中医诊治痹证学术源流探讨及文献整理与资料查询系统建立
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摘要
研究目的
痹证为现代中医临床常见病证之一,它是一种以皮肤、肢体关节、肌肉、筋骨等处酸麻重着、疼痛,麻木、肿胀、甚至关节红肿热痛、屈伸不利为主症,关节僵硬、畸形等病证的总称。相当于西医学风湿性关节炎、类风湿性关节炎、强直性脊柱炎、骨质增生等骨关节病。多为结缔组织和自身免疫有关,病程呈慢性,反复发作,进行性,该类疾病病因不明,可引起相当高的致残率和病死率,对糖皮质激素及免疫抑制剂类药物治疗有一定反应,西医缺乏特异性治疗。中医对本病的诊疗,进行了长期的研究并积累了丰富的经验。前人对痹证的论述留下的丰富内容,值得我们研究效法与发扬光大。中医药治疗以整体出发,以辨证论治为核心,具有综合作用的优势,现代临床研究也证明使用中药治疗痹证有良好的疗效,受到广泛的关注。因此,痹证证治不仅为古代医家所重视,亦是近代医家和研究者不可忽视的重要课题,所以总结整理历代医家对痹证的学术经验,具有重要的理论研究意义及临床实用价值。
近十年不同领域的专家学者分别从多个角度对该病进行剖析和阐发,内容相对集中在痹证经典文献整理、痹证与西医相关疾病研究、痹证病因病机探讨、痹证论治四个方面。痹证与西医相关疾病研究方面,寻找痹证相关联的西医疾病,概括起来,西医的类风湿性关节炎、风湿热、原发性坐骨神经痛、骨质增生病等,可归属于中医“痹证”范畴。此外,血栓闭塞性脉管炎、多发性肌炎、硬皮病、布氏杆菌病、结节性红斑、硬结性红斑、结节性脉管炎以及系统性红斑狼疮等病出现与痹证相似症状的,也可归于中医“脉痹、肌痹、虚痹、皮痹”等范畴予以论治。痹证病因病机,学者多从外邪侵袭、脏腑失调、痰瘀致病、邪气、痰瘀与脏气失调并存四方面探讨。痹证论治有从脏腑论治、从气血阴阳论治、从络病论治、从痰瘀论治、从寒热论治及分期论治六个方面。
基于以上研究现状得出,尽管在痹证的诊治研究中,中医取得了可喜的进展,但现代学者关于痹证证治研究重点仍然在临床,对古文献的整理研究在数量上比较少,而资料也多是围绕《内经》《金匮》等经典著作而作的零散报道,故当前学界关于痹证的研究,亟待对其学术源流进行系统梳理研究,以朝代为主轴,对痹证证治文献进行探析,从学术发展纵向的角度,对自汉墓马王堆出土医学文物到内难伤寒金匮等经典著作,从晋唐、宋金元到明清时期,以承先启后的精神,对痹证的历史沿革及历代医家学术成就进行探讨。此外,大量收集近现代学者关于痹证及相关病证的研究文献,并对资料进行分类汇编,从横向的角度,探讨当代医家痹证论治特点,为今天的临床提供借鉴。
研究方法
基础工作包括资料调研收集,资料归类汇编,分析评述,采用传统医史文献研究方法,重视原创一手资料的发掘、收集,整理。传统医史文献研究必须与现代文献研究整理相结合,在充分占有资料基础上,注重理论学说以及学术观点的凝练,并应用计算机技术,对大量资料信息进行处理。
研究方法强调阅读中医诊治痹证相关古籍原著,查阅核准近现代文献资料的出处。古籍原著资料截取,充分利用汇辑近人点校出版的中医古籍,如人民卫生出版社《中医临床必读丛书》、中医古籍出版社之《中医古籍珍本提要》、浙江科学技术出版社之《近代中医珍本集》、中国中医药出版社之《明清名医全书大成》(收载明代13位、清代17位医家全书)、《唐宋金元名医全书大成》(共4个朝代22位医学家著作)均列入探查范围。中国中医药出版社2000年出版,张文康主编之《中国百年百名中医临床家丛书》,对近代著名中医专家对痹证证治的学术思想以及临床经验进行分析整理。依据的文献除中医古籍原著外,主要从中国生物医学文献光盘数据库、中文科技期刊数据库(维普期刊数据库)、万方数据库及手工检索等方式,收集近十年来有关痹证的论文。共计搜索到中医诊治痹证文献2175篇,其中理论探讨326篇占15.0%,临床研究1051篇占48.4%,治验医案报道316篇占14.5%,专方专药治疗175篇占8.0%,实验研究185篇占8.5%,文献综述69篇占3.2%,其他53篇占2.4%。取有代表性的文献资料,进行归类整理发掘。
基于以上研究方法,论文设计分为三部分。第一部分痹证病名及证治学术沿革,以朝代为纲,按照年代沿革之先后,先秦两汉晋唐宋金元明清,及至近代百年,对历代医家之论述,从流溯源,知其由来,审其变迁,从纵向进行研究。第二部分中医诊治痹证文献整理,着重于中医诊治痹证的理论学说内涵研究,从横向探讨痹证的概念、病因病机、辨证特点、方药治疗等方面进行分类,取其中有代表性的著述资料归类整理中医痹证含义。第三部分作为附篇,把读研期间获取的50万多字关于中医诊治痹证的文献以及临床资料数据,通过计算机处理后保存,方便日后查询检索。
研究结果
论文通过对痹证古代中医原著及近现代中医药文献的发掘收集整理,分别从纵向、横向两方面进行研究,展现中医学对痹证的认识。
第一部分从纵向的角度阐述自秦汉到明清二千多年来历代主要医家诊治痹证的学术主张,按照历史时期划分大体有以下几个特点：①中医诊治痹证学术渊源于《内经》时代。②魏晋隋唐临证实践与理论深化认识,痹证既指风寒湿邪侵袭经络、痹阻气血,引起以关节、肌肉疫痛、拘急为主症的一类疾病；也泛指病邪痹阻肢体、经络、脏腑所致的各种疾病。③宋金元医学理论创新,发展中医诊治痹证的学说。以金元四大家为代表的医家在诊治痹证理论上有新的突破,如朱震亨“痛风”主血热主有痰说,这一新的学说对后世活血化瘀法、除痰化浊之法以治疗痹证产生深远影响。④明清时期中医诊治痹证理论与实践日臻成熟,在对痹证锁定在以肢体关节痹阻疼痛为主要症状,而之前的脏腑痹、气血痹、官窍痹等病证则归入其所属的内科病证中。对痹证诊治基调上有一定的学派聚集现象,如明代温补学派多从脏腑气血上求索,薛己治痹平调气血,张介宾治痹峻补真阴,李中梓治痹理血行痹；清代温病学派多责于热,叶桂、吴瑭从湿热中求,王孟英认为痹久化热,王清任突出论述了因瘀血致痹的理论与治疗方法。
上述关于中医诊治痹证学术源流四个时期的划分研究分类方法,以及各个时期学术特点理论凝练,与对原创中医古籍著作的引用,目前未见有更为全面者,这是本论文创新点之一。
