《醫(yi)(yi)(yi)學(xue)(xue)(xue)衷中(zhong)參(can)(can)(can)西(xi)(xi)(xi)錄(lu)》,中(zhong)醫(yi)(yi)(yi)叢書,又名《衷中(zhong)參(can)(can)(can)西(xi)(xi)(xi)錄(lu)》,張(zhang)錫純(壽甫)撰。此(ci)書分為(wei)《處(chu)方(fang)學(xue)(xue)(xue)》8卷、《醫(yi)(yi)(yi)論(lun)(lun)》8卷、《醫(yi)(yi)(yi)話拾(shi)零》、《三三醫(yi)(yi)(yi)書評》、《藥(yao)物(wu)講義(yi)》4卷、《傷寒(han)講義(yi)》4卷、《醫(yi)(yi)(yi)案(附詩草)》4卷。系作者(zhe)多年治(zhi)(zhi)學(xue)(xue)(xue)臨(lin)證經驗和心得之總結(jie)。是20世紀初(chu)我國重要的(de)(de)臨(lin)床(chuang)綜合性名著。張(zhang)氏致力溝(gou)(gou)通(tong)中(zhong)西(xi)(xi)(xi)醫(yi)(yi)(yi)學(xue)(xue)(xue),主(zhu)張(zhang)以中(zhong)醫(yi)(yi)(yi)為(wei)主(zhu)體(ti),取西(xi)(xi)(xi)醫(yi)(yi)(yi)之長,補(bu)中(zhong)醫(yi)(yi)(yi)之短。他認為(wei):“欲求醫(yi)(yi)(yi)學(xue)(xue)(xue)登峰(feng)造極,誠(cheng)非溝(gou)(gou)通(tong)中(zhong)西(xi)(xi)(xi)醫(yi)(yi)(yi)不可(ke)。”其于溝(gou)(gou)通(tong)中(zhong)西(xi)(xi)(xi)醫(yi)(yi)(yi)的(de)(de)主(zhu)導思(si)想,主(zhu)張(zhang)師(shi)古而(er)不泥古,參(can)(can)(can)西(xi)(xi)(xi)而(er)不背(bei)中(zhong)。張(zhang)氏重視基礎理論(lun)(lun),對(dui)臟象學(xue)(xue)(xue)說和解剖生理的(de)(de)互證尤為(wei)重視。書中(zhong)指出(chu):腦(nao)為(wei)元神,心為(wei)識神,心力衰竭(jie)與(yu)(yu)腎不納氣(qi)相(xiang)(xiang)通(tong);腦(nao)充血與(yu)(yu)薄厥相(xiang)(xiang)近等(deng)(deng)等(deng)(deng)。在(zai)(zai)臨(lin)證方(fang)面,講究細致的(de)(de)觀察和記述病情,建立(li)完整的(de)(de)病歷(li)。其于諸病治(zhi)(zhi)法(fa),注重實(shi)際(ji),勇于探索,并(bing)獨創了許多新的(de)(de)治(zhi)(zhi)療方(fang)劑,體(ti)驗了若干中(zhong)藥(yao)的(de)(de)性能。對(dui)諸如萸肉(rou)救(jiu)脫(tuo),參(can)(can)(can)芪(qi)利尿,白(bai)礬化(hua)痰熱(re),三七消瘡腫,生硫黃內(nei)服治(zhi)(zhi)虛寒(han)下痢(li),蜈蚣(gong)、蝎子定風消毒等(deng)(deng)等(deng)(deng),均能發揚(yang)古說,擴大藥(yao)用主(zhu)治(zhi)(zhi)。如對(dui)調治(zhi)(zhi)脾(pi)胃,主(zhu)張(zhang)脾(pi)陽與(yu)(yu)胃陰(yin)并(bing)重,升肝脾(pi)與(yu)(yu)降膽胃兼施(shi),補(bu)養與(yu)(yu)開破相(xiang)(xiang)結(jie)合。書中(zhong)結(jie)合中(zhong)西(xi)(xi)(xi)醫(yi)(yi)(yi)學(xue)(xue)(xue)理論(lun)(lun)和醫(yi)(yi)(yi)療實(shi)踐闡發醫(yi)(yi)(yi)理,頗(po)多獨到的(de)(de)見解。書中(zhong)載(zai)述張(zhang)氏所制定的(de)(de)若干有(you)效方(fang)劑;在(zai)(zai)方(fang)藥(yao)應用方(fang)面,創用中(zhong)西(xi)(xi)(xi)藥(yao)相(xiang)(xiang)結(jie)合的(de)(de)方(fang)劑,并(bing)對(dui)石膏、生山藥(yao)、代(dai)赭石等(deng)(deng)藥(yao)的(de)(de)臨(lin)床(chuang)施(shi)治(zhi)(zhi),在(zai)(zai)古人基礎上有(you)重要的(de)(de)補(bu)訂、發揮。
《醫(yi)學衷中參西錄》為張錫純唯一傳世的著作,其主要學術(shu)內(nei)容如下:
一、學術理論
(一)倡“衷中參西”
清末民(min)初,西(xi)學(xue)(xue)東(dong)漸,西(xi)醫(yi)(yi)(yi)(yi)學(xue)(xue)在我國流傳甚快。當時,醫(yi)(yi)(yi)(yi)學(xue)(xue)界(jie)有些人崇尚西(xi)學(xue)(xue),輕視中醫(yi)(yi)(yi)(yi),有些中醫(yi)(yi)(yi)(yi)則一味排斥(chi)西(xi)醫(yi)(yi)(yi)(yi),因循(xun)守(shou)舊。張(zhang)氏則主張(zhang)以(yi)中醫(yi)(yi)(yi)(yi)為本(ben)體,擷取西(xi)醫(yi)(yi)(yi)(yi)之長(chang)補中醫(yi)(yi)(yi)(yi)之短,倡(chang)導“衷中參(can)(can)西(xi)”,并從理論、實踐方面進行了嘗(chang)試(shi),《醫(yi)(yi)(yi)(yi)學(xue)(xue)衷中參(can)(can)西(xi)錄》的(de)(de)書名(ming)就鮮明(ming)地表明(ming)了張(zhang)氏的(de)(de)學(xue)(xue)術主張(zhang)。
在(zai)生理(li)、病理(li)方面,張氏于《醫學(xue)衷中(zhong)(zhong)參西(xi)錄》中(zhong)(zhong)有許多溝通(tong)中(zhong)(zhong)西(xi)醫學(xue)的新(xin)見(jian)解,如(ru):“中(zhong)(zhong)醫謂(wei)(wei)人之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)神明(ming)在(zai)心(xin),西(xi)說謂(wei)(wei)人之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)神明(ming)在(zai)腦,及觀《內經(jing)(jing)》,皆涵蓋(gai)其中(zhong)(zhong)也(ye)”。《素問(wen)·脈(mo)要精(jing)微論》中(zhong)(zhong)指出“頭者精(jing)明(ming)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)府(fu)”,說明(ming)神明(ming)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)體在(zai)腦,所謂(wei)(wei)“心(xin)主神明(ming)”,只不(bu)過是(shi)言(yan)神明(ming)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)用出于心(xin),由此可(ke)見(jian),中(zhong)(zhong)西(xi)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)說雖然不(bu)同,但(dan)理(li)可(ke)匯(hui)通(tong)。另(ling)如(ru),認(ren)為吐(tu)衄(nv)的原因是(shi)由于陽明(ming)胃(wei)(wei)(wei)(wei)腑氣機上(shang)逆(ni),胃(wei)(wei)(wei)(wei)中(zhong)(zhong)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)血(xue)亦恒(heng)隨之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)上(shang)逆(ni)。