1949年以前岭南医家医案的收集整理及姜桂附应用状况的相关研究
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摘要
一、研究目的及方法：
本课题针对岭南医家医案资料汇编整理研究明显不足的现状，综合运用文献研究、历史研究、比较研究、文献计量、中医学术研究等方法，通过全面调查广州、北京、上海、香港等地各大图书馆中历代岭南中医文献资料，对1949年以前医案进行全面清点收集整理，初步呈现各朝代岭南医家医案概况；从医史文献研究及临床研究的角度，解读其中主要的或具有大样本条件的医案，发掘其中的共性和个性，如对岭南医家医案中姜桂附应用状况的探讨分析，为下一步更深入的岭南医案疾病谱、学术思想探讨、处方用药特点等规律性研究打下基础。
二、研究内容：
研究主要分三部分：(一)全国中医医案研究及岭南中医医案研究现状；(二)岭南医家医案资料的收集及整理及岭南医家医案概貌；(三)岭南医家医案中姜桂附应用状况的探讨分析。
三、研究结果：
(一)形成历代岭南医家医案汇编数据库
经全面调查研究，发掘出现存历代医家医案医著已见书目共计50部，另已知未见的医案医著书目20部，存案杂志期刊9种，存案地方志16府县志。列出已见医案书目一览表，未见医案书目一览表。经反复比较甄别，从中筛选出现存岭南医家医案相关医著42部、杂志9刊、地方志16种，医家173位，辑录其相对完整、可资参考的历代岭南医家医案共1671则。
(二)呈现历代岭南医家医案概貌
在上述收集医案资料的基础上，列出已收录各朝代医家医案分布表；抽取有十则以上医案的医家医著名录表，以便今后可以从中审察其诊疗特长、诊治病种方向、用药特点及规律，并作为分析研究的大样本平台，展开相关研究；列出各医案医家籍贯分布表，得出某些医家较集中地区以便进一步探讨其相关因素；列出各医家医案病种分布表，初步显示其医学水平，并为医案汇编的分科排序、疾病谱的疏理打下基础。
以朝代和医家作线索，分析比较各时期医案特点及主要医家简介及部分医案举例，借此呈现岭南医家医案现存概貌。
认为晋唐时期，岭南医家医案发展尚处萌芽阶段。没有出现医案专著，现存唯占籍者葛洪书著中多则后人辑录他书之案，故晋代尚未见有岭南本地医家之案。唐代岭南医家医著中，目前尚未收录到一则医案，可见岭南医家医案在晋唐时期相当稀少。
宋元时期，宋代岭南医家医著有所增多，然未见有医案者。仅于笔记医事别录及地方志中收录医案三则。另有宋·李璆、张致远辑，元·释继洪纂修的《岭南卫生方》中李璆所记3则医案，可属宋代之案，专论岭南特有地方病瘴疟的治疗，价值菲然。到元代首次出现岭南籍贯医家医案4则。释继洪医案13则，其对岭南地方病瘴疟的诊治及对姜桂附等温阳药的应用很有参考价值。
明代，岭南医家医著较前代为多，其特点是本地医家仍以录自地方志者多，内容欠精到；而收集到的明·张继科《三合集》一书，相当于医案专著，论及岭南地区病症，内容相当精粹。另《名医类案》中有俞子容案四则，案短而精。
清代，岭南医家医案发展迅速，已步入成熟期。本地医家医案的数量和质量均有很大提高，目前计收录医家医著31书35人515则，地方志13志24人60则，共计清代收录医案资料为31书13志59人575则。其中岭南本地医家49人，占籍者10人。清代出现了擅治不同疾病，具有不同用药特点的医家流派苗头。如治疗鼠疫、白喉、霍乱等传染病的罗汝兰、黎佩兰、林庆铨、劳守慎、梁达樵等案；治疗岭南地方病瘴疟症的陈三农、章楠等案；更有陈伯坛、易巨荪、黎庇留等伤寒名家之案；有徐延祚、蒋希曾等占籍者对岭南与外省疾病诊治异同比较之案；另有潘兰坪为代表的岭南温病学家之案及经验方药的创立。
民国时期，医家医著最多最集中，同时医案也是最多的，是岭南医家医案发展的鼎盛时期。究其因，一是岭南医学发展到一定阶段的必然结果，是岭南医学兴盛的反映；更因广东地区各类期刊杂志的开办，形成了很好的流通途径，让民国时期的医家医案得以及时发表；也是因为广东地区的社会进步，文化发展，各地区图书校勘、印刷出版业的普及所致。这一时期有四部相关的医案汇编著作可作参考。此外，共收录医家医著4部，期刊杂志9刊，地方志3种，医家103人，医案999则。从民国期间医家医案用药特点中反映，有伤寒经方派如陈应期、陈渔州等，人数较多；有用药偏清凉者如蔡东荣、何奎垣等；有擅于中西汇通的卢觉愚等，有擅用针灸的陈秩平等。其医案表述内容、形式均较前代丰富，其水平较前代为高。
(三)历代岭南医家医案中姜桂附应用状况的统计分析
首先分析影响岭南医家处方用药的背景因素，认为自《内经》而下，历代各学派名医对岭南医家均有影响，其中对岭南温阳法运用上具有较明显影响的相关因素是仲景理论及经方应用的普及。其次提取岭南医家关于岭南地区应用姜桂附的理论阐述，总结出岭南医家关于岭南气候特点的再审视、岭南饮食习惯对人体体质的影响、对太极两仪图理论及天热井水反寒理论的论述、对上元年理论的提出和运用宜忌等观点，认为岭南地区应用姜桂附有其理论依据及临证实践经验，有某些适用时期，只要掌握好辨证论治的原则，应用姜桂附可以治疗不少危急重证。通过对医案的文献计量统计分析得出以下数据及信息。
晋唐宋元时期：收录医案总数25则，合用或单用姜桂附的医案共8则，三药未用的医案17则。其中姜附合用3则。单用姜2则，单用附3则。特点：姜桂附三药合用者、桂枝与其他二药合用者无，姜附合用稍多。关于附子的使用，似乎在晋唐宋元时期对附子、乌头、天雄的区分比较讲究，而后世医家案中明确强调使用者不多。应用医家：李璆、释继洪及杨吉老。治疗病种：瘴疠、风痰厥、虚冷吐泻等。常用方剂：三建汤等4方。特例：长期服用姜附保长寿；生姜治喉痈。
明代：收录医案总数72则，合用或单用姜桂附的医案共7则，三药未用的医案65则。其中姜附合用1则，姜桂合用1则。单用姜3则(生姜)，单用附1则，单用桂1则。特点：姜桂附三药合用者，或两两配伍者较少。出现吴茱萸的配伍。运用医家：俞子容。治疗病种：瘴疠等3种。常用方剂：生姜附子汤、吴茱萸汤。特例：散用归附治头痛。
