(一)
桂(gui)附八(ba)味(wei)丸(wan)，首(shou)見(jian)于仲(zhong)景《金(jin)匱要略(lve)》，但古(gu)今方(fang)(fang)名(ming)(ming)略(lve)有不同。本方(fang)(fang)于《金(jin)匱》書中凡兩見(jian)：先見(jian)于“血痹虛勞病脈(mo)證并治(zhi)第六”篇(pian)，名(ming)(ming)曰“八(ba)味(wei)腎氣(qi)丸(wan)”。又見(jian)于“婦人雜病脈(mo)證并治(zhi)第二(er)十二(er)”篇(pian)，刪去“八(ba)味(wei)”二(er)字，僅名(ming)(ming)“腎氣(qi)丸(wan)”。因此方(fang)(fang)首(shou)出《金(jin)匱》，后(hou)世稱之為“金(jin)匱腎氣(qi)丸(wan)”，此名(ming)(ming)至今尚在沿用。現時之“金(jin)匱腎氣(qi)丸(wan)”與仲(zhong)景原方(fang)(fang)不盡一致(zhi)，已(yi)略(lve)有變動，故有改稱“桂(gui)附八(ba)味(wei)丸(wan)”者(zhe)。
《金匱(kui)要略》之(zhi)(zhi)腎(shen)(shen)氣丸(wan)(wan)藥用(yong)(yong)(yong)(yong)：“干地(di)(di)黃(huang)八兩，山茱萸、薯蕷(yu)各四(si)兩，澤瀉(xie)、茯(fu)苓、牡丹皮(pi)各三兩，桂(gui)(gui)枝(zhi)、附子(zi)(炮(pao))各一兩。”其所治證為“虛勞腰痛，少腹(fu)拘急，小便不(bu)利(li)者”及“轉胞”而(er)“不(bu)得溺”者，用(yong)(yong)(yong)(yong)腎(shen)(shen)氣丸(wan)(wan)于補益腎(shen)(shen)氣之(zhi)(zhi)基(ji)礎上，“但利(li)小便則(ze)(ze)愈(yu)。”可(ke)見桂(gui)(gui)枝(zhi)于此方中不(bu)僅有協助附子(zi)以(yi)(yi)溫腎(shen)(shen)臟之(zhi)(zhi)效，更重要者在于增(zeng)強膀胱氣化，以(yi)(yi)利(li)小便。但后世之(zhi)(zhi)腎(shen)(shen)氣丸(wan)(wan)，多(duo)用(yong)(yong)(yong)(yong)以(yi)(yi)治療(liao)腎(shen)(shen)陽虛衰之(zhi)(zhi)證，常不(bu)兼挾水液代謝障礙，故不(bu)用(yong)(yong)(yong)(yong)桂(gui)(gui)枝(zhi)而(er)用(yong)(yong)(yong)(yong)肉桂(gui)(gui)，以(yi)(yi)增(zeng)溫腎(shen)(shen)納(na)氣、引火歸元之(zhi)(zhi)力(li)，更有利(li)于腎(shen)(shen)衰陽虛內寒(han)或虛陽浮動之(zhi)(zhi)證。原方中干地(di)(di)黃(huang)改用(yong)(yong)(yong)(yong)熟地(di)(di)，則(ze)(ze)滋腎(shen)(shen)之(zhi)(zhi)功尤勝。古時(shi)之(zhi)(zhi)干地(di)(di)黃(huang)即今(jin)時(shi)之(zhi)(zhi)生地(di)(di)黃(huang)，古之(zhi)(zhi)生地(di)(di)黃(huang)則(ze)(ze)為今(jin)之(zhi)(zhi)鮮生地(di)(di)。故仲景(jing)之(zhi)(zhi)百(bai)合地(di)(di)黃(huang)湯方可(ke)用(yong)(yong)(yong)(yong)生地(di)(di)黃(huang)搗汁，職是故也。仲景(jing)何(he)以(yi)(yi)于腎(shen)(shen)氣丸(wan)(wan)中不(bu)用(yong)(yong)(yong)(yong)熟地(di)(di)，余未加考證，似(si)漢時(shi)尚未發明加工熟地(di)(di)之(zhi)(zhi)法。
熟(shu)地(di)(di)滋(zi)(zi)補真陰、攝納(na)腎氣之(zhi)功遠(yuan)勝(sheng)生地(di)(di)。如清代許(xu)松如于《診(zhen)余脞談》中曰：“徐洄(hui)溪、陳修(xiu)園輩(bei)(bei)，以(yi)熟(shu)地(di)(di)柔膩滯胃(wei)(wei)(wei)，宜(yi)人丸(wan)劑而(er)不(bu)(bu)宜(yi)入煎劑，引古以(yi)為證(zheng)，此拘牽之(zhi)說(shuo)也。余見腎虛(xu)宜(yi)填納(na)而(er)胃(wei)(wei)(wei)氣不(bu)(bu)弱(ruo)者，服之(zhi)利益(yi)甚大。佐以(yi)流動之(zhi)品，絕不(bu)(bu)礙(ai)胃(wei)(wei)(wei)。且應用(yong)(yong)(yong)熟(shu)地(di)(di)之(zhi)時，即(ji)以(yi)枸杞、女貞、龜版輩(bei)(bei)代之(zhi)，效力亦(yi)遜(xun)，詎可(ke)懸以(yi)為禁(jin)，沒其功用(yong)(yong)(yong)乎?”許(xu)氏所(suo)說(shuo)為臨(lin)證(zheng)有得之(zhi)言，皆從經(jing)(jing)驗中來。熟(shu)地(di)(di)滋(zi)(zi)膩礙(ai)胃(wei)(wei)(wei)之(zhi)弊，除“佐以(yi)流動之(zhi)品”而(er)外，尚有重用(yong)(yong)(yong)一法(fa)。蓋熟(shu)地(di)(di)少(shao)用(yong)(yong)(yong)則(ze)滋(zi)(zi)膩，多(duo)用(yong)(yong)(yong)反(fan)不(bu)(bu)礙(ai)胃(wei)(wei)(wei)。所(suo)謂(wei)多(duo)用(yong)(yong)(yong)，即(ji)每劑或每次單服用(yong)(yong)(yong)至30g 即(ji)可(ke)。此余臨(lin)證(zheng)屢經(jing)(jing)試驗，乃歷歷不(bu)(bu)爽者也。世(shi)傳(chuan)有用(yong)(yong)(yong)熟(shu)地(di)(di)拌砂(sha)仁之(zhi)法(fa)，法(fa)非不(bu)(bu)善(shan)，而(er)虛(xu)損癥常多(duo)脾腎雙虧、胃(wei)(wei)(wei)氣傷殘者，雖些(xie)少(shao)砂(sha)仁亦(yi)難接受，不(bu)(bu)如上法(fa)為妥(tuo)。但熟(shu)地(di)(di)服用(yong)(yong)(yong)不(bu)(bu)當以(yi)致胃(wei)(wei)(wei)氣膩滯、經(jing)(jing)絡(luo)壅塞者，又非砂(sha)仁、沉香不(bu)(bu)能(neng)開。
