Historical Overview of Pulse Examination and Easy Interpretation of Pulse (Nabz) Through Unani Metaphysics

Abstract

Ancient science of pulse reading had existed from antiquity and still being practiced in some traditional medicine systems like Unani, Ayurveda and Chinese medicine etc. Examination of pulse still remains an integral part of these systems of medicine in disease diagnosis and monitoring the disease treatment. An experienced Unani physician can easily differentiate between normal and deranged temperament pulse through Unani metaphysics. As whole concept of disease and its management is based on temperament and its deviation under Unani system of medicine, therefore this unique and simple technique of pulse examination makes it easier to diagnose and treat any disease. In this article, it was tried to explore ancient history regarding knowledge base and practice of pulse reading and present various aspects of pulse examination described in Unani system of medicine and its interpretation through Unani metaphysics. This paper will be useful in generalizing the concept of pulse for better understanding.

INTRODUCTION

Ancient science of pulse reading had existed from antiquity. Ancient healers were aware of the cardiovascular system and its relation with the pulse. This science is still being practiced in some traditional medicine systems like Unani, Ayurveda and Chinese medicine etc. Examination of pulse still remains an integral part of these systems of medicine in disease diagnosis and monitoring the disease treatment. In modern medicine, examination of pulse is described based on pure physical nature with reductionist point of view. This approach of pulse examination has limited its application only as a subjective tool for diagnosis in the hands of modern physicians. Moreover, advances in objective parameters of diagnosis particularly in cardiac diseases have rendered pulse examination a neglected area for disease assessment.

Keeping all these factors in mind, an attempt has been made through this paper to explore ancient history regarding knowledge base and practice of pulse reading and study various aspects of pulse examination described in Unani system of medicine and its interpretation through Unani metaphysics. It is believed that this paper will act as a bridge between traditional and modern concept of pulse in a simple manner.

HISTORICAL OVERVIEW

Pulsology is not recent but existed since many years. Almost all the systems of medicine have described the importance of pulse examination, its types and usefulness in diagnosis.

Earliest recorded reference of awareness about the pulse is conceived through a wail uttered by the King of Mesopotamia- Gilgamesh in 2600 BC,[1,2] which indicates that heart and its palpation was not alien to human even at that time but because of various restrictions due to religious taboo it could not evolve as a guiding tool for diagnosis in that territory.[3]

Ancient Egyptian medicine

Ancient Egyptian physician had knowledge about the pulse, and that it is related with the function of the heart. It was believed that the heart gives rise to pulse which can be palpated. It was their belief that “the heart speaks out of every limb” as quoted in the Ebers Papyrus, written about 3500 years ago.[4] Relationship between heartbeat and peripheral pulse was first described by the ancient Egyptians. They used to examine the pulse with an equipment which resembles a clock. This equipment consisted of minute holes at the bottom, through which water used to drip, drop by drop. This escaping water drops from the equipment was correlated to calculate the pulse rate.[5]

Chinese medicine

In Chinese medical practice, examination of pulse was considered as an essential part by their ancient physicians. Pulse diagnosis was practiced in traditional Chinese medicine for assessing the health of all the major organ systems of the body. A recorded reference in this regard is found in one of the ancient treatise written by Huangdi on health and disease namely Huangdi Neijing (The Yellow Emperor's Classic of Medicine).[6] It is mentioned in the book that health and illness are caused due to an imbalance between two basic forces i.e. Yin and Yang which are influenced by the five elements i.e. earth, fire, metal, water, wood. This imbalance can be detected through pulse examination.[7] 26 categories of pulses have been mentioned in traditional Chinese medicine[8] and each category denotes a specific disease or syndrome.

