罗谦甫曰。顺德安抚张耘夫。年四十五岁。病消渴。舌上赤裂。饮水无度。小便数多。
东垣先师以生津甘露饮子治之。旬日良愈。古人云。消渴多传疮疡。以成不救之疾。今效后
不传疮疡。享年七十五岁而终。其论曰。消之为病。燥热之气胜也。内经云。热淫所胜。治
以甘苦。以甘泻之。热则伤气。气伤则无润。折热补气。非甘寒之剂不能。故以人参、石膏
炙甘草、生甘草之甘寒为君。启玄子云。益水之源。以镇阳光。故以知、柏、黄连、栀子
之苦寒。泻热补水为臣。以当归、麦冬、杏仁、全蝎、连翘、白芷、白葵、兰香。甘辛寒和
血润燥为佐。以升、柴之苦平。行阳明少阳二经。白豆蔻、荜澄茄、木香、藿香。反佐以取
之。重用桔梗为舟楫。使浮而不下也。为末。每服二钱。抄在掌内。以舌舐之。此制治之缓
震按古今治消渴诸方。不过以寒折热。惟苦与甘略不同耳。要皆径直。无甚深义。独此
方委蛇曲折。耐人寻味。
东坡集载眉山揭颖臣。长七尺。素健饮啖。忽得渴疾。日饮水数斗。饭亦倍进。小便频
数。服消渴药逾年。病日甚。自度必死。蜀医张 。取麝香当门子。以酒濡湿。作十余丸。
用枳 子煎汤。服之遂愈。问其故。张曰。消渴消中。皆脾衰而肾败。土不胜水。肾液不上
溯。乃成此疾。今诊颖臣脾脉极热。肾脉不衰。当由酒果过度。积热在脾。所以多食多饮。
饮多溺不得不多。非消渴也。麝香坏酒果。枳 能化酒为水。故假二物。去其酒果之毒也。
震按此人似消渴。实非消渴。张公之见识殊高。用药最巧。
汪石山治一妇年逾三十。常患消渴善饥。脚弱。冬亦不寒。小便白浊。浮于上者如油。
脉皆细弱而缓。右脉尤弱。曰。此脾瘅也。宜用甘温助脾。甘寒润燥。以参、 各钱半。麦
冬、白术各一钱。白芍、花粉各八分。黄柏、知母各七分。煎服病除。
张景岳治周公。年逾四旬。因案牍积劳。神困食减。时多恐惧。自冬春达夏。通宵不寐
者。半年有余。而上焦无渴。不嗜汤水。或有少饮。则沃而不行。然每夜必去溺二三升。莫
知其所从来。且半皆如膏浊液。 羸至极。自分必死。岂意诊之。脉犹带缓。肉亦未脱。知
其胃气尚存。慰以无虑。乃用归脾汤去木香。及大补丸煎之属。一以养阳。一以养阴。出入
间用。至三百余剂。计人参二十斤。乃得全愈。此神消于上精消于下之证。可见消有阴阳。
不得尽言火。
震按此条与汪案略同。但无渴。且不能饮。已具有虚无火之象。景岳喜用温药。然所谓
养阳者。并不参以桂、附。则知消而且渴。必非桂、附所宜矣。予请下一转语曰。消有虚实
不得遽认为寒。
孙东宿治一书办。年过五十。酒色无惮。忽患下消症。一日夜小便二十余度。清白而长
味且甜。少顷凝结如脂。色有油光。他医治半年不验。腰膝以下皆软弱。载身不起。饮食
减半。神色大瘁。孙诊之。六部大而无力。经云。脉至而从。按之不鼓。诸阳皆然。法当温
补下焦。以熟地六两为君。鹿角霜、山茱萸各四两。桑螵蛸、鹿角胶、人参、茯苓、枸杞、
远志、菟丝、山药各三两为臣。益智仁一两为佐。桂、附各七钱为使。蜜丸。早晚盐汤送四
五钱。不终剂而愈。此证由下元不足。无气升腾于上。故渴而多饮。以饮多小便亦多也。今
大补下元。使阳气充盛。熏蒸于上。则津生而渴止矣。
震按生生子此条。实宗仲景饮一斗小便亦一斗肾气丸主之之法也。张杲治黄沔久病渴。
极疲瘁。劝服八味丸数两而安。其学甚高。然治一水二火者患消渴而用此方。则大误。又阅
滑伯仁案。一消渴者医谓肾虚津不上升。合附子大丸服之。渴益甚。目疾亦作。滑斥之曰。
此以火济火。不焦则枯。令弃前药。以寒剂下之。荡去火毒。继以苦寒清润之剂乃愈。是不
可同年而语矣。洎宅编载一仕人患消渴。医者断其逾月死。又一医令急致北梨二担。食尽而
