The pulse is a movement of the heart and arteries, taking place by a
diastole and systole. Its object is twofold; for, by the diastole, which
is, as it were, an unfolding and expansion of the artery, the cold air
enters, ventilating and resuscitating the animal vigour, and hence the
formation of the vital spirits; and by the systole, which is, as it were,
a falling down and contraction of the circumference of the artery towards
the centre, the evacuation of the fuliginous superfluities is effected.
The arteries themselves are oblong hollow vessels like the veins, but
consist of two coats, in order to fit them for the afore-mentioned
motion, and because they have to contain blood and spirits. They arise
from the heart, and are distributed to all parts of the body; and,
therefore, all the arteries pulsate in a similar manner, and like the
heart, so that from one of them you may judge concerning all the rest.
But the movement of all cannot be equally well observed; for those
which are situated in parts not fleshy may be more conveniently felt,
whereas those that are in fleshy parts are more indistinct. Nor is any
one more conveniently situated for being felt than the one at the wrist.
The first kind of pulses is in regard to the time of their motion, as
observed in systole and diastole. Its differences are, the _quick_,
_slow_, and _moderate_; because every body which is moved must be moved
quickly, slowly, or intermediately, as to time; that is quick which
is moved over a great distance in a short time; that is slow which is
moved over a short distance in a long time; and that is moderate which
is intermediate as to motion. The second kind of pulses is in regard to
the extent of the diastole. For, since every body has three dimensions,
length, breadth, and depth, and an artery is a body, it follows, that an
artery must have these dimensions. When, therefore, an animal is in its
natural state, you will find its arteries dilated moderately every way;
but when not in its natural state, its dilatation will be deficient, or
exceed according to some one of its dimensions. In calculating this,
you must remember the natural state of the pulse; and if it is found to
exceed in breadth, you must call it _broad_; if in length, _long_; and
if in depth, _high_ or _deep_. It is clear that the opposites to these,
or those that are deficient, are to be named the _narrow_, the _short_,
and the _low_. And with regard to those which are altered from the
natural state in all their dimensions, that which is every way diminished
is called _small_, and that which is every way increased, _great_. The
third kind of pulses is with regard to the tone of the vital strength.
The varieties are three, the _strong_, the _weak_, and the _moderate_.
The strong is that which strikes the finger of the physician strongly,
and the weak, feebly and faintly; while the moderate is intermediate
between them, and is held by some to be the natural one; for that the
pulse is rendered stronger by passion and baths, not being naturally
so. In reply to which, Galen contends that a pulse rendered stronger by
non-natural causes soon undergoes a change; and that, therefore, a strong
pulse, which does not readily change, may be natural and moderate. The
fourth kind is in regard to the consistence of the instrument, I mean
the body of the artery. In this respect there are three differences; for
the artery is either harder than natural, and is called a _hard_ pulse;
or softer, and is called a _soft_, or intermediate, and is called in
this respect _moderate_. The fifth kind is in regard to the contents
of the artery; and their differences are, the _full_, the _empty_, and
the _moderate_, since every vessel must be full, empty, or moderately
full of liquids. A full pulse, then, as Archigenes defines it, is one
which indicates an artery that is completely full, and the impression of
which is, that it is distended with fluids; and an empty one conveys an
impression as if its contents were full of bubbles of air, so that the
finger, when pressed upon it, seems to fall into an empty space. These
five kinds of pulses regard one motion of the artery. And since the
quality of the heat in the heart may be more developed than usual in the
artery, some have hence reckoned a sixth kind of pulses. Of the other
kinds, whether they are in regard to one or more pulsations, they derive
their character either from the time of rest, or the rhythm, or their
equality and inequality, or their regularity and irregularity. The kind,
then, in regard to the time of rest, which is the seventh in order, is
divided into the _dense_, the _rare_, and the _moderate_. And, since an
artery has a double motion, composed of two opposite movements, it must
of necessity have two seasons of rest: the one after the diastole before
the systole, the other after the systole before the diastole, which to
most people appears imperceptible; and, therefore, the interval of rest
between two motions has been chosen. When, therefore, there is a long
interval of rest, the pulse is called _rare_; when short, _dense_; and
when intermediate, _moderate_. The eighth kind is in respect to rhythm.
Rhythm, then, in general, is the ratio and proportion of one time to
another. In regard to the pulse, it is, according to some, the ratio of
the time of motion to the time of rest, as of the systole and diastole,
to the intermediate time of rest; but, according to others, it is the
ratio of a time of motion and rest to another time of motion and rest, or
of motion to motion.
Of rhythm, then, there are two varieties, the rhythmic and the arhythmic.
Of the arhythmic, there is a threefold difference: first, when there is
a slight departure from rhythm; second, when there is a greater; and
third, when there is no rhythm at all. Thus, for example; in a child, if
his pulse has the rhythm of childhood, it is called its proper rhythm; if
it has that of an adult, it is said to be an improper rhythm; or if it
preserve no ratio at all, it is said to be devoid of rhythm.
The ninth kind of pulses is found in all the other kinds already
mentioned; namely, that which regards equality and inequality, which may
be remarked either in one pulse, or in many, which last is called the
systematic, of which we must speak first, as being more clear. An _equal_
pulse, then, is that which is alike in order, as regards magnitude,
strength, frequency, and certain other, or indeed all its other,
characters. The _unequal_ pulse is that which is unlike in order. For,
if all are alike, as, for example, all deficient in magnitude, such a
pulse is called equal. But if the first, second, and third appear alike,
but the fourth unlike, it is clear that such a pulse is _unequal_ as to
magnitude. Of this kind are the _intermitting_ and the _intercurrent_.
