Chapter 62 The Paradox of Obstruction

Leo takes Evan aside to discuss the treatment, only to find another doctor in the stairwell.

Leo was badly startled, even a little rattled. Was it that serious?

He hurried to compose himself. “Well… we'll go and discuss the case first,” he told the patient's husband.

“Oh… all right.” The man looked bewildered.

Evan glanced at the patient, then followed Leo out. They stayed on the same floor of the inpatient building and headed for the stairwell, where they could talk in private.

But when they pushed open the fire door, they found a doctor squatting inside, smoking.

“Leo?” The man looked surprised.

“Simon? What are you doing here?” Leo was just as surprised.

Dr. Liu smiled. “Sneaking a cigarette.”

Leo nodded and introduced them. “This is Dr. Simon Liu, from Chinese internal medicine. And this is Dr. Evan Xu.”

Simon took out his cigarettes. “Do you smoke, Dr. Xu?”

Evan shook his head. “No.”

“Should we find somewhere else to talk?” he asked Leo.

“No need. We can talk here. Simon's one of us.”

Simon looked over curiously.

Leo lost no time. “Why can't we use herbs to purge and promote elimination?”

Hearing them discuss Chinese medicine made Simon even more curious. Why was Leo discussing medicine with someone so young?

“Because the treatment is the wrong way around,” Evan explained. “Her problem isn't qi stagnation or an accumulation caused by excess heat. Her qi is too deficient to keep things moving. A woman is already deficient in qi and blood after childbirth.

“And she's had a cesarean, which has damaged her qi and blood still further. Her pulse is hollow—a sign of blood loss. Qi is the commander of blood; blood is the mother of qi.

“This is the mother's illness affecting the child. Losing blood has severely damaged her qi. With too little qi, there's no strength to move or propel anything. That's why she can't pass urine or stool. Three days, and she can't even pass gas. This is root deficiency with branch excess.”^[1]

“Qi deficiency?” Leo frowned, thinking.

Simon watched Evan curiously. Why did it seem that Leo was asking this young man for instruction?

“Leo, has she had a blood count?” he cut in.

“Yes.”

“What's her hemoglobin?”

“6 g.”^[2]

Simon smiled, blowing smoke through his nostrils. “Then what is there to ask? It's obviously blood deficiency!”

Evan frowned at that.

Leo remained deep in thought.

Evan continued. “Her abdomen is swollen but seems hollow inside. Her voice and breathing are faint. Taken together with her pulse, that tells us her qi in the middle is weak. Middle qi is Stomach qi, and hers is already extremely depleted.

“If you recklessly give more herbs to unblock and purge, her body won't withstand the attack. Once her Stomach qi is severely damaged, she'll truly be in danger. Remember: with Stomach qi, a person lives; without it, a person dies.”

Leo sucked in a breath.

Evan sighed. “The ‘Oral Inquiry’ chapter of the Lingshu says, ‘When middle qi is insufficient, urination and bowel movements are altered.’ If middle qi can't hold things in, it can cause prolonged diarrhea or dysentery. But if it is too weak to transform, transport, and expel, it can also cause obstruction. Deficiency of middle qi is the mechanism behind her illness.”^[3]

Leo considered that. It did seem to make sense. The small doses of purgative herbs he'd given her had only made her worse.

Simon ground out his cigarette. “Leo, is this the woman who can't pass urine or stool after her second cesarean?”

“Yes.”

“I think the young doctor's making some sense. Just look at her test report. She's a typical case of qi and blood deficiency.”

With Simon agreeing too, Leo asked, “Then should I prescribe something to tonify qi and blood?”

“Tangible blood can't be replenished quickly,” Evan said. “Intangible qi must be secured at once. She's already suffering almost beyond endurance, and the obstruction is severe. We need to strongly tonify her middle qi now. Once her qi gets moving, all the symptoms will disappear.”

“What?” Leo stared.

“A large dose of Buzhong Yiqi Tang.”^[4]

“What?” This time Simon stared too.

