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TRIPLE BURNER (SANJIAO) with reference to treatment of Sjögren’s Syndrome by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, OR
The Name Sanjiao The meaning of the name triple burner, sanjiao, is unclear; “burner” gives the impression that this “organ system” generates heat, perhaps a lot of heat, but there is little evidence that it does that, rather acting as a conduit for heat transferred between other organs. An alternative interpretation of the name has been the “three burning spaces” which is somewhat better, in the sense that the location or zone of influence of this organ system can encompass three “heat sources” without itself being the generator of the heat (e.g., kidney, spleen, and heart yang). Even then, the term is not entirely suitable. One of the commentators on the Nanjing—only his name Yang is retained—said that jiao stands for yuan (origin; the response to question 66 of the Nanjing states that “”Origin is an honorable designation for the Triple Burner”), and that the sanjiao refer to the three origins: heaven, earth, and water. This seems a reasonable understanding; the upper jiao receives ethereal influences and may be likened to heaven; the middle jiao is associated with the earth element; and the lower jiao is associated with draining of water. By contrast, one of the Nanjing commentators, Hua Shou, said that “the triple burner represents the ministerial fire;” this opinion is not supported by others; Xu Dajun considered that the triple burner provided a passageway between the fire of the kidney and of the heart (the latter called ministerial fire). The triple burner is not physically oriented as such a conduit, but a major function attributed to it is keeping open the flow of qi, and that may be its function in relation to the kidney and heart fires. Triple Burner: an Organ with Name but not Form or Shape The organ systems of Chinese medicine do not always correspond with physical organs, and even when they do the functions attributed to the organ in the Chinese understanding go beyond what we are able to discover about a physical organ. For example, the spleen, pancreas, and digestive system, as well as the pervasive immune system components, might correspond in some way to the Chinese “pi” (spleen), which is said to lie above the stomach. The lack of a direct linkage of such Chinese multi-functional descriptions with modern observational organs has led to the use of terms such as “organ system” (which I tend to make use of) or even “orb”, so as to avoid becoming caught up in these relational difficulties. As a discussion of the triple burner progresses, the divergence in thought about the form and function of organs will become obvious. The sanjiao has been recognized in the Chinese system as having less physicality than the other defined organs. The liver (gan) does not closely correspond with the functions of the liver that we identify today, yet there is a substantive organ in the body which the Chinese can point to, and we would say it is the same one we call the liver. This connection can be made, in part, because the associated organ, the gallbladder, which has some different properties in the Chinese system than are otherwise recognized, also has a physical connection with the observed liver. The Chinese specify that the liver and gallbladder each have a form, shape, size, capacity, etc. Since the Chinese view is not highly dependent on the physical characteristics, but associated with conceptual aspects, such organ descriptions may be adjusted to fit the dogmatic features. Thus, it can be said that there is a color associated with the triple burner, but this has to do with the general principles, not observable features. The lack of shape and “physicality” of the triple burner was disturbing to many Chinese medical scholars, and so they interpreted some of the Neijing and Lingshu statements about the triple burner as pointing to a membrane that encased the entire torso, having three parts: one covering the chest cavity; one for the upper/middle abdomen; and one for the lower abdomen. However, such projection of a “form” seems out of touch with the primary descriptions of the triple burner, and represents part of the struggle to figure out its nature and qualities. Before the Neijing was produced, there were deemed to be 11 organs and 11 associated meridians, not 12. In the Nanjing, one can see that there is a divergence of explanations, suggesting either 5 zang and 6 fu or 6 fu and 5 zang, or 6 zang and 6 fu, the latter was finally settled upon, with the triple burner being the 6th fu, as described response to question 38 of the Nanjing. The organs that were in flux in these differing counts were the pericardium (heart protector) and triple burner. The Neijing unequivocallydepicts the triple burner as one of the “fu,” but it is an “orphan” organ; it is unlike the other zang-fu. The saying is that the triple burner has a name but not a form or shape (mentioned in question 38 of the Nanjing). Despite its lack of specific physical bounds, this organ system can be described in terms of