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Dysentery with a sensation of heaviness in the anus: If it presents as a Shaoyin syndrome with drowsiness and cold extremities, use Sini Tang (Frigid Extremities Decoction) added with Xiebai (Allium macrostemon). If it is a heat syndrome, use Baitouweng Tang (Pulsatilla Decoction) (formula discussion see under Li).

If the pulse is floating, sweating should be used to resolve the exterior. If moxibustion is applied, the pathogenic factor has no outlet and becomes exacerbated by the fire; the disease will manifest as heaviness and bi-syndrome (numbness and obstruction) from the waist downwards, named Huoni (Fire Reversal).

If the pulse is slow, floating, and weak, with aversion to wind and cold, this is an exterior syndrome. The physician incorrectly uses purgation, resulting in inability to eat, hypochondriac pain, jaundice, neck stiffness, and difficult urination. Administering Chaihu Tang (Bupleurum Decoction) at this stage will inevitably cause a sensation of heaviness in the anus (discussion see under Hypochondriac Pain).

In dysentery, if the pulse is deep and wiry, there is a sensation of heaviness in the anus.

When a patient has high fever but desires to cover themselves with clothing, it indicates Heat in the Skin (superficial level) and Cold in the Marrow (deep level). When a patient has severe cold sensations but does not desire to cover themselves with clothing, it indicates Cold in the Skin (superficial level) and Heat in the Marrow (deep level). (Cheng Wuji's commentary: "Skin" refers to the superficial/exterior, while "Marrow" refers to the deep/interior. Fever with desire for clothing indicates Exterior Heat and Interior Cold; Cold sensation without desire for clothing indicates Exterior Cold and Interior Heat.)

Danbo Yuanjian notes: High fever with a desire for clothing suggests that the body cannot generate warmth on its own because the Wei-Qi (Defensive Qi) is solid enough to self-warm, thus fearing neither wind nor cold. In a high fever condition, the exterior Wei-Qi should be solid and prefer coolness; desiring clothing indicates deficient exterior Wei-Qi insufficient for self-warming. This may be due to Yin deficiency, causing Yang to lose its anchor and fly outward, manifesting as high fever. It should be treated as Yin deficiency. Severe cold sensation without desire for clothing suggests pathogenic factors in the exterior failing to generate heat spontaneously; although there is no external heat, pathogenic stagnation in the skin and pores makes the exterior Wei-Qi excessively solid, hence the aversion to covering up. It should be treated as a stagnation syndrome. The commentary stating "Exterior Heat and Interior Cold" implies shallow heat invasion and deep cold invasion internally; "Exterior Cold and Interior Heat" implies shallow cold invasion externally and deep heat invasion internally. Are these conditions caused by "Zhonggan" (secondary infection)? Secondary infections have specific names, e.g., Taiyang disease re-infected with cold becomes Wenmai (Warm Malaria); Taiyang disease encountering wind becomes Fengwen (Wind Warmth); Taiyang disease encountering warm-heat becomes Wendu (Warm Toxin); Taiyang disease encountering warm qi becomes Wenyi (Warm Epidemic); dampness encountering... becomes Shiwen (Damp Warmth). There is no such concept as "Exterior Heat/Interior Cold" or "Exterior Cold/Interior Heat." However, investigating the intent, these likely arise from the depth of cold/heat invasion. The *Neijing* states: "Hyperactivity causes harm, succession brings regulation," meaning extreme excess leads to pathology via the controlling element. Deep heat invasion causes external aversion to cold, so "Cold in the Skin" is actually Heat; "Heat in the Marrow" is Fire Extreme resembling Water. Zhang Zhongjing said: "Injury by cold results in heat disease"; even severe heat is not fatal. Deep cold invasion causes external fever, so "Heat in the Skin" is actually Cold; this is injury by cold with intense heat. The *Neijing* states: "Treat extremes with contrary methods," and "Use cold for heat, use heat for cold." When pathogenic qi is deep, Zhengqi (Upright Qi) is also deficient. Without contrary treatment, how can pathogenic qi be subdued and the disease healed?

Zhao Xianke elaborates: Zhang Zhongjing distinguishes only between Skin and Marrow, not Exterior and Interior, because the skin, flesh, vessels, sinews, and bones correspond to the Five Zang organs, governing the exterior and nourishing the body. Only Zang and Fu organs allow for the discussion of Exterior and Interior. Thus, Skin is the superficial part above the Marrow, and Marrow is the deep part below the Skin, differing from the principle where Meridians are Exterior and Zang-Fu are Interior. Furthermore, placing this syndrome at the beginning of the Taiyang chapter confirms it is an exterior syndrome. Therefore, in individuals with constitutional weakness and cold who contract pathogens and develop fever, the heat pathogen is superficial and cannot overcome the deep cold, leading to external fear of cold and desire for clothing ("Heat in Skin, Cold in Marrow"); treatment requires acrid-warm herbs. Conversely, in robust, constitutionally hot individuals, or drinkers, during initial pathogen contraction, cold has not yet transformed into heat; Yin pathogen closes off latent heat externally, condensing Yin outside while Heat stagnates inside, causing internal vexation and aversion to clothing ("Cold in Skin, Heat in Marrow"); treatment requires acrid-cool herbs. After sweating disperses the exterior pathogen and harmonizes Zhengqi, this is the unspoken brilliance of Zhang Zhongjing. If Skin were Exterior and Marrow were Interior, would Ma Huang Tang syndrome's bone and joint pain be considered both Exterior and Interior syndromes?

Huoren Shu (Zhu Gong): For the clause "Heat in Skin, Cold in Marrow," Zhang Zhongjing provides no treatment method. It is appropriate to first administer Yangdan Tang; after cold resolves, follow with Xiaochaihu Tang plus Guizhi (Cinnamon Twig) to warm the Interior. It also states that for Exterior Heat and Interior Cold, the pulse must be deep and slow, hands may be slightly cold, with diarrhea of undigested food. Thus, Yin syndromes can also present with fever, treated with Sini Tang or Tongmai Sini Tang. For "Cold in Skin, Heat in Marrow," Zhang Zhongjing also provides no treatment. It is appropriate to first use Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction); after heat clears, use Guizhi Mahuang Ge Ban Tang (Half Cinnamon Twig and Ephedra Decoction) to resolve the exterior. It also states that for Exterior Cold and Interior Heat, the pulse must be slippery with cold limbs, dry mouth and tongue. Thus, Shaoyin syndrome with aversion to cold, curling up, constant inner vexation, and desire to avoid thick clothing is cured by purging with Da Chaihu Tang. These are the遗意 (legacy intentions) of Zhang Zhongjing.