TCM Book Club Issue 1168
Daily issues to accompany the growth of TCM practitioners
IIntroduction: Last time I read Mr. Ke’s article on the dosage of herbs in the “Shang Han Lun” and “Jin Gui Yao Lue”, I was deeply impressed by his academic attitude. Today’s article on the detailed interpretation of the “Shang Han Lun” is equally profound. The “Medical Insights” states that the main treatment principles of Shang Han are the four characters: exterior, interior, cold, and heat. After reading this article, can we re-understand the meaning of “exterior and interior”? (Editor/Zhang Yajuan)
Detailed Interpretation of the Shang Han Lun: A Discussion on “Exterior and Interior”
Author/Ke Xuefan
In the autumn of 1981, I lectured in Kanagawa Prefecture, Japan. I had the fortune to interact with Mr. Masataka Shida, who introduced me to the discussions among Japanese Kampo practitioners regarding the “exterior and interior” issues in the “Shang Han Lun” and provided relevant materials, such as Professor Nagasawa Motofumi’s works on various issues in TCM and Mr. Yamada Mitsutaka’s treatise on “Where is the Exterior Evidence?” I also had the opportunity to discuss several topics in the “Shang Han Lun” face-to-face with the renowned Kampo physician Mr. Fujihira Ken. We respected each other’s opinions and benefited greatly from the exchange. This article aims to present some preliminary opinions on this issue and I welcome corrections from colleagues at home and abroad.
Basic Understandings of the “Shang Han Lun”
1. The “Shang Han Lun” is the first clinical monograph in our country, primarily studying exogenous febrile diseases. Exogenous febrile diseases are systemic diseases, and when diagnosing and treating, one should consider the whole body. The changes in each organ and meridian should also be noted, as they are parts of the systemic disease. One should not ignore the local but must pay attention to the whole.
2. The main method for diagnosing and treating exogenous febrile diseases in the “Shang Han Lun” is the “Six Meridians Differentiation.” This method considers cold evil (yin evil) as the fundamental cause of exogenous febrile diseases and further studies the development and changes after cold evil invades the body; the body’s yang qi is the fundamental force resisting the pathogenic evil (zheng qi), and further studies the fluctuations of yang qi and the situation of the struggle between righteous and evil. This leads to the summarization of the six stages of exogenous febrile disease: Taiyang disease, Yangming disease, Shaoyang disease, Taiyin disease, Shaoyin disease, and Jueyin disease. The second method for diagnosing and treating exogenous febrile diseases is “Decoction Differentiation.” This method analyzes the clinical manifestations of patients against the indications of various formulas in the “Shang Han Lun” and further analyzes the main symptoms, accompanying symptoms, and changing symptoms.
3. Research on the “Shang Han Lun” should start from the original text, examining it line by line and word by word. In this regard, Japanese colleagues have done much in-depth and detailed work that is worth our reference. I have five personal insights on this issue: 1. Be faithful to the original text and do not arbitrarily delete or modify it like Ke Yunbo. 2. Stay closely tied to the original text and do not deviate from it like Lu Yuanlei. 3. Interpret the original text with a certain flexibility and do not be constrained by individual words. For example, in Article 4 (the order of the articles follows the 1955 edition of the “New Compilation of the Song Version of the Shang Han Lun”), “In the first day of Shang Han, it is Taiyang that is affected,” the term “one day” should be understood as the early stage, not mechanically interpreted as 24 hours. 4. Pay attention to the comparison between articles, i.e., “intertextuality,” and do not interpret them in isolation. For example, in Article 39 regarding the Da Qinglong Decoction, many people believe it cannot be explained. However, when compared with Article 38, it can be seen that although the pulse is not floating and tight but floating and relaxed, the body is not painful but heavy, and the disease fluctuates between light and heavy, as long as the main symptoms of fever, chills, no sweating, and irritability remain unchanged, and there are no signs of weak pulse, it can still be treated with Da Qinglong Decoction. This further clarifies the main symptoms and contraindications of the Da Qinglong Decoction, indicating that it is not unexplainable but rather a very important article. 5. Look at the issue from the perspective of the entire “Shang Han Lun” and do not limit oneself to a single article or sentence. For example, in Article 40 regarding the Xiao Qinglong Decoction, there is “wheezing,” and later it states, “if wheezing goes away, Ma Huang is not needed.” If one looks at this article in isolation, the two instances of “wheezing” seem contradictory. However, from the perspective of the entire “Shang Han Lun,” wheezing can be suitable for using Ma Huang, such as in the Xiao Qinglong Decoction, Ma Huang Decoction, and Ma Xing Shi Gan Decoction; wheezing can also be unsuitable for using Ma Huang, such as in the Gui Zhi Jia Hou Po Xing Zi Decoction and Ge Gen Qin Lian Decoction. Thus, it can be seen that the two instances of “wheezing” in Article 40 are not contradictory but reflect the spirit of TCM differentiation and treatment.
