【纲】仲景曰。病患身大热。反欲近衣者。热在皮肤。寒在骨髓也。病患身大寒。反不欲近衣
者。寒在皮肤。热在骨髓也。
【目】朱肱曰。身大热。反欲近衣。此名表热里寒。身大寒。反不欲近衣。此名表寒里热。仲
景皆无治法。其热在皮肤寒在骨髓者。先与阳旦汤。寒已。次以小柴胡加桂以和其表。其寒在皮肤。
热在骨髓者。宜先与人参白虎汤热除。次以桂枝麻黄合半汤以解其外。大抵病有标本。治有先后。
表热里寒者。脉须沉而迟。手或微厥。下利清谷。所以阴症亦
有发热者。四逆汤、通脉四逆汤主之。表寒里热者。脉必滑而数。口燥舌干。所以少阴恶寒而蜷。
时时自烦。不欲浓衣。大柴胡下之而愈。此皆仲景之余议。
柯琴曰。此属内因。不是外感。亦不关七情。病在形躯。不涉脏腑。亦不犯经络。故无六经脉
症可凭。非天时寒热所可拘也。是病只在骨髓。不在皮肤。皮肤之寒热。指天时。不指病。骨髓之
寒热。是渐积之伏邪。故虽逢天令大寒大热之正气。亦不能除。时大热而反欲复衣。时大寒而反欲
裸身。病在骨髓。与病在营卫者不同。法当以六味八味二丸。补肾中之真阴真阳。而骨髓之蓄热痼
寒自愈。
【纲】仲景曰。问曰。病有洒淅恶寒而复发热者何。答曰。阴脉不足。阳往从之。阳脉不足。
阴往乘之。曰。何谓阳不足。答曰。假令寸口脉微。名曰阳不足。阴气上入阳中。则洒淅恶寒也。
曰。何谓阴不足。答曰。尺脉弱。名曰阴不足。阳气下陷入阴中则发热也。
【目】柯琴曰。前条病在骨髓。故着而不移。此病在经络。故寒热反复。却与外感之往来寒热。
疟疾之鼓寒战栗又不同。寸者阳所治。寸微为无阳。是阳脉不足。故阴寒得上乘阳位。而洒淅恶
寒也。尺者阴所治。尺弱而血虚。是阴脉不足。故上焦虚阳得以下陷阴部而发热也。夫阴阳互根。
又以阳为主。治之者。当以扶阳为急。此补中益气之方。为功最巨也。
【纲】仲景曰。病患脉微而涩者。此为医所病也。夫发其汗。又数大下之。其人亡血。病当恶
寒。后乃发热。无休止时。夏月盛热。欲着复衣。冬月盛寒。欲裸其身。所以然者。阳微则恶寒。
阴弱则发热。此医发其汗。使阳气微。又大下之。令阴气弱。五月之时。阳气在表。胃中虚冷。以
阳气内微。不能胜冷。故欲着复衣。十一月之时。阳气在里。胃中烦热。以阴气内弱。不能胜热。
故欲裸其身。又阴脉迟涩。故知亡血也。
【目】柯琴曰。先寒后热。阳微阴弱。具症与上文同。前条病因在血脉虚。此条病因在妄汗下。
以致亡血而脉微涩也。
【纲】张仲景说：病人身体非常发热，反而想要穿衣服，这是热在体表（皮肤），寒在体内深层（骨髓）的表现。病人身体非常寒冷，反而不想穿衣服，这是寒在体表（皮肤），热在体内深层（骨髓）的表现。
【目】朱肱说：身体非常发热，反而想要穿衣服，这叫做表热里寒。身体非常寒冷，反而不想穿衣服，这叫做表寒里热。张仲景对此都没有给出治疗方法。对于热在体表、寒在体内的情况，先用阳旦汤治疗，待寒气消除后，再用小柴胡汤加桂枝来调和体表。对于寒在体表、热在体内的情况，适宜先用白虎加人参汤清热，待热邪去除后，再用桂枝麻黄各半汤来解除表邪。大抵来说，疾病有标和本之分，治疗有先后顺序。表热里寒的病人，脉象应当沉而迟缓，手脚可能轻微厥冷，伴有腹泻且粪便中有未消化的食物。所以阴证也有发热的情况，用四逆汤或通脉四逆汤主治。表寒里热的病人，脉象必定滑而数，口燥舌干。所以少阴病表现为怕冷且身体蜷缩，时常自觉烦躁，但不想穿厚衣服，用大柴胡汤攻下即可痊愈。这些都是张仲景理论之外的补充议论。
柯琴说：这种情况属于内因致病，不是外感邪气引起，也不涉及七情内伤。病位在形体躯壳，不涉及脏腑，也不侵犯经络。因此没有六经病的症状可以凭据，不受外界天时寒热变化的拘束。这种病只在骨髓，不在皮肤。这里的“皮肤之寒热”指的是外界天时的寒热，而不是指病症；“骨髓之寒热”是指逐渐积累的伏邪。所以即使遇到自然界大寒大热的正气，也不能除去这种病邪。病人时而大热却反想多穿衣，时而大寒却反想脱衣裸身。这种病在骨髓的情况，与病在营卫（人体浅层防御系统）不同。治疗方法应当使用六味地黄丸和八味肾气丸，补肾中的真阴和真阳，那么骨髓中蓄积的热邪和顽固的寒邪自然就会痊愈。
【纲】张仲景说：有人问：有一种病症，表现为像被冷水洒在身上那样恶寒，随后又出现发热，这是什么原因？回答说：阴脉不足，阳气就会去依附它；阳脉不足，阴气就会去侵袭它。问：什么叫阳不足？回答说：假如寸口脉微细，叫做阳不足。阴气向上进入阳分，就会导致像被冷水洒在身上那样的恶寒。问：什么叫阴不足？回答说：尺脉虚弱，叫做阴不足。阳气向下陷入阴分，就会导致发热。
【目】柯琴说：前一条论述的病在骨髓，所以症状固定不移；这一条论述的病在经络，所以寒热反复交替。但这与外感病引起的往来寒热，以及疟疾引起的鼓颔战栗又不同。寸口脉由阳气所主，寸脉微弱说明无阳，即阳脉不足，所以阴寒之气得以乘袭阳位，导致像被冷水洒在身上那样的恶寒。尺部脉由阴血所主，尺脉弱说明血虚，即阴脉不足，所以上焦的虚阳得以陷入阴部，导致发热。阴阳互为根本，又以阳气为主导。治疗时，应当以扶助阳气为急务。补中益气汤在这方面功效最大。
【纲】张仲景说：病人脉象微而涩，这是医生误治造成的。医生先发了汗，接着又多次使用峻下法。导致病人亡失血液，病情应当表现为恶寒，随后才出现发热，且发热没有停止的时候。夏季天气酷热时，病人却想穿厚衣服；冬季天气严寒时，病人却想裸露身体。之所以这样，是因为阳气微弱则恶寒，阴血虚弱则发热。这是因为医生发了汗，使阳气微弱；又大剂量使用泻下药，使阴气虚弱。在五月之时，阳气浮越于体表，胃中虚冷，因为阳气内部微弱，不能抵御寒冷，所以想穿厚衣服。在十一月之时，阳气潜藏于体内，胃中烦热，因为阴气内部虚弱，不能抵御热邪，所以想裸露身体。另外，阴脉迟涩，所以知道这是亡血导致的。
