经义
二阳结，谓之消。○心移寒于肺，肺消。肺消者，饮一溲二，死不治。○心移热于肺，传为膈消。○瘅成为消中。（《素问》）
胃中热，则消谷，令人心悬善饥。（《灵枢》）
哲言
消证有三∶渴而多饮，为上消，肺热也；心移热于肺，传为膈消是也。多食善饥，为中消，胃热也；瘅
成为消中是也。渴而小便数，如膏，为下消；肾热而水亏也。○消证以渴为主，而分气血，故血分亦有渴者。
淋证以淋为主，而分气血，故血分有不渴者。（汪 庵）
消病有三∶曰消渴，曰消中，曰消肾。又有五石过度之人，真气既竭，石性独留，阳道兴强，不交精泄，
谓之强中。消渴轻也，消中甚焉，消肾又甚焉，若强中则其毙可待矣。（《仁斋直指》）
八卦之中，离能 物；五行之中，火能焚物；六气之中，火能消物。故火之为用，燔木则消而为炭，焚
土则消而为伏龙肝，炼金则消而为汁， 石则消而为灰，煮水则消而为汤，煎海则消而为盐，干汞则消而为粉，
熬锡则消而为丹。故泽中之潦，涸于炎晖；鼎中之水，干于壮火。盖五脏，心为君火正化，肾为君火对化；三
焦为相火正化，胆为相火对化。得其平，则烹炼饮食，糟粕去焉；不得其平，则燔灼脏腑，津液竭焉。故入水
无物不长，入火无物不消。夫火甚于上，为膈膜之消；甚于中，为肠胃之消；甚于下，为膏液之消；甚于外，
为肌肉之消。上甚不已，则消及肺；中甚不已，则消及脾；下甚不已，则消及肝肾；外甚不已，
则消及筋骨。四脏消尽，则心自焚而死矣。故《素问》有消瘅、消中、消渴、风消、膈消、肺消之说。消之证
不同，归之火则一也。消瘅者，众消之总名。消中者，善饥之通称。消渴者，善饮之同谓。惟风消、膈消、肺
消三说，不可不分。风消者，二阳之病也。又曰∶二阳结谓之消。此肠胃之消也。善食而瘦者，名曰食 ，此
肌肉之消也。膈消者，心移热于肺，传为膈消，此膈膜之消也。肺消者，心移寒于肺，饮一溲二者死。膈消不
为寒所薄，阳气得宣散于外，故可治；肺消为寒所薄，阳气自溃于中，故不可治，此消及于肺脏者也。又若脾
风传之肾，名曰疝瘕。少腹冤热而痛，出白，名曰蛊，此膏液之消也。夫消者必渴，渴者有三∶有肥甘之渴，
有石药之渴，有火燥之渴。肥者令人内热，甘者令人中满，故其气上溢，传为消渴，此肥甘之渴也。夫石药之
气悍，适足滋热，与热气相遇，必内伤脾，此药石之渴也。阳明司天，四之气，嗌干引饮；少阳司天，三之气，
炎暑至，民病渴；太阳司天，甚则渴而饮水；少阴之复，渴而欲饮；少阳之复，嗌络焦槁，渴饮水浆；又伤寒
五日，少阴受之，口燥舌干而渴；肾热病者，苦渴数饮；此皆燥热之渴也。膏粱之人，多肥甘、石药之渴；
藜藿之人，多燥热之渴，二者虽殊，其实一也。（张子和）
造化之机，水火而已。水火宜平不宜偏，宜交不宜分。水为湿为寒，火为热为燥。火性炎上，水性润下，
故火宜在下，水宜在上，则易交也。交为既济，不交为未济。不交之极，则分离而死矣。消渴证不交，火偏盛
也。水气证不交，水偏盛也。制其偏而使之交，治之良法也。（何伯斋）
五脏、五志之火，皆有真液以养之，故凝聚不动。而真液犹赖肾之阴精，胃之津液，交灌不竭。若肾胃
之水不继，则五脏之真阴随耗，五志之火翕然内动，上、中、下三消之病作矣。（《见闻录》）
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；继则以水投石，水去而石自若。至于饮一溲一、饮一溲二，则燥火劫其真阴，操
立尽之术，而势成 矣。○肾者胃之关也。关门不开，则水无输泄，而为肿满；关门不闭，则水无底止，而
为消渴。（喻嘉言）
消病之始，皆由不节嗜欲，不慎喜怒，膏粱炮炙，酒酪潼乳，湿热之气，浸淫燔灼，郁成燥热，气不宣平，
故其传变之形，为饮水多而小便多，曰消渴；此胃中津液干枯，不能上荣舌本也。为善饥多食而渴，小便数而
消瘦，曰消中；此胃中热极，所食之物，随火而化也。为渴而饮水不绝，腿消瘦而小便有脂液，曰肾消；是燥
热并及于胃底、大小二肠，故脂液凝浊，清浊不能分疏也。三消之证，上、中可治，下消难治；饮一溲一犹可
治，饮一溲二不可治矣。又消久小便作甘者，其病为重；更有浮在溺面，如猪脂，如烛泪者，此精不禁，而真
元竭矣。大抵水在天地与人身，皆有甘有咸，甘为生气，咸为死气，小便本咸而反甘，是生气泄也，是脾气下
陷入于肾也，土克水故死。（《己任编》）
