Bowels and viscera

脏腑〔臟腑〕zàng fǔ

The bowels and viscera (脏腑 zàng fǔ), also called zang and fu, are the chief internal organs located in the trunk. They are the major centers of physiological activity.

The Original Meanings of 脏 zàng (viscera) and 腑 fǔ (bowels)
The original meanings of 脏 zàng (viscera) and 腑 fǔ (bowels) help us to understand the two categories. Zàng is originally believed to have meant a long-term storage place for grain, important for the security of the nation, while fǔ meant a collecting place where grain was stored temporarily before being moved elsewhere. It is easy to see why physicians would have conceptualized the internal organs using such metaphors. The stomach, intestines, and bladder, for example, hold food and fluid temporarily before passing it on further. The heart, lung, spleen, liver, and kidney have functions associated with the storage of nutrients taken in from outside. Paul Unschuld reflects these original meanings using the terms depots and palaces. We prefer the terms storehouses and dispatch houses because they better reflect the greater importance of the viscera over the bowels.

The Original Meanings of 脏 zàng (viscera) and 腑 fǔ (bowels)

The original meanings of 脏 zàng (viscera) and 腑 fǔ (bowels) help us to understand the two categories. Zàng is originally believed to have meant a long-term storage place for grain, important for the security of the nation, while fǔ meant a collecting place where grain was stored temporarily before being moved elsewhere. It is easy to see why physicians would have conceptualized the internal organs using such metaphors. The stomach, intestines, and bladder, for example, hold food and fluid temporarily before passing it on further. The heart, lung, spleen, liver, and kidney have functions associated with the storage of nutrients taken in from outside. Paul Unschuld reflects these original meanings using the terms depots and palaces. We prefer the terms storehouses and dispatch houses because they better reflect the greater importance of the viscera over the bowels.

The viscera (脏 zàng) are the heart, lung, spleen, liver, and kidney. Since there are five, they are often called the five viscera (五脏 wǔ zàng).

The bowels (腑 fǔ) are the gallbladder, stomach, small intestine, large intestine, bladder, and triple burner. Being six in number, they are often called the six bowels (六腑 liù fǔ).

In addition, there are the extraordinary organs—the brain, marrow, bones, vessels, gallbladder (which is also classed as a bowel), and the uterus.

Knowledge of the bowels and viscera is often termed visceral manifestation theory (脏象论 zàng xiàng lùn), implying that it is derived from outward manifestation and reflects the principle of judging the inside from the outside (从外测内 cóng wài cè nèi). Theories concerning the bowels and viscera are the product of analytical inferences from direct observations combined with yīn-yáng, five phases, empire-paradigm, and qì-paradigm analogies.

The respiratory function of the lung, the digestive functions of the stomach and intestines, the blood-moving function of the heart, and the urinary functions of the kidney and bladder are all derived from analytical inferences from naked-sense observations and hence are roughly consistent with biomedicine, even though they are formulated somewhat differently. Other functions of the bowels and viscera, such as the water-moving function of the lung, the free-coursing function of the liver, and the digestive function of the spleen are derived by analogical reasoning in which yīn-yáng and the five phases figure prominently.

The Distinction Between the Bowels and Viscera

The distinction between the bowels and viscera rests on a functional difference. As the Huáng Dì Nèi Jīng (Sù Wèn, Chapter 11) states.

Storing vs Conveying and Transforming (Discharging)
The distinction that the viscera store essential qì, while the bowels convey and transform matter is only approximate. Amongst the viscera, the spleen seems to be an exception because it governs movement and transformation, which suggests that it should be classified as a bowel since its function seems to be one of conveying and transforming. The lung also seems to be an exception because it draws in air from outside the body and expels turbid qì from the body. The kidney, though storing essence, also produces urine, which is discharged via the bladder. Amongst the bowels, the triple burner is an exception, because although it carries fluids down and out of the body, it provides the pathways for original qì. So, the classifications do not appear to be as clear-cut as the Nèi Jīng would have them. They are understood relatively by comparison with the paired organs (discussed below).

