116 IRE TRANSACTIONS ON B10-MEDICAL ELECTRONICS A pril

Blood Pressure Measuring Methods*

HAMPTON W. SHIRERt, M.D., ASSOCIATE, IRE

Summary-Blood pressure can be measured directly or in- to review some of the more significant methods and to
directly. While direct methods provide the maximum quantity mention a few problems that remain unsolved.
of reliable information from probes inserted into the blood
stream, indirect methods produce much less disturbance to the CHARACTERISTICS OF BLOOD PRESSURE AND ITS SOURCE
subject. Indirect methods are based on the adjustment of a
known external pressure to equal the vascular pressure. Systolic The requirements of a measurement method are set to
and diastolic pressure can be determined intermittently from a large extent by the characteristics of the quantity to be
the pressure that will just collapse the vessel; an approxima- measured and its source. Briefly, the systemic arterial cir-
tion of the instantaneous pressure level is obtained from a sur- cuit, consisting of branched, distensible tubes, carries blood
rounding chamber adjusted to remove all vessel wall tension.
Direct methods can provide continuous, high fidelity recordings with little pressure drop from the heart to the load resist-
of the absolute vascular pressure via a catheter either to trans- ance of the arterioles and precapillaries. After losing most
mit the blood pressure through liquid to an external sensor or to of its pressure in the load, the blood returns at low pres-
carry the signal leads from a miniature internal sensor. External sure to the heart via highly distensible veins. The right
sensors require careful adjustment of the catheter dimensions to heart then pumps it through the pulmonary circuit which
obtain optimum dynamic response. Internal sensors provide the
maximum dynamic response and avoid acceleration artifacts. is similar to the systemic circuit but operates at a lower
Convenience of electrical signal manipulation, display and record- pressure due to the smaller load resistance. The blood re-
ing have made electrical transducers increasingly popular. turning from the pulmonary bed is then pumped by the
left heart into the aorta, the input of the systemic circuit.
INTRODUCTION The heart supplies blood to both circuits as simultaneous
B LOOD PRESSURE is one of the most frequently intermittent flow pulses of variable rate and volume.
measured quantities in medical and physiological The pressure and flow recorded from the ascending
practice [1]. The determination of only its maxi- aorta of an anesthetized dog are shown in Fig. 1. Similar
mum and minimum levels during each cardiac cycle, when recordings made from other mammals have much the same
supplemented by information gained from other diagnostic appearance. The blood pressure pulse is composed of a
procedures, allows estimates to be made of some important large sustained (dc) component, the mean blood pressure,
vascular conditions and of certain aspects of cardiac per- about which a pulsating (ac) component, the pulse pres-
formance. This can be done with simple equipment and sure, fluctuates. The shape of the pressure pulse is the
with negligible discomfort to the subject. Considerably resultant of both the cardiac output flow waveform and
more information is obtained by continuously recording the nature of the vascular load impedance. As pressures
the instantaneous level of pressure directly from the blood are recorded in arteries progressively farther from the
stream. A number of proposals have been made for the heart, the pressure pulse changes somewhat in shape and
calculation of cardiac output [2], aortic flow [31, and increases in peak-to-peak magnitude until the smaller ar-
vascular wall characteristics [4] from analysis of the teries are reached. The mean level of pressure changes
shape of the recorded pressure pulse. Waveform record- very little, however, until the smaller arterial branches are
ing from the cardiac chambers and great vessels is in- reached since most of the resistance to flow resides in the
valuable in the diagnosis of cardiac abnormalities [5]. terminal arterioles. The maximum pressure reached dur-
The additional information obtained by the direct record- ing cardiac ejection is termed systolic pressure and is
ing of pressure is gained, however, at the expense of about 125 mm Hg in the figure. The minimum pressure oc-
considerable increase in the disturbance to the subject and
the complexity of equipment.
Thus, the clinical or laboratory investigator finds that he
must weigh the need for maximum information against the
degree of disturbance he is willing to have the subject
experience.
Today, a large variety of blood pressure measuring
methods is available, each developed with the intent of pro-
viding a maximum of reliable information with a mini-
mum of disturbance. It is the purpose of this discussion
* Received by the PGBME, October 30, 1961.
t General Motors Corporation, Defense Research Laboratories, Fig. 1-Blood pressure and flow recorded from the ascending aorta
Warren, Mich. of an anesthetized dog.

