[Downloaded free from http://www.heartviews.org on Friday, October 09, 2015, IP: 197.32.93.122] HISTORY OF MEDICINE
4,500-YEAR VOYAGE: FROM PULSE TENSION TO HYPERTENSION
H.A. Hajar Albinali*, MD, FACC, FGHA The Blood Pressure and I Hypertension is still a frustrating problem for both p atient s and physicians in our region. I have Only recently during the 1950s, did physicians seen over the last couple of decades many become aware of the clinical import ance of high hypertensive p atient s not t aking their drugs, blood pressure (BP). The critical relationship thinking that they were cured because they felt between high blood pressure and mortality fine. It is dif ficult to convince some p atient s that caused by strokes, heart att acks, congestive this deadly disease could be silent. One p atient heart failure, and vascular disease is now well told me once: You doctors are not logical, how understood. could I be sick when I feel perfectly well . I came in cont act with hypertension probably Unlike epilep sy, tuberculosis or malaria which earlier than many of my colleagues. During my were known in our region for centuries and last year of high school in Doha, I was st aying described in both Arabic literature and Arabic awake late at night, studying very hard, aiming to medical books, hypertension which is probably maintain the top rank in my graduating class. I as old as mankind was not known or mentioned remember I hung a small poster I wrote in my in the old Arabic books. Measuring BP requires room quoting an Arabic poetry verse that could instrument ation that was not available in ancient be translated as follows: He, who seeks glory, times. Hence, I became interested in finding out accepts night s of sleep deprivation . But for me, when and how this devastating disease was sleep deprivation resulted in recurrent discovered. headaches. I was certainly not glorified, but rather horrified then. I consulted a Palestinian physician, a general practitioner (G.P.), in Rumailah hospit al, Dr . AboAlroub, (the literary meaning in Arabic Abo: Father , Alroub: butter milk . He was not father of hypertension for sure). He was my friend and I used to visit him socially and ask him about the study of medicine. During that time, because I was planning to be a physician, I wanted to join the club early . Therefore, I created friendship and maint ained good relations with several physicians in Rumailah hospit al. Dr . Aboalroub told me that I had hypertension due to stress of studying hard . He put me on diuretic t ablet s daily , probably hydrochlorothiazide. I returned to him two months later unable to study well with fatigue, p alpit ation, dizziness, severe weakness and muscular pain especially Fig. 1: Chinese feeling the Pulse: 23. of the legs. My BP was low but my blood test revealed very low pot assium level . He told me to First came the pulse stop the diuretic because it was the cause of the problem, drink a lot of orange juice, and sent me The Arab physicians during the 9 th century A.D. home. That GP probably did not know that very did not know blood pressure as we understand it low pot assium level required emergency today, as reflected by their books such as Al admission and intravenous potassium therapy. Razi s encyclopedic medical book Al-Hawi fit tib 1, Obviously I survived. A few days later, all the but they probably intuitively assessed the force of above symptoms resolved and my BP returned blood flow subjectively by pulse p alp ation. They to normal. knew the pulse very well, because it was known
*Chairman, Cardiology and Cardiothoracic Surgery Department, Hamad Medical Corporation, Doha, Qatar .
