Six Confirmation Diagnosis in Context: The Six Cosmic Qi (liu qi) and the Six Stages of Qi Transformation (liu jing)
By Heiner Fruehauf
The six conformations represent another system of symbolic methodology that is of great importance for the practice of classical Chinese medicine. Its origins are related to both yin-yang and five phase element theory, yet it is often the primary diagnostic modality that certain practitioners, especially those trained in the lineage of Shanghan lun herbalism, choose to utilize.
Numerology is an important aspect of ancient symbol science. As such, numbers were always used to symbolically represent a specific quality and/or dimension. While the number five is generally related to the earth element and the realm of the manifest, the number six most often signals a relationship to heavenly source energy. The Neijing devotes two entire chapters (9 and 68) to the “sixdom” of Heaven. Chapter 9 summarizes: “Heaven works in intervals of 2 x 6 in order to form the grand cycle of the year.” This is why certain Han dynasty texts, such as the Xinshu (New Writings), utilize the concept of “six elemental phases” (liuxing; in this context best translated as “the six behavioral modes”) to describe heavenly virtues, in contrast to the more manifest reality of organs, colors, smell, etc.–phenomena that are generally described via the five element system of symbolic representation.
The earliest definition of the six cosmic qi (liuqi) appeared in Daoist texts from the pre-Neijing period, and are listed as follows: yin, yang, wind, rain, darkness, and brightness. Around the second century B.C.E., these terms evolved into the now standard Neijing definition of the six cosmic influences, which later became the template for the six stages of bodily qi transformation utilized in the revolutionary diagnostic mode of Zhang Zhongjing’s Shanghan lun: wind (feng), heat (re), damp (shi), fire (huo), dryness (zao), and cold (han).
These six qi can be understood as another way to describe and differentiate the concrete influence of cyclically changing cosmic forces. As such, they represent the fundamental physiological influences which initiate the totality of nature’s patterned movements on earth. They are, in medical terms, the righteous qi of the sky. The following passage from Neijing chapter 67, entitled “The Great Treatise on the Evolutionary Movements of the Five Phases,” illustrates how the six qi represent a vital spectrum of physiological information contained in the universe:
“Yellow Emperor: ‘Is the earth underneath the Sky?’
Qibo: ‘The earth is underneath humans, but is suspended in space.’
Yellow Emperor: ‘How is it that it does not fall down?’
Qibo: ‘The Great Qi of the universe holds it suspended in space. The dry qi dries it, the heat qi steams it to maturity, the wind qi makes it move, the damp qi moistens it, the cold qi makes it firm, and the fire qi warms it. Wind and cold, therefore, are below, dry and heat are on top, damp is at the center, and fire roams in between. Thus the six qi penetrate the earth, and in this way the transformation of matter is initiated from the void.’”
According to the quantity of yin qi or yang qi involved, they were further differentiated into lesser yang (shaoyang), major yang (taiyang), and yang brightness (yangming), and respectively, lesser yin (shaoyin), major yin (taiyin), and exhausted yin (jueyin). (See Neijing Suwen, (chapter 66, “The Great Treatise on the Original Patterns of Universal Movement”):
” Yellow Emperor: ‘What does it mean when it is said that there is more or less qi, and consequently a prospering or decay of material form?’
Gui Yu Qu: ‘Both yin qi and yang qi come in different quantities, and therefore we talk about the three yin and the three yang.’”
It is evident from this and other passages of the Neijing that the six qi constitute an evolutionary stage of the concept of yin and yang. Chapter 6 of the medial classic, entitled “Yin yang lihe lun” (Treatise on the Opening and Closing Movements of Yin and Yang), is devoted in its entirety to explaining how the theory of yin and yang benefits from being differentiated into the system of the “three yin and three yang” (sanyin sanyang), as the six qi–and also in a microcosmic context, their associated channel systems–were originally referred to. The closing passage of this chapter summarizes as follows:
“ Therefore, the way in which the expansion and closure of the three yang functions occurs is as follows: taiyang opens, yangming closes, and shaoyang serves as the hinge. These three channel functions must work together in unison, by covering each other tightly and thus preventing the (yang tendency of) floating away. Their mission is to work as One Yang… Similarly, the way in which the opening and closure of the three yin functions occurs is as follows: taiyin opens, jueyin closes, and shaoyin serves as the hinge. These three channel functions must work together in unison, by covering each other tightly and thus preventing the (yin tendency of) sinking away. Thus their name is One Yin.”
