San Jiao Differentiation
A diagnostic framework developed for warm diseases (Wen Bing) that organizes disease progression vertically through the body's three regions—upper, middle, and lower—helping practitioners identify which organs are affected and determine appropriate treatment strategies.
Sān Jiāo Biàn Zhèng
Triple Burner Differentiation
Educational content · Consult qualified TCM practitioners for diagnosis and treatment
Overview
San Jiao Differentiation (三焦辨证, Sān Jiāo Biàn Zhèng) is a systematic diagnostic method specifically designed for analyzing and treating warm diseases (温病, Wēn Bìng)—febrile illnesses caused by heat pathogens entering the body. Think of it as a vertical map of disease progression through your body, divided into three zones from top to bottom.
The framework divides the body into three "burners" or regions: the Upper Jiao (chest area containing the Lungs and Heart), the Middle Jiao (abdomen containing the Spleen and Stomach), and the Lower Jiao (lower abdomen containing the Liver, Kidneys, and elimination organs). When warm pathogens enter the body—typically through the nose and mouth—they first affect the Upper Jiao, then may progress downward to the Middle and Lower Jiao if not properly treated.
This system complements the Four Levels Differentiation (卫气营血辨证), with Three Jiao showing vertical transmission (from top to bottom) while Four Levels shows horizontal transmission (from surface to depth). Together, they form a comprehensive grid for diagnosing warm diseases, allowing practitioners to precisely locate the disease and select targeted treatments.
Historical Context
The concept of dividing the body into three regions (San Jiao) originated in ancient classics like the Huangdi Neijing (Yellow Emperor's Classic), which described the San Jiao as managing fluid metabolism throughout the body. The Nanjing (Classic of Difficulties) famously stated that the Triple Burner 'has a name but no form,' sparking centuries of debate about its nature.
San Jiao Differentiation as a diagnostic system was formally established by Wu Jutong (吴鞠通, 1758-1836) in his landmark work Wen Bing Tiao Bian (温病条辨, Systematic Differentiation of Warm Diseases), first drafted in 1798 and published in 1813. Wu built upon Ye Tianshi's Four Levels theory, creating a complementary vertical framework. He famously described the relationship: 'Six Channels differentiation looks horizontally; Three Jiao differentiation looks vertically'—together providing a complete picture.
Wu's system transformed how practitioners approached febrile diseases, offering clear treatment strategies for each stage. His famous formulas like Yin Qiao San (for Upper Jiao wind-heat) and San Ren Tang (for damp-heat in all three Jiao) remain widely used today. The framework proved especially valuable during epidemic outbreaks and continues to inform modern treatment of infectious diseases.
Comparison
Upper Jiao (Shang Jiao)
上焦Location: Above the diaphragm (chest)
Organs: Lungs, Heart, Pericardium
Disease Stage: Initial/early stage
Key Symptoms: Fever, slight chills, cough, thirst, floating pulse
Treatment Nature: Light, ascending, dispersing (like a feather)
Representative Formulas: Yin Qiao San, Sang Ju Yin
Middle Jiao (Zhong Jiao)
中焦Location: Between diaphragm and navel (abdomen)
Organs: Spleen, Stomach
Disease Stage: Middle stage (intense pathogen-defense battle)
Key Symptoms: High fever, sweating, thirst, abdominal fullness, constipation, yellow coating
Treatment Nature: Balanced, harmonizing (like a scale)
Representative Formulas: Bai Hu Tang, Zeng Ye Cheng Qi Tang
Lower Jiao (Xia Jiao)
下焦Location: Below the navel (lower abdomen)
Organs: Liver, Kidneys, Bladder, Intestines
Disease Stage: Late stage (Yin depletion)
Key Symptoms: Low fever, night sweats, dry mouth, flushed cheeks, tremors, weak pulse, red tongue
Treatment Nature: Heavy, nourishing, anchoring (like a weight)
Representative Formulas: Fu Mai Tang, Da Ding Feng Zhu
Upper Jiao Syndrome
上焦证 (Shàng Jiāo Zhèng)Affects the Lungs and Heart/Pericardium in the chest region. This is typically the initial stage of warm disease. Symptoms include fever, mild chills, cough, thirst, and floating rapid pulse. If the pathogen is not expelled, it may transmit to the Pericardium (called 'reverse transmission'), causing delirium, unconsciousness, and crimson tongue—a dangerous progression.
