Qi Dynamics and the Six Phases
The Elements of Vitality and Constitution
Zhang Zhongjing, Han dynasty master physician and author of the Shanghan Zabing Lun
Annotated and commented on more than any other classical text (possibly including even the Neijing), accomplished physicians from Sun Simiao to Ye Tianshi have all emphasized the role of Zhang Zhongjing’s Han dynasty master work as the cornerstone of all clinical practice. Its format of six phasic diagnosis, dynamic exposition of shifting patient presentation and integrated formula composition distinguished the Shanghan Lun as entirely unique from all other fāngshū 方書[1] for nearly 1500 years until Wu Jutong completed the diagnostic circle, employing a similar format in Differentiation of Warm Disease (溫病條辯 wēnbìng tiáobiàn). Much like human beings, these classical texts possess body, energy and spirit that to remain fully intact depend equally as much on the spoken instruction and living example of master practitioners as it does on the physical record of the written word. This vital transmission of experience, much of which was never committed to writing, has therefore fallen greatest victim to the inevitable redaction of passing centuries and shifting cultural paradigms. Like all great classical works, a recreation of the ontological richness and depth of the Shanghan Lun cannot be reached solely by way of a literal reading of the lines alone. Repetitive deep readings must be accompanied by contemplation of the shifting qi dynamics that fill the space between the lines, like the soft tissue necessary to hold the bones of this corpus of wisdom firmly in place and imbue them with mobility and flexibility. Based largely on a ten-year clinical dialogue with my mentor Dr. Li Xin, this work-in-progress represents an attempt to make a small piece of the rich transmission of practical Shanhan knowledge available to a wider audience of practitioners.
We must approach the traditional discipline of Shanghan study first armed with a solid foundational view of Chinese medicine that will prevent the autopilot of our modern cognitive habits from kicking in. As we all know, Chinese medicine is a holistic science based on direct perception of the underlying principles governing the arising and development of all natural phenomena, human life among them. It teaches one to know the normal, or natural, state of things in order to understand that which is abnormal (以常知變yǐcháng zhī biàn). In the sphere of medical practice, this translates to an approach based on the physiological state of the patient, taking into account the current state of postnatal energy as shaped by unique prenatal physical and spiritual characteristics. Much like an investment analyst would consider the initial capital, various assets, current business operations and managerial competency of a given company to determine the likely trajectory of its stock value, we must begin by appraising both form and energy as rooted in the individual (形氣相得，以人為本 xíngqì xiāngdé, yǐ rén wéi běn).
“Appraising both form and energy as rooted in the individual.”
This represents a marked departure from our modern medical think, where pathology has been granted center stage and the question of how a person’s unique individual life situation, both past and present, may significantly contribute to the development of a given disease has been largely dismissed. Diagnosis is applied like a label that directly equates you with your disease, like a hat to wear, in many cases, until the day you die. You can imagine how this can be potentially problematic when faced with a work such as the Shanghan Lun that when read at face value, appears focused only on specific aspects of pathology from beginning to end. The opportunity is there to consider only the physical level by matching symptoms with formulas that often creates over simplified diagnostic equations along the way. “Chronic neck pain? Must be a Gegen Tang condition,” or “Having palpitations? Zhi Gancao Tang treats that.” And in doing so, we slide right into that well-greased groove of pathology focused medicine, forgetting to pause to appreciate the life space within which the condition is manifesting, namely the human being and their life situation, so that when treatment is ineffective, or worse, when a patient has an adverse reaction, we scratch our heads and begin to wonder how things went wrong.
To appreciate the full scope of meaning represented in the six phases we have to refer back to some basic principles of qi dynamics as outlined in the Neijing, mainly those of the six environmental factors (corresponding to heaven, exterior, yang, and the non-material) and the five elements (corresponding to earth, interior, yin, and the material). The six phases may be used in diagnosis to describe both the prenatal and postnatal aspects of the individual as they represent: 1) the dynamic natural forces that formulate the physical and spiritual constitution of an individual; 2) a simple delineation of the current functional capacity of yang qi and the characteristics likely to manifest as primary functionality enters each of these phases. Envision the six phases in their original capacity, as delineations of the incremental stages of yang qi emerging from the realm of the unmanifest enroute to full physical manifestation. This cycle is also a foundational element of the traditional calendar, beginning at the winter solstice as the original seed of yang energy begins to progressively expand toward spring. This initial period is known as the Jueyin wind wood phase (厥陰風木 juéyīn fēngmù) and represents the primal drive of life itself, pure motion without form or material substance. It is the power by which all of material form is catalyzed into action, as the biblical creation story goes “in the beginning was the Word”, the breath of life. In human physiology, it is responsible for the transformative processes of all metabolism and circulation. Wind is pure movement and the transmission of information, the “dredging and coursing” action of the wood energy, represented in the Liver, that largest of glands that is hard at work digesting and repairing during the winter solstice hours of the night.