“其上(shang)逆(ni)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)極,可(ke)將胃(wei)(wei)(wei)(wei)壁之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)膜排擠破裂,而(er)成嘔血(xue)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)證(zheng);或(huo)循(xun)陽明(ming)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)經(jing)(jing)絡上(shang)行,而(er)成衄(nv)血(xue)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)證(zheng)”,此即《素問(wen)·厥(jue)論》中(zhong)(zhong)所言(yan)“陽明(ming)厥(jue)逆(ni)衄(nv)嘔血(xue)”。其論衄(nv)血(xue)治療(liao),主張不(bu)論“或(huo)虛或(huo)實,或(huo)涼或(huo)熱,治之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)者皆當(dang)以(yi)降(jiang)胃(wei)(wei)(wei)(wei)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)品為主”,并(bing)制(zhi)平胃(wei)(wei)(wei)(wei)寒降(jiang)湯(tang)、滋陰清降(jiang)湯(tang)等(deng),皆主以(yi)生赭(zhe)石通(tong)降(jiang)胃(wei)(wei)(wei)(wei)氣,并(bing)輔(fu)以(yi)白芍、龍、牡(mu)等(deng)養陰鎮潛之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)品,提(ti)高(gao)了本病的療(liao)效(xiao)。
在用(yong)(yong)藥(yao)(yao)上,張氏認為(wei),西(xi)藥(yao)(yao)治(zhi)(zhi)在局部,是重在病之(zhi)(zhi)(zhi)標也(ye);中(zhong)(zhong)藥(yao)(yao)用(yong)(yong)藥(yao)(yao)求原因,是重在病之(zhi)(zhi)(zhi)本(ben)也(ye)。究之(zhi)(zhi)(zhi),標本(ben)原宜兼顧,若遇難治(zhi)(zhi)之(zhi)(zhi)(zhi)證,以(yi)西(xi)藥(yao)(yao)治(zhi)(zhi)其標,中(zhong)(zhong)藥(yao)(yao)治(zhi)(zhi)其本(ben),則奏效(xiao)必(bi)速,提(ti)出中(zhong)(zhong)藥(yao)(yao)、西(xi)藥(yao)(yao)不應互相(xiang)抵牾,而(er)應相(xiang)濟為(wei)用(yong)(yong)。張氏臨床治(zhi)(zhi)療(liao)癲癇,據(ju)中(zhong)(zhong)醫“諸風掉眩,皆屬于肝”理論,用(yong)(yong)西(xi)藥(yao)(yao)臭素、抱水諸品(pin)及鉛硫朱砂丸麻醉鎮靜(jing)治(zhi)(zhi)標,而(er)后則主張徐以(yi)健脾、利痰、祛風、清火之(zhi)(zhi)(zhi)藥(yao)(yao)以(yi)鏟除其病根(gen)。治(zhi)(zhi)療(liao)大氣下陷(xian),下血(xue)不止之(zhi)(zhi)(zhi)血(xue)崩(beng)癥,煎服生黃芪(qi)、白術(shu)、龍骨(gu)、牡(mu)蠣(li)、柴胡等升(sheng)舉固澀之(zhi)(zhi)(zhi)品(pin)時,加服西(xi)藥(yao)(yao)麥角(jiao),以(yi)加強(qiang)收縮止血(xue)功(gong)效(xiao)。張氏在辨證施治(zhi)(zhi)運(yun)用(yong)(yong)中(zhong)(zhong)醫方藥(yao)(yao)的(de)同時,加服西(xi)藥(yao)(yao),開(kai)中(zhong)(zhong)西(xi)藥(yao)(yao)聯合應用(yong)(yong)之(zhi)(zhi)(zhi)先河。
(二)大氣下陷論
繼喻昌“胸中(zhong)大(da)氣說”之后,張氏(shi)在《醫學衷(zhong)中(zhong)參西錄》中(zhong)對大(da)氣的(de)認識和治(zhi)療作了進一步的(de)闡發。
張氏認(ren)為,大氣(qi)即(ji)《內經》所(suo)言之宗氣(qi),它(ta)“以(yi)元(yuan)氣(qi)為根(gen)本(ben),以(yi)水谷之氣(qi)為養(yang)料,以(yi)胸(xiong)中之地為宅窟者(zhe)也(ye)”。因其“誠以(yi)能撐持全(quan)身,為諸氣(qi)之綱領,包舉(ju)肺(fei)外(wai),司(si)呼(hu)吸(xi)之樞機,故鄭(zheng)而重之曰大氣(qi)。”即(ji)大氣(qi)是搏(bo)聚(ju)于胸(xiong)中,包舉(ju)于肺(fei)外(wai)的(de)大量陽氣(qi),它(ta)源(yuan)于元(yuan)氣(qi),受水谷精微的(de)滋(zi)養(yang),除(chu)主司(si)呼(hu)吸(xi)外(wai),同時(shi)對全(quan)身產生重要影(ying)響。此氣(qi)撐持全(quan)身,振作精神,心(xin)及心(xin)思、腦力(li)、百骸動作,莫(mo)不(bu)賴于此。此氣(qi)一(yi)虛,呼(hu)吸(xi)即(ji)覺不(bu)利,而時(shi)時(shi)酸懶(lan),精神昏憒,腦力(li)、心(xin)思為之頓減。
大(da)(da)氣之病(bing)(bing)變(bian)主(zhu)要(yao)是(shi)虛而(er)陷,其(qi)病(bing)(bing)情有(you)(you)(you)(you)(you)緩急之別(bie),急者(zhe)(zhe)(zhe)(zhe)可引起猝死,“大(da)(da)氣既陷,無(wu)氣包舉(ju)肺外以(yi)鼓動(dong)其(qi)闔(he)辟之機,則呼(hu)吸停頓(dun),所以(yi)不(bu)(bu)病(bing)(bing)而(er)猝死。緩者(zhe)(zhe)(zhe)(zhe)則因(yin)大(da)(da)氣下陷而(er)致(zhi)呼(hu)吸不(bu)(bu)利,換氣不(bu)(bu)足缺氧(yang),全身(shen)性衰竭出(chu)現(xian)一系列表現(xian):“有(you)(you)(you)(you)(you)呼(hu)吸短(duan)氣者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)心中(zhong)怔(zheng)忡者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)淋漓大(da)(da)汗(han)者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)神昏健忘者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)聲(sheng)顫身(shen)動(dong)者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)寒熱往來者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)胸(xiong)中(zhong)滿(man)悶者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)努力呼(hu)吸似(si)喘者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)咽干(gan)作渴者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)常常呵欠者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)肢(zhi)體痿廢者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)食后(hou)易饑者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)二便不(bu)(bu)禁者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)癃閉身(shen)腫(zhong)者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)張口呼(hu)氣外出(chu)而(er)氣不(bu)(bu)上達,肛(gang)門突出(chu)者(zhe)(zhe)(zhe)(zhe),在女子有(you)(you)(you)(you)(you)下血不(bu)(bu)止,更有(you)(you)(you)(you)(you)經水逆行者(zhe)(zhe)(zhe)(zhe)”等(deng)等(deng)。,