location and functions. The Neijing was handed down to physicians and scholars and whatever it said was taken as the starting point for any further discussion; the Neijing is not organized like a modern textbook that attempts to be complete within its area of concern, and those relying upon the Neijing may need to intuit the intended meaning, taking into consideration the various statements it contains, some of them conflicting. Through acupuncture meridian theory and the basic concept of pairing that arises from yin/yang, the triple burner becomes associated with the pericardium, an organ system which is unlike any of the other zang in terms of functionality and form. The description of the triple burner as an “orphan” or “without form” does not imply any reduced consequence to its bodily influence, just a different nature. In the five element affiliations, there are five zang-fu; this pair (pericardium/triple burner) is outside the five, but placed along with the fire element, primarily via the close association of pericardium and heart. This association has contributed to the development of the concept that the triple burner is an organ that generates heat, or specifically channels heat, but that is not necessarily the case. My intention for the following discussion is to turn to a section of the Nanjing and the commentaries that have been recorded about it, as presented by Paul Unschuld (Medicine in China series; Nan-Ching: The Classic of Difficult Issues; 1986). I will diverge from the translated text only in backtracking from some of his translation terms: where he calls qi “influences” in an effort to be explanatory, I will go back to qi; he calls the fu “palaces” and I’ll return to fu, and so on. I don’t believe his efforts at clarification of these basic terms help us today as much as he hoped they would when he did this initial work thirty years ago. The commentaries about the Nanjing passages were originally made in Chinese but apparently lost; these were later recovered from Japanese translations, which were then put back to the Chinese. Many of the scholars commenting upon the Nanjing are not known, but some of them are. The commentator that seems to have the most relevant statements about the triple burner is Yȕ Shu. There are at least three “difficult issues” that include commentaries on the triple burner, I am focusing on the principal discussion, which is the first one, found in the 31st Difficult Question. Before proceeding, I’d like to relay one of the comments recorded about this “difficult issue” of the triple burner. It is by Liao Bing who says in response to the question posed about the triple burner: “The text of the Neijing is quite clear on this. Why should anybody make it the subject of a question?” In fact, the triple burner remains a subject of much debate. The Nature of the Triple Burner A model for the triple burner that came to be relied upon, at least as an image to work from, was a fermentation vat, such as used for making rice wine or beer. That fermentation process, developed in ancient times, was utilized in the Han Dynasty period (when the Neijing was written) to make health drinks that combined the alcoholic beverage with herbs. The fermentation vessels—and their contents—were cruder than what wine and beer producers use today. The brewers noted that at the top of the vessel, which was where the water and grain and yeast were poured in, there developed a fragrant mist that smelled like the wine or beer essence. At the upper part of the fluid was foam, made from the bubbling mixture that had some impurities contributing to generating the foamy top. Towards the bottom was a mixture in which solids were accumulating, and leaving a relatively clear liquid above them. The clear liquid would then be “tapped’ to provide the drinkable wine or beer. Thus, we will find a description of the upper burner involving “fog” or “mist”; the middle burner involving fermentation (rotting), foam, and collections of bubbles; and the lower burner involving clear liquid and turbid substance separating out as the dregs. This tripartite division of the vessel contents is not unlike the traditional description of qi that is modeled on the experience of the rice cooker: the steam above the cooking rice, which has the fragrance of the rice, is like qi; the lid of the pot is where the vapor condenses and falls back; the boiling rice is being transformed by the heat and water to make a soft, edible, and digestible product from the hard dry raw material; and the transformation of the rice and water take place by virtue of the fire that was stoked below the pot and which first heated the bottom portion. The main difference between these models is that the fermentation process, unlike the cooking process, does not require a significant amount of heat to be introduced, and the rice pot does not leave behind a waste residue from the cooking process. The Nanjing, 31st Difficult Issue The Nanjing is a series of questions with answers and the collection of 81 Difficult Issues is intended to be an examination and further explanation of the Neijing. Number 31 is about the triple