조갑제
'아프다 하하하'
在北작가 반디가 쓴 '고발'이란 단편집엔 일곱 편이 실렸는데 연극이 이야기의 소재로 자주 나온다. 북한 체제의 중요한 작동 원리가 연극이기 때문이다. 어버이 수령님과 인민은 지상 최대의 연극을 연기하듯이 살아간다. 평양은 그 중심 무대이다. 종국엔 연기와 삶이 일체화된다. ‘무대自感’인 것이다.
연극 중에서도 가장 잔인한 연극은 <아프다 하하하>, <간지럽다 엉엉>이다. 아파도 웃어야 하고, 간지러워도 울어야 한다. 보통 독재자는 公的 생활을 통제한다. 전체주의 독재자는 인간의 私생활까지 통제한다. 김일성 같은 ‘自感 독재자’는 인간의 감정까지 통제한다. 전체주의 독재보다 더 심한 것이 이런 감성독재이다. 반디는 김일성이야말로 스탈린과 히틀러를 능가한 최악의 감성 독재자였음을 고발한다. (발췌)
-------------------------------------------------------------
필리핀의 비협조적인 반미정책에 식상한 미국이 1992년에 철수해버림.
미국이 전략상 절대로 빠져 나가지 못할 것이라던 좌파들의 선동에 국민들이 멋 모르고 건방을 떤 댓가로
미군 철수 후 필리핀의 코 앞에 있던 스카보로섬을, 중공이 무력으로 강탈함.
필리핀이 국제사법재판소에 제소하여 승소했음에도 불구하고, 아예 군사 활주로까지 만들어 현재 남중국해 군사 요충지로 사용 중. 역시 '국제관계는 힘의 논리일 수밖에 없다'는 냉엄한 현실을 보여줌.
게다가 미군 철수와 함께 필리핀에 들어와 있던 외자들이 썰물처럼 빠져 나가면서 필리핀 경제는 하루 아침에 완전히 무너져 내림.
현재 7백만 명이나 되는 필리핀 여성이 외국에 나가 가정부 등으로 돈을 벌고, 몸까지 팔아 가면서 번 돈으로 겨우 나라를 지탱해 나가고 있는 실정.
더 웃긴 것은 아직도 정신을 못차리고 외국에 가정부 등으로 나가는 여성들이 대부분 대졸 출신의 고학력 출신으로 좌파적 사고를 가지고 있다는 사실.
* 제 2의 애치슨 라인
워싱턴 정가에서는 대만, 일본은 절대 포기 못해도 한국은 반반이라고 한다. / 일베
----------------------------------------------------------------------------------
----------------------------------------------------------------------------
붕괴하는 경제와 여의치 않은 무역 협상으로 인해, 시진핑은 홍콩에서의 승리를 필요로 한다.
---------------------------------------------------------------------------
사우디와 러시아를 포함해 37개국이 중국의 신장에서의 정책을 지지하고 있다.
-----------------------------------------------------------------------------------------
일단의 지식인들이 트럼프에 서한을 보내, 중국과의 대결 정책을 계속할 것을 요구했다.
이에 대해 중국 언론이 반박하다.
-------------------------------------------------------------------------------------
필리핀의 대통령 대변인이 베트남에게 중국의 영해 침략에 대응해서는 안된다고 발표.
필리핀은 이미 중국의 속국이 되어버린 듯. 미국이 개입하지 않으면 동남아시아의 모든 나라들은, 옛날 진시황 앞의 6국처럼 하나하나 차례로 복속이 될 것 같다.
--------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------
사학자 닐 퍼거슨
모든 거대한 역사적 인물은 두 번 등장한다. 한번은 비극으로, 두번재는 소극(笑劇)으로.
처칠과 보리스 존슨의 유사성.
---------------------------------------------------------------------------
-------------------------------------------------------------------------------
물은 우주에서 가장 기이한 물체이다.
-------------------------------------------------------------------------------
모든 것은 유전자에 달리지 않았다.
환경 역시 극히 중요하다.
---------------------------------------------------------------------------------------------
할머니의 뱃속에 있는 어머니와, 어머니의 뱃속에 이미 들어 있는 미래의 내가 되는 난자
--------------------------------------------------------------------------------------------
효율성을 단지 수량적으로만 측정하면, 사람들은 비윤리적 행동을 하려는 유혹에 빠진다.
---------------------------------------------------------------------
탈레브는 지능과 지능 검사를 가짜라고 주장하고, 그에 반대하는 사람들은 모두 멍청이로 부르고 있다. 이번엔 클레어 레이먼이 욕을 먿어먹고 있다.
탈레브는 자신의 막말로 인해, 필요없이 자신의 이론과 주장에 흠집을 내고 있다.
많은 사람들이 그의 수학 이론을 잘 이해하지 못하고 있다. 따라서 쉽게 설명해주면 되는데 막무가내로 멍청이라고 말해서 스스로의 신뢰성을 깎아내리고 있다.
---------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------
해즐릿의 책 <신경제학의 실패> 60주년
케인즈의 책에서 독창적인 것은 진실이 아니다. 그리고 진실인 부분은 그의 독창적인 생각이 아니다.
케인즈는 지속적인 실업은 정부와 노조가 잠재적인 시장 가격보다 높게 노동 가격을 책정한 결과라는 사실을 알지 못했다. (현재 한국의 최저임금으로 인한 실업이 바로 이것이다.)
Sixtieth Anniversary of Hazlitt's The Failure of the 'New Economics'
Nate White
[The Christian Science Monitor on 11 September 1959 ran a "Symposium on Keynes" prompted by the publication of Henry Hazlitt's book The Failure of the "New Economics" earlier that year. The invited contributors are an illustrious list of economists from the most prestigious universities of the day: Ludwig von Mises; Arthur F. Burns; Seymour E. Harris; Calvin B. Hoover; Adolf A. Berle, Jr.; Neil H. Jacoby; Sumner H. Slichter; Friedrich August von Hayek; and John Kenneth Galbraith. The contributions of Mises, Hayek, Burns, and Galbraith appear below. It is notable that Ludwig von Mises is the only non-academic to be invited to contribute to the symposium, and, for whatever reason, is the first contribution to appear in the article.]
Just mention the name Keynes in almost any circle of economists and in most circle of informed businessmen in the United States or Great Britain and Europe today and then sit back and watch the sparks fly. It has been 13 years since Lord Keynes (John Maynard Keynes) passed on, yet careful authors spend years in research on his work either to praise him or to argue the soundness of his theories.
This year [1959] Henry Hazlitt, business editor of Newsweek magazine, stirred up the old embers smoldering on Keynesian economics with the publication of his book, The Failure of the "New Economics," published in New York by Van Nostrand, $7.50.
The Hazlitt book proposes to end the debate on Keynes by arguing down closely and finally the validity of the Briton's theories. Mr. Hazlitt's position is not middle of the road. He takes off from a totally right-of-center point.
He never liked Keynes's theories. He has long criticized them in his writings, and his book develops this thesis thoroughly and well. For those who never saw any good in the Franklin Roosevelt New Deal, for the concepts of pump priming, of spending to win recovery, of using monetary policy to combat depression, of lowering interest rates to encourage spending, the Hazlitt thesis is a final proof that there was and is no good in Keynes.
~~~~
Yet, somehow one doesn't dispose of the provocative Briton's work so easily, even in such an exhaustively researched book as Henry Hazlitt's.
Most folks today agree that Lord Keynes was an expedientist, that he attempted to deal contemporaneously with special problems — mainly depression — and that if he were here today he would have completely abandoned his own views for new ones for the problems of today. The danger, according to Mr. Hazlitt, in such a work is that it might become accepted as final dogma.
Keynes early startled the world arguing that it was desperately wrong for the Allies to seek to exact reparations from Germany after World War I, at a time when many wanted to hang the Kaiser. He was concerned during the 1920s with the boom in the United States and approved Federal Reserve Board actions to try to dampen it.
During the 1930s, when the world was flattened by economic chaos, Keynes was constantly searching for ways to help his own country, Great Britain, get out of the morass. Most of his ideas were provocative. Some were new, some old but reworked. Because Britain and the United States were so linked economically he worked hard at ideas to help the United States lift itself out of depression.
Keynes was a good writer and an excellent publicist for his ideas. Many of his ideas are considered today to have been warmed up or rehashed theories with a special twist to meet depression problems. Whenever Keynes wrote or said something, the government leaders of the 1930s took notice.
Keynes visited the United States, talked over some of his ideas with President Roosevelt. The New Deal's fiery Secretary of the Interior, Harold L. Ickes, advanced government spending programs, especially in reclamation and power projects to counteract depression. Was it Ickes or Keynes?
But Keynes was not simply an advocate of government spending to end depression. He first of all wanted businesses themselves to plan needed capital expenditures to combat depression. He wanted consumers to buy. This is economic policy which was urged by the Eisenhower administration only last year. There isn't anything very spectacular about it, but the fact that Keynes urged it steadily and consistently won him credit which probably could be claimed by many another less-publicized economist. When business and consumer did not respond, Keynes urged governments to spend.
