- Email: [email protected]
The peripheral blood flow under basal conditions in older male subjects with normal and elevated blood pressures
THE
PERIPHERAL IN OLDER
BLOOD FLOW UNDER BASAL CONDITIONS MALE SUBJECTS WITH NORMAL AND ELEVATED BLOOD PRESSURES
N RECEi\T years, the peripheral circulation has been the subject of new interest because of the added attention whicll has beon given to inflammatory, occlusive,, and rasospastic states of the peripheral \-esscls. We have been interested in that part of the volume output of blood from the heart which is allotted to the peripheral circulation. In studies of normal male sub,jects in the earlier decades we found that 73 C.C. per square meter of body surface per minut,e was the average amount of blood allotted to the peripheral circulation in a room at 27” C. with a humidity of 50 per cent.’ Howewr, this w~ls reduced to -12 c.c’. pel square meter of body surface per minute when the room temperature was 2.‘)” C. The differences which are encountered in tllc peripllcral blood flow of subjects in the later decades who had clear-cut evidences of vascular disease form the basis of this report. The clinical diagnoses shown in Table I indicate that these patients exhibited a wide range of generalized vuscular disease, such as arteriocoronary artery disease, angina pec.toris, sclerotic heart disease, hypertension, coronary thrombosis, and generalized arteriosclerosis. The peripheral blood flow has been measured on 27 occasions in 25 male subjects from 38 to ‘ii years of age. The l)lood prcssurc was in the normal rarlge in 12 subjects and was elevated in 13 subjects; these h~~~‘oups are designated as the *‘normal blood pressure group ’ ’ and tile “ Ii)-pertensivt: group, ” respectively.
I
METHODS
Measurements of peripheral blood flow were made by tnudifying the method of Hardy and Soderstrom? in such a way that the use of a calorimeter was not necessary. This modification has been described previously.:‘-” The following dat.a are required: skin temperatures at clcvcn points on the anterior surface (Jf the body, as shown in E’ig. l3 ; rectal temperature ; oxygen consumption ; height; and body weight. In this method is measured the amount of blood allotted to the periphery of the whole body to a depth of 1 cm. below the surface. Blood pressure and pulse rate are recorded. The skin temperatures were measured with tht: Hardy-Soderstrom radiomet&; the rectal temperature was measured with a single-junction, copperconstantan thermocouple6; and the oxygen consumption was measured with a From the Department sity Medical College, New E;. Markle Foundation.
of Medicine of the New York, New York. Supported 343
York Hospital by a grant
and from
the Cornell Univerthe John and Mary
AVERAGE RECTAL TEMPERhTURE OC.
PERIPHERAL BLOOD FLOW (C.C./BI.? ,‘I\I IS. )
3i.11
::;.32
3G.40
1 G6
56
84
46
L. M. 65 255998
37.1::
3;.29
3fL;li
3G.94
114
(;‘I
36.91
39
::ti.h!l
RELATING
DATA
4;
I.
C. T. 52 355770
Eo574
A. K.
61672
70
J. S. 52 158786 M. K. 67 352240 N. M. 38 357527 F. 8. 54 342341 H. S.
CASE AGE (YRS.) HISTORY NO.
TABLE
, ’
3.3 (‘(0
34.60
3 .? i 9
.\KT-:*s
35.2
33.0
t44.S
35.2
<‘34 i
34.1)
34.;
34.8
) 3 , 4 / .' / ii j 7 1 Oc. 1 Oc. Oc. Oc. ’ oc.
,,b‘ 1“I.Evb:S
34.6
34.0
/ 8 1 cc.
34.5
3'7.8
! if ! “c.
c FS l{OI~Y
--.
33.9
32.9
/ 10 “C’.
33.9
33.h
11 "C.
OF AGE,
Sl~RF.\(‘I,:
l’.!T~~ssw kko~ :{X ‘I’O 77 YEARS TFXPERATUE~E OF 3i" C. --
:(4.-i :!4.:; :i:;.!l 34.L :i:;.4 :c:.:i
1 : 2 Oc. ; oc.
ED SKIS TEI,fPERATT'RE OC.
34.12
.i‘p:lI
I
~\I.\I.E
I’,~:Ii.\‘TL-I;E
__.-
WEIGIIT~
.\VEKAGE
To TWENTY-FIVE
VASCULAR
115/64
137,'Gl
71
60
5G
S
UIAGNOSIS
dir
disthrombo heart heart
heart
heart dispcctoris.
AT ROOM
.hteriosclerotic case. Angina Anemia .~rteriosclcrotic e:t~e. Coronary Sl:: .\rteriosclcrotic case. Enlarged
I&EASE,
\ I teriosclerotic heart dircnrc. Coronary artery tl iscwse. Enlarged lre:iyt .:!: History of fluctuation iu blood pressure and of being high in last two, years .-! Hypertensire heart ~llsease. Angina pectorie. AuricuIar fibrillation -0,~ .\I,teriosclerotic heart disease. Coronary artery dk case. -1ngina pectorls. Enlargrd heart & 4 .\rteriosclerotic heart disease. Coronary thrombw sis. Generalized arteriosclrrosis 4 &\rteriosclerotic heart disease. Enlarged heart. Au ricular fibrillation. Pnlrn~mnry fibrosis ;:i(i .\rtcriosc.lerotic gangrene of the right foot. Ohservation 41 days after nmpur:!ticm
-30
1
- $1
-
C.\S.lI. 511,:'rlI’REStJ’UI>SF 1 x0, 1IC Sl-RF: 1:ATE RATE NM. PER I’IX cl? s1 ! HC I 111X. BTdOOD
EXHIBITING
*Stewart
Average Standard deviations about . the means
J. S. 44 353263 P. L. 53 384879 II. s. 77 109660 B. C. 69 377456 Average Standard deviations about the means Average from both groups Standard deviations both groups about the means
S. MeD. 48 95209 w. c. 48 375325
(-=) HISTORY NO.
