《醫(yi)(yi)(yi)學(xue)(xue)衷(zhong)中(zhong)(zhong)(zhong)參(can)西(xi)錄》,中(zhong)(zhong)(zhong)醫(yi)(yi)(yi)叢書(shu),又(you)名《衷(zhong)中(zhong)(zhong)(zhong)參(can)西(xi)錄》,張(zhang)(zhang)錫純(壽甫)撰。此(ci)書(shu)分為(wei)《處方(fang)(fang)學(xue)(xue)》8卷(juan)(juan)、《醫(yi)(yi)(yi)論(lun)》8卷(juan)(juan)、《醫(yi)(yi)(yi)話拾(shi)零》、《三三醫(yi)(yi)(yi)書(shu)評》、《藥(yao)(yao)物講義》4卷(juan)(juan)、《傷寒講義》4卷(juan)(juan)、《醫(yi)(yi)(yi)案(附詩草)》4卷(juan)(juan)。系作者多(duo)年治學(xue)(xue)臨證(zheng)經驗(yan)和(he)心得之(zhi)總結(jie)。是20世紀初我國重(zhong)要(yao)的(de)(de)臨床(chuang)綜合(he)性(xing)名著。張(zhang)(zhang)氏(shi)(shi)致力溝通中(zhong)(zhong)(zhong)西(xi)醫(yi)(yi)(yi)學(xue)(xue),主(zhu)張(zhang)(zhang)以(yi)中(zhong)(zhong)(zhong)醫(yi)(yi)(yi)為(wei)主(zhu)體,取(qu)西(xi)醫(yi)(yi)(yi)之(zhi)長,補中(zhong)(zhong)(zhong)醫(yi)(yi)(yi)之(zhi)短。他(ta)認為(wei):“欲求醫(yi)(yi)(yi)學(xue)(xue)登峰造極,誠非溝通中(zhong)(zhong)(zhong)西(xi)醫(yi)(yi)(yi)不(bu)可(ke)。”其(qi)(qi)于(yu)溝通中(zhong)(zhong)(zhong)西(xi)醫(yi)(yi)(yi)的(de)(de)主(zhu)導思想,主(zhu)張(zhang)(zhang)師古而不(bu)泥古,參(can)西(xi)而不(bu)背中(zhong)(zhong)(zhong)。張(zhang)(zhang)氏(shi)(shi)重(zhong)視(shi)基礎理(li)論(lun),對(dui)(dui)臟象學(xue)(xue)說和(he)解剖生(sheng)理(li)的(de)(de)互證(zheng)尤為(wei)重(zhong)視(shi)。書(shu)中(zhong)(zhong)(zhong)指出(chu):腦為(wei)元神,心為(wei)識神,心力衰(shuai)竭與腎不(bu)納氣相(xiang)通;腦充血與薄厥相(xiang)近等等。在(zai)臨證(zheng)方(fang)(fang)面,講究細致的(de)(de)觀察和(he)記述病(bing)(bing)情(qing),建立完整的(de)(de)病(bing)(bing)歷。其(qi)(qi)于(yu)諸(zhu)病(bing)(bing)治法,注重(zhong)實(shi)際,勇于(yu)探索,并獨創(chuang)了許多(duo)新的(de)(de)治療方(fang)(fang)劑(ji)(ji)(ji),體驗(yan)了若干中(zhong)(zhong)(zhong)藥(yao)(yao)的(de)(de)性(xing)能(neng)。對(dui)(dui)諸(zhu)如萸肉救脫,參(can)芪利尿,白礬化痰(tan)熱,三七消(xiao)瘡腫(zhong),生(sheng)硫黃內(nei)服治虛寒下(xia)痢,蜈蚣(gong)、蝎子定風消(xiao)毒(du)等等,均能(neng)發(fa)揚古說,擴(kuo)大藥(yao)(yao)用主(zhu)治。如對(dui)(dui)調治脾(pi)胃(wei),主(zhu)張(zhang)(zhang)脾(pi)陽與胃(wei)陰并重(zhong),升肝(gan)脾(pi)與降膽胃(wei)兼施(shi),補養與開破相(xiang)結(jie)合(he)。書(shu)中(zhong)(zhong)(zhong)結(jie)合(he)中(zhong)(zhong)(zhong)西(xi)醫(yi)(yi)(yi)學(xue)(xue)理(li)論(lun)和(he)醫(yi)(yi)(yi)療實(shi)踐闡發(fa)醫(yi)(yi)(yi)理(li),頗(po)多(duo)獨到的(de)(de)見解。書(shu)中(zhong)(zhong)(zhong)載述張(zhang)(zhang)氏(shi)(shi)所制定的(de)(de)若干有(you)效方(fang)(fang)劑(ji)(ji)(ji);在(zai)方(fang)(fang)藥(yao)(yao)應用方(fang)(fang)面,創(chuang)用中(zhong)(zhong)(zhong)西(xi)藥(yao)(yao)相(xiang)結(jie)合(he)的(de)(de)方(fang)(fang)劑(ji)(ji)(ji),并對(dui)(dui)石(shi)膏、生(sheng)山藥(yao)(yao)、代赭石(shi)等藥(yao)(yao)的(de)(de)臨床(chuang)施(shi)治,在(zai)古人基礎上有(you)重(zhong)要(yao)的(de)(de)補訂(ding)、發(fa)揮。
《醫學衷中參(can)西(xi)錄》為張(zhang)錫純唯一傳世的著作,其主(zhu)要學術(shu)內容如(ru)下:
一、學術理論
(一)倡“衷中參西”
清(qing)末民(min)初,西(xi)學(xue)東漸,西(xi)醫(yi)(yi)學(xue)在我國(guo)流傳(chuan)甚快。當時(shi),醫(yi)(yi)學(xue)界有些人崇(chong)尚西(xi)學(xue),輕視(shi)中(zhong)(zhong)醫(yi)(yi),有些中(zhong)(zhong)醫(yi)(yi)則一(yi)味排斥(chi)西(xi)醫(yi)(yi),因循守舊。張(zhang)氏(shi)則主(zhu)張(zhang)以中(zhong)(zhong)醫(yi)(yi)為本(ben)體(ti),擷取西(xi)醫(yi)(yi)之長(chang)補(bu)中(zhong)(zhong)醫(yi)(yi)之短,倡導“衷中(zhong)(zhong)參西(xi)”,并從理論、實(shi)踐方(fang)面(mian)進(jin)行了嘗試,《醫(yi)(yi)學(xue)衷中(zhong)(zhong)參西(xi)錄》的(de)(de)書名就鮮明地表明了張(zhang)氏(shi)的(de)(de)學(xue)術主(zhu)張(zhang)。
在(zai)生理(li)、病(bing)理(li)方面,張氏于(yu)(yu)《醫學衷中(zhong)(zhong)參西(xi)錄(lu)》中(zhong)(zhong)有許(xu)多溝通中(zhong)(zhong)西(xi)醫學的(de)新見解,如:“中(zhong)(zhong)醫謂人(ren)之(zhi)(zhi)(zhi)(zhi)(zhi)神(shen)(shen)明(ming)(ming)在(zai)心,西(xi)說謂人(ren)之(zhi)(zhi)(zhi)(zhi)(zhi)神(shen)(shen)明(ming)(ming)在(zai)腦,及觀(guan)《內(nei)經》,皆(jie)(jie)涵蓋其中(zhong)(zhong)也”。《素問·脈要(yao)精微論(lun)(lun)》中(zhong)(zhong)指出“頭者(zhe)(zhe)精明(ming)(ming)之(zhi)(zhi)(zhi)(zhi)(zhi)府”,說明(ming)(ming)神(shen)(shen)明(ming)(ming)之(zhi)(zhi)(zhi)(zhi)(zhi)體在(zai)腦,所謂“心主神(shen)(shen)明(ming)(ming)”,只不過是言(yan)神(shen)(shen)明(ming)(ming)之(zhi)(zhi)(zhi)(zhi)(zhi)用出于(yu)(yu)心,由(you)此可(ke)見,中(zhong)(zhong)西(xi)之(zhi)(zhi)(zhi)(zhi)(zhi)說雖(sui)然(ran)不同,但理(li)可(ke)匯(hui)通。另(ling)如,認為吐衄(nv)(nv)的(de)原因是由(you)于(yu)(yu)陽(yang)明(ming)(ming)胃腑氣(qi)機上逆(ni),胃中(zhong)(zhong)之(zhi)(zhi)(zhi)(zhi)(zhi)血亦恒(heng)隨(sui)之(zhi)(zhi)(zhi)(zhi)(zhi)上逆(ni)。“其上逆(ni)之(zhi)(zhi)(zhi)(zhi)(zhi)極,可(ke)將胃壁之(zhi)(zhi)(zhi)(zhi)(zhi)膜排擠破裂,而成嘔血之(zhi)(zhi)(zhi)(zhi)(zhi)證;或循陽(yang)明(ming)(ming)之(zhi)(zhi)(zhi)(zhi)(zhi)經絡上行(xing),而成衄(nv)(nv)血之(zhi)(zhi)(zhi)(zhi)(zhi)證”,此即(ji)《素問·厥(jue)論(lun)(lun)》中(zhong)(zhong)所言(yan)“陽(yang)明(ming)(ming)厥(jue)逆(ni)衄(nv)(nv)嘔血”。其論(lun)(lun)衄(nv)(nv)血治療(liao),主張不論(lun)(lun)“或虛或實,或涼(liang)或熱,治之(zhi)(zhi)(zhi)(zhi)(zhi)者(zhe)(zhe)皆(jie)(jie)當以降胃之(zhi)(zhi)(zhi)(zhi)(zhi)品為主”,并(bing)制平胃寒降湯(tang)、滋陰清降湯(tang)等,皆(jie)(jie)主以生赭(zhe)石(shi)通降胃氣(qi),并(bing)輔以白(bai)芍、龍(long)、牡等養陰鎮潛之(zhi)(zhi)(zhi)(zhi)(zhi)品,提高(gao)了本(ben)病(bing)的(de)療(liao)效。