清代：收录医案总数575则，合用或单用姜桂附的医案共230则，三药未用的医案345则。其中姜桂附三者合用15则，姜附合用71则，姜桂合用36则，附桂合用23则。单用姜46则；单用附10则，单用桂29则。其中含生附17则，运用姜的形式有生姜50则，炮姜8则，干姜49则。特点：清代医家应用姜桂附的人数比例最大，普遍都有一二则应用姜桂附之验案。运用原则基本还是“有是证，用是药”的范围。其中姜附、姜桂、附桂的两两配伍组合增多，尤其是桂的使用增多，治疗病种也大幅上升。运用医家：黎庇留等12位。治疗病种：肿胀等38种。常用方剂：甘草附子汤等14方。
民国时期：汇总民国时期收录医案总数999则，合用或单用姜桂附的医案共342则，三药未用的医案657则。其中姜桂附三者合用60则，姜附合用94则，姜桂合用35则，附桂合用9则。单用姜93则，单用附20则，单用桂31则。特点：姜桂附三者合用明显增多，单用生姜之案增多，用成方少，散方组合为多。运用吴茱萸配伍加强温阳作用的案例明显增多。民国时期医案多集中在杂志期刊中是一大特点，有的医家特别擅用姜，不用桂附，如江济时；有的医家用附子多于姜，不用桂，如潘掌纶；有的用生姜汁入药。其中单用姜或桂之案，体现的不一定是温阳法，多取发散之意。运用医家：卢觉愚、陈应期等26位。治疗病种：湿性脚气、少阴寒化等39种。常用方剂：附子粳米汤等28方。特例：附子理中汤热药冷服；重剂治痹；炮天雄治糖尿病等。
汇总历代岭南医案中应用姜桂附状况：目前收录历代岭南医家医案共1671则，合用或单用姜桂附的医案共587则，三药未用的医案1085则。其中姜桂附三者合用75则，姜附合用169则，姜桂合用72则，附桂合用32则。单用姜144则，单用桂6l则，单用附子34则。历代主要应用医家有41人，治疗主要病种除去重复者约为42种，运用主要经方为33方。运用姜桂附方药的医案约为不用的三分之一，姜附合用比例远远大于姜桂与附桂的配伍。若除去单用姜之案则约为四分之一，但若除去记录简单之地方志案，则应用比例将会提高。目前统计数据仍较粗略，只能展现一些客观状况，而规律性的结论，有待下一步的研究。
主要医家医案举例分析：清末明初医家陈应期是历代岭南医家中个人医案最多，运用姜桂附最有经验的一位。通过考察其运用姜桂附的经验，能基本反映出岭南医家坚持辨证论治原则，在临床上灵活运用经方，运用温热药的特点。
陈应期226案中运用姜桂附的共140则，三药未用的为86则。用姜桂附者为不用者之一倍，其中姜桂附三药合用的是32则，姜附合用的是77则，姜桂合用的3则，桂附合用的1则，单用姜的14则，单用桂的9则，单用附子的4则，前医或病者误用、过用姜桂附者13则。
陈氏医案具有比较规范、重复性大的特点，其使用姜桂附多体现在对经方的运用上。如四逆加桂汤等13个主方。其中以白通汤使用最多，四逆加桂汤次之，其他随后。陈应期运用各经方的原则基本与仲景原意相近。运用通脉四逆汤的数则医案均强调以“脉微细，但欲寐”为用药标准；四逆加桂汤之案多有发呆、肢体僵直、项强、铁板症等，重在通阳；白通汤不仅用于太阳入少阴症，还用于厥阴寒化症、或各类合病。阳虚寒重，多加吴萸。并列举十数则运用姜桂附较有参考价值的特殊验案及误用、过用姜桂附出现狂、花颠、亡津、僵卧不起、气喘声嘶、肢冷抽筋、劫阴亡阳等危症案，总结出运用犀角地黄汤、清燥救肺汤、黄连阿胶汤、参苓芍草加阿胶等方药化解其燥化亡津之象的经验。甚至有认为服用姜桂附方药后病情从少阴寒化转为热化，出现适度的燥化伤津之象是可接受的病程反映，不为误治，因为少阴寒化相对于热化是更严重的危证，热化好治，寒化难治，救命为先，再行善后。
结论：收集整理出的历代岭南医家医案数量不少，有很大的研究价值，从中可了解到多方面的信息。姜桂附的应用状况探讨，反映了历代岭南医家对仲景经方温阳法在岭南地区应用的理论发展及临床实践过程。这只是医案研究中一个角度的尝试，今后或可深入探求其方证对应关系，用量比例宜忌，疾病谱以及同病异治，异病同治等方面的内容，取得经验，再扩大到历代医家用药特点及学术思想、学术渊源的分析研究中。
1 Objective and methods
An over-all investigation of Lingnan (in the southern region of five mountains) traditional Chinese medicinal (TCM) literature before the year of 1949 was carried out in libraries located in Guangzhou, Beijing, Shanghai and Hong Kong. Methods for literature study, history study, comparison study, statistical analysis and traditional Chinese medicinal academic study were used comprehensively to study the medical records recorded by Lingnan physicians before 1949, thus to present the general situation of Lingnan physicians' medical records in different dynasties. The generality and individuality of main medical records or large-sample medical records were explored by the methods for medicinal history and literature study and clinical study, for example, the clinical application of Rhizoma Zingiberis Recens, Ramulus Cinnamomi and Radix Aconiti Lateralis Preparata in the records of different dynasties, thus to lay a foundation for the further research of disease spectrum, academic thoughts, and prescriptions and medication.
