人有一生不能言者。此肺窍窒塞。肾气不能上通于咽。如管钥之固闭其窍。不能通呼吸之气
也。若因病而不能语者。惟中风伤寒暴病有之。近有顾允祥之妇。暴怒伤食。喘胀呕逆不止。医
者误认风邪。而与表药。遂昏愦目瞪不语。呼之不省。乃求救于石顽。其脉六部涩伏。知为痰因
气闭所致。本当因势利导。探吐以通其窍。缘病家畏其吐剧。遂与导痰汤加菖蒲、远志。一啜便
能语言。更与前药加槟榔、铁落。得下而安。门人问曰。此病既当探吐。何下之亦能取效。因谓
之曰。治病贵乎圆活。但得开通经络。管钥自空。设用橘皮浓煎。亦可探吐。参芦浓煎。亦可灌
吐。姜汁、竹沥。亦可取吐。在丰稔之家。局方至宝丹、牛黄丸、苏合香丸。皆可取用。奚必拘
于何药方为合剂耶。
经云。二阳结。谓之消。（二阳者阳明也。手阳明大肠主津。病消则目黄口干。是津不足也。
足阳明胃主血。热则消谷善饥。血中伏火。乃血不足也。结者津液不足结而不润。皆燥热为病也。）
瘅成为消中。心移热于肺。传为鬲消。（鬲上烦渴。饮水多而善消。肺气不化小便反少也。）心
移寒于肺。肺消。肺消者饮一溲二。死不治。（君火失政。则阴火乘之。故肺金虽有客热消水。
而下焦真阳失守。溲便反多。故死不治。）大肠移热于胃。善食而瘦。谓之食 。（食 谓食移易
而过。胃热不生肌肉。津液内烁而消见于外也。若胃移热于胆而食 。则有烦热口苦之患矣。）
肾热病者。先腰痛 酸。苦渴数饮身热。有口甘者。病名脾瘅。五味入口。藏于胃。脾为之行其
精气。津液在脾。故令人口甘也。此人必数食甘美而多肥。肥者令人内热。甘者令人中满。故其
气上溢。转为消渴。治之以兰。除陈气也。热中消中。不可服膏
粱芳草石药。石药发癫。芳草发狂。芳草之气美。石药之气悍。二者其气急疾坚劲。非缓心和人。
不可以服。热气留于小肠。肠中痛。瘅热焦渴。则坚干不得出。故痛而闭不通矣。消瘅脉实大。
病久可治。脉悬小坚。病久不可治。金匮云。男子消渴。小便反多。以饮一斗。小便一斗。肾气丸主之。
肾主藏精以施化。若精泄无度。火动不已。则肺气伤燥而思水。水入于胃。不得肺气之化。
不复上归下输。肾病则气不约束调布。岂不饮一斗而出一斗乎。故用肾气丸。全赖桂、附之辛温。
蒸发津气。以润脏腑百骸。岂云专补其肾哉。
脉浮小便不利。微热消渴者。宜利小便发汗。五苓散主之。
此言水气不化之渴。与渴欲饮水。水入即吐。名曰水逆之渴。证虽稍异。而水气阻碍津液则一。
故并宜五苓以输散之。水散则津液灌溉。而渴自已耳。
渴欲饮水不止者。文蛤散主之。
文蛤治伤寒冷水 灌。意欲饮水。反不渴者。是治表之水寒。今治里热而渴饮水不止者。亦
取其咸寒退火。有益水润燥之功。一味而两得之。若治心移热于肺。传为鬲消者尤宜。赵养葵云。
上消者。舌上赤裂。大渴引饮。逆调论谓心移热于肺。传为鬲消者是也。以白虎加人参汤治之。
中消者。善食而瘦自汗。大便硬。小便数。瘅成为消中者是也。以调胃承气汤治之。下消者。烦
躁引饮。耳叶焦干。小便如膏。此肾消也。六味丸治之。古人治三消之法。详别如此。余又有一
说焉。人之水火得其平。气血得其养。何消之有。其间调摄
失宜。水火偏胜。津液枯槁。以致龙雷之火上炎。熬煎既久。肠胃合消。五脏干燥。令人四肢瘦
削。精神倦怠。故治消之法。无分上中下。先治肾为急。惟六味、八味、加减八味。随证而服。
降其心火。滋其肾水。则渴自止矣。白虎与承气。非其所治也。总之是下焦命门火不归元。游于
肺则为上消。游于胃即为中消。以八味肾气丸引火归元。使火在釜底。水火既济。气上熏蒸。肺
受湿润。而渴疾愈矣。或□。人有服地黄汤而渴仍不止者。何也。曰。心肺位近。宜制小其服。
肾肝位远。宜制大其服。如上消中消。可以用前丸缓治。若下消已虚。大渴大燥。须加减八味丸
料一斤。肉桂一两。水煎六七碗。恣意冰冷服之。熟睡而渴病如失矣。处方之制存乎人之变通耳。
有等渴欲引饮。但饮水不过一二口即厌。少顷复渴。饮亦不过若此。但不若消渴者之饮水□厌也。
此是中气虚寒。寒水泛上。逼其浮游之火于咽喉口舌之间。故上焦一段。欲得水救。若到中焦。
以水见水。正其所恶也。治法。如面红烦躁者。理中汤送八味丸。
喻嘉言曰。消渴之患。常始于微而成于着。始于胃而极于肺肾。始如以水沃焦。水入犹能消
之。既而以水投石。水去而石自若。至于饮一溲一。饮一溲二。则燥火劫其真阴。操立尽之势而
成 矣。内经有其论。无其治。金匮有论有治也。而集书者。采伤寒论厥阴经消渴之文凑入。
后人不能决择。斯亦不适于用也。盖伤寒传经热邪。至厥阴而尽。热势入深。故渴而消水。及热
解则不渴。且不消矣。岂杂证积渐为患之比乎。谨从内经拟议言之。经谓治消瘅仆击。偏枯痿厥。
气满发逆。肥贵人则膏粱之疾也。此中消之所由来也。肥而不贵。食弗给于鲜。贵而不肥。餐弗
过于饕。肥而且贵。醇酒浓味。孰为限量哉。久之食饮酿成内热。津液干涸。求济于水。然水入
尚能消之也。愈消愈渴。其膏粱愈无已。而中消之病成矣。夫既瘅成为消中。随其或上或下。火
热炽盛之区。以次传入矣。上消者。胃以其热上输于肺。
而子受母累。心复以其热移之于肺。而金受火刑。金者。生水而出高源者也。饮入胃中。游溢精
气而上。则肺通调水道而下。今火热入之。高源之水。为炎威所逼。合外饮之水。建瓴而下。饮
一溲二。不但不能消外水。且并素酝水精。竭绝而尽输于下。较大府之暴注暴泄。尤为甚矣。故
死不治也。至于胃以其热由关门下传于肾。肾或以石药耗其真。女劳竭其精者。阳强于外。阴不
内守。而小溲混浊如膏。饮一溲二。肾消之病成矣。故肾者胃之关也。关门不开。则水无输泄而
为肿满。关门不闭。则无底止而为消渴。消渴属肾一证。金匮原文未脱。其曰饮一斗溲一斗者。
肾气丸主之。于此蒸动精水。上承君火。而止其下入之阳光。此正通天手眼。张子和辄敢诋之。
既诋仲景。复谀河间。谓其神芎丸。以黄芩味苦入心。牵牛、大黄驱火气而下。以滑石引入肾经。
将离入坎。真得黄庭之秘。颠倒其说。阿私所好。识趣卑陋若此。又何足以入仲景之门哉。何柏
斋消渴论中已辨其非。吾观戴人吐下诸按中。从无有治消渴一案者。然以承气治壮火之理。施之
消渴。又无其事矣。故以下消之火。水中之火也。下之则愈燔。中消之火。竭泽之火也。下之则
愈伤。上消之火。燎原之火也。水从天降可灭。徙攻肠胃。无益反损。夫地气上为云。然后天气
