昌着消渴论，聊会《内经》大意，谓始于胃而极于肺肾，定为中上下之三消。其他膈消亦积食证，要亦中上之消耳，
然未得《金匮》之实据，心恒不慊。越二岁，忽忆《内经》云∶有所劳倦，形气衰少，谷气不盛，上焦不行，胃气热，
热气熏胸中故内热。恍然悟胸中受病消息，唯是胃中水谷之气，与胸中天真灌注环周，乃得清明在躬，若有所劳倦，伤
其大气宗气，则胸中之气衰少。胃中谷气因而不盛，谷气不盛，胸中所伤之气愈益难复，而不能以克行。于是谷气
留于胃中，胃中郁而为热，热气熏入胸中，混合其衰少之气，变为内热，胸胃间不觉易其冲和之旧矣。求其不消不渴，
宁可得乎？透此一关，读《金匮》所不了了者，今始明之。其云∶寸口脉浮而迟，浮即为虚，迟即为劳，虚则卫气不足，
劳则荣气竭。趺阳脉浮而数，浮则为气，数则消谷而大坚，气盛则溲数，溲数则坚，坚数相搏，即为消渴。举寸口以候
胸中之气，举趺阳以候胃中之气，显然有脉之可循，显然有证之可察，然且难解其微焉。盖阴在内为阳之守，阳在外为
阴之固，寸口脉浮，阴不内守，故卫外之阳浮，即为虚也。寸口脉迟，阳不外固，故内守之阴迟，即为劳也，总因劳伤
荣卫，致寸口脉虚而迟也。然荣者水谷之精气，卫者水谷之悍气，虚而且迟，水谷之气不上充而内郁，已见膈虚胃热之
一斑矣。更参以趺阳脉之浮数，浮则为气，即《内经》热气熏胸中之变文，数则消谷而大坚。昌前论中既如以水投石，
水去而石自若，偶合胃中大坚，消谷不消水之象，可见火热本足消水也，水入本足救渴也。胃中坚燥，全不受水之浸润，
转从火热之势，急奔膀胱，故溲数。溲去其内愈燥，所以坚数相搏，即为消渴。直引《内经》味过于苦，久从火化，脾
气不濡，胃气乃浓之意，为消渴之源，精矣微矣。晋唐以后，代不乏贤，随其聪敏，揣摩《内经》，各自名家，卒皆不入
仲景堂奥，其所得于《内经》者浅耳。使深则能随证比类，各出脉证方治，以昭成法，而《金匮》遗编，家传户诵之矣。
即如消渴证，相沿谓中消者宜下之，共守一语，更无别商，岂一下可了其局乎？抑陆续徐下之乎？夫胃已大坚，不受膏
沐，辄投承气，坚者不受，瑕者受之矣。膀胱不受，大肠受之矣。岂不乘其药势，传为痢下、 溏、中满、肿胀之证乎？
总录谓末传能食者，必发脑疽背疮；不能食者，必传中满鼓胀，皆为不治之证。诸家不亟亟于始传中传，反于末传多方
疗治，如忍冬蓝叶荠 丸散，及紫苏葶苈中满分消汤丸，欲何为耶？《金匮》于小溲微觉不利，早用文蛤一味治之，方
书从不录用。讵知软坚之品，非劫阴即伤阴，独此一种平善无过，兼可利水，诚足宝乎。洁古谓能食而渴者，白虎加人
参汤；不能食而渴者，钱氏白术散加葛根。末传疮疽者，火邪盛也，急攻其阳，无攻其阴。下焦元气得强者生，失强者
死，末传中满者高消，中消制之太过，速过病所。上热未除，中寒复起，非药之罪，用药时失其缓急之制也。洁古老人
可谓空谷足音矣！所云无攻其阴，得强者生，失强者死，皆虑泉竭之微言，令人耸然起敬。于是追步后尘，徐商一语曰∶
三消总为火病，岂待末传疮疽，始为火邪胜耶？然火之在阳在阴，分何脏腑，合何脏腑，宜升宜降宜折宜伏，各各不同。
从其性而治之，使不相 格，乃为良法。若不治其火，但治其热，火无所归，热宁有止耶？如肾消阴病用六味丸，阳病
用八味丸，此亦一法。若谓下消只此一法，其去中消宜下之说，能以寸哉！
《内经·阴阳别论》曰∶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，病热则消谷善饥，血中伏火，乃血不足也。结者津血不足，结而不行，皆燥之为病也。
《内经》曰∶心移热于肺，传为膈消。张子和谓膈消犹未及于肺，至心移寒于肺，乃为肺消。如此泥文害意，非能
读《内经》者也。岂有心移热于肺，肺传其热于膈，犹未及肺之理，必变经文为心移热于膈，传为肺消，乃不泥乎？要