burner. The question is: “The triple burner: how is it supplied and what does it generate? Where does it start and where does it end? And where, in general, are its disorders regulated?” The response begins: “The triple burner encompasses the passageways of water and grain.” This is a critical description because the fu are generally receptacles, often receiving materials that have been processed by other organs. The stomach, gallbladder, small intestine, and large intestine are all receptacles. The stomach is the only one of them which can be said to receive material (food and water) which has not been processed by another organ (there is some processing in the mouth, but not through action of a zang or fu). As we understand it today, the bladder receives its liquid waste from the kidney, but that was not the way it was understood during the time period of triple burner description. Rather, the bladder received liquids that were separated from solids outside the kidney, an organ system which was viewed, instead, as the reservoir of yin and yang, and a source of yin essence and heat. The various receptacles (fu) retain material for a while and then pass it on; so they are not long-term retention sites (as, for example, the kidney stores the essence or the liver stores the blood). The triple burner is indicated in this initial response as not being a receptacle, but a passageway; that is to say, unlike the other fu organs, it is not retaining material that is later to be passed on. The next part of the answer is: “It represents the conclusion and the start of the course of qi.” The “start of qi” being discussed here has three meanings: the first is that the qi from the food starts in the stomach, at the site of the middle burner, and the other is that the qi coming upward from the stomach eventually transmits to the organs to make the “25 passages” through the body during the day, and again 25 passages at night. The third implication is that the yuan qi (original qi, source qi) transmits through the triple burner to the rest of the body. “The upper section of the triple burner extends from below the heart downward through the diaphragm and ends at the upper opening of the stomach.” This is a very small segment. From the modern viewpoint, a passageway for water and grain that comes to the upper opening of the stomach would represent a portion of the esophagus. That is consistent with one part of the concept the Chinese scholars expressed: it is literally the entry point for water and food that is consumed. The passageway described here is also the means by which the qi flows upward from the stomach to the cavity of the chest, ultimately to interact with lungs and heart. To move upward, it has to pass through the diaphragm, which also has a “hole’ in it. We consider the diaphragm as having a function related to breathing; the Chinese saw it as a membrane keeping the turbid substances below, and only allowing the purified and ethereal substances to move into the chest cavity, by coming up through this hole. Chinese medicine descriptions generally start from top to bottom. This burner is thus described as involving a small section “from below the heart downward…” Functionally, though, it is not only for a downward movement, but also for an upward flow. “It is responsible for intake but not for discharge.” This is a passive function, of receiving, but there is no active function of discharging, such as the gallbladder squeezing out its contents. This upper burner serves as a passageway to and from the stomach. What passes into the upper burner is described by the commentators; Yȕ Shu characterized the upward migrating qi this way: “the upper burner resembles fog.” That is to say, the upper burner allows the passage of qi that resembles mist gently flowing out from the stomach and eventually entering into all the conduits; one could even say that the upper burner is this mist. Note that it is not “steam” but fog. Steam carries more heat and has a stronger upward flow; fog expands but has little force. This fog moves upward from the stomach so that it can then be circulated; it can be taken up by the conduits and make its passages around the body because it can rain down by action of the lungs or be dispersed upward by action of the heart. There is a burning place in the chest, the heart, a fire organ, and one commentator, Yeh Lin, has noted that the upper burner essences “move upward from below; they disperse in the chest and evaporate—like steam—into the skin and pores.” So, that portion which does not rain downward can continue upward. Ass the qi moves beyond the upper boundary of this burner (below the heart), as it reaches the heart, it is then heated and transformed to steam, rushing outward to the skin. When, as it is sometimes considered, the upper burner is depicted not as it is here, but as involving the entire area above the stomach, one can say that there is a burner, the heart, and that it “steams” the qi and moisture upward and outward, observed as perspiration. “The central section of the triple burner is located in the central duct of the stomach; it does not extend