Chapter 31 What Makes the World Interesting

An injured back brings the discussion around to how Chinese medicine chooses a treatment.

Hearing that his roommate had a problem too made Max feel much better. See? He wasn't the only one making a fool of himself.

The two female classmates who had come with them covered their mouths in shock. Were all the guys in their class this weak?

Charlie turned in surprise. “Didn't you hurt your back playing ball yesterday?”

“Yes! Yes, I strained it!” Max's roommate declared loudly, eager to clear his name. “It's a strain. I'm not weak!”

Evan nodded. “Still hasn't healed?”

“Not completely.”

“Want me to treat it?”

The roommate hesitated, looking from Max to Charlie.

Max had started all this. Word had spread from one person to another until it reached Charlie, a senior student who was something of a celebrity at their medical school.

Building a medical education account with more than 300,000 followers while still a medical student was no small achievement. The younger students idolized him.

When Charlie said he was coming for an academic discussion and some publicity for his account, these younger students had all tagged along.

That was why Max's roommate was looking to Charlie. Charlie was leading the group today.

Charlie looked at Evan in puzzlement. “You treat injuries like this too?”

Evan nodded. “A little.”

He turned to Max. “Didn't you say the meridians and acupuncture points in Chinese medicine were imaginary? Today I'll show you they're real!”

Why was he being dragged into this again? Max stared at the floor, searching for a crack to crawl into…

His roommate, on the other hand, perked up. “Oh, I get to try it? All right, Dr. Xu. Take a look at me.”

Evan nodded. “Fifty yuan for acupuncture.”

“Sure. I've got medical insurance anyway.” The roommate came over, supporting his lower back with a hand.

Max kept looking for that crack in the floor.

Evan supported the roommate's lower back as he examined it. “Chinese medicine isn't as simple as you think. We don't just see a disease and treat the disease, or see a symptom and treat the symptom.

“We identify the pattern and treat accordingly. We need to understand what's going wrong in each patient. I know you're all medical students, but you can't just impose the framework of Western medicine on Chinese medicine.^[1]

“Of course, I'm not against Western medicine. In fact, I admire it. It's the differences that make the world interesting, and that goes for medicine too. That's why I can't stand prejudice between schools of medicine.

“Take Liuwei Dihuang Wan. Everybody knows it's supposed to strengthen the Kidneys. What they don't know is that it's for Kidney yin deficiency—heat and restlessness in the palms, soles, and chest, and waves of heat that seem to come from the bones. It's for depleted Kidney yin.^[2]

“You have a yang-deficiency pattern. Taking Liuwei Dihuang Wan won't help, and it might even make you worse. But instead of blaming yourself for taking the wrong medicine, you'll just say Chinese medicine is useless.”

Max turned bright red. He'd always attacked Chinese medicine, but when Liuwei Dihuang Wan had done nothing for him, he'd become even more hostile. Chinese herbs really were useless, weren't they?

“For Kidney yang deficiency,” Evan said, “there's Guifu Dihuang Wan or Jingui Shenqi Wan. But you shouldn't limit Guifu Dihuang Wan to Kidney yang deficiency alone. Never mind you students—plenty of Chinese medicine practitioners make that mistake now.

“Guifu Dihuang Wan is primarily for deficiency and exhaustion. Gui and fu—the cinnamon and fuzi—are both strongly heating medicinals, but the Dihuang formula nourishes yin. This is the medical sage Zhang Zhongjing's eight-ingredient Shenqi Wan, also called Cui's Eight-Ingredient Pill. Because it's in the Jingui Yaolüe, the Essential Prescriptions of the Golden Cabinet, later physicians called it Jingui Shenqi Wan.

“The ready-made Jingui Shenqi Wan you can buy today isn't the original classical formula. It has two extra ingredients that promote urination. Guifu Dihuang Wan is actually the original formula, with eight ingredients. Qian Yi, the famous Song-dynasty physician, adapted it by removing gui and fu. That left six ingredients, hence Liuwei Dihuang Wan.^[3]

“Liuwei Dihuang Wan started out as a pediatric medicine. But with all the marketing these days, everyone thinks it's some miracle Kidney tonic. How can you expect it to work if you take it without identifying your pattern?

“As for Guifu Dihuang Wan, Sun Simiao, the King of Medicine, summarized its indications in the Qianjin Fang: ‘Deficiency and exhaustion, intense thirst with a desire to drink water, lower back pain, cramping in the lower abdomen, and difficulty urinating.’ These are signs of deficiency and exhaustion, not just yang deficiency.^[4]

“So it can be used for an aching lower back, fatigue, and abnormal urination—either too frequent or difficult. These patients often have excessive sweating, night sweats, nosebleeds, or shortness of breath too. Abdominal pain and diarrhea are also common.