识心肺同居膈上，肺为娇藏，移寒移热，总之易入。但寒邪入而外束，热邪入而外传，均一肺消，而治则有分矣。
刘河间论三消之疾，本湿寒之阴气极衰，燥热之阳气太甚。六气中已遗风火二气矣。且以消渴、消中、消肾，分明
三消，岂中下二消，无渴可言耶？及引《经》言，有心肺气厥而渴；有肝痹而渴；有痹热而渴；有胃与大肠结热而渴；
有脾痹而渴；有肾热而渴；有小肠痹热而渴，愈推愈泛。其不合论消渴，但举渴之一端，为燥热亡液之验，诚不可解。
玉机微义，深取其说，发暖药补肾之误，吾不知暖药果为何药也！世岂有以暖药治消渴之理哉？其意盖在非《金匮》
之主肾气丸耳，夫肾气丸蒸动肾水，为治消渴之圣药，后世咸知之。而何柏斋复辨之，昌恐后学偶阅子和宗浓之说，反
滋疑眩，故再陈之。
瘅成为消中，胃热极深，胃火极炽，以故能食易饥多渴，诸家咸谓宜用大承气汤下之矣。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，故不得已而用大黄。当久蒸以和其性，更不可合枳实、浓朴同用，助
其疾趋之势。洁古用大黄，更其名曰顺利散，隐然取顺利，不取攻劫之意。方下云∶治中消热在胃而能食，小便色黄微
利，至不欲食为效，不可多利。昌恐微利至不欲食，胃气已不存矣。承气非微利之法，而可渎用哉？子和更其方为加减
三黄丸，合大黄、芩、连用之，不用枳、朴矣。方下云∶治丹石毒及热渴。以意测度，须大实者方用。曾不思消渴证，
真气为热火所耗，几见有大实之人耶？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，则急缓互调；
与人参合用，则攻补兼施。如 国之屯田金城，坐困先零，庶几可图三年之艾。目前纵有乘机斗捷之着，在所不举，如
之何欲取效眉睫耶？昔贤过矣。
【律五条】
凡治初得消渴病，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，不急救金水二藏，泉之竭矣。不云自中，医之罪也。
凡治肺消病而以地黄丸治其血分，肾消病而以白虎汤治其气分，执一不通，病不能除，医之罪也。
凡消渴病少愈，不亟回枯泽槁，听其土燥不生，致酿疮疽无救，医之罪也。
凡治消渴病，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。
我撰写《消渴论》，旨在综合《内经》的大意，认为消渴病始于胃，最终波及肺和肾，因此将其定为上、中、下三消。其他的如膈消，也是积食证的一种，本质上属于中消或上消的范畴。然而，由于缺乏《金匮要略》中的确凿依据，我心中始终感到不满足。过了两年，我突然想起《内经》中说：“如果因劳倦过度，导致形体与正气衰弱，水谷之气不旺盛，上焦之气不能宣通，胃气产生郁热，热气熏蒸胸中，所以体内发热。”我恍然大悟，明白了胸中发病的关键所在：这完全是因为胃中水谷之气与胸中天真之气（宗气）灌注循环周身，才能使身体清明；若因劳倦损伤了大气（宗气），则胸中之气就会衰弱。胃中的谷气因此也不旺盛，谷气不旺盛，胸中所伤之气更加难以恢复，无法正常运行。于是谷气滞留于胃中，在胃中郁结化为热，热气熏入胸中，与衰弱的胸气混合，变为内热，胸胃之间不知不觉失去了原本的冲和状态。在这种情况下，想要不出现消瘦和口渴的症状，怎么可能呢？透过这一层理解，之前读《金匮要略》时那些不明白的地方，现在才彻底明了。
