【作者】 郑永亮；

【导师】 祝维峰；

【作者基本信息】 广州中医药大学 ， 中医学， 2012， 博士

【摘要】 中风病(stroke)是指在气血内虚的基础上,因劳倦内伤、嗜食厚味及饮酒等诱因,引起脏腑阴阳失调,气血逆乱,直冲犯脑,导致脑脉痹阻或血溢脑外,以突然昏仆,半身不遂,口舌歪斜,语言蹇涩或不语,偏身麻木为主症,起病急、变化快,好发于中老年人,相当于西医的脑血管病或脑卒中。《中国缺血性脑卒中和短暂性脑缺血发作二级预防指南2010》中报告脑血管病已成为我国城市和农村人口的第一位致残和死亡原因,且发病有逐年增多的趋势。现代流行病学研究表明,我国每年有150万到200万新发脑卒,年脑卒中死亡率为58-142/10万人口。因此预防中风病是我国目前面临的重大医疗卫生课题。中医药学有数千年的发展历史,在中风病防治方面有,大量的临床实践,丰富的治疗方法,完善的治未病理论,这些都是我们宝贵的临床财富。那么如何将其整理、归纳、分析、总结,运用到今天中风病的治未病当中去,是当前的一项重要课题。从《黄帝内经》开始,在中医2000多年的发展历史上,历代中医学家对中风病的防治都倾注了大量的心血,中医药在防治中风病方面一直发挥着重要的作用。但遗憾的是,临床上一直存在对中风病“重治疗而轻预防”的现象。中医虽然有很好的“治未病”理论,但针对中风病治未病的论述基本上都是只言片语,散在于各种文献当中,纷繁散乱。为此,笔者搜集整理了从《内经》到当代在中风病防治方面做出重大贡献的著名医家的著作,对各位医家明确提出的预防中风发作或复发的原文,整理摘录出来,并借助现代的中国知网等数据库,以古今对照的方式,对这些中风病防治思想和治未病的思路进行探析。在此基础上,我们结合当今中风病防治“跟着指南走”的时代特点,探讨了如何在指南的基础上,利用现代计算机软件技术,发挥中医文献的价值,走出一条中西医结合中风治未病之路。研究目的：本文旨在发掘中医中风病防治的文献资源,探讨如何在目前医疗环境中更好地发挥中医治未病理论优势,开发中风治未病软件,为患者提供最佳的中风病综合预防方案。研究方法：本研究按照文献研究方法中“文献的收集、分析整理以及临床应用”的研究方法开展研究,具体研究方法包括：1.确定中风病的文献查找范围我们参考了上海文献研究所出版的《中风病专辑》、《古今名医临证金鉴》等中风病中医文献专著,它们收集了部分先秦到民国的有关中风病的文献论述,但这两本文献专辑在唐代以后所收集的中风病文献并不全面,而且没有对所收集的文献资料进行分析,很多内容与中风病无关,而是一些外感疾病、面神经炎或癫痫等其他内科疾病。鉴于此,本课题在参考两部专辑基础上,通过翻阅《黄帝内经》,《金匮要略》,《中藏经》,《黄帝明堂灸经》、《针灸甲乙经》、《诸病源候论》,《唐宋金元名医全书大成》,《明清名医全书大成》,《中医临床必读丛书》的通用著作、内科、针灸科、养生等方面的书目,《民国名医著作精华》,排除四部丛书中有关外科、妇科、儿科、眼科、骨伤科、耳鼻喉科等与中风病无关的论述,最终确定了《黄帝内经》、张仲景、《中藏经》、巢元方、孙思邈、王焘、刘完素、李东垣、朱丹溪、王执中、罗天益、薛己、张景岳、赵献可、李中梓、龚廷贤、喻嘉言、姜天叙、李用粹、沈金鳌、陈修园、叶天士、王清任、张士骧、张山雷、张锡纯26为医家为古代研究对象,现代文献部分以2009年国家首次评选的30位国医大师、当代中风病中医名家王永炎、石学敏等团队所发表的中风病相关论文、专著、近些年发表的一些国家级重大中风病预防相关课题成果为对象。确定研究对象后,对古代医家的研究,以目前出版的医学全书为文献来源,比如陈修园,以《陈修园医学全书》为本,无医学全书的医家通过网络、图书馆和自己购书,尽量全面地研究其所有著作,现代医家除了研究其中风专著外,结合中国知网等网络资源进行全面搜集整理。2.建立中风病相关文献纳入及排除标准纳入标准：本研究按照《中医大辞典》目录及具体词目介绍,制定如下主题词：“中风”、“风痱”、“风懿”、“类中风”、“内风”、“半身不遂”、“瘫”“痪”、“厥”、“偏枯”,在上述确定的研究文献范围内,严格按照本文提出的中风病定义对文献进行初步筛选,纳入符合要求的文献内容。第二步筛选是通过人工阅读,对文献中有关中风病发作之前的预防、延缓中风发作、发病之后预防病情加重、预防复发的理论和方法筛选出来,最终作为研究对象。对于预防和治疗都有涉及的文献只纳入有关预防部分,如果存在预防和治疗难以分开的文献,为了保证该研究的全面性,将其全部纳入为研究对象。排除标准：与中风病定义不符的内容,与中风病预防无关的内容,只涉及中风病治疗的内容,与前代医家论述重复的内容,以上内容予以排除。3.综合运用古汉语知识、中医脑病知识、西医神经内科知识及现代信息技术,对目标文献的使用价值进行综合分析。4.结合时代特点,探讨如何在西医指南治疗基础上利用好古今中医文献有关中风治未病的方法和思路,制定一条规范有效的中西医结合综合预防中风病之路。5.提出“中风治未病软件系统”的设想,并进行和初步的设计和开发。研究内容：1.第1篇的文献资料搜集整理和分析我们按照上述研究方法,对确定的古今30多个研究对象的中风病防治理论、方法、临床医案等进行了全面归纳总结,将文献中明确提出中风治未病的内容进行了原文摘录,并以古今对照、前后互参的方式进行了分析,总结了前人预防中风病理论和方法的可信性、可行性。2.第2篇中风治未病方法探讨第2篇在总结整理前人中风治未病文献的同时,不断反思中风病目前防治的现状。笔者认为,在靶向治疗、操作规范、循证医学证据丰富等方面西医存在优势,而中医“治未病”理论在中风病预防中则具有“更早干预”、“动态干预”、“手段多样”、“价廉效优”、“贴近生活”五方面优势。所以,中西医学各具优势,各有特点,互补性强,在目前的预防中风病方面,中西医结合综合防治中风是主流方向。那么,在西医治疗基础上,如何发挥中医药在中风病治未病中的优势,为患者提供更好的医疗服务,是目前中医药防治中风病面临的重要课题,也是本研究主要思考、探讨的问题。本研究在总结前人防治中风病的各种文献基础上,提出中风病的治未病应该表述为：无病养生,危险干预,辨治先兆,截断病程,防止复发5各方面。在“中篇”笔者以上述五个方面为纲领,系统探讨了这五个治未病的不同阶段的确切定义,诊断方法,并将中医对中风病因、中风先兆的理论,和现代医学对中风病因、中风风险评估的理论结合起来,提出了Framingham危险评分、高血压分层分级评估、血脂异常危险分层评估、房颤评估四大模型合一,并结合其他危险因素,比如镰状细胞病、动脉炎、下肢静脉栓塞症、脑血管畸形、高凝状态等,比较全面的包含了中风的各种危险因素,形成了一种全新的风险评估方法。对评估结果,本研究沿用目前公认的低危、中危、高危、很高危四个层次分层方法,并将这种风险评估的“五阶段四层次”推广到大多数人群。我们认为预防中风病的最好方式是“恰当的风险评估和针对性的干预措施”。在此基础上,我们又探讨了如何利用“上篇”总结归纳出的文献进行中风病中西医结合防治,发挥中医药中风治未病的优势。其中,西医的内容是根据目前我国发布的最新的国家级指南和部分美国、欧洲、澳大利亚等国外最新相关指南,中医部分采用的标准是：现代研究部分的证据原则上采用国家级课题的成果,古代部分采用标准是根据历代中医文献经过古今对比后广泛被后世认可的部分,部分有争议的内容采用后进行说明。我们的目标是为每位患者提供标准规范而又是目前证据最好的个体化中风治未病方案。3.第3篇“中风治未病软件系统”的设计在第3篇,考虑到中风病治未病的患者多数都是在医疗门诊或者在社区,我们为了更好的推广使用本研究提出的“恰当的风险评估和针对性的中西医综合预防方法”,我们提出了“中风治未病软件系统”的设想,希望借助现代计算机软件科技手段,研发一种可以面向社会任何人群进行风险评估并给出个体化预防方案的系统。这个系统是一个综合现代医学各种指南的证据,充分吸收中西医学各自优势,可以用于门诊和基层的中风病风险评估及治未病软件系统。它可以面向社会各个年龄阶段、不同性别和具有不同危险的人群进行中风病的危险评估,并给出个体化的预防建议,为患者提供一站式的中风病或心脑血管病的预防门诊服务。