芒果视频

基本介紹

《醫(yi)(yi)(yi)學(xue)衷中(zhong)(zhong)(zhong)參(can)(can)西(xi)(xi)錄》，中(zhong)(zhong)(zhong)醫(yi)(yi)(yi)叢書(shu)，又名(ming)《衷中(zhong)(zhong)(zhong)參(can)(can)西(xi)(xi)錄》，張(zhang)(zhang)(zhang)錫(xi)純(壽甫)撰。此書(shu)分為(wei)《處方(fang)學(xue)》8卷(juan)、《醫(yi)(yi)(yi)論(lun)》8卷(juan)、《醫(yi)(yi)(yi)話拾零》、《三(san)三(san)醫(yi)(yi)(yi)書(shu)評》、《藥(yao)(yao)(yao)物講(jiang)義》4卷(juan)、《傷寒講(jiang)義》4卷(juan)、《醫(yi)(yi)(yi)案(附詩草(cao))》4卷(juan)。系作者多(duo)年治學(xue)臨證(zheng)經驗(yan)和(he)心(xin)得之(zhi)(zhi)總結。是20世紀初我(wo)國重要的(de)(de)(de)(de)臨床綜(zong)合性名(ming)著。張(zhang)(zhang)(zhang)氏致力溝通中(zhong)(zhong)(zhong)西(xi)(xi)醫(yi)(yi)(yi)學(xue)，主(zhu)(zhu)張(zhang)(zhang)(zhang)以中(zhong)(zhong)(zhong)醫(yi)(yi)(yi)為(wei)主(zhu)(zhu)體(ti)，取西(xi)(xi)醫(yi)(yi)(yi)之(zhi)(zhi)長，補中(zhong)(zhong)(zhong)醫(yi)(yi)(yi)之(zhi)(zhi)短。他(ta)認為(wei)：“欲求(qiu)醫(yi)(yi)(yi)學(xue)登峰造(zao)極，誠(cheng)非溝通中(zhong)(zhong)(zhong)西(xi)(xi)醫(yi)(yi)(yi)不可。”其(qi)于(yu)(yu)溝通中(zhong)(zhong)(zhong)西(xi)(xi)醫(yi)(yi)(yi)的(de)(de)(de)(de)主(zhu)(zhu)導思(si)想，主(zhu)(zhu)張(zhang)(zhang)(zhang)師古(gu)而(er)不泥古(gu)，參(can)(can)西(xi)(xi)而(er)不背中(zhong)(zhong)(zhong)。張(zhang)(zhang)(zhang)氏重視基(ji)礎(chu)(chu)理(li)論(lun)，對(dui)臟(zang)象(xiang)學(xue)說和(he)解剖(pou)生(sheng)理(li)的(de)(de)(de)(de)互(hu)證(zheng)尤(you)為(wei)重視。書(shu)中(zhong)(zhong)(zhong)指(zhi)出：腦(nao)(nao)為(wei)元神，心(xin)為(wei)識神，心(xin)力衰竭與(yu)(yu)腎不納氣相通；腦(nao)(nao)充血與(yu)(yu)薄厥相近等(deng)(deng)(deng)等(deng)(deng)(deng)。在(zai)臨證(zheng)方(fang)面，講(jiang)究細(xi)致的(de)(de)(de)(de)觀察和(he)記述病(bing)(bing)(bing)情，建立完(wan)整(zheng)的(de)(de)(de)(de)病(bing)(bing)(bing)歷。其(qi)于(yu)(yu)諸病(bing)(bing)(bing)治法，注重實際，勇于(yu)(yu)探索，并(bing)獨(du)創了(le)許(xu)多(duo)新的(de)(de)(de)(de)治療(liao)(liao)方(fang)劑(ji)，體(ti)驗(yan)了(le)若干中(zhong)(zhong)(zhong)藥(yao)(yao)(yao)的(de)(de)(de)(de)性能。對(dui)諸如(ru)萸肉救脫，參(can)(can)芪利(li)尿(niao)，白礬化痰熱，三(san)七消(xiao)瘡腫(zhong)，生(sheng)硫黃(huang)內服治虛寒下痢，蜈蚣(gong)、蝎子(zi)定(ding)風消(xiao)毒等(deng)(deng)(deng)等(deng)(deng)(deng)，均能發揚古(gu)說，擴大藥(yao)(yao)(yao)用(yong)主(zhu)(zhu)治。如(ru)對(dui)調治脾胃，主(zhu)(zhu)張(zhang)(zhang)(zhang)脾陽與(yu)(yu)胃陰并(bing)重，升肝脾與(yu)(yu)降膽胃兼施，補養與(yu)(yu)開破相結合。書(shu)中(zhong)(zhong)(zhong)結合中(zhong)(zhong)(zhong)西(xi)(xi)醫(yi)(yi)(yi)學(xue)理(li)論(lun)和(he)醫(yi)(yi)(yi)療(liao)(liao)實踐闡發醫(yi)(yi)(yi)理(li)，頗多(duo)獨(du)到的(de)(de)(de)(de)見解。書(shu)中(zhong)(zhong)(zhong)載述張(zhang)(zhang)(zhang)氏所制定(ding)的(de)(de)(de)(de)若干有(you)效方(fang)劑(ji)；在(zai)方(fang)藥(yao)(yao)(yao)應(ying)用(yong)方(fang)面，創用(yong)中(zhong)(zhong)(zhong)西(xi)(xi)藥(yao)(yao)(yao)相結合的(de)(de)(de)(de)方(fang)劑(ji)，并(bing)對(dui)石(shi)膏(gao)、生(sheng)山(shan)藥(yao)(yao)(yao)、代赭石(shi)等(deng)(deng)(deng)藥(yao)(yao)(yao)的(de)(de)(de)(de)臨床施治，在(zai)古(gu)人(ren)基(ji)礎(chu)(chu)上有(you)重要的(de)(de)(de)(de)補訂、發揮(hui)。

內容介紹

《醫學(xue)衷(zhong)中(zhong)參西錄》為張錫純唯一傳世的著(zhu)作，其(qi)主(zhu)要學(xue)術內容如下：

一、學術理論

(一)倡“衷(zhong)中參西”

清末民初(chu)，西(xi)(xi)學(xue)(xue)東漸，西(xi)(xi)醫(yi)學(xue)(xue)在我國流傳甚快。當時，醫(yi)學(xue)(xue)界有些(xie)(xie)人(ren)崇尚西(xi)(xi)學(xue)(xue)，輕視(shi)中(zhong)醫(yi)，有些(xie)(xie)中(zhong)醫(yi)則(ze)(ze)一(yi)味排斥西(xi)(xi)醫(yi)，因循守舊(jiu)。張(zhang)氏則(ze)(ze)主(zhu)張(zhang)以中(zhong)醫(yi)為本(ben)體，擷取西(xi)(xi)醫(yi)之長補(bu)中(zhong)醫(yi)之短，倡導“衷中(zhong)參西(xi)(xi)”，并從理論、實(shi)踐方面進行了(le)嘗試(shi)，《醫(yi)學(xue)(xue)衷中(zhong)參西(xi)(xi)錄》的(de)書(shu)名就鮮明(ming)地表明(ming)了(le)張(zhang)氏的(de)學(xue)(xue)術主(zhu)張(zhang)。