下为雨。是故雨出地气。地气不上。天能雨乎。故亟升地气以慰三农。与亟蒸肾水以溉三焦。皆
事理之必然者耳。内经曰。心移热于肺。传为鬲消。戴人谓膈消犹未及于肺。至心移寒于肺。乃
为肺消。如此泥文害意。非能读内经者也。要识心肺同居膈上。肺为娇脏。移寒移热。总之易入。
但寒邪入而外束。热邪入而内传。均一肺消。而治则有分矣。肾消之病。古曰强中。又谓内消。
多因恣意色欲。或饵金石。肾气既衰。石气独在。精髓失养。故常发虚阳。不交精出。小便无度。
唇口干焦。加减八味丸。用生脉散下。千金云。有人苦热不已。皆由服石所致。种种服饵。不能制止。惟朴硝
煎。可以定之。男子消渴。饮一斗。溲一斗者。肾气丸。饮一溲二者难治。渴家误作火治。凉药
乱投。促人生命。宜多服生脉散滋养之。上焦蕴热消渴。小便赤涩。清心莲子饮。心膈有热。久
则引饮为消渴。名曰鬲消。胃满烦心。津液短少。宣明麦门冬饮子。老弱之人大渴。易老门冬饮。
消中能食而瘦。口舌干枯。大渴引饮自汗。大便秘燥。小便频数。兰香饮子。烦热大渴。引饮不
止。脉大滑实。甘露饮子。胃热口臭。烦渴引饮。面赤唇干。气口脉短滑者。泻黄散。食已如饥。
胃热消谷。阳明脉盛。心火上行。面黄肌瘦。胸满胁胀。小便赤涩。七味白术散。心膈有热消渴。
咽干面赤。生料固本丸加黄 、甘草、石斛、泽泻、枇杷叶。脉浮小便不利。微热消渴。或渴饮
水多停。蓄不散。心下辘辘有声。小便不利者。并宜五苓散。若热渴不止。加人参。三消久而小
便不臭。反作甜气。此脾气下脱。为病最重。七味白术散。有溺桶中浮在面上如猪脂溅在桶边。
或如地沥青者。此肾虚不能约制。脾胃之膏液下流。用白术散、肾气丸。可救十之一二。脾消之证。
饮食入腹。如汤沃雪。随小便而出。出于溷僻沟渠。皆旋结如白。肌肤日消。用热药则愈甚。用
凉药则愈虚。不能起止。精神恍惚。口舌焦干。或阳强兴盛。不交而泄。不久当毙。孙真人云。
消渴之人。愈与未愈。常须思虑有大痈。何者。消渴之人。必于大骨间发痈疽而卒。所以专虑发大痈也。
〔诊〕石顽曰。经言消瘅脉实大。病久可治。脉悬小坚。病久不可治。见消证脉显实大。为证
脉相符。虽久可治。若见悬小而坚。不但脉不应病。且真脏发露。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。大抵北人消瘅。脉多沉石滑数。以北方寒
水司权。且素食煤火。肾气多浓。故用刘张寒泻之法。往往获效。然间有恃力作强。以水为事。
乃致虚阳不守。封藏不固。而见右尺数大。为下消者。亦有真阴耗竭。肾气不升。肺脏枯燥。而
见寸口数盛。为上消者。又有竭力房室。服食 悍。火土太强。恣意饮啖。而见气口动滑。为中
消者。又不可限以风土。急须导火壮水。除陈气等法。若大江以南。木气始生之界。患消瘅者。
从无沉石之脉。即有滑数。按之必濡。多有尺内见弦。及气口命门大数。或两寸浮滑者。以东南
水土孱薄。虚阳属动。肾水易亏。当确遵金匮东垣养葵。犹恐不及。况可效用刘张之法乎。至若
庾岭而南。消瘅之脉。亦绝无沉石之候。多见浮大数盛。外示有余。中实不足。以其阳气泄而不
藏。肾气溢而不满。故其治仅可用辛凉以清其热。甘寒以滋其阴。若辛热导火。苦寒泻气等药。
总无于预也。至于临病审察。又当随左右尺寸之太过不及。而为决断。太过见于寸口。多为气病。
不及见于尺内。多为肾虚。又在左偏弦。为精髓受伤。在右偏旺。为虚阳发露。然其邪皆自内发。
故表证表脉绝少。即金匮五苓散一条。亦是水气不化。津液不行而渴。故显脉浮。小便不利。微
热消渴之证。见消瘅虽有浮脉。亦是客邪为患。非此证之本脉。故特表而出之。
石顽治太学赵雪访。消中善食。日进膏粱数次。不能敌其饥势。丙夜必进二餐。食过即昏昏
嗜卧。或时作酸作甜。或时梦交精泄。或时经日不饮。或时引饮不彻。自言省试劳心所致。询其
先前所服之药。屡用安神补心。滋阴清火。俱不应。延至麦秋。其证愈剧。始求治于石顽。察其
声音。浊而多滞。其形虽肥盛色苍。而肌肉绵软。其脉六部皆洪滑而数。惟右关特甚。其两尺亦
洪滑。而按之少神。此肾气不充。痰湿挟阴火泛溢于中之象。遂与加味导痰加兰香。数服。其势
大减。次以六君子合佐金。枳实汤泛丸服。后以六味丸去地黄。加鳔胶、蒺藜。平调两月而康。
又治朔客白小楼。中消善食。脾约便艰。察其形。瘦而质坚。诊其脉。数而有力。时喜饮冷气酒。
此酒之湿热内蕴为患。遂以调胃承气三下。破其蕴热。次与滋肾丸数服。涤其余火而安。
又治粤客李之 。上消引饮。时当三伏。触热到吴。初时自汗发热。烦渴引饮。渐至溲便频
数。饮即气喘。饮过即渴。察其脉象。惟右寸浮数动滑。知为热伤肺气之候。因以小剂白虎加人
参。三服。其势顿减。次与生脉散。调理数日而痊。
又治薛廉夫子。强中下消。饮一溲二。因新娶继室。真阴灼烁。虚阳用事。阳强不倒。恣肆
益甚。乃至气息不能相续。精滑不能自收。背曲肩随。腰胯疼软。足膝痿弱。寸步艰难。糜粥到
口即厌。惟喜膏粱方物。其脉或时数大少力。或时弦细数疾。此阴阳离决。中空不能主持。而随
虚火辄内辄外也。峻与八味、肾气、保元、独参。调补经年。更与六味地黄。久服而瘥。
又牙行邵渭宾。仲夏与一婢通。因客至惊恐。精气大脱。即凛凛畏寒。翕翕发热。畏食畏饮。
小便淋沥不禁。邀石顽诊之。六脉弦细如丝。责责如循刀刃。此肾中真阳大亏之兆。令服生料六
味。稍加桂、附以通阳气。其左右亲戚。咸谓夏暑不宜桂、附。另延一医。峻用人参、附子月余。
一个人一生都不能说话。这是因为肺窍闭塞，肾气不能上通至咽喉，就像锁钥紧紧封闭了孔窍，导致呼吸之气无法通畅。如果是因病而不能说话，只有中风、伤寒等突发疾病才会有这种情况。近来有顾允祥的妻子，因暴怒且伤食，出现喘息、腹胀、呕吐逆气不止的症状。医生误认为是风邪，给予解表药物，结果导致患者昏迷、两眼直视、不能说话，呼唤也不清醒。于是向石顽（张璐号）求救。诊察发现其六部脉象皆涩伏，判断这是痰浊因气机闭阻所致。本应当顺势利导，采用探吐法以开通其窍。但因为病家害怕剧烈的呕吐反应，于是给予导痰汤加石菖蒲、远志，喝一次后便能说话。随后又给前方加入槟榔、铁落，服药后大便通畅而病情安定。门人问道：这个病既然应当探吐，为什么用泻下法也能取效？对此解释说：治病贵在灵活变通，只要能够开通经络，管钥自然空虚。假如使用浓煎的橘皮，也可以探吐；参芦浓煎，也可以灌服催吐；姜汁、竹沥，也可以用来取吐。在富裕人家，局方至宝丹、牛黄丸、苏合香丸，都可以选用。何必拘泥于某种药方才算合适呢？
