·No text on this page.

·THE JOHNSON RECORDING OSCILLOMETER

·No text on this page.

·THE JOHNSON
RECORDING OSCILLOMETER
Its Use in the Study of
Arterial Circulation
CARL A JOHNSON
MS MD
Senior Attending Physician
St Lukes Hospital Chicago Illinois
Assistant Professor
Department of Clinical Science
University of Illinoi College of Medicine
LONDON
PERGAMON PRESS
NEW YORK PARIS LOS ANGELES
1959

·PERGAMON PRESS LTD
4 & 5 Fitzroy Square London WI
PERGAMON PRESS INC
122 East 55th Street New York 22 NY
PO Bor 47715 Los Angeles California
PERGAMON PRESS SARL
24 Rue des Ecoles Paris V
Copyright
1959
Pergamon Press Inc
Library of Congress Card Number 59 8986
PRINTED IN CRFAT BRITANY BY
THE WOODBRIDGE PRESS LTD
ONSLOW STREET GUILDFORD

·TABLE OF CONTENTS PREFACE Page V11 INTRODUCTION Chapter 5 THE JOHNSON RECORDING OSCILLOMETER The Calibrated Recording Tube The Recording Droplet The Optical System The Transmitting Device The Camera The Pickup Mechanism Calibration Projection of Recordings The Cabinet 17 CHARACTERISTICS OF THE JOHNSON RECORDING OSCILLOMETER Lag Natural Period of the System Responsiveness to Various Pulse Rates Sensitivity Responsiveness to Extraneous Factors Errors Due to Overshoot Errors Due to Undershoot Errors Due to Runoff Determination of the Correction Factor K Equipment for Testing Accuracy III 31 THE ARTERIAL PRESSURE PULSE AND THE ARTERIAL VOLUME PULSE The Pressure Pulse The Vorame Pulse IV ARTERIAL BLOOD PRESSURE Historical Background Method of Recording by Oscillometry Evaluation of Findings Y ·46 58 1 THE JOHNSON RECORDING OSCILLOVETER V THE RECORDING OF THE ARTERIAL VOLUME PULSE FROM THE FINGERS AND TOES Method of Recording The Nature of the Arterial Volume Pulse from the Fingers and Toes Raynaud s Symptoms Atherosclerosis Obliterans Buerger s Disease VI THE RECORDING AND CALIBRATION OF THE ARTERIAL VOLUME PULSE FROM ANYWHERE IN THE EXTREMITIES EXCEPT THE FINGERS AND TOES The Components of the Arterial Volume Pulse High Grade Aortic Stenosis Coarctation of the Aorta Asymmetrical Blood Pressure Cardiac Conditions Atherosclerosis Obliterans VII TREATMENT OF ATHEROSCLEROSIS OBLITERANS WITH MASSAGE Methods of Study Case Histories Comments and Conclusions VIII THE ARTERIAL VOLUME PULSE FROM THE HUMAN BRAIN IX THE ARTERIAL VOLUME PULSE FROM THE INTRAORBITAL TISSUES Construction of the Equipment Procedure for Recording Results Co and Conclusions х THE ARTERIAL VOLUME PULSE FROM THE TEMPORAL ARTERY Method of Recording Results and Comments YI THE ARTERIAL VOLUME PULSE TAKEN OVER THE FOREHEAD Method of Recording Results and Comments XII SUMMARY AND CONCLUSIONS BIBLIOGRAPHY 69 80 82 99 102 107 111 ·PREFACE The research reported in this monograph was initiated in 1930 when the author was on the faculty of the Physiology Department of the University of Chicago as well as on the faculty of the Departments of Physiology and Medicine of Northwestern University The work was continued in private practice and while the author was in the United States Air Force in World War II It was later carried on at the University of Illinois College of Medicine where the author is now a member of the faculty Almost all of the clinical studies were made in the Circulation Laboratories at St Lukes Hospital Chicago or in the authors private practice The author wishes to acknowledge his indebtedness to his many friends and associates who assisted in the research read the manuscript made helpful suggestions or aided in the technical details He is especially indebted to the Womens Board of St Lukes Hospital and to Dr Selim McArthur who were instrumental in making laboratory facilities available and in providing funds for the initial research to Professor Anton J Carlson and Professor Arno B Luckhardt of the University of Chicago to Dean Irving Cutter of Northwestern University to Professor Andrew C Ivy of the University of Illinois to Mr Howard A Carter and Dr Frederick T Jung of the American Medical Association to the Institute of Biological Research and its technical staff to Professors William and Francis Shonka of the Department of Physics of the University of Chicago and to Miss Gertrude Gscherdle Chief Librarian of the Chicago Public Library S yu

·No text on this page.

·INTRODUCTION The objective of this monograph is to present a detailed description of the Johnson Recording Oscillometer which makes possible the recording of the calibrated arterial volume pulse without arterial puncture from any where in the extremities the temporal artery the brain and the intraorbital tissues This monograph also summarizes published and unpublished data resulting from studies utilizing the Oscillometer some of which may bu only of academic interest while other aspects may have a direct clinical application in the diagnosis and treatment of patients The subject of arterial circulation which includes arterial blood pressure has been of interest since early times Interest in the subject is intensified at the present time because of the growing incidence of arterial disease associated with increased longevity improved methods of diagnosis and the varied surgical and non surgical methods used in the treatment of arterial disease For the most part the results of the above procedures are assessed by the subjective method only or by objective methods which require arterial puncture Furthermore some of the remedial procedures particularly those related to hypertension are assessed on the basis of studies on the arms only even though it has been known since 1924 that differences in the blood pressure may occur in all four extremities This knowledge is derived from the study by Bazett" which showed that differences in the blood pressure in all four extremities may be present in the normal dog The fact that differences in the blood pressure in all four extremities also exist in man has been amply confirmed by others and is re confirmed in this study Some of the events of the arterial circulation may occur as rapidly as 004 seconds This eliminates visual observation on non recording instru ments as a method of study since the human eye cannot detect such rapid changes For this reason a precision timed calibrated recording oscillo meter suitable for clinical studies and known as the Johnson Recording Oscillometer was developed A search of the literature shows that Swammerdam'' (1637-1680) had constructed a similar instrument (see Fig 1) which he used for the study of muscle physiology A significant difference between the Johnson Record ing Oscillometer and that of Swammerdam is in the nature of the recording droplet Swammerdam used water and the Johnson Recording Oscillo 1 ·2 THE JOHNSON RECORDING OSCILLOMETER meter uses 95 per cent ethyl alcohol Both use air conduction to transmit the changes which take place in the confined extremity The Johnson Recording Oscillometer was originally designed for the study of the arterial circulation in the legs of dogs It was later modified for studies on the human finger (see Fig 2) The more extensive and diversified use of the Oscillometer was not foreseen when the original equipment was developed and the initial studies on arterial circulation were madelai c IT Fic 1 This figure represents a reproduction from Boerhaave s Biblia Naturae and shows Illustrations of the plethysmographs used by Jan Swammerdam The text is a literal translation from part of the original text to this figure Muscle movement in the frog aa the two muscle tendons grasped by the fingers when hanging nerve is touched the muscle contraction draws the two hands together I Vethod showing thickening of muscle in contraction a Glass tube through which muscle is drawn bb - needles transpiercing tendons c thu nerve touched dd displacement of needles bh contracting muscle fills up center of glass tube J Method showing that the heart occupies less space in contraction a Contracting heart is placed upon piston of glass tabe on glass tube c water droplet introduced onio tube of siphon descends with heart contraction d place in tube showing distance moved by droplet during time of descent IV Method showing that contracted muscle takes up less space a Tube b muscle c silver thread through loop of which the nerve is passed d copper thread with loop at top through which silver thread is drawn water droplet in stphon tube / hand stimulating nerve muscle contracts and droplet descends a little V Another method of showing the above a Glass siphon arerture drilled in the siphon c nerve drawn through the aperture (Translation of legend hy Dr Arno B Luckhardt) ·INTRODUCTION 3 The first description of the instrument for making visual recordings of the arterial volume pulse of the fingers was published in 1931» as part of a manuscript on The Effect of Amyl Nitrite on the Finger Volume Since that time the instrument has been adapted to optical recording and has gone through several modifications which were described in 1932 19405) and 1951(61 The instrument was also described in a 1952 report by the Council on Physical Medicine and Rehabilitation of the American Medical Associa tion1 The Council on Physical Medicine and Rehabilitation in the above report stated Evidence obtained from sources acceptable to the Council indicated that this instrument provides a convenient method for obtaining pulse wave recordings as an aid in the diagnosis of cardiovascular disease The Oscillometer together with recordings and data taken from cases involving orthopedic surgery were exhibited for a conference of the www FIG? A line drawing of the original digital oscillometer A calibrated glass tube is sealed to one end and a rubber dam attached to the other end is perforated in such a manner that a finger or toe can be inserted into the glass chamber through this per foration as shown A by pass stopcock which is used during adjustments is sealed to the side of the chamber The droplet of 95 per cent alcohol is shown in black for illustrative purposes Hhen the finger or toe in the chamber as illus trated the droplet of alcohol oscillates with each volume change caused by the increased amount of blood entering the finger with each heart beat This calibrated volume change can be recorded with the latest instrument shown in Fig 3 American Academy of Orthopedic Surgeons in 1951 The exhibit received the Gold Medal Award() citing the clinical value of the Recording Oscillo meter in Orthopedic Surgery There is no other equipment which resembles the Johnson Recording Oscillometer in design Instruments operating on different principles have excessive overshoot undershoot and lag Therefore it is not possible to present comparative studies Because of the physics involved in the dynamics of arterial circulation competent physicists were consulted with the objective of correlating the operation of the instrument with the dynamics of the arterial circulation ·4 THE JOHNSOV RECORDING OSCILLOMCTER The publication of this monograph does not mean that this research project is completed Studies utılızıng the Johnson Recording Oscillometer are in progress in the authors laboratory and private practice and else where throughout the world The use of the equipment is not limited to research in the field of organic diseases of the cardiovascular system as is illustrated by a study of allergic manifestation on the cardiovascular system in progress in 1957 under the direction of Dr Grant H Laing at St Luke s Hospital Chicago In order to evaluate the results of the studies made with the Johnson Recording Oscillometer one must have an understanding of the basic principles involved in the construction of the Oscillometer as well as of the equipment specially built to test the accuracy of the Oscillometer ·CHAPTER 1 THE JOHNSON RECORDING OSCILLOMETER THE Johnson Recording Oscillometer in its simplest form (see Fig 2) was designed for recording the arterial volume pulse from the finger The latest model for recording the arterial volume pulse from the finger is shown in Fig 3 and for recording the arterial volume pulse from anywhere in the extremities from over the temporal artery or from the brain in Fig 9 The instrument as used for recording arterial blood pressure is illustrated in Figs 28 and 30 and for recording the arterial volume pulse from the intra orbital tissues in Fig S3 Each part of the instrument has been constructed to co ordinate precisely with other parts and in relation to the requirements of recording the human arterial volume pulse The timing of the recording is comparable to that of the electrocardiogram or 004 sec between divisions The Calibrated Recording Tube The calibrated recording tube is of critical dimensions and is accurately calibrated to 001 ml The bore cannot be too small so that the effects of capillary action will be introduced nor can it be too large so that the drop let of alcohol will not hold together Two calibrated tubes are available one with a smaller bore (2 1 mm) and greater sensitivity used for infants and children and the other with a larger bore (2 5 mm) used for adults The Recording Droplet The recording droplet is 95 per cent alcohol and was selected because it is easily available and has the physical properties necessary for the effective functioning of the Oscillometer It has a low specific gravity thus de creasing the mass per unit which has to be displaced The meniscus of the droplet extends to the ends of the pipette so that the droplet changes form not position as a result of the arterial volume pulse Its solvent properties are such that the walls of the calibrated tube do not collect a film of grease which so commonly happens when water is used The internal resistance of the instrument is largely determined by the menisci of the droplet of alcohol extending to the ends of the calibrated tube In this manner any change in volume affecting the droplet is a change in the form of the droplet (see Fig 4) The resistance to the change in form is largely of a molecular nature and not a resistance of movement of the droplet against the walls of the tube S

·6
THE JOHNSON RECORDING OSCILLOMETER
FIG 3
The Johnson According Oscillometer arranged for recording the arterial volume
pulse of the finger The optical principles are illustrated on f1g ( and the mechanical
details of consiruction are described in iis 7

·THE JOHNSON RECORDING OSCILLOVETER 7 FIG 4 An unretouched photograph taken of the calibrated tube and the recording droplet of al ohol while a recording was being made Note that the menisci of the droplet of 95 per cent alcohol extend to the ends of the tub As a result the droplet changes form instead of position while the volume changes are being recorded To further demonstrate the lack of resistance the time elapsed for a droplet to fall the length of the recording tube within the tube and in the air in front of the tube under the influence of gravity was determined and found to be approximately the same as illustrated in Fig 5 The Optical System When a beam of light is cast on the recording tube with the contained droplet of alcohol the calibration lines on the tube intercept the light rays and are transferred to the moving light sensitive paper The droplet of 95 per cent alcohol acts as a plus cylınder lens and focuses the light rays on 016. 015 FIG 3 Two recordings made with the Johnson Recording Oscillometer on its side so that the recording calibrated tube was vertical In both instances the droplet was allowed to fall under the forc of gravity In the allustration on the left the droplet fell within the alcohol wetted tube while in the illustration on the right the droplet was allowed to fall in front of the tube Note that the time of fall was approximately the same in both cases Jlustrating the fact that the alcobol wetted tube offered no more resistance to the falling droplet than the air surrounding the droplet ·8 THE JOHNSON RECORDING OSCILLOMETER Electrocardiograph Paper Pipette Source Light Princ pal focus of the Papelle Is Behind the EKG Paper Parallel Rays of Light ( ) Electrocardiograph Paper Pipette and Alcohol Source of Light Principa! Focus of PipeMe and Alcohol is on the EKG. Paper Parallel Rays of Light FIQ 6 The simplicity of the optical system of the instrument is illustrated above Note that the parallel light rays passing through the walls of the pipette only do not focus on the light sensitive paper while those passing through the walls of the tube and the droplet come to focus on the light sensitive paper The volumc calibrations on the tube intercept the light rays In this manner the droplet of alcohol produces a sharp intense black image on a light background with lines representing volume differences The recording is timed with vans intercepting the fight rays from a synchronous timer with intervals of 0-04 sec similar to the timing of the clectrocardiogram ·THE JOHNSON RECORDING OSCILLOMETER 9 the moving sensitive paper A synchronous timer with vans spaced to produce time intervals of 001 sec is placed so that it will intercept the rays of light The exposed and developed photosensitive paper reveals the following horizontal lines with a volume of difference butween an two lines of 001 ml vertical lines with a time difference of 004 seu between any two lines and a sharply defined black image which represents the droplet of alcohol These optical principles are illustrated in Fig 6 The optical slit is fixed at 00015 in By using intense illumination in relation to daylight the instrument can be used in broad dayli ht witbout visibly affecting the recording The possibility of making recordings with out darkening the room is advantageous in that it avoids influencing the patient s psychosomatic state thus obtaining better controls The instrument has eight rapidly interchangeable speeds varying from 14 to 52 cm/sec The high speeds spread the recordings of individual pulse waves and thus make possible the more detailed analysis of a single pulse wave The high speeds are also useful when recording very rapid heart rates as illustrated in Fig 16 In order to have approximately the same developing time for the exposed paper regardless of the speed used casily interchangeable light filters (see Fig 7) are built into the instrument By using the dark filter for the four low speeds and the light filter for the four high speeds approximately the same density is obtained on the developed paper The Oscillometer has a built in synchronous timing device designed to produce the same time interval as the electrocardiogram or 004 sec (see Fig 7) The Transmitting Device With chambers suitable for the fingers and toes and a special chamber for the intraorbital tissues recordings can be made directly from the calı brated tube In order to transmit the arterial volume pulse from other parts of the extremities the temporal artery or the brain it is necessary to use a special transmitting device constructed in the following manner The transmitting device (see Fig 7) has two chambers The inner cham ber is of a size and elasticity and is brased in such a way that it has practically the same sensitivity throughout the entire range of diastolic blood pressure it can also record systolic blood pressure over 300 mm Hg The outer chamber has a standard aneroid Tycos Blood Pressure Dial This chamber is of such dimensions in relation to the inner chamber and to the pickup mechanism as to affect a reduction of the artenal volume pulse when using the 12 cm blood pressure cuff of about 10 1 for adults and a reduction of about 5 1 when using the 6 cm cuff for infants and children 2 built in ·10 THC JOHNSON RECORDING OSCILLOMETER -15 5 21 12 9 18 17 23 10 2 - 20 23 1916 FIG 7 This illustration shows the component parts of the Johnson Recording Oscillometer (1) a reinforced Tycos Blood Pressure Cuff 12 cm wide () one of the rubber tubes which connects the cuff to the transmitting device of the Oscillometer (3) the inflating buth (4) an escape valve for adjustments (3) a Tycos blood pressure dial connected to the transmitting device to the double transmitting chamber with a reduction of about 101 (7) a rubber tube connecting the transmitting device to the calibrated recording tube containing the recording droplet of 95 per cent alcohol (8) a by pass stopcock for adju iments (9) the recording tube (10) the recording droplet of 95 per cent alcohol (1) the leveling screw for the camera (1) a measuring device giving the inches of exposed paper (13) a numbering device for marking the tracings (14) a red light which turns on when the paper is exhausted in the instru ment (13) the camera bor (16) a disk containing the vans of the synchronous timer (17) the light source (18) the interchangeable fitte (19) a switch to turn the light source off and on (20) the cable release which turns on the timer and operates the camera (21) the cabinet enclosing the in rumert (2) an intet socket for 110 60 cycle current ·THE JOHNSON RECORDING OSCILLOMETER 11 The Camera The camera mechanism is so constructed that it uses standard 50 ft rolls of 6 cm daylight loading cartridges of electrocardiograph paper (Camco No 30) Mechanical provision is made for a positive drive of paper at a uniform predetermined speed through the camera The exposed paper enters a removable light proof chamber which has a self contained paper-cutting device When the recording has been made thrs chamber can be removed and the paper taken to a darkroom for development Fur thermore a numbering mechanism is built into the camera so that the STOPCOCK SLIP-ON CONNECTOR FINGER CHAMBER FiG 8 This figure illustrates the detail of the pickup mechanism for making recordings of the arterial volume pulse from the digits The digit is inserted into the glass chamber through the hole in the rubber dam while the slip on connector is detached The open end of the rubber tubing is connected to the calibrated recording tube while the adjusting stopcock is left open The patient is made comfortable to avoid tremor and movement the slip on connector is attached the droplet of alcohol in the calibrated recording tube is centered the stopcock is closed and the recording made tracings are marked for identification The illumination is provided by a standard light bulb with a fixed resistance in series so that the life of the light source is over 1000 hr Suitable lenses concentrate the beam of light on the recording mechanism A cable release operates the camera (see Fig 7) The entire apparatus is operated on 110 V 60 c/s alternating current ·12 THC JOHNSON RECORDING OSCILLOMETER The Pickup Mechanism The pickup mechanism varies in accordance with the part of the body from which recordings of the arterial volume pulse are to be made The mechanism used for the fingers and toes (described in material pub lished in 1932") consists of a glass chamber which fits over the extremity One end forms an airtight seal over the finger or toe by means of a rubber dam The other end is connected to the recording instrument by rubber tubing with a suitable by pass for adjustment (see Fig 8) H मल्ट Tc 9 This illustration shows the procedure for making recordings of the diastolic blood pressure and the arterial volume pulse from anywhere in the extremities except the fingers and toes In this illustration recordings are being made from the right wrist The pickup mechanism which is used for recording the artenal volume pulse from the intraorbital tissues the temporal arteries and the forehead is specially constructed and is described in detail in Chapter IX and is ullustrated in Fig 53 This mechanism is also connected to the recording instrument by means of rubber tubing with a suitable for adju tments (see Fig 33) by pass ·THE JOFINSON RECORDING OSCILLOMETER 13 The pick up mechanism for recording the arterial volume pulse and the arterial diastolic pressure from anywhere in the extremities the temporal artery or the brain has been described in previously published materiale but briefly consists of a 12 cm Tycos Reinforced Blood Pressure Cuff for adults and a 6 cm blood pressure cuff for premature babies infants and children (see Fig 9) It would be desirable to have the latter cuff reinforced but none are available at this writing F10 10 A machine drawing of the metering device which accurately delivers 1 ml or + ml volume change at will by merely depressing the plun_er (1) knob ( ) stop pin half volume (1) piston rod (4) retaining collar (5) compression spring (6) upper body (7) Teflon pi ton (8) hose ends and (9) lower body Calibration The recording tube is accurately calibrated to 001 ml The pickup chambers for the fingers toes and infraorbital tissues are connected directly to this tube when recording from these areas The transmitting device described above is included in the system when making recordin,s of the arterial volume pulse from the arms and legs (exclusive of the fingers and toes) from the temporal artery and from the brain and when recording blood pressure in the arms and legs In the early models of the Oscillo meter recordings were individually calibrated by means of a 2 ml syringe containing oil (see Fig 9) The caltbration was set at 1 ml when using the 12 cm Tycos Reinforced Blood Pressure Cuff for adults and at 1 ml when using the 6 cm cuff for premature babies infants and children The calibration was made by depressing the plunger of the syringe while the recording was being taken In the later models a calibrating device of ·14 THE JOHNSON RECORDING OSCILLOMETER greater precision is built into the mechanism This device which does not require a reservoir of oil is illustrated in Fig 10 Projection of Recordings The arteriul volume pulse can be projected on a screen for visual ob servation by groups by means of a lantern slide adapter The adapter with a built in leveling adjustment replaces the lantern slide conveyor and carries the calibrated recording tube A holder for the transmitting device is connected to the adapter (see Fig 11) Tiru A special frame to carry the recording tube of the Oscillometer has been constructed to replace the standard slide carrier of the lantern slide projector as illustrated above The pipette (1) is connected to the transmitting mechanism By this means the arterial volume pulse can be projected on a lantern slide screen as illustrated in Fig 12 The results of a visual recording of the arterial volume pulse and blood pressure madu during a critical cardiac operation on an infant at the Children s Memorial Hospital Chicago was previously reported in 1951 and 15 reproduced in Fig 12 Fron such visual recordings an experienced observer can predict well in advance from disturbances of the cardiac rhythm and blood pressure the impending collapse of a patient The Cabine! The entire equipment described above is contained in a cabinet with dimensions of 22 x 95 x 95 in which weighs 35 lb For convenience u special table has been constructed so that the instrument can be rolled to the patient s bedside (sec Fig 13) ·THE SOHNSOV RECORDING OSCILLOMETER 15 15 0 45 60 75 90 105 120 133 130 PATIENT 1 year old DIAGNOSIS Tetrology of Fallot Multiple artenal embols TREATMENT Potts Smith oper otion 180 260 2401 2201 BOF 60) 40 RECORD ILLUSTRATES 27*UPATEN Lieto Teck VASCULAR CHANGES 100) CHEST OPZXIDJ CLAMP OTEX DURING SURGERY -1006 LUI IL TX PANDED L. CLAMP OPETE OVLT 101 2 ICE WATEN LAORTA CLAMP Method Experimental Coarctation of Aorta F16 ! The means of projecting the arterial volume pulse the screen is illustrated at the left of the figure and the data thus oblained during a critical (peration on a one year old infant is shown at the right

