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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 supplementation, while ‘Shi’ indicates purging, which are fundamental principles in treatment; supplementation leads to ‘Shi’, while purging leads to ‘Xu’, which are the inevitable results of accurate diagnosis and treatment. However, understanding the ‘Xu’ and ‘Shi’ of pathological changes and the methods of treatment can be quite challenging. To assist in research and provide references for differential diagnosis and treatment, the meanings of ‘Xu’ and ‘Shi’ are compiled as follows.
When analyzing the ‘Xu’ and ‘Shi’ of pathological changes during diagnosis, it has various meanings that should not be confused, as this would affect the accuracy of the diagnosis. Upon detailed analysis, there are approximately the following meanings:
1. Differentiating ‘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, it is called ‘internal Xu and external Shi’. When the pulse comes slowly and leaves quickly, it is called ‘internal Shi and external Xu’.”
Zhou Chengzhi explains in the “Bian Ping Mai Zhang Ju” that: “The coming and going refers to the pulse’s entry and exit; entry and exit refer to the internal and external aspects of Yin, Yang, blood, and Qi. Quick coming and slow going indicates more exit and less entry, thus Qi gathers externally, hence ‘external Shi’; slow coming and quick going indicates less exit and more entry, thus Qi gathers internally, hence ‘internal Shi’. External Shi indicates weak Yin absorption, hence internal Xu; internal Shi indicates weak Yang propulsion, hence external Xu.”
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).
2. Differentiating ‘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 Xu and Shi)” states: “When Xie Qi is strong, it is Shi; when essence Qi is depleted, it is Xu.”
Zhang Zhizong in the “Suwen Jizhu” explains: “Xie Qi refers to the evils of wind, cold, heat, and dampness, while essence Qi refers to Ying Qi (营气) and Wei Qi (卫气). Since Xie Qi can be slightly strong, when Xie Qi is strong, it is Shi; Zheng Qi can be strong or weak, hence when essence is depleted, it is Xu. ‘Deplete’ means to lose, which can be due to Xie Qi taking over.”
Japanese scholar Tanba Genkan in the “Suwen Shi” states: “When Xie Qi invades the body, it must first take advantage of the weakness of essence Qi to enter. If it enters and essence Qi is strong, both Xie and Zheng Qi are strong, resulting in Shi, such as in the case of a strong cold damage stomach condition. If Xie Qi enters and essence Qi cannot resist it, it is taken by Xie Qi, resulting in Xu, such as in the case of direct cold damage.”
Whenever Xie Qi is present, regardless of its strength, it is considered a Shi condition; whenever there is no Xie Qi present, only the depletion of essence Qi, regardless of whether it pertains to Qi or blood, in the organs or bowels, it is considered a Xu condition.
This concept is widely applied in clinical practice.
3. Differentiating ‘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 Shi, while non-disease is considered Xu.
As stated in the “Nanjing (Classic of Difficult Issues) – Difficulty 48”: “External pain and internal comfort indicate external Shi and internal Xu; internal pain and external comfort indicate internal Shi and external Xu.”
When Xie Qi invades externally, it causes external pain, indicating that Xie Qi is present on the surface. For example, in conditions treated with Gui Zhi Tang (Cinnamon Twig Decoction) or Ma Huang Tang (Ephedra Decoction), one may only see symptoms of aversion to cold, fever, and body aches, which are external manifestations. Since the Xie Qi has not penetrated internally, there is no internal suffering, hence it is called external Shi and internal Xu, which is not due to the weakness of Zheng Qi internally.
When the disease occurs internally and causes pain, regardless of whether it is cold or heat, it is classified as internal Shi; if the disease is not present externally, it is called external Xu.
Thus, Shi indicates disease, while Xu indicates non-disease, which is also a contrasting meaning.
Second, disease is considered Xu, while non-disease is considered Shi.
As stated in the “Nanjing – Difficulty 58”: “Yang Xu and Yin excess lead to sweating and recovery; purging leads to death; Yang excess and Yin Xu lead to sweating and death; purging leads to recovery.”
Hua Shou explains: “When the disease is considered Xu, the non-disease is considered strong. Only when it is Xu can Xie Qi invade; only when it is strong can Xie Qi not enter. This refers to the concept of exterior disease harmonizing with interior disease, particularly in cases of cold damage transmission. If the exterior disease is harmonized, sweating can be used to resolve it; if purging is applied, it harms the unillness of Zheng Qi and causes the exterior Xie Qi to penetrate deeply into the interior, leading to death.”
Thus, this differentiation of Xu and Shi is akin to the mutual terms of disease and non-disease, contrasting with the meaning in “Difficulty 48”.
4. Differentiating ‘Xu’ and ‘Shi’ based on the severity of the disease
Generally, milder diseases are considered Xu, while more severe diseases are considered Shi.
The differentiation between the large and small Xianxiong Tang (Major and Minor Decoctions for Chest Binding) in the “Shang Han Lun” belongs to this category.
In the “Shang Han Lun”, it states: “In cases of cold damage for six or seven days, if there is a hard stone-like pain in the heart area, it is a case for Da Xianxiong Tang (Major Decoction for Chest Binding); if there is a small pain in the heart area, it is a case for Xiao Xianxiong Tang (Minor Decoction for Chest Binding).”