第二部分对中医诊治痹证的学术内涵从横向进行文献整理研究。痹证的概念,虽有广义痹证与狭义痹证之分,但当代学者在认识上逐渐形成痹证是指风寒湿邪侵袭经络、痹阻气血,引起以关节、肌肉疫痛、拘急为主症的一类疾病,即以狭义痹证为主。痹证的病因病机,其发生主要是由于正气不足,感受风、寒、湿、热之邪所致,内因是痹证发生的基础,外邪侵袭是痹证形成的因素。痹证日久不愈,气血运行不畅,容易瘀血痰浊阻痹经络,从而出现关节周围结节、关节肿大、屈伸不利,甚至肌肤瘀斑。痹证病久可见骨节肿大而肌肉萎缩。痹证的主要证候,有关节疼痛、肢体重着、肌肤麻木、屈伸不利、关节肿胀变形、皮肤顽厚变色等。
痹证的辨证论治,当代比较一致认同的是：首先应辨清风寒湿痹与热痹的不同,其次要注意病程久者可能出现有气血损伤及内舍脏腑的证候。针对不同的证型,治疗以不同的方药。祛风、散寒、除湿、清热以及舒经通络为治疗痹证的基本原则,后期还应适当配伍益气养血之剂。痹证迁延不愈,应考虑痰瘀阻于经络,变为痰瘀痹阻之证,治疗佐以除痰化瘀药物。
第三部分作为附篇,是笔者在攻读博士学位期间收集50万字关于中医诊治痹证的文献以及整理临床资料数据,通过计算机技术处理后保存,方便日后查询检索,这也是古人治学资料长编的现代延续。
痹证文献整理研究突出学术内涵,从痹证定义概念、病因病机、证候特点、辨证论治等方面,并以名老中医学术经验为重点内容加以贯穿贯,最后通过计算机技术处理50万字文献临床资料,成为查询检索系统,传承古人治学资料长编优良传统,这一研究过去未见有更为详尽者。这是本论文创新点之二。
结论
本论文的第一部份以朝代为主轴,对历代主要医家及论著的观点进行剖析,总结其成果,分析其医学思想,重点阐述自秦汉到明清二千多年来历代主要医家诊治痹证的学术主张。第二部分对中医诊治痹证的学术内涵从横向进行文献整理研究。当代学者认为痹证是指风寒湿邪侵袭经络、痹阻气血,引起以关节、肌肉痠痛、拘急为主症的一类疾病。第三部分中医诊治痹证资料查询系统,延续前人治学资料长编的传统,显突中医医史文献专业研究生特色。
中医诊治痹证的理法方药,饱含了从秦汉到明清二千多年的时间长河里历代医家经验,也饱含了民国至现代百余年来学者们的努力,内容丰富宏阔。论文在掌握资料的时间跨度、检索文献的标目细度上努力探讨,条分缕析,凝练相关学术观点,力图给学界关于痹证在概念、学术源流、历代医家代表观点、病因病机、诊断治疗等方面一个相对清晰的认识。冀望通过对中医古籍原著以及近现代名老中医学术经验整理与当代学者对痹证研究成果整理,能够对未来痹证证治的临床研究提供更多的参考依据及更充分的理论基础。
Purpose:
Bi-syndrome, a collective term for symptoms such as stiffness or deformity of joints, is a common clinical symptom and recognized as tingling, pain, numbness, swelling, burning pain associated with redness, difficulties in bending and stretching of skin, joints, muscles, tendons and bones, etc. It is equivalent to bones and joints diseases such as Osseous arthtritis, Rheumatoid arthritis, Ankylosing Spondylitis, Hyperostosis in western medical science. The disease, chronic in nature, occurred repeatedly or gradually, without clear causes, is highly related to connective tissue diseases and self-immunity system and has high rate of disability and mortality. Although responsive to Corticosteroids and immunosuppressive drugs in a certain degree, western medicine practitioners still have no specific treatment for this disease. Chinese medicine practitioners, however, have researched into Bi-syndrome for a long period of time and accumulated wealth of experience worth further exploring. The holistic approach used by chinese medicine practitioners, with "discern patterns and institute treatment" as the basis, has an advantage of combined effects in treating Bi-syndrome. Recent medical researches have also proved that use of chinese medicine is effective to treat Bi-syndrome and has received much public attention. As both historic and current medical practitioners are keen to find out a means to treat Bi-syndrome, a systematic review of the literatures by historic scholars and consolidation of their findings on Bi-syndrome has significant values to both academic research and clinical treatment.
