小柴胡湯有何罪?
馮(feng)世綸 中日友好醫(yi)院
某大城市為加(jia)強中(zhong)藥不良反(fan)應監管力度,把(ba)小(xiao)柴(chai)胡(hu)(hu)湯與關木通、關防己同列(lie)!為什么如此對待小(xiao)柴(chai)胡(hu)(hu)湯,小(xiao)柴(chai)胡(hu)(hu)湯何罪之有(you)(you)?有(you)(you)關小(xiao)柴(chai)胡(hu)(hu)湯不良反(fan)應的(de)(de)翔實資料,國內并未多見(1980年(nian)~2000年(nian)僅4例),而是(shi)主要來(lai)自日本的(de)(de)報道。因(yin)此有(you)(you)必要回顧近(jin)三(san)十多年(nian)來(lai)日本對小(xiao)柴(chai)胡(hu)(hu)湯的(de)(de)研究和應用的(de)(de)概況。
“小柴胡湯”曾(ceng)風靡日本
20世紀(ji)70年(nian)(nian)代初期,日(ri)本(ben)的(de)(de)津(jin)村(cun)(cun)順天堂制成了小(xiao)柴(chai)胡(hu)湯(tang)(tang)(tang)顆(ke)粒(li)制劑( エキス顆(ke)粒(li)劑)。1972年(nian)(nian)~1976年(nian)(nian),近畿(ji)大(da)學(xue)(xue)東洋醫學(xue)(xue)研究(jiu)所(suo)主任有(you)(you)地滋(zi)教授通過4年(nian)(nian)研究(jiu),在和漢藥研討會上發表了“津(jin)村(cun)(cun)小(xiao)柴(chai)胡(hu)湯(tang)(tang)(tang)顆(ke)粒(li)對慢性肝(gan)炎有(you)(you)治療效果”的(de)(de)報告(gao),在日(ri)本(ben)引起不(bu)同(tong)凡響。此后又有(you)(you)21家漢方(fang)廠家加入生產開發小(xiao)柴(chai)胡(hu)湯(tang)(tang)(tang)行列(lie),對小(xiao)柴(chai)胡(hu)湯(tang)(tang)(tang)進行多方(fang)面的(de)(de)研究(jiu),呈現了空前的(de)(de)小(xiao)柴(chai)胡(hu)湯(tang)(tang)(tang)熱。
理論研究:證(zheng)實了對肝損害的(de)預防作用
小(xiao)(xiao)柴胡(hu)湯(tang)最先(xian)應(ying)(ying)用(yong)于治療慢性(xing)肝(gan)(gan)炎,因(yin)此(ci)實驗(yan)室注意了保護肝(gan)(gan)細(xi)(xi)(xi)(xi)(xi)胞(bao)(bao)的(de)(de)研究:小(xiao)(xiao)柴胡(hu)湯(tang)對(dui)四氯化碳和半乳糖胺造成的(de)(de)急性(xing)肝(gan)(gan)損傷(shang)具(ju)有(you)保護作(zuo)用(yong),不(bu)僅抑制(zhi)肝(gan)(gan)細(xi)(xi)(xi)(xi)(xi)胞(bao)(bao)的(de)(de)壞死,而且能直接抑制(zhi)肝(gan)(gan)纖維化。對(dui)肝(gan)(gan)再生(sheng)(sheng)(sheng)的(de)(de)實驗(yan)研究表(biao)明,肝(gan)(gan)組織的(de)(de)有(you)絲分(fen)(fen)(fen)裂指數為對(dui)照組的(de)(de)2倍。小(xiao)(xiao)柴胡(hu)湯(tang)通過(guo)加速細(xi)(xi)(xi)(xi)(xi)胞(bao)(bao)周(zhou)期,作(zuo)用(yong)于細(xi)(xi)(xi)(xi)(xi)胞(bao)(bao)G1(細(xi)(xi)(xi)(xi)(xi)胞(bao)(bao)準備復制(zhi)DNA的(de)(de)時期)后期而促進了肝(gan)(gan)臟(zang)再生(sheng)(sheng)(sheng)。以(yi)丙(bing)肝(gan)(gan)患者外周(zhou)單核(he)細(xi)(xi)(xi)(xi)(xi)胞(bao)(bao)分(fen)(fen)(fen)析(xi)白(bai)細(xi)(xi)(xi)(xi)(xi)胞(bao)(bao)介(jie)(jie)素(su)1(IL-1)、白(bai)細(xi)(xi)(xi)(xi)(xi)胞(bao)(bao)介(jie)(jie)素(su)3(IL-3)、白(bai)細(xi)(xi)(xi)(xi)(xi)胞(bao)(bao)介(jie)(jie)素(su)4(IL-4)、白(bai)細(xi)(xi)(xi)(xi)(xi)胞(bao)(bao)介(jie)(jie)素(su)5(IL-5)、白(bai)細(xi)(xi)(xi)(xi)(xi)胞(bao)(bao)介(jie)(jie)素(su)10(IL-10)及r-干擾素(su)(r-IFN)等細(xi)(xi)(xi)(xi)(xi)胞(bao)(bao)因(yin)子的(de)(de)產生(sheng)(sheng)(sheng)以(yi)及小(xiao)(xiao)柴胡(hu)湯(tang)對(dui)其影響,結(jie)果(guo)發現丙(bing)肝(gan)(gan)患者細(xi)(xi)(xi)(xi)(xi)胞(bao)(bao)因(yin)子產生(sheng)(sheng)(sheng)過(guo)量,可引起(qi)變態反應(ying)(ying)及體(ti)液免疫(yi)異(yi)常(chang),小(xiao)(xiao)柴胡(hu)湯(tang)可糾正其異(yi)常(chang)。又應(ying)(ying)用(yong)簡化mRNA差異(yi)顯示法分(fen)(fen)(fen)離和鑒定,從(cong)分(fen)(fen)(fen)子水平(ping)提(ti)示該方對(dui)肝(gan)(gan)損害具(ju)有(you)預防作(zuo)用(yong)機制(zhi)。
免疫調節(jie)研究:證實對乙肝治療有效
小(xiao)柴(chai)胡湯可(ke)增(zeng)(zeng)(zeng)強產(chan)(chan)生(sheng)IL-1和IL-2;雖抑制IL-3的(de)(de)產(chan)(chan)生(sheng),但可(ke)增(zeng)(zeng)(zeng)強IL-3的(de)(de)感受性(xing)(xing)(xing)(xing),并呈(cheng)濃度依賴性(xing)(xing)(xing)(xing);還增(zeng)(zeng)(zeng)強通過(guo)B細(xi)(xi)(xi)(xi)胞(bao)(bao)(bao)增(zeng)(zeng)(zeng)殖與抗體(ti)產(chan)(chan)生(sheng)系(xi)統有關的(de)(de)IL-4以及最終誘(you)(you)(you)導(dao)(dao)B細(xi)(xi)(xi)(xi)胞(bao)(bao)(bao)抗體(ti)IL-6的(de)(de)產(chan)(chan)生(sheng),具有增(zeng)(zeng)(zeng)強抗體(ti)產(chan)(chan)生(sheng)的(de)(de)作用;既可(ke)誘(you)(you)(you)導(dao)(dao)抑制性(xing)(xing)(xing)(xing)T細(xi)(xi)(xi)(xi)胞(bao)(bao)(bao)活(huo)性(xing)(xing)(xing)(xing),又(you)可(ke)激活(huo)輔(fu)助性(xing)(xing)(xing)(xing)T細(xi)(xi)(xi)(xi)胞(bao)(bao)(bao)活(huo)性(xing)(xing)(xing)(xing)。由于小(xiao)柴(chai)胡湯能促進生(sheng)成IL-1、IL-2,所(suo)以有誘(you)(you)(you)導(dao)(dao)r-IFN的(de)(de)作用。r-IFN不(bu)僅(jin)有抗病毒作用,而且增(zeng)(zeng)(zeng)強天然殺(sha)傷(shang)細(xi)(xi)(xi)(xi)胞(bao)(bao)(bao)(NK)和殺(sha)傷(shang)性(xing)(xing)(xing)(xing)T細(xi)(xi)(xi)(xi)胞(bao)(bao)(bao)的(de)(de)活(huo)性(xing)(xing)(xing)(xing),因而使用IFN及其誘(you)(you)(you)導(dao)(dao)劑可(ke)以破壞感染的(de)(de)肝(gan)(gan)細(xi)(xi)(xi)(xi)胞(bao)(bao)(bao),排除乙(yi)肝(gan)(gan)病毒。小(xiao)柴(chai)胡湯誘(you)(you)(you)導(dao)(dao)r-IFN的(de)(de)作用,是對乙(yi)肝(gan)(gan)治療有效的(de)(de)機制之(zhi)一。
臨(lin)床應用:擴大了治療范圍