For not only after one or more great pulsations may one smaller occur;
but sometimes this motion is wholly lost, and one pulsation is said to
be wanting. The other kind, the intercurrent, is the opposite to this;
for when we are expecting an interval of rest, a supernumerary pulsation,
as it were, occurs. When the second is a little smaller than the first,
and the third than the second, and the fourth than the third in like
manner, and so onwards, such pulses are called _sharp-tailed_ or _myuri_,
deriving their names from figures terminating in a sharp point. Such as
are altogether diminished, and never cease from this state, terminate
in a total loss of motion, and are called _failing_ or _fainting myuri_.
There are two varieties in respect to those which fail, for some of them
persevere in that state of smallness in which they terminated, whilst
others attain again their original magnitude, or less or more, and these
are called _recurrent myuri_. Pulses also are called myuri, from their
inequality in regard to one pulsation, concerning which we will speak
presently. And this is the nature of that inequality of pulse, called
systematic. But it takes place with regard to one pulse, or one part of
an artery, or more, as perhaps with regard to motion, for the inequality
is observed on one part of the artery, when the motion of the artery upon
the finger begins one way and terminates another, beginning quicker,
and terminating slower, or reversely. This happens in a threefold
manner, the motion either remaining constant, or being interrupted, or
recurring and beating double, as it were. If, then, remaining constant
and uninterrupted, it should change from quickness to slowness, or
conversely, such a pulse is said to be, and is of unequal velocity. But
if, after being interrupted by an interval of rest, it again appear
quicker, it is called the _goat-leap_ or _dorcadissans_, the term being
derived from the animal _dorcas_, which, in jumping aloft, stops in the
air, and then, unexpectedly, takes another and a swifter spring than the
former. But if after the diastole it recur, and before a complete systole
take place, strike the finger a second time, such a pulse is called a
_reverberating_ one, or _dicrotos_, from its beating twice. You may see
such a thing take place upon a stithy, when a hammer, swung by the hand,
first strikes the stithy, and afterwards, recoiling from the reaction of
the stithy, strikes of itself a second or third time. And not only may an
inequality in the time of motion take place as to one pulsation in one
part of an artery, but also in regard to the strength of the power; not
so, however, in regard to the extent of dilatation (for it is impossible
that the same pulse in the same place should be great and small at the
same time), nor in regard to the other kinds of pulses. But in different
places different parts of an artery may exhibit a double inequality in
one pulsation. For the motion may continue constant, and be swifter at
one finger and slower at another; or it may intermit, and one finger may
perceive it, and another not. And also, in regard to the extent of the
diastole, the same inequality becomes apparent in different places. Of
this kind are the myuri, diminishing once and again at one pulsation;
for, if at the inner finger the pulse should be great and swelled up,
but under the external at the thumb of the patient it appear smaller,
such a pulse is called myurus, from its resemblance to the tail of a
mouse; or meiurus, from its being diminished like a tail. But if the
pulse appear great, and swelled under the middle finger, but smaller on
each side, Archigenes called this impulse _innuens et circumnuens_, i.e.
_the declining, and the declining on both hands_, wishing to mark the
smallness of the diastole, with the declination, as it were, of the two
extremities; for these parts do not appear as if they were cut short, but
as if they were bent in, and a little contracted on each side, and hence
the pulse is curtailed (myurus) on both sides.
And when the inequality as to magnitude takes place at different times,
such pulses become _undulatory_ and _vermicular_. And if irregularity of
position be joined to them, they are called _spasmodic_ and _vibratory_.
Let us begin with the undulatory, in which the whole artery is not
dilated at the same time, according to the same inequality, but this
part of it first, that second, that third, and that fourth, the motion
continuing constant like the swelling of the waves. And some have the
wave carried straight forward, some obliquely; some have a sufficient
altitude in a short expansion as to length, and some conversely; some
have a broad, and some a narrow, and they have the like inequality
in regard to quickness and strength. When the undulatory is wholly
diminished in size, it is called the vermicular, which resembles the
motion of a worm. As the undulatory pulse, when it goes on diminishing,
terminates in the vermicular, so in like manner does the vermicular
in the _ant-like_, or _formicans_, when, most of its motions being
lost, it terminates in one, and it a very small motion. It is called
_formicans_ from its resemblance to the ant (_formica_), on account
of its smallness and kind of motion. The _ant-like_ pulse (called
formicans) is very small, there being none smaller than it; and, in
like manner, it is of all others the most indistinct and dense, but is
not quick, as Archigenes supposed. Nearly allied to it is the _hectic_.
