摘要
“筋”一词早在《内经》中已出现。《素问·痿论》曰:“宗筋主束骨而利机关也”,《素问·五藏生成篇》:“诸筋者,皆属于节”。《說文》日:“筋,肉之力也。从肉从力从竹。竹,物之多筋者。”从力,指出了筋可以产生力量;从月肉旁者,明确了筋是肉性组织。《内经》认为筋与脉、肉、皮、骨共为五体,为肝脏所主,气血所养。传统文献关于筋和筋伤论述散见不同篇幅中,缺乏系统化和条理化,需要加以收集、整理。目前关于筋和筋伤的一些基本概念,缺乏统一认识。对筋的功能,筋伤的病因、病机及治则、治法的认识,尚未形成系统,理论体系尚不够完善。这些基本问题如不能很好的解决,就会严重制约对筋伤的进一步研究,进而影响中医治疗筋伤的临床疗效,因此筋伤理论研究有着重要的意义。《内经》关于筋及筋伤的条文很多,但也分散在多个章节,缺乏完整性和系统性。本研究主要对《内经》中关于筋及筋伤的内容进行收集、梳理和归纳,并结合现代科学进行研究和探讨。以期形成对筋的功能,筋伤的病因、病机及治则、治法的系统认识,为建立筋伤辨证体系奠定必要的理论基础。
《内经》在第一篇“上古天真论中”详细地论述了人体由少而壮而老的整个发育过程,筋的发育也与之相应。其论述道:“(女子)四七,筋骨坚,发长极,身体盛壮”,“(男子)三八,肾气平均,筋骨劲强,故真牙生而长极;四八,筋骨隆盛,肌肉满壮……七八,肝气衰,筋不能动,……今五藏皆衰,筋骨解堕,天癸尽矣。”
《内经》认为人体筋主要具有以下三种功能。首先具有“利机关”主司关节运动的功能。《素问·痿论》:“宗筋主束骨而利机关也。”其次筋多附于骨和关节处,具有约束骨骼的功能。《素问·五藏生成篇》认为:“诸筋者皆属于节。”筋连于关节,能屈能伸,故诸筋者,皆属于节。另外筋具有保护作用。筋满布于躯体和四肢各部,对人体重要的脏器组织能起到一定的保护作用。《灵枢·经脉》:“骨为干,脉为营,筋为刚,肉为墙。”
《内经》认为外感内伤都可导致筋的损伤。首先是外感六淫所伤,常见病邪有风、寒、湿、热等。《素问·生气通天论》:“湿热不攘,大筋緛短,小筋弛长,绠短为拘,弛长为痿。”《素问·阴阳应象大论》:“风伤筋。”说明风邪可以损害筋。《素问·气穴论》:“积寒留舍,荣卫不居,卷肉缩筋,肋肘不得伸,内为骨痹,外为不仁,命曰不足,大寒留于谿谷也。”《灵枢·百病始生》:“是故虚邪之中人也,始于皮肤……,或着于伏冲之脉,或着于膂筋,或着于肠胃之募原,上连于缓筋,邪气淫泆,不可胜论。”《灵枢·刺节真邪》:“虚邪之中人也,洒晰动形,起毫毛而发腠理。其入深,内搏于骨,则为骨痹。搏于筋,则为筋挛。”
常见的内伤病因有饮食过嗜、七情所伤、五劳过极以及相关疾病的传变。如过食酸味,可以导致筋的损伤,辛味可以抑制酸味,《素问·阴阳应象大论》:“酸伤筋,辛胜酸。”《素问·五脏生成论》:“多食辛,则筋急而爪枯。”《灵枢·五味论》:“酸走筋,多食之,令人癃。”
过怒可以导致筋伤。《素问·生气通天论》:“阳气者,大怒则形气绝,而血菀于上,使人薄厥。有伤于筋,纵,其若不容,汗出偏沮,使人偏枯。”《素问·气厥论》:“脾移寒于肝,痈肿筋挛。”《素问·痹论》:“筋痹不已,复感于邪,内舍于肝。”筋痹如果拖延久,又感受了邪气则向内侵入而停留在肝。因为肝与筋相合,始病在外之有形,复伤在内之五气,外内形气相合,而邪舍于内矣。《素问·宣明五气篇》和《灵枢·九针论》都提到了五劳所伤,即:“久视伤血,久卧伤气,久坐伤肉,久立伤骨,久行伤筋。”
因此,多种病因都可以导致筋的损伤。常见的筋伤疾病有以下几种:筋痹、筋痿、筋急、筋缓、筋强、瘛疭、痉病,以及特殊筋病“息贲”、“伏梁”等。
