The Historical & Anatomical Evolution of the Sanjiao: Through the Chinese Classics to the Modern Era
By Cody McBeath
Mired in controversy and debate, the Sanjiao’s anatomical mystery has pervaded the Chinese medicine landscape since the earliest writings of the Huangdi Neijing up till present day. Dubbed the ‘unique’, ‘unusual’, or ‘orphaned’ fu, the Sanjiao’s location, shape, and structure has confounded many Chinese medicine practitioners, mirrored in the conflicted streams of thought found throughout classical Chinese literature and subsequent commentaries that followed (1). Even today, the Sanjiao is a concept that is at the center of puzzled discussions of the modern era, leading to numerous assumptions pertaining to its Western anatomical and physiological equivalent. By contextually exploring the anatomical and physiological framework surrounding this ‘unique’ fu and its evolution through Chinese medical history, our understanding of the Sanjiao will be greatly enhanced.
Specifically, this paper will assess the Sanjiao over the course of three distinct periods. The first historical era will highlight ideas pertaining to the Sanjiao as cited in the Huangdi Neijing Suwen compiled during the Warring States period and early Han dynasties. Next, analysis of the Sanjiao during the late Han dynasties will focus on writings found in the Lingshu, the Nanjing, and commentaries from famed Chinese scholar- practitioners. Lastly, hypotheses and correlations from modern Chinese medicine scholars and Western surgical doctors will be taken into account and evaluated in comparison to prior historical interpretations (5).
The idea of systematic correspondence is ubiquitous throughout Chinese philosophy, with roots in thought, perception, and cultural attitudes toward phenomena. Chinese culture symbolically viewed the human organism, both anatomically and physiologically, as a mirror image of political and economic entities of the state. This system of correspondence conceptualized the Sanjiao as some sort of heating device within the human being (6). The birth of Chinese medical literature coincided with great technological advancements during the Han dynasty, specifically one of the most sophisticated and important economic functions of the time: ironworking and metallurgy. Hence, one of the reasons the Sanjiao is often referred to as the Triple Heater, Triple Burner, or Three Burning Spaces. In addition, during the late Han dynasty and last centuries BCE, inductive reasoning was the dominant force of cognitive thought (5). So, hypotheses on physiological function of the organism were surprisingly precise, while ideas on anatomical form were rather simple and rudimentary. Therefore, the Sanjiao was given a variety of functions, yet neglected in attempts to define its physical location. Also, due to the Sanjiao’s all- pervasive influence on the interior and lack of form, some scholar- physicians viewed it within a Taoist scope of perception, associating it with a kind of ‘formlessness’ (7). All in all, these ideas can be summarized by the often quoted line alluding to the Sanjiao as having “a name but no form” (3).
From here, there is now a contextual basis that informs our discussion of the Sanjiao through the history of Chinese medical literature. Naturally, the Huangdi Neijing is the foundation for starting our analytical dissection of this unusual organ. Chapter 8 of Neijing Suwen states: “The Sanjiao is the officer who is in charge of drains and irrigation: it is the place from which water pathways emerge” (7). The Neijing Suwen symbolically designates the Sanjiao with a functional role as an official in the Imperial state. As we will see, over the span of about three hundred years, the Neijing Lingshu develops ideas surrounding the Sanjiao to include not only its functional aspects, but begins its designation as a tangible entity.
After the writings of the Huangdi Neijing Suwen were compiled, the Nanjing, translated as Classic of Difficulties, was designed in a question and answer format with specific intentions of examining and clarifying contradictory theories and ideas found in the Neijing Suwen. This era of dominant cultural thought was highlighted by the works of the famed philosopher Wang Ch’ung, in addition to medical theorists such as Chang Chung- ching, Wang Shu-ho, and whoever was responsible for the works of the legendary surgeon, Hua T’uo (5). During this period, the Sanjiao had come to be viewed as a distinct entity, in large part because its lack of form was disturbing to many Chinese medical scholars. Thus, attempts were made to define the spatial location of its substrate based on the crude anatomical knowledge available at the time.
The following excerpt from the Chapter 18 of the Lingshu emphasizes this point: “The upper jiao comes from the pylorus to the throat above, distributing in the chest and reaching the armpit, and follows the branches of the taiyin as it travels. It turns to reach yangming, ascends to the tongue, then descends to the leg yangming. The middle jiao is also together with the middle of the Stomach. It comes from the Stomach under the upper jiao. The lower jiao separates around the intestines, water comes out from the lower jiao and permeates the urinary Bladder” (2). From this description, we can infer that the Sanjiao encompasses three cavities located in the trunk of the body and encapsulates specific internal organs located in each jiao. Located above the diaphragm, the upper Burner includes the Heart and Lungs. Between the diaphragm to the umbilicus, the middle Burner includes the Spleen and Stomach. Lastly, below the umbilicus, the lower Burner includes the Liver, Kidney, and Bladder.
