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基本介紹

《醫(yi)(yi)學(xue)(xue)衷中(zhong)參西(xi)(xi)(xi)錄(lu)》，中(zhong)醫(yi)(yi)叢書，又名《衷中(zhong)參西(xi)(xi)(xi)錄(lu)》，張錫純(壽(shou)甫)撰。此書分為(wei)(wei)《處方(fang)(fang)(fang)學(xue)(xue)》8卷(juan)、《醫(yi)(yi)論》8卷(juan)、《醫(yi)(yi)話(hua)拾零(ling)》、《三三醫(yi)(yi)書評》、《藥物講義》4卷(juan)、《傷寒(han)講義》4卷(juan)、《醫(yi)(yi)案(附(fu)詩草)》4卷(juan)。系作者(zhe)多年治學(xue)(xue)臨(lin)(lin)證(zheng)經(jing)驗和心(xin)(xin)得之總(zong)結(jie)。是20世紀初我國(guo)重要(yao)的(de)(de)(de)臨(lin)(lin)床綜合性名著。張氏致力溝(gou)通(tong)(tong)中(zhong)西(xi)(xi)(xi)醫(yi)(yi)學(xue)(xue)，主(zhu)張以中(zhong)醫(yi)(yi)為(wei)(wei)主(zhu)體，取西(xi)(xi)(xi)醫(yi)(yi)之長，補(bu)中(zhong)醫(yi)(yi)之短。他認為(wei)(wei)：“欲求醫(yi)(yi)學(xue)(xue)登峰造極，誠非(fei)溝(gou)通(tong)(tong)中(zhong)西(xi)(xi)(xi)醫(yi)(yi)不可。”其于溝(gou)通(tong)(tong)中(zhong)西(xi)(xi)(xi)醫(yi)(yi)的(de)(de)(de)主(zhu)導思想，主(zhu)張師古(gu)(gu)而不泥(ni)古(gu)(gu)，參西(xi)(xi)(xi)而不背中(zhong)。張氏重視(shi)基(ji)礎(chu)理論，對(dui)臟(zang)象學(xue)(xue)說和解(jie)剖生(sheng)理的(de)(de)(de)互證(zheng)尤為(wei)(wei)重視(shi)。書中(zhong)指出：腦(nao)為(wei)(wei)元神，心(xin)(xin)為(wei)(wei)識神，心(xin)(xin)力衰竭(jie)與(yu)(yu)腎不納(na)氣相(xiang)(xiang)通(tong)(tong)；腦(nao)充血與(yu)(yu)薄厥相(xiang)(xiang)近等等。在(zai)(zai)臨(lin)(lin)證(zheng)方(fang)(fang)(fang)面(mian)，講究細致的(de)(de)(de)觀(guan)察(cha)和記述病(bing)(bing)情，建立完整的(de)(de)(de)病(bing)(bing)歷。其于諸(zhu)病(bing)(bing)治法，注重實際，勇(yong)于探(tan)索(suo)，并獨創(chuang)了(le)許多新的(de)(de)(de)治療(liao)方(fang)(fang)(fang)劑(ji)，體驗了(le)若干(gan)中(zhong)藥的(de)(de)(de)性能。對(dui)諸(zhu)如(ru)萸肉救脫，參芪利(li)尿，白礬化痰(tan)熱(re)，三七消瘡腫(zhong)，生(sheng)硫黃(huang)內(nei)服治虛寒(han)下(xia)痢，蜈蚣、蝎子(zi)定風消毒等等，均(jun)能發揚古(gu)(gu)說，擴大藥用主(zhu)治。如(ru)對(dui)調治脾胃(wei)，主(zhu)張脾陽與(yu)(yu)胃(wei)陰(yin)并重，升肝脾與(yu)(yu)降膽(dan)胃(wei)兼(jian)施，補(bu)養與(yu)(yu)開破(po)相(xiang)(xiang)結(jie)合。書中(zhong)結(jie)合中(zhong)西(xi)(xi)(xi)醫(yi)(yi)學(xue)(xue)理論和醫(yi)(yi)療(liao)實踐闡發醫(yi)(yi)理，頗多獨到的(de)(de)(de)見(jian)解(jie)。書中(zhong)載述張氏所制定的(de)(de)(de)若干(gan)有效方(fang)(fang)(fang)劑(ji)；在(zai)(zai)方(fang)(fang)(fang)藥應用方(fang)(fang)(fang)面(mian)，創(chuang)用中(zhong)西(xi)(xi)(xi)藥相(xiang)(xiang)結(jie)合的(de)(de)(de)方(fang)(fang)(fang)劑(ji)，并對(dui)石(shi)膏、生(sheng)山藥、代(dai)赭石(shi)等藥的(de)(de)(de)臨(lin)(lin)床施治，在(zai)(zai)古(gu)(gu)人基(ji)礎(chu)上有重要(yao)的(de)(de)(de)補(bu)訂、發揮。

內容介紹

《醫學(xue)衷中參西錄》為(wei)張(zhang)錫純唯(wei)一傳世的著作，其主要學(xue)術內容如下：

一、學術理論

(一)倡“衷(zhong)中參西”

清末民初，西(xi)(xi)學(xue)(xue)東漸，西(xi)(xi)醫(yi)(yi)(yi)學(xue)(xue)在我國流傳(chuan)甚快。當時(shi)，醫(yi)(yi)(yi)學(xue)(xue)界有些(xie)(xie)人崇尚西(xi)(xi)學(xue)(xue)，輕視中(zhong)醫(yi)(yi)(yi)，有些(xie)(xie)中(zhong)醫(yi)(yi)(yi)則一味排(pai)斥西(xi)(xi)醫(yi)(yi)(yi)，因循守舊。張氏(shi)則主張以中(zhong)醫(yi)(yi)(yi)為本體，擷(xie)取西(xi)(xi)醫(yi)(yi)(yi)之(zhi)長補中(zhong)醫(yi)(yi)(yi)之(zhi)短，倡導(dao)“衷(zhong)中(zhong)參(can)西(xi)(xi)”，并從理論、實踐方面進行(xing)了(le)嘗試，《醫(yi)(yi)(yi)學(xue)(xue)衷(zhong)中(zhong)參(can)西(xi)(xi)錄》的(de)書名就鮮明地表明了(le)張氏(shi)的(de)學(xue)(xue)術主張。

在生理(li)、病(bing)理(li)方面，張氏于(yu)《醫(yi)學衷中(zhong)(zhong)(zhong)參西(xi)(xi)錄》中(zhong)(zhong)(zhong)有許多溝通中(zhong)(zhong)(zhong)西(xi)(xi)醫(yi)學的(de)新見(jian)(jian)解，如：“中(zhong)(zhong)(zhong)醫(yi)謂人(ren)(ren)之(zhi)(zhi)(zhi)(zhi)神明(ming)在心(xin)，西(xi)(xi)說(shuo)謂人(ren)(ren)之(zhi)(zhi)(zhi)(zhi)神明(ming)在腦，及觀(guan)《內經》，皆涵蓋(gai)其(qi)中(zhong)(zhong)(zhong)也”。《素問·脈(mo)要精(jing)微論(lun)》中(zhong)(zhong)(zhong)指出“頭者(zhe)精(jing)明(ming)之(zhi)(zhi)(zhi)(zhi)府”，說(shuo)明(ming)神明(ming)之(zhi)(zhi)(zhi)(zhi)體在腦，所謂“心(xin)主(zhu)神明(ming)”，只不(bu)(bu)過(guo)是言神明(ming)之(zhi)(zhi)(zhi)(zhi)用出于(yu)心(xin)，由(you)此可見(jian)(jian)，中(zhong)(zhong)(zhong)西(xi)(xi)之(zhi)(zhi)(zhi)(zhi)說(shuo)雖(sui)然不(bu)(bu)同，但(dan)理(li)可匯通。另如，認為吐衄(nv)的(de)原因是由(you)于(yu)陽(yang)明(ming)胃(wei)腑(fu)氣機上(shang)逆(ni)，胃(wei)中(zhong)(zhong)(zhong)之(zhi)(zhi)(zhi)(zhi)血(xue)(xue)亦(yi)恒隨之(zhi)(zhi)(zhi)(zhi)上(shang)逆(ni)。“其(qi)上(shang)逆(ni)之(zhi)(zhi)(zhi)(zhi)極，可將胃(wei)壁之(zhi)(zhi)(zhi)(zhi)膜排(pai)擠破裂，而(er)成嘔血(xue)(xue)之(zhi)(zhi)(zhi)(zhi)證；或(huo)(huo)(huo)循陽(yang)明(ming)之(zhi)(zhi)(zhi)(zhi)經絡上(shang)行，而(er)成衄(nv)血(xue)(xue)之(zhi)(zhi)(zhi)(zhi)證”，此即《素問·厥(jue)論(lun)》中(zhong)(zhong)(zhong)所言“陽(yang)明(ming)厥(jue)逆(ni)衄(nv)嘔血(xue)(xue)”。其(qi)論(lun)衄(nv)血(xue)(xue)治(zhi)療，主(zhu)張不(bu)(bu)論(lun)“或(huo)(huo)(huo)虛(xu)或(huo)(huo)(huo)實，或(huo)(huo)(huo)涼或(huo)(huo)(huo)熱，治(zhi)之(zhi)(zhi)(zhi)(zhi)者(zhe)皆當(dang)以(yi)降胃(wei)之(zhi)(zhi)(zhi)(zhi)品(pin)為主(zhu)”，并制(zhi)平胃(wei)寒(han)降湯(tang)、滋陰清降湯(tang)等，皆主(zhu)以(yi)生赭石通降胃(wei)氣，并輔(fu)以(yi)白芍、龍、牡(mu)等養(yang)陰鎮(zhen)潛(qian)之(zhi)(zhi)(zhi)(zhi)品(pin)，提高了本病(bing)的(de)療效。