Finally, I want to emphasize again that the “Shang Han Lun” is a clinical work, and the results of studying the “Shang Han Lun” must be subjected to the test of clinical practice.
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What is “Exterior”?
In the main text of the “Shang Han Lun” (according to the 398-article version, i.e., the aforementioned “New Compilation of the Song Version of the Shang Han Lun”), there are 31 instances of the character “exterior” distributed across 24 articles. Four instances use the term “exterior syndrome” together, such as in Articles 46, 61, 121, and 170. This undoubtedly refers to exterior syndrome. There are 22 instances where, although the term “exterior syndrome” is not used together, the meaning also refers to exterior syndrome. For example, in Articles 29, 364, and 372, the terms “attack the exterior” or “attack its exterior”; in Articles 34, 134, 164, and 234, the terms “exterior not resolved”; in Articles 40 and 170, the terms “exterior not resolved”; in Articles 152 and 164, the terms “resolve the exterior” and “exterior resolved”; in Article 91, “rescue the exterior”; in Article 51, “disease in the exterior”; in Article 56, “still in the exterior”; in Article 148, “must have exterior”; and in Article 93, “sweating out is due to the exterior.” The exterior syndrome in the “Shang Han Lun” is the early stage of exogenous febrile disease, where the disease location is primarily superficial in the body, and the main force fighting against the external evil is the defensive qi circulating on the surface, which also affects the nutritive qi and impacts the lungs and stomach. Thus, the changes in exterior syndrome are not limited to the skin. The above 26 instances of the character “exterior” all refer to exterior syndrome.
Additionally, there are five instances of the character “exterior,” such as in Article 48, where “the complexion is bright red, indicating that the yin qi is stagnant in the exterior,” referring to visible changes in the skin’s surface; in Article 176, “exterior has heat, interior has cold” and in Article 225, “exterior heat and interior cold,” also refer to visible or palpable changes on the body surface; in Articles 217 and 218, “exterior deficiency and interior excess,” where exterior deficiency refers to the loosening of the skin’s pores after sweating. In summary, these five instances of the character “exterior” should not be interpreted as exterior syndrome but rather refer to the skin or body surface.
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What is “Outside”?
In the “Shang Han Lun,” there are 28 instances of the character “outside” distributed across 20 articles. Preliminary categorization shows that 17 instances of the character “outside” refer to exterior syndrome. For example, in Article 42, “Taiyang disease with unresolved exterior syndrome, if the pulse is floating and weak, one should resolve it with sweating, and Gui Zhi Decoction is appropriate.” In Article 44, “If the Taiyang disease’s exterior syndrome is unresolved, one must not purge; purging it would be counterproductive; to resolve the exterior, Gui Zhi Decoction is appropriate.” In Article 45, “If the Taiyang disease does not resolve after sweating and then is purged, if the pulse is floating, it will not recover. Floating indicates it is in the exterior, and purging it would prevent recovery. Now the pulse is floating, indicating it is in the exterior, and one must resolve the exterior to recover; Gui Zhi Decoction is appropriate.” These six instances of the character “outside” refer to Taiyang disease that can be treated with Gui Zhi Decoction, undoubtedly indicating exterior syndrome. This aligns with Mr. Yamada Mitsutaka’s views.