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1962 S1Sirer: Blood Pressure Measuring Methods 117

curring at the end of ventricular relaxation, the diastolic tending from dc that is required of the pressure record-
pressure, is about 88 mm Hg in the example. The average ing system is determined from an estimation of the
or mean pressure over one cardiac cycle is usually found highest heart rate expected and the number of signifi-
to be close to the sum of the diastolic pressure and '3 of cantharmonics. The upper cutoff frequencies for man,
the pulse pressure. dog, and the extreme case of the shrew, are shown in
The parameters associated with the pressure of the Table I. The recent advent of intracardiac heart sound
cardiovascular system that should be considered in its recording and the fact that such sounds are manifested
measurement are summarized in Table I. All but one of as pressure fluctuations, will require the cutoff fre-
the parameters listed are analogous to those considered in quency to be revised upward one or two orders of mag-
measuring most physical variables, whether they are in nitude when the same system is used to record both pres-
living or nonliving systems and regardless of whether they sure and sound. Other factors, too, will tend to move the
are mechanical, fluid, or electrical in nature. cutoff frequency requirements to higher values as more
1) The magnitude of blood pressure encountered in emphasis is placed on the significance of small and brief
most mammals, including man, rarely falls outside the pressure transients.
range of a few mm Hg below to 300 mm Hg above at-
mospheric pressure. Negative pressures do not occur in 3) The source impedance of a variable must be con-
sidered to determine the degree to which the variable
the arterial system but are present momentarily in the
veins of the thoracic cavity and in the heart chambers. will be disturbed by the load imposed by the measuring
process. The impedance presented by the cardiovascular
2) Since the pressure pulse is not sinusoidal and has a system is complex, consisting of a resistive, an elastic
large sustained component, its frequency content con- and a mass component. For most pressure determina-
sists of a zero frequency (dc) component, a funda- tions, only the first two require consideration. Since the
mental component at the heart rate, and harmonics of output resistance of the heart is effectively in parallel
the fundamental rate. To obtain the pressure pulse with- with that of the peripheral load, the source resistance of
out distortion, all contained frequency components must the arterial system is somewhat less than the peripheral
be recorded with equal amplification and time delay. load resistance. The input resistance of all devices used
Various authors have suggested that blood pressure for the measurement of blood pressure is infinite, since
pulses contain from 6 to 20 significant harmonics de- they require no sustained flow of blood; they do, how-
pending on the conditions, site of measurement and or- ever, possess a finite volume elasticity. In dog and man,
ganism. The range of uniform frequency response ex- the direct, intravascular arterial source impedance is

TABLE I
PARAMETERS ASSOCIATED WITH CARDIOVASCULAR PRESSURE

Range -10 to +300 mm Hg

1) Magnitude Typical Systolic/diastolic: 130/80 mm Hg
Adult Man Mean: 100 mm Hg
Mean (dc) Component plus
Fundamental (heart rate) plus 6 to 30 harmonics
2) Frequency Spectrum Man 1-3.3 beats/sec 20 cps 66 cps
Dog 1 .5-5 beats/sec 30 cps 100 cps
Shrew 12-22 beats/sec 72 cps 440 cps
Resistance Volume Elasticity
3) Source Impedance
Man 1 mm Hg-sec/ml, (Aorta) 0.3-10 mm Hg/ml, [7].
Dog 3 mm Hg-sec/ml, (Arterial system) 0.1-1.0 mm Hg/ml [6l.
Turbulence
4) Noise Acceleration I Position, ± ig; Ascending aorta, 1-8g; Heart, 0.1-2g.
Temperature Ambient to body, 200 C
Stray electric currents, electric and magnetic fields
Viscosity 3-4Xwater; temperature, composition, and tube diameter dependent
5) Blood
Coagulable
6) Accessibility indirect via elastic and viscous tissue
Direct via vessel puncture

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118 IRE TRANSACTIONS ON BIO-MEDICAL ELECTRONICS April
many times lower than that of even such highly com- such manipulations that permit its sensing through the
pliant devices as liquid manometers and their use pro- interposed tissue. In the first case problems associated
duces very little change in systemic pressure. This is with trauma and clotting are encountered; in the latter,
not the case for smaller animals, however, which re- a number of uncertainties due to the rigidity, compli-
quire the use of systems of low compliance to avoid pro- ance, changing volume and irritability of the interposed
ducing serious disturbances. tissue are of major concern.

