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基本介紹

《醫(yi)(yi)學(xue)(xue)衷中(zhong)(zhong)(zhong)(zhong)參(can)西(xi)錄(lu)》，中(zhong)(zhong)(zhong)(zhong)醫(yi)(yi)叢(cong)書，又名《衷中(zhong)(zhong)(zhong)(zhong)參(can)西(xi)錄(lu)》，張(zhang)錫純(壽(shou)甫)撰。此(ci)書分為(wei)《處方(fang)(fang)學(xue)(xue)》8卷、《醫(yi)(yi)論》8卷、《醫(yi)(yi)話拾零》、《三三醫(yi)(yi)書評》、《藥(yao)物講義》4卷、《傷寒(han)講義》4卷、《醫(yi)(yi)案(附詩草)》4卷。系(xi)作者多年治(zhi)學(xue)(xue)臨(lin)證經驗和心得之(zhi)總結。是20世紀(ji)初我(wo)國重(zhong)(zhong)(zhong)要(yao)的(de)(de)(de)(de)(de)臨(lin)床綜合(he)性名著。張(zhang)氏致(zhi)力溝(gou)通(tong)中(zhong)(zhong)(zhong)(zhong)西(xi)醫(yi)(yi)學(xue)(xue)，主(zhu)(zhu)張(zhang)以中(zhong)(zhong)(zhong)(zhong)醫(yi)(yi)為(wei)主(zhu)(zhu)體，取西(xi)醫(yi)(yi)之(zhi)長(chang)，補中(zhong)(zhong)(zhong)(zhong)醫(yi)(yi)之(zhi)短。他認為(wei)：“欲(yu)求醫(yi)(yi)學(xue)(xue)登峰造極，誠非溝(gou)通(tong)中(zhong)(zhong)(zhong)(zhong)西(xi)醫(yi)(yi)不可。”其(qi)于(yu)溝(gou)通(tong)中(zhong)(zhong)(zhong)(zhong)西(xi)醫(yi)(yi)的(de)(de)(de)(de)(de)主(zhu)(zhu)導思想，主(zhu)(zhu)張(zhang)師古(gu)而不泥古(gu)，參(can)西(xi)而不背中(zhong)(zhong)(zhong)(zhong)。張(zhang)氏重(zhong)(zhong)(zhong)視基(ji)礎理論，對臟(zang)象學(xue)(xue)說(shuo)和解剖生(sheng)理的(de)(de)(de)(de)(de)互(hu)證尤為(wei)重(zhong)(zhong)(zhong)視。書中(zhong)(zhong)(zhong)(zhong)指出：腦為(wei)元神，心為(wei)識神，心力衰竭與腎不納氣相通(tong)；腦充血與薄(bo)厥相近等(deng)等(deng)。在臨(lin)證方(fang)(fang)面(mian)，講究細致(zhi)的(de)(de)(de)(de)(de)觀(guan)察和記述病情，建(jian)立完整的(de)(de)(de)(de)(de)病歷。其(qi)于(yu)諸(zhu)病治(zhi)法，注(zhu)重(zhong)(zhong)(zhong)實際，勇于(yu)探索，并獨創了許多新的(de)(de)(de)(de)(de)治(zhi)療(liao)方(fang)(fang)劑(ji)(ji)，體驗了若(ruo)干中(zhong)(zhong)(zhong)(zhong)藥(yao)的(de)(de)(de)(de)(de)性能。對諸(zhu)如萸肉救脫，參(can)芪利尿(niao)，白礬化(hua)痰熱(re)，三七消瘡(chuang)腫，生(sheng)硫黃內(nei)服治(zhi)虛寒(han)下痢，蜈(wu)蚣、蝎子定風消毒等(deng)等(deng)，均能發揚(yang)古(gu)說(shuo)，擴(kuo)大藥(yao)用主(zhu)(zhu)治(zhi)。如對調治(zhi)脾胃(wei)，主(zhu)(zhu)張(zhang)脾陽與胃(wei)陰并重(zhong)(zhong)(zhong)，升肝脾與降膽(dan)胃(wei)兼施，補養與開破相結合(he)。書中(zhong)(zhong)(zhong)(zhong)結合(he)中(zhong)(zhong)(zhong)(zhong)西(xi)醫(yi)(yi)學(xue)(xue)理論和醫(yi)(yi)療(liao)實踐(jian)闡(chan)發醫(yi)(yi)理，頗多獨到的(de)(de)(de)(de)(de)見解。書中(zhong)(zhong)(zhong)(zhong)載(zai)述張(zhang)氏所制定的(de)(de)(de)(de)(de)若(ruo)干有效方(fang)(fang)劑(ji)(ji)；在方(fang)(fang)藥(yao)應用方(fang)(fang)面(mian)，創用中(zhong)(zhong)(zhong)(zhong)西(xi)藥(yao)相結合(he)的(de)(de)(de)(de)(de)方(fang)(fang)劑(ji)(ji)，并對石膏、生(sheng)山藥(yao)、代赭石等(deng)藥(yao)的(de)(de)(de)(de)(de)臨(lin)床施治(zhi)，在古(gu)人基(ji)礎上有重(zhong)(zhong)(zhong)要(yao)的(de)(de)(de)(de)(de)補訂、發揮。

內容介紹

《醫學衷中參西錄》為張錫(xi)純唯一傳世(shi)的(de)著作，其主要學術內容如下：

一、學術理論

(一)倡(chang)“衷中參西(xi)”

清(qing)末(mo)民(min)初，西(xi)(xi)學東漸，西(xi)(xi)醫(yi)(yi)學在我國流傳甚(shen)快。當時，醫(yi)(yi)學界(jie)有些人(ren)崇尚(shang)西(xi)(xi)學，輕視(shi)中(zhong)醫(yi)(yi)，有些中(zhong)醫(yi)(yi)則(ze)一(yi)味排(pai)斥西(xi)(xi)醫(yi)(yi)，因循守(shou)舊(jiu)。張(zhang)(zhang)氏(shi)則(ze)主(zhu)張(zhang)(zhang)以(yi)中(zhong)醫(yi)(yi)為本(ben)體，擷取西(xi)(xi)醫(yi)(yi)之長補中(zhong)醫(yi)(yi)之短，倡導“衷(zhong)中(zhong)參西(xi)(xi)”，并從理(li)論、實(shi)踐(jian)方面進行(xing)了(le)嘗試(shi)，《醫(yi)(yi)學衷(zhong)中(zhong)參西(xi)(xi)錄》的(de)書名就(jiu)鮮明地表明了(le)張(zhang)(zhang)氏(shi)的(de)學術主(zhu)張(zhang)(zhang)。

在生理(li)、病理(li)方(fang)面，張(zhang)氏于(yu)《醫(yi)學(xue)衷中(zhong)(zhong)(zhong)參(can)西錄》中(zhong)(zhong)(zhong)有許多(duo)溝通(tong)(tong)(tong)中(zhong)(zhong)(zhong)西醫(yi)學(xue)的新(xin)見解(jie)，如(ru)：“中(zhong)(zhong)(zhong)醫(yi)謂(wei)人(ren)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)神(shen)明在心，西說謂(wei)人(ren)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)神(shen)明在腦，及觀《內經(jing)(jing)》，皆(jie)涵蓋(gai)其(qi)中(zhong)(zhong)(zhong)也”。《素問·脈(mo)要精(jing)微論》中(zhong)(zhong)(zhong)指出“頭者精(jing)明之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)府(fu)”，說明神(shen)明之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)體(ti)在腦，所(suo)謂(wei)“心主神(shen)明”，只不過是(shi)言神(shen)明之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)用出于(yu)心，由此可(ke)見，中(zhong)(zhong)(zhong)西之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)說雖然不同(tong)，但(dan)理(li)可(ke)匯通(tong)(tong)(tong)。另如(ru)，認為吐(tu)衄(nv)的原因是(shi)由于(yu)陽(yang)明胃腑(fu)氣機上逆(ni)，胃中(zhong)(zhong)(zhong)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)血(xue)亦恒(heng)隨之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)上逆(ni)。“其(qi)上逆(ni)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)極(ji)，可(ke)將胃壁之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)膜排擠破裂，而成(cheng)嘔血(xue)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)證(zheng)(zheng)；或(huo)(huo)循陽(yang)明之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)經(jing)(jing)絡上行(xing)，而成(cheng)衄(nv)血(xue)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)證(zheng)(zheng)”，此即《素問·厥論》中(zhong)(zhong)(zhong)所(suo)言“陽(yang)明厥逆(ni)衄(nv)嘔血(xue)”。其(qi)論衄(nv)血(xue)治療，主張(zhang)不論“或(huo)(huo)虛或(huo)(huo)實，或(huo)(huo)涼或(huo)(huo)熱，治之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)者皆(jie)當以(yi)降胃之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)品為主”，并制平(ping)胃寒(han)降湯、滋陰清降湯等(deng)，皆(jie)主以(yi)生赭石(shi)通(tong)(tong)(tong)降胃氣，并輔以(yi)白(bai)芍、龍、牡等(deng)養陰鎮潛(qian)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)品，提高了(le)本病的療效。

