【摘 要】 陰水水腫的發生與肺脾腎三(san)臟功能失(shi)調(diao)及氣化失(shi)常密切相關，筆(bi)者用五苓散治療(liao)水腫一(yi)例(li)，取得滿(man)意療(liao)效。
【關(guan)鍵詞】 水(shui)腫；陰(yin)水(shui)；五(wu)苓散(san)
水(shui)(shui)(shui)(shui)(shui)腫(zhong)是(shi)(shi)由(you)于多(duo)種原因(yin)導致(zhi)(zhi)體(ti)(ti)內(nei)水(shui)(shui)(shui)(shui)(shui)液(ye)潴留，泛(fan)濫肌(ji)膚，引起以眼瞼、頭面、四(si)肢、腹部甚至全(quan)身浮腫(zhong)為(wei)(wei)主要臨床特征的(de)一(yi)類(lei)病證(zheng)[1]。由(you)于致(zhi)(zhi)病因(yin)素及(ji)體(ti)(ti)質差異，水(shui)(shui)(shui)(shui)(shui)腫(zhong)的(de)病理屬性(xing)有陰水(shui)(shui)(shui)(shui)(shui)、陽水(shui)(shui)(shui)(shui)(shui)之(zhi)分。陽水(shui)(shui)(shui)(shui)(shui)屬實，多(duo)由(you)外感風邪(xie)、瘡毒(du)、水(shui)(shui)(shui)(shui)(shui)濕而(er)(er)成；陰水(shui)(shui)(shui)(shui)(shui)屬虛(xu)或(huo)虛(xu)實夾雜(za)，多(duo)由(you)飲食(shi)勞倦、稟賦不(bu)足(zu)、久病體(ti)(ti)虛(xu)所致(zhi)(zhi)[2]。張景岳《景岳全(quan)書·雜(za)癥謨》記載(zai)：“凡水(shui)(shui)(shui)(shui)(shui)腫(zhong)等(deng)證(zheng)，乃脾(pi)、肺(fei)(fei)、腎三臟相干(gan)之(zhi)病。蓋(gai)水(shui)(shui)(shui)(shui)(shui)為(wei)(wei)至陰，故其(qi)(qi)本在腎；水(shui)(shui)(shui)(shui)(shui)化于氣(qi)，故其(qi)(qi)標(biao)在肺(fei)(fei)；水(shui)(shui)(shui)(shui)(shui)惟畏(wei)土，故其(qi)(qi)制在脾(pi)。”而(er)(er)“陰中(zhong)無陽，則(ze)(ze)氣(qi)不(bu)能(neng)化，所以水(shui)(shui)(shui)(shui)(shui)道(dao)不(bu)通，溢而(er)(er)為(wei)(wei)腫(zhong)。”故調理肺(fei)(fei)脾(pi)腎三臟功(gong)能(neng)，化氣(qi)利水(shui)(shui)(shui)(shui)(shui)是(shi)(shi)治(zhi)療陰水(shui)(shui)(shui)(shui)(shui)水(shui)(shui)(shui)(shui)(shui)腫(zhong)的(de)重要治(zhi)則(ze)(ze)[3]。老年(nian)人臟氣(qi)虛(xu)衰(shuai)，正(zheng)氣(qi)不(bu)足(zu)，是(shi)(shi)陰水(shui)(shui)(shui)(shui)(shui)水(shui)(shui)(shui)(shui)(shui)腫(zhong)的(de)多(duo)發(fa)群體(ti)(ti)，筆者用五(wu)苓散恢復(fu)機體(ti)(ti)氣(qi)化，兼顧(gu)調理肺(fei)(fei)脾(pi)腎三臟功(gong)能(neng)，治(zhi)療陰水(shui)(shui)(shui)(shui)(shui)水(shui)(shui)(shui)(shui)(shui)腫(zhong)一(yi)例，取得滿意(yi)療效，現報道(dao)如下(xia)。
1 病例資料
患者秦某，女，67歲，于(yu)2014年9月19日就(jiu)診(zhen)(zhen)(zhen)(zhen)。主訴“尿(niao)(niao)頻(pin)尿(niao)(niao)少尿(niao)(niao)痛1周余(yu)，發(fa)(fa)熱(re)伴嘔吐(tu)1天(tian)”。