缓脉的脉象特征及临床意义的文献研究
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摘要
背景
脉诊属于中医“四诊”中切诊的主要内容,当今临床主要依据28脉诊察疾病。因此,其脉象特征及临床意义是脉诊的主要内容。缓脉是28脉之一,但在当代高等中医药院校的相关教材及脉学专著中,对其脉象特征及临床意义的描述存在不一致、甚至有偷换概念和逻辑矛盾的情况,直接影响到对临床实践的指导和中医脉诊的传承。那么在古代文献中是如何论述缓脉的?当今大家又是如何认识缓脉的?我们应该赋予缓脉一个什么样的内涵呢?基于这些问题,开展关于缓脉的文献研究具有重要的理论价值和现实意义。
目的
探索古人对缓脉认识的演变轨迹,分析当今“缓脉”之所以“混乱”的主要原因,并密切结合临床,初步提出解决的方法,为规范缓脉的脉象特征和临床意义及提高脉诊的实用价值提供依据。
方法
1缓脉脉象特征及临床意义的文献研究
1.1古代文献研究
选择具有代表性的中医古医籍,解读、分析、梳理其有关“缓脉”脉象特征和临床意义的记载与论述,归纳、总结不同时期古代医家对于“缓脉”认识的脉络和演变轨迹。
1.2现代文献研究
以“缓脉”为关键词,系统搜集、整理当代历版中医诊断学及中医内、外、妇科等多种教材、现代脉学专著、以及中医各科常见病诊疗指南中对“缓脉”的描述和运用,分析、梳理当今中医对“缓脉”的认识现状,归纳其存在的问题及与古代文献记载中的关联性和差异性。
2缓脉脉象特征及临床意义的中医临床专家访谈调查
依据当前对于“缓脉”认识的一些分歧,制订访谈提纲,以开放性的问题,通过对小样本的不同专科中医临床专家的访谈,调查当代专家对“缓脉”脉象特征和临床意义的认识与运用,归纳、分析临床实际中对“缓脉”的运用及其与教材、专著的差异性。
结果
1缓脉脉象特征及临床意义的文献研究
1.1古代文献研究
秦汉时期,虽已有“缓脉”之名,然尚无专篇讨论,亦无对其脉象特征的确切描述,研究侧重点在其临床意义,医家们主张脉证结合、四诊合参,以判断主病及预后。关于“缓脉”内涵,据相关文献文义分析,在当时已有多种,包括“和缓”,主脉有胃气；“纵缓、松弛”,主外感风寒、湿邪伤脾；或并非指某种病脉,而是仅作为形容词用以说明某些脉象具有速率缓慢的特征。到三国两晋南北朝时期,脉学诊断学已成专科,代表性产物是《脉经》。该书第一次对“缓脉”脉象特征进行描述,即“来去亦迟,小驶于迟”,主张“缓脉”特征为“脉率缓慢”。临床主病方面,认为单缓脉主虚、风、寒、湿,缓兼脉则随其所兼脉之不同而主病不同。唐宋时期,“缓脉”内涵进一步发展,在其认识上存在的分歧已经凸显,即“缓脉”究竟属平脉还是病脉?如为病脉,其“缓”字究竟是在形容至数,还是在强调脉形,抑或二者兼而有之?部分医家主张,“缓脉”即平脉,“缓”为“和缓”之意；还有医家认为,“缓脉”具有“浮”、“软”、“微迟”的特征。缓脉及其兼脉可见于风、虚、寒、湿、内热等证。金元时期,明确缓脉至数应为“一息四至”,其脉形具有松弛、不紧的特点。就其临床意义而言,分“和缓之缓”和“不及之缓”,“和缓之缓”为正常平脉,“不及之缓”则为病脉,可主风、虚、痹、弱、疼等证。严格的讲,这种认识存在逻辑混乱,但它对后世影响深远,还沿用至今。明清时期,延续了金元时期的认识,并无大的发展变化。关于“缓脉”认识,医学家们依旧各执一说。脉象特征方面,有的指出,“缓脉”在脉形上与紧脉相反,在脉率上与迟脉相类；有的认为只要脉形上具备从容和缓、宽舒和匀特点的即可称为缓脉。在临床主病上,有的认为单缓脉为平脉,缓兼脉方为病脉；有的主张缓脉本为病脉,无生理性病理性之分。
1.2现代文献研究
《中医诊断学》教材把“缓脉”定义为既可以是平脉又可以是病脉的说法,是在偷换概念。严格来讲,“缓脉”应属病脉,是由双因素构成的复合脉,可描述为一息四至,来去弛纵、松懈。临床主病为湿和脾胃虚弱。同样,各临床教材在使用“缓”字形容脉象时,也是借用了“迟缓”、“怠缓”、“纵缓”等“缓”字本身的多个含义,并非严格意义上的“缓脉”。故应对“缓脉”内涵重新定义,当“缓”表“慢”时,可与迟脉合并;当“缓”表“弛纵”时,可命名为“松脉”；若同时具备脉率的一息四至、来去怠缓与脉势的松弛、懈怠两个特征时,方称为“缓脉”。
2缓脉脉象特征及临床意义的中医临床专家访谈调查
关于“缓脉”的脉象特征,有专家认为,“缓脉”为单因素脉,其中73%的人认为,其特征是脉率减慢,即稍快于迟脉而慢于常脉；少部分人认为,其特征为“来去怠缓”,即脉率不一定减慢,但来去有慢吞吞的感觉。上述两种情况临床使用时常直接写为“迟缓”。还有专家主张,“缓脉”具备多个要素,92%的人指出,它的特征包括脉率慢,脉形松弛两个方面。
关于“缓脉”临床意义,当其只具备一个“慢”的特征时,多见于寒证(实寒、虚寒)、虚证、窦性心动过缓等；当其只具备“松弛”或“来去怠缓”一个要素时,主病无特异性；如“慢”与其它脉形特征共同构成缓脉,往往主湿证、虚证(包括气虚、阳虚、气血不足、脾虚)；若脉象和缓、有力、速率相对较慢(60次／分),是有胃气、有神气的表现,见于身体强健的正常人
讨论
通过对古今相关文献中“缓脉”脉象特征和临床意义的内容进行疏理,以及对中医各科临床专家进行访谈调查,不难发现,“缓脉”这一概念已被赋予了几种完全不同的内涵：一是“不快不慢,从容和缓”的“常脉”的含义；二是“慢”的含义,即脉率迟缓,稍快于迟脉,略慢于常脉；三是脉形“松弛”、“懈怠”的含义,它与“紧脉”相对应；四是同时具备脉率“慢”与脉形“松弛”的含义,即“缓脉”应为双因素的复合脉。分析出现此种现象的原因,是由“缓”字的一字多义现象所造成。“缓”字有多种含义,如“舒缓”、“松弛”、“延迟”等,很显然,“缓脉”“不快不慢,从容和缓”这一内涵是运用了“缓”字的“舒缓”含义,“缓脉”“脉率迟缓”的内涵是用到了“缓”字“延迟”的含义,“缓脉”“脉形松弛、懈怠”这一内涵是使用了“缓”字“松弛”的含义。所以,“缓”字多种含义的存在,是造成“缓脉”含义及主病争议的根源所在。
结论
1如今关于“缓脉”描述和认识的混乱,与“缓”的一字多义有关。
