Vol 16, #3 - The Vital Importance Of The Triple Energizer In Traditional Chinese Medicine

Vol. 16, #3

The Vital Importance Of The
Triple Energizer In Traditional Chinese Medicine
Steven K. H. Aung, MD

ABSTRACT
In Traditional Chinese Medicine (TCM), the Triple Energizer (TE) is viewed as the central body cavity, Fu/Yang, in contrast to the more solid Zang/Yin viscera and their vital energetic pathways or meridians and their acupoint "gates" of Qi (vital energy) circulation. The TE contains all the major Zang Fu organ meridians. It is a hollow Fu organ (along with the gallbladder, stomach, small intestine, large intestine, and urinary bladder) that is connected to the solid Zang organs (heart, lungs, spleen, liver, and kidneys) by way of the pericardium. There is no biomedical equivalent of the TE (except perhaps to generally refer to the major internal organs). The multidimensional functions of the TE pertain to the transformation, purification, and distribution of air, food, and water. The upper TE regulates respiration and the circulation of protective Qi, the middle TE governs the Qi of the various digestive system functions, and the lower TE controls the Qi of the absorption of fluids/nutrients, waste disposal, and sexuality/reproduction. This is the central energetic structure and strength of human health and well-being.
KEY WORDS
Traditional Chinese Medicine, Medical Acupuncture, Energetics, Triple Energizer Meridian and Acupoints, Integrative Medicine

INTRODUCTION
Every fully experienced and empowered practitioner of Traditional Chinese Medicine (TCM), with respect to its theoretical aspects and clinical modalities, is aware of the vital importance of the Sanjiao. Also known as the Three/Triple Heater/Burner/Warmer/Energizer, the Sanjiao is regarded in the TCM Zang Fu organ<=>meridian system as the central hollow body cavity, Fu/Yang - in contrast to the more solid - Zang/Yin - viscera and their vital energetic (Qi) pathways, or meridians, and the various acupoint gates of Qi circulation. The Sanjiao is viewed as a major internal organ encompassing the gallbladder (GB), stomach (ST), small intestine (SI), large intestine (LI), and urinary bladder (BL). It is perceived to be directly connected to the Zang; namely, the heart (HT), lungs (LU), spleen (SP), liver (LR), and kidneys (KI), by way of the pericardium (PC).¹"San" denotes the number 3 and "jiao" represents a warm, hollow, burning, energizing space; taken together, the concept of "Sanjiao" alludes not only to the three great Taoist, Buddhist, and Confucian streams of Chinese philosophy but also, clinically, to the central physiological functions of a living, healthy human being (Figure 1).

Figure 1. A Characterization of the Triple Energizer: calligraphic artwork created by Steven K.H. Aung

In the late 1980s, the World Health Organization (WHO) standardized meridian€acupoint nomenclature and the Sanjiao is now appropriately referred to as the Triple Energizer (TE).2 Both the TE and the PC have an anomalous but excellently powerful status in the TCM Zang€Fu system. The TE is the central body cavity that contains all the Zang Fu organs which especially pertains to the Fu, while the PC is regarded as the Zang "shield," surrounding and protecting the Heart (Shen/Spirit) as well as the gate of emotional and spiritual ventilation.

There is no biomedical equivalent of the TE except to refer generally to the major internal organs, the diagnostics and therapeutics of which entail several biomedical specialties and subspecialties. In TCM theory and practice, the upper TE (thorax) is a region of "fog/mist" pertaining to the LU, HT, and PC; the middle TE (abdomen) is a region of "froth/foam/bubbles" relevant to the SP, ST, and GB; and the metaphor of the lower TE (pelvis) is that of a "swamp" or "drainage ditch" pertaining to the SI, LI, LR, KI, and BL. While it might appear anatomically that the LR belongs in the middle TE, it is perceived to be located in the lower TE due to its close affinity with the KI. The terms "upper," "middle," and "lower" are of equal significance with respect to the holistic function of the TE within the Zang Fu organ system. Each of these containers is equal.