在(zai)生理(li)、病理(li)方面，張(zhang)氏(shi)于(yu)(yu)《醫(yi)學衷中(zhong)(zhong)(zhong)(zhong)參(can)西錄》中(zhong)(zhong)(zhong)(zhong)有許(xu)多溝(gou)通(tong)中(zhong)(zhong)(zhong)(zhong)西醫(yi)學的(de)新(xin)見解，如(ru)：“中(zhong)(zhong)(zhong)(zhong)醫(yi)謂人之(zhi)(zhi)神(shen)(shen)明(ming)(ming)(ming)在(zai)心(xin)，西說謂人之(zhi)(zhi)神(shen)(shen)明(ming)(ming)(ming)在(zai)腦(nao)，及(ji)觀(guan)《內經(jing)》，皆(jie)(jie)涵蓋其(qi)中(zhong)(zhong)(zhong)(zhong)也”。《素問·脈要精(jing)微(wei)論》中(zhong)(zhong)(zhong)(zhong)指(zhi)出“頭者(zhe)精(jing)明(ming)(ming)(ming)之(zhi)(zhi)府”，說明(ming)(ming)(ming)神(shen)(shen)明(ming)(ming)(ming)之(zhi)(zhi)體在(zai)腦(nao)，所謂“心(xin)主神(shen)(shen)明(ming)(ming)(ming)”，只(zhi)不過(guo)是(shi)言神(shen)(shen)明(ming)(ming)(ming)之(zhi)(zhi)用出于(yu)(yu)心(xin)，由此可見，中(zhong)(zhong)(zhong)(zhong)西之(zhi)(zhi)說雖然不同(tong)，但理(li)可匯通(tong)。另如(ru)，認為吐衄的(de)原因(yin)是(shi)由于(yu)(yu)陽明(ming)(ming)(ming)胃(wei)(wei)腑(fu)氣機上逆，胃(wei)(wei)中(zhong)(zhong)(zhong)(zhong)之(zhi)(zhi)血亦恒隨之(zhi)(zhi)上逆。“其(qi)上逆之(zhi)(zhi)極(ji)，可將胃(wei)(wei)壁之(zhi)(zhi)膜(mo)排擠破裂(lie)，而成(cheng)嘔血之(zhi)(zhi)證；或(huo)循陽明(ming)(ming)(ming)之(zhi)(zhi)經(jing)絡(luo)上行(xing)，而成(cheng)衄血之(zhi)(zhi)證”，此即《素問·厥論》中(zhong)(zhong)(zhong)(zhong)所言“陽明(ming)(ming)(ming)厥逆衄嘔血”。其(qi)論衄血治療，主張(zhang)不論“或(huo)虛或(huo)實，或(huo)涼或(huo)熱，治之(zhi)(zhi)者(zhe)皆(jie)(jie)當以(yi)降(jiang)胃(wei)(wei)之(zhi)(zhi)品為主”，并制平胃(wei)(wei)寒(han)降(jiang)湯(tang)、滋(zi)陰清(qing)降(jiang)湯(tang)等(deng)(deng)，皆(jie)(jie)主以(yi)生赭石通(tong)降(jiang)胃(wei)(wei)氣，并輔以(yi)白芍、龍、牡等(deng)(deng)養陰鎮潛之(zhi)(zhi)品，提高了(le)本病的(de)療效。

在用(yong)藥(yao)(yao)(yao)(yao)(yao)(yao)(yao)上，張(zhang)氏認為(wei)，西(xi)(xi)藥(yao)(yao)(yao)(yao)(yao)(yao)(yao)治(zhi)在局(ju)部，是(shi)重在病(bing)之(zhi)標(biao)也；中(zhong)(zhong)藥(yao)(yao)(yao)(yao)(yao)(yao)(yao)用(yong)藥(yao)(yao)(yao)(yao)(yao)(yao)(yao)求原因(yin)，是(shi)重在病(bing)之(zhi)本(ben)也。究之(zhi)，標(biao)本(ben)原宜兼(jian)顧，若遇(yu)難治(zhi)之(zhi)證，以(yi)西(xi)(xi)藥(yao)(yao)(yao)(yao)(yao)(yao)(yao)治(zhi)其標(biao)，中(zhong)(zhong)藥(yao)(yao)(yao)(yao)(yao)(yao)(yao)治(zhi)其本(ben)，則(ze)(ze)奏效必速(su)，提出中(zhong)(zhong)藥(yao)(yao)(yao)(yao)(yao)(yao)(yao)、西(xi)(xi)藥(yao)(yao)(yao)(yao)(yao)(yao)(yao)不(bu)應互(hu)相抵牾，而應相濟為(wei)用(yong)。張(zhang)氏臨床(chuang)治(zhi)療(liao)癲癇，據(ju)中(zhong)(zhong)醫(yi)“諸風掉眩，皆屬于(yu)肝”理論(lun)，用(yong)西(xi)(xi)藥(yao)(yao)(yao)(yao)(yao)(yao)(yao)臭素、抱(bao)水諸品(pin)及(ji)鉛硫朱砂丸麻醉鎮(zhen)靜治(zhi)標(biao)，而后則(ze)(ze)主張(zhang)徐(xu)以(yi)健脾、利痰(tan)、祛風、清火之(zhi)藥(yao)(yao)(yao)(yao)(yao)(yao)(yao)以(yi)鏟除其病(bing)根。治(zhi)療(liao)大氣下(xia)陷(xian)，下(xia)血(xue)不(bu)止之(zhi)血(xue)崩癥(zheng)，煎服生(sheng)黃芪、白術、龍骨(gu)、牡蠣、柴胡等升舉固(gu)澀之(zhi)品(pin)時，加(jia)服西(xi)(xi)藥(yao)(yao)(yao)(yao)(yao)(yao)(yao)麥(mai)角，以(yi)加(jia)強收縮止血(xue)功效。張(zhang)氏在辨證施治(zhi)運用(yong)中(zhong)(zhong)醫(yi)方藥(yao)(yao)(yao)(yao)(yao)(yao)(yao)的同時，加(jia)服西(xi)(xi)藥(yao)(yao)(yao)(yao)(yao)(yao)(yao)，開(kai)中(zhong)(zhong)西(xi)(xi)藥(yao)(yao)(yao)(yao)(yao)(yao)(yao)聯(lian)合(he)應用(yong)之(zhi)先河(he)。

(二)大(da)氣下陷論

繼(ji)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(ren)識和(he)治療(liao)作了(le)進一(yi)步(bu)的(de)闡(chan)發。

張氏認為，大氣(qi)即《內(nei)經》所言(yan)之(zhi)(zhi)宗氣(qi)，它(ta)“以(yi)元(yuan)氣(qi)為根(gen)本(ben)，以(yi)水谷(gu)之(zhi)(zhi)氣(qi)為養(yang)料，以(yi)胸中(zhong)之(zhi)(zhi)地為宅窟者也(ye)”。因其(qi)“誠以(yi)能撐持全身(shen)(shen)，為諸氣(qi)之(zhi)(zhi)綱領，包舉肺外，司(si)呼吸(xi)之(zhi)(zhi)樞機，故鄭(zheng)而(er)重之(zhi)(zhi)曰大氣(qi)。”即大氣(qi)是搏聚于(yu)(yu)胸中(zhong)，包舉于(yu)(yu)肺外的(de)大量陽氣(qi)，它(ta)源于(yu)(yu)元(yuan)氣(qi)，受水谷(gu)精微(wei)的(de)滋養(yang)，除主司(si)呼吸(xi)外，同時對全身(shen)(shen)產生重要影響。此氣(qi)撐持全身(shen)(shen)，振作(zuo)(zuo)精神，心及心思、腦(nao)力、百骸動作(zuo)(zuo)，莫不(bu)賴于(yu)(yu)此。此氣(qi)一虛，呼吸(xi)即覺不(bu)利(li)，而(er)時時酸懶(lan)，精神昏憒，腦(nao)力、心思為之(zhi)(zhi)頓減。

大(da)(da)氣(qi)之病(bing)變主要是虛而(er)(er)陷，其病(bing)情有(you)(you)(you)緩急之別，急者(zhe)(zhe)(zhe)(zhe)(zhe)可引起猝死，“大(da)(da)氣(qi)既陷，無氣(qi)包舉肺(fei)外(wai)以(yi)鼓動其闔辟(pi)之機，則(ze)呼吸停頓(dun)，所以(yi)不(bu)(bu)(bu)病(bing)而(er)(er)猝死。緩者(zhe)(zhe)(zhe)(zhe)(zhe)則(ze)因大(da)(da)氣(qi)下(xia)陷而(er)(er)致呼吸不(bu)(bu)(bu)利，換(huan)氣(qi)不(bu)(bu)(bu)足缺(que)氧，全身性(xing)衰竭出(chu)現(xian)一系列(lie)表現(xian)：“有(you)(you)(you)呼吸短(duan)氣(qi)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)心中怔忡者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)淋漓大(da)(da)汗者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)神昏健(jian)忘者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)聲顫(zhan)身動者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)寒熱往來(lai)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)胸中滿悶者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)努力呼吸似喘(chuan)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)咽干作渴者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)常常呵(he)欠(qian)者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)肢體痿廢者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)食(shi)后(hou)易饑者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)二便不(bu)(bu)(bu)禁者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)癃閉身腫者(zhe)(zhe)(zhe)(zhe)(zhe)，有(you)(you)(you)張口呼氣(qi)外(wai)出(chu)而(er)(er)氣(qi)不(bu)(bu)(bu)上達，肛門突(tu)出(chu)者(zhe)(zhe)(zhe)(zhe)(zhe)，在(zai)女子有(you)(you)(you)下(xia)血不(bu)(bu)(bu)止，更有(you)(you)(you)經水(shui)逆行(xing)者(zhe)(zhe)(zhe)(zhe)(zhe)”等(deng)等(deng)。，