In the past decade, scholars from different fields have separately researched and analyzed Bi-syndrome from four perspectives, namely literature review, related diseases in western medical science, etiology of the disease, and treatment methods. Regarding research into related diseases in western medical science, it covers Rheumatoid arthritis, rheumatic fever, Primary sciatica, Hyperostosis, etc. Diseases such as Thromboangiitis Obliterans, Polymyositis, Scleroderma, Brucellosis, Erythema nodosum, Induration red spots, Nodular vasculitis and Systemic lupus erythematosus, etc., which have symptoms similar to those of Bi-syndrome, are categorized as "pulse numbness", "muscle numbness", "virtual numbness" and "skin numbness" in chinese medical science for discussion. About etiology of the disease, scholars usually researched by four aspects, namely "exterior pathogenic invasion", "viscera disorder", "diseases caused by phlegm and blood stasis", "Pathogenic Qi", "co-existence of phlegm and blood stasis with internal organs disorder". The six approaches to treat Bi-syndrome are the "viscera", "Qi, blood and Yin Yang", "diseases associated with meridians", "phlegm and blood stasis", "cold and heat" and "by stage of the disease" approaches respectively.
Although there is significant development in respect of treatments for Bi-syndrome by chinese medicine practitioners based on the above findings, the focus is still on clinical research without much work done on literature review. Details reported so far were mainly those from some classic books such as "Nei Jing" and "Jin Gui". Therefore, there is a need for a systematic literature review of the origins and developments of Bi-syndrome found in the medical relics unearthed from the Han Mawangdui and the classic books such as "Nei Nan Shang Han Jin Gui" etc., chronologically from the Jin, Tang, Jin, Yuan to the Ming and Qing Dynasties. There is also a need to categorize the characteristics of different treatment methods adopted by various historic scholars with a view to providing current medical practitioners with insight into the clinical approaches to treat Bi-syndrome.
Research methodology:
Review the relevant historic and modern literatures with importance accorded to first hand information and attention to convergence of theoratic and academic view points, and apply information technology to facilitate collection, compilation, categorization, and analyses of the mass volume of information.
1. Review historic literatures on Bi-syndrome and counter check origins of modern literatures. This covers Qing Dynasty's "Gu Jin Tu Shu Ji Cheng Yi Bu Quan Lu" edited by Chen Menglei, "Ming Qing Ming Yi Quan Shu Da Cheng" published by the Chinese Traditional Medicine Publishing House, "Chinese Hundred Years Hundred Renowned TCM Practician's Clinical Collection" edited by Zhang Wenkang and published by the Chinese Traditional Medicine Publishing House. Collect from a number of databases (e. g. China Journal Full-text Database(CJFD)) relevant theses and journals on treating Bi-syndrome with chinese medicine published in the past decade. About 2175 theses were extracted of which 326 (15%) were on researches into principles and theories, 1051 (48.4%) on clinical studies,316 (14.5%) on successful clinical trials, 175 (8%) on treatment with special prescriptions,185 (8.5%) on experimental studies,69 (3.2%) on literature review, and 53 (2.4%) on others respectively.
2. Through chronological study of the origins and developments of the Bi-syndrome and categorization of the characteristics of different treatment methods adopted by various historic scholars, provide a comprehensive understanding of handling Bi-syndrome in chinese medical science. This dissertation will be divided into three parts:
Literature review on chinese medicine practitioners'understanding and experience in Bi-syndrome chronologically from the early Qin Dynasty to the past ten decades, with a view to knowing the derivation and evolution of Bi-syndrome.
Literature review on the theories of the treatment methods by categorizing the concepts, causes, keys of diagnosis, medication, clinical case studies and preventive measures with a view to better defining Bi-syndrome in Chinese medical science.
An Annex in the form of a database containing information related to Bi-syndrome collected through literature reviews and compilation of clinical data to facilitate future reference.
