芒果视频下载

基本介紹

《醫(yi)(yi)(yi)學衷中(zhong)(zhong)(zhong)參(can)西(xi)錄(lu)》，中(zhong)(zhong)(zhong)醫(yi)(yi)(yi)叢書，又名《衷中(zhong)(zhong)(zhong)參(can)西(xi)錄(lu)》，張(zhang)錫純(壽甫)撰。此(ci)書分為(wei)《處方學》8卷(juan)、《醫(yi)(yi)(yi)論》8卷(juan)、《醫(yi)(yi)(yi)話拾零》、《三(san)三(san)醫(yi)(yi)(yi)書評》、《藥(yao)(yao)物講(jiang)義》4卷(juan)、《傷寒講(jiang)義》4卷(juan)、《醫(yi)(yi)(yi)案(an)(附詩(shi)草)》4卷(juan)。系作(zuo)者多(duo)(duo)年治學臨證(zheng)(zheng)(zheng)經驗和(he)心得之總(zong)結。是20世紀初我國重(zhong)(zhong)要的(de)(de)(de)(de)臨床綜合性(xing)(xing)名著。張(zhang)氏(shi)致(zhi)力(li)溝(gou)通(tong)中(zhong)(zhong)(zhong)西(xi)醫(yi)(yi)(yi)學，主(zhu)張(zhang)以中(zhong)(zhong)(zhong)醫(yi)(yi)(yi)為(wei)主(zhu)體(ti)，取西(xi)醫(yi)(yi)(yi)之長，補(bu)中(zhong)(zhong)(zhong)醫(yi)(yi)(yi)之短(duan)。他認(ren)為(wei)：“欲(yu)求醫(yi)(yi)(yi)學登峰造極，誠非溝(gou)通(tong)中(zhong)(zhong)(zhong)西(xi)醫(yi)(yi)(yi)不(bu)(bu)可。”其于溝(gou)通(tong)中(zhong)(zhong)(zhong)西(xi)醫(yi)(yi)(yi)的(de)(de)(de)(de)主(zhu)導思想，主(zhu)張(zhang)師古(gu)而不(bu)(bu)泥古(gu)，參(can)西(xi)而不(bu)(bu)背中(zhong)(zhong)(zhong)。張(zhang)氏(shi)重(zhong)(zhong)視基(ji)礎理(li)論，對(dui)臟象學說和(he)解(jie)剖(pou)生(sheng)理(li)的(de)(de)(de)(de)互證(zheng)(zheng)(zheng)尤為(wei)重(zhong)(zhong)視。書中(zhong)(zhong)(zhong)指出：腦為(wei)元神，心為(wei)識(shi)神，心力(li)衰竭與(yu)(yu)(yu)腎(shen)不(bu)(bu)納氣相通(tong)；腦充血與(yu)(yu)(yu)薄厥(jue)相近(jin)等(deng)等(deng)。在臨證(zheng)(zheng)(zheng)方面，講(jiang)究(jiu)細(xi)致(zhi)的(de)(de)(de)(de)觀察和(he)記述(shu)病(bing)情，建立完整(zheng)的(de)(de)(de)(de)病(bing)歷。其于諸病(bing)治法，注重(zhong)(zhong)實際，勇(yong)于探索(suo)，并獨創(chuang)了許(xu)多(duo)(duo)新的(de)(de)(de)(de)治療方劑，體(ti)驗了若干中(zhong)(zhong)(zhong)藥(yao)(yao)的(de)(de)(de)(de)性(xing)(xing)能。對(dui)諸如萸肉救脫(tuo)，參(can)芪利尿，白礬化痰熱，三(san)七消瘡腫，生(sheng)硫黃內(nei)服治虛寒下痢，蜈蚣(gong)、蝎子定風消毒(du)等(deng)等(deng)，均能發(fa)揚(yang)古(gu)說，擴大藥(yao)(yao)用(yong)主(zhu)治。如對(dui)調治脾(pi)(pi)胃，主(zhu)張(zhang)脾(pi)(pi)陽與(yu)(yu)(yu)胃陰并重(zhong)(zhong)，升肝脾(pi)(pi)與(yu)(yu)(yu)降膽胃兼施，補(bu)養與(yu)(yu)(yu)開破(po)相結合。書中(zhong)(zhong)(zhong)結合中(zhong)(zhong)(zhong)西(xi)醫(yi)(yi)(yi)學理(li)論和(he)醫(yi)(yi)(yi)療實踐闡發(fa)醫(yi)(yi)(yi)理(li)，頗多(duo)(duo)獨到(dao)的(de)(de)(de)(de)見解(jie)。書中(zhong)(zhong)(zhong)載述(shu)張(zhang)氏(shi)所制(zhi)定的(de)(de)(de)(de)若干有效方劑；在方藥(yao)(yao)應用(yong)方面，創(chuang)用(yong)中(zhong)(zhong)(zhong)西(xi)藥(yao)(yao)相結合的(de)(de)(de)(de)方劑，并對(dui)石(shi)(shi)膏、生(sheng)山藥(yao)(yao)、代(dai)赭石(shi)(shi)等(deng)藥(yao)(yao)的(de)(de)(de)(de)臨床施治，在古(gu)人基(ji)礎上有重(zhong)(zhong)要的(de)(de)(de)(de)補(bu)訂、發(fa)揮。

內容介紹

《醫(yi)學衷中(zhong)參西錄》為張錫純唯一傳世的著(zhu)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)東漸，西(xi)(xi)醫學(xue)在我(wo)國(guo)流傳甚快。當時，醫學(xue)界有(you)些(xie)人崇尚西(xi)(xi)學(xue)，輕視中(zhong)醫，有(you)些(xie)中(zhong)醫則一味排(pai)斥西(xi)(xi)醫，因循守舊。張(zhang)(zhang)氏則主張(zhang)(zhang)以中(zhong)醫為本體，擷取西(xi)(xi)醫之長補中(zhong)醫之短，倡導(dao)“衷(zhong)中(zhong)參(can)西(xi)(xi)”，并(bing)從理論(lun)、實(shi)踐方面進(jin)行了嘗試，《醫學(xue)衷(zhong)中(zhong)參(can)西(xi)(xi)錄》的(de)書名就(jiu)鮮明地表明了張(zhang)(zhang)氏的(de)學(xue)術主張(zhang)(zhang)。

在生理、病理方面，張(zhang)氏于(yu)(yu)《醫(yi)學衷(zhong)中(zhong)參西錄》中(zhong)有許多溝通中(zhong)西醫(yi)學的(de)新見解(jie)，如：“中(zhong)醫(yi)謂(wei)(wei)人之(zhi)(zhi)神(shen)明(ming)(ming)(ming)(ming)在心(xin)(xin)，西說謂(wei)(wei)人之(zhi)(zhi)神(shen)明(ming)(ming)(ming)(ming)在腦(nao)，及觀《內經》，皆(jie)(jie)(jie)涵蓋其中(zhong)也”。《素問·脈(mo)要(yao)精(jing)(jing)微論(lun)》中(zhong)指出(chu)(chu)“頭(tou)者(zhe)精(jing)(jing)明(ming)(ming)(ming)(ming)之(zhi)(zhi)府”，說明(ming)(ming)(ming)(ming)神(shen)明(ming)(ming)(ming)(ming)之(zhi)(zhi)體在腦(nao)，所謂(wei)(wei)“心(xin)(xin)主神(shen)明(ming)(ming)(ming)(ming)”，只(zhi)不過是(shi)言(yan)神(shen)明(ming)(ming)(ming)(ming)之(zhi)(zhi)用(yong)出(chu)(chu)于(yu)(yu)心(xin)(xin)，由(you)此可(ke)見，中(zhong)西之(zhi)(zhi)說雖(sui)然不同，但理可(ke)匯(hui)通。另如，認為吐衄(nv)的(de)原因是(shi)由(you)于(yu)(yu)陽明(ming)(ming)(ming)(ming)胃(wei)腑氣(qi)機上(shang)逆(ni)，胃(wei)中(zhong)之(zhi)(zhi)血(xue)亦恒隨之(zhi)(zhi)上(shang)逆(ni)。“其上(shang)逆(ni)之(zhi)(zhi)極，可(ke)將胃(wei)壁之(zhi)(zhi)膜排(pai)擠破(po)裂，而成嘔血(xue)之(zhi)(zhi)證；或(huo)(huo)循陽明(ming)(ming)(ming)(ming)之(zhi)(zhi)經絡(luo)上(shang)行(xing)，而成衄(nv)血(xue)之(zhi)(zhi)證”，此即《素問·厥論(lun)》中(zhong)所言(yan)“陽明(ming)(ming)(ming)(ming)厥逆(ni)衄(nv)嘔血(xue)”。其論(lun)衄(nv)血(xue)治(zhi)(zhi)療，主張(zhang)不論(lun)“或(huo)(huo)虛或(huo)(huo)實，或(huo)(huo)涼或(huo)(huo)熱，治(zhi)(zhi)之(zhi)(zhi)者(zhe)皆(jie)(jie)(jie)當以降胃(wei)之(zhi)(zhi)品為主”，并(bing)制平胃(wei)寒降湯、滋陰清降湯等，皆(jie)(jie)(jie)主以生赭石通降胃(wei)氣(qi)，并(bing)輔以白芍、龍、牡等養(yang)陰鎮潛之(zhi)(zhi)品，提高了本病的(de)療效。

