【作者】 游江；

【导师】 赖文；

【作者基本信息】 广州中医药大学 ， 中医医史文献， 2009， 博士

【摘要】 历代医案是研究古代常见病、多发病的主要临床依据。本研究尝试利用医案资料了解明弘治元年至清同治五年(1486—1866年)期间,中医温补、命门、温疫、温病学说11位代表性医家的临床常见病(证候)、多发病(证候)及其疾病(证候)谱的历史变化,从疾病史角度,量化地解释这些医家学术思想形成的临床依据,以及该时期中医学术主流从温补转向寒凉的原因与过程。本研究属于回顾性断代流行病史调查,同时也是疾病史与中医学术的交互研究。综合运用了文献研究、调查考证、中医学术研究、历史研究、统计分析、比较研究等方法,以及非严格意义上的流行病横断面调查与抽样调查方法。本研究完成了以下九项工作:一、制定了经实践证明可行的古代临床常见病、多发病调查方法在现代流行病学和当代中医学科划分的视野下审视和利用古代中医医案,研制古代临床常见病、多发病病谱,是一个新的尝试,有许多问题需要解决。本研究在如何从古代中医医案中收集疾病信息、如何制定属于古代中医内科学范畴的医案的纳入标准和排除标准、如何解决古代中医医案因历史局限和个人撰写习惯的差异而导致的特殊情况等方面,作了一些尝试性的工作,初步建立起经实践证明可行的工作方法。二、建立起明清时期11位代表性医家内科医案数据库对公元1486-1866年(明弘治元年至清同治五年)期间,薛己、孙一奎、赵献可、张介宾、吴有性、叶天士、薛雪、吴鞠通、王士雄、喻昌、徐大椿共11位代表性医家的内科医案,进行了较全面的收集和筛选,共整理出这11位医家的内科医案3783例,建立了“明清时期十一医家内科医案数据库”。三、编制出明清时期11位代表性医家内科临床疾病证候谱在数据库基础上,分别就每个医家临床所见疾病证候信息作分类统计和分析,编制出11位医家的“内科医案疾病证候总谱”、“外感病医案疾病证候谱”、“杂病医案疾病证候谱”,从中提取出各位医家临床见证比例较高的病种和证候。四、编制出明清时期11位代表性医家内科方药性质统计表在数据库基础上,分别就每个医家内科医案所用方药的寒、温、平属性作分类统计和分析,编制出11位医家的“内科医案方药性质统计总表”、“外感病医案方药性质统计表”、“杂病医案方药性质统计表”,即从方药和疗效角度为研判疾病证候的性质提供佐证,同时也为了解各临床医家学术思想及相互间的差异提供量化依据。五、编制出明清时期中医学术思想三个历史发展阶段的内科疾病证候谱和方药性质统计表在上述各医家疾病证候谱和方药性质统计表的基础上,分别对明弘治元年(1486年)至清同治五年(1866年)这近四百年间中医学术思想发展三个阶段(温补学说主导期、学术转型期、温病学说主导期)的内科临床疾病证候和方药性质作分类统计和分析,编制出各时期的“内科医案疾病证候总谱”、“外感病医案疾病证候谱”、“杂病医案疾病证候谱”,以及各时期的“内科医案方药性质统计总表”、“外感病医案方药性质统计表”、“杂病医案之方药性质统计表”,提取出各时期的临床常见病证,归纳整理出各时期医家临证常用的方药寒温属性。六、对同一时期中各医家以及三个历史时期的临床见症和方药寒温属性的差异作了分析比较。七、对十一位医家内科医案中有关医界学术思潮、民众体质情况、临床经验总结和援引经典著作、医患关系、心理疗法等方面的评述内容作了辑录并撮取有助于认识明清时期中医学术从温补向寒凉发展的临床背景和认识过程的内容具列于论文中。八、对三个历史时期中的误诊医案和同病异治现象作了对比研究。九、对利用古代医案进行疾病史研究的优越性和局限性进行了探讨。以上工作得出四点主要结论:一、利用医案资料,结合现代医学认识,在大样本基础上采用量化分析方法和进行比较研究,大致上复原了明弘治元年(1486)至清同治五年(1866)间以江浙地区为主涉及北京、安徽和江西部分地区的11位医家视野下的疾病证候谱。二、温补学说主导期(1486-1599年)、学术转型期(1600-1664年)、温病学说主导期(1665-1866年)三个时期的常见病、多发病病种既有共性,也有明显差异。共性是痢疾病始终稳居病谱榜前列。差异是:温补学说主导期,虚劳咳嗽和慢性传染病(麻风)分别占据病谱榜的第二、三位;学术转型期,前三位的病种多是与消化道有关的疾患(痢疾、呕吐、腹胀满);温病学说主导期,以寒热往来为主要见症的外感热病(疟疾病)上升为第一位,咯血病、内伤咳嗽病分居二、三位,痢疾退居第四。纵观三个时期,常见、多发病病种的历史性变化大致上呈现出从以慢性病为主到急性外感病增多的趋势。这一趋势在三个时期的疾病总谱上同样反映出来:急性发热性疾病(疟疾、外感高热病、春温、风温、湿温、伏暑、暑温、温燥、感冒、肺痈烂喉痧、大头瘟、水痘、天花等等)在所有疾病中的比例,依时期先后顺序是12.16%%、16.5%、21.14%,呈逐步递升趋势。三、随着时间向后推移,疾病证候总体上呈现出从以寒证、虚证为多到以热证、实证为主的变化过程。比较三个时期的外感病证型,基本上体现出这种变化趋势:辨证为寒证、虚证和夹虚、夹寒证之病例的比例,依时期先后顺序分别是40%、76%、28.14%。而在温病学说主导期的28.14%中,还包括不少热盛伤津、伤阴的病例数,真正的虚证、寒证较少。杂病亦有类似的情况。医案中的方药属性统计结果从治疗角度清楚地反映了这种疾病证型的历史性变化:温补学说主导期治疗外感病以使用辛温、平性方药居多(54.55%+1.82%),而温病学说主导期用寒凉药治愈的比例接近76.77%。温补学说主导期治愈杂病主要使用温热方药(74.38%),而温病学说主导期用温热方药的比例降至40.63%,而使用寒凉药治愈的比例达50.05%。学术转型期的用药总体上表现为从温补转向寒凉的过渡状态,但仍然偏重辛温。在辨证方面,无论外感还是杂病,寒证、虚证和夹虚、夹寒证之病例的比例都高于前后两个时期。这一现象有待研究。四、疾病、证候、方药三方面的统计数据证明:在一定的自然、社会、历史条件下所导致的人群疾病证候谱的变化,以及这种变化对临床辨证用药施加的压力,是推动中医学术思想发展的直接动力,是医家学术思想形成的临床背景,是中医学术思潮发生、起伏和演变的根本原因。更多还原

【Abstract】 Medical case history is the study of ancient diseases,the clinical basis for the major multiple.In this study,the use of medical information to try to understand from Hongzhi the first year of the Ming Dynasty to Tongzhi five years the Qing Dynasty(Year 1486-1866).TCM warming,Mingmen,Pestilence, 11 Doctrine of Epidemic Febrile Disease,said the representation of clinical medicine diseases(syndrome),frequently-occurring disease(syndrome) and disease(syndrome) spectrum of the history of changes.History from the perspective of disease,to quantify and explain the medical thinking of the formation of academic clinical basis,as