Results:
Through chronological study of the origins and developments of the Bi-syndrome and categorization of the characteristics of different treatment methods adopted by various historic scholars, provide a comprehensive understanding of handling Bi-syndrome in chinese medical science. It is found that the academic beliefs of historic scholars in treating Bi-syndrome can be broadly characterized as:
Treatment of Bi-syndrome by chinese medicine practitioners was originated from the era of "Nei Jin";
In the era of Wei, Jin, Sui and Tang, the understanding of Bi-syndrome was further enhanced in terms of theories and clinical studies. Bi-syndrome was considered to be an invasion of meridian by pathogenic factors (i. e. "wind", "cold", "dampness"), or phlegm and blood stasis, leading to tingling and spasm in joints and muscle. It was also considered to cover limbs, meridian, viscera related illnesses caused by Bi-syndrome.
Significant progress has been made in the era of Song, Jin and Yuan, where the theory proposed by Zhu Zhenheng-"Gout-Blood, heat and phlegm as factors" has long-lasting impact on the future methods to treat Bi-syndrome i. e. Bi-syndrome could be cured by improving the blood and Qi circulation with a view to minimizing blood stasis, and through thinning the phlegm to achieve detoxification.
The era of Ming and Qing where the theories and clinical studies of treating Bi-syndrome with chinese medicine have gained more grounds. That is, painful limbs and joints as the main symptom with "numbness in viscera, blood and Qi, and five orifices" etc., classified as internal medical illnesses. This approach, in certain extent, has consolidated the thoughts of various famous practitioners.
This is one of the distinct features of this dissertation as there is still no comprehensive categorization of TCM's understandings and beliefs on Bi-syndrome prevailing in these four periods with reference to historical
literatures.
A systematic presentation of the characteristics of TCM's clinical treatment for Bi-syndrome. Although there are generalized and localized beliefs of Bi-syndrome, academics nowadays generally consider the disease as an invasion of the meridian by pathogenic factors (i. e. "wind", "cold", "dampness"), and numbness caused by poor circulation of blood and Qi, leading to pain, tingling and apasm in joints and muscles i. e. the localized belief. In fact, Bi-syndrome is mainly caused by deficiency in Qi (i.e. the basis), with exterior pathogens related to "wind", "cold", "dampness" and'heat" as catalysts (i.e. factors). Prolonged Bi-syndrome without proper treatment will lead to poor circulation of blood and Qi, hence numbness of meridians by phlegm and blood stasis, resulting in hardening of areas surrounding the joints, swollen joints, difficulties in bending and stretching of joints, and ecchymosis on skin. Ones suffering from Bi-syndrome for a long period of time can be recognized by swollen joint with atrophy. Main symptoms of Bi-syndrome include painful joints, limbs tingling, numbness, difficulties in bending and stretching of skin, joints, muscles, tendons and bones, swollen and deformed joints, skin hyper trophy, etc.
At present, the agreed view to treat Bi-syndrome is first identify the differences between numbness caused by "wind", "cold" and "dampness" and those by "heat", then pay attention to possible symptoms like vacuity of Qi and blood as well as visceral illnesses for chronic patients. Use different medications for different types of the syndrome. Use eliminating the "wind", "cold", "dampness", clearing away "heat", and clearing meridian-Qi and regulating Qi and blood) as the basis of treatment, supplemented with drugs that would replenish Qi and nourish blood at a later stage where appropriate. In case of prolonged disturbance by Bi-syndrome, one should consider the case as phlegm and blood stasis instead of numbness of meridians caused by phlegm and blood stasis, and supplemented with drugs that would activate blood and resolve phlegm as the treatment method.
The third part, an Annex to this dissertation, is a database of Bi-syndrome related information collected by the author through review of literatures and compilation of clinical data during his study of the doctorate programme to facilitate future reference. This is also a method of historic scholars to pass on their knowledge and experience.
This is the second distinct feature of this dissertation as there is also no comprehensive analyses of the beliefs, causes, characteristics of symptoms, and various treatments for Bi-syndrome with reference to the academic knowledge of some famous chinese medicine practitioners, and use of information technology to establish a database containing relevant information to facilitate future reference.
Conclusion:
The first part of this dissertation analyzes and summarizes the various understandings and findings of historic scholars on Bi-syndrome in the past two thousand years, chronologically from early Qin Han to Ming Qing. The second part is a categorization of the concepts, causes, symptoms, medication, clinical case studies and preventive measures in relation to Bi-syndrome. Current academics consider Bi-syndrome as a kind of illness in which "wind", "cold" and "dampness" invade the meridians leading to poor circulation of blood and Qi hence resulting in tingling, pain and numbness in joints and muscle. The part is a database of Bi-syndrome related information to facilitate future reference, a practice of historic scholars to passing on their knowledge and experience and a characteristic of research study through review of chinese medicine literatures.
Treatment for Bi-syndorme using chinese medicine covers the experience of scholars of the past two thousand years (i.e. from the Qin Han to Ming Qing Dynasties) and efforts of academics of the past ten decades. This dissertation has tried to provide the academic sector with a clear understanding of Bi-syndrome both in breath and depth, covering concepts, origins, views of historic scholars, causes of the syndrome, treatment, etc. It aims to provide sophisticated and concrete principles and theories as well as clinical treatments for Bi-syndrome for future reference through literature review and categorization of the findings and experience of both academics and renowed chinese medicine practitioners.
