Inflammation and the Triple Burner Part 2 Clinical Strategies by Efrem Korngold, OMD, and Stephen Cowan, MD
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 hole 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).
Treating to Type: ADHD
Steve: In the Five Phase model, treatment is predicated on the characteristics of temperament or adaptive style that reflect the essential nature of the patient, as well as their symptoms. A patient who is described as a “Fire Child” (one of five basic temperaments or types) typically has a metabolism that tends to burn too hot, making him predisposed to dramatic bouts of inflammation. We monitor these patients for mood swings, excessive sweating and blood sugar instability, which are common complaints in Fire Children who are becoming imbalanced. We would want to address this to reduce the tendency towards production of excessive metabolic heat without suppressing the innate regulating response: i.e. we do not want to suppress physiologic function, but rather support the body’s ability to accomplish tasks more effectively and to maintain homeostatic equilibrium. In addition we would want to recommend counter balances to these tendencies by asking his parents to encourage more water intake, increase sleep time, reduce overstimulation, and eliminate excess carbohydrates and sugars. A troubled young man who first came to my practice when he was thirteen years old, at the peak of hormonal changes, was a quintessential “Fire Child.” His impulse control was getting worse rather than better as he got older, he was doing poorly in school, and he complained that everything bored him. He’d been diagnosed with ADHD and placed on a stimulant medication, but the drugs were no longer helping. At this point he could not retain anything he learned in school and began having panic attacks. Fortunately he was able to relax during our visits. (He called them his “cool out” sessions.) During acupuncture I introduced him to some breathing exercises, coupled with a visualization in which he imagined that he was sitting at the bottom of the sea. Taking gentle Chinese herbs and a few key supplements (omega-3 fish oils, magnesium glycinate, and 5-HTP) dramatically reduced his impulsivity. Today he is doing well in his first year of college and thinking about becoming an acupuncturist. The approach I use in pediatric treatment includes giving a child herbal formulas that support his own individual nature (type) and at the same time bolster the Middle Burner (the Spleen and Stomach), vital to healthy development. I use a line of herbal formulas from Kan Herb Company called Peacemakers for this approach to promote adaptogenic balance (See Resources for additional information). I also use acupuncture to treat the specific characteristics of the problem, remaining mindful of the fact that inflammation has its own developmental path. My selection of herbs and acupuncture points will be based on the child’s response to treatment and the progression of his condition.
Utilizing Traditional Remedies: Severe Infant Eczema
Efrem: In addition to the sophisticated paradigms of Chinese medicine, there are traditional folk remedies that have been passed down over the millennia, some of which are highly effective. This case involves an 18-month old boy who had suffered from severe eczema since birth. Eczema can be due to any number of factors, including genetic predispositions passed on by parents who had allergies or eczema during childhood or congenital events that occur during fetal development. This was a classic case of infant eczema that covered his entire body and face. I treated him using a traditional Chinese folk remedy, the Egg Cure, which resolved his condition within a few weeks. The remedy involves soaking a whole fresh egg in a jar of rice vinegar or malt vinegar. Once the shell is completely dissolved, the egg and its membrane are carefully removed, placed in a dish, and beaten with a wisk, creating a paste-like substance. The egg mixture is then painted over the entire body. Initially, there is a mild aggravation for 24 to 48 hours which resolves with continued applications. Twice daily, the mixture is applied, and later washed off and reapplied. Within a few days, the eczema will begin to resolve. Complete resolution may take up to 3-4 weeks, after which it will not recur. However, if it does return, repeating the treatment will almost always resolve the problem, in less time and without any aggravation of symptoms. I learned about this remedy from a patient who had been afflicted with terrible eczema his entire life and had seen all manner of doctors. Through his search for a cure, going from healer to healer, he heard about this remedy, tried it, and was cured. I have been using this treatment since that time, particularly for children. It is highly effective, and is sometimes almost as good as steroids for resolving inflammation and painful itching. In Chinese medicine, eczema is believed to be caused by Heat and Toxins in the Blood. One of the means of purifying the Blood is to enrich it with special nutrients, and eggs, particularly the yolk, are considered restorative because of their Blood- nourishing properties. The principle is that the more good nutrients that are present in the Blood (healthy ying and wei), the more effectively the Blood can detoxify and purify itself. In traditional medicine, the skin (couli) is considered to be a functional aspect of the Triple Burner. Steve and I have come to view the three dermal layers as a microcosmic representation of the Upper, Middle, and Lower Burners. The treatment of eczema always includes acupuncture points for the Lung and Large Intestine (the two organs that comprise the Lung Network), since in Chinese medicine the skin and the colon are viewed as the external expression of Lung Qi. Western physiology also recognizes the skin as a respiratory organ that, in a sense, functions as a third lung. Western doctors have long observed that respiratory problems like asthma are often associated with intestinal problems such as constipation. In CTM, we also use points that improve the function of the Liver, because the Liver has a commanding influence over the quality and distribution of the Blood. Finally, we include points that improve the function of the Stomach and the Spleen, since they are the source of the nourishment necessary for restoring the Blood. We do not aggressively detoxify without adding nutrients at the same time or immediately following a period of discharge and elimination. Otherwise we run the risk of damaging healthy Qi and Blood.
