【作者】 李囿松；

【导师】 刘德麟；

【作者基本信息】 中国中医科学院 ， 中医基础理论， 2011， 博士

【摘要】 脉象是中医诊治的重要组成部分,也是最具特色的诊疗方法之一。临床上弦脉是最常见的脉象之一,不仅与现代重大疾病关系密切,而且常出现在较为复杂难治的疾病中,古有“最难调治者弦脉也”的说法。弦脉理论丰富,而古代文献有关弦脉的论述较为零散。因此,深入、系统地整理和发掘弦脉有关文献,探其源头,析其内涵,理论结合临床,才能更好地指导临床应用。本文从弦脉的历史沿革、基础理论、临床应用以及在恶性肿瘤的应用四个方面对中医学弦脉理论进行系统而深入的研究。首先,本文通过对弦脉理论的历史回顾,阐明了弦脉的几个关键问题：(1)弦脉与内伤七情的关系。“怒”和“思”过度最易出现弦脉。“怒”可使人体气逆不顺,气血壅迫,经脉拘束而形成弦脉；“思”则伤脾,“土气凝结,肝木乘之”多见弦脉。(2)弦脉与外感六淫的关系。风邪伤人可见浮弦脉,尤其是风邪伤及足少阳胆与足厥阴肝常会出现弦脉。外感暑邪可见弦脉,因暑为阳邪,易耗气伤阴,致脉道气血不足,加之暑多夹湿,湿邪阻遏,故常见弦细脉。外感湿温多见弦细濡脉,由于湿温胶裹,阻滞气机,遏伤阳气,脉道涩滞而形成弦脉。寒邪侵入人体,易于阻遏血脉,血脉因受寒而拘紧收缩,多见脉弦而有力。(3)弦脉与五脏的关系。肝病可见弦脉,肝病累及他脏可见弦脉,还应明确：肝病亦非皆见弦脉,他脏病变也可见弦脉。(4)弦脉阴阳归类。弦脉为阳中之阴,可阴可阳,以阳为主。其次,本文将脉象与病证、脉理结合起来,系统而全面的论述弦脉主病理论,以及弦脉相关的证候特征和用药特点。提出弦脉主病特点呈现多样性：可阴可阳,可虚可实,可寒可热,可以是气病,也可以是痰饮病。弦脉常见伴随症状除疼痛外,还有烦、发热等。“弦为气敛”,气机郁滞,不通则痛,故弦脉主疼痛,疼痛性质以胀痛、肿痛、急痛为主,疼痛部位以腹痛、头痛、胁痛为主。气郁化热,郁热内扰则烦,邪热充斥内外表里则发热。弦脉相关病证常用药物有：一是风药,用于疏肝解郁,发散郁火,祛风解表,升发清气；二是酸甘药,用于泄肝补脾,敛阴柔肝；三是辛温(热)药,用于温阳通阳,散寒止痛；四是苦寒药,用于清肝泻火。本文对弦脉在疾病层次与病证层次的意义进行了探讨。在疾病层次,弦脉与高血压病、冠心病、肝病关系最为密切。在病证层次,内科病,弦脉可见于寒热虚实表里证；妇科病,弦脉主要与肝脏病证有关,临床用药侧重调肝；儿科病,弦脉多与肝脏病证、热证、风证有关,用药侧重清肝火,平肝风,散郁热；外科病,弦脉多与肝脏病证、痰热蕴结证或痰湿阻滞证有关,用药侧重祛风清热胜湿,化痰解郁散结。弦脉的现代研究主要集中在心脑血管病和肝病,对于弦脉与恶性肿瘤的系统报道较少,本文对此进行深入研究。弦脉与恶性肿瘤关系密切。恶性肿瘤中弦脉形成机制,从中医学角度来看,主要与邪气内阻有关,血瘀、痰凝、毒结皆可导致脉道不利,脉气收敛拘束而形成弦脉；从现代医学角度来看,主要与癌痛,癌细胞的浸润和转移,肿瘤血管形成以及恐惧、焦虑等心理因素有关。恶性肿瘤中弦脉相关病证用药特点：侧重化痰软坚,理气开郁,疏肝散结。本文还从481例临床恶性肿瘤脉象资料中,对弦脉所占比率,弦脉和弦兼脉所主病机,弦脉所在中医证型分布情况等做了初步统计,力求对恶性肿瘤中弦脉的临床意义作出合理的阐释,为临床工作者提供参考。更多还原