筋伤的常见病机有脾失健运、脏腑功能失常、筋之府受损等。《素问·脉要精微论》说:“夫膝者筋之府,屈伸不能,行则偻附,筋将惫矣。”《素问·太阴阳明论》说:“四肢皆禀气于胃而不得至经,必因于脾乃得禀也。今脾病不能为胃行其津液,四肢不得禀水谷气,气日以衰,脉道不利,筋骨肌肉皆无气以生,故不用。”《内经》有很多篇幅提到五运六气对肝与筋的影响。《素问·五常政大论》说:“太阳司天,寒气下临……,皮顽肉苛,筋脉不利,甚则胕肿,身后痈。”
关于筋伤的治疗,《内经》对治则治法有很多论述。强调预防为主,《素问·宣明五气篇》:“五味所禁:辛走气,气病无多食辛;咸走血,血病无多食咸;苦走骨,骨病无多食苦;甘走肉,肉病无多食甘;酸走筋,筋病无多食酸;是谓五禁,无令多食。”治疗应及时,《素问·阴阳应象大论》:“故善治者,治皮毛。其次治肌肤。其次治筋脉。其次治六腑。其次治五脏。治五脏者,半死半生也。故天之邪气,感则害人五脏,水谷之寒热,感则害于六腑,地之湿气,感则害皮肉筋脉。”明确病位,避免误治。《素问·痿论》:“刺脉无伤筋,筋伤则内动肝,肝动则春病热而筋弛。刺筋无伤骨,骨伤则内动肾,肾动则冬病胀、腰痛。”常用治疗方法有针刺、按摩、导引、热敷等,《素问·血气形志篇》:“形苦志乐,病生于筋,治之以熨引。”《灵枢·九针论》:“形乐志苦,病生于脉,治之以炙刺。形苦志乐,病生于筋,治之以熨引。”
《黄帝内经》主要从内科学和针灸经络学角度对筋伤的病因、病机、治则和治法进行的较为完整的阐述,相对而言对跌打外伤和劳损所致筋伤的论述较为缺乏。清代吴谦等编的《医宗金鉴·正骨心法要旨》则系统地总结了清代以前的正骨经验,对人体各部的骨度、损伤的治法记录周详,既有理论,亦重实践,图文并茂,很好的弥补了《黄帝内经》的不足。特别强调手法治疗在骨伤科学中的作用,认为“是则手法者,诚正骨之首务哉。”
人体的筋可随人的意志屈伸并产生力量,并牵拉肢体产生相应活动的组织,因此可以说筋相当于现代医学所指的骨骼肌。骨骼肌附着于骨骼上,其越过一个或多个关节,当肌肉收缩时,则牵引远端的肢体沿关节的某个运动轴活动而产生运动。其肌腱均附丽关节周围,正如《素问·五脏生成篇》所说,“诸筋者皆属于节”。其肌腹由肌纤维组成,维持着肌肉的外形,居两关节之间,正是“其所结所盛之处,则唯四肢溪谷之间为最”。筋肉包绕了关节,又隆盛于两关节之间。可见这里讲到的筋就是骨骼肌。
人类的肌纤维有两种基本类型:慢收缩纤维和快肌纤维两大类,慢肌纤维亦称作红肌纤维或TypeⅠ纤维;快肌纤维亦称作白肌纤维或TypeⅡ纤维,可以再被划分为ⅡA,ⅡB和ⅡC三类。快肌纤维直径较慢肌纤维大,含有较多的收缩蛋白。肌浆网较慢肌纤维发达,由较大的运动神经元支配,神经纤维较粗,传导速度较快。慢肌纤维周围毛细血管较快肌纤维丰富,慢肌纤维含有较多的肌红蛋白;慢肌纤维含有较多的线粒体,而且线粒体体积较大.慢肌纤维由较小的运动神经元支配,神经纤维较细,传导速度较慢。慢肌较快肌含有更多的肌梭。梭内肌纤维具有独立的神经支配,运动神经元不仅在肌肉收缩时(动态)刺激肌纤维,而且在肌肉安静弛缓时(静态)也刺激梭内肌纤维,从而保持肌肉始终处于具有持续适宜张力的状态。肌梭的感觉感受器对牵拉刺激敏感,极易感受牵拉刺激并向中枢传入神经冲动。牵拉产生的传入冲动引起脊髓的牵张反射,而且对于控制运动、维持姿势和肌紧张的中枢调节起着重要作用。躯体运动是人体对外界反应的主要活动。任何形式的躯体运动,都是以骨骼肌的活动为基础的。不同肌群在神经系统的调节下,互相协调和配合,形成各种有意义的躯体运动。神经系统不同部位对躯体运动的整合作用有明显的程度差别。越是复杂的躯体运动,越需要高水平的神经系统的参与。因此,人体运动功能的调控是一个非常复杂的过程,涉及中枢神经系统的多个层面。