瘥。隋炀帝服方士丹药。荡思不可制。日夕御女数十人。入夏烦躁。日引饮数百杯而渴不止
莫君锡进冰盘于前。俾时刻望之。是皆法外之法也。他如本草载淡煮韭苗。于清明前吃尽
一斤。刘完素以生姜自然汁一盆置室中具杓于傍。给病患入室HT 之。渴甚。不得已而饮。饮
渐尽。渴反减。是皆内经辛以润之之旨。而交州记曰。浮石体虚而轻。煮饮治渴。故本事方
神效散浮石为君。实神效无比。
又按风寒暑湿燥火。六淫之邪也。江氏分类集案。不立燥之一门。缘诸病有兼燥者。已
散见于各门。却无专门之燥病可另分一类耳。故于湿之下。火热之上。间以消渴。盖消渴有
燥无湿也。其见解极是。允宜配列在此。
罗谦甫说：顺德安抚张耘夫，四十五岁，患消渴病。舌面红赤且有裂纹，饮水无节制，小便次数多且量大。
东垣先师用生津甘露饮子治疗他，十天后病情大愈。古人说，消渴病容易转化为疮疡，从而成为不治之症。如今（张耘夫）后来没有发生疮疡，活到七十五岁才去世。他的论述说：消渴这种病，是燥热之气偏胜所致。《内经》说：“热邪过盛，要用甘苦味的药物来治疗，用甘味药来泻火。”热邪会损伤气，气受损则失去滋润作用。要折损热邪并补益气，非甘寒性质的药剂不能做到。所以用人参、石膏、炙甘草、生甘草的甘寒之性作为君药。启玄子（王冰）说：“滋补水之源，以镇摄阳光（虚火）。”所以用知母、黄柏、黄连、栀子的苦寒之性，作为臣药，以泻热并补充津液。再用当归、麦冬、杏仁、全蝎、连翘、白芷、白葵（可能指白蔹或类似药材）、兰香（罗勒），以甘辛寒的性质调和血液、润燥，作为佐药。用升麻、柴胡的苦平之性，运行于阳明、少阳二经；用白豆蔻、荜澄茄、木香、藿香，作为反佐药以引药入里。重用桔梗作为舟楫，使药力浮于上而不致下行。将上述药物研为末，每次服用二钱，放在手掌中，用舌头舔舐服用。这是制定该方剂治疗缓慢性质的思路。
俞震按语：古今治疗消渴的各种方剂，不过是用寒凉药来折损热邪，只是苦味和甘味的比例略有不同罢了。大多都是直截了当，没有什么深奥的含义。唯独这个方剂曲折委婉，值得细细品味。
《东坡集》记载眉山的揭颖臣，身高七尺，平时健康，饮食量大。忽然得了口渴的病，每天饮水数斗，饭量也加倍增加，小便频繁。服用治疗消渴的药物一年多，病情日益加重，自己估计必死无疑。蜀医张某，取麝香（当门子），用酒湿润，制成十余丸，用枳椇子煎汤送服，于是痊愈。询问其中的缘故，张医生说：“消渴、消中等病，都是脾衰肾败所致，土不胜水，肾液不能上溯，才形成这种病。如今诊察颖臣的脾脉极热，肾脉不衰，应当是由于饮酒吃水果过度，积热在脾，所以多吃多喝。喝得多，尿自然也多。这不是真正的消渴病。麝香能化解酒果之毒，枳椇子能将酒化为水，所以借用这两味药，去除酒果的毒性。”
俞震按语：这个人看似消渴，实际上并非消渴。张医生的见识非常高明，用药极其巧妙。
汪石山治疗一位三十多岁的女性，常患消渴且容易饥饿，脚部软弱，冬天也不觉得冷，小便浑浊，表面浮着如油一样的物质。脉象都细弱而缓，右脉尤其弱。他说：“这是脾瘅病。适宜用甘温药助脾，甘寒药润燥。用人参、黄芪各一钱半，麦冬、白术各一钱，白芍、天花粉各八分，黄柏、知母各七分，煎服，病就好了。”
张景岳治疗周姓官员，四十多岁，因为文书工作劳累过度，精神困倦，食欲减退，时常恐惧。从冬春持续到夏天，通宵不睡觉有半年多。但上焦并不口渴，不喜欢喝汤水，即使稍微喝一点，也停滞不行。然而每晚必定排尿二三升，不知道从哪里来的，而且有一半像膏状浊液。身体极度消瘦，自己认为必死无疑。没想到诊脉时，脉象还带有缓和之意，肌肉也没有完全脱失，知道胃气尚存，安慰他不要担忧。于是用归脾汤去掉木香，以及大补丸煎煮服用。一种用来养阳，一种用来养阴，交替使用。总共用了三百多剂，累计人参二十斤，才得以完全痊愈。这是“神消于上，精消于下”的证候。可见消渴病有阴阳之分，不能一概说是火邪。
