许学士曰仲景云假令寸口脉微名曰阳不足阴气上入阳中则洒淅恶寒也尺脉弱名曰阴不足
阳气
下陷入阴中则发热也此谓元受病而然也又云阳微则恶寒阴弱则发热此医发其汗使阳气微又大
下之令阴气弱此谓医所病而然也大抵阴不足阳往从之故阳内陷则发热阳不足阴往乘之故阴上
入阳中则恶寒阴阳不归其分故寒热交争是以发热而恶寒也
原病式曰身热恶寒热在表也邪热在表而浅邪畏其正故病热而反恶寒也或言恶寒为寒在表
或言
身热恶寒为热在皮肤寒在骨髓者皆误也仲景法曰无阳病寒不可发汗又言身热恶寒麻黄汤汗之
汗泄热去身凉即愈然则岂有寒者欤大法烦躁多渴欲寒恶热为病热也亦有亢则害承乃制之则病
热甚而反觉其冷者也虽觉其冷而病为热实非寒也其病热郁甚而反恶寒得寒转甚而得暖少愈者
谓暖则腠理疏通而阳气得散怫热少退故少愈也其寒则腠理因密阳气怫郁而热转甚故病加尔上
下中外周身皆然俗因之妄谓寒病误以热药投之为害多矣
又曰阴胜则寒阳胜则热者谓里气与邪热并之于表则为阳胜而发热也表气与邪热并之于里
则为
阴胜而寒栗也由表气虚而里热亢则害承乃制故反战栗也大抵本热非病寒也或伤寒病寒热往来
者邪热在表而浅邪恶其正故恶寒也邪热在里而深邪甚无畏物畏其极故不恶寒而反恶热也表里
进退不已故为寒热往来也此气不并于表里故异于疟而寒热微也
按此数论并言杂病阴阳相乘及火热盛反兼水化为病亢则害承乃制之例但河间所引伤寒身
热寒
热与仲景及明理论义不相合详赵氏曰明理论云往来寒热者邪正分争也邪气之入也正气不与之
争则但热而无寒若邪正分争于是寒热作矣盖以寒邪为阴热邪为阳里分为阴表分为阳邪之客于
表也为寒邪与阳争则为寒矣邪之入于里也为热邪与阴争则为热矣若邪在半表半里之间外与阳
争而为寒内与阴争而为热表里之不拘内外之无定由是寒热且往且来日有至于三五甚者则十数
发也若以阴阳相胜阳不足则先寒后热阴不足则先热后寒此特论杂病阴阳二气自相乘胜然也非
可以语伤寒斯论为甚精切深合仲景之意盖不唯释疑于活人书而已可与前篇兼看
又按河间言恶寒为寒在表或身热恶寒为热在皮肤寒在骨髓者皆误也而活人书亦以此为表
里言
之故赵氏曰详仲景论止分皮肤骨髓而不曰表里者盖以皮脉肉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
深沉之分与经络属表脏腑属里之例不同况仲景出此证于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谓热在皮肤寒在骨髓药用辛温至于壮
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
所为寒在皮肤热在骨髓药用辛凉必矣一发之余表解正和此仲景不言之妙若以皮肤为表骨髓为
里则麻黄汤证骨节疼痛其可名为有表复有里之证即然仲景伤寒一书人但知为方家之祖而未
解作秦汉文本观故于大经大法之意反有疑似而后世赖其余泽者往往类辑伤寒方论其间失其本
义及穿凿者亦有之矧以杂病为论但引其例乎兹赵氏释疑可谓得其旨趣且黄帝针经有论皮寒热
肌寒热骨寒热等例如此则仲景所论分邪在皮肤骨髓之殊虽欲以尽证例之变盖自有所本云
许叔微说：张仲景曾说，假如寸口脉微弱，这叫做阳气不足。阴气侵入阳分，就会感到战栗怕冷。尺部脉虚弱，这叫做阴气不足。阳气下陷进入阴分，就会发热。这是指疾病原本就是如此产生的。又说，阳气微弱则怕冷，阴气虚弱则发热。这是因为医生发汗过度导致阳气微弱，又用峻下法导致阴气虚弱。这是指由医疗失误导致的疾病。大抵来说，阴气不足时，阳气会随之向内陷入，所以发热；阳气不足时，阴气会乘虚而入占据阳位，所以怕冷。阴阳不能各守其位，因此寒热交争，从而出现既发热又怕冷的症状。
刘完素在《原病式》中说：身体发热、怕冷，说明邪热在表。邪热在表且位置浅显，邪气畏惧正气，所以生病表现为发热反而怕冷。有人说怕冷是因为寒邪在表，有人说身热怕冷是热在皮肤、寒在骨髓，这些都是错误的。张仲景的法度说：如果没有阳证（如脉微），患寒病不可发汗。又说身热怕冷，应用麻黄汤发汗。汗出后热退身凉即痊愈。那么，这怎么会有寒邪呢？大的法则是：烦躁、多渴、喜冷恶热，这是热病的表现。也有“亢盛则害，制约乃平”的情况，即病热极盛反而觉得冷。虽然觉得冷，但病实际上是热而非寒。如果病热郁结严重反而怕冷，遇冷加重，遇暖稍减，这是因为温暖能使腠理疏通，阳气得以发散，郁热稍微消退，所以稍好。如果寒冷，则腠理密闭，阳气郁结而热更重，所以病情加重。上下内外周身都是如此。世俗因此胡乱认为是寒病，误用热药投治，危害很大。
又说：“阴胜则寒，阳胜则热”，是指里气与邪热并合于表，则为阳胜而发热；表气与邪热并合于里，则为阴胜而寒战。由于表气虚而里热亢盛，遵循“亢则害，承乃制”的规律，所以反而出现寒战。大抵根本是热病，并非寒病。或者伤寒病中出现寒热往来的，是因为邪热在表且浅，邪气畏惧正气，所以怕冷；邪热在里且深，邪气极盛无所畏惧，所以不怕冷反而怕热。表里进退不已，所以出现寒热往来。这种气不偏并于表或里，所以不同于疟疾，且寒热程度较轻。
按：这几段论述都提到了杂病中阴阳相互乘袭，以及火热极盛反而兼有水象（寒象）的病机，属于“亢则害，承乃制”的例子。但是刘完素所引用的伤寒身热寒热与张仲景及成无己《明理论》的观点不相符合。详细考察赵嗣真说：《明理论》记载，寒热往来是邪正相争的结果。邪气入侵时，如果正气不与它争，就只发热而不怕冷；如果邪正相争，于是产生寒热。大概以寒邪为阴，热邪为阳；里分为阴，表分为阳。邪气客居在表，如果是寒邪与阳争，就表现为寒；邪气进入在里，如果是热邪与阴争，就表现为热。如果邪气在半表半里之间，外与阳争而为寒，内与阴争而为热，表里不拘泥于固定位置，内外没有定准，因此寒热且往且来，每天发作三五次，严重的甚至十几次。如果用阴阳相胜的理论，阳气不足就先寒后热，阴气不足就先热后寒，这只是讨论杂病中阴阳二气自相乘胜的情况罢了，并不适用于讨论伤寒。这个论述非常精切，深合张仲景的心意。不仅解释了《活人书》中的疑惑，还可以与前篇结合来看。
