Chinese Medicine, 2011, 2, 191-198
doi:10.4236/cm.2011.24030 Published Online December 2011 (http://www.SciRP.org/journal/cm)
191
The Pairing of Heart and Small Intestine
Xin Xiao Chang Xiang Biao Li 心 小 肠 相 表 里
Electra Peluffo
Faculty of Medicine, Universidad de Valencia, Valencia, Spain
Received March 1, 2011; revised April 1, 2011; accepted April 18, 2011
Abstract
This paper investigates the reasoning, based on both Chinese and Western medical data, which will lead to
an understanding of the relation of the heart and small intestine, organs which Chinese Medicine, in the Fire
energy phase, link both functionally and anatomically. The direct relationship between the liver and the gall
bladder and between the kidneys and the bladder is recognised and accepted in both Chinese and Western
Medicine. This is not the case with the pairings which in Eastern morphophisiology are formed by the heart
and small intestine and the lungs and large intestine. These pairings are not recognised in Western Medicine.
The writer in her dual capacity of Doctor of Western Medicine and acupuncturist is investigating the reasons
why in Chinese Medicine the heart and small intestine and their meridians form a relation which couples
them. For this the comparative method was used between data from Western anatomy which demonstrate the
interorganic and functional relation between the small intestine and the heart and the Chinese energy dyna-
mic of the corresponding zangf u and jingluo. Biomedicine which does not relate the heart with the small
intestine brings in the materiality of its anatomic descriptions which are valuable for the interpretation of
Oriental Medicine. This interrelation between the two organs and their meridians are well explicated in
Chinese Medicine whose traditional concepts in this respect are corroborated by Western anatomical des-
criptions which, nevertheless, do not admit the functional-organic coupling of the heart and small intestine.
Keywords: Organic Pairing, Chinese Medicine, Nanjing, Classic of Difficulties, Heart, Small Intestine,
Thoracic Duct
1. Introduction
Zangfu process the functions which are linked to the es-
sentials energies: breathing and eating. Zangfu constitute
functional units of coupled pairs. They are dynamisms
which because they are located in certain areas of the
body, induce to associate them with the organs seen from
a Western view. But such coincidence is not complete
since the functions described in China are not restrained
to a certain area and they significantly exceed the cor-
respondent topography. Each Zangfu pair is just one more
yingyang couple.
The heart-small intestine pair shares the fire move-
ment with another “organic” pair of imprecise anatomic
base and untranslatable name despite various attempts of
European languages to do so, it is xin bao luo―san jiao:
difficult to define and whose presence we shall try to
interpret.
Chinese Medicine for its fire phase links, both func-
tionally and anatomically, the heart with the small intes-
tine and during the metal phase the lungs with the large
intestine. Nanjing difficulty 35 [1] describes:
“The 5 viscera each have a place… and the bowels are
close together, only the heart and lungs are removed at a
distance from the small and large intestines.”
And gives reasons for this: the heart is responsible for
nutrition and the lungs for defence, and both commu- ni-
cate and move (tong 通 - xing 行) the yang energy and
that is why they are located in the yang area at the top of
the trunk. Both intestines transmit the yin energy down-
wards and therefore they are located in the lower part (yin)
Likewise, the small intestine anatomically is central, as the
heart is, and the large one is lateral as lungs are. The small
intestine is the bowel (腑fu) of abundance, receives the
surplus of the bowels and the large intestine is the bowel
(腑fu) of transmition and drainage of this surplus.

E. PELUFFO
192
2. Function and Energetics of the Heart in
Chinese Medicine
In Chinese Medicine four names or expressions define the
wide cardio-circulatory function 1) heart (xin); 2) centre
of chest (膛 中 tang zhong) mediastinum; 3) that by
which the heart commands (心 主 xin zhu); and 4) mesh
which surrounds the heart (心 包 络 xin bao luo).
Heart xin is the Emperor; the great chief of the body
since it supervises and controls all the organic sectors
and due to its functions, irrigates and nurtures even the
tiniest corners of the organism through its circulation.
This dynamic involves the movement of organic liquids,
notably the blood and lymph. It is important to un- der-
stand the Chinese meaning of the term xue, blood, which
is not only the red liquid that runs through arteries and
veins but, rather it designates all kinds of body secretions,
hormonal secretions included as well as the transforma-
tions produced in the interior of the body.