For as there is a hectic fever, so is there also a hectic pulse, which
undergoes little or no variation, but remains always alike contracted
as it first began, and never expanding, the whole habit being turned
into disease. The _spasmodic_ pulses appear as if they were dragged,
stretched, and drawn by the extremities, conveying the sensation of a
stretched cord. But no such thing takes place in the _vibratory_; for
in them the dilatation is greater, as if different parts of the artery
were carried upwards at one and the same time. They may be resembled to
darts, which, when thrown with force, are carried along with a vibratory
motion. The pulse is _serrated_ when part of the artery seems to be
dilated and part not; the artery itself also appearing to be harder than
natural. This pulse has some of the characters of the vibratory, and is
quick and dense, but not always great. In addition to those mentioned,
there is a tenth kind of pulses arising from inequality, namely, that
with regard to regularity and irregularity. The unequal pulses being
divided into those which are alike as to periods, and those which are
wholly unlike, the regular and irregular are formed according to each of
these divisions; from the equality of periods the _regular_ is formed,
and from the entire inequality the _irregular_. The equal pulse is also
always regular (since consequently we call it alike); but the unequal
is not altogether irregular; for, supposing it to have no equality, and
yet to preserve a certain period, such, for example, as to extent of
diastole, if there are two great and one small, then again two great
and one small, and so on successively, such a pulse would be called
anomalous, that is to say, unequal, but regular. But, if it not only had
no equality, but likewise no order in its inequality, such a pulse would
be not only unequal, but also irregular, and in like manner with regard
to the other kinds. Of the irregular, some are altogether so, observing
no period whatever; others are indeed regular as to periods, but, having
no continued order, they may in this respect be called irregular, but in
so far they observe a certain period regularly, they being regulated as
to their periods. As if, for example, there were two great and two small,
then three great and three small, and four great and an equal number
small; and, returning again, two great and two small, three great and
as many small, and so on in like manner. It is to be remarked that, of
all the other opposite kinds, there is one intermediate between the two
extremes, but that there is none between the equal and unequal, and the
regular and irregular, unless you choose to call the one which is regular
as to periods the medium between the regular and irregular. And the
intermediate pulses of all the other kinds are the natural, except that
which relates to strength and weakness, as we showed. But, in those we
have been describing, the equal alone is the natural, and all the others
are not natural, namely, the unequal, the regular, and the irregular.
These are all the kinds of pulses and their generic differences. Some add
two others to these, the one in regard to the position of the artery,
according as it seems to be carried upwards or downwards, to the right
or to the left, and the other in regard to the times of expansion. But
these we treated of along with the undulatory and vibratory. And we, for
the sake of brevity, have only delivered the simple varieties; but, from
what has been said, one may easily connect them, and discover those which
arise from their combinations.
The causes affecting the pulses are next to be treated of, with which
is connected the prognosis from them. We shall begin with those which
respect magnitude, because it is more obvious than the others. A great
pulse is produced either by some urgent necessity, such as an excess of
heat in the heart requiring refrigeration, and, as it were, ventilation
from without; or it may arise from leanness of the body, as we shall
soon show. The excess of heat is occasioned either by natural causes,
such as the ages of manhood and youth, or simply a hot season, place, or
a warmer temperament; or by non-natural causes, such as the air which
surrounds us being hotter than common, hot baths, exercises, food,
wine, heating medicines; or by preternatural causes, such as a hot
intemperament, putrefaction of the fluids, passion, or the like. You may
judge of these classes of pulse from the following observations. Those
which are natural are permanent and not very susceptible of change,
whilst the others readily change, so that often while you examine them,
or generally after a very short time, they will altogether alter. A
pulse also which owes its greatness to a hot bath has softness for
an accompaniment; and hardness is generally combined with greatness
proceeding from a hot intemperament, especially when combined with
dryness of the system. Those who have undergone moderate friction or
exercise have a pulse intermediate between hardness and softness; but
they have the parts about the chest warmer than natural, which is the
case also with those in a passion. Those that are influenced by food,
the use of wine, or rage, have vehemence joined to greatness. Those
who wish to conceal anger, or something which they have done without
permission of the physician, (such as if a person has taken a heating
medicine, and wishes to conceal it from the physician, who inquires about
it while he feels the pulse,) in such persons a manifest inequality is
joined to greatness. To the discovery of this state other considerations
may contribute, such as the habit of the patient, as if he appeared to
be fond of taking medicines, or his disposition, as if it be bad, and
cunning at concealments. A pulse which is great from putrefaction of the
fluids has a contraction more hasty than natural joined to its greatness.
To form a great pulse, an urgent necessity is not alone sufficient; but
the vital powers must also contribute, and a condition of the instrument
or artery intermediate between hardness and softness. When the heat,
therefore, is increased in the heart by any of the above-mentioned
causes, in the first place the pulse becomes great, and, the greatness
not being able to supply the want, quickness is straightway joined
to it; and if that is not sufficient, density is superadded. Small,
slow, and rare pulses are formed by the opposite causes. But when a
change first takes place from a great, quick, and dense pulse to their
opposites, namely, when the necessity is at an end, the first character
of the pulse is not the first that leaves it, but it loses first that
which it last acquired, becoming first rare, then slow and last small.
But if the slowness and smallness should go on increasing, the rarity
will again change to density, in order that the necessary want may be
supplied. Such are the causes of greatness, quickness, density, and
their opposite pulses. To these we shall connect the alteration of the
pulse in regard to one dimension only. Breadth alone then is increased,
principally by a redundancy of humidity, either natural, or from external
causes, as loftiness is occasioned by the softness of the instrument,
assisted by the vital power; but length is rendered apparent by the
dryness and melting of the surrounding flesh, the other dimensions being
contracted. For an artery cannot, in fact, become longer than natural;
and this ought more properly to be called _the lean_ pulse, as the
opposite one, namely, that which is increased only in breadth and depth,
should be called _the fat_. The pulse sometimes falls under the opposite
characters to this, when it is restrained as to any of its dimensions,
and appears low, narrow, and short, when it is not so in reality, but
seems so, owing to the thickness of the fat, flesh, or membranes which
press upon it. Sometimes, too, the whole seems small, when it is not so
in reality; and feeble in like manner. And what do I say? Sometimes an
asphyxy, or complete loss of pulsation, hath seemed to take place over
the whole arteries, when there is no such thing in reality; and this
has happened, more especially to those who have felt them carelessly,
when the motion, being really indistinct, escapes notice, owing to the
quantity of flesh; for it is impossible that a complete asphyxy could
take place while the man is alive. In like manner again in the emaciated,
small pulses appear great. When, therefore, the body is greatly wasted,
the artery which runs along the spine has often been felt by persons
touching the abdomen, and also the pulses in members which before used
not to be felt. Wherefore we must attend to all circumstances, that we
may not be mistaken in our diagnosis. A strong pulse is occasioned by
the force of the natural faculty, when not counteracted by any other
cause, such as the want failing, or from hardness of the instrument.
