4,500-Year Voyage: From Pulse Tension To Hypertension (2)
The road to the sphygmomanometer
Although physiologists who studied animals knew about the phenomenon of blood pressure in the 1700s, it was many years before physicians figured out how to measure it in humans.
Stephen Hales (1677-1761) a British physiologist was the first to be credited with direct blood pressure measurement in 1733. Hales studied the role of air and water in the maintenance of both plant and animal life. He also studied theology to become a priest and received a Bachelor of Divinity from Oxford. He was a practicing clergyman and devoted some of his time for scientific research. He became the father of sphygmomanometry for determining the blood pressure of animals. He bled to death sheep, dogs and a horse in his experiments. He was the first to measure arterial pressure8. After casting a white mare to the ground and tying her to a stable door, he laid open the carotid artery. Into it, he inserted a brass pipe which in turn was linked to a glass tube13. He measured a column of blood eight feet three inches tall above the level of the horse’s left ventricle (Fig. 5). The horse experiment was historic for the history of blood pressure. He kept bleeding the helpless horse and watching the effect on the pressure until the horse died. He then performed a post-mortem examination on it.
Carl Friedrich Wilhelm Ludwig (1816-1895): It was not until 1847 that human blood pressure was recorded by Ludwig, a German physician. Ludwig’s kymograph method used catheters inserted directly into the artery. He made the first graphical recording of BP using a U-shaped mercury manometer connected to a kymograph (wave writer). He was also a physiologist and devised the kymograph as a means of obtaining a written record of the variations in the pressure of the blood.
Karl Vierordt (1818-1884), a German physiologist made an instrument to measure the pulse pressure and called it Sphygmograph (Greek Spymo, pulse). In 1855, he found that with enough pressure, the arterial pulse could be obliterated. A cup was connected to a sensitive lever, which was placed on the pulsating radial artery and weights were placed on the cup until the pulse was obliterated. The arterial pulse lifted the cup in a rhythmic fashion and a pin connected to another lever produced a graphic record. It was a non-invasive method but it only measured the pulse amplitude7.
Etienne Jules Marey (1830-1904): A French physician who after taking his medical degree from Paris did not like the practice of medicine. He became a pioneer in movie picture and is credited as the father of cinematography. He was also interested in the pulse and developed Vierordt idea further in 1860. He invented the direct sphygmograph without arterial cannulation to be fixed on the forearm with a plate rest on the radial artery. Marey’s sphygmograph was one of the most famous scientific instrument of the 19th century7. Marey’s sphygmograph was portable and could easily be used by clinicians. The pulse could be recorded on paper away from the instrument (Fig. 6) It could accurately measure the pulse rate, but was very unreliable in determining the blood pressure. Yet his design was the first that could be used clinically with a small degree of success.
Samuel Siegfried Karl Ritter von Basch (1837-1904): Was a physician in Vienna who invented in 1881 another sphygmomanometer. His device consisted of a water-filled bag connected to a manometer. The manometer was used to determine the pressure required to obliterate the arterial pulse. His method was based on the principle of occluding the artery by external pressure and measuring that pressure when the pulse disappeared. His device was small, portable, and easy to use at the bedside7.
Yet his design was the first that could be used clinically with a small degree of success. century many modifications of the sphygmomanometer were produced in Europe but it is not necessary to mention all of them in this article.
Richard Bright (1789 – 1858): The story of hypertension, however, began with Richard Bright. His name appears in old medical textbooks as “Bright disease”, a vague and obsolete term for disease of the kidneys, acute or chronic.
Richard Bright enrolled at the University of Edinburgh, where he at first studied moral philosophy, political economy, natural philosophy and mathematics in 1808. The following year, he changed to medicine. Pathology and post-mortem examinations became his great interests, besides clinical work. In 1836 Bright published 100 autopsies with chronic kidney disease correlating clinical and pathological finding. He noted hypertrophy of the heart and blamed it on increased peripheral resistance14.
