Rhythms of Broken Hearts: History, Manifestations, and Treatment of Heart Rhythm Disorders and Heart Disease

By J. Anthony Gomes

This book provides an overview of the history, manifestations, and treatment of heart disease and heart rhythm disorders. In addition, it covers the effects on the lives of patients, coping mechanisms, and relationships with doctors, family, religion, and death. The book uniquely intersects the fields of medicine, literature, science, and art. Chapters begin by familiarizing the reader with the historical aspects of manifestations and treatment – discussing both scientific and psychological aspects of the disease. Chapters also discuss the evolution of several treatment modalities. Every chapter of the book contains interesting and evocative patient stories and their treatment.

Rhythms of Broken Hearts will be of interest to a wide spectrum of health care practitioners as well as to patients and related family members with interest in understanding their symptoms and disease entity.

_____________________________________________________________________

In Rhythm of Broken Hearts, Dr. Gomes distills a multifaceted perspective with a unique story that knits history, physiology, emotion, and wisdom.Jonathan L. Halperin, M.D.
If you ever have a broken heart -- romantic or medical -- you will be totally absorbed in this dazzling multicultural read.  Grace Schulman
Dr. Gomes’s affinity and empathy for his patients and their stories narrated in this book, make universal the experiences of illness that we all must navigate at some point in our lives.Jeremy N. Ruskin, MD

• Language: English
• Publisher: Springer
• Release date: Aug 25, 2021
• ISBN: 9783030773823

Book preview

Part IThe Mythology of the Human Heart

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

J. A. GomesRhythms of Broken Heartshttps://doi.org/10.1007/978-3-030-77382-3_1

1. Romanticizing the Heart

J. Anthony Gomes¹  

(1)

Icahn School of Medicine at Mount Sinai, New York, NY, USA

J. Anthony Gomes

Email: [e-mail]

I would rather have eyes that cannot see; ears that cannot hear; lips that cannot speak, than a heart that cannot love.—Robert Tizon

Tears come from the heart and not from the brain.—Leonardo da Vinci

Keywords

HeartEbers PapyrusCirculationIbn al-NafisMichael ServetusLeonardo da VinciWilliam Harvey

Since time immemorial, the heart has been likened to a household divinity, the source of life, and that of the immortal soul. Throughout history, the image of the heart has been symbolized as the seat of human emotions, and this characterization continues to this day. In this chapter, I will review the interpretations of the heart since ancient times to Harvey’s understanding of the heart through meticulous anatomic experimentation.

Ancient Egyptian View of the Heart

Some 2500 years ago, a woman in her late 30s or 40s died in ancient Thebes (now Luxor) in Egypt (Fig. 1.1). She was a wealthy married woman who stood about 5 feet tall. Her coffin bore the word Nestawedjat, meaning The one who belongs to the wedjat eye. Wedjat eyes symbolized regeneration, and the Egyptians thought that amulets depicting them helped the wearer pass safely into the afterlife. The unwrapped mummy was extremely well-preserved. CAT scans revealed her femininity and also showed the single internal organ left inside her body: her heart.

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Fig. 1.1

Coffin of Nestawedjat. The coffin has a striking polychrome painted face, enlivened by the use of inlaid eyes set into bronze sockets. The wig and collar are also painted. The surface of the body is simply decorated with a line of inscription on the lid and another around the case, both texts addressing the gods. (Reprinted from the British Museum) https://​www.​britishmuseum.​org/​collection/​object/​Y_​EA22813-b

Why leave the heart?

For ancient Egyptians, death was not the end. Nestawedjat’s soul would arise from her body and begin an extraordinary and dangerous journey through the underworld. At the very end of this journey, she’d face her biggest test of all. She’d enter the Hall of Two Truths and come before god Anubis. He’d weigh her heart to see if it had become heavy with sin during her life. If it weighed less than or equal to the feather of Ma’at—an ostrich feather symbolizing the goddess of truth, balance, and morality (Fig. 1.2)—she had been virtuous. Her soul would then rejoin her body—in the mummy, which had preserved it—and she would enter Aaru,¹ the heavenly paradise. There she’d live forever.

