Loading...
Chapter 68 of 81
黄帝内经·灵枢
The Yellow Emperor asked: With regard to the condition of Upper Diaphragm (where food is immediately regurgitated upon entering the stomach — i.e., vomiting right after eating), I already understand it. However, regarding Lower Diaphragm (where food is vomited only after a prolonged period in the stomach)—a condition caused by worm accumulation, where food entering the stomach is expelled only after about a full day and night—I have yet to grasp the underlying principle. I hope to hear a detailed explanation from you.
Qi Bo replied: If a person experiences inappropriate joy or anger (emotional dysregulation), immoderate eating and drinking (lack of dietary restraint), or untimely exposure to cold and warmth (inappropriate climate influences), this causes cold-natured fluids to flow into the intestinal tract. When cold fluids flow into the intestines, they cause worms (referring in ancient times to intestinal parasites) to become chilled and accumulate in clusters, coiling around the region of the lower passage (the lower opening of the stomach, i.e., near the pylorus). The accumulated worms create blockage, leading to distension and engorgement of the intestines and stomach (gastrointestinal fullness). The defensive qi (the qi that protects the body surface and resists pathogens) can no longer circulate properly, and pathogenic qi takes advantage of the deficiency to lodge within.
When a person eats, the worms smell the food's aroma and wriggle upward to feed. When the worms ascend to feed, the lower passage becomes vacuous (empty). Once the lower passage is vacuous, pathogenic qi seizes the opportunity to enter, and accumulation consequently settles and lingers. As accumulation persists over time, an abscess (a lesion where qi and blood stagnate and heat putrefies to form pus) forms. After the abscess forms, the lower passage becomes constricted and its channel narrows, so food cannot descend smoothly and is vomited only after a prolonged period.
If the abscess is within the passage (on the inner wall of the intestine), the pain is deep-seated. If the abscess is outside the passage (on the outer wall of the intestine), the pain is more superficial, and the skin above the abscess is warm to the touch.
The Yellow Emperor asked: How should needling therapy be applied?
Qi Bo said: First, use the fingers to gently press the abscess and observe the pathways of qi and blood movement as well as the abscess's depth and location. First needle superficially at the side of the abscess, then gradually advance deeper, repeatedly adjusting the needling, but do not exceed three passes. Determine the depth of needling based on the abscess's depth and superficiality (whether it is deep or shallow). After needling, the application of a warm compresses (hot ironing) is essential, allowing the heat to penetrate deep into the body, causing warmth to enter internally each day. In this way, pathogenic qi gradually recedes, and the great abscess will dissolve and disperse. At the same time, dietary restrictions (which ancient people called "can ji") should be observed to eliminate the internal pathogenic drivers. One should also maintain a state of calm tranquility and non-striving (inner peace and freedom from excessive exertion), so as to allow qi and blood to circulate. Thereafter, salty-tasting substances (salt softens hardness and resolves masses) can be used for regulation, and food and grains will be able to digest and descend normally.
📌 Editorial note on textual corrections: The original text of this chapter contains several scribal errors in transmission: "shang zhu" should be "shang ge" (Upper Diaphragm); "shi yin bu jie" (immoderate eating) was erroneously written and is corrected accordingly; "zhu fu" should be "chen fu" (deep and superficial); "yi zhi" should be "yi ci" (after needling); "tian zeng" should be "tian dan" (calm tranquility); "cheng ruo" is suspected to be "xian ruo" (salty-like [substances]). The translation above follows the commonly accepted revised version.
The central medical principle of this chapter lies in discussing the etiology, pathogenesis, and needling treatment of Lower Diaphragm disease, embodying several important ideas from the Inner Canon (Nei Jing):
I. The Three-Dimensional View of Etiology Qi Bo categorizes the causes of Lower Diaphragm into three types: emotional dysregulation (inappropriate joy and anger), dietary excess (immoderate eating and drinking), and improper exposure to exogenous influences (untimely cold and warmth). These three factors jointly give rise to cold-type pathological products (cold fluids) generated internally, which then trigger a cascade of pathological changes. This reflects the holistic perspective of "three categories of etiologic factors" consistently emphasized in the Inner Canon-internal, external, and neither-internal-nor-external causes interweaving, rather than any single factor acting in isolation.
II. The Chain-Like Progression of Pathogenesis This chapter presents a clear chain of pathological development:
Cold fluids flow into the intestines → Worms become chilled and accumulate → Intestines and stomach become distended → Defensive qi fails to circulate → Pathogenic qi takes lodging → Worms ascend to feed, the lower passage becomes vacuous → Pathogenic qi prevails and accumulation lingers → Abscess forms → Lower passage becomes constricted → Food cannot descend
This chain reveals the dialectical relationship between "vacuity" (deficiency) and "pathogenic qi": when worms ascend to feed, the lower passage becomes vacuous; when vacuous, pathogenic qi takes advantage to enter—this is a specific elaboration of the Inner Canon principle that "Where pathogenic qi aggregates, vacuity must necessarily exist." Additionally, the progression from accumulation to abscess formation reflects the pathological evolution of qi and blood stagnation that over time transforms into heat and generates pus.
III. Interior-Exterior Differentiation of Abscesses "When the abscess is within the passage, the pain upon palpation is deep; when the abscess is external, the pain upon palpation is superficial, and the skin over the abscess is warm"—this is a diagnostic method that distinguishes the location of the abscess focus through the depth of pain location and whether the local skin is warm, embodying traditional Chinese medicine's diagnostic principle of "inferring the internal from the external" (Si Wai Chuo Nei). Deep pain indicates the abscess is internal; superficial pain with warm skin indicates the abscess is external. This approach of deducing internal pathology from external surface manifestations remains diagnostically meaningful to this day.