在用(yong)藥(yao)(yao)(yao)上，張氏認為，西(xi)藥(yao)(yao)(yao)治(zhi)在局部，是(shi)重(zhong)在病(bing)之(zhi)(zhi)標也；中藥(yao)(yao)(yao)用(yong)藥(yao)(yao)(yao)求原因，是(shi)重(zhong)在病(bing)之(zhi)(zhi)本也。究之(zhi)(zhi)，標本原宜兼顧，若(ruo)遇難治(zhi)之(zhi)(zhi)證，以西(xi)藥(yao)(yao)(yao)治(zhi)其標，中藥(yao)(yao)(yao)治(zhi)其本，則奏效(xiao)必速，提出中藥(yao)(yao)(yao)、西(xi)藥(yao)(yao)(yao)不應互相抵牾，而(er)(er)應相濟為用(yong)。張氏臨(lin)床(chuang)治(zhi)療癲癇，據中醫“諸風掉眩，皆屬于肝”理論，用(yong)西(xi)藥(yao)(yao)(yao)臭(chou)素(su)、抱(bao)水諸品及鉛(qian)硫(liu)朱砂丸麻醉鎮靜治(zhi)標，而(er)(er)后(hou)則主張徐以健脾、利痰(tan)、祛風、清火(huo)之(zhi)(zhi)藥(yao)(yao)(yao)以鏟除其病(bing)根。治(zhi)療大氣(qi)下陷，下血(xue)不止(zhi)之(zhi)(zhi)血(xue)崩癥(zheng)，煎服(fu)生黃芪(qi)、白(bai)術(shu)、龍(long)骨(gu)、牡蠣、柴胡等升舉固澀之(zhi)(zhi)品時，加服(fu)西(xi)藥(yao)(yao)(yao)麥角，以加強收縮(suo)止(zhi)血(xue)功效(xiao)。張氏在辨證施治(zhi)運用(yong)中醫方(fang)藥(yao)(yao)(yao)的(de)同時，加服(fu)西(xi)藥(yao)(yao)(yao)，開中西(xi)藥(yao)(yao)(yao)聯合應用(yong)之(zhi)(zhi)先河。

(二)大氣下陷論(lun)

繼喻昌“胸中(zhong)(zhong)大氣(qi)說”之后，張氏在《醫學衷中(zhong)(zhong)參西錄》中(zhong)(zhong)對大氣(qi)的認識和(he)治療作了進(jin)一步的闡發。

張氏認(ren)為(wei)(wei)，大(da)(da)氣(qi)即(ji)《內(nei)經》所言(yan)之(zhi)宗氣(qi)，它“以(yi)元(yuan)氣(qi)為(wei)(wei)根本，以(yi)水谷之(zhi)氣(qi)為(wei)(wei)養料，以(yi)胸中之(zhi)地為(wei)(wei)宅窟者也”。因其“誠以(yi)能(neng)撐(cheng)持全(quan)(quan)身(shen)，為(wei)(wei)諸氣(qi)之(zhi)綱領，包(bao)舉肺外，司呼(hu)吸之(zhi)樞機，故鄭而重(zhong)之(zhi)曰大(da)(da)氣(qi)。”即(ji)大(da)(da)氣(qi)是(shi)搏聚(ju)于(yu)胸中，包(bao)舉于(yu)肺外的大(da)(da)量陽氣(qi)，它源于(yu)元(yuan)氣(qi)，受水谷精微的滋養，除主(zhu)司呼(hu)吸外，同時對全(quan)(quan)身(shen)產生重(zhong)要影響。此氣(qi)撐(cheng)持全(quan)(quan)身(shen)，振(zhen)作精神(shen)，心及心思、腦力、百骸動(dong)作，莫不賴(lai)于(yu)此。此氣(qi)一虛，呼(hu)吸即(ji)覺不利，而時時酸懶，精神(shen)昏憒，腦力、心思為(wei)(wei)之(zhi)頓減。

大氣(qi)之(zhi)病(bing)變主要(yao)是虛而陷，其病(bing)情有(you)(you)(you)(you)緩(huan)(huan)急之(zhi)別，急者(zhe)(zhe)(zhe)(zhe)(zhe)可引起猝死，“大氣(qi)既陷，無氣(qi)包(bao)舉肺外以鼓動(dong)(dong)其闔辟之(zhi)機，則呼(hu)(hu)吸停頓，所以不(bu)(bu)病(bing)而猝死。緩(huan)(huan)者(zhe)(zhe)(zhe)(zhe)(zhe)則因(yin)大氣(qi)下陷而致呼(hu)(hu)吸不(bu)(bu)利(li)，換氣(qi)不(bu)(bu)足(zu)缺氧，全(quan)身(shen)性衰(shuai)竭(jie)出現一(yi)系列表現：“有(you)(you)(you)(you)呼(hu)(hu)吸短氣(qi)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)心中怔忡(chong)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)淋漓大汗者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)神昏(hun)健忘者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)聲顫身(shen)動(dong)(dong)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)寒熱往來者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)胸中滿悶(men)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)努力呼(hu)(hu)吸似喘(chuan)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)咽干作渴者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)常(chang)常(chang)呵欠(qian)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)肢體痿廢者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)食后易饑者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)二便不(bu)(bu)禁(jin)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)癃閉身(shen)腫者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)張口呼(hu)(hu)氣(qi)外出而氣(qi)不(bu)(bu)上(shang)達(da)，肛(gang)門突出者(zhe)(zhe)(zhe)(zhe)(zhe)，在女(nv)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)(zhe)(zhe)(zhe)(zhe)”等等。，

以上見(jian)癥以心(xin)肺證(zheng)候(hou)為主(zhu)，常兼見(jian)脾胃(wei)證(zheng)候(hou)。若單見(jian)脾胃(wei)證(zheng)候(hou)而無(wu)心(xin)肺證(zheng)候(hou)者(zhe)(zhe)，是(shi)謂中(zhong)氣(qi)(qi)(qi)(qi)(qi)下(xia)陷(xian)(xian)(xian)。中(zhong)氣(qi)(qi)(qi)(qi)(qi)下(xia)陷(xian)(xian)(xian)之重者(zhe)(zhe)，張氏認為有(you)引起大氣(qi)(qi)(qi)(qi)(qi)下(xia)陷(xian)(xian)(xian)之可能，“夫中(zhong)氣(qi)(qi)(qi)(qi)(qi)誠有(you)下(xia)陷(xian)(xian)(xian)之時，然不(bu)若大氣(qi)(qi)(qi)(qi)(qi)下(xia)陷(xian)(xian)(xian)之尤屬危險也。間有(you)因中(zhong)氣(qi)(qi)(qi)(qi)(qi)下(xia)陷(xian)(xian)(xian)，泄瀉(xie)日久，或(huo)轉(zhuan)致大氣(qi)(qi)(qi)(qi)(qi)下(xia)陷(xian)(xian)(xian)者(zhe)(zhe)”。這樣把大氣(qi)(qi)(qi)(qi)(qi)下(xia)陷(xian)(xian)(xian)與中(zhong)氣(qi)(qi)(qi)(qi)(qi)下(xia)陷(xian)(xian)(xian)分別開來，確為閱(yue)歷之談。