《内经》说：二阳结，称为消。（二阳指阳明经。手阳明大肠主管津液，患消渴病则目黄口干，这是津液不足的表现。足阳明胃主管血分，热盛则消谷善饥，血中伏火，这是血分不足的表现。所谓“结”，是指津液不足，凝结而不滋润，都是燥热引起的疾病。）瘅热发展为消中，心将热邪移于肺，传变为鬲消。（膈上烦渴，饮水多且易消化，肺气不化，小便反而减少。）心将寒邪移于肺，形成肺消。肺消表现为饮水一分，排尿二分，属于死证，难以治愈。（君火失政，则阴火乘虚而入，所以肺金虽有客热消耗水分，但下焦真阳失守，小便反而增多，因此死亡难治。）大肠将热邪移于胃，食欲旺盛但身体消瘦，称为食ite（注：原文此处可能有缺字或异体字，通常指“食ite”或类似症状，意为饮食易消化但身体消瘦）。食ite是指食物经过肠胃很快排空。胃热导致肌肉不生，津液内耗而消瘦见于外表。如果胃将热邪移于胆而出现食ite，则会有烦热口苦的病患。肾热病患者，先出现腰痛、酸软，苦于口渴频饮，身体发热。口中发甜的，病名为脾瘅。五味入口，藏于胃，脾为之运行精气。津液存留于脾，所以使人嘴里发甜。这种人一定经常吃甘甜美味且多脂肪的食物。肥腻食物使人产生内热，甘甜食物使人中焦胀满，所以其气上溢，转化为消渴。治疗用兰草，以去除陈积之气。热中和消中的病人，不可服用膏粱厚味、芳草及石药。石药会引发癫狂，芳草会引发狂躁。芳草的气味芳香，石药的性质猛烈，这两种药的气机急疾坚劲，不是心境平和的人可以服用的。热气停留于小肠，肠中疼痛，瘅热焦渴，导致大便坚硬干燥无法排出，所以疼痛且闭塞不通。消瘅病脉象实大，病程久者可治；脉象悬小坚劲，病程久者不可治。《金匮要略》说：男子消渴，小便反多，以饮一斗，小便一斗，用肾气丸主治。肾主藏精以施化，如果精泄无度，火动不已，则肺气受伤干燥而思水。水进入胃中，得不到肺气的转化，不再向上回归向下输布。肾病则气不能约束调布，难道不是饮一斗而出一斗吗？所以用肾气丸，全赖桂枝、附子的辛温，蒸发津气，以滋润脏腑百骸，岂能说是专门补肾呢？
脉浮，小便不利，微热，消渴的，宜利小便发汗，用五苓散主治。
这是说水气不化引起的口渴，与渴欲饮水、水入即吐，名叫水逆的口渴，证候虽然稍有不同，但都是水气阻碍津液，所以都适宜用五苓散来输布消散。水气消散则津液灌溉，口渴自然停止。
渴欲饮水不止的，用文蛤散主治。
文蛤治疗因受寒冷冷水浇灌，想要饮水，反而不渴的情况，这是治疗体表的水寒。现在治疗里热而渴、饮水不止的情况，也是取其咸寒退火，有益水润燥的功效。一味药兼得两种功效。如果是治疗心移热于肺，传为鬲消的情况尤其适宜。赵养葵说：上消，舌上赤裂，大渴引饮，《逆调论》说心移热于肺，传为鬲消，就是用白虎加人参汤治疗。中消，善食而瘦，自汗，大便硬，小便数，是瘅成为消中，用调胃承气汤治疗。下消，烦躁引饮，耳叶焦干，小便如膏，这是肾消，用六味丸治疗。古人治疗三消的方法，详细区别如此。我又有一种说法：人的水火得到平衡，气血得到滋养，哪里有消渴之病呢？其间调养失宜，水火偏胜，津液枯槁，以致龙雷之火上炎，熬煎日久，肠胃俱消，五脏干燥，令人四肢瘦削，精神倦怠。所以治疗消渴的方法，不分上中下，先治肾为急，只用六味、八味、加减八味丸，随证服用，降其心火，滋其肾水，则口渴自然停止。白虎汤和承气汤不是它们所适用的。总之是下焦命门之火不归元，游移至肺则为上消，游移至胃即为中消，用八味肾气丸引火归元，使火在釜底，水火既济，气上熏蒸，肺受湿润，而渴疾痊愈。或者有人问：有人服用地黄汤而口渴仍不止，为什么呢？回答说：心肺位置近，宜制小其服；肾肝位置远，宜制大其服。如上消中消，可以用前面的丸剂缓治。若下消已虚，大渴大燥，须用加减八味丸料一斤，肉桂一两，水煎六七碗，恣意冰冷服用。熟睡之后，渴病如同消失。处方的剂量在于人的变通罢了。
有一种情况是渴欲引饮，但饮水不过一二口就厌恶，过一会儿又渴，喝也不过如此，但不像消渴者那样饮水不知厌。这是中气虚寒，寒水泛上，逼迫其浮游之火于咽喉口舌之间，所以上焦一段想要得水救助，若到了中焦，以水见水，正是它所厌恶的。治疗方法：如面红烦躁者，用理中汤送服八味丸。
喻嘉言说：消渴之患，常始于轻微而成于显著，始于胃而极于肺肾。开始像用水浇烧红的铁块，水入还能被蒸发；后来像用水投石头，水去而石头依旧。至于饮一溲一，饮一溲二，则是燥火劫夺真阴，处于立刻死亡的态势而成了废人。《内经》有其论述，没有其治法；《金匮要略》既有论述又有治法。但编纂书籍的人，采集《伤寒论》厥阴经消渴的文字凑入其中，后人不能决择，这也不适用于临床。盖伤寒传经热邪，至厥阴而尽，热势入深，所以渴而消水，等到热解则不渴，且不消了。这哪里是杂病积渐为患相比的呢？谨从《内经》拟议而言。《内经》说治疗消瘅、仆击、偏枯、痿厥、气满发逆，肥贵人则是膏粱之疾。这是中消的由来。肥而不贵，食物不给新鲜；贵而不肥，饮食不过于贪婪。既肥又贵，醇酒浓味，谁有限量呢？久而久之，饮食酿成内热，津液干涸，求济于水，然而水入尚能被蒸发。愈消愈渴，其膏粱无已，而中消之病形成了。既然瘅成为消中，随着或上或下，火热炽盛的区域，依次传入。上消，胃以其热上输于肺，子受母累，心复以其热移之于肺，金受火刑。金生水，出自高源。饮入胃中，游溢精气而上，则肺通调水道而下。今火热入之，高源之水，为炎威所逼，合外饮之水，建瓴而下，饮一溲二，不但不能消外水，且并素酝水精，竭绝而尽输于下，比大肠的暴注暴泄更为严重，所以死不治。至于胃以其热由关门下传于肾，肾或以石药耗其真阴，女劳竭其精者，阳强于外，阴不内守，而小便混浊如膏，饮一溲二，肾消之病形成了。所以肾是胃的关隘。关门不开，则水无输泄而为肿满；关门不闭，则无底止而为消渴。消渴属肾一证，《金匮》原文未脱漏，其曰饮一斗溲一斗者，肾气丸主治。于此蒸动精水，上承君火，而止其下入之阳光，这正是通天手段。