Storing vs Conveying and Transforming (Discharging)

The distinction that the viscera store essential qì, while the bowels convey and transform matter is only approximate. Amongst the viscera, the spleen seems to be an exception because it governs movement and transformation, which suggests that it should be classified as a bowel since its function seems to be one of conveying and transforming. The lung also seems to be an exception because it draws in air from outside the body and expels turbid qì from the body. The kidney, though storing essence, also produces urine, which is discharged via the bladder. Amongst the bowels, the triple burner is an exception, because although it carries fluids down and out of the body, it provides the pathways for original qì. So, the classifications do not appear to be as clear-cut as the Nèi Jīng would have them. They are understood relatively by comparison with the paired organs (discussed below).

The five viscera store essential qì but do not discharge (五脏者, 藏精气而不泻 wǔ zàng zhě, cáng jīng qì ér bù xi è); thus, they are full yet cannot be filled (实而不能满 shí ér bù néng mǎn). The six bowels convey and transform matter but do not store (六腑者, 传化物而不藏 liù fǔ zhě, cháng huà wù ér bù cán g); thus, they are filled yet cannot be full (满不能实 mǎn bù néng shí).

This tells us that the viscera store essential qì, here referring to internal products of the body—qì, blood, and fluids, but do not discharge. It says that the bowels convey and transform matter and are filled but yet cannot be full. In other words, the bowels discharge matter, meaning that they pass it on to other bowels or discharge it from the body. The gallbladder discharges bile; the stomach passes food to the small intestine; the small intestine passes it to the large intestine, which discharges it from the body in the form of stool; and the bladder discharges urine from the body. They fill and then empty but are never permanently full.

Because of these functions, the viscera and the bowels can also be called storehouses and dispatch houses.

The bowels include an organ called the triple burner. This does not correspond to any anatomical organ and its physical identity has therefore been disputed over the centuries. Nevertheless, its function is clearly defined as representing the actions of all the bowels and viscera regarding the movement of original qì and water.

The distinction between storing and discharging is a yīn-yáng distinction. Storing is retention, akin to inward movement, and hence yīn; discharging is an outward movement and hence is yáng. Thus, the viscera are classified as yīn and the bowels as yáng. Insofar as the bowels come into contact with food (which enters the body at the mouth and exits it at the anus after processing), they can be thought of as an interior body surface. Thus, although, like the viscera, they are yīn because they are internal, they are the yáng within yīn in that they are an interior body surface.

Pairing of the Bowels and Viscera

Pairing of the Bowels and Viscera
Viscera	Bowels
Liver	Gallbladder
Heart	Small intestine
Spleen	Stomach
Lung	Large intestine
Kidney	Bladder
Pericardium	Triple burner

Each viscus is paired with a bowel. For example, the liver is paired with the gallbladder, the heart with the small intestine, the spleen with the stomach. Since the viscera are interior and the bowels relatively exterior, this relationship is described as standing in exterior-interior relationship. So, we say the heart and the small intestine stand in exterior-interior relationship.

Since there are six bowels but only five viscera, a sixth viscus, the pericardium, is sometimes evoked as the triple burner’s counterpart for certain explanatory needs, notably the channel system. The pericardium is said to cover and protect the heart, the sovereign viscus, against the invasion of evils.

Note that meanings of interior and exterior here described originated in the Nèi Jīng, but they do not apply in all aspects of Chinese medicine. The bowels are said to be exterior because most of them convey matter of external origin or expel matter out of the body. However, in the six-channel system of cold damage described in the Shāng Hán Lùn, yáng brightness (yáng míng) disease, which is associated with the large intestine (a bowel), is understood to be disease of the interior.

Overview of Bowel and Visceral Functions

The bowels and viscera are here presented in the following order: heart; lung; spleen, stomach, and intestines; liver and gallbladder; kidney and bladder. While other authors sometimes adopt arrangements reflecting the yīn-yáng and five-phase associations, our arrangement emphasizes the primacy of the pragmatic understanding of the organs.