在用(yong)(yong)(yong)藥(yao)上,張氏(shi)認為,西藥(yao)治(zhi)(zhi)(zhi)在局部,是(shi)重(zhong)(zhong)在病之(zhi)(zhi)標也(ye);中(zhong)(zhong)(zhong)藥(yao)用(yong)(yong)(yong)藥(yao)求原(yuan)因(yin),是(shi)重(zhong)(zhong)在病之(zhi)(zhi)本(ben)也(ye)。究之(zhi)(zhi),標本(ben)原(yuan)宜兼顧(gu),若遇難(nan)治(zhi)(zhi)(zhi)之(zhi)(zhi)證(zheng),以(yi)西藥(yao)治(zhi)(zhi)(zhi)其標,中(zhong)(zhong)(zhong)藥(yao)治(zhi)(zhi)(zhi)其本(ben),則奏效必(bi)速,提(ti)出中(zhong)(zhong)(zhong)藥(yao)、西藥(yao)不應(ying)互相(xiang)抵牾(wu),而應(ying)相(xiang)濟為用(yong)(yong)(yong)。張氏(shi)臨床治(zhi)(zhi)(zhi)療癲癇,據中(zhong)(zhong)(zhong)醫(yi)“諸(zhu)風掉眩,皆(jie)屬于肝”理論,用(yong)(yong)(yong)西藥(yao)臭(chou)素(su)、抱水諸(zhu)品及鉛硫朱砂丸麻(ma)醉鎮靜(jing)治(zhi)(zhi)(zhi)標,而后則主張徐以(yi)健脾、利痰(tan)、祛(qu)風、清火之(zhi)(zhi)藥(yao)以(yi)鏟除其病根。治(zhi)(zhi)(zhi)療大氣下陷,下血(xue)不止之(zhi)(zhi)血(xue)崩(beng)癥(zheng),煎服(fu)生黃芪、白術(shu)、龍骨、牡(mu)蠣、柴胡等升(sheng)舉固澀(se)之(zhi)(zhi)品時,加服(fu)西藥(yao)麥角,以(yi)加強收縮止血(xue)功效。張氏(shi)在辨證(zheng)施(shi)治(zhi)(zhi)(zhi)運用(yong)(yong)(yong)中(zhong)(zhong)(zhong)醫(yi)方藥(yao)的同時,加服(fu)西藥(yao),開中(zhong)(zhong)(zhong)西藥(yao)聯合應(ying)用(yong)(yong)(yong)之(zhi)(zhi)先河。
(二)大(da)氣下陷(xian)論
繼喻昌(chang)“胸中大氣說(shuo)”之后(hou),張氏在(zai)《醫(yi)學衷中參西錄》中對大氣的(de)認識和治療(liao)作了進一(yi)步(bu)的(de)闡發。
張氏(shi)認為(wei),大(da)氣(qi)(qi)(qi)即(ji)《內(nei)經》所言之(zhi)宗氣(qi)(qi)(qi),它“以(yi)(yi)元(yuan)氣(qi)(qi)(qi)為(wei)根本,以(yi)(yi)水(shui)谷之(zhi)氣(qi)(qi)(qi)為(wei)養料(liao),以(yi)(yi)胸(xiong)中之(zhi)地(di)為(wei)宅窟者也”。因其“誠(cheng)以(yi)(yi)能(neng)撐(cheng)(cheng)持(chi)(chi)全(quan)身,為(wei)諸(zhu)氣(qi)(qi)(qi)之(zhi)綱領,包舉肺外,司(si)呼(hu)吸之(zhi)樞(shu)機,故鄭而(er)(er)重之(zhi)曰大(da)氣(qi)(qi)(qi)。”即(ji)大(da)氣(qi)(qi)(qi)是搏聚(ju)于(yu)胸(xiong)中,包舉于(yu)肺外的大(da)量陽(yang)氣(qi)(qi)(qi),它源于(yu)元(yuan)氣(qi)(qi)(qi),受水(shui)谷精微(wei)的滋養,除主司(si)呼(hu)吸外,同時(shi)對全(quan)身產(chan)生重要影響。此(ci)氣(qi)(qi)(qi)撐(cheng)(cheng)持(chi)(chi)全(quan)身,振作(zuo)精神,心(xin)及心(xin)思、腦(nao)力、百骸動作(zuo),莫不(bu)賴(lai)于(yu)此(ci)。此(ci)氣(qi)(qi)(qi)一(yi)虛,呼(hu)吸即(ji)覺不(bu)利(li),而(er)(er)時(shi)時(shi)酸懶,精神昏憒,腦(nao)力、心(xin)思為(wei)之(zhi)頓減。
大氣(qi)之(zhi)病變主要是虛(xu)而(er)陷,其病情有(you)(you)(you)(you)緩(huan)急之(zhi)別(bie),急者(zhe)可引起猝死,“大氣(qi)既(ji)陷,無氣(qi)包舉(ju)肺外以(yi)鼓動其闔辟之(zhi)機(ji),則呼(hu)吸停頓,所以(yi)不(bu)(bu)病而(er)猝死。緩(huan)者(zhe)則因大氣(qi)下陷而(er)致呼(hu)吸不(bu)(bu)利(li),換氣(qi)不(bu)(bu)足缺(que)氧,全身(shen)性衰竭出(chu)現一系列表(biao)現:“有(you)(you)(you)(you)呼(hu)吸短氣(qi)者(zhe),有(you)(you)(you)(you)心中怔(zheng)忡者(zhe),有(you)(you)(you)(you)淋漓大汗(han)者(zhe),有(you)(you)(you)(you)神昏健忘(wang)者(zhe),有(you)(you)(you)(you)聲(sheng)顫身(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)吸似喘者(zhe),有(you)(you)(you)(you)咽(yan)干(gan)作(zuo)渴者(zhe),有(you)(you)(you)(you)常(chang)常(chang)呵欠者(zhe),有(you)(you)(you)(you)肢體(ti)痿廢者(zhe),有(you)(you)(you)(you)食后易饑者(zhe),有(you)(you)(you)(you)二(er)便不(bu)(bu)禁(jin)者(zhe),有(you)(you)(you)(you)癃閉身(shen)腫(zhong)者(zhe),有(you)(you)(you)(you)張口(kou)呼(hu)氣(qi)外出(chu)而(er)氣(qi)不(bu)(bu)上(shang)達,肛門(men)突出(chu)者(zhe),在女子有(you)(you)(you)(you)下血不(bu)(bu)止,更有(you)(you)(you)(you)經水逆行者(zhe)”等(deng)等(deng)。,
以(yi)(yi)上見癥以(yi)(yi)心(xin)肺證候(hou)為主(zhu),常兼(jian)見脾胃證候(hou)。若單見脾胃證候(hou)而無心(xin)肺證候(hou)者(zhe),是謂中(zhong)氣下陷(xian)。中(zhong)氣下陷(xian)之(zhi)重者(zhe),張(zhang)氏認為有引起大(da)(da)氣下陷(xian)之(zhi)可能(neng),“夫中(zhong)氣誠有下陷(xian)之(zhi)時,然(ran)不若大(da)(da)氣下陷(xian)之(zhi)尤(you)屬危險也。間有因中(zhong)氣下陷(xian),泄瀉(xie)日久,或轉致大(da)(da)氣下陷(xian)者(zhe)”。這樣把大(da)(da)氣下陷(xian)與中(zhong)氣下陷(xian)分(fen)別開來,確為閱歷之(zhi)談(tan)。