张子和辄敢诋毁它，既诋毁仲景，又谄媚河间，谓其神芎丸，以黄芩味苦入心，牵牛、大黄驱火气而下，以滑石引入肾经，将离入坎，真得黄庭之秘，颠倒其说，阿私所好，识趣卑陋如此，又怎么足以进入仲景之门呢？何柏斋消渴论中已辨其非。我观戴人吐下诸案中，从无有治消渴一案者。然以承气治壮火之理，施之消渴，又无其事矣。故以下消之火，是水中之火也，下之则愈燃；中消之火，是竭泽之火也，下之则愈伤；上消之火，是燎原之火也，水从天降可灭，徙攻肠胃，无益反损。夫地气上为云，然后天气下为雨，是故雨出地气，地气不上，天能雨乎？故亟升地气以慰三农，与亟蒸肾水以溉三焦，皆是事理之必然者耳。《内经》曰：心移热于肺，传为鬲消。戴人谓膈消犹未及于肺，至心移寒于肺，乃为肺消。如此泥文害意，非能读《内经》者也。要识心肺同居膈上，肺为娇脏，移寒移热，总之易入。但寒邪入而外束，热邪入而内传，均一肺消，而治则有分矣。肾消之病，古曰强中，又谓内消，多因恣意色欲，或饵金石，肾气既衰，石气独在，精髓失养，故常发虚阳，不交精出，小便无度，唇口干焦，用加减八味丸，用生脉散送下。《千金方》云：有人苦热不已，皆由服石所致，种种服饵，不能制止，惟朴硝煎可以定之。男子消渴，饮一斗，溲一斗者，肾气丸；饮一溲二者难治。渴家误作火治，凉药乱投，促人生命，宜多服生脉散滋养之。上焦蕴热消渴，小便赤涩，用清心莲子饮。心膈有热，久则引饮为消渴，名曰鬲消，胃满烦心，津液短少，用宣明麦门冬饮子。老弱之人大渴，用易老门冬饮。消中能食而瘦，口舌干枯，大渴引饮自汗，大便秘燥，小便频数，用兰香饮子。烦热大渴，引饮不止，脉大滑实，用甘露饮子。胃热口臭，烦渴引饮，面赤唇干，气口脉短滑者，用泻黄散。食已如饥，胃热消谷，阳明脉盛，心火上行，面黄肌瘦，胸满胁胀，小便赤涩，用七味白术散。心膈有热消渴，咽干面赤，用生料固本丸加黄芪、甘草、石斛、泽泻、枇杷叶。脉浮小便不利，微热消渴，或渴饮水多停，蓄不散，心下辘辘有声，小便不利者，并宜五苓散。若热渴不止，加人参。三消久而小便不臭，反作甜气，此脾气下脱，为病最重，用七味白术散。有溺桶中浮在面上如猪脂溅在桶边，或如地沥青者，此肾虚不能约制，脾胃之膏液下流，用白术散、肾气丸，可救十之一二。脾消之证，饮食入腹，如汤沃雪，随小便而出，出于溷僻沟渠，皆旋结如白，肌肤日消，用热药则愈甚，用凉药则愈虚，不能起止，精神恍惚，口舌焦干，或阳强兴盛，不交而泄，不久当毙。孙真人云：消渴之人，愈与未愈，常须思虑有大痈。何者？消渴之人，必于大骨间发痈疽而卒。所以专虑发大痈也。
〔诊〕石顽说：《内经》言消瘅脉实大，病久可治；脉悬小坚，病久不可治。见消证脉显实大，为证脉相符，虽久可治。若见悬小而坚，不但脉不应病，且真脏发露，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。大抵北人消瘅，脉多沉石滑数，以北方寒水司权，且素食煤火，肾气多浓，故用刘张寒泻之法，往往获效。然间有恃力作强，以水为事，乃致虚阳不守，封藏不固，而见右尺数大，为下消者。亦有真阴耗竭，肾气不升，肺脏枯燥，而见寸口数盛，为上消者。又有竭力房室，服食悍烈，火土太强，恣意饮啖，而见气口动滑，为中消者。又不可限以风土，急须导火壮水，除陈气等法。若大江以南，木气始生之界，患消瘅者，从无沉石之脉，即有滑数，按之必濡，多有尺内见弦，及气口命门大数，或两寸浮滑者。以东南水土孱薄，虚阳属动，肾水易亏，当确遵金匮、东垣、养葵，犹恐不及，况可效用刘张之法乎？至若庾岭而南，消瘅之脉，亦绝无沉石之候，多见浮大数盛，外示有余，中实不足，以其阳气泄而不藏，肾气溢而不满，故其治仅可用辛凉以清其热，甘寒以滋其阴，若辛热导火，苦寒泻气等药，总无于预也。至于临病审察，又当随左右尺寸之太过不及，而为决断。太过见于寸口，多为气病；不及见于尺内，多为肾虚。又在左偏弦，为精髓受伤；在右偏旺，为虚阳发露。然其邪皆自内发，故表证表脉绝少，即金匮五苓散一条，亦是水气不化，津液不行而渴，故显脉浮，小便不利，微热消渴之证。见消瘅虽有浮脉，亦是客邪为患，非此证之本脉，故特表而出之。
石顽治疗太学赵雪访，消中善食，日进膏粱数次，不能敌其饥势，丙夜必进二餐，食过即昏昏嗜卧，或时作酸作甜，或时梦交精泄，或时经日不饮，或时引饮不彻，自言省试劳心所致。询其先前所服之药，屡用安神补心，滋阴清火，俱不应。延至麦秋，其证愈剧，始求治于石顽。察其声音，浊而多滞，其形虽肥盛色苍，而肌肉绵软，其脉六部皆洪滑而数，惟右关特甚，其两尺亦洪滑，而按之少神，此肾气不充，痰湿挟阴火泛溢于中之象。遂与加味导痰加兰香，数服，其势大减。次以六君子合佐金枳实汤泛丸服，后以六味丸去地黄，加鳔胶、蒺藜，平调两月而康。
又治疗朔客白小楼，中消善食，脾约便艰。察其形，瘦而质坚，诊其脉，数而有力，时喜饮冷气酒，此酒之湿热内蕴为患。遂以调胃承气三下，破其蕴热，次与滋肾丸数服，涤其余火而安。
又治疗粤客李之ite，上消引饮，时当三伏，触热到吴。初时自汗发热，烦渴引饮，渐至溲便频数，饮即气喘，饮过即渴。察其脉象，惟右寸浮数动滑，知为热伤肺气之候。因以小剂白虎加人参，三服，其势顿减。次与生脉散，调理数日而痊。
又治疗薛廉夫子，强中下消，饮一溲二。因新娶继室，真阴灼烁，虚阳用事，阳强不倒，恣肆益甚，乃至气息不能相续，精滑不能自收，背曲肩随，腰胯疼软，足膝痿弱，寸步艰难，糜粥到口即厌，惟喜膏粱方物。其脉或时数大少力，或时弦细数疾，此阴阳离决，中空不能主持，而随虚火辄内辄外也。峻与八味、肾气、保元、独参，调补经年，更与六味地黄，久服而瘥。
又牙行邵渭宾，仲夏与一婢通，因客至惊恐，精气大脱，即凛凛畏寒，翕翕发热，畏食畏饮，小便淋沥不禁。邀石顽诊之，六脉弦细如丝，责责如循刀刃，此肾中真阳大亏之兆。令服生料六味，稍加桂、附以通阳气。其左右亲戚，咸谓夏暑不宜桂、附，另延一医，峻用人参、附子月余。