The multidimensional functions of the TE relate to the transformation, purification, and distribution of air, food, and water with respect to harmonious Qi (vital energy) flow. The upper TE regulates respiration and the circulation of protective Qi; the middle TE governs the Qi of the various digestive system functions; and the lower TE controls the Qi of the absorption of fluids/nutrients and waste disposal and also, sexuality/reproduction. These interrelated systems, when working together harmoniously, embody and manifest the physiological processes and structures of human health and well-being.

This article characterizes the energetic nature of the TE and provides a modern clinical TCM appreciation and approach. General TE clinical protocols, as well as 4 clinical case examples, are presented. The aim is not to exalt the TE above the other organs and their meridians<=>acupoints, since they are all of equal value in the TCM system, but to show how it functions to generate and regenerate harmonious Qi flow and help maintain good health.

TE ENERGETICS
The paired meridian organ of the TE is the PC. Neither are recognized and defined as major internal organs within the Western biomedical system, and they seem to be regarded as substantial but anomalous constructs even within the TCM system.³ The focus in this article is on the TE Meridian of Hand Shaoyang. It originates from near the corner of the nail of the 4th (ring) finger, where it is linked to the PC meridian, and it then ascends up the wrist and arm to the shoulder, collarbone, and around the back of the ear, ending at the outer corner of the eyebrow and linking with the GB meridian. Its main and collateral Qi circulation is described in several modern TCM textbooks.^4,5The TE meridian has 23 acupoints, each of which is of equal energetic importance (Figure 2). When TCM therapies are likely to be most beneficial according to successive 2-hour time periods encompassing the 12 regular organs meridian system, it must be noted that the Qi flow of the TE peaks in the mid-evening (9 pm), 2 hours after the PC and 2 hours before the GB.

Figure 2. General Qi flow of the TE meridian: upper (TE 1-8), middle (TE 9-14), and lower (TE 15-18) and total (TE 19-22)

The numinous, watery yet fiery, peaceful but powerful, and transformative nature of the TE has been aptly appreciated and wisely characterized in the following ways:

The 3 heaters by themselves form a whole study whose expansion is so great that it could cover the entire pathogenesis of acupuncture. The upper heater is located at the level of the thorax, the middle heater in the upper part of the abdomen, and the lower heater in the lower region of the abdomen. In the adult, the heaters seem like a kind of felting surrounding all the organs, not just the heart and master-heart. The heaters oversee the whole torso, and extend their influence all the way to the bodily extremities, via the 3-heater meridian and by the participation of all the meridians of the organs whose environments are affected by the heaters. In this sense, they concern the entire organic functioning, as illustrated by an author of the Han Dynasty (2nd century BC-2nd century AD): Under their governance, they reunite the 5 Zang and the 6 Fu, the Ying (nutritive energy) and the Wei (defensive energy), the Jing (meridians), and the Lo (secondary pathways), the inside and the outside, left
and right, top and bottom - all these breaths.⁶

Generally, the following points of attention or "pearls" of acupuncture must be kept in mind when a physician or therapist becomes involved in diagnosing and treating a patient with TE Qi disharmonies:

The TE embodies and manifests Yang Qi and is similar to the "father" of energy.
Like a "traffic controller" system, the TE functions to determine the direction of movement for all modalities of Qi to all parts of the body via the meridians, both superficial and deeper.
The TE is associated with complex cases (multiple pathologies, signs, and symptoms).
It closely resonates with the CV (Conception Vessel - Ren) and GV (Governor Vessel - Du) extra meridian€acupoint system.
Its primary interconnections are PC 8<=>TE 1 and TE 21<=>GB 1.
Its major secondary interconnection is TE 5<=>PC 6 (the gates of human emotions).
If a patient is highly sensitive to the weather or other environmental conditions, circumstances, and changes, then TE 5 is the primary acupoint of choice (Figure 3).
TE 5 is used like a "key" to open the gates of the Upper TE, and it is also a major gate for what we might term "emotional ventilation."
TE 3 and TE 10 are also useful in this regard.
Major energetic functions: the upper TE for nourishing cardiopulmonary functions, the middle TE for nourishing gastrointestinal/digestive functions, and the lower TE for nourishing excretory and reproductive functions.