張氏認為(wei),引(yin)(yin)起大(da)(da)氣(qi)(qi)下陷的原因不外(wai)勞力(li)過(guo)度、久(jiu)病和(he)誤藥(yao)(yao)(yao)。如“力(li)小任重,或(huo)(huo)枵腹力(li)作,或(huo)(huo)病后氣(qi)(qi)力(li)未復而勤(qin)于(yu)動作,或(huo)(huo)泄瀉日久(jiu),或(huo)(huo)服破(po)氣(qi)(qi)藥(yao)(yao)(yao)太過(guo)或(huo)(huo)氣(qi)(qi)分虛(xu)(xu)極(ji)自(zi)下陷”。張氏治(zhi)療大(da)(da)氣(qi)(qi)下陷,創(chuang)制升(sheng)(sheng)(sheng)(sheng)陷湯(生(sheng)黃芪(qi)、知(zhi)母、桔梗、柴(chai)胡(hu)、升(sheng)(sheng)(sheng)(sheng)麻(ma)),該方以(yi)黃芪(qi)為(wei)君(jun),升(sheng)(sheng)(sheng)(sheng)補大(da)(da)氣(qi)(qi),佐知(zhi)母涼潤(run)以(yi)濟其之(zhi)(zhi)偏,柴(chai)胡(hu)引(yin)(yin)大(da)(da)氣(qi)(qi)之(zhi)(zhi)陷者自(zi)左上(shang)升(sheng)(sheng)(sheng)(sheng),升(sheng)(sheng)(sheng)(sheng)麻(ma)引(yin)(yin)大(da)(da)氣(qi)(qi)之(zhi)(zhi)陷者自(zi)右(you)上(shang)升(sheng)(sheng)(sheng)(sheng),桔梗為(wei)藥(yao)(yao)(yao)中之(zhi)(zhi)舟楫(ji),導諸藥(yao)(yao)(yao)之(zhi)(zhi)力(li)上(shang)達胸中。若氣(qi)(qi)虛(xu)(xu)極(ji)加人參或(huo)(huo)寄生(sheng),以(yi)培氣(qi)(qi)之(zhi)(zhi)本(ben),或(huo)(huo)更加山萸肉以(yi)防氣(qi)(qi)之(zhi)(zhi)渙散(san),氣(qi)(qi)虛(xu)(xu)甚者酌(zhuo)增升(sheng)(sheng)(sheng)(sheng)麻(ma)用量。
心(xin)(xin)肺之(zhi)陽(yang),尤賴胸(xiong)中(zhong)大氣為之(zhi)保護,大氣一陷,則心(xin)(xin)肺陽(yang)分素虛(xu)(xu)者(zhe),至此(ci)而益虛(xu)(xu),癥見其人(ren)心(xin)(xin)冷,背緊,惡寒(han),常覺短氣等。張氏認為欲助胸(xiong)中(zhong)心(xin)(xin)肺之(zhi)陽(yang),必(bi)須先(xian)升(sheng)(sheng)提下陷之(zhi)大氣,否則但服溫補心(xin)(xin)肺之(zhi)陽(yang)之(zhi)劑(ji)無效,制回陽(yang)升(sheng)(sheng)陷湯(生(sheng)黃(huang)芪、干姜、當歸身(shen)、桂枝炭(tan)、甘草)以治(zhi)之(zhi)。
胸中(zhong)大(da)氣(qi)正常,有(you)賴于(yu)少(shao)陽(yang)、陽(yang)明之氣(qi)的(de)升(sheng)(sheng)發(fa)。若大(da)氣(qi)下陷(xian),升(sheng)(sheng)發(fa)之氣(qi)被郁,氣(qi)分郁結,經絡瘀滯,常見胸中(zhong)滿痛或脅下撐脹、腹痛等。對(dui)此,張氏(shi)又制理(li)(li)郁升(sheng)(sheng)陷(xian)湯(生(sheng)黃(huang)芪、知母、當(dang)歸身、桂(gui)枝尖、柴胡、乳(ru)香、沒藥);對(dui)脾(pi)氣(qi)虛極下陷(xian),小便不禁者,制理(li)(li)脾(pi)升(sheng)(sheng)陷(xian)湯(生(sheng)黃(huang)芪、白術、桑寄生(sheng)、川斷、萸肉(rou)、龍骨、牡(mu)蠣、川萆薢、甘草)治之。
(三(san))寒溫統一,注重清透
《醫學衷中參西錄(lu)》論溫(wen)病(bing)(bing),主張(zhang)寒(han)(han)溫(wen)統一,認為溫(wen)病(bing)(bing)治法已備(bei)于(yu)傷(shang)寒(han)(han)。如溫(wen)病(bing)(bing)初(chu)起(qi)治宜辛涼(liang),然辛涼(liang)之(zhi)(zhi)(zhi)法亦備(bei)于(yu)傷(shang)寒(han)(han),麻杏甘石湯(tang)(tang)“誠為溫(wen)病(bing)(bing)初(chu)得(de)之(zhi)(zhi)(zhi)的方矣(yi)”。但其外表(biao)(biao)證未解,內有蘊熱(re)即可(ke)服(fu)用(yong)。至溫(wen)病(bing)(bing)傳經已深,清(qing)燥熱(re)之(zhi)(zhi)(zhi)白(bai)虎湯(tang)(tang)、白(bai)虎加人參湯(tang)(tang),通腑(fu)之(zhi)(zhi)(zhi)大(da)、小承氣湯(tang)(tang),開結(jie)胸之(zhi)(zhi)(zhi)大(da)、小陷胸湯(tang)(tang),治下利之(zhi)(zhi)(zhi)白(bai)頭(tou)翁(weng)湯(tang)(tang)、黃(huang)芩湯(tang)(tang),治發黃(huang)之(zhi)(zhi)(zhi)茵陳桅子柏皮湯(tang)(tang)等(deng)及一切涼(liang)潤、清(qing)火、育陰、安神之(zhi)(zhi)(zhi)劑(ji),皆(jie)可(ke)使用(yong)。并指出寒(han)(han)溫(wen)治法之(zhi)(zhi)(zhi)別,在于(yu)“始異而終同”。所謂(wei)“始異”,即傷(shang)寒(han)(han)發表(biao)(biao)可(ke)用(yong)溫(wen)熱(re),溫(wen)病(bing)(bing)發表(biao)(biao)必用(yong)辛涼(liang);謂(wei)其“終同”,即病(bing)(bing)傳陽明之(zhi)(zhi)(zhi)后,不論傷(shang)寒(han)(han)、溫(wen)病(bing)(bing),皆(jie)宜治以寒(han)(han)涼(liang),而大(da)忌溫(wen)熱(re)。
張(zhang)氏臨證將溫(wen)病分為風溫(wen)、春(chun)(chun)溫(wen)、濕(shi)溫(wen)三類。認(ren)為三類溫(wen)病雖見(jian)癥不同(tong),其本質皆緣郁熱。“大凡病溫(wen)之人(ren),多(duo)系內有(you)蘊熱,至春(chun)(chun)陽(yang)萌動之時,又薄(bo)受外感拘束,其熱即陡發(fa)而成溫(wen)”。他(ta)遵(zun)循(xun)“火郁發(fa)之”之旨,治(zhi)療上(shang)主張(zhang)宣(xuan)散(san)郁結(jie),疏通(tong)氣機,透(tou)邪外達。反對徒執(zhi)寒涼,只清(qing)(qing)(qing)不透(tou),使邪無(wu)由出。并(bing)自擬清(qing)(qing)(qing)解湯(tang)、涼解湯(tang)、寒解湯(tang)三方,徑以石膏清(qing)(qing)(qing)其內熱,又選(xuan)用薄(bo)荷、連翹、蟬蛻發(fa)表,且(qie)“引胃中化而欲(yu)散(san)之熱,仍還太陽(yang)作汗而解”。正(zheng)是基于對溫(wen)病“郁熱”這一本質的深刻認(ren)識(shi),初起治(zhi)療即立足(zu)于清(qing)(qing)(qing)透(tou)。
溫(wen)(wen)病(bing)入里化(hua)熱(re)(re),抑或傷(shang)寒(han)、中(zhong)風入里化(hua)熱(re)(re),是陽明(ming)熱(re)(re)盛之(zhi)(zhi)(zhi)(zhi)象,張氏(shi)皆以寒(han)涼清熱(re)(re)為主,不復有(you)傷(shang)寒(han)、中(zhong)風、溫(wen)(wen)病(bing)之(zhi)(zhi)(zhi)(zhi)分,投以白虎湯(tang)靈活(huo)加減化(hua)裁(cai)。臨證使用白虎湯(tang),張氏(shi)有(you)著豐富的(de)經驗,認為白虎湯(tang)之(zhi)(zhi)(zhi)(zhi)“四大(da)”典型癥狀(zhuang)中(zhong),唯脈洪(hong)為必(bi)見之(zhi)(zhi)(zhi)(zhi)癥。只要見脈洪(hong)大(da),又有(you)陽明(ming)熱(re)(re)盛之(zhi)(zhi)(zhi)(zhi)一二癥,則(ze)無(wu)論外(wai)感內傷(shang),皆可用之(zhi)(zhi)(zhi)(zhi),不必(bi)拘泥于古人之(zhi)(zhi)(zhi)(zhi)說。
