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脈癥的取合

祝由網(wang) 2023-11-12 21:55:18

一個正(zheng)確診斷(duan)的(de)(de)(de)確立,須要建立在對(dui)(dui)客(ke)觀病情(qing)全(quan)面占(zhan)有(you)的(de)(de)(de)基礎上,而望聞問切就(jiu)(jiu)是獲得(de)這種(zhong)材(cai)料的(de)(de)(de)必要手段(duan)。醫(yi)者(zhe)經過全(quan)而收集病情(qing)并對(dui)(dui)其做深入縝密的(de)(de)(de)分析,最后(hou)得(de)出合乎實際(ji)的(de)(de)(de)判斷(duan),從而完(wan)成了辨證的(de)(de)(de)全(quan)過程。通常對(dui)(dui)四診獲得(de)的(de)(de)(de)材(cai)料越(yue)豐富全(quan)而,越(yue)有(you)利于(yu)彼此間的(de)(de)(de)互相聯系與印證,診斷(duan)的(de)(de)(de)正(zheng)確性就(jiu)(jiu)越(yue)高。

每病皆有(you)應(ying)(ying)(ying)見之脈(mo)(mo)(mo)癥,如太陽傷(shang)寒(han)(han)出(chu)現發熱(re)惡(e)寒(han)(han),頭(tou)痛身痛,無(wu)汗而喘,口和不(bu)渴,脈(mo)(mo)(mo)浮緊。邪八少陽而現寒(han)(han)熱(re)往來,胸脅苦滿(man),心煩喜(xi)嘔,默默不(bu)欲食(shi),脈(mo)(mo)(mo)弦(xian)細。脈(mo)(mo)(mo)數(shu)見熱(re)證(zheng)(zheng)(zheng)(zheng),脈(mo)(mo)(mo)遲見寒(han)(han)證(zheng)(zheng)(zheng)(zheng),虛(xu)證(zheng)(zheng)(zheng)(zheng)脈(mo)(mo)(mo)弱,實(shi)證(zheng)(zheng)(zheng)(zheng)脈(mo)(mo)(mo)強,脈(mo)(mo)(mo)浮有(you)表證(zheng)(zheng)(zheng)(zheng),脈(mo)(mo)(mo)沉有(you)里證(zheng)(zheng)(zheng)(zheng),由于(yu)脈(mo)(mo)(mo)象與(yu)癥狀表現相一致,古人稱之為(wei)脈(mo)(mo)(mo)癥相應(ying)(ying)(ying),這是發病的一般情況。也有(you)虛(xu)證(zheng)(zheng)(zheng)(zheng)現實(shi)脈(mo)(mo)(mo),實(shi)證(zheng)(zheng)(zheng)(zheng)現虛(xu)脈(mo)(mo)(mo),熱(re)證(zheng)(zheng)(zheng)(zheng)脈(mo)(mo)(mo)遲,寒(han)(han)證(zheng)(zheng)(zheng)(zheng)脈(mo)(mo)(mo)數(shu)等,由于(yu)脈(mo)(mo)(mo)與(yu)癥不(bu)相吻合(he),這就是脈(mo)(mo)(mo)癥不(bu)應(ying)(ying)(ying)。脈(mo)(mo)(mo)癥相應(ying)(ying)(ying)者為(wei)順,治(zhi)療起(qi)來一般較為(wei)順手,脈(mo)(mo)(mo)癥不(bu)應(ying)(ying)(ying)為(wei)逆,治(zhi)療起(qi)來較為(wei)復雜。

由于脈(mo)(mo)癥(zheng)(zheng)(zheng)不(bu)(bu)(bu)應(ying)是癥(zheng)(zheng)(zheng)狀(zhuang)和脈(mo)(mo)象各反映一(yi)(yi)種性質(zhi)的(de)(de)(de)病(bing)癥(zheng)(zheng)(zheng),其(qi)中(zhong)因有一(yi)(yi)真一(yi)(yi)假而不(bu)(bu)(bu)能并(bing)存(cun),就須(xu)舍(she)(she)(she)棄一(yi)(yi)方(fang),而以另一(yi)(yi)方(fang)為(wei)判(pan)斷疾病(bing)的(de)(de)(de)依據,因有取(qu)(qu)有舍(she)(she)(she),前(qian)人(ren)對這(zhe)種情況就稱為(wei)脈(mo)(mo)癥(zheng)(zheng)(zheng)的(de)(de)(de)取(qu)(qu)舍(she)(she)(she)。辨證過程中(zhong)脈(mo)(mo)癥(zheng)(zheng)(zheng)取(qu)(qu)舍(she)(she)(she)說的(de)(de)(de)由來已久(jiu),陶(tao)(tao)節(jie)庵就是對此論述較早(zao)的(de)(de)(de)一(yi)(yi)位醫家。陶(tao)(tao)氏在其(qi)所謂(wei)邪熱(re)(re)入(ru)府,大便(bian)難也(ye),大便(bian)不(bu)(bu)(bu)難,豈敢下乎?其(qi)脈(mo)(mo)雖沉(chen),亦有可汗(han)者(zhe),謂(wei)少陰病(bing),身有熱(re)(re)也(ye),假若(ruo)身不(bu)(bu)(bu)發熱(re)(re),豈敢汗(han)乎?此取(qu)(qu)癥(zheng)(zheng)(zheng)不(bu)(bu)(bu)取(qu)(qu)脈(mo)(mo)也(ye)。”陶(tao)(tao)氏又說:“大抵(di)病(bing)人(ren)表里虛實不(bu)(bu)(bu)同,邪之(zhi)傳變有異(yi),有癥(zheng)(zheng)(zheng)變者(zhe),或(huo)有脈(mo)(mo)變者(zhe),或(huo)有取(qu)(qu)癥(zheng)(zheng)(zheng)不(bu)(bu)(bu)取(qu)(qu)脈(mo)(mo)者(zhe),或(huo)有取(qu)(qu)脈(mo)(mo)不(bu)(bu)(bu)取(qu)(qu)癥(zheng)(zheng)(zheng)者(zhe)。”爾后,李(li)中(zhong)梓(zi)、張(zhang)景岳、張(zhang)路玉、何夢(meng)瑤諸(zhu)醫家,都曾論及這(zhe)個(ge)問題并(bing)有所發揮(hui),成為(wei)診(zhen)斷學(xue)中(zhong)一(yi)(yi)個(ge)組成部分(fen)。下面(mian)分(fen)舍(she)(she)(she)脈(mo)(mo)從(cong)癥(zheng)(zheng)(zheng)與舍(she)(she)(she)癥(zheng)(zheng)(zheng)從(cong)脈(mo)(mo)兩個(ge)方(fang)面(mian)予以敘述。