~~~~
Newspapers' musty files are filled with the thunder from the busy Cambridge University economist. But the clippings, when fitted together today, show that Keynes was always seeking to get a temporary solution to a given problem. He was an experimenter. Many times he did not know how a proposal would work out. He was ready to risk failure and condemnation. But the one thing he would not risk during the dark days of depression was inaction.
Today when a body of doctrine is labeled Keynesian, it is difficult to pinpoint just what is meant. Usually it means government action of some sort to prevent a depression or to slow down a boom. The term Keynesian is almost without real meaning, because of the temporary nature of Keynes's efforts to find ways to end the 1930s depression. …
~~~~
Most of Keynes's severest critics today credit him with having stirred human thinking to a change of base. Keynes would probably be pleased but not content with having done this, even if many of his ideas went wild.
In any case, the debate over Keynes, revived so vigorously this year by Mr. Hazlitt, seems certain to continue for some time.
To Mr. Hazlitt, there is no middle ground on Keynes, and to those who oppose the Roosevelt New Deal, there was no middle ground. The Hazlitt challenge, thrown down in his book, is summarized as follows:
The Keynesian literature has perhaps grown to hundreds of books and thousands of articles. There are books wholly devoted to expounding the General Theory in simpler and more intelligible terms. But on the critical side there is a great dearth. The non-Keynesians and anti-Keynesians have contented themselves either with short articles, a few parenthetic pages, or a curt dismissal on the theory that his work will crumble from its own contradictions and will soon be forgotten. I know of no single work that devotes itself to a critical chapter-by-chapter or theorem-by-theorem analysis of the book. It is this task that I am undertaking here. …
Now though I have analyzed Keynes's General Theory in the following pages theorem by theorem, chapter by chapter, and sometimes even sentence by sentence, to what to some readers may appear a tedious length, I have been unable to find in it a single important doctrine that is both true and original. What is original in the book is not true; and what is true is not original. In fact, as we shall find, even much that is fallacious in the book is not original, but can be found in a score of previous writers.
In view of many of the present accepted uses of government power to control inflation or curb depression, ideas which were either publicized or advanced by Lord Keynes, it seems certain that the Hazlitt book will not end the debate on Keynes.
In commenting upon Keynes's contribution at the time of his passing in 1946, the Monitor editorialized:
His contributions to economic thought will be violently mooted for some time to come. As a writer in Fortune magazine has observed in the 30s "a profound gap … had been growing between the precepts of classical economics and the observable fact of chronic unemployment." To the question of "What?" and "Why?" raised at that time, John Maynard Keynes gave "the most provocative answer."
And the New York Times took Keynes's own words in his book, which had stirred so much dissent, General Theory of Employment, Interest, and Money, for its editorial tribute:
Practical men, who believe themselves to be quite exempt from any intellectual influences, are usually the slaves of some defunct economist. Madmen in authority, who hear voices in the air are distilling their frenzy from some academic scribbler of a few years back.
I am sure that the power of vested interests is vastly exaggerated compared with the gradual encroachment of ideas. … Soon or late, it is ideas, not vested interests, which are dangerous for good or evil.
Ludwig von Mises
Economist, New York City
Lord Keynes was not an innovator and not a harbinger of new methods of managing economic affairs. He merely revived old, a-hundred-times-refuted errors in order to provide an apparent justification for popular policies, the disastrous effects of which became more and more perceptible.
While it is obvious that higher productivity and a resulting improvement in the average standard of living can be achieved only be increasing the per-head quota of capital invested, he disparaged saving and capital formation. There is no other means to raise the marginal productivity of labor and thereby wage rates for all those eager to find a job than to accelerate the accumulation of capital as against population.
~~~~
Keynes failed to realize that the free unhampered labor market tends to determine wage rates for each kind of labor at a height that makes it possible for every job seeker to find employment. He did not see that the phenomenon of lasting unemployment is the inevitable consequence of the attempts of governments and labor unions to fix wage rates above the potential market rates. He advocated credit expansion and inflation and did not notice the fact that these policies cannot be continued endlessly and that the artificial boom created by them necessarily must bring about an economic crisis.
Keynes labored under the illusion that there prevails a shortage of investment opportunities. However, as long as we have not converted the earth into a Garden of Eden, there always will be people whose wants have not been fully satisfied and who are anxious to acquire more and better goods. Nothing but additional investment can supply what these indigent masses are asking for.
~~~~
Keynes's paradoxical teachings were enthusiastically acclaimed by governments and political parties that by reckless spending strive for popularity. The unbalanced budget is the pith of Keynesianism. But one ought not to overate the sinister influence of Keynes.
His precepts had been adopted and practiced by demagogues long before Keynes undertook to vindicate them. The methods that his adepts call the "new economics" or the "Keynesian revolution" were already in full swing when Keynes published his doctrine.
Its great publicity success is precisely due to the fact that he was not a pioneer of new policies, but the apologist of schemes that — unfortunately — had already been extremely popular for a long time.
The late Benjamin M. Anderson and many other authors have successfully unmasked the fallacies of Keynes's economic philosophy. But its most devastating criticism was given by Henry Hazlitt in his brilliant book The Failure of the "New Economics." Hazlitt has entirely demolished the Keynesian misconceptions.
Arthur F. Burns
Professor of economics, Columbia University; president, National Bureau of Economic Research; former chairman, President Eisenhower's Council of Economic Advisors
Keynes is and will remain a controversial figure. One may question his originality, condemn his love of paradox, criticize his tendency to draw sweeping generalizations, question his attachment to capitalism. But one cannot deny his being a towering figure in the history of economic thought.
Keynes's thinking has moved the world profoundly, as profoundly as Adam Smiths's Wealth of Nations did in his time. Some men and governments have doubtless been mislead by Keynes. By and large, however, everyone who has studied his writings carefully has gained, I think, a firmer grasp of economic principles in the process.
And as for the world we live in, I am inclined to think that it is a better place than it would have been if Keynes had not lived.
Friedrich August von Hayek
Economist, University of Chicago
It would be unfair to blame Lord Keynes too much for the undoubted harm his theories have done, for I am convinced from personal knowledge that had he lived he would have been one of the leaders in the fight against the postwar inflation. Yet he bears in a great measure the responsibility for it.
His great gifts have made it possible for his theories to exercise during the past 25 years an immediate and pervading influence which is unique in the history of economic thought.
Yet these gifts were not mainly those of an economic theorist, and, though his ideas seemed to constitute a revolution to the generation which they captivated, they will probably appear as no more than a passing phase in the history of economic thought.
~~~~
The main reproach to which Keynes laid himself open was that he presented as a "General Theory" what was essentially a tract for the times.
It was the successful one of repeated attempts he made to justify his practical inclinations by theoretical argument. It succeeded partly because it provided a highly sophisticated support for demands which are always popular in times of depression and partly because it was expressed in a form congenial to the scientific fashions of the moment.
Yet it was based on assumptions even more unrealistic than those Keynes ascribed to what he called classical economics. If it was a defect of the latter that it assumed for a first approach that there existed no reserves of unused resources. Keynes was even more unrealistic in assuming that there existed always ample reserves of all resources.
In short he assumed away that scarcity of resources which is the root of all our economic problems. In consequence, while of doubtful application even in times of depression, his original theory is entirely inapplicable in times of prosperity.
~~~~
Keynes's disciples have since succeeded in purging the original version of most of its unrealistic assumptions and internal inconsistencies and developed it into a formal apparatus of analysis which is largely neutral in policy applications.
It continues to enjoy popularity because it is more in accord with current methodological fashions than the classical approach. It is used by many who do not draw the conclusions Keynes drew from it. Yet I doubt whether even this will prove to be a permanent contribution to economics.
But apart from Keynes's peculiar factual assumptions it does not lead to conclusions essentially different from classical analysis. The most significant of those assumptions was that workers will resist a lowering of their money wages but will put up with a reduction of their real wages brought about by a fall in the value of money.
~~~~
Indeed the ultimate motive of Keynes's efforts was to find a roundabout method of reducing wages too high to allow employment of all seeking jobs. We know now better than to believe that workers will long allow themselves to be deceived in this way. This, however, was the most distinctive element of the Keynesian views of the '30s.
It was this argument which broke down the intellectual resistance to ever-present tendencies toward progressive inflation. Yet this crucial element has by now lost all plausibility.
If one may judge from the first accounts of the latest programmatic document on British monetary policy, the recently published "Radcliffe Report," Keynesianism in its original sense seems to have lost its appeal even more in its country of origin than elsewhere.
John Kenneth Galbraith
Paul M. Warburg professor of economics, Harvard University
Of course Keynes's position in history is perfectly secure. And so, in contemporary practice are the policies he advocated. It was Keynes's central thesis that the modern economy does not, necessarily, find its equilibrium at full employment and that, as a result, it must be ready to intervene to overcome depression or prevent inflation. This is now accepted and even commonplace.
The Eisenhower administration dealt with the recent recession by running a record peacetime deficit. In the last fiscal year, cash outgo exceeded income by $13,200,000,000. The purchasing power poured into the economy by this deficit far exceeded the total peacetime spending of the federal government in any year under Roosevelt.