小柴(chai)(chai)(chai)胡(hu)(hu)(hu)湯原是《傷寒(han)論》治療半表半里少陽(yang)證(zheng)的(de)(de)方劑(ji)(ji),當(dang)津村順(shun)天堂等(deng)(deng)廠家制(zhi)成顆粒劑(ji)(ji)后(hou)又擴大了臨床應用(yong)范(fan)圍,如(ru)應用(yong)于治療感冒(mao)、發熱等(deng)(deng)病,70年(nian)代以(yi)來有(you)(you)地(di)(di)滋等(deng)(deng)不斷發表的(de)(de)有(you)(you)關研究顯示(shi),小柴(chai)(chai)(chai)胡(hu)(hu)(hu)湯被廣(guang)泛(fan)應用(yong)于慢(man)性(xing)乙肝(gan)、丙肝(gan)、肝(gan)硬(ying)化(hua)、肝(gan)癌(ai)等(deng)(deng)治療。如(ru)有(you)(you)連續報道:小柴(chai)(chai)(chai)胡(hu)(hu)(hu)湯可(ke)明(ming)(ming)顯改善HBeAg陽(yang)性(xing)慢(man)性(xing)肝(gan)炎患(huan)者(zhe)的(de)(de)GPT及(ji)GOT,其(qi)后(hou)隨投(tou)藥(yao)時間(jian)的(de)(de)繼續而持續降低。小柴(chai)(chai)(chai)胡(hu)(hu)(hu)湯可(ke)以(yi)有(you)(you)效(xiao)地(di)(di)治療丙肝(gan),抑制(zhi)或延緩肝(gan)硬(ying)化(hua)、肝(gan)癌(ai)的(de)(de)發生。小柴(chai)(chai)(chai)胡(hu)(hu)(hu)湯可(ke)引起巨噬細(xi)(xi)胞等(deng)(deng)免疫(yi)細(xi)(xi)胞的(de)(de)連鎖反應,表明(ming)(ming)小柴(chai)(chai)(chai)胡(hu)(hu)(hu)湯對患(huan)癌(ai)機(ji)體和癌(ai)細(xi)(xi)胞有(you)(you)生物反應調節物(BRM)作用(yong)。認為小柴(chai)(chai)(chai)胡(hu)(hu)(hu)湯還可(ke)通過(guo)免疫(yi)機(ji)制(zhi)調節可(ke)用(yong)于腫瘤(liu)的(de)(de)預防及(ji)治療。另外,小柴(chai)(chai)(chai)胡(hu)(hu)(hu)湯治療支氣管(guan)哮喘、過(guo)敏性(xing)皮(pi)膚(fu)病、習慣性(xing)流(liu)產、中樞性(xing)味覺障礙、癲癇(xian)、IgA腎病、黑色素瘤(liu)、艾滋病等(deng)(deng)。
日本(ben)對小柴胡湯研究之深、應用之廣,引起(qi)了中(zhong)國乃至世(shi)界(jie)很(hen)多(duo)國家(jia)的關(guan)注。
小(xiao)柴胡湯副作用引風波
有(you)關資料(liao)顯示,小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)在日(ri)本是(shi)使用(yong)(yong)最多的(de)(de)(de)藥物(wu),估計每年(nian)服(fu)用(yong)(yong)小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)者有(you)100萬人,消費金額約90億~130億日(ri)元。但在廣泛地應(ying)用(yong)(yong)于(yu)治療(liao)(liao)慢(man)性(xing)(xing)肝炎過程中,卻連續出(chu)(chu)現(xian)了(le)小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)引起間(jian)質性(xing)(xing)肺(fei)炎甚至死亡(wang)的(de)(de)(de)報(bao)道。最初報(bao)道的(de)(de)(de)1例(li),是(shi)1989年(nian)報(bao)道小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)引起間(jian)質性(xing)(xing)肺(fei)炎。患(huan)者為(wei)一名70歲(sui)的(de)(de)(de)女性(xing)(xing),主訴發(fa)熱、干咳、呼吸困(kun)難,胸部X線檢(jian)查(cha)兩(liang)肺(fei)呈彌漫性(xing)(xing)粒狀(zhuang)網狀(zhuang)陰影,小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)引起的(de)(de)(de)淋(lin)巴細胞(bao)刺(ci)激試驗(DLST)陽性(xing)(xing),初步診斷為(wei)小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)引起的(de)(de)(de)間(jian)質性(xing)(xing)肺(fei)炎。立即(ji)停(ting)服(fu)小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang),并給(gei)予類固醇(chun)劑治療(liao)(liao),約2個月(yue)(yue)后肺(fei)炎痊愈。其后再(zai)用(yong)(yong)小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)進行誘(you)發(fa)試驗,結果同樣呈陽性(xing)(xing)反應(ying)。因此,認為(wei)是(shi)小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)引起的(de)(de)(de)間(jian)質性(xing)(xing)肺(fei)炎。1991年(nian)2月(yue)(yue),日(ri)本厚(hou)生省決(jue)定對(dui)漢方(fang)(fang)藥提取劑進行再(zai)評價,即(ji)把(ba)漢方(fang)(fang)藥提取劑適應(ying)證變換為(wei)西(xi)藥適應(ying)癥表現(xian)形式進行。1994年(nian)3月(yue)(yue),小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)被最先通過。醫(yi)生們(men)(包括(kuo)不大了(le)解漢方(fang)(fang)的(de)(de)(de)西(xi)醫(yi))更(geng)喜歡應(ying)用(yong)(yong)小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)治療(liao)(liao)慢(man)性(xing)(xing)肝炎,尤其是(shi)丙型肝炎。然而,此后不斷報(bao)出(chu)(chu)因服(fu)小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)出(chu)(chu)現(xian)間(jian)質性(xing)(xing)肺(fei)炎的(de)(de)(de)新聞。1996年(nian)3月(yue)(yue),日(ri)本厚(hou)生省在“緊急安全情報(bao)”中發(fa)出(chu)(chu)了(le)“關于(yu)小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)嚴重的(de)(de)(de)副作用(yong)(yong)——間(jian)質性(xing)(xing)肺(fei)炎的(de)(de)(de)警告”。《朝日(ri)新聞》還在頭版(ban)頭條(tiao)刊(kan)登(deng)“1994年(nian)以來,得間(jian)質性(xing)(xing)肺(fei)炎88人,其中有(you)10人死亡(wang)”消息(xi)。此后,NHK以及(ji)其他報(bao)紙、周(zhou)刊(kan)也陸續播放或刊(kan)登(deng)了(le)一些(xie)醫(yi)學專家對(dui)小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)以及(ji)漢方(fang)(fang)藥副作用(yong)(yong)的(de)(de)(de)看法。人們(men)對(dui)小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)更(geng)加(jia)關注。至1999年(nian)底(di),因服(fu)小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)造成間(jian)質性(xing)(xing)肺(fei)炎已升為(wei)188例(li),死亡(wang)22例(li)。日(ri)本厚(hou)生省2000年(nian)1月(yue)(yue)14日(ri)發(fa)出(chu)(chu)“醫(yi)藥品醫(yi)療(liao)(liao)用(yong)(yong)具等安全性(xing)(xing)情報(bao)”通令:全面禁止肝炎、肝硬化、肝癌患(huan)者使用(yong)(yong)小(xiao)(xiao)柴(chai)(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)(tang)。