2建议“缓脉”中所蕴含的“不快不慢,从容和缓”之“常脉”的含义,不再用“缓脉”命名；“缓脉”中“慢”的含义,可并入“迟脉”,称为“迟脉”或“迟缓”脉；“缓脉”中“松弛”、“懈怠”之意,用“松脉”来代替,与“紧脉”相对应；不再使用“缓脉”这一概念,或同时具备“慢”和“松弛”、“懈怠”两层含义的,才能称作“缓脉’
3限于所掌握资料和本人水平的受限,上述结论和建议还望批评斧正。
创新点
1目前尚未见到通过系统分析古今文献和访谈专家全面分析、梳理和归纳古今专家关于“缓脉”脉象特征认识的源流和轨迹。
2创新性地提出将当今因一字多义赋予“缓脉”的4个不同含义剥离,分别归入常脉、迟脉(或迟缓脉)、“松脉”和缓脉。
Background
Diagnosis by pulse-taking is the principal content of pulse-taking in the four ways of diagnosis of Traditional Chinese Medicine. At present, there are28diagnoses by pulse-taking to examine illnesses in the clinical. Hence, the main substance of diagnoses by pulse-taking is the characteristics of pulse conditions and their clinical meanings.
The moderate pulse is one of the28pulses. Nonetheless, there are inconsistencies in the description, regarding the characteristics of pulse conditions and their clinical meanings on the related teaching materials and monographs on sphygmology, among the higher Traditional Chinese Medicine institutions nowadays, so far as to substitute some concepts for others surreptitiously and cause contradiction in logic. These realities impact directly on instructing the clinical practice and passing on and carrying on concerning diagnosis by pulse-taking in Traditional Chinese Medicine.
How was the moderate pulse expounded in the documents from Chinese ancient times? Mow do people understand the moderate pulse nowadays? What connotations ought to be given to the moderate pulse? In view of these questions, it is significant, in value of theories and meaningfulness of actuality, to launch the research of documents on the moderate pulse.
Objective
This study is a preliminary to put forward means for solving the above problems-by exploring the forefathers" developing trajectories in understanding the moderate pulse, analyzing the main causes in the confusion of the moderate pulse at present, and combining with the clinical closely. This study is to provide a foundation for:1). standardizing or regulating the characteristics of pulse conditions in the moderate pulse;2). the clinical meanings of the moderate pulse;3). enhancing the practical value of the moderate pulse.
Methods
1. The research of documents on the features of pulse conditions of the moderate pulse and their clinical meanings
1.1Study on documents of Chinese ancient times:
Summarizing the understanding on sequence of ideas and the evolving tracks on Chinese ancient physicians throughout various periods, by selecting ancient medical literatures with representativeness from Traditional Chinese Medicine; interpreting, analyzing and sorting out the account and expounding on the characteristics regarding pulse conditions of the moderate pulse and their clinical meanings.