Acupuncture point RM 17 ren mai 17 (膛 中 tang
zhong “in the middle of the chest”) is a very important
place of exchange of energies and at the same time the
area where the heart resonates between the 2nd, 3rd and
4th intercostal spaces hosting three acupuncture points:
RM 17, 18 and 19 which in the centre of the sternum
relate to large vessels. Through tang zhong [2] runs the
ancestral energy (zong qi 宗 气) that mediates between
the genetic lineage we come from and the singular being
we are, and which is also known as thoracic energy since
it is stored in the centre of the chest, centre which is none
other than tang zhong, even though in fact more than
being the centre of the chest it is the chest as a centre
[3].
Ancestral energy (zong qi 宗 气) comes up here
through the large stomach luo vessel (xu li 虚 里)
which anatomically we think corresponds to the lym-
phatic circuit of the small intestine. Tang zhong centre
or sea of upper energy (also called膳 中 shan zhong)
has also the meaning of a container filled with fat that
smells (shan means ram smell) Tan the fat whether it be
in cholesterol or lymph form tends to have a strong and
particular odour.
The variation in names of structures, points and func-
tions is traditional in Chinese Medicine. Professor Hu-
ang in his thorough book [4] on imagery and artwork of
meridians and acupuncture points tells us that as a result
of the fact that numerous and diverse schools of acu-
puncture of the pastthe author here thinks something
similar is happening nowadays developed different the-
ories and practices, the same name could refer to differ-
ent points, different points could correspond to the same
name, and moreover, numerous old point locations are
currently unknown.
There are more meanings of tan: bile, gall. Tan is also
the inner lin ing of an object, e.g. the bladder of a football
bladder [5] (metaphor of the thorax here?) which would
suggest a membrane (pericardial, endocardial, pleural).
A link between all meanings and denominations is es-
tablished when Lingshu 35 [6] says that tang zhong is
the Imperial palace of that by which the heart commands,
that is none other than the above mentioned xin zhu, that
by which the heart commands.
The phase fire (火 huo) along with heart and small
intestine has two other organs or functions: xin bao luo
pericardium (imprecise translation) and triple heater (三
焦 san jiao) term which also has a difficult univocal
translation to our European languages.
As it happens heart and xin bao luo (possibly pericar-
dium) work in unison as a single circulatory organ, and
thus the four names we have analyzed above actually
refer to the same functional notion of interchangeable
anatomical basis. When treating with acupuncture it is
often advised not to use points of the heart meridian but
rather use the xin bao luo ones “so as not to disturb the
emperor” [7] since both tracts points treat very similar
symptoms. The author understands that xin bao luo is a
function associated to xin heart and through it to the
small intestine, but since in yin yang structure it is im-
possible to be without a pair, xin bao luo gets paired up
with san jiao which is a nearby visceral system, neigh-
bouring in topography and with an anatomical base of
membranes and envelopes related to the pericardium
membrane.
Xin zhu another name for xin bao luo (the protective
wrapping of the heart and hence its importance) refers to
another facet of its function because zhu is the one who
holds the authority, decides, administers, reigns, rules,
that is the mastery the heart exercises as holder of the
sovereign fire (君 火 jun huo) .
Xin is heart, bao is to wrap, to contain, to take control
and luo is net, mesh, therefore xin bao luo is a ramifica-
tion which inside the fire movement is minister fire (相
火 xiang huo) Xin bao luo is the function by which the
hearts rules, not only there on the site but in the distance
as well. Because of the latter Lavier [8] suggests the
analogy of xin bao luo with the sympathetic system re-
lating san jiao with the parasympathetic one. Nanjing 25
[9] when dealing with the subject of xin bao luo―san
jiao couple insists on the fact that both have a name but
not form because the pairing combines firstly visceral
systems and secondly circulatory tracts (meridians). This
matter about having no form is not new because before
linking san jiao with xin bao luo, the first one was as-
cribed to ming men, the immaterial energetic area be-
tween the two kidneys where the ancestral energy moves.
In the constant search of the necessary harmony that this

193 E. PELUFFO
function needs, the working of the ming men area (there
is no organ) is generally attributed to the hormonal yang
right kidney whereas the yin left kidney is urinary.