舍脈從癥

所謂(wei)(wei)舍(she)(she)脈(mo)(mo)(mo)(mo)(mo)從(cong)癥(zheng),是(shi)指(zhi)脈(mo)(mo)(mo)(mo)(mo)癥(zheng)不(bu)(bu)(bu)(bu)應,經過醫者分析,認(ren)為(wei)(wei)(wei)癥(zheng)狀反(fan)映了(le)疾病的(de)本質特(te)征(zheng),從(cong)而(er)(er)作為(wei)(wei)(wei)判斷疾病的(de)依據(ju),因脈(mo)(mo)(mo)(mo)(mo)象對(dui)辨(bian)證無(wu)(wu)甚意義而(er)(er)不(bu)(bu)(bu)(bu)予考慮,稱為(wei)(wei)(wei)舍(she)(she)脈(mo)(mo)(mo)(mo)(mo)從(cong)癥(zheng)。李中(zhong)梓說:“脈(mo)(mo)(mo)(mo)(mo)促為(wei)(wei)(wei)陽(yang),常(chang)用(yong)(yong)(yong)葛根(gen)芩(qin)連(lian)清(qing)之矣,若脈(mo)(mo)(mo)(mo)(mo)促厥冷(leng)(leng)為(wei)(wei)(wei)虛脫,非(fei)灸非(fei)溫(wen)不(bu)(bu)(bu)(bu)可(ke),此(ci)又非(fei)促為(wei)(wei)(wei)陽(yang)盛(sheng)之脈(mo)(mo)(mo)(mo)(mo)也。脈(mo)(mo)(mo)(mo)(mo)遲(chi)(chi)為(wei)(wei)(wei)寒(han),常(chang)用(yong)(yong)(yong)干姜附子溫(wen)之矣,若陽(yang)明脈(mo)(mo)(mo)(mo)(mo)遲(chi)(chi),不(bu)(bu)(bu)(bu)惡寒(han),身(shen)(shen)體(ti)濈濺汗出,則(ze)用(yong)(yong)(yong)大(da)(da)承(cheng)氣(qi),此(ci)又非(fei)遲(chi)(chi)為(wei)(wei)(wei)陰(yin)寒(han)為(wei)(wei)(wei)脈(mo)(mo)(mo)(mo)(mo)矣。皆從(cong)癥(zheng)不(bu)(bu)(bu)(bu)從(cong)脈(mo)(mo)(mo)(mo)(mo)也。”李氏舉例本之仲景(jing)《傷(shang)寒(han)論(lun)》。促脈(mo)(mo)(mo)(mo)(mo)數而(er)(er)時止(zhi)(一(yi)說乃急(ji)促之謂(wei)(wei))一(yi)般主(zhu)陽(yang)盛(sheng)傷(shang)陰(yin)。熱郁大(da)(da)腸(chang)麗致泄(xie)瀉并現(xian)促際,自(zi)當用(yong)(yong)(yong)葛根(gen)芩(qin)連(lian)清(qing)而(er)(er)止(zhi)之,這(zhe)是(shi)常(chang)法。若雖見促脈(mo)(mo)(mo)(mo)(mo),不(bu)(bu)(bu)(bu)但(dan)(dan)無(wu)(wu)熱象可(ke)言,反(fan)卻出現(xian)身(shen)(shen)冷(leng)(leng)肢厥等陽(yang)虛癥(zheng)狀,不(bu)(bu)(bu)(bu)但(dan)(dan)不(bu)(bu)(bu)(bu)能(neng)作熱泄(xie)治療,還(huan)急(ji)須溫(wen)壯心(xin)腎(shen)之陽(yang)。由于脈(mo)(mo)(mo)(mo)(mo)癥(zheng)不(bu)(bu)(bu)(bu)應,李氏通過辨(bian)析,認(ren)為(wei)(wei)(wei)應舍(she)(she)脈(mo)(mo)(mo)(mo)(mo)從(cong)癥(zheng)。另例亦是(shi)如(ru)此(ci),遲(chi)(chi)脈(mo)(mo)(mo)(mo)(mo)為(wei)(wei)(wei)陽(yang)不(bu)(bu)(bu)(bu)勝陰(yin)之候,若遲(chi)(chi)而(er)(er)有力,非(fei)但(dan)(dan)無(wu)(wu)虛寒(han)之象,反(fan)見到不(bu)(bu)(bu)(bu)惡寒(han),反(fan)惡熱,身(shen)(shen)濈然汗出,大(da)(da)便秘(mi)結等,此(ci)時不(bu)(bu)(bu)(bu)能(neng)循常(chang)以脈(mo)(mo)(mo)(mo)(mo)遲(chi)(chi)作寒(han)治,而(er)(er)應舍(she)(she)脈(mo)(mo)(mo)(mo)(mo)從(cong)癥(zheng)接實熱治之,須用(yong)(yong)(yong)大(da)(da)承(cheng)氣(qi)湯之類方劑(ji)瀉熱攻實。

