Hektoen International

A Journal of Medical Humanities

Early observations of the pulse

JMS Pearce
Hull, England

Over the centuries, various devices bearing names now unfamiliar (Clepsydra, water clock, pulsilogium, Sphygmologia, Pulse Watch) were used to measure the pulse.The examination of the pulse to assist in diagnosis and prognosis dates back to ancient Egyptian, Indian, and Chinese physicians. Because they had little understanding of cardiovascular physiology, we might wonder what first prompted their attention to the pulse.1 There are strong hints in the Ebers Papyrus c. 1550 BC, purchased at Luxor in the 1870s by Georg Ebers of Leipzig, for here was recorded:

Examining is… like measuring the ailment of a man in order to know the action of the heart. There are canals in it [the heart] to every member. If the priests of Sekhmet or any physician put his hands or his fingers upon the head, upon the two hands, . . . upon the two feet, he is measuring the heart.2

Egyptians related the pulse to the heartbeat but had no concept of the circulation. They used a clepsydra, an earthenware vessel with a tiny hole in the bottom through which water dripped into a collecting bowl. The pulse rate was correlated with the rate of drips: the markings inside the collecting bowl divided the day into twenty-four hourly increments, calibrated with a sundial.

The pulse was important in Ayurvedic medicine, practiced before the time of Buddha. Sage Kanada (600 BC), an ancient Ayurvedic physician, in his Sanskrit treatise Science of Sphygmica3 described several types of pulse (nadi) felt by applying three fingers at the wrist. Each corresponded to a particular dosha (humor): bayu or air, pitta or bile, and kaph or phlegm.4 The bayu was fast, irregular, and light—likened to the movement of a snake. The pitta was strong, forceful, and rhythmic—likened to the movement of a frog—and the kapha pulse slow, steady, and deep—likened to the movement of a swan. From these they diagnosed digestive, respiratory, and circulatory disorders, and emotional health.

In China, about 2,500 years ago, qi (vital energy) and disease were deduced from the volume, strength, weakness, regularity, or interruption of four varieties of pulse beats (superficial, deep, slow, and quick). This was recorded in Huang Ti Nei Ching Su Wen: The Yellow Emperor’s Book of Medicine (reprinted by Berkeley: Univ California Press in 1972). The Chinese physician Wang Shu-ho (AD fourth century) published A treatise on the pulse in which he read three different pulses on each wrist that pointed to disorders of various organs. However, much was shrouded in mystical practices, often in secrecy.

Greek era

Fig 1. Erasistratus the Physician Discovers the Love of Antiochus for Stratonice. Benjamin West, 1772. Birmingham Museum of Art.

In classical Greece, the pulse was examined in health and disease, and was thought to predicate prognosis. The main innovator was Praxagoras of Cos (c. 340 BC). The multi-author Hippocratic corpus contains reference to the pulse in the head and neck in fevers; the pulse and breathing were considered proportionate to aging.5 Erasistratus, Herophilus (335–280 BC), and Archigenes of Apamea in the reign of Trajan, AD 98–117, all described the pulse and its behavior as an indication of disorders of the animal spirits.6 Herophilus is often said to have been the first person to measure the heartbeat and the pulse. He had trained in Alexandria under Praxagoras and used the Clepsydra or water clock to time the pulse.7 He recognized four features of the pulse: its size, frequency, force, and rhythm.

An early correlation of the pulse with contraction of the heart was probably owing to Erasistratus, a contemporary of Herophilus, who noticed that the arteries dilate while the heart contracts, and vice versa. He used the pulse to aid diagnosis and noticed it was affected by the emotions. For instance, Antiochus, son of the King Seleucus I (c. 358–281 BC), in 294 BC had a grave illness that defied diagnosis until Erasistratus noticed that his pulse rate would increase when his stepmother Stratonice appeared. He correctly suggested that Antiochus was suffering from hidden lovesickness. According to legend, the king gave his wife to his beloved son, saving his life. (Fig 1).