痹证为现代中医临床常见病证之一,它是一种以皮肤、肢体关节、肌肉、筋骨等处酸麻重着、疼痛,麻木、肿胀、甚至关节红肿热痛、屈伸不利为主症,关节僵硬、畸形等病证的总称。相当于西医学风湿性关节炎、类风湿性关节炎、强直性脊柱炎、骨质增生等骨关节病。多为结缔组织和自身免疫有关,病程呈慢性,反复发作,进行性,该类疾病病因不明,可引起相当高的致残率和病死率,对糖皮质激素及免疫抑制剂类药物治疗有一定反应,西医缺乏特异性治疗。中医对本病的诊疗,进行了长期的研究并积累了丰富的经验。前人对痹证的论述留下的丰富内容,值得我们研究效法与发扬光大。中医药治疗以整体出发,以辨证论治为核心,具有综合作用的优势,现代临床研究也证明使用中药治疗痹证有良好的疗效,受到广泛的关注。因此,痹证证治不仅为古代医家所重视,亦是近代医家和研究者不可忽视的重要课题,所以总结整理历代医家对痹证的学术经验,具有重要的理论研究意义及临床实用价值。
近十年不同领域的专家学者分别从多个角度对该病进行剖析和阐发,内容相对集中在痹证经典文献整理、痹证与西医相关疾病研究、痹证病因病机探讨、痹证论治四个方面。痹证与西医相关疾病研究方面,寻找痹证相关联的西医疾病,概括起来,西医的类风湿性关节炎、风湿热、原发性坐骨神经痛、骨质增生病等,可归属于中医“痹证”范畴。此外,血栓闭塞性脉管炎、多发性肌炎、硬皮病、布氏杆菌病、结节性红斑、硬结性红斑、结节性脉管炎以及系统性红斑狼疮等病出现与痹证相似症状的,也可归于中医“脉痹、肌痹、虚痹、皮痹”等范畴予以论治。痹证病因病机,学者多从外邪侵袭、脏腑失调、痰瘀致病、邪气、痰瘀与脏气失调并存四方面探讨。痹证论治有从脏腑论治、从气血阴阳论治、从络病论治、从痰瘀论治、从寒热论治及分期论治六个方面。
基于以上研究现状得出,尽管在痹证的诊治研究中,中医取得了可喜的进展,但现代学者关于痹证证治研究重点仍然在临床,对古文献的整理研究在数量上比较少,而资料也多是围绕《内经》《金匮》等经典著作而作的零散报道,故当前学界关于痹证的研究,亟待对其学术源流进行系统梳理研究,以朝代为主轴,对痹证证治文献进行探析,从学术发展纵向的角度,对自汉墓马王堆出土医学文物到内难伤寒金匮等经典著作,从晋唐、宋金元到明清时期,以承先启后的精神,对痹证的历史沿革及历代医家学术成就进行探讨。此外,大量收集近现代学者关于痹证及相关病证的研究文献,并对资料进行分类汇编,从横向的角度,探讨当代医家痹证论治特点,为今天的临床提供借鉴。
研究方法
基础工作包括资料调研收集,资料归类汇编,分析评述,采用传统医史文献研究方法,重视原创一手资料的发掘、收集,整理。传统医史文献研究必须与现代文献研究整理相结合,在充分占有资料基础上,注重理论学说以及学术观点的凝练,并应用计算机技术,对大量资料信息进行处理。
研究方法强调阅读中医诊治痹证相关古籍原著,查阅核准近现代文献资料的出处。古籍原著资料截取,充分利用汇辑近人点校出版的中医古籍,如人民卫生出版社《中医临床必读丛书》、中医古籍出版社之《中医古籍珍本提要》、浙江科学技术出版社之《近代中医珍本集》、中国中医药出版社之《明清名医全书大成》(收载明代13位、清代17位医家全书)、《唐宋金元名医全书大成》(共4个朝代22位医学家著作)均列入探查范围。中国中医药出版社2000年出版,张文康主编之《中国百年百名中医临床家丛书》,对近代著名中医专家对痹证证治的学术思想以及临床经验进行分析整理。依据的文献除中医古籍原著外,主要从中国生物医学文献光盘数据库、中文科技期刊数据库(维普期刊数据库)、万方数据库及手工检索等方式,收集近十年来有关痹证的论文。共计搜索到中医诊治痹证文献2175篇,其中理论探讨326篇占15.0%,临床研究1051篇占48.4%,治验医案报道316篇占14.5%,专方专药治疗175篇占8.0%,实验研究185篇占8.5%,文献综述69篇占3.2%,其他53篇占2.4%。取有代表性的文献资料,进行归类整理发掘。
基于以上研究方法,论文设计分为三部分。第一部分痹证病名及证治学术沿革,以朝代为纲,按照年代沿革之先后,先秦两汉晋唐宋金元明清,及至近代百年,对历代医家之论述,从流溯源,知其由来,审其变迁,从纵向进行研究。第二部分中医诊治痹证文献整理,着重于中医诊治痹证的理论学说内涵研究,从横向探讨痹证的概念、病因病机、辨证特点、方药治疗等方面进行分类,取其中有代表性的著述资料归类整理中医痹证含义。第三部分作为附篇,把读研期间获取的50万多字关于中医诊治痹证的文献以及临床资料数据,通过计算机处理后保存,方便日后查询检索。
研究结果
论文通过对痹证古代中医原著及近现代中医药文献的发掘收集整理,分别从纵向、横向两方面进行研究,展现中医学对痹证的认识。
第一部分从纵向的角度阐述自秦汉到明清二千多年来历代主要医家诊治痹证的学术主张,按照历史时期划分大体有以下几个特点：①中医诊治痹证学术渊源于《内经》时代。②魏晋隋唐临证实践与理论深化认识,痹证既指风寒湿邪侵袭经络、痹阻气血,引起以关节、肌肉疫痛、拘急为主症的一类疾病；也泛指病邪痹阻肢体、经络、脏腑所致的各种疾病。③宋金元医学理论创新,发展中医诊治痹证的学说。以金元四大家为代表的医家在诊治痹证理论上有新的突破,如朱震亨“痛风”主血热主有痰说,这一新的学说对后世活血化瘀法、除痰化浊之法以治疗痹证产生深远影响。④明清时期中医诊治痹证理论与实践日臻成熟,在对痹证锁定在以肢体关节痹阻疼痛为主要症状,而之前的脏腑痹、气血痹、官窍痹等病证则归入其所属的内科病证中。对痹证诊治基调上有一定的学派聚集现象,如明代温补学派多从脏腑气血上求索,薛己治痹平调气血,张介宾治痹峻补真阴,李中梓治痹理血行痹；清代温病学派多责于热,叶桂、吴瑭从湿热中求,王孟英认为痹久化热,王清任突出论述了因瘀血致痹的理论与治疗方法。
上述关于中医诊治痹证学术源流四个时期的划分研究分类方法,以及各个时期学术特点理论凝练,与对原创中医古籍著作的引用,目前未见有更为全面者,这是本论文创新点之一。