2 Main content of the study
This study consists of four parts: (1) Research situation of traditional Chinese medical records in China and those in Lingnan; (2) Collection and arrangement of Lingnan physicians' medical records; (3) General situation of Lingnan physicians' medical records; (4) Analysis of clinical application of Rhizoma Zingiberis Recens, Ramulus Cinnamomiand Radix Aconiti Lateralis Preparata in Ling-nan physicians' medical records.
3 Results
(1) the establishment of database of Lingnan physicians' medical records in different dynasties
The results of over-all investigation showed that 50 bibliographies of medical records in different dynasties were found present, 20 were found disappeared, 9 kinds of magazines reported medical records, 16 kinds of local chronicles kept medical records。 After listing the bibliographies present and those disappeared, we screened 42 bibliographies, 9 kinds of magazines, 16 kinds of local chronicles which kept Lingnan physicians' medical records, and 173 Lingnan physicians who were contributed to medical records. We edited 1671 Lingnan physicians' medical records in different dynasties that are relatively completed and can be referred.
(2) Presenting the general situation of Lingnan physicians' medical records in different dynasties
The distribution of Lingnan physicians' medical records in different dynasties was described: bibliographies and physicians that had over 10 medical records were listed thus to study the clinical experience, diseases spectrum, medication and for the associated research of large-sample medical records: the native places of the physicians were listed for the study of related factors: Diseases spectrum in the records were listed to show the medical level of the physicians and for the collection of the records in the order of branches.
Based on the dynasty clue and physicians clue, the characteristics of medical records were compared, as well as the introduction of main physicians and medical records examples, thus to presenting the general situation of present Lingnan physicians' medical records.
Jing and Tang Dynasties: It is the germination of Lingnan physicians' medical records. No biography of medical records was found in Jing Dynasty, only the present biographyof Ge Hong who had been in Lingnan extracted Lingnan physicians' medical records. Also no medicinal record was found in Lingnan physicians' biography of Tang Dynasty.
Song and Yuan Dynasties: Lingnan physicians' biographies of Song Dynasty increased, but no medicinal record was found. Only 3 records were kept in notebook and local chronicles. Valuable records appeared in Yuan Dynasty, native Lingnan physicians recorded 4 records. The 15 medical records of Shi Jihong contributed to the diagnosis and treatment of malignant malaria and the clinical application of Rhizoma Zingiberis Recens, Ramulus Cinnamomi and Radix Aconiti Lateralis Preparata.
Ming Dynasty: Lingnan physicians' biography increased, with the characteristics of increase of medical records of native physicians from local chronicles and less accuracy of the contents. Meanwhile, San He Jin written by Zhang Jike, a biography of medical records, discussed diseases in Lingnan and showed a high academic level; Ming Yi Lei An kept 4 records of Yu Zirong, short but accurate.
Qing Dynasty: Lingnan physicians' medical records went to the adult period. The quantity and quality of native Lingnan physicians' medical records much increased: 31 Lingnan physicians' biographies kept 35 Lingnan physicians and 515 medical records, 13 local chronicles kept 24 Lingnan physicians and 60 medical records, and in toal 31 Lingnan physicians' biographies and 13 local chronicles kept 59 Lingnan physicians and 575 medical records. Among them, 49 were native in Lingnan and 10 had been in Lingnan. Some physicians were specialized in treating some diseases: Luo Rulan, Li Peilan, Lin Qingquan, Lao Shoushen and Liang Daqiao were specialized in plague, diphtheria and cholera; Chen Botan, Yi Jusun and Li Piliu were specialized in febrile diseases; Xu Yanzuo and Jian Xizeng who had been in Lingnan were specialized in comparing the Lingnan diseases with diseases occurring in other provinces; Pan Lanping, the preventative of physicians for Lingnan warm disease, showed experienced prescription and medication for warm disease.
The republic period: The republic period showed the largest amount of Lingnan physicians, biographies and medical records, which is great prosperity period for Lingnan physicians' medical records. This is the result of the development of Lingnan medicine. Moreover, the establishment of different kinds of periodicals in Guangdong province promoted the communication of Lingnan medicine, which contributed to the social advancement and cultural progress in Guangdong province. There were four biographies of medical records for reference during this period. Moreover, there were 4 biographies of Lingnan physicians' medical records, 9 kinds of periodicals, 3 local chronicles, 103 physicians and 999 medical records. The medication characteristics of in Lingnan physicians' medical records of the republic period were as follows: Chen Yingqi and Chen Yuzhou were specialized in application of prescriptions from Shanghan Lun; Cai Dongrong and He Kuiyuan were specialized in application of medicinal herbs with the clearing and cooling actions; Lu jueyu was good at applying western and traditional Chinese medicine; Chen Zhiping was good at acupuncture therapy. The contents and the styles of medical records in this period were various and the academic levels were higher than the previous periods.
(3) Analysis of clinical application of Rhizoma Zingiberis Recens, RamulusCinnamomiand Radix Aconiti Lateralis Preparata in different dynasties
Based on the analysis of 1671 medical records, clinical application of Rhizoma Zingiberis Recens (RZR), Ramulus Cinnamomi(RC) and Radix Aconiti Lateralis Preparata (RALP) was investigated in Lingnan physicians' medical records of different periods.
The evidence for Lingnan physicians applying RZR, RC and RALP in Lingnan region was firstly extracted. And then the characteristics of Lingnan climates, the influence of Lingnan residents'dietary on their constitution and some disputed TCM theories were investigated and discussed. It is indicated that there exist theoretical evidence and clinical experience for the application of RZR, RC and RALP in Lingnan regions. Under certain proper condition and based on syndrome differentiation and treatment, these three drugs had good effect for the treatment of acute and critical disease. The following supplied some data for the application of RZR, RC and RALP in Lingnan regions.
Jing, Tang, Song and Yuan Dynasties: There collected 25 medical records, in which there were 8 involving application of RZR, RC and RALP in combination or alone, and there were 17 not involving the application. In the 8 medical records, there were 3 involving the combined application of RZR and RC, 2 involving application of RZR alone, 3 involving application of RALP alone o It is indicated that there was no application of the three drugs together, or RC with other drug together. There were several medical records involving the combined application of RZR and RALP. For the use of RALP, there was differentiated use of Chuanwu, Wutou and Tianxiong in Jing, Tang, Song and Yuan Dynasties, but less mentioned by the physicians in the later period. The physicians used the above three drugs were Shi Jihong and Yang Jilao, they used them for miasma, wind-phlegm syncope and deficiency-cold vomiting and diarrhea. The common-used prescriptions were 4 including Sanjian Decoction. It is said that long-term use of RZR and RALP prolonged life span, and RZR cured throat abscess.