CASE AGE
33.92 0.35
37.32 0.26
37.15
0.39
55 24
63
31
Evans.’
34.35
37.01
91
and
36.79 0.16
33.80
37.39
87
73 30
33.71
37.49
79
33.74 0.33
0.38
33.93
33.86
37.46
34.30 33.97
37.27 37.10
62 70
21
33.52
AVERAGE WEIGHTED SKIN TEMPER^T
37.11
AVERAGE RECTAL PEMPERATURE “C.
25
PERIPHERAL BLOOD FLOW (C.C./M.2 /MIN.)
35.0
35.4
34.5
34.4
35.1 34.8
34.5
j 4.14.
34.9
34.8
33.8
34.2
34.5 34.3
33.7
5 OC.
1 6 / “C.
35.4
34.9
34.6
34.4
34.7 34.3
34.5
34.3
33.7
34.0
34.4 33.8
34.0
34.4
33.0
33.9
34.2 34.2
Hypertension 33.5 33.9 33.6
/ 4.1
OF ELEVEN
j 8 ( “C.
ON
1 9 / OC.
BODY
) 10 / *C.
SURFACE
34.4
34.2
34.5
34.8
35.0 34.8
33.9
33.1
32.6
33.5 33.2
.3&S 33.5
33.1
33.2
33.3
33.7 32.9
32.5
) 11 ( OC.
33.2
31.8
32.3
32.6
32.8
31.4
34.1
33.4
33.2 34.4 32.9 34.5
Group-Cant ‘d 34.2 33.1 32.2 33.0
j 7 ( OC.
AREAS
I.-CONT'D
0.5
34.8 0.6
34.4
34.4 34.2 34.1 0.3 0.4 0.5
0.5
34.9 1.2
33.5 0.7
33.0
0.7
32.6
32.9
156/98
105/X 5/5
0.8
34.6
Normul Subjects Gn Third Decade* 34.2 33.8 33.7 34.4 33.2 33.2 33.2 32.7 0.5 0.5 0.5 0.5 0.7 0.7 0.5 1.9
0.5
33.9
41127
0.4
34.2
194/117 22/19
163/91
176/87
197/103
211,026
198/113 193/112
177/133
BLOOD PRESSURE MM. HG
1.3
0.6
34.5
35.0 34.8 34.5 34.6 34.2 34.0 34.4 33.5 32.8 32.5 32.6 0.4 0.5 0.5 0.6 0.4 0.4 1.0 1.4 0.6 0.6 1.4
35.0
35.1
34.0
35.0
35.3 35.0
34.9
‘4.
TEMPERATURE
TABLE
61 7
11
72
77 10
74
7L’
x3
62
66 66
68
PULSE RATE PER MIN.
15
- 5 10
t9
+ 9 14
~23
-36
+29
+ 4
1 0
-3 1
BASAL METABOLIC RATE PER CENT
Chronic pyelonephritis. Hypertensive heart disease. Coronarv artery disease Hypertension. Arteriosclerotic heart disease. Auricular fibrillation Hypertension. Arteriosclerotic heart disease
Hypertensive cardiovascular heart disease. Myocardial infarction. Arteriosclerosis. Coronary thrombosis Hypertensive heart disease. Coronary thrombosis
Hypertensive cardiovascular heart disease
DIAGNOSIS
STEWART
ET
AL.:
PERIPHERAL
BLOOD
FLOW
UNDER
BASAL
MO1 j Cl0018 lW3HdIKId
CONDITIONS
346
AMERICAS
HEART
.JOTlRNAI~
Benedict-Roth metabolism apparatus.’ The basal metabolic rate was calculated from the Mayo F’oundation standards Uor age and sex,” and the surface area was calculated from the t,ahles nf DuRois and DuBois.” PROCEDURR
All observations wcrc made in t,he morning, when the patient,s were in a basal metabolic state. The rectal thermometer was inserted to a depth of 10 cm. as soon as the patient reached the constnnt~ temperat,ure room and remained in place during the morning’s observations. The subjects lay nude in bed, covered only with a sheet. The room temperature was maintained at or nea.r 27” C., and the humidity ranged bctwccn 45 and 50 per cent. In order to become accommodated to this environment, the patients lay at rest for one hour before observations were started. Three to eight. sets of observations were made, from which it was possible to ~trnltc two to seven calcalations of peripheral blood flow. In some instanc~cs tile oxygen cdollsumption was measured at thc end as well as at the beginning of ihe observat,ions. ln some instances tenminute and, in others, 1w?-cnty-minutc intervals were chosen for making thc3 measurement,s of skin temperatures, and the formulas used in making the calculations were adjusted accordingly.” ~~nslm\-;\‘I’Iu b, \s
The results bf the observations are shown in Table I and Fig. 1. Peripheral Blood I%~c~.-The data arc recorded in Table I, and the scatter diagram of the peripheral blood flow calculations is shown in Fig. 1. On the whole, the peripheral blood flow in the group with normal blood pressure was greater than in the group with cl(~vat,c~d blood pressure, alt,hough there was some overlapping. The average peripheral blood flow for the normal blood pressure group was ‘73 cc. per square meter of body. surface per minute, the same as that found in normal young individnals at 1llis l.cmperatnre.’ In the group wit11 hypertension, however, it was only 55 C.C.per square n1etc.r of body surface per minute, or approximately the same as that iound in normal subjects at the lower room temperature of 25” ( I_ The average for the combined groups xas 63 c.c per square meter of body surface per minute. RectaZ Temperatwtx- -The average rectal temperature for the group with normal blood pressnrr was 36.95’ C. : for the group wit.b hypertension, 37.32” C.; and for the combined groups, S7.18” (1. i’l’ahle I, F’ig. 1). Therefore, the rental t etnperat,ure of the g~*oupwit,11 hyltertcnsion was 0.37” C. higher, on an a.v~t*a,ge, t,han that of the grout> with rjorlnal l~lood pressure, and in both groups the rectal temperature was higher t.han it \\‘a~ in normal young men. in whom it averaged 36.79” C. Weighted Skin Tewpoutwc. -~‘Yhc weighted skin temperature averaged 33.99” C. for t,he group with normal blood pressure and 33.92” C. for the group with hypertension; it was 33.93” C. for the groups combined, as compared with 33.40” C. for the group ol’ normal young men (Table I, Fig. 1). In short the average skin temperat,ure \feashigher in this older age group with vascxnlar disease than in the younger normal subjects.