But a feeble pulse may arise from weakness of the natural powers alone,
although no other causes contribute. For a strong pulse stands in need
of all the other causes for its formation; but the feeble is produced
by weakness alone. The originally strong pulse accompanies moderate
ages, seasons, places, and temperaments; but the feeble the immoderate.
A pulse changing from feebleness to strength is formed by the vital
faculty growing strong, from a preceding state of debility. It is
strengthened either by things within the body, such as concoction of the
fluids, or an excretion of them, or passion; or by externals, such as
wines, food, exercises, and whatever will rectify the intemperament. The
natural powers are weakened by want of food, watchfulness, immoderate
evacuations, grief, cares, and more especially pains inducing syncope,
and whatever forms an intemperament. Some inexperienced persons have
thought a hard pulse strong, but a person of experienced understanding
and touch will not mistake them; for a strong pulse, being mostly
accompanied with greatness, is swelled up to loftiness and strikes the
finger forcibly; but the hard does not admit of greatness, on account
of the unyielding state of the artery. Wherefore a pulse becomes hard
owing to the hardness of the artery. This is occasioned by immoderate
cold, or dryness, or tension proceeding from inflammation, or spasm. To
the hardness, moreover, are joined smallness, quickness, and sometimes
density instead of greatness accompanying, owing to the exciting want.
A soft pulse follows a humid state of the artery. An artery is rendered
more humid by things not preternatural, such as more liquid food,
immoderate baths, much sleep, a more abundant diet, and hilarity; and
by preternatural causes, such as coma, lethargy, dropsy, and the other
pituitous affections. A full pulse indicates an abundance of fluids, or
plethora from food, or from drinking wine, as the empty, on the other
hand, indicates deficiency of food or evacuation. When the body of the
artery feels warmer under the finger, this indicates great heat in the
heart, while the rest of the body is cold, or a certain spasmodic state
of the arteries, which are warmed by the violent motion. Archigenes
says that the place of the artery will particularly be found warmer in
catochus and in those who are about to be affected with somnolency.
With regard to rhythm, when the ratio of the times of motion and rest
is equal, it indicates a proper temperament of the body, or no great
departure from it, as in early age, and the otherwise well-regulated
bodies. But when the time of rest is greater than that of motion, this
indicates that heat prevails, as in adults and those of the adjoining
ages; as, in aged bodies, which are entirely cold, the time of motion is
greater than that of rest. It is to be remarked that inequality in regard
to rhythm, being the measure of that as to quickness and density, this
holds the place as it were of the _matériel_ to the rhythm.
The intermittent and intercurrent pulses take place when the powers are
oppressed, and, as it were, borne down; but the intercurrent indicates
a lesser, and the intermittent a greater injury. And, in general, that
state in which the powers are oppressed and borne down, changes the
pulses to inequality and irregularity in every other respect, and also in
regard to strength and greatness. The pulses called myuri, being shown
to be of two kinds, (for they are found either in that inequality called
systematic, or in regard to one pulsation), the _failing_ or _fainting_
evince the last prostration of the powers; but, when they return, or are
_recurrent_, they indicate that the powers are weak, but that they are
struggling, contending, and have not yet submitted. As to the myuri, in
regard to one pulsation, called _the failing_, and _the failing on both
hands_ (innuentes et circumnuentes), these happen to persons who are
gradually wasted by inflammations not yet resolved, and to those who are
wasted from whatever cause, the bodies around the arteries being melted
down. Pulses of unequal velocity, and those called _dorcadissantes_ or
_goat-leap_, principally accompany febrile heat. But if the pulse render
the commencement of the diastole feeble, and increase in velocity towards
the end and beginning of the systole, this indicates that putrefaction
is prevailing, nature hastening on the discharge of the fuliginous
superfluities. But if, on the other hand, it render the commencement
of the systole feeble, and rather make speed towards the diastole, you
may be sure that the heat is prevailing, and longing for refrigeration.
These in fever are, for the most part, accompanied by density, and
sometimes greatness, if the powers be not restrained by the hardness of
the instrument. When the hardness of the artery increases, and the powers
are not weakened, the _double_ or _reverberating_ pulse is formed. The
_undulatory_ pulse most commonly attends the more humid affections, such
in particular as anasarcous swellings, lethargy, and peripneumony. When
the powers of life are beginning to fail, but are still making a faint
struggle, the undulatory pulse sinks into the _vermicular_; but when
they decline to their lowest ebb, this last passes into the _ant-like_
or _formicans_. The hectic particularly attends those in consumption and
marasmus. The spasmodic pulse takes place when the origin of the nerves
is suffering from some inflammatory affection, as in frenzy and acute
attacks of epilepsy, when those affected with them die while they are
yet warm, contrariwise to those in syncope, for they are alive after
they have become cold. The _clonodic_ or _vibratory_ pulse takes place
when the wants of the system require a great diastole, and the vital
powers are sufficient for that purpose, but are opposed by the body of
the artery; which, from its hardness, cannot be expanded to a large
diastole, as happens in great inflammations and chronic obstructions.