【目】柯琴说：先恶寒后发热，表现为阳微阴弱，具体症状与上文相同。前一条的病因在于血脉亏虚，这一条的病因在于误用汗法和下法，以致导致亡血，从而出现脉微涩的症状。
[Outline] Zhang Zhongjing said: When a patient's body is extremely hot, yet they desire to wear clothes, this indicates heat at the skin level (superficial) and cold in the bone marrow (deep/internal). When a patient's body is extremely cold, yet they do not desire to wear clothes, this indicates cold at the skin level (superficial) and heat in the bone marrow (deep/internal).
[Commentary] Zhu Gong said: Body extremely hot but desiring to wear clothes is named "Exterior Heat with Interior Cold" (Biao Re Li Han). Body extremely cold but not desiring to wear clothes is named "Exterior Cold with Interior Heat" (Biao Han Li Re). Zhang Zhongjing provided no treatment methods for these. For cases of heat in the exterior and cold in the interior, first administer Yang Dan Tang (Yang Dawn Decoction); after the cold dissipates, subsequently use Xiao Chai Hu Tang (Minor Bupleurum Decoction) added with Gui Zhi (Cinnamon Twig) to harmonize the exterior. For cases of cold in the exterior and heat in the interior, it is appropriate to first use Bai Hu Jia Ren Shen Tang (White Tiger Decoction plus Ginseng) to remove the heat; after the heat is cleared, subsequently use Gui Zhi Ma Huang Ban Tang (Half Dosage of Cinnamon Twig and Ephedra Decoction) to resolve the exterior. Generally speaking, diseases have a root (Ben) and branch (Biao), and treatments have a sequence. Patients with Exterior Heat and Interior Cold will have a pulse that is deep and slow, possibly with slightly cold extremities, and diarrhea with undigested food. Thus, Yin syndromes can also present with fever, treated primarily with Si Ni Tang (Frigid Extremities Decoction) or Tong Mai Si Ni Tang (Pulse-Resuscitating Frigid Extremities Decoction). Patients with Exterior Cold and Interior Heat will have a pulse that is slippery and rapid, with dry mouth and tongue. Thus, Shao Yin syndrome presents with aversion to cold and curling up, frequent inner irritability, but no desire for thick clothing, cured by purging with Da Chai Hu Tang (Major Bupleurum Decoction). These are all supplementary discussions beyond Zhang Zhongjing's original text.