在(zai)(zai)用藥(yao)(yao)上(shang)，張(zhang)氏認為(wei)，西藥(yao)(yao)治(zhi)在(zai)(zai)局部(bu)，是重在(zai)(zai)病之(zhi)(zhi)標(biao)也(ye)；中藥(yao)(yao)用藥(yao)(yao)求原因，是重在(zai)(zai)病之(zhi)(zhi)本(ben)也(ye)。究之(zhi)(zhi)，標(biao)本(ben)原宜(yi)兼顧，若遇(yu)難治(zhi)之(zhi)(zhi)證，以(yi)西藥(yao)(yao)治(zhi)其(qi)標(biao)，中藥(yao)(yao)治(zhi)其(qi)本(ben)，則奏(zou)效必速，提出中藥(yao)(yao)、西藥(yao)(yao)不應(ying)互(hu)相(xiang)抵牾，而(er)應(ying)相(xiang)濟為(wei)用。張(zhang)氏臨床治(zhi)療癲癇，據中醫“諸風掉眩，皆屬于肝”理論，用西藥(yao)(yao)臭素、抱水諸品(pin)(pin)及(ji)鉛硫(liu)朱砂丸麻醉鎮靜治(zhi)標(biao)，而(er)后則主張(zhang)徐以(yi)健脾(pi)、利(li)痰、祛風、清火之(zhi)(zhi)藥(yao)(yao)以(yi)鏟除其(qi)病根。治(zhi)療大(da)氣下陷，下血不止(zhi)(zhi)之(zhi)(zhi)血崩癥，煎服生黃芪(qi)、白術、龍骨、牡(mu)蠣、柴(chai)胡等升舉固(gu)澀(se)之(zhi)(zhi)品(pin)(pin)時(shi)，加(jia)服西藥(yao)(yao)麥角，以(yi)加(jia)強(qiang)收(shou)縮(suo)止(zhi)(zhi)血功效。張(zhang)氏在(zai)(zai)辨證施治(zhi)運(yun)用中醫方藥(yao)(yao)的同(tong)時(shi)，加(jia)服西藥(yao)(yao)，開中西藥(yao)(yao)聯合應(ying)用之(zhi)(zhi)先河(he)。

(二(er))大(da)氣下陷論

繼(ji)喻昌“胸中大(da)氣(qi)說”之后，張氏(shi)在《醫(yi)學衷中參(can)西錄》中對大(da)氣(qi)的認(ren)識和治療作了進一(yi)步的闡發(fa)。

張氏認為(wei)(wei)，大氣(qi)(qi)(qi)(qi)即《內經》所言之(zhi)(zhi)(zhi)宗氣(qi)(qi)(qi)(qi)，它“以元氣(qi)(qi)(qi)(qi)為(wei)(wei)根本，以水(shui)谷之(zhi)(zhi)(zhi)氣(qi)(qi)(qi)(qi)為(wei)(wei)養料，以胸(xiong)中之(zhi)(zhi)(zhi)地為(wei)(wei)宅窟(ku)者也”。因其“誠以能撐(cheng)持(chi)全身，為(wei)(wei)諸氣(qi)(qi)(qi)(qi)之(zhi)(zhi)(zhi)綱(gang)領(ling)，包(bao)舉(ju)肺外，司(si)呼吸(xi)之(zhi)(zhi)(zhi)樞(shu)機，故鄭而重之(zhi)(zhi)(zhi)曰(yue)大氣(qi)(qi)(qi)(qi)。”即大氣(qi)(qi)(qi)(qi)是(shi)搏聚于(yu)胸(xiong)中，包(bao)舉(ju)于(yu)肺外的大量陽氣(qi)(qi)(qi)(qi)，它源于(yu)元氣(qi)(qi)(qi)(qi)，受水(shui)谷精微的滋養，除主司(si)呼吸(xi)外，同時對全身產生重要影響。此(ci)氣(qi)(qi)(qi)(qi)撐(cheng)持(chi)全身，振作精神(shen)，心及心思、腦力(li)、百骸(hai)動作，莫不(bu)賴于(yu)此(ci)。此(ci)氣(qi)(qi)(qi)(qi)一虛(xu)，呼吸(xi)即覺不(bu)利，而時時酸懶(lan)，精神(shen)昏(hun)憒，腦力(li)、心思為(wei)(wei)之(zhi)(zhi)(zhi)頓減。

大氣(qi)(qi)(qi)之(zhi)(zhi)病變主(zhu)要是(shi)虛而陷(xian)，其病情有(you)(you)(you)(you)緩(huan)急之(zhi)(zhi)別(bie)，急者(zhe)可引起猝死(si)，“大氣(qi)(qi)(qi)既(ji)陷(xian)，無(wu)氣(qi)(qi)(qi)包舉肺外(wai)以鼓動其闔辟之(zhi)(zhi)機，則呼(hu)吸停頓(dun)，所以不(bu)(bu)病而猝死(si)。緩(huan)者(zhe)則因大氣(qi)(qi)(qi)下陷(xian)而致呼(hu)吸不(bu)(bu)利，換氣(qi)(qi)(qi)不(bu)(bu)足缺氧(yang)，全(quan)身(shen)(shen)性衰(shuai)竭(jie)出現(xian)一系列表現(xian)：“有(you)(you)(you)(you)呼(hu)吸短(duan)氣(qi)(qi)(qi)者(zhe)，有(you)(you)(you)(you)心(xin)中怔(zheng)忡者(zhe)，有(you)(you)(you)(you)淋(lin)漓大汗(han)者(zhe)，有(you)(you)(you)(you)神昏健忘者(zhe)，有(you)(you)(you)(you)聲(sheng)顫身(shen)(shen)動者(zhe)，有(you)(you)(you)(you)寒熱往來者(zhe)，有(you)(you)(you)(you)胸中滿悶者(zhe)，有(you)(you)(you)(you)努力呼(hu)吸似(si)喘者(zhe)，有(you)(you)(you)(you)咽干作(zuo)渴者(zhe)，有(you)(you)(you)(you)常常呵欠者(zhe)，有(you)(you)(you)(you)肢體(ti)痿廢者(zhe)，有(you)(you)(you)(you)食(shi)后易饑者(zhe)，有(you)(you)(you)(you)二便不(bu)(bu)禁者(zhe)，有(you)(you)(you)(you)癃閉身(shen)(shen)腫者(zhe)，有(you)(you)(you)(you)張(zhang)口呼(hu)氣(qi)(qi)(qi)外(wai)出而氣(qi)(qi)(qi)不(bu)(bu)上達，肛門突出者(zhe)，在女子有(you)(you)(you)(you)下血不(bu)(bu)止，更有(you)(you)(you)(you)經(jing)水逆行者(zhe)”等(deng)等(deng)。，

以上見(jian)(jian)癥以心(xin)肺證(zheng)候(hou)為主，常(chang)兼見(jian)(jian)脾胃證(zheng)候(hou)。若單(dan)見(jian)(jian)脾胃證(zheng)候(hou)而無(wu)心(xin)肺證(zheng)候(hou)者，是謂(wei)中(zhong)氣(qi)(qi)下(xia)陷(xian)(xian)(xian)(xian)(xian)。中(zhong)氣(qi)(qi)下(xia)陷(xian)(xian)(xian)(xian)(xian)之重者，張氏認為有引起大(da)氣(qi)(qi)下(xia)陷(xian)(xian)(xian)(xian)(xian)之可能(neng)，“夫中(zhong)氣(qi)(qi)誠有下(xia)陷(xian)(xian)(xian)(xian)(xian)之時(shi)，然不若大(da)氣(qi)(qi)下(xia)陷(xian)(xian)(xian)(xian)(xian)之尤屬危險也。間(jian)有因中(zhong)氣(qi)(qi)下(xia)陷(xian)(xian)(xian)(xian)(xian)，泄瀉日(ri)久(jiu)，或轉致(zhi)大(da)氣(qi)(qi)下(xia)陷(xian)(xian)(xian)(xian)(xian)者”。這(zhe)樣把大(da)氣(qi)(qi)下(xia)陷(xian)(xian)(xian)(xian)(xian)與中(zhong)氣(qi)(qi)下(xia)陷(xian)(xian)(xian)(xian)(xian)分(fen)別開來，確為閱歷之談。