以(yi)上見癥以(yi)心(xin)肺證(zheng)候(hou)為(wei)主(zhu),常兼見脾胃證(zheng)候(hou)。若單見脾胃證(zheng)候(hou)而無心(xin)肺證(zheng)候(hou)者,是謂中(zhong)氣(qi)下(xia)陷(xian)(xian)(xian)。中(zhong)氣(qi)下(xia)陷(xian)(xian)(xian)之重者,張氏認為(wei)有引起大(da)氣(qi)下(xia)陷(xian)(xian)(xian)之可能(neng),“夫(fu)中(zhong)氣(qi)誠(cheng)有下(xia)陷(xian)(xian)(xian)之時,然不若大(da)氣(qi)下(xia)陷(xian)(xian)(xian)之尤屬危險也。間(jian)有因中(zhong)氣(qi)下(xia)陷(xian)(xian)(xian),泄瀉日久,或轉(zhuan)致大(da)氣(qi)下(xia)陷(xian)(xian)(xian)者”。這(zhe)樣(yang)把(ba)大(da)氣(qi)下(xia)陷(xian)(xian)(xian)與中(zhong)氣(qi)下(xia)陷(xian)(xian)(xian)分別開(kai)來(lai),確為(wei)閱歷之談。
張氏認為(wei),引起大(da)氣(qi)下陷(xian)的(de)原因不外(wai)勞力(li)過(guo)度、久病(bing)(bing)和誤(wu)藥。如“力(li)小任重,或枵(xiao)腹力(li)作,或病(bing)(bing)后氣(qi)力(li)未復而(er)勤于動作,或泄(xie)瀉(xie)日(ri)久,或服破氣(qi)藥太過(guo)或氣(qi)分虛(xu)(xu)極自下陷(xian)”。張氏治療大(da)氣(qi)下陷(xian),創制(zhi)升陷(xian)湯(生(sheng)(sheng)黃(huang)(huang)芪、知(zhi)母(mu)(mu)、桔(jie)梗、柴胡(hu)、升麻),該(gai)方以(yi)黃(huang)(huang)芪為(wei)君,升補(bu)大(da)氣(qi),佐知(zhi)母(mu)(mu)涼潤以(yi)濟其之(zhi)偏(pian),柴胡(hu)引大(da)氣(qi)之(zhi)陷(xian)者(zhe)自左上(shang)升,升麻引大(da)氣(qi)之(zhi)陷(xian)者(zhe)自右(you)上(shang)升,桔(jie)梗為(wei)藥中(zhong)之(zhi)舟楫,導(dao)諸藥之(zhi)力(li)上(shang)達胸中(zhong)。若氣(qi)虛(xu)(xu)極加人參或寄生(sheng)(sheng),以(yi)培氣(qi)之(zhi)本,或更加山萸肉以(yi)防氣(qi)之(zhi)渙散,氣(qi)虛(xu)(xu)甚者(zhe)酌(zhuo)增升麻用量。
心(xin)肺之(zhi)陽(yang)(yang)(yang),尤賴胸中大(da)氣(qi)為(wei)之(zhi)保護,大(da)氣(qi)一陷(xian),則心(xin)肺陽(yang)(yang)(yang)分素虛者,至此(ci)而益(yi)虛,癥見其(qi)人心(xin)冷,背緊,惡寒,常覺短氣(qi)等。張(zhang)氏認為(wei)欲(yu)助胸中心(xin)肺之(zhi)陽(yang)(yang)(yang),必(bi)須先升提下陷(xian)之(zhi)大(da)氣(qi),否則但服溫補(bu)心(xin)肺之(zhi)陽(yang)(yang)(yang)之(zhi)劑無效,制(zhi)回陽(yang)(yang)(yang)升陷(xian)湯(生黃(huang)芪、干姜、當歸身(shen)、桂枝炭、甘草)以治(zhi)之(zhi)。
胸(xiong)中大氣(qi)正(zheng)常,有(you)賴于少陽(yang)、陽(yang)明之氣(qi)的升發(fa)。若大氣(qi)下(xia)陷(xian),升發(fa)之氣(qi)被郁,氣(qi)分郁結(jie),經(jing)絡(luo)瘀滯,常見胸(xiong)中滿痛或(huo)脅下(xia)撐脹(zhang)、腹(fu)痛等。對(dui)此,張氏又(you)制理郁升陷(xian)湯(tang)(生(sheng)黃(huang)芪、知母、當(dang)歸(gui)身(shen)、桂枝尖、柴胡、乳香、沒藥);對(dui)脾氣(qi)虛極(ji)下(xia)陷(xian),小便不禁(jin)者(zhe),制理脾升陷(xian)湯(tang)(生(sheng)黃(huang)芪、白術、桑寄(ji)生(sheng)、川(chuan)斷、萸肉、龍(long)骨、牡蠣、川(chuan)萆薢、甘草(cao))治之。
(三(san))寒溫統(tong)一(yi),注重(zhong)清透
《醫學(xue)衷中(zhong)參(can)西錄》論(lun)溫(wen)(wen)(wen)病(bing)(bing),主張寒(han)溫(wen)(wen)(wen)統一,認為(wei)溫(wen)(wen)(wen)病(bing)(bing)治(zhi)(zhi)法已備于傷寒(han)。如溫(wen)(wen)(wen)病(bing)(bing)初(chu)起治(zhi)(zhi)宜辛(xin)(xin)涼(liang),然辛(xin)(xin)涼(liang)之(zhi)法亦備于傷寒(han),麻杏甘石湯(tang)“誠為(wei)溫(wen)(wen)(wen)病(bing)(bing)初(chu)得之(zhi)的方矣”。但其外(wai)表證未(wei)解,內有蘊熱(re)(re)即(ji)(ji)可服用。至溫(wen)(wen)(wen)病(bing)(bing)傳經已深,清燥熱(re)(re)之(zhi)白虎湯(tang)、白虎加人參(can)湯(tang),通腑(fu)之(zhi)大、小承氣湯(tang),開結胸(xiong)之(zhi)大、小陷胸(xiong)湯(tang),治(zhi)(zhi)下利之(zhi)白頭翁(weng)湯(tang)、黃芩湯(tang),治(zhi)(zhi)發黃之(zhi)茵(yin)陳桅(wei)子(zi)柏皮湯(tang)等及一切涼(liang)潤、清火、育陰、安神之(zhi)劑,皆(jie)可使(shi)用。并(bing)指出寒(han)溫(wen)(wen)(wen)治(zhi)(zhi)法之(zhi)別,在(zai)于“始異而終同”。所謂“始異”,即(ji)(ji)傷寒(han)發表可用溫(wen)(wen)(wen)熱(re)(re),溫(wen)(wen)(wen)病(bing)(bing)發表必用辛(xin)(xin)涼(liang);謂其“終同”,即(ji)(ji)病(bing)(bing)傳陽明之(zhi)后(hou),不(bu)論(lun)傷寒(han)、溫(wen)(wen)(wen)病(bing)(bing),皆(jie)宜治(zhi)(zhi)以寒(han)涼(liang),而大忌溫(wen)(wen)(wen)熱(re)(re)。
張氏臨(lin)證將(jiang)溫(wen)(wen)(wen)病分為(wei)風溫(wen)(wen)(wen)、春(chun)溫(wen)(wen)(wen)、濕(shi)溫(wen)(wen)(wen)三類。認為(wei)三類溫(wen)(wen)(wen)病雖見癥不同,其本質皆緣(yuan)郁熱。“大凡病溫(wen)(wen)(wen)之(zhi)人,多系內有蘊(yun)熱,至春(chun)陽(yang)萌(meng)動之(zhi)時,又薄(bo)受外感拘束,其熱即(ji)陡(dou)發而成溫(wen)(wen)(wen)”。他(ta)遵循(xun)“火郁發之(zhi)”之(zhi)旨(zhi),治療上(shang)主張宣散郁結,疏(shu)通(tong)氣機,透邪外達。反對(dui)徒執寒涼(liang),只清(qing)不透,使(shi)邪無由出。并(bing)自擬清(qing)解湯(tang)、涼(liang)解湯(tang)、寒解湯(tang)三方,徑以石膏清(qing)其內熱,又選(xuan)用薄(bo)荷、連翹、蟬蛻發表,且“引胃(wei)中化而欲散之(zhi)熱,仍還太(tai)陽(yang)作汗而解”。正是(shi)基于(yu)對(dui)溫(wen)(wen)(wen)病“郁熱”這一本質的深刻認識,初(chu)起治療即(ji)立足于(yu)清(qing)透。