張氏認為(wei)，引起大(da)(da)氣(qi)(qi)(qi)下(xia)陷(xian)(xian)的原因不外勞力(li)過度、久(jiu)病和(he)誤藥(yao)。如“力(li)小任(ren)重，或枵腹力(li)作，或病后氣(qi)(qi)(qi)力(li)未復而(er)勤于動(dong)作，或泄瀉日久(jiu)，或服破氣(qi)(qi)(qi)藥(yao)太(tai)過或氣(qi)(qi)(qi)分虛(xu)(xu)(xu)極自下(xia)陷(xian)(xian)”。張氏治療大(da)(da)氣(qi)(qi)(qi)下(xia)陷(xian)(xian)，創制升(sheng)(sheng)陷(xian)(xian)湯(生黃(huang)芪、知母(mu)、桔梗(geng)、柴(chai)胡(hu)、升(sheng)(sheng)麻)，該方以黃(huang)芪為(wei)君，升(sheng)(sheng)補大(da)(da)氣(qi)(qi)(qi)，佐知母(mu)涼潤以濟其之(zhi)(zhi)偏，柴(chai)胡(hu)引大(da)(da)氣(qi)(qi)(qi)之(zhi)(zhi)陷(xian)(xian)者自左上(shang)(shang)升(sheng)(sheng)，升(sheng)(sheng)麻引大(da)(da)氣(qi)(qi)(qi)之(zhi)(zhi)陷(xian)(xian)者自右上(shang)(shang)升(sheng)(sheng)，桔梗(geng)為(wei)藥(yao)中(zhong)之(zhi)(zhi)舟楫，導諸(zhu)藥(yao)之(zhi)(zhi)力(li)上(shang)(shang)達胸中(zhong)。若氣(qi)(qi)(qi)虛(xu)(xu)(xu)極加人參(can)或寄生，以培氣(qi)(qi)(qi)之(zhi)(zhi)本，或更加山萸(yu)肉以防(fang)氣(qi)(qi)(qi)之(zhi)(zhi)渙散，氣(qi)(qi)(qi)虛(xu)(xu)(xu)甚者酌增升(sheng)(sheng)麻用(yong)量。

心肺(fei)之(zhi)陽(yang)(yang)，尤賴(lai)胸中大氣(qi)為之(zhi)保(bao)護，大氣(qi)一陷(xian)，則心肺(fei)陽(yang)(yang)分素虛者(zhe)，至此而益(yi)虛，癥(zheng)見其(qi)人心冷，背(bei)緊(jin)，惡寒，常覺短氣(qi)等。張氏認(ren)為欲(yu)助胸中心肺(fei)之(zhi)陽(yang)(yang)，必須先升(sheng)提(ti)下陷(xian)之(zhi)大氣(qi)，否(fou)則但服溫補心肺(fei)之(zhi)陽(yang)(yang)之(zhi)劑(ji)無效，制回陽(yang)(yang)升(sheng)陷(xian)湯(tang)(生(sheng)黃芪、干姜、當歸(gui)身、桂枝炭、甘草(cao))以治之(zhi)。

胸(xiong)(xiong)中大(da)氣(qi)(qi)(qi)正常(chang)，有賴于(yu)少陽(yang)、陽(yang)明之(zhi)氣(qi)(qi)(qi)的升(sheng)(sheng)(sheng)發。若大(da)氣(qi)(qi)(qi)下(xia)(xia)陷(xian)，升(sheng)(sheng)(sheng)發之(zhi)氣(qi)(qi)(qi)被郁(yu)，氣(qi)(qi)(qi)分(fen)郁(yu)結，經絡瘀滯(zhi)，常(chang)見胸(xiong)(xiong)中滿痛(tong)或脅下(xia)(xia)撐脹、腹痛(tong)等。對此，張氏(shi)又制理郁(yu)升(sheng)(sheng)(sheng)陷(xian)湯(tang)(生(sheng)黃(huang)芪(qi)、知母、當歸身(shen)、桂枝尖、柴胡(hu)、乳香(xiang)、沒藥)；對脾氣(qi)(qi)(qi)虛極下(xia)(xia)陷(xian)，小便不禁者，制理脾升(sheng)(sheng)(sheng)陷(xian)湯(tang)(生(sheng)黃(huang)芪(qi)、白術、桑寄(ji)生(sheng)、川斷(duan)、萸(yu)肉、龍骨、牡蠣(li)、川萆薢、甘草)治之(zhi)。

(三)寒溫(wen)統一，注重(zhong)清透

《醫學衷(zhong)中(zhong)參西(xi)錄》論溫(wen)(wen)(wen)病，主張寒(han)(han)(han)(han)溫(wen)(wen)(wen)統(tong)一，認為(wei)溫(wen)(wen)(wen)病治(zhi)法已備(bei)于傷(shang)寒(han)(han)(han)(han)。如溫(wen)(wen)(wen)病初(chu)起治(zhi)宜(yi)(yi)辛涼(liang)(liang)，然辛涼(liang)(liang)之(zhi)(zhi)法亦(yi)備(bei)于傷(shang)寒(han)(han)(han)(han)，麻(ma)杏(xing)甘石湯(tang)(tang)(tang)“誠為(wei)溫(wen)(wen)(wen)病初(chu)得之(zhi)(zhi)的方矣”。但其外表證未(wei)解，內有蘊熱(re)即(ji)(ji)可(ke)服用(yong)(yong)。至溫(wen)(wen)(wen)病傳經已深，清燥熱(re)之(zhi)(zhi)白虎湯(tang)(tang)(tang)、白虎加人參湯(tang)(tang)(tang)，通腑之(zhi)(zhi)大、小承氣湯(tang)(tang)(tang)，開結胸之(zhi)(zhi)大、小陷胸湯(tang)(tang)(tang)，治(zhi)下利之(zhi)(zhi)白頭翁湯(tang)(tang)(tang)、黃芩湯(tang)(tang)(tang)，治(zhi)發(fa)黃之(zhi)(zhi)茵陳桅子柏皮湯(tang)(tang)(tang)等及(ji)一切涼(liang)(liang)潤(run)、清火、育陰、安神之(zhi)(zhi)劑，皆(jie)可(ke)使用(yong)(yong)。并指(zhi)出(chu)寒(han)(han)(han)(han)溫(wen)(wen)(wen)治(zhi)法之(zhi)(zhi)別(bie)，在于“始(shi)異(yi)而終(zhong)同(tong)”。所謂“始(shi)異(yi)”，即(ji)(ji)傷(shang)寒(han)(han)(han)(han)發(fa)表可(ke)用(yong)(yong)溫(wen)(wen)(wen)熱(re)，溫(wen)(wen)(wen)病發(fa)表必用(yong)(yong)辛涼(liang)(liang)；謂其“終(zhong)同(tong)”，即(ji)(ji)病傳陽明之(zhi)(zhi)后，不(bu)論傷(shang)寒(han)(han)(han)(han)、溫(wen)(wen)(wen)病，皆(jie)宜(yi)(yi)治(zhi)以寒(han)(han)(han)(han)涼(liang)(liang)，而大忌溫(wen)(wen)(wen)熱(re)。

張氏臨證將溫(wen)病分為風溫(wen)、春溫(wen)、濕(shi)溫(wen)三(san)類(lei)。認(ren)為三(san)類(lei)溫(wen)病雖見癥不(bu)同，其本質(zhi)皆緣郁(yu)熱。“大凡(fan)病溫(wen)之人，多系內有蘊熱，至春陽萌動之時(shi)，又薄(bo)受外感拘束，其熱即陡發而(er)成溫(wen)”。他遵循“火郁(yu)發之”之旨，治療(liao)(liao)上主張宣散郁(yu)結，疏(shu)通氣機，透邪外達。反對(dui)徒執寒(han)(han)涼，只清(qing)不(bu)透，使邪無由出。并自(zi)擬清(qing)解湯(tang)、涼解湯(tang)、寒(han)(han)解湯(tang)三(san)方，徑以石膏清(qing)其內熱，又選用薄(bo)荷、連翹、蟬(chan)蛻發表，且(qie)“引胃中化而(er)欲(yu)散之熱，仍還太陽作汗而(er)解”。正是(shi)基(ji)于(yu)(yu)對(dui)溫(wen)病“郁(yu)熱”這一本質(zhi)的深刻(ke)認(ren)識，初(chu)起治療(liao)(liao)即立足于(yu)(yu)清(qing)透。