某些(xie)慢性病(bing)因(yin)(yin)為(wei)發病(bing)時(shi)(shi)間較久,脈(mo)(mo)(mo)(mo)象(xiang)多(duo)無顯著變化(hua)或呈(cheng)現(xian)平(ping)脈(mo)(mo)(mo)(mo),診斷用藥往往多(duo)據癥(zheng)(zheng)而(er)定。小兒發病(bing)因(yin)(yin)牛理特點及周(zhou)圍(wei)環境影(ying)響(xiang),脈(mo)(mo)(mo)(mo)象(xiang)變化(hua)起干瞬時(shi)(shi),舍脈(mo)(mo)(mo)(mo)從癥(zheng)(zheng)之機(ji)也(ye)(ye)不少。有(you)些(xie)老年人因(yin)(yin)年齡關系而(er)脈(mo)(mo)(mo)(mo)管(guan)變得(de)強硬有(you)力,診治時(shi)(shi)也(ye)(ye)應(ying)考慮(lv)到這種脈(mo)(mo)(mo)(mo)象(xiang)外(wai)雖強而(er)內則(ze)虛,不應(ying)一(yi)律視為(wei)實脈(mo)(mo)(mo)(mo)。選方用藥宜(yi)多(duo)據病(bing)癥(zheng)(zheng)之表(biao)現(xian),須(xu)溫則(ze)溫,須(xu)補則(ze)補,不要為(wei)脈(mo)(mo)(mo)(mo)之假(jia)象(xiang)所(suo)惑而(er)輕用涼(liang)肝(gan)瀉火之品。以上所(suo)舉是(shi)臨床(chuang)上常(chang)遇到的舍脈(mo)(mo)(mo)(mo)從癥(zheng)(zheng)的幾種情況。周(zhou)學霆有(you)“偏正頭痛不向(xiang)脈(mo)(mo)(mo)(mo)”,“痿癥(zheng)(zheng)不從脈(mo)(mo)(mo)(mo)”、“老痰不變脈(mo)(mo)(mo)(mo)”之說,這當然(ran)不能一(yi)概面論,但在脈(mo)(mo)(mo)(mo)不足憑(ping)時(shi)(shi)則(ze)憑(ping)癥(zheng)(zheng),這也(ye)(ye)確是(shi)事實。

合癥從脈

所(suo)謂舍(she)癥(zheng)(zheng)(zheng)(zheng)(zheng)從脈(mo),簡言之(zhi)是指辨(bian)癥(zheng)(zheng)(zheng)(zheng)(zheng)時(shi)脈(mo)癥(zheng)(zheng)(zheng)(zheng)(zheng)不符,舍(she)棄反(fan)映(ying)(ying)表面現(xian)象的(de)(de)癥(zheng)(zheng)(zheng)(zheng)(zheng)狀,取反(fan)映(ying)(ying)疾病本質的(de)(de)脈(mo)診為辨(bian)證論治的(de)(de)依(yi)據(ju),稱(cheng)為舍(she)癥(zheng)(zheng)(zheng)(zheng)(zheng)從脈(mo)。李中(zhong)梓說:“結胸(xiong)癥(zheng)(zheng)(zheng)(zheng)(zheng)具,常(chang)以大小陷(xian)(xian)胸(xiong)下(xia)之(zhi)矣,脈(mo)浮大者(zhe)不可(ke)(ke)下(xia),下(xia)之(zhi)則死,是宜從脈(mo)面治其(qi)表也(ye)。身疼(teng)痛者(zhe),常(chang)以桂(gui)枝麻黃解之(zhi)矣。然尺中(zhong)遲者(zhe)不可(ke)(ke)汗,以營血不足故也(ye),是宜從脈(mo)而(er)(er)調(diao)其(qi)營矣。此皆從脈(mo)不從癥(zheng)(zheng)(zheng)(zheng)(zheng)也(ye)。”這也(ye)是據(ju)《傷寒(han)論》以為舍(she)癥(zheng)(zheng)(zheng)(zheng)(zheng)從脈(mo)的(de)(de)例(li)證。大小陷(xian)(xian)朐湯(tang)(tang)治療的(de)(de)結胸(xiong)病由痰飲(yin)實(shi)熱(re)之(zhi)邪結聚(ju)胸(xiong)脅(xie)腸胃,脈(mo)當見(jian)沉緊或(huo)滑實(shi)有(you)(you)力(li),此時(shi)始可(ke)(ke)用(yong)二湯(tang)(tang)峻(jun)逐。若脈(mo)浮大,或(huo)因(yin)表邪未凈,或(huo)因(yin)正氣(qi)有(you)(you)虧,結胸(xiong)癥(zheng)(zheng)(zheng)(zheng)(zheng)雖具,不宜驟然一味攻(gong)下(xia),尤其(qi)是大陷(xian)(xian)胸(xiong)湯(tang)(tang)。身體疼(teng)痛或(huo)并兼其(qi)它表癥(zheng)(zheng)(zheng)(zheng)(zheng),常(chang)用(yong)桂(gui)枝湯(tang)(tang)、麻黃湯(tang)(tang)解表散(san)寒(han)治之(zhi);但若尺脈(mo)遲緩,是營血不足或(huo)陽氣(qi)式(shi)微(wei),猛(meng)浪施(shi)以麻桂(gui)之(zhi)劑,極易(yi)導致(zhi)傷陰亡陽,正確的(de)(de)治法(fa)是調(diao)其(qi)營和其(qi)衛。這主要是據(ju)脈(mo)斷病而(er)(er)決定治法(fa)。若舍(she)脈(mo)從癥(zheng)(zheng)(zheng)(zheng)(zheng),虛(xu)實(shi)不分,寒(han)熱(re)不辨(bian),誤發(fa)其(qi)汗,也(ye)易(yi)致(zhi)變癥(zheng)(zheng)(zheng)(zheng)(zheng)迭起。

