Some Novel Viewpoints on Physiology and Pathology of TCM Sphygmology

FANG Hui (方 辉), YANG Jie-zuan (杨介钻), XIAO Dang-sheng (肖党生)

1. Department of Internal Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310000, China

2. State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang, China

3. VIP ward, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310000, China

ABSTRACT In Traditional Chinese Medicine (TCM), pulse manifestation are an essential method for clinicians to make accurate diagnosis while researches on pulse manifestation are also an important direction for the modernization of TCM. According to the viewpoints of TCM, the abnormality of qi, xue,yin and yang will lead to some alterations of pulse manifestations while by detecting these alterations of pulse manifestation, TCM researchers can not only conclude the abnormality of the qi, xue, yin and yang in the patients, make exact diagnose in TCM but also afford the just therapies. Our past researches had abstracted all metabolisms in our body into to pathways: energy metabolism which should be regarded as yang and stem cell proliferation & differentiation (SCPD) which should be regarded as yin. These two pathways support the metabolisms of local tissue and organs while arteries play vital roles for transportation of energy agents and stem cells to local tissue and organs. By detecting the alterations of pulse manifestations, clinician can conclude the alterations of energy metabolism and SCPD in body. Moreover,many novel parameters should be taken into consideration for describing the pulse manifestations and uncovering the physiology and pathology of pulse manifestations.

KEYWORDS Yinyang; Pulse manifestations; TCM; Stem cell; Energy metabolism

INTRODUCTION

Diagnosis is the initial steps to treat all diseases.With the development of techniques, many new instruments are used clinically for diagnosis, such as computerized tomography (CT), B ultrasonic,magnetic resonance imaging (MRI), blood automatic analyzer. However, in TCM, inspection, auscultation,inquiring and pulse detection are traditional methods for diagnosis. In Nanjing, an ancient document of TCM, all excellent doctors are classified into four grades. The best doctors will make diagnosis by inspection; the better doctors will make diagnosis by auscultation; the good doctors will make diagnosis by inquiring; those doctors who make diagnosis by detecting the alterations of pulse are listed in the last grade. Even so, there are many difficulties to make accurate diagnosis by pulse manifestations for deeply understandings on TCM theories with rich clinic experiences are the necessities for the TCM researchers to study the TCM sphygmology.Moreover, studying TCM sphygmology will be helpful to make diagnosis by inspection, auscultation and inquiring as well as for studying the ancient documents of TCM. In Huangdi Neijing, 28 kinds of pulse manifestations were recorded firstly. In Shanghanlun, written by Zhang Zhongjing in Han Dynasty, there are three chapters to elucidate the clinic implications of pulse manifestations while some of pulse manifestations were listed as the parameters for the diagnosis of the certain diseases. For example,floating pulse (Fu Mai), moderate pulse (Huan Mai)，tense pulse (Jin Mai) care the indications for the diagnosing taiyang diseases while slender pulse (Xi Mai) and feeble pulse (Wei Mai) are the indications for the diagnosis of saoyin diseases. Pinhu Maixue,written by Li Shizhen in Ming Dynasty is another important document in TCM sphygmology. Recently,many researchers published their achievements on the pulse manifestations[1,2], which are beneficial for the integration of traditional and western medicine.Perhaps, giving physical and pathological explanation on the clinic prognostication of pulse manifestations is the just direction for the development of TCM.

After ten years researching and clinic practice,we realize that the ideal definitions on the nature of life will be the bridge connecting TCM and modern medicine[3-5]. Physical definitions on yin, yang, qi and xue, which are the vocabularies for the definition of life in TCM[3-6], will be beneficial for discussing the pulse manifestations and lead to a novel advancement of TCM sphygmology.

