歷史傳奇中的醫學傳承──以1880-1881年慈禧脈案為例

Medical Heritage in Historical Legends: Take the Case of Cixi from 1880 to 1881 as an Example

醫案類文獻是中國醫學的重要傳承體系。但是傳統中醫醫案的格式與術語的不統一，即使學界已用資料庫形式的數據化研究，仍有許多客觀化的問題待突破。醫史學界強調醫案文獻是醫家們彰顯社經或學術地位的出版品，本文則透過1880年至1881年的慈禧病案，來發掘呈現醫案類文獻中的醫學內涵。由翁同龢日記當主軸，輔以清宮脈案檔案，發掘出慈禧太后之月經周期不規律的紀錄，診斷應為更年期症候群。太醫們以歸脾湯為主治，但馬培之的「陰血虛」病機判斷與滋陰清熱的治則更適於更年期徵候群的治療。治療病程中太后諸多不適症狀仍有反覆，醫療團隊的主張由薛福辰主導逐漸由「甘平」向「辛溫」偏移，致使太后不適加重，並當月兩度月經來潮。但隨著冬季到來，慈禧太后貪食瓜果而導致脾胃陽氣虛弱的病機，逐漸凌駕於原有之更年期陰血虛的病機之上成為治療焦點，溫補腎陽的處方此時反而成為救命關鍵。透過這個歷史上記錄最為完整病案解析，也呈現出臨床論理中臟腑、經絡病機上複雜結構，還有隨著時間、節氣推移的生理病理變化。中醫病案文獻的分析研究，仍必須要從病案紀錄寫作與病機分析的基本功做起。

It is important for traditional Chinese medicine to have a knowledge stock of medical cases. The format and terminology of traditional Chinese medical cases remains inconsistent, leaving many objective issues unresolved. It is often stressed by medical historians that medical cases are publications by doctors to demonstrate their social, economic, or academic status. By analyzing the disease of Empress dowager Cixi in 1880-1881, this article explores and presents the medical connotation of medical cases. The irregular menstrual cycles of the Empress Dowager Cixi are found in the diary of Weng Tonghe and backed up by records from the medical archives of the Qing palace. This leads to the diagnosis of menopausal syndrome. It was the Guipi Decoction that was the main treatment for menopausal symptoms in the imperial era, but Ma Peizhi's diagnosis of ''Yin and blood deficiency'' and the treatment of nourishing yin and clearing heat was much more effective. Even after months of treatment, the Empress Dowager still experienced many uncomfortable symptoms. It was due to this shift in medical team's proposition, led by Xue Fuchen, that Empress Dowager Cixi's symptoms worsened and she had two menstrual cycles in a month. With the arrival of winter, however, weakness in the spleen and stomach caused by Empress Dowager Cixi's gluttony of fruits gradually overtook the original cause of menopause syndrome and became the focus of treatment. The prescription for ''Warm and tonify kidney yang'' was lifesaving at this time. Based on the most comprehensive medical records available, this study illustrates the complex structural level of visceral and meridian pathogenesis, and the changes in pathophysiology over time and seasons. In order to thoroughly analyze and research traditional Chinese medical cases, it is necessary to begin with the basic skills of composing medical records and understanding pathogenesis.