In ming men resides the source (原 yuan) the origin
of every human being and that is the reason why it is a
region where energies, quite mobile, get transformed and
evolve. San jiao originates in that source, ming men.
We have just described two symmetrical spaces: tang
zhong between the two lungs and ming men between the
two kidneys, without organicity, only functional, with an
important energy charge of great mobility, one at the top
of the splanchnic cavity―thorax and another one in the
lower part, the pelvic area.
3. Anatomy and Physiology of Heart-Small
Intestine Pair
The explanation of the relationship between heart and
small intestine has, in the author’s opinion, anatomical
foundations from Chinese Medicine with outstanding
physiological bases and we also have, along with the
Chinese background, anatomical reasons recognized in
the West. Irrigation, the blood perfusion of the small
intestine was and is very prominent; practically the blood
is in direct contact with the bowels content; that is to say
that from the duodenum (which is part of the stomach
according to the Chinese medical thought) everything is
blood and quil (lymph). In Histology the intestinal villus
contains an arteriole, a venule, a quil vessel, a nerve.
Both Heart and Small Intestine belong to the move-
ment fire, heart the emperor (imperial fire) expresses
itself upward, towards the sky and its pair the small in-
testine catalyzes downward the ashes of what was burnt
on the way up. H. and SI. share this energy phase with
xin bao luo and san jiao, exceptional circumstance since
each phase is covered by only one pair of organs. But,
the fact is that movement fire is divided into two hierar-
chies: sovereign fire and minister fire and each visceral
pair corresponds to a category.
Wu Yun movements (wood, fire…) are five. Liu Qi
climatic energies (wind, heat, dampness…) add to six.
Both combined form the Wu Yun Liu Qi theory (五 运
六 气) also known to simplify, as Yun Qi. In this way
one of the six energies would remain without organic
representation. Then, it is likely that the unfolding of the
fire phase arose from the search for symmetry in order to
keep the pairings. Both Suwen not mentioning even once
the name xin bao luo and Lingshu doing it only in refer-
ence to meridians or acupuncture support the hypothesis
that fire was duplicated only for organ pairing reasons
[11]. What both books (Suwen 8 and Lingshu 35) re-
peatedly mention is the place-point tang zhong we saw
above attributed to ren mai 17 but functionally related to
xin bao luo. The author personally thinks that although
there seems to be no organ to link it to xin bao luo, it
seems to be a place for tang zhong (the mediastinum) as
there is a without-organ place between both kidneys for
ming men, a function closely related with xin bao luo
and san jiao. Places and spaces are also Anatomy.
At the same time, it is not clear whether the Chinese
described a specific organic substrate for xin bao luo
which although not an organ is generally associated with
the heart for its topography, the similarity of clinical
symptoms and its pairing with san jiao, its yang com-
plement in this fire movement and whose organic base
would be the system of membranes of the thoraco-ab-
dominal cavity (pleura, peritoneum, aponeurosis, fascias,
mesentery, diaphragm) The membrane serving as a yin
counterpart of these san jiao envelopes would be xin
bao luo, thus it is named pericardium in many texts. This
elaboration of the subject adds reasons to the pairing of
the heart and the small intestine because, if the pericar-
dium is closely associated to the heart and most part of
the peritoneum (san jiao) to the small intestine, both
membranes belong to the same fire movement and
therefore its functions (and meridians) fit together. The
author personally has doubts: if san jiao is pleura and
peritoneum (parietal, visceral) what is the reason for it
not being the pericar- dial membrane as well? That is to
say: does san jiao need a parietal support to be itself?
Would it lack that support in the pericardium? Or is this
morphofunctional pair a necessity in ancient China to
explain organic material (membranes) which they em-
pirically checked at the thoraco-abdominal cavity but
could not attribute to any specific viscera?
Li Chan wrote Yi Xue Ju Men (Introduction to Medi-
cal Studies) in 1575 [12] and one of its paragraphs can
shed light on the subject as it is clear that the author at-
tended dissections and describes what can be recognized
as the fibrous external layer of the pericardium and as-
signs the inner serous layer to the cardiac system:
“The yellow- or brown-fatty substance (huang chih
黄
眙 ) that spreads and envelopes (the heart) b elongs to the
cardiac system. Outside this spreading fatty subs- tance
there is a fine sinewy silk-fiber-like membra ne connected
to the lung system and to the cardiac and pulmonary
systems; this is the Envelope Junction xin pao”.