1.2Research on contemporary documents
This study used "the moderate pulse" as a key word, systematically searched and sorted out the description and the application of the moderate pulse in the contemporary "Diagnostics of the Traditional Chinese Medicine" and a great deal of teaching materials on internal medicine, surgical department, gynaecology and etc. in Traditional Chinese Medicine, and Guidelines for Diagnosis and Treatment of Common Departmental Diseases in Traditional Chinese Medicine; then analyzed and put in order the current recognition of the moderate pulse in contemporary Traditional Chinese Medicine; summarized the existing issues and found out relations and discrepancies between documents from the contemporary and the ancient.
2. Interviews and surveys on clinical physicians of Traditional Chinese Medicine, concerning the characteristics of pulse conditions on the moderate pulse:
On the basis of the divergence in the recognition of the moderate pulse nowadays, this study drew up an outline for interviews, applying open-ended questions, through interviews on clinical experts of Traditional Chinese Medicine with various specialties in small sample, looked into the recognition and application on the features of pulse conditions of the moderate pulse among the contemporary experts, summed up amd analyzed the discrepancies between the actual clinical application and teaching materials/monographs on the moderate pulse.
Results
1. The study of documents on the characteristics of pulse conditions of the moderate pulse and their clinical meanings
1.1Research on documents of ancient times
During the dynasties of Qin and Han:
Although the term of "the moderate pulse" existed then, but there was not a specifie article written, nor any description on its features of pulse conditions.The study then laid special emphasis on its clinical meanings.The physicians stood for the combination of pulse and syndrome, and the synthesis of the four diagnostic methods (the integration and overall analysis of the inspection, auscultation and olfaetion, inqury and palpation),and determined the indications and prognoses accordingly.
Concerning the connotations of the moderate pulse, in the light of meaning analyses on related documents, there were many implications, including:gentle or mild, pulse with stomach-qi;"indulgently moderate, lax," wind-cold attacks the exterior and dampness tends to damage the spleen were the indications. Or,it was not some sort of pathological pulse, and the moderate pulse was just applied as an adjective to explain some pulse conditions which had the characteristics of slow rate.
In the periods of three kingdoms,two Jins and Northern Southern dynasties
Sphygmology diagnostics became a specialty, and the "Mai Jing"(the Pulse Classic) was a product of representativeness. It was the first time that the features of pulse conditions on the moderate pulse were described in the book, i.e.,"the moderate pulse was slow back and forth, slightly faster than the slow pulse," and viewed the characteristics of the moderate pulse as "slow pulse rate." On the aspect of clinical indications, the moderate pulse itself was deemed as "deficiency, wind, cold and dampness;" indications were different in line with various concurrent pulses along with the moderate pulse.
Tang and Song period:
The implications on the moderate pulse were progressed, and the existing divergence on recognition was obvious, i.e., after all, was the moderate pulse the normal pulse or a pathological pulse? In case of a pathological pulse, what does the word "moderate" describe? What is the number of beats or emphasizing on pulse conformation? Or both? Some doctors considered that "the moderate pulse" was "the normal pulse." and "moderate" meant "gentle or mild;" some other physicians held that "the moderate pulse" had the features of "floating,""softness." and "slight delay." The syndrome of wind, deficiency, cold, dampness and internal heat could be observed in the moderate pulse and its concurrent pulses.
Jin-Yuan period:
The number of beats for the moderate pulse was clarified as "four beats in one cycle of respiration." and its pulse conformation possessed the feature of laxity and it was not tense. As for the clinical meanings, there were two types of "moderation"-the moderation of "gentleness" and "insufficiency." The moderation of "gentleness" was the normal pulse, and which is regular; the moderation of "insufficiency" was the pathological pulse, the indications could be wind, deficiency, bi-arthralgia. weakness, pain and etc. Strictly speaking, this kind of recognition has its logical confusion, it has made enormous impact to the later generations, and it has been applied continuously to this day.
The Ming-Qing dynasty:
The same cognition from Jin-Yuan period was continued, major development and changes did not happen. Doctors still stuck to each one's own argument on knowledge of the moderate pulse. In the respect of features on pulse conditions, some pointed out that the moderate pulse was contrary to the tense pulse on their pulse conformations, while it was similar to the slow pulse on pulse rate:some considered that a pulse could be called as the moderate pulse when provided with the features of calm,gentleness and mildness. In clinical indications, some held that it was the normal pulse when only the moderate pulse showed up, and it was a pathological pulse while concurrent pulse(s) coexisted with the moderate pulse; some advocated that the moderate pulse was a pathological pulse at first, and there was no distinction between the physiological and the pathological.