Ayurvedic Medicine

The practice of pulse reading was highly prevalent amongst the ancient Ayurvedic physicians. Their wisdom on pulse dates back to a mythological antiquity like the Chinese. They described examination of pulse on three aspects i.e. the examiner, the examined, and method of examination.[9]

Among the eight parts of the body considered for physical examination in Ayurveda, the arterial pulse is given top priority.[10]

According to Ayurveda, disease in human is caused by imbalance of three humors i.e. Vāyu/Vāt (air), Pitta (bile) and Kaph/Kapha (phlegm) and this imbalance can be interpreted through changes in the pulse.[11] An imbalance in Kapha will exhibit slow and heavy pulse, corresponding to motion of a swan or peacock, whereas due to imbalance of Vāt, the pulse will appear like the motion of a serpent.

In case of disturbance of both the humours; the pulse will show both movements in sequence.[12] Ayurvedic physicians developed a special method to count pulse rate. They have also described different pulse rates according to various age groups.[9]

Unani medicine

The word “artery” has been derived from the Greek word “αρ” which means air.[13] Buqrāt (Hippocrates) (377 BC) has been considered as father of Unani medicine, he theoretically described arterial pulse and its characteristic during various conditions such as fever, lethargy etc.[14] but Braksaghuras (Praxagoras) (340 BC) is the one regarded in ancient Unani literature as the first physician to examine the pulse.[15] Pulsation only occurs in the arteries and not in the veins was discovered by Braksaghuras.[16] Braksaghuras also mentored Hīrufilūs (Herophilus) (335-280 BC), who described pulsus caprizans. An important invention by Hīrufilūs is construction of a unique portable water clock or clepsydra which was used by him for examining the pulse of his patients during medical rounds.[16]

Aerasīstratūs (Erasistratus) (304-250 BC) another famous physician has been mentioned by Jalīnūs (Galen) as someone who was not far from understanding the circulation.[15] It was Aerasīstratūs who determined that the movement of heart and arteries are asynchronous i.e. the arteries contract while the heart dilates, and vice versa[17] which is an established fact today.

'Arshijīnas (Archigenes) (98–117 CE) and his treatise on the pulse, frequently cited and regarded as important by Jalīnūs. Ten varieties of pulse have been described by 'Arshijīnas.[18] He has also been credited for discovery of the dicrotic pulse.[15]

Jalīnūs (131-200 CE) can be considered as the leading ancient Unani physician, may be of all time with respect to pulse-lore.

His methodology on the pulse hegemonized clinical practice for about sixteen centuries.[19] Unlike Aerasīstratūs, Jalīnūs claimed that contraction and dilatation of both the heart and the arteries are synchronous i.e. heart and arteries contract and dilate at the same instant.[20] On the basis of size, speed, and frequency; Galen described 27 characteristics for a single beat of pulse. Galen's findings on the double-hammer pulse are fascinating.[21]

Ibn Sīnā (Avicenna) (981-1037 CE) described the characteristics of pulse in relation with the interplay of four humors i.e. Dam (blood), Balgham (phlegm), Safrā′ (yellow bile) and Sawdā′ (black bile).[22] Moreover, he believed that arteries contain both blood and Ruḥ (pneuma).[22] He described various pulse modes and classified the pulse on the basis of distinct characteristics. This classification is similar to present understanding of the arterial pulse characteristics in arrhythmias. Single pulse beat irregularities and irregularities in succession of pulse beats have been described by Ibn Sīnā. In respect of irregularities of a single pulse beat, Ibn Sīnā propounded premature and dropped beats.[23]

EXAMINATION OF PULSE IN UNANI MEDICINE

In the Unani system of medicine, the human Nabz (pulse) is defined as a movement of the heart and arteries due to alternate expansion and contraction and the purpose of this movement is manipulation of breathing through inspired air.[23] Each pulse is comprised of two movements and two pauses.[23] The Nabz is fundamentally observed based on ten parameters viz. size, strength, speed, consistency (elasticity), fullness, temperature, rate, frequency (constancy), regularity and rhythm.[22,23,24,25,26,27] Some compound pulses have also been described in Unani system of medicine. Additionally based on general parameters, specific type of pulse in each disease is also mentioned.[28] Before discussing interpretation of pulse through Unani metaphysics, it is important to know about conditions and methods of pulse examination laid down by Unani physicians.