·16
TIJE JOHNSON RECORDING OSCILLOMETER
FIC 13
This figure shows the entire unit enclosed in a cabinet on a
movable table which can be rolled to the patients bedside

·CHAPTER 11 CHARACTERISTICS OF THE JOHNSON RECORDING OSCILLOMETER Las The term lag as used in this monoqraph indicates the time elapsed from the arterial volume pulse in the subject to the time of recording The arterial volume pulse is taken up by the pickup mechanism of the Oscillo meter and travels through the instrument with the speed of sound This was confirmed experimentally by making simultaneous recordings of the electrocardiogram and the arterial volume pulse while using S ft of tubing and while using 55 ft of tubing from the patient to the instrument The peak of the R wave of the electrocardiogram was used as a point of reference From the time difference (004 sec) of the two recordings the speed of the transmission of the artertal volume pulse in the instrument can be computed and the lao thus determined ſhe instrument is ordinarily used with 5 ft of tubing The lag is then 0 004 sec This figure is insignifi cant and not measurable When using less tubing the lag is approximately 0 002 sec A typical experiment is illustrated in Fig 14 Natural Period of the System Che inertia of the contained air and recording droplet of alcohol is so smull as compared to the inertia of the pickup unit (Tycos Reinforced Blood Pressure Cuff) that the natural frequency of the transmission tubing would be much greater than any heart rate encountered in man The pickup unit (blood pressure cuff) is never moving under forced vibration and therefore its natural frequency is not a factor Responsii eness to Various Puise Rares The instrument will record volume pulse rates of over 1000 per minute The average normal human subject can produce voluntary clonus in the arni with rates up to 500 contractions per minute By tapping the inflated pickup mechanism of the Oscillometer while so doing the contractions will be recorded Such a recording is shown in Fig 15 There has been no opportunity in this study to make recordings of the arterial volume pulse in many patients with heart rates of over 200 per minute in one patient with auricular fibrillation the rate between two single beats was the equivalent of 250 beats per minute This was recorded

·18
THE JOHNSON RECORDING OSCILLOMETER
CONTROL
CONTROL
CONTROL
til
"T
WITH 50 FEET OF TUBING
zellik upan
TI 776
WITH 50 FEET OF TUBING
Melaniella
WITH
50 FEET OF
TUBING
FIG 14
This illustration shows the manner of determining the lag of the Oscillomcier Simul
tancous recordings of the clectrocardiogram and the arterial volume puise from
above the right clbox ucre made using five fect of tubing from the patient to the
recorder and were repeated while using fity additional fect of tubing from point of
relerence on the electrocardiogram one can determine the time required for the
arterial volume pulse to travel soft which is approximalely 004 sec As the instru
ment is ordinarily used with 5 ft of tubing the lag 13 004 cc This is insignificant
and net measurable

·CHARACTERISTICS OF THE JOHNSON RECORDING OSCILLOVETLR 19 *** AL w NA FIG IS These recordings were made to show the responsiveness of the Oscilometer to rapidly induced volume changes the recording cuff was wrapped around a rigid lube about the size of the human arm and inflated to 100 mm Hg to simulate the diastolic blood pressure Rapidly induced volume changes were produced by tapping the cuff ar rates of about 500 per minute by the Oscillometer and us shown in Fig 16 Rites such as this are seldom observed but this case does illustrate the need for the higher speed in the instrument to provide for the accurate timing in such cases Extremely slow heart rates occasionally occur Fig 17 tlustrates the arterial volume pulse recordings from a patient in whom the heart rate of the dominant beat and of the coupled beat was 26 respectively making the combined rate 52 per minute This recording illustrates the fact that the coupled beat may contribute matersally to the minute arterial volume pulses Several patients with complete heart block have been studied A recording - Fic 16 Recording taken from above the right elbow 3x7 a seventy kve year old female with auricular fibrillazon and cardiovascular faslute with edema 11 represents the arterya! volume puise with an average heart rate of about 150 but in the recording on the nght betweco the two beats shown it represents a heart rate of 250 This demon strates that the Oscilometer is capable of recording any known human heart rate It is not possible to make an accurate calibration of the recording tit the presence of auricular fibriltalion but a rough approximation can be made as shown ·20 TUL JOHNSON RECORDING OSCILLOMETER FIG 17 Recording of the arterial volume pulse taken from above the right elbow in a sixty seven year old white male who had a history of a slow irregular heart beat The elec trocardiogram showed a sinus mechanism with coupling Note that the rate of the dominant rhythm is 26 per minute and of the coupled rhythm 26 per minute making a total of 52 beats per minute In this case the coupled beat is a very efficient beat and contributes about 46 per cent of the minute arterial volume pulses The corrected minute arterial volume pulses in this case are 166 ml which is within the normal range of the arterial volume pulse in one of these cases showing a heart rate of 33 per minute is illustrated in Fig 18 Sensilanity The Oscillometer is not equally sensitive at all cuff pressures It is less sensitive with the higher cuff pressure as shown in Fig 19A However the sensitivity is fairly constant in the range of diastolic blood pressure The amount of air in the pick up mechanisnı affects to some extent the sensitivity of the Oscillometer When the pick up is applied snugly the Oscillometer is more sensitive to volume changes than when the cuff is applied loosely as illustrated in Fig 19A-1 Observations made in the course of these studies indicate that the extremity can change in size rapidly due to shifts in tissue fluids It is obvious that the sunsitivity of the re cordings would change if this occurred fic 18 Recording of the arterial volume pulse taken from above the right clbow from a sixty five car old coloured female with complete heart block During the recording * superimposed volume change was induced into various phases of the cardiac cycle In no instance did thus induced volume change alter the recording for more than one cardiac cycle ·CHARACTI RISTICS OF THE JOBINSON RECORDING OSCILI OMETER 21 When the 6 cm cuff is used the amount of air in the system is markedly reduced and the sensitivity of the Oscillometer is markedly increased as shown in Fig 19B The above factors illustrate the need for calibrating each recording individually thus eliminating these conditions as sources of error In the instance of the 6 cm cuff the desirability of using 4 ml for calibration instead of 1 ml as is used for the 12 cm reinforced cuff is also apparent The size or volume of the recording droplet has very little effect on the sensitivity of the Oscillometer The size of the droplet is usually 004 ml 200 150 ***** 100 F16 19 These recordings illustrate the sensitivity of the instrument Recording A shows that the Oscillometer used with the 1 cm cuff is not equally sensitive at all cuff pressures and is more sensitive at cuff pressures in the range of diastolic blood pressure Recording A 1 shows that an increased amount of air in the pickup cuff reduces the sensitivity Recording B shows that the use of the 6 cm cuff markedly increases the Sensitivity of the instrument. Recording C shows that the size of the recording droplet does not affect the sensitivsty of the instrument Recording D shows that repeated similar volume changes produce identical results Note 1 ml volume change was used in every case ·22 THE JOHNSON RECORDING OSCILLOMETER 150 mm Hg Abose left elbow 80 ma WE . 139 mmHg- Systolic Above left elbow Diastolic 90mm Hg - MT werp EN GRADA Wh -- mt w SM WA W 44 co -4 440 ... 1 Tmi . ww 16/9 (89)K-158K ml/min At left wrist Diostolic 100 mm Hg - MON WOMAN Wor . Mwe --- w MAAR MOM WN SNUDAM - entre UNGHI AM her w 4 A 9/7(84) K 108K mt/min FIG 0 Recordings made of the arterial blood pressure and arterial volumc pulse above the left elbow and at the wrist in a seventy five year old while male with severe Parkin son s disease In most cases severe tremer is not an obstacle in obtaining grond recordings and a slightly smaller or larger droplet has very little effect as shown in Fig 19c The width of the recording surface of tho photosensitive paper is 6 cm and the recording of uny arterial volume pulse is limited to this distance which represents 0 28 ml with the calibrated tubų of large bore and 0 19 ml with the calibrated tube of small bore At any given pressure the ·CHARACTERISTICS OF THL JOHNSON RECORDING OSCILLOMETER 23 sensitivity is the same throughout this range as illustrated in Figs 194 19A-1 and 198 Repeated similar volume changes produce identical results as illustrated in Fig 190 Responsiveness 10 Extraneous Factors Extraneou factors which might be thought to modify the recordings do not do so because of the characteristics of the Oscillometer The following examples serve as illustrations (1) A single induced extraneous volume change while making a recording of the arterial volume pulse will not modify the recording for more than a single beat since it does not cause the instrument to oscillate as shown in Fig 18 (2) It is possible to obtain good recordings of the arterial blood pressure and the arterial volume pulse in severe Parkinson s disease as shown in Fig 20 (3) It is possible to make recordings of the arterial volume pulse from the arm while the patient is walking around the room if the subjec can keep his arm relaxed (4) It is possible to make recordings of the arterial volume pulse through heavy clothing with some loss of sensitivity This procedure is cited merely to demonstrate the sensitivity of the instrument Errors Due to Overshoot As used in this monograph the term overshoot refers to the recording droplet going beyond the actual arterial volume pulse change The over shoot due to various components of the Oscillometer namely the calibrated recording pipette the transmitting device and the pickup mechanism (Tycos Reinforced Blood Pressure Cuff) has been determined The overshoot in the calibrated recording tube is negligible when a fired volume is introduced at various rates and the time of rise of the volume recording is more than 0 1 sec As will be brought out in the chapters on the recording of the arterial volume pulse from the fingers and toes and from the intraorbital tissues the time rise of this component of the arterial volume pulse is always more than 01 sec For this reason over shoot does not introduce any error when taking recordings from these areas as illustrated in Fig 21 The overshoot for the combination of the calibrated recording tube and the transmitting device was determined by injecting a fired volume of air at various rates It was found that the degree of overshoot varied with the crest time (time of rise of the volume pulse) as shown in Fig 21 There is considerable overshoot with crest times comparable to those found in the human arterial volume pulse taken in the extremities exclusive of the fingers and toes ·22 THE JOHNSON RECORDING OSCILLOMETER 150 mmHg BO Above left elbow + BLAGA www PV 139 mmhg- Systolic Above lett elbow Diastolic 90mmHg 8 et 1 With * als thout Here w 4. Le W * We user * WEN Wu Wu w MALE 100 dese NA w . WW AR Tmi w m HO 16/9 (89) K 158 K ml/min At left wrist Diastolic 100 mmHg VE Ne per un own 4* MAN WAJAR do the Www. AWM 44 VO se MA AN WEB MANOWANAUME when MUU WA men -- WWW www. . Lyu 9/7184)K 108 K ml/min FIG_0 Recordings made of the arterial blood pressure and arterial volume pulse above th teft elbow and at the wrist in a seventy five year old white male with severe Parken son s discase In most cases severe tremor is not an ob tacte in obtaining good recordings and a slightly smaller or larger droplet has very little effect as shown in Fig 19c The width of the recording surface of the photosensitive paper is 6 cm and the recording of any arterial volume pulse is limited to this distance which represents 0 28 ml with the calibrated tube of large bore and 019 ml with the calibrated tube of small bore At any given pressure the