This was a straight Keynesian policy. Much of it was accomplished through the so-called stabilizers — unemployment compensation payments, farm price supports, other welfare payments, the reduction of effective tax rates as people move to lower income brackets with declining income — which come automatically to the support of private purchasing power as production and income decline in recession.
These measures were all inherited from the New Deal. They are the very essence of a Keynesian policy and not less so because they are now used by a Republican administration. It is worth noting, incidentally, that they appear to have worked.
What is really interesting is this curious effort to assert the unimportance of Keynes. It will pass and leave no mark as the effort to rewrite history to demote Roosevelt has passed. But it is a tribute to the nostalgia evoked perhaps not so much by Adam Smith as by Adam.
Nathaniel ("Nate") Ridgway White was an award-winning journalist known for his business and financial reporting at The Christian Science Monitor. He received the second and third Gerald Loeb Awards for Newspapers, the most prestigious award for business journalism.
---------------------------------------------------------------------
영계출감탕 해설
苓桂朮甘湯 作者：羅大倫
這個方子，一共就是四味藥：茯苓、桂枝、白朮、炙甘草，就是叫苓桂朮甘湯，是中醫裡面的一個了不起的方子，古時用藥，簡單而又直接，陣法分明，令人驚嘆。
劉渡舟教授評價苓桂朮甘湯：「藥僅四味，配伍精當，大有千軍萬馬之聲勢，臨床療效驚人」。
這個苓桂朮甘湯，就是張仲景的「撥云見日法」，當水濕遮蔽住心陽的時候，會導致心、肺、脾胃等系統都出現問題，張仲景用這個撥云見日的思路，就把濕氣化去，使得太陽重新出現，陽光明媚，則身體自然恢復常態。
水濕氾濫，還有很多證型，除了遮蔽心陽，還有在下焦出現的問題等情況，我後面會一個個給大家講解的。
大家明白了這些道理，如果遇到有類似的症狀，可以去諮詢醫生，讓醫生幫助分析一下，然後看看是否可以用類似的方劑。
67．傷寒若吐、若下後，心下逆滿，氣上衝胸，起則頭眩，脈沉緊，發汗則動經，身為振振搖者，茯苓桂枝白朮甘草湯主之。
茯苓（四兩） 桂枝（三兩，去皮） 白朮 甘草（各二兩，炙）
上四味，以水六升，煮取三升，去滓，分溫三服。
方歌：病因吐下氣沖胸，起則頭眩身振從，茯四桂三朮草二，溫中降逆效從容。
苓桂朮甘湯主治
中陽不足之痰飲。胸脅支滿，目眩心悸，短氣而咳，舌苔白滑，脈弦滑或沉緊。 主要用於治療多種原因引起的眩暈，慢支，哮喘，充血性心力衰竭，潰瘍病，神經性嘔吐，胃腸神經官能症，慢性腎炎，關節炎等疾病。
苓桂朮甘湯病症分析
脾陽不足，健運失職，則濕滯而為痰為飲。而痰飲隨氣升降，無處不到，停於胸脅，則見胸脅支滿；阻滯中焦，清陽不升，則見頭暈目眩；上凌心肺，則致心悸、短氣而咳；舌苔白滑、脈沉滑或沉緊皆為痰飲內停之征。
苓桂朮甘湯制方原理
中焦陽氣不足，脾陽不足，健運失職，則濕滯而為痰為飲。而痰飲隨氣升降，無處不到，停於胸脅，則見胸脅支滿；阻滯中焦，清陽不升，則見頭暈目眩；上凌心肺，則致心悸、短氣而咳；舌苔白滑、脈沉滑或沉緊皆為痰飲內停之征。
方中立茯苓為君藥，是識透了茯苓的藥效特性。此藥是由千年古松之靈氣所結，有益脾助陽，淡滲利竅，除濕化痰，降濁生新之功。能入手太陰、足太陽、少陽等經氣分，有浮升下降之力。入手太陰，補肺氣，清肺熱，養肺陰而化肺中濁痰；入手少陰，補心氣，溫心陽，育心陰，安心神，除驚悸，止心汗。又是去心下水飲的要藥。故入陽明胃腑，能溫暖脾胃，振奮升降機能，育養脾胃之陰液。其淡滲利濕之功，與甘溫化陽之力，能把胃脘部(即心下)的痰飲水邪化為溫暖水液，在脾氣升清，肺氣肅降，三焦氣化等作用下，下輸膀胱，經膀胱氣化，將胞中陳舊積垢和濕熱排出體外。此藥入肝腎，能溫補肝腎之陽氣，又能助元陽化腎中陰水以滋肝木。此藥與杜仲相伍是補肝腎的妙藥 。方中立桂枝為臣藥。因桂枝的甘溫化陽之力，能升能降，能陰能陽的雙向作用，及溫陽化氣，溫通血脈，調和氣血等功效，在方中起主導作用。桂枝又是太陽經去寒解表的主藥，它深入太陽經，開發腠理，去除表邪，振奮陽氣，使經脈溫順調和。太陽經的溫通，對督脈有振奮作用，因足太陽經行於督脈之旁，督脈又為陽經之主。而五臟六腑在後背各開出的俞穴，都立於督脈兩側，故督脈經氣旺盛，能溫通十二背俞，十二背俞各自向其臟腑傳導溫和之陽氣，這對茯苓、白朮、甘草運化痰飲濕邪，健補脾胃都非常有力。所以茯苓、白朮離開桂枝的辛甘溫熱之力和能升能降，能陰能陽的雙向作用，則力顯單薄而不足；合入桂枝，則力如蛟龍入海。桂枝和茯苓雖都具升降功能和甘溫之性，但茯苓不論多用還是少用，其浮降甘溫之力遠不如桂枝，其淡滲利水降濁之力則遠遠超出桂枝。而桂枝少用能升，中用能降，重用入腎補元陽和命門之火，誤用則多煩多燥。用之得當，外能解肌去寒，內能化氣調和陰陽。是開腠理，調和營衛，溫陽化氣，溫通血脈，溫補脾胃的妙藥。 白朮為方中臣藥，借其苦能燥濕，甘溫能溫補脾胃，又能溫通中州血脈，運化痰飲水濕，此藥具土德最厚，能與金、木、水、火四髒交媾。與涼潤藥相伍，能補潤肺臟，與升散藥相伍，能補肝氣，同鎮靜安神藥相伍，能安心神，養心氣，與滋陰藥相伍，則補益腎中精血。故是生養金、木、水、火的妙藥。 甘草在方中為使藥，以其甘緩之力制茯苓淡滲不過，以其清瀉之力，緩桂枝的辛溫之熱，以升浮施降之功，緩解白朮的壅滯之性。故使者，外交也。經其使達，三藥溫順平和，共盡相生相益去病康體之職。所以選甘草為使是明識也。因此藥是眾藥使主，又能協調諸藥，解百藥毒。四味藥配伍，溫陽化飲，健脾利濕。
