Lily brings a friend to the clinic, and Evan puts his lunch aside to examine her.
“Dr. Xu.” Lily Li greeted Evan.
Evan Xu had just bought two steamed buns next door for lunch. He had not eaten them yet when Lily came back. Her return surprised him. “What's wrong? Are you feeling unwell?”
Lily quickly shook her head. “No, no. My belly feels much better. It hardly hurts now, and the clots have come out.”
“Oh, good.” Evan was relieved.
“This is my friend April,” Lily said. “She gets period pain, too. Could you take a look?”
“Of course.” Evan went to his chair, sat down, and put the buns to one side.
“Dr. Xu, why don't you have lunch first?” Lily said.
Evan shook his head. “It's all right. Patients come first. Here, have a seat.”
April looked at his face. He didn't look like it, either.
She sat beside him. Evan took down her details, then noticed her holding her belly. “Give me your hand.”
April held it out. Her hand felt cold to his touch. It was summer already, yet her limbs were still so chilly.
Clara Zhang and Ben Song watched curiously from the side. A returning patient at Mingxin Clinic—now that was unusual.
Ben even wondered whether Evan had brought in someone to pose as a patient. Was this for real? He had stopped playing Dou Dizhu to watch Evan work. That was quite an honor.
“Does pressing on it ease the pain?” Evan asked.
“Yes. Especially with warm hands. That feels much better.”
Evan nodded. Relief from warmth and pressure. In Chinese medicine, menstrual pain could be classified as deficiency or excess. Pain relieved by warmth and pressure usually indicated deficiency; pain that could not tolerate pressure usually indicated excess. But the final distinction required the other diagnostic findings as well.[1]
And cold pain in the lower abdomen that eased with warmth generally suggested a cold pattern. There was deficiency, and there was cold. Could this be a deficiency-cold pattern?
“What are your periods like?” he asked. “Is the flow heavy? What color is it? Any clots? Does it come on time?”
“It's light, and the color's quite pale. There are clots. It's usually late…”
“Does your lower back hurt?”
“Yes,” April said miserably. “My back's about to break.”
Evan asked a few more questions and added her answers to the case record. He also inspected her face. Her complexion was pale with a bluish tinge, suggesting deficiency of qi and blood, and a yang-deficiency pattern.
“Let me see your tongue,” he told her.
The tongue body was pale, with little coating. A fairly typical picture of yang deficiency. A pale tongue body was the most important sign for diagnosing yang deficiency. Deficiency meant too little; yang deficiency meant too little yang qi. Too little yang produced cold signs, so yang deficiency generally meant deficiency cold. Supplement what was deficient; warm what was cold.[2]
Evan nodded inwardly. His tongue readings were still very accurate.
Ben leaned over for a look, then went back with a puzzled expression.
In Chinese medicine, the healthy state was described as yin being balanced and yang secure: “When yin is balanced and yang secure, essence and spirit are in order.” With yin and yang in balance, a person was naturally less likely to fall ill.[3]
What did that mean? Suppose yin scored 50 points and yang scored 50. Balanced, they made a perfect hundred. But if yin fell to 30, that shortage was yin deficiency.
The balance inside the body was upset. Yang now predominated, producing symptoms such as a dry mouth with a bitter taste, restless heat in the palms, soles, and chest, and scanty, dark urine.[4]
Supplement what was deficient. Restore yin to 50, and yin and yang would be balanced again.
But suppose yin was normal while yang suddenly rose to 70. That was excess: too much. The symptoms of yang excess closely resembled those of yin deficiency. With too much yang, though, it had to be drained, using medicines with cold or cool properties.
That was why Chinese medicine had to treat according to the pattern, not simply the symptoms. Yin deficiency and yang excess could look very similar. See signs of “heat” and immediately give a dose of cold-property medicine, and you could cause trouble.
The hardest part of Chinese medicine was therefore differentiating the pattern. A symptom was the manifestation; the pattern was the cause.[5]
Yet yin deficiency and yang excess could not be detected with modern medical equipment. These days, many doctors of Chinese medicine immediately sent people for an ultrasound, blood tests, and every other kind of laboratory test. How was that a way to treat illness?[5]
There was nothing wrong with conventional doctors doing this; it followed their diagnostic logic. Chinese medicine, however, worked through pattern differentiation and treatment. Its medicines treated patterns, not symptoms. The properties of a medicine counteracted the body's imbalance. Once the pattern was resolved, the symptoms would disappear.