俞震按语：这一条与汪医生的医案大致相同，但没有口渴，而且不能饮水，已经具有虚无火的现象。张景岳喜欢用温药，但所谓“养阳”，并没有参入桂枝、附子，由此可知，如果是消渴且伴有口渴，一定不是桂枝、附子所适宜的。我请补上一句转折的话：消渴病有虚实之分，不能立刻认定为寒证。
孙东宿治疗一名书办（文书小吏），五十多岁，纵欲酗酒无所顾忌。忽然患上下消症，一天一夜小便二十多次，尿液清白且长，味道甜，一会儿凝结如脂，颜色有油光。其他医生治疗半年无效，腰膝以下皆软弱，无法支撑身体，饮食减半，神色极度疲惫。孙医生诊察，六部脉大而无力。《内经》说：“脉象虽然顺从病势，但重按却不鼓动，诸阳脉都是如此。”治法应当温补下焦。用熟地黄六两为君药，鹿角霜、山茱萸各四两，桑螵蛸、鹿角胶、人参、茯苓、枸杞、远志、菟丝子、山药各三两为臣药，益智仁一两为佐药，肉桂、附子各七钱为使药。炼蜜为丸，早晚用盐汤送服四五钱。不到一个疗程就痊愈了。此证由于下元不足，没有气升腾于上，所以口渴而多饮。因为喝得多，小便也就多。现在大补下元，使阳气充盛，熏蒸于上，那么津液生成而口渴停止。
俞震按语：生生子（孙东宿）的这一条，实际上是遵循仲景“饮一斗，小便亦一斗”，用肾气丸主治的方法。张杲治疗黄沔久病口渴，极度疲惫，劝其服用几两八味丸而安定下来。他的学问很高，但如果治疗“一水二火”的消渴病患者而使用这个方子，那就大错特错了。又阅读滑伯仁的医案，有一位消渴病患者，医生认为是肾虚津液不能上升，合用附子大丸服用，结果口渴更严重，眼疾也发作了。滑伯仁斥责道：“这是以火救火，不烧焦就会干枯。”让他放弃前面的药，用寒凉药剂攻下，荡去火毒，接着用苦寒清润的药剂才痊愈。这不可同日而语。等到我家编撰医案时，记载一位仕人患消渴，医生断定他一个月后死亡。另一位医生让他赶紧准备两担北方梨子，吃完就好了。隋炀帝服用方士的丹药，欲望不可控制，日夜御女数十人。入夏后烦躁，每天喝几百杯仍止不住口渴。莫君锡在他面前放冰盘，让他时刻看着冰块。这些都是法外之法。其他的如《本草》记载淡煮韭苗，在清明前吃尽一斤；刘完素将一盆生姜自然汁放在房间里，旁边备好勺子，诱骗病人进入房间闻姜味，病人渴得受不了，不得已喝下去，随着姜汁喝完，口渴反而减轻。这都是《内经》“辛以润之”的宗旨。《交州记》说：浮石体虚心轻，煮水饮用可治口渴。所以《本事方》中的神效散以浮石为君药，确实神效无比。
我又按语：风、寒、暑、湿、燥、火，是六淫邪气。江氏的《分类集案》，没有设立“燥”这一门类，因为各种疾病中有兼夹燥邪的，已经散见于各个门类，却没有专门的燥病可以单独分为一类。所以在“湿”之下，“火热”之上，穿插了“消渴”。大概是因为消渴有燥无湿。这种见解非常正确，理应排列在此处。
Luo Qianfu said: Zhang Yunfu, the Pacification Commissioner of Shunde, was forty-five years old when he suffered from Xiao Ke (Wasting-Thirst). His tongue was red with cracks, he drank water without limit, and his urination was frequent and copious.