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Heart: The heart stores the spirit (consciousness, mental activity) and moves the blood. It governs the vessels and opens at the tongue. Its mind is joy. The heart is associated with fire among the five phases. Fire is associated with warmth and power. The light it provides is a symbol of perspicacity, intelligence, and wisdom, which are reflected in the notion of the spirit. The heart’s corresponding bowel is the small intestine.

Heart problems mostly manifest in spirit signs, which, depending on the cause, can take the form of heart vexation (restlessness) and insomnia, even manic agitation, or else clouded spirit (partial or complete loss of consciousness). Mental disorders invariably involve disturbances of the heart spirit. Conditions called myocardial infarction and other heart diseases in modern medicine are understood in Chinese medicine to involve both the heart’s blood-moving and its spirit-storing functions.

Lung: By its respiratory function, the lung absorbs air (traditionally called clear qì), which is required to produce the yáng qì of the body. For this reason, it is said to govern qì, which means that it has a dominant role over qì in the body. Qì is responsible, amongst other things, for the movement of all substances around the body and all their transformations. In this conception, the qì that powers the lung (lung qì) is also accorded an important role in the movement of fluids, sending them down to the kidney. This function is known as governing the waterways.

The lung also governs the skin and opens at the nose. Its mind is worry. The lung belongs to metal, whose epithet is the working of change. Metal is associated in the yearly cycle with autumn, the time when nature is purified by the first frosts. This is reflected in the fact that the lung draws in clear qì and expels turbid qì, ensuring that the body has plentiful supplies of yáng qì to work all the necessary changes in the body for human life. The lung’s corresponding bowel is the large intestine.

When the lung is not working properly, respiratory problems such as cough, abnormalities of breathing, and changes in the volume and quality of the voice may be observed. When the function of governing the waterways is affected, there may be accumulation of water in the form of edema, which in Chinese medicine is called water swelling.

Spleen, stomach, and intestines: The spleen and stomach stand in exterior-interior relationship with each other. The spleen is considered the main organ of digestion and absorption of nutrients contained in food: it governs movement and transformation of grain and water (i.e., food and drink). Food is digested in the stomach and small intestine. However, the spleen is said to move the fluids of the stomach, that is, it helps the stomach to digest the food. The spleen absorbs the essence of grain and water (nutrients contained in food) to provide the materials for the production of qì and blood. For this reason, the spleen is called the source of qì and blood formation. Accordingly, the spleen is also said to control the blood, which refers to its function of preventing spontaneous bleeding. The waste passes on to the large intestine, where it is formed into stool after more liquid is drawn off.

The spleen and stomach are ascribed to earth among the five phases because, just as earth produces crops for human food, so the spleen and stomach extract from food the nutrients for the human body. The spleen is also said to control the blood. The spleen opens at the mouth and governs the flesh. Its mind is thought.

When the spleen fails to function adequately, digestive problems such as poor appetite, abdominal fullness and sloppy stool arise. Qì and blood production may also be affected. Some forms of bleeding are attributed to the spleen failing to control the blood. When stomach function is disturbed, there may be poor appetite, a local sensation of fullness, nausea, vomiting, belching, and hiccup. The small intestine is prone to heat, which gives rise to painful voidings of reddish urine. The large intestine is susceptible to both diarrhea and constipation.

Liver and gallbladder: The liver has two main functions. One is storing the blood, which is apparent from the liver’s bloody texture and color. The other is free coursing, by which the liver maintains the spread of qì to all parts of the body. The liver governs the sinews (muscles and tendons) and opens at the eyes. Its mind is anger. The liver’s corresponding bowel is the gallbladder. In the five phases, the liver belongs to wood. The free coursing function is understood by analogy to trees spreading their branches.

The liver governs the sinews, which rely on plentiful supplies of blood stored by the liver. The sinews are understood by analogy to the bending and straightening qualities of wood.

Failure of the liver to store blood reduces the supply of blood for the sinews, eyes, and menstrual flow, giving rise to blurred vision or scant menstrual flow. Yīn-yáng imbalances can give rise to liver wind stirring internally, which manifests in spasm of the sinews. Impaired free coursing gives rise to qì stagnation, which manifests in distension and pain along the channel associated with the liver (throat, chest, rib-side, lower abdomen). Anger and frustration are associated with many liver problems.

