三消之病，自古大抵主肾虚为论，往往于肾虚证中，更立名称，盖以其自下消波及者居多也。但上消、中消
之治，则河间、东垣庶得经旨，而上消一证颇为罕有已。今采集诸家方说，不能判然区析，姑并合为条，以俟学
者审别焉。
病由肾虚 消HT 。HT ，渴也。肾气不周于胸胃中，津润消渴，故欲得水也。（《释名》）
凡人生放恣者众，盛壮之时，不自慎惜，快情纵欲，极意房中，稍至年长，肾气虚竭，百病滋生，又年少惧
不能房，多服石散，真气既尽，石气孤立，惟有虚耗，唇口干焦，精液自泄，或小便赤黄，大便干实，或渴而且
利，日夜一石，或渴而不利，或不渴而利，所食之物皆作小便，此皆由房室不节之所致也。（《千金》）（按∶巢
氏论消渴分为消渴、渴病、渴利、内消，其渴病以为脏腑由虚实而生热，津液竭少故渴，而不审何证，其他则谓
为少服五石，热结于肾所致。然服石今世所无，仍仅拈其证于后款，余不具载。）
《近效》祠部李郎中论曰∶消渴者，原其发动，此则肾虚所致，每发即小便至甜。医者多不知其疾，所以古
方论亦阙而不言，今略陈其要。按《洪范》稼穑作甘，以物理推之，淋饧醋酒作脯法，须臾即皆能甜也，足明人
食之后，滋味皆甜。流在膀胱，若腰肾气盛，则上蒸精气，气则下入骨髓，其次以为脂膏，其次为血肉也，其余别
为小便。故小便色黄，血之余也，臊气者，五脏之气；咸润者，则下味也。（按∶此五句，《圣惠》作上余为涕泪，
经循五脏百脉，下余为小便，黄者血之余也，臊者五脏之气，咸者润下之味也。）腰肾既虚冷，则不能蒸于上，谷
气则尽下为小便者
也。故甘味不变，其色清冷，则肌肤枯槁也。犹如乳母，谷气上泄，皆为乳汁。消渴疾者，下泄为小便，此皆精
气不实于内，则使羸瘦也。又肺为五脏之华盖，若下有暖气，蒸即肺润。若下冷极，即阳气不能升，故肺
干则热。故周易有否卦，干上坤下，阳阻阴而不降，阴无阳而不升，上下不交，故成痞也。譬如釜中有水，以火暖
之，其釜若以板盖之，则暖气上腾，故板能润也。若无火力，水气则不上，此板终不可得润也。火力者，则为腰
肾强盛也，常须暖将息。其水气即为食气，食气若得暖气，即润上而易消下，亦免干渴也。是故张仲景云∶宜服此
八味肾气丸，并不食冷物及饮冷水，今亦不复渴。比频得效，故录正方于后耳。（《外台》）
消渴之疾，皆起于肾，盛壮之时，不自保养，快情纵欲，饮酒无度，喜食脯炙 醢，或服丹石，遂使肾水枯
竭，心火燔炽，三焦猛烈，五脏干燥，由是渴利生焉。（《济生》）
天一生水，肾实主之。膀胱为津液之腑，所以宣行肾水，上润于肺。故识者以肺为津液之脏，自上而下，三焦脏
腑，皆囿乎天一真水之中，《素问》以水之本在肾、末在肺者此也。真水不竭，安有所谓渴哉。人惟淫欲恣情，
酒面无节，酷嗜炙 糟藏、咸酸酢醢、甘肥腥 之属，复以丹砂五石济其私，于是炎火上熏，腑脏生热，燥气炽
盛，津液干焦，渴引水浆而不能自禁矣。（《直指》）
盖肾之所主者水也，真水不竭，自足以滋养乎脾而上交于心，何至有干枯消渴之病乎。惟肾水一虚，则无以制
余火，火旺不能扑灭，煎熬脏腑，火因水竭而益烈，水因火烈而益干，阳盛阴衰，构成此症，而三消之患始剧矣，其
根源，非本于肾耶。（《玉案》）
病由饮酒 凡积久饮酒，未有不成消渴。然则大寒凝海
而酒不冻，明其酒性酷热，物无以加。脯炙盐咸，此味酒客耽嗜，不离其口，三HT 之后，制不由己，饮啖无度，
咀嚼 酱HT 觞不择酸咸，积年长夜，酣兴不解，遂使三焦猛热，五脏干燥，木石犹且焦枯，在人何能不渴。治之愈
否，属在病者。若能如方节慎，旬月而瘳∶不自爱惜，死不旋踵。方书医药实多有效，其如不慎者何。（《千金》）
脉候 消渴，脉数大者生，细小浮短者死。消渴，脉沉小者生，实坚大者死。（《脉经》）
三消之脉，浮大者生，细小微涩，形脱可惊。（《删补四言举要》）
消证，脉显实大，为证脉相符，虽久可治。若见悬小而坚，不但脉不应病，且真藏发露，其可疗乎。设消证
脉小，而不至于虚悬坚劲，又当从仲景肾气丸正治矣。然历诊消瘅之脉，无有不带数象者，但须察浮数沉数，在左
在右，尺甚寸甚，及有余不足，兼见何脉而为审治。又须详南北风土之强弱，病患禀气之浓薄，合脉象而推之，庶
几无虚虚之误矣。（《医通》）
三消燥热太过之候，脉宜实大洪滑，为可治；若涩而且微，真阴已竭，多不可救。（《医级》）
三消形证 夫消渴者，渴不止，小便多是也。渴利者，随饮小便故也。内消病者，不渴而小便多是也。
（《病源论》）（按∶此皆下消，《三因》曰消肾，亦曰内消。）
有人病渴利，始发于春，经一夏服栝蒌、豉汁得其力，渴渐瘥，然小便犹数甚，昼夜二十余行，常至三四升，
极瘥不减二升也。转久便止，渐食肥腻，日就羸瘦，喉咽唇口焦燥，吸吸少气，不得多语，心烦热，两脚酸，食乃
兼倍于常，故不为气力者，然此病皆由虚热所为耳。治法栝蒌汁可
长将服以除热，牛乳、杏酪善于补，此法最有益。（《千金》）（按∶此证与次证俱同于巢源所云，亦即下消。）
寻夫内消之为病，当由热中所作也。小便多于所饮，令人虚极短气。夫内消者，食物消作小便也，而又不渴
云云。此病虽稀，甚可畏也。利时脉沉细微弱，服枸杞汤即效。（同上）（枸杞汤见后）