PHYSIOLOGICAL RESEARCHES ON THE PULSE MANIFESTATIONS

In the ancient documents of TCM, all pulse manifestations are recorded in the form of analogy without any quantitative parameters, which take many difficulties to study them. Yinyang theory and wuxing theory, the core parts of TCM, are the fundamental theory in studying TCM sphygmology. Both yin and yang are the vocabularies for the definition of living entity while the interactions of yi and yang drive the motion of qi and xue. The coordination of yin and yang as well as the motion of qi and xue support not only all behaviors of our body but also the functions of local organs and tissues including arteries. On the other hand, it is artery to transport the energy agents and stem cell to local tissues for metabolisms. So, by detecting the alterations of pulse, we can evaluate the uncoordination between yin and yang as well as the abnormal motions of qi and xue.

An idea definition of living entity will be beneficial for uncovering the physiology and pathology of TCM sphygmology so that many pulse manifestations can be described in quantitative parameters. However, no general accepted definition of life is applied in clinic while the working definition published by National Aeronautics and Space Administration (NASA) had also arouse many discussion[7]. Our theoretical researches on the integration of traditional and western medicine had coined that energy metabolism and stem cell proliferation & differentiation(SCPD)are two essential pathways are in our body which is regarded as yang and as yin respectively[3,4].Energy metabolism is the oxidation of energy agents while by SCPD, the somatic cells in our body can get renewed so as to keep our body or organs in stability. Energy is been defined as qi while the motion of qi in our body should be regarded as the energy transformation from chemical energy to heat energy[6]. In Huangdi Neijing, the motion of qi is recorded, which can be translated as following according to our definition of qi:

Nutrients, that are taken, will be digested into energy agents which will be transported to all the cells in out body for storage or oxidation after being absorbed. Oxygen getting from lung will oxidize all of energy agents into end metabolites just like water,carbon dioxide and other small molecular agents,which will be excreted by urinary system. In case that these pathways are in normal, our body will be stay in health or we will not get any illness.

Unfortunately, the motion of xue is not recapitulated in Huangdi Neijing. Our thesis have pointed that the absorbed energy agents will be distributed into two pathways in our body: being oxidized or activating the stem cells and attending the SCPD so that the stem cell will produce a lot of somatic cell to replace the dead ones[8]. The motion of xue should be regarded as the process of SCPD,including the storage of stem cells, migration of stem cells and production of somatic cells[4].

Metabolism of energy agents and SCPD are not only the essential pathways in our body but also play the vital role in local tissue. Generally,the functions of organs and local tissue depend on the metabolism of energy agents while by SCPD,organs and local tissues will keep their structures in stability. Circulation system is the only way to transport the energy agents and stem cells. By negative feedback, the metabolisms of energy agents in local tissue can also affect the structure and function of arteries. Taking radial artery as an example, the energy agents and stem cells will be transported to our hands for energy metabolism and somatic cells renewal. So, the alteration of the energy metabolism of energy agents and SCPD in our body will impact on energy metabolism and SCPD in our hands which will take some changes of pulse manifestation of radial artery. Furthermore, the arterial pulse is also regulated by heart beating and neuroendocrine system. Be detecting the arterial beat and tension, we can evaluate the functions of heart and neuroendocrine system.

Pulse manifestations are the just methods to evaluate the abnormality of energy metabolism or/and SCPD. Radial artery is so superficial that it is easy to be touched. By detecting the alteration of pulse manifestations of radial artery, TCM clinician can give an evaluation on the abnormality of energy metabolism or/and SCPD in a patient. The followings are the methods for this kind of evaluation.

SOME NOVEL UNDERSTANDINGS ON THE PULSE MANIFESTATIONS IN TCM

In TCM, detecting pulse manifestations is an important method for diagnose. TCM clinicians can touch and feel the beating of radial artery easily but it is also every difficult for them to describe pulse manifestations and translate the implication of these pulse manifestations. The first barrier is that there are no just parameters to describe pulse manifestations. New parameters for describing pulse manifestations must be set on both the definitions of yin, yang, qi as well as xue, and clinic experiences more than waveforms of radial pulse and several indexes of hemodynamics. These parameters,including dimensions of radial artery, the rhythm of radial pulse, tension of arterial wall, the contents in radial artery as well as relationships between the radial artery and local tissues, should also be taken into considerations. By analyzing these parameters, clinician can not only understand most of pulse manifestations, but also can evaluate the abnormality of yin and yang in a patient.