Leo was puzzled. “Buzhong Yiqi Tang does tonify the middle and replenish qi, but it also raises yang and lifts what's sinking. You use it for chronic diarrhea and dysentery, uterine flooding and persistent bleeding, rectal prolapse, a prolapsed stomach, things like that. Nothing can get out of her already. Why give her something that holds things in? Isn't that backward?”

Evan sighed. This was tiring. Leo probably hadn't even reached the standard of a county-level expert.

“Treating apparent obstruction with tonification.”^[5]

Leo looked thoughtful.

Simon looked unconvinced. “Surely that won't work? There's no scientific basis for it, is there? She's already blocked up. If you block her some more, won't it be even harder for anything to come out?”

“As I said, the root is deficient and the branch is excessive,” Evan replied. “She can't pass urine or stool. It looks like an excess pattern. But trace it to its cause: her middle qi is too weak to transform and transport. It's a deficiency pattern.

“Chinese medicine doesn't just treat the presenting complaint. You don't simply purge whenever you see an obstruction. You identify the pattern and treat accordingly. The point of treating apparent obstruction with tonification is paradoxical treatment.

“She's deficient within, excessive in appearance. The root is deficient; the branch is excessive. Of course we have to treat the root. Even though she's blocked up, we mustn't purge. Instead, we need to tonify the middle and use a securing, astringent approach.

“Her middle qi is so weak that the rising and falling of qi have become disordered. Clear qi doesn't rise; turbid qi doesn't descend. This formula raises yang and lifts sinking, but it also tonifies qi and raises the clear.

“And the qi movement of all three burners depends on the Spleen and Stomach. When middle qi is insufficient, movement throughout the three burners is disrupted. We treat neither the upper nor the lower, only the middle. Restore middle qi, and qi can circulate. Clear yang rises, turbid yin descends, and the symptoms disappear.”^[6]

Simon frowned deeply. “This qi and that qi,” he muttered. “Isn't it all pseudoscience?”

Evan's frown deepened again.

Leo thought it over carefully. “Dr. Xu, I think you're right. I remember reading a case record where Buzhong Yiqi Tang was used for stubborn constipation. I trust you. Let's use it.”

Simon curled his lip to himself. Leo must be mad, trusting a youngster like this!

With the formula settled, Leo and Evan began discussing the doses. Simon listened, curling his lip now and then.

The veteran physician Wei Longxiang had described his experience treating constipation with baizhu in “Four Medical Notes.” He said the starting dose of baizhu must be at least 30 g; any less was ineffective.^[7]

A case of literary theft: this tale is not rightfully on Amazon; if you see it, report the violation.

Bencao Tongxuan also recorded: “As a medicine to tonify the Spleen and Stomach, baizhu has no equal.”

The Spleen and Stomach belonged to earth. When earth was strong, clear qi could rise and send refined nutrients upward, while turbid qi could descend and carry waste downward.

They too settled on 30 g.

At last Simon gave an approving opinion. “That herb's right. Baizhu can improve intestinal motility. That's the line of thought you need. You have to refer to pharmacological research.”

Evan gave him a baffled look. Was this a Chinese-medicine doctor in name only?

The patient's qi deficiency was severe, so securing her qi was urgent. They used 60 g of huangqi, 15 g of red ginseng to be simmered separately, and 30 g of danggui. They settled the doses of the remaining herbs one by one.^[8]

Leo hurried off to write the prescription and arrange for the herbs to be decocted.

Simon looked at Evan curiously. “Where do you practice, Dr. Xu?”

“A small clinic.”

Simon frowned. “Who was your teacher?”

Evan smiled without answering.

“You can't say?” Simon looked suspicious.

Evan chuckled. “I might frighten you.”

Simon drew a sharp breath. “Don't tell me you're the disciple of one of the country's greatest physicians?”^[9]

Evan said nothing.

Simon began turning this over, eyeing him with growing uncertainty. No wonder. He'd been wondering why Leo was being so friendly. So he was trying to get close to one of the country's greatest physicians! That scheming bastard never did anything unless there was something in it for him.