脈(mo)(mo)(mo)(mo)(mo)與(yu)癥(zheng)(zheng)(zheng)(zheng)都是(shi)(shi)疾病(bing)(bing)(bing)(bing)(bing)(bing)征象的(de)(de)(de)反(fan)映,大(da)體上(shang)(shang)癥(zheng)(zheng)(zheng)(zheng)以(yi)(yi)(yi)識病(bing)(bing)(bing)(bing)(bing)(bing),脈(mo)(mo)(mo)(mo)(mo)以(yi)(yi)(yi)定(ding)(ding)(ding)性(xing)。由于疾病(bing)(bing)(bing)(bing)(bing)(bing)種(zhong)類繁多,且(qie)又(you)變(bian)化奠測,又(you)兼以(yi)(yi)(yi)臺病(bing)(bing)(bing)(bing)(bing)(bing)宿疾,脈(mo)(mo)(mo)(mo)(mo)癥(zheng)(zheng)(zheng)(zheng)表現有(you)典型(xing)、非(fei)典型(xing)及反(fan)常之(zhi)(zhi)(zhi)各(ge)異,因(yin)此(ci),每一疾病(bing)(bing)(bing)(bing)(bing)(bing)都是(shi)(shi)復雜的(de)(de)(de)。一脈(mo)(mo)(mo)(mo)(mo)而(er)主數(shu)病(bing)(bing)(bing)(bing)(bing)(bing),異病(bing)(bing)(bing)(bing)(bing)(bing)可出現同(tong)一癥(zheng)(zheng)(zheng)(zheng)狀(zhuang)(zhuang),不(bu)(bu)但脈(mo)(mo)(mo)(mo)(mo)癥(zheng)(zheng)(zheng)(zheng)時有(you)不(bu)(bu)統(tong)一,即癥(zheng)(zheng)(zheng)(zheng)或(huo)(huo)(huo)(huo)脈(mo)(mo)(mo)(mo)(mo)本身在反(fan)映病(bing)(bing)(bing)(bing)(bing)(bing)情(qing)上(shang)(shang)也(ye)(ye)(ye)(ye)(ye)有(you)撲朔迷離(li)似(si)是(shi)(shi)面(mian)非(fei)的(de)(de)(de)情(qing)況。這就產(chan)生(sheng)了脈(mo)(mo)(mo)(mo)(mo)癥(zheng)(zheng)(zheng)(zheng)取舍(she)的(de)(de)(de)問題(ti)。前代有(you)的(de)(de)(de)醫家已研(yan)究了脈(mo)(mo)(mo)(mo)(mo)證取舍(she)問題(ti),提出的(de)(de)(de)見解也(ye)(ye)(ye)(ye)(ye)值得重視。徐靈胎說:“癥(zheng)(zheng)(zheng)(zheng)者(zhe)(zhe),病(bing)(bing)(bing)(bing)(bing)(bing)之(zhi)(zhi)(zhi)發現者(zhe)(zhe)也(ye)(ye)(ye)(ye)(ye)。病(bing)(bing)(bing)(bing)(bing)(bing)熱則(ze)癥(zheng)(zheng)(zheng)(zheng)熱,病(bing)(bing)(bing)(bing)(bing)(bing)寒(han)(han)(han)則(ze)癥(zheng)(zheng)(zheng)(zheng)寒(han)(han)(han),此(ci)一定(ding)(ding)(ding)之(zhi)(zhi)(zhi)理;然癥(zheng)(zheng)(zheng)(zheng)竟有(you)與(yu)病(bing)(bing)(bing)(bing)(bing)(bing)相(xiang)反(fan)者(zhe)(zhe),最(zui)易(yi)誤治,此(ci)不(bu)(bu)可不(bu)(bu)知者(zhe)(zhe)也(ye)(ye)(ye)(ye)(ye)。如(ru)(ru)冒寒(han)(han)(han)之(zhi)(zhi)(zhi)病(bing)(bing)(bing)(bing)(bing)(bing),反(fan)身熱而(er)惡熱;傷(shang)暑之(zhi)(zhi)(zhi)病(bing)(bing)(bing)(bing)(bing)(bing)反(fan)身寒(han)(han)(han)而(er)惡寒(han)(han)(han);本傷(shang)食(shi)也(ye)(ye)(ye)(ye)(ye),而(er)反(fan)易(yi)饑能(neng)(neng)(neng)食(shi);本傷(shang)飲也(ye)(ye)(ye)(ye)(ye),而(er)反(fan)大(da)渴口干(gan)。此(ci)等(deng)之(zhi)(zhi)(zhi)病(bing)(bing)(bing)(bing)(bing)(bing),尤(you)當(dang)細(xi)考(kao),一或(huo)(huo)(huo)(huo)有(you)誤,而(er)從癥(zheng)(zheng)(zheng)(zheng)用藥,即死生(sheng)判矣。此(ci)其(qi)中蓋有(you)故(gu)焉(yan):或(huo)(huo)(huo)(huo)一對病(bing)(bing)(bing)(bing)(bing)(bing)勢未(wei)(wei)定(ding)(ding)(ding),如(ru)(ru)傷(shang)寒(han)(han)(han)本當(dang)發熱,其(qi)時尚未(wei)(wei)發熱,將來必至于發熱,此(ci)先后之(zhi)(zhi)(zhi)不(bu)(bu)同(tong)也(ye)(ye)(ye)(ye)(ye);或(huo)(huo)(huo)(huo)內外異情(qing),如(ru)(ru)外雖寒(han)(han)(han)而(er)內仍熱是(shi)(shi)也(ye)(ye)(ye)(ye)(ye);或(huo)(huo)(huo)(huo)有(you)名無實,如(ru)(ru)欲(yu)食(shi)好飲,及至少進即止,飲食(shi)之(zhi)(zhi)(zhi)后,又(you)不(bu)(bu)易(yi)化是(shi)(shi)也(ye)(ye)(ye)(ye)(ye);或(huo)(huo)(huo)(huo)右(you)別癥(zheng)(zheng)(zheng)(zheng)相(xiang)雜,誤認此(ci)癥(zheng)(zheng)(zheng)(zheng)為筱癥(zheng)(zheng)(zheng)(zheng)是(shi)(shi)也(ye)(ye)(ye)(ye)(ye);或(huo)(huo)(huo)(huo)此(ci)人舊(jiu)有(you)他病(bing)(bing)(bing)(bing)(bing)(bing),新病(bing)(bing)(bing)(bing)(bing)(bing)方發,舊(jiu)病(bing)(bing)(bing)(bing)(bing)(bing)亦(yi)現是(shi)(shi)也(ye)(ye)(ye)(ye)(ye)。至于脈(mo)(mo)(mo)(mo)(mo)之(zhi)(zhi)(zhi)相(xiang)反(fan),亦(yi)各(ge)不(bu)(bu)同(tong):或(huo)(huo)(huo)(huo)其(qi)人體之(zhi)(zhi)(zhi)脈(mo)(mo)(mo)(mo)(mo),與(yu)常人不(bu)(bu)同(tong);或(huo)(huo)(huo)(huo)病(bing)(bing)(bing)(bing)(bing)(bing)耗未(wei)(wei)現于脈(mo)(mo)(mo)(mo)(mo);或(huo)(huo)(huo)(huo)痰氣阻(zu)塞,營氣不(bu)(bu)利,脈(mo)(mo)(mo)(mo)(mo)氣乖(guai)其(qi)所(suo)之(zhi)(zhi)(zhi);或(huo)(huo)(huo)(huo)一時為邪所(suo)閉,脈(mo)(mo)(mo)(mo)(mo)似(si)危險,氣通即復;或(huo)(huo)(huo)(huo)其(qi)本有(you)他癥(zheng)(zheng)(zheng)(zheng),仍其(qi)舊(jiu)癥(zheng)(zheng)(zheng)(zheng)之(zhi)(zhi)(zhi)脈(mo)(mo)(mo)(mo)(mo)。凡此(ci)之(zhi)(zhi)(zhi)類,非(fei)一端所(suo)能(neng)(neng)(neng)盡。總宜(yi)潛心體認,審其(qi)真實,然后不(bu)(bu)為脈(mo)(mo)(mo)(mo)(mo)癥(zheng)(zheng)(zheng)(zheng)所(suo)惑。”所(suo)有(you)這些歸根結底,與(yu)疾病(bing)(bing)(bing)(bing)(bing)(bing)的(de)(de)(de)多樣性(xing)、多變(bian)性(xing)及人體機能(neng)(neng)(neng)狀(zhuang)(zhuang)態有(you)關,尤(you)其(qi)是(shi)(shi)脈(mo)(mo)(mo)(mo)(mo)象受各(ge)方面(mian)因(yin)素(su)的(de)(de)(de)影響(xiang)尤(you)多。臨床上(shang)(shang)除據脈(mo)(mo)(mo)(mo)(mo)象所(suo)見探(tan)測其(qi)主病(bing)(bing)(bing)(bing)(bing)(bing)外,還要考(kao)慮(lv)到患者(zhe)(zhe)的(de)(de)(de)稟(bing)賦、生(sheng)活(huo)條件(jian)、職業居(ju)處、年齡男女(nv)及四時季節(jie)等(deng)等(deng)對脈(mo)(mo)(mo)(mo)(mo)象可能(neng)(neng)(neng)發生(sheng)的(de)(de)(de)影響(xiang)。只有(you)全面(mian)加以(yi)(yi)(yi)考(kao)慮(lv)分析,才能(neng)(neng)(neng)得脈(mo)(mo)(mo)(mo)(mo)診(zhen)之(zhi)(zhi)(zhi)真諦,正(zheng)確評定(ding)(ding)(ding)其(qi)實際價(jia)值。