The Three Dimensions of Radial Pulse

Vertical axis, horizontal axis and sagittal axis are the parameters to describe three dimensions of radial artery. Vertical axis is the parameter to describe the depth of radial artery. The radial artery is buried so superficially that we can easily feel the pulse beating when our finger touches the skin,which is the floating pulse (Fu Mai). When radial artery is buried closed to radius, this is deep pulse(Chen Mai). Horizontal axis is the parameter to describe the diameter of radial artery. The diameter of radial artery is big and we will feel radial artery is too wide, which is huge pulse (Da Mai). In contrast,the diameter of radial artery is small we will feel radial artery is too thin, which is slender pulse (Xi Mai). Sagittal axis can be used to describe that the radial artery we can touch is long or short, which can be regarded as long pulse (Chang Mai) or short pulse (Duan Mai), even feeble pulse (Wei Mai) or bean pulse (Dou Mai) respectively.

The Rhythm of Radical Artery

The rhythm of radical artery follows the heartbeat. The normal heart rate ranges from 60 to 100 times per minute and the average pulse rate is 76 times per minute, which should be considered as a normal or healthy pulse. The pulse rate is slower than 76 minute, which should be regarded as moderate pulse or slow pulse. The pulse rate is faster than 76 minute, which should be regarded as speedy pulse (Shuo Mai). Always, pulse is regular.Sometimes, a slight irregularity of pulse can be detected, which should be regarded as soft pulse (Ru Mai). An apparent irregularity of pulse rate such as arterial fibrillation, frequent premature beat and so on, should be regarded as slow-uneven pulse (Jie Mai) and interval pulse (Dai mai).

The Tension of Arterial Wall

Arterial wall can be divided into mucosa layer,submucosa layer, muscle layer and serous layer. In muscle layer, there are many smooth muscle cells which can be regulated by sympathetic nervous system. In case that the activity of sympathetic nervous system is decreased, vascular smooth muscle will be relaxed and the tension of radial artery will also get decreased, which be regarded as healthy pulse or soft pulse. With the increased activity of sympathetic nervous system, vascular smooth muscle will get contracted and the tension of radial artery will also get increased, which should be regarded as tense pulse (Jin Mai).

The submucosa layer of arterial wall is made of connective tissue with fibrins. When the fibrins increase in submucosa layer, the arterial wall will get stiffer which should be regarded as void-tight pulse(Ge Mai) or hidden-excessive pulse (Lao Mai). Voidtight pulse and hidden-excessive pulse are always detected in old patients. All somatic cell in artery will get renewed by SCPD. With the decreased SCPD,no ample new somatic cells are produced to replace the dead cell in tissue, which will also occur in artery.At this time, fibroblasts will synthesize more fibrin to take the place of dead cell and this can also be seen as the pathology of the chronic tissue sclerosis including arterosckerosis which will be detected as void-tight pulse and hidden-excessive pulse. So the appearances of the two pulses will prognosticate the decrease of SCPD which should be diagnosed as deficiency of kidney essence.

When we detect tight pulse, we will find the occasional relaxation of radial artery, which can not be detected in the patients with void-tight pulse and hidden-excessive pulse. This is the difference between tight pulse and void-tight pulse(or hiddenexcessive pulse).

The Contents in Radial Artery

When we touch the radial artery with a litter force, the artery will be compressed partly or completely. At this time, we will get many different feelings which can be defined as different pulse manifestations. For example, when we touch the radial artery with a litter force and the radial artery is compressed completely, we will feel no beat of artery under the finger and no contents in artery, which should be regarded as deficient pulse (Xu Mai). With the same force to touch the radial artery, we can also feel the beat of artery under the finger get much stronger than ever, which is excessive pulse (Shi Mai). Excessive pulse is one of normal or healthy pulses. With a little of force to detecting the pulse and the radial artery being partly compressed, we will feel that a ball is slipping under finger, which should be regarded as slippery pulse (Hua Mai). At the same condition, we feel the blood flow is not smooth,which should be regarded as hesitant pulse (Se Mai).Why will we get these feelings? Our hypothesis is following: when the radial artery is compressed with external force, artery will resist the compression and blood flow will get some alteration. If the resistance of artery and alteration of blood flow are normal, we will detect as excessive pulse. If the resistance of artery and alteration of blood flow are too faint to be detected, it should be seen as the deficient pulse.When artery is compressed, the normal blood flow will be disturbed and turbulent flows will appear which will be detected as slippery pulse. At this time, friction between the blood flow and the arterial wall will get increased and hesitant pulse can be detected.