·CHARACTERISTICS OF THE JOHVSOV RECORDIVG OSCILLOVITER
25
A
1
8
3

·20 THE JOHNSON RECORDING OSCIILOMETER A-1 A A-2 OR 1 . how B 40 Et « MNM. ope VES 4. Le Pet en CREST TIME 008 012 0.20 c Fic 23 Rccordings made from the artificial arm for the calibration of the Oscula meter to illustrate the effects of overshoot run oll and th artificial pulse waves which can be produced under controlled conditions A Recording AI shows a calibration of th Oscillomcicr to 1 ml and recording A. shows a calibration of the artificial arm 1o 1 ml Note that the amplitudes are identical indicating that there is no loss in transmission of 1 ml from the artificial arm to the recording mechanism 3 These recordings show the cflects of crest time on the degree of over shoot Similar studies at various crest times and various di3stolic pressures produce the data which makes it possible to compute correction factor A (see Fig 24) с These recordings show pulse waves produced from the artificial arm Thc proumal syringe was depressed so that the crest time was 0 18 sec in cach as The recordings simulate heart rates of $3 and 89 respectively Notc the difference in amplitude which is accounted for by the difference in run oft Also note the presence of a dicrolic notch which 15 similar to that scen in the human pulse wave ·CHARACT LRISTICS or THE JOHNSON RECORDING OSCILIOMETER 27 artificial arm with a rigid tube two inches in diameter around which the rubber portion of a standard 12 cm blood pressure cuff is wrapped The frormal outlet is connected to a ky podermic needle which can be changer at will and which acts as a resistant to the flow of fund The hypodermic needless in turn connected to a reservoir and a 2 ml syringe The whole system contains 100 ml of water with all air excluded through by puss stopcocks It has been found that this equipment will function satisfactoris with volumes of fluid in the system ranging from 50 o 125 si Greater or less fluid brings about other technical difficulties The equipment is shown in Fig 22A In operation the pickup mechanism of the Oscillo meter is wrapped around the rubber cuff as in making recordings from the human arm as shown in Fig 228 The following procedures are possible with the above combination of Instruments 3 The diastolic pressure can be controlled by inflation of the Oscillo meter cuff to the desired pressure 2 When the syringes of the artificial urm are set it I ml und the diastolic pressure is set at i selucted level injection of 1 ml into the artificial arm while recording on the Oscillometer gives a value corra sponding to 1 ml as cahbrated by the Oscillometer itself as shown in Fig 23A The crest timc or time of rise of the volume pulse can be con trolled by the rate of injection It is then possible to determine the degree of overshoot with different crest times as shown in Fig 238 4 The simulated heart rate can be controlled by changing ihe per pheral resistance The construction of a 20 gauge hypodermic needle will give a simulated volume pulse rate of about 100 per minute while a 22 gauge needle will give a simulated rate of About 50 per minute as shown in Fig 23c 5 An artificial precision volume pulse can be produced by depressing the distal syring! While recording the proximal syringe is depressed and the distal syringe is released and takes up the volume of 1 ml at a rate determined by the peripheral constriction or heart rate In this manner volume pulses simulating those seen in almost any cardiovascular condition can be produced al wil as shown in Fig 230 Errors Due to Undershoot Undershoot is comparable 10 overshoot except that it occurs during diastole of the descent of the volume pulse is rapid when a fast heart rate ·28 THIL JOHNSON RECORDING OSCILLOMETER is present it is negligible in recordings of the arterial volume pulse from the fingers toes and intraorbital tissues In the extremities exclusive of the fingers and toes it does become a factor in heart rates of over 100 as illustrated in Fig 23c The degree of undershoot has also been determined for various heart rates and enters into the computation of the correction factor K (see formula in the legend for Fig 24) 0 shoot 10 no vnout Z 1d IV + Id IX Fic41A) An analysis of the arterial volume pulse for overshoot and run off from which the correction factor A is obtained to construct the graph shown in Fig 24(B) The triangle OYX can be constructed equal and congruent to triangle WYZ of and only of Ox is parallel to Vy and the extension of VY meets WZ on the vertical axis through o Then did = 11 Note The triangle OYX did not need to be constructed to prove this but the assumption as made above is necessary in order to set up the proportion In terms of a correction factor A defined by d = aid da - d) then A = dld + d-d) Since d = 1 ml =lled Errors Due to Runoj In this monograph the term runoff refers to that quantity of blood which moves forward without contributing to the expansion of the arterial tree during cach systole It represents the effects of the kinetic energy as contrasted with the potential cnergy us a result of the expansion of the arterial tree to accommodate the increased amount of blood cjected by the heart during systole Thts is difficult to determine precisely ctperimentally An approximation can be determined on the artificial arm as shown in Fig 23c or it can be computed as being the ratio of the crest time over the length of the cardiac cycle multiplied by the calibrated recorded volume puise ·CHARACTERISTICS OF THIC JOHNSOV RECORDING OSCILLONETER 29 Determination of the Correction Factor In the preceding paragraphs it was pointed out that overshoot can be determined experimentally for different crest times and undershoot can be determined experimentally for different heart rates Runolf computed and varies with both crest time and heart rate K has been determined from the formula in the legend for Fig 244 can be Liso 125 18. 106 L7-1 16- 15- 14- 200 Rete 8 1.2 25 10- 09 as- 07- 09 10 112 14 16 18 20 22 24 26 29 22 Cre time F10 24(B) Graph giving for various crest times and various heart rates The runoff was computed from the formula set forth in Fig 41A) and d and d were deter mined experimentally The correction factor K is for overshoot and runoff for heart rates of less than one hundred bcats per minute The correction factor K for heart rates over one hundred beats per minute includes overshoot runoff and undershoot The correction factors for various heart rates and crest times are shown in Fig 24B The cuff pressures used made no appreciable difference in the results Eqmpment for Testing Accuracy In order to test the accuracy of the Oscillometer in recording the cali brated arterial volume pulse an artificial circulation instrument was made simulating the human circulation as closely as is mechanically possible ·30 THE JOHNSON RLCORDING OSCILLONETLR The apparatus used the principle of the artificial arm illustrated in Fig 22 but incorporated a mechanical pump with which it is possible to deliver a taxed volume pulse at various crest times and various heart rates The system contains two one way Butter valves which provide for flow in only one direction The opening and closing of these valves sound much like the tones of the human heart The peripheral resistance can be modified at will by means of a needle valve The instrument can be set at any desired diastolic pressure various heart rates and various crest times Con tinuous recordings from the artificial arm of this apparatus can be made 10 19 12 FIC I Interchangeable Cam 5 Return Flow 9 Flutter Valve 2-Blood Pressure 6 Needle Valve JO TO Alicial Arm 3 To Osillomete 7 Cut Off Valve JF Fron Artificial Arm 4 Re ery 8 Flutter Valve 12 Syringe 5 The equipment built to simulate the human systemic circulation The drive mechanism with multiple speeds is shown on the night and has a replacablu cam (1) which activates the plunger of 1 syringe (I.) through a lever mechanism The form of the cam can be computed from human arterial volume pulse recordings Recordings made from this instrument by means of the Oscillomcler simulate the arterial volume pulsc recordings in every detail Any human arterial volume pulse can be duplicated on this instru ment The flow through the simulated extremily is in one direction only controlled by means of two flutler values located at (8) and (9) The necdlc vulve (6) controls the peripheral reststance and returns the fund to the reservoir (4) The pickup mechanism of the Oscillometer is shown surrounding the simulated human cutremily at () on thc O cillometer and the recordings can be calibrated at will Thc simulated venous return can be collected and compared with the computed volume pulse from the Oscillometer recordings from this study it was determined that the error was less than 7 per cent with heart rates under 125 The precision instrument described about is shown in Fig 25 ·CHAPTER 111 THE ARTERIAL PRESSURE PULSE AND THE ARTERIAL VOLUME PULSE Some difference of opinion exists concerning the distinction between the arterial pressure pulse and the arterial volume pulse Arterial pressure pulse and arterial volume pulse are intimately related and have the same origin namely the action of the heart in the arterial system the speed of the arterial pressure pule is in part determined by the decree of existing elasticity The speed of the arterial pressure pulse can be measured in experimental models of the arterial circulation and in patients as illustrated in Fig 26 Because of the action of the heart and because of the anatomical struc ture of the arterial system both arterial pressure pulse and arterial volume pulse are created with each heart beat The Pressure Pulse The pressure pulse is created by the action of the heart suddenly ejecting additional blood into the elastic arterial system already under pressure This pressure pulse travels down the arterial system with a speed of from 15 to 60 ft/sec and has been measured by others It can be measured by the Johnson Recording Oscillometer as shown in Fig 26 The measure ment is made by taking simultaneous electrocardiograms and volume pulses above the elbow and at the wrist and noting the lag in the pressure pulse between the two areas from a point of reference on the electrocardiogram The distance between the elbow and wrist can be measured and from these figures one can compute the speed of the pressure pulse wave The pres sure pulse contributes virtually nothing to the forward flow of blood Although a great deal has been written concerning the pressure pulse no clear cut definition can be found in the literature as the term is used in this study Force and pressure are both involved in the genesis of the pressure pulse Force is generally defined as push or pull Forces are usually expressed in pounds grams or kilograms Pressure means the push or pull on a unit of surface acted upon Pulse is generally defined as a regular beating or throbbing caused in the arteries by contraction of the ventricles of the heart Therefore a pressure pulse could be defined as a push or pull on a unit area of the surface of an artery caused by the contraction of the ventncle 31 ·32 THE JOTINSON RECORDING OSCILLOMETER SPEED OF THE PULSE WAVE NORMAL KYPERTENSION A6E 77 CUFF PRESSURE 70 MM HG AGE 76 CUFF PRESSURE ROOMA NG 60 E ELBOW OOVE ELBOW + WR$ AT W1 BOVE ALDA 48 LOOD PRESSURE PEAR OF A WAYS TO RE OF PULLE WAY FERENCE IN SECONDS DISTANCE IN INCHES TE OF PUSE WAVE IN FEET PER HECON ELDON WEST KNEE ANKIE 110/60 120/80 14 27 19 21 03 11 25 $1 10 32.30 ELBON mest 151/92 22 14 02 10.15 45.00 KNEE ANKTS 220/140 27 19 02 13 00 11 75 5400 T LADI Cay ANA 900 36'wo Borg or voor KON VA M I SW 510 Won FC 26 This illustration shows the manner of measuring the speed of the atterial pressure pulse (not to be confused with the arterial volume pulse) The distinction between The two is illustrated in Fig 27 Simultancous recordings of the electrocardiogram and the arterial volume pulse are made from above the elbow and at the wrist From a point of reference on the electrocardiogram the time clapsed for the pulse wave to travel from the elbow to the wrist can be measured The distance in inches can also be measured From these figures the speed of the pressure pulse can be computed The same procedure can be used on the leg Illustrative cases are shown in the table ·THE ARTERIAL PRESSURE PULSE AND ARTERIAL VOLUME PULSE 33 of the heart However this must be modified in view of present know ledge to include in the concept of pressure pulse the delivery of blood from the left ventricle to the aorta The Volume Pulse The literature contains much material on the change in volume of the arterial tree as a result of the action of the heart Kowever the relationship of the pressure pulse to the genesis of this change has not been clearly defined For the purpose of this study the standard definition of volume and pulse apply namely volume is defined 15 space occupied as measured 17 PAES JRE PULSE @ 0 10 ches f- ELBOX On 4 eod VXUA PUL Systol Slope Da to $oge Cadac tyc Valur Pus 0165 ta ds Lyseco 116 secyd 222) ml 06 OTT coseco a 3x orgy B/SSK) FIG 7 The upper line drawing was made to illustrate a hypothetical cross section of the arterial tree above the elbow and at the wrist during dsastol (BC) and (B-C) and during systole (A-D) and ( AD) Note that the pre sure Pulse travels from the elbow to the wrist in 014 sec On the other hand the volume pule above the elbow and at the wrist takes 0 16 sec to reach a peak which is a reflection of the marimum d stension of the arterial tree in these locations cubic units The term volume pulse is defined as is the term pulse in Websters Dictionary le a regular heating or throbbing caused in the arteries by the contraction of the ventricles of the heart "The arteries already being filled with blood under pressure the additional quantity of blood forced joto them by each ventricular contraction causes a distension of the arterial walls These contracting again under their own elasticity force the blood along distending in turn the part of the artery next beyond ·36 THE JOHNSON RECORDING OSCILLOVETER the institution of the auscultatory technique by Korotkov in 1905 the era of modern clinical sphygmomanometry began Until 1924 it was assumed that no significant differences in the arterial blood pressure in the arms and legs in the reclining subject existed At this time Bazete' by direct arterial puncture in dogs in the horizontal position showed that the systolic pressure was higher in the femoral artery than in the brachial artery but that the diastolic pressure was the same F16 8 The instrument arranged for taking the diastolic blood pressure and the arterial circulation from above the cloow Recordings thus taken arc illustrated in Tags 9 and 4 throughout the arterial tree Previous isolated reports on human subjects with aortic regurgitation as well as hyperthyroidism had been reported with the same findings Comparative studies on arterial blood pressure by the auscultatory tech niques and direct arterial puncture were made possibly after the develop mest of the Hamilton Manometers 31 Numerous authors (Dyrdıckins Strangle"and Hamilton "S) have consistently found the blood pressures higher in the legs than in the arms of normal reclining subjects ·ARTERIAL BLOOD PRESSURE 37 ARM HO 630 120 IND 68 70 9.3 113 122 Anca Abe wn in Ihont Aroom 1 Cuff Pressunt-MHO 50 Start $1 119 Ahe ST blood pre Ostol Reeding Biod Pressure on Sat 93 fm Mo LEG Cut Pressure at Ha Ho 100 90 140 130 120 BO 70 60 90 100 94 122 LO 14430 125 106 houstolle 100 Amplitude of Pulse Wory Disions Frerire ICH Pneu MH 170 Stort Stop 143 ܣܗܕ timere Dlata Recording Rood pretve Gulf Set of Oom Hg FIG.9 Pulse wave recordings which the rterial blood pressure cant be determined A and B are pulse wave recordings at 10 mm Hy cuff pressure increments from 140 mm Hg down 10 60 mm Hg above the elbow and above the knee respectively The maximum amplitude of the pui c wave in the arm is recorded at 90 mm Hg which is the diastolic blood pressure and at 100 mm Hg in the leg which is the diastolic blood pressure A- and B-1 are recordings of the pulse wave below the elbow and below the knee respectively when known constrictions are applied above the elbow and above the knee by second cuffs as illustrated in Fig 30 in the illus fration for the arm (A-1) the pressure in the protimal cuff was 150 mm Hg when the recording was started and 119 mm M when ti was stopped The recorded strip of tracing represents 31 mm Hg and the systolic blood pressure is caterpolated at (36 mm Hg A sumilar study in the leg gave a systolic blood pressure of 157 mm Hg pressure Note the subject for this record ng was a pormal white male age 31 10 in last and weibing 180 16 ·38 THL JOHNSON RECORDING OSCILLOMETER The proper width of the cuff for taking blood pressure has been the sub ject of much controversy At present the 12 cm cuff is recommended for the arm and the 15 cm for the leg In a study by Sapp Arney and Mattingly published in 1955 an 18 cm cuff was advocated for the leg Erlanger and Hooler'16) stated that if the artery is compressed as much as 4 cm the cuff is adequate Wiggers!!) is of the opinion that the 13 cm cuff is adequate Attempts have been made to record the diastolic blood pressure by oscillometry using the pressure at which the maximum pulse wave was recorded as the diastolic pressure (Janeway(tk) Masing!Sahlı' " and Marey ) Reviews of the subject of arterial blood pressure have been written from time to time including a study by the Committee of the American Heart Association in the Standardı,ation of Blood Pressure Readings review of the subject in monograph form was published by Masters et al** in 1952 Method of Recording by Oscillometry In the work reported in this monograph the arterial blood pressure in the arms and legs is recorded by oscillometry In this method the recordin of the diastolic blood pressure is based on Marey s Principle which states that application of a definite force to an elastic vibrating structure causes it to oscillate most extensively when internal and external pressures are equal This is a physiological application of Hooke s Law from phy sics which states that of a displacement of an elastic body occurs the restoring force is proportional to it within the clastic limit of the body Periodic wave motion requires that this condition exist as is the case when the cuff is at the diastolic pressure From this discussion it is upparent that it is only necessary to discover at what cuff pressure the maximum amplitude of the pulse wave occurs A standard 12 cm Tycos Reinforced Blood Pressure Cuff is applied above the elbow in the usual way and it attached to the Oscillometer as shown in Fig 28 Recordings of one or ino arterial volume pulses at cult pressures ranging from 140 to 60 mm Hg taken at 10 mm Hg increments are made as shown in Fig 29 The amplitude of the recorded arterial volume puise is measured with a caliper and the pressure level at which the maximal pulse wave is recorded is the diastolic blood pressure The same procedure is carried out above the Inco to obtain the diastolic pressure as shown in Fig 29 The sistolic blood pressure is recorded by means of the Oscillomcter using the double cuff method as shown in Fig 30 A standard 12 cm Tycos Reinforced Blood Pressure Cult is applied above the elbow in the usual way and is connected to a standard ancroid blood pressure dial Thu ·ARTERIAL BLOOD PRESSURE 19 FG 30 This photograph shows the manner of applying the pickup cult for the recording of the systolic blood pressure The distal cuff is inflated to approximat ly the diastolic pressure and is used for recording The proximal cuff is inflated to a pressure above the level at which no recording of the puise beat is made by the di tal cuff The proximal cuff is deflated slowly while a recording is being made and the level at which the first beat is registered by the distal recording cuff is taken as the systolic blood pressure as shown in Fig 9 by pass system is modified by incorporating a air escape mechanism by which the pressure can be reduced at a uniform rate by merely opening a valve as shown in Fig 31 A second standard 12 cm Tycos Reinforced Blood Pressure Cuff is applied below the elbow and is connected to the Johnson Recording Oscillometer To obtain a recording of the systolic blood pressure the distal cuff is inflated to the diastolic blood pressure as previously determined The proximal cuff is inflated to above the antıcı pated systolic blood pressure and a visual note is made of this pressure Recordings from the distal cuff are made while the prorimal cuff is deflated at a fixed rate until recordings of the arterial pulse wave appear from the distal cuff A visual observation is made of the pressure in the proximal cuff at the point at which the recording is stopped The cuff pressure in ·40 THIC JOIINSON RECORDING OSCILLOMETER 1 FI 31 This figure illustrates the detail of the prormal blood pressure cuff and accessorics used in recording the systolic blood pressure as shown in Fig 30 The by pass con construction (1) can be altered at will by using various sizes of hypodermin neçdics In most instances a 37 gauge needle is used to record the systolic blood pressurt the instrument is arranged for recording from the distal blood pressure con 31 approtialely the dig stolic blood pressure The proximal curt is inhaled to prove the anticipated systolic pressure Re ordings from the distal cuff are started simul tancously with the opening of the by puss valve ( )and continued until recordings of the volume pulse from the distal cuff appear A note is made of the pressure in the proximal full at which recordings were started and stopped From the devel ped record one can inserpolate the systolic pressure the proximal cuff at the point when the recording was started and stopped is then Anoua The systone pressure can be interpolated from this re cording as shown in Fig 29 The same procedure can be carried out in the legs and with smaller culls on infants and children While coming out the procedure in the leg the proximal cuff will transmit an impulse ·ARTERIAL BLOOD PRESSURF 41 through the table which will be recorded by the distal cuff and give false readings This error can be eliminated by placing a pillow under the knee All studies were made on adults in the reclining position Some subjects were normal some had cardiovascular disease and others had diseases unrelated to the cardiovascular system The results of the studies are gren in Table 1 These indicate that normotension hypotension and hyper tension may exist in the same patient When the data on all four extremi ties are examined all combinations are found to be present in some patients regardless of adult age ser height body build and weight (Note except Case 11 a seven year old child) TABLE I BLOOD PRESSURE STUDIES Blood pressure Cases Art Leg Case Lot Sex Age Right Left Right Left NORMAL IN THE ARMS AND LEGS F F 11€ 190 115/90 125/90 bouw 6. 54 58 54 $4 52 130/90 112/90 127/100 1.5/80 1.7/90 137190 112190 | 179/80 145/110 149/100 142/90 138/90 148/10 147/100 138/90 143/90 134/90 148/100 1 8/80 145/80 146/80 154/90 150/90 146/90 C W 139/90 195/70 1 0/90 131/80 F 9 10 wwww NORMAL IN THE ARMS HYPERTENSION IN THE LEGS F 54 141/80 138/90 205/110 199/110 V 60 135/100 234/1 0 M 135/90 135/90 172/90 160/80 M 63 140/80 131/90 170/100 157/100 M SO 131/100 130/100 166/100 168/110 7 12 13 F 14 15 16 17 18 19 W W WY WV W M HYPERTENSION IN THE ARMS AND LEGS 30 -40/170 300+ /170 60 185/110 260/140 $3 230/120 752/140 65 173/110 186/90 13/100 193/90 59 178/100 164/100 2.4/110 11/110 64 187/110 163/1'0 139/100 156/110 75 158/80 158/80 214/90 701/100 300 + 180 300+ /170 300+ /160 100+ 1 63 187/100 187/110 215/100 2.6/100 42 1155/150 166/150 -16/160 2 /160 W W C F M ·42 THC JOHNSON RECORDING OSCILLOMETER BLOOD PRESSURE STUDIES continued Blood pressure Cases Arm Les Case Col Sex Age Right Left Right Left 24 25 26 27 28 30 M M M 32 73 34 35 OLCLUSIVE ARTERIAL DISEASE-ONE OR MORE EXTRCMITIES W F 42 131/90 131/90 80/60 75 50 ME 71 191/100 275/110 119/110 W M SO 171/100 175/100 160/110 161/110 W M1 63 110/80 102/70 166/110 W M 67 128/78 78/70 Amp 107/80 W M 76 180/90 180/100 110/90 115/90 W 6+ 160/100 133/90 198/130 07/120 W SO 130/90 139/90 91170 W 63 183/100 172/110 117/90 190/80 W M 66 188/90 164/100 127/100 123/100 W M 55 196/80 195/80 107/60 78/60 W M 66 POS/130 ?1./140 97/70 145/90 WV 175/80 161/80 109/80 165/80 OCCLUSIVE ARTERIAL DISEASE COARCIATION OF THIC AORTA M 23 1207/110 199/110 119/110 11/11 MISCELLANEOJS-MITRAL (OVVISLROTOVY-YEAR POST OF ERATIVE W F 10 111/70 120/70 160/70 160/70 MISCELLANEOUS--ATILD HYPERTIYROID W F 56 154/110 165/110 17/10 07/120 37 38 39 40 MISCELLANEOUS-POSSIBLC ADRENAL INSUFFICIENCY F 4 94/80 100/80 1 1/80 W 1 6/80 41 4 43 "53/110 MISCELLANEOUS COMPLETL HEART BLOCK F SO 185/100 M 65 173/110 186/90 M 69 LOS / 100 .16/10 с W W 13/100 238/100 193/90 06/110 44 45 V W MISCELLANEOUS-DISK SYNDROME SO 1-5/70 159/90 145/90 M 60 115/90 118/90 183/100 181/100 MISCELLANEOUS-EXTENSIVE THIRD DEGRFF BURNS OF LEGS 1 34 125/80 138/90 149/100 16*/90 M 46 116/80 11°/80 16 /80 156/90 M 30 130/90 125/80 155/100 165/90 MT 17 135/90 140/110 191/110 167/100 46 47 48 49 WHww MISCELLANEOLY-SCLERODERM4-SC ERODACTYLIA RAYNALDS SYNDROMECALCINOSIS T 61 132/80 198/90 50 VY 200/100 189/90 RAWAUDS SYNDROVEN THE FNNERS ONLY F 49 1 4/90 13/100 5) 148/100 145/100 ·ARTERIAL BLOOD PRESSURE The preceding table illustrates the differences in arterial blood pressure in the four extremities which one might encounter when the blood pressures are recorded oscillometrically with the standard 12 cm Tycos Reinforced Blood Pressure Cufi Some of the cases are of unusual interest 3$ indicated below Carc ll This is the only child in the series and is of unusual interest because hypertension exists in the legs even though the subject was only seven years old Cases 24-36 inclusie All had symptoms of intermittent claudia tion and in addition cases 24 25 28 29 33 34 and 35 kad rest pains Cases 25 and 33 These two ca es received hypotensive drugs with an aggration of the interment claudication and rest pains which lasted several weeks after cessation of therapy Cases 24 26 and 35 These cases had lumbar sympathectomies with out relief of symptoms Case 37 This case had a resection of the coarctalian which relieved the symptoms and confirmed the dsagnosis Case 50 This case had a bilateral sympathectomy to both arms about twenty years previous with no relief from the Raynauds Syndrome The patients varied in adult age (except Case 11) sex body buld height and weight although there were no cases of extreme obesity in this entre scries Eraluation of Findings Although the results produced by oscillometry may not quantitatively reflect the arterial blood pressure it is believed that they are more accurate than when the arterial blood pressure is taken by the auscultory method when similar cuffs are used The data indicates that the difference in the blood pressure in the arms and legs of some patients is so great that errors in the oscillometnical method are insignificant by comparison The method described uses mechanical principles for recording the arterial blood pressure while the auscultory method relies on the produc tion of sound within the range of hearing known as the Korotkov sounds*** It would seem that these may vary in pulch und intensity de pending on the speed of the rise of the pulse wave as well as the damping effect of the surrounding tissues If the speed of the rise of the pulse wave is much over 0 16 sec (normal 0 08-016) the sounds may not be heard ·44 THE JOHNSON RECORDING OSCILLOMETER This is well illustrated from records taken from the legs in patients with coarctation of the aorta Case 37 of this series had a speed in the rise of the pulse wave above the knee of 0 24 sec In six other patients with coarctation it averaged 0 25 sec in the legs This is also apparent in patients with occlusive arterial disease where distal to the occlusion the time of rise is markedly prolonged as in cases 24-36 of this series where the time of rise of the pulse wave ranged from 0 2-0 32 sec in the affected extremity This is also true for palpation of the peripheral arterial pulse as the palpating finger cannot feel the slowly rising pulse wave The obvious conclusion is that if the horotlov sounds are not in the range of hearing the arterial blood pressure must be recorded mechanically The sensitivity of the instrument for recording systolic arterial blood pressure is approximately 002 ml escaping past the proximal blood pressure cuff which means that in taking systolic blood pressure the error is less than 2 mm Hg The sensitivity for recording the diastolic blood pressure is within 10 mm Hg The instrument used in this study is a precision instrument for the re cording of the arterial volume pulse but the pickup mechanism (Tycos Reinforced Blood Pressure Cuff) may introduce significant error because of faulty design or dimensions in relation to the extremity It is significant to note that in the series of patients reported on Table I cases 1-8 varied in adult age height body build and weight Likewise in the rest of the patients who showed abnormalities of blood pressure in the extremities these abnormalities showed no relation to adult age (note casc 11 is the seven year old child) height sct body build or weight Furthermore patients 27 28 29 and 34 were studied once a month for more than two years with consistent results within the range of physiological variation For these reasons it would seem that the standard 12 cm cuff gives clinically consistent results for the recording of the arterial blood pressure in all four extremities A great deal of the work which has been done by others on hypertension was based upon blood pressure studies in the arms only with a disregard of the blood pressure in the legs It seems apparent that if hypertension of the arms is important hypertension of thc legs is cqually important per haps more so when one considers the large amount of arterial pathology in the legs as compared with that seen in the arms On the other hand patients have been observed with hypertension of the arms and hypotension of the legs associated with occlusive arterial disease Such patients when treated with hypotensile drugs may develop an inadequate arterial circula tion in the legs with further symptoms of rest pains and intermittent claudi cation They may develop psychosis brought about hy impaired circulation to the brain as in cases 25 and 33

·ARTERIAL ALOOD PRESSURE
45
It is significant that the following combination of arterial blood pressure
10 the arms and legs has been recorded
1 Normal in arms and legs
2 Normal in the arms and hypertension in legs
3 Normal in the arms and hypotension is the legs
4 Hypertension in the arms and legs
5 Hypertension in the arms and normal a legs
6 Hypotension in the arms 288 hypertension in legs
7 Significant differences in the two arms
8 Significant differences in the two legs
9 Significant differences in all four extremities
These findings are important because they emphasize the need for blood
ure studies throughout the entire body in order to complete y evaluule
the patient s state of arterial blood pressure and to bring about a better
understanding of the nature of artenal blood pressure per se This study
15 step in this direction

