation is necessary, and as you know I am an enthusiast in favor of the open air treatment of pneumonia. Typhoid fever is always accompanied by low pressure due to the effect of bacterial toxins causing vasomotor paresis of the splanchnics. This hypotension is slowly and regularly progressive with the development of the toxaemia and gives us an exact indication for the use of stimulation. With complications there is an increased fall, except in perforation and peritonitis, where there is an early and decided rise, which is followed by a fall as toxaemia increases. With hemorrhage, there is a fall of blood pressure with no initial rise, and thus in doubtful cases the estimation of pressure is of great value. Blood pressure estimations are of frequent value in surgery. The safety of anesthesia is increased by frequent application of this test during prolonged operations. As an indication for venesection, and saline infusion and stimulation, these tests are considered of great value by those who use them frequently. I believe the more we all study blood pressure records in our patients the more confidence we will have in the value of the instrument. The recent literature on this subject is very extensive, and I have not begun to cover the whole field in this short paper, but I hope it will draw out a thorough discussion of blood pressure in all its phases this evening. DISCUSSION. DR. ROE. The paper just read by Dr. Miner is so complete and so thoroughly covers the ground that I would not presume to add anything to it. I have been interested in blood pressure for quite a number of years and have made a good many observations both in private practice and in hospital work. I have found it a very interesting and instructive subject. To go back to the first cause of high blood pressure one must take into reckoning the strenuous life led by so many of the American people. The constant strain of hustle and competition in business; the over-eating and over-drinking without proper physical exercise; the over-training of many athletic sports; the fast pace of gay life in the large cities; all these are factors in the development of arterio-sclerosis, which is undoubtedly the primary cause of high blood pressure in the great majority of cases. I was very much interested in an article recently published by Dr. Roger I. Lee of Boston, giving the results of pathological conditions found in fifty-three autopsies performed at the Mass. Gen'l Hospital. Very careful records of blood pres |