Evan's teachers were far more frightening than that. Frightening in a very real sense. Dr. Qian had died in 1986; Dr. Cheng had died in 1957.

Those two were his teachers. Wouldn't that give someone a fright?

“Ha! A pleasure to meet you. Shall we add each other on WeChat?” Simon became friendly at once. The disciple wasn't much, but his teachers deserved respect.

Evan looked baffled. He didn't have WeChat, so they only exchanged phone numbers.

Some time later, the decoction was ready and was brought to the ward.

Evan and Leo hurried in after it. Simon followed too, curious.

They all watched for the patient's response after she took the medicine.

Less than ten minutes later, the woman, propped up in bed, suddenly frowned. She clutched her abdomen with both hands, looking uncomfortable.

“What's wrong?” Her husband grew anxious at once.

So did Leo. Had they really blocked her up even more?

Simon glanced at Evan. There, something had gone wrong, just as he'd expected. Disordered qi movement—nonsense! Not scientific at all! And this man was supposed to have studied under one of the country's greatest physicians!

He was about to speak when they heard a sound.

Pffft!

Their faces brightened.

“She's passed gas!” Leo exclaimed.

Simon was stunned. Really?

The patients in the neighboring beds looked over enviously. Pass gas after surgery, and you could soon be going home.^[10]

“Jing! How do you feel?” Her husband was astonished and delighted.

“Wait,” she said, still uncomfortable.

Pffft! Pffft! Pfft-pfft!

The gas kept coming.

Ordinarily it would have been embarrassing. Now it was cause for excitement.

They watched her for nearly another half hour. She passed a great deal of gas, and her abdomen felt much better. Then she went to sit on the toilet, and before long she was able to urinate.

“One dose, and it's working this fast!” Leo said delightedly. “One dose might be enough to cure her!”

This time Simon looked at Evan quite differently. An expert!

“Thank you. Thank you.” Her husband hurried to shake their hands. He bowed several times to Evan in particular. He wasn't a fool; he knew who'd done the most to help.

Evan kept telling him there was no need.

Leo thanked him too. “Dr. Xu, thank you. Dinner's on me tonight.”

Evan waved it away. “It's my job. No need to thank me.”

Simon considered for a moment. “Dr. Xu, I have a few outpatients myself. Would you give me your opinion on them?”

Evan was about to refuse when a message from the system arrived.

Help Simon Liu find his way back to Chinese medicine, and receive a special reward!