張(zhang)氏(shi)認為，引(yin)起大氣(qi)(qi)(qi)下陷(xian)的原(yuan)因不外勞力(li)(li)過度、久(jiu)(jiu)病(bing)和誤藥(yao)(yao)。如“力(li)(li)小任重，或枵腹力(li)(li)作(zuo)，或病(bing)后(hou)氣(qi)(qi)(qi)力(li)(li)未復而勤(qin)于動(dong)作(zuo)，或泄(xie)瀉日久(jiu)(jiu)，或服破氣(qi)(qi)(qi)藥(yao)(yao)太過或氣(qi)(qi)(qi)分(fen)虛極自(zi)下陷(xian)”。張(zhang)氏(shi)治療大氣(qi)(qi)(qi)下陷(xian)，創制升(sheng)(sheng)陷(xian)湯(tang)(生黃(huang)芪(qi)、知母(mu)、桔(jie)梗、柴胡、升(sheng)(sheng)麻)，該方以(yi)黃(huang)芪(qi)為君(jun)，升(sheng)(sheng)補(bu)大氣(qi)(qi)(qi)，佐(zuo)知母(mu)涼潤以(yi)濟其(qi)之(zhi)(zhi)偏，柴胡引(yin)大氣(qi)(qi)(qi)之(zhi)(zhi)陷(xian)者自(zi)左上(shang)升(sheng)(sheng)，升(sheng)(sheng)麻引(yin)大氣(qi)(qi)(qi)之(zhi)(zhi)陷(xian)者自(zi)右(you)上(shang)升(sheng)(sheng)，桔(jie)梗為藥(yao)(yao)中之(zhi)(zhi)舟楫，導(dao)諸藥(yao)(yao)之(zhi)(zhi)力(li)(li)上(shang)達胸中。若氣(qi)(qi)(qi)虛極加(jia)(jia)人參或寄生，以(yi)培(pei)氣(qi)(qi)(qi)之(zhi)(zhi)本，或更加(jia)(jia)山萸肉以(yi)防氣(qi)(qi)(qi)之(zhi)(zhi)渙散，氣(qi)(qi)(qi)虛甚者酌增(zeng)升(sheng)(sheng)麻用量。

心(xin)肺(fei)之(zhi)(zhi)(zhi)陽(yang)，尤賴(lai)胸中(zhong)(zhong)大(da)氣(qi)為之(zhi)(zhi)(zhi)保護，大(da)氣(qi)一陷(xian)(xian)，則(ze)心(xin)肺(fei)陽(yang)分(fen)素(su)虛(xu)者，至此而(er)益虛(xu)，癥見其人心(xin)冷(leng)，背緊，惡寒，常覺短氣(qi)等。張(zhang)氏認(ren)為欲助胸中(zhong)(zhong)心(xin)肺(fei)之(zhi)(zhi)(zhi)陽(yang)，必須先升提下陷(xian)(xian)之(zhi)(zhi)(zhi)大(da)氣(qi)，否則(ze)但服溫補心(xin)肺(fei)之(zhi)(zhi)(zhi)陽(yang)之(zhi)(zhi)(zhi)劑無效，制回陽(yang)升陷(xian)(xian)湯(生黃芪、干姜(jiang)、當歸(gui)身、桂(gui)枝炭(tan)、甘草)以治之(zhi)(zhi)(zhi)。

胸(xiong)中大(da)氣正常，有賴于少陽(yang)、陽(yang)明之氣的升(sheng)發。若(ruo)大(da)氣下(xia)陷(xian)，升(sheng)發之氣被郁(yu)，氣分郁(yu)結，經絡瘀滯，常見胸(xiong)中滿(man)痛或脅下(xia)撐脹、腹痛等。對(dui)此，張氏又制理郁(yu)升(sheng)陷(xian)湯(tang)(生黃芪(qi)、知母、當歸身、桂枝(zhi)尖、柴胡、乳香、沒藥)；對(dui)脾(pi)氣虛極下(xia)陷(xian)，小便不禁者，制理脾(pi)升(sheng)陷(xian)湯(tang)(生黃芪(qi)、白(bai)術、桑寄生、川斷、萸肉(rou)、龍(long)骨、牡蠣、川萆薢(xiao)、甘草)治之。

(三)寒溫(wen)統(tong)一(yi)，注重清透

《醫學衷中參西錄》論(lun)溫(wen)(wen)(wen)(wen)病(bing)(bing)(bing)(bing)，主張寒(han)溫(wen)(wen)(wen)(wen)統(tong)一(yi)，認為溫(wen)(wen)(wen)(wen)病(bing)(bing)(bing)(bing)治(zhi)(zhi)(zhi)法已備(bei)于傷(shang)寒(han)。如溫(wen)(wen)(wen)(wen)病(bing)(bing)(bing)(bing)初(chu)起治(zhi)(zhi)(zhi)宜(yi)辛涼，然辛涼之(zhi)(zhi)法亦備(bei)于傷(shang)寒(han)，麻杏甘石(shi)湯(tang)(tang)“誠(cheng)為溫(wen)(wen)(wen)(wen)病(bing)(bing)(bing)(bing)初(chu)得之(zhi)(zhi)的方矣”。但(dan)其(qi)外表證(zheng)未解，內有蘊熱(re)即(ji)可服用(yong)。至溫(wen)(wen)(wen)(wen)病(bing)(bing)(bing)(bing)傳經已深，清(qing)(qing)燥熱(re)之(zhi)(zhi)白(bai)虎湯(tang)(tang)、白(bai)虎加人參湯(tang)(tang)，通腑之(zhi)(zhi)大(da)(da)、小承氣湯(tang)(tang)，開結胸之(zhi)(zhi)大(da)(da)、小陷胸湯(tang)(tang)，治(zhi)(zhi)(zhi)下利之(zhi)(zhi)白(bai)頭翁湯(tang)(tang)、黃芩湯(tang)(tang)，治(zhi)(zhi)(zhi)發黃之(zhi)(zhi)茵陳桅子柏(bo)皮湯(tang)(tang)等(deng)及(ji)一(yi)切涼潤(run)、清(qing)(qing)火(huo)、育陰、安神之(zhi)(zhi)劑(ji)，皆可使用(yong)。并(bing)指出寒(han)溫(wen)(wen)(wen)(wen)治(zhi)(zhi)(zhi)法之(zhi)(zhi)別，在于“始異(yi)而終同”。所謂“始異(yi)”，即(ji)傷(shang)寒(han)發表可用(yong)溫(wen)(wen)(wen)(wen)熱(re)，溫(wen)(wen)(wen)(wen)病(bing)(bing)(bing)(bing)發表必用(yong)辛涼；謂其(qi)“終同”，即(ji)病(bing)(bing)(bing)(bing)傳陽明之(zhi)(zhi)后，不論(lun)傷(shang)寒(han)、溫(wen)(wen)(wen)(wen)病(bing)(bing)(bing)(bing)，皆宜(yi)治(zhi)(zhi)(zhi)以寒(han)涼，而大(da)(da)忌溫(wen)(wen)(wen)(wen)熱(re)。

張氏臨證將(jiang)溫(wen)(wen)病(bing)分(fen)為(wei)風溫(wen)(wen)、春(chun)溫(wen)(wen)、濕溫(wen)(wen)三類。認(ren)為(wei)三類溫(wen)(wen)病(bing)雖見癥不(bu)(bu)同(tong)，其(qi)本(ben)質皆緣郁熱(re)(re)(re)(re)。“大(da)凡病(bing)溫(wen)(wen)之人(ren)，多(duo)系(xi)內有(you)蘊熱(re)(re)(re)(re)，至(zhi)春(chun)陽萌(meng)動之時，又(you)(you)薄受外(wai)感拘束，其(qi)熱(re)(re)(re)(re)即陡發而成溫(wen)(wen)”。他遵循“火(huo)郁發之”之旨，治療上主(zhu)張宣散郁結(jie)，疏通氣機，透邪(xie)外(wai)達。反對(dui)徒執寒涼(liang)，只(zhi)清(qing)(qing)不(bu)(bu)透，使邪(xie)無由出。并(bing)自擬清(qing)(qing)解湯(tang)、涼(liang)解湯(tang)、寒解湯(tang)三方，徑以(yi)石(shi)膏清(qing)(qing)其(qi)內熱(re)(re)(re)(re)，又(you)(you)選用薄荷、連翹、蟬蛻發表，且“引胃(wei)中化(hua)而欲散之熱(re)(re)(re)(re)，仍還太陽作汗而解”。正是基于對(dui)溫(wen)(wen)病(bing)“郁熱(re)(re)(re)(re)”這一本(ben)質的深刻(ke)認(ren)識，初起(qi)治療即立足于清(qing)(qing)透。

