Two diagnoses leave Evan and Oliver with a difference to explain to Dr. Qian.
The two different diagnoses left the patient a little puzzled too.
Evan Xu and Oliver Liu exchanged a glance.
“Explain the basis for your diagnoses,” Dr. Qian said. “Who wants to go first?”
Oliver adjusted his glasses. “Evan, why don't you…”
“Sure. No problem.” Evan nodded.
“…let me go first.” Oliver drew out the last words.
Evan was speechless. The idiot never tired of that old joke, pausing just long enough to make you misunderstand.
“All right. You go first.”
Oliver nodded, took a step forward, and began with a slight smile.
“The patient's face and limbs are swollen. Clearly, water and dampness aren't being moved properly. Her tongue coating is white and greasy, another sign of turbid dampness trapped inside. Her pulse is deep, slippery, and slightly slow.
“A deep pulse indicates an interior pattern, a slow pulse a cold pattern. The slippery pulse goes with her pregnancy. I also touched her hands and feet just now and found them slightly cold.[1]
“Taken together, these findings indicate Spleen and Kidney yang deficiency. There isn't enough yang qi, and what there is has been suppressed by water and dampness. The middle burner can no longer carry out transformation and transport. Food and fluids aren't properly processed, water and dampness accumulate and overflow, and the result is edema during pregnancy. Treatment should warm and tonify Kidney yang, support the Spleen, and move dampness. I'd use a modified Zhenwu Tang.”[2]
He smiled in satisfaction.
Dr. Qian neither agreed nor disagreed. He turned to Evan. “Tell me what you think.”
“I agree with Dr. Liu on the other findings. The patient's water and dampness aren't being moved properly.
“But her pulse isn't slow. It's relaxed. The left wrist has a deep, slippery pulse; the right has a relaxed, slippery pulse without strength.”
Oliver froze. A relaxed pulse?
A slow pulse indicated cold; a slow pulse without strength indicated deficiency cold. A relaxed pulse, on the other hand, indicated dampness, often Spleen deficiency.
Evan continued. “The patient has Spleen deficiency. Spleen yang isn't vigorous enough to transform and transport water and dampness, so fluid stagnates and seeps into the skin and limbs. That's why the skin over the swelling is thin and shiny and retains a dent when pressed. Treatment should support the Spleen, remove dampness, move water, and reduce the swelling. I'd use a modified Baizhu San.”[3]
“Oliver,” Dr. Qian said, “what pulse does the patient actually have?”
“Well, Evan… if Evan says it's relaxed, it must be. He's better than me anyway!” Oliver said awkwardly.
Dr. Qian snorted. “Do you know the difference between a relaxed pulse and a slow one?”
Oliver scratched his head. “Three beats in one breath is slow; four is relaxed. A relaxed pulse comes and goes gently and unhurriedly. A slow pulse stays slow under both light and heavy pressure.”[4]
Dr. Qian glared at him. “They're very similar pulse qualities, and it's easy to get them wrong. But the distinction is there in the pulse itself.
“Evan spent ten minutes examining both wrists. You didn't even take five! I've practiced medicine for sixty years, and I still wouldn't dare spend less than five minutes. How can you be so reckless? I thought you must be extraordinarily good. Instead, you can't even tell a relaxed pulse from a slow one!”
Oliver's face turned red with embarrassment.
Evan stole a glance at him. He hadn't expected Professor Liu to have been so careless in his youth.
In Chinese-medicine theory, edema during pregnancy involved three organ systems: the Liver, Spleen, and Kidney. Put simply, the possibilities were qi stagnation, Spleen deficiency, and Kidney cold.
Qi stagnation disrupted ascent and descent. Clear yang failed to rise and turbid yin failed to descend, so the swelling began in the feet and gradually spread up the legs.
Wood controlled Earth. The Liver's normal regulation of qi flow restrained congestion and water-dampness in the Spleen. When Liver qi became constrained, water and dampness could no longer be transformed and remained inside.
This was the water-qi form of edema during pregnancy. The emphasis was on regulating qi and transforming dampness. Once Liver qi flowed smoothly and its regulation was restored, congestion in the Spleen would be restrained, the Spleen would function properly, and the swelling would disappear. Edema caused by qi stagnation generally affected only the legs and feet.