以(yi)上(shang)見(jian)(jian)癥以(yi)心肺(fei)證候為主(zhu)，常(chang)兼見(jian)(jian)脾(pi)(pi)胃證候。若單見(jian)(jian)脾(pi)(pi)胃證候而無(wu)心肺(fei)證候者(zhe)，是(shi)謂中(zhong)氣(qi)(qi)(qi)(qi)下(xia)(xia)(xia)(xia)(xia)(xia)陷(xian)(xian)(xian)。中(zhong)氣(qi)(qi)(qi)(qi)下(xia)(xia)(xia)(xia)(xia)(xia)陷(xian)(xian)(xian)之(zhi)(zhi)重者(zhe)，張氏認為有(you)引起大(da)(da)氣(qi)(qi)(qi)(qi)下(xia)(xia)(xia)(xia)(xia)(xia)陷(xian)(xian)(xian)之(zhi)(zhi)可能，“夫(fu)中(zhong)氣(qi)(qi)(qi)(qi)誠(cheng)有(you)下(xia)(xia)(xia)(xia)(xia)(xia)陷(xian)(xian)(xian)之(zhi)(zhi)時，然不(bu)若大(da)(da)氣(qi)(qi)(qi)(qi)下(xia)(xia)(xia)(xia)(xia)(xia)陷(xian)(xian)(xian)之(zhi)(zhi)尤屬危險也。間有(you)因中(zhong)氣(qi)(qi)(qi)(qi)下(xia)(xia)(xia)(xia)(xia)(xia)陷(xian)(xian)(xian)，泄瀉日久，或轉致大(da)(da)氣(qi)(qi)(qi)(qi)下(xia)(xia)(xia)(xia)(xia)(xia)陷(xian)(xian)(xian)者(zhe)”。這樣把(ba)大(da)(da)氣(qi)(qi)(qi)(qi)下(xia)(xia)(xia)(xia)(xia)(xia)陷(xian)(xian)(xian)與(yu)中(zhong)氣(qi)(qi)(qi)(qi)下(xia)(xia)(xia)(xia)(xia)(xia)陷(xian)(xian)(xian)分別開(kai)來(lai)，確(que)為閱歷之(zhi)(zhi)談。

張(zhang)氏認為(wei)(wei)，引起大氣(qi)下(xia)陷的原因不外勞力(li)(li)過度、久(jiu)病(bing)和誤藥(yao)。如“力(li)(li)小任重(zhong)，或(huo)(huo)枵腹力(li)(li)作，或(huo)(huo)病(bing)后(hou)氣(qi)力(li)(li)未復而勤于動(dong)作，或(huo)(huo)泄瀉日久(jiu)，或(huo)(huo)服破氣(qi)藥(yao)太過或(huo)(huo)氣(qi)分虛(xu)極自下(xia)陷”。張(zhang)氏治(zhi)療大氣(qi)下(xia)陷，創(chuang)制升(sheng)陷湯(tang)(生黃芪、知(zhi)母(mu)、桔梗(geng)(geng)、柴(chai)胡(hu)、升(sheng)麻(ma)(ma))，該方以(yi)(yi)黃芪為(wei)(wei)君，升(sheng)補大氣(qi)，佐(zuo)知(zhi)母(mu)涼潤以(yi)(yi)濟其之偏，柴(chai)胡(hu)引大氣(qi)之陷者自左上升(sheng)，升(sheng)麻(ma)(ma)引大氣(qi)之陷者自右上升(sheng)，桔梗(geng)(geng)為(wei)(wei)藥(yao)中之舟楫，導(dao)諸藥(yao)之力(li)(li)上達胸(xiong)中。若氣(qi)虛(xu)極加(jia)人(ren)參或(huo)(huo)寄(ji)生，以(yi)(yi)培氣(qi)之本(ben)，或(huo)(huo)更加(jia)山(shan)萸肉以(yi)(yi)防氣(qi)之渙散，氣(qi)虛(xu)甚者酌增升(sheng)麻(ma)(ma)用量。

心(xin)肺(fei)之陽，尤(you)賴胸中大氣為(wei)之保護，大氣一陷(xian)(xian)，則心(xin)肺(fei)陽分素虛(xu)者(zhe)，至此而益(yi)虛(xu)，癥(zheng)見其人心(xin)冷，背緊，惡寒(han)，常覺短氣等。張氏(shi)認為(wei)欲助胸中心(xin)肺(fei)之陽，必須先(xian)升提下陷(xian)(xian)之大氣，否則但服(fu)溫補(bu)心(xin)肺(fei)之陽之劑無效，制回陽升陷(xian)(xian)湯(生黃芪、干姜、當歸身、桂枝炭、甘草(cao))以治之。

胸中大氣(qi)(qi)正常，有(you)賴于少陽、陽明之(zhi)(zhi)氣(qi)(qi)的升(sheng)(sheng)發(fa)。若大氣(qi)(qi)下陷，升(sheng)(sheng)發(fa)之(zhi)(zhi)氣(qi)(qi)被郁，氣(qi)(qi)分郁結，經絡(luo)瘀(yu)滯，常見胸中滿痛(tong)或脅(xie)下撐脹、腹(fu)痛(tong)等。對此，張氏又制理郁升(sheng)(sheng)陷湯(生黃芪、知母、當歸身(shen)、桂枝尖、柴胡、乳香、沒藥)；對脾氣(qi)(qi)虛極下陷，小(xiao)便不禁者(zhe)，制理脾升(sheng)(sheng)陷湯(生黃芪、白術、桑(sang)寄(ji)生、川斷、萸肉、龍骨、牡(mu)蠣、川萆薢、甘(gan)草)治(zhi)之(zhi)(zhi)。

(三)寒溫(wen)統一(yi)，注重清透

《醫學(xue)衷中參(can)西錄》論溫(wen)(wen)病(bing)(bing)，主張(zhang)寒(han)(han)溫(wen)(wen)統一，認為(wei)溫(wen)(wen)病(bing)(bing)治(zhi)法已備于傷(shang)(shang)寒(han)(han)。如溫(wen)(wen)病(bing)(bing)初(chu)起(qi)治(zhi)宜辛(xin)涼(liang)，然(ran)辛(xin)涼(liang)之(zhi)(zhi)(zhi)法亦備于傷(shang)(shang)寒(han)(han)，麻(ma)杏甘石(shi)湯(tang)(tang)“誠為(wei)溫(wen)(wen)病(bing)(bing)初(chu)得(de)之(zhi)(zhi)(zhi)的(de)方矣”。但(dan)其外表證未解，內有蘊熱即可服用(yong)。至溫(wen)(wen)病(bing)(bing)傳經已深，清燥熱之(zhi)(zhi)(zhi)白(bai)虎(hu)湯(tang)(tang)、白(bai)虎(hu)加人參(can)湯(tang)(tang)，通腑之(zhi)(zhi)(zhi)大(da)、小承氣湯(tang)(tang)，開結胸(xiong)之(zhi)(zhi)(zhi)大(da)、小陷(xian)胸(xiong)湯(tang)(tang)，治(zhi)下利之(zhi)(zhi)(zhi)白(bai)頭翁(weng)湯(tang)(tang)、黃芩(qin)湯(tang)(tang)，治(zhi)發(fa)黃之(zhi)(zhi)(zhi)茵陳桅子(zi)柏(bo)皮湯(tang)(tang)等及一切涼(liang)潤、清火、育陰、安(an)神之(zhi)(zhi)(zhi)劑，皆可使用(yong)。并(bing)指出(chu)寒(han)(han)溫(wen)(wen)治(zhi)法之(zhi)(zhi)(zhi)別，在(zai)于“始(shi)異(yi)而終(zhong)(zhong)同”。所謂(wei)“始(shi)異(yi)”，即傷(shang)(shang)寒(han)(han)發(fa)表可用(yong)溫(wen)(wen)熱，溫(wen)(wen)病(bing)(bing)發(fa)表必用(yong)辛(xin)涼(liang)；謂(wei)其“終(zhong)(zhong)同”，即病(bing)(bing)傳陽明之(zhi)(zhi)(zhi)后(hou)，不(bu)論傷(shang)(shang)寒(han)(han)、溫(wen)(wen)病(bing)(bing)，皆宜治(zhi)以(yi)寒(han)(han)涼(liang)，而大(da)忌溫(wen)(wen)熱。

張氏臨證將溫(wen)(wen)病(bing)分為(wei)(wei)風溫(wen)(wen)、春溫(wen)(wen)、濕溫(wen)(wen)三(san)類。認(ren)(ren)為(wei)(wei)三(san)類溫(wen)(wen)病(bing)雖見癥不同，其本質皆緣郁(yu)(yu)(yu)熱(re)(re)。“大凡病(bing)溫(wen)(wen)之人，多系內(nei)有蘊熱(re)(re)，至春陽萌動(dong)之時，又(you)薄(bo)受外感拘束，其熱(re)(re)即陡(dou)發(fa)而成(cheng)溫(wen)(wen)”。他遵循“火郁(yu)(yu)(yu)發(fa)之”之旨，治(zhi)療上主張宣(xuan)散郁(yu)(yu)(yu)結，疏通(tong)氣機，透(tou)邪外達。反對徒(tu)執寒(han)涼，只清不透(tou)，使邪無由出(chu)。并自(zi)擬清解(jie)湯(tang)、涼解(jie)湯(tang)、寒(han)解(jie)湯(tang)三(san)方，徑以石膏清其內(nei)熱(re)(re)，又(you)選用薄(bo)荷(he)、連翹、蟬蛻發(fa)表，且“引胃中化而欲散之熱(re)(re)，仍還太陽作(zuo)汗(han)而解(jie)”。正是(shi)基于(yu)(yu)對溫(wen)(wen)病(bing)“郁(yu)(yu)(yu)熱(re)(re)”這一(yi)本質的深刻認(ren)(ren)識，初(chu)起治(zhi)療即立(li)足于(yu)(yu)清透(tou)。

