Chapter 48 Didn't Your Teacher Tell You?

Leo explains his diagnosis and prescription. Evan has a different reading of the same signs.

Evan certainly talked big.

The people around him could barely stand to listen.

To them, he was just a young man without an established public-sector post, stuck working in a little clinic.

Leo Cao, on the other hand, was a deputy department head at the county hospital of Chinese medicine. He was older, too. Surely he knew more than this youngster!^[1]

Leo stared at Evan in surprise for a long moment. “You're going to teach me? Fine! Fine. The patient vomits yellow fluid, feels dizzy, and has dry stools. Her tongue coating is thin and greasy, with a slightly dirty-yellow coating at the root. Her mouth is dry, and she has a bitter taste in her throat.

“Her pulse is wiry and rapid. The signs are very clear. It's disharmony between the Liver and Stomach, with excessive Liver fire attacking the Stomach. That forces Stomach qi upward and prevents turbid phlegm from descending. The tongue and pulse confirm it, and her symptoms fit excessive Liver fire. How else would you explain the dry mouth, bitter throat, and dizziness?^[2]

“Since the Liver and Stomach are out of harmony and turbid phlegm isn't descending, I used Jiawei Wendan Tang from the Yizong Jinjian. What's wrong with that? Erchen Tang and fresh ginger dry dampness, transform phlegm, direct counterflow downward, and stop vomiting. Huangqin, huanglian, and zhuru clear Liver heat, ease agitation, and stop vomiting.

“Zhishi relieves fullness in the chest, harmonizes the Stomach, regulates qi, and directs counterflow downward. Maidong and lugen nourish yin, clear heat, and ease agitation. Would you like me to tell you the doses as well, Dr. Xu?” His last few words were pointedly mocking. He gave a derisive laugh.^[3]

The others were stunned.

Ben knew his brother-in-law was a far better doctor than he was. A proper deputy department head! His diagnosis and treatment made perfect sense.

Ben's wife looked proud. She eyed Evan sidelong, looking down on him, waiting to see this fraud exposed.

Little Octopus was indignant. She couldn't stand anyone showing off in front of Dr. Xu. Her face went red with the effort, but she couldn't think of a single argument against him.

Even Second Sis couldn't help looking at Leo. She'd had no idea treating an illness could involve so many complications. This Dr. Cao seemed very capable.

Her Majesty shook her head slightly at Evan. Why ask for humiliation? He dropped several more points in her estimation.

Leo glanced at the friends beside him, all impressed without understanding a word, and lifted his chin a little. Surely he could play the expert in this shabby little private clinic?

Clara glanced at him with a smile that didn't reach her eyes. “You make it sound so impressive. Why didn't you get her better?”

Leo swayed. His air of expertise vanished at once.

Little Octopus turned to Clara in admiration. Holy shit. She'd finished him with one sentence. This woman was good!

Only then did the others come to their senses. Right. For all that talk, he hadn't got her better either.

Leo could no longer hide his embarrassment. “The medicine takes time to work, you know! Besides, you must have taken something else too. The medicines interfere with each other. Come back to the hospital with me later and have another examination.”

“Wrong.”

“What?” Leo was taken aback.

Evan gave a small sigh. “That isn't how to treat this.”

“Then how would you treat it?” Leo demanded irritably.

Evan looked at Leo, then at Ben. Leo was much better than Ben, but he still fell short.

“Your pattern differentiation is wrong. She doesn't have excessive Liver fire or disharmony between the Liver and Stomach. She has deficiency in the middle with Stomach cold.”^[4]

“What?” Leo almost laughed.

Ben was stunned too. “Deficiency cold?”

Leo shook his head with a laugh. “What brilliant medical skills, Dr. Xu. Deficiency cold? Heh. Young people these days really are something.”

Ben stared at Evan in confusion. How could it be deficiency cold? Had he really been deceiving everyone all along?

Ben's wife gave a couple of derisive snorts. There. The master manipulator had finally exposed himself.

Amused, Leo asked, “Come on, Dr. Xu. Tell me how you reached that conclusion. Dry mouth, bitter taste, heat and agitation inside. Since when did Spleen and Stomach deficiency cold give anyone a dry mouth and a bitter taste?”

“A bitter taste doesn't necessarily mean a heat pattern,” Evan replied. “The Gallbladder section of the Shengji Zonglu says, ‘Gallbladder deficiency gives rise to cold. Qi overflows into the chest and diaphragm, with dizziness, a bitter taste, frequent sighing, and repeated vomiting of long-retained fluid.’”^[5]

Leo's smile froze for a moment.

“That's a very unusual case,” he argued. “Besides the dry mouth and bitter taste, her tongue coating is thin, yellow, and greasy. How could someone with Spleen and Stomach deficiency cold have a yellow coating?”