葉霖說:“人(ren)(ren)之(zhi)(zhi)稟質,各(ge)有不同,而脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)應之(zhi)(zhi)。如血(xue)氣盛則(ze)(ze)(ze)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)盛,血(xue)氣衰(shuai)則(ze)(ze)(ze)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)衰(shuai);血(xue)氣熱則(ze)(ze)(ze)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)數,血(xue)氣寒則(ze)(ze)(ze)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)遲(chi);血(xue)氣微則(ze)(ze)(ze)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)弱(ruo),血(xue)氣平(ping)則(ze)(ze)(ze)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)和;性急人(ren)(ren)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)急,性緩(huan)人(ren)(ren)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)緩(huan);肥人(ren)(ren)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)沉,瘦人(ren)(ren)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)浮(fu);寡婦(fu)室(shi)女脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)濡弱(ruo),嬰兒稚子(zi)(zi)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)滑數;老人(ren)(ren)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)弱(ruo),壯人(ren)(ren)脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)強;男子(zi)(zi)寸強尺弱(ruo),女子(zi)(zi)尺強寸弱(ruo)。又有六脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)細小同等,謂之(zhi)(zhi)六陰;洪大同等,謂之(zhi)(zhi)六陽。至于酒后脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)數大,飯后脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)洪緩(huan),久饑脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)空,遠行脈(mo)(mo)(mo)(mo)(mo)(mo)(mo)疾,臨診者皆須詳察。”這些都是(shi)經(jing)驗(yan)之(zhi)(zhi)談,不容忽視(shi)。