Further, metaphorical descriptions of the energetic nature of the Sanjiao were created, suggesting that the Sanjiao was a key participant in the metabolic functioning of the organism, transmitting and assimilating energy through its conductive passageways (5). Another passage from Chapter 18 of the Lingshu describes this energetic, metabolic nature of the ‘three burning spaces’: “The upper Burner is like a mist, or fog; the middle Burner is like a maceration chamber, humidifier, pickling pot, or compost heap; the lower Burner is like a ditch or drainage canal” (1). Again, these ‘three burning spaces’ are correlated with specific regions of the trunk, with the upper, middle, and lower jiao corresponding to the physiological functions of the chest, abdominal, and pelvic cavities, respectively (2).
While the Suwen documents the symbolic functions of the Sanjiao, and the Lingshu furthers its physiological functions as a tangible entity, it is not until the compilation of various commentaries in the Nanjing that we begin to see conflicted discussions pertaining to the Sanjiao's specific anatomical substrate. From the 25th Difficult Issue, Yang states: “The Triple Burner has a position but no physical appearance”. In contrast, from the 31st Difficult Issue, Ye Lin describes: “It is a fatty membrane emerging from a tie between the kidneys. The Triple Burner is associated with the residence of the minister fire. The nature of fire is to ascend from below”. Also, from the 31st Difficult Issue, Huang Weisan mentions: “The Triple Burner encloses all the long- term depots and short - term repositories externally. It is a fatty membrane covering the entire physical body from the inside”. Finally, the most emphatic of scholarly commentators, Xu Dachun declares in the 38th Difficult Issue: “How could one say that it has no physical appearance! It is spread out all around the upper and lower [parts of the body], enclosing [all the other] long- term depots and short- term repositories. Its form differs from that of the five short- term repositories, each of which has its distinct body. Hence, its appearance cannot be defined [in the same way]. But to say ‘it has no physical appearance’ - - that is impossible” (6). It’s evident from the following passages that the Sanjiao constitutes a “membrane” enclosing the “long- term depots” and “short- term repositories”, and according to some, covers the entire physical body from the inside.
At this point, an interpretation of jiao may enhance our clarity of this fu. In the Cihai, the translation for jiao gives two entries: “1. special word for the Sanjiao; 2. muscles fail to fill the shell” (2). Therefore, we can imply that the Sanjiao represents the idea of an anatomical entity comprised of spaces that fail to fill the shell of the human organism. These spaces form large cavities not only in the trunk, but small spaces located throughout the extremities of the body. Looking back on a previous passage from Chapter 18 of the Lingshu, the Sanjiao follows the branches of the Taiyin channel of the Lung and Spleen and travels the Yangming channel of the Large Intestine and Stomach. Hence, this indicates that the Sanjiao's influence and location pervades the skin and flesh of the extremities as well. This is supported by Ding Jin’s reference to the treatise “Wu long jin ye bie lun” from the 25th Difficult Issue of the Nanjing: “The Triple Burner emits Qi to warm the muscles and the flesh and to fill the skin” (6). Also, the Sanjiao does not have a fixed, defined physical shape or size of its own, whereas the other fu are ‘repositories’ that can be measured, have their own shape, form, color, and have the ability to be filled and emptied. This implies that the Sanjiao does not occupy a concrete position of its own, but rather takes its form based on structures it encapsulates within the human frame. In Chinese medical theory, it is known that the Sanjiao is said to contain and regulate the physiology of the zang- fu organ network. The structural, three- dimensional network of the Sanjiao is not restricted to a particular area of the body, but rather mediates the physiology of the body trunk, the zang- fu organs, the muscles, the skin, and the spaces between these entities. By reviewing the classical texts, one can see that the all- pervasive network encompassed by the Sanjiao supports its physiological functions as a pathway for Qi, a pathway for fluids, a site for Qi transformation, and a passageway to distribute transformed materials and discharge turbid Qi (2).