·CHAPTER V THE RECORDING OF THE ARTERIAL VOLUME PULSL FROM THE FINGERS AND TOES THE recording of the arterial volume pulse from the fingers and tocs is especially significant for the following reasons (1) the method of making these recordings involves a different procedure from those used for making recordings from other parts of the body (2) the nature of the arterial volume pulse is different from those elsewhere in the body and (3) the clinical usefulness of this procedure is somewhat less than that of the procedure used for recording the arterial volume pulse elsewhere in the extremities except when disturbances in the arterial circulation of the digits per se erist Method of Recording Recordings of the arterial volume pulse can be made from the fingers with the patient in reclining sitting and standing positions but for the sake of uniformity and better control the recordings are usually made with the patient in the reclining position after a suitable rest period in order to avoid tremor in the recording as well as the effects of respiratory movu ments the hand is placed on a pillow laid over the abdomen A droplet of 95 per cent alcohol of a volume of 004 ml is placed in the calibrated recording tube and the instrument is adjusted with the leveling screw us shown in Figs 3 and 7 so that the droplet moves slowly toward the operator under the force of gravity The movement of the droplet is stopped by an offset device built into the recording tube The tracing is numbered with the built in numbering device for identification (see Fig 7) The digital chamber has a rubber dum placed over one cn.l with a hole just larbe enough to admit the digit The seal between the rubber dam and the walls of the digital chamber must be airtight since even a small leak will inter fere with the recording This can be insured by wrapping a piece of ad hesive tupe around the scal The digital chamber is applied to the finger with the by pass stopcock open (see Fig 8) and is connected to the recording tube The instrument is so hinged that the side toward the operator can bu elevated In this manner the recording droplet can be moved to th center of the recording {ubu Thc by puss stopcoch is closed the light switch (see Fig 7) is turned on and the cable relcase is depressed setting the instrument in motion and making the recording 11 there is a leal in the system which may happen due to ſaully application 46 ·RECORDING OF ARTERIAL SOLUUL POLSE. FROVE FINGERS AND TOES of the rubber dam to the walls of the digital chamber or of the digital chamber to the finger the droplet usli slowly move toward the operator und no pulsations will be seen Corrective measures are then laken A normal tracing from the fingers before 3nd after the application of local heat is shown in Fig 32 This lustrates the fact that che arterial volume pulse varies with the size of the finger but avera es 002 - for u 20 ml finger In the absence of organic oculusion local hest inureases the arterial volume pulse indicating vasodilstation Re application of the W BẾP 117 NATO ASTER CONTRAK FIERE-Try COR VN 2 FG 3? Recording of the finger volume pulse in a normal male The black are represents the width of the recording droples of ethyl alcohot and does not enter into the Seasurements Measurements are made from the depression to th peak of the oscs} lations The horizontal lines are projectsons of th graduations on the recording pelle and the distance between any ino lines is oo1 ml The vasodsatsng effects of local heat are well slustrated 15 idus record by the acreased amplitude of the excursions digital chamber followed by arterial olume recordings produces consistent results The Nature of the Arterial Volume Puise from the Fingers and Toes The contour of the arterial volume pulse from the fingers and toes is usually smooth without visible or promifent secondary waves as is fre quently not the case in recordings of the arterial volume pulse from else where in the extremity However peaks frequently appear following ·48 THE JOHNSON RECORDING OSCILLOMETER vasodilitation from local heat general heat fever nerve block and with some organic diseases of the heart such as high grade aortic regurgitation (see Fig 33) The crest time or time of rise of the arterial volume pulse from the fingers and toes is usually more than 02 sec while the normal values from elsewhere in the extremities fall between from 008 to 0 16 sec This is important since it precludes overshoot as an error in the recordings Undershoot also is insignificant since the time of descent of the arterial volume pulse is usually longer than 02 sec CONTROL RIGHT HAND- AFTER HEAT-<5C-OMIN FINGER CONTROL -LEFT HAND NTER HEAT 45C-ROVIN WAWAAN w BIP Pulse F1633 This figure illustrates the craggerated finger volume pulse from patients with severe aortic regurgitation These changes are a reflection of the increased stroke output of the heart Local heat produced a mark d tasodilatation The arterial volume pulse in the finger can be obliterated by the applica tion of pressure to the arms by means of a blood pressure cuff This obliteration is complete when the pressure in the cuff is at the systolic level (see Fig 34) The effects of artificial fever produced by general heat as well as foreign protein on the arterial volume pulse of the fingers has been studied The results were reported in 1935121) There is an immediate increase in the arterial volume pulse with artificial fever produced by all methods except the foreign protein reaction in which case there is a preliminary de crease followed by an increase ·49 RECORDING OF ARTLRIAL VOLUVE PULSE FROY FINGERS AND TOES CUT PRESSURE EL PRATE mm Hg 0 IRA 1700 60 ta 20 40 60 80 AM 100 4 w 120 A. LEMPAR WAL Parte 140 61 T 160 180 90 0 60 FIG 34 Volume pulse recordings from the third finger of the right hand from a colored male age 39 who had a luetic aneurysm of the aorta with an acquired communica tion between the aortic aneurysm and the pulmonary artery 1 5 by 06 cm proven at a subsequent post mortem examination The recordings were made during compres sion of the upper arm with a blood pressure cuff at 10 mm Hg increments Note the gradual decrease of the amplitudes with obliteration of the volume pulse as the systolic blood pressure was reached and the reappearance of the volume pulse when the pressure was released ·50 THE JOIINSON RECORDING OSCILLOVETER The arterial volume pulse from the fingers can be increased by the elimination of vasoconstrictor tone with median nerve block at the wrist through the use of novocain as shown in Fig 35 In this instance the arterial volume pulse becomes greater in the first four fingers and less in the fifth apparently because the blood is shunted into the first four fingers Further studies were made on the effects of the release of vasoconstrictor fone in a patient with rheumatoid arthritis following unilateral cervical sympathectomy From this study' 5* it was found that the arterial volume pulse returned to its control level in twenty eight days following surgery FINGER VOLUME CHANGES RAYNAUD'S OISEASE BEFORE SYMPATHEC TAMY LEFT YOU, NAFTEAM DIAN NERE ROCK LEFT Nybrossa 3336 -CONTROL SKAT RIGHT ISK AT 287 Ny Tones 26.5T T-1111 287 Det 37. 334 267 267 327 3336 KLE leil 26 MERTET 267,1 131 16 $267 26-7 BP Pulse 7 FIG 35 Recordings of the volume pulse from all of the fines as well as the skin tempera tures made from a white male age 47 with Raynaud 3 symptoms before and after median nerve block at the wrist Note the markedly increased volume pulse from the first three fingers less increase in the fourth and no change in thu fifth after the median arve block (see Fig 36) Furthermore the arterial volume pulse responded to local heat after this period as did the ones of the control hand However arti ficial fever induced with foreign protein did not produce increased arterial volume pulse in the sympathectomised finger comparable to the ones seen in the control finners of the other hand Finally the patient showed no clinical improvement following the surgery ·RECORDING OF ARTERIAL VOLUME PULSE FROM FINGERS AND TOES 51 HT 3RD FINGER RT HAND DATE 12,8,31 TEMP SKIN MOUTH RATE CIFI 312 988 86 9 SYMPATHECTOMY 10 339 99 2 102 11 34 2 100 110 12 33.7 99 92 14 32.9 986 84 18 333 986 84 FIC 36 This figure illustrates the change in the arterial volume pulse in the third finger of the right hand in a white female age with rheumatoid arthritis The recordings before and after removal of the night superior cervical and first and second thoracic sympathetic gangka Note that the volume pulse returned to its control level in 28 days The arterial pulse from the fingers may bu altered by cardiac lesions (see Fig 33) This illustration indicates marked increase in the arterial volume pulse before and after the application of local heat in a patient with high grade aortic regurgitation Also us illustrated in Fig 37 the arterial volume pulse in the fingers in a patient with complete heart block shows a more than normal amplitude as a result of the increased stroke output ·52 THE JOHNSON RECORDING OSCILLOVETER of the heart which compensates for the slow heart rate It is further in creased after the application of local heat Raynaud's Symptoms In 1941' 6 a report of A Study of the Clinica! Manifestations and Results of Treatment of Twenty two Patients with Raynaud s Symptoms confirmed the opinion of Hutchinson that what is now known as Ray naud s diseases 9) is not a clinical entity and that the peripheral mant festations observed are merely symptoms of a more fundamental disease FINGER CONTROL -30MIN AFTER MEDIAN NERVE BLOCK- TUMSNESS DAWA 1 0 2 4+ ANALIhte 3 M 2009 BIP Pulse Fio 37 This figure shows the effect of median nerve block on the finger volume pulse in a patient with complete heart block Note that the control finger volume changes arc about twice normal This is interpreted as being due to the increased stroke oviput of the heart to compensate for the slow heart rate Medran nerve bli ck produced a moderate increased amplitude of the pulse wave in the middle three fingers which is interpreted as vasodilation Five of the patients included in this study had surgery of the sympathetic nervous system without relief of symptoms It was indicated in the abox report that the symptoms may be caused by 3 passive vasoconstriction in the fingers due to i vasodilitation in the paimar arch with diversion of blood from the fingers This is contrary to the generally accepted explans tion that the simptoms are due to an actise asoconstriction of the digita) arteries ·RECORDING OF ARTERIAL SOLUVE PULSE FROV FINGERS AND TOES S3 Since the above report was published seventy five additional patients with Raynaud s symptoms have been studied In ten of the latter ( 15 s the arterial volume pulse at various levels in the entire upper extremity during the digital ischemia was recorded The follow up on the original tenty two cases was carried on a lorg a possible All of the patients improved on medical management or leard FINGER VOLUME CHANGES-3rd FINGER RAYNAUD'S DISEASE Odle Room Body Tause BIP SKAT RIGHT HAND LEFT HAND- 321239 372 1282 RE を 3 23 CONTROL SYLPAPECTANY 32 245 376 78 line 32 32 245 378 7212285 327 15 330 250 324 64 93 312 ON 245372 66 198 306 339 68 410 245 372 78 42827 | 32118 FC 38 The effects of removal of the stellate and second dorsal sympathetic ganglia on the body temperature the skin temperature of the third firger of both hands the pulse and blood pressures The right side was used for a control Note that the body temperature and pulse did not change appreciably that the skin temperatures of the third finger of the left hand which was also true of the other fingers remained elevated above that of the right hand and that the finger volume putse increased somewhat immediately following the operation but in 18 days returned to their control levels A similar operation was later dae on the right side to live with their condition particularly when they wore assured that they were not going to lose their fingers The surgical cases did not do any better than the pon surgical cases One of the surgical cases stayed under observation for eighteen years and another for ten years It is of interest to note that the first case did not sweat in the sympathectomised areas for ·54 THE JOHNSON RECORDING OSCILLOVETER eighteen years after surgery None of the twenty two original cases or seventy five succeeding cases developed gangrene of the fingers other than the slight Becking of tissues on the terminal phalanges seen on rare Occasions It is of further interest to note that the increase of the arterial volume pulse following sympathectomy of the arm is only of short duration being less than thirty five days in all cases as illustrated in Figs 38 and 39 FINGER VOLUME CHANGES -3rd FINGER RAYNAUDS DISEASE -RIGHT HANO -LEFT HANO- Dale Room BodyTpulse BIP Skin Skn Tip White WY 5 26 240 37084 300 PRE GANGLION SYMPAT MECTAMY 118 612 235 371 116 337 614 245 ! 323 93 40350 352lt 617 | 215 / 300 / 86 /136/344 340 621) 235 370 78 3337 20 623 256 36.790 320 FIG 39 which the sympi The effects of the preganglionic type of sympathetic operation thetic chain was severed below the third thoracic on both sides Note that there were no changes vascular or otherwise which persisted beyond the traumatic cifects of the surgery of the additional patients only three were of unusual interest Tho were female one white and onc colored with associated lupus erythematosis In one male patient with gout the Raynauds symptoms cleared up promptly on the control of the gout Studies of the arterial volume pulse at various lutels in the arms us ne!! as in the fingers during the digital ischemia in ten patients with Raynaud s symptoms all gave consistent results nuniely the arterial solume pulse was ·RECORDING OF ARTERIAL VOLUML PULSE FROY FINGERS AND TOLS 5> RAYNAUDS SYNDROME 150mm He 80 Irma Law ve with 123mm Hg - Systolic Blood Pressure 80mm He-Diastoliload Presse ABOVE ELBOW he VI 4 Tomme MAN ALAR HAI . WY 80mm Ho -Dis tolic Blood Pressure AT WRIST www. m. Won. ve how MACHA AN WRC CONTROL FINGERS AR AFTER LOCAL HEAT F10 40 A composite study of the recorded arterial blood pressure the minute arterial volume pulses above the elbow and at the wrist and the pulse yolume changes of the fingers of the right arm is a white female age 33 during an attack of Raynauds symptoms The recorded arterial blood pressure was 123/80 the movie arterial volume pulses above the elbow 94 ml at the wrist 33 ml and in the fingers not measurable The Raynaud s svmptoms in the fingers were relieved by local heat The record shows that the arterial circulation was normal in the arm ex epf in the fingers during an attack of Reynaud symptoms ·56 THE JOHNSON RECORDING OSCILLOVETER FINGER VOLUME CHANGES BUERGERS DISEASE RICHT HAND- AFTER HEAT 45C OMN CONTROL 352 CONTROL EFT HAND NIER HEAT 45C MEY 30 2 345 uz 345 0 2345 - 5 BIP Pulse Room T 24 TOE VOLUME CHANGES-LARGE TOE BUERGER'S DISEASE CONTROL RXHT FOOTAFTER HEAT SOC FOR IOVIN SAN TELP PULSE PULSE BLP SKNT 90 1166 100 340 365 90 LEFT FOOT 90 could nol 1291 obta 3507 90 ELECTROCARDIOGRAMS 17-19 FIG 41 ·are RECORDING OF ARTERIAL VOLUNIT PULSE FROM FINGERS AND TOES 57 normal above the elbows and at the wrist during and after thu attack as illustrated in Fig 40 The details pertaining to the recording of the arterial volume pulse at the elbow and at the wrist arc included in the following chapter The significance of the above findings is obvious Surgery of the sym pathetic nervous system designed to relieve digital ischemia would have to be highly selective in order to sympathectomise the fingers only without producing a sympathectomy of the whole arm Were the latter to occur it might bring about a shunt of blood from the fingers and possible aggravation of the Raynaud s symptoms The onginal conclusions set forth in the report published in 1941 correct as borne out by the poor results of surgery as well as by the addı tional experimental findings indicated above Atherosclerosis Obliterans A number of studies were made on patients with atherosclerosis obli terans which involved the arterial circulation of the fingers No arterial volume pulse could be recorded from the fingers or toes when the oblitera tion was complete Studies of the arterial volume pulse elsewhere in the extremities give more data as will be set forth in the following chapter Buergers Disease Many cases have been referred to the author with the tentative diagnosis of Buerger s disease Only two cases were proven by autopsy to have the disease The other cases were suffering from other arterial diseases Re cordings of the arterial volume changes in the fingers and toes in one case cited above are illustrated in Fig 41 This patient is of interest pnncipally because a complete post mortem was carried out All of the arteries of the body showed the presence of the characteristic arterial lesions for the post mortem study the author is indebted to Dr Edwin Hirsch of St Lukes Hospital Chicago FIG 41 Recordings of the arterial volume pulse from the fingers and toes from a white male aged 40 who had symptoms of occlusive arterial disease in his legs of cleven years duration This case was proven to have Buergers disease at autopsy The very low amplitudes or absent volume pulse in all of the fingers aod large toes was not modi fied by local heat or by median nerve block the fingers Also normal skin tem peratures existed in the presence of proven occlusive artenal disease in both legs and arms There recordings ]lustrate the fact that occlusive arterial disease cannot be Felieved by local heat or nerve block as is the case in functional occlusive arterial disease as illustrated in Fig 40 5 ·CHAPTER VI THE RECORDING AND CALIBRATION OF THE ARTERIAL VOLUME PULSE FROM ANYWHERE IN THE EXTREMITIES, EXCEPT THE FINGERS AND TOES In Chapter III the important relationship between the arterial pressure pulse the arterial volume pulse and the arterial blood pressure was indi cated Also it was pointed out that the arterial pressure pulse and arterial volume pulse had the same origin namely the emptying of blood from the left ventricle into an already distended elastic arterial system under pressure This important relationship will become increasingly apparent in the fol lowing presentation # NM OM LA Mr DI I c UM WOONDON WMNA MAN Am NAM CS Me MI AS SOMMAR UN SAMEDOM wwww COM F1G 49 Recording of the arterial volume pulse and diastolic pressure in a one day old infant taken from the upper arm with a 6 cm cuff and t ml calibration In this case the diastolic pressure was 50 mm Hg and the minute arterial volume pulse was 163 mi The objective of the procedure described in this chapter is to record the maximal arterial volume pulse which according to Marey s principle"! is at the diastolic pressure and to calibrate the arterial volume pulse to volume per beat or per minute and to correct these figures for oi crshoot undershoot and runoll The arrangement of the instrument as used for this procedure is shown in Figs 7 and 28 The pickup mechanism (Tycos Reinforced Blood Pres sure Cuff) is applied above the elbow in the usual way Houcser one of the emerging tubes 15 plugged and is not used and the other is connected to the inflating bulb By means of a T tube a connection is made with the 58 ·RECORDING AND CALIBRATION OF ARTERIAL VOLUMC PULSE 59 transmitting device of the Oscillometer and with the calibration device (see Fig 28) As already indicated it is necessary to obtain the maximal arterial Volume puise in order to record the diastolic pressure Recordings of one or two arterial volume pulses at cuff pressures from 140 to 60 mm Hg are made at 10 mm Hg increments as shown in Fig 29 To be certain that one has the maximal arterial volume pulse calibrated recordings of the arterial volume pulse at a cuff pressure 10 mm Hg above thu estimated maximal arterial volume pulse and at a cuff pressure 10 mm Hg below the estimated maximal arterial volume pulse are made While making these recordings a 1 ml volume change is introduced into the system by depress ing the calibration device as shown in Fig 28 From the processed recording the following information is obtained the heart rate the crest time the time of the diastolic slope the amplitude of the arterial volume pulse in horizontal lines and the amplitude of 1 ml volume change in horizontal lines To convert the arterial volume pulse to milliliters the number of intervals of the arterial volume pulse is divided by the number of intervals of the 1 ml volume change which gives the uncorrected arterial volume pulse in ml This can be corrected for over shoot undershoot and runoff by consulting Fig 24 for correction factor K This is accurate within an error of 7 per cent for the volume of the arterial volume pulse for heart rates of under 125 per minute Further studies are in progress to improve this degree of accuracy Although very little work has been done on premature babies and infants d recording on an infant is shown in Fig 42 The Components of the Arterial Volume Pulse The arterial volume pulse in the arms and legs exclusive of the fingers and toes usually reveals three peaks as follows (a) The first peak The first peak is always at the crest of the arterial volume pulse when recorded at the level of the diastolic blood pressure In certain types of patients such as some with aortic regurgitation complete heart block and bundle branch block it is definitely visible on the anacrotic limb of the artenal volume pulse when recordings are made with cuff pres sures above the diastolic pressure as shown in Figs 43 and 44 In other patients the first peak may be buried in the anacrotic limb It is a consistent point of reference for determining the crest time of the arterial volume pulse which has been recorded at the diastolic blood pres The crest time is measured from the beginning of the upstroke of the artenal volume pulse to the first peak The normal limits of the arterial volume pulse in the adult cover a very wide range depending on set individual differences degree of physical sure

·60
THL JOHNSON RECORDING OSCILLOULTER
LUETIC AORTIC REGURGITATION
CM AGE 49 BL P 160/50
2005
AD
VA
AND
CA
180
Stream
CUFF PRESSURE MM HO
100
140
80
FIG 43
Recordings of the arterial volume pulse made from above the right clbow if a
colored male aged 49 with luetic aortic regurgitation and blood pressure of 160,50
The recordings illustrate studies on the genesis of the three peaks of the arterial
volume pulse Each record was taken with different pressures in the pickup curl The
first peak is on the ascending limb until the diastolic pressure is reached at which
pornt it is at the crest of the pulse wave This phenomena has been observed mainly
in patients with aortic regurgitation and with bundle branch block as illustrated in
Fig 44

·RECORDING AND CALIBRATION OF ARTERIAL VOLUME PULSE
61
BUNDLE BRANCH BLOCK
WM AGE 67 BL P 172/98
200
120
IBO
பெயர் பட்டம் -னார்
CUFF PRESSURE MM HG
100%
160
140
MO
hem
60
FIG 44
Recordings made from above the right elbow in a white male aged 67 with bundle
branch block and a blood pressure of 172/98 The position of the first peak is on
the ascending limb untu the diastolic pressure is reached as in the case illustrated in
Fig 43

