泄利下重若少阴证欲寐四逆者四逆汤加薤白散若热者白头翁汤（方论见下利）
脉浮宜以汗解用火灸之邪无从出因火而盛病从腰以下必重而痹名火逆也
脉迟浮弱恶风寒者表证也医反下之遂不食胁痛身黄项强小便难复与柴胡汤必下重（论见胁痛）
下利脉沉弦者下重也
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（成 皮肤言浅骨髓言深皮
肤言外骨髓言内身热欲得衣者表热里寒也身寒不欲衣者表寒里热也）
丹 谨按身大热欲得衣盖人之身不能自温因表气之
实足以自温虽遇风寒无所畏惮大热病表气当实而喜冷今反欲得衣者表气虚不足以自温故欲近衣恐是病患阴弱阳无所附
飞越而出发为大热尔当作阴虚治之身大寒反不欲近衣者恐是邪在表不能自发而为热表虽无热邪郁肤腠表气大实故不欲
近衣尔当作郁病治之注言表热里寒者当是热感得浅寒感得深而在内也言表寒里热者当是寒感得浅而在外热感得深而在
内也表里之寒热为重感病耶重感之病必有其名如伤寒重感寒为温疟伤寒更遇风为风温伤寒更遇温热为温毒伤寒遇温气
为温疫病湿更中 为湿温未尝有所谓表里寒热也然表热里寒表寒里热何病耶窃尝求之论意矣恐为寒热感之深者发也内
经曰亢则害承乃制谓气盛之极则受胜已之化而为病也热感得深外必恶寒故曰寒在皮肤非寒也热也热在骨髓此火极似水
证仲景曰人伤于寒则为病热热虽甚不死寒感得深外必发热故曰热在皮肤非热也寒也此伤于寒而热甚也内经曰甚者反治
又曰寒因热用热因寒用病气深者正气虚也非反治因用邪何由伏病何由安
赵 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
髓即皮肤之下内部深沉之分与经络属表脏腑属里之例不同况仲景出此证在太阳篇首其为表证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辈感邪之初
寒未变热阴邪闭于伏热阴凝于外热郁于内故内烦而不欲近衣此所以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髓为里则麻黄证骨节疼痛其可名为有表复有里之证耶
活 热在皮肤寒在骨髓
一条仲景无治法宜先与阳旦汤寒已次以小柴胡加桂温其里又云表热里寒者脉须沉而迟手或微厥下利清谷也所以阴证亦
有发热者四逆汤通脉四逆汤主之寒在皮肤热在骨髓一条仲景亦无治法宜先以白虎加人参汤热除次以桂枝麻黄各半汤以
解其外又云表寒里热者脉必滑而厥口燥舌干所以少阴恶寒而蜷时时自烦不欲浓衣用大柴胡下之而愈此皆仲景之遗意也
泄利伴有肛门坠胀感，如果是少阴病证候，出现想睡觉、四肢厥冷的情况，使用四逆汤加入薤白散；如果是热证，使用白头翁汤（方剂论述见下利章节）。
脉象浮，适宜用发汗法解除表邪，如果用火灸治疗，邪气无法排出，反而因火邪而亢盛，疾病会导致腰部以下必然沉重且麻木不仁，这称为“火逆”。
脉象迟、浮而弱，恶风怕冷，这是表证。医生反而使用攻下法，导致患者不能进食、胁肋疼痛、身体发黄、颈项强直、小便困难。此时再给予柴胡汤，必然会出现肛门坠胀感（论述见胁痛章节）。
下利且脉象沉弦的，会有肛门坠胀感。
病人身体大热，反而想要靠近衣物取暖的，是热在体表（浅层），寒在骨髓（深层）；病人身体大寒，反而不想靠近衣物的，是寒在体表，热在骨髓。（成无己注：皮肤指浅表，骨髓指深层；皮肤指外部，骨髓指内部。身热想要穿衣，是表热里寒；身寒不想穿衣，是表寒里热。）
丹波元坚谨按：身体大热却想要穿衣，大概是因为人体自身不能产生温热，因为表气充实足以自我温煦，即使遇到风寒也不畏惧。大热病的表气应当充实而喜凉，现在反而想要穿衣，说明表气虚弱不足以自我温煦，所以想要靠近衣物。恐怕是病人阴气虚弱，阳气无所依附，飞越而出，从而表现为大热。这种情况应当作为阴虚来治疗。身体大寒却不想穿衣，恐怕是邪气在表，不能自发产生热量，虽然体表没有热邪，但邪气郁结于肤腠，表气非常充实，所以不想靠近衣物。这种情况应当作为郁证来治疗。注释中说“表热里寒”，应当是感受的热邪较浅，感受的寒邪较深而在体内；说“表寒里热”，应当是感受的寒邪较浅而在外，感受的热邪较深而在内。表里的寒热是由于重感（再次感受邪气）致病吗？重感的疾病必有其名称，如伤寒再次感受寒邪成为温疟，伤寒再次遇到风邪成为风温，伤寒再次遇到温热邪气成为温毒，伤寒遇到温气成为温疫病，湿邪再次中伤成为湿温。从未有所谓的表里寒热之分。然而表热里寒、表寒里热是什么病呢？我私下探究了原文的意思，恐怕是由感受寒热之邪深浅不同而引发的。《内经》说：“亢则害，承乃制。”意思是气盛到极点，就会受到克制它的五行之气的影响而发病。热邪感受得深，体外必然恶寒，所以说“寒在皮肤”并非真寒，而是热；“热在骨髓”这是火极似水的证候。张仲景说：“人伤于寒，则为病热。”热虽甚但不死。寒邪感受得深，体外必然发热，所以说“热在皮肤”并非真热，而是寒。这是伤于寒而热势很盛的情况。《内经》说：“甚者反治。”又说：“寒因热用，热因寒用。”病气深重的，正气也虚弱。如果不是反治法，依靠什么使邪气潜伏？依靠什么使疾病安宁？