“安全性情(qing)報”對小(xiao)柴胡湯評(ping)價偏頗
1989年12月《日本(ben)胸部疾患(huan)(huan)學(xue)會(hui)(hui)雜志》首(shou)次報道(dao)了(le)小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)引(yin)(yin)起(qi)(qi)(qi)(qi)(qi)藥(yao)物(wu)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan)1例,之(zhi)后其(qi)他報刊也陸續刊登(deng)了(le)小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)引(yin)(yin)起(qi)(qi)(qi)(qi)(qi)肝功(gong)損傷之(zhi)類的報道(dao),對間(jian)(jian)質(zhi)(zhi)(zhi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan)尤(you)為(wei)(wei)重視。《日本(ben)東(dong)洋(yang)醫(yi)學(xue)雜志》從(cong)1996年第47卷第1期起(qi)(qi)(qi)(qi)(qi)開(kai)辟了(le)漢(han)方(fang)藥(yao)副(fu)作用(yong)(yong)(yong)(yong)情報專攔。對小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)引(yin)(yin)起(qi)(qi)(qi)(qi)(qi)間(jian)(jian)質(zhi)(zhi)(zhi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan),1998年第49次日本(ben)東(dong)洋(yang)醫(yi)學(xue)會(hui)(hui)學(xue)術會(hui)(hui)上針對這一問題(ti)進(jin)行(xing)了(le)專題(ti)討(tao)論(lun)。從(cong)西醫(yi)的病理看,小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)引(yin)(yin)起(qi)(qi)(qi)(qi)(qi)的淋巴刺激(ji)試驗(yan)(DLST)陽性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing),所以(yi)考慮可(ke)(ke)能(neng)(neng)與(yu)變態(tai)(tai)反(fan)應(ying)(ying)(ying)有(you)關(guan)(guan)。實驗(yan)研(yan)究(jiu)亦發現(xian)(xian),在(zai)培(pei)養(yang)的肺(fei)(fei)(fei)(fei)(fei)(fei)成纖(xian)維(wei)(wei)細胞(bao)(bao)中加入(ru)小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang),會(hui)(hui)使(shi)IL-6、IL-8生(sheng)成增加,這與(yu)干擾素的作用(yong)(yong)(yong)(yong)相似(si)。所以(yi)小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)與(yu)干擾素合用(yong)(yong)(yong)(yong),更(geng)易(yi)(yi)引(yin)(yin)起(qi)(qi)(qi)(qi)(qi)間(jian)(jian)質(zhi)(zhi)(zhi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan)。發生(sheng)間(jian)(jian)質(zhi)(zhi)(zhi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan)者多為(wei)(wei)50歲~70歲的老人,而(er)且長(chang)期患(huan)(huan)有(you)慢性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肝炎(yan)(yan),所以(yi)考慮小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)引(yin)(yin)起(qi)(qi)(qi)(qi)(qi)間(jian)(jian)質(zhi)(zhi)(zhi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan)可(ke)(ke)能(neng)(neng)與(yu)免疫力低(di)下有(you)關(guan)(guan)。通過(guo)(guo)小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)對肺(fei)(fei)(fei)(fei)(fei)(fei)成纖(xian)維(wei)(wei)細胞(bao)(bao)產(chan)生(sheng)細胞(bao)(bao)因(yin)(yin)子的影響觀(guan)察到:間(jian)(jian)質(zhi)(zhi)(zhi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan)患(huan)(huan)者的支氣管肺(fei)(fei)(fei)(fei)(fei)(fei)泡(pao)的活性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)化(hua)中性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)粒細胞(bao)(bao)比正(zheng)常人增加10~100倍,服用(yong)(yong)(yong)(yong)小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)進(jin)一步(bu)促進(jin)IL-8的產(chan)生(sheng),分解細胞(bao)(bao)外(wai)基質(zhi)(zhi)(zhi)而(er)使(shi)肺(fei)(fei)(fei)(fei)(fei)(fei)纖(xian)維(wei)(wei)化(hua)進(jin)展,但是(shi)人體具(ju)有(you)防御功(gong)能(neng)(neng),IL-6產(chan)生(sheng)亢進(jin)有(you)抑(yi)制(zhi)(zhi)炎(yan)(yan)癥的作用(yong)(yong)(yong)(yong),而(er)且小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)也有(you)抑(yi)制(zhi)(zhi)肺(fei)(fei)(fei)(fei)(fei)(fei)纖(xian)維(wei)(wei)化(hua)細胞(bao)(bao)增殖的作用(yong)(yong)(yong)(yong),不(bu)能(neng)(neng)證實小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)引(yin)(yin)起(qi)(qi)(qi)(qi)(qi)間(jian)(jian)質(zhi)(zhi)(zhi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan)。有(you)人報道(dao)小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)還能(neng)(neng)治療間(jian)(jian)質(zhi)(zhi)(zhi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan)。有(you)的研(yan)究(jiu)認為(wei)(wei),小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)引(yin)(yin)起(qi)(qi)(qi)(qi)(qi)的肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan)屬藥(yao)物(wu)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)、變態(tai)(tai)反(fan)應(ying)(ying)(ying)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan),是(shi)完(wan)全能(neng)(neng)夠治愈的,但是(shi)為(wei)(wei)什么出現(xian)(xian)死(si)(si)亡呢(ni)?