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by the Greeks, Egyptians and the Chinese before The Therapeutic Papyrus of Thebes 1552 BC them. The Egyptians knew that blood flowed st ated: through the body . The ancients did not know the concept of blood pressure as we know it today but If the physician places his finger on the head, the character and the force of the pulse could neck, arms, hand, feet or body, everywhere he will find the heart, for the heart leads to every have given them a feeling of the pressure and the member and speaks in the vessels of every blood flow. Not so ancient, but relatively recently, member 9. W illiam Osler at 1892 mentioned in his discussion on chronic Bright disease increased pulse The description in Ebers Papyrus is as tension rather than hypertension 2. follows: The Chinese were probably the first to recognize the pulse around 2500 BC (Fig. 1). To know the movements of the heart and to The Yellow Emperor s Classic of Internal know the heart ... From the heart arise the vessels which go to the whole body ... if the Medicine, Nei Ching, cont ain references to the physician lay his finger on the head, on the 3 pulse . The Chinese gained so much experience neck, on the hand, on the epigastrium, on by feeling the arterial pulses that they were able the arm or the leg, everywhere the motion of to associate the bad ef fect of salt on the arteries. the heart touches him, coursing through the The Nei Ching noted If too much salt is used for vessels to all the members ... When the 4 heart is diseased its work is imperfectly food, the pulse hardens . performed; the vessels proceeding from the heart become inactive, so that you cannot The Egyptians feel them ...If the heart trembles, has little power and sinks, the disease is 8 Ancient Egyptians knew the origin of the pulse advancing . and the pumping function of the heart 5 . The Egyptians were the first to suggest that air and If you examine a man for illness in his cardia, blood enters the heart, and the heart distributes and if he suffers from pain in his arms, in his 6 breast, and in one side of his cardia, it is death them to the rest of the body . threatening him 10. The pulse was mentioned by the Egyptians in the Edwin Smith Papyrus, 1600 BC (Fig.2), The The Greeks Therapeutic Papyrus Of Thebes, 1552 BC, and Ebers Papyrus, 1550 BC 7 . The Greeks thought that the pulse was due to air The Edwin Smith papyrus has the following which filled the arteries. Erasistratus advanced observations on the pulse and it s relationship to the belief that the pneuma in the arteries was the heart beat: derived from respiration. But Galen thought that the arteries are solid body and the pulse was that ... examining is like one counting a certain quantity peculiar action initiated of the heart . He with a bushel, or counting something with the described the main characteristics of the pulse: fingers ... like measuring the ailment of a man in 8 order to know the action of the heart. There are speed, size, strength, quality and tension . canals in it [the heart] to every member. Now if the priests of Sekhmet or any physician put his hands The Arabs or his fingers upon the head, upon the two hands, ... upon the two feet, he measures to the heart ... Arab medicine reached it s highest level between because its pulsation is in every member ... th th Measure ... his heart in order to recognize the the 8 and the 13 century when Baghdad was indications which have arisen therein; meaning ... the scientific capit al of the world. The Arab and in order to know what is befalling therein 8. Muslim physicians based much of their theoretical information and clinical practice in relation to the heart and the pulse mainly on the Greek medicine. Arab physicians took full advant age of their position in history, acquiring knowledge from Chinese, Greek and Indian writings, free from the influence of the magic of the dark ages. They translated the available knowledge of other Fig. 2: Counting the pulse as described hieroglyphic civilizations before them and preserved it. They characters in Smith p apyrus. Symbol on the right represent added their own observations and wisdom and seeds being emptied from container 8.
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4,500-year Voyage: From Pulse Tension to Hypertension
passed their contribution to the world civilization respected. That was true from the 8 th to the 13 th that followed. century AD except for one Arab physician, IBN The first physician who wrote about the pulse AL-NAFIS (1207-1288 A.D.) the Arab father of in Arabic was Abu Zakariya Yuhanna Ibn circulation, dared to say that Galen was wrong Masawayh (777-857) a Christian, known in Latin on two accounts: the circulation and the literature as Mesue Senior. He learned anatomy nourishment of the heart muscles. by dissecting animals. He was a physician to the Ibn Al-Nafis wrote his finding in his manuscript caliph in Baghdad and a hospit al director . The of anatomy book ( Sharh Al Tashrih ) dated 1333. Galenic pulse was modified and greatly It was published only recently, 1988 in Cairo. A improved by Al Razi (Rahazes 865-932) 7 . few years before it s publication, I had to go to the Ibn Sina (Avicenna 980-1037A.D.) wrote in W ellcome library of medicine in London to see a his book The Canon, a det ailed description of the copy. It was very well preserved as if it was pulse, characteristics, and variation in health and written that day. I read the information related to disease. He was considered the successor of the circulation while librarian stood by watching Galen, and he kept that position for 500 years. me all the time until I gave it back to him. The He devoted a large portion of his work to the library provided me with a slide copy of that p age study of the pulse. He described more than 50 (Fig. 3). identifiable pulses. Avicenna wrote in The Ibn Al-Nafis did not accept Galen s and Ibn Canon: Sina s concept (Fig. 4) that the right heart cavity is full of blood and the lef t heart cavity is full of The pulse is a movement in the heart and vit al spirit s . . . and the blood from the right cavity arteries . . . which takes the form of alternate reaches the lef t cavity through pores across the expansion and contraction 7 . interventricular septum 11. Ibn Al-Nafis opposed that concept, first on He also referred to the pulse in his Arabic logical reasoning, If the blood from the right poetry: Dif ferences in pulsation mean illness ventricle will go directly to the lef t ventricle and causation . The Arabs referred to Galen as without modification, it will spoil the spirit . Then THE PHYSICIAN . His teaching was highly he added Anatomy proved that they were
Fig 3a: Ibn Alnafis manuscript first p age. Fig 3b: Ibn Alnafis manuscript.