The shampooing surgeon’s grandson
Frederick Akbar Mahomed (1849 1884): One of the first to systemically incorporate the measurement of the blood pressure as part of the clinical evaluation. He was an English physician of Indian descent6. He was probably the first to advocate in clinical practice that hypertension could exist without renal disease and that it could be the cause, rather than the result, of renal disease. Mahomed great contribution to medicine was ignored or forgotten over the years either because his name was not so attractive to some, or because of the fact that he lived a very short life to be well known. Therefore, it would be is appropriate to provide more detailed information about his life and contributions.
Akbar s grandfather Sake (sheikh) Dean Mahomed (1759-1851) grew up in India. His Moslem first name Sake Dean must be Sheikh Al-dean, while Dean from Arabic, meaning religion (Islam). His offsprings changed the name Dean to Dene later to avoid racial discrimination. He served in the English Army as a trainee surgeon. At age 25 he immigrated in 1786 to Ireland, where he wrote and published his book, entitled The Travels of Dean Mahomet. He became the first Indian to write a book in English.
Sheikh Dean Mahomed moved to London first then to Brighton and opened the first shampooing vapour masseur bath in England. It was a type of Turkish bath, a cure to many diseases and giving full relief when everything fails; particularly gout, rheumatic or stiff joints, old sprains, aches and pains in the joints etc. So successful was his treatment that hospitals referred patients to him. King George IV honoured him with the appointment of Shampooing Surgeon to His Majesty George IV. He also became Shampooing Surgeon for William IV.
His grandson Frederick Akbar Mahomed at age 18 went to study medicine at the Royal Sussex County Hospital. At age 20, he entered Guys Hospital in London to study medicine and became interested in Marey’s sphygmograph. He modified the sphygmograph while still student15. In 1870 Akbar won the pupils’ Physical Society Prize for developing the sphygmograph two years before graduation in 1872. When he started medical residency in the hospital he became interested in Bright’s disease. He used his instrument clinically to measure pressure in patients with scarlet fever thereby becoming the first person to discover that raised blood pressure was an early sign of inflammation of the kidneys. While a second-year resident he published his observation with the sphygmograph in 1874:
"that the pulse of acute Blight’s disease closely resembles that which had previously been described and illustrated by the sphygmograph as occurring in chronic Blight’s disease, or more strictly speaking, with cirrhosis of the kidney. Both conditions were accompanied by a pulse of high tension . . . and especially was distinguished by a prolongation or undue sustension of the tidal wave15."
He had already, at this stage of his training, recognized that high BP existed as a separate event, and was the precursor and cause of albuminuria, rather than the reverse as it was believed then:
". . . previous to the commencement of kidney change, or to the appearance of albumin in the urine, the first condition observable is high tension in the arterial system15."
In 1879 he wrote:
I feel sure, that the clinical symptoms and the pathological changes resulting from high arterial pressure are frequently seen in cases in which very slight if any disease is discoverable in the kidney15.
Mahomed’s sphygmograph was clumsy except in his own hands (Fig. 7), He was able to diagnose several arterial aneurysms from its tracing. It actually measured the tension of the pulse rather than the BP itself8.
After qualification guys hospital in 1872, Mahomed obtained his MD degree from Brussels (1874) and MB from Cambridge (1881), and in 1880 he was elected Fellow of the Royal College of Physicians15.
Louis J. Acierno the author of The History of Cardiology stated:
"Mahomed should be credited with being the first to realize that acute nephritis is associated with an increase in arterial pressure. This was reported in his paper: The etiology of Bright’s disease and the prealbuminuric stage, published in 1874, only two years after qualifying as a medical practitioner. This was followed by a series of papers dealing with “arteriocapillary fibrosis” and the various clinical manifestations of Bright’s disease. He combined for the first time estimates of arterial tension, measured in troy ounces, with clinical and pathological observations8."
