Lymphatic System and San Jiao

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Lymphatic System and San Jiao
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  Lymphatic System and San Jiao Traditional Chinese Medicine (TCM) is a medical system with a long history. TCM is not a static medicalsystem but a developing whole of theories, ideas and practices. Through the ages TCM haveexperienced influences from different ideas and practices. Without question today’s biggest influence for TCM is western medicine and the sciences related to. In the present era, TCM practitioners not onlyneed 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. Onlyin this way the patients can receive the highest quality holistic aid. This has been the task of the doctorsin all times; to combine the best of the past and present medical knowledge, no matter where it comesfrom, in order to give the best treatment that can beachieved. In the presented thesis an effort is made to explore the relationship of ―San Jiao‖ with the lymphaticsystem. ―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 n ame that is referred to today’s western medicine. But the functions of it were described from ancient times. Eventually it is just the same human holism to bedescribed; 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 itseparately because its functions are so different from those of the heart and blood vessels. Thelymphatic system is responsible for returning tissue fluid to the blood and for protecting the bodyagainst 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. Thesystem of lymph vessels begins as dead-end lymph capillaries found in most tissue spaces. Lymphcapillaries are very permeable and collect tissue fluid and proteins. Lacteals are specialized lymphcapillaries in the villi of the small intestine; they absorb the fat-soluble end products of digestion, suchas fatty acids and vitamins A, D, E, and K. Lymph capillaries unite to form larger lymph vessels, whosestructure is very much like that of veins. There is no pump for lymph but the lymph is kept movingwithin 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 isgoing 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 jointhe thoracic duct, which empties lymph into the left subclavian vein. Lymph vessels from the upper rightquadrant of the body unite to form the right lymphatic duct, which empties lymph into the rightsubclavian vein. Flaps in both subclavian veins permit the entry of lymph but prevent blood from flowinginto 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 today’s 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 medicine’s point of view a connection or at least an attempt could be made. In this way it would be clear that some conce ptions of ―Zang‖ –    ―Fu‖ organs are in therange of today’s 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 differentinstances. 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‖ resem bles 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 transportedand 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. Thefirst mention of lymphatic vessels was in 3rd century BC by Herophilus, a Greek anatomist, whoincorrectly 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 werefurther propagated by the Greek physician Galen, who described the lacteals and mesenteric lymphnodes 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‖ al so 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‖. Togetherwith 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 notionsof a ―calor innatus‖, an innate source of warmth responsible for changing temperatures in the human organism. Chap ter 8 of ―Su Wen‖ mention that the triple warmer takes the office of dreading water inthe watercourse of the whole body, it takes charge of the activity of the ―Qi‖, of the body fluid and theregulation 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 descri bed from the TCM’s point of view. Now there will be an attempt to get theconnection of ―San Jiao‖ with an important morphological and physiological structure, the lymphaticsystem. TCM’s first main function of ―San Jiao‖ is that it serves as a transmittin g system through which the primordial ―Qi‖ or ―Yuan Qi‖ is circulating. Also as is it written in the 8th chapter of ―Su Wen‖ ―SanJiao‖ is the ―opener of Channels‖ and passageway of water srcinates in it. ‖San Jiao‖ connect thebody’s different parts as t he lymphatic vessels being everywhere in the body connecting the differenttissues. Immunity and “San Jiao”        ―Yuan Qi‖ derives from kidney ―Qi‖ of the parents during pregnancy, which is closely related tocongenital 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 thelymphatic 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 andpromote 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 chargeof 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 saidin ―Su Wen‖ 43 it follows the vessels upward and downward, penetrates the five depots, and connectsthe six palaces. Chapter 52 of ―Ling Shu‖ describe ―Ying Qi‖ as a refined energy that runs inside thevessels in the contrary with ―Wei Qi‖ that flows outside the vessels.At the 9th chapter of ―Su Wen‖ it issaid that ―Ying Qi‖ passes through the vessels and all the core organs. The spleen ―Su Wen―test ifies is the basis of grain