Furthermore, in Article 146 regarding the Chai Hu Gui Zhi Decoction, the term “outside syndrome” clearly refers to exterior syndrome. In Articles 37, “If the Taiyang disease has lasted for ten days, and the pulse is floating and thin, and the person is drowsy, the exterior has resolved…” In Article 106, “If the Taiyang disease does not resolve, and there is heat binding in the bladder, the person is delirious, and blood flows out. If purging resolves it, the exterior is unresolved, and one should first resolve the exterior; once the exterior is resolved, if there is still urgency in the lower abdomen, then it can be purged, and Tao He Cheng Qi Decoction is appropriate.” In Article 163, “If the Taiyang disease’s exterior syndrome is unresolved and there are multiple purges… Gui Zhi Ren Shen Decoction is the main treatment,” these five instances of the character “outside” refer to the exterior syndrome in Taiyang disease, which is also exterior syndrome. Additionally, in Article 208 (the original text is too long to include), fever and chills are considered unresolved exterior, while sweating without chills indicates a desire to resolve the exterior. The presence of chills is a major sign of exterior syndrome; thus, the two instances of “outside” in this article also refer to exterior syndrome. Article 387 states, “If vomiting and diarrhea stop but body pain persists, one should harmonize and resolve the exterior, and Gui Zhi Decoction is appropriate.” Most people believe this article indicates treating the interior first and then the exterior, as body pain is an exterior syndrome, so Gui Zhi Decoction is used to resolve the exterior; others believe that the body pain after stopping vomiting and diarrhea is not an exterior syndrome but rather a disharmony of qi and blood in the muscles and joints, and using Gui Zhi Decoction is to harmonize qi and blood. Both interpretations have merit. For now, based on the former interpretation, this instance of the character “outside” can also be interpreted as exterior syndrome.
In Article 148, “If after five or six days of Shang Han, there is sweating from the head, slight aversion to cold, cold hands and feet, fullness under the heart, no desire to eat, hard stools, and a thin pulse, this indicates a slight yang binding, and there must be both exterior and interior; the pulse is also in the interior. Sweating indicates slight yang. If it were purely yin binding, there would be no exterior syndrome, and everything would be in the interior. This indicates half in the interior and half in the exterior… it can be treated with Xiao Chai Hu Decoction.” The “half in the interior and half in the exterior” mentioned in this article corresponds to “there must be both exterior and interior.” The symptoms described in this article indicate both exterior and interior syndromes. The two instances of the character “outside” in this article are equivalent to the character “exterior,” indicating exterior syndrome. Although this can be treated with Xiao Chai Hu Decoction, it is not a typical Xiao Chai Hu Decoction syndrome.
All 17 instances of the character “outside” refer to exterior syndrome.
In Article 182, “What is the exterior syndrome of Yangming disease?” The answer is: “Body heat with spontaneous sweating, not aversion to cold but aversion to heat.” In Article 228, “If purging Yangming disease, and there is heat outside, hands and feet are warm, there is no fullness in the chest, the heart feels vexed, and one cannot eat, but only sweating from the head, then Zhi Zi Shi Decoction is the main treatment.” In these two articles, the character “outside” refers to symptoms that can be perceived on the body surface, such as fever, sweating, and skin flushing. However, symptoms like abdominal fullness, bloating, and inability to eat, although belonging to Yangming disease, do not belong to “exterior syndrome.” Therefore, the precise meaning of these two instances of the character “outside” is neither exterior syndrome nor Yangming disease but rather refers to the body surface.
In Article 104, “… tidal fever indicates excess, and one should first take Xiao Chai Hu Decoction to resolve the exterior, and then use Chai Hu Jia Mang Xiao Decoction as the main treatment.” In Article 231, “… if the exterior is unresolved, and the disease has lasted for ten days, and the pulse remains floating, then Xiao Chai Hu Decoction is appropriate.” These two instances of the character “outside” refer to the fever of the Chai Hu Decoction syndrome, which is also a symptom that can be perceived on the body surface. Therefore, these two instances of the character “outside” also refer to the body surface.
Additionally, in Articles 317 and 370, “interior cold and exterior heat,” and in Article 389, “internal cold and external heat,” and in Article 380, “exterior qi stagnation,” the meanings of these four instances of the character “outside” are also clear, referring to the body surface.
All 8 instances of the character “outside” refer to the body surface.