這確是(shi)一個值(zhi)得研(yan)究(jiu)的問題(ti)。通過(guo)(guo)對死(si)(si)亡病例的研(yan)究(jiu)表明,患(huan)(huan)有(you)特發性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)間(jian)(jian)質(zhi)(zhi)(zhi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan)者服用(yong)(yong)(yong)(yong)小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang),部分患(huan)(huan)者出現(xian)(xian)急性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)炎(yan)(yan)癥,即一種(zhong)變應(ying)(ying)(ying)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan),此(ci)時若停用(yong)(yong)(yong)(yong)小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang),則(ze)這種(zhong)藥(yao)物(wu)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan)很容易(yi)(yi)治愈,如(ru)給激(ji)素就能(neng)(neng)使(shi)病情完(wan)全得到控制(zhi)(zhi)。之(zhi)所以(yi)出現(xian)(xian)使(shi)病情惡(e)(e)化(hua)甚至死(si)(si)亡的肺(fei)(fei)(fei)(fei)(fei)(fei)纖(xian)維(wei)(wei)化(hua),是(shi)由于在(zai)已病狀態(tai)(tai)下長(chang)期服用(yong)(yong)(yong)(yong)小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang),使(shi)IL-6、IL-8乃至整(zheng)個細胞(bao)(bao)因(yin)(yin)子網絡的功(gong)能(neng)(neng)失調,其(qi)反(fan)應(ying)(ying)(ying)超(chao)過(guo)(guo)變態(tai)(tai)反(fan)應(ying)(ying)(ying),從(cong)而(er)引(yin)(yin)起(qi)(qi)(qi)(qi)(qi)能(neng)(neng)夠導致(zhi)(zhi)肺(fei)(fei)(fei)(fei)(fei)(fei)纖(xian)維(wei)(wei)化(hua)的細胞(bao)(bao)因(yin)(yin)子的重新表達(da),使(shi)急性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)炎(yan)(yan)癥惡(e)(e)化(hua),肺(fei)(fei)(fei)(fei)(fei)(fei)組織(zhi)迅速(su)纖(xian)維(wei)(wei)化(hua)而(er)致(zhi)(zhi)死(si)(si)亡。小(xiao)(xiao)柴(chai)(chai)胡(hu)(hu)(hu)(hu)湯(tang)(tang)(tang)引(yin)(yin)起(qi)(qi)(qi)(qi)(qi)間(jian)(jian)質(zhi)(zhi)(zhi)性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing)肺(fei)(fei)(fei)(fei)(fei)(fei)炎(yan)(yan)歸為(wei)(wei)變態(tai)(tai)反(fan)應(ying)(ying)(ying)的主要(yao)依據是(shi)DLST陽性(xing)(xing)(xing)(xing)(xing)(xing)(xing)(xing),其(qi)作用(yong)(yong)(yong)(yong)機制(zhi)(zhi)尚不(bu)明確,但過(guo)(guo)度服用(yong)(yong)(yong)(yong)、不(bu)正(zheng)確服用(yong)(yong)(yong)(yong)是(shi)重要(yao)原因(yin)(yin)之(zhi)一。因(yin)(yin)此(ci),在(zai)日本(ben)有(you)4種(zhong)看法:①從(cong)漢(han)方(fang)藥(yao)引(yin)(yin)起(qi)(qi)(qi)(qi)(qi)變態(tai)(tai)反(fan)應(ying)(ying)(ying)報告分析,認為(wei)(wei)黃芩(qin)與(yu)變態(tai)(tai)反(fan)應(ying)(ying)(ying)有(you)關(guan)(guan),這是(shi)比較一致(zhi)(zhi)的看法。②可(ke)(ke)能(neng)(neng)與(yu)漢(han)方(fang)藥(yao)本(ben)身(shen)所具(ju)有(you)的免疫增強作用(yong)(yong)(yong)(yong)有(you)關(guan)(guan)。③可(ke)(ke)能(neng)(neng)與(yu)漢(han)方(fang)藥(yao)的香氣成分有(you)關(guan)(guan)。④漢(han)方(fang)藥(yao)提(ti)取劑在(zai)肺(fei)(fei)(fei)(fei)(fei)(fei)內沉著被巨噬細胞(bao)(bao)吞(tun)食其(qi)作為(wei)(wei)異物(wu)可(ke)(ke)能(neng)(neng)引(yin)(yin)起(qi)(qi)(qi)(qi)(qi)沉積或纖(xian)維(wei)(wei)化(hua)。
從藥(yao)(yao)理(li)學流行(xing)病學進行(xing)探討,血清藥(yao)(yao)理(li)研(yan)究認為小(xiao)(xiao)(xiao)(xiao)柴(chai)(chai)(chai)胡湯(tang)(tang)(tang)抑(yi)制(zhi)成(cheng)纖(xian)維細(xi)胞增殖,從而抑(yi)制(zhi)臟(zang)器(qi)纖(xian)維化;抑(yi)制(zhi)肝(gan)細(xi)胞損害,特別具有(you)(you)細(xi)胞膜穩定作(zuo)用(yong)等。未能證實小(xiao)(xiao)(xiao)(xiao)柴(chai)(chai)(chai)胡湯(tang)(tang)(tang)引(yin)(yin)起間(jian)(jian)質(zhi)性肺炎。日(ri)本(ben)1996年3月統計表明(ming),引(yin)(yin)起間(jian)(jian)質(zhi)性肺炎的(de)發(fa)病率(lv)為十萬分(fen)之(zhi)一,死(si)亡率(lv)為百萬分(fen)之(zhi)一。這(zhe)一統計數(shu)字表明(ming),小(xiao)(xiao)(xiao)(xiao)柴(chai)(chai)(chai)胡湯(tang)(tang)(tang)安全性是(shi)目前西(xi)藥(yao)(yao)所達不到的(de)高度(du)。因而對(dui)(dui)小(xiao)(xiao)(xiao)(xiao)柴(chai)(chai)(chai)胡湯(tang)(tang)(tang)引(yin)(yin)起間(jian)(jian)質(zhi)性肺炎有(you)(you)3種觀(guan)點:①是(shi)小(xiao)(xiao)(xiao)(xiao)柴(chai)(chai)(chai)胡湯(tang)(tang)(tang)毒性副(fu)作(zuo)用(yong)或誤治結果。②是(shi)一種變態反(fan)(fan)應。③小(xiao)(xiao)(xiao)(xiao)柴(chai)(chai)(chai)胡湯(tang)(tang)(tang)與間(jian)(jian)質(zhi)性肺炎無因果關(guan)系(xi)。一部分(fen)醫(yi)(yi)(yi)生(sheng)認為小(xiao)(xiao)(xiao)(xiao)柴(chai)(chai)(chai)胡湯(tang)(tang)(tang)是(shi)一種藥(yao)(yao)物,既然是(shi)藥(yao)(yao)物就會(hui)有(you)(you)副(fu)作(zuo)用(yong)。干擾(rao)素(su)無論(lun)是(shi)副(fu)作(zuo)用(yong)嚴重程度(du),還是(shi)出現(xian)率(lv),都高于小(xiao)(xiao)(xiao)(xiao)柴(chai)(chai)(chai)胡湯(tang)(tang)(tang)。