1.2Research on contemporary documents
In "Diagnostics of Traditional Chinese Medicine"(the teaching materials), the moderate pulse is defined as pulse of the normal as well as the pathological, this is to substitute some concepts for others surreptitiously. Strictly speaking,"the moderate pulse" should be put in the category of the pathological pulse, it is a compound pulse constituted by two factors; it could be described as "four beats in one cycle of respiration; moderate, loose, weak and lax." The clinical indications are dampness and the weakness of the spleen and stomach. Likewise,"slow moderate.""lax moderate,""indulgently moderate" and etc. are borrowed from the multiple meanings of "moderate" itself, when the word "moderate" is applied to describe pulse conditions in clinical teaching materials. Notwithstanding, these are not the strict meanings for the moderate pulse. Thus, the connotation for "the moderate pulse" should be redefined. When "moderate" means "slow," it could be combined with "the slow pulse;" when "moderate" represents "slackly indulgent." it could be named "the lax pulse." And it could be called "the moderate pulse" when the two features, the pulse rate of four beats in one cycle of respiration,sloth back and forth and the pulse force of laxity and slack, are provided simultaneously.
2. Interviews and surveys on Traditional Chinese Medicine clinical doctors/experts
On the characteristics of pulse conditions in the moderate pulse, some experts deem that "the moderate pulse'" is a pulse of single factor,73%of them hold that the feature is decrease in pulse rate, i.e., slightly faster than the slow pulse but slower than the normal pulse. A few consider that the feature is "slack back and forth." the pulse rate is not necessarily decreasing, but "languid back and forth."
The two circumstances,mentioned above, are frequently written as "slow" in the clinical. Some other experts hold that "the moderate pulse" possesses many essential elements.92%of them point out that its features include two aspects:slowness in pulse rate and laxity in pulse conformation.
Concerning the clinical meanings of "the moderate pulse," when it possesses only one characteristic of "slowness." it is often observed in the syndrome of cold (defilcient cold and excessive cold), deficieney syndrome, too slow on aperture heartbeat and etc. When it has only one element of "laxity" or "sloth back and forth,"there is no particularity with the indications. In case of the moderate pulse is formed by "sluggishness" along with other features of pulse conformation,usually the indications are syndrome of dampness and deficiency; including qi-dellcicncy,yang-dellciency,qi and blood deficiency and spleen deficiency. If the pulse condition is gentle but vigorous, and pulse rate is relatively slower (60times per minute), it demonstrates that these are stomach-qi and spirit-qi, these could be seen in strong and healthy people.
It is thus evident that the discrepancies on the recognition of the moderat pulse have existed all the way from ancient to modern times. The conclusion, on the study of the indications in features of pulse conditions with the moderate pulse, has not been unified as well. There are many kinds of implications in the word of "moderate," of them, the connotation on "laxity" and "postponement" has been the source of causing the implications of the moderate pulse and its dispute on indications.
Discussions
It has been long-standing on the existing discrepancies in the cognition of the moderate pulse. It has not arrived in unification, all along, on the study conclusion with regard to the features of pulse conditions in the moderate pulse and its indications. Of them, the dispute of the characteristics of pulse conditions on the moderate pulse has encircled mainly at the word "moderate." Does "moderate" exactly describe pulse rate or pulse conformation? Or, it has both at the same time;yet, it might posses other connotations. As to the clinical meanings of the moderate pulse, there are approximately three kinds of cognition:
1. the moderate pulse is deemed as pathological pulse;
2. it is held as the normal pulse and it does not have any meanings in pathology;
3. it is considered that there are two kinds of moderate pulse-normal and pathological in
nature, it is normal pulse sometimes and pathological now and then. Evidently, there are issues of ambiguous concepts and confused logic, when we look at the problems today. Search to the bottom, it is rational to say that the issues have been caused from the multiple meanings of the word "moderate.""Moderate" has diversified implications; among them,"laxity or slackness" and "delay or postponement," the two connotations are the major reasons which have created the controversy on moderate pulse.
Conclusions
1. The confusion on the description and recognition of the moderate pulse, nowadays, is pertinent to the one word "moderate." however, with multiple meanings.
2. The moderate pulse contains the implications of "the normal pulse":"not fast nor slow, calm and gentle." no longer will "the moderate pulse" be named; the connotation of "slowness" in the moderate pulse could be incorporated into "the slow pulse,"and be named "the slow pulse" or "the slow moderate pulse;" the meanings of "laxity" and "slackness" in the moderate pulse could be replaced by "the lax pulse," and be in contrast with "the tense pulse." The notion of "the moderate pulse" would not be used any more; perhaps it could be called "the moderate pulse" when the pulse possesses the two implications of "slowness" and "laxity, slackness.'
3. Limited by personal level of profession and materials that could be taken into hands, critique and comments on the above conclusions/suggestions are greatly appreciated, and corrections could be made.
Points of Innovation
1. This study is unprecedented. It has been done by systematically analyzing documents from ancient times as well as the contemporary; visitations of experts; comprehensive analyses--sorting out and putting in a nutshell on knowledge of the experts (antient and contemporary)-regarding the origin, development and trajectory on features with pulse conditions of "the moderate pulse.'
2. Innovatively put forward the coming off of the three implications in the present moderate pulse and include the connotations to the normal pulse, the slow pulse (or the slow moderate pulse) and "the lax pulse" respectively. And terminate the concept of "the moderate pulse.'