My teacher Dongyuan treated him with Shengjin Ganlu Yinzi (Sputum-Generating Sweet Dew Decoction), and after ten days, he recovered significantly. The ancients said that Xiao Ke often transforms into Chuang Yang (sores and ulcers), becoming an incurable disease. However, in this case, no sores or ulcers developed later, and he lived to the age of seventy-five before passing away. His discussion states: The disease of Xiao Ke is caused by the predominance of Zao Re (Dryness-Heat). The *Neijing* (Inner Canon) says: "When Heat is excessive, treat it with sweet and bitter flavors; use sweet flavor to drain the heat." Heat damages Qi, and when Qi is damaged, there is a lack of moistening. To reduce heat and tonify Qi, only agents with Gan Han (Sweet-Cold) properties can achieve this. Therefore, Ren Shen (Ginseng Root), Shi Gao (Gypsum Fibrosum), Zhi Gan Cao (Honey-fried Licorice Root), and Sheng Gan Cao (Raw Licorice Root) are used as Jun Yao (Emperor/Chief herbs) for their sweet-cold nature. Qixuanzi (Wang Bing) stated: "Nourish the source of Water to suppress the Yang light (deficient fire)." Therefore, Zhi Mu (Anemarrhena Rhizome), Huang Bo (Phellodendron Bark), Huang Lian (Coptis Rhizome), and Zhi Zi (Gardenia Fruit) are used as Chen Yao (Minister/Assistant herbs) with their bitter-cold nature to drain heat and replenish fluids. Dang Gui (Angelica Sinensis Root), Mai Dong (Ophiopogon Tuber), Xing Ren (Apricot Seed), Quan Xie (Scorpion), Lian Qiao (Forsythia Fruit), Bai Zhi (Angelica Dahurica Root), Bai Kui (likely referring to Bai Lian or similar herb), and Lan Xiang (Basil) are used as Zuo Yao (Adjuvant herbs) with sweet-pungent-cold properties to harmonize blood and moisten dryness. Sheng Ma (Cimicifuga Rhizome) and Chai Hu (Bupleurum Root) with their bitter-neutral properties are used to circulate through the Yangming and Shaoyang meridians. Bai Dou Kou (Cardamom Fruit), Bi Cheng Qie (Long Pepper Fruit), Mu Xiang (Aucklandia Root), and Huo Xiang (Patchouli Herb) are used as Fan Zuo (Reverse Adjuvant) to guide the medicine inward. Jie Geng (Platycodon Root) is heavily used as a Zhou Ji (Boat/Pilot herb) to keep the medicinal action floating upward rather than descending. These were ground into powder. Each dose was two qian, placed in the palm, and licked with the tongue. This reflects the slow and gradual approach to treating this condition.
Yu Zhen's commentary: Ancient and modern formulas for treating Xiao Ke generally rely on using cold-natured herbs to reduce heat, differing only slightly in the proportion of bitter and sweet flavors. Most are straightforward, lacking profound meaning. Only this formula is intricate and nuanced, worthy of careful study.