well as the academic mainstream of Chinese medicine during the shift from the warming of the causes and the process of cold.This study is a retrospective investigation dating pop history,but also the history of the disease with traditional Chinese medicine research academic interaction.Comprehensive use of the literature research and surveys, research,Chinese medicine practitioners in academic research,historical research,statistical analysis,comparative study of methods,as well as non-strict sense of the cross-sectional epidemiological survey methods and sample surveys.In this study,seven completed the following tasks:(A) developed by the ancient practice has proved feasible clinical diseases,multiple methods of investigation.Epidemiology in modern and contemporary Chinese medicine into the vision of subjects under review and the use of ancient Chinese medicine medical case, the clinical development of the ancient common,frequently-occurring disease spectrum,is a new attempt,there are many issues that need to be resolved. In this study,how the ancient Chinese medicine doctor from the collection of diseases in which information,how to belong to ancient Chinese medicine within the scope of medical science into the standard case and exclusion criteria,how to solve the ancient history of Chinese medicine because of the limitations of medical cases and personal writing habits caused the differences special circumstances and so on,made some attempt to work and initially set up the proven methods of work possible.(B) to establish the representativeness of the Ming and Qing Dynasties 11 Medical Doctors of internal medicine database.Of the Year in 1486-1866(from Hongzhi the first year of the Ming Dynasty to Tongzhi five years the Qing Dynasty) period,Xue Ji,Sun Yikui,Zhao Xianke, Zhang Jiebin,Wu Youxing,Ye Tianshi,Xue Xue,Wu Jutong,Wang Shixiong,Yu Chang,Xu Da chun representation of 11 medical doctors of internal medicine case,a more comprehensive collection and screening,which sorted out a total of 11 medical doctors of internal medicine 3783 cases of the case,the establishment of the "Ming and Qing Dynasties 11 Medical Doctors of internal medicine database."(C) the preparation of a 11 representation of the Ming and Qing Dynasties internal medicine doctors clinical spectrum of disease syndromes.In the database based on the medical home for each of the respective clinical disease syndromes information see separate statistics and analysis, preparation of the 11 Doctors of the "diseases of internal medicine Medical Syndromes score," "Medical exopathic disease syndrome spectrum of diseases", "Miscellaneous Diseases Medical syndrome spectrum of diseases," extracted from clinical medicine to witness that a higher proportion of the diseases and syndromes.(D) the preparation of the Ming and Qing Dynasties 11 representative nature of medicine prescription medicine tables.Basis in the database,respectively,internal medicine physicians in respect of each case by the medical prescription of the cold,temperature, level attributes for classification and analysis of statistics,the preparation of the 11 medical home "prescription medicine Medical statistical summary in nature," "Medical exopathic disease Recipe nature of tables"," Miscellaneous Diseases Medical prescription tables nature",both from the point of prescription and efficacy for the study of the nature of the disease syndromes to provide support,as well as understand the thinking of clinical medicine and academic differences between the provision of quantitative basis.