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Fig. 1.2

The weighing of the heart against the feather of Ma’at. Legend: God Anubis proceeds to the weighing of the dead person’s heart against the feather of Ma’at (the symbol of truth) on a balance. (Book of the Dead, circa 1250 BCE). (From: https://​commons.​wikimedia.​org/​wiki/​File:​BD_​Weighing_​of_​the_​Heart.​jpg)

But without her heart, she couldn’t reach paradise.

The heart had paramount importance for the ancient Egyptians in earthly life as well. In their worldview, the heart, or ib, was actually part of the soul. It was the source of intelligence, as it was for the Mesopotamians and Babylonians. The ancient Egyptians had also linked the heart to the pulse.

Ancient Indian View of the Heart

The oldest Hindu scriptures, the Vedic texts (c. 1500–c. 1000 BCE), considered the heart or hridaya (derived from hrd, center) a light of consciousness, the abode of the soul and that of Brahman. In the Rig Veda, the human heart is the sacrificial fire altar, and more, the cosmic axis. In the later Hindu scriptures of the Upanishads (c. 800–c. 500 BCE), the heart is the source of the immortal soul or the Self (Atman):

The shining self, dwells hidden in the heart.

Everything in the cosmos, great and small,

Lives in the Self—the source of life.

It is rather a majestic concept, the entire universe dwelling in one’s heart. In many usages, the heart is our core, our essence.

Ancient Greek View of the Heart

Among the early Greek scientists and philosophers, the heart also had broad significance. Philosopher Empedocles (c. 492–c. 432 BCE) believed that intelligence resided in the heart. And so did one of the most famous minds of all time: Aristotle (c. 384–383 BCE). He never dissected a human, but examined animals after strangulation, when their hearts had ceased beating. He concluded that the heart was the origin of the soul, the seat of thought, reason, and emotion.

Stoic philosophy founded in Athens by Zeno of Citium (331–262 BCE) and advanced by Chrysippus of Soli (277–204 BCE), viewed the soul as the unity of thoughts, feelings, and desires all governed by a single principle, the hegomonikon, located in the heart. Hegomonikon is the source of our word hegemony, meaning dominance.

Greek physician Aelius Galenus or Claudius Galenus, better known as Galen (129–c. 200/216 CE), challenged Aristotle’s point of view. He was a brilliant man who, at age 28, became surgeon to gladiators in Pergamum, on the Aegean coast of modern Turkey. With injuries constantly before him, he learned fast. At the age of 33, he went to Rome and became physician to Emperor Marcus Aurelius. He was also a showman and a self-promoter, and he had seen how brain damage in gladiators affected the rest of the body. In Rome, he once gave a dramatic demonstration before a hall of eminent political and academic figures. He lashed down a squealing pig and cut the nerve leading to its larynx. The pig instantly stopped oinking. He thus showed that the brain controls voice and provided evidence that our thoughts, sensations, and movements arise there. The brain, he held, was the seat of the soul.

However, his views about the heart were complex and mislead physicians for centuries. He viewed the blood as moving outward in two separate systems, like rivers running into desert lakebeds and evaporating. In one, the liver turned food into the darker, venous blood, which flowed out to flesh and organs. Some of this blood, he believed, also seeped through invisible pores in the heart wall, the septum, where it mixed with air from the lungs and become the brighter arterial blood. In this second system, the arteries provided heat and motion to the rest of the body and psychic spirits to the brain. Galen also believed in tiny blood vessels he called rete mirabile (wonderful net) at the base of the brain, where vital spirits changed to animal spirits before going throughout the body.

Ancient Islamic View of the Heart

The Persian philosopher Avicenna (Ibn Sina, 980–1037) was one of the great minds of his time. At the age of 10, he reputedly memorized the Qur’an. Then he turned his attention to medicine, and when the sultan of Bukhara (then in Iran, now in Uzbekistan) fell ill with a mysterious ailment, the young Avicenna apparently cured him. In gratitude, the sultan allowed him into his vast library and Avicenna soaked up knowledge. Because of political instability, he spent much of his life on the move. Accounts of him vary, but most suggest a brilliant wit, political shrewdness, and a sybaritic love of music and alcohol. In his The Canon of Medicine, he integrated Aristotle’s ideas into his largely Galenic physiology. He wrote: The heart is the root of all faculties and gives the faculties of nutrition, life, apprehension, and movement to several other members. His ideas exerted much influence on medieval Europe.