第二部分对中医诊治痹证的学术内涵从横向进行文献整理研究。痹证的概念,虽有广义痹证与狭义痹证之分,但当代学者在认识上逐渐形成痹证是指风寒湿邪侵袭经络、痹阻气血,引起以关节、肌肉疫痛、拘急为主症的一类疾病,即以狭义痹证为主。痹证的病因病机,其发生主要是由于正气不足,感受风、寒、湿、热之邪所致,内因是痹证发生的基础,外邪侵袭是痹证形成的因素。痹证日久不愈,气血运行不畅,容易瘀血痰浊阻痹经络,从而出现关节周围结节、关节肿大、屈伸不利,甚至肌肤瘀斑。痹证病久可见骨节肿大而肌肉萎缩。痹证的主要证候,有关节疼痛、肢体重着、肌肤麻木、屈伸不利、关节肿胀变形、皮肤顽厚变色等。
痹证的辨证论治,当代比较一致认同的是：首先应辨清风寒湿痹与热痹的不同,其次要注意病程久者可能出现有气血损伤及内舍脏腑的证候。针对不同的证型,治疗以不同的方药。祛风、散寒、除湿、清热以及舒经通络为治疗痹证的基本原则,后期还应适当配伍益气养血之剂。痹证迁延不愈,应考虑痰瘀阻于经络,变为痰瘀痹阻之证,治疗佐以除痰化瘀药物。
第三部分作为附篇,是笔者在攻读博士学位期间收集50万字关于中医诊治痹证的文献以及整理临床资料数据,通过计算机技术处理后保存,方便日后查询检索,这也是古人治学资料长编的现代延续。
痹证文献整理研究突出学术内涵,从痹证定义概念、病因病机、证候特点、辨证论治等方面,并以名老中医学术经验为重点内容加以贯穿贯,最后通过计算机技术处理50万字文献临床资料,成为查询检索系统,传承古人治学资料长编优良传统,这一研究过去未见有更为详尽者。这是本论文创新点之二。
结论
本论文的第一部份以朝代为主轴,对历代主要医家及论著的观点进行剖析,总结其成果,分析其医学思想,重点阐述自秦汉到明清二千多年来历代主要医家诊治痹证的学术主张。第二部分对中医诊治痹证的学术内涵从横向进行文献整理研究。当代学者认为痹证是指风寒湿邪侵袭经络、痹阻气血,引起以关节、肌肉痠痛、拘急为主症的一类疾病。第三部分中医诊治痹证资料查询系统,延续前人治学资料长编的传统,显突中医医史文献专业研究生特色。
中医诊治痹证的理法方药,饱含了从秦汉到明清二千多年的时间长河里历代医家经验,也饱含了民国至现代百余年来学者们的努力,内容丰富宏阔。论文在掌握资料的时间跨度、检索文献的标目细度上努力探讨,条分缕析,凝练相关学术观点,力图给学界关于痹证在概念、学术源流、历代医家代表观点、病因病机、诊断治疗等方面一个相对清晰的认识。冀望通过对中医古籍原著以及近现代名老中医学术经验整理与当代学者对痹证研究成果整理,能够对未来痹证证治的临床研究提供更多的参考依据及更充分的理论基础。
Purpose:
Bi-syndrome, a collective term for symptoms such as stiffness or deformity of joints, is a common clinical symptom and recognized as tingling, pain, numbness, swelling, burning pain associated with redness, difficulties in bending and stretching of skin, joints, muscles, tendons and bones, etc. It is equivalent to bones and joints diseases such as Osseous arthtritis, Rheumatoid arthritis, Ankylosing Spondylitis, Hyperostosis in western medical science. The disease, chronic in nature, occurred repeatedly or gradually, without clear causes, is highly related to connective tissue diseases and self-immunity system and has high rate of disability and mortality. Although responsive to Corticosteroids and immunosuppressive drugs in a certain degree, western medicine practitioners still have no specific treatment for this disease. Chinese medicine practitioners, however, have researched into Bi-syndrome for a long period of time and accumulated wealth of experience worth further exploring. The holistic approach used by chinese medicine practitioners, with "discern patterns and institute treatment" as the basis, has an advantage of combined effects in treating Bi-syndrome. Recent medical researches have also proved that use of chinese medicine is effective to treat Bi-syndrome and has received much public attention. As both historic and current medical practitioners are keen to find out a means to treat Bi-syndrome, a systematic review of the literatures by historic scholars and consolidation of their findings on Bi-syndrome has significant values to both academic research and clinical treatment.