在用(yong)藥(yao)上，張(zhang)氏(shi)認為，西藥(yao)治在局(ju)部，是(shi)重(zhong)在病之(zhi)(zhi)(zhi)(zhi)(zhi)標也(ye)；中(zhong)藥(yao)用(yong)藥(yao)求原因(yin)，是(shi)重(zhong)在病之(zhi)(zhi)(zhi)(zhi)(zhi)本也(ye)。究之(zhi)(zhi)(zhi)(zhi)(zhi)，標本原宜兼顧，若(ruo)遇難治之(zhi)(zhi)(zhi)(zhi)(zhi)證，以(yi)西藥(yao)治其標，中(zhong)藥(yao)治其本，則奏效必速，提(ti)出中(zhong)藥(yao)、西藥(yao)不應(ying)互相抵牾，而(er)應(ying)相濟為用(yong)。張(zhang)氏(shi)臨床治療(liao)癲癇，據中(zhong)醫“諸(zhu)風(feng)掉眩，皆屬于肝”理論，用(yong)西藥(yao)臭(chou)素(su)、抱水諸(zhu)品(pin)及鉛硫(liu)朱砂(sha)丸麻(ma)醉鎮(zhen)靜治標，而(er)后則主張(zhang)徐以(yi)健脾、利痰、祛風(feng)、清火之(zhi)(zhi)(zhi)(zhi)(zhi)藥(yao)以(yi)鏟(chan)除其病根(gen)。治療(liao)大氣下(xia)陷，下(xia)血(xue)(xue)不止(zhi)之(zhi)(zhi)(zhi)(zhi)(zhi)血(xue)(xue)崩(beng)癥(zheng)，煎服(fu)生(sheng)黃芪(qi)、白(bai)術、龍骨、牡蠣(li)、柴胡等升舉固(gu)澀之(zhi)(zhi)(zhi)(zhi)(zhi)品(pin)時，加(jia)服(fu)西藥(yao)麥角，以(yi)加(jia)強收(shou)縮止(zhi)血(xue)(xue)功(gong)效。張(zhang)氏(shi)在辨(bian)證施治運用(yong)中(zhong)醫方藥(yao)的同時，加(jia)服(fu)西藥(yao)，開中(zhong)西藥(yao)聯合應(ying)用(yong)之(zhi)(zhi)(zhi)(zhi)(zhi)先河。

(二)大氣下陷論

繼(ji)喻(yu)昌“胸(xiong)中大氣說”之后，張氏在《醫學衷中參西錄》中對大氣的(de)認(ren)識(shi)和(he)治療作了(le)進(jin)一(yi)步的(de)闡(chan)發。

張氏認為(wei)(wei)，大(da)氣(qi)(qi)(qi)即《內經》所言之(zhi)宗氣(qi)(qi)(qi)，它(ta)“以(yi)元氣(qi)(qi)(qi)為(wei)(wei)根本，以(yi)水(shui)(shui)谷(gu)之(zhi)氣(qi)(qi)(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)能撐持(chi)全身，為(wei)(wei)諸氣(qi)(qi)(qi)之(zhi)綱領，包舉(ju)肺外，司呼吸(xi)之(zhi)樞(shu)機，故(gu)鄭(zheng)而重之(zhi)曰大(da)氣(qi)(qi)(qi)。”即大(da)氣(qi)(qi)(qi)是搏聚于胸中，包舉(ju)于肺外的(de)大(da)量(liang)陽氣(qi)(qi)(qi)，它(ta)源(yuan)于元氣(qi)(qi)(qi)，受水(shui)(shui)谷(gu)精微(wei)的(de)滋(zi)養，除主(zhu)司呼吸(xi)外，同時(shi)(shi)對全身產生重要影響(xiang)。此(ci)氣(qi)(qi)(qi)撐持(chi)全身，振(zhen)作精神(shen)，心(xin)及心(xin)思、腦力、百骸(hai)動作，莫(mo)不賴于此(ci)。此(ci)氣(qi)(qi)(qi)一(yi)虛，呼吸(xi)即覺不利，而時(shi)(shi)時(shi)(shi)酸懶，精神(shen)昏(hun)憒，腦力、心(xin)思為(wei)(wei)之(zhi)頓(dun)減(jian)。

大(da)氣之(zhi)病變(bian)主要是虛而陷(xian)，其(qi)病情有(you)(you)(you)(you)(you)(you)緩(huan)急之(zhi)別，急者(zhe)(zhe)(zhe)(zhe)(zhe)可引起(qi)猝死，“大(da)氣既陷(xian)，無(wu)氣包舉(ju)肺外(wai)以(yi)鼓動其(qi)闔辟之(zhi)機，則(ze)呼(hu)(hu)吸停(ting)頓，所以(yi)不(bu)病而猝死。緩(huan)者(zhe)(zhe)(zhe)(zhe)(zhe)則(ze)因大(da)氣下(xia)陷(xian)而致(zhi)呼(hu)(hu)吸不(bu)利(li)，換氣不(bu)足(zu)缺氧，全身性(xing)衰竭出(chu)現一系列(lie)表現：“有(you)(you)(you)(you)(you)(you)呼(hu)(hu)吸短氣者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)(you)(you)心中(zhong)(zhong)怔忡者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)(you)(you)淋(lin)漓大(da)汗者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)(you)(you)神昏健忘(wang)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)(you)(you)聲顫(zhan)身動者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)(you)(you)寒熱往來者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)(you)(you)胸中(zhong)(zhong)滿悶者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)(you)(you)努力呼(hu)(hu)吸似喘(chuan)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)(you)(you)咽干作渴者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)(you)(you)常常呵欠者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)(you)(you)肢體痿(wei)廢(fei)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)(you)(you)食后易饑(ji)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)(you)(you)二便不(bu)禁者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)(you)(you)癃閉(bi)身腫者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)(you)(you)(you)張口呼(hu)(hu)氣外(wai)出(chu)而氣不(bu)上達，肛(gang)門突(tu)出(chu)者(zhe)(zhe)(zhe)(zhe)(zhe)，在女子(zi)有(you)(you)(you)(you)(you)(you)下(xia)血不(bu)止，更有(you)(you)(you)(you)(you)(you)經水逆行者(zhe)(zhe)(zhe)(zhe)(zhe)”等等。，

以上見(jian)癥以心(xin)(xin)肺(fei)證(zheng)候為主，常兼見(jian)脾胃(wei)證(zheng)候。若(ruo)單見(jian)脾胃(wei)證(zheng)候而無心(xin)(xin)肺(fei)證(zheng)候者(zhe)，是(shi)謂中(zhong)(zhong)氣(qi)下(xia)(xia)陷(xian)(xian)(xian)。中(zhong)(zhong)氣(qi)下(xia)(xia)陷(xian)(xian)(xian)之(zhi)(zhi)(zhi)重者(zhe)，張氏(shi)認為有引(yin)起大氣(qi)下(xia)(xia)陷(xian)(xian)(xian)之(zhi)(zhi)(zhi)可能，“夫中(zhong)(zhong)氣(qi)誠有下(xia)(xia)陷(xian)(xian)(xian)之(zhi)(zhi)(zhi)時，然不若(ruo)大氣(qi)下(xia)(xia)陷(xian)(xian)(xian)之(zhi)(zhi)(zhi)尤屬危(wei)險也。間(jian)有因中(zhong)(zhong)氣(qi)下(xia)(xia)陷(xian)(xian)(xian)，泄瀉日久，或轉致大氣(qi)下(xia)(xia)陷(xian)(xian)(xian)者(zhe)”。這樣把(ba)大氣(qi)下(xia)(xia)陷(xian)(xian)(xian)與中(zhong)(zhong)氣(qi)下(xia)(xia)陷(xian)(xian)(xian)分(fen)別開來，確(que)為閱(yue)歷之(zhi)(zhi)(zhi)談。