溫(wen)病入里化熱，抑或傷(shang)寒、中風入里化熱，是陽明熱盛之(zhi)(zhi)(zhi)象，張氏(shi)皆(jie)以寒涼清(qing)熱為(wei)(wei)主，不復有傷(shang)寒、中風、溫(wen)病之(zhi)(zhi)(zhi)分，投以白(bai)虎湯靈(ling)活加減化裁。臨證(zheng)使用白(bai)虎湯，張氏(shi)有著豐富的(de)經驗(yan)，認為(wei)(wei)白(bai)虎湯之(zhi)(zhi)(zhi)“四大”典型癥狀中，唯脈(mo)洪為(wei)(wei)必見(jian)之(zhi)(zhi)(zhi)癥。只要見(jian)脈(mo)洪大，又有陽明熱盛之(zhi)(zhi)(zhi)一二癥，則(ze)無論外感內(nei)傷(shang)，皆(jie)可用之(zhi)(zhi)(zhi)，不必拘泥于古(gu)人之(zhi)(zhi)(zhi)說。

陽(yang)明(ming)腑實用(yong)三(san)承氣(qi)(qi)湯(tang)(tang)，此(ci)乃大法，然張氏認(ren)為(wei)承氣(qi)(qi)力猛，倘或審證(zheng)(zheng)(zheng)不確，即(ji)足誤事。于(yu)(yu)是(shi)據(ju)其(qi)三(san)十余(yu)年臨(lin)證(zheng)(zheng)(zheng)經(jing)驗，強(qiang)調“凡(fan)遇(yu)陽(yang)明(ming)應下證(zheng)(zheng)(zheng)，亦先(xian)投(tou)以白(bai)虎(hu)湯(tang)(tang)一二(er)劑(ji)，更改其(qi)服(fu)法，將(jiang)石膏為(wei)末而不入煎，以藥湯(tang)(tang)送(song)服(fu)之(zhi)”，因屢用(yong)此(ci)方奏(zou)效，遂名之(zhi)曰白(bai)虎(hu)承氣(qi)(qi)湯(tang)(tang)。對于(yu)(yu)溫熱(re)(re)(re)病(bing)神(shen)昏(hun)(hun)譫語，張氏遵(zun)從陸九芝“胃(wei)熱(re)(re)(re)之(zhi)甚(shen)(shen)，神(shen)為(wei)之(zhi)昏(hun)(hun)，從來神(shen)昏(hun)(hun)之(zhi)病(bing)，皆屬胃(wei)家”之(zhi)說，將(jiang)熱(re)(re)(re)病(bing)神(shen)昏(hun)(hun)分為(wei)虛實兩類。其(qi)脈象洪(hong)而有力，按之(zhi)甚(shen)(shen)實者(zhe)，可按陽(yang)明(ming)胃(wei)實治之(zhi)，投(tou)以大劑(ji)白(bai)虎(hu)湯(tang)(tang)；若脈兼(jian)弦、兼(jian)數，或重按仍甚(shen)(shen)實者(zhe)，治宜白(bai)虎(hu)加(jia)人參湯(tang)(tang)；對邪入陽(yang)明(ming)，淫熱(re)(re)(re)于(yu)(yu)肝，致(zhi)肝風(feng)內動者(zhe)，以白(bai)虎(hu)撤(che)其(qi)陽(yang)明(ming)之(zhi)熱(re)(re)(re)，生龍骨、生牡蠣以鎮肝熄風(feng)。

張氏治療溫(wen)病不(bu)僅(jin)擅用白虎(hu)(hu)，而(er)且依據病證不(bu)同(tong)，化(hua)裁(cai)組成了眾多新方，如石膏粳米湯(tang)、鎮逆白虎(hu)(hu)湯(tang)、通變白虎(hu)(hu)加(jia)人參(can)湯(tang)等(deng)，皆(jie)由(you)白虎(hu)(hu)湯(tang)衍(yan)化(hua)而(er)來(lai)。

二、治療經驗

張氏一生勤于(yu)臨證，《醫學衷中(zhong)(zhong)參西錄》記(ji)載了他豐富的(de)臨床經驗，其中(zhong)(zhong)尤以論治中(zhong)(zhong)風、脫證等最(zui)具特色。

(一)分(fen)別中風論(lun)治

中(zhong)風(feng)有真中(zhong)、類中(zhong)之別。張氏認(ren)為真中(zhong)者極少，因(yin)而著(zhu)意對類中(zhong)進行研(yan)究(jiu)、發(fa)揮(hui)。指出類中(zhong)風(feng)亦(yi)即內中(zhong)風(feng)，此(ci)“風(feng)自內生，非(fei)風(feng)自外來也”，其治療(liao)分充血、貧血，以(yi)虛實論治。

1、腦充血治療

張氏根據(ju)“血(xue)菀于上，使(shi)人(ren)薄(bo)厥”的(de)理論(lun)，認(ren)為腦充血(xue)即《內經》中所言的(de)煎(jian)厥、薄(bo)厥、大厥。其病(bing)位(wei)在“肝”，陰虛(xu)陽(yang)亢、上實下(xia)虛(xu)、臟腑之氣升(sheng)發太過(guo)或失之下(xia)行(xing)，血(xue)隨氣逆為主要病(bing)機。即“人(ren)之血(xue)隨氣行(xing)，氣上升(sheng)不已(yi)，血(xue)即隨之上升(sheng)不已(yi)，以(yi)致腦中血(xue)管充血(xue)過(guo)甚”(《醫學衷中參西(xi)錄·醫案(an)·腦充血(xue)門》)，有礙(ai)神(shen)經，以(yi)致語言肢體謇澀不利，口(kou)眼歪斜等等。

根據腦(nao)充血(xue)(xue)之(zhi)(zhi)(zhi)(zhi)“肝(gan)(gan)(gan)木失和(he)，肺氣(qi)(qi)不(bu)降，腎氣(qi)(qi)不(bu)攝，沖氣(qi)(qi)、胃(wei)氣(qi)(qi)又復上逆(ni)，臟腑之(zhi)(zhi)(zhi)(zhi)氣(qi)(qi)化皆上升太過(guo)”之(zhi)(zhi)(zhi)(zhi)病機，張氏提出治療本病應“清(qing)其臟腑之(zhi)(zhi)(zhi)(zhi)熱(re)，滋(zi)其臟腑之(zhi)(zhi)(zhi)(zhi)陰(yin)，更(geng)降其臟腑之(zhi)(zhi)(zhi)(zhi)氣(qi)(qi)，引腦(nao)部(bu)(bu)所充之(zhi)(zhi)(zhi)(zhi)血(xue)(xue)下行(xing)”的“鎮(zhen)肝(gan)(gan)(gan)熄風、引血(xue)(xue)下行(xing)”的原則(ze)，并創制(zhi)(zhi)鎮(zhen)肝(gan)(gan)(gan)熄風湯(懷牛膝(xi)、生(sheng)(sheng)(sheng)赭(zhe)石(shi)、生(sheng)(sheng)(sheng)杭(hang)芍(shao)、天(tian)(tian)冬、生(sheng)(sheng)(sheng)龍骨、生(sheng)(sheng)(sheng)牡蠣(li)、生(sheng)(sheng)(sheng)龜板(ban)、玄(xuan)參(can)(can)、川楝(lian)子、生(sheng)(sheng)(sheng)麥芽、茵陳(chen)、甘草)作(zuo)為治療本病的主方。方中赭(zhe)石(shi)降胃(wei)，平肝(gan)(gan)(gan)鎮(zhen)沖，下行(xing)通便；牛膝(xi)善(shan)引上部(bu)(bu)之(zhi)(zhi)(zhi)(zhi)血(xue)(xue)下行(xing)，二藥合用，相(xiang)輔相(xiang)成；玄(xuan)參(can)(can)、天(tian)(tian)冬、白芍(shao)滋(zi)陰(yin)退(tui)熱(re)；龍骨、牡蠣(li)、龜板(ban)、芍(shao)藥斂肝(gan)(gan)(gan)火、鎮(zhen)熄肝(gan)(gan)(gan)風，以緩其肝(gan)(gan)(gan)氣(qi)(qi)上升之(zhi)(zhi)(zhi)(zhi)勢；玄(xuan)參(can)(can)、天(tian)(tian)冬清(qing)肺制(zhi)(zhi)肝(gan)(gan)(gan)；山藥、甘草和(he)胃(wei)緩肝(gan)(gan)(gan)；茵陳(chen)為“青(qing)蒿之(zhi)(zhi)(zhi)(zhi)嫩者，稟(bing)少陽初生(sheng)(sheng)(sheng)之(zhi)(zhi)(zhi)(zhi)氣(qi)(qi)，與肝(gan)(gan)(gan)木同氣(qi)(qi)相(xiang)求，最能將順肝(gan)(gan)(gan)木之(zhi)(zhi)(zhi)(zhi)性(xing)，且又善(shan)瀉肝(gan)(gan)(gan)熱(re)”，為清(qing)涼腦(nao)部(bu)(bu)之(zhi)(zhi)(zhi)(zhi)涼藥也；麥芽“善(shan)助肝(gan)(gan)(gan)木疏泄以行(xing)腎氣(qi)(qi)”；川楝(lian)子善(shan)引肝(gan)(gan)(gan)氣(qi)(qi)下達，又能折其更(geng)動(dong)之(zhi)(zhi)(zhi)(zhi)力。本方標本兼治，鎮(zhen)潛共用，引涵(han)兼施，直中病之(zhi)(zhi)(zhi)(zhi)肯綮，確有獨到之(zhi)(zhi)(zhi)(zhi)處。