In his paper on the sphygmographic evidence of “arteriocapillary fibrosis” he commented on how he observed people with no overt evidence of kidney disease, either in the urine or otherwise, and yet, who manifested “high arterial tension”16.
Even in his collection of postmortem studies on the kidneys, he describes patients with “red contracted kidneys” with symptoms of heart disease or cerebral hemorrhage who had “signs of high arterial tension with the absence of albuminuria”17. Before Mahomed paper, it was assumed that the etiology of high BP was kidney disease. He recognized the existence of high BP without kidney disease. He stated:
"My first contention is that high pressure is a constant condition in the circulation of some individuals and that this condition is a symptom of a certain constitution or diathesis . . . These persons appear to pass on through life pretty much as others do and generally do not suffer from their high blood pressures, except in their petty ailments upon which it imprints itself . . . As age advances the enemy gains accession of strength ... the individual has now passed forty years, perhaps fifty years of age, his lungs begin to degenerate, he has a cough in the wintertime, but by his pulse, you will know him . . . Alternatively, headache, vertigo, epistaxis, a passing paralysis, a more severe apoplectic seizure, and then the final blow . . . Of this, I feel sure, that the clinical symptoms and the pathological changes resulting from high arterial pressure are frequently seen in cases in which very slight if any disease is discoverable in the kidney. The observations provide strong evidence of Gull and Sutton’s work. It appears to me that these clinical, and their pathological, observations must stand or fall together; that one is pathological, the other the clinical aspect of the same condition"17,18.
In October 1884, while working in the fever hospital, Mahomed, fell ill with typhoid fever and died in November 1884 at the age of 35. He had such fruitful but short professional career of just 15 years.
Louis J. Acierno commented on his death: “I wonder what he could have accomplished if he had lived for at least another two or three decades”8.
The mercury sphygmomanometer
Scipione Riva-Rocci (1863-1937): An Italian professor, developed the mercury sphygmomanometer in 1896 (Fig. 8). He reported a non-invasive method of obtaining BP that ultimately led to the present technique with mercury sphygmomanometer19. An inflatable cuff was placed over the upper arm to constrict the brachial artery. This cuff was connected to a glass manometer filled with mercury to measure the pressure exerted onto the arm. A column of mercury was used to quantify the pressure required to inflate a rubber cuff. The air was pumped until the pulse disappeared; it was then released until the pulse reappears and the reading was then taken (systolic BP)20.
Riva-Roccis cuff was too narrow, resulting in inaccurate measurements. Von Recklinghausen, a German professor in 1901 recognized this error and widened the cuff from 5 to 13 cm.
While all the above development on pulse and BP instruments was taking place in Europe during the 19th century, there was little, if any development, taking place in that field, across the ocean in the USA. In 1901, while travelling in Europe, the American neurosurgeon Harvey Cushing (1869-1939) visited Riva-Rocci in Pavia, Italy7. He saw Riva-Roccis blood pressure instrument in clinical use21. Cushing solicited a gift of one of the Riva-Rocci cuffs and brought it back with him to Baltimore, USA, where he began to encourage its use among the house officers at Johns Hopkins Hospital22. He introduced BP recording in anesthesia charts during surgery to check the heart strength. From 1912, Massachusetts General Hospital started BP measurement of all admissions20.
Cushing was not only a famous neurosurgeon but he was also a medical historian and is recognized as the biographer of Sir William Osler. One of his quotations I found
on the internet: “I would like to see the day when somebody would be appointed surgeon somewhere, who had no hands, for the operative part is the least part of the work”24.
The above method of determining BP was cumbersome and not very accurate. The stethoscope was already invented and available by that time but no one discovered its value for BP determination yet.