4) Any deflection or indication at the output of a meas- COUPLING METHODS

uring system that results from something other than the Blood pressure measuring methods rather naturally
desired characteristic of the subject quantity is classed divide themselves, according to the means of coupling, into
as noise. In some cases real components of the subject the direct or intravascular class and the indirect or blood-
quantity may be regarded as noise because they are of less class. Those of the direct class yield a maximum of
no immediate interest and tend to confuse the desired reliable information but require the trauma of vessel punc-
components. Most troublesome, however, are those fac- ture with its several associated problems. Those of the in-
tors in both the subject and instrument that produce de- direct class provide far less information, but also produce
flections unrelated to the desired quantity and that would less disturbance to the subject.
not appear if ideal sensing methods were available. A The routine clinical method of measuring blood pressure
common offender of this sort is acceleration. It is difficult with the sphygmomanometer is the most familiar example
to make a pressure sensing system that is not subject to of the indirect method. Based on the technique introduced
deflection by the acceleration of part of its mass or the by Riva-Rocci [8], it can determine intermittently only
coupling liquid. Small accelerations can be produced by the systolic and diastolic levels from the pressure in a
simple position changes. Sensors placed in the heart surrounding cuff that will interrupt the flow in the
chambers or great vessels will tend to ride the flow contained vessel by just exceeding the pressure within the
stream and, therefore, experience the same acceleration, vessel. A second indirect method introduced by Huirthle
or more, when struck against the vessel or heart wall. requires that the segment of limb containing the vessel be
The accelerations of active subjects will be added to enclosed in a noncompliant, liquid-filled chamber [9].
those mentioned above. Temperature fluctuation can also When sufficient liquid is added to the chamber to just "un-
be quite troublesome by producing dimensional changes load" or remove all tension from the vessel wall, the cham-
and altering viscous damping. The change from room to ber pressure will equal that within the vessel [10]-[14].
body temperature is often encountered by critical com- The direct method couples the pressure-sensing element to
ponents of the pressure sensing elements. In addition the blood stream via a catheter or needle inserted through
some sensors are susceptible to stray currents arising the vessel wall. The catheter may either serve to conduct
from the organism or currents and electrostatic and the endovascular pressure to an external transducer by
magnetic fields arising from other measuring devices contained liquid or to carry the connecting leads from an
being used simultaneously. internal transducer to the external indicating equipment.
Indirect Riva-Rocci Method
5) Blood will coagulate when it comes in contact with
foreign material. Even when rendered noncoagulable by The Riva-Rocci method requires the simultaneous de-
termination of the occlusive cuff pressure and the state
certain agents, it still tends to deposit solid material on
irregular surfaces. Such deposits can produce serious of flow in the vessel. In the common clinical instrument,
harm to the subject if they break loose and circulate in the sphygmomanometer, the cuff pressure is produced with
the blood stream. Where orifices must be maintained at a squeeze bulb air pump and measured with a mercury or
precise diameters for damping purposes, some means is aneroid manometer. Electrical pressure-sensing means are
required to prevent such deposits from occurring. The used in automatic recording sphygmomanometers. The
viscosity of blood is several times that of water and, onset and disappearance of flow interruption are sensed by
like most watery mixtures, decreases about 2 per cent a variety of methods, as discussed below. The graph of
Fig. 2 illustrates the operation of the method. Initially, the
per degree Centigrade temperature increase. In addition it
is altered by the concentrations of formed elements and cuff pressure is raised to a level well above systolic pres-
protein which vary from time to time in both healthy sure terminating all signs of flow in the region distal to
and diseased states. Thus, the addition of but a small the cuff. The pressure in the cuff is then released at a rate
quantity of blood can produce large changes in the vis- of a few mm of Hg per second. When it reaches a level
cous resistance of the liquid, coupling a pressure sensorjust below the peak of systolic pressure, a brief flow occurs
to the vascular system. producing a pressure or volume pulsation, or sound, down-
stream. As the pressure continues to drop in the cuff, flow
6) The vascular system pressure is accessible, either by occurs over an increasingly greater fraction of the cardiac
is no
puncturing the vessel wall through overlying tissue with cycle until, at just below diastolic pressure when flow reach
a hollow needle and sensing the pressure directly or by longer interrupted anyat time, the volume pulsations