Conditions of examination of pulse

As per Unani literature[29] following 12 conditions should be fulfilled before examining the pulse: -

• 1) At the time of examination of the pulse the hand of the patient should be in a position that the thumb is directed upwards

• 2) At the time of examination patient should be free from any emotional or mental disturbance and neither should be full stomach nor hungry

• 3) The pulse of patient should be studied in comparison with the pulse of the healthy and temperamentally moderate person

• 4) The physician should place the pulp of all finger tips on the radial artery of the patient in such a position that his index finger should be towards the thumb and the little finger towards the elbow of the patient

• 5) Physician should examine pulse of right hand with his right hand and that of left hand with his left hand and his other hand should be used for supporting the patient's arm

• 6) The pulps of fingers of the examiner should be soft and smooth, and not rough and hard

• 7) At the time of examination, physician should also be devoid of any physical and mental ailments that can reduce or disturb his concentration

• 8) The pressure applied on the artery should be in accordance with the strength of the pulse. Weak pulse should be examined by putting less pressure and strong pulse by applying more pressure

• 9)T he patients' hand should not move during examination and ligatures which may press upon the vessels may be removed

• 10) Patient should rest for a while before examination or in case the doctor has to walk towards the resting patient, he should wait for while before initiating the examination

• 11) Pulse should be examined for adequate time. Some people have suggested examining at least for thirty pulse cycles

• 12) Both the patient and physician should be resting peacefully and avoid distractions. The physician should be gazing on the eyes and facial expression of the patient and should diligently concentrate on the status of pulse. The place where examination is done should be quiet and peaceful.

Methods of pulse examination

1. One finger method: The radial pulse is felt with the pulp of index finger only. The index finger is placed on radial artery in such way that the pulp falls longitudinally along the length of the artery and tip of the finger is directed towards the wrist of the patient. This method is considered better and authentic because the sensations and sensitivity of the pulp of single finger are practically uniform and errors can be avoided which may arise due to difference in sensitivity of fingers when more than one finger is used.

   The classical physicians may have considered this method better but practically it is slightly difficult, due to longitudinal positioning of the palpating finger which makes it difficult to exert considerable pressure on the artery during examination. This may be the reason that this method is not so popular among physicians today[29]

2. Three fingers method: This method was in practice among Indian physicians. Three fingers i.e. index finger, middle finger and ring finger are used in such a way that their pulp falls on the radial artery where index finger is towards the wrist and ring finger is towards the elbow of patient. Some physicians place their fingers in reverse manner also[29]

3. Four fingers method: In this method the examining physician uses the little finger also in addition to the other three fingers. This method is thought to be appropriate on patients who have Ṭawīl Nabz (long pulse) i.e., the pulse wave in the radial artery is felt beyond the four fingers. Note that during examination other hand of the physician should support the patients' palm and the arrangement of fingers should be such that little finger is towards the elbow and index finger is placed towards the wrist of the patient[29]

4. Two hands method: Sometime radial arteries of both arms of the patient are examined by the physician in such a way that the pulse of the right arm is examined with right hand and that of the left arm with left hand.[29]

Interpretation of pulse through Unani metaphysics

The basic principle of Unani system is based on deep philosophical understanding and scientific principles. There are three main theories described in Unani system of medicine. Four Arkān (elements) theory i.e. air, water, fire and earth; four proximate Kayfiyāt (qualities) theory i.e. hot, cold, moist and dry, and the Hippocratic theory of four Akhlā (humours) i.e. Dam (blood), Balgham (phlegm), Safrā′ (yellow bile) and Sawdā′ (black bile). Mizāj (temperament) in a particular entity, whether living or non-living, is denominated by admixture of different elements and their qualities in specific ratio.