脉诊属于中医“四诊”中切诊的主要内容,当今临床主要依据28脉诊察疾病。因此,其脉象特征及临床意义是脉诊的主要内容。缓脉是28脉之一,但在当代高等中医药院校的相关教材及脉学专著中,对其脉象特征及临床意义的描述存在不一致、甚至有偷换概念和逻辑矛盾的情况,直接影响到对临床实践的指导和中医脉诊的传承。那么在古代文献中是如何论述缓脉的?当今大家又是如何认识缓脉的?我们应该赋予缓脉一个什么样的内涵呢?基于这些问题,开展关于缓脉的文献研究具有重要的理论价值和现实意义。
目的
探索古人对缓脉认识的演变轨迹,分析当今“缓脉”之所以“混乱”的主要原因,并密切结合临床,初步提出解决的方法,为规范缓脉的脉象特征和临床意义及提高脉诊的实用价值提供依据。
方法
1缓脉脉象特征及临床意义的文献研究
1.1古代文献研究
选择具有代表性的中医古医籍,解读、分析、梳理其有关“缓脉”脉象特征和临床意义的记载与论述,归纳、总结不同时期古代医家对于“缓脉”认识的脉络和演变轨迹。
1.2现代文献研究
以“缓脉”为关键词,系统搜集、整理当代历版中医诊断学及中医内、外、妇科等多种教材、现代脉学专著、以及中医各科常见病诊疗指南中对“缓脉”的描述和运用,分析、梳理当今中医对“缓脉”的认识现状,归纳其存在的问题及与古代文献记载中的关联性和差异性。
2缓脉脉象特征及临床意义的中医临床专家访谈调查
依据当前对于“缓脉”认识的一些分歧,制订访谈提纲,以开放性的问题,通过对小样本的不同专科中医临床专家的访谈,调查当代专家对“缓脉”脉象特征和临床意义的认识与运用,归纳、分析临床实际中对“缓脉”的运用及其与教材、专著的差异性。
结果
1缓脉脉象特征及临床意义的文献研究
1.1古代文献研究
秦汉时期,虽已有“缓脉”之名,然尚无专篇讨论,亦无对其脉象特征的确切描述,研究侧重点在其临床意义,医家们主张脉证结合、四诊合参,以判断主病及预后。关于“缓脉”内涵,据相关文献文义分析,在当时已有多种,包括“和缓”,主脉有胃气；“纵缓、松弛”,主外感风寒、湿邪伤脾；或并非指某种病脉,而是仅作为形容词用以说明某些脉象具有速率缓慢的特征。到三国两晋南北朝时期,脉学诊断学已成专科,代表性产物是《脉经》。该书第一次对“缓脉”脉象特征进行描述,即“来去亦迟,小驶于迟”,主张“缓脉”特征为“脉率缓慢”。临床主病方面,认为单缓脉主虚、风、寒、湿,缓兼脉则随其所兼脉之不同而主病不同。唐宋时期,“缓脉”内涵进一步发展,在其认识上存在的分歧已经凸显,即“缓脉”究竟属平脉还是病脉?如为病脉,其“缓”字究竟是在形容至数,还是在强调脉形,抑或二者兼而有之?部分医家主张,“缓脉”即平脉,“缓”为“和缓”之意；还有医家认为,“缓脉”具有“浮”、“软”、“微迟”的特征。缓脉及其兼脉可见于风、虚、寒、湿、内热等证。金元时期,明确缓脉至数应为“一息四至”,其脉形具有松弛、不紧的特点。就其临床意义而言,分“和缓之缓”和“不及之缓”,“和缓之缓”为正常平脉,“不及之缓”则为病脉,可主风、虚、痹、弱、疼等证。严格的讲,这种认识存在逻辑混乱,但它对后世影响深远,还沿用至今。明清时期,延续了金元时期的认识,并无大的发展变化。关于“缓脉”认识,医学家们依旧各执一说。脉象特征方面,有的指出,“缓脉”在脉形上与紧脉相反,在脉率上与迟脉相类；有的认为只要脉形上具备从容和缓、宽舒和匀特点的即可称为缓脉。在临床主病上,有的认为单缓脉为平脉,缓兼脉方为病脉；有的主张缓脉本为病脉,无生理性病理性之分。
1.2现代文献研究
《中医诊断学》教材把“缓脉”定义为既可以是平脉又可以是病脉的说法,是在偷换概念。严格来讲,“缓脉”应属病脉,是由双因素构成的复合脉,可描述为一息四至,来去弛纵、松懈。临床主病为湿和脾胃虚弱。同样,各临床教材在使用“缓”字形容脉象时,也是借用了“迟缓”、“怠缓”、“纵缓”等“缓”字本身的多个含义,并非严格意义上的“缓脉”。故应对“缓脉”内涵重新定义,当“缓”表“慢”时,可与迟脉合并;当“缓”表“弛纵”时,可命名为“松脉”；若同时具备脉率的一息四至、来去怠缓与脉势的松弛、懈怠两个特征时,方称为“缓脉”。
2缓脉脉象特征及临床意义的中医临床专家访谈调查
关于“缓脉”的脉象特征,有专家认为,“缓脉”为单因素脉,其中73%的人认为,其特征是脉率减慢,即稍快于迟脉而慢于常脉；少部分人认为,其特征为“来去怠缓”,即脉率不一定减慢,但来去有慢吞吞的感觉。上述两种情况临床使用时常直接写为“迟缓”。还有专家主张,“缓脉”具备多个要素,92%的人指出,它的特征包括脉率慢,脉形松弛两个方面。
关于“缓脉”临床意义,当其只具备一个“慢”的特征时,多见于寒证(实寒、虚寒)、虚证、窦性心动过缓等；当其只具备“松弛”或“来去怠缓”一个要素时,主病无特异性；如“慢”与其它脉形特征共同构成缓脉,往往主湿证、虚证(包括气虚、阳虚、气血不足、脾虚)；若脉象和缓、有力、速率相对较慢(60次／分),是有胃气、有神气的表现,见于身体强健的正常人
讨论
通过对古今相关文献中“缓脉”脉象特征和临床意义的内容进行疏理,以及对中医各科临床专家进行访谈调查,不难发现,“缓脉”这一概念已被赋予了几种完全不同的内涵：一是“不快不慢,从容和缓”的“常脉”的含义；二是“慢”的含义,即脉率迟缓,稍快于迟脉,略慢于常脉；三是脉形“松弛”、“懈怠”的含义,它与“紧脉”相对应；四是同时具备脉率“慢”与脉形“松弛”的含义,即“缓脉”应为双因素的复合脉。分析出现此种现象的原因,是由“缓”字的一字多义现象所造成。“缓”字有多种含义,如“舒缓”、“松弛”、“延迟”等,很显然,“缓脉”“不快不慢,从容和缓”这一内涵是运用了“缓”字的“舒缓”含义,“缓脉”“脉率迟缓”的内涵是用到了“缓”字“延迟”的含义,“缓脉”“脉形松弛、懈怠”这一内涵是使用了“缓”字“松弛”的含义。所以,“缓”字多种含义的存在,是造成“缓脉”含义及主病争议的根源所在。
结论
1如今关于“缓脉”描述和认识的混乱,与“缓”的一字多义有关。
2建议“缓脉”中所蕴含的“不快不慢,从容和缓”之“常脉”的含义,不再用“缓脉”命名；“缓脉”中“慢”的含义,可并入“迟脉”,称为“迟脉”或“迟缓”脉；“缓脉”中“松弛”、“懈怠”之意,用“松脉”来代替,与“紧脉”相对应；不再使用“缓脉”这一概念,或同时具备“慢”和“松弛”、“懈怠”两层含义的,才能称作“缓脉’