The last stage of our analysis will extend to the beginning of the twentieth century, examining the Sanjiao based on modern scientific thought and its association with concrete anatomical structures and physiological systems. This period is characterized by hypotheses and reductionist assumptions pertaining to its Western medical equivalent. Many of these scientific inferences analyze the Sanjiao through the lens of a scientific materialist. By aligning the Sanjiao with specific structures and systems of the Western medical establishment, the hypotheses fail to account for ancient cultural conceptions and Chinese medical theories. For example, the modern physicians, Bachmann and Schmitt believed that the Sanjiao can be identified with the endocrine system. However, this assumption lacks validity because pathology of the Sanjiao includes neuralgia and neuralgic affections. Thus, these symptoms cannot be attributed to dysfunction caused by the endocrine system (5). In addition, some modern acupuncture practitioners have likened the Sanjiao to the lymphatic system. While similarities between the Sanjiao and the lymphatic system include Wei Qi circulation/ immunity, Yuan Qi/ body fluid circulation, removal of Turbid Qi/ waste, and assistance in transforming of food and grain in the Spleen/ digestion via lacteals, the relationship doesn’t account for the vastness of the Sanjiao's connective network and distribution of small spaces throughout the extremities. However, hypotheses that relate the Sanjiao to the connective tissue/ fascial network and interstitial fluid spaces do seem to take into account the vast energetic conductivity and spatial distribution that permeates the human body (4). In Chinese medical theory, these smaller spaces are known as couli. In clause 1-2 of the Jinkui Yaolue Fanglun, author Zhang Zhongjing states: “Cou is a place of the Sanjiao where there is a passageway of circulation and convergence of yuan qi and zhen qi, filled by blood and qi; li is texture of skin and zangfu” (2). According to Qu Lifang and Mary Garvey in their article, The Location and Function of the Sanjiao, li historically meant “the markings in jade or the fibers in muscle; as a verb it meant to cut things according to their natural grain or divisions” (2). The interpretation of li as “cutting things according to their natural grain” bears striking resemblance to the description of Western surgeons cutting incisions along the fascial planes to reduce scarring (4). Further, Donald Harper, a scholar who studied the Mawangdui medical manuscripts, interprets li as “network” or “network of vessels”, conveying the idea of li as a pattern or system. Taken together, couli can be interpreted as space and texture within a network or system. From an anatomical standpoint, the couli are correlated with the texture of the skin, muscles, zang- fu, and the interstitial spaces that exist between these physical forms. Therefore, the couli takes on the shape and size of the spaces they fill or the structures that they surround. Together, the couli form a matrix that spans upper and lower, interior and exterior. The spaces, textures, and interstices of the couli are emblematic of the Sanjiao’s membranous nature and passageways permeating the body.
By reviewing and comparing the Sanjiao through classical Chinese medical literature with modern Western hypotheses as to its anatomical equivalent, the Sanjiao's evolution can be understood with enhanced clarity. From a formless ‘unique’ fu, to a membranous anatomical substrate composed of small spaces, to its relationship with the fascial network and interstitial spaces, the Sanjiao has been contextually framed based upon the period of the inquirer. For the curious scholar, practitioner, or layperson, returning to classical sources will continue to reveal the mysterious, enigmatic nature of the Sanjiao.
(1) Dharmananda, S. Triple Burner (Sanjiao) with reference to treatment of Sjögren's Syndrome. http://www.itmonline.org/articles/triple_burner/triple_burner.htm. Published October 2010. Accessed November 13, 2017.
(2) Garvey, M. & Lifang, Q. “The Location and Function of the Sanjiao". The Journal of Chinese Medicine. 65 (2001) 26-32. Print.
(3) Grossman, G. The Medical Acupuncture Web Page. Cultural Reference for Increased Understanding of the San Jiao. https://med-vetacupuncture.org/ english/articles/sanjiao.html. Accessed November 13, 2017.
(4) Keown, D. The Spark in the Machine: How the Science of Acupuncture Explains the Mysteries of Western Medicine. London: Singing Dragon; 2014.
(5) Porkert, M. The Theoretical Foundations of Chinese Medicine: Systems of Correspondence. Cambridge Mass.: MIT Press; 1985. pp. 158-162.
(6) Unschuld, P.U. & Bian, Q.: Nan-Ching the classic of difficult issues. Berkeley: University of California Press; 1986.
(7) Wang, J-Y. & Robertson, JD. Applied Channel Theory in Chinese Medicine: Wang Ju-Yis Lectures on Channel Therapeutics. Seattle: Eastland Press; 2008.