Human temperament is categorized into four humours i.e. Damawī (sanguine)- hot & moist, Balghamī (phlegmatic)- cold & moist, Safrāwī (choleric)- hot & dry and Sawdāwī (melancholic)- cold & dry. It is believed that any disturbance in the equilibrium of humors causes disease, and therefore the treatment aims at restoring the equilibrium by giving factors (including drugs) of opposite temperament, this principle of treatment is called ′Ilāj bi′l Zidd (heterotherapy).[28] This indicates that assessment of Mizāj-i InsānĪ(human temperament) & its derangement and Ghalaba-i Akhlā (humoral preponderance) is of outmost importance. Pulse variations explain the derangement in Mizāj and Akhlāt. Thus, the applicability of pulse observation in Unani medicine has more value than diagnosis of disease only. It also serves as referential criterion for the process of cure in disease management.

It is believed that pulse in Damawī temperament individual is fast/rapid but weak and dull. This is because person of hot temperament has greater need of pulsation. If the power and Shiryān (artery) are favorable, the pulse is large. In case of Safrāwī individuals pulse is rapid and strong but sharp may be because of presence of dryness. In cold temperament the pulse shows a tendency towards deficiency, for example it becomes smaller, slower and irregular and in moist temperament person pulse is wavy and wide. Therefore, pulse in Balghamī individuals is slow, soft and infrequent. Dry temperament pulse is narrow and hard, hence Sawdāwī temperament pulse is hard and small.[23,30]

An experienced Unani physician can easily differentiate between normal and deranged temperament pulse through Unani metaphysics. This unique and simple technique makes it easier to diagnose and treat any disease as whole concept of disease and its management is based on temperament and its deviation in Unani system of medicine.

Pulse characteristic of various diseases

Other than general features of pulse according to sex, age, situations, seasons etc., Unani physicians also described some specific pulses of various diseases as mentioned in Table 1.

Table 1.

Pulse characteristic in various diseases

Disease	Pulse characteristic	References
Sill (Tuberclosis)	Small, swift, regular and hard	[30,31]
Zāt al-Ri?a (Pneumonia)	Weak, swift, soft and wavy	[30,31,32]
Iltihāb Darūn-i-Qalb (Endocarditis)	Small, fast, infrequent	[30,31]
Hayza (Cholera)	Weak, irregular	[30,31]
Yaraqān (Jaundice)	Regular and hard	[29]
Istisqā? Ziqqī (Ascitis)	Small, weak and regular	[30,31,32]
Waram al-Masāna (Cystitis)	Weak	[30,31]
Fālij (Paralysis)	Infrequent, slow	[30,31]
Laqwa (Facial palsy)	Hard	[31,32]
Saqtā (Stroke)	Small, weak, slow and irregular	[29]
Ḥumma Mi?wiyya (Enteric fever)	Fast, soft, full,	[30,31]
Ḥumma Wabā?iyya (Epidemic fever)	Regular and weak	[29]
Juzām (Leprosy)	Small, weak and regular	[30,31,32]
Baraṣ (Leucoderma)	Slow, soft and wider	[30,31]
Ḥaṣba (Measles)	Rapid	[30,31]

CONCLUSION

Interpretation of health through pulse is an ancient art form. Unique methods to read pulse were developed by different medical traditions in their own way. Intention with this review was to make the reader aware about the progress made over the decades to the present time regarding understanding of the pulse and discuss detailed pulse examination through Unani concepts. It can be said that contribution of Unani scholars is immense with regard to pulse examination. It provided a compendium before the discovery of circulation in an era, where no rational basis existed for understanding the pulse. Current art of pulse examination as diagnostic tool was originally conceptualized and developed by Unani physicians. In Unani system of medicine excellent physician is perceived as the one who is well versed in interpreting the nuances of the pulse.

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Conflicts of interest

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