further upward or downward.” This is a very small segment, and is within the stomach; do not seek out a central duct from modern anatomy, for this is a conceptual term not an observable one; a commentator indicated that the liver was within this duct, so the visualization of this portion has been difficult. “It is responsible for the spoiling and processing of water and grains.” The Chinese daily experience of this kind of process would be a compost pile or a fermentation vat. These involve passive processes, one that simply requires having the raw materials and allowing some time. However, here is where the process involves some heat. Fermentation requires some minimal warmth, which is ultimately from the kidney and spleen yang; this is why physically cold food is of concern. Some warmth is generated from the fermentation process, which is thus self-maintaining. One must be careful to distinguish this warmth from the pathological condition “stomach fire.” The normal fermentative action is displayed by production of bubbles, which can yield gasses within the digestive system. One commentator, Yȕ Shu notes that the central burner “resembles foam.” “The lower section of the triple burner begins exactly at the upper opening of the bladder and extends downward.” This section appears to be within the bladder, but in fact, the bladder is within it. “It is responsible for separating the clear from the turbid portions.” This separation is a passive process that is like silt coming out of water that previously was flowing but is now held still. Xu Dajun explains: “Water and grains are normally present in the stomach simultaneously. They become dregs and move downward together. When they reach the large intestine, they enter the realm of the lower burner. The liquid portions are then strained off; they follow the lower burner and leak into the bladder.” The solid portion is then eliminated via the large intestine. “It [lower section of the triple burner] masters discharge, but not intake, and it severs as a transmitter.” This is the opposite of the upper burner, which is responsible for intake but not discharge. There is some active function here, but not strongly so; letting the urine flow outward is primarily a relaxation of the sphincter, with some contraction of the bladder wall. The lower burner also masters the discharge of feces, which similarly involves relaxation of the sphincter and some contraction of the intestinal wall. The Nanjing commentator Yang says “the triple burner masters the timely passage downward of the stools.” When defecation and urination are normal, they are quick and relatively effortless actions. A model is the Japanese bamboo tipping fountains, where water drips into a piece of bamboo, and once it accumulates past the half way point, the bamboo tips and dumps its contents, this is somewhat like this “transmitter” function. The waters flowing downward are not all eliminated; there are “ditches” that run to the legs, and some water is directed to the kidney where it steams upward to reach the lungs. The lower burner serves as a transmitter, in that it maintains the openness of the bodily passages: excess moisture is drained; the dregs are isolated and eliminated; channels are relaxed to allow free flow of qi. “Hence one speaks of a triple burner. Its qi is collected at the street of qi (qijie). Jie indicates a street. Yȕ Shu, notes that qi jie refers to points two cun on either side of the center in the hair of the lower abdomen (clarified as being at the hairline, that is, the top of the pubic hair; so on either side of CV-2, qugu). Such collection of qi, resting of flow of qi, is also attributed to the shu point of the triple burner, which is BL-22 (sanjiaoshu). The Nanjing text indicates acupuncture points where one can regulate each of the burners: between the breasts (CV-17, which is the meeting point of the qi and of several vessels, including the spleen and triple burner); on either side of the navel (lateral to CV-8), and one inch below the navel (CV-7), for the upper, middle, and lower burners respectively. These treatments are not the subject of the current paper. Giovanni Maciocia (“Resolving dampness and phlegm with acupuncture”) has given examples of points that might be selected to activate water transformation by the sanjiao, which is only one of its functions: Upper Burner: GV-26, CV-17, LU-7; LI-4; LI-6; TB-4; TB-6 Middle Burner: CV-9, BL-22, CV-12, ST-22, CV-11 Lower Burner: ST-28, CV-5, BL-22, BL-39, SP-9, SP-6, KI-7 He notes that TB-4 and BL-64 together move qi in the Triple Burner and activate water passages. Triple Burner Functions: The Ditches It is said that the triple burner, and especially the lower burner, represents the official responsible for maintaining the ditches. Unlike rivers, streams, and seas, all of which maintain themselves via their natural functions, ditches are provided as a means for transmitting the water to a desired place, passively directing and facilitating its movement. Ditches have to be maintained because they tend to fill in and clog up. Keeping the ditches open is what the triple burner must do, but how? One