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The concept of exterior and interior is a guiding principle for distinguishing the location of diseases and the depth of their severity.
It is a relative concept. In terms of the body structure and internal organs, the body structure is considered the exterior, while the internal organs are the interior; in terms of the viscera and bowels, the bowels are the exterior, and the viscera are the interior; in terms of meridians and viscera, the meridians are the exterior, and the viscera are the interior, and so on. From the perspective of disease depth, for external pathogenic diseases, the pathogenic factor enters the interior one layer deeper, and the disease becomes more severe; when it exits the exterior, the disease is lighter. Understanding this relative concept is particularly important in the differentiation of the six meridians and the differentiation of defensive qi, nutritive qi, and blood. The above is the broad concept of exterior and interior.
The narrow definition of exterior and interior refers to the skin, muscles, and meridians as the exterior, where these areas are affected by pathogens, belonging to exterior syndrome; while the viscera, qi, blood, and bone marrow are considered the interior, where diseases occur, collectively referred to as interior syndrome.
The differentiation of exterior and interior syndromes is of great significance in the diagnosis of external pathogenic diseases. It allows for the assessment of the severity of the disease, clarifies the depth of the pathological changes, and predicts the trend of pathological changes. Exterior syndrome is shallow and light, while interior syndrome is deep and severe. When the exterior pathogenic factor enters the interior, it indicates disease progression; when the interior pathogenic factor exits the exterior, it indicates disease regression. Understanding the severity and progression of the disease allows for grasping the evolution of the disease and taking appropriate treatment measures.
1. Exterior Syndrome
Exterior syndrome refers to the symptoms produced when the six excesses (liuyin) and epidemic pathogens invade the body through the skin and mucous membranes. It is commonly seen in the early stages of external pathogenic diseases, generally presenting with an acute onset and a short course of illness.
Exterior syndrome has two obvious characteristics. First, it is caused by the invasion of pathogenic factors into the human body. Second, the pathogenic condition is light.
The location of exterior syndrome is in the skin, muscles, and meridians, and it is easily treatable.
Clinical Manifestations: Chills, fever, headache, body aches, thin white tongue coating, floating pulse, often accompanied by nasal congestion, runny nose, cough, sneezing, and sore throat.
Pathological Analysis: The six excesses invade the muscle surface, obstructing the normal dissemination of defensive qi, leading to heat. The defensive qi is obstructed, losing its function of warming and nourishing the muscle surface. The muscle surface does not receive normal warmth, hence the chills. The pathogenic factor stagnates in the meridians, causing qi and blood to flow poorly, resulting in headache and body aches. The lungs govern the skin and hair, and the nose is the orifice of the lungs; the pathogenic factor enters the lungs through the skin and mucous membranes, affecting the lungs, leading to nasal congestion, runny nose, and cough. Sneezing and sore throat are often present. Since the pathogenic factor is still on the exterior and has not harmed the interior, the tongue coating may show no changes, remaining primarily thin and white. The righteous qi rises to resist the pathogenic factor, hence the pulse is floating.
2. Interior Syndrome
Interior syndrome refers to a type of syndrome where the disease is deeply located in the interior (viscera, qi, blood, bone marrow). It is contrasted with exterior syndrome. It is commonly seen in the middle and later stages of external pathogenic diseases or in internal injuries. The causes of interior syndrome can generally be categorized into three situations: first, the exterior pathogenic factor transmits into the interior, invading the viscera; second, the external pathogenic factor directly invades the viscera; third, emotional disturbances, irregular diet, and excessive exertion can damage the viscera, leading to functional disorders and chaotic qi and blood, resulting in disease.
The scope of interior syndrome is very broad; apart from exterior syndrome, other diseases can be considered interior syndromes. The characteristics of interior syndrome can be summarized in two points: first, the disease is located deeply; second, the condition of interior syndrome is generally more severe.
Clinical Manifestations: The causes of interior syndrome are complex, with a wide range of locations and numerous symptoms, often appearing in forms of either cold or heat, or deficiency or excess, thus detailed content can be found in various chapters on differentiation. Here are a few common symptom and pulse analyses:
High fever with aversion to heat or slight fever with tidal heat, irritability and confusion, thirst with a desire to drink, or aversion to cold with cold limbs, fatigue and weakness, and a pale tongue with excessive saliva. Constipation, short and red urine, or loose stools, clear and long urine, abdominal pain and vomiting, thick tongue coating and deep pulse.