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wrong. There were no visible nor invisible holes receive nourishment from the arteries [coronary in the interventricular septum 11. arteries] that p ass through it, not directly from the Ibn Al Nafis said that blood from right heart blood in the heart cavity as Galen claimed. He cavity goes to the lung through the Arterialized described his finding in his book Sharh Al Vein (Pulmonary Artery). In the lungs the blood Tashrih four hundred years before Harvey divides into two: thin blood filters through published De Motu Cordis . Ibn Al Nafis book pores of the arterialized vein (pulmonary was available for Harvey to see when he went to Artery) and thick blood remains in the lung for It aly to study in Padua University. it s nutrition. The thin blood mixes with the air Ibn Al Nafis wrote more than twenty books, that comes from the trachea and enters the including Alshamil , a multivolume encyclopedia vein-like artery (pulmonary veins) through it s of medicine. He also wrote books on pediatrics wall. The thin blood mixed with air, reach the and ophthalmology. He devoted one paper to the lef t heart cavity , the center where vit al spirit pulses. form. The spirit moves from the lef t heart W estern writers admit that: The Arabic cavity to the aort a and the rest of the arteries teaching on the pulse became standard to the tissues. reference works, many of which have survived So Ibn Al-Nafis suggested that blood moves into the present day 7. from Arteries to V eins across the wall inside the Until the death of Ibn Al Nafis in 1288, there lungs, but his student, Ibn Al Quff , explained was no mention of blood pressure or later in his book kit ab al-omda fi sina at altib , i.e., hypertension in the medical literature. A few basic works concerning the art of surgery 12, and centuries later , physiologist s made the discovery. proposed the existence of capillaries. This was not actually confirmed until the era of the The road to sphygmomanometer microscope when Malphighi saw the capillaries in 1661. Although physiologist s who studied animals Ibn Al Nafis also said that the heart muscles 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 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 sheeps, dogs and a horse in his experiment s. He was the first to measure arterial pressure 8 . Af ter casting a white mare to the ground and tying her to a st able door, he laid open the carotid artery. Into it he inserted a brass pipe which in turn was linked to a glass tube 13. He measured a column of blood eight feet three inches t all above the level of the horse s lef t ventricle (Fig. 5). The horse experiment was historic for the history of blood pressure. He kept bleeding the helpless horse and watching the ef fect on the pressure until the horse died. He then performed a post-mortem examination on it 7. Carl Friedrich Wilhelm Ludwig (1816-1895): It Fig 4: Galen physiology.