The Relationships between the Radial Artery and Local Tissues

Generally，the boundaries between radial artery and local tissues is very clear and the beat point of radial artery is stable. In some patient, the boundaries between radial artery and local tissues are blurred and the beat of radial artery is so scattered that we cannot detect a stable beat point,which should be defined as loose pulse(San Mai).

THE CLINICAL IMPLICATION OF PULSE MANISTESTATION

The Differences of the Both Radial Arteries

Radial artery beside styloid process of the radius is the standard point for detecting the pulse manifestations, which is called as guanwei. Closed to the guanwei, distal radial arteries were names as cunwei while the proximal radial arteries were names as chiwei. In our body, there are two radial arteries and six points which can be used for detecting the pulse manifestations. Huangdi Neijing have recapitulated some theories on the motion of qi and one of viewpoints is that qi will go up in the left of our body and go down in the right of body. According to these recapitulations, the pulse manifestations of each radial artery had the different clinical implications and the conclusion should be acceptable that the pulse manifestations in left radial artery prognosticate the motion of xue while the pulse manifestions in right radial artery prognosticate the motion of qi. After several years' researches and clinic experiences, we can detect the tiny differences between the two radial arteries. If pulse of the left radial artery is stronger than that of right, it indicates that motion of xue in the patient is stronger than motion of qi, which means xue is in favor. On the contrary, pulse of the right radial artery is stronger than that of left, which means the patient's motion of xue is stronger and qi is in favor. These differences are caused by anatomic structure of circulation. The structure of circulation system determines that blood will reach the left radial artery along the clockwise direction and reach the left radial artery along the counterclockwise direction. The law of inertia has pointed that the mass with high weight will be easier to keep stable in motion, which implies that cells,proteins and other molecules with high weight in blood easier reach the left hand more easily than the right hand while those molecules with low weight such as water, oxygen and so on reach the right hand more easily than the left hand. Perhaps, these are the physical evidences that qi will go up in the left of our body and go down in the right of body,which have been recapitulated in huangdi Neijing.Although SCPD and energy metabolisms are the core pathways in both hands, SCPD is favored in left hand while the energy metabolisms are favored in right hand. According to these theories, the pulse manifestations in left radial artery can be used to evaluate the SCPD in our body while the pulse manifestations in right radial artery can be used to evaluate the energy metabolisms in our body.

The Relationships between the Pulse Manifestations and the Functions of Organs

There are six points for detecting the pulse manifestations in both radial arteries and each point can be used to evaluate the energy metabolism and SCDP in certain organs. The pulse manifestations in the left radial artery can be used to evaluate the motions of xue. In left radial artery, blood, carrying stem cells, flows from the proximal end to the distal end (from chiwei to guanwei). In left radial artery, the blood, enter proximal end (guanwei), had determined the ability of local organs to get stem cells, which can be use to evaluate the function of kidneyTCM. At same time, blood will flows out of the distal radius of the radial artery to nourish the organs of local tissues, so the left cunwei can be used to evaluate the function of heartTCM. Guanwei is the pathway for blood flow which can be used to evaluate the function of liverTCM. The pulse manifestations in right radial artery can be used to evaluate the motions of qi(energy metabolism in body). All energy agents in blood vessel will be oxidized into end metabolites which will be released by urinary system. The relationships between energy agents and end metabolites imply that pulse manifestations of chiwei in right radial artery, can be used to evaluate the functions of bladderTCMfor blood, carrying the energy agents, will enter chiwei and these energy agents will be oxidized into end metabolites. All energy agents for the metabolisms in our body come from the digested nutrients in gut, so pulse manifestations of guanwei in right radial artery, can be used to evaluate the functions of stomachTCM& spleenTCM.Oxygen is another substrate for metabolisms in our body and comes from lung which locates in superior part of our body, so pulse manifestations of cunwei in right radial artery, can be used to evaluate the functions of lungTCM. In all, local tissues and organs have the similar energy metabolism and SCPD as our body, so the both radial arteries can be seen as mini human body and the pulse manifestations of each radial artery can be used to evaluate the energy metabolism or SCPD in our body. Cunwei,guanwei and chiwei are arranged just like upper,middle and lower parts of the human body, so the pulse manifestations in every part can be used to evaluate the functions of certain organs.