陽(yang)明腑實(shi)(shi)用(yong)(yong)三承(cheng)氣(qi)湯(tang)(tang),此(ci)(ci)乃(nai)大法,然張氏(shi)(shi)認為(wei)承(cheng)氣(qi)力(li)(li)猛,倘(tang)或審(shen)證(zheng)不確,即足誤事(shi)。于是據其(qi)三十余年臨證(zheng)經(jing)驗,強調(diao)“凡遇(yu)陽(yang)明應下證(zheng),亦(yi)先(xian)投以白(bai)虎湯(tang)(tang)一二(er)劑,更改其(qi)服(fu)法,將石(shi)膏為(wei)末(mo)而不入煎,以藥湯(tang)(tang)送服(fu)之(zhi)”,因屢用(yong)(yong)此(ci)(ci)方奏效,遂名之(zhi)曰白(bai)虎承(cheng)氣(qi)湯(tang)(tang)。對于溫熱病(bing)神昏(hun)譫語,張氏(shi)(shi)遵從陸九芝“胃(wei)熱之(zhi)甚(shen),神為(wei)之(zhi)昏(hun),從來神昏(hun)之(zhi)病(bing),皆屬胃(wei)家(jia)”之(zhi)說(shuo),將熱病(bing)神昏(hun)分為(wei)虛實(shi)(shi)兩類(lei)。其(qi)脈象(xiang)洪而有(you)力(li)(li),按(an)之(zhi)甚(shen)實(shi)(shi)者,可按(an)陽(yang)明胃(wei)實(shi)(shi)治之(zhi),投以大劑白(bai)虎湯(tang)(tang);若脈兼弦、兼數,或重按(an)仍甚(shen)實(shi)(shi)者,治宜(yi)白(bai)虎加人(ren)參湯(tang)(tang);對邪入陽(yang)明,淫熱于肝(gan),致肝(gan)風內動者,以白(bai)虎撤其(qi)陽(yang)明之(zhi)熱,生(sheng)龍骨、生(sheng)牡(mu)蠣以鎮肝(gan)熄風。
張(zhang)氏治療(liao)溫病(bing)不僅擅用白(bai)虎(hu)(hu),而(er)且依據病(bing)證不同,化裁(cai)組成了(le)眾多新方(fang),如石膏粳米湯、鎮逆白(bai)虎(hu)(hu)湯、通變(bian)白(bai)虎(hu)(hu)加人參湯等,皆由(you)白(bai)虎(hu)(hu)湯衍化而(er)來。
二、治療經驗
張氏(shi)一生勤于臨證,《醫學衷中(zhong)參西錄》記載(zai)了他豐富的臨床(chuang)經驗,其中(zhong)尤(you)以論治中(zhong)風、脫證等最具特色(se)。
(一)分別中(zhong)風論治
中(zhong)風有真中(zhong)、類(lei)中(zhong)之別。張(zhang)氏(shi)認為真中(zhong)者(zhe)極少(shao),因(yin)而著意對類(lei)中(zhong)進行研究、發揮(hui)。指出類(lei)中(zhong)風亦(yi)即內(nei)中(zhong)風,此“風自內(nei)生,非(fei)風自外來(lai)也”,其治療(liao)分充血、貧血,以虛實論(lun)治。
1、腦充血治療
張氏根據“血菀(yu)于上(shang),使人薄(bo)厥(jue)”的理論,認(ren)為(wei)(wei)腦充血即(ji)《內經》中(zhong)所言的煎厥(jue)、薄(bo)厥(jue)、大(da)厥(jue)。其病位在“肝”,陰虛陽亢(kang)、上(shang)實下(xia)(xia)虛、臟腑之(zhi)氣(qi)升(sheng)發(fa)太過或失(shi)之(zhi)下(xia)(xia)行(xing),血隨氣(qi)逆為(wei)(wei)主(zhu)要病機。即(ji)“人之(zhi)血隨氣(qi)行(xing),氣(qi)上(shang)升(sheng)不已,血即(ji)隨之(zhi)上(shang)升(sheng)不已,以致腦中(zhong)血管充血過甚”(《醫(yi)學衷(zhong)中(zhong)參西錄·醫(yi)案·腦充血門》),有礙神經,以致語言肢體謇澀不利,口(kou)眼歪斜等等。
根據(ju)腦(nao)充血之(zhi)(zhi)(zhi)(zhi)“肝(gan)(gan)(gan)(gan)(gan)(gan)木(mu)失和,肺氣(qi)(qi)不(bu)降,腎氣(qi)(qi)不(bu)攝,沖氣(qi)(qi)、胃(wei)氣(qi)(qi)又(you)復上(shang)逆,臟腑之(zhi)(zhi)(zhi)(zhi)氣(qi)(qi)化(hua)皆上(shang)升(sheng)太過”之(zhi)(zhi)(zhi)(zhi)病機,張氏提出治(zhi)療本病應(ying)“清其(qi)(qi)臟腑之(zhi)(zhi)(zhi)(zhi)熱(re),滋其(qi)(qi)臟腑之(zhi)(zhi)(zhi)(zhi)陰,更降其(qi)(qi)臟腑之(zhi)(zhi)(zhi)(zhi)氣(qi)(qi),引(yin)(yin)(yin)腦(nao)部(bu)(bu)所充之(zhi)(zhi)(zhi)(zhi)血下(xia)行(xing)”的“鎮(zhen)(zhen)肝(gan)(gan)(gan)(gan)(gan)(gan)熄風、引(yin)(yin)(yin)血下(xia)行(xing)”的原則(ze),并創制鎮(zhen)(zhen)肝(gan)(gan)(gan)(gan)(gan)(gan)熄風湯(tang)(懷牛膝(xi)、生(sheng)(sheng)(sheng)赭石、生(sheng)(sheng)(sheng)杭芍、天冬、生(sheng)(sheng)(sheng)龍(long)(long)骨、生(sheng)(sheng)(sheng)牡蠣(li)、生(sheng)(sheng)(sheng)龜(gui)板、玄(xuan)參、川(chuan)楝子、生(sheng)(sheng)(sheng)麥(mai)芽、茵陳、甘草)作為(wei)治(zhi)療本病的主方(fang)(fang)。方(fang)(fang)中赭石降胃(wei),平肝(gan)(gan)(gan)(gan)(gan)(gan)鎮(zhen)(zhen)沖,下(xia)行(xing)通便(bian);牛膝(xi)善(shan)引(yin)(yin)(yin)上(shang)部(bu)(bu)之(zhi)(zhi)(zhi)(zhi)血下(xia)行(xing),二(er)藥合用(yong),相(xiang)輔相(xiang)成;玄(xuan)參、天冬、白芍滋陰退熱(re);龍(long)(long)骨、牡蠣(li)、龜(gui)板、芍藥斂肝(gan)(gan)(gan)(gan)(gan)(gan)火(huo)、鎮(zhen)(zhen)熄肝(gan)(gan)(gan)(gan)(gan)(gan)風,以緩其(qi)(qi)肝(gan)(gan)(gan)(gan)(gan)(gan)氣(qi)(qi)上(shang)升(sheng)之(zhi)(zhi)(zhi)(zhi)勢;玄(xuan)參、天冬清肺制肝(gan)(gan)(gan)(gan)(gan)(gan);山(shan)藥、甘草和胃(wei)緩肝(gan)(gan)(gan)(gan)(gan)(gan);茵陳為(wei)“青蒿之(zhi)(zhi)(zhi)(zhi)嫩者,稟少(shao)陽初生(sheng)(sheng)(sheng)之(zhi)(zhi)(zhi)(zhi)氣(qi)(qi),與肝(gan)(gan)(gan)(gan)(gan)(gan)木(mu)同氣(qi)(qi)相(xiang)求,最能將順肝(gan)(gan)(gan)(gan)(gan)(gan)木(mu)之(zhi)(zhi)(zhi)(zhi)性,且又(you)善(shan)瀉(xie)肝(gan)(gan)(gan)(gan)(gan)(gan)熱(re)”,為(wei)清涼腦(nao)部(bu)(bu)之(zhi)(zhi)(zhi)(zhi)涼藥也;麥(mai)芽“善(shan)助(zhu)肝(gan)(gan)(gan)(gan)(gan)(gan)木(mu)疏泄以行(xing)腎氣(qi)(qi)”;川(chuan)楝子善(shan)引(yin)(yin)(yin)肝(gan)(gan)(gan)(gan)(gan)(gan)氣(qi)(qi)下(xia)達(da),又(you)能折其(qi)(qi)更動之(zhi)(zhi)(zhi)(zhi)力。本方(fang)(fang)標本兼(jian)治(zhi),鎮(zhen)(zhen)潛(qian)共用(yong),引(yin)(yin)(yin)涵(han)兼(jian)施(shi),直中病之(zhi)(zhi)(zhi)(zhi)肯綮,確有獨(du)到(dao)之(zhi)(zhi)(zhi)(zhi)處。
