·ARI
CARDIAC EMERGENCIES AND HEART FAILURF
Pretention and Treatment
BY
ARTHUR M MASTER MD
MARVIN MOSFR MD
AND
HARRY L JAFFE MD
12 m 159 pa es illustrated

·NORMAL
BLOOD PRESSURE
AND
EN
HYPERTENSION
New Definitions
BY
ARTHUR M MASTER MIDE
Cardiologist The Vount Hospital Tew l ork and 1ssociate ul Professor
of Vedicine Columbia Unilersily Tai York
CHARLES I GARFIELD N D
Research 1ssistant in Cardiology The Mount Sinai IIospital em Lerk
AND
MAX B WALTERS M D FRCP (CAN)
vember Heart Slation le coute General IIospital Canada Formerly Research
1 ssistant in Cardiology The Vount Sina: Hospital ew Bork
Il ith 6 Illustrations
LONDON
HENRI KIMP TON
25 BLOOVISBURY 111 11C1

·ALL RIGHTS RLSERI CD 19,2
IT DI
NE

·DEDICATION
This book is dedicated to Mrs Hilda Vaster to
Irthur Jr to Edith and to Camilla Vaster who have
been a source of great help and of deep inspiration to
the authors
Arthur Vaster
Charles I Garfield
Max B Walters

·No text on this page.

·PREFACE Every physician be he general practitioner or specialist uses a sphyg momanometer The blood pressure reading thereby obtained may fre quently serve as an aid in diagnosis and prognosis of the clearly defined normal zanations in the limits of the blood pressure are taken into con sideration in each case Hitherto the almost universally accepted limits of normal blood pressure and of hypertension have been constants They were fixed unvarying criteria by which the normality or abnormality of the blood pressure was determined They were applied to adults of all ages of both seres and of different weights In tracing the evolution of the concept of normal blood pressure in clinical medicine it is surprsing to find that the definition of its normality depended largely on the results of statistical studies by life insurance companies The conclusions drawn from such investigations however are obviously not applicable to clinical medicine since they are based on findings in a selective group of individuals and are derived from a sta tistical analysis of group mortalty rather than from an examination of large numbers of unselected normal people In clinical medicine it is advisable to make a diagnosis of a disease or pathological condition only when at least several signs or symptoms are present Such a sound approach has been bypassed in cases of hy per tension Most physicians arbitrarily classify a person as hypertensive if he has a systolic blood pressure of 150 mm mercury and a diastolic blood pressure above 90 or 95 mm mercury in the absence of any other findings This attitude is unsound Because unvarying blood pressure limits have been applied to all age groups and to both men and women numerous mistaken diagnoses of hypertension have been made in the past I atients who were in reality normal have been made emotional and physical invalids They were advised to lessen their activities and to engage only in non strenuous occupations The Psychic trauma there by imposed upon these normal hypertensives the resultant disruption of the social life of the patients and their families the economic loss to the individual to industry and to the state have been great ·S PREI ICC The present work was undertaken in an attempt to establish the true normal limits of the blood pressure A statistical study was made of 74 000 unselected individuals representative of the average healthy work ing population These ner limits have been found to be definitely higher than those heretofore used and to vary with the age the sex and the weight of the subject The new limits of normal blood pressure herein proposed should be applied in each case not as an isolated criterion of disease but in correla tion with the entire clinical picture lhe same blood pressure may be an indication of disease in one patient and of little or no clinical signifi cance in another Used sensibly these new limits will prevent the frequent erroneous diagnosis of hvpertension lle have applied them in clinical practice for more than three years and art convinced that they arc well founded The evolution of the concept of blood pressure is of grcat medical and historical interest The circulation poorly understood as it was im pressed men even in ancient times The old I gyptians compared the force of the pulse beat to the cbb and flow of the vile which they con sidered to be one of the majestic phenomena of their time The history of blood pressure and of hypertension is interwoven rhe concept of increased blood pressure was clear in the mind of some chini cians even bcfore the era of chnical sphygmomanometry The sphygmo manometer the instrument with which every medical student is familiar after his tirst day on a hospital ward is in itself the evolutionary product of long lasting rescarch by famous physicists and physiologists It is our hope that this book will prove to be of help to physicians in their practice and to investigators engaged in various cyperimental and clinical studies It is a pleasure to acknowledge our debt of gratitude to Dr Samuel hahn of \en York His generous help in editing has made the prepara tion of this book a pleasure Vrs Henry Tamblın of Walpole Vass laborud cfficiently at tedious details Dr Harrs 1 Jaffe of low York gave us valuable criticisms Vir llcrbert H Varks and Dr Iouis I Dublin of the Vetropolitan Life Insurance Company kere co authors in the onginal investigations on which this book is fundamentally based AVV CIC VIB ·CONTENTS CHAPTER I History of Principles and Methods of Clinical Sphygmomanometry 11 CHAPTER II History of Blood Pressure Evolution of Normal Limits 37 CHAPTER III Factors Affecting the Blood Pressure Level 53 Age > 3 53 > » 5 Sex Emotional States Sleep Basal Casual and Supplemental Blood Pressure Soft Tissue and Vascular Factors Weight Race and Geographic Location Meals Ingestion of Liquids Diet Stars ation Exercise Altitude etc 27 61 62 63 CHAPTER IV 71 The need for Increasing the Range and Limits of Normal Blood Pressure-New Limits of Hypertension Blood Pressure Increases Significantly With Age High Incidence of So-called Hypertension in the Normal Population Benign Course of Many Hypertensies 73 77 81 CHAPTER 86 Presentation of Mes Limits of Normal Blood Pressure Material Statistical Technique 87 89 (9)

·10
CONTENTS
95
9
9)
Results
Normal Range of Blood Pressure
Mean Blood Pressure Values
A Comparison of Blood Pressures Found in Various Surveys
Influence of ll eight on Blood Pressure
Influence of Height on Blood Pressure
Relative Influence of Height and Weight
Incidence of Hipertension
Appendix
104
106
106
110
110
115
CHAPTER VI
Interpretation and Clinical Application of
Men Blood Pressure Limits
Coronary Occlusion and Hypertension
Blood Pressure Level Coronary Occlusion and Enlarged leart
123
116
179

·Chapter I HISTORY OF PRINCIPLES AND METHODS OF CLINICAL SPHI GMOMANOMETRI now in use To a medical student entering the medical wards of a hospital for the first time the present day measurement of blood pressure appears to be a simple routine procedure Yet the evolution of this important common chnical test required more than a century of research and experimenta tion by manv famous physiologists and physicians-Hales Maret von Basch Potain and others Their brilliant ideas and skillful devices pointed the way to the ultimate solution of the problem of accurate clinical blood pressure measurement During the course of their experi mentation many modifications were introduced by numerous other in vestigators resulting in the production of a large number of devices to measure the blood pressure The great majority of these were cumber some and impractical and did not withstand the test of time and experi ence only occasionally did they improve upon the original ideas and methods of procedure The noteworthy developments of this long series of experimental studies finally culminated in the simple technique We shall attempt in this presentation to discuss the more important milestones in this ey olution The first actual measurement of the blood pressure was performed by Stephen Hales! (Figure 1) in 1733 about a hundred years after Harvey had elucidated the mechanics of the circulation Hales used the direct approach and his method can best be described in his own words In December I caused a mare to be tied down alive on her bach she was 14 hands high and about fourteen years of age had a fistula on her withers was neither very lean nor yet lusty having laid open the left crural artery about 3 inches from her belly I inserted into it a brass pipe whose bore was of an inch in diameter and to that by means of another brass pipe which was fitly adapted to it I fired a glass tube of nearly the same diameter which was 0 feet in length then untying the ligature on the artery the blood rose in the tube 8 feet in length 3 inches perpen dicular above the level of the left ventricle of the heart We may admire the skillfulness and accuracy of his technique crude as it was by taking special care to place the tube at the heart level he obtained an accurate blood pressure measurement Sitruilar measurements were carried out by Hales on sheep dogs and other animals the results he obtained are still considered to be correct Obviously Hales method is crude and (11) ·12 HJSTORI OF PIIYCVOVANOVETRI impractical and is only of historical interest but it represents the first measurement of blood pressure ever performed It was not until another century had passed following Hales classical experiment before the first technical improvement for measuring the blood pressure was made In 1828 Poiseuille : introduced the U form of mercury manometer for blood pressure measurement - the hemo dynamometre (Figure 2A) This consisted of a U shaped tube 7 mm in diameter The shorter arm has introduced into the artery of an animal FIG 1 - STEPHEY HALES (1677 1761) First to measure the blood pressure (in animals) with the direct intra arterial method after having been filled with a solution of subcarbonate of soda to present clotting The intraartenal pressure was transmitted directh to the mercun column and could be read on the manometer Continuous approrimate determinations of the blood pressure could thus be made in animalsThe disadvantage of this method was that the large dameter of the tube and the heau scight of the mercun column presented the registration of smaller oscillations and pressure sariations ·HISTORY OF SI III GMOVANODIETRI 13 Magendie 15 in 1850 improved the Poiseuille manometer by intro ducing a large reservoir partly filled with mercury (Figure 2B) From its lower end arose a thin 2 mm tube The reservoir was connected to the artery of the animal so that the pressure variations acted over a comparatively large surface of mercury These variations could be meas ured by changes in the height of the mercury column in the attached tube By increasing the surface over which the pressure variations could B Fr 24-POIS EUILLE HEMODYNAMOMETRE (1828) U tube hilled with mercury Short arm connected to artery of animal and filled with solution of subcarbonate of soda to prevent clotting FIG 2B --MAGENDIE MANOMETER (1850) Increased the sensitivity of the Poiseuille Manometer by introducing a mercury reservoir and decreasing the diameter of the glass act and by decreasing the diameter of the manometer and hence the weight of the mercury column in it this system was much more sensitive to small changes in pressure Its principle was incorporated in later instruments which employed a mercury manometer to measure the blood pressure In 1841 Carl Ludwig of the University of Leipzig introduced a method for the direct registration of the intraarterial blood pressure and its variations He placed an ivory float in the taller arm of the Poiseuille ·14 HISTORY OF SPUIGION INOVETRI manometer to this he attached a rigid writing arm (Figure 3) The movements of the mercury column sere thus transmitted to the writing arm and were recorded on the revolving drum of a himograph Although the humograph had actually been descloped by other physicists (Pon celet Vorin) 's It was first introduced into medical physiology by Ludwig It still is a fundamental device in the physiology laboratory employed to register various mechanical phenomena Ludwig was the first to use it to record the blood pressure Although the determination of the direct intraarterial blood pressure by these procedures was possible in animals it was not feasible in man Vany physicians in the past had been impressed with the importance Fi 3-LL DHIL YVOX RAPAT (1817) sminked paper B stand it ase) C-heinht D-pendulum of clockwork Farting point f-foot - Mercury manometer Ilie non float is placed in the taller arm of the losseulle monometer and 15 connected to the writing am The blood pressure changes are recorded contin uously on a reiolsing kymograph ·HISTORY OF SPIIGVOVANOVETRY 15 of the force of the pulse but Julius Herrison 78 of Paris was the first to devise a method for the objective demonstration of the force of ar terial pulsation in man llith him began the indirect measurement of blood pressure in human beings In 1834 he introduced his Sphyg mometre (Figure 4) This consisted of half a metal sphere connected to a graduated capillary tube with a membrane covering its plane surface The system was filled with mercun so that the column of mercury ex tended part way up to the capillary tube When the membrane was FK 4 -HERRISON SPHEGMOMETRE (1874) AB-half a metal sphere covered with membrane C-stopcock D-capillary tube filled with mercury The membrane is placed on the radial attery and the magnitude of oscillation of the mercury column is noted placed on the radial artery Herrison saw the oscillations of the mercury column which corresponded to the arterial pulsations and actually measured the magnitude of these pulsations He stated that with this instrument it would be possible for the physican to record the exact magnitude of the pulse in each patient hence for the first time an objective method was available to follow changes in radial artery pulsa tions during the course of an illness or during health Although Herri son s original purpose was only to demonstrate the degree of oscillation ·16 HISTORI OI SPHIGUO IMOVETRI of the radial pulse his instrument indirectly demonstrated and measured the blood pressure in man In 1895 Karl Vierordta German physiologist introduced the prin ciple of measuring the amount of counter pressure necessary to obliterate the pulsations in a peripheral arters as an inder of the blood pressure level Hc devised an ingenious but cumbersome and impractical sphyg mograph for the purpose of utilizing and demonstrating this new approach to blood pressure measurement A partially weighted button connected by means of a metal rod to a writing lever (I igure »), was placed on the radial pulse The oscillations were recorded on a kimograph Increasing weights scre placed in receptacles on the metal rod The amount of weight required to obliterate the radial pulsation was taken as an index of sys tolic pressure "1111 W San MTN படபடப்பைப்பப்பப்படி Z FC 5 - IERORDT STHYGYOC RAPH (1855) b-metal button 1-metal bar with plates to hold weights 5-unting point Vetal button applied to radial artery amount of weight required to obliterate radial artery rulsations taken as inder of systolic pressure Vares 101 the well known I rench physiologist was able to improve the rough and cumbersome sphygmograph of lierordt In 1860 he devised a small accurate instrument which was applied to the forearm and gave excellent radial pulse records (Figure 6B) Later he improved the sensitivity and accuracy of his sphygmograph by using a rubber tambour to transmit the arterial pulsations to the writing arm (Figure 6C) following the introduction of Varct s practical sphygmograph numerous physiologists employed it to determine the peripheral blood pressure by utilizing rerordt s principle-se measuring the weight required to obliterate the radial pulsations I oster" (1867) Bahieri (1869) Landois" (1872) Ihiladelphien! (1896) -all used this principle in the instruments the constructed An erample of this type of appara {us is the one devised by Thiladelphien (Figure 7) sshich enjoved a wide use for a short period of time it was soon discarded when more accurate device emplos ing different principles fiecame available Thc mensure ment of the blood pres url sith this type of apparatus was gros ly

·A
B
C
6 MAREY SPYGYOGRAPH
Awinnsple of method used --Compact sphygmographs eassly attached to
forearm
AA-segment nf artery L-ting arm
C-small rounded button wrich
transmits arterial movement to the writing arm
& First model Direct trafismission sphygmographs Introdu ed 1860 The
expansions of the astery are tran mitted to a leer recording the movements on
the smoked paper
6- Improsed model Indere t (pneumatic) transmission sphygmograph The
No ements of the pulse are transmitted to a rubber tambour and the changes in
pressures in this tambuur are recorded on the smoked paper
D-Tambour with wnring att
2
( 17 )

·18 HISTORY OF SPILGIOVANOVCTRI inaccurate the results obtained being between two and ten times the normal Using Vierordt s method of radial pulse obliteration by means of a solid medium several other machines were later produced Iyalden burg" in 1875 introduced a rather complicated instrument ( Pulsuhr or pulse watch ) (Figure 8) which is of historic interest in that he used the blood pressure readings thereby obtained to publish the first book on blood pressure in man In 1888 Bloch's devised a simple instru ment which was small enough to casily fit into a physician s vest pocket (Figure 0) Pressure was gradually exerted by the metal button on a fingernail placed directly on the radial artery At the instant the radial Tih mm NI N 2 FIG 7-PHILADELPHIE SEXYGVOYE TROGRAPHF (1896) No I - the large leather armler at the loser right of the figure is fastened around the forearm Mo -revolving paper roll onnected with watch system-Mo 7- resting on the forearm -No 8 No 3-graduated aluminum bar connected with the nor) bution-No 6-thich obliterates the radial artery no +-weight mring without friction on graduated metal bar by Ineans of which the pressure on the arters is increased until the oscillations recorded on the paper disappear No 9-screw tor regulating the position of the story button on the radial artery simultaneously putung the long an-Mo 9-sith wating point-lo 10-paralle! to the aluminum bar permitting the inscription of the pulsations of the radial arteri on the mo ing paper No il -handle to start and stop sphygmometro graph C-leser attached to pory burton-No 6-which compresses the radial artery The pressure on the graduated aluminum bar necessary to obiscerate the radial artery corresponds to the true blood pressure ·HISTORY OF SP: GVOVANOMETRS 10 pulsations disappeared the systolic pressure was read on the gauge All these devices were grossly inaccurate rather diſhcult to apply in clinical medicine and hence were employed for only short periods of time WWW s $* Arm rest --- Fir 8-V ALDFNBURG PULSUHR (1879) --metal button farten Batertical adjustment horizontal adjustment g---box with spring mechanism and scale Metal button placed on tradual artery amount of force required to obhterate puisation taken as an indication of systolic pressure In 1875 Varey is introduced an apparatus for the more accurate measurement of the blood pressure Instead of appling local pressure to the arterial wall only this instrument compressed the blood vessels of the forearm from all sides equallı (Figure 10) The forearm and hand were inserted through a tight fitting rubber collar into a metal bor sshich was filled with sater Aglass windos in the bor gave a view of its interior The boy was connected with a mercun manometer and a recording tambour By means of an attached reservoir the pressure in ·20 HISTORI or SVGVOVATOVETRY the bou could be gradually raised As the pressure in the bor nas raised, the pulse waves were transmitted to the fluid and thence to the tambour The pulsations increased in amplitude up to a certain point and then diminished Long before the pulsations disappeared entirely the skin of the arm was secn to blanch thus shox ing that the vessels had been collapsed and their intraarterial pressure or ercome *SVERDIN Fr 9--BLOCK SPACYOMETER (1899) Pressure everted by a mecal button on a fingernai placed on radial artery until the pulse is obliterated At that instant the pressure is read on the gauge Vare behered that the point at shich the maximum oscillations oc curred and the time when the skin was seen to blanch were the two im portant indexes of blood pressure measurement He thought that at the point when the maximum o cillations developed the external pressure of the water in the lor eracth balanced the internal pressure of the blood within the arter so that the arterial wall was merch a floating mem brang Hence at this instant the pressure of the blood within the arten could be considered as being transmitted direct to the mercun manometer and the recording tambour This Varey felt represented the true level of the intravascular pressure Later man inuestigators including Janeway 2 Believed that the point of maximum pulsation represented the level of the diastolic pressure Subsequenth " Varut was credited with having held the opinion which Janesas had expressed It isesident however from reaching his original

·HISTORI or SU 111CVOIVOVETRI
21
C
A
Fic 10 VAREY SPHYGYOY VOYETER (1878)
A-forearm inbox filled with water and having small glass window Reset
voir
C-puller system
m-mercury manometer V-rubber cambour
Pressure ss gradually raised is the metal box to the point of maximum oscillation
and to the point of skin blanching Both criteria are used as indexes of blood
pressure measurement