此外，張氏還參(can)照西醫病(bing)理，闡述了腦(nao)(nao)(nao)充(chong)血(xue)、腦(nao)(nao)(nao)溢血(xue)、腦(nao)(nao)(nao)出血(xue)之證型及用(yong)(yong)藥的(de)不同。對腦(nao)(nao)(nao)部血(xue)管中之血(xue)滲出者(zhe)(zhe)，他在友(you)人“腦(nao)(nao)(nao)充(chong)血(xue)證，宜(yi)于(yu)引(yin)血(xue)下行藥中加(jia)(jia)(jia)破(po)血(xue)之藥以治之”的(de)啟發(fa)下，指出對其(qi)(qi)身(shen)體(ti)壯實(shi)者(zhe)(zhe)，可(ke)酌加(jia)(jia)(jia)大黃數錢以逐瘀(yu)；其(qi)(qi)身(shen)形脈象不甚壯實(shi)者(zhe)(zhe)，加(jia)(jia)(jia)桃(tao)仁(ren)、丹參(can)等化瘀(yu)。并(bing)明確提(ti)出“腦(nao)(nao)(nao)充(chong)血(xue)當通(tong)大便為要(yao)務”。對腦(nao)(nao)(nao)充(chong)血(xue)后(hou)期(qi)脈象柔和而肢(zhi)體(ti)痿廢者(zhe)(zhe)，主(zhu)張“少(shao)用(yong)(yong)黃芪助(zhu)活血(xue)之品(pin)以通(tong)絡(luo)”，但應謹(jin)(jin)慎從事。而對于(yu)“血(xue)菀于(yu)上”的(de)腦(nao)(nao)(nao)充(chong)血(xue)者(zhe)(zhe)，因(yin)黃芪之情，補而兼升(sheng)，氣升(sheng)則(ze)血(xue)必隨之升(sheng)，故(gu)病(bing)初應忌用(yong)(yong)黃芪，誤(wu)用(yong)(yong)則(ze)兇危立(li)見(jian)(jian)。其(qi)(qi)辨(bian)證之嚴謹(jin)(jin)，用(yong)(yong)藥之精確，可(ke)見(jian)(jian)一(yi)斑(ban)。

2、腦貧血治療

與腦(nao)充血(xue)(xue)(xue)(xue)證相反，張氏認為(wei)腦(nao)貧(pin)血(xue)(xue)(xue)(xue)證則為(wei)血(xue)(xue)(xue)(xue)之上注于(yu)腦(nao)過少，無以養(yang)(yang)其腦(nao)髓神經，致使腦(nao)神經失其所(suo)司。而血(xue)(xue)(xue)(xue)之上注過少，實由(you)“宗氣(qi)虛寒，不能助(zhu)(zhu)血(xue)(xue)(xue)(xue)上升川(chuan)”。故治(zhi)療(liao)腦(nao)貧(pin)血(xue)(xue)(xue)(xue)證，主張“應峻補(bu)其胸中(zhong)(zhong)大(da)氣(qi)”，自擬(ni)當歸補(bu)血(xue)(xue)(xue)(xue)湯(tang)(tang)益氣(qi)溫陽(yang)、補(bu)血(xue)(xue)(xue)(xue)活血(xue)(xue)(xue)(xue)，治(zhi)療(liao)中(zhong)(zhong)風脈象(xiang)遲弱，身軟，肢(zhi)(zhi)體漸覺不利，或(huo)(huo)頭(tou)重目(mu)眩，或(huo)(huo)神昏(hun)健忘，甚(shen)或(huo)(huo)昏(hun)仆，移時蘇醒致成偏(pian)枯者。方中(zhong)(zhong)主以黃(huang)芪升補(bu)胸中(zhong)(zhong)大(da)氣(qi)，使血(xue)(xue)(xue)(xue)隨氣(qi)升，上達(da)腦(nao)中(zhong)(zhong)；用(yong)當歸、龍眼肉、鹿角(jiao)膠養(yang)(yang)血(xue)(xue)(xue)(xue)生髓；丹(dan)參、乳、沒開(kai)血(xue)(xue)(xue)(xue)痹，化瘀滯；甘松(song)助(zhu)(zhu)心房運行有力，以多輸血(xue)(xue)(xue)(xue)于(yu)腦(nao)，且又(you)為(wei)調養(yang)(yang)神經之品。對于(yu)腦(nao)貧(pin)血(xue)(xue)(xue)(xue)肢(zhi)(zhi)體痿(wei)廢或(huo)(huo)偏(pian)枯，脈象(xiang)極(ji)微(wei)細無力者，又(you)擬(ni)干頹湯(tang)(tang)、補(bu)腦(nao)振痿(wei)湯(tang)(tang)治(zhi)療(liao)。并指出肢(zhi)(zhi)體偏(pian)廢，服藥(yao)久不效者，應著重補(bu)腎通絡，多選(xuan)用(yong)胡桃肉、地龍、馬錢子等(deng)。

(二)重視沖(chong)氣為(wei)病，善用鎮(zhen)沖(chong)降逆

沖(chong)(chong)(chong)(chong)脈為(wei)(wei)(wei)奇經八脈之(zhi)(zhi)一(yi)，張氏(shi)論病(bing)(bing)極重(zhong)視沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)，指出“沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)上沖(chong)(chong)(chong)(chong)之(zhi)(zhi)病(bing)(bing)甚(shen)多(duo)，而(er)醫(yi)者識其(qi)(qi)(qi)(qi)病(bing)(bing)者甚(shen)少。即或(huo)(huo)能識此病(bing)(bing)，亦多(duo)不(bu)能洞悉其(qi)(qi)(qi)(qi)病(bing)(bing)因”。因而(er)，對(dui)沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)的(de)(de)(de)生理，尤其(qi)(qi)(qi)(qi)是沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)上沖(chong)(chong)(chong)(chong)的(de)(de)(de)病(bing)(bing)因、病(bing)(bing)理、病(bing)(bing)脈、治(zhi)法都作了詳(xiang)細(xi)闡述(shu)，自成一(yi)家之(zhi)(zhi)言。其(qi)(qi)(qi)(qi)述(shu)沖(chong)(chong)(chong)(chong)脈，、兼采(cai)《內》《難》之(zhi)(zhi)說，認為(wei)(wei)(wei)其(qi)(qi)(qi)(qi)“在胞室之(zhi)(zhi)兩(liang)(liang)旁，與(yu)任脈相(xiang)(xiang)連，為(wei)(wei)(wei)腎臟(zang)之(zhi)(zhi)輔弼，氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)化相(xiang)(xiang)通(tong)……上系原(yuan)隸(li)陽明胃(wei)(wei)(wei)腑”，并認為(wei)(wei)(wei)“沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)上沖(chong)(chong)(chong)(chong)之(zhi)(zhi)證，固(gu)由于腎臟(zang)之(zhi)(zhi)虛，亦多(duo)由于肝(gan)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)恣(zi)橫，素性(xing)多(duo)怒之(zhi)(zhi)人，其(qi)(qi)(qi)(qi)肝(gan)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)之(zhi)(zhi)暴發，更助沖(chong)(chong)(chong)(chong)胃(wei)(wei)(wei)之(zhi)(zhi)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)上逆(ni)(ni)”。即腎虛無以涵木，不(bu)能收斂沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)，沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)上行，肝(gan)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)橫逆(ni)(ni)，胃(wei)(wei)(wei)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)上逆(ni)(ni)而(er)呈上沖(chong)(chong)(chong)(chong)之(zhi)(zhi)弊。張氏(shi)描(miao)述(shu)的(de)(de)(de)沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)上沖(chong)(chong)(chong)(chong)證，除自覺有氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)自下(xia)上沖(chong)(chong)(chong)(chong)，脈多(duo)弦(xian)硬而(er)長外，主(zhu)(zhu)要表現有胃(wei)(wei)(wei)脘或(huo)(huo)腹中(zhong)滿(man)悶，噦氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)，呃逆(ni)(ni)連連，嘔吐不(bu)止，或(huo)(huo)見吐血(xue)、衄血(xue)等(deng)胃(wei)(wei)(wei)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)上逆(ni)(ni)不(bu)降(jiang)見癥；或(huo)(huo)兩(liang)(liang)脅痛(tong)脹，頭目眩暈，甚(shen)而(er)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)火挾痰上沖(chong)(chong)(chong)(chong)，發生突然昏仆等(deng)；或(huo)(huo)為(wei)(wei)(wei)胸(xiong)滿(man)窒(zhi)塞，喘息大(da)作。其(qi)(qi)(qi)(qi)治(zhi)療(liao)，主(zhu)(zhu)張以斂沖(chong)(chong)(chong)(chong)鎮(zhen)(zhen)沖(chong)(chong)(chong)(chong)為(wei)(wei)(wei)主(zhu)(zhu)，降(jiang)胃(wei)(wei)(wei)平(ping)肝(gan)為(wei)(wei)(wei)佐，獨創參(can)赭鎮(zhen)(zhen)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)湯(tang)、鎮(zhen)(zhen)沖(chong)(chong)(chong)(chong)降(jiang)胃(wei)(wei)(wei)湯(tang)等(deng)鎮(zhen)(zhen)沖(chong)(chong)(chong)(chong)諸(zhu)方(fang)。其(qi)(qi)(qi)(qi)組(zu)方(fang)特(te)色，一(yi)為(wei)(wei)(wei)善用(yong)(yong)鎮(zhen)(zhen)沖(chong)(chong)(chong)(chong)降(jiang)逆(ni)(ni)之(zhi)(zhi)品，如赭石、龍、牡等(deng)；一(yi)為(wei)(wei)(wei)善用(yong)(yong)補(bu)虛固(gu)澀之(zhi)(zhi)品，如山(shan)萸肉、山(shan)藥、白芍(shao)、芡(qian)實等(deng)，攻中(zhong)有補(bu)，降(jiang)斂結(jie)合，用(yong)(yong)之(zhi)(zhi)臨(lin)床，確(que)有良效。其(qi)(qi)(qi)(qi)沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)(qi)學說為(wei)(wei)(wei)中(zhong)醫(yi)臨(lin)床治(zhi)療(liao)雜病(bing)(bing)又辟新徑。