此外,張氏還參照西醫病(bing)理(li),闡述了(le)腦(nao)(nao)(nao)充(chong)血(xue)(xue)(xue)、腦(nao)(nao)(nao)溢血(xue)(xue)(xue)、腦(nao)(nao)(nao)出(chu)血(xue)(xue)(xue)之(zhi)(zhi)(zhi)證(zheng)型及用藥(yao)的不同。對腦(nao)(nao)(nao)部血(xue)(xue)(xue)管中之(zhi)(zhi)(zhi)血(xue)(xue)(xue)滲出(chu)者(zhe),他(ta)在友人“腦(nao)(nao)(nao)充(chong)血(xue)(xue)(xue)證(zheng),宜于(yu)引(yin)血(xue)(xue)(xue)下(xia)行藥(yao)中加(jia)(jia)破(po)血(xue)(xue)(xue)之(zhi)(zhi)(zhi)藥(yao)以治之(zhi)(zhi)(zhi)”的啟(qi)發下(xia),指出(chu)對其身(shen)(shen)體(ti)壯(zhuang)實(shi)者(zhe),可酌加(jia)(jia)大(da)黃(huang)數錢以逐瘀(yu);其身(shen)(shen)形(xing)脈(mo)象不甚(shen)壯(zhuang)實(shi)者(zhe),加(jia)(jia)桃仁、丹參等(deng)化(hua)瘀(yu)。并明(ming)確提出(chu)“腦(nao)(nao)(nao)充(chong)血(xue)(xue)(xue)當通大(da)便(bian)為要務”。對腦(nao)(nao)(nao)充(chong)血(xue)(xue)(xue)后期脈(mo)象柔和而(er)肢體(ti)痿廢者(zhe),主張“少用黃(huang)芪(qi)助(zhu)活(huo)血(xue)(xue)(xue)之(zhi)(zhi)(zhi)品以通絡”,但(dan)應謹慎從事。而(er)對于(yu)“血(xue)(xue)(xue)菀于(yu)上(shang)”的腦(nao)(nao)(nao)充(chong)血(xue)(xue)(xue)者(zhe),因(yin)黃(huang)芪(qi)之(zhi)(zhi)(zhi)情,補(bu)而(er)兼升,氣升則血(xue)(xue)(xue)必隨之(zhi)(zhi)(zhi)升,故病(bing)初(chu)應忌用黃(huang)芪(qi),誤(wu)用則兇危立見。其辨證(zheng)之(zhi)(zhi)(zhi)嚴謹,用藥(yao)之(zhi)(zhi)(zhi)精確,可見一斑。
2、腦貧血治療
與腦(nao)(nao)(nao)充血(xue)(xue)證相反(fan),張(zhang)氏認為(wei)腦(nao)(nao)(nao)貧血(xue)(xue)證則為(wei)血(xue)(xue)之上(shang)注于腦(nao)(nao)(nao)過少(shao)(shao),無以養其腦(nao)(nao)(nao)髓(sui)神(shen)(shen)經,致(zhi)使腦(nao)(nao)(nao)神(shen)(shen)經失(shi)其所司。而血(xue)(xue)之上(shang)注過少(shao)(shao),實由(you)“宗氣虛寒(han),不(bu)能助血(xue)(xue)上(shang)升川”。故治療(liao)腦(nao)(nao)(nao)貧血(xue)(xue)證,主張(zhang)“應峻補(bu)其胸中(zhong)(zhong)大氣”,自擬當歸補(bu)血(xue)(xue)湯(tang)益(yi)氣溫(wen)陽、補(bu)血(xue)(xue)活血(xue)(xue),治療(liao)中(zhong)(zhong)風脈象(xiang)遲弱,身軟,肢體漸覺不(bu)利,或(huo)頭(tou)重目(mu)眩,或(huo)神(shen)(shen)昏健忘,甚(shen)或(huo)昏仆,移時蘇醒致(zhi)成偏枯者。方中(zhong)(zhong)主以黃(huang)芪(qi)升補(bu)胸中(zhong)(zhong)大氣,使血(xue)(xue)隨氣升,上(shang)達腦(nao)(nao)(nao)中(zhong)(zhong);用當歸、龍眼肉、鹿角膠(jiao)養血(xue)(xue)生髓(sui);丹參(can)、乳、沒(mei)開血(xue)(xue)痹,化瘀滯;甘(gan)松助心房運行有力,以多輸血(xue)(xue)于腦(nao)(nao)(nao),且又為(wei)調養神(shen)(shen)經之品。對于腦(nao)(nao)(nao)貧血(xue)(xue)肢體痿(wei)廢或(huo)偏枯,脈象(xiang)極(ji)微(wei)細無力者,又擬干頹(tui)湯(tang)、補(bu)腦(nao)(nao)(nao)振(zhen)痿(wei)湯(tang)治療(liao)。并指出(chu)肢體偏廢,服(fu)藥久不(bu)效(xiao)者,應著重補(bu)腎通絡(luo),多選(xuan)用胡(hu)桃肉、地龍、馬錢子等(deng)。
(二)重視沖氣(qi)為病,善用鎮沖降逆
沖(chong)(chong)脈(mo)為(wei)奇(qi)經八脈(mo)之(zhi)(zhi)(zhi)一(yi),張(zhang)氏論病(bing)極(ji)重(zhong)視沖(chong)(chong)氣(qi)(qi),指(zhi)出“沖(chong)(chong)氣(qi)(qi)上(shang)(shang)沖(chong)(chong)之(zhi)(zhi)(zhi)病(bing)甚(shen)多(duo)(duo),而(er)醫者識其(qi)(qi)(qi)(qi)病(bing)者甚(shen)少。即或(huo)能識此病(bing),亦多(duo)(duo)不(bu)能洞悉其(qi)(qi)(qi)(qi)病(bing)因(yin)”。因(yin)而(er),對沖(chong)(chong)氣(qi)(qi)的生(sheng)理,尤其(qi)(qi)(qi)(qi)是沖(chong)(chong)氣(qi)(qi)上(shang)(shang)沖(chong)(chong)的病(bing)因(yin)、病(bing)理、病(bing)脈(mo)、治法都(dou)作了(le)詳細闡述,自(zi)成一(yi)家之(zhi)(zhi)(zhi)言。其(qi)(qi)(qi)(qi)述沖(chong)(chong)脈(mo),、兼(jian)采《內》《難》之(zhi)(zhi)(zhi)說(shuo)(shuo),認為(wei)其(qi)(qi)(qi)(qi)“在(zai)胞室之(zhi)(zhi)(zhi)兩旁(pang),與任脈(mo)相(xiang)連,為(wei)腎(shen)(shen)臟(zang)之(zhi)(zhi)(zhi)輔(fu)弼,氣(qi)(qi)化相(xiang)通……上(shang)(shang)系原隸陽明胃(wei)腑”,并認為(wei)“沖(chong)(chong)氣(qi)(qi)上(shang)(shang)沖(chong)(chong)之(zhi)(zhi)(zhi)證(zheng),固由于腎(shen)(shen)臟(zang)之(zhi)(zhi)(zhi)虛(xu)(xu),亦多(duo)(duo)由于肝(gan)氣(qi)(qi)恣橫,素性(xing)多(duo)(duo)怒之(zhi)(zhi)(zhi)人,其(qi)(qi)(qi)(qi)肝(gan)氣(qi)(qi)之(zhi)(zhi)(zhi)暴發,更助(zhu)沖(chong)(chong)胃(wei)之(zhi)(zhi)(zhi)氣(qi)(qi)上(shang)(shang)逆(ni)(ni)”。即腎(shen)(shen)虛(xu)(xu)無以涵木,不(bu)能收斂(lian)(lian)沖(chong)(chong)氣(qi)(qi),沖(chong)(chong)氣(qi)(qi)上(shang)(shang)行(xing),肝(gan)氣(qi)(qi)橫逆(ni)(ni),胃(wei)氣(qi)(qi)上(shang)(shang)逆(ni)(ni)而(er)呈上(shang)(shang)沖(chong)(chong)之(zhi)(zhi)(zhi)弊。張(zhang)氏描述的沖(chong)(chong)氣(qi)(qi)上(shang)(shang)沖(chong)(chong)證(zheng),除自(zi)覺(jue)有氣(qi)(qi)自(zi)下上(shang)(shang)沖(chong)(chong),脈(mo)多(duo)(duo)弦硬(ying)而(er)長(chang)外,主要表現有胃(wei)脘(wan)或(huo)腹中(zhong)滿悶,噦氣(qi)(qi),呃逆(ni)(ni)連連,嘔(ou)吐不(bu)止(zhi),或(huo)見(jian)(jian)吐血(xue)、衄血(xue)等(deng)胃(wei)氣(qi)(qi)上(shang)(shang)逆(ni)(ni)不(bu)降(jiang)(jiang)見(jian)(jian)癥;或(huo)兩脅(xie)痛(tong)脹(zhang),頭目眩暈,甚(shen)而(er)氣(qi)(qi)火挾痰上(shang)(shang)沖(chong)(chong),發生(sheng)突然(ran)昏仆等(deng);或(huo)為(wei)胸滿窒塞,喘息(xi)大作。