溫(wen)病入里化(hua)熱(re)(re),抑或傷(shang)寒、中(zhong)風入里化(hua)熱(re)(re),是陽明熱(re)(re)盛之象,張氏皆(jie)以寒涼清(qing)熱(re)(re)為主,不(bu)復有(you)傷(shang)寒、中(zhong)風、溫(wen)病之分(fen),投以白(bai)虎(hu)湯靈活加(jia)減化(hua)裁。臨證使用白(bai)虎(hu)湯,張氏有(you)著豐富的經驗,認(ren)為白(bai)虎(hu)湯之“四大(da)”典型癥狀(zhuang)中(zhong),唯脈洪為必(bi)見之癥。只要(yao)見脈洪大(da),又有(you)陽明熱(re)(re)盛之一二癥,則無論外感(gan)內傷(shang),皆(jie)可用之,不(bu)必(bi)拘(ju)泥(ni)于古人之說。
陽(yang)明(ming)(ming)腑實用(yong)三承(cheng)氣(qi)(qi)湯(tang)(tang),此乃大法,然張(zhang)氏(shi)認為(wei)承(cheng)氣(qi)(qi)力猛,倘或審證(zheng)不(bu)確(que),即足誤事。于(yu)是據其(qi)(qi)三十余年臨證(zheng)經驗,強調“凡遇陽(yang)明(ming)(ming)應(ying)下證(zheng),亦先投以白虎(hu)湯(tang)(tang)一二劑,更(geng)改其(qi)(qi)服法,將石膏(gao)為(wei)末而不(bu)入煎,以藥(yao)湯(tang)(tang)送服之(zhi)”,因屢用(yong)此方(fang)奏效,遂(sui)名之(zhi)曰白虎(hu)承(cheng)氣(qi)(qi)湯(tang)(tang)。對(dui)于(yu)溫熱(re)(re)病神(shen)昏譫語,張(zhang)氏(shi)遵(zun)從陸九芝“胃(wei)熱(re)(re)之(zhi)甚,神(shen)為(wei)之(zhi)昏,從來神(shen)昏之(zhi)病,皆(jie)屬(shu)胃(wei)家(jia)”之(zhi)說,將熱(re)(re)病神(shen)昏分為(wei)虛(xu)實兩類。其(qi)(qi)脈(mo)象洪而有(you)力,按之(zhi)甚實者(zhe)(zhe),可按陽(yang)明(ming)(ming)胃(wei)實治之(zhi),投以大劑白虎(hu)湯(tang)(tang);若脈(mo)兼(jian)弦、兼(jian)數(shu),或重(zhong)按仍甚實者(zhe)(zhe),治宜白虎(hu)加(jia)人(ren)參湯(tang)(tang);對(dui)邪入陽(yang)明(ming)(ming),淫(yin)熱(re)(re)于(yu)肝(gan),致肝(gan)風(feng)內動者(zhe)(zhe),以白虎(hu)撤其(qi)(qi)陽(yang)明(ming)(ming)之(zhi)熱(re)(re),生龍骨、生牡(mu)蠣(li)以鎮肝(gan)熄風(feng)。
張氏治療(liao)溫(wen)病(bing)不僅擅(shan)用白(bai)虎,而且依(yi)據(ju)病(bing)證(zheng)不同,化裁組成了眾多新方,如石膏粳(jing)米湯、鎮(zhen)逆白(bai)虎湯、通變白(bai)虎加人參湯等(deng),皆(jie)由白(bai)虎湯衍化而來。
二、治療經驗
張氏一生勤于臨(lin)證(zheng),《醫學衷中(zhong)參西錄(lu)》記載了(le)他豐富的臨(lin)床經驗,其中(zhong)尤以(yi)論治(zhi)中(zhong)風(feng)、脫證(zheng)等最具特(te)色。
(一)分別(bie)中(zhong)風(feng)論治
中(zhong)(zhong)風(feng)有真中(zhong)(zhong)、類中(zhong)(zhong)之別。張氏認為真中(zhong)(zhong)者極少,因而著意(yi)對(dui)類中(zhong)(zhong)進行研究、發(fa)揮。指出類中(zhong)(zhong)風(feng)亦即內中(zhong)(zhong)風(feng),此“風(feng)自內生,非風(feng)自外來也”,其治(zhi)療分充血、貧血,以虛實(shi)論治(zhi)。
1、腦充血治療
張氏(shi)根(gen)據“血(xue)菀于上(shang),使人(ren)薄厥”的理論,認為腦充(chong)血(xue)即(ji)(ji)(ji)《內經(jing)》中(zhong)(zhong)所言的煎厥、薄厥、大厥。其病(bing)位在“肝”,陰(yin)虛(xu)陽亢、上(shang)實下虛(xu)、臟(zang)腑之氣(qi)(qi)升發太過(guo)或失之下行(xing),血(xue)隨(sui)氣(qi)(qi)逆為主(zhu)要病(bing)機(ji)。即(ji)(ji)(ji)“人(ren)之血(xue)隨(sui)氣(qi)(qi)行(xing),氣(qi)(qi)上(shang)升不已,血(xue)即(ji)(ji)(ji)隨(sui)之上(shang)升不已,以致(zhi)腦中(zhong)(zhong)血(xue)管充(chong)血(xue)過(guo)甚”(《醫學衷中(zhong)(zhong)參(can)西錄·醫案·腦充(chong)血(xue)門》),有礙神(shen)經(jing),以致(zhi)語言肢體謇(jian)澀不利,口(kou)眼歪斜等(deng)(deng)等(deng)(deng)。
根據腦充血(xue)之(zhi)(zhi)(zhi)(zhi)(zhi)“肝(gan)(gan)(gan)(gan)(gan)木(mu)失和(he),肺(fei)氣(qi)不(bu)降,腎(shen)氣(qi)不(bu)攝,沖氣(qi)、胃(wei)氣(qi)又(you)(you)復上(shang)(shang)逆,臟腑(fu)之(zhi)(zhi)(zhi)(zhi)(zhi)氣(qi)化皆上(shang)(shang)升(sheng)太(tai)過”之(zhi)(zhi)(zhi)(zhi)(zhi)病機(ji),張氏提出治(zhi)(zhi)療本(ben)病應(ying)“清其(qi)臟腑(fu)之(zhi)(zhi)(zhi)(zhi)(zhi)熱(re),滋其(qi)臟腑(fu)之(zhi)(zhi)(zhi)(zhi)(zhi)陰(yin),更(geng)降其(qi)臟腑(fu)之(zhi)(zhi)(zhi)(zhi)(zhi)氣(qi),引腦部(bu)所充之(zhi)(zhi)(zhi)(zhi)(zhi)血(xue)下(xia)行”的(de)“鎮(zhen)肝(gan)(gan)(gan)(gan)(gan)熄(xi)風(feng)(feng)、引血(xue)下(xia)行”的(de)原(yuan)則,并創制(zhi)鎮(zhen)肝(gan)(gan)(gan)(gan)(gan)熄(xi)風(feng)(feng)湯(懷牛膝(xi)、生(sheng)(sheng)赭石、生(sheng)(sheng)杭(hang)芍、天冬、生(sheng)(sheng)龍骨、生(sheng)(sheng)牡(mu)蠣、生(sheng)(sheng)龜(gui)板、玄參、川楝子(zi)、生(sheng)(sheng)麥芽(ya)、茵陳、甘草(cao))作(zuo)為治(zhi)(zhi)療本(ben)病的(de)主方(fang)。方(fang)中(zhong)赭石降胃(wei),平(ping)肝(gan)(gan)(gan)(gan)(gan)鎮(zhen)沖,下(xia)行通便(bian);牛膝(xi)善引上(shang)(shang)部(bu)之(zhi)(zhi)(zhi)(zhi)(zhi)血(xue)下(xia)行,二藥合用,相輔相成(cheng);玄參、天冬、白芍滋陰(yin)退熱(re);龍骨、牡(mu)蠣、龜(gui)板、芍藥斂肝(gan)(gan)(gan)(gan)(gan)火(huo)、鎮(zhen)熄(xi)肝(gan)(gan)(gan)(gan)(gan)風(feng)(feng),以(yi)緩其(qi)肝(gan)(gan)(gan)(gan)(gan)氣(qi)上(shang)(shang)升(sheng)之(zhi)(zhi)(zhi)(zhi)(zhi)勢;玄參、天冬清肺(fei)制(zhi)肝(gan)(gan)(gan)(gan)(gan);山藥、甘草(cao)和(he)胃(wei)緩肝(gan)(gan)(gan)(gan)(gan);茵陳為“青(qing)蒿(hao)之(zhi)(zhi)(zhi)(zhi)(zhi)嫩者,稟少陽初生(sheng)(sheng)之(zhi)(zhi)(zhi)(zhi)(zhi)氣(qi),與肝(gan)(gan)(gan)(gan)(gan)木(mu)同氣(qi)相求,最能將順肝(gan)(gan)(gan)(gan)(gan)木(mu)之(zhi)(zhi)(zhi)(zhi)(zhi)性(xing),且(qie)又(you)(you)善瀉肝(gan)(gan)(gan)(gan)(gan)熱(re)”,為清涼腦部(bu)之(zhi)(zhi)(zhi)(zhi)(zhi)涼藥也;麥芽(ya)“善助肝(gan)(gan)(gan)(gan)(gan)木(mu)疏泄(xie)以(yi)行腎(shen)氣(qi)”;川楝子(zi)善引肝(gan)(gan)(gan)(gan)(gan)氣(qi)下(xia)達,又(you)(you)能折其(qi)更(geng)動之(zhi)(zhi)(zhi)(zhi)(zhi)力(li)。本(ben)方(fang)標本(ben)兼(jian)治(zhi)(zhi),鎮(zhen)潛共用,引涵兼(jian)施,直中(zhong)病之(zhi)(zhi)(zhi)(zhi)(zhi)肯(ken)綮(qi),確有(you)獨到之(zhi)(zhi)(zhi)(zhi)(zhi)處。