There are individuals who cannot speak throughout their entire lives. This is due to the obstruction of the lung orifices, where Kidney Qi fails to ascend to the throat, akin to a lock firmly sealing the aperture, preventing the free flow of respiratory Qi. If the inability to speak arises from illness, it occurs only in sudden diseases such as wind-stroke (Zhong Feng) and cold damage (Shang Han). Recently, the wife of Gu Xunxiang suffered from violent anger and food stagnation, presenting with panting, abdominal distension, and incessant vomiting and regurgitation. The physician mistakenly diagnosed it as wind pathogen and administered exterior-releasing herbs, resulting in coma, staring eyes, aphasia, and unresponsiveness to calls. She sought help from Shi Wan (Zhang Lu's pseudonym). Examination revealed a choppy and submerged pulse in all six positions, indicating that phlegm was caused by Qi closure. Ideally, one should follow the momentum and induce vomiting to open the orifices. However, fearing severe vomiting, the family was given Dao Tan Tang (Phlegm-Draining Decoction) supplemented with Chang Pu (Acori Tatarinowii Rhizoma) and Yuan Zhi (Polygalae Radix). After one dose, speech was restored. Subsequently, Bing Lang (Arecae Semen) and Tie Luo (Iron Filings) were added to the formula; after defecation, the patient recovered. A disciple asked: Since this condition requires induced vomiting, why does purgation also yield results? I replied: Treating disease requires flexibility. As long as the meridians are unblocked, the "lock" naturally opens. For instance, concentrated decoction of Chen Pi (Citri Reticulatae Pericarpium) can induce vomiting; Shen Lu (Ginseng Radicis Caulis) concentrated decoction can be灌ed to induce vomiting; Jiang Zhi (Zingiberis Recens Juice) and Zhu Li (Bambusae Succus) can also induce vomiting. In wealthy households, Ju Fang Zhi Bao Dan (Official Formula Treasure Box Pill), Niu Huang Wan (Calculus Bovis Pill), and Su He Xiang Wan (Styrax Pill) are all usable. Why insist on a specific formula?
The Classic states: "Obstruction of the Two Yangs is called Xiao (Wasting-Thirst)." (The Two Yangs refer to the Yangming channels. Hand-Yangming Large Intestine governs body fluids; in Wasting-Thirst, there is yellowing of the eyes and dry mouth, indicating fluid deficiency. Foot-Yangming Stomach governs blood; heat causes rapid digestion and hunger, with latent fire in the blood, indicating blood deficiency. "Obstruction" means insufficient fluids leading to coagulation and lack of moistening, all caused by dryness-heat.) "Dan heat develops into Xiao Zhong (Middle Wasting); Heart transfers heat to the Lung, transmitting as Ge Xiao (Diaphragm