Ming Dynasty: There collected 72 medical records, in which there were 7 involving application of RZR, RC and RALP in combination or alone, and there were 65 not involving the application. In the 7 medical records, there were 1 involving the combined application of RZR and RALP, 1 involving, the combined application of RZR and RC, 3 involving application of RZR alone, 1 involving application of RC alone o It is indicated that there were few records recorded the combined application of the three or two. The combination with Fructus Evodiae occurred. The physician used the above three drugs was Yu Zirong, he used them for 3 kinds of diseases including miasma. The common-used prescriptions were Shengjiang Fuzi Decoction and Wuzhuyu Decoction. It is said that use of RALP and Radix Angelicae Sinensis in granule cured headache.
Qing Dynasty: There collected 575 medical records, in which there were 230 involving application of RZR, RC and RALP in combination or alone, and there were 345 not involving the application. In the 230 medical records, there were 15 involving the combined use of three, 71 1 involving the combined application of RZR and RALP, 36 involving the combined application of RZR and RC, 23 involving the combined application of RALP and RC, 46 involving application of RZR alone, 10 involving application of RALP alone and 29 involving application of RC alone o Raw RALP was used un-prepared in 17 medical records. Fresh common ginger rhizome was used in 50 records, prepared ginger rhizome in 8 and dry ginger rhizome in 49. It is indicated that there were many physicians used the three drugs in clinics and they usually had one or two effective cases. The applied principle is using the proper drug for the certain syndrome. The application of drug pairs of RZR & RC, RZR & RALP, RALP & TC increased, in particular the use of RC. The number of indicative diseases also increased. The physician used the above three drugs were 12 including Li Piliu, they used the drugs for 38 kinds of diseases including edema. The common-used prescriptions were 12 including Gancao Fuzi Decoction.
The republic period: There collected 999 medical records, in which there were 342 involving application of RZR, RC and RALP in combination or alone, and there were 657 not involving the application. In the 342 medical records, there were 60 involving the combined use of three, 94 involving the combined application of RZR and RALP, 35 involving the combined application of RZR and RC, 9 involving the combined application of RALP and RC, 93 involving application of RZR alone, 20 involving application of RALP alone and 31 involving application of RC alone. It is indicated that there were many physicians used the three drugs in clinics, and the flesh ginger rhizome was used in more medical records. Meanwhile, the set prescription was less used while the self-prepared prescriptions were used frequently. The combination with Fructus Evodiae was used in more medical records to increase the yang-warrning action. More medical records were issued in the periodicals: some physicians were good at using RZR while not using RC & RALP, for example Jiang Jishi; some used RALP More often than RZR, for example Pan Zhanglun; some used ginger juice. Physicians using RZR or RC alone was not for warming yang, mostly for dispersing evils. The physician used the above three drugs were 26 including Lu Jueyu and Chen Yingqi, they used the drugs for 39 kinds of diseases including damp-type beriberi and Shaoyin cold transformation syndrome. The common-used prescriptions were 28 including Fuzi Jingmi Decoction. It is said that Fuzi Lizhong Decoction with the heat property should be taken in cold decoction, large-dose prescription cured obstruction syndrome and prepared Tianxiong cured diabetes.
Summary: There collected 1671 Lingnan physicians' medical records, in which there were 587 involving application of RZR, RC and RALP in combination or alone, and there were 1085 not involving the application. In the 587 medical records, there were 75 involving the combined use of three, 169 involving the combined application of RZR and RALP, 72 involving the combined application of RZR and RC, 32 involving the combined application of RALP and RC, 144 involving application of RZR alone, 61 involving application of RC alone and 34 involving application of RALP alone~ There collected 41 physicians, 42 entitys, 33 classical prescriptions. It is indicated that the records involving application of the three were one third of those not involving, the percentage of combined use of RZR & RALP was higher than that of combined use of RALP & RC.
Analysis of some examples from main physicians: Chen Yingqi, a Lingnan physician lived between the end of Ming dynasty and the beginning of Qing Dynasty, left the largest medical records in different periods, and was good at application of RZR, RC and RALP. His experience embodied the principle of Lingnan physicians' medication, and their application of classic prescription and warm-heat drugs.
IN Chen's 226 medical records, there were 140 involving application of RZR, RC and RALP in combination or alone, and there were 86 not involving the application which was one third of the former. In the 140 medical records, there were 32 involving the combined use of three, 77 involving the combined application of RZR and RALP, 3 involving the combined application of RZR and RC, 1 involving the combined application of RALP and RC, 14 involving application of RZR alone, 9 involving application of RC alone and 4 involving application of RALP alone, 11 involving the mis-application or overuse of the three drugs by the previous physicians。
Chen's medical records showed the characteristics of standardization, repeatability, he used the combination usually in the classic prescription, for example in 13 prescriptions with the leading of Baitong Decoction, Sini with Guizhi added Decoction. Chen Yingqi kept the same basic medication principle as Zhang Zhongjing. For the use of Tongmai Sini Decoction, the indications should be feeble pulse and with the desire of sleeping, and the patients usually had the symptoms of dumbness, stiff body, stiff neck; Baitong Decoction not only was indicated for Taiyang disease invading Shaoyin Meridian, also for Junyin cold transformation syndrome and meridians concurrent diseases. The critical diseases induced by misapplication and overuse of RZR, RC and RALP were also discussed, usually used by Xijiao Dihuang Decoction, Qingzao Jiufei Decotion, Huanglian Ejiao Decoction and Shen Ling Shao Cao and Ejiao Decoction. He also brought forward that Shaoyin cold transformation syndrome turning into heat transformation syndrome after treatment with the three drugs was a good sign for prognosis. For heat transformation syndrome was easy to be cured and cold transformation syndrome was difficult to be treated.
Conclusion: Although the amount of Lingnan physicians' medical records in different periods was not big enouth, the records are valuable for research and can give clinical evidence and some experience. The analysis of clinical application of RZR, RC and RALP is just a beginning, the future further research will supply more evidence for prescription according to the syndrome, dosage of medication, indications and contraindications, disease spectrum and treating the same disease with different therapies in the Lingnan medical records, as well as the medication characteristics, academic thought and academic origins of Lingnan physicians in the different period.