此(ci)外(wai),張氏還(huan)參(can)照西醫病理,闡述了腦(nao)(nao)充(chong)(chong)血(xue)(xue)、腦(nao)(nao)溢血(xue)(xue)、腦(nao)(nao)出(chu)血(xue)(xue)之(zhi)證(zheng)型(xing)及用(yong)(yong)藥(yao)的不同。對(dui)(dui)腦(nao)(nao)部血(xue)(xue)管中之(zhi)血(xue)(xue)滲出(chu)者(zhe),他在友人(ren)“腦(nao)(nao)充(chong)(chong)血(xue)(xue)證(zheng),宜于(yu)(yu)引(yin)血(xue)(xue)下行藥(yao)中加(jia)(jia)(jia)破血(xue)(xue)之(zhi)藥(yao)以治(zhi)之(zhi)”的啟發下,指出(chu)對(dui)(dui)其(qi)身體壯實者(zhe),可酌加(jia)(jia)(jia)大黃數(shu)錢以逐瘀;其(qi)身形(xing)脈象不甚壯實者(zhe),加(jia)(jia)(jia)桃仁、丹參(can)等化(hua)瘀。并明(ming)確提出(chu)“腦(nao)(nao)充(chong)(chong)血(xue)(xue)當通大便為要務”。對(dui)(dui)腦(nao)(nao)充(chong)(chong)血(xue)(xue)后(hou)期脈象柔和而(er)肢(zhi)體痿廢者(zhe),主(zhu)張“少(shao)用(yong)(yong)黃芪(qi)助活(huo)血(xue)(xue)之(zhi)品(pin)以通絡”,但(dan)應謹慎從事。而(er)對(dui)(dui)于(yu)(yu)“血(xue)(xue)菀于(yu)(yu)上”的腦(nao)(nao)充(chong)(chong)血(xue)(xue)者(zhe),因黃芪(qi)之(zhi)情,補而(er)兼(jian)升(sheng),氣(qi)升(sheng)則(ze)血(xue)(xue)必隨(sui)之(zhi)升(sheng),故病初應忌用(yong)(yong)黃芪(qi),誤用(yong)(yong)則(ze)兇危立見。其(qi)辨(bian)證(zheng)之(zhi)嚴謹,用(yong)(yong)藥(yao)之(zhi)精確,可見一斑。
2、腦貧血治療
與腦(nao)充血(xue)(xue)證(zheng)相反,張(zhang)氏認為(wei)腦(nao)貧(pin)血(xue)(xue)證(zheng)則為(wei)血(xue)(xue)之(zhi)上(shang)注于(yu)腦(nao)過(guo)少,無以(yi)養其腦(nao)髓(sui)神(shen)經,致(zhi)使(shi)腦(nao)神(shen)經失其所司。而血(xue)(xue)之(zhi)上(shang)注過(guo)少,實(shi)由“宗氣(qi)虛寒,不能助血(xue)(xue)上(shang)升川(chuan)”。故治(zhi)(zhi)療腦(nao)貧(pin)血(xue)(xue)證(zheng),主(zhu)張(zhang)“應(ying)峻(jun)補其胸中大(da)氣(qi)”,自擬(ni)當歸(gui)補血(xue)(xue)湯益氣(qi)溫(wen)陽、補血(xue)(xue)活血(xue)(xue),治(zhi)(zhi)療中風脈(mo)象遲弱(ruo),身軟,肢(zhi)體漸(jian)覺不利,或頭(tou)重目眩,或神(shen)昏(hun)健忘(wang),甚或昏(hun)仆,移時(shi)蘇醒(xing)致(zhi)成偏枯(ku)者(zhe)(zhe)。方中主(zhu)以(yi)黃芪升補胸中大(da)氣(qi),使(shi)血(xue)(xue)隨氣(qi)升,上(shang)達腦(nao)中;用當歸(gui)、龍(long)眼肉(rou)、鹿角膠養血(xue)(xue)生髓(sui);丹參、乳、沒開血(xue)(xue)痹,化瘀滯(zhi);甘(gan)松助心房(fang)運行有力,以(yi)多輸血(xue)(xue)于(yu)腦(nao),且又為(wei)調養神(shen)經之(zhi)品。對(dui)于(yu)腦(nao)貧(pin)血(xue)(xue)肢(zhi)體痿廢或偏枯(ku),脈(mo)象極微細無力者(zhe)(zhe),又擬(ni)干頹湯、補腦(nao)振痿湯治(zhi)(zhi)療。并指出肢(zhi)體偏廢,服(fu)藥久不效者(zhe)(zhe),應(ying)著重補腎通絡(luo),多選用胡桃(tao)肉(rou)、地龍(long)、馬錢子(zi)等。
(二)重視沖氣為病,善(shan)用鎮沖降逆
沖(chong)(chong)(chong)脈(mo)(mo)為(wei)(wei)奇(qi)經八脈(mo)(mo)之(zhi)(zhi)(zhi)一(yi),張氏論(lun)病(bing)(bing)(bing)極重視(shi)沖(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi),指出“沖(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)沖(chong)(chong)(chong)之(zhi)(zhi)(zhi)病(bing)(bing)(bing)甚(shen)多,而(er)醫者識(shi)其病(bing)(bing)(bing)者甚(shen)少。即(ji)或能識(shi)此病(bing)(bing)(bing),亦多不(bu)(bu)能洞悉其病(bing)(bing)(bing)因(yin)”。因(yin)而(er),對沖(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)的(de)生理,尤(you)其是沖(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)沖(chong)(chong)(chong)的(de)病(bing)(bing)(bing)因(yin)、病(bing)(bing)(bing)理、病(bing)(bing)(bing)脈(mo)(mo)、治法都作了詳細闡述(shu),自成一(yi)家(jia)之(zhi)(zhi)(zhi)言(yan)。其述(shu)沖(chong)(chong)(chong)脈(mo)(mo),、兼采《內》《難》之(zhi)(zhi)(zhi)說(shuo),認為(wei)(wei)其“在胞(bao)室之(zhi)(zhi)(zhi)兩旁,與任脈(mo)(mo)相(xiang)連(lian),為(wei)(wei)腎(shen)臟之(zhi)(zhi)(zhi)輔弼(bi),氣(qi)(qi)(qi)(qi)(qi)化(hua)相(xiang)通……上(shang)(shang)(shang)系原隸陽(yang)明(ming)胃(wei)腑(fu)”,并認為(wei)(wei)“沖(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)沖(chong)(chong)(chong)之(zhi)(zhi)(zhi)證,固由于腎(shen)臟之(zhi)(zhi)(zhi)虛,亦多由于肝(gan)氣(qi)(qi)(qi)(qi)(qi)恣橫,素性多怒之(zhi)(zhi)(zhi)人,其肝(gan)氣(qi)(qi)(qi)(qi)(qi)之(zhi)(zhi)(zhi)暴發(fa),更助(zhu)沖(chong)(chong)(chong)胃(wei)之(zhi)(zhi)(zhi)氣(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)逆(ni)(ni)”。即(ji)腎(shen)虛無以涵木,不(bu)(bu)能收斂(lian)沖(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi),沖(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)行,肝(gan)氣(qi)(qi)(qi)(qi)(qi)橫逆(ni)(ni),胃(wei)氣(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)逆(ni)(ni)而(er)呈(cheng)上(shang)(shang)(shang)沖(chong)(chong)(chong)之(zhi)(zhi)(zhi)弊。