赵献可详析：张仲景的论述中只区分皮肤和骨髓，而不说表里，大概是因为皮、肉、脉、筋、骨这五者，《素问》认为它们是五脏的外合，主管外部并充盈全身。只有说脏、说腑，才可以谈论表里。可见皮肤即骨髓之上的外部浮浅部分，骨髓即皮肤之下的内部深沉部分，这与经络属表、脏腑属里的例子不同。况且张仲景将此证放在太阳篇首，其为表证明显可知。因此知道，素体虚弱且寒冷的人感受邪气发热，热邪浮浅不胜沉寒，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”，药物宜用辛温。至于体质壮盛且素来有热的人，或者嗜酒之人，在感受邪气的初期，寒邪未变为热，阴邪闭阻于伏热之外，阴凝于外，热郁于内，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”，药物宜用辛凉。必须是一发汗之后，既解散了表邪，又调和了正气，这是张仲景不言自明的妙处。如果把皮肤当作表，骨髓当作里，那么麻黄汤证的骨节疼痛，难道可以称为既有表证又有里证的病吗？
活人书（朱肱）：关于“热在皮肤，寒在骨髓”一条，张仲景没有给出治法，适宜先给予阳旦汤，寒邪去除后，次用小柴胡汤加桂枝以温补其里。又说：表热里寒者，脉象须沉而迟，手可能微厥冷，下利清谷。所以阴证也有发热的，用四逆汤或通脉四逆汤主治。关于“寒在皮肤，热在骨髓”一条，张仲景也没有给出治法，适宜先用白虎加人参汤，热除之后，次用桂枝麻黄各半汤以解其外邪。又说：表寒里热者，脉必滑而厥冷，口燥舌干。所以少阴病恶寒而蜷卧，时时自觉烦闷，不想穿厚衣服，用大柴胡汤攻下而痊愈。这些都是张仲景遗留下来的意旨。
Dysentery with tenesmus (a feeling of incomplete defecation and straining): If it presents as a Shaoyin syndrome with drowsiness (欲寐) and cold extremities (Si Ni), use Si Ni Tang (Four Counterflow Decoction) added with Xie Bai (Allium macrostemon Bulb). If it is a heat syndrome, use Bai Tou Weng Tang (Pulsatilla Decoction) (for formula discussion, see under "Diarrhea").
If the pulse is floating, sweating should be used to resolve the exterior. If moxibustion is applied, the pathogenic factor cannot exit; instead, it becomes exacerbated by fire. The disease will cause heaviness and numbness below the waist, termed "Fire Reversal" (Huo Ni).
If the pulse is slow, floating, and weak, with aversion to wind and cold, this is an exterior syndrome. If the physician erroneously uses purgation, the patient may lose appetite, experience hypochondriac pain, jaundice (yellowing of the body), stiff neck, and difficult urination. Administering Chai Hu Tang (Bupleurum Decoction) at this stage will inevitably cause tenesmus (for discussion, see under "Hypochondriac Pain").
In diarrhea, if the pulse is deep and wiry, there is tenesmus.