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He became a pioneer in movie picture and is credited as the father of cinematography. He was also interested in the pulse and developed Vierord t 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 19 th century 7. 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
Fig. 5: Hales BP measurement Repainted for Heart Fig 6: Single pulse curve from a spygmograph views 8. was not until 1847 that human blood pressure was the first that could be used clinically with a was recorded by Ludwig, a German physician. small degree of success. The Ludwig s kymograph method used catheters inserted directly into the artery. He made the first Samuel Siegfried Karl Ritter von Basch graphical recording of BP using a U-shaped (1837-1904): W as a physician in V ienna who mercury manometer connected to a kymograph invented in 1881 another sphygmomanometer. (wave writer). He was also a physiologist and His device consisted of a water-filled bag devised the kymograph as a means of obtaining connected to a manometer . The manometer was a written record of the variations in the pressure used to determine the pressure required to of the blood. obliterate the arterial pulse. His method was based on the principle of occluding the artery by Karl Vierordt (1818-1884), a German external pressure and measuring that pressure physiologist made an instrument to measure the when the pulse disappeared. His device was pulse pressure and called it Sphygmograph small, port able, and easy to use at the bedside 7. (Greek Spymo, pulse). In 1855, he found that During the 19 th century many modifications of with enough pressure, the arterial pulse could be the sphygmomanometer was produced in obliterated. A cup was connected to a sensitive Europe but it is not necessary to mention all of lever , which was placed on the pulsating radial them in this article. artery and weight s were placed on the cup until the pulse was obliterated. The arterial pulse lif ted Richard Bright (1789 1858): The story of the cup in a rhythmic fashion and a pin hypertension, however, began with Richard connected to another lever produced a graphic Bright. His name appears in old medical record. It was a non-invasive method but it only textbooks as Bright disease , a vague and measured the pulse amplitude 7. obsolete term for disease of the kidneys, acute or chronic. Etienne Jules Marey (1830-1904): A French Richard Bright enrolled at the University of physician who af ter t aking his medical degree Edinburgh, where he at first studied moral from Paris did not like the practice of medicine. philosophy, political economy, nature philosophy
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and mathematics in 1808. The following year, he old sprains, aches and p ains in the joint s etc. So changed to medicine. Pathology and post- successful was his treatment that hospit als mortem examinations became his great referred p atient s to him. King George IV interest s, besides clinical work. In 1836 Bright honored him with the appointment of published 100 autopsies with chronic kidney Shampooing Surgeon to His Majesty George disease correlating clinical and p athological IV . He also became Shampooing Surgeon for finding. He noted hypertrophy of the heart and W illiam IV . blamed it on increased peripheral resist ance 14. His grand son Frederick Akbar Mahomed at age 18 went to study medicine at the Royal The shampooing surgeon’s grandson Sussex County Hospital. At age 20, he entered Guys Hospital in London to study medicine and Frederick Akbar Mahomed (1849 1884): One became interested in Marey s sphymograph. He of the first to systemically incorporate the modified the sphymograph while still student 15. In measurement of the blood pressure as part of 1870 Akbar won the pupils Physical Society the clinical evaluation. He was an English Prize for developing the sphygmograph two physician of Indian descent 6. He was probably years before graduation in 1872. When he the first to advocate in clinical practice that st arted medical residency in the hospit al he hypertension could exist without renal disease became interested in Bright s disease. He used and that it could be the cause, rather than the his instrument clinically to measure pressure in result, of renal disease. Mahomed great patient s with scarlet fever thereby becoming contribution to medicine was ignored or forgotten the first person to discover that raised blood over the years either because his name was not pressure was an early sign of inflammation of the so attractive to some, or because of the fact that kidneys. While a second year resident he he lived a very short life to be well known. published his observation with the Therefore, it would be is appropriate to provide sphygmograph in 1874: more detailed information about his life and contributions. that the pulse of acute Blight s disease closely Akbar s grandfather Sake (sheikh) Dean resembles that which had previously been described and illustrated by the sphygmograph Mahomed (1759-1851) grew up in India. His as occurring in chronic Blight s disease, or Moslem first name Sake Dean must be Sheikh more strictly speaking, with cirrhosis of the Al-dean, while Dean from Arabic, meaning kidney. Both conditions were accompanied by a religion (Islam). His of fsprings changed the pulse of high tension . . . and especially was name Dean to Dene later to avoid racial distinguished by a prolongation or undue sustension of the tidal wave 15. discrimination. He served in the English Army as a trainee surgeon. At age 25 he immigrated in He had already, at this st age of his training, 1786 to Ireland, where he wrote and published recognized that high BP existed as a sep arate his book, entitled The Travels of Dean event, and was the precursor and cause of Mahomet . He became the first Indian to write a albuminuria, rather than the reverse as it was book in English. believed then: Sheikh Dean Mahomed moved to London first then to Brighton and opened the first . . . previous to the commencement of kidney shampooing vapor masseur bath in England. It change, or to the appearance of albumien in the urine, the first condition observable is high was a type of Turkish bath, a cure to many tension in the arterial system 15. diseases and giving full relief when every thing fails; p articularly gout, rheumatic or stif f joint s, In 1879 he wrote:
Fig 7a: Mahomed s sphygmograph. Fig 7b: Mahomed s sphygmograph illustrated sketch.