Reader Notes

1. ↩︎ Qi, blood, and the root of the problem. In Chinese medicine, qi describes bodily activity and functions, while blood provides nourishment and supports qi. “Commander” and “mother” express this interdependence. Here the mother-and-child comparison concerns blood and qi, not the patient's baby. “Root” means the underlying deficiency; “branch” means the resulting signs, including the apparent obstruction. Evan is arguing that insufficient power to move things can resemble an excess that needs purging. These are traditional categories used in his reasoning, rather than measurements of a physical substance called qi. Source: WHO — Chinese medicine terminology, entries 243, 250–255, 384–385.
2. ↩︎ Two kinds of evidence. As in Chapter 61, “6 g” preserves the source's incomplete hemoglobin unit; no volume denominator is supplied. A hollow pulse is a traditional tactile finding, not a blood-test result. Simon's “blood deficiency” is his interpretation in Chinese-medicine terms. Sources: MedlinePlus — Hemoglobin test; WHO — Chinese medicine terminology, entry 905.
3. ↩︎ Middle qi and the classical quotation. Here “middle qi” refers to the functions associated with the Spleen and Stomach, including processing and transporting nourishment. Capitals distinguish these traditional functional systems from anatomical organs. Evan also calls it Stomach qi. The Lingshu, or Spiritual Pivot, is a classical medical text; its “Oral Inquiry” chapter contains the line he quotes about altered elimination. The quotation itself does not specify that this patient needs a particular formula. His argument about both failure to retain and failure to expel follows in his own explanation. Sources: WHO — entries 188 and 243; Lingshu — chapter 28, electronic transcription (in Chinese).
4. ↩︎ Buzhong Yiqi Tang. The name means a decoction for supplementing the middle and replenishing qi. In its traditional description, it also raises yang and lifts sinking, which explains Leo's association with persistent diarrhea and prolapse. “Raising” concerns the formula's role in that theoretical framework; it does not mean pushing a physical blockage upward. The name identifies a formula, while the quantities and preparation in this scene describe the doctors' particular prescription. The reference below records the formula's conventional composition and traditional purposes, rather than the outcome of this fictional consultation. Source: Hong Kong Baptist University — Chinese Medicinal Formulae Images Database, F00069 (in Chinese).
5. ↩︎ Treating apparent obstruction with tonification. The Chinese phrase sai yin sai yong deliberately pairs two uses of “blocking.” The first is the appearance of obstruction; the second refers to tonifying or securing treatments that might seem to hold things in. The rationale is to address an underlying deficiency that prevents movement. This belongs to “paradoxical treatment”: following the appearance of the symptoms while treating what is understood to cause them. Evan's explanation supplies the application to this patient. It does not mean physically plugging an outlet. Source: Jiangxi University of Chinese Medicine — He Xiaohui's account of sai yin sai yong, opening definition (in Chinese).
6. ↩︎ The three burners and rising and falling. Sanjiao, translated here as the three burners, is a traditional division into upper, middle, and lower regions and their related functions. It is not three literal furnaces or a single anatomical structure. “Clear” and “turbid” distinguish what nourishes the body from what is directed onward or eliminated. Evan links their movement to the Spleen and Stomach. The later earth comparison belongs to the five-phases framework, in which these systems correspond to earth. None of these terms describes visible currents inside the patient. Sources: WHO — entries 118, 188–194, 207–210 and 245; Bencao Tongxuan — baizhu entry (in Chinese).
7. ↩︎ Baizhu and the medical writings. Baizhu is a medicinal material, distinct from the similarly named cangzhu. The passage attributes an experience with constipation and a minimum quantity to Wei Longxiang's “Four Medical Notes.” That precise dose statement has not been checked against the original article. The following praise of baizhu and the explanation using earth, ascent, and descent can be located in the baizhu entry of Bencao Tongxuan, a historical materia medica. That supports the literary attribution and traditional explanation; it does not establish a generally effective minimum dose. Source: Bencao Tongxuan — baizhu entry, electronic transcription (in Chinese).
8. ↩︎ The prescription in the scene. Huangqi, baizhu, and danggui are retained as consistent medicinal names. Red ginseng is kept distinct from an unspecified ginseng preparation. The source explicitly gives baizhu 30 g, huangqi 60 g, red ginseng 15 g, and danggui 30 g, with the red ginseng simmered separately. It says the other quantities were settled but does not list them. They have not been reconstructed from a standard formula. The database below provides a conventional formula for comparison, not these exact quantities or an independent verification of Simon's intestinal-motility claim. Source: Hong Kong Baptist University — Buzhong Yiqi Tang, composition and explanation (in Chinese).
9. ↩︎ A physician's teacher. Studying as a master's disciple is a relationship of training and lineage, not biological descent. Simon's “one of the country's greatest physicians” conveys the source's admiring da guoshou; it is not presented here as a formal credential or government-awarded title. Source: Taiwan Ministry of Education — shifu, first definition (in Chinese).
10. ↩︎ Why everyone welcomes the sound. Passing gas can be a sign that the bowel is active after surgery, which explains the relief and envy in the room. It is distinct from passing stool or urine. The neighboring patients' expectation of going home soon belongs to the scene; passage of gas alone does not establish a discharge date or complete recovery. The hospital leaflet below concerns bowel surgery and supports only the general point about bowel activity, not this cesarean case's diagnosis or treatment. Source: Norfolk and Norwich University Hospitals — Discharge information following bowel surgery, p. 1.