溫病(bing)入(ru)里化熱(re)，抑或傷寒(han)(han)、中風(feng)入(ru)里化熱(re)，是(shi)陽明(ming)(ming)熱(re)盛之(zhi)象，張(zhang)(zhang)氏皆以(yi)寒(han)(han)涼清熱(re)為主，不復有(you)傷寒(han)(han)、中風(feng)、溫病(bing)之(zhi)分，投以(yi)白虎湯靈活加減(jian)化裁。臨(lin)證使用白虎湯，張(zhang)(zhang)氏有(you)著豐富的經驗，認(ren)為白虎湯之(zhi)“四(si)大(da)”典型癥(zheng)狀中，唯(wei)脈洪(hong)為必見之(zhi)癥(zheng)。只要(yao)見脈洪(hong)大(da)，又有(you)陽明(ming)(ming)熱(re)盛之(zhi)一二(er)癥(zheng)，則無論外感內(nei)傷，皆可用之(zhi)，不必拘泥于古人之(zhi)說。

陽明(ming)腑實用三承(cheng)氣(qi)(qi)湯(tang)(tang)，此(ci)乃大(da)法，然張(zhang)氏認為(wei)(wei)承(cheng)氣(qi)(qi)力猛，倘或(huo)審證不確，即足誤事。于是據其(qi)三十(shi)余年臨證經驗，強調“凡遇(yu)陽明(ming)應下證，亦先投以(yi)白(bai)虎(hu)(hu)湯(tang)(tang)一(yi)二劑，更改其(qi)服法，將石膏為(wei)(wei)末而(er)(er)不入煎(jian)，以(yi)藥湯(tang)(tang)送服之(zhi)”，因屢用此(ci)方奏效，遂名之(zhi)曰白(bai)虎(hu)(hu)承(cheng)氣(qi)(qi)湯(tang)(tang)。對(dui)于溫熱病神昏(hun)(hun)譫語(yu)，張(zhang)氏遵從陸(lu)九芝(zhi)“胃(wei)熱之(zhi)甚(shen)，神為(wei)(wei)之(zhi)昏(hun)(hun)，從來(lai)神昏(hun)(hun)之(zhi)病，皆屬胃(wei)家(jia)”之(zhi)說，將熱病神昏(hun)(hun)分為(wei)(wei)虛實兩類(lei)。其(qi)脈(mo)象洪而(er)(er)有力，按(an)之(zhi)甚(shen)實者(zhe)，可按(an)陽明(ming)胃(wei)實治(zhi)之(zhi)，投以(yi)大(da)劑白(bai)虎(hu)(hu)湯(tang)(tang)；若(ruo)脈(mo)兼(jian)(jian)弦、兼(jian)(jian)數，或(huo)重(zhong)按(an)仍甚(shen)實者(zhe)，治(zhi)宜白(bai)虎(hu)(hu)加人參湯(tang)(tang)；對(dui)邪(xie)入陽明(ming)，淫熱于肝，致肝風(feng)內(nei)動者(zhe)，以(yi)白(bai)虎(hu)(hu)撤其(qi)陽明(ming)之(zhi)熱，生龍骨、生牡蠣以(yi)鎮肝熄(xi)風(feng)。

張氏治(zhi)療溫病不僅擅用白(bai)(bai)(bai)虎(hu)，而且依據病證不同，化裁組成了眾多新方，如石膏粳(jing)米(mi)湯(tang)(tang)、鎮逆白(bai)(bai)(bai)虎(hu)湯(tang)(tang)、通(tong)變(bian)白(bai)(bai)(bai)虎(hu)加人參湯(tang)(tang)等(deng)，皆(jie)由白(bai)(bai)(bai)虎(hu)湯(tang)(tang)衍化而來。

二、治療經驗

張氏一生勤于臨證，《醫學衷中參西錄(lu)》記載了他豐(feng)富的臨床經驗，其中尤以論治中風、脫證等最具特(te)色(se)。

(一)分別(bie)中風論(lun)治

中風(feng)有真(zhen)中、類(lei)(lei)中之別。張氏認(ren)為真(zhen)中者極少，因而著意對類(lei)(lei)中進行(xing)研究、發揮(hui)。指(zhi)出類(lei)(lei)中風(feng)亦即內中風(feng)，此“風(feng)自(zi)內生(sheng)，非風(feng)自(zi)外來也”，其(qi)治療分(fen)充血、貧血，以(yi)虛實(shi)論治。

1、腦充血治療

張氏根據“血(xue)(xue)菀于(yu)上(shang)(shang)，使(shi)人薄厥(jue)(jue)(jue)”的理(li)論(lun)，認(ren)為腦(nao)(nao)充血(xue)(xue)即《內(nei)經》中所言的煎厥(jue)(jue)(jue)、薄厥(jue)(jue)(jue)、大厥(jue)(jue)(jue)。其病位在“肝”，陰虛陽亢、上(shang)(shang)實(shi)下虛、臟腑之氣(qi)升發太(tai)過或失之下行，血(xue)(xue)隨氣(qi)逆為主要病機。即“人之血(xue)(xue)隨氣(qi)行，氣(qi)上(shang)(shang)升不(bu)已，血(xue)(xue)即隨之上(shang)(shang)升不(bu)已，以(yi)致腦(nao)(nao)中血(xue)(xue)管(guan)充血(xue)(xue)過甚”(《醫學衷中參西錄·醫案·腦(nao)(nao)充血(xue)(xue)門》)，有礙(ai)神(shen)經，以(yi)致語言肢體謇(jian)澀不(bu)利(li)，口(kou)眼(yan)歪斜等等。

根據腦(nao)充(chong)血(xue)之(zhi)“肝(gan)木(mu)失和，肺(fei)氣(qi)(qi)不降(jiang)，腎氣(qi)(qi)不攝，沖氣(qi)(qi)、胃(wei)氣(qi)(qi)又復上(shang)逆，臟(zang)腑(fu)(fu)之(zhi)氣(qi)(qi)化皆上(shang)升(sheng)太過”之(zhi)病(bing)(bing)機(ji)，張氏提出(chu)治療本病(bing)(bing)應“清(qing)其(qi)臟(zang)腑(fu)(fu)之(zhi)熱(re)，滋其(qi)臟(zang)腑(fu)(fu)之(zhi)陰(yin)，更降(jiang)其(qi)臟(zang)腑(fu)(fu)之(zhi)氣(qi)(qi)，引腦(nao)部(bu)所充(chong)之(zhi)血(xue)下(xia)行(xing)”的“鎮(zhen)(zhen)肝(gan)熄(xi)(xi)(xi)風、引血(xue)下(xia)行(xing)”的原則，并(bing)創(chuang)制鎮(zhen)(zhen)肝(gan)熄(xi)(xi)(xi)風湯(懷牛(niu)(niu)膝、生(sheng)赭石、生(sheng)杭芍(shao)、天(tian)冬、生(sheng)龍(long)骨、生(sheng)牡(mu)蠣、生(sheng)龜板(ban)、玄參、川(chuan)楝子、生(sheng)麥芽、茵陳、甘(gan)草)作為治療本病(bing)(bing)的主方。方中(zhong)赭石降(jiang)胃(wei)，平(ping)肝(gan)鎮(zhen)(zhen)沖，下(xia)行(xing)通便；牛(niu)(niu)膝善(shan)(shan)引上(shang)部(bu)之(zhi)血(xue)下(xia)行(xing)，二藥合用，相輔相成(cheng)；玄參、天(tian)冬、白芍(shao)滋陰(yin)退(tui)熱(re)；龍(long)骨、牡(mu)蠣、龜板(ban)、芍(shao)藥斂(lian)肝(gan)火、鎮(zhen)(zhen)熄(xi)(xi)(xi)肝(gan)風，以(yi)緩其(qi)肝(gan)氣(qi)(qi)上(shang)升(sheng)之(zhi)勢(shi)；玄參、天(tian)冬清(qing)肺(fei)制肝(gan)；山藥、甘(gan)草和胃(wei)緩肝(gan)；茵陳為“青(qing)蒿之(zhi)嫩(nen)者，稟(bing)少陽初生(sheng)之(zhi)氣(qi)(qi)，與(yu)肝(gan)木(mu)同氣(qi)(qi)相求，最能將順肝(gan)木(mu)之(zhi)性，且又善(shan)(shan)瀉肝(gan)熱(re)”，為清(qing)涼腦(nao)部(bu)之(zhi)涼藥也；麥芽“善(shan)(shan)助肝(gan)木(mu)疏泄(xie)以(yi)行(xing)腎氣(qi)(qi)”；川(chuan)楝子善(shan)(shan)引肝(gan)氣(qi)(qi)下(xia)達(da)，又能折其(qi)更動之(zhi)力。本方標本兼(jian)治，鎮(zhen)(zhen)潛共(gong)用，引涵兼(jian)施(shi)，直中(zhong)病(bing)(bing)之(zhi)肯綮，確(que)有獨到之(zhi)處。