IV. The Hierarchical Approach to Needling "Gently press the abscess, observe where qi moves"—first palpation for localization; "first needle superficially at the side, then gradually deepen progressively"—a from-superficial-to-deep, stepwise advancement in needling layers; "do not exceed three passes"—the therapeutic principle of moderation and knowing when to stop, avoiding excessive needling; "observe its depth and superficiality, and determine the depth [of needling] accordingly"—the individualized treatment philosophy of adjusting according to each person and each condition. Together these constitute the Inner Canon's principles of needling safety and precision.
V. The Holistic Treatment Approach of Post-Needling Care After needling, treatment does not end-rather, three approaches must be combined: warm compression (heat penetrating internally to help pathogenic qi recede), dietary restrictions (eliminating internal causes), and calm tranquility and non-striving (regulating emotions to facilitate qi circulation). This embodies the Inner Canon's idea of "integrating treatment with recuperation"—treatment measures are only interventions; ultimate recovery depends on the body's own restoration of righteous qi, which in turn requires dietary and emotional cooperation.
Regarding "worm accumulation" and Lower Diaphragm What the ancients called "worms," viewed from a modern medical perspective, primarily refers to intestinal parasites (such as roundworms). When roundworms accumulate in large numbers within the intestines, they can indeed cause intestinal obstruction, presenting with abdominal pain, distension, and vomiting—which is considerably consistent with the symptoms of "distension of the intestines and stomach" and "food entering that recurs" or "food expelled after about four hours" described in this chapter. The ancients' ability to link both ingestion and subsequent regurgitation with intestinal parasites over two millennia ago demonstrates acute clinical observation.
Regarding the "abscess" The description "when the abscess forms, then the lower passage is constricted" corresponds, in terms of modern pathology, most likely to localized inflammatory masses or ulcerations of the intestine, causing luminal narrowing or obstruction that hinders the passage of food. While the ancients employed the concept of "abscess" to encapsulate this localized lesion of qi and blood stagnation with heat putrefaction generating pus, their macroscopic-level recognition is directed correctly regarding the pathological processes of inflammation and suppuration.
Regarding "cold fluids flowing into the intestines" The interpretation of "cold fluids" cannot be simply equated with "fluid" in the modern anatomical sense. Understanding this from the perspective of TCM pathogenesis, it refers to metabolic dysregulation of fluids due to yang deficiency with cold congelation, where normal fluid distribution fails and pathological accumulation lodges in the intestines. Though modern medicine has no concept like "cold fluids," we do observe abnormal intestinal secretions, edema, and exudation in numerous digestive system diseases. The ancients' descriptions are abstract encapsulated insights within the yin-yang, cold-heat theoretical framework about pathological phenomena.
Historical Limitations Observation: The ancients attributing the cause solely to the unitary chain of "worms chilled, then accumulation" oversimplifies the complex etiologies of intestinal obstruction, pyloric obstruction, and similar conditions. The causes of Lower Diaphragm in modern medicine include tumors, ulcer scars, hernias, adhesions, parasites, and many other possibilities—far beyond "worm accumulation" alone. Furthermore, the specific "needling not exceeding three passes" technique described in the chapter, given differences between ancient and modern needles and anatomical understandings, cannot be assessed for actual efficacy using modern standards and should not be directly applied unmodified in clinical practice.
Although this chapter discusses lower diaphragm disease specifically, the general principles of lifestyle regulation embedded within still hold relevance for ordinary people:
Maintain emotional equilibrium ⚡: Uncontrolled joy or anger disrupts qi movement and affects digestive function. In daily life, maintaining emotional stability—avoiding violent anger, excessive elation, or prolonged worry—helps sustain normal gastrointestinal function. This corresponds meaningfully to the modern medical "gut-brain axis" theory—that emotional states significantly affect the digestive system.
Practice dietary moderation ⚡: Immoderate eating—in food quantity, in the frequency and volume context that lifestyle engenders—is explicitly identified as one of this chapter's etiological factors. Daily life should emphasize regular timing and appropriate quantity, avoiding bingeing, avoiding excessive raw or cold food, advising thorough chewing and slow swallowing, to facilitate a consistent pattern permitting the digestive system to work regularly.
Demonstrate care in protecting against cold in daily routines ⚡: Untimely exposure to cold and warmth can permit cold pathogenic influences to invade internally. Especially during season transitions and cold periods, attention to abdominal warmth and avoidance of cold foods and beverages irritating the digestive tract directly are everyday health maintenance essentials.
Cultivate a tranquil mind for nurturing spirit ⚡: The text particularly emphasizes "calm tranquility and non-striving, then qi can circulate." Maintaining inner peace and freedom from excessive exertion assists systemic qi flow and enables normal digestive function. Modern life is pressured; aware space must intentionally be created for relaxation and rest.
Nourish the spleen and stomach with warmth ⚡: The warm compression method reflects ancient emphasis on "warming and unblocking." In daily life, moderately warm food and drink, avoiding long-term, large quantities of cold beverages, fall under a behavioral range demonstrating consideration for the spleen and stomach that is benign facilitatively (and useful without being placed conceptually against diseases specifically).
Related Concepts:
Further Reading:
This content on classical Chinese medical canons is provided for traditional culture learning and research purposes only. It does not constitute any medical diagnosis, prescription, or treatment recommendation; in case of symptoms of conditions/disval clinical concerns please promptly seek qualified appropriate professional institutional visitation.