“A pale tongue with a white coating can also occur in a heat pattern. A thick yellow coating covering the tongue can also occur in a cold pattern. A deep-crimson tongue without moisture can also occur in a phlegm pattern. You have to consider the pulse, the symptoms, the stools, and the urine together.”

Evan asked Second Sis, “Comrade, would you stick out your tongue again, please?”

“Oh. All right.” Second Sis stuck out her tongue again.

Evan pointed. “When inspecting the tongue, you can't look only at the coating. You need to pay more attention to the tongue body itself. A red tongue with a yellow coating usually indicates accumulated heat in the zang-fu organ systems. But a yellow coating on a tongue that isn't red usually indicates cold inside and heat outside.”^[6]

Leo was completely bewildered.

The others listened, fascinated. Why did treating an illness sound like solving a mystery, unraveling one clue after another? How could there be so many misleading signs?

“No, no!” Leo said hastily. “Those are all very uncommon patterns. What about the pulse? Her pulse is rapid. A rapid pulse indicates heat!”

He let out a long breath. He'd almost let Evan talk him around. Thank goodness there was still the pulse to prove his point.

Evan nodded and smiled. “Being able to identify a rapid pulse is a good start.”

Leo rolled his eyes. Did he need this kid's fucking approval?

“Yes, a rapid pulse indicates a heat pattern,” Evan continued. “There are deficiency and excess forms: excess heat and deficiency heat. Either can give a patient a dry mouth and a bitter taste. But we can't make assumptions like that when treating someone.

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“The Maili Qiuzhen says, ‘People see a rapid pulse and often treat it as heat, without knowing that pulses can be true or misleading, and that rapid pulses can reflect deficiency or excess. One must examine the accompanying symptoms and pulse qualities, and distinguish whether the pulse has strength or lacks it… If it is fine, small, forceful and slippery, or fine, rapid and soft, warming treatment is appropriate even when the body is hot.’”

Evan said to Leo, “Examine her pulse carefully again. Is it still just wiry and rapid? You weren't careful enough!”

Leo suddenly looked embarrassed. “Then what… what pulse does she have?”

“Thready, wiry, and rapid on the left. Slippery and rapid on the right.”^[7]

Leo stood rooted to the spot.

Evan explained patiently. “A thready pulse is quite like a wiry pulse. But a thready pulse feels like silk thread under your fingers, while a wiry pulse feels like a bowstring. The thready pulse is deep, fine, and soft; the wiry pulse feels like pressing a bowstring.

“You haven't been careful!”

Leo was rather dazed by the criticism.

Evan sighed. In this world, no one knew he was Dr. Qian's disciple. Oliver Liu wouldn't remember having him as a senior fellow disciple either.^[8]

But the affection of those eight years and more in the system was real. In his heart, Evan had always held himself to the standard of someone carrying on Dr. Qian's teaching. That was why he was still so patient in teaching Leo.

“You must be meticulous and completely focused when examining a pulse,” Evan said. “You can't treat it casually, or you'll very easily make a wrong diagnosis.

“A thready pulse can indicate deficiency or dampness. The Maili Qiuzhen says, ‘A thready pulse is a sign of waning yang qi.’ So this pulse can also indicate insufficient yang qi. Of course, that alone isn't enough to establish yang deficiency.

“Then consider her wiry pulse. It can indicate Liver disease, but it can also indicate malaria, retained phlegm and fluids, pain, or painful spasms. The Sizhen Juewei says, ‘A superficial, wiry, urgent pulse at the chi position indicates pain in the lower body; a deep, wiry, thready, hesitant pulse indicates a yin pattern with lingering cold.’^[9]

“We must consider all four diagnostic methods together and proceed carefully. You can't see a wiry, rapid pulse and apparent heat symptoms, then disregard everything else and decide she has excessive Liver fire and disharmony between the Liver and Stomach!”^[10]

His tone grew reproachful. “The underlying mechanism in this case is well hidden. It's understandable that you missed it the first time. But after cooling medicines failed, why were you still so determined to stick to your diagnosis?

“You even shifted all the blame onto the patient! You said she'd been taking other medicines, and that your prescription needed more time. If your medicine matched the pattern, would it be slow to work?”

Leo's lips trembled slightly. He couldn't find anything to say in reply.

For a moment, it was as though he were looking at Professor Martin He, the elderly specialist from the provincial hospital of Chinese medicine who had come to advise their county hospital the month before. The old specialist had spoken with exactly that tone and authority.

Evan was just like him.

Leo could only stare.

Evan gave him a puzzled look too. “Didn't your teacher tell you any of this?”

Leo's whole face turned red.

Ben stole a cautious look at his brother-in-law's expression and shook his head slightly.