《金匮要略》中说：“寸口脉浮而迟，浮脉代表虚，迟脉代表劳损，虚则卫气不足，劳则营气竭尽。趺阳脉浮而数，浮脉代表气盛，数脉代表消谷善饥且大便坚硬，气盛则小便频数，小便频数则大便更坚，坚与数相互搏结，就形成了消渴。”这里举寸口脉来候察胸中之气，举趺阳脉来候察胃中之气，显然有脉象可以遵循，显然有证候可以观察，然而其中的微奥之处却难以解释清楚。大概阴在内作为阳的守持者，阳在外作为阴的固护者。寸口脉浮，说明阴不能在内守持，所以卫外的阳气浮越，这就是“虚”。寸口脉迟，说明阳不能在外固护，所以内守的阴气迟缓，这就是“劳”。总归是因为劳倦损伤了营卫，导致寸口脉呈现虚而迟的脉象。然而，营气是水谷的精气，卫气是水谷的悍气，既虚又迟，说明水谷之气不能向上充养而向内郁结，已经显露出膈虚胃热的端倪了。再结合趺阳脉的浮数来看，浮则为气，即《内经》中“热气熏胸中”的另一种表述；数则消谷善饥且大便坚硬。我在之前的论述中曾比喻为以水投石，水流走了石头依然如故，偶尔合于胃中大便坚硬、消谷却不消水的现象，可见火热本性足以消耗水分，水进入体内本足以解渴。但胃中干燥坚硬，完全不受水的浸润，水反而顺着火热的势头，急奔膀胱，所以小便频数。小便排出后体内更加干燥，所以坚与数相互搏结，就形成了消渴。这直接引用了《内经》中“味过于苦，久从火化，脾气不濡，胃气乃浓”的意思，作为消渴的根源，真是精妙入微啊。
晋朝、唐朝以后，历代不乏贤能之士，他们凭借自己的聪敏，揣摩《内经》，各自成为名家，但最终都没有进入张仲景学术思想的堂奥，因为他们从《内经》中得到的东西太浅薄了。如果他们学得深，就能随证比类，分别提出脉证方治，以彰显成法，那么《金匮要略》这部遗编，就会家家相传、户户诵读。就拿消渴证来说，相沿成习的说法是“中消适宜用攻下法”，大家共同遵守这一句话，更没有别的商量余地，难道一次攻下就能解决所有问题吗？还是陆续缓慢地攻下呢？胃已经变得非常坚硬，不接受膏润之物，如果贸然投用承气汤，坚硬的部位承受不住，反而是有瑕疵的部位受药了。膀胱受不了，大肠就受之了。这岂不是乘着药势，传变为痢疾、溏泄、中满、肿胀等证候吗？《总录》说，末期传到还能吃东西的，一定会发脑疽背疮；不能吃东西的，一定会传变为中满鼓胀，这些都是不治之症。各家不急于在初传、中传阶段治疗，反而在末传阶段多方疗治，比如使用忍冬、蓝叶、荠菜等的丸散，以及紫苏、葶苈子的中满分消汤丸，这究竟是为了什么呢？《金匮要略》在小便稍微觉得不利时，早就只用一味文蛤来治疗，后世方书从不收录。哪里知道软坚的药物，不是劫夺阴液就是损伤阴液，唯独这一种平和善良没有过错，兼可利水，确实值得珍视啊。
洁古（张元素）说：能吃东西而口渴的，用白虎加人参汤；不能吃东西而口渴的，用钱氏白术散加葛根。末期出现疮疽的，是火邪盛也，必须急攻其阳分，不要攻其阴分。下焦元气得以强盛的就能生，失去强盛的就会死。末期出现中满的，是高消（上消）和中消治疗太过，迅速超过了病所。上部的热还没有清除，中部的寒又起来了，这不是药的罪过，而是用药时失去了缓急的法度啊。洁古老人真可谓空谷足音（难得的声音）啊！他所说的“不要攻其阴，得强者生，失强者死”，都是担心津泉枯竭的微言大义，令人肃然起敬。于是我追随其后，慢慢商讨一句话道：三消总归是火病，难道要等到末期出现疮疽，才算是火邪胜吗？然而火在阳分还是在阴分，涉及哪些脏腑，配合哪些脏腑，宜升宜降宜折宜伏，各不相同。顺应火的性质来治疗它，使阴阳不相格拒，这才是良法。如果不治火，只治热，火就没有归宿，热怎么会有止境呢？比如肾消属阴病用六味丸，属阳病用八味丸，这也是一种方法。如果说下消只有这一种方法，那这与中消适宜用攻下的说法相比，相差岂止一尺一寸呢！
《内经·阴阳别论》说：“二阳结谓之消。”二阳指的是阳明经。手阳明大肠主司津液，患消渴病则目黄口干，这是津液不足的表现。足阳明胃主司血液，患热病则消谷善饥，血中有伏火，这是血液不足的表现。结，就是津血不足，凝结而不运行，这都是燥邪造成的疾病。
《内经》说：“心移热于肺，传为膈消。”张子和说膈消还不及于肺，直到心移寒于肺，才称为肺消。如此拘泥文字而损害原意，不是能读懂《内经》的人。难道有心将热移于肺，肺将热传于膈，还说不及于肺的道理吗？一定要把经文改为“心移热于膈，传为肺消”，才算不拘泥吗？要知道心肺同居膈上，肺为娇脏，无论是移寒还是移热，总之都容易侵入。只是寒邪侵入则外束，热邪侵入则外传，虽然都是肺消，但治疗方法却有区别。