《古今录验》论消渴病有三∶一渴而饮水多，小便数，无脂似麸片甜者，皆是消渴病也。二吃食多，不甚渴，
小便少，似有油而数者，此是消中病也。三渴饮水不能多，但腿肿脚先瘦小，阴痿弱，数小便者，此是肾消病也。
特忌房劳。若消渴者倍黄连，消中者倍栝蒌，肾消者加芒硝六分，服前件铅丹丸。（《外台》）（按∶铅丹丸方未
见，疑是《千金》铅丹散为丸，然方中无黄连，存考。又此三证俱以一方治，知是皆下消之属。）
夫消渴者，日夜饮水百盏，尚恐不足，若饮酒则愈渴，三焦之疾。自风毒瓦斯酒色所伤于上焦，久则其病变为
小便频数，其色如浓油，上有浮膜，味甘甜如蜜，淹浸之久，诸虫聚食，是恶候也，此名消渴。中焦得此病，谓之
脾消，吃食倍常，往往加三两倍，只好饮冷，入口甚美，早夜小便频数，腰膝无力，小便如泔，日渐瘦弱，此名消
中也。下焦得此病，谓之肾消，肾宫日耗，饮水不多，吃食渐少，腰脚细瘦，遗沥散尽，手足久如竹形，其疾已牢
矣。愚医不识义理，呼为劳疾，或云下冷。如此不见痊期，疾久之，或变为水肿，或发背疮，或足膝发恶疮漏疮，
至死不救。（《卫生家宝》）
渴疾有三∶曰消渴，曰消中，曰消肾，分上中下焦而言之。夫三焦为无形之火热内烁，致精液枯乏，脏腑焦腐，饮
有形之水以浇沃，欲其润泽也。若热气上腾，心虚受之，火气散漫而不收敛（按∶《三因》曰∶消渴属心，故烦心，
致心火散蔓，渴而引饮。此黎氏所本），胸中烦躁，舌赤如血，唇红如坯，渴饮水浆，小便频数，名曰 渴，
属于上焦，病在标也。若热蓄于中，脾虚受之，伏阳蒸内，消谷喜饥，食饮倍常，不生肌肉，好饮冷水，小便频数，
色白如泔，味甜如蜜，名曰消中，又曰脾消，属于中焦，病在水谷之海也。若热伏于下焦，肾虚受之，致精髓枯竭，
引水自救而不能消，饮水一斗，小便反倍，味甘而气不臊，阴强而精自走，腿膝枯细，渐渐无力，名曰 肾，又曰
急，属于下焦，病在本也。无形之火热日炽，有形之水饮日加，五脏乃伤，气血俱败。水气内胜，溢于皮肤，则
传为跗肿；火热内胜，留于分肉之间，必为痈肿疮疡。此皆病之深而多致不疗，良可悯哉。（《简易》）
消渴轻也，消中甚焉，消肾又甚焉（按∶原举三证与黎氏同），若强中则其毙可立待也。虽然真水不充，日从
事于杯勺之水，其间小便或油腻，或赤黄，或泔白，或渴而且利，或渴而不利，或不渴而利，但所食之物，皆从
小便出焉。甚而水气浸渍，溢于肌肤，则胀为肿满；猛火自炎，留于分肉，则发为痈疽。此又病之深而证之变者
也。（《直指》）
消渴之疾，三焦受病也，有上消、中消、肾消。上消者，上焦受病，又谓之膈消病也，多饮水而少食，大便如
常，或小便清利，知其燥在上焦也，治宜流湿润燥。中消者，胃也，渴而饮食多，小便黄，经曰热能消谷，知热在中，
法云宜下之，至不欲饮食则愈。肾消者，病在下焦，初发为膏淋，下如膏油之状，至病成而面色黧黑，形瘦而耳焦，
小便浊而有脂，治法宜养血以整肃，分其清浊而自愈也。（《保
命集》）
复分为三消∶高消者，舌上赤裂，大渴引饮，《逆调论》云心移热于肺，传为膈消者是也，以白虎加人参汤治
之。中消者，善食而瘦，自汗，大便硬，小便数，叔和云口干饮水，多食善饥，虚瘅成消中者是也，以调胃承气、
三黄丸治之。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，以六味地黄丸治之。《总
录》所谓未传能食者，必发脑疽背疮，不能食者，必得中满鼓胀，皆谓不治之证。洁古老人分而治之，能食而渴者，
白虎加人参汤，不能食而渴者，钱氏方白术散，倍加葛根治之。上中既平，不复传下消矣。前人用药，厥有旨哉。
（《东垣试效方》）
消渴有三等，肺消、脾消、肾消。肺消、肾消可治，惟有脾消不可治。肺消，热在上焦，可用凉药，如黄连等
皆可用，此疾多出于饮酒人，冬月盛寒，多以葱椒鸠鸽煮酒，或加食热面，遂得此疾，故可用凉药解之。如脾消则
饮食入腹，如汤浇雪，则随小便而出，落于混僻沟渠中，皆凝结如白脂，日可倍食数食，肌肤日益消瘦，用热药则
热愈甚，用凉药则愈见虚羸，故无治法。肾消者，渴而多饮水，小便白浊，肌肤虽日消瘦，然小便不如脾消之凝结坚
硬，饮食亦不倍多，此是肾虚弱，心气泮散所致，故可以补心肾，去烦热，则其疾可愈。（《活法秘方》）
中焦消渴，饮食入胃，传送太急，不生津液，食已则饥，胃中有热，宜用黄芩、石膏。（《丹溪纂要》）
三消，小便去多。上消消心，心火炎上，大渴而小便多。中消消脾，脾气热燥，饮食倍常，皆消为小便。下
消消肾，肾衰不能摄水，故小便虽多而渴。然小便既多，津液必
竭，久而未有不渴者，谓之全不渴，未有的论。（《要诀》）
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（按∶经无此名，当作肺消），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，而津液之精微者，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。（《纲目》）