The _serrated_ pulse is indicative of inflammation, and particularly in
some tendinous parts. It is no less so of pleurisy, and when slight,
indicates that the inflammation is gentle, and easily to be concocted;
but when intense, that it is severe and of difficult concoction, and will
be attended with urgent danger, if the powers be weak, or, if they be
strong, that it will be slowly concocted, for it will either terminate in
empyema, or a consumptive marasmus will supervene. One ought also to know
that irregularity of the pulse commonly accompanies its inequalities;
for you will rarely find an unequal pulse orderly. Wherefore, the lesser
constitutional injuries occasion unequal and regular pulses, but the
greater, unequal and irregular.
These are the simple causes of the pulses and their prognosis, and from
them the compound, as we stated when treating of their differences, may
easily be discovered.
* * * * *
COMMENTARY. The ancient authorities on the pulse are the following:
Celsus (iii, 6); Galen (Libel. de Pulsi. ad Tirones; de different. Puls.,
de Dignos. Puls., de Caus. Puls., de Præsag. ex Puls., Synopsis librorum
de Puls.); Philaretus (de Pulsu); Theophilus Protospatharius (de Pulsibus
ap. Ermerins Anecd. Med. Gr.); Actuarius (de Diagnosi); Avicenna (i, 2,
3); Averrhoes (Collig. iv, 16); Haly Abbas (Theor. vii); Alsaharavius
(Theor. vii); Rhases (ad Mansor. x, 32; Contin. xxxi); Psellus (Opus
Medicum apud Boissonade, Anecdota Græca.)
Prosper Alpinus gives an excellent exposition of the ancient doctrines
on the pulse (de præs. Vit. et Morte ægrot. iv, 3); Le Clerc’s account
is not so accurate (Hist. de la Méd.) Wetsch’s is tolerably correct (de
Pulsu.)
Hippocrates, although Galen affirms that he was not entirely unacquainted
with the pulse, does not appear to have attached much importance to the
observation of it, for he generally neglects to mention its characters,
where we would most expect to find them stated, as, for example, when he
is detailing the symptoms of epidemical fevers. Celsus, too, expresses
himself in doubtful terms respecting the indications furnished by the
pulse: “Venis enim maxime credimus, fallacissimæ rei; quia sæpe istæ
leniores, celerioresve sunt, et ætate, et sexu, et corporum naturâ; et
plerumque satis sano corpore, si stomachus infirmus est, nonnunquam
etiam incipiente febre, subeunt et quiescunt; ut imbecillus is videri
possit, cui facile laturo gravis instat accessio. Contra sæpe eas
concitat et resolvit sol, et balneum, et exercitatio, et metus, et ira,
et quilibet alius animi affectus.” Aretæus and Cælius Aurelianus are
indeed sufficiently minute and accurate in detailing the characters
of the pulse, while describing the symptoms of various diseases,
but neither of them has written expressly on the subject; and, as
the works of Herophilus, Agathinus, Magnus, Athenæus, and Archigenes
are entirely lost, Galen must be considered as our first and great
authority on the pulse—we might almost have said our sole authority,
for all subsequent writers were content to adopt his system, without
the slightest alteration. As our author’s account of the subject is
professedly taken from the elaborate treatises of Galen, it may, perhaps,
appear unnecessary to attempt any further exposition of the system; but
the importance of the subject, and, we may add, its novelty to modern
readers, have induced us to make some detached observations upon it, in
order to explain some parts of it which are confessedly obscure, and to
answer certain objections which have been stated against it, by modern
writers who have not properly understood its principles.
We shall first notice the objection stated to Galen’s Theory of
Respiration by Van Helmont, who, although compelled to admit the
ingenuity of Galen’s system, pretends to differ from him respecting the
final cause of arterial action and respiration, which, he maintains, is
not refrigeration, but the maintenance of animal heat. (Opera, p. 112.)
But if he had read Galen’s work ‘de Usu Respirationis’ carefully, he
would have found that this is the very sense which Galen attaches to
the terms refrigeration and ventilation. Van Helmont states, as a new
discovery, that a sort of concoction of the blood takes place in the left
ventricle of the heart. But he might have found this doctrine also in the
works of Galen.
According to Galen, the pulse consists of four parts: of a diastole and
a systole with two intervals of rest, one after the diastole before
the systole, and the other after the systole before the diastole.
He maintains that by practice and attention all these parts can be
distinguished. (De Dignos. Puls. iii, 3.)
The first distinctions of the pulse are derived from the extent of the
diastole, according to its three dimensions, namely, length, breadth, and
depth. These give rise to the characters _long_, _broad_, and _deep_ or
_high_. Le Clerc renders the last by _élevé_. A long pulse, of course,
refers solely to the impression on the finger, as in reality one pulse
cannot properly be said to be longer than another; but when a person is
lean a larger portion of the artery can be felt under the finger than
when he is fat.
