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Xu and Shi (Deficiency and Excess) refer to the states of excess and deficiency. There are Xu and Shi in the Exterior and Interior, in Qi and Blood, in the Zang-Fu organs, and in Yin and Yang.
Generally, diseases entering from the exterior tend to be Excess (Shi), while diseases arising from within tend to be Deficient (Xu). "Excess" implies that when pathogenic factors are abundant, purgative methods should be used; "Deficiency" implies that when healthy Qi is weak, tonifying methods should be employed. When diagnosing Xu and Shi, the purpose is to understand the fundamental condition and determine whether attacking or tonifying is appropriate. Although the Excess state of disease is certainly concerning, the Deficiency of Yuan Qi (Original Qi) is even more worrisome. Therefore, in diagnosing any disease, one must first examine the Yuan Qi as the priority, and then investigate the disease itself. If an Excess condition is mistakenly treated with tonification, it can often be remedied; however, if a Deficient condition is mistakenly treated with purgation/attacking, recovery is impossible. In summary, the key to distinguishing Xu and Shi lies in the pulse. A pulse that is truly forceful and truly possesses Shen (Spirit/Vitality) indicates a true Excess condition. A pulse that appears forceful and appears to possess Shen indicates a false Excess condition. How much more so for a pulse that is without force and without Shen, or completely devoid of both? Clinicians must never neglect this point.

1. In cases of Exterior Excess, symptoms may include fever, body pain, aversion to heat leading to discarding clothing, or aversion to cold accompanied by shivering. When cold binds the exterior, there is no sweating; when fire/pathogenic heat abounds in the exterior, sores or ulcers may appear. Migratory redness and pain indicate heat in Ying (Nutrient) and Wei (Defensive) levels. Cramping, urgency, and sour pain indicate cold in the meridians.

2. In cases of Interior Excess, symptoms may include distension and pain, fullness and hardness, obstruction and stagnation, wheezing and chest fullness, mental restlessness and irritability, agitation and insomnia, accumulation of Qi and Blood causing stagnation in the abdomen that does not dissipate, or deep retention of cold pathogens and hot toxins between the Zang-Fu organs.

3. In cases of Yang Excess, there is excessive heat and aversion to heat. In cases of Yin Excess, there is painful knotting and aversion to cold. In cases of Qi Excess, breathing is necessarily rapid and labored, and the voice is loud and harsh. In cases of Blood Excess, blood coagulates, resulting in pain and hardness.

4. In cases of Heart Excess, there is excessive fire and frequent laughter. In cases of Liver Excess, there is often pain in the hypochondrium and lower abdomen, accompanied by irritability and anger. In cases of Spleen Excess, there is distension, qi obstruction, or heavy sensation in the body. In cases of Lung Excess, there is rebellious Qi in the Upper Jiao, or coughing and wheezing. In cases of Kidney Excess, there is congestion and obstruction in the Lower Jiao, or pain, distension, or signs of heat manifesting in urination and defecation.

5. In cases of Exterior Deficiency, symptoms may include profuse sweating, muscle tremors, fear of cold, dim vision and photophobia, deafness and vertigo, numbness in the limbs, inability to endure physical exertion, dry hair and emaciated muscles, haggard complexion, and depleted Shen (Spirit).

6. In cases of Interior Deficiency, symptoms include palpitations, fright and panic, unsettled Hun and Po (Soul and Corporeal Soul), and insufficiency of Jin-Ye (Body Fluids). Symptoms may also include hunger without appetite, thirst without preference for cold drinks, fear of opening the eyes to look, or startle response to human voices. Upper Deficiency leads to inability to transform and transport food, vomiting, nausea, and middle-jiao fullness due to Qi deficiency. Lower Deficiency leads to incontinence of the two orifices, fecal or urinary incontinence, rectal prolapse, diarrhea, and seminal emission. In women, this manifests as blood exhaustion and amenorrhea, as well as spontaneous abortion, metrorrhagia, leukorrhea, and turbid discharge.