Wasting)." (Irritability and thirst above the diaphragm, drinking much and digesting quickly, lung Qi fails to transform, resulting in reduced urination.) "Heart transfers cold to the Lung, forming Fei Xiao (Lung Wasting)." (Fei Xiao presents as drinking one part and urinating two parts; it is incurable/deadly. When Minister Fire loses control, Yin Fire takes over. Although Lung Metal has exogenous heat consuming water, the True Yang of the Lower Jiao fails to hold, causing increased urination, hence death.) "Large Intestine transfers heat to the Stomach, causing excessive eating but emaciation, called Shi Yi (Food Migration/Easy Digestion)." (Shi Yi refers to food passing through quickly. Stomach heat prevents muscle formation, internal consumption of fluids leads to external emaciation. If Stomach heat transfers to Gallbladder, irritability and bitter taste occur.) "Kidney Heat Disease begins with lower back pain and soreness, bitterness and thirst with frequent drinking, and body heat. Sweet taste in the mouth indicates Pi Dan (Spleen Heat)." (Five flavors enter the mouth and store in the Stomach; the Spleen distributes their essence. Fluids remaining in the Spleen cause sweet taste. Such individuals likely consume excessive sweet, fatty foods. Fatty foods generate internal heat; sweet foods cause middle Jiao fullness. Thus, Qi overflows upward, transforming into Xiao Ke (Wasting-Thirst). Treatment uses Lan Cao (Orchid Herb) to remove stale Qi.) Patients with Re Zhong (Internal Heat) and Xiao Zhong must avoid rich foods (Gao Liang), fragrant herbs (Fang Cao), and mineral drugs (Shi Yao). Mineral drugs cause mania; fragrant herbs cause frenzy. Their qi is rapid and forceful, unsuitable for those without calm hearts. Heat lingering in the Small Intestine causes pain; Dan heat scorches and thins, making stool hard and dry, leading to painful obstruction. Pulse in Xiao Dan is excess-large (curable if chronic) or suspended-small-firm (incurable if chronic). *Jin Gui* states: "Men with Wasting-Thirst have excessive urination; drinking one dou yields one dou of urine; treat with Shen Qi Wan." Kidney stores essence for transformation. Excessive loss of essence and restless fire injure Lung Dryness, causing thirst. Water entering the Stomach lacks Lung transformation to circulate. Kidney failure to constrain leads to 1:1 output ratio. Shen Qi Wan relies on Gui Zhi (Cinnamomi Ramulus) and Fu Zi (Aconiti Lateralis Radix Praeparata) for acrid-warmth to evaporate fluids and moisten organs, not merely tonifying Kidney.
