Five Quarts: A Personal and Natural History of Blood (5 page)

An impetus for writing his treatise was Broadbent’s grave concern that physicians’ tactile skills were eroding (or, among young doctors, not fully maturing) as technology was relied upon more and more. Back in the late 1850s, when he’d begun his lengthy career at London’s St. Mary’s Hospital, a newfangled device had started attracting notice, the “sphygmograph,” an ingenious though initially clunky contraption that could create an ink tracing of a patient’s pulse. It worked this way: With the wrist upturned, the forearm was immobilized. A small sensor plate rested atop the pulse point and, in essence, rode the gentle waves; the motion was translated simultaneously onto a strip of paper, forming a steady sequence of squiggles. To the medical community, an instrument that could provide an objective reading of the pulse was an important advance (the modern blood pressure cuff is the sphygmograph’s direct descendant). However, while Broadbent used various models throughout his career, he was never a full convert. In
The Pulse
he praised the machine’s ability to mimic what a skilled physician could do by hand but emphasized that it was “not an infallible court of appeal.” The device was tricky to operate—it wasn’t like placing a thermometer under a tongue. In fact, Broadbent maintained, many of the “niceties of information” were out of its reach; no machine could ever replace the power of human touch.

In mastering the language of the pulse, Broadbent was linked to a timeless tradition, one transcending cultures and medical philosophies. The physician-priests loyal to the lion-headed Egyptian goddess Sekhmet relied on pulse palpation to reach their diagnoses, as evidenced by tomb inscriptions circa 2000
B.C.
, and medical papyri from this same era contain repeated reference to the pulse. “The heart speaks out of the vessels of every limb,” one particularly lovely line translates. In the history of medicine, however, the literature of ancient China is unmatched in its extravagant attention to deciphering the body’s rhythmic code.

The Chinese text called
Huang Ti Nei Ching Su Wen
(
The Yellow Emperor’s Classic of Internal Medicine
) is one of the world’s earliest and most famous medical guides. Although the work is attributed to the legendary first ancestor of the Chinese nation, historians concede that it is the product of neither a single writer nor single time period but rather a compilation of many teachings over hundreds of years. The oldest portions may date as far back as the fifth century
B.C.
To me
The Yellow Emperor’s Classic
is best appreciated not for its physiological accuracy but for its richness of ideas. All of the disciplines of traditional Chinese medicine sprang from its theories.

The entirety of what Broadbent could read at the wrist pulse was just the starting point for what
The Yellow Emperor’s Classic
describes. By applying varying pressure to different points along that single stretch of artery, an accomplished physician could derive a full accounting of every internal organ as well as a sense of the subtlest qualities of yin and yang, the positive and negative cosmic forces that balance in good health. The physician intuitively correlated into his reading a bewildering string of external factors—the climate, the direction of the wind, colors, odors, tastes, sounds, the natural elements, the positions of constellations, and more—and arrived at a diagnosis. To a Westerner such as myself, this ability seems almost supernatural and far-fetched. I find a stronger resonance in the text’s evocative characterizations. The resting pulse rate of a healthy heart will resemble “a piece of wood floating on water,” for instance, and the throb of a vigorous heart “should feel like continuous hammer blows.” The pulses relating to unhealthy conditions are also lyrical. A sickly pulse might reverberate like “the notes of a string instrument” or feel like “fish gliding through waves”—descriptions that nonetheless thrum and flicker with life.

Dr. Broadbent was never so poetic. On the contrary, he encouraged physicians to express no personal style whatsoever when writing about a patient’s pulse, thus eliminating the risk of ambiguity. The rate of pulse beats should be described as either
frequent
or
infrequent,
he insisted, with no shades in between. Arteries were
large
or
small,
and the “tension” or blood pressure within them
high
or
low.
What’s interesting is that this colorless vocabulary obviously did not reflect his wonder at the pulse. “It is impossible to examine a large number of pulses,” he enthused, “without being struck by the extraordinary diversity of frequency, size, character, tension, and force met with.” Of course, Broadbent’s contribution to his field went beyond the crafting of a glossary. During his nearly four decades at St. Mary’s Hospital, he was able to confirm definitively the link between high blood pressure and disease, paying particular note to hypertension in late-stage kidney disease. He was also among the first researchers to elucidate the risks of low blood pressure. In his midsixties William Henry Broadbent was recognized as one of Great Britain’s leading clinicians.