Triple Energizer Diagnostic and Therapeutic Protocol
The main differentiation of syndromes of disease/illness according to the theory of TE pertains to Damp Heat in the upper, middle, and lower regions. Damp is a Yin pathogenic factor, generally obstructing Qi flow in the organs<=>meridians, while Damp Heat is a more serious Yin<=>Yang condition, encompassing a variety of severe signs and symptoms such as mental cloudiness, headache, loss of appetite, indigestion, excessive sweating, thirst (but often without the desire to drink), recurrent fever (especially in the afternoon), heaviness of the limbs, fullness of the chest, nausea, vomiting, and abnormal urination and defecation (such as scanty yellow urine and scanty loose stools).

An efficacious 3-stage acupuncture needling protocol is presented below, between patients and practitioners, according to their specific energetic conditions and competency:

Initial Stage

Opening the keys of the gates of the TE

Upper: TE 5
Middle: PC 6
Lower: ST 44

Promoting the total TE

CV 5: Influential point of the TE

Cleansing the TE

TE 3 for rejuvenation of Shen (Spirit)
TE 10 for removal of emotional pollution

Nourishing the TE

BL 22 and BL 39 (Shu points of the TE)

Energizing Stage

Strengthening the Zang Fu organs in the TE

LR 13 for Zang (solid) organs
CV 12 for Fu (hollow) organs

Promoting harmonious Qi circulation in the TE

GV 4 for connection of GV 4€CV 6
GV 4 for Congenital Qi
CV 6 for Acquired Qi
CV 17 for movement of Qi
LR 3 for smooth flow of Qi

Promoting harmonious Blood circulation in the TE

GB 39 for bone marrow
BL 17 for enhancing Blood
SP 10 for smooth flow of Blood
LU 9 for peripheral circulation of Blood

Balancing the Yin<=>Yang of the TE

SP 2 for balancing the Luo-Connecting points
LI 11 for physiological homeostasis
GV 20 for physical and mental harmonization
BL 17 for spiritual harmonization

Stabilization Stage

"Skipping stones" technique

Anterior alignment: CV 4, CV 6, CV 12, CV 17, CV 23
Posterior alignment: GV 4, GV 7, GV 9, GV 14, GV 20

Reinforcing the stability of the TE

LU 7, SI 3, GB 41, EX-HN 1

CLINICAL CASE EXAMPLES
Upper TE: Case 1
A 30-year-old man presented with a history of frequent colds as well as ear infections, bronchitis, and at least 2 episodes of pneumonia in the past 10 years. He was born prematurely and as an infant and child, he began to manifest allergic reactions to mold spores, plant pollen, and animal dander. According to TCM diagnostics, the patient's body is hyperreactive to the impact of these external allergens, which frequently results in an Upper TE syndrome of the Excess (Yang) type generally perceived to be Damp Heat in the LU, which also affects its pertaining organ meridian, the LI. This, in turn, may lead to Spleen Qi Deficiency. The patient's condition is a typical case of an Upper TE disorder. The general therapeutic approach is to sedate the lungs with needling at LU 5 and LU 6, and cupping on LU 1, BL 13, and CV 17.

The patient responded well to weekly treatments except that he still had occasional recurrences, especially when directly exposed to the allergens. The acupoints SP 10, LI 11, and LI 20 were added to his treatment protocol and he responded well. TE 5 was used to open the gates, and LR 13 (influential point of the Zang) and CV 12 (influential point of the Fu) were added. The patient's condition continued to improve, and he learned Qi Gong breathing exercises to help maintain and enhance his health and quality of life.^7-9

^{Figure 3. TE 5: Profile of an Acupoint
Name: Waigun, "Outer Gate"
Location: 2.0 cun above TE 4 on the midline of the forearm}

^{A cun is the TCM "body inch" assessment of the width of the interphalangeal joint of a patient's thumb (easily seen as the widest line across the center of the thumb).}

^{TE 4 is on the transverse crease of the dorsum of the wrist in the depression lateral to the tendon of the exterior digitorum communis muscle.}

^{Vascular and Innervation}

^{The posterior and anterior antebrachial interosseous arteries and veins.}

^{The posterior antebrachial cutaneous nerve.}

^{The posterior and anterior interosseous nerves.}

^{Traditional Indications}

^{Clears wind, cold and heat; nourishes general Qi, blood and body fluid circulation.}

