河间谓∶由水虚火炎，燥热之甚，故渴而饮水多。子和亦谓∶心火太盛，津液
耗涸，在上则为膈消，甚则消及肺脏；在中则为肠胃之消，甚则消及脾脏；在下则
为膏液之消，甚则消及肾脏；在外则为肌肉之消，甚则消及筋骨；四脏皆消，则心
自焚而死矣。治此者，但调之而不下，则小濡小润，固不能杀炎上之势；下之而不
调，亦终不能沃膈膜之干；下之调之，而下减滋味，戒嗜欲，节喜怒，亦病已而复
作。证分上中下，皆从火断之。
上消者，大渴饮多，甚者舌亦赤裂，《经》谓心移热于肺，传为膈消者是也。
二便如常，知其燥在上焦，白虎加人参汤（见发热）主之。小便少者，乃热消烁其水也，
（此消之一义也。）亦用前汤加生津滋燥之药，如花粉、北味、麦冬、干葛之属。若小便
不利者，（不利非少也，盖有水而不利耳。）前汤合五苓散。（见伤湿。）子和谓∶恐变
为水肿者是也。
若小便利者，所谓饮多溲亦多也，（详见下文。）前汤加辛润之品，以开通腠理可也。上
消大概心火盛，黄连一味煎汤，候冷，遇渴烦饮，久而自愈。若用心过度致此者，
黄六一汤加莲肉、远志各一钱，吞玄兔丹，仍以大麦煎汤，间下灵砂丸。糯谷炒
爆、桑根白皮等份，每服一两，水煎，渴即饮之，使水谷之气上蒸于肺，化为津液，
此金生水之义，二物皆肺药，又淡渗，故取之。缲丝汤，能引清气上朝于口，又蚕
与马同属午火，心也。作茧成蛹，退藏之义，故能抑心火而止渴也。治上者剂宜小
而服宜频。东垣谓消渴，未传能食者，必发脑疽背疮；不能食者，必传中满鼓胀。
盖能食者为实火，火盛则血壅于经络，故生疽疮。（痛甚而不溃，或溃出赤水。）不能食者为
虚寒，虚寒则气不运，故胀满。而所以致虚寒者何？曰∶以寒治热，固如绳墨之不
能废。然脏腑有远近，心肺位近，宜制小其服，肝肾位远，宜制大其服，使之适至
病所而止。否则或过或不及，皆为诛罚无过。如上消而制大，则速过病所，而寒其
中下焦，因致胀满之病，所谓上热未除，中寒复起也。是以处方宜审，故曰心肺之
药，莫厌烦而少。
中消者，善食而瘦，（热能消谷也，此消之一义也。瘦，热灼肌肉消削也，此消之有一义也。）渴，自
汗，大便硬，小便频数、黄赤，是胃热盛。叔和所谓口干饮水，多食饥虚，成消中
者是也。（子和释《经》，二阳之病发心脾，男子少精，女子不月，其传为风消。谓二阳乃胃与大肠病热，
心受之则
血不流，故女子不月；脾受之则味不化，故男子少精。风火消涸肠胃，此肠胃之消也。）调胃承气汤，（见大便不
通。）或三黄丸，（见发热。）生地、白莲藕各自然汁，牛乳各一斤，熬膏，和黄连末一
斤，丸如桐子大，白汤下三五十丸，日十服。黄连猪肚丸、清凉饮子。（见伤燥。）
下消者，烦渴引饮，小便如膏，面色黧黑，耳叶焦枯，两腿消瘦，此肾热也，
又名肾消，六味地黄丸（见虚损。）主之。多因色欲过度，服金石药，肾水涸竭，虚阳上
炎，不交精出，小便淋浊，阳道常坚，古谓之强中也。
按三消，在河间、子和以为热证。而《金匮》谓消渴，小便反多，饮一斗溲一
斗，肾气丸主之。又《内经》谓心移寒于肺，为肺消，饮一溲二者死，不治。是三
消固有寒证乎？曰∶此虽亦名消渴，而实不当以消渴名者也。盖《金匮》所言，乃
因其人命门火衰，不能蒸动肾水与脾胃中谷气，以上达于肺，故上焦失润而渴。其
所饮之水，未经火化，直下膀胱，故饮一溲一，其味不咸，肾气丸。（即八味丸。）用附、
桂以壮其命门之火，如釜底加薪，则水谷之气上腾，蒸为润泽也。然此证止因水不
上滋而渴，非如盛火之焚灼，则其渴不甚，饮亦必不多，（其谓饮一斗溲一斗者，乃合算之词，
非言每饮必一斗也。）其与热证之大渴引饮不止者，安得无殊哉？肾热则小便如膏，肾寒则小