「《靈樞》謂心包絡之脈動則病胸脅支滿者，謂痰飲積於心包，其病則必若是也。目眩者，痰飲阻其胸中之陽，不能布精於上也。茯苓淡滲，逐飲出下竅，因利而去，故用以為君。桂枝通陽輸水走皮毛，從汗而解，故以為臣。白朮燥濕，佐茯苓消痰以除支滿。甘草補中，佐桂枝建土以制水邪也。」（《醫宗金鑑•刪補名醫方論》趙良）
七二：「傷寒」,若吐若下後,心下逆滿,氣上衝胸,起則頭眩,脈沉緊,發汗則動經,身為振振搖者,「茯苓桂枝白朮甘草湯」主之。
傷寒,如果吐了又大下,腸胃就傷到了,結果心下逆滿,就是胃的地方感覺到脹滿,氣上衝胸,起則頭眩,脈沉緊,發汗則動經,身為振振搖者。為什麼會這樣子?這人平素就有水飲,水停在橫膈膜,一種是平常喝水喝太快,慢慢累積在這裡；還有一種是「思」,「思」能傷脾,造成脾的運化不好,結果水的運化不好,土生金的時候,一部份會氣化上來,一部份會停在這橫膈
膜上,橫膈膜像海綿一樣,裡面都是水。被吐、被下了以後,上下的水都沒有了,這水就開始要動起來,這水不在胃的裡面,如果在胃的裡面,胃就會把它氣化掉,這水停在胃的旁邊,病人一動的時候,這水就開始晃了,頭就昏了,西醫說這是中耳不平衡,因為頭在暈眩,和貧血不一樣貧血是眼前發黑,他是天旋地轉,苓桂朮甘湯下去,把這水排掉,就好了。所以起則頭眩,移動或站起來的時候會暈眩,就是苓桂朮甘湯證；如果是躺在床上不動會暈眩,就不是苓桂朮甘湯證,後面會提到真武湯的時候,再說明。
白朮就是因為濕太盛了而用的,健脾整胃最好的藥就是伏苓、白朮,白朮能去濕,茯苓能把水利掉,桂枝甘草在中膈,如果在臍下就加茯苓大棗,所以這是桂枝甘草湯演變出來的,先是桂枝甘草湯,再來是桂枝甘草加茯苓大棗,再來是苓桂朮甘湯,所以苓桂朮甘湯專門去中膈的水。
傷寒,若吐若下後被吐被下後,水飲就跑出來了,平常不會的,結果心下逆滿,胃裡面脹滿得很難過,然後氣往上衝,因為這水沒能氣化上來,是水停在這裡,當然感覺氣下不去,呼吸的時候,氣會往回逆,一般來說,橫膈膜會下降,氣才會充滿,吐氣的時候,橫膈膜會上升,結果橫膈膜都是水,它根本不下降,一吸它就滿了,滿了就會有氣逆的現象。起則頭眩,脈沉緊,沉代表病在裡,緊就是塞,水就是塞的,因為水在中膈,沒有在皮膚表面上,一發汗會動經,因為身體的血脈、經絡、肌肉,都要靠我們的水份來滋養,一發汗就沒有水份了,他就抽筋,所以身為振振搖,就是晃來晃去的,就中膈的水在晃,就用苓桂朮甘湯。臨床上看到,暈眩得很厲害的時候會吐的,就可用苓桂朮甘湯裡面再加半夏。
茯苓桂枝白朮甘草湯方
茯苓四兩 桂枝三兩去皮 白朮二兩 甘草二兩
右四味,以水六升,煮取三升,去滓,分溫三服。
苓桂朮甘湯是治療水飲的,因為水已經太多,造成水患了,所以一定重用茯苓,再來是桂枝,再來是白朮。
【勿誤藥室方函口訣】本方條曰：足或腰仍動劇者,臥時則脊骨仍戰動,或一身體中經脈跳動,有耳鳴逆上之候者,都可以用此方。平常感覺肌肉跳兩下,面皮在跳,這是因為水飲,這時候就可以用苓桂朮甘湯,因為脾主肌肉,也主四肢。
《經方的魅力》
苓桂朮甘湯（茯苓、桂枝、白朮、甘草）可看作是桂枝甘草湯加茯苓、白朮而成。桂枝甘草湯在《傷寒論》中主治「發汗過多，其人叉手自冒心，心下悸，欲得按者。」是以心悸為主證。茯苓、白朮主治小便不利兼有浮腫者，是仲景常用的利尿劑。「夫短氣，有微飲，當從小便去之，苓桂朮甘湯主之。」可知此方有利水作用。因此，本方主要用於以心悸、浮腫為主訴的心臟病，尤其多見於以風心為代表的心瓣膜病。這類疾病出現輕度心衰時可用本方。此時，既要用桂枝，又要加肉桂，心悸甚者還要加龍骨、牡蠣。心衰嚴重者加附子，或與真武湯合用。另外，一些神經衰弱，胃神經官能症，慢性腸炎也有用此方的機會。
值得一提的是桂枝甘草茯苓這個方根。它多用於體質虛弱的瘦人伴有心悸者。加上白朮即是本方。加上大棗是苓桂棗甘湯，主治自覺腹主動脈異常搏動者。腹主動脈異常搏動多見於瘦人，大棗是營養安神劑，方中重用茯苓與大棗以加強鎮靜作用。加上五味子是苓桂味甘湯，用於肺氣腫、肺心病的咳喘。此喘為虛喘，多伴有心悸、汗出，我多加麥冬、人參、山萸肉、龍骨、牡蠣。桂枝甘草茯苓變化之方，其所主之病總離不開心血管疾病。（黃煌著）
治療驗案
1 治療高血壓
患者男，60歲，退休幹部，於2004年7月5日初診。自訴患高血壓20餘年。頭昏反復發作10餘年，加重1個月伴心悸，雙下肢水腫。經攝X線胸片和心電圖檢查，提示高心病、心電圖左偏。刻診：頭昏乏力，胸悶心悸，雙下肢浮腫，面色淡白、舌質淡，邊有齒痕，苔薄白，脈細緩。BP 180/100 mm Hg。證屬心脾陽虛，水濕內停，故面色白光白，舌質淡邊有齒印，水飲上逆凌心則心悸，阻塞清竅則頭目眩暈，水飲外溢則水腫，治宜溫助脾腎，化氣利水，兼以寧心安神。投苓桂朮甘湯輔以溫養心脾治療。處方：茯苓30 g，肉桂5 g，白朮15 g，甘草10 g，制附片10 g，棗仁10 g，澤瀉10 g，遠志10 g，每日1劑。服藥3劑後，胸悶心悸消失，水腫漸退，血壓下降到150/95 mm Hg，繼服10劑而愈。
2 血管神經性頭痛
患者男，45歲，農民，於2004年10月7日初診。頭痛頭昏反覆發作5年餘，加重2個月。伴有噁心、嘔吐痰涎、耳鳴、頭重如裹，胃脘痞滿不適，納差、舌淡紅、苔白、脈滑。腦電圖提示：椎動脈兩側波幅不對稱。縣醫院診斷血管神經性頭痛。根據辨證分析，此為痰阻中焦，清陽不宣。治療當溫化痰濕。擬用苓桂朮甘湯加減治療。處方：茯苓15 g，白朮15 g，桂枝5 g，炙甘草10 g，細辛5 g，白芷10 g，石菖蒲10 g。上方服用5劑後症狀明顯好轉，繼服15劑，頭痛頭昏消失。隨訪至今未復發。
3 慢性哮喘性支氣管炎
患者男，60歲，農民。於2005年3月10日初診，哮喘反覆10餘年遇寒發作。每年住院一次而效果不明顯。刻診：呼吸喘促，張口抬肩，鼻翼搧動，喉中痰鳴，心下痞滿不適，咳吐清痰如涎，乏力、納呆，舌淡邊有齒痕，苔薄白，脈滑。此乃痰飲阻隔，肺氣不宜，氣機不利。當用苓桂朮甘湯加減以溫化痰飲治療。處方：茯苓10 g，桂枝10 g，白朮10 g，甘草5 g，川牛膝10 g，蘇子10 g，法夏10 g，乾薑5 g，麻黃炙5 g，每日1劑。3劑後症狀大減，繼進上方3劑後愈。
4 治療神經性耳鳴
患者男，58歲，農民。2005年4月2日初診，眩暈耳鳴反覆2年，曾在五官科醫師診斷為神經性耳鳴。中西醫診治均無效，後延吾診治。刻診：自覺頭眩暈，耳鳴如蟬不止，晨起加重，脘腹滿悶，納呆，時伴心悸，舌質淡胖，苔白，脈弦緩，證屬濁陰上犯，蒙閉清竅，竅機不利。因濁陰致病纏綿，故耳鳴久而不癒。治擬苓桂朮甘湯加減以溫陽化濁，昇陽通竅。擬方：茯苓30 g，桂枝10 g，白朮15 g，甘草5 g，葛根20 g，石菖蒲10 g，服藥5劑痊癒。
5 治療急性腎炎
患者女，50歲，農民，於2007年5月10日初診。全身反覆水腫伴腰膝痠軟6個月，查尿常規：蛋白尿(++)，紅細胞(+)，透明管型(+)，雙下肢凹陷性水腫，目窠水腫，小便短少，腎區有叩擊痛，納差，脘腹滿悶，舌質淡，苔白滑，脈沉。症屬脾腎陽虛，水濕內停，飲溢肌膚而腫。治擬健脾益腎，溫陽利水。投苓桂朮甘湯化裁。處方：茯苓30 g，桂枝6 g，甘草5 g，白朮10 g，澤瀉10 g，制附片10 g，豬苓10 g，服藥5劑後水腫漸退，小便增多，繼服5劑而愈。