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of arteriocapillary fibrosis he commented on I feel sure, that the clinical symptoms and the how he observed people with no overt evidence pathological changes resulting from high of kidney disease, either in the urine or otherwise, arterial pressure are frequently seen in cases in 16 which very slight, if any disease is discoverable and yet, who manifested high arterial tension . in the kidney 15. Even in his collection of postmortem studies on the kidneys, he describes p atient s with red Mahomed s sphymograph was clumsy except contracted kidneys with symptoms of heart in his own hands (Fig. 7), He was able to disease or cerebral hemorrhage who had signs diagnose several arterial aneurysms from it s of high arterial tension with absence of tracing. It actually measured the tension of the albuminuria 17. Before Mahomed paper, it was pulse rather than the BP it self 8 . assumed that the etiology of high BP was kidney Af ter qualification in Guys hospit al in 1872, disease. He recognized the existence of high BP Mahomed obtained his MD degree from with out kidney disease. He st ated: Brussels (1874) and MB from Cambridge (1881), and in 1880 he was elected Fellow of the Royal My first contention is that high pressure is a 15 constant condition in the circulation of some College of Physicians . individuals and that this condition is a symptom Louis J. Acierno the author of The History of of a certain constitution or diathesis . . . These Cardiology st ated: persons appear to pass on through life pretty much as others do and generally do not suffer Mahomed should be credited with being the first from their high blood pressures, except in their to realize that acute nephritis is associated with petty ailments upon which it imprints itself . . . an increase in arterial pressure. This was As age advances the enemy gains accession of reported in his paper: The etiology of Bright s strength ... the individual has now passed forty disease and the prealbuminuric stage, years, perhaps fifty years of age, his lungs published in 1874, only two years after begin to degenerate, he has a cough in the qualifying as a medical practitioner. This was winter time, but by his pulse you will know him . followed by a series of papers dealing with . . Alternatively, headache, vertigo, epistaxis, a arteriocapillary fibrosis and the various clinical passing paralysis, a more severe apoplectic manifestations of Bright s disease. He seizure, and then the final blow . . . Of this, I feel combined for the first time estimates of arterial sure, that the clinical symptoms and the tension, measured in troy ounces, with clinical pathological changes resulting from high and pathological observations 8. arterial pressure are frequently seen in cases in which very slight, if any disease is discoverable in the kidney. The observations provide strong In his p aper on the sphygmographic evidence 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 the pathological, the other the clinical aspect of the same condition 17,18.
In October 1884, while working in the fever hospit al, Mahomed, fell ill with typhoid fever and died in November 1884 at the age of 35. He had such fruit ful but short professional career of just 15 years. Louis J. Acierno commented on his death: I
Fig 8a: Riva-Rocci sphygmomanometer. Fig 8b: Riva-Rocci sphygmomanometer diagram.
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wonder what he could have accomplished if he had lived for at least another two or three decades 8.
