Evan has the theory. Under Dr. Qian's guidance, he must learn what his fingers can tell him.
Dr. Qian's remark left Evan thoroughly embarrassed. Diagnosis and treatment in Chinese medicine called for weighing the findings from all four diagnostic methods together, identifying the pattern, and treating accordingly. Pulse and tongue examination carried particular weight, and pulse examination mattered most of all.[1]
Evan was already poor at examining tongues; he was worse at taking pulses. It wasn't that he knew nothing about it. He simply wasn't good at it. Few young doctors of Chinese medicine these days were skilled at pulse examination, let alone a student fresh out of university like him.
Graduates went to Chinese medicine hospitals and went through the motions of taking a pulse, then sent patients for conventional medical tests anyway. There were a few older doctors at the hospital who knew how to examine a pulse, but Evan had been fired before he could study under one of them.
“I'm not very good at pulse examination,” Evan admitted awkwardly.
“Didn't they teach you at university?” Dr. Qian asked.
“I didn't learn it very well?”
Dr. Qian shook his head slightly and studied Evan's hand position. “You've located the cun, guan, and chi positions quite accurately. You've used the body's own proportions correctly, too. But you have very little experience.”[2]
Evan made an embarrassed sound of agreement.
“You'll have to work hard. Listen to me first. Begin by calming yourself. The ‘Mai Yao Jing Wei Lun’ chapter of the Suwen says, ‘There is a method to examining the pulse; a quiet, undistracted mind is its safeguard.’ It isn't only the patient who must be calm. The doctor must be calm too.”[3]
Evan slowly breathed out several times and settled himself. His three fingers rested precisely over the woman's cun, guan, and chi positions.
“First establish the broad categories,” Dr. Qian said slowly. “What does the pulse tell you about yin and yang, exterior and interior?”[4]
Evan pressed with all three fingers together to assess the pulse.
“The pulse has three depths: superficial, intermediate, and deep. The corresponding methods are lifting, pressing, and searching, used to distinguish its depth. A light touch is called lifting; firm pressure is pressing; careful exploration at an intermediate pressure is searching.
“If you feel it lightly and find the pulse at the skin, it corresponds to yang and the fu organs, and reflects the Heart and Lung. If you press firmly and find it beneath the flesh, it corresponds to yin and the zang organs, and reflects the Liver and Kidney. If you feel it midway, neither lightly nor firmly, the pulse lies among the flesh and blood and reflects the Spleen and Stomach…”
Evan examined the pulse carefully, though his technique was still unpracticed. He searched with all three fingers, then pressed the cun, guan, and chi positions individually.
At the wrist, the cunkou pulse had three positions: cun, guan, and chi. The index finger went on cun, the middle finger on guan, and the ring finger on chi. Each position had superficial, intermediate, and deep levels, making nine in all. This was the three-position, nine-level method of Chinese-medicine pulse examination.[5]
Each level at each position reflected a particular aspect of the body's condition. Every position therefore had to be examined, which was why individual fingers were used. At least 50 pulse beats had to be felt at each position.
An inexperienced examiner might need three or four sets of 50 beats at one position. Examining one hand could take 5–6 minutes, and examining both would certainly take more than 10 minutes.
Evan concentrated on the pulse. His mind settled as he carefully distinguished its qualities at each position. Dr. Qian guided him attentively, while Evan recalled the feeling from his practice sessions after class.
Seeing him like this, Dr. Qian nodded slightly. The young doctor might be weak in clinical practice, but his theoretical knowledge was solid. He had talent, too, and could quiet his mind.
Evan was stronger in theory; Oliver Liu was still better in clinical practice. Both were worth training.
Dr. Qian continued to guide Evan carefully.
At last, Evan opened his eyes and released the woman's hand. A little excited, he said to Dr. Qian, “It should be a deep, wiry pulse. The Maijing says, ‘Insufficient when lifted, ample when pressed.’ That describes a deep pulse. It runs deep, at the tendons and bones, and is felt only with firm pressure. I'm sure it is deep.
“The Maijing says, ‘A wiry pulse is absent when lifted, but when pressed feels like a bowstring.’ This pulse feels straight and long, like a taut bowstring, and doesn't shift under pressure. So it should be wiry.[6]
“A deep pulse indicates an interior pattern. The pulse at her left guan position is deep. A deep left guan pulse indicates Liver constraint, fullness and pain in the flanks, fullness in the upper abdomen and abdominal distension, poor appetite, agitation, and irritability. That agrees with her symptoms. A wiry pulse can also indicate a Liver disorder. A pulse that feels like a bowstring is a Liver pulse. When it is both wiry and deep, qi is constrained and cannot flow freely.
“So I can be certain that she has Liver qi constraint. Qi is the commander of blood. When qi stagnates, it cannot drive blood forward, so qi stagnation readily leads to blood stasis. This is an interior excess pattern. Excess must be drained. We should soothe the Liver and relieve its constraint.”[7]
Dr. Qian smiled.
Evan's confidence immediately faltered. “Did I… get the pattern wrong?”