The character _deep_ or _high_ is easily understood, and is evidently
produced by a free dilatation of the artery. It does not indeed appear
evident how there can be a difference between a _deep_ and a _broad_
pulse, if the dilatation of an artery were equal on all sides; but Galen
positively affirms that it is a fact ascertained by ample experience,
that sometimes there is a free dilatation of the artery upwards with a
contracted one laterally, constituting a _high_ and _narrow_ pulse; and,
on the other hand, that there is often a free dilatation laterally with a
contracted one upwards, constituting a _low_ and _broad_ pulse. He gives
directions for detecting these peculiarities of the artery. (De Diff.
Puls. iii, 2.)
The characters of _quick_ and _slow_ are derived from the length of
time occupied in the actions of systole and diastole. They seem to
be sufficiently well marked, and yet Fyens denied that there is any
difference between _frequency_ and _quickness_. However, many of our
late authorities in medicine acknowledge a distinction between these two
characters, and they appear to us sufficiently obvious. In fact, Galen
establishes the distinction in the most satisfactory manner. (De Dignos.
ii.)
The distinctions of _strong_ and _feeble_ are derived from the force with
which the artery strikes the finger. No one can possibly mistake them.
The relaxation and constriction of the arterial tube give rise to the
characters of _soft_ and _hard_, which are so obvious that they cannot be
misunderstood. The character of _hardness_ is called _tension_ by Galen,
who states that it is characteristic of inflammation.
The next class of pulses derive their characters from the time which
elapses between two diastoles or pulsations of the artery. They are
called _dense_ and _rare_, in the ancient system, being used in the same
sense that _frequent_ and _slow_ are in modern works.
The terms _equal_ and _unequal_ (or, as they might have been translated,
_equable_ and _unequable_) arise from the constancy or inconstancy
of any peculiar character of the arterial pulsation. The _regular_
and _irregular_ are distinguished from these, inasmuch as a series of
pulsations, although unequal may be regular, when they observe a certain
ratio, as when four strong pulsations are succeeded by a feeble one, and
this series goes on successively.
An inequality may take place in respect to one pulsation; for the
dilatation of the artery may be interrupted, and then completed, when
it is called _dorcadissans_, _caprizans_ or _goat-leap_; or the stroke
may be suddenly repeated, when it is called _dicrotos_, which may be
translated the _double_, _reverberating_, or _rebounding_ pulse. The term
_dorcadissans_ is derived from _dorcas_, an animal generally supposed
to have been the goat, but it is now satisfactorily ascertained that it
was the _antelope dorcas_ or _gazelle_; and, in the Latin translations
of Avicenna and Haly Abbas, it is rendered _gazellans_. It is said that
when this animal leaps upwards it at first takes a short spring, then
seems to make a sudden stop, and afterwards takes a much larger and
swifter bound. This character was applied to the pulse when an imperfect
dilatation of the artery is succeeded by a fuller and a stronger one.
(Galen, de diff. Puls. i, 28.) It is thus described by Haly Abbas:
“Gazellans pulsus est qui cum a celeritate incipiat antequam percussiat
stat, dehinc velociter movetur: vocatur autem hujusmodi gazelenus suâ ex
similitudine caprioli saltu: quum capriolus quem Gazel Arabicè vocant cum
saltum dederit pedes tollit et suspensus pauco videtur tempore atque sic
ad terram velociùs redit.” The translator of Alsaharavius renders it by
_fusalis_. It is correctly stated by Fouquet that the second pulsation
is necessarily larger than the first. The _dicrotos_ consists of two
pulsations, following upon one another so rapidly as to form, as it were,
but one beat of the artery. In the translation of Alsaharavius it is
called _mallearis_, and is thus defined: “Est autem pulsus mallearis qui
percutit manum et recedit, deinde redit et percutit secundario.”
When there is a succession of pulsations which diminish in magnitude
regularly, such a system of pulses is called myuri, that is to say,
_decurtate_ or _sharp-tailed_, from their supposed resemblance to the
tapering tail of a mouse. Those who are acquainted with the Scholiast
on Hephæstion, and the other ancient writers on prosody, will readily
recognize a term with which they are familiar. Galen inclines to the
opinion that this state of the artery is connected with an intemperament
of the portion where the expansion is limited. Of these pulses, some
end in complete asphyxia, and hence are called _swooning_, _failing_,
or _fainting_ myuri, (Le Clerc renders it by _le myurus defaillant_;)
and others again gradually recover their former magnitude, and are
called _recurrent myuri_. Nearly allied to these are the _innuentes
et circumnuentes_, for which it is scarcely possible to find any
appropriate term in English. Le Clerc thus renders and explains this
pulse, in French: “Le myurus _qui va en baissant de côté et d’autre_,
c’est a dire qui frappe moins sensiblement le premier et le dernier
doigt que celui ou ceux du milieu.” It consists, as Avicenna explains,
of a double myurus, which swells out in the middle, and diminishes at
both extremities. It was therefore a sort of double inclined plane.
The myurus, and the innuens et circumnuens, are thus described by Haly
Abbas: “Est autem et in hac specie unius pulsationis pulsus qui _muris
cauda_ appellatur; quique inclinus vocatur pulsus. Et qui muris cauda
vocatur fit cum arteria dilatatur sub primo digito qui a superioribus
est grossa, et sub secundo minus grossa, sub tertio parva, sub quarto
minima. _Inclinus_ autem pulsus est qui sub duobus mediis movetur digitis
grossus et sub extremis hinc et inde subtilis et tenuis; aut medium ejus
elatum est, et extremitates demissæ, videturque tangenti arteriæ extrema
ad inferiora declinari.” Sprengel appears to think that the _pulsus
inclinus_ of Haly Abbas is one first described by him, but there can
be no doubt of its being identical with the _innuens et circumnuens_
(νενυκὼς καὶ περινενευκὼς) of Galen’s system. It is likewise the same as
the _pulsus inclinatus_ of Rhases, who says it occurs in hectic fevers
and consumption. Galen attempts to explain this pulse by referring it to
weakness of the vessel and an unequal wasting of the parts around, which
convey the impression, when several fingers are applied together, as if
the vessel swelled out in the middle. (De Diff. Puls. ii.)