我们在研究过程中,充分考虑了目前门诊医生工作的现状和患者的需求,针对性的设计软件,使其具有操作简单、适用广泛、开放发展、方法全面、个体化治疗和医学教育六大特性,并进一步总结了软件辅助下,医生如何为患者提供中风风险评估和中西结合预防中风的综合性、个体化方案。研究结果：1.文献整理价值本研究是中风病中医文献研究中第一次针对预防中风病而非治疗中风病的一次文献整理,我们对所有最终确立的医家的著作进行了完整的搜集,对筛选出的文献进行了详细的分析,把这些医家明确提出预防中风的理论方法以文献摘录的形式呈现出来,对其中的方剂、针灸、医案进行了整理,(方剂整理见附录：中风治未病方剂索引),这样我们对古今中医在中风病预防方面的文献就一目了然,是本研究的文献整理价值的集中体现。2.中风治未病方法本研究在对历代医家防治中风病的理论和方法总结基础上提出：中医治未病的五大优势是：更早干预、动态干预、手段多样、价廉效优、贴近生活；中风病的治未病应该表述为：无病养生,危险干预,辨治先兆,截断病程,防止复发5个阶段,并对这五个阶段进行了定义；提出了Framingham危险评分、高血压分层分级评估、血脂异常危险分层评估房颤评估四大模型合一的风险评估方法,它与五阶段理论相结合,可适合大多数人群的中风病风险评估；按照上述五个阶段和不同风险分层,以中西医结合方式探讨并制定了如何为患者提供标准规范的、综合性、个体化中风预防方案；最后,笔者探讨了中风治未病软件系统的前期规划和设计思路,为下一步开发软件奠定了基础,为更好的实现中风分阶段预防,发挥中医治未病优势做好技术准备。研究结论：在国家脑卒中及其相关疾病防治指南指导下,借助于现代计算机软件技术,深入挖掘中医在中风病防治方面2000多年积累下的文献资源,发挥中医在中风病治未病方面的优势,可以更好地预防中风病的发生和复发。更多还原

【Abstract】 Stroke refers to a disease which is due to the reversed flow of Qi and blood to cause the cerebral thrombosis or hemorrhage, and on the basis of deficiency of Qi and blood, the common pathogenesis are over fatigue and internal injury, over eating greasy food and over drinking; the main clinical symptoms are sudden fainting, hemiplegia, wry eyes and mouth, dysphasia or aphasia, hemianesthesia. It marked by acute onset and quick change and is a common senile disease, the same as acute cerebral accident in modern medicine. According to2010China guideline of the secondary prevention of ischemic stroke and transient ischemic attack, stoke has become to the first reason of disability and death, and the morbidity is increasing rapidly. Some epidemic studies show that there are1500000to2000000new strokes per year, and the yearly mortality is58to142death per one hundred thousand people. The prevention of stoke is one of the major task of national public health. Traditional Chinese medicine(TCM) has2000years development and a large of clinical practice and therapies on stroke and systematical theories on Zhiweibing (preventive treatment of disease), so it is meaningful on how to use these values for the help of stroke prevention today.TCM doctors have taken profound studies on prevention and treatment of stroke in more than2000years of Chinese medicine history. Unfortunately most doctors have been focusing on treating but not preventing stroke throughout history. Traditional Chinese Medicine has systematical theories on Zhiweibing, but for stroke, they are some words scattering in a large number of ancient or present documents. These words are valuable today for the prevention of stroke, so we make a work on collecting and reorganizing these volumes, and take passages on the prevention of stroke occurrence or recrudescence from them. Further more, we contrast these ideas old and new, under the help of some data centers, such as CNKI, and conmbine the west medicine guideline with TCM methods, and design a software system, which all are in order to find a better way for stroke prevention today.Objective:To explore TCM documents on stroke prevention and treatment, and to discuss how to bring Zhiweibing theory into play at present health care system; and finally to develop a software of stroke prevention, which can provide patients a comprehensive prevention scheme on the base of best evidence.Methods:1. TCM documents collection and reorganizationIt is referred to Zhongfenbing Zhuanji (Stroke album), Guji Mingyi Linzheng Jinjian etc. which makes a good collection of the stroke literature old and new, i n add i t ion with Tang Song Jin Yuan Mingyi Quanshu Dacheng, Ming