刘河间论述三消的疾病，认为是湿寒的阴气极衰，燥热的阳气太甚。在六气中已经遗漏了风、火二气。而且将消渴、消中、消肾分明列为三消，难道中消和下消没有口渴可言吗？等到他引用《内经》的话时，有心肺气厥而渴的；有肝痹而渴的；有痹热而渴的；有胃与大肠结热而渴的；有脾痹而渴的；有肾热而渴的；有小肠痹热而渴的，推演得越来越泛泛。他的论述不符合消渴的本义，只是列举了口渴的一端，作为燥热亡液的验证，实在让人无法理解。《玉机微义》深深采纳了他的说法，批评使用暖药补肾的错误，但我不知道所谓的暖药到底是什么！世上哪有使用暖药治疗消渴的道理呢？他的意思大概是指非《金匮》中的主肾气丸而言。夫肾气丸蒸动肾水，是治疗消渴的圣药，后世人都知道。为什么何柏斋又要辩驳它呢？我担心后学偶然阅读到张子和、李东垣（注：原文“宗浓”疑为李东垣或其学派观点，此处依语境理解为对前人观点的辨析）等人的说法，反而滋生疑惑眩晕，所以再次陈述我的观点。
瘅热发展成为消中，胃热极深，胃火极炽，所以能吃东西、容易饥饿、多口渴，各家都说适宜用大承气汤攻下。却不知道这种逐渐积聚的热，素来蕴藏的火，不需要急下，即使下了也去不掉，只会徒然损伤肠胃，反而增加病人的困顿罢了，所以不得已才使用大黄。应当通过久煎来缓和它的药性，更不可以合枳实、厚朴一起使用，以免助长其急趋之势。洁古使用大黄，改名为顺利散，隐含取“顺利”之意，不取“攻劫”之意。方剂下方注明：治疗中消热在胃而能吃东西，小便色黄轻微通利，直到不想吃东西为止效，不可过多通利。我担心轻微通利直到不想吃东西，胃气就已经不存在了。承气汤不是轻微通利的方法，怎么能滥用呢？张子和又将方子改为加减三黄丸，合用大黄、黄芩、黄连，不用枳实、厚朴了。方剂下方注明：治疗丹石毒及热渴。凭推测，必须是真正大实证才能使用。怎不曾想到消渴证中，真气被热火耗损，哪里有见到真正大实证的人呢？既然如此，要想去除胃中的火热，必须怎么做才可以呢？我认为久煎大黄，与甘草合用，则急缓互相调节；与人参合用，则攻补兼施。就像国家的屯田金城，坐困先零（匈奴部落名，喻敌人），或许可以图谋长远的治疗。目前纵然有乘机斗捷的着数，在所不论，怎么能指望立刻见效呢？以前的贤人有过错了。
【五条法则】
凡是治疗初得的消渴病，不急于生津补水、降火彻热。用药不当，拖延延误病人，是医生的罪过。
凡是治疗中消病已成，不急救金（肺）水（肾）二脏，泉水枯竭了。不从内部源头救治，是医生的罪过。
凡是治疗肺消病却用地黄丸治疗其血分，治疗肾消病却用白虎汤治疗其气分，固执一端不通变，病不能除，是医生的罪过。
凡是消渴病稍有好转，不急于恢复枯槁润泽的状态，听任土燥不生，导致酿成疮疽无法挽救，是医生的罪过。
凡是治疗消渴病，使用寒凉药物太过，以至于水胜火灭，还不知道反悔，渐渐变成肿满无法挽救，是医生的罪过。
I composed the "Treatise on Xiao Ke (Wasting-Thirst)," aiming to synthesize the general principles of the *Nei Jing* (Inner Canon), asserting that the disease originates in the Stomach and culminates in the Lung and Kidney, thus categorizing it into Upper, Middle, and Lower Xiao. Other conditions such as Ge Xiao (Diaphragm Thirst) are also