·22 HISTOR 21 SP: 4101480\CTR description that Marey considered the external pressure at which the maximum pulsation of the arterial walls occurs as a ner indirekt measure of the blood pressure giving no thought to its relationship to sistolic or diastolic pressure Von Recklinghausen and other investigators subsequenth) shored that external pressure which produced the maximum Oscillations 1 as actually closer to the pressure * than to the diastolic pressure mean blood Fig 11 -MAREY FINGER SPHYCHOM ANOMETER (1878) M-glass receptacle b-mercun, manometer a-T tube c-bulb ro increase pressure in water filled system Oscillations of dittat arteries are transmitted directly to the mercury column The mean pressure is usually quien as half the sum of the values for the systolic and diastolic pressures This is not strictly accurate and a true numerical erpression in millimeters of mercunt of the mean pressure is not simpli the average of the values of si stolic and diastolic pressures 12 the sum of these values disided by 2 (arithmetic mean) The 11 crane pressure throughout the cardiac cycle te the true or gcom metric mean is somewhat lower than this lying nearer the diastolic than the su stolic pressure If the pressure fell in a steady slope from its systolic to its diastolic lesel throughout the cardiac cycle and the pulse wave inscribed a serfect triangle then the arithmetic and geometric means would be identical The descending limb of the pulse cunc however presents one or more secondan waves which present at front assuming the purely triangular form ·HISTORI OF SPIGVOVANOTICTRI 23 Three years later (1878) Marey ? 23 devised a second smaller apparatus into which only one finger was inserted (Figure 11) The pulsations were transmitted directly to the mercury column According to Varey s description One finds at which pressure the maximum oscillations occur and at this moment one reads on the scale of the manometer the absolute value of the maximum and the minimum Using this finger apparatus Marey discusses the possibility for the first time of measuring the constant level or minimum level of the blood pressure So Varey may be considered the first to make a successful attempt at indirectly measuring the diastolic pressure in man QUIET VERDIN 1 3 FIC 12 - Mosso SPILYCHOVATOVETER (1899) Same principle as used by Marey but volume changes are measured simultan cously in fingers ·24 HISTORI OF SPHYCHOVAVOVETKI This instrument was unsatisfactory because the volume changes in one finger proved too slight to gue satisfacton readings In 1993 Vosso a pupil of Vares s used the same principle to construct a laboratory sphigmomanometer (Tigure 12) Bi utilizing the cumulatne volume changes in four hngers simultaneousls llosco was able to obtain satisfactori oscillations His device was considered to give fairls STUTTE B FIC 13 -CARTNER JOVOVETFR (1899) A-mercuri manometer 13--pneumatic cuff encircling finger C-bulb screw device to compress bulb Ehinger rest Pressure at which a flush or pulse returns to the bloodless finger is taken as the index of systolic pressure accurate readings and was emploser for a long period of time but be cause it was so cumikrome it remained as a laboratori procedure In 1899, Gartner (Figure 13) introduced his Tonometer which al o involved the principle of blood pressure measurement m the digital arterics It was much more compact than Vos os instrument and because it could be easily applied it gained fairly side popularity for a ·А B B Fic 140-VON BASCH SPHEGMOVANOMETER (1876) A-mercury manometer B-pelote consisting of glass funnel with membrane distended with water C-glass funnel to introduce water E-pinchcock Dtube First practical device for clinical measurement of blood pressure-systolic only FIG 14B - IMPROVED VON Bescu SPEYGMOVANOMETER a--pelote b-connecting tube between manometer and pelote still filled with c-metal manometer (2) water ·26 HISTORY OF SPUIGVOVANOVETRI short period of time The point at which a flush returned to the bloodless finger, or the moment when pulsations were felt by the patient was con sidered to be a measure of the su stolic pressure These instruments all had the disadvantage of measuring the pressure only in the small blood vessels of the finger Is is well known these small blood vessels are readılı subject to vasomotor changes, and variations in pressure within Oro M FIG 15 - IOTAN SPHYCHOVANOMETER (1899) A-relore consisting of a rubber cushion 3 x 2 cm filled with air B-thin part put directly on arterial wall Vanaeroid manometer R-sale connected to rubber bulb Vodification of lon Basch sphygmomanometer but portable and utilizing the first anzerord manometer them may occur as a purch local manifestation I or this reason the instruments proved unsati factors and were soon discarded Ilthough Varey was the first to measure blood pressure in man with reasonable accuracy by indirect methods his method was too complicated ·HISTORI OF SPUIGVOVATOUCTRI 27 for practical clinical work and it remained a laborator procedure The first to make indirect blood pressure readings a clinical practical proce dure in man was von Bascha Viennese physician who ill always be remembered as the inventor and father of clinical sphygmomanometry In 1876 he constructed an apparatus that utilized a pelote originals consisting of a glass funnel covered nith an elastic membrane connected with a reservoir and with a mercury manometer (tigure 144) The pelote and tubing were filled with water from the reservoir and the zero point of the manometer was determined after the mercury came to equi librium The mode of applcation was as follows In artery which lies directly upon bone such as the temporal or radial is selected and pressure exerted upon it with the membrane of the pilote The pressure thus exerted on the artery is transmitted through the water blied system to the mercury manometer The pulse i simultaneoush felt uth atinger of the opposite hand just besond the point of compression It the mo ment when the pulse disappears or when it first returns as the pressure is decreased the manometer is read this is the systolic pressure Although the von Basch sphygmomanometer could be used clinically it had the disadvantage of being rather bulk and cumbersome Thrs objection was partially overcome bt von Basch when he replaced the mercury manometer with a more compact mctal manometer in 1890 (Figure 148} Houever water was still used to fill the system In 1889 Potain"? modtied the von Basch instrument mahing it much more compact and portable (Figure 15) He replaced the crude pelotc von Basch had employed with a rubber cushion 3 X 25 cms and replaced the water with air the pressure in tht si stem could be raised by a rubber bulb lotusas the first to employ an anaerord manometer is a result of these modifications the Potain sphygmomanometer htted easily into a small compact box which could be readily carried by the physician on his calls to the home and hospital Von Basch s and Potain s machines became widely known and were employed chnicalls for a long time Their method however had seseral disad vantages The amount of tissut surrounding the arter and the quality of the arterial wall were variable factors which could infuence the level of the blood pressure Besides the experience and ability of the indi vidual physician in applying the proper technique was an important consideration in obtaining accurate readings Potain himself warned that a frequent source of error arose from an inabilty to distinguish betneen the capillary pulse of the physician s finger and the pulse of the patient For these reasons blood pressure (su stose only obtamed with this type of apparatus were not veri accurate and were usually too high In 1896 a marked advance in chnical sphygmomanometry was made by Riva Roces 'anho was professor of medical pathology at the Uni versity of Padua The apparatus he devised is the forerunner of the modern sphygmomanometer (Figure 16) The important feature was ·28 HISTORY OF SPH GYOMANOVCTRI the introduction of a compressing mechanism, consisting of a rubber tube or bag 5 cm wide which encircled the middle of the upper arm and was inflated by means of a hand bulb The rubber bag was connected with a mercury or anaeroid manometer The radial artery was simultane ously palpated at the wrist At the instant before the oscillations dis appeared, the level of the systolic pressure was read on the manometer This method had the advantage of applying the pressure in a mort even manner over a wide area without the difficulties involved in the direct obliteration of the radial artery necessitated by the Potain von Basch and other instruments VERON FIC 16-Riva Rocci SPUYGWOYANONETFR (1896) In principle the model used at present The narrow cm armlet was later replaced by a 12-14 cm cuff Ascar later 1897 Hill and Barnard' brought forth a sphygmometer similar in principle to that of Riva Rocci (I igure 17) An anncroid manometer was attached to the encircling cuff Vovements of the nucdlc of this delicate mctal manometer considerably magnified the oscillations of the pulse wave As the criterion for blood pressure measurement Hill and Barnard recommended the mid point of the maximum oscillation of the necdle which they thought corresponded to the mean blood pressure ·HISTORY OF SPUIGVOVANOVETRI 29 However Janeway 354 and others later suggested that the lowest point at which the maximum oscillation of the needle occurred as the diastolic pressure The method of Hill and Barnard is the forerunner of the more modern oscillometric methods which employed a wider cuff and more accurate recording methods eg Erlanger s sphygmometers (1901) and Pachon s oscillometric sphygmometer*" (1909) In 1901 von Recklinghausen" pointed out that the readings obtained were about 10 per cent too high when a 5 cm wide armlet was used He introduced the 12 to 14 cm wide cuff which is emploved today and which gives accurate readings 1 MARS SP YOMOM TER 10 150 А E 50 150 cm с GE J MICKS OFES 89 1000 B FIG 17 -HILL AND BARNARD SPHYGMOMETER (1897) A-sensitive anaeroid manometer B-5 cm wide armlet C-inflating pump E-valve for slow escape of air Point of maximum oscillation is used as the measure of diastolic pressure Many instruments using the wide cuff connected to a manometer have been described by different investigators each making some modification of the samne pnnciple eg Stanton ** Janeway • Erlanger " Cook 3 etc With all of these the systolic pressure was recorded when the radial pulse disappeared at the wrist and the diastolic pressure when the lowest point of maximal oscillations of the pulse occurred The instrument devised by Erlanger (Figure 18) although cumbersome and complicated in its construction was considered to be one of the most accurate in the measurement of the blood pressure The point of disappearance or return of the pulse and the point of maximum pulsation were made so clearly visible that subjective errors were minimized These methods were used until the auscultatory technique became known and generally employed This technique was first described in ·30 HISTORI OF SPHII GMOVANOMETRY 1903 by Korotkow,"7 a Russian physician in St Petersburg Hith the bell of a stethoscope applied over the artery below the compressing cuff four distinct phases of sound can be heard and clearly differentiated, phase I the sudden appearance of a clear faint tapping sound, growing gradually louder phase II, the sound assumes a hissing murmurish quality phase III the murmur disappears and the sound becomes clear and louder phasc IV the sound suddenly becomes muffled and phase the sound disappears Korothow suggested that the systolic pressure PINION ToArm To Inllator Fig 18 - FRLAYERS SPYGVOY AAOYETER (1901) The instrument is connected to the encircling cuff on arm Pressure in the system is gradually increased by the inflator and its level is indicated on the mer cury manometer Arterial pulsations are transmitted through the thin rubber bulb (B) enclosed in glass case (C) to the enting arm and is inscribed on the ky mograph A complicated but sery accurate instrument to measure the blood pressure ·HISTORY OF SPHSGVOV INOVETRI be recorded at the very beginning of the first phase and that the diastolic pressure be recorded at the end of the fourth phase ie when the sounds disappear Vans ins estigatorsknd found that the beginning of the fourth auscultaton phase (when the sounds become muffled) corresponds to the diastolic pressure found with the oscillometric method (n hen a sudden drop in maximal oscillation occurs) They therefore concluded that the diastolic pressure reading should be recorded at the beginning of the phase Using the same techniques however others** found the oscillo metric diastolic pressure corresponds to the beginning of the fifth auscul tatory phase In 1939 the Committee on Standardızation of Blood Pressure Readings of the American Heart Association and of Great Britain and Ireland recommended that the point of muflling of the sounds (beginning of phase NV ) be accepted as the diastolic pressure When the level of disappearance of the sound is lower than the level when the change occurred that level also should be recorded és 10/100 mm mercury Very recently however (1951) The Councy For High Blood Pressure Research of the Scientific Council of the Ameri can Heart Association through the Commttee to revise Standardization of High Blood Pressure Readings concluded that the post of complete cessation of the sounds is the best index of the diastolic pressure * Under hermodynamic conditions in which no cessation of sounds occurs the point of muffling should be taken as diastolic pressure if distinctis heard and should be recorded as the pont of muftled sounds When no clear demarcation of the mufiling is heard drastolic pressure should be left indefinite and so indicated e f 150/30% The recommendations formulated in 1939 contained the suggestion that two values for diastolic pressure be recorded & 140/80-10 It is the impression of the Committee that such a practice has not been fol loned very generally It doubts on the grounds of hemodynamics the propriety of listing tuo figures as diastolic pressure The disappear ance of auscultatort sounds as a criterion of diastolic pressure is recom mended on the following grounds (A) The current practice of using the point of sudden muflling of the sound: nas based (1) on comparisons with oscillator) criteria and (2) on hemodynamic data derived from studies of excised or isolated artenes undergoing direct compression or decompression The former (1) ss of dubious salue since no general agreement has been reached regarding the oscillatory criteria of diastolic pressure The latter (2) appears to be nisky owing to the fact that unsolved physical factors may enter when pressure is translerred to arteries from a cus of arbitrary size through the tissues of a limb Form Recoram adat on for Human Biond peu D terminat ons by Sphygmo manomet > Jame Badi 11 UD Cha! A R Connor VDB mllen NID B am err VD and C. 13 Wgge D C vlat on 503 2951 ·30 HISTORI OF SPHY GHOVANOMETRY 1903 by horotkou 37 a Russian physician in St Petersburg With the bell of a stethoscope applied over the artery below the compressing cuff four distinct phases of sound can be heard and clearl differentiated phase I the sudden appearance of a clear faint tapping sound growing gradually louder phase II the sound assumes a hissing murmurish quality phase III the murmur disappears and the sound becomes clear and louder phase If the sound suddenly becomes muffled and phase 1 the sound disappears Korothon suggested that the sistolic pressure Qonun MTN PIXION ToArm To Inflator Fic 18 - FRLAYCERS Spr}( VOX INOMETER (1901) The instrument is connected to the encircling cuff on arm 1 ressure in the system is gradually increased by the infator and its level is indicated on the mer cur manometer Arterial pulsations are transmitted through the thin rubber Iulb (B) enclosed in plass case (C) to the writing arm and is inscribed on the Ismograph A complicated but sers accurate instrument to measure the blood pressure ·TABLET - CHRONOLOGIC ELOLUTION OF THE TECHNIQUE OF BLOOD PRE strE NEASL REMENT Dale of 1 vention 1733 Vame of Inte for Hal Pnet pie Insolied Pressure and cat d by blood 1 1 a tube connected to artery of an mal 1828 Poiseu 11 Introduced U form of me cury man met 1834 Hérri on Devised first phygmomete arterial pul tonis a man ob rved ampl tude of 1847 Luds g Connet d A tand writing arm to Poiseudle manom ter for th d tegist at on of blood pressure 1830 M gende Mod fi d and improved the Po eu lle manometer 1955 Verordt Sy tol c blood pssu Il man m 11 d nd rectly by weight regu d to oblt t d al pulsations Devis da ompact sphygmograph easly attach d to forearm 1860 Viarey 1867 1868 1872 1875 1896 Foste B hie: Lando: Waldenbu g Ph lad Iph Led ser at to mea u P.pl wth M tol ssur y s sphygmograph 1875 Ma ey P apr! d to nt ad laty by enclos ng for arm in & m tal bo Le 1 of m inal arterial pul at on nd blanch ng of sk n tak n as nd ces of Hoodp u Pnger pl thy nog aph emplove it measu the blood Pssu Same prin pl as abo e but appled to one fing only 1878 Mia ey 1876 Von Bah Ft pact cal ln al phygmomanometer Util zed Pne ple floral comp ess on of art ry tll pul at n di app ad 1888 Bloch A ve t pock t sphygmom t Veasured amount of local pe su qu d to obi te at ad al pulsat ons 1889 Potan Imp Ud ed th von Basch sphygmom nom t first ana od manom t 1895 Voo Vea u d d gital a typ by to tetung volum hanges n 4 finger smultaneou ly 1896 R va Roc Employ a 1 cula оор 5 IT wd rubb bg sphyginomanometer n of upper mth a Fo runn of nod ת 1897 Hill & Barn d but used metal ini nom te Sam pncipl as abos employ do cliom tr m thods 1899 Gå tne р Masu d y tot met of dg tal rten by tono- 1901 Von R kl ngbau en Int oduced wd 12 14 cm uff Stanton 1903 1903 1904 1904 Amec ns who were amo g the first to mploy pr cti al dvices f blod p masur ment El ng 190 hroth w Introdu d auscultatory techniqu ·34 HISTORI OF SPHIGHOVANOULTRI BIBLIOGRAPHY 1 HALES S Statical Essays Containing Haemostaticks or an Account of Some Hydraulic and Hydrostatical Experiments Made on the Blood and Blood Vessels of Animals London i Innys and R Manly 1733 2 POISEUILLE J L M Recherches sur la force du coeur aortique Journal de Physiologie Experimentale et Pathologique par F Magendie S 272 1828 3 POISEVILLE J L M Recherches sur la force du coeur aortique Journal de Physiologie Experimentale et Pathologique par F Magendie 9 341 1829 4 GUETTET Memoire sur les hemometres Comptes Rendus Hebdomadaires des Seances de L Academie des Sciences 30 64 1850 5 VASCHIDE N and LAHY J V La Technique de la Mesure de la Pression sanguine particulierement chez l homme Arch Generales de Medicine 7 349 180 602 1902 6 Lupus C Beitraege zur Kenntnis des Finflusses der Respirationsbeweg ungen auf den Blutlauf im Aortensystem Arch fuer Anatomie I hy sio logie und Wissensch Medızın p 242 1847 7 HERRISON J Le Sphygmometre Instrument qui traduit a loeil toute Taction des arteres Utilite de cet instrument dans letude de toutes les maladies (memoire presente a 1 Institut 1834) Cired by Marey J La Circulation du Sang a l État Physiologyue Lans ( Masson 1881 8 VON RECKLINGHAUSEN H Blutdruckmessung und kretslauf in den Arterien des Menschen p 7 Dresden and Leipzig 1910 Theodor Steinkopff 9 VIERORPT Die Lehre vom Arterienpuls Braunschweig 1893 r 161 10 MAREY FJ Recherches sur le pouls au moyen d un nouvel appareil enregistreur (sphygmographe) Gazette Medicale de Paris 1860 pr 225 236 298 11 VAREY E J La Methode Graphique dans les Sciences F xperimentales et l'rincipalement en Thysiologie et en Medicine p 274 Paris 1878 (Masson 1? VARFY I J La Circulation du Sang a I ftat Physiologique Iaris 1881 p 222 G Masson 19 FOSTER BW More on the Regulation of the Pressure on the Artery in the Application of the Sphygmograph British and foreign Kledico-chir urgical Reven in 210 1867 14 BFHIFR Mouselu sphygmograph imagine par V Longuet (azette Med Paris p 660 1869 15 LANDOIS L Die Lehre som Arterienpuls nach eigenen Versuchen und Be obachtungen dargestellt Berlin 1872 A Ilirschwald 16 PHILADELPRIEN VIA Le Sphygmometrographe imagine construit par V Charles Verdin Comptes Rendues llebdomadaire des Seances et Memoires de la Societe de Biologie 78 199 1896 17 WALDFBLRC L Die Vessung des I ulses und des Blutdrucksam Vienschen Berlin 1840 A Flirschu ald 18 BLOCR AV Touscau Sphygmometre Comptes Rendus Hebdomadaires des Seances et le moires de la Societe de Biologie 5 88 1899 19 MARET FJ Viesure Manometrique de la I ression du Sang dans les Arteres de 1 Ilomme Ihysiologie Foperimentale ? 315 1876 "O TIILLILS IA and Dry TJ Allistory of the Heart and the Circulation Ihiladelphia and London p 179 1948 1B Saunders Co ·HISTORY OF SPUIGVOVANOVCTRI 35 212 BEST CH and TAYLOR NB The 1 hysiolo.ical Basis of Medical I rac tice Baltimore Williams & Wkins Company p 146 1930 216 BEST CI and TAYLOR NB The Physiological Basis of Medical Prac rice Baltimore Williams & Wilkins Company p 194 19,0 72 MAREY EJ Nouvelles Recherches sur la Mesure Manometrique de la Pression du Sang chez Illomme Physiologie Experimentale p 253 Tol i 1878 1879 23 VAREY EJ Recherches sur la tension Arterielle Physiologie Experi mentale # 175 1878-1879 24 Vlosso A Sphygmomanometre pour Mesurer la I ression du Sang chez I Homme Arch Italiennes de Biologie 23 177 1893 7) GAERTNER G Ueber Einen Neuen Blutdruckmesser Wien Med Wschr 19 1412 1899 76 VON BASCH S Ueber die Volumetrische Bestimmung am Menschen Wiener Mediz Jahrbuecher 1876 27 POTAIN PC La Pression Arterielle de 1 Homme a I ftat Normale et l'athologique I aris 1902 G Masson 28 Riva Rocci S Un nuovo sfigmomanometro Gazz Vled di Torino 17 112 1896 29 Riva Rocci S De la Mesuration de la Pression Arterielle en Clinique La Presse Medicale 22 307 1899 30 Hill L and BARNARD H A Simple and Accurate Form of Sphygmometer or Arterial Pressure Gauge Contined for Clinical Use Brit M J > 904 1897 31 ERLANGER J A New Instrument for Determining the Minimum and Maxt mum Blood Pressure in Man Johns Hopkins Hospital Report 12 53 1904 32 PACHON V Ocıllometre Sphygmometrque a Grande Sensibilite et a Sen sibilite Constante Comptes Rendus Hebdomadaires des Seances et Memontes de la Societe de Biologie 66 776 1909 33 VON RECKLINGHAUSEN H Ueber Blutdruckmessung beim Menschen Arch f Exper Path 46 88 1901 34 STANTON WB A Practical Clinical Method for Determining Blood I res sure in Man with a Discussion of the Methods Hitherto Fmplo, ed Univ of Penn Med Bull 15 466 1903 35Q JANEWAY F C The Clinical Study of Blood Pressure New York D Apple ton & Co ( 73 1907 35. JANEWAY TC The Clinical Study of Blood I ressure New York D Apple ton & Co p 90 1907 356 JANEWAY TC The Clinical Study of Blood Pressure New York D Appleton & Co p 109 1907 350 JANEWAY 1 C The Clinical Study of Blood I ressure New York D Appleton & Co p 121 1907 36 Cook HW and BRIGGS J B Clinical Observations on Blood Pressure Johns Hopkins Hospital Reports 11 451 1903 37 KOROTOW Ber Militararztl Alad St Petersburg 1903 5 From kylın E Der Blutdruck des Menschen Dresden und Leipzig 1937 T Steinkopff 38 FISCHER J Die Auskultatorische Blutdruckmessung im Vergleich mit der Oscillatorischen von Heinrich ron Recklinghausen und ihr durch die I hasenbestimmung Bedingter Klinischer Vert Zeitschr f diaetetu physik Therap 12 389 1909 39 LANG G and WANSWETOVA S Zur Merhodil. der Blutdruckmessung nach von Recklinghausen und horotloff Deutsch Archi Alin Med 09 441 1908 ·36 HISTORY OF SPHY CHOVITOVETRI 10 TAUSSIG A E and Cook J E The Determination of the Diastolic P'res sure in Aortic Regurgitation Arch Int Med 11 S4? 1913 11 WARFIELD L M The Classification of the Chronic High Blood Pressure Cases Am J M Sc 151 414 1917 47 \ EYSSE AN and LUTZ, BR A Comparison of the Auscultatory Phe nomena in Man with the Tracing of the Erlanger Sphy momanometer Am J Physiol 32 427 1913 13 GITTINGS ) C Auscultatory Blood Pressure Determinations Arch Int Med 6 196 1910 44 GOODVAN EH and Hon ELL A A Further Clinical Studies in the Aus kultaton Method of Determining Blood Pressure Am J Med Sc I? 334 1911 45 Hooker DR and SOUTHWORTH ) D Interpretation of the Auscultator Blood Pressure Sounds Arch Int Vied 13 384 1914 46 Standard Method for Taking Blood Pressure Readings By the Committee for the Standardızation of Blood Pressure Readings of the American Heart Association and the Committee for the Standardization of Blood Pressure Readings of the Cardiac Society of Great Britain and Ireland JAMA 113 294 1939 ·Chapter II HISTORY OF BLOOD PRESSURE EVOLUTION OF NORMAL LIMITS ABOUT 30 000 years ago the Cro Magnon race hived throughout Western Europe Thev were apparently intelligent and keen observers and the signs of their artistic skill and power of observation are visible today in paintings on the walls of the caves in which they lived One of these paintings was found in the cavern of Pindal (Asturias-Spain) (Figure 19) The primitive artist drew the outline of a mammoth in red ochre, and in the center of it he placed a dark spot that may represent the heart Sigerist ** in his excellent history of medicine makes the following comments regarding this drawing the organ (the heart) must have attracted the attention of man from the earliest time because he found it beating as long as there was life because he soon must have discovered that the best way to kill an animal was to hit it through the heart and perhaps also because he felt his own heart hammering in the breast when fear seized him if the dark spot of the mammoth of Iındal actually represents the heart we may well consider this the earliest anatomical picture An understanding of the circulation of the blood in the body neces Sarily preceded the study of the blood pressure Although the history of blood pressure measurement is comparativels recent, some newer paleographic discoveries have indicated that the history of the circulation begins as long as four or five thousand years ago Even at that early time the observations about many of the phenomena of the circulation were remarkably accurate though the interpretation of these observations was often inaccurate and full of fantasy Igypt can be considered the cradle of human civilization The pros perity of Egypt rightly called by Herodotus a gift of the Nile was the result of the Inowledge of the Laws of Hydraulics which the Igyptians possessed About 5000 years ago they constructed a network of canals which brought the water and mud from the Nile to the remotest places and transformed the desert into a flourishing countryside Vedicine hept pace with other branches of human knowledge in ancient Egypt and must have been a widespread specialized ut Herodotus 19 in his second book says Medicine with them is distributed in the follow ing way Excry physician is for one disease and not for several and the whole country is full of physicians for there are physicians of the eves others of the head others of the teeth others of the belly others of (37) ·38 BLOOD PRESSURT TIOLUTION OF VORMAL LIMITS obscure disease Egyptologists are inclined to assume that media! science was sers highly duseloped in the Old hingdom 12500 BC) so that no physician could master st, specialization in consequence was unavoidable then as it is today A few lapynı dealing with medicine (Smith Ebers Hearst and Ber lin)** have recently been unearthed They tend to show that the ancient Egyptians were trult as are of the importance of the heart and perspheral circulation They are a collection of monographs, each dcroted to a For 19 - VAKIOTH 1STE PART Whouetre drawn by a primite artist in a casem-Pindal (Asturias pron) approximately 30000 years ago Red achre was employed for the entire design The color is sealt brilliant The red spot on the mammoth apparently represents the heart Il scture reproduced from }huhn Valeret der tuszert Delphin Veslag Vunchen 1922 p 42 ) particular subject - the Smith and rhers l'apın nere katten at the beginning of the VIII dynasty (about 1600 BC) Both are copies of much older texts that may go back to the P'ramid Age (2000 2000 BC** The longest most interesting and most important is the burs I apyrus (20 23 meters long) said to have been wntten about 1600 BC In it, the re is a long treatise on the phi colag of the circulation in which the mutual relationship between the heart and sussus clearly de scribe! This begins sith the caption The l'hysicians Secset knowledge of the Ilearts Vovement and knold of the Heart ·BLOOD PRESSURE EVOLUTION OF NORVIAL LIMITS 39 (Eburs)+84 From the following quotation it is obvious that the Egyptians had some understanding of the circulation of the blood and were well versed in the art of pulse palpation If the physician places the hands or his fingers to the head to the back of the head to the hands to the place of the stomach to the arms or to the feet, then he examines the heart because all his limbs possess its vessels that is the heart speaks out of the vessels of every limb * His heart beats feebly 48 was an alarming symptom for an Egyptian physician feeling the weak pulse of a patient It is interesting that in the Ebers Papyrus the pulsations in the vessels are compared to the ebb and flow of the Nile 51 The ancient Egyptians therefore must have been deeply impressed with the vital importance of the circulatory system to have compared it with the tide of the Nile for they considered the Nile and its tides to be one of the most majestic and important natural phenomena of their time As is emphasized by Grapow 62 one of the recognized experts in Egyp tian medicine the basic idea was that in the normal human body there is a system of vessels originating in the heart and connecting it with all other parts of the body These vessels supposedly carried air liquids such as blood urine tears sperm and solid matter such as feces the heart being the center and pumping force of this system of distributing vessels It seems logical that this concept of circulation of fluids and solid matter in the body was applied also in pathology (Berlin Papyrus) because they knew through their own experience that their land suffered when the canals bringing the Nile water were out of order just as disease resulted when canals of the human body did not function as they should 8d This wonderful observation which brought the Egyptians so close to the discovery of the circulation - remained dormant for many centuries The art of mummification perfected in ancient Egypt enabled the priestly embalmers to become acquainted with the internal structure of the human body It is of interest to note that during the process of embalming the heart and kidneys were the only internal organs that were carefully left 112 situ suggesting that the heart was considered to be essential to the individual not only during life but even after death Since the peripheral pulse could be readily palpated and observed it was the one phase of the circulation which impressed many ancient phy sicians 4 good deal of time and attention was devoted to the pulse 51 and many long descriptive treatises were written about it In ancient Chinese writings (1123 to 256 B C) at least 23 varieties of the radial pulse were described Many of the observers were aware of the impor tance of various qualities of the pulse hard and soft pulses were long identified with certain diseases Thus in 200 BC Choven You 1 54 wrote that kidney disease is present when the pulse is hard and very difficult to obliterate by superficial palpation! Although attention was paid to the force of the pulse its correlation with the pumping force of the heart was not considered ·40 BLOOD PRESSURE CIOLUTION OF NORVIL LIMITS The ancient Grechs also accumulated much information about the pulse but their detailed observations were frequently misinterpreted They believed, for example, that the heart and vessels contained air rather than blood 4s carly as 310 BC Herophilus, considered the Father of Anatomy proved the synchronicity of the arterial pulse with the beat of the heart and attributed to the pulse four main qualities size frequency, force and rhythm However the Greeks too, did not understand the relationship between the pumping force of the heart and the beat of the pulse Galen (131-201) much later showed that the vcs sels contained blood and demonstrated the motor power of the heart by the pulsation of blood which occurred between the heart and the point of ligation of an artery FIG 20 -- 1 illius LARVEY (1578-1637) lortrait by Illiam on Bemmel (1699-1760) engraved by Jacob Houbralen (17391 This portrait was in possession of Sir Francis Mullman VD (1746-1871) and Rackard Becht (1789-1898) the famous physician discoverer of the kidney condition called Brighes Disease This observation of Galen s las dormant until larves » (Iigure 20) classical sork was published in 1628,- rercitatın anatomita de motu cordis et sanguinis in animalibus (Anatomical Faeroe on the Motion of the Heart and Blood in Animals) (I igure 21) This was subsequentis translated and published in English in 1653 * Harses clucidate the ·EXERCITATIO ANATOMICA DE MOTV CORDIS ET SAN GVINIS IN ANIMALI- GVILIELMI HARVEI ANGLI Medics Regni, és*Profeſſores Arasomsa in Col. logo Medicorum Londinenſi BYS, FRANCOFVRTI, Sumpubus GVILIELMI FITZERL ANNO MDC. XXVIII FIG 21 - Frontispiece of the famous treati e on the physiolo of the circulation published by W Harvey The text is in Latin and printed in Frankfurt (Cermany) Iwenty five years later it was translated into English and published in England (41) ·42 BLOOD PRESSURE EVOLUTION OF NORMAL LIMITS mechames of the circulation and proved the central propulsive action of the heart which in the nature of a force pump propels the blood along the vascular channels in a continuous cycle He stated that the pulsation of the arteries arises from the impulsion of the blood from the left ventricle also according to the tension of the heart the pulsations are greater more vehement A hundred years or more had passed before Stephen Hiles' (1733) measured the intra arterial blood pressure for the first time Heexpressed the pressure in terms of the weight of the blood itself His measurements of the blood pressure in various animals -sheep dogs horses etc - were amazingly accurate Hales estimated the blood pressure in man to be about 71 feet of blood This corresponds to about 176 mm of mercury Despite the crudeness of this method and the limitation of his work to experimental animals this estimate was indeed remarkable In 1856 the first accurate blood pressure measurement in man was done by laivre 69 a French physician from Lyon He connected the I'oiseuille manometer directly with the lumen of a large arter in thret patients prior to the amputation of a limb In two cases the pressure was measured in the upper part of the brachial artery in the third case it was measured in the femoral artery In each instance the pressure was found to be about 120 min mercury As a result of his observations Faivre thought that this was the mean aortic pressure in man The determination of what constitutes the normal blood pressure kas earl recognized as a problem of great importance Sanderson 57 in his monograph on the clinical value of the sphygmograph published in London in 1867 places the normal arterial pressure at six or seven inches of a column of mercury (152 179 mm mercury) H houcier does not describe the method he used to obtain this measurement It depended on the development of suitable devices which could measure the blood pressure by indirect means The first of such measurements which were performed by crordt Behrer Landois and others were grossly inaccurate being about two to ten times higher than the truc level and were therefore of no value in establishing true normal limits I hc first book devoted to blood pressure Die Messung des Pulses und des Blutdrucks am Venschen was written by Waldenburg 17 in Berlin and published in 1980 It directed attention to the importance of the blood pressure in clinical medicine On the basis of studies of thienti ning healthy persons between the ages of scienten and sixty five I ears he too set limits of 200 to 260 mm mercury These high values are the result of his inaccurate technique and art onls of historical interest Ion Basch is considered to be the father of clinical sphygmomanom etrs since he introduced the first practical device to measure the blood pressure I ollowing ils introduction in 1870 it was employed by a num ber of physicians in clinical practice Using von Basch s apparatus ·BLOOD PRESSURE CIOLUTIO OF VORMAL LIVITS 43 Zadeh 59 in 1881 published a long and comprehensive report on his findings As a result of measurements done on a number of healthy men and women he concluded that the upper limit of the normal pressure was 150 mm mercury and that the lower limit was 70 mm How close his figures are to those commonly accepted today! He also pointed out that the blood pressure was lower in children that it increased after meals in the afternoons following exercise and in high altitudes and that it usually decreased with rest These were indeed remarkably accurate clinical observations Ion Basche himself in a series of five articles in 1887 summarized his own experience with his apparatus as well as that of other investigators He predicted the very important TABLE II -BLOOD PRES URE N 276 HE LTHY INDIVIDUALS-THAYER (1904) A et ge Syll Pess e (mm nec rv) 104 6 48 1-10 Vmber 10 37 10-20 128 7 87 20-30 1369 89 30-40 140 8 37 40-50 142 2 20 154 8 co 50-60 60-70 180 cine role that blood pressure measurements would play in the future of medı cine His conclusions were that the normal blood pressure was 110 to 160 mm mercury in the radial artery and 90 to 120 mm in the temporal artery Von Basch preferred to take the pressure in the latter vessel With the introduction of the Riva Rocci apparatus in 1896 a new impetus was given to the measurement of blood pressure in clinical medı Many workers in different parts of the world employed this technique and each set forth what he considered to be normal values- Gumprechtei (1900) Hensen (1900) Hay ash16 (1901) Cooh and Briggs36 (1903) Thayers (1904) However their values were about 10 per cent too high because of the narrow ) cm armlet which was used Their observations also were made on only a small number of normal indiv duals and were therefore of very limited value It is interesting to note that one of the first men to use the Riva Rocci apparatus in the United States was the famous neurosurgeon Harvey Cushing While visiting in Pavia he was impressed by this apparatus and recognized the value of blood pressure measurements in surgery As early as 1907 68 he published an article on the importance of the blood pressure level during operative procedures as determined by the Riva Rocci instru ment In 1903 Cook and Briggs 18 of Johns Hopkins University wrote one of the first extensive articles to appear in the American literature ·BLOOD PRESSURE EVOLUTION OF NORMAL LIVITS on the measurement and clinical interpretation of blood pressure They analyzed the blood pressure findings in a series of normal, surgical obstetrical and medical patients and stressed the importance of blood pressure measurements in clinical practice In an article published in 1904, Thayerat found that there were still insufficient data available on blood pressure in the normal population In order to assess his findings in a series of old typhoid patients, he had to measure the blood pressure in 276 normal individuals in an attempt to cstablish a normal level His data (Table II) are representative of the findings of various authors between 1900 and 1904 who employed the Riva Rocci apparatus with a 5 cm armlet Potain 67 a brilliant clinical observer published little of his findings on blood pressure measurement during his lifetime In 1902 he collected the results of thirty years of study entailınz 11 000 blood pressure readings and wrote the first extensive work on blood pressure and its limits His book published two recks after his death was entitled La Pression Arterielle de l Homme Although his readingy today are considered too high because of the technique he cmploved his book has great historical interest In it Potain emphasized the importance of three major factors in the determination of the blood pressure level 1) the function of the heart 2) the peripheral resistance of the arter oles which he considered the most important factor and 3) the quality of the arterial wall He stressed the effect of age on the normal range of the systolic pressure and investigated extensnek the effects of various other factors such as weight sex activiti altitude and fever The following is a summary of the results obtained by lotain on normal individuals TABLE III-ASERAGE SYSTOLIC PRF SURF (mmh mercury) 89 ige 30-40 (mmere ) 190 ge 6 10 10-15 15 20 135 200 150 40-50 50-60 60-80 210 20-25 170 220 25-30 180 Although the readings are high because of the method of measurement he used the increase in the blood pre sure with increasing abc which he found is certainly striking In the scars between 1901-1901 Jancka: " Vasing" and Sahlin endeavored to measure the diastolic pressure bs means of the oncillo metric method is the pressure in the encircling arm cult was slowly decreased the los est point of marimal oscillation of the radial pulse was taken as the diastolic pressure the oscillations ixing recorded on ·BLOOD PRCSSURF LIOLUTIO or NORMAL LIMITS 45 a sphygmograph The readings were much higher than those nbtained with the auscultatory method which was later introduced by horotkow Tollowing the introduction of the wide 12 to 14 cm armlet by von Rechlinghausen in 1901 and the institution of the auscultatory technique for blood pressure measurement by horothon in 1905 the era of modern clinical sphygmomanometry began The evolution of the present day normal blood pressure limits dates from this time In 1901 Theodore C Janeway! in a monograph entitled The Clini cal Study of Blood Pressure gave the upper limit of normal systolic pressurt as 160 mm mercuri In 1913 on the basis of the experience derived from the blood pressure measurements in 7 872 cases done by his father and himself Janeway " Again stated that a pressure over 160 mm mercury may be considered abnormal Brunton (1910) in England and Cook" (1911) of Johns Hopkins lowered this limit to 135 mm up to middle life and to 143 to 150 mm thereaſter In 1915 Janeway * revised his former opinion and accepted these standards Although he recognized the importance of the diastolic pressure he did not have sufficient data to establish its normal limits At that time Janeway was a pioneer and probably the highest authority in the United States in this field The results of his investigations and publications un doubtedly harl an important influence on the establishment and accept ance of these blood pressure limits as normal The present commonly accepted normal limits of blood pressure have been established largely through studies by life insurance companies in the past four decades With the introduction of the sphygmomanometer and its regular use in life insurance examinations vast numbers of blood pressure readings on men and women at various ages have been accumu lated The data thus obtained have been analyzed statistically from time to time and the average blood pressures in men and women at various ages have been thereby determined Fisher 76 of the North western Mutual Life Insurance Company in 1914 was one of the first to publish the results of blood pressure measurements on 19 339 accepted candidates for life insurance Subsequently a large number of similar studies was issued 76–8 - Symonds Rogers and Hunter Mackenzie and Wells and others Representative findings of the insurance company studies are shown in Table IV The conclusions of Symonds are based on the examination of over 160 000 applicants while those of Hunter are based on the examination of a quarter of a million applicants According to the insurance company statistics the a crage blood pres ure increases very little with age the systolic pressure increased from 12 to 22 mm mercury bets een the ages of fifteen and sixty five while the diastolic increased Trom 8 to 14 mm mercury Symonds also tound a difference in the blood pressure in the two sexes In women below the age of forty he reported the systolic pressure to be slightly lower than in mụn alter forty he found it slightly higher (1 to ·46 BLOOD PRESSURE CIOLUTION OF VORVIL LIMITS 2 mm mercury) The diastolic pressure in women below forty was slightly lower (1 mm mercury) than in men but over fifty it was higher Fisher was the first to find that a persistent increase of 15 mm in the auscultatory sy tolic pressure above the average for the age (1 able IV) resulted in an unexpected rise in the mortality rate Hence he concluded that an increased systolic pressure of 15 mm or more from the given TABLEIL - ATERACE BLOOD PRESSE RE OF IS ERICE APPLICANTS Symon ls (100 000) Iunier ( 50 000) Dia 1 Ag $ 15-19 Syst 123 Syst 113 Diast 15 9 20-24 1244 80 120 80 25-29 124 91 122 81 30-34 125 82 123 82 35-39 125 83 124 83 40-44 126 84 126 84 45-49 129 85 128 85 50-54 1.30 86 130 86 55 59 133 87 132 87 00&oler 135 & 135 80 in average should be regarded as pathological His conclusion was cor roborated by the statistical findings based on mortality rates of other hfe insurance studies and sas accepted by many investigators (hy monds Rogers Hunter and others) Vachenzie suggested that the normal systolic pressure limits be set at 9 to 135 mm mercury for fifteen to nineteen year old applicants and that they bc progressively increased (110-155 mm mercury) until after the age of satu Regarding the diastolic pressure Fisher believed that a pressure above 90 mm in patients under the age of forty and one above 95 mm patients over forti scre abnormal Si monds thought that anı diastolic pressure above 91 mm vas probably abnormal Vachonzic using the 5th auscultator phase is the inder considered a diastolic pressure of 60 to 83 mm mercurs to be normal for the fifteen to nineteen scar age group and one of 69 to 100 mm mercury to be normal for those over the age of sixty kogers and Ilunter placed the diastolic limit at two thirds of the si stolic On the basis of these insurance company studies the present com mortis accepted normal limits of 140 to 130 mm mercuri si stolic and 90 to 95 mm diastolic hase been accepted by many authorities Alvarez "? Fishbcrg Aholisirs" White ? Indberg " and others Robinson and Brucer" in a widely quoted investigation hoxeser set the normal ·BLOOD PRESSURE FIOLUTION OF NORMAL LIMITS 47 upper limit of blood pressure at 120 mm systolic and 80 mm diastolic regardless of age and sex As will subsequently be shown these limits are unacceptable ESSENTIAL HYPERTENSION man Simultaneously with the evolution of normal blood pressure limits came recognition of the hypertensive state and of its effects upon the cardiovascular and renal systems The gradual awareness of the hyper tensive state as a distinct entity further served to stress the importance of establishing kmits of normal blood pressure The historical evolution of the concepts of hypertension and of normal blood pressure are rather closely integrated Many early physicians were aware of the importance of increased blood pressure in man Its presence was discovered long before methods to measure it were available Careful study and obser vation led some of the early clinicians to recognize in some patients the increased tension and hammering pulsations in the peripheral arteries Ludwig Traube® 94 was the first to describe increased arterial tension in In 1856 he published some of his clinico pathological studies among which he reported the case of a forty year old physician in whom he found the arteries of middle caliber to be definitely under tension Thus he realized at the bedside by palpation of the arteries that a state of increased intravascular pressure existed Following Bright s' classical description of the disease that bears his name it was commonly felt that increased arterial tension was always a consequence of pre existing renal disease or arteriosclerosis Much later it was discovered that hypertension may be the primary disturb ance and may antedate the development of arteriosclerosis and renal disease Sanderson 570 was one of the first to suggest that arterial hyper tension may exist before manifest clinical signs of kidney disease appear In 1867 in a monograph on the clinical value and use of the Marey sphygmograph he described two patients with postmortem evidence of left ventricular hypertrophy and Brght disease During life both patients had had bounding visible pulses the arteries knoching against the finger like a hammer Sanderson emphasized the value of the pulse tracing obtained with the sphygmograph in providing evidence of the presence of increased arterial pressure in these cases He suggested that the sphygmograph be used to detect increased arterial tension in patients with no other clinical evidence of left ventricular hypertrophy and kidney disease He believed that many persons have a high tension pulse without any other trace of ailment and that the arterial resistance in them is excessive but he did not have enough experience to understand the significance of this finding Though clinical sphygmomanometry had not yet been developed Sanderson pointed out the importance of the sphvgmogram as an objective method of detecting early cases with ·48 FLOOD PRESSURE ET OLUTION OF NORI IL LIVITS increased arterial tension before the appearance of heart and kidney disease Several months before Sanderson s monograph appeared, roster pub lished a booklet on the same subject " Using the Marey sphygmograph on a man of 37 he demonstrated a pulse tracing which was typical of strong tension in the arteries Foster stated that this condition can easily be recognized by the form of the pulse tracing He was icry en thusiastic about the clinical use of Narey s sphygmograph as an objec tive method for detecting what he called ' senile changes in the arteries in its carly phase ze when the diagnosis cannot be established by pal pation of the arteries He explained the frequent coexistence of harden ing of the peripheral arteries and left ventricular hypertrophy in elderly people by the necessity of the heart to act more forcibly in order to carry on the circulation of the blood The presentation of Foster s and Sanderson s publications to the English medical profession aroused great interest at that time English physicians were aware of the importance of recognizing the presence of high blood pressure and other conditions detectable through the sphug mograph 4 controversi arose among them as to who should be con sidered the first to have employed Narci s sphygmomraph in clinical medicine in England I rom a survey of the exchange of letters published in The Lancet at that time 100 101 it seems nou that Burston Sanderson his collaborator Francis Instie and Walter B Foster can all share this honor Mahomed 104 103 an i nglish pupil of Varu s enlarged on Sanderson s observations and suggestions Using the sphygmograph in a large num ber of cases he also found that an increase of arterial pressure mas precede the appearance of simptoms of renal disease He termed this tht jye albuminuric stage of Bright s disease In 1874 he stated Previous to the commencement of any hidnes changes or the appearance of albu min in the urine the first condition obscrvable is high tension in the * It a interesting to note that arteriosclerosis is a prouess which can be traced far back in the history of man Ruffer the founder of I aleopathom logi (the pathology of ancient specimens) in his classical word "Studies in the Jaleopatholow of Egypt demonstrated that old Fes prians suf fered also from arterosclerosis of the aorta and reripheral vessels lle pre sents clear preparations from specimens of the aorta and antenes from mummies revealing the same picture as that found in modern material Atheromatas atheromatous patches and uicers more or less compierel calcified hing lernepteh. the I haraoh of the llebren crodus suffered from arteriosclerosis of the aorta Voodie with the aid of toys could deinonstrate sclerott Sessel in an unwrapped Mummy Field Museum in Chicago ? he opinion that arteriosclerosis is a disease of modem times and , selared to modern nutrition and the physical and mental strains of modern life is evidency contradicted by these cleaf objectise findings in the ·BLOOD PRESSURF EVOLUTION or NORVAL LIMITS 49 arterial system Mahomed did not yet disassociate the two conditions but felt that the hypertension always represented an early stage of Bright s discase In a later article in 1879 however Mahomed expressed doubt concerning the absolute relationship between increased blood pres sure and Bright s disease for he wrote I have tried to prove that the high arterial pressure and the subsequent cardiovascular changes are the primary and most important conditions to recognize while the kidney symptoms are only secondary and are not even essential conditions He was one of the first to be aware of the existence of increased arterial tension in the absence of hidney disease and of the importance of its effects on the various systems of the body His deductions are most impressive since they were made without actual measurement of the arterial blood pressure Von Basch 104 using the first practical sphygmomanometer which he devised also realized that hypertension may exist in the absence of neph ritis and demonstrable arteriosclerosis He attributed the high blood pressure in these cases to latent angiosclerosis It was not until 1895 that Sır Clifford Thomas Albutto clearly separated the syndrome of essential hypertension from Bright s disease He described in detail his long and careful observation of patients with essential hypertension and concluded that they did not necessarily develop renal discase In a paper read before the Hunterian Society in London he stated I had begun to recognize that rising pressure did not necessarily mean incipient stages of renal disease in the ordinary sense Albutt intro duces the term hyperpiesia to describe these cases This term is still popular in England In America the term essential hypertension 15 widely used and is derived from the German essentielle Hypertonie introduced by Frank 106 in 1911 Huchard 107 in 1899 wrote a masterful description of the clinical picture of essential hypertension He pointed out that arterial hypertension is the cause of arteriosclerosis and precedes for a variable period the development of cardio renal involvement In 1914 Volhard and Fahr108 differentiated between the benign and malignant forms of hyper tension SUMMARY A brief historical review of the study of the circulation and of the blood pressure in man has been presented The development of the present commonly accepted limits of normal blood pressure -140-150/90-95 has been traced These were initially introduced by a few authoritative early workers in the field-notably Janeway Brunton and Cook It is however the life insurance company studies that are mainly responsible for the present dav limits These studies have been based on an analysis of blood pressure readings on large numbers of applicants for life insurance 1 ·50 BLOOD PRESSURI CI OLUTIO OF MORVAL LIMITS The normal limits have been established by an analı sis of blood pressure findings in relation to the mortality rates A brief account of the histori cal evolution of the concept of essential hipertension has been pre sented BIBLIOGRAI HY +7 KUHN H Malerei der Eiszeit Delphin Verlag, Munchen 1929 p +2 480 SIGERIST HE A History of Medicine Vol I Primitive and Archajc Medicine Oxford University Press 1951 p 100 186 SIGERIST HE A History of Medicine loi I I rmırııe and Archaic Medicine Oxford Lniversity Press 1951 p 313 18c SIGFRIST HE A History of Medicine Vol 1 Primitive and Archaic Medicine Oxford Unis ersity Press 1951 p 304 48d SICERIST HE A flistory of Medicine Vol I Printre and Archaic Medicine Oxford Uni ersity I ress 1991 r 319 46 SICERIST HF A History of Medicine Vol 1 Primitive and Archaic Medicine Oxford University Press 1951 p 329 49 SPIEGELBERC W Zu dem Spezialistentum in der agyptischer Vedızın Zeitschrift agyptischer Sprache 53 111 1917 50 JUNKER H Die Stele des llofarztes ir Zeitschrift agyptischer Sprache 63 53 1928 > 1 VAKEL RJ A Historical Study of the Pulse and Circulation Indian Heart Jour 1 259 1949 52 GRAPOW H Uber die anatomischen Kenntnisse der altagyptischen Aerzteim Morgenland Darstellungen aus Ceschichte und kultur des Ostens-- Verlag der J C Finnich schen Buchandlung Heft1933 53 BREASTED ) H The Edson Smith Surgical Papy rres lali Chicago The University of Chicago Press 1930 5+ VOLIARD I Blutdruck und Miere in Nierenerkrankungen und Hochdruck 2nd Ed Leipzig Barth 1949 p 198 5) Ciba Symposia 1 84 1943 56 The Anatomical Exercises of Hallam llarses London Francis Leach 16 3 >7a SANDERSOY J B Hand Book of the Sphygmograph Being a (ude to its L se in Clincal Research London R Hardwiche 1867 P 67 7b SANDERSON J B Hand Book of the Sphygmograph Being Curde to its Lse in Clinical Research London R Hardwiche 1867 p 3) » FAIVRE J I hysiologie I athologique ftudes experimentales sur les lesions organiques du coeur Cazette Vedicale de aris 2 717 1876 > LADEN I Die Messung des Blutdruchs am Menschen mittelst des Basch schen Apparatus Zeitschrift fur hlinische Medizin 2 509 1881 60 lov BASCH S Der Sphigmomanometer und seine leihung in der 75xis Berliner Klin Il chnschrift 34 179 206 294 244 79 1887 61 GUNPRFCHT Experimentelle und Klinische I rufung des Rna Rocca schen Sphygmomanometer leitschrift fur flintsche Medizin > 377 1900 62 ITENS 11 Bestrage zur Thysiologie und Iathologie des Blutdrucks Deutsche Arch fur Klinische Medizin 67 416 1900 63 Arashi T Vergleichende B]utdruckmessungen an Cesunden und Kranken mmt den Apparaten son Cartner Rosa Rocco und 18) Inaug Dissert Frlangen December 1901 61 THYFR 11S On the Late Fffects of Typhoid Haier on the Sirart and las sels A Clinical Study Am ) 115c 197 391 1901 ·BLOOD PRESSURE EVOLUTION OF NORYAL LIVITS 51 65 FULTON JF Harvey Cushing A Biography Springfield Charles Thomas p 213 1946 66 CUSHING H On the Avoidance of Shock in Major Amputations by Cocain ization of Large Nerve Trunks Preliminary to Their Division with Ob servations on Blood Pressure Chan,es in Surgical Cases Ann Surg 36 321 1902 67 POTAIN C La Pression Arterielle de L homme Paris G Masson 1902 68 JANEWAY TC Come Observations on the Estimation of Blood Pressure in Man New York Univ Med Sciences 1 10) 1901 69 Masing E Das Verhalten des Blutdrucks des Jungen und des Bejahrten Menschen bei der Muskelarbeit Deutsch Arch klin Med 74 253 1907 70 SAHLI H1 Uber das Absolute Sphygmogram nebst Kritischen Bemerkungen Dtsch Arch klin Med 81 193 1901 71 JANEWAY TC A Clinical Study of Hypertensive Cardiovascular Disease Arch Int Med 12 755 1913 72 BRUNTON TL Blood Pressure in Man Its Estimation and Indications for Treatment British Medical Journal 2 64 1909 73 Cook HW Blood Pressure in Prognosis Med Rec 80 909 1911 74 JANEWAY TC Important Contributions to Clinical Medicine during the Past Thirty Years from the Study of Human Blood Pressure Bull Johns Hopkins Hosp 20 341 1915 75 FISHER J W The Diagnostic Value of the Sphygmomanometer in Exam ination for Life Insurance JAMA 63 1752 1914 76 FISHER J W Cited in Norris GW Bazett HC and McMillan TM Blood Pressure Its Clinical Applications 4th Ed Philadelphia Lea & Feber pp 131 132 1927 77 SYMONDS B The Blood Pressure of Healthy Men and Women JAMA 80 232 1923 78 SYMONDS B The Blood Pressure of Healthy Men and Women Proceedings of the Association of Life Insurance Medical Directors of America Vol I New York 1974 79 ROGERS O H and HUNTER A Mortality Study of Impaired Lives No 5 Systolic Diastolk and Pulse Pressures Higher than Average for the Age Proceedings of the Association of Life Insurance Medical Directors of America Yol XIII New York 1997 p 176 80 MACKENZIE LF and WELLS P V On the Interpretation of Blood Pres sure Proceedings of the Association of Life Insurance Medical Directors of America Vol V1 New York 1933 p 89 81 Joint Committee on Mortality Blood Pressure The Association of Life Insurance Medical Directors and the Actuarial Society of America New York 1925 82 Joint Committee on Mortality Medical Impairment Study The Associa tion of Life Insurance Medical Directors and the Actuarial Society of America New York 1931 83 Joint Committee on Mortality Blood Pressure The Association of Life Insurance Medical Directors and the Actuarial Society of America New York 1910 84 HUNTER A Blood Pressure that Affects It? Proceedings of the Associa tion of Life Insurance Presidents 17 64 1973 85 GOEPP RM Blood Pressure as a Pronostic Factor Penna Med Jour 72 795 1919 86 MACKENZIE LF The Significance of the Diastolic Pressure Medical Records 91 1019 1970 ·2 BLOOD PRESSURE LI OLUTION OF NORWAL LIMITS 87 ALVAREZ IC Blood Pressure in University Freshmen and Office Patients Arch Int Med 20 381 1920 88a FISHBERG A M Hypertension and Nechstus 4th Ed Philadelphia Lea & Febiger 213 1939 896 FISHBERG AM Hypertension and Mephritis fth Ed I hiladelphia Lea & Febiger p 214 1939 89 11 1GGERS C J Physiology in Health and Disease 3rd Ed Philadelphia Lea & Febiger p 645 1939 90 WHITE PD Heart Disease 3rd Ed Tes York The Macmillan Comsans p 97-98 1947 91 FRIEDPERC CK Diseases of the Heart Philadelphia HB Saunders Co P 854 1950 92 ROBINSON SC and BRUCER M Range of Normal Blood Pressure ta cistical and Clinical Study of 11 383 Persons Arch Int Med of 109 1939 93 TRAUBE L Uber den Zusammenhang von Herz--und Nieren-hrankheiten A Hirschwald Berlin 1856 p 66 94 TRAUBE L Gesammelte Beitrage Zur Pathologie und Physiologie Tol II A Hırschwald Berlin 1871 p 319 9, BRIGHT R Reports of Medical Cases London 1877 Cired by Bech gaard P Arterial Hypertension Acta Med Scandinav suppl 172 1946 96 FOSTER BK On the Use of the Sphygmo,raph in the Investigation of Disease John Churchill & Sons London 1860 np 6 29 97 RUFFER VIA Studies in the Paleopathology of Egypt Edited by Moodie RL The Chicago l niversity Press Chualo p 26 1921 98 SHATTOX SG Microscopic Sections of the torta of hing Vernestah Lan cet 1 319 1909 99 MOODIE RL Roentgenolomic Studies of Fertian and Ieruvian Vum Field Vuseum of Natural History Anthropolo) Memoirs Vol III Chicago 1931 p 26 100 FOSTER B To the Editor of The Lancet The hygmomraph in English Medical Practice Lancet 1 634 1866 101 A STIE F E The Sphs grograph in English Medical Practice Lancer 1 671 1866 102 VAHONED A The Etiology of Brushes Disease and the l'realbuminuri Stage Vedico-Chirurgical Transactions 5. 197 1874 103 MAHOVED FA Sorre of the Clinical Aspects of Chronic Briches Disease Guy s Hospital Reports 14 363 1879 104 Tov BASCHS Einige Frgebnisse der Blutdruckmessung an Cesunden und hranken Leitschr i Alin Vied 79 1481 10. ALBUTT CT SIR Diseases of the Arteries Including An, ina lectors Hol I Macmillan and Co Ltd London r 313 1915 106 FRANE Bestchen Beziehungen zwischen chromaffinem System und der chronischen Ils ferronie des Menschen Deutsches Arch Fun Wed 103 297 1911 107 ICHARD II Traite clinique des maladies du coeur et de laurier Doin Pans 1899 10 VOLJARD F and FAHR T Die Bright sche NierenLrankheit | Springer Berlin 1914 mies ·Chapter II FACTORS AGFCCTING THE BLOOD PRESSURL LEI EL' Many factors may affect the level of the blood pressure True at tempts have been made to standardize the technique of sphygmomanom etry for example by committees of cardiologists from Great Britain Ireland and America The blood pressure of an indusdual is often found to var The vanations are caused bs one or more of the factors which may be actre and are in part responsible for the difficulties encountered when attempts are made to establish the upper and lower lists of the normal blood pressure A discussion of some of these more important factors therefore and of their effects on the blood pressure seems to be necessary AGE Many textbooks minmize the influence of age on the blood pres sute 270 8X8 90 209 4 systolic pressure of 140 to 190 mm mercury and a diastolic pressure of 9 to 95 mm mercury are usually accepted as the upper limits of normal in adults at the age of forts as well as in those at the age of sixty five Studses made on children 10-24 however have shown that the systolic pressure gradually increases with age The in crease is more marked at puberty and soon thereafter the blood pressure reaches adult lesels There is an addition overwhelming clinical evidence to indicate that there is normally a significant increase in the blood pres sure in adults with increasing age Thuis Bormal increase has been found to be more marked after forty and to affect the si stolic more than the diastolic pressure The studies supporting this contention are fully pre sented in Chapter 11 Sri Relativel little attention has hitherto been paid to the influence of sex on the blood pressure so that dentical finits have been set for men and women The pressure in females below the age of forty honeser has been found to be slighth lower than that in males while in females over fifts it has been found to be somes hat higher Because of these findings no single figure can be accepted as the upper hmit of the normal blood pressure The age and the ser of the individual must in all cases be taken into account (53) ·54 FACTORS FFECTINC BLOOD PRESSURF LEI EL LMOTIONAL STAICS It has long been known that a nervous or emotional upset partiru larly fear may cause a transient increase in the blood pressure In 1899 hapsamer's asserted that the true level of the blood pressure can be determined only after many blood pressure readings have been taken in order to avoid variations due to psychic factors Subsequently this observation was confirmed and emphasyed by many others-Jellinch 1:8 Potain Janeway 3d and Thrstrom"? This psy chic effect on the blood pressure is apt to occur particularly at the time of the first medical cramı nation for entrance into the military service for life insurance for emplo ment or for routine clinical study Diehl and Lees'' measured the blood pressure of 100 unselected healthy students every five minutes for one hour They found a definite decrease in pressure on the second and third reading and a lesser decrcase up to the ergèth reading which was the lowest Thereafter the pressure rose slightly The gradual drop in the blood pressure was considered to be due to a gradual diminution of excitement of the subjects studied Zabel 119 after having repeatedly determined the blood pressure of a great number of individuals found that onl 15 to 20 per cent had a constant pressure level He felt that the psychic effect of the cramı nation, which caused the blood pressure variations can be overcome only after at least 50 consecutive blood pressure determinations This suggestion is rather impractical and can only result in a rise of the physicians pressure! Is man and Goldshinc in and others lim com pared the blood pressure in cases of essential hypertension taken at home and in the clinic and always found the home readings lower Since their observation of each patient was long continued it indicates the importance of the pressor effect ererted by the examining physician even after repeated visits Cannon 15 and others 4-1 showed that great ercitement or pain increases the blood pressure I andis and Guilettel studying 23 young subjects found that by inducing such marked emotional changes as surprise fear and serual excitement the blood pressure was increased Surprisingly anger and disgust produced practicalls no changes Scott and others ! * recorded the blood »CSsure of 100 health men nineteen to thirty one y cars old during the exhibition of a special film designed to aroust the emotions of love sex fear and anger They found a definite rise in blood pressurt as a result of cer stimulation and a lesser risc as a result of anger and ferr SLEEP The effect of the emotions on the blood pressure has also been studied indirectly by recording it during sleep llose!! 139 in 1897, was one of ·TACTORS AFFECTING BLOOD PRESSURE LEIEL SS the first to point out that the blood pressure drops at the onset of sleep as a result of the absence of psychic and emotional stimuli which affect the wakeful state Later others132–134 confirmed Howells findings Muller,195 and others 186 in an extensive study of 155 healthy individuals from three to ninety vears of age (33 being children) found an average drop in blood pressure after one to two hours of sleep of 26 mm mercury # in males and 21 mm in females In a study of 26 normal individuals Vuller and Brown's found that the systolic blood pressure dropped till 3-4 4 M and then rose slowly and steadily The diastolic pressure also dropped but much less markedly than the systolic Macllilliam'34 asserted that the systolic pressure may fall as much as 20 mm mercury during sleep However when the sleep is restless or is disturbed by dreams a considerable rise in both the systolic and diastolic pressure may occur In hvpertensives also the blood pressure falls during sleep Vuller 13 in 25 cases of benign hypertension found an average drop of 60 mm mercury in the systolic pressure during sleep though the pressure still remained higher than normal In 18 cases of acute or chronic glomerulo nephritis the findings were similar but less marked The same results were given by other investigators 13 137–189 BASAL CASUAL AND SUPPLEMENTAL BLOOD PRESSURE Addis 140 in 1922 first introduced the term basal blood pressure He applied this term to the pressure found in patients before they arose from bed in the morning He contrasted these low levels with those found later in the day The true basal blood pressure has been defined as the pressure present when all physical emotional and metabolic activa ties are reduced to a physiological minimum Such a reading is difficult to obtain The Committee of the Cardiac Society of Great Britain and Ireland and of the American Heart Association have recommended the following procedure A preparation similar to that used in making a basal metabolism test is recommended Such a basal blood pressure determination should be made from ten to twelve hours after a previous meal (preferably in the morning) after the patient has rested for thirty minutes in a comfortably warmed room The patient should be mentally as well as physically at ease In addition Smırh 141-145 and co workers have stressed the need for deliberate emoţional desensitization of the subject to the presence of the examiner and to the procedure of sphyg momanometry This desensitization is produced by taking the blood pressure as frequently as possible during the first three minutes after ade quate preparation of the patient The pressure is then taken every few minutes for a half hour period in order to habituate the patient to the ·56 FACTORS {FFECTING BLOOD PRESSURE LEI EL procedure To allas apprehension the patient is placed in a comfortable position and is fully informed of what will be done The room is kept quiet, and unnecessary movements by the observer are avoided Using this procedure in combination with the one outlined by the Committee Smur, obtained loner blood pressure readings than when he used each method separately It is evident that many precautions must be taken in order to insure complete physical and mental rest for the patient if a true basal reading is to be obtained The casual blood pressure reading represents the systolic and dia stolic pressures obtained during the ordinari clinical examination without employing any special means to eliminate psychogenic factors which may affect it The difference in pressure between it and the basal blood pressure (called the supplemental pressure by Alam and Smirh") is the result of physical emotional and supra basal meta bolic activits Vost of the supplemental pressure is of mental origin due especially to fear It is well known that a stay in a hospital usually produces an appreciable fall in the blood pressure of patients with essential hypertension This is the result of the physical rest of an in creasing familianty with the procedures used and of a more intimate acquaintance with the phu sicians Perera and Atchley #7 Wathina al 11' and others have emphasized the importance of hospital environment in lonering the blood pressure and the necessits of considering this factor in determining the value of particular therapeutic measures undoubtedl is of great importance to use basal readings when the effect of any therapeutic procedure on the blood pressure level is studied To obtain a true basal blood pressure reading is obviously too time consuming and therefore impractical in daily clinical practice Hence the casual blood pressure obtained under ordinary clinical conditions is the one which is usually tahen and with which the physician is mainly concerned Indeed clinical evidence shows that a transient clevation in the blood pressure due to emotional influences may have great prog Nostic signibcance on Yonahon "* in 1920 and Stieglitz 150 in 1930 on the basis of their clinical experience asserted that a transient ne in blood pressure due to emotional factors may indicate a predisposition to the later development of hypertension I almer is and others » »» after long follow up studies have shown that a transient elevation ol the sistolic and diastolic pres ures cien in young people gratis in creases the possibility of persistent hipertension in later life Master re-cramined 30 patients forts years of age and over scho had had a single blood presause seading which was at the upper limit of normal (140 156/ 80-94) during their stay in the hospital one to reson scars previously On the re-etamination 38 of the 30 serc found to have hypertension and at least 25 per cent had a diastolic pressure of over 100 Jt therefore concluded that even a single borderline reading mas be of some prognostic significance In a recent studi bi l2nt, et al* the medical records of ·FACTORS AFFECTING BLOOD RESSURE LEVEL 57 22 741 officers of the United States Army were analyzed The observa tion period extended from one to more than twenty five years They found that sustained hypertension occurred more frequently in those who had had previous transient hypertension at all ages than in those who never showed an elevation of blood pressure In both groups the rate increased with advancing Vears These studies also indicate that an increase in the casual blood pressure may be of prognostic importance Finally it is clear that the casual blood pressure is that level of blood pressure to which the individual is subjected during the manifold emotional and mental strains and tensions of his everyday life From a Practical point of view this level may be of more prognostic significance and of more importance to a patient than the basal blood pressure which is probably attained only occasionally iſ at all during the day For all these reasons it is of paramount importance to establish the normal range of the casual blood pressure fluctuations as obtained in every day clinical practice SOFT TISSUE AND VASCULAR FACTORS The degree to which soft tissue and vascular factors may influence the level of the blood pressure reading as obtained with the pneumatic cuff is of practical and clinical importance Unfortunately not much work has been done in this field and the problem is far from being solved It has hitherto been generally believed that the soft parts of the arm have a negligible influence on the blood pressure readings Hensen and Janeway 157 each reported a case with extreme muscular atrophy in one arm and with well developed muscks in the other In these cases the blood pressure was identical in both arms Janewav also pointed out that low systolic readings may be obtained in individuals with obese or muscular arms Hence the conclusion was reached that the soft parts do not influence the blood pressure reading More recent work however questions the validity of this conclusion The discrepancy between the direct arterial pressure and the indirect blood pressure as measured with the pneumatic cuff has often been observed The results have been somewhat conflicting Most observers reported the direct pressure reading to be lower than the indirect 158-16 while others 163–16 found in the majority of cases the converse to be true None of these investigators attempted to explain the discrepancy by the size of the In 1934 Hamilton16 and his associates introduced an improved optical manometer which was particularly well adapted for recording human intra arterial pressure Subsequently in studies of children Hamilton 167 164 and his associates compared the direct and indirect blood pressure readings They demonstrated that the relationship between the Si e of the arm and the width of the cuff greatly influenced the accuracy of the indirect blood pressure readings in general they believed that arm ·58 FACTORS EFECTING BLOOD RESSURT IETIL the size of the cuff should be varied directly with the circumference and length of the arm in children The subcested a 2 cm cuff for neu born infants a 5 cm cuff for small children and a 9 cm cuff for older and more developed children A 13 cm cuff is considered satisfactory for adults If the person is unusualls obese honever a wider cuil must be used and even then it will be difficult to obtain an accurate reading Ragan and Bordley 169 simultaneousl measured the blood pressure bi the intra arterial method of Hamilton and by an auscultaton method similar to that used in routine clinical blood pressurt determinations They also found that the difference in the pressure obtained by these two methods was affected by the size of the arm Incorrect readings were obtained particularly in subjects with unusually large or unusuall small arms When the arm was large and the standard 13 cm «ull was used thci found that the systolic and diastolic pressure was likeh to be 100 high The error in either direction mai ciceed 30 mm mercurs In somt obese subjects the use of a wide 20 cm blood pressure cult resulted in more accurate auscultatory measurement of both the systolic and the diastolic pressure In most patients honeser the wider cuti sickled readings which were too low In order to obtain an accurate measurement of the pressure in the femoral arter a cuff at least 15 cm wide must be used the ordinary 13 cm cuff gres false readings 170 Some authors have shown that the pressure in the femoral artery is higher than that in the brachual in both man and animals 1 2 The American Heart is.ociation felt that this important problem must be clarified and specihe instructions for taking tht blood prussurt in relation to the size of the limb should be gren In June 1951 the Scientific Council of the American Heart Association * discussed the accuracy of the indirect auscultatory blood pre sure meas urement in comparison with that of direct blood pressure measurement by means of calibrated intra arterial manometers It found that the au cul tatory systolic pressure in the brachialanteria on the allrag. 