(E) the preparation of the academic thinking of the Ming and Qing Dynasties of Chinese medicine in three stages of the historical development of medical disease and syndrome prescriptions spectrum nature of statistical tables.Doctors in the above spectrum of disease syndromes and prescriptions based on the nature of statistical tables,respectively,the first year of the Ming Hongzhi(1486) to Qing Dynasty Tongzhi five years(1866) The nearly four hundred years of academic thinking of the development of Chinese medicine in three stages(temperature period leading up theory,academic transformation, Science of Seasonal Febrile Diseases,said the leading period) of the Internal Medicine clinical disease syndromes and prescriptions for the classification of the nature of statistics and analysis,preparation of the various periods of "Internal Medicine Medical Syndromes disease score," "exogenous disease treatment the case of the disease spectrum syndrome","Miscellaneous Diseases Medical syndrome spectrum of diseases," and the period of "the nature of medical prescriptions medical case statistical summary," "exogenous disease the nature of the medical herbs which tables","Miscellaneous Diseases of Medical Records Recipe nature of tables",to extract the common period of clinical evidence,collate and analyze periods of clinical medicine herbs commonly used in cold temperature properties.(F) of the same period in the medical home and the three historical periods, see the clinical disease and prescription cold temperature properties were analyzed and compared the difference.(G) of the three historical periods in the case and the doctors misdiagnosed disease varies with the administration made a comparative study of the phenomenon.More than four points to draw major conclusions:(A) the use of medical information,combined with modern medical understanding,in large samples using quantitative analysis based on a comparative study of methods and general rehabilitation of the first year of the Ming Hongzhi(1486) to Qing Dynasty Tongzhi five years(1866) to inter-Jiang Zhejiang region mainly involved in Beijing,Anhui and Jiangxi in some areas of the 11 physicians from the Perspective of spectrum of disease syndromes.(B) warming theory lead period(1486-1599),the academic transition (1600-1664),the Science of Seasonal Febrile Diseases,said the leading period (1665-1866 years) three periods of common,frequently-occurring diseases, both common,there are significant differences.Dysentery disease is still common in retaining its position as the forefront of disease spectrum standings. Differences are:warming theory-led period,Weak cough and chronic infectious diseases(leprosy) patients,respectively,occupy the top of the second spectrum,three;academic transition,the top three diseases are related with the digestive tract disorders(diarrhea,vomiting,abdominal distension or above);Science of