The *Dongpo Collection* records the case of Jie Yingchen from Meishan, who was seven chi tall, generally healthy, with a robust appetite. He suddenly developed a thirst disease, drinking several dou of water daily, and his food intake doubled. His urination was frequent. After taking medicines for Xiao Ke for over a year, his condition worsened, and he believed he would surely die. A physician from Sichuan, named Zhang, took She Xiang (Musk), moistened it with wine, made more than ten pills, and administered them with a decoction of Zhi Ju Zi (Ardisia Fruit or Hovenia Dulcis Seed). He recovered. When asked for the reason, Dr. Zhang said: "Xiao Ke and Xiao Zhong are all caused by Spleen deficiency and Kidney failure, where Earth cannot control Water, preventing Kidney fluids from ascending, thus forming this disease. However, upon examining Yingchen’s pulse, the Spleen pulse was extremely hot, while the Kidney pulse was not deficient. This was likely due to excessive consumption of alcohol and fruits, leading to accumulated heat in the Spleen, causing polyphagia and polydipsia. Since he drank much, he urinated much. This is not true Xiao Ke. She Xiang resolves the toxicity of alcohol and fruits, and Zhi Ju Zi transforms alcohol into water. Thus, these two herbs were borrowed to eliminate the toxicity of alcohol and fruits."
Yu Zhen's commentary: This patient resembled Xiao Ke but was not actually suffering from it. Dr. Zhang’s insight was exceptionally high, and his prescription was most ingenious.
Wang Shishan treated a woman over thirty years old who frequently suffered from Xiao Ke and easy hunger, weak legs, did not feel cold even in winter, and had cloudy urine with an oily film on top. Her pulses were all fine, weak, and slow, with the right pulse being particularly weak. He said: "This is Pi Dan (Spleen Pox/Heat). It is suitable to use Gan Wen (Sweet-Warm) herbs to assist the Spleen and Gan Han (Sweet-Cold) herbs to moisten dryness. Use Ren Shen (Ginseng Root) and Huang Qi (Astragalus Root) each 1.5 qian, Mai Dong (Ophiopogon Tuber) and Bai Zhu (Atractylodes Macrocephala Rhizome) each 1 qian, Bai Shao (White Peony Root) and Hua Fen (Trichosanthes Root) each 8 fen, Huang Bo (Phellodendron Bark) and Zhi Mu (Anemarrhena Rhizome) each 7 fen. Decoct and take orally, and the illness was cured."
Zhang Jingyue treated Official Zhou, who was over forty years old. Due to fatigue from paperwork, his spirit was exhausted, appetite decreased, and he experienced frequent fear. From winter and spring through summer, he suffered from insomnia throughout the night for over half a year. However, he felt no thirst in the Upper Jiao and had no desire for soups or drinks. Even if he drank a little, it stagnated and did not move. Yet, every night he voided two to three sheng of urine, originating from nowhere specific, and half of it resembled pasty turbid fluid. His body became extremely emaciated, and he considered himself doomed to die. Unexpectedly, upon examination, his pulse still showed a hint of slowness/harmony, and his flesh had not completely wasted away. Knowing that his Stomach Qi remained, he comforted him not to worry. He then prescribed Guipi Tang (Restore the Spleen Decoction) minus Mu Xiang (Aucklandia Root), along with Da Bu Wan (Great Tonifying Pill) decocted together. One formula nourishes Yang, the other nourishes Yin, used alternately. After more than three hundred doses, totaling twenty jin of Ren Shen (Ginseng Root), he fully recovered. This is a syndrome of "Shen (Spirit) wasting above and Jing (Essence) wasting below." It shows that Xiao Ke has Yin and Yang distinctions and cannot be entirely attributed to Fire.
Yu Zhen's commentary: This case is somewhat similar to Wang’s case, but without thirst and inability to drink, already presenting signs of emptiness without fire. Zhang Jingyue liked to use warm herbs, but the so-called "nourishing Yang" here did not include Gui Zhi (Cinnamon Twig) or Fu Zi (Aconite Root). Thus, we know that if Xiao Ke involves thirst, Gui Zhi and Fu Zi are certainly not appropriate. I would add a turning point: Xiao Ke has excess and deficiency patterns; one should not hastily diagnose it as Cold.