溫(wen)病入里化(hua)熱(re)(re)，抑或傷寒(han)、中(zhong)(zhong)(zhong)風入里化(hua)熱(re)(re)，是(shi)陽明(ming)熱(re)(re)盛之(zhi)(zhi)象，張(zhang)氏(shi)皆以(yi)(yi)寒(han)涼清熱(re)(re)為主(zhu)，不(bu)復有傷寒(han)、中(zhong)(zhong)(zhong)風、溫(wen)病之(zhi)(zhi)分(fen)，投以(yi)(yi)白虎(hu)湯靈活加(jia)減化(hua)裁。臨(lin)證使用(yong)白虎(hu)湯，張(zhang)氏(shi)有著豐富的經(jing)驗，認為白虎(hu)湯之(zhi)(zhi)“四(si)大(da)”典型(xing)癥狀中(zhong)(zhong)(zhong)，唯脈洪為必見之(zhi)(zhi)癥。只要見脈洪大(da)，又有陽明(ming)熱(re)(re)盛之(zhi)(zhi)一二癥，則(ze)無論外感內傷，皆可用(yong)之(zhi)(zhi)，不(bu)必拘泥于古人之(zhi)(zhi)說。

陽明(ming)腑實(shi)用三承(cheng)氣湯(tang)(tang)，此(ci)乃(nai)大法，然張氏(shi)認(ren)為承(cheng)氣力猛(meng)，倘或審證(zheng)不確，即足誤(wu)事(shi)。于是據其(qi)三十余年臨證(zheng)經驗，強(qiang)調“凡遇陽明(ming)應下(xia)證(zheng)，亦(yi)先投以白虎(hu)(hu)湯(tang)(tang)一二(er)劑(ji)，更改其(qi)服法，將石膏為末而不入煎，以藥湯(tang)(tang)送服之(zhi)(zhi)”，因屢用此(ci)方奏效(xiao)，遂名(ming)之(zhi)(zhi)曰白虎(hu)(hu)承(cheng)氣湯(tang)(tang)。對于溫熱(re)(re)病(bing)神昏(hun)譫語，張氏(shi)遵從陸(lu)九芝“胃(wei)熱(re)(re)之(zhi)(zhi)甚，神為之(zhi)(zhi)昏(hun)，從來神昏(hun)之(zhi)(zhi)病(bing)，皆屬(shu)胃(wei)家(jia)”之(zhi)(zhi)說，將熱(re)(re)病(bing)神昏(hun)分為虛實(shi)兩類。其(qi)脈象洪而有力，按(an)之(zhi)(zhi)甚實(shi)者(zhe)，可按(an)陽明(ming)胃(wei)實(shi)治之(zhi)(zhi)，投以大劑(ji)白虎(hu)(hu)湯(tang)(tang)；若脈兼弦、兼數，或重按(an)仍甚實(shi)者(zhe)，治宜白虎(hu)(hu)加人參湯(tang)(tang)；對邪(xie)入陽明(ming)，淫(yin)熱(re)(re)于肝(gan)，致肝(gan)風內(nei)動者(zhe)，以白虎(hu)(hu)撤其(qi)陽明(ming)之(zhi)(zhi)熱(re)(re)，生龍骨(gu)、生牡蠣以鎮肝(gan)熄風。

張氏治療(liao)溫病(bing)不(bu)僅擅用白(bai)虎，而(er)且(qie)依(yi)據(ju)病(bing)證不(bu)同，化裁(cai)組成了眾(zhong)多(duo)新方，如石膏粳米湯、鎮逆白(bai)虎湯、通(tong)變白(bai)虎加人參湯等，皆(jie)由(you)白(bai)虎湯衍(yan)化而(er)來。

二、治療經驗

張氏一生勤于臨(lin)證，《醫學(xue)衷中(zhong)參西錄(lu)》記載了他豐(feng)富的臨(lin)床經驗(yan)，其中(zhong)尤以論治中(zhong)風(feng)、脫證等最具特色(se)。

(一)分別中風(feng)論治

中(zhong)(zhong)風有(you)真中(zhong)(zhong)、類(lei)中(zhong)(zhong)之別。張氏認為真中(zhong)(zhong)者極少(shao)，因而著(zhu)意對(dui)類(lei)中(zhong)(zhong)進(jin)行(xing)研究、發揮(hui)。指出類(lei)中(zhong)(zhong)風亦即內中(zhong)(zhong)風，此(ci)“風自內生(sheng)，非(fei)風自外來也”，其治療分充血、貧血，以(yi)虛實論治。

1、腦充血治療

張氏(shi)根(gen)據“血菀于上(shang)，使人(ren)薄(bo)厥(jue)”的理論(lun)，認為腦(nao)充血即《內(nei)經(jing)》中所言(yan)的煎厥(jue)、薄(bo)厥(jue)、大厥(jue)。其病(bing)位(wei)在“肝”，陰虛陽亢、上(shang)實(shi)下虛、臟(zang)腑之(zhi)(zhi)氣升(sheng)發太過或失之(zhi)(zhi)下行(xing)，血隨(sui)氣逆為主要病(bing)機。即“人(ren)之(zhi)(zhi)血隨(sui)氣行(xing)，氣上(shang)升(sheng)不已，血即隨(sui)之(zhi)(zhi)上(shang)升(sheng)不已，以(yi)(yi)致(zhi)腦(nao)中血管充血過甚”(《醫(yi)學衷中參西(xi)錄·醫(yi)案·腦(nao)充血門(men)》)，有礙神經(jing)，以(yi)(yi)致(zhi)語言(yan)肢(zhi)體謇(jian)澀不利，口(kou)眼歪斜(xie)等等。

根據(ju)腦充血(xue)之(zhi)(zhi)(zhi)(zhi)“肝(gan)(gan)木(mu)失和，肺氣(qi)(qi)(qi)不(bu)降，腎氣(qi)(qi)(qi)不(bu)攝(she)，沖氣(qi)(qi)(qi)、胃氣(qi)(qi)(qi)又(you)復上逆，臟(zang)腑之(zhi)(zhi)(zhi)(zhi)氣(qi)(qi)(qi)化皆上升太過”之(zhi)(zhi)(zhi)(zhi)病(bing)(bing)機(ji)，張氏提(ti)出治(zhi)療(liao)(liao)本(ben)病(bing)(bing)應“清其(qi)臟(zang)腑之(zhi)(zhi)(zhi)(zhi)熱，滋其(qi)臟(zang)腑之(zhi)(zhi)(zhi)(zhi)陰(yin)，更降其(qi)臟(zang)腑之(zhi)(zhi)(zhi)(zhi)氣(qi)(qi)(qi)，引(yin)腦部所(suo)充之(zhi)(zhi)(zhi)(zhi)血(xue)下(xia)(xia)行(xing)”的(de)“鎮(zhen)肝(gan)(gan)熄(xi)風(feng)、引(yin)血(xue)下(xia)(xia)行(xing)”的(de)原則(ze)，并創制鎮(zhen)肝(gan)(gan)熄(xi)風(feng)湯(懷牛膝、生(sheng)赭石(shi)、生(sheng)杭(hang)芍、天(tian)冬、生(sheng)龍骨、生(sheng)牡蠣、生(sheng)龜(gui)板(ban)、玄(xuan)(xuan)參、川楝(lian)子、生(sheng)麥(mai)芽、茵(yin)陳(chen)、甘草)作為治(zhi)療(liao)(liao)本(ben)病(bing)(bing)的(de)主方。方中赭石(shi)降胃，平(ping)肝(gan)(gan)鎮(zhen)沖，下(xia)(xia)行(xing)通便；牛膝善(shan)引(yin)上部之(zhi)(zhi)(zhi)(zhi)血(xue)下(xia)(xia)行(xing)，二藥合用，相(xiang)輔相(xiang)成(cheng)；玄(xuan)(xuan)參、天(tian)冬、白芍滋陰(yin)退(tui)熱；龍骨、牡蠣、龜(gui)板(ban)、芍藥斂肝(gan)(gan)火、鎮(zhen)熄(xi)肝(gan)(gan)風(feng)，以緩(huan)其(qi)肝(gan)(gan)氣(qi)(qi)(qi)上升之(zhi)(zhi)(zhi)(zhi)勢；玄(xuan)(xuan)參、天(tian)冬清肺制肝(gan)(gan)；山(shan)藥、甘草和胃緩(huan)肝(gan)(gan)；茵(yin)陳(chen)為“青(qing)蒿之(zhi)(zhi)(zhi)(zhi)嫩(nen)者，稟少(shao)陽(yang)初(chu)生(sheng)之(zhi)(zhi)(zhi)(zhi)氣(qi)(qi)(qi)，與肝(gan)(gan)木(mu)同氣(qi)(qi)(qi)相(xiang)求，最(zui)能(neng)將(jiang)順(shun)肝(gan)(gan)木(mu)之(zhi)(zhi)(zhi)(zhi)性，且又(you)善(shan)瀉肝(gan)(gan)熱”，為清涼(liang)腦部之(zhi)(zhi)(zhi)(zhi)涼(liang)藥也；麥(mai)芽“善(shan)助肝(gan)(gan)木(mu)疏泄以行(xing)腎氣(qi)(qi)(qi)”；川楝(lian)子善(shan)引(yin)肝(gan)(gan)氣(qi)(qi)(qi)下(xia)(xia)達(da)，又(you)能(neng)折其(qi)更動之(zhi)(zhi)(zhi)(zhi)力(li)。本(ben)方標(biao)本(ben)兼(jian)治(zhi)，鎮(zhen)潛(qian)共用，引(yin)涵兼(jian)施，直(zhi)中病(bing)(bing)之(zhi)(zhi)(zhi)(zhi)肯綮，確有獨到之(zhi)(zhi)(zhi)(zhi)處。

