Library

When both exterior and interior syndromes are present, it means that the righteous qi (Zheng Qi) of both levels has been injured by pathogenic factors; it does not refer to a situation where exterior pathogens are excess and solid while interior righteous qi is deficient. The "qi" mentioned here refers to the Six Excesses (Liu Yin: Wind, Cold, Summerheat, Dampness, Dryness, Fire). Let us clarify this with examples of Cold and Heat.

In cases of simultaneous exterior and interior Cold, treatment should focus on warming the Middle Jiao to disperse Cold. Once the interior righteous qi is strengthened, the exterior pathogens can be repelled. Zhang Zhongjing, in cases involving body pain and diarrhea with undigested food (Xia Li Qing Gu), advocated first warming the interior and then attacking the exterior. This indicates the general principle of treatment. In reality, when both exterior and interior are simultaneously affected by Cold, methods for warming the interior and releasing the exterior can be used concurrently, without necessarily requiring a strict sequence.

In cases of simultaneous exterior and interior Heat, treatment should employ Sweet-Cold methods, assisted by Pungent-Cool methods to dissipate and resolve, similar to Ye Tianshi's approach to treating Warm Diseases. If there is Yangming Fu-organ excess syndrome, one should first use Bitter-Cold or Salty-Cold purgatives, such as administering Chengqi Tang. Once the stool becomes unobstructed, sweat will naturally occur. These two scenarios involve the same nature in both exterior and interior (Biao Li Tong Qi). Therefore, the emphasis is on the interior; treating the interior will cause the exterior symptoms to resolve promptly. Even if some residual exterior pathogens remain, a slight clearing of the exterior suffices. If one attacks the exterior first, it will not only further weaken the interior but also fail to completely clear the exterior pathogens; even if the exterior is cleared, the righteous qi will be damaged, leaving no proper pathway to expel the interior pathogens.

In cases of exterior Heat and interior Cold, if the patient constitutionally suffers from Middle Jiao Cold and has recently contracted Wind-Heat, treatment requires only releasing the exterior. If the patient has suffered internal injury from raw/cold foods and external injury from Wind-Heat, meaning both exterior and interior involve newly acquired pathogens, treatment should combine Pungent-Cool methods to疏解 (release/disperse) the exterior with Aromatic methods to regulate Qi and transform interior Cold.

In cases of exterior Cold and interior Heat, if the heat is caused by the closure of Cou Li (pores/skin texture) due to exterior pathogens, simply releasing the exterior is sufficient. If the heat is due to the accumulation of Warm pathogens internally, compounded by a new contraction of Wind-Cold externally, mild cases can be treated with Pungent-Cool methods to vent interior Heat, causing external Cold to dispel spontaneously. In severe cases, the power of Cold may mask the Heat; treatment should utilize light, penetrating, and vigorous Pungent-Aromatic agents to rapidly open the exterior. This prevents the exterior pathogens from binding for long, which would drive interior Heat deeper, infiltrating the meridians and stagnating in the Blood level, making treatment difficult. However, cooling and moistening agents should be added to the prescription to avoid excessive dryness; once the exterior is resolved, interior Heat must be cleared immediately. These two scenarios involve different natures in exterior and interior (Biao Li Yi Qi); thus, the emphasis is on the exterior, following the principle of "attacking the easier target first." If one attacks the interior first, it risks driving exterior pathogens inward; moreover, the interior pathogens may not be easily eliminated, while the exterior pathogens become entrenched. This outlines the general framework of this method. Furthermore, one must constantly assess the urgency of the disease progression to determine the sequence of treatment, applying wisdom within the rules rather than rigidly adhering to fixed formulas. Is this not the way?

Generally, when diseases sink from the exterior to the interior, one must open the exterior and support the interior, allowing pathogens to exit via their original pathway. Ancients stated that Shaoyin pathogens still use the Taiyang channel as an exit route; Taiyang pathogens still use the Yangming channel as an exit route. Therefore, in cases of prolonged interior sinking of exterior pathogens, if symptoms reappear at the exterior level after medication, it indicates the expulsion of pathogens. Similarly, if Chills result from dietary injury, resolving stagnation must be accompanied by regulating Qi; if Fever results from injury to Essence and Blood, nourishing Yin must incorporate subduing Yang. These represent the treatment methods for mutual deficiency and excess between exterior and interior.