The health pulse manifestations of radial artery include following features: straight and smooth,moderate size and buried depth, slow and powerful fluctuation, regular rhythm, soft vessel wall without tension, full contents and normal pulse rate (70-75 times per minute). These features of health pulse manifestation are abstracted from long time clinical practice and it is very difficult to detect same health pulse manifestations in a healthy individual for many factors have impacts on the pulse manifestations, such as gender, season, and pulse position. Male and female have some different pulse manifestations. In male, floating pulse always appears in cunwai while deep pulse always appears in guanwei. However, in female, floating pulse always appears in chiwai while deep pulse always appears in cunwei. In different seasons, the pulse manifestations have some alterations. Generally,tight pulse (Xuan Mai) always is detected in spring,grand pulse (Hong Mai) in summer, floating pulse in autumn and deep pulse in winter. Some pulse manifestations can forecast serious disease. For example, in a few of patients who feel very healthy with little discomfort, floating pulse can be detected in the six parts with the strong pulse beats, stiff arterial wall, the empty contents in radial artery which can be regarded as viod pulse (Kou Mai).These pulse manifestations imply that the extreme uncoordination between yin and yang in this patient and the death is coming. Floating pulse and strong pulse beats in six parts imply the strong motion of qi while the empty contents in radial artery (deficient pulse) with every stiff arterial wall (void-tight pulse or hidden-excessive pulse) in six parts imply the weak motion of xue. Discomforts of a patient stem from the abnormal motion of qi while too strong motion of qi will cover up these discomforts. In case that the weak motion of xue cannot support the strong motion of qi, the death will be evitable. Energy metabolisms of energy agents and SCPD had the same characteristic as yang and yin. Too strong motions of qi imply that the energy metabolism in patient is too strong while the weak motions of xue imply the decreased SCPD with weak renewal of somatic cells. In case that the uncoordination of energy metabolisms and SCPD reaches the threshold level, the death of individual will be evitable. This is an extreme case. However, every manifestation can prognosticate the abnormalities of yin and yang (SCPD and energy metabolism).

Deficient Pulse and Excessive Pulse

When we touch radial artery and we will fell little contents even no contents in artery, this is deficient pulse. When we feel that the artery is filled with contents, this is excessive pulse. Deficient pulse appears in left radial artery, which should be diagnosed as bloodTCMdeficiency(decreased SCPD), while deficient pulse appears in right radial artery, which should be diagnosed as qi deficiency(decreased energy metabolisms of energy agents).When radial artery is filled with contents and beat very strong, this is excessive pulse, which imply that normal or healthy motions of qi and xue.

Huge Pulse, Feeble Pulse and Bean Pulse

In our body, motions of qi are regarded as the oxidation of energy agents. All energy agents come from the digested nutrients in gut and are distributed by circulation system. Huge pulse implies that there are many contents in artery which come from gut and the functions of gut are strong. So,in shanghanlun, huge pulse prognosticates the functions of yangming meridians with the strong motions of qi and xue. Huge pulses, appearing in right guanwai, should be regarded as health pulse manifestation. In case the large pulse appears in other parts, the abnormal motions of qi and xue can be concluded by analyzing the interrelationships between stomachTCM and other organs. Feeble pulse implies the weak motions of qi and xue. Bean pulse implies the stagnation of qi and blood stasis.