“Some middle-aged and older people have prostate problems, difficulty urinating, and frequent lower back pain. They have diarrhea too, but a colonoscopy finds nothing.

“Some even get frequent mouth ulcers. Middle-aged and older people are more prone to deficiency and exhaustion, and their Kidney qi is more likely to lose its holding function. Taking some Guifu Dihuang Wan can clear up all those symptoms.

“We also use it when treating diabetes, which Chinese medicine calls xiaoke, or wasting-thirst. But if you find out you have diabetes and simply start taking this medicine, you've got it wrong again.

“Xiaoke is divided into upper, middle, and lower wasting. If you drink a dou of water and pass a dou of urine, with Kidney qi failing to hold it in, that's lower wasting. That's when you should use this medicine. Chinese medicine has to identify the pattern and treat accordingly. The same symptoms often appear in different patterns, with different underlying mechanisms. If you try to match a Chinese formula to a Western disease name, you'll go even further wrong.^[5]

“Once you've seen enough patients in clinical practice, you'll find plenty of diseases that Western medicine struggles to treat but Chinese medicine handles readily.

“And there are conditions that give Chinese medicine all sorts of trouble but are easy for Western medicine to treat.

“They can complement each other because their medical theories are fundamentally different. As I said, it's the differences that make the world interesting.”

Evan was giving these students of Western medicine a lesson in Chinese medicine, and they were listening in a daze. Mostly, they were still stunned by what he'd just done.

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A pulse, a look at the tongue and face, and he could identify the pattern—and he was pretty accurate too. Wasn't he practically a walking laboratory?

“Do you have the symptoms I just mentioned?” Evan asked Max.

Max nodded before he could think.

“Then go get the medicine. Though… it does contain fuzi.”^[6]

Max immediately looked embarrassed again.

Evan shook his head with a slight smile, then turned to the roommate. “All right. Twist at the waist. Stop if it hurts.”

The roommate twisted gently.

“Lift your leg. Keep it straight as you raise it, and stop if it hurts.” Evan then performed a neck-flexion and abdominal-lift test on him.^[7]

After writing in the case record, Evan asked, “How long ago did you strain it?”

“Yesterday, playing basketball. Then I twisted it again just now, messing around, and it started hurting again.”

Evan nodded. “Let me see your tongue.”

The roommate stuck it out.

Evan took a look. “Pale tongue, thin white coating. Give me your hand so I can feel your pulse.”

The roommate sat down, supporting his back with a hand.

Evan felt his pulse.

Meanwhile, the chubby Max paid for his medicine, collected it, and immediately hid it in his backpack as discreetly as he could.

After a while, Evan finished taking the pulse and wrote up the case. The patient's lumbar curve was flattened, with some muscle swelling on both sides and pain on pressure. The neck-flexion and abdominal-lift test was positive. Straight-leg raising: 80 degrees on the left, 80 on the right. Pale tongue, thin white coating, wiry pulse. Qi stagnation and blood stasis.^[8]

Evan fetched his acupuncture kit and took out a filiform acupuncture needle.

The roommate went pale. “Holy shit, that's long!”

“Don't be scared. Hold still.” Needle in one hand, Evan gripped the roommate's chin with the other and brought the needle toward him.

The roommate panicked. “What the hell are you sticking it in my face for?”

Holding his chin, Evan said, “It's your Renzhong point. Don't move, or I'll miss.”

“Holy shit! Help! It's so big and thick!”

“It's a damn filiform needle!” Evan snapped.

“Can I still change my mind?”

“Too late.” Evan inserted the filiform needle into the roommate's Renzhong point at an upward angle of 45 degrees, to a depth of 0.4 cun.^[9]

The roommate sucked in a sharp breath. He didn't dare move. He was afraid he'd spring a leak.

Watching this, Max suddenly felt his own situation wasn't so bad after all.