但小(xiao)(xiao)(xiao)(xiao)柴(chai)(chai)(chai)胡湯(tang)(tang)(tang)副(fu)作(zuo)用(yong)死(si)亡事件驚心動(dong)魄,人(ren)們懼(ju)怕小(xiao)(xiao)(xiao)(xiao)柴(chai)(chai)(chai)胡湯(tang)(tang)(tang),再也不敢服用(yong)。不少人(ren)認為,風(feng)波的(de)產(chan)生(sheng)與目前日(ri)本(ben)醫(yi)(yi)(yi)療體(ti)系(xi)在行(xing)政(zheng)管理(li)上以西(xi)醫(yi)(yi)(yi)為基礎不無關(guan)系(xi)。人(ren)們對(dui)(dui)日(ri)本(ben)厚生(sheng)省(sheng)的(de)管理(li)不滿(man),對(dui)(dui)厚生(sheng)省(sheng)2000年1月14日(ri)發(fa)出對(dui)(dui)“肝(gan)癌、肝(gan)硬化患者(zhe)全面禁(jin)止使用(yong)小(xiao)(xiao)(xiao)(xiao)柴(chai)(chai)(chai)胡湯(tang)(tang)(tang)”禁(jin)令不滿(man),認為厚生(sheng)省(sheng)忽視中醫(yi)(yi)(yi)理(li)論(lun)、只(zhi)(zhi)重視西(xi)醫(yi)(yi)(yi)觀(guan)察(cha)指(zhi)導,使能治愈的(de)患者(zhe)沒有(you)(you)治愈反(fan)(fan)致死(si)亡。“安全性情報”只(zhi)(zhi)強調了對(dui)(dui)小(xiao)(xiao)(xiao)(xiao)柴(chai)(chai)(chai)胡湯(tang)(tang)(tang)不利的(de)消息。
藥方無錯
辨證有誤
日(ri)本漢(han)方(fang)界普遍認為(wei)(wei):震驚世界的(de)(de)小柴(chai)胡湯(tang)(tang)風波是(shi)(shi)(shi)一(yi)個嚴重(zhong)事件,其元兇是(shi)(shi)(shi)有(you)(you)(you)地(di)(di)滋(zi)論文(wen)(wen):有(you)(you)(you)地(di)(di)滋(zi)的(de)(de)論文(wen)(wen)提出只根據西醫(yi)的(de)(de)診斷(慢(man)性肝炎(yan)肝硬化(hua))就(jiu)(jiu)用(yong)小柴(chai)胡湯(tang)(tang),使(shi)新(xin)藥開發走向一(yi)條(tiao)新(xin)路(lu)。其業績(ji)得(de)到(dao)西醫(yi)醫(yi)師的(de)(de)高(gao)度評(ping)價,也(ye)引起中(zhong)(zhong)(zhong)國(guo)、韓國(guo)及使(shi)用(yong)中(zhong)(zhong)(zhong)藥的(de)(de)世界各國(guo)的(de)(de)關(guan)注(zhu)。漢(han)方(fang)界認為(wei)(wei),只根據西醫(yi)診斷,就(jiu)(jiu)用(yong)一(yi)個處方(fang)治療,這不符合中(zhong)(zhong)(zhong)醫(yi)辨(bian)證理(li)論,又把小柴(chai)胡湯(tang)(tang)當成是(shi)(shi)(shi)慢(man)性肝炎(yan)、肝硬化(hua)的(de)(de)特效藥更(geng)是(shi)(shi)(shi)錯誤(wu),是(shi)(shi)(shi)言過(guo)其實。特別值得(de)注(zhu)意的(de)(de)是(shi)(shi)(shi),有(you)(you)(you)地(di)(di)滋(zi)在宣講其論文(wen)(wen)時(shi),強(qiang)調“漢(han)方(fang)藥非(fei)常安(an)全,長期服(fu)用(yong)也(ye)沒(mei)問題(ti)”、“漢(han)方(fang)的(de)(de)證容易(yi)消失(shi),這是(shi)(shi)(shi)重(zhong)要(yao)有(you)(you)(you)效信號,但即使(shi)肝功能(neng)沒(mei)有(you)(you)(you)恢復,證也(ye)可以(yi)消失(shi),只是(shi)(shi)(shi)證消失(shi)就(jiu)(jiu)認為(wei)(wei)成功了(le),這樣會耽誤(wu)病情”,故主(zhu)張慢(man)性肝炎(yan)患者,沒(mei)有(you)(you)(you)了(le)小柴(chai)胡湯(tang)(tang)方(fang)證也(ye)要(yao)長期服(fu)用(yong)小柴(chai)胡湯(tang)(tang)。更(geng)值得(de)注(zhu)意的(de)(de)是(shi)(shi)(shi),在近畿大(da)學(xue)演講時(shi),有(you)(you)(you)地(di)(di)滋(zi)指責徒(tu)弟學(xue)習《傷寒論》是(shi)(shi)(shi)落后于(yu)時(shi)代(dai)、是(shi)(shi)(shi)徒(tu)勞(lao)的(de)(de),而強(qiang)調惟有(you)(you)(you)他(ta)對小柴(chai)胡湯(tang)(tang)進(jin)行西洋醫(yi)學(xue)的(de)(de)研究(jiu)才是(shi)(shi)(shi)正確的(de)(de)學(xue)術(shu)研究(jiu)方(fang)向。有(you)(you)(you)地(di)(di)滋(zi)這種只重(zhong)西醫(yi)輕(qing)視中(zhong)(zhong)(zhong)醫(yi)的(de)(de)思想,受到(dao)眾(zhong)多漢(han)方(fang)界強(qiang)烈的(de)(de)批判。
日本春光苑漢(han)方(fang)研修會(hui)主持者(zhe)栗(li)島行(xing)春揭露“因小柴(chai)(chai)(chai)胡(hu)湯副作(zuo)(zuo)用(yong)(yong)(yong)死(si)亡事(shi)件”的(de)真(zhen)相認為:“讓(rang)慢性(xing)肝炎(yan)、肝硬化(hua)等患(huan)者(zhe)長(chang)期服用(yong)(yong)(yong)小柴(chai)(chai)(chai)胡(hu)湯,發(fa)生(sheng)間(jian)(jian)質(zhi)性(xing)肺炎(yan)而死(si)亡,是(shi)(shi)由一個(ge)追求名(ming)利的(de)醫(yi)(yi)師發(fa)表(biao)論文開始(shi)的(de)……進一步探(tan)討其真(zhen)相,發(fa)現有的(de)患(huan)者(zhe)并(bing)用(yong)(yong)(yong)了攻下(xia)劑(桃(tao)核(he)承(cheng)氣(qi)湯顆粒(li)、桂枝茯苓丸顆粒(li)),使(shi)體液(ye)(津液(ye))損傷,致生(sheng)間(jian)(jian)質(zhi)性(xing)肺炎(yan),這(zhe)是(shi)(shi)誤(wu)治,不是(shi)(shi)副作(zuo)(zuo)用(yong)(yong)(yong)”。明確指出:“小柴(chai)(chai)(chai)胡(hu)湯副作(zuo)(zuo)用(yong)(yong)(yong)死(si)亡事(shi)件,是(shi)(shi)不學(xue)習中醫(yi)(yi)理論,只(zhi)用(yong)(yong)(yong)西醫(yi)(yi)的(de)病名(ming)來(lai)決定處方(fang)的(de)結果,是(shi)(shi)研究失敗的(de)根本,而把責任委過于(yu)小柴(chai)(chai)(chai)胡(hu)湯有副作(zuo)(zuo)用(yong)(yong)(yong),是(shi)(shi)錯(cuo)上加錯(cuo)”。
對(dui)這(zhe)一(yi)(yi)事件,國內(nei)中(zhong)(zhong)醫界一(yi)(yi)致(zhi)認為(wei):不(bu)是(shi)方(fang)藥(yao)(yao)有過錯(cuo)(cuo),而(er)是(shi)用(yong)(yong)(yong)藥(yao)(yao)的人(ren)錯(cuo)(cuo)誤(wu)地使用(yong)(yong)(yong)中(zhong)(zhong)藥(yao)(yao)。1991年(nian)在香港召開的中(zhong)(zhong)日學(xue)術(shu)會(hui)上,爭(zheng)論的焦點是(shi)中(zhong)(zhong)藥(yao)(yao)的副(fu)(fu)作(zuo)用(yong)(yong)(yong),中(zhong)(zhong)國學(xue)者一(yi)(yi)致(zhi)認為(wei),用(yong)(yong)(yong)中(zhong)(zhong)醫治(zhi)病是(shi)以(yi)偏(pian)糾偏(pian),以(yi)毒攻毒,強調辨(bian)證(zheng)(zheng)論治(zhi),有是(shi)證(zheng)(zheng)用(yong)(yong)(yong)是(shi)方(fang)。