The mercury sphymomanometer
Scipione Riva-Rocci (1863-1937): An It alian professor, developed the mercury sphygmomanometer in 1896 (Fig. 8). He reported a non-invasive method of obt aining BP that ultimately led to the present technique with mercury sphygmomanometer19 . An inflat able cuf f was placed over the upper arm to constrict the brachial artery . This cuf f 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 cuf f. The air was pumped until the pulse disappeared; it was then released until the pulse reappears and the reading was then t aken (systolic BP) 20 . Riva-Rocci s cuf f was too narrow, resulting in inaccurate measurements. V on Recklinghausen, a German professor in 1901 recognized this error and widened the cuf f from 5 to 13 cm. Fig. 9: Laennec using his stethoscope, repainted for Heart While all the above development on pulse and Views. BP instrument s was t aking 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 traveling in It was the Inhibition and shyness of a young Europe, the American neurosurgeon Harvey physician that led to the invention of the Cushing (1869-1939) visited Riva-Rocci in stethoscope. The first stethoscope (Fig. 9) was Pavia, It aly 7. He saw Riva-Rocci s blood fashioned in 1816 by a young French physician pressure instrument in clinical use 21. Cushing, in Paris, Dr. Rene Theophile Hyacinthe solicited a gif t of one of the Riva-Rocci cuf fs and Laennec (1781-1826) . A young lady with signs brought it back with him to Baltimore, USA, and symptoms of heart disease was presented where he began to encourage its use among the to him. He wanted to listen to the chest to house officers at Johns Hopkins Hospit al 22. He confirm his diagnosis. The st andard introduced BP recording in anesthesia chart s auscult atory technique for a physician then during surgery to check the heart strength. From would be to press his head against the p atient s 1912, Massachusetts General Hospital st arted chest in order to listen to the resonations. He BP measurement of all admissions 20 . was too inhibited and shy to touch her chest. Cushing was not only a famous neurosurgeon Rather than cause himself undue but he was also a medical historian and is embarrassment, he rolled a piece of p aper into recognized as the biographer of Sir W illiam a tube, and used that rather than touch her Osler. One of his quot ations I found in the chest. To his astonishment, he could hear the internet: I would like to see the day when heart just as well as if he had put his ear on the somebody would be appointed surgeon chest. somewhere, who had no hands, for the operative He also found that the tubercle lesion were part is the least p art of the work 24. not limited to the lungs but could be present in all The above method of determining the BP was organs of the body; he did not, however, realize cumbersome and not very accurate. The that the condition was infectious. His mother, his stethoscope was already invented and available uncle and a close friend died with tuberculosis. by that time but no one discovered it s value for Unfortunately while studying tuberculosis (Fig. BP determination yet. 10), he contracted the disease and died at the Necessity is the mother of invention early age of forty-five.
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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 af ter her death that he discovered that she had ventral hernia, and prolap se of the uterus - proof that he had never given her a full physical examination 20. It is possible that physicians then avoided physical touch of female p atient s to prevent others from accusing them with indecent behavior . A painter (W. Ward in 1802 af ter J. Opie) p ainted a physician t aking a young lady s pulse as seducer 20 (Fig. 1 1). For reasons unknown to me, the Hindus palp ated the pulse on the right side in men, and on the lef t side in women 8.
