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Liu Hejian (Liu Wansu) believed: This arises from the deficiency of Yin water and the flaming of Fire, leading to extreme dryness-heat, thus causing thirst and excessive drinking. Zhang Zihe also stated: When Heart Fire is excessively strong, body fluids are consumed and dried up. If located above, it becomes Ge Xiao (Diaphragm Diabetes); if severe, it affects the Lung. If located in the middle, it becomes Gastrointestinal Xiao; if severe, it affects the Spleen. If located below, it becomes Gao Xiao (Paste/Fluid Diabetes); if severe, it affects the Kidney. If located on the exterior, it becomes Muscle Xiao; if severe, it affects the sinews and bones. If all four Zang organs undergo Xiao (wasting), the Heart will naturally be burned out, leading to death. In treating this condition, if one only regulates without purging, slight moistening cannot extinguish the upward-flaming fire; if one purges without regulating, it ultimately cannot irrigate the dry diaphragm. Even if both purging and regulating are employed, along with reducing rich flavors, abstaining from desires, and moderating emotions, the disease may recur after remission. The syndromes are divided into Upper, Middle, and Lower Xiao, all of which should be diagnosed and treated based on "Fire".

Upper Xiao is characterized by extreme thirst and excessive drinking; in severe cases, the tongue becomes red and cracked. As stated in the *Classic* (*Huangdi Neijing*), when Heart transfers heat to the Lung, it transmits to become Ge Xiao. Urination and defecation are normal, indicating dryness-heat is in the Upper Jiao. Baihu Tang with Ginseng (White Tiger Decoction with Ginseng) is the primary formula. If urine output is low, it is because heat has consumed the body's water. (This is one meaning of "Xiao" wasting.) One should use the aforementioned decoction plus herbs that generate fluids and moisten dryness, such as Tianhuafen (Trichosanthes Root), Beiweizi (Schisandra Fruit), Maidong (Ophiopogon Tuber), and Gegen (Pueraria Root). If urination is obstructed (obstruction is not the same as low volume; it means there is fluid but it cannot be discharged), combine the aforementioned decoction with Wuling San (Five-Ingredient Powder with Poria). Zhang Zihe said: One must fear it may transform into edema.

If urination is free, this is what is meant by "drinking much and urinating much." Add acrid-moistening herbs to the previous formula to open the interstices (Cou Li). Upper Xiao is generally due to excess Heart Fire. A single herb, Huanglian (Coptis Rhizome), decocted in water, cooled, and drunk whenever thirst or vexation occurs, will heal over time. If caused by excessive mental exertion, use Huang Liu Yi Tang plus Lianrou (Lotus Seed) and Yuanzhi (Polygala Root), each 1 qian, taken with Xuan Tu Dan, while alternating with Ling Sha Wan taken in Da Mai (Barley) decoction. Equal parts of Nuogu (Glutinous Rice popped like popcorn) and Sanggen Baipi (Mulberry Root Bark), 1 liang per dose, decocted in water and drunk when thirsty, allows the Qi of food and drink to steam upward to the Lung, transforming into body fluids. This follows the principle of Metal generating Water. Both herbs enter the Lung and have mild diuretic properties, hence their selection. Sao Si Tang (Silkworm Cocoon Decoction) can guide clear Yang upward to the mouth. Furthermore, silkworms and horses belong to Wu Fire, corresponding to the Heart. Silkworms spinning cocoons and becoming pupae symbolize retreat and storage, thus they can suppress Heart Fire and stop thirst. For treating Upper Xiao, the dosage should be small, and administration frequent. Li Dongyuan stated: In Xiao Ke (Wasting-Thirst), if the patient has not yet progressed to increased appetite, brain abscesses or back sores will likely develop; if the patient cannot eat, it will progress to abdominal fullness and distension (Gu Zhang). Those who can eat have Excess Fire; when Fire is strong, blood stagnates in the collaterals, causing sores. (Severe pain without ulceration, or ulceration with red pus.) Those who cannot eat have Deficiency-Cold; Deficiency-Cold causes Qi stagnation, leading to distension. What causes this Deficiency-Cold? Using cold herbs to treat heat is indeed indispensable, like a carpenter's ink line. However, Zang organs have proximity differences. Heart and Lung are proximal, so small doses are appropriate; Liver and Kidney are distant, so larger doses are needed to ensure the medicine reaches the target site. Otherwise, overdose or underdose constitutes punishing the innocent. For Upper Xiao, using large doses would cause the cold to pass quickly through the target and chill the Middle and Lower Jiao, resulting in distension—this is "Upper Heat not cleared, Middle Cold arising." Therefore, prescriptions must be careful; thus it is said, do not neglect or reduce the dosage for Heart and Lung medicines due to inconvenience.