即便在辨(bian)證(zheng)(zheng)不(bu)正確時,是(shi)藥(yao)(yao)不(bu)對(dui)證(zheng)(zheng),為(wei)辨(bian)證(zheng)(zheng)失(shi)誤(wu),應(ying)(ying)重新辨(bian)證(zheng)(zheng),改(gai)換(huan)用(yong)(yong)(yong)藥(yao)(yao)。就是(shi)說小柴胡(hu)湯有其適應(ying)(ying)證(zheng)(zheng),辨(bian)證(zheng)(zheng)準確,方(fang)藥(yao)(yao)對(dui)證(zheng)(zheng)則能(neng)治(zhi)愈疾病,辨(bian)證(zheng)(zheng)不(bu)準確,則不(bu)能(neng)治(zhi)病,且(qie)對(dui)人(ren)體起傷害作(zuo)用(yong)(yong)(yong),如(ru)同西地蘭主要(yao)用(yong)(yong)(yong)于(yu)心(xin)衰,如(ru)用(yong)(yong)(yong)于(yu)無(wu)心(xin)衰者便可造成死亡,這(zhe)怎么(me)稱(cheng)作(zuo)副(fu)(fu)作(zuo)用(yong)(yong)(yong)、不(bu)良反應(ying)(ying)呢?怎能(neng)與關(guan)木通、關(guan)防己(ji)一(yi)(yi)樣被列為(wei)“問題(ti)藥(yao)(yao)”呢?這(zhe)一(yi)(yi)事件應(ying)(ying)引起我們冷靜深思。
對小柴(chai)胡(hu)湯“蒙冤”的思考
思考一(yi):濫用小柴胡湯是造(zao)成悲劇的(de)主因
重(zhong)視(shi)兩(liang)種科(ke)(ke)(ke)學(xue)(xue)(xue)觀的(de)(de)(de)不同(tong):對中(zhong)(zhong)(zhong)(zhong)藥(yao)(yao)的(de)(de)(de)研究(jiu)與(yu)應(ying)用,不但(dan)要(yao)重(zhong)視(shi)西(xi)(xi)醫(yi)(yi)的(de)(de)(de)理(li)(li)(li)論(lun)而(er)且要(yao)重(zhong)視(shi)中(zhong)(zhong)(zhong)(zhong)醫(yi)(yi)理(li)(li)(li)論(lun):中(zhong)(zhong)(zhong)(zhong)醫(yi)(yi)和西(xi)(xi)醫(yi)(yi)是(shi)(shi)兩(liang)種不同(tong)的(de)(de)(de)科(ke)(ke)(ke)學(xue)(xue)(xue)體系,西(xi)(xi)醫(yi)(yi)理(li)(li)(li)論(lun)接近(jin)于(yu)現(xian)代科(ke)(ke)(ke)技(ji),備受人(ren)(ren)們(men)重(zhong)視(shi),是(shi)(shi)理(li)(li)(li)所應(ying)該的(de)(de)(de)。而(er)中(zhong)(zhong)(zhong)(zhong)醫(yi)(yi)理(li)(li)(li)論(lun)成(cheng)(cheng)熟于(yu)古代,往(wang)(wang)往(wang)(wang)難于(yu)理(li)(li)(li)解,甚至被否定其(qi)科(ke)(ke)(ke)學(xue)(xue)(xue)價值。研究(jiu)開發中(zhong)(zhong)(zhong)(zhong)藥(yao)(yao)往(wang)(wang)往(wang)(wang)重(zhong)視(shi)現(xian)代醫(yi)(yi)學(xue)(xue)(xue)的(de)(de)(de)理(li)(li)(li)論(lun),而(er)忽視(shi)中(zhong)(zhong)(zhong)(zhong)醫(yi)(yi)的(de)(de)(de)理(li)(li)(li)論(lun),應(ying)該引起人(ren)(ren)們(men)警惕(ti)。有(you)(you)(you)(you)地滋用小柴(chai)(chai)胡(hu)湯(tang)(tang)(tang)治(zhi)療慢性(xing)(xing)肝(gan)(gan)炎、肝(gan)(gan)硬(ying)化(hua)的(de)(de)(de)研究(jiu),其(qi)科(ke)(ke)(ke)研設(she)計、方(fang)(fang)(fang)法、完全符(fu)合西(xi)(xi)醫(yi)(yi)的(de)(de)(de)科(ke)(ke)(ke)研要(yao)求(qiu),其(qi)科(ke)(ke)(ke)學(xue)(xue)(xue)性(xing)(xing)似(si)無可懷疑。但(dan)中(zhong)(zhong)(zhong)(zhong)醫(yi)(yi)的(de)(de)(de)辨(bian)(bian)證(zheng)(zheng)論(lun)治(zhi)體系是(shi)(shi)通過患病(bing)人(ren)(ren)體的(de)(de)(de)癥狀反(fan)應(ying),經過長(chang)期臨(lin)(lin)床實踐(jian)總結(jie)出(chu)的(de)(de)(de)具(ju)有(you)(you)(you)(you)普遍規律(lv)性(xing)(xing)的(de)(de)(de)科(ke)(ke)(ke)學(xue)(xue)(xue)理(li)(li)(li)論(lun),是(shi)(shi)經過了(le)幾千(qian)年(nian)臨(lin)(lin)床考驗的(de)(de)(de)。如果不根據癥狀反(fan)應(ying)用小柴(chai)(chai)胡(hu)湯(tang)(tang)(tang),又長(chang)期服(fu)(fu)用一個(ge)方(fang)(fang)(fang)藥(yao)(yao),就(jiu)脫離了(le)中(zhong)(zhong)(zhong)(zhong)醫(yi)(yi)辨(bian)(bian)證(zheng)(zheng)論(lun)治(zhi)理(li)(li)(li)論(lun)。特別是(shi)(shi)小柴(chai)(chai)胡(hu)湯(tang)(tang)(tang)出(chu)自于(yu)《傷寒(han)(han)論(lun)》,《傷寒(han)(han)論(lun)》則是(shi)(shi)中(zhong)(zhong)(zhong)(zhong)醫(yi)(yi)經方(fang)(fang)(fang)的(de)(de)(de)辨(bian)(bian)證(zheng)(zheng)論(lun)治(zhi)體系,更講求(qiu)辨(bian)(bian)方(fang)(fang)(fang)證(zheng)(zheng)。書中(zhong)(zhong)(zhong)(zhong)提出(chu)了(le)“病(bing)皆與(yu)方(fang)(fang)(fang)相應(ying)者(zhe),乃服(fu)(fu)之(zhi)”(《傷寒(han)(han)論(lun)》第317條),即指(zhi)出(chu):臨(lin)(lin)床用方(fang)(fang)(fang)必須辨(bian)(bian)清(qing)其(qi)適應(ying)方(fang)(fang)(fang)證(zheng)(zheng),即“有(you)(you)(you)(you)是(shi)(shi)證(zheng)(zheng),用是(shi)(shi)方(fang)(fang)(fang)”。有(you)(you)(you)(you)地滋強調(diao):“慢性(xing)(xing)肝(gan)(gan)炎肝(gan)(gan)硬(ying)化(hua)患者(zhe)有(you)(you)(you)(you)關小柴(chai)(chai)胡(hu)湯(tang)(tang)(tang)的(de)(de)(de)‘證(zheng)(zheng)’消(xiao)失了(le),還要(yao)繼(ji)續長(chang)期服(fu)(fu)用小柴(chai)(chai)胡(hu)湯(tang)(tang)(tang)”、“漢方(fang)(fang)(fang)非常安全,長(chang)期服(fu)(fu)用也沒有(you)(you)(you)(you)問題”,誤(wu)導人(ren)(ren)們(men)濫用小柴(chai)(chai)胡(hu)湯(tang)(tang)(tang),不遵守(shou)“有(you)(you)(you)(you)是(shi)(shi)證(zheng)(zheng),用是(shi)(shi)方(fang)(fang)(fang)”方(fang)(fang)(fang)證(zheng)(zheng)對應(ying)原(yuan)則,是(shi)(shi)造成(cheng)(cheng)悲劇的(de)(de)(de)主要(yao)原(yuan)因。
