Chapter 119 You're… Showing… Showing…

Alex arrives hoping to learn from Evan. A house call gives him the chance.

The next morning, Evan came to work at Mingxin Clinic.

First, he asked Clara to pack the herbs. They would go straight upstairs in a little while to decoct them for Adam.

“Morning, Dr. Xu!”

Someone ran in while the two of them were busy.

It was Alex Xu.

Evan turned to him. “Morning. Did your hospital director send you to see me?”

Alex quickly shook his head. “No, no. It's my day off. I thought I could come and learn from you—take down your prescriptions and study them… Would that be all right?”^[1]

Clara and Ben both looked at him.

Neither of them knew what had been going on between Evan and the Chinese medicine hospital over the past few days. They only knew he'd been there to help a few times. They hadn't expected a young man to turn up asking to learn from him.

Sitting at the back, Ben asked, “Is this the young doctor who came with Director Zhong last time?”

Clara nodded and put it more bluntly. “Yes. The one who came to pick a fight.”

Alex's face went red. This was embarrassing.

He coughed a couple of times to cover his discomfort. “About last time… I was out of line. I'm sorry. I'm sorry.”

“It's all right,” Evan said. “I'm just about to make a house call. Come along.”

“Oh, great!” Alex agreed at once, delighted.

Clara glanced at him and pointed to the packets of herbs on the counter. “Little Xu, bring the medicine.”

Alex froze. “Little Xu?”

She rolled her eyes. “Of course. I'm Dr. Xu's boss, you know.”

Well, that settled it. He wasn't about to cross her. Alex gave an awkward laugh and obediently picked up the herbs.

Ben shook his head too, looking as though he knew exactly how Alex felt.

The three of them walked into the residential community and went upstairs to Clara's home.

Once they were inside, Evan said, “Shut all the doors and windows.”

Clara nodded. “Right, Little Xu. Go and close the windows.”

Alex was bewildered all over again.

Evan shook his head, lost for words. “Come on, get a move on. We've still got work to do.”

Clara laughed. “All right, all right. Let's all help.”

Alex put down the herbs, and together they closed all the doors and windows in the apartment.

Clara went into the other room to wheel her father out.

Evan told Alex, “The patient had a stroke two months ago and still hasn't recovered. His right side is paralyzed, his tongue is stiff, and his speech is slurred. Do you know why I wanted the doors and windows shut tight?”

Alex was visibly taken aback. He didn't know.

Clara had already wheeled Adam out.

His eyes and mouth were still skewed. He looked dejected, as though nothing in life interested him.

“This is the patient?” Alex asked.

Adam slowly raised his head. The moment he saw Evan's face, his listless eyes opened wide.

Puzzled, Alex looked from Adam to Evan.

Evan gave a slight nod, then asked Alex, “Do you know what causes wind stroke?”

An examination! Alex immediately perked up. He gathered his thoughts.

“Wind stroke results from the cumulative effects of internal damage. Overexertion, sexual excess, diet, emotions, or external pathogenic influences disrupt yin and yang, throwing qi and blood into disorder and driving them upward to affect the brain. The main symptoms are sudden collapse, loss of consciousness, paralysis on one side, deviation of the eyes and mouth, and difficulty speaking.”^[2]

Evan smiled. “The standard textbook answer.”

Alex scratched his head, embarrassed.

Adam looked at the two young men in puzzlement. What were they up to? Questions and answers, as though they were taking an exam?

He glanced at Clara, standing nearby. His daughter was watching Evan without blinking.

Adam's eyes showed that he understood at once.

“Wind stroke has been known for a very long time,” Evan said. “The Neijing calls it da jue, pu ji, pian ku, and fei feng.

“The name zhongfeng, wind stroke, was first listed in the Jinkui Yaolue. It proposed that internal deficiency allows a pathogenic influence to strike. ‘Where pathogenic influences gather, qi must be deficient.’ Zhongjing identified the cause of wind stroke as ‘empty collateral vessels allowing pathogenic wind to enter.’

“Depending on how deeply the pathogenic influence has entered and how severe the condition is, it is divided into wind striking the collaterals, the channels, the fu organs, and the zang organs. Treatment is based on dispersing wind, expelling the pathogenic influence, and supporting upright qi.”^[3]

Alex had already taken out a notebook and begun to write.