As for the two instances of the character “inside” in Article 53, “Wei Qi flows outside,” and in Article 213, “body fluids flow outside,” these two instances of the character “inside” are general terms; the instance of “outside not harmonious” in Article 53 is a synonym for defensive qi and also belongs to general terms. These three instances of the character “outside” have little significance for the differentiation of exogenous febrile diseases.
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Comparison of “Exterior” and “Outside”
From the above analysis, the meanings of “exterior” and “outside” are fundamentally the same. Mr. Okita Kenzo also shares this view in his book “Summary of the Shang Han Lun.” Both “exterior” and “outside” can refer to exterior syndrome, and in certain contexts, they can refer to the body surface. It should be noted that the “exterior” character refers to exterior syndrome, which can be purely Taiyang exterior syndrome, or Yangming combined exterior syndrome (Article 234), or three yin combined exterior syndrome (Article 91), or water retention combined exterior syndrome (Articles 40 and 152), or blood stasis combined exterior syndrome (Article 124), or fullness syndrome combined exterior syndrome (Article 164), etc.; the “outside” character also refers to exterior syndrome, which can be purely Taiyang exterior syndrome, or Shaoyang combined exterior syndrome (Article 146), or Yangming combined exterior syndrome (Article 208), or three yin combined exterior syndrome (Article 163), or blood stasis combined exterior syndrome (Article 106), etc. From the perspective of exterior syndrome, there is no difference in the scope between “exterior” and “outside.” The symptoms of the body surface referred to by the “exterior” character include those belonging to the two Yang diseases (Article 48), those belonging to Yangming disease (Articles 217 and 218), and those belonging to three yin diseases (Article 225); the symptoms of the body surface referred to by the “outside” character include those belonging to Shaoyang disease (Articles 104 and 231), those belonging to Yangming disease (Articles 182 and 228), and those belonging to three yin diseases (Articles 317 and 370). From the perspective of the body surface, there is also no significant difference in scope between the “exterior” and “outside” characters. The difference is merely in usage habits; the “exterior” character is more often used in typical exterior syndromes, while the “outside” character is more often used in atypical exterior syndromes, but this is merely a quantitative difference, and in medical meaning, they are the same.
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What is “Interior”?
In the “Shang Han Lun,” there are 32 instances of the character “interior” distributed across 27 articles. Preliminary categorization shows that 14 instances of the character “interior” refer to “interior syndrome.” For example, in Article 56, “If Shang Han does not have a bowel movement for six or seven days, and there is headache with heat, one should use Cheng Qi Decoction; if the urination is clear, it indicates it is not in the interior but still in the exterior…” In Article 148, “… this indicates slight yang binding. There must be both exterior and interior; the pulse is also in the interior. Sweating indicates slight yang. If it were purely yin binding, there would be no exterior syndrome, and everything would be in the interior. This indicates half in the interior and half in the exterior… it can be treated with Xiao Chai Hu Decoction.” In Article 91, the two instances of “rescue the interior,” in Article 372, “first warm the interior” and “warm the interior,” in Article 93 and Article 152, “interior not harmonized,” and in Article 208, “can attack the interior,” these 12 instances of the character “interior” can all be interpreted as “interior syndrome” and correspond to “exterior syndrome.”
Additionally, there are 18 instances of the character “interior” that can only be understood as “the interior of the human body,” such as in Articles 217 and 218, “exterior deficiency and interior excess,” in Article 176, “exterior has heat, interior has cold,” in Article 225, “exterior heat and interior cold,” in Articles 317 and 370, “interior cold and exterior heat.” These six instances of the character “interior” in the articles correspond to the characters “exterior” or “outside” that are interpreted as “body surface” (as mentioned earlier), so these six instances of the character “interior” can also be interpreted as “inside the body.”
In Articles 49 and 214, the character “interior deficiency”; in Articles 136 and 168, “heat binding in the interior”; in Articles 262 and 124, “blood stasis heat in the interior”; in Articles 127 and 392, “interior urgency”; in Article 259, “cold dampness in the interior”; in Article 245, “yang is exhausted in the interior”; in Article 151, “tightness reverses into the interior”; and in Article 350, “heat in the interior.” These 12 instances of the character “interior” should be understood as referring to “inside the body” from both a medical and textual perspective.
