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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.