method is to open constriction points: relaxing sphincters or pores; reducing tension of muscles around transportation tubes; freeing up spaces in the joints. A term that has gained popularity in recent times is to “disinhibit” (herbs formally referred to as being diuretics are described as “disinhibiting” urination.) Acupuncture at points of the triple burner meridian, or at the other points that influence its activities, aid the opening action. Failure to maintain the healthy function of the triple burner can lead to frequent or deficient urination and to diarrhea or constipation; there may be cases where moisture and dryness separate or alternate, and where the moisturizing and drying actions of the organs fail to produce the beneficial physiological effects. The “opening” function of triple burner is not just for the “ditches”; it influences other body components. This action is revealed in the functions associated with the acupuncture points on the triple burner meridian. In Fundamentals of Chinese Acupuncture (1988; Ellis, Wiseman, and Boss), the following functional terms are included:
The opening, freeing, soothing, and quickening aspect of the Triple Burner is expressed in the response to Difficult Issue 66 of the Nanjing where it is said that “The Triple Burner is the special envoy that transmits the yuan qi. It is responsible for the passage of the three qi through the body’s five zang and six fu.” The function of “transmitting,” gives the impression of activity, but it is like the wires that are used to “transmit” electricity across great distances; the wires are not active, but are necessary for the transmission. Final Comments about the Sanjiao The important lesson about the triple burner is its relative passivity, its minimal “fire,” its starting point for the circulation of qi, its control over the discharge of waste (urine and feces), and the general function of disinhibiting. Scholars throughout the centuries since the Neijing was written have speculated upon the triple burner, and the descriptions of it run the full gambit from being somewhat passive, as I’ve described, to being central to the actions of the body. It must be kept in mind that passive functions are not unimportant or ineffective, just as an orphan organ without form is not without consequence. All the organs of the body play a role, ultimately, in all the functions of the body. Thus, for example, in a modern text Essentials of Chinese Medicine (1989; Xu Xiangcai) it is noted that with regard to fluid metabolism: “Normal production, distribution, and excretion of body fluid are inseparable from ascending or descending and incoming or outgoing movements of qi and the functional activities, transporting and transforming function of the spleen, dispersing and descending function of the lungs, water-regulating function of the kidneys, and clearance and regulation of water passage by the sanjiao.” The lack of a firm dividing line between these bodily components and their actions means that the primarily passive organs/functions and the primarily active organs/functions are integrated. The view of the triple burner presented here, based especially on the Nanjing and some of its commentators, ultimately may aid understanding of how this organ system can be addressed through acupuncture therapy to treat numerous diseases. Since the upper jiao receives water and grain from the mouth and the qi passes upward through the upper jiao to interact with the heart and lungs, it is reasonable to consider that the chest area represents the zone of action of the upper burner. Again, since the middle jiao operates in the stomach and sends its qi through the spleen, where it both nourishes the spleen and is acted upon by the spleen, it is reasonable to consider the upper abdomen, the area of the stomach and spleen, to be the zone of the middle burner. Finally, since the lower jiao affects the separation and discharge that occurs in the lower abdomen, which is the area of the kidney and liver and intestines, it is reasonable to consider the entire lower abdomen the zone of the lower burner. The ying essence derived from food, a process taking place in the middle burner with passage through the upper burner, will then rain down to the lower body; the yang essence, including wei qi, will rise up from the lower jiao, especially under the influence of the upward action of liver and kidney yang. All these essences circulate throughout the body, so one can only speak of an “origin” point in a relative manner. The triple burner, subtending the three zones and involving the processing of grains and water, is a fitting marker for the beginning movements of fog and mist, ying and wei, and the yin and yang passageways. Sample Application: Sjögren’s Syndrome Sjögren’s Syndrome (or disease) is characterized through modern investigations as a type of autoimmune disorder in which the immune system attacks, and eventually destroys, the glands that secrete tears and saliva. Hence, the two primary symptoms are dry eyes and dry mouth (other organs dependent on secretion of fluids can be impacted over time). This disorder primarily