又按：刘完素说恶寒是寒在表，或身热怕冷是热在皮肤、寒在骨髓，这些都是错误的。而《活人书》也以此作为表里来论述。所以赵嗣真说：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、脉、肉、筋、骨五者，《素问》认为它们是五脏的外合，主司于外并充盈于全身。只有称为脏、腑的才可以说是里。可见皮肤即是骨髓之上的外部浮浅部分，骨髓即是皮肤之下的外部深沉部分。这与经络属表、脏腑属里的例证不同。况且张仲景将此证放在太阳篇首，其为表证明显可知。由此可知，体质虚弱素来有寒的人，感受邪气发热，热邪浮浅不胜沉寒，所以外表怯冷想要靠近衣物，这就是所谓的“热在皮肤，寒在骨髓”，用药应当用辛温的。至于体质壮实素来有热的人，或者嗜酒之人，感邪之初，寒未变为热，阴邪闭阻于伏热之外，阴凝于外，热郁于内，所以内心烦闷而不愿靠近衣物，这就是所谓的“寒在皮肤，热在骨髓”，用药应当用辛凉的。一旦发汗之后，表解正和，这是张仲景不言其中的妙处。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？既然这样，张仲景的《伤寒论》一书，人们只知道它是方家的始祖，却不懂得把它当作秦汉时期的文本去阅读，所以对于大经大法的意思反而产生怀疑。而后世依赖其恩泽的人，往往类辑伤寒方论，其中失去本义及穿凿附会的也有。何况这是以杂病为论述，只是引用其体例罢了。这次赵嗣真的释疑可以说是得其旨趣。而且《黄帝针经》中有论述皮寒热、肌寒热、骨寒热等体例，像这样，张仲景所论述的区分邪在皮肤、骨髓的不同，虽然想要穷尽证候的变化，但自有其本源。
Xu Shuwei said: Zhang Zhongjing stated, for instance, if the Cun (inch) pulse is faint, it is named Yang insufficiency. When Yin Qi invades the Yang region, one experiences shivering and aversion to cold. If the Chi (cubit) pulse is weak, it is named Yin insufficiency. When Yang Qi sinks into the Yin region, fever occurs. This refers to the condition arising from the disease's original nature. It is also stated that faint Yang leads to aversion to cold, while weak Yin leads to fever. This is because excessive sweating by physicians caused Yang to become faint, and severe purgation caused Yin to become weak; this refers to iatrogenic illness. Generally speaking, when Yin is insufficient, Yang follows inward and sinks, resulting in fever; when Yang is insufficient, Yin takes advantage of the deficiency to occupy the Yang position, resulting in aversion to cold. Because Yin and Yang fail to remain in their respective positions, cold and heat contend with each other, leading to simultaneous fever and aversion to cold.
Liu Wansu, in *Yuan Bing Shi* (Original Causes of Disease), stated: Body heat with aversion to cold indicates pathogenic heat at the Exterior. Pathogenic heat at the Exterior is superficial; the pathogen fears the Healthy Qi, so the manifestation is fever accompanied by aversion to cold. Some say aversion to cold is due to Cold pathogen at the Exterior; some say body heat with aversion to cold means heat is in the