在肌组织中,受到主动收缩力或被动牵拉力时,其应力点基本在肌的起止点处,中医称作筋结点。这里也正是劳损并引起关节痹痛的重要部位。而在该部位的附属组织更首当其冲,是劳损最早发生的部位,筋结点反复损伤,尤其有“横络”形成时,则称之为结筋病灶点。某些特殊易磨损的部位,如肱二头肌长头肌腱沟处,因肌腱受肱骨大小粗隆及其上附着的横韧带的限制,也是常出现结筋病灶的部位。与此相同,神经纤维管、骨性纤维管、腱鞘、滑液囊、滑车、籽骨等也是容易出现结筋病灶点的部位。《素问·宣明五气篇》所说“五劳所伤”“久坐伤肉……久行伤筋”。“久坐伤肉”是古代医家对长期静坐不动而致劳损的总结。久坐需要长时间的维持躯干的直立状态,那么维持体位和肌张力的慢肌纤维就需要持续收缩,时间过长就可导致Ⅰ型肌纤维的慢性损伤,即伤肉。“久行”是指肢体的持续运动状态。较大幅度的关节活动需要多组快肌纤维的持续反复收缩、牵拉肌腱,将拉力传到多个大的关节,协调运动。如时间过长就可造成Ⅱ型肌纤维的损伤,即伤筋。
通过对传统理论的复习以及对现在相关文献的研究,我们可以明确“肝脏”除了具有“主疏泄”“主藏血”“藏魂”的功能以外,还有一个重要的生理功能“主筋”,即对人体的骨骼肌进行控制。《素问·宣明五气篇》云:“肝主筋”。表明“肝”与“筋”之间有密切联系,“主”在这里是动词,有“主持、控制、调节”的含义。目前研究表明,中医所说的筋应包括现代解剖学的骨骼肌、肌腱及韧带。“肝主筋”主要是指骨骼肌的运动功能,是一个完整的运动系统,表明“肝”对“筋”运动有控制和调节的作用。目前研究认为肝功能与神经系统的部分功能密切相关。“肝主筋”主要是指肝对骨骼肌的运动功能的调控作用,上有相关的运动中枢,中间有传导神经,末端有效应器即骨骼肌及其附属物。
综上所述我们认为中医学的筋与现代解剖学上的Ⅱ型肌纤维、“肉”与Ⅰ型肌纤维有相关性;“肝主筋”主要是指肝对骨骼肌运动功能的调控功能。
因此中医学认为筋的疾病,多与肝有关。《素问·至真要大论》中说:“诸风掉眩,皆属于肝”。掉,振掉,指肢体振颤,动摇不定的一种症状。这与现代医学所说的帕金森病、小儿抽动症、面肌痉挛以及不宁腿综合征等伴有肌肉抽动症状的疾病有关。运动神经元疾病在早期可出现肌肉跳动,不同与中医痿证,而类似“肌肉膶动”,因此本病中医认为以“肝风”为主,应从肝从风论治。
筋伤是骨伤科最常见的疾病,引起筋伤的原因比较复杂,往往是内外因素综合的结果。全身性的内在因素与局部筋伤的发生有密切的联系,局部筋伤也可引起全身性的病理变化。凡人体遭受暴力,强力扭转,牵拉压迫,跌扑闪挫、经久积劳及风寒湿邪侵袭等原因都可引起筋的损伤。《医宗金鉴·正骨心法要旨》总结筋的损伤有:“筋强、筋柔、筋歪、筋正、筋断、筋走、筋粗、筋翻、筋寒、筋热。”近年来,常见的筋伤疾病如颈椎病、腰腿痛的发病率越来越高。颈椎病发病出现低龄化趋势,其中中小学生的颈椎病发病率急速上升。目前中医治疗筋伤在临床上应用广泛,取得了良好的临床疗效。其中筋伤手法具有自己鲜明的专业特色,是在长期的临床实践中逐渐发展起来的。近年来生物力学等新的研究反映了筋伤手法的科学性、有效性和实用性。现有的研究结果表明,手法不仅能纠正筋出槽、骨错缝,达到《素问·生气通天论》所说的“骨正筋柔,气血以流”的良好生理状态,还可以提高痛阈、改善微循环、调节内脏和神经系统功能。从而使筋伤手法的适应症日趋扩大,应用广泛,疗效提高。筋伤手法研究、常见病筋伤手法的应用研究已开展多年,并已取得了很多成果。本研究初步总结了中医治疗筋伤的研究现状、特点和优势。今后还有大量的工作要做,来揭示筋的本质、筋伤后的功能改变、病理变化等。