·62 THE JOHNSON RECORDING OSCILLONCIER fitness and somewhat on age and body build There are probably a great many other factors The approximate range is listed below Location Rance Above the elbow 100-250 ml/min At the wrist 40-125 ml/min Above the knee 125-250 ml/min Below the knee 100-225 ml/min At the ankle 40-125 ml/min The range is given in milliliters per minute because there seems to be a reciprocal effect between the beat volume and heart rate (b) The second peak The second peal may be at the crest of the arterial volume puise when recordings are made above the diastolic blood pressure It may be at the crest following the first peak by 0 08 sec when the record ings of the arterial volume pulse are made at the diastolic blood pressure It may be on the dicrotic limb when recordings of the arterial volume pulsc are made at or below the diastolic blood pressure as shown in Figs 43 and 44 Www ARTERIAL CIRCULATION 3 2711(100) (122) - 35 4 ml per minute CREST TIME 2 seconds FIG 45 Recordings of the arterial volunk pulse made above the right elbow from a colored male age 62 with a high grade calcific aortic stenosis Tour days after the recording was made this diagnosis was onfirmed at autopsy The aortic valve at that time Hould only admit the head of a match Note the reduced arterial olume pulse As well as the prolonged crest time the recorded diastolic pressure was 90 mm Hs (c) The flurd peak The third peak is called the diastolic peak and is preceded by the diastolic potch It is present on the dicrotic limb of the arterial solum pulst It also OLLUT when recordings of the volume pulses are made froni cıperimental models of the arterial circulation as shown in It is appurently due to a reflected wale It would seem that one of the most important readings obtained from the recordings of the arterial volume puise is a quantitative estimation of the crest time or time of rise of the arterial Yolunc pulse if this quantita live estimation is prolonged beyond 0 16 sec it usually means artonal Fig 23 ·RECORDING AND CALIBRATION OF ARTFRIAL VOLUME PULSI 63 5 ALLOC 04 BEFORE SURGERY ABOVE ELBOW ABOVE KNEE 5 DAYS AFTER SURGERY ABOVE ELBOW ALOVE KNEE 2220 inssi (1) 3112231 CLEFFES REM HG 0022001 QOWEGO E00000 RM 1 55111 ) ** 20/4 K RO/ 199 M 20/0 FIG 46 A composite study taken from a seventeen ycar old white male who had a proved coarctation of the aorta Preoperative studies indicated the hypertension in both arms and an inability to obtain an auscultatory blood pressure in the legs The recordings from the arms are what one would expect in hypertensiv heart discase but the ampli tude in the left arm was somewhat greater than in the right duc to annomical differencer observed at operation The recordings from the legs indicated that the blood pressure was at least 140 mm Hg or more despite the fact that the auscultatory blood pressure could not be obtained This was partially verified at operation by palpating the disent aorta Also the recordings note a long crest time in the legs of approximately 0 scconds as compared with a normal of 0-12 The amplitudes were also less than normal in a resection of the aorta done by Doctor John Reynolds the chest wng open for five hours The specimen is shown Recordings were taken during the entire surgical procedure as well as at regular intersals following the operation i he secured ings taken five days after the surgery from the arms were approxtmately what one would expect in hypertensive heart disease while those in the legs had returned to a normal type of curic Furthermore the peripheral arteries in the Icus cu ull he rol pated and the auscultatory blood pressure was found to be 200/130 in the risht lex and 190/1.0 in the left 1 g pathology proumal to the site of recording or aorhic sienosis The will be illustrated by studies of aortic stenosis courctation of the torti usymetri cal blood pressure and atherosclerosis obliterans When the crest time is longer than 0 16 seconds the Korotkov sounds for dctermunin arterial blood pressure by the auscultatory method may not be in the norm il ringe of hearing and tactile discrimination is usually not suflicient to pulpite the w ·64 THIC JOHNSON RLCORDING OSCILLOMITIR arterial pulse although it can be demonstrated to be present by the use of the Oscillometer High Grade Aortic Stenosis A recording of the arterial volume pulse in a case of high gradu aortic stenosis is presented in Fig 45 and illustrates the prolonged crest time of 02 sec and the very low amplitude of the arterial volume pulse A post mortem one week after the recording was made revealed a calcific aortic stenosis with an opening in the aortic valve which would just admit the head of a match PRECHERATIVE ABOVE OG TELIJK 00 LUITIN YO ITO My Blood Pres M stok de Dom Me Now Snad ww OMA Awwww (304 AADY RC TONE ArteV ru ML 1 Mon Diedrasi Dunod Ma Lond Dosta Kod Now - A Relate FIG 47 These recordings of the arterial blood pressure and the arterial volume pulse of the night and left arms and legs were made from a white male age 23 with coarctation and hypoplasia of the aorta Note the high blood pressures in the arms as compared with the legs Also note the very short crest times of thc pulse wave in the arms as compared with the prolonged crest times in the legs The artertal volume pulse in the legs was below the normal values The dorsals pedis and posterior trbral arteries were not palpable Carclation of the forta A recording of the arterial volume pulse in a cuse of coarctation of the aorta is presented in Fig 46 The figure shows the recordings of the artenal volume pulse talen above the elbou and above the knees before and after surgery These recordings were made before the method of calı ·RICORDING AND CALIBRATIDY OF ARTERIAL VOLUVE PULSC 65 bration of arterial volume pulse was developed and unfortunately were not calibrated Hoseier they do illustrate the pomts in question namely blood pressures could not be obtained in the legs by the auscultator method and the pulses could not be paipated After surgery the blood pressures could be obtained by the auscultatory method in the legs and the peripheral volunte pulses could be palpated The crest times of the arterial volume puise in the legs was 0 24 sec before surgery and 0 16 sec after Surgery ECHT DAYS POS OPERATIVE MAKU ACM TU IM Why we had Hy Sy the An 130 H Deslor Bid At Tor Bad A Oku ABOVE RICHTE Aut wat 10 79 *Box Print 0w the yout Ar Dom My Doo New A Ni Per t VW FIG 48 The above recordings are similar to those illustrated in Fig 47 sepeated erkht days following corrective subacry for coarctation of the sorta Note from the recordings from th kes the in reased blood pressure increased arenal volume pulae and 17e decreased crest time The dorsalis pedis and posterior tibiat arteries of both legs became palpable the results are not as striking as those from the patient illustrated La Fig 46 probadly because of the associated hypoplasia of the aorta The treatment of coarctation of the aorta by surgery is not always so Successful soce the patient may also kave x hypoplast of the abdomusal aorta in which the surgical result may not be as effective Figs 47 and 48 illustrate such a case in a twenty three year old white male The protonged crest times in the arenal volume pulse from the legs both before and after surgery are apparent Age and senous hean discuse have been contra indications for the surgi cal correction of courctation of the aorta but the results of artenal volume ·06 THE JOUINSOY RECORDING OSCILLOVCTER pulse studies before and after surgery on a patient with both an auricular fibrillation and coarctation of the aorta are given below Since the patient had an auricular fibrillation the results are a rough approximation The patient was a white female aged fifty two BEFORE SURGERY Recorded Crest Arterial volume blood pressure time puisce per minute Above right elbow 145/90 01? 73 ml Above left elbow 155/90 012 73 ml Above right knee 111/80 06 9 ml Above left knee 104/80 076 23 m! Above right elbow Above left elbow Above right knec Above left knee AFIER SURGERY 5 days post operative 138/80 010 139/90 010 173/100 012 88/10 01. 103 m! 83 ml 80 ml 92 m! ASYMMETRICAL BLOOD PRESSURE IN THE ARMS PATIENT Mite Battage S STAMPSONS Home FADINCS Blood pressure higher in the night are the in the left light em longer than AIO ARGELOW ALOVE LEST LLBOW 200 PRONTMAL CUFF PRESS RE 140 1PROLIMA NI PRESSURE INO An MAN MASYTOUC AP PASTOUC 6009 niss MOOR tant SITUKA DIASTOUC LLOOD PRESAH ACRA VONTA hoog Are Wwwportet Wote the prolonged crest time and Sandler anouat of arterial oculmon the left arm FIC 49 Recordings made from above the clbow in a while male aged 55 with a marked duference in blood pressure in the two arms The blood pressure in the night arm was 174/110 and in the Icft 118/110 Note the markedly increased amount of blood going to the right arm as compared with the left Also the crest time is increased in the left arm suggesting some degree of arterial occlusion to this arm Also the right biceps measured 31 cm 10 circumference while the left measured 27 $ The most likely diagnosis is that of a congenital defect in the Icft subclavian artery Following surgery the peripheral arteries in the legs were casily pulpable and showed a normal crest time this recording again illustrates the et treme importance of the crest time in indicating occlusne arterial disease proximal to the site of recording In eight other unoperated children and young adults with coarctation of the porta auscultatory blood pressures could not be obtained in the legs ·RECORDING AND CALIBRATION OT ARTERIAL VOLUWE PULSE 67 the peripheral arteries in the legs could not be palpated and the average crest time in these eight cases *$ 026 sec as compared to a normal range of 08-0 16 sec Asymmetrical Ekod Pressure The recordings presented ia Fig 19 were taken from a patient who had asymmetrical blood pressure between the two arms probably due to a con genital defect in the left subclavsan artery The recordings show the marked difference in blood pressures and the prolonged crest times in the left arm indicating some arterial occlusion Cardiac Conditions Many of the cardiac arsythmias are reflected in the recordings of the arterial volune pisise Although tive Johnson Recording Oscillometer has Ils place in the study of the effects of these arrythmas on the circulation it does not replace the electrocardiographs since the one measures the electrical component of cardiac activity and the other the mechesxal component Each instrument has its place s1 the study of the cardiovascular system Atherosclerosis Obiterans The frequency with which atherosclerosis obliterans occurs and the marked disability which it produces particularly when the antenes supply ing the legs are involved makes this condiloa of special interest Observa tions in the treatment of patients with this condition are presented in the following chapter One illustration showing occiusive anerull disease from this condition in one leg is presented in this chapter The sinking difference between the diseased and the normal leg is apparent The purient was 4 5ity three year old white mal with symptoms first of pains in the right hip on walking and later of intermittent claudication in the right leg x rays showed calcium deposits in the abdominal aorta extending into the conmont sac arteries Recordings of the arteras! blood pressure and Arterial volume pulse in both legs above the knee below the knee and at the ankles are illustrated in Fig 50 The points of interest in this case are as follows (3) visualization of arterial calcrum deposits by X ray does not necessarily mean occlusive arterial disease (2) the recorded blood pres sures were 102/70 in the night leg and 366/110 in the left leg (3) the crest tip of the artenal volume pulse in the night leg w35 28 sec and in the left leg 016 sec (4) the arterial volume pulse per minute in the right leg above the knee was 42 m) per minute and in the left leg 258 ml per minute and (5) the dorsalss pedis and posterior tibial arteries were not palpable in the right leg and were palpable in the left leg ·68 THE JOHNSOV RECORDING OSCILLOVETER R GHT LEG LEET LET 94 13 Me Sy k fayre *nt $b Mew Pre BEL ul خيالي FIG SO The upper section shows recordings of the systolic blood pressure in the legs Vote the hypotension in the right les associated with occlu ive arterial discase The lower recordings were taken at the drastolic pressure above the knee below the ance and at the ankle Corrected Arier al clume P. Ise Fipressed in multilaters RIGHT LEC Dastolic Heart Cresi pressure rats tim A Omm Hg 75 0_8 13? 60 75 0.8 60 75 08 1 32 Above knce Below knee At ankle Pulsevol change 40 60) 177 LEFT LEG Above knet STO 73 016 09 580 Below knee 100 75 016 09 1680 At ankle 100 75 0-16 09 8 S The difference betweer the legs is very apparent The prolonged crest times and the decreased minute arterial volume rules distal to occlusive arterial disease are characteristic These changes are present to an esco greater degree in the three other cases reported This patient was chosen for illustration since he had a normal leg to compare with one with acclusine arterial disease ·CHAPTER VII TREATMENT OF ATHEROSCLEROSIS OBLITERANS WITH MASSAGE muscle anoxia INTERMITTENT chudication and rest pains or distress due to o lus ve artenal disease are now increasingly prevalent as a cause of varying d grees of disability The principal reason for this is probably extended lon evity but the tensions of modern living may also contabule important factors Although there are a number of conditions which lead to occlusive arterial disease of the legs with symptoms of intermittent claudication and rest pains the most common cause is arteriosclerosis which includes arterio sclerosis medalis and atherosclerosis obliterans The physiological mechanism which produces the pains of intermitt nt claudication is not well understood but it is generally believed to be due to ischemia of the involved muscles The cause of the rest pains is even less well understood as these occur in the absence of contracting muscles The current theory 13 that the pain of intermittent claudication is related to metabolic by product of contracting muscle P Factor associated with The work of Lewis(30) a tert book review by Best and Taylor and a review by Wesseler ) summarizes the knowledge to date on the subject There are many treatments which have been recommended for this con dition However the following statement is presented in Wesseler s review There is today no effective measure for the treatment of intermittent claudication that has gained wide acceptance Among the drugs investigated Wesseler lists calcium vitamin E theobromine methyl testosterone depropaner cytochrome Cintravenous hypertonic saline solution thiourcil histamine and various sympatholytic agents In addı tion to the above Allen Barker and Hines(33) list thyroid extract and estrogens Among the aids in physical medicine Wesseler lists intermittent venous occlusion pavex and Buerger s exercises The surgical procedures are too numerous to list Tobacco has been suspected and its discontinu ance is thought to exert a favorable influence The author has made ex tensive studies of the arterial blood pressure and the arterial volume pulse before and after the use of tobacco However the results are not yet con clusive because of the complex nature of the problem It is obvious that co existing diseases such as polycy themia vera diabetes mellitus and the cologen diseases should be brought under control 69 of the subject ·70 THE JOLINSON RECORDING OSCILLOVETER One hesitates to add to so formidable a list of treatments for intermittent claudication and rest pains Moreover discussion of treatments is not the primary purpose of this chapter which is rather intended to present objec tive and subjective data resulting from an experimental study on the use of massage in the treatment of this condition The objective duta was obtained by controlled serial oscillometric studies and the subjective data by the clinical evaluation of the results of treatment In the past oscillometry had limited usefulness because of the lack of pre cision in existing oscillometers as well as the lack of proper calibration of the recordings With the Johnson Recording Oscillometer it is now pos sible to make comparative studies on patients over long periods of time painlessly and without arterial puncture Methods of Study The patients were non diabetic males with obliterating types of arterio sclerosis All had been under treatment and observation for three or more years The clinical details are given in the case studies which follow All of the recordings were made with the patient in the reclining position Patients were required to take a 15 min rest penod before euch recording This rest period was originally thought to be adequate but was later revised The arterial blood pressure was recorded in all four extremities by the method outlined in Chapter IV The calibrated arterial volume pulse was recorded in all four extremities at various levels by the method outlined in Chapter VI From these recordings as well as from other clinical and laboratory observations the degree and location of the arterial occlusions were determined In order to ascertain the immediate effect of massage d control record of the calibrated arterial volume pulse at both ankles was made before treatment was initiated Massage was given for 1 hr to one leg by means of a hand massager weighing 21 lb and oscillating at 60 c/s in a circular motion over a diameter of 4 mm Immediately after the massage the call brated arterial volume pulse was again recorded at the ankles for compari son with the controls Each patient was instructed to buy a hand massager and was trained to g1sc his own massage for 1 hr by the clock duly for each leg or legs affected the patient returned once a month for follow up studies The effects of the pain of intermittent claudication on the corrected minute arterial solume pulses was determined by first making a control recording at both ankles The patient was then told to walk rapidly until he had the pain of intermittent claudication and to return immediately for ·TRCATMENT OF ATITROSCLEROSIS OBLITERANS WITH MASSAGT 71 further recordings which were made during the pain and after a ten and twenty minute rest period In addition to the objective studies noted above the clinical condition of the patient was evaluated from such subjective factors as the disappear ance of rest pains and increased walking tolerance The results of these studies are presented in separate case histories for cach patient and are followed by a general discussion Case Histories CASE I Mr B white male age surly three first complained of pain in the hip on walking in December 1953 Since 2 December 1954 after walk ing ooc block he developed a pain in the right calf which was relieved by resting for 1 min A general physical etamination was negative except for the right leg The recorded arterial blood pressures in the arms were normal The recorded arterial blood pressure in the right leg was low at 102/70 and in the left leg normal at 166/110 The arterial pulse was normally palpable in the arms and left leg while the femoral popliteal dorsales pedis and posterior ubual artery in the right leg could not be palpated The laboratory studies were within the normal range except for an ray of the abdominal aorta which revealed calcsam deposits ex tending into both common sliac arteries Recordings of the arterul blood pressure and artenal volume pulse at various lesels in the legs are illustra ted in F12 50 The minute artersal volume pulses were corrected for errors of overshoot undershoot and runoff with K obtained from Fig 24 An examination of Fig 50 reveals that the crest fimes at all levels from the right leg were prolonged to 0 28 sec while the crest times as all levels from the left leg were normal at 0 16 sec Also the corrected minute urterial volume pulses were markedly decreased being 42 ml above the knee 26 m below the knee and 177 ml at ibe ankle Os she left leg they were 258 mi above the knee 168 ml below the knee and 825 mi at the ankle In the left leg these are within the normal range The immediate effects of massage on the corrected munute acterial volume pulses were studied at the ankles by making control recordings The nght leg was massaged for one half hour A second set of recordings were made which showed no significant change over the control recordings The immediate and later effects of the pain of intermittent claudication were studied by making control recordings of the corrected minute arterial Yolume pulses at both ankles The patient was then required to walk briskly until pain developed and to return for a further recording which was made during the pain The recordings were repeated after a ten and fuenty minute rest The gastrocnemius muscle was flacid dunng the pain as has been obsersed by others These recordings are dlustrated in Fig 51 ·72 THIC JOHNSON RECORDING OSCILLOMCTER RIGHT ANYLE LEFT ANKLE CDL PN kx www WW AFTER V OF N M ATAL RET M TIK 20 BLU w FIO 51 This figure illustrates the effects of the pain of intermittent claudication on the cor rected minute arterial volume pulses and the effects of 10 and 0 min rest after the pain Corrected Imute Irterial Polume Pulses Expressed as ml RIGHT ANKLE Diastolic Heart pressure rate 60 mm Hg 75 Not measurable 60 75 80 75 Crest fume 0.8 Control During pain After 10 min rest After 20 min rest 139 Pulse vol change 17 9 ml 00 342 473 028 0 28 1 32 1 32 Control No pain After 10 min rest After 0 min test 90 90 90 100 LEFT ANKLE 75 75 75 75 016 016 016 0-16 092 092 09 092 920 712 632 712 Note the complete absence of a measurable volume pulse during the pain of intermittent claudication Also the reactive hyperemia following a 10 and 0 min rest period after the pain ·TREATMENT OF ATHEROSCLEROSIS OBLITERANS WITH MASSAGE 73 This illustration shows that no arterial volume pulse was present during the pain but following a rest of 20 min the minute arterial volume pulses increased approximately 250 per cent The patient was instructed to massage his right leg for one half hour by the clock once a day and to return for study once a month which he did faithfully The corrected minute arterial volume pulses recorded at the ankles were at first somewhat variable since the patient did not make any effort to walk slowly while coming to the office After the profound effect of the puin of intermittent claudication was discovered the patient was instructed to get to the office with at little effort as possible in the course of the year on this management the corrected minute arterial volume pulses approximately doubled The patient could then walk at a moderate rate indefinitely with out pain while previous to this form of therapy walking one block brought on pain This case report illustrates (1) a relative hypotension in the right leg prolonged crest time of the arterial volume pulse decreased corrected minute arterial volume pulses and dorsalis pedis and posterior tibial arteries not palpable (2) a normal blood pressure in the left leg normal crest time of the arterial volume pulse normal corrected minute arterial volume pulses and palpable dorsalis pedis and posterior tibial arteries (3) no immediate effects of message on the corrected minute arterial volume pulses (4) absent arterial volume pulse during the pain of intermittent claudication with an eraggerated response ten and twenty minutes after the pain (5) the cor rected minute arterial volume pulses in tho right leg improved by over one hundred per cent in the course of a year's treatment and (6) a marked im provement of walking tolerance during the course of a year s treatment with massage CASE 2 Mr S a white male aged fifty five first came under observation on 30 October 1954 with symptoms of intermittent claudication of 2 years duration After walking about one half block the patient developed calf paios in both legs but worse in the left leg These pains disappeared after resting about 1 mn and he could then walk another one half block The general physical examination was negative except with reference to the legs. The recorded arterial blood pressure was 126/80 in the right arm 125/80 in the left arm 101/60 in the right leg and 78/60 in the left leg The arterial volume pulse in the arms was normally palpable and in the legs both femoral arteries were palpable while the dorsalis pedis und posterior tibial arteries could not be palpated in either leg An X ray of the abdominal aorta showed calcium plaques while X rays of both legs showed no evidence of calcium deposits in the course of the large arteries Recordings of the corrected minute arterial volume pulses at various levels 6 ·74 THE JOHNSON RECORDING OSCILLOVCTER in both legs showed prolonged crest times and low minute arterial volume pulses indicating Occlusive arterial disease in both legs well above the knec The immediate elfects of massage as well as the effects of the pain of inter mittent claudication were the same as in Case 1 The patient was trained to massage his legs with a portable massager and was told to massage each leg 1 hr daily