The gallbladder stores and discharges bile, which is made from the surplus qì of the liver. It also governs decision. The functions of the gallbladder are closely related to the liver’s free coursing action.

Kidney and bladder: The kidney is associated with water in the five phases. It governs water, reflecting the fact that it produces urine from fluids. Urine is sent to the bladder for temporary storage before discharge.

The kidney also stores essence, the substance that is responsible for reproduction, physical and mental development, and aging. This function was derived by analogy to the kidney’s association between water in the five phases and winter, the season when nature stores its potential for growth and development until the coming spring. The health of the kidney is crucial to the body’s yīn-yáng balance, and hence it is called the root of yīn and yáng of the whole body. The kidney also has the function of helping the lung to absorb qì. It opens at the two yīn (anus and genitals) and governs the bones. Its mind is fear.

Impairment of the kidney’s function of governing water is impaired manifests in urinary problems such as copious urine, frequent urination, enuresis, urinary incontinence, or water swelling. Insufficiency of kidney essence manifests in poor development in childhood, in reproductive problems such as amenorrhea and infertility, or in premature aging. When the kidney qì’s absorption function fails (called kidney failing to absorb qì), there is panting (labored breathing).

How Functions are Described
The descriptions of organ functions come from the Huáng Dì Nèi Jīng, earliest extant text describing them in detail. The statements of the Nèi Jīng have been virtually uncontested over the centuries and have remained authoritative to this day. Some are in keeping with modern medicine; others differ. The Nèi Jīng sums up the functions of each organ in several points. The heart, for example, governs the spirit and the blood and vessels; the lung governs the qì and diffusion and depurative downbearing; the spleen governs movement and transformation; the liver governs free coursing and stores the blood; the kidney governs water and stores essence. These descriptive phrases are concise encapsulations of often quite complex functions. For example, the lung governs qì has several different connotations. Chinese medicine places greater emphasis on pathology than physiology. It provides more detail about impairment of functions than about normal performance of them. For example, the numerous manifestations of disturbance in the liver’s function of governing free coursing are described in greater detail than the normal function of free coursing. Physiology appears to have been largely deduced from pathology. Functions are expressed in unique ways. The term govern (主 zhǔ) is used in two ways. On the one hand, it denotes influence of an organ over a specific substance, as in the lung governs qì. On the other, it means responsibility for a function, as in the spleen governs movement and transformation. Under the influence of biomedicine, modern Chinese medical texts often use the word function (功能 gōng néng), but in traditional texts, 主 zhǔ expresses the idea of function in most cases, e.g., 肝之主疏泄 gān zhī shū xiè, the liver’s governance of free coursing (the liver’s free coursing function). The use of主 zhǔ reflects the conception of the organs as officials who are in charge of things or activities. A further reflection of this conception is seen in the expressions 失职 shī zhí, failure to perform (its) job and 失权 shī quán or 无权 wú quán, failure to exert (its) power. It is interesting to note that the English word function originally meant the position held or job done by a person, and its application to organs was a later metaphorical development. However, the metaphor has died. By contrast, the traditional language of Chinese medicine is rife with live political metaphors, which are most prominent in the political epithets of the viscera (e.g., the heart holds the office of Sovereign). In the context of the liver, Chinese medical discourse uses the word 用 yòng, literally use, in the sense of function, contrasted with the term 体 tǐ, literally body (substance, physical substratum). The term storing (藏 cáng) commonly occurs in descriptions of the bowels and viscera. Each viscus is said to store a mental faculty. For example, the liver stores the ethereal soul; the heart stores the spirit; the spleen stores ideation; the lung stores the corporeal soul; the kidney stores mind/memory. Some viscera also store other substances. For example, the the liver stores blood and the kidney stores essence. Among the mental faculties stored by the five viscera, the heart stores the spirit. Since the heart’s storing of the spirit is the heart’s main function, this is often expressed as the heart governs the spirit.

How Functions are Described

The descriptions of organ functions come from the Huáng Dì Nèi Jīng, earliest extant text describing them in detail. The statements of the Nèi Jīng have been virtually uncontested over the centuries and have remained authoritative to this day. Some are in keeping with modern medicine; others differ.

