渴而多饮，为上消。消谷善饥，为中消。渴而便数有膏，为下消。
〔垣〕上消者，舌上赤裂，大渴引饮。逆调论云∶心移热于肺，传为膈消是也。以白虎加人参
汤主之。（洁古曰∶上消者，上焦受病，又谓之膈消。多饮水而少食，大便如常，小便清利，
知其燥在上焦。治宜流湿，以润其燥。中消者，善食而瘦，自汗，大
便硬，小便频数。叔和云∶口干，饮水多，食亦饥，虚瘅成为消中者是也。以调胃承气汤及
三黄丸主之。（洁古云∶中消者，胃也。渴而饮食多，小便赤黄，热能消谷，知其热在中焦也，
宜下之。）下消者，烦躁引饮，耳叶焦干，小便如膏。叔和云∶焦烦水易亏，此肾消也，以六味
地黄丸主之。（洁古云∶肾消者，病在下焦。初发为膏淋，谓淋下如膏油之状。至病成面色黧黑，
形瘦而耳焦，小便浊而有脂液，治宜养血，以分其清浊而自愈矣。）
上上消者，经谓之膈消。膈消者，渴而多饮是也。中消者，经谓之消中。消中者，渴而饮
食俱多，或不渴而独饮是也。下消者，经谓之肾消。肾消者饮一溲二，其溲如膏油，即膈消、
消中之传变。王注谓肺脏消燥，气无所持是也。盖肺藏气，肺无病则气能管摄津液，而津液之清微
者，收养筋骨血脉，余者为溲。肺病则津液无气管摄，而精微者亦随溲下，故饮一溲二，而溲如
膏油也。筋骨血脉无津液以养之，故其病成，渐形瘦焦干也。然肺病本于肾虚，肾虚则心寡于畏，
妄行凌肺，而移寒与之，然后肺病消。故仲景治渴而小便反多，用肾气丸补肾救肺，后人因名之
肾消及下消也。或曰∶《经》既云肺消死不治，仲景复用肾气丸治之何也？曰∶饮一溲二者，
死不治。若饮一未至溲二者，病尚浅犹或可治。故仲景肾气丸治饮水一斗小便亦一斗之症，若小
便过于所饮者，亦无及矣。
病式服药
熬猪肚汤 小承气汤 益火之源以消阴翳，则便溺有节。
羊肉冬瓜汤 肾气丸地黄丸
消渴手太阴（大渴不止。）消中足阳明（瘅成消中而数小便，胃热消谷善饥。）肾消足少阴（膏瘅，
饮少溲多。）
麦冬饮子 内化丸 凤髓丹
化水丹 易老顺气散 壮水之主以制阳光，则渴饮不思。
〔垣〕论消渴末传能食者，必发脑疽背疮；不能食者，必传中满鼓胀。《圣济总录》皆为必死
不治之症。洁古分而治之∶能食而渴者，白虎加人参汤主之；不能食而渴者，钱氏白术散倍加
葛根主之，上中既平，不复
传下消矣。前人用药，厥有旨哉。或曰∶未传疮疽者，何也？此火邪胜也。其疮痛甚，而不溃，
或赤水者是也。经曰∶有形而不痛者，阳之类也。急攻其阳，无攻其阴，治在下焦。元气得强者生；
失强者死。末传中满者，何也？以寒治热，虽方士不能废绳墨而更其道也。然脏腑有远近，心、
肺位近，宜制小其服；肾、肝位远，宜制大其服。皆适其所至所为。故知过与不及，皆诛罚无过
之地也。如膈消、中消，制之太急，速过病所，久而成中满之疾。正谓上热未除，中寒复生者，
非药之罪，失其缓急之宜也。处方之际，宜加审焉。
〔《本》〕《总录》论消渴有三种∶一者，渴而饮水多，小便数有脂似麸片而甜者，消渴病也。
二者，吃食多，不甚渴，小便少有似油而数者，消中病也。三者，虽渴饮水不能多，腿脚瘦小痿
弱，小便数，此肾消病也。特忌房劳。《千金》云∶消渴病宜慎者有三∶一饮酒；二房劳；三咸食
及面。能慎此三者，虽不服药亦自可愈。消渴之人，愈与未愈，尝须虑患大痈，必于骨节间忽
发痈疽而卒。
〔《素》〕帝曰∶夫子数言热中、消中，不可服膏粱、芳草、石药，石药发 ，芳草发狂。
夫热中、消中，皆富贵人也。今禁膏粱，是不合其心，禁芳草石药，是病不愈，愿闻其详。岐伯曰∶芳
草之气美，石药之气悍，二者其气急疾坚劲，故非缓心和人不可以服此二者。帝曰∶不可以服此二
者，何以然？岐伯曰∶热气 悍，药气亦然，二者相遇，恐内伤脾。脾者土也，而恶木。服此
药者，至甲乙日更论。（腹中论 王注云∶多饮、数溲，谓之热中；多食、数溲，谓之消中。
芳草即白芷，石药即钟乳之类。）
〔垣〕滑石治渴，本为窍不利而用之。以燥能亡津液也，天令湿气太过者当用之，若无湿用之
是犯禁也。
〔《灵》〕黄帝曰∶人之善病消瘅者，何以候之？少俞答曰∶五脏皆柔弱者，善病消瘅。黄帝
曰∶何以知五脏之柔弱也？少俞曰∶夫柔弱者必有刚强，刚强多怒，柔者易伤也。黄帝曰∶何
以候柔弱之与刚强？曰∶此人薄皮肤，而目坚固以深者，长冲直扬，其心刚，刚则多怒，怒则气
上逆，胸中蓄积，气血逆留， 皮充肌，血脉不行，转而为热，热则消肌肤，故为消瘅。此言
其人暴刚而肌肉弱者也。（五变篇） KT 弱小以薄者，心脆，心脆则善病消瘅热中。肩背薄者肺脆，
肺脆则善病消瘅易伤。胁骨弱者肝脆，肝脆则善病消瘅易伤。唇大而不坚
者脉脆，脉脆则善病消瘅易伤。耳薄不坚者肾脆，肾脆则善病消瘅易伤。（全文见诊法。）心脉
微小为消瘅，滑甚为善渴。肺脉微小为消瘅。肝脉微小为消瘅；小甚为多饮。脾脉微小为消瘅。
肾脉微小为消瘅。诸脉小者，阴阳俱不足也。勿取以针，而调以甘药。（全文见治虚实法。）凡
治消瘅，肥贵人则膏粱之疾。
〔《素》〕心脉 而散者，当消环自已。（脉要精微论）帝曰∶消瘅何如？岐伯曰∶脉实大，
病久可治；脉悬小坚，病久不可治。（虚实论）
〔《难》〕病若开目而渴，心下牢者，脉当得紧实而数，反得沉涩而微者死也。（十七难）
〔《脉》〕消渴，脉数大者生；细小浮短者死。