affects women (9:1 ratio over men), and mainly menopausal women. Since menopause is associated with dryness—affecting skin, hair, intestines, and vaginal wall—the experience of Sjögren’s Syndrome can be extensive dry conditions. Sjögren’s Syndrome can be of considerably different severity, with some people having mild symptoms that can be managed with relatively simple remedies for dryness, others having a remitting/relapsing condition in which there are periods of relative freedom from symptoms and then flare ups of more severe symptoms, and others have a persistent or worsening disorder with severe symptoms. Thus, from the modern medical viewpoint there are two primary targets for treatment: the immune system to protect against destruction of the glands, and the dried surfaces, to give relief from the symptoms and also prevent other damage due to dryness (especially of the eyes). TCM developed without a basic knowledge of autoimmune disorders, so utilizes a different way of interpreting the condition. A typical TCM response to Sjögren’s Syndrome is to focus on the dryness as a sign of insufficient yin, and treat with herbs that are moistening in nature. Such a response is further suggested when there are menopausal symptoms, which are generally attributed to deficiency of kidney and liver yin. Some of the yin nourishing and moistening herbs are considered especially suitable for the upper body, and these may be of special interest because of the dry eyes and mouth. The discussion of the triple burner is of interest in regard to a sophisticated approach to the problem, because of the “mist” rising up in the upper burner, and the reputation of the triple burner in regulating fluid distribution (namely, that the ditches serve as a starting point for transportation of water). In fact, some cases of Sjogren’s Syndrome are seen by TCM doctors as accumulation of dampness, perhaps accompanied by heat; the problem is one of improper separation and flow of the moisture, rather than its absence. The first part of the treatment plan involves making sure that the fermentation in the middle burner is fully active. The “grain and water” refer to food generally, but grain is considered an important part of the qi generating process, so if the patient has deleted or cut back significantly on grains, that could be a beginning problem. We usually don’t administer yeast (qu, or chu) to promote digestion, but there is a Chinese yeast that is commonly used: shenqu (shen-chu). Similarly, in Chinese medicine the chicken gizzard lining (jineijin) is utilized to aid the breakdown and metabolism of foods in the stomach. These ingredients, and digestive formulations made with one or both, may help promote this fermentation process. The other thing we use in modern times for this purpose is digestive enzymes. Then, with a healthy “foaming” and “fermentation” there will be the mist or fog that rises upward. This passage is controlled, in part, by acupuncture at CV-17. As the vapors reach the lungs, some of the moisture is rained downward. This is a good thing, but if the lungs are “cold” then there is too much of the fragrant qi going down. Platycodon is an example of a gently warming herb for the lungs that has an opening and diffusive quality. If the heart is too hot, then the mist is steamed rapidly to the surface, causing excessive perspiration. Herbs such as gardenia and coptis may be used to reduce the excess fire of the heart, and acupuncture of HT-5 or other draining points of the heart channel can be used. Astragalus may be of value in that it promotes the digestive function, warms the lung, and closes the pores. The clear qi that makes it past the lung (when it is warm enough) and past the heart (when it is cool enough) makes it to the head. Here, herbs and acupuncture that keep the channels open are of value. This is especially a role of the triple burner meridian. Of course, other meridians may be needled to address problems with stomach, spleen, or other involved organs. The approach of regulating the sanjiao for Sjögren’s has been suggested in recent literature. For example, the following abstract is from the Medical Acupuncture Online Journal: Wu Z, Wang H. Sjögren’s syndrome treated by regulating Sanjiao. International Journal of Clinical Acupuncture. 2000;11:39-42. Abstract: Sjögren’s syndrome, with dry mouth, eyes, and other organs, is a chronic autoimmune disease. Traditional Chinese Medicine (TCM) links it to deficiency of body fluid and exhaustion of Yin and blood. Detail of the symptoms, diagnosis, and TCM factors is given. Sanjiao is the water passage point, and points along this meridian are selected along with lung meridian and local points. If there are signs of heat, GV-14, LI-4, and LU-11 are added. For dry mouth and nose, CV-12, Stomach meridian and Spleen meridian points are added. If the lower jiao is involved (bladder, genitals), Kidney, Bladder, Stomach, and Large Intestine meridian points become important. The authors “have had good fortune” treating with acupuncture and a typical case is presented.
September 2010
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