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• 檢視主題 - 張錫純先生論治肝病中所見坤載先生思想

張錫純先生論治肝病中所見坤載先生思想

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版主: 阿旺

張錫純先生論治肝病中所見坤載先生思想

文章阿旺 發表於 2010年 9月 15日, 15:44

近日在矽谷中醫損友團小弟有一篇文章:
到底是「土」的整治最要,還是「木」的調理為上呢?


其中可見到張錫純先生對之前cch網友的問題解答。
而他論治肝病的方式頗有出奇制勝之妙。
謹錄先生文字如下,以為查找方便



論肝病治法

肝為厥陰,中見少陽,且有相火寄其中,故《內經》名為將軍之官,其性至剛也。為其性剛,當有 病時恆侮其所勝,以致脾胃受病,至有脹滿、疼痛、泄瀉種種諸証。因此方書有平肝之說,謂平肝即所以扶脾。若遇肝氣橫恣者,或可暫用而不可長用。因肝應春令,為氣化發生之始,過平則人身之氣化必有所傷損也。有謂肝于五行屬木,木性原善條達,所以治肝之法當以散為補(方書謂肝以斂為瀉以散為補)。散者即升發條達之也,然升散常用,實能傷氣耗血,且又暗傷腎水以損肝木之根也。

有謂︰肝惡燥喜潤。燥則肝體板硬,而肝火肝氣即妄動;潤則肝體柔和,而肝火肝氣長寧靜。是以方書有以潤藥柔肝之法。然潤藥屢用,實與脾胃有礙,其法亦可暫用而不可長用。然則治肝之法將惡乎宜哉?

《內經》謂︰“厥陰不治,求之陽明”。《金匱》謂︰“知肝之病,當先實脾。”
先聖後聖,其揆如一,此誠為治肝者之不二法門也。惜自漢、唐以還,未有發明其理者。獨至黃坤載,深明其理謂︰“肝氣宜升,膽火宜降。然非脾氣之上行,則肝氣不升,非胃氣之下行,則膽火不降。”旨哉此言,誠窺《內經》、《金匱》之精奧矣。由斯觀之,欲治肝者,原當升脾降胃,培養中宮,俾中宮氣化敦濃,以聽肝木之自理。

即有時少用理肝之藥,亦不過為調理脾胃劑中輔佐之品。所以然者,五行之土原能包括金木水火四行,人之脾 胃屬土,其氣化之敷布,亦能包括金木水火諸臟腑。所以脾氣上行則肝氣自隨之上升,胃氣下行則膽火自隨之下降也。又《內經》論厥陰治法,有“調其中氣,使之和平”之語。所謂調其中氣者,即升脾降胃 之謂也。所謂使之和平者,即升脾降胃而肝氣自和平也。至仲景著《傷寒論》,深悟《內經》之旨,其厥陰治法有吳茱萸湯;厥陰與少陽臟腑相依,乃由厥陰而推之少陽治法,有小柴胡湯。二方中之人參、半夏、大棗、生薑、甘草,皆調和脾胃之要藥也。且小柴胡湯以柴胡為主藥,而《神農本草經》謂其主腸胃中結氣,飲食積聚,寒熱邪氣,推陳致新。三複《神農本草經》之文,則柴胡實亦為陽明胃府之藥,而兼治少 陽耳。欲治肝膽之病者,易弗祖《內經》而師仲景哉﹗

獨是,肝之為病不但不利于脾,舉凡驚癇、癲狂、眩暈、腦充血諸証西人所謂腦氣筋病者,皆與肝經有涉。蓋人之腦氣筋發源于腎,而分派于督脈,系淡灰色之細筋。肝原主筋,肝又為腎行氣,故腦氣筋之病實與肝臟有密切之關系也。治此等証者,當取五行金能製木之理,而多用五金之品以鎮之,如鐵鏽、鉛灰、 金銀箔、赭石(赭石鐵養化合亦含有金屬)之類,而佐以清肝潤肝之品,若羚羊角、青黛、芍藥、龍膽草、牛膝(牛膝味酸入肝,善引血火下行,為治腦充血之要藥,然須重用方見奇效)諸藥,俾肝經風定火熄,而腦氣筋亦自循其常度,不至有種種諸病也。若目前不能速癒者,亦宜調補脾胃之藥佐之,而後金屬及寒涼之品可久服無弊。且諸証多系挾有痰涎,脾胃之升降自若而痰涎自消也。