此外，張氏(shi)還參照西(xi)醫病(bing)理，闡述了腦(nao)充血(xue)(xue)、腦(nao)溢血(xue)(xue)、腦(nao)出(chu)血(xue)(xue)之(zhi)(zhi)(zhi)證(zheng)型及(ji)用(yong)(yong)(yong)藥(yao)(yao)的不(bu)同。對腦(nao)部血(xue)(xue)管中之(zhi)(zhi)(zhi)血(xue)(xue)滲出(chu)者(zhe)，他在友人“腦(nao)充血(xue)(xue)證(zheng)，宜于(yu)引血(xue)(xue)下行藥(yao)(yao)中加(jia)(jia)破血(xue)(xue)之(zhi)(zhi)(zhi)藥(yao)(yao)以(yi)治(zhi)之(zhi)(zhi)(zhi)”的啟(qi)發下，指出(chu)對其身體壯實者(zhe)，可酌加(jia)(jia)大黃(huang)數錢(qian)以(yi)逐瘀；其身形(xing)脈象(xiang)不(bu)甚壯實者(zhe)，加(jia)(jia)桃仁、丹(dan)參等化瘀。并明確提(ti)出(chu)“腦(nao)充血(xue)(xue)當(dang)通(tong)大便為(wei)要務”。對腦(nao)充血(xue)(xue)后期脈象(xiang)柔(rou)和而肢(zhi)體痿廢(fei)者(zhe)，主張“少用(yong)(yong)(yong)黃(huang)芪助活血(xue)(xue)之(zhi)(zhi)(zhi)品以(yi)通(tong)絡”，但應謹慎從事。而對于(yu)“血(xue)(xue)菀于(yu)上”的腦(nao)充血(xue)(xue)者(zhe)，因黃(huang)芪之(zhi)(zhi)(zhi)情，補而兼升(sheng)，氣升(sheng)則血(xue)(xue)必隨之(zhi)(zhi)(zhi)升(sheng)，故病(bing)初應忌用(yong)(yong)(yong)黃(huang)芪，誤用(yong)(yong)(yong)則兇(xiong)危立見。其辨(bian)證(zheng)之(zhi)(zhi)(zhi)嚴謹，用(yong)(yong)(yong)藥(yao)(yao)之(zhi)(zhi)(zhi)精確，可見一斑。

2、腦貧血治療

與腦(nao)充血(xue)(xue)(xue)(xue)證(zheng)相反，張(zhang)氏認為腦(nao)貧(pin)(pin)血(xue)(xue)(xue)(xue)證(zheng)則(ze)為血(xue)(xue)(xue)(xue)之上注于(yu)腦(nao)過(guo)少，無以養其腦(nao)髓(sui)(sui)神(shen)經(jing)，致(zhi)使腦(nao)神(shen)經(jing)失(shi)其所司。而血(xue)(xue)(xue)(xue)之上注過(guo)少，實由“宗(zong)氣(qi)(qi)(qi)虛寒，不(bu)能助血(xue)(xue)(xue)(xue)上升川”。故治(zhi)療(liao)腦(nao)貧(pin)(pin)血(xue)(xue)(xue)(xue)證(zheng)，主張(zhang)“應峻補(bu)(bu)其胸(xiong)中大氣(qi)(qi)(qi)”，自擬(ni)當(dang)歸(gui)補(bu)(bu)血(xue)(xue)(xue)(xue)湯(tang)益氣(qi)(qi)(qi)溫陽、補(bu)(bu)血(xue)(xue)(xue)(xue)活(huo)血(xue)(xue)(xue)(xue)，治(zhi)療(liao)中風脈象遲弱，身軟，肢體(ti)漸覺(jue)不(bu)利，或(huo)(huo)(huo)頭(tou)重目眩，或(huo)(huo)(huo)神(shen)昏(hun)健忘(wang)，甚或(huo)(huo)(huo)昏(hun)仆，移(yi)時蘇(su)醒致(zhi)成偏枯(ku)者(zhe)。方中主以黃芪(qi)升補(bu)(bu)胸(xiong)中大氣(qi)(qi)(qi)，使血(xue)(xue)(xue)(xue)隨氣(qi)(qi)(qi)升，上達腦(nao)中；用當(dang)歸(gui)、龍(long)眼肉、鹿角(jiao)膠養血(xue)(xue)(xue)(xue)生髓(sui)(sui)；丹(dan)參、乳、沒開血(xue)(xue)(xue)(xue)痹，化瘀滯；甘(gan)松助心(xin)房運行有力(li)，以多(duo)輸血(xue)(xue)(xue)(xue)于(yu)腦(nao)，且又為調養神(shen)經(jing)之品。對于(yu)腦(nao)貧(pin)(pin)血(xue)(xue)(xue)(xue)肢體(ti)痿廢或(huo)(huo)(huo)偏枯(ku)，脈象極微細無力(li)者(zhe)，又擬(ni)干頹湯(tang)、補(bu)(bu)腦(nao)振(zhen)痿湯(tang)治(zhi)療(liao)。并指出肢體(ti)偏廢，服藥久不(bu)效者(zhe)，應著(zhu)重補(bu)(bu)腎通絡，多(duo)選用胡(hu)桃肉、地龍(long)、馬(ma)錢子等(deng)。