張氏描述(shu)的(de)沖(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)沖(chong)(chong)(chong)證,除自覺有氣(qi)(qi)(qi)(qi)(qi)自下上(shang)(shang)(shang)沖(chong)(chong)(chong),脈(mo)(mo)多弦硬而(er)長(chang)外,主要表(biao)現有胃(wei)脘(wan)或腹中(zhong)滿(man)悶(men),噦氣(qi)(qi)(qi)(qi)(qi),呃逆(ni)(ni)連(lian)連(lian),嘔吐不(bu)(bu)止,或見吐血、衄血等(deng)(deng)胃(wei)氣(qi)(qi)(qi)(qi)(qi)上(shang)(shang)(shang)逆(ni)(ni)不(bu)(bu)降見癥;或兩脅痛(tong)脹,頭目(mu)眩暈,甚(shen)而(er)氣(qi)(qi)(qi)(qi)(qi)火挾痰上(shang)(shang)(shang)沖(chong)(chong)(chong),發(fa)生突然昏(hun)仆(pu)等(deng)(deng);或為(wei)(wei)胸(xiong)滿(man)窒塞,喘息大作。其治療,主張以斂(lian)沖(chong)(chong)(chong)鎮(zhen)沖(chong)(chong)(chong)為(wei)(wei)主,降胃(wei)平肝(gan)為(wei)(wei)佐,獨創參赭鎮(zhen)氣(qi)(qi)(qi)(qi)(qi)湯(tang)、鎮(zhen)沖(chong)(chong)(chong)降胃(wei)湯(tang)等(deng)(deng)鎮(zhen)沖(chong)(chong)(chong)諸方。其組方特色,一(yi)為(wei)(wei)善(shan)用(yong)鎮(zhen)沖(chong)(chong)(chong)降逆(ni)(ni)之(zhi)(zhi)(zhi)品,如(ru)赭石(shi)、龍、牡等(deng)(deng);一(yi)為(wei)(wei)善(shan)用(yong)補虛固澀之(zhi)(zhi)(zhi)品,如(ru)山(shan)萸(yu)肉、山(shan)藥、白芍(shao)、芡實等(deng)(deng),攻中(zhong)有補,降斂(lian)結合,用(yong)之(zhi)(zhi)(zhi)臨(lin)床,確有良(liang)效(xiao)。其沖(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)學說(shuo)為(wei)(wei)中(zhong)醫臨(lin)床治療雜(za)病(bing)(bing)(bing)又(you)辟(pi)新徑。
(三)脫(tuo)分上下內外,治脫(tuo)重視(shi)肝虛
張(zhang)氏認為脫(tuo)雖(sui)有上(shang)、下(xia)、內、外(wai)之(zhi)別,概(gai)由(you)(you)肝(gan)(gan)(gan)(gan)虛,其云:“凡人(ren)元氣(qi)(qi)(qi)之(zhi)脫(tuo),皆(jie)脫(tuo)在肝(gan)(gan)(gan)(gan)”。他根據肝(gan)(gan)(gan)(gan)主疏(shu)泄、調暢氣(qi)(qi)(qi)機(ji)的功(gong)能(neng),認為元氣(qi)(qi)(qi)的運行(xing)和胃(wei)氣(qi)(qi)(qi)的布化,全賴于肝(gan)(gan)(gan)(gan)臟正常的疏(shu)泄功(gong)能(neng)。倘肝(gan)(gan)(gan)(gan)虛則(ze)損泄元氣(qi)(qi)(qi),耗(hao)散腎(shen)氣(qi)(qi)(qi),而(er)為上(shang)脫(tuo)或下(xia)脫(tuo)。“蓋元氣(qi)(qi)(qi)上(shang)脫(tuo)由(you)(you)于肝(gan)(gan)(gan)(gan),其下(xia)脫(tuo)亦由(you)(you)于肝(gan)(gan)(gan)(gan)。誠(cheng)以(yi)(yi)肝(gan)(gan)(gan)(gan)能(neng)為腎(shen)行(xing)氣(qi)(qi)(qi),即能(neng)瀉(xie)(xie)元氣(qi)(qi)(qi)自下(xia)出(chu)也(ye)”。(《醫(yi)(yi)學衷中(zhong)(zhong)參(can)西錄·醫(yi)(yi)案(an)·霍亂門》)上(shang)脫(tuo)之(zhi)證(zheng),“喘(chuan)逆迫促,脈(mo)若水上(shang)浮麻”,張(zhang)氏制參(can)赭鎮氣(qi)(qi)(qi)湯(tang)(tang)救之(zhi)。方(fang)中(zhong)(zhong)以(yi)(yi)人(ren)參(can)補虛極(ji)(ji)之(zhi)諸氣(qi)(qi)(qi),借(jie)“赭石下(xia)行(xing)之(zhi)力,挽(wan)回將(jiang)脫(tuo)之(zhi)元氣(qi)(qi)(qi)”;蘇(su)子助赭石降氣(qi)(qi)(qi);生(sheng)(sheng)山藥(yao)(yao)、生(sheng)(sheng)白芍滋(zi)補肝(gan)(gan)(gan)(gan)胃(wei)之(zhi)陰,以(yi)(yi)守持元氣(qi)(qi)(qi);山萸肉(rou)、生(sheng)(sheng)芡實(shi)、生(sheng)(sheng)龍骨(gu)、生(sheng)(sheng)牡蠣(li)酸斂收澀(se)(se),固攝元氣(qi)(qi)(qi)。下(xia)脫(tuo),如(ru)“日夜吐(tu)瀉(xie)(xie)不已,脈(mo)沉細欲無,虛極(ji)(ji)將(jiang)脫(tuo)者,為至危(wei)之(zhi)候”,張(zhang)氏以(yi)(yi)急救回陽(yang)(yang)湯(tang)(tang)救之(zhi),方(fang)用人(ren)參(can)以(yi)(yi)回陽(yang)(yang);山藥(yao)(yao)、芍藥(yao)(yao)滋(zi)陰;重用山萸肉(rou)斂肝(gan)(gan)(gan)(gan)固脫(tuo)。上(shang)下(xia)兩脫(tuo)兼見者,挽(wan)陰回陽(yang)(yang),以(yi)(yi)“既濟(ji)湯(tang)(tang)”酸斂固澀(se)(se)。
除元氣(qi)(qi)(qi)上脫(tuo)(tuo)(tuo)、下脫(tuo)(tuo)(tuo)之外,又有(you)所謂外脫(tuo)(tuo)(tuo)、內(nei)脫(tuo)(tuo)(tuo)。外脫(tuo)(tuo)(tuo)者,癥見周身汗出不(bu)止(zhi),或“目睛(jing)上竄(cuan),或喘(chuan)逆,或怔(zheng)忡,或氣(qi)(qi)(qi)虛不(bu)足(zu)以息(xi)”,張氏(shi)認為此乃“肝膽(dan)虛極(ji)而元氣(qi)(qi)(qi)欲脫(tuo)(tuo)(tuo)也(ye)”。即肝陰過虛,肝風萌(meng)動,元氣(qi)(qi)(qi)欲脫(tuo)(tuo)(tuo),用來復湯治之。內(nei)脫(tuo)(tuo)(tuo),如(ru)“胸中大氣(qi)(qi)(qi)下陷(xian)(xian)(xian),氣(qi)(qi)(qi)短(duan)不(bu)足(zu)以息(xi),或努力呼吸,有(you)似乎喘(chuan),或氣(qi)(qi)(qi)息(xi)將停(ting),危在頃刻(ke)……其脈象沉遲微(wei)弱,關前尤甚;其劇者,或六(liu)脈不(bu)全(quan),或參(can)伍不(bu)調”,此系(xi)中氣(qi)(qi)(qi)自(zi)內(nei)而陷(xian)(xian)(xian)的內(nei)脫(tuo)(tuo)(tuo)證,張氏(shi)以“升陷(xian)(xian)(xian)湯”升補(bu)下陷(xian)(xian)(xian)之氣(qi)(qi)(qi),再(zai)加山萸肉收斂(lian)氣(qi)(qi)(qi)分(fen)之耗(hao)散,使升者不(bu)至復陷(xian)(xian)(xian),共挽中氣(qi)(qi)(qi)下陷(xian)(xian)(xian)所致之內(nei)脫(tuo)(tuo)(tuo)。