A year after
The Pulse
was published, he was contacted by officials at Buckingham Palace. The queen’s grandson, Prince George of Wales, had come down with typhoid fever, and the doctor’s expertise was requested. He remained in attendance at the prince’s residence for a month, seeing the twenty-six-year-old through to a complete recovery. Not a week had passed before he was summoned yet again. Now one of George’s brothers had been stricken by influenza, and he died in a matter of days. Word reached Dr. Broadbent that Her Majesty, Queen Victoria herself, wished to see him. Somehow I doubt he was expecting a promotion.

“The Queen sent for me about 3, and I had to tell her the whole story of the illness,” he wrote in a letter to his sister, dated January 17, 1892. “She was sitting in an ordinary chair at a writing table, and of course I had to stand. I was there almost exactly an hour and a quarter.” Though he betrays not a whit of emotion in this retelling, the royal visit did go well. Soon thereafter he was appointed Physician Extraordinary to Queen Victoria.

William Broadbent held the queen’s wrist. Now a queen holds mine: one named Ernesto, the physician’s assistant in my doctor’s office. Up to this point on a recent visit, nothing extraordinary has occurred. A good forty minutes after my arrival, Ernesto flung open the inner office door and sang out,
“Willlllllyaaaammm!”
He then weighed me in the hallway, led me into a stuffy cubicle, quizzed me about why I’d come, and just as I was beginning to regret making the appointment—to broach the topic of anti-anxiety medication, no less—something relatively pleasant happened: The room went quiet. It was time for Ernesto to check my pulse.

At that moment it seemed as if a tiny Dr. Broadbent perched atop Ernesto’s hooped earring, whispering instructions in his ear: “Three fingers should be placed on the artery, and it will not be amiss to observe the old-fashioned rule of letting the index finger always be nearest to the heart; the different points with regard to the pulse should then be ascertained, each by a distinct and separate act of attention.”

Ernesto’s technique is flawless: his grip, firm yet gentle; his bare hand warm. Utterly focused, he studies his wristwatch. He stands so close to me, I can feel his pillowy belly at my arm. I have the sensation of being anchored by this heavyset man as he listens with his fingers to my heart. I stop thinking about what brought me here and what Dr. Knox might say. For thirty seconds I am absolutely grounded in present tense.

Then Ernesto looks up from his watch, releases his grip. “Sixty-eight. Heart rate’s sixty-eight,” he says. “Perfectly normal.”

At which point I feel tempted to compliment him back:
How fashion-forward of you to be wearing white clogs,
for instance. But no, I could never say that with a straight face. Anyhow, the moment is lost. He’s already jammed a thermometer into a plastic sleeve and has placed it under my tongue. My pulse appears on my chart as a scribbled number at which Dr. Knox will scarcely glance. Dr. Broadbent would’ve been disappointed.

Today pulse palpation is a central part of an exam only in cases of serious cardiovascular disease. What’s more, in hospitals and many doctors’ offices, beats-per-minute is often obtained not by hand but through a monitor attached to the blood pressure cuff or a sensor clipped like a clothespin to the index finger. These digital devices, sensitive enough to detect the heart rate through capillaries in the skin, operate just like the pulse calculators built into sports watches, stationary bikes, and so forth. They’re used in the interest of speed, accuracy, convenience, and, I’m told, patient comfort. Some people do not like to be touched. While there’s no such high-tech revolution yet under way at Dr. Knox’s office, Steve’s doctor visits are different. In an office gone digital, the haste with which his body is stripped of its secrets—weight, body temperature, heart rate—is dizzying. Every second shaved from an exam is, of course, money saved by an HMO. But at a time when patients are encouraged to turn to WebMD with the questions their family doctor didn’t have time to answer, it strikes me that pulse taking by hand remains an uncorrupted tradition, one with strong roots in the classical age.