"Tendons" as early as in the word "nejing" has emerged."suwen·weilun"said:"the Main beam tendon organs constraint in bone and also making it motion。" "suwen·wuzangshengcheng":"all tendons connection the joints." Tendon is an anatomical structure of medicine,and intended from the word,the tendons for knowing the word. "suowen" said:"tendon is the powerful part of the muscle."nejing" that the tendons and mais,muscle,skin,bone a total of five parts,for the gan regulation it,by raising qi and blood.Traditional literature on the tendons and tendon injury scattered on different length, the lack of systematic and well-organized,and the need to collect,collate.At present, tendons and tendon injury on some of the basic concepts,the lack of common understanding.
Understanding about the function of tendons,tendon injury etiology and pathogenesis,therapeutic principle and method,the theory system has not yet been formed,the theoretical system is not perfect yet.If these basic issues can not be good solution,that will be seriously constrained the further study of tendon injury,and the impact of traditional Chinese medicine clinical efficacy tendon injuries.Tendon injuries theoretical research therefore has important significance."Neijing" on the tendons and tendon injuries in many provisions,but also scattered in a number of chapters,the lack of integrity and systemic.The purpose of this study of " Neijing " on the tendons and tendon injuries of the contents of the collection,sorted and summarized,combined with modern scientific research and exploration.In order to formation a systematic knowledge to the function of tendons,tendon injury etiology and pathogenesis,therapeutic principle and method,understand the treatment system for the establishment of tendon injury lay the necessary dialectical system theory.