本课题针对岭南医家医案资料汇编整理研究明显不足的现状，综合运用文献研究、历史研究、比较研究、文献计量、中医学术研究等方法，通过全面调查广州、北京、上海、香港等地各大图书馆中历代岭南中医文献资料，对1949年以前医案进行全面清点收集整理，初步呈现各朝代岭南医家医案概况；从医史文献研究及临床研究的角度，解读其中主要的或具有大样本条件的医案，发掘其中的共性和个性，如对岭南医家医案中姜桂附应用状况的探讨分析，为下一步更深入的岭南医案疾病谱、学术思想探讨、处方用药特点等规律性研究打下基础。
二、研究内容：
研究主要分三部分：(一)全国中医医案研究及岭南中医医案研究现状；(二)岭南医家医案资料的收集及整理及岭南医家医案概貌；(三)岭南医家医案中姜桂附应用状况的探讨分析。
三、研究结果：
(一)形成历代岭南医家医案汇编数据库
经全面调查研究，发掘出现存历代医家医案医著已见书目共计50部，另已知未见的医案医著书目20部，存案杂志期刊9种，存案地方志16府县志。列出已见医案书目一览表，未见医案书目一览表。经反复比较甄别，从中筛选出现存岭南医家医案相关医著42部、杂志9刊、地方志16种，医家173位，辑录其相对完整、可资参考的历代岭南医家医案共1671则。
(二)呈现历代岭南医家医案概貌
在上述收集医案资料的基础上，列出已收录各朝代医家医案分布表；抽取有十则以上医案的医家医著名录表，以便今后可以从中审察其诊疗特长、诊治病种方向、用药特点及规律，并作为分析研究的大样本平台，展开相关研究；列出各医案医家籍贯分布表，得出某些医家较集中地区以便进一步探讨其相关因素；列出各医家医案病种分布表，初步显示其医学水平，并为医案汇编的分科排序、疾病谱的疏理打下基础。
以朝代和医家作线索，分析比较各时期医案特点及主要医家简介及部分医案举例，借此呈现岭南医家医案现存概貌。
认为晋唐时期，岭南医家医案发展尚处萌芽阶段。没有出现医案专著，现存唯占籍者葛洪书著中多则后人辑录他书之案，故晋代尚未见有岭南本地医家之案。唐代岭南医家医著中，目前尚未收录到一则医案，可见岭南医家医案在晋唐时期相当稀少。
宋元时期，宋代岭南医家医著有所增多，然未见有医案者。仅于笔记医事别录及地方志中收录医案三则。另有宋·李璆、张致远辑，元·释继洪纂修的《岭南卫生方》中李璆所记3则医案，可属宋代之案，专论岭南特有地方病瘴疟的治疗，价值菲然。到元代首次出现岭南籍贯医家医案4则。释继洪医案13则，其对岭南地方病瘴疟的诊治及对姜桂附等温阳药的应用很有参考价值。
明代，岭南医家医著较前代为多，其特点是本地医家仍以录自地方志者多，内容欠精到；而收集到的明·张继科《三合集》一书，相当于医案专著，论及岭南地区病症，内容相当精粹。另《名医类案》中有俞子容案四则，案短而精。
清代，岭南医家医案发展迅速，已步入成熟期。本地医家医案的数量和质量均有很大提高，目前计收录医家医著31书35人515则，地方志13志24人60则，共计清代收录医案资料为31书13志59人575则。其中岭南本地医家49人，占籍者10人。清代出现了擅治不同疾病，具有不同用药特点的医家流派苗头。如治疗鼠疫、白喉、霍乱等传染病的罗汝兰、黎佩兰、林庆铨、劳守慎、梁达樵等案；治疗岭南地方病瘴疟症的陈三农、章楠等案；更有陈伯坛、易巨荪、黎庇留等伤寒名家之案；有徐延祚、蒋希曾等占籍者对岭南与外省疾病诊治异同比较之案；另有潘兰坪为代表的岭南温病学家之案及经验方药的创立。
民国时期，医家医著最多最集中，同时医案也是最多的，是岭南医家医案发展的鼎盛时期。究其因，一是岭南医学发展到一定阶段的必然结果，是岭南医学兴盛的反映；更因广东地区各类期刊杂志的开办，形成了很好的流通途径，让民国时期的医家医案得以及时发表；也是因为广东地区的社会进步，文化发展，各地区图书校勘、印刷出版业的普及所致。这一时期有四部相关的医案汇编著作可作参考。此外，共收录医家医著4部，期刊杂志9刊，地方志3种，医家103人，医案999则。从民国期间医家医案用药特点中反映，有伤寒经方派如陈应期、陈渔州等，人数较多；有用药偏清凉者如蔡东荣、何奎垣等；有擅于中西汇通的卢觉愚等，有擅用针灸的陈秩平等。其医案表述内容、形式均较前代丰富，其水平较前代为高。
(三)历代岭南医家医案中姜桂附应用状况的统计分析
首先分析影响岭南医家处方用药的背景因素，认为自《内经》而下，历代各学派名医对岭南医家均有影响，其中对岭南温阳法运用上具有较明显影响的相关因素是仲景理论及经方应用的普及。其次提取岭南医家关于岭南地区应用姜桂附的理论阐述，总结出岭南医家关于岭南气候特点的再审视、岭南饮食习惯对人体体质的影响、对太极两仪图理论及天热井水反寒理论的论述、对上元年理论的提出和运用宜忌等观点，认为岭南地区应用姜桂附有其理论依据及临证实践经验，有某些适用时期，只要掌握好辨证论治的原则，应用姜桂附可以治疗不少危急重证。通过对医案的文献计量统计分析得出以下数据及信息。
晋唐宋元时期：收录医案总数25则，合用或单用姜桂附的医案共8则，三药未用的医案17则。其中姜附合用3则。单用姜2则，单用附3则。特点：姜桂附三药合用者、桂枝与其他二药合用者无，姜附合用稍多。关于附子的使用，似乎在晋唐宋元时期对附子、乌头、天雄的区分比较讲究，而后世医家案中明确强调使用者不多。应用医家：李璆、释继洪及杨吉老。治疗病种：瘴疠、风痰厥、虚冷吐泻等。常用方剂：三建汤等4方。特例：长期服用姜附保长寿；生姜治喉痈。
明代：收录医案总数72则，合用或单用姜桂附的医案共7则，三药未用的医案65则。其中姜附合用1则，姜桂合用1则。单用姜3则(生姜)，单用附1则，单用桂1则。特点：姜桂附三药合用者，或两两配伍者较少。出现吴茱萸的配伍。运用医家：俞子容。治疗病种：瘴疠等3种。常用方剂：生姜附子汤、吴茱萸汤。特例：散用归附治头痛。
清代：收录医案总数575则，合用或单用姜桂附的医案共230则，三药未用的医案345则。其中姜桂附三者合用15则，姜附合用71则，姜桂合用36则，附桂合用23则。单用姜46则；单用附10则，单用桂29则。其中含生附17则，运用姜的形式有生姜50则，炮姜8则，干姜49则。特点：清代医家应用姜桂附的人数比例最大，普遍都有一二则应用姜桂附之验案。运用原则基本还是“有是证，用是药”的范围。其中姜附、姜桂、附桂的两两配伍组合增多，尤其是桂的使用增多，治疗病种也大幅上升。运用医家：黎庇留等12位。治疗病种：肿胀等38种。常用方剂：甘草附子汤等14方。