6治「背寒冷如手大」
患者范某，男，52歲，農民。背部惡寒月餘，口乾，但飲水少，喜熱飲，晨起口微苦，痰多易咯，飲食尚可，小便可，大便溏，舌淡白、胖大，有齒痕，苔白，脈弦滑，以手觸其肩胛下角偏上處，約手掌大的範圍有冰涼感。否認近期感冒病史，無發熱。聽診顯示雙肺呼吸音清，未聞及乾濕性囉音。因患者口乾少飲，喜熱飲，痰多易咯，便溏，舌胖大有齒痕，脈弦滑，脈症合參，辨證屬脾陽不足，水氣上犯之痰飲。治以健脾益氣，溫陽利水，方用苓桂朮甘湯加味。處方：茯苓20克，白朮15克，桂枝15克，甘草10克，葛根10克，生薑5片。10劑，水煎服，日1劑。囑其注意禦寒保暖，忌辛辣刺激性食物。
服藥後，患者背部惡寒明顯減輕，其他不適症狀亦有好轉。藥已見效，故採取守方之法，連續服用1月後，患者電話告知「背部已經不感到涼了，但是感覺嗓子還有痰，其他沒有不舒服的」。筆者囑其在上方基礎上加用桔梗10克，半夏10克，繼續服1月後，症狀完全消失。
按：本例患者屬《金匱要略•痰飲咳嗽病脈證並治第十二》中「夫心下有留飲，其人背寒冷如手大」，是脾陽不足，水飲泛溢，停留心下所致。清代李珥臣於《金匱要略廣注》中亦有論及「背為陽，陽中之陽，心也。故心下留飲，則陰寒氣徹於背，而陽氣衰息，背寒冷如手大也」，此「心下」指胃與胸膈之處。背部腧穴是人體臟腑經絡氣血輸注之處，心之俞穴在背部，飲留心下，寒飲注其俞，陽氣不能展佈，影響督脈溫煦功能，故背部寒冷如手大。病機為飲阻心下陽氣，背俞穴失於溫煦。
《金匱要略•痰飲咳嗽病脈證並治第十二》第16條「心下有痰飲，胸脅支滿，目眩，苓桂朮甘湯主之」。以溫運脾陽，補氣行水為主，從而達祛痰飲、通經絡而諸症得消的目的。處方以苓桂朮甘湯加味，體現了《金匱要略•痰飲咳嗽病脈證並治第十二》第15條「病痰飲者，當以溫藥和之」的治法，其中茯苓淡滲利水，化飲降濁，為治飲病之要藥；桂枝辛溫通陽，振奮陽氣以消飲邪，兩藥合用可溫陽化飲；白朮健脾燥濕；甘草和中益氣；葛根昇陽，舒筋脈；生薑溫陽化痰。複診則參入桔梗、半夏加強化痰的力量，且桔梗載藥上行，直達病所。諸藥為伍，共奏溫陽健脾，行氣利水之功。日期：2011年2月23日 -來自[臨床驗案]欄目
7治療眩暈醫案
張某, 男, 60歲, 農民, 於2002 年5月30 日來診。觀其面色黧黑、身體瘦削。自25 歲開始, 一躺下便開始頭暈, 自覺天旋地轉、噁心欲吐, 入睡後及坐或站起後眩暈即停, 諸症若失。為減輕痛苦, 每每熬至夜深方眠, 余無所苦。幾十年未患他疾, 遍做各種檢查, 服用許多藥物, 病情未有絲毫轉機。詢其納眠可、二便調, 舌質稍黯, 苔白而濕潤, 脈左平右弦。李老為書苓桂朮甘湯原方10 劑, 水煎早晚服。二診眩暈大減, 繼服10劑, 眩暈未再發。隨診1年病未再發。
8治腸鳴證案
腸鳴主要由腸功能紊亂或腸道菌群失調引起，多見於腸易激綜合徵以及功能性消化不良。《金匱要略》有關腸鳴，證治的論述主要有以下凡條：「水走腸間，瀝瀝有聲，謂之痰飲」：「病痰飲者，當以溫藥和之」；「心下有痰飲，胸脅支滿，目眩，苓桂朮甘湯主之」；「夫短氣有微飲，當從小便去之，苓桂朮甘湯主之，腎氣丸亦主之」；「腹滿，口舌乾燥，此腸間有水氣．己椒藶黃丸主之」等。筆者認為苓桂朮甘湯與己椒藶黃丸的證治有以下區別：苓桂朮甘湯證主要在胃(「心下有痰飲」)，由痰飲引起，以脾虛為主，其證較輕(「微飲」)，無腹部脹滿，大便稀薄；己椒藶黃丸湯證主要在腸(「此腸間有水氣」)。由痰飲水氣與飲食積滯引起，以邪實為主，其證稍重，有腹部脹滿，大便秘結。茲結合具體案例，說明如下。
例1．苓桂朮甘湯證沈男，41歲，2005年9月2日就診。主訴：腸鳴1周，大便日行1次，便質質稀軟，腰痛，肝硬化脾切除術後。舌嫩紅，邊有齒痕，苔薄黃膩，脈細。肝硬化脾切除術後。脾陽不足；治宜溫陽化飲；處方：茯苓20g，桂枝log，白朮15g，甘草6g，黃芪30g，杜仲15g，川斷12g，狗脊12g。補骨脂12g，7劑。方中黃芪益氣健脾以助苓桂朮甘湯化飲，余藥補腎強腰。二診時腸鳴止，腰酸明顯改善。
例2．已椒藶黃丸證王女，36歲，2006年12月8日就診。主訴：腸鳴、腹脹3周余，大便裡急後重，矢氣頻，胃脘亦痞脹，體瘦，舌偏紅，苔薄，脈細弦。慢性萎縮性胃炎7~8年。氣滯食阻，腸間水氣；治宜消食理氣，化飲導滯；處方：防己 log，椒目6g，葶藶子9g，制大黃6g，枳殼12g，青陳皮各12g，佛手6g，木蝴蝶6g。木香6g，莪朮12g，神曲12g，麥芽12g，萊菔子9g，7劑。方中己椒藶黃丸逐飲導滯；枳殼、青陳皮、佛手、木蝴蝶、木香、莪朮理氣；神曲、麥芽、菜菔子消食。二診：腹脹、腸鳴、大便裡急後重明顯減少至幾無，唯胃脘仍有些許不適，以香砂六君子湯合保和丸鞏固療效。
例3．苓桂朮甘湯合已椒藶黃丸證楊女，50歲，2007年11月2日就診。主訴：腸鳴，大便不成形而量少，胃脘痞堵，頭暈，舌淡紅，苔薄潤，脈細弦。飲停胃腸；治宜利尿化飲；處方：防己log，椒目6g，葶藶子6g，桂枝12g，茯苓15g，白朮12g，澤瀉15g，車前子15g，炮姜12g，7劑。方中澤瀉、車前子助滲濕利尿，炮姜助溫陽化飲。三診：腸鳴止，大便稍成形，胃脘痞堵減而未盡。
後人根據《金匱要略》有關論述，認為腸鳴乃腸間痰飲水氣所致，固然無錯。但筆者根據己椒藶黃丸中葶藶子與大黃的藥物性能認為凡胃腸氣滯、飲食積滯也可引起腸鳴，非獨痰飲水氣。大黃的功能眾所周知，勿庸贅述。葶藶子有瀉肺平喘作用，肺與大腸相表裡，提示葶藶子既能降肺氣，亦能順大腸逆氣，腸鳴可以理解為腸中氣滯不順。古書有載：「腹內氣脹滿喘息不得臥，葶藶子一升炒紫色，酒浸七日。研爛，每服三匙，溫酒調服無時，大效」。己椒藶黃丸能夠治療「腹滿」．其中應有葶藶子的功勞。從案例2似可窺見葶藶子及其它理氣藥在腸鳴中．的作用。以下案例可以直接證明筆者「凡胃腸氣滯、飲食積滯也可引起腸鳴，非獨痰飲水氣」的觀點。
例4．木香檳榔丸夏女，73歲，2007年4月3日就診。主訴：近來腸鳴、矢氣，脘腹痞脹，泛酸、燒心，舌暗紅、齒痕，苔薄黃，脈細弦。胃經檢查示有慢性淺表性胃炎。處方：黨參12g，白朮12g，茯苓12g，青陳皮各log，木香lOg，檳榔lOg，莪朮log，路路通lOg，烏藥lOg，枳殼log，連翹30g，川連6g，吳茱萸2g，鍛瓦楞40g，甘草3g，7劑。二診：腸鳴止，脘腹痞脹減半，輕微泛酸及燒心。日期：2010年1月14日 - 來自[辯證施治]欄目
上世紀初，章太炎曾說過：「近世多信西醫術，以漢醫為巫，如其徵效，則漢醫反勝。」這種現象，至今仍是，許多病西醫不能治來找中醫，中醫治好病，卻說中醫不科學。究其原因，乃一些人沒有弄清中醫科學的內涵，往往一葉障目。近治癒眩暈一例感觸頗深：10月17日，82歲老嫗患起則頭眩，到某大醫院急診，查CT、B超、心電圖等未見異常，而靜脈輸入丹參等藥，同時給服多種中成藥、西藥，花去二千多元，得到的結果是起則撲地，頭破血流，無奈找中醫診治，我僅根據患者的症狀特點，判定為苓桂朮甘湯方證，給服一劑效，三劑愈。此事引人深思，深感是有關《傷寒論》的科學內涵值得探討。