Qin Mingyi Quanshu Dacheng, the volumes on acupuncture, internal medicine, life cultivation of Zhongyi Linchuang Bidu Congshu, Minguo Mingyi Zhuzuo Jinghua, in which limits we make comparison and contrast, and finally makes out nearly30famous books or doctors who made a large contribution on strokes. They are Huangdi Neijing(Huangdi’s canon of internal medicine), Zhang Zongjing, Zhongzangjing, Chao Yuanfang, Sun simiao, Wang Tao, Liu Wansu, Li Dongyuan, Zhu Danxi, Wang Zhizhong, Luo Tianyi, Xue Ji, Zhang Jingyue, Zhao Xianke, Li Zhongzi, Gong Tingxian, Yu Jiayan, Jiang Tianxu, Li Yongcui, Shen Jin’ao, Chen Xiuyuan, Ye Tianshi, Wang Qingren, Zhang Shixiang, Zhang Shanlei, Zhang Xichun, Ren Ji xue, Zhang Xuewen. First, we collect every book of these doctors and read the passages on stroke in, and take out the words on stroke prevention, recognize their ideas from pathogenesis, mechanism, and treatment principle and prevention theory. And then a discussion about these ideas would take by the way of historical comparison and CNKI data which may tell us the acceptance and confirm by the following doctors. For the present doctors’study, we take use of the database of CNKI, Weipu, China biological literature, studied from five points, life cultivation, risk intervention, stokes sign treatment, truncation course and recurrence prevention, especially the studies from state level task or famous doctors, such as Wang Yongyan, Shi Xuemin, etc.2. The discussion on preventive process At the same time, we rethink the present situation of stroke prevention. Compared with western medicine, Chinese medicine’s Zhiweibing theory has five advantages:earlier intervention, dynamic intervention, more therapies, lower-priced effect and close to daily life. But it has disadvantage either. First, almost all therapies are doctors’ personal experiences but not evidenced base medicine and no standard for the application result into no guaranteed effect for every patient. Secondly, though we know Chinese medicine has effect on prevention of stroke, but we do not know how much effect it has, and whether the effect exist or not at the base of western medicine treatment. Thirdly, for the same prescription or the same problem, different doctors may have different opinions and always have conflict results. So we get a conclusion that Chinese and Western medicine have complementary advantages. We should take a combination for stroke prevention. So the question is how to take advantage of TCM Zhiweibing theory at the base of standard treatment by western medicine, which is the main focus of us.According to the study of TCM documents, we conclude Zhiweibing theory for stroke into five stages:life cultivation, risk intervention, stokes sign treatment, truncation course and recurrence prevention. We explored the five stages’definitions and ways of diagnosis. And further the newly achievement of western medicine, such as Framingham study, high blood pressure layered grading diagnosis and dyslipidemia risk stratification are taken into use of stroke risk assessment, and the result described into four levels:low-risk, intermediate-risk, high-risk and very high-risk. Five stages and four levels are united into one and it could be applied to stroke-risk-assessment for most of people. We believe that the best way to prevent stroke is good risk assessment and personal treatment. Next, Five stages and four levels are taken as an outline, and the