Swelling from Spleen deficiency arose because the Spleen governed transformation and transport. When it was deficient, those functions fell short and water and dampness accumulated. The Spleen also governed the flesh and limbs, so the fluid could spread through the skin and limbs, causing facial swelling or even swelling throughout the body. Water overflowing beneath the skin made it thin and shiny, with a dent left by pressure.
With Spleen deficiency, the warming yang of the middle burner lacked vigor, resulting in fullness and bloating in the upper abdomen, shortness of breath, and a reluctance to speak. When the Spleen couldn't move fluids and dampness stayed inside, the mouth felt bland and greasy and the appetite declined.
The Spleen belonged to Earth, the Lung to Metal, and Earth generated Metal. A deficient Spleen meant insufficient Lung qi. The Lung governed outward diffusion, downward movement, and regulation of the water pathways. Insufficient Lung qi impeded those pathways, so urination became scanty. Water and dampness passing into the intestines produced loose stools.
Edema during pregnancy caused by Spleen deficiency was called zizhong. There were plenty of signs beyond what could be seen on the skin. If history-taking had been allowed, Oliver probably wouldn't have made such a mess of it.[5]
The final possibility was insufficient Kidney yang. As Kidney yang weakened, qi transformation lost its power and the regulation of opening and closing became disordered, producing edema.
The Kidney was the body's constitutional foundation. Kidney yang was the fire of the Life Gate, which warmed all the organ systems. If Kidney yang weakened and the Life Gate's fire faded, it couldn't warm Spleen yang; Spleen yang deficiency could follow. Many patients therefore had yang deficiency in both systems, requiring treatment that supported the Spleen, warmed yang, moved water, and drained dampness.[6]
Both approaches used medicines that warmed yang. The difference was in their emphasis. The Spleen-focused approach gave priority to supporting the Spleen, dispelling dampness, and warming and tonifying Spleen yang.
The Kidney-focused approach gave priority to warming and tonifying Kidney yang while also supporting the Spleen and dispelling dampness, because Kidney yang deficiency was the root mechanism. Once yang qi returned to normal, so would qi transformation. Water would be vaporized and distributed throughout the body, and the swelling would disappear.
The logic of Chinese medicine was to treat the sick person rather than just the person's illness. A person in balance was free of illness. A healthy person didn't fall ill; if you were ill, something in your body must have gone out of balance.
Use medicine to restore the body's balance, and the illness would resolve. Counter the body's imbalance with the medicine's particular tendencies.
Oliver's proposed treatment would have had an effect too. But it didn't quite fit the pattern, so it would act more slowly and work less well.
Often, then, it wasn't Chinese medicine that was slow. The doctor hadn't identified the pattern correctly, hadn't chosen the right formula. If the medicine didn't fit the pattern, how could it work quickly?
With the right formula for the pattern, the response was usually as prompt as a drum answering a strike. In many cases, even one dose could bring immediate recovery from a serious, lingering illness![7]
As Dr. Qian wrote the patient's prescription, he continued to instruct them.
“The general approach to edema during pregnancy is to support the Spleen and dispel dampness. But you must also distinguish water-qi from water swelling and adjust the emphasis of the medicines. Only then can the effect be as prompt as a drum responding to a strike.
“When you drain water, pay particular attention to the kind of draining action. You can't use medicines with a lubricating, freely draining action: they could harm the Kidney and affect fetal vitality. Medicines for women should be mild and balanced. In pregnancy especially, take great care with warming and drying medicines, cold and cooling medicines, drastic purgatives, and lubricating, freely draining medicines. Avoid harming the fetus. Be careful, and then be more careful.”[8]
Oliver and Evan nodded earnestly.
Dr. Qian finished the prescription and handed it to the patient. Then he shot Oliver an irritated glance. “You especially. What's been going on with you lately? Always rushing, never able to settle down.”
Oliver's face flushed with embarrassment.
The examination was over. The two of them headed back to the dormitory.
“I've been meaning to ask you the same thing,” Evan said. “What's wrong lately?”
Oliver scratched his head awkwardly. “Nothing!”
Evan was amused. “You can't even tell me?”
Oliver looked shy.
“What is it?” Evan asked. “Are you seeing someone?”