有至要之証,其病因不盡在肝,而急則治標,宜先注意於肝者,元氣之虛而欲上脫者是也。其病狀多大汗不止,或少止複汗,而有寒熱往來之象。或危極至於戴眼,不露黑睛;或無汗而心中搖搖,需人按住;或兼喘促。此時宜重用斂肝之品,使肝不疏泄,即能杜塞元氣將脫之路。至汗止、怔忡、喘促諸疾暫愈,而後徐圖他治法。宜重用山茱萸淨肉至二兩(《神農本草經》山萸肉主治寒熱即指此証),斂肝即以補肝,而以人參、赭石、龍骨、牡蠣諸藥輔之。拙著來復湯後載有本此法挽回垂絕之証數則,可參閱也。究之肝膽之為用,實能與脾胃相助為理。因五行之理,木能侮土,木亦能疏土也。曾治有飲食不能消化,服健脾暖胃之藥百劑不效。診其左關太弱,知系肝陽不振,投以黃(其性溫升肝木之性亦溫升有同氣相求之義,故為補肝之主藥)一兩,桂枝尖三錢,數劑而癒。又治黃膽,診其左關特弱,重用黃煎湯,送服《金匱》黃膽門硝石礬石散而癒。若是皆其明征也。且膽汁入於小腸,能助小腸消化食物,此亦木能疏土之理。蓋小腸雖屬火,而實與胃腑一體相連,故亦可作土論。膽汁者,原由肝中回血管之血化出,而注之于膽,實得甲乙木氣之全,是以在小腸中能化胃中不能化之食,其疏土之效愈捷也。又西人謂肝中為回血管會合之處,或肝體發大,或肝內有熱,各管即多凝滯壅脹。由斯知疏達肝鬱之藥,若柴胡、川芎、香附、生麥芽、乳香、沒藥皆可選用;而又宜佐以活血之品,若桃仁、紅花、樗雞、蟲之類,且又宜佐以瀉熱之品,然不可驟用大涼之藥,恐其所瘀之血得涼而凝,轉不易消散,宜選用連翹、茵陳、川楝子、梔子(梔子為末,燒酒調敷,善治跌打處青紅腫疼,能消瘀血可知)諸藥,涼而能散,方為對証。

肝體木硬,宜用柔肝之法。至柔肝之藥,若當歸、芍藥、柏子仁、玄參、枸杞、阿膠、鱉甲皆可選用,而亦宜用活血之品佐之。而活血藥中尤以三七之化瘀生新者為最緊要之品,宜煎服湯藥之外,另服此藥細末日三次,每次錢半或至二錢。則肝體之木硬者,指日可柔也。

《內經》謂︰“肝苦急,急食甘以緩之。”所謂苦急者,乃氣血忽然相並於肝中,致肝臟有急迫難緩之勢,因之失其常司。當其急迫之時,肝體亦或木硬,而過其時又能複常。故其治法,宜重用甘緩之藥以緩其急,其病自愈,與治肝體長此木硬者有異。曾閱《山西醫志》二十四期,有人過服燥熱峻烈之藥,驟發痙厥,角弓反張,口吐血沫。喬××遵《內經》之旨,但重用甘草一味,連煎服,數日痊癒,可謂善讀《內經》者矣。然此証若如此治法仍不癒者,或加以涼潤之品,若羚羊角、白芍,或再加鎮重之品,若朱砂(研細送服) 、鐵鏽,皆可也。

【新擬和肝丸】治肝體木硬,肝氣鬱結,肝中血管閉塞,及肝木橫恣侮克脾土。其現病或脅下脹疼,或肢體串疼,或飲食減少,嘔噦,吞酸,或噫氣不除,或呃逆連連,或頭疼目脹、眩暈、痙癇,種種諸証。

粉甘草(五兩細末) 生杭芍(三兩細末) 青連翹(三兩細末) 廣肉桂(兩半去粗皮細末)冰片(三錢細末) 薄荷冰(四錢細末) 片朱砂(三兩細末)

上藥七味,將前六味和勻,水泛為丸,梧桐子大,晾干(不宜晒),用朱砂為衣,勿餘剩。務令堅實光滑始不走味。每於飯後一點鐘服二十粒至三十粒,日再服。病急劇者,宜空心服;或於服兩次之後,臨睡時又服一次更佳。若無病者,但以為健胃消食藥,則每飯後一點鐘服十粒即可。

數年來肝之為病頗多,而在女子為尤甚。醫者習用香附、青皮、枳殼、延胡開氣之品,及柴胡、川芎升氣之品。連連服之,恆有肝病未除,元氣已弱,不能支持,後遇良醫,亦殊難為之挽救,若斯者良可慨也。

此方用甘草之甘以緩肝;芍藥之潤以柔肝;連翹以散其氣分之結(嘗單用以治肝氣鬱結有殊效);冰片、薄荷冰以通其血管之閉;肉桂以抑肝木之橫恣;朱砂以製肝中之相火妄行。且合之為丸,其味辛香甘美,能醒脾健胃,使飲食加增。又其藥性平和,在上能清,在下能溫(此藥初服下覺涼及行至下焦則又變為溫性)。 故凡一切肝之為病,服他藥不癒者,徐服此藥,自能奏效。
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阿旺
 
文章: 272
註冊時間: 2009年 10月 8日, 10:28

Re: 張錫純先生論治肝病中所見坤載先生思想

文章阿旺 發表於 2010年 9月 15日, 15:47

張錫純先生的文章中的這話很值得再三思考:

數年來肝之為病頗多,而在女子為尤甚。醫者習用香附、青皮、枳殼、延胡開氣之品,及柴胡、川芎升氣之品。連連服之,恆有肝病未除,元氣已弱,不能支持,後遇良醫,亦殊難為之挽救,若斯者良可慨也。

在近日看不少人治肝之病,果然如張先生所言,多用前述之藥。
若治一時之疾苦則可,但是長期來用自是不宜。
也許這個【新擬和肝丸】可在臨床上辨證而在長期調理時用之。
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阿旺
 
文章: 272
註冊時間: 2009年 10月 8日, 10:28


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