Rufus of Ephesus (c. AD 70–110) and Archigenes (AD 1st–2nd century) recognized different characteristics of the pulse in different illnesses. Archigenes described eight characteristics, including hardness of the pulse wall, its regularity, and irregularity. A rapid, strong pulse might indicate a fever or inflammation; a weak pulse indicated a loss of vital energy or a chronic illness. Rufus, like Erasistratus, observed that the pulse was caused by the contraction and relaxation of the heart and noted that exercise made the pulse vigorous, large, and frequent.

Roman era

In ancient Rome, the philosopher Seneca the Younger said, “The physician cannot prescribe by letter; he must feel the pulse.” Examination of the pulse was a fundamental diagnostic and prognostic method used by physicians and was subjected to much competitive professional and public debate and rivalry.

Galen related the pulse to the vital spirits and to the balance of the four humors. Seemingly obsessed, he wrote eight treatises on the subject,8 its differentiation, identification, cause, and prognosis—lucidly expounded by Lewis.9 He described its volume, tone, distension, rate, regularity, and a bewildering array of characteristics of a single pulse beat. Perhaps this complexity mirrored his early struggles in interpretation, which he recorded in his treatise On Prognosis by the Pulse:

For many years, I was doubtful about clearly discerning the movement of contraction by touch, and I shelved the question until such time as I could learn enough to fill the gap in my knowledge. After that, the doors of the pulse were open to me.

Another important but little-known treatise, De Pulsibus, was written by Marcellinus (c. AD 2nd century) in Galen’s time, describing the physiology and interpretation of the pulse in different conditions and the actual method of palpating the pulse.10

Medieval era

Fig 2. Rhazes visiting a patient and considering his pulse and urine. Gerardus Cremonensis, “Recueil des traités de médecine”, AD 1250–1260 AD. Via Wikimedia.

Rhazes (Bakr Muhammad ibn Zakariya Razi) (AD 865–925), (Figure 2*) was one of the outstanding Persian physicians of the medieval era. He described irregularities of the pulse in syncope and in heart disease: “In the heart, there are eight types of bad tempers, blockage in its arteries, blockage in its opening and swelling followed by irregular pulses, fast and then syncope.”11

Avicenna, known as Abu Ali Ibn Sina (c. AD 970–1037), the preeminent philosopher and physician of the Islamic world extensively discussed the pulse in his Canon of Medicine (Al-Qānūn fī al-ṭibb).12 He probably observed atrial fibrillation and its prognostic significance: “if the [pulse’s] irregularity is orderly, it betokens lesser constitutional injuries; if disorderly, it shows that there are more serious constitutional defects.”

Fig 3. Floyer’s Pulse Watch.

In the thirteenth century, a Muslim physician, Ibn Nafis, deduced that the blood must pass from the right ventricle to the left ventricle through the lungs. His statement remained unheeded until William Harvey’s (1578–1657) celebrated Exercitatio anatomica de motu cordis et sanguinis in animalibus (1628)provided the first comprehensive account of the circulation.13 In Chapter Three he stated:

There is just the one cause of arterial pulsation throughout the body, and that is contraction of the left ventricle.

In the seventeenth and eighteenth centuries, the routine medical examination was usually restricted to assessment of the pulse and simple inspection of the tongue, skin, and urine. Sanctorius Sanctorius (1561–1636) of Padua invented a pulsilogium based on Galileo’s pendulum.14 The physician would adjust the length of the pendulum until it synchronized with the patient’s pulse. From this device he described the circadian rhythm of the heart rate. More accurate measurement of pulse rate only became possible in 1710 when Sir John Floyer (1649–1734) invented the Physician’s Pulse Watch with a second hand. (Fig 3)

Floyer’s pulse watch (Sphygmologia) had a second hand with which he measured physiological variations of pulse rate with age, respiration, temperature, and disease.5 Despite these scientific advances, the physician taking the pulse was sometimes the object of jest and ridicule (Fig 4).

