Part 47

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.

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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.