3限于所掌握资料和本人水平的受限,上述结论和建议还望批评斧正。
创新点
1目前尚未见到通过系统分析古今文献和访谈专家全面分析、梳理和归纳古今专家关于“缓脉”脉象特征认识的源流和轨迹。
2创新性地提出将当今因一字多义赋予“缓脉”的4个不同含义剥离,分别归入常脉、迟脉(或迟缓脉)、“松脉”和缓脉。
Background
Diagnosis by pulse-taking is the principal content of pulse-taking in the four ways of diagnosis of Traditional Chinese Medicine. At present, there are28diagnoses by pulse-taking to examine illnesses in the clinical. Hence, the main substance of diagnoses by pulse-taking is the characteristics of pulse conditions and their clinical meanings.
The moderate pulse is one of the28pulses. Nonetheless, there are inconsistencies in the description, regarding the characteristics of pulse conditions and their clinical meanings on the related teaching materials and monographs on sphygmology, among the higher Traditional Chinese Medicine institutions nowadays, so far as to substitute some concepts for others surreptitiously and cause contradiction in logic. These realities impact directly on instructing the clinical practice and passing on and carrying on concerning diagnosis by pulse-taking in Traditional Chinese Medicine.
How was the moderate pulse expounded in the documents from Chinese ancient times? Mow do people understand the moderate pulse nowadays? What connotations ought to be given to the moderate pulse? In view of these questions, it is significant, in value of theories and meaningfulness of actuality, to launch the research of documents on the moderate pulse.
Objective
This study is a preliminary to put forward means for solving the above problems-by exploring the forefathers" developing trajectories in understanding the moderate pulse, analyzing the main causes in the confusion of the moderate pulse at present, and combining with the clinical closely. This study is to provide a foundation for:1). standardizing or regulating the characteristics of pulse conditions in the moderate pulse;2). the clinical meanings of the moderate pulse;3). enhancing the practical value of the moderate pulse.
Methods
1. The research of documents on the features of pulse conditions of the moderate pulse and their clinical meanings
1.1Study on documents of Chinese ancient times:
Summarizing the understanding on sequence of ideas and the evolving tracks on Chinese ancient physicians throughout various periods, by selecting ancient medical literatures with representativeness from Traditional Chinese Medicine; interpreting, analyzing and sorting out the account and expounding on the characteristics regarding pulse conditions of the moderate pulse and their clinical meanings.