Sun Dongsu treated a clerk over fifty years old who indulged in alcohol and sex without restraint. He suddenly developed Xia Xiao (Lower Wasting-Thirst), urinating more than twenty times a day and night. The urine was clear, long, and sweet-tasting, coagulating like fat shortly after, with an oily sheen. Other doctors failed to cure him after half a year. His waist and knees below were weak, unable to support his body, his diet halved, and his spirit and color were greatly exhausted. Sun examined him and found the pulses in all six positions large but powerless. The *Classic* says: "When the pulse follows the disease but does not throb under pressure, all Yang pulses are like this." The treatment method should be to warm and tonify the Lower Jiao. Use Shu Di Huang (Prepared Rehmannia Root) 6 liang as Jun Yao (Chief herb); Lu Jiao Shuang (Deer Antler Glue Powder), Shan Zhu Yu (Cornus Fruit), Sang Piao Xiao (Mantis Egg Case), Lu Jiao Jiao (Deer Antler Glue), Ren Shen (Ginseng Root), Fu Ling (Poria), Gou Qi Zi (Goji Berry), Yuan Zhi (Polygala Root), Tu Si Zi (Dodder Seed), and Shan Yao (Dioscorea Rhizome) each 3 liang as Chen Yao (Minister herbs); Yi Zhi Ren (Alpinia Oxyphylla Fruit) 1 liang as Zuo Yao (Adjuvant herb); Gui Zhi (Cinnamon Twig) and Fu Zi (Aconite Root) each 7 qian as Shi Yao (Envoy herb). Make honey pills. Take four to five qian morning and evening with salt water. He recovered before finishing the course. This syndrome is due to insufficiency of the Lower Yuan, with no Qi ascending to the upper, causing thirst and excessive drinking. Because he drinks much, he urinates much. Now, by greatly tonifying the Lower Yuan, Yang Qi becomes abundant and steams upward, generating Jin Ye (Body Fluids) and stopping thirst.
Yu Zhen's commentary: Sun Dongsu’s case here actually follows Zhongjing’s method of "drinking one dou, urinating one dou," treating with Shen Qi Wan (Kidney Qi Pill). Zhang Gao treated Huang Mian, who suffered from long-term thirst and extreme exhaustion, advising him to take several liang of Ba Wei Wan (Eight-Ingredient Pill), which stabilized him. His learning was profound. However, applying this formula to a patient with "one water and two fires" suffering from Xiao Ke would be a major error. I also read Hua Borun’s case: a Xiao Ke patient was told by a doctor that Kidney deficiency prevented Jin Ye from rising, so he took large pills containing Fu Zi (Aconite Root). His thirst worsened, and eye diseases appeared. Hua criticized this, saying: "This is using fire to aid fire; unless burned, it will dry up." He ordered the cessation of previous medicines, used cold purgatives to wash away fire toxins, and then used bitter-cold moistening agents to cure him. This cannot be compared to the former cases. In my own compilation, I recorded an official suffering from Xiao Ke whom a doctor predicted would die within a month. Another doctor advised him to urgently acquire two loads of northern pears, and after eating them all, he recovered. Emperor Yang of Sui took alchemical pills, his desires became uncontrollable, he slept with dozens of women nightly, and in summer became irritable, drinking hundreds of cups daily yet remaining thirsty. Mo Junxi placed a ice plate before him, instructing him to gaze at it constantly. These are methods beyond standard practice. Others include records in *Bencao* stating that boiling chives lightly and consuming one jin before Qingming Festival cures thirst; Liu Wansu placed a basin of fresh ginger juice in a room with spoons nearby, tricking the patient into entering, smelling the ginger, and eventually drinking it out of desperation. As the ginger juice was consumed, his thirst surprisingly decreased. These all embody the principle of "Pungent flavor moistens" from the *Neijing*. The *Jiaozhou Ji* states that Fu Shi (Floating Stone) is hollow and light; boiling and drinking it treats thirst. Therefore, in *Ben Shi Fang*, Shen Xiao San (Miraculously Effective Powder) uses Fu Shi as the chief herb, truly possessing miraculous efficacy.
I further note: Wind, Cold, Summerheat, Dampness, Dryness, and Fire are the Six Excesses (Six Evils). Jiang’s *Classification of Collected Cases* does not establish a separate category for "Dryness" because diseases involving Dryness are scattered across various categories, and there is no specific "Dryness Disease" to form a standalone class. Therefore, between "Dampness" and "Fire-Heat," "Xiao Ke" is inserted. This is likely because Xiao Ke involves Dryness but not Dampness. This understanding is very correct and deserves its placement here.