Disturbances of the Heart / Discussion of the Treatment of the Heart in Its Various Disorders, With a Chapter on Blood Pressure

by Oliver T. Osborne

Sometimes the compression of the arm by the armlet leads to a rise in blood pressure. [Footnote: MacWilliams and Melvin: Brit. Med. Jour., Nov. 7, 1914.] It has been suggested that the diastolic pressure be taken at the point where the sound is first heard on gradually raising the pressure in the armlet.

In some persons the auscultatory readings cannot be made, or are very unsatisfactory, and it becomes necessary to use the palpation method in taking the systolic pressure. In instances in which the auscultatory method is unsatisfactory, the artery below the bend of the elbow at which the reading is generally taken may be misplaced, or there may be an unusual amount of fat and muscle between the artery and the skin.

The various sounds heard with the stethoscope, when the pressure is gradually lowered, have been divided into phases. The first phase begins with the first audible sound, which is the proper point at which to read the, systolic pressure. The first phase is generally, not always, succeeded by a second phase in which there is a murmurish sound. The third phase is that at which the maximum sharp, ringing note begins, and throughout this phase the sound is sharp and intense, gradually increasing, and then gradually diminishing to the fourth phase, where the sound suddenly becomes a duller tone. The fourth phase lasts until what is termed the fifth phase, or that at which all sound has disappeared. As previously stated, the diastolic pressure may be read at the beginning of the fourth phase, or at the end of the fourth phase, that is, the beginning of the fifth; but the difference is from 3 to 10 mm. of mercury, with an average of perhaps 5 mm.; therefore the difference is not very great. When the diastolic pressure is high, for relative subsequent readings, it is much better to read the diastolic at the beginning of the fifth phase.

It is urged by many observers that the proper reading of the diastolic pressure is always at the beginning of the fourth phase. However, for general use, unless one is particularly expert, it is better to read the diastolic pressure at the beginning of the fifth phase. There can rarely be a doubt in the mind of the person who is auscultating as to the point at which all sound ceases. There is frequently a good deal of doubt, even after large experience, as to just the moment at which the fourth phase begins. With the understanding that the difference is only a few millimeters, which is of very little importance, when the diastolic pressure is below 95, it seems advisable to urge the reading of the diastolic pressure at the beginning of the fifth phase.

The incident of the first phase, or when sound begins, is caused by the sudden distention of the blood vessel below the point of compression by the armlet. In other words, the armlet pressure has at this point been overcome. Young [Footnote: Young: Indiana State Med. Assn. Jour., March, 1914.] believes that the murmurs of the second phase, which in all normal conditions are heard during the 20 mm. drop below the point at which the systolic pressure had been read, is "due to whirlpool eddies produced at the point of constriction of the blood vessel by the cuff of the instrument." The third phase is when these murmurs cease and the sound resembles the first, lasting he thinks for only 5 mm. The third phase often lasts much longer. He thinks the fourth phase, when the sound becomes dull, lasts for about 6 mm.

TECHNIC

It is essential that the patient on whom the examination is to be made should be at rest, either comfortably seated, or lying down. All clothing should be removed from the arm, and there should be no constriction by sleeves, either of the upper arm or the axilla. When the blood pressure is taken over the sleeve of a garment, the instrument will register from 10 to 30 mm. higher than on the bare arm. [Footnote: Rowan, J. J.: The Practical Application of Blood Pressure Findings, The JOURNAL A. M. A., March 18, 1916, p. 873.]

While it may be better, for insurance examinations, to take the blood pressure of the left arm in right handed persons as a truer indicator of the general condition, the difference is generally not great. The right arm of right handed persons usually registers a full 5 mm. higher systolic pressure than the left arm.

The patient, being at rest and removed as far as possible from all excitement, may be conversed with to take his mind away from the fact that his blood pressure is being taken. He also should not watch the dial, as any tensity on his part more or less raises the systolic pressure, the diastolic not being much affected by such nervous tension. The armlet having been carefully applied, it is better to inflate gradually 10 mm. higher than the point at which the pulsation ceases in the radial. The stethoscope is then firmly applied, but with not too great pressure, to the forearm just below the flexure of the elbow. The exact point at which the sound is heard in the individual patient, and the exact amount of pressure that must be applied, will be determined by the first reading, and then thus applied to the second reading. One reading is never sufficient for obtaining the correct blood pressure. The blood pressure may be read by means of the stethoscope during the gradual raising of pressure in the cuff, note being taken of the first sound that is heard (the diastolic pressure), and the point at which all sound disappears, as the pressure is increased (the systolic pressure). The former method is the one most frequently used.

By taking the systolic and diastolic pressures, the difference between the two being the pressure pulse, we learn to interpret the pressure pulse reading. While the average pressure pulse has frequently been stated as 30 mm., it is probable that 35 at least, and often 40 mm. represents more nearly the normal pressure pulse, and from 25 mm. on the one hand to 50 on the other may not be abnormal.