張氏認(ren)為(wei)(wei)，引(yin)(yin)起大氣(qi)(qi)(qi)(qi)下陷(xian)的(de)原因不(bu)外(wai)勞力(li)(li)(li)過(guo)度、久病和誤(wu)藥。如(ru)“力(li)(li)(li)小(xiao)任(ren)重，或(huo)(huo)(huo)枵腹力(li)(li)(li)作，或(huo)(huo)(huo)病后氣(qi)(qi)(qi)(qi)力(li)(li)(li)未復而(er)勤于動作，或(huo)(huo)(huo)泄瀉日久，或(huo)(huo)(huo)服(fu)破氣(qi)(qi)(qi)(qi)藥太過(guo)或(huo)(huo)(huo)氣(qi)(qi)(qi)(qi)分虛極自下陷(xian)”。張氏治療(liao)大氣(qi)(qi)(qi)(qi)下陷(xian)，創制升陷(xian)湯(生黃芪、知母(mu)、桔梗(geng)、柴胡(hu)、升麻(ma))，該方以黃芪為(wei)(wei)君，升補大氣(qi)(qi)(qi)(qi)，佐知母(mu)涼潤以濟(ji)其之(zhi)(zhi)偏，柴胡(hu)引(yin)(yin)大氣(qi)(qi)(qi)(qi)之(zhi)(zhi)陷(xian)者自左上升，升麻(ma)引(yin)(yin)大氣(qi)(qi)(qi)(qi)之(zhi)(zhi)陷(xian)者自右上升，桔梗(geng)為(wei)(wei)藥中(zhong)之(zhi)(zhi)舟楫，導(dao)諸藥之(zhi)(zhi)力(li)(li)(li)上達胸中(zhong)。若氣(qi)(qi)(qi)(qi)虛極加人參或(huo)(huo)(huo)寄生，以培氣(qi)(qi)(qi)(qi)之(zhi)(zhi)本，或(huo)(huo)(huo)更加山萸肉(rou)以防氣(qi)(qi)(qi)(qi)之(zhi)(zhi)渙散，氣(qi)(qi)(qi)(qi)虛甚者酌增升麻(ma)用量。

心肺(fei)之(zhi)陽，尤賴胸中(zhong)大(da)氣為之(zhi)保護，大(da)氣一陷，則心肺(fei)陽分素虛(xu)者，至此而益虛(xu)，癥(zheng)見其(qi)人(ren)心冷(leng)，背(bei)緊，惡寒，常覺(jue)短氣等。張氏認為欲(yu)助胸中(zhong)心肺(fei)之(zhi)陽，必須先(xian)升提(ti)下(xia)陷之(zhi)大(da)氣，否則但服溫補心肺(fei)之(zhi)陽之(zhi)劑無效，制(zhi)回陽升陷湯(生黃芪、干姜、當(dang)歸身、桂(gui)枝(zhi)炭、甘草)以(yi)治(zhi)之(zhi)。

胸(xiong)中(zhong)(zhong)大氣(qi)(qi)正常(chang)，有賴于少(shao)陽、陽明之氣(qi)(qi)的升發(fa)。若(ruo)大氣(qi)(qi)下(xia)陷(xian)，升發(fa)之氣(qi)(qi)被郁，氣(qi)(qi)分郁結，經絡瘀滯，常(chang)見胸(xiong)中(zhong)(zhong)滿痛(tong)或脅下(xia)撐脹、腹痛(tong)等(deng)。對(dui)(dui)此，張氏又制(zhi)理郁升陷(xian)湯(生(sheng)黃(huang)芪、知(zhi)母、當(dang)歸(gui)身、桂(gui)枝尖、柴胡、乳香、沒藥(yao))；對(dui)(dui)脾(pi)氣(qi)(qi)虛極下(xia)陷(xian)，小便不禁者，制(zhi)理脾(pi)升陷(xian)湯(生(sheng)黃(huang)芪、白術、桑寄生(sheng)、川斷、萸肉(rou)、龍骨(gu)、牡蠣(li)、川萆薢、甘草)治之。

(三)寒溫統一，注重(zhong)清透(tou)

《醫學衷中參西錄》論溫(wen)(wen)(wen)病(bing)(bing)(bing)(bing)，主(zhu)張寒(han)溫(wen)(wen)(wen)統一，認(ren)為(wei)溫(wen)(wen)(wen)病(bing)(bing)(bing)(bing)治(zhi)法(fa)(fa)已備于傷(shang)(shang)寒(han)。如溫(wen)(wen)(wen)病(bing)(bing)(bing)(bing)初(chu)起治(zhi)宜(yi)辛(xin)涼(liang)，然辛(xin)涼(liang)之(zhi)(zhi)(zhi)(zhi)(zhi)法(fa)(fa)亦備于傷(shang)(shang)寒(han)，麻杏(xing)甘石湯(tang)“誠(cheng)為(wei)溫(wen)(wen)(wen)病(bing)(bing)(bing)(bing)初(chu)得之(zhi)(zhi)(zhi)(zhi)(zhi)的方(fang)矣”。但其外表證未解，內有蘊(yun)熱(re)即可(ke)(ke)服(fu)用(yong)。至溫(wen)(wen)(wen)病(bing)(bing)(bing)(bing)傳(chuan)經已深，清燥熱(re)之(zhi)(zhi)(zhi)(zhi)(zhi)白(bai)虎(hu)湯(tang)、白(bai)虎(hu)加人參湯(tang)，通腑(fu)之(zhi)(zhi)(zhi)(zhi)(zhi)大、小承(cheng)氣湯(tang)，開結胸之(zhi)(zhi)(zhi)(zhi)(zhi)大、小陷胸湯(tang)，治(zhi)下利之(zhi)(zhi)(zhi)(zhi)(zhi)白(bai)頭翁湯(tang)、黃(huang)芩湯(tang)，治(zhi)發(fa)黃(huang)之(zhi)(zhi)(zhi)(zhi)(zhi)茵陳桅子柏皮(pi)湯(tang)等及一切涼(liang)潤、清火、育(yu)陰、安(an)神之(zhi)(zhi)(zhi)(zhi)(zhi)劑，皆可(ke)(ke)使用(yong)。并指出(chu)寒(han)溫(wen)(wen)(wen)治(zhi)法(fa)(fa)之(zhi)(zhi)(zhi)(zhi)(zhi)別，在于“始異(yi)而終同”。所謂“始異(yi)”，即傷(shang)(shang)寒(han)發(fa)表可(ke)(ke)用(yong)溫(wen)(wen)(wen)熱(re)，溫(wen)(wen)(wen)病(bing)(bing)(bing)(bing)發(fa)表必用(yong)辛(xin)涼(liang)；謂其“終同”，即病(bing)(bing)(bing)(bing)傳(chuan)陽明之(zhi)(zhi)(zhi)(zhi)(zhi)后(hou)，不論傷(shang)(shang)寒(han)、溫(wen)(wen)(wen)病(bing)(bing)(bing)(bing)，皆宜(yi)治(zhi)以寒(han)涼(liang)，而大忌(ji)溫(wen)(wen)(wen)熱(re)。

張(zhang)氏臨證將溫(wen)(wen)病(bing)分為風溫(wen)(wen)、春(chun)溫(wen)(wen)、濕(shi)溫(wen)(wen)三類。認為三類溫(wen)(wen)病(bing)雖見癥不(bu)同，其本質皆緣(yuan)郁(yu)(yu)熱(re)。“大凡病(bing)溫(wen)(wen)之(zhi)(zhi)人，多系內有蘊(yun)熱(re)，至春(chun)陽(yang)萌動之(zhi)(zhi)時(shi)，又薄受(shou)外感拘束，其熱(re)即陡發而成溫(wen)(wen)”。他(ta)遵循“火郁(yu)(yu)發之(zhi)(zhi)”之(zhi)(zhi)旨，治(zhi)(zhi)療上(shang)主(zhu)張(zhang)宣散郁(yu)(yu)結，疏(shu)通(tong)氣機(ji)，透(tou)邪(xie)外達。反(fan)對徒執寒涼，只清(qing)(qing)不(bu)透(tou)，使邪(xie)無由出。并自擬清(qing)(qing)解湯(tang)、涼解湯(tang)、寒解湯(tang)三方，徑(jing)以(yi)石(shi)膏(gao)清(qing)(qing)其內熱(re)，又選用薄荷(he)、連(lian)翹(qiao)、蟬蛻發表，且“引胃中化而欲(yu)散之(zhi)(zhi)熱(re)，仍還太(tai)陽(yang)作汗而解”。正是基于對溫(wen)(wen)病(bing)“郁(yu)(yu)熱(re)”這一本質的深刻認識，初(chu)起治(zhi)(zhi)療即立(li)足于清(qing)(qing)透(tou)。