Adam eyed the pair with distaste, his crooked mouth twisting in disdain. What a performance. The same old trick of showing off to impress a girl? How long had that one been around?

Evan continued, “Wind striking the zang organs can be divided into yang-closed, yin-closed, and collapse patterns. In a yang-closed pattern, the patient collapses and loses consciousness, with the jaws clenched and both fists tightly closed. The face is red and breathing rapid. There may be a sawing rasp of phlegm, or bodily heat and agitation. The tongue coating is yellow or greasy, and the pulse is usually wiry, slippery, and rapid. As for a yin-closed pattern…”^[4]

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Point by point, he went over the clinical essentials of pattern differentiation with Alex.

Alex dutifully took notes.

When he had finished, Evan asked, “I've just given you the key points. Can you now work out the underlying cause in this patient's case?”

Alex considered it.

Evan turned to Clara. “Go and start decocting the herbs.”

“Okay.” She took the medicine into the kitchen.

After some thought, Alex asked, “Um… what about his tongue findings?”

Evan didn't have him examine Adam's tongue. He simply told him, “Slightly red, with a thin white coating.”

“Huh?” Alex paused. Those findings didn't give him much to go on.

He asked Adam about his symptoms.

Adam couldn't be bothered to answer him.

Alex was at a loss.

With the patient so uncooperative, Evan didn't have much choice either. “The symptoms are just what you can see. There aren't any others. Also, he can't move his right hand. It's his right side that's paralyzed.”

“That's all?” Alex asked, taken aback.

Evan nodded.

Alex was even more confused. Nothing about the symptoms stood out. They were essentially the usual problems after a stroke: unclear speech and difficulty moving.

That was one of the difficulties of treating illness. A textbook might lay out all the symptoms neatly, but patients didn't get sick according to the textbook.

Alex thought for a while. “Well… judging by how long it's been since the onset, he's past the acute phase and into recovery. And if he has no other symptoms apart from paralysis on one side, I think we could use Buyang Huanwu Tang.

“Paralysis on one side is often due to depletion of original qi. Buyang Huanwu Tang uses a large amount of huangqi—astragalus root—to replenish qi strongly. It also includes herbs that invigorate blood and unblock the channels, so it can treat stagnant blood in the channels. It should work.”^[5]

Adam looked sideways at him. It took some effort, but he still managed to roll his eyes.

“Qi deficiency with blood stasis?” Evan asked. “What makes you think so?”

“Uh… because his symptoms aren't very distinctive. And what we call zhongfeng, Western medicine calls a cerebral stroke. Generally, when one side is paralyzed, it's because the blood vessels in the brain are blocked.

“There's a blockage, you see. Qi commands the blood, so strongly replenishing qi has to be right. With qi commanding the blood, how could there be any blockage? Then add herbs to invigorate blood and resolve stasis, clear the stagnant blood in the brain, and it should work.”^[6]

Evan smiled and shook his head.

Alex was suddenly worried. “Dr. Xu, am I wrong?”

“Typical Western medical thinking. See stasis, clear stasis. See a blockage, remove it. You're lucky we have all these instruments now that can show a blockage in the brain. But in ancient times, without any of those instruments, how would you establish that there was stasis?”

“Uh…” Alex didn't know what to say.

“I'm not saying you can't use Buyang Huanwu Tang,” Evan said. “But first you have to establish whether the patient's pattern is qi deficiency with blood stasis. The tongue might be pale purple or have spots of stasis. This patient's tongue doesn't suggest that. When the symptoms are unclear, rely on pulse examination.

“You've made two mistakes. First, you heard that the stroke happened two months ago and simply decided he must be in recovery. Second, when the symptoms were unclear, you ignored the pulse and signs and jumped to a conclusion based on the Western medical diagnosis.

“When practicing Chinese medicine, you mustn't have the slightest preconception. Remember Zhongjing's instruction: ‘Examine the pulse and signs, understand what has gone wrong, and treat according to the pattern.’^[7]

“From now on, recite those twelve Chinese characters before you treat any patient.”

“Understood,” Alex replied gloomily.

