Exterior syndromes (biao zheng) are a unique pathological concept in Traditional Chinese Medicine (TCM) and hold significant importance within the TCM diagnostic and treatment system. Not only are exterior syndromes associated with diseases like the common cold, but they are also often present in many internal injuries and miscellaneous diseases. Concurrent interior-exterior syndromes (biao li jian zheng) are frequently encountered in clinical practice, making the differentiation between exterior syndromes and concurrent interior-exterior syndromes crucial for improving clinical efficacy.
Current TCM internal medicine, while it includes a section on the common cold, generally places insufficient emphasis on exterior syndromes. Many diseases seen in various clinical departments, such as cardiovascular diseases, respiratory, digestive, endocrine disorders, and even orthopedic and gynecological conditions, often arise from the mismanagement of exterior syndromes. These diseases frequently present with concurrent exterior syndromes. If the exterior syndrome is not resolved, treatment is unlikely to be effective, leading to prolonged illness. Addressing exterior syndromes can often yield significant results with minimal effort, making the effective resolution of exterior syndromes a vital aspect of disease treatment.
In 1987, while studying the “Shang Han Lun” (Treatise on Cold Damage) at my alma mater, I analyzed and summarized the concept of concurrent interior-exterior syndromes, writing a paper titled “Discussion on Concurrent Interior-Exterior Syndromes” which was presented at our school’s second student academic seminar and received an award for excellence. (This paper was later revised and published under the title “Exploration of Treatment Principles for Concurrent Interior-Exterior Syndromes” in the Hebei Journal of Traditional Chinese Medicine.) Since then, I have often paid attention to exterior syndromes and concurrent interior-exterior syndromes in my studies and clinical practice. In the spring of 1992, I treated an elderly patient who had suffered from stubborn diarrhea for eleven years. For many years, his stools were like water, and he was extremely emaciated. Upon inquiry, I learned that the patient had suffered from eczema since childhood, which suddenly disappeared eleven years ago, followed by the onset of diarrhea, which had not responded to treatment from both Western and Chinese medicine. At that moment, I recalled a case of chronic nephritis I had seen during my internship in the “Yue Mei Zhong Medical Case Collection.” The patient had previously suffered from chronic eczema, which suddenly disappeared eight years ago, followed by nephritis that was resistant to treatment. The elder Yue believed it was due to damp-heat penetrating internally, and treated it with a formula of Ma Huang (Ephedra), Lian Qiao (Forsythia), and Chi Xiao Dou (Adzuki Bean) to clear heat and transform dampness, resulting in a quick recovery. I applied a similar method, using this formula combined with Yin Chen (Artemisia) and Wu Ling San (Five-Ingredient Powder), and after five doses, the patient showed improvement, and after twenty doses, he was cured, which caused quite a stir at the time.
At that time, I gradually began to pay more attention to exterior syndromes, but my overall understanding of classical formulas and exterior syndromes was still superficial, and I was not satisfied with the treatment outcomes for many diseases. For instance, in my early years of treating shoulder periarthritis, the results were not satisfactory, which was quite embarrassing and frustrating, especially in front of patients who had great trust in me. I found it particularly difficult to understand certain special medical cases from historical figures, such as Song Dynasty’s Xu Shuwei using Ma Huang Tang (Ephedra Decoction) to treat hemoptysis, Li Shicai using Gui Zhi Tang (Cinnamon Twig Decoction) for febrile diseases with delirium, and Shu Chi Yuan using Ma Huang Tang for difficult labor, and Ding Gan Ren using Gui Zhi Tang for back abscesses. It was not until 1995, when I had the fortune to study classical formulas systematically under my mentor, Professor Huang Huang in Nanjing, that I gained a deeper understanding of exterior syndromes, and my clinical efficacy underwent a qualitative change. The medical cases from ancient classical formula masters are truly ingenious and remarkable, but once one truly grasps the thinking behind classical formulas, it becomes easier to understand.
