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From the Townsend Letter
December 2014

Dialogue: Inflammation and the Triple Burner
Efrem Korngold, OMD, and Stephen Cowan, MD
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Inflammation is a normal aspect of the adaptive response of the organism to challenge, essential to survival. But there has been an epidemic of inflammatory disorders in our era, particularly since World War II. From our perspective of Chinese medicine, the accelerated pace of modern life creates a condition of excess Heat. In Western terms, this is a result of sympathetic overdrive – too much cortisol and adrenaline – that sets the stage for inflammation.
Chinese medicine approaches to treating inflammatory problems emphasize restoring the inner terrain, supporting host resilience, and countering adverse environmental influences, termed Pathogenic Qi. The Triple Burner, one of the primary theoretical models in Chinese traditional medicine, is an elegant, holistic construct for understanding terrain, resilience and adaptation to stress. It not only provides a map of the territory in which inflammation takes root, but an integrated approach to treatment.

Korngold and CowanTHE TRIPLE BURNER
Efrem Korngold, OMD: We both see pediatric patients, and over the course of our collaboration in the past twenty years, we have formulated a developmental perspective for understanding inflammation, based on the Triple Burner model. The Triple Burner (the San Jiao) emerges as the central mechanism that organizes and guides growth and development. In this model, the Lower Burner (Jing) corresponds to the Kidney network, which governs the most essential functions of life. The Jing is our material root, our inherited source of vitality, and our primal capacity for making a life and a future. It is the soil from which we grow ourselves. The Middle Burner (Qi) corresponds to the Spleen, which encompasses all digestive, assimilative, and absorptive functions. The Upper Burner corresponds to the Heart/Mind (Shen) or consciousness of the individual.

Stephen Cowan, MD:
Recent advances in contemporary medical theory and research have given credence to a psycho-neuro-gastro-immunological perspective – replacing the view that the "immune system" is a discreet, isolated entity. This new conceptualization of immunity comes closer to the holistic model articulated in the classical literature of Chinese medicine. All too often allopathic medicine has oversimplified the concept of immune function, neatly compartmentalizing it as an independent system. In pediatrics, we have known for some time that 80% of immune activity is located in the gut. This "neuro-gastro-immune system" details a more comprehensive paradigm for understanding the mutual communication and coordination of biologic information processing, and this fits nicely into the Triple Burner model.
The Triple Burner also directs the integration, communication, and coordination of the five organ systems or networks of the body (Kidney, Liver, Heart, Spleen and Lung). As a "developmental organ," it is responsible for managing our defensive (wei qi) and nutritive (ying qi) functions. Qi is ultimately the vital force or power that creates and sustains all life. Each of the three Burners has both immune and nutritional functions essential to coordinating healthy integration of growth and development whether we are well or ill. Metabolism and immunity can be thought of as two sides of the same coin, a Yin-Yang relationship, focused on maintaining a coherent conversation between the organ systems and the external environment.
Efrem has coined the term "euflammation" to describe the normal metabolic heat of the organism. Whenever the balancing, homeodynamic process in the body (the conversation) is overtaxed, the Triple Burner will facilitate greater communication by up-regulating metabolism to raise the temperature of the inner terrain. This is the genesis of a shift towards inflammation. Young children especially are in a highly active phase of growth and consequently, they are more naturally prone to acute inflammatory reactions and high fevers. Fever is a signal – it tells us that the Triple Burner is rallying the wei qi (our innate immune cells). Yet all too often, there is a tendency to suppress this totally normal adaptive response to stress. This can have significant long-term effects on an individual's resilience. Indeed, several studies have shown that overuse of antipyretics will often prolong infections.
In simple terms, we can think of the Lower Burner as our root, our inherited ability to maintain healthy biorhythms (breathing, sleeping, digesting, eliminating, recycling). Too little attention paid to these basic rhythms (stress during pregnancy, too little sleep, too little time to eat or to think or to play) sets the stage for chronic inflammation, what we refer to as "Hyperflammation." The euflammatory state exists on a continuum of metabolic heat production, and it is only when things are pushed too far that we find the organism losing its balance.
The Middle Burner is responsible for facilitating the processing and digesting of food and information, received and incorporating it into our body-mind. Food is broken down, sorted, and becomes part of our physical self, energizing our mental and emotional experience. In this sense, education is also a process of digestion. The four most common causes of imbalance in the Middle Burner are improper eating, mental overstimulation, emotional overexcitement, and improper timing of vaccinations. When these imbalances overburden the Middle Burner, we begin to see congestion (stagnation of Qi and Blood in the form of Phlegm, alterations of circulation (hot head and trunk and cold limbs), and a general increase in metabolic heat.