其(qi)(qi)(qi)(qi)治療(liao),主張(zhang)以斂(lian)(lian)沖(chong)(chong)鎮沖(chong)(chong)為(wei)主,降(jiang)(jiang)胃(wei)平肝(gan)為(wei)佐,獨創參赭鎮氣(qi)(qi)湯、鎮沖(chong)(chong)降(jiang)(jiang)胃(wei)湯等(deng)鎮沖(chong)(chong)諸方(fang)。其(qi)(qi)(qi)(qi)組(zu)方(fang)特色,一(yi)為(wei)善(shan)用(yong)鎮沖(chong)(chong)降(jiang)(jiang)逆(ni)(ni)之(zhi)(zhi)(zhi)品,如赭石、龍、牡(mu)等(deng);一(yi)為(wei)善(shan)用(yong)補虛(xu)(xu)固澀(se)之(zhi)(zhi)(zhi)品,如山萸肉、山藥、白(bai)芍、芡實等(deng),攻中(zhong)有補,降(jiang)(jiang)斂(lian)(lian)結合,用(yong)之(zhi)(zhi)(zhi)臨床,確有良效。其(qi)(qi)(qi)(qi)沖(chong)(chong)氣(qi)(qi)學說(shuo)(shuo)為(wei)中(zhong)醫臨床治療(liao)雜病(bing)又辟新徑。
(三)脫(tuo)分上下(xia)內(nei)外(wai),治脫(tuo)重視肝虛(xu)
張氏認為(wei)脫(tuo)(tuo)(tuo)雖(sui)有上(shang)(shang)、下(xia)、內、外之(zhi)別,概由肝(gan)虛,其云:“凡人(ren)元(yuan)(yuan)(yuan)氣(qi)(qi)(qi)(qi)(qi)之(zhi)脫(tuo)(tuo)(tuo),皆脫(tuo)(tuo)(tuo)在肝(gan)”。他根據(ju)肝(gan)主疏泄(xie)(xie)、調暢氣(qi)(qi)(qi)(qi)(qi)機的(de)功(gong)能(neng),認為(wei)元(yuan)(yuan)(yuan)氣(qi)(qi)(qi)(qi)(qi)的(de)運行和胃氣(qi)(qi)(qi)(qi)(qi)的(de)布化(hua),全賴于肝(gan)臟正(zheng)常的(de)疏泄(xie)(xie)功(gong)能(neng)。倘肝(gan)虛則損泄(xie)(xie)元(yuan)(yuan)(yuan)氣(qi)(qi)(qi)(qi)(qi),耗散腎氣(qi)(qi)(qi)(qi)(qi),而為(wei)上(shang)(shang)脫(tuo)(tuo)(tuo)或下(xia)脫(tuo)(tuo)(tuo)。“蓋元(yuan)(yuan)(yuan)氣(qi)(qi)(qi)(qi)(qi)上(shang)(shang)脫(tuo)(tuo)(tuo)由于肝(gan),其下(xia)脫(tuo)(tuo)(tuo)亦(yi)由于肝(gan)。誠以(yi)肝(gan)能(neng)為(wei)腎行氣(qi)(qi)(qi)(qi)(qi),即能(neng)瀉(xie)元(yuan)(yuan)(yuan)氣(qi)(qi)(qi)(qi)(qi)自下(xia)出也”。(《醫學衷中參(can)西(xi)錄·醫案·霍亂門(men)》)上(shang)(shang)脫(tuo)(tuo)(tuo)之(zhi)證,“喘(chuan)逆迫促(cu),脈若水上(shang)(shang)浮麻(ma)”,張氏制(zhi)參(can)赭鎮氣(qi)(qi)(qi)(qi)(qi)湯救之(zhi)。方中以(yi)人(ren)參(can)補(bu)虛極之(zhi)諸氣(qi)(qi)(qi)(qi)(qi),借“赭石(shi)(shi)下(xia)行之(zhi)力,挽(wan)回(hui)將脫(tuo)(tuo)(tuo)之(zhi)元(yuan)(yuan)(yuan)氣(qi)(qi)(qi)(qi)(qi)”;蘇子助赭石(shi)(shi)降氣(qi)(qi)(qi)(qi)(qi);生(sheng)(sheng)山(shan)藥、生(sheng)(sheng)白芍滋補(bu)肝(gan)胃之(zhi)陰(yin),以(yi)守(shou)持元(yuan)(yuan)(yuan)氣(qi)(qi)(qi)(qi)(qi);山(shan)萸肉、生(sheng)(sheng)芡(qian)實、生(sheng)(sheng)龍(long)骨(gu)、生(sheng)(sheng)牡蠣酸斂(lian)收澀,固攝元(yuan)(yuan)(yuan)氣(qi)(qi)(qi)(qi)(qi)。下(xia)脫(tuo)(tuo)(tuo),如“日夜吐瀉(xie)不已,脈沉細(xi)欲(yu)無,虛極將脫(tuo)(tuo)(tuo)者(zhe),為(wei)至危之(zhi)候(hou)”,張氏以(yi)急救回(hui)陽湯救之(zhi),方用(yong)人(ren)參(can)以(yi)回(hui)陽;山(shan)藥、芍藥滋陰(yin);重用(yong)山(shan)萸肉斂(lian)肝(gan)固脫(tuo)(tuo)(tuo)。上(shang)(shang)下(xia)兩脫(tuo)(tuo)(tuo)兼見者(zhe),挽(wan)陰(yin)回(hui)陽,以(yi)“既濟湯”酸斂(lian)固澀。
除(chu)元氣(qi)(qi)上脫(tuo)(tuo)(tuo)、下脫(tuo)(tuo)(tuo)之(zhi)(zhi)外,又有所謂外脫(tuo)(tuo)(tuo)、內(nei)(nei)脫(tuo)(tuo)(tuo)。外脫(tuo)(tuo)(tuo)者,癥見周身汗出不(bu)止(zhi),或(huo)(huo)“目睛上竄,或(huo)(huo)喘(chuan)逆,或(huo)(huo)怔(zheng)忡,或(huo)(huo)氣(qi)(qi)虛(xu)(xu)不(bu)足(zu)以息(xi)(xi)”,張氏認為此(ci)乃“肝膽虛(xu)(xu)極而元氣(qi)(qi)欲脫(tuo)(tuo)(tuo)也”。即肝陰過虛(xu)(xu),肝風(feng)萌動,元氣(qi)(qi)欲脫(tuo)(tuo)(tuo),用(yong)來復(fu)湯治之(zhi)(zhi)。內(nei)(nei)脫(tuo)(tuo)(tuo),如“胸中(zhong)(zhong)大氣(qi)(qi)下陷(xian)(xian),氣(qi)(qi)短(duan)不(bu)足(zu)以息(xi)(xi),或(huo)(huo)努力呼吸,有似乎(hu)喘(chuan),或(huo)(huo)氣(qi)(qi)息(xi)(xi)將(jiang)停(ting),危在頃(qing)刻(ke)……其脈象沉(chen)遲(chi)微弱,關(guan)前尤甚;其劇者,或(huo)(huo)六脈不(bu)全(quan),或(huo)(huo)參伍不(bu)調”,此(ci)系中(zhong)(zhong)氣(qi)(qi)自內(nei)(nei)而陷(xian)(xian)的(de)內(nei)(nei)脫(tuo)(tuo)(tuo)證,張氏以“升(sheng)陷(xian)(xian)湯”升(sheng)補下陷(xian)(xian)之(zhi)(zhi)氣(qi)(qi),再加山萸肉收(shou)斂(lian)氣(qi)(qi)分之(zhi)(zhi)耗散,使升(sheng)者不(bu)至復(fu)陷(xian)(xian),共挽中(zhong)(zhong)氣(qi)(qi)下陷(xian)(xian)所致(zhi)之(zhi)(zhi)內(nei)(nei)脫(tuo)(tuo)(tuo)。
從(cong)上(shang)述救(jiu)(jiu)脫(tuo)方可見,張氏救(jiu)(jiu)脫(tuo)善(shan)用山萸肉。他認為山英肉味酸(suan)性溫,固澀滑(hua)脫(tuo),通(tong)利九竅,流通(tong)血(xue)脈,為補肝之妙藥,其(qi)救(jiu)(jiu)脫(tuo)之功,較參(can)、術、芪更勝。“蓋萸肉之性,不獨補肝也,凡(fan)人(ren)(ren)身之陰陽,氣(qi)血(xue)將散者,皆能斂之,故救(jiu)(jiu)脫(tuo)之藥,當以萸肉為第一”。常用萸肉治(zhi)療各種虛脫(tuo)危證,或(huo)配(pei)以生(sheng)龍骨、牡(mu)蠣斂汗;或(huo)配(pei)人(ren)(ren)參(can)、附(fu)子、山藥、炙甘(gan)草益氣(qi)回陽固脫(tuo);或(huo)配(pei)當歸、熟(shu)地(di)填(tian)補精血(xue)等。其(qi)論脫(tuo)證病(bing)機及治(zhi)法用藥,別(bie)開(kai)生(sheng)面,對后(hou)人(ren)(ren)啟迪尤深。
(四)遣(qian)藥制(zhi)方心得
