《醫(yi)學(xue)(xue)衷中(zhong)(zhong)(zhong)(zhong)參西(xi)(xi)(xi)錄》,中(zhong)(zhong)(zhong)(zhong)醫(yi)叢書,又(you)名《衷中(zhong)(zhong)(zhong)(zhong)參西(xi)(xi)(xi)錄》,張(zhang)錫(xi)純(chun)(壽甫)撰。此書分(fen)為(wei)(wei)《處方(fang)學(xue)(xue)》8卷(juan)(juan)、《醫(yi)論(lun)》8卷(juan)(juan)、《醫(yi)話(hua)拾零(ling)》、《三(san)(san)三(san)(san)醫(yi)書評》、《藥物講義》4卷(juan)(juan)、《傷(shang)寒講義》4卷(juan)(juan)、《醫(yi)案(附詩草)》4卷(juan)(juan)。系作者多年治(zhi)(zhi)學(xue)(xue)臨證經驗(yan)和心(xin)得之(zhi)總(zong)結(jie)。是20世紀(ji)初我國重(zhong)要的(de)(de)(de)(de)(de)臨床(chuang)(chuang)綜合(he)性名著(zhu)。張(zhang)氏(shi)致力溝(gou)通(tong)(tong)中(zhong)(zhong)(zhong)(zhong)西(xi)(xi)(xi)醫(yi)學(xue)(xue),主(zhu)(zhu)張(zhang)以中(zhong)(zhong)(zhong)(zhong)醫(yi)為(wei)(wei)主(zhu)(zhu)體,取西(xi)(xi)(xi)醫(yi)之(zhi)長(chang),補(bu)中(zhong)(zhong)(zhong)(zhong)醫(yi)之(zhi)短。他(ta)認為(wei)(wei):“欲求(qiu)醫(yi)學(xue)(xue)登峰造極,誠非溝(gou)通(tong)(tong)中(zhong)(zhong)(zhong)(zhong)西(xi)(xi)(xi)醫(yi)不(bu)(bu)可(ke)。”其于(yu)溝(gou)通(tong)(tong)中(zhong)(zhong)(zhong)(zhong)西(xi)(xi)(xi)醫(yi)的(de)(de)(de)(de)(de)主(zhu)(zhu)導思想(xiang),主(zhu)(zhu)張(zhang)師古(gu)(gu)而(er)不(bu)(bu)泥古(gu)(gu),參西(xi)(xi)(xi)而(er)不(bu)(bu)背(bei)中(zhong)(zhong)(zhong)(zhong)。張(zhang)氏(shi)重(zhong)視基礎理(li)(li)(li)論(lun),對臟象(xiang)學(xue)(xue)說和解(jie)剖生理(li)(li)(li)的(de)(de)(de)(de)(de)互證尤為(wei)(wei)重(zhong)視。書中(zhong)(zhong)(zhong)(zhong)指出:腦為(wei)(wei)元神(shen)(shen),心(xin)為(wei)(wei)識(shi)神(shen)(shen),心(xin)力衰竭與(yu)腎不(bu)(bu)納(na)氣相(xiang)通(tong)(tong);腦充血與(yu)薄厥相(xiang)近等(deng)等(deng)。在(zai)臨證方(fang)面(mian),講究(jiu)細致的(de)(de)(de)(de)(de)觀察和記述病情,建立完整的(de)(de)(de)(de)(de)病歷。其于(yu)諸病治(zhi)(zhi)法,注(zhu)重(zhong)實際(ji),勇于(yu)探索,并(bing)(bing)獨創了許(xu)多新的(de)(de)(de)(de)(de)治(zhi)(zhi)療方(fang)劑(ji),體驗(yan)了若干中(zhong)(zhong)(zhong)(zhong)藥的(de)(de)(de)(de)(de)性能(neng)。對諸如(ru)萸肉(rou)救脫(tuo),參芪利尿,白礬(fan)化痰熱,三(san)(san)七消瘡(chuang)腫,生硫黃內服(fu)治(zhi)(zhi)虛寒下痢,蜈蚣、蝎子定風消毒等(deng)等(deng),均(jun)能(neng)發(fa)揚古(gu)(gu)說,擴大藥用(yong)主(zhu)(zhu)治(zhi)(zhi)。如(ru)對調治(zhi)(zhi)脾胃(wei)(wei),主(zhu)(zhu)張(zhang)脾陽(yang)與(yu)胃(wei)(wei)陰并(bing)(bing)重(zhong),升肝脾與(yu)降膽胃(wei)(wei)兼施,補(bu)養(yang)與(yu)開(kai)破相(xiang)結(jie)合(he)。書中(zhong)(zhong)(zhong)(zhong)結(jie)合(he)中(zhong)(zhong)(zhong)(zhong)西(xi)(xi)(xi)醫(yi)學(xue)(xue)理(li)(li)(li)論(lun)和醫(yi)療實踐闡(chan)發(fa)醫(yi)理(li)(li)(li),頗(po)多獨到的(de)(de)(de)(de)(de)見解(jie)。書中(zhong)(zhong)(zhong)(zhong)載述張(zhang)氏(shi)所制定的(de)(de)(de)(de)(de)若干有效方(fang)劑(ji);在(zai)方(fang)藥應用(yong)方(fang)面(mian),創用(yong)中(zhong)(zhong)(zhong)(zhong)西(xi)(xi)(xi)藥相(xiang)結(jie)合(he)的(de)(de)(de)(de)(de)方(fang)劑(ji),并(bing)(bing)對石(shi)膏、生山藥、代(dai)赭石(shi)等(deng)藥的(de)(de)(de)(de)(de)臨床(chuang)(chuang)施治(zhi)(zhi),在(zai)古(gu)(gu)人基礎上有重(zhong)要的(de)(de)(de)(de)(de)補(bu)訂、發(fa)揮。
《醫學衷中參西錄》為張錫(xi)純(chun)唯一傳世的著作,其主要學術內(nei)容如下:
一、學術理論
(一)倡“衷中參西”
清末民初(chu),西(xi)(xi)學(xue)東(dong)漸,西(xi)(xi)醫學(xue)在我國流傳(chuan)甚快。當時,醫學(xue)界有(you)些人崇尚(shang)西(xi)(xi)學(xue),輕(qing)視中(zhong)醫,有(you)些中(zhong)醫則一(yi)味排斥(chi)西(xi)(xi)醫,因循守舊。張氏則主張以(yi)中(zhong)醫為本體,擷取(qu)西(xi)(xi)醫之長補中(zhong)醫之短(duan),倡導“衷中(zhong)參(can)西(xi)(xi)”,并(bing)從理論、實(shi)踐方面進行了嘗試,《醫學(xue)衷中(zhong)參(can)西(xi)(xi)錄》的(de)書(shu)名就鮮明(ming)地(di)表明(ming)了張氏的(de)學(xue)術主張。
在生理、病理方面(mian),張氏于(yu)《醫學(xue)衷(zhong)中(zhong)(zhong)(zhong)(zhong)參(can)西(xi)錄》中(zhong)(zhong)(zhong)(zhong)有許多溝通(tong)(tong)中(zhong)(zhong)(zhong)(zhong)西(xi)醫學(xue)的(de)新見解,如(ru):“中(zhong)(zhong)(zhong)(zhong)醫謂人(ren)之(zhi)(zhi)(zhi)(zhi)神(shen)(shen)(shen)明(ming)(ming)在心(xin),西(xi)說(shuo)謂人(ren)之(zhi)(zhi)(zhi)(zhi)神(shen)(shen)(shen)明(ming)(ming)在腦(nao)(nao),及觀《內經(jing)》,皆涵蓋其中(zhong)(zhong)(zhong)(zhong)也”。《素(su)問·脈要精(jing)微(wei)論》中(zhong)(zhong)(zhong)(zhong)指出“頭者精(jing)明(ming)(ming)之(zhi)(zhi)(zhi)(zhi)府”,說(shuo)明(ming)(ming)神(shen)(shen)(shen)明(ming)(ming)之(zhi)(zhi)(zhi)(zhi)體在腦(nao)(nao),所(suo)謂“心(xin)主(zhu)神(shen)(shen)(shen)明(ming)(ming)”,只不(bu)過是言(yan)神(shen)(shen)(shen)明(ming)(ming)之(zhi)(zhi)(zhi)(zhi)用出于(yu)心(xin),由此可(ke)見,中(zhong)(zhong)(zhong)(zhong)西(xi)之(zhi)(zhi)(zhi)(zhi)說(shuo)雖(sui)然不(bu)同(tong),但理可(ke)匯通(tong)(tong)。