accumulations of food stagnation, essentially falling under the categories of Middle or Upper Xiao. However, lacking solid evidence from the *Jin Gui Yao Lue* (Essential Prescriptions of the Golden Cabinet), my heart remained unsatisfied. Two years later, I suddenly recalled a passage from the *Nei Jing*: "If there is fatigue and overexertion, the physical form and Qi decline, the Qi from grain and water is not abundant, the Qi of the Upper Jiao fails to circulate, the Stomach Qi becomes hot, and the hot Qi steams the chest, resulting in internal heat." I suddenly realized the mechanism of pathology in the chest: it is entirely due to the fact that the Qi of grain and water in the Stomach and the Tian Zhen Qi (innate Qi/Zong Qi) circulating throughout the body maintain clarity in the body; if fatigue and overexertion injure the Da Qi (Grand Qi/Zong Qi), then the Qi in the chest declines. Consequently, the Qi from grain in the Stomach becomes insufficient. When the Qi from grain is insufficient, the injured Qi in the chest becomes even harder to recover and cannot function properly. Thus, the Qi from grain remains stagnant in the Stomach, stagnates and transforms into heat, the hot Qi steams into the chest, mixes with the declining Qi there, and transforms into internal heat. The relationship between the chest and Stomach unknowingly loses its original harmonious state. Under these circumstances, how could one avoid wasting and thirst? By penetrating this understanding, the matters in the *Jin Gui Yao Lue* that were previously unclear are now fully illuminated.