Pulse floating, difficult urination, slight fever, and Wasting-Thirst indicate need for diuresis and sweating; treat with Wu Ling San (Polyporus Powder). This addresses thirst from failing water-Qi transformation, similar to Shui Ni (Water-Reversal) where drinking leads to vomiting. Both involve water-Qi blocking fluids, so Wu Ling San disperses water, allowing fluid irrigation and stopping thirst.
For incessant thirst and desire to drink, use Wen Sha San (Clam Shell Powder). Wen Sha treats cold-water exposure causing thirst without actual dryness (exterior cold-water). Here, it treats interior heat-thirst using its salty-cold nature to clear fire and moisten dryness. It is particularly suitable for Heart transferring heat to Lung (Ge Xiao). Zhao Yangkui states: Upper Xiao features red cracks on the tongue and extreme thirst; treated with Bai Hu Jia Ren Shen Tang (White Tiger Plus Ginseng Decoction). Middle Xiao features polyphagia, emaciation, spontaneous sweating, constipation, and frequent urination; treated with Tiao Wei Cheng Qi Tang (Regulate the Stomach Order the Qi Decoction). Lower Xiao features irritability, thirst, dry earlobes, and greasy urine (Kidney Xiao); treated with Liu Wei Wan (Six-Ingredient Pill with Rehmannia). Ancient methods distinguish these clearly. My view: When Water-Fire balance and Qi-Blood nourishment exist, no Wasting-Thirst occurs. Improper regulation causes Fire-Water imbalance, fluid depletion, and Dragon-Leopard Fire flaming upward, scorching intestines and drying five viscera, leading to emaciation and fatigue. Thus, treating Wasting-Thirst prioritizes the Kidney regardless of upper/middle/lower classification, using Liu Wei, Ba Wei, or Jia Jian Ba Wei Wan to descend Heart Fire and nourish Kidney Water. Bai Hu and Cheng Qi formulas are inappropriate. Ultimately, Ming Men Fire fails to return to its source; wandering to Lung causes Upper Xiao, to Stomach causes Middle Xiao. Ba Wei Shen Qi Wan guides fire back to source, achieving Water-Fire interaction, steaming moisture to the Lung. Some ask why Di Huang Tang fails for some. Answer: Heart/Lung are proximal (small dosage); Kidney/Liver are distant (large dosage). For Lower Xiao with severe dryness/thirst, use one jin of Jia Jian Ba Wei Wan material plus one liang of Rou Gui, decocted in seven bowls, taken cold while sleeping. Prescription dosage depends on flexibility.
Some desire to drink but reject water after one or two sips, then become thirsty again. This is Middle Qi deficiency-cold with cold-water flooding upward, forcing floating fire to the throat/mouth. Upper Jiao seeks water relief, but Middle Jiao rejects water. Treat with Li Zhong Tang (Regulate the Middle Decoction) delivering Ba Wei Wan if face is red and irritable.
Yu Jiayan states: Wasting-Thirst starts mild and becomes severe, starting in Stomach and ending in Lung/Kidney. Initially like water on hot iron (evaporates); later like water on stone (passes through). Drinking one, urinating one or two indicates true Yin depletion by dry-fire, leading to imminent death. *Nei Jing* discusses but lacks treatment; *Jin Gui* has both. Compilers incorrectly inserted *Shang Lun* Jueyin chapter text, confusing later generations. *Shang Lun* heat resolves without thirst; unlike chronic mixed diseases. *Nei Jing* says treating Xiao Dan, stroke, hemiplegia, flaccidity, and reverse Qi relates to rich people's dietary issues (Middle Xiao origin). Fat but poor eat poorly; noble but thin eat moderately; fat and noble consume unlimited rich food, creating internal heat and fluid depletion. Thirst increases, Middle Xiao forms. Heat spreads upward to Lung (Upper Xiao) or downward to Kidney (Lower Xiao). Upper Xiao: Stomach heat transmits to Lung, Heart heat transfers to Lung, Metal suffers Fire punishment. High source water is forced down by heat, causing 1:2 urine ratio, exhausting essence, worse than acute diarrhea, thus fatal. Lower Xiao: Stomach heat transmits to Kidney via gate; Kidney essence depleted by minerals or sexual excess, Yang strong externally, Yin insecure internally, urine greasy, 1:2 ratio, Kidney Xiao forms. Kidney is Stomach's gate. Open gate causes edema; closed gate causes Wasting-Thirst. *Jin Gui* prescribes Shen Qi Wan for 1:1 ratio to steam essence upward. Zhang Zihe criticized this, praising He Jian's Shen Xiong Wan instead, which is biased and shallow. He Baixai refuted this. Dai Ren never treated Wasting-Thirst with purgation. Lower Xiao fire is fire in water; purging intensifies it. Middle Xiao fire is fire in drained pond; purging damages it. Upper Xiao fire is prairie fire; extinguished by rain, not gut attack. Earth Qi rises to form clouds, Heaven Qi falls as rain. Must raise Earth Qi (steep Kidney Water) to irrigate Three Jiao. *Nei Jing*: Heart heat to Lung is Ge Xiao. Dai Ren confused this with Lung Xiao (Cold). Heart and Lung share the diaphragm; Lung is delicate, susceptible to both cold and heat. Cold binds externally, heat transmits internally; treatments differ. Kidney Xiao (Qiang Zhong/Nei Xiao) often from lust or minerals, causing deficient Yang, nocturnal emission, incontinence, dry lips, treated with Jia Jian Ba Wei Wan delivered by Sheng Mai San. *Qian Jin* notes mineral-induced heat cured by Piao Xiao (Mirabilite). *Jin Gui* Shen Qi Wan for 1:1 ratio; 1:2 is difficult. Misdiagnosing as Fire and using cold herbs kills; use Sheng Mai San. Upper Jiao heat: Qing Xin Lian Zi Yin. Ge Xiao (Heart/Diaphragm heat): Xuan Ming Mai Men Dong Yin Zi. Elderly thirst: Yi Lao Men Dong Yin. Middle Xiao (polyphagia/emaciation): Lan Xiang Yin Zi. Severe heat/thirst/pulse large-slippery: Gan Lu Yin Zi. Stomach heat/bad breath: Xie Huang San. Post-meal hunger/Stomach heat/Yangming pulse strong: Qi Wei Bai Zhu San. Heart/Diaphragm heat/dry mouth: Sheng Liao Gu Ben Wan plus Huang Qi, Gan Cao, Shi Hu, Ze Xie, Pi Pa Ye. Floating pulse/difficult urination/Wu Ling San indicated. If heat/thirst persists, add Ren Shen. Sweet-smelling urine indicates Spleen Qi sinking; Qi Wei Bai Zhu San. Greasy urine indicates Kidney deficiency; Bai Zhu San/Shen Qi Wan save 10-20%. Pi Xiao (Spleen Wasting) digests food instantly like snow in soup, exiting as white curds in urine, wasting muscles. Hot herbs worsen; cold herbs weaken. Sun Simiao warns of carbuncles in Wasting-Thirst patients.