(二)重視沖氣為病，善用鎮沖降(jiang)逆

沖(chong)(chong)(chong)(chong)(chong)(chong)脈(mo)(mo)為(wei)(wei)奇經八脈(mo)(mo)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)一(yi)，張氏(shi)論病(bing)(bing)極重視(shi)沖(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)，指出(chu)“沖(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)沖(chong)(chong)(chong)(chong)(chong)(chong)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)病(bing)(bing)甚多，而醫者識其(qi)(qi)(qi)(qi)病(bing)(bing)者甚少(shao)。即(ji)或能(neng)(neng)識此(ci)病(bing)(bing)，亦(yi)多不(bu)(bu)能(neng)(neng)洞悉其(qi)(qi)(qi)(qi)病(bing)(bing)因(yin)”。因(yin)而，對沖(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)的(de)(de)生理(li)，尤其(qi)(qi)(qi)(qi)是沖(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)沖(chong)(chong)(chong)(chong)(chong)(chong)的(de)(de)病(bing)(bing)因(yin)、病(bing)(bing)理(li)、病(bing)(bing)脈(mo)(mo)、治法都作了(le)詳細闡述(shu)，自(zi)成一(yi)家之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)言。其(qi)(qi)(qi)(qi)述(shu)沖(chong)(chong)(chong)(chong)(chong)(chong)脈(mo)(mo)，、兼采《內》《難》之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)說(shuo)，認(ren)為(wei)(wei)其(qi)(qi)(qi)(qi)“在胞(bao)室之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)兩旁，與任(ren)脈(mo)(mo)相連，為(wei)(wei)腎臟(zang)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)輔弼，氣(qi)(qi)(qi)(qi)(qi)(qi)化(hua)相通……上(shang)(shang)系原隸陽明胃(wei)腑(fu)”，并認(ren)為(wei)(wei)“沖(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)沖(chong)(chong)(chong)(chong)(chong)(chong)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)證(zheng)，固由于腎臟(zang)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)虛，亦(yi)多由于肝氣(qi)(qi)(qi)(qi)(qi)(qi)恣橫，素性多怒之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)人，其(qi)(qi)(qi)(qi)肝氣(qi)(qi)(qi)(qi)(qi)(qi)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)暴發(fa)，更助沖(chong)(chong)(chong)(chong)(chong)(chong)胃(wei)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)逆(ni)”。即(ji)腎虛無以涵(han)木，不(bu)(bu)能(neng)(neng)收斂沖(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)，沖(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)行，肝氣(qi)(qi)(qi)(qi)(qi)(qi)橫逆(ni)，胃(wei)氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)逆(ni)而呈(cheng)上(shang)(shang)沖(chong)(chong)(chong)(chong)(chong)(chong)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)弊(bi)。張氏(shi)描述(shu)的(de)(de)沖(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)沖(chong)(chong)(chong)(chong)(chong)(chong)證(zheng)，除自(zi)覺有氣(qi)(qi)(qi)(qi)(qi)(qi)自(zi)下上(shang)(shang)沖(chong)(chong)(chong)(chong)(chong)(chong)，脈(mo)(mo)多弦硬而長外(wai)，主(zhu)要表現有胃(wei)脘(wan)或腹中滿悶，噦(hui)氣(qi)(qi)(qi)(qi)(qi)(qi)，呃(e)逆(ni)連連，嘔吐不(bu)(bu)止，或見吐血、衄血等(deng)胃(wei)氣(qi)(qi)(qi)(qi)(qi)(qi)上(shang)(shang)逆(ni)不(bu)(bu)降(jiang)(jiang)見癥；或兩脅(xie)痛脹(zhang)，頭目眩(xuan)暈(yun)，甚而氣(qi)(qi)(qi)(qi)(qi)(qi)火(huo)挾痰(tan)上(shang)(shang)沖(chong)(chong)(chong)(chong)(chong)(chong)，發(fa)生突然(ran)昏仆等(deng)；或為(wei)(wei)胸滿窒塞(sai)，喘息大作。其(qi)(qi)(qi)(qi)治療，主(zhu)張以斂沖(chong)(chong)(chong)(chong)(chong)(chong)鎮(zhen)(zhen)沖(chong)(chong)(chong)(chong)(chong)(chong)為(wei)(wei)主(zhu)，降(jiang)(jiang)胃(wei)平肝為(wei)(wei)佐，獨創參赭(zhe)鎮(zhen)(zhen)氣(qi)(qi)(qi)(qi)(qi)(qi)湯(tang)(tang)、鎮(zhen)(zhen)沖(chong)(chong)(chong)(chong)(chong)(chong)降(jiang)(jiang)胃(wei)湯(tang)(tang)等(deng)鎮(zhen)(zhen)沖(chong)(chong)(chong)(chong)(chong)(chong)諸方。其(qi)(qi)(qi)(qi)組方特(te)色，一(yi)為(wei)(wei)善(shan)(shan)用鎮(zhen)(zhen)沖(chong)(chong)(chong)(chong)(chong)(chong)降(jiang)(jiang)逆(ni)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)品(pin)，如(ru)赭(zhe)石、龍(long)、牡(mu)等(deng)；一(yi)為(wei)(wei)善(shan)(shan)用補虛固澀(se)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)品(pin)，如(ru)山萸肉(rou)、山藥、白芍、芡實等(deng)，攻(gong)中有補，降(jiang)(jiang)斂結合，用之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)臨(lin)床(chuang)，確有良效。其(qi)(qi)(qi)(qi)沖(chong)(chong)(chong)(chong)(chong)(chong)氣(qi)(qi)(qi)(qi)(qi)(qi)學說(shuo)為(wei)(wei)中醫臨(lin)床(chuang)治療雜(za)病(bing)(bing)又辟新徑。

(三)脫分上(shang)下內外，治脫重視肝(gan)虛

張氏認(ren)為(wei)(wei)脫雖有(you)上(shang)(shang)(shang)、下(xia)、內、外之別，概由(you)(you)肝(gan)(gan)虛，其(qi)云：“凡人(ren)元(yuan)氣(qi)(qi)之脫，皆脫在肝(gan)(gan)”。他(ta)根據肝(gan)(gan)主疏泄、調暢氣(qi)(qi)機的(de)(de)功能(neng)，認(ren)為(wei)(wei)元(yuan)氣(qi)(qi)的(de)(de)運行(xing)和胃(wei)氣(qi)(qi)的(de)(de)布(bu)化，全賴于肝(gan)(gan)臟(zang)正常的(de)(de)疏泄功能(neng)。倘肝(gan)(gan)虛則損泄元(yuan)氣(qi)(qi)，耗散腎(shen)氣(qi)(qi)，而(er)為(wei)(wei)上(shang)(shang)(shang)脫或下(xia)脫。“蓋元(yuan)氣(qi)(qi)上(shang)(shang)(shang)脫由(you)(you)于肝(gan)(gan)，其(qi)下(xia)脫亦由(you)(you)于肝(gan)(gan)。誠以肝(gan)(gan)能(neng)為(wei)(wei)腎(shen)行(xing)氣(qi)(qi)，即能(neng)瀉元(yuan)氣(qi)(qi)自下(xia)出也(ye)”。(《醫學衷(zhong)中參(can)西(xi)錄·醫案(an)·霍亂門(men)》)上(shang)(shang)(shang)脫之證，“喘(chuan)逆迫(po)促，脈若(ruo)水上(shang)(shang)(shang)浮麻(ma)”，張氏制參(can)赭鎮(zhen)氣(qi)(qi)湯(tang)救(jiu)之。方中以人(ren)參(can)補虛極之諸(zhu)氣(qi)(qi)，借“赭石下(xia)行(xing)之力，挽回(hui)(hui)將(jiang)脫之元(yuan)氣(qi)(qi)”；蘇子(zi)助赭石降氣(qi)(qi)；生山(shan)(shan)藥、生白芍滋(zi)補肝(gan)(gan)胃(wei)之陰，以守(shou)持元(yuan)氣(qi)(qi)；山(shan)(shan)萸(yu)肉、生芡實、生龍(long)骨、生牡蠣酸斂收澀，固(gu)攝(she)元(yuan)氣(qi)(qi)。下(xia)脫，如“日夜吐瀉不已，脈沉(chen)細欲(yu)無，虛極將(jiang)脫者，為(wei)(wei)至(zhi)危之候(hou)”，張氏以急(ji)救(jiu)回(hui)(hui)陽湯(tang)救(jiu)之，方用人(ren)參(can)以回(hui)(hui)陽；山(shan)(shan)藥、芍藥滋(zi)陰；重用山(shan)(shan)萸(yu)肉斂肝(gan)(gan)固(gu)脫。上(shang)(shang)(shang)下(xia)兩(liang)脫兼見者，挽陰回(hui)(hui)陽，以“既濟(ji)湯(tang)”酸斂固(gu)澀。

除(chu)元(yuan)(yuan)氣(qi)上脫(tuo)、下(xia)(xia)脫(tuo)之(zhi)外，又有所謂外脫(tuo)、內脫(tuo)。外脫(tuo)者，癥(zheng)見(jian)周身汗出不(bu)(bu)止(zhi)，或(huo)(huo)“目睛上竄，或(huo)(huo)喘逆，或(huo)(huo)怔忡，或(huo)(huo)氣(qi)虛不(bu)(bu)足以息”，張氏認為此乃“肝(gan)膽虛極而元(yuan)(yuan)氣(qi)欲脫(tuo)也”。即肝(gan)陰過虛，肝(gan)風萌動，元(yuan)(yuan)氣(qi)欲脫(tuo)，用來(lai)復湯治之(zhi)。內脫(tuo)，如“胸中(zhong)大氣(qi)下(xia)(xia)陷，氣(qi)短不(bu)(bu)足以息，或(huo)(huo)努力呼(hu)吸，有似(si)乎(hu)喘，或(huo)(huo)氣(qi)息將停(ting)，危在頃(qing)刻……其脈象(xiang)沉(chen)遲微弱，關前尤甚；其劇者，或(huo)(huo)六脈不(bu)(bu)全，或(huo)(huo)參伍不(bu)(bu)調”，此系中(zhong)氣(qi)自(zi)內而陷的內脫(tuo)證，張氏以“升陷湯”升補下(xia)(xia)陷之(zhi)氣(qi)，再加(jia)山萸肉收斂(lian)氣(qi)分之(zhi)耗散，使升者不(bu)(bu)至復陷，共(gong)挽中(zhong)氣(qi)下(xia)(xia)陷所致之(zhi)內脫(tuo)。