消渴脚力盛衰时月 凡此疾与香港脚，虽同为肾虚所致，其香港脚始发于二三月，盛于五六月，衰于七八月，
凡消渴始发于七八月，盛于十一月十二月，衰于二月三月，其故何也？夫香港脚者，壅疾也，消渴者，宣疾也。春夏
阳气上，故壅疾发，即宣疾愈也；秋冬阳气下，故宣疾发，即壅疾愈也。审此二者，疾可理也。（《外台》引《近
效》祠部李郎中论）
重证 三消久而小便不臭，反作甜气，在溺桶中滚涌，其病为重。更有浮在溺面如猪脂，溅在桶边如 烛
泪，此精不禁，真元竭矣。（《要诀》）
病变痈疽 其病变多发痈疽，此坐热气留于经络不引（按∶此二字《外台》作经络不利），血气壅涩，
故成痈脓。（《病源论》）（按∶又渴病候曰∶或成水疾。）
消渴之人，愈与未愈，常须思虑有大痈。何者？消渴之人，必于大骨节间发痈疽而卒，所以戒之在大痈也，
当预备痈药以防之。（《千金》）
痈疽科谓有先渴而后疮者，先疮而后渴者，或有二证俱发，其危尤甚焉。愚且尝亲见有不幸而遭此者，故每
疗渴为之防疮，疗疮为之防渴，不过用八味丸、忍冬丸之类。（《澹寮》）（按∶忍冬丸系忍冬、甘草。）
夫消渴者，多变聋盲疮癣痤痱之类，皆肠胃燥热怫郁，水液不能浸润于周身故也。或热甚而膀胱怫郁，不能渗泄，
水液妄行而面上肿也。（《三消论》）
病变肿胀 脾土制水，通调水道，下输于膀胱。消渴饮水过度，内溃脾土，土不制水，故胃胀则为腹满之疾也。
三消病，自古以来大多以肾虚作为立论基础，往往在肾虚证候中再设立不同的名称，大概是因为由下消波及而来的情况居多。但是，对于上消和中消的治疗，刘河间、李东垣两位医家或许更符合经典原意，而上消这一证候颇为罕见。如今采集各家方论，不能截然区分，暂且合并为条目，以等待学者仔细辨别。
病由肾虚 消（消渴），就是渴的意思。肾气不能周流于胸胃之中，津液滋润不足导致消渴，所以想要喝水。（《释名》）
大凡人生放纵的人很多，在壮年之时，不自我谨慎爱惜，尽情情欲，极尽房中之事，稍至年长，肾气虚竭，百病滋生。又有人年少时害怕不能行房，多服用石散（五石散等矿物药），真气耗尽，石气孤立无援，只有虚耗，唇口干焦，精液自泄，或者小便赤黄，大便干结坚硬，或者口渴而且多尿，一天一夜喝一石水，或者口渴但不多尿，或者不口渴但多尿，所吃的食物都变成小便排出，这都是因为房事不节制所导致的。（《千金方》）（按：巢元方论述消渴分为消渴、渴病、渴利、内消，他认为渴病是由于脏腑虚实而生热，津液枯竭减少所以口渴，而不明确是何种证候，其他则认为是少服五石，热结于肾所致。然而服用石散当今已无，仍仅摘录其证候在后款，其余不详细记载。）
《近效方》祠部李郎中论述说：消渴病，推究其发病原因，这是由于肾虚所致，每次发作小便就会变甜。医生们大多不知道这个疾病，所以古方论中也缺失而没有提及，现在略述其要点。按照《尚书·洪范》所说“稼穑作甘”（庄稼和收割物味道甘甜），用物理道理推断，淋饧醋酒制作肉脯的方法，片刻之间都能变甜，足以证明人进食之后，滋味都是甜的。流注到膀胱，如果腰肾气盛，就能向上蒸腾精气，气则向下进入骨髓，其次形成脂膏，其次形成血肉，其余部分别化为小便。所以小便色黄，是血的余绪；臊味，是五脏之气；咸润，是向下的味道。（按：这五句，《太平圣惠方》作“上余为涕泪，经循五脏百脉，下余为小便，黄者血之余也，臊者五脏之气，咸者润下之味也。”）腰肾既然虚冷，就不能向上蒸腾，谷气就全部向下变为小便。所以甘味不变，其色清冷，肌肤就会枯槁。就像乳母，谷气向上泄露，都成为乳汁。消渴病患者，向下泄露为小便，这都是精气不能在体内充实，从而导致消瘦。另外肺是五脏的华盖，如果下部有暖气，蒸腾则肺润。如果下部极冷，阳气就不能上升，所以肺干则热。所以《周易》有否卦，乾上坤下，阳阻阴而不降，阴无阳而不升，上下不交，所以形成痞塞。譬如锅中有水，用火温暖它，如果用板盖住锅，那么暖气上腾，所以板能湿润。如果没有火力，水气就不上腾，这块板终究不可得湿润。火力，就是腰肾强盛，必须经常保暖调养。水气就是食气，食气如果得到暖气，就向上滋润而易消化，也能免除干渴。所以张仲景说：适宜服用八味肾气丸，并且不吃冷物及饮冷水，现在也不再口渴。近来屡获疗效，所以记录正方的在后面。（《外台秘要》）
消渴之疾，都起于肾，壮年之时，不自我保养，尽情情欲，饮酒无度，喜欢吃肉干烤肉酱，或者服用丹石，致使肾水枯竭，心火炽盛，三焦猛烈，五脏干燥，由此渴利产生。（《济生方》）
天一生水，肾实主之。膀胱是津液的腑，用来宣行肾水，向上滋润肺脏。所以懂的人认为肺是津液之脏，自上而下，三焦脏腑，都被天一真水所包容，《素问》说水之本在肾、末在肺就是这个意思。真水不枯竭，哪里有所谓的渴呢？人只是淫欲放纵，酒面无节制，酷嗜烤炙糟藏、咸酸酢醢、甘肥腥膻之类，又以丹砂五石来满足私欲，于是炎火上熏，脏腑生热，燥气炽盛，津液干焦，渴而引水浆而不能自禁。（《直指方》）
大概肾所主管的是水，真水不枯竭，自然足以滋养脾并上交于心，何至于有干枯消渴的病呢？只有肾水一虚，就无法制约其余的火，火旺不能扑灭，煎熬脏腑，火因水竭而更烈，水因火烈而更干，阳盛阴衰，构成此症，而三消的祸患才开始严重，其根源，难道不是本于肾吗？（《玉案》）