溫病(bing)入里(li)化(hua)熱，抑(yi)或傷(shang)(shang)寒、中(zhong)(zhong)風(feng)入里(li)化(hua)熱，是陽(yang)明熱盛(sheng)之(zhi)(zhi)(zhi)象，張氏皆以寒涼清熱為主，不(bu)(bu)復有(you)(you)傷(shang)(shang)寒、中(zhong)(zhong)風(feng)、溫病(bing)之(zhi)(zhi)(zhi)分，投以白虎湯靈(ling)活加減化(hua)裁(cai)。臨證(zheng)使用白虎湯，張氏有(you)(you)著(zhu)豐富的經(jing)驗(yan)，認(ren)為白虎湯之(zhi)(zhi)(zhi)“四大”典型癥狀中(zhong)(zhong)，唯脈洪(hong)(hong)為必(bi)(bi)見(jian)(jian)之(zhi)(zhi)(zhi)癥。只要(yao)見(jian)(jian)脈洪(hong)(hong)大，又有(you)(you)陽(yang)明熱盛(sheng)之(zhi)(zhi)(zhi)一二癥，則無論(lun)外感內傷(shang)(shang)，皆可用之(zhi)(zhi)(zhi)，不(bu)(bu)必(bi)(bi)拘(ju)泥于古(gu)人之(zhi)(zhi)(zhi)說。

陽(yang)(yang)明腑(fu)實用三承氣(qi)湯(tang)(tang)，此乃大法(fa)，然(ran)張氏(shi)認(ren)為承氣(qi)力猛，倘或審證不(bu)確，即足(zu)誤事。于(yu)是據(ju)其(qi)三十余年臨證經驗，強(qiang)調“凡(fan)遇陽(yang)(yang)明應下證，亦先投(tou)以(yi)(yi)白(bai)(bai)虎(hu)(hu)湯(tang)(tang)一二劑，更改其(qi)服(fu)法(fa)，將(jiang)石(shi)膏為末而不(bu)入(ru)(ru)煎，以(yi)(yi)藥湯(tang)(tang)送(song)服(fu)之(zhi)”，因屢用此方奏(zou)效(xiao)，遂名之(zhi)曰白(bai)(bai)虎(hu)(hu)承氣(qi)湯(tang)(tang)。對于(yu)溫熱病(bing)神(shen)昏譫語，張氏(shi)遵從(cong)陸九芝“胃(wei)熱之(zhi)甚(shen)，神(shen)為之(zhi)昏，從(cong)來神(shen)昏之(zhi)病(bing)，皆屬胃(wei)家(jia)”之(zhi)說，將(jiang)熱病(bing)神(shen)昏分(fen)為虛實兩類。其(qi)脈(mo)象洪而有(you)力，按(an)之(zhi)甚(shen)實者，可按(an)陽(yang)(yang)明胃(wei)實治之(zhi)，投(tou)以(yi)(yi)大劑白(bai)(bai)虎(hu)(hu)湯(tang)(tang)；若脈(mo)兼弦(xian)、兼數，或重按(an)仍甚(shen)實者，治宜白(bai)(bai)虎(hu)(hu)加(jia)人參(can)湯(tang)(tang)；對邪(xie)入(ru)(ru)陽(yang)(yang)明，淫熱于(yu)肝(gan)，致肝(gan)風(feng)內動者，以(yi)(yi)白(bai)(bai)虎(hu)(hu)撤其(qi)陽(yang)(yang)明之(zhi)熱，生(sheng)龍骨、生(sheng)牡蠣以(yi)(yi)鎮肝(gan)熄風(feng)。

張氏治(zhi)療溫病(bing)不僅擅(shan)用白(bai)虎(hu)，而且依據(ju)病(bing)證不同，化裁組成了眾(zhong)多新方，如石膏(gao)粳米(mi)湯(tang)、鎮逆(ni)白(bai)虎(hu)湯(tang)、通變(bian)白(bai)虎(hu)加人參(can)湯(tang)等，皆由白(bai)虎(hu)湯(tang)衍化而來(lai)。

二、治療經驗

張氏一生勤于臨(lin)證(zheng)(zheng)，《醫學衷中參(can)西錄(lu)》記載了他豐(feng)富(fu)的(de)臨(lin)床經(jing)驗(yan)，其中尤以(yi)論治中風、脫(tuo)證(zheng)(zheng)等最具(ju)特色(se)。

(一)分別中風論治

中(zhong)風(feng)有真中(zhong)、類中(zhong)之別。張氏(shi)認為(wei)真中(zhong)者極少(shao)，因(yin)而(er)著(zhu)意(yi)對類中(zhong)進(jin)行(xing)研究、發(fa)揮。指出類中(zhong)風(feng)亦(yi)即(ji)內中(zhong)風(feng)，此“風(feng)自內生，非風(feng)自外來也”，其治療分充血、貧血，以虛實論治。

1、腦充血治療

張氏(shi)根(gen)據“血(xue)(xue)菀于上，使(shi)人(ren)薄(bo)厥”的理論，認為腦(nao)充(chong)血(xue)(xue)即《內經》中所言的煎(jian)厥、薄(bo)厥、大厥。其病位在“肝”，陰(yin)虛陽(yang)亢、上實下虛、臟(zang)腑之(zhi)氣升發太過或失之(zhi)下行(xing)(xing)，血(xue)(xue)隨氣逆為主要(yao)病機。即“人(ren)之(zhi)血(xue)(xue)隨氣行(xing)(xing)，氣上升不已，血(xue)(xue)即隨之(zhi)上升不已，以(yi)致(zhi)腦(nao)中血(xue)(xue)管充(chong)血(xue)(xue)過甚”(《醫學衷中參(can)西錄·醫案·腦(nao)充(chong)血(xue)(xue)門》)，有礙神經，以(yi)致(zhi)語言肢體謇澀不利，口眼歪(wai)斜等(deng)等(deng)。

根據腦充(chong)血之(zhi)(zhi)(zhi)“肝(gan)(gan)(gan)(gan)(gan)木失(shi)和(he)，肺氣(qi)(qi)(qi)不(bu)降，腎(shen)氣(qi)(qi)(qi)不(bu)攝，沖氣(qi)(qi)(qi)、胃氣(qi)(qi)(qi)又(you)復上(shang)(shang)逆，臟(zang)(zang)腑(fu)之(zhi)(zhi)(zhi)氣(qi)(qi)(qi)化皆上(shang)(shang)升太過(guo)”之(zhi)(zhi)(zhi)病(bing)機，張氏(shi)提出治療本(ben)病(bing)應“清(qing)其(qi)臟(zang)(zang)腑(fu)之(zhi)(zhi)(zhi)熱，滋(zi)其(qi)臟(zang)(zang)腑(fu)之(zhi)(zhi)(zhi)陰，更(geng)降其(qi)臟(zang)(zang)腑(fu)之(zhi)(zhi)(zhi)氣(qi)(qi)(qi)，引腦部所充(chong)之(zhi)(zhi)(zhi)血下行”的(de)“鎮(zhen)(zhen)(zhen)肝(gan)(gan)(gan)(gan)(gan)熄(xi)風(feng)、引血下行”的(de)原(yuan)則，并創(chuang)制(zhi)鎮(zhen)(zhen)(zhen)肝(gan)(gan)(gan)(gan)(gan)熄(xi)風(feng)湯(懷(huai)牛膝(xi)、生(sheng)赭石、生(sheng)杭(hang)芍(shao)、天冬(dong)、生(sheng)龍骨(gu)、生(sheng)牡蠣、生(sheng)龜板(ban)、玄參、川楝子、生(sheng)麥(mai)芽、茵(yin)陳、甘草)作為治療本(ben)病(bing)的(de)主方。方中赭石降胃，平肝(gan)(gan)(gan)(gan)(gan)鎮(zhen)(zhen)(zhen)沖，下行通(tong)便；牛膝(xi)善引上(shang)(shang)部之(zhi)(zhi)(zhi)血下行，二(er)藥(yao)(yao)合用(yong)，相(xiang)輔(fu)相(xiang)成；玄參、天冬(dong)、白芍(shao)滋(zi)陰退熱；龍骨(gu)、牡蠣、龜板(ban)、芍(shao)藥(yao)(yao)斂肝(gan)(gan)(gan)(gan)(gan)火、鎮(zhen)(zhen)(zhen)熄(xi)肝(gan)(gan)(gan)(gan)(gan)風(feng)，以(yi)緩(huan)其(qi)肝(gan)(gan)(gan)(gan)(gan)氣(qi)(qi)(qi)上(shang)(shang)升之(zhi)(zhi)(zhi)勢；玄參、天冬(dong)清(qing)肺制(zhi)肝(gan)(gan)(gan)(gan)(gan)；山(shan)藥(yao)(yao)、甘草和(he)胃緩(huan)肝(gan)(gan)(gan)(gan)(gan)；茵(yin)陳為“青(qing)蒿之(zhi)(zhi)(zhi)嫩者，稟少陽(yang)初生(sheng)之(zhi)(zhi)(zhi)氣(qi)(qi)(qi)，與肝(gan)(gan)(gan)(gan)(gan)木同氣(qi)(qi)(qi)相(xiang)求，最能將(jiang)順肝(gan)(gan)(gan)(gan)(gan)木之(zhi)(zhi)(zhi)性(xing)，且(qie)又(you)善瀉肝(gan)(gan)(gan)(gan)(gan)熱”，為清(qing)涼腦部之(zhi)(zhi)(zhi)涼藥(yao)(yao)也；麥(mai)芽“善助肝(gan)(gan)(gan)(gan)(gan)木疏泄(xie)以(yi)行腎(shen)氣(qi)(qi)(qi)”；川楝子善引肝(gan)(gan)(gan)(gan)(gan)氣(qi)(qi)(qi)下達，又(you)能折其(qi)更(geng)動(dong)之(zhi)(zhi)(zhi)力。本(ben)方標本(ben)兼治，鎮(zhen)(zhen)(zhen)潛共用(yong)，引涵兼施(shi)，直中病(bing)之(zhi)(zhi)(zhi)肯(ken)綮(qi)，確有(you)獨到(dao)之(zhi)(zhi)(zhi)處(chu)。