(三(san))脫(tuo)分上(shang)下(xia)內外(wai)，治脫(tuo)重視(shi)肝虛

張(zhang)氏(shi)認為脫(tuo)(tuo)雖有(you)上(shang)、下(xia)(xia)、內(nei)、外之(zhi)別(bie)，概由(you)肝(gan)(gan)(gan)虛(xu)(xu)(xu)，其云：“凡人(ren)(ren)元(yuan)氣(qi)(qi)(qi)(qi)之(zhi)脫(tuo)(tuo)，皆脫(tuo)(tuo)在肝(gan)(gan)(gan)”。他根據肝(gan)(gan)(gan)主疏泄、調暢氣(qi)(qi)(qi)(qi)機的(de)功(gong)能(neng)，認為元(yuan)氣(qi)(qi)(qi)(qi)的(de)運行(xing)和(he)胃氣(qi)(qi)(qi)(qi)的(de)布(bu)化，全賴于肝(gan)(gan)(gan)臟(zang)正常的(de)疏泄功(gong)能(neng)。倘(tang)肝(gan)(gan)(gan)虛(xu)(xu)(xu)則損泄元(yuan)氣(qi)(qi)(qi)(qi)，耗(hao)散腎氣(qi)(qi)(qi)(qi)，而為上(shang)脫(tuo)(tuo)或下(xia)(xia)脫(tuo)(tuo)。“蓋元(yuan)氣(qi)(qi)(qi)(qi)上(shang)脫(tuo)(tuo)由(you)于肝(gan)(gan)(gan)，其下(xia)(xia)脫(tuo)(tuo)亦由(you)于肝(gan)(gan)(gan)。誠以(yi)(yi)肝(gan)(gan)(gan)能(neng)為腎行(xing)氣(qi)(qi)(qi)(qi)，即能(neng)瀉元(yuan)氣(qi)(qi)(qi)(qi)自下(xia)(xia)出也”。(《醫學(xue)衷中參(can)西錄·醫案·霍(huo)亂門(men)》)上(shang)脫(tuo)(tuo)之(zhi)證，“喘逆迫促，脈若水上(shang)浮麻”，張(zhang)氏(shi)制(zhi)參(can)赭(zhe)(zhe)鎮(zhen)氣(qi)(qi)(qi)(qi)湯救之(zhi)。方中以(yi)(yi)人(ren)(ren)參(can)補虛(xu)(xu)(xu)極之(zhi)諸氣(qi)(qi)(qi)(qi)，借“赭(zhe)(zhe)石(shi)下(xia)(xia)行(xing)之(zhi)力，挽回將(jiang)脫(tuo)(tuo)之(zhi)元(yuan)氣(qi)(qi)(qi)(qi)”；蘇子助赭(zhe)(zhe)石(shi)降氣(qi)(qi)(qi)(qi)；生(sheng)山(shan)藥、生(sheng)白芍滋(zi)補肝(gan)(gan)(gan)胃之(zhi)陰(yin)，以(yi)(yi)守持元(yuan)氣(qi)(qi)(qi)(qi)；山(shan)萸(yu)肉、生(sheng)芡實、生(sheng)龍骨、生(sheng)牡蠣酸(suan)斂(lian)收澀(se)，固攝元(yuan)氣(qi)(qi)(qi)(qi)。下(xia)(xia)脫(tuo)(tuo)，如“日夜吐瀉不已，脈沉細欲無，虛(xu)(xu)(xu)極將(jiang)脫(tuo)(tuo)者(zhe)，為至危之(zhi)候”，張(zhang)氏(shi)以(yi)(yi)急救回陽湯救之(zhi)，方用人(ren)(ren)參(can)以(yi)(yi)回陽；山(shan)藥、芍藥滋(zi)陰(yin)；重用山(shan)萸(yu)肉斂(lian)肝(gan)(gan)(gan)固脫(tuo)(tuo)。上(shang)下(xia)(xia)兩脫(tuo)(tuo)兼見(jian)者(zhe)，挽陰(yin)回陽，以(yi)(yi)“既濟湯”酸(suan)斂(lian)固澀(se)。

除元氣(qi)上脫(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)、下脫(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)之(zhi)(zhi)外(wai)(wai)，又有所謂外(wai)(wai)脫(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)、內(nei)(nei)(nei)脫(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)。外(wai)(wai)脫(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)者，癥見周(zhou)身(shen)汗出(chu)不止，或(huo)“目睛(jing)上竄，或(huo)喘逆，或(huo)怔忡，或(huo)氣(qi)虛(xu)不足以(yi)(yi)息(xi)”，張氏(shi)認為此(ci)乃(nai)“肝膽虛(xu)極而元氣(qi)欲(yu)脫(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)也(ye)”。即肝陰過虛(xu)，肝風(feng)萌動，元氣(qi)欲(yu)脫(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)，用來復湯(tang)治(zhi)之(zhi)(zhi)。內(nei)(nei)(nei)脫(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)，如“胸中大氣(qi)下陷(xian)，氣(qi)短不足以(yi)(yi)息(xi)，或(huo)努力呼(hu)吸，有似乎喘，或(huo)氣(qi)息(xi)將停，危在頃刻……其脈象沉(chen)遲微弱，關前尤甚；其劇者，或(huo)六(liu)脈不全，或(huo)參伍不調”，此(ci)系中氣(qi)自(zi)內(nei)(nei)(nei)而陷(xian)的(de)內(nei)(nei)(nei)脫(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)證，張氏(shi)以(yi)(yi)“升陷(xian)湯(tang)”升補下陷(xian)之(zhi)(zhi)氣(qi)，再加山(shan)萸肉收斂氣(qi)分之(zhi)(zhi)耗(hao)散，使(shi)升者不至復陷(xian)，共挽中氣(qi)下陷(xian)所致之(zhi)(zhi)內(nei)(nei)(nei)脫(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)(tuo)。