It was Arab physician Ibn al-Nafis (1210–1288) who first challenged Galen’s and Avicenna’s concepts of blood circulation. Born in Damascus and practicing in Cairo, he like many other great talents of the time wrote on varied topics, including law, sociology, astronomy, and fiction. But he is remembered for his The Commentary on Anatomy in Avicenna’s Canon, written at the age of 29. In it, he became the first to describe pulmonary circulation. Blood flows from the right half of the heart to the lungs, he said, and thence down to the left half. In addition, he said that around the lungs, blood passes through minute channels from veins to arteries and turns from dark to bright. Not until the microscope and Marcello Malpighi (1628–1694) would anyone see these capillaries. Finally, al-Nafis firmly stated that Galen’s invisible pores in the septum did not exist. His views were largely ignored, and his Commentary was only made known to the Western world around the late 1920s, when a Berlin student happened upon it in the Prussian State Library.

The Renaissance Heart

The revival of anatomy during the Renaissance period fostered the study of the basic structures of the heart. The great Leonardo da Vinci (1452–1519), who painted the Mona Lisa, the Last Supper, Salvator Mundi, and many other masterpieces, was also an architect, an engineer, and a scientist with keen interest in human anatomy. Somewhere between 1504 and 1508, the human heart occupied his interest. During this time, he met a very old man in the hospital of Santa Maria Nuova in Florence, who told him he was hundred years old and did not feel, in Leonardo’s own words, any bodily ailment other than weakness. While Leonardo was at his bedside, the centenarian suddenly died. It is then that he did something unheard of for a man with no medical background. He did an autopsy on the old man and found that it proceeded from weakness through the failure of blood and of the artery that feeds the heart and the other lower members, which I found to be very dry, shrunken and withered. It is believed that he was the first to describe atherosclerosis of the aorta. His drawings illustrate the typical Renaissance image of the heart with two basic chambers, the ventricles, divided by the septum. He showed that the heart is a muscle and that it does not warm the blood as previously thought. He also attributed the pulse to the contraction of the left ventricle. However, Leonardo was not aware of the concept of circulation.

Much later, the Aragonese Michael Servetus (1509–1553) also independently identified pulmonary circulation, but his discovery, first written in the Manuscript of Paris (1546), did not reach the public. It was later incorporated into the theological work Christianismi Restitutio (Restoration of Christianity, 1553). In this book, he rejected the doctrine of the Trinity and the concept of predestination, both of which were fundamental to Christianity since the time of St. Augustine and reemphasized by John Calvin in his magnum opus, Institutio Christianae Religionis. It also contained by way of illustration his views on pulmonary circulation, in which he wrote: The blood is passed through the pulmonary artery to the pulmonary vein for a lengthy pass through the lungs, during which it becomes red, and gets rid of the sooty fumes by the act of exhalation. He was soon arrested as a heretic by order of Geneva’s Protestant governing council and burned at the stake near the city gates. The book was suppressed, but Servetus had been in communication with many other scholars in Europe, and possibly some of them knew of his ideas.

William Harvey’s View of the Heart

It was ultimately the English physician William Harvey (1578–1657, Fig. 1.3) who overthrew Galenic circulation of blood completely. His contribution was monumental. He was born in Folkestone, England, where his father was a merchant and the town’s mayor in 1600. After graduating from Cambridge, he pursued medical studies at the University of Padua at the same time Galileo was teaching there. He graduated as a doctor of Medicine in 1602, at the age of 24. He immediately returned to England and in the same year obtained his doctorate in Medicine from Cambridge University. He married the daughter of Queen Elizabeth’s physician in 1604, and in 1618, he became royal physician to King James I and later King Charles I. Among his many dictums, two stand out: All we know is still infinitely less than all that remains unknown. I profess both to learn and to teach anatomy, not from books but from dissections; not from positions of philosophers but from the fabric of nature.