病由饮酒 凡是长期饮酒，没有不成为消渴的。然而大寒凝结海面而酒不冻，说明酒性酷热，没有比这更热的了。肉干烤肉盐咸，这是酒客沉迷嗜好，不离口的东西，三餐之后，控制不住自己，饮食无度，咀嚼酱菜酒杯不择酸咸，积年累月，酣畅兴致不解，致使三焦猛热，五脏干燥，木头石头尚且焦枯，在人怎么能不渴。治疗痊愈与否，取决于病人。如果能像方子那样节制谨慎，一个月左右就能痊愈；如果不自我爱惜，死期不远。方书医药实在有很多有效的，无奈那些不慎重的病人怎么办。（《千金方》）
脉候 消渴，脉数大的预后好，脉细小浮短的预后差。消渴，脉沉小的预后好，脉实坚大的预后差。（《脉经》）
三消的脉象，浮大的预后好，细小微涩，形体脱失令人惊恐。（《删补四言举要》）
消证，脉象显现实大，是证与脉相符，虽然病久也可治。如果见到悬小而坚，不但脉不应病，而且真脏脉显露，还能治疗吗？假设消证脉小，而不至于虚悬坚劲，又应当遵循张仲景用肾气丸正治。然而历诊消瘅的脉象，无不带有数象的，只须察辨浮数沉数，在左在右，尺部甚还是寸部甚，以及有余不足，兼见何种脉象来审慎治疗。又须详察南北风土的强弱，病患禀赋气的浓薄，结合脉象来推断，才差不多没有虚虚之误了。（《医宗必读》/《医通》）
三消燥热太过的证候，脉宜实大洪滑，为可治；如果涩而且微，真阴已竭，大多不可救。（《医级》）
三消形证 所谓消渴病，是口渴不止，小便多是。渴利病，是随饮随小便。内消病，是不口渴而小便多是。（《诸病源候论》）（按：这些都是下消，《三因方》叫消肾，也叫内消。）
有人患渴利病，开始于春季，经过一个夏天服用栝蒌、豆豉汁得到效力，口渴逐渐好转，然而小便仍然很频数，昼夜二十多次，常达到三四升，极好转也不少于二升。时间久了便停止，渐渐吃肥腻食物，日益消瘦，喉咽唇口焦燥，呼吸短促少气，不能多说话，心烦热，两脚酸软，饮食加倍于常人，所以不为气力所使，然而此病都是由虚热所为。治疗方法栝蒌汁可以长期服用以除热，牛乳、杏酪善于补益，此法最有益。（《千金方》）（按：此证与次证俱同于巢元方所说，也就是下消。）
寻究内消这种病，应当是由热中所致。小便多于所饮，使人极度虚弱短气。所谓内消，是食物消化后变成小便，而且不口渴等等。此病虽稀少，非常可怕。利时脉沉细微弱，服用枸杞汤即有效。（同上）（枸杞汤见后文）
《古今录验》论述消渴病有三种：一是渴而饮水多，小便频数，无脂似麸片甜者，都是消渴病。二是吃食多，不甚渴，小便少，似有油而频数者，这是消中病。三是渴饮水不能多，但腿肿脚先瘦小，阳痿弱，数小便者，这是肾消病。特别忌讳房劳。如果是消渴者倍加黄连，消中者倍加栝蒌，肾消者加芒硝六分，服用前件铅丹丸。（《外台秘要》）（按：铅丹丸方未见，疑是《千金方》铅丹散为丸，然方中无黄连，存疑考察。又此三证俱以一方治，知是皆下消之属。）
所谓消渴病，日夜饮水百盏，尚恐不足，如果饮酒则更渴，是三焦的疾病。自从风毒瓦斯酒色损伤上焦，久了病变为小便频数，其色如浓油，上有浮膜，味甘甜如蜜，浸泡久了，诸虫聚食，这是恶候，名叫消渴。中焦得此病，叫脾消，吃食加倍，往往增加两三倍，只好饮冷，入口甚美，早晚小便频数，腰膝无力，小便如米泔水，日渐瘦弱，这叫消中。下焦得此病，叫肾消，肾宫日耗，饮水不多，吃食渐少，腰脚细瘦，遗沥散尽，手足久如竹形，此疾已牢固难治。愚医不识义理，呼为劳疾，或云下冷。如此不见痊愈之期，病久了，或变为水肿，或发背疮，或足膝发恶疮漏疮，至死不救。（《卫生家宝》）
渴疾有三种：叫消渴，叫消中，叫消肾，分上中下焦而言。三焦为无形之火热内烁，致使精液枯乏，脏腑焦腐，饮有形之水以浇沃，欲其润泽。若热气上腾，心虚受之，火气散漫而不收敛（按：《三因方》说：消渴属心，故烦心，致心火散蔓，渴而引饮。这是黎氏所依据的），胸中烦躁，舌赤如血，唇红如坯，渴饮水浆，小便频数，名叫膈渴，属于上焦，病在标。若热蓄于中，脾虚受之，伏阳蒸内，消谷喜饥，食饮倍常，不生肌肉，好饮冷水，小便频数，色白如米泔，味甜如蜜，名叫消中，又叫脾消，属于中焦，病在水谷之海。若热伏于下焦，肾虚受之，致使精髓枯竭，引水自救而不能消，饮水一斗，小便反倍，味甘而气不臊，阴强而精自走，腿膝枯细，渐渐无力，名叫肾消，又叫急劳，属于下焦，病在本。无形之火热日炽，有形之水饮日加，五脏乃伤，气血俱败。水气内胜，溢于皮肤，则传为跗肿；火热内胜，留于分肉之间，必为痈肿疮疡。这都是病之深而多致不疗，良可悯惜。（《简易方论》）
消渴轻，消中重，消肾又重（按：原举三证与黎氏同），如果强中则死亡可立即等待。虽然真水不充，终日从事于杯勺之水，其间小便或油腻，或赤黄，或泔白，或渴而且利，或渴而不利，或不渴而利，但所食之物，都从小便出。甚至水气浸渍，溢于肌肤，则胀为肿满；猛火自炎，留于分肉，则发为痈疽。这又是病之深而证之变者。（《直指方》）
消渴之疾，三焦受病，有上消、中消、肾消。上消，上焦受病，又叫膈消病，多饮水而少食，大便如常，或小便清利，知其燥在上焦，治宜流湿润燥。中消，胃也，渴而饮食多，小便黄，经曰热能消谷，知热在中，法云宜下之，至不欲饮食则愈。肾消，病在下焦，初发为膏淋，下如膏油之状，至病成而面色黧黑，形瘦而耳焦，小便浊而有脂，治法宜养血以整肃，分其清浊而自愈也。（《保命集》）