When a patient has high fever but desires to wrap themselves in clothing, it indicates heat on the skin (superficial level) and cold in the bone marrow (deep level). When a patient has severe cold sensation but does not desire to wrap themselves in clothing, it indicates cold on the skin and heat in the bone marrow. (Cheng Wuji's commentary: "Skin" refers to the superficial/exterior, while "bone 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 likely occurs because the body cannot generate warmth internally; however, if the exterior qi is sufficient, it can self-warm and resist wind-cold. In a high-fever condition, the exterior qi should be robust and prefer coolness. The fact that the patient desires clothing suggests deficient exterior qi insufficient for self-warming. This may indicate that the patient's yin is weak, causing yang to float away unattached, manifesting as high fever. This should be treated as yin deficiency. Severe cold sensation without desire for clothing may indicate 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 qi overly full, hence the aversion to clothing. This should be treated as a stagnation syndrome. The commentary stating "exterior heat, interior cold" implies that the heat pathogen was shallow, while the cold pathogen was deep within. "Exterior cold, interior heat" implies the cold pathogen was shallow externally, while the heat pathogen was deep internally. Are these conditions caused by "double contraction" (re-infection)? Diseases of double contraction have specific names, e.g., Taiyang disease contracting cold again becomes Warm Malaria; contracting wind becomes Wind-Warmth; contracting warm-heat becomes Warm Toxin; contracting warm qi becomes Warm Epidemic Disease; dampness contracting again becomes Damp-Warmth. There is traditionally no concept of "exterior heat/interior cold" or vice versa. However, what disease do these represent? I have sought the meaning in the text, suspecting it arises from the depth of cold/heat pathogens. The *Nei Jing* states: "Excess leads to harm, succession brings regulation." When qi reaches extreme excess, it is controlled by its opposing element. Deep heat causes external aversion to cold, so "cold on the skin" is actually heat; "heat in the bone marrow" is a case of extreme fire resembling water. Zhang Zhongjing said: "Cold injury leads to heat disease." Even severe heat is not fatal. Deep cold causes external fever, so "heat on the skin" is actually cold; this is cold injury manifesting as intense heat. The *Nei Jing* states: "Treat extremes with reverse methods," and "Use cold for heat, use heat for cold." When disease qi is deep, righteous qi is also deficient. Without reverse treatment, how can pathogenic factors be subdued and the disease resolved?
Zhao Xianke elaborates: Zhang Zhongjing distinguishes only between skin and bone marrow, not exterior and interior, because skin, flesh, vessels, sinews, and bones are associated with the five zang organs externally, filling the body. Only zang and fu organs allow for the discussion of exterior and interior. Thus, skin is the superficial exterior above the bone marrow, and bone marrow is the deep interior below the skin, differing from the example where meridians are exterior and zang-fu are interior. Moreover, 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 is superficial and cannot overcome deep cold, leading to external fear of cold and desire for clothing ("heat on skin, cold in bone marrow"); treatment requires acrid-warm herbs. Conversely, in robust individuals with constitutional heat, or those who consume alcohol, upon initial pathogen contraction, cold has not yet transformed into heat. Yin pathogen closes off latent heat externally, condensing outside while heat stagnates inside, causing internal vexation and aversion to clothing ("cold on skin, heat in bone marrow"); treatment requires acrid-cool herbs. Only after releasing the exterior and harmonizing righteous qi is the subtle brilliance of Zhang Zhongjing revealed. If one equates skin with exterior and bone marrow with interior, then the bone joint pain in Ma Huang Tang syndrome would incorrectly be classified as having both exterior and interior syndromes.
*Ren Shu* (Book of Human Life): Regarding "heat on skin, cold in bone marrow," Zhang Zhongjing provides no treatment method. It is appropriate to first administer Yang Dan Tang. Once cold is resolved, follow with Xiao Chai Hu Tang plus Gui Zhi to warm the interior. It also states: 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 present with fever, treated with Si Ni Tang or Tong Mai Si Ni Tang. Regarding "cold on skin, heat in bone marrow," Zhang Zhongjing also provides no treatment. It is appropriate to first use Bai Hu Jia Ren Shen Tang to remove heat, followed by Gui Zhi Ma Huang Ge Ban Tang to resolve the exterior. It also states: For exterior cold and interior heat, the pulse must be slippery and wiry with cold limbs, dry mouth, and dry tongue. Thus, Shaoyin syndrome with aversion to cold, curling up, constant inner vexation, and desire for light clothing is cured by purging with Da Chai Hu Tang. These are the遗意 (legacy intentions) of Zhang Zhongjing.