便清白，又自有辨也。至若《内经》所言，心火衰微，反为水冷金寒之化，不特所饮之
水无气以化，且并身中之津液，亦无气提摄，相并下趋，而成饮一溲二之证，
则肺气之消索已甚，尚何大渴大饮之有？此皆不当名消渴，致后人泾渭不分，动手
即从温补，热证逢之，不死何待？此河间、子和二公所谓大声疾呼，而痛诋其非也。
河间谓∶饮多而小便多者，非虚寒无火，不能制水，乃燥热太甚，肠胃三焦之腠理
怫郁结滞，致密壅塞，水液不能渗泄于外，（如水沃石，过而不留。）故溲多也。（此消之又
一义也。）
当除其燥热，济津液之衰，使道路散而不结，气血利而不涩。（即前所谓以辛润之品，开通腠
理也。）又谓常有阳极似阴者，下部觉冷，两足如冰，乃心火不降，宜寒药下之三五
次，则火降水升，寒化自退，其言可谓名通。子和谓∶心为阳火，先受寒邪，火
郁伤肺，火与寒皆来乘肺，肺外为寒所薄，阳气不得泄，内为火所燥，故皮肤消索，
溲溺与积湿频并，饮一溲二。膈消不为寒所薄，阳得宣散，故可治。肺消为寒所薄，
阳气自溃于中，故不治，亦一说也。
三消通治∶好黄连治净为末，冬瓜自然汁和成饼，阴干，再为末再和，如是者
七次，仍用冬瓜汁丸，桐子大，每服三十丸，大麦仁汤入冬瓜汁送下。寻常渴，一
服效。小便既多，大便必秘，宜常服四物汤（见血）调之。糯米泔折二，亦可冷进。三消
久而小便不臭，反作甜气，在溺桶中涌沸，其病为重。更有如猪脂浮在溺面，如
烛泪溅在桶边，此精竭也，难治。水在天地与人身，皆有甘有咸，甘者生气，
咸者死气。小便死水也，本咸而反甘，是生气泄也，脾胃之生气下陷矣。（参汗门脱汗
味淡更明。）三消久之精血亏，或目无所见，或手足偏废如中风，须滋生精血。愈后须
防发痈疽，黄 六一汤下忍冬丸。末传鼓胀水气，五皮饮（见肿胀）送济生肾气丸。（见虚损。）
东垣中满分消诸方（见肿胀。）可选用。坎、干水也。气也，小而井，大而江河也。兑、
坤水也，形也，微而露，大而雨也。一阳陷于二阴之中为坎，坎以气潜行万物之中，
为受命之根本，故润万物莫如水。一阴彻于二阳之上为兑，兑以形普施于万物之上，
为资生之利泽，故说万物莫说于兑。三焦为形之火。制以有形之水者，兑，泽也，
可暂者也。吾身自有上池真水，气也，天一所生也。以无形之水，沃无形之火，
常而可久者也。是为真水火，升降既济，渴自止矣。
寻常消渴，饮食劳倦，气虚发热，致津液不足而渴，不可与五苓（见伤湿，）宜补中
益气汤（见气）加五味子、葛根。无病自渴，与瘥后渴，参术饮、四君子汤（见气）、缩
脾饮（见中暑），俱加干葛。久病阴虚，黄 饮、四物汤（见血），加人参、木瓜。
或七珍散去
术，加木瓜。产妇血虚，渴，宜益血。酒渴，干葛饮调五苓散。多食果子致渴，药
中加麝香。停饮致渴，详痰饮门。
刘河间认为：这是由于阴水亏虚、心火亢盛，导致燥热极甚，所以口渴且饮水多。张子和也认为：心火过于旺盛，津液耗竭干枯，病位在上则形成膈消，严重时波及肺脏；病位在中则形成肠胃之消，严重时波及脾脏；病位在下则形成膏液之消，严重时波及肾脏；病位在体表则形成肌肉之消，严重时波及筋骨；如果四脏都发生消损，那么心脏自然会被焚毁而死。治疗这种病，如果只是调理而不攻下，那么轻微的滋润固不能扑灭炎上之势；如果只攻下而不调理，也终究不能浇灌膈膜的干燥；如果既攻下又调理，但患者减少滋味饮食，戒除嗜欲，节制喜怒，病好了也会复发。证候分为上、中、下三消，都要从“火”的角度来断治。