by the clock and to return once a month for observation Objectively the patient did not improve as much as other patients as the corrected minute arterial volume pulses increased only about fifty per cent over the initial studies This is attributed to the fact that the patient could not take his massage as consistently as the other patients Subjectively he was markedly improved to the point where he could walk slowly for about a mile without pain The same comment applies to this patient us to Case 1 ercept that he had occlusive arterial disease in both legs and that he did not show the marked objective improvement CASE 3 Mr S white male uged sixty eight was first seen on 28 September 1954 with the following complaints (1) he had cramps in the left calf muscle at might lasting as long as 15 min during which time hu sat up in bed and hung his leg in the dependent position and rubbed the calf muscle to obtain relief Sometimes this gave him relief and sometimes it did not The following day the calf muscle was sorc These symptoms had occurred two or three times a night for 14-2 years (2) he developed pain on walking short distances (3) he had a scaly rush which involved the hands and forearms the left foot and foreleg and the face which had been present since 1947 The application of ointments und about twenty X ray treatments brought no relief (4) the right leg was amputated above the knee with a painful stump The past history revealed the amputation of the right leg above the knew on 26 Januury 1951 for occlusive arterial disease and gangrene of the large toe and foot The uncalibrated recordings of the arterial volume pulse made at that time revealed severe occlusive arterial disease There was total absence of pulsations in the right leg The pathological report inde cated that the lining of the popliteal artery showed marked fatty and fibrous changes as well as atheromatous plaques The posterior tibial artery was occluded for 3 or 4 cm and patent beyond this The anterior tibial artery The was completely occluded by confluent yellow atheromatous plaques femoral vein showed no changes The Gullian Barre syndrome was present in February 1948 with temporary paralysis of the arms trunk and legs The essential findings of physical etamination were as follows (1) amputated right leg above the Ance (2) a scaly rash involving the hand forearms the left foot and foreleg and the face (3) left radial ulnar ·TREATMENT or ATHEROSCLEROSIS ORLITERANS WITH MASSAGI 75 dorsalis pedis and posterior tibial arteries were not palpable Both femoral artenes were easily pulpable The recorded arterial blood pressure was as follows night arm 128/70 left arm 78/70 and left leg 107/80 The laboratory studies were negative except for a moderate hypo.hromic anemia *The corrected minute arterial volume pulses in the arms and legs are as follows CREST TIME Right 0 14 sec OIS Left 0.4 sec CORRECTED MINUTE ARTERIAL VOLUME PULSES Right Left 155 mi 106 ml 53 ml 38 ml 84 ml 22 ml 1 ml Above elbow Al wrist Above Knee Below knee At ankle 04 0 4 0.4 0 24 One notes the prolonged crest times and reduced corrected minute arterial volume pulses in the left arm and leg indicating occlusive arterial disease in the left arm and leg The following dragnoses were made (1) occlusive arterial disease of the left arm originating above the elbow (2) occlusive arterial disease of the left let onginating above the knee (3) amputation of the right leg above the knee and (4) dermatitis of the hands and forearms the left foot and foreleg and face secondary to a chronic nutritional deficiency and (5) a moderate hypochromic anemia After a half hour massage to the left leg with a portable massager the corrected minute arterial volume pulses were studied No immediate effect of massage was apparent as occurred in Cuse 1 and Case 2 The patient was trained to give his own massage to the left leg with a portable massager 1 hr daily by the clock He returned once a month for observation Also he was given one ampule of Solu B with 1 ml of 2018 liver extract intra muscularly every other day The corrected arterial volume pulse was determined at the left ankle once a month After a year the corrected minute arterial volume pulses improved from 12 to 20 ml per minute Subjectively the jerking symp toms disappeared in about 2 weeks the rest pains disappeared gradually over the course of 2 months the dermatitis completely disappeared in six months and the walking tolerance improved to the extent that the patient could walk as far as he wished without pain It must be remem bered that the patient wore a prosthesis on his right leg which presented his walking very fast ·76 THE JOHNSON RECORDING OSCILLOYETER The patient had been under treatment for a year before it was decided to study the effects of intermittent claudication pain on the arterial volume pulse but pain could not be produced by having the patient walk for fifteen minutes The results of this study are as follows LEFT ANALE Corrected minute Arterial volume pulses 176 ml Crest time 0 24 sec 0 24 sec 0 24 sec Control After walking After ten minute rest 14.ml 18 5 ml These figures are somewhat misleading since there was a marked decrease in the artenal volume pulse which was in part compensated for by the in creased heart rate Note This patient died suddenly of heart failure in November 1956 The same comments hold for this case as for Case I In addition this is a proven case of atherosclerosis obliterans Also the improvement in the nutritional status may have had some bearing on the improvement in his walking tolerance CASE 4 Mr T a white male aged seventy seven was first secn in April 1953 with symptoms of intense tingling in both legs ubich to him were indescribable and which occurred at night and were so severe that he could not sleep He obtained some relief from sitting up in bed with his legs horizontal This distress had been present for 2 years and was more severe in the left foot than in the night He also complained of intermittent claudication of 12 years duration and when first seen could not walk more than one half block without resting The latter symptoms were more severe in the left leg than in the right He also complained of a cold sens. tion in his feet and the feet felt cold to the touch The general physical examination was essentially negative except for the legs The recorded arterial blood pressure was 150/90 in the right arm and 160/90 in the left while in the right ley it was 112/90 and 115/90 in the left The radial and ulnar arteries in both arms and femoral arteries in both legs ucre normally palpable while the dorsalis pedis and posterior tibial artenes could not be palpated 19 either lug Laboratory studies were in the normal range including Y rays of the abdominal aorta and large arteries of the legs There were no visiblc cal cium deposits The recorded minute arterial volume pulses were within the normal range in the arms The legs at various levels showed marked impairment indicating occlusive arterial discase above the knee in both legs Studies of the corrected minute arterial volume pulses recorded at the anhles showed no significant difference before and immediately after one ·TREATMENT OF ATHEROSCLEROSIS OBLITERANS WITH MASSAGE half hour massage with a portable hand massager The patient was in structed to massage his legs with a portable hand massager hr duly per leg He preferred to have a masseur massage his legs three times a week with the conventional method and to use the hand massager as instructed on the other days Recordings of the corrected musule arterial solune pulses were made once a month for over 4 years and these figures were about three times the original controls The effects of the push of inter mittent claudication on the corrected minute arterial volume pulses were studied in a similar manner to those of Cases 1 and 2 and with similar results After two years of treatment with massage the recorded minute artenal volume pulses taken at the ankles were approximately two and one half times greater than the original control studies It 15 of interest to note that the crest times were 0 24 sec in the night leg and 0 32 sec in the left Symptomatically the rest pasas disappeared in about one month and walking tolerance increased from one half block to eight blocks without pain in 1 year The comments are essentially the same as those cited for Case 1 except that this patient had more pathology in both legs and the improvement was more striking Comments and Conclusions The accuracy of the Johnson Recording Oscillometer for recording the artersal volume pulse was evaluated in Chapter Vi Under the conditions of these studies it was found to be accurate within 7 per cent in the patients included in this phase of the study the improvements in the re corded volume pulse ranged from 200 to 300 per cent Therefore the error is insigmficant by comparison The lag of the instrument has been found by experiment to be approximately 0 004 sec which is insignificant and non measurable as the instrument is used Clinically the amplitude and form of the pulse wave are important for several reasons The amplitude is important for the arterial volume pulse can be calibrated accurately to 002 ml in volume change which can be corrected for overshoot undershoot and runoff and the value expressed in ml per beat or per minute By this means the adequacy of the arteria! circulation at a particular site in the body can be estimated and compared with future studies The form is important because it is related to crest time which can be determined with precision If it is prolonged beyond 0-16 sec se usually means occlusive anterial disease proximal to the site of recording or high grade aonic stenosis Detailed reports on four patients with oclusive arterial dsscase were presented All showed a decreuse in the umpluude of the arterial volume pulse as well as a change in form with prolonged crest umes from the ·THE JOHNSON RECORDING OSCILLOMETER in weight portable sturdy and has a frequency of 60 c/s in a circular 78 affected extremities On repeated examinations the results remained fairly constant within the limits of physiological variations The value of massage in the presence of severe arterial occlusions has occasionally been questioned on the grounds that it raises the metaboliu requirements of the tissues and might therefore be harmful to the patient in the more than twenty patients included in this study no harmful effects were apparent On the contrary varying degrees of subjective and objective improvement were noted No beneficial effects could be measured objectively after a single massage treatment although all patients reported subjective improvement Repeated massage brought relief of rest pains or distress in about 1 month associa ted with increased arterial volume pulse Further treatment led to increased walking tolerance without pain as well as a doubling in the arterial volume pulse in a year and a tripling of arterial volume pulse in a year and a half Some inconsistencies in the recordings in early studies are thought to be due to inadequate control rest periods It was found later in the study that the pain of intermittent claudication had a profound effect on the arterial volume pulse During the pain no pulse could be measured which means that it was less than 002 ml while after a rest of 10 and 20 min there was a tremendous increase over the control level The explanation for this improvement is not clear It may be due to the opening up of preformed collaterals which are known anatomically to exist It does suggest that walking is beneficial to the patient The cause for the progressive and marked improvement in these patients is not known At first it was believed to be due to the development of new collateral circulation rather than to the release of spasm in pre existing collaterals The marked improvement in the recorded arterial volume pulse shortly after the pain of intermittent claudication indicates the existence of preformed collateral circulation which is very important the release of spasm in these vessels is a major factor although new collaterals may slowly be developed It has been noted by other investigators that on occasion there is some spontaneous improvement in patients with intermittent claudication and rest pains This was not the case in the patients reported herein as in all cases the condition was of long standing and of a progressite nature 02 patient Mr J S had already had one lg amputated because of inadequate circulation Very little is known concerning the relative merits of various eypes of massage In this study a method was chosen which is applicable to the home treatment of ambulatory patients The instrument selected was L. He motion over a 4 mm circle Possibly a comparative study of instruments ·TREATMENT OF ATIEROSCLEROSIS OBLITLRANS WITH MASS4UL 79 may reveal one which is superior The length of time of massage was also arbitrarily chosen as 1 hr per leg per day With increased longevity atherosclerosis obliterans of the extremities will become one of our major problems This condition causes a great deal of suffering on the part of the patient considerable disability and even loss of limbs For these reasons most patients are willing to make the sacrifice in time and effort faithfully to carry out the prolonged treat ment and to return for periodic checkups especially since all patients obtained a large measure of relief even though subjective and objective improvement was slow ·CHAPTER VIII THE ARTERIAL VOLUME PULSE FROM THE HUMAN BRAIN The data on the arterial volume pulse of the human brain is of purely Academic interest and is presented solely as introduction to the discussion of the arterial volume pulse of the intraorbital tissues with which it is intimately related The study of the brain was made principally on a patient with a brain tumor which was surgically removed through a trephine hole in the skull from which the arterial volume pulse could be recorded In reference to the dynamics of the arterial circulation of the brain in 1783 Monro " formulated the theory that since the cranium of the adult RIGHT ARM ASOV BROR BL 149/100 CVER LEFT TEMPORAL TRIARIVE MOLE 10 www.D WW USB In FIC S. Recordings of the arterial volume puise from a patient who had had a brain tumor removed about one year before the records were taken Note in the skull picture the large trephine hole The series of recordings on the left were obtained from the right arms above the elbow the blood pressure was 140/100 The series of recordings taken over the trephine hole indicates that it look more than 00 mm Hg to neutralize the pulsatile arterial changes from the brain The entirely different character of the pulse wave may indicate that the brain has some cushioning effect upon the arterial pulse volume is a rigid indistensable box completely filled with incompressible contents the quantity of blood contained within cannot change appreciably This work was supported by studies of Kellie's in 1824 and is known as the Monro-Kellie doctrine The latter study noted that changes in the volume of any one of the three major components of the cranial cavity were com pensated for by changes in the other two The Monro-Kellte doctrine is not applicable to the cranium possessing defects such as trephine holes or in infants with open fontonelles The results of this study on a patient with a trephine hole are presented 80 ·ARTLRIAL VOLUMI PULSL FROM TAIL HUVAN BRUIN 81 because they do shed some light on the possible compensatory mechanism in the altered artenal circulation when a cranial defect exists In the adult when the pulsations over the trephine hole are of consider able magnitude the recordings are made from a 6 cm cuff wrapped around the head over the trephine hole The cult is connected to the Osullometer in the usual manner in an infant or child with open fontonelles the wap sule described for use on the intraorbital tissues serves more eflectively The diastolic blood pressure can be determined as outlined in Chapter IV and calibrated recordings of the arterial volume pulse can then be made as outlined in Chapter VI Comparative studies of the arterial volume pulse over the trephine hole and in the right arm show an entirely different contour as illustrated in Fjo 52 The diastolic pressure within the brain and in the right arm were the same at 100 mm Hg An extra systole was recorded both from the brain and from the right arm with a change in the base line The results of this study show only the character of the arterial volume pulse in the presence of a defective cranium which allows for an increased amount of blood to enter the cranial cavity with each heart beat If the Monro-Kellie doctrine is correct in the intact cranium one would expect the arterial pulse to be only longitudinal and not mainly transverse as seen elsewhere in the body for example in the arms and legs Vasodilitation would not be possible unless one of the intracranial components decreased in volume and conversely vasoconstriction could not take place unless the volume of one or both of the intracranial components became greater in volume However as will be shown in Chapter IX The Arterial Volume Pulse of the Intraorbital Tissues greater or smaller quantities of blood can How through the brain with changes in the longitudinal volume puise At present the nature of the arterial volume pulse wave as recorded from a patient with a trephine hole in the skull or in infants before the fon tonelles are closed is only of academic interest However it may be that a better understanding of the circulatory readjustments of the brain follow ing trepluging of the adult skull may lead to procedures decreasing the surgical risk to the patient Furthermore a knowledge of the changes in the circulatory system of the brain which occur between infancy and adult hood may also lead to an improved understanding of the developmental defects of the central nervous system Suggested methods of study will be indicated in the following chapter In taking the arterial volume pulse over a trephine hole there is some element of danger In the case reported the recordings shown here taken without mishap About 2 months later an attempt to repeat the study was made and the patient went into a coma but recovered on release of the pressure ·CHAPTER IX THE ARTERIAL VOLUME PULSE FROM THE INTRAORBITAL TISSUES The intraorbital tissues of the human being have only one arterial blood supply which is from the ophthalmic division of the internal carotid artery'361 Furthermore under normal conditions there is considerable evidence which indicates that functionally at least there is no communication between the two sides by way of the Circle of Willisi! However by special methods in cerebral angiography the radiopaque material can be made to pass to the contra lateral side by way of the Circle of Willis For this reason the human eye is thought to be an ideal site for recordings of a reflection of the cerebral circulation Although this may be in part true for the record ing of minute arterial volume pulses it is not truo for the dynamics of the cerebral circulation because the intraorbital cavity is not a closed cavily and the Monro-kellie doctrine as cited in the preceding chapter dous not apply All of the evidenco indicates that the arterial volume pulse of the intraorbital tissue is mainly transverse in nature and similar to that seen elsewhere in the body with the erception of the adult intracranial cavity where because the tissues are not compressible it is mainly longitudinal in nature (see Chapter VIII) As will be shown later this is not always the case and it is possible that this may be a contributing factor in the genesis of some eye conditions At present there are five methods listed for the study of the cerebral Circulation' These are (1) direct observation of the retinal circulation (2) thermocouple measurements of the temperature of the exposed brain surface or of the blood in the internal jugular vein (3) determinations of the cerebral urteriovenous oxygen difference (4) measurement of the dis placement of cerebrospinal fluid during obstruction of the internal jugular vein and (5) the use of the Fick principle The present study should pro vide another method and because of its simplicity accuracy and safety should find a large field of usefulness of unusual interest in this study are the many perplexing problems observed for which no adequate erplanation can be found in the literature Nothing can be found in the literature which cien remotely resembles the present study and for this reason it is difficult to correlate results with statements appearing in textbooks and periodicals on the cye The author is in private practice in internal medicine but has an interest in the cyc 82 ·ARTERIAL SOLUMC PULSL TROY INTRAORBITAL TISSUES 83 because its delicate structure often suggests organic and functional diseases of the body Furthermore impaired arterial circulation to the intraorbital tissues might be classed as peripheral vascular diseast as is impared circulation of the legs in this study of the arterial volume pulse of the intraorbital tissues ru cordings have been made on normal patients on patients with cardic disease with cardiovascular disease with developmental differences of the arterial circulation to the eye with intracranial conditions and with eye diseases However this report is contined almost exclusively to a detailed description of the method of study with a few illustrative records 9 & 54 73 2 3 Fic A photograph of the instrument with the adaptor for making recordings from the Introarbetat issues the temporal artery and the cranium (1) The doubled chambered capsule ( ) stopcock from the innating bulb (3) storcock protecting the pressure gauge (4) the bleeder stopcock (5) the outlet from the reservoir to the calibrating device (6) the calibrating device with lub ny to the outer chamber of the capsule (1) (7) the reservoir (8) stopcock for adjusting the recording droplet of al ohol (9) light switch Construction of the Equipment The equipment used is the camera of the Oscillometer a double chamber pickup capsule pressure regulating mechanism und a special metering ·84 THE JOHNSON RECORDING OSCILLOMSTER device The essential features of this metering device are illustrated in FI 53 and in the drawing in Fig 54 The construction of the equipment is fully described in the legends for the above illustrations The camera is the same as that described in Chapter 1 The double chamber pick up capsule is one supplied by the Cambridge Instrument Com pany The glycerine filled chamber has been removed and a specially constructed capsule inserted (see Fig 53 - 1) This rubber chamber is of the same dimensions as the Cambridge Instrument Chamber but the rubber dam is of 0 2 mm thickness and has an outlet so that water can be injected into this chamber under known pressure from the regulator For con venience a metal stopcock has been fastened to the back of the metal portion of the Cambridge Instrument capsule one end of which is con nected to the rubber chamber and the other to the metering device (seu O 2 Fiu 54 A machine drawing of the metering device which accurately delivers 01 mi volume change at will by merely depressing the plunger (1) The knob (2) piston rod (3) upper body (4) lower body (5) retaining collar (6) compression spring (7) teflon collar (8) taper joint Fig 53-6) The second chamber of the capsule is connected to the record ing tube of the Oscillometer The regulating mechanism consists of a glass tube 42 mm in internal diameter and 8 5 cm long (sec Fig 53 - 7) It has four outlets cach with a glass stopcock connected as follows The top center stopcock (see Fig 53 - 3) is connected to a Tycos Pressure Gauge The right upper stopcock (see Fig 53 - 2) is connected to an inflating bulb a third top outlet (see Fig 53-4) is connected to a bleeder tube und a fourth outlet (see Fig 53-5) is at the bottom of the tube and is connected to one side of the me ering device by means of transparent plastic tubing By using trans ·parent tubing it is possible at all times to see that no air is contained in the hydraulic system The precision metering device had to be specially constructed buudusu 00 existing metering equipment could be found which would accurately deliver 0 1 ml as required The device also has a tapered joint which makes it possible to remove the essential mechanism for inspection for trapped air One end of the metering device is connected to the regulator by means of transparent plastic tubing us indicated above and the other end is connected to the special rubber capsule so th it at any time the ne le ARTERIAL VOLUML PUI SI TROM INTRAORBITAL TISSUIS X5 NO A. wort how teda wwport MUSIC ATTIT tine 11 TE! Hi RAT week Nu uit Te. ...1 Minute HITL ter NCHINA Por 21"JLLE Lour and mit sehr per nwmr ASTA *** . FEW UPADAS TIEKTID Nel MINI 15 MF4 R IN EH ### **FREE* YANG IWXUAH MATIM www *** suwerter K WIL FIG 55 This figure illustrates the effects of changing the center of bravity of the capsulem the volume recording from the inner chamber of the capsule Th capsule was held Vertical while recording tipped horizontal with the back side down returned to the Vertical position tipped horizontal with its front sid down and then refurned to the vertical position The volume change with each change of position was approximately 003 to 004 ml volume of the capsule can be increased by exactly 01 ml of fluid hy de pressing the plunger of the metering device Likewise the volume can be decreased by exactly 0 1 ml by releasing the plunger The combination of the metering device the rubber capsule and the connecting transparent tubing are filled with water in such a way that when the lower stopcock on the regulator is shut a closed hydraulic system is formed The glass chamber acts as a reservoir for water It should be emphasized that the entire mechanism is constructed to a very fine tolerance ·86 TUE JOHNSON RECORDING OSCILLOHETER 1 Procedure for Recording The procedure for making recordings of the arterial diastolic pressure is as follows The patient sits erect in a chair and is told to hold his head in the same position while the recordings are being made The centre of gravity of the pickup capsule is thereby mjintained the recording can also be made when the patient is reclining Fig 55 illustrates the effect of changing the center of gravity of the pickup capsule by filling it one way or the other FIG 56 This photograph shows the instrument arried to a subject for recording from the intraorbital 115sucs 2 Thu deflated pickup capsule is applied over the intraorbital 1155ues snugly shown in Fit 56 3 As illustrated in Fig 53 the metal stopcock on the pickup capsule (1) is in the open position the class stopcock (2) attached in the inflating bulb is open the glass stopuock to the pressure guuge () is open the glass stopcock to the bleeder capillary (4) is closed the glass stopcock (5) to the metering device (6) is opxn und the siopoch to the recording the (8) is open # A droplet of 95 per cent alcohol of a volume of upprorimately 003 ml is placed in the recording tube ·ARTERIAL VOLUME PULSE FRON INTRAORBITAL TISSLIS 87 N Capsule Pressure -mm Hg 120 BIO 100 90 80 70 60 - the ne Tu 110 1 Ver Allo LA Capsule Pressure -mm Hg N IE 90 Roma 49 WANNA om! 80 JE FIG 57 Recordings of the arterial volume pulse from the intraorbital issues mid from 1 normat white male age 6. with no demonstrable cyc pathology The upper record ing is of a single pulse wave at capsule pressures from 1 O to (0 mm Ilg at 10 mm Hg intervals The pulse wave of maximum amplitude is recorded at 2010 100 mm Hg which is the diastolic blood pressure Calibrated recordings were then made at 110 100 90 and 80 mm Hg uung a calibralion of 01 ml The miximal arterial volume pulse in this case was found to be at a diastolic pressure of 30 mm He and equalled 0069 ml per heart heat ·88 THE JOHNSON RECORDING OSCILLOWFTER Capsule Pressure 90 mm Hg RE 14 R. - ISA w HAL EA UDA CAT AN 2 STANCE RRRR! MA* SUWS 1 1 1 HS 1481 HUAM Baher LA CON TOTES stanu Hot De Mert ry wer TE HP pet HELA . wa RRER www re BUS StemXCESINDA www. VEDROS LA dir ALDR TIJD MATA Capsule Pressure 80 mm Hg Ru Det IR MER rura WATU WA ON PU PESMI RADO! ne the EMER VLC AMED al BE TINO BORDER DARRERS regata runy 709 SMS TIPS EI HAAMER WINTERFETE FI UTILES TRUE MI NRK We are 344 RW.HUIS 2 w . 