刘鸿恩应用大黄的经验

·历代名医及其著作· 刘鸿恩应用大黄的经验 贾燕平　韩冠先　连华敏　洛阳市第二中医院( 471003) 摘要　　晚清医家刘鸿恩在其《医门八法》一书中,对大黄的应用独具匠心。对一切实证,不论伤寒、温病,刘氏均主 张及早用大黄攻邪,否则就会护疾养毒,致生他变;刘氏把舌苔的有无、苔色的黄白作为是否应用大黄攻下的依据; 对于实热之证,刘氏不主张用清热法直折热势,却力主用大黄攻逐实邪,如此则实既去,热无所生,势必消退;对当 下难下者,则巧妙配伍,但“必以祛邪为首务”。再如实热隆闭、外感表实,通便攻下,辄有效验。 主题词　/刘鸿恩 /中医师 　《医门八法》　大黄/治疗应用 　　晚清医家刘鸿恩, 河南尉氏人, 所著《医门八 法》涉及到应用大黄的病证 26 种, 占所列病证的 42. 6% ,且立意精卓,匠心颇具, 兹作初步探讨。 1　谨察虚实,当下不厌 刘氏对各种疾病每以虚实提纲挈领, 认为虚则 气血, 实则饮食, 若果系实证, 唯攻下才能去其实。 对一切实证, 不论伤寒、温病,刘氏均主张及早用大 黄攻邪, 否则就会护疾养毒,致生他变。他还主张药 过病所, 超剂应用, 指出: “大黄正自柔和, 果系实 证, 宜用大黄五钱者,即予七钱,不过多下两次耳”, “不必以虚脱为虑也。”切不可视大黄如虎狼, 裹足 不前, 养奸遗患。若遇邪热胶固之证 ,则又“必须大 下、屡下, 始足以胜之。”如果用量不足,次数不够, 则“虽用大黄与不用等耳⋯⋯误入性命, 亦在皆 然。”可见刘氏用大黄重在察别虚实, 只要有实象, 则下不厌早, 下不厌大,下不厌频, 务使邪尽为要。 2　舌上有苔,攻下之征 既然实证非大黄攻下不能祛疾, 那么如何来判 断果系实证呢? 对此, 刘氏推崇吴又可:“舌无苔则 胃无物”之说,把舌苔的有无,苔色的黄白作为是否 应用大黄攻下的依据。他认为,一般情况下,舌上有 苔即可用大黄, 尤其当正虚邪盛, 非下不可, 欲下不 敢之际, “宜详查舌上是否有苔,有苔则可下。”但对 温疫初期, 则应同时看舌苔是否变黄, “若舌苔已 黄, 则必重用大黄”。刘氏不仅验苔以决定大黄的去 留, 还据此来判断大黄的用度, 若洞下数次, 舌苔退 去或“舌苔刮去,即不复生者,方为痊愈”, 大黄可不 复用, 反之则须再用大黄,“再下数次,即痊愈矣”。 3　实热之证,唯攻其实 对于实热之证的治疗, 刘氏不主张用清热法直 折热势, 而是遵循“见热休治热, 而治其所以热”的 原则, 认为“实为本, 热为标”。由于热因实而生,故 不能清热, 清热则实不去而热旋生, “徒伤胃气而无 损于病”,结果使正气消残, 邪反为痼,疾必不除。所 以, 刘氏平生最忌用黄连、黄芩等清热之品治疗实 热证, 力主用大黄攻逐实邪, 如此则实既去, 热无所 生, 势必消退,实为治病求本之施。 4　当下难下,巧妙配伍 疾病在其发展演变过程中,往往会出现正邪胜 伏, 虚实挟杂的局面。此时下恐伤正, 不下遗患。当 下难下之际刘氏认为应及早以大黄攻下, 只是在应 用时要针对具体情况适当配伍。如血虚者配当归, “当归原属补血之品,然能润燥滑肠, 可以助下剂之 力”, 二者配伍则邪易去而正易复; 气虚者配党参, “党参原系补气之品,然能助胃气,胃气虚而屡下不 通者”,二者配伍可取“一服而宿垢顿下”之功; 若欲 缓大黄攻下之力, 则可配用少量甘草,“若重用甘草 以缓之, 虽用大黄直不泻矣”。总之, 刘氏对当下难 下之证, “养正以祛邪,祛邪以安正”, 互为加减, 迭 为进退, 而以祛邪为首务。 5　实热癃闭,法当通便 刘氏认为癃闭乃“最急最危之证”。因为“水道 不通则上浸脾胃而为胀, 外浸肌肉而为肿,泛及中 焦则为呕, 再及上焦则为喘”。此证实热为多, 治疗 上多采用清利湿热之法, 但效果多不理想。为此,刘 氏指出: “若夫实热癃闭, 服清热利水之剂不效者, 宜分清饮重加大黄”, “但得大便通利, 则热随大便 而泄, 小便将自利矣。” 6　外感表实,宜当攻下 一般认为外感表实,治当表散,不能攻里, 若误 用下法则有引邪入里之虞。刘氏则不以为然, 他说 “外感风寒,热证也”。其初虽可见到憎寒,皆因阳气 被风寒所郁之故, 很快就会转变成热证。既是热证, 治当攻下, “热虽百而下则一”, 下则热除病愈, 切不 可表散, 而致“反烦不解”。尤其是外感重证,往往表 现与温疫同证, 治“宜用吴氏三消饮以攻里”, 极有 效验, 值得临床研究。 综上所述, 刘氏用大黄攻里通下,别出心裁,可 资临床借鉴。 ( 收稿日期　1998 05 12 ) ·276· 1998年 第 18卷 第 5期　　　 　 河南中医　HENAN TRADITIONAL CHINESE MEDICINE　　　　 Vol. 18 No. 5 1998 Abstracts of Major Papers in This Issue Breeding and Development of the Doctrine of Six Meridians in Constitution L iang H ualong Henan Col leg e of T radit ional Chinese M edicine( 450003) 　　Constitution is the indiv idual specificity produced and influenced by the congenital endow ment and ac- quir ed env ir onment. The author g iv es a systematic and br ief explanation fo r the pathogenics, patholo gy , dr omotr opics therapeutics and nursing of constitution in T r eatise on Febr ile D iseases , hoping t o furt her bring to light the pro found intension of Zhang Zhong jing′s t heo r y fr om the constit ut ion point of v iew . ( See Page　261) Treatment Based on Disease, Treatment by Differentiating Sydrome, Treatment According to Symptoms Wang Yuz hong, Wang H aicheng , Luohe