舍(she)(she)(she)脈(mo)從(cong)癥(zheng)(zheng)與舍(she)(she)(she)癥(zheng)(zheng)從(cong)脈(mo)是中(zhong)(zhong)醫診斷(duan)學發展到一定階(jie)段的(de)(de)(de)產物。這(zhe)種(zhong)方(fang)法就(jiu)其(qi)實(shi)質來(lai)談,乃是全(quan)面收集材料,并對其(qi)做全(quan)面的(de)(de)(de)綜合(he)分析,通過對脈(mo)癥(zheng)(zheng)之(zhi)互勘互證,在(zai)知(zhi)常達變的(de)(de)(de)基礎上,透過現(xian)象,由(you)表及(ji)里,由(you)此(ci)及(ji)被,去偽存(cun)真,揭示本質,最后得出(chu)合(he)乎實(shi)際(ji)的(de)(de)(de)正確判斷(duan)。可(ke)見脈(mo)癥(zheng)(zheng)從(cong)舍(she)(she)(she)說的(de)(de)(de)出(chu)現(xian),是有(you)其(qi)進步意(yi)義的(de)(de)(de)。但(dan)對于古(gu)人(ren)所(suo)(suo)謂的(de)(de)(de)從(cong)和舍(she)(she)(she),我們不(bu)(bu)(bu)(bu)應(ying)停留在(zai)字(zi)面上做機械的(de)(de)(de)理解,而應(ying)領(ling)會(hui)其(qi)精神實(shi)質。實(shi)際(ji)上舍(she)(she)(she)中(zhong)(zhong)有(you)從(cong),從(cong)中(zhong)(zhong)也有(you)舍(she)(she)(she),不(bu)(bu)(bu)(bu)過對不(bu)(bu)(bu)(bu)同疾病及(ji)發病的(de)(de)(de)不(bu)(bu)(bu)(bu)同階(jie)段,脈(mo)與癥(zheng)(zheng)在(zai)辨(bian)析疾病上各有(you)側重與專長,所(suo)(suo)發揮(hui)的(de)(de)(de)作用不(bu)(bu)(bu)(bu)盡相同而已。無(wu)論(lun)是癥(zheng)(zheng)是脈(mo),若把(ba)其(qi)孤(gu)立隔絕起來(lai),其(qi)本身(shen)的(de)(de)(de)診斷(duan)價值就(jiu)會(hui)大為減弱,直至喪(sang)失(shi)。它們是互為依存(cun),互相補充的(de)(de)(de),只有(you)把(ba)二者(zhe)融為一體,始(shi)能(neng)收相得益彰之(zhi)功。對前面所(suo)(suo)舉脈(mo)癥(zheng)(zheng)從(cong)舍(she)(she)(she)病案,也應(ying)作如是觀(guan),它們并不(bu)(bu)(bu)(bu)曾(ceng)完全(quan)的(de)(de)(de)從(cong)一方(fang),也不(bu)(bu)(bu)(bu)曾(ceng)完全(quan)的(de)(de)(de)舍(she)(she)(she)一方(fang),只是相對而言罷了。張(zhang)景岳說:“凡診病之(zhi)法,固奠妙于脈(mo),然(ran)有(you)病脈(mo)相符者(zhe),有(you)脈(mo)病相左者(zhe),此(ci)中(zhong)(zhong)大有(you)玄(xuan)理。故(gu)凡值疑似難明處,必須(xu)用四(si)診之(zhi)法詳問其(qi)病由(you),兼辨(bian)其(qi)聲色,但(dan)于本來(lai)先后中(zhong)(zhong)正之(zhi)以理,斯(si)得其(qi)真。若不(bu)(bu)(bu)(bu)察此(ci)而但(dan)謂診可(ke)憑,信手亂(luan)治,亦豈知(zhi)脈(mo)疰最多真假。見有(you)不(bu)(bu)(bu)(bu)確,安能(neng)無(wu)誤?且常診者(zhe)知(zhi)之(zhi)猶易,初診者(zhe)決之(zhi)甚難,此(ci)四(si)診之(zhi)所(suo)(suo)以不(bu)(bu)(bu)(bu)可(ke)忽也。”此(ci)論(lun)允當,可(ke)遵可(ke)行(xing)。