Among the 32 instances of the character “interior,” except for Article 392, “lower abdomen urgency,” none of the other 31 instances in the original text of the “Shang Han Lun” clearly indicate the specific location or organ of the disease. This indicates that the character “interior” in the “Shang Han Lun” primarily refers to the interior of the human body from a holistic perspective, without being confined to a specific local area. However, attention should still be paid to which organ or local area the disease primarily occurs. Based on the content of the articles, the 32 instances of the character “interior” primarily indicate changes occurring in the stomach and intestines in 10 instances, in the bladder or lower abdomen in 3 instances, and in the hypochondrium in 1 instance. The remaining 18 instances of the character “interior” are completely general references to the interior of the human body.
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What is “Inside”?
In the “Shang Han Lun,” there are 11 instances of the character “inside” distributed across 10 articles. Three instances of the character “inside” have little medical significance and can be understood as general terms. For example, in Article 134, “pain inside the diaphragm,” refers to pain in the diaphragm that resists pressure. In Article 233, “body fluids inside are exhausted,” refers to excessive sweating leading to insufficient body fluids. In Article 121, “this is due to internal vexation caused by vomiting,” refers to restlessness caused by vomiting. Three instances of the character “inside” refer to “interior syndrome.” For example, in Article 30, “Yangming internal binding,” and in Articles 105 and 181, “internal excess.” Although these three instances of the character “inside” can be interpreted as “interior syndrome,” their meanings are not very clear.
Excluding “diaphragm inside,” the 10 instances of the character “inside” do not clearly indicate specific organ locations. Based on the content of the articles, six instances of the character “inside” relate to the stomach and intestines, namely, “Yangming internal binding,” “internal excess” (two instances), “internal vexation due to vomiting,” “internal urgency” (Article 353), and “internal long-standing cold” (Article 352). The other four instances of the character “inside” do not refer to specific organs but rather to the interior of the human body, namely, “internal attack is strong” (Article 116), “yang qi is trapped inside” (Article 134), “internal cold and external heat” (Article 389), and “body fluids inside are exhausted.”
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Comparison of “Interior” and “Inside”
The meanings of “interior” and “inside” are generally similar, either referring to interior syndrome or the interior of the human body. There is a difference in usage habits between “interior” and “inside.” When strictly referring to interior syndrome, the character “interior” is more commonly used, while the character “inside” is more often used as a general term. It should also be noted that the character “interior” refers to the stomach and intestines in 10 instances (10/32), while the character “inside” refers to the stomach and intestines in 6 instances (6/11), indicating that both “inside” and “interior” can refer to the stomach and intestines, and the character “inside” does not exclusively refer to the stomach and intestines.
The combined use of “exterior” and “interior” with “inside” and “outside”
In the “Shang Han Lun,” the terms “exterior” and “interior” are used together in 8 instances. In Article 74, “there are exterior and interior syndromes,” and in Articles 252 and 257, “there are no exterior and interior syndromes,” the original text has already clarified that this refers to exterior syndrome and interior syndrome. In Article 163, “if the exterior and interior are unresolved, Gui Zhi Ren Shen Decoction is the main treatment,” it also refers to exterior syndrome and interior syndrome. In Articles 49, “must have both exterior and interior excess,” in Articles 93 and 153, “both exterior and interior are deficient,” and in Article 168, “both exterior and interior are hot,” these four instances of the terms “exterior and interior” should be interpreted as referring to body surface and body interior, indicating that the combined use of “exterior and interior” can be understood as “the whole body.”
In the “Shang Han Lun,” the terms “inside” and “outside” are only used together once, in Article 60, “both inside and outside are deficient.” This also refers to the body’s parts, with the meaning being the same as that of “both exterior and interior are deficient.”
It can be seen that the combined use of the terms “exterior” and “interior” or “inside” and “outside” has the same meaning, and does not change due to their combined use.
My level is limited, and errors are inevitable. I welcome readers’ criticism and corrections. I would also like to thank Professor Nagasawa Motofumi, Dr. Yamada Mitsutaka, Dr. Masataka Shida, and Dr. Fujihira Ken for their many inspirations!
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