STFWIRT 1 r
ET
AL.
:
PERIPHERAL
BLOOD
FLOW
UNDER
BASAL
CONDITIONS
349
Tempemtures of tile Han&.-The average of the temperatures of the hands (Area 7) was 34.7” C. for the group of older subjects with normal blood pressure and 34.4” C. for the group with hypertension. That is to say that the average hand temperatures in the older group with normal blood pressure are slightly higher than those in the group of normal young men, whose hand temljeratures averaged 34.4” C. In the group with hypertension the average hancl temperature of 34.4” C. was the same as that in the normal group. Tempcrcrtztrcs of the Fe&.--The average of the temperatures of the feet was 33.4” C. for the group of older subjects wit 11 1111rrna1blood prcssuw :t11(1 X2.6” C. for the hypcrteusion group (Table I, E’ig. 1 1. ‘1‘11~Feet were therefurc, warmer in the group with normal blood pressure I llilll iI1 the group of lo131al J oung men in which the tenipcrat~nes of tlio i’(l~i a\.c~ragecl X2.7” ( ‘. : iI1 t !I(, hypertension group the tcmpr~ratr~res ~1’ t11c f(lc$ lv~r(: slightl!- bttlow tiorl1ial Temperutures of Other Areas of fhc Botl!/.-l*‘or Xrvxs 1 to 6, inclusive, of the body surface, that is, for the upper part of the body, the skin temperature was higher in the hypertension group than in the grlJLi1) with normal blood pressure, each being appreciably higher than in normal young subject,s (,Table I, Fig. 1). Beginning with the hands (L1rea 7): however, and continuing to the lower part of the body and the feet (Areas 7 to 11, inclusive), the relationship of the first two groups is reversed: in these areas the temperatures in the group with hypertension are cooler than in the normal blood pressure group. As compared with normal young subjects, the group of older subjects with normal blood pressure, except for the shin (Area 10 !, show higher temperatures. 011 the other hand, in the hypertension group the temperatures are loner than normal esc&ept in the hands (Area 7)) M-hcrc it is t.he same, and in the upper 1high (Area 8) where it is higher. ‘k2 avcr:l~cS for the llOrmd hlOOd ~mSSUre grmp
alid
h>-p3rtCIlSiOU
grOLlp
are
hi&et’
thrl
the
~l~~!ragY’S
f(Jr
t,ht?
IlOrIll:l~
yOU?lg
group
for all areas except 9 and 10. namely llrc lowcjr thigh and shin. KTuotl I’r~css~~x-The average of tlic t)lootl l)ressurc for the older sllbjc~ts with normal blood pressure was 124,/$3, and IN/l 17 ft~r i he hypertension group, the avt’rage for the tWcJ ciombined gro~ips bcia g 1:56,‘9$. as c.c~mparcd wit11 105 ‘71 for the group of normal y~ang men (Tahlc I. l’ig. 1 ‘i. Heart Kclte.-The average hcalt rate t’or the CJI~C~I~ grOU[) With Ii~JImd bhJ4Jll pressure was 65 per minute ; for the hypertension gronp slightly higher, 7; l)er minute; and for both groups 72 1~ minute (Table 1, Fig. 1,. These arc to 1~. compared with the rate of 61 per minute in the gronl) of normal young men. Basd Netabo2ic h’tr/t .-~--The basal melabolic~ rate \T.ils csseutiall>- the same for the normal blood pressure am1 hypertension grolil), nanlc~l~~ ! 7 per cent and +9 per cent, respectively, as compared wit 11 -:‘i JX’t’ vrwt for t IIV grou]~ of normal young men (Table I, Fig. 1). DISCUSSIOX
It appears, therefore, from observations made on these patients that there are certain differences in the peripheral circulation in older meu as compared with normal young men. This is the case not only in those older men with
350
AMERICAN
HEART
JOURNAL
normal blood pressure but also in those wit,11 hyl~ertcnsion. In only one of the patients (I-J. M., No. 255998, Table I) in this study were there signs or symptoms of occlusive peripheral vascular disease. 111 the normal young subjects already reported1 it was found that more blood was allotted to the pcripherlwhen the environmental temperature was 270 C., than at a lower temperature uf 25” c. The data relating to this older age group have been subjected to statistical analysis. On comparison of the hypertension group with the normal blood pressure group none of the differences wets significant when the test of twice the standard deviation was applied; but. thelc was a trend toward decrease in peripheral blood flow, inc*rease in rccst al temperatures and decrease in avcragt’ weighted skin tempernturc, with increase in tcmpcrature of the upper parts OI the body and decrease in temperature of the lower parts of the body. When the older people with normal blood prcssurc are compared with young normal individuals, again the differences are not statistically significant. The peripheral blood flows are the same. The trend is for the rectal and average weighted skin temperature and the temperature of all the areas of the body to be increased in older people. Again in older people with hypertension as compared with young normal subjects the differences are not significant, but, there is a trend toward deereast, in peripheral blood flow, an increase in rectal (all over 3’7” C. except one subject) and in average weighted skin temperature, and an increase in lempcraturc: of the upper part of the body and a decrease in the lower part. When the whole old age group, including those with hypertension as well as those with a normal blood pressure, arc compared with