消渴小便甜者，医多不知其故。《洪范》曰∶稼穑作甘。人之食后，滋味皆甜。若肾气强盛，则上蒸化成
精气，其次为脂膏，又其次为血肉，其余则为小便，故小便色黄者，血之余气也。咸者味之正也。若肾气虚冷，
则无力蒸化，谷气尽下而为小便，故味甘而不变，其色清冷，则肌肤枯槁也。犹如乳母，谷气上泄而为乳汁，
其味甜；消渴病者，谷气下泄而为小便，其味亦甜，此皆精气不实于内也。且肺为五脏之华盖，暖气上蒸则肺
润；若下元虚冷，则阳气不能上升，故肺干而渴。《易》于否卦言之矣，干上坤下，阳无阴不降，阴无阳不升，
上下不交，而成痞也。譬如釜中有水，以火暖之，以版覆之，则暖气上腾，故版能润；若无火力，则水气不能
上升，版不得润。火力者，肾之强盛也。常须温补肾气，饮食得火力则润上，可免干渴之患。（许学士）
消有阴阳，不可不察。如多渴者，曰消渴；善饥者，曰消谷；
小便淋浊如膏者，曰肾消。凡此者，多由于火，火盛则阴虚，是皆阳消之证也。至于阴消之义，则未有知之者。
盖消者消烁也，亦消耗也，凡阴阳血气之属，日见消失者，皆谓之消，故不可尽以火证为言。如《气厥论》
曰∶心移寒于肺，为肺消，饮一溲二，死不治。此正以元气之衰，而金寒水冷，故水不化气，而气悉化水，岂
非阳虚之阴证乎？又如《邪气脏腑病形篇》言∶五脏之脉细小者，皆为消瘅。岂以细小之脉，而为有余之阳
证乎？此《内经》阴消之义，固已显然言之。故凡治消证，必当察其脉气病形，但见本元亏竭，及假火等证，
必当速救根本，以资化源。若但知为火，而专务清凉，未有不败者矣。（张景岳）
凡消病日久，能食者，末传脑疽背疮；不能食者，末传中满鼓胀，皆不治之证也。（《圣济总录》）
或问∶末传痈疽者何故？此火邪胜也，其疮痛甚，或溃赤水是也。末传中满者何故？此上、中二消，治之
太急，寒药伤胃，所谓上热未除，中寒复起也。（李东垣）
消渴宜慎有三∶一、饮酒；二、房劳；三、咸食面食，及炙爆之物。能慎此三者，虽不服药，亦可自愈。
（《千金方》）
上消心火亢极，肺金受囚，饮一溲二者死。中消胃阳独旺，脾阴困败，下利而厥，食已善饥者死。下消肾
阴枯涸，邪火煎熬，精溺时泄，如油如脂者死。（《医学六要》）
论治
男子消渴，小便反多，以饮一斗，小便一斗，肾气丸主之。○渴欲饮水不止者，文蛤散主之。○脉浮，小
便不利，发热消渴者，宜利小便，发汗，五苓散主之。○小便不利者，有水气，其人苦渴，栝蒌瞿麦丸主之。
○渴欲饮水，口干燥者，白虎加人参汤主之。○脉浮发热，渴欲饮水，小便不利者，猪苓汤主之。（《金匮》）
治消渴者，补肾水阴寒之虚，泻心火阳热之实，除肠胃燥热
之甚，济身中津液之衰，使道路散而不结，津液生而不枯，气血利而不涩，则病自已矣。（《儒门事亲》）
瘅成为消中，胃热极深极炽，以故能食易饥多渴，诸家咸谓宜用承气汤下之，不知渐积之热，素蕴之火，
无取急下，下之亦不去，徒损肠胃，转增其困耳。然则欲除胃中火热，必如之何而后可？昌谓久蒸大黄，与甘
草合用，则缓急互调；与人参合用，则攻补兼施，庶几可图三年之艾。○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，徒攻肠胃无益。夫地气上为云，
然后天气下为雨，地气不上，天能雨乎？故亟升地气，以慰三农，与亟升肾气，以溉三焦，皆事理之必然者耳。（喻嘉言）
治消之法，无分上、中、下，当先治肾为急。惟六味、八味，及加减八味丸，随证而服，降其心火，滋其
肾水；白虎、承气，皆非所宜。或问∶有服地黄汤，而渴仍不止者，何也？曰∶心肺位近，制小其服；肾肝位
远，制大其服。如上消中消，可以用前丸缓治。若下消已极，大渴大燥，须加减八味丸料一斤，纳肉桂一两，
水煎六、七碗，恣意冷服，熟睡而渴病如失矣。（《赵氏医贯》）
三消之证，皆燥热结聚也。大法∶治上消者，宜润其肺，兼清其胃，二冬汤主之；治中消者，宜清其胃，
兼滋其肾，生地八物汤主之；治下消者，宜滋其肾，兼补其肺，地黄汤、生脉散并主之。夫上消清胃者，使胃
火不得伤肺也；中消滋肾者，使相火不得攻胃也；下消清肺者，滋上源以生水也。三消之治，不必专执本经，
但滋其化源，则病易痊矣。（程钟龄）
三消一证，古人以上消属肺、中消属胃、下消属肾，而多从火治，是固然矣。以余论之，三焦之火，多有
病本于肾，而无不由乎命门者。夫命门为水火之府，凡水亏固能为消为渴，而火亏亦能为消为渴者，何也？盖