--摘自馮世倫醫案
體會
苓桂朮甘湯由茯苓、桂枝、白朮、甘草四味藥物組成，是溫陽化飲、健脾滲濕主要方劑，方中茯苓為君，健脾滲濕，祛痰化飲;桂枝為臣，既可溫陽化飲，又能化氣利水，且可平沖降逆。桂枝與茯苓相伍，溫陽利水，陽氣振奮則陰水得散，對於水飲滯留而偏寒者，實有溫化滲利之妙用。濕源於脾，脾虛生濕，故佐白朮健脾燥濕，助脾運化，俾脾陽健旺，則水濕自除，更佐甘草為使和中。四藥合用，共奏溫化痰飲健脾利濕之功。方中四藥配伍嚴謹，溫而不熱，利而不峻，藥少力專，正邪兼顧。在臨床中，只要具有痰飲徵象，病雖異而病因病機相似，皆可用苓桂朮甘湯為基本方溫陽化飲，健脾利濕，再隨症加減，而取得良好效果。
苓桂朮甘湯加味治療慢性心力衰竭30例臨床觀察（討論）
本病應歸屬於中醫學「心悸」、「水腫」、「喘症」等範疇，認為本證皆由心臟自病或它髒相因為病，病位在心，涉及它髒，其基本病機為本虛標實，本虛為中焦陽虛、心陽不振，標實則以痰飲為主。痰飲之生成，與人體五臟六腑皆有關，其中尤以脾最為相關，痰飲為陰邪，其生成停聚與陽氣的盛衰密切相關。心陽虛從脾論治是仲景學術思想的重要組成部分。心體陰而用陽，故心陽之強弱，根於心血之盈虧，亦取決於脾之盛衰。若脾胃虛弱，氣血乏源，宗氣失充，心失所養，其溫煦功能減弱，則可致心陽虛衰，同時還會產生諸多病理變化。故欲實心陽，當先調脾胃，可從根本上起到益心之功。脾陽不足，健運失常，不能正常運化輸布水液，就會導致水濕內停，凝聚為飲，飲邪上泛則心衰加重。《素問•至真要大論》云：「太陰在泉，濕淫所勝，民病飲積。」故治以溫陽化飲，健脾利濕。《金匱要略》中「夫痰飲者，當以溫藥和之」之法，方以苓桂朮甘湯加味。《醫宗金鑑•刪補名醫方論》趙良日：「《靈樞》謂心包絡之脈動則病胸脅支滿者，謂痰飲積於心包，其病則必若是也。目眩者，痰飲阻其胸中之陽，不能布精於上也。茯苓淡滲，逐飲出下竅，因利而去，故用以為君。桂枝通陽輸水走皮毛，從汗而解，故以為臣。白朮燥濕，佐茯苓消痰以除支滿。甘草補中，佐桂枝建土以制水邪也。」實驗證明，茯苓有較強的利尿作用。白朮益氣健脾，通利水道，有明顯而持久的利尿作用，並能促進電解質，特別是鈉的排出，桂枝溫通經脈，通陽化氣，具有較強的強心作用。現代藥理表明，苓桂朮甘湯減輕CHF兔體重，改善一般狀況，減慢心率，可減輕充血水腫，降低心肌耗氧量，加強心肌收縮力，提高心臟功能。心鈉素(ANP)是心房肌細胞產生和分泌的一種激素，它具有明顯的擴張血管、利鈉、利尿和降低血壓、調節水電解質平衡的作用。研究表明，苓桂朮甘湯能降低ANP水平，可能與該方利尿、減輕心臟容量負荷，減少ANP分泌有關，從內分泌角度上顯示了苓桂朮甘湯是治療CHF較理想的中藥。本研究發現，在西醫治療基礎上，加服苓桂朮甘湯，可明顯增加左室射血分數，增強心功能，改善患者臨床症狀，提高患者生存質量。日期：2010年1月14日 - 來自[藥物與臨床]欄目
試論苓桂劑的加減證治 劉渡舟編著
苓桂劑，指《傷寒論》中以茯苓、桂技為主藥的方劑，其中包括苓桂朮甘湯、苓桂姜甘湯、五苓散等方劑在內。為使本講內容更為完備，也將《金匱要略》中的苓桂劑和自制之方補充了進去。苓桂劑主要是用來治療水氣上衝證的，此病為常見病和多發病，歷代醫家都比較重視，在臨床治療上也有所發展。水氣上衝證，散見於《傷寒論》與《金匱要略方論》，張仲景提出了以苓桂為主藥的一類方劑的相應治法。但文中的苓桂諸方證，分列於不同的疾病篇章，缺乏系統歸納和有機聯繫，使人難以掌握全面。為此，綜合各條有關方證，結合個個臨床體會，將苓桂劑在臨床中的加減運用加以論述，以治療包括太陽病腑證在內的各種有關水氣的疾患。
一、水氣的概念 古人對水氣的概念，認識也頗不一致，有人認為水氣是水之寒氣，如成無己注水氣上衝時說：「水寒相搏，肺寒氣逆」；也有認為水氣即水飲，如錢天來註：「水氣，水飲之屬也」。我認為上述兩種不同的見解，似乎各自說了一半，周為水與寒、水與飲，往往協同發病，水指其形，寒指其氣，飲則指其邪，二者相因，故不能加以分割。
水氣的概念，應是既有水飲，又有寒氣，這樣去理解，則比較恰當。
二、水氣上衝的證機 水氣上衝的證機是和心、脾、腎的陽氣虛襲有關，而心陽應衰，又為發病的關鍵。
心屬火，為陽中之陽髒，上居於胸，能行陽令而制陰於下。若心陽不足，坐鎮無權，不能降伏下陰，則使寒水上泛，而發為水氣上衝。同時，脾氣之虛，不能治水於下，水無所制，也易上衝而為患。另外，腎主水而有主宰水氣的作用，如腎陽不足，氣化無權，不能主水於下，則亦可導致水氣上衝。由此可見，水氣上衝，實與心、脾、腎三髒陽氣之虛有關，其中尤以心陽虛不能降伏下陰而為前提。
水氣上衝的起點有二：一是由「心下」氣往上衝，一是由「臍下」氣往上衝。由心下氣往上衝的，多因心脾氣虛，由臍下氣往上衝的，多因心腎氣虛之所致。至於對此證的辨認，典型的則可出現明顯的氣由下往上衝動的感覺，不典型的，雖不見明顯的氣沖之感，但從下往上依次出現的或脹、或滿、或悸等等見證也十分明確，故也不難辨認為水氣上衝證。
心下的水氣上衝證：由於水寒之氣先犯心下的胃脘部位，則胃中脹滿，若再上衝於胸，因胸為心之城郭，陽氣之所會，今被水寒所抑，則白覺憋悶；胸又為心肺所居之地，水寒之氣犯胸，則心肺必蒙其害，若肺氣受阻，則咳嗽、短氣；若心陽被凌，則心悸不安，若水氣再上衝於咽喉，則氣結成痺，猶如「梅核氣」狀，自覺一物梗喉嚨間，吐之不出，咽之不下；如水氣再往上衝，必冒蔽清陽之氣，證見頭目眩暈，動則為甚。頭面部的眼、耳、鼻、舌，皆屬清竅，藉賴清陽之氣的溫養，則耳聰目明，鼻聞香臭，口知滋味。今濁陰之氣冒蔽清陽，清陽之氣不能溫養清竅，則往往出現耳聾、目障、鼻塞、口失滋味等證。因此，水氣上衝每有眼、耳、鼻、喉等證出現，務須注意。
臍下的水氣上衝證：由子心腎陽虛，以致水寒之氣得逞，遂發為水氣上衝之證。此證因水與氣搏，其先驅症狀必見臍下悸動，而小便不利。如不及時治療，則氣從臍下上衝咽喉，來勢突然，其行甚速，凡氣所過之處，或脹、或悸、或窒塞，皆歷歷有征，古人叫傲「奔豚氣」。猶以衝至咽喉，每每使人憋悶、窒息、出冷汗，而有如面臨死亡的一種恐怖感出現，然少項則氣衰下行，其證也隨之面減。
除上述兩種水氣上衝的特點以外，還可從色診、脈診，進行診斷，這也是十分必要的。
（一）色診 水為陰邪，上凌於心，心之華在面。今陰邪搏陽，營衛凝澀，心血不榮，故其人面帶虛浮，其色黧黑，或出現水斑（額、頰、鼻柱、口角等處，皮裡肉外，出現黑斑，類似色素沉著）。昔陳修園在保定望丁攀龍「面上皮裡黧黑，環口更甚，臥蠶微腫，鼻上帶青，•••••直告之曰：君有水飲之病，根挾肝氣，而肆行無忌」。質之於丁，其證情果如陳氏所言。此證又因心陽先虛，舌質必見淡嫩，水從下而上，苔則水滑而主津液不化。
（二）脈診 仲景認為，水氣上衝脈當沉緊，質諸臨床，緊當弦體會為是。蓋弦與緊，古人有時互相借用。沉脈主水，弦脈主飲，兩脈皆為陰，故可反映水寒之邪為病。
以上所述水氣上衝之證，如見一證兩證，而色脈相應時，便可辨為水氣上衝，大可不必諸證備。
三、水氣上衝的證治