3–4 mm mercury too low and that it varics #8 mm mercury It found too that the auscultators diastolic pressure taken at the 4th phasc mufilling of the sounds) is on the as crage 8 mm mercury too luigh The Council therefore concluded that the indirect auscultatori method of measuring systolic and diastohe pressures mas be expected to result in a mean error of * 8 mm mercuri The Council for High Blood Pressure Revarch of the Scientific Council of the American Heart Issociation through the Commitet io Kevese Standardization of High Blood Pressure headings recommenils that in general the blood pre sure cuff must be 20 pxr cent under than the • Prom Recommendations for Human B1 2 Pre ure Determ nations ly Show manorneters by Jam 3 Bor ile 11 UD Chale AK Connor UDF tamit n UD Am J herr VID Ani Carl 3 I 182055 D Circulation + 501 1951 ·FACTORS AFFECTING BLOOD PRFSSURE LEVEL 59 diameter of the extremity to which it is applied It suggests that a 12 cm cuff be used on the arms of adults I or children under the age of nine the Council advised that a cufi 8-9 cm in width be used for children under four years of age it suggests a 5-6 cm cufi and for infants under one year of age a cuff of 2 5 cm or less The Council believes that the systolic pressure in the thigh is from 10- 40 mm mercury higher than in the arm but that the diastolic pressure is the same in both It recommends that an 18 cm cuff be used on the thighs of adults They also believe that a variation in the diastolic pres sure in the upper and lower extremities of a normal person is due to the use of an insufficiently wide thigh cuff and is a test of the adequacy of the cuff emploved The inflatable bag should be at least long enough to cover half the cir cumference of the limb care should be taken however that the bag is placed over the artery that is to be compressed Since the danger of the improper application of the bag must be obviated it evidently prefer able that the bag be long enough to encircle the limb or to cover the greater part of it The results of these recent extensive investigations prove that the size of the limb is an important factor in the production of minor depressions and elevations of the blood pressure when the standard cuff is used The size of the limb therefore must also be considered when an evaluation is made of the diagnostic and prognostic significance of these minor variations in the blood pressure Thus when the standard cuff 1 used on an obese person an elevation of the blood pressure may be due en tirely to soft tissue factors and may not be evidence of an abnormal con dition When it is used on a thin armed person on the contrary the blood pressure reading may be too low This soft tissue factor there fore should be considered and assessed in each individual case The relationship of the ascular factor to the blood pressure readingthe quality and tonus of the arterial wall- has been a matter of interest and concern for a number of vears There appears to be general agree ment that the quality of the arterial _all has a negligible influence on the blood pressure reading Von Bascho crudely measured the amount of pressure necessary to obliterate the empty radial artery and found it to be 1 mm mercury for normal vessels and not much above 5 mm mer cury for sclerotic vessels Janeway 74 using a wide armlet studied many cases with marked thickening or calcification of the larger arteries also found that the error from this source was negii,ible Martin 18 in a few experiments on the carotid arteries of man horse and dog found that a pressure of 2 mm merrury was sufficient to collapse the normal arterial wall and that a pressure of only 7 mm was required to collapse markedly sclerotic vessels In more extensive experiments on segments of surviving arterial wall in animals and man Jancway and Park 174 and MacWilliam and Lesson"? have shown that the lumen of large ar ·60 FACTORS AFFECTING BLOOD PRESSURE ITI FL teries such as the brachial may be obliterated by the pressure of onls a few mm mercury Atheroma and calcification eten of considerable degree are without appreciable effect on the compressibility of the arteri and, hence on the blood pressure There is general agreement however that the state of contraction or tonicity of the underlying segment of arterial wall may have a more impor tant effect on the blood pressure than calcıhcation of the arteries Con traction of the muscular coat of the arterial wall may cause an increase in the blood pressure level Russell'74 was one of the first to recognize the effect of hypertonus of the underlying arterial wall on the blood pressure However he exaggerated its importance He even thought that arterial hypertonus rather than arterial hypertension is measured when the obliteration method is used Experimental work was done on blood vessels in animals and man to evaluate the arterial factor Macllilliam and hesson's found that spasm of the arteries of sheep and cattle could greatly increase their r sistance to compression Only a few mm mercurs here necessary to compress the relayed carotid artery of the sheep and or The reststancı of contracted arteries to compression however varied directly with the amount of contraction present Thus a pressure of 35 mm was re quired to obliterate the carotid of the sheep contracted at body tempera ture and a pressure of 64 mm was required to obhtcrate the chrotrd of the or when the temperature was loner a pressure of 186 mm mercury was at times required to collapse the latter i rom a study of human be ings Nacllilliam and Lesson 17 concluded that abnormal resistance of the arterial wall due to contraction of the muscular coat can play an im portant role in elevating the blood pressure Janeway and Park 154 on the contrary as a result of experiments on surviving oi arteries and of a study of human arteries after amputation and postmortem felt that hypertonic contraction of the brachial artery sufficient to cause an error of more than 30 mm mercury was improbable Although the results of the animal experiments cannot be applied directly to man it seems evident that spasm of the segment of the arterial wall underlying the pneumatic cuff may be a significant factor in some cases in causing an increase of the blood pressure According to Vacılıllam and Lesson 1? continued or repxated com pression as well as massage of the arterial wall segment mat overcome an existing spasm To eliminate it the blood pressure should be taken several times in rapid succession on the same arm this procedure mu not only ofercome the underlying spasm of the arterial wall but may also reduce the psychu stimulation caused by the cramination comparis of the blood pressure in both arms should be made after such a procedura in an endeavor to determine the degree of elevation of the blood pressure caused bs the spasm ·FACTORS FFECTIVG BLOOD PRESSURE LEVEL 61 11 EIGHT The blood preure tends to increase rtbirce me shi Theba: been hown to be true bi mans init2ton and has been generall accepted Srmoad in comparing the blood prize of the ternet and lightet groups of accepted in arcenes of all aga tund that there wa. an average increaze ot 10 mm? in the systolic per the former and a proportional increase the d...tol pe Hlheria alter eramının 1 332 health mren tourd that per cent o those who Tere Tore than 10 per cent Lrde eh had a normal blood pm wie while 16 per cent of tho e who were overe.zer had ahh blood poze Hartman and Ghn tu corelui.rs the boot pe to the wech of 2012 regarrants in the Vio CLL teen 173 2.d over tolcd a tep-like iscrease in stole b'ood pazucare i bado OVERWEIGHT AND HYPERTENSION Frequeecy of Elevated Du telic Eood frestare Rates Development of Sustered Hmertera (90 ea. Hz. or over) According to 4.6 Rare per te Aan Ases 45 57 Agus 35-44 305 25.5% 20.0" 15.4 IB 9.03 Ligh Mati Henry Lagt Mete Henry wid according to Ponderal leder (West-teste Light, under 2 Medier 2 to 24 Herrer Vetroportar Legrance Corper More Cienca Erdo tes atea nung a7 29 1930 1923 Tomson Art eneroaghe Crusht Lmon Scars anycowy en el arter ܘܬܲܢ weight Short and John-03 -16 cards #bo ap plied for penordic health exzm.catrod also od thing the problem pres ure vas con Istenth Laber - the creme fra Faber obtainedd milar findings u 1000 kea! 5 raste is the same of trenty to twents tre res Hace real e edade the in some vay increang meski tanda Teat patholomac husetten on te? CR-V more the crea Weight than in those of rormal vez cette ruderzen is also a rell estable.hed fact **** Oleme baze bere as to be a very definite factor the ci hrperc (F ·62 FACTORS ATFECTING BLOOD PRESSURE LEVIL The mechanism whereby increasing weight causes a rise in the blood pressure is not clear Ragan and Bordles 169 using the standard 13 cm wide cuff have shown that the soft tissue factor in very obese arms may be important in producing an increase of the blood pressure reading However this would apply only in a small number of cases Moschco witz!S7 has suggested that the rise in pressure is a compensatori effect to meet the extra burden placed on the heart which does not always keep pace in size and weight with the growth of the body He felt that this could explain the reduction in blood pressure after weight loss and the tendency to los blood pressure in thin individuals Conversely reduction in teght produces a lowering of the blood pres. This holds true not only for hypertensives but also for normal in dividuals Thus in a study of 1000 obese patients Preble188 demon strated that a reduction of 10 pounds in weight caused an average drop of 18 points in the systolic pressure and 10 points in the diastolic pres ure Similar results were reported by Terry ? Bauman In Moschcowitz 157 and others Sure RACL AND (COGRAPHIC IOC ITION The blood pressure level seems to vary with race and geographic lo cation People in tropical and subtropical climates appear to have lower blood pressures and the incidence of hypertension among them is lon Thus certain groups of Chinese Filipinos Puerto Ricans Last Africans Indians Trabs and aborigine Australians seem to have a lower blood pressure and less hypertension than do the North Imerican or other li estern peoples 189-198 Il hether this difference is racial or climatic in origin or is mostly due to a slower tempo of hfe in the warmer climates it is difficult to say American negroes however have higher blood pressures than do white males after the age of twenty Alvarez and Stanlcı 19 in a study of blood pressure readings in 6000 prisoners found that the blood pressure rose more rapidk with age in negrocs than in whites In a comparative study of 8000 apparenth healthy white individuals and 6000 apparently healthy negrocs Adams " in \ck Oricans found that the blood pressures of the colored were higher than those of the whites Ifter the age of forts also the pressure increased more rapidly in the negroes than in the whites Musa anu l'usmach 19 found a reportedly greater incidence of hypertension in the negro than in the white race among 1000 negro male factory sorkers in the Cin cinnati area 219 had hypertension whereas among 1000 male white sorhers of approximately the same age in the same communiti onlı 91 had huxrtension These findings are in distinct contrast to those it ported by Donnison ** he found that the blood pressure among African ne grocs is about the same as that among whites up to tht fourth dracle aiter which it is distinctis lover Thus African negroes appx ar to have ·TICTORS AFTECTING BLOOD PRESSURE LCI EL 63 sures a lower blood pressure than do those of their race who live in America This at once suggests that psychogenic factors probably play an impor tant role in the production of the higher blood pressures among the American negroes Chine appears to provide an environment favoring lower blood pres Cadbury 34 tahing the blood pressure of 774 oung Cantonese students found that the systolic and diastolic pressures were lower when compared to the pressures of Luropean ox American youths of similar age scight and height Tung " studied the blood pressures of 58 Americans before and after the resided in China He found that the average systolic pressure decreased 9 mm mercurs and that the diastolc decreased 11 mm during their residence in China Forster? also found that Occidentals lying in China have a lower blood pressure than Americans the average for the foreigners being the same as for the local Chinese Conversely hralowe206 has stated that the blood pressure of Chinese after long residence in Canada approximates that of other Canadian residents and that essential hypertension is common among them This tends to indicate that the differences 8 pressure may be related to the physical environment The slower tempo of uſe and the decreased amount of pysy chic stress in the eastern countries undoubtedly have an important effect on the blood pressure VEAIS INGESTIO OF LIQUIDS DIET STIRI ATION EXERCISE ALTITUDE ETC There are many other factors which affect the blood pressure but these art of little cinical importance and as a rule exert a negligible influence on it Vany of these factors were illustrated by various observers at the beginning of chnical sphygmomanometry However their technique was inaccurate as compared with present das standards (thes emploved the > cm armlet with the Riva Raccı sphygmomanometer the von Basch and Gartner sphigmomanometer) but the trend of their results is still correct As nas previously stated a number of studies have shown that the blood pressure falls during the early hours of sleep During the da: the pressure has been found to increase slowly reaching a maximum in the early esoning as a rule at 61 and then decreasing somewhat until bedtime. 127209 Some of this diurnal rise has been attributed to the digestion of food **+ **) 07 09-21 since this causes a slight but definite rise in the su stolic pressure and a lesser rise in the diastolic Ingestion of liquids ? $ 155 can also increase the blood pres sure Diet also may evert a minor effect on the blood pressure Thus Satles compared the pressure of vegetarian and meat eating monks and found that the latter had a consistently hugher blood pressure in each age group Starvation can lower the blood pressure as was straight demon ·6+ FACTORS 1FFECTING BLOOD PRESSURE LEILL strated during and immediately after the troll orld llars by obseries in Germany 216 217 It is of course a factor of minor importance in this land of plenty 1/uscular ererciseli 1 18 may account for some of the increase in the pressure during the day llith light clercise the diastolic pressure mai remain at a normal level while the si stolic rises several mullinieters Strenuous exercise horen er causes a murhed increase in the sistolic pressure and a lesser increase in the diastolic pressure both during and after the period of evercise Vl these factors account to some degree for the diurnal variation in the blood pressure Posilion usually has little effect on the blood pressure The Committee on Standardization of Blood Pressure feels that there is no significant difference in the blood pressure taken in the lung or sitting position The standing and recumbent si stolic blood pressures also diffcr ieri little as a rule However the diastolic pressure is usually higher in the standing than in the recumbent position Tlus difference may amount to 8 mm mercury or more in some cases 1 Pregnancy is considered a factor which may influence the level of the blood pressure but the changes cannot be foreseen Faught in a study of 100 normal pregnant women found marhed variations below or above the normal limits but the average remuned within normal limits Comell *** in 1000 pregnant women found 18 per cent to have a si stolic pressure of more than 140 mm mereurs in general he found a slight drop during the third and fourth months of pregnancy and a gradual increase from the seventh month unul tht time of deliver An mequalın of the blood pressure in both arms 15 at one time con sidered to be a sign of an aneurysm of the ascending aorta It has been shown honcier that many normal people mai have a different pre ure in each arm horn and Cuinand ** in 1000 health people (31 males and 269 females) ranging in age from sitteen to forto ginc scars found this condition present in 38 per cent of the cases In 21 per cent the difference was more than 10 mm mercuri Sesenti fore per cent had a higher pressure in the night arm than in the left The exact mechanism of this di party in the brachtal pres ure is not known Changes in altde have very little effect on the blood pressure and what effect occurs is a variable one Clough *** and others *** found that it was impossible as a rule to forecast the influence which a change in altitude would have on the blood pressure In some caves a slight 5ice occurred in some a slight fall while in many the findings wert un changed SUVIR Vans factors allect the blood pre sure reading Thou should Ise con aidered in cach individual case in es aluating vanitions of the box pris cure from the normal ·FICTOPS FHFCTING NI IRINA LIIL 6 The most important factors are (1) fecond Ser -Blool pnt sunt simili ini s3 with 10 It en lower in females under 10 years of it mare with nak ind in higher in females after the age of o Int and we the retor mu 1 l considered ahen the normal range of bini pn urt is de hned (21 Fmotion - Emotional disturhanit percall hear tau e tran cient blood pressure elevation Thus mai hart ani progno ta sitt canct indicating an incrca id tundena tumani tht alt vilopment of a sustained hipertension later in luit The 13nabihti oi the blood pres sure caused by the emotional tactor ha been large chmnated birt cording basal blood pressures Hostexer this is not prctical in chnical medicint where the (3 ual blent pn ur nding i the one utilized The latter is undoubtedly a tour approvmation to tht level of the blood pressure with which tht painnt les in his tund hre It is important there fort to endeavor to estab? h tht normal range of the casual blood pressure Las important factors are (3) Soft Tissue and I asculur Puctors -llith the tandard 1 cm cuit an excess of soft I suc such as UL curs in a very ole seruan may cause an increase in the blood pre sure readm. a thin arm may crust that mad to be too lont Thickening of the sitt nal wall and arterionck my to do not affect the blood pressure reading "pistit contration of the muscular coat of the segment of the arterial at underling the peumatic cuir may cause an elevation in the blood pressure 1 hrs mit be tlminated by macage or repeated compre un with the cuti (4) Obesit - Ihe blood pres ure with incre i ed ucight and is lowered by neight reduction (5) Race Vlcals Erercise Position Illude 'resurser and Clary hon - These are manor factors which do not csert an Ajin cablu ettet on the blood pressure incres BIBLIOGRAFII 109 ALLEN EV Normal Blood I ressure and its histol 1 nations in nannosis and Treatment of Cardonasiular Diese futello Stud 1 D 3rd Ed vol II, 1314 Ibladelgha 194%EDIN) 110 HOLFENSOHN KRISS P i ber den Burdnunk m Andesalter Trch f hunderh 53 337 1910 111 VICHAEL MA Studi of Blood I res utc mcmal Children im J Dis Child 1 27" 1911 11? 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Ain Heart) 9 396 1934 207 KARRENSTEIN Blutdruck und Kurperarbeit Ztsthr f Non Med 50 579 1903 208 BROWN GE Daily and Monthly Rhythm in the Blood Pressure of a Mun with Hypertension--A Three Year Study Ann Int Med ? 1177 1930 209 WEISS H Blutdruckmessungen mit Gartners Tonometer Munchen med Ichnschr 17 69 1900 210 CROLLYAN A Physiological anations in the Cardiac Output in Man The Effect of Ingestion of Food on the Cardiac Output Tulse Rate Blood Pressure and Oxygen Consumption in Man Am J I lostol 80 367 1929 211 ERLANGER ) and Hooker DR An Experimental Study of Blood ressure and of Pulse Pressure in Man Johns Hopkins Reports 1' 1t3 1904 212 LOEPER M La Tension Arterielle Pendant La Digestion Arch de mal du coeur 5 22 1912 213 v MariNOVITCH ind RIEDER Intersuchungen uber die durch Muskel arbeit und Flussigkeitsaufnahme bedingten Blutdruchschwankungen Deutsches Arch i klin Med 46 329 1890 214 GROLLMAN A Physiological Vanations in the Cardia. Output in Man II Changes in the Cardiac Output Metabolism Blood l ressure and Pulse Rate of Man Following the Ingestion of Fluids Am ) I hy siol 09 157 1929 215 SAILE F Uber den Einfluss der Vegetaris hen Ernahrung auf den Blutdruck Med Win 26 929 1930 216 LICHTWITZ L Uber Interern shrung Verhandl d deursch Gesellsch f inn ved 35 18, 1923 217 HOTTINGER A (SELL OLEHLINGER FSALZMANN Cand LABNART A Hungerkrankheit Hungerodem llungertuberkulose B Schwabe Pa el 1948 pp 82 86 218 SCHNEIDER EC and TRUESDALL D A Statistical Study of the Iulse Rate and the Arterial Blood I ressures in Recumbency Srinding and After Standard Exercise Am J I hy stol 01 +29 1927 219 FALGHT F 4 Blood I ressure and lunary Findings in 100 cases of Normal Pregnancies Am J Obst and Cynec 11 633 1976 220 CORNELL FL Blood Pressure Readings in Thousand I regnant Women Am J Obst and Cynec 18 7 1979 221 KORY HS and GLIYADI Il Inequality of Blood Pressure in the Bra chial Arteries with Especial Reference to Disease of the Arch of the Aorta J Clin Investigation ?? 143 1933 222 Cloici FF Blond I ressure lanations as Influenced by Rapid Changes sa Altitude A Study of 100 orma) Men Arch Int Ved 11 500 1913 223 JENISCH Pard JIALG Der Blutdruck der Ilypertoniker bei Luftdruck verminderung Munchen med Wchnschir 761 1670 1929 274 SCHNEIDER EC and Sisco DL The Circulation of Blood in Van at Fligh Altitudes 1 The Iulse Rate Arterial Capillary and I enous I ressures Am J I hy stol 34 I 1914 ·Chapter IV THE NEED FOR INCREASING THE RANGE AND LIMITS OF NORMAL BLOOD PRESSURE-NEW LIMITS OF HYPERTENSION SINCE hypertension and hypertensive heart disease are today considered to be among the commonest types of cardio vascular affections the cor rect clmcal interpretation of blood pressure readings is of paramount in portance This is assuming an ever increasing importance because many more people now undergo routine health eraminations in the physicians office in industrial plants in public health studies in the military estab Iishments and in life insurance companies The need for the proper inter pretation of blood pressure values is growing more urgent also because of the increase in the number of older people in the United Statesthe increase resulting from the lengthening of the span of life during the past several decades In spite of the large amount of data that has accumulated a wide diver gence of opinion still exists concerning the normal range of the arterial blood pressure During the past thirty years an increasing number of authorities in the field has accepted 140-150 mm mercury as the upper limit of the normal systolic pressure and 90–95 mm as the upper limit of the normal diastolic pressure irrespective of age and sex These constitute the present commonly accepted limits and have been estab lished largely through studies made by life insurance companies Their results were based on data which related the average blood pressure readings to group mortality rates Their tables are still cited in most textbooks as the basis of normal blood pressure levels Notwithstanding the fact that insurance companies have contributed much to medical progress through their accumulation of vast amounts of material and of experience in various fields their conclusions regarding normal blood pressure limits cannot be accepted in clinical medicine The objections to using insurance company mortalty statistics as a basis for the establishment of normal blood pressure limits are manifold insurance companies are concerned only with a highly selected group of accepted risks they consider the longevity and mortality of large groups and their results cannot properly be applied in clinical practice which considers individual cases They examine more males than females the majority of whom is young-and since hypertension is known to be more serious in youth than in age and to result in higher mortalits in men than in women the insurance company figures are biased The ( 71 ) ·72 RANGE AND LIVITS OF BLOOD PRESSURE insurance companies disregard also the degree of individual variability of blood pressure, which is a physiologic characteristic and disregard also the increase in the pressure with increasing years Indeed the in surance companies approach to the problem has in reality been an attempt to define an ideal blood pressure rather than its normal range of variation Insurance statisticians sech to determine the particular range of blood pressure within which they can accept risks with profit Hunter ? actuary of the Neu Jork Life Insurance Compans franhly stated that the purpose of the preparation of these statistics was not to cicite public interest or curiosity but for actual use in a great business Simonds Vedical Director of the Vlutual Life Insurance Company put the matter rather well Probabli life insurance and general medicine will never regard blood pressure in the same light Life insurance sees only persons who are healthy or think they are (eneral medicine knows that many patients with high pressures (170-200 mm) wall live for many years If a practitioner should see 1000 patients with high blood pressure at age sixty and wager with himself that 9:4 sould survive the car and only 960 surulle he would not feel downcast In fact he would probably point to the record with pride and boast of his ability in prognosis But life insurance would have to tell him that his mortality was 150 per cent in that group and a medical director who did not make a better guess than that would not hold his position long General medicine would look complacentis at the living but lift insurance would ruefully regard the dead for 40 claims would have to be paid instead of the 26 xpected Other insurance authorities have emphasized the point that it was unwise to accept insurance company limits too literalls and that a less dogmatic point of view was indicated Vachenzie 86 of the Prudential Life Insurance Compans states that ? he systolic may vary to such an extent under emotion nervousness muscular strain etc that in our judgment we may usually disregard when the diastolic is normal for the age and the applicant normal in other particulars Furthermore according to Vlackenzie blood pres sure readings decidedls besond the acceptable limits are constantl reported but are not usually considered cause for immediate action in otherwine insurable risks The figures which lachenzie gives should be used 1 guides and not arbitrarı limits It seems obvious from the foregoing that the blood pressure limits set by the insurance companies are too rigid but before release this topic we must mention the limits set by Robinson and Brucer" whose study is widely quoted because these are cren kas liberal than those set by life insurance companies Ihes maintuned that the uppxr limit of the normal blood pressure was 120'80 mm mercurs for all ages and for both scies Treloars believed that the statistical methods imploser by Robinson and Brucer Here unsound His main criticism was that ·RANGE AND LIMITS or BLOOD PRESSURE 73 their conclusions were based on a biased selection of cases and did not represent a fair random sample Furthermore all cases with a blood pressure greater than 140/90 mm mercury had been eliminated from their study without proper justification For these and other statistical reasons the validity of their conclusions is highly questionable Since as has been shown the present day blood pressure limits, set by the insurance companies are unsound and since the same tired limits for all ages and both seves cannot be accepted a more liberal ap proach to the blood pressure problem, and a correct clinical interpretation of blood pressure measurements are necessary From time to time various reports have stressed the need for liberalızıng our concepts of the limits of the normal blood pressure The results of these investiga tions fall into 3 large groups 1 Those indicating that the blood pressure increases significantly with age 2 Those demonstrating the high incidence of so called hypertension in the normal population 3 Those showing the benign course of many hypertensives 1 BLOOD PRESSURE INCREASES SIGNIFICANTLI WITH AGE Physicians have long known that the systolic blood pressure increases with age The dictum that the normal systolic blood pressure expressed in mm mercury equals 100 plus the patient sage expressed in years was commonly accepted in the early period of clinical sphygmomanometry Other formulas ? 8 based on the age of the patient were later intro duced Peters ? 7 in 1925 stated that the normal systolic pressure ranged from 90 to 130 mm plus one half the patient s age in years-thus for a man of forty its normal range was between 110-150 mm Alvarez and Stanley 199 on the contrary stated that a pressure of 115 mm is just as normal and a pressure of 140 is just as abnormal in an old man as in a young man According to them the blood pressure varied little with age-and this opinon has been generally accepted Within the last twenty years or so therefore the upper limit of the normal systolic pressure has been lowered so that today 140-150 mm mercury systolic and 90-95 mm mercury diastolic are generally regarded as uppermost normal levels irrespective of age Observations reported by numerous investigators over the course of many years however disprove the concept that the blood pressure is normally altered little by age I otain in his extensive experience with over 11 000 blood pressure readings found that the systolic pressure normally did increase with age In 1909 Tavaststjarna *9 in Finland reported the normal pressure ranges which he had found in 487 people ·RANGE AND LIMITS OF BLOOD PRESSURE from seven to ninety years of age The following table has been adapted from his results TABLE-BLOOD PRESSURE IY 175 INDIIDUALS-TAY 4STSTJIRI (1909 ADAPTED FROM KYLIN) Systolc Pressure umber Ronge 1strage of Cars 16 89 142 111 28 18 95-132 112 12 22 92-142 110 58 25 95-142 122 20 26-30 110-142 121 21 31-40 99 170 121 21 41-45 102-180 134 3 01-0 130-175 555 3 71-80 142 248 199 7 Although the number of cases in each age group is relatively small the trend to an increase in the blood pressure with age is apparent Similar results were obtained in studies on older age groups Wildt 10 in 1912 liner 231 in 1916 Boncs 23% in 1917 and Richter 3 in 1923 Table 11 taken from Richter is representative of their findings 11 the patients were ambulatory Those with nephritis and heart de-casc had been excluded TABLE VI \ORMAL BLOOD I RESSURE IN OLDER AGE CROL Ps-RICHTER (1923) 310788 xmber Systole Pessue of Cases Age 60-03 138 10 65-69 50 22 70-74 156 35 75 79 155 52 80-81 157 85 89 161 15 It must be stressed that averages are given in thus table These do not talc into account the normal variation of the blood pressure and hena do not represent the limits of the normal The upper limit of the normal blood pressure is necessarıls higher than i the average pressure This is important and should be bome in mind when subsequent reports are evaluated ·RANGE AND LIVITS OF BLOOD PRESSURE 75 In 1928 a very important study was published by Saller 3+ who recorded the blood pressure in 4 128 people in an out patient clinic in hiel He excluded all patients with organic heart disease kidney disease anemia diabetes fever and endocrinologic disturbances His results are summarized in Table VII TABLE VII - BLOOD PRESSURE RANGE IN 4 128 PEOPLE-SALLER (199) R & Syll P55 re I ช 98-111 Age 21-35 36-47 48 53 S4-59 60-67 It omen 99 139 100-155 100-190 104-196 102 216 96-154 97-159 93 173 68-8) 86-156 112 222 The salient finding of Saller was a gradual increase in blood pressure after the age of forty seven the rise being higher in the females than in the males The wide range of the systolic pressure found by Saller is also of great importance It is obvious that the use of the a erage blood pressure as a criterion has very little value when such a wide range exists Saller did not claim that all blood pressures lying within these limits were normal He concluded however that if the blood pressure is within these limits one cannot be sure that it will have any influence upon the length of life of the individual He suggested that the increase of blood pressure with old age should be considered a part of the ageing process and that it may be likened to other changes which occur with age such as those found in the hair the teeth the eyes and the libido In an excellent critical review in 1936 Bordley and Eichna2 presented a table arranged from material collected by Weatherby which demon strates nicely the rise in blood pressure with age and the higher blood pressure levels in females in the older age groups Cases with nephritis and aortic insufficiency had been excluded TABLE VIII-ALERACE BOOD PRESSURE ( M M RCLRY)-WEATHERBY (1935) It om * (3258) D Syt loc D 47 73 118 75 Syi? 116 120 123 77 120 77 SO 126 80 4g 15 19 20-29 30-39 40-49 50-59 60-69 70 & over 12 82 139 86 137 83 153 90 89 164 93 158 89 174 95 ·76 RANGE AND LIVITS OF BLOOD PRESSURE W'catherby found that a rise in diastolic pressure also occurred with in creasing age Lewis 38 in 1938 studied the blood pressure of 100 men 20 in cach des ade from forts to eighty nine years and found a definite rise in the systolic pressure with increasing age The average diastolic pressure however did not change much In 1941 Miller 37 reported on blood pressure studies on 853 men and 128 women fifty years of age and over He also found a definite rise in the average systolic pressure rith age the pressure being higher in women than in men of all age groups The diastolic pressure however varied only slightly In 1946 Russeh 15 and his associates reported on the blood pressure levels of 5331 men between fort and sixty five years of age Their results were as follows EX (1946) TABLE IY - BLOOD PRESSURE IN 5331 VEY-RI rerage Blood Preise (onm Jerev) Systol DIC umh of Cases 135 86 1640 40-49 50-59 60-69 87 1414 151 89 1124 70-79 89 772 157 162 80-95 88 381 Russek concluded therefrom that the a crage si stolic pressure increases significantly with age whereas the a cruge diastolic pressure shows little Variation after the sixth decade On the basis of these and other studies Russck "-suggested that the formula 100 plus the age mai reflect fairly accurately the tendency of the normal si stolic blood pressure to increase with age Vary Gover de in 1948 reported the blood pressure measurements in 9 776 white persons who ined in rural communities The craminations had been made under the supervision of the Farm Security administra tion in 1940 Although this was a selected group of individuals her findings are of interest TABLE-BLOX 1 PRE URFIN 97 6 RURAL IN IAL-COSTR (1949) irage Pess (mm Vorom y) Fem les Detalic Sy lulc D Systolte 126 15 21 73 7 126 129 8 130 03 140 85 133 25 34 JS-44 45 $# 55&or 142 25 KB 152 91 158 169 92 ·RANGE AND LIMITS or BLOOD PRESSURE Thus in addition to the rise in sy stolic pressure Gover found that the diastolic pressure also increased with age The increase in the pressure was greater in women after the age of forty All these findings present a potent argument against the thesis that age does not significantly affect the blood pressure It is evident there fore that the physiologic effects of age and sex on the blood pressure must be taken into account when new normal blood pressure limits are determined 2 HIGH INCIDENCE OF SO CALLED HYPERTENSION IN THE NORMAL POPULATION As a corollary to the fact that the blood pressure increases significantly with age one would expect to find a high incidence of hypertension in the normal adult population Indeed this has been evident to many ob servers in the last thirty to forty vears as shall be shown directly Since the normal increase in the blood pressure occurs at a much more rapid rate after the age of forty the incidence of so called hypertension in the normal population over forty should especially be striking and should increase with increasing age That this is so has been shown by many studies on groups under and over forty years of age Barach and Marks 243 in 1914 were among the first to point out that a significant number of voung healthy men (below fortv) had an increased blood pressure They examined 74? male university students who presumably were in good health Four hundred and two (75 per cent) of the cases were between seventeen and twenty one years of age only 2 being over thirty one They divided the group in 2 series only for the diastolic readings They employed the hfth phase in the first group and the fourth phase in the second group for their blood pressure readings They found that 24 per cent of 656 of these students had a systolic pressure of over 140 mm mercury and that 9 4 per cent had a systolic pressure of over 150 mm Thirteen per cent of the second group (312 cases) had a diastolic pressure of over 100 mm mercury Lee 44 examined 662 Harvard freshmen whose average age was eighteen years Twelve per cent of these young men had a systolic pressure of over 140 mm mercury Alvarez24 found that 22 per cent of a large group of healthy college fresh men (sixteen to forty years of age) had a systolic blood pressure of over 140 mm mercury Diehl and Sutherland 46 obtained the same results in 11 5 per cent of a similar group The great majority of these students was under thirty years of age (Table VI) Durig '7 in Germany Walko 48 in Czechoslovakia and Moisset de Espanęs '' in Argentina also reported a large number of young people (under thirty years of age) with a systolic pressure of over 110 mm mercury The incidence of elevated arterial blood pressure according to the old accepted limits in the healthy young adult population is thus prosen ·78 RANGE AND LIVITS OF BLOOD PRESSURE TABLE XI -PER CENT OF HEALTHY LOUNG WALES (L DER 40) 11TH Sisto IC PRESSE RE 01 ER 140 VV VERCLRS Ircia Totslumber 1 ttho Systoli ar 10 Barach & Varis (1914) 24 per cent 6S6 Lee (1915) 12 Det 062 22 per cent 600 Al ar z (1923) Diehl & Sutherland (1925) 11 S per cent 5122 to be quite high perhaps therefore the limits of normal that are com monly accepted are too losy If they are not an undul large number of the young adult population will be considered to be hipertensic The necd for a new approach to the problem is therefore again evident Po cent 100 OVER 40 YEARS OF AGE -MALES Syut ! P 130 mm Dp 95 mm Rchter 80 Ma tor Mak, Dck 60 Russk 40 Maste Mak Dk 20 Rus ok 53 60 70 80 40 to 49 Age Group ta 90 to 99 to 69 59 79 89 FIG 13 --Percentage of sa es with systolic pressure of 10 mm mercury or more and diastolic pressure of 99 mm mercury and over given by different authors In the groups who are over forts cars of age tht high proportion of hypertensies In even mort striking and signiheint if the pie «nt dat criterra (19049 9 mm mercury) are implored a numlxr of impres il studies has been published on this subject a les of the more important ·RANGE AND LIVITS OF BLOOD PRESSURE ones are summarized in Figure 23 In 1912 Wildt 30 found tha per cent of people over sixty years of age had a systolic hy Similar findings were reported by Weitz and by Richter 33/ studies done on an unselected large group of patients Gager'in 19. Blachford Bowers and Baker in 1930 and Braasch Walters and Hammer 253 in 1910 found a steadily increasing percentage of high blood pressure with increasing years and a conspicuous rise in its frequency in the fifth decade Furthermore, after the age of forty the incidence of hypertension was found to be greateun women than in men This is in accordance with the finding that the normal blood pressure increases with the vears, and is greater in females after the fifth decade than in males y In 1943 Master Marks and Dach 254 analyzed the blood pressure meas urements found in 14 819 people (8 483 men and 6 366 women) These were industrial workers residents in homes for the aged and non selected patients in a general hospital The following table, taken fro their report summarizes the incidence of hypertension found according to the various defnitions of the normal TABLE XII --INCIDENCE OF HYPERTENSJOY IV VOR IAL POPULATION- MASTER MARKS AND DACK (1943) Percent 8 Degree of Hyp I nston N » MOTY Age G Yeas Vale Fem 1 140,90 or ov 40 and over 50 60 50 51 72 60 70 70 70 77 82 150/90 ooer 40 41 51 50 50 62 60 60 70 70 66 74 150, 100 or over 40 32 50 43 56 60 55 66 70 62 70 A study of their results reveals that the incidence of hypertension rises in each decade until the age of eighty whatever the accepted normal limits may be The percentage ts always higher in women Thus using the commonly accepted limits they found that almost one half of the people who are forty years of age and over has hypertension High blood pressure was present in the majonty of men who were sixty and over and in women who were fifty years or older ·78 RANOT AND LIVITS OF BLOOD I RESSURE TABLE VI - PER CENT OF HEALTH) lov WALES (L\DER 40) w STOLIC PRESSE RE OS ER 140 MW VERCURY Per Cent fath Totul her totho Systol coer 140 tramax Barach & Marks (1914) 24 per ent 650 Lee (1915) 12 per cent 662 Als arez (1923) 22 per cent 6000 Denil & Sutherland (1925) 11 5 per cent 5122 to be quite high perhaps therefore the limits of norma) that are com monly accepted are too lou If they are not an undult large number of the young adult population will be considered to be hypertensne The need for a neu approach to the problem is therefore again evident Parcent OVER 40 YEARS OF AGE -MALES 100 Sy tlap 150 mm . 95 mm I chto 80 Mot Mark Dok 60 •Russek 40 Marta Mis Dack 20 Ru JK 50 70 10 0 AO ty 49 &O to Ag. Grop to to 90 to 99 to 59 79 89 F1c 13 -Sessestage of cases with sistolic pressure of 150 mm mercur or more and diastolic pressure of 9, man mercury and over grenlv different authors In the group, who are over forts cars of 3r the high proportion of hypertensies is even more striking and significant if the present day criteria (130/90 9 mm mercury ) are emplored A number of impressive studies has been published on this subject, a fen of the more important ·RANGE AND LIVITS OF BLOOD PRESSURE 81 sure smits must be libcralized Indeed so called hypertension is the rule rather than the exception in women over fifty and in men over sitty Master Marks and Dack share stated that the high incidence of systolic pressure in people over the age of fifty should not be a cause for alarm A slight or perhaps even a moderate degree of hyperten 520n in older age groups should not be considered abnormat, the com monly accepted criteria of normal blood pressure limits are used *** 3 BEVIGN COURSE OF NANI HIPERTL VSIVES Nany physicians have seen people with blood pressure readings above the commonly accepted limits who ine their normal lafe spans without complications related to their blood pressure-their so called hyper tension runs a benign uncomplicated course for long periods of time Several reports have appeared sshich confirm this finding In 1926 Weitz sin a three to fourteen year follow up study of 100 hypertensives, the great majority of whom had a systolic pressure of over 200 mm mer cury concluded that the course of hypertension is often relatively favorable In 51 of the cases the blood pressure remained unchanged or showed a tendency to all over a period of from three to eleven years Blood and Perera? have recentis reported on 50 patients who when first seen exhibited asymptomatic and uncomplicated hypertensive vas cular disease Their initial pressure repeatedly crceeded 140/90 mm crcury These patients were followed for from ten to twenty seven years the average length of observation being seventeen years The majority showed well established hypertension at the time of the first examination and may have had an elevation of the blood pressure for an indetinite period before it on the basis of their findings, Blood ansi Perera7% concluded that high blood pressure way ly compatible with many cars of survival and well being Similarly, Perêrā in a survey of 2 14, hypertensive records systh a detailed study and observation of a group of 230 patients, found that long survival (more than twenty cars) often with mparative well being is not a ranity He emphasized the fact that the aserage life expectancy, theSC CISS ISundoubtedly longer than is generally assumesi. A similar study by Ranges of 241 cases of hyper also demonstrated that its course was frequently benigs Burgess e observed 100 patients with blood pressures of 180/100 m mercury or more for at least eight years Il concluded that the prognosis in even severe hypertension was usually fair though the condi tion had been present for eight ye375 or more provided that it was not associated with well established cardiac or renal disease Such patients may lose to within three or four years of the average le ex pectancs By far the most extensic and comprehenssıc follow up study was done by Bechgaard 165 He studied 1 038 chmc patients (32) mer 713 women), tension ·82 RANCE AND LIMITS OF BLOOD PRESSURE who, at the first examination had a blood pressure of 160/100 mm mer cury, or a systolic pressure of 180 mm or more A second examination of 1 002 of these patients was made four to elevcn vears later Bechgaard compared the mortahty of this group with the expected mortality in the Danish population in similar age groups As was to be expected he found that the mortality ratio rose directly with the height of the blood pressure However the increase of this ratio was marked for those with a systolic pressure only exceeding 200 mm mercury in men and above 220 mm mercury in women As regards the diastolic pressure again Sy tel Pes 160 199 mm Hg 100 129 mm Hg MALE FEMALE 70 10 8 2 40 50 60 70 40 50 60 70 A9 F1 24 - Mortality rate of patients with systolic pressure of 160 to 199 mm mercury and diastolic pressure of 100 to 129 mm mercury -compared to the mor tality rate of the general Danish population (modified from Bechgaard) a distinct rise in the mortality ratio was observed among males only when this reading erceeded 130 mm mercury (Fig 24) and among the females when it exceeded 129 mm mercury Thus based on the blood pressure readings alone this study shows that the surnal record is fair in the great majority of cases with moderate elevation of the blood pressure This is especially true of women in whom the mortality from non complicated hypertension climinating the most scIcre degrees is but slightly hq,her than is that of the general population The findings of Bechguard are indeed striking The observation that many people with high blood pressure Ine to l ripe old age suggests that undue signi ficance is frequently attached to the degree of hipertension The benign course that many so called hypertensii es run suggests that manı patients are included in this group sho might ach classired as being within the normal blood pressure range These people are often enthusiasticalls but apparentis unnecessarily treated for high blond! pressure The handwriting on the sall proclaiming the need for a liberalization of present day normal blood pressure limits has ikin discernible for some time as a result some phu sicians have arbitranih st lugher normal limits Thus, in the older age groups I ast and Bain*used a limit of ·RANGE AND LIMITS OF BLOOD PRESSURE 83 160/100 Evans 69 180/110 Deschamps 59 180/100 and Perera and Atchley 147 180/100 mm mercury Others have commented on the dim culty of defining the normal blood pressure limits Dexter 70 states that it is impossible to define a truly normal level Gavey 57 has written that there is no normal for old age None of the earlier accepted limits takes into account the important influence of age and sex which must be considered in establishing new limits of normal blood pressure SUMARY 1 The present day normal blood pressure limits were established largely as a result of life insurance company studies Conclusions drawn from these studies are not applicable to clinical medicine since they are based on the findings in a selected group and are derived from a statistical analysis of group mortaltv rather than from a consideration of individual unselected cases 2 Many studies indicate that the blood pressure normally increases significantly with age This rise is more rapid and greater in females than in males after the age of forty There exists a high incidence of so called hy pertension in the normal population Using present day limits studies indicate that the majority of women over fifty and of men over sixty is hypertensive 4 Many people with elevated blood pressure may live their normal hfe spans without complications related to the blood pressure 5 The need for upward revision of the commonly accepted limits of normal blood pressure-140 to 150 mm mercury systolic and 90 to 9) mm mercury diastolic---for each age group and for both sexes is there fore clear BIBLIOGRAPHY 225 HUNTER A Can Insurance Experience be Applied to Lengthen Life? Proc of the Assoc of Life Ins Pres 8 27 1914 226 TRELOAR A E Normal Blood Pressure Arch Int Med 66 848 1940 227 PETERS J T Die Diagnostik von Hypertension bzw Hypotension des Systolischen und Diastolischen Blutdrucks Munchen med Wohnschr 72 503 1975 228 LYON DM Blood Pressure Normal and Abnormal Edinburgh M J +7 297 1940 229 TAVASTSTJARNA cited by KYLIN E Der Blutdruch des Menschen Dresden 8 Leipzig Th Steinkopff 1937 p 11 230 WILDT H Über Blutdruck im Greisenalter Zentralbl f Herzkrankheiten und Gefasskrankheiten 4 41 1912 231 WINNER Svenska Lakaresallshepets Handl ? 1489 1916 cited by Fleisch A Handbuch der Normalen und Pathologischen Phystologie Vol VII Part 2 Berlin Julius Springer 1977 p 1276 232 Bowes L NI Blood Pressure in the Aged | Lab Clin Med ? 256 1917 233 RICHTER A Uber Blutdruck in Hoherem Alter Deutsches Arch f Win Med 3 148 1923 ·8+ RACE AND LIVITS OF BLOOD PRLSSURS 234 SALLER Über die Altersieranderungen des Blutdrucks Zuschr fd Ges Exper Ved 58 683 1928 23 BORDLEY ) III and EICHYA LW Tormal Blood Pressure Internat Clin 49 17, 1938 236 LEWIS 1 H JR Changes with Age in the Blood Pressures in Adult Hen Am J Ph) siel }2} +91 1938 237 MILLER I Blood Pressure Studies in the Aged New York State Med 11 1631 1941 238 RUSSER RI RATH VI M ZOHVAN BL and VILLFR 1 Influence of Age on Blood Pressure Study of > 331 ll hite Wale Subjects Am Heart J 39 46 1946 239 RussEk HI Blood Pressure in the Aged A Study of 1000 Flderly Male Subjects Am Heart J ? 11 1913 240 Resex HI and Zonson BL Normal Blood Pressure in Senescence Ceriatrics 1 113 1916 241 Russek H What is Mormal Blood I ressure' New York State Med 48 1489 1948 GOTER VARY Phisical Impairments of Members of Low Income Farm Families Variation of Blood Pressure and Heart Disease with Age and the Correlation of Blood I ressure with Height and Weiche Pub Health Rep 63 1083 1948 243 BARACK J I and Varas #L Blood I ressures 7 heir Relation to Fach Other and I hysical Ficienci Arch Int Wed 13 618 1914 244 LEE RI Blood Pressure Determinations lnnary Findings and Differ ential Blood Counts in a Group of 60 Young Vale Adults Boston Med and Surg 1 1/3 I 1913 24) ALVAREZ C Blood Pressure in 1,000 l naersity Freshmen Arch Int Ved 37 17 1923 246 DIEHL, IS and SLTHERLANDA II Systolic Blood I ressures in Youn. Vien Including a Special Seuds of Those with Hypertension Arch Int Ved 36 11 1922 747 DBC Obes Blutdruck und Blutdruckmessung Wien und I cinta Moritz Perles 1932 249 Walho cited by Deschamps I in Iraite de dicinc lol V lans Vasson & Cie 1948 P 161 249 MoissET DE I SPAm F Frequencia Cardiaca fresion Sanguinea Arterial on Estudiantes Conscriptos de Cordoba Re Soc Argent de Biol 11 >64 1941 7,01 EITZ, 11 Lur trologie der Cenuinen oder Vascularen His pertension Ztschr f klin Ved 90 191 1923 1 (ACER LT The Incidence and Management of li pertension JAMS 90 8? 1928 2, BLAWFORD J V Bow ERS) Wand BARJA Follow up Study of Hypertensson JAVLA 94 328 1980 253 BRAASCHI 11 F HALTERS 1 and TAYVER HJ Ihrenenvon in the Surgical Adnet SAVA 115 1837 DIO 24 MASTER IV Varas }} and Dicks is pertension 10 i mople Over 30 JAVA 17} 1931 1943 7, Thoyr OY Rjt and ToDD R ! Old Age and Blood I ressure I rob Jems Lanert 793 OJ 1977 26 HULLIL FA The Icart in Old At A Study of 700 latients Seients fic cats of ice and Older Am ) 11 Sc 1991 1931 237 GAY ( ) The Cardiologs of Old Age Lancet 237 72, 1919 ·RANGF AND LIMITS OF BLOOD PRESSURE 85 2382 MONROE RT Disease in Old Age Cambridge Harvard University Press 19,1 p 88 2585 MONROE RT Disease in Old Age Cambridge Harvard University Press 1991 r 92 259 PULLMAN TN and ALVING AS Malı nant Hypertension The Medical Clinics of North America Philadelphia WB Saunders 1991 260 MURPHY FD GRILL JPESSIN B and MORON GF Essential (Pri mary) Hysertension A Clinical and Morphological Study of 373 Cases Ann Int Med 6 31 1932 261 WEITZ Beitrag zur Prognose der Essentiellen Hypertension Munchen med \chnschr 75 2196 1926 262 BLOOD DW and PERERA GA Hypertensive Vascular Disease Dura tion of Life in Selected Series Am J Med 4 83 1948 763 PERFRA GA Diagnosis and Natural History of Hypertensive Vascular Disease Am J Med 1 416 1913 761 RANGES HA Benign Aspects of Hypertensive Disease A Group Study Medical Clinics of North America 1919 p 611 265 BURGESS AM Excessive Hypertension of Long Duration New England J Med 239 75 1948 266 BECHCAARD P Arterial Hypertension Follow up of One Thousand Hy pertonics Acta Med Scandinay susp 172 3 1946 767 EAST T and BAIN C Recent Advances in Cardiology 4th Ed London J and A Churchill Ltd 1918 p 114 269 EVANS W Cardiology London Butterworth & Co 1948 r 204 269 DESCHAMPS PN In Traite de Médicine Vol II Paris Masson & Cie 1948 p 112 270a DEXTER L Textbook of Medtune ed by Ceci RL and Loeb RF 8th Ed Philadelphia and London WB Saunders Co 1991 1066 7700 DEXTER L Textbook of Medicine ed by CECIL RL and LOEB RF 8th Ed Philadelphia and London WB Saunders Co 1951 p 1072 ·Chapter 1 PRESENTATIO OF VEN LIMITS OF NORIAI BLOOD PRESSURE \UBIEROUS studies have hitherto been made on the limits of the normal blood pressure and various results have been obtained It is difficult to corroborate the data thus made available especially because each student of the problem has used his own particular technique and has applied it to some particular age group The medical literature is replete with the reports of studies made on children soldiers students insurees prisoners elderlı persons and inmates of old age homes The curves representing the results thus found cannot be combined since their ends are rarels continuous Besides many of the studies have heretofore dealt larger with the average or mean values of the normal blood pressure and obviously the average blood pressure reading ones no indication of the frequency or degree of the normal variation around it Important though it is the range of this normal variation has been disregarded because of the difficults of delimiting it satisfactoril Tet it is precisely the limits of the normal blood pressure range which interest the practicing phı sician and not the average or mean pressure It is evident also that one pair of figures for the systolic and diastolic pressurt cannot apply to all age groups and to both seres ll'hen nex limits of normal blood pressure are propounded they must make allowance for the eficct of sct and in creasing vears on the blood pressure of the normal population Several methods can be employed to determine the normal range of the blox pressure The most accurate but least tastyle is to examine cach individual in a large representativc group of the population epeatedly year after lear until his death The range of variation of the normal blood pressure could thus be discovered as well as the significance of certain particular variations An alternative method is to collect and tabulate voluminous data on blood pressure fusely in the normal popul: tion and to endeat or to determine the normal pressure range by statis lical studies 11ith such a method 3 (33r cumpling of the population is en important Ikarcz" has suggested that an ideal was would be to cramine (en tenth individual passing a curtain point on a buss Street lllen and Ilincs ' discuss the difficults of getting a large un elected group of presumablı normal persons for blooi pressure readings and suggested that The ideal was would be perhap to put up [xxyths in various parts of several towns and cities and there to make a pressure (86) ·SEU LIMITS OF VORI IL BLOOD PRESSURT 87 reading on each of the first 5000 persons to pass bv However, this too is not a practicable procedure The insurance companies examined a very select group of the popula tion in amassing their data and used mortality figures to determine the normal blood pressure levels acceptable to them Tor these reasons particularly the results of their studies cannot be applied in clinical medicine In the study to be presented a statistical detinition based upon the distribution of the blood pressure readings around the mean was em played 27 Casual blood pressure readings were utilved since the casual reading is most often used by the physician as an aid in the diagnosis and prognosis of discase Allen and Hinesio stress the importance and value of the casual blood pressure because it is the pressure which the patient has during the many hours of the day in which the patient as subject to the wear and tear of work emotion and fatigue As has already been shown transient elevations in the casual readings may have prognostic significance For this reason also it is of paramount importance to endeavor to establish the normal range of fluctuation of the casual blood pressure as obtained in everyday clinical practice and on special medical examination We believe that the dara presented and analyzed in this report detine the limits of normal blood pressure for both men and women between the ages of sixteen and sixty fire The group studied is large enough to be representative of the general population of the United States Tht blood pressure readings were accurately taken by trained personnel under conditions which were fairly uniform WATCRIAL Through the extensive industrial medical services established during World War II blood pressure readings were taken in large numbers of workers who were in good health These readings obtained from in dustrial plants in various sections of the country form the basis of the present analysis The majority of those examined was at work but the readings at those who had apphed for employment were included though they may have been rejected 'xecutives clerical workers and manual workers both skilled and un killed all were examined although no attempt was made to identify specific occupations The records did not show whether the individuals were white or colored but the great majority was white The method of recording the pressure and the general care used in taking it was determined by correspondence Altogether unselected records of about 4000 persons in to industrial plants and Army Burlelds (civilian personnel only) were collected (Figure 25) This is only at out cne hall of the number of persons who had been examined and whose records ·88 NEIL LIMITS or VORUL BLOOD PRESSURI were available to us The blood pressure readings of the others were not considered by us to have been accuratek taken and were therefore not deemed acceptable for our analytical study All the reports here carefully scrutinized Where for example, every reading ended with zero, they were all discarded, since it was assumed that they were not accurate Because of the large volume of material 74 000 acccpted readings random samples were taken so that at least 500 readings on men and Spokan Wash Sacram to Call Ogden Utah San Beda Cail Oklah mà C • ke New Yrk Pen syl Bit more San Anton Texas Mob! Ala Mols DISTRIBUTION BY AGE AND SEX Age F males 16 24 2994 3 627 25 34 1 282 > 298 35 44 ( 129 1 214 45 54 1041 1072 766 7 357 77 55 64 Totul fir 29 - Geographical distribution and number of all cases employed in this study huir age women in each five y car age group were collected In a fun instances honcier when the numlxt available was less than 500 all the cases vare used The data thus tabulated cover 15 706 px rsons (7 722 min and 7984 women) in eleven industrial plants (I igure 25) * ranged from sixteen to sist five scars I hox. Over sitty tuye icars of age were omitted from this studs since their numixr was ar small Samples were taken at the ages of 16 17 18 and 19 particularly in male Can work in Army a fell at Votile Vaha Cus olas De nard nn Cal Sacramento Cal San Inton Tex phase Ah Onlihavwirty in the Drooklyn Navy Yard Be Hichem Steel Tannlatiront CSI ant the Eastern bir rart Baltimore Wa ·NEW LIMITS OF NORMAL BLOOD PRESSURE 89 during the period before full growth had been attained in order to de termine the variation in the range of the blood pressure during these years Though the material used had been collected during wartime it was but little distorted, because hypertension and hypotension were relatively unimportant as causes of rejection for military service The men in this study are more representative of the male population however than are the women of the female population The men were married or single approximately in the same proportion as is found in the general popula tion except at the military age The occupational distribution was presumably similar to that of the urban population The women in this study as is characteristic of any group of working women were predominantly single or childless most of them were doing clerical work This type of bias in the female group occurred at practically all ages and was probably most pronounced after the age of forty five It is doubtful however whether this bias seriously affects the value of the results since many married women were employed during the war The data gathered were analyzed as a whole and examined according to the ser the age the weight and the height of the subjects The mean readings the standard deviations * and the coefficient of variation of the systolic and diastolic measurements were computed directlv from the In addition the frequency of hypertension as variously de fined was determined according to age and sex raw data STATISTICAL TECHNIQUE As is well known most measurable natural characteristics yield a fairly symmetrical normal curve or distribution In analyzing the measurements of such a variable physiologic function as the pressure of the blood however difficulties are encountered because exact figures cannot often be obtained Especially is this true since physicians tend to round out the blood pressure readings they obtain to the nearest even digit-most frequently to zero and eight in the present study as in all records of blood pressure measurements the commonest terminal even digit was zero or eight These terminal digits occurred more often in the diastolic readings than in the systolic The distribution of the blood pressure figures below the average for all ages combined is also somewhat different than it is for those above the average For these various reasons a perfectly smooth distribution curve could not be ex pected let in each age group and sex the frequency distribution of the blood pressure levels did yield a fairly normal curve (Figure 26) The tand d deviat on measu es in ab olute trms the dg ee of scatter ord pers n of figur n the dist but on The coeth nt of varsat on spre the stand d d v at on A AP TC ntage of th mean It is ac n tant and d ff I om th tandard dev at on n that the stand d det measu es degrees of v lation cone te un t3 8 pound inch mm Hg etc while the coefficient of van ton is a elat ve m asu e of variato ·90 NEW LIMITS OF VORMAL BLOOD PRESSURE MALES SYSTOLIC DIASTOLIC % % 20 AGES 20-24 20 10 0 10 0 20 25-29 20 10 0 10 0 20 30 34 10 0 20 10 0 20F 35 39 20 10 0 10 0 20 20 40-44 10 0 10 0 20 2045 49 30 0 Mai 10 o 205 50 54 10 0 20 10 0 20+ 55-59 20 mo 10 OL 10 0 man inn 2060 64 20 10 O 80 90 100 110 120 130 140 150 160 170 180 190 200 PRESSURE in mm ng 10 0 50 60 70 80 90 100 110 FG 64-Frequency distribution curses of entire material (in 5 year ago groups) employed to establish een limits of blood pressure for males ·91 NEW LIMITS OF NORIAL BLOOD PRESSURE FEMALES SYSTOLIC % DIASTOLIC % AGES 20 20 24 20 10 0 10 0 20 25 29 20 10 10 0 20 30 34 20 J 10 10 0 20 20 35 39 10 M 10 o 20 40 44 20 10 10 0 20 201 45 49 10 0 whid 10- 0 A chi mi hi 2050 54 20 10 0 10 O 205 55 59 20 10 O 101 0 2060 64 20 101 0 80 90 100 110 120 130 140 150 160 170 180 190 200 50 60 70 80 90 100 110 PRESSURE in mming Ho 203 Frequency distribution curves of entire material (in 5 year age groups) employed to establish new lumits of blood pressure for females ·92 NEW LIVITS OF NORVIL BLOOD PRESSURE The determination of either the true mean or modal* blood pressure in the various groups studied however was not practicable without labori ous curve titting And since the accuracy of such figures is doubtful, this determination was not attempted EXAMPLE OF FREQUENCY DISTRIBUTION CURVE MALES AGES 40-44 SYSTOLIC PRESSURE (mm ng) PER ENT 20 MEAN 1 282 0 +1 282 -20 10 0 60 9D 100 110 150 160 170 180 190 200 120 130 140 -40% NORMAL RANGE in NYPTOTENSION TO HIG 27 The range of the normal blood pressure is defined statistically, and is based upon the distribution of blood pressure readings around the mean according to age and ses The closer a reading is to the a crage or min the greater is the chance of its being normal con cruels the further a reading is from the average or mean the greater is the chance of its lring abnormal The standard des nation is the sandstick commonly used to measure the amount of deration from the mean In a normal distribu tion, roughli tho thirds (69 27 per cent) of all the obscnations are found to be within one standard deulation from the mean (mean #r) and ap proumatel 99 per cent of all the observations are found to Ix within The mode u the alue *h ch occurs most frequently ·NEW LIVITS OF NORMAL BLOOD PRESSURE 93 two times the standard deviation from the mean275 (mean +20) Since there is no definition of what constitutes physiological normality the statistical determination of the normal blood pressure range must of necessity be an arbitrary one Statistically speaking one may assume that any reading within one standard deviation from the mean is within the normal range Indeed the normal range may reasonably be ex tended to include 80 per cent of all observations-40 per cent on either side of the mean (= 1 282 ) (For computed values see Appendix RANGE OF NORMAL SYSTOLIC PRESSURE AND LIMITS OF HYPERTENSION AND HYPOTENSION MALES mm Hg. 200 190 LOWENU OF HY EKTE 180 BORDEAL EK PERTENSO 170 160 150 140 NORM PROV LA E BOX OF REA EAN FOR AGE MEAN? 130 120 110 BORDERLI EN POTE S ON 100 UPPER LIM 1 OFW POTE SON 90 16 20 25 30 35 55 60 65 40 45 50 AGE FIG 78 Master Dublin and Marks The Normal Blood Pressure Range and Its Clinical Implications courtesy of J AM A Tables 1 2 3 4 5 and 6) All blood pressure readings which are found to be beyond two times the standard deviation from the mean are probably abnormal These include 2 5 per cent of all the observations at either extreme The area between the limits of the normal and the probably abnormal constitutes a narrow borderline range In Figure 2. a magnified typical frequency distribution curve for the systolic pressure in the forty to fort; four year age male group is shown The calculated mean the normal the borderline and the abnormal range according to the definitions given are indicated Based upon the ·94 NEW LIMITS OF NORVIL BLOOD PRESSURE TABLE VI-VORMIL RANGE AND LIVETS OF HYPERTEN ION SYSTOLIC Il y perlension Somal Range Lotyr Lumil Vole Female fmate 16 105-135 110 17 145 140 105-135 105 1.35 18 145 140 10 140 105-140 105 140 150 140 104 140 150 110 14 100-130 100-130 100-130 100-130 100-130 102 130 102-135 105 140 105 130 JO 155 110-105 110-170 115 1 5 SS 20--24 23-29 30-31 3S 39 40-44 45-49 145 160 140 110-145 110-150 165 165 170 50-54 110-15$ 115 160 115 105 175 1R) 181) 185 SS 59 60-64 115 170 100 100 Se poge 13 TABLE XI - TORVA RANGE AND LIMITS OF 3] PERTH TON DIASTOLIC Il yn #I# Torm 1 Ras Lotert mi Val Female Vale female 16 60-86 90 90 00-85 60-85 17 60 86 90 18 00 R6 90 90 19 40 88 95 90 80-85 608S 60-85 60 86 62 88 95 90 20 24 25 2 65 90 96 92 64 92 609 9 91 69 92 JUN) ON 30-34 35 39 40 41 45 49 5054 03 90 <502 x 10-94 10-96 10) 105 65 96 104 os 104 0-100 10) 10% 108 55 59 7098 100 611 0 100 70-100 110 110 See por 13 Resant d ft m she at LLFTIY OF THE YFH WRACAT FMY (NICH Jul> 1951 series Vol 37 39 7460-461 and Du Dir tos por Ini Swahcatre of the rely Estadisted Lom !