此(ci)外，張氏還參(can)照西醫病理，闡述了腦(nao)充(chong)(chong)(chong)血、腦(nao)溢血、腦(nao)出(chu)血之證(zheng)型及(ji)用(yong)藥(yao)的不(bu)同。對(dui)(dui)腦(nao)部血管(guan)中(zhong)之血滲(shen)出(chu)者(zhe)(zhe)，他在友(you)人“腦(nao)充(chong)(chong)(chong)血證(zheng)，宜于引血下行藥(yao)中(zhong)加(jia)破血之藥(yao)以治(zhi)之”的啟發(fa)下，指出(chu)對(dui)(dui)其(qi)身(shen)體壯實者(zhe)(zhe)，可(ke)酌加(jia)大黃數錢以逐瘀；其(qi)身(shen)形脈象不(bu)甚壯實者(zhe)(zhe)，加(jia)桃(tao)仁、丹參(can)等(deng)化(hua)瘀。并明確(que)提出(chu)“腦(nao)充(chong)(chong)(chong)血當通大便為要務”。對(dui)(dui)腦(nao)充(chong)(chong)(chong)血后期脈象柔和而(er)肢體痿廢者(zhe)(zhe)，主張“少用(yong)黃芪(qi)助活血之品(pin)以通絡”，但(dan)應(ying)謹慎從事。而(er)對(dui)(dui)于“血菀于上”的腦(nao)充(chong)(chong)(chong)血者(zhe)(zhe)，因黃芪(qi)之情，補而(er)兼升(sheng)，氣升(sheng)則血必(bi)隨之升(sheng)，故病初應(ying)忌用(yong)黃芪(qi)，誤用(yong)則兇(xiong)危立見。其(qi)辨(bian)證(zheng)之嚴謹，用(yong)藥(yao)之精確(que)，可(ke)見一斑(ban)。

2、腦貧血治療

與腦(nao)(nao)充血(xue)(xue)(xue)(xue)(xue)證相(xiang)反，張氏認(ren)為腦(nao)(nao)貧血(xue)(xue)(xue)(xue)(xue)證則為血(xue)(xue)(xue)(xue)(xue)之(zhi)上注于腦(nao)(nao)過(guo)少，無以養(yang)(yang)其腦(nao)(nao)髓神經，致使腦(nao)(nao)神經失其所(suo)司(si)。而(er)血(xue)(xue)(xue)(xue)(xue)之(zhi)上注過(guo)少，實(shi)由“宗氣虛(xu)寒，不能助血(xue)(xue)(xue)(xue)(xue)上升(sheng)(sheng)川”。故治(zhi)療(liao)(liao)腦(nao)(nao)貧血(xue)(xue)(xue)(xue)(xue)證，主張“應峻補其胸中(zhong)(zhong)大(da)氣”，自擬(ni)當歸(gui)補血(xue)(xue)(xue)(xue)(xue)湯益氣溫(wen)陽、補血(xue)(xue)(xue)(xue)(xue)活血(xue)(xue)(xue)(xue)(xue)，治(zhi)療(liao)(liao)中(zhong)(zhong)風脈(mo)象(xiang)遲弱，身軟(ruan)，肢體(ti)漸(jian)覺不利(li)，或頭(tou)重(zhong)目眩，或神昏(hun)(hun)健(jian)忘，甚或昏(hun)(hun)仆，移時蘇醒(xing)致成偏(pian)枯者(zhe)(zhe)。方中(zhong)(zhong)主以黃(huang)芪(qi)升(sheng)(sheng)補胸中(zhong)(zhong)大(da)氣，使血(xue)(xue)(xue)(xue)(xue)隨氣升(sheng)(sheng)，上達腦(nao)(nao)中(zhong)(zhong)；用(yong)當歸(gui)、龍眼肉、鹿角(jiao)膠(jiao)養(yang)(yang)血(xue)(xue)(xue)(xue)(xue)生髓；丹參、乳、沒開血(xue)(xue)(xue)(xue)(xue)痹，化瘀(yu)滯；甘(gan)松(song)助心房(fang)運行有力，以多輸血(xue)(xue)(xue)(xue)(xue)于腦(nao)(nao)，且又為調養(yang)(yang)神經之(zhi)品。對于腦(nao)(nao)貧血(xue)(xue)(xue)(xue)(xue)肢體(ti)痿廢或偏(pian)枯，脈(mo)象(xiang)極微細無力者(zhe)(zhe)，又擬(ni)干(gan)頹湯、補腦(nao)(nao)振痿湯治(zhi)療(liao)(liao)。并指出肢體(ti)偏(pian)廢，服藥(yao)久不效者(zhe)(zhe)，應著(zhu)重(zhong)補腎(shen)通絡，多選用(yong)胡桃肉、地龍、馬錢(qian)子等。

(二)重視沖氣為病，善用鎮(zhen)沖降逆(ni)

沖(chong)(chong)(chong)(chong)脈(mo)為(wei)(wei)奇(qi)經八(ba)脈(mo)之(zhi)(zhi)(zhi)(zhi)(zhi)一(yi)(yi)，張(zhang)氏論病(bing)(bing)(bing)極重視沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)，指(zhi)出“沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)沖(chong)(chong)(chong)(chong)之(zhi)(zhi)(zhi)(zhi)(zhi)病(bing)(bing)(bing)甚多，而醫者識其病(bing)(bing)(bing)者甚少。即(ji)或能(neng)(neng)識此病(bing)(bing)(bing)，亦多不能(neng)(neng)洞悉(xi)其病(bing)(bing)(bing)因”。因而，對(dui)沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)的生理，尤其是沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)沖(chong)(chong)(chong)(chong)的病(bing)(bing)(bing)因、病(bing)(bing)(bing)理、病(bing)(bing)(bing)脈(mo)、治法(fa)都(dou)作了詳細闡述，自(zi)(zi)成一(yi)(yi)家(jia)之(zhi)(zhi)(zhi)(zhi)(zhi)言(yan)。其述沖(chong)(chong)(chong)(chong)脈(mo)，、兼(jian)采《內》《難(nan)》之(zhi)(zhi)(zhi)(zhi)(zhi)說，認為(wei)(wei)其“在胞室之(zhi)(zhi)(zhi)(zhi)(zhi)兩旁，與任脈(mo)相(xiang)連，為(wei)(wei)腎(shen)臟(zang)之(zhi)(zhi)(zhi)(zhi)(zhi)輔弼，氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)化相(xiang)通……上(shang)(shang)系原(yuan)隸陽明胃腑(fu)”，并(bing)認為(wei)(wei)“沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)沖(chong)(chong)(chong)(chong)之(zhi)(zhi)(zhi)(zhi)(zhi)證，固(gu)由于腎(shen)臟(zang)之(zhi)(zhi)(zhi)(zhi)(zhi)虛，亦多由于肝(gan)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)恣橫(heng)，素性多怒之(zhi)(zhi)(zhi)(zhi)(zhi)人，其肝(gan)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)之(zhi)(zhi)(zhi)(zhi)(zhi)暴發，更(geng)助沖(chong)(chong)(chong)(chong)胃之(zhi)(zhi)(zhi)(zhi)(zhi)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)逆”。即(ji)腎(shen)虛無以(yi)涵木，不能(neng)(neng)收斂沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)，沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)行，肝(gan)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)橫(heng)逆，胃氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)逆而呈上(shang)(shang)沖(chong)(chong)(chong)(chong)之(zhi)(zhi)(zhi)(zhi)(zhi)弊(bi)。張(zhang)氏描述的沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)沖(chong)(chong)(chong)(chong)證，除(chu)自(zi)(zi)覺(jue)有(you)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)自(zi)(zi)下上(shang)(shang)沖(chong)(chong)(chong)(chong)，脈(mo)多弦硬而長外，主要表現有(you)胃脘(wan)或腹中滿(man)悶，噦氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)，呃(e)逆連連，嘔吐不止(zhi)，或見吐血、衄血等胃氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)逆不降見癥；或兩脅痛脹，頭目(mu)眩(xuan)暈，甚而氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)火挾痰上(shang)(shang)沖(chong)(chong)(chong)(chong)，發生突(tu)然昏(hun)仆等；或為(wei)(wei)胸滿(man)窒塞，喘(chuan)息大作。其治療(liao)，主張(zhang)以(yi)斂沖(chong)(chong)(chong)(chong)鎮(zhen)(zhen)(zhen)沖(chong)(chong)(chong)(chong)為(wei)(wei)主，降胃平肝(gan)為(wei)(wei)佐(zuo)，獨創(chuang)參赭鎮(zhen)(zhen)(zhen)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)湯(tang)、鎮(zhen)(zhen)(zhen)沖(chong)(chong)(chong)(chong)降胃湯(tang)等鎮(zhen)(zhen)(zhen)沖(chong)(chong)(chong)(chong)諸方。其組方特色，一(yi)(yi)為(wei)(wei)善用(yong)鎮(zhen)(zhen)(zhen)沖(chong)(chong)(chong)(chong)降逆之(zhi)(zhi)(zhi)(zhi)(zhi)品，如(ru)赭石(shi)、龍、牡等；一(yi)(yi)為(wei)(wei)善用(yong)補虛固(gu)澀(se)之(zhi)(zhi)(zhi)(zhi)(zhi)品，如(ru)山萸肉、山藥、白芍、芡實等，攻中有(you)補，降斂結合，用(yong)之(zhi)(zhi)(zhi)(zhi)(zhi)臨床(chuang)，確(que)有(you)良效。其沖(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)(qi)學說為(wei)(wei)中醫臨床(chuang)治療(liao)雜病(bing)(bing)(bing)又辟新徑(jing)。