Sivin, translator of the Chinese text into English, warns
that Li Chan writes uterus (胞 bao) and not wrapping
(袍 pao) the ideographs have similar components and
are, of course, homophones. It is not easy to write Chi-
nese using only phonetics.
Let us remember that also for Galen the pericardium is
analogous to the protective structures (peritoneum and
meninges [13]) due to its two layers which, overlapped at
the base of the heart, allow its free contractility.

E. PELUFFO
194
In morphophisiology it is comprehensible, for instance,
that the liver gets coupled with the gall bladder but what
is not clear is the harmonization of the heart with the
small intestine. Each pair of coupled organs has its inner
yin aspect, the heart here, and its outer yang aspect, here
the small intestine. Being coupled, their meridians have
attached and opposite routes; the heart from the axillary
gap, through the palmar ulnar side of the arm and hand to
the little finger, and the small intestine through the dorsal
cubital edge of hand and arm from the small finger to the
face. In Chinese Medicine they are so related that one of
the branches of the heart meridian goes straight to the
small intestine; and this one after edging the scapula pe-
netrates deeply from the scapular waist to the heart where
it ramifies. See Figures 2 and 3.
In her investigations, the author confirmed an anato-
mical fact not usually taken into account, which seldom
appears in Anatomy charts and which helped her to un-
derstand the relation heart-small intestine: the thoracic
duct.
Herophilos, in Hellenistic Greece, described and na-
med the duodenum, (duodenum whose length is meas-
ured in twelve-finger units, but for the purposes of this
paper the author would like to highlight Herophilos’ de-
scription of the chyliferous vessels (chylo = liquid, hu-
mour) which were later more precisely distinguished by
Erasistratus but forgotten until two thousand years later
when Gasparo Aselli [14] (1581-1626) rescued this study
(Figure 1).
Chinese Medicine gives the lymphatic network func-
tional importance of a first order as a circulatory system
for a matter which from the intestine where it has its ori-
gin until it plunges into the heart cooperates in the pro-
duction of blood.
Figure 1. Intestinal villus [10].
Figure 2. Heart meridian.
Figure 3. SI. Meridian.

195 E. PELUFFO
Sodeman [15] explains:
“the lymphatic system is older that the venous one be-
cause in the primitive philogenetic levels the whole blood
goes straight from the small vessels to the tisular spaces
[…] blood and other components of the tisular liquid
then enter the lymphatic type vessels that go back to the
heart as a whole. In higher animals some of these vessels
stayed as lymphatic vessels whereas in others they trans-
formed themselves into less porous tubes: capillary and
veins”.
The great stomach luo vessel (虚 里 xu li) (Figure 4)
already appears, although a single time, in Suwen 18 (13
in some versions).
“Xu li passes through the diaphragm and connects
with the lung collateral channel luo; leaves from below
the left breast where its pulsing, the pulsing of the an-
cestral energy, can be felt (zong qi)” [16].
This point corresponds to S18 ru gen (base of the
breast 乳 根) For Schatz et al. [17] xu li is an embrionic
luo consecrated to nutrition.
One translation of xu li is “inner void” inner in the
endo [18] sense, although the author can see in dictionar-
ies other possibilities of interpretation related to the term
xu in Chinese Medicine: free circulation [19] which then
would read “free inner circulation” linking this to the
concept of void as space for the interchange of energies,
whichever those energies might be. According to Un-
schuld [20] Chinese and Japanese philologists are trying
Figure 4. Xu li.
to find a sense for the phrase xu li, a subject which is still
under discussion and, although the author does not want
to force a meaning ascribing it to the Greek chyl oi, is
close to a possible parallelism between this Chinese de-
scription of xu li and the circulation of lymph, include-
ing the thoracic duct.