Skin and Cold is in the Marrow. Both are erroneous. The method of Zhang Zhongjing states: If there is no Yang syndrome (e.g., faint pulse), Cold diseases must not be treated with diaphoresis. It also states that for body heat with aversion to cold, Ma Huang Tang should be used to induce sweating. After sweat is discharged, heat dissipates, the body cools, and recovery ensues. Thus, how could there be a Cold pathogen? The general principle is: restlessness, polydipsia, preference for cold, and aversion to heat indicate Heat diseases. There is also the principle of "Excess causes harm, restraint brings balance," where extreme Heat may paradoxically feel cold. Although feeling cold, the pathology is truly Heat, not Cold. If Heat is severely constrained and manifests as aversion to cold, worsening with cold and improving slightly with warmth, it is because warmth unblocks the Cou Li (pores/skin texture), allowing Yang Qi to disperse and slightly reducing the constrained Heat. Conversely, Cold closes the Cou Li, causing Yang Qi to be constrained and Heat to intensify, thus worsening the disease. This applies to the upper, lower, interior, exterior, and whole body. Laypeople mistakenly call this a Cold disease and erroneously administer Hot medicines, causing great harm.
It is further stated: "Yin excess leads to Cold, Yang excess leads to Heat." This refers to Interior Qi combining with pathogenic Heat at the Exterior, resulting in Yang excess and fever; or Exterior Qi combining with pathogenic Heat at the Interior, resulting in Yin excess and chills. Due to deficient Exterior Qi and hyperactive Interior Heat, following the rule of "Excess causes harm, restraint brings balance," chills occur paradoxically. Fundamentally, this is a Heat disease, not a Cold disease. In cases of Taiyang disease presenting with alternating chills and fever, pathogenic Heat is at the Exterior and superficial, fearing Healthy Qi, hence aversion to cold; pathogenic Heat is at the Interior and deep, being extremely strong and fearless, hence no aversion to cold but aversion to heat. The continuous advance and retreat between Interior and Exterior result in alternating chills and fever. This Qi does not bias toward either Interior or Exterior, differing from Malaria, and the chills and fever are milder.