Oliver waved a hand bashfully. “Not yet.”
Evan understood at once. “Right. Unrequited love.”
He shook his head. No wonder the fellow had been off his game lately. He was lovesick.
“Oh, come on!” Oliver said irritably. “All you do is make smart remarks. Help me think of something.”
“Which comrade has caught your eye?”[9]
Oliver glanced carefully around, then lowered his voice. “It's… Rose Wang, the nurse in internal medicine.”
Evan thought for a moment. He couldn't remember who she was.
“Hey,” Oliver whispered, “have you ever dated anyone? Do you know what I should do? Help me out.”
Evan grew serious at once. Professor Oliver Liu, a Changjiang Scholar, was asking him for help. He'd walk through fire to help him![10]
Besides, he had to help Professor Liu make progress. If Oliver went on pining like this, China might lose one of its foremost specialists in Chinese medicine gynecology.
“Easy,” Evan said. “Go and tell her you like her and want to marry her and have children.”
Oliver was startled. His face reddened. “What? Isn't that… a little too direct?”
“What's there to hide?”
Oliver squirmed. “But what if she says no?”
“I'll teach you what to say. Guaranteed to work.”
“Really?” Oliver's eyes lit up. He stared at Evan. “If it actually works, you're my big brother from now on!”
“Ahem.” Evan cleared his throat and stopped walking. He turned to Oliver and asked seriously, “Oliver, aren't you tired?”
Oliver stopped too, looking confused. “No. Why?”
“You've been running through my heart all day. Aren't you tired?”
“Ah!” Oliver's mouth fell open. His whole face went red.
Evan tried another line. “Oliver, will you marry me? I'll make you the second-happiest person in the world.”
Oliver blushed and stammered. “Wh… why the second?”
“Because with you, I'll be the happiest person in the world.”
Oliver was stunned. At that moment, Oliver Liu—the Changjiang Scholar, the Nationally Renowned Physician of Chinese Medicine—felt as though his heart were about to leap out of his chest.
“Awooo! Awooo! Awooo!”
He sprang up and bounced about, waving his arms and howling like a wolf.
The idiot was beside himself with excitement. He'd had no idea such irresistible words even existed.
“I've got it! I've got it!”
Overjoyed, he rushed off, still waving his arms.
Evan smiled and shook his head. “Good luck, Oliver!” he called after him.
Then he went back to the dormitory alone, sat down, and opened a medical book. He hadn't been reading long when someone began pounding urgently on the door.
“Evan, open up! Something's happened! Oliver's been taken in by the security office for indecent behavior!”[11]
Thud.
The book dropped from Evan's hands onto the floor.
Reader Notes
↩︎ Reading the examination terms. A tongue's “greasy” coating describes its appearance. A “slippery” pulse describes the smooth sensation felt under the examiner's fingers; it does not mean the wrist is slippery. “Deep” concerns how firmly the examiner presses before feeling the pulse, while “slow” concerns its tempo. Several qualities can describe the same pulse. Oliver is interpreting these findings within Chinese medicine, including its traditional association between pregnancy and a slippery pulse. Sources: WHO — Chinese medicine terminology, entries 890, 891, and 900; Hong Kong Polytechnic University — Four Diagnostic Methods.
↩︎ Yang, dampness, and the middle burner. The capitalized Spleen and Kidney denote traditional functional systems. Yang here concerns their warming and activating functions. “Water and dampness” describes a traditional account of fluid accumulating or failing to circulate; “transformation and transport” concerns processing food and distributing fluids and nourishment. The middle burner, or middle jiao, is a functional division of the torso, not a literal furnace. Zhenwu Tang is the formula Oliver proposes; tang conventionally denotes a decoction. “Modified” translates jia jian, adjustments to a formula. The passage supplies no ingredients, quantities, or preparation instructions. Source: WHO — Chinese medicine terminology, entries 116, 156, 207–209, and 2777.
↩︎ Baizhu San. Baizhu names a medicinal plant material; san conventionally identifies a powder formula. The word in a formula name does not, by itself, tell us the preparation used in this scene. A Nanjing University of Chinese Medicine reference discusses a formula of this name in the traditional context of Spleen deficiency and swelling during pregnancy. That provides background for the name, without establishing which historical version or modifications Evan intends. Sources: Nanjing University of Chinese Medicine — Baizhu, “Applications and combinations” (in Chinese); WHO — Chinese medicine terminology, entry 2785.