·NEN LIVITS or NORVAL BLOOD PRESSURE given statistical deficution Figure 28 shons the application of the pro posed procedure to the determination of the limits of the systolic pressure among men The wide diagonal area in the middle shows the readings that may be accepted as being within the normal range in successive age groups The heavier lines at the top and the bottom indicate read ings according to age that are probably abnormal in the areas between these two are the borderline hypertensive and hypotensive zones This graph is based on the actual computations Honever since blood pres sure readings themselves are not eract same degree of modification of the computed values is necessary This has been carried out in a series of tables which show the range of the normal systolic and diastolic pres sure according to ser and age and the limits beyond which readings are probably abnorma!(Tables VIV \V) Blood pressure reachings which fall in the normal range should be considered entirely normal Those in the intermediate zone--betn een this and the lover limit of hypertension should be considered as probably normal but patients who have such readings should be thoroughlt studied before a final diagnosis is established Those readings above the lower limits of hypertension should not apso facto be considered hypertensive though they probably are normal range RESULTS 1 MORTAL RANGE OF BLOOD PRESSURE The frequency distribution curves of the systolic and diastolic pressure for each age group and in both se res are shown in Figure 26 The curves tend to be somewhat fatter in the older age groups and more symmetrical in the younger age groups but on the whole they shou a fairls smooth distribution The calculated mean and normal range are indicated on each curve In Table I the calculated mean the standard deviation and the coefficient of vanation are shann The latter tuo indicate the degree of indkvidual drversity or scatter of the blood pressure readings 1ean Blood Pressure I alues Viean blood pressure readings both sistolse and diastolic increase with age in both sexes (Table 111 Figure 29) The average systolic reading in men shaxs , fassts, smooth nee up to the age Bi tifty after hity, the rise is accelerated in women the rise in the average sysfolie pressure with age is somewhat less smooth, but it also is accettarci after the age of fifts. Ader the age of twents, the rise of the diastolic pressure with age is fairly stcady in both seres a sistematic acceleration of the average diastolic firessurt 15 not Found over any broads are period ·96 VEH LIMITS OF NORVAL BLOOD PRESSURE TABLE YUI --SYSTOLIC ASD DIASTOLIC BLOOD PRESSURE READING B: SEX AND ACE Sex Age Systol Dastoisc Wan Stand Dn Coef of Variation Stand Det Bean Coef of le lom Males 16 1184 12 17 10 28 72 9 10 33 14 17 17 121 0 12 88 10 64 74 4 9 36 12 58 18 119 % 11 95 997 74 4 10 03 19 121 8 16 90 12 31 74 6 10 29 13 79 20-24 122 9 13 74 11 18 760 9 93 13 07 25-29 125 1 12 58 10 06 78 8 99 11 S4 30 34 126 1 13 61 10 79 78 5 969 12 33 35-39 127 1 14 20 11 17 80 4 10 42 12 06 40 44 129 0 15 07 11 68 81 9 53 11 74 45-49 130 0 16 93 13 02 82 0 10 81 13 18 50-54 134 5 19 21 14 29 &3 4 11 31 13 56 55-59 137 8 18 80 13 64 26 0 11 40 13 57 60-64 141 8 21 11 14 89 8+ S 12 38 14 63 Females 16 1161 12 10 10 42 2 3 9 55 13 21 17 116 0 11 51 992 72 0 9 16 1Z 72 78 116 3 11 42 9 82 77 8 8 00 17 99 19 115 11 87 10 31 71 1 93 12 56 20-24 115 7 11 83 10 22 71 7 9 67 13 49 25 29 116 8 1 43 9 79 73 7 0 05 12 24 30-34 119 8 13 97 11 66 74 9 10 78 14 39 35-39 123 9 13 85 11 18 78 0 10 01 12 83 4044 127 0 17 07 13 44 70 S 10 60 13 33 45-49 130 6 19 47 14 91 R1 5 11 OJ 14 27 50-54 137 3 21 29 15 31 83 S 11 36 1480 SS-59 139 5 21 40 15 15 83 3 11 72 14 0+ 60-64 1440 22 33 15 51 93 0 12 95 15 24 Rejnintet from Vaster 4 VDubla Lan 1 Vark 11 11 The Worm BlwPh¢ Range and Its C1 nscal Impl caricas JANA 13145* 1950 Among hois between the ages of sexteen and nineteen an upuard trend in the averages of both the si stolic and The listolic pre SSUTE > JS found mong girls on the other hand both the systolic and the diastolic pres sures remain practically unchanged veineen the ages of sixteen and ·NEW LIMITS OF VORJI IL BLOOD PRESSURE 97 eightees and continue to be unchanged until the age of trents ave This diference may be due to the fact that boss mature between the ages of Sixteen and ninetcen, nhereas girls mature cartier Boys at that time become heavier and art much more autre than arc girls of the years, and it has been long tecagnard that a sapit rise in blood pressure occurs during puberty and adolescence MEAN BLOOD PRESSURE READINGS mm Hg $50 140 SYSTOLIC 130 MALES 120 FEMALES 110 100 90 DIASTOLIC BO MALES FEMALES 70 T $6 20 25 30 35 50 55 60 65 40 45 AGE Fio 29 ·98 VEH LIVITS OF NORNAL BLOOD PRESSURE In the present study the averages of the systolic pressures among men ranged from 118 4 mm mercury, at the age of sixteen to 141 8 mm in the sixty to sixty four year group the average diastolic pressures ranged from 72 9 mm mercun at the age of suitecn to 845 mm in the sixty to sity four year group among women the averages of the su stolic pres sures ranged from 115 1 mm mercury at the age of 19 to 1410 mm in the sixty to sixty four year group the average diastolic pressures ranged from 71 1 mm mercury at the age of nineteen to 850 mm in the sixty to sixty four year group Up to the age of forty five the average systolic pressure was higher among men than among women Between the ages of thents five and twenty nine this difference was 8 mm mercury After the age of forty five the average blood pressure of women was higher but the difference between the sexes nas smal! It has long been known that the blood pres sure increases in both sexes after the age of forty five The average diastolic readings among men were also higher than among women up to the age of fifty The maximum difference about 4 mm mercuri was found between the 20 and 24 years After the age of fifty the diastolic averages scre about the same in both scres the differences which were found were neither consistent nor large The figures for the standard deviation given in Table II indicate that there is an absolute increase in the range of the readings with increas ing age The selative variation moreover as measured by the coefficent of variation also has an upward trend with age This increase begins after the age of twenty five and is found in both the systolic and the diastolic readings for example among men between the ages of twenty fivc and trenty nine the standard deviation of the systolic readings around the mean is 12 58 mm or 10 per cent of the mcan figure while among men between the ages of sitts to sixts four the standard devia tion is 21 11 mm, or nearly 13 per cent of the mean figure The absolute range of the diastolic readings is of course, smaller than is the range of the systolic readings The relatie variation in both seres however is larger for the diastolic than for the sistolic readings up to the age of forts thereafter the systolic pressures have a somewhat larger relative variation but the differences are small In men butscen the ages of thirty and thuirt four for example the standard deviation of the systolic pressure from the mean was 13 01 mm mercury (10 8 Exer cent of the mean salue) while the standard deviation of the diastolic pressure was 9 68 mm (123 per cent of the mean value) In men be tween the ages of fifts and fifts four hoseier the standard devation of the sistolic pressure was 19 21 mm mercury (14 3 per cent of the mean value) while the standard deviation of the diastolic pressure was 11 11 mm (136 per cent of the mean salue) The range of blood pressure readings both absolutels and relatives For trimple is greater among komen than men after the age of fort;

