With the patient eclamptic and stupid, whatever the date of the pregnancy, Hirst would do venesection immediately in amount from 16 to 24 ounces, depending on what amount seems advisable. If venesection is done before actual convulsions have occurred, the blood pressure falls temporarily but rapidly rises again. He finds that if a patient is past the eighth month, rupture of the membranes will usually bring a rapid fall of from 50 to 90 points in systolic pressure. Usually, of course, such rupture of the membranes will induce labor. He finds that the fluidextract of veratrum viride is valuable when eclampsia is in evidence or imminent. He gives it hypodermically, 15 minims at the first dose and 5 minims subsequently, until the systolic pressure is reduced to 140 or less. He admits that this is rather strenuous treatment. He does not speak of treatment by thyroid extracts, which has been regarded as valuable by some other workers.

In these patients who show eclamptic symptoms, he maintains a milk diet, and purging and sweating. It should be remembered that venesection or profuse bleeding during induced parturition is more valuable than sweating in all eclamptic cases and in all nephritic convulsions. Profuse sweating does little more than take the water out of the blood, and even concentrates the poisons in the blood.

Hirst causes purging by 2 ounces of castor oil and a few minims of croton oil. He also advises large doses of magnesium sulphate. In such serious disturbances as eclampsia, it is not necessary to give a magnesium salt, which, it has been shown, can have unpleasant action on the nervous system. Sodium sulphate is as valuable and is not open to this danger.

Hirst urges that whatever the blood pressure, with albuminuria, as soon as persistent headache occurs, and especially if there are disturbances of vision, the pregnancy must be terminated at once. On this there can be no other opinion. Temporizing with such a case is inexcusable.

After labor has been induced there is an immediate fall of blood pressure, which lasts some hours. The pressure will again rise, and usually is the last sign of toxemia to disappear, and he finds that this increased pressure may last from two to three weeks when there is not much nephritis, and several months when there is nephritis.

Although he says he has found no bad action from ergot, either by the mouth or hypodermically in these eclamptic cases, it would seem inadvisable to use ergot, which may raise the blood pressure. He finds that pituitary extract "can cause dangerous rise of blood pressure."

Pelissier [Footnote: Pelissier: Archiv. mens., d'obst. et de gynec., Paris, 1915, iv, No. 5.] believes that when there is prolonged vomiting in early pregnancy, with an increase in systolic blood pressure, and with an increased viscosity of the blood, the outlook is serious, and active treatment should be inaugurated.

Irving [Footnote: Irving, F. C.: The Systolic Blood Pressure in Pregnancy, THE JOURNAL A. M. A., March 25, 1916, p. 935.] reports, after a study of 5,000 pregnant women, that in 80 percent the systolic blood pressure varied from 100 to 130; in 9 percent it was below 100, at least at times, but a pressure below 90 does not mean that the woman will suffer shock; in 11 percent the pressure was above 130, and high pressure in young pregnant women more frequently indicates toxemia than when it occurs in older women; high pressure is more indicative of toxemia than is albuminuria; a progressively increasing blood pressure is of bad omen, and most cases of eclampsia occur with a pressure of 160 or more, but eclampsia may occur with a moderate blood pressure. Irving believes that with proper preliminary preventive treatment most eclampsia is preventable.

ALTITUDE

It has long been known that altitude increases the heart rate and tends to lower the systolic and diastolic blood pressures; that these conditions, though actively present at first, gradually return to normal, and that after a prolonged stay at the altitude may become nearly normal for the individual. Burker [Footnote: Burker, K.; Jooss, E.; Moll, E., and Neumann, E.: Ztschr. f. Biol., 1913, lxi, 379. The Influence of Altitude on the Blood, editorial, THE JOURNAL A. M. A., Nov. 1, 1913, p. 1634.] showed that altitude increases the red blood cells from 4 to 11.5 percent, and the hemoglobin from 7 to 10 percent The greatest increase in these readings is in the first few days. It has also been shown that with every 100 mm. of fall of atmospheric pressure there is an increased hemoglobin percentage of 10 percent over that at the sea level. [Footnote: Blood and Respiration at Moderate Altitudes, editorial, THE JOURNAL A. M. A., Feb. 20, 1915, p. 670.]