有(you)腎陰(yin)虧極、虛陽上浮者，舍熟(shu)(shu)地(di)(di)難能滋(zi)填攝納以歸窟宅。余曾治(zhi)一虛損癥，真陰(yin)虛衰(shuai)而致倦(juan)怠(dai)乏力(li)，吸(xi)吸(xi)少氣，上重(zhong)下輕，頭(tou)腦昏沉不(bu)清(qing)，腰酸(suan)肢(zhi)軟，遺精頻頻，納差神(shen)呆，余于其對癥方中加(jia)熟(shu)(shu)地(di)(di)30g，首次服藥后即覺(jue)有(you)氣自頭(tou)中下降入腹(fu)，立見頭(tou)腦清(qing)醒、精神(shen)倍(bei)增，腹(fu)笥充實，兩足有(you)力(li)。以后續服前方，胸腹(fu)經絡之間，常(chang)有(you)氣機走動之感，不(bu)用熟(shu)(shu)地(di)(di)則(ze)不(bu)見氣感，此(ci)乃(nai)熟(shu)(shu)地(di)(di)招納虛陽下歸之效。由此(ci)可知，真陰(yin)虛衰(shuai)者，要非熟(shu)(shu)地(di)(di)無以為用。無怪乎景岳好用熟(shu)(shu)地(di)(di)，致有(you)“張熟(shu)(shu)地(di)(di)”之美名，不(bu)為無因。
熟(shu)地之(zhi)選材加(jia)工炮制(zhi)方法(fa)，對于藥(yao)效至關(guan)重要。王汝霖曰(yue)：“惟(wei)此(ci)(ci)丸(桂(gui)附(fu)八味丸)中之(zhi)熟(shu)地，必(bi)須(xu)用(yong)九煮(zhu)九蒸(zheng)九曬制(zhi)極透者，否則(ze)無效。有心活(huo)人者，須(xu)自制(zhi)為妥。”此(ci)(ci)說聊備一格，姑且存而勿論。
(二)
桂附(fu)八味(wei)丸之(zhi)方義解釋，多屬(shu)隨(sui)文敷衍，未抉精(jing)(jing)要。如《醫方集解》釋曰：“熟(shu)地(di)滋(zi)陰(yin)(yin)補(bu)(bu)(bu)腎，生血生精(jing)(jing)；山茱溫肝逐風，澀精(jing)(jing)秘氣；牡丹(dan)(dan)瀉(xie)(xie)君相之(zhi)伏(fu)火(huo)，涼血退蒸；山藥(yao)(yao)(yao)清(qing)(qing)虛(xu)熱于肺脾，補(bu)(bu)(bu)脾固腎；茯苓(ling)(ling)滲脾中(zhong)(zhong)濕(shi)熱，而(er)(er)通(tong)腎交心(xin)；澤(ze)(ze)瀉(xie)(xie)瀉(xie)(xie)膀(bang)胱水(shui)邪，而(er)(er)聰(cong)耳(er)明目。”“惟(wei)附(fu)子(zi)、肉桂，能(neng)入腎命之(zhi)間而(er)(er)補(bu)(bu)(bu)之(zhi)，故加入六(liu)(liu)味(wei)丸中(zhong)(zhong)，為(wei)補(bu)(bu)(bu)火(huo)之(zhi)劑。”又如《醫貫》曰：“熟(shu)地(di)、山萸、丹(dan)(dan)皮、澤(ze)(ze)瀉(xie)(xie)、山藥(yao)(yao)(yao)、茯苓(ling)(ling)、皆濡潤之(zhi)品，所以(yi)(yi)能(neng)壯水(shui)之(zhi)主。肉桂、附(fu)子(zi)，辛潤之(zhi)物，能(neng)于水(shui)中(zhong)(zhong)補(bu)(bu)(bu)火(huo)，所以(yi)(yi)益火(huo)之(zhi)原。水(shui)火(huo)得其養(yang)，則(ze)腎氣復其天矣。”以(yi)(yi)上釋義，皆就(jiu)腎臟本身之(zhi)生理(li)病理(li)及方中(zhong)(zhong)諸藥(yao)(yao)(yao)之(zhi)功能(neng)而(er)(er)言，固屬(shu)不(bu)謬，然則(ze)難免有(you)淺(qian)近之(zhi)嫌。而(er)(er)尤在(zai)涇于《醫學讀書記》中(zhong)(zhong)論六(liu)(liu)味(wei)地(di)黃丸則(ze)曰：“六(liu)(liu)味(wei)地(di)黃丸多用(yong)(yong)熟(shu)地(di)、萸肉、山藥(yao)(yao)(yao)、味(wei)厚(hou)體重(zhong)者(zhe)(zhe)，補(bu)(bu)(bu)陰(yin)(yin)益精(jing)(jing)。而(er)(er)以(yi)(yi)茯苓(ling)(ling)、澤(ze)(ze)瀉(xie)(xie)之(zhi)甘淡助(zhu)之(zhi)下(xia)降(jiang)。……氣浮者(zhe)(zhe)多熱，牡丹(dan)(dan)之(zhi)寒所以(yi)(yi)清(qing)(qing)浮熱。”腎氣虧損，陰(yin)(yin)陽(yang)失調(diao)之(zhi)病理(li)中(zhong)(zhong)，屬(shu)腎陰(yin)(yin)虛(xu)耗(hao)者(zhe)(zhe)，必致陰(yin)(yin)不(bu)戀陽(yang)而(er)(er)虛(xu)陽(yang)上浮，若單以(yi)(yi)熟(shu)地(di)滋(zi)填(tian)攝(she)納(na)猶難招浮陽(yang)歸于窟宅，故佐苓(ling)(ling)澤(ze)(ze)以(yi)(yi)引(yin)導(dao)下(xia)降(jiang)，直趨(qu)命門。