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1962
mm
Hgi
150-
100l
SO1
0
Fig. 2-The relationship of the sphygmomanometer cuff pressure and
the indices of flow peripheral to the cuff. Systolic pressure of 140
mm Hg is indicated by the first appearance of a peripheral pulsa-
tion or sound and diastolic pressure of 75 mm Hg by the maxi-
mum amplitude of pulsation or the disappearance or change in
character of the sound.
a maximum, or sounds either disappear or change in char-
acter. As the cuff pressure continues to drop to zero, there
may be no further changes, the remaining sounds may dis-
appear, or the volume pulsations may decrease in ampli-
tude.
The several variations of the method are essentially in
the means used to determine the onset and cessation of
flow. The common clinical method introduced by Korotow
is based on the sounds produced by the flow changes [15].
The sounds first appear when the cuff pressure falls to
just below systolic pressure and are produced by the brief
turbulent flow terminated by a sharp collapse of the ves-
sel; they persist as the cuff pressure continues to fall, and
disappear or change in character at just below diastolic
pressure when flow is no longer interrupted over any por-
tion of the cardiac cycle. There is some controversy over
the best sound criteria of true diastolic pressure [16],
[17]. The state of flow can be determined from the optical
density of the tissue supplied by the vessel by the first ap-
pearance of an increase of pulsations in density as cuff
pressure is lowered [18]-[21]. The density pulsations in-
crease in amplitude as the cuff pressure continues to de-
crease and reach maximum at diastolic pressure. The on-
set of flow at systolic pressure is indicated by direct meas-
urement of volume pulsation, or plethysmography, in the
region distal to the cuff [22]-[25]. The determination of
diastolic pressure by plethysmography has been either im-
possible or, at best, ambiguous. The direct visualization of
a vessel to determine the onset of flow interruption can
be used in certain regions, such as the retina of the eye
[26]. The direct measurement of blood flow in the vessel,
by implanting both a magnetic flowmeter probe and the
pressure cuff directly about the vessel, has been used in
experimental animals [27].
A number of automatic recorders have been devised
utilizing the Riva-Rocci method and operate in a manner
quite analogous to that employed by a human operator.
The cuff pressure is either recorded continuously along
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Shirer: Blood Pressure Measuring Methods 119
with the Korotkow's sounds via a microphone or only
IKorotkow's Sounds
when the sounds occur. The cuff pressures, at the appear-
ance and disappearance of the sounds, are taken as systolic
I Peripheral Volume, and diastolic pressures respectively [28]-[30]. Systolic
Flow, Density, Etc,
pressure has been recorded by a "pressure-follower" as
I- -I - AI II1;
~I
l;
^Q I
I
1
i Iti l; I. I I' the pressure maintained in a cuff by a servo loop that just
1 prevents a plethysmographic finger pulse [311].
40
I-- While the Riva-Rocci method is elegant in its simplicity,
QI I
- ~~Pressu it has a number of shortcomings. Probably most serious
I75II is that the measurements are necessarily intermittent and
a number of cardiac cycles intervene between the determi-
nation of systolic and diastolic pressures. When applied to
Time active subjects, it requires a bulky cuff inflation system
and partial incapacitation of the cuffed limb. Large errors
are common since the pressure applied to the exterior ves-
sel wall is not identical to that in the cuff but is attenuated
by a variable degree of rigidity of the interposed tissue,
and the precise state of flow cannot be determined in any
but the direct flowmeter method. The latter problem is so
severe that several methods do not permit determination
of diastolic pressure, and, in most methods, the diastolic
pressure is less reliable than systolic.
Indirect Unloading Type
This method is based on the assumption that when all
tension is removed from a vessel wall, it becomes a slack
tube of finite bore. It is also assumed that when the vessel
is enclosed in a chamber, the chamber is of sufficiently
small compliance to allow the vessel wall to remain un-
stretched over the range of endovascular pressure. If these
assumptions hold true, the pressure in the chamber will
be determined by the amount of liquid added and the vas-
cular pressure as shown in Fig. 3. When the chamber is
first applied to the limb containing the artery and just
filled with liquid, its pressure will fluctuate with each
cardiac cycle as the vessel tends to expand. There is al-
ways some chamber compliance, and therefore, the cham-
ber pressure pulsations will not equal the pulse pressure
since some of the pulse pressure energy will be expended
in stretching the vessel wall. As liquid is added to the
chamber, it is done so at the expense of vessel volume and
will reduce the vessel diameter, relieving wall tension and
raising the chamber pressure. When sufficient volume has
been added to just relieve all tension from the vessel wall,
the vessel will be a slack tube and the chamber pressure
will equal the endovascular pressure. Under these condi-
tions, the pulsating pressure in the chamber will be maxi-
mum and.equal to the true pulse pressure. A slight further
addition of liquid to the chamber will have no effect on
the chamber pressure; it will merely reduce the volume oc-
cupied by the vessel. Recorded systolic, diastolic, and mean
pressure will be unchanged and the recorded pulse pres-
sure will remain at maximum. When sufficient liquid has
been added to the chamber to just collapse the vessel dur-
ing diastole, the chamber pressure will rise in proportion
to the amount of liquid added and the pulse pressure will
decrease, falling to zero when sufficient volume has been
 120 IRE TRANSACTIONS ON BIO-MEDICAL ELECTRONICS April
mm been used as a virtually fool-proof transducer for this
Hg
200
Lit H ll
purpose. However, when rapid changes in pressure or the
pressure pulse waveform must be recorded with good fidel-
ity, the system must respond uniformly to all pressure in-
put frequencies from zero to many cycles per second (six
to several hundred). This requires that the natural fre-
50
lo Prsure- quency of the system be considerably higher than the high-
est frequency of uniform response. The natural frequency
of liquid manometers is far too low for this application
due to their large inertia and compliance. For this applica-
,---Volume added
to Chamber tion the small compliance and mass of the membrane ma-
Time- e
nometer is required.
The theory of membrane manometers coupled via a
Fig. 3-The relationship between the chamber pressure and the liquid column has been discussed in detail by a number of
amount of liquid added in the vessel wall unloading method. Cham-
ber pressure is equal to the vascular pressure when all tension is authors [32]-[37]. While several have clearly pointed out
removed from the vessel wall as indicated by the lack of pressure complicating factors, such as the distributed rather than
change on addition of liquid beyond a certain quantity.
lumped characteristics produced by the elasticity of the
catheter and the compressibility of the filling liquid, the
added to keep the vessel collapsed throughout the cardiac response of such devices can be well approximated for
cycle. most purposes by simply considering them as lumped sys-
This method offers, in principle, a means of continu- tems with a single natural frequency and certain degree of
ously monitoring systolic and diastolic pressure as well as damping. The amplitude response of such systems to in-
the pressure waveform without the problems encountered puts over a range of frequencies is given by
by vessel puncture. The method falls short of this ideal in
its present state of development, however, for several Af = Ao (2Dflf,)2 + [(f1f)2- 1i2j-1/2 (1)
reasons. The chamber which is applied to the skin surface where
encloses other tissue in addition to the vessel, and there- Af amplitude of response at frequency f cps
fore, cannot be made sufficiently noncompliant to keep the Ao amplitude of response at zero frequency
vessel wall unloaded over the entire range of blood pres- D =damping coefficient
sure. There is a tendency for bulging from beneath the
chamber edges and unpredictable volume changes occur
fn = natural frequency in cps
when such active tissue as muscle is enclosed. Combined and the phase response by
with the chamber compliance is the viscous resistance of
q = tan- '(2Dff,,) [I(f )2]- 1, (2)
the tissue and chamber liquid which is to act as a low-pass
filter of cutoff frequency insufficient for undistorted re- where
cording. The congestion resulting from the collapse of =-angle of the phase delay of the system.
veins traversing the region enclosed by the chamber pre-
vents its use for extended recording. Despite these several The amplitude response according to (1) is shown
problems, the method offers considerable promise as a graphically in Fig. 4 from which it is readily apparent that
means of obtaining much of the information of the vessel the natural frequency must be greater than any input fre-
puncture method but without its serious problems. quency and that the damping coefficient must be close to
0.7 (rational damping) if the maximum range of uniform
Direct Hydraulic Coupling to External Transducers response is to be obtained. A similar plot of phase re-
Direct coupling of the pressure-sensing element to the sponse according to (2) would show a linear phase delay
blood stream with a hollow needle or catheter is used when (equal time delay) vs input frequency below the natural
the highest degree of absolute accuracy, dynamic response frequency when the damping coefficient is near 0.7. Thus,
or continuous monitoring is required. This method must the natural frequency must be at least one and one-half to
also be used to measure pressures in deep regions inac- two times the highest input frequency when optimum damp-
cessible by indirect means. The oldest and, as yet, com- ing is present, but considerably higher if it is not.
monest method uses the catheter to couple an external The inset in the graph of Fig. 5 shows in diagramatic
transducer to the blood stream via the liquid in its lumen. fashion the catheter and pressure sensing element. The
The connecting catheter can be of almost any length and pressure sensing element is the elastic membrane or dia-
bore when recording is confined to the relatively slow phragm closing the chamber at the end of the catheter. In
changes in mean blood pressure. In addition the volume virtually all such systems, the diameter of the chamber
elasticity or compliance of the pressure transducer is not and diaphragm is many times that of the catheter bore.
particularly critical so long as it does not disturb the pres- The means of converting the pressure-induced diaphragm
sure source. The recording mercury manometer has long flexion into an electrical signal is not shown. The natural