Sanitar y School Henan Province ( 452000) 　　In view o f the disease o f modern medicine, same disease should be tr eated with sam e m ethod and dif- ferent disease w ith differ ent method, especially for tho se w hich have no“syndrome”for differentiation and can be tr eated by specific remedy . During the differ ent st age o f diagnosis and trea tment based on disease, ther e ar e special pat holog ic changes: if the syndrone is differ ent, the diagno sis and treat ment should be based on specific disease and sydrome, ( that is, the same fr eatment for the same syndrome, differ ent treat - ment for differ ent syndrome , the cer tain medicine for the certain syndrome ) , especially fo r t ho se w hich have indistinct cause and mechanism, the same disease can be tr eated w ith differ ent methods, and difer ent diseaese w it h same method. And for those which have clear and cr itical main symptoms and the concurr ent symptom is prominent, the method o f tr eatment according to symptoms can be used. In o rder to take ad- vantage of three methods to g ain the best cur ative effect, after distinguishing the pr imary and secondar y , w eighing the relative impor tance, the thr ee methods o f trea ting disease, tr eating syndrom e ane t reating symptoms can be used at the same time. ( See Page　265) Liu Hongen's Experience in the Application of Rhubarb H an Guanx ian, L ian H uamin T he Second Hospital of T CM of Luoyang City. ( 471003) 　　L iu Hongen, phy sician of Late Q ing Dynasty , had a distinguished under standing for the application of rhubarb in his wo rk Eight Pr incip les f or Med ical Prof ession. T o any excess sydrome, r ega rdless of ex oge- nous febrile disease and epidemic febr ile disease, he maintained that rhuba rb should promptly be applied t o eliminate the pathogenic facto r , otherwise, it may produce o ther patholog ic change. He maintained that w het her t o use rhubrb o r no t fo r pur gat ion should be based on t he tongue fur's ex istence and co lo r. He maintained t hat heat - clear ing method should not be used to set back t he heat momentum, but that rhubarb should be used to eliminate pathogenic factor of ex cess type, hence , the excess syndrome is elimi- na ted, the heat has no chance to breed, and the moment um dispears. Fo r those w hich should have been e- liminated but difficult to be done, the pr escr iption should be made up ingeniously, but t he key purpose is to eliminate t he pathogenic fa cto r . F or instance, t o the heat of ex cess type and difficulty in ur ination, and the ex terior syndrom e of ex cess due to exopat hy , t he method of r elax ing the bowels and purgation has the rapeutic effect. ( See Page　276) ·327· 1998年 第 18卷 第 5期　　　 　 河南中医　HENAN TRADITIONAL CHINESE MEDICINE　　　　 Vol. 18 No. 5 1998