尚(shang)有(you)散見之(zhi)浮陽(yang)，則(ze)以(yi)(yi)丹(dan)(dan)皮清(qing)(qing)之(zhi)。由是陰(yin)(yin)陽(yang)重(zhong)歸和合，水(shui)火(huo)繼(ji)續(xu)交媾(gou)，而(er)(er)復其生理(li)之(zhi)常矣。據此，方中(zhong)(zhong)茯苓(ling)(ling)、澤(ze)(ze)瀉(xie)(xie)，非僅為(wei)通(tong)利小便而(er)(er)設，仲景制方有(you)出神(shen)入化(hua)之(zhi)妙(miao)，而(er)(er)錢仲陽(yang)將八味(wei)丸去桂附(fu)而(er)(er)變為(wei)六(liu)(liu)味(wei)地(di)黃丸，立滋(zi)補(bu)(bu)(bu)真陰(yin)(yin)之(zhi)祖方，乃深得個中(zhong)(zhong)意(yi)趣者(zhe)(zhe)。故用(yong)(yong)方之(zhi)時，更(geng)須斟(zhen)酌盡善，不(bu)宜(yi)隨(sui)便刪除澤(ze)(ze)瀉(xie)(xie)，易以(yi)(yi)他物。
澤(ze)(ze)(ze)(ze)(ze)瀉除用(yong)以利(li)水(shui)之(zhi)外，李時珍謂其還具(ju)固(gu)(gu)精(jing)(jing)之(zhi)功(gong)，可(ke)(ke)治遺(yi)(yi)泄。而腎(shen)精(jing)(jing)為腎(shen)中(zhong)(zhong)陰(yin)陽二氣(qi)之(zhi)物質(zhi)基礎，無(wu)論(lun)腎(shen)陰(yin)虛癥或腎(shen)陽虛癥，必然波及腎(shen)精(jing)(jing)，因(yin)而固(gu)(gu)護精(jing)(jing)氣(qi)實為治療腎(shen)氣(qi)虧損必不可(ke)(ke)少(shao)之(zhi)環節(jie)(jie)，而于(yu)全(quan)方(fang)中(zhong)(zhong)雖地(di)、萸、山藥(yao)皆兼此能，而無(wu)突出之(zhi)效，惟有澤(ze)(ze)(ze)(ze)(ze)瀉獨擅其功(gong)，是以仲景用(yong)澤(ze)(ze)(ze)(ze)(ze)瀉不特治水(shui)而已，自有更為重(zhong)要之(zhi)作用(yong)在。澤(ze)(ze)(ze)(ze)(ze)瀉固(gu)(gu)精(jing)(jing)止遺(yi)(yi)其功(gong)獨特，單(dan)味(wei)煎服(fu)即(ji)可(ke)(ke)取效，一般每次(ci)用(yong)10g 即(ji)可(ke)(ke)。余(yu)曾治一少(shao)年，遺(yi)(yi)精(jing)(jing)頻作，諸藥(yao)罔效，以致神思恍(huang)惚，記憶減退，讀書(shu)成績節(jie)(jie)節(jie)(jie)下降，其母深以為慮，央余(yu)設法治療。余(yu)囑每日以澤(ze)(ze)(ze)(ze)(ze)瀉30g 煎服(fu)，連服(fu)七天，從(cong)此不再遺(yi)(yi)泄。一周(zhou)內服(fu)用(yong)澤(ze)(ze)(ze)(ze)(ze)瀉200余(yu)克，未見任何(he)不適。《本草綱目)渭此物宜(yi)于(yu)濕(shi)熱遺(yi)(yi)精(jing)(jing)，其實用(yong)于(yu)虛證(zheng)(zheng)亦效，第虛證(zheng)(zheng)宜(yi)辨證(zheng)(zheng)選加(jia)熟地(di)、山藥(yao)、枸杞、沙苑之(zhi)類(lei)，則(ze)效驗(yan)更彰。
澤(ze)(ze)瀉(xie)具止(zhi)、通(tong)兩種功能，除固精(jing)止(zhi)遺之(zhi)(zhi)外，還(huan)善治(zhi)前列腺肥大之(zhi)(zhi)排(pai)尿(niao)不(bu)暢以(yi)(yi)(yi)至(zhi)癃閉(bi)。是(shi)以(yi)(yi)(yi)說明六味地(di)黃(huang)丸(wan)，桂(gui)附(fu)(fu)八味丸(wan)用(yong)(yong)澤(ze)(ze)瀉(xie)，并(bing)非僅為利水一端而(er)已(yi)。倘仲景腎(shen)氣(qi)丸(wan)中用(yong)(yong)澤(ze)(ze)瀉(xie)只(zhi)為通(tong)利小便，則后世之(zhi)(zhi)用(yong)(yong)六味、八味多為單純腎(shen)虛(xu)而(er)設(she)，理宜效景岳之(zhi)(zhi)左右歸(gui)，去澤(ze)(ze)瀉(xie)而(er)不(bu)用(yong)(yong)之(zhi)(zhi)，何以(yi)(yi)(yi)直(zhi)至(zhi)今時，六味、八味方中，仍用(yong)(yong)苓(ling)澤(ze)(ze)哉(zai)!錢仲陽將腎(shen)氣(qi)丸(wan)方去桂(gui)附(fu)(fu)而(er)成補陰(yin)(yin)之(zhi)(zhi)祖方，而(er)卻(que)留利水、傷陰(yin)(yin)之(zhi)(zhi)澤(ze)(ze)瀉(xie)，抑何不(bu)思之(zhi)(zhi)甚也(ye)!可見(jian)此(ci)方(六味丸(wan)同)中用(yong)(yong)澤(ze)(ze)瀉(xie)，其(qi)意至(zhi)深，既能降上升之(zhi)(zhi)浮陽，又(you)可攝下流(liu)之(zhi)(zhi)陰(yin)(yin)精(jing)，更能于生殖(zhi)系統(tong)散結(jie)、消炎、決(jue)癃排(pai)尿(niao)，不(bu)可以(yi)(yi)(yi)其(qi)“能瀉(xie)澤(ze)(ze)中之(zhi)(zhi)水”而(er)淺(qian)之(zhi)(zhi)乎視(shi)之(zhi)(zhi)也(ye)。然腎(shen)虛(xu)兼(jian)見(jian)津液損(sun)傷者，則不(bu)用(yong)(yong)苓(ling)澤(ze)(ze)為宜。
(三)