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1962 Shirer: Blood Pressure Measuring Methods 121

500

300
*p e ws,
* v. IIUW
'II_
cmt Y -
2r
.
....

200
%2()0-- 14D2 ff+(f P. ) 5.\ S
200

10

50 __
iooCi
0 ; :

30 5.10 - l. -l '[
LL
.. i1 1
~ 0

3*;1dl 1 1 f EaApres/Avoi, fs2

5 10 20 30 50 100 200 300

% of Natural Frequency (100 f/fn)
1 235 10 203050 100200 501 000
Fig. 4-Frequency response for various degrees of damping. A._ Volume Elasticity, E, In lo Oynes/crn5
response amplitude at zero f requency, A f = response amplitude at
frequency f. Fig. S- Natural frequency of a needle- or catheter-transducer system
vs transducer volume elasticity. The volume elasticities of a
number of commercial transducers are shown by the arrows A-
frequency of this system is determined by its effective G H indicates the volume elasticity of 0.5 cc of water.
mass and volume elasticity and is given by: by:
fn =
(r,,/2) (E/7rl,) 1/2 7
(3) D = (4qj/r63) (1,/7rEp) 1"2 (4)
where where
f natural frequency in cps -=viscosity of the liquid in poises
r =radius of the catheter bore in cm p =liquid density in g/cm3.
IC= length of the catheter bore in cm The graph shown in Fig. 6 is convenient to determine the
E = volume elasticity of the sensing element in
dynes/cm'. length necessary for a particular catheter bore and trans-
ducer compliance to obtain the desired degree of damping.
The filling liquid density is assumed to be 1.0. Since the Each of the curves is a plot for a particular catheter bore
kinetic energies of the two segments of the fluid column of the length necessary to produce rational damping when
are proportional to the square of the respective velocities used with a transducer of a particular compliance. Under
which are in turn inversely proportional to the square of these conditions, the radius of the catheter bore is the sole
the relative diameters, only the mass of the liquid in the determinant of natural frequency and is indicated for each
catheter bore is of consequence; that contributed by the of the curves. By selecting a smaller damping coefficient, a
chamber fluid and the diaphragm is negligibly small. shorter catheter is required which will raise both the nat-
The natural frequency versus the volume elasticity for ural frequency and its fraction of nominally uniform re-
systems using different lengths of two catheter bores is sponse. The chief advantage of the low compliance trans-
plotted in the graph of Fig. 5. The volume elasticities of ducers is that they allow the use of practical lengths of the
several commercial blood pressure transducers are indi- small bore catheters with their optimally damped high nat-
cated along the abscissa by the arrows A to G. F repre- ural frequency.
sents a recent model of a popular resistance wire "strain The futility of attempting to set the damping of a system
gage" type, and G, a capacitance manometer. As the com- to some precise value by the viscous resistance of the
pliance is reduced, the natural frequency for any particular coupling liquid column is suggested by the pair of curves
size of catheter increases. However, to show that the prac- in Fig. 6 for the No. 22 needle. Since damping is directly
tical limit has been virtually reached, H indicates the vol- proportional to the viscosity of the liquid, a simple change
ume elasticity of an imaginary transducer of 0.5 cc cham- in temperature will cause a significant damping change.
ber with a completely rigid diaphragm. The volume elastic- The viscosity of water at 370C is about 0.7 of that at 200C
ity of 386 X 108 dynes/cm5 is due to the compressibility and will reduce the damping correspondingly. The admix-
of water. ture of a small amount of blood to a water-filled catheter
In most pressure measuring systems of the external will likewise produce large changes in damping.
transducer type, damping is provided by the viscous re- When transducers of larger volume elasticity are used
sistance of the liquid in the catheter or needle and is given or long catheters are required, higher uniform frequency