Syndrome Analysis: The above-listed symptoms are some common manifestations that may appear in various interior syndromes of cold, heat, deficiency, and excess. In terms of heat and cold, interior syndromes can be either heat without cold or cold without heat; heat can manifest as high fever with aversion to heat. Slight fever with tidal heat is often seen in internal injury with yin deficiency and empty fire rising. Cold manifestations include aversion to cold, which can be alleviated by covering with clothing, indicating insufficient yang qi or internal invasion of cold, damaging yang qi, leading to cold due to yang deficiency. Irritability and confusion are manifestations of excess heat disturbing the mind; thirst with a desire to drink and short red urine are due to excess heat consuming body fluids. Constipation occurs due to heat binding in the intestines, leading to depletion of fluids and loss of normal function. Those with insufficient yang qi often present with fatigue and weakness, while those with deficiency cold may show a pale tongue with excessive saliva, and those with spleen deficiency may have loose stools.
The abdomen is associated with the viscera, and symptoms in this area include abdominal pain and vomiting, constipation or loose stools, short red urine or clear long urine, all of which are signs of interior disease. Thick tongue coating and deep pulse are both signs of disease in the interior.
[Appendix] Half Exterior Half Interior Syndrome
When an external pathogenic factor transmits into the interior but has not yet fully entered, or when an interior pathogenic factor penetrates to the exterior but has not yet reached the exterior, and the pathogenic and righteous qi are in conflict between the exterior and interior, it is referred to as half exterior half interior syndrome. Its manifestations include alternating chills and fever, fullness in the chest and hypochondria, irritability with a preference for vomiting, lack of desire to eat or drink, bitter mouth, dry throat, dizziness, and wiry pulse. This understanding of half exterior and half interior is fundamentally similar to the Shaoyang syndrome in the differentiation of the six meridians.
3. Differentiation Between Exterior and Interior Syndromes
The differentiation between exterior and interior syndromes primarily involves examining changes in cold and heat, tongue appearance, and pulse characteristics. Generally speaking, in external pathogenic diseases, the simultaneous presence of fever and aversion to cold indicates exterior syndrome, while heat without cold or cold without heat indicates interior syndrome. The tongue coating in exterior syndrome does not change, while in interior syndrome, the tongue coating often shows changes; a floating pulse indicates exterior syndrome, while a deep pulse indicates interior syndrome.
4. Relationship Between Exterior and Interior Syndromes
The skin and viscera of the human body are interconnected through the meridians, allowing for communication between the exterior and interior. During the progression of a disease, under certain conditions, there can be a mixture of exterior and interior syndromes and mutual transformation, such as simultaneous exterior and interior diseases, exterior pathogenic factors entering the interior, and interior pathogenic factors exiting the exterior.
(1) Simultaneous Exterior and Interior Diseases
When exterior and interior syndromes appear at the same time, it is referred to as simultaneous exterior and interior diseases. This situation arises when both exterior and interior syndromes are present at the onset of the disease, or when the exterior syndrome has not resolved and has affected the interior, or when the original disease has not healed and has been compounded by an exterior disease, such as having an internal injury compounded by an external pathogenic factor, or having an external pathogenic factor that has caused damage to the diet.
The occurrence of simultaneous exterior and interior diseases is often associated with the interplay of cold and heat, deficiency and excess. Common patterns include exterior cold with interior heat, exterior heat with interior cold, exterior deficiency with interior excess, and exterior excess with interior deficiency, as detailed in the differentiation of cold, heat, deficiency, and excess.
(2) Exterior Pathogenic Factors Entering the Interior
When there is an exterior syndrome, if the exterior pathogenic factor does not resolve and transmits into the interior, it is referred to as exterior pathogenic factors entering the interior. This often occurs due to a decrease in the body’s ability to resist pathogens, excessive pathogenic factors, improper care, or misdiagnosis and mistreatment. For example, in the case of an exterior syndrome with chills and fever, if the chills resolve but the fever persists, accompanied by thirst, red tongue with yellow coating, and red urine, this indicates the presence of exterior pathogenic factors entering the interior.
(3) Interior Pathogenic Factors Exiting the Exterior
Some interior syndromes may have the pathogenic factor penetrating from the interior to the exterior, referred to as interior pathogenic factors exiting the exterior. This is a result of appropriate treatment and care, leading to an increase in the body’s resistance. For example, internal heat causing irritability, cough, and chest tightness may subsequently lead to fever and sweating, or rashes appearing on the skin, indicating that the pathogenic factor has moved from the interior to the exterior.
The entry of exterior pathogenic factors into the interior indicates a worsening of the disease, while the exit of interior pathogenic factors reflects a reduction in the severity of the disease. Understanding the changes in the entry and exit of exterior and interior syndromes is of great significance for predicting the development and outcome of the disease.
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