This Jueyin yang dynamic is tempered and wed with form with the arising of the next phase of the cycle, the Shaoyin emperor fire (少陰君火 shǎoyīn jūnhuǒ). Embodying the dynamic interplay of opposites – water and fire, Kidney and Heart, this is the foundational level of the organization of all organic life. Corresponding to the water element, the Shaoyin represents substance without form, like crude oil that amasses deep in the interior recesses of the system in places such as the marrow, brain and sex organs. Collectively referred to as jing essence, it is both the blueprint and raw building material for the entire body that takes shape around its receptacle of the Kidney. At this level, yin water is imbued with the yang spirit of light, consciousness and sense of purpose in the fire of the Heart. This fire is the cool clarity of a mind deeply embedded in the flow of life, both intimately engaged with the informational environment of Spirit and yet fully present within the material body. Just as the Emperor’s connection to Heaven and his resulting edicts were embodied in every aspect of the healthy activity of his kingdom, the Spirit must remain open to the limitless potential of the transcendent and in mindful connection with the imminent processes of earthly life (traditionally known as the domains of the 魂 hún and 魄 pò, respectively). It is one key aspect of the Shaoyin’s role as the pivot or hinge of the yin phases.
Together the Jueyin and Shaoyin levels represent the cooperative functioning of the deep blood level, which anatomically correlates to the microcirculation of the pelvis, low back, chest and head. The raw wind power of the Jueyin drives the material processes of life in accordance with the directives of the Spirit as it flows and expands through the Shaoyin level. At this deepest level, life is a balanced dynamic between the accumulation and storage of essence at the Shaoyin level and the unrelenting drive of the wind from the Jueyin level. Given the importance bestowed to the Kidney as the root of all life, there exists some confusion as to which of these levels is truly the “deepest” in diagnostic terms. Think of the body as a cup filled with water. The water represents the vital energies of the Shaoyin within the container of the physical body. Now imagine you were to gradually exhaust this water by drinking it through a straw, as is roughly the case as an individual moves deeper and deeper into states of depletion. In the final split second any remaining fluid would be drawn upward into the straw with that last slurp. This is much the same as the Shaoyin and Jueyin phases of pathology. “Normal” physiology is rooted in the rhythmic expansion and contraction of the jingqi of the Shaoyin as in the activity of day and the passivity of night, but life may go on even after all the water has been sucked from the glass. Unmoored from its anchor, the Jueyin wind energy will continue to circulate chaotically through the “straws” of the channel body, divorced from the material and spiritual regulation of the Shaoyin. This explains the potentially explosive and highly contradictory presentation of the full Jueyin state; it is life with one foot in this world and one foot in a world unknown.
Just as a river depends on its banks to shape its path to the sea, the formless substance of the water element requires the structure of the earth element to give it shape. Naturally then, the Taiyin damp earth phase (太陰濕土 tàiyīn shītǔ) arises next in this progression of manifestation as the earth that controls water.[2] It is the fertile soil from which all things grow and to which all things eventually return. This maternal capacity to accept, nourish and transform represents the healthy physiological functions of the yin earth. It is referred to as the opening of the yin phases, again indicating that continued motion within the dense material substrate of the muscle layer is of utmost importance. As yang qi goes into decline and transformation wanes, the Taiyin is prone to all manner of physical and psycho-emotional accumulation. Yang qi is unable to extend upward through this middle strata above ground into the yang phases when the Taiyin is laden with excessive fluids. Instead, begins the process of downward sinking and stagnation.
Imagine then the Shaoyang minister fire (少陽相火 shǎoyáng xiānghuǒ), or yang wood phase, as the tender shoots of early spring that emerge from the healthy soil of the Taiyin. Now reaching toward the heavens, this phase represents the initial external movement of yang qi. This is also in keeping with the traditional elemental designation of the minister fire as the combination of, or existing in the space between, earth and fire. It is a yang fire of activity and physical action that while strong in its position as the executor of the emperor’s vision, will always remain subject to the directive of the brightness and clarity of the conduit of Heaven that is the Heart and the Shaoyin. Therefore, the Shaoyang will have difficulty taking on life independently, achieving that full opening of the yang phases and is prone to retreat inward to the safety of the yin phases when under stress. This is in keeping with the Shaoyang designation of the pivot of the yang phases, a role clearly reflected physically in the various schema of mixed heat and cold as well as psychologically in alternating extroverted social behavior and withdrawn introverted contemplation or moodiness. This is even reflected in the placement of the Shaoyang channels on the side body, with the Gallbladder channel trajectory proceeding forward and back multiple times as if stitching together the yin and yang sides of the body.