張景岳(yue)有(you)(you)(you)(you)(you)“從(cong)(cong)舍(she)辨”,于(yu)脈(mo)(mo)(mo)癥(zheng)(zheng)(zheng)(zheng)(zheng)從(cong)(cong)舍(she)不(bu)無(wu)新意。此(ci)(ci)(ci)引錄(lu)之(zhi),以(yi)(yi)資參考。“凡(fan)治病(bing)之(zhi)法,有(you)(you)(you)(you)(you)當舍(she)癥(zheng)(zheng)(zheng)(zheng)(zheng)從(cong)(cong)脈(mo)(mo)(mo)者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)當舍(she)脈(mo)(mo)(mo)從(cong)(cong)疰(zhu)者(zhe)(zhe)(zhe)(zhe),何也(ye)(ye)(ye)(ye)?蓋(gai)(gai)癥(zheng)(zheng)(zheng)(zheng)(zheng)有(you)(you)(you)(you)(you)真假(jia)(jia)(jia)(jia),脈(mo)(mo)(mo)亦有(you)(you)(you)(you)(you)真值,凡(fan)見(jian)(jian)(jian)脈(mo)(mo)(mo)癥(zheng)(zheng)(zheng)(zheng)(zheng)有(you)(you)(you)(you)(you)不(bu)相合者(zhe)(zhe)(zhe)(zhe),則必(bi)有(you)(you)(you)(you)(you)一真一值隱乎(hu)其(qi)(qi)中矣。故(gu)有(you)(you)(you)(you)(you)以(yi)(yi)陽(yang)(yang)癥(zheng)(zheng)(zheng)(zheng)(zheng)見(jian)(jian)(jian)胡脈(mo)(mo)(mo)者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)以(yi)(yi)陰(yin)癥(zheng)(zheng)(zheng)(zheng)(zheng)見(jian)(jian)(jian)陽(yang)(yang)脈(mo)(mo)(mo)者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)以(yi)(yi)虛(xu)(xu)(xu)證(zheng)見(jian)(jian)(jian)實(shi)(shi)(shi)(shi)(shi)脈(mo)(mo)(mo)者(zhe)(zhe)(zhe)(zhe),有(you)(you)(you)(you)(you)以(yi)(yi)實(shi)(shi)(shi)(shi)(shi)證(zheng)見(jian)(jian)(jian)虛(xu)(xu)(xu)脈(mo)(mo)(mo)者(zhe)(zhe)(zhe)(zhe)。此(ci)(ci)(ci)陰(yin)彼陽(yang)(yang),此(ci)(ci)(ci)虛(xu)(xu)(xu)彼實(shi)(shi)(shi)(shi)(shi),將何從(cong)(cong)乎(hu)?病(bing)而(er)遇此(ci)(ci)(ci),最(zui)難(nan)下手,最(zui)易差錯,不(bu)有(you)(you)(you)(you)(you)真見(jian)(jian)(jian),必(bi)致殺人(ren)。矧今人(ren)只知見(jian)(jian)(jian)在,不(bu)識隱微,凡(fan)遇癥(zheng)(zheng)(zheng)(zheng)(zheng)之(zhi)實(shi)(shi)(shi)(shi)(shi)而(er)脈(mo)(mo)(mo)之(zhi)虛(xu)(xu)(xu)者(zhe)(zhe)(zhe)(zhe),必(bi)直攻(gong)(gong)(gong)其(qi)(qi)癥(zheng)(zheng)(zheng)(zheng)(zheng)而(er)忘(wang)其(qi)(qi)脈(mo)(mo)(mo)之(zhi)真虛(xu)(xu)(xu)也(ye)(ye)(ye)(ye);或遇脈(mo)(mo)(mo)之(zhi)弦大面(mian)癥(zheng)(zheng)(zheng)(zheng)(zheng)之(zhi)盅者(zhe)(zhe)(zhe)(zhe),亦必(bi)直攻(gong)(gong)(gong)其(qi)(qi)脈(mo)(mo)(mo)面(mian)忘(wang)其(qi)(qi)癥(zheng)(zheng)(zheng)(zheng)(zheng)之(zhi)無(wu)實(shi)(shi)(shi)(shi)(shi)也(ye)(ye)(ye)(ye)。此(ci)(ci)(ci)其(qi)(qi)故(gu)正以(yi)(yi)似虛(xu)(xu)(xu)似實(shi)(shi)(shi)(shi)(shi),疑本(ben)難(nan)明,當舍(she)當從(cong)(cong),孰(shu)知其(qi)(qi)要?醫有(you)(you)(you)(you)(you)迷途,莫此(ci)(ci)(ci)為(wei)甚。余(yu)嘗(chang)熟察之(zhi)矣,大都癥(zheng)(zheng)(zheng)(zheng)(zheng)實(shi)(shi)(shi)(shi)(shi)脈(mo)(mo)(mo)虛(xu)(xu)(xu)者(zhe)(zhe)(zhe)(zhe),必(bi)其(qi)(qi)癥(zheng)(zheng)(zheng)(zheng)(zheng)為(wei)假(jia)(jia)(jia)(jia)實(shi)(shi)(shi)(shi)(shi)也(ye)(ye)(ye)(ye);脈(mo)(mo)(mo)實(shi)(shi)(shi)(shi)(shi)癥(zheng)(zheng)(zheng)(zheng)(zheng)虛(xu)(xu)(xu)者(zhe)(zhe)(zhe)(zhe),必(bi)其(qi)(qi)脈(mo)(mo)(mo)為(wei)假(jia)(jia)(jia)(jia)實(shi)(shi)(shi)(shi)(shi)也(ye)(ye)(ye)(ye)。何以(yi)(yi)見(jian)(jian)(jian)之(zhi)?如外雖煩熱而(er)脈(mo)(mo)(mo)見(jian)(jian)(jian)微弱者(zhe)(zhe)(zhe)(zhe),必(bi)火虛(xu)(xu)(xu)也(ye)(ye)(ye)(ye);腹(fu)雖脹(zhang)病(bing)而(er)脈(mo)(mo)(mo)見(jian)(jian)(jian)微弱者(zhe)(zhe)(zhe)(zhe),必(bi)胃(wei)盤也(ye)(ye)(ye)(ye)。虛(xu)(xu)(xu)火虛(xu)(xu)(xu)脹(zhang),其(qi)(qi)堪攻(gong)(gong)(gong)乎(hu)?此(ci)(ci)(ci)宜(yi)從(cong)(cong)脈(mo)(mo)(mo)之(zhi)虛(xu)(xu)(xu)不(bu)從(cong)(cong)癥(zheng)(zheng)(zheng)(zheng)(zheng)之(zhi)實(shi)(shi)(shi)(shi)(shi)也(ye)(ye)(ye)(ye)。其(qi)(qi)有(you)(you)(you)(you)(you)本(ben)無(wu)煩熱面(mian)脈(mo)(mo)(mo)見(jian)(jian)(jian)洪敬者(zhe)(zhe)(zhe)(zhe),非(fei)火邪也(ye)(ye)(ye)(ye);本(ben)無(wu)脹(zhang)滯面(mian)脈(mo)(mo)(mo)見(jian)(jian)(jian)弦強者(zhe)(zhe)(zhe)(zhe),非(fei)內實(shi)(shi)(shi)(shi)(shi)也(ye)(ye)(ye)(ye)。無(wu)熱無(wu)脹(zhang),其(qi)(qi)堪瀉乎(hu)?此(ci)(ci)(ci)宜(yi)從(cong)(cong)癥(zheng)(zheng)(zheng)(zheng)(zheng)之(zhi)虛(xu)(xu)(xu),不(bu)從(cong)(cong)脈(mo)(mo)(mo)之(zhi)實(shi)(shi)(shi)(shi)(shi)也(ye)(ye)(ye)(ye)。凡(fan)此(ci)(ci)(ci)之(zhi)類,但言(yan)假(jia)(jia)(jia)(jia)實(shi)(shi)(shi)(shi)(shi),不(bu)言(yan)假(jia)(jia)(jia)(jia)虛(xu)(xu)(xu),果何意也(ye)(ye)(ye)(ye)?蓋(gai)(gai)實(shi)(shi)(shi)(shi)(shi)有(you)(you)(you)(you)(you)假(jia)(jia)(jia)(jia)實(shi)(shi)(shi)(shi)(shi),虛(xu)(xu)(xu)無(wu)假(jia)(jia)(jia)(jia)虛(xu)(xu)(xu)。假(jia)(jia)(jia)(jia)實(shi)(shi)(shi)(shi)(shi)者(zhe)(zhe)(zhe)(zhe)病(bing)多變幻,此(ci)(ci)(ci)其(qi)(qi)所(suo)(suo)以(yi)(yi)有(you)(you)(you)(you)(you)假(jia)(jia)(jia)(jia)也(ye)(ye)(ye)(ye);假(jia)(jia)(jia)(jia)虛(xu)(xu)(xu)者(zhe)(zhe)(zhe)(zhe)虧損(sun)既露,此(ci)(ci)(ci)其(qi)(qi)所(suo)(suo)以(yi)(yi)無(wu)假(jia)(jia)(jia)(jia)也(ye)(ye)(ye)(ye)。大凡(fan)脈(mo)(mo)(mo)癥(zheng)(zheng)(zheng)(zheng)(zheng)不(bu)合者(zhe)(zhe)(zhe)(zhe),中必(bi)有(you)(you)(you)(you)(you)奸;必(bi)察其(qi)(qi)盤以(yi)(yi)求(qiu)根本(ben),庶乎(hu)無(wu)誤,此(ci)(ci)(ci)談不(bu)易之(zhi)要法也(ye)(ye)(ye)(ye)。