從上述(shu)救脫(tuo)方可(ke)見(jian)，張氏(shi)救脫(tuo)善用山(shan)萸肉(rou)。他認為山(shan)英(ying)肉(rou)味酸性溫，固(gu)澀(se)滑(hua)脫(tuo)，通利(li)九竅，流(liu)通血(xue)脈(mo)，為補肝之妙藥(yao)，其(qi)救脫(tuo)之功，較參、術(shu)、芪更(geng)勝。“蓋萸肉(rou)之性，不獨(du)補肝也，凡(fan)人身之陰(yin)陽(yang)，氣(qi)血(xue)將散者，皆能斂之，故救脫(tuo)之藥(yao)，當(dang)以萸肉(rou)為第一”。常用萸肉(rou)治(zhi)療各種虛脫(tuo)危證，或(huo)配以生龍骨(gu)、牡蠣斂汗(han)；或(huo)配人參、附子(zi)、山(shan)藥(yao)、炙甘草益氣(qi)回(hui)陽(yang)固(gu)脫(tuo)；或(huo)配當(dang)歸、熟(shu)地填(tian)補精(jing)血(xue)等。其(qi)論脫(tuo)證病(bing)機及治(zhi)法用藥(yao)，別(bie)開生面，對后人啟迪尤深。

(四)遣藥制(zhi)方(fang)心得

張氏制方用藥(yao)頗(po)有獨到經驗(yan)，通性味，善(shan)配伍，別具匠心。具體表現(xian)在以下幾(ji)個方面。

1、精研藥(yao)物，頗多新見

張氏認(ren)為學醫的(de)(de)(de)第一(yi)層功夫即(ji)是識藥(yao)(yao)性，其對(dui)藥(yao)(yao)性的(de)(de)(de)理解，于諸家本草學之(zhi)外，頗多新見。《醫學衷中(zhong)參(can)西錄》書中(zhong)專列《藥(yao)(yao)物(wu)》一(yi)章，對(dui)常(chang)用(yong)的(de)(de)(de)79種藥(yao)(yao)物(wu)詳(xiang)加解釋，闡述了張氏對(dui)藥(yao)(yao)物(wu)的(de)(de)(de)獨(du)到認(ren)識與經驗(yan)。其中(zhong)他研(yan)究(jiu)最精(jing)的(de)(de)(de)藥(yao)(yao)物(wu)有黃芪、山(shan)萸肉、赭石、山(shan)藥(yao)(yao)、三七、黨參(can)、乳香、沒藥(yao)(yao)、三棱、水蛭、牛(niu)膝、龍骨、牡(mu)蠣等。

例如，他廣泛(fan)應用(yong)(yong)(yong)大(da)(da)劑量石膏治療外感熱(re)(re)性(xing)病屢收良效(xiao)，認(ren)為(wei)并無損傷(shang)脾胃之(zhi)弊(bi)，且隨著熱(re)(re)退病愈而飲食倍(bei)增，為(wei)清解(jie)(jie)大(da)(da)熱(re)(re)之(zhi)特效(xiao)藥(yao)。善(shan)(shan)用(yong)(yong)(yong)三棱、莪(e)(e)術，認(ren)為(wei)二(er)(er)藥(yao)善(shan)(shan)破(po)血、調氣(qi)(qi)(qi)(qi)，化(hua)(hua)(hua)瘀則三棱優(you)于(yu)(yu)(yu)莪(e)(e)術，理氣(qi)(qi)(qi)(qi)則莪(e)(e)術優(you)于(yu)(yu)(yu)三棱，若(ruo)“二(er)(er)藥(yao)合用(yong)(yong)(yong)，常有(you)協同之(zhi)功”。認(ren)為(wei)水蛭破(po)瘀最效(xiao)，善(shan)(shan)除日久之(zhi)瘀滯，能(neng)(neng)使瘀血默(mo)消于(yu)(yu)(yu)無形之(zhi)中，乳香善(shan)(shan)透竅(qiao)理氣(qi)(qi)(qi)(qi)，沒藥(yao)善(shan)(shan)化(hua)(hua)(hua)瘀理血，二(er)(er)藥(yao)并用(yong)(yong)(yong)為(wei)宣(xuan)通臟腑、流(liu)通經(jing)絡之(zhi)要(yao)藥(yao)，常用(yong)(yong)(yong)于(yu)(yu)(yu)治心、胃、脅(xie)、腹(fu)及肢體(ti)關節(jie)諸痛(tong)，經(jing)痛(tong)，產后瘀血腹(fu)痛(tong)，月(yue)經(jing)不(bu)(bu)調，風寒濕(shi)痹，中風四肢不(bu)(bu)遂(sui)及一(yi)切(qie)(qie)瘡瘍腫痛(tong)；雞(ji)內金味酸性(xing)溫藥(yao)性(xing)平和(he)(he)，有(you)補(bu)脾胃之(zhi)妙，善(shan)(shan)化(hua)(hua)(hua)有(you)形之(zhi)瘀積；山(shan)楂化(hua)(hua)(hua)瘀血而不(bu)(bu)傷(shang)新(xin)血，開(kai)郁氣(qi)(qi)(qi)(qi)而不(bu)(bu)傷(shang)正氣(qi)(qi)(qi)(qi)；茵陳、麥芽皆具疏肝(gan)(gan)解(jie)(jie)郁之(zhi)效(xiao)，體(ti)弱(ruo)陰虛不(bu)(bu)任柴胡升散(san)者，常以(yi)其代之(zhi)；黃芪性(xing)溫味微甘，補(bu)氣(qi)(qi)(qi)(qi)兼能(neng)(neng)升氣(qi)(qi)(qi)(qi)，善(shan)(shan)治氣(qi)(qi)(qi)(qi)虛、氣(qi)(qi)(qi)(qi)陷(xian)諸證，且其“性(xing)溫而上升，以(yi)之(zhi)補(bu)肝(gan)(gan)有(you)同氣(qi)(qi)(qi)(qi)相求之(zhi)妙用(yong)(yong)(yong)”，故凡肝(gan)(gan)氣(qi)(qi)(qi)(qi)虛弱(ruo)不(bu)(bu)能(neng)(neng)條達，用(yong)(yong)(yong)一(yi)切(qie)(qie)補(bu)肝(gan)(gan)之(zhi)藥(yao)皆不(bu)(bu)效(xiao)者，倡重用(yong)(yong)(yong)黃芪為(wei)主，而少佐以(yi)理氣(qi)(qi)(qi)(qi)之(zhi)品(pin)，并據此(ci)批評“肝(gan)(gan)虛無補(bu)法”之(zhi)談。這些獨創性(xing)見解(jie)(jie)，擴大(da)(da)和(he)(he)豐富了藥(yao)物的臨床應用(yong)(yong)(yong)范圍。

2、善(shan)用生藥，注重配伍

張錫(xi)純在(zai)(zai)《醫學衷中(zhong)(zhong)參(can)西(xi)錄》中(zhong)(zhong)自(zi)擬良方百余首，以(yi)生(sheng)(sheng)(sheng)藥(yao)見長(chang)，對生(sheng)(sheng)(sheng)藥(yao)的使(shi)用(yong)獨具卓見。如水蛭(zhi)，方書多謂必須炙(zhi)透(tou)方可使(shi)用(yong)，但(dan)張氏認為，此物生(sheng)(sheng)(sheng)于水中(zhong)(zhong)，原得水之(zhi)(zhi)精氣(qi)而生(sheng)(sheng)(sheng)，炙(zhi)之(zhi)(zhi)則傷(shang)水之(zhi)(zhi)精氣(qi)，不(bu)(bu)若(ruo)生(sheng)(sheng)(sheng)用(yong)。因而在(zai)(zai)治(zhi)(zhi)療(liao)經閉(bi)不(bu)(bu)行、產后惡露不(bu)(bu)盡或(huo)瘀血頑(wan)癥時，常于理(li)沖(chong)湯、理(li)沖(chong)丸中(zhong)(zhong)加入水蛭(zhi)一(yi)錢或(huo)一(yi)兩(liang)，并標明(ming)“不(bu)(bu)用(yong)炙(zhi)”。認為赭石色赤性微涼，生(sheng)(sheng)(sheng)血兼能(neng)涼血，且(qie)(qie)因其質重(zhong)墜，又可鎮(zhen)逆(ni)、降痰、止(zhi)嘔、通便，“生(sheng)(sheng)(sheng)研服之(zhi)(zhi)不(bu)(bu)傷(shang)腸胃……且(qie)(qie)生(sheng)(sheng)(sheng)服則養氣(qi)純全(quan)，大能(neng)養血”。故治(zhi)(zhi)陰陽兩(liang)虛、喘逆(ni)迫促之(zhi)(zhi)喘息，重(zhong)用(yong)生(sheng)(sheng)(sheng)赭石伍以(yi)生(sheng)(sheng)(sheng)龍牡斂沖(chong)降逆(ni)；又與肉蓯蓉、當歸并用(yong)，補腎斂沖(chong)，潤便通結。張氏臨床常用(yong)的生(sheng)(sheng)(sheng)藥(yao)還有生(sheng)(sheng)(sheng)乳香、生(sheng)(sheng)(sheng)沒(mei)藥(yao)、生(sheng)(sheng)(sheng)雞內金、生(sheng)(sheng)(sheng)黃(huang)芪、生(sheng)(sheng)(sheng)山藥(yao)、生(sheng)(sheng)(sheng)杭芍、生(sheng)(sheng)(sheng)石膏等。

