【作者】 曹霞；

【导师】 常存库；

【作者基本信息】 黑龙江中医药大学 ， 中医医史文献， 2020， 博士

【摘要】 中风病发病为势最暴,猝然倾仆,痰壅涎流,而瘫痪不仁、舌强语謇、痉厥瘛疭、抽搐昏愦诸危症接踵而来,甚则不动不言、如痴如醉,因为中风病起病突然、变化迅速,且发病率、致残率、死亡率皆高,故中医学将中风病列为“风、痨、臌、膈”四大疑难病之首,历代医家无不知是险候,治之颇难。中医古文献中蕴含着丰富的历代医家治疗中风病的理论思想与治疗经验,而中医之成绩,医案最突出,医案是医家实践的真实记录,其真切性、生动性、时效性、综合性为其他中医理论著作和方药古籍所不及,更具有临床参考的可靠性。正如章太炎所云:“中医之成绩,医案最著。欲求前人之经验心得,医案最有线索可寻。循此钻研,事半功倍。”因而,本文以中风病古医案为研究对象,以期为现代人们呈现历代医家治疗中风病的学术思想与临床诊疗方法。为了更好地厘清我国古代医家描述与治疗本病的学术思想与治疗经验,本文对七十六部古文献中的六百一十五则古代中风病医案进行考察,其中先秦至晋唐时期十则,宋金元时期十七则,明代一百八十六则,清代四百零二则,在梳理中风病古医案发展脉络基础上,归纳解析中风病古医案,并探讨其各发展阶段的病名、病因病机、辨证要点及组方用药等特点。本文主要分为四个部分:第一部分绪论,首先对“中风”和“医案”及其相关概念进行术语释义,同时阐明了本文的研究目的与意义、研究方法与思路,以及以往研究文献综述。第二部分上篇中风病古医案史发展概述,将分为三个方面概述中风病古医案的发展过程。首先,根据各阶段中风病医案所载的内容与形式特征,将中风病医案的发展过程分为四个时期,即先秦至晋唐的中风病医案萌芽时期、宋金元的中风病医案酝酿时期、明代的中风病医案形成时期、清代的中风病医案成熟时期,逐一梳理各个时期医家治疗中风病的学术思想和诊疗技巧;然后,依据整理出的中风病医案,归纳分析中风病医案在各个时期呈现出的特点,即从萌芽时期零散的记载,酝酿时期的结构逐步完整,至形成时期医案书写规范,成熟时期大量高质量的中风医案倍出;最后,依据中风病医案中各医家辨证认识本病的角度不同,整理其对中风病辨证分型的描述,以期更好地展现古代医家对中风病的辨证施治。第三部分中篇中风病古医案整理与解析,从六百一十五则中风病医案中精选出有代表性的一百五十六则典型案例,依据中经络、中脏腑、中风先兆、中风后遗症进行分类整理与解析,其中中经络分为风痰入络证、风阳上扰证、阴虚风动证三个证型,中脏腑分为阳闭证、阴闭证、脱证,中风先兆、中风后遗症医案分别分为风痰阻络证、气虚络瘀证、肝肾亏虚证三个证型,并具体评析、探究以上每一类中风病古医案中辨证施治的要点和处方用药的特色。第四部分下篇讨论,基于中风病古医案对中风的病名,中风患者的年龄及体质特点,中经络、中脏腑、中风先兆、中风后遗症的辨证施治,中风病病因、病机学特点,中风病的治疗原则和方法、用药特点及方剂规律等进行探讨。总体来看,唐宋以前医家强调外风致病,治疗多以“驱风扶正”,方药多为麻黄、防风、秦艽等散风驱邪,参、芍、归、芎等益气养营扶助正气;金元以后医家以内风立论,对病因病机的多样化认识,使治法方药由较为单一的“驱风扶正”发展为祛风化痰、顺气、养血、活血、益气、补脾胃、益肝肾等,医案中可见防风、麻黄、羌活等解表药,当归、川芎、牛膝等活血药,肉桂、附子等温里药,人参、黄芪等补虚药医家最为喜用。通过对中风病古医案的分析与讨论,可理清中风病中医理论发展的脉络和规律,加深对中风病基础理论的认识和理解,提炼并总结古代医家诊治中风病的共性规律,为现代临床医生提供一手可靠资料,帮助现代临床治疗中风病选择更快捷、高效的途径。更多还原