The *Jin Gui Yao Lue* states: "The pulse at Cun Kou (radial artery) is floating and slow; floating indicates deficiency, slow indicates labor/exhaustion. Deficiency means Wei Qi (Defensive Qi) is insufficient, and exhaustion means Ying Qi (Nutritive Qi) is exhausted. The pulse at Fu Yang (dorsalis pedis artery) is floating and rapid; floating indicates Qi abundance, rapid indicates consumption of food and hard stools. Qi abundance leads to frequent urination; frequent urination leads to hardness. The interaction of hardness and rapidity constitutes Xiao Ke." Here, the Cun Kou pulse is used to observe the Qi in the chest, and the Fu Yang pulse is used to observe the Qi in the Stomach. Clearly, there are pulses to follow and signs to observe, yet the subtle nuances remain difficult to explain. Generally, Yin inside serves as the guardian of Yang, and Yang outside serves as the protector of Yin. A floating pulse at Cun Kou indicates that Yin cannot guard within, so the Yang defending the exterior floats, which is termed "deficiency." A slow pulse at Cun Kou indicates that Yang cannot protect externally, so the Yin guarding internally slows down, which is termed "labor/exhaustion." Ultimately, this is because fatigue and injury to Ying and Wei cause the Cun Kou pulse to be both deficient and slow. However, Ying Qi is the essence of grain and water, while Wei Qi is the fierce Qi of grain and water. Being both deficient and slow indicates that the Qi of grain and water fails to ascend and nourish, instead stagnating internally, revealing a glimpse of Diaphragm deficiency and Stomach heat. Further considering the floating and rapid Fu Yang pulse, floating indicates Qi abundance, which is a variation of the "hot Qi steaming the chest" mentioned in the *Nei Jing*; rapidity indicates consumption of food and hard stools. In my previous discussion, I likened this to throwing water at a stone; the water flows away while the stone remains unchanged, occasionally aligning with the phenomenon of a hard Stomach that consumes food but not water. This shows that fire/heat inherently consumes water, and water entering the body should theoretically quench thirst. However, the dryness and hardness in the Stomach completely reject the infiltration of water. Instead, following the momentum of fire/heat, the water rushes urgently to the Bladder, causing frequent urination. As urine leaves, the interior becomes drier, so the interaction of hardness and rapidity constitutes Xiao Ke. This directly references the *Nei Jing* saying, "Excessive consumption of bitter flavors leads to transformation into fire over time; Spleen Qi becomes unmoistened, and Stomach Qi becomes concentrated," identifying this as the source of Xiao Ke. It is truly exquisite and subtle.
Since the Jin and Tang dynasties, there have been no lack of sages who, relying on their intelligence, speculated upon the *Nei Jing* and established their own schools. Yet none entered the inner sanctum of Zhang Zhongjing's scholarship because their understanding of the *Nei Jing* was superficial. Had they studied deeply, they could have classified symptoms according to patterns, presenting pulse, sign, formula, and treatment methods to clarify standard practices, and the *Jin Gui Yao Lue* would have been passed down from family to family and recited by every household. Take Xiao Ke for example: the prevailing view holds that "Middle Xiao is suitable for purgation." Everyone adheres to this single phrase without further discussion. Can one purge resolve the entire situation? Or should one purge gradually and slowly? If the Stomach is already extremely hard and rejects moistening agents, administering Cheng Qi Tang (Gut-Regulating Decoction) abruptly means the hard parts will not accept it, while the flawed parts will. If the Bladder cannot tolerate it, the Large Intestine will. Would this not, riding the momentum of the medicine, transmit into dysentery, loose stools, abdominal fullness, and swelling? The *Zong Lu* states that in the late stage, if the patient can eat, they will likely develop brain abscesses or back sores; if they cannot eat, they will develop abdominal fullness and distension. These are all incurable conditions. Various practitioners do not rush to treat during the initial or middle transmission stages but instead employ various treatments in the late stage, such as pills and powders containing Honeysuckle, Isatis leaf, and Shepherd's purse, or formulas like Perilla and Lepidium Powder for Abdominal Fullness. What is the purpose of this? The *Jin Gui Yao Lue*, when slight difficulty in urination is perceived, early on uses only one herb, Wen Ge (Clam Shell), to treat it. Later formularies never record this. Who knows that softening-hardness herbs either rob Yin or damage Yin; only this one is gentle and harmless, and additionally promotes diuresis. It is indeed worthy of treasure.