·VESIIVITS OF YORUL BLOOD PRESSURE among men between forts and forty four years of age the standard deviation of the systolic pressure is 13 07 mm mercury and the coefficient of variation is 11 7 per cent the corresponding figures lot women are 17 07 mm merkury and 13.4 per cent Simlarly the diastolic figures are 03 im sercury (11 7 per cent) among men and 10 60 mm (133 pxr cent) among women RANGE OF NORMAL BLOOD PRESSURE AND LIMITS OF HYPERTENSION AND HYPOTENSION mm Mo SYSTOLIC MALES 200 190 180 HYPERTENSION LOWER LIMIT iTo 160 $50 BORDERLINE HYPERTENSION 140 NORMAL RANGE 1 $20 110 BORDERLINE WYPOTENSION 100 HYPOTENSION UPPER LIMIT 90 16 20 25 30 35 45 50 SS 40 AGE 60 65 Fic 30 In the fourth decade the differences in the actual and relative sarı abinty of blood pressure readings betuen the seres shos no constant pattern in subjects rho are kess than thirts Tears of age the figures tend to be the reverse of those found in subjects who are over fifty ? the figurts for men are higher than are the figures for women The differ ences that do occur however are generally smaller than those found in the older age groups a possible exception occurs among those who are ·AV LIVITS OF NORVIL BLOOD PRESSURE under twenty It is likely that the greater variability in the blood pres surt among young males is a reflection of the later age at which they at tain maturity From I burc 29 and fable TVI several broad conclusions may be draun RANGE OF NORMAL BLOOD PRESSURE AND LIMITS OF HYPERTENSION AND HYPOTENSION mm Hg SYSTOLIC FEMALES 200 790 180 HYPERTENSION LOWER LIMIT 170 160 150 140 BORDERLINE HYPERTENSION 130 NORMAL RANGE 320 110 (DORDERLINE HYPOTENSION 100 MYPOTENSION UPPER LIMIT 90 16 20 25 30 35 45 50 55 60 65 40 AGE Fic 31 A) The mcan blood pressure reading both sistolic and diastolic in creases with age in both seves The increase in the systolic pressure is more rapid after the age of fifty There no systematic acceleration of the diastolic pressure over any broad age period B) The range of the blood pressure readings also increases with age as does the relatne variation measured by the coefficient of variation This increase begins after the age of twentific and affects both the systolic and the diastolic readings ·VON LIVITS ON VORVAL BLOOD PRESSURE 101 C) The absolute range of the diastolic nadings is smaller than is the range of the systolic readings D) The range of blood pre sure readings both absolutely and rela nely is greater in women than in men after the age of forts in the fourth decade the differences between the tro seres shox no constant pattern Under the age of thats the figures tend to be reversed the sc in men beng hyber than those women RANGE OF NORMAL BLOOD PRESSURE AND LIMITS OF HYPERTENSION AND HYPOTENSION DIASTOLIC MALES mm Hg 120 10 HYPERTENSION LOWER LIMIT BORDER INE. HYPERTENSION 100 90 NORMAL RANGE 80 70 BORDERLINE HYPOTENSION 60 KYDOTEKSION VPPER {M} 50 16 20 25 30 35 45 50 40 AGE 55 60 65 For 3? The normal range of the systoli and the diastolic presure as deter mmed in this stuch is given in Figs 39-33 and Tables 1-111 The normal range of the sistolir pressure is suidt It increases with age from 10 to 53 mm mercurs in males and from 30 to comm mercury in femals The upper kmit of the normal si stolic pressure to slightly ·102 NCU LIMITS OF MORIL BLOOD PRESSURE lower in females under the age of forty, than in males after the age of tifty it is higher in the females Thus in the sixteen to twenty year group the normal systolic ringe is 105 to 133 mm mercury in males and 100 to 135 mm mercury in females In the sixty to sixty four ear group it is 115 to 170 mm mercurs in males and 115 to 175 mm mercury in females RANGE OF NORMAL BLOOD PRESSURE AND LIMITS OF HYPERTENSION AND HYPOTENSION mm Hg DIASTOLIC FEMALES 120 110 HYPERTENSION LOWER LIMIT BORDERLINE HYPERTENSION 100 90 80 NORMAL RANGE 70 BORDERLINE HYPOTENSION 60 HYPOTENSION UPPER LIMIT 50 16 20 25 30 35 45 50 55 60 65 40 AGE FIG 33 The normal range of the diastolic pressure is not as wide as that of the systolic varving from 26 to 30 mm mercury in males and from 25 to 30 mm in females Furthermore the increase of the diastolic pressure with age is less marked than is the increase of the sistolic pressure this ac counts for the well known tendency of the pulse pressure to increase with age Thus in the sixteen to tnenti rear group the normal diastolic range is sixty to eighty sie mm mercury in males and 60 to 85 mm ·NEW LIMITS OF NORJI AL BLOOD PRESSURE 103 mercury in females In the sixty to sixty four Vear group it is 70 to 100 mm mercury in both males and females The borderline'group is indicated in both figures It necessarily includes all the cases which fall between the upper limit of the normal range and the lower limit of hypertension as well as those which fall between the lower limit of the normal range and the upper limit of hypotension Cases in this borderline group must be judged individually They may belong to the normal the hyperten sive or the hypotensive group depending entireli upon their clinical status This will be more fully discussed in the final chapter TABLE YU II -VE BLOOD PRES LRE RE DINGS IN SELECTED STUDIES, MALES Sy lol Dastolc RO Pese S! dy Rod on & Age Gorer R:55 & P ext Study Bucer Cot Ru k высо 20-24 1229 132 5 119 0 76 0 76 8 70 8 25-29 123 1 130 9 118 5 178 77 1 72 0 30-34 126 1 131 3 117 5 78 5 77 2 72 7 35-39 127 1 132 1 1176 80 4 79 1 74 0 40 44 129 0 132 4 133 3 120 1 81 2 79 2 84 8 75 7 45-49 130 0 138 7 137 0 122 7 82 0 83 1 86 6 77 0 50-5+ 134 S 1.41 4 138 9 125 6 83 4 83 7 87 0 77 3 55-59 1378 151 9 142 4 129 6 84 0 899 8 7 78 2 60-64 141 8 154 4 147 7 131 7 84 S 86 7 87 6 77 5 FEMALES Systolic D tot 20-24 115 7 124 & 105 4 71 7 76 5 65 4 25-29 116 8 127 S 110 2 73 7 84 67 1 30-34 119 8 128 7 111 6 749 80 4 69 0 35-39 123 9 133 4 114 4 78 0 82 6 70 7 40-44 127 0 141 0 119 0 95 85 7 73 2 4549 130 6 149 2 125 4 81 5 89 s 75 4 50-54 137 3 1580 125 8 83 S 90 9 75 7 5>-59 138 S 1674 138 2 83 5 93 5 90 60-64 144 0 1629 1428 85 O 89 1 81 0 ·101 NEW LIVITS or VORIL BLOOD PRESSURI 1 Comparison of Blood Pressures l'ound in 1 anous Surels ligure 34 and Table \VII compare the systolic and diastolic averages for men and women in the present study with those found in other se lected investigations The reports chosen for this purpose are those from Gover s3 studs on members of hite farm familics who received assist ance from the I arm Security Administration of Robinson and Brucerº on life insurance polici holders who were examined by the Life Extension MEAN BLOOD PRESSURE READINGS IN SELECTED STUDIES MALES mm HQ FEMALES 7170 160 ESET SUO - COVER -- RUSSEX ROBINSON & BRUCER 150 SYSTOLIC. 140 SYSTOLIC 120 30 100 DIASTOLIC 90 DIASTOLIC 110 BO 70 60 35 60 65 20 45 AGE 0 20 25 30 35 40 45 50 55 60 65 20 25 30 50 55 AGE FIG 34 Master Dublin and Marks The Normal Blood Pressure Range and Its Clinical Implications courtesy of J A MA Institute in Chicago and of Russel +8 and his associates un merchant seamen active or retired coast guardsmen candidates for civil service and an older group of city indigents l'he Robinson and Brucer data in clude their entire esperience and not only that limited to cascs with read ings under 140/90 mm mercury It is readth scen in the graph that the averages obtained from our study are about intermediate betreen those obtained from the other sources ben the data from other numerous studies were cramined the averages obtained in the present series were also found to occupy an approximatels intermediate position ·TARLE YIN - STOLIC AND DIAST 27 B IRF RX AC ROY HEICUT CK 13 SET Illy Oru irha {tetose 1010 [! urrik 41f7ag 15 gft stor Voc RUTH? she 5 ur More 1 st Mio y to 02 ser o More Stand and SAN Tint Vad Dat It mi 11 ond Oni Vand Da un NN Stand Na Mean va fan Brun leon 17 14 47 3 Mia 16 17 19 29 71 5 72 0 71 2 71 4 73 7 769 775 774 78 9 115 8 11&S 116 7 1181 119 5 125 Z 129 124 3 77 1 77 2 TO 2 1189 ARS 9 76 8 63 949 30 2+ 7+ 13 99 13 07 17 39 12 03 12 17 14 76 28 29 1193 1209 1200 12 1 123 7 124 1 126 0 126 1 129 + 1307 1345 138 142) 11 77 12 13 11 80 19 (KI 14 46 12 65 11 56 12 86 14 11 184 57 17 49 20 89 117 2 1225 1Z2 3 ? 36 $24 ! 125 * 128 7 1299 ISI 2121 1167 143 1 14 2 10 16 99 0 80 13 61 8 77 8 04 953 9 67 9 35 11 89 (3 34 10 47 10 40 12 36 11 87 14 11 13 3 16 79 18 79 18 24 22 8? 22 42 30-34 35 10 04 (5-49 So $4 35 50 1004 123 9 1245 124 3 120 + 126 2 123 Z (328 1370 131 3 1100 1394 145 5 1483 13 OS 33 37 12 6) 14 93 12 29 1473 13 31 17 66 17 2 12 87 19 75 21 89 22 59 X2 2 870 93 8,9 OG * 92 9 61 u 93 10 13 X 93 92 940 > 64 10 03 11 10 11 04 2 33 74 0 75+ 77 2 78 4 MO 81 2 93 8 83 3 84 0 846 76 € 76 3 3 79 6 0 1 R1 D 2 82 6 14 94 48 10 55 11 9 17 8 22 9 (5 9 97 9 42 12 52 76 10) 22 12 40 13 09 14 41 RO 5 835 813 85 O 5 3 87 4 1277 10 15 11 25 # 9 1270 it 02 13 42 31 91 17 82 13 9 1349 13) 2 17 16 18 (o 20 2 K7 » 597 914 NO 4 10 26 11 81 720 1150 113 3 (130 7 16 8 19 73 X 12 64 129) 70 S 39 755 74 7 te 37 16 17 19 19 20 24 25 29 10-31 JS 39 115 3 1159 116 2 114 S 11 99 10 (6 IOS 11 74 11 25 10 14 122 2 124 1 (27 240 123 4 123 6 1117 115 ) V03 18 33 10 63 10 37 11 18 11 69 13 01 12 34 10 1 71 19 RY 19 92 21 58 10 74 11 47 12 15 ( 72 1 36 10 9+ 17 00 14 0 16 76 116 4 1645 123 3 116 0 1165 1180 116 4 110 1186 125 0 126 1 128 7 360 143 4 1414 154 8 15 95 3F35 12 12 12 07 1 02 (3 74 14 50 13 34 0 29 193 47 23 94 126 5 71 4 09 71 6 13 35 77 2 79 2 814 943 80 9 39 31 39 17 12 9 06 10 56 10 91 759 7 4 &1 7 1182 120 7 112 + 123 6 1324 135 1 141 0 V 21 R 06 8 11 (XO ♡ 507 12 9 28 > 17 02 11 #2 1095 1) 07 12 12 9 69 9 #7 885 54 ► 13 (1 79 11 ( 11 97 11 77 13 1 V 25 72 2 75 5 77 2 79 7 X2 #53 het ) 90 2 002 70) 71 % 72 75 X 6 6 77 7 80 3 81 4 29 7 R4 11 83 10 22 10 22 10 00 164 13 93 15 12 19 02 19 46 11 15 89 50 54 S 59 60 + (361 1373 140 6 147 3 86 7 35 131 0 135 1373 1376 (105) 11 81 12 X2 1540 24 63 20 94 214 13 2 829 47 6 13 00 13 ( + 12 49 Clu flcd ng tod at on fr 1 cs ge Igbt for * Aht a di Standard ue te the 4er ses fonts + Into A 1912 Inc Rs 25 ou or and trmth Ved 177 m ni Std: 1929 1 r af Ardi olior al Mortality ouer 25 ·106 NEW LIMIT5 Or NORMAL BLOOD PRESSURE 2 INFLUENCE OF WLIGHT ON BLOOD PRESSURE Data showing the relation of weight to blood pressure are given in Table VIII The subjects were divided into four weight groups Underweight 10 per cent or more below average lverage Il cight less than 10 per cent above or below average Overweight moderate 10-24 per cent above average Overweight severe 25 per cent or more above average The standard tables of average weight for height and age of men and women were used These tables are based on the average weight of 100 000 consecutive insurance cases It is apparent that scight is an im portant and consistent factor in blood pressure changes (Table 11 111) ilith an increase in weight there is a progressive increase in the arcrages of the systolic and diastolic blood pressure, regardless of age or sex This is in conformity with the known effect of weight on blood pressure which has alrcady been discussed Reduction in werght therefore is a routine therapeutic procedure for patients with hypertension The difference in the mean sy stolic blood pressure at each extreme of the underweight and overweight groups exceeded 10 mm mercury in some instances the difference in the diastolic pressure was almost as great The differences in the mean systolic and diastolic pressure among women of each extreme weight group particularly after the age of forty were even greater than those among men Absolute and relative variations in blood pressures as measured by the standard deviation and the co efficient of variation also tended to increase with weight particularly after the age of 40 years In general the greatest contrast in the mean pressures was found in the older age groups and among women 3 INFLUENCI OF HEIGHT ON BLOOD PRESSURE The subjects were divided into three groups-short medium and tall - the height being tabulated at the nearest inch Short Vedium Tall Vale 55 and less 56 -5 10 511 and over Female 51 and less 52-5'6" 57 and over No clear relationship between height and blood pressure was found Table VI The mean sistolic blood pressure was consistently highest in tall men between the ages of thirty five and thirty nine it was higher ·TABLE YI-SI TOLIC AYU DIA TOLIC BLOOD PRES IRR ACCORDING TO STATERE stolic > tolic Short Tad Veto BIN ng Shot Scart Sr d Ssod Dat Stod Da Siod ney Sand Dee Stand Ory WON leo! Veon Do 71 1207 123 3 123 7 124 6 73 6 726 74 3 74 0 73 3 3 119 115 6 119 T 120 1 123 4 9 02 9 77 > 37 890 9 42 Males 16 17 18 19 20 24 219 367 34 35 40-44 45 4 ) 50-54 55 69 60-64 124 2 123 8 12 4+ 12 45 10 02 086 11 76 IZ RJ 14 90 14 33 17 17 21 05 18 23 39 97 19 09 118 ) 120 6 1198 121 3 123 0 125 1 126 1 176 2 192 1300 1352 137 3 142 1 12 57 13 91 156 13 57 1$ 6 12 67 13 91 13 59 14 SO 16 30 19 97 19 32 1 51 943 15 58 13 46 14 17 1 21 12 OS 14 59 15 77 14 01 14 16 1 04 19 38 zt o 125 8 127 1 230 8 128 $ 1290 1329 137 6 143 4 23 24 10 77 10 6 12 16 10 00 9 82 12 19 10 01 9 64 13 43 10 35 11 95 11 75 72 8 75 7 77 3 77 8 99 82 5 *27 819 841 84 5 126 4 228 2 131 D 1 39 9 14 10 02 10 20 10 08 8 61 9 32 10 18 9 57 10 32 (1 95 11 21 12 40 75 5 82 88 80 2 SO 9 81 9 836 840 841 75 6 75 3 77 0 76 4 77 2 7 3 78 3 Q18 81 2 81 7 R38 438 R6 6 9 29 10 81 3 53 9 51 11 61 12 77 VLK LIMITS OF NORI IL RLOOD PRESSURF 1399 139 6 729 Fen als 16 17 28 15 96 8 15 1113 114 7 115 8 113 4 115 5 114 6 99 8 74 8 57 1149 115 8 116 5 1350 1153 117 2 119 5 1181 1156 127 1 115 5 117 5 12 13 9 56 8 60 8 98 74 8 71 6 72 5 3 2 74 5 11 12 32 10 04 15 09 14 61 17 17 9 99 11 20 10 98 11 81 11 46 11 49 1 1 27 13 51 14 80 19 07 21 40 20 36 22 60 20 24 2) 29 30 34 35 39 40 44 45 19 50 54 55 50 119 3 121 $ 14 95 14 38 10 74 12 00 12 92 12 12 15 77 14 60 14 01 19 65 19 35 25 90 2 16 72 0 71 0 71 7 738 74 5 77 7 9 3 87 8 856 $26 775 70 7 ( 7 0 3 699 72 6 74 3 78 1 9 8 SOO 83 7 85 87 3 6 83 10 20 869 33 10 <<<? 9 36 12 34 11 08 IN 10 11 67 10 53 14 94 23 + 128 2 1789 138 4 1401 1458 7 90 1299 9 29 11 11 12 93 12 36 12 57 15 59 123 129 2 131 7 137 2 137 2 144 7 125 4 129 8 127 0 1369 1-25 % 950 9 20 9 77 98? 10 57 11 31 12 (6 10 26 IZ 50 KU & 413 429 87 7 28 22 12 23 3 Not ser fcant le s than 20 ca es 107 ·108 TABLE XX --SISTOLI AND DIASTOLIC BLCUN PRESSERE ACCORDING TO HICK 27 AND TIEK KT GRIP ystols Dasd dec Short 11 drum Tai Shr Vedir Tau Stand De SIND Det Year Stand Det Stand 7 an Start Stand 1 an Sex 1&ph GO** Males 20-20 100 more undernellt lucrage ne sht 10-24% overuc ght 250 or more on esht 1208 123 5 123 2 4 17 13 29 12 43 9 78 122 S 1244 125 2 125 4 13 10 14 09 11 ) 53 83 123 2 124 4 120 10 83 12 39 13 36 74 3 766 784 0 (2 9 29 75 6 770 97 830 756 772 78 0 7 34 A5 0 67 8 38 8 57 30 39 1007 Tore un ler cight Ar gcwe pht 30 24" xcru esht 25% or mer overu ight 125 2 124 1 127 2 16 19 74 R6 11 10 122 7 125 9 128 5 134 6 12 67 1 2 67 1 3 54 1251 128 3 1335 14 59 13 54 35 Da 75 7 79 7 70D 11 23 10 ) 12 43 76 8 7R 923 X6 ) 13 9 31 1 37 10 8 77 1 101 X2 3 9 91 8 01 # LIMITS OF VORVIL BLOOD PRESSURE 40-49 100 or more underweight Average necht 10 24% overy night 250+ mor oser cight 128 3 128 5 132 0 223 15 (6 23 IS 9 2 $26 X 130 1309 1339 15 12 15 06 1h #7 16 24 128 9 129 4 110 # 14 02 14 X 13 47 819 814 84 3 11 97 11 77 10 683 > 01 993 1030) 10 94 XO 1 &16 830 » 04 10 11 6 07 84 3 899 90 59 100 or m re un lens cght 1 vc eisht 10 24 0 ght 23 mote FC Aht 1365 135 1995 19 25 1% 42 21 53 134 2 1363 139 7 140 X 17 (7 1) 23 28 RT 22 29 131 2 137 4 1985 81 & 83 3 30 51 52 40 14 ag X2 S 834 10 os 31 47 X) 85 % 922 10 68 () 4 ·20-29 9 24 1136 113 6 10 11 06 693 70 5 865 10 or more under &ht TAR tght 1CH-240 r ght 2 om ght 116 2 116 & 324 5 11 32 10 61 22 11 13 39 125 2 1149 120 4 120 3 13 28 11 25 946 1992 72 3 2 5 77 2 70 9 T4 1 T69 73 7 9 01 955 7 94 1189 97 109 122 3 23 24 167 9 39 1579 30 39 100 77 ad ht gh1 10--24O Aht 2*** mr 0 ent 3340 $225 14 12 11 91 73 6 76 2 12 01 10 09 Arag 11 95 IZ 10 15 6+ 14 61 1995 124 0 124 8 { 30 1 14 49 15 89 14 88 11 07 74 7 78 989 9 34 9 49 9 90) 74 0 77 504 &S 7 12 82 9 24 12 02 10 28 { 25 1277 124 11 83 78 7 971 NEW LIMITS OF YORVAL BLOOD PRESSURE 48 49 10) mre und и ght ag ght 10 24 ey 256 It re r sht 120 S 130 D 326 6 137 7 350 20 91 56 $$ 16 94 124 1296 131 3 1359 15 97 16 53 18 10 20 OT 120 2 3246 1304 139 2 22 03 17 07 18 80 21 78 75 1 0 1 $36 973 10 81 12 21 31 93 77 8 9 7 83 S 85 2 9 38 10 30 12 $1 11 98 75 6 80 4 83 3 89 4 10 20 9 25 9 8s 11 84 1.34 2 50 TO 10% menler A ghe 10-2467 ghi 24 o mer er she U17 3 139 3 21 06 22 36 21 27 26 74 7329 135 & 140 19 40 19 3+ 22 47 22 53 16 96 23 17 21 89 0 0 896 151 tt 93 12 32 13 9 30 09 RO? 821 862 87 & 10 43 10 37 14 10 13 39 B2 3 839 XV 234 2 it 97 15 21 1354 Mot gn ant ? s than 20 ase 109 ·110 NEW LIVITS or NORVAL BLOOD PRESSURE in men of medium height than in short men up to the age of thirty four After the age of forty the differences in the mean systolic pressures of men according to height were not significant Among women there was no apparent correlation between mean sy stolic readings and height The mean diastolic readings in men showed no definite pattern accord ing to height except in those under the age of twenty Among these young men there was a constatent increase in the averages with an increase in height the difference being a httle over 3 mm mercury The average diastolic blood pressure of tall women was consistently higher than that of shorter women at most ages up to forty five years Bevond that age the pattern was not consistent Relalı e Influence of llcght and Il eight In order to clarify further the influence of body build on blood pressure the data for short medium and tall men were analyzed separately according to the four weight classes (Table \\ and ce appendix Table 4) It is evident from this detailed analysis also that weight has a consistent influence on the level of the blood pressure The averages of both the systolic and the diastolic pressures in every height class tended to rise with an increase in weight However the effect of height itself on blood pressure seemed to be negligible because there was no syste matic trend in the averages due to height in the sei eral weight groups 4 INCIDENCE OF HIPERTENSION In view of the differences of opinion concerning the definition of hyper tension its incidence has been computed according to various definitions some of which are based on the separate systolic and diastolic readings and some on combinations of them The groupings based on the com bined systolic and diastolic readings include cases in which either reading was within the specified limits For example the hypertensive group (140/90 mm mercury or over) includes those with readings of 138/90 or 142/88 mm mercury Table LlIand Figure 35 show the incidence of hypertension according to the several standards It is readily seen that the frequency of so called hypertension increases steadily with age Minor deviations from the upward trend are unimportant and may be attributed to the size of the samples in the particular categories involved Hypertension of mild degree was fairly common at comparatively young ages particularly among men About one fifth of the men between the ages of twenty and twenty nine had readings of 140 '90 mm mercury or higher However hypertension of more severe degree was relatively infrequent at theme ages, readings of 150/100 mm mercury or more occurred in only one of every 20 cases ·VIY LIMITS OF VORVIL BLOOD PRESSURE Tư Y -> Ex : ( ht tex acco Gol or DITIONS SEX VP AGE Pet Cont $1,4 d Cup 1511 O DOS 77 10 . Sy for Dostore Di I wil 107 97 TO 7 DAY O orat Or PRET OF OTOY + 16-19 9 3 33 70 18 10 18 3 15 7 3 200 12 2n 701 14 5 53 3 6 36 IZT 31 30-34 24 SY 9 88 65 9 7 Ut 3. 291 3 3 95 1 7 3 08 7 3 $ 3 10-44 38 24 22 9 20 37 177 7 38 19 37 3 6 184 15% 3B 33 4 2r 3 119 7.7 37 g 2 13 & 88 544 558 23 A 3 34 2 CO 64 €3 435 396 36 9 8 34 J MO F males 18-33 $ 3 0 47 14 - 2 8 4 1-24 53 17 ia 2 8 y 3 84 67 21 20 15 D 1 3 3 34 132 206 51 9 34 30 O 36 19 35-39 20 8 16 4 TS 53 548 1 40-44 B5 0 22 9a 180 76 4749 324 33 ] MB 19 1 57 3 77 ( 8 9 SO SA 50 6 el 9 31 98 8. 3 37 4 120 120 55-59 121 33 4 31 0 33 1 167 21 - B4 23 40$ 23 39 9 37 3 mam Hg til ddc 11 form Hypertension of at least mild degret was common in middle aged and old people Blood pressures of 140'90 mm or higher were present in about 40 per cent of both men and women between the ages of forty fire and forty nine and in 60 per cent of those beineen the ages of sixty and sixty four Readings of 150/100 mm or more were found in nearls 20 per cent of the subjects under the age of lorty fie Thereafter the m cidence of such readings rose steadily in both scres to over 15 per cent in those between the ages of sixty and ssuts four Whatcuer definition of hypertension is used the condstion was found more frequently in mon up to the age of forty fise and more frequently in women thercaſter ·110 NEW LIVITS OF NORVAL BLOOD PRESSURE in men of medium height than in short men up to the age of thirty four After the age of forts the differences in the mean systolic pressures of men according to height, were not significant Among women, there was no apparent correlation between mean si stolic readings and height The mcan diastolic readings in men shon ed no definite pattern accord ing to height ercept in those under the age of twenty Among these young men there was a consistent increase in the averages with an increase in height the difference being a little over 3 mm mercury The average diastolic blood pressure of tall women was consistently higher than that of shorter women at most ages up to forty five years Bevond that age the pattern was not consistent Relan e Influence of tleight and If eight In order to clarify further the influence of body build on blood pressure the data for short medium and tall men were analyzed neparately according to the four weight classes (Table and ace appende Table 4) It is evident from this detailed analysis also that weight has a consistent influence on the level of the blood pressure The averages of both the systolic and the diastolic pressures in every height class tended to rise with an increase in weight However the effect of height itself on blood pressure seemed to be negligible because there was no sy ste matic trend in the averages due to height in the several weight groups 4 INCIDLNCE OF H PERTENSION In view of the differences of opinion concerning the definition of hyper tension its incidence has been computed according to various detinitions some of which are based on the separate systolic and diastolic readings and some on combinations of them The groupings based on the com bined systolic and diastolic readings include cases in which either reading was within the specified limits For example the hypertensive group (140 90 mm mercury or over) includes those with readings of 138/90 or 142 88 mm mercury Table Wrand Figure 35 show the incidence of hypertension according to the several standards It is readily seen that the frequency of so called hypertension increases steadık with age Minor deviations from the upward trend are unimportant and may be attributed to the size of the samples in the particular categories involved Hypertension of miid degree was fairly common at comparatively young ages particularh, among men About one fifth of the men between the ages of twenty and tuenty nine had readings of 140'90 mm mercury or higher Hovseter hypertension of more ses crt degree was relatively infrequent at these ages readings of 150/100 mm mercury or more occurred in only one of every 20 cases ·NEW LIMITS or NORVIAL BLOOD PRFSSURE 113 pressure at sexteen years of age is between 105-133 mm mercury at seventeen the range is between 103-133 mm at eighteen years 105-135 mm at nineteen ears 10-140 mm at twenty to twenty four vears 105-110 mm at twenty five to twenty nine years 108-140 mm, at thirty to thirty four years of age 110-145 mm at thirty five to thirty nine years 110-140 mm at forty to forty four years 110-150 mm at forty five to forty nine years 110-135 mm at filty to fifty four ycars 113-160 mm at fifty five to fifty nine years 115-165 mm at sixty to sixt four years of age 115-170 mm mercury In females the normal range of systolic blood pressure begins at sixteen vears of age with 100- 130 mm mercuri at seventeen years 100-130 mm at eighteen years 100-130 mm at nineteen years 100-130 mm at twenty to twenty four years 100-130 mm at twenty five to twenty nine years 102 130 mm at thirty to thirts four years 102-133 mm at thirty hve to thirty nine Vears 103-140 mm at forts to forty four years 105-150 mm at forty five to ſorty nine vears 105-155 mm at fifty to fifty four years 110 165 mm at fifty five to hfty nine vears 110-170 mm and at sixty to sixty four years of age 113 173 mm of mercury The normal range for dia stolic pressure in males is at sixteen years of age 60-86 mm mercury at seventeen years 60-86 mm at eighteen years 60-86 mm at nineteen years 60-88 mm at twenty to twenty four years 62-88 mm at twenty five to twenty nine years of age 63-90 mm at thirty to thirty four years 68-92 mm at thirty five to thirty nine years 68-92 mm at forty to forty four years 70-94 mm at forty five to forty nine years 70-96 mm at fifty to fiſt four years 70-98 mm at fifty five to fifty nine years 70-98 mm at sixty to sixty four years of age 70-100 mm mercury In females the normal range for diastolic pressure is at sixteen years of age 60-83 mm at seventeen Vears 60-80 mm at eighteen years 60-80 mm at nineteen years 60-85 mm at twenty to twenty four years 60-83 mm at twenty five to twenty nine years 60-86 mm at thirty to thirty four years 60-88 mm at thirts five to thirty nine years 65-90 mm at forty to forty four years 65-92 mm at forty five to forty nine years 65-96 mm at fifty to fifty four years 70-100 mm at fifty five to fifty nine years 70-100 mm and at sixty to sixty four years of age 70-100 mm mercury Blood pressures falling in the borderline range (between the upper limit of normal and the lower limit of hypertension) may be either normal or abnormal and each patient should be thoroughly studied for the presence of vascular disease before concluding whether the blood pressure is normal or not Readings above the lower limit of hypertension are not 1pso facto evidence of the existence of clinical hypertension though the chances are very high that hypertension exists 3 The effect of weight and height on the blood pressure was also in vestigated With an increase in weight there was a progressive increase in the averages of the systolic and diastolic pressure regardless of age and ser Height was found to have no influence on the blood pressure ·11 11 LIVIT OI NORI IL BLOOD I RFSURE BIBLIOCRAHY 271a ALLEN ET and lines EA Normal Blood Pressure and Its Physiologi, Vanations in Stroud D Diagnosis and freatment of Cardiovascular Disease lol I l Ed I hiladelphia F A Days Co 1990 p &>> 271) ALLEN I V and HINES EA Normal Blood Pressure and Its Phisiologic Variations in Stroud ID Diagnosis and Treatment of Cardiovascular Disease Vol III Ed Philadelphia F A Davis Co 1990, 830 272 MASTER A 11 DUBLIN LI and Marks HH The Normal Blood Pres sure Rane and Its Clinical Implications JANA 143 1464 19 0 273 MASTER AM COLDSTE I and WALTERS MB es and Old Det tions of Mormal Blood Pressure Clinical Sr nificanie of the end Established Limits Bull New York Acad Med »7 1991 274 PEARL R Introduction to Medical Biometri and Statistics 353 355 Philadelphia and London B Saunders Co 1940 275 HILL AB Principles of Medical Statistics th Fd London Lancet 1910 p 67 ord Fd IF ·APPENDIX TO CHAPTER V TABLE 1 --SistOLIC AND DIASTOLIC BLOOD PRES I RE RFADINGS A SEY AND ACE SHOWING 80 11 282 STANDARD DEVIATIO) NIT'S Sy tolc Da foi dg +1 28 Wed MALE 16 102 8 118 4 134 0 50 7 729 80 1 17 10+ 5 121 0 13 5 62 4 74 + 86 4 18 104 S 119 8 133 1 61 5 74 4 87 3 19 102 6 121 8 141 0 61 4 74 6 87 8 20 24 105 3 1229 140 5 63 3 76 0 887 25 29 109 0 125 1 141 2 66 3 7 8 89 3 30-35 109 7 126 1 143 6 66 1 18 5 90 9 3$ 39 1089 127 1 145 3 67 0 80 4 93 8 40-44 109 7 129 0 118 3 69 0 81 2 93 4 45 49 109 3 130 0 ] S1 7 68 ) 82 0 9 9 50-5+ 109 9 134 5 159 1 68 834 97 9 55 59 113 137 8 161 9 69 4 84 0 98 6 00-64 114 7 141 8 1689 69 7 84 5 100 4 FEMALE 16 100 6 116 1 131 6 60 0 72 3 84 5 17 101 2 116 0 130 8 60 3 72 0 83 7 18 t01 7 116 3 1309 608 71 8 82 8 19 999 115 1 1 30 3 59 7 71 1 82 6 21) 2+ 100 115 7 130 9 59 3 71 7 841 25 29 102 2 1168 131 S 62 1 73 7 85 1 30-34 101 9 119 8 137 7 61 1 74 9 887 35 39 106 1 123 9 141 65 2 78 90 % 105 1 127 0 148 9 659 79 5 93 1 45 49 105 6 130 6 1536 66 6 &1 96 4 50-54 110 0 137 3 1646 83 S 994 $ 59 111 1 138 5 165 9 68 5 83 3 98 5 G0-04 115 4 1410 1726 684 85 O 101 6 (115) ·116 on 5 5 10 TAPIE 2 --DISTRIN TION OF SYSTOLIC BJ OODI RISSI RO RRADI CS B SEX AND Ace Ditari ilm Abc li il tam nalina of Implaza sani loplicants f 11 Large In lu t al Plants and treny Aur Mel! (tulians only) Sans le : Int te Lepenn Males yst loc itt 72 Bloovt irse 754 ( 17 10 0 301 14 35 30 +0) 44 15 9 177)+7 S54 ny ry 1001) S5 So 00 ) ) 70X) ) 100 ) 2010 70 ) IN 100 () 76 and Ir 0 IONI O 100 o intr D 2 77 81 82 R6 D 87 93 2 $ 5 92 96 S 8 0 2 2 4 2 2 41 lut 52 2 3 33 24 102 1076 95 1 7 Si 67 03 $0 22 3 D 1 S 30 107 lit 37 93 129 120 28 116 7 100 12 12 2 7 92 112 116 158 6 3 13 6 116 85 $ 2 40 4 1 78 59 90 117 124 18 7 21 3 20 26 0 22 ? SQ 20 7 30 21 3 20 181 »7 6 ISO 16 & 97 122 126 124 16 14 1 123 $34 13 + 151 127 131 12 1 12 + 1 100 11 6 10 3 10 8 15 3 16 155 98 6 7 (12 435 73 3 R 16 ISS 43 12 3 8 12 0 11 6 137 141 * 38 +6 82 127 50 12) 77 6A 0 1 S9 76 142 146 10 2 3 4 93 1 2 27 95 12 7 35 15 2 15 7 31 48 40 147 151 37 20 71 56 16 2 J 24 152 153 26 3 0 7 38 4 7 62 3 7 98 69 IS 105 76 7 27 26 24 3 43 162 166 14 3 99 30 S 49 2 64 167 176 iOS 2 2 1 6 2 2 1 & 2 2 1 172 176 13 14 3 19 4 4 177 181 2 2 6 1 6 IRL 186 3 10 187 IDI 3 6 4 192 396 B 8 3 197 204 2 6 3 202 306 2 9 207 211 212 216 217 27! 211 225 227 an! 0 - PPC\DI 0 ܐܬ 5 2 2 ·Blood Pro WPC To! 7077 132 19 30-14 100 59 OU O 35 36 100 O FOL کوسره 50 55 SOOO 55 56 000 60-6+ 1000 1000 1000 NL WN NOCN om A N we 9 101 102 106 107 11 112 116 117 121 00 On NA DOLA OOON DOM ONN NO N ya u xu NNY WOO No 122 126 127 131 13 216 137 141 142 140 147 151 152 156 157 111 161 166 167 171 ت و با ما پ yuv On a WWN Now APPENDIS 3 z 1111 1 00 - - -- 176 177 181 04 182 186 187 101 192 196 لما بد با شما هم ZZZ NNO C NN 11 5 N -- 2 N 6 0 197 201 202 206 207 211 212 216 217 721 111 ON 227 226 278 Dier De 11 11 11 11 11 2 117 11 - ·118 TABLE 3 - DISTRIBUTION OF DIASTOLIC BLOOD PRESSURE READINCS1: SEX AND ALE Males Data Dedio Vedi al Exam nations of Emplose s and Appli ants [ 11 Large Industrial Plants and A m) Al Said (Cauzitans onit) Sampl of Fnti e Exper ence Dia tolc P Lent of Tolat Blood Press re Tof *1 in 7557 10 19 59 30 34 rekry JS 39 100 0 100 000 15 19 50 54 55 58 1000 1000 60-04 100 G Voo 1000 1000 1000 1000 100 13 16 17-21 22 26 27 31 OOO 2 2 2 - N - 11 NN 2 ew 2 la 2 2 2 3 N A AO APPT DIT NA -S 1 2 9 87 86 87 01 92 96 97 101 102 106 - 0 Oo ena ANNO an NW W + MOOC 2 2 M 3 107-111 112 116 117-121 122 126 127 131 2 2 3 5 N - NNews 1 11 132 136 137 141 142 140 147 151 OO - 0 Il NN N 2 ·le C 1 of Tor? 0 loc Irod 97 10 18 19 100 0 59 5 100 31-34 F000 35 30 no + or ONIT +5 10 100 0 55 50 1000) 109 0 100 O ON 07 OT OX U wil U11 2 11 - -- 2 11 III iHa打好丑msn NO Www и ми ill! OC نما 00 N w UN NO با ما لیا ط و 200 Via didt MOON NOEN DOO NOR XN X A X2 XT X7 91 924 v7 101 1(12 TOK ve wo De SOT II 3 5 6 wen 117 121 122 126 127 11 111 COM Na 2 - 0 132 136 13 111 142 116 147 1 1111 111 11 111 2 119 ·3 B A . జట్లు A 巴音与三 www 148 uch Didnade mm 1 おかい、 3 100 111 to ox iyo 1 1 *53 OY wa en 0 á 00C OLMIN NIJ 2005 N SYSTOLIC ir mine sme pols i edilme ជួង Sec 31 110 30 90 N SOC A co roll ! HT AND Hlagt Group ܕܟ ܢܕ دبی و W YN 9 G fit on SX c pe mt 10 11 SEN a 8 它是一 MO DO IPPENDIL 120 ·APPENDI 121 Toll CRI Cor !! PA Vad m GO 3. Ce M من ل من با اني بة دي به- A PIASTOLIC pot aOCO SO C ya COM 00 *** wa re Deo + 00 w - om Rat 美 2 Et 3 - .