normal srtbjects, no statistically significant differences are revealed ; but again the trend is toward a decrease in peripheral blood flow< a rise in the rectal and the average weighted skin temperatures, and a rise in ~e~upcratu~x: of th(: dapper’ part elf the body and a decrease in the lower part. How can these data be fitted tugctlw’! There is a l.rend toward decrease in peripheral blood flow when there is hypertension, with a rise in rectal and a decrease in average weighted skin temperature, both as compared to normal young subject,s and to older suh,jecls with normal blood pressure. Also it would appear to be more than ehmw that the tcmperai IIIY of the upper part of the body is warmer and that of the louver ~)al’i,is cooler in these hgpertensivc subjcrts wit,11 normal blood pressure, a than in those subjects in the sault’ agv group pattern which is similar 10 that cirllil)itc4 1)y hpgert,ensivc patients in tlic earlie], age group.“’ StiM~~ARY
The peripheral blood flow and skin and rectal temperatures have been measured in 25 male patients from 35 to ‘77years of age, that is to say in patients in the older age group. In 12 subjects there were clinical signs of vascular damage without hypertension, and in 13 there was also hypertension. In onl) one subject was there evidence of occlusive peripheral vascular disease. The rt:suits in these patients have been compared with those in normal young male
STEWART
ET
AL. :
PERIPHERAL
BLOOD
FLOW
UNDER
BASAL
CONDITIONS
351
subjects. The peripheral blood flow was measured by a modification of the method of Ilardy and Soderstrom. The following facts emerged : 1. The average peripheral blood flow at 27O C. (room temperature) is in the same range in older individuals with normal blood pressure, 73 C.C. per square meter of body surface per minute, as in younger male subjects, but is lower, namely 55 C.C. per square meter of body surface per minute in those with hypertension, and approaches the value recorded for normal young subjects at the cooler environmental temperature of 25” C. 2. The rectal temperature is higher in older lw~pk than in the young normal group (36.79” C.) and was slightly higher in the hypertension group (37.32” C.) than in the normal blood pressure group (36.95’ C.). 3. The average weighted skin temperature was higher in both the normal blood pressure group (33.99” C.) and the hypcrtensicm group (33.92” C.) than in younger subjects (33.74O C.). 4. The skin temperatures of the individual areas of the body surface are warmer in the older patients with normal blood pressure than in younger individuals, except in one area, namely the shins (drea lo), where the ten)perature is lower in the older group. On the other hand patients with h;r-pertensiotl in the older age group have a warmer skin tem])eraturc iu the upper part of the body, and a cooler temperature in the lower part of the body than do poun:: normal subjects. The inference is that the peripheral blood flow to the feet is reduced, since their temperature is lo~r, and that the blood flow to the uppet part, of the body is increased, since its temperature is warmer. The reduction in peripheral blood flow in the lower part of the body is apparently greater t,han the increase in the upper part of the body so that the net result is an average I~cripllcral blood How for the whole body which is less than the value in normal J (Jllllg Tildes at the Same room temp?mture. 111 short, it is comparat,le to the constriction observed in normal yo~ulg subjects in a11 environment of 25” C. 5. Patients with hypertension in this older age group show the same trends. but to a lesser extent! as are shown l)y patients with hypertension in the earlier decades. REFERENCES H. J., and Evans, W. F.: The Peripheral Blood E’low Under Basal Conditions 1. Stewart, in Normal Male Subjects in the Third Decade, _4~. HEART J. 26: 67: 1943. 2. Hardy, J. D., and Soderstrom, G. F.: Heat Loss From the Nude Body and Penpheral Blood Flow at Temperatures of 22” C. to 35” C’., .J. Xutri’tion 16: 493, 1938. 2. Stewart, H. J., and Jack, h’. B.: The Effect of hminophyllin on Peripheral Blood Flow, Ax. HEART J. 20: 005, 1940. H. J., and Evans, TV. F.: The Peripheral L(lou~l FIaj\r in Hyperthyroidism, .\>I. 4. Stewart, HEART J. 20: 715, 1940. H. J.> and E:vans, W. E’.: Peripheral Blood Yluw in Nyxedema? hrch. Int. .J Stewart, Med. 69: 808, 1942. 6. Hardy, J. D., and Soderstrom, G. F.: An Improved Apparatus for Measuring Surface and Body Temperature Rev. Scient. Instruments 8: 418, 1937. i. Roth, P.: Modification of Apparatus and Improved Technique Adaptable to the Benedict Type of Respiration Apparatus, Boston M. & 5. J. 186: 457, 1922. 9. Boothby, W. M., Berkson, J., and Dunn, H. L.: Studies of the Energy of Metabolism of Normal Individuals: A Standard for Basal Metabolism With a Nomogram fol Clinical Application, Am. J. Physiol. 116: 468, 1936. D., and DuBois, E. F.: 9. DuBois, A Formula to Estimate Approximate Surface Area if Height and Weight Be Known, Arch. Int. Med. 17: 863, 1916. H. J., Evans, W. F., Haskell, H. S., and Brown, H.: The Peripheral flood 10. Stewart, Flow, Rectal and Skin Temperatures in Hypertension. In press, AM. HEART J.