^{Opens the emotional/spiritual gates.}

^{Opens the Upper TE.}

^{Modern Indications}

^{Febrile conditions, headache, neck strain, deafness, tinnitus, pain in the hyponchondriac region, motor impairment of the elbow and arm, finger joint pain, hand tremors.}

^{Common cold, influenza, osteoarthritis, parkinsonism.}

^{Major points for harmonizing the endocrine and metabolic systems.}

^{TCM Energetics: TE 5 is a Luo-Connecting and Confluent Point}

^{Luo-connecting points link exterior and interior related meridians, in this case, the TE and PC.}

^{Confluent points link the 8 Extra meridians with the 12 regular meridian system.}

^{Stimulation Method}

^{Needle perpendicularly 0.5-1.0 cun.}

^{Illustrative Combinations/Prescriptions}

^{TE 5 + Bl 22 + BL 39 + PC 6 + ST 43 + CV 5 for revitalization and rejuvenation.}

^{* TE 5 + GV 14 + LI 4 + LI 11 for febrile conditions, common cold and influenza.}

^{Clinical Notes}

^{Moxibustion, cupping, and electroacupuncture are also applicable.}

^{Auricular acupuncture is applicable on the TE region of the anterior ear (microsystem).}

^Commentary

^{Each acupoint has its own energetic nature and power with respect to each patient, which compassionate, competent, and creative practitioners will discover.}

^{Acupoints exist not only in themselves but in a complex interrelationship with one another.}

^{The precise position of a classical TCM acupoint is slightly variable, depending on the energetic condition of the patient and the skill of the practitioner.}

^{Ah Shi (tender points) must also be taken into account, where/whenever they arise in relation to classical acupoints like TE 5.}

Middle TE: Case 2
A 26-year-old woman manifested signs and symptoms encompassing stomach pain, indigestion, abdominal distention, and bad breath. These were most severely expressed during times of stress. Her complexion was pale-yellowish and the surface of her tongue reflected this coloration in the middle area, with teeth marks and shiny edges. Pulse diagnosis indicated a knotted pulse in the SP and an accentuated pulse in the ST. According to TCM, she had 2 middle TE syndromes, notably SP Qi deficiency due to phlegm accumulation, and ST Qi stagnation causing mild heat in the stomach. She was treated with various relevant acupoints, including moxibustion on SP 6, SP 9, and BL 20. Needling on ST 36 and ST 40 was added to help remove the phlegm.

The patient reported improvement after 4 treatment sessions, but she still complained of gastric irritation and distention. Therefore, needling of TE 5, PC 6, LR 13, and CV 12 were added. She began to feel more relaxed and symptom-free. However, since she still experienced occasional gastric distention, BL 22 and BL 39 were added. Dietetic suggestions included avoiding sweet, cold, raw, and greasy foods. She was advised to practice Tai Chi Chuan (TCM slow motion, rhythmic movement exercises) to balance her total Qi flow. Currently, she has medical acupuncture treatment once every few months for health maintenance and practices yoga, meditation, and other self-care therapeutic modalities.

Lower TE: Case 3
A 60-year-old man was referred for urinary problems, especially frequency, difficulty urinating, and a burning sensation upon urination. His other major complaints were discomfort in the supra pubic area, low back pain, and weakness of the knees. Swelling of his lower legs was evident, eyes were puffy with dark rings, chin and ears were red and tender, and his tongue had a yellowish coating in the root area (KI and BL areas at the back of the tongue). The patient's pulse was knotted in the SP, his LR pulse was slightly elevated, and his KI pulse was low (especially on the left side). Urinalysis indicated an increased red and white blood cell count with cast cells. His blood pressure was high (180/100 mm Hg).

Pelvic examination indicated enlargement of the prostate gland - in Western diagnosis, benign prostatic hypertrophy with possible uri-nary bladder infection. In TCM, these signs and symptoms are generally considered syndromes affecting the lower TE, such as damp in the BL with possible heat involvement, KI Qi deficiency, and LR Yang excess.

