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Appendix: Various Decoctions with Modifications

Treating Yangming disease, characterized by a floating and tight pulse, dryness of the throat and bitter taste in the mouth, abdominal fullness with panting, fever with sweating, aversion to cold absent but aversion to heat present, heaviness of the body, irritability, mental restlessness (Xin Zhong Kui Kui), palpitations and remorsefulness (Chu Ti Ao Nao), eye pain and nasal dryness, and inability to sleep.

Zhi Zi (Gardeniae Fructus) [broken] 14 pieces; Xiang Chi (Fermented Sojae Semen Nigrum) [wrapped in cotton cloth] 4 he. The above two ingredients are boiled in 4 sheng of water. First, boil Zhi Zi until the liquid reduces to 2.5 sheng; then add Xiang Chi and boil until 1.5 sheng remains. Strain the dregs, divide into two doses, and take warm. After taking the first dose, if vomiting occurs, discontinue subsequent doses. If there is shortness of breath (Shao Qi), add Gan Cao (Glycyrrhizae Radix et Rhizoma) 2 liang. If there is vomiting, add Sheng Jiang (Zingiberis Rhizoma Recens) 3 liang. If after purgation, there is irritability, abdominal fullness, and restlessness (Qi Wo Bu An), remove Xiang Chi and add Hou Po (Magnoliae Officinalis Cortex) 4 liang and Zhi Shi (Aurantii Fructus Immaturus) 4 pieces. If a physician mistakenly used pill-based purgatives, resulting in persistent fever and a knotted pain in the heart region (Xin Zhong Jie Tong), remove Xiang Chi and add Gan Jiang (Zingiberis Rhizoma) 2 liang. If there is fever accompanied by jaundice (Fa Huang), remove Xiang Chi and add Gan Cao (Glycyrrhizae Radix et Rhizoma) 1 liang and Huang Bo (Phellodendri Cortex) 2 liang.

[Collected Annotations] Ke Qin stated: In Taiyang disease, the heart and abdomen are considered the interior; in Yangming disease, the heart and abdomen are considered the exterior. Essentially, the "interior" of Yangming refers to gastric excess (Wei Shi). Not only are symptoms such as fever, aversion to heat, eye pain, nasal dryness, sweating, and body heaviness termed "exterior"; all conditions involving empty irritability (Xu Fan), empty heat, dry throat, bitter taste, abnormal tongue coating, abdominal fullness, irritability, insomnia, thirst with difficult urination, etc., that exist outside the stomach organ, are all considered the "exterior" of Yangming. Zhang Zhongjing formulated diaphoretic agents to provide an exit for pathogenic factors in the Taiyang exterior, and emetic agents to provide an exit for pathogenic factors in the Yangming exterior. Therefore, Taiyang exterior syndromes should be treated with diaphoresis rather than emesis, while Yangming exterior syndromes should be treated with emesis rather than diaphoresis. If Taiyang requires diaphoresis but emesis is used instead, symptoms such as spontaneous sweating, absence of aversion to cold, hunger without ability to eat, morning intake with evening vomiting, desire for cold food, and dislike of being near clothing will appear. This represents the method of Taiyang transforming into Yangming exterior syndrome, which should be treated with Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) to induce emesis. If Yangming requires emesis but it is not performed, and instead diaphoresis, purgation, or warm needle therapy are used, leading to mental restlessness, palpitations, remorsefulness, irritability, and abnormal tongue coating, these symptoms still belong to the Yangming exterior and should still be primarily treated with Zhi Zi Chi Tang. Zhi Zi is bitter and can induce emesis and purgation, and cold in nature to overcome heat. Its shape resembles the heart, and its red color connects to the heart, so it treats all conditions affecting the heart region and upper/lower areas. The bean shape resembles the kidney, and black enters the kidney; when processed into Chi (fermented soybean), it becomes light and floats upward, enabling turbid pathogens in the heart and abdomen to emerge from the mouth. One episode of emesis relieves the heart and abdomen, resolving all exterior and interior irritability and heat. This is because urgently removing heat outside the stomach prevents the formation of gastric excess; thus, this Zhi Zi Chi Tang is the supreme agent for resolving the exterior of Yangming. Heat damaging Qi causes shortness of breath; adding Gan Cao tonifies Qi. Empty heat clashing with deficiency causes frequent vomiting; adding Sheng Jiang disperses pathogens. If after purgation there is heart and abdominal fullness with restlessness, the heat has entered the stomach, so emesis is inappropriate; hence, Xiang Chi is removed. Since the stool is not yet dry and hard, further purgation is unsuitable; thus, only Zhi Zi is used to remove irritability, assisted by Zhi Shi and Hou Po to drain fullness. This is a subtle method to resolve both heart and abdominal issues, serving as a mild version of Xiao Cheng Qi Tang. If pill-based purgatives were used, persistent fever indicates the exterior is unresolved; knotted pain in the heart indicates cold lingering in the middle jiao. With exterior heat and interior cold, one relies on the bitterness of Zhi Zi to clear heat and doubles the pungency of Gan Jiang to drive out cold, thereby naturally resolving exterior heat and eliminating interior cold. However, since emesis is required to reach the exterior, this formula is used to probe for emesis, representing a combination of cold and heat to harmonize the middle and resolve the exterior. When internal and external heat are blazing, causing yellowing of the muscles, bitter-sweet agents must be used to regulate. Huang Bo Pi and Gan Cao are yellow and moistening, assisting Zhi Zi to remove internal irritability and resolve external heat; diseases of form and color are addressed by utilizing corresponding forms and colors. These are all modifications of Zhi Zi Chi Tang to manage the variations of Yangming exterior syndromes. The nature of Zhi Zi allows it to descend curving downward; it is not an emetic agent itself. Only the fermented aroma of Chi steaming upward to the heart and lungs can induce vomiting. Observing Gua Di San (Melon Seed Powder), which must be taken mixed with Chi juice, shows that the emetic effect lies in Chi, not Zhi Zi. In Zhi Zi Gan Jiang Tang, removing Chi and using Jiang takes advantage of horizontal opening. In Zhi Zi Hou Po Tang, replacing Chi with Zhi Shi and Hou Po takes advantage of downward drainage. These seem to avoid upward surging meanings. Although bitter flavors can also cause emesis, without probing for emesis, vomiting cannot be induced. Patients with a history of loose stools should not receive this formula, clarifying the nature of Zhi Zi.