PERIPHERAL IN OLDER
BLOOD FLOW UNDER BASAL CONDITIONS MALE SUBJECTS WITH NORMAL AND ELEVATED BLOOD PRESSURES
N RECEi\T years, the peripheral circulation has been the subject of new interest because of the added attention whicll has beon given to inflammatory, occlusive,, and rasospastic states of the peripheral \-esscls. We have been interested in that part of the volume output of blood from the heart which is allotted to the peripheral circulation. In studies of normal male sub,jects in the earlier decades we found that 73 C.C. per square meter of body surface per minut,e was the average amount of blood allotted to the peripheral circulation in a room at 27” C. with a humidity of 50 per cent.’ Howewr, this w~ls reduced to -12 c.c’. pel square meter of body surface per minute when the room temperature was 2.‘)” C. The differences which are encountered in tllc peripllcral blood flow of subjects in the later decades who had clear-cut evidences of vascular disease form the basis of this report. The clinical diagnoses shown in Table I indicate that these patients exhibited a wide range of generalized vuscular disease, such as arteriocoronary artery disease, angina pec.toris, sclerotic heart disease, hypertension, coronary thrombosis, and generalized arteriosclerosis. The peripheral blood flow has been measured on 27 occasions in 25 male subjects from 38 to ‘ii years of age. The l)lood prcssurc was in the normal rarlge in 12 subjects and was elevated in 13 subjects; these h~~~‘oups are designated as the *‘normal blood pressure group ’ ’ and tile “ Ii)-pertensivt: group, ” respectively.
I
METHODS
Measurements of peripheral blood flow were made by tnudifying the method of Hardy and Soderstrom? in such a way that the use of a calorimeter was not necessary. This modification has been described previously.:‘-” The following dat.a are required: skin temperatures at clcvcn points on the anterior surface (Jf the body, as shown in E’ig. l3 ; rectal temperature ; oxygen consumption ; height; and body weight. In this method is measured the amount of blood allotted to the periphery of the whole body to a depth of 1 cm. below the surface. Blood pressure and pulse rate are recorded. The skin temperatures were measured with tht: Hardy-Soderstrom radiomet&; the rectal temperature was measured with a single-junction, copperconstantan thermocouple6; and the oxygen consumption was measured with a From the Department sity Medical College, New E;. Markle Foundation.
of Medicine of the New York, New York. Supported 343
York Hospital by a grant
and from
the Cornell Univerthe John and Mary
AVERAGE RECTAL TEMPERhTURE OC.
PERIPHERAL BLOOD FLOW (C.C./BI.? ,‘I\I IS. )
3i.11
::;.32
3G.40
1 G6
56
84
46
L. M. 65 255998
37.1::
3;.29
3fL;li
3G.94
114
(;‘I
36.91
39
::ti.h!l
RELATING
DATA
4;
I.
C. T. 52 355770
Eo574
A. K.
61672
70
J. S. 52 158786 M. K. 67 352240 N. M. 38 357527 F. 8. 54 342341 H. S.
CASE AGE (YRS.) HISTORY NO.
TABLE
, ’
3.3 (‘(0
34.60
3 .? i 9
.\KT-:*s
35.2
33.0
t44.S
35.2
<‘34 i
34.1)
34.;
34.8
) 3 , 4 / .' / ii j 7 1 Oc. 1 Oc. Oc. Oc. ’ oc.
,,b‘ 1“I.Evb:S
34.6
34.0
/ 8 1 cc.
34.5
3'7.8
! if ! “c.
c FS l{OI~Y
--.
33.9
32.9
/ 10 “C’.
33.9
33.h
11 "C.
OF AGE,
Sl~RF.\(‘I,:
l’.!T~~ssw kko~ :{X ‘I’O 77 YEARS TFXPERATUE~E OF 3i" C. --
:(4.-i :!4.:; :i:;.!l 34.L :i:;.4 :c:.:i
1 : 2 Oc. ; oc.
ED SKIS TEI,fPERATT'RE OC.
34.12
.i‘p:lI
I
~\I.\I.E
I’,~:Ii.\‘TL-I;E
__.-
WEIGIIT~
.\VEKAGE
To TWENTY-FIVE
VASCULAR
115/64
137,'Gl
71
60
5G
S
UIAGNOSIS
dir
disthrombo heart heart
heart
heart dispcctoris.
AT ROOM
.hteriosclerotic case. Angina Anemia .~rteriosclcrotic e:t~e. Coronary Sl:: .\rteriosclcrotic case. Enlarged
I&EASE,
\ I teriosclerotic heart dircnrc. Coronary artery tl iscwse. Enlarged lre:iyt .:!: History of fluctuation iu blood pressure and of being high in last two, years .-! Hypertensire heart ~llsease. Angina pectorie. AuricuIar fibrillation -0,~ .\I,teriosclerotic heart disease. Coronary artery dk case. -1ngina pectorls. Enlargrd heart & 4 .\rteriosclerotic heart disease. Coronary thrombw sis. Generalized arteriosclrrosis 4 &\rteriosclerotic heart disease. Enlarged heart. Au ricular fibrillation. Pnlrn~mnry fibrosis ;:i(i .\rtcriosc.lerotic gangrene of the right foot. Ohservation 41 days after nmpur:!ticm
-30
1
- $1
-
C.\S.lI. 511,:'rlI’REStJ’UI>SF 1 x0, 1IC Sl-RF: 1:ATE RATE NM. PER I’IX cl? s1 ! HC I 111X. BTdOOD
EXHIBITING
*Stewart
Average Standard deviations about . the means
J. S. 44 353263 P. L. 53 384879 II. s. 77 109660 B. C. 69 377456 Average Standard deviations about the means Average from both groups Standard deviations both groups about the means
S. MeD. 48 95209 w. c. 48 375325
(-=) HISTORY NO.