水不济火，则火不归原，故有火游于肺，而为上消者；有火游于胃，而为中消者；有火烁于肾，而为
下消者，是皆真阴不足，水亏于下之证也。又有阳不化气，则水精不布，水不得火，则有降无升，所以直入膀
胱，而饮一溲二，以致泉源不滋，天壤枯涸者，是皆真阳不升，火消于下之证也。阴虚之消，治宜壮水，固有
言之者；阳虚之消，谓宜补火，则人必不信。不知釜底加薪，氤氲彻顶，槁禾得雨，生意归巅，此无他，皆
阳气之使然也。余因消证多虚，难堪剥削，若不求其因，而再伐其生气，则消者愈消，无从复矣。○渴虽云火，
亦有数种当辨∶如实热之渴，火有余也；亡阴之渴，水不足也。故凡大泻、大汗、大劳、大病、新产失血、痈
疽大溃、过食咸味之后，皆能作渴，皆由亡阴亡液而然，本非热证，不得误认为火。总之渴而喜冷，脉实便结
者，固火证也。其有冷冻饮料入腹，则滞沃不行；或口虽作渴，而但喜热饮；及脉弱便溏者，皆非火证。矧复有口
虽干而不欲饮者，此干也，非渴也，若作渴治，能无误乎？治法∶凡火盛于上者，宜清肺清胃；水亏于下者，
宜补脾补肾。若阳虚而阴无以生，气虚而精无以化者，使非水火并济，何益之有？（张景岳）
三消一证，虽有上、中、下之分，其实不越阴亏阳亢，津涸热淫而已。考古治法，惟仲景之肾气丸，助真
火蒸化，上升津液；《本事方》之神效散，取水中咸寒之物，遂其性而治之，可谓具通天手眼，万世准绳矣。
如病在中上者，膈膜之地，而成燎原之场，用景岳玉女煎，六味加二冬、龟甲，一清阳明之热以滋少阴，一
救心肺之阴而顾真液。如元阳变动而为消烁者，用河间甘露饮，生津清热，润燥养阴，甘缓和阳。至于壮水以
制阳光，则有六味之补三阴，而加车前、牛膝，导引肝肾。斟酌变通，斯诚善矣。（《临证指南》）
消渴初起，宜养肺清心，久则宜滋肾养脾。盖五脏之津液，皆本乎肾，故肾暖则气上升而肺润，肾冷则气
不升而肺枯，故肾气丸为消渴之良方。又五脏之精华，悉运乎脾，脾旺则心肾相交，脾健而津液自化，故参苓
白术散为收功之神药。（《证治汇补》）
治渴必须益血。盖血即津液所化，津液既少，其血必虚。凡吐血之后，必多发渴，益知渴病生于血虚也。（王宇泰）
小便不利而渴，内有湿也；小便自利而渴，内有燥也。湿者泄之，燥者润之。（李东垣）
有汗而渴者，以辛润之；无汗而渴者，以苦坚之。（朱丹溪）
凡治初得消渴，不急生津补水，降火彻热，用药无当，迁延误人，医之罪也。○凡治中消病成，不急救金、
水二脏，泉之竭矣，不云自中，医之罪也。○凡治肺消，而以地黄丸治其血分；肾消，而以白虎汤治其气分，
执一不通，病不能除，医之罪也。○凡消渴少愈，不亟回枯泽槁，听其土燥不生，致酿疮疽无救，医之罪也。
○凡治消渴，用寒凉太过，乃至水胜火湮，犹不知反，渐成肿满不救，医之罪也。（《医门法律》）
脉候
帝曰∶消瘅虚实何如？岐伯曰∶脉实大，病久可治；脉悬小坚，病久不可治。（《素问》）
趺阳脉浮而数，浮即为气，数则消谷而大坚，气盛则溲数，溲数即坚，坚数相搏，即为消渴。（《金匮》）
按∶“而大坚句”不成文。“大”字下，当有“便”字，当补之。（《医宗金鉴》）
[Classic Discourses]
The *Huangdi Neijing Suwen* (Yellow Emperor's Inner Canon: Basic Questions) states: When the Qi of the Yangming channel (Stomach and Large Intestine) becomes knotted, it is called Xiao (Wasting-Thirst). ○ If Cold from the Heart transmits to the Lung, it results in Fei Xiao (Lung Wasting-Thirst). In Fei Xiao, one drink yields two urinations; this is a death syndrome and cannot be treated. ○ If Heat from the Heart transmits to the Lung, it transforms into Ge Xiao (Diaphragm Wasting-Thirst). ○ If Dan-Reat (Febrile Heat) accumulates over time, it forms Xiao Zhong (Middle Wasting-Thirst). (From *Suwen*)