另如(ru),認(ren)為吐(tu)衄(nv)的(de)原因是由于(yu)陽明(ming)(ming)胃(wei)(wei)腑氣機(ji)上(shang)逆(ni)(ni),胃(wei)(wei)中(zhong)(zhong)(zhong)(zhong)之(zhi)(zhi)(zhi)(zhi)血(xue)亦恒(heng)隨之(zhi)(zhi)(zhi)(zhi)上(shang)逆(ni)(ni)。“其上(shang)逆(ni)(ni)之(zhi)(zhi)(zhi)(zhi)極,可(ke)將胃(wei)(wei)壁(bi)之(zhi)(zhi)(zhi)(zhi)膜(mo)排(pai)擠破裂,而成嘔血(xue)之(zhi)(zhi)(zhi)(zhi)證;或(huo)(huo)循陽明(ming)(ming)之(zhi)(zhi)(zhi)(zhi)經(jing)絡上(shang)行(xing),而成衄(nv)血(xue)之(zhi)(zhi)(zhi)(zhi)證”,此即《素(su)問·厥論》中(zhong)(zhong)(zhong)(zhong)所(suo)言(yan)“陽明(ming)(ming)厥逆(ni)(ni)衄(nv)嘔血(xue)”。其論衄(nv)血(xue)治(zhi)療(liao),主(zhu)張不(bu)論“或(huo)(huo)虛(xu)或(huo)(huo)實,或(huo)(huo)涼或(huo)(huo)熱,治(zhi)之(zhi)(zhi)(zhi)(zhi)者皆當以(yi)降胃(wei)(wei)之(zhi)(zhi)(zhi)(zhi)品為主(zhu)”,并(bing)制(zhi)平胃(wei)(wei)寒降湯(tang)、滋陰清降湯(tang)等,皆主(zhu)以(yi)生赭石通(tong)(tong)降胃(wei)(wei)氣,并(bing)輔以(yi)白芍、龍(long)、牡等養陰鎮潛之(zhi)(zhi)(zhi)(zhi)品,提(ti)高(gao)了本病的(de)療(liao)效。
在用(yong)(yong)(yong)藥(yao)(yao)上,張(zhang)氏認為(wei),西藥(yao)(yao)治(zhi)(zhi)(zhi)(zhi)在局部,是重(zhong)在病(bing)之標(biao)(biao)也;中藥(yao)(yao)用(yong)(yong)(yong)藥(yao)(yao)求原(yuan)因,是重(zhong)在病(bing)之本(ben)(ben)也。究(jiu)之,標(biao)(biao)本(ben)(ben)原(yuan)宜兼顧,若遇難治(zhi)(zhi)(zhi)(zhi)之證,以西藥(yao)(yao)治(zhi)(zhi)(zhi)(zhi)其(qi)(qi)標(biao)(biao),中藥(yao)(yao)治(zhi)(zhi)(zhi)(zhi)其(qi)(qi)本(ben)(ben),則奏效(xiao)必速,提出中藥(yao)(yao)、西藥(yao)(yao)不(bu)(bu)應(ying)(ying)互相抵牾(wu),而應(ying)(ying)相濟為(wei)用(yong)(yong)(yong)。張(zhang)氏臨床治(zhi)(zhi)(zhi)(zhi)療(liao)癲癇(xian),據中醫“諸風(feng)掉眩,皆屬于肝”理論,用(yong)(yong)(yong)西藥(yao)(yao)臭(chou)素、抱(bao)水諸品及鉛硫(liu)朱砂丸麻醉鎮靜治(zhi)(zhi)(zhi)(zhi)標(biao)(biao),而后則主張(zhang)徐以健脾、利痰、祛風(feng)、清(qing)火之藥(yao)(yao)以鏟除其(qi)(qi)病(bing)根。治(zhi)(zhi)(zhi)(zhi)療(liao)大氣下陷,下血(xue)不(bu)(bu)止之血(xue)崩(beng)癥,煎服生黃芪(qi)、白術、龍骨、牡蠣、柴胡等升舉固澀之品時,加(jia)服西藥(yao)(yao)麥角,以加(jia)強收縮止血(xue)功效(xiao)。張(zhang)氏在辨證施治(zhi)(zhi)(zhi)(zhi)運用(yong)(yong)(yong)中醫方(fang)藥(yao)(yao)的同時,加(jia)服西藥(yao)(yao),開中西藥(yao)(yao)聯(lian)合(he)應(ying)(ying)用(yong)(yong)(yong)之先河。
(二)大(da)氣(qi)下陷論
繼喻昌(chang)“胸(xiong)中(zhong)大氣(qi)說(shuo)”之后,張(zhang)氏(shi)在(zai)《醫學衷(zhong)中(zhong)參西錄》中(zhong)對大氣(qi)的認(ren)識(shi)和治療(liao)作(zuo)了進一步(bu)的闡發(fa)。
張氏(shi)認為(wei),大氣(qi)(qi)即《內(nei)經(jing)》所言之(zhi)宗氣(qi)(qi),它(ta)“以(yi)元(yuan)氣(qi)(qi)為(wei)根本(ben),以(yi)水谷之(zhi)氣(qi)(qi)為(wei)養(yang)(yang)料,以(yi)胸中(zhong)之(zhi)地(di)為(wei)宅窟(ku)者也”。因其(qi)“誠以(yi)能撐持全身(shen),為(wei)諸氣(qi)(qi)之(zhi)綱領,包舉肺外(wai),司呼吸之(zhi)樞機,故鄭而重之(zhi)曰大氣(qi)(qi)。”即大氣(qi)(qi)是搏聚于(yu)胸中(zhong),包舉于(yu)肺外(wai)的大量(liang)陽氣(qi)(qi),它(ta)源于(yu)元(yuan)氣(qi)(qi),受水谷精微(wei)的滋養(yang)(yang),除(chu)主(zhu)司呼吸外(wai),同(tong)時(shi)(shi)對全身(shen)產生重要影響。此(ci)氣(qi)(qi)撐持全身(shen),振作精神,心及心思、腦(nao)力、百骸動作,莫不(bu)(bu)賴于(yu)此(ci)。此(ci)氣(qi)(qi)一虛(xu),呼吸即覺(jue)不(bu)(bu)利(li),而時(shi)(shi)時(shi)(shi)酸懶,精神昏憒(kui),腦(nao)力、心思為(wei)之(zhi)頓減。
大氣(qi)(qi)之(zhi)病變(bian)主要是虛而(er)陷,其病情有(you)緩急之(zhi)別,急者(zhe)(zhe)(zhe)(zhe)可引起(qi)猝(cu)死,“大氣(qi)(qi)既陷,無氣(qi)(qi)包舉肺(fei)外以鼓動其闔(he)辟之(zhi)機,則呼(hu)吸停頓,所以不(bu)病而(er)猝(cu)死。緩者(zhe)(zhe)(zhe)(zhe)則因大氣(qi)(qi)下(xia)陷而(er)致呼(hu)吸不(bu)利,換氣(qi)(qi)不(bu)足缺氧,全身(shen)性衰竭出現一(yi)系列表現:“有(you)呼(hu)吸短氣(qi)(qi)者(zhe)(zhe)(zhe)(zhe),有(you)心中(zhong)怔忡(chong)者(zhe)(zhe)(zhe)(zhe),有(you)淋漓(li)大汗(han)者(zhe)(zhe)(zhe)(zhe),有(you)神昏健(jian)忘者(zhe)(zhe)(zhe)(zhe),有(you)聲顫身(shen)動者(zhe)(zhe)(zhe)(zhe),有(you)寒(han)熱往來者(zhe)(zhe)(zhe)(zhe),有(you)胸中(zhong)滿悶者(zhe)(zhe)(zhe)(zhe),有(you)努(nu)力(li)呼(hu)吸似喘者(zhe)(zhe)(zhe)(zhe),有(you)咽干作(zuo)渴者(zhe)(zhe)(zhe)(zhe),有(you)常常呵欠者(zhe)(zhe)(zhe)(zhe),有(you)肢體痿廢者(zhe)(zhe)(zhe)(zhe),有(you)食后易饑者(zhe)(zhe)(zhe)(zhe),有(you)二(er)便不(bu)禁者(zhe)(zhe)(zhe)(zhe),有(you)癃(long)閉身(shen)腫者(zhe)(zhe)(zhe)(zhe),有(you)張(zhang)口呼(hu)氣(qi)(qi)外出而(er)氣(qi)(qi)不(bu)上達,肛門(men)突出者(zhe)(zhe)(zhe)(zhe),在女子(zi)有(you)下(xia)血不(bu)止,更有(you)經水逆行者(zhe)(zhe)(zhe)(zhe)”等等。,