實(shi)際(ji)有關(guan)小柴(chai)(chai)(chai)(chai)胡(hu)(hu)湯(tang)(tang)(tang)的使用(yong)(yong)注意(yi)事項,早在《傷寒論》已(yi)(yi)有說(shuo)明(ming),如第97條:“血弱、氣(qi)(qi)盡(jin)、腠理開,邪氣(qi)(qi)因入(ru)……往來(lai)寒熱(re),休作有時(shi),嘿嘿不(bu)(bu)欲飲(yin)食(shi)……小柴(chai)(chai)(chai)(chai)胡(hu)(hu)湯(tang)(tang)(tang)主之。服(fu)柴(chai)(chai)(chai)(chai)胡(hu)(hu)湯(tang)(tang)(tang)已(yi)(yi),渴(ke)者(zhe)屬(shu)陽(yang)(yang)明(ming),以法治之。”即服(fu)小柴(chai)(chai)(chai)(chai)胡(hu)(hu)湯(tang)(tang)(tang)一(yi)劑后,證(zheng)變(bian)了,所用(yong)(yong)的方藥也要變(bian)化(hua)。以法治之,即渴(ke)者(zhe)屬(shu)陽(yang)(yang)明(ming)病(bing),治用(yong)(yong)清(qing)陽(yang)(yang)明(ming)熱(re)的白虎、承(cheng)氣(qi)(qi)等(deng)。應(ying)根(gen)據證(zheng)用(yong)(yong)方,即絕不(bu)(bu)能再用(yong)(yong)小柴(chai)(chai)(chai)(chai)胡(hu)(hu)湯(tang)(tang)(tang)了。中醫治病(bing),不(bu)(bu)論是(shi)急性病(bing)還(huan)是(shi)慢(man)性病(bing),皆是(shi)服(fu)一(yi)次藥即看變(bian)化(hua),根(gen)據癥狀(zhuang)變(bian)化(hua)而變(bian)換方藥,不(bu)(bu)允許長(chang)期服(fu)一(yi)個處方,一(yi)方到底。由臨(lin)床經驗也可(ke)知,不(bu)(bu)論是(shi)急性病(bing)還(huan)是(shi)慢(man)性病(bing)、不(bu)(bu)論是(shi)感冒、肺炎(yan)(yan)、肝(gan)炎(yan)(yan)、膽囊(nang)炎(yan)(yan)、胃炎(yan)(yan)……患(huan)者(zhe)都(dou)可(ke)能出現小柴(chai)(chai)(chai)(chai)胡(hu)(hu)湯(tang)(tang)(tang)方證(zheng),用(yong)(yong)小柴(chai)(chai)(chai)(chai)胡(hu)(hu)湯(tang)(tang)(tang)治療肯定有效(xiao)。但不(bu)(bu)根(gen)據患(huan)者(zhe)臨(lin)床癥狀(zhuang),一(yi)見感冒、肺炎(yan)(yan)、肝(gan)炎(yan)(yan)、膽囊(nang)炎(yan)(yan)、胃炎(yan)(yan)……不(bu)(bu)見小柴(chai)(chai)(chai)(chai)胡(hu)(hu)湯(tang)(tang)(tang)方證(zheng)就(jiu)用(yong)(yong)小柴(chai)(chai)(chai)(chai)胡(hu)(hu)湯(tang)(tang)(tang)治療那必(bi)然無效(xiao),而且(qie)還(huan)必(bi)會傷害人體。
思考二:中藥必須在中醫理(li)論指導(dao)下應用(yong)
必須重視中西醫的用語不同:副作用一詞來自于西醫科學體系,其詞義《辭海》謂:“①泛指在主要作用之外的作用,多指不良反應。②藥物不良反應的主要類型之一,指藥物在防治某些疾病時發生的不需要的藥理作用,而這些作用別的場合可能有用,如阿托品抑制唾液分泌的作用,在流涎癥為治療作用,但對消化性潰瘍便成為口干的副作用。副作用-詞有時也用來泛指任何類型的藥物不良反應。③化學上副反應的別名。”以上也提到,一些人認為,凡是藥物都有副作用,是西醫理論的觀點,副作用一詞適用于西醫。而中醫是根據癥狀反應用藥,又認為凡是藥皆有毒。《淮南子》謂:“神農嘗百草(cao)……一日而遇七十毒(du)(du)(du)”。《周禮(li)》謂(wei):“聚(ju)毒(du)(du)(du)藥(yao)(yao)(yao)(yao)(yao)(yao)以(yi)共醫(yi)事”,這里的(de)毒(du)(du)(du)藥(yao)(yao)(yao)(yao)(yao)(yao)為(wei)(wei)中(zhong)藥(yao)(yao)(yao)(yao)(yao)(yao)的(de)總(zong)稱,毒(du)(du)(du)性(xing)即為(wei)(wei)藥(yao)(yao)(yao)(yao)(yao)(yao)物。明(ming)代張景岳(yue)認(ren)為(wei)(wei):“藥(yao)(yao)(yao)(yao)(yao)(yao)以(yi)治病(bing)(bing)(bing)(bing),因(yin)毒(du)(du)(du)為(wei)(wei)能(neng),所謂(wei)毒(du)(du)(du)者(zhe)(zhe),因(yin)氣(qi)味之(zhi)偏也(ye)”。中(zhong)醫(yi)的(de)理論是(shi)(shi)(shi)(shi)來自長期用(yong)(yong)(yong)(yong)(yong)(yong)藥(yao)(yao)(yao)(yao)(yao)(yao)的(de)經(jing)驗總(zong)結,《漢書(shu)·藝文志》曰(yue):“經(jing)方者(zhe)(zhe),本(ben)(ben)草(cao)石之(zhi)寒(han)溫(wen),量疾病(bing)(bing)(bing)(bing)之(zhi)淺深(shen),假(jia)藥(yao)(yao)(yao)(yao)(yao)(yao)味之(zhi)滋,因(yin)氣(qi)感之(zhi)宜,辨五苦六辛,致(zhi)水火之(zhi)齊,以(yi)通閉解結,反(fan)(fan)之(zhi)于(yu)(yu)平。及(ji)失(shi)其(qi)(qi)宜者(zhe)(zhe),以(yi)熱(re)(re)益(yi)熱(re)(re),以(yi)寒(han)增寒(han),精氣(qi)內傷(shang),不(bu)見于(yu)(yu)外(wai),是(shi)(shi)(shi)(shi)所獨(du)(du)失(shi)也(ye)。”中(zhong)醫(yi)治病(bing)(bing)(bing)(bing)的(de)實質,是(shi)(shi)(shi)(shi)以(yi)藥(yao)(yao)(yao)(yao)(yao)(yao)物之(zhi)偏,糾正(zheng)疾病(bing)(bing)(bing)(bing)之(zhi)偏,以(yi)毒(du)(du)(du)攻毒(du)(du)(du),不(bu)能(neng)失(shi)其(qi)(qi)宜。日本(ben)(ben)的(de)“小柴(chai)胡湯(tang)副作(zuo)用(yong)(yong)(yong)(yong)(yong)(yong)死亡事件”實質,是(shi)(shi)(shi)(shi)違反(fan)(fan)了中(zhong)醫(yi)辨證論治的(de)原則(ze),違反(fan)(fan)了經(jing)方“有(you)是(shi)(shi)(shi)(shi)證,用(yong)(yong)(yong)(yong)(yong)(yong)是(shi)(shi)(shi)(shi)方”必(bi)辨方證的(de)原則(ze),用(yong)(yong)(yong)(yong)(yong)(yong)藥(yao)(yao)(yao)(yao)(yao)(yao)“失(shi)其(qi)(qi)宜”,造(zao)成患(huan)者(zhe)(zhe)“精氣(qi)內傷(shang),不(bu)見于(yu)(yu)外(wai),是(shi)(shi)(shi)(shi)所獨(du)(du)失(shi)也(ye)。”而沒(mei)有(you)副作(zuo)用(yong)(yong)(yong)(yong)(yong)(yong)概(gai)(gai)念。有(you)地滋用(yong)(yong)(yong)(yong)(yong)(yong)小柴(chai)胡湯(tang)治療(liao)慢性(xing)肝炎、肝硬(ying)化(hua)時(shi),當患(huan)者(zhe)(zhe)沒(mei)有(you)了小柴(chai)胡湯(tang)對應證后仍(reng)給長期服(fu)(fu)用(yong)(yong)(yong)(yong)(yong)(yong),這當然是(shi)(shi)(shi)(shi)服(fu)(fu)毒(du)(du)(du)藥(yao)(yao)(yao)(yao)(yao)(yao),不(bu)能(neng)治病(bing)(bing)(bing)(bing)而是(shi)(shi)(shi)(shi)添病(bing)(bing)(bing)(bing),豈能(neng)稱是(shi)(shi)(shi)(shi)副作(zuo)用(yong)(yong)(yong)(yong)(yong)(yong)?這里西(xi)醫(yi)、中(zhong)醫(yi)的(de)藥(yao)(yao)(yao)(yao)(yao)(yao)理概(gai)(gai)念存在(zai)明(ming)顯不(bu)同。