Middle Xiao is characterized by good appetite but emaciation (Heat digests grain, a meaning of "Xiao"; emaciation is Heat scorching muscles, another meaning of "Xiao"), thirst, spontaneous sweating, hard stools, and frequent, yellow-red urine. This indicates Stomach Heat excess. Wang Shuhe described it as dry mouth desiring water, eating much but feeling hungry and weak, developing into Zhong Xiao (Middle Diabetes). Zhang Zihe explained the *Classic*: Diseases of Er Yang (Stomach and Large Intestine) originate in Heart and Spleen. In men, it leads to scanty essence; in women, amenorrhea. It transmits as Feng Xiao (Wind Wasting). Er Yang refers to heat in Stomach and Large Intestine. If Heart is affected, blood does not flow, causing amenorrhea; if Spleen is affected, flavors are not transformed, causing scanty essence. Wind-Fire consumes and dries the intestines and stomach, constituting Gastrointestinal Xiao. Tiaowei Chengqi Tang (Regulate the Stomach and Purge the Yellow Decoction) or Sanhuang Wan (Three-Yellow Pill) are used. Natural juices of Shengdi (Rehmannia Root) and Bailian'ou (White Lotus Rhizome), and 1 jin each of Niu Nai (Cow Milk), are boiled into an ointment, mixed with 1 jin of Huanglian powder, formed into pills the size of paulownia seeds, taken with warm water, 30-50 pills per dose, ten times daily. Huanglian Zhudu Wan (Coptis Pig Stomach Pill) or Qingliang Yinzi (Cooling Drink) are also options.

Lower Xiao is characterized by vexed thirst desiring drinks, urine resembling paste, dark complexion, withered earlobes, and emaciated legs. This is Kidney Heat, also named Shen Xiao (Kidney Diabetes). Liuwang Dihuang Wan (Six-Ingredient Pill with Rehmannia) is the primary formula. It is often caused by excessive sexual activity or ingestion of mineral drugs, leading to exhaustion of Kidney Water, rising of Empty Yang, failure of Jing-Essence to interact and retain, turbid urination, persistent penile erection (anciently called Qiang Zhong).

Commentary: Regarding the Three Xiao, Liu Hejian and Zhang Zihe considered them Heat syndromes. However, the *Jin Gui Yao Lue* states that in Xiao Ke, urination is excessive: drinking one dou results in urinating one dou, treated with Shenqi Wan (Kidney Qi Pill). Also, the *Neijing* states that when Heart transfers Cold to the Lung, forming Fei Xiao (Lung Diabetes), drinking one dou and urinating two dou is fatal and incurable. Thus, do the Three Xiao inherently include Cold syndromes? I reply: Although these are also named Xiao Ke, they should not truly be classified under Xiao Ke. The case in *Jin Gui* arises because the patient's Mingmen Fire (Gate of Life Fire) is deficient, unable to vaporize Kidney Water and Grain Qi from the Spleen/Stomach to reach the Lung, causing Upper Jiao dryness and thirst. The ingested water, not transformed by Fire, goes directly to the Bladder, hence drinking one and urinating one, with tasteless urine. Shenqi Wan (which is Bawei Wan/Eight-Ingredient Pill) uses Fuzi (Aconite) and Guizhi (Cinnamon Twig) to strengthen Mingmen Fire, like adding fuel to a furnace, allowing Grain Qi to rise and vaporize into moisture. However, this condition involves thirst only due to lack of upper nourishment, not the burning of intense Fire; thus, the thirst is not severe, and intake is not high. (The phrase "drink one, urinate one" is an aggregate description, not implying every single instance.) How can this differ from Heat syndromes involving extreme thirst and continuous drinking? Kidney Heat causes pasty urine; Kidney Cold causes clear urine; the distinction is natural. As for the *Neijing* case, Heart Fire is weak, transforming into Cold Water and Cold Metal. Not only is the ingested water unable to be transformed, but even body fluids lack Qi to lift and hold them, causing them to sink downward, resulting in drinking one and urinating two. At this point, Lung Qi is extremely depleted; where would extreme thirst come from? These conditions should not be named Xiao Ke, causing later generations to confuse them and mistakenly apply warming tonification. Applying warming tonification to Heat syndromes leads inevitably to death. This is why Liu Hejian and Zhang Zihe loudly denounced this error.