In the _spasmodic_ pulse, the artery is said to convey the sensation of
a string or cord tightly stretched, which, when touched, starts from its
place. It seems to be the _pulsus tortuosus_ of Alsaharavius, and is
commonly met with when convulsions are impending.
The _vibratory_ derives its name from an imaginary resemblance to the
motions of a rod or dart when thrown into the air, and it can only take
place when the artery is hard, and the strength good. Le Clerc renders it
_le pouls dardant_. It is generally named _thrilling_ in modern works.
According to Actuarius, it is hard, quick, and dense, and indicates
inflammation of nervous parts.
The _undulatory_ derives its name from a supposed resemblance to the
rolling of the waves, and can only take place when the artery is
particularly soft, being accompanied with an unequal elevation of it
in the diastole. It is thus described by Rhases: “Undosus vero est qui
secundum latitudinem, magnum digiti occupat locum, cum lenitate et
repletione, cum eo tamen non est magna elevatio neque subita, sed videtur
quod elevationem ejus una post aliam contingit, donec fit ut undis
assimilatur, quarum una aliam sequitur.” It is the _pulsus fluctuosus_ of
Haly Abbas, and the _pulsus fluens_ of C. Aurelianus. (Morb. Acut. ii,
32.) Le Clerc renders it _ondoyant_.
The _vermicular_ differs from the last mentioned only in magnitude
and strength, being soft, small, and weak. Nearly allied to it is
the _formicans_ or _ant-like_ pulse, which is one of the last degree
of weakness, smallness, and density. They are thus described by
Rhases: “Vermicolosi forma est ut forma undosi, in elevatione quæ
secundum diastolem eadem invenitur, non tamen est latus, neque plenus,
cujus inundatio existit debilis, qui vermibus per foramen arteriæ
discurrentibus assimulatur: formicans vero pulsus adeo invenitur in
ultimo parvitatis, et spissitudinis consistere, ut pulsui pueri recens
nati assimuletur.” According to Galen the _formicans_ is a pulse which it
requires great experience to detect. (De Dignos. Puls. ii, 1.) Haly Abbas
states that it is the termination of the vermicular. It is the _pulsus
formicabilis_ of Cælius Aurelianus. The Chinese compare the formicans to
a silk thread, a capillary tube, or a hair.
The _intermittent_ and _intercurrent_ pulses are opposed to one another,
there being a complete failure of a pulsation in the one case, and an
accessory or superfluous one in the other. There cannot be a better proof
of the imperfection in our modern systems of the pulse, than that there
should be no mention in them of the intercurrent pulse.
The _hectic_ pulse, it is well known, is small and dense. Alexander
Trallian says, small and feeble. (xii, 4.)
The _serrated_ is hard, quick, and unequal in its feel. Rhases says that
it is principally observed in inflammations of the pleura and diaphragm.
According to Actuarius, the pulse characteristic of inflammation is
serrated and hard, more especially if seated in a tendinous part. (Meth.
Med. i, 25.) Le Clerc renders it _le pouls en manière de scie_. (Hist. de
la Méd. p. iii, l. iii, c. 3.) It appears to correspond with the pulse
called _harsh_ in the works of English writers on medicine.
Borden speaks of the terms _formicans_, _myurus_, and _caprizans_ as
having been justly banished from our modern nomenclatures. But it may be
doubted whether it be from superior information or from ignorance that
we have rejected these nice distinctions. Some of these terms were in
use long before the time of Galen, (he mentions that Herophilus used the
term _dorcadissans_,) and for more than a thousand years afterwards the
characters of the pulse to which they were applied were acknowledged as
real; and, on a matter depending solely upon experience and observation,
the concurring suffrages of so many ages must be admitted to be entitled
to some consideration. That many of the Greek and Arabian physicians were
men of great learning and of much practical skill in medicine cannot
admit of a doubt; and therefore their opinions ought not to be hastily
rejected as visionary and unfounded. Galen, indeed, expresses in strong
terms the difficulty which he found in defining accurately the states of
the artery to which the terms we are treating of are applied, and warns
the reader that such characters are to be detected only by a person well
experienced in the art of feeling pulses, which he pronounces to be
one not easily attained. (Synops. viii.) Alsaharavius insists strongly
on the necessity of having a nice sense of touch, and that it be well
cultivated in order to attain the tact of feeling pulses properly. Haly
Abbas and Actuarius in like manner state the difficulty and importance of
the art of feeling pulses. It is to be borne in mind that the ancients
performed the operation of feeling the pulse more methodically than is
now generally done, which may in part account for our having lost sight
of some of the nicer shades of distinction which they recognized. It is
worthy of remark, further, that the truly learned and experienced Prosper
Alpinus recognized and described these characters of the pulse which we
have been treating of. (De pr. Vit. et Morte ægrot.)