The *Huangdi Neijing Lingshu* (Yellow Emperor's Inner Canon: Spiritual Pivot) states: Heat in the Stomach causes rapid digestion of food, leading to a sensation of emptiness in the heart and frequent hunger. (From *Lingshu*)
[Masters' Discourses]
Wang An stated: There are three types of Xiao syndromes: Thirst with excessive drinking is called Shang Xiao (Upper Wasting-Thirst), caused by Lung Heat; this corresponds to "Heat from the Heart transmitting to the Lung, transforming into Ge Xiao." Excessive eating with easy hunger is called Zhong Xiao (Middle Wasting-Thirst), caused by Stomach Heat; this corresponds to "Dan-Heat forming Xiao Zhong." Thirst with frequent urination, where urine resembles paste, is called Xia Xiao (Lower Wasting-Thirst), caused by Kidney Heat and Yin deficiency. ○ Xiao syndromes are characterized by thirst and are differentiated by Qi and Blood; therefore, Blood-level pathologies can also present with thirst. Lin syndromes (Dysuria) are characterized by painful/dribbling urination and are also differentiated by Qi and Blood; therefore, Blood-level pathologies may not present with thirst.
The *Renzhai Zhizhi Fang* (Direct Instructions from Renzhai) states: There are three types of Xiao diseases: Xiao Ke (Wasting-Thirst), Xiao Zhong (Middle Wasting-Thirst), and Xiao Shen (Kidney Wasting-Thirst). Furthermore, individuals who have excessively consumed the Five Minerals Powder (Wushi San) may exhaust their True Qi while the mineral properties remain. This leads to hyperactive Yang energy without seminal emission, known as Qiang Zhong (Excessive Middle). Xiao Ke is mild; Xiao Zhong is severe; Xiao Shen is more severe; if it is Qiang Zhong, death is imminent.