Commentary: These several discussions mention the mutual overacting of Yin and Yang in miscellaneous diseases, and the phenomenon where extreme Fire/Heat mimics Water/Cold, illustrating the example of "Excess causes harm, restraint brings balance." However, Liu Hejian's citation of Taiyang fever and alternating chills contradicts Zhang Zhongjing and Cheng Wuji's *Ming Li Lun*. Zhao Sizhen elaborated: *Ming Li Lun* states that alternating chills and fever result from the struggle between Pathogenic Qi and Healthy Qi. When Pathogenic Qi enters, if Healthy Qi does not struggle against it, only fever occurs without chills; if they struggle, both chills and fever arise. Generally, Cold pathogen is Yin, Heat pathogen is Yang; Interior is Yin, Exterior is Yang. When Pathogenic Qi lodges in the Exterior, if it is a Cold pathogen struggling with Yang, it manifests as Cold; when entering the Interior, if it is a Heat pathogen struggling with Yin, it manifests as Heat. If Pathogenic Qi is between Exterior and Interior, struggling with Yang externally causes Cold, and struggling with Yin internally causes Heat. Since the Exterior and Interior are not fixed, and internal/external boundaries are fluid, chills and heat come and go, occurring three to five times daily, or up to ten-plus times in severe cases. The theory of Yin-Yang mutual overacting, where Yang insufficiency leads to chills then fever, and Yin insufficiency leads to fever then chills, applies only to miscellaneous diseases where Yin and Yang Qi overact upon themselves, and cannot be applied to Taiyang disease. This discussion is very precise and aligns deeply with Zhang Zhongjing's intent. It not only clarifies doubts in *Huo Ren Shu* but can also be read in conjunction with the previous chapter.
Furthermore, Liu Hejian claimed that aversion to cold is Cold at the Exterior, or that body heat with aversion to cold means heat in the Skin and Cold in the Marrow, which are errors. *Huo Ren Shu* also interpreted this as Interior-Exterior. Zhao Sizhen commented: Examining Zhang Zhongjing's treatise, he distinguishes only between Skin and Marrow, not using terms like Exterior-Interior. This is because Skin, Vessels, Flesh, Tendons, and Bone are considered external combinations of the Zang-Fu organs in *Su Wen*, governing the exterior and filling the body. Only Zang and Fu organs can be termed Interior. Thus, Skin is the superficial part above the Marrow, and Marrow is the deep part below the Skin. This differs from the principle that Meridians belong to the Exterior and Zang-Fu belong to the Interior. Moreover, Zhang Zhongjing placed this syndrome at the beginning of the Taiyang Chapter, clearly indicating it is an Exterior syndrome. Therefore, in individuals constitutionally weak and prone to Cold, contracting pathogens and developing fever, the superficial Heat cannot overcome deep-seated Cold, causing external fear of cold and desire for clothing; this is "Heat in the Skin, Cold in the Marrow," requiring Acrid-Warm medicines. Conversely, in robust individuals constitutionally prone to Heat, or wine drinkers, upon initial contraction, Cold has not yet transformed into Heat; Yin pathogen closes off latent Heat externally, condensing Yin outside while Heat constrains inside, causing internal vexation and aversion to clothing; this is "Cold in the Skin, Heat in the Marrow," requiring Acrid-Cool medicines. Once sweating resolves the Exterior and restores harmony, this is the subtle point Zhang Zhongjing did not explicitly state. If Skin were Exterior and Marrow were Interior, then the bone-joint pain in Ma Huang Tang syndrome would constitute a disease with both Exterior and Interior aspects. Since this is not the case, although people know Zhang Zhongjing's *Shang Han Lun* as the ancestor of formulas, they fail to read it as a Qin-Han era text, leading to ambiguity regarding its fundamental principles. Later generations, relying on its benefits, compiled Shang Han formula discussions, often losing the original meaning or engaging in forced interpretations. Since this discussion focuses on miscellaneous diseases, it merely cites examples. Zhao Sizhen's clarification indeed grasps the essence. Furthermore, the *Huang Di Zhen Jing* discusses examples such as Skin Cold-Heat, Muscle Cold-Heat, and Bone Cold-Heat. Thus, Zhang Zhongjing's distinction between pathogenic location in the Skin versus Marrow, though aiming to exhaust variations in syndromes, has its own origins.