從上述救(jiu)脫方可見，張氏救(jiu)脫善用(yong)山(shan)萸(yu)肉。他(ta)認(ren)為山(shan)英肉味酸(suan)性溫，固澀滑脫，通利九竅，流通血脈，為補(bu)肝之妙藥，其救(jiu)脫之功，較參(can)、術、芪更勝。“蓋萸(yu)肉之性，不獨補(bu)肝也(ye)，凡人(ren)(ren)身之陰陽，氣血將散者，皆能斂之，故救(jiu)脫之藥，當以(yi)(yi)萸(yu)肉為第一”。常用(yong)萸(yu)肉治療各種虛脫危證(zheng)，或配以(yi)(yi)生(sheng)龍骨、牡(mu)蠣斂汗；或配人(ren)(ren)參(can)、附子(zi)、山(shan)藥、炙甘草益(yi)氣回陽固脫；或配當歸、熟地(di)填補(bu)精血等(deng)。其論(lun)脫證(zheng)病機及治法用(yong)藥，別開生(sheng)面，對(dui)后人(ren)(ren)啟迪尤深(shen)。

(四)遣藥制方心得(de)

張氏制(zhi)方用藥頗有獨到經驗(yan)，通性味，善配伍，別具匠(jiang)心。具體表現在以下幾個方面(mian)。

1、精研(yan)藥物，頗多新見

張氏(shi)認為學(xue)醫(yi)(yi)的(de)第一層功(gong)夫(fu)即是識藥(yao)(yao)性，其(qi)對(dui)藥(yao)(yao)性的(de)理解，于諸(zhu)家本草學(xue)之外，頗多新見。《醫(yi)(yi)學(xue)衷(zhong)中(zhong)參西錄》書中(zhong)專列《藥(yao)(yao)物(wu)》一章，對(dui)常用的(de)79種藥(yao)(yao)物(wu)詳(xiang)加(jia)解釋，闡述了張氏(shi)對(dui)藥(yao)(yao)物(wu)的(de)獨到(dao)認識與經驗。其(qi)中(zhong)他研(yan)究最精的(de)藥(yao)(yao)物(wu)有黃芪、山(shan)萸肉(rou)、赭石、山(shan)藥(yao)(yao)、三七、黨參、乳香(xiang)、沒藥(yao)(yao)、三棱、水蛭、牛膝、龍骨(gu)、牡蠣等。

例如，他廣泛應用(yong)大(da)劑(ji)量石膏治(zhi)療外感熱(re)性(xing)病(bing)(bing)屢收(shou)良效(xiao)，認(ren)為并(bing)無(wu)損傷(shang)脾胃(wei)之(zhi)(zhi)弊，且隨著熱(re)退病(bing)(bing)愈(yu)而(er)(er)飲食倍(bei)增，為清解(jie)大(da)熱(re)之(zhi)(zhi)特效(xiao)藥(yao)(yao)。善(shan)用(yong)三(san)(san)棱(leng)(leng)、莪(e)術，認(ren)為二藥(yao)(yao)善(shan)破(po)血(xue)、調氣(qi)(qi)(qi)(qi)(qi)，化(hua)瘀(yu)則三(san)(san)棱(leng)(leng)優于莪(e)術，理(li)氣(qi)(qi)(qi)(qi)(qi)則莪(e)術優于三(san)(san)棱(leng)(leng)，若“二藥(yao)(yao)合用(yong)，常(chang)有協同(tong)之(zhi)(zhi)功”。認(ren)為水蛭破(po)瘀(yu)最(zui)效(xiao)，善(shan)除日久之(zhi)(zhi)瘀(yu)滯，能(neng)使瘀(yu)血(xue)默(mo)消于無(wu)形之(zhi)(zhi)中(zhong)，乳香(xiang)善(shan)透竅理(li)氣(qi)(qi)(qi)(qi)(qi)，沒藥(yao)(yao)善(shan)化(hua)瘀(yu)理(li)血(xue)，二藥(yao)(yao)并(bing)用(yong)為宣通(tong)臟腑、流(liu)通(tong)經(jing)絡之(zhi)(zhi)要(yao)藥(yao)(yao)，常(chang)用(yong)于治(zhi)心、胃(wei)、脅、腹(fu)及肢(zhi)體(ti)關節(jie)諸痛(tong)(tong)，經(jing)痛(tong)(tong)，產后瘀(yu)血(xue)腹(fu)痛(tong)(tong)，月經(jing)不(bu)(bu)調，風(feng)寒濕痹，中(zhong)風(feng)四(si)肢(zhi)不(bu)(bu)遂(sui)及一切瘡瘍腫(zhong)痛(tong)(tong)；雞內金味(wei)酸性(xing)溫(wen)藥(yao)(yao)性(xing)平和(he)(he)，有補(bu)脾胃(wei)之(zhi)(zhi)妙，善(shan)化(hua)有形之(zhi)(zhi)瘀(yu)積(ji)；山楂化(hua)瘀(yu)血(xue)而(er)(er)不(bu)(bu)傷(shang)新血(xue)，開(kai)郁氣(qi)(qi)(qi)(qi)(qi)而(er)(er)不(bu)(bu)傷(shang)正(zheng)氣(qi)(qi)(qi)(qi)(qi)；茵陳、麥芽(ya)皆具疏(shu)肝解(jie)郁之(zhi)(zhi)效(xiao)，體(ti)弱(ruo)陰虛不(bu)(bu)任(ren)柴胡升散者，常(chang)以(yi)其代(dai)之(zhi)(zhi)；黃(huang)芪性(xing)溫(wen)味(wei)微甘，補(bu)氣(qi)(qi)(qi)(qi)(qi)兼能(neng)升氣(qi)(qi)(qi)(qi)(qi)，善(shan)治(zhi)氣(qi)(qi)(qi)(qi)(qi)虛、氣(qi)(qi)(qi)(qi)(qi)陷諸證(zheng)，且其“性(xing)溫(wen)而(er)(er)上升，以(yi)之(zhi)(zhi)補(bu)肝有同(tong)氣(qi)(qi)(qi)(qi)(qi)相求(qiu)之(zhi)(zhi)妙用(yong)”，故凡肝氣(qi)(qi)(qi)(qi)(qi)虛弱(ruo)不(bu)(bu)能(neng)條達，用(yong)一切補(bu)肝之(zhi)(zhi)藥(yao)(yao)皆不(bu)(bu)效(xiao)者，倡重用(yong)黃(huang)芪為主，而(er)(er)少佐以(yi)理(li)氣(qi)(qi)(qi)(qi)(qi)之(zhi)(zhi)品，并(bing)據(ju)此批評“肝虛無(wu)補(bu)法”之(zhi)(zhi)談(tan)。這(zhe)些獨創性(xing)見解(jie)，擴(kuo)大(da)和(he)(he)豐富(fu)了藥(yao)(yao)物的臨床應用(yong)范圍。

2、善用生藥，注重配伍(wu)

張錫純(chun)在《醫(yi)學衷中參西錄》中自擬良方(fang)百余首，以生(sheng)(sheng)(sheng)藥(yao)見(jian)長，對生(sheng)(sheng)(sheng)藥(yao)的使(shi)用(yong)獨(du)具卓見(jian)。如水(shui)蛭，方(fang)書多謂必(bi)須炙(zhi)透方(fang)可(ke)使(shi)用(yong)，但張氏認為(wei)，此物生(sheng)(sheng)(sheng)于水(shui)中，原(yuan)得(de)水(shui)之(zhi)(zhi)精氣(qi)而(er)生(sheng)(sheng)(sheng)，炙(zhi)之(zhi)(zhi)則傷水(shui)之(zhi)(zhi)精氣(qi)，不(bu)若(ruo)生(sheng)(sheng)(sheng)用(yong)。因而(er)在治療經閉不(bu)行、產(chan)后惡露不(bu)盡或瘀(yu)血(xue)頑癥時，常(chang)于理沖(chong)(chong)湯、理沖(chong)(chong)丸中加入水(shui)蛭一(yi)錢或一(yi)兩，并(bing)(bing)標明“不(bu)用(yong)炙(zhi)”。認為(wei)赭(zhe)石色赤(chi)性微涼(liang)(liang)，生(sheng)(sheng)(sheng)血(xue)兼(jian)能涼(liang)(liang)血(xue)，且因其(qi)質重墜(zhui)，又可(ke)鎮(zhen)逆、降痰(tan)、止嘔、通便，“生(sheng)(sheng)(sheng)研服之(zhi)(zhi)不(bu)傷腸胃(wei)……且生(sheng)(sheng)(sheng)服則養(yang)氣(qi)純(chun)全(quan)，大能養(yang)血(xue)”。故治陰陽兩虛、喘逆迫(po)促之(zhi)(zhi)喘息，重用(yong)生(sheng)(sheng)(sheng)赭(zhe)石伍以生(sheng)(sheng)(sheng)龍牡斂沖(chong)(chong)降逆；又與肉蓯蓉(rong)、當歸并(bing)(bing)用(yong)，補腎斂沖(chong)(chong)，潤便通結。張氏臨床常(chang)用(yong)的生(sheng)(sheng)(sheng)藥(yao)還(huan)有生(sheng)(sheng)(sheng)乳香、生(sheng)(sheng)(sheng)沒藥(yao)、生(sheng)(sheng)(sheng)雞內金、生(sheng)(sheng)(sheng)黃芪、生(sheng)(sheng)(sheng)山藥(yao)、生(sheng)(sheng)(sheng)杭芍、生(sheng)(sheng)(sheng)石膏(gao)等。