The concept of Phlegm is important in understanding how pathology is conceptualized in Chinese medicine. This term connotes a general distortion of the quality, viscosity and distribution of body secretions that can interfere with circulation, breathing, and cognition. When Phlegm and Heat accumulate in the Middle Burner, they are said to transform into a fog-like mist that rises upward, obstructing the organs of perception (eyes, ears, nose, mouth, tongue). The term for this is "Phlegm Heat misting the Mind." In other words, the congestion of Qi, Blood and Fluids in the head impairs the ability to see, hear and think clearly, to learn, or make intelligent choices. Developmental disorders such as ADHD and ASD may be understood as chronic inflammatory processes that extend to the Upper Burner.

The role of the Upper Burner is to take in information from our environment through our senses and to expand our awareness, our consciousness. The Upper Burner governs our desires and aversions, our curiosity and the intellectual and spiritual facets of our nature. In young children–and this is an extremely important point – the Upper Burner is the last of the three to fully mature. Consequently, children tend to be more vulnerable to overstimulation and are more easily overwhelmed.

Steve: The distractions of modern life perpetually overstimulate us all. In our digital society, 90% of us live in urban areas, disconnected from the natural environment. Everything is too much, too fast: energy-rich, nutrient-poor food, food additives, vaccinations, polluted air and water, pesticides, artificial light, artificial heat, TV, video games, smart phones, and wi-fi magnetic field pollution are just a few examples. The Middle Burner can no longer moderate the conversation between outside and inside, between Upper Burner (cognitive/sensory) and Lower (genetic, biorhythmic) functions. Many of the chronic clinical inflammatory disorders we see today develop when the Middle Burner is caught in the crossfire.
From a Western medical perspective we can say that there is an imbalance between the sympathetic and parasympathetic nervous systems that leads to a state of chronic inflammation. Allergies are a clear example of this phenomenon. Like a false alarm, the allergic response is essentially an over-reaction to a perceived threat or invasion, when in fact there is none. Teaching the body to down-regulate this reaction pattern requires that we look first at what's going on between the three Burners.

This type of meltdown gives rise to an array of conditions in our children such as indigestion, allergies, obesity, juvenile diabetes, and casein-glutenophobia, leading to other inflammatory disorders such as chronic asthma and eczema. Even neurological conditions such as ADD/ADHD and ASD may be associated with inflammatory changes in the CNS, also due to systemic inflammation. Similarly, in adults, systemic inflammation is contributing to the modern epidemics of metabolic syndrome, diabetes, IBS, IBD, hypertension, atherosclerosis, cardiovascular disease, and dementia. The individual is essentially overheating to such an extent that the body's normal ability to "quench the fire" is disabled.
Many hyperinflammatory disorders are the result of a failure to process (absorb and incorporate) information that not only is contained in the food a child (or an adult) eats, but is embedded in her physical environment and social milieu. In children especially, these phenomena almost always arise from one fundamental problem: the Middle Burner functions are being caught in the crossfire. To optimally foster a child's growth and healthy development, we need to enrich the soil of the inner terrain (Blood and Essence), manage the social environment (the family and community), slow down the rhythms of daily life, and reduce sympathetic overdrive.
These same principles are applicable to the treatment of adults who are suffering from stress-induced inflammatory disorders (adrenal overstimulation) and exhaustion due to diminishing reserves (adrenal fatigue). Consequently, one of the goals of treatment is to support the Triple Burner in order to restore equilibrium – the innate capacity to adequately regulate normal, adaptive, integrated responses to challenges.
In terms of development, it is the Middle Burner, the gut (the network of Stomach and Spleen) that is the primary source of nourishment for the young child, not the Upper Burner (the Shen/Mind). Too much emphasis by parents, educators, and politicians is placed on achieving levels of cognitive performance that are really beyond a child's developmental stage and capacity. This also means allowing each child to mature at his or her own pace since every child is different and follows a unique developmental path. Close observation is necessary to determine the genuine nature (type) of the child (li) according to the Five Phase Model of Chinese medicine that Steve and I have described in depth in our books (see Resources).
In every case, I pose this question: What are the conditions that will be optimum, not only for growth and development, but also for that particular individual to learn to cope with physical and psychological challenges and change?

Steve: I want to introduce the idea of the vagus nerve as the governor of the inflammatory process and a functional component of the Triple Burner. When we talk about nutrition, for example, it's not just what we eat, it's also where we eat, how we eat, and when we eat, that bring about a kind of natural, healthy vagal tone. The vagus nerve is an amazing network that has the capacity to up regulate and down regulate our immune system by directly interfacing with macrophages and other immune cell lines. Like the Triple Burner, the vagus neural network modulates and promotes all the functions and processes of healthy digestion. We have the opportunity to directly influence vagal tone from the moment a child is born. Yet working with infants, I often observe that caregivers have a tendency to shove a bottle into a baby's mouth as soon as she cries. Feeding becomes a kind of emergency intervention, and there is no time to activate proper vagal responses: saliva production, peristalsis, gastric acid production, and pancreatic digestive enzymes to prepare the Middle Burner to receive food. Consequently, many inflammatory problems begin here. It's no accident that we see an epidemic rise in the treatment of infants with Zantac and Prevacid for reflux in recent years, not to mention the rise in childhood obesity, now seen as early as six months of age.
The quality of food directly influences immune competence and resilience. Unlike over-processed foods, fresh, organically grown food contains a rich, array of phytochemicals that improve our capacity to mitigate the harmful effects of stress. I believe children may be prone to chronic ear infections in part because of the harm caused by industrially processed foods (particularly dairy) that cause excessive accumulation of Phlegm and subsequent Heat. One of the first steps in treating children with chronic ear infections is to look at their diet, environment, and lifestyle and remove those factors that are overloading the Middle Burner. Often this is all it takes to clear conditions such as otitis media and get the child back on track. Herbs and acupuncture provide additional interventions that can gently and effectively activate the parasympathetic vagus network to counterbalance sympathetic overdrive.