(三)脫(tuo)分上下內外(wai)，治(zhi)脫(tuo)重視(shi)肝(gan)虛

張(zhang)氏認為(wei)脫(tuo)(tuo)(tuo)雖有上(shang)、下(xia)(xia)、內、外(wai)之(zhi)(zhi)別(bie)，概(gai)由肝(gan)(gan)(gan)虛(xu)，其云：“凡人(ren)(ren)元(yuan)(yuan)氣(qi)(qi)之(zhi)(zhi)脫(tuo)(tuo)(tuo)，皆(jie)脫(tuo)(tuo)(tuo)在肝(gan)(gan)(gan)”。他根(gen)據肝(gan)(gan)(gan)主疏(shu)泄、調(diao)暢氣(qi)(qi)機的功能(neng)(neng)(neng)，認為(wei)元(yuan)(yuan)氣(qi)(qi)的運行和胃(wei)氣(qi)(qi)的布化(hua)，全賴于肝(gan)(gan)(gan)臟正(zheng)常的疏(shu)泄功能(neng)(neng)(neng)。倘肝(gan)(gan)(gan)虛(xu)則損泄元(yuan)(yuan)氣(qi)(qi)，耗散腎氣(qi)(qi)，而為(wei)上(shang)脫(tuo)(tuo)(tuo)或下(xia)(xia)脫(tuo)(tuo)(tuo)。“蓋元(yuan)(yuan)氣(qi)(qi)上(shang)脫(tuo)(tuo)(tuo)由于肝(gan)(gan)(gan)，其下(xia)(xia)脫(tuo)(tuo)(tuo)亦由于肝(gan)(gan)(gan)。誠以(yi)(yi)肝(gan)(gan)(gan)能(neng)(neng)(neng)為(wei)腎行氣(qi)(qi)，即能(neng)(neng)(neng)瀉元(yuan)(yuan)氣(qi)(qi)自(zi)下(xia)(xia)出也”。(《醫學(xue)衷中參(can)西(xi)錄·醫案·霍亂門》)上(shang)脫(tuo)(tuo)(tuo)之(zhi)(zhi)證，“喘逆迫促(cu)，脈若水(shui)上(shang)浮(fu)麻”，張(zhang)氏制(zhi)參(can)赭(zhe)鎮氣(qi)(qi)湯(tang)救之(zhi)(zhi)。方中以(yi)(yi)人(ren)(ren)參(can)補虛(xu)極之(zhi)(zhi)諸氣(qi)(qi)，借“赭(zhe)石下(xia)(xia)行之(zhi)(zhi)力，挽回(hui)(hui)將(jiang)脫(tuo)(tuo)(tuo)之(zhi)(zhi)元(yuan)(yuan)氣(qi)(qi)”；蘇(su)子(zi)助赭(zhe)石降氣(qi)(qi)；生(sheng)(sheng)(sheng)山(shan)藥、生(sheng)(sheng)(sheng)白芍滋補肝(gan)(gan)(gan)胃(wei)之(zhi)(zhi)陰，以(yi)(yi)守(shou)持元(yuan)(yuan)氣(qi)(qi)；山(shan)萸(yu)肉(rou)、生(sheng)(sheng)(sheng)芡(qian)實、生(sheng)(sheng)(sheng)龍骨(gu)、生(sheng)(sheng)(sheng)牡蠣酸(suan)斂(lian)收澀，固攝元(yuan)(yuan)氣(qi)(qi)。下(xia)(xia)脫(tuo)(tuo)(tuo)，如“日夜(ye)吐瀉不(bu)已，脈沉細欲無，虛(xu)極將(jiang)脫(tuo)(tuo)(tuo)者(zhe)，為(wei)至危之(zhi)(zhi)候(hou)”，張(zhang)氏以(yi)(yi)急救回(hui)(hui)陽(yang)湯(tang)救之(zhi)(zhi)，方用人(ren)(ren)參(can)以(yi)(yi)回(hui)(hui)陽(yang)；山(shan)藥、芍藥滋陰；重用山(shan)萸(yu)肉(rou)斂(lian)肝(gan)(gan)(gan)固脫(tuo)(tuo)(tuo)。上(shang)下(xia)(xia)兩脫(tuo)(tuo)(tuo)兼見者(zhe)，挽陰回(hui)(hui)陽(yang)，以(yi)(yi)“既濟湯(tang)”酸(suan)斂(lian)固澀。

除元氣(qi)(qi)上(shang)脫(tuo)、下(xia)脫(tuo)之(zhi)(zhi)外(wai)，又(you)有(you)(you)所謂外(wai)脫(tuo)、內脫(tuo)。外(wai)脫(tuo)者，癥(zheng)見周身汗出不(bu)止，或(huo)(huo)(huo)“目(mu)睛(jing)上(shang)竄，或(huo)(huo)(huo)喘逆，或(huo)(huo)(huo)怔忡，或(huo)(huo)(huo)氣(qi)(qi)虛不(bu)足以(yi)(yi)息”，張氏(shi)認(ren)為此乃(nai)“肝(gan)膽(dan)虛極而元氣(qi)(qi)欲(yu)脫(tuo)也”。即肝(gan)陰過(guo)虛，肝(gan)風萌動，元氣(qi)(qi)欲(yu)脫(tuo)，用來復湯治之(zhi)(zhi)。內脫(tuo)，如“胸中(zhong)大氣(qi)(qi)下(xia)陷，氣(qi)(qi)短不(bu)足以(yi)(yi)息，或(huo)(huo)(huo)努力呼吸，有(you)(you)似乎喘，或(huo)(huo)(huo)氣(qi)(qi)息將停(ting)，危(wei)在(zai)頃刻……其(qi)(qi)脈(mo)象沉遲微弱(ruo)，關前尤甚；其(qi)(qi)劇者，或(huo)(huo)(huo)六(liu)脈(mo)不(bu)全，或(huo)(huo)(huo)參伍(wu)不(bu)調”，此系(xi)中(zhong)氣(qi)(qi)自(zi)內而陷的內脫(tuo)證，張氏(shi)以(yi)(yi)“升陷湯”升補下(xia)陷之(zhi)(zhi)氣(qi)(qi)，再加山萸肉收斂氣(qi)(qi)分之(zhi)(zhi)耗(hao)散，使升者不(bu)至復陷，共挽中(zhong)氣(qi)(qi)下(xia)陷所致之(zhi)(zhi)內脫(tuo)。

從上(shang)述救脫方可見(jian)，張氏(shi)救脫善用山萸肉(rou)。他認為山英肉(rou)味酸性溫，固澀滑脫，通利九竅，流(liu)通血(xue)(xue)脈，為補肝(gan)之(zhi)妙藥，其救脫之(zhi)功，較參、術、芪更勝。“蓋萸肉(rou)之(zhi)性，不獨補肝(gan)也，凡人身之(zhi)陰陽，氣血(xue)(xue)將(jiang)散者，皆(jie)能斂(lian)之(zhi)，故救脫之(zhi)藥，當以萸肉(rou)為第(di)一”。常用萸肉(rou)治(zhi)療各(ge)種虛脫危證，或(huo)配以生龍骨、牡(mu)蠣斂(lian)汗；或(huo)配人參、附子(zi)、山藥、炙甘草益氣回陽固脫；或(huo)配當歸、熟地(di)填(tian)補精血(xue)(xue)等。其論脫證病機及治(zhi)法用藥，別開生面，對后(hou)人啟迪尤深。