此外，張氏根(gen)據其臨床(chuang)(chuang)經驗和體會(hui)，總(zong)結(jie)出(chu)許多新的藥對配伍關系。如山藥配牛蒡子，疏補(bu)(bu)兼行，補(bu)(bu)腎健脾(pi)，清肺止(zhi)咳，祛痰降氣；人參配代(dai)赭石，剛柔(rou)相(xiang)濟，升降互用(yong)，治療脾(pi)胃氣虛(xu)(xu)，沖氣相(xiang)干，或用(yong)于上盛下虛(xu)(xu)、氣血將(jiang)脫；黃芪配知母，寒熱平調以益(yi)氣升舉；人參配威靈仙治氣虛(xu)(xu)小便不利；生龍(long)、牡配萸肉，三(san)藥聯合應用(yong)，收斂固脫、澀(se)精(jing)止(zhi)汗等，均可資臨床(chuang)(chuang)參考。

3、潛心實踐(jian)，創制新方

張氏對方藥的(de)(de)(de)運用(yong)也頗(po)有(you)心得，在《醫(yi)學衷中(zhong)(zhong)參西錄》中(zhong)(zhong)創立了許多(duo)有(you)效的(de)(de)(de)方劑，廣及內、外、婦(fu)、兒(er)各(ge)科(ke)，其多(duo)有(you)所宗，遵經(jing)而(er)(er)不(bu)泥古，通變而(er)(er)不(bu)失規矩。其中(zhong)(zhong)，有(you)不(bu)少為(wei)(wei)師法(fa)仲景原意而(er)(er)化裁創制(zhi)的(de)(de)(de)新(xin)方。如治(zhi)(zhi)吐衄(nv)諸方是(shi)受《金匱》瀉心湯影(ying)響，以(yi)(yi)降胃(wei)為(wei)(wei)主，故喜用(yong)赭石(shi)、半(ban)夏。治(zhi)(zhi)療胸(xiong)(xiong)(xiong)中(zhong)(zhong)蘊熱為(wei)(wei)外感(gan)所束，不(bu)能發泄而(er)(er)致煩躁(zao)的(de)(de)(de)猶龍湯，立意源于大(da)(da)(da)青龍湯，由連翹(qiao)、生石(shi)膏、蟬(chan)蛻(tui)、牛蒡子(zi)(zi)組成。治(zhi)(zhi)滿悶短氣，呼(hu)吸不(bu)利的(de)(de)(de)蕩胸(xiong)(xiong)(xiong)湯，于大(da)(da)(da)陷胸(xiong)(xiong)(xiong)湯中(zhong)(zhong)取用(yong)芒硝，于小陷胸(xiong)(xiong)(xiong)湯中(zhong)(zhong)取用(yong)瓜蔞(lou)，又(you)于治(zhi)(zhi)心下(xia)痞硬之(zhi)(zhi)旋覆代赭湯中(zhong)(zhong)取用(yong)赭石(shi)，而(er)(er)復(fu)加蘇(su)子(zi)(zi)以(yi)(yi)為(wei)(wei)下(xia)行(xing)之(zhi)(zhi)向導，可(ke)以(yi)(yi)代大(da)(da)(da)陷胸(xiong)(xiong)(xiong)湯、丸(wan)，亦可(ke)代小陷胸(xiong)(xiong)(xiong)湯。又(you)如其治(zhi)(zhi)療婦(fu)科(ke)病之(zhi)(zhi)理沖(chong)湯、理沖(chong)丸(wan)，用(yong)參、術(shu)、當歸、山(shan)藥等補(bu)氣健(jian)脾扶正(zheng)，莪(e)術(shu)、三(san)棱(leng)、水(shui)蛭(zhi)等活(huo)血(xue)化瘀，為(wei)(wei)攻補(bu)兼(jian)施(shi)，扶正(zheng)化瘀，治(zhi)(zhi)閉經(jing)及癥(zheng)瘕之(zhi)(zhi)虛(xu)(xu)(xu)實夾雜證良方。又(you)如治(zhi)(zhi)崩漏的(de)(de)(de)安沖(chong)湯、固沖(chong)湯，熔塞流、澄源、補(bu)虛(xu)(xu)(xu)于一爐，止血(xue)而(er)(er)不(bu)留(liu)瘀，清熱而(er)(er)不(bu)涼(liang)遏，溫補(bu)而(er)(er)不(bu)閉邪。再如，如治(zhi)(zhi)陰虛(xu)(xu)(xu)勞嗽(sou)之(zhi)(zhi)資生湯，治(zhi)(zhi)腦(nao)充血(xue)頭目眩暈之(zhi)(zhi)建(jian)瓴湯，治(zhi)(zhi)心腹疼痛、癥(zheng)瘕痰(tan)癖(pi)的(de)(de)(de)活(huo)絡效靈丹(dan)，治(zhi)(zhi)腎虛(xu)(xu)(xu)滑胎的(de)(de)(de)壽胎丸(wan)等等，都(dou)是(shi)行(xing)之(zhi)(zhi)有(you)效的(de)(de)(de)名方。

背景介紹

張氏(shi)治學(xue)嚴謹，重視實踐，主張溝通(tong)中(zhong)西(xi)，取(qu)長補短，是近代中(zhong)西(xi)醫(yi)匯(hui)通(tong)派的代表之一。結合其多年(nian)臨證經驗與(yu)匯(hui)通(tong)中(zhong)西(xi)的體會，著成《醫(yi)學(xue)衷中(zhong)參西(xi)錄(lu)》。

作者介紹

張錫純，字壽甫，清(qing)末民初(chu)河北省鹽山(shan)縣人。生活于公元1860～1933年(nian)(nian)(清(qing)咸豐十(shi)年(nian)(nian)至民國二十(shi)二年(nian)(nian))。幼敏而好學，攻讀經史之(zhi)余，兼習岐黃之(zhi)書，后(hou)(hou)因兩試秋闈不第，遂潛心醫(yi)學。早年(nian)(nian)懸壺鄉梓(zi)，革命軍興，應聘從戎去武漢為軍醫(yi)。1917年(nian)(nian)在沈陽創(chuang)建“立(li)達中醫(yi)院”。直奉戰起，回故(gu)居河北滄州行醫(yi)，1926年(nian)(nian)移居天津，創(chuang)辦“天津國醫(yi)函授學校”，培養了大批中醫(yi)后(hou)(hou)繼(ji)人才。

張(zhang)氏治學(xue)(xue)嚴(yan)謹(jin)，重視實(shi)踐，主張(zhang)溝通中(zhong)西，取長補(bu)短，是近代(dai)中(zhong)西醫(yi)匯通派的(de)代(dai)表(biao)之(zhi)(zhi)一。其醫(yi)德高尚(shang)，常舍藥濟貧(pin)，遇(yu)疑難重癥，殫思(si)竭慮，并(bing)親自攜藥到病家督煎，守護達旦。為了體驗藥物的(de)毒性反應(ying)和(he)用(yong)量，曾親嘗(chang)巴豆、花椒、甘(gan)遂等(deng)藥，足見其對病人極端(duan)負責的(de)精神(shen)和(he)重視實(shi)踐的(de)治學(xue)(xue)態度。他醫(yi)術精湛，常能力(li)排眾議，獨任(ren)其責，起群醫(yi)束手之(zhi)(zhi)沉疴(ke)，療效卓著，名震(zhen)遐(xia)邇。當時與江蘇(su)陸晉笙、楊如侯，廣東劉(liu)蔚楚同負盛名，又與慈溪張(zhang)生甫、嘉定張(zhang)山雷并(bing)稱(cheng)名醫(yi)三張(zhang)。

張氏勤于鉆研，善于總結，平生著述甚(shen)多(duo)，后因天津洪水沒其居(ju)，遺書蕩盡，傳世者僅《醫學(xue)衷(zhong)中參西錄(lu)》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(chuang)醫(yi)(yi)學名著，素為醫(yi)(yi)家所重視。