病(bing)史：患者于(yu)1周前(qian)(qian)(qian)無(wu)明顯(xian)(xian)(xian)誘因出現(xian)(xian)尿(niao)(niao)頻(pin)尿(niao)(niao)少尿(niao)(niao)痛，小(xiao)便淋漓，尿(niao)(niao)量減(jian)少，口(kou)干多(duo)(duo)(duo)飲(yin)，胃納差(cha)，時有惡(e)心欲吐(tu)感(gan)，遂(sui)往門診(zhen)(zhen)(zhen)(zhen)就(jiu)診(zhen)(zhen)(zhen)(zhen)，門診(zhen)(zhen)(zhen)(zhen)醫師查(cha)尿(niao)(niao)常(chang)規：尿(niao)(niao)膽原(yuan)（+），膽紅(hong)素（+），隱血（+++），蛋白質(zhi)（+），白細胞（+++），考慮尿(niao)(niao)路(lu)感(gan)染，予(yu)左氧氟沙星口(kou)服(fu)(fu)(fu)抗(kang)感(gan)染，及(ji)清熱(re)利(li)濕中藥(yao)(yao)治療，服(fu)(fu)(fu)藥(yao)(yao)后(hou)尿(niao)(niao)頻(pin)尿(niao)(niao)急癥狀減(jian)輕(qing)(qing)(qing)，仍(reng)小(xiao)便不利(li)，且口(kou)干渴(ke)益(yi)甚(shen)，飲(yin)水(shui)較前(qian)(qian)(qian)增多(duo)(duo)(duo)。9月19日上(shang)午開始出現(xian)(xian)惡(e)寒(han)發(fa)(fa)熱(re)即前(qian)(qian)(qian)來就(jiu)診(zhen)(zhen)(zhen)(zhen)。癥見(jian)：尿(niao)(niao)頻(pin)尿(niao)(niao)少尿(niao)(niao)痛，伴惡(e)寒(han)發(fa)(fa)熱(re)，最高體溫達38℃，多(duo)(duo)(duo)次(ci)嘔吐(tu)，雙下肢(zhi)(zhi)中度(du)浮(fu)腫(zhong)，顏面及(ji)上(shang)肢(zhi)(zhi)輕(qing)(qing)(qing)度(du)浮(fu)腫(zhong)，脈沉，舌紅(hong)苔(tai)少。查(cha)下肢(zhi)(zhi)血管(guan)及(ji)心臟、腎臟彩超，血液生(sheng)化未見(jian)明顯(xian)(xian)(xian)異常(chang)。診(zhen)(zhen)(zhen)(zhen)斷：西醫診(zhen)(zhen)(zhen)(zhen)斷：特發(fa)(fa)性水(shui)腫(zhong)。中醫診(zhen)(zhen)(zhen)(zhen)斷：水(shui)腫(zhong)，證屬陰水(shui)。方藥(yao)(yao)：五苓散。處方：桂枝15g，茯苓20g，豬(zhu)苓20g，澤瀉20g，白術15g。共3劑，水(shui)煎250ml，分兩次(ci)溫服(fu)(fu)(fu)，多(duo)(duo)(duo)飲(yin)暖水(shui)。服(fu)(fu)(fu)藥(yao)(yao)一(yi)劑即小(xiao)便量明顯(xian)(xian)(xian)增多(duo)(duo)(duo)，嘔吐(tu)止，水(shui)腫(zhong)漸(jian)消，顏面、上(shang)肢(zhi)(zhi)皮膚皺(zhou)陷，下肢(zhi)(zhi)浮(fu)腫(zhong)較前(qian)(qian)(qian)減(jian)輕(qing)(qing)(qing)，發(fa)(fa)熱(re)僅于(yu)午后(hou)，口(kou)渴(ke)減(jian)輕(qing)(qing)(qing)。二劑后(hou)小(xiao)便量仍(reng)多(duo)(duo)(duo)，下肢(zhi)(zhi)浮(fu)腫(zhong)減(jian)半，無(wu)發(fa)(fa)熱(re)，仍(reng)口(kou)渴(ke)。三劑后(hou)小(xiao)便量仍(reng)多(duo)(duo)(duo)，下肢(zhi)(zhi)水(shui)腫(zhong)已消除，口(kou)渴(ke)明顯(xian)(xian)(xian)改善但仍(reng)有口(kou)渴(ke)。原(yuan)方再予(yu)2劑，服(fu)(fu)(fu)后(hou)諸癥消除，隨訪半年無(wu)復發(fa)(fa)。
2 按語
本(ben)例中(zhong)患者(zhe)為典型(xing)的(de)陰水(shui)(shui)(shui)(shui)水(shui)(shui)(shui)(shui)腫(zhong)，緣其年老陽(yang)(yang)(yang)(yang)氣(qi)(qi)(qi)(qi)(qi)虛(xu)(xu)衰，氣(qi)(qi)(qi)(qi)(qi)化(hua)(hua)(hua)(hua)不利(li)(li)加(jia)(jia)之(zhi)(zhi)(zhi)尿(niao)路感染而(er)致尿(niao)頻(pin)、尿(niao)少、尿(niao)痛及(ji)(ji)口干多飲(yin)(yin)。前(qian)醫(yi)以(yi)(yi)抗感染、清(qing)熱利(li)(li)濕(shi)治(zhi)(zhi)(zhi)之(zhi)(zhi)(zhi)，尿(niao)頻(pin)尿(niao)急得(de)(de)緩解(jie)(jie)，但(dan)苦寒(han)之(zhi)(zhi)(zhi)藥傷及(ji)(ji)已虛(xu)(xu)之(zhi)(zhi)(zhi)陽(yang)(yang)(yang)(yang)，氣(qi)(qi)(qi)(qi)(qi)不化(hua)(hua)(hua)(hua)水(shui)(shui)(shui)(shui)，故小(xiao)便(bian)(bian)不利(li)(li)加(jia)(jia)重而(er)口干益甚。