(四)遣藥制方(fang)心得(de)

張氏制方(fang)(fang)用藥頗有(you)獨到經驗，通性味，善配伍，別具(ju)匠心(xin)。具(ju)體(ti)表現在以下(xia)幾個方(fang)(fang)面。

1、精研藥物，頗多新見(jian)

張(zhang)氏認(ren)為學醫的(de)第一層功(gong)夫即是識(shi)藥(yao)性，其對藥(yao)性的(de)理(li)解(jie)(jie)，于諸家本草學之外，頗(po)多新見。《醫學衷(zhong)中參西錄》書中專列(lie)《藥(yao)物(wu)》一章，對常用的(de)79種藥(yao)物(wu)詳加解(jie)(jie)釋，闡述了張(zhang)氏對藥(yao)物(wu)的(de)獨到認(ren)識(shi)與經驗。其中他研究最精的(de)藥(yao)物(wu)有黃芪、山萸(yu)肉、赭石(shi)、山藥(yao)、三七、黨參、乳香、沒藥(yao)、三棱、水(shui)蛭、牛膝、龍骨、牡蠣(li)等。

例如，他廣泛應用(yong)(yong)大(da)劑量石膏治(zhi)療外感熱性病(bing)屢(lv)收良效(xiao)(xiao)，認(ren)(ren)為并無損傷(shang)脾胃之(zhi)(zhi)弊，且隨著熱退病(bing)愈而(er)飲食倍(bei)增，為清解(jie)大(da)熱之(zhi)(zhi)特效(xiao)(xiao)藥(yao)(yao)(yao)。善(shan)用(yong)(yong)三(san)棱、莪(e)(e)(e)術，認(ren)(ren)為二(er)(er)藥(yao)(yao)(yao)善(shan)破血、調(diao)氣(qi)(qi)(qi)，化(hua)(hua)(hua)瘀(yu)(yu)則三(san)棱優于(yu)莪(e)(e)(e)術，理(li)氣(qi)(qi)(qi)則莪(e)(e)(e)術優于(yu)三(san)棱，若“二(er)(er)藥(yao)(yao)(yao)合用(yong)(yong)，常有協(xie)同(tong)之(zhi)(zhi)功”。認(ren)(ren)為水蛭破瘀(yu)(yu)最效(xiao)(xiao)，善(shan)除日久之(zhi)(zhi)瘀(yu)(yu)滯(zhi)，能使瘀(yu)(yu)血默消于(yu)無形(xing)之(zhi)(zhi)中(zhong)，乳香善(shan)透竅理(li)氣(qi)(qi)(qi)，沒(mei)藥(yao)(yao)(yao)善(shan)化(hua)(hua)(hua)瘀(yu)(yu)理(li)血，二(er)(er)藥(yao)(yao)(yao)并用(yong)(yong)為宣通臟(zang)腑、流通經(jing)絡之(zhi)(zhi)要(yao)藥(yao)(yao)(yao)，常用(yong)(yong)于(yu)治(zhi)心、胃、脅(xie)、腹及肢體(ti)關(guan)節諸痛(tong)(tong)，經(jing)痛(tong)(tong)，產后(hou)瘀(yu)(yu)血腹痛(tong)(tong)，月(yue)經(jing)不調(diao)，風(feng)寒濕痹，中(zhong)風(feng)四(si)肢不遂及一(yi)切瘡瘍腫(zhong)痛(tong)(tong)；雞(ji)內金味(wei)酸性溫(wen)藥(yao)(yao)(yao)性平(ping)和(he)(he)，有補脾胃之(zhi)(zhi)妙，善(shan)化(hua)(hua)(hua)有形(xing)之(zhi)(zhi)瘀(yu)(yu)積；山楂化(hua)(hua)(hua)瘀(yu)(yu)血而(er)不傷(shang)新血，開(kai)郁氣(qi)(qi)(qi)而(er)不傷(shang)正氣(qi)(qi)(qi)；茵陳、麥芽皆(jie)具(ju)疏肝(gan)解(jie)郁之(zhi)(zhi)效(xiao)(xiao)，體(ti)弱陰(yin)虛不任(ren)柴胡升散者，常以(yi)其代之(zhi)(zhi)；黃芪(qi)性溫(wen)味(wei)微甘，補氣(qi)(qi)(qi)兼能升氣(qi)(qi)(qi)，善(shan)治(zhi)氣(qi)(qi)(qi)虛、氣(qi)(qi)(qi)陷諸證，且其“性溫(wen)而(er)上升，以(yi)之(zhi)(zhi)補肝(gan)有同(tong)氣(qi)(qi)(qi)相(xiang)求之(zhi)(zhi)妙用(yong)(yong)”，故(gu)凡肝(gan)氣(qi)(qi)(qi)虛弱不能條達，用(yong)(yong)一(yi)切補肝(gan)之(zhi)(zhi)藥(yao)(yao)(yao)皆(jie)不效(xiao)(xiao)者，倡重用(yong)(yong)黃芪(qi)為主，而(er)少佐以(yi)理(li)氣(qi)(qi)(qi)之(zhi)(zhi)品，并據此批評“肝(gan)虛無補法”之(zhi)(zhi)談。這些(xie)獨創性見解(jie)，擴大(da)和(he)(he)豐富了藥(yao)(yao)(yao)物的臨床(chuang)應用(yong)(yong)范圍。

2、善用生藥，注重配伍

張錫純在(zai)《醫(yi)學衷中(zhong)參西錄(lu)》中(zhong)自擬良(liang)方百余(yu)首，以生(sheng)(sheng)(sheng)(sheng)藥見(jian)長，對(dui)生(sheng)(sheng)(sheng)(sheng)藥的使用(yong)獨具卓見(jian)。如水蛭，方書多謂必須炙(zhi)(zhi)透(tou)方可(ke)使用(yong)，但(dan)張氏(shi)認(ren)(ren)為，此物生(sheng)(sheng)(sheng)(sheng)于水中(zhong)，原得(de)水之(zhi)精(jing)氣而生(sheng)(sheng)(sheng)(sheng)，炙(zhi)(zhi)之(zhi)則傷水之(zhi)精(jing)氣，不(bu)若生(sheng)(sheng)(sheng)(sheng)用(yong)。因而在(zai)治療(liao)經(jing)閉不(bu)行、產后惡(e)露不(bu)盡(jin)或瘀血(xue)頑(wan)癥時，常于理沖(chong)湯、理沖(chong)丸中(zhong)加(jia)入水蛭一錢或一兩，并(bing)標(biao)明“不(bu)用(yong)炙(zhi)(zhi)”。認(ren)(ren)為赭(zhe)石(shi)(shi)色赤性微涼，生(sheng)(sheng)(sheng)(sheng)血(xue)兼能(neng)涼血(xue)，且(qie)因其質重墜，又可(ke)鎮逆、降痰、止嘔(ou)、通便，“生(sheng)(sheng)(sheng)(sheng)研服之(zhi)不(bu)傷腸胃……且(qie)生(sheng)(sheng)(sheng)(sheng)服則養氣純全，大(da)能(neng)養血(xue)”。故治陰陽兩虛(xu)、喘逆迫(po)促之(zhi)喘息，重用(yong)生(sheng)(sheng)(sheng)(sheng)赭(zhe)石(shi)(shi)伍以生(sheng)(sheng)(sheng)(sheng)龍牡斂沖(chong)降逆；又與肉蓯蓉(rong)、當(dang)歸并(bing)用(yong)，補腎斂沖(chong)，潤便通結。張氏(shi)臨床常用(yong)的生(sheng)(sheng)(sheng)(sheng)藥還有生(sheng)(sheng)(sheng)(sheng)乳香、生(sheng)(sheng)(sheng)(sheng)沒藥、生(sheng)(sheng)(sheng)(sheng)雞內(nei)金、生(sheng)(sheng)(sheng)(sheng)黃芪、生(sheng)(sheng)(sheng)(sheng)山藥、生(sheng)(sheng)(sheng)(sheng)杭(hang)芍、生(sheng)(sheng)(sheng)(sheng)石(shi)(shi)膏等(deng)。