At this point, the diagnosis was all but certain: a deficiency-cold pattern, specifically deficiency cold in the womb. But he still could not omit the pulse examination. Bringing together all four diagnostic methods was essential.[6]
“Let's check your pulse as well,” Evan told April.
“Should she lie down?” Lily asked before April could answer.
Evan nodded. “Either way is fine. The pulse is clearer if she's lying down.”
In the end, they decided she would lie down.
Evan led them to the treatment room. On the way, Lily said, “Dr. Xu, please help April. Her pain gets terrible. Sometimes she almost passes out.”
Evan gave a slight nod. “All right.”
“Good!” Lily nodded firmly.
April lay on her back on the examination bed, her hand resting naturally, palm up, on the pulse cushion. Evan sat beside her and carefully examined her pulse.
Clara and Ben followed to watch. Seeing how meticulously Evan took the pulse, the two exchanged glances.
Ben rubbed his chin. “He's faking it, isn't he?” he muttered.
Lily watched Evan's fingers on April's wrist. Sometimes he used all three together, sometimes each in turn. He pressed lightly, then deeply, then searched up and down…[7]
Her eyes widened. At last, she gritted her teeth in irritation and muttered, “Ugh. What a player!”
After a while, Evan finished examining both wrists. The pulse was deep, slow, and weak, with a thready quality as well. A deep pulse indicated an interior pattern.[8]
Besides distinguishing deficiency from excess, Chinese medicine had to distinguish exterior from interior. The words could be understood fairly literally: exterior patterns usually involved the body's surface, while interior patterns usually involved the zang-fu organ systems. The treatment approaches differed accordingly.
A slow pulse indicated cold. What counted as slow? The Maijing, or Pulse Classic, described “three beats in one breath, coming and going very slowly”: only three pulse beats in a single breathing cycle.[9]
People in ancient times had no clocks to time it accurately, so they used their own breathing to judge the pulse rate. Today a clock could be used. A slow pulse was roughly 50 to 60 beats per minute.[10]
A relaxed pulse resembled a slow pulse, but the two were different: four beats per breath for a relaxed pulse, three for a slow one. A slow pulse indicated cold; a relaxed pulse indicated dampness. A mistake in identifying the pattern could lead to a very different treatment. That was why all four diagnostic methods had to be considered together to reduce errors.
Take a professional athlete whose pulse was only in the fifties. Could you immediately conclude that they had a cold pattern? No. All four methods had to be used together.
Then there was the thready pulse. It could indicate deficiency, but also dampness. Was the main problem deficiency of qi and blood, or water-dampness encumbering the Spleen? Again, all the findings had to be weighed together.
While examining the individual positions, Evan had found that April's pulse was particularly slow at the left chi position. The traditional association was Kidney deficiency cold, cloudy urine, and, in women, periods that failed to arrive.[11]
Kidney deficiency cold meant Kidney yang deficiency. Without enough Kidney yang to warm the Spleen, Spleen yang could become deficient too. The Spleen would then produce too little qi and blood. That deficiency accounted for her light menstrual flow, as well as the thready quality of her pulse.[12]
Menstrual blood also had its source in the Kidney. When the Kidney was deficient, essence failed to transform into blood, and the Chong and Ren Vessels had too little qi and blood. That, too, could make the flow scanty.[13]
Her deficiency cold was severe, and her Spleen qi was insufficient, making cold congealment especially likely. Hence the clots during her period. The Spleen also governed the containment of blood. Weak Spleen qi could not perform that function, so the clots stagnated instead of dispersing.[14]
The deficiency cold in her womb was quite severe. Knowing that she was married, Evan said, “The cold in your womb is quite severe. Have you been having trouble conceiving?”[15]
Before April could say anything, Lily exclaimed, “How did you know? April's been married for three years, and she still hasn't gotten pregnant.”
“Oh, stop!” Embarrassed, April gave Lily a swat.
Clara and Ben were even more astonished. Was he really that good? Was this for real? Were these women really not just posing as patients?
Clara bit her lip and stared blankly at Evan's face.
Evan considered for a moment, then asked, “Have you ever lost a pregnancy?”[16]
April's expression immediately grew uncomfortable.