Jie Gu (Zhang Yuansu) stated: For those who can eat and feel thirsty, use Bai Hu Jia Ren Shen Tang (White Tiger Decoction plus Ginseng); for those who cannot eat and feel thirsty, use Qian Shi Bai Zhu San (Dr. Qian's Atractylodes Powder) plus Kudzu Root. For late-stage sores and carbuncles, Fire Evil is abundant; urgently attack the Yang aspect, do not attack the Yin aspect. If the Yuan Qi (Primal Qi) of the Lower Jiao becomes strong, life is preserved; if it loses strength, death ensues. Late-stage abdominal fullness results from excessive treatment of High Xiao (Upper Xiao) and Middle Xiao, rapidly surpassing the disease site. The heat above has not been cleared, yet cold arises in the middle. This is not the fault of the medicine, but the failure to regulate the urgency and slowness of treatment. Elder Jie Gu can be described as a rare voice in an empty valley! His statements about "not attacking the Yin," "survival if strength is gained," and "death if strength is lost" are profound warnings against the depletion of the spring (fluids), inspiring awe and respect. Following in his footsteps, I slowly propose this statement: All three Xiao types are fundamentally Fire diseases. Does one wait until late-stage sores appear to consider Fire Evil dominant? However, whether Fire is in the Yang or Yin, which Zang-Fu organs are involved, and whether it is appropriate to ascend, descend, suppress, or subdue, each case differs. Treating according to its nature, ensuring no mutual rejection, is the good method. If one does not treat the Fire but only treats the Heat, the Fire will have no abode, and how can the Heat ever cease? For instance, for Kidney Xiao (Yin disease), use Liu Wei Wan (Six-Ingredient Pill with Rehmannia); for Yang disease, use Ba Wei Wan (Eight-Ingredient Pill). This is also one method. But if one claims that Lower Xiao has only this one method, how does it compare to the theory that Middle Xiao requires purgation? They differ by more than just an inch!
The *Nei Jing · Treatise on Distinctions of Yin and Yang* says: "Binding of the Two Yangs is called Xiao." The Two Yangs refer to the Yangming channels. Hand Yangming Large Intestine governs Jin Ye (Body Fluids); in Xiao disease, yellow eyes and dry mouth occur, indicating insufficiency of fluids. Foot Yangming Stomach governs Blood; in heat disease, food consumption increases and hunger is frequent, with latent fire in the blood, indicating insufficiency of blood. Binding refers to insufficiency of Jin Ye and Blood, binding and failing to circulate, all being diseases of Dryness.
The *Nei Jing* says: "Heart transfers heat to the Lung, transmitting as Ge Xiao." Zhang Zihe claimed that Ge Xiao has not yet reached the Lung; only when Heart transfers cold to the Lung is it called Lung Xiao. Such rigidity in text harms the meaning; one who reads the *Nei Jing* thus is not truly reading it. Is there any logic that Heart transferring heat to the Lung, and Lung transmitting heat to the Diaphragm, means it hasn't reached the Lung? Must one change the text to "Heart transfers heat to the Diaphragm, transmitting as Lung Xiao" to avoid rigidity? One must recognize that Heart and Lung reside together above the Diaphragm. The Lung is a delicate organ; whether cold or heat is transferred, it easily enters. Cold pathogen entering binds externally; heat pathogen entering transmits externally. Both result in Lung Xiao, but treatments differ.