腎(shen)(shen)(shen)為(wei)(wei)先(xian)天之(zhi)(zhi)(zhi)(zhi)(zhi)本，中(zhong)(zhong)含(han)真(zhen)(zhen)(zhen)(zhen)陰(yin)(yin)(yin)(yin)(yin)真(zhen)(zhen)(zhen)(zhen)陽(yang)(yang)，就形質(zhi)而(er)言，陰(yin)(yin)(yin)(yin)(yin)陽(yang)(yang)即水(shui)(shui)(shui)(shui)(shui)火(huo)(huo)(huo)(huo)(huo)也(ye)(ye)。趙獻可(ke)曰(yue)：“君子(zi)(zi)觀(guan)(guan)象(xiang)(xiang)于(yu)(yu)(yu)坎，而(er)知腎(shen)(shen)(shen)中(zhong)(zhong)具(ju)水(shui)(shui)(shui)(shui)(shui)火(huo)(huo)(huo)(huo)(huo)之(zhi)(zhi)(zhi)(zhi)(zhi)道焉。夫一(yi)(yi)(yi)陽(yang)(yang)居于(yu)(yu)(yu)二陰(yin)(yin)(yin)(yin)(yin)為(wei)(wei)坎，此(ci)(ci)人(ren)(ren)生(sheng)與天地相似也(ye)(ye)。”昔賢每以卦(gua)象(xiang)(xiang)易(yi)理(li)以釋岐黃(huang)之(zhi)(zhi)(zhi)(zhi)(zhi)學(xue)，以坎卦(gua)象(xiang)(xiang)于(yu)(yu)(yu)腎(shen)(shen)(shen)，卦(gua)之(zhi)(zhi)(zhi)(zhi)(zhi)上下(xia)各為(wei)(wei)陰(yin)(yin)(yin)(yin)(yin)爻而(er)中(zhong)(zhong)間則為(wei)(wei)陽(yang)(yang)爻，以明腎(shen)(shen)(shen)中(zhong)(zhong)陰(yin)(yin)(yin)(yin)(yin)陽(yang)(yang)水(shui)(shui)(shui)(shui)(shui)火(huo)(huo)(huo)(huo)(huo)，含(han)蓄(xu)交融之(zhi)(zhi)(zhi)(zhi)(zhi)義。而(er)坎中(zhong)(zhong)一(yi)(yi)(yi)點(dian)真(zhen)(zhen)(zhen)(zhen)陽(yang)(yang)，亦稱命門之(zhi)(zhi)(zhi)(zhi)(zhi)火(huo)(huo)(huo)(huo)(huo)，為(wei)(wei)人(ren)(ren)身(shen)生(sheng)命之(zhi)(zhi)(zhi)(zhi)(zhi)根(gen)，景岳于(yu)(yu)(yu)“大寶論(lun)”中(zhong)(zhong)振筆捷書：“天之(zhi)(zhi)(zhi)(zhi)(zhi)大寶惟此(ci)(ci)一(yi)(yi)(yi)丸紅日，人(ren)(ren)之(zhi)(zhi)(zhi)(zhi)(zhi)大寶，只(zhi)此(ci)(ci)一(yi)(yi)(yi)息真(zhen)(zhen)(zhen)(zhen)陽(yang)(yang)。”是以命門之(zhi)(zhi)(zhi)(zhi)(zhi)真(zhen)(zhen)(zhen)(zhen)火(huo)(huo)(huo)(huo)(huo)于(yu)(yu)(yu)人(ren)(ren)身(shen)最為(wei)(wei)重要(yao)也(ye)(ye)。然朱丹(dan)溪倡“陽(yang)(yang)常有余，陰(yin)(yin)(yin)(yin)(yin)常不足”之(zhi)(zhi)(zhi)(zhi)(zhi)論(lun)，奠定滋陰(yin)(yin)(yin)(yin)(yin)學(xue)說之(zhi)(zhi)(zhi)(zhi)(zhi)理(li)論(lun)基(ji)礎。其實，腎(shen)(shen)(shen)中(zhong)(zhong)陰(yin)(yin)(yin)(yin)(yin)陽(yang)(yang)二氣(qi)(qi)(qi)皆不可(ke)偏廢。《素問(wen)》“陰(yin)(yin)(yin)(yin)(yin)陽(yang)(yang)應象(xiang)(xiang)大論(lun)”曰(yue)：“陰(yin)(yin)(yin)(yin)(yin)在(zai)內，陽(yang)(yang)之(zhi)(zhi)(zhi)(zhi)(zhi)守也(ye)(ye)：陽(yang)(yang)在(zai)外(wai)，陰(yin)(yin)(yin)(yin)(yin)之(zhi)(zhi)(zhi)(zhi)(zhi)使也(ye)(ye)。”真(zhen)(zhen)(zhen)(zhen)陰(yin)(yin)(yin)(yin)(yin)為(wei)(wei)真(zhen)(zhen)(zhen)(zhen)陽(yang)(yang)之(zhi)(zhi)(zhi)(zhi)(zhi)物質(zhi)基(ji)礎，無(wu)陰(yin)(yin)(yin)(yin)(yin)則陽(yang)(yang)為(wei)(wei)獨(du)陽(yang)(yang)；而(er)真(zhen)(zhen)(zhen)(zhen)陽(yang)(yang)又為(wei)(wei)真(zhen)(zhen)(zhen)(zhen)陰(yin)(yin)(yin)(yin)(yin)之(zhi)(zhi)(zhi)(zhi)(zhi)發揮運(yun)(yun)用(yong)，無(wu)陽(yang)(yang)則陰(yin)(yin)(yin)(yin)(yin)為(wei)(wei)孤陰(yin)(yin)(yin)(yin)(yin)，“孤陰(yin)(yin)(yin)(yin)(yin)不生(sheng)，獨(du)陽(yang)(yang)不長(chang)，”孤陰(yin)(yin)(yin)(yin)(yin)獨(du)陽(yang)(yang)必致陰(yin)(yin)(yin)(yin)(yin)陽(yang)(yang)離決(jue)。