此外，張氏(shi)根據其(qi)臨床經(jing)驗(yan)和(he)體會，總結出許多新的藥(yao)(yao)對配(pei)(pei)伍關(guan)系(xi)。如山藥(yao)(yao)配(pei)(pei)牛蒡子，疏補(bu)兼行，補(bu)腎健脾(pi)，清肺(fei)止(zhi)咳(ke)，祛痰降氣(qi)；人參(can)配(pei)(pei)代(dai)赭石，剛柔相濟，升降互用，治療脾(pi)胃氣(qi)虛(xu)，沖(chong)氣(qi)相干(gan)，或(huo)用于上盛(sheng)下虛(xu)、氣(qi)血將脫；黃(huang)芪配(pei)(pei)知母(mu)，寒熱平(ping)調以(yi)益氣(qi)升舉；人參(can)配(pei)(pei)威靈仙治氣(qi)虛(xu)小(xiao)便不利；生龍(long)、牡配(pei)(pei)萸肉(rou)，三(san)藥(yao)(yao)聯合應用，收斂固(gu)脫、澀精(jing)止(zhi)汗(han)等，均(jun)可資(zi)臨床參(can)考。

3、潛心實踐，創(chuang)制新方

張氏對方藥(yao)的(de)(de)運用(yong)也頗有(you)心(xin)(xin)得，在(zai)《醫(yi)學衷(zhong)中參(can)西錄》中創立了許多(duo)有(you)效的(de)(de)方劑，廣及(ji)內、外、婦、兒各科，其多(duo)有(you)所宗，遵經而(er)(er)不(bu)(bu)泥古，通(tong)變而(er)(er)不(bu)(bu)失規矩。其中，有(you)不(bu)(bu)少為(wei)師(shi)法仲景原意而(er)(er)化(hua)裁(cai)創制的(de)(de)新方。如(ru)治(zhi)吐(tu)衄諸方是受《金匱(kui)》瀉心(xin)(xin)湯(tang)(tang)(tang)影響，以(yi)降胃為(wei)主，故喜用(yong)赭(zhe)石(shi)、半夏。治(zhi)療(liao)胸(xiong)中蘊熱(re)為(wei)外感所束，不(bu)(bu)能(neng)發(fa)泄而(er)(er)致(zhi)煩躁的(de)(de)猶龍湯(tang)(tang)(tang)，立意源于(yu)(yu)大(da)(da)青龍湯(tang)(tang)(tang)，由連(lian)翹、生(sheng)石(shi)膏(gao)、蟬蛻(tui)、牛蒡(bang)子組(zu)成。治(zhi)滿悶短氣，呼吸不(bu)(bu)利的(de)(de)蕩胸(xiong)湯(tang)(tang)(tang)，于(yu)(yu)大(da)(da)陷(xian)胸(xiong)湯(tang)(tang)(tang)中取用(yong)芒硝，于(yu)(yu)小陷(xian)胸(xiong)湯(tang)(tang)(tang)中取用(yong)瓜蔞，又(you)于(yu)(yu)治(zhi)心(xin)(xin)下(xia)痞硬之(zhi)(zhi)(zhi)旋覆代(dai)赭(zhe)湯(tang)(tang)(tang)中取用(yong)赭(zhe)石(shi)，而(er)(er)復加蘇子以(yi)為(wei)下(xia)行之(zhi)(zhi)(zhi)向導，可以(yi)代(dai)大(da)(da)陷(xian)胸(xiong)湯(tang)(tang)(tang)、丸，亦可代(dai)小陷(xian)胸(xiong)湯(tang)(tang)(tang)。又(you)如(ru)其治(zhi)療(liao)婦科病之(zhi)(zhi)(zhi)理沖湯(tang)(tang)(tang)、理沖丸，用(yong)參(can)、術、當歸、山藥(yao)等補(bu)氣健脾扶正，莪(e)術、三棱、水蛭等活血化(hua)瘀，為(wei)攻補(bu)兼施，扶正化(hua)瘀，治(zhi)閉經及(ji)癥瘕(jia)之(zhi)(zhi)(zhi)虛實(shi)夾(jia)雜證良方。又(you)如(ru)治(zhi)崩漏的(de)(de)安沖湯(tang)(tang)(tang)、固沖湯(tang)(tang)(tang)，熔塞流、澄源、補(bu)虛于(yu)(yu)一爐，止血而(er)(er)不(bu)(bu)留瘀，清熱(re)而(er)(er)不(bu)(bu)涼遏(e)，溫(wen)補(bu)而(er)(er)不(bu)(bu)閉邪(xie)。再如(ru)，如(ru)治(zhi)陰虛勞嗽之(zhi)(zhi)(zhi)資生(sheng)湯(tang)(tang)(tang)，治(zhi)腦充(chong)血頭目眩暈之(zhi)(zhi)(zhi)建瓴(ling)湯(tang)(tang)(tang)，治(zhi)心(xin)(xin)腹疼痛、癥瘕(jia)痰癖(pi)的(de)(de)活絡效靈丹(dan)，治(zhi)腎虛滑胎的(de)(de)壽胎丸等等，都是行之(zhi)(zhi)(zhi)有(you)效的(de)(de)名方。

背景介紹

張(zhang)氏(shi)治學(xue)(xue)嚴謹，重視實踐，主張(zhang)溝通(tong)中(zhong)(zhong)西(xi)，取長(chang)補短，是近代中(zhong)(zhong)西(xi)醫匯通(tong)派(pai)的(de)代表之一。結合其多年(nian)臨證(zheng)經驗與(yu)匯通(tong)中(zhong)(zhong)西(xi)的(de)體會，著成《醫學(xue)(xue)衷(zhong)中(zhong)(zhong)參西(xi)錄》。

作者介紹

張錫純，字壽(shou)甫，清末民初(chu)河北省(sheng)鹽(yan)山縣人。生活于公元1860～1933年(nian)(清咸豐十(shi)年(nian)至民國二十(shi)二年(nian))。幼敏而好學，攻讀經(jing)史(shi)之余，兼習岐黃之書，后因兩試秋闈不第，遂潛心(xin)醫(yi)(yi)學。早年(nian)懸壺鄉梓，革命(ming)軍(jun)(jun)興(xing)，應(ying)聘從戎去武漢為軍(jun)(jun)醫(yi)(yi)。1917年(nian)在(zai)沈陽(yang)創建“立達(da)中(zhong)醫(yi)(yi)院(yuan)”。直奉戰起，回(hui)故居河北滄州(zhou)行醫(yi)(yi)，1926年(nian)移居天津(jin)，創辦“天津(jin)國醫(yi)(yi)函授學校”，培(pei)養(yang)了大批中(zhong)醫(yi)(yi)后繼(ji)人才。

張(zhang)(zhang)氏治學(xue)嚴謹(jin)，重視(shi)實踐，主張(zhang)(zhang)溝通中西，取長補短，是近代中西醫(yi)匯通派(pai)的代表之(zhi)一。其(qi)醫(yi)德高尚，常舍藥(yao)(yao)濟貧，遇疑難重癥，殫思竭慮，并親自攜藥(yao)(yao)到病(bing)(bing)家督(du)煎，守護達旦(dan)。為了體驗(yan)藥(yao)(yao)物的毒性反應(ying)和(he)用量，曾(ceng)親嘗巴豆、花椒、甘(gan)遂(sui)等藥(yao)(yao)，足見其(qi)對(dui)病(bing)(bing)人(ren)極端負(fu)責的精(jing)神和(he)重視(shi)實踐的治學(xue)態度。他醫(yi)術精(jing)湛，常能力排眾議，獨任其(qi)責，起群醫(yi)束(shu)手(shou)之(zhi)沉疴(ke)，療效卓著，名(ming)震遐邇(er)。當時與(yu)江蘇陸晉笙、楊如侯，廣東劉蔚楚(chu)同負(fu)盛名(ming)，又與(yu)慈溪(xi)張(zhang)(zhang)生甫、嘉定張(zhang)(zhang)山雷并稱名(ming)醫(yi)三張(zhang)(zhang)。

張氏勤于(yu)鉆研，善(shan)于(yu)總結，平生著述甚多，后因天津洪水沒其居(ju)，遺書蕩盡，傳(chuan)世者僅《醫學衷中參西錄》一書。

鑒賞評價

《醫(yi)學(xue)衷中參西錄》為20世紀(ji)中醫(yi)臨床醫(yi)學(xue)名著，素為醫(yi)家所重視。