Fig. 10: Laennec examining a patient with lung disease, probably TB 20. 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 palpit ation. 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 any way, because we found out later, that he was not a doctor. He was a dent al 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 Fig 11: Suducer. and even the European. In ancient China, the female pulse was palp ated across a bamboo The stethoscope joins the curt ain. The t aboo against any form of physical sphygmomanometer cont act with the female p atient brought about the introduction of diagnostic dolls. The patient would The marriage between the stethoscope and the mark the site of the disorder on the figurine. sphygmomanometer was performed by a Diagnostic dolls were also used during Russian. In 1905, a humble Russian surgeon, Victorian era in England 8. Queen Victoria (1819- Nikolai Sergeyevich Korotkoff (1874-1920), 1901) was noted for her great aversion to the described the sounds heard with a stethoscope stethoscope. Sir James Reid, her attending placed over the brachial artery below the Riva-
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4,500-year Voyage: From Pulse Tension to Hypertension
Rocci-von Recklinghausen cuff during slow References: deflation. W ith the Korotkof f method it became easy for the first time in history to determine both 1. Al Razi: Alhawi fit tib . 2000; Dar Alkutob systolic and diastolic BP . This bright Russian Alalmyyah, Beirut. 2. William Osler: The principle and practice of surgeon died at the young age of forty six. His Medicine, D. Appleton & Com. p.754. discovery was one of the most out st anding 3. Veith, Ilza: The yellow Emperor s classic of events in the history of medicine. It put in the internal medicine . 1949; Univ. of California press. hand of clinicians throughout the world an 4. Michael Wood et al : Athe Ancient medicine. extremely simple diagnostic approach capable at 2000; Runestone Press. the same time of being very accurate. 5. Rashkind W J: Historical aspects of surgery for Af ter 1910, physicians steadily simplified their congenital heart disease. J. Thorasic. Cardiovas . practice of pulse p alp ation and accepted Surg. 1982; 84:619-625. auscult ation of systolic and diastolic blood 6. P. Ghalioungui: Ktoof min tareekh et-tib (Arabic). pressure. 7. N. H. Naqvi and Blaufox: Blood Pressure Korotkof f s finding was the reason for the measurement. 1998; The Parthenon Publishing discovery of a disease that must have been Group. present for millennia. The disease is 8. Louis J. Acierno: The History of Cardiology , hypertension, one of the leading causes of death 1994; The Parthenon Publishing Group. 9. V. Robinsons: The story of medicine , Tudor in the world. Untreated, it could cause severe Publishing co. 1931; p.22 damage to the heart, kidneys, the brain and 10. Ebers papyrus J. of Royal . Phys. of London other t arget organs. I was threatened with it as a 1984;18(3):182-186. high school student, probably due to a faulty 11. Ibn Al Nafis: Sharh Tashreeh Al Canon. 1988; sphygmomanometer when I complained of Egyptian Gen. Auth. For book. (Arabic) headache. My headache then was caused by 12. Ibn Al Quff: Kitab al-omda fi at altib (Arabic) school tension rather than hypertension. ♦ printed in Hyderbad, India. 13. Bettmann Otto: A pictorial history of medicine . 1956; Charles C. Thomas Publisher. 14. Bright, R. Tabular view of morbid appearance in 100 cases of hypertension connected with albuminous urine. With observation. 1836; Guy s hospital. Rep.1, 380. 15. Lewis O. J. of Human Hypertension. 1997; 11: 255-261. 16. Mahomed F.A. 3. On the sphygmographic evidence of arteriocappillary fibrosis. 1877; Trans. Path.soc. 28, 394. 17. Mahomed F.A. On chronic Bright disease, and its essential symptoms. Lancet 1879; I: 46. 18. Mahomed F.A.. Some clinical aspects of chronic Bright disease. 1879; Guy s Hosp. Rep., 3rd. ser., 24, 363. 19. Riva-Rocci, S. un nuovo sfigmomanometro. Gasetta medical di Torino. 1986; 47: 51 &52. 20. Porter Roy: Greatest Benefit to mankind. 1997; Harper Collins Publishers. 21. Cushing H. On routine determinations of arterial tension in operating room and clinic. Boston Medical and Surgical Journal. 1903; 148:250-2 22. Fulton JF. Harvey Cushing: A Biography. Springfield, IL; Charles C. Thomas publisher. 1946:178-9, 184. 23. Lyones A. S: Medicine an Illustrated History 1912; Abradale Press. 24. Letter to Dr Henry Christian Nov 20, 1911. Fig 12: Stethescope anf Sphygmomanometer. http://www.surgical-tutor.org.uk/default- home.htm?surgeons/cushing.htm~right
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