90 TI 10 M Ի Է ՈՒ TIM wat - D.LA ULVER 3 TL MANO TOWY #Vimeo T#BA AUSTROKURATTSTARTER. TONDA BACA ZARA MIKROMOC WIRELAWATAN RA L ta ht arter Rrih Caps le Pressure 70 mm Hg MEM rom Lote were LEYFI ARRON MA To MON TARA RCEDES FERON WRIDA TATO REGIU MB LI 1920 TTC MONSALE w TALK FAS WELI TOMAS * PERSON PARRUCAR XA17 CAS REALE - turun M tut Heart mi Fa S8 Recordings of the intraorbital arterial volume pulse from the right side made at various capsular pressures from a whit male age 7. with no obvious cardiac or intraorbital pathology The results are as follows Intraorbital Arterial Volume Pulse Capsule Ampluude Calibration Beat Minute Pressure 0-1 mi rate vclume volume 90 mm Hg 013 0085 68 0153 ml 10 4 ml 80 mm Hg 0143 007 68 0204 ml 14 l ml 70 mm Hg 007 68 0-1 8 ml 8 7 ml The greatest volume amplitude is at 80 mm Hg which according to Marcy. Prin ciple is the diastolic pressure The minute arterial intraorbital volume pulses in this case are about twice the average normal obtained in other patients No explanation is offered - 009 ·ARTERIAL VOLUME PULSE FROM INTRAORBITAL TISSUES 84 5 The pickup capsule is sowiy inflated with water from the re ervoir (7) until a pressure of 120 mm Hg is reached 6 The droplet of 95 per cent alcohol is adjusted for tucording and the stopcak (8) is closed 7 The illumination is turned on with switch (9) 8 Recordings of two arterial volume pulses are made at pressures of 120 110 100 90 80 70 and 60 mm Hg These pressures are abluined by means of opening and closing the bleeder stopack (4) as required 9 The pickup capsule is completely deflated by leaving the bleeder stopcock (4) open 10 The exposed tracing is developed 11 The developed tracing is examined wet and the dissiolic pressure is obtained by determining the pressure at which the maumum amplitude of the pulse wave is recorded The procedure for calibrating the arterial volume pulse is as follows 1 The method for making these recordings is the same as for tukin, the diastolic pressure except that recordings are made 10 mm Hg above the predetermined diastolic pressure at the diastolic pressure and 10 mm Hg below the diastolic pressure While making the recordings the glass stopcock to the metering device (5) is closed 2 Three beats are recorded the metering device is depressed while recording three more beats and then released while recording three more beats 3 The exposed tracing is then developed In recording the wink reflexes the patient is told to wink and this reflex is recorded superimposed on the pulse wave It modifies the pulse wave for only a single beat No effort has been made to study the effect of rotation of the cyeball on the recordings but this should present no problem Results Although recordings of the intraorbital volume pulse can be made with the head in any position it is necessary to keep the head in a fixed position during any given recording Otherwise an error will be introduced from the effects of gravity on the capsule and thus alter the buse line This effect 1$ illustrated in Fig 55 Movement of the orbital contents forward or back ward by moving the head forward or backward might also occur but this experiment has not been done The diastolic blood pressure in normal individuals has been found to average 100-110 mm Hg as shown in ris 37 ·90 TIIE JOHNSOY RECORDING OSCILLOMETER Lood Leod V 2 Y4 V3 This PLAN CA LORES w w BAL D w DOBLO SY H+ 11 ve AN FIG 59 Recordings of the intraorbital volume puls from the right side made on a white male aged 68 who had a history of a coronary occlusion 8 years previous These recordings of the electrocardiogram ard the intraorbital volume pulse were made on the patient when he had an acute attack of shortness of breath The initial disturb ance of cardiac rhythm was interpreted as an auricular fibrillation from the above electrocardiogram There were continuous changes in rhythm as illustrated by the recordings of the intraorbital volume pulse It is of interest to note that although the bear ampintude or the intraordital arterial volume pulse was below normal during the auricular fibrillation or 005 ml the minute arterial volume pulses were in the normal range or 77 ml as shown in the upper left hand illustration In the suc ceeding recordings note the profound changes in the arterial volume pulse with the changing rhythms wheh were not felt by the patient in the cyc Note the wink reflex in the lower recording which takes only 02 sec It has been estimated that any change in the rate rhythm or stroke output of the heart is reflected into the orbitat ussues within 00sec The normal arterial volume pulse taken at the diastolic pressure is in the range of 007 ml us shown in Fig 57 Honever normal recordings may gile values well above this as shown in Fig 58 and well below this This indicates that the normal value covers a wide range The form of the arterial volume pulse shows wide variations in both crest times as well as superimposed notches us illustrated in Figs 57 throuch 65 The arterist volume pulse is modified by any change in cardiac rate rhythm and stroke output as illustrated in Fig 50 Equipment is being constructed to determine the time required for any cardiac change to bu ·ARTERIAL VOLUMC PULSE FROM INTRAORBITAL TISSUES 91 HYPERTENSION CASE 1 ANAR AWUN WANDRUOMURGULAN CP 130 mm Hg . LES TTT HANS MAAN 11 VINO MAYWEAR Pardu. ECG Mithricht No me interes IN 16 La A INLESS STMAWA James He Helen www.al A#pean ARE WA ** 1 CASE 2 CP 110 mm Hg mwen hehe W.MAY 20. MAJD BLOW MAAN ml Awaren AURI WWWWER NO Home harim Tur ARIMI DEVAM red at the OR WWW MMDW le 4 AP their Www We www We w JON ella + # 1 4 HAWA WA www.www. MAS CASE 3 CP 110 mm Hg E Www Arthur ter ANTAR YPNP MA where pot www.ORCA OR Wor NE ka UPONE RO negre M MA A. REAL LLL were AN W WAREN ww VAMMAI 10V TUM WWWMWWM CREARE M FIG 60 Recordings of the intraorbital volume pulse made from three patients with various degrees of hyperten ton without evidence of diabetis or kidney disease Case 1 is a white male age 68 without eye symptoms but with an auscultatory blood pressure in the right arm of 50/130 The minute arterial volume pulses from the right eye are 0 045/008(63)= 35 ml Case is from 7 white male age 60 with a high degree of myopia requiring corrective lenses of 7 diopters Also the patient has had a retinal detachment in the left eye The auscultatory blood pressure in the right arm was 160/110 The orbital minute arterial volume pulses were 003/008(83)= 3 1 ml Case 3 is from a wbite female age 44 with a right sided hemiplegia with some residual loss of function The auscultatory blood pressure in th right arm was 190/80 The orbital minute arterial volume pulses were 0 04/0 09(75)=33_ mi Note that the minute arterial volume pulses 10 all three cases are about one half the average nortat ·92 THF JOHNSON RECORDING OSCILLOVETER recorded in the orbital tissues but available evidence indicates that this occurs in less than 004 sec Several recordings of the arterial volume pulse from patients with gross arterial lesions elsewhere in the body or with severe hypertensive cardio vascular disease are presented in Figs 60 and 61 Ocular conditions may or may not modify the recordings of the intra orbital volume pulse Fig 62 illustrates the recordings from a patient with homonomous hemianopsia in one eye and an artificial eve in the other socket Recordings on a number of patients with glaucoma are illustrated in Fig 63 Fig 64 illustrates recordings on a patient with pigmentary degeneration of the retina The recording of the intraorbital volume pulse may be markedly modified by simple physiological procedures such as taking a forced inspiration as illustrated in Fig 65 Connents and Conclusions This study of the arterial volume pulse of the intraorbital tissues has raised many interesting questions the first and most important of which is its relationship to the arterial circulation of the intraorbital tissues It is the opinion of the author that what is recorded is a volume pulse which is calibrated to a fixed induced volume change and not a pressure pulse The same reasoning upplies as that set forth in Chapter lji on the differ ence between the volume and the pressure pulses The importance of the subject is set forth by Dule Elder There are few questions in the whole of ophthalmology more important and more fundamental than the physiology of the vascular circulation Not only must this form the only logical basis of a rational understanding of the pathology of many ocular diseases but inasmuch as the entire metabolism of the tyc depends primarily upon it a clear understanding of the problems which if pse sents is of paramount importance in the physiology of this organ Although this study is not concerned specifically with the eyeball itsell the recording of the arterial volume pulse of the intraorbital tissues may provide valuable information concerning the circulation of the eyeball The arterial volume pulse of the intraorbital tissues is a composite of (1) the action of the heart (2) the dynamics of the pulse wave itself as it leaves the heart as it is modified in its passage through the internal carou artery and its reversion partly or wholly to its original form (3) develop mental differences in the internal carotid and ophthalmic arteries (4) intra cranial conditions (5) diseases of the arteries themselves (6) discuses of the intraorbital tissues including the eye and (7) elasticity of the bon, Toof of the orbit This indicates the complex nature of the subject A brief discussion of the sensitivity of the instrument used for maling these recordings is in order The Johnson Recording Oscillometer is as follows ·20 W! IN P 80 mm Hg SURGLAR 1 1 W bell LAVANH ARTFRIAL VOLUMC PULSE FROM INTRAORBITAL TISSUES 93 CP 90 mm Hg Case ! 1 f6 11n NO. ARI 年学班,排位, trener . Ser AL SAN ut . WA 1 ws + * w Y s. SA * LAN W un at the Case 2 A 1 For It + R Ferro Rew AUT fins EP typy 6 ON BES. CA US ArdhwW.ANM. WWW VIP 19 the come with 868 Re14 PM wwwwwwwwwww W 04 NORWARD WWW * * PRAWA w RELY CP 100 mm Hg Case 3 WWE WRANUM **bath with two WW DW wa din TSNUMME VA 2 www have Wilt in PA NIWA 40 W Yunit WATWA . 1 WWW.SUMAN ww* WIRTUVENOMOTOWE W Manning 16 WARI www. TRAVINY TYD MASON PWC en hatte unter den weltweither that they JE4 WANANDA NON ri BAN MAN HUA shwe 97 Mua Con 4 VIE CP 100 mm Hg MS WANA ME hin WAS J. HA how ANNUR UANANA VANA CARA QUE VANENDO www W CELL. KAM WWWWMA BRIDERS hing VONIOS CATED po WUR NA MAR WON FIG 61 Recordings ma le of the intraorbital arterial ve lume şulse from four patients with cardiac arrythmias which illustrate that changes of cardiac rate i hythm and stroke output are reflected into the recordings This is thought to occur in less than 004 sec Case 1 was made from the right introarbital tissues from a white female age 60 with a chronic auricular fibrillation and an associated diabetes mellitus Case 7 was made from a white female led > with paroxysmal auricular fibrillation Cases 1 and Illustrate the fact that cardiac changes associated with auricular fibril fation are recorded in the intraorbital tissues Case 3 was made from a white male age 70 with evidence of myoc rdial damage bundle branch block and congestive heart fatlure The patient had a sious mechanism with the exception of frequent premature ventricular contractions Case 4 was made from a white male age 65 with gout occlusive arterial disease of the legs hypertensiv cardiovascular disease evi dence of myocardial damage but with a sinus mechanism with an occasional prema ture ventricular contraction Cases 3 and 4 illustrate the fact that the premature ventricular contractions are reflected into the recordings of the arterial volume pulse of the intraorbital tissues ·94 THE JOHNSON RECORDING OSCILLOMETER ܚܚܚܝܬ "Right Orbitt** 1 Capsule Pressure 100mm Hg M DHE w ERNSTELLE EUR HEPHk .. Rob Brett O ACTION MINIAT pe HASTU JETA WHE hy MR. TRAMMEN! HIDRANTY PIN Left Orbit Capsule Pressure 100mm Hg MEL 16 MAR om w WM F wy NES ANN *** DOFT! ARA NE 1740 VRS #t Ohm HELMIR INACTER DE ROUT. ALL RILA MER W 20 Duka PINTU LE BRIS CA hon KOU SBIn IN FI 6. Recordings made from the intraorbital tissue of a white male age 66 who had a history of acute glaucoma of eight years duration in the left eye for which an iridectomy had been done This in turn was followed by an enucleation of the felt cye At present the patient has an artificial eye has hypertension of 160/106 and evidence of myocardial damage the right eye has a homonymous hemianopsia no intracranial lesion could be found Th arterial volume pulse of the intraorbitat fissues of the right side are 0035/009 or 0039 ml and the minute arterial volume pulses 29 ml The arterial volume pulse of the intraorbital tissues of the left ce plus the artificial glass cyc is 0015/009 or 0039 ml ard the minute arterial volume pulses 29. ml The diastolic pressure was determined to be 100 mm Hg at whil pressur these recordings were made These results are presented without comment ·ARTERIAL VOLUME PULSE FROY INTRXORBITAT TISSUES 95 GLAUCOMA CASE 1 Co 100mm Hg I Roh! Ey Drops ...www. Www pag #rxYETU TT TAROT A FER 27. دوماد که بی بلد نقاء له معدة لجولتيه w a * WM kh 2 w ff Serve. ياعيد يعفو WWW.Onth way Chow CP 100mm Hg Left Eye Id tromy Al lentos ww WAT LET Why Ayu.. wATP Long ch Na WWW.BA tarihi TER AU VIT 1 AULA ww STY 77 1 AN Rotte ta WA Vww.th LUMNO IREM Warto terrassa أيديه الدلوعة CASE 2 CP toomm Hg Rght Eye Id ctomy Forte N. te wy ALSADE WWW PARIWWWWWW WASSA More C We below 190RON ANTHOUS RA Ah 7.9924 ... Abwe w www.they AN Olmln mann *** 45 MAMA ww 材出一個地名。 SAR ANNOW 12W Congo WA. w art an Home Nieuw BRA mahul FIO 63 Recordings of the intraorbital asterisi volume pulse of two patients with glaucoma Case 1 is a white male age 68 with a diabetes mellitus evidence of myocardial damage with angina amputation of the right arm at the shoulder and glaucoma The patient was using drons in the right cye and had had an indectomy in the left eve the previous car the recordings were made at the diastols pressure of 100 mm Hg The trainure arterial volume pulses of the right eve were 0085101995 $1) 725 ml The minute arterial volume putses in the tett eye were 00410 09175)-33 mi Comment The amputacion of the right arm at the shoulder may have some bearing on the marked discrepancy in the recordings Case white female are 44 with a mild thyrotonico us, and a history of bilateral cute glaucoma of twenty years duration for which a priateral ndectomy had been done The recording shown was made at the diastolic pres use of the intraorbitat arterial system which was 100 mm Hg The minule arterial volume ruises of the intraorbital tissues were 009, 0085475)= 16 mm Contrast this extremely I w value with some of the ormal recordings ·96 THE JOHNSON RECORDING OSCILLOVETER adapted to the intraorbital tissues provides a precision method for record ing calibrating and timing rapidly recurring volume changes The re cording 1$ accurate to a change in volume of less than 0002 ml will respond to rates of over 1000 per minute and has virtually no overshoot or undershoot The influence of runoft has not been determined Although extensive studies have not been made it would seem that the normal arterial volume pulse from the adult is close 10 007 ml plus or minus 20 per cent There are a few individuals with values far in ercess Right Orbit Capsul PSU 100 mm Hg SALAKUL PARA w E SELJA We Left Orbit Cap IP 100 mm Hg CA NOV Para ALENE ER host nautinthet terrabaho Fi 64 Recordin s of the intraorbital arterial volume puls of the rht and left cycs mau from a white male age 56 yih diabetes mellitus and a diffuse pigmentary reunity of both Thc m nule arterial volume pulses the right intraorbital tissues are 013/0 10456)=73 ml per minute and of the left 0 10/0 10:56) 56 ml The fasting blood sugar in this patent was 160 on tuo occasions of this and many apparently normal subjects with normal vision with values far below this One might say that the latter subjects hare kss than normal oculur reserve und muy present symptoms under stress Most subjects do not complain of pain while the recordings are being made but there are a few who do complain of pain which may or my not be significant The disstolic blood pressure of the intraorbital arteries is higher in this Study than is reported by Adler for the eyeball ·ARTERIAL VOLUME PULSE FROM INTRAORBITAL TISSUCS 97 The wink reflex has occasionally been recorded incidental to the study The timing of the wink reflex as cited by Adler') is 036-04 sec In this study it has uniformly been less than 02 sec No attempt has been made to measure the effects of refler constriction or dilation of the pupil or ocular movements on the intraorbital volume but this should be possible with this equipment It should be mentioned before closing this discussion that the bones of iho skull have elasticity as discussed in Chapter XI und the bony roof of the orbit is very thin and may move considerably with pressure changes within the cranial vault If this occurs it would markedly modify the recordings obtained from the intraorbital tissues and explain some of the unusual results observed in this study Further studies are in progress on this subject sto FIG 65 Recordings of the intraorbital arterial volum pulse from a white male age 52 which show the effects of a forced inspiration posible recession of the intraorbital tissues or a decrease in the average radius of the cranium A control study was made with a capsule pressure of 100 mm Hg Note the heart rate of 83 and the arterial volume pulse of 004 ml On deep inspiration the heart rate slowed to 63 the arterial volume pulse increased to 07 ml and the base line moved down by 005 ml On release of the forced inspiration the heart rate returned to 83 nd the arterial volume pulse decreased to 0038 ml Computations indicate that the nyerage radius of the cranium decreased by 47 y during the deep inspiration The record also indicates the fact that chan es in the ca diovascular status are immediately reflected into the otra orbital tissues Three Wink reflexes are recorded which took 07 sec each A comparable record taken over the forehead is illustrated in Fig 71 This me hod of recording the arterial volume pulse may not have im mediate clinical application in ophthalmology but it does open up a new avenue for the study of the various unsolved problems in the physiology of the eye with particular reference to movements of the eyeball and the circulation of the intraorbital tissues some of which are as follows The possible movement of the eyeball during reflex constriction of the pupil 2 The possible movement of the eyeball during accommodation 3 The efects of blood pressure on the intraorbital circulation 1 DO ·98 THE JOHNSON RECORDING OSCILLOMETER 4 The effects of sympathetic block on the intraorbital circulation 5 The effects of drugs on movements of the eyeball and the intraorbital circulation 6 The effects of ocular diseases on the intraorbital circulation 7 The effects of metabolic diseases on the intraorbital circulation Further work is in progress on the development of improved equipnient for the analysis of the complex intraorbital arterial volume pulso with the objective of gaining a better understanding of the genesis and nature of diseases of the orbit which are related to the circulation ·CHAPTER X THE ARTERIAL VOLUME PULSE FROM THL TEMPORAL ARTERY THE arterial volume pulse from the temporal artery is important because of its relationship to the external carotid artery just as the ophthalm artery is important because of its relationship to the internal carotid artery The two together are important because of their relationship to the wommon caroud artery It would seem that much useful information can be obtained from a study of the arterial volume pulse of the temporal artery and intraorbital tissues in relation to congenital defects developmental defects acquired disease and the normal circulation of the intraorbital contents brain and temporal artery A combined study of the arterial volume pulse of the intraorbital 114sues as well as of the temporal artery provides data which could not b obtained by a study of one or the other alone A description of the method of making recordings from the temporal artery is presented without much comment since the studies are not sufli cient to afford a basis for definite conclusions Method of Recording The same equipment is used as in recording the arterial volume pulse from the intraorbital tissues The capsule is placed over the temporal artery in front of the car as illustrated in Fig 66 A recording of one or two volume pulses is made at intracapsular pressures beginning with 140 mm Hg and at decreasing intervals of 10 mm Hg down to 60 mm Hg The recording is developed and the arterial pulso wave of greatest ampli tude indicates the diastolic pressure according to Marey s Principle (Chap Calibrated recordings are then made at pressures 10 mm Hg above the diastolic pressure at the diastolic pressure and 10 mm Hg below the diastolic pressure as in recording the intraorbital arterial solume pulse Results and Comments The results of the studies of the arterial solume pulse from the temporal arteries differ somewhat from results of tht studies of the arteria) volume pulse in the extremities in that the end point is not sharp Therefore it is not as easy to determine the diastolic pressure in the temporal artery by 99 ter IV) ·100 THE JOHNSON RECORDING OSCILLOMLTFR means of Marey s Principle This is clearly indicated in Fig 67 which illustrates recordings of the arterial volume pulse of the right temporal artery at capsule pressure of 10 mm Hg intervals from 120 mm Hg to 60 mm Hg The calibration which is illustrated by the change in base line is 01 ml Another interesting factor in this study is the marked variation of the arterial volume pulse from the temporal artery in different subjects both with regard to form and volume This is illustrated in Fig 67 FIG 66 The method of applying the capsule for recording the arterial volume pulse from