CASE AGE
33.92 0.35
37.32 0.26
37.15
0.39
55 24
63
31
Evans.’
34.35
37.01
91
and
36.79 0.16
33.80
37.39
87
73 30
33.71
37.49
79
33.74 0.33
0.38
33.93
33.86
37.46
34.30 33.97
37.27 37.10
62 70
21
33.52
AVERAGE WEIGHTED SKIN TEMPER^T
37.11
AVERAGE RECTAL PEMPERATURE “C.
25
PERIPHERAL BLOOD FLOW (C.C./M.2 /MIN.)
35.0
35.4
34.5
34.4
35.1 34.8
34.5
j 4.14.
34.9
34.8
33.8
34.2
34.5 34.3
33.7
5 OC.
1 6 / “C.
35.4
34.9
34.6
34.4
34.7 34.3
34.5
34.3
33.7
34.0
34.4 33.8
34.0
34.4
33.0
33.9
34.2 34.2
Hypertension 33.5 33.9 33.6
/ 4.1
OF ELEVEN
j 8 ( “C.
ON
1 9 / OC.
BODY
) 10 / *C.
SURFACE
34.4
34.2
34.5
34.8
35.0 34.8
33.9
33.1
32.6
33.5 33.2
.3&S 33.5
33.1
33.2
33.3
33.7 32.9
32.5
) 11 ( OC.
33.2
31.8
32.3
32.6
32.8
31.4
34.1
33.4
33.2 34.4 32.9 34.5
Group-Cant ‘d 34.2 33.1 32.2 33.0
j 7 ( OC.
AREAS
I.-CONT'D
0.5
34.8 0.6
34.4
34.4 34.2 34.1 0.3 0.4 0.5
0.5
34.9 1.2
33.5 0.7
33.0
0.7
32.6
32.9
156/98
105/X 5/5
0.8
34.6
Normul Subjects Gn Third Decade* 34.2 33.8 33.7 34.4 33.2 33.2 33.2 32.7 0.5 0.5 0.5 0.5 0.7 0.7 0.5 1.9
0.5
33.9
41127
0.4
34.2
194/117 22/19
163/91
176/87
197/103
211,026
198/113 193/112
177/133
BLOOD PRESSURE MM. HG
1.3
0.6
34.5
35.0 34.8 34.5 34.6 34.2 34.0 34.4 33.5 32.8 32.5 32.6 0.4 0.5 0.5 0.6 0.4 0.4 1.0 1.4 0.6 0.6 1.4
35.0
35.1
34.0
35.0
35.3 35.0
34.9
‘4.
TEMPERATURE
TABLE
61 7
11
72
77 10
74
7L’
x3
62
66 66
68
PULSE RATE PER MIN.
15
- 5 10
t9
+ 9 14
~23
-36
+29
+ 4
1 0
-3 1
BASAL METABOLIC RATE PER CENT
Chronic pyelonephritis. Hypertensive heart disease. Coronarv artery disease Hypertension. Arteriosclerotic heart disease. Auricular fibrillation Hypertension. Arteriosclerotic heart disease
Hypertensive cardiovascular heart disease. Myocardial infarction. Arteriosclerosis. Coronary thrombosis Hypertensive heart disease. Coronary thrombosis
Hypertensive cardiovascular heart disease
DIAGNOSIS
STEWART
ET
AL.:
PERIPHERAL
BLOOD
FLOW
UNDER
BASAL
MO1 j Cl0018 lW3HdIKId
CONDITIONS
346
AMERICAS
HEART
.JOTlRNAI~
Benedict-Roth metabolism apparatus.’ The basal metabolic rate was calculated from the Mayo F’oundation standards Uor age and sex,” and the surface area was calculated from the t,ahles nf DuRois and DuBois.” PROCEDURR
All observations wcrc made in t,he morning, when the patient,s were in a basal metabolic state. The rectal thermometer was inserted to a depth of 10 cm. as soon as the patient reached the constnnt~ temperat,ure room and remained in place during the morning’s observations. The subjects lay nude in bed, covered only with a sheet. The room temperature was maintained at or nea.r 27” C., and the humidity ranged bctwccn 45 and 50 per cent. In order to become accommodated to this environment, the patients lay at rest for one hour before observations were started. Three to eight. sets of observations were made, from which it was possible to ~trnltc two to seven calcalations of peripheral blood flow. In some instanc~cs tile oxygen cdollsumption was measured at thc end as well as at the beginning of ihe observat,ions. ln some instances tenminute and, in others, 1w?-cnty-minutc intervals were chosen for making thc3 measurement,s of skin temperatures, and the formulas used in making the calculations were adjusted accordingly.” ~~nslm\-;\‘I’Iu b, \s
The results bf the observations are shown in Table I and Fig. 1. Peripheral Blood I%~c~.-The data arc recorded in Table I, and the scatter diagram of the peripheral blood flow calculations is shown in Fig. 1. On the whole, the peripheral blood flow in the group with normal blood pressure was greater than in the group with cl(~vat,c~d blood pressure, alt,hough there was some overlapping. The average peripheral blood flow for the normal blood pressure group was ‘73 cc. per square meter of body. surface per minute, the same as that found in normal young individnals at 1llis l.cmperatnre.’ In the group wit11 hypertension, however, it was only 55 C.C.per square n1etc.r of body surface per minute, or approximately the same as that iound in normal subjects at the lower room temperature of 25” ( I_ The average for the combined groups xas 63 c.c per square meter of body surface per minute. RectaZ Temperatwtx- -The average rectal temperature for the group with normal blood pressnrr was 36.95’ C. : for the group wit.b hypertension, 37.32” C.; and for the combined groups, S7.18” (1. i’l’ahle I, F’ig. 1). Therefore, the rental t etnperat,ure of the g~*oupwit,11 hyltertcnsion was 0.37” C. higher, on an a.v~t*a,ge, t,han that of the grout> with rjorlnal l~lood pressure, and in both groups the rectal temperature was higher t.han it \\‘a~ in normal young men. in whom it averaged 36.79” C. Weighted Skin Tewpoutwc. -~‘Yhc weighted skin temperature averaged 33.99” C. for t,he group with normal blood pressure and 33.92” C. for the group with hypertension; it was 33.93” C. for the groups combined, as compared with 33.40” C. for the group ol’ normal young men (Table I, Fig. 1). In short the average skin temperat,ure \feashigher in this older age group with vascxnlar disease than in the younger normal subjects.