肺(fei)衛不足，不耐風寒(han)而(er)惡寒(han)發(fa)(fa)熱，飲(yin)(yin)水(shui)(shui)(shui)(shui)不化(hua)(hua)(hua)(hua)，小(xiao)便(bian)(bian)不利(li)(li)，水(shui)(shui)(shui)(shui)飲(yin)(yin)內盛，上(shang)(shang)逆則(ze)(ze)嘔吐，泛于(yu)肌膚(fu)則(ze)(ze)見(jian)全身浮腫(zhong)，脈沉為陽(yang)(yang)(yang)(yang)虛(xu)(xu)之(zhi)(zhi)(zhi)征。而(er)西醫(yi)學的(de)相關(guan)檢查未見(jian)明顯異常(chang)，診斷為特(te)發(fa)(fa)性水(shui)(shui)(shui)(shui)腫(zhong)，特(te)發(fa)(fa)性水(shui)(shui)(shui)(shui)腫(zhong)[4]是臨床(chuang)常(chang)見(jian)病(bing)(bing)(bing)(bing)、多發(fa)(fa)病(bing)(bing)(bing)(bing)， 病(bing)(bing)(bing)(bing)因至(zhi)今不清(qing)，但(dan)從病(bing)(bing)(bing)(bing)理(li)(li)(li)生(sheng)理(li)(li)(li)角(jiao)度上(shang)(shang)說是水(shui)(shui)(shui)(shui)鹽代謝(xie)紊亂，細胞(bao)外(wai)(wai)液(ye)在(zai)(zai)皮下(xia)異常(chang)增多而(er)致，其病(bing)(bing)(bing)(bing)癥屬(shu)于(yu)中(zhong)醫(yi)“水(shui)(shui)(shui)(shui)腫(zhong)”范疇，其本(ben)質不外(wai)(wai)乎脾腎(shen)功(gong)(gong)(gong)能衰弱， 腎(shen)氣(qi)(qi)(qi)(qi)(qi)虛(xu)(xu)衰， 氣(qi)(qi)(qi)(qi)(qi)化(hua)(hua)(hua)(hua)不利(li)(li)，膀胱開合失調(diao)所致，恰與本(ben)案相符。關(guan)于(yu)水(shui)(shui)(shui)(shui)腫(zhong)，《素問·湯液(ye)醪醴論》提出(chu)：“平治(zhi)(zhi)(zhi)于(yu)權衡，去菀(yu)陳(chen)莝(cuo)……開鬼門，潔凈府。”治(zhi)(zhi)(zhi)療水(shui)(shui)(shui)(shui)腫(zhong)的(de)治(zhi)(zhi)(zhi)則(ze)(ze)，張仲景(jing)《金(jin)匱要略·水(shui)(shui)(shui)(shui)氣(qi)(qi)(qi)(qi)(qi)病(bing)(bing)(bing)(bing)脈證并治(zhi)(zhi)(zhi)》提出(chu)：“腰以(yi)(yi)下(xia)腫(zhong)，當利(li)(li)小(xiao)便(bian)(bian)，要以(yi)(yi)上(shang)(shang)腫(zhong)，當發(fa)(fa)汗乃愈”的(de)治(zhi)(zhi)(zhi)法(fa)。五苓(ling)散兼發(fa)(fa)汗、利(li)(li)小(xiao)便(bian)(bian)雙功(gong)(gong)(gong)，恰恰與之(zhi)(zhi)(zhi)相符。該例中(zhong)，患者(zhe)水(shui)(shui)(shui)(shui)腫(zhong)的(de)關(guan)鍵在(zai)(zai)于(yu)小(xiao)便(bian)(bian)不利(li)(li)，水(shui)(shui)(shui)(shui)飲(yin)(yin)無出(chu)路。病(bing)(bing)(bing)(bing)機(ji)(ji)為下(xia)焦膀胱氣(qi)(qi)(qi)(qi)(qi)化(hua)(hua)(hua)(hua)不利(li)(li)，水(shui)(shui)(shui)(shui)蓄(xu)下(xia)焦。治(zhi)(zhi)(zhi)療以(yi)(yi)化(hua)(hua)(hua)(hua)氣(qi)(qi)(qi)(qi)(qi)利(li)(li)水(shui)(shui)(shui)(shui)，兼調(diao)理(li)(li)(li)肺(fei)脾腎(shen)三臟(zang)功(gong)(gong)(gong)能為法(fa)。