the temporal artery Since the temporal artery is a branch of the crternul carotid artery re cordings from this urtery will provide some data concerning the patency und the degree of development of the external carotid artery as compared with the degreu of development of the internal carotid urtery as recorded from the intraorbital tissues desenbed in the preceding chapter The end point for determining the diastolic pressure in the temporal artery is not sharp as it is in the arms The rather high diastolic pressure of the temporal arteries and the intraorbital arteries suegests that there might be some auxiliary blood pressure regulating mechanism to the vascu lar system of the head However the work done in this area is too fragmentary to justify any positie conclusion ·ARTERIAL VOLUME PULSE FROV TEMPORAL ARTFRY 101 10 8C th CHOI ec ME VALE WA t 11 rue Mat c9/a 09517) - Ipo M w -- NU SON TA M AM Mama and SATEN WANA WANN We WANOVO PEREIRA w A NE w ChA PZ C 9/0 075175)- 902 - AM LIM M VASALO www. Ad www. MITT NI SWA ALA wed 07/0 055675) all FIG 67 This figure illustrates the procedure for deferming the diastolic divod pressurt ore The temporal artery as well as obtaining calibrated recordings of the arterial volume pulse over the temporal artery The upper pornon Shons recordings of single volume puisc waves at capsule pressures from 1 0 to 60 mm Hg The maximum volume pulse is recorded at 70 mm Hg which is the diastolic hood pressure Calibrated arteriat volume pulses are then recorded at this pressure and af 10 mm Hg above and 10 mm Hg below this pressure in order to be certain of obtaining recordings of the mavmal arterial value pulse Noie from the record that the maximal afteria? volume pulse was recorded at 70 mm Hg and gave a valve for the minute anera! vofume pulses of 90 m ·CHAPTER VI THE ARTERIAL VOLUME PULSE TAKEN OVER THE FOREHEAD THE present chapter is concerned with a description of making tuned calibrated arterial volume pulse recordings from over the forehead These recordings may be of only academnc interest but future studies may lead to an improved understanding of the significance of this method for a better interpretation of the intraorbital arterial volume pulse us presented in Chapter IX In the initial studies it was believed that these recordings were from the arterial bed of the skin and subcutaneous tissues but certuin variations in the recordings could not be esplained on the busis of known physiological principles This study therefore may shed light on the degree of accuracy of the Monro-hellte doctrine Method of Recording The equipment used is the same as that for recording the arterial volume pulse from the intraorbital tissues and the temporal artery The record FIO 68 This figure illustrates the procedure for applying the capsule 1 r makina recordings of the arterial volume pulse from over the forched 102 ·ARTERIAL VOLUVIL PULSE TAKEN OVER FORI HEAD 103 ings can be made from anywhere over the cranium but for illustration the forehead is used as shown in Fig 68 The recordings can be made with the head in almost any position but all of the studies herein reported were made with the patient sitting upright The patient sits comfortably in a chair and the pickup capsule is applied snugly to the forehead as shown in Fig 68 Serial recordings of a singl Capaule Pr asure - Py 150 10 ܘܐܐ 6C ta NE FIG 69 Recordings of the arterial volume pulse taken over the forehead from a white male age 56 with a history of untreated diabetis mellitus of twelve years duration The intraorbital recordings are illustrated in Fig 64 The patient has an associated dffuse pigmentary relinitis Recordings of single pulse waves were made with capsule pres sures from 160 mm Hg to 60 mm Hg Note that there is very little difference in the amplitude of these pulse waves which indicates that these recordings result from distension of the cranial cavity and pot from the arterial system of the skin and subcutaneous tissues A calibrated recording is also shown and indicates the arterial volume pulse to be 003 ml per beat volume pulse are made in a manner similar to the procedures outlined for the intraorbital tissues at pressures from 160 to 60 mm Hg at 10 mm Hg intervals A calibrated recording is made at 110 mm Hg pressure The recording is then developed in the usual manner ·104 THE SOFINSON RECORDING OSCILLOYETER Results and Comments The results of such a study art illustrated in Fig 60 They show simular amplitudes of the arterial volume pulse throughout a wide range of pres Sures There is a tremendous variation in recordings taken from different individuals with amplitudes of the arterial volume pulse varying from 0005 to 005 m! The average for adults is about 003 ml The method Is accurate to 0 002 ml volume change Any change in the rate rhythm or stroke output of the heart is reflected in these recordings This change is thought to occur in less than 001 seconds Such a recording is illustrated in Fig 70 The simple procedure of taking a forced inspiration modifies the record ings as indicated in Fig 71 which illustrates not only a change in the arterial volume puise but also a change in the base line Variations in the recordings presented are such that there is doubt as to whether the recordings reflect the arterial volume pulse from the soft tissues of the forehead or the increased volunie of the cranial cavity isso ciated with systole It is apparent from the recordings presented in Fig 69 that Marcy s Principle cannot be used for obtaining the diastolt pressure Also that equal arterial volume pulses can be recorded throughout the range of diastolic and systolic blood pressures Furthermore the arterial volume pulse is in excess of what one would expect to record from the shun and subcutaneous tissues of this area Moreover the pressure gradient theory would suggest that no such arerial pressures exist in the small vessels of this area which would produce the marked volume changes observed These results indicate that what is recorded might possibly be an increase in the volume of the cranial vault with each heart beat for the salc of simplicity the craniul vault may be considered a sphere with a radius of 7 cm the following computations indicate that a scry slight distension of the cranial vault can explain the recorded measurements The diameter of the recording capsule is 4 cm 2 The radius of the skull during distole is 7 om which is also the altitude of a cone with the recording capsule as a base 3 The volume of the basal segment of the cone during systole is 003 ml in the average sdult 4 Computations indicate that the ultitude of the basal segment of the cone during systol will be 00022 cm 5 The altitude of the cone during systolt would then be 70022 cm which is also the radius of the skull during systole This would mean that the average radius of the adult sku] would have to increase by only 00022 cm dunne systoli to produce a 003 m) change ·ARTERIAL VOLUME PULSE TAKEN OVER FOREHEAD 10= Over the Forehead - talitataLa 。 - 一一一 由于---- 中国中学生 TL-TIP ] 社长一部HDME lulel 一一一一一 期 中 POT 多田羅蘭明址邮码 有一 law,更非一样 Over the Right Temporal Artery 1 本土和自由的名单。 The Amy 事件,一 HTT 里里 “是的,”中学 时 } CMMIT的uh附中山由曲由M社 |||| } WWW. 11 由日本 日出其中 在国明由相 TEA #HORITHILTRARE 中国 M闻社 中 中国人 有! hell AS IELAM.DORUR 十一不中--- -- Mari 化中山Fuun Tile 到中出18 m From the Right Intraorbital 119 Bues 也行。 1 perall Film 国时任山阳月 矿山础加納lu IMATHE牌照 10 L础研 1 一 当日,日本 #HIN Hui | 日 ||| 1回他的生們生平。 世田中理 时 | | 114 | 同时, 。 THE 中国 柳树的种种都拥 199出 bar his WWDLENIT 群 然是站在PT; 地方, Mitant 中国中中1 htt FIG 70 A composite recording of the arterial volume pulse from over the forehead the right temporal artery and the right intraorbital tissues from a patient with chronic auncu tar fibrillation Note that all changes of rate rhythm and stroke output of the heart are reflected into the recordings from these regions All of the recordings were made at a capsule pressure of 110 mm Hg ·106 THC JOHNSON RECORDING OSCILLOTILTER in the volume as outlined above This may be entirely possible Tha human skull is normally thought of as a rigid non distensible structure However the results of this study indicate that it is distensible within its elastic limits The importance of this concept is that this factor must be considered in the results of the study of the minute volume pulse both from the temporal artery and the intraorbital tissues It is especially important in the inter 4 FK. 71 Recording of the effects of a forced inspiration on the arterial volume puise taken over the forehead at a capsule pr ssure of 130 mm Hg Note that the base line becomes lower the heart slows and the arterial volume am lude becomes greater On recovcry the recordings revert to the control statu The lower recording is cali brated and shows the arterial volume pulse to be 007./009 or 004 ml per heari beat The significance of this study is discussed in the fort pretation of the recordings for the intraorbital tissues when one considers the thinness of the roof of the orbit Additional studies should be made on individuals with thick as well as thin skulls and also on children in whom the suturcs art not closed to sustain this hypothesis From this discussion one might conclude that the accuracy of the Monro Kellie doctrine Hould be limited by the elasticity of the bones of the cranial vault in addition to the other factors listed by Weed " ·CHAPTER XII SUMMARY AND CONCLUSIONS This monograph on the Johnson Recording Oscillometer and its use in the study of the arterial circulation summarizes progress in the development of the instrument and its application to experimental and clinical studies of the arterial circulation in health and disease The Johnson Recording Oscillometer males possible the recording of arterial blood pressure in the extremities and the recording of the calibrated arterial volume pulse with out arterial puncture or pain from anywhere in the extremities the temporal artery the intraorbital tissues the brain and the cranium in adults child ren infants and premature babies The rostrument is a precision timed recording oscillometer which pro vides a means of obtaining a permanent calibrated record of the artenal volume pulse It is built to fine tolerances The recording droplet of 95 per cent ethyl alcohol changes form instead of position in recording the arterial volume pulse This fact indicates that only molecular resistance is involved for the recording of volume changes The lag normally is not measurable The recordings are accurate to 0002 ml of volume change from the fingers toes temporal artery intraorbital tissues and the skull and to 002 ml volume change from the extremities exclusive of the digits It has eight rapidly interchangeable speeds whilh make it possible to spread recordings of individual pulse waves for detailed analysis The timing of the record is comparable to that of the electrocardiogram or 004 sec The equipment is portable and can be taken to the patients bedside Good recordings can be made in dayli_ht and recordings of the arterial volume pulse can be made with the patient in any position Extra neous factors such as the tremor of severe Parkinson s disease do not inter fere with recordings with a suitable adaptor on a lantern slide projector the recordings can be projected on a screen for visual observation by groups The differentiation between the arterial pressure pulse and the arterial Volume pulse is implicit in this study The arterial volume pulse is what the Oscillometer records what the finger feels shen palpating the arterial pulse and what causes the oscillation in the blood pressure dial when taking the blood pressure Although arternal pressure change is associated with these phenomena the arterial volume change is of prime importance and forms the basis of this study The pressure changes in the arterial system are very important clinically Although it has been known since 1924 that differences in blood pressure 107 ·108 THE JOHNSON RECORDING OSCILLOMETFR can be present in all four extremities this has not been generally recog nized The procedure for recording the arterial blood pressure in all four extremities with the Oscillometer is described This method uses mechani cal principles in contrast to the Korotkov sounds used in the contenuional method It is thus possible to record blood pressures by means of the Oscillometer when the Korotkov sounds are not in the range of hearing The application of this procedure to fifty one patients is presented The results demonstrate that it is possible for the same individual to have normotension hypotension and hypertension as evidenced by the recording of the blood pressure in all four extremities The importance of these find ings to current therapy for hypertension is indicated by the severe uggrava tion of the symptoms of occlusive arterial disease of the legs when hypertension of the arms is reduced through the use of some of the new antı hypertensive drugs The procedure for recording the volume pulse of the fingers and toes with case and precision is described This method makes possible a better understanding of the normal physiology of the circulation as well as the abnormal physiology of some clinical conditions involving the digits 'The usefulness of the oscillometric procedure is illustrated in the study of functional and organic diseases of the digital circulation The application of local heat and nerve block in the digits produced a markedly increased volume pulse in normal patients and those with vasospastic conditions while in the presence of organic disease this did not occur A study of Raynauds syndrome atherosclerosis obliterans and Buur ger s disease by this method is presented in the presence of Raynaud s syndrome the changes observed indicate that arterial circulation of the arm 10 the wrist is normal during the blanching stuge This sulgests that the blanching may not be due to an active vasospasm but to the diversion of blood through the paimar arch This would indicatc that surgery of the sympathetic nervous system for the treatment of Raynauds syndrome would have to be highly selective to sympathectomise the fingers only without producing sympathectomy of the arm with the possible aegtala tion of the diversion of blood from the fingers This study also showed that the arterial volume pulse of the fingers returns to the control level within thirty five days following this type of surgery The components the time relationships and the amplitude of the arterial volume pulse are important as part of the study of the artessat circulation The first peak of the arterial volume puise may be buried in the ascending limb of the pulse wave when pressures in the pickup cul are abosc the diastolic pressure or may be pluinly visibic on the escending limb with these cuff pressures particularly in the presence of bundle bran h block and serere aortic regurgitation When the pressure in the pickup cuff is at ·SUMMARY AND CONCLUSIONS 109 the diastolic level it is always at the peak of the pulse wave The first peak is important in this study because it is used as a point of reference for determining the crest time The second peak at the crest of the pulse wave with pressures above the diastolic level in the pickup cuff and at or slightly below the crest with pressures in the pickup cuff below the diastolic level The third peak is the diastolic peak and is preceded by the diastolic notch This study confirms the fact that the third peak may be due to a reflected wave The time of rise or crest time of the arterial volume pulse is measured at the diastolic pressure from the beginmng of the volume pulse to the first peak and is normally 0 08-0 16 sec If prolonged beyond this it usually means high grade aortic stenosis or occlusive arterial disease proximal to the site of recording When the crest time is prolonged beyond 0 16 sec the amplitude of the pulse wave is decreased and the Korotkov sounds are usually out of the range of hearing thus making it impossible to use the ausculatory method for taking blood pressure The amplitude of the volume pulse is calibrated in milhliters and is corrected for overshoot undershoot and runoff by suitable correction factors The amplitude varies with age body build physical condition and the presence of many diseases Any change in the rate rhythm or stroke output of the heart is recorded in the arterial volume pulse within 004 sec The specific study of the components the time relationships and ampli tude of the arterial volume pulse was made from four patients with inter futtent claudication associated with atherosclerosis obiiterans but without evidence of diabetis These patients were studied before and after treat ment with massage All had a relative or actual hypotension in the affected leg or legs a prolonged crest time and decreased minute arterial volume pulses Ausculatory blood pressures could not be obtained in the legs and the dorsalis pedis and posterior tibial arteries could not be palpated No immediate effect of a single massage on the arterial volume pulse could be demonstrated Daily massages for one year doubled the minute arterial volume pulses No arterial volume pulse could be recorded during the pain of intermittent claudication and the arterial volume pulse increased 300 per cent after a 20 min rest following the pain of intermittent claudication After repeated massage for one month the rest pains disappeared The walking tolerance without pain increased from about one half block to one mile following daily massage for one year The beneficial effects of daily massage in the patients is believed to be due to the opening of pre formed capillanes which are known anatomically to exist The arterial volume pulse was recorded from the human brain through a trephine hole in the skull Although this study is of purely academic interest it serves as an introduction to the study of the arterial volume pulse from the temporal artery the intraorbital tissues and the forehead ·110 THC JOIINSON RECORDING OSCILLOWETER The recordings of the arterial volume puise from the intraorbitul tissues the temporal artery and the forehead require a special adaptation of the Oscillometer The results of these studies indicate that in the adult the average arterial volume pulse from the temporal artery is 005 ml from thu mtraorbital 11ssues 007 ml and that an increase in the average radius of the skull of twenty four microns occurs during systole Studies from patients with cardiac arrythmias illustrate that the disturbances of rhythm are reflected into these recordings It has been estimated that any changes in rate rhythm or stroke output of the heart is recorded from these sites within 004 sec Recordings of the intraorbital volume pulse from patients with glaucoma hypertension and other eye conditions are presented with out comment because of the complex nature of the subject it is believed that the amplitude of the latter recordings are in part determined by the elasticity of the roof of the orbit which pushes the intraorbital contents forward with each systole The study of the arterial volume pulse taken over the foreheld indicates that the human adult skull is not rigid non distensible structure as indicated by the Monro-Kellie doctrine but is sufficiently elastic to distend with each heart beat The enlargement is casily measurable by the oscillometric method In conclusion it should be emphasized that the primary objective of this monograph is to describe the Johnson Recording Oscillometer its sensitivity and its accuracy and to indicate its present and potential usefulness in experimental and clinical medicine ·BIBLIOGRAPHY 1 1 BAZETT HC Factors in the Causation of Differcitial Blood Pressure Ameri can Journal of PhysiofosTO 5SO 585 Novembr 19 4 SWAMMERDAR JAN Bidla Nature Edited by HERNAN BOERHAAVE Leyden ! Severinus (1738) Vol 1 Table 49 3 JORNSON CARL A The Effect of Amyl Nitrite the Finger Volume Journal of Laboratory and Clinical Medicine 17 59-61 October 1931 4 JOHNSON CARL A Studies on Perspheral Vascular Phenomena A New Device for the Study of Peripheral Vascular Phenomena in Health and Disease Surgery Gynecology on! Obsteines 55 731 737 December 193. 5 JOHNSON CARL A The Digital Pleibysmograph as a Measure of the Peripheral Circulation Surgery Gynecology and Obstetrics D 31-41 January 1940 6 JOHNSON CARL The Measurement of the Pulsatile Arteriał Circulation Surgery Gynecology and Obstetrics 93 735--754 December 1951 7 American Medical Association Council on Physical Medicine and Rekabsta tiou Johnson Recording Oscultometer Accepted Journal of the vinerican Medical AssociaNon 149 148 May 19 1952 8 Certificate of Gold Medal Award The American Academy of Orthopedic Sur geons 1951 Certificate in authors Bics 9 SAPP OSCAR L ARNEY GLEN K and MATSINGLEY THOMAS W o termination of Arterial Blood Pressure in the Lower Extremity Journal of the American Medical Association 159 17.7-1730 December 31 1953 VON RECKLINGHAUSEN N Iber Blutdruckmessung Bere Menschen Arciu lur Experimentelle Pathologie und Pharmaholare 46 78 13. 1901 11 KOROTNOV NS Ber Anlurar il Axad St Petersbury 1905 5 1 ron KYLIN ESKIN Der Bluturi ck des Menschen Dresden und Leag 1937 1 Steinkopff Cited by MASTERS GARFIELD and WALTLRS 17 HAMILTON WE BREWER GLORGE and BROTMAV IRVIN Pressure Pulse Con tours in the latact Animal American Journal of Physiology 107 447 433 February 1934 13 BURDICK W et al Differences in Blood Pressure in the Arm and Log in Nor mal Subjects American Journal of Physiology 1. 169 176 March 19 5 14 STRANG 7 The Variations of Blood Pressure in the Extremitics Nek England Journal of Afedicine .00 187 173 January 94 199 15 HAMILTON WF WOODBURY RA and HARPER HT Physiologic Relati ships between Intrathoracic Intraspinal and Arterial Pressures Journal of the Amercan Medical Associahon 107 853-856 Sepiember 1 1936 16 ERLANGER 1 and HOOKER, DE Studies 10 Blood Pressure Bulletin alt Hopkins Hospital is 179 1904 17 WIGOERS CARL JOHN Physiology of Health and Disease ed $ HII Lea and Febiger 694 1949 18 JANEWAY TC Some Observations on the Estimation of 3 $ f**#* 1# Nan New York Undersity Aledical Sciences 1 Jo5 1901 19 MASINO L Das Verhalten des Blutdrucks des Junger und stes Hinttan ( schen bei der Muskelarbait Deutsches Arelines fur Alnische Atr tuine 1907 0 SARILIH Uber das Absolute Sphygmogram nebst bei uy tin Dewisches Archives fur aliasche Aledraine 81 493 1904 21 MARTY ETIENVE JULES Ctted by WIGGERS CARL JOHN 11) ·BEST CHARLES HERBERT and TAYLOR NORMAY BURKE Physiological Busso 32 WCSSLER STANFORD Medical Progress Medical Management of Peripheral Arterial Occlusive Diseases Nen England Journal of Medicine 149Ji BARKER NELSON W and HINES EDGAR H Peripheral for 34 MONRO ALEXANDER Observations on the Structure and Functions of the Monous 35 KELLIE GEORGE Appearances Observed in the Dissection of Two Individuals Edinburgh 1 84 1824 Cited by WEED LOUIS H 1391 SIR WILLIAM STEWART Textbook of Ophthalmol gv Development Form and Funcion of the sual Apparatus St Louis C 37 SCHMIDT CARL F The Cerebral Circulation in Health and Disease Sprogheld, 38 ADLER FRANCIS HEED Phisiology of the Eye edSt Louis, Cosby 39 WEED LOLIS H Limitations of the Monto-helle Hypothesis Archives of Sur 112 THE JOHNSON RECORDING OSCILLOMETER -2 Standardization of Blood Pressure Readings Joint Recommendations of the American Heart Association and the Cardiac Society of Great Britain and Ireland Journal of the American Medical Association 113 294 July -? 1939 23 MASTER ARTHUR MORRIS GARFIELD CHARLES I und WALTERS MAX B 10 mal Blood Pressure and Hypertension neu definitions Philadelphua Lea and Febiger (1952) -4 JOHNSON CARL A OSBORNE STAFFORD and SCUPHAM George # Studies of Peripheral Vascular Phenomen: The Effect of Artificual Fever on the Pulse Volume Changes of the Finger American Journal of the Medical Sciences, 190 485-494 October 1935 75 JOHNSON CARL A SCUPHAM GEORGE W and Gil.BERT NEWELL C Studies on Peripheral Vascular Phenom na Observations on Peripheral Circua on Changes following Unilateral Cervical Ganglionectomy and Ramisectomy Surgers Gynecology and Obstetrics 53 737-741 December 193 26 JOHNSON CARLA A Study of the Clinical Manifestations and the Resis of Treatment of Twenty two patients with Raynaud s Symptoms Surgers Gynecom log) and Obstetrics 72 889 907 May 1941 27 HUTCHINSON I Cuted from HUNT JOHN H16) 28 RAYNAUD MAURICE De l'asphyxie locale et de la Gangrene sometrique des ertremis 29 RAYNAUD MAURICE Nouvelles recherches sur a nature et le traitement de 1 asphy tie locale des extrémités Archives Generales de Médecine 15 189 18 + Cuted from HUNT JOHN H(R) 30 LEWIS T Muscular Pain in intermiten celandication leant 15 359 383 27 July 2017 31 Medical Practice Tertbook in Applied Physiology Wilkins 1955 6 August 1953 33 ALLEN EDGAR V cular Diseases ed 2 Philadelphia WB Saunders Company 1989, System W Creech (1783) Cited by WCED LOUIS H (39 Death from Coke and Congestion of the Brain Chirurg Society 36 DUKE ELDER Mosby 1933 Vol 1 p 401 Illinois Charles C Thomas (1950) 1953 and ROTHCHILD PAUL Observatre os on Balumore Williams and Transachons of the Wa.com Inc gery 18 1049-1068 April 1929 40 HUNT JOIN H The Raynaud Phenomena Journal of Medicine (Nen Series) 3 399-444 July 1936 A Critical Review The Quarterly