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 122 IRE TRANSACTIONS ON BIO-MEDICAL ELECTRONICS April

8 150 . ---IT
_~~~~~~~~~~ /fd
0
200 M2(H0 at 20)
125. - 17i 2
* I~~~~~~~~~~~~~~~~~~~~~I
0~~~~
'~~~~~~b
MI I~~~~~~~~~~~~~~~ _FT
z0

Time
Fig. 7-Transient response to a step input. The solid curve is an
example of damping less than critical (damping coefficient < 1.0),
the dashed curve of damping greater than critical. A.0 response
1 23 S 10203050100200 5001000 amplitude at infinite time after beginning of step input, At = re-
mn sponse at time t, fd = damped nattiral frequency, t, IO per cent
Volume Elasticity, E, lO8Dynes/cm5
to 90 per cent response time, fc=frequency where respoinse is 30
Fig. 6 The needle or catheter length vs. transducer volume elasticity
per cent less than zero frequency response.
necessary to produce rational damping. The resulting natural fre-
quency, fn,
iS indicated on the curves for each needle or catheter. can be found from the damped natural frequency, fd, and
the damping coefficient by
response can be obtained by not using the entire length of

the catheter bore to provide damping. Rather, the largest

f* -fd(l -
D2)-1/2 (6)
bore permissible is used to obtain the highest natural fre- A damping coefficient damping, is the
of 1.0, or critical
quency for a given compliance and then the proper damp- greatest degree of damping that just permits no overshoot.
ing is provided by inserting a relatively pure resistance in When the system damping is near or exceeds critical, the
the form of a very short constriction between the catheter above method cannot be used to determine frequency re-
and the transducer [38]. sponse. Rather, a fair approximation is obtained from the
Changes in compliance and damping resulting from risetime, the time required for the system to make the ex-
trapped air, imperfect connections, debris in the catheter cursion from the point at 10 per cent to the point at 90
bore, etc., can produce large and unpredictable changes in per cent of the step input. The cutoff frequency, or fre-
the system frequency response. It is, therefore, highly de- quency where the response has fallen by 30 per cent from
sirable to have some means of checking this important its zero frequency value, is obtained by dividing the rise-
characteristic. Ideally, a variable frequency sinusoidal time into the constant 0.35.
pressure generator of known output is used for this pur-
Direct Miniature Enldovascular Transducers
pose. Such devices are not commonly available, however,

nor are they easily improvised and calibrated [39]-[42]. The limitation in frequency response of hydraulically
In lieu of this, the response to a step change in pressure,
coupled pressure transducers arises primanrilyffrom the
easily produced with the tongue or finger, can be used for
combination of the series impedance of the coupling liquid
satisfactory estimation of the over-all response. This is
column (mass and resistance) and the volume elasticity of
illustrated for two degrees of damping in Fig. 7. A system
the transducer chamber. Since even a completely rigid
with a damping coefficient less than unity will first over- diaphragm would not greatly reduce volume elasticity be-
shoot and then oscillate in a diminishing fashion about the
low that of modern transducers due to the compressibi.ty
new equilibrium level at its damped natural frequency. The
of water, little improvement can be made in this direction.
degree of damping determines how quickly the oscillations However, by immersing the transducer itself in the blood
die out and may be calculated from the ratio of successive
stream at the site of interest, the series impedance arising
half cycle amplitudes or overshoots from from the coupling liquid column is eliminated. The remain-
ing series impedance is simply the source impedance of
D - [wr2/(ln a/b)2 + 11-112(5
the cardiovascular system at the sensing point and in most
where
cases, is so low that its combination with the transducer
a/b = step amplitude/first overshoot amplitude or first
compliance results inpa natural frequency many times
overshoot/second overshoot, etc. higher than any significant pressure harmonic. In addition,
In the case of rational damping, the first overshoot is about the elimination of the long coupling liquid column removes
5 per cent of the- step in amplitude. The natural frequency the serious acceleration artifact present in pressure re-