Thirst accompanied by excessive drinking is termed Upper Xiao (Upper Wasting-Thirst). Excessive appetite with easy hunger is termed Middle Xiao (Middle Wasting-Thirst). Thirst accompanied by frequent urination and urine containing a pasty substance is termed Lower Xiao (Lower Wasting-Thirst).
[Li Dongyuan] The symptoms of Upper Xiao include a red and cracked tongue surface, and extreme thirst with a desire for copious drinking. *Ni Diao Lun* states: "Heart heat transfers to the Lung, transforming into Ge Xiao (Diaphragm Wasting-Thirst)," which refers to this condition. It is primarily treated with Baihu Jia Renshen Tang (White Tiger Decoction plus Ginseng). [Zhang Jiegu says: Upper Xiao is a disease of the Upper Jiao, also called Ge Xiao. It manifests as desiring more water but eating less, with normal stools and clear, free urination, indicating dryness-heat in the Upper Jiao. Treatment should promote the flow of dampness to moisten dryness. Middle Xiao manifests as eating much yet becoming thin, spontaneous sweating, hard stools, and frequent urination. Wang Shuhe says: "Dry mouth, drinking much, eating easily causing hunger, forming Xiao Zhong due to deficiency heat," refers to this condition. It is primarily treated with Tiaowei Chengqi Tang (Regulate the Stomach Purging Decoction) and Sanhuang Wan (Three-Yellow Pill). [Zhang Jiegu says: Middle Xiao involves the Stomach. It manifests as thirst with large food intake, dark yellow urine, and heat digesting food, indicating heat in the Middle Jiao; purgation is appropriate.] Lower Xiao manifests as irritability with a desire to drink, dry and scorched earlobes, and urine resembling paste. Wang Shuhe says: "Irritability and thirst, fluids easily depleted, this is Shen Xiao (Kidney Wasting-Thirst)," treated primarily with Liuwei Dihuang Wan (Six-Ingredient Pill with Rehmannia). [Zhang Jiegu says: Shen Xiao is located in the Lower Jiao. Initially it presents as Gao Lin (Pasty Strangury), where urine resembles oil paste. When the disease becomes established, the complexion is dark, the body is thin with scorched ears, and urine is turbid with lipid fluid; treatment should nourish blood to separate clear from turbid, leading to self-healing.]