民国时期：汇总民国时期收录医案总数999则，合用或单用姜桂附的医案共342则，三药未用的医案657则。其中姜桂附三者合用60则，姜附合用94则，姜桂合用35则，附桂合用9则。单用姜93则，单用附20则，单用桂31则。特点：姜桂附三者合用明显增多，单用生姜之案增多，用成方少，散方组合为多。运用吴茱萸配伍加强温阳作用的案例明显增多。民国时期医案多集中在杂志期刊中是一大特点，有的医家特别擅用姜，不用桂附，如江济时；有的医家用附子多于姜，不用桂，如潘掌纶；有的用生姜汁入药。其中单用姜或桂之案，体现的不一定是温阳法，多取发散之意。运用医家：卢觉愚、陈应期等26位。治疗病种：湿性脚气、少阴寒化等39种。常用方剂：附子粳米汤等28方。特例：附子理中汤热药冷服；重剂治痹；炮天雄治糖尿病等。
汇总历代岭南医案中应用姜桂附状况：目前收录历代岭南医家医案共1671则，合用或单用姜桂附的医案共587则，三药未用的医案1085则。其中姜桂附三者合用75则，姜附合用169则，姜桂合用72则，附桂合用32则。单用姜144则，单用桂6l则，单用附子34则。历代主要应用医家有41人，治疗主要病种除去重复者约为42种，运用主要经方为33方。运用姜桂附方药的医案约为不用的三分之一，姜附合用比例远远大于姜桂与附桂的配伍。若除去单用姜之案则约为四分之一，但若除去记录简单之地方志案，则应用比例将会提高。目前统计数据仍较粗略，只能展现一些客观状况，而规律性的结论，有待下一步的研究。
主要医家医案举例分析：清末明初医家陈应期是历代岭南医家中个人医案最多，运用姜桂附最有经验的一位。通过考察其运用姜桂附的经验，能基本反映出岭南医家坚持辨证论治原则，在临床上灵活运用经方，运用温热药的特点。
陈应期226案中运用姜桂附的共140则，三药未用的为86则。用姜桂附者为不用者之一倍，其中姜桂附三药合用的是32则，姜附合用的是77则，姜桂合用的3则，桂附合用的1则，单用姜的14则，单用桂的9则，单用附子的4则，前医或病者误用、过用姜桂附者13则。
陈氏医案具有比较规范、重复性大的特点，其使用姜桂附多体现在对经方的运用上。如四逆加桂汤等13个主方。其中以白通汤使用最多，四逆加桂汤次之，其他随后。陈应期运用各经方的原则基本与仲景原意相近。运用通脉四逆汤的数则医案均强调以“脉微细，但欲寐”为用药标准；四逆加桂汤之案多有发呆、肢体僵直、项强、铁板症等，重在通阳；白通汤不仅用于太阳入少阴症，还用于厥阴寒化症、或各类合病。阳虚寒重，多加吴萸。并列举十数则运用姜桂附较有参考价值的特殊验案及误用、过用姜桂附出现狂、花颠、亡津、僵卧不起、气喘声嘶、肢冷抽筋、劫阴亡阳等危症案，总结出运用犀角地黄汤、清燥救肺汤、黄连阿胶汤、参苓芍草加阿胶等方药化解其燥化亡津之象的经验。甚至有认为服用姜桂附方药后病情从少阴寒化转为热化，出现适度的燥化伤津之象是可接受的病程反映，不为误治，因为少阴寒化相对于热化是更严重的危证，热化好治，寒化难治，救命为先，再行善后。
结论：收集整理出的历代岭南医家医案数量不少，有很大的研究价值，从中可了解到多方面的信息。姜桂附的应用状况探讨，反映了历代岭南医家对仲景经方温阳法在岭南地区应用的理论发展及临床实践过程。这只是医案研究中一个角度的尝试，今后或可深入探求其方证对应关系，用量比例宜忌，疾病谱以及同病异治，异病同治等方面的内容，取得经验，再扩大到历代医家用药特点及学术思想、学术渊源的分析研究中。
1 Objective and methods
An over-all investigation of Lingnan (in the southern region of five mountains) traditional Chinese medicinal (TCM) literature before the year of 1949 was carried out in libraries located in Guangzhou, Beijing, Shanghai and Hong Kong. Methods for literature study, history study, comparison study, statistical analysis and traditional Chinese medicinal academic study were used comprehensively to study the medical records recorded by Lingnan physicians before 1949, thus to present the general situation of Lingnan physicians' medical records in different dynasties. The generality and individuality of main medical records or large-sample medical records were explored by the methods for medicinal history and literature study and clinical study, for example, the clinical application of Rhizoma Zingiberis Recens, Ramulus Cinnamomi and Radix Aconiti Lateralis Preparata in the records of different dynasties, thus to lay a foundation for the further research of disease spectrum, academic thoughts, and prescriptions and medication.
2 Main content of the study
This study consists of four parts: (1) Research situation of traditional Chinese medical records in China and those in Lingnan; (2) Collection and arrangement of Lingnan physicians' medical records; (3) General situation of Lingnan physicians' medical records; (4) Analysis of clinical application of Rhizoma Zingiberis Recens, Ramulus Cinnamomiand Radix Aconiti Lateralis Preparata in Ling-nan physicians' medical records.