STFWIRT 1 r
ET
AL.
:
PERIPHERAL
BLOOD
FLOW
UNDER
BASAL
CONDITIONS
349
Tempemtures of tile Han&.-The average of the temperatures of the hands (Area 7) was 34.7” C. for the group of older subjects with normal blood pressure and 34.4” C. for the group with hypertension. That is to say that the average hand temperatures in the older group with normal blood pressure are slightly higher than those in the group of normal young men, whose hand temljeratures averaged 34.4” C. In the group with hypertension the average hancl temperature of 34.4” C. was the same as that in the normal group. Tempcrcrtztrcs of the Fe&.--The average of the temperatures of the feet was 33.4” C. for the group of older subjects wit 11 1111rrna1blood prcssuw :t11(1 X2.6” C. for the hypcrteusion group (Table I, E’ig. 1 1. ‘1‘11~Feet were therefurc, warmer in the group with normal blood pressure I llilll iI1 the group of lo131al J oung men in which the tenipcrat~nes of tlio i’(l~i a\.c~ragecl X2.7” ( ‘. : iI1 t !I(, hypertension group the tcmpr~ratr~res ~1’ t11c f(lc$ lv~r(: slightl!- bttlow tiorl1ial Temperutures of Other Areas of fhc Botl!/.-l*‘or Xrvxs 1 to 6, inclusive, of the body surface, that is, for the upper part of the body, the skin temperature was higher in the hypertension group than in the grlJLi1) with normal blood pressure, each being appreciably higher than in normal young subject,s (,Table I, Fig. 1). Beginning with the hands (L1rea 7): however, and continuing to the lower part of the body and the feet (Areas 7 to 11, inclusive), the relationship of the first two groups is reversed: in these areas the temperatures in the group with hypertension are cooler than in the normal blood pressure group. As compared with normal young subjects, the group of older subjects with normal blood pressure, except for the shin (Area 10 !, show higher temperatures. 011 the other hand, in the hypertension group the temperatures are loner than normal esc&ept in the hands (Area 7)) M-hcrc it is t.he same, and in the upper 1high (Area 8) where it is higher. ‘k2 avcr:l~cS for the llOrmd hlOOd ~mSSUre grmp
alid
h>-p3rtCIlSiOU
grOLlp
are
hi&et’
thrl
the
~l~~!ragY’S
f(Jr
t,ht?
IlOrIll:l~
yOU?lg
group
for all areas except 9 and 10. namely llrc lowcjr thigh and shin. KTuotl I’r~css~~x-The average of tlic t)lootl l)ressurc for the older sllbjc~ts with normal blood pressure was 124,/$3, and IN/l 17 ft~r i he hypertension group, the avt’rage for the tWcJ ciombined gro~ips bcia g 1:56,‘9$. as c.c~mparcd wit11 105 ‘71 for the group of normal y~ang men (Tahlc I. l’ig. 1 ‘i. Heart Kclte.-The average hcalt rate t’or the CJI~C~I~ grOU[) With Ii~JImd bhJ4Jll pressure was 65 per minute ; for the hypertension gronp slightly higher, 7; l)er minute; and for both groups 72 1~ minute (Table 1, Fig. 1,. These arc to 1~. compared with the rate of 61 per minute in the gronl) of normal young men. Basd Netabo2ic h’tr/t .-~--The basal melabolic~ rate \T.ils csseutiall>- the same for the normal blood pressure am1 hypertension grolil), nanlc~l~~ ! 7 per cent and +9 per cent, respectively, as compared wit 11 -:‘i JX’t’ vrwt for t IIV grou]~ of normal young men (Table I, Fig. 1). DISCUSSIOX
It appears, therefore, from observations made on these patients that there are certain differences in the peripheral circulation in older meu as compared with normal young men. This is the case not only in those older men with
350
AMERICAN
HEART
JOURNAL
normal blood pressure but also in those wit,11 hyl~ertcnsion. In only one of the patients (I-J. M., No. 255998, Table I) in this study were there signs or symptoms of occlusive peripheral vascular disease. 111 the normal young subjects already reported1 it was found that more blood was allotted to the pcripherlwhen the environmental temperature was 270 C., than at a lower temperature uf 25” c. The data relating to this older age group have been subjected to statistical analysis. On comparison of the hypertension group with the normal blood pressure group none of the differences wets significant when the test of twice the standard deviation was applied; but. thelc was a trend toward decrease in peripheral blood flow, inc*rease in rccst al temperatures and decrease in avcragt’ weighted skin tempernturc, with increase in tcmpcrature of the upper parts OI the body and decrease in temperature of the lower parts of the body. When the older people with normal blood prcssurc are compared with young normal individuals, again the differences are not statistically significant. The peripheral blood flows are the same. The trend is for the rectal and average weighted skin temperature and the temperature of all the areas of the body to be increased in older people. Again in older people with hypertension as compared with young normal subjects the differences are not significant, but, there is a trend toward deereast, in peripheral blood flow, an increase in rectal (all over 3’7” C. except one subject) and in average weighted skin temperature, and an increase in lempcraturc: of the upper part of the body and a decrease in the lower part. When the whole old age group, including those with hypertension as well as those with a normal blood pressure, arc compared with