Taking blood pressure measurements is a routine part of medical visits,
regardless of the reason for the visit. Most patients are well accustomed to
having a Velcro cuff placed and inflated around their arm. In fact, blood
pressure machines are available to give readings at many local pharmacies or
drug stores, and blood pressure is even sometimes taken prior to dental
The measurement of blood pressure and the meaning of blood pressure both
have a long history. Although methods to measure the force of circulating blood
on blood vessel walls had their earliest days in the late 1800s and early
1900s, the meaning behind the numbers did not become clear until well into the
second half of the 20th century.
In 1943, the National Heart, Lung, and Blood Institute launched the
Framingham Heart Study to discover the cause of heart disease and stroke. At
that time, mortality due to heart disease and stroke had been steadily rising
for years. In 1961, the researchers discovered that high blood pressure —
once thought to be a normal part of aging —increased risk for heart
disease. In 1970, high blood pressure was also linked to stroke.
The earliest methods of measuring blood pressure required arterial
puncture. These methods are largely traced back to the work of Hales, Ludwig,
Faivre and Poiseuille, who introduced the measurement mm Hg. The sphygmograph
was the first noninvasive instrument used to measure blood pressure. Invented
in 1860 by Étienne Jules Marey, the sphygmograph determined blood
pressure by discovering the weight at which the radial pulse was obliterated.
Despite some adaption and modification of the instrument by different
researchers, it proved to have little clinical utility and was never adopted
throughout medical practice. Many physicians believed the finger to be just as
useful an instrument.
The next major milestone in blood pressure measurement was made by
Samuel Siegfriend Ritter von Basch in 1880. It was then that he first described
the sphygmomanometer, which consisted of a water-filled bulb connected to a
manometer. The manometer was used to determine the amount of pressure required
to obliterate the pulse, done by hand above the placed instrument. Again,
although a useful advance in science, the instrument was difficult to use in
day-to-day clinical practice.
Unlike many earlier attempts, a breakthrough came in 1896 when Scipione
Riva-Rocci introduced the mercury sphygmomanometer. Blood pressure instruments
today are only slightly different from Riva-Rocci’s early designs.
Riva-Rocci published four articles in the Gazzetta Medica Di
Torino; two discussed his new sphygmomanometer and two, the methods for
using it to measure blood pressure. His new instrument used an inflatable cuff
to obliterate the brachial artery and incorporated a mercury manometer.
Despite this breakthrough in design, all of these instruments could only
provide physicians with readings of systolic blood pressure, not diastolic.
The measurement of both diastolic and systolic blood pressure is most
often credited to Nicolai Korotkoff. In 1905, he presented a paper to the
Imperial Military Academy detailing a new technique for measuring blood
pressure that incorporated the use of the newly popularized stethoscope.
Later, reprinted in the Reports of the Imperial Military Medical
Academy, Korotkoff wrote, “The cuff of Riva-Rocci is placed on the
middle third of the upper arm; the pressure within the cuff is quickly raised
up to complete cessation of circulation below the cuff. Then, letting the
mercury of the manometer fall one listens to the artery just below the cuff
with a children’s stethoscope.” He further described the tones, or
lack of, that one could recognize to measure systolic and diastolic blood
An early sphygmomanometer of the von Basch
Courtesy of The National Library of
Korotkoff’s new method required much more skill on the part of the
physician, but it also seemed to be a turning point for the blood pressure
cuff’s popularity in the United States.
Harvey Cushing first brought a Riva-Rocci cuff to the United States in
1901 as a method to reduce mortality while patients were under anesthesia
during his early experiments with intracranial surgeries. Although Cushing had
been promoting the cuff’s use for almost a decade, more widespread
adoption of the blood pressure cuff did not occur until about 1910 with the
introduction of Korotkoff’s method. This new method, which required
knowledge of auscultation, was deemed much more worthy of a physician’s
Unlike the thermometer, a tool that was quickly passed to nurses, the
sphygmomanometer joined the ranks of other new instruments, such as the
stethoscope, that required the much more practiced skills of a physician. Soon
blood pressure measurements replaced pulse palpation as the standard practice
for assessing the force of blood flow.
After this, blood pressure measurements began to appear with more
regularity in clinical case reports and on patient charts. However, it took
years for a standardization of methods to be established and adopted by
physicians in the United States. In fact, physicians measured diastolic
pressure for many years by different sounds: either the “muffling” of
pulse sounds or the disappearance of pulse sounds.
The call for a standardized definition of diastolic blood pressure came
from a U.S. insurance company in 1917 and from the U.S. Bureau of Standards in
1924. However, it was not until the 1970s that one was established.
Despite its widespread use, the mercury sphygmomanometer’s days may
be numbered. The use of mercury in hospitals is slowly being banned due to the
element’s toxicity. In addition, more accurate digital or automated
devices are now available for use.
For more information:
- Crenner CW. Ann Intern Med. 1998;128:488-493.
- Laher M. BMJ. 1982;285:1796-1798.
- Lawrence C. Medical History. 1979;23:474-478.
- O’Brien E. Lancet. 1996;348:1569-1570.