“The pattern is correct. What formula should you use?”
Evan's expression turned tense at once.
Noticing how strained he looked, Dr. Qian asked curiously, “What's wrong? You've identified the pattern correctly. Don't you know how to prescribe?”
“That's not it.” Evan pressed his lips together and shook his head slightly.
“Then what is it?”
Evan lowered his head, growing more anxious.
He clasped his hands tightly. “I… I'm afraid I'll prescribe the wrong formula. Instead of treating her, I'll harm her.”
“The difficulty in Chinese medicine lies in identifying patterns and treating accordingly,” Dr. Qian said. “To treat illness, you must understand pattern differentiation through the four diagnostic methods and eight principles; how the six channels correspond to the six qi; and how yin and yang rise and descend. You must also understand how to differentiate the defensive, nutritive, qi, and blood patterns and their circulation, and the generating and controlling relationships of the channels and zang-fu organ systems.[8]
“Treating illness in Chinese medicine comes down to twelve Chinese characters: observe the pulse and symptoms, understand what has gone wrong, and treat according to the pattern. You've identified the pattern correctly. Treat accordingly. What's so difficult?”[9]
Evan thought again of what had happened before. He wasn't very good in clinical practice, but that didn't mean he couldn't treat anyone. He was afraid to treat anyone. That incident had left him with a terrible fear and had almost ruined his life.
Clutching at his clothes, he said anxiously, “I'm afraid… afraid I've identified the wrong pattern. Afraid I'll choose the wrong formula. Most of all, afraid I'll use the wrong dose…”
Dr. Qian's face hardened. “A doctor must proceed as though walking on thin ice: cautiously, looking ahead and behind. But a doctor needs not only the skill to subdue dragons and tigers, but the confidence to reach into the fire for a chestnut.
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“A doctor must take responsibility for relieving people's suffering. Your patient is sitting right in front of you, in unbearable pain, and you shrink back like this. How can you be a doctor? Why be one at all?”
Evan clasped his hands tightly together.
“Doctors, please hurry up and prescribe something,” the woman said impatiently. “The pain is really awful.”
“A doctor's whole life is a struggle,” Dr. Qian said with solemn intensity. “But the first thing we must overcome isn't disease. It's ourselves.”
Evan looked up at him, stunned.
Dr. Qian looked at Evan and said evenly, “If you can't overcome yourself, you don't deserve to be a doctor!”
Evan clenched his hands, his brows drawn into a knot. He remembered the cold, mocking looks he'd seen the day he was fired.
It wasn't that he couldn't treat patients. He didn't dare!
After a long while, he still hadn't spoken. The struggle on his face only grew more intense.
Disappointment showed in Dr. Qian's eyes. He shook his head slightly and said to the woman, “Comrade, come with me. I'll examine and treat you.”
“All right.” She stood, holding her lower abdomen.
They were about to leave. Just as they opened the door again, a rough voice suddenly rose behind them.
“Abdominal pain before the menstrual flow! When a woman has abdominal pain for several days before menstruation and the flow comes afterward, it is often purplish-black and clotted. People suppose this is due to extreme cold. Who realizes that it is extreme heat, with fire failing to transform?”
They both turned. Evan was clenching his fists, his face taut, shouting the passage.
“The Liver belongs to Wood, and within it there is fire. When it is free, movement is unobstructed; when constrained, it cannot unfold. When menstruation is about to begin and the Liver fails to respond, its qi is checked and pain arises. But once menstrual blood is full, it can no longer be stored within. The constrained fire in the Liver burns, forcing the menstrual flow out, and the fire is fiercely released with it.
“Its purplish-black color is the sign of Water and Fire at war. The clots are what fire has cooked into shape. Menstruation loses its proper function because constrained fire has seized its authority within. The treatment would seem to be to drain the fire in the Liver forcefully. Yet if we drain Liver fire without relieving Liver constraint, we may remove the branch—the heat—but leave its root untouched. What good can that do?
“Therefore, the formula is… Xuanyu Tongjing Tang.”[10]
Having finished the passage, Evan drew great, gasping breaths, as though he had used every bit of his strength. And at that moment, those cold, mocking eyes receded.
Dr. Qian smiled. This young comrade…
Reader Notes
↩︎ Four methods and patterns. The four methods are inspection, listening and smelling, inquiry, and palpation; the previous chapter showed Evan using several of them. A pattern brings their findings together within Chinese-medicine theory and guides the treatment approach. This is the framework behind Dr. Qian's criticism. Source: Hong Kong Polytechnic University — Four Diagnostic Methods.
↩︎ Body-proportional measurement. Tongshen cun is a traditional way of measuring in relation to a person's own body, rather than using a fixed inch or centimeter. Here it concerns locating the wrist pulse positions; it does not introduce a ruler or a new examination. The measurement sense of cun should be distinguished from the pulse position also called cun. The WHO acupuncture-location standard distinguishes body-proportional and finger-based measurements, although that standard is about locating acupuncture points, not this patient's diagnosis. Source: WHO — Standard Acupuncture Point Locations, measurement conventions.