复分为三消：高消者，舌上赤裂，大渴引饮，《逆调论》说心移热于肺，传为膈消者是也，用白虎加人参汤治之。中消者，善食而瘦，自汗，大便硬，小便数，叔和说口干饮水，多食善饥，虚瘅成消中者是也，用调胃承气汤、三黄丸治之。下消者，烦躁引饮，耳叶焦干，小便如膏，叔和说焦烦水易亏，此肾消也，用六味地黄丸治之。《总录》所谓未传能食者，必发脑疽背疮，不能食者，必得中满鼓胀，皆谓不治之证。洁古老人分而治之，能食而渴者，白虎加人参汤，不能食而渴者，钱氏方白术散，倍加葛根治之。上中既平，不复传下消矣。前人用药，厥有旨哉。（《东垣试效方》）
消渴有三等，肺消、脾消、肾消。肺消、肾消可治，惟有脾消不可治。肺消，热在上焦，可用凉药，如黄连等都可用，此疾多出于饮酒人，冬月盛寒，多以葱椒鸠鸽煮酒，或加食热面，遂得此疾，故可用凉药解之。如脾消则饮食入腹，如汤浇雪，则随小便而出，落于混僻沟渠中，皆凝结如白脂，日可倍食数食，肌肤日益消瘦，用热药则热愈甚，用凉药则愈见虚羸，故无治法。肾消者，渴而多饮水，小便白浊，肌肤虽日消瘦，然小便不如脾消之凝结坚硬，饮食亦不倍多，此是肾虚弱，心气涣散所致，故可以补心肾，去烦热，则其疾可愈。（《活法秘方》）
中焦消渴，饮食入胃，传送太急，不生津液，食已则饥，胃中有热，宜用黄芩、石膏。（《丹溪纂要》）
三消，小便去多。上消消心，心火炎上，大渴而小便多。中消消脾，脾气热燥，饮食倍常，皆消为小便。下消消肾，肾衰不能摄水，故小便虽多而渴。然小便既多，津液必竭，久而未有不渴者，谓之全不渴，未有的论。（《要诀》）
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（按：经无此名，当作肺消），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，而津液之精微者，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。（《本草纲目》）
消渴脚力盛衰时月 凡此疾与脚气，虽同为肾虚所致，其脚气始发于二三月，盛于五六月，衰于七八月，凡消渴始发于七八月，盛于十一月十二月，衰于二月三月，其故何也？夫脚气者，壅疾也，消渴者，宣疾也。春夏阳气上，故壅疾发，即宣疾愈也；秋冬阳气下，故宣疾发，即壅疾愈也。审此二者，疾可理也。（《外台秘要》引《近效方》祠部李郎中论）
重证 三消久而小便不臭，反作甜气，在溺桶中滚涌，其病为重。更有浮在溺面如猪脂，溅在桶边如烛泪，此精不禁，真元竭矣。（《要诀》）
病变痈疽 其病变多发痈疽，这是因为热气留于经络不引（按：此二字《外台秘要》作经络不利），血气壅涩，故成痈脓。（《诸病源候论》）（按：又渴病候曰：或成水疾。）
消渴之人，愈与未愈，常须思虑有大痈。为何？消渴之人，必于大骨节间发痈疽而卒，所以戒之在大痈也，当预备痈药以防之。（《千金方》）
痈疽科谓有先渴而后疮者，先疮而后渴者，或有二证俱发，其危尤甚焉。愚且尝亲见有不幸而遭此者，故每疗渴为之防疮，疗疮为之防渴，不过用八味丸、忍冬丸之类。（《澹寮方》）（按：忍冬丸系忍冬、甘草。）
夫消渴者，多变聋盲疮癣痤痱之类，皆肠胃燥热怫郁，水液不能浸润于周身故也。或热甚而膀胱怫郁，不能渗泄，水液妄行而面上肿也。（《三消论》）
Sanxiao (Three Wasting-Thirst Diseases) has, since ancient times, generally been discussed on the basis of Kidney Deficiency. Often, different names are established within the pattern of Kidney Deficiency, mostly because it spreads from Xiaxiao (Lower Wasting-Thirst). However, regarding the treatment of Shangxiao (Upper Wasting-Thirst) and Zhongxiao (Middle Wasting-Thirst), Liu Hejian and Li Dongyuan perhaps grasped the essence of the classics, although Shangxiao is quite rare. Now, collecting formulas and theories from various schools, they cannot be clearly distinguished; thus, they are tentatively combined into sections for scholars to examine and differentiate.