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Fig. 1.3

William Harvey. https://​en.​wikipedia.​org/​wiki/​William_​Harvey

He began studying the heart and found it bewildering. He was working with small animals whose heart contractions and dilations occurred in the twinkling of an eye, like a flash of lighting. Systole seemed at one time here, diastole there, and then all reversed, varied, and confused. So, I could reach no decision. He even wondered if God alone could understand the heart. But eventually, through patience and meticulous observation, he said, I felt my way out of this labyrinth, and gained information, which I desired, of the motions and functions of the heart and arteries.

He described his findings in the landmark 1628 work: Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus. It was in Latin, standard for scholars at the time, and the English translation appeared two decades later: On the Motion of the Heart and Blood in Living Beings. In it, he expounded that the heart was actively at work when it was small, hard and contracted (systole), expelling blood, and at rest when it was large and filled with blood (diastole). In his writing, William Harvey strongly refuted the Galenic concept of passage of blood through pores in the interventricular septum.

The heart’s one role, Harvey said, is the transmission of the blood and its propulsion, by means of the arteries, to the extremities everywhere. Yet, he did not entirely challenge the metaphysical interpretation of the heart. He also wrote: The heart, consequently, is the beginning of life; the sun of the microcosm, even as the sun in his turn might well be designated the heart of the world; for it is the heart by whose virtue and pulse the blood is moved, perfected, and made nutrient, and is preserved from corruption and coagulation; it is the household divinity which, discharging its function, nourishes, cherishes, quickens.

French philosopher René Descartes (1596–1650) was one of the first scholars to accept the new theory. He took Harvey’s ideas a step further when he argued that the heart was like a pump or, better yet, a combustion engine. Yet, he also noted that Harvey had not actually explained the heartbeat.

What made the heartbeat? He wondered.

We imagine some faculty which causes the movement, the nature of which is much more difficult to conceive than what it is invoked to explain, he said. He believed that the heart had an innate heat, but the true answer would lie far ahead. Meanwhile, Harvey’s findings became widely accepted in the decades after his death.

The Heart as Metaphor

We have romanticized the heart perhaps sometime after our species began linking it to love and other emotions. The heart had been romantically characterized throughout the Middle Ages by poets, kings, lords, and their subjects.

If indeed from the heart alone rise anger or passion, fear, terror, and sadness; if from it alone spring shame, delight, and joy, why should I say more? wrote Andrés Laguna de Segovia (1499–1559), a Spanish physician to popes and kings and a pharmacologist and botanist.

Just as we know that stars are infernos, yet, they enchant us twinkling in the night, and though we know that the moon is a barren rock, it charms us in the sky, and so it is with the heart. It is associated with love and other emotions as in the phrase give your heart to and in ads and stickers as I ../images/505484_1_En_1_Chapter/505484_1_En_1_Figa_HTML.gif New York, and the heart remains the symbol for Valentine’s Day. Pearl Buck (1892–1973) wrote: The person who tries to live alone will not succeed as a human being. His heart withers if it does not answer another heart.

The heart is our center—a heart’s desire is an inmost yearning. It is kindness, as A Good Heart, while a cruel person doesn’t have a heart. It is also an expression of compassion, as in Have A Heart, the title of my recently published novel, and a Heart of Gold. It is commitment—we can no longer have the heart to perform a task, and we can have a change of heart. It is intuition, as in The Little Prince, Antoine de Saint-Exupéry (1900–1944) wrote, It is only with the heart that one can see rightly; what is essential is invisible to the eye. It can express an inner truth, when we express feelings in our hearts. In The Unbearable Lightness of Being, Milan Kundera wrote: When the heart speaks, the mind finds it indecent to object. Poet Ted Hughes (1930–1998) wrote: The only thing people regret is that they didn’t live boldly enough, that they didn’t invest enough heart, didn’t love enough. Nothing else really counts at all.

In the Old Testament, King David states: the sacrifices of God are a broken spirit; a broken and contrite heart. Deuteronomy 6:5 instructs to love the Lord your God with all your heart. The Sacred Heart of Jesus is a Catholic devotion in which the heart of Jesus stands for his love of everyone, while the devotion of the Immaculate Heart of Mary focuses more on her love of Jesus and God. In her image, seven swords typically pierce her heart, for her Seven Sorrows.