此外，張氏還參照西醫病理，闡述了腦(nao)(nao)充血(xue)(xue)(xue)(xue)、腦(nao)(nao)溢血(xue)(xue)(xue)(xue)、腦(nao)(nao)出(chu)血(xue)(xue)(xue)(xue)之(zhi)證型及用(yong)藥(yao)(yao)的(de)不同。對(dui)腦(nao)(nao)部血(xue)(xue)(xue)(xue)管中之(zhi)血(xue)(xue)(xue)(xue)滲(shen)出(chu)者(zhe)，他(ta)在友(you)人“腦(nao)(nao)充血(xue)(xue)(xue)(xue)證，宜于(yu)(yu)引(yin)血(xue)(xue)(xue)(xue)下行藥(yao)(yao)中加(jia)破血(xue)(xue)(xue)(xue)之(zhi)藥(yao)(yao)以(yi)治之(zhi)”的(de)啟發下，指出(chu)對(dui)其身體(ti)壯實者(zhe)，可(ke)酌加(jia)大(da)黃(huang)數錢以(yi)逐瘀；其身形脈(mo)象不甚壯實者(zhe)，加(jia)桃仁、丹參等(deng)化瘀。并明(ming)確提出(chu)“腦(nao)(nao)充血(xue)(xue)(xue)(xue)當通(tong)大(da)便為(wei)要務”。對(dui)腦(nao)(nao)充血(xue)(xue)(xue)(xue)后期(qi)脈(mo)象柔和而肢體(ti)痿(wei)廢者(zhe)，主張“少用(yong)黃(huang)芪(qi)助活血(xue)(xue)(xue)(xue)之(zhi)品以(yi)通(tong)絡”，但(dan)應謹(jin)慎從事。而對(dui)于(yu)(yu)“血(xue)(xue)(xue)(xue)菀(yu)于(yu)(yu)上(shang)”的(de)腦(nao)(nao)充血(xue)(xue)(xue)(xue)者(zhe)，因(yin)黃(huang)芪(qi)之(zhi)情，補而兼(jian)升，氣升則血(xue)(xue)(xue)(xue)必(bi)隨之(zhi)升，故病初(chu)應忌用(yong)黃(huang)芪(qi)，誤用(yong)則兇危立見。其辨證之(zhi)嚴謹(jin)，用(yong)藥(yao)(yao)之(zhi)精(jing)確，可(ke)見一斑。

2、腦貧血治療

與腦(nao)(nao)充血(xue)(xue)證(zheng)相反(fan)，張(zhang)氏認(ren)為腦(nao)(nao)貧(pin)(pin)血(xue)(xue)證(zheng)則(ze)為血(xue)(xue)之上(shang)注于(yu)腦(nao)(nao)過少(shao)，無以養其腦(nao)(nao)髓神(shen)經(jing)(jing)，致使腦(nao)(nao)神(shen)經(jing)(jing)失其所(suo)司。而血(xue)(xue)之上(shang)注過少(shao)，實由(you)“宗氣虛寒，不能助血(xue)(xue)上(shang)升(sheng)川”。故治療(liao)腦(nao)(nao)貧(pin)(pin)血(xue)(xue)證(zheng)，主張(zhang)“應峻補(bu)其胸中大(da)氣”，自擬當歸補(bu)血(xue)(xue)湯(tang)益氣溫(wen)陽、補(bu)血(xue)(xue)活血(xue)(xue)，治療(liao)中風(feng)脈(mo)象(xiang)遲弱(ruo)，身(shen)軟，肢(zhi)(zhi)體(ti)漸覺不利，或頭重(zhong)目眩(xuan)，或神(shen)昏健(jian)忘，甚或昏仆，移時蘇醒(xing)致成偏(pian)枯者。方中主以黃芪升(sheng)補(bu)胸中大(da)氣，使血(xue)(xue)隨(sui)氣升(sheng)，上(shang)達腦(nao)(nao)中；用(yong)當歸、龍眼肉、鹿(lu)角膠養血(xue)(xue)生(sheng)髓；丹參、乳、沒開血(xue)(xue)痹，化瘀滯；甘(gan)松(song)助心(xin)房運行(xing)有(you)力(li)，以多(duo)輸血(xue)(xue)于(yu)腦(nao)(nao)，且又為調養神(shen)經(jing)(jing)之品。對于(yu)腦(nao)(nao)貧(pin)(pin)血(xue)(xue)肢(zhi)(zhi)體(ti)痿廢或偏(pian)枯，脈(mo)象(xiang)極微細無力(li)者，又擬干頹湯(tang)、補(bu)腦(nao)(nao)振痿湯(tang)治療(liao)。并指出肢(zhi)(zhi)體(ti)偏(pian)廢，服(fu)藥久(jiu)不效者，應著重(zhong)補(bu)腎通(tong)絡(luo)，多(duo)選用(yong)胡桃肉、地龍、馬錢子等。