Reader Notes

1. ↩︎ Posts and status. Bianzhi refers to an authorized place in a public institution's staffing establishment. Evan lacks such a post; Leo's deputy-head appointment gives the onlookers an institutional reason to respect him. Their assumption about who must be the better doctor belongs to the scene. Source: Ministry of Justice — Regulations on Personnel Management in Public Institutions, chapters II–III (in Chinese).
2. ↩︎ Liver fire, counterflow, and phlegm. The capitalized organ names refer to Chinese medicine's functional systems. In Leo's account, excessive Liver activity disrupts the Stomach's downward movement, producing vomiting. Phlegm here also belongs to the traditional account of disordered fluids; it need not mean mucus coughed from the lungs. The tongue and pulse are signs he uses to identify that pattern. This is his explanation of how the findings fit together. Source: WHO — International Standard Terminologies on Traditional Chinese Medicine, entries 1234 and 1317.
3. ↩︎ Jiawei Wendan Tang. Jiawei means that ingredients have been added to a formula, while tang denotes a decoction. The Yizong Jinjian lists this version among its pregnancy formulas. Erchen Tang is itself a formula, used here as a building block; the other pinyin names identify individual medicinals. Leo groups them by traditional functions: drying dampness, transforming phlegm, directing qi downward, clearing heat, and nourishing yin. “Cooling” and “warming” in this discussion describe traditional medicinal properties. Leo gives no doses in this exchange. Sources: Yizong Jinjian — Pregnancy formulas, no. 3, historical-text transcription (in Chinese); Hong Kong Baptist University — Wendan Tang.
4. ↩︎ Deficiency in the middle with Stomach cold. “The middle” refers to the digestive functional region associated with the Spleen and Stomach. Deficiency means that the system lacks sufficient functional support; cold describes the nature of the pattern. Neither term is a measured stomach temperature. Evan selects this pattern from the possibilities he outlined earlier. The dispute concerns how to weigh the findings together, especially when a sign appears to point toward heat. Source: WHO — International Standard Terminologies on Traditional Chinese Medicine, entries 209, 995 and 1225.
5. ↩︎ A historical counterexample. The Shengji Zonglu, a Song-dynasty medical compilation, includes the quoted cluster of bitter taste, dizziness, sighing, and vomiting retained fluid in its Gallbladder-deficiency section. Evan cites it to challenge the rule that bitterness must indicate heat. The passage concerns a traditional functional pattern; the name Gallbladder does not establish a modern anatomical diagnosis. Source: Shengji Zonglu — Volume 42, Gallbladder deficiency, Tianxiong Wan passage, historical-text transcription (in Chinese).
6. ↩︎ Tongue body and coating. Tongue inspection distinguishes the tissue of the tongue from the coating on its surface. Color, moisture, and coating are considered alongside other findings. Evan's argument turns on that distinction: a coating's color alone cannot settle the case. The exceptional combinations and the conclusion about cold inside and heat outside remain his clinical claims in the dialogue. The narrative does not separately state Holly's tongue-body color. Sources: WHO — International Standard Terminologies on Traditional Chinese Medicine, entries 634–635 and 696; Hong Kong Polytechnic University — Inspection within the four diagnostic methods.
7. ↩︎ Several qualities in one pulse. Rapid describes speed; thready describes a fine, threadlike feel; wiry suggests a taut string; slippery describes a smooth, rolling sensation. A pulse can receive several of these descriptions together. Evan also distinguishes the patient's left and right wrists, rather than revising both sides into a single label. His argument depends on the combination and strength of the qualities. Source: WHO — International Standard Terminologies on Traditional Chinese Medicine, entries 892, 896, 900 and 904.
8. ↩︎ Remembered seniority. Evan and Oliver studied under the same master in Evan's system experience. “Senior fellow disciple” expresses his place in that teaching lineage. It need not indicate greater physical age, and Oliver in this world does not remember the relationship. Source: Ministry of Education — Shixiong, first definition (in Chinese).
9. ↩︎ The pulse texts. The Maili Qiuzhen discusses apparent heat and cold under rapid pulses; the Sizhen Juewei passage discusses combinations involving a wiry pulse at the chi position, one of the wrist's three examination positions. The quotations here follow the novel's Chinese. One wording differs from the consulted transcription: Maili Qiuzhen calls a feeble pulse a sign of waning yang qi, where the novel says thready. Those qualities are distinct. The attribution is retained with that textual difference made explicit. Sources: Maili Qiuzhen — Rapid and feeble pulses, historical-text transcription (in Chinese); Sizhen Juewei — Wiry pulse, historical-text transcription (in Chinese).
10. ↩︎ Combining the findings. The four methods are inspection, listening and smelling, questioning, and palpation. Evan's criticism is that Leo has treated a few findings as decisive instead of considering the whole assessment and the failed treatment. Source: Hong Kong Polytechnic University — Four Diagnostic Methods.