Etiology: Kidney Deficiency. Xiao (Wasting-Thirst) refers to thirst. When Qi of the Kidney does not circulate freely in the chest and stomach, the lack of fluid moistening leads to wasting-thirst, causing a desire to drink water. (*Shiming*)
Generally, many people live unrestrainedly. In their prime, failing to exercise caution and cherish their health, indulging in desires and sexual activity to excess, as they age, Kidney Qi becomes deficient and exhausted, giving rise to myriad diseases. Others, fearing impotence in youth, take mineral powders (such as Five-Stone Powder); once True Qi is depleted, the mineral Qi stands alone, resulting only in depletion. Symptoms include dry and cracked lips and mouth, spontaneous seminal emission, or red-yellow urine, dry and hard stools, or thirst with polyuria drinking one *shi* per day, or thirst without polyuria, or no thirst but polyuria, where all ingested food passes out as urine. All these result from unregulated sexual activity. (*Qianjin Fang*) [Note: Chao Yuanfang discusses wasting-thirst by dividing it into Xiao Ke, Ke Bing, Ke Li, and Neixiao. He attributes Ke Bing to heat generated by deficiency/excess in the Zang-Fu organs, leading to depleted fluids and thirst, without specifying the exact pattern. Others attribute it to heat accumulation in the Kidney from taking Five-Stone Powder. Since taking mineral powders is obsolete today, only the symptoms are excerpted below.]
Li Langzhong of the Shrine Department in *Jin Xiao Fang* states: The origin of wasting-thirst lies in Kidney Deficiency; upon onset, the urine becomes sweet. Physicians often do not understand this disease, so ancient texts omit it. Briefly stated: According to the *Hong Fan*, crops yield sweetness. Physically, syrups, vinegar, and wine can become sweet quickly, proving that food tastes sweet after ingestion. This flows to the Bladder. If Kidney Qi is strong, it steams Essence upward; Qi enters the Marrow, then forms fat, then blood and flesh; the remainder becomes urine. Thus, urine is yellow (excess of blood) and smells musky (Qi of the five Zang organs); salty and moist is the downward flavor. [Note: *Taiping Shenghui Fang* reads: "The upper remainder becomes tears/saliva... the lower remainder becomes urine..."] If the腰部 and Kidneys are deficient and cold, they cannot steam upward; grain Qi descends entirely as urine. Thus, the sweet taste remains unchanged, the color is clear and cold, and the skin and muscles wither. Like a nursing mother whose grain Qi transforms into milk, wasting-thirst patients excrete downward as urine; lacking internal Essence leads to emaciation. The Lung is the canopy of the five Zang organs; if there is warmth below, it steams and moistens the Lung. If the lower part is extremely cold, Yang Qi cannot ascend, causing Lung dryness and heat. The *I Ching* Hexagram Pi describes Heaven above and Earth below, where Yang blocks Yin from descending and Yin lacks Yang to ascend, causing obstruction. Like a pot of water heated by fire under a lid: steam rises and moistens the lid. Without fire, water vapor does not rise, and the lid remains dry. Fire represents strong腰部 and Kidneys, requiring warmth and care. Water vapor represents food Qi; with warmth, it moistens upward and aids digestion, preventing dryness. Therefore, Zhang Zhongjing said: It is suitable to take Ba Wei Shen Qi Wan (Eight-Ingredient Pill of the Kidney Qi), avoid cold foods and drinks, and thirst will cease. Having achieved frequent success, the correct formula is recorded below. (*Waitai Miyao*)
Wasting-thirst originates in the Kidney. In youth, failing to preserve health, indulging in sex and alcohol, eating dried meats and roasted foods, or taking cinnabar/minerals, causes Kidney Water to dry up, Heart Fire to blaze, Sanjiao to become fierce, and the five Zang organs to dry out, generating wasting-thirst. (*Jisheng Fang*)
Heaven generates Water, governed by the Kidney. The Bladder is the Fu organ of fluids, disseminating Kidney Water to moisten the Lung upwards. Thus, experts consider the Lung the organ of fluids; from top to bottom, the Sanjiao and Zang-Fu are contained within the True Water of Heaven. As *Suwen* states, the root of water is in the Kidney, and the branch in the Lung. If True Water is inexhaustible, what need is there for thirst? Only through licentiousness, unregulated alcohol, craving roasted/salty/sour/sweet/greasy foods, and using cinnabar/five stones to satisfy desires does flame scorch upwards, generating heat in the Zang-Fu, blazing dryness, drying fluids, and causing uncontrollable thirst. (*Zhizhi Fang*)
The Kidney governs Water. If True Water is inexhaustible, it nourishes the Spleen and communicates with the Heart, preventing dry wasting-thirst. But when Kidney Water is deficient, it fails to control residual Fire. Fire blazes, simmering the Zang-Fu; Fire intensifies due to Water's exhaustion, and Water dries due to Fire's intensity. Yang excess and Yin deficiency constitute this syndrome, making Sanxiao severe. Is not the root in the Kidney? (*Yu An*)
Etiology: Alcoholism. Long-term alcohol consumption invariably leads to wasting-thirst. Alcohol is extremely hot, hotter than any other substance. Dried meats and salt are staples for drinkers. After meals, self-control is lost; eating and drinking are excessive. Year after year, intoxication persists, causing fierce heat in Sanjiao and dryness in the five Zang organs. Wood and stone may scorch; how much more so humans? Cure depends on the patient. If regulated according to prescriptions, recovery occurs in weeks; if neglected, death follows swiftly. Many remedies exist, but what of those who are careless? (*Qianjin Fang*)