以上見癥(zheng)以心肺證(zheng)候(hou)(hou)為(wei)主,常兼(jian)見脾(pi)胃證(zheng)候(hou)(hou)。若單見脾(pi)胃證(zheng)候(hou)(hou)而無心肺證(zheng)候(hou)(hou)者,是謂(wei)中氣(qi)(qi)下(xia)陷(xian)(xian)。中氣(qi)(qi)下(xia)陷(xian)(xian)之(zhi)(zhi)重者,張氏認為(wei)有(you)引起大氣(qi)(qi)下(xia)陷(xian)(xian)之(zhi)(zhi)可(ke)能,“夫中氣(qi)(qi)誠有(you)下(xia)陷(xian)(xian)之(zhi)(zhi)時(shi),然不若大氣(qi)(qi)下(xia)陷(xian)(xian)之(zhi)(zhi)尤屬危險(xian)也(ye)。間有(you)因中氣(qi)(qi)下(xia)陷(xian)(xian),泄(xie)瀉日久,或轉(zhuan)致大氣(qi)(qi)下(xia)陷(xian)(xian)者”。這樣把(ba)大氣(qi)(qi)下(xia)陷(xian)(xian)與中氣(qi)(qi)下(xia)陷(xian)(xian)分別開來,確(que)為(wei)閱歷之(zhi)(zhi)談。
張(zhang)氏認(ren)為,引起(qi)大氣(qi)(qi)(qi)下(xia)陷(xian)的原因不外勞(lao)力(li)過度、久(jiu)病(bing)和誤藥(yao)。如“力(li)小任重,或(huo)(huo)枵腹力(li)作,或(huo)(huo)病(bing)后(hou)氣(qi)(qi)(qi)力(li)未復而勤(qin)于動(dong)作,或(huo)(huo)泄瀉日久(jiu),或(huo)(huo)服破氣(qi)(qi)(qi)藥(yao)太過或(huo)(huo)氣(qi)(qi)(qi)分虛極(ji)自下(xia)陷(xian)”。張(zhang)氏治(zhi)療大氣(qi)(qi)(qi)下(xia)陷(xian),創制升(sheng)(sheng)陷(xian)湯(生黃(huang)芪、知母、桔(jie)梗、柴胡、升(sheng)(sheng)麻),該(gai)方以黃(huang)芪為君,升(sheng)(sheng)補大氣(qi)(qi)(qi),佐知母涼潤以濟其之(zhi)(zhi)偏,柴胡引大氣(qi)(qi)(qi)之(zhi)(zhi)陷(xian)者(zhe)自左(zuo)上(shang)升(sheng)(sheng),升(sheng)(sheng)麻引大氣(qi)(qi)(qi)之(zhi)(zhi)陷(xian)者(zhe)自右(you)上(shang)升(sheng)(sheng),桔(jie)梗為藥(yao)中之(zhi)(zhi)舟楫,導(dao)諸藥(yao)之(zhi)(zhi)力(li)上(shang)達胸(xiong)中。若氣(qi)(qi)(qi)虛極(ji)加(jia)(jia)人(ren)參或(huo)(huo)寄(ji)生,以培氣(qi)(qi)(qi)之(zhi)(zhi)本,或(huo)(huo)更加(jia)(jia)山(shan)萸肉以防氣(qi)(qi)(qi)之(zhi)(zhi)渙(huan)散,氣(qi)(qi)(qi)虛甚者(zhe)酌增升(sheng)(sheng)麻用量。
心(xin)肺之(zhi)陽(yang),尤賴胸中(zhong)大氣(qi)為之(zhi)保護,大氣(qi)一陷,則(ze)心(xin)肺陽(yang)分素虛者,至此而(er)益虛,癥見其人(ren)心(xin)冷,背緊,惡寒,常覺(jue)短氣(qi)等(deng)。張氏認為欲(yu)助胸中(zhong)心(xin)肺之(zhi)陽(yang),必須(xu)先升(sheng)提下陷之(zhi)大氣(qi),否則(ze)但服溫補心(xin)肺之(zhi)陽(yang)之(zhi)劑無效(xiao),制(zhi)回(hui)陽(yang)升(sheng)陷湯(生(sheng)黃芪、干(gan)姜、當歸身、桂枝炭、甘草)以治之(zhi)。
胸(xiong)中大氣(qi)(qi)(qi)正常(chang)(chang),有賴于少陽、陽明之(zhi)氣(qi)(qi)(qi)的(de)升(sheng)發(fa)。若大氣(qi)(qi)(qi)下(xia)(xia)陷(xian),升(sheng)發(fa)之(zhi)氣(qi)(qi)(qi)被郁(yu),氣(qi)(qi)(qi)分郁(yu)結,經(jing)絡瘀(yu)滯,常(chang)(chang)見胸(xiong)中滿痛或脅下(xia)(xia)撐脹(zhang)、腹痛等(deng)。對(dui)此,張(zhang)氏又制理郁(yu)升(sheng)陷(xian)湯(生(sheng)(sheng)黃芪(qi)(qi)、知母、當歸身、桂枝(zhi)尖、柴胡、乳香、沒藥);對(dui)脾(pi)氣(qi)(qi)(qi)虛極下(xia)(xia)陷(xian),小(xiao)便不(bu)禁(jin)者,制理脾(pi)升(sheng)陷(xian)湯(生(sheng)(sheng)黃芪(qi)(qi)、白術(shu)、桑寄生(sheng)(sheng)、川(chuan)斷、萸肉、龍(long)骨、牡蠣、川(chuan)萆薢、甘(gan)草)治之(zhi)。
(三)寒溫(wen)統一,注(zhu)重清透
《醫(yi)學衷中參西錄(lu)》論溫(wen)(wen)(wen)(wen)病(bing),主張寒(han)(han)溫(wen)(wen)(wen)(wen)統(tong)一,認為(wei)溫(wen)(wen)(wen)(wen)病(bing)治(zhi)法(fa)已(yi)備于(yu)傷(shang)寒(han)(han)。如溫(wen)(wen)(wen)(wen)病(bing)初起(qi)治(zhi)宜辛涼(liang)(liang)(liang)(liang),然辛涼(liang)(liang)(liang)(liang)之(zhi)(zhi)(zhi)(zhi)法(fa)亦(yi)備于(yu)傷(shang)寒(han)(han),麻杏甘(gan)石(shi)湯“誠為(wei)溫(wen)(wen)(wen)(wen)病(bing)初得之(zhi)(zhi)(zhi)(zhi)的方矣”。但(dan)其(qi)外表(biao)證未(wei)解,內有(you)蘊熱(re)即可(ke)(ke)服(fu)用(yong)(yong)。至溫(wen)(wen)(wen)(wen)病(bing)傳經已(yi)深,清燥熱(re)之(zhi)(zhi)(zhi)(zhi)白虎湯、白虎加(jia)人參湯,通腑(fu)之(zhi)(zhi)(zhi)(zhi)大、小承氣湯,開結胸之(zhi)(zhi)(zhi)(zhi)大、小陷胸湯,治(zhi)下利之(zhi)(zhi)(zhi)(zhi)白頭翁湯、黃芩湯,治(zhi)發(fa)黃之(zhi)(zhi)(zhi)(zhi)茵陳桅子柏皮湯等及一切涼(liang)(liang)(liang)(liang)潤、清火、育陰、安神之(zhi)(zhi)(zhi)(zhi)劑,皆可(ke)(ke)使用(yong)(yong)。并指(zhi)出(chu)寒(han)(han)溫(wen)(wen)(wen)(wen)治(zhi)法(fa)之(zhi)(zhi)(zhi)(zhi)別,在于(yu)“始(shi)異而終同”。所謂(wei)“始(shi)異”,即傷(shang)寒(han)(han)發(fa)表(biao)可(ke)(ke)用(yong)(yong)溫(wen)(wen)(wen)(wen)熱(re),溫(wen)(wen)(wen)(wen)病(bing)發(fa)表(biao)必用(yong)(yong)辛涼(liang)(liang)(liang)(liang);謂(wei)其(qi)“終同”,即病(bing)傳陽明之(zhi)(zhi)(zhi)(zhi)后,不論傷(shang)寒(han)(han)、溫(wen)(wen)(wen)(wen)病(bing),皆宜治(zhi)以寒(han)(han)涼(liang)(liang)(liang)(liang),而大忌(ji)溫(wen)(wen)(wen)(wen)熱(re)。
張氏臨證將溫(wen)(wen)(wen)病(bing)分為風溫(wen)(wen)(wen)、春溫(wen)(wen)(wen)、濕溫(wen)(wen)(wen)三(san)(san)類。認(ren)為三(san)(san)類溫(wen)(wen)(wen)病(bing)雖見癥不同,其(qi)(qi)本質皆(jie)緣郁熱。“大(da)凡(fan)病(bing)溫(wen)(wen)(wen)之人(ren),多系(xi)內有蘊(yun)熱,至(zhi)春陽萌動之時,又薄受(shou)外(wai)(wai)感拘束,其(qi)(qi)熱即(ji)(ji)陡發(fa)而(er)(er)成溫(wen)(wen)(wen)”。他遵循(xun)“火(huo)郁發(fa)之”之旨,治療上主張宣散郁結,疏通氣機(ji),透邪外(wai)(wai)達。反對(dui)徒執寒(han)涼(liang)(liang),只清(qing)不透,使邪無由出。并自擬清(qing)解湯(tang)、涼(liang)(liang)解湯(tang)、寒(han)解湯(tang)三(san)(san)方,徑以石膏清(qing)其(qi)(qi)內熱,又選用薄荷、連翹、蟬蛻發(fa)表(biao),且“引胃中化(hua)而(er)(er)欲散之熱,仍(reng)還太陽作(zuo)汗而(er)(er)解”。正是基于對(dui)溫(wen)(wen)(wen)病(bing)“郁熱”這一本質的深刻(ke)認(ren)識,初起治療即(ji)(ji)立足于清(qing)透。