故(gu)陰(yin)(yin)(yin)(yin)(yin)陽(yang)(yang)二氣(qi)(qi)(qi)對于(yu)(yu)(yu)人(ren)(ren)身(shen)，皆至關(guan)重要(yao)，不可(ke)執此(ci)(ci)以廢彼。腎(shen)(shen)(shen)中(zhong)(zhong)真(zhen)(zhen)(zhen)(zhen)陰(yin)(yin)(yin)(yin)(yin)真(zhen)(zhen)(zhen)(zhen)陽(yang)(yang)并不等量齊觀(guan)(guan)，雖有參差，但在(zai)健(jian)(jian)康人(ren)(ren)體(ti)，兩者不斷處(chu)于(yu)(yu)(yu)交融協(xie)調之(zhi)(zhi)(zhi)(zhi)(zhi)動態平衡中(zhong)(zhong)。陽(yang)(yang)火(huo)(huo)(huo)(huo)(huo)剛勁，秉乾健(jian)(jian)之(zhi)(zhi)(zhi)(zhi)(zhi)運(yun)(yun)；陰(yin)(yin)(yin)(yin)(yin)水(shui)(shui)(shui)(shui)(shui)滋柔，具(ju)坤順(shun)之(zhi)(zhi)(zhi)(zhi)(zhi)德。因而(er)，在(zai)正常人(ren)(ren)體(ti)，以水(shui)(shui)(shui)(shui)(shui)多(duo)(duo)火(huo)(huo)(huo)(huo)(huo)少為(wei)(wei)順(shun)。近賢彭子(zi)(zi)益于(yu)(yu)(yu)其遺著《古方推論(lun)》中(zhong)(zhong)曰(yue)：“腎(shen)(shen)(shen)中(zhong)(zhong)水(shui)(shui)(shui)(shui)(shui)火(huo)(huo)(huo)(huo)(huo)二氣(qi)(qi)(qi)，水(shui)(shui)(shui)(shui)(shui)氣(qi)(qi)(qi)多(duo)(duo)于(yu)(yu)(yu)火(huo)(huo)(huo)(huo)(huo)氣(qi)(qi)(qi)為(wei)(wei)順(shun)。緣(yuan)人(ren)(ren)身(shen)中(zhong)(zhong)氣(qi)(qi)(qi)，為(wei)(wei)身(shen)體(ti)整個運(yun)(yun)動之(zhi)(zhi)(zhi)(zhi)(zhi)樞(shu)機(ji)，腎(shen)(shen)(shen)氣(qi)(qi)(qi)為(wei)(wei)中(zhong)(zhong)氣(qi)(qi)(qi)運(yun)(yun)動之(zhi)(zhi)(zhi)(zhi)(zhi)始基(ji)。水(shui)(shui)(shui)(shui)(shui)氣(qi)(qi)(qi)多(duo)(duo)于(yu)(yu)(yu)火(huo)(huo)(huo)(huo)(huo)氣(qi)(qi)(qi)，火(huo)(huo)(huo)(huo)(huo)藏(zang)水(shui)(shui)(shui)(shui)(shui)中(zhong)(zhong)，乃能生(sheng)氣(qi)(qi)(qi)。若(ruo)火(huo)(huo)(huo)(huo)(huo)氣(qi)(qi)(qi)多(duo)(duo)于(yu)(yu)(yu)水(shui)(shui)(shui)(shui)(shui)氣(qi)(qi)(qi)，水(shui)(shui)(shui)(shui)(shui)氣(qi)(qi)(qi)不能包藏(zang)火(huo)(huo)(huo)(huo)(huo)氣(qi)(qi)(qi)，火(huo)(huo)(huo)(huo)(huo)氣(qi)(qi)(qi)遂直沖上越，運(yun)(yun)動遂滅(mie)。”寥寥數語，已將腎(shen)(shen)(shen)中(zhong)(zhong)水(shui)(shui)(shui)(shui)(shui)火(huo)(huo)(huo)(huo)(huo)二氣(qi)(qi)(qi)之(zhi)(zhi)(zhi)(zhi)(zhi)交融平衡關(guan)系(xi)點(dian)破真(zhen)(zhen)(zhen)(zhen)蒂。故(gu)“此(ci)(ci)方附子(zi)(zi)極(ji)少，山藥(yao)地黃(huang)丹(dan)皮茱萸(yu)獨(du)多(duo)(duo)，即是此(ci)(ci)理(li)。然人(ren)(ren)身(shen)陰(yin)(yin)(yin)(yin)(yin)陽(yang)(yang)二氣(qi)(qi)(qi)，陽(yang)(yang)火(huo)(huo)(huo)(huo)(huo)易(yi)盛(sheng)，水(shui)(shui)(shui)(shui)(shui)寒(han)易(yi)散，而(er)真(zhen)(zhen)(zhen)(zhen)陰(yin)(yin)(yin)(yin)(yin)極(ji)難滋填。故(gu)有“水(shui)(shui)(shui)(shui)(shui)多(duo)(duo)生(sheng)寒(han)之(zhi)(zhi)(zhi)(zhi)(zhi)病，用(yong)附子(zi)(zi)以溫水(shui)(shui)(shui)(shui)(shui)寒(han)，一(yi)(yi)(yi)劑便奏全(quan)功。若(ruo)水(shui)(shui)(shui)(shui)(shui)少補水(shui)(shui)(shui)(shui)(shui)，一(yi)(yi)(yi)年(nian)(nian)半年(nian)(nian)尚難補起也(ye)(ye)”之(zhi)(zhi)(zhi)(zhi)(zhi)說。中(zhong)(zhong)醫五行學(xue)說中(zhong)(zhong)，有生(sheng)克(ke)制化規(gui)律，將五臟六腑之(zhi)(zhi)(zhi)(zhi)(zhi)關(guan)系(xi)，統一(yi)(yi)(yi)于(yu)(yu)(yu)一(yi)(yi)(yi)個有機(ji)整體(ti)之(zhi)(zhi)(zhi)(zhi)(zhi)中(zhong)(zhong)，腎(shen)(shen)(shen)臟亦不例外(wai)。按五行理(li)論(lun)，肺(fei)為(wei)(wei)