In other words, to demonstrate the smooth and eternal nature of the opening and closing movement of yin and yang, ancient cosmologists differentiated the yang, or expansive aspect of this cyclical motion, into three functional aspects, comparing the entire yang phase to the process of opening a door. In this process, the opening of the door is described as taiyang, while the built-in control mechanism which ensures that the door does not continue to open forever—in essence, reigning in the opening function–is described as yangming; both of them rotate around a central hinge function called shaoyang. Similarly, the entire yin or contractive phase is compared to the closing of a door, with the initiation of the closing motion being described as taiyin, while the built-in control mechanism which ensures that the door does not continue to close forever is described as jueyin; both of them pivot round a central hinge function called shaoyin.
The classics encourage us to look at these six categories as names for different stages of a giant heavenly breath, which directly influence weather patterns, plant growth, and disease development on earth. This is the basis of the most complex and sophisticated part of ancient Chinese science, called wuyun liuqi theory. Every year has a different qi in predominance, having different reverberations in the realms of the material and the physiological. In the language of the Neijing, at the source of heavenly influences is the invisible root qi of Heaven that broke up into “six source qi” (liuyuan); and at the surface there is the celestial dial that was divided into six segments in which take place as the six successive stages of transformation (liujing). As a result, the following associations between the invisible root influences (ben) and the observable surface phenomena (biao) were established:
- Jueyin (Extreme Yin) wind
- Shaoyin (Minor Yin) heat
- Taiyin (Major Yin) damp
- Shaoyang (Minor Yang) fire
- Yangming (Yang Brightness) dryness
- Taiyang (Major Yang) cold
The six qi and their associated stages of energetic transformation are in turn closely linked to the five heavenly movements (wuyun), which represent the totality of celestial movements classified via the positions of the five planets. The six qi are thus related to the five phases, and their concrete associations are as follows:
- Jueyin Wind Wood
- Shaoyin Imperial Fire
- Taiyin Damp Earth
- Shaoyang Ministerial Fire
- Yangming Dry Metal
- Taiyang Cold Water
Zhang Zhongjing (fl. 2nd century A.D.) utilized this ancient method of describing and predicting the intricate weather patterns of the universe to create the classic diagnostic approach that is known today as “six stage (or layer, or pathway) differentiation” (liujing bianzheng). In what is perhaps the most important act of individual creation in the history of Chinese medicine, Zhang synopsized his clinical experiences in the original six stage classic that later became divided into two parts, the Shanghan zabing lun (The Treatise On Disorders Caused By Cold and Miscellaneous Disorders). Like all fundamental concepts of Chinese medicine, Zhang’s approach was guided by the ancient conviction that all microcosmic processes follow energetic precedents that play out in the macrocosmic sphere. Based on the Neijing theory that the five celestial movements and the six qi are the invisible root of all material transformation in nature that can be observed, measured, and classified through the observation of surface phenomena, and that consequently the interrelated movements of the five organ networks are at the root of all physiological and pathological processes that can be observed and classified through inspection of the body’s surface, Zhang created a highly effective clinical system of diagnostics and therapeutics.
The Shanghan lun is organized into six sections. Each section covers the diagnosis and treatment of various imbalances in the respective stage of physiological qi transformation. The “Taiyang Chapter,” for instance, describes the various manifestations of Taiyang Syndrome, which is a blockage of the body’s physiological processes that are of taiyang quality (like the sun: outwardly dispersing, pore opening, surface warming), take place in the taiyang layer (body surface), and closely associated with the taiyang channels (bladder and small intestine) which run along the outermost boundaries of the physical body (both the small intestine and bladder channels are located on the most lateral—outward/yang of the body’s external surfaces).
Zhang Zhongjing’s ingenious system marks the first time that certain symptoms and pulses lead to diagnosis, which directly leads to a specific treatment—the dream of every Chinese medicine practitioner. The format, described through the example of its opening chapter, taiyang, is as follows: taiyang, in correlation to macrocosmic forces with the same name, is described as a certain physiological force in the microcosm of the body. When this force gets pathologically obstructed, often by excessive macrocosmic forces of the same quality (taiyang syndrome, for instance, is caused by external invasion of taiyang cold), then a syndrome pattern with the same name occurs, i.e. taiyang syndrome. It was part of Zhang Zhongjing’s genius to create highly precise material markers in the form of symbolic key pulses and symptoms. In this context, the term symbolic means that while there is a literal dimension to these signs and symptoms, a given syndrome is by no means limited to the display of these symptoms. Since theoretically all diseases can be classified within the six conformation system, there are thousands of potential symptoms, making it impossible for Zhang to mention them all. Therefore, he had to pick some that capture the essence of a specific syndrome, whether somebody actually displays them or not. The recognition of this essence remains mysterious for many practitioners until today, and needs to be fully unlocked in the direct transmission from teacher to disciple in actual clinical context.