Pulse Diagnosis. In wasting-thirst, a rapid and large pulse indicates survival; a fine, small, floating, and short pulse indicates death. A deep and small pulse indicates survival; a solid, firm, and large pulse indicates death. (*Maijing*)
For Sanxiao, a floating and large pulse indicates survival; a fine, small, minute, and choppy pulse with physical collapse is alarming. (*Shanbu Siyan Juyao*)
In wasting patterns, a solid and large pulse matches the syndrome and is treatable even if chronic. A hanging, small, and firm pulse indicates the pulse does not match the disease and reveals the True Zang pulse, making treatment difficult. If the pulse is small but not hollow and firm, follow Zhang Zhongjing’s Zhengzhi with Shen Qi Wan. Historically, wasting-diabetes pulses always show rapidity; one must distinguish floating vs. deep rapidity, left vs. right, Chi vs. Cun excess/deficiency, and accompanying pulses for accurate treatment. Consider regional climate and constitutional strength to avoid treating deficiency as excess. (*Yitong*)
For Sanxiao with excessive dryness-heat, a solid, large, surging, and slippery pulse is treatable; a choppy and minute pulse indicates exhaustion of True Yin and is likely incurable. (*Yiji*)
Clinical Manifestations of Sanxiao. Xiao Ke is characterized by incessant thirst and polyuria. Ke Li is drinking followed immediately by urination. Neixiao is polyuria without thirst. (*Bingyuan Lun*) [Note: These refer to Xiaxiao; *Sanyin Fang* calls it Xiaoshen or Neixiao.]
A case of Ke Li starting in spring improved with Trichosanthes and Perilla juice over summer, yet urination remained frequent (20+ times/day, 2-3 sheng). Eventually stopped, but weight loss continued due to rich diet. Symptoms included dry throat/mouth, shortness of breath, irritability, heat, sore legs, and increased appetite without strength gain. This is caused by deficiency-heat. Treatment: Long-term Trichosanthes juice clears heat; cow’s milk and apricot cheese tonify. This method is beneficial. (*Qianjin Fang*) [Note: Matches Chao Yuanfang’s description of Xiaxiao.]
Neixiao arises from interior heat. Urine volume exceeds intake, causing extreme weakness and shortness of breath. Food digests directly into urine without thirst. Though rare, it is feared. Pulse is deep, fine, and weak; Gouqi Tang is effective. (*Same source*)
*Gujin Luyan* describes three types: 1. Thirst with heavy drinking and frequent sweet-smelling urine resembling bran flakes: Xiao Ke. 2. Heavy eating, slight thirst, infrequent oily urine: Xiaozhong. 3. Little drinking, leg swelling, thin feet, impotence, frequent urination: Xiaoshen. Avoid sexual exertion. For Xiao Ke, double Coptis; for Xiaozhong, double Trichosanthes; for Xiaoshen, add 6 fen Mangxiao. Take Qian Dan Wan. (*Waitai Miyao*) [Note: Formula missing; likely related to Qianjin Fang. Treated with one formula suggests all are Xiaxiao.]
Xiao Ke involves drinking hundreds of cups daily; alcohol worsens thirst. Caused by wind-toxin, qi, sex, and alcohol damaging the Upper Jiao. Long-term changes lead to frequent, dark-oily urine with a floating membrane, sweet as honey, attracting insects—a bad omen called Xiao Ke. Middle Jiao involvement is Pí Xiāo (Spleen Wasting): eating doubles, prefers cold drinks, frequent white turbid urine like rice wash, weak waist/knees, emaciation. Lower Jiao involvement is Shèn Xiāo (Kidney Wasting): Kidney palace depletes, little drinking/eating, thin waist/legs, dribbling urine, bamboo-like limbs, stubborn disease. Ignorant doctors call it劳疾 (Labor Disease) or lower cold. No cure; later complications include edema, back sores, or foul leg ulcers, leading to death. (*Weisheng Jiabao*)
Thirst diseases have three types based on Sanjiao: Invisible fire scorches fluids, drying Zang-Fu. Drinking water tries to moisten them.
1. Heat rises to the Heart (deficient), scattering Fire. Symptoms: irritability, red tongue/lips, thirst, frequent urination. Called Ge Ke (Diaphragm Thirst), Upper Jiao, manifest level.
2. Heat accumulates in the Middle, affecting the Spleen. Hidden Yang steams internally, digesting food quickly, hunger, double intake, no muscle gain, likes cold water, frequent white sweet urine. Called Xiaozhong or Pi Xiao, Middle Jiao, level of water/grain.
3. Heat hides in Lower Jiao, affecting the Kidney. Essence dries, drinking to save self but unable to absorb. Drink 1 dou, urinate 2 dou, sweet/non-musky urine, strong libido with sperm leakage, thin knees. Called Shen Xiao or Ji Lao, Lower Jiao, root level.
Invisible fire grows, visible water increases, injuring five Zang, ruining Qi/Blood. Water overflow causes edema; Fire retention causes abscesses. Deep diseases are hard to treat. (*Jianyi Fang*)
Xiao Ke is mild, Xiaozhong is severe, Xiaoshen is severest. Qiangzhong (Excessive Strength) leads to immediate death. True Water is insufficient; urine varies (oily, red, white). Food exits via urine. Severe cases: water overflow causes edema; fire causes carbuncles. (*Zhizhi Fang*)
Sanjiao is affected in wasting-thirst: Shangxiao, Zhongxiao, Xiaoxiao.