normal srtbjects, no statistically significant differences are revealed ; but again the trend is toward a decrease in peripheral blood flow< a rise in the rectal and the average weighted skin temperatures, and a rise in ~e~upcratu~x: of th(: dapper’ part elf the body and a decrease in the lower part. How can these data be fitted tugctlw’! There is a l.rend toward decrease in peripheral blood flow when there is hypertension, with a rise in rectal and a decrease in average weighted skin temperature, both as compared to normal young subject,s and to older suh,jecls with normal blood pressure. Also it would appear to be more than ehmw that the tcmperai IIIY of the upper part of the body is warmer and that of the louver ~)al’i,is cooler in these hgpertensivc subjcrts wit,11 normal blood pressure, a than in those subjects in the sault’ agv group pattern which is similar 10 that cirllil)itc4 1)y hpgert,ensivc patients in tlic earlie], age group.“’ StiM~~ARY
The peripheral blood flow and skin and rectal temperatures have been measured in 25 male patients from 35 to ‘77years of age, that is to say in patients in the older age group. In 12 subjects there were clinical signs of vascular damage without hypertension, and in 13 there was also hypertension. In onl) one subject was there evidence of occlusive peripheral vascular disease. The rt:suits in these patients have been compared with those in normal young male
STEWART
ET
AL. :
PERIPHERAL
BLOOD
FLOW
UNDER
BASAL
CONDITIONS
351
subjects. The peripheral blood flow was measured by a modification of the method of Ilardy and Soderstrom. The following facts emerged : 1. The average peripheral blood flow at 27O C. (room temperature) is in the same range in older individuals with normal blood pressure, 73 C.C. per square meter of body surface per minute, as in younger male subjects, but is lower, namely 55 C.C. per square meter of body surface per minute in those with hypertension, and approaches the value recorded for normal young subjects at the cooler environmental temperature of 25” C. 2. The rectal temperature is higher in older lw~pk than in the young normal group (36.79” C.) and was slightly higher in the hypertension group (37.32” C.) than in the normal blood pressure group (36.95’ C.). 3. The average weighted skin temperature was higher in both the normal blood pressure group (33.99” C.) and the hypcrtensicm group (33.92” C.) than in younger subjects (33.74O C.). 4. The skin temperatures of the individual areas of the body surface are warmer in the older patients with normal blood pressure than in younger individuals, except in one area, namely the shins (drea lo), where the ten)perature is lower in the older group. On the other hand patients with h;r-pertensiotl in the older age group have a warmer skin tem])eraturc iu the upper part of the body, and a cooler temperature in the lower part of the body than do poun:: normal subjects. The inference is that the peripheral blood flow to the feet is reduced, since their temperature is lo~r, and that the blood flow to the uppet part, of the body is increased, since its temperature is warmer. The reduction in peripheral blood flow in the lower part of the body is apparently greater t,han the increase in the upper part of the body so that the net result is an average I~cripllcral blood How for the whole body which is less than the value in normal J (Jllllg Tildes at the Same room temp?mture. 111 short, it is comparat,le to the constriction observed in normal yo~ulg subjects in a11 environment of 25” C. 5. Patients with hypertension in this older age group show the same trends. but to a lesser extent! as are shown l)y patients with hypertension in the earlier decades. REFERENCES H. J., and Evans, W. F.: The Peripheral Blood E’low Under Basal Conditions 1. Stewart, in Normal Male Subjects in the Third Decade, _4~. HEART J. 26: 67: 1943. 2. Hardy, J. D., and Soderstrom, G. F.: Heat Loss From the Nude Body and Penpheral Blood Flow at Temperatures of 22” C. to 35” C’., .J. Xutri’tion 16: 493, 1938. 2. Stewart, H. J., and Jack, h’. B.: The Effect of hminophyllin on Peripheral Blood Flow, Ax. HEART J. 20: 005, 1940. H. J., and Evans, TV. F.: The Peripheral L(lou~l FIaj\r in Hyperthyroidism, .\>I. 4. Stewart, HEART J. 20: 715, 1940. H. J.> and E:vans, W. E’.: Peripheral Blood Yluw in Nyxedema? hrch. Int. .J Stewart, Med. 69: 808, 1942. 6. Hardy, J. D., and Soderstrom, G. F.: An Improved Apparatus for Measuring Surface and Body Temperature Rev. Scient. Instruments 8: 418, 1937. i. Roth, P.: Modification of Apparatus and Improved Technique Adaptable to the Benedict Type of Respiration Apparatus, Boston M. & 5. J. 186: 457, 1922. 9. Boothby, W. M., Berkson, J., and Dunn, H. L.: Studies of the Energy of Metabolism of Normal Individuals: A Standard for Basal Metabolism With a Nomogram fol Clinical Application, Am. J. Physiol. 116: 468, 1936. D., and DuBois, E. F.: 9. DuBois, A Formula to Estimate Approximate Surface Area if Height and Weight Be Known, Arch. Int. Med. 17: 863, 1916. H. J., Evans, W. F., Haskell, H. S., and Brown, H.: The Peripheral flood 10. Stewart, Flow, Rectal and Skin Temperatures in Hypertension. In press, AM. HEART J.