【Abstract】 Wiry pulse is one of the most common pulses in clinical practice, which is closely related to major modern diseases. As an ancient Chinese saying goes, "wiry pulse is the pulse which is the most difficult to diagnose". The theory of wiry pulse is very rich, including yin and yang properties, shape property of wiry pulse, the diseses related to wiry pulse, and syndrome type of wiry pulse. Therefore, we can instruct the clinical application of wiry pulse and develop its scientific research, by systematically sorting and further uncovering the literature related with wiry pulse, exploring the source of wiry pulse, analyzing the meaning of wiry pulse, and combining the theory and clinical practice.In the article, four aspects of the wiry pulse theory are systematically studied: reserch history, basic theory, clinical application and the application in tumor diseases.First of all, by reviewing the history of wiry pulse theory, we illustrate several important issues. (1) The relationship between wiry pulse and inernal injuries caused by seven emotions. Internal injuries can lead to the dysfunction of five internal organs and cause the changes in pulse. Excessive anger and thought are often associated with wiry pulse. Anger induces the formation of wiry pulse by causing qi adverseness, stagnation of qi and blood, stress of meridian vessel. Thought induces the formation of wiry pulse by causing spleen injure, qi coagulation of earth, liver (wood) overwhelming spleen (earth). (2) The relationship between wiry pulse and six exogenous pathogenic factors. Wiry floating pulse is caused by wind because it is often found in the unhealthy body injured by wind. Wiry pulse is related to liver and wind. The gallbladder meridian of foot shaoyang, liver channel of foot jueyin, orifice of the uterine cervix, thoroughfare and conception vessels are damaged by wind, which result in wiry pulse. Summer heat also leads to wiry thready pulse, wiry rapid pulse and wiry slippery pulse, because summer heat is one of yang pathogens, consumes qi and injures yin, causes insufficiency of vital energy and blood, and is often accompanyed by dampness-pathogen. Exogenous damp and warm induce wiry thready soft pulse, by obstruction of qi, impairment of yang, and stagnation of vessel system. Wiry thready pulse is often found in the later stage of exogenous damp and warm disease. Cold pathogen lead to strong wiry pulse beacause of blockade and tense of blood vessel, just as a saying, wiry pulse must be found in the body injured by cold pathogen. (3) The relationship between wiry pulse and five internal organs. Wiry pulse is often found in liver disease or other disease caused by liver disease. (4) The nature of yin and yang of wiry pulse. Wiry pulse is yin within yang,later is mainly character.Secondly, in this article pulse manifestation is combined with disease and pulse reason. We systematically and comprehensively discuss the theory including disease, syndrome features, and treatment characteristics related with wiry pulse. Moreover we propose the characteristics of disease related with wiry pulse:cold or heat, deficiency or excess, exterior or interior, qi disease or phlegm disease. Symptoms related with wiry pulse include:pain, worry and fever. Wiry pulse suggests convergence and stagnation of qi, which induce the pain. Stagnation of qi induces heat, and later induces worry. The inside and outside, the exterior and interior are full of Heat and worry, which is the reason of fever. The pain related with wiry pulse includes:bloat pain, swelling pain, and shoot pain. Drugs related with wiry pulse include:(1) Carminative, which is used for soothing the liver and dispeling melancholy, dispersing the stagnated heat, inducing diaphoresis to dispel wind, and regulating activities of qi. (2) Sour and sweet drug, which is used for purging the liver of pathogenic fire, invigorating the splee, astringing yin, softening the liver, benefiting qi and nourishing blood. (3) Acrid and warming drug, which is used for warming yang, activating yang, dispeling cold and relieving pain. (4) Bitter and cold drug, which is used for removing heat from the liver and purging the pathogenic fire. This article also points out that pathological mechanism and drugs on clinical differentiation of syndromes are slightly different, because of the physiological basis difference in surgery, gynecology and pediatrics. The mechanism of wiry pulse in internal medicine is complex and diverse, including cold, heat, deficiency, excess, exterior and interior. The mechanism of wiry pulse in gynecology is liver disease, so the treatment is mainly regulation of liver function. The mechanism of wiry pulse in pediatrics is heat syndrome and wind syndrome, so the treatment includes clearing away stagnant heat and calming liver wind. The mechanism of wiry pulse in surgery is liver and gall heat, liver depression and spleen dampness, so the drugs are used to dispel the wind, clear heat and dampness, reduce phlegm, soften hard masses and dissipate stagnation.The recent research of Wiry focuses on cardiovascular disease, cerebrovascular disease and liver disease. There are few reports on the relationship of wiry and cancer disease. In this study, we found that wiry pulse and cancer disease are closely related. A book named mai jing has been saying:the pulse related with mass accumulation is wiry and tense pulse, wiry and hidden pulse indicates the mass in abdomen and fatal illness. From the traditional Chinese medical science point of view, the wiry formation mechanism of tumor disease is mainly related to the attack body inside of pathogenic factors, which include blood stasis, phlegm coagulation, poisoning accumulate, and lead to blockage of vessel, strain of meridian qi. From the perspective of modern medicine, the wiry formation mechanism of tumor disease mainly related to cancer pain, cancer invasion, cancer metastasis, tumor angiogenesis, and psychological factors including fear and worry.These factors can lead to the formation of wiry pulse by increasing myocardial contractility, cardiac output, vasoconstriction, peripheral vascular resistance and blood pressure. The drug characteristics of cancer disease related with wiry pulse are as follows:the drugs are focused on reducing phlegm, softening hard masses, regulating qi to alleviate mental depression, and soothing the liver to dispel melancholy. Furthermore, by analysising the pulse database collected from 481 cases of clinical malignant disease, we study the percentage of wiry pulse, the mechanism of wiry or/and other pulse, the distribution of traditional Chinese medical science syndromes. Then we illustrate the clinical significance of wiry pulse in neoplastic diseases, and provide the treatment reference for clinical practitioners.更多还原