張氏制方用藥頗(po)有獨(du)到經驗(yan),通性味,善配伍,別具(ju)匠心(xin)。具(ju)體表現在以下幾(ji)個(ge)方面。
1、精研藥物,頗多新見
張氏(shi)認(ren)為學醫(yi)的(de)(de)第一層功夫即是(shi)識藥(yao)(yao)(yao)性,其(qi)(qi)對(dui)藥(yao)(yao)(yao)性的(de)(de)理(li)解,于諸家本草學之(zhi)外,頗(po)多(duo)新見(jian)。《醫(yi)學衷中參(can)西錄》書中專列(lie)《藥(yao)(yao)(yao)物(wu)(wu)》一章,對(dui)常(chang)用(yong)的(de)(de)79種藥(yao)(yao)(yao)物(wu)(wu)詳加解釋,闡述了張氏(shi)對(dui)藥(yao)(yao)(yao)物(wu)(wu)的(de)(de)獨到(dao)認(ren)識與經驗。其(qi)(qi)中他(ta)研(yan)究最精的(de)(de)藥(yao)(yao)(yao)物(wu)(wu)有黃芪、山萸肉、赭石、山藥(yao)(yao)(yao)、三(san)七、黨參(can)、乳(ru)香、沒藥(yao)(yao)(yao)、三(san)棱、水蛭、牛膝(xi)、龍骨、牡蠣等。
例如(ru),他廣泛(fan)應(ying)用(yong)(yong)(yong)(yong)大劑量石膏治(zhi)療外感熱(re)性病屢(lv)收良(liang)效,認為并(bing)無(wu)損傷(shang)(shang)脾(pi)胃之(zhi)(zhi)(zhi)(zhi)弊,且隨著(zhu)熱(re)退(tui)病愈(yu)而(er)飲食(shi)倍增,為清解大熱(re)之(zhi)(zhi)(zhi)(zhi)特效藥(yao)。善(shan)(shan)用(yong)(yong)(yong)(yong)三棱、莪術(shu),認為二(er)藥(yao)善(shan)(shan)破(po)血(xue)(xue)、調(diao)氣(qi)(qi),化瘀(yu)(yu)(yu)則三棱優(you)于莪術(shu),理氣(qi)(qi)則莪術(shu)優(you)于三棱,若“二(er)藥(yao)合用(yong)(yong)(yong)(yong),常(chang)有(you)協同之(zhi)(zhi)(zhi)(zhi)功”。認為水蛭破(po)瘀(yu)(yu)(yu)最(zui)效,善(shan)(shan)除日久之(zhi)(zhi)(zhi)(zhi)瘀(yu)(yu)(yu)滯,能(neng)使(shi)瘀(yu)(yu)(yu)血(xue)(xue)默消于無(wu)形之(zhi)(zhi)(zhi)(zhi)中,乳香善(shan)(shan)透(tou)竅理氣(qi)(qi),沒藥(yao)善(shan)(shan)化瘀(yu)(yu)(yu)理血(xue)(xue),二(er)藥(yao)并(bing)用(yong)(yong)(yong)(yong)為宣通(tong)臟腑、流通(tong)經絡之(zhi)(zhi)(zhi)(zhi)要藥(yao),常(chang)用(yong)(yong)(yong)(yong)于治(zhi)心(xin)、胃、脅(xie)、腹(fu)及肢(zhi)體(ti)關節諸(zhu)痛,經痛,產后瘀(yu)(yu)(yu)血(xue)(xue)腹(fu)痛,月經不(bu)(bu)調(diao),風寒濕痹(bi),中風四肢(zhi)不(bu)(bu)遂(sui)及一(yi)切瘡瘍腫痛;雞內金味酸(suan)性溫藥(yao)性平和,有(you)補(bu)脾(pi)胃之(zhi)(zhi)(zhi)(zhi)妙(miao),善(shan)(shan)化有(you)形之(zhi)(zhi)(zhi)(zhi)瘀(yu)(yu)(yu)積;山(shan)楂化瘀(yu)(yu)(yu)血(xue)(xue)而(er)不(bu)(bu)傷(shang)(shang)新血(xue)(xue),開郁(yu)氣(qi)(qi)而(er)不(bu)(bu)傷(shang)(shang)正氣(qi)(qi);茵陳、麥(mai)芽皆(jie)具疏肝(gan)解郁(yu)之(zhi)(zhi)(zhi)(zhi)效,體(ti)弱(ruo)陰虛(xu)不(bu)(bu)任柴(chai)胡升(sheng)散者,常(chang)以(yi)其代之(zhi)(zhi)(zhi)(zhi);黃(huang)芪性溫味微甘,補(bu)氣(qi)(qi)兼能(neng)升(sheng)氣(qi)(qi),善(shan)(shan)治(zhi)氣(qi)(qi)虛(xu)、氣(qi)(qi)陷諸(zhu)證,且其“性溫而(er)上升(sheng),以(yi)之(zhi)(zhi)(zhi)(zhi)補(bu)肝(gan)有(you)同氣(qi)(qi)相求(qiu)之(zhi)(zhi)(zhi)(zhi)妙(miao)用(yong)(yong)(yong)(yong)”,故凡肝(gan)氣(qi)(qi)虛(xu)弱(ruo)不(bu)(bu)能(neng)條達,用(yong)(yong)(yong)(yong)一(yi)切補(bu)肝(gan)之(zhi)(zhi)(zhi)(zhi)藥(yao)皆(jie)不(bu)(bu)效者,倡重(zhong)用(yong)(yong)(yong)(yong)黃(huang)芪為主,而(er)少(shao)佐以(yi)理氣(qi)(qi)之(zhi)(zhi)(zhi)(zhi)品,并(bing)據此(ci)批評(ping)“肝(gan)虛(xu)無(wu)補(bu)法”之(zhi)(zhi)(zhi)(zhi)談。這些獨(du)創性見解,擴大和豐富了藥(yao)物(wu)的臨(lin)床(chuang)應(ying)用(yong)(yong)(yong)(yong)范圍。
2、善用生藥,注重配伍(wu)
張(zhang)(zhang)錫純(chun)在《醫學衷(zhong)中(zhong)(zhong)參西錄》中(zhong)(zhong)自擬(ni)良方百余(yu)首,以生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)藥(yao)(yao)見長,對生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)藥(yao)(yao)的(de)使用(yong)(yong)獨具(ju)卓見。如水(shui)蛭,方書多(duo)謂必須(xu)炙(zhi)透方可(ke)使用(yong)(yong),但張(zhang)(zhang)氏認為,此物生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)于(yu)水(shui)中(zhong)(zhong),原得水(shui)之精氣而(er)生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng),炙(zhi)之則傷(shang)水(shui)之精氣,不(bu)若生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)用(yong)(yong)。因而(er)在治(zhi)療經閉不(bu)行、產(chan)后惡露不(bu)盡或(huo)瘀(yu)血頑癥(zheng)時,常于(yu)理(li)沖湯、理(li)沖丸中(zhong)(zhong)加入水(shui)蛭一(yi)錢或(huo)一(yi)兩,并標明“不(bu)用(yong)(yong)炙(zhi)”。認為赭(zhe)石色赤性微涼,生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)血兼(jian)能(neng)涼血,且因其(qi)質(zhi)重墜,又可(ke)鎮逆、降痰、止(zhi)嘔、通便,“生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)研服(fu)之不(bu)傷(shang)腸胃……且生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)服(fu)則養(yang)氣純(chun)全(quan),大能(neng)養(yang)血”。故治(zhi)陰陽兩虛、喘逆迫促之喘息,重用(yong)(yong)生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)赭(zhe)石伍(wu)以生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)龍(long)牡斂沖降逆;又與肉蓯蓉(rong)、當歸并用(yong)(yong),補(bu)腎斂沖,潤便通結(jie)。張(zhang)(zhang)氏臨床常用(yong)(yong)的(de)生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)藥(yao)(yao)還有生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)乳香(xiang)、生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)沒藥(yao)(yao)、生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)雞內金、生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)黃芪(qi)、生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)山藥(yao)(yao)、生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)杭(hang)芍、生(sheng)(sheng)(sheng)(sheng)(sheng)(sheng)石膏等。