溫(wen)病(bing)(bing)入里化熱(re),抑或傷寒(han)(han)、中(zhong)風(feng)入里化熱(re),是陽明熱(re)盛之象,張氏(shi)皆(jie)以(yi)寒(han)(han)涼清熱(re)為(wei)主(zhu),不(bu)復(fu)有傷寒(han)(han)、中(zhong)風(feng)、溫(wen)病(bing)(bing)之分(fen),投以(yi)白虎湯(tang)靈活加(jia)減化裁。臨證使用白虎湯(tang),張氏(shi)有著豐富的經驗,認為(wei)白虎湯(tang)之“四大”典型癥狀中(zhong),唯脈洪為(wei)必見之癥。只要見脈洪大,又有陽明熱(re)盛之一二癥,則無(wu)論外感內傷,皆(jie)可用之,不(bu)必拘泥于(yu)古人(ren)之說(shuo)。
陽(yang)明(ming)腑實(shi)(shi)用三承氣(qi)湯(tang)(tang),此(ci)乃大法,然張氏認為承氣(qi)力猛,倘或審證(zheng)不(bu)確,即足誤事。于是據其(qi)三十(shi)余年臨證(zheng)經驗,強調“凡遇陽(yang)明(ming)應下(xia)證(zheng),亦先(xian)投以(yi)白虎湯(tang)(tang)一二劑,更改其(qi)服(fu)法,將石膏為末而不(bu)入煎,以(yi)藥(yao)湯(tang)(tang)送(song)服(fu)之(zhi)”,因(yin)屢用此(ci)方奏效,遂名之(zhi)曰白虎承氣(qi)湯(tang)(tang)。對于溫熱病神(shen)昏譫語,張氏遵從陸九(jiu)芝“胃(wei)熱之(zhi)甚(shen),神(shen)為之(zhi)昏,從來(lai)神(shen)昏之(zhi)病,皆屬(shu)胃(wei)家(jia)”之(zhi)說,將熱病神(shen)昏分(fen)為虛(xu)實(shi)(shi)兩類。其(qi)脈象洪而有力,按(an)之(zhi)甚(shen)實(shi)(shi)者(zhe),可按(an)陽(yang)明(ming)胃(wei)實(shi)(shi)治之(zhi),投以(yi)大劑白虎湯(tang)(tang);若脈兼弦(xian)、兼數,或重按(an)仍甚(shen)實(shi)(shi)者(zhe),治宜白虎加人參(can)湯(tang)(tang);對邪入陽(yang)明(ming),淫熱于肝,致肝風(feng)內動(dong)者(zhe),以(yi)白虎撤其(qi)陽(yang)明(ming)之(zhi)熱,生龍骨、生牡蠣以(yi)鎮肝熄風(feng)。
張氏治療溫病(bing)不僅(jin)擅用白虎,而且依據病(bing)證(zheng)不同,化裁組成了眾多(duo)新方,如石膏粳(jing)米湯、鎮逆白虎湯、通(tong)變白虎加(jia)人(ren)參湯等,皆(jie)由白虎湯衍(yan)化而來。
二、治療經驗
張(zhang)氏一(yi)生勤于臨證,《醫學衷中(zhong)參西錄(lu)》記載了他豐富的臨床經驗,其中(zhong)尤以論治中(zhong)風、脫證等最具特(te)色。
(一)分別中風論治
中(zhong)(zhong)風(feng)有真中(zhong)(zhong)、類(lei)中(zhong)(zhong)之(zhi)別。張氏(shi)認為真中(zhong)(zhong)者極少,因而著意對類(lei)中(zhong)(zhong)進行研究、發(fa)揮(hui)。指(zhi)出類(lei)中(zhong)(zhong)風(feng)亦即內中(zhong)(zhong)風(feng),此“風(feng)自內生,非風(feng)自外來也”,其治療分充(chong)血(xue)、貧血(xue),以虛實論治。
1、腦充血治療
張(zhang)氏根據(ju)“血菀于上(shang),使人(ren)薄(bo)厥”的理(li)論,認(ren)為(wei)腦(nao)充血即《內經(jing)》中(zhong)所(suo)言的煎厥、薄(bo)厥、大厥。其(qi)病(bing)位在(zai)“肝”,陰虛陽亢、上(shang)實下虛、臟腑之(zhi)氣升發太過或(huo)失之(zhi)下行(xing),血隨氣逆為(wei)主要病(bing)機。即“人(ren)之(zhi)血隨氣行(xing),氣上(shang)升不已,血即隨之(zhi)上(shang)升不已,以致(zhi)腦(nao)中(zhong)血管充血過甚(shen)”(《醫學衷中(zhong)參西錄·醫案·腦(nao)充血門》),有礙神經(jing),以致(zhi)語言肢體謇澀不利,口眼歪斜等(deng)等(deng)。
根據(ju)腦(nao)(nao)充血(xue)之(zhi)(zhi)(zhi)(zhi)“肝(gan)(gan)(gan)木(mu)失和,肺氣(qi)(qi)(qi)不降,腎(shen)(shen)氣(qi)(qi)(qi)不攝,沖(chong)氣(qi)(qi)(qi)、胃氣(qi)(qi)(qi)又復上(shang)(shang)逆,臟腑(fu)之(zhi)(zhi)(zhi)(zhi)氣(qi)(qi)(qi)化皆(jie)上(shang)(shang)升太過”之(zhi)(zhi)(zhi)(zhi)病(bing)機,張氏提出治(zhi)療本(ben)病(bing)應“清(qing)其(qi)臟腑(fu)之(zhi)(zhi)(zhi)(zhi)熱(re)(re),滋其(qi)臟腑(fu)之(zhi)(zhi)(zhi)(zhi)陰(yin),更降其(qi)臟腑(fu)之(zhi)(zhi)(zhi)(zhi)氣(qi)(qi)(qi),引腦(nao)(nao)部(bu)所(suo)充之(zhi)(zhi)(zhi)(zhi)血(xue)下(xia)(xia)行(xing)”的(de)(de)“鎮(zhen)(zhen)(zhen)(zhen)肝(gan)(gan)(gan)熄(xi)風、引血(xue)下(xia)(xia)行(xing)”的(de)(de)原則,并創制(zhi)鎮(zhen)(zhen)(zhen)(zhen)肝(gan)(gan)(gan)熄(xi)風湯(懷牛膝(xi)、生(sheng)(sheng)赭石(shi)、生(sheng)(sheng)杭芍、天(tian)(tian)冬、生(sheng)(sheng)龍骨(gu)、生(sheng)(sheng)牡(mu)(mu)蠣、生(sheng)(sheng)龜板(ban)、玄(xuan)(xuan)參、川楝(lian)子(zi)、生(sheng)(sheng)麥芽、茵陳、甘(gan)草)作為治(zhi)療本(ben)病(bing)的(de)(de)主(zhu)方(fang)。方(fang)中赭石(shi)降胃,平肝(gan)(gan)(gan)鎮(zhen)(zhen)(zhen)(zhen)沖(chong),下(xia)(xia)行(xing)通便;牛膝(xi)善引上(shang)(shang)部(bu)之(zhi)(zhi)(zhi)(zhi)血(xue)下(xia)(xia)行(xing),二藥合(he)用,相(xiang)輔相(xiang)成;玄(xuan)(xuan)參、天(tian)(tian)冬、白芍滋陰(yin)退熱(re)(re);龍骨(gu)、牡(mu)(mu)蠣、龜板(ban)、芍藥斂(lian)肝(gan)(gan)(gan)火、鎮(zhen)(zhen)(zhen)(zhen)熄(xi)肝(gan)(gan)(gan)風,以(yi)緩(huan)其(qi)肝(gan)(gan)(gan)氣(qi)(qi)(qi)上(shang)(shang)升之(zhi)(zhi)(zhi)(zhi)勢;玄(xuan)(xuan)參、天(tian)(tian)冬清(qing)肺制(zhi)肝(gan)(gan)(gan);山藥、甘(gan)草和胃緩(huan)肝(gan)(gan)(gan);茵陳為“青蒿之(zhi)(zhi)(zhi)(zhi)嫩者(zhe),稟少陽(yang)初生(sheng)(sheng)之(zhi)(zhi)(zhi)(zhi)氣(qi)(qi)(qi),與肝(gan)(gan)(gan)木(mu)同(tong)氣(qi)(qi)(qi)相(xiang)求,最(zui)能將順肝(gan)(gan)(gan)木(mu)之(zhi)(zhi)(zhi)(zhi)性(xing),且又善瀉肝(gan)(gan)(gan)熱(re)(re)”,為清(qing)涼(liang)腦(nao)(nao)部(bu)之(zhi)(zhi)(zhi)(zhi)涼(liang)藥也;麥芽“善助肝(gan)(gan)(gan)木(mu)疏泄以(yi)行(xing)腎(shen)(shen)氣(qi)(qi)(qi)”;川楝(lian)子(zi)善引肝(gan)(gan)(gan)氣(qi)(qi)(qi)下(xia)(xia)達(da),又能折(zhe)其(qi)更動之(zhi)(zhi)(zhi)(zhi)力(li)。本(ben)方(fang)標本(ben)兼(jian)治(zhi),鎮(zhen)(zhen)(zhen)(zhen)潛(qian)共用,引涵(han)兼(jian)施,直中病(bing)之(zhi)(zhi)(zhi)(zhi)肯(ken)綮,確有獨(du)到之(zhi)(zhi)(zhi)(zhi)處。