The gradually building yang qi next reaches its most stable expression in the Yangming dry metal phase (陽明燥金 yángmíng zàojīn). It is the only system that is designated as rich in both qi and blood, owing to the unique capacity of the Stomach as the yang organ of the middle to take in physical matter directly from the outside world and nourish the 12 channels, further evidenced by the macrocosmic orbit and the Lung channel originating in the middle burner. Naturally optimistic and beneficent, this positively charged state of yang earth is comfortable in the manifest world, endowed with both the energetic resources and the stability to outwardly achieve much. This is further complimented by the descending, gathering gesture of the dry metal energy of the autumn harvest, manifest in the characteristic Yangming clarity of mind, assertive action and the unmatched capacity to “digest” the experiences of life, in all their various forms. Synonymous with the action of the pò 魄, the Yangming is the confident, affable and adaptable energy of outer worldly involvement and accomplishment.
Yang qi reaches its final stage of outward expression in the Taiyang cold water phase (太陽寒水 tàiyáng hánshuǐ). Here now, the cup is being filled closer and closer to overflowing and so we see sweat as one of the primary concerns at the physical level in this phase. But sweat is actually reflective of the deeper ongoing energetic dynamic of the expanding heat energy of the interior and the holding capacity, or “cold”, of the exterior. It is important to understand the traditional view of cold as much more than the physical experience of low temperature; it is the force of contraction that drives the return flow of metal energy into the interior. Cold is responsible for our very first experience of self-identity as we emerge from the uniform state of integration in the womb into the shockingly frigid independence of our infant body. In healthy balance, it helps us maintain appropriate physical and energetic boundaries. This ebb and flow through a selectively porous energetic surface represents the meeting point of our internal world with that of the physical, energetic and social environment of our life.
Understood in this context, we can begin to appreciate the six phases as essential pieces of the complete journey of embodiment. Each and every one of us is composed of these six aspects of being in varying proportion that although set into motion with a particular blueprint at birth in the form of our prenatal inheritance, is prone to some degree of change throughout our lives. And this is what the vision of Chinese medical diagnosis teaches us to see: an individual human being with a body and mind that reflects each of these six aspects in a unique fashion, currently based in one of these six energetic stages of the unfolding of life, either moving forward toward a fuller expression of possibility or retreating backward into greater limitation. Zhang Zhongjing’s work is by no means exhaustive; he has provided us key examples from which we can recreate the complete vision of this process. It allows us to appreciate the unfolding of the struggle between the vital qi and pathogenic factors much like we would a play: each phase provides the background setting and context within which the lead role of the patient is now acting out the specific physical and psychological symptoms of a particular scene.
This opens us up to a greatly enhanced understanding of the title phrase “cold damage”. Pathology in the Shanghan model can be simply understood as progressive or sudden movement in the opposing direction of life’s unfolding due to the shifting balance of vital energy and the contractive forces of our internal and external environments, from the fullest outward manifestation at the Taiyang back toward the chaos of the unmanifest at the Jueyin. As in any true tale of Chinese medicine, the two sides of the coin of life are fully represented in the text. The detailed exposition of patho-dynamics in the Shanghan Lun also points to the most extant model of qi dynamics in the Chinese medical cannon.[3] Traditionally, the text would be approached from the two perspectives of using the presentation to determine the formula (以證測方 yǐzhèng cèfāng) and using the formula to determine the presentation (以方測證 yǐfāng cèzhèng). Ultimately, these critical reading strategies come together to create a singular unified image of the shifting manifestations of yuan qi, combining the background of each phase with the presentation described and/or formula given to create a clear image of the individual and their energetic state for which it would be most appropriate. Through this contemplative process of stepping through the text into the reality of an actual embodied state, we prepare ourselves to recognize that situation when it is mirrored back to us in a patient interaction. It moves us away from the separation inherent in trying to match symptoms or indications directly with formulas, and into a diagnostic flow where the information we require is readily available during an intake because we have trained our senses to recognize the essential image of each phase and eventually, each individual strategy. In this manner, perhaps we can draw ourselves a step nearer to the artistry of a master such as Zhang Zhongjing. It can help remove much of the guesswork of clinical Chinese herbalism, create more consistent patient outcomes and ultimately establish a practical paradigm that progressively draws us closer to its ancient source.
[1] Formula compilations
[2] In the annual 五運六氣 wǔyùn liùqì cycle, the Shaoyang minister fire follows the Shaoyin emperor fire, correlating to the warm fire of spring to early summer and the scorching fire of mid to late summer. This article follows the traditional order of the six phases according to the functional level of vital qi as laid out in the Shanghan Lun.
[3]In classical diagnosis, the 病機 bìngjī, or “patho-dynamic”, is the direct result of the incomplete or unbalanced action of the 氣機 qìjī, or “normal” state of physiological activity.