Middle Jiao Syndrome
中焦证 (Zhōng Jiāo Zhèng)Involves the Spleen and Stomach in the abdominal region. This represents the middle stage where the battle between pathogen and body's defenses intensifies. Symptoms include high fever, profuse sweating, intense thirst, abdominal fullness, constipation, and a yellow tongue coating. This stage requires clearing heat from the Stomach or resolving dampness from the Spleen.
Lower Jiao Syndrome
下焦证 (Xià Jiāo Zhèng)Affects the Liver, Kidneys, and elimination organs. This is the late stage where prolonged heat has depleted the body's Yin fluids. Symptoms include low-grade fever, dry mouth, flushed cheeks, night sweats, tremors or involuntary movements, and a deep red tongue with little coating. Treatment focuses on nourishing Yin and anchoring wayward Yang.
Sequential Transmission
顺传 (Shùn Chuán)The normal disease progression from Upper to Middle to Lower Jiao—like water flowing downhill. When disease follows this 'downstream' pattern (for example, from Lung to Stomach), it is considered more favorable because it follows the body's natural hierarchy. Early treatment at each stage can prevent further progression.
Reverse Transmission to Pericardium
逆传心包 (Nì Chuán Xīn Bāo)A dangerous deviation where the pathogen jumps directly from the Lungs to the Pericardium (the Heart's protective membrane), bypassing the normal sequential pattern. This causes rapid deterioration with high fever, delirium, coma, and stiff tongue. This represents a medical emergency requiring immediate intervention to open the Heart's orifices.
Treatment Principle: Like a Feather for Upper Jiao
治上焦如羽 (Zhì Shàng Jiāo Rú Yǔ)Upper Jiao diseases require light, ascending treatments—like a feather floating upward. Formulas should use light herbs in small doses that disperse and ventilate the Lungs. Heavy, downward-draining herbs are contraindicated at this stage.
Treatment Principle: Like a Balance for Middle Jiao
治中焦如衡 (Zhì Zhōng Jiāo Rú Héng)Middle Jiao diseases require balanced, harmonizing treatments—like a level scale. The Spleen and Stomach represent the body's center, so treatments must restore equilibrium between ascending and descending functions without being too harsh or too weak.
Treatment Principle: Like a Weight for Lower Jiao
治下焦如权 (Zhì Xià Jiāo Rú Quán)Lower Jiao diseases require heavy, sinking treatments—like a weight pulling downward. At this stage, Yin essence is depleted, so treatments must use rich, substantial herbs that nourish and anchor the body's depleted resources.
Practical Application
Diagnostic Process: When a patient presents with warm disease symptoms, practitioners first determine which Jiao is affected based on the location of symptoms. Upper Jiao symptoms (cough, chest tightness, slight fever) indicate early-stage disease. Middle Jiao symptoms (digestive disturbance, high fever, abdominal pain) indicate the pathogen has penetrated deeper. Lower Jiao symptoms (tremors, night sweats, depleted appearance) indicate late-stage Yin damage.
Integrating with Four Levels: San Jiao Differentiation works alongside Wei-Qi-Ying-Xue (Four Levels) differentiation. For example, a patient with Upper Jiao disease might also show Wei (Defensive) level symptoms—together indicating superficial disease of the Lungs requiring light, dispersing herbs. If the same patient develops Ying (Nutritive) level symptoms like delirium, this suggests reverse transmission to the Pericardium despite remaining in the Upper Jiao anatomically.
Treatment Selection: Each Jiao has characteristic formulas. Upper Jiao wind-heat responds to Yin Qiao San or Sang Ju Yin (light, aromatic herbs). Middle Jiao Stomach-heat requires Bai Hu Tang (strong heat-clearing). Lower Jiao Yin deficiency needs nourishing formulas like Fu Mai Tang or Da Ding Feng Zhu. The practitioner selects based on precise pattern identification.