此外,張氏(shi)還參照西醫(yi)病理,闡(chan)述了(le)腦(nao)(nao)(nao)(nao)充(chong)血(xue)(xue)(xue)、腦(nao)(nao)(nao)(nao)溢(yi)血(xue)(xue)(xue)、腦(nao)(nao)(nao)(nao)出血(xue)(xue)(xue)之(zhi)(zhi)(zhi)證型及用(yong)藥的(de)不同。對(dui)腦(nao)(nao)(nao)(nao)部血(xue)(xue)(xue)管中之(zhi)(zhi)(zhi)血(xue)(xue)(xue)滲出者,他在友人“腦(nao)(nao)(nao)(nao)充(chong)血(xue)(xue)(xue)證,宜于引血(xue)(xue)(xue)下行藥中加破血(xue)(xue)(xue)之(zhi)(zhi)(zhi)藥以治(zhi)之(zhi)(zhi)(zhi)”的(de)啟發下,指出對(dui)其身體壯實者,可(ke)酌(zhuo)加大(da)黃(huang)數(shu)錢(qian)以逐瘀;其身形脈象(xiang)(xiang)不甚壯實者,加桃仁、丹參等化瘀。并明確(que)提出“腦(nao)(nao)(nao)(nao)充(chong)血(xue)(xue)(xue)當通大(da)便為要務”。對(dui)腦(nao)(nao)(nao)(nao)充(chong)血(xue)(xue)(xue)后(hou)期(qi)脈象(xiang)(xiang)柔和(he)而(er)(er)肢體痿廢者,主張“少(shao)用(yong)黃(huang)芪助(zhu)活血(xue)(xue)(xue)之(zhi)(zhi)(zhi)品以通絡”,但(dan)應謹慎(shen)從事(shi)。而(er)(er)對(dui)于“血(xue)(xue)(xue)菀于上”的(de)腦(nao)(nao)(nao)(nao)充(chong)血(xue)(xue)(xue)者,因黃(huang)芪之(zhi)(zhi)(zhi)情,補而(er)(er)兼升(sheng)(sheng),氣升(sheng)(sheng)則(ze)血(xue)(xue)(xue)必隨之(zhi)(zhi)(zhi)升(sheng)(sheng),故病初應忌用(yong)黃(huang)芪,誤用(yong)則(ze)兇危立見(jian)。其辨證之(zhi)(zhi)(zhi)嚴謹,用(yong)藥之(zhi)(zhi)(zhi)精(jing)確(que),可(ke)見(jian)一(yi)斑(ban)。
2、腦貧血治療
與腦(nao)(nao)(nao)充血(xue)證(zheng)(zheng)相(xiang)反,張氏認(ren)為腦(nao)(nao)(nao)貧血(xue)證(zheng)(zheng)則為血(xue)之(zhi)上(shang)注于腦(nao)(nao)(nao)過(guo)少,無以養其腦(nao)(nao)(nao)髓神(shen)經(jing),致使腦(nao)(nao)(nao)神(shen)經(jing)失其所司。而血(xue)之(zhi)上(shang)注過(guo)少,實由“宗氣(qi)(qi)虛寒,不能助血(xue)上(shang)升(sheng)川”。故治療(liao)腦(nao)(nao)(nao)貧血(xue)證(zheng)(zheng),主張“應峻補(bu)其胸中大氣(qi)(qi)”,自擬(ni)(ni)當(dang)歸(gui)補(bu)血(xue)湯(tang)益氣(qi)(qi)溫(wen)陽、補(bu)血(xue)活(huo)血(xue),治療(liao)中風脈(mo)象(xiang)遲(chi)弱,身軟,肢(zhi)體漸覺不利,或頭重(zhong)目眩,或神(shen)昏(hun)(hun)健忘,甚或昏(hun)(hun)仆,移時蘇醒致成偏枯者(zhe)(zhe)。方中主以黃芪升(sheng)補(bu)胸中大氣(qi)(qi),使血(xue)隨氣(qi)(qi)升(sheng),上(shang)達腦(nao)(nao)(nao)中;用(yong)當(dang)歸(gui)、龍眼肉、鹿角膠養血(xue)生(sheng)髓;丹參、乳、沒(mei)開(kai)血(xue)痹,化(hua)瘀(yu)滯;甘松助心房運行有力,以多輸血(xue)于腦(nao)(nao)(nao),且(qie)又(you)為調養神(shen)經(jing)之(zhi)品。對于腦(nao)(nao)(nao)貧血(xue)肢(zhi)體痿廢(fei)或偏枯,脈(mo)象(xiang)極微(wei)細無力者(zhe)(zhe),又(you)擬(ni)(ni)干頹湯(tang)、補(bu)腦(nao)(nao)(nao)振(zhen)痿湯(tang)治療(liao)。并指出肢(zhi)體偏廢(fei),服(fu)藥久(jiu)不效者(zhe)(zhe),應著重(zhong)補(bu)腎通絡,多選用(yong)胡桃肉、地龍、馬錢子等。
(二(er))重視(shi)沖(chong)氣為病,善用鎮沖(chong)降逆
沖(chong)(chong)(chong)(chong)脈(mo)(mo)為(wei)(wei)奇經(jing)八脈(mo)(mo)之(zhi)一(yi),張(zhang)氏(shi)論病(bing)(bing)極重視沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi),指出“沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)沖(chong)(chong)(chong)(chong)之(zhi)病(bing)(bing)甚多(duo)(duo),而(er)(er)醫者(zhe)識(shi)其(qi)病(bing)(bing)者(zhe)甚少。即(ji)或(huo)(huo)(huo)能(neng)識(shi)此病(bing)(bing),亦(yi)多(duo)(duo)不(bu)(bu)能(neng)洞悉(xi)其(qi)病(bing)(bing)因”。因而(er)(er),對沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)的生(sheng)理,尤其(qi)是沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)沖(chong)(chong)(chong)(chong)的病(bing)(bing)因、病(bing)(bing)理、病(bing)(bing)脈(mo)(mo)、治(zhi)法都作了(le)詳(xiang)細闡(chan)述(shu),自成一(yi)家之(zhi)言。其(qi)述(shu)沖(chong)(chong)(chong)(chong)脈(mo)(mo),、兼采《內》《難》之(zhi)說(shuo),認(ren)為(wei)(wei)其(qi)“在胞室之(zhi)兩(liang)旁,與任脈(mo)(mo)相連(lian),為(wei)(wei)腎(shen)臟之(zhi)輔弼,氣(qi)(qi)(qi)(qi)(qi)(qi)化相通……上(shang)(shang)(shang)系原(yuan)隸陽明胃腑”,并認(ren)為(wei)(wei)“沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)沖(chong)(chong)(chong)(chong)之(zhi)證,固由于(yu)腎(shen)臟之(zhi)虛,亦(yi)多(duo)(duo)由于(yu)肝(gan)氣(qi)(qi)(qi)(qi)(qi)(qi)恣(zi)橫,素性多(duo)(duo)怒之(zhi)人,其(qi)肝(gan)氣(qi)(qi)(qi)(qi)(qi)(qi)之(zhi)暴發(fa),更助沖(chong)(chong)(chong)(chong)胃之(zhi)氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)逆”。