凡水氣上衝，從心以下而發的，治當溫陽降沖，化飲利水，方用茯苓桂枝白朮甘草湯。本方由茯苓、桂技、白朮、炙甘草四藥組成。方中以茯苓、桂枝為主藥，白朮、甘草為配伍藥。茯苓在方中有四個方面的作用．一是甘淡利水以消陰；二是寧心安神而定悸；三是行肺之制節之令而通利三焦；四是補脾固堤以防水泛，故為方中主藥，列於首位。桂枝在本方則有三方面的作用：一是通陽以消陰，二是下氣以降沖，三是補心以制水，亦為方中主要藥物，列於第二位。此方如有茯苓而無桂枝，則不能化氣以行津液，如有桂枝而無茯苓，則不能利水以伐陰。祈以苓桂相須相成，而缺一不可。至於白朮則協茯苓補脾以利水，甘草助桂枝扶心陽以降沖。諸藥配伍精當，療效確實，故為苓桂諸劑之冠。下邊的加減諸證皆從此方證衍繹而來。
（一）苓桂朮甘湯治驗
陳×× ，女，52 歲。大便秘結，五、六日一行，堅如羊屎，伴有口乾渴，但又不能飲。自覺有氣上衝，頭暈、心悸、胸滿。每到夜間隨上衝之勢加甚，而頭目昏眩則更甚。周身輕度浮腫，小便短少不利，面部虛浮，目下色青，舌胖質淡，舌苔水滑。
辨證：此證為心脾陽虛，水氣上乘陽位，水氣不化，津液不行，則大便秘結而小便不利。水氣上衝，陰來搏陽，故心悸、胸滿、眩暈。水邪流溢，則身面浮腫。
治法：溫通陽氣，伐水降沖。
處方：茯苓30克 桂枝10克 白朮10克 炙甘草6克
服兩劑頭暈、心悸與氣沖之感均減，這是水飲得以溫化的反映。二診乃於上方更加肉桂3克，助陽以消陰，澤瀉12克，利水以行津。服兩劑，口乾止，大便自下，精神轉佳，沖氣又有進一步的減輕。三診轉方用苓桂朮甘與真武湯合方：桂枝10克茯苓24克 豬苓10克 生薑10克 附子10克 白芍10克。
服至三劑，諸證皆除，面色亦轉紅潤，從此獲愈。
（二） 苓桂杏甘湯治驗
苓桂杏甘湯，即於上方減白朮加杏仁而成。此方治水氣上衝，迫使肺氣不利，不能通調水道，而見小便困難，面目浮腫以及咳喘等證。1980年我帶78屆研究生在門診實習，治一老年婦女，咳嗽而微喘，面目浮腫，小便較短。曾服藥不下百餘劑而面腫迄未消退。切其脈弦，舌略胖，苔水滑。
辨證：水氣乘肺，則咳而微喘，肺氣不能通調水道，則小便不利而面腫。
治法：通陽下氣，利肺消腫。
處方：茯苓12克 桂枝10克 杏仁10克 炙甘草6克
患者見方僅四味，又皆普通藥物，甚疑其效。然服五劑，則小便暢利，面腫消退，咳喘皆平而愈。
（三）五苓散治驗
五苓散，即苓桂朮甘湯減甘草、加豬苓、澤瀉而成。此方能治「渴欲飲水，水入則吐」的水逆證（為水氣上衝之一），以及「臍下有悸、吐涎沫而癲癇」的癲癇證。
王×× ，男，18 歲。自覺有一股氣從小腹上衝，至胃則嘔，至心胸則煩悶不堪，上至頭則暈厥、不省人事。少頃，氣下行則甦醒，小便少而頻數。其脈沉，舌淡嫩，苔白潤滑。
辨證：心脾陽虛，氣不化津，發為水氣上衝之證。水氣上冒清陽，故有癲癇發作。脈沉主水，舌淡為心陽虛，小便不利為水氣不化。故知此證為水氣所致。
治法：利水下氣、通陽消陰。
處方：茯苓30克 澤瀉12克 豬苓、白朮、桂枝各10克 肉桂3克
服三劑，病發次數見減，小便通利，繼服六劑，病除。
（四）苓桂味甘湯治驗
苓桂味甘湯，即於上方減白朮、加五味子而成。此方一是治療腎氣素虛之人，因誤服小青龍湯發動腎氣，引發腎氣不攝，氣從少腹上衝於胸，甚或為上厥巔疾，頭目眩昏、面赤如醉、心悸、脈結、少氣而喘等證。二是治老人下虛，不主攝納，飲從下泛，氣阻升降而為喘咳之變。昔葉香岩用本方，或另加姜棗，治療此證，效果非常理想。因為他從甘溫化飲、酸溫納氣為治，故深得仲景治病之法。《臨證指南》載有此案，可以作為借鑑，故不多錄。
（五）苓桂姜甘湯治驗
苓桂姜甘湯，原名為茯苓甘草湯。為了便於記憶，故易今名而收於苓桂劑群之內。
此方即苓桂朮甘湯減白朮、加生薑而成。其治療水飲瀦留於胃，迫使氣與飲搏，而證見心下悸動不安。若胃中水飲上逆，則可出現「水吐」，若胃中水飲下流於腸，則可出現 「水瀉」，若胃中水飲阻遏清陽不達四肢，則見手足厥冷，名叫「水厥」。
農民陳××，男，26 歲。因夏天抗旱，擔水澆地，過勞之餘，汗出甚多，口中乾渴殊甚，乃俯首水桶而暴飲。當時甚快，未兒發現心下悸動殊甚，以致影響睡眠。屢次就醫，服藥無算，然病不得除。經友人介紹，請余診治。令其仰臥床上，以手捫其心下，則跳動應手，如是用手振顫其上腹部，則水在胃中漉漉作響，聲聞於外。余曰：此振水音也，為胃中有水之征。問其小便尚利，『脈弦而苔水滑。
處方：茯苓12克 桂枝10克 生薑汁一大杯 炙甘草6克
囑用煎好藥湯兌薑汁服。服後便覺熱辣氣味直抵於胃，而胃中響動更甚。不多時覺腹痛欲瀉，登廁瀉出水液甚多，因而病減。照方又服一劑，而悸不發矣。
（六）苓桂棗甘湯治驗
苓桂棗甘湯證，是心陽上虛，寒水下動，待發未發，先見「臍下悸」、「欲作奔豚」。也就是水氣之邪從臍下上衝的一種。於苓桂朮甘湯方減白朮、加大棗，並增添茯苓的劑量，用甘瀾水煮藥，服之則愈。此方治「奔豚」已發亦同樣有效。奔豚證：為氣從少腹上衝咽喉，憋悶欲死，使人精神緊張。而氣沖所經之處，或脹、或悸。成窒，皆歷歷有征。少頃，氣往下行，其證則減。
郭××，男，56 歲。患奔豚氣證，發作時氣從少腹往上衝逆，至心胸則悸煩不安、胸滿憋氣、呼吸不利、頭身出汗。每日發作兩三次。切其脈沉弦無力，視其舌質淡而苔水，問其小便則稱甚少，而又有排尿不盡之感。
辨證：水氣下蓄，乘心脾陽虛而發為奔豚。考仲景治奔豚有兩方，而小便不利者，則用本方為宜。
處方：茯苓30克 桂枝12克 大棗12枚 炙甘草6克
囑患者以大盆貯水，以杓揚水，水面有珠子五六千顆相逐，用以煮藥。
患者服兩劑，小便通暢而「奔豚」不作。轉方又用桂枝10克、炙甘草6克，以扶心陽，其病得愈。
以上列舉十一個苓桂劑加減治案，在於使人隨證加減，觸類旁通，以見圓機活法之妙。然余有所思焉，以今之各種心勝病，就余所診，其中有相當一部分是屬於水氣上衝證者。而目前之治冠心病者，又僅守活血化瘀之一法，美則美矣，而法未盡也。如能從水氣上衝證中而補其所缺，則思過半矣。
▲（七）苓桂杏苡湯治驗
苓桂杏苡湯即苓桂朮甘湯減白朮、甘草加杏仁、苡米而成。本方治水邪上逆，兼挾濕濁，水濕相因而為病。多見咳嗽多痰，頭重如裹，胸滿似塞，小便不利，周身痠楚，不欲飲食等證。
曾治一李姓患者，年已八旬開外，然身體猶健，生活尚能自理。入冬以來，即時覺胸滿、氣短、咳嗽吐白痰，周身痠懶，不欲行動。不喜肥甘，喜欲素食。切其脈弦緩無力，視其舌質淡而苔白膩。
辨證：心胸陽虛，陰霾用事，是以胸滿而氣短，水濕皆盛，化而為痰，阻於肺則咳而吐痰，滯於胃濕濁不利，故不欲食肥甘而欲素食。
治法：通陽化飲，滲利水濕。
方藥： 茯苓12克 桂枝10克 杏仁6克 焦苡米12克
此方服六劑，則諸證皆減。轉方用五味異功散鞏固療效，以善其後。
▲（八）苓桂芥甘湯治驗
水為陰邪，性本就下。若發為上衝，亦有因於肝氣激揚使然。清人張令韶、陳修園等人註釋苓桂朮甘湯證有「脾虛而肝乘之，故逆滿」的說法，是有一定道理，可供參考。據此，余在臨床治療水氣上衝，而又有肝氣作噯、頭暈目脹，又以夜晚為甚、脈沉弦等症時，則於苓桂朮甘湯減白朮、又加白芥子3克，使其疏肝下氣，開陰凝之邪，每收功效。
曾治一曹姓婦女、年43 歲。胸脅發滿、入夜為甚，頭目眩暈、心悸氣短、時時作噯、而易發怒。問其月事，則經來過期，而且小腹作脹。脈沉弦、舌苔水滑，面色黧青。
