The diastolic pressure has been estimated to be about 35 to 45 mm. Hg lower than the systolic pressure, and consequently these figures represent the pulse pressure in the brachial artery of man. This is equivalent to saying that every systole of the left ventricle distends this artery by a sudden increase in pressure equal to the weight of a column of mercury 2 mm. in diameter and 35 to 45 mm. high. Naturally, at the heart the pressure is highest. As the blood goes toward the capillary area the pressure gradually decreases until, at the openings of the great veins into the heart, the pressure is least. At the aorta (A) the pressure (systolic) is approximately 150 mm. Hg, at the brachial artery (B) it is 130 mm., in the capillary system (C) it is 30 mm., in the femoral vein (F) it is 20 mm., at the opening of the inferior vena cava (I) it is 3 mm.
Attention has been called to the normal systolic pressure at different ages. This is not the only cause for variations in the blood pressure. Normally, it is greater when in the erect position than when seated, and greater when seated than when lying down. During the day there are well-recognized changes. The pressure is lowest during the early morning hours, when the person is asleep. In women there are variations due to menstruation. Muscular exercise raises the blood pressure markedly. The effect of a full meal is to raise the blood pressure. The explanation is that during and following a meal there is dilatation of the abdominal vessels. This takes blood from other parts of the body, provided that the other factors in the circulation remain constant. A fall of pressure would necessarily occur in the aorta. To compensate for this, there is increased work on the part of the heart, which reveals itself as increased pressure and pulse pressure. It is well known that the interest in the process taken by an individual upon whom the blood pressure is estimated for the first time tends to increase the rate of the heart and to raise the blood pressure. For this reason the first few readings on the instrument must be discarded, and not until the patient looks upon the procedure calmly can the true blood pressure be obtained. As a corollary to this statement, mental excitement, of whatever kind, has a marked influence on the pressure. The patient must remain absolutely quiet. Raising the head or the free arm causes the pressure to rise. Another important physiologic variation is produced by concentrated mental activity. This tends to hurry the heart and increase the force of the beat. In short, it may be stated as a general rule that any active functioning of a part of the body which naturally requires a great excess of blood tends to elevate the blood pressure. At rest the pressure is constant. Variations caused by the factors mentioned act only transitorily, and the pressure shortly returns to normal.
The Auscultatory Blood Pressure Phenomenon
Since the first description of the auscultatory blood pressure sounds by Korotkov in 1905, this method has been more and more employed until today it is the standard, recognized method of determining the points in the blood pressure reading. When one applies the 12 cm. arm band over the brachial artery and listens with the bell of the stethoscope about one cm. below the cuff directly over the brachial artery near the bend of the elbow, one hears an interesting series of sounds when the air in the cuff is gradually reduced. The cuff is blown up above the maximum pressure. As the air pressure around the arm gradually is lowered, the series of sounds begins with a rather low-pitched, clear, clicking sound. This is the first phase. This only lasts through a few millimeters fall when a murmur is added and the tone becomes louder. This click and murmur phase is the second phase. A few millimeters more of drop in pressure and a clear, sharp, loud tone is audible. Usually this tone lasts through a greater drop than any of the other tones. This is the third phase. Rather suddenly the loud, clear tone gives place to a dull muffled tone. In general the transition is quite sharp and distinct. This is the fourth phase. The tone gradually or quickly ceases until no tone is heard. This is the fifth phase (Ettinger.)
The first phase is due to the sudden expansion of the collapsed portion of the artery below the cuff and to the rapidity of the blood flow. This causes the first sharp clicking sound which measures the systolic pressure.
The second, or murmur and sound phase, is due to the whorls in the blood stream as the pressure is further released and the part of the artery below the cuff begins to fill with blood.
The third tone phase is due to the greater expansion of the artery and to the lowered velocity in the artery. A loud tone may be produced by a stiff artery and a slow stream or by an elastic artery and a rapid stream. This tone is clear cut and in general is louder than the first phase.
The fourth phase is a transition from the third and becomes duller in sound as the artery approaches the normal size.
The fifth phase, no sound phase, occurs when the pressure in the cuff exerts no compression on the artery and the vessel is full throughout its length.
It is generally conceded that the sounds heard are produced in the artery itself and not at the heart.