Reader Notes
↩︎ Deficiency, excess, and cold. These are dimensions of a traditional diagnostic pattern. Deficiency concerns an insufficiency of qi, blood, yin, or yang; excess concerns a predominance or accumulation of pathogenic influences. A cold pattern describes a cluster of findings interpreted through that framework. Here Evan considers relief from pressure and warmth alongside the other signs. The distinction continues the earlier chapters' discussion of treating according to a pattern. “Deficiency” does not mean imaginary illness, and “cold” does not by itself establish a low measured body temperature. Source: WHO — Chinese medicine terminology, entries 994–995, 1027 and 1225.
↩︎ Yang deficiency and the tongue. Yang qi is associated with warming and activating functions. In this account, insufficient yang provides the link between cold limbs, pallor, and the principle of warming and supplementing. Tongue body and tongue coating are separate observations: “pale” describes the tongue itself, while “little coating” describes its covering. The narrator's assessment and ranking of the pale tongue as the most important sign are retained here. The terminology source describes overlapping findings across patterns; it does not establish that this appearance alone determines April's diagnosis. Source: WHO — Chinese medicine terminology, entries 400, 640–642, 673, 1092 and 1096.
↩︎ Balance, rather than a numerical test. Yin and yang are complementary, interdependent categories in Chinese medical theory. In the example that follows, yin deficiency leaves yang relatively predominant; yang excess describes an actual predominance of yang in the model. The scores of 50, 30, and 70 are the narrator's teaching analogy, with no laboratory units. The quoted ideal of balanced yin and secure yang echoes the Suwen, “Discourse on Vital Qi Communicating with Heaven,” a section of the Huangdi Neijing. The English quotation is translated from the Chinese supplied in this novel. Sources: WHO — Chinese medicine terminology, entries 3–12 and 390–400; Chinese Text Project — Annotated Suwen, book 3 (in Chinese).
↩︎ Heat in the “five centers.” The Chinese expression counts the two palms, the two soles, and the chest as five centers. It refers to a combination of heat sensations and restlessness, rather than five separate organs or a requirement for a measured fever. The narrator gives it as an example in an explanation of yin deficiency; it is not another symptom reported by April. The same applies to the dry mouth, bitter taste, and scanty, dark urine in this illustrative list. Source: WHO — Chinese medicine terminology, entry 741, printed p. 70.
↩︎ Symptom and pattern. Chinese distinguishes zheng, 症, a symptom or manifestation, from the identically pronounced zheng, 证, a diagnostic pattern. A pattern summarizes findings and their interpreted relationships, including location and nature of illness within Chinese medical theory. The narrator compresses this distinction into “manifestation” and “cause.” “Cold” and “cool” medicines refer to traditional properties, rather than the temperature at which a dose is swallowed. The criticism of ultrasound and laboratory testing is also the narrator's argument. The terminology definitions explain pattern-based reasoning; they do not establish that biomedical testing is inappropriate. Source: WHO — Chinese medicine terminology, entries 546–554 and 2639–2641. ↩︎
↩︎ Combining the four methods. These are inspection, listening and smelling, inquiry, and palpation. Tongue and facial inspection, questions about symptoms and history, and pulse examination contribute different kinds of information. The phrase calls for considering their findings together. It does not say that Evan performs every possible examination at this moment or that these are four laboratory tests. Source: Hong Kong Polytechnic University — Four Diagnostic Methods.
↩︎ Three fingers and changing pressure. As in earlier pulse examinations, the doctor examines adjacent wrist positions called cun, guan, and chi, using the index, middle, and ring fingers. The practitioner may compare positions together or separately and vary the pressure and contact point. “Searching” describes finding and assessing the pulsation through such adjustments. Lily's reaction follows the care she sees Evan taking with April; the passage gives her insult without spelling out a further accusation. Source: WHO — Chinese medicine terminology, entries 856–860, printed p. 84.
↩︎ Depth, width, and location. A deep pulse requires more pressure to feel clearly; a thready pulse feels narrow or threadlike. Neither term is simply a statement about blood pressure or heart rate. Exterior and interior are traditional classifications of the level at which illness is understood to act. “Zang-fu organ systems” refers to the theory's functional groupings, whose scope extends beyond the anatomical organs bearing similar names. Here the narrator combines several pulse qualities rather than treating them as interchangeable labels. Source: WHO — Chinese medicine terminology, entries 890, 896 and 996–997.