Zhang Zihe stated: Among the Eight Trigrams, Li (Fire) melts objects; among the Five Elements, Fire burns objects; among the Six Qi, Fire consumes objects. Thus, the function of Fire: burning wood turns it to charcoal; burning earth turns it to Fulonggan (Stove Earth); smelting metal turns it to liquid; burning stone turns it to ash; boiling water turns it to soup; evaporating seawater turns it to salt; drying mercury turns it to powder; refining tin turns it to cinnabar. Therefore, swamp water dries under intense sun; water in a cauldron dries under strong fire. Generally, among the Zang organs, the Heart is the primary transformation of Jun Fire (Monarch Fire), and the Kidney is the secondary transformation; the Sanjiao (Triple Burner) is the primary transformation of Xiang Fire (Ministerial Fire), and the Gallbladder is the secondary transformation. When balanced, they cook and digest food, expelling waste; when unbalanced, they scorch the Zang organs and deplete Jin-Ye (Body Fluids). Thus, in water, nothing does not grow; in fire, nothing does not consume. If Fire is excessive above, it causes Diaphragm Xiao; if excessive in the middle, it causes Intestinal/Stomach Xiao; if excessive below, it causes Paste/Fluid Xiao; if excessive externally, it causes Muscle Xiao. If Upper Xiao persists, it affects the Lung; if Middle Xiao persists, it affects the Spleen; if Lower Xiao persists, it affects the Liver and Kidney; if External Xiao persists, it affects sinews and bones. When the Xiao of the four Zang organs is exhausted, the Heart itself burns and death occurs. Thus, the *Suwen* mentions Xiao Dan, Xiao Zhong, Xiao Ke, Feng Xiao (Wind Xiao), Ge Xiao, and Fei Xiao. Although Xiao syndromes differ, they all归结 to Fire. Xiao Dan is the general term for all Xiao syndromes. Xiao Zhong is the general term for easy hunger. Xiao Ke is the term for excessive drinking. Only Feng Xiao, Ge Xiao, and Fei Xiao must be distinguished. Feng Xiao is a disease of the Yangming (Intestines/Stomach). It is said: "Knotted Yangming is called Xiao," which refers to intestinal/stomach Xiao. Eating much but losing weight is called Shi Xuan (Food-related Muscle Wasting), which is muscle Xiao. Ge Xiao is "Heat from the Heart transmitting to the Lung, transforming into Ge Xiao," which is diaphragm Xiao. Fei Xiao is "Cold from the Heart transmitting to the Lung," with one drink yielding two urinations, which is fatal. Ge Xiao is not attacked by cold, so Yang Qi can disperse outwardly, making it treatable; Fei Xiao is attacked by cold, so Yang Qi collapses internally, making it untreatable; this is Xiao affecting the Lung organ. Additionally, if Spleen Wind transmits to the Kidney, it is called Shan Jia (Hernia/Mass). Painful heat in the lower abdomen with white discharge is called Gu (Parasitic Disease), which is paste/fluid Xiao. Generally, Xiao involves thirst. There are three types of thirst: thirst from rich/greasy foods, thirst from mineral drugs, and thirst from dryness-heat. Rich foods cause internal heat; sweet foods cause middle fullness; thus heat rises, transforming into Xiao Ke—this is thirst from rich/sweet foods. Mineral drugs have fierce Qi, which nourishes heat; meeting internal heat injures the Spleen—this is thirst from drugs. When Yangming governs the year, in the fourth Qi phase, there is dry throat and desire to drink; when Shaoyang governs, in the third Qi phase, heat arrives causing thirst; when Taiyang governs, severe cases involve thirst and drinking; when Shaoyin rebounds, there is thirst and desire to drink; when Shaoyang rebounds, throat meridians become dry and brittle with thirst for fluids; after five days of Cold Damage, Shaoyin is affected, causing dry mouth/tongue and thirst; Kidney Heat disease causes bitter thirst and frequent drinking; these are all thirst from dryness-heat. Those eating fine foods often have thirst from rich/greasy or mineral sources; those eating coarse foods often have thirst from dryness-heat. Though different, their essence is the same.
He Bozhai stated: The mechanism of creation lies only in Water and Fire. Water and Fire should be balanced, not biased; they should interact, not separate. Water is damp/cold; Fire is hot/dry. Fire flares upward; Water moistens downward. Thus, Fire should be below and Water above to facilitate interaction. Interaction is Ji Ji (Completed Hexagram); non-interaction is Wei Ji (Uncompleted Hexagram). Extreme non-interaction leads to separation and death. Xiao Ke syndrome is non-interaction due to excess Fire. Edema syndrome is non-interaction due to excess Water. Restraining the bias to restore interaction is a good treatment method.