These metaphoric expressions give the heart immediacy—symbolizing life.

♥

Footnotes

1

Aaru is also known as Sekhet-Aaru.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

J. A. GomesRhythms of Broken Heartshttps://doi.org/10.1007/978-3-030-77382-3_2

2. The Mysteries of the Age-Old Pulse

J. Anthony Gomes¹  

(1)

Icahn School of Medicine at Mount Sinai, New York, NY, USA

J. Anthony Gomes

Email: [e-mail]

Very often conditions are recorded as observable under thy fingers… Among such observations it is important to notice that the pulsations of the human heart are observed.―James Henry Breasted (1865–1935), archeologist, on the Edwin Smith Surgical Papyrus, c. 1600 BCE

I love yoga... I also see an Ayurvedic doctor, which is an ancient Indian thing. I go and see the doctor to balance my system twice a year; it’s preventative. They take my pulse, give me some herbs, and tell me what I should eat and what I should avoid.―Jerry Hall

Keywords

PulseEbersPapyrusClepsydrasPulsilogiumStopwatchPulsus paradoxusPulsus parvus et tardusPulsus bigeminusThready pulse

Since antiquity, the pulse has had a lofty and mysterious position in medical practice. Physicians viewed it not only as a surrogate for the heart but also as evidence of the health of other organs. This was likely because the pulse was the most accessible organ. The liver, kidneys, and lungs are largely silent, but the pulse can always be felt in the neck, the wrist, the feet, and elsewhere. As a result, physicians in antiquity and medieval times used it to diagnose illness, yet they misunderstood its very generation. Some falsely believed that the heart and the arteries each had separate pulses, which contracted at about the same time. Furthermore, they made highly exaggerated claims in diagnosing diseases of a host of organs by feeling the pulse, but there is no evidence that they actually measured its rate (with the exceptions of the Greek Herophilus, the father of anatomy, and the Ayurveda healers of India). Overall, the pulse was a mystery that became a magnet for some of the best age-old minds.

The Rosetta Stone of Ancient Egyptian Medicine

In 1872, German Egyptologist George Ebers was investigating sites in Thebes when a prosperous Egyptian approached him with an offer of antiquities. Inside a box, Ebers saw a statue of Osiris carved perhaps in the past year and a papyrus of no value. He politely spurned the offer but said he would pay well for items of value. The next day the man returned and showed him a metal box. Inside were mummy cloths. When Ebers unwrapped them, he found another papyrus. This one was different. It had been discovered 10 years earlier between a mummy’s legs in a tomb at Thebes. It was marvelously preserved, with text easy to read, and it seemed to date from at least a millennium before Christ. Ebers was elated, but the seller, perhaps sensing a windfall, asked a price he could hardly afford. Fortunately, a wealthy friend materialized, the deal took place, and Ebers brought the papyrus back to the University of Leipzig.

We now know the Ebers Papyrus (Fig. 2.1) dates back to around 1550 BC, over a thousand years before Hippocrates, and it is one of the most important writings in ancient medicine. It is a 68-foot scroll, replete with archaic phrases and magic chants, but it also has a chapter on the heart and the pulse, for it says: "In the Heart are the vessels to the whole of the body. As to these, every physician, every sexet-priest, every magician, will feel them when he lays his finger on the head, on the back of the head, on the hands, on the stomach region, on the arms, on the legs. Everywhere he feels his Heart because its vessels run to all his limbs." In other words, physicians place their hands all over the body, but they are really examining the heart, because it beats before they feel the pulse elsewhere.