Liu Hejian stated: Excessive drinking with polyuria is not due to Deficiency-Cold lacking Fire to control Water, but rather extreme dryness-heat causing stagnation and blockage in the interstices of the intestines, stomach, and Triple Burner. Fluids cannot permeate and excrete outwardly (like water poured on stone, passing through without staying), hence polyuria. (This is another meaning of "Xiao".) One must eliminate dryness-heat, supplement declining fluids, making pathways loose and unblocked, and Qi-Blood smooth and unobstructed (as previously mentioned, using acrid-moistening herbs to open interstices). He also noted cases of Extreme Yang resembling Yin: cold sensation in the lower body, feet like ice, due to Heart Fire failing to descend. Administer cold herbs to purge 3-5 times, then Fire descends, Water rises, and Cold transforms away. His words are logically sound. Zhang Zihe stated: Heart is Yang Fire. If first attacked by Cold Evil, Fire becomes depressed and injures the Lung. Both Fire and Cold attack the Lung. Exteriorly, Cold constrains the Lung, preventing Yang dispersion; interiorly, Fire scorches it. Thus skin wastes, and urine mixes with dampness frequently, drinking one and urinating two. Ge Xiao is not constrained by Cold, Yang can disperse, so it is treatable. Fei Xiao is constrained by Cold, Yang collapses internally, so it is incurable. This is another perspective.

Universal treatment for Three Xiao: Select pure Huanglian (Coptis), grind to powder. Mix with natural juice of Donggua (Winter Melon) to form cakes, dry in shade, grind again, mix again with Donggua juice. Repeat seven times. Finally, make pills with Donggua juice, size of paulownia seeds. Take 30 pills per dose, washed down with Barley Kernel Decoction mixed with Donggua juice. Effective immediately for ordinary thirst. Since polyuria often leads to constipation, regularly take Siwu Tang (Four-Substance Decoction) to regulate. Mi Tan (Rice wash water) can be taken cold. If Three Xiao persists and urine loses odor, turns sweet, and bubbles in the chamber, the disease is severe. If fat floats on the surface like lard, or splashes on the rim like candle wax, Essence is exhausted; this is difficult to treat. Water in heaven, earth, and the human body has both Sweet (Gan) and Salty (Xian) qualities. Sweet represents Living Qi; Salty represents Dead Qi. Urine is Dead Water; originally salty, if it turns sweet, Living Qi is leaking, and Spleen-Stomach Rising Qi is sinking. (See Sweating section regarding tasteless sweat confirming this.) Long-standing Three Xiao depletes Jing-Blood, potentially causing blindness or hemiplegia resembling stroke. Must nourish Jing-Blood. After recovery, prevent carbuncles and sores; use Huang Liu Yi Tang with Rendong Wan (Honeysuckle Pill). If progressing to Gu Zhang (Abdominal Distension) and Shui Qi (Water Retention), use Wupi Yin (Five-Bark Drink) with Jisheng Shenqi Wan (Jisheng Kidney Qi Pill). Li Dongyuan's Zhongman Fenxiao formulas can be selected. Kan Trigram represents Water as Qi, small as wells, large as rivers. Dui and Kun Trigrams represent Water as Form, small as dew, large as rain. Kan is one Yang trapped between two Yins; it carries Qi through all things, being the root of life, thus no substance moisturizes better than water. Dui is one Yin extending above two Yangs; it distributes Form over all things, being the benefit of generation, thus nothing delights more than Dui. Triple Burner is Fire of Form. It is controlled by Form-Water, which is Dui (Marsh), temporary. Our body possesses True Water from Shangchi (Upper Pool), which is Qi, generated by Heaven One. Using Formless Water to irrigate Formless Fire is constant and enduring. This is True Water and Fire; when ascending and descending balance each other, thirst stops.

For ordinary Xiao Ke caused by diet and fatigue, Qi-deficiency fever, leading to insufficient fluids and thirst, do not use Wuling San. Use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) plus Wuweizi (Schisandra) and Gegen (Pueraria). Spontaneous thirst without illness, or thirst after convalescence, use Shenzhu Yin, Sijunzi Tang (Four-Gentlemen Decoction), or Suopi Yin (Contract Spleen Drink), all added with Gegen. Long-term illness with Yin deficiency, use Huangqi Yin (Astragalus Drink) or Siwu Tang, plus Renshen (Ginseng) and Mugua (Chaenomeles). Or Qizhen San minus Baizhu, plus Mugua. Postpartum Blood deficiency causing thirst requires Blood tonification. Alcohol-induced thirst: Gan Ge Yin (Kudzu Drink) combined with Wuling San. Thirst from excessive fruit consumption: add She Xiang (Musk) to the prescription. Thirst from retained fluids: refer to the Phlegm-Fluid section.