·122 UPPEDIT Tunty 5 - DISTRIBUTION OF SESTOLIC BLOOD PRES LRE READINGS ALL ACES COMBINED Luis Teis 0 3 5 6 7 8 Total 50 60 1 0 1 3 &0 + 1 $ 1 - 8 10 90 40 4 5 79 1९९ 5 1 6 3 3 3 297 3,40 569 270 97 39 65 222 491 391 210 99 3 6 S 2 1 5 4 > 36 157 457 675 30%) 162 43 23 13 3 5 1 93 500 1351 2123 1330 83 380 21 130 81 31 23 8 5 5 2 1 102 56 3-6 19 399 970 509 313 132 2 3 21 5 5 01 100 110 120 110 140 150 100 170 180 190 200 210 2'0 230 240 250 1633 3 07 445 2555 1413 652 409 205 16 1 1-4 16 13 + 12 9 5 3 2 26 10 o 1 1 1 7210 196 27 1456 691 IS + 19 2528 20 15711 TAI LE 6 -- DISTRIBUTION OF DIA TOLK Bzoor PRE SURE READIN S ALL AGES CO 18INED L » 15 Tens 0 / 3 + 5 8 D Tot 1 0 10 2 S 20 2 10 10 4 1 1 30 40 SO 60 1 6 19 3 1 7 10 2 7 2 3 2 14 89 881 2443 2963 1235 35+ 100 29 3 1 42 324 555 645 107 23 4 1 5 13 92 100 114 43 27 3 180 370 480 138 28 o 2 2 1 1 15 175 689 9>2 329 160 20 7 10 3 6 75 239 753 442 136 17 5 2 80 90 100 110 120 130 140 150 160 11-5-IIlllll 413 2418 5448 48R 820 472 131 3 9 1 3 1 1 4 2 2 8036 490 2319 1393 12 15711 1709 1678 2$ 9 11 ·Chapter II I\TERPRETATION HID CLINICAL APPLICATIO\ OF MEIL BLOOD PRESSURE LIMITS Vlci useful clinical information has been acquired as a result of the general adoption of sphygmomanometri about fifty years ago The sphygmomanometer has been of particular salue as an aid in the diagnosis of hypertension but the use of the sphugmomanometer has not been wholk beneficial When new clinical and laboraton procedures are in troduced improper interpretation of the results obtained through their use often causes much harm and sphygmomanometry has been no ex ception After approximately fifty years of the application of the sphyg momanometer to the care of the sich an assay of its value would not veld a wholly favorable balance sheet Unhappih it is probable that as many patients have been harmed as have been helped owing to its injudicious use by both physicians and lay men (Perera and Atchle HT) Houston 7% discussing the same problem concludes that the measurement of blood pressure often serves to focus anxiety on certain figures which the patient interprets as ominous and which the doctor can do little about save to allay the anxiety which he has occa sioned he later says that the goal to be sought is always intelligent utilization of information not binding oneself to the facts of a situation Since there has been a great increase in the older age groups of the popu lation during the past several decades and since hypertensive and other cardio vascular diseases are the leading causes of death in the United States * widespread publicits has been given to the importance of blood pressure readings and public attention has been focused on the subject Physicians as well as the laity have thus become very sensitive to varia tions of the blood pressure levels from the so called normal limits The number of patients who appear in offices of internists or cardiologists simply because they have been told that they have high blood pressure is nou so large that the use of the expression blood pressure phobia is justified In the great majority of instances this concern over the blood pressure level is unnecessary and undesirable The American Heart Association recently published provisional official figures on the mortality rate durin 1990 in the Cnited States Vlore than 74,00 indis iduals died from distases of the heart and blood essels including hypertension The other > important causes of death (cancer accidents pneumonia tuberculosis and nephritis) took a toll of only 107 000 indi iduals Thus heart and vascular diseases produce al frost twice as many deaths as do all the <ther five major causes of death combined 1123) ·12-1 APPLICATION OLEH BLOOD PRESSURE LIMITS The proper clinical interpretation of individual blood pressure rradings has bech and still is a most difficult problem since the limits of the nor mal and abnormal havc hitherto not been clearly defined Vans phisi cians have accepted somewhat arbitrarily fixed limits of the normal blood pressure without giving due consideration to the various factors which cause these limits to vari cg age sex and vascular conditions Age and sex particularly evert an important míluence on the blood pressure and should be considered in each case Since the present commonly accepted normal limits are entirely too lox, many people (especially in the older age groups) have been classified as hypertensies The new normal blood pressure limits now proposed are higher than those hitherto accepted and do make allowance for the effects of age and seu on the blood pressure with these new limits many patients who haic been considered hipertensie will now be considered normal they will thus be relesed of the an riety and emotional strain often associated with the fear of a high blood pressure as well as of the seeming need for medication to reduce their pressure In evaluating blood pressure readings the proposed new limits must be reasonabls applied loo much attention is often paid to the height of the blood pressure and not enough to the clinical picture as a whole In clinical medicine the blood pressure levci is not as important as is the absence or presence of underlying vascular disease Increased blood pres sure in itself is not a disease it is a sign of some underlying disorder Many studies 2700 978-9 have shown that there is little or no correlation between the height of the blood pressure and the symptoms the rate of progression and the development of complications of the underlying disease The most important factor in determining the prognosis and future course of patients with hypertension is the presence of vası ular discase as manifested bi cardiac enlargement albuminuria hipertensive encephalopathy eseground changes and electrocardiographic alterarion Bechgaard in a four to eles en vear follow up study of 1002 hyperten site patients found that elevation of the systolic pressure to 200-220 mm mercury and of the diastolic to 120-130 mm mercury had not too signifcant an effect on the mortalıtı rate when the elevated blood pres sure was combined with miocardiac degeneration however the prognosis bec ime very bad Stieglitz 78 Paullin ??º and Pereras have also shown that the degree of the artenal tension alont is wholly inade quate as a criterion of the prognosis in any individual Lase Griep, Barry Hall and Hoobler 80 in a recent follow up study of 117 hyper tensiles again emphasized the unreliabilits of the height of the blood pressure or of a change in its level as a prognostic sign in hyperten Lon, and stressed the importance of determining the degree and the pro gression of the vascular damage in the heart brain kidness and retma The blood pressure reading must therefore he correlated math the clinical status of the patient as a whole and should not in itself sene as ·APPLICATION OF F# BLOOD PRESSURE LIVIITS 125 VO the basis for a diagnosis or prognosis in any filen case Page criticizes the physician who makes a diagnosis of hypertension on the basis of the blood pressure alone and who does not search for the other signs associ ated with hypertension He stresses the fact that the isolated finding of an elevated blood pressure is not sufficient for a positive diagno is This consideration is of utmost importance when the borderline group of cases 15 considered A careful histon should be taken and a physical examination done in every case in this group Special attention should be paid to the size of the heart to electrocardiographic changes to renal function studies to the retinal examination and to the functional tests of the heart (og 2 step test) Thus a man or woman of fifty two with a sistolic pressure of 175 mm mercury or a disatolic pressure of 101 mm mercury should be thoroughly examined before the significance of the blood pressure level is evaluated If the entire examination is nega tive and fails to reveal evidence of vascular disease of the heart the hidneys or the fundal arteries the blood pressure may be considered normal for this particular individual However the same level of ar terial pressure or even a lower one would be considered abnormal in another individual who shoned evidence of some vascular damage such as increase in the size of the heart electrocardiographic changes suggestine of left ventricular hypertrophy and strain or albuminuria Just as dependence for diagnosis on any other single finding or test may be dangerous practice in clinical medicine so the evaluation of the blood pressure reading without correlation with the entire physical status of the patient is unsound The acceptance and utilization of the newly proposed normal blood pressure limits will obviously have a wide held of application and a wide effect in the practice of clinical medicine and in climcal research The use of the nes normal limits in clinical practice will be of utmost impor tance in relieving the anxiety which has beset man patients incorrectly classified as hypertensives llans of those who have hitherto been re garded as moderate hypertensives and who have had a gloomy outlook cast upon their futures may now be considered to have essentially normal blood pressures They will also be spared much needless medı cation The use of these new limits in the vast field of industrial medicine too will have a considerable effect blood pressure rcading is part of every pre-employment physical examination and is too often undult cm phasized Vany men particularly tho cover middle age who have been rejected becau e of so called hipertension will again haic the opportunity to be gainfully employed Since the manpower situation is now critical this effect assumes even greater importance As voluntary health and accident insurance spreads and as retirement for illness becomes morc common the range of normal blood pressure will have increased application In cases in which workmen s compensation is a considera tion the blood pressure may be of importance in determining the state ·126 III LICITIO or VW BLOOD I RESSURE LIIT of health of the clainant and in resolving the relationship between the blood pressurc and occupation effort or trauma In the military service during the last war blood pressure readings were taken routinely and standards acre adopted for accepting and rejecting applicants as well as for appraising the necd for medical care and for retirement while in service Since a large Army Tir Corce and Vai are again being formed the evaluation of the blood pressure is again of great military importance The proposed new blood pressure standards should also prove to be useful in clinical research Thus the relationship of hypertension to coronari occlusion angina pectoris diahetes mitral stenosis cardiac en largement electrocardiographic changes and other disturbances should be re-evaluated using the new limits as criteria Some studies in this field have alreads teen undertaken and merit a brief review 1 COPOIRI OCCLUSIO\ A\D HII ERTL ISOS In the past hypertension has been considered to be one of the most important etiologic factors in the production of coronan occlusion For example Vlaster Dach Jaffe and Silver289 29 reported studies done on over 300 cases of coronary occlusion Initial attacks of coronari ou clusion scre found to occur more frequently in each older age group among both men and women The incidence of hypertension al o was found to rise with increasing age of the constant limits 1909, were used as criteria Thus 28 per cent of the men under thirty five years of age had hypertension while 80 per cent of those who were serents had hypertension In women with coronari occlusion hypertension was found to be more common being present in actually 90 per cent of those over forts four years of age Hence the conclusion had bech drasti that hypertension is an important precursor of coronary occlusion both in males and females These findings must now be re evaluated however since it has been shown that the blood pressure normally increases with age and varies i ith ser and that the same linits should not be used for all ages and in both seves in determining the presence of hypertension in cases of coronary occlusion The relationship of hypertension to coro nary occlusion has recently been re investigated using the new limits of normal blood pressure that have been proposed five hundred and fifty four consecutre patients with coronary occlusion (454 men and 100 women) under the age of sixty five were studied The cases were un selected though those over sixtı four were not included in the study because the nex blood pressure limits extend only to that age among the 454 men (Table (VII) the highest incidence of coronarz ocelusion was found in the hity to hifts four year age group (121 cases) and the second highest in the fiftt fire to fifty nine year age group (103 cases) Among the 100 women the highest incidena, of occlusion occurred in the sixty to sixts four year age group (32 ca es) and the second highest ·PILICATIO OF VCW BLOOD PRESSURI LIMITS 127 in the fifty five to fifty nine Vear age group (28 cases) Seventy eight per cent of the women were over fifty years of age as against 63 per rent of the men Women therefore tend to be older than men when the first attack of coronary occlusion occurs In this series of cases the aver age age at which men sustained their first attack was forty eight while the average age of the women was fifty two In another series (Wright " and others?Ay) the women were on the avera, e 6 years older than the men at the time of the first attach of coronary occlusion TABLE XXII -INCIDE CE OF HJERTES ION CUROVARI UCCLLSON Vial mi le Totalc ses Hyptent Tiit ses Il perse Vo ho afge Gops A11 Agc 454 1000 124 27 0 100 100 71 10 25 2) 0 0 D 31-34 3 07 1 0 3> 39 18 4 0 3 16 4 0 3 50 10 44 66 14 S 1 S8 9 90 4 44 4 45 49 80 176 22 2 S 9 90 7 77 6 0 $4 121 26 7 35 28 9 18 18 0 14 78 55 $9 105 23 2 27 25 6 28 28 O 18 64 + 60-64 61 13 4 19 31 2 32 32 0 25 78 2 La than 3 р nt at al u ted Three possible explanations can be given for the later occurrence of coronary occlusion in women than in men 1 Since women after forty normally have a higher blood pressure than hey may have a better coronary circulation and flow than men do men of the same ase 2 Women tolerate hypertension much better than do men and its course in women is more benign longer period of time may be re quired therefore for women to develop coronary sclerosis as a result of the hyperten on Men have a much greater tendency to develop coronary sclerosis than do nomen This may be due to endocrine factors or as suggested by Doch 29 to the fact that males are born with a thicker coronary intima than females Since the artenal tension almost invariably falls after an occlusion the blood pressure which had been present before the occlusion occurred was definitely ascertained in 454 of the cases studied The readings were obtained either from the referring physcian or from the patient if he ·128 IPPLICATION OF VEN BLOOD PRESSURE LIMITS actually knew shat they were Frequently the investigators themselves had measured the pressure before the occlusion developed In 99 cases no previous readings were available, though the patient may have known whether his blood pressure had ever been high or low Thus if the patient had had no difficulty in passing an insurance examination in the recent past it was assumed that his blood pressure had been normal Furthermore clinical judgment was also used in evaluating the blood pressure If for example the blood pressure was 100/100 mm mercury on the second or third day of the coronary occlusion it had probably been higher before the attack. If the blood pressure returned to a hypertensie level a few months or a vear after the acute coronary episode the patient was probably hypertensive before the acute attack had occurred Con sideration also was given to the finding that about one third of hyper tensive patients lose their hypertension permanently after an acute coronary occlusion The borderline cases were omitted in the tables shown because there were so few of them and because a clearer picture can be obtained by comparing cases at the two extremes--those with definiteh clevated blood pressure and those with a normal reading PERCENT OF HYPERTENSIVES MALES (455) AGES FEMALES (100) 240 35 44 54 d 28 45 49 78 30 34 78 290 26 $5 59 64 31 60 64 78 FIG 36 ~ Frequency of hypertension in 435 cases of coronary occlusion (blood pressure readings taken before the onset of coronary occlusion) Using the new definitions of hypertension according to age and ser 195 (35 per cent) of the 574 patients studied were found to be hiperten stve The frequency of hypertension was higher among the women (71 per cent) than among the men (27 per cent) In each age group the frequency of hypertension among the women was more than twice that among the men (Table 1\II and Figure 16) It will be noted that the frequency of hypertension varied little in the various age groups Using the nen limits the inudence of hiperlension remained fairh stationary even though the actual blood pressure rose with increasing age I revious reports shich were based on a single defnition of hipertension for all age groups eg 130 90 and which did not take into account the normal increase in blood pressure with increasing years erroneously showed that the incidence of hypertension in patients with coronary occlusion rore with age ·(f the heart were also considered Ungerleider and Clark 11 tables mer used, in each case 19 a further check on the preserre or arance of a diameter at the level of the diaphragm The shape and goneral houette 129 ATILICITIO OH CH BLOOD PRESSURE LIMITS The striking finding in this study was that hypertension was present in only 27 per cent of the males 10 put it positively over 70 per cent of the men who suffered coronary occlusion had normal blood pressures The cvident conclusion to be drawn is that there is no very close relation ship between hypertension and coronary artery disease and occlusion in the males at least in those under sixtı five years of age The reverse was true in the women-71 per cent of those who had a coronary occlusion did have hypertension 1 hus among women hypertension does appear to have an important relationship with coronary occlusion I hese findings were substantiated by Zeman and Schwartz 23 in a recent post mortem study of 150 unselected cases from the Home for Aged and Infirm Hebreus of New York City All of the patients had lucen over sixty ycars of age Sixty six were male and 84 female They were di vided into 3 groups--those with normal blood pressure those with systolic hypertension and those with both systolic and diastolic hypertension Among the males there was no significant difference in the incidence of coronary occlusion in the 3 groups Among the females the incidence of coronary occlusion in both groups with hypertension was the same None of the females with normal blood pressure suffered from coronary occlusion Zeman and Schwartz thus confirm our conclusions -- that hypertension does not appear to be an important factor in proluring coronary artery di.ease and occlusion in males but is an important factor in producing these diseases in fernales In coronary artery discauwith angina pectoris which is the underlying condition for coronary occluson the same trend exists 294 29 BLOOD PRESSURI LLTEL CORONARI OCCIUSION AND ENLARGED HEART Using the new limits of normal blood pressure wc hase +xamined anul re evaluated the relationship between hipertension coronas artisy or ease and coronarv occlusion The relationship between ligguruin » and cardiac cnlargement as well as between coronary artery line and cardiac enlargement has not yet been clearly establi hraf Alth unto vity many investigators of have maintained that coronary artery disease alone dous not lead to an enlargemert of the fact many others 8157-21 have held the opposite point of vier We have attempted in this study to determine abrthes fiy sostete 230 alone or coronary artery disease alone is related to enlar, mint of the heart heart was considered to be enlarged if its trtal transsere di ameter was definitely greater than one half of the internal thoracic ·130 APPLICATION OF NET BLOOD PRESSURE LIMITS diac enlargement In each case studied the area and volume of the heart were evidently increased beyond the normal One hundred and trents two of our 554 cases of coronary occlusion (454 men and 100 women) (22 per cent) had a cardiac enlargement (Table \VIII) Among these there were 78 men (17 2 per cent) and 44 komen (44 per cent) The incidence of enlargement of the heart was much higher in women than in men as was the incidence of hypertension How ever cardiac enlargement was found to increase in frequency with ad vancing age whereas hypertension did not increase with age in either sex From this one could reason that the coronary artery disease which was present in these cases could be a primary factor in the causation of the cardiac enlargement Other evidence also supported this conclusion car diac enlargement was found in 47 patients whose blood pressure was normal prior to the coronary attack (Table VIV) Of these +2 were men and 5 were women In our series of patients with coronari occlusion and with enlargement of the heart hypertension was found in 25 8 per cent of the men and normal blood pressure in only 13 9 per cent In fe males with coronary occlusion and with enlargement of the heart hyper tension was found in 52 2 per cent and normal blood pressure in 23 8 per cent These results coincide with the common observation that hyperten TABLE XXIII -COROVARY OCCLUSION AND ENLARCEMENT OF THE HEART Wales Fmolcs 1 ge Total Mo Mouth Ex Puth En Group of Cases I ged It al larg dH 6 AU Age 454 78 17 2 Total no North En 7 u ih E GOP of cas larg d 11 i larg d Itea 1 All Ages 100 44 44 0 25-29 0 0 0 30-34 3 0 0 35 39 18 3 16 7 35-39 40-44 65 9 13 9 40-44 9 1 45-49 80 13 8 11 44 5 45-49 9 50-54 15 1 2 3 18 S 121 50-54 27 8 55-59 105 22 21 0 12 42 9 S$ 59 28 22 68 8 60-64 61 18 29 5 60-64 32 Less than 3 cases per cent not calculated sion is a definite factor in enlargement of the heart levertheless an en larged heart can also be found with normal blood pressure At least in men coronary artery disease alone appears to be a major factor in the en largement of the heart We have shown previously that in cases with coronary occlusion (554 cases) hypertension was found in 27 per cent of males and in 71 per cent of females prior to the occlusion It seems there ·APPLICATION OF VEN BLOOD PRESSURE LIMITS 131 т VID -E LARGEM 0 1 HEART BLOOD PRESS Ax 54 C or Coo Y OCCLC IY Val Hyperion to Hyperlen so Normal OY G & T ta! Tral 1 E11 Talal Y 1 EH G 4 Tel Til H V EI OV EIT tal EH EI EH 411 Agen 7 3 8 I 3 30 5 13 9 71 100 3 1 5 5 38 30-34 3 1 0 2 0 37-39 18 3 1 14 2 4 3 0 0 1 10 44 65 17 5 23 5 47 9 4 1 5 0 80 49 5 8 51 6 111 9 0 3 50-54 122 3 5 14 3 81 10 124 18 14 5 38 4 0 53 105 24 7 27 0 69 12 17 4 s 19 8 7 4 7 60-64 61 19 9 17 3 3. 32 2 800 4 1 8 cases the retted 2 i thene had wr mitt d س م ليمر || PE ged 29 Apgwthd! blood p ens 4 f these hd nlarged hearts Lew cha 3 sea pe ce tute leul ted Il hyp 1 EHT &d brart Warm 1 Ley th 3 ANPP cet not 1 lid FNL. Nyt TYY ---Eloop P ACRE DATUTIN 68 C WRC (F mm & 543 I Pt > Ja! Femal Amber ruk Elgd Il y per # Tene Nmber s Can 4g Tlal No Amber Ent ord Hyper Bd Ten sc Hea Teng Border Vormal Tenni Gour Ud 20 1 20-34 30 3 37-39 38 1 1 40 41 2 18 2 2 1543 79 1 1 1 23 1 1 0-54 & 17 13 30 6 4 1 1 55-9 63 13 8 13 4 2 60 6 5 10 6 3 1 8 3 1 T] 404 31 8 8 139 1 2 7 Tb ze (th heart -dim 1000 consecut pnyat 1 10 th AP or th Of I 3 ere on 1 ed tall 1 th fett dy Th th $7p 1 et 14 teru th htts ** La god sex It ( ry or httle tro beumt ca on 1 durane congr tal heart dora beca in thy Jen th 18 ov 64 years I brause ! no i tdt ·132 AI PLIC ITIO or NCH BLOOD PRESSURE LIMITS fore that high blood pressure is a primary factor in enlargement of the heart in females and that coronary sclerosis alone appears to be capable of producing enlargement of the heart in males * In order stil} further to resolve whether coronary sclerosis alone (in the absence of hypertension) may cause cardiac enlargement the size of the heart was determined in 1000 consecutie private patients Tischun dred and forty three were considered suitable for this studı (Table 111) Suty eight of these had an enlargement of the heart in 15 the blood pres sure was normal A clinical diagnosis of coronary sclerosis was established in 14 of these 15 cases 1hc evident conclusion to be drawn from these findings is that cardiac enlargement may occur in individuals with normal blood pressures and that the enlargement appears to be related to coro nary sclerosis This opinion is held by many other observers aloo 873 111 later ind his co workers 315 recently made a clinical and postmortem dy of 950 men cighteen to eighty nine years of age who had had coro nary occlusion They found a definite increase in the size of the heart with increasing age The presence of hypertension alone could not account for this marked cardiac enlargement Coronary artery disease therefore may have been an important factor in the production of the enlarged heart in these cases SU 313LAR The importance of the newly proposed limits of normal blood pressure and their application in all branches of medicine have been discussed It has been emphasized that the new lumits should be applied reasonably and not too hterally The blood pressure reading must always be cor related with the clinical picture as a whole especially with the presence or absence of underlying vascular disease as determined by the history the cveground findings electrocardiographic changes renal function studies cardiac enlargement and functional tests of the heart The demonstration of such underlying vascular disease constitutes the most important evidence for the diagnosis of essential hypertension and is the most important factor in determining the prognosis The necessity crists for re investigating the effects of hypertension in many clinical conditions using the nen limits of blood pressure snce these take into account the effects of age and ser on the blood pressure levels The results of several such studies have been presented 1 Relationship between coronary occlusion and hypertension Hitherto, it was commonly believed that there probably was an ctrologic relationship between hypertension and coronary occlusion in both seves Using the new limits of normal blood pre-sure however we have shown that such a * Since very few of our patients were under forty and since none over sixty four was included our figures can be applied only to patients between forty and sixty four years of age Hoses er it should be remembered that only 7 5 per cent of the population was sixty five years of age and over ·APPLICATIO OF NEW BLOOD PRESSURE LIMITS 133 It was close relationship existed only in women in men no such important association of hypertension with coronary occlusion was found 2 Relationship of enlargement of the heart to coronary occlusion and hypertension Using the new limits of normal blood pressure we have found that enlargement of the heart not uncommonly occurred in men with coronary occlusion whose blood pressure was normal therefore concluded that the coronary artery disease alone was a factor in the production of the cardiac enlargement in men In women with coronary occlusion on the contrary cardiac enlargement rarely occurred in the presence of normal blood pressure Hypertension therefore appeared to be an important factor in the production of enlargement of the heart in women 3 Relationship between enlarged heart and coronary artery disease In a study of 68 patients with cardiac enlargement none of whom suffered from coronary occlusion heart farlure valvular disease or congenital abnormalities 15 were found to have normal blood pressures In 14 of the 15 a diagnosis of coronary artery disease was estabhshed Again then coronar sclerosis alone in the absence of hypertension may cause enlargement of the heart BIBLIOGRAPHY 276 HOUSTON WR Psychic Factors in Essential Hypertension In Stroud D Diagnosis and Treatmen of Cardiovascular Disease Vol I 4th Ed I hiladelphia F A Davis Co 1930 p 926 277 Editorial The American Heart > 2 Summer 1991 278 STIEGLITZ ES Arterial Hypertension Evaluation of the Prognosis Arch Int Med 46 277 1930 279 PAULLIN J E Ultimate Results of Essential Hypertension JAMA 81 975 1926 280 GRIEP AH BARRY GR HALL W Cand HOOBLER SI The Prog nosis in Arterial Hypertension Report on 117 Patients under 53 Years of Age Follos ed 8-10 Years Am J M Sc 221 239 19,1 281 LEVINE S A Clinical Heart Disease 4th Ed I biladelphia and London WB Saunders Co 19,1 p 133 282 PAGE IH Arterial Hypertension In Stroud WD Diagnosis and Treatment of Cardiovascular Disease Vol II 4th Ed Philadelphia FA Davis Co 1990 p 1006 283 PARAINSON ] and BEDFORD DE Cardiac Infarction and Coronary Thrombosis Lancet 1 4 1928 28+ LEVINE SA and BROWN CL Coronary Thrombosis Its Various Clinical Features Medicine 8 245 1999 285 CONNER LA and HOLT E The Subsequent Course and Prognosis in Coronary Thrombosis An Analysis of 787 Cases Am Heart J 5 705 1930 286 COTTON TF Some Clinical Aspects of Coronary Disease Bnt V ) 1 368 1937 287 BEAN WB Infarction of the Heart Am Heart J 14 681 1937 288 MASTER AV Duck Sand JAFFE HL Age Sex and Hisertension in Myocandal Infarction Due to Coronary Occlusion Arch Int Ved 61 767 1939 ·134 APPLICATION OF NEU BLOOD PRESSURE LISTS 289 I ALVER ) il The Blood Pressure in the Years Following Recovery from Coronary Thrombosis Lancet 1 741 1937 290 MASTER A M JAFFT HL Dack S and SILVER N The Course of the Blood Pressure Before During and After Coronary Occlusion Am Heart 26 92 1913 291 RIGHT IS MARPLE CD and Beck DF Report of the Committee for the Evaluation of Antı oagulants in the Treatment of Coronars 1 hrombosis with Myocardial Infarction Am Heart J 36 601 1948 297 Dock 1 The I redilection of Atherosclerosis for the Coronary Artenes JAMA 131 875 1946 293 ZEVAN FD and SCHWARTZ BM The Effect of Arteriosclerosis on the Dj namics of Hypertension in the Aged Preliminary Clinical and Pathon logical Study of 130 Cases J Gerontol 3 10 1948 294 GALLAVARDIN L Furologie de Angine de poitrine Dapres une nouvelle statistique J de Med de Lyon 107 527 1938 29 DAVIS D and LLAINER MJ Studies in Hypertensive Heart Disease Factors in Production of Congestive Failure Am Heart] 20 98 1940 206 APPELBAUM E and NICHOLSON GUB Occlusive Diseases of the Coronary Arteries An Analysis of the Pathological Anatomy in 168 Cases pith Electrocardiographie Correlation in 36 of These Am Heart ) 10 66' 1935 297 BELL E T and CLAWSON BJ Primary Essential Hypertension Studs of 4'0 Cases Arch Path 5 939 1978 294 FYSTER JA E Experimental and Clinical Studies in Cardiac Hyper trophy JAMA 91 1881 1978 299 (ROSS H and Lis4 ) R The Role of Coronary Arterioscleroses in Cardiac Hypertrophy New York State J Med 43 1030 1943 300 NEMET ( and CROSSH The Interrelationship of Arteriosclerotic Heart Disease and Chronic Congestive tallure Am Heart) 10 643 191, 101 BFOFORD I Discussion of the Recognition of Myocardial Disease Pro Roy Soc Aled 291 14+ 1935 302 BARTELS EC and SMITH HL Gross Cardiac Hypertrophy in Myo cardial Infirction Am J Mc 181 452 1937 303 DEXTER SO JR and FARNSWORTH DL Nonvalvular Heart Disease Under the Ace of 16 Years Am Int Med 10 1514 1937 304 DEAN JIB Relation of Carduc Enlargement to Hypertension in Acute and Chront Glomerulonephriti Ain J Med 1 161 1946 305 MCCAIN FH KLINE E MI and GIBSON Í S A Clinical Study of 247 Autopsy Reports on Patients with Myocardial Infarction Am Heart) 19 263 1950 306 KAUNITZ PE Origin of Left Coronary Artery from Pulmonary Artery Ar Herrt) 37 182 1947 307 Boyd W Textbook of Pathology 5th Ed Philadelphia Lea & Febiger 1917 p 375 308 Sont AS TALB S ) and KUPERSYTH H Studies in Coronary Disease Relation of Coronary Sclerosis to Heart Weight and to Richt and Left Ventricular Hypertrophy Illinois M 77 210 1910 309 SuITH HL and BARTELS FC Coronary Thrombosis nith Myocardial Infarction and His pertrophy in loung lersons Report of 2 Cases anh Necropsy JANA 98 1072 1932 310 YATER UM TRALY A H BROWN # FITZGERALD RP FISLEX MA and ILCOX BB 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the Armed Forces Institute of Pathology Ann Int Med 34 357 1951