3 Results
(1) the establishment of database of Lingnan physicians' medical records in different dynasties
The results of over-all investigation showed that 50 bibliographies of medical records in different dynasties were found present, 20 were found disappeared, 9 kinds of magazines reported medical records, 16 kinds of local chronicles kept medical records。 After listing the bibliographies present and those disappeared, we screened 42 bibliographies, 9 kinds of magazines, 16 kinds of local chronicles which kept Lingnan physicians' medical records, and 173 Lingnan physicians who were contributed to medical records. We edited 1671 Lingnan physicians' medical records in different dynasties that are relatively completed and can be referred.
(2) Presenting the general situation of Lingnan physicians' medical records in different dynasties
The distribution of Lingnan physicians' medical records in different dynasties was described: bibliographies and physicians that had over 10 medical records were listed thus to study the clinical experience, diseases spectrum, medication and for the associated research of large-sample medical records: the native places of the physicians were listed for the study of related factors: Diseases spectrum in the records were listed to show the medical level of the physicians and for the collection of the records in the order of branches.
Based on the dynasty clue and physicians clue, the characteristics of medical records were compared, as well as the introduction of main physicians and medical records examples, thus to presenting the general situation of present Lingnan physicians' medical records.
Jing and Tang Dynasties: It is the germination of Lingnan physicians' medical records. No biography of medical records was found in Jing Dynasty, only the present biographyof Ge Hong who had been in Lingnan extracted Lingnan physicians' medical records. Also no medicinal record was found in Lingnan physicians' biography of Tang Dynasty.
Song and Yuan Dynasties: Lingnan physicians' biographies of Song Dynasty increased, but no medicinal record was found. Only 3 records were kept in notebook and local chronicles. Valuable records appeared in Yuan Dynasty, native Lingnan physicians recorded 4 records. The 15 medical records of Shi Jihong contributed to the diagnosis and treatment of malignant malaria and the clinical application of Rhizoma Zingiberis Recens, Ramulus Cinnamomi and Radix Aconiti Lateralis Preparata.
Ming Dynasty: Lingnan physicians' biography increased, with the characteristics of increase of medical records of native physicians from local chronicles and less accuracy of the contents. Meanwhile, San He Jin written by Zhang Jike, a biography of medical records, discussed diseases in Lingnan and showed a high academic level; Ming Yi Lei An kept 4 records of Yu Zirong, short but accurate.
Qing Dynasty: Lingnan physicians' medical records went to the adult period. The quantity and quality of native Lingnan physicians' medical records much increased: 31 Lingnan physicians' biographies kept 35 Lingnan physicians and 515 medical records, 13 local chronicles kept 24 Lingnan physicians and 60 medical records, and in toal 31 Lingnan physicians' biographies and 13 local chronicles kept 59 Lingnan physicians and 575 medical records. Among them, 49 were native in Lingnan and 10 had been in Lingnan. Some physicians were specialized in treating some diseases: Luo Rulan, Li Peilan, Lin Qingquan, Lao Shoushen and Liang Daqiao were specialized in plague, diphtheria and cholera; Chen Botan, Yi Jusun and Li Piliu were specialized in febrile diseases; Xu Yanzuo and Jian Xizeng who had been in Lingnan were specialized in comparing the Lingnan diseases with diseases occurring in other provinces; Pan Lanping, the preventative of physicians for Lingnan warm disease, showed experienced prescription and medication for warm disease.
The republic period: The republic period showed the largest amount of Lingnan physicians, biographies and medical records, which is great prosperity period for Lingnan physicians' medical records. This is the result of the development of Lingnan medicine. Moreover, the establishment of different kinds of periodicals in Guangdong province promoted the communication of Lingnan medicine, which contributed to the social advancement and cultural progress in Guangdong province. There were four biographies of medical records for reference during this period. Moreover, there were 4 biographies of Lingnan physicians' medical records, 9 kinds of periodicals, 3 local chronicles, 103 physicians and 999 medical records. The medication characteristics of in Lingnan physicians' medical records of the republic period were as follows: Chen Yingqi and Chen Yuzhou were specialized in application of prescriptions from Shanghan Lun; Cai Dongrong and He Kuiyuan were specialized in application of medicinal herbs with the clearing and cooling actions; Lu jueyu was good at applying western and traditional Chinese medicine; Chen Zhiping was good at acupuncture therapy. The contents and the styles of medical records in this period were various and the academic levels were higher than the previous periods.
(3) Analysis of clinical application of Rhizoma Zingiberis Recens, RamulusCinnamomiand Radix Aconiti Lateralis Preparata in different dynasties
Based on the analysis of 1671 medical records, clinical application of Rhizoma Zingiberis Recens (RZR), Ramulus Cinnamomi(RC) and Radix Aconiti Lateralis Preparata (RALP) was investigated in Lingnan physicians' medical records of different periods.
The evidence for Lingnan physicians applying RZR, RC and RALP in Lingnan region was firstly extracted. And then the characteristics of Lingnan climates, the influence of Lingnan residents'dietary on their constitution and some disputed TCM theories were investigated and discussed. It is indicated that there exist theoretical evidence and clinical experience for the application of RZR, RC and RALP in Lingnan regions. Under certain proper condition and based on syndrome differentiation and treatment, these three drugs had good effect for the treatment of acute and critical disease. The following supplied some data for the application of RZR, RC and RALP in Lingnan regions.
Jing, Tang, Song and Yuan Dynasties: There collected 25 medical records, in which there were 8 involving application of RZR, RC and RALP in combination or alone, and there were 17 not involving the application. In the 8 medical records, there were 3 involving the combined application of RZR and RC, 2 involving application of RZR alone, 3 involving application of RALP alone o It is indicated that there was no application of the three drugs together, or RC with other drug together. There were several medical records involving the combined application of RZR and RALP. For the use of RALP, there was differentiated use of Chuanwu, Wutou and Tianxiong in Jing, Tang, Song and Yuan Dynasties, but less mentioned by the physicians in the later period. The physicians used the above three drugs were Shi Jihong and Yang Jilao, they used them for miasma, wind-phlegm syncope and deficiency-cold vomiting and diarrhea. The common-used prescriptions were 4 including Sanjian Decoction. It is said that long-term use of RZR and RALP prolonged life span, and RZR cured throat abscess.