Reader Notes

1. ↩︎ Patterns and disease names. A pattern brings together findings such as symptoms, tongue appearance, and pulse qualities within Chinese medicine's theoretical framework. Pattern differentiation identifies that configuration; treatment is then chosen accordingly. “What's going wrong” renders bingji, the mechanism understood to underlie it. Evan distinguishes that process from choosing a medicine by a disease name alone. This is an explanation of his terminology, rather than independent confirmation of the diagnoses or comparisons he makes. Source: WHO — International standard terminologies on traditional Chinese medicine, entries 545–552.
2. ↩︎ Yin deficiency and heat sensations. Yin is associated here with nourishing and moistening functions; yang with warming functions. The “five centers” of the Chinese symptom phrase are the two palms, two soles, and chest. “Bone-steaming” describes heat felt deep within the body, while “tidal” suggests recurring waves. These are descriptions within the traditional symptom vocabulary, not findings that the bones are physically steaming. Capitalized Kidney continues to indicate a traditional functional system, rather than a diagnosis involving the anatomical kidneys. Source: WHO — International standard terminologies on traditional Chinese medicine, entries 741–742 and 1277–1278.
3. ↩︎ Six ingredients, eight ingredients, and later formulas. Liuwei means “six ingredients”; bawei means “eight.” Wan denotes a pill formula. These names belong to a related family, but historical and modern versions need distinguishing. The modern Guifu product lists eight ingredients, including cinnamon bark and prepared fuzi; the modern Jingui product lists ten, including niuxi and cheqianzi. The classical Shenqi formula uses cinnamon twig and dried rehmannia, so Evan's “original formula” is a simplified account of that relationship. Qian Yi's pediatric text contains Dihuang Wan, the six-ingredient formula. Sources: Xinjiang drug administration — Dihuang formula variants, sections six and eight (in Chinese); HKBU — Shenqi Wan, ingredients; Qian Yi — Xiao'er Yaozheng Zhijue, “Dihuang Wan,” electronic transcription (in Chinese).
4. ↩︎ Deficiency and exhaustion; the classical quotation. Xulao is a broad traditional category of chronic depletion, involving qi, blood, yin, or yang, rather than ordinary tiredness alone. Zhang Zhongjing's Jingui Yaolüe and Sun Simiao's Qianjin Fang are medical works; “medical sage” and “King of Medicine” are honorifics. The latter title means “Prescriptions Worth a Thousand Gold Pieces.” Its eight-ingredient Shenqi entry contains the indications quoted here. The English is translated from the novel's wording; the historical text does not establish the broader claims Evan goes on to make. Sources: WHO — Terminologies, entry 1713; Beiji Qianjin Yaofang — “Bawei Shenqi Wan,” electronic transcription (in Chinese).
5. ↩︎ Xiaoke and the equal measures of water. Wasting-thirst is a traditional category associated with excessive thirst, hunger, and urination. Its upper, middle, and lower divisions describe different configurations within that framework; the term is not an exact replacement for every modern diabetes diagnosis. Here “holding” refers to Kidney qi's traditional retaining function. A dou is an old Chinese capacity measure. The line echoes the Jingui Yaolüe: the point is that as much water comes out as goes in, so no modern volume is substituted. Sources: WHO — Terminologies, entries 1752–1755; Jingui Yaolüe — “Xiaoke, urinary difficulty, and strangury,” electronic transcription (in Chinese).
6. ↩︎ The fuzi callback. Fuzi is the aconite-derived medicinal discussed in the earlier argument. Prepared forms are used in Chinese formulas, and aconite alkaloids can be toxic. Evan's pointed reminder returns Max to that dispute. The chapter does not specify the dispensed product, dose, or an outcome from taking it. Source: Hong Kong Department of Health — Chinese medicines containing aconitum alkaloids (in Chinese).
7. ↩︎ The back examination. Straight-leg raising is a named physical examination; the later figures record the angles reached on each side. “Positive” reports a finding that the examiner elicited, rather than a favorable outcome. The Chinese combines neck flexion and an abdominal-lift maneuver in one test name. Clinical literature also lists those maneuvers separately. The English keeps the novel's combined wording descriptively, without assigning an uncertain English eponym or adding a disc diagnosis. Source: Geng and Sun — Lumbar disc herniation study, diagnostic criteria, section 1.2 (in Chinese).
8. ↩︎ A wiry pulse; qi stagnation and blood stasis. Wiry describes a taut, stringlike sensation beneath the examining fingers. Qi stagnation and blood stasis names a traditional pattern in which impaired movement of qi is understood to impede blood's movement. These terms continue the vocabulary introduced earlier. In the case record they are Evan's interpretation of the findings; “blood stasis” here does not report an imaging result or establish that the patient has a blood clot. Source: WHO — Terminologies, entries 440 and 904.
9. ↩︎ The needle, Renzhong, and cun. Filiform means threadlike: this is a fine acupuncture needle, not a hollow injection needle. Renzhong is an acupuncture point in the philtrum, the groove between the nose and upper lip; it is also known as Shuigou, or GV26. Cun is a proportional body measure used in acupuncture, not a fixed English inch. The angle and depth in this passage reproduce the fictional treatment; the sources below supply terminology and location, rather than a recommendation for treating this injury. Sources: WHO — Standard Acupuncture Point Locations, general guidelines, pp. 2 and 13; Liu et al. — Study protocol, Table 2, GV26.