The Nèi Jīng sums up the functions of each organ in several points. The heart, for example, governs the spirit and the blood and vessels; the lung governs the qì and diffusion and depurative downbearing; the spleen governs movement and transformation; the liver governs free coursing and stores the blood; the kidney governs water and stores essence. These descriptive phrases are concise encapsulations of often quite complex functions. For example, the lung governs qì has several different connotations.

Chinese medicine places greater emphasis on pathology than physiology. It provides more detail about impairment of functions than about normal performance of them. For example, the numerous manifestations of disturbance in the liver’s function of governing free coursing are described in greater detail than the normal function of free coursing. Physiology appears to have been largely deduced from pathology.

Functions are expressed in unique ways. The term govern (主 zhǔ) is used in two ways. On the one hand, it denotes influence of an organ over a specific substance, as in the lung governs qì. On the other, it means responsibility for a function, as in the spleen governs movement and transformation. Under the influence of biomedicine, modern Chinese medical texts often use the word function (功能 gōng néng), but in traditional texts, 主 zhǔ expresses the idea of function in most cases, e.g., 肝之主疏泄 gān zhī shū xiè, the liver’s governance of free coursing (the liver’s free coursing function). The use of主 zhǔ reflects the conception of the organs as officials who are in charge of things or activities. A further reflection of this conception is seen in the expressions 失职 shī zhí, failure to perform (its) job and 失权 shī quán or 无权 wú quán, failure to exert (its) power.

It is interesting to note that the English word function originally meant the position held or job done by a person, and its application to organs was a later metaphorical development. However, the metaphor has died. By contrast, the traditional language of Chinese medicine is rife with live political metaphors, which are most prominent in the political epithets of the viscera (e.g., the heart holds the office of Sovereign).

In the context of the liver, Chinese medical discourse uses the word 用 yòng, literally use, in the sense of function, contrasted with the term 体 tǐ, literally body (substance, physical substratum).

The term storing (藏 cáng) commonly occurs in descriptions of the bowels and viscera. Each viscus is said to store a mental faculty. For example, the liver stores the ethereal soul; the heart stores the spirit; the spleen stores ideation; the lung stores the corporeal soul; the kidney stores mind/memory. Some viscera also store other substances. For example, the the liver stores blood and the kidney stores essence. Among the mental faculties stored by the five viscera, the heart stores the spirit. Since the heart’s storing of the spirit is the heart’s main function, this is often expressed as the heart governs the spirit.

Predominance of the Viscera

The viscera are preeminent in the body. They each exert influence over the bowels paired with them, and over various other parts of the body.

Dominance over the bowels: The spleen, for example, moves the fluids of the stomach, which means that the stomach’s capacity to perform preliminary digestion is dependent on the spleen. Similarly, the bladder’s capacity to store and discharge urine is dependent on kidney qì.

Dominance over body parts, substances, and faculties: Each viscus has a special connection with the following:

One of the five orifices (liver with eyes; heart with tongue; spleen with mouth; lung with nose; kidney with ears and the two yīn).
One of the five body constituents (liver with sinews; heart with the vessels; spleen with the flesh; lung with skin; kidney with bone).
One of the five blooms (liver with nails; heart with face; spleen with lips; lung with body hair; kidney with hair).
One of the five humors (liver with tears, heart with sweat; spleen with drool; lung with snivel; kidney with spittle).
One of the five storings (the liver stores the ethereal soul; the heart stores the spirit; the spleen stores ideation; the lung stores the corporeal soul; the kidney stores mind). The ethereal soul, spirit, ideation, corporeal soul, and mind are sometimes called the five spirits (五神 wǔ shén).
One of the five minds (the liver with anger; the heart with joy; the spleen with thought; the lung with worry; the kidney with fear). (Note that a sevenfold classification of emotions and mental states, the seven affects, also includes sorrow and fright.)