Many acute and chronic diseases can often achieve remarkable results if approached from the perspective of exterior syndromes or by considering exterior syndromes. One patient had a headache for over twenty years; although he could not be exposed to wind on his head during the summer, he was fine below the chest and abdomen. By examining his tongue and pulse, I prescribed Gui Zhi Tang with modifications, and he recovered in half a month. Another patient suffered from dacryocystitis for many years and was in great pain. Observing that the corner of his eyes was dirty and seemed like a heat syndrome, but he complained of coldness in his feet and often preferred to wear cotton shoes even in summer, I treated him with Gui Zhi Tang with modifications, and he recovered. A patient presented with fever, chills, body aches, and wheezing, and examination revealed a large pleural effusion. The attending physician initially planned to perform a thoracentesis but canceled due to the chills. Observing symptoms of aversion to wind, sweating, palpitations, and stiff neck, I used a combination of Gui Zhi Jia Ge Gen Tang (Cinnamon Twig Decoction with Kudzu) and Ting Li Da Zao Xie Fei Tang (Lepidium and Jujube Decoction) for three doses, and the patient’s condition improved daily, with follow-up showing the pleural effusion had disappeared. The Western medicine department head exclaimed, “Where did the fluid go? Where did the fluid go?” Initially dismissive of TCM, he had claimed he would eliminate TCM within two years, but later became even more obsessed with TCM than practitioners themselves. Another patient had left chest pain for several days, making it difficult to bend or straighten. An external hospital diagnosed him with “moderate pleural effusion” and advised him to prepare 10,000 yuan for hospitalization and thoracentesis. I observed clear exterior syndrome and suggested he first take Chinese medicine. Based on his pulse and symptoms, I prescribed Chai Hu Gui Zhi Tang (Bupleurum and Cinnamon Twig Decoction) with Zhi Shi (Bitter Orange) and after one dose, his pain was halved, and after three doses, all symptoms disappeared, costing only a few dozen yuan. Many patients with chronic gastric diseases showed improvement after I treated them with Gui Zhi Tang with modifications upon observing aversion to wind in the epigastric area. For many patients with shoulder periarthritis, as long as they had aversion to wind in the shoulder area, using Gui Zhi Tang with modifications often yielded rapid results. The ancient concept of “leak shoulder wind” indicates that the ancients recognized the relationship between shoulder periarthritis and wind-cold.
I began treating gout during my internship, but the treatment course was always long, and I could not find a quick method. One patient came to me with red, swollen, and painful toes, presenting a clear heat syndrome, but upon careful examination of his tongue and pulse, I suspected a concurrent exterior syndrome, so I prescribed Gui Zhi Jia Da Huang Tang (Cinnamon Twig Decoction with Rhubarb), and unexpectedly, it had an extraordinary effect. I later used this formula with modifications to treat many cases of gout, achieving rapid results. This case greatly inspired me; some exterior syndromes are quite obvious, while others are more subtle and difficult to detect. In clinical practice, many patients with cardiovascular diseases also present with concurrent exterior syndromes. I often use Xuming Decoction, Ge Gen Tang, and Hou Po Qi Wu Tang (Magnolia Bark Seven-Ingredient Decoction) with modifications to achieve satisfactory results.
Due to differences in physical constitution and the varying strengths of external pathogens, individuals respond differently when ill. Some people exhibit very obvious exterior symptoms when affected by external pathogens, making them easy to identify and treat. Others may show mild and atypical symptoms, often leading to neglect in treatment. It is these easily overlooked atypical exterior syndromes that can linger in the body, causing various degrees of pathological damage over time. Whenever they encounter external wind-cold, they may exacerbate, which I refer to as “the original form is revealed.” For example, one patient presented with chest pain and hemoptysis, and upon examination, he was found to have diabetes, pneumonia, and suspected lung cancer. Western medicine was ineffective, and he was referred to me, but initially, I was not satisfied with the treatment outcome. One time, he caught a cold, presenting symptoms of aversion to wind, palpitations, and sweating, so I immediately used Gui Zhi Tang with modifications, and unexpectedly, all symptoms resolved.
Many bone and joint diseases, cervical spondylosis, cardiovascular diseases, respiratory diseases, and rhinitis are all related to this. Symptoms such as frequent coughing, sneezing, runny nose, and tearing are often associated with exterior syndromes. Chronic diseases that easily worsen upon slight exposure to cold are mostly related to lingering exterior syndromes. For those with a yellow tongue coating but a thin white coating on the surface, they often accompany exterior syndromes.
In the book “Zheng Zhi Ge Jue” by Guo Chengxun, which is broad in scope and concise in reasoning, collecting the essence of the sages and providing keys for later scholars, the section on hemoptysis states: “First discuss external causes, which are the key points.” The section on epistaxis states: “When wind and cold are severe, it is advisable to follow the method of Gui and Ma.” This book differs from other internal medicine formula books in that it places great emphasis on exterior syndromes and stresses the importance of addressing exterior syndromes in the differentiation and treatment of many diseases, which has greatly inspired me.
Ten years ago, I fortuitously obtained the long-desired “Selected Medical Cases of Six Classics Differentiation” by Fan Zhonglin, which brought a new change to my understanding and application of exterior syndromes. The book frequently mentions the use of Ma Huang Tang and Gui Zhi Tang to treat acute and chronic difficult diseases, further deepening my understanding of exterior syndromes and significantly altering my clinical thinking patterns. It includes cases of using Ma Huang Tang to treat chronic hepatitis and liver cirrhosis, which were previously unheard of and unimaginable. This is why I later thought of using Gui Zhi Tang and Ma Huang Tang to treat diabetes and cardiovascular diseases with effective results.