The patient was treated with electroacupuncture on BL 40 and BL 66 for his urinary condition, together with ST 40 for removal of damp/phlegm; LI 11, GV 14 for immunoenhancement, and KI 3, KI 7, KI 10, and BL 23 for KI Qi deficiency. LR 2 and LR 3 were added, together with cupping, to BL 18 for Liver Yang excess.

The patient was treated initially once a week for a 2-month period with some improvement. Subsequently, a number of acupoints were added including ST 44, BL 39, BL 22, LR 13, and CV 12 and his condition improved. The following prescription was developed especially
for him: TE 5, PC 6, GB 41, SP 21, and LI 11. This, together with TCM herbology and Qi Gong, helped to manage the patient's condition.

Upper, Middle, and Lower (Total) TE: Case 4
A 55-year old woman presented with chronic pain in her neck, shoulder, back, and extremities. She was referred by her family physician as well as her gynecologist for TCM evaluation and treatment of the complex condition known as fibromyalgia or chronic fatigue syndrome, as well as postmenopausal symptoms and prolapse of the uterus with cystocele and rectocele. Apart from the pain, she also experienced fatigue, sleeplessness, gastric distention, diarrhea, stomach cramps, hot flushes, and a bearing-down sensation in the pelvic region. She was seen by various specialists for shortness of breath, palpitations, and gastric disorders. Overall, the difficulty of her case represented multisystem involvement which, in TCM, is viewed as a complex syndrome of the total TE.

Her treatment began by needling and opening the keys of the gates of the TE, namely TE 5 as well as PC 6 and ST 44. Then, I moved Qi into the 3 Energizers by needling BL 22 and BL 39. Following this, I moved Qi into her internal organs by needling LR 13 (Zang) and CV 12 (Fu). I balanced her TE by using LI 11 (physical body), SP 21 (mental body), and GB 41 (spiritual body). To stabilize the TE, it was important to add LU 7 and SI 3. Vital alignment may be necessary if there has been prior unconsciousness due to an injury, illness, or biomedical anesthesia.¹⁰The patient's treatment protocol involved several treatment sessions. She responded positively to these treatments over a period of 2 months, starting with twice-weekly treatments for 2 weeks, then once a week for 6 weeks. Her symptoms appeared well controlled except for subsequent prolapse of the uterus. I then needled GV 20, EX-HN 1, and BL 57, and used moxibustion on SP 6. Although the patient's initial response to acupuncture was positive, there were complications in her condition and a hysterectomy was necessary. This was performed and currently, she receives acupuncture once a month for maintenance which appears to be beneficial, and she is learning Qi Gong for self-cultivation.

CONCLUSION
This article has presented a characterization of the TE based on the available literature along with 4 brief comprehensive case studies. It is up to practitioners of TCM and medical acupuncture to comprehend the TE in their own way, according to their own clinical expertise. Certainly, "evidence-based" scientific research is needed regarding the TE, but since it is a complex multisystem, the research parameters and methodology may be difficult to frame and enact. Perhaps simple comparative studies of patients with similar conditions treated (or not treated) within the context of a well-defined TE protocol would be an appropriate starting point and ongoing challenge.

ACKNOWLEDGEMENT
Heartfelt gratitude is expressed to Dr Richard Niemtzow, Ms Roz Royal, and the dedicated employees and referees of Medical Acupuncture for making this article so much better than it was when originally submitted.

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AUTHOR INFORMATION
Dr Steven Aung is a Geriatric and Family Practice physician and a TCM practitioner and teacher. At the University of Alberta, Dr Aung is Associate Clinical Professor in Faculty of Medicine and Dentistry, and an Adjunct Professor in the Faculty of Extension. He is a World Health Organization (WHO) advisor on TCM. Dr Aung's primary interest is the integration of TCM and Western biomedicine within the context of a more natural, compassionate approach to health and primary health care.

Steven KH Aung, MD, OMD, PHD, FAAFP*
9904 - 106 Street NW
Edmonton, AB T5K 1C4
Canada
Phone: 780-426-2760
Fax: 780-426-5650
E-mail: draung@aung.com
http://www.aung.com
*Correspondence and reprint requests

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