“真實(shi)假(jia)(jia)虛(xu)之(zhi)候,非(fei)曰必(bi)(bi)(bi)無(wu),如(ru)如(ru)寒(han)邪(xie)(xie)內(nei)傷(shang),或(huo)食停(ting)氣滯而(er)心假(jia)(jia)急痛,以(yi)致(zhi)脈(mo)(mo)(mo)(mo)道沉伏(fu).或(huo)促或(huo)結—證(zheng),此(ci)(ci)以(yi)邪(xie)(xie)閉經絡而(er)然,脈(mo)(mo)(mo)(mo)雖若(ruo)(ruo)虛(xu),而(er)必(bi)(bi)(bi)有(you)(you)(you)(you)痛脹等癥(zheng)可據者(zhe),是(shi)(shi)誠假(jia)(jia)虛(xu)之(zhi)脈(mo)(mo)(mo)(mo),本(ben)非(fei)虛(xu)也(ye)(ye)(ye)。又(you)若(ruo)(ruo)四肢厥(jue)逆,或(huo)惡風怯寒(han)面脈(mo)(mo)(mo)(mo)見滑微-癥(zheng),此(ci)(ci)由(you)熱極(ji)生寒(han),外雖若(ruo)(ruo)虛(xu)而(er)內(nei)有(you)(you)(you)(you)煩(fan)熱便結等癥(zheng)可據者(zhe),是(shi)(shi)誠假(jia)(jia)虛(xu)之(zhi)病,本(ben)非(fei)虛(xu)也(ye)(ye)(ye)。大抵假(jia)(jia)虛(xu)之(zhi)證(zheng),只此(ci)(ci)二條。若(ruo)(ruo)有(you)(you)(you)(you)是(shi)(shi)實(shi)脈(mo)(mo)(mo)(mo)而(er)無(wu)是(shi)(shi)實(shi)癥(zheng),即假(jia)(jia)實(shi)脈(mo)(mo)(mo)(mo)也(ye)(ye)(ye);有(you)(you)(you)(you)是(shi)(shi)實(shi)癥(zheng)而(er)無(wu)實(shi)脈(mo)(mo)(mo)(mo),即假(jia)(jia)實(shi)癥(zheng)也(ye)(ye)(ye)。知(zhi)(zhi)假(jia)(jia)知(zhi)(zhi)真,即知(zhi)(zhi)所(suo)從(cong)舍(she)矣(yi)。近見有(you)(you)(you)(you)治傷(shang)寒(han)者(zhe),每以(yi)陰脈(mo)(mo)(mo)(mo)作伏(fu)脈(mo)(mo)(mo)(mo),不知(zhi)(zhi)伏(fu)脈(mo)(mo)(mo)(mo)之(zhi)體,雖細雖微,亦必(bi)(bi)(bi)隱隱有(you)(you)(you)(you)力,亦必(bi)(bi)(bi)明(ming)明(ming)有(you)(you)(you)(you)癥(zheng),豈容任意(yi)胡猜以(yi)草菅人命哉!仁者(zhe)必(bi)(bi)(bi)不然也(ye)(ye)(ye)。

“又有從脈從癥之法,乃以病有輕重為言也。如病本輕淺別無危候者,但因見在以治其標,

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