【纲】仲景曰。病患身大热。反欲得近衣者。热在皮肤。寒在骨髓也。身大寒。反不欲近衣者。
寒在皮肤。热在骨髓也。
【目】赵嗣真曰。详仲景论中。止分皮肤骨髓。而不曰表里者。盖以皮肉脉筋骨五者。素问以
为五脏之合。主于外而充于身者也。惟曰脏曰腑。方可言表里。可见皮肤即骨髓之上。外部浮浅之分。
骨髓即皮肤之下。外部深沉之分。与经络脏腑属里之例不同。况仲景出此症在太阳篇首。其为
表症明矣。是知虚弱素寒之人。感邪发热。热邪浮浅。不胜沉寒。故外怯而欲得近衣。此所以为热
在皮肤。寒在骨髓。药宜辛温。至于壮盛素热之人。或酒客重感邪之初。寒未变热。阴邪闭乎伏热。
阴凝于外。热郁于内。故内烦而不欲近衣。此所谓寒在皮肤。热在骨髓。药宜辛凉。必也一发之余。
既散表邪。又和正气。此仲景不言之妙。若以皮肤为表。骨肉为里。则麻黄症骨节疼痛。其可名
为有表复有里也乎。
危亦林曰。热在皮肤一条。仲景不立方治。宜先与阳旦汤。寒已。次以小柴胡加桂温其表。
鳌按。本条自成注以表里释皮肤骨髓。后人宗之。误也。仲景论言表热里寒。表寒里热症甚多。
宁此条不曰表里。而偏曰皮肤骨髓耶。其可知矣。故独赵氏之说。披剥精当。识见过人。足以破
千古之惑。至表热里寒。乃少阴症。详少阴篇中。
【纲要】张仲景说：病人身体大热，反而想要靠近衣物取暖的，是热邪在皮肤（体表浅层），寒邪在骨髓（体内深层）。身体大寒，反而不想靠近衣物的，是寒邪在皮肤，热邪在骨髓。
【注释】赵嗣真说：详细考察张仲景的论述，只区分皮肤和骨髓，而不说表里，这是因为皮、肉、脉、筋、骨这五种组织，《素问》认为它们是五脏的外合，主要位于外部并充盈全身。只有说到脏和腑，才可以谈论表里关系。由此可见，皮肤即位于骨髓之上，属于外部浮浅的部分；骨髓即位于皮肤之下，属于外部深沉的部分。这与经络脏腑归属于里的情况不同。况且张仲景将此症列在《太阳篇》之首，其为表证是明确的。因此知道，平素虚弱且体寒的人，感受邪气后发热，热邪浮浅，不能胜过沉寒，所以外表怯冷而想要靠近衣物，这就是所谓的“热在皮肤，寒在骨髓”，用药宜用辛温之剂。至于平素壮盛且体热的人，或者嗜酒之人再次感受邪气的初期，寒邪尚未转化为热邪，阴邪闭塞于伏热之外，阴气凝结于外，热气郁结于内，所以内心烦闷而不想靠近衣物，这就是所谓的“寒在皮肤，热在骨髓”，用药宜用辛凉之剂。必须是一发汗之后，既疏散了表邪，又调和了正气，这才是张仲景不言自明的妙处。如果把皮肤当作表，骨肉当作里，那么麻黄汤证中的骨节疼痛，难道可以称为既有表证又有里证吗？
危亦林说：关于“热在皮肤”这一条，张仲景没有给出方剂治疗，适宜先给予阳旦汤。待寒气消除后，再给予小柴胡汤加桂枝以温煦其表。
沈金鳌按语：本条自从注家以表里来解释皮肤和骨髓以来，后人沿袭此说，这是错误的。张仲景的论述中言及表热里寒、表寒里热的症状非常多，难道唯独这一条不说表里，而偏要说皮肤和骨髓吗？由此可知其理。所以只有赵氏的说法，剖析精当，见识超过常人，足以破除千古以来的困惑。至于表热里寒，乃是少阴病，详见于《少阴篇》中。
[General Principle] Zhang Zhongjing stated: If a patient presents with high body heat but desires to be covered with clothing, it indicates that the heat is in the skin (superficial exterior) and the cold is in the bone marrow (deep interior). If a patient presents with severe body coldness but does not desire to be covered with clothing, it indicates that the cold is in the skin and the heat is in the bone marrow.
[Commentary] Zhao Sizhen stated: In detail, examining Zhang Zhongjing's discussions, he only distinguishes between the skin and the bone marrow, rather than using the terms "exterior" (Biao) and "interior" (Li). This is because, according to the *Suwen* (Basic Questions), the five tissues—skin, flesh, vessels, sinews, and bones—are the external correspondences of the Five Zang Organs, governing the exterior and filling the body. Only when referring to the Zang and Fu organs can one speak of exterior and interior relationships. Thus, the skin is located above the bone marrow, representing the superficial external layer; the bone marrow is located beneath the skin, representing the deep external layer. This differs from the principle where meridians and zang-fu organs belong to the interior. Moreover, since Zhang Zhongjing placed this syndrome at the beginning of the *Taiyang Chapter*, it is clearly an exterior syndrome. Therefore, we understand that individuals who are constitutionally weak and prone to cold, upon contracting pathogenic factors and developing fever, have heat pathogens that are superficial and cannot overcome the deep-seated cold. Consequently, they feel fearful of the cold externally and desire to be covered. This is what is meant by "heat in the skin, cold in the bone marrow," and the treatment should employ acrid-warm herbs. Conversely, for individuals who are constitutionally robust and prone to heat, or for wine drinkers in the early stage of re-contracting pathogenic factors, if the cold has not yet transformed into heat, yin pathogens close off the latent heat from the outside, with yin condensing externally and heat郁 (stagnating) internally. Thus, they feel internal irritability and do not desire to be covered. This is what is meant by "cold in the skin, heat in the bone marrow," and the treatment should employ acrid-cool herbs. It is essential that after inducing sweating once, both the exterior pathogen is dispersed and the healthy qi is harmonized; this is the profound meaning implicit in Zhang Zhongjing's work. If one were to consider the skin as the exterior and the flesh/bones as the interior, then in the *Mahuang Tang* (Ephedra Decoction) syndrome characterized by joint pain, could it be named as having both exterior and interior involvement?
Wei Yilin stated: Regarding the clause "heat in the skin," Zhang Zhongjing did not prescribe a formula. It is appropriate to first administer Yangdan Tang (Yang Guarding Decoction). Once the cold is resolved, subsequently administer Xiaochaihu Tang (Minor Bupleurum Decoction) with added Guizhi (Cinnamon Twig) to warm the exterior.
Shen Jin'ao's Note: Since commentators interpreted the skin and bone marrow in this clause through the lens of exterior and interior, later generations followed this error. Zhang Zhongjing's treatise mentions many cases of exterior-heat/interior-cold and exterior-cold/interior-heat. Why would this specific clause avoid the terms exterior and interior, preferring instead to specify skin and bone marrow? This makes the logic clear. Therefore, only Zhao's explanation is precise and insightful, surpassing others in understanding, sufficient to dispel millennia of confusion. As for exterior-heat and interior-cold, this constitutes a Shaoyin Syndrome (Shaoyin Disease), which is detailed in the *Shaoyin Chapter*.