Lymphatic System and San Jiao

Traditional Chinese Medicine (TCM) is a medical system with a long history. TCM is not a static medical system but a developing whole of theories, ideas and practices. Through the ages TCM have experienced influences from different ideas and practices. Without question todays biggest influence for TCM is western medicine and the sciences related to. In the present era, TCM practitioners not only need to master the ancient knowledge but also should be able to combine it with the knowledge of western medicine. Only in this way it is possible to achieve inter-comprehension between the theory of TCM and the science of western medicine, in order to manage a holistic treatment for the patients. Only in this way the patients can receive the highest quality holistic aid. This has been the task of the doctors in all times; to combine the best of the past and present medical knowledge, no matter where it comes from, in order to give the best treatment that can be achieved. In the presented thesis an effort is made to explore the relationship of San Jiao with the lymphatic system. San Jiao is not the lymphatic system, first of all because the concept of San Jiao is quite bigger than the lymphatic system. But after reading this thesis will become obvious that the lymphatic system could be regarded as a part of San Jiao. Lymphatic system was never mentioned in the ancient or the recent books of TCM with the name that is referred to todays western medicine. But the functions of it were described from ancient times. Eventually it is just the same human holism to be described; the only difference between TCM and western medicine is the way to comprehend it.

Although the lymphatic system may be considered part of the circulatory system, we will consider it separately because its functions are so different from those of the heart and blood vessels. The lymphatic system is responsible for returning tissue fluid to the blood and for protecting the body against foreign material. The parts of the lymphatic system are the lymph, the system of lymph vessels, and lymphatic tissue, which includes lymph nodes and nodules, the spleen, and the thymus gland. The system of lymph vessels begins as dead-end lymph capillaries found in most tissue spaces. Lymph capillaries are very permeable and collect tissue fluid and proteins. Lacteals are specialized lymph capillaries in the villi of the small intestine; they absorb the fat-soluble end products of digestion, such as fatty acids and vitamins A, D, E, and K. Lymph capillaries unite to form larger lymph vessels, whose structure is very much like that of veins. There is no pump for lymph but the lymph is kept moving within lymph vessels by the same mechanisms that promote venous return. The smooth muscle layer of the larger lymph vessels constricts, and the one-way valves prevent backflow of lymph. The lymph is going back to the blood to become plasma again. The lymph vessels from the lower body unite in front of the lumbar vertebrae to form a vessel called the cisterna chyli, which continues upward in front of the vertebral column as the thoracic duct. Lymph vessels from the upper left quadrant of the body join the thoracic duct, which empties lymph into the left subclavian vein. Lymph vessels from the upper right quadrant of the body unite to form the right lymphatic duct, which empties lymph into the right subclavian vein. Flaps in both subclavian veins permit the entry of lymph but prevent blood from flowing into the lymph vessels. In order to understand San Jiao the theory of Zangxiang should be stated. The term Zangxiang appeared for the first time in Huangdi Neijing. Even though the theory of Zangxiang was established on the basis of life experience and clinical practice there is a need of connecting the concept of internal organs with todays anatomy and physiology. TCM way of understanding the internal organs is through observing the physiological and pathological phenomena, as well as the therapeutic effects. By making the same observations through western medicines point of view a connection or at least an attempt could be made. In this way it would be clear that some conceptions of Zang Fu organs are in the range of todays anatomical and physiological understanding.