special treatments are discussed. Among the treatments, the western medicine part is according to the Chinese guideline such as2010Chinese guideline on prevention and treatment of high blood pressure, some from the guideline of oversea countries such as Guidelines for the primary prevention of stroke:a guideline for healthcare professionals from the American Heart Association, the Chinese medicine part is from the conclusion we collected and reorganized out from the ancient and present TCM documents, among which we choose the widely accepted and used in history or which are the results from Chinese state level research. The present situation of stroke prevention is not good in china. Most patients get such medical service from clinics or community healthcare center; the revised guideline can not be applied into patients quickly as doctor’s low profession or busy work. Some patients may not be given enough time to get such knowledge; some may be treated by specialists who have little relative to stroke or known little about these guidelines. Considering stroke prevention is related to many kind of diseases and too much information, a doctor can not manage all, we propose to make an invention of software, called stroke prevention software system. It is software that can provide every people stroke-risk assessment and personal preventing therapies. The therapies are combinations of both TCM methods and western interventions, both daily life guiding and medical suggestions. It takes as much as advantage from both Chinese and western medicines, and characterized by six aspects, which are easy use, wide indication, open and developing, comprehensive interventions, personal intervention and medical education function. It is used specially for clinical or community patients. So at last, we introduce the process of stroke risk assessment and prevention under the help of this software for clinic patients.Result and Achievements:1. Literature resultsAs far as I know, it is the first TCM documentary reorganization on stroke prevention but not stroke treatment. After the study, we get all of the passages from the famous doctors in Chinese history. Peoples later can easily reach their viewpoints, herbal prescriptions, acupuncture or moxibustion methods and case reports on stroke prevention.2. A new stroke prevention methodTCM Zhiweibing theory has five advantages of earlier intervention, dynamic intervention, more therapies, lower-priced effect and close to daily life. Stroke prevention should be treated according life cultivation, risk intervention, stokes sign treatment, truncation course and recurrence prevention, five stages and low-risk, intermediate-risk, high-risk and very high-risk, four levels. A new risk assessment way is initiated including Framingham scores, high blood pressure layered grading diagnosis and dyslipidemia risk stratification. Both the risk diagnosis and treatments are according to Chinese guideline and in a integrated medicine framework, which aim to provide patients a personal and best-evidence based treatment. At last, we propose a software to help doctors achieve this new stroke prevention means, and we draw out the blueprint of it.Conclusion:Under the help of modern computer software technology, it can make a better result to take good use of2000years TCM documents and Zhiweibing theory at base of national guideline of stroke prevention and prevention of some relative diseases.更多还原