Adam rolled his eyes and, through his crooked mouth, muttered in a low stammer, “You're… showing…

“Showing…”

Reader Notes

Reader Notes

1. ↩︎ Learning through prescriptions. Copying prescriptions here means recording and studying a clinician's prescriptions as part of learning beside that doctor. The aim is to understand how observations and reasoning lead to a choice of medicines. Modern descriptions of Chinese medical mentorship likewise include supervised clinical learning, notes, and case records. Alex's request is for that kind of practical learning; the exchange does not establish a formal master–disciple ceremony or a new professional qualification. Source: National Administration of Traditional Chinese Medicine — Mentorship education measures, Articles 3, 6, and 15–16 (in Chinese).
2. ↩︎ Wind stroke.Zhongfeng, literally “struck by wind,” is a traditional disease category associated with sudden collapse, one-sided paralysis, facial deviation, and related symptoms. Its historical scope does not map exactly onto a single modern diagnosis. In Alex's textbook explanation, yin and yang describe interdependent aspects of bodily function, and qi and blood belong to the traditional account of how that function is maintained or disrupted. “Wind” is part of this medical vocabulary, rather than a statement that an ordinary draft causes every biomedical stroke. Source: WHO — International standard terminologies on traditional Chinese medicine, entries 3, 224, and 1758.
3. ↩︎ The classical account. The Neijing is the Huangdi Neijing, or Yellow Emperor's Inner Classic. The Jinkui Yaolue, commonly called Essentials from the Golden Cabinet, is associated with Zhang Zhongjing. Its wind-stroke chapter describes pathogenic influences affecting collaterals, channels, fu, and zang: categories within traditional medicine, rather than modern imaging locations. Evan's historical summary remains his dialogue. The saying about pathogenic influences gathering where qi is deficient also appears in the Suwen section of the Neijing, chapter 33; its placement here should not imply that Zhongjing originated it. Sources: Jinkui Yaolue — chapter 5, Chinese transcription; Suwen — “Ping Re Bing Lun,” chapter 33, Chinese transcription.
4. ↩︎ Closed and collapse patterns. In this traditional classification, severe wind stroke can be discussed in terms of “closure,” an obstructed state, and “collapse,” a state of profound depletion. Yang-closed and yin-closed distinguish presentations associated with heat and cold respectively. These names concern patterns inferred from a collection of observations; they do not mean a blood vessel is simply open or closed. Evan is reviewing the categories with Alex. The lecture has not yet assigned Adam to any of them. Source: Beijing Tiantan Hospital, via the Beijing Municipal Health Commission — Explanation of wind-stroke closure and collapse (in Chinese).
5. ↩︎ Buyang Huanwu Tang. This traditional formula is described as replenishing qi, invigorating blood, and unblocking the collaterals, particularly within a qi-deficiency-and-blood-stasis pattern. Huangqi, astragalus root, has a leading role in its traditional rationale: supplementing qi is meant to help move blood. The formula's name is retained in pinyin; tang denotes a decoction. Alex is proposing it on that reasoning. Its mention does not establish that Evan has prescribed this formula, or identify the herbs Clara has taken into the kitchen. Source: Hong Kong Baptist University — Bu Yang Huan Wu Tang, F00116, “Action,” “Indication,” and “Pathogenesis”.
6. ↩︎ Blood stasis and a blocked vessel. Blood stasis is a traditional pattern concept; “qi commands the blood” expresses qi's role in moving and containing blood within that model. Neither phrase by itself establishes a clot on a scan. Biomedical stroke includes both ischemic stroke, involving interrupted blood supply, and hemorrhagic stroke, involving bleeding. Alex's generalization about blockage is part of the reasoning being questioned here. No scan findings or biomedical stroke subtype for Adam have been supplied. Sources: WHO — TCM terminology, entries 250, 1113, and 1134; CDC — About Stroke, “What it is” and “Types”.
7. ↩︎ The twelve characters. Evan quotes a maxim associated with Zhang Zhongjing's Shanghan Lun. “Twelve” counts the Chinese characters, rather than the words in this English translation. In its classical setting, the instruction concerns reassessment after treatment has gone wrong: examine the pulse and signs, understand the adverse development, and respond to the resulting pattern. Evan applies it here as a rule against approaching a patient with a fixed conclusion. The quotation does not itself establish that Adam's previous treatment was mistaken. Source: Shidianguji — Quotation and source in the annotated Shanghan Lun (in Chinese).