Ke Qin said: This belongs to internal causes, not external contraction, nor does it involve the Seven Emotions. The disease is located in the physical form, not involving the Zang-Fu organs, nor invading the meridians. Therefore, there are no Six Meridian syndrome patterns to rely upon, and it is not constrained by seasonal climatic changes. The disease lies only in the bone marrow, not in the skin. Here, "heat and cold in the skin" refers to seasonal climate, not the disease itself; "heat and cold in the bone marrow" refers to gradually accumulated latent pathogens. Thus, even when encountering extreme natural cold or heat, these cannot be eliminated. The patient may feel intensely hot yet desire to cover up, or feel intensely cold yet desire to expose the body. This condition in the bone marrow differs from conditions in the Ying and Wei (Nutritive and Defensive levels). The method should be to use Liu Wei Di Huang Wan (Six-Ingredient Rehmannia Pill) and Ba Wei Shen Qi Wan (Eight-Ingredient Kidney Qi Pill) to tonify the True Yin and True Yang in the Kidneys, thereby allowing the accumulated heat and stubborn cold in the bone marrow to heal spontaneously.
[Outline] Zhang Zhongjing said: Someone asked: What is the reason for a disease that manifests as shivering aversion to cold followed by fever? The answer is: When the Yin pulse is deficient, Yang moves to follow it; when the Yang pulse is deficient, Yin moves to invade it. Asked: What is meant by Yang deficiency? Answered: If the Cun (Inch) position pulse is faint, it is called Yang deficiency. Yin Qi ascending into the Yang region causes shivering aversion to cold. Asked: What is meant by Yin deficiency? Answered: If the Chi (Cubit) position pulse is weak, it is called Yin deficiency. Yang Qi sinking down into the Yin region causes fever.
[Commentary] Ke Qin said: The previous clause discussed disease in the bone marrow, so the symptoms were fixed and unchanging. This clause discusses disease in the meridians, so the cold and heat alternate repeatedly. However, this is different from the alternating chills and fever of external contractions, or the rattling teeth and trembling of malaria. The Cun position is governed by Yang; a faint Cun indicates absence of Yang, i.e., Yang pulse deficiency, allowing Yin-Cold to ascend and occupy the Yang position, causing shivering aversion to cold. The Chi position is governed by Yin; a weak Chi indicates blood deficiency, i.e., Yin pulse deficiency, allowing Deficient Yang from the Upper Jiao to sink into the Yin region, causing fever. Yin and Yang are mutually rooted, yet Yang is primary. In treatment, one should prioritize supporting Yang. Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) has the greatest efficacy in this regard.
[Outline] Zhang Zhongjing said: A patient with a faint and choppy pulse is suffering from medical error. The physician induced sweating, then repeatedly used severe purgation. This caused the patient to lose blood. The illness should manifest as aversion to cold, followed later by fever, which continues without cessation. In the height of summer heat, the patient desires to wear extra clothes; in the depth of winter cold, the patient desires to expose the body. The reason is that faint Yang causes aversion to cold, and weak Yin causes fever. This occurred because the physician induced sweating, making Yang faint, and then heavily purged, making Yin weak. In the fifth month, Yang Qi is on the surface, and the Stomach is cold due to deficiency; because internal Yang is faint and cannot overcome the cold, the patient desires to wear extra clothes. In the eleventh month, Yang Qi is inside, and the Stomach is vexed with heat; because internal Yin is weak and cannot overcome the heat, the patient desires to expose the body. Furthermore, the Yin pulse being slow and choppy indicates blood loss.
[Commentary] Ke Qin said: First chills then fever, presenting with faint Yang and weak Yin, shares the same symptoms as the previous text. The cause in the previous clause was deficiency of blood vessels; the cause in this clause is reckless use of sweating and purging methods, leading to blood loss and a faint, choppy pulse.