The Xianxiong condition generally belongs to the category of Yang heat and Shi evil binding in the chest, hence it is called “Xianxiong heat Shi”.
If the heat evil is severe and deeply bound, it is classified as Da Xianxiong, hence the use of Da Huang (Rhubarb), Mang Xiao (Mirabilite), and Gan Sui (Kansui) to purge the heat Shi; if the heat evil is mild and bound superficially, it is classified as Xiao Xianxiong, hence the use of Huang Lian (Coptis), Ban Xia (Pinellia), and Gua Lou Shi (Trichosanthes Fruit) to clear heat and disperse the binding.
Although there are differences in severity, they are both classified as heat Shi conditions.
The Xie Xin Tang (Purge the Heart Decoction) condition, which is a Xu Pi condition, is due to the initial weakness of Yang Qi in the middle burner and the internal invasion of formless heat evil, hence the various decoctions like Ban Xia Xie Xin Tang (Pinellia Decoction), Sheng Jiang Xie Xin Tang (Fresh Ginger Decoction), and Gan Cao Xie Xin Tang (Licorice Decoction) differ in treatment but all use Ren Shen (Ginseng), Da Zao (Jujube), Gan Jiang (Dried Ginger), and Gan Cao (Licorice) as the basis to warm and tonify the Yang Qi of the middle burner, supplemented with Huang Qin (Scutellaria) and Huang Lian (Coptis) to clear the formless heat evil that has invaded internally, thus the Pi condition is fundamentally a Xu condition.
The “Shang Han Lun” states: “If the disease occurs in Yang and purging is applied, heat enters and causes Xianxiong; if the disease occurs in Yin and purging is applied, it causes Pi.”
Thus, the Xianxiong condition is referred to as “Xianxiong heat Shi”, while the Pi condition is referred to as: “This is not heat Shi, but due to the weakness of the stomach, causing Qi to reverse upwards, hence the hardness.” This indicates that the heat in Xianxiong is severe, thus it is a Shi condition, while the mild heat in Pi is classified as a Xu condition.
5. Differentiating ‘Xu’ and ‘Shi’ based on cold and heat
Initially, cold is considered Xu, while heat is considered Shi.
The “Suwen – Tai Yin Yang Ming Lun” states: “Yang is Shi, Yin is Xu”, which carries such meaning. Tanba Genkan in the “Yao Zhi Tong Yi” states: “Cold leading to diarrhea is widely recognized as a major Xu that requires supplementation; tidal heat and delirium are widely recognized as a major Shi that requires purging.”
The former represents a Xu cold condition, while the latter represents a Shi heat condition.
Secondly, cold is considered Yin Shi and Yang Xu, while heat is considered Yang Shi and Yin Xu.
The “Suwen – Tiao Jing Lun” states: “When Yin is excessive, it leads to internal cold; when Yang is Xu, it leads to external cold”, which belongs to the former; “When Yang is excessive, it leads to external heat; when Yin is Xu, it leads to internal heat”, which belongs to the latter. These are all opposing concepts of Yin and Yang, each according to its category.
6. Differentiating ‘Xu’ and ‘Shi’ based on the form of the disease
This primarily involves differentiating based on the accumulation, dispersion, emptiness, and hardness of the disease.
For example, Qi stagnation upwards is Shi, while downward sinking is Xu; Qi accumulation internally is Shi, while external dispersion is Xu.
7. Differentiating ‘Xu’ and ‘Shi’ based on wind evil
The “Ling Shu – Nine Palaces and Eight Winds” states: “Wind that comes from its native place is called Shi wind, which promotes growth and nourishes all things; wind that comes from the opposing direction is called Xu wind, which harms people and is deadly. One should be cautious of Xu wind and avoid it.”
Zhang Jiebin explains: “The native place refers to the place where Tai Yi resides. For example, when the moon is in the first month, the wind comes from the north, which is the correct winter Qi; when the moon is in the fourth month, the wind comes from the east, which is the correct spring Qi; when the moon is in the seventh month, the wind comes from the south, which is the correct summer Qi; when the moon is in the tenth month, the wind comes from the west, which is the correct autumn Qi. The four corners and twelve months all have such Qi.”
When Qi is in its correct state, Zheng Qi is abundant, hence it is called Shi wind, which can promote growth and nourish all things. When Qi is not in its correct state, Zheng Qi is insufficient, hence it is called Xu wind, which can harm people and is most to be avoided.
In the “Neijing (Inner Canon)”, Xu wind and Shi wind are also referred to as “Xu evil and Zheng evil”, as stated in the “Ling Shu – Evil Qi Hidden in the Organs and Disease Forms”: “Xu evil is within the body, causing sweating and movement; Zheng evil is within the person, causing subtle changes…”
Based on the above analysis, the concept of ‘Xu’ and ‘Shi’ in Traditional Chinese Medicine is extensive, encompassing multiple aspects.
Within Zheng Qi, there is both Xu and Shi, and within Xie Qi, there is also both Xu and Shi. Therefore, in pathological changes and conditions, there is always a presence of Xu and Shi. Simply relying on the phrase from the “Tong Ping Xu Shi Lun” that “when Xie Qi is strong, it is Shi; when essence Qi is depleted, it is Xu” cannot encompass the full scope of Xu and Shi.
This article is from: Ren Yingqiu
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