1.2Research on contemporary documents
This study used "the moderate pulse" as a key word, systematically searched and sorted out the description and the application of the moderate pulse in the contemporary "Diagnostics of the Traditional Chinese Medicine" and a great deal of teaching materials on internal medicine, surgical department, gynaecology and etc. in Traditional Chinese Medicine, and Guidelines for Diagnosis and Treatment of Common Departmental Diseases in Traditional Chinese Medicine; then analyzed and put in order the current recognition of the moderate pulse in contemporary Traditional Chinese Medicine; summarized the existing issues and found out relations and discrepancies between documents from the contemporary and the ancient.
2. Interviews and surveys on clinical physicians of Traditional Chinese Medicine, concerning the characteristics of pulse conditions on the moderate pulse:
On the basis of the divergence in the recognition of the moderate pulse nowadays, this study drew up an outline for interviews, applying open-ended questions, through interviews on clinical experts of Traditional Chinese Medicine with various specialties in small sample, looked into the recognition and application on the features of pulse conditions of the moderate pulse among the contemporary experts, summed up amd analyzed the discrepancies between the actual clinical application and teaching materials/monographs on the moderate pulse.
Results
1. The study of documents on the characteristics of pulse conditions of the moderate pulse and their clinical meanings
1.1Research on documents of ancient times
During the dynasties of Qin and Han:
Although the term of "the moderate pulse" existed then, but there was not a specifie article written, nor any description on its features of pulse conditions.The study then laid special emphasis on its clinical meanings.The physicians stood for the combination of pulse and syndrome, and the synthesis of the four diagnostic methods (the integration and overall analysis of the inspection, auscultation and olfaetion, inqury and palpation),and determined the indications and prognoses accordingly.
Concerning the connotations of the moderate pulse, in the light of meaning analyses on related documents, there were many implications, including:gentle or mild, pulse with stomach-qi;"indulgently moderate, lax," wind-cold attacks the exterior and dampness tends to damage the spleen were the indications. Or,it was not some sort of pathological pulse, and the moderate pulse was just applied as an adjective to explain some pulse conditions which had the characteristics of slow rate.
In the periods of three kingdoms,two Jins and Northern Southern dynasties
Sphygmology diagnostics became a specialty, and the "Mai Jing"(the Pulse Classic) was a product of representativeness. It was the first time that the features of pulse conditions on the moderate pulse were described in the book, i.e.,"the moderate pulse was slow back and forth, slightly faster than the slow pulse," and viewed the characteristics of the moderate pulse as "slow pulse rate." On the aspect of clinical indications, the moderate pulse itself was deemed as "deficiency, wind, cold and dampness;" indications were different in line with various concurrent pulses along with the moderate pulse.
Tang and Song period:
The implications on the moderate pulse were progressed, and the existing divergence on recognition was obvious, i.e., after all, was the moderate pulse the normal pulse or a pathological pulse? In case of a pathological pulse, what does the word "moderate" describe? What is the number of beats or emphasizing on pulse conformation? Or both? Some doctors considered that "the moderate pulse" was "the normal pulse." and "moderate" meant "gentle or mild;" some other physicians held that "the moderate pulse" had the features of "floating,""softness." and "slight delay." The syndrome of wind, deficiency, cold, dampness and internal heat could be observed in the moderate pulse and its concurrent pulses.
Jin-Yuan period:
The number of beats for the moderate pulse was clarified as "four beats in one cycle of respiration." and its pulse conformation possessed the feature of laxity and it was not tense. As for the clinical meanings, there were two types of "moderation"-the moderation of "gentleness" and "insufficiency." The moderation of "gentleness" was the normal pulse, and which is regular; the moderation of "insufficiency" was the pathological pulse, the indications could be wind, deficiency, bi-arthralgia. weakness, pain and etc. Strictly speaking, this kind of recognition has its logical confusion, it has made enormous impact to the later generations, and it has been applied continuously to this day.
The Ming-Qing dynasty:
The same cognition from Jin-Yuan period was continued, major development and changes did not happen. Doctors still stuck to each one's own argument on knowledge of the moderate pulse. In the respect of features on pulse conditions, some pointed out that the moderate pulse was contrary to the tense pulse on their pulse conformations, while it was similar to the slow pulse on pulse rate:some considered that a pulse could be called as the moderate pulse when provided with the features of calm,gentleness and mildness. In clinical indications, some held that it was the normal pulse when only the moderate pulse showed up, and it was a pathological pulse while concurrent pulse(s) coexisted with the moderate pulse; some advocated that the moderate pulse was a pathological pulse at first, and there was no distinction between the physiological and the pathological.