辨證：水氣上衝，兼挾肝氣，是以氣血不和而噯氣腹脹、月經後期也。
治法：溫陽化飲、疏肝理氣。
處方：茯苓12克 桂枝10克 白芥子3克 香附6克 炙甘草6克
此方續服六劑，諸症皆減，尤以噯氣不作，而胸脅敞快。轉方以小劑桂枝茯苓丸為湯，另加郁金、香附等解郁之藥而獲全績。
▲（九）苓桂茜紅湯治驗
苓桂茜紅湯，即苓桂朮甘湯減去白朮、甘草，加紅花，茜草而成。此方為余手制。常用於某些冠心病患者。他們既有水氣上衝的症候，復有心前區疼痛控背及手指發麻等氣血瘀阻的證候。此方用苓桂通陽化飲，紅花、茜草活血脈而行瘀滯。根據臨床觀察，服後療效頗顯。例如，曾治太原曹××，自稱患有冠心病。最近頭暈、胸滿且疼、控及後背。切其脈弦，視其舌邊有瘀血斑，而苔則水滑欲滴。余辨為水氣上衝，挾有血脈瘀滯，而思出此方，姑且試之。病人連服五劑，竟覺症狀大減，喜出望外。從此，余又在臨床用過幾次，也同樣的有效。並且，如遇患者血壓偏高的，可加用牛膝10克，有很好的降壓作用。
▲（十） 苓桂龍牡湯治驗
苓桂龍牡湯，即苓桂朮甘湯減白朮，加龍骨、牡蠣而成。此方治療水氣上衝，兼見心中驚悸、睡臥不安、頭暈耳噪、夜不成寐等症。
陸××，男，42 歲，因息冠心病住院。經治兩月餘，病情未解。其證為心前區疼痛、憋氣、心悸、恐怖欲死。每當心痛發作，自覺有氣上衝於喉，則氣窒殊甚、周身出冷汗。脈弦而結，舌淡、苔白。
辨證，此繫心陽盛衰，坐鎮無權，水氣上衝，陰來搏陽，而使胸陽痺塞，則心胸作痛，水氣凌心，則心悸而動，心律失調，則脈弦而結，陰霾密佈，胸陽不振，故胸中憋氣而喉中窒塞，水邪發動，腎陽失於約束（腎志為恐），則其人恐怖欲死。
治法：通陽下氣、利水寧心。
處方：茯苓18克 桂枝10克 炙甘草6克 龍骨、牡蠣各12克
服三劑，心神得安，氣逆得平，但脈仍結，並伴有明顯的畏寒肢冷的現象。轉方用真武湯加桂枝、甘草而逐漸恢復，因而出院。
附苓桂棗甘湯臨證治驗
苓桂棗甘湯，見於《傷寒論》第65條：「發汗後，其人臍下有悸者，欲作奔豚，苓桂棗甘湯主之。」以及《金匱要略•奔豚病》第5條：「發汗後，其人臍下悸者，欲作奔豚，苓桂棗甘湯主之。」筆者應用本方取得了較好的療效，現舉例探討如下。
病案1：尹某，男，41歲，初診日期：2009年9月20日。高血壓病5年餘，經服降壓藥效果不顯，且時有氣上衝之症，經人介紹用中醫一試。當時測BP 150/110mmHg。刻下症見：口微干，晨起頭昏沉，胸口涼，自覺有氣上衝胸口，上衝時氣短、胸憋，十幾秒鐘後消失，日2～3次。胃脘部時有脹滿不適，偶呃逆，大便調，食納可。舌紅苔白厚膩，脈沉滑。
患者苔白厚膩、脈沉，為水飲內停；晨起頭昏沉、胸口涼、自覺有氣上衝胸口、上衝時氣短、胸憋，為水飲上衝之證，正合苓桂朮甘湯的病機，《傷寒論》第67條：「傷寒，若吐若下後，心下逆滿、氣上衝胸、起則頭眩、脈沉緊，發汗則動經，身為振振搖者，苓桂朮甘湯主之。」《金匱要略•痰飲咳嗽病脈證並治》第16條：「心下有痰飲，胸脅支滿，目眩，苓桂朮甘湯主之。」患者胃脘部時有脹滿不適、偶呃逆，正是心下（胃脘部）有水飲內停、胃氣上逆所致。針對患者氣短、胸憋之證，加一味杏仁，有茯苓杏仁甘草湯之意，因茯苓杏仁甘草湯亦治療水飲所致的「胸痺，胸中氣塞，短氣」。另外，患者口微干、舌紅、脈滑為陽明裡熱之證，加用一味生石膏清解陽明之熱。處方：苓桂朮甘湯合茯苓杏仁甘草湯加生石膏：茯苓30g，桂枝10g，白朮10g，炙甘草6g，杏仁10g，生石膏30g。七服，水煎服，日一服。當時認為，患者方證藥吻合，應該會有明顯療效。
結果：患者服完七服後，訴胃脘部脹滿不適及呃逆消失，口乾、晨起頭昏沉等症較前減輕，但患者氣上衝胸、氣短、胸憋等症未見明顯好轉。當時考慮患者雖然有一些症狀改善，但其氣上衝胸、氣短、胸憋等主症沒有好轉，肯定是方證對應不準確，需要重新辨證。後來追問患者症狀，患者訴除了氣上衝胸、氣短、胸憋等症外，小腹部亦有脹滿之不適感。這時筆者考慮到，患者小腹不適病位實為臍下，苓桂棗甘湯較之苓桂朮甘湯更適合該患者的病機，《傷寒論》第65條：「發汗後，其人臍下有悸者，欲作奔豚，苓桂棗甘湯主之。」處方：苓桂棗甘湯加杏仁：茯苓40g，桂枝15g，大棗15枚，炙甘草6g，杏仁10g。七服，水煎服，日一服。結果：患者又服完七服後，腹脹及矢氣消失，氣上衝胸、氣短、胸憋等症也明顯好轉。後以苓桂棗甘湯為主調理一月，氣上衝胸等症完全消失，血壓亦恢復正常。
病案2：王某，男，29歲。初診日期：2009年8月6日。患者口微干，大便偏稀，日一行，胃脘及小腹部怕涼，且小腹部脹滿，重按有輕壓痛，食納可，小便調，舌紅苔白微膩，脈沉細。當時考慮患者口微干、舌紅為上熱證，大便偏稀、胃脘部及小腹部怕涼、苔白微膩、脈沉細為下寒證，上熱下寒，屬於半表半裡寒熱錯雜之證，即六經的厥陰病。厥陰病屬於半表半裡，因為邪無出路，故不能採用汗吐下法，治以和解之法，又見腹部脹滿，故方用柴胡桂枝幹薑湯清上溫下又治腹滿。
結果：患者服完七服後，訴口乾消失，胃脘部及小腹部怕涼變化不大，且患者自覺小腹部有股涼氣向胃脘部冒，有輕壓痛，大便仍偏稀。筆者這次特別注意到了患者「小腹部有股涼氣向胃脘部冒」，這不就是《傷寒論》第65條「發汗後，其人臍下有悸者，欲作奔豚，苓桂棗甘湯主之」中之「臍下悸」嗎？雖然患者沒有「氣從少腹起、上衝咽喉、發作欲死」之奔豚病，但患者之「自覺小腹部有股涼氣向胃脘部冒」，亦是氣上衝的表現，與苓桂棗甘湯的病機是一致的，故選用苓桂棗甘湯。處方：茯苓50g，桂枝18g，大棗20枚，炙甘草6g。七服，水煎服，日一服。結果：患者又服完七服後，胃脘部及小腹部怕涼以及小腹部有股涼氣向胃脘部冒、腹部輕壓痛等症消失，大便調，病告痊癒。
討論：苓桂棗甘湯的條文簡約，且與苓桂朮甘湯相差不大，以致很多人對苓桂朮甘湯關注較多，而對本方則有所忽略，其實二方在臨床上有很大的其別，具體如下：
在病位方面，苓桂棗甘湯證亦是水飲內停，但其水飲部位偏於下焦，多在肚臍以下的小腹部，故條文曰「臍下有悸」；而苓桂朮甘湯證的病位在中焦，故有「心下有痰飲，胸脅支滿，目眩」以及「心下逆滿、氣上衝胸、起則頭眩、脈沉緊」等症。
在藥物組成方面，苓桂棗甘湯與苓桂朮甘湯相比，雖只以大棗與白朮之差，但於主治則大異其趣。苓桂棗甘湯中茯苓量用半斤，《本經》言茯苓：「主胸脅逆氣，憂恚驚邪恐悸，心下結痛，寒熱煩滿咳逆，口焦舌干，利小便。久服安魂養神，不飢延年。」茯苓大量用，不僅能主胸脅逆氣、驚邪恐悸，亦能散飲逐水、利小便，特別是重用則偏走於下，急瀉下焦之水飲濕氣。《神農本草經》曰大棗：「主心腹邪氣，安中，養脾氣，通九竅，助十二經，補少氣、少津液，身中不足，大驚，四肢重，和百藥。」 苓桂棗甘湯中重用大棗15枚，既能主心腹邪氣、安中養脾，又能治大驚悸，且大棗則還可腹攣急，故本方有明顯的下腹部「按之則痛」。
總之，苓桂棗甘湯主之水飲內停偏於下焦，如小腹部怕涼、脹滿、大便稀溏，或腹部有壓痛，同時伴有氣從小腹或臍下上衝等症，有本方應用的機會。
--------------------------------------------------------------------------
댓글 없음:
댓글 쓰기