即(ji)腎(shen)虛無以涵木,不(bu)(bu)能(neng)收斂沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi),沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)行,肝(gan)氣(qi)(qi)(qi)(qi)(qi)(qi)橫逆,胃氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)逆而(er)(er)呈上(shang)(shang)(shang)沖(chong)(chong)(chong)(chong)之(zhi)弊。張(zhang)氏(shi)描述(shu)的沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)沖(chong)(chong)(chong)(chong)證,除自覺有氣(qi)(qi)(qi)(qi)(qi)(qi)自下(xia)上(shang)(shang)(shang)沖(chong)(chong)(chong)(chong),脈(mo)(mo)多(duo)(duo)弦硬而(er)(er)長外,主(zhu)要表(biao)現有胃脘或(huo)(huo)(huo)腹中(zhong)滿悶,噦氣(qi)(qi)(qi)(qi)(qi)(qi),呃逆連(lian)連(lian),嘔吐不(bu)(bu)止(zhi),或(huo)(huo)(huo)見吐血、衄血等(deng)(deng)胃氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)逆不(bu)(bu)降(jiang)見癥(zheng);或(huo)(huo)(huo)兩(liang)脅痛脹,頭目眩暈,甚而(er)(er)氣(qi)(qi)(qi)(qi)(qi)(qi)火挾痰上(shang)(shang)(shang)沖(chong)(chong)(chong)(chong),發(fa)生(sheng)突然昏(hun)仆(pu)等(deng)(deng);或(huo)(huo)(huo)為(wei)(wei)胸滿窒塞,喘息大作。其(qi)治(zhi)療,主(zhu)張(zhang)以斂沖(chong)(chong)(chong)(chong)鎮(zhen)(zhen)沖(chong)(chong)(chong)(chong)為(wei)(wei)主(zhu),降(jiang)胃平肝(gan)為(wei)(wei)佐,獨(du)創(chuang)參赭(zhe)鎮(zhen)(zhen)氣(qi)(qi)(qi)(qi)(qi)(qi)湯、鎮(zhen)(zhen)沖(chong)(chong)(chong)(chong)降(jiang)胃湯等(deng)(deng)鎮(zhen)(zhen)沖(chong)(chong)(chong)(chong)諸方。其(qi)組方特(te)色,一(yi)為(wei)(wei)善(shan)(shan)用鎮(zhen)(zhen)沖(chong)(chong)(chong)(chong)降(jiang)逆之(zhi)品,如赭(zhe)石、龍、牡等(deng)(deng);一(yi)為(wei)(wei)善(shan)(shan)用補虛固澀之(zhi)品,如山萸肉(rou)、山藥、白芍、芡實等(deng)(deng),攻中(zhong)有補,降(jiang)斂結合,用之(zhi)臨床,確有良效。其(qi)沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)學說(shuo)為(wei)(wei)中(zhong)醫臨床治(zhi)療雜病(bing)(bing)又辟新徑。
(三)脫(tuo)分上(shang)下內(nei)外(wai),治(zhi)脫(tuo)重(zhong)視肝虛
張(zhang)氏認為(wei)脫(tuo)(tuo)雖(sui)有上(shang)、下(xia)(xia)(xia)、內、外(wai)之(zhi)別,概由(you)肝(gan)虛,其(qi)云:“凡人(ren)元(yuan)氣(qi)(qi)(qi)(qi)之(zhi)脫(tuo)(tuo),皆脫(tuo)(tuo)在肝(gan)”。他(ta)根(gen)據(ju)肝(gan)主疏泄(xie)(xie)、調(diao)暢氣(qi)(qi)(qi)(qi)機的(de)功(gong)能(neng),認為(wei)元(yuan)氣(qi)(qi)(qi)(qi)的(de)運行和胃(wei)氣(qi)(qi)(qi)(qi)的(de)布(bu)化,全賴(lai)于(yu)(yu)(yu)肝(gan)臟正(zheng)常的(de)疏泄(xie)(xie)功(gong)能(neng)。倘肝(gan)虛則(ze)損泄(xie)(xie)元(yuan)氣(qi)(qi)(qi)(qi),耗散腎(shen)氣(qi)(qi)(qi)(qi),而為(wei)上(shang)脫(tuo)(tuo)或下(xia)(xia)(xia)脫(tuo)(tuo)。“蓋元(yuan)氣(qi)(qi)(qi)(qi)上(shang)脫(tuo)(tuo)由(you)于(yu)(yu)(yu)肝(gan),其(qi)下(xia)(xia)(xia)脫(tuo)(tuo)亦由(you)于(yu)(yu)(yu)肝(gan)。誠以肝(gan)能(neng)為(wei)腎(shen)行氣(qi)(qi)(qi)(qi),即能(neng)瀉元(yuan)氣(qi)(qi)(qi)(qi)自(zi)下(xia)(xia)(xia)出也”。(《醫學(xue)衷中參(can)(can)西錄·醫案·霍亂門》)上(shang)脫(tuo)(tuo)之(zhi)證,“喘逆迫促,脈若水上(shang)浮麻(ma)”,張(zhang)氏制參(can)(can)赭(zhe)鎮氣(qi)(qi)(qi)(qi)湯(tang)救(jiu)之(zhi)。方(fang)中以人(ren)參(can)(can)補虛極(ji)之(zhi)諸氣(qi)(qi)(qi)(qi),借“赭(zhe)石下(xia)(xia)(xia)行之(zhi)力,挽(wan)回(hui)將(jiang)(jiang)脫(tuo)(tuo)之(zhi)元(yuan)氣(qi)(qi)(qi)(qi)”;蘇(su)子助(zhu)赭(zhe)石降氣(qi)(qi)(qi)(qi);生(sheng)山藥(yao)、生(sheng)白芍滋補肝(gan)胃(wei)之(zhi)陰(yin)(yin),以守持(chi)元(yuan)氣(qi)(qi)(qi)(qi);山萸肉、生(sheng)芡實、生(sheng)龍(long)骨、生(sheng)牡蠣酸(suan)斂(lian)收澀,固攝(she)元(yuan)氣(qi)(qi)(qi)(qi)。下(xia)(xia)(xia)脫(tuo)(tuo),如“日夜吐瀉不已,脈沉細欲無,虛極(ji)將(jiang)(jiang)脫(tuo)(tuo)者(zhe),為(wei)至危之(zhi)候”,張(zhang)氏以急救(jiu)回(hui)陽湯(tang)救(jiu)之(zhi),方(fang)用人(ren)參(can)(can)以回(hui)陽;山藥(yao)、芍藥(yao)滋陰(yin)(yin);重用山萸肉斂(lian)肝(gan)固脫(tuo)(tuo)。上(shang)下(xia)(xia)(xia)兩脫(tuo)(tuo)兼見(jian)者(zhe),挽(wan)陰(yin)(yin)回(hui)陽,以“既濟湯(tang)”酸(suan)斂(lian)固澀。
除元氣(qi)(qi)(qi)上脫(tuo)(tuo)(tuo)(tuo)、下(xia)(xia)脫(tuo)(tuo)(tuo)(tuo)之(zhi)外,又(you)有所謂外脫(tuo)(tuo)(tuo)(tuo)、內(nei)脫(tuo)(tuo)(tuo)(tuo)。外脫(tuo)(tuo)(tuo)(tuo)者,癥見周身汗出不(bu)(bu)止(zhi),或(huo)(huo)(huo)(huo)“目睛上竄(cuan),或(huo)(huo)(huo)(huo)喘逆,或(huo)(huo)(huo)(huo)怔忡,或(huo)(huo)(huo)(huo)氣(qi)(qi)(qi)虛(xu)不(bu)(bu)足以(yi)(yi)息”,張氏認為此(ci)乃“肝(gan)膽虛(xu)極而(er)元氣(qi)(qi)(qi)欲脫(tuo)(tuo)(tuo)(tuo)也”。即肝(gan)陰過虛(xu),肝(gan)風萌動,元氣(qi)(qi)(qi)欲脫(tuo)(tuo)(tuo)(tuo),用(yong)來復湯(tang)治之(zhi)。內(nei)脫(tuo)(tuo)(tuo)(tuo),如“胸(xiong)中大(da)氣(qi)(qi)(qi)下(xia)(xia)陷(xian),氣(qi)(qi)(qi)短不(bu)(bu)足以(yi)(yi)息,或(huo)(huo)(huo)(huo)努力呼吸(xi),有似(si)乎喘,或(huo)(huo)(huo)(huo)氣(qi)(qi)(qi)息將停(ting),危在頃(qing)刻(ke)……其(qi)(qi)脈象沉遲微弱(ruo),關前尤甚;其(qi)(qi)劇者,或(huo)(huo)(huo)(huo)六脈不(bu)(bu)全(quan),或(huo)(huo)(huo)(huo)參伍不(bu)(bu)調”,此(ci)系中氣(qi)(qi)(qi)自(zi)內(nei)而(er)陷(xian)的內(nei)脫(tuo)(tuo)(tuo)(tuo)證(zheng),張氏以(yi)(yi)“升陷(xian)湯(tang)”升補下(xia)(xia)陷(xian)之(zhi)氣(qi)(qi)(qi),再加山萸肉收斂氣(qi)(qi)(qi)分之(zhi)耗散,使升者不(bu)(bu)至復陷(xian),共挽中氣(qi)(qi)(qi)下(xia)(xia)陷(xian)所致之(zhi)內(nei)脫(tuo)(tuo)(tuo)(tuo)。