↩︎ Slow and relaxed pulses. Chi and huan are distinct traditional pulse categories. This translation uses “slow” and “relaxed” to keep the contrast audible in conversation; huan is also rendered “moderate” or “slowdown.” The older counting convention measures beats during one complete breathing cycle. Oliver gives three versus four beats, as the Chinese text does. The terminology reference describes chi as fewer than four and huan as about four. Dr. Qian's examination times express his teaching standard in the story. Source: WHO — Chinese medicine terminology, entries 867, 891, and 907.
↩︎ The fluid relationships. The five-phase correspondences connect Liver with Wood, Spleen with Earth, and Lung with Metal. Wood controlling Earth describes regulation; Earth generating Metal describes support. Here they link qi movement, digestion, fluid distribution, and the Lung's traditional “water pathways,” rather than literal materials or anatomical plumbing. “Clear” rising and “turbid” descending describe a functional sorting and movement. The account connects these relationships to the symptoms just listed. Zizhong is a broader traditional name for pregnancy swelling; its use here for the Spleen-deficiency discussion does not make it exclusive to that pattern. Sources: Beijing University of Chinese Medicine — Five-phase relationships (in Chinese); WHO — Chinese medicine terminology, entries 94–98, 116–120, and 2002.
↩︎ The Life Gate. Mingmen, translated here as the Life Gate, has several uses in Chinese medicine. In this explanation its “fire” is a metaphor for the Kidney system's warming and activating functions, including qi transformation. It is not a flame in the body or a reference to treating an acupuncture point of the same name. The narrator uses this relationship to explain how weakened Kidney yang can also weaken Spleen yang, and why the two proposed approaches have different emphases. Source: WHO — Chinese medicine terminology, entries 179–180.
↩︎ Matching treatment to the pattern. Pattern differentiation is the traditional process of interpreting findings to choose a treatment. The narrator's argument is that treatments for the same illness can differ with the pattern. The struck-drum comparison expresses the narrator's claim of an immediate response; it does not report an observed result for this patient. The terminology source explains the treatment framework and provides no evidence for the novel's claims about speed or recovery after one dose. Source: WHO — Chinese medicine terminology, entry 552.
↩︎ Dr. Qian's distinctions. “Water-qi” and “water swelling” retain the passage's shuiqi and shuizhong labels and its emphasis on different mechanisms; they are not separate biomedical diagnoses. “Draining,” “warming,” “cooling,” and “lubricating” describe traditional medicinal actions. “Slippery” in the earlier pulse discussion describes touch and is a different use of the word. “Fetal vitality” renders taiyuan, the traditional idea of the pregnancy's sustaining basis. The source records traditional cautions about pregnancy medicines, including forceful purging and freely draining actions. It does not establish this fictional prescription's safety or its ingredients. Source: Beijing Administration of Traditional Chinese Medicine — Treatment principles before and after childbirth (in Chinese).
↩︎ Comrade. As in the previous chapter, tongzhi preserves a respectful period form of address. Here Evan is asking which woman Oliver likes. The word does not establish her political affiliation. Source: Laishan District Government — Social forms of address (in Chinese).
↩︎ Changjiang Scholar. The Changjiang, or Yangtze River, Scholars Program is a Chinese higher-education distinction associated with academic appointments and research leadership. The Ministry of Education dates its establishment to 1998. Evan is recalling Oliver's later standing, already known to him from his own time, while looking at the young man in 1978. The professor title and later honors are part of that comic perspective; they are not the young trainee's current appointments. Source: Ministry of Education — Background to the Changjiang Scholars Program, section I (in Chinese).
↩︎ The report at the door. The Chinese phrase shua liumang is an accusation of improper behavior; its force depends on context. The dictionary gives a broad sense of behaving like a lawless bully. “Indecent behavior” is the contextual translation for this romantic mishap. The speaker reports that the security office has taken Oliver in. This chapter supplies neither the incident itself nor a finding about what he did. Source: Taiwan Ministry of Education — Shua liumang (in Chinese).