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·NORMAL RANGE AND LINUITS OF HYPERTEN 104 SYSTOLIC Il y pertension Louer Lom! No mal Range Vale Fem! Kral Femal 16 145 140 17 145 140 18 140 10S 135 105-133 105-135 105-140 105-140 108 140 145 130 19 140 150 150 140 140 20-24 25-29 30-34 35 19 100-130 100-130 100-130 100-130 100-130 102-130 102 135 105-140 105-150 105-155 110-165 110-170 115-175 145 150 110-145 110-145 110-150 110-155 115-160 115-165 115-10 155 160 165 170 175 165 175 45-49 50-54 53-59 60-64 180 180 185 190 190 NORMAL RANGE AND LI SITS OF HYPERTENSION DIASTOLIC Hyperut on Louer L M Jomal Range Hale male F male 16 60-86 60-85 90 90 17 60-86 60-85 90 90 18 60-86 90 90 60-85 60-85 19 95 90 60-88 62 88 95 90 20-24 25-29 65 90 96 92 30-34 68 92 60-85 60-86 00-88 6$ 90 65 92 98 95 98 35 39 40-44 68 92 70-9.4 100 100 100 45-49 70-00 104 105 65 96 70-100 50-54 70-98 106 108 70-100 108 108 SS 59 60-64 70-99 70-100 70-100 110 110 NOR (AL BLOI 1) PRE IRRAND IYPERTENSION w Definto Arthur Vater VD Ch 1 I Garf ld Van Aar I l altrs VD Tab! Win! Ya Irint 11 oth van te te lot anis perman lyde k