In the past decade, scholars from different fields have separately researched and analyzed Bi-syndrome from four perspectives, namely literature review, related diseases in western medical science, etiology of the disease, and treatment methods. Regarding research into related diseases in western medical science, it covers Rheumatoid arthritis, rheumatic fever, Primary sciatica, Hyperostosis, etc. Diseases such as Thromboangiitis Obliterans, Polymyositis, Scleroderma, Brucellosis, Erythema nodosum, Induration red spots, Nodular vasculitis and Systemic lupus erythematosus, etc., which have symptoms similar to those of Bi-syndrome, are categorized as "pulse numbness", "muscle numbness", "virtual numbness" and "skin numbness" in chinese medical science for discussion. About etiology of the disease, scholars usually researched by four aspects, namely "exterior pathogenic invasion", "viscera disorder", "diseases caused by phlegm and blood stasis", "Pathogenic Qi", "co-existence of phlegm and blood stasis with internal organs disorder". The six approaches to treat Bi-syndrome are the "viscera", "Qi, blood and Yin Yang", "diseases associated with meridians", "phlegm and blood stasis", "cold and heat" and "by stage of the disease" approaches respectively.
Although there is significant development in respect of treatments for Bi-syndrome by chinese medicine practitioners based on the above findings, the focus is still on clinical research without much work done on literature review. Details reported so far were mainly those from some classic books such as "Nei Jing" and "Jin Gui". Therefore, there is a need for a systematic literature review of the origins and developments of Bi-syndrome found in the medical relics unearthed from the Han Mawangdui and the classic books such as "Nei Nan Shang Han Jin Gui" etc., chronologically from the Jin, Tang, Jin, Yuan to the Ming and Qing Dynasties. There is also a need to categorize the characteristics of different treatment methods adopted by various historic scholars with a view to providing current medical practitioners with insight into the clinical approaches to treat Bi-syndrome.
Research methodology:
Review the relevant historic and modern literatures with importance accorded to first hand information and attention to convergence of theoratic and academic view points, and apply information technology to facilitate collection, compilation, categorization, and analyses of the mass volume of information.
1. Review historic literatures on Bi-syndrome and counter check origins of modern literatures. This covers Qing Dynasty's "Gu Jin Tu Shu Ji Cheng Yi Bu Quan Lu" edited by Chen Menglei, "Ming Qing Ming Yi Quan Shu Da Cheng" published by the Chinese Traditional Medicine Publishing House, "Chinese Hundred Years Hundred Renowned TCM Practician's Clinical Collection" edited by Zhang Wenkang and published by the Chinese Traditional Medicine Publishing House. Collect from a number of databases (e. g. China Journal Full-text Database(CJFD)) relevant theses and journals on treating Bi-syndrome with chinese medicine published in the past decade. About 2175 theses were extracted of which 326 (15%) were on researches into principles and theories, 1051 (48.4%) on clinical studies,316 (14.5%) on successful clinical trials, 175 (8%) on treatment with special prescriptions,185 (8.5%) on experimental studies,69 (3.2%) on literature review, and 53 (2.4%) on others respectively.
2. Through chronological study of the origins and developments of the Bi-syndrome and categorization of the characteristics of different treatment methods adopted by various historic scholars, provide a comprehensive understanding of handling Bi-syndrome in chinese medical science. This dissertation will be divided into three parts:
Literature review on chinese medicine practitioners'understanding and experience in Bi-syndrome chronologically from the early Qin Dynasty to the past ten decades, with a view to knowing the derivation and evolution of Bi-syndrome.
Literature review on the theories of the treatment methods by categorizing the concepts, causes, keys of diagnosis, medication, clinical case studies and preventive measures with a view to better defining Bi-syndrome in Chinese medical science.
An Annex in the form of a database containing information related to Bi-syndrome collected through literature reviews and compilation of clinical data to facilitate future reference.
