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In cases where Shanghan (Cold Damage) does not transmit from the Yang meridians but directly invades the Yin meridians, presenting with limb coldness (Zhi Jue), faint pulse (Mai Wei), and diarrhea with undigested food (Xia Li Qing Gu), it is termed Zhong Han (Middle Cold). This corresponds to Zhang Zhongjing's principle of urgent warming, for which Sini Tang (Four Reversal Decoction) is indicated.

[Commentary by Xu Rongzhai] The evidence presented in this section is too simple; therefore, I specially quote the theory of Shi Feinan to supplement it. In his work *Yi Yuan* (Origin of Medicine), he pointed out: "The syndrome of Interior Cold essentially involves deficiency of Spleen and Kidney Yang. When Yang is deficient, it transforms into Dampness, so cases complicated by Dampness are common. The treatment methods do not go beyond three approaches: Sini Tang, Zhenwu Tang, and Lizhong Tang. Sini Tang-type formulas rely on Ganjiang (Dried Ginger) and Fuzi (Prepared Aconite Root); observing their modifications, they aim to unblock Yang and open obstruction, focusing on the Kidney. Zhenwu Tang-type formulas rely on Fuling (Poria), Fuzi, and Shengjiang (Fresh Ginger); they aim to warm Yang and suppress Water, also focusing on the Kidney. Lizhong Tang-type formulas rely on Ganjiang and Baizhu (Atractylodes Macrocephala Rhizome); they aim to secure the Middle Jiao, focusing on the Spleen." From this, we can see that although the syndrome is Interior Cold, the treatments differ: Sini Tang focuses on unblocking Yang and opening obstruction; Zhenwu Tang focuses on warming Yang and suppressing Water; Lizhong Tang focuses on warming the Spleen and securing the Middle.

When the body is exposed to Cold pathogenic factors and cold food is ingested, resulting in sudden abdominal pain, vomiting, diarrhea, limb coldness, and a deep pulse, this is a syndrome of simultaneous exterior and interior Cold invasion. For mild cases, Shenzhu Tang (Divine Efficacy Formula) with added Ganjiang and Rougui (Cinnamon Bark) is used. For severe cases, Fuzi Lizhong Tang (Aconite Lizhong Decoction) with added Jiangzhi (Ginger Juice) and Banxia (Pinellia Tuber) is used.

In Wenbing (Warm Diseases) or Shubing (Summerheat Diseases), although there may initially be slight aversion to wind and cold, once fever occurs, aversion to cold ceases, and instead, there is aversion to heat, spontaneous sweating, intense thirst, eye pain, nasal dryness, dry and stiff teeth, irritability, and insomnia. Although these all belong to Yangming Exterior Heat, one must distinguish between those with dry body heat and no sweat, who still require acrid-cool diaphoresis to release the muscle layer and allow heat to dissipate outward, using Congchi Jiegeng Tang (Scallion and Fermented Soybean Platycodon Decoction) as the main formula with modifications based on symptoms; and those with high fever and spontaneous sweating, who should only use sweet-cold herbs to preserve fluids and prevent heat from consuming Yin, using Xinjia Baihu Tang (Newly Added White Tiger Decoction) as the main formula.

When Shanghan pathogens transmit inward, or when Warm-Heat pathogens accumulate in the interior, both belong to Yangming Fu-organ syndromes. Symptoms include sweating on the hands and feet, tidal fever, constipation, dysuria, abdominal fullness and distension, periumbilical pain, irritability and aversion to heat, wheezing, dizziness, inability to lie down, flatus, delirium, mania, coma with loss of recognition, sticky fecal impaction, or spontaneous purging of pure green water. Zhang Zhongjing stated that urgent purgation is required, using the Three Chengqi Decoctions (San Chengqi Tangs).

[Commentary by Xu Rongzhai] Yangming urgent purgation syndromes in Shanghan are only a part of Interior Heat syndromes; the content in this section cannot cover them comprehensively. He Shi, in *Chongding Guang Wenre Lun* (Revised Extensive Treatise on Warm-Heat Diseases), divided Interior Heat syndromes into seven types, which is quite clear and lucid. It is quoted below:
(1) Heat in Ying and Wei stages: Fever with spontaneous sweating, no aversion to cold but aversion to heat, local redness or swelling of the body and face, yellow sclera, swollen eyeballs, dry nostrils, dry lips, restlessness. Mild cases present with macules; severe cases present with erysipelas-like rashes. Tongue coating is white with a crimson base, or white on sides and red in center. Or fever decreases while aversion to heat increases, accompanied by cough with yellow sputum and upper airway wheezing.
(2) Heat in Chest/Diaphragm and Qi level depression: Dry and painful throat, chest and hypochondriac fullness and pain, even redness and swelling of the chest front, feeling hot upon pressure. Yellow urine. Tongue coating is thick white and rough, or yellow greasy and dry, or has red spots, cracks, yellow-white mixture, or gray-white.
(3) Heat sinking into Pericardium and Heart, burning in Blood level: Delirium and mania, or lethargy and excessive sleepiness, or irritability and insomnia, limb coldness, crimson-purple fingernails, loose black foul-smelling stool, red and scanty or painful urination, crimson tongue without coating, or slightly sticky coating on tongue.
(4) Pathogenic Heat attacking the Brain: Syncope and mutism, hand spasms resembling convulsions, intermittent twitching, independent head shaking, even enuresis and fixed gaze, muscle tremors, picking at clothes and empty air grasping, tongue coating putrid with occasional black spots.
(5) Heat in Stomach and Intestines: Hematochezia, pus and blood in stool, verbose delirium, abdominal fullness and pain, cracked lips and dry teeth, yellow and dry tongue coating.
(6) Heat sinking into Liver and Kidneys: Milder in day, heavier at night; cool in morning, hot in evening; lackluster complexion, dry mouth and polydipsia, Qi rushing to heart, hot pain in heart, hunger but no desire to eat, vomiting roundworms after eating; limb coldness, irritability and insomnia, scanty painful urination, even urinary retention, cold waist and lower limbs, constipation or watery diarrhea; crimson tongue without coating, or dry/sticky/astringent, or purple with black spots.
(7) Heat sinking into Chong and Ren vessels: Cool in morning, hot in evening; pulsation of Chong and Ren vessels, tightness in lower abdomen, contraction in genitalia, even tongue curling and testicular retraction, scanty painful urination, male seminal emission and backache, female profuse leukorrhea. Tongue color scorched purple with prickles like bayberry, or red without coating and sticky, or red with white fungal spots.