從(cong)上述救(jiu)(jiu)脫(tuo)方可見,張氏(shi)救(jiu)(jiu)脫(tuo)善用(yong)山(shan)萸(yu)(yu)肉(rou)(rou)。他認為(wei)山(shan)英(ying)肉(rou)(rou)味酸性溫,固澀滑脫(tuo),通(tong)利九竅,流通(tong)血脈(mo),為(wei)補(bu)肝(gan)之(zhi)(zhi)妙藥,其(qi)救(jiu)(jiu)脫(tuo)之(zhi)(zhi)功,較參、術(shu)、芪更勝(sheng)。“蓋萸(yu)(yu)肉(rou)(rou)之(zhi)(zhi)性,不(bu)獨補(bu)肝(gan)也,凡人身之(zhi)(zhi)陰陽(yang),氣血將散(san)者,皆(jie)能斂之(zhi)(zhi),故救(jiu)(jiu)脫(tuo)之(zhi)(zhi)藥,當(dang)以萸(yu)(yu)肉(rou)(rou)為(wei)第(di)一”。常(chang)用(yong)萸(yu)(yu)肉(rou)(rou)治療各種虛脫(tuo)危證(zheng),或配(pei)以生(sheng)龍骨、牡蠣斂汗;或配(pei)人參、附子、山(shan)藥、炙甘草益氣回(hui)陽(yang)固脫(tuo);或配(pei)當(dang)歸(gui)、熟地填補(bu)精血等。其(qi)論脫(tuo)證(zheng)病機(ji)及治法用(yong)藥,別(bie)開(kai)生(sheng)面,對后人啟迪尤深。
(四)遣藥制方心得(de)
張氏制方(fang)用藥頗有(you)獨到(dao)經驗,通性味,善配伍,別具匠心(xin)。具體(ti)表(biao)現在以(yi)下幾(ji)個方(fang)面。
1、精研藥物,頗多新見(jian)
張氏認為學(xue)醫的(de)第一層(ceng)功(gong)夫即(ji)是識(shi)藥(yao)(yao)性,其(qi)對(dui)藥(yao)(yao)性的(de)理解,于諸家(jia)本草學(xue)之外,頗(po)多新見。《醫學(xue)衷(zhong)中(zhong)參(can)西錄》書(shu)中(zhong)專列《藥(yao)(yao)物》一章,對(dui)常用(yong)的(de)79種藥(yao)(yao)物詳加解釋,闡述了張氏對(dui)藥(yao)(yao)物的(de)獨(du)到認識(shi)與經驗。其(qi)中(zhong)他研究最精(jing)的(de)藥(yao)(yao)物有黃芪、山萸肉、赭石、山藥(yao)(yao)、三七、黨參(can)、乳香、沒藥(yao)(yao)、三棱、水(shui)蛭、牛膝、龍骨、牡蠣等(deng)。
例如,他廣泛(fan)應用(yong)大劑量石(shi)膏治(zhi)療外感熱性(xing)(xing)病屢(lv)收良(liang)效(xiao),認(ren)為(wei)并無損(sun)傷(shang)脾胃之(zhi)弊,且隨著熱退病愈而(er)飲食倍增,為(wei)清解(jie)(jie)大熱之(zhi)特(te)效(xiao)藥(yao)(yao)。善(shan)(shan)用(yong)三(san)(san)棱、莪術(shu),認(ren)為(wei)二(er)藥(yao)(yao)善(shan)(shan)破(po)血(xue)、調氣(qi)(qi),化(hua)(hua)瘀(yu)(yu)則三(san)(san)棱優(you)于(yu)(yu)莪術(shu),理(li)氣(qi)(qi)則莪術(shu)優(you)于(yu)(yu)三(san)(san)棱,若“二(er)藥(yao)(yao)合用(yong),常有(you)協同之(zhi)功”。認(ren)為(wei)水蛭破(po)瘀(yu)(yu)最(zui)效(xiao),善(shan)(shan)除(chu)日久(jiu)之(zhi)瘀(yu)(yu)滯,能(neng)使瘀(yu)(yu)血(xue)默消于(yu)(yu)無形(xing)之(zhi)中(zhong),乳香善(shan)(shan)透竅(qiao)理(li)氣(qi)(qi),沒藥(yao)(yao)善(shan)(shan)化(hua)(hua)瘀(yu)(yu)理(li)血(xue),二(er)藥(yao)(yao)并用(yong)為(wei)宣(xuan)通臟腑(fu)、流通經絡之(zhi)要藥(yao)(yao),常用(yong)于(yu)(yu)治(zhi)心(xin)、胃、脅(xie)、腹及肢體關節諸痛(tong),經痛(tong),產(chan)后瘀(yu)(yu)血(xue)腹痛(tong),月經不(bu)(bu)調,風寒濕痹(bi),中(zhong)風四肢不(bu)(bu)遂及一(yi)切(qie)瘡(chuang)瘍腫(zhong)痛(tong);雞內金味酸性(xing)(xing)溫(wen)藥(yao)(yao)性(xing)(xing)平和,有(you)補(bu)脾胃之(zhi)妙,善(shan)(shan)化(hua)(hua)有(you)形(xing)之(zhi)瘀(yu)(yu)積;山楂(zha)化(hua)(hua)瘀(yu)(yu)血(xue)而(er)不(bu)(bu)傷(shang)新血(xue),開郁(yu)氣(qi)(qi)而(er)不(bu)(bu)傷(shang)正氣(qi)(qi);茵陳、麥芽皆(jie)具(ju)疏肝(gan)解(jie)(jie)郁(yu)之(zhi)效(xiao),體弱陰虛(xu)不(bu)(bu)任柴(chai)胡升散者,常以(yi)其(qi)代(dai)之(zhi);黃芪性(xing)(xing)溫(wen)味微甘,補(bu)氣(qi)(qi)兼能(neng)升氣(qi)(qi),善(shan)(shan)治(zhi)氣(qi)(qi)虛(xu)、氣(qi)(qi)陷諸證,且其(qi)“性(xing)(xing)溫(wen)而(er)上(shang)升,以(yi)之(zhi)補(bu)肝(gan)有(you)同氣(qi)(qi)相求之(zhi)妙用(yong)”,故凡肝(gan)氣(qi)(qi)虛(xu)弱不(bu)(bu)能(neng)條(tiao)達,用(yong)一(yi)切(qie)補(bu)肝(gan)之(zhi)藥(yao)(yao)皆(jie)不(bu)(bu)效(xiao)者,倡重用(yong)黃芪為(wei)主,而(er)少佐以(yi)理(li)氣(qi)(qi)之(zhi)品,并據此(ci)批評“肝(gan)虛(xu)無補(bu)法”之(zhi)談。這些(xie)獨創性(xing)(xing)見解(jie)(jie),擴大和豐富(fu)了(le)藥(yao)(yao)物的(de)臨床應用(yong)范圍。
2、善用生(sheng)藥,注重配伍
張(zhang)(zhang)(zhang)錫純(chun)在《醫(yi)學(xue)衷中(zhong)參(can)西錄》中(zhong)自擬良方百余首(shou),以生(sheng)(sheng)(sheng)(sheng)藥(yao)(yao)見長,對(dui)生(sheng)(sheng)(sheng)(sheng)藥(yao)(yao)的使(shi)用(yong)(yong)獨具卓見。如水蛭(zhi),方書多謂必須炙(zhi)透方可(ke)使(shi)用(yong)(yong),但張(zhang)(zhang)(zhang)氏(shi)認(ren)為,此(ci)物(wu)生(sheng)(sheng)(sheng)(sheng)于水中(zhong),原得水之精氣(qi)而生(sheng)(sheng)(sheng)(sheng),炙(zhi)之則傷水之精氣(qi),不(bu)(bu)若生(sheng)(sheng)(sheng)(sheng)用(yong)(yong)。因而在治療(liao)經閉不(bu)(bu)行(xing)、產后惡露不(bu)(bu)盡或瘀(yu)血(xue)頑癥時,常于理沖(chong)(chong)湯、理沖(chong)(chong)丸中(zhong)加入水蛭(zhi)一錢或一兩,并標明“不(bu)(bu)用(yong)(yong)炙(zhi)”。認(ren)為赭(zhe)石(shi)(shi)色(se)赤性(xing)微涼(liang),生(sheng)(sheng)(sheng)(sheng)血(xue)兼能涼(liang)血(xue),且(qie)因其質重墜,又可(ke)鎮逆、降(jiang)痰、止嘔、通便(bian),“生(sheng)(sheng)(sheng)(sheng)研服之不(bu)(bu)傷腸胃……且(qie)生(sheng)(sheng)(sheng)(sheng)服則養(yang)氣(qi)純(chun)全,大能養(yang)血(xue)”。故(gu)治陰陽兩虛、喘(chuan)逆迫促(cu)之喘(chuan)息(xi),重用(yong)(yong)生(sheng)(sheng)(sheng)(sheng)赭(zhe)石(shi)(shi)伍以生(sheng)(sheng)(sheng)(sheng)龍牡斂(lian)沖(chong)(chong)降(jiang)逆;又與(yu)肉蓯蓉、當歸并用(yong)(yong),補腎斂(lian)沖(chong)(chong),潤便(bian)通結(jie)。張(zhang)(zhang)(zhang)氏(shi)臨床常用(yong)(yong)的生(sheng)(sheng)(sheng)(sheng)藥(yao)(yao)還(huan)有(you)生(sheng)(sheng)(sheng)(sheng)乳香、生(sheng)(sheng)(sheng)(sheng)沒藥(yao)(yao)、生(sheng)(sheng)(sheng)(sheng)雞內金、生(sheng)(sheng)(sheng)(sheng)黃芪、生(sheng)(sheng)(sheng)(sheng)山藥(yao)(yao)、生(sheng)(sheng)(sheng)(sheng)杭芍、生(sheng)(sheng)(sheng)(sheng)石(shi)(shi)膏等(deng)。