In ancient Greece the art of feeling the pulse (
sphygmopalpation,
from the Greek
sphygmos,
for “throb”) was first taught by the physician Praxagoras, a contemporary of Hippocrates, one of the earliest fathers of Western medicine. Praxagoras’s star pupil, Herophilus (335–280
B.C.
), was the first physician to methodically time the pulse. He used a primitive water clock that had been invented to time the speeches of orators. Erasistratus, Galen’s phantom bloodletting rival, is credited with incorporating the pulse into clinical exams. His first diagnosis: lovesickness, in a young man whose pulse quickened dangerously whenever his crush drew near. The attention paid the pulse at that time is all the more impressive given that the ancients were missing huge pieces of the puzzle. Though these healers knew they had their fingers on the pulse of the body’s innermost workings, they did not understand the actual role of the heart in circulating blood any better than they knew the distinction between veins and arteries.

Not until the intellectual watershed of the Renaissance did this begin to change. A major upheaval in how the body was viewed required first the systematic dismantling of the hallowed teachings of Galen. A key figure in this deconstruction was the Belgian anatomist Andreas Vesalius, who, in his illustrated seven-volume masterwork of 1543, soundly disproved two hundred of Galen’s factual errors. No, the liver did not distribute blood throughout the body. No, blood did not “sweat” from the right side of the heart to the left. No, animal anatomy wasn’t interchangeable with human. And on and on. Vesalius, among others, paved the way for Great Britain’s William Harvey, who in 1628 turned the world on its ear: Blood circulates, he announced in his historic
An Anatomical Essay on the Movement of the Heart and Blood in Animals.
For its role in launching the modern era of medicine, contemporary historians have called Harvey’s book one of the three greatest works in the English language—all three, curiously, dating from the early 1600s—alongside the King James version of the Bible (1611) and the First Folio Edition of Shakespeare’s plays (1623). By comparison with these other two works, Harvey’s tour de force is small in size (five by seven inches), short in length (seventy-two pages), and written in deceptively simple language.

“The movement of the blood in a circle is caused by the beat of the heart,” he declared, summing up in one sentence his entire theory of the circulatory system. Then, as if to head off any
But what about . . . ?
from the unconvinced, Harvey added, “This is the only reason for the motion and beat of the heart.”

Through animal vivisection, human dissections, and observations of living patients, Harvey poked more holes in Galenism. Blood did not ebb and flow within the same vessels, as the Greek physician had taught. Instead, the arteries carry it away from the heart, and the veins bring it back. Valves inside the veins help the depleted blood make the return trip. Further, although he couldn’t explain how, Harvey theorized that blood passes via some unknown mechanism from the arteries into the veins. The crude new microscopes of his day were not nearly powerful enough to reveal the minute bridging vessels now known as capillaries. In a final slap to Galen, Harvey also proved that the arteries themselves did not contract and dilate like blacksmith bellows, thereby producing the pulse. “The pulsation of the arteries,” Harvey wrote, “is nothing else than the impulse of the blood within.”

William Harvey

Accomplishments notwithstanding, Harvey was not necessarily a “better” scientist than Galen, contemporary writer-physician Jonathan Miller contends. “The difference between the two men is not one of ingenuity and skill—in fact, if these were the sufficient conditions of scientific progress, Galen rather than Harvey might have been the discoverer of the circulation of the blood.” Instead, the difference between them was one of “metaphorical equipment,” Miller argues in his book
The Body in Question
(1978). Galen likened the heart to a common household item of his time, the oil lamp: The organ heated and transformed blood from a dusky fuel to a flaming scarlet stream, illuminated by Vital Spirits. In his reckoning, however, that was the extent of the heart’s role. “Galen’s inability to see the heart as a pump was due to the fact that such machines did not become a significant part of the cultural scene until long after his death,” Miller states. By the end of the sixteenth century, though, mechanical pumps began to be widely employed in mining, firefighting, and civil engineering, such as in the design of ornamental public fountains. Therefore, when Harvey conducted his experiments (among them, watching as hearts slowly failed during animal vivisections), he was able to see the organ for what it was: a pump, resembling the marvelous inventions in use around him.