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Source: Yipin Ge
‘Xu’ (虚) and ‘Shi’ (实) refer to the nature of pathological changes and are extremely important in differential diagnosis.
Thus, ‘Xu’ indicates deficiency and ‘Shi’ indicates excess, which are essential methods for diagnosis and treatment; to tonify is to create excess, and to drain is to create deficiency, which is the inevitable result of accurate diagnosis and treatment. However, understanding the deficiency and excess of pathological changes and the methods of tonification and drainage is relatively easy at a superficial level, but achieving precise differentiation and application is quite challenging.
Based on literature review and clinical experience, the meanings of ‘Xu’ and ‘Shi’ are compiled as follows for research purposes, which may assist in differential diagnosis and treatment.
When analyzing the deficiency and excess of pathological changes, there are various meanings that should not be confused, as this would affect the accuracy of diagnosis. Upon detailed analysis, there are approximately the following categories:
1. Differentiation of ‘Xu’ and ‘Shi’ based on the strength of Zheng Qi (正气)
In the “Shang Han Lun (Treatise on Cold Damage) – Ping Mai Fa (Method of Pulse Diagnosis)” it states: “When the pulse comes quickly and leaves slowly, this indicates internal deficiency and external excess. When the pulse comes slowly and leaves quickly, this indicates internal excess and external deficiency.”
Zhou Chengzhi explains in the “Bian Ping Mai Zhang Ju (Commentary on the Pulse Diagnosis)” that: “The terms ‘coming’ and ‘leaving’ refer to the pulse’s entry and exit; entry and exit pertain to the internal and external aspects of Yin, Yang, blood, and Qi. A quick coming and slow leaving indicates more Qi is exiting than entering, hence external excess; a slow coming and quick leaving indicates more Qi is entering than exiting, hence internal excess. External excess indicates weak Yin absorption, thus internal deficiency; internal excess indicates weak Yang propulsion, thus external deficiency.”
The entry and exit of pulse Qi, whether Yin or Yang, all belong to the category of Zheng Qi. Therefore, the ‘Xu’ and ‘Shi’ mentioned here refer to Zheng Qi and do not include Xie Qi (邪气, pathogenic factors).
2. Differentiation of ‘Xu’ and ‘Shi’ based on the strength of Xie Qi (邪气) and the weakness of Zheng Qi
The “Suwen (Plain Questions) – Tong Ping Xu Shi Lun (Discussion on Deficiency and Excess)” states: “When Xie Qi is strong, it indicates excess; when vital essence is depleted, it indicates deficiency.”
Zhang Zhizong in the “Suwen Jizhu (Commentary on the Plain Questions)” explains: “Xie Qi refers to the pathogenic factors of wind, cold, heat, and dampness, while vital essence refers to Ying Qi (营气) and Wei Qi (卫气). Xie Qi can be slightly strong, hence when Xie Qi is strong, it indicates excess; Zheng Qi can be strong or weak, hence when vital essence is depleted, it indicates deficiency. ‘Depletion’ means loss, which may be due to Xie Qi’s invasion.”
Japanese scholar Tanba Genkan in the “Suwen Shi (Commentary on the Plain Questions)” states: “When Xie Qi invades the body, it must first take advantage of the deficiency of vital essence to enter. If it enters and vital essence is abundant, both will be strong, indicating excess, as seen in the case of cold damage with excess stomach heat. If Xie Qi enters and the vital essence cannot resist it, it is considered deficiency, as seen in the case of direct cold damage.”
Whenever Xie Qi is present, regardless of its strength, it is considered an excess condition; whenever there is no Xie Qi present, it is merely a deficiency of vital essence, regardless of whether it pertains to Qi or blood, in the organs or bowels, it is considered a deficiency condition.
This concept is widely applied in clinical practice.
3. Differentiation of ‘Xu’ and ‘Shi’ based on the presence or absence of disease
There are two situations regarding the differentiation of disease and non-disease.
First, disease is considered excess, while non-disease is considered deficiency.
As stated in the “Nanjing (Classic of Difficult Issues) – Difficulty 48”: “External pain and internal comfort indicate external excess and internal deficiency; internal pain and external comfort indicate internal excess and external deficiency.”
When Xie Qi invades externally, it causes external pain, indicating that the pathogenic factor is on the surface. For example, in cases of Gui Zhi Tang (Cinnamon Twig Decoction) or Ma Huang Tang (Ephedra Decoction), one may only observe symptoms such as chills, fever, and body aches, which are external manifestations. Since the pathogenic factor has not penetrated internally, there is no internal suffering.