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1962 Shirer: Blood Pressure Measuring Methods 123

cordings made via endo- and transcardiac catheterization. cient output for direct galvanometer deflection, the ampli-
The fabrication of a transducer sufficiently small to fication of small dc signals is not as easily handled as that
place on the tip of a catheter and insert into the vascular of a comparable ac signal. Ac excitation allows simpler
system has not been an easy task. A few such transducers amplification means and permits selection of virtually any
have been produced by careful craftsmanship or this plus frequency to take best advantage of transmission and re-
the aid of new semiconducting transducing materials. These cording media.
units are sufficiently small (3 to 3T2 mm OD) to be placed In the resistance wire or "strain gage" transducer, the
on cardiac catheters [43]-[50]. diaphragm motion stretches or relaxes one or more resist-
The establishment of the zero pressure baseline with ance elements. The elements, usually in the form of metal-
such transducers in situ is not so simple as in the case of lic alloy wire, are connected as a bridge and may be ex-
external transducer systems where they may simply be cited by either ac or dc. Large output and the reliability
valved periodically to atmospheric pressure. Warnick of the strain-sensitive resistance element have resulted in
solved the problem by employing a cylindrical diaphragm its becoming the most popular of the electrical blood pres-
through which mean pressure is recorded simultaneously sure transducing methods. It is used in external trans-
by a liquid manometer [49]. The remaining types employ ducers [38], and in miniature intravascular types [47],
a diaphragm in the form of a disk closing the intravascular [49]. Semiconducting piezoresistive materials in place of
tip and must rely upon the baseline established before in- metallic resistance wire elements provide a much larger
sertion or following withdrawal. The in situ sensitivity change in resistance for a given strain (gage factor of 170
can be established, however, by applying known changes vs 2 for most metals) and have made construction of min-
in pressure to the exterior side of the diaphragm. iature intravascular transducers far simpler [50]. In an-
The several advantages obtained from intravascular other form, the Hall effect is used to cause a resistance
transducing should be sufficient motivation for further de- change in a pair of bismuth coils moved in a nonuniform
velopment in miniaturization in order to extend this magnetic field [51].
method to a wider variety of pressure recording than just The inductive type has also been frequently used but its
in the great vessels and cardiac chambers. requirement of ac excitation does not permit as simple an
TRANSDUCING METHODS operation as the resistance type. In most forms, the dia-
phragm moves an armature which serves either to alter
Indication of the magnitude of pressure requires the the inductance of a solenoid or to vary the coupling be-
conversion of the pressure energy, force per unit area, into tween two or more coils. It has been used both in trans-
a proportional displacement of an indicator. A proportional ducers of the external type [52], [53] and in miniature
displacement is most conveniently obtained from the height endovascular tip transducers [43]-[461.
at which a steady or slowly changing pressure will support The capacitative transducer still boasts the highest volume
a liquid column of known density. The simplicity and elasticity of the commercial types. A fixed plate is spaced
reliability of the liquid manometer have made it a refer- a very small distance from the diaphragm, which forms
ence standard used to calibrate other pressure measuring the movable plate of the capacitor. The dielectric may be
systems. Its use as a recording transducer for many appli- either air or oil. It is usually connected as an arm of an
cations has no peer. The registration of rapidly changing impedance bridge and, like the inductive types, requires ac
pressure or pressure in a low volume system, requires the excitation. The small capacitance of a few picofarads ne-
much smaller volume change and inertia of the membrane cessitates the use of high excitation frequencies, usually in
manometer where pressure is determined from the pro- the range of a few hundred kilocycles to a few megacycles
portional displacement of a diaphragm of known area re- [33], [54]. This type has not been made in miniature form
strained by a spring of known force. Early high frequency for intravascular use.
manometers recorded photographically the rotation of a Photoelectric methods have been used in which the dia-
lengthy optical lever from a mirror fastened to the dia- phragm motion varies the amount of light falling on a
phragm. Today, this cumbersome method has been re- photocell by either shutter action or mirror rotation, but
placed by electrical transducing, amplifying, and recording is far too large for intravascular transduction [55]-[57].
means. A method designed exclusively for endovascular trans-
Electrical transduction is brought about by the diaphragm ducing uses a double lumen catheter to conduct sound to
deflection altering the characteristic of an electrical element and from the internal tip where it is modulated by the
or the coupling of one element to another. One type (piezo- diaphragm position altering the width of a gap [48].
electric) produces the signal by generating an electrostatic An electronic transducing method uses a special vacuum
potential from the stress induced by the diaphragm; the triode (RCA 5734) constructed so that the anode may be
remainder by modulation of an external source of ac or moved in relation to the other electrodes by the diaphragm
dc excitation. Advantages of dc excitation are the ease of via a flexible seal. The anode position alters the transcon-
obtaining a stable source and the need for only a sensitive ductance of the tube and hence, the anode current. In one
indicating or recording galvanometer to complete the sys- scheme, the transducer tube is connected as an oscillator
tem. On the other hand, if the transducer produces insuffi- which is in turn amplitude modulated by the diaphragm-