上消的症状是：极度口渴，饮水很多，严重的舌头也会发红开裂，《黄帝内经》所说的心将热邪移于肺，传变为膈消，就是这种情况。大小便正常，可知燥热在上焦，用白虎加人参汤（见发热章节）主治。如果小便量少，是因为热邪消烁了体内的水分，（这是“消”的一种含义。）也用前面的方剂加入生津滋燥的药物，如天花粉、北五味子、麦冬、葛根之类。如果小便不通利，（不通利不等于量少，而是指有水但不能排出。）用前面的方剂合五苓散。（见伤湿章节。）张子和说：恐怕会转变为水肿病。
如果小便通利，这就是所说的饮水多排尿也多，（详见下文。）在前面的方剂中加入辛润性质的药物，以开通腠理即可。上消大概都是心火旺盛，单用黄连一味煎汤，待冷却后，遇到口渴心烦时饮用，时间久了自然会痊愈。如果是因用心过度导致此病的，用黄六一汤加入莲肉、远志各一钱，吞服玄兔丹，仍用大麦煎汤，间隔服用灵砂丸。糯谷炒爆、桑根白皮等份，每次服用一两，水煎，口渴就喝它，使水谷之气上蒸于肺，化为津液，这是“金生水”的道理，这两味药都是入肺的药，又有淡渗作用，所以选用它们。缲丝汤，能引导清气上行至口腔，另外蚕与马同属午火，对应心脏。蚕作茧成蛹，有退藏的含义，所以能抑制心火而止渴。治疗上消的药剂剂量宜小，服药次数宜频。李东垣说：消渴病，尚未发展到能食阶段的，必定会发脑疽背疮；不能食的，必定会发展为中满鼓胀。因为能食的是实火，火盛则血液壅滞于经络，所以生疽疮。（疼痛剧烈但不溃破，或者溃破流出赤色脓水。）不能食的是虚寒，虚寒则气机不运化，所以出现胀满。而导致虚寒的原因是什么呢？回答说：用寒凉药治疗热证，固然像墨线一样不可废弃。但是脏腑有远近之分，心肺位置近，适宜制作小剂量的药，肝肾位置远，适宜制作大剂量的药，使药力恰好到达病所为止。否则要么过量，要么不足，都是对无过之处的诛罚。如上消却使用大剂量药，则会迅速越过病所，而寒凝其中下焦，因而导致胀满的病，这就是所谓的上热未除，中寒又起。因此处方应当审慎，所以说心肺的药，不要嫌麻烦而减量。
中消的症状是：食欲好但身体消瘦，（热能消化谷物，这是“消”的一种含义。消瘦，是热邪灼烧肌肉使其消削，这也是“消”的一种含义。）口渴，自汗，大便干硬，小便频数、颜色黄赤，这是胃热旺盛。王叔和所说的口干想喝水，吃得多却感觉饥饿虚弱，发展成消中，就是这种情况。（张子和解释《内经》，二阳的病发于心脾，男子精少，女子月经不来，其传变为风消。解释说二阳是指胃与大肠的热病，心受之则血不流，所以女子月经不来；脾受之则味道不能运化，所以男子精少。风火消涸肠胃，这就是肠胃之消。）用调胃承气汤，（见大便不通章节。）或三黄丸，（见发热章节。）生地、白莲藕各取自然汁，牛乳各一斤，熬成膏，加入黄连末一斤，制成梧桐子大小的丸药，白开水送服三五十丸，每天十次。黄连猪肚丸、清凉饮子。（见伤燥章节。）
下消的症状是：烦躁口渴引水，小便像膏脂一样，面色黧黑，耳廓焦枯，双腿消瘦，这是肾热，又名肾消，用六味地黄丸（见虚损章节）主治。多因房事过度，服用金石类药物，导致肾水枯竭，虚阳上炎，精气不交而外泄，小便淋浊，阳道常坚硬，古时候称为强中。
按语：对于三消，刘河间、张子和认为是热证。而《金匮要略》说消渴，小便反而多，喝一杯水排出一杯水，用肾气丸主治。又《黄帝内经》说心将寒邪移于肺，形成肺消，喝一杯水排出两杯水，预后不良，难以治愈。那么三消固有寒证吗？回答说：这虽然也叫消渴，但实际上不应当以消渴命名。大概《金匮》所说的，是因为病人命门火衰，不能蒸动肾水与脾胃中的谷气，以上达于肺，所以上焦失去滋润而口渴。他所喝的水，未经火气气化，直接下行进入膀胱，所以喝一杯排一杯，尿液味道不咸，肾气丸。（即八味丸。）用附子、桂枝来壮旺命门之火，如同在锅底下添加柴火，那么水谷之气就会上腾，蒸腾为润泽。