7. Yang Deficiency refers to Fire Deficiency, characterized by insufficient Shen Qi, blackouts, dizziness, chills, and aversion to cold. Yin Deficiency refers to Water Insufficiency, characterized by loss of blood, Dai Yang (Floating Yang) syndrome, and bone-steaming tidal fever. Qi Deficiency is marked by a faint voice and shortness of breath resembling asthma. Blood Deficiency presents as dry, rough skin and spasmodic tendons and vessels.

8. Heart Deficiency involves Yang Deficiency with excessive sadness. Liver Deficiency presents as blurred vision, retraction of the genitals, tendon spasms, and timidity. Spleen Deficiency manifests as inability to use the four limbs, indigestion, abdominal bloating, and melancholy. Lung Deficiency results in faint respiration, dry and rough skin and hair. Kidney Deficiency may present as obstruction of the two orifices, incontinence, frequent emission, inability to bend or extend the waist and spine, bone soreness, flaccidity, and cold extremities.

9. Regarding pain: pain that is relieved by pressure indicates Deficiency; pain that rejects pressure indicates Excess.

10. Regarding Distension and Fullness: Zhang Zhongjing stated, "If abdominal fullness does not decrease, or decreases insignificantly, it should be treated with purgation. If abdominal fullness decreases intermittently but returns to its previous state, this is Cold, and warming herbs should be administered." The phrase "decreases insignificantly" means the central fullness is severe and does not subside at any time, indicating Excess distension, thus requiring purgation. Intermittent decrease in fullness occurs because there is no pathogenic Excess in the abdomen, allowing temporary relief. When fullness returns after decreasing, it is due to Spleen Qi Deficiency and Cold, thus requiring warming herbs. Warming methods inherently include tonification.

11. The chapters of *Nei Jing* (Inner Canon) all speak of Shen Qi. Shen Qi is Yuan Qi. If Yuan Qi is solid and complete, Shen and Jing (Spirit and Essence) will flourish, which needs no further explanation. If Yuan Qi is slightly deficient, Shen Qi will slightly depart; if Yuan Qi is severely deficient, Shen Qi will completely depart. When Shen departs, vital functions cease; how can one not fear this? *Su Wen: Mai Yao Jing Wei Lun* states: "The bright eyes are used to see all things, distinguish black and white, and judge length and shortness. To perceive long as short, or white as black, indicates the depletion of Jing (Essence)." Speaking in a low voice, only managing to speak a few words throughout the day, indicates that Qi has been seized. Disheveled clothing and speech lacking discrimination regarding good/evil or kinship/strangers indicates chaos of Ming (Clarity/Spirit). Failure of the granaries to store indicates failure of the gates (orifices) to control. Unceasing urine indicates failure of the Bladder to store. Retention of Shen brings life; loss of Shen brings death. The Five Zang organs are the strength of the body; the head is the mansion of Ming (Clarity); a drooping head and sunken eyes indicate that Spirit is being depleted. The back is the mansion of the Chest; a curved back and drooping shoulders indicate the mansion is failing. The waist is the mansion of the Kidneys; inability to twist or turn indicates the Kidneys are exhausted. The knees are the mansion of the legs; inability to flex and extend, and stooping while walking, indicate the bones are exhausted. Bones are the mansion of Marrow; inability to stand for long periods and trembling while walking indicate the bones are exhausted. Gaining strength brings life; losing strength brings death. These are the statements on Deficiency syndromes in *Nei Jing*; their meaning should be carefully examined.