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124 IRE TRANSACTIONS ON BIO-MEDICAL ELECTRONICS A pril

anode position [58]. Due to the size of the tube, it has [17] L. N. Roberts, J. R. Smiley, and G. W. Manning, "A compari-
not been used for intravascular transduction. son of direct and indirect blood-pressure determinations," Cir-
culation Research, vol. 8, pp. 232-242; August, 1953.
Piezoelectric crystals generate an electrostatic potential [18] E. H. Wood, W. F. Sutterer, and L. Cronin, "Oximetry," in
proportional to the applied stress. Since the electrostatic "Medical Physics," vol. 3, 0. Glasser, Ed., Year Book Pub-
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potential produced by a sustained stress, such as mean [19] J. Weinman, C. Bicher, and D. Levy, "Application of a photo-
conductive cell to the study of peripheral circulation in limbs
blood pressure, would leak away via the finite input resist- of animals and man," J. Appl. Physiol., vol. 15, pp. 317-320;
ance of an amplifier or galvanometer connected to its termi- March, 1960.
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nals, such devices are not suitable for recording true mean sphygmometer in indirect blood pressure measurement," Anes-
pressure directly. A method for overcoming this problem thesiology, vol. 20, pp. 704-707; September-October, 1959.
[21] P. Weisz, S. Roza, and J. Bartfai, "Vergleichende Blutdruck-
uses a motor driven valve to convert the applied blood messungen am Menschen hinsichtlich des 'wahren' (auf der
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tolischen Blutdrucks," Z. ges. inn. Med., vol. 15, pp. 449-451;
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compared to the time constant of the crystal capacity and [22] A. B. Callahan, J. Degelman, and B. R. Lutz, "Systolic blood
pressure in the hamster as determined by a strain-gauge trans-
input resistance of the following amplifier, the mean pres- ducer," J. Appl. Physiol., vol. 14, pp. 1051-1052; November,
sure as well as some details of the pressure waveform can 1959.
[23] H. N. Rice and L. J. Posener, "A practical method for measur-
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valve can also sample one or more reference pressures on manometer for the newborn," Lancet, vol. 1 (7077), pp. 801-
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[25] G. Weissbach, "Sekundire rheographische Blutdruckmessung,"
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1962 Smith: Nonlinear Computations in the Human Controller 125

[451 E. Wetterer, "Eine neue manometrische Sonde mit elektrischer melstein, and D. W. Richards, "Intravascular and intracardiac
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Nonlinear Computations in the Human Controller*

OTTO J. M. SMITHt, FELLOW, IRE

Summary-The response of the human forearm following

random input step commands was observed to approach at its
best the same kind of response as that of a maximum-effort
minimum-time optimum bang-bang servo in which the magni-
tude of the error is compared with a nonlinear function of the
stored energy in the load. Tests were made which required the
hand to move both small and large inertias, small and large
friction coefficients, and small and large springs, with combina-
tions of these. The muscle force was calculated and plotted as
a function of time for a great many tests on different indi-
viduals. This paper will not describe the average response, but
the best response which any individual is capable of achieving.
The muscle forces were relatively constant for each individual
regardless of the dynamics of the load or the magnitude of the
command.

HIGH INERTIA LOAD

f- HE MATHEMATICALLY optimum minimum-
Jitime response for a maximum possible muscle force POSITION TIME

was generally observed when the subject had to Fig. 1 Heavy inertia being moved by arm following a step command.
move a very large inertia load. The general shape of the
response curves is shown in Fig. 1. The most characteristic the load until the error was reduced to approximately one-
feature was the constant maximum force which was of half, and then an equal reverse force was used to de-
the same magnitude for both positive and negative accelera- celerate the load and bring both the error velocity and the
tions. The magnitude of this force varied between differ- error to zero simultaneously. Region y in Fig. 1 shows the
ent individuals. The range observed was from 10 to 40 sudden reversal of muscle force. In many cases this re-
newtons, which is approximately 2 to 9 pounds. The sub- versal appeared to be instantaneous. However, we could
ject used a constant force within this range to accelerate not resolve times less than 0.01 sec; therefore the rate of
change of muscle force was estimated to be between 1000
and 2500 newtons/sec, which is between 200 and 600
* Received by the PGBME, October 26, 1961.
t Department of Electrical Engineering, University of California, pounds/sec. In this same region T, the rate of change of
Berkeley, Calif. acceleration was between 700 and 2000 m/sec3. It can be

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