It is considered that tendons can produce flexion and extension strength following with the people's will in the body,and stretch to produce physical activity organizations. Modern medicine referred to the same skeletal muscle function."Shuo Wen Jie Zi" release said:"tendons,and the power part of the muscle." "Lingshu·Jingmai," added: "bone as trunk,tendon as hard part." Is the description of the skeletal muscle.Skeletal muscle are attached to bones on one or more of its crossing the joints,when the muscle contraction,then the traction of the limb distal to a movement along the axis of the joint activities have a movement.The tendons attach around the joints,as " Suwen·five internal organs generated Part" said,"all tendons belong to joints." Muscle belly is composed of muscle fiber,and maintain the shape,ranking between the two joints.Brawn wrapping the joint and Uplift between the two joints.Mentioned here can be seen that skeletal muscle tendons in essence.
Theory of traditional literature review and the current study,we can be clear,"Gan" in addition to the " governing conveyance and dispersion " outside the function,there is an important physiological function " Regulation tendons ",that is,on the human body regulate skeletal muscle." Suwen·Xuan ming wu qi Part " said:" Gan Regulation tendons." That "Gan" and " tendons " in close contact.The "master" is a verb here,a "chair,control,regulation" means that the "Gan" of "tendons" movement control and regulation.At present,studies have shown that Chinese medicine should be mentioned, including modern anatomy tendons of the skeletal muscle,tendon and ligaments.
Traditional Chinese medicine theory,the basic function of the brain covering.So that the Gan function and nervous system function is closely related to the part."Gan Regulation tendons " mainly refers to the Gan of the motor function of the skeletal muscle of control, there are related to the central movement,the middle nerve conduction,the end device that is effective should be skeletal muscle and its appendage.
Human muscle fibers,there are two basic types:the slow muscle fibers and the fast muscle fibers.The slow muscle fibers are also known as the red muscle fiber,or TypeⅠfiber;the fast muscle fibers are also known as white muscle fiber or TypeⅡmuscle fiber.Slow muscle fibers are controlled by smaller motor neuron,the smaller motor neuron have thinner nerve fibers and slower conduction velocity.While fast muscle fibers are controlled by the larger motor neurons which have thicker nerve fibers,and faster conduction velocity.
Slow muscle fibers contain more muscle spindles than fast muscle fibers,and spindles within the muscle fibers are innervated independently.Motor neurons,stimulate the muscle fiber not only when muscle contracting but also when the muscles in flaccid quiet time so as to maintain the muscles always appropriate for a continuing state of tension.The feeling receptors of muscle spindle are sensitive to the stretch stimulation, easily feel the stretch stimulation to afferent nerve impulses to the hub.The tendons of Chinese medicine should be equivalent to the typeⅡmuscle fibers of modern anatomy.
Tendon injury is the most common orthopedic disease,the cause of the damage is complex,often caused by internal and external factors.Internal factors of systemic and occurrence of local tendon injury are closely linked,and local tendon injuries can also cause systemic pathological changes.
when body suffered violence,strong reverse,repression,stretch,flap down,durable tired,wind-cold invasion and other factors can cause tendon damage.
"YiZongJinJian·ZhengGuXinFaYaoZhi" Summarize tendon injuryincluding: "JinQiang、JinRou、JinWai、JinZheng、JinDuan、JinZou、JinCu、JinFan、JinHan、JinRe".
At present,Chinese medicine treatment of tendon injuries are widely used in clinical, and achieved a good clinical efficacy.The treatment skill of tendon injury developed gradually in a long-term clinical practice and is a wonderful work of Chinese traditional medicine,which has its own distinct characteristics.
"YiZongJinJian·ZhengGuXinFaYaoZhi" points out "Once facing clinical disease, Touch on the outside Ji,Qiao was born,Hands operation by heart,methods Production by hands
引文
1.李志安.肝与筋的关系及其临床意义探析.中国中医基础医学杂志[J],2001,7(3):10.
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