因(yin)此,副作(zuo)用(yong)(yong)(yong)(yong)(yong)(yong)一詞(ci)是(shi)(shi)(shi)(shi)西(xi)醫(yi)藥(yao)(yao)(yao)(yao)(yao)(yao)理論的(de)用(yong)(yong)(yong)(yong)(yong)(yong)語,不(bu)適用(yong)(yong)(yong)(yong)(yong)(yong)于(yu)(yu)中(zhong)醫(yi)藥(yao)(yao)(yao)(yao)(yao)(yao)理論用(yong)(yong)(yong)(yong)(yong)(yong)語。中(zhong)醫(yi)把(ba)誤治服(fu)(fu)藥(yao)(yao)(yao)(yao)(yao)(yao)稱之(zhi)為(wei)(wei)“獨(du)(du)失(shi)”。此用(yong)(yong)(yong)(yong)(yong)(yong)語已(yi)引起國內一些(xie)科技研(yan)究者(zhe)(zhe)、專家(jia)的(de)關注,趨向于(yu)(yu)把(ba)不(bu)正(zheng)確服(fu)(fu)用(yong)(yong)(yong)(yong)(yong)(yong)中(zhong)藥(yao)(yao)(yao)(yao)(yao)(yao)造(zao)成的(de)后果(guo),稱之(zhi)為(wei)(wei)藥(yao)(yao)(yao)(yao)(yao)(yao)害。
思(si)考三(san):從“小柴胡湯事(shi)件(jian)”中引取(qu)教訓
要(yao)(yao)(yao)分(fen)清問題(ti)性(xing)(xing)質的(de)不(bu)同(tong):關(guan)(guan)木通(tong)、關(guan)(guan)防己引起(qi)腎損(sun)害,報(bao)道(dao)后引起(qi)人們(men)注(zhu)意(yi),經(jing)(jing)進一(yi)步查為300年(nian)前誤用品種,稱(cheng)其(qi)為問題(ti)藥,“定(ding)罪”事(shi)(shi)實清楚。而小(xiao)(xiao)柴(chai)胡(hu)(hu)湯(tang)為中(zhong)(zhong)藥復方(fang),中(zhong)(zhong)醫(yi)據證(zheng)用方(fang)幾(ji)千(qian)年(nian),不(bu)存(cun)在什么副(fu)作(zuo)(zuo)用問題(ti),即便按西醫(yi)實驗室研(yan)究,小(xiao)(xiao)柴(chai)胡(hu)(hu)湯(tang)的(de)副(fu)作(zuo)(zuo)用比干擾(rao)素明(ming)顯小(xiao)(xiao),沒有(you)確鑿的(de)證(zheng)據說(shuo)其(qi)造成了(le)間質性(xing)(xing)肺炎,在日(ri)本(ben)并沒有(you)給其(qi)“定(ding)罪”。但(dan)目前,不(bu)論(lun)是(shi)西醫(yi)、中(zhong)(zhong)醫(yi)皆未把(ba)小(xiao)(xiao)柴(chai)胡(hu)(hu)湯(tang)與關(guan)(guan)木通(tong)、關(guan)(guan)防己同(tong)視為問題(ti)方(fang)藥,主(zhu)(zhu)要(yao)(yao)(yao)是(shi)由(you)于(yu)在日(ri)本(ben)產生的(de)“小(xiao)(xiao)柴(chai)胡(hu)(hu)湯(tang)副(fu)作(zuo)(zuo)用事(shi)(shi)件風(feng)波”中(zhong)(zhong)日(ri)本(ben)的(de)媒(mei)體(ti)和厚生省(sheng)(sheng)誤導起(qi)了(le)主(zhu)(zhu)要(yao)(yao)(yao)作(zuo)(zuo)用。試想,如果按照有(you)地滋們(men)的(de)研(yan)究方(fang)法應(ying)用小(xiao)(xiao)柴(chai)胡(hu)(hu)湯(tang)和經(jing)(jing)方(fang),又按照日(ri)本(ben)的(de)厚生省(sheng)(sheng)、媒(mei)體(ti)那樣(yang)對待小(xiao)(xiao)柴(chai)胡(hu)(hu)湯(tang)和經(jing)(jing)方(fang),那么《傷(shang)寒雜病論(lun)》的(de)方(fang)劑無一(yi)不(bu)會(hui)出現副(fu)作(zuo)(zuo)用和不(bu)良反應(ying)甚至死人;由(you)于(yu)這些經(jing)(jing)方(fang)都與關(guan)(guan)木通(tong)、關(guan)(guan)防己同(tong)列,所以中(zhong)(zhong)醫(yi)將(jiang)無方(fang)無藥可用。因此,我國的(de)科研(yan)和管理部門及(ji)媒(mei)體(ti)都必須重視中(zhong)(zhong)醫(yi)理論(lun),從“小(xiao)(xiao)柴(chai)胡(hu)(hu)湯(tang)”事(shi)(shi)件中(zhong)(zhong)引取教訓,分(fen)清問題(ti)的(de)性(xing)(xing)質,慎把(ba)小(xiao)(xiao)柴(chai)胡(hu)(hu)湯(tang)與關(guan)(guan)木通(tong)、關(guan)(guan)防己同(tong)列,不(bu)要(yao)(yao)(yao)重蹈(dao)日(ri)本(ben)媒(mei)體(ti)厚生省(sheng)(sheng)誤導的(de)覆轍。
小柴胡湯出自于傷寒論,小柴胡湯只為治療外感病出生的,治療邪入少陽,或者,邪轉屬少陽,治療始終是針對的是邪氣,需要把邪氣由半表半里把它清解了。我們在臨床上可以把小柴胡湯引用于治療內傷病。引用于治療內傷病,可能與治療外感病多少有一點不一樣。
明朝的薛己在《內科摘要》里寫道:小柴胡湯:治肝膽癥,寒熱往來,或日晡發熱,或潮熱身熱,默默不欲食;或怒火口苦耳聾,咳嗽發熱,脅下作痛,甚者轉側不便,兩胠痞滿;或泄瀉咳嗽;或吐酸食苦水;或因怒而患瘧痢等癥。
我們從薛己的這一段文字得知,小柴胡湯的使用范圍很大,寒熱往來,日晡發熱,這是指的內傷。我們在外傷里面說到的日晡發熱,經常是陽明發熱見多。或者是潮熱,經常是陽明發熱見得比較多。而在內傷發熱里面,小柴胡湯可以治療,寒熱往來,日晡發熱,潮熱身熱。
我們單拿外感發熱去涵蓋內傷發熱經常會出問題的。或者拿內傷的表現去涵蓋外感的表現也經常會用錯的。
小柴胡湯用于外感病和小柴胡湯用于內傷病有什么不同呢?
小柴胡湯用于外感病,主要作用在于和解表里,祛邪外出。小柴胡湯用于內傷病,每每用其疏調肝脾、疏解郁熱等。
小柴胡湯用于外感病,我們辨證用的是六經辨證,小柴胡湯于內傷病,我們辨證用的是臟腑辨證。
我們來看薛己在《內科摘要》里的一則醫案:太守朱陽山因怒腹痛作瀉,或兩脅作脹,或胸乳作痛,或寒熱往來,或小便不利,飲食不入,嘔吐痰涎,神思不清。此肝木乘脾土,用小柴胡加山梔,泡姜,茯苓,陳皮,制黃連,一劑即愈。
這個病因是怒,癥狀是腹痛作瀉,兩脅作脹,胸乳作痛,寒熱往來,小便不利,飲食不入,嘔吐痰涎,神思不清。這一組病癥反復或者交替出現,這一組病證上下,里外都有。
開了一劑病就好了,這個療效是很快的。看他的癥狀表現確實是很重的。如果這個病證,我們從六經辨證應該怎么來辨?會不會辨證辨到少陽上來?如果是辨到少陽,應該如何來治療?
薛己在這里用的是臟腑辨證,肝脾不和,肝木乘脾土,方用小柴胡湯加山梔,泡姜,茯苓,陳皮,制黃連。這個制黃連是用黃連和吳茱萸各等分,用熱水拌濕罨兩三天,同時炒焦,取黃連為用。實際上就是左金丸。也就是說小柴胡湯和左金丸,在這個基礎上用了泡姜,茯苓和陳皮,小柴胡湯里有人參,甘草,再加上泡姜,這就是半個理中湯了。
小柴胡湯合理中湯合左金丸,小柴胡湯里有半夏,半夏配上茯苓,陳皮,二陳湯又出來了;半夏,泡姜,黃連,人參,炙甘草,這差不多半夏瀉心湯又出來了。這樣一來,就是小柴胡湯合半夏瀉心湯合理中湯合二陳湯,四個方子合起來,藥味都不多。而臟腑辨證的用方用藥,經常會這樣用。而這種風格和六經辨證用方用藥的風格完全不一樣。這里,實際上是把小柴胡湯改造成了一張治療內傷病肝脾同調的一張方子了。
分析本案處方,實為小柴胡湯、半夏瀉心湯、二陳湯三方合方加減(如果把“制黃連”看作左金丸法,則為四方化裁)如果治療外感病,如果從六經辨證法用方,小柴胡湯不該有這種用法。如果我們從六經辨證用方,小柴胡湯不會隨便和半夏瀉心湯,二陳湯,左金丸這些方合方的,這一合就合亂了,就沒有辦法去治療少陽病。
而治療(liao)內傷病,用臟(zang)腑(fu)辨證法(fa)用方(fang),本(ben)案中小柴(chai)胡湯的(de)這種(zhong)用法(fa)似乎非(fei)常自然、合(he)理(li)。這應該是經(jing)方(fang)從張仲(zhong)景開始,通過后(hou)世的(de)發展,把(ba)經(jing)方(fang)在臨床運用的(de)一種(zhong)自然的(de)發展,自然的(de)拓展。
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