Shangxiao (Upper Jiao/Ge Xiao): Drinks much, eats little, normal stool/clear urine. Dryness in Upper Jiao. Treat with moistening.
Zhongxiao (Stomach): Thirsty, eats much, yellow urine. Heat in Middle. Treat with purgatives until appetite returns.
Xiaoxiao (Lower Jiao/Kidney): Starts as Gaolin (paste-like urine), turns black face, thin body, burnt ears, turbid fatty urine. Treat with blood-nourishing and separating clear/turbid. (*Baoming Ji*)
Re-divided into three:
Gao Xiao (High Thirst): Red cracked tongue, great thirst. Heart heat transfers to Lung (Ge Xiao). Treat with Baihu Jia Renshen Tang.
Zhong Xiao: Eats well but loses weight, sweating, hard stool, frequent urine. Stomach heat. Treat with Tiaowei Chengqi Tang or Sanhuang Wan.
Xia Xiao: Irritable, thirsty, burnt ear lobes, paste-like urine. Kidney deficiency. Treat with Liuwei Dihuang Wan.
If able to eat, brain/back sores develop; if unable to eat, abdominal distension develops—both untreatable. Jiegu treats separately: Eating/thirsty -> Baihu Jia Renshen Tang; Not eating/thirsty -> Qian’s Baizhu San plus Ge Gen. Once Upper/Middle settle, it won’t transmit to Lower. Precious wisdom. (*Dongyuan Shi Xiao Fang*)
Three grades: Fei Xiao, Pi Xiao, Shen Xiao. Fei and Shen are treatable; Pi is not.
Fei Xiao: Heat in Upper Jiao. Use cooling herbs like Huanglian. Common in drinkers consuming spicy/pigeon wine or hot noodles in winter. Cooling herbs resolve it.
Pi Xiao: Food melts like snow in urine, congeals like white fat. Eats multiples, wastes away. Hot herbs increase heat; cold herbs increase deficiency. No treatment.
Shen Xiao: Thirsty, drinks much, white turbid urine, wastes away but urine doesn’t congeal, eats normally. Kidney deficiency, Heart Qi scattered. Tonify Heart/Kidney, clear heat. (*Huofa Mifang*)
Middle Jiao Wasting-Thirst: Food transmits too fast, no fluids produced, hungry after eating. Stomach heat. Use Huangqin, Shigao. (*Danxi Zuanya*)
Sanxiao involves excessive urine loss.
Shangxiao affects Heart: Heart Fire flares, great thirst, polyuria.
Zhongxiao affects Spleen: Spleen heat/dryness, double intake, all converts to urine.
Xiaxiao affects Kidney: Kidney failure to control water, polyuria despite thirst.
Long-term polyuria exhausts fluids, inevitably causing thirst. Total absence of thirst is debated. (*Yaojue*)
Shangxiao is Ge Xiao (thirst + drinking). Zhongxiao is Xiaozhong (thirst + eating/drinking). Xiaxiao is Shen Xiao (drink 1, urinate 2, paste-like urine). Wang Bing notes Lung dryness lacks Qi support. Lung stores Qi; healthy Lung controls fluids. Fine fluids nourish sinews/bones/vessels; remainder becomes urine. Lung disease loses control, fine fluids drain with urine. Sinews/bones lack nourishment, leading to emaciation. Lung disease stems from Kidney Deficiency; Kidney deficiency allows Heart Fire to insult Lung. Zhang Zhongjing uses Shen Qi Wan to tonify Kidney/save Lung. Hence named Xiaxiao. (*Bencao Gangmu*)
Seasonality of Leg Strength in Wasting-Thirst vs. Jiaogong (Foot Distemper). Both stem from Kidney Deficiency. Jiaogong starts Feb-Mar, peaks May-Jun, subsides Jul-Aug. Wasting-Thirst starts Jul-Aug, peaks Nov-Dec, subsides Feb-Mar. Why? Jiaogong is an obstructive disease; Wasting-Thirst is a dispersing disease. Spring/Summer Yang rises: Obstructive disease flares, Dispersing heals. Autumn/Winter Yang sinks: Dispersing flares, Obstructive heals. Understanding this manages the disease. (*Waitai Miyao* citing *Jin Xiao*)
Severe Cases. Long-term Sanxiao urine loses odor, smells sweet, bubbles in chamber. Floating fat like lard on surface or candle wax on sides indicates Essence leakage and exhaustion of True Yuan. (*Yaojue*)
Complications: Carbuncles/Abscesses. Heat stays in meridians, blocking Qi/Blood stasis, forming pus. (*Bingyuan Lun*) [Note: Also mentions water diseases.]
Patients recovering or not must guard against major carbuncles. Death often occurs from carbuncles at major joints. Prepare carbuncle medicines. (*Qianjin Fang*)
Carbuncle specialists note: Thirst before sore, sore before thirst, or both together are critical. I have seen this. Treating thirst requires guarding against sores, and vice versa, using Bawei Wan or Rendong Wan. (*Danliao Fang*) [Note: Rendong Wan contains Honeysuckle and Licorice.]
Wasting-thirst often complicates into deafness, blindness, sores, tinea, acne, prickly heat. Intestines/Stomach dryness-heat stagnates, preventing fluid distribution. Or bladder heat stagnation prevents excretion, causing facial edema. (*Sanxiao Lun*)
Complications: Edema/Swelling. Spleen Earth controls Water, regulating channels to Bladder. Excessive drinking in wasting-thirst damages Spleen Earth. Earth fails to control Water, causing stomach distension and abdominal fullness.