(二)重(zhong)視沖氣為病，善用鎮沖降逆

沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)脈(mo)為(wei)奇經(jing)八脈(mo)之(zhi)(zhi)一(yi)，張氏論(lun)病(bing)極(ji)重視沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)，指(zhi)出“沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)上沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)之(zhi)(zhi)病(bing)甚多(duo)，而(er)醫者(zhe)識(shi)其(qi)(qi)(qi)(qi)病(bing)者(zhe)甚少。即(ji)或(huo)能識(shi)此病(bing)，亦(yi)多(duo)不能洞悉(xi)其(qi)(qi)(qi)(qi)病(bing)因(yin)”。因(yin)而(er)，對沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)的生理(li)，尤其(qi)(qi)(qi)(qi)是沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)上沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)的病(bing)因(yin)、病(bing)理(li)、病(bing)脈(mo)、治法都作了詳細(xi)闡述，自(zi)成一(yi)家之(zhi)(zhi)言(yan)。其(qi)(qi)(qi)(qi)述沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)脈(mo)，、兼(jian)采(cai)《內》《難》之(zhi)(zhi)說(shuo)，認(ren)為(wei)其(qi)(qi)(qi)(qi)“在胞(bao)室之(zhi)(zhi)兩(liang)旁(pang)，與任脈(mo)相連(lian)，為(wei)腎(shen)臟之(zhi)(zhi)輔弼(bi)，氣(qi)(qi)化相通……上系(xi)原隸陽明胃(wei)腑”，并(bing)認(ren)為(wei)“沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)上沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)之(zhi)(zhi)證，固由于腎(shen)臟之(zhi)(zhi)虛(xu)，亦(yi)多(duo)由于肝氣(qi)(qi)恣(zi)橫，素性多(duo)怒(nu)之(zhi)(zhi)人，其(qi)(qi)(qi)(qi)肝氣(qi)(qi)之(zhi)(zhi)暴發，更助(zhu)沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)胃(wei)之(zhi)(zhi)氣(qi)(qi)上逆”。即(ji)腎(shen)虛(xu)無(wu)以涵木，不能收(shou)斂沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)，沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)上行，肝氣(qi)(qi)橫逆，胃(wei)氣(qi)(qi)上逆而(er)呈(cheng)上沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)之(zhi)(zhi)弊。張氏描述的沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)上沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)證，除(chu)自(zi)覺有氣(qi)(qi)自(zi)下上沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)，脈(mo)多(duo)弦硬而(er)長外，主要(yao)表現有胃(wei)脘或(huo)腹中(zhong)滿(man)悶，噦氣(qi)(qi)，呃逆連(lian)連(lian)，嘔吐不止，或(huo)見吐血、衄血等(deng)(deng)胃(wei)氣(qi)(qi)上逆不降見癥；或(huo)兩(liang)脅痛脹，頭目(mu)眩暈，甚而(er)氣(qi)(qi)火挾痰上沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)，發生突然昏仆(pu)等(deng)(deng)；或(huo)為(wei)胸滿(man)窒塞，喘(chuan)息大作。其(qi)(qi)(qi)(qi)治療(liao)，主張以斂沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)鎮(zhen)沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)為(wei)主，降胃(wei)平肝為(wei)佐，獨(du)創參赭鎮(zhen)氣(qi)(qi)湯(tang)、鎮(zhen)沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)降胃(wei)湯(tang)等(deng)(deng)鎮(zhen)沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)諸方。其(qi)(qi)(qi)(qi)組方特色，一(yi)為(wei)善(shan)用鎮(zhen)沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)降逆之(zhi)(zhi)品(pin)，如(ru)赭石、龍(long)、牡(mu)等(deng)(deng)；一(yi)為(wei)善(shan)用補虛(xu)固澀之(zhi)(zhi)品(pin)，如(ru)山萸肉、山藥、白(bai)芍、芡實等(deng)(deng)，攻中(zhong)有補，降斂結合，用之(zhi)(zhi)臨床，確有良效。其(qi)(qi)(qi)(qi)沖(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)學說(shuo)為(wei)中(zhong)醫臨床治療(liao)雜病(bing)又辟(pi)新徑。

(三)脫(tuo)分上下(xia)內外(wai)，治(zhi)脫(tuo)重視肝(gan)虛

張氏認(ren)為(wei)脫(tuo)(tuo)(tuo)(tuo)雖有上(shang)(shang)(shang)、下、內、外之(zhi)(zhi)(zhi)別，概由肝(gan)(gan)虛(xu)(xu)(xu)，其云(yun)：“凡人(ren)元(yuan)(yuan)氣(qi)(qi)(qi)(qi)之(zhi)(zhi)(zhi)脫(tuo)(tuo)(tuo)(tuo)，皆(jie)脫(tuo)(tuo)(tuo)(tuo)在肝(gan)(gan)”。他根據肝(gan)(gan)主疏泄(xie)、調(diao)暢氣(qi)(qi)(qi)(qi)機的(de)功能(neng)，認(ren)為(wei)元(yuan)(yuan)氣(qi)(qi)(qi)(qi)的(de)運行和(he)胃氣(qi)(qi)(qi)(qi)的(de)布化，全賴于肝(gan)(gan)臟正常(chang)的(de)疏泄(xie)功能(neng)。倘肝(gan)(gan)虛(xu)(xu)(xu)則損泄(xie)元(yuan)(yuan)氣(qi)(qi)(qi)(qi)，耗散腎氣(qi)(qi)(qi)(qi)，而為(wei)上(shang)(shang)(shang)脫(tuo)(tuo)(tuo)(tuo)或下脫(tuo)(tuo)(tuo)(tuo)。“蓋元(yuan)(yuan)氣(qi)(qi)(qi)(qi)上(shang)(shang)(shang)脫(tuo)(tuo)(tuo)(tuo)由于肝(gan)(gan)，其下脫(tuo)(tuo)(tuo)(tuo)亦由于肝(gan)(gan)。誠以(yi)(yi)肝(gan)(gan)能(neng)為(wei)腎行氣(qi)(qi)(qi)(qi)，即能(neng)瀉(xie)元(yuan)(yuan)氣(qi)(qi)(qi)(qi)自下出也”。(《醫(yi)(yi)學衷中(zhong)參(can)西錄·醫(yi)(yi)案·霍亂門(men)》)上(shang)(shang)(shang)脫(tuo)(tuo)(tuo)(tuo)之(zhi)(zhi)(zhi)證(zheng)，“喘逆迫促，脈(mo)(mo)若水上(shang)(shang)(shang)浮麻(ma)”，張氏制參(can)赭鎮(zhen)氣(qi)(qi)(qi)(qi)湯救之(zhi)(zhi)(zhi)。方中(zhong)以(yi)(yi)人(ren)參(can)補虛(xu)(xu)(xu)極之(zhi)(zhi)(zhi)諸(zhu)氣(qi)(qi)(qi)(qi)，借“赭石下行之(zhi)(zhi)(zhi)力，挽回將脫(tuo)(tuo)(tuo)(tuo)之(zhi)(zhi)(zhi)元(yuan)(yuan)氣(qi)(qi)(qi)(qi)”；蘇(su)子助赭石降氣(qi)(qi)(qi)(qi)；生(sheng)(sheng)山藥(yao)、生(sheng)(sheng)白(bai)芍滋補肝(gan)(gan)胃之(zhi)(zhi)(zhi)陰(yin)，以(yi)(yi)守持元(yuan)(yuan)氣(qi)(qi)(qi)(qi)；山萸肉、生(sheng)(sheng)芡實(shi)、生(sheng)(sheng)龍骨、生(sheng)(sheng)牡蠣(li)酸斂收澀，固(gu)攝元(yuan)(yuan)氣(qi)(qi)(qi)(qi)。下脫(tuo)(tuo)(tuo)(tuo)，如“日夜(ye)吐瀉(xie)不已，脈(mo)(mo)沉細欲無，虛(xu)(xu)(xu)極將脫(tuo)(tuo)(tuo)(tuo)者，為(wei)至危之(zhi)(zhi)(zhi)候”，張氏以(yi)(yi)急救回陽(yang)(yang)(yang)湯救之(zhi)(zhi)(zhi)，方用人(ren)參(can)以(yi)(yi)回陽(yang)(yang)(yang)；山藥(yao)、芍藥(yao)滋陰(yin)；重用山萸肉斂肝(gan)(gan)固(gu)脫(tuo)(tuo)(tuo)(tuo)。上(shang)(shang)(shang)下兩脫(tuo)(tuo)(tuo)(tuo)兼(jian)見者，挽陰(yin)回陽(yang)(yang)(yang)，以(yi)(yi)“既濟(ji)湯”酸斂固(gu)澀。

除元氣上(shang)脫(tuo)(tuo)、下脫(tuo)(tuo)之(zhi)(zhi)外，又(you)有所(suo)謂外脫(tuo)(tuo)、內(nei)脫(tuo)(tuo)。外脫(tuo)(tuo)者，癥見周(zhou)身(shen)汗出不(bu)(bu)止，或(huo)“目睛上(shang)竄(cuan)，或(huo)喘(chuan)逆，或(huo)怔(zheng)忡，或(huo)氣虛(xu)(xu)不(bu)(bu)足以息(xi)”，張氏認(ren)為此(ci)(ci)乃“肝(gan)膽虛(xu)(xu)極而元氣欲(yu)脫(tuo)(tuo)也(ye)”。即肝(gan)陰(yin)過(guo)虛(xu)(xu)，肝(gan)風萌(meng)動(dong)，元氣欲(yu)脫(tuo)(tuo)，用來復湯治之(zhi)(zhi)。內(nei)脫(tuo)(tuo)，如“胸中大氣下陷(xian)，氣短不(bu)(bu)足以息(xi)，或(huo)努力呼吸，有似乎喘(chuan)，或(huo)氣息(xi)將停(ting)，危(wei)在頃刻……其脈象沉(chen)遲微弱，關前尤甚；其劇者，或(huo)六脈不(bu)(bu)全，或(huo)參伍(wu)不(bu)(bu)調”，此(ci)(ci)系中氣自內(nei)而陷(xian)的內(nei)脫(tuo)(tuo)證，張氏以“升陷(xian)湯”升補下陷(xian)之(zhi)(zhi)氣，再加山萸肉收斂氣分(fen)之(zhi)(zhi)耗散，使升者不(bu)(bu)至復陷(xian)，共挽中氣下陷(xian)所(suo)致之(zhi)(zhi)內(nei)脫(tuo)(tuo)。