腎(shen)母(mu)(mu)(mu)，肝為(wei)(wei)(wei)(wei)腎(shen)子(zi)，心為(wei)(wei)(wei)(wei)所勝，脾為(wei)(wei)(wei)(wei)所不(bu)(bu)勝。其中對(dui)(dui)于(yu)腎(shen)臟(zang)生理關系(xi)最(zui)大者，無過肺肝兩臟(zang)，虛(xu)(xu)則(ze)(ze)補(bu)(bu)其母(mu)(mu)(mu)，實則(ze)(ze)瀉其子(zi)，則(ze)(ze)補(bu)(bu)肺可(ke)(ke)以(yi)(yi)益腎(shen)之(zhi)(zhi)(zhi)虛(xu)(xu)，瀉肝可(ke)(ke)以(yi)(yi)泄腎(shen)之(zhi)(zhi)(zhi)實。然肝腎(shen)為(wei)(wei)(wei)(wei)母(mu)(mu)(mu)子(zi)之(zhi)(zhi)(zhi)臟(zang)，肝木(mu)既可(ke)(ke)子(zi)盜母(mu)(mu)(mu)氣以(yi)(yi)虛(xu)(xu)腎(shen)，亦可(ke)(ke)反饋奉養(yang)以(yi)(yi)益之(zhi)(zhi)(zhi)。故治腎(shen)虛(xu)(xu)之(zhi)(zhi)(zhi)證(zheng)，須兼(jian)顧肺肝，始為(wei)(wei)(wei)(wei)周全。彭子(zi)益先生對(dui)(dui)此研究甚深：“腎(shen)氣丸補(bu)(bu)金潤木(mu)滋腎(shen)水，又(you)用附子(zi)溫(wen)腎(shen)陽(yang)。凡(fan)陰液不(bu)(bu)足(zu)，腎(shen)陽(yang)又(you)虛(xu)(xu)之(zhi)(zhi)(zhi)病，總以(yi)(yi)此方為(wei)(wei)(wei)(wei)大法(fa)”。
不(bu)(bu)僅(jin)腎(shen)(shen)(shen)(shen)氣(qi)(qi)(qi)(qi)丸具(ju)有(you)(you)金(jin)水(shui)(shui)相生(sheng)(sheng)(sheng)、肝(gan)腎(shen)(shen)(shen)(shen)同(tong)源(yuan)關系(xi)，即六(liu)味地黃(huang)丸理亦(yi)一(yi)致，錢仲(zhong)陽將腎(shen)(shen)(shen)(shen)氣(qi)(qi)(qi)(qi)丸方去桂附(fu)，名六(liu)味地黃(huang)丸，專治(zhi)(zhi)(zhi)腎(shen)(shen)(shen)(shen)水(shui)(shui)不(bu)(bu)足，極(ji)有(you)(you)功效(xiao)。彭子益曰：“而(er)不(bu)(bu)知全是補(bu)金(jin)潤(run)木之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)功。補(bu)金(jin)以(yi)培生(sheng)(sheng)(sheng)水(shui)(shui)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)源(yuan)，潤(run)木以(yi)杜耗水(shui)(shui)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)路。腎(shen)(shen)(shen)(shen)水(shui)(shui)有(you)(you)生(sheng)(sheng)(sheng)而(er)無(wu)(wu)耗，故(gu)腎(shen)(shen)(shen)(shen)水(shui)(shui)足也(ye)。再于(yu)水(shui)(shui)中(zhong)補(bu)火(huo)，水(shui)(shui)中(zhong)有(you)(you)火(huo)則(ze)生(sheng)(sheng)(sheng)氣(qi)(qi)(qi)(qi)，此(ci)腎(shen)(shen)(shen)(shen)氣(qi)(qi)(qi)(qi)二(er)(er)字之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)起(qi)源(yuan)也(ye)。腎(shen)(shen)(shen)(shen)氣(qi)(qi)(qi)(qi)者，元氣(qi)(qi)(qi)(qi)也(ye)，中(zhong)氣(qi)(qi)(qi)(qi)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)根(gen)也(ye)。”可見腎(shen)(shen)(shen)(shen)中(zhong)真(zhen)陰真(zhen)陽，與其他諸臟(zang)(zang)，尤其肺(fei)肝(gan)二(er)(er)臟(zang)(zang)，有(you)(you)其生(sheng)(sheng)(sheng)克(ke)制化關系(xi)，故(gu)一(yi)旦發生(sheng)(sheng)(sheng)疾病(bing)，必(bi)須考(kao)慮(lv)并(bing)利(li)用五臟(zang)(zang)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)相互(hu)關系(xi)以(yi)為治(zhi)(zhi)(zhi)，始更(geng)切(qie)合實際。