By Trish Cooper
The Earlier Development of Taijiquan
As with most ancient art forms, the history of Taijiquan begins with a mythical story. In 1200ce there was a young peasant boy by the name of Chang Chun-Pao. He spent his childhood in a Shaolin Monastery where he mastered Chan Buddhist meditation and Shaolin Martial Arts. At age 15, he left the monastery in search for a teacher that could help further his studies.
In his later years, Chang Chun-Pao settled in Szechuan where he spent his days meditating and contemplating the art of fighting. Through careful observation of nature, and meticulous practice, he attempted to combine the best quality of each animal into his martial arts. He soon realized the answer he was searching for could not be found in any man or animal. He must follow the Tao, and in order to create the ultimate fighting style he must incorporate the principles of nature. The rest of his life was dedicated to the creation of an effortless martial art that encompassed the principles of nature. After a life time of study, Chang Chun-Pao wandered off into the mountains, never to be seen again.
As legend has it, Chang Chun-Pao’s fighting style was passed down to Chen Village several hundred years later. One of Chang Chun-Pao’s alleged students (Jiang Fa), wandered into Chen village and trained Chen Changxing (1771-1853). This is where myth and history collide, and where Taijiquan originated. (1)
Chen Family History of Taijiquan
Martial arts in the Chen family existed long before Jiang Fa’s visit. Their style of fighting was developed from Shaolin Boxing, and from fighting techniques acquired during their time in war. A garrison commander by the name of Chen Wangting (1600-1680), played a key role in the development of Chen style martial arts, and helped build the foundation that Taijiquan would later be derived from. Chen Wangting was a 9th generation member of the Chen family and an exceptional martial artist. He chose to further his practice by developing a style of martial arts that incorporated Yin-Yang theory and the Five Elements. This system of martial arts continued to evolve and with the help of Chang Chun-Pao, became the art of Taijiquan. (1)
Chen and Yang Style Taijiquan
Shortly after Chen Changxing was trained by Jiang Fa, he taught his new system of fighting to a young man named Yang Luchan(1799-1872). Yang Luchan was the first outsider to learn the Chen family system of martial arts, and was the first to teach Taijiquan outside of Chen Village. Yang Luchan went on to train people of noble roots how to fight, and later trained his own grandchildren. (2)
His grandsons, Yang Chengfu(1883-1936) and Yang Shaohou(1862-1930), went on to teach two contrasting styles of Taijiquan. Yang Chengfu was a gentle man who developed a slow, gentle form of martial arts. It consisted of large, soft movements that were done at a slow and even pace. This form was later coined Yang style, and is the common form taught around the world. Yang style Taijiquan is great for developing balance, maintaining health, and calming the mind. (2)
Unlike his brother, Yang Shouhou had an aggressive demeanor and very few disciples. He practiced the style his grandfather had taught him but used small, forceful movements. Rather than maintaining a slow pace, Yang Shouhuo would use a mixture of slow and fast movements, and would fa jin (issue power) throughout the form. This style of martial arts is now referred to as Chen style Taijiquan, and is considered to be closer to the original martial art of Chen Village. (3)
By Trish Cooper
Gua Sha is an age-old healing modality that involves applying pressure and scraping the skin with smooth strokes. In Traditional Chinese Medicine, “Gua” means to scrape and “Sha” refers to the red skin rash (petechiae) that rises up as a result of the scraping (Suttie E., 2013). By creating friction along the skin, the therapy increases circulation of blood along the surface. The body’s immune system then recruits cells to pick up the blood and break it down. Increasing the breakdown of hemoglobin within the blood has been shown to up-regulate an enzyme called heme-oxygenase-1 (HO-1). This is where the real magic begins! HO-1 has both anti-oxidant and anti-inflammatory properties, meaning it can support neuronal health and help reduce inflammatory symptoms. For this reason, Gua Sha has shown to be useful in treating an array of conditions including muscle and joint pain, colds, fever, lung issues, and chronic active hepatitis B. (Nielsen A., 2019) (Uttara B, et al. 2009).
From a TCM perspective, gua sha is said to open the pores, which allows the release of wind, heat and pathogens. It can also improve blood circulation, move blood stasis, and break up fascial adhesions. This is important because stagnation is a common source of pain and illness, which is why improving circulation is essential for reducing symptoms. Once smooth flow of blood has been restored, the body can efficiently send its defenses to repair the damages caused by stagnation.