The defining symptoms of Taiyang Syndrome, for instance, are directly deducted from the physiology and location of the taiyang process of qi transformation. According to the crucial line of the “Taiyang Chapter” in the Shanghan lun they are: “floating pulse, stiff neck, and fever accompanied by chills.” A floating pulse indicates that the body’s energy is most active in the body’s surface layer where the damage has occurred. The standard symptoms of stiff neck and headache indicate that the energy flow in the taiyang channels is obstructed. The exemplary selection of the neck and head (the place where both channels converge) reflects the symbolic communication style of a time when the technicalities of writing were tedious, and only the most representative information was written down. Back pain (along the bladder channel) and shoulder pain (on the small intestine channel), for instance, are also typical taiyang symptoms, but are not mentioned in the Shanghan lun’s basic syndrome definition. Furthermore, the exemplary symptom of feeling chilled makes reference to a) the original meaning of taiyang transformation on a cosmic level, where a binding relationship between cold root qi and taiyang phenomena at the surface is stipulated, and consequently b) the fact that Taiyang Syndrome is basically caused by an overexposure to external cold, or by an insufficiency of internal taiyang (surface warming) activity, or by a combination thereof.
The designation of a disease as a Taiyang Syndrome, therefore, yields a host of useful information that goes beyond the methodology of the five phase approach: 1) which of the body’s physiological processes is disturbed? The one that compares to the power of the sun, moving up and out, warming the surface of the body, and regulating the opening of the pores; 2) what is the basic quality of the energetic influence that originally caused the disease? Cold, either internally (not enough outwardly radiating warmth) or externally (overexposure to cold influences); 3) how does the disease most typically manifest itself in physical symptoms? Via acute sensations of cold; 4) what is the depth of the disease? Surface layer; 5) in what channels systems do most of the symptoms occur? The bladder and small intestine systems; 6) which acupuncture points that are located on, or in close proximity to, the respective channel network could be considered for treatment? BL1, GB 20, BL10–BL28, SI 3, SI 11; 7) which herbs that primarily enter these channels should be considered as lead herbs in treatment? Guizhi (cinnamon twig) and/or Mahuang (ephedra).
The body’s physiological taiyang function manifests on the body surface, especially along the spine, as it is primarily here that the protective taiyang qi (derived from pre-natal qi transformation) circulates. External cold generally stimulates this transformative process (root/cause relationship)—hence the healthful hydrotherapy practice of cold dipping to boost circulation—causing the healthy body to feel as if warmed by “sunlight” (taiyang). However, if the body’s defense layer gets overwhelmed by an onslaught of cold yin forces, then the taiyang process of transformation gets interrupted, the circulation of protective qi gets obstructed, and chills and other taiyang symptoms appear.
In conclusion, one should also note that similar to the five phase elements, the six conformations do not only refer to physiological functions and their pathological potential. They are associated with specific body layers, where the respective forces of qi transformation are most active. Starting on the outside, the depth level is as follows: Taiyang (surface), shaoyang (half inside, half outside), yangming (inside), taiyin (deeper inside), shaoyin (even deeper inside), jueyin (deepest inside layer). Syndromes of the yang layers tend to symptomatically express as heat on the surface, since there still is enough energy to express that way, while the yin syndromes are generally the chronic yang deficient diseases that are deeply withdrawn inside the body and tend to not manifest as obviously at the surface, such as cancer.
In accordance with six conformation theory, the qi transformation from one layer of the body to another thus occurs from outside to inside, and all physical processes start from taiyang. The “Taiyang Chapter,” therefore, occupies more than 50% of the entire volume of the Shanghan lun. Taiyang, by the definition encoded in its name, is at the very surface of the body’s three yang systems. It is the external gate of the body’s zhengqi (righteous qi), and is also the gate through which pathological qi first enters the body. If pathological qi overpowers taiyang, then the body’s “opening” momentum becomes disturbed, the circulation of surface yang stagnates, and disease occurs. From this perspective, similar in Ayurvedic medicine, it is the best preventive method to guard the surface, and prevent pathogens such as wind or cold to enter into the taiyang layer, from where it would invariably go deeper and cause more chronic and difficult to treat problems.
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