[Diagnosis] Shi Wan: *Nei Jing* says excess-large pulse in Xiao Dan is curable even if chronic; suspended-small-firm pulse is incurable. Excess-large matches syndrome. Suspended-small-firm reveals True Visceral pulse, untreatable. If pulse is small but not suspended/firm, follow *Jin Gui* Shen Qi Wan. All Xiao Dan pulses show rapidity. Check floating/sinking, left/right, cun/chixia, excess/deficiency, and regional climate/person constitution to avoid errors. Northern patients often have deep-stone-slippery-rapid pulses due to cold water authority and coal heating, thick Kidney Qi; Liu/Zhang cold-purging methods work. Some laborers/water-workers have deficient Yang/unsealed storage (Right Chixi rapid-large, Lower Xiao) or exhausted Yin/dry Lung (Cunkou rapid-excess, Upper Xiao). Sexual excess/rich diet causes Slippery pulse at Qikou (Middle Xiao). Do not limit by region; guide fire, strengthen water, remove stale Qi. Southern patients (South of Yangtze) rarely have deep-stone pulses; slippery-rapid pulses feel soft upon pressure, often string-like at Chixi or large-rapid at Qikou/Mingmen due to weak soil/water and easy Kidney Yin depletion. Follow *Jin Gui*, Dong Yuan, Yangkui; Liu/Zhang methods are unsuitable. South of Yuling: floating-large-rapid pulses, apparent excess but actual deficiency. Use acrid-cool to clear heat, sweet-cold to nourish Yin; avoid acrid-hot or bitter-cold. Assess cun/chixi excess/deficiency: Cun excess indicates Qi disease; Chi deficiency indicates Kidney deficiency. Left stringy indicates essence injury; Right vigorous indicates deficient Yang. Pathogens originate internally; exterior signs are rare. Even *Jin Gui* Wu Ling San case involves water-Qi failure, not original Wasting-Thirst pulse. Floating pulse here is from exogenous pathogen, not the syndrome's root.
Shi Wan treated Scholar Zhao Xuefang: Middle Xiao, polyphagia, night meals, drowsiness after eating, acid/sweet belching, dream emissions, irregular drinking. Previously treated with calming/nourishing/clearing herbs failed. Pulse all positions large-slippery-rapid, especially Right Guan, with weak Shen at Chixi. Diagnosis: Kidney Qi deficiency, Phlegm-Damp with Yin Fire flooding. Treated with Modified Dao Tan Tang + Lan Xiang, symptoms reduced. Then Liu Jun Zi combined with Zuo Jin Zhi Shi Wan. Finally Liu Wei Wan minus Di Huang, adding Biao Jiao and Ji Li. Recovered in two months.
Treated traveler Bai Xiaolou: Middle Xiao, constipation. Thin, firm constitution, rapid-forceful pulse, likes cold wine. Damp-heat from wine. Purged three times with Tiao Wei Cheng Qi Tang to break heat, then Zi Shen Wan to clear residual fire.
Treated Cantonese guest Li Zhi...: Upper Xiao, summer heat travel. Sweating, fever, thirst, frequent urination, wheezing when drinking. Right Cun floating-rapid-slippery. Heat injuring Lung Qi. Small dose Bai Hu Jia Ren Shen Tang x3 doses reduced symptoms. Then Sheng Mai San for recovery.
Treated Xue Lianfu: Qiang Zhong/Lower Xiao, 1:2 ratio. New marriage depleted Yin, deficient Yang active, persistent erection, exhaustion, back curvature, weak knees, aversion to food, preference for rich food. Pulse variable (rapid-large-weak or stringy-rapid-fast). Yin-Yang separation. Treated aggressively with Ba Wei, Shen Qi, Bao Yuan, Du Shen for a year, then Liu Wei Di Huang Wan long-term.
Treated broker Shao Weibin: Summer intercourse with maid, fear caused Qi/Essence loss, chills, fever, aversion to food/drink, incontinence. Pulse stringy-thin like silk, sharp like blade. True Yang severely deficient. Prescribed Sheng Liao Liu Wei plus Gui/Fu Zi. Relatives objected to Gui/Fu in summer, hired another doctor who used massive Ren Shen/Fu Zi for a month.