Results:
Through chronological study of the origins and developments of the Bi-syndrome and categorization of the characteristics of different treatment methods adopted by various historic scholars, provide a comprehensive understanding of handling Bi-syndrome in chinese medical science. It is found that the academic beliefs of historic scholars in treating Bi-syndrome can be broadly characterized as:
Treatment of Bi-syndrome by chinese medicine practitioners was originated from the era of "Nei Jin";
In the era of Wei, Jin, Sui and Tang, the understanding of Bi-syndrome was further enhanced in terms of theories and clinical studies. Bi-syndrome was considered to be an invasion of meridian by pathogenic factors (i. e. "wind", "cold", "dampness"), or phlegm and blood stasis, leading to tingling and spasm in joints and muscle. It was also considered to cover limbs, meridian, viscera related illnesses caused by Bi-syndrome.
Significant progress has been made in the era of Song, Jin and Yuan, where the theory proposed by Zhu Zhenheng-"Gout-Blood, heat and phlegm as factors" has long-lasting impact on the future methods to treat Bi-syndrome i. e. Bi-syndrome could be cured by improving the blood and Qi circulation with a view to minimizing blood stasis, and through thinning the phlegm to achieve detoxification.
The era of Ming and Qing where the theories and clinical studies of treating Bi-syndrome with chinese medicine have gained more grounds. That is, painful limbs and joints as the main symptom with "numbness in viscera, blood and Qi, and five orifices" etc., classified as internal medical illnesses. This approach, in certain extent, has consolidated the thoughts of various famous practitioners.
This is one of the distinct features of this dissertation as there is still no comprehensive categorization of TCM's understandings and beliefs on Bi-syndrome prevailing in these four periods with reference to historical
literatures.
A systematic presentation of the characteristics of TCM's clinical treatment for Bi-syndrome. Although there are generalized and localized beliefs of Bi-syndrome, academics nowadays generally consider the disease as an invasion of the meridian by pathogenic factors (i. e. "wind", "cold", "dampness"), and numbness caused by poor circulation of blood and Qi, leading to pain, tingling and apasm in joints and muscles i. e. the localized belief. In fact, Bi-syndrome is mainly caused by deficiency in Qi (i.e. the basis), with exterior pathogens related to "wind", "cold", "dampness" and'heat" as catalysts (i.e. factors). Prolonged Bi-syndrome without proper treatment will lead to poor circulation of blood and Qi, hence numbness of meridians by phlegm and blood stasis, resulting in hardening of areas surrounding the joints, swollen joints, difficulties in bending and stretching of joints, and ecchymosis on skin. Ones suffering from Bi-syndrome for a long period of time can be recognized by swollen joint with atrophy. Main symptoms of Bi-syndrome include painful joints, limbs tingling, numbness, difficulties in bending and stretching of skin, joints, muscles, tendons and bones, swollen and deformed joints, skin hyper trophy, etc.
At present, the agreed view to treat Bi-syndrome is first identify the differences between numbness caused by "wind", "cold" and "dampness" and those by "heat", then pay attention to possible symptoms like vacuity of Qi and blood as well as visceral illnesses for chronic patients. Use different medications for different types of the syndrome. Use eliminating the "wind", "cold", "dampness", clearing away "heat", and clearing meridian-Qi and regulating Qi and blood) as the basis of treatment, supplemented with drugs that would replenish Qi and nourish blood at a later stage where appropriate. In case of prolonged disturbance by Bi-syndrome, one should consider the case as phlegm and blood stasis instead of numbness of meridians caused by phlegm and blood stasis, and supplemented with drugs that would activate blood and resolve phlegm as the treatment method.
The third part, an Annex to this dissertation, is a database of Bi-syndrome related information collected by the author through review of literatures and compilation of clinical data during his study of the doctorate programme to facilitate future reference. This is also a method of historic scholars to pass on their knowledge and experience.
This is the second distinct feature of this dissertation as there is also no comprehensive analyses of the beliefs, causes, characteristics of symptoms, and various treatments for Bi-syndrome with reference to the academic knowledge of some famous chinese medicine practitioners, and use of information technology to establish a database containing relevant information to facilitate future reference.
Conclusion:
The first part of this dissertation analyzes and summarizes the various understandings and findings of historic scholars on Bi-syndrome in the past two thousand years, chronologically from early Qin Han to Ming Qing. The second part is a categorization of the concepts, causes, symptoms, medication, clinical case studies and preventive measures in relation to Bi-syndrome. Current academics consider Bi-syndrome as a kind of illness in which "wind", "cold" and "dampness" invade the meridians leading to poor circulation of blood and Qi hence resulting in tingling, pain and numbness in joints and muscle. The part is a database of Bi-syndrome related information to facilitate future reference, a practice of historic scholars to passing on their knowledge and experience and a characteristic of research study through review of chinese medicine literatures.
Treatment for Bi-syndorme using chinese medicine covers the experience of scholars of the past two thousand years (i.e. from the Qin Han to Ming Qing Dynasties) and efforts of academics of the past ten decades. This dissertation has tried to provide the academic sector with a clear understanding of Bi-syndrome both in breath and depth, covering concepts, origins, views of historic scholars, causes of the syndrome, treatment, etc. It aims to provide sophisticated and concrete principles and theories as well as clinical treatments for Bi-syndrome for future reference through literature review and categorization of the findings and experience of both academics and renowed chinese medicine practitioners.
引文
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