*Jianwen Lu* (Records of Observations) states: The Fire of the Five Zang organs and Five Emotions is nourished by True Fluids, keeping it condensed and still. True Fluids rely on Kidney Yin Essence and Stomach Jin-Ye for continuous mutual irrigation. If Kidney/Stomach water fails to continue, the True Yin of the Five Zang is consumed, and the Fire of the Five Emotions moves violently internally, causing Upper, Middle, and Lower Xiao diseases.
Yu Jiayan stated: The harm of Xiao Ke often starts subtly and becomes manifest; it starts in the Stomach and extremes in the Lung and Kidney. Initially, it is like pouring water on red-hot iron; the water is absorbed. Later, it is like throwing water on stone; the water flows away, leaving the stone unchanged. When one drink yields one or two urinations, Dry-Fire has robbed the True Yin, employing a method of total destruction, and the situation is set. ○ The Kidney is the gate of the Stomach. If the gate does not open, water cannot be transported/excreted, leading to edema/fullness; if the gate does not close, water has no limit, leading to Xiao Ke.
*Jiren Bian* stated: The onset of Xiao disease is due to unrestrained desires and imprudent emotions, combined with rich foods, fried items, wine, dairy, etc. Damp-Heat infiltrates and scorches,郁结 (stagnates) into Dryness-Heat, preventing smooth Qi flow. Thus, drinking much and urinating much is called Xiao Ke; this is dryness of Stomach Jin-Ye failing to nourish the tongue base. Eating much with hunger/thirst and frequent thin urination with emaciation is called Xiao Zhong; this is extreme Stomach Heat digesting food via fire. Thirst with incessant drinking, leg emaciation, and fatty urine is called Kidney Xiao; this is Dryness-Heat affecting the stomach bottom and intestines, causing turbid lipids that cannot be separated. Upper and Middle Xiao are treatable; Lower Xiao is difficult. One drink/one urine is treatable; one drink/two urinations is not. If Xiao persists and urine becomes sweet, the disease is severe. If fat floats on urine like lard or candle wax, Jing (Essence) is uncontrolled and Yuan Qi is exhausted. Generally, water in heaven/earth and body has sweet and salty flavors. Sweet represents Sheng Qi (Vital Qi); Salty represents Si Qi (Dead Qi). Urine should be salty but becomes sweet, indicating leakage of Vital Qi and Spleen Qi sinking into the Kidney. Earth overcoming Water leads to death.
Xu Xueshi stated: Doctors often do not know why Xiao Ke urine is sweet. The *Hongfan* says: "Grains and beans produce sweetness." After eating, flavors are sweet. If Kidney Qi is strong, it steams upward to transform into Essence, then Lipids, then Flesh/Blood; the remainder is urine. Yellow urine is the residual Qi of Blood. Salty is the correct flavor. If Kidney Qi is deficient/cold, it lacks power to steam/transform, so Grain Qi descends entirely as urine, tasting sweet and clear/cold, leading to withered skin/muscles. Like a nursing mother whose Grain Qi leaks upward as sweet milk; Xiao Ke patients have Grain Qi leaking downward as sweet urine. This indicates Essence is not solid internally. The Lung is the canopy of the Five Zang; warm air steaming up moistens the Lung. If the lower origin is deficient/cold, Yang Qi cannot rise, causing dry Lung and thirst. The *I Ching* explains this in the Pi (Standstill) hexagram: Heaven above, Earth below; Yang cannot descend without Yin, Yin cannot rise without Yang. Non-interaction creates blockage. Imagine a pot of water heated by fire and covered; steam rises, moistening the lid. Without fire, water vapor doesn't rise, and the lid stays dry. Firepower represents strong Kidney Qi. One must constantly warm/nourish Kidney Qi so dietary warmth rises, avoiding dryness/thirst.