↩︎ A still mind in pulse examination. The Suwen, introduced in the previous chapter, is the Basic Questions portion of the Huangdi Neijing. Its “Mai Yao Jing Wei Lun” chapter discusses the subtleties of examining a pulse. “Empty and still” describes undistracted attention, not an absence of medical knowledge. Dr. Qian invokes the line to ask Evan to settle his own mind as well as the patient's. The English quotation here is translated from the novel's Chinese wording. Source: Shidian Guji — Suwen, chapter 17 quotation and textual location (in Chinese).
↩︎ Yin, yang, organ systems, and depth. Yin and yang are relational categories in Chinese medicine, not visible substances. Here they help organize findings at different pulse depths. Exterior and interior concern a pattern's location within that framework. Zang names the yin organ systems; fu names the yang systems often called “bowels.” Capitalized Heart, Lung, Liver, Kidney, Spleen, and Stomach refer to functional systems in this edition, not solely anatomical organs. Dr. Qian's particular groupings belong to his lesson. The distinctions ask Evan to interpret the pulse, rather than report an imaging finding. Sources: WHO — Chinese medicine terminology; National Certification Commission — terminology, candidate handbook p. 52.
↩︎ Three positions, nine levels. Cunkou is the wrist area used for this form of pulse examination. Cun, guan, and chi are adjacent positions, each assessed at superficial, intermediate, and deep pressure. Three positions multiplied by three depths make the nine levels described here; they are not nine arteries. “Lifting,” “pressing,” and “searching” name changes in the examiner's pressure. The per-position beat counts and examination times are the novel's account; the source describes a traditional fifty-beat assessment but does not establish this timetable. Source: National Research Institute of Chinese Medicine — terminology transcription, entries 856–860 and 865.
↩︎ The Maijing and pulse qualities. The Maijing, or Pulse Classic, is traditionally associated with Wang Shuhe. “Deep” concerns the pressure needed to feel a pulse; “wiry” describes its straight, taut, bowstring-like feel. They are distinct qualities, so Evan can describe a pulse as both. His references to lifting and pressing concern his examining fingers, not movements made by the patient. The classical descriptions are translated from the novel's wording; their presence in a classic does not independently establish this patient's pattern. Sources: Shidian Guji — Maijing excerpt (in Chinese); National Research Institute of Chinese Medicine — deep and wiry pulses, entries 890 and 904.
↩︎ Qi and blood. “Qi is the commander of blood” is an image for qi's role in moving blood within traditional theory. It extends the qi-stagnation and blood-stasis connection introduced in the previous chapter. “Interior excess” and “drain” likewise name a pattern and a treatment principle, not an instruction to drain blood. Source: WHO — Chinese medicine terminology, qi stagnation with blood stasis and deficiency/excess.
↩︎ Several diagnostic frameworks. The eight principles are four paired distinctions: yin/yang, exterior/interior, cold/heat, and deficiency/excess. The six channels, or six stages, are Taiyang, Yangming, Shaoyang, Taiyin, Shaoyin, and Jueyin. Here they are diagnostic categories; “channel” is not simply an anatomical tube. Six qi refers to a separate traditional set of climatic influences and their theoretical correspondences. The defensive, qi, nutritive, and blood levels belong to another framework used especially for warm diseases. The novel lists them in a different order, which the dialogue preserves. Generating and controlling relationships refer to the Five Phases, already introduced earlier. Dr. Qian is surveying bodies of knowledge, not giving this patient several new diagnoses. Sources: National Certification Commission — diagnostic frameworks, 2022 candidate handbook; Beijing University of Chinese Medicine — six-qi correspondences (in Chinese); Beijing University of Chinese Medicine — warm-disease theory (in Chinese).
↩︎ The twelve-character maxim. The three clauses each contain four Chinese characters, giving twelve in all; the count does not apply to their English translation. The wording comes from the Shanghan Lun tradition. In its classical context, “what has gone wrong” includes adverse changes after inappropriate treatment, and treatment must follow the resulting pattern. Dr. Qian uses the line more broadly to urge Evan to connect examination with treatment. It does not disclose further details of the earlier incident that frightens Evan. Source: Shidian Guji — Shanghan Lun quotation and context (in Chinese).
↩︎ Xuanyu Tongjing Tang, root, and branch. Evan's recitation comes from the menstrual-disorders section of Fu Qingzhu Nüke, the classic quoted in the previous chapter. Xuanyu Tongjing Tang is the named decoction in its discussion of abdominal pain before menstruation. Tongjing here concerns menstrual flow, not clearing an anatomical blood vessel. “Branch” refers to the manifest heat; “root” to the Liver constraint said to produce it. Water, Fire, and cooking are the passage's traditional explanatory images. The argument distinguishes clearing heat from also relieving constraint; the novel has not yet described treatment or its outcome. Source: Fu Qingzhu Nüke — abdominal pain before menstruation, section 21 (in Chinese).