從上述救(jiu)(jiu)脫方可見，張氏救(jiu)(jiu)脫善用(yong)山(shan)萸(yu)肉(rou)。他(ta)認為(wei)山(shan)英肉(rou)味酸性(xing)溫，固(gu)澀(se)滑脫，通利(li)九竅(qiao)，流通血(xue)脈，為(wei)補肝之妙藥(yao)，其(qi)救(jiu)(jiu)脫之功，較參、術、芪更勝。“蓋萸(yu)肉(rou)之性(xing)，不獨補肝也，凡人(ren)身(shen)之陰陽(yang)(yang)，氣血(xue)將散者，皆能斂(lian)(lian)之，故救(jiu)(jiu)脫之藥(yao)，當以萸(yu)肉(rou)為(wei)第一”。常用(yong)萸(yu)肉(rou)治(zhi)療各種虛脫危證，或(huo)配以生龍骨、牡蠣斂(lian)(lian)汗；或(huo)配人(ren)參、附子、山(shan)藥(yao)、炙甘草(cao)益氣回陽(yang)(yang)固(gu)脫；或(huo)配當歸(gui)、熟地填(tian)補精血(xue)等。其(qi)論脫證病機及治(zhi)法用(yong)藥(yao)，別(bie)開生面，對后人(ren)啟迪尤深。

(四)遣藥制方心得

張氏(shi)制(zhi)方用藥頗有(you)獨到經(jing)驗，通性味，善配伍，別具匠(jiang)心。具體表現在以下幾個方面。

1、精研(yan)藥物，頗多新見(jian)

張(zhang)氏認為學醫的(de)(de)第一層(ceng)功(gong)夫即是識藥(yao)(yao)(yao)性，其對藥(yao)(yao)(yao)性的(de)(de)理解(jie)，于諸(zhu)家本草學之外，頗多(duo)新見。《醫學衷(zhong)中(zhong)參西錄》書中(zhong)專列《藥(yao)(yao)(yao)物(wu)(wu)》一章，對常用的(de)(de)79種藥(yao)(yao)(yao)物(wu)(wu)詳加解(jie)釋，闡述了張(zhang)氏對藥(yao)(yao)(yao)物(wu)(wu)的(de)(de)獨到認識與(yu)經驗。其中(zhong)他研(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(qi)、黨(dang)參、乳香(xiang)、沒藥(yao)(yao)(yao)、三(san)棱(leng)、水蛭、牛膝(xi)、龍(long)骨、牡(mu)蠣等。

例如，他廣泛應用(yong)(yong)大劑量石(shi)膏治療外感熱性病屢收(shou)良效(xiao)(xiao)(xiao)，認為并無(wu)(wu)損傷脾(pi)(pi)胃(wei)之(zhi)(zhi)弊(bi)，且(qie)隨著熱退(tui)病愈而(er)(er)飲食倍(bei)增，為清解大熱之(zhi)(zhi)特效(xiao)(xiao)(xiao)藥(yao)。善(shan)用(yong)(yong)三(san)(san)棱、莪(e)術，認為二(er)藥(yao)善(shan)破血(xue)(xue)、調氣(qi)(qi)(qi)(qi)，化(hua)瘀(yu)(yu)(yu)(yu)(yu)則三(san)(san)棱優于(yu)莪(e)術，理氣(qi)(qi)(qi)(qi)則莪(e)術優于(yu)三(san)(san)棱，若“二(er)藥(yao)合用(yong)(yong)，常(chang)有協(xie)同之(zhi)(zhi)功”。認為水蛭破瘀(yu)(yu)(yu)(yu)(yu)最效(xiao)(xiao)(xiao)，善(shan)除(chu)日久(jiu)之(zhi)(zhi)瘀(yu)(yu)(yu)(yu)(yu)滯(zhi)，能(neng)(neng)使(shi)瘀(yu)(yu)(yu)(yu)(yu)血(xue)(xue)默消于(yu)無(wu)(wu)形之(zhi)(zhi)中，乳(ru)香善(shan)透竅理氣(qi)(qi)(qi)(qi)，沒(mei)藥(yao)善(shan)化(hua)瘀(yu)(yu)(yu)(yu)(yu)理血(xue)(xue)，二(er)藥(yao)并用(yong)(yong)為宣(xuan)通(tong)臟腑、流通(tong)經絡之(zhi)(zhi)要藥(yao)，常(chang)用(yong)(yong)于(yu)治心、胃(wei)、脅(xie)、腹及(ji)肢體關節諸痛(tong)(tong)(tong)，經痛(tong)(tong)(tong)，產后瘀(yu)(yu)(yu)(yu)(yu)血(xue)(xue)腹痛(tong)(tong)(tong)，月經不(bu)(bu)調，風(feng)寒濕痹(bi)，中風(feng)四(si)肢不(bu)(bu)遂及(ji)一切(qie)瘡瘍腫(zhong)痛(tong)(tong)(tong)；雞內金味酸性溫(wen)藥(yao)性平和(he)，有補(bu)脾(pi)(pi)胃(wei)之(zhi)(zhi)妙，善(shan)化(hua)有形之(zhi)(zhi)瘀(yu)(yu)(yu)(yu)(yu)積；山楂化(hua)瘀(yu)(yu)(yu)(yu)(yu)血(xue)(xue)而(er)(er)不(bu)(bu)傷新血(xue)(xue)，開郁氣(qi)(qi)(qi)(qi)而(er)(er)不(bu)(bu)傷正氣(qi)(qi)(qi)(qi)；茵陳、麥(mai)芽皆具疏肝(gan)解郁之(zhi)(zhi)效(xiao)(xiao)(xiao)，體弱(ruo)陰虛(xu)(xu)不(bu)(bu)任柴胡升(sheng)散者，常(chang)以其代之(zhi)(zhi)；黃(huang)芪性溫(wen)味微甘，補(bu)氣(qi)(qi)(qi)(qi)兼能(neng)(neng)升(sheng)氣(qi)(qi)(qi)(qi)，善(shan)治氣(qi)(qi)(qi)(qi)虛(xu)(xu)、氣(qi)(qi)(qi)(qi)陷諸證，且(qie)其“性溫(wen)而(er)(er)上升(sheng)，以之(zhi)(zhi)補(bu)肝(gan)有同氣(qi)(qi)(qi)(qi)相求(qiu)之(zhi)(zhi)妙用(yong)(yong)”，故凡(fan)肝(gan)氣(qi)(qi)(qi)(qi)虛(xu)(xu)弱(ruo)不(bu)(bu)能(neng)(neng)條達，用(yong)(yong)一切(qie)補(bu)肝(gan)之(zhi)(zhi)藥(yao)皆不(bu)(bu)效(xiao)(xiao)(xiao)者，倡(chang)重用(yong)(yong)黃(huang)芪為主(zhu)，而(er)(er)少(shao)佐以理氣(qi)(qi)(qi)(qi)之(zhi)(zhi)品，并據此(ci)批(pi)評(ping)“肝(gan)虛(xu)(xu)無(wu)(wu)補(bu)法”之(zhi)(zhi)談(tan)。這些獨創(chuang)性見解，擴大和(he)豐富了藥(yao)物的臨床應用(yong)(yong)范(fan)圍。

2、善用生藥(yao)，注重(zhong)配伍

張錫(xi)純在《醫學衷中(zhong)參西錄》中(zhong)自擬良方百(bai)余首，以生(sheng)(sheng)藥見長，對生(sheng)(sheng)藥的使(shi)(shi)用獨具卓見。如水(shui)蛭，方書多謂必須炙(zhi)(zhi)透方可使(shi)(shi)用，但(dan)張氏(shi)認為，此物生(sheng)(sheng)于水(shui)中(zhong)，原得(de)水(shui)之精(jing)(jing)氣而(er)生(sheng)(sheng)，炙(zhi)(zhi)之則傷(shang)水(shui)之精(jing)(jing)氣，不(bu)(bu)若(ruo)生(sheng)(sheng)用。因而(er)在治療經閉不(bu)(bu)行、產后惡(e)露不(bu)(bu)盡或瘀血頑癥(zheng)時，常(chang)于理(li)沖(chong)湯、理(li)沖(chong)丸中(zhong)加入水(shui)蛭一(yi)錢或一(yi)兩，并標明“不(bu)(bu)用炙(zhi)(zhi)”。認為赭石(shi)色赤性微涼(liang)，生(sheng)(sheng)血兼能涼(liang)血，且因其質重(zhong)墜，又可鎮逆、降痰、止嘔、通便，“生(sheng)(sheng)研服(fu)之不(bu)(bu)傷(shang)腸胃……且生(sheng)(sheng)服(fu)則養(yang)氣純全，大能養(yang)血”。故治陰陽兩虛、喘(chuan)逆迫促之喘(chuan)息，重(zhong)用生(sheng)(sheng)赭石(shi)伍(wu)以生(sheng)(sheng)龍牡(mu)斂沖(chong)降逆；又與(yu)肉(rou)蓯蓉、當歸并用，補腎斂沖(chong)，潤(run)便通結。張氏(shi)臨床常(chang)用的生(sheng)(sheng)藥還有生(sheng)(sheng)乳香、生(sheng)(sheng)沒藥、生(sheng)(sheng)雞內金(jin)、生(sheng)(sheng)黃芪、生(sheng)(sheng)山(shan)藥、生(sheng)(sheng)杭芍、生(sheng)(sheng)石(shi)膏等。