本(ben)文(wen)中(zhong)引彭氏(shi)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)論較繁，并(bing)非故(gu)意引襲，彭氏(shi)“人(ren)身中(zhong)氣(qi)(qi)(qi)(qi)為人(ren)體整(zheng)個運動(dong)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)樞機”及“腎(shen)(shen)(shen)(shen)氣(qi)(qi)(qi)(qi)為中(zhong)氣(qi)(qi)(qi)(qi)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)根(gen)”二(er)(er)語，精辟揭(jie)示人(ren)體先天后天之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)關系(xi)及其在(zai)生(sheng)(sheng)(sheng)命活動(dong)中(zhong)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)重要作用，同(tong)時深刻揭(jie)示虛勞病(bing)證之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)治(zhi)(zhi)(zhi)療首重脾腎(shen)(shen)(shen)(shen)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)理論根(gen)據，對于(yu)先賢(xian)“補(bu)脾不(bu)(bu)如補(bu)腎(shen)(shen)(shen)(shen)”、“補(bu)腎(shen)(shen)(shen)(shen)不(bu)(bu)如補(bu)脾”之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)爭，細繹此(ci)文(wen)必(bi)有(you)(you)心得。進一(yi)步考(kao)慮(lv)五臟(zang)(zang)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)間之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)平(ping)衡協調，則(ze)理無(wu)(wu)余(yu)蘊而(er)治(zhi)(zhi)(zhi)無(wu)(wu)不(bu)(bu)中(zhong)矣。
明(ming)代綺(qi)石先生(sheng)亦早已認識并倡導運用五臟關(guan)系以(yi)(yi)(yi)治病(bing)(bing)。其(qi)(qi)治虛(xu)(xu)(xu)(xu)勞一癥(zheng)，從陰(yin)(yin)(yin)虛(xu)(xu)(xu)(xu)陽(yang)虛(xu)(xu)(xu)(xu)兩(liang)者入手，但(dan)不(bu)(bu)直接補(bu)(bu)益腎(shen)臟。而(er)是(shi)陰(yin)(yin)(yin)虛(xu)(xu)(xu)(xu)之(zhi)證(zheng)養其(qi)(qi)肺陰(yin)(yin)(yin)，陽(yang)虛(xu)(xu)(xu)(xu)之(zhi)證(zheng)益其(qi)(qi)脾(pi)氣。腎(shen)陰(yin)(yin)(yin)不(bu)(bu)足，養肺陰(yin)(yin)(yin)以(yi)(yi)(yi)滋化源(yuan)，此(ci)虛(xu)(xu)(xu)(xu)則補(bu)(bu)母之(zhi)法。而(er)補(bu)(bu)脾(pi)以(yi)(yi)(yi)治真(zhen)陽(yang)之(zhi)虛(xu)(xu)(xu)(xu)，有(you)火土相生(sheng)之(zhi)妙。理雖如此(ci)，而(er)病(bing)(bing)已涉及(ji)先天，不(bu)(bu)治其(qi)(qi)腎(shen)終非其(qi)(qi)治。綺(qi)石于(yu)(yu)《理虛(xu)(xu)(xu)(xu)元鑒》中(zhong)將陽(yang)虛(xu)(xu)(xu)(xu)成勞歸納為(wei)三(san)種(zhong)類型：“日(ri)奪精，日(ri)奪氣，日(ri)奪火。”而(er)最(zui)后以(yi)(yi)(yi)“急救中(zhong)氣為(wei)先，將‘陽(yang)虛(xu)(xu)(xu)(xu)三(san)奪統(tong)于(yu)(yu)脾(pi)’。”須知(zhi)虛(xu)(xu)(xu)(xu)勞之(zhi)病(bing)(bing)癥(zheng)及(ji)肝腎(shen)者，常兼真(zhen)火衰(shuai)微，純補(bu)(bu)中(zhong)氣恒見(jian)病(bing)(bing)情好轉(zhuan)而(er)難徹效，觀彭氏(shi)之(zhi)論其(qi)(qi)義自(zi)明(ming)。至于(yu)(yu)桂(gui)附之(zhi)雄(xiong)烈，不(bu)(bu)宜于(yu)(yu)久(jiu)虛(xu)(xu)(xu)(xu)之(zhi)體，自(zi)可(ke)改用柔潤之(zhi)品，正不(bu)(bu)必執定桂(gui)附也。
真陰(yin)(yin)損傷之人，用六(liu)味丸(wan)滋陰(yin)(yin)，亦(yi)宜(yi)參(can)(can)酌肺(fei)肝。蓋六(liu)味地(di)黃丸(wan)為(wei)陰(yin)(yin)凝之物，易礙胃氣，而肝木具疏泄之能，可(ke)以疏達土氣。故彭氏倡(chang)言：“六(liu)味地(di)黃丸(wan)補(bu)(bu)水(shui)(shui)，不(bu)如(ru)歸(gui)芍地(di)黃丸(wan)補(bu)(bu)水(shui)(shui)功(gong)大而活動”，因(yin)“歸(gui)芍活動木氣，不(bu)用活動木氣之藥(yao)，必凝胃矣。”同樣“肺(fei)為(wei)陰(yin)(yin)根，肺(fei)陰(yin)(yin)足(zu)則全身津液自足(zu)。”而肺(fei)為(wei)腎母，有(you)金水(shui)(shui)相生之妙，陰(yin)(yin)虧及津者，更(geng)(geng)宜(yi)于六(liu)味丸(wan)中加(jia)西洋(yang)(yang)參(can)(can)、麥門冬，謂(wei)之參(can)(can)麥地(di)黃丸(wan)，亦(yi)有(you)稱為(wei)八仙長壽丸(wan)者。現(xian)代成藥(yao)則以北沙參(can)(can)易洋(yang)(yang)參(can)(can)，則更(geng)(geng)易推廣使用。