The so-called "Shang Shang Xiao" is called Ge Xiao in the classics. Ge Xiao manifests as thirst and excessive drinking. The so-called "Zhong Xiao" is called Xiao Zhong in the classics. Xiao Zhong manifests as both thirst and excessive food/water intake, or no thirst but only a desire to drink water. The so-called "Xia Xiao" is called Shen Xiao in the classics. Shen Xiao manifests as drinking one part and urinating two parts, with urine resembling oil paste; this is actually a transmission/progression of Ge Xiao and Xiao Zhong. Wang Bing's commentary states this is due to the Lung organ consuming dryness, leaving Qi unsupported. Generally, the Lung stores Qi; when the Lung is healthy, Qi can control and hold fluids, where the clear and subtle parts of fluids nourish sinews, bones, vessels, and blood, while the remainder becomes urine. When the Lung is diseased, fluids lose Qi's control, and essence/substance follows urine downward, hence drinking one part results in urinating two parts, with urine resembling oil paste. Sinews, bones, vessels, and blood lack fluid nourishment, so as the disease progresses, the body gradually becomes thin and dry. However, the root of Lung disease lies in Kidney deficiency; Kidney deficiency means the Heart lacks restraint, allowing Heart Fire to act recklessly and oppress the Lung, transferring cold to it, thereby causing Lung disease and wasting-thirst. Thus, Zhang Zhongjing treats thirst with abnormally increased urination using Shenqi Wan (Kidney Qi Pill) to tonify the Kidney and rescue the Lung; later generations named this Shen Xiao and Lower Xiao. One might ask: Since the Classics state Lung Xiao is incurable death, why does Zhang Zhongjing use Shenqi Wan to treat it? The answer is: Drinking one part and urinating two parts is an incurable death case. If drinking one part has not yet reached urinating two parts, the disease is still shallow and perhaps treatable. Therefore, Zhang Zhongjing's Shenqi Wan treats the symptom of "drinking one dou, urinating one dou"; if urine volume exceeds intake, it is beyond help.
Disease progression and medication methods:
Boiled Pig Stomach Soup; Xiaochengqi Tang (Minor Order the Yangming Decoction). By supplementing the source of Fire to eliminate Yin shadows, urination and defecation will have regulation.
Mutton and Winter Melon Soup; Shenqi Wan (Kidney Qi Pill); Dihuang Wan (Rehmannia Pill).
For Xiao Ke (Wasting-Thirst), select Hand Taiyin [Lung Meridian] points (for unceasing great thirst); For Xiao Zhong, select Foot Yangming [Stomach Meridian] points (for Dan Re forming Xiao Zhong with frequent urination, Stomach heat digesting food causing easy hunger); For Shen Xiao, select Foot Shaoyin [Kidney Meridian] points (for Gao Dan, drinking little urinating much).
Maidong Yinzi (Ophiopogon Drink); Neihua Wan (Internal Transformation Pill); Fengsui Dan (Phoenix Marrow Pill).
Huashui Dan (Transform Water Pill); Yilao Shunqi San (Master Yi's Qi-Promoting Powder). By nourishing the master of Water to restrain Sunlight (deficient fire), the desire for thirsty drinking disappears.
[Li Dongyuan] Discussing the terminal stage of Xiao Ke: those who can eat will inevitably develop Brain Abscess or Back Carbuncle; those who cannot eat will inevitably transmit to Fullness and Drum Distension. *Shengji Zonglu* lists these as invariably fatal and incurable conditions. Zhang Jiegu treats them separately: those who can eat and are thirsty are primarily treated with Baihu Jia Renshen Tang; those who cannot eat and are thirsty are primarily treated with Qianyi's Baizhu San (Atractylodes Macrocephala Powder) with added Ge Gen (Kudzu Root); once Upper and Middle Jiao are pacified, transmission to Lower Xiao ceases. The medication of predecessors indeed has profound meaning. One might ask: Why did it not transmit to carbuncles? This is because Fire pathogen prevails. The carbuncle is very painful, does not suppurate, or discharges red water. The Classics say: "Having form but no pain belongs to the Yang category." Urgently attack the Yang, do not attack the Yin; the disease location is in the Lower Jiao. Life if Yuan Qi becomes strong; death if Yuan Qi loses strength. What is the reason for terminal transmission to Fullness? Using cold to treat heat, even masters cannot abandon rules and change their method. However, Zang-Fu organs have near and far positions; Heart and Lung are near, so dosage should be small; Kidney and Liver are far, so dosage should be large. All must suit the place reached and action performed. Thus, knowing excess and insufficiency punishes places without fault. For Ge Xiao and Xiao Zhong, if prescription is too urgent, medicine passes the disease site quickly, and over time becomes Fullness disease. This is precisely when Upper Heat is not removed, Middle Cold arises again; this is not the drug's fault, but losing the appropriateness of slowness and urgency. At the time of prescribing, one must examine carefully.