↩︎ Slow and relaxed pulses. A traditional “breath” means a complete inhalation and exhalation. The Maijing passage characterizes a slow pulse by three beats per breath. This chapter gives roughly 50–60 beats per minute; the terminology standard describes slow as fewer than four beats per breath, below 60 per minute, and huan, rendered “relaxed” here, as about four beats per breath. These categories also involve their felt qualities. A low resting rate alone does not settle the pattern, as the athlete example emphasizes. Sources: Chinese Text Project — Maijing, book 1 (in Chinese); WHO — Chinese medicine terminology, entries 891 and 907; American Heart Association — Slow heart rate, including physically active adults.
↩︎ A historical simplification. The explanation about having “no clocks” describes the use of breathing as the immediate reference for counting a pulse. It should not be read as a claim that ancient China had no timekeeping instruments: surviving sundials and accounts of water clocks show otherwise. The National Museum of China's Han-dynasty sundial description explains how sundials could help calibrate water clocks. That history does not specify which instrument a particular physician had available. Source: National Museum of China — Han-dynasty sundial and water-clock calibration (in Chinese).
↩︎ The left chi position. Chi is the wrist-pulse position on the forearm side of guan, farther from the hand. Traditional mappings associate this region with the Kidney and reproductive functions. It is a position along the same artery, rather than a separate artery running from the wrist to the Kidney. The sentence about cloudy urine and absent periods gives a traditional association. April has reported scanty, delayed menstruation; the story has not added a urine finding or established that her periods have stopped entirely. Source: WHO — Chinese medicine terminology, entries 856–858 and 928.
↩︎ Kidney warmth and Spleen nourishment. Capitalized Kidney and Spleen name functional systems in Chinese medical theory. The Kidney's yang aspect is associated with warming and activating; the Spleen is associated with transforming food and fluids and supplying nourishment. The narrator links inadequate warming to impaired production of qi and blood, using that relationship to interpret April's scanty flow and thready pulse. Kidney yang deficiency is a traditional pattern label; it does not, by itself, state that she has anatomical kidney damage or kidney failure. Source: WHO — Chinese medicine terminology, entries 116, 153–161, 1200, 1276 and 1323.
↩︎ Essence, Chong, and Ren. The Chong and Ren Vessels belong to Chinese medicine's meridian framework and have appeared in earlier menstrual cases. They are also called the Thoroughfare and Conception Vessels. “Essence,” or jing, is a traditional concept associated with nourishment, growth, and reproduction; here it is not simply a synonym for semen. The account connects Kidney essence, blood, and the two Vessels to explain scanty menstruation. This is a theoretical relationship, rather than a description of two newly identified anatomical blood vessels. Source: WHO — Chinese medicine terminology, entries 153, 158, 223, 2928–2929, 2953 and 2955.
↩︎ Containing blood and blood stasis. In the traditional phrase “the Spleen contains blood,” Spleen qi is understood to keep blood circulating within the vessels. Blood stasis refers to impaired or obstructed movement of blood in the same theoretical framework. The narrator links severe cold, insufficient Spleen qi, and clots here. The terminology source explains the two concepts; it does not itself establish the further causal step from failure to contain blood to clots failing to disperse. The translation retains that step as the novel's explanation. Source: WHO — Chinese medicine terminology, entries 117, 350, 428 and 1198.
↩︎ A cold-womb pattern. Gong han, literally “womb cold,” is traditional diagnostic language. Here Evan uses a deficiency-cold interpretation that brings together the symptoms and examination findings described in the scene. The label is not a report that the uterus has been measured at an abnormally low temperature. Traditional terminology includes difficulty conceiving among possible features of deficiency cold in the uterus. That classification explains the question he asks; it does not independently establish the cause of April's difficulty conceiving. Source: WHO — Chinese medicine terminology, entries 1343 and 1965.
↩︎ The question's wording. The Chinese uses two overlapping terms, xiaochan and liuchan, for a pregnancy ending before term. The question is rendered broadly here to preserve what has been asked without selecting an unstated cause, gestational stage, or distinction between spontaneous and induced loss. The dictionary cross-references the two terms. April's changed expression is the chapter's final information; the question has not yet received an answer. Sources: Ministry of Education — Xiaochan (in Chinese); Ministry of Education — Liuchan (in Chinese).