然而这个病只是因为水不上滋而口渴，不像烈火焚烧那样，所以他的口渴不严重，饮水也必然不多，（所谓喝一杯排一杯，是合计而言，不是说每次必喝一杯排一杯。）这与热证的大渴引饮不止的情况，怎么会有相同之处呢？肾热则小便像膏脂，肾寒则小便清白，这自然有区别。至于《内经》所说的，心火衰微，反化为水冷金寒的变化，不仅所喝的水没有气化，而且连身体中的津液，也没有气化提摄，一同向下趋行，而成喝一杯排两杯的证候，那么肺气的消索已经非常严重，哪里还有大渴大饮的情况呢？这些都不应当命名为消渴，致使后人混淆不清，动手就用温补法，热证遇到温补，不死还等什么？这就是刘河间、张子和二位先生大声疾呼，痛斥其错误的原因。
刘河间说：饮水多而小便多的，不是虚寒无火，不能制约水液，而是燥热太甚，肠胃三焦的腠理郁结阻滞，致密壅塞，水液不能渗透排泄到体外，（就像水浇在石头上，流过而不留下。）所以小便多。（这是“消”的另一种含义。）应当清除燥热，救济津液的衰少，使道路疏散而不结滞，气血通畅而不涩滞。（就是前面所说的用辛润的药物，开通腠理。）又说常有阳极似阴的情况，下部觉得冷，双脚像冰一样，这是心火不降，适宜用寒凉药攻下三五次，则火降水升，寒象自然消退，他的话可以说是名理通达。张子和说：心是阳火，先受寒邪，火郁伤肺，火与寒都来乘袭肺脏，肺外在寒邪的逼迫下，阳气不得宣泄，内在被火邪燥灼，所以皮肤消损，小便与积湿频繁并见，喝一杯排两杯。膈消不被寒邪逼迫，阳气得以宣散，所以可治。肺消被寒邪逼迫，阳气在中部自行溃败，所以不治，这也是一种说法。
三消通用治法：选好黄连洗净研为细末，用冬瓜自然汁调和做成饼，阴干，再研为细末再次调和，像这样重复七次，最后仍用冬瓜汁制成丸药，梧桐子大小，每次服用三十丸，用大麦仁汤加冬瓜汁送下。寻常口渴，服一次见效。小便既然多，大便必然秘结，适宜常服四物汤（见血章节）调理。糯米泔水折半，也可以冷服。三消日久，小便不臭，反而散发甜气，在尿桶中涌沸，病情较重。更有像猪脂浮在尿面，像烛泪溅在桶边的，这是精气枯竭，难治。水在天地与人身，都有甘味和咸味，甘味代表生气，咸味代表死气。小便属于死水，本是咸味却反现甘味，这是生气泄漏，脾胃的生气下陷了。（参考汗门脱汗味淡更明显。）三消日久精血亏损，或者眼睛看不见，或者手足偏废像中风，必须滋生精血。痊愈后须防发痈疽，用黄六一汤送服忍冬丸。末期传变鼓胀水气，用五皮饮（见肿胀章节）送服济生肾气丸。（见虚损章节。）李东垣的中满分消诸方（见肿胀章节。）可选用。坎卦，象征水，是气，小如井泉，大如江河。兑卦、坤卦，象征水，是形，微小如露水，广大如雨水。一阳陷于二阴之中为坎卦，坎卦以气潜行于万物之中，是受命的根本，所以滋润万物没有比水更好的。一阴彻于二阳之上为兑卦，兑卦以形普施于万物之上，是资生的利泽，所以喜悦万物没有比兑卦更好的。三焦是形的火。用有形之水来制约它的是兑卦，泽是水，是可以暂时的。我们身体自有上池真水，是气，是天一所生的。用无形之水，浇灌无形之火，是常规且可以长久的。这就是真水火，升降既济，口渴自然停止。
寻常消渴，因饮食劳倦，气虚发热，导致津液不足而口渴，不可用五苓散（见伤湿章节），宜用补中益气汤（见气章节）加五味子、葛根。无病自渴，以及病愈后口渴，用参术饮、四君子汤（见气章节）、缩脾饮（见中暑章节），都加葛根。久病阴虚，用黄芪饮、四物汤（见血章节），加人参、木瓜。或者七珍散去白术，加木瓜。产妇血虚口渴，宜补血。酒渴，用干葛饮调服五苓散。多吃果子导致口渴，药中加麝香。停饮导致口渴，详查痰饮门。
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.