When the pathogenic factor is external, it is termed external excess, and since there is no internal suffering, it is termed internal deficiency, which is in contrast to external excess; when the pathogenic factor occurs internally and causes internal pain, regardless of whether it is cold or heat, it is termed internal excess; since the pathogenic factor is not external, there is no external suffering, hence it is termed external deficiency.
Thus, excess indicates disease, while deficiency indicates non-disease, which is also a contrasting meaning.
Second, disease is considered deficiency, while non-disease is considered excess.
As stated in the “Nanjing – Difficulty 58”: “Yang deficiency and Yin excess lead to sweating and recovery; purging leads to death; Yang excess and Yin deficiency lead to sweating and death; purging leads to recovery.”
Hua Shou explains: “When one is afflicted by disease, it is considered deficiency; when one is not afflicted, it is considered excess. Only in deficiency can Xie Qi invade; only in excess can Xie Qi not enter. This refers to the concept of exterior disease harmonizing with interior disease, particularly in cases of cold damage transmission. When exterior disease harmonizes with interior, sweating can be beneficial; however, if purging is applied, the exterior pathogenic factor remains and the internal Qi is depleted. Conversely, when internal disease harmonizes with exterior, purging can be beneficial; however, if sweating is applied, the internal pathogenic factor does not retreat, and the exterior Qi is depleted, leading to death. This is because sweating can deplete Yang, while purging can damage Yin.”
According to Hua’s explanation, Yang deficiency indicates that Wei Qi is not sufficient on the exterior, allowing wind and cold to invade; Yin excess indicates that vital essence is abundant internally, and the organs are not diseased.
When the disease is on the exterior, inducing sweating can resolve the exterior; however, if purging is applied, it harms the unillness of Zheng Qi and causes the exterior pathogenic factor to penetrate deeply, leading to death.
Yang excess indicates that Zheng Qi is abundant on the exterior, and the exterior is not diseased; Yin deficiency indicates that vital essence is deficient internally, and Xie Qi is strong in the organs. Since Xie Qi is strong in the organs, purging can lead to recovery; however, if sweating is induced, it may harm the exterior Yang, leading to both exterior and interior deficiency, and the Xie Qi becomes more consolidated, leading to death.
Thus, this differentiation of ‘Xu’ and ‘Shi’ is synonymous with the terms for disease and non-disease, which is contrary to the meaning in “Difficulty 48”.
4. Differentiation of ‘Xu’ and ‘Shi’ based on the severity of the disease
Generally, milder diseases are considered deficiency, while more severe diseases are considered excess.
The differentiation between the major and minor forms of the Xianxiong Tang (Major Sinking the Chest Decoction) and the Xiexin Tang (Minor Sinking the Heart Decoction) in the “Shang Han Lun” belongs to this category.
The “Shang Han Lun” states: “In cases of cold damage lasting six to seven days, if there is a hard, painful mass under the heart, it is a major sinking the chest condition, treated with Da Huang (Rhubarb), Mang Xiao (Mirabilite), and Gan Sui (Kansui) to purge the heat and excess; if there is a small mass under the heart, which is painful upon pressure and the pulse is floating and slippery, it is a minor sinking the chest condition, treated with Huang Lian (Coptis), Ban Xia (Pinellia), and Gua Lou (Trichosanthes) to clear heat and disperse the mass.”
The sinking the chest condition is categorized as a Yang heat excess pathogenic factor accumulating in the chest, hence termed “sinking the chest heat excess.”
When the heat pathogenic factor is strong and deeply accumulated, it is termed major sinking the chest, hence the use of Da Huang, Mang Xiao, and Gan Sui to purge the heat and excess; when the heat pathogenic factor is mild and superficially accumulated, it is termed minor sinking the chest condition, hence the use of Huang Lian, Ban Xia, and Gua Lou to clear heat and disperse the mass.
Despite the differences in severity, they are both categorized as heat excess conditions.