方(fang)中(zhong)澤瀉利(li)(li)水(shui)(shui)(shui)(shui)滲(shen)濕(shi)為君(jun)，臣(chen)以(yi)(yi)茯苓(ling)、豬苓(ling)助君(jun)藥利(li)(li)水(shui)(shui)(shui)(shui)滲(shen)濕(shi)，腎(shen)主水(shui)(shui)(shui)(shui)，水(shui)(shui)(shui)(shui)濕(shi)去有利(li)(li)于(yu)腎(shen)陽(yang)(yang)(yang)(yang)恢(hui)復，且桂枝溫(wen)(wen)陽(yang)(yang)(yang)(yang)化(hua)(hua)(hua)(hua)氣(qi)(qi)(qi)(qi)(qi)以(yi)(yi)助腎(shen)陽(yang)(yang)(yang)(yang)化(hua)(hua)(hua)(hua)氣(qi)(qi)(qi)(qi)(qi)利(li)(li)水(shui)(shui)(shui)(shui)，水(shui)(shui)(shui)(shui)濕(shi)去、氣(qi)(qi)(qi)(qi)(qi)化(hua)(hua)(hua)(hua)利(li)(li)，使虛(xu)(xu)憊(bei)之(zhi)(zhi)(zhi)腎(shen)陽(yang)(yang)(yang)(yang)有恢(hui)復之(zhi)(zhi)(zhi)機(ji)(ji)。佐以(yi)(yi)白術(shu)補氣(qi)(qi)(qi)(qi)(qi)以(yi)(yi)運化(hua)(hua)(hua)(hua)水(shui)(shui)(shui)(shui)濕(shi)，合茯苓(ling)既可彰(zhang)健脾制(zhi)水(shui)(shui)(shui)(shui)之(zhi)(zhi)(zhi)效，又可奏(zou)輸津四(si)布之(zhi)(zhi)(zhi)功(gong)(gong)(gong)，津液(ye)上(shang)(shang)承口渴解(jie)(jie)以(yi)(yi)杜飲(yin)(yin)水(shui)(shui)(shui)(shui)加(jia)(jia)重蓄(xu)水(shui)(shui)(shui)(shui)之(zhi)(zhi)(zhi)虞，脾氣(qi)(qi)(qi)(qi)(qi)得(de)(de)健，則(ze)(ze)水(shui)(shui)(shui)(shui)濕(shi)生(sheng)化(hua)(hua)(hua)(hua)無源。《素問·靈蘭秘典論》謂：“膀胱者(zhe)，洲(zhou)都之(zhi)(zhi)(zhi)官，津液(ye)藏焉，氣(qi)(qi)(qi)(qi)(qi)化(hua)(hua)(hua)(hua)則(ze)(ze)能出(chu)矣。”故又佐以(yi)(yi)桂枝溫(wen)(wen)陽(yang)(yang)(yang)(yang)化(hua)(hua)(hua)(hua)氣(qi)(qi)(qi)(qi)(qi)以(yi)(yi)助利(li)(li)水(shui)(shui)(shui)(shui)而(er)腎(shen)陽(yang)(yang)(yang)(yang)得(de)(de)溫(wen)(wen)，并可辛溫(wen)(wen)發(fa)(fa)散以(yi)(yi)祛表邪，表邪除肺(fei)氣(qi)(qi)(qi)(qi)(qi)不受束得(de)(de)以(yi)(yi)宣發(fa)(fa)，使肺(fei)氣(qi)(qi)(qi)(qi)(qi)得(de)(de)以(yi)(yi)恢(hui)復通調(diao)水(shui)(shui)(shui)(shui)道的(de)功(gong)(gong)(gong)能。全方(fang)化(hua)(hua)(hua)(hua)氣(qi)(qi)(qi)(qi)(qi)利(li)(li)水(shui)(shui)(shui)(shui)，并能兼顧(gu)腎(shen)陽(yang)(yang)(yang)(yang)溫(wen)(wen)化(hua)(hua)(hua)(hua)、脾氣(qi)(qi)(qi)(qi)(qi)運化(hua)(hua)(hua)(hua)散精(jing)、肺(fei)通調(diao)水(shui)(shui)(shui)(shui)道功(gong)(gong)(gong)能，氣(qi)(qi)(qi)(qi)(qi)化(hua)(hua)(hua)(hua)恢(hui)復，小(xiao)便(bian)(bian)得(de)(de)出(chu)，水(shui)(shui)(shui)(shui)腫(zhong)自除，諸癥自愈。
參考文獻
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文(wen)章來源：中國民(min)族(zu)民(min)間醫藥(yao)·下半月
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