(四)
王(wang)汝(ru)霖曰(yue)：“腎(shen)為(wei)(wei)人生(sheng)(sheng)之最(zui)重(zhong)者也，腎(shen)中藏一(yi)(yi)水(shui)一(yi)(yi)火，左腎(shen)屬水(shui)，水(shui)生(sheng)(sheng)木(mu)(mu)，木(mu)(mu)行春令，為(wei)(wei)萬(wan)物發生(sheng)(sheng)之源。右腎(shen)屬火，火生(sheng)(sheng)土，土為(wei)(wei)萬(wan)物之母。故腎(shen)為(wei)(wei)五臟六腑之總(zong)樞紐，最(zui)為(wei)(wei)重(zhong)要，不(bu)(bu)可不(bu)(bu)補，以遂其生(sheng)(sheng)生(sheng)(sheng)不(bu)(bu)息之機也。且(qie)腎(shen)為(wei)(wei)坎水(shui)，不(bu)(bu)易滿而易招損(sun)，故腎(shen)一(yi)(yi)虛，而百病叢生(sheng)(sheng)。”
然(ran)則腎虛而(er)宜用桂附(fu)八味(wei)丸之(zhi)(zhi)指(zhi)征若何?王(wang)氏之(zhi)(zhi)經驗為(wei)(wei)(wei)：“凡(fan)脈(mo)見(jian)浮濡、浮虛、浮大、浮散(san)，或(huo)微細短弱(ruo)，或(huo)數大無根，左虛于右，或(huo)尺脈(mo)無根者，每用桂附(fu)八味(wei)丸治之(zhi)(zhi)，無不(bu)效驗如神。”《筆花醫鏡》則詳列本方之(zhi)(zhi)適應(ying)證(zheng)候：“腎之(zhi)(zhi)虛，脈(mo)左右常(chang)細軟。其癥為(wei)(wei)(wei)頭痛、為(wei)(wei)(wei)耳鳴(ming)、為(wei)(wei)(wei)耳聾(long)、為(wei)(wei)(wei)盜汗(han)、為(wei)(wei)(wei)夜熱(re)、為(wei)(wei)(wei)健忘、為(wei)(wei)(wei)咳嗽(sou)、為(wei)(wei)(wei)喘(chuan)、為(wei)(wei)(wei)吐(tu)血(xue)、為(wei)(wei)(wei)腰(yao)痛、為(wei)(wei)(wei)腿酸足(zu)軟、為(wei)(wei)(wei)目視無光(guang)、為(wei)(wei)(wei)大便結、為(wei)(wei)(wei)小便不(bu)禁(jin)、為(wei)(wei)(wei)戴陽(yang)、為(wei)(wei)(wei)久痢(li)久瘧。”
彭子(zi)益則曰：“人年四十(shi)(shi)以后，善保腎家(jia)，左脈充足，皆(jie)能有八十(shi)(shi)以上之壽。因水(shui)足乃能有藏(zang)火(huo)之處。水(shui)虧(kui)不能藏(zang)火(huo)，中氣(qi)失根，則陽氣(qi)飛越，中氣(qi)消散(san)，無藥可回也。”
(五)
臨證(zheng)所見，有腎陽(yang)(yang)(yang)虛而(er)(er)不(bu)(bu)宜用桂附(fu)(fu)(fu)剛藥者，尤(you)其附(fu)(fu)(fu)子(zi)(zi)(zi)，走而(er)(er)不(bu)(bu)守，通行十二經，辛烈異常。故《理虛元鑒》論“陽(yang)(yang)(yang)虛三奪(duo)”謂“回衰甚之火(huo)者，有相激之危。”關于此(ci)點，彭子(zi)(zi)(zi)益經驗(yan)豐富，議論極精(jing)：“附(fu)(fu)(fu)子(zi)(zi)(zi)純陽(yang)(yang)(yang)，其性(xing)上升。如(ru)水(shui)寒(han)不(bu)(bu)大(da)而(er)(er)多(duo)用附(fu)(fu)(fu)子(zi)(zi)(zi)或水(shui)不(bu)(bu)寒(han)而(er)(er)誤用附(fu)(fu)(fu)子(zi)(zi)(zi)，附(fu)(fu)(fu)子(zi)(zi)(zi)下咽，能(neng)將(jiang)腎中陽(yang)(yang)(yang)根拔動而(er)(er)起，使水(shui)氣(qi)從此(ci)不(bu)(bu)能(neng)包(bao)藏火(huo)氣(qi)，為禍不(bu)(bu)小。”如(ru)遇此(ci)等情況如(ru)何處治，同：“除(chu)純寒(han)之證(zheng)不(bu)(bu)能(neng)不(bu)(bu)用附(fu)(fu)(fu)子(zi)(zi)(zi)外，其內傷腎陽(yang)(yang)(yang)不(bu)(bu)足，腎并不(bu)(bu)寒(han)之證(zheng)，莫如(ru)用甜蓯蓉、巴戟天．柔潤和平益腎之品，以代附(fu)(fu)(fu)子(zi)(zi)(zi)，最為妥當(dang)。豬腰(yao)子(zi)(zi)(zi)不(bu)(bu)去(qu)膜，用生(sheng)黃土拌濕包(bao)固，柴火(huo)燒熟放冷，胃(wei)強者嚼食(shi)腰(yao)子(zi)(zi)(zi)，胃(wei)弱者將(jiang)腰(yao)子(zi)(zi)(zi)煮(zhu)湯食(shi)。”“此(ci)方溫(wen)補腎陽(yang)(yang)(yang)，和平力大(da)，凡先天不(bu)(bu)足，與(yu)腎家陽(yang)(yang)(yang)虛之人，皆可奉為再造之寶。”然豬腰(yao)子(zi)(zi)(zi)雖(sui)為和平服食(shi)之物(wu)，而(er)(er)終(zhong)帶(dai)溫(wen)熱之性(xing)，食(shi)多(duo)熱動者，可配養陰(yin)之品。
如患者陽(yang)虛而難受桂(gui)附(fu)八味丸者，彭氏尚(shang)有單服甜蓯蓉法：“剪碎吞(tun)服一錢，水(shui)火雙補(bu)，可(ke)代腎氣(qi)丸。”
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