Tense Pulse, Void-tight Pulse and Hiddenexcessive Pulse

The physical mechanism of tense pulse is the contraction of smooth muscle, which can be controlled by sympathetic nervous system. Patients in anxiety and stress have tense pulse for sympathetic nervous system in these patients is always excited. In new explanation on wuxing theory, nervous system is classified as heartTCMand the excitation of nervous system implies that qi of heartTCMgets floating with the deficiency of heartTCMyin. In shanghanlun, tense pulse is the parameter for diagnosing the cold in taiyang marderian. One of physical thesis on this viewpoint is following: muscle fiber, a device for energy transformation from chemical energy to mechanic energy with ATP as the energy supplier,will keep the period of contraction-relaxation in normality. When a cell lives in cold, more chemical energy is transformed into heat energy with less chemical energy for synthesis of ATP. So, muscle fiber in arterial wall will be in tetanic contraction and tense pulse will be detected. Void-tight pulse and hidden-excessive pulse always usually appear in the aged patients. When the two pulses are detected,deficiency of both xue and kidney essence should be considered. Arteriosclerosis is the pathology of the two pulses. Our hypothesis is the decreased SCPD is the pathology of arteriosclerosis and the decrease SCPD have the same characteristics as deficiency of both xue and kidney essence.

Floating Pulse and Deep Pulse

The depth of the radial artery indicates if qi and xue move toward body surface or not. In shanghanlun, floating pulse is one of parameters for diagnosing taiyang disease which can be divided into two parts: syndrome of cold pathogen of Taiyang and syndrome of affection of Taiyang by wind. In syndrome of cold pathogen of taiyang,taiyang meridian gets cold and cold will stay in body surface. At this time, the pathways for sweating is partly inhabited while the tendency that qi drives the xue toward body surface get no change. The xue will aggregate in artery and radial artery will be full and floating. So, the floating pulse will be detected.When wind attack taiyang meridians, the metabolism in body will get increased and more chemical energy will be transformed into mechanic energy which will drive more xue toward the body surface. This alteration can also lead to the accumulation of xue in artery and radial artery will be full and floating.

Deep pulse implies that motions of qi and xue operate toward the inside of body instead of surface.Sometimes, deep pulse should be regarded as a health pulse. In the patients with the deficiency of kidney essence and xue, the motion of qi will also be inhabited so qi can not drive xue to go toward body surface and the beat of radial artery will also turn weak. In these patients, deep pulse can also be detected and implies that metabolisms get decreased with the decreased SCPD.

Faint Pulse and Feeble Pulse

Faint pulse and feeble pulse indicated the deficiency of kidney essence and xue. The two manifestations can not be detected at the same time.When faint pulse is detected, it always company with little pusle and deep pulse. Faint pulse always appears in obese patients with the implication of spleen deficiency, stagnation of fluid-dampness, and obstacle motion of qi and xue. Feeble pulse always appears with large pulse and floating pulse, and implies the deficiency of both xue and essence with strong motion of qi.

Speedy Pulse and Moderate Pulse

The pulse beating is a process that chemical energy is converted into mechanical energy, in which no more than 40 percent of chemical energy is used for synthesis of ATP. So, the increased mechanical movement is always company with y a large amount of heat energy being released. So, Speedy pulse implies more heat energy being released. Moderate pulse can also be regarded as a healthy pulse. In case that radial artery beats too slow, this pulse manifestation indicated that our body gets cold, or has weak motion of qi and xue as well as the energy metabolisms in our body get decreased.

In all, the life of our body stems in the interrelationships between the SCPD and energy metabolism, which presents new viewpoint for the modernization of TCM, including sphygmology of TCM.Now, many parameters are taken into considerations for recapitulation of pulse manifestations. However,many pulse manifestations should be discussed such as stringy pulse, soft pulse, thready pulse，regularly or irregularly intermittent pulse and so on, which can also prognosticate the abnormality of yin and/or yang, energy metabolism and/or SCPD. Even so,more researches on the sphygmology of TCM should be carried out.