The route of the small intestine meridian and the sto-
mach in Chinese anatomy can explain why the author
considers that the xu li stomach vessel is related to the
chyliferous vessels and the thoracic duct: is known that
the thoracic duct comes directly from the small intestine
(Pecquet’s cistern) Loaded with lymph, it empties itself
into the right auricule which is no other that the dilate-
tion of the left subclavian vein which together with the
left internal jugular forms the vena cava superior. The
small intestine empties its processed content directly into
the right heart which sends it to the lung and from there
to the left heart and general circulation (Chinese Medi-
cine states that the heart commands the blood that nour-
ishes all the organs) It should not be forgotten that blood
in Chinese language involves all the nutritious liquids,
among which the lymph stands out. For more interior-
ganic relations, let us say that point Bladder 22 in the
lumbar region, point to treat the san jiao pathology, is
located between the L1 and L2 vertebrae where, from the
inside, Pecquet’s cistern rests. The meridian system is
clearly conceived as a network linking the functions of
all the organic structures. There have been attempts to
relate the thoracic duct with the meridian rem mai as
mentioned by Maspero [21] in a text where he identifies
the ren “vena” with the thoracic lymphatic channel. Me-
ridians, although they were conceived by the Chinese as
invisible energetic routes, do not represent the author’s
idea of the thoracic duct as an actual organ.
3.1. Anatomy of the Intestinal Blood Circulation
It may be useful to know the description that Chinese
Medicine doctors did of both intestines. They differenti-
ated with certainty the small intestine from the large one,
and they also analyzed the vascular patterns that nour-
ished both of them to deduce their respective functions.
Let us remember that one way to interpret the meridians
is to assimilate them to the routes of vessels and/or ner-
ves.
The small intestine starts, according to Chinese Medi-
cine, in, gate of darkness (幽 门 you men) pyloric re-
gion which comprises the duodenum and the jejunum
(Figure 5). The large intestine, which they called wide,
shared the ileum with the small bowel as far as the, gate
of interception region (阑 门 lan men) ileocecal valve
that in other texts [22] is cited as 关 门 guan men,
name of the point Stomach 22 on both sides of the ven-

E. PELUFFO
196
tral midline, 2 cun above and out of the navel and serves
to treat low digestive disorders. Ling Shu 31 [23] de-
scribes its Anatomy:
“The small intestine rests from the back on the ver-
tebral column, on the left it twists and makes 16 loops in
superposed layers, approaching the large intestine and
turning backwards, it rests on th e navel”.
The navel ventrally corresponds to the second lumbar
vertebrae, where adheres to and fixes the mesentery that
holds the Pecquet’s cistern [24].
Large intestine includes the left half of the transverse,
the descending colon, the sigmoid, the rectum, and anus
from western nomenclature. This apparently strange divi-
sion of the intestine comes from the way of distributing
the circulation that irrigates this part of the digestive tract
The author would like to re-state the fact that the itiner-
ary of both blood and energy (meridians) depended on
vascular routes, and in this particular case jejunum, il-
eum, caecum and transverse colon united because they
were supplied by the superior mesenteric artery whereas
the Chinese “wide” intestine would get blood from colla-
terals to the inferior mesenteric artery. This description
would point to the practice of dissections.
Each intestine had a different task: the small intestine
would rule the digestion process because it absorbed
nutrients and digestive juices and, since the wide bowel
only absorbed water, it was considered that it would con-
trol not exactly the quality but rather the quantity of the
organic liquids.
Figure 5. Small intestine and “Wide” intestine [25].
3.2. Meridians
The paths of the meridians, another way of explaining
the Anatomy in China, express relationships among vis-
cera. The internal path of the meridian of the heart from
its origins in the middle of the heart (literally in the cen-
tre of the heart) but not penetrating it, rather lies on the
“heart support”―the pericardium xin bao luo, probably
the aorta and some other large vessels going in and out of
the heart and along with them crosses through the dia-
phragm, passes to the mesenteric artery and branches out
in the small intestine which is spirally enveloped by it.
Another branch coming out of the heart too outlines the
sides of the oesophagus and ascends up to the eye (“to
the support of the eye”) probably the optic nerve where it
connects with the peripheral tissues of the eyeball and
continues to the brain. The external path: the meridian
itself leads off from the heart, goes through the lung and
into the axilla in whose pit lies jiquan the first point H1.
It goes along the arm through the palmar surface radial
side next to the meridian xin bao luo on some paths that
coincide with the angina pectoris clinics.