Ming Dynasty: There collected 72 medical records, in which there were 7 involving application of RZR, RC and RALP in combination or alone, and there were 65 not involving the application. In the 7 medical records, there were 1 involving the combined application of RZR and RALP, 1 involving, the combined application of RZR and RC, 3 involving application of RZR alone, 1 involving application of RC alone o It is indicated that there were few records recorded the combined application of the three or two. The combination with Fructus Evodiae occurred. The physician used the above three drugs was Yu Zirong, he used them for 3 kinds of diseases including miasma. The common-used prescriptions were Shengjiang Fuzi Decoction and Wuzhuyu Decoction. It is said that use of RALP and Radix Angelicae Sinensis in granule cured headache.
Qing Dynasty: There collected 575 medical records, in which there were 230 involving application of RZR, RC and RALP in combination or alone, and there were 345 not involving the application. In the 230 medical records, there were 15 involving the combined use of three, 71 1 involving the combined application of RZR and RALP, 36 involving the combined application of RZR and RC, 23 involving the combined application of RALP and RC, 46 involving application of RZR alone, 10 involving application of RALP alone and 29 involving application of RC alone o Raw RALP was used un-prepared in 17 medical records. Fresh common ginger rhizome was used in 50 records, prepared ginger rhizome in 8 and dry ginger rhizome in 49. It is indicated that there were many physicians used the three drugs in clinics and they usually had one or two effective cases. The applied principle is using the proper drug for the certain syndrome. The application of drug pairs of RZR & RC, RZR & RALP, RALP & TC increased, in particular the use of RC. The number of indicative diseases also increased. The physician used the above three drugs were 12 including Li Piliu, they used the drugs for 38 kinds of diseases including edema. The common-used prescriptions were 12 including Gancao Fuzi Decoction.
The republic period: There collected 999 medical records, in which there were 342 involving application of RZR, RC and RALP in combination or alone, and there were 657 not involving the application. In the 342 medical records, there were 60 involving the combined use of three, 94 involving the combined application of RZR and RALP, 35 involving the combined application of RZR and RC, 9 involving the combined application of RALP and RC, 93 involving application of RZR alone, 20 involving application of RALP alone and 31 involving application of RC alone. It is indicated that there were many physicians used the three drugs in clinics, and the flesh ginger rhizome was used in more medical records. Meanwhile, the set prescription was less used while the self-prepared prescriptions were used frequently. The combination with Fructus Evodiae was used in more medical records to increase the yang-warrning action. More medical records were issued in the periodicals: some physicians were good at using RZR while not using RC & RALP, for example Jiang Jishi; some used RALP More often than RZR, for example Pan Zhanglun; some used ginger juice. Physicians using RZR or RC alone was not for warming yang, mostly for dispersing evils. The physician used the above three drugs were 26 including Lu Jueyu and Chen Yingqi, they used the drugs for 39 kinds of diseases including damp-type beriberi and Shaoyin cold transformation syndrome. The common-used prescriptions were 28 including Fuzi Jingmi Decoction. It is said that Fuzi Lizhong Decoction with the heat property should be taken in cold decoction, large-dose prescription cured obstruction syndrome and prepared Tianxiong cured diabetes.
Summary: There collected 1671 Lingnan physicians' medical records, in which there were 587 involving application of RZR, RC and RALP in combination or alone, and there were 1085 not involving the application. In the 587 medical records, there were 75 involving the combined use of three, 169 involving the combined application of RZR and RALP, 72 involving the combined application of RZR and RC, 32 involving the combined application of RALP and RC, 144 involving application of RZR alone, 61 involving application of RC alone and 34 involving application of RALP alone~ There collected 41 physicians, 42 entitys, 33 classical prescriptions. It is indicated that the records involving application of the three were one third of those not involving, the percentage of combined use of RZR & RALP was higher than that of combined use of RALP & RC.
Analysis of some examples from main physicians: Chen Yingqi, a Lingnan physician lived between the end of Ming dynasty and the beginning of Qing Dynasty, left the largest medical records in different periods, and was good at application of RZR, RC and RALP. His experience embodied the principle of Lingnan physicians' medication, and their application of classic prescription and warm-heat drugs.
IN Chen's 226 medical records, there were 140 involving application of RZR, RC and RALP in combination or alone, and there were 86 not involving the application which was one third of the former. In the 140 medical records, there were 32 involving the combined use of three, 77 involving the combined application of RZR and RALP, 3 involving the combined application of RZR and RC, 1 involving the combined application of RALP and RC, 14 involving application of RZR alone, 9 involving application of RC alone and 4 involving application of RALP alone, 11 involving the mis-application or overuse of the three drugs by the previous physicians。
Chen's medical records showed the characteristics of standardization, repeatability, he used the combination usually in the classic prescription, for example in 13 prescriptions with the leading of Baitong Decoction, Sini with Guizhi added Decoction. Chen Yingqi kept the same basic medication principle as Zhang Zhongjing. For the use of Tongmai Sini Decoction, the indications should be feeble pulse and with the desire of sleeping, and the patients usually had the symptoms of dumbness, stiff body, stiff neck; Baitong Decoction not only was indicated for Taiyang disease invading Shaoyin Meridian, also for Junyin cold transformation syndrome and meridians concurrent diseases. The critical diseases induced by misapplication and overuse of RZR, RC and RALP were also discussed, usually used by Xijiao Dihuang Decoction, Qingzao Jiufei Decotion, Huanglian Ejiao Decoction and Shen Ling Shao Cao and Ejiao Decoction. He also brought forward that Shaoyin cold transformation syndrome turning into heat transformation syndrome after treatment with the three drugs was a good sign for prognosis. For heat transformation syndrome was easy to be cured and cold transformation syndrome was difficult to be treated.
Conclusion: Although the amount of Lingnan physicians' medical records in different periods was not big enouth, the records are valuable for research and can give clinical evidence and some experience. The analysis of clinical application of RZR, RC and RALP is just a beginning, the future further research will supply more evidence for prescription according to the syndrome, dosage of medication, indications and contraindications, disease spectrum and treating the same disease with different therapies in the Lingnan medical records, as well as the medication characteristics, academic thought and academic origins of Lingnan physicians in the different period.
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