1.2Research on contemporary documents
In "Diagnostics of Traditional Chinese Medicine"(the teaching materials), the moderate pulse is defined as pulse of the normal as well as the pathological, this is to substitute some concepts for others surreptitiously. Strictly speaking,"the moderate pulse" should be put in the category of the pathological pulse, it is a compound pulse constituted by two factors; it could be described as "four beats in one cycle of respiration; moderate, loose, weak and lax." The clinical indications are dampness and the weakness of the spleen and stomach. Likewise,"slow moderate.""lax moderate,""indulgently moderate" and etc. are borrowed from the multiple meanings of "moderate" itself, when the word "moderate" is applied to describe pulse conditions in clinical teaching materials. Notwithstanding, these are not the strict meanings for the moderate pulse. Thus, the connotation for "the moderate pulse" should be redefined. When "moderate" means "slow," it could be combined with "the slow pulse;" when "moderate" represents "slackly indulgent." it could be named "the lax pulse." And it could be called "the moderate pulse" when the two features, the pulse rate of four beats in one cycle of respiration,sloth back and forth and the pulse force of laxity and slack, are provided simultaneously.
2. Interviews and surveys on Traditional Chinese Medicine clinical doctors/experts
On the characteristics of pulse conditions in the moderate pulse, some experts deem that "the moderate pulse'" is a pulse of single factor,73%of them hold that the feature is decrease in pulse rate, i.e., slightly faster than the slow pulse but slower than the normal pulse. A few consider that the feature is "slack back and forth." the pulse rate is not necessarily decreasing, but "languid back and forth."
The two circumstances,mentioned above, are frequently written as "slow" in the clinical. Some other experts hold that "the moderate pulse" possesses many essential elements.92%of them point out that its features include two aspects:slowness in pulse rate and laxity in pulse conformation.
Concerning the clinical meanings of "the moderate pulse," when it possesses only one characteristic of "slowness." it is often observed in the syndrome of cold (defilcient cold and excessive cold), deficieney syndrome, too slow on aperture heartbeat and etc. When it has only one element of "laxity" or "sloth back and forth,"there is no particularity with the indications. In case of the moderate pulse is formed by "sluggishness" along with other features of pulse conformation,usually the indications are syndrome of dampness and deficiency; including qi-dellcicncy,yang-dellciency,qi and blood deficiency and spleen deficiency. If the pulse condition is gentle but vigorous, and pulse rate is relatively slower (60times per minute), it demonstrates that these are stomach-qi and spirit-qi, these could be seen in strong and healthy people.
It is thus evident that the discrepancies on the recognition of the moderat pulse have existed all the way from ancient to modern times. The conclusion, on the study of the indications in features of pulse conditions with the moderate pulse, has not been unified as well. There are many kinds of implications in the word of "moderate," of them, the connotation on "laxity" and "postponement" has been the source of causing the implications of the moderate pulse and its dispute on indications.
Discussions
It has been long-standing on the existing discrepancies in the cognition of the moderate pulse. It has not arrived in unification, all along, on the study conclusion with regard to the features of pulse conditions in the moderate pulse and its indications. Of them, the dispute of the characteristics of pulse conditions on the moderate pulse has encircled mainly at the word "moderate." Does "moderate" exactly describe pulse rate or pulse conformation? Or, it has both at the same time;yet, it might posses other connotations. As to the clinical meanings of the moderate pulse, there are approximately three kinds of cognition:
1. the moderate pulse is deemed as pathological pulse;
2. it is held as the normal pulse and it does not have any meanings in pathology;
3. it is considered that there are two kinds of moderate pulse-normal and pathological in
nature, it is normal pulse sometimes and pathological now and then. Evidently, there are issues of ambiguous concepts and confused logic, when we look at the problems today. Search to the bottom, it is rational to say that the issues have been caused from the multiple meanings of the word "moderate.""Moderate" has diversified implications; among them,"laxity or slackness" and "delay or postponement," the two connotations are the major reasons which have created the controversy on moderate pulse.
Conclusions
1. The confusion on the description and recognition of the moderate pulse, nowadays, is pertinent to the one word "moderate." however, with multiple meanings.
2. The moderate pulse contains the implications of "the normal pulse":"not fast nor slow, calm and gentle." no longer will "the moderate pulse" be named; the connotation of "slowness" in the moderate pulse could be incorporated into "the slow pulse,"and be named "the slow pulse" or "the slow moderate pulse;" the meanings of "laxity" and "slackness" in the moderate pulse could be replaced by "the lax pulse," and be in contrast with "the tense pulse." The notion of "the moderate pulse" would not be used any more; perhaps it could be called "the moderate pulse" when the pulse possesses the two implications of "slowness" and "laxity, slackness.'
3. Limited by personal level of profession and materials that could be taken into hands, critique and comments on the above conclusions/suggestions are greatly appreciated, and corrections could be made.
Points of Innovation
1. This study is unprecedented. It has been done by systematically analyzing documents from ancient times as well as the contemporary; visitations of experts; comprehensive analyses--sorting out and putting in a nutshell on knowledge of the experts (antient and contemporary)-regarding the origin, development and trajectory on features with pulse conditions of "the moderate pulse.'
2. Innovatively put forward the coming off of the three implications in the present moderate pulse and include the connotations to the normal pulse, the slow pulse (or the slow moderate pulse) and "the lax pulse" respectively. And terminate the concept of "the moderate pulse.'
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