Liu Hejian discussed the disease of Three Xiao, attributing it to extreme deficiency of damp-cold Yin Qi and excess of dry-heat Yang Qi. In the Six Qi, he omitted Wind and Fire. Moreover, distinguishing Xiao Ke, Xiao Zhong, and Xiao Shen clearly as Three Xiao, does this imply Middle and Lower Xiao have no thirst? Yet when citing the Classics, he mentions thirst due to Heart-Lung Qi reversal, Liver Bi, Bi-heat, Stomach and Large Intestine binding-heat, Spleen Bi, Kidney heat, and Small Intestine Bi-heat. His reasoning became increasingly generalized. His discussion did not conform to the essence of Xiao Ke but merely cited thirst as evidence of dry-heat consuming fluids, which is truly incomprehensible. *Yu Ji Wei Yi* deeply adopted his view, criticizing the error of using warm medicines to tonify the Kidney. I do not know what specific warm medicines he referred to! How could there be a rationale for using warm medicines to treat Xiao Ke? His intent likely targeted the non-*Jin Gui* preference for Shen Qi Wan. Shen Qi Wan steams and moves Kidney Water, serving as a sacred medicine for treating Xiao Ke, known by later generations. Why did He Bozhai refute it? I fear that later students, accidentally reading the views of Zhang Zihe and others, might become confused and dizzy, so I reiterate my position.
Dan Re transforming into Xiao Zhong involves extremely deep Stomach heat and blazing Stomach fire, hence the ability to eat, easy hunger, and excessive thirst. Various practitioners claim Da Cheng Qi Tang (Major Order of the Gut Decoction) should be used for purgation. They fail to realize that gradually accumulated heat and originally stored fire do not require urgent purgation; even if purged, it will not remove them, only damaging the intestines and stomach and increasing distress. Thus, Dahuang (Rhubarb) is used only as a last resort. It should be decocted for a long time to moderate its nature. It must not be combined with Zhishi (Immature Bitter Orange) and Houpo (Magnolia Bark), as this aids its rapid downward momentum. Jie Gu used Dahuang but renamed it Shun Li San (Smooth Flowing Powder), implicitly taking "smooth flow" rather than "assault" as the intent. The prescription notes: "Treats Middle Xiao with heat in the Stomach and ability to eat, yellow urine with slight looseness; effective until appetite is lost. Do not cause excessive looseness." I worry that if slight looseness progresses to loss of appetite, Stomach Qi will be depleted. Cheng Qi Tang is not a method for slight looseness; how can it be abused? Zhang Zihe further modified the formula into Jia Jian San Huang Wan (Modified Three Yellows Pill), combining Dahuang, Huang Qin (Scutellaria), and Huang Lian (Coptis), omitting Zhishi and Houpo. The prescription notes: "Treats Dan Shi poison and heat-thirst." Speculatively, this must be used only for true Excess patterns. Did he not consider that in Xiao Ke, True Qi is consumed by fire-heat; where are there people with true Excess patterns? Then, how must one proceed to remove Stomach fire-heat? I suggest decocting Dahuang for a long time and combining it with Gancao (Licorice) to balance urgency and moderation; combining it with Renshen (Ginseng) to simultaneously attack and tonify. Like national border defense, sitting tight to困 (besiege) the enemy, one might plan for long-term healing ("three-year-old mugwort"). Currently, although there may be opportunistic quick-fix tactics, they are not advocated. How can one expect immediate results? The ancients erred.
[Five Laws]
1. Whenever treating newly acquired Xiao Ke, if one does not urgently generate fluids, replenish water, lower fire, and clear heat, and uses inappropriate medication, delaying and harming the patient, it is the doctor's fault.
2. Whenever treating established Middle Xiao, if one does not urgently rescue the Metal (Lung) and Water (Kidney) organs, letting the spring dry up without addressing the source, it is the doctor's fault.
3. Whenever treating Lung Xiao by using Di Huang Wan (Rehmannia Pill) to treat the Blood aspect, or treating Kidney Xiao by using Bai Hu Tang (White Tiger Decoction) to treat the Qi aspect, sticking rigidly to one approach without flexibility, failing to cure the disease, it is the doctor's fault.
4. Whenever Xiao Ke slightly improves, if one does not urgently restore withered moisture, allowing the Earth (Spleen/Stomach) to become dry and barren, leading to incurable sores and carbuncles, it is the doctor's fault.
5. Whenever treating Xiao Ke, if one uses cold-cooling medicines excessively, causing Water to overcome and extinguish Fire, yet fails to reverse course, gradually leading to incurable edema and fullness, it is the doctor's fault.