【Abstract】 Stroke is one of the most difficulty diseases to treat in Traditional Chinese Medicine.Stroke has a sudden onset,a dangerous state,a various kinds of symptoms,and has a lot of sequelas,also has a high incidence rate,disability rate,death rate.It is often difficult for ancient doctors to treat it.The study of traditional Chinese medicine,which originated in ancient times,has lasted for more than four thousand years.The achievements of traditional Chinese medicine and medical records are the most outstanding.Ancient Chinese medicine literature contains rich theoretical thoughts and treatment experience of doctors in the past dynasties in the treatment of stroke,and the achievements of traditional Chinese medicine,medical case is the real record of doctors’practice,its authenticity,vividness,timeliness and comprehensiveness are not as good as other traditional Chinese medicine theoretical works and ancient Chinese medicine books,and it has more reliability of clinical reference.As Zhang taiyan said,"Medical records play an important role in traditional Chinese medicine,the achievements of traditional Chinese medicine are the most outstanding.In order to seek for the experience of the predecessors,medical record is the best way for us to do so.If we follow this principle,we will get twice the result with half the effort."Every stroke consilia is a true record of the disease,reflected the successful experience and the lessons of failure.Every medical case is the crystallization of the efforts of ancient doctors,from which we can find out the experience and treatment rules of the sages.A good medical record can fully reflect the soul of method and creativity of doctors,the basic theory of treating diseases,and the characteristics of medication.Therefore,this paper takes the ancient medical records of stroke as the research object,in order to present the academic thoughts and clinical diagnosis and treatment methods of treating stroke for modern clinical doctors.In order to clarify the academic thoughts and treatment experience of ancient Chinese doctors in describing and treating this disease,this paper will investigate six hundred and fifteen ancient stroke cases in seventy-six ancient documents,including ten cases from Qin to Tang Dynasty,seventeen cases from song,Jin and Yuan Dynasty,one hundred and eighty-six cases from Ming Dynasty,and 402 cases from Qing Dynasty.This paper uses different research methods,such as:literature investigation,content analysis,to analysis the medical records,which takes the medical records of stroke as the research object.Through the analysis of ancient medical records,this paper sums up the unique features of etiology,pathogenesis,key points of syndrome differentiation,principles and methods of treatment,rules of drug use embodied in the ancient medical records of stroke.To explore the academic thought and clinical diagnosis and treatment experience of ancient sages on stroke,and to sort out the valuable contents for the theory and clinical practice of traditional Chinese medicine.Sums up the academic thoughts and clinical diagnosis and treatment experience of doctors in the past dynasties,and provides reference for the modern clinical work of traditional Chinese medicine.This paper is divided into four parts:The first part is the introduction,which mainly analyzes the related concepts of stroke and consilia,and introduces the research purpose,significance,methods and ideas of this study,as well as the summary of previous research literature.In the second part,it is an overview of the history of the development of stroke medical records,which will be divided into three aspects to summarize the development process of stroke medical records.First of all,according to the content and form characteristics of stroke medical records in each stage,the development process of stroke medical records is divided into four periods:the embryonic stage of stroke records,from Qin to Tang dynasty;the brewing period of stroke records,from Song to Yuan dynasty;Ming dynasty,the formation period of stroke records;Qing dynasty,the mature stage of stroke records.Based on the dynasty as the guiding principle,the author concludes the academic thoughts and clinical experience of each generation of traditional Chinese medicine and their representative medical records,and summarizes the understanding of the representative doctors of the past dynasties on the syndrome differentiation of stroke in the process of combing the medical records.And then,according to the stroke medical records sorted out,we analyzed the characteristics of stroke cases in different periods,that means,from the scattered records of the embryonic form of expression,to the brewing development,to the writing standard of medical cases in Ming Dynasty and a large number of stroke cases appeared in Qing Dynasty.Finally,according to the different angles of syndrome differentiation and recognition of stroke in the medical records,the description of syndrome differentiation and classification of stroke was sorted out,in order to show the ancient doctors’differentiation and treatment of stroke.The third part is the arrangement and analysis of the ancient medical records of stroke.There are one hundred and fifty-six representative cases of stroke are classified from the six hundred and fifteen cases,sorted and discussed in this part,which based on the theory of Traditional Chinese Medical diagnosis and treatment of stroke in ancient Chinese medicine documents.We study the cause,pathological mechanism,treatment principle,medication and so on.This paper explores the etiology,pathogenesis,treatment rules,related prescriptions and medicines of each type of stroke in the ancient medical cases,and makes a specific evaluation and analysis,in order to get relevant conclusion,so as to give us a better way to show the ancient doctors’understanding and dialectical treatment of stroke more clearly.What’s more,to draw relevant conclusions to guide clinical work of Traditional Chinese Medicine.The fourth part discusses the name of apoplexy,the age and physical characteristics of stroke patients,the syndrome differentiation and treatment of middle meridians.This paper summarizes and discusses the selected ancient medical records of stroke in different ways as fellows.From the perspective of the medical records of stroke,we can sum up the age and constitution characteristics of stroke,the etiology and pathogenesis characteristics of stroke,the key points of syndrome differentiation of stroke,and the treatment characteristics of stroke,including treatment principles,treatment methods,characteristics of medication,prescriptions,etc,so as to clarify the context and principle of the development of traditional Chinese medicine theory of stroke,promote the understanding of the basic theory of stroke.Generally speaking,before the Tang and Song Dynasties,the doctors emphasized the pathogenic factors of“exogenous wind”in TCM,and most of the treatments were“expelling wind and strengthening the vital energy”.After the Jin and Yuan Dynasties,the doctors discussed the“endogenous wind”and diversified their understanding of etiology and pathogenesis,which led to the development of therapeutic prescriptions from a single“expelling wind and strengthening the vital energy”to a compound treatment in TCM.In this paper,we refine and summarize the universality principles of diagnosis and treatment of stroke,provides first-hand reliable information for traditional Chinese clinicians,and choose a better and more effective avenue for the development of modern Chinese medicine and the diagnosis and treatment of stroke,help modern clinical TCM doctors to choose a faster and more efficient way to cure stroke patients.更多还原