Clinical Relevance
Modern Application: San Jiao Differentiation remains highly relevant for treating acute febrile illnesses, viral infections, and inflammatory conditions. During the COVID-19 pandemic, Chinese medical authorities applied these principles to categorize disease stages and guide herbal interventions, demonstrating the framework's continued utility for epidemic diseases.
Distinguishing Warm-Heat vs. Damp-Heat: The system differentiates between dry warm diseases (which progress quickly and damage Yin) and damp-heat conditions (which linger and cause heaviness and turbidity). Damp-heat often affects the Middle Jiao first and requires different treatment—resolving dampness rather than just clearing heat.
Prognosis: The Three Jiao framework helps predict disease course. Sequential transmission from Upper to Middle to Lower Jiao, while indicating disease progression, follows a predictable pattern allowing timely intervention. Reverse transmission to the Pericardium signals rapid deterioration requiring emergency measures. Lower Jiao involvement generally indicates prolonged illness with depleted resources.
Common Misconceptions
Misconception 1: San Jiao is just anatomical location. While the three Jiao correspond to body regions, San Jiao Differentiation is primarily about disease stage and pathological process, not just anatomy. A Lower Jiao pattern indicates late-stage Yin depletion regardless of where symptoms manifest—the Liver, though physically in the Middle abdomen, functionally belongs to Lower Jiao in this system because of its relationship to Yin and Blood.
Misconception 2: It replaces other diagnostic methods. San Jiao Differentiation was designed specifically for warm diseases and works best when integrated with Zang-Fu (organ), Eight Principles, and Four Levels differentiation. It supplements rather than replaces other systems, each offering different diagnostic insights.
Misconception 3: Disease always follows the sequential pattern. While 'begins in Upper, ends in Lower' describes the typical progression, diseases can skip stages, stall at one level, or reverse transmit. The framework describes tendencies, not rigid rules—clinical reality requires flexible application.
Classical Sources
Wen Bing Tiao Bian (温病条辨)
Chapter 1 - Upper Jiao温病自口鼻而入，鼻气通于肺，口气通于胃。肺病逆传则为心包。上焦病不治则传中焦，中焦病不治则传下焦。始上焦，终下焦。
Warm diseases enter through the mouth and nose—the nose connects to the Lungs, the mouth connects to the Stomach. When Lung disease transmits reversely, it reaches the Pericardium. If Upper Jiao disease is not treated, it transmits to the Middle Jiao; if Middle Jiao disease is not treated, it transmits to the Lower Jiao. It begins in the Upper Jiao and ends in the Lower Jiao.
Wen Bing Tiao Bian (温病条辨)
Treatment Principles治上焦如羽，非轻不举；治中焦如衡，非平不安；治下焦如权，非重不沉。
Treat the Upper Jiao like a feather—only lightness can lift it. Treat the Middle Jiao like a balance scale—only equilibrium can stabilize it. Treat the Lower Jiao like a weight—only heaviness can sink it.
Huangdi Neijing Lingshu (黄帝内经灵枢)
Chapter 18 - Ying Wei Sheng Hui上焦如雾，中焦如沤，下焦如渎。
The Upper Jiao is like mist, the Middle Jiao is like a maceration chamber, the Lower Jiao is like a drainage ditch.
Nanjing (难经)
Chapter 38三焦者，原气之别使也，主通行三气，经历于五脏六腑。
The Triple Burner is the special envoy of the Original Qi; it governs the passage of the three types of Qi and circulates through the five Zang and six Fu organs.
Modern References
Warm Disease Theory (Wen Bing Xue)
Comprehensive modern textbook integrating all warm disease schools including San Jiao differentiation
Differentiation and treatment of cough according to Sanjiao based on Treatise on Febrile Diseases and Differentiation of Epidemic Febrile Diseases
Beijing Journal of Traditional Chinese Medicine research comparing San Jiao approaches in classical texts
The Foundations of Chinese Medicine
Widely-used Western text explaining San Jiao theory and its clinical applications for modern practitioners