12. It is easy to know that Deficiency requires tonification and Excess requires purgation. However, one must not fail to realize that Excess may contain Deficiency, and Deficiency may contain Excess. Thus, a severely Deficient disease may falsely present with vigorous symptoms, and a severely Excess disease may falsely present with emaciated symptoms. This distinction is crucial. For example, if a disease originates from emotional injury, irregular diet, overwork, sexual excess, or congenital insufficiency, once illness sets in, it may present with fever, constipation, Dai Yang, distension, false mania, or false macules, appearing as an Excess condition. However, the root cause is actually Deficiency. If the physician fails to investigate the etiology and uses purgation, the patient will surely die unnecessarily. Conversely, if external pathogenic factors remain latent in the meridians, or dietary stagnation accumulates in the Zang-Fu, or constrained rebellious Qi cannot disperse, or stubborn phlegm and blood stasis remain stored, prolonged illness may lead to emaciation, appearing as Deficiency. Yet, knowing the root pathology remains, one must treat the root. Mistakenly using tonification will only worsen the disease. This is what is meant by "Do not reinforce Excess, do not deplete Deficiency." Damaging the insufficient and benefiting the excessive leads to death caused by medical error.

Appendix: Hua Yuanhua's Discussion on the Essentials of Xu and Shi states: Diseases involve Deficiency and Excess of the Zang and Fu, Upper and Lower, each presenting differently, requiring deep contemplation. Bowel sounds, moving gas, cold feet and hands, food refusing to enter the stomach, untimely vomiting and regurgitation, haggard skin and hair, wrinkled muscles, dull ears and eyes, fragmented speech, panting while walking, and scattered spirit indicate Deficiency of the Five Zang organs. Palpating the pulse: slippery upon light pressure but faint upon heavy pressure, analyzed by location to determine the affected Zang. Additionally, sinking, small, weak, short, choppy, soft, and soggy pulses all indicate Zang Deficiency. Overeating, difficulty with urination and defecation, chest and diaphragm fullness, joint pain, heavy body, dizzy head and eyes, swollen lips and mouth, blocked throat, urgent gas in intestines, insensate skin and flesh, sudden panting and fatigue, intermittent chills and fever, simultaneous appearance of sores and carbuncles, erratic emotions, spontaneous flaccidity or hyperactivity, stagnant Qi, and unflowing Blood indicate Excess of the Zang. Palpating the pulse: vigorous upon both light and heavy pressure indicates Excess. Long, floating, rapid, hurried, surging, tight, wiry, and large pulses are all termed Excess. Analyze by meridian to determine the affected Zang. Headache, red eyes, hot skin and cold bones, relaxed limbs, congested Qi and Blood, recurrence of erysipelas-like tumors, swollen and painful throat, pain upon light pressure but relief upon heavy pressure, and normal diet indicate Excess of the Fu organs. Palpating the pulse: floating and large/excess indicates this. Itchy skin, muscular distension, undigested food, loose and uncontrolled stools, slippery pulse upon light pressure and level upon heavy pressure, indicate Deficiency of the Fu organs. Analyze by meridian to correct the timing. Chest and diaphragm stuffiness, fragmented head/eye pain, inability to eat, heavy brain and neck, obstructed throat, thick sputum and saliva, with sinking, firm, solid, and large pulses at the Left and Right Cun positions, indicate Upper Excess. Red cheeks, palpitations, trembling movements, hoarse voice, dry cracked lips and mouth, panting and weakness, pale face, swollen chin and jaw, with weak and faint pulses at the Left and Right Cun positions, indicate Upper Deficiency. Difficulty with urination and defecation, normal diet, heavy/sore waist and legs, umbilical and abdominal pain, with hidden and choppy pulses at the Left and Right Chi positions, indicate Lower Excess. Difficulty with urination and defecation, variable appetite, heavy waist and legs (as if sitting in water), difficult walking, rushing Qi upward, dangerous dreams, with slippery and choppy pulses at the Left and Right Chi positions, indicate Lower Deficiency. Patients with micro, choppy, short, and small pulses all fall under Lower Deficiency.

Note: Any incomplete aspects of Xu and Shi syndromes in this chapter are detailed in the "Xu Sun" (Deficiency Damage) section; they should be cross-referenced.