It was more seriously portrayed in several seventeenth century paintings, such as Love Sickness by Jan Steen and Consultation by Quiringh Gerritsz Van Brekelenkam. (Fig 5)

Fig 4. A lecherous doctor taking the pulse of an old woman while fondling a young one. Colored etching by T. Rowlandson, 1810. Wellcome Collection.
Fig 5. Consultation. Quiringh Gerritsz Van Brekelenka. Via Wikimedia.

Auscultation of the heart did not begin until 1816 when at the Necker Hospital in Paris, René-Théophile-Hyacinthe Laennec (1781–1826) listened with his ear applied to the chest; three years later he listened through a hollow wooden tube, the earliest stethoscope. Augustus D. Waller (who on mention of his famous father’s name, remarked: “I am the Wallerian degeneration”), recorded the first electrocardiogram (ECG) with a mercury capillary electrometer in 1887 at St. Mary’s Hospital, London. But his tracings showed only two deflections. Willem Einthoven (1860–1927) of Leiden improved Waller’s technique and published a paper based on the string galvanometer in 1901. He described P, Q, R, S, and T waves, the leads I, II, and III, and calculated the electrical axis depicted as a single vector two years later. He was awarded the Nobel Prize in Physiology or Medicine in 1924 “for his discovery of the mechanism of the electrocardiogram.” This was confirmed and applied to diagnose heart diseases by Sir Thomas Lewis.

The ECG did not quite replace the clinical examination of the pulse, but it advanced the understanding of cardiac physiology and heralded a host of technological devices used in modern cardiological practice.

End note

* Note the physician’s palpating thumb is on the ulnar side of the wrist. Perhaps we should allow for artistic license.

References

  1. David Osborn. Pulse Diagnosis: Reading the River of Life. GreekMedicine.net. http://www.greekmedicine.net/diagnosis/Pulse_Diagnosis.html
  2. Ebbell B. The Papyrus Ebers: The Greatest Egyptian Medical Document. London, UK: Oxford University Press; 1937.
  3. Gupya KRL. Science of Sphygmica or Sage Kanad on Pulse. English translation. Calcutta, SC Addy 1893. https://iiif.wellcomecollection.org/pdf/b2440035x
  4.  Ghasemzadeh N, Zafari AM. A brief journey into the history of the arterial pulse. Cardiol Res Pract. 2011;2011:164832.
  5. Sir John Floyer. The Physicians Pulse Watch. London: S. Smith & B. Walford; J. Nicholson, etc., 1707-1710. https://wellcomecollection.org/works/r49ykdus/items
  6. Horine E. An epitome of ancient pulse lore. Bulletin of the History of Medicine. 1941;10:209-49.
  7. Bedford DE. The ancient art of feeling the Pulse. Brit Heart J. 1951;13:423-7.
  8.  Galen. On the Pulse for Beginners. (De puls. ad tir.). Ed. C.G. Kühn. Vol. 8. (1824). Leipzig: Prostat in officina libraria Car. Cnoblochii (reprint Cambridge: Cambridge University Press, 2011).
  9. Lewis O. In: Hankinson R, & Havrda M. (Eds). Galen’s Epistemology: Experience, Reason, and Method in Ancient Medicine. Cambridge: Cambridge University Press, 2022.
  10. Lewis O. Marcellinus’ De pulsibus: a Neglected Treatise on the Ancient “Art of the Pulse.” Scripta Classica Israelica 2015; 34:195-214.
  11. Hajar R. The Air of History (Part IV): Great Muslim Physicians Al Rhazes. Heart Views. 2013;14(2):93-5.
  12. Bakhtiar L, Gruner OC, Shah MH, Crook JR. The Canon of Medicine (al-Qānūn Fī’l-ṭibb). Great Books of the Islamic World, 2014.
  13. Harvey WWR. The works of William Harvey. London, UK: The Sydenham Society, 1847.
  14. Lippi D, Mascia G, Padeletti L. The pulsilogium and the diagnosis of love sickness. Hektoen International Spring 2017

JMS PEARCE is a retired neurologist and author with a particular interest in the history of medicine and science.

Fall 2024

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