Seasonal Febrile Diseases period that led to cold and heat exchanges see as the major exogenous disease fever(malaria) increased for the first hemoptysis disease,cough internal separated second and third, dysentery back fourth.Throughout the three periods,it is common, frequently-occurring diseases,the historical changes in generally showed mainly from chronic disease to the acute increase in exogenous trends.This trend in the three periods of the disease reflected the same score: acute febrile disease(malaria,Exogenous high fever,spring temperature,air temperature,wet temperature,Fushu,summer temperature,dry temperature,cold, bad throat pulmonary carbuncle fever,bulk disease,chickenpox,smallpox,etc.) in the proportion of all diseases,according to the order period is 12.16%%, 16.5%21.14%,showing a gradual upward trend.(C) As time goes backward,disease syndromes in general showing a certificate from a cold,to a deficiency for more than heat,evidence-based process of change.Comparison of three periods of Exogenous syndrome type, basically reflecting the trend of this change:Differentiation for the cold syndrome,deficiency and virtual folders,folder of cold syndrome of the proportion of cases,respectively,in accordance with the order period is 40%, 76%,28.14%.Science of Seasonal Febrile Diseases,said in the lead of 28.14 percent in the period,but also a lot of heat injury,including Tianjin,loss yin number of cases,the real deficiency,less cold syndrome.Miscellaneous diseases have similar situations. Medical prescriptions in the treatment of properties results from the perspective of a clear evidence of the disease reflects the historical changes in type:Warming period of the treatment of exogenous theory of disease led to the use of Xin Wen,Ping majority of prescriptions(54.55%+1.82%),while the dominant view that the Doctrine of Epidemic Febrile Disease cold medicines used to cure closer to the 76.77 percent ratio.Theory-led period of warming and Miscellaneous Diseases cured using hot prescriptions(74.38%),while the Science of Seasonal Febrile Diseases,said the lead period the proportion of prescriptions with warm down 40.63 percent, while the use of cold medicine to cure the proportion of 50.05%.This phenomenon of diarrhea diseases and injuries in the coughing disease appear even more evident.Academic medicine in transition of the performance of the overall shift from a warming of the transition state of cold,but still biased towards Xin Wen.In differentiation,whether exogenous or miscellaneous diseases,cold syndrome,deficiency and virtual folders,folder of cold syndrome were higher than the proportion of cases before and after the two periods.This phenomenon to be considered.(D) of diseases,syndromes,three prescriptions statistics prove that: in the natural,social and historical conditions of the population caused by disease syndrome spectrum changes,as well as the clinical differentiation of this change on the pressure medication,Chinese medicine is to promote the development of academic thinking of the direct driving force,is the medical thinking of the formation of academic clinical background,is the academic trend of Chinese medicine occurred downs and evolution of the root causes.更多还原