Whether you have stagnation or deficiency, the “sha” that comes up during treatment can provide diagnostic information for the practitioner. For example, light pink can signify blood deficiency, while fresh red can indicate heat or an acute condition. If the sha appears to be dark red or black, that points to deep stagnation and chronicity. As the sha begins to fade, it can change to a yellow color signifying dampness or a light green which represents toxicity. So next time you get gua sha, take a look at your petechiae to better understand what is happening in your body!
Five Theories on the Mechanisms of Acupuncture: How it Works from a Western Physiological Perspective
By Cody McBeath
As acupuncture has emerged into mainstream medicine as a treatment option for a wide variety of conditions and disorders, it has garnered a great deal of attention from the western medical community. Curiosity, investigation, and scientific inquiry into this ancient modality has steadily increased ever since New York Times reporter James Reston received pain relief after an appendectomy during President Nixon’s visit to China in the early 1970’s. (https://www.nytimes.com/1971/07/26/archives/now-about-my-operation-in-peking-now-let-me-tell-you-about-my.html). Since this time, many theories have been proposed as to the exact physiological mechanisms behind acupuncture’s efficacy. Thus, as scientific inquiry and research studies steadily increase, so too have the mechanisms of acupuncture become elucidated. What has been found is that acupuncture has three main effects: it restores homeostasis, it reduces inflammation, and it relieves pain. The scope of this article is to look at five specific theories that have been proposed and review their findings on acupuncture’s mechanism of action in brief detail.
1. Neurotransmitter & Endorphin Theory
Acupuncture needle insertion stimulates the release of specific neurotransmitters, such as serotonin, norepinephrine & GABA, and endogenous opioids, such as endorphins and enkephalins. It has been proposed that the release of these neurotransmitters and endogenous opioids lead to the analgesic, pain reducing, mood improving qualities often experienced during acupuncture sessions. Studies have shown that the use of low frequency electro-acupuncture leads to an increased release of endorphins and enkephalins that act to block our perception of pain and relieve stress. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC442119/)
2. Gate Control Theory
Acupuncture regulates our pain physiology system. We have two types of pain receptors (A- fibers & C- fibers) that carry pain signals to our spinal cord and central nervous system. Needle stimulation may inhibit the transmission of pain signals from A- fibers during acupuncture treatment. The basis of this theory is rooted in competition of pain signaling to the brain. Thus, when acupuncture activates receptors at a distal point on the body, these other pain- signaling mechanisms are “gated out” and unable to elicit a pain response.
3. Circulatory/Blood Chemistry Theory
Acupuncture affects the circulatory system by dilating the blood vessels through nitric oxide release, ultimately increasing blood flow and oxygenation to local tissues and muscles. The insertion of needles creates a “micro-trauma” to the body that increases the amount and migration of white blood cells to the area that helps improve immune function, removes metabolic waste, and reduces inflammation in the local area. As blood flow is increased, more nutrients and inflammatory mediators are circulating which leads to a faster healing response time after injury.
4. Growth Control Theory
It is believed that acupuncture points have a high correlation to areas on the body known as organizing centers that form during our embryonic development. Further, it has been shown that acupuncture points are areas where there is a high level of electrical conductivity as opposed to adjacent tissue. So, by stimulating an acupuncture needle we are regulating this growth control system of the body that is responsible for cellular adaptation and tissue growth and regeneration. (https://www.ncbi.nlm.nih.gov/pubmed/11388686)
5. Connective Tissue Model
While the previous theories represented biological models of acupuncture, this theory presents a bio-mechanical mechanism of acupuncture. This model looks at the interaction between the muscles, connective tissue, and fascia, in response to the acupuncture needle. By stimulating what are known as trigger points (taut bands of connective tissue) or the muscle spindle (motor nerve innervation into muscle belly), acupuncture can release these tight bands of tissue and re-establish proprioceptive communication between the muscle and the central nervous system. When the strands of fascia wrap around the needle, leading to what’s called tissue-needle coupling, the body elicits a response to allow these areas to relax. This communication between the muscle spindle, or motor point, and the central nervous system assists in resetting muscle tone and increasing muscle strength.
The research into the mechanisms of acupuncture show us that there isn't one unifying theory as to why it works. Rather, the efficacy of acupuncture is seen when we assess it from a panoramic lens. The stimulus of an acupuncture needle signals various responses from the body, as the circulatory, endocrine, muscular, and nervous systems all seem to be involved. Due to the physiological response from these multiple systems, we can begin to explain how and why acupuncture can be effective for such a wide variety of medical conditions. As research into acupuncture evolves, a greater clarity will begin to emerge as to the exact "how" and "why" that underlies acupuncture's magic.