[*Bencao*] *Shengji Zonglu* discusses three types of Xiao Ke: First, thirst with much drinking, frequent urination with lipid-like bran flakes that are sweet, this is Xiao Ke disease. Second, eating much, not very thirsty, little urine resembling oil and frequent, this is Xiao Zhong disease. Third, though thirsty, cannot drink much, legs and feet are thin, small, weak and flaccid, frequent urination, this is Shen Xiao disease. Specifically avoid sexual exertion. *Qianjin Fang* says: Three things Xiao Ke patients must be cautious about: 1. Alcohol; 2. Sexual exertion; 3. Salty foods and noodles. If cautious of these three, even without medication, one can heal naturally. Xiao Ke patients, whether healed or not, must always worry about major abscesses; they will suddenly develop carbuncles between bone joints and die suddenly.
[*Suwen*] Emperor Huangdi said: Master often mentions Re Zhong (Heat Middle) and Xiao Zhong, stating one cannot consume Gao Liang (rich/fatty foods), Fang Cao (fragrant herbs), or Shi Yao (mineral drugs); Shi Yao causes macules, Fang Cao causes madness. Re Zhong and Xiao Zhong are diseases of the wealthy. Now prohibiting Gao Liang goes against their desires; prohibiting Fang Cao and Shi Yao means the disease won't heal. I wish to hear the details. Qibo said: Fang Cao has beautiful aroma, Shi Yao has fierce qi; both have rapid, firm, and strong qi, so people with slow and gentle hearts cannot take these two. Emperor Huangdi said: Why cannot one take these two? Qibo said: Heat qi is fierce, drug qi is likewise; meeting together, they fear internal injury to the Spleen. Spleen is Earth, and dislikes Wood. Those taking these drugs, discuss again on Jia/Yi days. (*Fuzhong Lun* Wang Bing note: Much drinking, frequent urination is called Re Zhong; much eating, frequent urination is called Xiao Zhong. Fang Cao is Bai Zhi (Angelica Dahurica), Shi Yao is Zhong Ru (Antler Glue/Calcite etc.).)
[Li Dongyuan] Hua Shi (Talcum) treats thirst originally because of obstructed orifices. Because dryness destroys body fluids, it should be used when heavenly humidity is excessive; using it without dampness violates prohibitions.
[*Lingshu*] Yellow Emperor said: How to observe those prone to Xiao Dan (Wasting-Thirst)? Shao Yu answered: Those with weak Five Zang are prone to Xiao Dan. Yellow Emperor said: How to know Five Zang weakness? Shao Yu said: Weakness must have rigidity; rigid ones are often angry, weak ones are easily injured. Yellow Emperor said: How to observe weakness vs rigidity? Answer: This person has thin skin, firm and deep-set eyes, long straight eyebrows, heart is rigid, rigid means often angry, anger causes Qi counterflow, accumulation in chest, Qi and Blood逆流 stagnation, skin fills muscles, vessels do not flow, turning into heat, heat consumes flesh/skin, thus becoming Xiao Dan. This describes someone violent-rigid but weak muscle. (*Wu Bian Pian*) Weak and thin constitution, Heart fragile, Heart fragile prone to Xiao Dan/Re Zhong. Thin shoulder/back, Lung fragile, Lung fragile prone to Xiao Dan/easily injured. Weak costal bones, Liver fragile, Liver fragile prone to Xiao Dan/easily injured. Large but not firm lips, Vessel fragile, Vessel fragile prone to Xiao Dan/easily injured. Thin and not firm ears, Kidney fragile, Kidney fragile prone to Xiao Dan/easily injured. (Full text in Diagnostic Methods.) Heart pulse minute/small is Xiao Dan, slippery excessive is prone to thirst. Lung pulse minute/small is Xiao Dan. Liver pulse minute/small is Xiao Dan; excessively small is polydipsia. Spleen pulse minute/small is Xiao Dan. Kidney pulse minute/small is Xiao Dan. All pulses small indicate Yin and Yang both insufficient. Do not use needles, regulate with sweet medicines. (Full text in Treating Deficiency/Excess methods.) Generally treating Xiao Dan, fat/noble people suffer from Gao Liang diseases.
[*Suwen*] Heart pulse soft and scattered, Xiao Huan will heal itself. (*Mai Yao Jing Wei Lun*) Emperor Huangdi said: How is Xiao Dan? Qibo said: Pulse solid and large, disease long-term is treatable; pulse hanging small and firm, disease long-term is untreatable. (*Xu Shi Lun*)
[*Nanjing*] Disease where opening eyes brings thirst, hardness below heart, pulse should be tight, solid, and rapid; if instead sinking, choppy, and faint, indicates death. (*Seventeenth Difficulty*)
[*Maijing*] Xiao Ke, pulse rapid and large indicates life; fine, small, floating, short indicates death.