Promoting Immune Equilibrium: Chronic Arthritis
Steve: In treating inflammation, Efrem and I encourage a holistic view of what balanced immunity means, in the sense of resilience. When treating a child with chronic arthritis, one goal of treatment is to address Lower Burner function (genetic predispositions, promotion of healthy sleep, hydration, and elimination). Middle burner functions are supported through dietary changes that reduce inflammatory triggers (elimination diet, gluten free-casein free diet, GAPS diet, SCD diet), and improve absorption of nutrients (probiotics, Spleen tonic herbs, glutamine). I recommend avoiding overstimulation of the immune system with too many vaccines all at once. Acupuncture directed at Spleen and Stomach disharmonies has a powerfully positive effect on arthritis. Vagal nerve tone can be influenced by ear acupuncture in particular. Upper Burner function is promoted by reducing sensory overstimulation (cutting down on screen time), improving emotional regulation (learning to express emotions more effectively), and shifting attention down from the Upper and into the Middle and Lower Burners. Diaphragmatic breathing exercises help the child to “get out of her head” and back into her body, quieting the over-thinking often evident in systemic inflammation. Meditation and Qigong practices also help develop healthy vagal tone and support a balanced immune-nutritive conversation (wei qi- ying qi). Heart rate variability is another interest of mine. HRV has been linked to immune resilience and can be used effectively with children, as well as adults. When variability is optimized, DHEA levels rise, wounds heal better, and emotional reactivity is tamed, simply by learning to consciously alter breathing.
Efrem: A large body of outcomes research in China, Japan, and Korea focuses on an integrative approach, for example in cancer care, utilizing Chinese herbal medicine and acupuncture in concert with conventional protocols of surgery, radiation, and chemotherapy. What the studies repeatedly demonstrate is that patients who use Chinese traditional medicine along with conventional care have significantly better outcomes than people who only do one or the other. Using CTM in conjunction with standard care or together with functional medicine produces greater benefit to patients than reliance on a single approach. My own predilection is to be collaborative. In my practice, when I see patients that I cannot adequately treat with acupuncture, herbal medicine, diet, and nutritional supplements, I refer them to a provider who has tools that I do not possess or cannot use because of the limits on my scope of practice. I have no hesitancy in referring patients to my medical colleagues, including chiropractors, osteopaths, homeopaths, naturopaths, surgeons, endocrinologists, gynecologists, integrative docs, and holistic pediatricians. Unfortunately, our medical care system is severely Balkanized, which prevents like-minded health care providers with differing medical specialties and methodologies from really working together in an environment that would maximally benefit our patients. Steve: I frame clinical recommendations within a context that demonstrates how everything fits together, how all the dots are connected. Rather than simply encouraging patients to “get more sleep,” for example, we want to be clear that the goal is specifically to restore a natural rhythm by providing counterbalances to asynchronies both internally and externally. In physiologic terms, our emphasis is on restoring healthy biorhythms associated with heart rate variability, breathing, sleep-wake cycles, eating, and elimination. We have found that we get much better outcomes when we help to promote harmony of the Triple Burner by reducing sympathetic overdrive, achieved through more exercise, more time in nature, mindful eating (taking the time to really relax and enjoy a meal), time spent with loved ones, and simple pleasures such as storytelling. Building on this foundation, we add herbs and supplements to target specific organ networks. In tandem, these efforts help promote healthy immune regulation and detoxification by recalibrating the immune response and fostering a more resilient way to meet the challenges of life.
About the Authors
Efrem Korngold, OMD, Dipl Ac (NCCAOM), RH (AHG), LAc Efrem Korngold is a pioneer in the education and practice of Chinese medicine in the West. He studied Chinese herbal medicine in Kunming, China in 1980, acupuncture in Shanghai in 1984, and subsequently continued his training with Asian herbalists in the U.S. Applying his 40 years of scholarship and clinical experience, Korngold has developed unique practice models that blend ancient and modern knowledge. A Diplomate of the National Certification Commission of Acupuncture and Oriental Medicine (NCCAOM), he is also a charter member of the American Association of Acupuncture and Oriental Medicine (AAAOM) and a founding and Advisory Board member of the Holistic Pediatric Association. He has lectured nationally and internationally at sites such as the UCSF School of Medicine, University of Arizona, Beth Israel Hospital in New York, and the American College of Traditional Chinese Medicine in San Francisco. Efrem and Harriet Beinfield, LAc are founders of Chinese Medicine Works, an acupuncture clinic and herbal pharmacy in San Francisco. Efrem and Harriet are formulators of an innovative repertoire of 68 Chinese herbal formulas manufactured and distributed by Kan Herb Company www.KanHerb.com. They also authored Between Heaven and Earth a seminal work on Chinese traditional medicine. For more information visit their website: www.chinesemedicineworks.com Stephan Scott Cowan, MD, FAAP, CAc Stephen Cowan is a board-certified pediatrician with 30 years of clinical experience working with children. Steve has a subspecialty in Developmental Pediatrics and is certified in Medical Acupuncture. He has developed a unique holistic approach to the evaluation and treatment of children struggling with chronic physical, emotional, and cognitive disorders. Steve is a Fellow in the American Academy of Pediatrics (AAP), a member of the AAP Section on Children with Disabilities, member of the American Academy of Medical Acupuncture, and clinical faculty at New York Medical College. He is a founding and Advisory Board member of the Holistic Pediatric Association and practices in Mt. Kisco, NY and New York City. He is the author of Fire Child, Water Child an innovative guide to parenting a child with attention deficit hyperactivity disorder (ADHD). Dr. Cowan provides in-depth, holistic developmental/medical evaluations that explore the child within the context of his or her life to treat the root cause of chronic health conditions and not just the symptoms. Dr. Cowan sees patients at two offices The Westchester Center For Holistic Families and The Shen Center for Integrative Medicine. For more information visit http://stephencowanmd.com