The ideograph for heart (心 xin) is said to show the
heart body: above the aorta, in the middle the viscera and
to the sides a synthesis of the pericardium. In Chinese
Medicine the heart is principal: “it is the chief of the five
zang and the six fu and therein lies Shen the spirit”. The
Classics explain that “if the heart is attacked, the Shen go
and if the Shen go, then it is death”, “the heart is the
trunk where life gets rooted”, “all the blood depends on
the heart” [26]. Its functioning is expressed in the mouth,
at the tip of the tongue, in the speech.
The pre-eminence of the heart is due to the fact that it
is the residence of mental energy (神 shen). By the way,
let us say that this concept is not strange to the West
where for the hermetic medicine practiced by Paracelsus
[27] among others, mind is located at the highest part of
the right auricle.
Meridians are a speculative product of Chinese thought in
its application to both body and Medicine. Nanjing 35 [28]
already explains that the small intestine as a highly vas-
cularised organ (see histological illustration) is the red
intestine (movement fire) the large bowel is white intes-
tine (metal) the gall bladder is the green intestine (wood)
stomach is the yellow intestine (earth) and the bladder
the black one (water).
The external path of the small intestine meridian – en-
ergetically yang starts at the little finger external ungual
angle, continues along the cubital side of the hand, as-
cends by the posterior external side of the arm, then by
the posterior axillary fold, after that it goes to the supra-
clavicular pit and enters the thorax to interact with the
heart, descends along the oesophagus, crosses the dia-

197 E. PELUFFO
phragm, reaches the stomach and finally the small intes-
tine. A branch leaves the small intestine to join the sto-
mach at the S39 point.
The picture (Figure 3) clearly shows how the SI meri-
dian enters the supraclavicular pit, moves towards the
thorax to spirally envelope the heart as well as the oe-
sophagus and the stomach where it comes in contact with
the intragastric material, beginning of the quil that will
transport the above mentioned xu li, the stomach luo
large vessel.
Nanjing 35 shows in a detailed way that the small in-
testine has a dynamic relation with the RM 9 point, ren-
mai 9 shui fen water partition or water separation point
which located on the midline of the abdomen slightly
above the navel, regulates the abdominal vasomotricity
and is also related to ren mai 10 xia wan “the place of
the small intestine” [29]. The small intestine receives
water and food from the stomach and during digestion
proceeds to separate clear from turbid. The clear are the
interstitial liquids, the turbid are the dregs that will move
to the large bowel to be evacuated. It is understood what
turbid is, and the clear points towards the bowel absorp-
tion that will transport the noble materials from the lim-
phosanguineum circuit once they have been passed th-
rough the liver.
Classic texts are precise in their description “The
small intestine is responsible for receiving and filling up,
and the transformed goes out”. Sheng filling up (剩)
refers to an intense physiological activity taking place in
the contact surfaces of the bowel villus. The product of
this is the transfer of the material so processed to the
blood and lymph circulation and to the large intestine as
well. For ancient texts the motility of the small bowel
“mixes and transports”, that is what we call peristaltism.
To make reference to the separation between clear and
turbid they use the terms press and sift [30].
There are more data to help understand the relation-
ship heart-small intestine. Let us remember that in em-
bryology heart and small intestine are formed in the same
movement between the 3rd and 4th weeks when the pri-
mitive bowel is defined and both cardiac tubes [31] join
together. The jejuno-ileon is the result of the anterior
portion of the primitive intestine [32].
4. Conclusions
There are Eastern and Western anatomical reasons as well
as energetic ones from Chinese Medicine which explain
the forming of the heart-small intestine pair.
This anatomo-functional approach describes the ab-
stract speculative aspects as well as the concrete ones,
generally Taoist in origin, on which Chinese Medicine
bases its conception of the human body as well as its in-
ter relationships. Western culture reasons in a different
way, and does not take part in an integrative conception
of the body, rather it fractions the human body in appa-
ratus with scarce mutual functional connectivity. How-
ever, researching and trying to bring together these two
conceptions, Western Anatomy has available data to
complement the explanation of the Eastern idea.
Chinese theoretical-practical notions are the product of
a fine and thorough clinical and anatomical observation
interested in justifying the integration of organ-function
zang 脏 with organ-function fu 腑 at every energy
state according to the yin yang principle and qi dynam-
ics, which proves the morphophysiologycal interadjust-
ment between the naturalistic theoretical conception of the
body according to secular Chinese Medicine.
5. References
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[5] “Diccionario Español de la Lengua China,” Madrid,
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