Zhang Jingyue stated: Xiao has Yin and Yang aspects that must be observed. Thirst is Xiao Ke; hunger is Xiao Gu; cloudy/fatty urine is Kidney Xiao. These are mostly due to Fire; Fire excess causes Yin deficiency, constituting Yang Xiao syndromes. The meaning of Yin Xiao is unknown to many. "Xiao" means consumption/scorching. Any daily loss of Yin/Yang/Qi/Blood is called Xiao, so it cannot be solely attributed to Fire. The *Qi Jue Lun* says: "Heart Cold transmitting to Lung causes Fei Xiao, one drink/two urinations, fatal." This is due to Yuan Qi decline, Metal cold/Water cold, so Water fails to transform to Qi, and Qi transforms entirely to Water—is this not a Yang-deficient Yin syndrome? The *Xieqi Zangfu Bingxing Pian* says: "Fine/small pulses in all Five Zang indicate Xiao Dan." Does a fine/small pulse indicate an Excess Yang syndrome? The *Neijing* clearly explains Yin Xiao. Thus, treating Xiao requires observing pulse/form. If Yuan root is exhausted or False Fire is present, one must quickly rescue the root to aid the source of transformation. Knowing only Fire and using only cooling herbs will inevitably fail.
*Shengji Zonglu* stated: Long-term Xiao patients who can eat will eventually develop brain abscesses/back sores; those who cannot eat will develop abdominal distension/bloating. Both are untreatable.
Li Dongyuan stated: Why does it transmit to carbuncles/ulcers? Because Fire Evil is dominant, causing severe pain or bloody discharge. Why does it transmit to fullness? Because Upper/Middle Xiao were treated too urgently with cold herbs, injuring the Stomach. Upper heat remains, Middle cold arises.
*Qianjin Fang* stated: Three precautions for Xiao Ke: 1. Alcohol; 2. Sexual exertion; 3. Salty foods, wheat products, and fried/grilled items. Observing these allows self-healing even without medicine.
*Yixue Liuyao* stated: Upper Xiao: Heart Fire hyperactive, Lung Metal trapped, one drink/two urinations → Death. Middle Xiao: Stomach Yang alone prosperous, Spleen Yin defeated, diarrhea/cold limbs, postprandial hunger → Death. Lower Xiao: Kidney Yin dried up, Evil Fire simmering, essence/urine leaking like oil/fat → Death.
[Treatment Discussion]
*Jingui Yaolue* (Essential Prescriptions of the Golden Cabinet) states: Male Xiao Ke with excessive urination, drinking one dou producing one dou of urine, is treated with Shenqi Wan (Kidney Qi Pill). ○ Thirst with inability to stop drinking is treated with Wenha San (Clam Shell Powder). ○ Floating pulse, difficulty urinating, fever, and Xiao Ke are treated with Wuling San (Five-Ling Powder) to promote urination and induce sweating. ○ Difficulty urinating with fluid retention and severe thirst is treated with Gualou Qu Mai Wan (Trichosanthes and Phellodendron Pill). ○ Thirst with dry mouth is treated with Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction). ○ Floating pulse, fever, thirst, and difficulty urinating are treated with Zhuling Tang (Polyporus Decoction).
*Rumen Shiqin* stated: Treating Xiao Ke involves tonifying the deficiency of Kidney Water/Yin-Cold, purging the excess of Heart Fire/Yang-Heat, removing severe dryness-heat in intestines/stomach, and assisting depleted body fluids. This ensures pathways are open, fluids generate, and Qi/Blood flow smoothly, curing the disease.
Yu Jiayan stated: Dan-Heat transforming into Xiao Zhong involves deep Stomach Heat, causing hunger/thirst. Many suggest Chengqi Tang (Gut-Purging Decoctions), but gradual accumulated heat and inherent fire do not require urgent purging. Purging fails to remove it and damages the intestines/stomach. To remove Stomach Fire, use long-steamed Dahuang (Rhubarb) with Gancao (Licorice) to balance speed/slowness, or with Renshen (Ginseng) to combine attack/tonification. ○ Lower Xiao Fire is Fire within Water; purging makes it burn hotter. Middle Xiao Fire is Fire in a drained pond; purging causes more damage. Upper Xiao Fire is Prairie Fire; rain from heaven extinguishes it, but purging intestines is useless. Earth Qi rising forms clouds, then Heaven Qi rains down. If Earth Qi doesn't rise, can it rain? Thus, raising Earth Qi (and Kidney Qi to irrigate Sanjiao) is necessary.