The Xiexin Tang condition, which is a deficiency condition, is characterized by the Yang Qi of the middle jiao being deficient, with an invisible heat pathogenic factor penetrating internally, hence the various forms of Xiexin Tang, Sheng Jiang Xiexin Tang (Fresh Ginger Decoction), and Gan Cao Xiexin Tang (Licorice Decoction) differ in treatment, but all utilize Ren Shen (Ginseng), Da Zao (Jujube), Gan Jiang (Dried Ginger), and Gan Cao (Licorice) as the foundation to warm and tonify the Yang Qi of the middle jiao, supplemented with Huang Qin (Scutellaria) and Huang Lian to clear the invisible heat pathogenic factor, thus the sinking condition is fundamentally a deficiency condition.
The “Shang Han Lun” states: “When the disease arises from Yang, purging leads to sinking the chest; when the disease arises from Yin, purging leads to sinking condition.”
Thus, the sinking the chest condition is termed “sinking the chest heat excess,” while the sinking condition is termed: “This is not heat excess, but due to deficiency in the stomach, causing Qi to rebel upwards, hence the hardness.” This indicates that the heat in the sinking the chest condition is severe, hence it is an excess condition, while the mild heat in the sinking condition is categorized as a deficiency condition.
5. Differentiation of ‘Xu’ and ‘Shi’ based on cold and heat
First, cold is considered deficiency, while heat is considered excess.
The “Suwen – Tai Yin Yang Ming Lun (Discussion on the Tai Yin and Yang Ming)” states: “Yang is excess, Yin is deficiency,” which carries this meaning. Tanba Genkan in the “Yao Zhi Tong Yi (General Principles of Medicinal Treatment)” states: “Cold leading to diarrhea is widely recognized as a major deficiency that requires tonification; tidal heat with delirium is widely recognized as a major excess that requires purging.”
The former represents a deficiency cold condition, while the latter represents an excess heat condition.
Secondly, cold is considered Yin excess and Yang deficiency, while heat is considered Yang excess and Yin deficiency.
The “Suwen – Tiao Jing Lun (Discussion on Regulating the Menstrual Cycle)” states: “When Yin is abundant, it leads to internal cold; when Yang is deficient, it leads to external cold;” while “When Yang is abundant, it leads to external heat; when Yin is deficient, it leads to internal heat,” which pertains to the opposing nature of Yin and Yang.
6. Differentiation of ‘Xu’ and ‘Shi’ based on the form of the disease
This primarily involves differentiation based on the accumulation, dispersion, emptiness, and hardness of the disease.
For example, Qi stagnation upwards indicates excess, while downward sinking indicates deficiency; Qi accumulation internally indicates excess, while external dispersion indicates deficiency.
7. Differentiation of ‘Xu’ and ‘Shi’ based on wind pathogenic factors
The “Ling Shu (Spiritual Pivot) – Nine Palaces and Eight Winds” states: “Wind that comes from its native region is considered real wind, which promotes and nourishes all things; wind that comes from a conflict is considered false wind, which harms and kills. One should be cautious of false wind and avoid it.”
Zhang Jiebin explains: “The native region refers to the native region of Tai Yi. For example, when the moon is in the first month, the wind comes from the north, indicating the proper cold of winter; when the moon is in the second month, the wind comes from the east, indicating the proper warmth of spring; when the moon is in the third month, the wind comes from the south, indicating the proper heat of summer; when the moon is in the fourth month, the wind comes from the west, indicating the proper coolness of autumn. The four corners and twelve months all have this principle.”
When the Qi is in its proper state, Zheng Qi is abundant, hence it is termed real wind, which can promote and nourish all things. When the Qi is out of balance, Zheng Qi is insufficient, hence it is termed false wind, which can harm people and is to be avoided.” (From “Lei Jing – Nine Palaces and Eight Winds” Commentary Volume 27)
False wind and real wind are also referred to as “false pathogenic factors and true pathogenic factors” in the “Neijing (Inner Canon)”, as stated in the “Ling Shu – Pathogenic Factors Hidden in the Body” which says: “False pathogenic factors cause the body to feel cold and shiver. True pathogenic factors cause the body to feel subtle…”
Based on the analysis of the above materials, the concept of ‘Xu’ and ‘Shi’ in Traditional Chinese Medicine is extensive, encompassing multiple aspects.
Both Zheng Qi and Xie Qi can have deficiency and excess, thus in pathological changes and conditions, there is always a presence of deficiency and excess. Simply relying on the phrase from the “Tong Ping Xu Shi Lun” that “when Xie Qi is strong, it indicates excess; when vital essence is depleted, it indicates deficiency” cannot encompass the full scope of deficiency and excess.
This article is from: Ren Yingqiu
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