此外,張氏根據其臨(lin)床經驗和體會,總結出許(xu)多新的藥(yao)(yao)對配(pei)伍關(guan)系。如(ru)山藥(yao)(yao)配(pei)牛蒡子,疏補兼行,補腎健脾(pi),清(qing)肺(fei)止咳(ke),祛痰降氣(qi)(qi)(qi);人(ren)參(can)配(pei)代赭石,剛柔相濟,升降互用(yong),治療脾(pi)胃氣(qi)(qi)(qi)虛,沖氣(qi)(qi)(qi)相干,或用(yong)于上盛下(xia)虛、氣(qi)(qi)(qi)血將脫;黃芪配(pei)知母,寒(han)熱(re)平調以益氣(qi)(qi)(qi)升舉;人(ren)參(can)配(pei)威靈仙治氣(qi)(qi)(qi)虛小便不利;生(sheng)龍、牡配(pei)萸肉,三藥(yao)(yao)聯合應用(yong),收斂固脫、澀精止汗等(deng),均可資(zi)臨(lin)床參(can)考。
3、潛心實踐,創制新方(fang)
張氏對(dui)方(fang)(fang)(fang)藥(yao)的(de)運(yun)用(yong)也頗有心(xin)得,在《醫學衷中(zhong)(zhong)(zhong)參(can)西錄》中(zhong)(zhong)(zhong)創立(li)了(le)許(xu)多有效(xiao)的(de)方(fang)(fang)(fang)劑,廣及內(nei)、外、婦(fu)、兒各科(ke),其(qi)(qi)(qi)多有所宗,遵經而(er)不泥古,通變而(er)不失規矩。其(qi)(qi)(qi)中(zhong)(zhong)(zhong),有不少為(wei)(wei)(wei)師法仲景(jing)原意(yi)而(er)化(hua)裁(cai)創制的(de)新方(fang)(fang)(fang)。如治(zhi)吐衄諸方(fang)(fang)(fang)是(shi)受《金匱》瀉心(xin)湯(tang)(tang)影響,以降胃為(wei)(wei)(wei)主,故喜用(yong)赭石、半夏。治(zhi)療胸中(zhong)(zhong)(zhong)蘊熱(re)為(wei)(wei)(wei)外感所束(shu),不能發泄而(er)致煩躁的(de)猶龍(long)湯(tang)(tang),立(li)意(yi)源于(yu)大(da)青(qing)龍(long)湯(tang)(tang),由連翹、生石膏、蟬蛻、牛蒡子組成。治(zhi)滿悶(men)短氣,呼吸(xi)不利(li)的(de)蕩胸湯(tang)(tang),于(yu)大(da)陷胸湯(tang)(tang)中(zhong)(zhong)(zhong)取用(yong)芒(mang)硝(xiao),于(yu)小陷胸湯(tang)(tang)中(zhong)(zhong)(zhong)取用(yong)瓜(gua)蔞(lou),又(you)于(yu)治(zhi)心(xin)下(xia)痞硬之(zhi)(zhi)旋覆代赭湯(tang)(tang)中(zhong)(zhong)(zhong)取用(yong)赭石,而(er)復(fu)加(jia)蘇(su)子以為(wei)(wei)(wei)下(xia)行之(zhi)(zhi)向導(dao),可(ke)(ke)以代大(da)陷胸湯(tang)(tang)、丸(wan),亦可(ke)(ke)代小陷胸湯(tang)(tang)。又(you)如其(qi)(qi)(qi)治(zhi)療婦(fu)科(ke)病之(zhi)(zhi)理(li)(li)沖湯(tang)(tang)、理(li)(li)沖丸(wan),用(yong)參(can)、術、當歸、山藥(yao)等(deng)(deng)(deng)補(bu)氣健脾扶正,莪(e)術、三棱(leng)、水蛭(zhi)等(deng)(deng)(deng)活血化(hua)瘀(yu),為(wei)(wei)(wei)攻補(bu)兼施,扶正化(hua)瘀(yu),治(zhi)閉經及癥(zheng)瘕(jia)之(zhi)(zhi)虛實夾(jia)雜證良方(fang)(fang)(fang)。又(you)如治(zhi)崩漏的(de)安(an)沖湯(tang)(tang)、固沖湯(tang)(tang),熔塞流、澄源、補(bu)虛于(yu)一爐(lu),止血而(er)不留瘀(yu),清熱(re)而(er)不涼遏,溫補(bu)而(er)不閉邪。再如,如治(zhi)陰虛勞嗽之(zhi)(zhi)資生湯(tang)(tang),治(zhi)腦充(chong)血頭目(mu)眩(xuan)暈之(zhi)(zhi)建瓴湯(tang)(tang),治(zhi)心(xin)腹(fu)疼(teng)痛(tong)、癥(zheng)瘕(jia)痰癖的(de)活絡效(xiao)靈丹,治(zhi)腎虛滑胎(tai)的(de)壽胎(tai)丸(wan)等(deng)(deng)(deng)等(deng)(deng)(deng),都(dou)是(shi)行之(zhi)(zhi)有效(xiao)的(de)名(ming)方(fang)(fang)(fang)。
張氏治學(xue)嚴(yan)謹,重視實(shi)踐,主張溝通中(zhong)(zhong)西(xi)(xi),取長(chang)補短,是近代(dai)中(zhong)(zhong)西(xi)(xi)醫匯(hui)通派的代(dai)表之一。結合其多(duo)年臨證經(jing)驗與匯(hui)通中(zhong)(zhong)西(xi)(xi)的體會(hui),著成《醫學(xue)衷中(zhong)(zhong)參(can)西(xi)(xi)錄(lu)》。
張錫純(chun),字壽甫,清末民初河北省鹽山縣(xian)人。生活于公元1860~1933年(nian)(清咸(xian)豐十年(nian)至(zhi)民國二十二年(nian))。幼敏(min)而好(hao)學,攻讀(du)經史(shi)之余,兼(jian)習岐(qi)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(zi),革命軍興,應(ying)聘(pin)從戎去武漢為軍醫(yi)(yi)。1917年(nian)在(zai)沈(shen)陽創(chuang)(chuang)建“立達中醫(yi)(yi)院(yuan)”。直(zhi)奉(feng)戰起,回(hui)故居河北滄州行醫(yi)(yi),1926年(nian)移居天(tian)津,創(chuang)(chuang)辦“天(tian)津國醫(yi)(yi)函授學校”,培(pei)養了大批中醫(yi)(yi)后繼人才。
張氏(shi)治學嚴謹,重(zhong)視實踐(jian),主張溝通中西(xi)(xi),取(qu)長補短,是近代中西(xi)(xi)醫(yi)匯(hui)通派(pai)的代表之(zhi)一。其醫(yi)德高尚(shang),常舍藥濟貧,遇疑難(nan)重(zhong)癥,殫思竭慮,并親自(zi)攜藥到病家督煎,守護達旦。為了(le)體驗藥物的毒(du)性反應和(he)(he)用量,曾親嘗巴豆(dou)、花椒、甘遂等藥,足(zu)見其對(dui)病人極(ji)端負責的精神和(he)(he)重(zhong)視實踐(jian)的治學態度(du)。他(ta)醫(yi)術精湛,常能力(li)排眾議,獨任(ren)其責,起群醫(yi)束手之(zhi)沉疴(ke),療(liao)效卓(zhuo)著,名震遐邇(er)。當時與江蘇陸晉笙、楊(yang)如侯,廣東劉蔚楚同負盛名,又與慈溪張生甫、嘉定(ding)張山雷并稱名醫(yi)三張。
張(zhang)氏(shi)勤于鉆研,善于總結,平(ping)生著述甚多,后因天津洪水沒其居,遺(yi)書(shu)蕩盡(jin),傳世者(zhe)僅(jin)《醫學衷中參西錄》一書(shu)。
《醫學(xue)(xue)衷中參西錄》為20世紀中醫臨床(chuang)醫學(xue)(xue)名著,素為醫家所重(zhong)視。