Fu term appear in Han era texts but with two different metaphorical contexts. First is the meaning of storehouse and the second meaning is palace. Actually both meaning can be used in different instances. It is quite difficult to know which meaning, if any, an author may have had in mind when he was using the term Fu. Fu is a place where important things are received temporarily to be handled, assigned and transmitted. In Su Wen Fu is described to enclosure, house and shelter to something important. Triple energizer or San Jiao is a Fu organ. The 11th chapter of Su Wen mentions that the triple burner, the stomach, the large intestine, the small intestine, and the urinary bladder are generated by the Qi of heaven. Their Qi resembles heaven. Hence, they drain and do not store. This quality is related to Fu. These are locations where nothing can stay for long, but where things are transported and drained. San Jiao was first mentioned in the biographical account of the lives of Bian Que and Chunyu Yi in the Shi Ji of the early first century B.C. and in Huangdi Neijing. From the other hand Hippocrates was the first to mention the lymphatic system in fifth century BC. In his work "On Joints," he briefly mentioned the lymph nodes. Rufus of Ephesus, a Roman physician, identified the axillary, inguinal and mesenteric lymph nodes as well as the thymus during the first to second century AD. The first mention of lymphatic vessels was in 3rd century BC by Herophilus, a Greek anatomist, who incorrectly concluded that the "absorptive veins of the lymphatics", by which he meant the lacteals, drained into the hepatic portal veins, and thus into the liver. Findings of Ruphus and Herophilus were further propagated by the Greek physician Galen, who described the lacteals and mesenteric lymph nodes which he observed in his dissection of apes and pigs in the second century A.D. San Jiao or Gu Fu is composed of three parts. In Su Wen it is written that the chest is separated from the abdomen by a horizontal membrane plane, that is, the diaphragm. Whatever is above diaphragm regards to be the upper energizer or Shang Jiao. Su Wen also states that at the center of abdomen, indicating a dividing line between the upper and the lower abdomen is the navel. The part of the body which is between the diaphragm and the line of the navel is considered as middle energizer or Zhong Jiao and the part of the body below the navel line is the lower energizer or Xia Jiao. Together with liver Qi, the Triple Burner controls the smooth and proper movement of Qi in all three burners: in the upper burner, Qi goes up and exits and is under control of the lungs; in the middle burner Qi goes up and down and in and out and is under the control of stomach and spleen; in the lower burner, Qi mostly descends and exits and is under the control of the kidneys, bladder and intestines. The Triple Burner assists all the other organs in their functions an, in particular, it makes sure that all passages of Qi or fluids are open, that the various types of Qi flow smoothly, that the Yuan Qi emerges from between the kidneys and assumes different forms in different places and that wastes are excreted smoothly. Some readers believe that San Jiao is possibly parallel to ancient European notions of a calor innatus, an innate source of warmth responsible for changing temperatures in the human organism. Chapter 8 of Su Wen mention that the triple warmer takes the office of dreading water in the watercourse of the whole body, it takes charge of the activity of the Qi, of the body fluid and the regulation and the dredging of the fluid. According to TCM San Jiao, from the one hand is an independent functional system but from the other hand is based on the morphological structure and the physiological function of the internal organs. This morphology and physiology that San Jiao is based on have been described from the TCMs point of view. Now there will be an attempt to get the connection of San Jiao with an important morphological and physiological structure, the lymphatic system. TCMs first main function of San Jiao is that it serves as a transmitting system through which the primordial Qi or Yuan Qi is circulating. Also as is it written in the 8th chapter of Su Wen San Jiao is the opener of Channels and passageway of water originates in it. San Jiao connect the bodys different parts as the lymphatic vessels being everywhere in the body connecting the different tissues. Immunity and San Jiao