此外，張氏(shi)根據其臨床經驗(yan)和體會，總(zong)結出(chu)許(xu)多(duo)新的藥對配(pei)伍(wu)關系(xi)。如山(shan)藥配(pei)牛蒡子(zi)，疏(shu)補(bu)兼行，補(bu)腎健脾，清肺(fei)止(zhi)咳，祛(qu)痰(tan)降(jiang)氣(qi)；人參配(pei)代(dai)赭石，剛柔相濟(ji)，升(sheng)降(jiang)互用(yong)，治(zhi)療脾胃氣(qi)虛，沖氣(qi)相干，或用(yong)于上盛下虛、氣(qi)血將脫；黃(huang)芪配(pei)知母(mu)，寒熱平調以益氣(qi)升(sheng)舉；人參配(pei)威靈仙治(zhi)氣(qi)虛小(xiao)便不利；生龍、牡配(pei)萸肉，三藥聯合(he)應用(yong)，收斂固脫、澀精(jing)止(zhi)汗等(deng)，均(jun)可資臨床參考。

3、潛心實踐，創制新方(fang)

張氏對方(fang)藥的(de)(de)(de)運(yun)用(yong)(yong)也頗有(you)(you)心(xin)(xin)得，在《醫(yi)學(xue)衷中(zhong)(zhong)(zhong)參西錄》中(zhong)(zhong)(zhong)創立了許(xu)多有(you)(you)效(xiao)的(de)(de)(de)方(fang)劑，廣及內、外、婦(fu)、兒各科，其多有(you)(you)所宗，遵經而(er)不泥古(gu)，通變而(er)不失規矩。其中(zhong)(zhong)(zhong)，有(you)(you)不少為師法仲景原意(yi)而(er)化裁創制的(de)(de)(de)新方(fang)。如治(zhi)(zhi)(zhi)吐衄諸方(fang)是受《金(jin)匱》瀉心(xin)(xin)湯(tang)(tang)影響，以(yi)降胃(wei)為主，故喜用(yong)(yong)赭(zhe)石、半夏(xia)。治(zhi)(zhi)(zhi)療胸(xiong)(xiong)中(zhong)(zhong)(zhong)蘊熱為外感所束，不能發泄而(er)致(zhi)煩(fan)躁(zao)的(de)(de)(de)猶龍(long)湯(tang)(tang)，立意(yi)源于(yu)大青龍(long)湯(tang)(tang)，由連翹、生(sheng)石膏(gao)、蟬(chan)蛻、牛蒡子組成。治(zhi)(zhi)(zhi)滿(man)悶短氣，呼吸(xi)不利的(de)(de)(de)蕩胸(xiong)(xiong)湯(tang)(tang)，于(yu)大陷(xian)胸(xiong)(xiong)湯(tang)(tang)中(zhong)(zhong)(zhong)取用(yong)(yong)芒硝(xiao)，于(yu)小(xiao)陷(xian)胸(xiong)(xiong)湯(tang)(tang)中(zhong)(zhong)(zhong)取用(yong)(yong)瓜蔞(lou)，又(you)(you)于(yu)治(zhi)(zhi)(zhi)心(xin)(xin)下痞硬之(zhi)(zhi)旋覆代赭(zhe)湯(tang)(tang)中(zhong)(zhong)(zhong)取用(yong)(yong)赭(zhe)石，而(er)復加蘇子以(yi)為下行之(zhi)(zhi)向導，可以(yi)代大陷(xian)胸(xiong)(xiong)湯(tang)(tang)、丸(wan)，亦可代小(xiao)陷(xian)胸(xiong)(xiong)湯(tang)(tang)。又(you)(you)如其治(zhi)(zhi)(zhi)療婦(fu)科病之(zhi)(zhi)理(li)沖(chong)湯(tang)(tang)、理(li)沖(chong)丸(wan)，用(yong)(yong)參、術(shu)、當歸、山藥等(deng)補氣健脾扶正，莪術(shu)、三(san)棱、水蛭(zhi)等(deng)活血(xue)化瘀，為攻補兼施(shi)，扶正化瘀，治(zhi)(zhi)(zhi)閉經及癥瘕之(zhi)(zhi)虛實夾雜證良(liang)方(fang)。又(you)(you)如治(zhi)(zhi)(zhi)崩漏的(de)(de)(de)安沖(chong)湯(tang)(tang)、固沖(chong)湯(tang)(tang)，熔(rong)塞流(liu)、澄源、補虛于(yu)一(yi)爐，止血(xue)而(er)不留瘀，清熱而(er)不涼遏，溫補而(er)不閉邪。再如，如治(zhi)(zhi)(zhi)陰虛勞嗽之(zhi)(zhi)資(zi)生(sheng)湯(tang)(tang)，治(zhi)(zhi)(zhi)腦(nao)充(chong)血(xue)頭目眩暈之(zhi)(zhi)建瓴湯(tang)(tang)，治(zhi)(zhi)(zhi)心(xin)(xin)腹疼痛、癥瘕痰癖的(de)(de)(de)活絡效(xiao)靈丹，治(zhi)(zhi)(zhi)腎虛滑胎的(de)(de)(de)壽胎丸(wan)等(deng)等(deng)，都是行之(zhi)(zhi)有(you)(you)效(xiao)的(de)(de)(de)名方(fang)。

背景介紹

張氏治學(xue)嚴謹，重視(shi)實踐，主張溝通(tong)(tong)中西(xi)，取長補短，是(shi)近代中西(xi)醫(yi)匯通(tong)(tong)派的代表之一。結合其多年臨證經驗與匯通(tong)(tong)中西(xi)的體會，著成(cheng)《醫(yi)學(xue)衷中參西(xi)錄》。

作者介紹

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)(nian)(清(qing)咸豐(feng)十(shi)年(nian)(nian)(nian)至民國二十(shi)二年(nian)(nian)(nian))。幼敏而好(hao)學(xue)，攻讀經史之(zhi)余，兼習岐黃之(zhi)書，后因兩試秋闈不(bu)第，遂潛心醫(yi)(yi)(yi)學(xue)。早(zao)年(nian)(nian)(nian)懸壺鄉梓(zi)，革命軍(jun)興，應聘從戎去(qu)武漢為(wei)軍(jun)醫(yi)(yi)(yi)。1917年(nian)(nian)(nian)在(zai)沈(shen)陽創建“立(li)達(da)中醫(yi)(yi)(yi)院”。直(zhi)奉戰起，回(hui)故居河北滄州(zhou)行醫(yi)(yi)(yi)，1926年(nian)(nian)(nian)移居天津(jin)，創辦“天津(jin)國醫(yi)(yi)(yi)函授學(xue)校(xiao)”，培養了(le)大批中醫(yi)(yi)(yi)后繼人才。

張氏(shi)治學嚴謹(jin)，重(zhong)視(shi)實(shi)踐，主張溝(gou)通中西，取長(chang)補短，是近(jin)代中西醫匯通派的代表之一(yi)。其醫德高尚，常(chang)舍(she)藥濟貧，遇疑難(nan)重(zhong)癥，殫思(si)竭慮，并親自攜藥到病家(jia)督煎，守護達旦(dan)。為了體驗藥物的毒性(xing)反(fan)應和用量，曾親嘗巴(ba)豆、花椒、甘遂等(deng)藥，足見其對病人極(ji)端負(fu)責(ze)的精(jing)神和重(zhong)視(shi)實(shi)踐的治學態度。他醫術精(jing)湛，常(chang)能(neng)力(li)排眾議，獨任(ren)其責(ze)，起群醫束手(shou)之沉疴，療(liao)效卓著(zhu)，名震遐邇。當時與江蘇陸晉笙(sheng)、楊如(ru)侯(hou)，廣東(dong)劉蔚楚同負(fu)盛(sheng)名，又與慈溪張生甫、嘉定張山雷并稱名醫三張。

張氏勤于(yu)鉆研(yan)，善于(yu)總結，平生著述甚多，后因天津洪(hong)水沒其居，遺書蕩盡(jin)，傳世(shi)者僅《醫學衷中(zhong)參西錄》一書。

鑒賞評價

《醫(yi)(yi)學衷中參西錄》為20世紀中醫(yi)(yi)臨床醫(yi)(yi)學名著，素為醫(yi)(yi)家所(suo)重視(shi)。