Efrem: Over the past two millennia, Chinese medicine has developed as a vast repository of knowledge that embraces numerous paradigms, many of which merge and overlap and some that are even mutually contradictory. All pay homage to the overarching concepts of Yin Yang and Wu Xing (the Five Phases). When integrated together into one coherent paradigm, they provide a dynamic representation of how life works. Western science and medicine, beginning with the ancient Greeks, has always sought the one theory, a conceptual model that will wholly explain everything we know about the world and completely resolve all contradictions. Conceptualizing how the body works from an exclusive, internally consistent theory inevitably leads us to seek the one silver bullet that will cure each specific disease. In contrast, throughout Chinese history, doctors have chosen from among diverse models the ones that are most appropriate for solving the particular health problem at hand. Today, there is a well-developed movement within the professional medical community in China to integrate Eastern and Western models of care whenever possible. Chinese patients, quite often, will select traditional or modern medicine, or both, depending on how they perceive and understand their own condition.

Modulating the Terrain: A Case of Cellulitis
Efrem: Cellulitis is an inflammation under the skin involving the lymphatic tissue and the small vessels, causing massive edema, heat, and pain. It can be caused by trauma or infection, and when it is the result of bacterial infection such as strep, staph, or particularly MRSA (Methicillin-resistant Staphylococcus aureus), it can be quite serious.
One of the most extreme examples of inflammation I've seen was the case of a woman who suffered from chronic recurring cellulitis in both legs. This woman had been treated with several series of antibiotics that would temporarily resolve the problem. The condition continued to recur, an indication that she was dealing with a stubborn, entrenched inflammatory process. Over several months, treating her with acupuncture and herbal medicine to clear Heat, dispel Toxins, and to strengthen her Liver and Spleen, the condition gradually resolved and did not return.
If we use the analogy of a forest fire that continues to burn in spite of heroic efforts to suppress it, similarly, a recurring inflammatory process that resists resolution requires that we first alter the environment, the terrain that is allowing the fire to rage on and the inflammation to fester. This approach underscores the importance of supporting and modulating normal physiological processes in order to restore the patient's body to a condition in which his or her innate homeodynamic mechanisms are able to re-assert themselves.

Herbs and Acupuncture:
In treating less severe cases, the usual approach is to counter toxicity with herbs that enable the body to clear Heat (inflammation), neutralize Toxins, and discharge them from the body. At the same time, we remember to support healthy Qi (the terrain) by using herbs or medicines that nourish the Blood and activate the circulation of blood and body fluids. These tonic herbs provide nourishment, activate digestion, and improve absorption of nutrients, having the restorative properties of both food and medicine.

Terrain and Type
Efrem: To effectively address inflammation, we need to determine what is out of balance that is allowing this problem to emerge. Everything is important to note: how a person lives, where she lives, how she thinks, what she feels, how she spends her days at school or at work, how she sleeps, what she eats, when she eats, how she eats, who she eats with – these different spheres that an individual inhabits reveal her nature, how she relates to herself and her world, her way or pattern of being.
We tend to pigeonhole these patterns as someone's "lifestyle," but it can be something deeper. The patterns are reflections of that person's temperament on the subtlest level. When considering the health concerns of the patient, whether they are as simple as a headache, as stubborn as chronic eczema, or as frightening as cancer, if we can understand the pattern of our patients' development and the way they approach the world, we can maximize the beneficial results of whatever treatments they are receiving. For example, two people with colitis may respond in completely different ways to the same dietary changes, so we must consider their developmental patterns and constitutional makeup, what we call their type.
Essentially what we are attempting to achieve is a harmonic "conversation," a coherent and coordinated dialogue within and between the Three Burners and the Organ Networks (Kidney, Liver, Heart, Spleen and Lung) that execute all of the body's functions. These domains of process integrate the metabolic transformations necessary to foster, empower, and preserve the life of the person. We call this supporting a person's bodily life (xing), affirming her true nature (li) and empowering the fulfillment of her mission or purpose – her destiny (ming).

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