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Fig. 2.1

The Ebers Papyrus. Legend: The Ebers Papyrus, also known as Papyrus Ebers, is an Egyptian medical papyrus dating to circa 1550 BC. It was purchased at Luxor (Thebes) by Georg Ebers and is currently kept at the library of the University of Leipzig, in Germany. The papyrus is thought to have been copied from earlier texts, perhaps dating as far back as 3400 BC. It is a 110-page scroll and about 20 meters long and is among the oldest preserved medical documents. The papyrus contains a treatise on the heart. It notes that the heart is the center of the blood supply, with vessels attached for every member of the body. https://​en.​wikipedia.​org/​wiki/​Ebers_​Papyrus#/​media/​File:​PEbers_​c41-bc.​jpg

It remains unclear whether the Egyptian physicians counted the pulse rate with the help of the clepsydra, the water clock possibly invented under Thutmosis III (18th Dynasty, fifteenth century BCE). It also remains unknown whether they were able to recognize the differences in pulse rate and quality.

Classifying the Pulse: Ancient Asian Medicine

As far back as 600 BCE, Chinese physician Pien Ts’Io asserted the importance of the pulse both for the diagnosis and prognosis of disease. He viewed the human body as a string instrument with a wide array of pulses corresponding to the different strings and their tones. Much later, Wang Shuhe (c. 180–c. 270 CE) wrote a highly influential treatise called The Pulse Classic. Born into a noble family and later a physician to royalty, Wang described 24 kinds of pulses, such as slippery, knotted, and scattered, and subdivided each by location, speed, strength, and feeling, such as hollow. All told, there were more than 100 variations of the pulse, assessed on both hands in the morning hours when the yin and yang were in balance. It may be easy to understand the difference among pulse types theoretically, he observed, but it is difficult to distinguish them with the fingers. And whether right or wrong or highly speculative, ancient Chinese physicians must have developed outstanding tactile skills. Wang also linked the type of pulse to specific organs, which suggests that these physicians tried to diagnose diseases of other organs such as the liver by taking the pulse. His work dominated Chinese thinking on the pulse for over 1300 years.

Ancient Indian Ayurveda physician Sage Kanád (c. 550 BCE) is best known as a forceful proponent of atomic theory before Democritus (c. 460–c. 370 BCE), and his very name Kanád, bestowed on him later in life, means atom eater. But he also wrote an important book on the pulse called Science of Sphygmica, where he says:

"Immediately after pressing the pulse just below the hand-joint, firstly there is the perception of the beating of bdyu (air); secondly . . . there is the perception of pitta (bile); thirdly or the last, the perception of the beating of slesmd or kaph (phlegm), is gained."

As the quote indicates, he theorized that each pulse has three phases, and abnormality in any of them reflects disease in one of the three main humors of the body: air, bile, and phlegm. Perhaps most intriguingly, Ayurveda physicians also counted the pulse rate. They calculated it per pal, with each pal equaling 24 seconds. It is unclear whether they used a water clock, since one scholar says pulse examination required not only extensive practice but also trancelike concentration, so the physician could enter into the very inside of a patient.

Dissections and Clepsydras: The Ancient Greeks and Romans

Hippocrates (c. 460–c. 375 BCE), the father of medicine, described the characteristics of the arterial pulse in conditions such as fever and lethargy in his book on humors. But Praxagoras of Kos (c. 340) is the first physician who discovered that pulsations only occur in the arteries, not in the veins. His student Herophilus (c. 335–c. 280 BCE) worked in Alexandria during the few decades when the Ptolemaic rulers allowed dissection of corpses, a practice that would be forbidden for the next 1800 years. He was the first person to measure pulse with an instrument, a portable clepsydra he built for this purpose, which he used on his medical rounds (Fig. 2.2). The clepsydra exploits the principle of the drip—like the regularity of a dripping faucet. He also compared the pulse to musical rhythm, using upbeats and downbeats as units to link the two. Among other phenomena, he described pulsus caprizans as similar to the leap of a goat, with two phases, an initial stroke followed by a stronger one, akin to what we call today—pulsus bisferiens.