*Zhao Shi Yiguan* stated: Treat Xiao by prioritizing the Kidney regardless of Upper/Middle/Lower. Use Liuwei Wan (Six-Ingredient Pill), Bawei Wan (Eight-Ingredient Pill), or Jiaban Bawei Wan to descend Heart Fire and nourish Kidney Water. Baihu Tang and Chengqi Tang are unsuitable. If Rehmannia Soup fails to stop thirst, it is because Heart/Lung are near (small dose) while Liver/Kidney are far (large dose). For extreme Lower Xiao with severe thirst/dryness, use one jin of Jiaban Bawei Wan material plus one liang of Rougui (Cinnamon Bark), decocted in water, taken cold after sleep, curing the thirst.
Cheng Zhongling stated: All Xiao syndromes involve Dryness-Heat accumulation. General rule: Treat Upper Xiao by moistening Lung and clearing Stomach (Er Dong Tang); treat Middle Xiao by clearing Stomach and nourishing Kidney (Shengdi Bawu Tang); treat Lower Xiao by nourishing Kidney and supplementing Lung (Dihuang Tang, Shengmai San). Clearing Stomach in Upper Xiao prevents Fire from harming Lung; nourishing Kidney in Middle Xiao prevents Ministerial Fire from attacking Stomach; clearing Lung in Lower Xiao nourishes the upper source to generate Water. Treating Xiao need not focus solely on the meridian; nourishing the source of transformation cures it easily.
Zhang Jingyue stated: Although Xiao is divided into Upper/Middle/Lower, it essentially involves Yin deficiency/Yang hyperactivity and fluid depletion/Heat invasion. Ancient methods: Zhang Zhongjing’s Shenqi Wan aids True Fire to steam/rise fluids; *Benshi Fang*’s Shenxiao San uses salty-cold substances from water. If disease is in Upper/Middle (Diaphragm/Prairie Fire), use Jingyue’s Yunu Jian (Jade Woman Decoction) or Liuwei Wan plus Er Dong/Guiban to clear Yangming Heat/nourish Shaoyin and save Heart/Lung Yin. If Yuan Yang moves causing consumption, use Hejian’s Ganlu Yin (Sweet Dew Drink) to generate fluids/clear heat. To strengthen Water to control Sunlight, use Liuwei Wan tonifying Three Yin, adding Cheqianzi and Niuxi to guide Liver/Kidney.
*Zhengzhi Huibu* stated: Early Xiao Ke benefits from nourishing Lung/clearing Heart; late stages benefit from nourishing Kidney/Spleen. All Zang fluids originate in Kidney; warm Kidney raises Qi/moistens Lung; cold Kidney fails to raise Qi/wither Lung. Thus, Shenqi Wan is excellent. Zang essences are transported by Spleen; strong Spleen allows Heart/Kidney interaction; healthy Spleen generates fluids. Thus, Shenling Baizhu San is excellent for recovery.
Wang Yutai stated: Treating thirst must benefit Blood, as Blood is transformed from Jin-Ye. Low fluids mean weak Blood. Post-hematemesis thirst confirms thirst arises from Blood deficiency.
Li Dongyuan stated: Difficulty urinating with thirst indicates internal Dampness; free urination with thirst indicates internal Dryness. Dampness is drained; Dryness is moistened.
Zhu Danxi stated: Thirst with sweat is treated with Pungent-Moistening methods; thirst without sweat is treated with Bitter-Solidifying methods.
*Yimen Falü* stated: Failing to promptly generate fluids/nourish water and purge heat in early Xiao Ke is a doctor's fault. Failing to urgently rescue Lung (Metal) and Kidney (Water) in established Middle Xiao, allowing the spring to dry up, is a doctor's fault. Using Dihuang Wan (Blood level) for Fei Xiao or Baihu Tang (Qi level) for Kidney Xiao rigidly, without flexibility, is a doctor's fault. Failing to restore withered tissues after slight improvement, allowing dry earth to breed sores, is a doctor's fault. Overusing cold/cool herbs until Water overwhelms Fire, refusing to reverse course, leading to fatal edema, is a doctor's fault.
[Pulse Diagnosis]
*Suwen* records: Huangdi asks about deficiency/excess in Xiao Dan. Qibo answers: Solid/large pulse in long-standing disease is treatable; hanging/small/firm pulse in long-standing disease is untreatable.
*Jingui Yaolue* records: Duyang pulse floating and rapid. Floating indicates Qi excess; rapid indicates digestion and hard stool. Qi excess causes frequent urination; frequent urination causes hardness. Hardness and frequency interacting result in Xiao Ke.
Commentary: *Yizong Jinjian* notes: "And large/hard sentence" is grammatically incorrect. A "Bian" (Stool) character should follow "Da".