從上述救(jiu)脫(tuo)方可見,張(zhang)氏救(jiu)脫(tuo)善用(yong)(yong)山萸(yu)(yu)肉。他認為(wei)山英肉味(wei)酸性(xing)溫,固(gu)澀滑脫(tuo),通利九竅(qiao),流通血脈,為(wei)補(bu)肝(gan)之(zhi)妙藥(yao),其救(jiu)脫(tuo)之(zhi)功(gong),較參(can)、術、芪更勝。“蓋萸(yu)(yu)肉之(zhi)性(xing),不(bu)獨(du)補(bu)肝(gan)也,凡人(ren)身之(zhi)陰陽,氣血將散者,皆能斂之(zhi),故救(jiu)脫(tuo)之(zhi)藥(yao),當以萸(yu)(yu)肉為(wei)第一”。常用(yong)(yong)萸(yu)(yu)肉治療各種虛脫(tuo)危證,或(huo)配(pei)(pei)以生龍骨、牡蠣斂汗(han);或(huo)配(pei)(pei)人(ren)參(can)、附子(zi)、山藥(yao)、炙甘草(cao)益氣回陽固(gu)脫(tuo);或(huo)配(pei)(pei)當歸、熟(shu)地填補(bu)精血等。其論脫(tuo)證病(bing)機及治法(fa)用(yong)(yong)藥(yao),別開生面,對后人(ren)啟迪(di)尤深(shen)。
(四(si))遣藥制(zhi)方心得
張氏(shi)制方用藥頗有獨到經驗,通性味(wei),善配伍,別具匠心。具體(ti)表(biao)現在以下幾(ji)個方面。
1、精(jing)研藥物,頗多新見
張氏(shi)認(ren)(ren)為學(xue)醫的第一(yi)層功夫(fu)即是識(shi)藥(yao)(yao)性(xing),其對(dui)藥(yao)(yao)性(xing)的理解,于諸家本草學(xue)之外,頗多新見。《醫學(xue)衷中(zhong)參西錄》書中(zhong)專列(lie)《藥(yao)(yao)物(wu)(wu)》一(yi)章,對(dui)常用的79種藥(yao)(yao)物(wu)(wu)詳加解釋(shi),闡述了張氏(shi)對(dui)藥(yao)(yao)物(wu)(wu)的獨(du)到認(ren)(ren)識(shi)與(yu)經驗(yan)。其中(zhong)他研究(jiu)最精的藥(yao)(yao)物(wu)(wu)有黃芪、山(shan)萸肉、赭石、山(shan)藥(yao)(yao)、三七、黨(dang)參、乳香、沒藥(yao)(yao)、三棱、水蛭、牛膝、龍骨、牡蠣等(deng)。
例(li)如,他(ta)廣泛(fan)應用大劑(ji)量石膏治療(liao)外感熱性(xing)(xing)病屢收良效(xiao)(xiao),認為(wei)并(bing)無(wu)(wu)損傷(shang)脾胃(wei)之(zhi)(zhi)弊,且隨著熱退病愈而(er)(er)(er)飲食倍增,為(wei)清(qing)解(jie)大熱之(zhi)(zhi)特效(xiao)(xiao)藥(yao)(yao)(yao)。善(shan)(shan)用三(san)棱、莪術,認為(wei)二(er)藥(yao)(yao)(yao)善(shan)(shan)破血(xue)(xue)、調氣(qi)(qi)(qi)(qi)(qi)(qi),化(hua)瘀則(ze)三(san)棱優于(yu)莪術,理(li)氣(qi)(qi)(qi)(qi)(qi)(qi)則(ze)莪術優于(yu)三(san)棱,若“二(er)藥(yao)(yao)(yao)合(he)用,常有(you)協(xie)同之(zhi)(zhi)功”。認為(wei)水(shui)蛭破瘀最效(xiao)(xiao),善(shan)(shan)除(chu)日久之(zhi)(zhi)瘀滯(zhi),能(neng)(neng)使瘀血(xue)(xue)默消于(yu)無(wu)(wu)形(xing)之(zhi)(zhi)中(zhong),乳香善(shan)(shan)透竅理(li)氣(qi)(qi)(qi)(qi)(qi)(qi),沒藥(yao)(yao)(yao)善(shan)(shan)化(hua)瘀理(li)血(xue)(xue),二(er)藥(yao)(yao)(yao)并(bing)用為(wei)宣通(tong)臟腑、流通(tong)經絡(luo)之(zhi)(zhi)要藥(yao)(yao)(yao),常用于(yu)治心、胃(wei)、脅、腹及肢體關節諸痛(tong),經痛(tong),產后瘀血(xue)(xue)腹痛(tong),月經不(bu)調,風(feng)(feng)寒濕(shi)痹,中(zhong)風(feng)(feng)四肢不(bu)遂及一(yi)切(qie)瘡瘍腫痛(tong);雞內金味(wei)酸性(xing)(xing)溫(wen)藥(yao)(yao)(yao)性(xing)(xing)平(ping)和,有(you)補(bu)脾胃(wei)之(zhi)(zhi)妙,善(shan)(shan)化(hua)有(you)形(xing)之(zhi)(zhi)瘀積;山楂化(hua)瘀血(xue)(xue)而(er)(er)(er)不(bu)傷(shang)新血(xue)(xue),開郁(yu)氣(qi)(qi)(qi)(qi)(qi)(qi)而(er)(er)(er)不(bu)傷(shang)正氣(qi)(qi)(qi)(qi)(qi)(qi);茵陳、麥芽皆具(ju)疏肝解(jie)郁(yu)之(zhi)(zhi)效(xiao)(xiao),體弱陰虛不(bu)任柴胡升散者,常以其代之(zhi)(zhi);黃芪(qi)性(xing)(xing)溫(wen)味(wei)微甘,補(bu)氣(qi)(qi)(qi)(qi)(qi)(qi)兼能(neng)(neng)升氣(qi)(qi)(qi)(qi)(qi)(qi),善(shan)(shan)治氣(qi)(qi)(qi)(qi)(qi)(qi)虛、氣(qi)(qi)(qi)(qi)(qi)(qi)陷諸證(zheng),且其“性(xing)(xing)溫(wen)而(er)(er)(er)上升,以之(zhi)(zhi)補(bu)肝有(you)同氣(qi)(qi)(qi)(qi)(qi)(qi)相求之(zhi)(zhi)妙用”,故(gu)凡肝氣(qi)(qi)(qi)(qi)(qi)(qi)虛弱不(bu)能(neng)(neng)條達,用一(yi)切(qie)補(bu)肝之(zhi)(zhi)藥(yao)(yao)(yao)皆不(bu)效(xiao)(xiao)者,倡重用黃芪(qi)為(wei)主,而(er)(er)(er)少佐以理(li)氣(qi)(qi)(qi)(qi)(qi)(qi)之(zhi)(zhi)品,并(bing)據此批評“肝虛無(wu)(wu)補(bu)法”之(zhi)(zhi)談。這些獨創性(xing)(xing)見解(jie),擴大和豐(feng)富了藥(yao)(yao)(yao)物(wu)的臨床(chuang)應用范圍。
2、善用生藥,注(zhu)重(zhong)配伍