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Fig. 2.2

Clepsydra or Greek water clock. A portable water clock used by Herophilus for the purpose of arterial pulse examination. This water clock contained a specified amount of water for natural pulse beats of every age. Nima Ghasemzadeh, A. Maziar Zafari, A Brief Journey into the History of the Arterial Pulse, Cardiology Research and Practice, vol. 2011, Article ID 164832, 14 pages, 2011. https://​doi.​org/​10.​4061/​2011/​164832

Erasistratus (c. 304–c. 250 BCE) was a Greek anatomist and royal physician under Seleucus I Nicator (or victor) of Syria, and together with Herophilus, he founded a school of anatomy in Alexandria. They had erroneous ideas on the circulation of blood, believing that arteries contained pneuma (air), while veins contained blood. And indeed, our word artery is derived from the Greek airein. They believed that the arterial pulse arose when arteries contracted, drew pneuma from the heart, and moved it forward. Additionally, and also falsely, they believed that the pulse was inherent to the arteries and different from that of the heart.

Galen (c. 129–c. 200/216 CE) laid out his thoughts on the pulse in four books entitled De Pulsuum Differentiis. He posited that the genesis of the pulse had to lie in the heart itself. He believed that the pulsations of the arteries were unequal and that a variety of pulses arose based on the degree of dilation on each side. Like Herophilus, he wrongly held the view that the arterial wall itself generated the pulse. He described several types of arterial pulse such as saw-edged pulse, undulating pulse, and worm-like pulse. He felt that the pulse varied according to the temperature and illnesses, and in concert with other ancient physicians, he described hot pulses and cold pulses, the pulse of pain, inflammation, lethargy, convulsions, jaundice, and even elephantiasis.¹ Overall, Galen described 27 characteristics for a single pulse based on its size, speed, and frequency.

Avicenna and Maimonides

Persian polymath Avicenna (981–1037) helped perpetuate ancient errors about the heart, but he made inroads in our knowledge of the pulse. In his treatise, he described eight different pulse variations depending on dilation, duration, temperature, fullness, compressibility, equality or inequality of consecutive beats, and even regularity or irregularity of rhythm. Thus, in his analysis, we note for the first time an assessment of heart rhythm abnormalities. He was also the first to define resistance and elasticity in the pulse (compressibility). His description of the irregularity both in a single pulsation and in a succession of pulses likely reflects premature and dropped heartbeats and atrial fibrillation. He also described several types of pulses in different disease states: the mouse-tail pulse (pulsus alternans as it is known today), undulating pulse, dicrotic (M-shaped) pulse, and vermicular pulse (a small, quick pulse that feels like a writhing worm to the finger).

Moses Maimonides (1135–1204) born in Cordoba, Spain, spent much of his early life moving from place to place to avoid persecution. He, together with his family, finally settled in Cairo, then relatively tolerant, but soon after his father and older brother died, his family was in financial straits. He became a physician partly to provide for them. Today, he is best known as a major Jewish philosopher and author of books like the landmark The Guide for the Perplexed. He was also a brilliant doctor and eventually became the physician to Saladin, the legendary Muslim general. In his writings, he correlated the pulse with disease severity of a host of organs, as his predecessors had.

The Pulsilogium and the Stopwatch

One day while still a student, Galileo Galilei (1564–1642) was watching a lamp swing back and forth in a cathedral. He began checking its swings with his pulse and found that each swing took the same amount of time, regardless of the distance it covered. He made his findings known and created a few pendulum devices to keep time, known as metronomes.

Venetian physician Santorio Sanctorius (1561–1636) was a friend of Galileo, and he became the first to build a pendulum device explicitly for measuring pulse. Called a pulsilogium, it consisted of a scale in inches and a cord with a movable weight marked with a crosswise line, and the physician adjusted the length of the pendulum until its swing matched the heartbeat. As a result, he wrote in 1603, We can monitor at what day and at which hour the pulse deviated in intensity and frequency from its natural state. It has been called the first man/machine interaction in medicine.

However, it was the English physician Sir John Floyer (1649–1734) who first counted the pulse rate in its current form. There was a clever watchmaker in town, and Floyer had him create a spring-driven watch with two key features: a second hand and a lever to stop it. Thus, Floyer had the first stopwatch with a second hand to enjoy general, practical use. In his book, The Physician’s Pulse Watch (1707), he wrote in all modesty: All I pretend is the discovery of a rule whereby we may know the natural pulse and the excesses and defects from this in diseases. He ushered in the modern era of recording the pulse rate in the examination of patients. In fact, his pulse watch gave physicians their first truly effective bedside measuring device of any