storage. It is the main location of the ―Ying Qi‖. A later author supplemented thisstatement, adding five ―Fu‖ organs to the spleen. Hence, in today’s 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‖ isconsidered the most important ―Qi‖ for the protection of the organism, again to what weste rn 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 fles h. ―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 foreignmaterial. This is immunity. Immunity may be defined as the ability to destroy pathogens or otherforeign material and to prevent further cases of certain infectious diseases. This ability is of vitalimportance because the body is exposed topathogens from the moment of birth. Immunity has two major categories: genetic immunity andacquired immunity. Genetic immunity is conferred by our DNA, and acquired immunity is developed oracquired by natural or artificial means. TCM has only one type of immunity but this is not a significantdifference.The aging of the lymphatic system is apparent in the decreased efficiency of immune responses. Elderlypeople are more likely than younger ones to develop shingles, when an aging immune system cannotkeep the chickenpox virus dormant. They are also more susceptible to infections such as influenza andto what are called secondary infections, such as pneumonia following a case of the flu. Autoimmunedisorders are also more common among older people. The incidence of cancer is also higher. Malignantcells that once might have been quickly destroyed remain alive and proliferate. All these are related tothe 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‖ relatedto it, is decreased and that results to improper function of ―Wei Qi‖. Improper function of ―Wei Qi‖ isrelated to decreased immunity. It is only the theoretical explanation that difference. Deficiency of ―YuanQi‖ and ―Wei Qi‖ wou ld 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. Tounderstand 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 conditionof the lymphatic system is again retention of fluid and edema. Lymphatic obstruction is defined as ablockage of the lymph vessels or nodes that drain fluid from tissues throughout the body and allowimmune 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 butthe most common is infections with parasites such as filariasis, injury, radiation therapy, skin infectionssuch 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 causelymphedema of the arm in 10% - 15% of patients. This occurs because the lymphatic drainage of thearm 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 system’s fluidpromotion function with ―San Jiao’s‖ fluid promotion function. The lymph tissue that is removed during mast ectomy can be considered to be body fluid pathway from TCM’s 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 TCM’s aspect. Body Fluid and Lymph  The lymphatic system main function is to return tissue fluid to the blood stream to maintain bloodvolume. So there is a close interconnection between blood and lymph. Lymph should be consideredfrom TCM as an important part of body fluid. Lymph in western medical physiology is the name fortissue 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 fluidremains 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 isa watery clear liquid with the same composition as the interstitial fluid. As it flows through the lymphvessels and nodes tends to accumulate cells (particularly lymphocytes) and proteins. In TCM there is nodefinition for lymph, but what is called lymph today could be considered as a part what TCM regards asbody fluid. According to TCM blood is connected to body fluid in various ways. The same relationship existsbetween blood and lymph in the western medicine. TCM describes that body fluid and blood moistensthe 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 bloodstream into the left and right subclavian vein. TCM says that body fluid after its formation from thetransformation of food and water is transported first to the vessels and then flows with blood to thewhole body. Then part of the body fluid in the blood extravasates from the vessels and flows outsidethe vessels to moisten and nourish the viscera and the body. At the same time part of body fluidoutside the vessels enters the vessels again to participate in the production of blood. TCM describes adynamic balance between body fluid inside and outside the vessels. Also blood and body fluid cantransform and supplement each other. This idea is exactly the same with the facts described fromwestern medical physiology. Blood supplies nutrients to the tissues and collects back the waste productsthat 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 thatoccupies the spaces between the cells and acts as their immediate environment. The blood and thesurrounding cells continually add and remove substances from the interstitial fluid. Water and solutescan diffuse between the interstitial fluid and blood, and thus both are in dynamic equilibrium with eachother. 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 10  — 20%) enters the lymphcapillaries as lymph. Lymph and body fluid is the same thing with different name and their relationshipwith blood resembles in both TCM and western medicine. San Jiao and Digestion  
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