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·INDEX The Italıcı ed folios indicate principle references A Arteriosclerosis Bright s disease and 17 hypertension and 49 ADAMS J M 67 in ancient Egyptians 43 Addis 1 55 Atchley DW 56 83 123 Adolescence 97 Australians 67 Age blood pressure increase and 45 53 Average blood pressure 45 65 13-17 79 100 Ayman D 54 blood pressure in older groups 129 diastolic pressure and 80 102 hypertension and 110 B new blood pressure limits and 83 size of heart and 132 BAIN C 82 sy stolic pressure and 44 76 80 102 Baker J W 79 Alam M 56 Barach JH 77 78 Albuminuria 18 124 125 Barnard 28 29 33 Albutt C T Sir 49 Barry GR 12+ Allen E V 86 87 Basal blood pressure 55-57 Altitude 43 44 64 Bauman L 62 Alvarez W C 62 73 77 78 86 Bechgaard P 81 87 124 American Heart Association 55 123 Behier 16 33 42 Committee on Standardization of Blachford M 79 Blood Pressure Readings of the Bloch AM 18 33 Scientific Council of 31 32 58 Blood DW 81 64 Blood pressure animals 11 12 42 Anaeroid manometer 28 32 average 45 Anemia 32 basal 55-57 Aneurysm of ascending aorta 64 casual 55-57 87 Angina pectoris coronary artery disease coefficient of variation 98 and 129 coronary occlusion and enlarged hypertension and 126 heart 129-133 Animals 11 17 47 diastolic See Diastolic pressure Anstie F 48 emotional desensitization 55 Aortic insufficiency 3% factors influencing 53-65 Arabs blood pressure of 67 age See Age Arterial pulsations 15 16 adolescence 97 Artertes brachial 43 58 altitude 43 44 6+ calcification of 59 anemia 32 carotid 59 aortic insufficiency 32 contraction of 60 arterial wall 27 44 59 60 digital 74 climate 62 63 femoral 42 58 diet 63 64 peripheral resistance of ++ emotion 54 radial 15 18 77 28 exercise 43 44 64 spasm of in animals 60 fever 41 temporal 27 fluid intale 63 tissue surroundin, 27 geographic location 67 63 Arterioles See Arteries height 106-110 (139) ·140 INDEL 54 מובת sex > ! -- Blood pressure factors influencing hos : Blood pressure apparatus lotain P pital environment 56 C 27 hyperthyroidism 32 Rosa Roca S 28 63 meals 43 63 Stanton WB 29 33 obesity 61 62 63 Vlerordt Asphygmograph 16 son Basch S 27 19 63 position 6+ Haldenburg L pulsuhr 18 19 pregnancy 6+ Blood pressure cuff 28 29 37 43 ) psychic > 63 57-59 puberty 97 Blood pressure measurement ausculta race 62 63 tory criteria 29-3? digital artery 24 sexual excitenlent St direct arterial 11-15 7 size of arm or les 57-59 femoral artery 12 ) sleep 5+ 55 63 history of 37-50 soft tissue and vascular 57-60 indirect old historical 11-19 starvation 63 64 indirect modern 29-3? 57 58 Cume of day #63 oscillometric method 28 29 weight See eight Blood pressure sounds five phases of 30 weight loss 62 Blood vessels collapse of 20 inequality of arms 64 asomoror changes of 16 life insurance compant studies 49 Bordler III 58 67 75 71 Bowers J 179 limits set bi 72 73 83 Bones LM 74 mean "2 92 93 95 100 103 Braasch F 79 new limits of normal 83 86-133 Briggs J B +3 material for 87-89 Bricht R +7 statistical technique 89-95 Bright s disease and hy pestension 41-49 normal range of 86 93 95 105 Brown 6 E 55 standard devotion of 97 98 106 Brucer M 72 10+ supplemental 55 56 Bruncon 1 L 19 systolic Sue Systolic pressure Burgess 1 11 91 Variation of 72 86 Sre Factors influencin, prognostic significance 56 с Blood pressure apparatus Behier 16 Bloch AM 18 CADBURY 1 M 63 Cool HW 29 33 Cannon WR 5+ Erlanger 29 Casual blood pressure >»-57 87 Foster 1 B 16 Children blood pressure of 3 Gartner G tonometer 24 63 Chinese blood pressure of 67 63 Hales S 11 Choren You 1 39 Herrison J sphygmometre 15 Circulation of the blood history of 37- Hili and Barnard 28 2 Janeway 1 C 29 Clark CP, 129 Landois C 16 Climate 62 63 Ludwig C 13 Clough F E 67 Marey ES 19 47 48 Committee of the Cardiac Society of Mosso A 24 Great Britain and Ireland 55 l'achon V 29 Cook HW 29 33 +34 +9 Philadelphien M A 16 Comell E L 64 sphygmometrgoraphe 18 Coronary artery disease and cardiac Poiseuille ) LV hemodyn3 enlargement 179 133 with an iha se totis 129 mometre 11 ·INDE 141 Coronary occlusion enlarged heart and Evans W 83 129-133 Exercise 43 4 64 hypertension and 196-199 Ez eground changes in hypertension 124 Cro-Magnon race 37 Cushing H 13 F Blood pressure D FABER A 61 Fahr T 49 DACK S 79 81 126 Faivre 42 Deschamps I N 83 Faught FA 6+ Dexter L 83 Females blood pressure levels 53 76 83 Diastolic pressure abnormal 46 coronary intima in 127 absolute range 98 101 coronary occlusion in 126 auscultatory criteria 3 enlargement of heart in 129 average of the values of 22 98 mortality from hypertension 82 casual 56 new limits of normal blood pressure in effect of age 45 96 113 effect of hes 101 110 Femoral cuff 58 59 factors influencing See under Fever 4+ Filipinos blood pressure of 62 femoral 59 Fishberg A M 46 frequency distribution curves 95 Fisher J W 45 46 indirect measurement 23 Fluid intake 63 influence of sex 06 Forster J H 63 mean 95-97 Foster WB 16 33 48 new normal range 46 95-103 113 Frank E 49 oscillatory criteria 79 31 4+ Friedberg CK 46 radial pulse 4+ transient elevation 56 upper limits of normal (old criteria) G 53 Diabetes and hypertension 126 CAGER LT 79 Diehl HS 54 77 78 Galen 40 Diet 63 Gartner G 24 33 Dogs blood pressure measurement on Gavey CJ 80 83 11 42 Geographic location 62 63 experiments on carotid arteries of 59 Ghrst DG 61 DonnSon P 6? Glomerulonephritis 55 Duri. A 77 Goldshine A D 54 Gover M 76 77 104 Grapo v H 39 E Greeks 10 Griep AH 124 EAST AFRICANS blood pressure of 62 Guilette R54 East T 82 Guinand PH 61 Egypt 37-39 Cumprecht 43 arteriosclerosis in mummies 48 Fhrstr m MC 5+ Eichna LW 75 H Electrocardiogram in hypertension 12+- 126 HALES S 11 Emotion + blood pressure measurement in Erlanger J 29 33 animals 11 12 42 ·J 142 INDE Ha}} 11 C 124 Hamilton WF 57 58 li potension 101 Hammer H 79 Hartman H R 61 Harvey 10 Hayaskı T43 INDIANS 62 Heart hypertrophy 47 48 124 125 Intraarterial blood tessure 12 14 20 two-step exercise test 125 32 +2 Height effect on blood pressure 106-110 optical manometer for recordin of 57 Hemodynamometre 12 Hensen H 3 7 Herodotus 37 Herophilus 10 Herrison J1) 33 Hill and Barnard 28 29 33 JAFFE RL 126 Janeway T C 20 29 33 +4 +5 +9 54 Hines EA 86 87 57 59 60 Hoobler SW 124 Jellinek S 54 Horse blood pressure of +2 Johnson H J 61 experiments on carotid arteries of 59 Houston WR 123 Howell H >> Huber EG 61 Huchard H 19 Hunter A 45 46 72 katsANSER G+ Hyperpiesia +9 kesson J E 59 60 Hypertension arteriosclerosis and 49 kidney Bright s disease 47 benign 49 hy pertension 47 48 Bright s disease and 48 49 renal function studies 137 vascular damage 124 concepts of 17 Ikorn HS 64 coronary occlusion and 176-133 Korotkos 30 32 33 +5 diastolic 30 hrakoxer A 63 effect of overweight on 61 effect of sleep on 55 hymograph 14 16 essential 41-50 51 63 132 frequency 89 L hypertensive encephalopathy 12+ hypertensive heart disease 113 hypertensu es benign course of man, LANDIS C 54 73 81-83 Landous L 16 33 42 Lee RI 77 78 life expectancy of 81 weight reduction in 106 Lees HD 54 incidence of 110-11) Levy R L 56 in normal population 73 77-81 83 Lewis WH Jr 76 in older age groups 80 81 Life insurance companies blood pressure influence of emotional factors on 56 lumits set by 45 19 71-73 83 louer limits of 9 mortality rate 71 and normal blood pressure malignant 19 limits 87 mortality rate 82 new limits of 86-103 128 Ludwig C 13 I4 33 persistent 56 prognosis 124 132 Si scolc 80 transient 37 Hyperthyroidism 32 MackE SIE LF 45 46 72 stacheast ·IND 113 113 MacWilliam J A 55 59 60 P Magendie F 13 33 Mahomed FA 18 19 Pachov V 79 Males blood pressure levels 53 76 83 Page I H 124 coronary intima of 177 Pain 5+ coronary occlusion in 126 I almer RS 56 mortality from hy pertension 82 Park E A 59 60 new limits of normal blood pressure Paullin J E 124 Perera GA 96 81 83 123 124 Marey E J 11 Peters J T 73 indirect measurement of blood Philadelphien MA 16 33 pressure 19-24 26 Poiseuille J LM 12 13 33 sphygmograph 16 19 48 Poncelet 14 Marks H H 79 81 Position 61 Varls XL 77 78 Iotain 1 C 11 28 33 1 54 Martin CJ 59 anaeroid manometer 77 Masing F4 Preb VE 62 Master AV 56 79 81 87 126 Pregnancy 67 Meals 43 63 Prusmach J 62 Mercury column movements of 12-15 Psychi factors 54 63 23 Puberty 97 Mercury manometer Lugwig C 13 Puerto Ricans 62 Magendie F 13 Pulse 28 39 40 Marey E J 19 23 Poiseuille J L M 12 Iulsuhr 18 Riva Rocci 28 with tambour 19 20 von Basch 27 R Metal manometer 27 28 Miller I 76 RACE and geographic location 62-63 Moisset de Fspanes E 77 Radial artery pressure 15 16 18 44 Monroe RT 80 Ragan C 56 62 Noodie RL 48 Ranges HA 81 Vorn 14 Richter A 74 79 Mortality rate effect of increased sys- Riva Rocci S 27 28 43 44 tolic pressure 46 Robinson SC 72 101 Voschcowitz F 67 Rogers CH +) 46 Vosso A 24 33 Ruffer VA 43 Vuller C5) Russel H76 CO 101 Russel W 60 pressure 102 S NEGROES African blood pressure of 69 SALI 11 H hypertension in 62 Saile F 63 New blood pressure limits 86-133 Saller 73 Sanderson B 17 17 +5 hwartz B 179 Scott J Ct Sex > 3 Sexual excitement OBESITY 61 62 63 Sheep 11 4 60 Optical man meter 3? 27 Short J 61 + ·141 INDCY UNGERLEIDER HE 129 V VERORDT 16 18 42 Trolhard F 19 von Basch S 11 27 2 +2 +3 +9 59 on Monalon P 56 ton Recklinghausen H 22 29 37 4> - 11 Simerist HE 37 Sleep 54 55 63 Smirk FH 55 56 Sphygmograph 16 Sphygmomanometer Sue Blood pressure apparatus Sphygmometre 15 Sphy momctrographe 18 Stanley L 62 73 Stanton 1 B 29 Starvation 63 Stieglitz E) 56 124 Supplemental blood pressure 55 56 Sutherland KH 77 78 Symonds B 45 46 61 72 Sy stolic pressure auscultatory criteria 30 31 ay cage 98 casual 56 effect of age 4+ 45 53 76 96 factors influencing See under Blood pressure femoral 59 frequency distribution curves 90 91 9 mean 93-97 new normal range 95-103 113 palpation method of determining 27 transient elevation 56 upper limit of normal (old criteria) 4) 53 73 11 ALDENBURG L 19 42 Halho 77 Walters 1 79 Watkin D M 56 leatherby 75 76 Height infuence of on blood pressure ++ 61 62 6) 106 110 overseroht 61 65 106 underweight 61 106 Werss M M 62 Weitz H 79 81 Wells PH White PD 46 Wiggers C J16 Pikner 74 Wadr H 79 V us FA 80 17 right I S 127 T YATER M 132 TAVASTSTJARNA 73 74 Terry AH Jr 67 Thayer WS 43 44 Thompson RIC 80 Todd RE 80 Tonometer 24 63 Traube L 47 Treloar AE 72 Tung CL 63 z ZABEL B 54 Zadek I 3 Zeman FD 129

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