Necessity is the mother of invention
It was the Inhibition and shyness of a young physician that led to the invention of the stethoscope. The first stethoscope (Fig. 9) was fashioned in 1816 by a young French physician in Paris, Dr. Rene Theophile Hyacinthe Laennec (1781-1826). A young lady with signs and symptoms of heart disease was presented to him. He wanted to listen to the chest to confirm his diagnosis. The standard auscultatory technique for a physician then would be to press his head against the patient’s chest in order to listen to the resonations. He was too inhibited and shy to touch her chest. Rather than cause himself undue embarrassment, he rolled a piece of paper into a tube and used that rather than touch her chest. To his astonishment, he could hear the heart just as well as if he had put his ear on the chest.
He also found that the tubercle lesion were not limited to the lungs but could be present in all organs of the body; he did not, however, realize that the condition was infectious. His mother, his uncle and a close friend died with tuberculosis. Unfortunately while studying tuberculosis (Fig. 10), he contracted the disease and died at the early age of forty-five.
I never thought that a French man would be so shy to touch a lady. The Arab woman, in general, is inhibited of being examined by a male physician. When I was a child, a “doctor” from our village came back from a school in India. My father requested him to treat my anemic mother who complained of palpitation. She did not agree to be seen by a male doctor. She stood behind the door and I had to put the stethoscope over her chest for him to listen. He did not know what he was hearing anyway, because we found out later, that he was not a doctor. He was a dental technician.
From reading the history of medicine, I learned that the examination of the female pulse was approached differently than that of a male in many cultures such as the Chinese, the Indian and even the European. In ancient China, the female pulse was palpated across a bamboo curtain. The taboo against any form of physical contact with the female patient brought about the introduction of diagnostic dolls. The patient would mark the site of the disorder on the figurine.
Diagnostic dolls were also used during the victorian era in England8. Queen Victoria (1819-1901) was noted for her “great aversion” to the stethoscope. Sir James Reid, her attending physician said on remembering her: “the first time I had ever seen the Queen . . . in bed was when she was actually dying”, and it was only after her death that he discovered that she had “ventral hernia, and prolapse of the uterus” - proof that he had never given her a full physical examination20. It is possible that physicians then avoided the physical touch of female patients to prevent others from accusing them of indecent behaviour. A painter (W. Ward in 1802 after J. Opie) painted a physician taking a young lady’s pulse as seducer20 (Fig. 11).
For reasons unknown to me, the Hindus palpated the pulse on the right side in men, and on the left side in women8.
The stethoscope joins the sphygmomanometer
The marriage between the stethoscope and the sphygmomanometer was performed by a Russian. In 1905, a humble Russian surgeon, Nikolai Sergeyevich Korotkoff (1874-1920), described the sounds heard with a stethoscope placed over the brachial artery below the Riva-Rocci-von Recklinghausen cuff during slow deflation. With the Korotkoff method, it became easy for the first time in history to determine both systolic and diastolic BP. This bright Russian surgeon died at the young age of forty-six. His discovery was one of the most outstanding events in the history of medicine. It put in the hand of clinicians throughout the world an extremely simple diagnostic approach capable at the same time of being very accurate.
After 1910, physicians steadily simplified their practice of pulse palpation and accepted auscultation of systolic and diastolic blood pressure.
Korotkoff’s finding was the reason for the discovery of a disease that must have been present for millennia. The disease is hypertension, one of the leading causes of death in the world. Untreated, it could cause severe damage to the heart, kidneys, the brain, and other target organs. I was threatened with it as a high school student, probably due to a faulty sphygmomanometer when I complained of a headache. My headache then was caused by school tension rather than hypertension.¨
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Fig. 5: Hales BP measurement
Fig 6: Single pulse curve from a spygmograph
Fig 7a: Mahomeds sphygmograph.
Fig 7b: Mahomeds sphygmograph illustrated sketch.
Fig 8a: Riva-Rocci sphygmomanometer.
Fig 8b: Riva-Rocci sphygmomanometer diagram.
Fig. 9: Laennec using his stethoscope, repainted for Heart Views.
Fig. 10: Laennec examining a patient with lung disease, probably TB20
Fig 11: Suducer.
Fig 12: Stethescope anf Sphygmomanometer.