此外，張氏根據(ju)其臨(lin)床(chuang)經驗(yan)和體會，總結出許多新的藥對配(pei)(pei)伍關系(xi)。如山藥配(pei)(pei)牛蒡子，疏補兼行，補腎健脾，清肺止咳(ke)，祛痰降氣(qi)；人(ren)參(can)配(pei)(pei)代(dai)赭石，剛柔相(xiang)濟，升(sheng)降互用(yong)，治(zhi)療脾胃氣(qi)虛，沖氣(qi)相(xiang)干，或用(yong)于上(shang)盛下(xia)虛、氣(qi)血(xue)將脫；黃(huang)芪配(pei)(pei)知母，寒熱平調(diao)以益氣(qi)升(sheng)舉；人(ren)參(can)配(pei)(pei)威靈(ling)仙治(zhi)氣(qi)虛小便不利；生龍、牡配(pei)(pei)萸肉，三藥聯(lian)合(he)應(ying)用(yong)，收斂固脫、澀精止汗等，均可資(zi)臨(lin)床(chuang)參(can)考。

3、潛心實(shi)踐(jian)，創(chuang)制新方

張氏對方(fang)(fang)藥(yao)的(de)運用(yong)(yong)也頗有心(xin)(xin)得(de)，在《醫學衷中(zhong)參西錄》中(zhong)創立了許多(duo)有效的(de)方(fang)(fang)劑，廣及(ji)內、外(wai)、婦(fu)、兒各科，其多(duo)有所宗，遵經而(er)(er)不(bu)泥古，通變而(er)(er)不(bu)失(shi)規矩。其中(zhong)，有不(bu)少為(wei)(wei)師法仲(zhong)景原意(yi)而(er)(er)化裁創制的(de)新方(fang)(fang)。如(ru)治吐衄諸方(fang)(fang)是(shi)受《金匱》瀉心(xin)(xin)湯(tang)(tang)(tang)影響，以降胃(wei)為(wei)(wei)主，故喜用(yong)(yong)赭石、半(ban)夏。治療胸中(zhong)蘊熱為(wei)(wei)外(wai)感(gan)所束，不(bu)能發泄而(er)(er)致煩躁的(de)猶龍湯(tang)(tang)(tang)，立意(yi)源于大(da)(da)青(qing)龍湯(tang)(tang)(tang)，由連(lian)翹(qiao)、生石膏、蟬蛻、牛蒡子組(zu)成。治滿悶短氣，呼吸(xi)不(bu)利的(de)蕩胸湯(tang)(tang)(tang)，于大(da)(da)陷(xian)(xian)(xian)胸湯(tang)(tang)(tang)中(zhong)取用(yong)(yong)芒硝，于小(xiao)陷(xian)(xian)(xian)胸湯(tang)(tang)(tang)中(zhong)取用(yong)(yong)瓜蔞，又(you)于治心(xin)(xin)下痞硬之旋覆(fu)代(dai)赭湯(tang)(tang)(tang)中(zhong)取用(yong)(yong)赭石，而(er)(er)復(fu)加蘇(su)子以為(wei)(wei)下行之向(xiang)導，可以代(dai)大(da)(da)陷(xian)(xian)(xian)胸湯(tang)(tang)(tang)、丸，亦可代(dai)小(xiao)陷(xian)(xian)(xian)胸湯(tang)(tang)(tang)。又(you)如(ru)其治療婦(fu)科病之理沖(chong)湯(tang)(tang)(tang)、理沖(chong)丸，用(yong)(yong)參、術(shu)、當歸、山藥(yao)等(deng)補(bu)氣健脾扶正，莪術(shu)、三棱、水蛭等(deng)活血(xue)化瘀，為(wei)(wei)攻補(bu)兼(jian)施，扶正化瘀，治閉(bi)經及(ji)癥瘕之虛實夾雜證良方(fang)(fang)。又(you)如(ru)治崩漏(lou)的(de)安沖(chong)湯(tang)(tang)(tang)、固(gu)沖(chong)湯(tang)(tang)(tang)，熔塞(sai)流、澄源、補(bu)虛于一(yi)爐，止血(xue)而(er)(er)不(bu)留瘀，清熱而(er)(er)不(bu)涼遏，溫補(bu)而(er)(er)不(bu)閉(bi)邪(xie)。再(zai)如(ru)，如(ru)治陰虛勞嗽之資生湯(tang)(tang)(tang)，治腦充血(xue)頭目眩暈(yun)之建瓴湯(tang)(tang)(tang)，治心(xin)(xin)腹疼(teng)痛、癥瘕痰癖的(de)活絡效靈丹，治腎(shen)虛滑胎(tai)的(de)壽胎(tai)丸等(deng)等(deng)，都是(shi)行之有效的(de)名(ming)方(fang)(fang)。

背景介紹

張氏治學(xue)嚴謹，重視實踐，主張溝(gou)通(tong)中(zhong)(zhong)西(xi)(xi)，取長補短，是近代中(zhong)(zhong)西(xi)(xi)醫(yi)匯通(tong)派的(de)代表(biao)之一(yi)。結合(he)其多年(nian)臨證經驗與匯通(tong)中(zhong)(zhong)西(xi)(xi)的(de)體會，著成《醫(yi)學(xue)衷(zhong)中(zhong)(zhong)參西(xi)(xi)錄》。

作者介紹

張(zhang)錫純，字壽甫，清末民初河北(bei)省鹽山縣人。生活于公元(yuan)1860～1933年(nian)(清咸豐十年(nian)至民國二(er)十二(er)年(nian))。幼敏而好學，攻讀經史之余，兼習岐(qi)黃之書(shu)，后(hou)因兩試秋(qiu)闈不第，遂潛(qian)心醫(yi)(yi)學。早年(nian)懸壺鄉梓，革命軍(jun)興(xing)，應聘從戎去武(wu)漢為軍(jun)醫(yi)(yi)。1917年(nian)在沈陽創建“立達中醫(yi)(yi)院”。直奉戰起，回故居(ju)河北(bei)滄州行醫(yi)(yi)，1926年(nian)移居(ju)天(tian)津(jin)，創辦“天(tian)津(jin)國醫(yi)(yi)函授學校”，培養了大批中醫(yi)(yi)后(hou)繼人才(cai)。

張(zhang)氏治學嚴謹，重(zhong)視實踐，主張(zhang)溝通中西，取長補短(duan)，是近代中西醫匯通派的代表之(zhi)一。其醫德高尚，常舍藥(yao)濟貧，遇疑難重(zhong)癥，殫思(si)竭慮，并親(qin)(qin)自攜藥(yao)到病(bing)家督煎，守護達旦。為(wei)了體驗藥(yao)物的毒性反應(ying)和用(yong)量，曾親(qin)(qin)嘗巴豆、花椒、甘遂等藥(yao)，足見其對病(bing)人極端負責(ze)的精神和重(zhong)視實踐的治學態度。他醫術精湛，常能(neng)力排眾議，獨任其責(ze)，起(qi)群醫束手之(zhi)沉疴，療效卓(zhuo)著，名震遐(xia)邇。當時與(yu)江蘇陸晉(jin)笙、楊如侯，廣東劉蔚楚同負盛名，又與(yu)慈(ci)溪張(zhang)生甫、嘉定張(zhang)山雷并稱名醫三張(zhang)。

張氏勤于(yu)(yu)鉆研，善于(yu)(yu)總結，平(ping)生(sheng)著述甚多(duo)，后因天津洪水沒(mei)其居，遺書(shu)蕩盡(jin)，傳世者僅《醫學衷中參西(xi)錄》一書(shu)。

鑒賞評價

《醫(yi)(yi)學(xue)衷中參西錄(lu)》為20世紀中醫(yi)(yi)臨床醫(yi)(yi)學(xue)名著(zhu)，素(su)為醫(yi)(yi)家所重視。