In recent years, I have used Xuming-type formulas to treat strokes, often achieving results with just one dose. In the formula books before the Han and Tang Dynasties, there are numerous Xuming-type formulas, indicating that treating strokes from external wind was a common method at that time. Song Dynasty’s Xu Shuwei stated: “For strokes, use Xuming, expel wind, Feng Yin, Zhu Li Zhu Tang, and Shen Jing Dan, along with moxibustion, and none will fail to recover.” Tang Dynasty’s Sun Simiao further stated: “According to ancient methods, using the large and small Xuming decoctions to treat the five organs’ deficiency and the evil wind… the effect is miraculous.” However, after the Jin and Yuan Dynasties, there was a fundamental change in the understanding of the pathogenesis and treatment concepts of strokes, emphasizing the theory of internal wind and completely denying the role of expelling wind formulas in the treatment of stroke diseases.
A few years ago, when I read the words of the classical formula master Wu Jianhou in “Application of Classical Formulas According to Symptoms”: “Exterior evil is hidden within,” I immediately felt a strong resonance, as it succinctly revealed the pathological state of exterior evils lingering within the body.
Today, with the widespread use of air conditioning, fans, motorcycles, and cold drinks, many people are exposed to wind-cold evils for extended periods without realizing it, leading to corresponding pathological changes over time. If practitioners lack sufficient awareness of this and fail to take effective measures or use appropriate formulas and medicines, the condition will become chronic and difficult to cure.
Clinically, I often see patients who are robust and have a large abdomen. When they suffer from diseases like diabetes, hypertension, and hyperlipidemia, clinicians usually focus more on their internal symptoms, while these individuals often have concurrent exterior syndromes that go unnoticed. This is because these individuals tend to be heat-sensitive and prefer coolness, leading to exterior evils lingering within their bodies.
The entire “Shang Han Lun” places particular emphasis on exterior syndromes, devoting a significant amount of space to discussing exterior syndromes and concurrent interior-exterior syndromes. Its first line states: “In the case of Taiyang disease, the pulse is floating, and there is stiffness and pain in the head and neck with aversion to cold,” clearly articulating the basic pulse and symptoms of Taiyang exterior syndrome, and from there, it systematically discusses the various typical and atypical pulses and symptoms of exterior syndromes, interior syndromes, and concurrent interior-exterior syndromes. It details the differentiation methods for exterior syndromes, such as in section 56: “In cases of cold damage, if there is no bowel movement for six or seven days, and there is a headache with heat, use Cheng Qi Tang; if the urine is clear, it indicates that the condition is still in the exterior, and sweating is necessary; if there is a headache, it must be accompanied by epistaxis, and Gui Zhi Tang should be used.” Li Shicai had a profound understanding of this section; when he encountered a patient with delirium and laughter, the consensus was to use Cheng Qi Tang, but Li observed that the urine was clear and insisted on using Gui Zhi Tang, resulting in recovery.
It is important to note that exterior syndromes are not unique to Taiyang diseases; most subsequent diseases also have exterior syndromes and concurrent interior-exterior syndromes. Although the “Jin Gui Yao Lue” discusses the treatment of miscellaneous diseases, exterior syndromes and concurrent interior-exterior syndromes can be found throughout. In the major discussions, it is usually first to resolve the exterior before treating the interior, or to resolve both simultaneously, with occasional special cases requiring treatment of the interior before resolving the exterior. For example, in section 91: “In cases of cold damage, if the physician administers treatment and the patient continues to have clear diarrhea without stopping, and there is body pain, urgent treatment of the interior is necessary; afterward, if the body pain resolves and the bowel movements normalize, urgent treatment of the exterior is necessary. To rescue the interior, use Si Ni Tang; to rescue the exterior, use Gui Zhi Tang.” And in section 104: “In cases of cold damage for thirteen days without resolution, it is advisable to first take Xiao Chai Hu Tang to resolve the exterior, and then use Chai Hu Jia Mang Xiao Tang to treat it.” The repeated mention of exterior symptoms in the discussions refers to exterior syndromes and emphasizes the importance of treating exterior symptoms.
Regarding the pulse of exterior syndromes, it is usually characterized by a floating pulse, but occasionally there may be a sinking pulse, as seen in section 62’s Xin Jia Tang and section 301’s Ma Huang Xi Xin Fu Zi Tang. The herbs used to resolve exterior syndromes are not limited to Ma Huang and Chai Hu; ginger and aconite-based formulas can also be used to treat exterior syndromes. For example, in section 92: “If the patient has fever and headache, and the pulse is sinking, if there is no error, and there is body pain, the interior should be rescued. Use Si Ni Tang.”
Learning to apply classical formulas requires special attention to exterior syndromes and concurrent interior-exterior syndromes because these are not only common in clinical practice but also crucial for treatment outcomes. Mastering the exterior syndromes and concurrent interior-exterior syndromes discussed in the major texts can significantly enhance the clinical efficacy of applying classical formulas.