Yuan Qi derives from kidney Qi of the parents during pregnancy, which is closely related to congenital essence. Yuan Qi is distributed to the whole body in order to exert normal physiological functions. Even though not all the functions of Yuan Qi can be related to the functions of the lymphatic system some of them can. It is known that Yuan Qi shares the same functions of Qi, for example the protecting function and the transforming function. Qi can protect the body from the pathogenic factors and can prevent from falling ill. Also it can fight against the pathogenic factors and promote the healing of the disease. This is similar to the idea of immunity which is closely related to the lymphatic system. Above that TCM also states that San Jiao is in charge of Qi. The Qi is in charge of immunity. In addition the transforming function of Yuan Qi upon Zong Qi at the upper energizer will produce the Zhen Qi. Zhen Qi will be divided to Ying Qi and to Wei Qi. Ying Qi as it is said in Su Wen 43 it follows the vessels upward and downward, penetrates the five depots, and connects the six palaces. Chapter 52 of Ling Shu describe Ying Qi as a refined energy that runs inside the vessels in the contrary with Wei Qi that flows outside the vessels.At the 9th chapter of Su Wen it is said that Ying Qi passes through the vessels and all the core organs. The spleen Su Wentestifies is the basis of grain storage. It is the main location of the Ying Qi. A later author supplemented this statement, adding five Fu organs to the spleen. Hence, in todays textus receptus, it is said that the triple burner, the spleen and the stomach, the large intestine, the small intestine and the urinary bladder are the basis of grain storage. They are the place of location of the Ying Qi. Now Wei Qi is considered the most important Qi for the protection of the organism, again to what western terminology defines as immunity. At the 43 chapter of Su Wen it said that Wei Qi is the violent Qi of water and grain. This Qi is fast and unrestrained and cannot enter the vessels. Hence, it moves inside the skin and in the partings of the flesh. Wei Qi is mainly distributed to the surface of the body for the protection of the organism. One of the lymphatic system main functions is to protect the body against pathogens and other foreign material. This is immunity. Immunity may be defined as the ability to destroy pathogens or other foreign material and to prevent further cases of certain infectious diseases. This ability is of vital importance because the body is exposed to pathogens from the moment of birth. Immunity has two major categories: genetic immunity and acquired immunity. Genetic immunity is conferred by our DNA, and acquired immunity is developed or acquired by natural or artificial means. TCM has only one type of immunity but this is not a significant difference. The aging of the lymphatic system is apparent in the decreased efficiency of immune responses. Elderly people are more likely than younger ones to develop shingles, when an aging immune system cannot keep the chickenpox virus dormant. They are also more susceptible to infections such as influenza and to what are called secondary infections, such as pneumonia following a case of the flu. Autoimmune disorders are also more common among older people. The incidence of cancer is also higher. Malignant cells that once might have been quickly destroyed remain alive and proliferate. All these are related to the aging of the lymphatic system and the decreased immunity. Aging in TCM brings the same results. TCM describes it in different way; the kidney Qi of old people become deficient, so Yuan Qi related to it, is decreased and that results to improper function of Wei Qi. Improper function of Wei Qi is related to decreased immunity. It is only the theoretical explanation that difference. Deficiency of Yuan Qi and Wei Qi would also bring tendency to disease. Both physiologically and pathologically the immunity functions of lymphatic system and San Jiao are related. Body Fluid Circulation and San Jiao The most important organs for water metabolism are the lung in the upper energizer, the spleen in the middle and the kidney in the lower. San Jiao is the connection pathway between these organs. To understand the connection of the San Jiao with the lymphatic system at this part, an observation of the pathologic phenomena should be made. The main pathologic condition of the San Jiao serving as a water passage is the retention of fluid and edema. From the other hand the main pathologic condition of the lymphatic system is again retention of fluid and edema. Lymphatic obstruction is defined as a blockage of the lymph vessels or nodes that drain fluid from tissues throughout the body and allow immune cells to travel where they are needed. Lymphatic obstruction results to lymphedema, which

means swelling due to lymph related pathology. There are many causes of lymphatic obstruction but the most common is infections with parasites such as filariasis, injury, radiation therapy, skin infections such as cellulites, surgery and tumors. In western societies, one of the most common causes of lymphedema is mastectomy and underarm lymph tissue removal for breast cancer. This can cause lymphedema of the arm in 10% - 15% of patients. This occurs because the lymphatic drainage of the arm passes through the axilla and lymphatic tissue in the axilla is removed during mastectomy. This is a pathological situation that makes it easy to understand the connection of lymphatic systems fluid promotion function with San Jiaos fluid promotion function. The lymph tissue that is removed during mastectomy can be considered to be body fluid pathway from TCMs point of view. From the moment that this pathway is removed then pathology emerges in the form of edema. This is the main symptom of these patients no mater you observe this from western or TCMs aspect.