Government offices: In the Huáng Dì Nèi Jīng (Sù Wèn, Chapter 8), each viscus is likened to a government office responsible for certain functions. The heart is the Sovereign; the liver holds the office of (Military) General; the spleen (and stomach) holds the office of the Granaries; the lung holds the office of Minister-Mentor; the kidney holds the office of Forceful Action (labor). This reflects the early conception of the body functioning like an empire. These association do not appear in all English-language texts because they have little clinical significance. However, they provide an important means to understand the nature and functions of the bowels and viscera in their original conception.

The five aversions: It is classically said that the heart is averse to heat, the lung is averse to cold, the spleen is averse to dampness, the liver is averse to wind, and the kidney is averse to dryness. In the case of the heart, lung, and spleen, the aversion corresponds to the season with which the viscus is associated. In five-phase theory, cold is normally associated with winter and dryness with autumn. However, the Nèi Jīng states that lung is averse to cold, while the kidney is averse to dryness. In practice, the lung is susceptible to externally contracted heat and dryness, as well as cold. The kidney is said to be averse to dryness, not because it is susceptible to external dryness (or any other externally contracted evil for that matter), but because the waning of essence leads to signs such as dryness of the hair, brittleness of the bones, cessation of menstruation, and decrease in semen, which naturally occur in later life.

Linkage by channel: The pairing of the bowels and viscera is supported by channel links. Each bowel and viscus has its own associated channel. With the pericardium evoked as a counterpart to the triple burner, there are twelve channels. Each channel homes to its own bowel or viscus and nets the one it is paired with.

Five Phases in the Associations of the Viscera

The predominance of five organs is of great significance since it reflects the fact that the understanding of the bowels and viscera are rooted in five-phase thought, which holds that individual substances and parts of the body fall into sets of five items each of which belongs to a phase and hence has a special resonance with the item in any other set that has the same phase correspondence.

Associations of the Five Viscera
Phase	Wood	Fire	Earth	Metal	Water
Viscus	Liver	Heart	Spleen	Lung	Kidney
Bowel	Gallbladder	Small Intestine	Stomach	Large Intestine	Bladder
Orifice	Eyes	Tongue	Mouth	Nose	Ears
Body Constituent	Sinew	Vessels	Flesh	Skin (and body hair)	Bone
Bloom	Nails	Face	Lips (and four whites)	Body Hair	Hair of the head
Humor	Tears	Sweat	Drool	Snivel (nasal mucus)	Spittle
Spiritual entity	Ethereal soul	Spirit	Ideation	Corporeal soul	Mind
Mind	Anger	Joy	Thought	Worry	Fear
Voice	Shouting	Laughing	Singing	Wailing	Groaning
Government office	(Military) general	Sovereign	Office of the Granaries	Minister-Mentor	Official for forceful action
Aversion	Wind	Heat	Dampness	Cold	Dryness

The Extraordinary Organs

In addition to the bowels and viscera, Chinese medicine recognizes several extraordinary organs, (奇恒之腑 qí héng zhī fǔ), namely the brain, marrow, bones, vessels, gallbladder, and the uterus. These are placed in a category of their own, because they do not store or discharge like the bowels and viscera. Furthermore, the gallbladder is an oddity because it is classed as both a bowel and an extraordinary organ. This may be because the gallbladder, having the function of discharging bile, is a bowel, but since bile is considered a refined substance, it also bears similarities to the viscera.

Qì, Blood, Yīn, and Yáng

The bowels, viscera, and extraordinary organs are perfused with qì and blood; they each have yīn and yáng aspects. Their individual functions in some cases are specifically related to qì, blood, yīn, and yáng. The functioning of the heart, for example, is closely related to all four. Hence, we speak of heart qì, heart blood, heart yīn, and heart yáng. Insufficiency of any of the four can result in morbidity of the heart; hence disease patterns of the heart include heart qì vacuity, heart blood vacuity, heart yīn vacuity, and heart yáng vacuity. In the case of the lung, we normally only speak of lung qì and lung yīn, because blood and yáng are not directly relevant to the lung. Disease patterns of the lung accordingly include lung qì vacuity and lung yīn vacuity, but not normally lung yáng vacuity and lung blood vacuity.

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