Whoever will consult Galen’s treatises on the pulse will find discussed
in them many subtle questions which are now seldom thought of. For
example, he enters into a disquisition whether or not we can perceive
the systole of the artery. He informs us that Agathinus had denied and
Herophilus affirmed the possibility of this. He, after having, as he
says, examined the matter fully, agrees with the latter. (De Dignosc.
Puls. i, 3.)
Psellus gives the characters of the pulses in not inelegant politic
verses. A very clear and satisfactory description of them is given in the
short treatise of Theophilus Protospatharius.
The causes which produce all these varieties of pulse, and the changes
of the system which they indicate, are, upon the whole, pretty clearly
explained by our author; and the reader who wishes to consult other
abridgments of the doctrines of Galen, may find them in the works of
Rhases, Haly Abbas, and Actuarius. We shall merely make a few more
remarks upon some of the more obscure and least understood parts of the
system.
Respecting the myuri, Galen states that they all indicate a prostration
of the vital powers, but differing in degree, according to circumstances.
When the pulse gradually becomes smaller, and in like manner recovers its
magnitude gradually, and so on alternately, so as to form the _recurrent
myuri_, it indicates an inferior degree of prostration; and, when the
diminished state of pulsation continues permanent, a greater degree of
oppression is indicated. In the former case the powers of the system seem
able to struggle against the load, but in the latter they are completely
overcome. This state is next in danger to that of complete asphyxia.
These three are the worst kinds of pulse. The _intermitting_ is said
by him to be allied to these, being indicative of great danger, though
inferior to that of those we have mentioned. Next to the intermitting
is the _intercurrent_, which indicates that the powers of the system
are strong, but oppressed, and contending against some great load.
Galen was particularly apprehensive of the _intermitting_ pulse, which
he held to indicate that the system is struggling against some urgent
cause. He remarks, however, that, when the pulse is otherwise strong and
frequent, it indicates less danger than when it is weak and slow. But,
upon the whole, he considered this kind of pulse so full of danger, that
he affirms he had never known a person recover whose pulse intermitted
during the interval of two pulsations. When the pulse intermits during
the space of only one pulsation or a little more, he says he had often
seen the patient recover. He also states that an intermitting pulse
is less dangerous in old persons than in adults or children. Some,
he says, affirm that they have seen cases of intermission which did
not prove dangerous, but he believes that they had confounded rarity
with intermission. The intermitting is to be distinguished from the
rare by the length of the time of rest, and by the latter being often
equable, whereas the former is always unequable. He says it is generally
occasioned by frigidity of the heart. These doctrines may be traced
through all the subsequent authorities, both Greek and Arabian, down to
Actuarius.
Galen, Rhases, and Haly Abbas repeatedly inculcate that the undulatory
pulse indicates an approaching crisis by a sweat. They describe it as
being strong, full, soft, bounding, and unequable. According to Galen it
is most commonly met with in lethargic affections, quotidian, marsh, and
typhoid fevers. (De Præs. ii, 9.) It is also said to be common in sudden
attacks of dropsy. (Ib.) In some instances, however, it is the precursor
of some critical evacuation, such as that by the hemorrhoids, or by the
bowels. (Synops. 22.) Actuarius particularly states that critical sweats
are indicated by the undulatory pulse. (Meth. Med. ii, 2.)
The _dicrotos_ is distinguished by a smaller pulsation suddenly
succeeding to a larger one. Galen compares it to a hammer, which, when
forcibly struck against the anvil, rebounds, and strikes it again. The
artery in such cases is always strong and vibratory. Philaretus describes
the pulsation as being hard, vehement, and rebounding. Galen says it can
only occur when the powers of the system are strong, the artery hard, and
the body oppressed with a redundance of humours. He repeatedly inculcates
that it indicates an approaching crisis.
The singular pulse called _dorcadissans_, which we have translated
_goat-leap_, is said by Galen to occur most frequently in affections of
the heart and inflammations of the parts within the chest. (De Prognos.
ii, 8.) It is the same as the pulse now called _jerking_, which the best
authorities agree to be characteristic of pericarditis. In such cases,
Hope says, the pulse is “full, hard, _jerking_, and often with a thrill.”
(Diseases of the Heart, p. 99.) We suspect the modern term _jerking_,
although perfectly intelligible to one experienced in the art of feeling
pulses with discrimination, will be found fully as difficult to define as
the _dorcadissans_ of the ancients.
The _vermicular_ appears to have been the same as that which is now
sometimes denominated _creeping_. In fact, Galen derives its name from
its resemblance to the motion of a creature _creeping_. (Synops. 22.)
It is said by the ancient authorities to occur in cases of sudden
prostration of the vital powers, produced by inordinate evacuations, such
as hemorrhage, cholera, diarrhœa, and the like. (De Prognos. Puls. ii.)
The pulse called _innuens et circumnuens_, is said to occur only in cases
of extreme debility and danger, more especially when attended with a
great chill. It is connected, says Galen, with idiosyncrasy. (De Præs.
ii, 11.) Is it the same as the pulse now named _flickering_?
Galen gives the following ingenious explanation why the pulse is
contracted and frequent, in cases of acute inflammations. He remarks
that, if a person have an inflammation in a limb, he will experience
most ease in a state of complete rest; but if obliged, by some urgent
necessity, to perform a journey, he will find that he can accomplish this
most easily by taking short and frequent steps. In like manner, when
any part is inflamed, it would afford most relief if the motion of the
arteries could be altogether suspended for a time; but, as this cannot
be, nature renders the dilatation as confined as possible, and makes up
for its smallness by frequency. (De Usu Respirationis.)