此外,張氏根據其臨床(chuang)經驗和體會,總結出許多新的藥(yao)對(dui)配(pei)伍關系。如山藥(yao)配(pei)牛蒡(bang)子,疏補兼(jian)行,補腎健脾,清(qing)肺止咳(ke),祛痰降(jiang)氣(qi);人參配(pei)代赭石,剛柔相濟,升(sheng)降(jiang)互(hu)用(yong),治(zhi)療脾胃氣(qi)虛,沖氣(qi)相干(gan),或用(yong)于上盛下虛、氣(qi)血將脫(tuo);黃芪配(pei)知母,寒熱平(ping)調以益氣(qi)升(sheng)舉;人參配(pei)威靈仙治(zhi)氣(qi)虛小(xiao)便(bian)不(bu)利;生龍、牡配(pei)萸肉(rou),三(san)藥(yao)聯(lian)合應用(yong),收斂固脫(tuo)、澀精止汗等,均可資臨床(chuang)參考。
3、潛心實踐,創制新方
張氏(shi)對方(fang)藥(yao)的(de)運用(yong)(yong)也頗有(you)(you)(you)心(xin)(xin)得,在(zai)《醫學衷(zhong)中(zhong)參西錄(lu)》中(zhong)創(chuang)(chuang)立了許多有(you)(you)(you)效的(de)方(fang)劑,廣及內、外、婦、兒(er)各科(ke),其多有(you)(you)(you)所宗,遵經而(er)(er)不(bu)(bu)泥(ni)古,通(tong)變(bian)而(er)(er)不(bu)(bu)失(shi)規矩。其中(zhong),有(you)(you)(you)不(bu)(bu)少為師(shi)法仲景(jing)原意而(er)(er)化(hua)裁創(chuang)(chuang)制的(de)新方(fang)。如(ru)治(zhi)(zhi)(zhi)(zhi)吐衄諸方(fang)是受《金匱》瀉心(xin)(xin)湯(tang)(tang)影響,以降胃為主,故喜用(yong)(yong)赭石、半(ban)夏。治(zhi)(zhi)(zhi)(zhi)療胸中(zhong)蘊(yun)熱(re)為外感所束,不(bu)(bu)能發(fa)泄而(er)(er)致(zhi)煩躁的(de)猶龍湯(tang)(tang),立意源于(yu)大青龍湯(tang)(tang),由連(lian)翹、生石膏、蟬蛻(tui)、牛(niu)蒡子(zi)組(zu)成。治(zhi)(zhi)(zhi)(zhi)滿悶(men)短氣,呼吸不(bu)(bu)利的(de)蕩胸湯(tang)(tang),于(yu)大陷胸湯(tang)(tang)中(zhong)取用(yong)(yong)芒硝,于(yu)小陷胸湯(tang)(tang)中(zhong)取用(yong)(yong)瓜蔞(lou),又于(yu)治(zhi)(zhi)(zhi)(zhi)心(xin)(xin)下痞硬之(zhi)(zhi)(zhi)旋覆代(dai)赭湯(tang)(tang)中(zhong)取用(yong)(yong)赭石,而(er)(er)復加(jia)蘇子(zi)以為下行之(zhi)(zhi)(zhi)向導,可以代(dai)大陷胸湯(tang)(tang)、丸,亦(yi)可代(dai)小陷胸湯(tang)(tang)。又如(ru)其治(zhi)(zhi)(zhi)(zhi)療婦科(ke)病之(zhi)(zhi)(zhi)理(li)沖(chong)湯(tang)(tang)、理(li)沖(chong)丸,用(yong)(yong)參、術(shu)、當歸、山藥(yao)等補(bu)氣健脾扶正,莪術(shu)、三棱、水蛭等活(huo)血(xue)化(hua)瘀(yu),為攻補(bu)兼施,扶正化(hua)瘀(yu),治(zhi)(zhi)(zhi)(zhi)閉(bi)經及癥瘕(jia)之(zhi)(zhi)(zhi)虛實夾雜證良方(fang)。又如(ru)治(zhi)(zhi)(zhi)(zhi)崩漏的(de)安沖(chong)湯(tang)(tang)、固沖(chong)湯(tang)(tang),熔塞流、澄源、補(bu)虛于(yu)一爐,止血(xue)而(er)(er)不(bu)(bu)留瘀(yu),清(qing)熱(re)而(er)(er)不(bu)(bu)涼遏,溫補(bu)而(er)(er)不(bu)(bu)閉(bi)邪。再如(ru),如(ru)治(zhi)(zhi)(zhi)(zhi)陰虛勞嗽(sou)之(zhi)(zhi)(zhi)資生湯(tang)(tang),治(zhi)(zhi)(zhi)(zhi)腦(nao)充血(xue)頭目(mu)眩(xuan)暈(yun)之(zhi)(zhi)(zhi)建瓴湯(tang)(tang),治(zhi)(zhi)(zhi)(zhi)心(xin)(xin)腹疼痛、癥瘕(jia)痰癖的(de)活(huo)絡(luo)效靈丹,治(zhi)(zhi)(zhi)(zhi)腎虛滑胎的(de)壽胎丸等等,都是行之(zhi)(zhi)(zhi)有(you)(you)(you)效的(de)名方(fang)。
張氏(shi)治(zhi)學嚴謹,重視實踐,主張溝通中(zhong)西,取(qu)長補(bu)短(duan),是近代中(zhong)西醫(yi)匯通派的代表之一。結合其多年臨證(zheng)經(jing)驗(yan)與匯通中(zhong)西的體會,著成《醫(yi)學衷中(zhong)參西錄》。
張錫純,字(zi)壽甫,清(qing)末民初河北省鹽山縣人。生活(huo)于公元1860~1933年(nian)(nian)(清(qing)咸豐十年(nian)(nian)至民國二(er)(er)十二(er)(er)年(nian)(nian))。幼敏而好學,攻讀(du)經史之(zhi)余(yu),兼習(xi)岐黃之(zhi)書,后(hou)(hou)因兩(liang)試秋(qiu)闈不第(di),遂(sui)潛(qian)心(xin)醫學。早年(nian)(nian)懸壺鄉(xiang)梓,革命軍興,應聘從戎(rong)去武(wu)漢為軍醫。1917年(nian)(nian)在(zai)沈(shen)陽(yang)創(chuang)建“立達中(zhong)醫院”。直奉戰起,回(hui)故居(ju)河北滄州(zhou)行醫,1926年(nian)(nian)移(yi)居(ju)天津(jin),創(chuang)辦“天津(jin)國醫函授學校(xiao)”,培養了大批中(zhong)醫后(hou)(hou)繼人才。
張(zhang)(zhang)氏治學嚴謹,重視(shi)實踐,主張(zhang)(zhang)溝通(tong)中(zhong)西(xi)(xi),取(qu)長補(bu)短,是近代(dai)中(zhong)西(xi)(xi)醫匯通(tong)派的(de)代(dai)表之一。其醫德(de)高(gao)尚(shang),常舍藥(yao)(yao)濟(ji)貧,遇疑難(nan)重癥,殫思(si)竭(jie)慮,并親(qin)自攜藥(yao)(yao)到病家督煎,守護達旦。為了體驗(yan)藥(yao)(yao)物的(de)毒性(xing)反應和(he)用量,曾親(qin)嘗巴豆(dou)、花椒、甘遂等藥(yao)(yao),足見其對病人極端(duan)負(fu)責的(de)精神和(he)重視(shi)實踐的(de)治學態度。他醫術精湛,常能力排眾議(yi),獨任其責,起(qi)群醫束手之沉疴,療效卓著(zhu),名震遐邇。當時(shi)與江蘇(su)陸晉(jin)笙、楊如(ru)侯,廣東劉蔚楚同負(fu)盛名,又與慈(ci)溪張(zhang)(zhang)生甫、嘉定張(zhang)(zhang)山雷并稱(cheng)名醫三(san)張(zhang)(zhang)。
張氏勤于(yu)鉆研,善于(yu)總結(jie),平(ping)生(sheng)著述甚(shen)多,后因天(tian)津洪水(shui)沒其(qi)居,遺書蕩盡(jin),傳(chuan)世者僅《醫學(xue)衷中參西(xi)錄》一書。
《醫(yi)學衷中參西錄》為(wei)20世紀中醫(yi)臨床醫(yi)學名著,素為(wei)醫(yi)家(jia)所重視。