Body Fluid and Lymph The lymphatic system main function is to return tissue fluid to the blood stream to maintain blood volume. So there is a close interconnection between blood and lymph. Lymph should be considered from TCM as an important part of body fluid. Lymph in western medical physiology is the name for tissue fluid that enters lymph capillaries. Filtration in capillaries creates tissue fluid from blood plasma, most of which returns almost immediately to the blood in the capillaries by osmosis. Some tissue fluid remains in interstitial spaces and must be returned to the blood by way of the lymphatic vessels. Without this return, blood volume and blood pressure would very soon decrease. Lymph when formed is a watery clear liquid with the same composition as the interstitial fluid. As it flows through the lymph vessels and nodes tends to accumulate cells (particularly lymphocytes) and proteins. In TCM there is no definition for lymph, but what is called lymph today could be considered as a part what TCM regards as body fluid.

According to TCM blood is connected to body fluid in various ways. The same relationship exists between blood and lymph in the western medicine. TCM describes that body fluid and blood moistens the viscera and the whole body; on top of that physiologically are transformed to each other. Lymph, which can be considered as body fluid, is created from blood plasma and finally will empty in the blood stream into the left and right subclavian vein. TCM says that body fluid after its formation from the transformation of food and water is transported first to the vessels and then flows with blood to the whole body. Then part of the body fluid in the blood extravasates from the vessels and flows outside the vessels to moisten and nourish the viscera and the body. At the same time part of body fluid outside the vessels enters the vessels again to participate in the production of blood. TCM describes a dynamic balance between body fluid inside and outside the vessels. Also blood and body fluid can transform and supplement each other. This idea is exactly the same with the facts described from western medical physiology. Blood supplies nutrients to the tissues and collects back the waste products that they produce, which requires exchange of respective constituents between the blood and tissues. This exchange is effected through interstitial fluid that the blood forms. Interstitial fluid is the fluid that occupies the spaces between the cells and acts as their immediate environment. The blood and the surrounding cells continually add and remove substances from the interstitial fluid. Water and solutes can diffuse between the interstitial fluid and blood, and thus both are in dynamic equilibrium with each other. Interstitial fluid forms at the arterial end of the capillaries because of higher pressure of blood, and most of it returns to its venous ends and venules; the rest (about 1020%) enters the lymph capillaries as lymph. Lymph and body fluid is the same thing with different name and their relationship with blood resembles in both TCM and western medicine.

San Jiao and Digestion

TCM reports that the San Jiao is closely associated with the spleen functions of transformation and transportation, particularly the metabolism of incoming food. This can be again related with the lymphatic system. Lacteals are specialized lymph capillaries in the villi of the small intestine; they absorb the fat-soluble end products of digestion, such as fatty acids and vitamins A, D, E, K and promote them to the blood stream at the subclavian veins via the thoracic duct. This is the most important link of lymphatic system to digestion. TCM says that after food is transformed by spleen and stomach the body fluid is transported through San Jiao first to the vessels and then with the blood to the whole body. Western medicine describes water being absorbed by intestine mainly travels in portal venous blood and little is delivered to the body by a lymphatic pathway after absorption. Chapter 36 of Ling Su mentions that when the triple warmer fail to transport the water and cereals there will be distention in the lower warmer and edema. Once again we observe a physiological and pathological link between the two systems.

Conclusion

San Jiao being a wide complex concept makes it relatively easy to be connected with western oriented anatomical systems and tissues. The connection of San Jiao with the lymphatic system is quite obvious. If a lymph vessel block, then the result is edema. The same will take place if the water pathways of San Jiao are blocked. Dysfunction of lymphatic system will bring serious immunity insufficiency. The same will be if the movement of Yuan Qi and Wei Qi through San Jiao is impaired. These examples derived from human pathology and analyzed from both western medicine and TCM point of view makes a clear connection between San Jiao and lymphatic system. The conclusion is that lymphatic system is not San Jiao but an important part of it.

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Ioannis P. Dimitriou M.D. Physiotherapist, Msc TCM