張錫純在(zai)《醫學衷(zhong)中(zhong)參西錄(lu)》中(zhong)自(zi)擬良方(fang)百余首,以生(sheng)(sheng)(sheng)藥見長,對生(sheng)(sheng)(sheng)藥的(de)使用(yong)(yong)獨具卓見。如(ru)水蛭,方(fang)書多謂必須炙透方(fang)可使用(yong)(yong),但(dan)張氏(shi)認為(wei),此物生(sheng)(sheng)(sheng)于水中(zhong),原得水之精(jing)氣(qi)而(er)生(sheng)(sheng)(sheng),炙之則傷水之精(jing)氣(qi),不(bu)若生(sheng)(sheng)(sheng)用(yong)(yong)。因而(er)在(zai)治(zhi)療經(jing)閉不(bu)行、產(chan)后惡露不(bu)盡或瘀血頑癥時(shi),常(chang)于理(li)沖湯、理(li)沖丸中(zhong)加入水蛭一(yi)錢或一(yi)兩(liang),并標明“不(bu)用(yong)(yong)炙”。認為(wei)赭石色赤性微涼,生(sheng)(sheng)(sheng)血兼能涼血,且(qie)因其(qi)質重墜,又(you)可鎮逆(ni)(ni)、降痰(tan)、止嘔、通便(bian),“生(sheng)(sheng)(sheng)研服之不(bu)傷腸胃……且(qie)生(sheng)(sheng)(sheng)服則養氣(qi)純全,大(da)能養血”。故治(zhi)陰(yin)陽兩(liang)虛、喘逆(ni)(ni)迫(po)促(cu)之喘息,重用(yong)(yong)生(sheng)(sheng)(sheng)赭石伍以生(sheng)(sheng)(sheng)龍牡斂(lian)沖降逆(ni)(ni);又(you)與肉蓯(cong)蓉(rong)、當歸(gui)并用(yong)(yong),補腎(shen)斂(lian)沖,潤(run)便(bian)通結。張氏(shi)臨床常(chang)用(yong)(yong)的(de)生(sheng)(sheng)(sheng)藥還(huan)有生(sheng)(sheng)(sheng)乳(ru)香(xiang)、生(sheng)(sheng)(sheng)沒藥、生(sheng)(sheng)(sheng)雞內金(jin)、生(sheng)(sheng)(sheng)黃芪(qi)、生(sheng)(sheng)(sheng)山藥、生(sheng)(sheng)(sheng)杭(hang)芍、生(sheng)(sheng)(sheng)石膏等(deng)。
此外,張氏根據其臨床(chuang)經驗和體會,總(zong)結出許多新(xin)的藥對配(pei)伍關系。如(ru)山(shan)藥配(pei)牛(niu)蒡子,疏補兼行,補腎(shen)健脾,清肺止咳(ke),祛痰降氣;人(ren)參(can)配(pei)代赭石,剛(gang)柔相(xiang)濟,升降互用(yong),治(zhi)療脾胃氣虛,沖氣相(xiang)干,或用(yong)于上盛下虛、氣血將脫;黃芪配(pei)知母,寒(han)熱(re)平(ping)調以益氣升舉;人(ren)參(can)配(pei)威靈(ling)仙治(zhi)氣虛小(xiao)便不利;生龍(long)、牡配(pei)萸肉,三藥聯合(he)應(ying)用(yong),收斂固脫、澀精止汗等,均可(ke)資臨床(chuang)參(can)考。
3、潛心實踐(jian),創制新方(fang)
張氏對方(fang)(fang)藥的運用也頗有心(xin)得(de),在(zai)《醫學(xue)衷中(zhong)(zhong)參西(xi)錄》中(zhong)(zhong)創(chuang)立了許多(duo)有效的方(fang)(fang)劑,廣及(ji)內、外、婦、兒各科,其(qi)多(duo)有所(suo)宗,遵經而(er)(er)(er)不(bu)(bu)泥古,通變(bian)而(er)(er)(er)不(bu)(bu)失規矩。其(qi)中(zhong)(zhong),有不(bu)(bu)少為(wei)師法仲景原意而(er)(er)(er)化裁(cai)創(chuang)制(zhi)的新方(fang)(fang)。如治(zhi)吐(tu)衄諸方(fang)(fang)是受《金匱(kui)》瀉(xie)心(xin)湯(tang)(tang)(tang)(tang)影響,以(yi)降胃為(wei)主,故喜用赭(zhe)石、半夏。治(zhi)療胸(xiong)(xiong)中(zhong)(zhong)蘊熱(re)為(wei)外感所(suo)束,不(bu)(bu)能發(fa)泄而(er)(er)(er)致煩躁(zao)的猶龍湯(tang)(tang)(tang)(tang),立意源(yuan)于大(da)青龍湯(tang)(tang)(tang)(tang),由連翹、生石膏、蟬蛻(tui)、牛(niu)蒡子(zi)組成(cheng)。治(zhi)滿悶短氣(qi),呼吸不(bu)(bu)利的蕩胸(xiong)(xiong)湯(tang)(tang)(tang)(tang),于大(da)陷(xian)胸(xiong)(xiong)湯(tang)(tang)(tang)(tang)中(zhong)(zhong)取(qu)用芒硝,于小陷(xian)胸(xiong)(xiong)湯(tang)(tang)(tang)(tang)中(zhong)(zhong)取(qu)用瓜蔞,又(you)于治(zhi)心(xin)下痞硬之(zhi)(zhi)旋(xuan)覆(fu)代赭(zhe)湯(tang)(tang)(tang)(tang)中(zhong)(zhong)取(qu)用赭(zhe)石,而(er)(er)(er)復加蘇子(zi)以(yi)為(wei)下行之(zhi)(zhi)向(xiang)導,可以(yi)代大(da)陷(xian)胸(xiong)(xiong)湯(tang)(tang)(tang)(tang)、丸,亦可代小陷(xian)胸(xiong)(xiong)湯(tang)(tang)(tang)(tang)。又(you)如其(qi)治(zhi)療婦科病(bing)之(zhi)(zhi)理沖(chong)湯(tang)(tang)(tang)(tang)、理沖(chong)丸,用參、術、當歸、山藥等補氣(qi)健脾扶正(zheng),莪術、三棱(leng)、水蛭等活血化瘀,為(wei)攻補兼(jian)施,扶正(zheng)化瘀,治(zhi)閉經及(ji)癥瘕之(zhi)(zhi)虛(xu)實夾雜證(zheng)良方(fang)(fang)。又(you)如治(zhi)崩(beng)漏的安沖(chong)湯(tang)(tang)(tang)(tang)、固沖(chong)湯(tang)(tang)(tang)(tang),熔塞(sai)流、澄源(yuan)、補虛(xu)于一爐,止血而(er)(er)(er)不(bu)(bu)留(liu)瘀,清熱(re)而(er)(er)(er)不(bu)(bu)涼遏(e),溫(wen)補而(er)(er)(er)不(bu)(bu)閉邪。再如,如治(zhi)陰(yin)虛(xu)勞(lao)嗽之(zhi)(zhi)資生湯(tang)(tang)(tang)(tang),治(zhi)腦(nao)充血頭目(mu)眩暈之(zhi)(zhi)建瓴(ling)湯(tang)(tang)(tang)(tang),治(zhi)心(xin)腹疼痛、癥瘕痰癖的活絡效靈丹,治(zhi)腎虛(xu)滑(hua)胎(tai)的壽胎(tai)丸等等,都(dou)是行之(zhi)(zhi)有效的名(ming)方(fang)(fang)。
張氏治學嚴謹(jin),重(zhong)視實(shi)踐,主(zhu)張溝通中(zhong)西(xi),取長(chang)補(bu)短,是近代中(zhong)西(xi)醫匯通派(pai)的(de)代表之(zhi)一。結合其多年臨證經驗與(yu)匯通中(zhong)西(xi)的(de)體會,著成《醫學衷(zhong)中(zhong)參(can)西(xi)錄》。
張錫純,字壽(shou)甫,清末民初河北省鹽山縣人。生活于(yu)公元(yuan)1860~1933年(清咸豐十年至民國二十二年)。幼(you)敏而好(hao)學(xue)(xue),攻(gong)讀經史之余,兼習岐(qi)黃之書,后因兩試秋闈不第(di),遂潛心醫學(xue)(xue)。早年懸壺鄉梓,革命軍興(xing),應聘從戎(rong)去武漢為軍醫。1917年在沈陽創建(jian)“立達(da)中醫院”。直奉戰起,回故(gu)居河北滄州行醫,1926年移居天(tian)(tian)津,創辦“天(tian)(tian)津國醫函授(shou)學(xue)(xue)校”,培(pei)養(yang)了大批中醫后繼人才。
張(zhang)氏(shi)治學嚴謹,重視實踐,主張(zhang)溝通(tong)中西(xi),取長(chang)補(bu)短,是(shi)近代中西(xi)醫(yi)匯通(tong)派的(de)代表之一(yi)。其(qi)醫(yi)德(de)高尚(shang),常(chang)舍藥濟貧(pin),遇疑難重癥,殫思(si)竭慮,并親自(zi)攜藥到病家督(du)煎,守護達旦。為了體驗(yan)藥物(wu)的(de)毒(du)性反(fan)應和(he)用量,曾親嘗(chang)巴豆、花椒、甘遂等藥,足見其(qi)對病人(ren)極端(duan)負責的(de)精神和(he)重視實踐的(de)治學態(tai)度。他醫(yi)術精湛,常(chang)能力排眾議,獨(du)任其(qi)責,起群(qun)醫(yi)束手之沉(chen)疴(ke),療效卓(zhuo)著,名震(zhen)遐邇。當(dang)時與江蘇陸晉笙、楊如(ru)侯,廣東(dong)劉蔚楚同負盛名,又與慈溪張(zhang)生甫、嘉定張(zhang)山雷并稱名醫(yi)三張(zhang)。
張氏勤于(yu)鉆研,善于(yu)總(zong)結(jie),平生(sheng)著述甚多(duo),后因天津洪水沒其(qi)居,遺書(shu)蕩盡,傳世者僅(jin)《醫學衷中參西錄》一書(shu)。
《醫(yi)學衷中(zhong)參西錄》為20世紀(ji)中(zhong)醫(yi)臨床(chuang)醫(yi)學名著,素(su)為醫(yi)家所重視(shi)。